hospital_name,last_updated_on,version,location_name,hospital_address,type_2_npi,license_number|MO,attester_name,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula."
NKC Health,2026-03-06,3.0.0,NKC Health,"2800 Clay Edwards Drive, North Kansas City, MO 64116",1629062799|1598719387,166,Austin Jones,true
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,billing_class,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,modifiers,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,median_amount,10th_percentile,90th_percentile,count,standard_charge|min,standard_charge|max,standard_charge|methodology,additional_generic_notes
Room And Bed Med Surg,7631979,CDM,110,RC,,,,,facility,inpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,1324.80,2603.00,percent of total billed charges,
Room And Bed Rehab,7631989,CDM,118,RC,,,,,facility,inpatient,,,2663.00000,772.27000,Aetna,First Health,,2178.33,,,,,,,1520.00,2671.24,percent of total billed charges,
Room And Bed Nursery,7631978,CDM,170,RC,,,,,facility,inpatient,,,2683.00000,778.07000,Aetna,First Health,,2194.69,,,,,,,257.50,2194.69,percent of total billed charges,
Room And Bed Neonatal ICU II,7631984,CDM,172,RC,,,,,facility,inpatient,,,5690.00000,1650.10000,Aetna,First Health,,4654.42,,,,,,,1899.89,4654.42,percent of total billed charges,
Room And Bed Intermediate Nursery,7631998,CDM,172,RC,,,,,facility,inpatient,,,5690.00000,1650.10000,Aetna,First Health,,4654.42,,,,,,,1899.89,4654.42,percent of total billed charges,
Room And Bed Neonatal ICU III,7631992,CDM,173,RC,,,,,facility,inpatient,,,8292.00000,2404.68000,Aetna,First Health,,6782.86,,,,,,,2163.00,6782.86,percent of total billed charges,
Room And Bed ICU,7631983,CDM,200,RC,,,,,facility,inpatient,,,5854.00000,1697.66000,Aetna,First Health,,4788.57,,,,,,,2603.00,4788.57,percent of total billed charges,
Room And Bed CCU,7631981,CDM,210,RC,,,,,facility,inpatient,,,5854.00000,1697.66000,Aetna,First Health,,4788.57,,,,,,,2603.00,4788.57,percent of total billed charges,
Room And Bed Telemetry,7631991,CDM,214,RC,,,,,facility,inpatient,,,4473.00000,1297.17000,Aetna,First Health,,3658.91,,,,,,,2603.00,3658.91,percent of total billed charges,
NORMAL SALINE ALBUMIN,7734602,CDM,250,RC,P9048,HCPCS,,,facility,inpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,59.57,131.70,percent of total billed charges,
NORMAL SALINE ALBUMIN,7734602,CDM,250,RC,P9048,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,34.63,196.75,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),8723516,CDM,250,RC,J0281,HCPCS,,,facility,inpatient,,,97.26000,28.21000,Aetna,First Health,,79.56,,,,,,,35.99,79.56,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),8723516,CDM,250,RC,J0281,HCPCS,,,facility,outpatient,,,97.26000,28.21000,Aetna,First Health,,79.56,,,,,,,1.53,79.56,percent of total billed charges,
Hetastarch 6% -NS 500mL,8724320,CDM,250,RC,,,,,facility,inpatient,,,356.81000,103.47000,Aetna,First Health,,291.87,,,,,,,132.02,291.87,percent of total billed charges,
Hetastarch 6% -NS 500mL,8724320,CDM,250,RC,,,,,facility,outpatient,,,356.81000,103.47000,Aetna,First Health,,291.87,,,,,,,128.63,291.87,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,8726055,CDM,250,RC,,,,,facility,inpatient,,,263.15000,76.31000,Aetna,First Health,,215.26,,,,,,,97.37,215.26,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,8726055,CDM,250,RC,,,,,facility,outpatient,,,263.15000,76.31000,Aetna,First Health,,215.26,,,,,,,94.87,215.26,percent of total billed charges,
Dornase Alfa 2.5mg/2.5mL Inhl UD,8724890,CDM,250,RC,,,,,facility,inpatient,,,703.25000,203.94000,Aetna,First Health,,575.26,,,,,,,260.20,575.26,percent of total billed charges,
Dornase Alfa 2.5mg/2.5mL Inhl UD,8724890,CDM,250,RC,,,,,facility,outpatient,,,703.25000,203.94000,Aetna,First Health,,575.26,,,,,,,253.52,575.26,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,8725160,CDM,250,RC,,,,,facility,inpatient,,,48.33000,14.02000,Aetna,First Health,,39.53,,,,,,,17.88,39.53,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,8725160,CDM,250,RC,,,,,facility,outpatient,,,48.33000,14.02000,Aetna,First Health,,39.53,,,,,,,17.42,39.53,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,8724697,CDM,250,RC,,,,,facility,inpatient,,,341.10000,98.92000,Aetna,First Health,,279.02,,,,,,,126.21,279.02,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,8724697,CDM,250,RC,,,,,facility,outpatient,,,341.10000,98.92000,Aetna,First Health,,279.02,,,,,,,122.97,279.02,percent of total billed charges,
Cupric Cl (Copper) I 10mL,8723455,CDM,250,RC,,,,,facility,inpatient,,,197.42000,57.25000,Aetna,First Health,,161.49,,,,,,,73.05,161.49,percent of total billed charges,
Cupric Cl (Copper) I 10mL,8723455,CDM,250,RC,,,,,facility,outpatient,,,197.42000,57.25000,Aetna,First Health,,161.49,,,,,,,71.17,161.49,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,8724717,CDM,250,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.70,8.18,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,8724717,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
PrismaSol BGK 4/2.5 - 5L,8725288,CDM,250,RC,,,,,facility,inpatient,,,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,181.30,400.82,percent of total billed charges,
PrismaSol BGK 4/2.5 - 5L,8725288,CDM,250,RC,,,,,facility,outpatient,,,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,176.65,400.82,percent of total billed charges,
Sodium Chloride 23.4% Inj 30mL,8725323,CDM,250,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,37.00,81.80,percent of total billed charges,
Sodium Chloride 23.4% Inj 30mL,8725323,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,8725332,CDM,250,RC,,,,,facility,inpatient,,,238.49000,69.16000,Aetna,First Health,,195.08,,,,,,,88.24,195.08,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,8725332,CDM,250,RC,,,,,facility,outpatient,,,238.49000,69.16000,Aetna,First Health,,195.08,,,,,,,85.98,195.08,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,8725361,CDM,250,RC,,,,,facility,inpatient,,,114.23000,33.13000,Aetna,First Health,,93.44,,,,,,,42.27,93.44,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,8725361,CDM,250,RC,,,,,facility,outpatient,,,114.23000,33.13000,Aetna,First Health,,93.44,,,,,,,41.18,93.44,percent of total billed charges,
Calamine-Zinc Oxide 8% Topical Lotion,8725867,CDM,250,RC,,,,,facility,inpatient,,,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,6.16,13.62,percent of total billed charges,
Calamine-Zinc Oxide 8% Topical Lotion,8725867,CDM,250,RC,,,,,facility,outpatient,,,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,6.00,13.62,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),8723468,CDM,250,RC,,,,,facility,inpatient,,,16.10000,4.67000,Aetna,First Health,,13.17,,,,,,,5.96,13.17,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),8723468,CDM,250,RC,,,,,facility,outpatient,,,16.10000,4.67000,Aetna,First Health,,13.17,,,,,,,5.80,13.17,percent of total billed charges,
Potassium Phosphate Inj 5mL,8725748,CDM,250,RC,,,,,facility,inpatient,,,94.55000,27.42000,Aetna,First Health,,77.34,,,,,,,34.98,77.34,percent of total billed charges,
Potassium Phosphate Inj 5mL,8725748,CDM,250,RC,,,,,facility,outpatient,,,94.55000,27.42000,Aetna,First Health,,77.34,,,,,,,34.09,77.34,percent of total billed charges,
NS (Sterile Field) IS 10mL,8725796,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
NS (Sterile Field) IS 10mL,8725796,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Acetic Acid 3% TS 30mL,8725773,CDM,250,RC,,,,,facility,inpatient,,,30.20000,8.76000,Aetna,First Health,,24.70,,,,,,,11.17,24.70,percent of total billed charges,
Acetic Acid 3% TS 30mL,8725773,CDM,250,RC,,,,,facility,outpatient,,,30.20000,8.76000,Aetna,First Health,,24.70,,,,,,,10.89,24.70,percent of total billed charges,
Mannitol 20% 500mL,8723714,CDM,250,RC,,,,,facility,inpatient,,,194.35000,56.36000,Aetna,First Health,,158.98,,,,,,,71.91,158.98,percent of total billed charges,
Mannitol 20% 500mL,8723714,CDM,250,RC,,,,,facility,outpatient,,,194.35000,56.36000,Aetna,First Health,,158.98,,,,,,,70.06,158.98,percent of total billed charges,
Poractant 120mg/1.5mL Intratrach I(Curosurf),8725823,CDM,250,RC,,,,,facility,inpatient,,,2576.30000,747.13000,Aetna,First Health,,2107.41,,,,,,,953.23,2107.41,percent of total billed charges,
Poractant 120mg/1.5mL Intratrach I(Curosurf),8725823,CDM,250,RC,,,,,facility,outpatient,,,2576.30000,747.13000,Aetna,First Health,,2107.41,,,,,,,928.76,2107.41,percent of total billed charges,
PrismaSol BGK 2/3.5 - 5L,8725381,CDM,250,RC,,,,,facility,inpatient,,,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,181.30,400.82,percent of total billed charges,
PrismaSol BGK 2/3.5 - 5L,8725381,CDM,250,RC,,,,,facility,outpatient,,,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,176.65,400.82,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,8725393,CDM,250,RC,,,,,facility,inpatient,,,330.83000,95.94000,Aetna,First Health,,270.62,,,,,,,122.41,270.62,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,8725393,CDM,250,RC,,,,,facility,outpatient,,,330.83000,95.94000,Aetna,First Health,,270.62,,,,,,,119.26,270.62,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL - for IV Set,8725432,CDM,250,RC,,,,,facility,inpatient,,,3313.25000,960.84000,Aetna,First Health,,2710.24,,,,,,,1225.90,2710.24,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL - for IV Set,8725432,CDM,250,RC,,,,,facility,outpatient,,,3313.25000,960.84000,Aetna,First Health,,2710.24,,,,,,,1194.43,2710.24,percent of total billed charges,
Labetalol 100mg/20mL - for IV Set,8725436,CDM,250,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,37.00,81.80,percent of total billed charges,
Labetalol 100mg/20mL - for IV Set,8725436,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Isoproterenol HCl 1mg/5mL Inj - for IV Set,8725438,CDM,250,RC,,,,,facility,inpatient,,,12883.50000,3736.21000,Aetna,First Health,,10538.70,,,,,,,4766.90,10538.70,percent of total billed charges,
Isoproterenol HCl 1mg/5mL Inj - for IV Set,8725438,CDM,250,RC,,,,,facility,outpatient,,,12883.50000,3736.21000,Aetna,First Health,,10538.70,,,,,,,4644.50,10538.70,percent of total billed charges,
Norepinephrine 8mg/8mL Inj - IV Set Use,8725440,CDM,250,RC,,,,,facility,inpatient,,,360.98000,104.68000,Aetna,First Health,,295.28,,,,,,,133.56,295.28,percent of total billed charges,
Norepinephrine 8mg/8mL Inj - IV Set Use,8725440,CDM,250,RC,,,,,facility,outpatient,,,360.98000,104.68000,Aetna,First Health,,295.28,,,,,,,130.13,295.28,percent of total billed charges,
Hip/Knee Periarticular Syringe,8725500,CDM,250,RC,,,,,facility,inpatient,,,533.80000,154.80000,Aetna,First Health,,436.65,,,,,,,197.51,436.65,percent of total billed charges,
Hip/Knee Periarticular Syringe,8725500,CDM,250,RC,,,,,facility,outpatient,,,533.80000,154.80000,Aetna,First Health,,436.65,,,,,,,192.43,436.65,percent of total billed charges,
Nitroglycerin 40mcg/mL D5W Vial - OR Use ONLY,8725526,CDM,250,RC,,,,,facility,inpatient,,,79.70000,23.11000,Aetna,First Health,,65.19,,,,,,,29.49,65.19,percent of total billed charges,
Nitroglycerin 40mcg/mL D5W Vial - OR Use ONLY,8725526,CDM,250,RC,,,,,facility,outpatient,,,79.70000,23.11000,Aetna,First Health,,65.19,,,,,,,28.73,65.19,percent of total billed charges,
Lidocaine 4% Topical Trach Kit,8725574,CDM,250,RC,,,,,facility,inpatient,,,253.50000,73.52000,Aetna,First Health,,207.36,,,,,,,93.80,207.36,percent of total billed charges,
Lidocaine 4% Topical Trach Kit,8725574,CDM,250,RC,,,,,facility,outpatient,,,253.50000,73.52000,Aetna,First Health,,207.36,,,,,,,91.39,207.36,percent of total billed charges,
HYDROmorphone 1mg/1mL Oral Soln,8725580,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
HYDROmorphone 1mg/1mL Oral Soln,8725580,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Amino Acids (for TPN/PPN),8725685,CDM,250,RC,,,,,facility,inpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,21.09,46.63,percent of total billed charges,
Amino Acids (for TPN/PPN),8725685,CDM,250,RC,,,,,facility,outpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,20.55,46.63,percent of total billed charges,
Dextrose (For TPN/PPN),8725686,CDM,250,RC,,,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.50,40.90,percent of total billed charges,
Dextrose (For TPN/PPN),8725686,CDM,250,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
Sugammadex 100mg/mL Inj 2mL(Bridion SD),8725653,CDM,250,RC,,,,,facility,inpatient,,,714.10000,207.09000,Aetna,First Health,,584.13,,,,,,,264.22,584.13,percent of total billed charges,
Sugammadex 100mg/mL Inj 2mL(Bridion SD),8725653,CDM,250,RC,,,,,facility,outpatient,,,714.10000,207.09000,Aetna,First Health,,584.13,,,,,,,257.43,584.13,percent of total billed charges,
Mineral Oil Light 10mL(Muri-Lube),8723421,CDM,250,RC,,,,,facility,inpatient,,,194.90000,56.52000,Aetna,First Health,,159.43,,,,,,,72.11,159.43,percent of total billed charges,
Mineral Oil Light 10mL(Muri-Lube),8723421,CDM,250,RC,,,,,facility,outpatient,,,194.90000,56.52000,Aetna,First Health,,159.43,,,,,,,70.26,159.43,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,8724133,CDM,250,RC,,,,,facility,inpatient,,,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,20.96,46.34,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,8724133,CDM,250,RC,,,,,facility,outpatient,,,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,20.42,46.34,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,8724038,CDM,250,RC,J2865,HCPCS,,,facility,inpatient,,,120.40000,34.92000,Aetna,First Health,,98.49,,,,,,,44.55,98.49,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,8724038,CDM,250,RC,J2865,HCPCS,,,facility,outpatient,,,120.40000,34.92000,Aetna,First Health,,98.49,,,,,,,0.03852,98.49,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,8723539,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,8723539,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,8723536,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,8723536,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,8723537,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,8723537,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Sugammadex 100mg/mL Inj 5mL(Bridion SD),8725829,CDM,250,RC,,,,,facility,inpatient,,,1183.45000,343.20000,Aetna,First Health,,968.06,,,,,,,437.88,968.06,percent of total billed charges,
Sugammadex 100mg/mL Inj 5mL(Bridion SD),8725829,CDM,250,RC,,,,,facility,outpatient,,,1183.45000,343.20000,Aetna,First Health,,968.06,,,,,,,426.63,968.06,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,8725830,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,8725830,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
NUTR- Isosource HN (250mL),8725911,CDM,250,RC,,,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.50,40.90,percent of total billed charges,
NUTR- Isosource HN (250mL),8725911,CDM,250,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
Citric Acid/MgOx/Na pico Oral Soln,9005005,CDM,250,RC,,,,,facility,inpatient,,,1395.45000,404.68000,Aetna,First Health,,1141.48,,,,,,,516.32,1141.48,percent of total billed charges,
Citric Acid/MgOx/Na pico Oral Soln,9005005,CDM,250,RC,,,,,facility,outpatient,,,1395.45000,404.68000,Aetna,First Health,,1141.48,,,,,,,503.06,1141.48,percent of total billed charges,
NS 3000mL Irrigation - Bag,8725935,CDM,250,RC,,,,,facility,inpatient,,,87.80000,25.46000,Aetna,First Health,,71.82,,,,,,,32.49,71.82,percent of total billed charges,
NS 3000mL Irrigation - Bag,8725935,CDM,250,RC,,,,,facility,outpatient,,,87.80000,25.46000,Aetna,First Health,,71.82,,,,,,,31.65,71.82,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,8723416,CDM,250,RC,,,,,facility,inpatient,,,50.10000,14.53000,Aetna,First Health,,40.98,,,,,,,18.54,40.98,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,8723416,CDM,250,RC,,,,,facility,outpatient,,,50.10000,14.53000,Aetna,First Health,,40.98,,,,,,,18.06,40.98,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,8723981,CDM,250,RC,,,,,facility,inpatient,,,751.85000,218.04000,Aetna,First Health,,615.01,,,,,,,278.18,615.01,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,8723981,CDM,250,RC,,,,,facility,outpatient,,,751.85000,218.04000,Aetna,First Health,,615.01,,,,,,,271.04,615.01,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,8723426,CDM,250,RC,,,,,facility,inpatient,,,197.15000,57.17000,Aetna,First Health,,161.27,,,,,,,72.95,161.27,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,8723426,CDM,250,RC,,,,,facility,outpatient,,,197.15000,57.17000,Aetna,First Health,,161.27,,,,,,,71.07,161.27,percent of total billed charges,
Potassium Phosphate Inj 15mL,8723469,CDM,250,RC,,,,,facility,inpatient,,,150.90000,43.76000,Aetna,First Health,,123.44,,,,,,,55.83,123.44,percent of total billed charges,
Potassium Phosphate Inj 15mL,8723469,CDM,250,RC,,,,,facility,outpatient,,,150.90000,43.76000,Aetna,First Health,,123.44,,,,,,,54.40,123.44,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,8723541,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,8723541,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Labetalol 5mg/mL 4mL I(Normodyne),8726135,CDM,250,RC,,,,,facility,inpatient,,,28.43000,8.24000,Aetna,First Health,,23.26,,,,,,,10.52,23.26,percent of total billed charges,
Labetalol 5mg/mL 4mL I(Normodyne),8726135,CDM,250,RC,,,,,facility,outpatient,,,28.43000,8.24000,Aetna,First Health,,23.26,,,,,,,10.25,23.26,percent of total billed charges,
aminolevulinic acid 50mL REC Pwd Oral Soln,8726098,CDM,250,RC,,,,,facility,inpatient,,,17287.80000,5013.46000,Aetna,First Health,,14141.42,,,,,,,6396.49,14141.42,percent of total billed charges,
aminolevulinic acid 50mL REC Pwd Oral Soln,8726098,CDM,250,RC,,,,,facility,outpatient,,,17287.80000,5013.46000,Aetna,First Health,,14141.42,,,,,,,6232.25,14141.42,percent of total billed charges,
nirmatrelvir-ritonavir 300mg-100mg Dose Tab,8726145,CDM,250,RC,,,,,facility,inpatient,,,1091.85000,316.64000,Aetna,First Health,,893.13,,,,,,,403.98,893.13,percent of total billed charges,
nirmatrelvir-ritonavir 300mg-100mg Dose Tab,8726145,CDM,250,RC,,,,,facility,outpatient,,,1091.85000,316.64000,Aetna,First Health,,893.13,,,,,,,393.61,893.13,percent of total billed charges,
NS Bacteriostatic 0.9% 10mL I,8726150,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
NS Bacteriostatic 0.9% 10mL I,8726150,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Lidocaine 2% Topical Jelly w/ Appl,8974995,CDM,250,RC,,,,,facility,inpatient,,,50.60000,14.67000,Aetna,First Health,,41.39,,,,,,,18.72,41.39,percent of total billed charges,
Lidocaine 2% Topical Jelly w/ Appl,8974995,CDM,250,RC,,,,,facility,outpatient,,,50.60000,14.67000,Aetna,First Health,,41.39,,,,,,,18.24,41.39,percent of total billed charges,
docusate/phosphate/water 250mL enema,8984010,CDM,250,RC,,,,,facility,inpatient,,,138.80000,40.25000,Aetna,First Health,,113.54,,,,,,,51.36,113.54,percent of total billed charges,
docusate/phosphate/water 250mL enema,8984010,CDM,250,RC,,,,,facility,outpatient,,,138.80000,40.25000,Aetna,First Health,,113.54,,,,,,,50.04,113.54,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,8986201,CDM,250,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.70,8.18,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,8986201,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
etomidate 2mg/mL 20mL Inj,8986277,CDM,250,RC,,,,,facility,inpatient,,,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.45,20.90,percent of total billed charges,
etomidate 2mg/mL 20mL Inj,8986277,CDM,250,RC,,,,,facility,outpatient,,,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
sodium citrate 4%(120mg/3mL) IS,8986968,CDM,250,RC,,,,,facility,inpatient,,,77.20000,22.39000,Aetna,First Health,,63.15,,,,,,,28.56,63.15,percent of total billed charges,
sodium citrate 4%(120mg/3mL) IS,8986968,CDM,250,RC,,,,,facility,outpatient,,,77.20000,22.39000,Aetna,First Health,,63.15,,,,,,,27.83,63.15,percent of total billed charges,
Ethiodized Oil 480 mg/mL Inj Soln 10mL,8990224,CDM,250,RC,,,,,facility,inpatient,,,4628.20000,1342.18000,Aetna,First Health,,3785.87,,,,,,,1712.43,3785.87,percent of total billed charges,
Ethiodized Oil 480 mg/mL Inj Soln 10mL,8990224,CDM,250,RC,,,,,facility,outpatient,,,4628.20000,1342.18000,Aetna,First Health,,3785.87,,,,,,,1668.47,3785.87,percent of total billed charges,
trace elements (Cu/Mn/Se/Zn) 0.3mg-55mcg-60mcg-3mg/mL I,9000947,CDM,250,RC,,,,,facility,inpatient,,,166.88000,48.40000,Aetna,First Health,,136.51,,,,,,,61.75,136.51,percent of total billed charges,
trace elements (Cu/Mn/Se/Zn) 0.3mg-55mcg-60mcg-3mg/mL I,9000947,CDM,250,RC,,,,,facility,outpatient,,,166.88000,48.40000,Aetna,First Health,,136.51,,,,,,,60.16,136.51,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,8723404,CDM,250,RC,,,,,facility,inpatient,,,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,10.64,23.52,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,8723404,CDM,250,RC,,,,,facility,outpatient,,,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,10.36,23.52,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,8723394,CDM,250,RC,,,,,facility,inpatient,,,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,33.19,73.37,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,8723394,CDM,250,RC,,,,,facility,outpatient,,,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,32.34,73.37,percent of total billed charges,
nirmatrelvir-ritonavir 150 mg-100 mg (Renal Dose) Tab,9090588,CDM,250,RC,,,,,facility,inpatient,,,1091.85000,316.64000,Aetna,First Health,,893.13,,,,,,,403.98,893.13,percent of total billed charges,
nirmatrelvir-ritonavir 150 mg-100 mg (Renal Dose) Tab,9090588,CDM,250,RC,,,,,facility,outpatient,,,1091.85000,316.64000,Aetna,First Health,,893.13,,,,,,,393.61,893.13,percent of total billed charges,
Norepinephrine 8mg/NS 250mL-Dbl Conc,9098880,CDM,250,RC,,,,,facility,inpatient,,,481.00000,139.49000,Aetna,First Health,,393.46,,,,,,,177.97,393.46,percent of total billed charges,
Norepinephrine 8mg/NS 250mL-Dbl Conc,9098880,CDM,250,RC,,,,,facility,outpatient,,,481.00000,139.49000,Aetna,First Health,,393.46,,,,,,,173.40,393.46,percent of total billed charges,
ePHEDrine sulfate 25mg/5mL IS,9115161,CDM,250,RC,,,,,facility,inpatient,,,78.85000,22.87000,Aetna,First Health,,64.50,,,,,,,29.17,64.50,percent of total billed charges,
ePHEDrine sulfate 25mg/5mL IS,9115161,CDM,250,RC,,,,,facility,outpatient,,,78.85000,22.87000,Aetna,First Health,,64.50,,,,,,,28.43,64.50,percent of total billed charges,
Ketamine 10mg/mL Inj 10mL,9144896,CDM,250,RC,,,,,facility,inpatient,,,88.00000,25.52000,Aetna,First Health,,71.98,,,,,,,32.56,71.98,percent of total billed charges,
Ketamine 10mg/mL Inj 10mL,9144896,CDM,250,RC,,,,,facility,outpatient,,,88.00000,25.52000,Aetna,First Health,,71.98,,,,,,,31.72,71.98,percent of total billed charges,
Ketamine 500mg/NS 250mL IV,9160464,CDM,250,RC,,,,,facility,inpatient,,,81.70000,23.69000,Aetna,First Health,,66.83,,,,,,,30.23,66.83,percent of total billed charges,
Ketamine 500mg/NS 250mL IV,9160464,CDM,250,RC,,,,,facility,outpatient,,,81.70000,23.69000,Aetna,First Health,,66.83,,,,,,,29.45,66.83,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),8723502,CDM,250,RC,,,,,facility,inpatient,,,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,9.36,20.70,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),8723502,CDM,250,RC,,,,,facility,outpatient,,,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,9.12,20.70,percent of total billed charges,
Sodium Phosphate Inj,8723470,CDM,250,RC,,,,,facility,inpatient,,,324.18000,94.01000,Aetna,First Health,,265.18,,,,,,,119.95,265.18,percent of total billed charges,
Sodium Phosphate Inj,8723470,CDM,250,RC,,,,,facility,outpatient,,,324.18000,94.01000,Aetna,First Health,,265.18,,,,,,,116.87,265.18,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,8723583,CDM,250,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.70,8.18,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,8723583,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,8723400,CDM,250,RC,,,,,facility,inpatient,,,107.10000,31.06000,Aetna,First Health,,87.61,,,,,,,39.63,87.61,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,8723400,CDM,250,RC,,,,,facility,outpatient,,,107.10000,31.06000,Aetna,First Health,,87.61,,,,,,,38.61,87.61,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,8724145,CDM,250,RC,,,,,facility,inpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,12.95,28.63,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,8724145,CDM,250,RC,,,,,facility,outpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,12.62,28.63,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,8723538,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,8723538,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Alcohol (Dehydrated) - 5g/5mL Inj,8725953,CDM,250,RC,,,,,facility,inpatient,,,4154.10000,1204.69000,Aetna,First Health,,3398.05,,,,,,,1537.02,3398.05,percent of total billed charges,
Alcohol (Dehydrated) - 5g/5mL Inj,8725953,CDM,250,RC,,,,,facility,outpatient,,,4154.10000,1204.69000,Aetna,First Health,,3398.05,,,,,,,1497.55,3398.05,percent of total billed charges,
Folic Acid 5mg/mL I,8723445,CDM,250,RC,J1808,HCPCS,,,facility,inpatient,,,615.28000,178.43000,Aetna,First Health,,503.30,,,,,,,227.65,503.30,percent of total billed charges,
Folic Acid 5mg/mL I,8723445,CDM,250,RC,J1808,HCPCS,,,facility,outpatient,,,615.28000,178.43000,Aetna,First Health,,503.30,,,,,,,0.04815,503.30,percent of total billed charges,
Urea 15g Oral Rec Powder,8725966,CDM,250,RC,,,,,facility,inpatient,,,30.80000,8.93000,Aetna,First Health,,25.19,,,,,,,11.40,25.19,percent of total billed charges,
Urea 15g Oral Rec Powder,8725966,CDM,250,RC,,,,,facility,outpatient,,,30.80000,8.93000,Aetna,First Health,,25.19,,,,,,,11.10,25.19,percent of total billed charges,
RAD- Iohexol 9mg/mL Oral  500mL,8726019,CDM,250,RC,,,,,facility,inpatient,,,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,31.76,70.23,percent of total billed charges,
RAD- Iohexol 9mg/mL Oral  500mL,8726019,CDM,250,RC,,,,,facility,outpatient,,,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,30.95,70.23,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,8726023,CDM,250,RC,,,,,facility,inpatient,,,2410.10000,698.93000,Aetna,First Health,,1971.46,,,,,,,891.74,1971.46,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,8726023,CDM,250,RC,,,,,facility,outpatient,,,2410.10000,698.93000,Aetna,First Health,,1971.46,,,,,,,868.84,1971.46,percent of total billed charges,
Tranexamic Acid 1g/100mL Bolus,8726057,CDM,250,RC,,,,,facility,inpatient,,,214.37000,62.17000,Aetna,First Health,,175.35,,,,,,,79.32,175.35,percent of total billed charges,
Tranexamic Acid 1g/100mL Bolus,8726057,CDM,250,RC,,,,,facility,outpatient,,,214.37000,62.17000,Aetna,First Health,,175.35,,,,,,,77.28,175.35,percent of total billed charges,
Lidocaine-NaHCO1%-8.4% IS 10mL,8726089,CDM,250,RC,,,,,facility,inpatient,,,50.10000,14.53000,Aetna,First Health,,40.98,,,,,,,18.54,40.98,percent of total billed charges,
Lidocaine-NaHCO1%-8.4% IS 10mL,8726089,CDM,250,RC,,,,,facility,outpatient,,,50.10000,14.53000,Aetna,First Health,,40.98,,,,,,,18.06,40.98,percent of total billed charges,
Multiple Vitamin Inj,8724124,CDM,250,RC,,,,,facility,inpatient,,,103.20000,29.93000,Aetna,First Health,,84.42,,,,,,,38.18,84.42,percent of total billed charges,
Multiple Vitamin Inj,8724124,CDM,250,RC,,,,,facility,outpatient,,,103.20000,29.93000,Aetna,First Health,,84.42,,,,,,,37.20,84.42,percent of total billed charges,
Selenium 2.5% 120mL Lotion,8723661,CDM,250,RC,,,,,facility,inpatient,,,140.20000,40.66000,Aetna,First Health,,114.68,,,,,,,51.87,114.68,percent of total billed charges,
Selenium 2.5% 120mL Lotion,8723661,CDM,250,RC,,,,,facility,outpatient,,,140.20000,40.66000,Aetna,First Health,,114.68,,,,,,,50.54,114.68,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,8723696,CDM,250,RC,,,,,facility,inpatient,,,319.40000,92.63000,Aetna,First Health,,261.27,,,,,,,118.18,261.27,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,8723696,CDM,250,RC,,,,,facility,outpatient,,,319.40000,92.63000,Aetna,First Health,,261.27,,,,,,,115.14,261.27,percent of total billed charges,
Bismuth Subgallate Pwd,8723879,CDM,250,RC,,,,,facility,inpatient,,,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.23,13.78,percent of total billed charges,
Bismuth Subgallate Pwd,8723879,CDM,250,RC,,,,,facility,outpatient,,,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.07,13.78,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),8723818,CDM,250,RC,,,,,facility,inpatient,,,42.44000,12.31000,Aetna,First Health,,34.72,,,,,,,15.70,34.72,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),8723818,CDM,250,RC,,,,,facility,outpatient,,,42.44000,12.31000,Aetna,First Health,,34.72,,,,,,,15.30,34.72,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,8724468,CDM,250,RC,,,,,facility,inpatient,,,196.35000,56.94000,Aetna,First Health,,160.61,,,,,,,72.65,160.61,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,8724468,CDM,250,RC,,,,,facility,outpatient,,,196.35000,56.94000,Aetna,First Health,,160.61,,,,,,,70.78,160.61,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,8723382,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,8723382,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,8723414,CDM,250,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,8723414,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
NICU- Sodium Acetate 2mEq/mL Inj,8725108,CDM,250,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,37.00,81.80,percent of total billed charges,
NICU- Sodium Acetate 2mEq/mL Inj,8725108,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,8725311,CDM,250,RC,,,,,facility,inpatient,,,53.65000,15.56000,Aetna,First Health,,43.89,,,,,,,19.85,43.89,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,8725311,CDM,250,RC,,,,,facility,outpatient,,,53.65000,15.56000,Aetna,First Health,,43.89,,,,,,,19.34,43.89,percent of total billed charges,
Anticoag Citr Dextr-A 1L (ACDA),8725309,CDM,250,RC,,,,,facility,inpatient,,,118.95000,34.50000,Aetna,First Health,,97.30,,,,,,,44.01,97.30,percent of total billed charges,
Anticoag Citr Dextr-A 1L (ACDA),8725309,CDM,250,RC,,,,,facility,outpatient,,,118.95000,34.50000,Aetna,First Health,,97.30,,,,,,,42.88,97.30,percent of total billed charges,
Na Citrate 4% 500mL Inj,8724092,CDM,250,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,37.00,81.80,percent of total billed charges,
Na Citrate 4% 500mL Inj,8724092,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
RX6308491,646493,CDM,250,RC,,,,,facility,inpatient,,,37.50000,10.88000,Aetna,First Health,,30.68,,,,,,,13.88,30.68,percent of total billed charges,
RX6308491,646493,CDM,250,RC,,,,,facility,outpatient,,,37.50000,10.88000,Aetna,First Health,,30.68,,,,,,,13.52,30.68,percent of total billed charges,
Sodium Bica 50mEq/50mL I,8723572,CDM,250,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,37.00,81.80,percent of total billed charges,
Sodium Bica 50mEq/50mL I,8723572,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),8724175,CDM,250,RC,,,,,facility,inpatient,,,1206.00000,349.74000,Aetna,First Health,,986.51,,,,,,,446.22,986.51,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),8724175,CDM,250,RC,,,,,facility,outpatient,,,1206.00000,349.74000,Aetna,First Health,,986.51,,,,,,,434.76,986.51,percent of total billed charges,
Indocyanine Green 25 mg I,8724169,CDM,250,RC,,,,,facility,inpatient,,,868.19000,251.78000,Aetna,First Health,,710.18,,,,,,,321.23,710.18,percent of total billed charges,
Indocyanine Green 25 mg I,8724169,CDM,250,RC,,,,,facility,outpatient,,,868.19000,251.78000,Aetna,First Health,,710.18,,,,,,,312.98,710.18,percent of total billed charges,
Zinc Chloride 1mg/mL I 10mL,8724753,CDM,250,RC,,,,,facility,inpatient,,,151.03000,43.80000,Aetna,First Health,,123.54,,,,,,,55.88,123.54,percent of total billed charges,
Zinc Chloride 1mg/mL I 10mL,8724753,CDM,250,RC,,,,,facility,outpatient,,,151.03000,43.80000,Aetna,First Health,,123.54,,,,,,,54.45,123.54,percent of total billed charges,
Fluorescein Ophth Test Strip,8724831,CDM,250,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.70,8.18,percent of total billed charges,
Fluorescein Ophth Test Strip,8724831,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,8724865,CDM,250,RC,,,,,facility,inpatient,,,77.85000,22.58000,Aetna,First Health,,63.68,,,,,,,28.80,63.68,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,8724865,CDM,250,RC,,,,,facility,outpatient,,,77.85000,22.58000,Aetna,First Health,,63.68,,,,,,,28.06,63.68,percent of total billed charges,
EPINEPHrine 1:1000 Topical Soln 30mL,8725964,CDM,250,RC,,,,,facility,inpatient,,,1812.50000,525.62000,Aetna,First Health,,1482.62,,,,,,,670.62,1482.62,percent of total billed charges,
EPINEPHrine 1:1000 Topical Soln 30mL,8725964,CDM,250,RC,,,,,facility,outpatient,,,1812.50000,525.62000,Aetna,First Health,,1482.62,,,,,,,653.41,1482.62,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),8724288,CDM,250,RC,,,,,facility,inpatient,,,27.30000,7.92000,Aetna,First Health,,22.33,,,,,,,10.10,22.33,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),8724288,CDM,250,RC,,,,,facility,outpatient,,,27.30000,7.92000,Aetna,First Health,,22.33,,,,,,,9.84,22.33,percent of total billed charges,
Isoflurane Inhl Sol 100mL,8723623,CDM,250,RC,,,,,facility,inpatient,,,169.95000,49.29000,Aetna,First Health,,139.02,,,,,,,62.88,139.02,percent of total billed charges,
Isoflurane Inhl Sol 100mL,8723623,CDM,250,RC,,,,,facility,outpatient,,,169.95000,49.29000,Aetna,First Health,,139.02,,,,,,,61.27,139.02,percent of total billed charges,
dilTIAZem 125mg /125mL Premix IVPB,8726035,CDM,250,RC,,,,,facility,inpatient,,,237.15000,68.77000,Aetna,First Health,,193.99,,,,,,,87.75,193.99,percent of total billed charges,
dilTIAZem 125mg /125mL Premix IVPB,8726035,CDM,250,RC,,,,,facility,outpatient,,,237.15000,68.77000,Aetna,First Health,,193.99,,,,,,,85.49,193.99,percent of total billed charges,
pyRIDostigmine 10mg/2mL I,8724313,CDM,250,RC,,,,,facility,inpatient,,,102.15000,29.62000,Aetna,First Health,,83.56,,,,,,,37.80,83.56,percent of total billed charges,
pyRIDostigmine 10mg/2mL I,8724313,CDM,250,RC,,,,,facility,outpatient,,,102.15000,29.62000,Aetna,First Health,,83.56,,,,,,,36.83,83.56,percent of total billed charges,
Docosanol 10%  2g TC,8724343,CDM,250,RC,,,,,facility,inpatient,,,218.85000,63.47000,Aetna,First Health,,179.02,,,,,,,80.97,179.02,percent of total billed charges,
Docosanol 10%  2g TC,8724343,CDM,250,RC,,,,,facility,outpatient,,,218.85000,63.47000,Aetna,First Health,,179.02,,,,,,,78.90,179.02,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),8724361,CDM,250,RC,,,,,facility,inpatient,,,74.65000,21.65000,Aetna,First Health,,61.06,,,,,,,27.62,61.06,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),8724361,CDM,250,RC,,,,,facility,outpatient,,,74.65000,21.65000,Aetna,First Health,,61.06,,,,,,,26.91,61.06,percent of total billed charges,
Lido 40mg/Epi 0.5mg/Tetr 5mg Top Gel 3mL,8726034,CDM,250,RC,,,,,facility,inpatient,,,89.61000,25.99000,Aetna,First Health,,73.30,,,,,,,33.16,73.30,percent of total billed charges,
Lido 40mg/Epi 0.5mg/Tetr 5mg Top Gel 3mL,8726034,CDM,250,RC,,,,,facility,outpatient,,,89.61000,25.99000,Aetna,First Health,,73.30,,,,,,,32.30,73.30,percent of total billed charges,
Miscellaneous Medication - Pharmacy,8726061,CDM,250,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,37.00,81.80,percent of total billed charges,
Miscellaneous Medication - Pharmacy,8726061,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Parenteral Nutrition Chg,8723895,CDM,251,RC,,,,,facility,inpatient,,,970.00000,281.30000,Aetna,First Health,,793.46,,,,,,,358.90,793.46,percent of total billed charges,
Parenteral Nutrition Chg,8723895,CDM,251,RC,,,,,facility,outpatient,,,970.00000,281.30000,Aetna,First Health,,793.46,,,,,,,349.69,793.46,percent of total billed charges,
Open Heart Kit,8723804,CDM,251,RC,,,,,facility,inpatient,,,4044.10000,1172.79000,Aetna,First Health,,3308.07,,,,,,,1496.32,3308.07,percent of total billed charges,
Open Heart Kit,8723804,CDM,251,RC,,,,,facility,outpatient,,,4044.10000,1172.79000,Aetna,First Health,,3308.07,,,,,,,1457.90,3308.07,percent of total billed charges,
Poractant 240mg/3mL Intratrach Inj,8724729,CDM,252,RC,,,,,facility,inpatient,,,4895.45000,1419.68000,Aetna,First Health,,4004.48,,,,,,,1811.32,4004.48,percent of total billed charges,
Poractant 240mg/3mL Intratrach Inj,8724729,CDM,252,RC,,,,,facility,outpatient,,,4895.45000,1419.68000,Aetna,First Health,,4004.48,,,,,,,1764.81,4004.48,percent of total billed charges,
NICU- Indomethacin 0.1mg/1mL IS,8725711,CDM,252,RC,,,,,facility,inpatient,,,3504.40000,1016.28000,Aetna,First Health,,2866.60,,,,,,,1296.63,2866.60,percent of total billed charges,
NICU- Indomethacin 0.1mg/1mL IS,8725711,CDM,252,RC,,,,,facility,outpatient,,,3504.40000,1016.28000,Aetna,First Health,,2866.60,,,,,,,1263.34,2866.60,percent of total billed charges,
NEOnatal Lipid 20% Inf,8724911,CDM,252,RC,,,,,facility,inpatient,,,128.50000,37.26000,Aetna,First Health,,105.11,,,,,,,47.55,105.11,percent of total billed charges,
NEOnatal Lipid 20% Inf,8724911,CDM,252,RC,,,,,facility,outpatient,,,128.50000,37.26000,Aetna,First Health,,105.11,,,,,,,46.32,105.11,percent of total billed charges,
D50W 50mL Inj Syr,8723571,CDM,258,RC,,,,,facility,inpatient,,,121.37000,35.20000,Aetna,First Health,,99.28,,,,,,,57.04,99.28,percent of total billed charges,
D50W 50mL Inj Syr,8723571,CDM,258,RC,,,,,facility,outpatient,,,121.37000,35.20000,Aetna,First Health,,99.28,,,,,,,43.75,99.28,percent of total billed charges,
D5.45NS 500mL,8723717,CDM,258,RC,J7030,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
D5.45NS 500mL,8723717,CDM,258,RC,J7030,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,1.92,81.80,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,8723735,CDM,258,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,8723735,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
0.45% Sodium Cl 500mL,8723722,CDM,258,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
0.45% Sodium Cl 500mL,8723722,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
0.45% Sodium Cl 1000mL,8723976,CDM,258,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
0.45% Sodium Cl 1000mL,8723976,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,8723746,CDM,258,RC,,,,,facility,inpatient,,,173.75000,50.39000,Aetna,First Health,,142.13,,,,,,,81.66,142.13,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,8723746,CDM,258,RC,,,,,facility,outpatient,,,173.75000,50.39000,Aetna,First Health,,142.13,,,,,,,62.64,142.13,percent of total billed charges,
NS Inj,8723972,CDM,258,RC,J7030,HCPCS,,,facility,inpatient,,,178.40000,51.74000,Aetna,First Health,,145.93,,,,,,,83.85,145.93,percent of total billed charges,
NS Inj,8723972,CDM,258,RC,J7030,HCPCS,,,facility,outpatient,,,178.40000,51.74000,Aetna,First Health,,145.93,,,,,,,1.92,145.93,percent of total billed charges,
D5W  250mL,8723685,CDM,258,RC,J7060,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
D5W  250mL,8723685,CDM,258,RC,J7060,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,1.69,81.80,percent of total billed charges,
D5.45NS+ KCl 10mEq 1000mL,8723750,CDM,258,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
D5.45NS+ KCl 10mEq 1000mL,8723750,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Dextrose 5% in Water 1L,8724128,CDM,258,RC,J7070,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
Dextrose 5% in Water 1L,8724128,CDM,258,RC,J7070,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,2.83,81.80,percent of total billed charges,
D5LR 1000 mL,8723740,CDM,258,RC,J7121,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
D5LR 1000 mL,8723740,CDM,258,RC,J7121,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,8.94,81.80,percent of total billed charges,
NS 1000mL Irrigation Bag-Sterile,8723730,CDM,258,RC,J7040,HCPCS,,,facility,inpatient,,,1037.70000,300.93000,Aetna,First Health,,848.84,,,,,,,487.72,848.84,percent of total billed charges,
NS 1000mL Irrigation Bag-Sterile,8723730,CDM,258,RC,J7040,HCPCS,,,facility,outpatient,,,1037.70000,300.93000,Aetna,First Health,,848.84,,,,,,,1.24,848.84,percent of total billed charges,
D5.45NS 1000mL,8723739,CDM,258,RC,J7030,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
D5.45NS 1000mL,8723739,CDM,258,RC,J7030,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,1.92,81.80,percent of total billed charges,
D10W 1000mL,8723741,CDM,258,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
D10W 1000mL,8723741,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
D10W 250mL,8723683,CDM,258,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
D10W 250mL,8723683,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
LR 500 mL,8723720,CDM,258,RC,J7120,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
LR 500 mL,8723720,CDM,258,RC,J7120,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,2.29,81.80,percent of total billed charges,
NS + 20mEq KCl 1000mL,8723733,CDM,258,RC,,,,,facility,inpatient,,,106.17000,30.79000,Aetna,First Health,,86.85,,,,,,,49.90,86.85,percent of total billed charges,
NS + 20mEq KCl 1000mL,8723733,CDM,258,RC,,,,,facility,outpatient,,,106.17000,30.79000,Aetna,First Health,,86.85,,,,,,,38.27,86.85,percent of total billed charges,
D5NS+20 mEq KCl/L,8723732,CDM,258,RC,,,,,facility,inpatient,,,108.50000,31.46000,Aetna,First Health,,88.75,,,,,,,50.99,88.75,percent of total billed charges,
D5NS+20 mEq KCl/L,8723732,CDM,258,RC,,,,,facility,outpatient,,,108.50000,31.46000,Aetna,First Health,,88.75,,,,,,,39.11,88.75,percent of total billed charges,
NS 500mL,8723721,CDM,258,RC,J7040,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
NS 500mL,8723721,CDM,258,RC,J7040,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,1.24,81.80,percent of total billed charges,
Dextrose 5%/Water PVC Free 250mL,8724363,CDM,258,RC,J7060,HCPCS,,,facility,inpatient,,,101.01000,29.29000,Aetna,First Health,,82.63,,,,,,,47.47,82.63,percent of total billed charges,
Dextrose 5%/Water PVC Free 250mL,8724363,CDM,258,RC,J7060,HCPCS,,,facility,outpatient,,,101.01000,29.29000,Aetna,First Health,,82.63,,,,,,,1.69,82.63,percent of total billed charges,
Dextrose 5% / Water PVC Free,8724364,CDM,258,RC,J7060,HCPCS,,,facility,inpatient,,,130.99000,37.99000,Aetna,First Health,,107.15,,,,,,,61.57,107.15,percent of total billed charges,
Dextrose 5% / Water PVC Free,8724364,CDM,258,RC,J7060,HCPCS,,,facility,outpatient,,,130.99000,37.99000,Aetna,First Health,,107.15,,,,,,,1.69,107.15,percent of total billed charges,
NS 500mL PVC Free,8724366,CDM,258,RC,J7040,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
NS 500mL PVC Free,8724366,CDM,258,RC,J7040,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,1.24,81.80,percent of total billed charges,
Dextose 5% in Water 50mL,8723596,CDM,258,RC,J7060,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,23.50,40.90,percent of total billed charges,
Dextose 5% in Water 50mL,8723596,CDM,258,RC,J7060,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,1.69,40.90,percent of total billed charges,
Water For Inj 50mL I,8723570,CDM,258,RC,A4216,HCPCS,,,facility,inpatient,,,32.16000,9.33000,Aetna,First Health,,26.31,,,,,,,15.12,26.31,percent of total billed charges,
Water For Inj 50mL I,8723570,CDM,258,RC,A4216,HCPCS,,,facility,outpatient,,,32.16000,9.33000,Aetna,First Health,,26.31,,,,,,,0.63000,26.31,percent of total billed charges,
D5.9NS 1000mL,8723743,CDM,258,RC,J7042,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
D5.9NS 1000mL,8723743,CDM,258,RC,J7042,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,1.26,81.80,percent of total billed charges,
0.45NS + 20mEq/L KCl 1000mL,8724162,CDM,258,RC,J3480,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
0.45NS + 20mEq/L KCl 1000mL,8724162,CDM,258,RC,J3480,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,0.11556,81.80,percent of total billed charges,
Sterile Water 1000mL,8723748,CDM,258,RC,A4217,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
Sterile Water 1000mL,8723748,CDM,258,RC,A4217,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,3.80,81.80,percent of total billed charges,
Dextrose 5% / Water/mL IV Room,8726119,CDM,258,RC,J7070,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,11.75,20.45,percent of total billed charges,
Dextrose 5% / Water/mL IV Room,8726119,CDM,258,RC,J7070,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,2.83,20.45,percent of total billed charges,
LR 1000mL,8723744,CDM,258,RC,J7120,HCPCS,,,facility,inpatient,,,100.01000,29.00000,Aetna,First Health,,81.81,,,,,,,47.00,81.81,percent of total billed charges,
LR 1000mL,8723744,CDM,258,RC,J7120,HCPCS,,,facility,outpatient,,,100.01000,29.00000,Aetna,First Health,,81.81,,,,,,,2.29,81.81,percent of total billed charges,
NS 10mL PF Inj,8724129,CDM,258,RC,,,,,facility,inpatient,,,40.52000,11.75000,Aetna,First Health,,33.15,,,,,,,19.04,33.15,percent of total billed charges,
NS 10mL PF Inj,8724129,CDM,258,RC,,,,,facility,outpatient,,,40.52000,11.75000,Aetna,First Health,,33.15,,,,,,,14.61,33.15,percent of total billed charges,
"Heparin 5,000 unit/0.5mL Inj Syr",9028090,CDM,258,RC,J1644,HCPCS,,,facility,inpatient,,,38.22000,11.08000,Aetna,First Health,,31.26,,,,,,,17.96,31.26,percent of total billed charges,
"Heparin 5,000 unit/0.5mL Inj Syr",9028090,CDM,258,RC,J1644,HCPCS,,,facility,outpatient,,,38.22000,11.08000,Aetna,First Health,,31.26,,,,,,,0.17334,31.26,percent of total billed charges,
Water For Inj 10mL I,8723393,CDM,258,RC,A4216,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,11.75,20.45,percent of total billed charges,
Water For Inj 10mL I,8723393,CDM,258,RC,A4216,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.63000,20.45,percent of total billed charges,
NEOnatal TPN Starter Bag,8726082,CDM,258,RC,,,,,facility,inpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,100.11,174.23,percent of total billed charges,
NEOnatal TPN Starter Bag,8726082,CDM,258,RC,,,,,facility,outpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,76.79,174.23,percent of total billed charges,
D50W 50mL,8723573,CDM,258,RC,,,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,23.50,40.90,percent of total billed charges,
D50W 50mL,8723573,CDM,258,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
NS 1000mL PVC Free,8724839,CDM,258,RC,J7030,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
NS 1000mL PVC Free,8724839,CDM,258,RC,J7030,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,1.92,81.80,percent of total billed charges,
NICU- Heparin 1unit/mL IS 2mL(Neonatal),8724844,CDM,258,RC,J1642,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,11.75,20.45,percent of total billed charges,
NICU- Heparin 1unit/mL IS 2mL(Neonatal),8724844,CDM,258,RC,J1642,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.01926,20.45,percent of total billed charges,
NICU- NEOnatal TPN Infusion,8724910,CDM,258,RC,,,,,facility,inpatient,,,836.80000,242.67000,Aetna,First Health,,684.50,,,,,,,393.30,684.50,percent of total billed charges,
NICU- NEOnatal TPN Infusion,8724910,CDM,258,RC,,,,,facility,outpatient,,,836.80000,242.67000,Aetna,First Health,,684.50,,,,,,,301.67,684.50,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),8724905,CDM,258,RC,A4216,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,11.75,20.45,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),8724905,CDM,258,RC,A4216,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.63000,20.45,percent of total billed charges,
0.45% Sodium Cl 250mL,8724936,CDM,258,RC,,,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,47.00,81.80,percent of total billed charges,
0.45% Sodium Cl 250mL,8724936,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
IV Infusion Sequential Drug,9094166,CDM,260,RC,96367,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
IV Infusion Sequential Drug,9094166,CDM,260,RC,96367,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,62.50,305.93,percent of total billed charges,
IV Infusion First Drug Each Hour,9092696,CDM,260,RC,96366,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
IV Infusion First Drug Each Hour,9092696,CDM,260,RC,96366,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,40.51,305.93,percent of total billed charges,
IV Infusion Concurrent Drug,9094167,CDM,260,RC,96368,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
IV Infusion Concurrent Drug,9094167,CDM,260,RC,96368,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,134.83,305.93,percent of total billed charges,
IV Push Additional drug,9094168,CDM,260,RC,96375,HCPCS,,,facility,inpatient,,,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,223.80,305.11,percent of total billed charges,
IV Push Additional drug,9094168,CDM,260,RC,96375,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,40.51,305.11,percent of total billed charges,
Hydration IV Infusion Each Hour,9094170,CDM,260,RC,96361,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
Hydration IV Infusion Each Hour,9094170,CDM,260,RC,96361,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,40.51,305.93,percent of total billed charges,
IV Infusion Initial First Hour,9092745,CDM,260,RC,96365,HCPCS,,,facility,inpatient,,,662.00000,191.98000,Aetna,First Health,,541.52,,,,,,,397.20,541.52,percent of total billed charges,
IV Infusion Initial First Hour,9092745,CDM,260,RC,96365,HCPCS,,,facility,outpatient,,,662.00000,191.98000,Aetna,First Health,,541.52,,,,,,,185.00,562.35,percent of total billed charges,
IV Push Sequential,9094169,CDM,260,RC,96376,HCPCS,,,facility,inpatient,,,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,223.80,305.11,percent of total billed charges,
IV Push Sequential,9094169,CDM,260,RC,96376,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,134.47,305.11,percent of total billed charges,
Initial IV Hydration First Hour,9094312,CDM,260,RC,96360,HCPCS,,,facility,inpatient,,,575.00000,166.75000,Aetna,First Health,,470.35,,,,,,,345.00,470.35,percent of total billed charges,
Initial IV Hydration First Hour,9094312,CDM,260,RC,96360,HCPCS,,,facility,outpatient,,,575.00000,166.75000,Aetna,First Health,,470.35,,,,,,,185.00,562.35,percent of total billed charges,
IV Push Initial,9092748,CDM,260,RC,96374,HCPCS,,,facility,inpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,396.60,540.70,percent of total billed charges,
IV Push Initial,9092748,CDM,260,RC,96374,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,185.00,562.35,percent of total billed charges,
IV Infusion 8Hrs Or More,9092697,CDM,260,RC,C8957,HCPCS,,,facility,inpatient,,,2936.00000,851.44000,Aetna,First Health,,2401.65,,,,,,,1761.60,2401.65,percent of total billed charges,
IV Infusion 8Hrs Or More,9092697,CDM,260,RC,C8957,HCPCS,,,facility,outpatient,,,2936.00000,851.44000,Aetna,First Health,,2401.65,,,,,,,213.05,2401.65,percent of total billed charges,
IV Infusion Initial Of Pts Own,9094171,CDM,260,RC,96365,HCPCS,,,facility,inpatient,,,662.00000,191.98000,Aetna,First Health,FB,541.52,,,,,,,397.20,541.52,percent of total billed charges,
IV Infusion Initial Of Pts Own,9094171,CDM,260,RC,96365,HCPCS,,,facility,outpatient,,,662.00000,191.98000,Aetna,First Health,FB,541.52,,,,,,,185.00,562.35,percent of total billed charges,
IV Infusion Ea Hr Of Pts Own Med,9094314,CDM,260,RC,96366,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,FB,305.93,,,,,,,224.40,305.93,percent of total billed charges,
IV Infusion Ea Hr Of Pts Own Med,9094314,CDM,260,RC,96366,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,FB,305.93,,,,,,,40.51,305.93,percent of total billed charges,
IV Infusion Sequent Of Pts Own,9092746,CDM,260,RC,96367,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,FB,305.93,,,,,,,224.40,305.93,percent of total billed charges,
IV Infusion Sequent Of Pts Own,9092746,CDM,260,RC,96367,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,FB,305.93,,,,,,,62.50,305.93,percent of total billed charges,
IV Infusion Concurrent Of Pts Own,9092747,CDM,260,RC,96368,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,FB,305.93,,,,,,,224.40,305.93,percent of total billed charges,
IV Infusion Concurrent Of Pts Own,9092747,CDM,260,RC,96368,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,FB,305.93,,,,,,,134.83,305.93,percent of total billed charges,
IV Infusion 8Hrs Of Pts Own Med,9094320,CDM,260,RC,C8957,HCPCS,,,facility,inpatient,,,2295.00000,665.55000,Aetna,First Health,,1877.31,,,,,,,1377.00,1877.31,percent of total billed charges,
IV Infusion 8Hrs Of Pts Own Med,9094320,CDM,260,RC,C8957,HCPCS,,,facility,outpatient,,,2295.00000,665.55000,Aetna,First Health,,1877.31,,,,,,,213.05,1877.31,percent of total billed charges,
IV Push Initial Of Pts Own Med,9094172,CDM,260,RC,96374,HCPCS,,,facility,inpatient,,,661.00000,191.69000,Aetna,First Health,FB,540.70,,,,,,,396.60,540.70,percent of total billed charges,
IV Push Initial Of Pts Own Med,9094172,CDM,260,RC,96374,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,First Health,FB,540.70,,,,,,,185.00,562.35,percent of total billed charges,
IV Push Of Pts Own Med,9094315,CDM,260,RC,96375,HCPCS,,,facility,inpatient,,,373.00000,108.17000,Aetna,First Health,FB,305.11,,,,,,,223.80,305.11,percent of total billed charges,
IV Push Of Pts Own Med,9094315,CDM,260,RC,96375,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,First Health,FB,305.11,,,,,,,40.51,305.11,percent of total billed charges,
IV Push Sequential of Pts Own Med,9092749,CDM,260,RC,96376,HCPCS,,,facility,inpatient,,,373.00000,108.17000,Aetna,First Health,FB,305.11,,,,,,,223.80,305.11,percent of total billed charges,
IV Push Sequential of Pts Own Med,9092749,CDM,260,RC,96376,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,First Health,FB,305.11,,,,,,,134.47,305.11,percent of total billed charges,
Irrigate Implanted Delivery Device Not pre or post injection,8997081,CDM,260,RC,96523,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Irrigate Implanted Delivery Device Not pre or post injection,8997081,CDM,260,RC,96523,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,52.15,213.50,percent of total billed charges,
Irrigate Implanted Delivery Device,8999394,CDM,260,RC,96523,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Irrigate Implanted Delivery Device,8999394,CDM,260,RC,96523,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,52.15,213.50,percent of total billed charges,
PROGRAMMER,7697116,CDM,270,RC,C1787,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,2467.50,3364.03,percent of total billed charges,
PROGRAMMER,7697116,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
CHARGING SYSTEM,7695290,CDM,270,RC,L8689,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,4410.00,6012.30,percent of total billed charges,
CHARGING SYSTEM,7695290,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2113.62,6012.30,percent of total billed charges,
CHARGING SYSTEM,7969749,CDM,270,RC,L8689,HCPCS,,,facility,inpatient,,,5465.25000,1584.92000,Aetna,First Health,,4470.57,,,,,,,3279.15,4470.57,percent of total billed charges,
CHARGING SYSTEM,7969749,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,5465.25000,1584.92000,Aetna,First Health,,4470.57,,,,,,,1970.22,4470.57,percent of total billed charges,
PROGRAMMER,7736629,CDM,270,RC,C1787,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,1104.00,1505.12,percent of total billed charges,
PROGRAMMER,7736629,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
PROGRAMMER,7924581,CDM,270,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,2572.50,3507.18,percent of total billed charges,
PROGRAMMER,7924581,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INTERSTIM PROGRAMMER,7968188,CDM,270,RC,C1787,HCPCS,,,facility,inpatient,,,4952.50000,1436.22000,Aetna,First Health,,4051.14,,,,,,,2971.50,4051.14,percent of total billed charges,
INTERSTIM PROGRAMMER,7968188,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,4952.50000,1436.22000,Aetna,First Health,,4051.14,,,,,,,1785.38,4051.14,percent of total billed charges,
CATHETER DILATOR,7965295,CDM,270,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,390.58,532.49,percent of total billed charges,
CATHETER DILATOR,7965295,CDM,270,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
CHARGING SYSTEM IN KIT,8339348,CDM,270,RC,L8689,HCPCS,,,facility,inpatient,,,56246.00000,16311.34000,Aetna,First Health,,46009.23,,,,,,,33747.60,46009.23,percent of total billed charges,
CHARGING SYSTEM IN KIT,8339348,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,56246.00000,16311.34000,Aetna,First Health,,46009.23,,,,,,,2113.62,46009.23,percent of total billed charges,
ROD,8437301,CDM,270,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,744.00,1014.32,percent of total billed charges,
ROD,8437301,CDM,270,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
RECHARGER,9084224,CDM,270,RC,L8689,HCPCS,,,facility,inpatient,,,5465.25000,1584.92000,Aetna,First Health,,4470.57,,,,,,,3279.15,4470.57,percent of total billed charges,
RECHARGER,9084224,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,5465.25000,1584.92000,Aetna,First Health,,4470.57,,,,,,,1970.22,4470.57,percent of total billed charges,
SCREW TORX,9093619,CDM,270,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,391.50,533.75,percent of total billed charges,
SCREW TORX,9093619,CDM,270,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
Catheter 5fr,9082639,CDM,270,RC,C1887,HCPCS,,,facility,inpatient,,,88.52000,25.67000,Aetna,First Health,,72.41,,,,,,,53.11,72.41,percent of total billed charges,
Catheter 5fr,9082639,CDM,270,RC,C1887,HCPCS,,,facility,outpatient,,,88.52000,25.67000,Aetna,First Health,,72.41,,,,,,,31.91,72.41,percent of total billed charges,
Catheter 12fr,9098580,CDM,270,RC,C1887,HCPCS,,,facility,inpatient,,,28732.50000,8332.42000,Aetna,First Health,,23503.19,,,,,,,17239.50,23503.19,percent of total billed charges,
Catheter 12fr,9098580,CDM,270,RC,C1887,HCPCS,,,facility,outpatient,,,28732.50000,8332.42000,Aetna,First Health,,23503.19,,,,,,,10358.07,23503.19,percent of total billed charges,
CAPSULE PILLCAM ENDOSCOPY SB 3,7694336,CDM,272,RC,,,,,facility,inpatient,,,2604.40000,755.28000,Aetna,First Health,,2130.40,,,,,,,1562.64,2130.40,percent of total billed charges,
CAPSULE PILLCAM ENDOSCOPY SB 3,7694336,CDM,272,RC,,,,,facility,outpatient,,,2604.40000,755.28000,Aetna,First Health,,2130.40,,,,,,,938.89,2130.40,percent of total billed charges,
MORCELLATOR,7696744,CDM,272,RC,C1782,HCPCS,,,facility,inpatient,,,2426.60000,703.71000,Aetna,First Health,,1984.96,,,,,,,1455.96,1984.96,percent of total billed charges,
MORCELLATOR,7696744,CDM,272,RC,C1782,HCPCS,,,facility,outpatient,,,2426.60000,703.71000,Aetna,First Health,,1984.96,,,,,,,874.79,1984.96,percent of total billed charges,
MORCELLATOR,8328437,CDM,272,RC,C1782,HCPCS,,,facility,inpatient,,,1841.91000,534.15000,Aetna,First Health,,1506.68,,,,,,,1105.15,1506.68,percent of total billed charges,
MORCELLATOR,8328437,CDM,272,RC,C1782,HCPCS,,,facility,outpatient,,,1841.91000,534.15000,Aetna,First Health,,1506.68,,,,,,,664.01,1506.68,percent of total billed charges,
HEMOSPRAY,8170766,CDM,272,RC,C1052,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,5490.00,7484.70,percent of total billed charges,
HEMOSPRAY,8170766,CDM,272,RC,C1052,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
HEMOSPRAY,8170767,CDM,272,RC,C1052,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,5490.00,7484.70,percent of total billed charges,
HEMOSPRAY,8170767,CDM,272,RC,C1052,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
INCISION MANAGEMENT,7972134,CDM,272,RC,A6550,HCPCS,,,facility,inpatient,,,2676.00000,776.04000,Aetna,First Health,,2188.97,,,,,,,1605.60,2188.97,percent of total billed charges,
INCISION MANAGEMENT,7972134,CDM,272,RC,A6550,HCPCS,,,facility,outpatient,,,2676.00000,776.04000,Aetna,First Health,,2188.97,,,,,,,31.78,2188.97,percent of total billed charges,
MORCELLATOR,8168049,CDM,272,RC,C1782,HCPCS,,,facility,inpatient,,,1220.00000,353.80000,Aetna,First Health,,997.96,,,,,,,732.00,997.96,percent of total billed charges,
MORCELLATOR,8168049,CDM,272,RC,C1782,HCPCS,,,facility,outpatient,,,1220.00000,353.80000,Aetna,First Health,,997.96,,,,,,,439.81,997.96,percent of total billed charges,
HANDPIECE,8950540,CDM,272,RC,C2596,HCPCS,,,facility,inpatient,,,12720.00000,3688.80000,Aetna,First Health,,10404.96,,,,,,,7632.00,10404.96,percent of total billed charges,
HANDPIECE,8950540,CDM,272,RC,C2596,HCPCS,,,facility,outpatient,,,12720.00000,3688.80000,Aetna,First Health,,10404.96,,,,,,,4585.56,10404.96,percent of total billed charges,
KIT PROCEDURE MILD,7695188,CDM,272,RC,C1889,HCPCS,,,facility,inpatient,,,12579.00000,3647.91000,Aetna,First Health,,10289.62,,,,,,,7547.40,10289.62,percent of total billed charges,
KIT PROCEDURE MILD,7695188,CDM,272,RC,C1889,HCPCS,,,facility,outpatient,,,12579.00000,3647.91000,Aetna,First Health,,10289.62,,,,,,,4534.73,10289.62,percent of total billed charges,
HEMOSTATIC NEXPOWDER,9012618,CDM,272,RC,C1052,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,2158.80,2943.16,percent of total billed charges,
HEMOSTATIC NEXPOWDER,9012618,CDM,272,RC,C1052,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1297.08,2943.16,percent of total billed charges,
Catheter Mapping,9088702,CDM,272,RC,C1730,HCPCS,,,facility,inpatient,,,756.00000,219.24000,Aetna,First Health,,618.41,,,,,,,453.60,618.41,percent of total billed charges,
Catheter Mapping,9088702,CDM,272,RC,C1730,HCPCS,,,facility,outpatient,,,756.00000,219.24000,Aetna,First Health,,618.41,,,,,,,272.54,9959.00,percent of total billed charges,
Introducer,9091167,CDM,272,RC,C1766,HCPCS,,,facility,inpatient,,,3601.50000,1044.44000,Aetna,First Health,,2946.03,,,,,,,2160.90,2946.03,percent of total billed charges,
Introducer,9091167,CDM,272,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,First Health,,2946.03,,,,,,,1298.34,2946.03,percent of total billed charges,
Catheter,9088876,CDM,272,RC,C1733,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,864.00,1177.92,percent of total billed charges,
Catheter,9088876,CDM,272,RC,C1733,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,9959.00,percent of total billed charges,
CATHETER,9088875,CDM,272,RC,C1887,HCPCS,,,facility,inpatient,,,3220.00000,933.80000,Aetna,First Health,,2633.96,,,,,,,1932.00,2633.96,percent of total billed charges,
CATHETER,9088875,CDM,272,RC,C1887,HCPCS,,,facility,outpatient,,,3220.00000,933.80000,Aetna,First Health,,2633.96,,,,,,,1160.81,2633.96,percent of total billed charges,
KIT PROCEDURE MILD,9098522,CDM,272,RC,C1889,HCPCS,,,facility,inpatient,,,12579.00000,3647.91000,Aetna,First Health,,10289.62,,,,,,,7547.40,10289.62,percent of total billed charges,
KIT PROCEDURE MILD,9098522,CDM,272,RC,C1889,HCPCS,,,facility,outpatient,,,12579.00000,3647.91000,Aetna,First Health,,10289.62,,,,,,,4534.73,10289.62,percent of total billed charges,
PROBE,9180595,CDM,272,RC,C2618,HCPCS,,,facility,inpatient,,,2276.00000,660.04000,Aetna,First Health,,1861.77,,,,,,,1365.60,1861.77,percent of total billed charges,
PROBE,9180595,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,2276.00000,660.04000,Aetna,First Health,,1861.77,,,,,,,820.50,1861.77,percent of total billed charges,
Ablation Antenna,9184498,CDM,272,RC,C2618,HCPCS,,,facility,inpatient,,,7935.00000,2301.15000,Aetna,First Health,,6490.83,,,,,,,4761.00,6490.83,percent of total billed charges,
Ablation Antenna,9184498,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,First Health,,6490.83,,,,,,,2860.57,6490.83,percent of total billed charges,
Ablation Antenna,9182903,CDM,272,RC,C2618,HCPCS,,,facility,inpatient,,,7935.00000,2301.15000,Aetna,First Health,,6490.83,,,,,,,4761.00,6490.83,percent of total billed charges,
Ablation Antenna,9182903,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,First Health,,6490.83,,,,,,,2860.57,6490.83,percent of total billed charges,
Ablation Needle,9196884,CDM,272,RC,C2618,HCPCS,,,facility,inpatient,,,7935.00000,2301.15000,Aetna,First Health,,6490.83,,,,,,,4761.00,6490.83,percent of total billed charges,
Ablation Needle,9196884,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,First Health,,6490.83,,,,,,,2860.57,6490.83,percent of total billed charges,
Enteral Feeding Tube Declogging Kit,9074404,CDM,272,RC,,,,,facility,inpatient,,,112.00000,32.48000,Aetna,First Health,,91.62,,,,,,,67.20,91.62,percent of total billed charges,
Enteral Feeding Tube Declogging Kit,9074404,CDM,272,RC,,,,,facility,outpatient,,,112.00000,32.48000,Aetna,First Health,,91.62,,,,,,,40.38,91.62,percent of total billed charges,
OTS Orthotic Elbow Static Custom,4922320,CDM,274,RC,L3702,HCPCS,,,facility,inpatient,,,523.00000,151.67000,Aetna,First Health,,427.81,,,,,,,188.54,427.81,percent of total billed charges,
OTS Orthotic Elbow Static Custom,4922320,CDM,274,RC,L3702,HCPCS,,,facility,outpatient,,,523.00000,151.67000,Aetna,First Health,,427.81,,,,,,,168.41,427.81,percent of total billed charges,
OTS Orthotic Elbow Dynamic Custom,4922323,CDM,274,RC,L3730,HCPCS,,,facility,inpatient,,,1171.00000,339.59000,Aetna,First Health,,957.88,,,,,,,422.15,957.88,percent of total billed charges,
OTS Orthotic Elbow Dynamic Custom,4922323,CDM,274,RC,L3730,HCPCS,,,facility,outpatient,,,1171.00000,339.59000,Aetna,First Health,,957.88,,,,,,,377.06,1207.08,percent of total billed charges,
OTS Orthotic Elbow Wrist Hand Sta,4922326,CDM,274,RC,L3763,HCPCS,,,facility,inpatient,,,798.00000,231.42000,Aetna,First Health,,652.76,,,,,,,287.68,652.76,percent of total billed charges,
OTS Orthotic Elbow Wrist Hand Sta,4922326,CDM,274,RC,L3763,HCPCS,,,facility,outpatient,,,798.00000,231.42000,Aetna,First Health,,652.76,,,,,,,256.96,790.13,percent of total billed charges,
OT Splint Hand Wrist Elbow Dynamic Units,8185135,CDM,274,RC,L3763,HCPCS,,,facility,inpatient,,,798.00000,231.42000,Aetna,First Health,,652.76,,,,,,,287.68,652.76,percent of total billed charges,
OT Splint Hand Wrist Elbow Dynamic Units,8185135,CDM,274,RC,L3763,HCPCS,,,facility,outpatient,,,798.00000,231.42000,Aetna,First Health,,652.76,,,,,,,256.96,790.13,percent of total billed charges,
OTS Orthotic Elbow Wrist Hand Dyn,4922329,CDM,274,RC,L3764,HCPCS,,,facility,inpatient,,,838.00000,243.02000,Aetna,First Health,,685.48,,,,,,,302.10,685.48,percent of total billed charges,
OTS Orthotic Elbow Wrist Hand Dyn,4922329,CDM,274,RC,L3764,HCPCS,,,facility,outpatient,,,838.00000,243.02000,Aetna,First Health,,685.48,,,,,,,269.84,830.76,percent of total billed charges,
OT Splint Hand Wrist Elbow Static Units,8185127,CDM,274,RC,L3764,HCPCS,,,facility,inpatient,,,838.00000,243.02000,Aetna,First Health,,685.48,,,,,,,302.10,685.48,percent of total billed charges,
OT Splint Hand Wrist Elbow Static Units,8185127,CDM,274,RC,L3764,HCPCS,,,facility,outpatient,,,838.00000,243.02000,Aetna,First Health,,685.48,,,,,,,269.84,830.76,percent of total billed charges,
OTS Orthotic Wrist Hand Finger Static Custom,4922332,CDM,274,RC,L3808,HCPCS,,,facility,inpatient,,,428.00000,124.12000,Aetna,First Health,,350.10,,,,,,,154.29,350.10,percent of total billed charges,
OTS Orthotic Wrist Hand Finger Static Custom,4922332,CDM,274,RC,L3808,HCPCS,,,facility,outpatient,,,428.00000,124.12000,Aetna,First Health,,350.10,,,,,,,137.82,382.44,percent of total billed charges,
OTS Orthotic Wrist Hand Finger Dynamic Custom,4922335,CDM,274,RC,L3806,HCPCS,,,facility,inpatient,,,728.00000,211.12000,Aetna,First Health,,595.50,,,,,,,262.44,595.50,percent of total billed charges,
OTS Orthotic Wrist Hand Finger Dynamic Custom,4922335,CDM,274,RC,L3806,HCPCS,,,facility,outpatient,,,728.00000,211.12000,Aetna,First Health,,595.50,,,,,,,234.42,595.50,percent of total billed charges,
OTS Orthotic Wrist Hand Static Custom,4922338,CDM,274,RC,L3906,HCPCS,,,facility,inpatient,,,453.00000,131.37000,Aetna,First Health,,370.55,,,,,,,163.31,370.55,percent of total billed charges,
OTS Orthotic Wrist Hand Static Custom,4922338,CDM,274,RC,L3906,HCPCS,,,facility,outpatient,,,453.00000,131.37000,Aetna,First Health,,370.55,,,,,,,145.87,449.45,percent of total billed charges,
OTS Orthotic Wrist Hand Dynam Custom,4922321,CDM,274,RC,L3905,HCPCS,,,facility,inpatient,,,1060.00000,307.40000,Aetna,First Health,,867.08,,,,,,,382.13,867.08,percent of total billed charges,
OTS Orthotic Wrist Hand Dynam Custom,4922321,CDM,274,RC,L3905,HCPCS,,,facility,outpatient,,,1060.00000,307.40000,Aetna,First Health,,867.08,,,,,,,341.32,1103.73,percent of total billed charges,
OTS Orthotic Hand Finger Stat Cu,4922324,CDM,274,RC,L3913,HCPCS,,,facility,inpatient,,,370.00000,107.30000,Aetna,First Health,,302.66,,,,,,,133.38,302.66,percent of total billed charges,
OTS Orthotic Hand Finger Stat Cu,4922324,CDM,274,RC,L3913,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,First Health,,302.66,,,,,,,119.14,302.66,percent of total billed charges,
OTS Orthotic Hand Finger Dynamic,4922327,CDM,274,RC,L3921,HCPCS,,,facility,inpatient,,,596.00000,172.84000,Aetna,First Health,,487.53,,,,,,,214.86,487.53,percent of total billed charges,
OTS Orthotic Hand Finger Dynamic,4922327,CDM,274,RC,L3921,HCPCS,,,facility,outpatient,,,596.00000,172.84000,Aetna,First Health,,487.53,,,,,,,191.91,487.53,percent of total billed charges,
OTS Orthotic Hand Static Custom,4922330,CDM,274,RC,L3919,HCPCS,,,facility,inpatient,,,304.00000,88.16000,Aetna,First Health,,248.67,,,,,,,109.59,248.67,percent of total billed charges,
OTS Orthotic Hand Static Custom,4922330,CDM,274,RC,L3919,HCPCS,,,facility,outpatient,,,304.00000,88.16000,Aetna,First Health,,248.67,,,,,,,97.89,301.44,percent of total billed charges,
OTS Orthotic Finger Static Custom,4922333,CDM,274,RC,L3933,HCPCS,,,facility,inpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,86.52,196.32,percent of total billed charges,
OTS Orthotic Finger Static Custom,4922333,CDM,274,RC,L3933,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,77.28,237.46,percent of total billed charges,
OTS Orthotic Finger Dynamic Cust,4922336,CDM,274,RC,L3935,HCPCS,,,facility,inpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,96.25,218.41,percent of total billed charges,
OTS Orthotic Finger Dynamic Cust,4922336,CDM,274,RC,L3935,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,85.97,245.89,percent of total billed charges,
OTS Orthotic Ankle Foot Stat Cus,4922339,CDM,274,RC,L1940,HCPCS,,,facility,inpatient,,,535.00000,155.15000,Aetna,First Health,,437.63,,,,,,,192.87,437.63,percent of total billed charges,
OTS Orthotic Ankle Foot Stat Cus,4922339,CDM,274,RC,L1940,HCPCS,,,facility,outpatient,,,535.00000,155.15000,Aetna,First Health,,437.63,,,,,,,172.27,622.32,percent of total billed charges,
OTS Orthotic Shoulder Prefab,4922322,CDM,274,RC,L3670,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,55.88,126.79,percent of total billed charges,
OTS Orthotic Shoulder Prefab,4922322,CDM,274,RC,L3670,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,49.91,169.54,percent of total billed charges,
OTS Orthotic Wrist Hand Finger Prefab,4922325,CDM,274,RC,L3807,HCPCS,,,facility,inpatient,,,281.00000,81.49000,Aetna,First Health,,229.86,,,,,,,101.30,229.86,percent of total billed charges,
OTS Orthotic Wrist Hand Finger Prefab,4922325,CDM,274,RC,L3807,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,First Health,,229.86,,,,,,,90.48,278.25,percent of total billed charges,
OTS Orthotic Wrist Hand Prefab,4922328,CDM,274,RC,L3908,HCPCS,,,facility,inpatient,,,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,27.40,62.17,percent of total billed charges,
OTS Orthotic Wrist Hand Prefab,4922328,CDM,274,RC,L3908,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,24.47,68.45,percent of total billed charges,
OTS Orthotic Hand Finger Glove Pr,4922331,CDM,274,RC,L3912,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,48.31,109.61,percent of total billed charges,
OTS Orthotic Hand Finger Glove Pr,4922331,CDM,274,RC,L3912,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,43.15,131.94,percent of total billed charges,
OTS Orthotic Hand Finger Prefab,4922334,CDM,274,RC,L3923,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,48.31,109.61,percent of total billed charges,
OTS Orthotic Hand Finger Prefab,4922334,CDM,274,RC,L3923,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,43.15,109.61,percent of total billed charges,
OTS Orthotic Finger Prefab Static,4922337,CDM,274,RC,L3927,HCPCS,,,facility,inpatient,,,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,27.40,62.17,percent of total billed charges,
OTS Orthotic Finger Prefab Static,4922337,CDM,274,RC,L3927,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,24.47,62.17,percent of total billed charges,
OTS Orthotic Finger Prefab Dyn,4922340,CDM,274,RC,L3925,HCPCS,,,facility,inpatient,,,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,91.21,206.95,percent of total billed charges,
OTS Orthotic Finger Prefab Dyn,4922340,CDM,274,RC,L3925,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,71.46,206.95,percent of total billed charges,
OT Orthotic Thumb Spica,8235904,CDM,274,RC,L3809,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,93.73,212.68,percent of total billed charges,
OT Orthotic Thumb Spica,8235904,CDM,274,RC,L3809,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,83.72,278.25,percent of total billed charges,
OT Orthotic Ulnar Drift,8235912,CDM,274,RC,L3917,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,43.98,99.80,percent of total billed charges,
OT Orthotic Ulnar Drift,8235912,CDM,274,RC,L3917,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,39.28,117.52,percent of total billed charges,
OT Orthotic Cool Comfort,8235908,CDM,274,RC,L3924,HCPCS,,,facility,inpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,33.89,76.89,percent of total billed charges,
OT Orthotic Cool Comfort,8235908,CDM,274,RC,L3924,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,30.27,99.87,percent of total billed charges,
OTS Orthotic Humerus,8282801,CDM,274,RC,L3671,HCPCS,,,facility,inpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,605.64,1374.24,percent of total billed charges,
OTS Orthotic Humerus,8282801,CDM,274,RC,L3671,HCPCS,,,facility,outpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,540.96,1374.24,percent of total billed charges,
ANCHOR,9116839,CDM,275,RC,C1713,HCPCS,,,facility,inpatient,,,3810.21000,1104.96000,Aetna,First Health,,3116.75,,,,,,,1373.58,3116.75,percent of total billed charges,
ANCHOR,9116839,CDM,275,RC,C1713,HCPCS,,,facility,outpatient,,,3810.21000,1104.96000,Aetna,First Health,,3116.75,,,,,,,1226.89,3116.75,percent of total billed charges,
CATHETER URETERAL,7694745,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1384.72000,401.57000,Aetna,First Health,,1132.70,,,,,,,499.19,1132.70,percent of total billed charges,
CATHETER URETERAL,7694745,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1384.72000,401.57000,Aetna,First Health,,1132.70,,,,,,,445.88,1132.70,percent of total billed charges,
Lead Pacemaker,8063006,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
Lead Pacemaker,8063006,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
LEAD,8400632,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
LEAD,8400632,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
TISSUE GRAFT DURAL,7694890,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,3527.83000,1023.07000,Aetna,First Health,,2885.76,,,,,,,1271.78,2885.76,percent of total billed charges,
TISSUE GRAFT DURAL,7694890,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,3527.83000,1023.07000,Aetna,First Health,,2885.76,,,,,,,1135.96,2885.76,percent of total billed charges,
GRAFT STRAIT,7694566,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2347.00000,680.63000,Aetna,First Health,,1919.85,,,,,,,846.09,1919.85,percent of total billed charges,
GRAFT STRAIT,7694566,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2347.00000,680.63000,Aetna,First Health,,1919.85,,,,,,,755.73,1919.85,percent of total billed charges,
STENT BILIARY,7694927,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
STENT BILIARY,7694927,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695001,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695001,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
GUIDEWIRE,7702887,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,134.40000,38.98000,Aetna,First Health,,109.94,,,,,,,48.45,109.94,percent of total billed charges,
GUIDEWIRE,7702887,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,134.40000,38.98000,Aetna,First Health,,109.94,,,,,,,43.28,109.94,percent of total billed charges,
CATHETER HALO 90,7695079,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,7539.00000,2186.31000,Aetna,First Health,,6166.90,,,,,,,2717.81,6166.90,percent of total billed charges,
CATHETER HALO 90,7695079,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,7539.00000,2186.31000,Aetna,First Health,,6166.90,,,,,,,2427.56,6166.90,percent of total billed charges,
CATHETER HALO 360,7695074,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2936.27,6662.61,percent of total billed charges,
CATHETER HALO 360,7695074,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2622.69,6662.61,percent of total billed charges,
ROD,7696776,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1532.00000,444.28000,Aetna,First Health,,1253.18,,,,,,,552.29,1253.18,percent of total billed charges,
ROD,7696776,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1532.00000,444.28000,Aetna,First Health,,1253.18,,,,,,,493.30,1253.18,percent of total billed charges,
SCREW,7695460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7695460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
PLATE,7696556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,666.58,1512.51,percent of total billed charges,
PLATE,7696556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,595.39,1512.51,percent of total billed charges,
BALLOON,8135822,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135822,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
SHEATH,8135823,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,432.25000,125.35000,Aetna,First Health,,353.58,,,,,,,155.83,353.58,percent of total billed charges,
SHEATH,8135823,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,432.25000,125.35000,Aetna,First Health,,353.58,,,,,,,139.18,353.58,percent of total billed charges,
BALLOON,8135722,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135722,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
CATHETER,8135647,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER,8135647,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
STENT,7696334,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7696334,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,7696341,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7696341,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
GUIDEWIRE,8151668,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
GUIDEWIRE,8151668,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
MESH,7696710,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2891.42000,838.51000,Aetna,First Health,,2365.18,,,,,,,1042.36,2365.18,percent of total billed charges,
MESH,7696710,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2891.42000,838.51000,Aetna,First Health,,2365.18,,,,,,,931.04,2365.18,percent of total billed charges,
CATHETER BALLOON,7702795,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
CATHETER BALLOON,7702795,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
GUIDEWIRE,7694998,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,792.00000,229.68000,Aetna,First Health,,647.86,,,,,,,285.52,647.86,percent of total billed charges,
GUIDEWIRE,7694998,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,First Health,,647.86,,,,,,,255.02,647.86,percent of total billed charges,
PEG,7696586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
PEG,7696586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
BALLOON,7695317,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
BALLOON,7695317,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
MESH,7695970,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2705.91000,784.71000,Aetna,First Health,,2213.43,,,,,,,975.48,2213.43,percent of total billed charges,
MESH,7695970,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2705.91000,784.71000,Aetna,First Health,,2213.43,,,,,,,871.30,2213.43,percent of total billed charges,
SCREW,7695463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7695463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
TRANSSPHENOIDAL SELLAR IMPLANT,7696666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2455.20000,712.01000,Aetna,First Health,,2008.35,,,,,,,885.10,2008.35,percent of total billed charges,
TRANSSPHENOIDAL SELLAR IMPLANT,7696666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2455.20000,712.01000,Aetna,First Health,,2008.35,,,,,,,790.57,2008.35,percent of total billed charges,
CATHETER,7693596,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,First Health,,1194.28,,,,,,,526.33,1194.28,percent of total billed charges,
CATHETER,7693596,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,First Health,,1194.28,,,,,,,470.12,1194.28,percent of total billed charges,
CATHETER SWAN,7695755,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2532.48000,734.42000,Aetna,First Health,,2071.57,,,,,,,912.96,2071.57,percent of total billed charges,
CATHETER SWAN,7695755,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2532.48000,734.42000,Aetna,First Health,,2071.57,,,,,,,815.46,2071.57,percent of total billed charges,
CATHETER,7695042,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7695042,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
GLIDEWIRE,7694368,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,368.13000,106.76000,Aetna,First Health,,301.13,,,,,,,132.71,301.13,percent of total billed charges,
GLIDEWIRE,7694368,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,368.13000,106.76000,Aetna,First Health,,301.13,,,,,,,118.54,301.13,percent of total billed charges,
GLIDEWIRE,7694367,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,First Health,,275.87,,,,,,,121.58,275.87,percent of total billed charges,
GLIDEWIRE,7694367,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,First Health,,275.87,,,,,,,108.59,275.87,percent of total billed charges,
GRAFT,7699403,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,789.08000,228.83000,Aetna,First Health,,645.47,,,,,,,284.46,645.47,percent of total billed charges,
GRAFT,7699403,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,789.08000,228.83000,Aetna,First Health,,645.47,,,,,,,254.08,645.47,percent of total billed charges,
GRAFT,7694918,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4857.30000,1408.62000,Aetna,First Health,,3973.27,,,,,,,1751.06,3973.27,percent of total billed charges,
GRAFT,7694918,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4857.30000,1408.62000,Aetna,First Health,,3973.27,,,,,,,1564.05,3973.27,percent of total billed charges,
GUIDEWIRE,7695671,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,375.25000,108.82000,Aetna,First Health,,306.95,,,,,,,135.28,306.95,percent of total billed charges,
GUIDEWIRE,7695671,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,375.25000,108.82000,Aetna,First Health,,306.95,,,,,,,120.83,306.95,percent of total billed charges,
GUIDEWIRE,7694747,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,175.35000,50.85000,Aetna,First Health,,143.44,,,,,,,63.21,143.44,percent of total billed charges,
GUIDEWIRE,7694747,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,175.35000,50.85000,Aetna,First Health,,143.44,,,,,,,56.46,143.44,percent of total billed charges,
GUIDEWIRE,7695038,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,680.76000,197.42000,Aetna,First Health,,556.86,,,,,,,245.41,556.86,percent of total billed charges,
GUIDEWIRE,7695038,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,680.76000,197.42000,Aetna,First Health,,556.86,,,,,,,219.20,556.86,percent of total billed charges,
CATHETER,7696705,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,616.32000,178.73000,Aetna,First Health,,504.15,,,,,,,222.18,504.15,percent of total billed charges,
CATHETER,7696705,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,616.32000,178.73000,Aetna,First Health,,504.15,,,,,,,198.46,504.15,percent of total billed charges,
MESH,7694067,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,724.95000,210.24000,Aetna,First Health,,593.01,,,,,,,261.34,593.01,percent of total billed charges,
MESH,7694067,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,724.95000,210.24000,Aetna,First Health,,593.01,,,,,,,233.43,593.01,percent of total billed charges,
MESH,7694321,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2211.76000,641.41000,Aetna,First Health,,1809.22,,,,,,,797.34,1809.22,percent of total billed charges,
MESH,7694321,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2211.76000,641.41000,Aetna,First Health,,1809.22,,,,,,,712.19,1809.22,percent of total billed charges,
MESH,7696737,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4047.59000,1173.80000,Aetna,First Health,,3310.93,,,,,,,1459.16,3310.93,percent of total billed charges,
MESH,7696737,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4047.59000,1173.80000,Aetna,First Health,,3310.93,,,,,,,1303.32,3310.93,percent of total billed charges,
MESH,7696738,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1968.07000,570.74000,Aetna,First Health,,1609.88,,,,,,,709.49,1609.88,percent of total billed charges,
MESH,7696738,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1968.07000,570.74000,Aetna,First Health,,1609.88,,,,,,,633.72,1609.88,percent of total billed charges,
GRAFT,7702876,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2370.56000,687.46000,Aetna,First Health,,1939.12,,,,,,,854.59,1939.12,percent of total billed charges,
GRAFT,7702876,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2370.56000,687.46000,Aetna,First Health,,1939.12,,,,,,,763.32,1939.12,percent of total billed charges,
ANCHOR,7696379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ANCHOR,7696379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
ANCHOR,7694438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,First Health,,1476.49,,,,,,,650.70,1476.49,percent of total billed charges,
ANCHOR,7694438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,First Health,,1476.49,,,,,,,581.21,1476.49,percent of total billed charges,
SCREW,7695452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7695452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
PLATE,7695476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1861.44000,539.82000,Aetna,First Health,,1522.66,,,,,,,671.05,1522.66,percent of total billed charges,
PLATE,7695476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1861.44000,539.82000,Aetna,First Health,,1522.66,,,,,,,599.38,1522.66,percent of total billed charges,
BONE GRAFT,7702856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,First Health,,3421.28,,,,,,,1507.79,3421.28,percent of total billed charges,
BONE GRAFT,7702856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,First Health,,3421.28,,,,,,,1346.77,3421.28,percent of total billed charges,
PLATE,7698337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,694.54,1575.96,percent of total billed charges,
PLATE,7698337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,620.37,1575.96,percent of total billed charges,
SCREW,7695458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7695458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
TENDON ACHILLES,7702911,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8651.37000,2508.90000,Aetna,First Health,,7076.82,,,,,,,3118.82,7076.82,percent of total billed charges,
TENDON ACHILLES,7702911,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8651.37000,2508.90000,Aetna,First Health,,7076.82,,,,,,,2785.74,7076.82,percent of total billed charges,
TENDON,7741660,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
TENDON,7741660,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
BONE GRAFT,7696453,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16502.08000,4785.60000,Aetna,First Health,,13498.70,,,,,,,5949.00,13498.70,percent of total billed charges,
BONE GRAFT,7696453,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16502.08000,4785.60000,Aetna,First Health,,13498.70,,,,,,,5313.67,13498.70,percent of total billed charges,
BONE GRAFT,7702855,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22795.38000,6610.66000,Aetna,First Health,,18646.62,,,,,,,8217.73,18646.62,percent of total billed charges,
BONE GRAFT,7702855,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22795.38000,6610.66000,Aetna,First Health,,18646.62,,,,,,,7340.11,18646.62,percent of total billed charges,
GRAFT ROPE,7702857,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8965.17000,2599.90000,Aetna,First Health,,7333.51,,,,,,,3231.94,7333.51,percent of total billed charges,
GRAFT ROPE,7702857,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8965.17000,2599.90000,Aetna,First Health,,7333.51,,,,,,,2886.78,7333.51,percent of total billed charges,
NAIL,7696820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7696820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
STENT,7696265,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,4634.42000,1343.98000,Aetna,First Health,,3790.96,,,,,,,1670.71,3790.96,percent of total billed charges,
STENT,7696265,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,4634.42000,1343.98000,Aetna,First Health,,3790.96,,,,,,,1492.28,3790.96,percent of total billed charges,
BAND ANNULOPLASTY,7702702,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,2097.03,4758.31,percent of total billed charges,
BAND ANNULOPLASTY,7702702,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,1873.07,4758.31,percent of total billed charges,
GUIDEWIRE,7695595,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,545.40000,158.17000,Aetna,First Health,,446.14,,,,,,,196.62,446.14,percent of total billed charges,
GUIDEWIRE,7695595,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,545.40000,158.17000,Aetna,First Health,,446.14,,,,,,,175.62,446.14,percent of total billed charges,
SCREW,7695456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7695456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7695457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7695457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
CATHETER,7702798,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,222.77,505.47,percent of total billed charges,
CATHETER,7702798,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,198.98,505.47,percent of total billed charges,
CEMENT,7694049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,395.68000,114.75000,Aetna,First Health,,323.67,,,,,,,142.64,323.67,percent of total billed charges,
CEMENT,7694049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,395.68000,114.75000,Aetna,First Health,,323.67,,,,,,,127.41,323.67,percent of total billed charges,
MESH,7694068,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,815.85000,236.60000,Aetna,First Health,,667.37,,,,,,,294.11,667.37,percent of total billed charges,
MESH,7694068,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,815.85000,236.60000,Aetna,First Health,,667.37,,,,,,,262.70,667.37,percent of total billed charges,
RETRIEVAL DEVICE,7694844,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,First Health,,1201.64,,,,,,,529.57,1201.64,percent of total billed charges,
RETRIEVAL DEVICE,7694844,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,First Health,,1201.64,,,,,,,473.02,1201.64,percent of total billed charges,
SCREW,7695287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
SCREW,7695287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
SHUNT,7694647,CDM,278,RC,,,,,facility,inpatient,,,340.61000,98.78000,Aetna,First Health,,278.62,,,,,,,122.79,278.62,percent of total billed charges,
SHUNT,7694647,CDM,278,RC,,,,,facility,outpatient,,,340.61000,98.78000,Aetna,First Health,,278.62,,,,,,,109.68,278.62,percent of total billed charges,
CATHETER BALLOON,7703364,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,1432.00000,415.28000,Aetna,First Health,,1171.38,,,,,,,516.24,1171.38,percent of total billed charges,
CATHETER BALLOON,7703364,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,1432.00000,415.28000,Aetna,First Health,,1171.38,,,,,,,461.10,1171.38,percent of total billed charges,
STENT,7695655,CDM,278,RC,C1877,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
STENT,7695655,CDM,278,RC,C1877,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PLATE,7695839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,375.11000,108.78000,Aetna,First Health,,306.84,,,,,,,135.23,306.84,percent of total billed charges,
PLATE,7695839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,375.11000,108.78000,Aetna,First Health,,306.84,,,,,,,120.79,306.84,percent of total billed charges,
SLING,7695670,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,7505.27000,2176.53000,Aetna,First Health,,6139.31,,,,,,,2705.65,6139.31,percent of total billed charges,
SLING,7695670,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,7505.27000,2176.53000,Aetna,First Health,,6139.31,,,,,,,2416.70,6139.31,percent of total billed charges,
SCREW,7695389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1544.00000,447.76000,Aetna,First Health,,1262.99,,,,,,,556.61,1262.99,percent of total billed charges,
SCREW,7695389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1544.00000,447.76000,Aetna,First Health,,1262.99,,,,,,,497.17,1262.99,percent of total billed charges,
OCCLUDER,7696140,CDM,278,RC,,,,,facility,inpatient,,,2230.00000,646.70000,Aetna,First Health,,1824.14,,,,,,,803.91,1824.14,percent of total billed charges,
OCCLUDER,7696140,CDM,278,RC,,,,,facility,outpatient,,,2230.00000,646.70000,Aetna,First Health,,1824.14,,,,,,,718.06,1824.14,percent of total billed charges,
RENAL DILATOR,7694500,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1423.24000,412.74000,Aetna,First Health,,1164.21,,,,,,,513.08,1164.21,percent of total billed charges,
RENAL DILATOR,7694500,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1423.24000,412.74000,Aetna,First Health,,1164.21,,,,,,,458.28,1164.21,percent of total billed charges,
MESH,7694846,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1902.32000,551.67000,Aetna,First Health,,1556.10,,,,,,,685.79,1556.10,percent of total billed charges,
MESH,7694846,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1902.32000,551.67000,Aetna,First Health,,1556.10,,,,,,,612.55,1556.10,percent of total billed charges,
SEPRA FILM,7694879,CDM,278,RC,C1765,HCPCS,,,facility,inpatient,,,1904.50000,552.30000,Aetna,First Health,,1557.88,,,,,,,686.57,1557.88,percent of total billed charges,
SEPRA FILM,7694879,CDM,278,RC,C1765,HCPCS,,,facility,outpatient,,,1904.50000,552.30000,Aetna,First Health,,1557.88,,,,,,,613.25,1557.88,percent of total billed charges,
GRAFT,7703356,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,First Health,,5053.19,,,,,,,2226.99,5053.19,percent of total billed charges,
GRAFT,7703356,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,First Health,,5053.19,,,,,,,1989.15,5053.19,percent of total billed charges,
TUBE MYRINGOTOMY,7696094,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,148.74000,43.13000,Aetna,First Health,,121.67,,,,,,,53.62,121.67,percent of total billed charges,
TUBE MYRINGOTOMY,7696094,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,148.74000,43.13000,Aetna,First Health,,121.67,,,,,,,47.89,332.38,percent of total billed charges,
CATHETER,7697045,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
CATHETER,7697045,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
SCREW,7698916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7698916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
CATHETER,7696938,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,913.59000,264.94000,Aetna,First Health,,747.32,,,,,,,329.35,747.32,percent of total billed charges,
CATHETER,7696938,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,913.59000,264.94000,Aetna,First Health,,747.32,,,,,,,294.18,747.32,percent of total billed charges,
GRAFT,7696119,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1951.93,4429.06,percent of total billed charges,
GRAFT,7696119,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1743.47,4429.06,percent of total billed charges,
GUIDEWIRE,7736634,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,336.30000,97.53000,Aetna,First Health,,275.09,,,,,,,121.24,275.09,percent of total billed charges,
GUIDEWIRE,7736634,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,336.30000,97.53000,Aetna,First Health,,275.09,,,,,,,108.29,275.09,percent of total billed charges,
ROD,7696876,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD,7696876,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
GLIDEWIRE,7693894,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,311.13000,90.23000,Aetna,First Health,,254.50,,,,,,,112.16,254.50,percent of total billed charges,
GLIDEWIRE,7693894,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,311.13000,90.23000,Aetna,First Health,,254.50,,,,,,,100.18,254.50,percent of total billed charges,
MESH,7694066,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,716.27000,207.72000,Aetna,First Health,,585.91,,,,,,,258.22,585.91,percent of total billed charges,
MESH,7694066,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,716.27000,207.72000,Aetna,First Health,,585.91,,,,,,,230.64,585.91,percent of total billed charges,
BALLOON DILATOR,7696284,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1592.60000,461.85000,Aetna,First Health,,1302.75,,,,,,,574.13,1302.75,percent of total billed charges,
BALLOON DILATOR,7696284,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1592.60000,461.85000,Aetna,First Health,,1302.75,,,,,,,512.82,1302.75,percent of total billed charges,
PUMP,7695396,CDM,278,RC,C1772,HCPCS,,,facility,inpatient,,,31810.50000,9225.04000,Aetna,First Health,,26020.99,,,,,,,11467.69,26020.99,percent of total billed charges,
PUMP,7695396,CDM,278,RC,C1772,HCPCS,,,facility,outpatient,,,31810.50000,9225.04000,Aetna,First Health,,26020.99,,,,,,,10242.98,26020.99,percent of total billed charges,
CAGE,7697085,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15710.00000,4555.90000,Aetna,First Health,,12850.78,,,,,,,5663.45,12850.78,percent of total billed charges,
CAGE,7697085,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15710.00000,4555.90000,Aetna,First Health,,12850.78,,,,,,,5058.62,12850.78,percent of total billed charges,
LEAD,7697114,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
LEAD,7697114,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
TISSUE EXPANDER,7697120,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697120,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
GENERATOR,7702853,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,39656.25000,11500.31000,Aetna,First Health,,32438.81,,,,,,,14296.08,32438.81,percent of total billed charges,
GENERATOR,7702853,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,39656.25000,11500.31000,Aetna,First Health,,32438.81,,,,,,,12769.31,32438.81,percent of total billed charges,
CATHETER,7696458,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,918.00000,266.22000,Aetna,First Health,,750.92,,,,,,,330.94,750.92,percent of total billed charges,
CATHETER,7696458,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,918.00000,266.22000,Aetna,First Health,,750.92,,,,,,,295.60,750.92,percent of total billed charges,
SHUNT,7696613,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8787.00000,2548.23000,Aetna,First Health,,7187.77,,,,,,,3167.71,7187.77,percent of total billed charges,
SHUNT,7696613,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8787.00000,2548.23000,Aetna,First Health,,7187.77,,,,,,,2829.41,7187.77,percent of total billed charges,
INTRODUCER,7697058,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2800.00000,812.00000,Aetna,First Health,,2290.40,,,,,,,1009.40,2290.40,percent of total billed charges,
INTRODUCER,7697058,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2800.00000,812.00000,Aetna,First Health,,2290.40,,,,,,,901.60,2290.40,percent of total billed charges,
STENT,7694669,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,418.19000,121.28000,Aetna,First Health,,342.08,,,,,,,150.76,342.08,percent of total billed charges,
STENT,7694669,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,418.19000,121.28000,Aetna,First Health,,342.08,,,,,,,134.66,342.08,percent of total billed charges,
PIN,7707512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
PIN,7707512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
ENDOBUTTON,7697179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1596.00000,462.84000,Aetna,First Health,,1305.53,,,,,,,575.36,1305.53,percent of total billed charges,
ENDOBUTTON,7697179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1596.00000,462.84000,Aetna,First Health,,1305.53,,,,,,,513.91,1305.53,percent of total billed charges,
ENDOBUTTON,7697181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1928.00000,559.12000,Aetna,First Health,,1577.10,,,,,,,695.04,1577.10,percent of total billed charges,
ENDOBUTTON,7697181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1928.00000,559.12000,Aetna,First Health,,1577.10,,,,,,,620.82,1577.10,percent of total billed charges,
ANCHOR,7697187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,First Health,,1600.01,,,,,,,705.14,1600.01,percent of total billed charges,
ANCHOR,7697187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,First Health,,1600.01,,,,,,,629.83,1600.01,percent of total billed charges,
CATHETER,7697235,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,6125.00000,1776.25000,Aetna,First Health,,5010.25,,,,,,,2208.06,5010.25,percent of total billed charges,
CATHETER,7697235,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,6125.00000,1776.25000,Aetna,First Health,,5010.25,,,,,,,1972.25,5010.25,percent of total billed charges,
PIN,7698060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
PIN,7698060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
ANCHOR,7697251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,870.25,1974.65,percent of total billed charges,
ANCHOR,7697251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,777.31,1974.65,percent of total billed charges,
CATHETER,7694751,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1667.28000,483.51000,Aetna,First Health,,1363.84,,,,,,,601.05,1363.84,percent of total billed charges,
CATHETER,7694751,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1667.28000,483.51000,Aetna,First Health,,1363.84,,,,,,,536.86,1363.84,percent of total billed charges,
BALLOON,7697270,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697270,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PEG,7695346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7695346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
GRAFT,7696363,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,6123.99,13895.77,percent of total billed charges,
GRAFT,7696363,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,5469.98,13895.77,percent of total billed charges,
STENT,7694310,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7694310,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
GUIDEWIRE,7696449,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,577.47000,167.47000,Aetna,First Health,,472.37,,,,,,,208.18,472.37,percent of total billed charges,
GUIDEWIRE,7696449,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,577.47000,167.47000,Aetna,First Health,,472.37,,,,,,,185.95,472.37,percent of total billed charges,
GLIDEWIRE,7697323,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1294.00000,375.26000,Aetna,First Health,,1058.49,,,,,,,466.49,1058.49,percent of total billed charges,
GLIDEWIRE,7697323,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1294.00000,375.26000,Aetna,First Health,,1058.49,,,,,,,416.67,1058.49,percent of total billed charges,
GLIDEWIRE,7697322,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
GLIDEWIRE,7697322,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
ANCHOR,7696269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1406.00000,407.74000,Aetna,First Health,,1150.11,,,,,,,506.86,1150.11,percent of total billed charges,
ANCHOR,7696269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1406.00000,407.74000,Aetna,First Health,,1150.11,,,,,,,452.73,1150.11,percent of total billed charges,
ANCHOR,7695417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1272.00000,368.88000,Aetna,First Health,,1040.50,,,,,,,458.56,1040.50,percent of total billed charges,
ANCHOR,7695417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1272.00000,368.88000,Aetna,First Health,,1040.50,,,,,,,409.58,1040.50,percent of total billed charges,
LEAD,7695108,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
LEAD,7695108,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,7695338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7695338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7696560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,563.54000,163.43000,Aetna,First Health,,460.98,,,,,,,203.16,460.98,percent of total billed charges,
SCREW,7696560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,563.54000,163.43000,Aetna,First Health,,460.98,,,,,,,181.46,460.98,percent of total billed charges,
PLATE,7701062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4752.34000,1378.18000,Aetna,First Health,,3887.41,,,,,,,1713.22,3887.41,percent of total billed charges,
PLATE,7701062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4752.34000,1378.18000,Aetna,First Health,,3887.41,,,,,,,1530.25,3887.41,percent of total billed charges,
BREAST PROSTHESIS,7697384,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7697384,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,764.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7697388,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
BREAST PROSTHESIS,7697388,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
PLATE,7696897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2714.36000,787.16000,Aetna,First Health,,2220.35,,,,,,,978.53,2220.35,percent of total billed charges,
PLATE,7696897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2714.36000,787.16000,Aetna,First Health,,2220.35,,,,,,,874.02,2220.35,percent of total billed charges,
NAIL,7697395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,2149.26,4876.83,percent of total billed charges,
NAIL,7697395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,1919.73,4876.83,percent of total billed charges,
SCREW,7696850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,565.26,1282.62,percent of total billed charges,
SCREW,7696850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,504.90,1282.62,percent of total billed charges,
SCREW,7695817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,171.36000,49.69000,Aetna,First Health,,140.17,,,,,,,61.78,140.17,percent of total billed charges,
SCREW,7695817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,171.36000,49.69000,Aetna,First Health,,140.17,,,,,,,55.18,140.17,percent of total billed charges,
SHOULDER GLENOSPHERE REVERSE,7697434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
SHOULDER GLENOSPHERE REVERSE,7697434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,7697406,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2669.14,6056.47,percent of total billed charges,
CAGE,7697406,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2384.09,6056.47,percent of total billed charges,
SCREW,7697408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,688.50000,199.66000,Aetna,First Health,,563.19,,,,,,,248.20,563.19,percent of total billed charges,
SCREW,7697408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,688.50000,199.66000,Aetna,First Health,,563.19,,,,,,,221.70,563.19,percent of total billed charges,
ROD,7697410,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1708.00000,495.32000,Aetna,First Health,,1397.14,,,,,,,615.73,1397.14,percent of total billed charges,
ROD,7697410,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1708.00000,495.32000,Aetna,First Health,,1397.14,,,,,,,549.98,1397.14,percent of total billed charges,
ROD,7696567,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7696567,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
PLATE,7697416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8346.00000,2420.34000,Aetna,First Health,,6827.03,,,,,,,3008.73,6827.03,percent of total billed charges,
PLATE,7697416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8346.00000,2420.34000,Aetna,First Health,,6827.03,,,,,,,2687.41,6827.03,percent of total billed charges,
STENT,7695221,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
STENT,7695221,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
STENT,7695222,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
STENT,7695222,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
BALLOON,8135809,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135809,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135810,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135810,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135811,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135811,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
FILTER VENA CAVA,8135664,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5718.83000,1658.46000,Aetna,First Health,,4678.00,,,,,,,2061.64,4678.00,percent of total billed charges,
FILTER VENA CAVA,8135664,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5718.83000,1658.46000,Aetna,First Health,,4678.00,,,,,,,1841.46,4678.00,percent of total billed charges,
PLATE,7697439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6552.84000,1900.32000,Aetna,First Health,,5360.22,,,,,,,2362.30,5360.22,percent of total billed charges,
PLATE,7697439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6552.84000,1900.32000,Aetna,First Health,,5360.22,,,,,,,2110.01,5360.22,percent of total billed charges,
GUIDEWIRE,7697440,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,329.79000,95.64000,Aetna,First Health,,269.77,,,,,,,118.89,269.77,percent of total billed charges,
GUIDEWIRE,7697440,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,329.79000,95.64000,Aetna,First Health,,269.77,,,,,,,106.19,269.77,percent of total billed charges,
GUIDEWIRE,7694448,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,128.31000,37.21000,Aetna,First Health,,104.96,,,,,,,46.26,104.96,percent of total billed charges,
GUIDEWIRE,7694448,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,128.31000,37.21000,Aetna,First Health,,104.96,,,,,,,41.32,104.96,percent of total billed charges,
PLATE,7945880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8271.00000,2398.59000,Aetna,First Health,,6765.68,,,,,,,2981.70,6765.68,percent of total billed charges,
PLATE,7945880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8271.00000,2398.59000,Aetna,First Health,,6765.68,,,,,,,2663.26,6765.68,percent of total billed charges,
TISSUE EXPANDER,7696663,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7696663,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
SCREW,7695464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7695464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
NAIL,7697517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,7697517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
CATHETER,7697529,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,964.71000,279.77000,Aetna,First Health,,789.13,,,,,,,347.78,789.13,percent of total billed charges,
CATHETER,7697529,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,964.71000,279.77000,Aetna,First Health,,789.13,,,,,,,310.64,789.13,percent of total billed charges,
CATHETER,7693595,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,981.00000,284.49000,Aetna,First Health,,802.46,,,,,,,353.65,802.46,percent of total billed charges,
CATHETER,7693595,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,981.00000,284.49000,Aetna,First Health,,802.46,,,,,,,315.88,802.46,percent of total billed charges,
SHEATH,7697567,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,First Health,,407.20,,,,,,,179.46,407.20,percent of total billed charges,
SHEATH,7697567,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,First Health,,407.20,,,,,,,160.29,407.20,percent of total billed charges,
FEMORAL HEAD,7697538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7697538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
SCREW,7697550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7697550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
MESH,7697612,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2670.40000,774.42000,Aetna,First Health,,2184.39,,,,,,,962.68,2184.39,percent of total billed charges,
MESH,7697612,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2670.40000,774.42000,Aetna,First Health,,2184.39,,,,,,,859.87,2184.39,percent of total billed charges,
BONE SUBSTITUTE,7697640,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9877.35000,2864.43000,Aetna,First Health,,8079.67,,,,,,,3560.78,8079.67,percent of total billed charges,
BONE SUBSTITUTE,7697640,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9877.35000,2864.43000,Aetna,First Health,,8079.67,,,,,,,3180.51,8079.67,percent of total billed charges,
PLATE,7697656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5577.88000,1617.59000,Aetna,First Health,,4562.71,,,,,,,2010.83,4562.71,percent of total billed charges,
PLATE,7697656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5577.88000,1617.59000,Aetna,First Health,,4562.71,,,,,,,1796.08,4562.71,percent of total billed charges,
MESH,7697658,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3684.23000,1068.43000,Aetna,First Health,,3013.70,,,,,,,1328.16,3013.70,percent of total billed charges,
MESH,7697658,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3684.23000,1068.43000,Aetna,First Health,,3013.70,,,,,,,1186.32,3013.70,percent of total billed charges,
MESH,7697659,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2200.50000,638.14000,Aetna,First Health,,1800.01,,,,,,,793.28,1800.01,percent of total billed charges,
MESH,7697659,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2200.50000,638.14000,Aetna,First Health,,1800.01,,,,,,,708.56,1800.01,percent of total billed charges,
MESH,7697660,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4434.85000,1286.11000,Aetna,First Health,,3627.71,,,,,,,1598.76,3627.71,percent of total billed charges,
MESH,7697660,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4434.85000,1286.11000,Aetna,First Health,,3627.71,,,,,,,1428.02,3627.71,percent of total billed charges,
PLATE,7697664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1510.76000,438.12000,Aetna,First Health,,1235.80,,,,,,,544.63,1235.80,percent of total billed charges,
PLATE,7697664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1510.76000,438.12000,Aetna,First Health,,1235.80,,,,,,,486.46,1235.80,percent of total billed charges,
PLATE,7697668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1665.92000,483.12000,Aetna,First Health,,1362.72,,,,,,,600.56,1362.72,percent of total billed charges,
PLATE,7697668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1665.92000,483.12000,Aetna,First Health,,1362.72,,,,,,,536.43,1362.72,percent of total billed charges,
SCREW,7935274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7935274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
BLOCKER CERV,7702771,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
BLOCKER CERV,7702771,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
MESH,7697865,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1554.21000,450.72000,Aetna,First Health,,1271.34,,,,,,,560.29,1271.34,percent of total billed charges,
MESH,7697865,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1554.21000,450.72000,Aetna,First Health,,1271.34,,,,,,,500.46,1271.34,percent of total billed charges,
STENT,7774084,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1250.70,2837.92,percent of total billed charges,
STENT,7774084,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1117.13,2837.92,percent of total billed charges,
INTRODUCER,7695683,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,741.19,1681.81,percent of total billed charges,
INTRODUCER,7695683,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,662.03,1681.81,percent of total billed charges,
INTRODUCER,7916959,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,729.36000,211.51000,Aetna,First Health,,596.62,,,,,,,262.93,596.62,percent of total billed charges,
INTRODUCER,7916959,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,729.36000,211.51000,Aetna,First Health,,596.62,,,,,,,234.85,596.62,percent of total billed charges,
PLATE,7697881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2948.00000,854.92000,Aetna,First Health,,2411.46,,,,,,,1062.75,2411.46,percent of total billed charges,
PLATE,7697881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2948.00000,854.92000,Aetna,First Health,,2411.46,,,,,,,949.26,2411.46,percent of total billed charges,
FEMORAL ADAPTER,7697897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1843.60000,534.64000,Aetna,First Health,,1508.06,,,,,,,664.62,1508.06,percent of total billed charges,
FEMORAL ADAPTER,7697897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1843.60000,534.64000,Aetna,First Health,,1508.06,,,,,,,593.64,1508.06,percent of total billed charges,
RING ANNULOPLASTY,7697914,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3790.66,8601.27,percent of total billed charges,
RING ANNULOPLASTY,7697914,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3385.83,8601.27,percent of total billed charges,
EXPLOR HEAD,7697918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
EXPLOR HEAD,7697918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
STEM AND SCREW,7697917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM AND SCREW,7697917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7697919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7697919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
STEM SPLINED KNEE,7697561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1871.68,4246.97,percent of total billed charges,
STEM SPLINED KNEE,7697561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1671.79,4246.97,percent of total billed charges,
TIBIAL TRAY,7697553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,3290.36,7466.05,percent of total billed charges,
TIBIAL TRAY,7697553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,2938.96,7466.05,percent of total billed charges,
PLATE,7697933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7697933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
CORE REVISION,7697947,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4428.38000,1284.23000,Aetna,First Health,,3622.41,,,,,,,1596.43,3622.41,percent of total billed charges,
CORE REVISION,7697947,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4428.38000,1284.23000,Aetna,First Health,,3622.41,,,,,,,1425.94,3622.41,percent of total billed charges,
ACL TIGHTROPE,7697360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,839.97,1905.94,percent of total billed charges,
ACL TIGHTROPE,7697360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,750.26,1905.94,percent of total billed charges,
PLATE,7697950,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7697950,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
FEMORAL HEAD,7697962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1173.43,2662.59,percent of total billed charges,
FEMORAL HEAD,7697962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1048.11,2662.59,percent of total billed charges,
MEDPOR IMPLANT,7697964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.72000,560.20000,Aetna,First Health,,1580.15,,,,,,,696.39,1580.15,percent of total billed charges,
MEDPOR IMPLANT,7697964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.72000,560.20000,Aetna,First Health,,1580.15,,,,,,,622.01,1580.15,percent of total billed charges,
SCREW,7697967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7697967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
BLOCKER,7697969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
BLOCKER,7697969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
CAGE,7697972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CAGE,7697972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
SCREW,7695300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,452.36,1026.43,percent of total billed charges,
SCREW,7695300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,404.05,1026.43,percent of total billed charges,
PIN,7695562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2498.00000,724.42000,Aetna,First Health,,2043.36,,,,,,,900.53,2043.36,percent of total billed charges,
PIN,7695562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2498.00000,724.42000,Aetna,First Health,,2043.36,,,,,,,804.36,2043.36,percent of total billed charges,
CRUCIATE TIBIAL,7698010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3027.20000,877.89000,Aetna,First Health,,2476.25,,,,,,,1091.31,2476.25,percent of total billed charges,
CRUCIATE TIBIAL,7698010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3027.20000,877.89000,Aetna,First Health,,2476.25,,,,,,,974.76,2476.25,percent of total billed charges,
LINER,7698056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10658.40000,3090.94000,Aetna,First Health,,8718.57,,,,,,,3842.35,8718.57,percent of total billed charges,
LINER,7698056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10658.40000,3090.94000,Aetna,First Health,,8718.57,,,,,,,3432.00,8718.57,percent of total billed charges,
SCREW,7987302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7987302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
PIN,7695378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PIN,7695378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7698099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1485.60000,430.82000,Aetna,First Health,,1215.22,,,,,,,535.56,1215.22,percent of total billed charges,
SCREW,7698099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1485.60000,430.82000,Aetna,First Health,,1215.22,,,,,,,478.36,1215.22,percent of total billed charges,
PLATE,7698159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2649.80000,768.44000,Aetna,First Health,,2167.54,,,,,,,955.25,2167.54,percent of total billed charges,
PLATE,7698159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2649.80000,768.44000,Aetna,First Health,,2167.54,,,,,,,853.24,2167.54,percent of total billed charges,
SCREW,7696207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,631.90,1433.82,percent of total billed charges,
SCREW,7696207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,564.41,1433.82,percent of total billed charges,
DISTAL CENTRALIZER,7698167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
DISTAL CENTRALIZER,7698167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
COMPONENT NECK LENGTH ADAPTER,7698168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
COMPONENT NECK LENGTH ADAPTER,7698168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
COMPONENT UNIPOLAR,7698169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
COMPONENT UNIPOLAR,7698169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
PLATE,7698173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,850.50000,246.64000,Aetna,First Health,,695.71,,,,,,,306.61,695.71,percent of total billed charges,
PLATE,7698173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,850.50000,246.64000,Aetna,First Health,,695.71,,,,,,,273.86,695.71,percent of total billed charges,
SCREW,7698188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,7698188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
GUIDEWIRE,7696660,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,77.60,176.07,percent of total billed charges,
GUIDEWIRE,7696660,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,69.31,176.07,percent of total billed charges,
AUGMENT FEMORAL,7698021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
COMPONENT HEAD,7698195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
COMPONENT HEAD,7698195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
LINER,7698197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1873.70,4251.56,percent of total billed charges,
LINER,7698197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1673.60,4251.56,percent of total billed charges,
VASCULAR PATCH,7698211,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2196.00000,636.84000,Aetna,First Health,,1796.33,,,,,,,791.66,1796.33,percent of total billed charges,
VASCULAR PATCH,7698211,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2196.00000,636.84000,Aetna,First Health,,1796.33,,,,,,,707.11,1796.33,percent of total billed charges,
VALVE,7696913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,First Health,,17178.00,,,,,,,7570.50,17178.00,percent of total billed charges,
VALVE,7696913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,First Health,,17178.00,,,,,,,6762.00,17178.00,percent of total billed charges,
PLUG,7695982,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
PLUG,7695982,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
GRAFT,7696120,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,11175.00000,3240.75000,Aetna,First Health,,9141.15,,,,,,,4028.59,9141.15,percent of total billed charges,
GRAFT,7696120,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,11175.00000,3240.75000,Aetna,First Health,,9141.15,,,,,,,3598.35,9141.15,percent of total billed charges,
CATHETER BALLOON,7698231,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3381.00000,980.49000,Aetna,First Health,,2765.66,,,,,,,1218.85,2765.66,percent of total billed charges,
CATHETER BALLOON,7698231,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3381.00000,980.49000,Aetna,First Health,,2765.66,,,,,,,1088.68,2765.66,percent of total billed charges,
PLATE,7697901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1995.20000,578.61000,Aetna,First Health,,1632.07,,,,,,,719.27,1632.07,percent of total billed charges,
PLATE,7697901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1995.20000,578.61000,Aetna,First Health,,1632.07,,,,,,,642.45,1632.07,percent of total billed charges,
HUMERAL HEAD,7698226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
HUMERAL HEAD,7698226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
HUMERAL BEARING,7698228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
HUMERAL BEARING,7698228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
HUMERAL TRAY,7698229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
HUMERAL TRAY,7698229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
FEMORAL AUGMENT,7698243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
FEMORAL AUGMENT,7698243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
STEM EXTENSION,7698068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1534.16,3481.12,percent of total billed charges,
STEM EXTENSION,7698068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1370.32,3481.12,percent of total billed charges,
HIP NECK ADAPTER,7698249,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,First Health,,1308.15,,,,,,,576.51,1308.15,percent of total billed charges,
HIP NECK ADAPTER,7698249,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,First Health,,1308.15,,,,,,,514.94,1308.15,percent of total billed charges,
FIXATOR,7697849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1949.08000,565.23000,Aetna,First Health,,1594.35,,,,,,,702.64,1594.35,percent of total billed charges,
FIXATOR,7697849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1949.08000,565.23000,Aetna,First Health,,1594.35,,,,,,,627.60,1594.35,percent of total billed charges,
GLIDEWIRE,7695880,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
GLIDEWIRE,7695880,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
BALLOON,7697269,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697269,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CEMENT,7696310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,293.63,666.26,percent of total billed charges,
CEMENT,7696310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,262.27,666.26,percent of total billed charges,
BIO PUSHLOCK,7696346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,703.70,1596.74,percent of total billed charges,
BIO PUSHLOCK,7696346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,628.54,1596.74,percent of total billed charges,
GUIDEWIRE,7698604,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,51.10,115.95,percent of total billed charges,
GUIDEWIRE,7698604,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,45.64,115.95,percent of total billed charges,
GUIDEWIRE,7698654,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,174.09000,50.49000,Aetna,First Health,,142.41,,,,,,,62.76,142.41,percent of total billed charges,
GUIDEWIRE,7698654,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,174.09000,50.49000,Aetna,First Health,,142.41,,,,,,,56.06,142.41,percent of total billed charges,
CLOSURE DEVICE VASCULAR,7696653,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,504.70,1145.20,percent of total billed charges,
CLOSURE DEVICE VASCULAR,7696653,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,450.80,1145.20,percent of total billed charges,
PIN,8380724,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
PIN,8380724,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
FEMORAL HEAD,7698286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7698286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
PLATE,7698277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6188.91000,1794.78000,Aetna,First Health,,5062.53,,,,,,,2231.10,5062.53,percent of total billed charges,
PLATE,7698277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6188.91000,1794.78000,Aetna,First Health,,5062.53,,,,,,,1992.83,5062.53,percent of total billed charges,
LOCKING CAP,7698278,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,746.78000,216.57000,Aetna,First Health,,610.87,,,,,,,269.21,610.87,percent of total billed charges,
LOCKING CAP,7698278,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,746.78000,216.57000,Aetna,First Health,,610.87,,,,,,,240.46,610.87,percent of total billed charges,
INSERT,7698289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7698289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SHELL,7698290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,7698290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
PLATE,7698299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3285.91000,952.91000,Aetna,First Health,,2687.87,,,,,,,1184.57,2687.87,percent of total billed charges,
PLATE,7698299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3285.91000,952.91000,Aetna,First Health,,2687.87,,,,,,,1058.06,2687.87,percent of total billed charges,
PLATE,7698305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3356.50000,973.38000,Aetna,First Health,,2745.62,,,,,,,1210.02,2745.62,percent of total billed charges,
PLATE,7698305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3356.50000,973.38000,Aetna,First Health,,2745.62,,,,,,,1080.79,2745.62,percent of total billed charges,
PLATE,7698332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
PLATE,7698332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
MODULAR HEAD,7698335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
MODULAR HEAD,7698335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
WEDGE,7698330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
WEDGE,7698330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
SHEATH,7694428,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
SHEATH,7694428,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
PLATE,7696899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3863.48000,1120.41000,Aetna,First Health,,3160.33,,,,,,,1392.78,3160.33,percent of total billed charges,
PLATE,7696899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3863.48000,1120.41000,Aetna,First Health,,3160.33,,,,,,,1244.04,3160.33,percent of total billed charges,
COMPONENT DISTAL,7698362,CDM,278,RC,L8631,HCPCS,,,facility,inpatient,,,7443.00000,2158.47000,Aetna,First Health,,6088.37,,,,,,,2683.20,6088.37,percent of total billed charges,
COMPONENT DISTAL,7698362,CDM,278,RC,L8631,HCPCS,,,facility,outpatient,,,7443.00000,2158.47000,Aetna,First Health,,6088.37,,,,,,,2396.65,6088.37,percent of total billed charges,
NAIL,7695436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7695436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
SCREW,7698710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,First Health,,1112.38,,,,,,,490.24,1112.38,percent of total billed charges,
SCREW,7698710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,First Health,,1112.38,,,,,,,437.88,1112.38,percent of total billed charges,
SCREW,7698373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7698373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7698388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
PLATE,7695611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1256.00000,364.24000,Aetna,First Health,,1027.41,,,,,,,452.79,1027.41,percent of total billed charges,
PLATE,7695611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1256.00000,364.24000,Aetna,First Health,,1027.41,,,,,,,404.43,1027.41,percent of total billed charges,
CABLE,7702780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2125.60000,616.42000,Aetna,First Health,,1738.74,,,,,,,766.28,1738.74,percent of total billed charges,
CABLE,7702780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2125.60000,616.42000,Aetna,First Health,,1738.74,,,,,,,684.44,1738.74,percent of total billed charges,
CABLE,7695386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,First Health,,1092.85,,,,,,,481.63,1092.85,percent of total billed charges,
CABLE,7695386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,First Health,,1092.85,,,,,,,430.19,1092.85,percent of total billed charges,
SCREW,7698427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,First Health,,1525.68,,,,,,,672.38,1525.68,percent of total billed charges,
SCREW,7698427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,First Health,,1525.68,,,,,,,600.57,1525.68,percent of total billed charges,
SCREW,7695813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7695813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
PLATE,7698444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6433.32000,1865.66000,Aetna,First Health,,5262.46,,,,,,,2319.21,5262.46,percent of total billed charges,
PLATE,7698444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6433.32000,1865.66000,Aetna,First Health,,5262.46,,,,,,,2071.53,5262.46,percent of total billed charges,
GUIDEWIRE,7695428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,121.96000,35.37000,Aetna,First Health,,99.76,,,,,,,43.97,99.76,percent of total billed charges,
GUIDEWIRE,7695428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,121.96000,35.37000,Aetna,First Health,,99.76,,,,,,,39.27,99.76,percent of total billed charges,
NAIL,7695502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7695502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
ROD,7698255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1648.40000,478.04000,Aetna,First Health,,1348.39,,,,,,,594.25,1348.39,percent of total billed charges,
ROD,7698255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1648.40000,478.04000,Aetna,First Health,,1348.39,,,,,,,530.78,1348.39,percent of total billed charges,
PLATE,7695475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1634.88000,474.12000,Aetna,First Health,,1337.33,,,,,,,589.37,1337.33,percent of total billed charges,
PLATE,7695475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1634.88000,474.12000,Aetna,First Health,,1337.33,,,,,,,526.43,1337.33,percent of total billed charges,
PLATE,7702984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,878.67000,254.81000,Aetna,First Health,,718.75,,,,,,,316.76,718.75,percent of total billed charges,
PLATE,7702984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,878.67000,254.81000,Aetna,First Health,,718.75,,,,,,,282.93,718.75,percent of total billed charges,
PLATE,7698471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2348.72000,681.13000,Aetna,First Health,,1921.25,,,,,,,846.71,1921.25,percent of total billed charges,
PLATE,7698471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2348.72000,681.13000,Aetna,First Health,,1921.25,,,,,,,756.29,1921.25,percent of total billed charges,
SCREW,7695368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,7695368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
SCREW,7698489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW,7698489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PLATE,7698475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2680.56000,777.36000,Aetna,First Health,,2192.70,,,,,,,966.34,2192.70,percent of total billed charges,
PLATE,7698475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2680.56000,777.36000,Aetna,First Health,,2192.70,,,,,,,863.14,2192.70,percent of total billed charges,
PLATE,7698476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2714.36000,787.16000,Aetna,First Health,,2220.35,,,,,,,978.53,2220.35,percent of total billed charges,
PLATE,7698476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2714.36000,787.16000,Aetna,First Health,,2220.35,,,,,,,874.02,2220.35,percent of total billed charges,
CAGE,7698508,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20837.50000,6042.88000,Aetna,First Health,,17045.08,,,,,,,7511.92,17045.08,percent of total billed charges,
CAGE,7698508,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20837.50000,6042.88000,Aetna,First Health,,17045.08,,,,,,,6709.68,17045.08,percent of total billed charges,
ANCHOR,7695900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
ANCHOR,7695900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
GRAFT,7702867,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,9312.00000,2700.48000,Aetna,First Health,,7617.22,,,,,,,3356.98,7617.22,percent of total billed charges,
GRAFT,7702867,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,9312.00000,2700.48000,Aetna,First Health,,7617.22,,,,,,,2998.46,7617.22,percent of total billed charges,
STENT,7695332,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1250.70,2837.92,percent of total billed charges,
STENT,7695332,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1117.13,2837.92,percent of total billed charges,
PLATE,7698560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.22000,1054.50000,Aetna,First Health,,2974.43,,,,,,,1310.86,2974.43,percent of total billed charges,
PLATE,7698560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.22000,1054.50000,Aetna,First Health,,2974.43,,,,,,,1170.86,2974.43,percent of total billed charges,
SCREW,7695459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7695459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
PIN,7698569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
PIN,7698569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
PIN,7698573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,777.47000,225.47000,Aetna,First Health,,635.97,,,,,,,280.28,635.97,percent of total billed charges,
PIN,7698573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,777.47000,225.47000,Aetna,First Health,,635.97,,,,,,,250.35,635.97,percent of total billed charges,
ROD,7698589,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7698589,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,7698590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7698590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
CATHETER HALO 60,7695237,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,7539.00000,2186.31000,Aetna,First Health,,6166.90,,,,,,,2717.81,6166.90,percent of total billed charges,
CATHETER HALO 60,7695237,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,7539.00000,2186.31000,Aetna,First Health,,6166.90,,,,,,,2427.56,6166.90,percent of total billed charges,
NAIL,7701070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
SPACER SHOULDER,7699269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14010.75000,4063.12000,Aetna,First Health,,11460.79,,,,,,,5050.88,11460.79,percent of total billed charges,
SPACER SHOULDER,7699269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14010.75000,4063.12000,Aetna,First Health,,11460.79,,,,,,,4511.46,11460.79,percent of total billed charges,
LOCKING RING,7699090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,205.70,466.75,percent of total billed charges,
LOCKING RING,7699090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,183.73,466.75,percent of total billed charges,
COMPONENT GLENOSPHERE,7699249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
COMPONENT GLENOSPHERE,7699249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
TROCHANTERIC CLAW,7699101,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3698.10000,1072.45000,Aetna,First Health,,3025.05,,,,,,,1333.17,3025.05,percent of total billed charges,
TROCHANTERIC CLAW,7699101,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3698.10000,1072.45000,Aetna,First Health,,3025.05,,,,,,,1190.79,3025.05,percent of total billed charges,
ROD,7700811,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,533.11,1209.66,percent of total billed charges,
ROD,7700811,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,476.17,1209.66,percent of total billed charges,
PLUG,7699108,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,873.00000,253.17000,Aetna,First Health,,714.11,,,,,,,314.72,714.11,percent of total billed charges,
PLUG,7699108,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,873.00000,253.17000,Aetna,First Health,,714.11,,,,,,,281.11,714.11,percent of total billed charges,
SCREW,7699109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7614.00000,2208.06000,Aetna,First Health,,6228.25,,,,,,,2744.85,6228.25,percent of total billed charges,
SCREW,7699109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7614.00000,2208.06000,Aetna,First Health,,6228.25,,,,,,,2451.71,6228.25,percent of total billed charges,
SCREW,7695841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,First Health,,501.06,,,,,,,220.82,501.06,percent of total billed charges,
SCREW,7695841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,First Health,,501.06,,,,,,,197.24,501.06,percent of total billed charges,
STENT,7695193,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695193,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
LINER,7699133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3576.63,8115.62,percent of total billed charges,
LINER,7699133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3194.66,8115.62,percent of total billed charges,
LOCKING RING,7699135,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,First Health,,2034.20,,,,,,,896.49,2034.20,percent of total billed charges,
LOCKING RING,7699135,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,First Health,,2034.20,,,,,,,800.75,2034.20,percent of total billed charges,
STEM,7696942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1871.68,4246.97,percent of total billed charges,
STEM,7696942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1671.79,4246.97,percent of total billed charges,
STEM,7702135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,7702135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
PLATE,7700228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1613.16000,467.82000,Aetna,First Health,,1319.56,,,,,,,581.54,1319.56,percent of total billed charges,
PLATE,7700228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1613.16000,467.82000,Aetna,First Health,,1319.56,,,,,,,519.44,1319.56,percent of total billed charges,
PLATE,7702283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3410.82000,989.14000,Aetna,First Health,,2790.05,,,,,,,1229.60,2790.05,percent of total billed charges,
PLATE,7702283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3410.82000,989.14000,Aetna,First Health,,2790.05,,,,,,,1098.28,2790.05,percent of total billed charges,
PLATE,7700064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5048.37000,1464.03000,Aetna,First Health,,4129.57,,,,,,,1819.94,4129.57,percent of total billed charges,
PLATE,7700064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5048.37000,1464.03000,Aetna,First Health,,4129.57,,,,,,,1625.58,4129.57,percent of total billed charges,
PLATE,7698079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.32000,1538.83000,Aetna,First Health,,4340.57,,,,,,,1912.93,4340.57,percent of total billed charges,
PLATE,7698079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.32000,1538.83000,Aetna,First Health,,4340.57,,,,,,,1708.64,4340.57,percent of total billed charges,
PLATE,7699725,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1971.60000,571.76000,Aetna,First Health,,1612.77,,,,,,,710.76,1612.77,percent of total billed charges,
PLATE,7699725,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1971.60000,571.76000,Aetna,First Health,,1612.77,,,,,,,634.86,1612.77,percent of total billed charges,
PLATE,7697489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.22000,1054.50000,Aetna,First Health,,2974.43,,,,,,,1310.86,2974.43,percent of total billed charges,
PLATE,7697489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.22000,1054.50000,Aetna,First Health,,2974.43,,,,,,,1170.86,2974.43,percent of total billed charges,
FIBULAR SHAFT,7695784,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3121.80000,905.32000,Aetna,First Health,,2553.63,,,,,,,1125.41,2553.63,percent of total billed charges,
FIBULAR SHAFT,7695784,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3121.80000,905.32000,Aetna,First Health,,2553.63,,,,,,,1005.22,2553.63,percent of total billed charges,
PLATE,7700794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
STEM EXTENSION,7698146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM EXTENSION,7698146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
STEM EXTENSION,7699187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,2052.78,4657.90,percent of total billed charges,
STEM EXTENSION,7699187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,1833.55,4657.90,percent of total billed charges,
SHELL,7700825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7700825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
PLATE,7698577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,7698577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,7700520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,First Health,,7565.68,,,,,,,3334.26,7565.68,percent of total billed charges,
PLATE,7700520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,First Health,,7565.68,,,,,,,2978.18,7565.68,percent of total billed charges,
PLATE,7702010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,1065.64,2418.01,percent of total billed charges,
PLATE,7702010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,951.83,2418.01,percent of total billed charges,
PLATE,7736621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,794.54,1802.87,percent of total billed charges,
PLATE,7736621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,709.69,1802.87,percent of total billed charges,
CATHETER,7694402,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1352.00000,392.08000,Aetna,First Health,,1105.94,,,,,,,487.40,1105.94,percent of total billed charges,
CATHETER,7694402,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1352.00000,392.08000,Aetna,First Health,,1105.94,,,,,,,435.34,1105.94,percent of total billed charges,
STENT GRAFT,7740529,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21567.50000,6254.58000,Aetna,First Health,,17642.22,,,,,,,7775.08,17642.22,percent of total billed charges,
STENT GRAFT,7740529,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21567.50000,6254.58000,Aetna,First Health,,17642.22,,,,,,,6944.73,17642.22,percent of total billed charges,
COMPONENT DISTAL,7699599,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,8306.10000,2408.77000,Aetna,First Health,,6794.39,,,,,,,2994.35,6794.39,percent of total billed charges,
COMPONENT DISTAL,7699599,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,8306.10000,2408.77000,Aetna,First Health,,6794.39,,,,,,,2364.47,6794.39,percent of total billed charges,
STENT GRAFT,7698235,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
STENT GRAFT,7698235,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
CATHETER BALLOON,7699524,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,892.60,2025.37,percent of total billed charges,
CATHETER BALLOON,7699524,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,797.27,2025.37,percent of total billed charges,
STENT GRAFT,7697986,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7697986,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
CATHETER,8135831,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,1652.00000,479.08000,Aetna,First Health,,1351.34,,,,,,,595.55,1351.34,percent of total billed charges,
CATHETER,8135831,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,1652.00000,479.08000,Aetna,First Health,,1351.34,,,,,,,531.94,9959.00,percent of total billed charges,
PLATE,7699218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,829.85000,240.66000,Aetna,First Health,,678.82,,,,,,,299.16,678.82,percent of total billed charges,
PLATE,7699218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,829.85000,240.66000,Aetna,First Health,,678.82,,,,,,,267.21,678.82,percent of total billed charges,
TIGHTROPE,7697463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5105.63000,1480.63000,Aetna,First Health,,4176.41,,,,,,,1840.58,4176.41,percent of total billed charges,
TIGHTROPE,7697463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5105.63000,1480.63000,Aetna,First Health,,4176.41,,,,,,,1644.01,4176.41,percent of total billed charges,
CATHETER BALLOON,7694850,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1652.76000,479.30000,Aetna,First Health,,1351.96,,,,,,,595.82,1351.96,percent of total billed charges,
CATHETER BALLOON,7694850,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1652.76000,479.30000,Aetna,First Health,,1351.96,,,,,,,532.19,1351.96,percent of total billed charges,
CATHETER DIALYSIS,7693559,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,414.92000,120.33000,Aetna,First Health,,339.40,,,,,,,149.58,339.40,percent of total billed charges,
CATHETER DIALYSIS,7693559,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,414.92000,120.33000,Aetna,First Health,,339.40,,,,,,,133.60,339.40,percent of total billed charges,
BONE PUTTY,7694362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,427.83000,124.07000,Aetna,First Health,,349.96,,,,,,,154.23,349.96,percent of total billed charges,
BONE PUTTY,7694362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,427.83000,124.07000,Aetna,First Health,,349.96,,,,,,,137.76,349.96,percent of total billed charges,
PLATE,7701183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,130.14,295.30,percent of total billed charges,
PLATE,7701183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,116.24,295.30,percent of total billed charges,
CATHETER BALLOON,7694442,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
CATHETER BALLOON,7694442,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
BARRIER ADHESION,7694666,CDM,278,RC,C1765,HCPCS,,,facility,inpatient,,,2308.40000,669.44000,Aetna,First Health,,1888.27,,,,,,,832.18,1888.27,percent of total billed charges,
BARRIER ADHESION,7694666,CDM,278,RC,C1765,HCPCS,,,facility,outpatient,,,2308.40000,669.44000,Aetna,First Health,,1888.27,,,,,,,743.30,1888.27,percent of total billed charges,
CEMENT,7694853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1466.40000,425.26000,Aetna,First Health,,1199.52,,,,,,,528.64,1199.52,percent of total billed charges,
CEMENT,7694853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1466.40000,425.26000,Aetna,First Health,,1199.52,,,,,,,472.18,1199.52,percent of total billed charges,
TENDON,7694896,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17859.38000,5179.22000,Aetna,First Health,,14608.97,,,,,,,6438.31,14608.97,percent of total billed charges,
TENDON,7694896,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17859.38000,5179.22000,Aetna,First Health,,14608.97,,,,,,,5750.72,14608.97,percent of total billed charges,
NEUROSTIMULATOR,7695394,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,29632.50000,8593.42000,Aetna,First Health,,24239.38,,,,,,,10682.52,24239.38,percent of total billed charges,
NEUROSTIMULATOR,7695394,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,29632.50000,8593.42000,Aetna,First Health,,24239.38,,,,,,,9541.67,24239.38,percent of total billed charges,
PLATE,7695887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,868.50000,251.86000,Aetna,First Health,,710.43,,,,,,,313.09,710.43,percent of total billed charges,
PLATE,7695887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,868.50000,251.86000,Aetna,First Health,,710.43,,,,,,,279.66,710.43,percent of total billed charges,
SCREW,7701649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
SCREW,7701649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
GRAFT,7696123,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8055.00000,2335.95000,Aetna,First Health,,6588.99,,,,,,,2903.83,6588.99,percent of total billed charges,
GRAFT,7696123,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8055.00000,2335.95000,Aetna,First Health,,6588.99,,,,,,,2593.71,6588.99,percent of total billed charges,
MESH,7696128,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,940.69000,272.80000,Aetna,First Health,,769.48,,,,,,,339.12,769.48,percent of total billed charges,
MESH,7696128,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,940.69000,272.80000,Aetna,First Health,,769.48,,,,,,,302.90,769.48,percent of total billed charges,
MESH,7696129,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,932.73000,270.49000,Aetna,First Health,,762.97,,,,,,,336.25,762.97,percent of total billed charges,
MESH,7696129,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,932.73000,270.49000,Aetna,First Health,,762.97,,,,,,,300.34,762.97,percent of total billed charges,
INTRODUCER,8135599,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,260.37,590.80,percent of total billed charges,
INTRODUCER,8135599,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,232.56,590.80,percent of total billed charges,
BALLOON,8135847,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135847,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135846,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135846,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135844,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135844,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135843,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135843,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135842,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135842,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135840,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135840,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
SNARE SYSTEM,8135849,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2806.72000,813.95000,Aetna,First Health,,2295.90,,,,,,,1011.82,2295.90,percent of total billed charges,
SNARE SYSTEM,8135849,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2806.72000,813.95000,Aetna,First Health,,2295.90,,,,,,,903.76,2295.90,percent of total billed charges,
SNARE GOOSENECK,8135850,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
SNARE GOOSENECK,8135850,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
CATHETER ABLATION,8135469,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1242.82,2820.05,percent of total billed charges,
CATHETER ABLATION,8135469,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1110.10,9959.00,percent of total billed charges,
GUIDE CATHETER,8135523,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135523,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
BALLOON CATHETER,8135853,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,167.81,380.78,percent of total billed charges,
BALLOON CATHETER,8135853,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,149.89,380.78,percent of total billed charges,
BALLOON CATHETER,8135852,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,167.81,380.78,percent of total billed charges,
BALLOON CATHETER,8135852,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,149.89,380.78,percent of total billed charges,
BALLOON CATHETER,8135851,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,167.81,380.78,percent of total billed charges,
BALLOON CATHETER,8135851,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,149.89,380.78,percent of total billed charges,
PUMP SET AIC IMPELLA,8135854,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,52000.00000,15080.00000,Aetna,First Health,,42536.00,,,,,,,18746.00,42536.00,percent of total billed charges,
PUMP SET AIC IMPELLA,8135854,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,52000.00000,15080.00000,Aetna,First Health,,42536.00,,,,,,,16744.00,42536.00,percent of total billed charges,
GUIDE CATHETER,8135496,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135496,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
PLATE,7699179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2389.04000,692.82000,Aetna,First Health,,1954.23,,,,,,,861.25,1954.23,percent of total billed charges,
PLATE,7699179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2389.04000,692.82000,Aetna,First Health,,1954.23,,,,,,,769.27,1954.23,percent of total billed charges,
PLATE,7699180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1845.92000,535.32000,Aetna,First Health,,1509.96,,,,,,,665.45,1509.96,percent of total billed charges,
PLATE,7699180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1845.92000,535.32000,Aetna,First Health,,1509.96,,,,,,,594.39,1509.96,percent of total billed charges,
CABLE,7695520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1658.08000,480.84000,Aetna,First Health,,1356.31,,,,,,,597.74,1356.31,percent of total billed charges,
CABLE,7695520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1658.08000,480.84000,Aetna,First Health,,1356.31,,,,,,,533.90,1356.31,percent of total billed charges,
CATHETER,7699171,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
CATHETER,7699171,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
CATHETER DIL BALLOON,7698172,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7698172,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
STENT,7694311,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7694311,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
VALVE,7695606,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,6218.62,14110.50,percent of total billed charges,
VALVE,7695606,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,5554.50,14110.50,percent of total billed charges,
PIN,7695842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.48000,143.40000,Aetna,First Health,,404.48,,,,,,,178.26,404.48,percent of total billed charges,
PIN,7695842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.48000,143.40000,Aetna,First Health,,404.48,,,,,,,159.22,404.48,percent of total billed charges,
NAIL,7699296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7699296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
FEMORAL IMPLANT,7699315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17887.00000,5187.23000,Aetna,First Health,,14631.57,,,,,,,6448.26,14631.57,percent of total billed charges,
FEMORAL IMPLANT,7699315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17887.00000,5187.23000,Aetna,First Health,,14631.57,,,,,,,5759.61,14631.57,percent of total billed charges,
COMPONENT GLENOID,7695587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
COMPONENT GLENOID,7695587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
STEM,7695590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7695590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
HUMERAL HEAD,7699331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7699331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
PLATE,7699106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,First Health,,6338.19,,,,,,,2793.30,6338.19,percent of total billed charges,
PLATE,7699106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,First Health,,6338.19,,,,,,,2494.98,6338.19,percent of total billed charges,
PLATE,7694881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,870.20,1974.55,percent of total billed charges,
PLATE,7694881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,777.27,1974.55,percent of total billed charges,
COMPONENT FEMORAL,7699338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15425.00000,4473.25000,Aetna,First Health,,12617.65,,,,,,,5560.71,12617.65,percent of total billed charges,
COMPONENT FEMORAL,7699338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15425.00000,4473.25000,Aetna,First Health,,12617.65,,,,,,,4966.85,12617.65,percent of total billed charges,
COMPONENT TIBIAL,7699343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2752.42,6245.43,percent of total billed charges,
COMPONENT TIBIAL,7699343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2458.47,6245.43,percent of total billed charges,
INSERT,7699345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1932.00000,560.28000,Aetna,First Health,,1580.38,,,,,,,696.49,1580.38,percent of total billed charges,
INSERT,7699345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1932.00000,560.28000,Aetna,First Health,,1580.38,,,,,,,622.10,1580.38,percent of total billed charges,
COMPONENT FEMORAL,7699365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7699365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
SPACER,7696939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3759.70000,1090.31000,Aetna,First Health,,3075.43,,,,,,,1355.37,3075.43,percent of total billed charges,
SPACER,7696939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3759.70000,1090.31000,Aetna,First Health,,3075.43,,,,,,,1210.62,3075.43,percent of total billed charges,
INSERT,7699368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7699368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT FEMORAL,7698055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7698055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT PATELLA,7699356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
COMPONENT PATELLA,7699356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
PLATE,7701575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5471.97000,1586.87000,Aetna,First Health,,4476.07,,,,,,,1972.65,4476.07,percent of total billed charges,
PLATE,7701575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5471.97000,1586.87000,Aetna,First Health,,4476.07,,,,,,,1761.97,4476.07,percent of total billed charges,
PLATE,7699377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2426.28000,703.62000,Aetna,First Health,,1984.70,,,,,,,874.67,1984.70,percent of total billed charges,
PLATE,7699377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2426.28000,703.62000,Aetna,First Health,,1984.70,,,,,,,781.26,1984.70,percent of total billed charges,
NAIL CAP,7698918,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
NAIL CAP,7698918,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
PLATE,7699572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1361.95,3090.35,percent of total billed charges,
PLATE,7699572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1216.50,3090.35,percent of total billed charges,
SCREW,7699422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2009.40000,582.73000,Aetna,First Health,,1643.69,,,,,,,724.39,1643.69,percent of total billed charges,
SCREW,7699422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2009.40000,582.73000,Aetna,First Health,,1643.69,,,,,,,647.03,1643.69,percent of total billed charges,
COMPONENT GLENOID,7699428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
COMPONENT GLENOID,7699428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
HUMERAL HEAD,7699432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
HUMERAL HEAD,7699432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
SCREW,7699437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,7699437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
COMPONENT TIBIAL,7699185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8611.20000,2497.25000,Aetna,First Health,,7043.96,,,,,,,3104.34,7043.96,percent of total billed charges,
COMPONENT TIBIAL,7699185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8611.20000,2497.25000,Aetna,First Health,,7043.96,,,,,,,2772.81,7043.96,percent of total billed charges,
PLATE,7699441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3737.30000,1083.82000,Aetna,First Health,,3057.11,,,,,,,1347.30,3057.11,percent of total billed charges,
PLATE,7699441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3737.30000,1083.82000,Aetna,First Health,,3057.11,,,,,,,1203.41,3057.11,percent of total billed charges,
FEMORAL IMPLANT,7698527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17887.00000,5187.23000,Aetna,First Health,,14631.57,,,,,,,6448.26,14631.57,percent of total billed charges,
FEMORAL IMPLANT,7698527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17887.00000,5187.23000,Aetna,First Health,,14631.57,,,,,,,5759.61,14631.57,percent of total billed charges,
FEMORAL HEAD,7698529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
FEMORAL HEAD,7698529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PLATE,7699458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6077.86000,1762.58000,Aetna,First Health,,4971.69,,,,,,,2191.07,4971.69,percent of total billed charges,
PLATE,7699458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6077.86000,1762.58000,Aetna,First Health,,4971.69,,,,,,,1957.07,4971.69,percent of total billed charges,
LINER,7699461,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7699461,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SHELL,7699460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7699460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BALLOON,7694389,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
BALLOON,7694389,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
TAPER,7699478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
TAPER,7699478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
TAPER,7699480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.80000,359.83000,Aetna,First Health,,1014.97,,,,,,,447.31,1014.97,percent of total billed charges,
TAPER,7699480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.80000,359.83000,Aetna,First Health,,1014.97,,,,,,,399.54,1014.97,percent of total billed charges,
PLATE,7699463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5693.10000,1651.00000,Aetna,First Health,,4656.96,,,,,,,2052.36,4656.96,percent of total billed charges,
PLATE,7699463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5693.10000,1651.00000,Aetna,First Health,,4656.96,,,,,,,1833.18,4656.96,percent of total billed charges,
CABLE,7696190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,347.16,787.73,percent of total billed charges,
CABLE,7696190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,310.09,787.73,percent of total billed charges,
SCREW,7695801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7695801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
PLATE,7702394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2993.56000,868.13000,Aetna,First Health,,2448.73,,,,,,,1079.18,2448.73,percent of total billed charges,
PLATE,7702394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2993.56000,868.13000,Aetna,First Health,,2448.73,,,,,,,963.93,2448.73,percent of total billed charges,
HUMERAL HEAD,7695589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7695589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
SLEEVE,7699491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,First Health,,2856.56,,,,,,,1258.91,2856.56,percent of total billed charges,
SLEEVE,7699491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,First Health,,2856.56,,,,,,,1124.47,2856.56,percent of total billed charges,
INSERT,7699493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7699493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
COMPONENT FEMORAL,7699494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,7689.47,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7699494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,6868.26,17447.94,percent of total billed charges,
WEDGE,7699497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7699497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
RADIAL HEAD,7699498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2812.98,6382.85,percent of total billed charges,
RADIAL HEAD,7699498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2512.57,6382.85,percent of total billed charges,
STEM,7699499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
STEM,7699499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,7699502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1549.73,3516.45,percent of total billed charges,
PLATE,7699502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1384.23,3516.45,percent of total billed charges,
STENT DUODENAL,7695159,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,3356.09,7615.20,percent of total billed charges,
STENT DUODENAL,7695159,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,2997.67,7615.20,percent of total billed charges,
CATHETER HALO ULTRA,7695245,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8142.00000,2361.18000,Aetna,First Health,,6660.16,,,,,,,2935.19,6660.16,percent of total billed charges,
CATHETER HALO ULTRA,7695245,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8142.00000,2361.18000,Aetna,First Health,,6660.16,,,,,,,2621.72,6660.16,percent of total billed charges,
GRASPING DEVICE TALON,7695186,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,720.00000,208.80000,Aetna,First Health,,588.96,,,,,,,259.56,588.96,percent of total billed charges,
GRASPING DEVICE TALON,7695186,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,720.00000,208.80000,Aetna,First Health,,588.96,,,,,,,231.84,588.96,percent of total billed charges,
BONE CEMENT,7694306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.16000,352.69000,Aetna,First Health,,994.82,,,,,,,438.43,994.82,percent of total billed charges,
BONE CEMENT,7694306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.16000,352.69000,Aetna,First Health,,994.82,,,,,,,391.60,994.82,percent of total billed charges,
ANCHOR,7697453,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
ANCHOR,7697453,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
GUIDEWIRE,7695081,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
GUIDEWIRE,7695081,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
STENT GRAFT,7768032,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4558.52,10343.61,percent of total billed charges,
STENT GRAFT,7768032,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4071.69,10343.61,percent of total billed charges,
BIOCONVEX PATELLA,7768031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7665.00000,2222.85000,Aetna,First Health,,6269.97,,,,,,,2763.23,6269.97,percent of total billed charges,
BIOCONVEX PATELLA,7768031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7665.00000,2222.85000,Aetna,First Health,,6269.97,,,,,,,2468.13,6269.97,percent of total billed charges,
LEAD,7697309,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
LEAD,7697309,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
LEAD,7694970,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
LEAD,7694970,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STENT,7694386,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,774.00000,224.46000,Aetna,First Health,,633.13,,,,,,,279.03,633.13,percent of total billed charges,
STENT,7694386,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,774.00000,224.46000,Aetna,First Health,,633.13,,,,,,,249.23,633.13,percent of total billed charges,
STENT INTRO,7695006,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
STENT INTRO,7695006,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
STENT,7695192,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
STENT,7695192,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
GUIDEWIRE,8148864,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
GUIDEWIRE,8148864,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
CATHETER,7699512,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,First Health,,2296.94,,,,,,,1012.28,2296.94,percent of total billed charges,
CATHETER,7699512,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,First Health,,2296.94,,,,,,,904.18,2296.94,percent of total billed charges,
COIL,7699513,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,First Health,,3070.57,,,,,,,1353.23,3070.57,percent of total billed charges,
COIL,7699513,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,First Health,,3070.57,,,,,,,1208.71,3070.57,percent of total billed charges,
STEM,7699528,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,5515.65,12515.40,percent of total billed charges,
STEM,7699528,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,4926.60,12515.40,percent of total billed charges,
TIBIAL TRAY,7698027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,First Health,,15018.48,,,,,,,6618.78,15018.48,percent of total billed charges,
TIBIAL TRAY,7698027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,First Health,,15018.48,,,,,,,5911.92,15018.48,percent of total billed charges,
NAIL,7695503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7695503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
SCREW,7698920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7698920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
COMPONENT PATELLA,7698618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7698618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
STENT GRAFT,7699544,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,18652.27,42323.32,percent of total billed charges,
STENT GRAFT,7699544,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,16660.28,42323.32,percent of total billed charges,
STENT GRAFT,7699545,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,16524.24,37494.67,percent of total billed charges,
STENT GRAFT,7699545,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,14759.51,37494.67,percent of total billed charges,
PLATE,7699547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1802.48000,522.72000,Aetna,First Health,,1474.43,,,,,,,649.79,1474.43,percent of total billed charges,
PLATE,7699547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1802.48000,522.72000,Aetna,First Health,,1474.43,,,,,,,580.40,1474.43,percent of total billed charges,
PLATE,7699548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1920.40000,556.92000,Aetna,First Health,,1570.89,,,,,,,692.30,1570.89,percent of total billed charges,
PLATE,7699548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1920.40000,556.92000,Aetna,First Health,,1570.89,,,,,,,618.37,1570.89,percent of total billed charges,
PLATE,7699553,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2816.00000,816.64000,Aetna,First Health,,2303.49,,,,,,,1015.17,2303.49,percent of total billed charges,
PLATE,7699553,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2816.00000,816.64000,Aetna,First Health,,2303.49,,,,,,,906.75,2303.49,percent of total billed charges,
SCREW,7699557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7699557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7965481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7965481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
CATHETER,7702688,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,3671.50000,1064.73000,Aetna,First Health,,3003.29,,,,,,,1323.58,3003.29,percent of total billed charges,
CATHETER,7702688,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,3671.50000,1064.73000,Aetna,First Health,,3003.29,,,,,,,1182.22,3003.29,percent of total billed charges,
PLATE,7699568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,958.50000,277.96000,Aetna,First Health,,784.05,,,,,,,345.54,784.05,percent of total billed charges,
PLATE,7699568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,958.50000,277.96000,Aetna,First Health,,784.05,,,,,,,308.64,784.05,percent of total billed charges,
PLATE,7699566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8144.13000,2361.80000,Aetna,First Health,,6661.90,,,,,,,2935.96,6661.90,percent of total billed charges,
PLATE,7699566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8144.13000,2361.80000,Aetna,First Health,,6661.90,,,,,,,2622.41,6661.90,percent of total billed charges,
PLATE,7701314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1580.00000,458.20000,Aetna,First Health,,1292.44,,,,,,,569.59,1292.44,percent of total billed charges,
PLATE,7701314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1580.00000,458.20000,Aetna,First Health,,1292.44,,,,,,,508.76,1292.44,percent of total billed charges,
ROD,7697970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7697970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
LINER,7699615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7699615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
PLATE,7699607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1566.60000,454.31000,Aetna,First Health,,1281.48,,,,,,,564.76,1281.48,percent of total billed charges,
PLATE,7699607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1566.60000,454.31000,Aetna,First Health,,1281.48,,,,,,,504.45,1281.48,percent of total billed charges,
SCREW,7695800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,302.94,687.39,percent of total billed charges,
SCREW,7695800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,270.59,687.39,percent of total billed charges,
INSERT,7698144,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7698144,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
COMPONENT FEMORAL,7698145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6862.61,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7698145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6129.71,15571.76,percent of total billed charges,
SLEEVE,7699636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1894.12000,549.29000,Aetna,First Health,,1549.39,,,,,,,682.83,1549.39,percent of total billed charges,
SLEEVE,7699636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1894.12000,549.29000,Aetna,First Health,,1549.39,,,,,,,609.91,1549.39,percent of total billed charges,
SCREW,7696955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
SCREW,7696955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
TAPER,7699640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
TAPER,7699640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SHELL,7699644,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7699644,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
PLATE,7699679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7699679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
INSERT,7698397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2826.49,6413.50,percent of total billed charges,
INSERT,7698397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2524.63,6413.50,percent of total billed charges,
COMPONENT TIBIAL,7698401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,5416.16,12289.66,percent of total billed charges,
COMPONENT TIBIAL,7698401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,4837.74,12289.66,percent of total billed charges,
ROD,7699107,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
ROD,7699107,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
PLATE,7699704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,742.63,1685.08,percent of total billed charges,
PLATE,7699704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,663.32,1685.08,percent of total billed charges,
GUIDEWIRE,7699703,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,118.15,268.10,percent of total billed charges,
GUIDEWIRE,7699703,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,105.54,268.10,percent of total billed charges,
PLATE,7699728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7407.00000,2148.03000,Aetna,First Health,,6058.93,,,,,,,2670.22,6058.93,percent of total billed charges,
PLATE,7699728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7407.00000,2148.03000,Aetna,First Health,,6058.93,,,,,,,2385.05,6058.93,percent of total billed charges,
FILTER,7697285,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
FILTER,7697285,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
SHELL,7698477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
SHELL,7698477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
LINER,7697960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,First Health,,2470.36,,,,,,,1088.71,2470.36,percent of total billed charges,
LINER,7697960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,First Health,,2470.36,,,,,,,972.44,2470.36,percent of total billed charges,
FEMORAL HEAD,7699737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1173.43,2662.59,percent of total billed charges,
FEMORAL HEAD,7699737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1048.11,2662.59,percent of total billed charges,
BREAST IMPLANT,7697096,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697096,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
FEMORAL HEAD,7698320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7698320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
TISSUE EXPANDER,7699764,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
TISSUE EXPANDER,7699764,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
TIGHTROPE,7699786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.68000,235.10000,Aetna,First Health,,663.14,,,,,,,292.25,663.14,percent of total billed charges,
TIGHTROPE,7699786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.68000,235.10000,Aetna,First Health,,663.14,,,,,,,261.04,663.14,percent of total billed charges,
TIGHTROPE,7699787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,452.36,1026.43,percent of total billed charges,
TIGHTROPE,7699787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,404.05,1026.43,percent of total billed charges,
TIGHTROPE,7699788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,802.11,1820.05,percent of total billed charges,
TIGHTROPE,7699788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,716.45,1820.05,percent of total billed charges,
INSERT,7698196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7698196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
LEAD,7699792,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
LEAD,7699792,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
COMPONENT FEMORAL,7699799,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,7699799,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
GRAFT,7699809,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,1957.20000,567.59000,Aetna,First Health,,1600.99,,,,,,,705.57,1600.99,percent of total billed charges,
GRAFT,7699809,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,1957.20000,567.59000,Aetna,First Health,,1600.99,,,,,,,630.22,1600.99,percent of total billed charges,
CATHETER,7699841,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
CATHETER,7699841,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
BONE GRAFT,7699822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8932.50000,2590.42000,Aetna,First Health,,7306.78,,,,,,,3220.17,7306.78,percent of total billed charges,
BONE GRAFT,7699822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8932.50000,2590.42000,Aetna,First Health,,7306.78,,,,,,,2876.26,7306.78,percent of total billed charges,
SCREW,7695366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7695366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
STEM,7893608,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,7893608,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
PLATE,7893610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4673.59000,1355.34000,Aetna,First Health,,3823.00,,,,,,,1684.83,3823.00,percent of total billed charges,
PLATE,7893610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4673.59000,1355.34000,Aetna,First Health,,3823.00,,,,,,,1504.90,3823.00,percent of total billed charges,
CATHETER,7695623,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER,7695623,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
LINER,7893912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
LINER,7893912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STEM,7893913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7893913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
ANCHOR,7893958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1820.00000,527.80000,Aetna,First Health,,1488.76,,,,,,,656.11,1488.76,percent of total billed charges,
ANCHOR,7893958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1820.00000,527.80000,Aetna,First Health,,1488.76,,,,,,,586.04,1488.76,percent of total billed charges,
PROBE CRYOABLATION,7852029,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3460.80,7852.80,percent of total billed charges,
PROBE CRYOABLATION,7852029,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3091.20,7852.80,percent of total billed charges,
PROBE CRYOABLATION,7694870,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,11280.00000,3271.20000,Aetna,First Health,,9227.04,,,,,,,4066.44,9227.04,percent of total billed charges,
PROBE CRYOABLATION,7694870,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,11280.00000,3271.20000,Aetna,First Health,,9227.04,,,,,,,3632.16,9227.04,percent of total billed charges,
SCREW,7695559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,582.57,1321.89,percent of total billed charges,
SCREW,7695559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,520.35,1321.89,percent of total billed charges,
PLUG,7894125,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,906.12000,262.77000,Aetna,First Health,,741.21,,,,,,,326.66,741.21,percent of total billed charges,
PLUG,7894125,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,906.12000,262.77000,Aetna,First Health,,741.21,,,,,,,291.77,741.21,percent of total billed charges,
BONE VOID FILLER,7894202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
BONE VOID FILLER,7894202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
BONE VOID FILLER,7894203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14700.00000,4263.00000,Aetna,First Health,,12024.60,,,,,,,5299.35,12024.60,percent of total billed charges,
BONE VOID FILLER,7894203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14700.00000,4263.00000,Aetna,First Health,,12024.60,,,,,,,4733.40,12024.60,percent of total billed charges,
GUIDEWIRE,7699120,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,230.78000,66.93000,Aetna,First Health,,188.78,,,,,,,83.20,188.78,percent of total billed charges,
GUIDEWIRE,7699120,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,230.78000,66.93000,Aetna,First Health,,188.78,,,,,,,74.31,188.78,percent of total billed charges,
PLATE,7894228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2078.68000,602.82000,Aetna,First Health,,1700.36,,,,,,,749.36,1700.36,percent of total billed charges,
PLATE,7894228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2078.68000,602.82000,Aetna,First Health,,1700.36,,,,,,,669.33,1700.36,percent of total billed charges,
PLATE,7894231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,First Health,,1515.03,,,,,,,667.69,1515.03,percent of total billed charges,
PLATE,7894231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,First Health,,1515.03,,,,,,,596.38,1515.03,percent of total billed charges,
SCREW,7695301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,452.36,1026.43,percent of total billed charges,
SCREW,7695301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,404.05,1026.43,percent of total billed charges,
PLATE,7894284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9978.00000,2893.62000,Aetna,First Health,,8162.00,,,,,,,3597.07,8162.00,percent of total billed charges,
PLATE,7894284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9978.00000,2893.62000,Aetna,First Health,,8162.00,,,,,,,3212.92,8162.00,percent of total billed charges,
WEDGE,7894315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5675.25000,1645.82000,Aetna,First Health,,4642.35,,,,,,,2045.93,4642.35,percent of total billed charges,
WEDGE,7894315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5675.25000,1645.82000,Aetna,First Health,,4642.35,,,,,,,1827.43,4642.35,percent of total billed charges,
MODULAR HEAD,7895648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2920.05,6625.80,percent of total billed charges,
MODULAR HEAD,7895648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2608.20,6625.80,percent of total billed charges,
STEM,7895649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,7895649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
ALLOGRAFT,7895465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1854.68000,537.86000,Aetna,First Health,,1517.13,,,,,,,668.61,1517.13,percent of total billed charges,
ALLOGRAFT,7895465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1854.68000,537.86000,Aetna,First Health,,1517.13,,,,,,,597.21,1517.13,percent of total billed charges,
PATELLA,7895673,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
PATELLA,7895673,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SPACER HIP CEMENT,7698839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,First Health,,3944.93,,,,,,,1738.57,3944.93,percent of total billed charges,
SPACER HIP CEMENT,7698839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,First Health,,3944.93,,,,,,,1552.89,3944.93,percent of total billed charges,
INSERT,7896397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5600.00000,1624.00000,Aetna,First Health,,4580.80,,,,,,,2018.80,4580.80,percent of total billed charges,
INSERT,7896397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5600.00000,1624.00000,Aetna,First Health,,4580.80,,,,,,,1803.20,4580.80,percent of total billed charges,
SCREW,7896389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7896389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
PLATE,7896749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1847.20,4191.43,percent of total billed charges,
PLATE,7896749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1649.93,4191.43,percent of total billed charges,
INSERT,7896843,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7896843,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INTRODUCER,7896881,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,First Health,,407.20,,,,,,,179.46,407.20,percent of total billed charges,
INTRODUCER,7896881,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,First Health,,407.20,,,,,,,160.29,407.20,percent of total billed charges,
PIN,7896875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,166.10,376.89,percent of total billed charges,
PIN,7896875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,148.36,376.89,percent of total billed charges,
SCREW,7698614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7698614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
CATHETER BRONCHIAL THERMOPLASTY,7896969,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
CATHETER BRONCHIAL THERMOPLASTY,7896969,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
STEM,7882483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,7882483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
LEAD,7897116,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
LEAD,7897116,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
GENERATOR,7897118,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,58000.00000,16820.00000,Aetna,First Health,,47444.00,,,,,,,20909.00,47444.00,percent of total billed charges,
GENERATOR,7897118,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,58000.00000,16820.00000,Aetna,First Health,,47444.00,,,,,,,18676.00,47444.00,percent of total billed charges,
LEAD,7897119,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
LEAD,7897119,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PROGRAMMER,7897120,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4494.00000,1303.26000,Aetna,First Health,,3676.09,,,,,,,1620.09,3676.09,percent of total billed charges,
PROGRAMMER,7897120,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4494.00000,1303.26000,Aetna,First Health,,3676.09,,,,,,,1447.07,3676.09,percent of total billed charges,
CHARGING SYSTEM,7897121,CDM,278,RC,C1822,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
CHARGING SYSTEM,7897121,CDM,278,RC,C1822,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BOLT,7897352,CDM,278,RC,,,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,First Health,,2856.56,,,,,,,1258.91,2856.56,percent of total billed charges,
BOLT,7897352,CDM,278,RC,,,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,First Health,,2856.56,,,,,,,1124.47,2856.56,percent of total billed charges,
INSERT,7897359,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9144.09000,2651.79000,Aetna,First Health,,7479.87,,,,,,,3296.44,7479.87,percent of total billed charges,
INSERT,7897359,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9144.09000,2651.79000,Aetna,First Health,,7479.87,,,,,,,2944.40,7479.87,percent of total billed charges,
SCREW,7910231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7910231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
PLATE,7897361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1421.99,3226.60,percent of total billed charges,
PLATE,7897361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1270.13,3226.60,percent of total billed charges,
HUMERAL HEAD,7695586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7695586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
ANCHOR,7696403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,680.98,1545.20,percent of total billed charges,
ANCHOR,7696403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,608.26,1545.20,percent of total billed charges,
CATHETER,7900150,CDM,278,RC,C1755,HCPCS,,,facility,inpatient,,,4980.50000,1444.34000,Aetna,First Health,,4074.05,,,,,,,1795.47,4074.05,percent of total billed charges,
CATHETER,7900150,CDM,278,RC,C1755,HCPCS,,,facility,outpatient,,,4980.50000,1444.34000,Aetna,First Health,,4074.05,,,,,,,1603.72,4074.05,percent of total billed charges,
BONE GRAFT,7900141,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
BONE GRAFT,7900141,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
PLATE,7900295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1596.11,3621.70,percent of total billed charges,
PLATE,7900295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1425.65,3621.70,percent of total billed charges,
RADIAL HEAD,7900297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
RADIAL HEAD,7900297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7900326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,First Health,,3638.62,,,,,,,1603.57,3638.62,percent of total billed charges,
PLATE,7900326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,First Health,,3638.62,,,,,,,1432.32,3638.62,percent of total billed charges,
PLATE,7900534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1771.97,4020.72,percent of total billed charges,
PLATE,7900534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1582.73,4020.72,percent of total billed charges,
VALVE,7741812,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
VALVE,7741812,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
RADIAL HEAD,7699527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,First Health,,18047.12,,,,,,,7953.53,18047.12,percent of total billed charges,
RADIAL HEAD,7699527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,First Health,,18047.12,,,,,,,7104.12,18047.12,percent of total billed charges,
FEMORAL HEAD,7901616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7901616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
CATHETER,7901621,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
CATHETER,7901621,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
BASEPLATE,7901700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
BASEPLATE,7901700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
BASEPLATE,7901703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1299.40,2948.43,percent of total billed charges,
BASEPLATE,7901703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1160.63,2948.43,percent of total billed charges,
PASTE BEADS,7698897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9810.03000,2844.91000,Aetna,First Health,,8024.60,,,,,,,3536.52,8024.60,percent of total billed charges,
PASTE BEADS,7698897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9810.03000,2844.91000,Aetna,First Health,,8024.60,,,,,,,3158.83,8024.60,percent of total billed charges,
SCREW,7901799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,507.78000,147.26000,Aetna,First Health,,415.36,,,,,,,183.05,415.36,percent of total billed charges,
SCREW,7901799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,507.78000,147.26000,Aetna,First Health,,415.36,,,,,,,163.51,415.36,percent of total billed charges,
PLATE,7901853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5936.39000,1721.55000,Aetna,First Health,,4855.97,,,,,,,2140.07,4855.97,percent of total billed charges,
PLATE,7901853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5936.39000,1721.55000,Aetna,First Health,,4855.97,,,,,,,1911.52,4855.97,percent of total billed charges,
INSERT,7901859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,7901859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SHELL,7902103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,4027.94,9139.68,percent of total billed charges,
SHELL,7902103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,3597.77,9139.68,percent of total billed charges,
STERNA BAND,7702706,CDM,278,RC,,,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
STERNA BAND,7702706,CDM,278,RC,,,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
STEM,7902345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM,7902345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
STEM EXTENSION,7902350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM EXTENSION,7902350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
GRIP CABLE,7902352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3493.00000,1012.97000,Aetna,First Health,,2857.27,,,,,,,1259.23,2857.27,percent of total billed charges,
GRIP CABLE,7902352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3493.00000,1012.97000,Aetna,First Health,,2857.27,,,,,,,1124.75,2857.27,percent of total billed charges,
CATHETER,7902637,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,646.47000,187.48000,Aetna,First Health,,528.81,,,,,,,233.05,528.81,percent of total billed charges,
CATHETER,7902637,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,646.47000,187.48000,Aetna,First Health,,528.81,,,,,,,208.16,528.81,percent of total billed charges,
SCREW,7902622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7902622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7902655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,324.90000,94.22000,Aetna,First Health,,265.77,,,,,,,117.13,265.77,percent of total billed charges,
SCREW,7902655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,324.90000,94.22000,Aetna,First Health,,265.77,,,,,,,104.62,265.77,percent of total billed charges,
NAIL,7700046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1803.80,4092.94,percent of total billed charges,
NAIL,7700046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1611.16,4092.94,percent of total billed charges,
GLENOSPHERE,7901701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
GLENOSPHERE,7901701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
BASEPLATE,7902776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6268.50000,1817.86000,Aetna,First Health,,5127.63,,,,,,,2259.79,5127.63,percent of total billed charges,
BASEPLATE,7902776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6268.50000,1817.86000,Aetna,First Health,,5127.63,,,,,,,2018.46,5127.63,percent of total billed charges,
BALLOON CATHETER,7880447,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,1220.00000,353.80000,Aetna,First Health,,997.96,,,,,,,439.81,997.96,percent of total billed charges,
BALLOON CATHETER,7880447,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,1220.00000,353.80000,Aetna,First Health,,997.96,,,,,,,392.84,997.96,percent of total billed charges,
COIL,7902978,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4163.25000,1207.34000,Aetna,First Health,,3405.54,,,,,,,1500.85,3405.54,percent of total billed charges,
COIL,7902978,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4163.25000,1207.34000,Aetna,First Health,,3405.54,,,,,,,1340.57,3405.54,percent of total billed charges,
SCREW,7965486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,330.96,750.96,percent of total billed charges,
SCREW,7965486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,295.61,750.96,percent of total billed charges,
HUMERAL CUP,7903145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1622.36,3681.25,percent of total billed charges,
HUMERAL CUP,7903145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1449.10,3681.25,percent of total billed charges,
COMPONENT GLENOSPHERE,7903148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
COMPONENT GLENOSPHERE,7903148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
PEG,7903504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11521.50000,3341.23000,Aetna,First Health,,9424.59,,,,,,,4153.50,9424.59,percent of total billed charges,
PEG,7903504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11521.50000,3341.23000,Aetna,First Health,,9424.59,,,,,,,3709.92,9424.59,percent of total billed charges,
SCREW,7903577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7903577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE,7903581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8952.00000,2596.08000,Aetna,First Health,,7322.74,,,,,,,3227.20,7322.74,percent of total billed charges,
PLATE,7903581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8952.00000,2596.08000,Aetna,First Health,,7322.74,,,,,,,2882.54,7322.74,percent of total billed charges,
BONE CEMENT HV FOR AUTOPLEX SYST,7903761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3806.69000,1103.94000,Aetna,First Health,,3113.87,,,,,,,1372.31,3113.87,percent of total billed charges,
BONE CEMENT HV FOR AUTOPLEX SYST,7903761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3806.69000,1103.94000,Aetna,First Health,,3113.87,,,,,,,1225.75,3113.87,percent of total billed charges,
CONNECTOR SPINAL,7903659,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1124.76,2552.16,percent of total billed charges,
CONNECTOR SPINAL,7903659,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1004.64,2552.16,percent of total billed charges,
GUIDEWIRE,7911814,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,First Health,,120.68,,,,,,,53.18,120.68,percent of total billed charges,
GUIDEWIRE,7911814,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,First Health,,120.68,,,,,,,47.50,120.68,percent of total billed charges,
GUIDEWIRE,7911815,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,191.63000,55.57000,Aetna,First Health,,156.75,,,,,,,69.08,156.75,percent of total billed charges,
GUIDEWIRE,7911815,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,191.63000,55.57000,Aetna,First Health,,156.75,,,,,,,61.70,156.75,percent of total billed charges,
GUIDEWIRE,7911816,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,169.58000,49.18000,Aetna,First Health,,138.72,,,,,,,61.13,138.72,percent of total billed charges,
GUIDEWIRE,7911816,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,169.58000,49.18000,Aetna,First Health,,138.72,,,,,,,54.60,138.72,percent of total billed charges,
MESH,7912133,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1828.28000,530.20000,Aetna,First Health,,1495.53,,,,,,,659.09,1495.53,percent of total billed charges,
MESH,7912133,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1828.28000,530.20000,Aetna,First Health,,1495.53,,,,,,,588.71,1495.53,percent of total billed charges,
MESH,7912134,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2592.76000,751.90000,Aetna,First Health,,2120.88,,,,,,,934.69,2120.88,percent of total billed charges,
MESH,7912134,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2592.76000,751.90000,Aetna,First Health,,2120.88,,,,,,,834.87,2120.88,percent of total billed charges,
STEM,7776325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,3136.35,7116.60,percent of total billed charges,
STEM,7776325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,2801.40,7116.60,percent of total billed charges,
INSERT,7909484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7909484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7912143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7912143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
GRAFT,7912168,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,34537.50000,10015.88000,Aetna,First Health,,28251.67,,,,,,,12450.77,28251.67,percent of total billed charges,
GRAFT,7912168,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,34537.50000,10015.88000,Aetna,First Health,,28251.67,,,,,,,11121.08,28251.67,percent of total billed charges,
COMPONENT PATELLA,7912141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
COMPONENT PATELLA,7912141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
TIGHTROPE,7912137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4554.38000,1320.77000,Aetna,First Health,,3725.48,,,,,,,1641.85,3725.48,percent of total billed charges,
TIGHTROPE,7912137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4554.38000,1320.77000,Aetna,First Health,,3725.48,,,,,,,1466.51,3725.48,percent of total billed charges,
TOE IMPLANT,7912193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
TOE IMPLANT,7912193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
INSERT,7912273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9633.75000,2793.79000,Aetna,First Health,,7880.41,,,,,,,3472.97,7880.41,percent of total billed charges,
INSERT,7912273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9633.75000,2793.79000,Aetna,First Health,,7880.41,,,,,,,3102.07,7880.41,percent of total billed charges,
CAGE,7912276,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7912276,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
SCREW,7912342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,261.39,593.12,percent of total billed charges,
SCREW,7912342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,233.48,593.12,percent of total billed charges,
PLATE,7912353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2634.24000,763.93000,Aetna,First Health,,2154.81,,,,,,,949.64,2154.81,percent of total billed charges,
PLATE,7912353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2634.24000,763.93000,Aetna,First Health,,2154.81,,,,,,,848.23,2154.81,percent of total billed charges,
SCREW,7912614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,7912614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
CATHETER,7912610,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CATHETER,7912610,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CATHETER,7912607,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,11025.00000,3197.25000,Aetna,First Health,,9018.45,,,,,,,3974.51,9018.45,percent of total billed charges,
CATHETER,7912607,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,11025.00000,3197.25000,Aetna,First Health,,9018.45,,,,,,,3550.05,9018.45,percent of total billed charges,
BREAST IMPLANT,7912611,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST IMPLANT,7912611,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7912753,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7912753,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
FEMORAL HEAD,7912755,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,First Health,,1914.12,,,,,,,843.57,1914.12,percent of total billed charges,
FEMORAL HEAD,7912755,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,First Health,,1914.12,,,,,,,753.48,1914.12,percent of total billed charges,
SPACER,7912756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,806.18000,233.79000,Aetna,First Health,,659.46,,,,,,,290.63,659.46,percent of total billed charges,
SPACER,7912756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,806.18000,233.79000,Aetna,First Health,,659.46,,,,,,,259.59,659.46,percent of total billed charges,
ACETABULAR RING,7912875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,2061.39,4677.43,percent of total billed charges,
ACETABULAR RING,7912875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,1841.24,4677.43,percent of total billed charges,
ACETABULAR RING,7912884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,3144.73,7135.62,percent of total billed charges,
ACETABULAR RING,7912884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,2808.89,7135.62,percent of total billed charges,
SHELL,7912894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
LINER,7912905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
SCREW,7912921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,349.19,792.34,percent of total billed charges,
SCREW,7912921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,311.90,792.34,percent of total billed charges,
SCREW,7913082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7913082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
PLATE,7913093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3706.50000,1074.88000,Aetna,First Health,,3031.92,,,,,,,1336.19,3031.92,percent of total billed charges,
PLATE,7913093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3706.50000,1074.88000,Aetna,First Health,,3031.92,,,,,,,1193.49,3031.92,percent of total billed charges,
PLATE,7913208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
PLATE,7913208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
PLATE,7913216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
PLATE,7913216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7913279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,7913279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,7929998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
SCREW,7929998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
SHELL,7913629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,7913629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
STEM,7913652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM,7913652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
PLATES IN A KIT,7913653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5198.20000,1507.48000,Aetna,First Health,,4252.13,,,,,,,1873.95,4252.13,percent of total billed charges,
PLATES IN A KIT,7913653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5198.20000,1507.48000,Aetna,First Health,,4252.13,,,,,,,1673.82,4252.13,percent of total billed charges,
SCREW,7913655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7913655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
INSERT,7913849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3465.42000,1004.97000,Aetna,First Health,,2834.71,,,,,,,1249.28,2834.71,percent of total billed charges,
INSERT,7913849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3465.42000,1004.97000,Aetna,First Health,,2834.71,,,,,,,1115.87,2834.71,percent of total billed charges,
INSERT,7913880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7913880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
GUIDEWIRE,7913883,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1225.68000,355.45000,Aetna,First Health,,1002.61,,,,,,,441.86,1002.61,percent of total billed charges,
GUIDEWIRE,7913883,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1225.68000,355.45000,Aetna,First Health,,1002.61,,,,,,,394.67,1002.61,percent of total billed charges,
INSERT,7913929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7913929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
ADAPTER,7913914,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
ADAPTER,7913914,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
PLATE,7914034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5257.46000,1524.66000,Aetna,First Health,,4300.60,,,,,,,1895.31,4300.60,percent of total billed charges,
PLATE,7914034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5257.46000,1524.66000,Aetna,First Health,,4300.60,,,,,,,1692.90,4300.60,percent of total billed charges,
ANCHOR,7914403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,179.80,407.98,percent of total billed charges,
ANCHOR,7914403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,160.60,407.98,percent of total billed charges,
ROD,7914556,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7914556,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
PLATE,7916467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8559.00000,2482.11000,Aetna,First Health,,7001.26,,,,,,,3085.52,7001.26,percent of total billed charges,
PLATE,7916467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8559.00000,2482.11000,Aetna,First Health,,7001.26,,,,,,,2756.00,7001.26,percent of total billed charges,
STEM,7916470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2893.01,6564.45,percent of total billed charges,
STEM,7916470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2584.05,6564.45,percent of total billed charges,
NAIL,7697981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7736.40000,2243.56000,Aetna,First Health,,6328.38,,,,,,,2788.97,6328.38,percent of total billed charges,
NAIL,7697981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7736.40000,2243.56000,Aetna,First Health,,6328.38,,,,,,,2491.12,6328.38,percent of total billed charges,
AUGMENT TIBIAL,7916494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,5404.09,12262.25,percent of total billed charges,
AUGMENT TIBIAL,7916494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,4826.95,12262.25,percent of total billed charges,
STEM,7916496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7916496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
ANCHOR,7916709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2057.00000,596.53000,Aetna,First Health,,1682.63,,,,,,,741.55,1682.63,percent of total billed charges,
ANCHOR,7916709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2057.00000,596.53000,Aetna,First Health,,1682.63,,,,,,,662.35,1682.63,percent of total billed charges,
LINER,7916710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7916710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
SCREW,7909031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7909031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
PLATE,7916927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2934.80000,851.09000,Aetna,First Health,,2400.67,,,,,,,1058.00,2400.67,percent of total billed charges,
PLATE,7916927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2934.80000,851.09000,Aetna,First Health,,2400.67,,,,,,,945.01,2400.67,percent of total billed charges,
COMPONENT GLENOID,7916929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6300.00000,1827.00000,Aetna,First Health,,5153.40,,,,,,,2271.15,5153.40,percent of total billed charges,
COMPONENT GLENOID,7916929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6300.00000,1827.00000,Aetna,First Health,,5153.40,,,,,,,2028.60,5153.40,percent of total billed charges,
STEM,7916930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13275.00000,3849.75000,Aetna,First Health,,10858.95,,,,,,,4785.64,10858.95,percent of total billed charges,
STEM,7916930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13275.00000,3849.75000,Aetna,First Health,,10858.95,,,,,,,4274.55,10858.95,percent of total billed charges,
PLATE,7916935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5088.30000,1475.61000,Aetna,First Health,,4162.23,,,,,,,1834.33,4162.23,percent of total billed charges,
PLATE,7916935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5088.30000,1475.61000,Aetna,First Health,,4162.23,,,,,,,1638.43,4162.23,percent of total billed charges,
SLING,7916982,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,5603.50000,1625.02000,Aetna,First Health,,4583.66,,,,,,,2020.06,4583.66,percent of total billed charges,
SLING,7916982,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,5603.50000,1625.02000,Aetna,First Health,,4583.66,,,,,,,1804.33,4583.66,percent of total billed charges,
COMPONENT FEMORAL,7916997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7916997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7917333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2053.88000,595.63000,Aetna,First Health,,1680.07,,,,,,,740.42,1680.07,percent of total billed charges,
PLATE,7917333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2053.88000,595.63000,Aetna,First Health,,1680.07,,,,,,,661.35,1680.07,percent of total billed charges,
BONE GRAFT,7917356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BONE GRAFT,7917356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
VALVE,7917667,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,17399.73000,5045.92000,Aetna,First Health,,14232.98,,,,,,,6272.60,14232.98,percent of total billed charges,
VALVE,7917667,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,17399.73000,5045.92000,Aetna,First Health,,14232.98,,,,,,,5602.71,14232.98,percent of total billed charges,
HUMERAL HEAD,7917697,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HUMERAL HEAD,7917697,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
ROD,7910312,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7910312,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
CONNECTOR SPINAL,7909290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7909290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
HUMERAL HEAD,7917854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7917854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
TIGHTROPE,7917894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
TIGHTROPE,7917894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
PLATE,7917898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6270.39000,1818.41000,Aetna,First Health,,5129.18,,,,,,,2260.48,5129.18,percent of total billed charges,
PLATE,7917898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6270.39000,1818.41000,Aetna,First Health,,5129.18,,,,,,,2019.07,5129.18,percent of total billed charges,
ROD,7918133,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1648.40000,478.04000,Aetna,First Health,,1348.39,,,,,,,594.25,1348.39,percent of total billed charges,
ROD,7918133,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1648.40000,478.04000,Aetna,First Health,,1348.39,,,,,,,530.78,1348.39,percent of total billed charges,
SCREW,7918134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,7918134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SHELL,7816132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,2211.03,5016.98,percent of total billed charges,
SHELL,7816132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,1974.90,5016.98,percent of total billed charges,
INSERT,7918189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
INSERT,7918189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
PENILE IMPLANT,7918404,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,First Health,,27552.28,,,,,,,12142.54,27552.28,percent of total billed charges,
PENILE IMPLANT,7918404,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,First Health,,27552.28,,,,,,,10845.76,27552.28,percent of total billed charges,
STEM,7918508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
STEM,7918508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
TENDON,7918862,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7868.40000,2281.84000,Aetna,First Health,,6436.35,,,,,,,2836.56,6436.35,percent of total billed charges,
TENDON,7918862,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7868.40000,2281.84000,Aetna,First Health,,6436.35,,,,,,,2533.62,6436.35,percent of total billed charges,
RESERVOIR,7698317,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,11145.00000,3232.05000,Aetna,First Health,,9116.61,,,,,,,4017.77,9116.61,percent of total billed charges,
RESERVOIR,7698317,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,11145.00000,3232.05000,Aetna,First Health,,9116.61,,,,,,,3588.69,9116.61,percent of total billed charges,
NAIL,7918565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1544.88000,448.02000,Aetna,First Health,,1263.71,,,,,,,556.93,1263.71,percent of total billed charges,
NAIL,7918565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1544.88000,448.02000,Aetna,First Health,,1263.71,,,,,,,497.45,1263.71,percent of total billed charges,
NAIL,7918566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1613.16000,467.82000,Aetna,First Health,,1319.56,,,,,,,581.54,1319.56,percent of total billed charges,
NAIL,7918566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1613.16000,467.82000,Aetna,First Health,,1319.56,,,,,,,519.44,1319.56,percent of total billed charges,
PLUG,7918560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,906.12000,262.77000,Aetna,First Health,,741.21,,,,,,,326.66,741.21,percent of total billed charges,
PLUG,7918560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,906.12000,262.77000,Aetna,First Health,,741.21,,,,,,,291.77,741.21,percent of total billed charges,
STEM,7918561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7932.00000,2300.28000,Aetna,First Health,,6488.38,,,,,,,2859.49,6488.38,percent of total billed charges,
STEM,7918561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7932.00000,2300.28000,Aetna,First Health,,6488.38,,,,,,,2554.10,6488.38,percent of total billed charges,
ANCHOR,7918628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,703.70,1596.74,percent of total billed charges,
ANCHOR,7918628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,628.54,1596.74,percent of total billed charges,
ANCHOR,7918629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1928.00000,559.12000,Aetna,First Health,,1577.10,,,,,,,695.04,1577.10,percent of total billed charges,
ANCHOR,7918629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1928.00000,559.12000,Aetna,First Health,,1577.10,,,,,,,620.82,1577.10,percent of total billed charges,
FEMORAL HEAD,7698879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7698879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
SCREW,7918643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
SCREW,7918643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
GLENOSPHERE,7918811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
GLENOSPHERE,7918811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
BASEPLATE,7918812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
BASEPLATE,7918812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
STEM,7918815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,7918815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
HUMERAL CUP,7918816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
HUMERAL CUP,7918816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
INSERT,7918817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7918817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
FEMORAL HEAD,7918849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4540.73000,1316.81000,Aetna,First Health,,3714.32,,,,,,,1636.93,3714.32,percent of total billed charges,
FEMORAL HEAD,7918849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4540.73000,1316.81000,Aetna,First Health,,3714.32,,,,,,,1462.12,3714.32,percent of total billed charges,
SHELL,7918850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,1002.19,2274.04,percent of total billed charges,
SHELL,7918850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,895.16,2274.04,percent of total billed charges,
PLATE,7894080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1963.88000,569.53000,Aetna,First Health,,1606.45,,,,,,,707.98,1606.45,percent of total billed charges,
PLATE,7894080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1963.88000,569.53000,Aetna,First Health,,1606.45,,,,,,,632.37,1606.45,percent of total billed charges,
LINER,7900102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7900102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
BREAST IMPLANT,7903505,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7903505,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
CATHETER BALLOON,7858116,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858116,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858113,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858113,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858110,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858110,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
BALLOON CATHETER,7750487,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750487,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
TUBE MYRINGOTOMY,7694026,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,96.78000,28.07000,Aetna,First Health,,79.17,,,,,,,34.89,79.17,percent of total billed charges,
TUBE MYRINGOTOMY,7694026,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,96.78000,28.07000,Aetna,First Health,,79.17,,,,,,,31.16,332.38,percent of total billed charges,
STENT GRAFT,7918877,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13587.00000,3940.23000,Aetna,First Health,,11114.17,,,,,,,4898.11,11114.17,percent of total billed charges,
STENT GRAFT,7918877,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13587.00000,3940.23000,Aetna,First Health,,11114.17,,,,,,,4375.01,11114.17,percent of total billed charges,
AUGMENT TIBIAL,7918898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8611.20000,2497.25000,Aetna,First Health,,7043.96,,,,,,,3104.34,7043.96,percent of total billed charges,
AUGMENT TIBIAL,7918898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8611.20000,2497.25000,Aetna,First Health,,7043.96,,,,,,,2772.81,7043.96,percent of total billed charges,
COMPONENT FEMORAL,7918937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
COMPONENT FEMORAL,7918937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PLATE,7918945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9102.00000,2639.58000,Aetna,First Health,,7445.44,,,,,,,3281.27,7445.44,percent of total billed charges,
PLATE,7918945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9102.00000,2639.58000,Aetna,First Health,,7445.44,,,,,,,2930.84,7445.44,percent of total billed charges,
AUGMENT TIBIAL,7918977,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6114.33000,1773.16000,Aetna,First Health,,5001.52,,,,,,,2204.22,5001.52,percent of total billed charges,
AUGMENT TIBIAL,7918977,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6114.33000,1773.16000,Aetna,First Health,,5001.52,,,,,,,1968.81,5001.52,percent of total billed charges,
LINER,7918989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
LINER,7918989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
GLENOSPHERE,7910999,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2811.90,6380.40,percent of total billed charges,
GLENOSPHERE,7910999,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2511.60,6380.40,percent of total billed charges,
GRAFT,7919019,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2657.48000,770.67000,Aetna,First Health,,2173.82,,,,,,,958.02,2173.82,percent of total billed charges,
GRAFT,7919019,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2657.48000,770.67000,Aetna,First Health,,2173.82,,,,,,,855.71,2173.82,percent of total billed charges,
THYROPLASTY IMPLANT IN KIT,7916655,CDM,278,RC,C1878,HCPCS,,,facility,inpatient,,,1912.00000,554.48000,Aetna,First Health,,1564.02,,,,,,,689.28,1564.02,percent of total billed charges,
THYROPLASTY IMPLANT IN KIT,7916655,CDM,278,RC,C1878,HCPCS,,,facility,outpatient,,,1912.00000,554.48000,Aetna,First Health,,1564.02,,,,,,,615.66,1564.02,percent of total billed charges,
FEMORAL HEAD,7920353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1645.01,3732.64,percent of total billed charges,
FEMORAL HEAD,7920353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1469.33,3732.64,percent of total billed charges,
AUGMENT ACETABULAR,7700111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,3057.18,6936.97,percent of total billed charges,
AUGMENT ACETABULAR,7700111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,2730.69,6936.97,percent of total billed charges,
FIXATOR,7920398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10194.00000,2956.26000,Aetna,First Health,,8338.69,,,,,,,3674.94,8338.69,percent of total billed charges,
FIXATOR,7920398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10194.00000,2956.26000,Aetna,First Health,,8338.69,,,,,,,3282.47,8338.69,percent of total billed charges,
PLATE,7920468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1771.48000,513.73000,Aetna,First Health,,1449.07,,,,,,,638.62,1449.07,percent of total billed charges,
PLATE,7920468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1771.48000,513.73000,Aetna,First Health,,1449.07,,,,,,,570.42,1449.07,percent of total billed charges,
PLATE,7920470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2072.52000,601.03000,Aetna,First Health,,1695.32,,,,,,,747.14,1695.32,percent of total billed charges,
PLATE,7920470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2072.52000,601.03000,Aetna,First Health,,1695.32,,,,,,,667.35,1695.32,percent of total billed charges,
FILTER,7920462,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
FILTER,7920462,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
ROD,7920488,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7920488,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
CONNECTOR SPINAL,7912365,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7912365,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
GRAFT,7920509,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1552.00000,450.08000,Aetna,First Health,,1269.54,,,,,,,559.50,1269.54,percent of total billed charges,
GRAFT,7920509,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1552.00000,450.08000,Aetna,First Health,,1269.54,,,,,,,499.74,1269.54,percent of total billed charges,
PLATE,7701529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,703.70,1596.74,percent of total billed charges,
PLATE,7701529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,628.54,1596.74,percent of total billed charges,
SCREW,7920546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7920546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
STEM,7707515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3783.50000,1097.21000,Aetna,First Health,,3094.90,,,,,,,1363.95,3094.90,percent of total billed charges,
STEM,7707515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3783.50000,1097.21000,Aetna,First Health,,3094.90,,,,,,,1218.29,3094.90,percent of total billed charges,
STEM,7707521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5845.00000,1695.05000,Aetna,First Health,,4781.21,,,,,,,2107.12,4781.21,percent of total billed charges,
STEM,7707521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5845.00000,1695.05000,Aetna,First Health,,4781.21,,,,,,,1882.09,4781.21,percent of total billed charges,
GRAFT EXTENDER,7920563,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11775.00000,3414.75000,Aetna,First Health,,9631.95,,,,,,,4244.89,9631.95,percent of total billed charges,
GRAFT EXTENDER,7920563,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11775.00000,3414.75000,Aetna,First Health,,9631.95,,,,,,,3791.55,9631.95,percent of total billed charges,
SCREW,7699560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,179.55000,52.07000,Aetna,First Health,,146.87,,,,,,,64.73,146.87,percent of total billed charges,
SCREW,7699560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,179.55000,52.07000,Aetna,First Health,,146.87,,,,,,,57.82,146.87,percent of total billed charges,
TENDON,7921011,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4656.75000,1350.46000,Aetna,First Health,,3809.22,,,,,,,1678.76,3809.22,percent of total billed charges,
TENDON,7921011,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4656.75000,1350.46000,Aetna,First Health,,3809.22,,,,,,,1499.47,3809.22,percent of total billed charges,
BASEPLATE,7921145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7921145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
INSERT,7921146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7921146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
COMPONENT FEMORAL,7921147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7921147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
PLATE,7695834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5729.99000,1661.70000,Aetna,First Health,,4687.13,,,,,,,2065.66,4687.13,percent of total billed charges,
PLATE,7695834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5729.99000,1661.70000,Aetna,First Health,,4687.13,,,,,,,1845.06,4687.13,percent of total billed charges,
STEM,7786150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7786150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
PLATE,7921296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2351.80000,682.02000,Aetna,First Health,,1923.77,,,,,,,847.82,1923.77,percent of total billed charges,
PLATE,7921296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2351.80000,682.02000,Aetna,First Health,,1923.77,,,,,,,757.28,1923.77,percent of total billed charges,
BIO TRANSFIX,7702903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1653.80000,479.60000,Aetna,First Health,,1352.81,,,,,,,596.19,1352.81,percent of total billed charges,
BIO TRANSFIX,7702903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1653.80000,479.60000,Aetna,First Health,,1352.81,,,,,,,532.52,1352.81,percent of total billed charges,
PLATE,7921297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2438.72000,707.23000,Aetna,First Health,,1994.87,,,,,,,879.16,1994.87,percent of total billed charges,
PLATE,7921297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2438.72000,707.23000,Aetna,First Health,,1994.87,,,,,,,785.27,1994.87,percent of total billed charges,
PLATE,7921298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2947.72000,854.84000,Aetna,First Health,,2411.23,,,,,,,1062.65,2411.23,percent of total billed charges,
PLATE,7921298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2947.72000,854.84000,Aetna,First Health,,2411.23,,,,,,,949.17,2411.23,percent of total billed charges,
GUIDEWIRE,7922475,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
GUIDEWIRE,7922475,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
CATHETER CONTURA,7695239,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
CATHETER CONTURA,7695239,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
SLEEVE,7786155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SLEEVE,7786155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
GUIDEWIRE,7922574,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1976.48000,573.18000,Aetna,First Health,,1616.76,,,,,,,712.52,1616.76,percent of total billed charges,
GUIDEWIRE,7922574,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1976.48000,573.18000,Aetna,First Health,,1616.76,,,,,,,636.43,1616.76,percent of total billed charges,
TIGHTROPE EXTENDER,7922871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1385.00000,401.65000,Aetna,First Health,,1132.93,,,,,,,499.29,1132.93,percent of total billed charges,
TIGHTROPE EXTENDER,7922871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1385.00000,401.65000,Aetna,First Health,,1132.93,,,,,,,445.97,1132.93,percent of total billed charges,
PUMP,7698319,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,32951.25000,9555.86000,Aetna,First Health,,26954.12,,,,,,,11878.93,26954.12,percent of total billed charges,
PUMP,7698319,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,32951.25000,9555.86000,Aetna,First Health,,26954.12,,,,,,,10610.30,26954.12,percent of total billed charges,
PLATE,7923285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.70000,1465.86000,Aetna,First Health,,4134.74,,,,,,,1822.22,4134.74,percent of total billed charges,
PLATE,7923285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.70000,1465.86000,Aetna,First Health,,4134.74,,,,,,,1627.61,4134.74,percent of total billed charges,
STEM,7923287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7923287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7924580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,793.10,1799.60,percent of total billed charges,
STEM,7924580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,708.40,1799.60,percent of total billed charges,
PROGRAMMER,7699612,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
PROGRAMMER,7699612,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHEATH,7924638,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,422.85000,122.63000,Aetna,First Health,,345.89,,,,,,,152.44,345.89,percent of total billed charges,
SHEATH,7924638,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,422.85000,122.63000,Aetna,First Health,,345.89,,,,,,,136.16,345.89,percent of total billed charges,
CATHETER HALO 360,7924634,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,10128.00000,2937.12000,Aetna,First Health,,8284.70,,,,,,,3651.14,8284.70,percent of total billed charges,
CATHETER HALO 360,7924634,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,10128.00000,2937.12000,Aetna,First Health,,8284.70,,,,,,,3261.22,8284.70,percent of total billed charges,
PLATE,7924774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3930.50000,1139.84000,Aetna,First Health,,3215.15,,,,,,,1416.95,3215.15,percent of total billed charges,
PLATE,7924781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3930.50000,1139.84000,Aetna,First Health,,3215.15,,,,,,,1265.62,3215.15,percent of total billed charges,
PEG,7911781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7911781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7908256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7908256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7707465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7707465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
WASHER,7924873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
WASHER,7924873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
PLATE,7924877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2520.00000,730.80000,Aetna,First Health,,2061.36,,,,,,,908.46,2061.36,percent of total billed charges,
PLATE,7924877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2520.00000,730.80000,Aetna,First Health,,2061.36,,,,,,,811.44,2061.36,percent of total billed charges,
SCREW,7924878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,549.00000,159.21000,Aetna,First Health,,449.08,,,,,,,197.91,449.08,percent of total billed charges,
SCREW,7924878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,549.00000,159.21000,Aetna,First Health,,449.08,,,,,,,176.78,449.08,percent of total billed charges,
PLATE,7924879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5456.50000,1582.38000,Aetna,First Health,,4463.42,,,,,,,1967.07,4463.42,percent of total billed charges,
PLATE,7924879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5456.50000,1582.38000,Aetna,First Health,,4463.42,,,,,,,1756.99,4463.42,percent of total billed charges,
ANCHOR IN KIT,7924904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
ANCHOR IN KIT,7924904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SPACER,7924903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,2191.66,4973.03,percent of total billed charges,
SPACER,7924903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,1957.60,4973.03,percent of total billed charges,
STEM,7924910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7924910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
HOLE COVER,7924913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,940.19000,272.66000,Aetna,First Health,,769.08,,,,,,,338.94,769.08,percent of total billed charges,
HOLE COVER,7924913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,940.19000,272.66000,Aetna,First Health,,769.08,,,,,,,302.74,769.08,percent of total billed charges,
WASHER,7925233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,438.37,994.69,percent of total billed charges,
WASHER,7925233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,391.55,994.69,percent of total billed charges,
PLATE,7925235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,First Health,,7023.35,,,,,,,3095.25,7023.35,percent of total billed charges,
PLATE,7925235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,First Health,,7023.35,,,,,,,2764.69,7023.35,percent of total billed charges,
SPACER HIP CEMENT,7924900,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,First Health,,3944.93,,,,,,,1738.57,3944.93,percent of total billed charges,
SPACER HIP CEMENT,7924900,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,First Health,,3944.93,,,,,,,1552.89,3944.93,percent of total billed charges,
PLATE,7925243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2525.64000,732.44000,Aetna,First Health,,2065.97,,,,,,,910.49,2065.97,percent of total billed charges,
PLATE,7925243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2525.64000,732.44000,Aetna,First Health,,2065.97,,,,,,,813.26,2065.97,percent of total billed charges,
GUIDEWIRE,7912606,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,172.99000,50.17000,Aetna,First Health,,141.51,,,,,,,62.36,141.51,percent of total billed charges,
GUIDEWIRE,7912606,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,172.99000,50.17000,Aetna,First Health,,141.51,,,,,,,55.70,141.51,percent of total billed charges,
SCREW,7925369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,438.37,994.69,percent of total billed charges,
SCREW,7925397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,391.55,994.69,percent of total billed charges,
WASHER,7925455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,129.50000,37.56000,Aetna,First Health,,105.93,,,,,,,46.68,105.93,percent of total billed charges,
WASHER,7925455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,129.50000,37.56000,Aetna,First Health,,105.93,,,,,,,41.70,105.93,percent of total billed charges,
STEM,7909306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7909306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
FEMORAL HEAD,7925627,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7925627,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
COMPONENT FEMORAL,7954585,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
COMPONENT FEMORAL,7954585,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
STEM,7894318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7894318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
BASEPLATE,7925633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
BASEPLATE,7925633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
SCREW,7702213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,7702213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
PLATE,7925797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
PLATE,7925797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
CAGE,7925800,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,23000.00000,6670.00000,Aetna,First Health,,18814.00,,,,,,,8291.50,18814.00,percent of total billed charges,
CAGE,7925800,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,First Health,,18814.00,,,,,,,7406.00,18814.00,percent of total billed charges,
GRAFT,7908759,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
GRAFT,7908759,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
SCREW,7913091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,873.04,1981.00,percent of total billed charges,
SCREW,7913091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,779.81,1981.00,percent of total billed charges,
SPACER SHOULDER,7925917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,First Health,,9245.94,,,,,,,4074.77,9245.94,percent of total billed charges,
SPACER SHOULDER,7925917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,First Health,,9245.94,,,,,,,3639.60,9245.94,percent of total billed charges,
PLATE,7926501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,744.07,1688.35,percent of total billed charges,
PLATE,7926501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,664.61,1688.35,percent of total billed charges,
WEDGE,7926526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9222.90000,2674.64000,Aetna,First Health,,7544.33,,,,,,,3324.86,7544.33,percent of total billed charges,
WEDGE,7926526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9222.90000,2674.64000,Aetna,First Health,,7544.33,,,,,,,2969.77,7544.33,percent of total billed charges,
STENT GRAFT,7926548,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
STENT GRAFT,7926548,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
STENT GRAFT,7926549,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5634.61,12785.34,percent of total billed charges,
STENT GRAFT,7926549,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5032.86,12785.34,percent of total billed charges,
COMPONENT FEMORAL,7926551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4515.97,10247.05,percent of total billed charges,
COMPONENT FEMORAL,7926551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4033.68,10247.05,percent of total billed charges,
PATELLA IMPLANT,7926564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4812.68,10920.30,percent of total billed charges,
PATELLA IMPLANT,7926564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4298.70,10920.30,percent of total billed charges,
STENT GRAFT,7926577,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21272.50000,6169.02000,Aetna,First Health,,17400.90,,,,,,,7668.74,17400.90,percent of total billed charges,
STENT GRAFT,7926577,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21272.50000,6169.02000,Aetna,First Health,,17400.90,,,,,,,6849.74,17400.90,percent of total billed charges,
RADIAL HEAD,7926579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9083.55000,2634.23000,Aetna,First Health,,7430.34,,,,,,,3274.62,7430.34,percent of total billed charges,
RADIAL HEAD,7926579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9083.55000,2634.23000,Aetna,First Health,,7430.34,,,,,,,2924.90,7430.34,percent of total billed charges,
SCREW,7926650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
SCREW,7926650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
CERVICAL DISC,7926672,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926672,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
VALVE,7926711,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,7480.38,16973.50,percent of total billed charges,
VALVE,7926711,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,6681.50,16973.50,percent of total billed charges,
PLATE,7926825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3447.33000,999.73000,Aetna,First Health,,2819.92,,,,,,,1242.76,2819.92,percent of total billed charges,
PLATE,7926825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3447.33000,999.73000,Aetna,First Health,,2819.92,,,,,,,1110.04,2819.92,percent of total billed charges,
INSERT,7926932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,7926932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
SPINAL CORD STIMULATOR,7926956,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,54586.00000,15829.94000,Aetna,First Health,,44651.35,,,,,,,19678.25,44651.35,percent of total billed charges,
SPINAL CORD STIMULATOR,7926956,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,54586.00000,15829.94000,Aetna,First Health,,44651.35,,,,,,,17576.69,44651.35,percent of total billed charges,
SCREW,7926982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7926982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
NAIL,7926984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2903.18,6587.52,percent of total billed charges,
NAIL,7926984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2593.13,6587.52,percent of total billed charges,
PLATE,7926978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,First Health,,2249.50,,,,,,,991.38,2249.50,percent of total billed charges,
PLATE,7926978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,First Health,,2249.50,,,,,,,885.50,2249.50,percent of total billed charges,
BALLOON CATHETER,7927051,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
BALLOON CATHETER,7927051,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
INSERT,7927096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7927096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
CABLE,7927136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3249.75000,942.43000,Aetna,First Health,,2658.30,,,,,,,1171.53,2658.30,percent of total billed charges,
CABLE,7927136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3249.75000,942.43000,Aetna,First Health,,2658.30,,,,,,,1046.42,2658.30,percent of total billed charges,
STEM,7927135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,37091.48000,10756.53000,Aetna,First Health,,30340.83,,,,,,,13371.48,30340.83,percent of total billed charges,
STEM,7927135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,37091.48000,10756.53000,Aetna,First Health,,30340.83,,,,,,,11943.46,30340.83,percent of total billed charges,
SCREW,7927168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7927168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
CATHETER DIALYSIS SHORT TERM,7736620,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,428.23000,124.19000,Aetna,First Health,,350.29,,,,,,,154.38,350.29,percent of total billed charges,
CATHETER DIALYSIS SHORT TERM,7736620,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,428.23000,124.19000,Aetna,First Health,,350.29,,,,,,,137.89,350.29,percent of total billed charges,
STEM,7927181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4053.00000,1175.37000,Aetna,First Health,,3315.35,,,,,,,1461.11,3315.35,percent of total billed charges,
STEM,7927181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4053.00000,1175.37000,Aetna,First Health,,3315.35,,,,,,,1305.07,3315.35,percent of total billed charges,
TIBIAL TRAY,7736435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3420.78,7762.00,percent of total billed charges,
TIBIAL TRAY,7736435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3055.46,7762.00,percent of total billed charges,
STEM,7927183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3783.50000,1097.21000,Aetna,First Health,,3094.90,,,,,,,1363.95,3094.90,percent of total billed charges,
STEM,7927183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3783.50000,1097.21000,Aetna,First Health,,3094.90,,,,,,,1218.29,3094.90,percent of total billed charges,
ACETABULAR CUP,7927186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7927186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
BASEPLATE,7927258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7927258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
HUMERAL HEAD,7927270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
HUMERAL HEAD,7927270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
INSERT,7927271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,7927271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
COMPONENT TALAR,7707520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,7151.42,16227.08,percent of total billed charges,
COMPONENT TALAR,7707520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,6387.68,16227.08,percent of total billed charges,
COMPONENT FEMORAL,7927338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
COMPONENT FEMORAL,7927338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
AUGMENT FEMORAL,7927340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7927340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
FEMORAL ADAPTER,7927342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3458.00000,1002.82000,Aetna,First Health,,2828.64,,,,,,,1246.61,2828.64,percent of total billed charges,
FEMORAL ADAPTER,7927342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3458.00000,1002.82000,Aetna,First Health,,2828.64,,,,,,,1113.48,2828.64,percent of total billed charges,
SPACER,7927344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3738.75,8483.48,percent of total billed charges,
SPACER,7927344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3339.46,8483.48,percent of total billed charges,
SCREW,7927348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7927348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
STEM,7924912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,7924912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
INSERT,7927351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7927351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
PLATE,7701863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.80000,391.73000,Aetna,First Health,,1104.95,,,,,,,486.96,1104.95,percent of total billed charges,
PLATE,7701863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.80000,391.73000,Aetna,First Health,,1104.95,,,,,,,434.96,1104.95,percent of total billed charges,
END CAP,7927506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.99000,167.33000,Aetna,First Health,,471.98,,,,,,,208.00,471.98,percent of total billed charges,
END CAP,7927506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.99000,167.33000,Aetna,First Health,,471.98,,,,,,,185.79,471.98,percent of total billed charges,
PLATE,7927548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3170.00000,919.30000,Aetna,First Health,,2593.06,,,,,,,1142.79,2593.06,percent of total billed charges,
PLATE,7927548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3170.00000,919.30000,Aetna,First Health,,2593.06,,,,,,,1020.74,2593.06,percent of total billed charges,
SCREW,7929693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7929693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
TENDON,7929702,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5439.00000,1577.31000,Aetna,First Health,,4449.10,,,,,,,1960.76,4449.10,percent of total billed charges,
TENDON,7929702,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5439.00000,1577.31000,Aetna,First Health,,4449.10,,,,,,,1751.36,4449.10,percent of total billed charges,
STENT,7929705,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1250.70,2837.92,percent of total billed charges,
STENT,7929705,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1117.13,2837.92,percent of total billed charges,
STENT GRAFT,7929723,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12426.00000,3603.54000,Aetna,First Health,,10164.47,,,,,,,4479.57,10164.47,percent of total billed charges,
STENT GRAFT,7929723,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12426.00000,3603.54000,Aetna,First Health,,10164.47,,,,,,,4001.17,10164.47,percent of total billed charges,
SHEATH,7929725,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,4284.00000,1242.36000,Aetna,First Health,,3504.31,,,,,,,1544.38,3504.31,percent of total billed charges,
SHEATH,7929725,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,4284.00000,1242.36000,Aetna,First Health,,3504.31,,,,,,,1379.45,3504.31,percent of total billed charges,
PLATE,7929741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1211.28,2748.48,percent of total billed charges,
PLATE,7929741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1081.92,2748.48,percent of total billed charges,
RING ANNULOPLASTY,7929752,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929752,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
TENDON,7930116,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3896.38000,1129.95000,Aetna,First Health,,3187.24,,,,,,,1404.64,3187.24,percent of total billed charges,
TENDON,7930116,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3896.38000,1129.95000,Aetna,First Health,,3187.24,,,,,,,1254.63,3187.24,percent of total billed charges,
SCREW,7930117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,680.98,1545.20,percent of total billed charges,
SCREW,7930117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,608.26,1545.20,percent of total billed charges,
SPACER HIP CEMENT,7895932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,2104.22,4774.63,percent of total billed charges,
SPACER HIP CEMENT,7895932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,1879.50,4774.63,percent of total billed charges,
ROD,7930146,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD,7930146,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
CAGE,7930181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
CAGE,7930181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
COMPONENT FEMORAL,7700832,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13117.38000,3804.04000,Aetna,First Health,,10730.02,,,,,,,4728.82,10730.02,percent of total billed charges,
COMPONENT FEMORAL,7700832,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13117.38000,3804.04000,Aetna,First Health,,10730.02,,,,,,,4223.80,10730.02,percent of total billed charges,
NUT,7930203,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,484.88000,140.62000,Aetna,First Health,,396.63,,,,,,,174.80,396.63,percent of total billed charges,
NUT,7930203,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,484.88000,140.62000,Aetna,First Health,,396.63,,,,,,,156.13,396.63,percent of total billed charges,
WEDGE,7930206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9222.90000,2674.64000,Aetna,First Health,,7544.33,,,,,,,3324.86,7544.33,percent of total billed charges,
WEDGE,7930206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9222.90000,2674.64000,Aetna,First Health,,7544.33,,,,,,,2969.77,7544.33,percent of total billed charges,
FINGER IMPLANT,7930262,CDM,278,RC,L8630,HCPCS,,,facility,inpatient,,,4560.50000,1322.54000,Aetna,First Health,,3730.49,,,,,,,1644.06,3730.49,percent of total billed charges,
FINGER IMPLANT,7930262,CDM,278,RC,L8630,HCPCS,,,facility,outpatient,,,4560.50000,1322.54000,Aetna,First Health,,3730.49,,,,,,,412.46,3730.49,percent of total billed charges,
SCREW,7930267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2592.00000,751.68000,Aetna,First Health,,2120.26,,,,,,,934.42,2120.26,percent of total billed charges,
SCREW,7930267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2592.00000,751.68000,Aetna,First Health,,2120.26,,,,,,,834.62,2120.26,percent of total billed charges,
BUTTON,7930308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,444.13000,128.80000,Aetna,First Health,,363.30,,,,,,,160.11,363.30,percent of total billed charges,
BUTTON,7930308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,444.13000,128.80000,Aetna,First Health,,363.30,,,,,,,143.01,363.30,percent of total billed charges,
BUTTON,7926648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,First Health,,1914.12,,,,,,,843.57,1914.12,percent of total billed charges,
BUTTON,7926648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,First Health,,1914.12,,,,,,,753.48,1914.12,percent of total billed charges,
NEUROSTIMULATOR TEST,7922458,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,670.53,1521.48,percent of total billed charges,
NEUROSTIMULATOR TEST,7922458,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,598.92,1521.48,percent of total billed charges,
PLATE,7696557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,7696557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
ROD,7696542,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7696542,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
SCREW,7696872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
SCREW,7696872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
SCREW,7696547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1406.85,3192.24,percent of total billed charges,
SCREW,7696547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1256.61,3192.24,percent of total billed charges,
ANCHOR,7702698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ANCHOR,7702698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,7696879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1406.85,3192.24,percent of total billed charges,
SCREW,7696879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1256.61,3192.24,percent of total billed charges,
STEM,7697959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7550.10000,2189.53000,Aetna,First Health,,6175.98,,,,,,,2721.81,6175.98,percent of total billed charges,
STEM,7697959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7550.10000,2189.53000,Aetna,First Health,,6175.98,,,,,,,2431.13,6175.98,percent of total billed charges,
STEM,7736531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7736531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
SCREW,7904340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
SCREW,7904340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
WASHER,7933915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,620.33000,179.90000,Aetna,First Health,,507.43,,,,,,,223.63,507.43,percent of total billed charges,
WASHER,7933915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,620.33000,179.90000,Aetna,First Health,,507.43,,,,,,,199.75,507.43,percent of total billed charges,
COMPONENT FEMORAL,7933955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13059.00000,3787.11000,Aetna,First Health,,10682.26,,,,,,,4707.77,10682.26,percent of total billed charges,
COMPONENT FEMORAL,7933955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13059.00000,3787.11000,Aetna,First Health,,10682.26,,,,,,,4205.00,10682.26,percent of total billed charges,
BONE GRAFT,7934011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3358.53000,973.97000,Aetna,First Health,,2747.28,,,,,,,1210.75,2747.28,percent of total billed charges,
BONE GRAFT,7934011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3358.53000,973.97000,Aetna,First Health,,2747.28,,,,,,,1081.45,2747.28,percent of total billed charges,
STEM,7934019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,First Health,,7901.88,,,,,,,3482.43,7901.88,percent of total billed charges,
STEM,7934019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,First Health,,7901.88,,,,,,,3110.52,7901.88,percent of total billed charges,
SLEEVE,7934020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3281.25000,951.56000,Aetna,First Health,,2684.06,,,,,,,1182.89,2684.06,percent of total billed charges,
SLEEVE,7934020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3281.25000,951.56000,Aetna,First Health,,2684.06,,,,,,,1056.56,2684.06,percent of total billed charges,
STEM,7934021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,First Health,,7901.88,,,,,,,3482.43,7901.88,percent of total billed charges,
STEM,7934021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,First Health,,7901.88,,,,,,,3110.52,7901.88,percent of total billed charges,
GUIDEWIRE,7934063,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,737.60000,213.90000,Aetna,First Health,,603.36,,,,,,,265.90,603.36,percent of total billed charges,
GUIDEWIRE,7934063,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,737.60000,213.90000,Aetna,First Health,,603.36,,,,,,,237.51,603.36,percent of total billed charges,
TRANSCONNECTOR SPINAL,7695522,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7657.02000,2220.54000,Aetna,First Health,,6263.44,,,,,,,2760.36,6263.44,percent of total billed charges,
TRANSCONNECTOR SPINAL,7695522,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7657.02000,2220.54000,Aetna,First Health,,6263.44,,,,,,,2465.56,6263.44,percent of total billed charges,
COMPONENT HUMERAL,7935071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
COMPONENT HUMERAL,7935071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
LIGAMENT,7935114,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,19710.00000,5715.90000,Aetna,First Health,,16122.78,,,,,,,7105.45,16122.78,percent of total billed charges,
LIGAMENT,7935114,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,19710.00000,5715.90000,Aetna,First Health,,16122.78,,,,,,,6346.62,16122.78,percent of total billed charges,
WEDGE,7935107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,First Health,,3717.89,,,,,,,1638.51,3717.89,percent of total billed charges,
WEDGE,7935107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,First Health,,3717.89,,,,,,,1463.52,3717.89,percent of total billed charges,
STENT GRAFT,7695327,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8079.00000,2342.91000,Aetna,First Health,,6608.62,,,,,,,2912.48,6608.62,percent of total billed charges,
STENT GRAFT,7695327,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8079.00000,2342.91000,Aetna,First Health,,6608.62,,,,,,,2601.44,6608.62,percent of total billed charges,
RESERVOIR,7696921,CDM,278,RC,,,,,facility,inpatient,,,2288.00000,663.52000,Aetna,First Health,,1871.58,,,,,,,824.82,1871.58,percent of total billed charges,
RESERVOIR,7696921,CDM,278,RC,,,,,facility,outpatient,,,2288.00000,663.52000,Aetna,First Health,,1871.58,,,,,,,736.74,1871.58,percent of total billed charges,
CATHETER,7694978,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,153.30000,44.46000,Aetna,First Health,,125.40,,,,,,,55.26,125.40,percent of total billed charges,
CATHETER,7694978,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,153.30000,44.46000,Aetna,First Health,,125.40,,,,,,,49.36,125.40,percent of total billed charges,
BULKING AGENT,7696685,CDM,278,RC,L8606,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
BULKING AGENT,7696685,CDM,278,RC,L8606,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,268.67,1227.00,percent of total billed charges,
PLATE,7935272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
PLATE,7935272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
SCREW,7935278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,7935278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
FEMORAL HEAD,7935284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2750.40000,797.62000,Aetna,First Health,,2249.83,,,,,,,991.52,2249.83,percent of total billed charges,
FEMORAL HEAD,7935284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2750.40000,797.62000,Aetna,First Health,,2249.83,,,,,,,885.63,2249.83,percent of total billed charges,
COMPONENT FEMORAL,7935335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7935335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
CATHETER,7694587,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1476.00000,428.04000,Aetna,First Health,,1207.37,,,,,,,532.10,1207.37,percent of total billed charges,
CATHETER,7694587,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1476.00000,428.04000,Aetna,First Health,,1207.37,,,,,,,475.27,1207.37,percent of total billed charges,
BALLOON DILATOR,7700511,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1490.84000,432.34000,Aetna,First Health,,1219.51,,,,,,,537.45,1219.51,percent of total billed charges,
BALLOON DILATOR,7700511,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1490.84000,432.34000,Aetna,First Health,,1219.51,,,,,,,480.05,1219.51,percent of total billed charges,
BALLOON,7696455,CDM,278,RC,C1727,HCPCS,,,facility,inpatient,,,2163.68000,627.47000,Aetna,First Health,,1769.89,,,,,,,780.01,1769.89,percent of total billed charges,
BALLOON,7696455,CDM,278,RC,C1727,HCPCS,,,facility,outpatient,,,2163.68000,627.47000,Aetna,First Health,,1769.89,,,,,,,696.70,1769.89,percent of total billed charges,
STENT GRAFT,7696019,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,11078.35,25137.55,percent of total billed charges,
STENT GRAFT,7696019,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,9895.22,25137.55,percent of total billed charges,
SLING GRAFT,7696357,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,8728.27000,2531.20000,Aetna,First Health,,7139.72,,,,,,,3146.54,7139.72,percent of total billed charges,
SLING GRAFT,7696357,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,8728.27000,2531.20000,Aetna,First Health,,7139.72,,,,,,,2810.50,7139.72,percent of total billed charges,
ROD,7935340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD,7935340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
SCREW,7935341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,7935341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
HUMERAL HEAD,7944264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,2197.43,4986.12,percent of total billed charges,
HUMERAL HEAD,7944264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,1962.75,4986.12,percent of total billed charges,
STENT,7696248,CDM,278,RC,C1877,HCPCS,,,facility,inpatient,,,5321.54000,1543.25000,Aetna,First Health,,4353.02,,,,,,,1918.42,4353.02,percent of total billed charges,
STENT,7696248,CDM,278,RC,C1877,HCPCS,,,facility,outpatient,,,5321.54000,1543.25000,Aetna,First Health,,4353.02,,,,,,,1713.54,4353.02,percent of total billed charges,
GUIDEWIRE,7696767,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,5398.72000,1565.63000,Aetna,First Health,,4416.15,,,,,,,1946.24,4416.15,percent of total billed charges,
GUIDEWIRE,7696767,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,5398.72000,1565.63000,Aetna,First Health,,4416.15,,,,,,,1738.39,4416.15,percent of total billed charges,
BALLOON DILATOR,7696809,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1518.80000,440.45000,Aetna,First Health,,1242.38,,,,,,,547.53,1242.38,percent of total billed charges,
BALLOON DILATOR,7696809,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1518.80000,440.45000,Aetna,First Health,,1242.38,,,,,,,489.05,1242.38,percent of total billed charges,
VASCULAR PATCH,7694425,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
VASCULAR PATCH,7694425,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
ADAPTER,7696940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3220.70000,934.00000,Aetna,First Health,,2634.53,,,,,,,1161.06,2634.53,percent of total billed charges,
ADAPTER,7696940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3220.70000,934.00000,Aetna,First Health,,2634.53,,,,,,,1037.07,2634.53,percent of total billed charges,
GUIDE CATHETER,7694371,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
GUIDE CATHETER,7694371,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
COIL,7935389,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4625.25000,1341.32000,Aetna,First Health,,3783.45,,,,,,,1667.40,3783.45,percent of total billed charges,
COIL,7935389,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4625.25000,1341.32000,Aetna,First Health,,3783.45,,,,,,,1489.33,3783.45,percent of total billed charges,
COIL,7935390,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,First Health,,4779.78,,,,,,,2106.49,4779.78,percent of total billed charges,
COIL,7935390,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,First Health,,4779.78,,,,,,,1881.53,4779.78,percent of total billed charges,
COIL,7935395,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4345.25000,1260.12000,Aetna,First Health,,3554.41,,,,,,,1566.46,3554.41,percent of total billed charges,
COIL,7935395,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4345.25000,1260.12000,Aetna,First Health,,3554.41,,,,,,,1399.17,3554.41,percent of total billed charges,
COIL,7935396,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5514.25000,1599.13000,Aetna,First Health,,4510.66,,,,,,,1987.89,4510.66,percent of total billed charges,
COIL,7935396,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5514.25000,1599.13000,Aetna,First Health,,4510.66,,,,,,,1775.59,4510.66,percent of total billed charges,
SHEATH,7697082,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
SHEATH,7697082,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
COIL,7699837,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4345.25000,1260.12000,Aetna,First Health,,3554.41,,,,,,,1566.46,3554.41,percent of total billed charges,
COIL,7699837,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4345.25000,1260.12000,Aetna,First Health,,3554.41,,,,,,,1399.17,3554.41,percent of total billed charges,
PLATE,7772038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,507.58,1151.74,percent of total billed charges,
PLATE,7772038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,453.38,1151.74,percent of total billed charges,
MENISCAL DART,7935473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.73000,204.95000,Aetna,First Health,,578.11,,,,,,,254.78,578.11,percent of total billed charges,
MENISCAL DART,7935473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.73000,204.95000,Aetna,First Health,,578.11,,,,,,,227.57,578.11,percent of total billed charges,
BASEPLATE,7935481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
BASEPLATE,7935481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
CATHETER,7697291,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,16562.50000,4803.12000,Aetna,First Health,,13548.12,,,,,,,5970.78,13548.12,percent of total billed charges,
CATHETER,7697291,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,16562.50000,4803.12000,Aetna,First Health,,13548.12,,,,,,,5333.12,13548.12,percent of total billed charges,
BASEPLATE,7697433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8736.57000,2533.61000,Aetna,First Health,,7146.51,,,,,,,3149.53,7146.51,percent of total billed charges,
BASEPLATE,7697433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8736.57000,2533.61000,Aetna,First Health,,7146.51,,,,,,,2813.18,7146.51,percent of total billed charges,
BASEPLATE,7935533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1299.40,2948.43,percent of total billed charges,
BASEPLATE,7935533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1160.63,2948.43,percent of total billed charges,
AUGMENT TIBIAL,7935560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8524.20000,2472.02000,Aetna,First Health,,6972.80,,,,,,,3072.97,6972.80,percent of total billed charges,
AUGMENT TIBIAL,7935560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8524.20000,2472.02000,Aetna,First Health,,6972.80,,,,,,,2744.79,6972.80,percent of total billed charges,
HUMERAL HEAD,7699624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7699624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
EXCLUDER,7935590,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16057.50000,4656.67000,Aetna,First Health,,13135.03,,,,,,,5788.73,13135.03,percent of total billed charges,
EXCLUDER,7935590,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16057.50000,4656.67000,Aetna,First Health,,13135.03,,,,,,,5170.52,13135.03,percent of total billed charges,
EXCLUDER,7935591,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
EXCLUDER,7935591,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
EXTENSION LEAD,7935588,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,2678.39000,776.73000,Aetna,First Health,,2190.92,,,,,,,965.56,2190.92,percent of total billed charges,
EXTENSION LEAD,7935588,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,2678.39000,776.73000,Aetna,First Health,,2190.92,,,,,,,862.44,2190.92,percent of total billed charges,
PLATE,7935613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3957.21,8979.19,percent of total billed charges,
PLATE,7935613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3534.59,8979.19,percent of total billed charges,
EMBOLIC PROTECTOR,7697570,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
EMBOLIC PROTECTOR,7697570,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
SCREW,7935722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7935722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
CAGE,7935723,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19620.00000,5689.80000,Aetna,First Health,,16049.16,,,,,,,7073.01,16049.16,percent of total billed charges,
CAGE,7935723,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19620.00000,5689.80000,Aetna,First Health,,16049.16,,,,,,,6317.64,16049.16,percent of total billed charges,
STENT GRAFT,7927397,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7927397,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7962570,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7962570,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
CAGE,7945882,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,23750.00000,6887.50000,Aetna,First Health,,19427.50,,,,,,,8561.88,19427.50,percent of total billed charges,
CAGE,7945882,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,23750.00000,6887.50000,Aetna,First Health,,19427.50,,,,,,,7647.50,19427.50,percent of total billed charges,
STENT GRAFT,7918349,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7918349,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7702261,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7702261,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
GRAFT,7766038,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,First Health,,9936.25,,,,,,,4378.99,9936.25,percent of total billed charges,
GRAFT,7766038,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,First Health,,9936.25,,,,,,,3911.33,9936.25,percent of total billed charges,
SCREW,7935807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2592.00000,751.68000,Aetna,First Health,,2120.26,,,,,,,934.42,2120.26,percent of total billed charges,
SCREW,7935807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2592.00000,751.68000,Aetna,First Health,,2120.26,,,,,,,834.62,2120.26,percent of total billed charges,
AORTIC EXTENSION,7700076,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15217.50000,4413.08000,Aetna,First Health,,12447.92,,,,,,,5485.91,12447.92,percent of total billed charges,
AORTIC EXTENSION,7700076,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15217.50000,4413.08000,Aetna,First Health,,12447.92,,,,,,,4900.03,12447.92,percent of total billed charges,
AORTIC EXTENSION,7744661,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
AORTIC EXTENSION,7744661,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7700124,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7700124,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
GRAFT,7700126,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,First Health,,9936.25,,,,,,,4378.99,9936.25,percent of total billed charges,
GRAFT,7700126,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,First Health,,9936.25,,,,,,,3911.33,9936.25,percent of total billed charges,
BONE MATRIX,7707536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10473.00000,3037.17000,Aetna,First Health,,8566.91,,,,,,,3775.52,8566.91,percent of total billed charges,
BONE MATRIX,7707536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10473.00000,3037.17000,Aetna,First Health,,8566.91,,,,,,,3372.31,8566.91,percent of total billed charges,
BONE MATRIX,7935027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10473.00000,3037.17000,Aetna,First Health,,8566.91,,,,,,,3775.52,8566.91,percent of total billed charges,
BONE MATRIX,7935027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10473.00000,3037.17000,Aetna,First Health,,8566.91,,,,,,,3372.31,8566.91,percent of total billed charges,
PLATE,7935846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8869.20000,2572.07000,Aetna,First Health,,7255.01,,,,,,,3197.35,7255.01,percent of total billed charges,
PLATE,7935846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8869.20000,2572.07000,Aetna,First Health,,7255.01,,,,,,,2855.88,7255.01,percent of total billed charges,
ROD,7935848,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,987.77,2241.32,percent of total billed charges,
ROD,7935848,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,882.28,2241.32,percent of total billed charges,
FEMORAL HEAD,7935880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,First Health,,1914.12,,,,,,,843.57,1914.12,percent of total billed charges,
FEMORAL HEAD,7935880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,First Health,,1914.12,,,,,,,753.48,1914.12,percent of total billed charges,
CATHETER THROMBECTOMY,7698210,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,15800.00000,4582.00000,Aetna,First Health,,12924.40,,,,,,,5695.90,12924.40,percent of total billed charges,
CATHETER THROMBECTOMY,7698210,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,15800.00000,4582.00000,Aetna,First Health,,12924.40,,,,,,,5087.60,12924.40,percent of total billed charges,
INTRODUCER IN A KIT,7917307,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1431.96000,415.27000,Aetna,First Health,,1171.34,,,,,,,516.22,1171.34,percent of total billed charges,
INTRODUCER IN A KIT,7917307,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1431.96000,415.27000,Aetna,First Health,,1171.34,,,,,,,461.09,1171.34,percent of total billed charges,
PLATE,7935940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1421.99,3226.60,percent of total billed charges,
PLATE,7935940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1270.13,3226.60,percent of total billed charges,
CATHETER DILATION URETRAL BALLOON,7696485,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1574.88000,456.72000,Aetna,First Health,,1288.25,,,,,,,567.74,1288.25,percent of total billed charges,
CATHETER DILATION URETRAL BALLOON,7696485,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1574.88000,456.72000,Aetna,First Health,,1288.25,,,,,,,507.11,1288.25,percent of total billed charges,
CATHETER,7694335,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,32.41,73.53,percent of total billed charges,
CATHETER,7694335,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,28.94,73.53,percent of total billed charges,
STEM,7936056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9950.01000,2885.50000,Aetna,First Health,,8139.11,,,,,,,3586.98,8139.11,percent of total billed charges,
STEM,7936056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9950.01000,2885.50000,Aetna,First Health,,8139.11,,,,,,,3203.90,8139.11,percent of total billed charges,
STEM,7936057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19864.05000,5760.57000,Aetna,First Health,,16248.79,,,,,,,7160.99,16248.79,percent of total billed charges,
STEM,7936057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19864.05000,5760.57000,Aetna,First Health,,16248.79,,,,,,,6396.22,16248.79,percent of total billed charges,
STEM,7936058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10667.67000,3093.62000,Aetna,First Health,,8726.15,,,,,,,3845.70,8726.15,percent of total billed charges,
STEM,7936058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10667.67000,3093.62000,Aetna,First Health,,8726.15,,,,,,,3434.99,8726.15,percent of total billed charges,
COMPONENT TIBIAL,7936060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16741.50000,4855.04000,Aetna,First Health,,13694.55,,,,,,,6035.31,13694.55,percent of total billed charges,
COMPONENT TIBIAL,7936060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16741.50000,4855.04000,Aetna,First Health,,13694.55,,,,,,,5390.76,13694.55,percent of total billed charges,
COMPONENT ROTATION,7936061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6613.88000,1918.03000,Aetna,First Health,,5410.15,,,,,,,2384.30,5410.15,percent of total billed charges,
COMPONENT ROTATION,7936061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6613.88000,1918.03000,Aetna,First Health,,5410.15,,,,,,,2129.67,5410.15,percent of total billed charges,
COMPONENT FEMORAL,7936062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25606.63000,7425.92000,Aetna,First Health,,20946.22,,,,,,,9231.19,20946.22,percent of total billed charges,
COMPONENT FEMORAL,7936062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25606.63000,7425.92000,Aetna,First Health,,20946.22,,,,,,,8245.33,20946.22,percent of total billed charges,
SCREW,7936089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1608.00000,466.32000,Aetna,First Health,,1315.34,,,,,,,579.68,1315.34,percent of total billed charges,
SCREW,7936089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1608.00000,466.32000,Aetna,First Health,,1315.34,,,,,,,517.78,1315.34,percent of total billed charges,
CONNECTOR SPINAL,7904345,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7904345,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
ROD,7936111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD,7936111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
SCREW,7936114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1468.68,3332.53,percent of total billed charges,
SCREW,7936114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1311.83,3332.53,percent of total billed charges,
PLATE,7936117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10929.00000,3169.41000,Aetna,First Health,,8939.92,,,,,,,3939.90,8939.92,percent of total billed charges,
PLATE,7936117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10929.00000,3169.41000,Aetna,First Health,,8939.92,,,,,,,3519.14,8939.92,percent of total billed charges,
COMPONENT FEMORAL,7808031,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,7886.67000,2287.13000,Aetna,First Health,,6451.30,,,,,,,2843.14,6451.30,percent of total billed charges,
COMPONENT FEMORAL,7808031,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,7886.67000,2287.13000,Aetna,First Health,,6451.30,,,,,,,2364.47,6451.30,percent of total billed charges,
CAGE,7936395,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11472.00000,3326.88000,Aetna,First Health,,9384.10,,,,,,,4135.66,9384.10,percent of total billed charges,
CAGE,7936395,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11472.00000,3326.88000,Aetna,First Health,,9384.10,,,,,,,3693.98,9384.10,percent of total billed charges,
STEM,7936398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7936398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
GUIDEWIRE,7698909,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,895.50000,259.70000,Aetna,First Health,,732.52,,,,,,,322.83,732.52,percent of total billed charges,
GUIDEWIRE,7698909,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,895.50000,259.70000,Aetna,First Health,,732.52,,,,,,,288.35,732.52,percent of total billed charges,
MODULAR HEAD,7937667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
MODULAR HEAD,7937667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
INSERT,7937697,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7937697,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
COMPONENT FEMORAL,7937699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7937699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
BASEPLATE,7937700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7937700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
INSERT,7937701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7937701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,7937719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,290.06,658.16,percent of total billed charges,
SCREW,7937719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,259.08,658.16,percent of total billed charges,
PLATE,7937737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4920.30000,1426.89000,Aetna,First Health,,4024.81,,,,,,,1773.77,4024.81,percent of total billed charges,
PLATE,7937737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4920.30000,1426.89000,Aetna,First Health,,4024.81,,,,,,,1584.34,4024.81,percent of total billed charges,
CAGE,7937748,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16050.00000,4654.50000,Aetna,First Health,,13128.90,,,,,,,5786.02,13128.90,percent of total billed charges,
CAGE,7937748,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16050.00000,4654.50000,Aetna,First Health,,13128.90,,,,,,,5168.10,13128.90,percent of total billed charges,
FEMORAL HEAD,7880522,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
FEMORAL HEAD,7880522,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
HUMERAL ASSEMBLY,7918609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,6398.88,14519.50,percent of total billed charges,
HUMERAL ASSEMBLY,7918609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,5715.50,14519.50,percent of total billed charges,
STEM,7937956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,First Health,,9385.08,,,,,,,4136.09,9385.08,percent of total billed charges,
STEM,7937956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,First Health,,9385.08,,,,,,,3694.37,9385.08,percent of total billed charges,
BASEPLATE,7762384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1299.40,2948.43,percent of total billed charges,
BASEPLATE,7762384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1160.63,2948.43,percent of total billed charges,
COMPONENT FEMORAL,7938033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7938033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
CAGE,7938337,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CAGE,7938337,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE,7938778,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
BASEPLATE,7938778,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
LEAD,7938909,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,15637.50000,4534.88000,Aetna,First Health,,12791.48,,,,,,,5637.32,12791.48,percent of total billed charges,
LEAD,7938909,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,15637.50000,4534.88000,Aetna,First Health,,12791.48,,,,,,,5035.27,12791.48,percent of total billed charges,
BASEPLATE,7938927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,First Health,,15018.48,,,,,,,6618.78,15018.48,percent of total billed charges,
BASEPLATE,7938927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,First Health,,15018.48,,,,,,,5911.92,15018.48,percent of total billed charges,
SLEEVE,7938928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12638.40000,3665.14000,Aetna,First Health,,10338.21,,,,,,,4556.14,10338.21,percent of total billed charges,
SLEEVE,7938928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12638.40000,3665.14000,Aetna,First Health,,10338.21,,,,,,,4069.56,10338.21,percent of total billed charges,
INSERT,7938965,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8362.50000,2425.12000,Aetna,First Health,,6840.52,,,,,,,3014.68,6840.52,percent of total billed charges,
INSERT,7938965,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8362.50000,2425.12000,Aetna,First Health,,6840.52,,,,,,,2692.72,6840.52,percent of total billed charges,
COMPONENT FEMORAL,7938994,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7938994,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7938996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
COMPONENT FEMORAL,7938996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
BASEPLATE,7938997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
BASEPLATE,7938997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
BASEPLATE,7939039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BASEPLATE,7939039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
CONNECTOR SPINAL,7939263,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7939263,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
VALVE,7697859,CDM,278,RC,,,,,facility,inpatient,,,14132.91000,4098.54000,Aetna,First Health,,11560.72,,,,,,,5094.91,11560.72,percent of total billed charges,
VALVE,7697859,CDM,278,RC,,,,,facility,outpatient,,,14132.91000,4098.54000,Aetna,First Health,,11560.72,,,,,,,4550.80,11560.72,percent of total billed charges,
PLUG,7939277,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
PLUG,7939277,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
SCREW,7939317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7939317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
CAGE,7939319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,7939319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
INSERT,7939305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,First Health,,4551.92,,,,,,,2006.07,4551.92,percent of total billed charges,
INSERT,7939305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,First Health,,4551.92,,,,,,,1791.83,4551.92,percent of total billed charges,
STEM,7939306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13275.00000,3849.75000,Aetna,First Health,,10858.95,,,,,,,4785.64,10858.95,percent of total billed charges,
STEM,7939306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13275.00000,3849.75000,Aetna,First Health,,10858.95,,,,,,,4274.55,10858.95,percent of total billed charges,
TIBIAL TRAY,7939311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,6518.74,14791.49,percent of total billed charges,
TIBIAL TRAY,7939311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,5822.56,14791.49,percent of total billed charges,
COMPONENT TALAR,7939312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18910.00000,5483.90000,Aetna,First Health,,15468.38,,,,,,,6817.06,15468.38,percent of total billed charges,
COMPONENT TALAR,7939312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18910.00000,5483.90000,Aetna,First Health,,15468.38,,,,,,,6089.02,15468.38,percent of total billed charges,
SHEATH,7939327,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,First Health,,2545.62,,,,,,,1121.88,2545.62,percent of total billed charges,
SHEATH,7939327,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,First Health,,2545.62,,,,,,,1002.06,2545.62,percent of total billed charges,
PLATE,7939415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1211.28,2748.48,percent of total billed charges,
PLATE,7939415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1081.92,2748.48,percent of total billed charges,
PLATE,7939425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
PLATE,7939425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
PLATE,7939426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3819.38000,1107.62000,Aetna,First Health,,3124.25,,,,,,,1376.89,3124.25,percent of total billed charges,
PLATE,7939426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3819.38000,1107.62000,Aetna,First Health,,3124.25,,,,,,,1229.84,3124.25,percent of total billed charges,
PLATE,7939428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,7939428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
SCREW,7702332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,174.10,395.04,percent of total billed charges,
SCREW,7702332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,155.50,395.04,percent of total billed charges,
GENERATOR,7939860,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,32256.00000,9354.24000,Aetna,First Health,,26385.41,,,,,,,11628.29,26385.41,percent of total billed charges,
GENERATOR,7939860,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,32256.00000,9354.24000,Aetna,First Health,,26385.41,,,,,,,10386.43,26385.41,percent of total billed charges,
ANCHOR,7939861,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,558.23000,161.89000,Aetna,First Health,,456.63,,,,,,,201.24,456.63,percent of total billed charges,
ANCHOR,7939861,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,558.23000,161.89000,Aetna,First Health,,456.63,,,,,,,179.75,456.63,percent of total billed charges,
GUIDEWIRE,7939433,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
GUIDEWIRE,7939433,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,43.95,111.66,percent of total billed charges,
STEM,7939953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4667.92000,1353.70000,Aetna,First Health,,3818.36,,,,,,,1682.79,3818.36,percent of total billed charges,
STEM,7939953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4667.92000,1353.70000,Aetna,First Health,,3818.36,,,,,,,1503.07,3818.36,percent of total billed charges,
INSERT,7940060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1137.20,2580.40,percent of total billed charges,
INSERT,7940060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1015.76,2580.40,percent of total billed charges,
PLATE,7698567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5648.51000,1638.07000,Aetna,First Health,,4620.48,,,,,,,2036.29,4620.48,percent of total billed charges,
PLATE,7698567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5648.51000,1638.07000,Aetna,First Health,,4620.48,,,,,,,1818.82,4620.48,percent of total billed charges,
CAGE,7940794,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7940794,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
PLATE,7940797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8979.00000,2603.91000,Aetna,First Health,,7344.82,,,,,,,3236.93,7344.82,percent of total billed charges,
PLATE,7940797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8979.00000,2603.91000,Aetna,First Health,,7344.82,,,,,,,2891.24,7344.82,percent of total billed charges,
LINER,7940826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
LINER,7940826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
BREAST IMPLANT,7941863,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,987.77,2241.32,percent of total billed charges,
BREAST IMPLANT,7941863,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,882.28,2241.32,percent of total billed charges,
SCREW,7942655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7942655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
TIGHTROPE IN A KIT,7699083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
TIGHTROPE IN A KIT,7699083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
BASEPLATE,7943246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3420.78,7762.00,percent of total billed charges,
BASEPLATE,7943246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3055.46,7762.00,percent of total billed charges,
MODULAR HEAD,7943248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
MODULAR HEAD,7943248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
ROD,7943288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7943288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
PLATE,7943317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3192.92000,925.95000,Aetna,First Health,,2611.81,,,,,,,1151.05,2611.81,percent of total billed charges,
PLATE,7943317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3192.92000,925.95000,Aetna,First Health,,2611.81,,,,,,,1028.12,2611.81,percent of total billed charges,
PLATE,7943319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3342.96000,969.46000,Aetna,First Health,,2734.54,,,,,,,1205.14,2734.54,percent of total billed charges,
PLATE,7943319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3342.96000,969.46000,Aetna,First Health,,2734.54,,,,,,,1076.43,2734.54,percent of total billed charges,
INSERT,7943400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,First Health,,5454.73,,,,,,,2403.95,5454.73,percent of total billed charges,
INSERT,7943400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,First Health,,5454.73,,,,,,,2147.22,5454.73,percent of total billed charges,
PENILE IMPLANT,7943627,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,First Health,,27552.28,,,,,,,12142.54,27552.28,percent of total billed charges,
PENILE IMPLANT,7943627,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,First Health,,27552.28,,,,,,,10845.76,27552.28,percent of total billed charges,
SPACER SHOULDER,7943679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,First Health,,9245.94,,,,,,,4074.77,9245.94,percent of total billed charges,
SPACER SHOULDER,7943679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,First Health,,9245.94,,,,,,,3639.60,9245.94,percent of total billed charges,
ROD,7943725,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
ROD,7943725,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
CAGE,7943806,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16425.00000,4763.25000,Aetna,First Health,,13435.65,,,,,,,5921.21,13435.65,percent of total billed charges,
CAGE,7943806,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16425.00000,4763.25000,Aetna,First Health,,13435.65,,,,,,,5288.85,13435.65,percent of total billed charges,
ROD,7943807,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,533.11,1209.66,percent of total billed charges,
ROD,7943807,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,476.17,1209.66,percent of total billed charges,
INSERT,7943844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
INSERT,7943844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
ROD,7943912,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7943912,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
BASEPLATE,7943916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
BASEPLATE,7943916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7943918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
COMPONENT PATELLA,7943918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
STEM,7943923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,7943923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
ROD,7943930,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD,7943930,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
LEAD KIT,7943971,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LEAD KIT,7943971,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
INSERT,7944034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1753.28000,508.45000,Aetna,First Health,,1434.18,,,,,,,632.06,1434.18,percent of total billed charges,
INSERT,7944034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1753.28000,508.45000,Aetna,First Health,,1434.18,,,,,,,564.56,1434.18,percent of total billed charges,
COMPONENT FEMORAL,7944036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25225.20000,7315.31000,Aetna,First Health,,20634.21,,,,,,,9093.68,20634.21,percent of total billed charges,
COMPONENT FEMORAL,7944036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25225.20000,7315.31000,Aetna,First Health,,20634.21,,,,,,,8122.51,20634.21,percent of total billed charges,
STEM EXTENSION,7944037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM EXTENSION,7944037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
CAGE,7944075,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,7944075,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
BONE GRAFT,7944204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3872.44000,1123.01000,Aetna,First Health,,3167.66,,,,,,,1396.01,3167.66,percent of total billed charges,
BONE GRAFT,7944204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3872.44000,1123.01000,Aetna,First Health,,3167.66,,,,,,,1246.93,3167.66,percent of total billed charges,
LIGAMENT,7944206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10701.00000,3103.29000,Aetna,First Health,,8753.42,,,,,,,3857.71,8753.42,percent of total billed charges,
LIGAMENT,7944206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10701.00000,3103.29000,Aetna,First Health,,8753.42,,,,,,,3445.72,8753.42,percent of total billed charges,
LIGAMENT,7944207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
LIGAMENT,7944207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
GRAFT,7944226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
GRAFT,7944226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
STEM,7944262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,First Health,,10720.37,,,,,,,4724.57,10720.37,percent of total billed charges,
STEM,7944262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,First Health,,10720.37,,,,,,,4220.00,10720.37,percent of total billed charges,
BIOMONITOR 2 AF,8136109,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
BIOMONITOR 2 AF,8136109,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
CATHETER,7953969,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,8782.32000,2546.87000,Aetna,First Health,,7183.94,,,,,,,3166.03,7183.94,percent of total billed charges,
CATHETER,7953969,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,8782.32000,2546.87000,Aetna,First Health,,7183.94,,,,,,,2827.91,7183.94,percent of total billed charges,
GUIDEWIRE,8136108,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,113.66000,32.96000,Aetna,First Health,,92.97,,,,,,,40.97,92.97,percent of total billed charges,
GUIDEWIRE,8136108,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,113.66000,32.96000,Aetna,First Health,,92.97,,,,,,,36.60,92.97,percent of total billed charges,
BALLOON CATHETER,7911544,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7911544,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON,7882791,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON,7882791,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7750492,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750492,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7750483,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750483,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
GUIDEWIRE,8136120,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
GUIDEWIRE,8136120,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
GUIDEWIRE,8136121,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
GUIDEWIRE,8136121,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
GUIDEWIRE,8136119,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
GUIDEWIRE,8136119,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
ABLATION CATHETER,8136221,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
ABLATION CATHETER,8136221,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
LASER ARTHRECTOMY CATHETER,8136224,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
LASER ARTHRECTOMY CATHETER,8136224,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
ABLATION CATHETER,8136225,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
ABLATION CATHETER,8136225,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
STENT GRAFT,7701403,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4805.10,10903.12,percent of total billed charges,
STENT GRAFT,7701403,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4291.94,10903.12,percent of total billed charges,
GUIDEWIRE,7697528,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,790.20000,229.16000,Aetna,First Health,,646.38,,,,,,,284.87,646.38,percent of total billed charges,
GUIDEWIRE,7697528,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,790.20000,229.16000,Aetna,First Health,,646.38,,,,,,,254.44,646.38,percent of total billed charges,
CATHETER BALLOON,8136227,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8136227,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,8988115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SCREW,8988115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
BASEPLATE,7944414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7944414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
CAGE,7944417,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11472.00000,3326.88000,Aetna,First Health,,9384.10,,,,,,,4135.66,9384.10,percent of total billed charges,
CAGE,7944417,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11472.00000,3326.88000,Aetna,First Health,,9384.10,,,,,,,3693.98,9384.10,percent of total billed charges,
HUMERAL HEAD,7944553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5463.50000,1584.42000,Aetna,First Health,,4469.14,,,,,,,1969.59,4469.14,percent of total billed charges,
HUMERAL HEAD,7944553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5463.50000,1584.42000,Aetna,First Health,,4469.14,,,,,,,1759.25,4469.14,percent of total billed charges,
SHEATH,7944566,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
SHEATH,7944566,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
GUIDEWIRE,7944573,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,790.20000,229.16000,Aetna,First Health,,646.38,,,,,,,284.87,646.38,percent of total billed charges,
GUIDEWIRE,7944573,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,790.20000,229.16000,Aetna,First Health,,646.38,,,,,,,254.44,646.38,percent of total billed charges,
SCREW,7945881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,728.50,1653.01,percent of total billed charges,
SCREW,7945881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,650.70,1653.01,percent of total billed charges,
CAGE,7945949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,7945949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
ROD,7945951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7945951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
SPACER KNEE,7698064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7844.40000,2274.88000,Aetna,First Health,,6416.72,,,,,,,2827.91,6416.72,percent of total billed charges,
SPACER KNEE,7698064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7844.40000,2274.88000,Aetna,First Health,,6416.72,,,,,,,2525.90,6416.72,percent of total billed charges,
SPACER KNEE,7698065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3907.58000,1133.20000,Aetna,First Health,,3196.40,,,,,,,1408.68,3196.40,percent of total billed charges,
SPACER KNEE,7698065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3907.58000,1133.20000,Aetna,First Health,,3196.40,,,,,,,1258.24,3196.40,percent of total billed charges,
CAGE,7697936,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
CAGE,7697936,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
PLATE,7946021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7946021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,7946023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7946023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
STENT,7946040,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,647.19000,187.69000,Aetna,First Health,,529.40,,,,,,,233.31,529.40,percent of total billed charges,
STENT,7946040,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,647.19000,187.69000,Aetna,First Health,,529.40,,,,,,,208.40,529.40,percent of total billed charges,
GENERATOR,7946119,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,69264.00000,20086.56000,Aetna,First Health,,56657.95,,,,,,,24969.67,56657.95,percent of total billed charges,
GENERATOR,7946119,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,69264.00000,20086.56000,Aetna,First Health,,56657.95,,,,,,,22303.01,56657.95,percent of total billed charges,
LEAD,7946120,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,22607.50000,6556.17000,Aetna,First Health,,18492.94,,,,,,,8150.00,18492.94,percent of total billed charges,
LEAD,7946120,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,22607.50000,6556.17000,Aetna,First Health,,18492.94,,,,,,,7279.61,18492.94,percent of total billed charges,
GRAFT,7947887,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5634.61,12785.34,percent of total billed charges,
GRAFT,7947887,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5032.86,12785.34,percent of total billed charges,
PLATE,7947893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7947893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CAGE,7947896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,7947896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
PENILE IMPLANT,7947914,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,32951.25000,9555.86000,Aetna,First Health,,26954.12,,,,,,,11878.93,26954.12,percent of total billed charges,
PENILE IMPLANT,7947914,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,32951.25000,9555.86000,Aetna,First Health,,26954.12,,,,,,,10610.30,26954.12,percent of total billed charges,
INSERT,7947922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,7947922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
COMPONENT FEMORAL,7947952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3942.07,8944.83,percent of total billed charges,
COMPONENT FEMORAL,7947952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3521.07,8944.83,percent of total billed charges,
PLATE,7948061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1433.16000,415.62000,Aetna,First Health,,1172.32,,,,,,,516.65,1172.32,percent of total billed charges,
PLATE,7948061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1433.16000,415.62000,Aetna,First Health,,1172.32,,,,,,,461.48,1172.32,percent of total billed charges,
SCREW,7948084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7948084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
COMPONENT GLENOID,7948096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT GLENOID,7948096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
HUMERAL HEAD,7948097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HUMERAL HEAD,7948097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STENT GRAFT,7948124,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12426.00000,3603.54000,Aetna,First Health,,10164.47,,,,,,,4479.57,10164.47,percent of total billed charges,
STENT GRAFT,7948124,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12426.00000,3603.54000,Aetna,First Health,,10164.47,,,,,,,4001.17,10164.47,percent of total billed charges,
INSERT,7948126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
INSERT,7948126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
SHELL,7948152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7948152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
CUP,7948170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1906.06,4325.00,percent of total billed charges,
CUP,7948170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1702.50,4325.00,percent of total billed charges,
MESH,7948206,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3804.50000,1103.30000,Aetna,First Health,,3112.08,,,,,,,1371.52,3112.08,percent of total billed charges,
MESH,7948206,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3804.50000,1103.30000,Aetna,First Health,,3112.08,,,,,,,1225.05,3112.08,percent of total billed charges,
DERMIS,7948209,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9888.00000,2867.52000,Aetna,First Health,,8088.38,,,,,,,3564.62,8088.38,percent of total billed charges,
DERMIS,7948209,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9888.00000,2867.52000,Aetna,First Health,,8088.38,,,,,,,3183.94,8088.38,percent of total billed charges,
ROD,7948225,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,289.57,657.06,percent of total billed charges,
ROD,7948225,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,258.65,657.06,percent of total billed charges,
SCREW,7948226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,7948226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
SCREW,7948227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,122.78,278.59,percent of total billed charges,
SCREW,7948227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,109.67,278.59,percent of total billed charges,
CAGE,7948214,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,7948214,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
BONE MATRIX,7948218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
BONE MATRIX,7948218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
BONE MATRIX,7948219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
BONE MATRIX,7948219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
BONE MATRIX,7948220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
BONE MATRIX,7948220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
PLATE,7948228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,1072.65,2433.91,percent of total billed charges,
PLATE,7948228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,958.09,2433.91,percent of total billed charges,
CAGE BASE,7948230,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE BASE,7948230,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
COMPONENT FEMORAL,7948357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6214.74000,1802.27000,Aetna,First Health,,5083.66,,,,,,,2240.41,5083.66,percent of total billed charges,
COMPONENT FEMORAL,7948357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6214.74000,1802.27000,Aetna,First Health,,5083.66,,,,,,,2001.15,5083.66,percent of total billed charges,
BOLT,7948358,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1748.32000,507.01000,Aetna,First Health,,1430.13,,,,,,,630.27,1430.13,percent of total billed charges,
BOLT,7948358,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1748.32000,507.01000,Aetna,First Health,,1430.13,,,,,,,562.96,1430.13,percent of total billed charges,
STEM,7948359,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17212.25000,4991.55000,Aetna,First Health,,14079.62,,,,,,,6205.02,14079.62,percent of total billed charges,
STEM,7948359,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17212.25000,4991.55000,Aetna,First Health,,14079.62,,,,,,,5542.34,14079.62,percent of total billed charges,
STEM,7948360,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15369.90000,4457.27000,Aetna,First Health,,12572.58,,,,,,,5540.85,12572.58,percent of total billed charges,
STEM,7948360,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15369.90000,4457.27000,Aetna,First Health,,12572.58,,,,,,,4949.11,12572.58,percent of total billed charges,
STENT GRAFT,7948411,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33862.50000,9820.12000,Aetna,First Health,,27699.53,,,,,,,12207.43,27699.53,percent of total billed charges,
STENT GRAFT,7948411,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33862.50000,9820.12000,Aetna,First Health,,27699.53,,,,,,,10903.73,27699.53,percent of total billed charges,
TIBIAL CONE,7948412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
TIBIAL CONE,7948412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
ANCHOR IN KIT,7948519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
ANCHOR IN KIT,7948519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
TESTICULAR IMPLANT,7948610,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8499.00000,2464.71000,Aetna,First Health,,6952.18,,,,,,,3063.89,6952.18,percent of total billed charges,
TESTICULAR IMPLANT,7948610,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8499.00000,2464.71000,Aetna,First Health,,6952.18,,,,,,,2736.68,6952.18,percent of total billed charges,
BOLT,7948232,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BOLT,7948232,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
CAGE,7948596,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,7948596,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
ROD,7948606,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7948606,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD,7948525,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD,7948525,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
TENDON,7948683,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10871.25000,3152.66000,Aetna,First Health,,8892.68,,,,,,,3919.09,8892.68,percent of total billed charges,
TENDON,7948683,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10871.25000,3152.66000,Aetna,First Health,,8892.68,,,,,,,3500.54,8892.68,percent of total billed charges,
BALLOON CATHETER,7948614,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7948614,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
MESH,7948749,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4403.00000,1276.87000,Aetna,First Health,,3601.65,,,,,,,1587.28,3601.65,percent of total billed charges,
MESH,7948749,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4403.00000,1276.87000,Aetna,First Health,,3601.65,,,,,,,1417.77,3601.65,percent of total billed charges,
INSERT,7948778,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7948778,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7948815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7948815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BONE MATRIX,7948894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6107.50000,1771.18000,Aetna,First Health,,4995.94,,,,,,,2201.75,4995.94,percent of total billed charges,
BONE MATRIX,7948894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6107.50000,1771.18000,Aetna,First Health,,4995.94,,,,,,,1966.62,4995.94,percent of total billed charges,
BONE MATRIX,7948895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10914.00000,3165.06000,Aetna,First Health,,8927.65,,,,,,,3934.50,8927.65,percent of total billed charges,
BONE MATRIX,7948895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10914.00000,3165.06000,Aetna,First Health,,8927.65,,,,,,,3514.31,8927.65,percent of total billed charges,
STENT GRAFT,7948864,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7948864,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
FILTER IN A KIT,7948866,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
FILTER IN A KIT,7948866,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
ROD,7950093,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7950093,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
VALVE,7950154,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
VALVE,7950154,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
COMPONENT TALAR,7950207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3486.76,7911.70,percent of total billed charges,
COMPONENT TALAR,7950207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3114.38,7911.70,percent of total billed charges,
STENT GRAFT,7950343,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
STENT GRAFT,7950343,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
PLATE,7702498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,461.65000,133.88000,Aetna,First Health,,377.63,,,,,,,166.42,377.63,percent of total billed charges,
PLATE,7702498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,461.65000,133.88000,Aetna,First Health,,377.63,,,,,,,148.65,377.63,percent of total billed charges,
SHELL,7950458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,608.52,1380.78,percent of total billed charges,
SHELL,7950458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,543.54,1380.78,percent of total billed charges,
INSERT,7950460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7950460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
ROD,7950498,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7950498,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
INSERT,7950551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7950551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
SHEATH,7945854,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,5264.00000,1526.56000,Aetna,First Health,,4305.95,,,,,,,1897.67,4305.95,percent of total billed charges,
SHEATH,7945854,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,5264.00000,1526.56000,Aetna,First Health,,4305.95,,,,,,,1695.01,4305.95,percent of total billed charges,
PLATE,7950558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
PLATE,7950558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
MEDPOR IMPLANT,7951863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8464.05000,2454.57000,Aetna,First Health,,6923.59,,,,,,,3051.29,6923.59,percent of total billed charges,
MEDPOR IMPLANT,7951863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8464.05000,2454.57000,Aetna,First Health,,6923.59,,,,,,,2725.42,6923.59,percent of total billed charges,
PROXIMAL BODY,7699723,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22591.50000,6551.54000,Aetna,First Health,,18479.85,,,,,,,8144.24,18479.85,percent of total billed charges,
PROXIMAL BODY,7699723,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22591.50000,6551.54000,Aetna,First Health,,18479.85,,,,,,,7274.46,18479.85,percent of total billed charges,
STEM,7951935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19208.75000,5570.54000,Aetna,First Health,,15712.76,,,,,,,6924.75,15712.76,percent of total billed charges,
STEM,7951935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19208.75000,5570.54000,Aetna,First Health,,15712.76,,,,,,,6185.22,15712.76,percent of total billed charges,
STENT IMPLANTS IN KIT,7953868,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9126.00000,2646.54000,Aetna,First Health,,7465.07,,,,,,,3289.92,7465.07,percent of total billed charges,
STENT IMPLANTS IN KIT,7953868,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9126.00000,2646.54000,Aetna,First Health,,7465.07,,,,,,,2938.57,7465.07,percent of total billed charges,
ANCHOR,7953912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.00000,578.26000,Aetna,First Health,,1631.09,,,,,,,718.84,1631.09,percent of total billed charges,
ANCHOR,7953912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.00000,578.26000,Aetna,First Health,,1631.09,,,,,,,642.07,1631.09,percent of total billed charges,
FEMORAL CONE,7953972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
FEMORAL CONE,7953972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
CONNECTOR SPINAL,7954116,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
CONNECTOR SPINAL,7954116,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,7954127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7954127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7954135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7954135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SHEATH,7954474,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,First Health,,2545.62,,,,,,,1121.88,2545.62,percent of total billed charges,
SHEATH,7954474,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,First Health,,2545.62,,,,,,,1002.06,2545.62,percent of total billed charges,
ROD,7954587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7954587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
STENT GRAFT,7954612,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3824.18,8677.34,percent of total billed charges,
STENT GRAFT,7954612,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3415.78,8677.34,percent of total billed charges,
PLATE,7954648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE,7954648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
SCREW,7954649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7954649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
BASEPLATE,7954747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7954747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
ANCHOR,7954749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
ANCHOR,7954749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
CONTROLLER,7954750,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,6475.00000,1877.75000,Aetna,First Health,,5296.55,,,,,,,2334.24,5296.55,percent of total billed charges,
CONTROLLER,7954750,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,6475.00000,1877.75000,Aetna,First Health,,5296.55,,,,,,,2084.95,5296.55,percent of total billed charges,
COMPONENT GLENOID,7954791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT GLENOID,7954791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
HUMERAL HEAD,7954792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HUMERAL HEAD,7954792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
FEMORAL HEAD,7955062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7955062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
PLATE,7955808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1681.44000,487.62000,Aetna,First Health,,1375.42,,,,,,,606.16,1375.42,percent of total billed charges,
PLATE,7955808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1681.44000,487.62000,Aetna,First Health,,1375.42,,,,,,,541.42,1375.42,percent of total billed charges,
SCREW,7956547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7956547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
INSERT,7956662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7956662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7956683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7956683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
GRAFT,7956955,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3249.05000,942.22000,Aetna,First Health,,2657.72,,,,,,,1171.28,2657.72,percent of total billed charges,
GRAFT,7956955,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3249.05000,942.22000,Aetna,First Health,,2657.72,,,,,,,1046.19,2657.72,percent of total billed charges,
ABSORBABLE SECURESTRAP,7697287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2503.71000,726.08000,Aetna,First Health,,2048.03,,,,,,,902.59,2048.03,percent of total billed charges,
ABSORBABLE SECURESTRAP,7697287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2503.71000,726.08000,Aetna,First Health,,2048.03,,,,,,,806.19,2048.03,percent of total billed charges,
STENT GRAFT,7957694,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
STENT GRAFT,7957694,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
SHELL,7957716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3524.61,7997.59,percent of total billed charges,
SHELL,7957716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3148.19,7997.59,percent of total billed charges,
PLATE,7957760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7716.45000,2237.77000,Aetna,First Health,,6312.06,,,,,,,2781.78,6312.06,percent of total billed charges,
PLATE,7957760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7716.45000,2237.77000,Aetna,First Health,,6312.06,,,,,,,2484.70,6312.06,percent of total billed charges,
FEMORAL HEAD,7957790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7957790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
LEAD KIT,7957816,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
LEAD KIT,7957816,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
PLATE,7957844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,First Health,,1208.02,,,,,,,532.39,1208.02,percent of total billed charges,
PLATE,7957844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,First Health,,1208.02,,,,,,,475.53,1208.02,percent of total billed charges,
PLATE,7957846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,First Health,,1208.02,,,,,,,532.39,1208.02,percent of total billed charges,
PLATE,7957846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,First Health,,1208.02,,,,,,,475.53,1208.02,percent of total billed charges,
FEMORAL HEAD,7957909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7957909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
LINER,7957910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
LINER,7957910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
BALLOON CATHETER,7957913,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
BALLOON CATHETER,7957913,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
STEM,7957935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,First Health,,9385.08,,,,,,,4136.09,9385.08,percent of total billed charges,
STEM,7957935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,First Health,,9385.08,,,,,,,3694.37,9385.08,percent of total billed charges,
STEM,7957959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7957959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CONNECTOR SPINAL,7958052,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1304.00000,378.16000,Aetna,First Health,,1066.67,,,,,,,470.09,1066.67,percent of total billed charges,
CONNECTOR SPINAL,7958052,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1304.00000,378.16000,Aetna,First Health,,1066.67,,,,,,,419.89,1066.67,percent of total billed charges,
STEM,7958095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,10392.54,23581.41,percent of total billed charges,
STEM,7958095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,9282.66,23581.41,percent of total billed charges,
SCREW,7958103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,731.09,1658.90,percent of total billed charges,
SCREW,7958103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,653.02,1658.90,percent of total billed charges,
SCREW,7958108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,210.00000,60.90000,Aetna,First Health,,171.78,,,,,,,75.70,171.78,percent of total billed charges,
SCREW,7958108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,First Health,,171.78,,,,,,,67.62,171.78,percent of total billed charges,
LEAD,7958109,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
LEAD,7958109,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
ALLOGRAFT,7959591,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,33862.50000,9820.12000,Aetna,First Health,,27699.53,,,,,,,12207.43,27699.53,percent of total billed charges,
ALLOGRAFT,7959591,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,33862.50000,9820.12000,Aetna,First Health,,27699.53,,,,,,,10903.73,27699.53,percent of total billed charges,
NAIL,7959958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,843.86,1914.77,percent of total billed charges,
NAIL,7959958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,753.74,1914.77,percent of total billed charges,
SCREW,7959983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7959983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
BALLOON DILATOR,7744546,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,First Health,,7393.85,,,,,,,3258.54,7393.85,percent of total billed charges,
BALLOON DILATOR,7744546,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,First Health,,7393.85,,,,,,,2910.54,7393.85,percent of total billed charges,
BREAST IMPLANT,7960019,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6125.00000,1776.25000,Aetna,First Health,,5010.25,,,,,,,2208.06,5010.25,percent of total billed charges,
BREAST IMPLANT,7960019,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6125.00000,1776.25000,Aetna,First Health,,5010.25,,,,,,,1972.25,5010.25,percent of total billed charges,
SPACER,7960041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
SPACER,7960041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
CAGE,7960155,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,7960155,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
FIXATOR,7962229,CDM,278,RC,,,,,facility,inpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,504.70,1145.20,percent of total billed charges,
FIXATOR,7962229,CDM,278,RC,,,,,facility,outpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,450.80,1145.20,percent of total billed charges,
STEM,7962243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,7962243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
COMPONENT FEMORAL,7962545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
COMPONENT FEMORAL,7962545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
COMPONENT FEMORAL,7962546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7962546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7962643,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BASEPLATE,7962643,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BASEPLATE,7963012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8077.50000,2342.48000,Aetna,First Health,,6607.40,,,,,,,2911.94,6607.40,percent of total billed charges,
BASEPLATE,7963012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8077.50000,2342.48000,Aetna,First Health,,6607.40,,,,,,,2600.95,6607.40,percent of total billed charges,
CAGE,7963934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,7963934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
INTRODUCER SHEATH,7963957,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,325.85000,94.50000,Aetna,First Health,,266.55,,,,,,,117.47,266.55,percent of total billed charges,
INTRODUCER SHEATH,7963957,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,325.85000,94.50000,Aetna,First Health,,266.55,,,,,,,104.92,266.55,percent of total billed charges,
INTRODUCER SHEATH,7963958,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,360.48000,104.54000,Aetna,First Health,,294.87,,,,,,,129.95,294.87,percent of total billed charges,
INTRODUCER SHEATH,7963958,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,360.48000,104.54000,Aetna,First Health,,294.87,,,,,,,116.07,294.87,percent of total billed charges,
MEDPOR IMPLANT,7963961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4365.90000,1266.11000,Aetna,First Health,,3571.31,,,,,,,1573.91,3571.31,percent of total billed charges,
MEDPOR IMPLANT,7963961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4365.90000,1266.11000,Aetna,First Health,,3571.31,,,,,,,1405.82,3571.31,percent of total billed charges,
GLENOID,7964335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,First Health,,4551.92,,,,,,,2006.07,4551.92,percent of total billed charges,
GLENOID,7964335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,First Health,,4551.92,,,,,,,1791.83,4551.92,percent of total billed charges,
CAGE,7964476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,First Health,,8255.26,,,,,,,3638.17,8255.26,percent of total billed charges,
CAGE,7964476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,First Health,,8255.26,,,,,,,3249.62,8255.26,percent of total billed charges,
SCREW,7964479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1490.13,3381.20,percent of total billed charges,
SCREW,7964479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1330.99,3381.20,percent of total billed charges,
GRAFT,7964997,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3983.00000,1155.07000,Aetna,First Health,,3258.09,,,,,,,1435.87,3258.09,percent of total billed charges,
GRAFT,7964997,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3983.00000,1155.07000,Aetna,First Health,,3258.09,,,,,,,1282.53,3258.09,percent of total billed charges,
BREAST IMPLANT,7965057,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BREAST IMPLANT,7965057,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
BREAST IMPLANT,7965061,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
BREAST IMPLANT,7965061,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
BASEPLATE,7965235,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
BASEPLATE,7965235,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
WEDGE,7965448,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
WEDGE,7965448,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
GRAFT STENT,7965452,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
GRAFT STENT,7965452,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
MESH,7965480,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,10224.57000,2965.13000,Aetna,First Health,,8363.70,,,,,,,3685.96,8363.70,percent of total billed charges,
MESH,7965480,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,10224.57000,2965.13000,Aetna,First Health,,8363.70,,,,,,,3292.31,8363.70,percent of total billed charges,
PENILE IMPLANT,7965485,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,First Health,,27552.28,,,,,,,12142.54,27552.28,percent of total billed charges,
PENILE IMPLANT,7965485,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,First Health,,27552.28,,,,,,,10845.76,27552.28,percent of total billed charges,
SPINAL IMPLANT,7965924,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
SPINAL IMPLANT,7965924,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
SCREW,7965929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,First Health,,2180.79,,,,,,,961.09,2180.79,percent of total billed charges,
SCREW,7965929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,First Health,,2180.79,,,,,,,858.45,2180.79,percent of total billed charges,
SPINAL IMPLANT,7966067,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
SPINAL IMPLANT,7966067,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
PLATE,7966068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,3076.87,6981.63,percent of total billed charges,
PLATE,7966068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,2748.27,6981.63,percent of total billed charges,
SCREW,7966069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,7966069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
PIN,7966070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1266.60000,367.31000,Aetna,First Health,,1036.08,,,,,,,456.61,1036.08,percent of total billed charges,
PIN,7966070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1266.60000,367.31000,Aetna,First Health,,1036.08,,,,,,,407.85,1036.08,percent of total billed charges,
ROD,7966074,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1652.00000,479.08000,Aetna,First Health,,1351.34,,,,,,,595.55,1351.34,percent of total billed charges,
ROD,7966074,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1652.00000,479.08000,Aetna,First Health,,1351.34,,,,,,,531.94,1351.34,percent of total billed charges,
PLATE,7966075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
PLATE,7966075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
CONNECTOR SPINAL,7966077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,876.74,1989.38,percent of total billed charges,
CONNECTOR SPINAL,7966077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,783.10,1989.38,percent of total billed charges,
LINER,7966086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7966086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
MESH,7966087,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2428.28000,704.20000,Aetna,First Health,,1986.33,,,,,,,875.39,1986.33,percent of total billed charges,
MESH,7966087,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2428.28000,704.20000,Aetna,First Health,,1986.33,,,,,,,781.91,1986.33,percent of total billed charges,
CAGE,7975017,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4544.46,10311.71,percent of total billed charges,
CAGE,7975017,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4059.13,10311.71,percent of total billed charges,
SPINAL CORD STIM,7966235,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,54586.00000,15829.94000,Aetna,First Health,,44651.35,,,,,,,19678.25,44651.35,percent of total billed charges,
SPINAL CORD STIM,7966235,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,54586.00000,15829.94000,Aetna,First Health,,44651.35,,,,,,,17576.69,44651.35,percent of total billed charges,
BASEPLATE,7967968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
BASEPLATE,7967968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
PLATE,7967971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5404.11000,1567.19000,Aetna,First Health,,4420.56,,,,,,,1948.18,4420.56,percent of total billed charges,
PLATE,7967971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5404.11000,1567.19000,Aetna,First Health,,4420.56,,,,,,,1740.12,4420.56,percent of total billed charges,
STEM,7967960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11374.50000,3298.60000,Aetna,First Health,,9304.34,,,,,,,4100.51,9304.34,percent of total billed charges,
STEM,7967960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11374.50000,3298.60000,Aetna,First Health,,9304.34,,,,,,,3662.59,9304.34,percent of total billed charges,
FEMORAL HEAD,7967962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5771.50000,1673.74000,Aetna,First Health,,4721.09,,,,,,,2080.63,4721.09,percent of total billed charges,
FEMORAL HEAD,7967962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5771.50000,1673.74000,Aetna,First Health,,4721.09,,,,,,,1858.42,4721.09,percent of total billed charges,
LEAD,7967974,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,21158.90000,6136.08000,Aetna,First Health,,17307.98,,,,,,,7627.78,17307.98,percent of total billed charges,
LEAD,7967974,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,21158.90000,6136.08000,Aetna,First Health,,17307.98,,,,,,,6813.17,17307.98,percent of total billed charges,
STEM,7968104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26350.50000,7641.64000,Aetna,First Health,,21554.71,,,,,,,9499.36,21554.71,percent of total billed charges,
STEM,7968104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26350.50000,7641.64000,Aetna,First Health,,21554.71,,,,,,,8484.86,21554.71,percent of total billed charges,
AUTOGRAFT,7968114,CDM,278,RC,C9399,HCPCS,,,facility,inpatient,,,3286.50000,953.08000,Aetna,First Health,,2688.36,,,,,,,1184.78,2688.36,percent of total billed charges,
AUTOGRAFT,7968114,CDM,278,RC,C9399,HCPCS,,,facility,outpatient,,,3286.50000,953.08000,Aetna,First Health,,2688.36,,,,,,,1058.25,2688.36,percent of total billed charges,
SCREW,7968116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7968116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7968117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,7968117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CAP,7968118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
CAP,7968118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SPINAL SPACER,7969242,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
SPINAL SPACER,7969242,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
INSERT,7968123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,First Health,,4551.92,,,,,,,2006.07,4551.92,percent of total billed charges,
INSERT,7968123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,First Health,,4551.92,,,,,,,1791.83,4551.92,percent of total billed charges,
NEUROSTIMULATOR,7968187,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,43616.25000,12648.71000,Aetna,First Health,,35678.09,,,,,,,15723.66,35678.09,percent of total billed charges,
NEUROSTIMULATOR,7968187,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,43616.25000,12648.71000,Aetna,First Health,,35678.09,,,,,,,14044.43,35678.09,percent of total billed charges,
MODULAR HEAD,7968189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
MODULAR HEAD,7968189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
PLATE,7968220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1869.80000,542.24000,Aetna,First Health,,1529.50,,,,,,,674.06,1529.50,percent of total billed charges,
PLATE,7968220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1869.80000,542.24000,Aetna,First Health,,1529.50,,,,,,,602.08,1529.50,percent of total billed charges,
CONNECTOR SPINAL,7968225,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1445.72000,419.26000,Aetna,First Health,,1182.60,,,,,,,521.18,1182.60,percent of total billed charges,
CONNECTOR SPINAL,7968225,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1445.72000,419.26000,Aetna,First Health,,1182.60,,,,,,,465.52,1182.60,percent of total billed charges,
CAGE,7968230,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1254.66,2846.91,percent of total billed charges,
CAGE,7968230,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1120.67,2846.91,percent of total billed charges,
ROD SPINAL,7974720,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
ROD SPINAL,7974720,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
GUIDEWIRE,7968236,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
GUIDEWIRE,7968236,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
CONNECTOR SPINAL,7968237,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR SPINAL,7968237,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
SCREW,7972176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,First Health,,2883.04,,,,,,,1270.58,2883.04,percent of total billed charges,
SCREW,7972176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,First Health,,2883.04,,,,,,,1134.89,2883.04,percent of total billed charges,
COMPONENT FEMORAL,7903716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,8029.01,18218.40,percent of total billed charges,
COMPONENT FEMORAL,7903716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,7171.55,18218.40,percent of total billed charges,
BUTTON,7903720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7447.50000,2159.77000,Aetna,First Health,,6092.06,,,,,,,2684.82,6092.06,percent of total billed charges,
BUTTON,7903720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7447.50000,2159.77000,Aetna,First Health,,6092.06,,,,,,,2398.09,6092.06,percent of total billed charges,
SCREW,7903728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1527.56000,442.99000,Aetna,First Health,,1249.54,,,,,,,550.69,1249.54,percent of total billed charges,
SCREW,7903728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1527.56000,442.99000,Aetna,First Health,,1249.54,,,,,,,491.87,1249.54,percent of total billed charges,
NERVE GRAFT,7903784,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3738.75,8483.48,percent of total billed charges,
NERVE GRAFT,7903784,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3339.46,8483.48,percent of total billed charges,
NERVE GRAFT,7736565,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15675.00000,4545.75000,Aetna,First Health,,12822.15,,,,,,,5650.84,12822.15,percent of total billed charges,
NERVE GRAFT,7736565,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15675.00000,4545.75000,Aetna,First Health,,12822.15,,,,,,,5047.35,12822.15,percent of total billed charges,
NERVE GRAFT,7903791,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,21347.50000,6190.78000,Aetna,First Health,,17462.26,,,,,,,7695.77,17462.26,percent of total billed charges,
NERVE GRAFT,7903791,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,21347.50000,6190.78000,Aetna,First Health,,17462.26,,,,,,,6873.90,17462.26,percent of total billed charges,
NERVE GRAFT,7903793,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,22570.00000,6545.30000,Aetna,First Health,,18462.26,,,,,,,8136.48,18462.26,percent of total billed charges,
NERVE GRAFT,7903793,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,22570.00000,6545.30000,Aetna,First Health,,18462.26,,,,,,,7267.54,18462.26,percent of total billed charges,
NERVE GRAFT,7903778,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,25885.00000,7506.65000,Aetna,First Health,,21173.93,,,,,,,9331.54,21173.93,percent of total billed charges,
NERVE GRAFT,7903778,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,25885.00000,7506.65000,Aetna,First Health,,21173.93,,,,,,,8334.97,21173.93,percent of total billed charges,
NERVE GRAFT,7903780,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,27960.75000,8108.62000,Aetna,First Health,,22871.89,,,,,,,10079.85,22871.89,percent of total billed charges,
NERVE GRAFT,7903780,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,27960.75000,8108.62000,Aetna,First Health,,22871.89,,,,,,,9003.36,22871.89,percent of total billed charges,
SCREW,7866113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7866113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
GUIDEWIRE,7904053,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
GUIDEWIRE,7904053,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
SCREW,7894169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,338.17,767.34,percent of total billed charges,
SCREW,7894169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,302.06,767.34,percent of total billed charges,
INTRODUCER,7904148,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,122.87000,35.63000,Aetna,First Health,,100.51,,,,,,,44.29,100.51,percent of total billed charges,
INTRODUCER,7904148,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,122.87000,35.63000,Aetna,First Health,,100.51,,,,,,,39.56,100.51,percent of total billed charges,
CATHETER,7694140,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1938.32000,562.11000,Aetna,First Health,,1585.55,,,,,,,698.76,1585.55,percent of total billed charges,
CATHETER,7694140,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1938.32000,562.11000,Aetna,First Health,,1585.55,,,,,,,624.14,1585.55,percent of total billed charges,
HUMERAL HEAD,7904740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HUMERAL HEAD,7904740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,7904939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,7904939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CERVICAL STABILZATION,7904977,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CERVICAL STABILZATION,7904977,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
LINER,7905031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
HIP MODULAR,7905308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
HIP MODULAR,7905308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
RESERVOIR,7694586,CDM,278,RC,,,,,facility,inpatient,,,2171.64000,629.78000,Aetna,First Health,,1776.40,,,,,,,782.88,1776.40,percent of total billed charges,
RESERVOIR,7694586,CDM,278,RC,,,,,facility,outpatient,,,2171.64000,629.78000,Aetna,First Health,,1776.40,,,,,,,699.27,1776.40,percent of total billed charges,
FEMORAL HEAD,7760137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7760137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
PLATE,7905389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2659.08000,771.13000,Aetna,First Health,,2175.13,,,,,,,958.60,2175.13,percent of total billed charges,
PLATE,7905389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2659.08000,771.13000,Aetna,First Health,,2175.13,,,,,,,856.22,2175.13,percent of total billed charges,
PLATE,7905455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1979.40000,574.03000,Aetna,First Health,,1619.15,,,,,,,713.57,1619.15,percent of total billed charges,
PLATE,7905455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1979.40000,574.03000,Aetna,First Health,,1619.15,,,,,,,637.37,1619.15,percent of total billed charges,
GUIDEWIRE,7905403,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3228.96000,936.40000,Aetna,First Health,,2641.29,,,,,,,1164.04,2641.29,percent of total billed charges,
GUIDEWIRE,7905403,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3228.96000,936.40000,Aetna,First Health,,2641.29,,,,,,,1039.73,2641.29,percent of total billed charges,
GUIDEWIRE,7905404,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2974.12000,862.49000,Aetna,First Health,,2432.83,,,,,,,1072.17,2432.83,percent of total billed charges,
GUIDEWIRE,7905404,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2974.12000,862.49000,Aetna,First Health,,2432.83,,,,,,,957.67,2432.83,percent of total billed charges,
GUIDEWIRE,7905410,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2293.12000,665.00000,Aetna,First Health,,1875.77,,,,,,,826.67,1875.77,percent of total billed charges,
GUIDEWIRE,7905410,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2293.12000,665.00000,Aetna,First Health,,1875.77,,,,,,,738.38,1875.77,percent of total billed charges,
FEMORAL HEAD,7804053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7804053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
INTRODUCER,7905548,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,741.19,1681.81,percent of total billed charges,
INTRODUCER,7905548,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,662.03,1681.81,percent of total billed charges,
CATHETER,7905550,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1991.36000,577.49000,Aetna,First Health,,1628.93,,,,,,,717.89,1628.93,percent of total billed charges,
CATHETER,7905550,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1991.36000,577.49000,Aetna,First Health,,1628.93,,,,,,,641.22,1628.93,percent of total billed charges,
ANCHOR,7905567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
ANCHOR,7905567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
NAIL,7802049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4650.45,10552.20,percent of total billed charges,
NAIL,7802049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4153.80,10552.20,percent of total billed charges,
AUGMENT TIBIAL,7893762,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1693.52,3842.72,percent of total billed charges,
AUGMENT TIBIAL,7893762,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1512.66,3842.72,percent of total billed charges,
STEM,7905617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM,7905617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
PLATE,7702146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.48000,574.92000,Aetna,First Health,,1621.67,,,,,,,714.68,1621.67,percent of total billed charges,
PLATE,7702146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.48000,574.92000,Aetna,First Health,,1621.67,,,,,,,638.36,1621.67,percent of total billed charges,
INSERT,7698877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
INSERT,7698877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW,7908235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7908235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
ACETABULAR RING,7908258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,205.70,466.75,percent of total billed charges,
ACETABULAR RING,7908258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,183.73,466.75,percent of total billed charges,
STEM,7698777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1871.68,4246.97,percent of total billed charges,
STEM,7698777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1671.79,4246.97,percent of total billed charges,
GLENOSPHERE,7698227,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GLENOSPHERE,7698227,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
PLATE,7908365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5781.58000,1676.66000,Aetna,First Health,,4729.33,,,,,,,2084.26,4729.33,percent of total billed charges,
PLATE,7908365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5781.58000,1676.66000,Aetna,First Health,,4729.33,,,,,,,1861.67,4729.33,percent of total billed charges,
SCREW,7908499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3328.50000,965.26000,Aetna,First Health,,2722.71,,,,,,,1199.92,2722.71,percent of total billed charges,
SCREW,7908499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3328.50000,965.26000,Aetna,First Health,,2722.71,,,,,,,1071.78,2722.71,percent of total billed charges,
GRAFT,7908507,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,6286.00000,1822.94000,Aetna,First Health,,5141.95,,,,,,,2266.10,5141.95,percent of total billed charges,
GRAFT,7908507,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,6286.00000,1822.94000,Aetna,First Health,,5141.95,,,,,,,2024.09,5141.95,percent of total billed charges,
STEM,7908597,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7908597,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE,7908714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
PLATE,7908714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
PLATE,7878470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8445.00000,2449.05000,Aetna,First Health,,6908.01,,,,,,,3044.42,6908.01,percent of total billed charges,
PLATE,7878470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8445.00000,2449.05000,Aetna,First Health,,6908.01,,,,,,,2719.29,6908.01,percent of total billed charges,
RESERVOIR,7908749,CDM,278,RC,,,,,facility,inpatient,,,1936.00000,561.44000,Aetna,First Health,,1583.65,,,,,,,697.93,1583.65,percent of total billed charges,
RESERVOIR,7908749,CDM,278,RC,,,,,facility,outpatient,,,1936.00000,561.44000,Aetna,First Health,,1583.65,,,,,,,623.39,1583.65,percent of total billed charges,
SPACER,7909029,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
SPACER,7909029,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7909287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5152.00000,1494.08000,Aetna,First Health,,4214.34,,,,,,,1857.30,4214.34,percent of total billed charges,
PLATE,7909287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5152.00000,1494.08000,Aetna,First Health,,4214.34,,,,,,,1658.94,4214.34,percent of total billed charges,
INSERT,7909307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7909307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM,7909325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7909325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PLATE,7909327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6102.04000,1769.59000,Aetna,First Health,,4991.47,,,,,,,2199.79,4991.47,percent of total billed charges,
PLATE,7909327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6102.04000,1769.59000,Aetna,First Health,,4991.47,,,,,,,1964.86,4991.47,percent of total billed charges,
SPACER,7698399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
SPACER,7698399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
SHEATH,7909407,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,987.77,2241.32,percent of total billed charges,
SHEATH,7909407,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,882.28,2241.32,percent of total billed charges,
STEM,7700436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7700436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
BONE PLUG,7909414,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
BONE PLUG,7909414,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
COMPONENT FEMORAL,7700406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7700406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
PATELLA IMPLANT,7909483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
PATELLA IMPLANT,7909483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
COMPONENT TIBIAL,7909485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
COMPONENT TIBIAL,7909485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,7910125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7910125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
MESH,7910136,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
MESH,7910136,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
PLATE,7701902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5950.35000,1725.60000,Aetna,First Health,,4867.39,,,,,,,2145.10,4867.39,percent of total billed charges,
PLATE,7701902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5950.35000,1725.60000,Aetna,First Health,,4867.39,,,,,,,1916.01,4867.39,percent of total billed charges,
SCREW,7910162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,290.06,658.16,percent of total billed charges,
SCREW,7910162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,259.08,658.16,percent of total billed charges,
STEM,7910164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9409.02000,2728.62000,Aetna,First Health,,7696.58,,,,,,,3391.95,7696.58,percent of total billed charges,
STEM,7910164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9409.02000,2728.62000,Aetna,First Health,,7696.58,,,,,,,3029.70,7696.58,percent of total billed charges,
GRAFT,7910198,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,16350.00000,4741.50000,Aetna,First Health,,13374.30,,,,,,,5894.18,13374.30,percent of total billed charges,
GRAFT,7910198,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,16350.00000,4741.50000,Aetna,First Health,,13374.30,,,,,,,5264.70,13374.30,percent of total billed charges,
GRAFT,7910199,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,28192.50000,8175.82000,Aetna,First Health,,23061.47,,,,,,,10163.40,23061.47,percent of total billed charges,
GRAFT,7910199,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,28192.50000,8175.82000,Aetna,First Health,,23061.47,,,,,,,9077.99,23061.47,percent of total billed charges,
GRAFT,7910200,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,43357.50000,12573.68000,Aetna,First Health,,35466.43,,,,,,,15630.38,35466.43,percent of total billed charges,
GRAFT,7910200,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,43357.50000,12573.68000,Aetna,First Health,,35466.43,,,,,,,13961.11,35466.43,percent of total billed charges,
GRAFT,7910201,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,52520.00000,15230.80000,Aetna,First Health,,42961.36,,,,,,,18933.46,42961.36,percent of total billed charges,
GRAFT,7910201,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,52520.00000,15230.80000,Aetna,First Health,,42961.36,,,,,,,16911.44,42961.36,percent of total billed charges,
GRAFT,7910202,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,35797.50000,10381.28000,Aetna,First Health,,29282.35,,,,,,,12905.00,29282.35,percent of total billed charges,
GRAFT,7910202,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,35797.50000,10381.28000,Aetna,First Health,,29282.35,,,,,,,11526.80,29282.35,percent of total billed charges,
GRAFT,7910203,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,42232.50000,12247.42000,Aetna,First Health,,34546.18,,,,,,,15224.82,34546.18,percent of total billed charges,
GRAFT,7910203,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,42232.50000,12247.42000,Aetna,First Health,,34546.18,,,,,,,13598.86,34546.18,percent of total billed charges,
MESH,7910204,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,13629.00000,3952.41000,Aetna,First Health,,11148.52,,,,,,,4913.25,11148.52,percent of total billed charges,
MESH,7910204,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,13629.00000,3952.41000,Aetna,First Health,,11148.52,,,,,,,4388.54,11148.52,percent of total billed charges,
MESH,7910205,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,20345.00000,5900.05000,Aetna,First Health,,16642.21,,,,,,,7334.37,16642.21,percent of total billed charges,
MESH,7910205,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,20345.00000,5900.05000,Aetna,First Health,,16642.21,,,,,,,6551.09,16642.21,percent of total billed charges,
MESH,7910206,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,28273.50000,8199.31000,Aetna,First Health,,23127.72,,,,,,,10192.60,23127.72,percent of total billed charges,
MESH,7910206,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,28273.50000,8199.31000,Aetna,First Health,,23127.72,,,,,,,9104.07,23127.72,percent of total billed charges,
COMPONENT PROXIMAL,7698363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10362.00000,3004.98000,Aetna,First Health,,8476.12,,,,,,,3735.50,8476.12,percent of total billed charges,
COMPONENT PROXIMAL,7698363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10362.00000,3004.98000,Aetna,First Health,,8476.12,,,,,,,3336.56,8476.12,percent of total billed charges,
COMPONENT PROXIMAL,7910253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,First Health,,7082.24,,,,,,,3121.21,7082.24,percent of total billed charges,
COMPONENT PROXIMAL,7910253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,First Health,,7082.24,,,,,,,2787.88,7082.24,percent of total billed charges,
FEMORAL HEAD,7910310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,First Health,,4584.24,,,,,,,2020.31,4584.24,percent of total billed charges,
FEMORAL HEAD,7910310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,First Health,,4584.24,,,,,,,1804.55,4584.24,percent of total billed charges,
MEDPOR IMPLANT,7910275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5791.42000,1679.51000,Aetna,First Health,,4737.38,,,,,,,2087.81,4737.38,percent of total billed charges,
MEDPOR IMPLANT,7910275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5791.42000,1679.51000,Aetna,First Health,,4737.38,,,,,,,1864.84,4737.38,percent of total billed charges,
FEMORAL HEAD,7910504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMORAL HEAD,7910504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CAGE,7910512,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CAGE,7910512,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7910540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2322.80000,673.61000,Aetna,First Health,,1900.05,,,,,,,837.37,1900.05,percent of total billed charges,
PLATE,7910540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2322.80000,673.61000,Aetna,First Health,,1900.05,,,,,,,747.94,1900.05,percent of total billed charges,
GLENOSPHERE HELMET,7910541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1764.64000,511.75000,Aetna,First Health,,1443.48,,,,,,,636.15,1443.48,percent of total billed charges,
GLENOSPHERE HELMET,7910541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1764.64000,511.75000,Aetna,First Health,,1443.48,,,,,,,568.21,1443.48,percent of total billed charges,
INSERT,7910692,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7910692,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
MESH,7910976,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,792.32000,229.77000,Aetna,First Health,,648.12,,,,,,,285.63,648.12,percent of total billed charges,
MESH,7910976,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,792.32000,229.77000,Aetna,First Health,,648.12,,,,,,,255.13,648.12,percent of total billed charges,
MESH,7910978,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1244.80000,360.99000,Aetna,First Health,,1018.25,,,,,,,448.75,1018.25,percent of total billed charges,
MESH,7910978,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1244.80000,360.99000,Aetna,First Health,,1018.25,,,,,,,400.83,1018.25,percent of total billed charges,
SPACER,7911003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
SPACER,7911003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
SPACER,7911005,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1491.35,3383.98,percent of total billed charges,
SPACER,7911005,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1332.08,3383.98,percent of total billed charges,
LINER,7911035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7911035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW,7911086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
STEM,7911243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2970.88,6741.14,percent of total billed charges,
STEM,7911243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2653.60,6741.14,percent of total billed charges,
FEMORAL HEAD,7911246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7911246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FIXATION DEVICE IMPLANT IN KIT,7911304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4494.00000,1303.26000,Aetna,First Health,,3676.09,,,,,,,1620.09,3676.09,percent of total billed charges,
FIXATION DEVICE IMPLANT IN KIT,7911304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4494.00000,1303.26000,Aetna,First Health,,3676.09,,,,,,,1447.07,3676.09,percent of total billed charges,
WEDGE,7911312,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,First Health,,5033.15,,,,,,,2218.16,5033.15,percent of total billed charges,
WEDGE,7911312,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,First Health,,5033.15,,,,,,,1981.27,5033.15,percent of total billed charges,
COMPONENT PATELLA,7794037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,4133.49,9379.19,percent of total billed charges,
COMPONENT PATELLA,7794037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,3692.05,9379.19,percent of total billed charges,
SCREW,7911408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,116.29,263.86,percent of total billed charges,
SCREW,7911408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,103.87,263.86,percent of total billed charges,
TOTAL KNEE,7911437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,5497.62,12474.50,percent of total billed charges,
TOTAL KNEE,7911437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,4910.50,12474.50,percent of total billed charges,
SHELL,7911439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SHELL,7911439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
LINER,7911440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
LINER,7911440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
HIP BIPOLAR M,7911441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
HIP BIPOLAR M,7911441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
DRILL GUIDE,7911589,CDM,278,RC,,,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
DRILL GUIDE,7911589,CDM,278,RC,,,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
STEM,7911720,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,7911720,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
SHELL,7911724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
SHELL,7911724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW,7911741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,497.63,1129.17,percent of total billed charges,
SCREW,7911741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,444.49,1129.17,percent of total billed charges,
SCREW,7911778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7911778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
INSERT,7968241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7968241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
ROD SPINAL,7968227,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2028.40000,588.24000,Aetna,First Health,,1659.23,,,,,,,731.24,1659.23,percent of total billed charges,
ROD SPINAL,7968227,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2028.40000,588.24000,Aetna,First Health,,1659.23,,,,,,,653.14,1659.23,percent of total billed charges,
LEAD,7968234,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,7596.00000,2202.84000,Aetna,First Health,,6213.53,,,,,,,2738.36,6213.53,percent of total billed charges,
LEAD,7968234,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,7596.00000,2202.84000,Aetna,First Health,,6213.53,,,,,,,2445.91,6213.53,percent of total billed charges,
TENDON,7968246,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9321.42000,2703.21000,Aetna,First Health,,7624.92,,,,,,,3360.37,7624.92,percent of total billed charges,
TENDON,7968246,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9321.42000,2703.21000,Aetna,First Health,,7624.92,,,,,,,3001.50,7624.92,percent of total billed charges,
CAGE,7968354,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4544.46,10311.71,percent of total billed charges,
CAGE,7968354,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4059.13,10311.71,percent of total billed charges,
LINER,7968409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
LINER,7968409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
SCREW,7968420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7968420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
STEM,7968430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7968430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CONNECTOR SPINAL,7968431,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
CONNECTOR SPINAL,7968431,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PLATE,7968434,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
PLATE,7968434,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
SPINAL SPACER,7968435,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
SPINAL SPACER,7968435,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
CONNECTOR SPINAL,7968483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2091.92000,606.66000,Aetna,First Health,,1711.19,,,,,,,754.14,1711.19,percent of total billed charges,
CONNECTOR SPINAL,7968483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2091.92000,606.66000,Aetna,First Health,,1711.19,,,,,,,673.60,1711.19,percent of total billed charges,
CEMENT,7968506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,432.25000,125.35000,Aetna,First Health,,353.58,,,,,,,155.83,353.58,percent of total billed charges,
CEMENT,7968506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,432.25000,125.35000,Aetna,First Health,,353.58,,,,,,,139.18,353.58,percent of total billed charges,
SCREW,7968525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7968525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
INSERT,7968507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7968507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SPINAL SPACER,7968510,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26000.00000,7540.00000,Aetna,First Health,,21268.00,,,,,,,9373.00,21268.00,percent of total billed charges,
SPINAL SPACER,7968510,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26000.00000,7540.00000,Aetna,First Health,,21268.00,,,,,,,8372.00,21268.00,percent of total billed charges,
BALLOON CATHETER,7975099,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975099,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
STRUT CORTICAL,7967963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3070.00000,890.30000,Aetna,First Health,,2511.26,,,,,,,1106.73,2511.26,percent of total billed charges,
STRUT CORTICAL,7967963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3070.00000,890.30000,Aetna,First Health,,2511.26,,,,,,,988.54,2511.26,percent of total billed charges,
STRUT CORTICAL,7967964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,First Health,,1701.44,,,,,,,749.84,1701.44,percent of total billed charges,
STRUT CORTICAL,7967964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,First Health,,1701.44,,,,,,,669.76,1701.44,percent of total billed charges,
FEMORAL ADAPTER,7968693,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
FEMORAL ADAPTER,7968693,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
PLATE,7968698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8913.30000,2584.86000,Aetna,First Health,,7291.08,,,,,,,3213.24,7291.08,percent of total billed charges,
PLATE,7968698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8913.30000,2584.86000,Aetna,First Health,,7291.08,,,,,,,2870.08,7291.08,percent of total billed charges,
SCREW,7968699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,728.50,1653.01,percent of total billed charges,
SCREW,7968699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,650.70,1653.01,percent of total billed charges,
SCREW,7968703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2142.40000,621.30000,Aetna,First Health,,1752.48,,,,,,,772.34,1752.48,percent of total billed charges,
SCREW,7968703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2142.40000,621.30000,Aetna,First Health,,1752.48,,,,,,,689.85,1752.48,percent of total billed charges,
TIGHTROPE,7968723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
TIGHTROPE,7968723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
ROD SPINAL,7968825,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD SPINAL,7968825,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
MESH,7968954,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4028.15000,1168.16000,Aetna,First Health,,3295.03,,,,,,,1452.15,3295.03,percent of total billed charges,
MESH,7968954,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4028.15000,1168.16000,Aetna,First Health,,3295.03,,,,,,,1297.06,3295.03,percent of total billed charges,
SCREW,7968960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,7968960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
PLATE,7968959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1395.50,3166.48,percent of total billed charges,
PLATE,7968959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1246.46,3166.48,percent of total billed charges,
ALLOGRAFT,7968967,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,25750.00000,7467.50000,Aetna,First Health,,21063.50,,,,,,,9282.88,21063.50,percent of total billed charges,
ALLOGRAFT,7968967,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,25750.00000,7467.50000,Aetna,First Health,,21063.50,,,,,,,8291.50,21063.50,percent of total billed charges,
SCREW,7968968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7968968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
STEM EXTENSION,7968969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM EXTENSION,7968969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
SCREW,7969007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7969007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
NAIL,7969017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7969017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
SCREW,7969025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,First Health,,2883.04,,,,,,,1270.58,2883.04,percent of total billed charges,
SCREW,7969025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,First Health,,2883.04,,,,,,,1134.89,2883.04,percent of total billed charges,
ROD SPINAL,7969028,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
ROD SPINAL,7969028,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
NAIL,7969029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7969029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
ROD SPINAL,7969033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,7969033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
SCREW,7969037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7969037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
CATHETER,7969024,CDM,278,RC,C1714,HCPCS,,,facility,inpatient,,,13185.00000,3823.65000,Aetna,First Health,,10785.33,,,,,,,4753.19,10785.33,percent of total billed charges,
CATHETER,7969024,CDM,278,RC,C1714,HCPCS,,,facility,outpatient,,,13185.00000,3823.65000,Aetna,First Health,,10785.33,,,,,,,4245.57,10785.33,percent of total billed charges,
PLATE,7969023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5618.62000,1629.40000,Aetna,First Health,,4596.03,,,,,,,2025.51,4596.03,percent of total billed charges,
PLATE,7969023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5618.62000,1629.40000,Aetna,First Health,,4596.03,,,,,,,1809.20,4596.03,percent of total billed charges,
FEMORAL CONE,7969316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3738.75,8483.48,percent of total billed charges,
FEMORAL CONE,7969316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3339.46,8483.48,percent of total billed charges,
SCREW,7969317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7969317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
PLATE,7969321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.76000,961.57000,Aetna,First Health,,2712.29,,,,,,,1195.33,2712.29,percent of total billed charges,
PLATE,7969321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.76000,961.57000,Aetna,First Health,,2712.29,,,,,,,1067.67,2712.29,percent of total billed charges,
STENT GRAFT,7974079,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7974079,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
LINER,7969473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
LINER,7969473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
CONNECTOR SPINAL,7969476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,801.38,1818.38,percent of total billed charges,
CONNECTOR SPINAL,7969476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,715.79,1818.38,percent of total billed charges,
MESH,7969540,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1958.96000,568.10000,Aetna,First Health,,1602.43,,,,,,,706.21,1602.43,percent of total billed charges,
MESH,7969540,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1958.96000,568.10000,Aetna,First Health,,1602.43,,,,,,,630.79,1602.43,percent of total billed charges,
PLATE,7969481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2283.52000,662.22000,Aetna,First Health,,1867.92,,,,,,,823.21,1867.92,percent of total billed charges,
PLATE,7969481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2283.52000,662.22000,Aetna,First Health,,1867.92,,,,,,,735.29,1867.92,percent of total billed charges,
PLATE,7969482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2137.68000,619.93000,Aetna,First Health,,1748.62,,,,,,,770.63,1748.62,percent of total billed charges,
PLATE,7969482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2137.68000,619.93000,Aetna,First Health,,1748.62,,,,,,,688.33,1748.62,percent of total billed charges,
PLATE,7969484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1939.04000,562.32000,Aetna,First Health,,1586.13,,,,,,,699.02,1586.13,percent of total billed charges,
PLATE,7969484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1939.04000,562.32000,Aetna,First Health,,1586.13,,,,,,,624.37,1586.13,percent of total billed charges,
PLATE,7969485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1631.80000,473.22000,Aetna,First Health,,1334.81,,,,,,,588.26,1334.81,percent of total billed charges,
PLATE,7969485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1631.80000,473.22000,Aetna,First Health,,1334.81,,,,,,,525.44,1334.81,percent of total billed charges,
ROD SPINAL,7969544,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
ROD SPINAL,7969544,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
TIGHTROPE,7969566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1469.63,3334.68,percent of total billed charges,
TIGHTROPE,7969566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1312.67,3334.68,percent of total billed charges,
ROD SPINAL,7969634,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,7969634,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
PLATE,7969678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6637.02000,1924.74000,Aetna,First Health,,5429.08,,,,,,,2392.65,5429.08,percent of total billed charges,
PLATE,7969678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6637.02000,1924.74000,Aetna,First Health,,5429.08,,,,,,,2137.12,5429.08,percent of total billed charges,
PEG,7969679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
PEG,7969679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
CAGE,7969714,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
CAGE,7969714,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
FEMORAL CONE,7976331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
FEMORAL CONE,7976331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
FEMORAL HEAD,7969724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1855.02,4209.18,percent of total billed charges,
FEMORAL HEAD,7969724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1656.92,4209.18,percent of total billed charges,
GENERATOR,7969747,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,39829.50000,11550.55000,Aetna,First Health,,32580.53,,,,,,,14358.53,32580.53,percent of total billed charges,
GENERATOR,7969747,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,39829.50000,11550.55000,Aetna,First Health,,32580.53,,,,,,,12825.10,32580.53,percent of total billed charges,
CONTROLLER,7969748,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3578.56000,1037.78000,Aetna,First Health,,2927.26,,,,,,,1290.07,2927.26,percent of total billed charges,
CONTROLLER,7969748,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3578.56000,1037.78000,Aetna,First Health,,2927.26,,,,,,,1152.30,2927.26,percent of total billed charges,
ROD SPINAL,7969742,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
ROD SPINAL,7969742,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
SCREW,7969746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,731.09,1658.90,percent of total billed charges,
SCREW,7969746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,653.02,1658.90,percent of total billed charges,
PLATE,7969776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5941.78000,1723.12000,Aetna,First Health,,4860.38,,,,,,,2142.01,4860.38,percent of total billed charges,
PLATE,7969776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5941.78000,1723.12000,Aetna,First Health,,4860.38,,,,,,,1913.25,4860.38,percent of total billed charges,
CEMENT,7969784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1244.00000,360.76000,Aetna,First Health,,1017.59,,,,,,,448.46,1017.59,percent of total billed charges,
CEMENT,7969784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1244.00000,360.76000,Aetna,First Health,,1017.59,,,,,,,400.57,1017.59,percent of total billed charges,
PLATE,7969785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7969785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
WEDGE,7969826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6210.33000,1801.00000,Aetna,First Health,,5080.05,,,,,,,2238.82,5080.05,percent of total billed charges,
WEDGE,7969826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6210.33000,1801.00000,Aetna,First Health,,5080.05,,,,,,,1999.73,5080.05,percent of total billed charges,
CAGE,7969827,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9564.00000,2773.56000,Aetna,First Health,,7823.35,,,,,,,3447.82,7823.35,percent of total billed charges,
CAGE,7969827,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9564.00000,2773.56000,Aetna,First Health,,7823.35,,,,,,,3079.61,7823.35,percent of total billed charges,
ROD SPINAL,7969828,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7969828,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW,7972280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7972280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7969831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7969831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SPACER SPINAL,7969833,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
SPACER SPINAL,7969833,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
INTRODUCER IN A KIT,7969832,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,114.19000,33.12000,Aetna,First Health,,93.41,,,,,,,41.17,93.41,percent of total billed charges,
INTRODUCER IN A KIT,7969832,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,114.19000,33.12000,Aetna,First Health,,93.41,,,,,,,36.77,93.41,percent of total billed charges,
SCREW,7969868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7969868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
MESH,7971855,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1547.56000,448.79000,Aetna,First Health,,1265.90,,,,,,,557.90,1265.90,percent of total billed charges,
MESH,7971855,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1547.56000,448.79000,Aetna,First Health,,1265.90,,,,,,,498.31,1265.90,percent of total billed charges,
NAIL,7971861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1913.07,4340.88,percent of total billed charges,
NAIL,7971861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1708.76,4340.88,percent of total billed charges,
PEG,7971854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2876.80000,834.27000,Aetna,First Health,,2353.22,,,,,,,1037.09,2353.22,percent of total billed charges,
PEG,7971854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2876.80000,834.27000,Aetna,First Health,,2353.22,,,,,,,926.33,2353.22,percent of total billed charges,
PLATE,7972002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2168.72000,628.93000,Aetna,First Health,,1774.01,,,,,,,781.82,1774.01,percent of total billed charges,
PLATE,7972002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2168.72000,628.93000,Aetna,First Health,,1774.01,,,,,,,698.33,1774.01,percent of total billed charges,
PLATE,7972020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2365.78,5368.12,percent of total billed charges,
PLATE,7972020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2113.12,5368.12,percent of total billed charges,
CONNECTOR SPINAL,7972021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR SPINAL,7972021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
SCREW,7972022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7972022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,7972129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,7972129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
CAGE,7973848,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7973848,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
PLATE,7972172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,7972172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE,7972173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,7972173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE,7972174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,7972174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,7972182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
ROD SPINAL,7972278,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7972278,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
WEDGE,7972238,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,First Health,,3717.89,,,,,,,1638.51,3717.89,percent of total billed charges,
WEDGE,7972238,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,First Health,,3717.89,,,,,,,1463.52,3717.89,percent of total billed charges,
WEDGE,7972232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5527.55000,1602.99000,Aetna,First Health,,4521.54,,,,,,,1992.68,4521.54,percent of total billed charges,
WEDGE,7972232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5527.55000,1602.99000,Aetna,First Health,,4521.54,,,,,,,1779.87,4521.54,percent of total billed charges,
WEDGE,7972233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6180.65000,1792.39000,Aetna,First Health,,5055.77,,,,,,,2228.12,5055.77,percent of total billed charges,
WEDGE,7972233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6180.65000,1792.39000,Aetna,First Health,,5055.77,,,,,,,1990.17,5055.77,percent of total billed charges,
WEDGE,7972234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3892.18000,1128.73000,Aetna,First Health,,3183.80,,,,,,,1403.13,3183.80,percent of total billed charges,
WEDGE,7972234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3892.18000,1128.73000,Aetna,First Health,,3183.80,,,,,,,1253.28,3183.80,percent of total billed charges,
BREAST IMPLANT,7972263,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BREAST IMPLANT,7972263,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
STENT GRAFT,7972277,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7972277,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
SCREW,7972588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,First Health,,1786.51,,,,,,,787.33,1786.51,percent of total billed charges,
SCREW,7972588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,First Health,,1786.51,,,,,,,703.25,1786.51,percent of total billed charges,
FEMORAL HEAD,7972594,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4309.20000,1249.67000,Aetna,First Health,,3524.93,,,,,,,1553.47,3524.93,percent of total billed charges,
FEMORAL HEAD,7972594,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4309.20000,1249.67000,Aetna,First Health,,3524.93,,,,,,,1387.56,3524.93,percent of total billed charges,
SCREW,7972581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,7972581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
STAPLE,7972583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5012.00000,1453.48000,Aetna,First Health,,4099.82,,,,,,,1806.83,4099.82,percent of total billed charges,
STAPLE,7972583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5012.00000,1453.48000,Aetna,First Health,,4099.82,,,,,,,1613.86,4099.82,percent of total billed charges,
FUSION DEVICE,7972656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
FUSION DEVICE,7972656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
BONE GRAFT,7973830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4945.50000,1434.20000,Aetna,First Health,,4045.42,,,,,,,1782.85,4045.42,percent of total billed charges,
BONE GRAFT,7973830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4945.50000,1434.20000,Aetna,First Health,,4045.42,,,,,,,1592.45,4045.42,percent of total billed charges,
PLATE,7973839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5153.40000,1494.49000,Aetna,First Health,,4215.48,,,,,,,1857.80,4215.48,percent of total billed charges,
PLATE,7973839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5153.40000,1494.49000,Aetna,First Health,,4215.48,,,,,,,1659.39,4215.48,percent of total billed charges,
GRAFT,7694901,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4541.88000,1317.15000,Aetna,First Health,,3715.26,,,,,,,1637.35,3715.26,percent of total billed charges,
GRAFT,7694901,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4541.88000,1317.15000,Aetna,First Health,,3715.26,,,,,,,1462.49,3715.26,percent of total billed charges,
SCREW LOCKING,7962808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW LOCKING,7962808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
CAGE,8160823,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,8160823,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
ROD SPINAL,8160911,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8160911,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW,8160913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,8160913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,8160915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,8160915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,8160917,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,8160917,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
INSERT,8160919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8160919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8160970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5793.90000,1680.23000,Aetna,First Health,,4739.41,,,,,,,2088.70,4739.41,percent of total billed charges,
PLATE,8160970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5793.90000,1680.23000,Aetna,First Health,,4739.41,,,,,,,1865.64,4739.41,percent of total billed charges,
COMPONENT FEMORAL,8160983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,8160983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
COMPONENT TIBIAL,8160984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,8160984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
INSERT,8160985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8160985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,8160981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
BASEPLATE,8160981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
SCREW,8161263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,8161263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
NAIL,8161098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8161098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
IMPLANT HUMAN TISS,8161100,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6083.00000,1764.07000,Aetna,First Health,,4975.89,,,,,,,2192.92,4975.89,percent of total billed charges,
IMPLANT HUMAN TISS,8161100,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6083.00000,1764.07000,Aetna,First Health,,4975.89,,,,,,,1958.73,4975.89,percent of total billed charges,
SHELL,8161261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8161261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW POLYAXIAL,8161144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW POLYAXIAL,8161144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SPINAL FIXATION,8161167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,6060.91,13752.62,percent of total billed charges,
SPINAL FIXATION,8161167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,5413.62,13752.62,percent of total billed charges,
SCREW,8161168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.00000,516.20000,Aetna,First Health,,1456.04,,,,,,,641.69,1456.04,percent of total billed charges,
SCREW,8161168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.00000,516.20000,Aetna,First Health,,1456.04,,,,,,,573.16,1456.04,percent of total billed charges,
ROD,8161169,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD,8161169,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
COMPONENT FEMORAL,8161170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,11294.92,25628.96,percent of total billed charges,
COMPONENT FEMORAL,8161170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,10088.66,25628.96,percent of total billed charges,
IMPLANT CORE,8161173,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
IMPLANT CORE,8161173,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
ENDPLATE,8161174,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8161174,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
ENDPLATE,8161175,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8161175,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
STENT GRAFT,8161299,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,First Health,,41219.35,,,,,,,18165.74,41219.35,percent of total billed charges,
STENT GRAFT,8161299,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,First Health,,41219.35,,,,,,,16225.71,41219.35,percent of total billed charges,
PLATE,8161260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
PLATE,8161260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
CAGE,8161301,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8161301,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
ACETABULAR CUP,8161366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,8161366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
COMPONET FEMORAL,8161367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
COMPONET FEMORAL,8161367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
PLUG MICROVASCULAR,8161369,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,2170.21,4924.36,percent of total billed charges,
PLUG MICROVASCULAR,8161369,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,1938.44,4924.36,percent of total billed charges,
STEM,8161373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8161373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
HEAD FEMORAL,8161375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8161375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
COMPONENT FEMORAL,8161407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
COMPONENT FEMORAL,8161407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
INSERT,8161408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8161408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
ROD SPINAL,8161409,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8161409,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
INSERT,8161410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8161410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
PACEMAKER,8161404,CDM,278,RC,C1785,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
PACEMAKER,8161404,CDM,278,RC,C1785,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
CAGE,8161547,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8061.39000,2337.80000,Aetna,First Health,,6594.22,,,,,,,2906.13,6594.22,percent of total billed charges,
CAGE,8161547,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8061.39000,2337.80000,Aetna,First Health,,6594.22,,,,,,,2595.77,6594.22,percent of total billed charges,
SCREW,8161549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,258.04,585.50,percent of total billed charges,
SCREW,8161549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,230.48,585.50,percent of total billed charges,
PLATE,8161592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8161592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
MESH,8161594,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,20820.00000,6037.80000,Aetna,First Health,,17030.76,,,,,,,7505.61,17030.76,percent of total billed charges,
MESH,8161594,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,20820.00000,6037.80000,Aetna,First Health,,17030.76,,,,,,,6704.04,17030.76,percent of total billed charges,
GLENOSPHERE,8161595,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
GLENOSPHERE,8161595,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
INSERT,8161596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,8161596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
SCREW,8161597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8161597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SHELL,8161598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,8161598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
SCREW,7966236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,7966236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
SCREW,8161724,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8161724,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,8161726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8161726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,8161736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8161736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,8161728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8161728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8161730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8161730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
PLATE,8161732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,8161732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
COMPONENT FEMORAL,8161774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,11294.92,25628.96,percent of total billed charges,
COMPONENT FEMORAL,8161774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,10088.66,25628.96,percent of total billed charges,
PLATE,8161776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.39000,1486.07000,Aetna,First Health,,4191.75,,,,,,,1847.34,4191.75,percent of total billed charges,
PLATE,8161776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.39000,1486.07000,Aetna,First Health,,4191.75,,,,,,,1650.05,4191.75,percent of total billed charges,
ROD SPINAL,8161799,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8161799,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SCREW,8161801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8161801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
SPINAL IMPLANT,8161803,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
SPINAL IMPLANT,8161803,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
HEAD HUMERAL,8163806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HEAD HUMERAL,8163806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
CAGE,8163807,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,6060.91,13752.62,percent of total billed charges,
CAGE,8163807,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,5413.62,13752.62,percent of total billed charges,
SCREW,8163808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8163808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
NAIL,8163862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,First Health,,3555.85,,,,,,,1567.09,3555.85,percent of total billed charges,
NAIL,8163862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,First Health,,3555.85,,,,,,,1399.73,3555.85,percent of total billed charges,
NAIL,8163864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,First Health,,3555.85,,,,,,,1567.09,3555.85,percent of total billed charges,
NAIL,8163864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,First Health,,3555.85,,,,,,,1399.73,3555.85,percent of total billed charges,
NAIL,8163866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,First Health,,3555.85,,,,,,,1567.09,3555.85,percent of total billed charges,
NAIL,8163866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,First Health,,3555.85,,,,,,,1399.73,3555.85,percent of total billed charges,
SCREW,8163983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,8163983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
SCREW,8166016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8166016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
PLATE,8166017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,8166017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
STEM,8166018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8166018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
ROD SPINAL,8166020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,8166020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
CAGE,8166021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
CAGE,8166021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
MESH,8166126,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
MESH,8166126,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
MESH,8166128,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8082.00000,2343.78000,Aetna,First Health,,6611.08,,,,,,,2913.56,6611.08,percent of total billed charges,
MESH,8166128,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8082.00000,2343.78000,Aetna,First Health,,6611.08,,,,,,,2602.40,6611.08,percent of total billed charges,
MESH,8166224,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8082.00000,2343.78000,Aetna,First Health,,6611.08,,,,,,,2913.56,6611.08,percent of total billed charges,
MESH,8166224,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8082.00000,2343.78000,Aetna,First Health,,6611.08,,,,,,,2602.40,6611.08,percent of total billed charges,
MESH,8166130,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,11970.00000,3471.30000,Aetna,First Health,,9791.46,,,,,,,4315.19,9791.46,percent of total billed charges,
MESH,8166130,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,11970.00000,3471.30000,Aetna,First Health,,9791.46,,,,,,,3854.34,9791.46,percent of total billed charges,
MESH,8166132,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17460.00000,5063.40000,Aetna,First Health,,14282.28,,,,,,,6294.33,14282.28,percent of total billed charges,
MESH,8166132,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17460.00000,5063.40000,Aetna,First Health,,14282.28,,,,,,,5622.12,14282.28,percent of total billed charges,
MESH,8166134,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17460.00000,5063.40000,Aetna,First Health,,14282.28,,,,,,,6294.33,14282.28,percent of total billed charges,
MESH,8166134,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17460.00000,5063.40000,Aetna,First Health,,14282.28,,,,,,,5622.12,14282.28,percent of total billed charges,
MESH,8166136,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5948.25,13497.00,percent of total billed charges,
MESH,8166136,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5313.00,13497.00,percent of total billed charges,
MESH,8166138,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,28462.50000,8254.12000,Aetna,First Health,,23282.33,,,,,,,10260.73,23282.33,percent of total billed charges,
MESH,8166138,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,28462.50000,8254.12000,Aetna,First Health,,23282.33,,,,,,,9164.92,23282.33,percent of total billed charges,
CAGE,8166143,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7734.60000,2243.03000,Aetna,First Health,,6326.90,,,,,,,2788.32,6326.90,percent of total billed charges,
CAGE,8166143,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7734.60000,2243.03000,Aetna,First Health,,6326.90,,,,,,,2490.54,6326.90,percent of total billed charges,
SCREW,8166144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,525.09,1191.47,percent of total billed charges,
SCREW,8166144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,469.01,1191.47,percent of total billed charges,
SCREW,8166145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,525.09,1191.47,percent of total billed charges,
SCREW,8166145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,469.01,1191.47,percent of total billed charges,
CAGE,8166146,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,8166146,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
SCREW,8166140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,843.86,1914.77,percent of total billed charges,
SCREW,8166140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,753.74,1914.77,percent of total billed charges,
NAIL,8166141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1913.07,4340.88,percent of total billed charges,
NAIL,8166141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1708.76,4340.88,percent of total billed charges,
SCREW,8166142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8166142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
STEM,8166291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8166291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,8167850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,10392.54,23581.41,percent of total billed charges,
STEM,8167850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,9282.66,23581.41,percent of total billed charges,
INSERT,8166264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8166264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
insert,8166266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
insert,8166266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8166268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8166268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
HEAD FEM,8167808,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1645.01,3732.64,percent of total billed charges,
HEAD FEM,8167808,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1469.33,3732.64,percent of total billed charges,
RING LCKNG,8167809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,First Health,,2034.20,,,,,,,896.49,2034.20,percent of total billed charges,
RING LCKNG,8167809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,First Health,,2034.20,,,,,,,800.75,2034.20,percent of total billed charges,
LINER ACETABULAR,8167810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3576.63,8115.62,percent of total billed charges,
LINER ACETABULAR,8167810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3194.66,8115.62,percent of total billed charges,
HEAD FEM,8167811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1645.01,3732.64,percent of total billed charges,
HEAD FEM,8167811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1469.33,3732.64,percent of total billed charges,
LINER ACETABULAR,8167812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3576.63,8115.62,percent of total billed charges,
LINER ACETABULAR,8167812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3194.66,8115.62,percent of total billed charges,
STENT GRAFT,8167852,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21412.50000,6209.62000,Aetna,First Health,,17515.42,,,,,,,7719.21,17515.42,percent of total billed charges,
STENT GRAFT,8167852,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21412.50000,6209.62000,Aetna,First Health,,17515.42,,,,,,,6894.82,17515.42,percent of total billed charges,
STEM,8167854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,8167854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
RING ANNULOPLASTY,8167963,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6545.00000,1898.05000,Aetna,First Health,,5353.81,,,,,,,2359.47,5353.81,percent of total billed charges,
RING ANNULOPLASTY,8167963,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6545.00000,1898.05000,Aetna,First Health,,5353.81,,,,,,,2107.49,5353.81,percent of total billed charges,
BALLOON CATHETER,7911543,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7911543,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
PLATE,7701908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6620.25000,1919.87000,Aetna,First Health,,5415.36,,,,,,,2386.60,5415.36,percent of total billed charges,
PLATE,7701908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6620.25000,1919.87000,Aetna,First Health,,5415.36,,,,,,,2131.72,5415.36,percent of total billed charges,
WEDGE,7701605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7701605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
PEG,7701954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
PEG,7701954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
PEG,7697909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
PEG,7697909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STENT GRAFT,7702144,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,17763.64,40306.95,percent of total billed charges,
STENT GRAFT,7702144,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,15866.55,40306.95,percent of total billed charges,
PLATE,7695340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7695340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7701576,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5520.87000,1601.05000,Aetna,First Health,,4516.07,,,,,,,1990.27,4516.07,percent of total billed charges,
PLATE,7701576,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5520.87000,1601.05000,Aetna,First Health,,4516.07,,,,,,,1777.72,4516.07,percent of total billed charges,
SCREW,7702161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7702161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
ROD,7702166,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7702166,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,7701783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7701783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
PLATE,7695610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,277.40,629.45,percent of total billed charges,
PLATE,7695610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,247.78,629.45,percent of total billed charges,
WIRE,7699669,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,594.00000,172.26000,Aetna,First Health,,485.89,,,,,,,214.14,485.89,percent of total billed charges,
WIRE,7699669,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,594.00000,172.26000,Aetna,First Health,,485.89,,,,,,,191.27,485.89,percent of total billed charges,
PLATE,7702222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
PLATE,7702222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
EXTENSION LIMB,7702228,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,First Health,,9936.25,,,,,,,4378.99,9936.25,percent of total billed charges,
EXTENSION LIMB,7702228,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,First Health,,9936.25,,,,,,,3911.33,9936.25,percent of total billed charges,
STEM,7702232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7702232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE,7702974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,209.27,474.85,percent of total billed charges,
PLATE,7702974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,186.92,474.85,percent of total billed charges,
BASEPLATE,7702252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7702252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BONE CEMENT,7702255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3408.13000,988.36000,Aetna,First Health,,2787.85,,,,,,,1228.63,2787.85,percent of total billed charges,
BONE CEMENT,7702255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3408.13000,988.36000,Aetna,First Health,,2787.85,,,,,,,1097.42,2787.85,percent of total billed charges,
PEG,7702239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.80000,386.51000,Aetna,First Health,,1090.23,,,,,,,480.47,1090.23,percent of total billed charges,
PEG,7702239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.80000,386.51000,Aetna,First Health,,1090.23,,,,,,,429.16,1090.23,percent of total billed charges,
PLATE,7698672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3745.00000,1086.05000,Aetna,First Health,,3063.41,,,,,,,1350.07,3063.41,percent of total billed charges,
PLATE,7698672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3745.00000,1086.05000,Aetna,First Health,,3063.41,,,,,,,1205.89,3063.41,percent of total billed charges,
PLATE,7702270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5376.95000,1559.32000,Aetna,First Health,,4398.35,,,,,,,1938.39,4398.35,percent of total billed charges,
PLATE,7702270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5376.95000,1559.32000,Aetna,First Health,,4398.35,,,,,,,1731.38,4398.35,percent of total billed charges,
PLATE,7702273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.00000,508.08000,Aetna,First Health,,1433.14,,,,,,,631.60,1433.14,percent of total billed charges,
PLATE,7702273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.00000,508.08000,Aetna,First Health,,1433.14,,,,,,,564.14,1433.14,percent of total billed charges,
PLATE,7701839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,First Health,,1094.16,,,,,,,482.20,1094.16,percent of total billed charges,
PLATE,7701839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,First Health,,1094.16,,,,,,,430.71,1094.16,percent of total billed charges,
SCREW,7702278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,62.32,141.42,percent of total billed charges,
SCREW,7702278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,55.67,141.42,percent of total billed charges,
PLATE,7702284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2345.64000,680.24000,Aetna,First Health,,1918.73,,,,,,,845.60,1918.73,percent of total billed charges,
PLATE,7702284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2345.64000,680.24000,Aetna,First Health,,1918.73,,,,,,,755.30,1918.73,percent of total billed charges,
PLATE,7699877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,605.93,1374.89,percent of total billed charges,
PLATE,7699877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,541.22,1374.89,percent of total billed charges,
PLATE,7701820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,739.17,1677.23,percent of total billed charges,
PLATE,7701820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,660.23,1677.23,percent of total billed charges,
PLATE,7701825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1548.80000,449.15000,Aetna,First Health,,1266.92,,,,,,,558.34,1266.92,percent of total billed charges,
PLATE,7701825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1548.80000,449.15000,Aetna,First Health,,1266.92,,,,,,,498.71,1266.92,percent of total billed charges,
PLATE,7701827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1601.60000,464.46000,Aetna,First Health,,1310.11,,,,,,,577.38,1310.11,percent of total billed charges,
PLATE,7701827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1601.60000,464.46000,Aetna,First Health,,1310.11,,,,,,,515.72,1310.11,percent of total billed charges,
PLATE,7695866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1414.56000,410.22000,Aetna,First Health,,1157.11,,,,,,,509.95,1157.11,percent of total billed charges,
PLATE,7695866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1414.56000,410.22000,Aetna,First Health,,1157.11,,,,,,,455.49,1157.11,percent of total billed charges,
PLATE,7701846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2499.20000,724.77000,Aetna,First Health,,2044.35,,,,,,,900.96,2044.35,percent of total billed charges,
PLATE,7701846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2499.20000,724.77000,Aetna,First Health,,2044.35,,,,,,,804.74,2044.35,percent of total billed charges,
INSERT,7702288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2811.20000,815.25000,Aetna,First Health,,2299.56,,,,,,,1013.44,2299.56,percent of total billed charges,
INSERT,7702288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2811.20000,815.25000,Aetna,First Health,,2299.56,,,,,,,905.21,2299.56,percent of total billed charges,
STEM,7736587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7736587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
PLATE,7772034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,472.69,1072.56,percent of total billed charges,
PLATE,7772034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,422.21,1072.56,percent of total billed charges,
PLATE,7701870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,605.93,1374.89,percent of total billed charges,
PLATE,7701870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,541.22,1374.89,percent of total billed charges,
PLATE,7699886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,701.10,1590.85,percent of total billed charges,
PLATE,7699886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,626.23,1590.85,percent of total billed charges,
PLATE,7701881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4067.70000,1179.63000,Aetna,First Health,,3327.38,,,,,,,1466.41,3327.38,percent of total billed charges,
PLATE,7701881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4067.70000,1179.63000,Aetna,First Health,,3327.38,,,,,,,1309.80,3327.38,percent of total billed charges,
PLATE,7701886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1958.00000,567.82000,Aetna,First Health,,1601.64,,,,,,,705.86,1601.64,percent of total billed charges,
PLATE,7701886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1958.00000,567.82000,Aetna,First Health,,1601.64,,,,,,,630.48,1601.64,percent of total billed charges,
PLATE,7701889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4137.00000,1199.73000,Aetna,First Health,,3384.07,,,,,,,1491.39,3384.07,percent of total billed charges,
PLATE,7701889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4137.00000,1199.73000,Aetna,First Health,,3384.07,,,,,,,1332.11,3384.07,percent of total billed charges,
PLATE,7701891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2882.00000,835.78000,Aetna,First Health,,2357.48,,,,,,,1038.96,2357.48,percent of total billed charges,
PLATE,7701891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2882.00000,835.78000,Aetna,First Health,,2357.48,,,,,,,928.00,2357.48,percent of total billed charges,
PLATE,7701904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8932.50000,2590.42000,Aetna,First Health,,7306.78,,,,,,,3220.17,7306.78,percent of total billed charges,
PLATE,7701904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8932.50000,2590.42000,Aetna,First Health,,7306.78,,,,,,,2876.26,7306.78,percent of total billed charges,
CABLE,7694909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
CABLE,7694909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
STEM,7699290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,3098.50,7030.71,percent of total billed charges,
STEM,7699290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,2767.59,7030.71,percent of total billed charges,
TOE IMPLANT,7702625,CDM,278,RC,L8641,HCPCS,,,facility,inpatient,,,3712.80000,1076.71000,Aetna,First Health,,3037.07,,,,,,,1338.46,3037.07,percent of total billed charges,
TOE IMPLANT,7702625,CDM,278,RC,L8641,HCPCS,,,facility,outpatient,,,3712.80000,1076.71000,Aetna,First Health,,3037.07,,,,,,,428.55,3037.07,percent of total billed charges,
HUMERAL CUP,7702621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
HUMERAL CUP,7702621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
PLATE,7702644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,2173.83,4932.58,percent of total billed charges,
PLATE,7702644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,1941.68,4932.58,percent of total billed charges,
PLATE,7702646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7360.47000,2134.54000,Aetna,First Health,,6020.86,,,,,,,2653.45,6020.86,percent of total billed charges,
PLATE,7702646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7360.47000,2134.54000,Aetna,First Health,,6020.86,,,,,,,2370.07,6020.86,percent of total billed charges,
PLATE,7702667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7419.12000,2151.54000,Aetna,First Health,,6068.84,,,,,,,2674.59,6068.84,percent of total billed charges,
PLATE,7702667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7419.12000,2151.54000,Aetna,First Health,,6068.84,,,,,,,2388.96,6068.84,percent of total billed charges,
SCREW,7695283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
SCREW,7695283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
ROD,7703022,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2360.00000,684.40000,Aetna,First Health,,1930.48,,,,,,,850.78,1930.48,percent of total billed charges,
ROD,7703022,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2360.00000,684.40000,Aetna,First Health,,1930.48,,,,,,,759.92,1930.48,percent of total billed charges,
INSERT,7707439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2520.00000,730.80000,Aetna,First Health,,2061.36,,,,,,,908.46,2061.36,percent of total billed charges,
INSERT,7707439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2520.00000,730.80000,Aetna,First Health,,2061.36,,,,,,,811.44,2061.36,percent of total billed charges,
NAIL,7695373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,First Health,,3312.49,,,,,,,1459.84,3312.49,percent of total billed charges,
NAIL,7695373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,First Health,,3312.49,,,,,,,1303.94,3312.49,percent of total billed charges,
PLATE,7736064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.40000,730.63000,Aetna,First Health,,2060.87,,,,,,,908.24,2060.87,percent of total billed charges,
PLATE,7736064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.40000,730.63000,Aetna,First Health,,2060.87,,,,,,,811.25,2060.87,percent of total billed charges,
NAIL,7698919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,First Health,,4684.44,,,,,,,2064.48,4684.44,percent of total billed charges,
NAIL,7698919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,First Health,,4684.44,,,,,,,1844.00,4684.44,percent of total billed charges,
TIGHTROPE,7736079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7564.05000,2193.57000,Aetna,First Health,,6187.39,,,,,,,2726.84,6187.39,percent of total billed charges,
TIGHTROPE,7736079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7564.05000,2193.57000,Aetna,First Health,,6187.39,,,,,,,2435.62,6187.39,percent of total billed charges,
CATHETER CONTURA,7695235,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,872.55000,253.04000,Aetna,First Health,,713.75,,,,,,,314.55,713.75,percent of total billed charges,
CATHETER CONTURA,7695235,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,872.55000,253.04000,Aetna,First Health,,713.75,,,,,,,280.96,713.75,percent of total billed charges,
PIN,7736085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,209.27,474.85,percent of total billed charges,
PIN,7736085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,186.92,474.85,percent of total billed charges,
SPACER,7700188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15691.15000,4550.43000,Aetna,First Health,,12835.36,,,,,,,5656.66,12835.36,percent of total billed charges,
SPACER,7700188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15691.15000,4550.43000,Aetna,First Health,,12835.36,,,,,,,5052.55,12835.36,percent of total billed charges,
LINER,7736096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,526.16,1193.89,percent of total billed charges,
LINER,7736096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,469.97,1193.89,percent of total billed charges,
CATHETER CONTURA,7736107,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,10252.50000,2973.22000,Aetna,First Health,,8386.55,,,,,,,3696.03,8386.55,percent of total billed charges,
CATHETER CONTURA,7736107,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,10252.50000,2973.22000,Aetna,First Health,,8386.55,,,,,,,3301.30,8386.55,percent of total billed charges,
FEMORAL HEAD,7736115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7736115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
COMPONENT FEMORAL,7700179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
COMPONENT FEMORAL,7700179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
CATHETER,7699418,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7699418,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
TENDON,7736131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7731.00000,2241.99000,Aetna,First Health,,6323.96,,,,,,,2787.03,6323.96,percent of total billed charges,
TENDON,7736131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7731.00000,2241.99000,Aetna,First Health,,6323.96,,,,,,,2489.38,6323.96,percent of total billed charges,
PLATE,7699388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3423.00000,992.67000,Aetna,First Health,,2800.01,,,,,,,1233.99,2800.01,percent of total billed charges,
PLATE,7699388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3423.00000,992.67000,Aetna,First Health,,2800.01,,,,,,,1102.21,2800.01,percent of total billed charges,
SPINAL IMPLANT,7736170,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,20587.50000,5970.38000,Aetna,First Health,,16840.58,,,,,,,7421.79,16840.58,percent of total billed charges,
SPINAL IMPLANT,7736170,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,20587.50000,5970.38000,Aetna,First Health,,16840.58,,,,,,,6629.18,16840.58,percent of total billed charges,
PLATE,7736186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3430.00000,994.70000,Aetna,First Health,,2805.74,,,,,,,1236.52,2805.74,percent of total billed charges,
PLATE,7736186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3430.00000,994.70000,Aetna,First Health,,2805.74,,,,,,,1104.46,2805.74,percent of total billed charges,
GRAFT,7736197,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14382.00000,4170.78000,Aetna,First Health,,11764.48,,,,,,,5184.71,11764.48,percent of total billed charges,
GRAFT,7736197,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14382.00000,4170.78000,Aetna,First Health,,11764.48,,,,,,,4631.00,11764.48,percent of total billed charges,
STENT,7695215,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3414.53,7747.82,percent of total billed charges,
STENT,7695215,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3049.87,7747.82,percent of total billed charges,
PLATE,7736204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,7736204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
SHELL,7736097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7736097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
STEM,7736211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7736211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7736212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7736212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7736217,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,555.75000,161.17000,Aetna,First Health,,454.60,,,,,,,200.35,454.60,percent of total billed charges,
STEM,7736217,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,555.75000,161.17000,Aetna,First Health,,454.60,,,,,,,178.95,454.60,percent of total billed charges,
BASEPLATE,7736221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
BASEPLATE,7736221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
WEDGE,7698194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
WEDGE,7698194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
COMPONENT FEMORAL,7700422,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7700422,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
SHELL,7736272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
SHELL,7736272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
STEM,7736273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,7736273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
BASEPLATE,7736285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7736285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
COMPONENT PATELLA,7697458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7697458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT FEMORAL,7700414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7700414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
BASEPLATE,7736351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7736351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
COMPONENT FEMORAL,7736352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7736352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
INSERT,7736353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7736353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
COMPONENT PATELLA,7736354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7736354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CABLE,7736448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6696.76000,1942.06000,Aetna,First Health,,5477.95,,,,,,,2414.18,5477.95,percent of total billed charges,
CABLE,7736448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6696.76000,1942.06000,Aetna,First Health,,5477.95,,,,,,,2156.36,5477.95,percent of total billed charges,
PLATE,7860047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1664.96000,482.84000,Aetna,First Health,,1361.94,,,,,,,600.22,1361.94,percent of total billed charges,
PLATE,7860047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1664.96000,482.84000,Aetna,First Health,,1361.94,,,,,,,536.12,1361.94,percent of total billed charges,
SCREW,7695385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5934.95000,1721.14000,Aetna,First Health,,4854.79,,,,,,,2139.55,4854.79,percent of total billed charges,
SCREW,7695385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5934.95000,1721.14000,Aetna,First Health,,4854.79,,,,,,,1911.05,4854.79,percent of total billed charges,
NAIL,7736496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,First Health,,3312.49,,,,,,,1459.84,3312.49,percent of total billed charges,
NAIL,7736496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,First Health,,3312.49,,,,,,,1303.94,3312.49,percent of total billed charges,
CABLE,7736506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,906.53000,262.89000,Aetna,First Health,,741.54,,,,,,,326.80,741.54,percent of total billed charges,
CABLE,7736506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,906.53000,262.89000,Aetna,First Health,,741.54,,,,,,,291.90,741.54,percent of total billed charges,
TENDON,7736512,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
TENDON,7736512,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,7736538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.76000,516.42000,Aetna,First Health,,1456.66,,,,,,,641.96,1456.66,percent of total billed charges,
PLATE,7736538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.76000,516.42000,Aetna,First Health,,1456.66,,,,,,,573.40,1456.66,percent of total billed charges,
INSERT,7736542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7736542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SHELL,7736544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
SHELL,7736544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
SCREW,7973840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7973840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7973841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,892.35000,258.78000,Aetna,First Health,,729.94,,,,,,,321.69,729.94,percent of total billed charges,
SCREW,7973841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,892.35000,258.78000,Aetna,First Health,,729.94,,,,,,,287.34,729.94,percent of total billed charges,
BONE MATRIX,7973843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2001.72000,580.50000,Aetna,First Health,,1637.41,,,,,,,721.62,1637.41,percent of total billed charges,
BONE MATRIX,7973843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2001.72000,580.50000,Aetna,First Health,,1637.41,,,,,,,644.55,1637.41,percent of total billed charges,
BONE MATRIX,7973844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3042.72000,882.39000,Aetna,First Health,,2488.94,,,,,,,1096.90,2488.94,percent of total billed charges,
BONE MATRIX,7973844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3042.72000,882.39000,Aetna,First Health,,2488.94,,,,,,,979.76,2488.94,percent of total billed charges,
BONE MATRIX,7973845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4361.25000,1264.76000,Aetna,First Health,,3567.50,,,,,,,1572.23,3567.50,percent of total billed charges,
BONE MATRIX,7973845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4361.25000,1264.76000,Aetna,First Health,,3567.50,,,,,,,1404.32,3567.50,percent of total billed charges,
ROD SPINAL,7973849,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,7973849,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
NEUROSTIMULATOR,7973851,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,25250.00000,7322.50000,Aetna,First Health,,20654.50,,,,,,,9102.62,20654.50,percent of total billed charges,
NEUROSTIMULATOR,7973851,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,25250.00000,7322.50000,Aetna,First Health,,20654.50,,,,,,,8130.50,20654.50,percent of total billed charges,
SCREW,7974026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7974026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
CAGE,7974077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,7974077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STENT GRAFT,7974141,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,7974141,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
COMPONENT PATELLA,7974588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
COMPONENT PATELLA,7974588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
STEM,7974595,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,7974595,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
COMPONENT HEAD,7974596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
COMPONENT HEAD,7974596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SHEATH,7974648,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
SHEATH,7974648,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
SCREW,7974656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,7974656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
GUIDEWIRE,7974702,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1895.60000,549.72000,Aetna,First Health,,1550.60,,,,,,,683.36,1550.60,percent of total billed charges,
GUIDEWIRE,7974702,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1895.60000,549.72000,Aetna,First Health,,1550.60,,,,,,,610.38,1550.60,percent of total billed charges,
NAIL,7974703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7974703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
MESH,7974756,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,6218.62,14110.50,percent of total billed charges,
MESH,7974756,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,5554.50,14110.50,percent of total billed charges,
PLATE,7982428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,666.58,1512.51,percent of total billed charges,
PLATE,7982428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,595.39,1512.51,percent of total billed charges,
SCREW,7974766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7974766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
NAIL,7974759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1803.80,4092.94,percent of total billed charges,
NAIL,7974759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1611.16,4092.94,percent of total billed charges,
HUMERAL HEAD,7974815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7974815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
PLATE,7974817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
PLATE,7974817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
GLENOSPHERE,7974816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2947.09,6687.15,percent of total billed charges,
GLENOSPHERE,7974816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2632.35,6687.15,percent of total billed charges,
ROD SPINAL,7974856,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
ROD SPINAL,7974856,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
COMPONENT FEMORAL,7976743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
COMPONENT FEMORAL,7976743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
COMPONENT TIBIAL,7976741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
COMPONENT TIBIAL,7976741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
INSERT,7974861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7974861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7974908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7974908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE,7974906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4822.93000,1398.65000,Aetna,First Health,,3945.16,,,,,,,1738.67,3945.16,percent of total billed charges,
PLATE,7974906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4822.93000,1398.65000,Aetna,First Health,,3945.16,,,,,,,1552.98,3945.16,percent of total billed charges,
BUTTON,7975021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,444.13000,128.80000,Aetna,First Health,,363.30,,,,,,,160.11,363.30,percent of total billed charges,
BUTTON,7975021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,444.13000,128.80000,Aetna,First Health,,363.30,,,,,,,143.01,363.30,percent of total billed charges,
NAIL,7975047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5995.50000,1738.70000,Aetna,First Health,,4904.32,,,,,,,2161.38,4904.32,percent of total billed charges,
NAIL,7975047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5995.50000,1738.70000,Aetna,First Health,,4904.32,,,,,,,1930.55,4904.32,percent of total billed charges,
COMPONENT HUMERAL,7975065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
COMPONENT HUMERAL,7975065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
HUMERAL HEAD,7975066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,7975066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STEM,7980714,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STEM,7980714,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7975078,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7975078,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7975087,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
STENT,7975087,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
BALLOON CATHETER,7975094,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
BALLOON CATHETER,7975094,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
BALLOON CATHETER,7975119,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7975119,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CAP,7975185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
CAP,7975185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
ROD,7975186,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD,7975186,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,7982825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7982825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
STEM,7976362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,3098.50,7030.71,percent of total billed charges,
STEM,7976362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,2767.59,7030.71,percent of total billed charges,
SCREW,7976403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,7976403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SHELL,7976428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7976428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
LINER,7976429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,7976429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,7976435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6167.00000,1788.43000,Aetna,First Health,,5044.61,,,,,,,2223.20,5044.61,percent of total billed charges,
SCREW,7976435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6167.00000,1788.43000,Aetna,First Health,,5044.61,,,,,,,1985.77,5044.61,percent of total billed charges,
PLATE,7976536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3753.65000,1088.56000,Aetna,First Health,,3070.49,,,,,,,1353.19,3070.49,percent of total billed charges,
PLATE,7976536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3753.65000,1088.56000,Aetna,First Health,,3070.49,,,,,,,1208.68,3070.49,percent of total billed charges,
CEMENT,7976531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,701.28000,203.37000,Aetna,First Health,,573.65,,,,,,,252.81,573.65,percent of total billed charges,
CEMENT,7976531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,701.28000,203.37000,Aetna,First Health,,573.65,,,,,,,225.81,573.65,percent of total billed charges,
BASEPLATE,7976624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7976624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
COMPONENT FEMORAL,7976625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7976625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
PLATE,7976644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,1312.94,2979.16,percent of total billed charges,
PLATE,7976644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,1172.72,2979.16,percent of total billed charges,
SPINAL IMPLANT,7976652,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
SPINAL IMPLANT,7976652,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
COMPONENT FEMORAL,7976756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
COMPONENT FEMORAL,7976756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
SCREW,7982821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7982821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
STENT,7982902,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
STENT,7982902,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
EMBOLIC PROTECTOR,7976733,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,14217.00000,4122.93000,Aetna,First Health,,11629.51,,,,,,,5125.23,11629.51,percent of total billed charges,
EMBOLIC PROTECTOR,7976733,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,14217.00000,4122.93000,Aetna,First Health,,11629.51,,,,,,,4577.87,11629.51,percent of total billed charges,
GUIDEWIRE,7978329,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
GUIDEWIRE,7978329,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7987805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,577.91,1311.32,percent of total billed charges,
SCREW,7987805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,516.19,1311.32,percent of total billed charges,
COMPONENT FEMORAL,7978416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3544.10000,1027.79000,Aetna,First Health,,2899.07,,,,,,,1277.65,2899.07,percent of total billed charges,
COMPONENT FEMORAL,7978416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3544.10000,1027.79000,Aetna,First Health,,2899.07,,,,,,,1141.20,2899.07,percent of total billed charges,
MESH,7980352,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,670.53,1521.48,percent of total billed charges,
MESH,7980352,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,598.92,1521.48,percent of total billed charges,
SCREW,7980366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7980366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
COMPONENT ELBOW,7980402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
COMPONENT ELBOW,7980402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
COMPONENT ELBOW,7980403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
COMPONENT ELBOW,7980403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
STEM,7980404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,5028.98,11411.10,percent of total billed charges,
STEM,7980404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,4491.90,11411.10,percent of total billed charges,
STEM,7980405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,6038.38,13701.50,percent of total billed charges,
STEM,7980405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,5393.50,13701.50,percent of total billed charges,
PLATE,7980406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5488.28000,1591.60000,Aetna,First Health,,4489.41,,,,,,,1978.52,4489.41,percent of total billed charges,
PLATE,7980406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5488.28000,1591.60000,Aetna,First Health,,4489.41,,,,,,,1767.23,4489.41,percent of total billed charges,
SHELL,7980407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7980407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
PLATE,7980595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2205.72000,639.66000,Aetna,First Health,,1804.28,,,,,,,795.16,1804.28,percent of total billed charges,
PLATE,7980595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2205.72000,639.66000,Aetna,First Health,,1804.28,,,,,,,710.24,1804.28,percent of total billed charges,
STEM,7980688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,First Health,,23827.85,,,,,,,10501.15,23827.85,percent of total billed charges,
STEM,7980688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,First Health,,23827.85,,,,,,,9379.67,23827.85,percent of total billed charges,
INSERT,7980689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,7980689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
CARDIAC DEFIBRILLATOR,7980699,CDM,278,RC,C1882,HCPCS,,,facility,inpatient,,,44887.50000,13017.38000,Aetna,First Health,,36717.97,,,,,,,16181.94,36717.97,percent of total billed charges,
CARDIAC DEFIBRILLATOR,7980699,CDM,278,RC,C1882,HCPCS,,,facility,outpatient,,,44887.50000,13017.38000,Aetna,First Health,,36717.97,,,,,,,14453.77,36717.97,percent of total billed charges,
LEAD,7980698,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
LEAD,7980698,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7980711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6110.16000,1771.95000,Aetna,First Health,,4998.11,,,,,,,2202.71,4998.11,percent of total billed charges,
PLATE,7980711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6110.16000,1771.95000,Aetna,First Health,,4998.11,,,,,,,1967.47,4998.11,percent of total billed charges,
COMPONENT FEMORAL,7980712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
COMPONENT FEMORAL,7980712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
HUMERAL HEAD,7980713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,7980713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PLATE,7980815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5844.02000,1694.77000,Aetna,First Health,,4780.41,,,,,,,2106.77,4780.41,percent of total billed charges,
PLATE,7980815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5844.02000,1694.77000,Aetna,First Health,,4780.41,,,,,,,1881.77,4780.41,percent of total billed charges,
PLATE,7980835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2616.04000,758.65000,Aetna,First Health,,2139.92,,,,,,,943.08,2139.92,percent of total billed charges,
PLATE,7980835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2616.04000,758.65000,Aetna,First Health,,2139.92,,,,,,,842.36,2139.92,percent of total billed charges,
SCREW,7980836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2649.80000,768.44000,Aetna,First Health,,2167.54,,,,,,,955.25,2167.54,percent of total billed charges,
SCREW,7980836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2649.80000,768.44000,Aetna,First Health,,2167.54,,,,,,,853.24,2167.54,percent of total billed charges,
PLATE,7980838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2781.96000,806.77000,Aetna,First Health,,2275.64,,,,,,,1002.90,2275.64,percent of total billed charges,
PLATE,7980838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2781.96000,806.77000,Aetna,First Health,,2275.64,,,,,,,895.79,2275.64,percent of total billed charges,
PLATE,7980839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2815.80000,816.58000,Aetna,First Health,,2303.32,,,,,,,1015.10,2303.32,percent of total billed charges,
PLATE,7980839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2815.80000,816.58000,Aetna,First Health,,2303.32,,,,,,,906.69,2303.32,percent of total billed charges,
PLATE,7980841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2846.52000,825.49000,Aetna,First Health,,2328.45,,,,,,,1026.17,2328.45,percent of total billed charges,
PLATE,7980841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2846.52000,825.49000,Aetna,First Health,,2328.45,,,,,,,916.58,2328.45,percent of total billed charges,
PLATE,7981158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5724.57000,1660.13000,Aetna,First Health,,4682.70,,,,,,,2063.71,4682.70,percent of total billed charges,
PLATE,7981158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5724.57000,1660.13000,Aetna,First Health,,4682.70,,,,,,,1843.31,4682.70,percent of total billed charges,
PLATE,7980842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5987.98000,1736.51000,Aetna,First Health,,4898.17,,,,,,,2158.67,4898.17,percent of total billed charges,
PLATE,7980842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5987.98000,1736.51000,Aetna,First Health,,4898.17,,,,,,,1928.13,4898.17,percent of total billed charges,
SCREW,7980843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7980843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
PLATE,7980845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8271.03000,2398.60000,Aetna,First Health,,6765.70,,,,,,,2981.71,6765.70,percent of total billed charges,
PLATE,7980845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8271.03000,2398.60000,Aetna,First Health,,6765.70,,,,,,,2663.27,6765.70,percent of total billed charges,
SCREW,7980846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,62.32,141.42,percent of total billed charges,
SCREW,7980846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,55.67,141.42,percent of total billed charges,
SCREW,7980849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW,7980849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
SCREW,7980852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,338.17,767.34,percent of total billed charges,
SCREW,7980866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,302.06,767.34,percent of total billed charges,
SCREW,7980868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,302.94,687.39,percent of total billed charges,
SCREW,7980868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,270.59,687.39,percent of total billed charges,
SCREW,7980869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7980869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7980878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7980878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7980882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7980882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7982323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
PLATE,7980833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.35000,1115.15000,Aetna,First Health,,3145.50,,,,,,,1386.25,3145.50,percent of total billed charges,
PLATE,7980833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.35000,1115.15000,Aetna,First Health,,3145.50,,,,,,,1238.20,3145.50,percent of total billed charges,
CAGE,7981168,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2669.14,6056.47,percent of total billed charges,
CAGE,7981168,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2384.09,6056.47,percent of total billed charges,
SCREW,7982341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,155.72000,45.16000,Aetna,First Health,,127.38,,,,,,,56.14,127.38,percent of total billed charges,
SCREW,7982341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,155.72000,45.16000,Aetna,First Health,,127.38,,,,,,,50.14,127.38,percent of total billed charges,
SCREW,7982342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7982342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7982369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7982385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7982391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7982391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
WASHER,7982397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.59000,194.47000,Aetna,First Health,,548.54,,,,,,,241.75,548.54,percent of total billed charges,
WASHER,7982397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.59000,194.47000,Aetna,First Health,,548.54,,,,,,,215.93,548.54,percent of total billed charges,
PLATE,7982400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5868.45000,1701.85000,Aetna,First Health,,4800.39,,,,,,,2115.58,4800.39,percent of total billed charges,
PLATE,7982400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5868.45000,1701.85000,Aetna,First Health,,4800.39,,,,,,,1889.64,4800.39,percent of total billed charges,
PLATE,7982401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5974.36000,1732.56000,Aetna,First Health,,4887.03,,,,,,,2153.76,4887.03,percent of total billed charges,
PLATE,7982401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5974.36000,1732.56000,Aetna,First Health,,4887.03,,,,,,,1923.74,4887.03,percent of total billed charges,
PLATE,7982403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5230.30000,1516.79000,Aetna,First Health,,4278.39,,,,,,,1885.52,4278.39,percent of total billed charges,
PLATE,7982403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5230.30000,1516.79000,Aetna,First Health,,4278.39,,,,,,,1684.16,4278.39,percent of total billed charges,
PLATE,7982405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5284.58000,1532.53000,Aetna,First Health,,4322.79,,,,,,,1905.09,4322.79,percent of total billed charges,
PLATE,7982405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5284.58000,1532.53000,Aetna,First Health,,4322.79,,,,,,,1701.63,4322.79,percent of total billed charges,
PLATE,7982408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5436.69000,1576.64000,Aetna,First Health,,4447.21,,,,,,,1959.93,4447.21,percent of total billed charges,
PLATE,7982408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5436.69000,1576.64000,Aetna,First Health,,4447.21,,,,,,,1750.61,4447.21,percent of total billed charges,
PLATE,7982410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1855.24000,538.02000,Aetna,First Health,,1517.59,,,,,,,668.81,1517.59,percent of total billed charges,
PLATE,7982410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1855.24000,538.02000,Aetna,First Health,,1517.59,,,,,,,597.39,1517.59,percent of total billed charges,
PLATE,7982411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,878.67000,254.81000,Aetna,First Health,,718.75,,,,,,,316.76,718.75,percent of total billed charges,
PLATE,7982411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,878.67000,254.81000,Aetna,First Health,,718.75,,,,,,,282.93,718.75,percent of total billed charges,
PLATE,7982412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1802.48000,522.72000,Aetna,First Health,,1474.43,,,,,,,649.79,1474.43,percent of total billed charges,
PLATE,7982412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1802.48000,522.72000,Aetna,First Health,,1474.43,,,,,,,580.40,1474.43,percent of total billed charges,
PLATE,7982413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.14000,132.28000,Aetna,First Health,,373.12,,,,,,,164.44,373.12,percent of total billed charges,
PLATE,7982413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.14000,132.28000,Aetna,First Health,,373.12,,,,,,,146.88,373.12,percent of total billed charges,
PLATE,7982414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,474.62000,137.64000,Aetna,First Health,,388.24,,,,,,,171.10,388.24,percent of total billed charges,
PLATE,7982414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,474.62000,137.64000,Aetna,First Health,,388.24,,,,,,,152.83,388.24,percent of total billed charges,
PLATE,7982416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,First Health,,272.14,,,,,,,119.93,272.14,percent of total billed charges,
PLATE,7982416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,First Health,,272.14,,,,,,,107.13,272.14,percent of total billed charges,
PLATE,7982417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,358.53000,103.97000,Aetna,First Health,,293.28,,,,,,,129.25,293.28,percent of total billed charges,
PLATE,7982417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,358.53000,103.97000,Aetna,First Health,,293.28,,,,,,,115.45,293.28,percent of total billed charges,
PLATE,7982424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3215.28000,932.43000,Aetna,First Health,,2630.10,,,,,,,1159.11,2630.10,percent of total billed charges,
PLATE,7982424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3215.28000,932.43000,Aetna,First Health,,2630.10,,,,,,,1035.32,2630.10,percent of total billed charges,
PLATE,7982427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2078.68000,602.82000,Aetna,First Health,,1700.36,,,,,,,749.36,1700.36,percent of total billed charges,
PLATE,7982427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2078.68000,602.82000,Aetna,First Health,,1700.36,,,,,,,669.33,1700.36,percent of total billed charges,
PLATE,7982457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1383.48000,401.21000,Aetna,First Health,,1131.69,,,,,,,498.74,1131.69,percent of total billed charges,
PLATE,7982457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1383.48000,401.21000,Aetna,First Health,,1131.69,,,,,,,445.48,1131.69,percent of total billed charges,
PLATE,7982458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1445.56000,419.21000,Aetna,First Health,,1182.47,,,,,,,521.12,1182.47,percent of total billed charges,
PLATE,7982458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1445.56000,419.21000,Aetna,First Health,,1182.47,,,,,,,465.47,1182.47,percent of total billed charges,
BOLT,7982463,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7982463,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
COMPONENT TIBIAL,7982777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
COMPONENT TIBIAL,7982777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
COMPONENT FEMORAL,7982774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
COMPONENT FEMORAL,7982774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
INSERT,7982775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7982775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
SCREW,7982786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,7982786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
LIGAMENT,7982868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13680.00000,3967.20000,Aetna,First Health,,11190.24,,,,,,,4931.64,11190.24,percent of total billed charges,
LIGAMENT,7982868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13680.00000,3967.20000,Aetna,First Health,,11190.24,,,,,,,4404.96,11190.24,percent of total billed charges,
INTRODUCER IN A KIT,7982898,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
INTRODUCER IN A KIT,7982898,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
FEMORAL HEAD,7982906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7982906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SLEEVE,7982907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SLEEVE,7982907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
CUP,7983031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1876.22,4257.28,percent of total billed charges,
CUP,7983031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1675.85,4257.28,percent of total billed charges,
STEM,7983032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12166.50000,3528.28000,Aetna,First Health,,9952.20,,,,,,,4386.02,9952.20,percent of total billed charges,
STEM,7983032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12166.50000,3528.28000,Aetna,First Health,,9952.20,,,,,,,3917.61,9952.20,percent of total billed charges,
AUGMENT ACETABULAR,7983035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9298.80000,2696.65000,Aetna,First Health,,7606.42,,,,,,,3352.22,7606.42,percent of total billed charges,
AUGMENT ACETABULAR,7983035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9298.80000,2696.65000,Aetna,First Health,,7606.42,,,,,,,2994.21,7606.42,percent of total billed charges,
ACETABULAR AUGMENT,7983036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3497.90000,1014.39000,Aetna,First Health,,2861.28,,,,,,,1260.99,2861.28,percent of total billed charges,
ACETABULAR AUGMENT,7983036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3497.90000,1014.39000,Aetna,First Health,,2861.28,,,,,,,1126.32,2861.28,percent of total billed charges,
STRUT CORTICAL,7983037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4213.65000,1221.96000,Aetna,First Health,,3446.77,,,,,,,1519.02,3446.77,percent of total billed charges,
STRUT CORTICAL,7983037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4213.65000,1221.96000,Aetna,First Health,,3446.77,,,,,,,1356.80,3446.77,percent of total billed charges,
SCREW,7983041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,7983041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
PLATE,7983045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5952.66000,1726.27000,Aetna,First Health,,4869.28,,,,,,,2145.93,4869.28,percent of total billed charges,
PLATE,7983045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5952.66000,1726.27000,Aetna,First Health,,4869.28,,,,,,,1916.76,4869.28,percent of total billed charges,
GENERATOR,7985605,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,124381.00000,36070.49000,Aetna,First Health,,101743.66,,,,,,,44839.35,101743.66,percent of total billed charges,
GENERATOR,7985605,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,124381.00000,36070.49000,Aetna,First Health,,101743.66,,,,,,,40050.68,101743.66,percent of total billed charges,
STENT GRAFT,7986469,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7986469,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7986566,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4558.52,10343.61,percent of total billed charges,
STENT GRAFT,7986566,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4071.69,10343.61,percent of total billed charges,
PLATE,7986604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2968.00000,860.72000,Aetna,First Health,,2427.82,,,,,,,1069.96,2427.82,percent of total billed charges,
PLATE,7986604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2968.00000,860.72000,Aetna,First Health,,2427.82,,,,,,,955.70,2427.82,percent of total billed charges,
MESH,7986853,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2132.80000,618.51000,Aetna,First Health,,1744.63,,,,,,,768.87,1744.63,percent of total billed charges,
MESH,7986853,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2132.80000,618.51000,Aetna,First Health,,1744.63,,,,,,,686.76,1744.63,percent of total billed charges,
MESH,7986855,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2172.40000,630.00000,Aetna,First Health,,1777.02,,,,,,,783.15,1777.02,percent of total billed charges,
MESH,7986855,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2172.40000,630.00000,Aetna,First Health,,1777.02,,,,,,,699.51,1777.02,percent of total billed charges,
MESH,7986857,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2212.00000,641.48000,Aetna,First Health,,1809.42,,,,,,,797.43,1809.42,percent of total billed charges,
MESH,7986857,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2212.00000,641.48000,Aetna,First Health,,1809.42,,,,,,,712.26,1809.42,percent of total billed charges,
MESH,7987151,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2251.60000,652.96000,Aetna,First Health,,1841.81,,,,,,,811.70,1841.81,percent of total billed charges,
MESH,7987151,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2251.60000,652.96000,Aetna,First Health,,1841.81,,,,,,,725.02,1841.81,percent of total billed charges,
SCREW,7986859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SCREW,7986859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SCREW,7986863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7986863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
ROD,7986865,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD,7986865,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
URINARY CONTROL SYSTEM,7987206,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,24850.00000,7206.50000,Aetna,First Health,,20327.30,,,,,,,8958.42,20327.30,percent of total billed charges,
URINARY CONTROL SYSTEM,7987206,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,24850.00000,7206.50000,Aetna,First Health,,20327.30,,,,,,,8001.70,20327.30,percent of total billed charges,
PROSTHESIS URETHRAL,7987208,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,13440.00000,3897.60000,Aetna,First Health,,10993.92,,,,,,,4845.12,10993.92,percent of total billed charges,
PROSTHESIS URETHRAL,7987208,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,13440.00000,3897.60000,Aetna,First Health,,10993.92,,,,,,,4327.68,10993.92,percent of total billed charges,
URINARY CONTROL PUMP,7987210,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,24100.00000,6989.00000,Aetna,First Health,,19713.80,,,,,,,8688.05,19713.80,percent of total billed charges,
URINARY CONTROL PUMP,7987210,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,24100.00000,6989.00000,Aetna,First Health,,19713.80,,,,,,,7760.20,19713.80,percent of total billed charges,
COMPONENT PATELLA,7987238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
COMPONENT PATELLA,7987238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
COLLAGEN,7987582,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,4004.53000,1161.31000,Aetna,First Health,,3275.71,,,,,,,1443.63,3275.71,percent of total billed charges,
COLLAGEN,7987582,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,4004.53000,1161.31000,Aetna,First Health,,3275.71,,,,,,,1289.46,3275.71,percent of total billed charges,
STEM,7987556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3184.00000,923.36000,Aetna,First Health,,2604.51,,,,,,,1147.83,2604.51,percent of total billed charges,
STEM,7987556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3184.00000,923.36000,Aetna,First Health,,2604.51,,,,,,,1025.25,2604.51,percent of total billed charges,
STEM,7987524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11412.00000,3309.48000,Aetna,First Health,,9335.02,,,,,,,4114.03,9335.02,percent of total billed charges,
STEM,7987524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11412.00000,3309.48000,Aetna,First Health,,9335.02,,,,,,,3674.66,9335.02,percent of total billed charges,
COLLAGEN,7987577,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,1529.60000,443.58000,Aetna,First Health,,1251.21,,,,,,,551.42,1251.21,percent of total billed charges,
COLLAGEN,7987577,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,1529.60000,443.58000,Aetna,First Health,,1251.21,,,,,,,492.53,1251.21,percent of total billed charges,
COLLAGEN,7987578,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2068.40000,599.84000,Aetna,First Health,,1691.95,,,,,,,745.66,1691.95,percent of total billed charges,
COLLAGEN,7987578,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2068.40000,599.84000,Aetna,First Health,,1691.95,,,,,,,666.02,1691.95,percent of total billed charges,
COLLAGEN,7987580,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,5720.58000,1658.97000,Aetna,First Health,,4679.43,,,,,,,2062.27,4679.43,percent of total billed charges,
COLLAGEN,7987580,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,5720.58000,1658.97000,Aetna,First Health,,4679.43,,,,,,,1842.03,4679.43,percent of total billed charges,
COLLAGEN,7987581,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2382.00000,690.78000,Aetna,First Health,,1948.48,,,,,,,858.71,1948.48,percent of total billed charges,
COLLAGEN,7987581,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2382.00000,690.78000,Aetna,First Health,,1948.48,,,,,,,767.00,1948.48,percent of total billed charges,
COLLAGEN,7987583,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,5720.58000,1658.97000,Aetna,First Health,,4679.43,,,,,,,2062.27,4679.43,percent of total billed charges,
COLLAGEN,7987583,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,5720.58000,1658.97000,Aetna,First Health,,4679.43,,,,,,,1842.03,4679.43,percent of total billed charges,
PENILE IMPLANT,7987619,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,34008.75000,9862.54000,Aetna,First Health,,27819.16,,,,,,,12260.15,27819.16,percent of total billed charges,
PENILE IMPLANT,7987619,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,34008.75000,9862.54000,Aetna,First Health,,27819.16,,,,,,,10950.82,27819.16,percent of total billed charges,
SCREW,7987621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,873.04,1981.00,percent of total billed charges,
SCREW,7987621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,779.81,1981.00,percent of total billed charges,
NUT,7987677,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
NUT,7987677,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
NAIL,7987733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7987733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
FIXATION DEVICE IN KIT,7987803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9652.50000,2799.22000,Aetna,First Health,,7895.74,,,,,,,3479.73,7895.74,percent of total billed charges,
FIXATION DEVICE IN KIT,7987803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9652.50000,2799.22000,Aetna,First Health,,7895.74,,,,,,,3108.11,7895.74,percent of total billed charges,
PLATE,7987902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,First Health,,6338.19,,,,,,,2793.30,6338.19,percent of total billed charges,
PLATE,7987902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,First Health,,6338.19,,,,,,,2494.98,6338.19,percent of total billed charges,
PLATE,7987904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7987904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
COMPONENT FEMORAL,7987908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
COMPONENT FEMORAL,7987908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
INSERT,7987910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16743.20000,4855.53000,Aetna,First Health,,13695.94,,,,,,,6035.92,13695.94,percent of total billed charges,
INSERT,7987910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16743.20000,4855.53000,Aetna,First Health,,13695.94,,,,,,,5391.31,13695.94,percent of total billed charges,
WEDGE,7987912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4958.73000,1438.03000,Aetna,First Health,,4056.24,,,,,,,1787.62,4056.24,percent of total billed charges,
WEDGE,7987912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4958.73000,1438.03000,Aetna,First Health,,4056.24,,,,,,,1596.71,4056.24,percent of total billed charges,
COMPONENT FEMORAL,7987914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25606.63000,7425.92000,Aetna,First Health,,20946.22,,,,,,,9231.19,20946.22,percent of total billed charges,
COMPONENT FEMORAL,7987914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25606.63000,7425.92000,Aetna,First Health,,20946.22,,,,,,,8245.33,20946.22,percent of total billed charges,
SHEATH,8147624,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SHEATH,8147624,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
CATHETER,8136122,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136122,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136123,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136123,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136124,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136124,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136125,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136125,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136126,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136126,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136127,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136127,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136129,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136129,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136130,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136130,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136131,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136131,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136132,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136132,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136133,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136133,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136134,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136134,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136135,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136135,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136136,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136136,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136137,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136137,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136138,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136138,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136139,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136139,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136140,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136140,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136141,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136141,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136142,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136142,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136143,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136143,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136144,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136144,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136145,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136145,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136146,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136146,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136147,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136147,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136148,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136148,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136149,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136149,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136150,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136150,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136158,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136158,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136162,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136162,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136166,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136166,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136170,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136170,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136174,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136174,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136178,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136178,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136182,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136182,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136151,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136151,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136155,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136155,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136159,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136159,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136163,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136163,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136167,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136167,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136171,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136171,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136175,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136175,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136179,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136179,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136183,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136183,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136186,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136186,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136189,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136189,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136152,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136152,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136156,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136156,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136160,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136160,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136164,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136164,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136168,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136168,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136172,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136172,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136176,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136176,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136180,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136180,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136184,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136184,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136187,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136187,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136190,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136190,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136153,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136153,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136157,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136157,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136161,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136161,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136165,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136165,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136169,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136169,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136173,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136173,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136177,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136177,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136181,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136181,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136185,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136185,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136188,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136188,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8136191,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136191,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER GUIDE,8136238,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,First Health,,1525.57,,,,,,,672.33,1525.57,percent of total billed charges,
CATHETER GUIDE,8136238,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,First Health,,1525.57,,,,,,,600.53,1525.57,percent of total billed charges,
CATHETER GUIDE,8136239,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,First Health,,1525.57,,,,,,,672.33,1525.57,percent of total billed charges,
CATHETER GUIDE,8136239,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,First Health,,1525.57,,,,,,,600.53,1525.57,percent of total billed charges,
PACEMAKER,8136236,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,26375.00000,7648.75000,Aetna,First Health,,21574.75,,,,,,,9508.19,21574.75,percent of total billed charges,
PACEMAKER,8136236,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,26375.00000,7648.75000,Aetna,First Health,,21574.75,,,,,,,8492.75,21574.75,percent of total billed charges,
CATHETER BALLOON,8148644,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
CATHETER BALLOON,8148644,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
DILATOR,8136237,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,138.92000,40.29000,Aetna,First Health,,113.64,,,,,,,50.08,113.64,percent of total billed charges,
DILATOR,8136237,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,138.92000,40.29000,Aetna,First Health,,113.64,,,,,,,44.73,113.64,percent of total billed charges,
CATHETER BALLOON,8136038,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136038,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER GUIDE,8136240,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,First Health,,1525.57,,,,,,,672.33,1525.57,percent of total billed charges,
CATHETER GUIDE,8136240,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,First Health,,1525.57,,,,,,,600.53,1525.57,percent of total billed charges,
BALLOON,8136241,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,First Health,,2814.33,,,,,,,1240.30,2814.33,percent of total billed charges,
BALLOON,8136241,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,First Health,,2814.33,,,,,,,1107.84,2814.33,percent of total billed charges,
CATHETER,8148865,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
CATHETER,8148865,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
Sensor and Delivery System,8136242,CDM,278,RC,C2624,HCPCS,,,facility,inpatient,,,57000.00000,16530.00000,Aetna,First Health,,46626.00,,,,,,,20548.50,46626.00,percent of total billed charges,
Sensor and Delivery System,8136242,CDM,278,RC,C2624,HCPCS,,,facility,outpatient,,,57000.00000,16530.00000,Aetna,First Health,,46626.00,,,,,,,18354.00,46626.00,percent of total billed charges,
LOOP RECORDER,8143326,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
LOOP RECORDER,8143326,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
BALLOON,7750486,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON,7750486,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON,8136284,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
BALLOON,8136284,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
BALLOON,8136285,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
BALLOON,8136285,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
BALLOON,8136286,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
BALLOON,8136286,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
BALLOON,8136287,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
BALLOON,8136287,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
GUIDEWIRE,8155957,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,8155957,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
GUIDEWIRE,8155958,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,8155958,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
STENT,8159922,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159922,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159924,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159924,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159926,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159926,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159928,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159928,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159930,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159930,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159932,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159932,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159934,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159934,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159936,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159936,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159938,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159938,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159940,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159940,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159942,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159942,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159944,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159944,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159946,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159946,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159948,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159948,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159950,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159950,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159952,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159952,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159954,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159954,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159956,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159956,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159958,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159958,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159960,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159960,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159962,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159962,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159964,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159964,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159966,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159966,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159968,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159968,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159970,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159970,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159972,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159972,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159974,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159974,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159976,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159976,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159978,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159978,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159980,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159980,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159982,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159982,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159984,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159984,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159986,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159986,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159988,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159988,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159990,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159990,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159992,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159992,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159994,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159994,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159996,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159996,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8159998,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8159998,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160000,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160000,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160002,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160002,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160004,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160004,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160006,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160006,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160008,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160008,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160010,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160010,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160012,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160012,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160014,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160014,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160016,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160016,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160018,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160018,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160020,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160020,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160022,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160022,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160024,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160024,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160026,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160026,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8160028,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8160028,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
GUIDEWIRE,8161163,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,8161163,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
CATHETER,8161164,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER,8161164,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER,8161165,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8161165,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
STENT,8161166,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8161166,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
GUIDEWIRE,8167879,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,364.17000,105.61000,Aetna,First Health,,297.89,,,,,,,131.28,297.89,percent of total billed charges,
GUIDEWIRE,8167879,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,364.17000,105.61000,Aetna,First Health,,297.89,,,,,,,117.26,297.89,percent of total billed charges,
BALLOON,8167880,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
BALLOON,8167880,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
BALLOON,8167881,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
BALLOON,8167881,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
BALLOON,8167882,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
BALLOON,8167882,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
STENT,8167893,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8167893,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
BALLOON CATHETER,8168647,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,277.40,629.45,percent of total billed charges,
BALLOON CATHETER,8168647,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,247.78,629.45,percent of total billed charges,
BALLOON,8168648,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
BALLOON,8168648,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
STENT,8170299,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4736.97,10748.52,percent of total billed charges,
STENT,8170299,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4231.08,10748.52,percent of total billed charges,
STENT,8170300,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4736.97,10748.52,percent of total billed charges,
STENT,8170300,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4231.08,10748.52,percent of total billed charges,
STENT,8170301,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4736.97,10748.52,percent of total billed charges,
STENT,8170301,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4231.08,10748.52,percent of total billed charges,
STENT,8170302,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4736.97,10748.52,percent of total billed charges,
STENT,8170302,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4231.08,10748.52,percent of total billed charges,
STENT,8170303,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4736.97,10748.52,percent of total billed charges,
STENT,8170303,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4231.08,10748.52,percent of total billed charges,
STENT,8170304,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4736.97,10748.52,percent of total billed charges,
STENT,8170304,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,First Health,,10748.52,,,,,,,4231.08,10748.52,percent of total billed charges,
CATHETER,8214486,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,8625.00000,2501.25000,Aetna,First Health,,7055.25,,,,,,,3109.31,7055.25,percent of total billed charges,
CATHETER,8214486,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,8625.00000,2501.25000,Aetna,First Health,,7055.25,,,,,,,2777.25,9959.00,percent of total billed charges,
ROD,8994477,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD,8994477,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
STEM,7698622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7698622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
HUMERAL ASSEMBLY,7698633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,6398.88,14519.50,percent of total billed charges,
HUMERAL ASSEMBLY,7698633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,5715.50,14519.50,percent of total billed charges,
ULNAR ASSEMBLY,7698635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5948.25,13497.00,percent of total billed charges,
ULNAR ASSEMBLY,7698635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5313.00,13497.00,percent of total billed charges,
GRAFT,7698637,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14649.00000,4248.21000,Aetna,First Health,,11982.88,,,,,,,5280.96,11982.88,percent of total billed charges,
GRAFT,7698637,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14649.00000,4248.21000,Aetna,First Health,,11982.88,,,,,,,4716.98,11982.88,percent of total billed charges,
PLATE,7698666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1445.56000,419.21000,Aetna,First Health,,1182.47,,,,,,,521.12,1182.47,percent of total billed charges,
PLATE,7698666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1445.56000,419.21000,Aetna,First Health,,1182.47,,,,,,,465.47,1182.47,percent of total billed charges,
MESH,7698625,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
MESH,7698625,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
SCREW,7913092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,873.04,1981.00,percent of total billed charges,
SCREW,7913092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,779.81,1981.00,percent of total billed charges,
PLATE,7698705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1743.52000,505.62000,Aetna,First Health,,1426.20,,,,,,,628.54,1426.20,percent of total billed charges,
PLATE,7698705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1743.52000,505.62000,Aetna,First Health,,1426.20,,,,,,,561.41,1426.20,percent of total billed charges,
PLATE,7698706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7523.40000,2181.79000,Aetna,First Health,,6154.14,,,,,,,2712.19,6154.14,percent of total billed charges,
PLATE,7698706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7523.40000,2181.79000,Aetna,First Health,,6154.14,,,,,,,2422.53,6154.14,percent of total billed charges,
COMPONENT HEAD,7698717,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
COMPONENT HEAD,7698717,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PLATE,7698738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5692.40000,1650.80000,Aetna,First Health,,4656.38,,,,,,,2052.11,4656.38,percent of total billed charges,
PLATE,7698738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5692.40000,1650.80000,Aetna,First Health,,4656.38,,,,,,,1832.95,4656.38,percent of total billed charges,
PLATE,7698764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2556.64000,741.43000,Aetna,First Health,,2091.33,,,,,,,921.67,2091.33,percent of total billed charges,
PLATE,7698764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2556.64000,741.43000,Aetna,First Health,,2091.33,,,,,,,823.24,2091.33,percent of total billed charges,
PLATE,7698765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2745.96000,796.33000,Aetna,First Health,,2246.20,,,,,,,989.92,2246.20,percent of total billed charges,
PLATE,7698765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2745.96000,796.33000,Aetna,First Health,,2246.20,,,,,,,884.20,2246.20,percent of total billed charges,
PLATE,7698766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,First Health,,1515.03,,,,,,,667.69,1515.03,percent of total billed charges,
PLATE,7698766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,First Health,,1515.03,,,,,,,596.38,1515.03,percent of total billed charges,
PLATE,7698767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3028.40000,878.24000,Aetna,First Health,,2477.23,,,,,,,1091.74,2477.23,percent of total billed charges,
PLATE,7698767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3028.40000,878.24000,Aetna,First Health,,2477.23,,,,,,,975.14,2477.23,percent of total billed charges,
INSERT,7698349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7698349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
PLATE,7698781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2159.40000,626.23000,Aetna,First Health,,1766.39,,,,,,,778.46,1766.39,percent of total billed charges,
PLATE,7698781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2159.40000,626.23000,Aetna,First Health,,1766.39,,,,,,,695.33,1766.39,percent of total billed charges,
PLATE,7697486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1314.51,2982.71,percent of total billed charges,
PLATE,7697486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1174.12,2982.71,percent of total billed charges,
STEM,7698803,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,7126.63,16170.84,percent of total billed charges,
STEM,7698803,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,6365.54,16170.84,percent of total billed charges,
ROD,7698813,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD,7698813,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
ROD,7698827,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3457.48000,1002.67000,Aetna,First Health,,2828.22,,,,,,,1246.42,2828.22,percent of total billed charges,
ROD,7698827,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3457.48000,1002.67000,Aetna,First Health,,2828.22,,,,,,,1113.31,2828.22,percent of total billed charges,
FEMORAL HEAD,7698817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7698817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
STEM,7698819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2970.88,6741.14,percent of total billed charges,
STEM,7698819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2653.60,6741.14,percent of total billed charges,
SHELL,7698198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2999.00,6804.94,percent of total billed charges,
SHELL,7698198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2678.72,6804.94,percent of total billed charges,
PLATE,7698846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2748.16000,796.97000,Aetna,First Health,,2247.99,,,,,,,990.71,2247.99,percent of total billed charges,
PLATE,7698846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2748.16000,796.97000,Aetna,First Health,,2247.99,,,,,,,884.91,2247.99,percent of total billed charges,
SCREW,7695809,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7695809,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
PLATE,7695864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,461.81,1047.89,percent of total billed charges,
PLATE,7695864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,412.49,1047.89,percent of total billed charges,
GUIDEWIRE,7697657,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.86000,59.41000,Aetna,First Health,,167.58,,,,,,,73.85,167.58,percent of total billed charges,
GUIDEWIRE,7697657,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.86000,59.41000,Aetna,First Health,,167.58,,,,,,,65.96,167.58,percent of total billed charges,
PLATE,7695863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
PLATE,7695863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
PLATE,7698939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7698939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
SHELL,7698100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7698100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PLATE,7698978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2463.52000,714.42000,Aetna,First Health,,2015.16,,,,,,,888.10,2015.16,percent of total billed charges,
PLATE,7698978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2463.52000,714.42000,Aetna,First Health,,2015.16,,,,,,,793.25,2015.16,percent of total billed charges,
CATHETER,7693562,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,383.71000,111.28000,Aetna,First Health,,313.87,,,,,,,138.33,313.87,percent of total billed charges,
CATHETER,7693562,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,383.71000,111.28000,Aetna,First Health,,313.87,,,,,,,123.55,313.87,percent of total billed charges,
CATHETER,7911607,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,444.86,1009.41,percent of total billed charges,
CATHETER,7911607,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,397.35,1009.41,percent of total billed charges,
GRAFT,7696883,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2810.64000,815.09000,Aetna,First Health,,2299.10,,,,,,,1013.24,2299.10,percent of total billed charges,
GRAFT,7696883,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2810.64000,815.09000,Aetna,First Health,,2299.10,,,,,,,905.03,2299.10,percent of total billed charges,
GRAFT,7695666,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,First Health,,2376.68,,,,,,,1047.43,2376.68,percent of total billed charges,
GRAFT,7695666,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,First Health,,2376.68,,,,,,,935.56,2376.68,percent of total billed charges,
GUIDEWIRE,7698713,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,168.95000,49.00000,Aetna,First Health,,138.20,,,,,,,60.91,138.20,percent of total billed charges,
GUIDEWIRE,7698713,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,168.95000,49.00000,Aetna,First Health,,138.20,,,,,,,54.40,138.20,percent of total billed charges,
GUIDEWIRE,7694874,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,345.36000,100.15000,Aetna,First Health,,282.50,,,,,,,124.50,282.50,percent of total billed charges,
GUIDEWIRE,7694874,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,345.36000,100.15000,Aetna,First Health,,282.50,,,,,,,111.21,282.50,percent of total billed charges,
GUIDEWIRE,7696456,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,133.61000,38.75000,Aetna,First Health,,109.29,,,,,,,48.17,109.29,percent of total billed charges,
GUIDEWIRE,7696456,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,133.61000,38.75000,Aetna,First Health,,109.29,,,,,,,43.02,109.29,percent of total billed charges,
MESH,7696127,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,948.64000,275.11000,Aetna,First Health,,775.99,,,,,,,341.98,775.99,percent of total billed charges,
MESH,7696127,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,948.64000,275.11000,Aetna,First Health,,775.99,,,,,,,305.46,775.99,percent of total billed charges,
PLATE,7698779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3603.64000,1045.06000,Aetna,First Health,,2947.78,,,,,,,1299.11,2947.78,percent of total billed charges,
PLATE,7698779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3603.64000,1045.06000,Aetna,First Health,,2947.78,,,,,,,1160.37,2947.78,percent of total billed charges,
SCREW,7736559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7736559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
CATHETER,7694694,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,403.42000,116.99000,Aetna,First Health,,330.00,,,,,,,145.43,330.00,percent of total billed charges,
CATHETER,7694694,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,403.42000,116.99000,Aetna,First Health,,330.00,,,,,,,129.90,330.00,percent of total billed charges,
STENT,7695665,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,770.99000,223.59000,Aetna,First Health,,630.67,,,,,,,277.94,630.67,percent of total billed charges,
STENT,7695665,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,770.99000,223.59000,Aetna,First Health,,630.67,,,,,,,248.26,630.67,percent of total billed charges,
STEM,7987921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,First Health,,5369.19,,,,,,,2366.25,5369.19,percent of total billed charges,
STEM,7987921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,First Health,,5369.19,,,,,,,2113.54,5369.19,percent of total billed charges,
COMPONENT ROTATION,7987922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6613.88000,1918.03000,Aetna,First Health,,5410.15,,,,,,,2384.30,5410.15,percent of total billed charges,
COMPONENT ROTATION,7987922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6613.88000,1918.03000,Aetna,First Health,,5410.15,,,,,,,2129.67,5410.15,percent of total billed charges,
CRANIAL IMPLANT,7987935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
CRANIAL IMPLANT,7987935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
COIL,7987937,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1819.44,4128.45,percent of total billed charges,
COIL,7987937,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1625.13,4128.45,percent of total billed charges,
LINER,7987949,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7987949,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SHELL,7987951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7987951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
GRAFT,7987971,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,11850.00000,3436.50000,Aetna,First Health,,9693.30,,,,,,,4271.93,9693.30,percent of total billed charges,
GRAFT,7987971,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,11850.00000,3436.50000,Aetna,First Health,,9693.30,,,,,,,3815.70,9693.30,percent of total billed charges,
STEM,7988511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,10392.54,23581.41,percent of total billed charges,
STEM,7988511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,9282.66,23581.41,percent of total billed charges,
LINER,7988515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7988515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
WEDGE,7988521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5131.18000,1488.04000,Aetna,First Health,,4197.31,,,,,,,1849.79,4197.31,percent of total billed charges,
WEDGE,7988521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5131.18000,1488.04000,Aetna,First Health,,4197.31,,,,,,,1652.24,4197.31,percent of total billed charges,
SLING SYSTEM,7696292,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,7766.97000,2252.42000,Aetna,First Health,,6353.38,,,,,,,2799.99,6353.38,percent of total billed charges,
SLING SYSTEM,7696292,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,7766.97000,2252.42000,Aetna,First Health,,6353.38,,,,,,,2500.96,6353.38,percent of total billed charges,
COMPONENT HUMERAL,7989146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
COMPONENT HUMERAL,7989146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
COMPONENT FEMORAL,7989241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,7989241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
TISSUE WEDGE,7989185,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,First Health,,6650.34,,,,,,,2930.86,6650.34,percent of total billed charges,
TISSUE WEDGE,7989185,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,First Health,,6650.34,,,,,,,2617.86,6650.34,percent of total billed charges,
ALLOGRAFT,7989268,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1783.07,4045.91,percent of total billed charges,
ALLOGRAFT,7989268,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1592.64,4045.91,percent of total billed charges,
ANCHOR,7989396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,3076.60,6981.02,percent of total billed charges,
ANCHOR,7989396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,2748.03,6981.02,percent of total billed charges,
NAIL,7989503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7989503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
INSERT,7989501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7989501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7989502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7989502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
PLATE,7989565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7395.00000,2144.55000,Aetna,First Health,,6049.11,,,,,,,2665.90,6049.11,percent of total billed charges,
PLATE,7989565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7395.00000,2144.55000,Aetna,First Health,,6049.11,,,,,,,2381.19,6049.11,percent of total billed charges,
SCREW,7989618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
SCREW,7989618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,421.18,1069.94,percent of total billed charges,
SCREW,7989567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
SCREW,7989567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,421.18,1069.94,percent of total billed charges,
SCREW,7989633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
SCREW,7989633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,421.18,1069.94,percent of total billed charges,
SCREW,7989569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
SCREW,7989569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
SCREW,7989571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
SCREW,7989571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
SCREW,7989573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,7989573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
GUIDEWIRE,7989580,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,686.25000,199.01000,Aetna,First Health,,561.35,,,,,,,247.39,561.35,percent of total billed charges,
GUIDEWIRE,7989580,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,686.25000,199.01000,Aetna,First Health,,561.35,,,,,,,220.97,561.35,percent of total billed charges,
ROD,7989584,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
ROD,7989584,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
SCREW,7989582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7989582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
CAGE,7989586,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4902.21000,1421.64000,Aetna,First Health,,4010.01,,,,,,,1767.25,4010.01,percent of total billed charges,
CAGE,7989586,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4902.21000,1421.64000,Aetna,First Health,,4010.01,,,,,,,1578.51,4010.01,percent of total billed charges,
PLATE,7989620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1151.87,2613.67,percent of total billed charges,
PLATE,7989620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1028.85,2613.67,percent of total billed charges,
SCREW,7989587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7989587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7989588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7989588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
STENT GRAFT,7989635,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,7989635,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
GLENOSPHERE,7989637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
GLENOSPHERE,7989637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
HUMERAL BODY,7989638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11571.00000,3355.59000,Aetna,First Health,,9465.08,,,,,,,4171.35,9465.08,percent of total billed charges,
HUMERAL BODY,7989638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11571.00000,3355.59000,Aetna,First Health,,9465.08,,,,,,,3725.86,9465.08,percent of total billed charges,
STEM,7989655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9531.00000,2763.99000,Aetna,First Health,,7796.36,,,,,,,3435.93,7796.36,percent of total billed charges,
STEM,7989655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9531.00000,2763.99000,Aetna,First Health,,7796.36,,,,,,,3068.98,7796.36,percent of total billed charges,
INSERT,7989657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6569.50000,1905.16000,Aetna,First Health,,5373.85,,,,,,,2368.30,5373.85,percent of total billed charges,
INSERT,7989657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6569.50000,1905.16000,Aetna,First Health,,5373.85,,,,,,,2115.38,5373.85,percent of total billed charges,
CONNECTOR SPINAL,7989636,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR SPINAL,7989636,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
NAIL,7989674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1951.93,4429.06,percent of total billed charges,
NAIL,7989674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1743.47,4429.06,percent of total billed charges,
GENERATOR,7989675,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,48037.50000,13930.87000,Aetna,First Health,,39294.68,,,,,,,17317.52,39294.68,percent of total billed charges,
GENERATOR,7989675,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,48037.50000,13930.87000,Aetna,First Health,,39294.68,,,,,,,15468.08,39294.68,percent of total billed charges,
CONTROLLER,7989676,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
CONTROLLER,7989676,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
FEMORAL CONE,7989677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
FEMORAL CONE,7989677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
HUMERAL HEAD,7989672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7989672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
TENDON SHEATH,7989698,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
TENDON SHEATH,7989698,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
BALLOON,7989726,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
BALLOON,7989726,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CAGE,7989830,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,7989830,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
SPINAL IMPLANT,7989832,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,801.38,1818.38,percent of total billed charges,
SPINAL IMPLANT,7989832,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,715.79,1818.38,percent of total billed charges,
SPINAL IMPLANT,7989877,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SPINAL IMPLANT,7989877,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
ROD SPINAL,7989890,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7989890,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
CAGE,7989891,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2669.14,6056.47,percent of total billed charges,
CAGE,7989891,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2384.09,6056.47,percent of total billed charges,
SCREW,7989898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7989898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7989899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7989899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7989900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7989900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7989901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7989901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7989902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7989902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
FEMORAL HEAD,7989892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD,7989892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
ANCHOR,7989894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3136.40000,909.56000,Aetna,First Health,,2565.58,,,,,,,1130.67,2565.58,percent of total billed charges,
ANCHOR,7989894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3136.40000,909.56000,Aetna,First Health,,2565.58,,,,,,,1009.92,2565.58,percent of total billed charges,
ANCHOR,7989895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3136.40000,909.56000,Aetna,First Health,,2565.58,,,,,,,1130.67,2565.58,percent of total billed charges,
ANCHOR,7989895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3136.40000,909.56000,Aetna,First Health,,2565.58,,,,,,,1009.92,2565.58,percent of total billed charges,
ANCHOR,7989896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3064.40000,888.68000,Aetna,First Health,,2506.68,,,,,,,1104.72,2506.68,percent of total billed charges,
ANCHOR,7989896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3064.40000,888.68000,Aetna,First Health,,2506.68,,,,,,,986.74,2506.68,percent of total billed charges,
SCREW,7989897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,671.84,1524.46,percent of total billed charges,
SCREW,7989897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,600.09,1524.46,percent of total billed charges,
SHELL,7989952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7989952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
INSERT,7989954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7989954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
LINER,7989956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7989956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
STEM,7989958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7989958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
INSERT,7989960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7989960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT FEMORAL,7989962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7989962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7989964,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7989964,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
FEMORAL HEAD,7989966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
FEMORAL HEAD,7989966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
STENT GRAFT,7989969,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
STENT GRAFT,7989969,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
SCREW,7990084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7990084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE,7990086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9528.00000,2763.12000,Aetna,First Health,,7793.90,,,,,,,3434.84,7793.90,percent of total billed charges,
PLATE,7990086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9528.00000,2763.12000,Aetna,First Health,,7793.90,,,,,,,3068.02,7793.90,percent of total billed charges,
FEMORAL HEAD,7990089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7990089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
COMPONENT FEMORAL,7990090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
COMPONENT FEMORAL,7990090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
BALLOON CATHETER,7990091,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
BALLOON CATHETER,7990091,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
GENERATOR,7990103,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,47362.50000,13735.12000,Aetna,First Health,,38742.53,,,,,,,17074.18,38742.53,percent of total billed charges,
GENERATOR,7990103,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,47362.50000,13735.12000,Aetna,First Health,,38742.53,,,,,,,15250.73,38742.53,percent of total billed charges,
ROD SPINAL,7990104,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
ROD SPINAL,7990104,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
COMPONENT HEAD,7990113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
COMPONENT HEAD,7990113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SPINAL IMPLANT,7990115,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
SPINAL IMPLANT,7990115,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
COMPONENT FEMORAL,7990126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
COMPONENT FEMORAL,7990126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
BASEPLATE,7990129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
BASEPLATE,7990129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
SCREW,7990131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7990131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7990133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7990133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
STEM,7990135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,7990135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
GLENOSPHERE,7990137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
GLENOSPHERE,7990137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
INSERT,7990139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7990139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SPINAL IMPLANT,7991223,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
SPINAL IMPLANT,7991223,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
ROD SPINAL,7991224,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,First Health,,1786.51,,,,,,,787.33,1786.51,percent of total billed charges,
ROD SPINAL,7991224,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,First Health,,1786.51,,,,,,,703.25,1786.51,percent of total billed charges,
PLATE,7991256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
PLATE,7991256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
PLATE,7991258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
PLATE,7991258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
ROD SPINAL,7991260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
ROD SPINAL,7991260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
FEMORAL HEAD,7991281,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7991281,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SLEEVE,7698927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SLEEVE,7698927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
GLENOID,7991284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GLENOID,7991284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
HUMERAL HEAD,7991285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,7991285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
COMPONENT GLENOID,7991497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
COMPONENT GLENOID,7991497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
COMPONENT FEMORAL,7991498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7991498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
STENT GRAFT,7991499,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7991499,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STEM,7991500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7991500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,7991501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7991501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
LINER,7991623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7991623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
INSERT,7991624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
INSERT,7991624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
AUGMENT TIBIAL,7991625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8162.25000,2367.05000,Aetna,First Health,,6676.72,,,,,,,2942.49,6676.72,percent of total billed charges,
AUGMENT TIBIAL,7991625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8162.25000,2367.05000,Aetna,First Health,,6676.72,,,,,,,2628.24,6676.72,percent of total billed charges,
SCREW,7991626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,134.94,306.18,percent of total billed charges,
SCREW,7991626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,120.52,306.18,percent of total billed charges,
SCREW,7991627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7991627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
ROD SPINAL,7991628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,7991628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
INSERT,7991629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7991629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7991630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,7991630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
CAGE,7991631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,7991631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
SCREW,7991678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,7991678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,7991680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7991680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
INSERT,7991683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,7991683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
COMPONENT FEMORAL,7991704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7991704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7991706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7991706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
LINER,7991708,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
LINER,7991708,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STEM,7991710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7991710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
SCREW,7991712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7991712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
ACETABULAR CUP,7991714,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7991714,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
STEM,7991854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7991854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
SCREW,7991855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7991855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,7991856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7991856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
PLATE,7991857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,7991857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
SCREW,7991858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7991858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7991860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7991860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
PLATE,7991861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1948.00000,564.92000,Aetna,First Health,,1593.46,,,,,,,702.25,1593.46,percent of total billed charges,
PLATE,7991861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1948.00000,564.92000,Aetna,First Health,,1593.46,,,,,,,627.26,1593.46,percent of total billed charges,
PLATE,7991859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1395.50,3166.48,percent of total billed charges,
PLATE,7991859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1246.46,3166.48,percent of total billed charges,
INSERT,7991969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7991969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SCREW,7991971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7991971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7991973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7991973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
STEM,7993519,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STEM,7993519,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
HUMERAL HEAD,7993521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,7993521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STENT GRAFT,7993523,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7993523,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7993525,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7993525,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
PLATE,7993527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5577.88000,1617.59000,Aetna,First Health,,4562.71,,,,,,,2010.83,4562.71,percent of total billed charges,
PLATE,7993527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5577.88000,1617.59000,Aetna,First Health,,4562.71,,,,,,,1796.08,4562.71,percent of total billed charges,
SCREW,7993529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7993529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7993531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7993531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7993533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7993533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7993535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,261.39,593.12,percent of total billed charges,
SCREW,7993535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,233.48,593.12,percent of total billed charges,
SCREW,7993537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7993537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7993539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7993539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
PLATE,7993575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2205.24000,639.52000,Aetna,First Health,,1803.89,,,,,,,794.99,1803.89,percent of total billed charges,
PLATE,7993575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2205.24000,639.52000,Aetna,First Health,,1803.89,,,,,,,710.09,1803.89,percent of total billed charges,
SCREW,7993577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,7993577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,7993579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7993579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
HUMERAL HEAD,7993593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,7993593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,7993597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,7993597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
PLATE,7993603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9885.00000,2866.65000,Aetna,First Health,,8085.93,,,,,,,3563.54,8085.93,percent of total billed charges,
PLATE,7993603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9885.00000,2866.65000,Aetna,First Health,,8085.93,,,,,,,3182.97,8085.93,percent of total billed charges,
SCREW,7993605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,7993605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
STEM,7993606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM,7993606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
GUIDEWIRE,8135984,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,153.20000,44.43000,Aetna,First Health,,125.32,,,,,,,55.23,125.32,percent of total billed charges,
GUIDEWIRE,8135984,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,153.20000,44.43000,Aetna,First Health,,125.32,,,,,,,49.33,125.32,percent of total billed charges,
GUIDEWIRE,8135985,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,790.20000,229.16000,Aetna,First Health,,646.38,,,,,,,284.87,646.38,percent of total billed charges,
GUIDEWIRE,8135985,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,790.20000,229.16000,Aetna,First Health,,646.38,,,,,,,254.44,646.38,percent of total billed charges,
INTRODUCER,8143404,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
INTRODUCER,8143404,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
GUIDEWIRE,8135986,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,295.07000,85.57000,Aetna,First Health,,241.37,,,,,,,106.37,241.37,percent of total billed charges,
GUIDEWIRE,8135986,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,295.07000,85.57000,Aetna,First Health,,241.37,,,,,,,95.01,241.37,percent of total billed charges,
CROWN DIAMONDBACK,8135988,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,13635.00000,3954.15000,Aetna,First Health,,11153.43,,,,,,,4915.42,11153.43,percent of total billed charges,
CROWN DIAMONDBACK,8135988,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,13635.00000,3954.15000,Aetna,First Health,,11153.43,,,,,,,4390.47,11153.43,percent of total billed charges,
GUIDEWIRE,8135987,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1220.00000,353.80000,Aetna,First Health,,997.96,,,,,,,439.81,997.96,percent of total billed charges,
GUIDEWIRE,8135987,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1220.00000,353.80000,Aetna,First Health,,997.96,,,,,,,392.84,997.96,percent of total billed charges,
INTRODUCER TRANSEPTAL,8135989,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
INTRODUCER TRANSEPTAL,8135989,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
STENT,7700200,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT,7700200,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT,7818076,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT,7818076,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT,7741655,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT,7741655,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT,7696333,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7696333,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,7696335,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7696335,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,7696337,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7696337,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,7696340,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7696340,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,7696342,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7696342,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,7696343,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7696343,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,7696344,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7696344,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
CATHETER BALLOON,7858082,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858082,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858080,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858080,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858088,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858088,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858263,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858263,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7794048,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7794048,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858086,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858086,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858087,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858087,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858092,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858092,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858093,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858093,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858100,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858100,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858098,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858098,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858099,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858099,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858104,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858104,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858117,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858117,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858105,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858105,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858107,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858107,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858109,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858109,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858112,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858112,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858115,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858115,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8135991,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8135991,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8135992,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8135992,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8135993,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8135993,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8135995,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8135995,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8135996,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8135996,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8135997,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8135997,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8135998,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8135998,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8135999,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8135999,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8136000,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8136000,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8136001,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8136001,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8136002,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8136002,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8136003,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8136003,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8136004,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8136004,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8136005,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8136005,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8136006,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8136006,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8136007,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8136007,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,8136008,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8136008,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
STENT BILIARY,8136009,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136009,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136010,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136010,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136011,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136011,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136012,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136012,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136013,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136013,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136014,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136014,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136015,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136015,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136016,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
STENT BILIARY,8136016,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
STENT BILIARY,8136017,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136017,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136018,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
STENT BILIARY,8136018,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
STENT BILIARY,8136019,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136019,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136020,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136020,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136021,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136021,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136022,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136022,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136023,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136023,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136024,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STENT BILIARY,8136024,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STENT BILIARY,8136025,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
STENT BILIARY,8136025,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
CATHETER BALLOON,8136026,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
CATHETER BALLOON,8136026,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
CATHETER BALLOON,8136027,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
CATHETER BALLOON,8136027,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
CATHETER BALLOON,8136028,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
CATHETER BALLOON,8136028,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
CATHETER BALLOON,8136029,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136029,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136030,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136030,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136031,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136031,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136032,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136032,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136033,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136033,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136034,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136034,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136035,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136035,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136036,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136036,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136037,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136037,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136039,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136039,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136040,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136040,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136041,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136041,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136042,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136042,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7927605,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7927605,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136043,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136043,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136044,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136044,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7927606,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7927606,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,8136045,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,8136045,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
STENT LIFESTENT,8136046,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT LIFESTENT,8136046,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT LIFESTENT,8136047,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT LIFESTENT,8136047,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT LIFESTENT,8136048,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT LIFESTENT,8136048,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT LIFESTENT,8136049,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT LIFESTENT,8136049,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
GUIDEWIRE,7894328,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,720.00000,208.80000,Aetna,First Health,,588.96,,,,,,,259.56,588.96,percent of total billed charges,
GUIDEWIRE,7894328,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,720.00000,208.80000,Aetna,First Health,,588.96,,,,,,,231.84,588.96,percent of total billed charges,
INTRODUCER SAFESHEATH,8136052,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,506.83000,146.98000,Aetna,First Health,,414.59,,,,,,,182.71,414.59,percent of total billed charges,
INTRODUCER SAFESHEATH,8136052,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,506.83000,146.98000,Aetna,First Health,,414.59,,,,,,,163.20,414.59,percent of total billed charges,
STENT BILIARY,8136050,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
STENT BILIARY,8136050,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
INTRODUCER SAFESHEATH,8136053,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,506.83000,146.98000,Aetna,First Health,,414.59,,,,,,,182.71,414.59,percent of total billed charges,
INTRODUCER SAFESHEATH,8136053,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,506.83000,146.98000,Aetna,First Health,,414.59,,,,,,,163.20,414.59,percent of total billed charges,
INTRODUCER SAFESHEATH,8136054,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,506.83000,146.98000,Aetna,First Health,,414.59,,,,,,,182.71,414.59,percent of total billed charges,
INTRODUCER SAFESHEATH,8136054,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,506.83000,146.98000,Aetna,First Health,,414.59,,,,,,,163.20,414.59,percent of total billed charges,
INTRODUCER SAFESHEATH,8136051,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,319.20000,92.57000,Aetna,First Health,,261.11,,,,,,,115.07,261.11,percent of total billed charges,
INTRODUCER SAFESHEATH,8136051,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,319.20000,92.57000,Aetna,First Health,,261.11,,,,,,,102.78,261.11,percent of total billed charges,
STENT,7696336,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7696336,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
PUMP SET IMPELLA CP,8136105,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,62000.00000,17980.00000,Aetna,First Health,,50716.00,,,,,,,22351.00,50716.00,percent of total billed charges,
PUMP SET IMPELLA CP,8136105,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,62000.00000,17980.00000,Aetna,First Health,,50716.00,,,,,,,19964.00,50716.00,percent of total billed charges,
GUIDEWIRE,8136107,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,115.92000,33.62000,Aetna,First Health,,94.82,,,,,,,41.79,94.82,percent of total billed charges,
GUIDEWIRE,8136107,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,115.92000,33.62000,Aetna,First Health,,94.82,,,,,,,37.33,94.82,percent of total billed charges,
WIRE,8136106,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,164.39,373.01,percent of total billed charges,
WIRE,8136106,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,146.83,373.01,percent of total billed charges,
CATHETER,8136103,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3377.50000,979.47000,Aetna,First Health,,2762.80,,,,,,,1217.59,2762.80,percent of total billed charges,
CATHETER,8136103,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3377.50000,979.47000,Aetna,First Health,,2762.80,,,,,,,1087.56,2762.80,percent of total billed charges,
CATHETER BALLOON,8135994,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,8135994,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,7908715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7908715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7904940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,7904940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,7947860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,7947860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CERVICAL STABILZATION,7904978,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CERVICAL STABILZATION,7904978,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CERVICAL STABILZATION,7937702,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CERVICAL STABILZATION,7937702,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
LINER,7905032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,7905033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,7905034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,7905035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,7905036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,7905037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,7905038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,7905039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,7905040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,7905044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,7905045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,7905045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
HIP MODULAR,7911244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
HIP MODULAR,7911244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
RESERVOIR,7905310,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2171.64000,629.78000,Aetna,First Health,,1776.40,,,,,,,782.88,1776.40,percent of total billed charges,
RESERVOIR,7905310,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2171.64000,629.78000,Aetna,First Health,,1776.40,,,,,,,699.27,1776.40,percent of total billed charges,
ANCHOR,7951856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1868.00000,541.72000,Aetna,First Health,,1528.02,,,,,,,673.41,1528.02,percent of total billed charges,
ANCHOR,7951856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1868.00000,541.72000,Aetna,First Health,,1528.02,,,,,,,601.50,1528.02,percent of total billed charges,
FEMORAL HEAD,7866104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7866104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7912230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7912230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7920463,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7920463,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
CATHETER,7905551,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1991.36000,577.49000,Aetna,First Health,,1628.93,,,,,,,717.89,1628.93,percent of total billed charges,
CATHETER,7905551,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1991.36000,577.49000,Aetna,First Health,,1628.93,,,,,,,641.22,1628.93,percent of total billed charges,
NAIL,7905578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4650.45,10552.20,percent of total billed charges,
NAIL,7905578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4153.80,10552.20,percent of total billed charges,
NAIL,7920464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4650.45,10552.20,percent of total billed charges,
NAIL,7920464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4153.80,10552.20,percent of total billed charges,
NAIL,7939309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4650.45,10552.20,percent of total billed charges,
NAIL,7939309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4153.80,10552.20,percent of total billed charges,
NAIL,7939854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4650.45,10552.20,percent of total billed charges,
NAIL,7939854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4153.80,10552.20,percent of total billed charges,
AUGMENT FEMORAL,7905616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1693.52,3842.72,percent of total billed charges,
AUGMENT FEMORAL,7905616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1512.66,3842.72,percent of total billed charges,
AUGMENT FEMORAL,7918961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1693.52,3842.72,percent of total billed charges,
AUGMENT FEMORAL,7918961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1512.66,3842.72,percent of total billed charges,
STEM,7916495,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM,7916495,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM,7918976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM,7918976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
PLATE,7905620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,744.07,1688.35,percent of total billed charges,
PLATE,7905620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,664.61,1688.35,percent of total billed charges,
PLATE,7926502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,744.07,1688.35,percent of total billed charges,
PLATE,7926502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,664.61,1688.35,percent of total billed charges,
SCREW,7908236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7908236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7908237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7908237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7908238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7908238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7908239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7908239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
ACETABULAR RING,7908259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,205.70,466.75,percent of total billed charges,
ACETABULAR RING,7908259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,183.73,466.75,percent of total billed charges,
ACETABULAR RING,7908260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,205.70,466.75,percent of total billed charges,
ACETABULAR RING,7908260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,183.73,466.75,percent of total billed charges,
ACETABULAR RING,7908261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,205.70,466.75,percent of total billed charges,
ACETABULAR RING,7908261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,183.73,466.75,percent of total billed charges,
ACETABULAR RING,7908262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,205.70,466.75,percent of total billed charges,
ACETABULAR RING,7908262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,183.73,466.75,percent of total billed charges,
ACETABULAR RING,7858549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,205.70,466.75,percent of total billed charges,
ACETABULAR RING,7858549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,183.73,466.75,percent of total billed charges,
STEM,7806233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7806233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7806351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7806351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7832097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7832097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7850174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7850174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7908483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7908483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
GLENOSPHERE,7700295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GLENOSPHERE,7700295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
GLENOSPHERE,7832098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GLENOSPHERE,7832098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
GLENOSPHERE,7901683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GLENOSPHERE,7901683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
GLENOSPHERE,7908337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6062.00000,1757.98000,Aetna,First Health,,4958.72,,,,,,,2185.35,4958.72,percent of total billed charges,
GLENOSPHERE,7908337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6062.00000,1757.98000,Aetna,First Health,,4958.72,,,,,,,1951.96,4958.72,percent of total billed charges,
GLENOSPHERE,7908467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GLENOSPHERE,7908467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
GLENOSPHERE,7908468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GLENOSPHERE,7908468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
GLENOSPHERE,7925635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6062.00000,1757.98000,Aetna,First Health,,4958.72,,,,,,,2185.35,4958.72,percent of total billed charges,
GLENOSPHERE,7925635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6062.00000,1757.98000,Aetna,First Health,,4958.72,,,,,,,1951.96,4958.72,percent of total billed charges,
SCREW,7918955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3328.50000,965.26000,Aetna,First Health,,2722.71,,,,,,,1199.92,2722.71,percent of total billed charges,
SCREW,7918955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3328.50000,965.26000,Aetna,First Health,,2722.71,,,,,,,1071.78,2722.71,percent of total billed charges,
PLATE,7948835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7948835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,7908719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7908719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7908720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7908720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
STEM,7920747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7920747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7940364,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7940364,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7963015,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7963015,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE,7914404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8445.00000,2449.05000,Aetna,First Health,,6908.01,,,,,,,3044.42,6908.01,percent of total billed charges,
PLATE,7914404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8445.00000,2449.05000,Aetna,First Health,,6908.01,,,,,,,2719.29,6908.01,percent of total billed charges,
PLATE,7930001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,First Health,,7082.24,,,,,,,3121.21,7082.24,percent of total billed charges,
PLATE,7930001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,First Health,,7082.24,,,,,,,2787.88,7082.24,percent of total billed charges,
PLATE,7935844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8259.60000,2395.28000,Aetna,First Health,,6756.35,,,,,,,2977.59,6756.35,percent of total billed charges,
PLATE,7935844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8259.60000,2395.28000,Aetna,First Health,,6756.35,,,,,,,2659.59,6756.35,percent of total billed charges,
CAGE,7912363,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CAGE,7912363,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
CAGE,7912364,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CAGE,7912364,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
INSERT,7909469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7909469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7910124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7910124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7910301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7910301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7911547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7911547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7912328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7912328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7912339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7912339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7912340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7912340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7916469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7916469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7917357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7917357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7917825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7917825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7917875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7917875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7918904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7918904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7918957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7918957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7918999,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7918999,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7919077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7919077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7920371,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7920371,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7920374,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7920374,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7920521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7920521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7920522,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7920522,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7920524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7920524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7920780,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7920780,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7921021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7921021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7921202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7921202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7921203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7921203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7921282,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7921282,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7926550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7926550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7927043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7927043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7927184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7927184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7927421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7927421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7927551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7927551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7929759,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7929759,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7929760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7929760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7929761,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7929761,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7930204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7930204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7934016,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7934016,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7935339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7935339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7935500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7935500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7935501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7935501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7935503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7935503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7935562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7935562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7935563,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7935563,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7935786,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7935786,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7936193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7936193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7937648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7937648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7938369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7938369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7938391,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7938391,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7938812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7938812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7938967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7938967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7939808,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7939808,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7939954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7939954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7946095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7946095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7946096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7946096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7947861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7947861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7948043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7948043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7948115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7948115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7950494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7950494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7951959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7951959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7953854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7953854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7954584,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7954584,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7957915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7957915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7960034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7960034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7960313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7960313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7961943,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7961943,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7961944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7961944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7962114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7962114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7962115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7962115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM,7911400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7911400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7913848,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7913848,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7943706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7943706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7943993,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7943993,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PLATE,7955809,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5887.49000,1707.37000,Aetna,First Health,,4815.97,,,,,,,2122.44,4815.97,percent of total billed charges,
PLATE,7955809,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5887.49000,1707.37000,Aetna,First Health,,4815.97,,,,,,,1895.77,4815.97,percent of total billed charges,
AUGMENT TIBIAL,7700015,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7700015,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7909382,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7909382,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7918190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7918190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7926533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7926533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7943286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7943286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
STEM,7804042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7804042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7806409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7806409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7822262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7822262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7838116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7838116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7880290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7880290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7908233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7908233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7909413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7909413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7911549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7911549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7913628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7913628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7921149,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7921149,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7924546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7924546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7927097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7927097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7935566,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7935566,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7938034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7938034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
COMPONENT FEMORAL,7909462,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7909462,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7924907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7924907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT TIBIAL,7956573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
COMPONENT TIBIAL,7956573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
PLATE,7910143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3945.90000,1144.31000,Aetna,First Health,,3227.75,,,,,,,1422.50,3227.75,percent of total billed charges,
PLATE,7910143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3945.90000,1144.31000,Aetna,First Health,,3227.75,,,,,,,1270.58,3227.75,percent of total billed charges,
SCREW,7910165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,290.06,658.16,percent of total billed charges,
SCREW,7910165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,259.08,658.16,percent of total billed charges,
SCREW,7910166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,290.06,658.16,percent of total billed charges,
SCREW,7910166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,259.08,658.16,percent of total billed charges,
SCREW,7912233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,290.06,658.16,percent of total billed charges,
SCREW,7912233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,259.08,658.16,percent of total billed charges,
SCREW,7917897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW,7917897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
SCREW,7937739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,290.06,658.16,percent of total billed charges,
SCREW,7937739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,259.08,658.16,percent of total billed charges,
COMPONENT PROXIMAL,7910251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10362.00000,3004.98000,Aetna,First Health,,8476.12,,,,,,,3735.50,8476.12,percent of total billed charges,
COMPONENT PROXIMAL,7910251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10362.00000,3004.98000,Aetna,First Health,,8476.12,,,,,,,3336.56,8476.12,percent of total billed charges,
FEMORAL HEAD,7925631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,First Health,,4584.24,,,,,,,2020.31,4584.24,percent of total billed charges,
FEMORAL HEAD,7925631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,First Health,,4584.24,,,,,,,1804.55,4584.24,percent of total billed charges,
CATHETER BALLOON,7912214,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1242.82,2820.05,percent of total billed charges,
CATHETER BALLOON,7912214,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1110.10,2820.05,percent of total billed charges,
FEMORAL HEAD,7935820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMORAL HEAD,7935820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
FEMORAL HEAD,7939806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMORAL HEAD,7939806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
INSERT,7912871,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7912871,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7913632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7913632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7918160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7918160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7920547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3486.76,7911.70,percent of total billed charges,
INSERT,7920547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3114.38,7911.70,percent of total billed charges,
INSERT,7922572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7922572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7939313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2708.08,6144.82,percent of total billed charges,
INSERT,7939313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2418.86,6144.82,percent of total billed charges,
MESH,7910977,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,792.29000,229.76000,Aetna,First Health,,648.09,,,,,,,285.62,648.09,percent of total billed charges,
MESH,7910977,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,792.29000,229.76000,Aetna,First Health,,648.09,,,,,,,255.12,648.09,percent of total billed charges,
MESH,7910979,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1244.80000,360.99000,Aetna,First Health,,1018.25,,,,,,,448.75,1018.25,percent of total billed charges,
MESH,7910979,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1244.80000,360.99000,Aetna,First Health,,1018.25,,,,,,,400.83,1018.25,percent of total billed charges,
SPACER,7911004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
SPACER,7911004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
SPACER,7947963,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
SPACER,7947963,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
SPACER,7947964,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
SPACER,7947964,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
SPACER,7957908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
SPACER,7957908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
LINER,7911319,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7911319,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW,7911087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7911098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,509.33,1155.70,percent of total billed charges,
SCREW,7911098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,First Health,,1155.70,,,,,,,454.93,1155.70,percent of total billed charges,
SCREW,7966082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,7966082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
SCREW,7702910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1360.00000,394.40000,Aetna,First Health,,1112.48,,,,,,,490.28,1112.48,percent of total billed charges,
SCREW,7702910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1360.00000,394.40000,Aetna,First Health,,1112.48,,,,,,,437.92,1112.48,percent of total billed charges,
STEM,7917873,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2970.88,6741.14,percent of total billed charges,
STEM,7917873,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2653.60,6741.14,percent of total billed charges,
WEDGE,7911313,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,First Health,,5033.15,,,,,,,2218.16,5033.15,percent of total billed charges,
WEDGE,7911313,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,First Health,,5033.15,,,,,,,1981.27,5033.15,percent of total billed charges,
WEDGE,7911314,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,First Health,,5033.15,,,,,,,2218.16,5033.15,percent of total billed charges,
WEDGE,7911314,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,First Health,,5033.15,,,,,,,1981.27,5033.15,percent of total billed charges,
WEDGE,7911315,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,First Health,,5033.15,,,,,,,2218.16,5033.15,percent of total billed charges,
WEDGE,7911315,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,First Health,,5033.15,,,,,,,1981.27,5033.15,percent of total billed charges,
WEDGE,7911316,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,First Health,,5033.15,,,,,,,2218.16,5033.15,percent of total billed charges,
WEDGE,7911316,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,First Health,,5033.15,,,,,,,1981.27,5033.15,percent of total billed charges,
COMPONENT PATELLA,7911318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,4133.49,9379.19,percent of total billed charges,
COMPONENT PATELLA,7911318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,3692.05,9379.19,percent of total billed charges,
COMPONENT PATELLA,7911773,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,4133.49,9379.19,percent of total billed charges,
COMPONENT PATELLA,7911773,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,3692.05,9379.19,percent of total billed charges,
COMPONENT PATELLA,7927419,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,4133.49,9379.19,percent of total billed charges,
COMPONENT PATELLA,7927419,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,3692.05,9379.19,percent of total billed charges,
SCREW,7920824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7920824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7944179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7944179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7944181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7944181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7914397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,497.63,1129.17,percent of total billed charges,
SCREW,7914397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,444.49,1129.17,percent of total billed charges,
SCREW,7937742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7937742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7925632,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7925632,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
WEDGE,7702068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7702068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7784278,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7784278,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7882860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7882860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7954586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7954586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
PEG,7701955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
PEG,7701955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
PEG,7701956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
PEG,7701956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
PEG,7701957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
PEG,7701957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
PEG,7701958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
PEG,7701958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
PEG,7701959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
PEG,7701959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
PEG,7702133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
PEG,7702133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PEG,7736193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
PEG,7736193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PEG,7812180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
PEG,7812180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STENT GRAFT,7740551,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,47556.00000,13791.24000,Aetna,First Health,,38900.81,,,,,,,17143.94,38900.81,percent of total billed charges,
STENT GRAFT,7740551,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,47556.00000,13791.24000,Aetna,First Health,,38900.81,,,,,,,15313.03,38900.81,percent of total billed charges,
STENT GRAFT,7740552,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,47556.00000,13791.24000,Aetna,First Health,,38900.81,,,,,,,17143.94,38900.81,percent of total billed charges,
STENT GRAFT,7740552,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,47556.00000,13791.24000,Aetna,First Health,,38900.81,,,,,,,15313.03,38900.81,percent of total billed charges,
STENT GRAFT,7764087,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,17763.64,40306.95,percent of total billed charges,
STENT GRAFT,7764087,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,15866.55,40306.95,percent of total billed charges,
STENT GRAFT,7764088,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,17763.64,40306.95,percent of total billed charges,
STENT GRAFT,7764088,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,15866.55,40306.95,percent of total billed charges,
STENT GRAFT,7764089,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,17763.64,40306.95,percent of total billed charges,
STENT GRAFT,7764089,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,15866.55,40306.95,percent of total billed charges,
STENT GRAFT,7764094,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,17763.64,40306.95,percent of total billed charges,
STENT GRAFT,7764094,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,15866.55,40306.95,percent of total billed charges,
STENT GRAFT,7905309,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,17763.64,40306.95,percent of total billed charges,
STENT GRAFT,7905309,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,15866.55,40306.95,percent of total billed charges,
STENT GRAFT,7943626,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,17763.64,40306.95,percent of total billed charges,
STENT GRAFT,7943626,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,15866.55,40306.95,percent of total billed charges,
PLATE,7695341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7695341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7695342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7695342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7696571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7696571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7696587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7696587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7696654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7696654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7697149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7697149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7698695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7698695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7699114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7699114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7699115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7699115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7702138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5420.38000,1571.91000,Aetna,First Health,,4433.87,,,,,,,1954.05,4433.87,percent of total billed charges,
PLATE,7702138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5420.38000,1571.91000,Aetna,First Health,,4433.87,,,,,,,1745.36,4433.87,percent of total billed charges,
PLATE,7702139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5420.38000,1571.91000,Aetna,First Health,,4433.87,,,,,,,1954.05,4433.87,percent of total billed charges,
PLATE,7702139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5420.38000,1571.91000,Aetna,First Health,,4433.87,,,,,,,1745.36,4433.87,percent of total billed charges,
PLATE,7702142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5420.38000,1571.91000,Aetna,First Health,,4433.87,,,,,,,1954.05,4433.87,percent of total billed charges,
PLATE,7702142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5420.38000,1571.91000,Aetna,First Health,,4433.87,,,,,,,1745.36,4433.87,percent of total billed charges,
PLATE,7707547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5420.38000,1571.91000,Aetna,First Health,,4433.87,,,,,,,1954.05,4433.87,percent of total billed charges,
PLATE,7707547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5420.38000,1571.91000,Aetna,First Health,,4433.87,,,,,,,1745.36,4433.87,percent of total billed charges,
PLATE,7741727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,7741727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
PLATE,7702141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5520.87000,1601.05000,Aetna,First Health,,4516.07,,,,,,,1990.27,4516.07,percent of total billed charges,
PLATE,7702141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5520.87000,1601.05000,Aetna,First Health,,4516.07,,,,,,,1777.72,4516.07,percent of total billed charges,
PLATE,7702196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5520.87000,1601.05000,Aetna,First Health,,4516.07,,,,,,,1990.27,4516.07,percent of total billed charges,
PLATE,7702196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5520.87000,1601.05000,Aetna,First Health,,4516.07,,,,,,,1777.72,4516.07,percent of total billed charges,
PLATE,7736569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7736569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7935162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,First Health,,6338.19,,,,,,,2793.30,6338.19,percent of total billed charges,
PLATE,7935162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,First Health,,6338.19,,,,,,,2494.98,6338.19,percent of total billed charges,
SCREW,7702304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.26000,96.36000,Aetna,First Health,,271.79,,,,,,,119.78,271.79,percent of total billed charges,
SCREW,7702304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.26000,96.36000,Aetna,First Health,,271.79,,,,,,,106.99,271.79,percent of total billed charges,
SCREW,7702305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.26000,96.36000,Aetna,First Health,,271.79,,,,,,,119.78,271.79,percent of total billed charges,
SCREW,7702305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.26000,96.36000,Aetna,First Health,,271.79,,,,,,,106.99,271.79,percent of total billed charges,
SCREW,7702306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.26000,96.36000,Aetna,First Health,,271.79,,,,,,,119.78,271.79,percent of total billed charges,
SCREW,7702306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.26000,96.36000,Aetna,First Health,,271.79,,,,,,,106.99,271.79,percent of total billed charges,
SCREW,7702373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,439.09000,127.34000,Aetna,First Health,,359.18,,,,,,,158.29,359.18,percent of total billed charges,
SCREW,7702373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,439.09000,127.34000,Aetna,First Health,,359.18,,,,,,,141.39,359.18,percent of total billed charges,
SCREW,7702374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,439.09000,127.34000,Aetna,First Health,,359.18,,,,,,,158.29,359.18,percent of total billed charges,
SCREW,7702374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,439.09000,127.34000,Aetna,First Health,,359.18,,,,,,,141.39,359.18,percent of total billed charges,
SCREW,7702375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,439.09000,127.34000,Aetna,First Health,,359.18,,,,,,,158.29,359.18,percent of total billed charges,
SCREW,7702375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,439.09000,127.34000,Aetna,First Health,,359.18,,,,,,,141.39,359.18,percent of total billed charges,
SCREW,7702376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,439.09000,127.34000,Aetna,First Health,,359.18,,,,,,,158.29,359.18,percent of total billed charges,
SCREW,7702376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,439.09000,127.34000,Aetna,First Health,,359.18,,,,,,,141.39,359.18,percent of total billed charges,
SCREW,7702377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,439.09000,127.34000,Aetna,First Health,,359.18,,,,,,,158.29,359.18,percent of total billed charges,
SCREW,7702377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,439.09000,127.34000,Aetna,First Health,,359.18,,,,,,,141.39,359.18,percent of total billed charges,
SCREW,7802395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7802395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
STENT,7695648,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7695648,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7695652,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7695652,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7695653,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7695653,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695002,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,711.00000,206.19000,Aetna,First Health,,581.60,,,,,,,256.32,581.60,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695002,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,711.00000,206.19000,Aetna,First Health,,581.60,,,,,,,228.94,581.60,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695003,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,711.00000,206.19000,Aetna,First Health,,581.60,,,,,,,256.32,581.60,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695003,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,711.00000,206.19000,Aetna,First Health,,581.60,,,,,,,228.94,581.60,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695004,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,711.00000,206.19000,Aetna,First Health,,581.60,,,,,,,256.32,581.60,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695004,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,711.00000,206.19000,Aetna,First Health,,581.60,,,,,,,228.94,581.60,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695211,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,776.12000,225.07000,Aetna,First Health,,634.87,,,,,,,279.79,634.87,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695211,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,776.12000,225.07000,Aetna,First Health,,634.87,,,,,,,249.91,634.87,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695212,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,776.12000,225.07000,Aetna,First Health,,634.87,,,,,,,279.79,634.87,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695212,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,776.12000,225.07000,Aetna,First Health,,634.87,,,,,,,249.91,634.87,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695213,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,776.12000,225.07000,Aetna,First Health,,634.87,,,,,,,279.79,634.87,percent of total billed charges,
BALLOON STONE EXTRACTOR RX,7695213,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,776.12000,225.07000,Aetna,First Health,,634.87,,,,,,,249.91,634.87,percent of total billed charges,
WASHER,7703333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,144.43000,41.88000,Aetna,First Health,,118.14,,,,,,,52.07,118.14,percent of total billed charges,
WASHER,7703333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,144.43000,41.88000,Aetna,First Health,,118.14,,,,,,,46.51,118.14,percent of total billed charges,
CATHETER HALO 360,7695075,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2936.27,6662.61,percent of total billed charges,
CATHETER HALO 360,7695075,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2622.69,6662.61,percent of total billed charges,
CATHETER HALO 360,7695076,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2936.27,6662.61,percent of total billed charges,
CATHETER HALO 360,7695076,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2622.69,6662.61,percent of total billed charges,
CATHETER HALO 360,7695077,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2936.27,6662.61,percent of total billed charges,
CATHETER HALO 360,7695077,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2622.69,6662.61,percent of total billed charges,
CATHETER HALO 360,7695080,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2936.27,6662.61,percent of total billed charges,
CATHETER HALO 360,7695080,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2622.69,6662.61,percent of total billed charges,
SHEATH,7694683,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,421.80000,122.32000,Aetna,First Health,,345.03,,,,,,,152.06,345.03,percent of total billed charges,
SHEATH,7694683,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,421.80000,122.32000,Aetna,First Health,,345.03,,,,,,,135.82,345.03,percent of total billed charges,
SHEATH,7694685,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,421.80000,122.32000,Aetna,First Health,,345.03,,,,,,,152.06,345.03,percent of total billed charges,
SHEATH,7694685,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,421.80000,122.32000,Aetna,First Health,,345.03,,,,,,,135.82,345.03,percent of total billed charges,
SHEATH,7696162,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
SHEATH,7696162,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
SHEATH,7696404,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,339.53000,98.46000,Aetna,First Health,,277.74,,,,,,,122.40,277.74,percent of total billed charges,
SHEATH,7696404,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,339.53000,98.46000,Aetna,First Health,,277.74,,,,,,,109.33,277.74,percent of total billed charges,
MESH,7696443,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1992.24000,577.75000,Aetna,First Health,,1629.65,,,,,,,718.20,1629.65,percent of total billed charges,
MESH,7696443,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1992.24000,577.75000,Aetna,First Health,,1629.65,,,,,,,641.50,1629.65,percent of total billed charges,
SCREW,7695461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7695461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7695512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7695512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7695526,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7695526,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7695527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7695527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7695799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,338.17,767.34,percent of total billed charges,
SCREW,7695799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,302.06,767.34,percent of total billed charges,
SCREW,7897186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7897186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7894131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7894131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7695805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7695805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7695806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7695806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7695807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7695807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7695808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7695808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7696543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7696543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7696707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7696707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7696712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7696712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7696713,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7696713,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7696839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7696839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7696881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,619.79000,179.74000,Aetna,First Health,,506.99,,,,,,,223.43,506.99,percent of total billed charges,
SCREW,7696881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,619.79000,179.74000,Aetna,First Health,,506.99,,,,,,,199.57,506.99,percent of total billed charges,
SCREW,7696965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7696965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7697142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7697142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7697150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7697150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7697165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7697165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7697241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7697241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7697247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7697247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7697422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7697422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7697423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7697423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7697443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7697443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7697564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7697564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7697632,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7697632,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7697633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7697633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7697650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1430.60000,414.87000,Aetna,First Health,,1170.23,,,,,,,515.73,1170.23,percent of total billed charges,
SCREW,7697650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1430.60000,414.87000,Aetna,First Health,,1170.23,,,,,,,460.65,1170.23,percent of total billed charges,
SCREW,7698016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7698016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7698018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7698018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7698192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1262.80000,366.21000,Aetna,First Health,,1032.97,,,,,,,455.24,1032.97,percent of total billed charges,
SCREW,7698192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1262.80000,366.21000,Aetna,First Health,,1032.97,,,,,,,406.62,1032.97,percent of total billed charges,
SCREW,7698579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7698579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7698887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7698887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7698925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7698925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7698933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,451.25000,130.86000,Aetna,First Health,,369.12,,,,,,,162.68,369.12,percent of total billed charges,
SCREW,7698933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,451.25000,130.86000,Aetna,First Health,,369.12,,,,,,,145.30,369.12,percent of total billed charges,
SCREW,7699075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7699075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7699076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7699076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7699152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7699152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7699500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7699500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7699918,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7699918,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7699930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7699930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7700369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7700370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7700370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7700702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7701205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7701205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7701206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7701206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7702157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7702157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7702158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7702158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7702577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7702577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7702590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,759.92000,220.38000,Aetna,First Health,,621.61,,,,,,,273.95,621.61,percent of total billed charges,
SCREW,7702590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,759.92000,220.38000,Aetna,First Health,,621.61,,,,,,,244.69,621.61,percent of total billed charges,
SCREW,7707444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7707444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7707445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7707445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7750085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7750085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7768118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7768118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7814058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7814058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7872075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7872075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7880361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7880361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7893925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7893925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7893977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7893977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7894283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7894283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,7896877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7896877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7897187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7897187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7897188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7897188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7897189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7897189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7903365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7903365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7905090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7905090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,7905091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7905091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,7909468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7909468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7910371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7910371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7910372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7910372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7912534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7912534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7703059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7703059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7703060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7703060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7703065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7736625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7736625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7703174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7703175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7703175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7703177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7703177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7703178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,284.93,646.53,percent of total billed charges,
SCREW,7703178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,First Health,,646.53,,,,,,,254.50,646.53,percent of total billed charges,
SCREW,7703395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7703398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7703398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
PLATE,7699406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,666.58,1512.51,percent of total billed charges,
PLATE,7699406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,595.39,1512.51,percent of total billed charges,
PLATE,7866083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,666.58,1512.51,percent of total billed charges,
PLATE,7866083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,595.39,1512.51,percent of total billed charges,
PLATE,7911722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2074.60000,601.63000,Aetna,First Health,,1697.02,,,,,,,747.89,1697.02,percent of total billed charges,
PLATE,7911722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2074.60000,601.63000,Aetna,First Health,,1697.02,,,,,,,668.02,1697.02,percent of total billed charges,
PLATE,7930348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,666.58,1512.51,percent of total billed charges,
PLATE,7930348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,595.39,1512.51,percent of total billed charges,
PLATE,7939423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
PLATE,7939423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
FILTER,7695143,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5100.20000,1479.06000,Aetna,First Health,,4171.96,,,,,,,1838.62,4171.96,percent of total billed charges,
FILTER,7695143,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5100.20000,1479.06000,Aetna,First Health,,4171.96,,,,,,,1642.26,4171.96,percent of total billed charges,
PLATE,7695833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5577.88000,1617.59000,Aetna,First Health,,4562.71,,,,,,,2010.83,4562.71,percent of total billed charges,
PLATE,7695833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5577.88000,1617.59000,Aetna,First Health,,4562.71,,,,,,,1796.08,4562.71,percent of total billed charges,
PLATE,7696648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,7696648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,7696723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,7696723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,7697621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
PLATE,7697621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
PLATE,7699618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5970.30000,1731.39000,Aetna,First Health,,4883.71,,,,,,,2152.29,4883.71,percent of total billed charges,
PLATE,7699618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5970.30000,1731.39000,Aetna,First Health,,4883.71,,,,,,,1922.44,4883.71,percent of total billed charges,
PLATE,7699800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5970.30000,1731.39000,Aetna,First Health,,4883.71,,,,,,,2152.29,4883.71,percent of total billed charges,
PLATE,7699800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5970.30000,1731.39000,Aetna,First Health,,4883.71,,,,,,,1922.44,4883.71,percent of total billed charges,
PLATE,7699819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5970.30000,1731.39000,Aetna,First Health,,4883.71,,,,,,,2152.29,4883.71,percent of total billed charges,
PLATE,7699819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5970.30000,1731.39000,Aetna,First Health,,4883.71,,,,,,,1922.44,4883.71,percent of total billed charges,
PLATE,7702664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5970.30000,1731.39000,Aetna,First Health,,4883.71,,,,,,,2152.29,4883.71,percent of total billed charges,
PLATE,7702664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5970.30000,1731.39000,Aetna,First Health,,4883.71,,,,,,,1922.44,4883.71,percent of total billed charges,
PLATE,7736449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5575.19000,1616.81000,Aetna,First Health,,4560.51,,,,,,,2009.86,4560.51,percent of total billed charges,
PLATE,7736449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5575.19000,1616.81000,Aetna,First Health,,4560.51,,,,,,,1795.21,4560.51,percent of total billed charges,
PLATE,7904045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5575.19000,1616.81000,Aetna,First Health,,4560.51,,,,,,,2009.86,4560.51,percent of total billed charges,
PLATE,7904045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5575.19000,1616.81000,Aetna,First Health,,4560.51,,,,,,,1795.21,4560.51,percent of total billed charges,
DERMIS,7736553,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8329.50000,2415.55000,Aetna,First Health,,6813.53,,,,,,,3002.78,6813.53,percent of total billed charges,
DERMIS,7736553,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8329.50000,2415.55000,Aetna,First Health,,6813.53,,,,,,,2682.10,6813.53,percent of total billed charges,
NAIL,7736558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15486.75000,4491.16000,Aetna,First Health,,12668.16,,,,,,,5582.97,12668.16,percent of total billed charges,
NAIL,7736558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15486.75000,4491.16000,Aetna,First Health,,12668.16,,,,,,,4986.73,12668.16,percent of total billed charges,
NAIL,7736567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4396.95000,1275.12000,Aetna,First Health,,3596.71,,,,,,,1585.10,3596.71,percent of total billed charges,
NAIL,7736567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4396.95000,1275.12000,Aetna,First Health,,3596.71,,,,,,,1415.82,3596.71,percent of total billed charges,
SCREW,7736571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7736571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
NAIL,7736580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5995.50000,1738.70000,Aetna,First Health,,4904.32,,,,,,,2161.38,4904.32,percent of total billed charges,
NAIL,7736580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5995.50000,1738.70000,Aetna,First Health,,4904.32,,,,,,,1930.55,4904.32,percent of total billed charges,
SCREW,7736582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.80000,818.03000,Aetna,First Health,,2307.41,,,,,,,1016.90,2307.41,percent of total billed charges,
SCREW,7736582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.80000,818.03000,Aetna,First Health,,2307.41,,,,,,,908.30,2307.41,percent of total billed charges,
GUIDEWIRE,7736585,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
GUIDEWIRE,7736585,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
COMPONENT FEMORAL,7736617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,7689.47,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7736617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,6868.26,17447.94,percent of total billed charges,
INSERT,7736614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,First Health,,5454.73,,,,,,,2403.95,5454.73,percent of total billed charges,
INSERT,7736614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,First Health,,5454.73,,,,,,,2147.22,5454.73,percent of total billed charges,
PLATE,7736608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4137.00000,1199.73000,Aetna,First Health,,3384.07,,,,,,,1491.39,3384.07,percent of total billed charges,
PLATE,7736608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4137.00000,1199.73000,Aetna,First Health,,3384.07,,,,,,,1332.11,3384.07,percent of total billed charges,
WEDGE,7700839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1543.44,3502.17,percent of total billed charges,
WEDGE,7700839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1378.60,3502.17,percent of total billed charges,
LINER,7908263,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LINER,7908263,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
STEM,7736654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8475.00000,2457.75000,Aetna,First Health,,6932.55,,,,,,,3055.24,6932.55,percent of total billed charges,
STEM,7736654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8475.00000,2457.75000,Aetna,First Health,,6932.55,,,,,,,2728.95,6932.55,percent of total billed charges,
CONNECTOR SPINAL,7736658,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR SPINAL,7736658,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
STENT GRAFT,7736664,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21412.50000,6209.62000,Aetna,First Health,,17515.42,,,,,,,7719.21,17515.42,percent of total billed charges,
STENT GRAFT,7736664,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21412.50000,6209.62000,Aetna,First Health,,17515.42,,,,,,,6894.82,17515.42,percent of total billed charges,
PLATE,7740531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4701.90000,1363.55000,Aetna,First Health,,3846.15,,,,,,,1695.03,3846.15,percent of total billed charges,
PLATE,7740531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4701.90000,1363.55000,Aetna,First Health,,3846.15,,,,,,,1514.01,3846.15,percent of total billed charges,
PEG,7740532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7740532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7740757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.73000,141.15000,Aetna,First Health,,398.15,,,,,,,175.47,398.15,percent of total billed charges,
SCREW,7740757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.73000,141.15000,Aetna,First Health,,398.15,,,,,,,156.73,398.15,percent of total billed charges,
GUIDE CATHETER,7740760,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,488.12,1107.57,percent of total billed charges,
GUIDE CATHETER,7740760,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,435.99,1107.57,percent of total billed charges,
SPACER,7740779,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7740779,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
MESH,7740889,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2512.36000,728.58000,Aetna,First Health,,2055.11,,,,,,,905.71,2055.11,percent of total billed charges,
MESH,7740889,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2512.36000,728.58000,Aetna,First Health,,2055.11,,,,,,,808.98,2055.11,percent of total billed charges,
GRAFT,7740890,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,19300.00000,5597.00000,Aetna,First Health,,15787.40,,,,,,,6957.65,15787.40,percent of total billed charges,
GRAFT,7740890,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,19300.00000,5597.00000,Aetna,First Health,,15787.40,,,,,,,6214.60,15787.40,percent of total billed charges,
MESH,7740891,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,7953.00000,2306.37000,Aetna,First Health,,6505.55,,,,,,,2867.06,6505.55,percent of total billed charges,
MESH,7740891,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,7953.00000,2306.37000,Aetna,First Health,,6505.55,,,,,,,2560.87,6505.55,percent of total billed charges,
LINER,7698929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7698929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
COMPONENT FEMORAL,7697893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7838.67,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7697893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7001.53,17786.49,percent of total billed charges,
LINER,7699732,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2556.80000,741.47000,Aetna,First Health,,2091.46,,,,,,,921.73,2091.46,percent of total billed charges,
LINER,7699732,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2556.80000,741.47000,Aetna,First Health,,2091.46,,,,,,,823.29,2091.46,percent of total billed charges,
INSERT,7741340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
INSERT,7741340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
PORT,7741436,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,713.79,1619.64,percent of total billed charges,
PORT,7741436,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,637.56,1619.64,percent of total billed charges,
STENT,7695008,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695008,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
VALVE,7894156,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
VALVE,7894156,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
PLATE,7741661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4903.50000,1422.02000,Aetna,First Health,,4011.06,,,,,,,1767.71,4011.06,percent of total billed charges,
PLATE,7741661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4903.50000,1422.02000,Aetna,First Health,,4011.06,,,,,,,1578.93,4011.06,percent of total billed charges,
ANCHOR,7741657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,665.84,1510.85,percent of total billed charges,
ANCHOR,7741657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,594.73,1510.85,percent of total billed charges,
FEMORAL HEAD,7741711,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
FEMORAL HEAD,7741711,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CONNECTOR,7741717,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR,7741717,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
ROD,7741721,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7741721,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
STEM,7741766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9083.55000,2634.23000,Aetna,First Health,,7430.34,,,,,,,3274.62,7430.34,percent of total billed charges,
STEM,7741766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9083.55000,2634.23000,Aetna,First Health,,7430.34,,,,,,,2924.90,7430.34,percent of total billed charges,
ANCHOR,7741811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2844.00000,824.76000,Aetna,First Health,,2326.39,,,,,,,1025.26,2326.39,percent of total billed charges,
ANCHOR,7741811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2844.00000,824.76000,Aetna,First Health,,2326.39,,,,,,,915.77,2326.39,percent of total billed charges,
MESH,7694313,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,6421.10000,1862.12000,Aetna,First Health,,5252.46,,,,,,,2314.81,5252.46,percent of total billed charges,
MESH,7694313,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,6421.10000,1862.12000,Aetna,First Health,,5252.46,,,,,,,2067.59,5252.46,percent of total billed charges,
STENT GRAFT,7949854,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7949854,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
MESH,7744659,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,849.81000,246.44000,Aetna,First Health,,695.14,,,,,,,306.36,695.14,percent of total billed charges,
MESH,7744659,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,849.81000,246.44000,Aetna,First Health,,695.14,,,,,,,273.64,695.14,percent of total billed charges,
COMPONENT FEMORAL,7748105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7748105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
BASEPLATE,7748107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7748107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
INSERT,7700175,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7700175,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
COMPONENT PATELLA,7748108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7748108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
STEM,7748745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7748745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7748824,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7748824,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
BALLOON,7695939,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7695939,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
AUGMENT FEMORAL,7750114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7750114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7750116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
AUGMENT FEMORAL,7750116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
WEDGE,7754164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5455.63000,1582.13000,Aetna,First Health,,4462.71,,,,,,,1966.75,4462.71,percent of total billed charges,
WEDGE,7754164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5455.63000,1582.13000,Aetna,First Health,,4462.71,,,,,,,1756.71,4462.71,percent of total billed charges,
BALLOON CATHETER,7694866,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,352.89,800.73,percent of total billed charges,
BALLOON CATHETER,7694866,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,315.20,800.73,percent of total billed charges,
BALLOON DILATOR,7695082,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1340.04000,388.61000,Aetna,First Health,,1096.15,,,,,,,483.08,1096.15,percent of total billed charges,
BALLOON DILATOR,7695082,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1340.04000,388.61000,Aetna,First Health,,1096.15,,,,,,,431.49,1096.15,percent of total billed charges,
PLATE,7754281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,608.52,1380.78,percent of total billed charges,
PLATE,7754281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,543.54,1380.78,percent of total billed charges,
KNEE IMPLANT,7754286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,9270.49,21035.40,percent of total billed charges,
KNEE IMPLANT,7754286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,8280.44,21035.40,percent of total billed charges,
GUIDEWIRE,7695158,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,515.04000,149.36000,Aetna,First Health,,421.30,,,,,,,185.67,421.30,percent of total billed charges,
GUIDEWIRE,7695158,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,515.04000,149.36000,Aetna,First Health,,421.30,,,,,,,165.84,421.30,percent of total billed charges,
GUIDEWIRE,7694357,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,219.00,496.94,percent of total billed charges,
GUIDEWIRE,7694357,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,195.62,496.94,percent of total billed charges,
CONNECTOR,7756253,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR,7756253,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CONNECTOR,7756256,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR,7756256,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
HOOK,7756279,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756279,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
SCREW,7756295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
PLATE,7756710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8271.03000,2398.60000,Aetna,First Health,,6765.70,,,,,,,2981.71,6765.70,percent of total billed charges,
PLATE,7756710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8271.03000,2398.60000,Aetna,First Health,,6765.70,,,,,,,2663.27,6765.70,percent of total billed charges,
PLATE,7756732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1765.24000,511.92000,Aetna,First Health,,1443.97,,,,,,,636.37,1443.97,percent of total billed charges,
PLATE,7756732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1765.24000,511.92000,Aetna,First Health,,1443.97,,,,,,,568.41,1443.97,percent of total billed charges,
CATHETER GUIDE,7695005,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
CATHETER GUIDE,7695005,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
CABLE PIN,7703360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,First Health,,1201.64,,,,,,,529.57,1201.64,percent of total billed charges,
CABLE PIN,7703360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,First Health,,1201.64,,,,,,,473.02,1201.64,percent of total billed charges,
STENT,7758256,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8587.38000,2490.34000,Aetna,First Health,,7024.48,,,,,,,3095.75,7024.48,percent of total billed charges,
STENT,7758256,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8587.38000,2490.34000,Aetna,First Health,,7024.48,,,,,,,2765.14,7024.48,percent of total billed charges,
STENT,7695157,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8882.13000,2575.82000,Aetna,First Health,,7265.58,,,,,,,3202.01,7265.58,percent of total billed charges,
STENT,7695157,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8882.13000,2575.82000,Aetna,First Health,,7265.58,,,,,,,2860.05,7265.58,percent of total billed charges,
STENT,7695029,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,3356.09,7615.20,percent of total billed charges,
STENT,7695029,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,2997.67,7615.20,percent of total billed charges,
STENT,7695218,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9262.38000,2686.09000,Aetna,First Health,,7576.63,,,,,,,3339.09,7576.63,percent of total billed charges,
STENT,7695218,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9262.38000,2686.09000,Aetna,First Health,,7576.63,,,,,,,2982.49,7576.63,percent of total billed charges,
CATHETER BALLOON,7760042,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,876.74,1989.38,percent of total billed charges,
CATHETER BALLOON,7760042,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,783.10,1989.38,percent of total billed charges,
ANCHOR,7760078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,817.25,1854.41,percent of total billed charges,
ANCHOR,7760078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,729.97,1854.41,percent of total billed charges,
LINER,7760073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
LINER,7760073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
MESH,7760126,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,3001.16,6809.85,percent of total billed charges,
MESH,7760126,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,2680.65,6809.85,percent of total billed charges,
LEAD,7699221,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LEAD,7699221,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
PIN,7736447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6209.00000,1800.61000,Aetna,First Health,,5078.96,,,,,,,2238.34,5078.96,percent of total billed charges,
PIN,7736447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6209.00000,1800.61000,Aetna,First Health,,5078.96,,,,,,,1999.30,5078.96,percent of total billed charges,
SHELL,7698324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
SHELL,7698324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CARTILAGE,7762377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
CARTILAGE,7762377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
COMPONENT FEMORAL,7699292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10758.00000,3119.82000,Aetna,First Health,,8800.04,,,,,,,3878.26,8800.04,percent of total billed charges,
COMPONENT FEMORAL,7699292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10758.00000,3119.82000,Aetna,First Health,,8800.04,,,,,,,3464.08,8800.04,percent of total billed charges,
STEM,7762382,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4812.68,10920.30,percent of total billed charges,
STEM,7762382,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4298.70,10920.30,percent of total billed charges,
BALLOON CATHETER,7702169,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,10635.00000,3084.15000,Aetna,First Health,,8699.43,,,,,,,3833.92,8699.43,percent of total billed charges,
BALLOON CATHETER,7702169,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,10635.00000,3084.15000,Aetna,First Health,,8699.43,,,,,,,3424.47,8699.43,percent of total billed charges,
GENERATOR,7736624,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,31072.50000,9011.02000,Aetna,First Health,,25417.31,,,,,,,11201.64,25417.31,percent of total billed charges,
GENERATOR,7736624,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,31072.50000,9011.02000,Aetna,First Health,,25417.31,,,,,,,10005.34,25417.31,percent of total billed charges,
GRIP CABLE,7695958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2892.00000,838.68000,Aetna,First Health,,2365.66,,,,,,,1042.57,2365.66,percent of total billed charges,
GRIP CABLE,7695958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2892.00000,838.68000,Aetna,First Health,,2365.66,,,,,,,931.22,2365.66,percent of total billed charges,
SHOULDER REPLACE,7764046,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
SHOULDER REPLACE,7764046,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
GRAFT,7764096,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
GRAFT,7764096,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
CONNECTOR SPINAL,7695284,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1124.76,2552.16,percent of total billed charges,
CONNECTOR SPINAL,7695284,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1004.64,2552.16,percent of total billed charges,
CATHETER,7696401,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,3869.78000,1122.24000,Aetna,First Health,,3165.48,,,,,,,1395.06,3165.48,percent of total billed charges,
CATHETER,7696401,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,3869.78000,1122.24000,Aetna,First Health,,3165.48,,,,,,,1246.07,3165.48,percent of total billed charges,
STENT,7695019,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,308.23000,89.39000,Aetna,First Health,,252.13,,,,,,,111.12,252.13,percent of total billed charges,
STENT,7695019,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,308.23000,89.39000,Aetna,First Health,,252.13,,,,,,,99.25,252.13,percent of total billed charges,
LEAD,7768152,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,8844.00000,2564.76000,Aetna,First Health,,7234.39,,,,,,,3188.26,7234.39,percent of total billed charges,
LEAD,7768152,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,8844.00000,2564.76000,Aetna,First Health,,7234.39,,,,,,,2847.77,7234.39,percent of total billed charges,
NEUROSTIMULATOR,7768154,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,63790.00000,18499.10000,Aetna,First Health,,52180.22,,,,,,,22996.29,52180.22,percent of total billed charges,
NEUROSTIMULATOR,7768154,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,63790.00000,18499.10000,Aetna,First Health,,52180.22,,,,,,,20540.38,52180.22,percent of total billed charges,
COMPONENT ULNAR,7770032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
COMPONENT ULNAR,7770032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
ARTICULATION KIT,7770033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
ARTICULATION KIT,7770033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE GRAFT DURAL,7695897,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,1785.36000,517.75000,Aetna,First Health,,1460.42,,,,,,,643.62,1460.42,percent of total billed charges,
TISSUE GRAFT DURAL,7695897,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,1785.36000,517.75000,Aetna,First Health,,1460.42,,,,,,,574.89,1460.42,percent of total billed charges,
GUIDEWIRE,7695680,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1583.20000,459.13000,Aetna,First Health,,1295.06,,,,,,,570.74,1295.06,percent of total billed charges,
GUIDEWIRE,7695680,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1583.20000,459.13000,Aetna,First Health,,1295.06,,,,,,,509.79,1295.06,percent of total billed charges,
PLATE,7772037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1482.80000,430.01000,Aetna,First Health,,1212.93,,,,,,,534.55,1212.93,percent of total billed charges,
PLATE,7772037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1482.80000,430.01000,Aetna,First Health,,1212.93,,,,,,,477.46,1212.93,percent of total billed charges,
PLATE,7772041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1469.60000,426.18000,Aetna,First Health,,1202.13,,,,,,,529.79,1202.13,percent of total billed charges,
PLATE,7772041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1469.60000,426.18000,Aetna,First Health,,1202.13,,,,,,,473.21,1202.13,percent of total billed charges,
PLATE,7772042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1839.20000,533.37000,Aetna,First Health,,1504.47,,,,,,,663.03,1504.47,percent of total billed charges,
PLATE,7772042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1839.20000,533.37000,Aetna,First Health,,1504.47,,,,,,,592.22,1504.47,percent of total billed charges,
SCREW,7772049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,300.28,681.35,percent of total billed charges,
SCREW,7772049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,268.21,681.35,percent of total billed charges,
PLATE,7772062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.40000,422.36000,Aetna,First Health,,1191.34,,,,,,,525.03,1191.34,percent of total billed charges,
PLATE,7772062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.40000,422.36000,Aetna,First Health,,1191.34,,,,,,,468.96,1191.34,percent of total billed charges,
END CAP,7695875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,708.48000,205.46000,Aetna,First Health,,579.54,,,,,,,255.41,579.54,percent of total billed charges,
END CAP,7695875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,708.48000,205.46000,Aetna,First Health,,579.54,,,,,,,228.13,579.54,percent of total billed charges,
STEM,7774085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2741.60,6220.89,percent of total billed charges,
STEM,7774085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2448.81,6220.89,percent of total billed charges,
PLATE,7774102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,7774102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
MESH,7774227,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,10853.10000,3147.40000,Aetna,First Health,,8877.84,,,,,,,3912.54,8877.84,percent of total billed charges,
MESH,7774227,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,10853.10000,3147.40000,Aetna,First Health,,8877.84,,,,,,,3494.70,8877.84,percent of total billed charges,
PLATE,7774228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.70000,2383.71000,Aetna,First Health,,6723.71,,,,,,,2963.20,6723.71,percent of total billed charges,
PLATE,7774228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.70000,2383.71000,Aetna,First Health,,6723.71,,,,,,,2646.74,6723.71,percent of total billed charges,
CATHETER,7697051,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1484.00000,430.36000,Aetna,First Health,,1213.91,,,,,,,534.98,1213.91,percent of total billed charges,
CATHETER,7697051,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1484.00000,430.36000,Aetna,First Health,,1213.91,,,,,,,477.85,1213.91,percent of total billed charges,
SCREW,7774233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7774233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SHEATH,7930141,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,838.31000,243.11000,Aetna,First Health,,685.74,,,,,,,302.21,685.74,percent of total billed charges,
SHEATH,7930141,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,838.31000,243.11000,Aetna,First Health,,685.74,,,,,,,269.94,685.74,percent of total billed charges,
TRIAL TIBIAL TRAY,7696303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,450.30000,130.59000,Aetna,First Health,,368.35,,,,,,,162.33,368.35,percent of total billed charges,
TRIAL TIBIAL TRAY,7696303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,450.30000,130.59000,Aetna,First Health,,368.35,,,,,,,145.00,368.35,percent of total billed charges,
NUT,7696874,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,658.40000,190.94000,Aetna,First Health,,538.57,,,,,,,237.35,538.57,percent of total billed charges,
NUT,7696874,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,658.40000,190.94000,Aetna,First Health,,538.57,,,,,,,212.00,538.57,percent of total billed charges,
FEMORAL HEAD,7776326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD,7776326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
INTRODUCER,7742027,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
INTRODUCER,7742027,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
BALLOON,7760046,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1952.80000,566.31000,Aetna,First Health,,1597.39,,,,,,,703.98,1597.39,percent of total billed charges,
BALLOON,7760046,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1952.80000,566.31000,Aetna,First Health,,1597.39,,,,,,,628.80,1597.39,percent of total billed charges,
BALLOON,7760047,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1642.80000,476.41000,Aetna,First Health,,1343.81,,,,,,,592.23,1343.81,percent of total billed charges,
BALLOON,7760047,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1642.80000,476.41000,Aetna,First Health,,1343.81,,,,,,,528.98,1343.81,percent of total billed charges,
IMPLANT HAND WRIST,7698732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3670.38000,1064.41000,Aetna,First Health,,3002.37,,,,,,,1323.17,3002.37,percent of total billed charges,
IMPLANT HAND WRIST,7698732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3670.38000,1064.41000,Aetna,First Health,,3002.37,,,,,,,1181.86,3002.37,percent of total billed charges,
INTRODUCER,7694292,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,335.35000,97.25000,Aetna,First Health,,274.32,,,,,,,120.89,274.32,percent of total billed charges,
INTRODUCER,7694292,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,335.35000,97.25000,Aetna,First Health,,274.32,,,,,,,107.98,274.32,percent of total billed charges,
LINER,7700227,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,957.20000,277.59000,Aetna,First Health,,782.99,,,,,,,345.07,782.99,percent of total billed charges,
LINER,7700227,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,957.20000,277.59000,Aetna,First Health,,782.99,,,,,,,308.22,782.99,percent of total billed charges,
PLATE,7780090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5987.98000,1736.51000,Aetna,First Health,,4898.17,,,,,,,2158.67,4898.17,percent of total billed charges,
PLATE,7780090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5987.98000,1736.51000,Aetna,First Health,,4898.17,,,,,,,1928.13,4898.17,percent of total billed charges,
GRAFT EXTENSION,7782099,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
GRAFT EXTENSION,7782099,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
NAIL,7695446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,714.57,1621.41,percent of total billed charges,
NAIL,7695446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,638.26,1621.41,percent of total billed charges,
NAIL,7700597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3746.12000,1086.37000,Aetna,First Health,,3064.33,,,,,,,1350.48,3064.33,percent of total billed charges,
NAIL,7700597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3746.12000,1086.37000,Aetna,First Health,,3064.33,,,,,,,1206.25,3064.33,percent of total billed charges,
NAIL,7699983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,700.74,1590.03,percent of total billed charges,
NAIL,7699983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,625.90,1590.03,percent of total billed charges,
NAIL,7702206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2056.68000,596.44000,Aetna,First Health,,1682.36,,,,,,,741.43,1682.36,percent of total billed charges,
NAIL,7702206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2056.68000,596.44000,Aetna,First Health,,1682.36,,,,,,,662.25,1682.36,percent of total billed charges,
BONE CHIPS,7784067,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,1755.16000,509.00000,Aetna,First Health,,1435.72,,,,,,,632.74,1435.72,percent of total billed charges,
BONE CHIPS,7784067,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,1755.16000,509.00000,Aetna,First Health,,1435.72,,,,,,,565.16,1435.72,percent of total billed charges,
FEMORAL ADAPTER,7697892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9226.20000,2675.60000,Aetna,First Health,,7547.03,,,,,,,3326.05,7547.03,percent of total billed charges,
FEMORAL ADAPTER,7697892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9226.20000,2675.60000,Aetna,First Health,,7547.03,,,,,,,2970.84,7547.03,percent of total billed charges,
PLATE,7784276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,7784276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
TENDON,7784280,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7793.25000,2260.04000,Aetna,First Health,,6374.88,,,,,,,2809.47,6374.88,percent of total billed charges,
TENDON,7784280,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7793.25000,2260.04000,Aetna,First Health,,6374.88,,,,,,,2509.43,6374.88,percent of total billed charges,
NAIL,7695501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,757.22,1718.19,percent of total billed charges,
NAIL,7695501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,676.35,1718.19,percent of total billed charges,
GRAFT EXTENSION,7786143,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,First Health,,9936.25,,,,,,,4378.99,9936.25,percent of total billed charges,
GRAFT EXTENSION,7786143,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,First Health,,9936.25,,,,,,,3911.33,9936.25,percent of total billed charges,
INSERT,7698415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7698415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STEM,7786154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
STEM,7786154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
SPINAL IMPLANT,7695280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,793.10,1799.60,percent of total billed charges,
SPINAL IMPLANT,7695280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,708.40,1799.60,percent of total billed charges,
GRAFT,7947886,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
GRAFT,7947886,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
COMPONENT FEMORAL,7790171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7790171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
STEM,7790231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,First Health,,10720.37,,,,,,,4724.57,10720.37,percent of total billed charges,
STEM,7790231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,First Health,,10720.37,,,,,,,4220.00,10720.37,percent of total billed charges,
SCREW,7790234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,7790234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
ROD,7790237,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD,7790237,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PENILE IMPLANT,7790243,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,26475.00000,7677.75000,Aetna,First Health,,21656.55,,,,,,,9544.24,21656.55,percent of total billed charges,
PENILE IMPLANT,7790243,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,26475.00000,7677.75000,Aetna,First Health,,21656.55,,,,,,,8524.95,21656.55,percent of total billed charges,
COMPONENT FEMORAL,7794030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7794030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
LINER,7794031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7794031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7794033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7794033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
COMPONENT FEMORAL,7794035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7794035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
STENT GRAFT,7700077,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
STENT GRAFT,7700077,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
TOTAL KNEE,7794300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
TOTAL KNEE,7794300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT FEMORAL,7794405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7794405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
BASEPLATE,7794406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7794406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT PATELLA,7794407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
COMPONENT PATELLA,7794407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
INSERT,7794410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7794410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
GUIDEWIRE,7794448,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,290.06,658.16,percent of total billed charges,
GUIDEWIRE,7794448,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,259.08,658.16,percent of total billed charges,
STEM,7794452,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STEM,7794452,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
GRAFT,7794453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16192.50000,4695.82000,Aetna,First Health,,13245.47,,,,,,,5837.40,13245.47,percent of total billed charges,
GRAFT,7794453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16192.50000,4695.82000,Aetna,First Health,,13245.47,,,,,,,5213.98,13245.47,percent of total billed charges,
COMPONENT FEMORAL,7794487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,7794487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
INSERT,7699908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2956.98,6709.60,percent of total billed charges,
INSERT,7699908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2641.19,6709.60,percent of total billed charges,
COMPONENT FEMORAL,7800037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7800037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
BONE GRAFT,7802038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
BONE GRAFT,7802038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
SHELL,7802040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7802040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
FEMORAL IMPLANT,7802046,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9201.00000,2668.29000,Aetna,First Health,,7526.42,,,,,,,3316.96,7526.42,percent of total billed charges,
FEMORAL IMPLANT,7802046,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9201.00000,2668.29000,Aetna,First Health,,7526.42,,,,,,,2962.72,7526.42,percent of total billed charges,
COMPONENT FEMORAL,7802119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20923.00000,6067.67000,Aetna,First Health,,17115.01,,,,,,,7542.74,17115.01,percent of total billed charges,
COMPONENT FEMORAL,7802119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20923.00000,6067.67000,Aetna,First Health,,17115.01,,,,,,,6737.21,17115.01,percent of total billed charges,
LINER,7802063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7802063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
GUIDEWIRE,7736555,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,7736555,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
PENILE RESERVOIR,7802100,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,12540.00000,3636.60000,Aetna,First Health,,10257.72,,,,,,,4520.67,10257.72,percent of total billed charges,
PENILE RESERVOIR,7802100,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,12540.00000,3636.60000,Aetna,First Health,,10257.72,,,,,,,4037.88,10257.72,percent of total billed charges,
SCREW,7696569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,755.10000,218.98000,Aetna,First Health,,617.67,,,,,,,272.21,617.67,percent of total billed charges,
SCREW,7696569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,755.10000,218.98000,Aetna,First Health,,617.67,,,,,,,243.14,617.67,percent of total billed charges,
NAIL CAP,7802054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1672.00000,484.88000,Aetna,First Health,,1367.70,,,,,,,602.76,1367.70,percent of total billed charges,
NAIL CAP,7802054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1672.00000,484.88000,Aetna,First Health,,1367.70,,,,,,,538.38,1367.70,percent of total billed charges,
STEM,7802069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,7802069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
STEM CENTRALIZER,7802071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
STEM CENTRALIZER,7802071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
STEM,7802082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7802082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
LINER,7802085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,7802085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
INSERT,7802086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
INSERT,7802086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CATHETER BALLOON,7858076,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858076,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858077,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858077,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858078,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858078,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858079,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858079,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858081,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858081,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858083,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858083,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858084,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858084,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858085,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858085,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858089,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858089,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858090,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858090,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858091,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858091,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858094,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858094,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858095,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858095,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858096,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858096,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858097,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858097,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858101,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858101,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858102,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858102,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858103,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858103,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858106,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858106,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858108,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858108,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858111,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858111,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7858114,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7858114,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7939375,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7939375,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7948916,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7948916,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7964533,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7964533,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
GUIDEWIRE,7695840,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,398.86000,115.67000,Aetna,First Health,,326.27,,,,,,,143.79,326.27,percent of total billed charges,
GUIDEWIRE,7695840,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,398.86000,115.67000,Aetna,First Health,,326.27,,,,,,,128.43,326.27,percent of total billed charges,
GUIDEWIRE,7696565,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,887.94000,257.50000,Aetna,First Health,,726.33,,,,,,,320.10,726.33,percent of total billed charges,
GUIDEWIRE,7696565,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,887.94000,257.50000,Aetna,First Health,,726.33,,,,,,,285.92,726.33,percent of total billed charges,
GUIDEWIRE,7697400,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,887.94000,257.50000,Aetna,First Health,,726.33,,,,,,,320.10,726.33,percent of total billed charges,
GUIDEWIRE,7697400,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,887.94000,257.50000,Aetna,First Health,,726.33,,,,,,,285.92,726.33,percent of total billed charges,
GUIDEWIRE,7697591,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,382.57000,110.95000,Aetna,First Health,,312.94,,,,,,,137.92,312.94,percent of total billed charges,
GUIDEWIRE,7697591,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,382.57000,110.95000,Aetna,First Health,,312.94,,,,,,,123.19,312.94,percent of total billed charges,
GUIDEWIRE,7956953,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
GUIDEWIRE,7956953,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,7697992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7697992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,7697993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7697993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
X STOP,7696575,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,14461.20000,4193.75000,Aetna,First Health,,11829.26,,,,,,,5213.26,11829.26,percent of total billed charges,
X STOP,7696575,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,14461.20000,4193.75000,Aetna,First Health,,11829.26,,,,,,,4656.51,11829.26,percent of total billed charges,
X STOP,7696964,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,14461.20000,4193.75000,Aetna,First Health,,11829.26,,,,,,,5213.26,11829.26,percent of total billed charges,
X STOP,7696964,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,14461.20000,4193.75000,Aetna,First Health,,11829.26,,,,,,,4656.51,11829.26,percent of total billed charges,
GRAFT,7697594,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697594,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697595,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697595,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697596,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697596,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697597,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697597,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697598,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697598,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697599,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697599,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697600,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697600,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697601,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697601,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697602,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697602,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697603,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697603,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697604,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697604,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697605,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697605,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697606,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697606,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697607,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697607,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697608,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697608,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697609,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697609,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697610,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697610,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
GRAFT,7697611,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT,7697611,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
PEG,7696652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
PEG,7696652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
PEG,7697144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
PEG,7697144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
PEG,7697148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
PEG,7697148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
PEG,7697156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
PEG,7697156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
PEG,7697464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
PEG,7697464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
PEG,7699181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
PEG,7699181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
ACETABULAR CUP,7696669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1722.29,3907.99,percent of total billed charges,
ACETABULAR CUP,7696669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1538.36,3907.99,percent of total billed charges,
ACETABULAR CUP,7696670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1722.29,3907.99,percent of total billed charges,
ACETABULAR CUP,7696670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1538.36,3907.99,percent of total billed charges,
ACETABULAR CUP,7696671,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1722.29,3907.99,percent of total billed charges,
ACETABULAR CUP,7696671,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1538.36,3907.99,percent of total billed charges,
ACETABULAR CUP,7696672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1722.29,3907.99,percent of total billed charges,
ACETABULAR CUP,7696672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1538.36,3907.99,percent of total billed charges,
ACETABULAR CUP,7882520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1722.29,3907.99,percent of total billed charges,
ACETABULAR CUP,7882520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1538.36,3907.99,percent of total billed charges,
ACL TIGHTROPE,7697143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
ACL TIGHTROPE,7697143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7696810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7696810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7697152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7697152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7697254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7697254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7697401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7697401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7697402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7697402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7697505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7697505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7698247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7698247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7698248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7698248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7698425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7698425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7698503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7698503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7698953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7698953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7699110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7699110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7699111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7699111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7700030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7700030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7700114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7700114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7700197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7700197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7700198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7700198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7700810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7700810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7707457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7707457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7707458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7707458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7736078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7736078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7736660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7736660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7736680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2671.30,6061.38,percent of total billed charges,
SCREW,7736680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,First Health,,6061.38,,,,,,,2386.02,6061.38,percent of total billed charges,
SCREW,7740892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7740892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7772161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7772161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7880453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7880453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7965925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7965925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7965926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7965926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7965927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7965927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
BALLOON,7696149,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1592.00000,461.68000,Aetna,First Health,,1302.26,,,,,,,573.92,1302.26,percent of total billed charges,
BALLOON,7696149,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1592.00000,461.68000,Aetna,First Health,,1302.26,,,,,,,512.62,1302.26,percent of total billed charges,
BALLOON,7696245,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1592.00000,461.68000,Aetna,First Health,,1302.26,,,,,,,573.92,1302.26,percent of total billed charges,
BALLOON,7696245,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1592.00000,461.68000,Aetna,First Health,,1302.26,,,,,,,512.62,1302.26,percent of total billed charges,
SCREW,7925801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SCREW,7925801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
SCREW,7925802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SCREW,7925802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
SCREW,7937875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7937875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7695815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7695815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7695816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7695816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7696599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,164.39,373.01,percent of total billed charges,
SCREW,7696599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,146.83,373.01,percent of total billed charges,
SCREW,7696600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,164.39,373.01,percent of total billed charges,
SCREW,7696600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,146.83,373.01,percent of total billed charges,
SCREW,7696728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7696728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7696729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7696729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7696730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7696730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7696896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7696896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7696902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7696902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7696903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7696903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7696904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7696904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7697484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7697484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7697485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7697485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7697512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7697512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7697513,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7697513,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7697516,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7697516,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7698114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,821.48000,238.23000,Aetna,First Health,,671.97,,,,,,,296.14,671.97,percent of total billed charges,
SCREW,7698114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,821.48000,238.23000,Aetna,First Health,,671.97,,,,,,,264.52,671.97,percent of total billed charges,
SCREW,7698115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,821.48000,238.23000,Aetna,First Health,,671.97,,,,,,,296.14,671.97,percent of total billed charges,
SCREW,7698115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,821.48000,238.23000,Aetna,First Health,,671.97,,,,,,,264.52,671.97,percent of total billed charges,
SCREW,7698367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7698367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7698368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7698368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7698369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7698369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7698370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7698370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7698371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7698371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7698542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7698542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7698543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7698543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7698563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7698563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7698564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7698564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7698760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7698760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7698847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,637.79000,184.96000,Aetna,First Health,,521.71,,,,,,,229.92,521.71,percent of total billed charges,
SCREW,7698847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,637.79000,184.96000,Aetna,First Health,,521.71,,,,,,,205.37,521.71,percent of total billed charges,
SCREW,7698891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7698891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7698892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7698892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7698893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7698893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7698894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7698894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7698895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7698895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7698896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7698896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7699503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7699503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7699504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7699504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7699538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7699538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7699539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7699539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7699642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,47.83,108.52,percent of total billed charges,
SCREW,7699642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,42.72,108.52,percent of total billed charges,
SCREW,7699643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,47.83,108.52,percent of total billed charges,
SCREW,7699643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,42.72,108.52,percent of total billed charges,
SCREW,7699661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7699661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7699662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7699662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7699664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7699664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7699665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7699665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7699666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7699666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7699667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7699667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7699668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7699668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7699716,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7699716,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,7699724,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7699724,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7699874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,300.28,681.35,percent of total billed charges,
SCREW,7699874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,268.21,681.35,percent of total billed charges,
SCREW,7699991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7699991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7700024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7700024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,7700099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7700099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7700100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7700100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7700101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7700101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7700135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7700135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7700136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7700136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7700311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7700311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7700478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7700478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,7700479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7700479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,7700480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7700480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,7700481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7700481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,7700521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7700521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7700654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7700654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7700757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7700757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7700939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7700939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7700940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7700940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7700941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7700941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7700942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7700942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7700943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7700943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7700967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7700967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7701220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,164.39,373.01,percent of total billed charges,
SCREW,7701220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,146.83,373.01,percent of total billed charges,
SCREW,7701221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,164.39,373.01,percent of total billed charges,
SCREW,7701221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,146.83,373.01,percent of total billed charges,
SCREW,7701497,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,77.60,176.07,percent of total billed charges,
SCREW,7701497,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,69.31,176.07,percent of total billed charges,
SCREW,7701566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.09000,110.81000,Aetna,First Health,,312.55,,,,,,,137.74,312.55,percent of total billed charges,
SCREW,7701566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.09000,110.81000,Aetna,First Health,,312.55,,,,,,,123.03,312.55,percent of total billed charges,
SCREW,7701567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.09000,110.81000,Aetna,First Health,,312.55,,,,,,,137.74,312.55,percent of total billed charges,
SCREW,7701567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.09000,110.81000,Aetna,First Health,,312.55,,,,,,,123.03,312.55,percent of total billed charges,
SCREW,7701568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.09000,110.81000,Aetna,First Health,,312.55,,,,,,,137.74,312.55,percent of total billed charges,
SCREW,7701568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.09000,110.81000,Aetna,First Health,,312.55,,,,,,,123.03,312.55,percent of total billed charges,
SCREW,7701569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.09000,110.81000,Aetna,First Health,,312.55,,,,,,,137.74,312.55,percent of total billed charges,
SCREW,7701569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.09000,110.81000,Aetna,First Health,,312.55,,,,,,,123.03,312.55,percent of total billed charges,
SCREW,7701570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.09000,110.81000,Aetna,First Health,,312.55,,,,,,,137.74,312.55,percent of total billed charges,
SCREW,7701570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.09000,110.81000,Aetna,First Health,,312.55,,,,,,,123.03,312.55,percent of total billed charges,
SCREW,7701571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7701571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,9088201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,9088201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7701572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,7701572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,7701598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7701598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7701659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7701659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7701688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7701688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7702075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7702075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7702307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,108.03,245.14,percent of total billed charges,
SCREW,7702307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,96.50,245.14,percent of total billed charges,
SCREW,7702308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,108.03,245.14,percent of total billed charges,
SCREW,7702308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,96.50,245.14,percent of total billed charges,
SCREW,7702309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,108.03,245.14,percent of total billed charges,
SCREW,7702309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,96.50,245.14,percent of total billed charges,
SCREW,7702310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,108.03,245.14,percent of total billed charges,
SCREW,7702310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,96.50,245.14,percent of total billed charges,
SCREW,7702311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,108.03,245.14,percent of total billed charges,
SCREW,7702311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,96.50,245.14,percent of total billed charges,
SCREW,7702312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,108.03,245.14,percent of total billed charges,
SCREW,7702312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,96.50,245.14,percent of total billed charges,
SCREW,7702313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,108.03,245.14,percent of total billed charges,
SCREW,7702313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,First Health,,245.14,,,,,,,96.50,245.14,percent of total billed charges,
SCREW,7702321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,508.16000,147.37000,Aetna,First Health,,415.67,,,,,,,183.19,415.67,percent of total billed charges,
SCREW,7702321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,508.16000,147.37000,Aetna,First Health,,415.67,,,,,,,163.63,415.67,percent of total billed charges,
SCREW,7702322,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,508.16000,147.37000,Aetna,First Health,,415.67,,,,,,,183.19,415.67,percent of total billed charges,
SCREW,7702322,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,508.16000,147.37000,Aetna,First Health,,415.67,,,,,,,163.63,415.67,percent of total billed charges,
SCREW,7702386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,209.27,474.85,percent of total billed charges,
SCREW,7702386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,186.92,474.85,percent of total billed charges,
SCREW,7702387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.05000,167.05000,Aetna,First Health,,471.21,,,,,,,207.67,471.21,percent of total billed charges,
SCREW,7702387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.05000,167.05000,Aetna,First Health,,471.21,,,,,,,185.49,471.21,percent of total billed charges,
SCREW,7702388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.05000,167.05000,Aetna,First Health,,471.21,,,,,,,207.67,471.21,percent of total billed charges,
SCREW,7702388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.05000,167.05000,Aetna,First Health,,471.21,,,,,,,185.49,471.21,percent of total billed charges,
SCREW,7702389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.05000,167.05000,Aetna,First Health,,471.21,,,,,,,207.67,471.21,percent of total billed charges,
SCREW,7702389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.05000,167.05000,Aetna,First Health,,471.21,,,,,,,185.49,471.21,percent of total billed charges,
SCREW,7702390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,209.27,474.85,percent of total billed charges,
SCREW,7702390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,186.92,474.85,percent of total billed charges,
SCREW,7702391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,209.27,474.85,percent of total billed charges,
SCREW,7702391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,186.92,474.85,percent of total billed charges,
SCREW,7702392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,209.27,474.85,percent of total billed charges,
SCREW,7702392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,186.92,474.85,percent of total billed charges,
SCREW,7707478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,7707478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,7707479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,7707479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,7707480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,7707480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,7707481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,7707481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,7707482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,7707482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,7736069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,47.83,108.52,percent of total billed charges,
SCREW,7736069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,42.72,108.52,percent of total billed charges,
SCREW,7736479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7736479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7736480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7736480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7736481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7736481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7736653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7736653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7772050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,767.61000,222.61000,Aetna,First Health,,627.90,,,,,,,276.72,627.90,percent of total billed charges,
SCREW,7772050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,767.61000,222.61000,Aetna,First Health,,627.90,,,,,,,247.17,627.90,percent of total billed charges,
SCREW,7772051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,300.28,681.35,percent of total billed charges,
SCREW,7772051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,268.21,681.35,percent of total billed charges,
SCREW,7784084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7784084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7802401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,605.25000,175.52000,Aetna,First Health,,495.09,,,,,,,218.19,495.09,percent of total billed charges,
SCREW,7802401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,605.25000,175.52000,Aetna,First Health,,495.09,,,,,,,194.89,495.09,percent of total billed charges,
SCREW,7870036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7870036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7880650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7880650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7880658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7880658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7882522,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7882522,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7894135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7894135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7935184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7935184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7935777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7935777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7935778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7935778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7938128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7938128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7938129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7938129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7938130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7938130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7938131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7938131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7939855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,7939855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,7965482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,948.02000,274.93000,Aetna,First Health,,775.48,,,,,,,341.76,775.48,percent of total billed charges,
SCREW,7965482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,948.02000,274.93000,Aetna,First Health,,775.48,,,,,,,305.26,775.48,percent of total billed charges,
SCREW,7703208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703242,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703242,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7703246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7703246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7935161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2062.40000,598.10000,Aetna,First Health,,1687.04,,,,,,,743.50,1687.04,percent of total billed charges,
SCREW,7935161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2062.40000,598.10000,Aetna,First Health,,1687.04,,,,,,,664.09,1687.04,percent of total billed charges,
SCREW,7935845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2062.40000,598.10000,Aetna,First Health,,1687.04,,,,,,,743.50,1687.04,percent of total billed charges,
SCREW,7935845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2062.40000,598.10000,Aetna,First Health,,1687.04,,,,,,,664.09,1687.04,percent of total billed charges,
SCREW,7939320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,122.78,278.59,percent of total billed charges,
SCREW,7939320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,109.67,278.59,percent of total billed charges,
PLATE,7698557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10578.00000,3067.62000,Aetna,First Health,,8652.80,,,,,,,3813.37,8652.80,percent of total billed charges,
PLATE,7698557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10578.00000,3067.62000,Aetna,First Health,,8652.80,,,,,,,3406.12,8652.80,percent of total billed charges,
PLATE,7699240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2816.00000,816.64000,Aetna,First Health,,2303.49,,,,,,,1015.17,2303.49,percent of total billed charges,
PLATE,7699240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2816.00000,816.64000,Aetna,First Health,,2303.49,,,,,,,906.75,2303.49,percent of total billed charges,
PLATE,7700148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2488.40000,721.64000,Aetna,First Health,,2035.51,,,,,,,897.07,2035.51,percent of total billed charges,
PLATE,7700148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2488.40000,721.64000,Aetna,First Health,,2035.51,,,,,,,801.26,2035.51,percent of total billed charges,
CATHETER,7695043,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7695043,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
CATHETER,7696304,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7696304,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
CATHETER,7696480,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7696480,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
CATHETER,7696692,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7696692,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
CATHETER,7700023,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7700023,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
CATHETER,7700573,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7700573,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
VASCULAR PATCH,7694877,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,First Health,,1600.01,,,,,,,705.14,1600.01,percent of total billed charges,
VASCULAR PATCH,7694877,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,First Health,,1600.01,,,,,,,629.83,1600.01,percent of total billed charges,
ROD,7802410,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD,7802410,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
COMPONENT PATELLA,7804043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4144.70000,1201.96000,Aetna,First Health,,3390.36,,,,,,,1494.16,3390.36,percent of total billed charges,
COMPONENT PATELLA,7804043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4144.70000,1201.96000,Aetna,First Health,,3390.36,,,,,,,1334.59,3390.36,percent of total billed charges,
COMPONENT FEMORAL,7804044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7804044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE,7804045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BASEPLATE,7804045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
SCREW,7698656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1639.29000,475.39000,Aetna,First Health,,1340.94,,,,,,,590.96,1340.94,percent of total billed charges,
SCREW,7698656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1639.29000,475.39000,Aetna,First Health,,1340.94,,,,,,,527.85,1340.94,percent of total billed charges,
STEM,7770031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
STEM,7770031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
INSERT,7698868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4599.00000,1333.71000,Aetna,First Health,,3761.98,,,,,,,1657.94,3761.98,percent of total billed charges,
INSERT,7698868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4599.00000,1333.71000,Aetna,First Health,,3761.98,,,,,,,1480.88,3761.98,percent of total billed charges,
INSERT,7699344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3213.00000,931.77000,Aetna,First Health,,2628.23,,,,,,,1158.29,2628.23,percent of total billed charges,
INSERT,7699344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3213.00000,931.77000,Aetna,First Health,,2628.23,,,,,,,1034.59,2628.23,percent of total billed charges,
BASEPLATE,7699347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8265.00000,2396.85000,Aetna,First Health,,6760.77,,,,,,,2979.53,6760.77,percent of total billed charges,
BASEPLATE,7699347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8265.00000,2396.85000,Aetna,First Health,,6760.77,,,,,,,2661.33,6760.77,percent of total billed charges,
SLEEVE,7697895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12638.40000,3665.14000,Aetna,First Health,,10338.21,,,,,,,4556.14,10338.21,percent of total billed charges,
SLEEVE,7697895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12638.40000,3665.14000,Aetna,First Health,,10338.21,,,,,,,4069.56,10338.21,percent of total billed charges,
SLEEVE,7760136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,8029.01,18218.40,percent of total billed charges,
SLEEVE,7760136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,7171.55,18218.40,percent of total billed charges,
SLEEVE,7760138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2893.01,6564.45,percent of total billed charges,
SLEEVE,7760138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2584.05,6564.45,percent of total billed charges,
SLEEVE,7699346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1684.00000,488.36000,Aetna,First Health,,1377.51,,,,,,,607.08,1377.51,percent of total billed charges,
SLEEVE,7699346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1684.00000,488.36000,Aetna,First Health,,1377.51,,,,,,,542.25,1377.51,percent of total billed charges,
SHELL,7697957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7872.75000,2283.10000,Aetna,First Health,,6439.91,,,,,,,2838.13,6439.91,percent of total billed charges,
SHELL,7697957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7872.75000,2283.10000,Aetna,First Health,,6439.91,,,,,,,2535.03,6439.91,percent of total billed charges,
SHELL,7699091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7516.80000,2179.87000,Aetna,First Health,,6148.74,,,,,,,2709.81,6148.74,percent of total billed charges,
SHELL,7699091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7516.80000,2179.87000,Aetna,First Health,,6148.74,,,,,,,2420.41,6148.74,percent of total billed charges,
PLATE,7702978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,684.00000,198.36000,Aetna,First Health,,559.51,,,,,,,246.58,559.51,percent of total billed charges,
PLATE,7702978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,684.00000,198.36000,Aetna,First Health,,559.51,,,,,,,220.25,559.51,percent of total billed charges,
PLATE,7696426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,596.48000,172.98000,Aetna,First Health,,487.92,,,,,,,215.03,487.92,percent of total billed charges,
PLATE,7696426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,596.48000,172.98000,Aetna,First Health,,487.92,,,,,,,192.07,487.92,percent of total billed charges,
PLATE,7695869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1433.16000,415.62000,Aetna,First Health,,1172.32,,,,,,,516.65,1172.32,percent of total billed charges,
PLATE,7695869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1433.16000,415.62000,Aetna,First Health,,1172.32,,,,,,,461.48,1172.32,percent of total billed charges,
PLATE,7696435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.36000,365.50000,Aetna,First Health,,1030.97,,,,,,,454.36,1030.97,percent of total billed charges,
PLATE,7696435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.36000,365.50000,Aetna,First Health,,1030.97,,,,,,,405.84,1030.97,percent of total billed charges,
PLATE,7697580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9100.20000,2639.06000,Aetna,First Health,,7443.96,,,,,,,3280.62,7443.96,percent of total billed charges,
PLATE,7697580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9100.20000,2639.06000,Aetna,First Health,,7443.96,,,,,,,2930.26,7443.96,percent of total billed charges,
SPACER,7694905,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13324.62000,3864.14000,Aetna,First Health,,10899.54,,,,,,,4803.53,10899.54,percent of total billed charges,
SPACER,7694905,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13324.62000,3864.14000,Aetna,First Health,,10899.54,,,,,,,4290.53,10899.54,percent of total billed charges,
SPACER,7694900,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9934.83000,2881.10000,Aetna,First Health,,8126.69,,,,,,,3581.51,8126.69,percent of total billed charges,
SPACER,7694900,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9934.83000,2881.10000,Aetna,First Health,,8126.69,,,,,,,3199.02,8126.69,percent of total billed charges,
WEDGE,7694903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4041.94000,1172.16000,Aetna,First Health,,3306.31,,,,,,,1457.12,3306.31,percent of total billed charges,
WEDGE,7694903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4041.94000,1172.16000,Aetna,First Health,,3306.31,,,,,,,1301.50,3306.31,percent of total billed charges,
WEDGE,7694409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3414.11000,990.09000,Aetna,First Health,,2792.74,,,,,,,1230.79,2792.74,percent of total billed charges,
WEDGE,7694409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3414.11000,990.09000,Aetna,First Health,,2792.74,,,,,,,1099.34,2792.74,percent of total billed charges,
INTRODUCER,7740787,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2164.80000,627.79000,Aetna,First Health,,1770.81,,,,,,,780.41,1770.81,percent of total billed charges,
INTRODUCER,7740787,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2164.80000,627.79000,Aetna,First Health,,1770.81,,,,,,,697.07,1770.81,percent of total billed charges,
MESH,7806238,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3498.67000,1014.61000,Aetna,First Health,,2861.91,,,,,,,1261.27,2861.91,percent of total billed charges,
MESH,7806238,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3498.67000,1014.61000,Aetna,First Health,,2861.91,,,,,,,1126.57,2861.91,percent of total billed charges,
MESH,7806239,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4220.48000,1223.94000,Aetna,First Health,,3452.35,,,,,,,1521.48,3452.35,percent of total billed charges,
MESH,7806239,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4220.48000,1223.94000,Aetna,First Health,,3452.35,,,,,,,1358.99,3452.35,percent of total billed charges,
FEMORAL HEAD,7806293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7806293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
COMPONENT FEMORAL,7806294,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,7806294,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
BALLOON DILATOR,7806344,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,2887.72000,837.44000,Aetna,First Health,,2362.15,,,,,,,1041.02,2362.15,percent of total billed charges,
BALLOON DILATOR,7806344,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,2887.72000,837.44000,Aetna,First Health,,2362.15,,,,,,,929.85,2362.15,percent of total billed charges,
SHELL,7698719,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7698719,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
INSERT,7699748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7699748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
BALLOON CATHETER,7694753,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1356.68000,393.44000,Aetna,First Health,,1109.76,,,,,,,489.08,1109.76,percent of total billed charges,
BALLOON CATHETER,7694753,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1356.68000,393.44000,Aetna,First Health,,1109.76,,,,,,,436.85,1109.76,percent of total billed charges,
STENT,7695085,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2329.43,5285.65,percent of total billed charges,
STENT,7695085,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2080.66,5285.65,percent of total billed charges,
GUIDEWIRE,7694374,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,515.04000,149.36000,Aetna,First Health,,421.30,,,,,,,185.67,421.30,percent of total billed charges,
GUIDEWIRE,7694374,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,515.04000,149.36000,Aetna,First Health,,421.30,,,,,,,165.84,421.30,percent of total billed charges,
BOLT,7707510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7707510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
TIBIA ADAPTER,7697456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3266.90000,947.40000,Aetna,First Health,,2672.32,,,,,,,1177.72,2672.32,percent of total billed charges,
TIBIA ADAPTER,7697456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3266.90000,947.40000,Aetna,First Health,,2672.32,,,,,,,1051.94,2672.32,percent of total billed charges,
SLEEVE,7816131,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23750.00000,6887.50000,Aetna,First Health,,19427.50,,,,,,,8561.88,19427.50,percent of total billed charges,
SLEEVE,7816131,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23750.00000,6887.50000,Aetna,First Health,,19427.50,,,,,,,7647.50,19427.50,percent of total billed charges,
STEM,7818167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,2052.78,4657.90,percent of total billed charges,
STEM,7818167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,1833.55,4657.90,percent of total billed charges,
COMPONENT FEMORAL,7820087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2920.05,6625.80,percent of total billed charges,
COMPONENT FEMORAL,7820087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2608.20,6625.80,percent of total billed charges,
COMPONENT TIBIAL,7820088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2920.05,6625.80,percent of total billed charges,
COMPONENT TIBIAL,7820088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2608.20,6625.80,percent of total billed charges,
CEMENT,7820143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.84000,487.15000,Aetna,First Health,,1374.11,,,,,,,605.58,1374.11,percent of total billed charges,
CEMENT,7820143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.84000,487.15000,Aetna,First Health,,1374.11,,,,,,,540.91,1374.11,percent of total billed charges,
NAIL,7822088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1951.93,4429.06,percent of total billed charges,
NAIL,7822088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1743.47,4429.06,percent of total billed charges,
SCREW,7822090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7822090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
ANCHOR,7822096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,624.39,1416.78,percent of total billed charges,
ANCHOR,7822096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,557.70,1416.78,percent of total billed charges,
CABLE BUTTON,7822181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,884.70000,256.56000,Aetna,First Health,,723.68,,,,,,,318.93,723.68,percent of total billed charges,
CABLE BUTTON,7822181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,884.70000,256.56000,Aetna,First Health,,723.68,,,,,,,284.87,723.68,percent of total billed charges,
SCREW,7822182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
SCREW,7822182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
CABLE END PLATE,7822188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1498.40000,434.54000,Aetna,First Health,,1225.69,,,,,,,540.17,1225.69,percent of total billed charges,
CABLE END PLATE,7822188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1498.40000,434.54000,Aetna,First Health,,1225.69,,,,,,,482.48,1225.69,percent of total billed charges,
LINER,7699117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7699117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7822260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
LINER,7822260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SPACER HUMERAL,7824044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7831.80000,2271.22000,Aetna,First Health,,6406.41,,,,,,,2823.36,6406.41,percent of total billed charges,
SPACER HUMERAL,7824044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7831.80000,2271.22000,Aetna,First Health,,6406.41,,,,,,,2521.84,6406.41,percent of total billed charges,
PROXIMAL TENODESIS,7828029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3268.13000,947.76000,Aetna,First Health,,2673.33,,,,,,,1178.16,2673.33,percent of total billed charges,
PROXIMAL TENODESIS,7828029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3268.13000,947.76000,Aetna,First Health,,2673.33,,,,,,,1052.34,2673.33,percent of total billed charges,
TOTAL ELBOW,7828152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5948.25,13497.00,percent of total billed charges,
TOTAL ELBOW,7828152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5313.00,13497.00,percent of total billed charges,
MESH,7832043,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,676.61000,196.22000,Aetna,First Health,,553.47,,,,,,,243.92,553.47,percent of total billed charges,
MESH,7832043,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,676.61000,196.22000,Aetna,First Health,,553.47,,,,,,,217.87,553.47,percent of total billed charges,
MESH,7832044,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,707.17000,205.08000,Aetna,First Health,,578.47,,,,,,,254.93,578.47,percent of total billed charges,
MESH,7832044,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,707.17000,205.08000,Aetna,First Health,,578.47,,,,,,,227.71,578.47,percent of total billed charges,
NAIL,7832104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1480.00000,429.20000,Aetna,First Health,,1210.64,,,,,,,533.54,1210.64,percent of total billed charges,
NAIL,7832104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1480.00000,429.20000,Aetna,First Health,,1210.64,,,,,,,476.56,1210.64,percent of total billed charges,
PROXIMAL BODY,7832060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
PROXIMAL BODY,7832060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
STEM,7834079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,4346.82,9863.24,percent of total billed charges,
STEM,7834079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,3882.60,9863.24,percent of total billed charges,
SHELL,7794032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,1002.19,2274.04,percent of total billed charges,
SHELL,7794032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,895.16,2274.04,percent of total billed charges,
CATHETER,7834106,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,752.40000,218.20000,Aetna,First Health,,615.46,,,,,,,271.24,615.46,percent of total billed charges,
CATHETER,7834106,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,752.40000,218.20000,Aetna,First Health,,615.46,,,,,,,242.27,615.46,percent of total billed charges,
COMPONENT FEMORAL,7834108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7834108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
LEAD,7834118,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,7029.75,15951.00,percent of total billed charges,
LEAD,7834118,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,6279.00,15951.00,percent of total billed charges,
PLATE,7695835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1740.40000,504.72000,Aetna,First Health,,1423.65,,,,,,,627.41,1423.65,percent of total billed charges,
PLATE,7695835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1740.40000,504.72000,Aetna,First Health,,1423.65,,,,,,,560.41,1423.65,percent of total billed charges,
FEMORAL HEAD,7836140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
FEMORAL HEAD,7836140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
GLENOSPHERE,7700062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,2191.66,4973.03,percent of total billed charges,
GLENOSPHERE,7700062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,1957.60,4973.03,percent of total billed charges,
COMPONENT PATELLA,7836189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
COMPONENT PATELLA,7836189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
ROD,7836196,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD,7836196,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
VALVE,7836198,CDM,278,RC,,,,,facility,inpatient,,,17389.45000,5042.94000,Aetna,First Health,,14224.57,,,,,,,6268.90,14224.57,percent of total billed charges,
VALVE,7836198,CDM,278,RC,,,,,facility,outpatient,,,17389.45000,5042.94000,Aetna,First Health,,14224.57,,,,,,,5599.40,14224.57,percent of total billed charges,
CRANIAL IMPLANT,7840037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,29176.11000,8461.07000,Aetna,First Health,,23866.06,,,,,,,10517.99,23866.06,percent of total billed charges,
CRANIAL IMPLANT,7840037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,29176.11000,8461.07000,Aetna,First Health,,23866.06,,,,,,,9394.71,23866.06,percent of total billed charges,
PLATE,7701211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9306.00000,2698.74000,Aetna,First Health,,7612.31,,,,,,,3354.81,7612.31,percent of total billed charges,
PLATE,7701211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9306.00000,2698.74000,Aetna,First Health,,7612.31,,,,,,,2996.53,7612.31,percent of total billed charges,
FEMORAL HEAD,7846131,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7846131,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7846132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7846132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7846155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7846155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
PLATE,7846251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6389.88000,1853.07000,Aetna,First Health,,5226.92,,,,,,,2303.55,5226.92,percent of total billed charges,
PLATE,7846251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6389.88000,1853.07000,Aetna,First Health,,5226.92,,,,,,,2057.54,5226.92,percent of total billed charges,
SCREW,7846252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,637.79000,184.96000,Aetna,First Health,,521.71,,,,,,,229.92,521.71,percent of total billed charges,
SCREW,7846252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,637.79000,184.96000,Aetna,First Health,,521.71,,,,,,,205.37,521.71,percent of total billed charges,
SPACER,7846253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,865.20,1963.20,percent of total billed charges,
SPACER,7846253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,772.80,1963.20,percent of total billed charges,
BONE CHIPS,7848091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12972.60000,3762.05000,Aetna,First Health,,10611.59,,,,,,,4676.62,10611.59,percent of total billed charges,
BONE CHIPS,7848091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12972.60000,3762.05000,Aetna,First Health,,10611.59,,,,,,,4177.18,10611.59,percent of total billed charges,
BASEPLATE,7850086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7850086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7850087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7850087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
BUTTON,7699777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,210.49,477.61,percent of total billed charges,
BUTTON,7699777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,188.01,477.61,percent of total billed charges,
BASEPLATE,7850192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7850192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
PLATE,7852069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
PLATE,7852069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
SCREW,7858075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,795.98,1806.14,percent of total billed charges,
SCREW,7858075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,710.98,1806.14,percent of total billed charges,
BALLOON CATHETER,7780213,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7780213,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
AORTIC EXTENSION,7858548,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
AORTIC EXTENSION,7858548,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
GRAFT,7858550,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,19825.00000,5749.25000,Aetna,First Health,,16216.85,,,,,,,7146.91,16216.85,percent of total billed charges,
GRAFT,7858550,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,19825.00000,5749.25000,Aetna,First Health,,16216.85,,,,,,,6383.65,16216.85,percent of total billed charges,
GRAFT,7698090,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,24775.00000,7184.75000,Aetna,First Health,,20265.95,,,,,,,8931.39,20265.95,percent of total billed charges,
GRAFT,7698090,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,24775.00000,7184.75000,Aetna,First Health,,20265.95,,,,,,,7977.55,20265.95,percent of total billed charges,
GRAFT,7858552,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,25737.50000,7463.87000,Aetna,First Health,,21053.28,,,,,,,9278.37,21053.28,percent of total billed charges,
GRAFT,7858552,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,25737.50000,7463.87000,Aetna,First Health,,21053.28,,,,,,,8287.48,21053.28,percent of total billed charges,
GRAFT,7858553,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,29103.75000,8440.09000,Aetna,First Health,,23806.87,,,,,,,10491.90,23806.87,percent of total billed charges,
GRAFT,7858553,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,29103.75000,8440.09000,Aetna,First Health,,23806.87,,,,,,,9371.41,23806.87,percent of total billed charges,
GRAFT,7858554,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,30501.00000,8845.29000,Aetna,First Health,,24949.82,,,,,,,10995.61,24949.82,percent of total billed charges,
GRAFT,7858554,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,30501.00000,8845.29000,Aetna,First Health,,24949.82,,,,,,,9821.32,24949.82,percent of total billed charges,
GRAFT,7858555,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,33750.00000,9787.50000,Aetna,First Health,,27607.50,,,,,,,12166.88,27607.50,percent of total billed charges,
GRAFT,7858555,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,33750.00000,9787.50000,Aetna,First Health,,27607.50,,,,,,,10867.50,27607.50,percent of total billed charges,
PLATE,7860042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4866.75000,1411.36000,Aetna,First Health,,3981.00,,,,,,,1754.46,3981.00,percent of total billed charges,
PLATE,7860042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4866.75000,1411.36000,Aetna,First Health,,3981.00,,,,,,,1567.09,3981.00,percent of total billed charges,
CATHETER,7860077,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
CATHETER,7860077,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
TIGHTROPE,7866032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1338.80000,388.25000,Aetna,First Health,,1095.14,,,,,,,482.64,1095.14,percent of total billed charges,
TIGHTROPE,7866032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1338.80000,388.25000,Aetna,First Health,,1095.14,,,,,,,431.09,1095.14,percent of total billed charges,
SCREW,7866080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7866080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
PLATE,7700270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3753.65000,1088.56000,Aetna,First Health,,3070.49,,,,,,,1353.19,3070.49,percent of total billed charges,
PLATE,7700270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3753.65000,1088.56000,Aetna,First Health,,3070.49,,,,,,,1208.68,3070.49,percent of total billed charges,
SLEEVE,7868038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,109.87,249.29,percent of total billed charges,
SLEEVE,7868038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,98.13,249.29,percent of total billed charges,
FEMORAL IMPLANT,7868039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
FEMORAL IMPLANT,7868039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
FIXATOR,7911038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,758.70000,220.02000,Aetna,First Health,,620.62,,,,,,,273.51,620.62,percent of total billed charges,
FIXATOR,7911038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,758.70000,220.02000,Aetna,First Health,,620.62,,,,,,,244.30,620.62,percent of total billed charges,
ANCHOR,7697335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1784.00000,517.36000,Aetna,First Health,,1459.31,,,,,,,643.13,1459.31,percent of total billed charges,
ANCHOR,7697335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1784.00000,517.36000,Aetna,First Health,,1459.31,,,,,,,574.45,1459.31,percent of total billed charges,
PLATE,7872039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6571.85000,1905.84000,Aetna,First Health,,5375.77,,,,,,,2369.15,5375.77,percent of total billed charges,
PLATE,7872039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6571.85000,1905.84000,Aetna,First Health,,5375.77,,,,,,,2116.14,5375.77,percent of total billed charges,
DERMIS,7872045,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7364.25000,2135.63000,Aetna,First Health,,6023.96,,,,,,,2654.81,6023.96,percent of total billed charges,
DERMIS,7872045,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7364.25000,2135.63000,Aetna,First Health,,6023.96,,,,,,,2371.29,6023.96,percent of total billed charges,
COMPONENT GLENOID,7872097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
COMPONENT GLENOID,7872097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
HUMERAL BODY,7872099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11100.00000,3219.00000,Aetna,First Health,,9079.80,,,,,,,4001.55,9079.80,percent of total billed charges,
HUMERAL BODY,7872099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11100.00000,3219.00000,Aetna,First Health,,9079.80,,,,,,,3574.20,9079.80,percent of total billed charges,
LINER,7872100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
LINER,7872100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
STEM,7872102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
STEM,7872102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
HUMERAL EXTENSION,7872103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
HUMERAL EXTENSION,7872103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,7874118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7874118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
STEM,7874121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7874121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
BASEPLATE,7874123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7874123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
COMPONENT FEMORAL,7874125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,6524.15,14803.75,percent of total billed charges,
COMPONENT FEMORAL,7874125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,5827.40,14803.75,percent of total billed charges,
HEART VALVE SYSTEM S,7874266,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7874266,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
WEDGE,7874326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE,7874326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
WASHER,7874337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,289.75000,84.03000,Aetna,First Health,,237.02,,,,,,,104.45,237.02,percent of total billed charges,
WASHER,7874337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,289.75000,84.03000,Aetna,First Health,,237.02,,,,,,,93.30,237.02,percent of total billed charges,
MODULAR HEAD,7874341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1855.02,4209.18,percent of total billed charges,
MODULAR HEAD,7874341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1656.92,4209.18,percent of total billed charges,
HUMERAL HEAD,7874394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
HUMERAL HEAD,7874394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
BREAST IMPLANT,7874422,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6125.00000,1776.25000,Aetna,First Health,,5010.25,,,,,,,2208.06,5010.25,percent of total billed charges,
BREAST IMPLANT,7874422,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6125.00000,1776.25000,Aetna,First Health,,5010.25,,,,,,,1972.25,5010.25,percent of total billed charges,
GRAFT,7876345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8915.49000,2585.49000,Aetna,First Health,,7292.87,,,,,,,3214.03,7292.87,percent of total billed charges,
GRAFT,7876345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8915.49000,2585.49000,Aetna,First Health,,7292.87,,,,,,,2870.79,7292.87,percent of total billed charges,
STEM,7878328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
STEM,7878328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
FEMORAL HEAD,7878485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7878485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW,7878535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7878535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
COMPONENT FEMORAL,7878536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2920.05,6625.80,percent of total billed charges,
COMPONENT FEMORAL,7878536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2608.20,6625.80,percent of total billed charges,
COMPONENT TIBIAL,7878537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2920.05,6625.80,percent of total billed charges,
COMPONENT TIBIAL,7878537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2608.20,6625.80,percent of total billed charges,
STERNAL CLOSURE FLATWIRE,7878544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2320.00000,672.80000,Aetna,First Health,,1897.76,,,,,,,836.36,1897.76,percent of total billed charges,
STERNAL CLOSURE FLATWIRE,7878544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2320.00000,672.80000,Aetna,First Health,,1897.76,,,,,,,747.04,1897.76,percent of total billed charges,
STEM,7878556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7880434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7880434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
INSERT,7880435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7880435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
CAGE,7696694,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,4078.34,9254.03,percent of total billed charges,
CAGE,7696694,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,3642.79,9254.03,percent of total billed charges,
STEM,7880512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2947.09,6687.15,percent of total billed charges,
STEM,7880512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2632.35,6687.15,percent of total billed charges,
COMPONENT FEMORAL,7880515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,7880515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
COMPONENT PATELLA,7880516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
COMPONENT PATELLA,7880516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
BASEPLATE,7880517,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
BASEPLATE,7880517,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
GLIDEWIRE,7880534,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
GLIDEWIRE,7880534,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
GLIDEWIRE,7880535,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,588.34,1334.98,percent of total billed charges,
GLIDEWIRE,7880535,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,525.50,1334.98,percent of total billed charges,
COMPONENT FEMORAL,7880646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7880646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
CATHETER,7880752,CDM,278,RC,A4305,HCPCS,,,facility,inpatient,,,584.10000,169.39000,Aetna,First Health,,477.79,,,,,,,210.57,477.79,percent of total billed charges,
CATHETER,7880752,CDM,278,RC,A4305,HCPCS,,,facility,outpatient,,,584.10000,169.39000,Aetna,First Health,,477.79,,,,,,,188.08,477.79,percent of total billed charges,
FEMORAL HEAD,7880761,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1392.66,3160.04,percent of total billed charges,
FEMORAL HEAD,7880761,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1243.93,3160.04,percent of total billed charges,
BUTTON SEPTAL,7876343,CDM,278,RC,L8047,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,First Health,,1092.85,,,,,,,481.63,1092.85,percent of total billed charges,
BUTTON SEPTAL,7876343,CDM,278,RC,L8047,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,First Health,,1092.85,,,,,,,430.19,1561.74,percent of total billed charges,
BUTTON SEPTAL,7880782,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1335.28000,387.23000,Aetna,First Health,,1092.26,,,,,,,481.37,1092.26,percent of total billed charges,
BUTTON SEPTAL,7880782,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1335.28000,387.23000,Aetna,First Health,,1092.26,,,,,,,429.96,1092.26,percent of total billed charges,
SHOULDER ANATOMIC PROSTHESIS,7880788,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
SHOULDER ANATOMIC PROSTHESIS,7880788,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
HUMERAL HEAD,7880789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7880789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
FEMORAL HEAD,7880787,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7880787,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
BASEPLATE,7882246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7882246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
INSERT,7882247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7882247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
COMPONENT FEMORAL,7882256,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,38051.55000,11034.95000,Aetna,First Health,,31126.17,,,,,,,13717.58,31126.17,percent of total billed charges,
COMPONENT FEMORAL,7882256,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,38051.55000,11034.95000,Aetna,First Health,,31126.17,,,,,,,12252.60,31126.17,percent of total billed charges,
SLEEVE,7882259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,174.66,396.32,percent of total billed charges,
SLEEVE,7882259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,156.01,396.32,percent of total billed charges,
COMPONENT FEMORAL,7882366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,7882366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
COMPONENT GLENOID,7882320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
COMPONENT GLENOID,7882320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
AORTIC EXTENSION,7882345,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
AORTIC EXTENSION,7882345,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
COMPONENT FEMORAL,7882382,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7882382,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
HUMERAL HEAD,7882482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HUMERAL HEAD,7882482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
BASEPLATE,7882586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.60000,3007.76000,Aetna,First Health,,8483.97,,,,,,,3738.96,8483.97,percent of total billed charges,
BASEPLATE,7882586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.60000,3007.76000,Aetna,First Health,,8483.97,,,,,,,3339.66,8483.97,percent of total billed charges,
PLATE,7882613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,920.57000,266.97000,Aetna,First Health,,753.03,,,,,,,331.87,753.03,percent of total billed charges,
PLATE,7882613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,920.57000,266.97000,Aetna,First Health,,753.03,,,,,,,296.42,753.03,percent of total billed charges,
AUGMENT TIBIAL,7882688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7882688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
INSERT,7882691,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,7882691,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
ANCHOR,7882692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
ANCHOR,7882692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
JOINT TOE CERAMIC SPHERIC,7882766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8421.00000,2442.09000,Aetna,First Health,,6888.38,,,,,,,3035.77,6888.38,percent of total billed charges,
JOINT TOE CERAMIC SPHERIC,7882766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8421.00000,2442.09000,Aetna,First Health,,6888.38,,,,,,,2711.56,6888.38,percent of total billed charges,
TENDON,7882781,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10410.00000,3018.90000,Aetna,First Health,,8515.38,,,,,,,3752.80,8515.38,percent of total billed charges,
TENDON,7882781,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10410.00000,3018.90000,Aetna,First Health,,8515.38,,,,,,,3352.02,8515.38,percent of total billed charges,
SCREW,7882782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1445.92000,419.32000,Aetna,First Health,,1182.76,,,,,,,521.25,1182.76,percent of total billed charges,
SCREW,7882782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1445.92000,419.32000,Aetna,First Health,,1182.76,,,,,,,465.59,1182.76,percent of total billed charges,
GENERATOR,7882828,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,45787.50000,13278.37000,Aetna,First Health,,37454.18,,,,,,,16506.39,37454.18,percent of total billed charges,
GENERATOR,7882828,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,45787.50000,13278.37000,Aetna,First Health,,37454.18,,,,,,,14743.58,37454.18,percent of total billed charges,
BALLOON,7882789,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON,7882789,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON,7882792,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON,7882792,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
BONE MATRIX,7882868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
BONE MATRIX,7882868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
WASHER,7870089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,449.02000,130.22000,Aetna,First Health,,367.30,,,,,,,161.87,367.30,percent of total billed charges,
WASHER,7870089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,449.02000,130.22000,Aetna,First Health,,367.30,,,,,,,144.58,367.30,percent of total billed charges,
NAIL,7893284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1913.07,4340.88,percent of total billed charges,
NAIL,7893284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1708.76,4340.88,percent of total billed charges,
ROD,7893287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD,7893287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
PLATE,7893329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5724.57000,1660.13000,Aetna,First Health,,4682.70,,,,,,,2063.71,4682.70,percent of total billed charges,
PLATE,7893329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5724.57000,1660.13000,Aetna,First Health,,4682.70,,,,,,,1843.31,4682.70,percent of total billed charges,
INSERT,7893348,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,7893348,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
CATHETER,7694071,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,824.94000,239.23000,Aetna,First Health,,674.80,,,,,,,297.39,674.80,percent of total billed charges,
CATHETER,7694071,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,824.94000,239.23000,Aetna,First Health,,674.80,,,,,,,265.63,674.80,percent of total billed charges,
GRAFT,7893473,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5110.00000,1481.90000,Aetna,First Health,,4179.98,,,,,,,1842.15,4179.98,percent of total billed charges,
GRAFT,7893473,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5110.00000,1481.90000,Aetna,First Health,,4179.98,,,,,,,1645.42,4179.98,percent of total billed charges,
CATHETER,7834044,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
CATHETER,7834044,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
CATHETER,7902824,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
CATHETER,7902824,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
CATHETER,7905711,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
CATHETER,7905711,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
CATHETER,7702805,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7702805,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
CATHETER,7702806,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7702806,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
CATHETER,7703392,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7703392,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
EMBOLIZATION COIL,7695678,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,985.50000,285.79000,Aetna,First Health,,806.14,,,,,,,355.27,806.14,percent of total billed charges,
EMBOLIZATION COIL,7695678,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,985.50000,285.79000,Aetna,First Health,,806.14,,,,,,,317.33,806.14,percent of total billed charges,
EMBOLIZATION COIL,7696513,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,220.03,499.26,percent of total billed charges,
EMBOLIZATION COIL,7696513,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,196.53,499.26,percent of total billed charges,
EMBOLIZATION COIL,7699124,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,220.03,499.26,percent of total billed charges,
EMBOLIZATION COIL,7699124,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,196.53,499.26,percent of total billed charges,
GLIDEWIRE,7695883,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,368.13000,106.76000,Aetna,First Health,,301.13,,,,,,,132.71,301.13,percent of total billed charges,
GLIDEWIRE,7695883,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,368.13000,106.76000,Aetna,First Health,,301.13,,,,,,,118.54,301.13,percent of total billed charges,
GLIDEWIRE,7695936,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,351.50000,101.93000,Aetna,First Health,,287.53,,,,,,,126.72,287.53,percent of total billed charges,
GLIDEWIRE,7695936,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,351.50000,101.93000,Aetna,First Health,,287.53,,,,,,,113.18,287.53,percent of total billed charges,
GLIDEWIRE,7698515,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,351.50000,101.93000,Aetna,First Health,,287.53,,,,,,,126.72,287.53,percent of total billed charges,
GLIDEWIRE,7698515,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,351.50000,101.93000,Aetna,First Health,,287.53,,,,,,,113.18,287.53,percent of total billed charges,
GRAFT,7694913,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1120.28,2541.98,percent of total billed charges,
GRAFT,7694913,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1000.63,2541.98,percent of total billed charges,
GRAFT,7694914,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1120.28,2541.98,percent of total billed charges,
GRAFT,7694914,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1000.63,2541.98,percent of total billed charges,
GRAFT,7954369,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1120.28,2541.98,percent of total billed charges,
GRAFT,7954369,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1000.63,2541.98,percent of total billed charges,
GRAFT,7702868,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1120.28,2541.98,percent of total billed charges,
GRAFT,7702868,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1000.63,2541.98,percent of total billed charges,
GRAFT,7702869,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1120.28,2541.98,percent of total billed charges,
GRAFT,7702869,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1000.63,2541.98,percent of total billed charges,
GRAFT,7702880,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1120.28,2541.98,percent of total billed charges,
GRAFT,7702880,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1000.63,2541.98,percent of total billed charges,
GRAFT,7703391,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
GRAFT,7703391,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
GRAFT,7695905,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3531.22000,1024.05000,Aetna,First Health,,2888.54,,,,,,,1273.00,2888.54,percent of total billed charges,
GRAFT,7695905,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3531.22000,1024.05000,Aetna,First Health,,2888.54,,,,,,,1137.05,2888.54,percent of total billed charges,
GRAFT,7695906,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3531.22000,1024.05000,Aetna,First Health,,2888.54,,,,,,,1273.00,2888.54,percent of total billed charges,
GRAFT,7695906,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3531.22000,1024.05000,Aetna,First Health,,2888.54,,,,,,,1137.05,2888.54,percent of total billed charges,
GUIDEWIRE,7696289,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,375.25000,108.82000,Aetna,First Health,,306.95,,,,,,,135.28,306.95,percent of total billed charges,
GUIDEWIRE,7696289,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,375.25000,108.82000,Aetna,First Health,,306.95,,,,,,,120.83,306.95,percent of total billed charges,
GUIDEWIRE,7696271,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,222.55000,64.54000,Aetna,First Health,,182.05,,,,,,,80.23,182.05,percent of total billed charges,
GUIDEWIRE,7696271,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,222.55000,64.54000,Aetna,First Health,,182.05,,,,,,,71.66,182.05,percent of total billed charges,
GUIDEWIRE,7702892,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,184.70000,53.56000,Aetna,First Health,,151.08,,,,,,,66.58,151.08,percent of total billed charges,
GUIDEWIRE,7702892,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,184.70000,53.56000,Aetna,First Health,,151.08,,,,,,,59.47,151.08,percent of total billed charges,
GUIDEWIRE,7702893,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,222.55000,64.54000,Aetna,First Health,,182.05,,,,,,,80.23,182.05,percent of total billed charges,
GUIDEWIRE,7702893,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,222.55000,64.54000,Aetna,First Health,,182.05,,,,,,,71.66,182.05,percent of total billed charges,
GUIDEWIRE,7695037,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,487.78000,141.46000,Aetna,First Health,,399.00,,,,,,,175.84,399.00,percent of total billed charges,
GUIDEWIRE,7695037,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,487.78000,141.46000,Aetna,First Health,,399.00,,,,,,,157.07,399.00,percent of total billed charges,
GUIDEWIRE,7702894,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,336.30000,97.53000,Aetna,First Health,,275.09,,,,,,,121.24,275.09,percent of total billed charges,
GUIDEWIRE,7702894,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,336.30000,97.53000,Aetna,First Health,,275.09,,,,,,,108.29,275.09,percent of total billed charges,
GUIDEWIRE,7702899,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,720.90000,209.06000,Aetna,First Health,,589.70,,,,,,,259.88,589.70,percent of total billed charges,
GUIDEWIRE,7702899,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,720.90000,209.06000,Aetna,First Health,,589.70,,,,,,,232.13,589.70,percent of total billed charges,
GUIDEWIRE,7695955,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,680.76000,197.42000,Aetna,First Health,,556.86,,,,,,,245.41,556.86,percent of total billed charges,
GUIDEWIRE,7695955,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,680.76000,197.42000,Aetna,First Health,,556.86,,,,,,,219.20,556.86,percent of total billed charges,
GUIDEWIRE,7695688,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.55000,107.46000,Aetna,First Health,,303.11,,,,,,,133.58,303.11,percent of total billed charges,
GUIDEWIRE,7695688,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.55000,107.46000,Aetna,First Health,,303.11,,,,,,,119.32,303.11,percent of total billed charges,
GUIDEWIRE,7702237,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,354.73000,102.87000,Aetna,First Health,,290.17,,,,,,,127.88,290.17,percent of total billed charges,
GUIDEWIRE,7702237,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,354.73000,102.87000,Aetna,First Health,,290.17,,,,,,,114.22,290.17,percent of total billed charges,
INTRODUCER,7696984,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,306.90000,89.00000,Aetna,First Health,,251.04,,,,,,,110.64,251.04,percent of total billed charges,
INTRODUCER,7696984,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,306.90000,89.00000,Aetna,First Health,,251.04,,,,,,,98.82,251.04,percent of total billed charges,
INTRODUCER,7702801,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
INTRODUCER,7702801,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
MESH,7903364,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2130.08000,617.72000,Aetna,First Health,,1742.41,,,,,,,767.89,1742.41,percent of total billed charges,
MESH,7903364,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2130.08000,617.72000,Aetna,First Health,,1742.41,,,,,,,685.89,1742.41,percent of total billed charges,
MESH,7696974,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2833.67000,821.76000,Aetna,First Health,,2317.94,,,,,,,1021.54,2317.94,percent of total billed charges,
MESH,7696974,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2833.67000,821.76000,Aetna,First Health,,2317.94,,,,,,,912.44,2317.94,percent of total billed charges,
MESH,7697864,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1968.07000,570.74000,Aetna,First Health,,1609.88,,,,,,,709.49,1609.88,percent of total billed charges,
MESH,7697864,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1968.07000,570.74000,Aetna,First Health,,1609.88,,,,,,,633.72,1609.88,percent of total billed charges,
GRAFT,7702872,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2270.40000,658.42000,Aetna,First Health,,1857.19,,,,,,,818.48,1857.19,percent of total billed charges,
GRAFT,7702872,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2270.40000,658.42000,Aetna,First Health,,1857.19,,,,,,,731.07,1857.19,percent of total billed charges,
GRAFT,7702874,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2270.40000,658.42000,Aetna,First Health,,1857.19,,,,,,,818.48,1857.19,percent of total billed charges,
GRAFT,7702874,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2270.40000,658.42000,Aetna,First Health,,1857.19,,,,,,,731.07,1857.19,percent of total billed charges,
GRAFT,7702877,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2370.56000,687.46000,Aetna,First Health,,1939.12,,,,,,,854.59,1939.12,percent of total billed charges,
GRAFT,7702877,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2370.56000,687.46000,Aetna,First Health,,1939.12,,,,,,,763.32,1939.12,percent of total billed charges,
ANCHOR,7696419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ANCHOR,7696419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
ANCHOR,7696944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ANCHOR,7696944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
ANCHOR,7696945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ANCHOR,7696945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
ANCHOR,7696949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3318.00000,962.22000,Aetna,First Health,,2714.12,,,,,,,1196.14,2714.12,percent of total billed charges,
ANCHOR,7696949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3318.00000,962.22000,Aetna,First Health,,2714.12,,,,,,,1068.40,2714.12,percent of total billed charges,
ANCHOR,7697182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,670.53,1521.48,percent of total billed charges,
ANCHOR,7697182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,598.92,1521.48,percent of total billed charges,
ANCHOR,7700237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1832.00000,531.28000,Aetna,First Health,,1498.58,,,,,,,660.44,1498.58,percent of total billed charges,
ANCHOR,7700237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1832.00000,531.28000,Aetna,First Health,,1498.58,,,,,,,589.90,1498.58,percent of total billed charges,
ANCHOR,7707499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ANCHOR,7707499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
STENT,7748125,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7748125,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,7748126,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7748126,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,7748127,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
STENT,7748127,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
SHEATH,7943790,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,799.79000,231.94000,Aetna,First Health,,654.23,,,,,,,288.32,654.23,percent of total billed charges,
SHEATH,7943790,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,799.79000,231.94000,Aetna,First Health,,654.23,,,,,,,257.53,654.23,percent of total billed charges,
SHEATH,7962120,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,799.79000,231.94000,Aetna,First Health,,654.23,,,,,,,288.32,654.23,percent of total billed charges,
SHEATH,7962120,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,799.79000,231.94000,Aetna,First Health,,654.23,,,,,,,257.53,654.23,percent of total billed charges,
ANCHOR,7702697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,703.70,1596.74,percent of total billed charges,
ANCHOR,7702697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,628.54,1596.74,percent of total billed charges,
SCREW,7695453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7695453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7695454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7695454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7695455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7695455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7695488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7695488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
CROSS CONNECTOR,7698587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CROSS CONNECTOR,7698587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW,7695853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7695853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7695856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7695856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7695857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7695857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7695858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7695858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7696763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7696763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7698783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.12000,90.51000,Aetna,First Health,,255.31,,,,,,,112.52,255.31,percent of total billed charges,
SCREW,7698783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.12000,90.51000,Aetna,First Health,,255.31,,,,,,,100.50,255.31,percent of total billed charges,
SCREW,7699456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7699456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7699501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7699501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7699573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7699573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7699681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7699681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7699682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7699682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7699683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7699683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7699684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7699684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7699744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7699744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7699782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7699782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7699783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7699783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7699784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7699784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7699965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7699965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7700095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7700095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7700266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7700266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7700304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7700304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7700357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7700357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7700358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7700358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7700359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7700359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7700360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7700360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7700371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7700371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7700469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.12000,90.51000,Aetna,First Health,,255.31,,,,,,,112.52,255.31,percent of total billed charges,
SCREW,7700469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.12000,90.51000,Aetna,First Health,,255.31,,,,,,,100.50,255.31,percent of total billed charges,
SCREW,7700759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7700759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7700898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7700898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7700916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7700916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7700945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7700945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7701010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7701010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7701011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7701011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7701264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7701502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7701595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7701595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7701773,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7701773,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7701774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7701774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7701775,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7701775,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7702136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7702136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7702673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7702673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7702674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7702674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7736084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7736084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7736166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7736166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7740887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,114.73,260.33,percent of total billed charges,
SCREW,7740887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,102.48,260.33,percent of total billed charges,
SCREW,7750592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7750592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7750594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7750594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7794445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7794445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7794446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7794446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7804057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7804057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7812124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7812124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7816123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7816123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7822147,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.12000,90.51000,Aetna,First Health,,255.31,,,,,,,112.52,255.31,percent of total billed charges,
SCREW,7822147,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.12000,90.51000,Aetna,First Health,,255.31,,,,,,,100.50,255.31,percent of total billed charges,
SCREW,7822148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.12000,90.51000,Aetna,First Health,,255.31,,,,,,,112.52,255.31,percent of total billed charges,
SCREW,7822148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.12000,90.51000,Aetna,First Health,,255.31,,,,,,,100.50,255.31,percent of total billed charges,
SCREW,7822149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.12000,90.51000,Aetna,First Health,,255.31,,,,,,,112.52,255.31,percent of total billed charges,
SCREW,7822149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.12000,90.51000,Aetna,First Health,,255.31,,,,,,,100.50,255.31,percent of total billed charges,
SCREW,7828149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7828149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7828150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7828150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7840032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7840032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7872041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7872041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7876321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7876321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7880451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7880451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7880528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,7880528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
SCREW,7894134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7894134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7896388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,7896388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
SCREW,7901794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7901794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7901795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7901795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7901796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7901796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7901797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7901797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7901798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7901798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7905099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,7905099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
SCREW,7926826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7926826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7938059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,109.98,249.56,percent of total billed charges,
SCREW,7938059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,First Health,,249.56,,,,,,,98.24,249.56,percent of total billed charges,
SCREW,7944022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7944022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7944292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7944292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,7957662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,249.49,percent of total billed charges,
SCREW,7957662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,98.21,249.49,percent of total billed charges,
SCREW,7957663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,249.49,percent of total billed charges,
SCREW,7957663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,98.21,249.49,percent of total billed charges,
SCREW,7957664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,249.49,percent of total billed charges,
SCREW,7957664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,98.21,249.49,percent of total billed charges,
SCREW,7703159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7703159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7703217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7703217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7703230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7703230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7696764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7696764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7696765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7696765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7698109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7698109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7698110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7698110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7698111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7698111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7698112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7698112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7698113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7698113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7698116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7698116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7698117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7698117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7698118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7698118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7698119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7698119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7699098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7699098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7699239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7699298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7699554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7699944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7700113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7700113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7701376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7701517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7701924,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701924,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7701942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7702176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,7702176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,7702177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,7702177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,7901704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7901704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7901705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7901705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7902771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7902771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7902783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7902783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7903058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7903058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7905298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7905298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7925896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7925896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7950390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7950390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7950391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7950391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7950392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7950392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7954646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7954646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
ANCHOR,7698446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,648.90,1472.40,percent of total billed charges,
ANCHOR,7698446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,579.60,1472.40,percent of total billed charges,
ANCHOR,7698585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
ANCHOR,7698585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
PLATE,7696769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,First Health,,1515.03,,,,,,,667.69,1515.03,percent of total billed charges,
PLATE,7696769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,First Health,,1515.03,,,,,,,596.38,1515.03,percent of total billed charges,
PLATE,7698664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1796.28000,520.92000,Aetna,First Health,,1469.36,,,,,,,647.56,1469.36,percent of total billed charges,
PLATE,7698664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1796.28000,520.92000,Aetna,First Health,,1469.36,,,,,,,578.40,1469.36,percent of total billed charges,
PLATE,7702163,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,892.60,2025.37,percent of total billed charges,
PLATE,7702163,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,797.27,2025.37,percent of total billed charges,
PLATE,7756054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1880.08000,545.22000,Aetna,First Health,,1537.91,,,,,,,677.77,1537.91,percent of total billed charges,
PLATE,7756054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1880.08000,545.22000,Aetna,First Health,,1537.91,,,,,,,605.39,1537.91,percent of total billed charges,
PLATE,7772060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,739.17,1677.23,percent of total billed charges,
PLATE,7772060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,660.23,1677.23,percent of total billed charges,
PLATE,7772063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,739.17,1677.23,percent of total billed charges,
PLATE,7772063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,660.23,1677.23,percent of total billed charges,
PLATE,7802394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,892.60,2025.37,percent of total billed charges,
PLATE,7802394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,797.27,2025.37,percent of total billed charges,
PLATE,7695838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,554.00000,160.66000,Aetna,First Health,,453.17,,,,,,,199.72,453.17,percent of total billed charges,
PLATE,7695838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,554.00000,160.66000,Aetna,First Health,,453.17,,,,,,,178.39,453.17,percent of total billed charges,
PLATE,7696429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,223.23000,64.74000,Aetna,First Health,,182.60,,,,,,,80.47,182.60,percent of total billed charges,
PLATE,7696429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,223.23000,64.74000,Aetna,First Health,,182.60,,,,,,,71.88,182.60,percent of total billed charges,
PLATE,7772061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,714.15000,207.10000,Aetna,First Health,,584.17,,,,,,,257.45,584.17,percent of total billed charges,
PLATE,7772061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,714.15000,207.10000,Aetna,First Health,,584.17,,,,,,,229.96,584.17,percent of total billed charges,
PLATE,7698762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,694.54,1575.96,percent of total billed charges,
PLATE,7698762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,620.37,1575.96,percent of total billed charges,
PLATE,7698763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,694.54,1575.96,percent of total billed charges,
PLATE,7698763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,620.37,1575.96,percent of total billed charges,
PLATE,7699564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1864.52000,540.71000,Aetna,First Health,,1525.18,,,,,,,672.16,1525.18,percent of total billed charges,
PLATE,7699564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1864.52000,540.71000,Aetna,First Health,,1525.18,,,,,,,600.38,1525.18,percent of total billed charges,
PLATE,7702262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2494.40000,723.38000,Aetna,First Health,,2040.42,,,,,,,899.23,2040.42,percent of total billed charges,
PLATE,7702262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2494.40000,723.38000,Aetna,First Health,,2040.42,,,,,,,803.20,2040.42,percent of total billed charges,
PLATE,7836197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,694.54,1575.96,percent of total billed charges,
PLATE,7836197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,620.37,1575.96,percent of total billed charges,
PLATE,7894229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,694.54,1575.96,percent of total billed charges,
PLATE,7894229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,620.37,1575.96,percent of total billed charges,
PLATE,7894230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,694.54,1575.96,percent of total billed charges,
PLATE,7894230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,First Health,,1575.96,,,,,,,620.37,1575.96,percent of total billed charges,
PLATE,7900160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2128.00000,617.12000,Aetna,First Health,,1740.70,,,,,,,767.14,1740.70,percent of total billed charges,
PLATE,7900160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2128.00000,617.12000,Aetna,First Health,,1740.70,,,,,,,685.22,1740.70,percent of total billed charges,
SCREW,7695467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7695467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7695490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7695490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7695567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7695567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7695568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7695568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7695570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7695570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7695571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7695571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7695803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7695803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7697627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7697627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7697628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7697628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7697669,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7697669,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7697670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7697670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7697671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7697671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7698240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7698240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7698241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7698241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7698667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7698667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7698668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7698668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7698669,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7698669,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7698670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7698670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7699230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7699230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7699238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7699238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7699379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7699379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7699382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7699382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7699404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7699404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7699408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7699408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7699442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7699442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7699443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7699443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7699444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7699444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7699549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7699549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7699550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7699550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7699551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7699551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7699569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7699569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7699586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,7699586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,7699988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7699988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7700009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7700009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7700011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7700011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7700088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7700088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7700149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7700149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7700150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7700150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7700231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7700231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7700232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7700232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7700256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7700256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7700271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7700271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7700272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7700272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7700284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7700284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7700384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7700384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7700385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7700385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7700388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7700388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7700400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7700400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7701020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7701063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7701217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7701217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7701578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7701578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7701593,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7701593,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7701594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7701594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7702235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7702235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7702265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7702265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7702266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7702266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7702277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7702277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7702281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7702281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7702282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7702282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7736057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,129.10000,37.44000,Aetna,First Health,,105.60,,,,,,,46.54,105.60,percent of total billed charges,
SCREW,7736057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,129.10000,37.44000,Aetna,First Health,,105.60,,,,,,,41.57,105.60,percent of total billed charges,
SCREW,7756861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7756861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7768119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7768119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7802397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7802397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7806342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7806342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7806290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7806290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7878335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7878335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7878339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7878339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7894221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7894221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7736049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7736049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7921012,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7921012,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703147,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703147,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703154,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703154,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7703156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,128.05000,37.13000,Aetna,First Health,,104.74,,,,,,,46.16,104.74,percent of total billed charges,
SCREW,7703156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,128.05000,37.13000,Aetna,First Health,,104.74,,,,,,,41.23,104.74,percent of total billed charges,
SCREW,7703397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7703397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
CONNECTOR,7954115,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
CONNECTOR,7954115,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,7695451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7695451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7695594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,467.40000,135.55000,Aetna,First Health,,382.33,,,,,,,168.50,382.33,percent of total billed charges,
SCREW,7695594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,467.40000,135.55000,Aetna,First Health,,382.33,,,,,,,150.50,382.33,percent of total billed charges,
SCREW,7696490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,147.26,334.15,percent of total billed charges,
SCREW,7696490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,131.54,334.15,percent of total billed charges,
SCREW,7696558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7696558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7696559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7696559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7697362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,467.40000,135.55000,Aetna,First Health,,382.33,,,,,,,168.50,382.33,percent of total billed charges,
SCREW,7697362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,467.40000,135.55000,Aetna,First Health,,382.33,,,,,,,150.50,382.33,percent of total billed charges,
SCREW,7697499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7697499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7697500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7697500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7697501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7697501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7697886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7697886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7698031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7698032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7698292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7698755,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7698755,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7698756,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7698756,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7698757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7698757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7698758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7698758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7698759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7698759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7699244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
SCREW,7699246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
SCREW,7699247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7699562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7699563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7699563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7700086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7700086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,7700087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7700087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,7700470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7700470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,7701207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7701207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7701581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,169.87,385.44,percent of total billed charges,
SCREW,7701780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,151.73,385.44,percent of total billed charges,
SCREW,7701781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,169.87,385.44,percent of total billed charges,
SCREW,7701781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,151.73,385.44,percent of total billed charges,
SCREW,7701782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,169.87,385.44,percent of total billed charges,
SCREW,7701782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,151.73,385.44,percent of total billed charges,
SCREW,7701787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,169.87,385.44,percent of total billed charges,
SCREW,7701787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,151.73,385.44,percent of total billed charges,
SCREW,7701790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701793,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701793,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7701835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7701835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7702034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7702034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7702086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,111.13,252.17,percent of total billed charges,
SCREW,7702323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,99.27,252.17,percent of total billed charges,
SCREW,7702324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,309.18000,89.66000,Aetna,First Health,,252.91,,,,,,,111.46,252.91,percent of total billed charges,
SCREW,7702324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,309.18000,89.66000,Aetna,First Health,,252.91,,,,,,,99.56,252.91,percent of total billed charges,
SCREW,7702325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,309.18000,89.66000,Aetna,First Health,,252.91,,,,,,,111.46,252.91,percent of total billed charges,
SCREW,7702325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,309.18000,89.66000,Aetna,First Health,,252.91,,,,,,,99.56,252.91,percent of total billed charges,
SCREW,7702326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,111.13,252.17,percent of total billed charges,
SCREW,7702326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,99.27,252.17,percent of total billed charges,
SCREW,7702327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,111.13,252.17,percent of total billed charges,
SCREW,7702327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,99.27,252.17,percent of total billed charges,
SCREW,7702328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,111.13,252.17,percent of total billed charges,
SCREW,7702328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,99.27,252.17,percent of total billed charges,
SCREW,7702329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,111.13,252.17,percent of total billed charges,
SCREW,7702329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,99.27,252.17,percent of total billed charges,
SCREW,7702330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,111.13,252.17,percent of total billed charges,
SCREW,7702330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,First Health,,252.17,,,,,,,99.27,252.17,percent of total billed charges,
SCREW,7774106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7774106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7882619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7882619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7882620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7882620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7882621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7882621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7882622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7882622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7882623,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7882623,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7882624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7882624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7882625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7882625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7882626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7882626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7882627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7882627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7882628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7882628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7903366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7903366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,7703096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,783.00000,227.07000,Aetna,First Health,,640.49,,,,,,,282.27,640.49,percent of total billed charges,
SCREW,7703096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,783.00000,227.07000,Aetna,First Health,,640.49,,,,,,,252.13,640.49,percent of total billed charges,
SCREW,7703099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,783.00000,227.07000,Aetna,First Health,,640.49,,,,,,,282.27,640.49,percent of total billed charges,
SCREW,7703099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,783.00000,227.07000,Aetna,First Health,,640.49,,,,,,,252.13,640.49,percent of total billed charges,
SCREW,7703116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.25000,86.78000,Aetna,First Health,,244.79,,,,,,,107.88,244.79,percent of total billed charges,
SCREW,7703116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.25000,86.78000,Aetna,First Health,,244.79,,,,,,,96.36,244.79,percent of total billed charges,
SCREW,7703117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,418.00000,121.22000,Aetna,First Health,,341.92,,,,,,,150.69,341.92,percent of total billed charges,
SCREW,7703117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,418.00000,121.22000,Aetna,First Health,,341.92,,,,,,,134.60,341.92,percent of total billed charges,
SCREW,7703139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7703139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7703140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7703140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7703141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7703141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
SCREW,7703166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,147.26,334.15,percent of total billed charges,
SCREW,7703166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,131.54,334.15,percent of total billed charges,
STENT,7768156,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7768156,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
STENT,7703278,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7703278,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
BONE CHIPS,7699916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,795.98,1806.14,percent of total billed charges,
BONE CHIPS,7699916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,710.98,1806.14,percent of total billed charges,
TENDON,7702912,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6662.25000,1932.05000,Aetna,First Health,,5449.72,,,,,,,2401.74,5449.72,percent of total billed charges,
TENDON,7702912,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6662.25000,1932.05000,Aetna,First Health,,5449.72,,,,,,,2145.24,5449.72,percent of total billed charges,
CATHETER URETERAL,7696249,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,381.71000,110.70000,Aetna,First Health,,312.24,,,,,,,137.61,312.24,percent of total billed charges,
CATHETER URETERAL,7696249,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,381.71000,110.70000,Aetna,First Health,,312.24,,,,,,,122.91,312.24,percent of total billed charges,
ROD,7698287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7698287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
ROD,7699112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7699112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
NAIL,7696840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7696840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7696860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7696860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7697468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7697468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7698238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7698238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7698251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7698251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7698270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7698270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7700263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7700263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7700286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7700286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7736641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7736641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7702619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7702619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7736137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7736137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7740751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7740751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7746049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7746049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7762379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7762379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7874432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7874432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7901860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7901860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7905300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7905300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7910833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7910833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7913430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7913430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7913881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7913881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7917332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7917332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7920822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7920822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7922465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7922465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7926457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7926457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7927552,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7927552,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7935609,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7935609,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7955060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7955060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,7965171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7965171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
END CAP,7695435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.58000,214.48000,Aetna,First Health,,604.98,,,,,,,266.62,604.98,percent of total billed charges,
END CAP,7695435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.58000,214.48000,Aetna,First Health,,604.98,,,,,,,238.14,604.98,percent of total billed charges,
END CAP,7695445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.58000,214.48000,Aetna,First Health,,604.98,,,,,,,266.62,604.98,percent of total billed charges,
END CAP,7695445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.58000,214.48000,Aetna,First Health,,604.98,,,,,,,238.14,604.98,percent of total billed charges,
END CAP,7696821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.58000,214.48000,Aetna,First Health,,604.98,,,,,,,266.62,604.98,percent of total billed charges,
END CAP,7696821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.58000,214.48000,Aetna,First Health,,604.98,,,,,,,238.14,604.98,percent of total billed charges,
END CAP,7698293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.58000,214.48000,Aetna,First Health,,604.98,,,,,,,266.62,604.98,percent of total billed charges,
END CAP,7698293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.58000,214.48000,Aetna,First Health,,604.98,,,,,,,238.14,604.98,percent of total billed charges,
END CAP,7699807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,876.74000,254.25000,Aetna,First Health,,717.17,,,,,,,316.06,717.17,percent of total billed charges,
END CAP,7699807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,876.74000,254.25000,Aetna,First Health,,717.17,,,,,,,282.31,717.17,percent of total billed charges,
END CAP,7893926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,876.74000,254.25000,Aetna,First Health,,717.17,,,,,,,316.06,717.17,percent of total billed charges,
END CAP,7893926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,876.74000,254.25000,Aetna,First Health,,717.17,,,,,,,282.31,717.17,percent of total billed charges,
END CAP,7904024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,876.74000,254.25000,Aetna,First Health,,717.17,,,,,,,316.06,717.17,percent of total billed charges,
END CAP,7904024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,876.74000,254.25000,Aetna,First Health,,717.17,,,,,,,282.31,717.17,percent of total billed charges,
STENT,7696829,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,4634.42000,1343.98000,Aetna,First Health,,3790.96,,,,,,,1670.71,3790.96,percent of total billed charges,
STENT,7696829,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,4634.42000,1343.98000,Aetna,First Health,,3790.96,,,,,,,1492.28,3790.96,percent of total billed charges,
STENT,7697009,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,4634.42000,1343.98000,Aetna,First Health,,3790.96,,,,,,,1670.71,3790.96,percent of total billed charges,
STENT,7697009,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,4634.42000,1343.98000,Aetna,First Health,,3790.96,,,,,,,1492.28,3790.96,percent of total billed charges,
STENT,7699142,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,4634.42000,1343.98000,Aetna,First Health,,3790.96,,,,,,,1670.71,3790.96,percent of total billed charges,
STENT,7699142,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,4634.42000,1343.98000,Aetna,First Health,,3790.96,,,,,,,1492.28,3790.96,percent of total billed charges,
SCREW,7695390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1544.00000,447.76000,Aetna,First Health,,1262.99,,,,,,,556.61,1262.99,percent of total billed charges,
SCREW,7695390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1544.00000,447.76000,Aetna,First Health,,1262.99,,,,,,,497.17,1262.99,percent of total billed charges,
SCREW,7696488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7696488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7696489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7696489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7696598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,164.39,373.01,percent of total billed charges,
SCREW,7696598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,146.83,373.01,percent of total billed charges,
SCREW,7696772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7696772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7696773,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7696773,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
CATHETER,8148643,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,431.59000,125.16000,Aetna,First Health,,353.04,,,,,,,155.59,353.04,percent of total billed charges,
CATHETER,8148643,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,431.59000,125.16000,Aetna,First Health,,353.04,,,,,,,138.97,353.04,percent of total billed charges,
GLIDESHEATH,8135906,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
GLIDESHEATH,8135906,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
GUIDEWIRE,8135905,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
GUIDEWIRE,8135905,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
GUIDEWIRE,8135907,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
GUIDEWIRE,8135907,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
GUIDEWIRE,8135908,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,1128.84,percent of total billed charges,
GUIDEWIRE,8135908,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,444.36,1128.84,percent of total billed charges,
CATHETER,8135909,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
CATHETER,8135909,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
CROWN STEALTH,7895438,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12435.00000,3606.15000,Aetna,First Health,,10171.83,,,,,,,4482.82,10171.83,percent of total billed charges,
CROWN STEALTH,7895438,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12435.00000,3606.15000,Aetna,First Health,,10171.83,,,,,,,4004.07,10171.83,percent of total billed charges,
CROWN STEALTH,7905197,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12435.00000,3606.15000,Aetna,First Health,,10171.83,,,,,,,4482.82,10171.83,percent of total billed charges,
CROWN STEALTH,7905197,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12435.00000,3606.15000,Aetna,First Health,,10171.83,,,,,,,4004.07,10171.83,percent of total billed charges,
CATHETER,7913195,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12435.00000,3606.15000,Aetna,First Health,,10171.83,,,,,,,4482.82,10171.83,percent of total billed charges,
CATHETER,7913195,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12435.00000,3606.15000,Aetna,First Health,,10171.83,,,,,,,4004.07,10171.83,percent of total billed charges,
GUIDEWIRE,7921035,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,189.63000,54.99000,Aetna,First Health,,155.12,,,,,,,68.36,155.12,percent of total billed charges,
GUIDEWIRE,7921035,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,189.63000,54.99000,Aetna,First Health,,155.12,,,,,,,61.06,155.12,percent of total billed charges,
CATHETER,7695243,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,15512.50000,4498.62000,Aetna,First Health,,12689.23,,,,,,,5592.26,12689.23,percent of total billed charges,
CATHETER,7695243,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,15512.50000,4498.62000,Aetna,First Health,,12689.23,,,,,,,4995.02,12689.23,percent of total billed charges,
GUIDEWIRE,8135965,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,148.68000,43.12000,Aetna,First Health,,121.62,,,,,,,53.60,121.62,percent of total billed charges,
GUIDEWIRE,8135965,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,148.68000,43.12000,Aetna,First Health,,121.62,,,,,,,47.87,121.62,percent of total billed charges,
GUIDEWIRE,8135966,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,489.25000,141.88000,Aetna,First Health,,400.21,,,,,,,176.37,400.21,percent of total billed charges,
GUIDEWIRE,8135966,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,489.25000,141.88000,Aetna,First Health,,400.21,,,,,,,157.54,400.21,percent of total billed charges,
BALLOON,8135969,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
BALLOON,8135969,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
BALLOON,8135970,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
BALLOON,8135970,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
BALLOON,8135972,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,947.88,2150.82,percent of total billed charges,
BALLOON,8135972,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,846.65,2150.82,percent of total billed charges,
BALLOON,8135973,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,947.88,2150.82,percent of total billed charges,
BALLOON,8135973,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,846.65,2150.82,percent of total billed charges,
BALLOON,8135974,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,947.88,2150.82,percent of total billed charges,
BALLOON,8135974,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,846.65,2150.82,percent of total billed charges,
BALLOON,8135975,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,947.88,2150.82,percent of total billed charges,
BALLOON,8135975,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,846.65,2150.82,percent of total billed charges,
BALLOON,8135976,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,947.88,2150.82,percent of total billed charges,
BALLOON,8135976,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,846.65,2150.82,percent of total billed charges,
GUIDEWIRE,8135977,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,214.62000,62.24000,Aetna,First Health,,175.56,,,,,,,77.37,175.56,percent of total billed charges,
GUIDEWIRE,8135977,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,214.62000,62.24000,Aetna,First Health,,175.56,,,,,,,69.11,175.56,percent of total billed charges,
BALLOON CATHETER,7750490,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750490,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7750493,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750493,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
INTRODUCER SHEATH,8135981,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,113.30000,32.86000,Aetna,First Health,,92.68,,,,,,,40.84,92.68,percent of total billed charges,
INTRODUCER SHEATH,8135981,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,113.30000,32.86000,Aetna,First Health,,92.68,,,,,,,36.48,92.68,percent of total billed charges,
GUIDEWIRE,8135971,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,728.10000,211.15000,Aetna,First Health,,595.59,,,,,,,262.48,595.59,percent of total billed charges,
GUIDEWIRE,8135971,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,728.10000,211.15000,Aetna,First Health,,595.59,,,,,,,234.45,595.59,percent of total billed charges,
CATHETER,7950525,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
CATHETER,7950525,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
GUIDEWIRE,8135968,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,173.67000,50.36000,Aetna,First Health,,142.06,,,,,,,62.61,142.06,percent of total billed charges,
GUIDEWIRE,8135968,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,173.67000,50.36000,Aetna,First Health,,142.06,,,,,,,55.92,142.06,percent of total billed charges,
GUIDEWIRE,7694369,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
GUIDEWIRE,7694369,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
GUIDEWIRE,8135565,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,207.38000,60.14000,Aetna,First Health,,169.64,,,,,,,74.76,169.64,percent of total billed charges,
GUIDEWIRE,8135565,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,207.38000,60.14000,Aetna,First Health,,169.64,,,,,,,66.78,169.64,percent of total billed charges,
INTRODUCER,8135983,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,133.35000,38.67000,Aetna,First Health,,109.08,,,,,,,48.07,109.08,percent of total billed charges,
INTRODUCER,8135983,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,133.35000,38.67000,Aetna,First Health,,109.08,,,,,,,42.94,109.08,percent of total billed charges,
INTRODUCER,8135982,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
INTRODUCER,8135982,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
GUIDEWIRE,8135463,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
GUIDEWIRE,8135463,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
SCREW,7696901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7696901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7697192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7697192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7697430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7697430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7697473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,164.39,373.01,percent of total billed charges,
SCREW,7697473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,146.83,373.01,percent of total billed charges,
SCREW,7697904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7697904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7697907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7697907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7698130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,964.35000,279.66000,Aetna,First Health,,788.84,,,,,,,347.65,788.84,percent of total billed charges,
SCREW,7698130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,964.35000,279.66000,Aetna,First Health,,788.84,,,,,,,310.52,788.84,percent of total billed charges,
SCREW,7698956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,164.39,373.01,percent of total billed charges,
SCREW,7698956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,146.83,373.01,percent of total billed charges,
SCREW,7699086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,7699086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,7699087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,7699087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,7699088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,7699088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,7699089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,7699089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,7699130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,164.39,373.01,percent of total billed charges,
SCREW,7699130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,146.83,373.01,percent of total billed charges,
SCREW,7699131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,164.39,373.01,percent of total billed charges,
SCREW,7699131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,First Health,,373.01,,,,,,,146.83,373.01,percent of total billed charges,
SCREW,7700162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7700162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7700299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7700299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7700300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7700300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7700930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7700930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,7700931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7700931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,7700932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7700932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,7700934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7700934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,7701932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7701932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7701933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7701933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7701934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7701934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7701943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7701943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7701944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7701944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7701945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7701945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7701946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7701946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7701947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7701947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7758068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7758068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7758069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7758069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7760139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,7760139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,7806374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7806374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7806376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7806376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7806378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7806378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7880521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7880521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7893980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7893980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7897082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7897082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7912613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1227.20000,355.89000,Aetna,First Health,,1003.85,,,,,,,442.41,1003.85,percent of total billed charges,
SCREW,7912613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1227.20000,355.89000,Aetna,First Health,,1003.85,,,,,,,395.16,1003.85,percent of total billed charges,
SCREW,7920467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7920467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,7926974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7926974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7926975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7926975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7930261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7930261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,7939810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7939810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7940889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7940889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,7943368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,283.89,644.17,percent of total billed charges,
SCREW,7943368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,253.57,644.17,percent of total billed charges,
SCREW,7943371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,283.89,644.17,percent of total billed charges,
SCREW,7943371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,253.57,644.17,percent of total billed charges,
SCREW,7966079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7966079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7703167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1227.20000,355.89000,Aetna,First Health,,1003.85,,,,,,,442.41,1003.85,percent of total billed charges,
SCREW,7703167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1227.20000,355.89000,Aetna,First Health,,1003.85,,,,,,,395.16,1003.85,percent of total billed charges,
BAND ANNULOPLASTY,7702703,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,2097.03,4758.31,percent of total billed charges,
BAND ANNULOPLASTY,7702703,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,1873.07,4758.31,percent of total billed charges,
BAND ANNULOPLASTY,7702704,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,2097.03,4758.31,percent of total billed charges,
BAND ANNULOPLASTY,7702704,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,1873.07,4758.31,percent of total billed charges,
BAND ANNULOPLASTY,7741715,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,2097.03,4758.31,percent of total billed charges,
BAND ANNULOPLASTY,7741715,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,1873.07,4758.31,percent of total billed charges,
BAND ANNULOPLASTY,7702705,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,2097.03,4758.31,percent of total billed charges,
BAND ANNULOPLASTY,7702705,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,1873.07,4758.31,percent of total billed charges,
BAND ANNULOPLASTY,7784068,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,2097.03,4758.31,percent of total billed charges,
BAND ANNULOPLASTY,7784068,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,First Health,,4758.31,,,,,,,1873.07,4758.31,percent of total billed charges,
INTRODUCER,7694515,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
INTRODUCER,7694515,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
INTRODUCER,7695328,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,451.25000,130.86000,Aetna,First Health,,369.12,,,,,,,162.68,369.12,percent of total billed charges,
INTRODUCER,7695328,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,451.25000,130.86000,Aetna,First Health,,369.12,,,,,,,145.30,369.12,percent of total billed charges,
INTRODUCER,7696831,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,360.86000,104.65000,Aetna,First Health,,295.18,,,,,,,130.09,295.18,percent of total billed charges,
INTRODUCER,7696831,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,360.86000,104.65000,Aetna,First Health,,295.18,,,,,,,116.20,295.18,percent of total billed charges,
GUIDEWIRE,7695596,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,545.40000,158.17000,Aetna,First Health,,446.14,,,,,,,196.62,446.14,percent of total billed charges,
GUIDEWIRE,7695596,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,545.40000,158.17000,Aetna,First Health,,446.14,,,,,,,175.62,446.14,percent of total billed charges,
SCREW,7700512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
SCREW,7700512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,7903625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
SCREW,7903625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,7916584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
SCREW,7916584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,7703079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
SCREW,7703079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,7703080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
SCREW,7703080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,7703081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
SCREW,7703081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,7703082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
SCREW,7703082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,7703083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
SCREW,7703083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,7703248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
SCREW,7703248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
PLATE,7698481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5541.90000,1607.15000,Aetna,First Health,,4533.27,,,,,,,1997.85,4533.27,percent of total billed charges,
PLATE,7698481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5541.90000,1607.15000,Aetna,First Health,,4533.27,,,,,,,1784.49,4533.27,percent of total billed charges,
PLATE,7700652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3559.50000,1032.25000,Aetna,First Health,,2911.67,,,,,,,1283.20,2911.67,percent of total billed charges,
PLATE,7700652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3559.50000,1032.25000,Aetna,First Health,,2911.67,,,,,,,1146.16,2911.67,percent of total billed charges,
PLATE,7707528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3444.00000,998.76000,Aetna,First Health,,2817.19,,,,,,,1241.56,2817.19,percent of total billed charges,
PLATE,7707528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3444.00000,998.76000,Aetna,First Health,,2817.19,,,,,,,1108.97,2817.19,percent of total billed charges,
GRAFT,7696884,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2489.64000,722.00000,Aetna,First Health,,2036.53,,,,,,,897.52,2036.53,percent of total billed charges,
GRAFT,7696884,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2489.64000,722.00000,Aetna,First Health,,2036.53,,,,,,,801.66,2036.53,percent of total billed charges,
SCREW,7695819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,180.50000,52.34000,Aetna,First Health,,147.65,,,,,,,65.07,147.65,percent of total billed charges,
SCREW,7695819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,180.50000,52.34000,Aetna,First Health,,147.65,,,,,,,58.12,147.65,percent of total billed charges,
SCREW,7699457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7699457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7699806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7699806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7702127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7702127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7707493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7707493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7740884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,114.73,260.33,percent of total billed charges,
SCREW,7740884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,102.48,260.33,percent of total billed charges,
SCREW,7740885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,114.73,260.33,percent of total billed charges,
SCREW,7740885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,102.48,260.33,percent of total billed charges,
SCREW,7802402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,116.29,263.86,percent of total billed charges,
SCREW,7802402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,103.87,263.86,percent of total billed charges,
SCREW,7834151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7834151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7836162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7836162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7880285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,7880285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
SCREW,7880286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,7880286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
SCREW,7894167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,180.50000,52.34000,Aetna,First Health,,147.65,,,,,,,65.07,147.65,percent of total billed charges,
SCREW,7894167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,180.50000,52.34000,Aetna,First Health,,147.65,,,,,,,58.12,147.65,percent of total billed charges,
SCREW,7894168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7894168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7902588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7902588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7903565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7903565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7905299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7905299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7917351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7917351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7703090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,467.40000,135.55000,Aetna,First Health,,382.33,,,,,,,168.50,382.33,percent of total billed charges,
SCREW,7703090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,467.40000,135.55000,Aetna,First Health,,382.33,,,,,,,150.50,382.33,percent of total billed charges,
SCREW,7696762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7696762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7697497,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7697497,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7697498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7697498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7697511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7697511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7697554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7697554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7697630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7697630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7697667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7697667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7697899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7697899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7698001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,114.73,260.33,percent of total billed charges,
SCREW,7698001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,102.48,260.33,percent of total billed charges,
SCREW,7698002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,114.73,260.33,percent of total billed charges,
SCREW,7698002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,102.48,260.33,percent of total billed charges,
SCREW,7698273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7698273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7698750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7698750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7698751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7698751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7698752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7698752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7698753,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7698753,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7698754,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7698754,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7700265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7700265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7700383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7700383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7700386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7700386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7700859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7700859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7701026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7701026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7701251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7790473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7790473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7790474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7790474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7790476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7790476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7893330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7893330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7894222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7894222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7894223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7894223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7894224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7894224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7894225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7894225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7894226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7894226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7894227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,68.06,154.43,percent of total billed charges,
SCREW,7894227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,First Health,,154.43,,,,,,,60.79,154.43,percent of total billed charges,
SCREW,7939328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7939328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7948217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,122.78,278.59,percent of total billed charges,
SCREW,7948217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,109.67,278.59,percent of total billed charges,
SCREW,7703124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,156.61000,45.42000,Aetna,First Health,,128.11,,,,,,,56.46,128.11,percent of total billed charges,
SCREW,7703124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,156.61000,45.42000,Aetna,First Health,,128.11,,,,,,,50.43,128.11,percent of total billed charges,
SCREW,7703126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7703126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7703127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7703127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7703130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7703130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7703132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7703132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7703133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7703133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7703157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7703157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7703158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7703158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7703162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7703162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7703231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7703231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
CATHETER,7702804,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,451.11000,130.82000,Aetna,First Health,,369.01,,,,,,,162.63,369.01,percent of total billed charges,
CATHETER,7702804,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,451.11000,130.82000,Aetna,First Health,,369.01,,,,,,,145.26,369.01,percent of total billed charges,
CATHETER,7702799,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,222.77,505.47,percent of total billed charges,
CATHETER,7702799,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,198.98,505.47,percent of total billed charges,
CATHETER,7694470,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,1744.00000,505.76000,Aetna,First Health,,1426.59,,,,,,,628.71,1426.59,percent of total billed charges,
CATHETER,7694470,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,1744.00000,505.76000,Aetna,First Health,,1426.59,,,,,,,561.57,1426.59,percent of total billed charges,
RETRIEVAL DEVICE,7701195,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
RETRIEVAL DEVICE,7701195,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW,7695335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7695335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7695336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7695336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7695337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7695337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7696261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,398.00000,115.42000,Aetna,First Health,,325.56,,,,,,,143.48,325.56,percent of total billed charges,
SCREW,7696261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,398.00000,115.42000,Aetna,First Health,,325.56,,,,,,,128.16,325.56,percent of total billed charges,
SCREW,7696527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7696527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7696528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7696528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7696572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7696572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7696573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7696573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7696591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7696591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7696889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7696889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7697157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7697157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7697237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7697237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7698502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7698502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7698650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,398.00000,115.42000,Aetna,First Health,,325.56,,,,,,,143.48,325.56,percent of total billed charges,
SCREW,7698650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,398.00000,115.42000,Aetna,First Health,,325.56,,,,,,,128.16,325.56,percent of total billed charges,
SCREW,7699875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,300.28,681.35,percent of total billed charges,
SCREW,7699875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,268.21,681.35,percent of total billed charges,
SCREW,7700223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,335.87000,97.40000,Aetna,First Health,,274.74,,,,,,,121.08,274.74,percent of total billed charges,
SCREW,7700223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,335.87000,97.40000,Aetna,First Health,,274.74,,,,,,,108.15,274.74,percent of total billed charges,
SCREW,7700577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,7700577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,7700578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,7700578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,7700579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,7700579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,7700580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,7700580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,7700843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,398.00000,115.42000,Aetna,First Health,,325.56,,,,,,,143.48,325.56,percent of total billed charges,
SCREW,7700843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,398.00000,115.42000,Aetna,First Health,,325.56,,,,,,,128.16,325.56,percent of total billed charges,
SCREW,7702164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,167.81,380.78,percent of total billed charges,
SCREW,7702164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,149.89,380.78,percent of total billed charges,
SCREW,7702165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,167.81,380.78,percent of total billed charges,
SCREW,7702165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,149.89,380.78,percent of total billed charges,
SCREW,7744542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7744542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7911375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7911375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7927549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7927549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7703030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7703030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7703249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7703249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7695818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7695818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7696259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7696259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7698833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7698833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7699317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7699317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7699318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7699318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7699380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7699380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7699381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7699381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7699405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,7699405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,7701171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,47.32,107.36,percent of total billed charges,
SCREW,7701171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,42.26,107.36,percent of total billed charges,
SCREW,7701172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,47.32,107.36,percent of total billed charges,
SCREW,7701172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,42.26,107.36,percent of total billed charges,
SCREW,7701173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,47.32,107.36,percent of total billed charges,
SCREW,7701173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,42.26,107.36,percent of total billed charges,
SCREW,7701174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,47.32,107.36,percent of total billed charges,
SCREW,7701174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,42.26,107.36,percent of total billed charges,
SCREW,7701175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,47.32,107.36,percent of total billed charges,
SCREW,7701175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,42.26,107.36,percent of total billed charges,
SCREW,7701176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,47.32,107.36,percent of total billed charges,
SCREW,7701176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,42.26,107.36,percent of total billed charges,
SCREW,7701177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,47.32,107.36,percent of total billed charges,
SCREW,7701177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,42.26,107.36,percent of total billed charges,
SCREW,7701178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,47.32,107.36,percent of total billed charges,
SCREW,7701178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,42.26,107.36,percent of total billed charges,
SCREW,7701382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
SCREW,7701387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,7701389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
SCREW,7701389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,7701390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
SCREW,7701390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,7701391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
SCREW,7701391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,7701392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
SCREW,7701394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,7701395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
SCREW,7701395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,7701396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
SCREW,7701396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,7701397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
SCREW,7701397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,7701398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
SCREW,7701398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,7701426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7701444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,7701444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,7748123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7748123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7707530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7707530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7703118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
SCREW,7703138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7703138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
ANCHOR,7702153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,670.53,1521.48,percent of total billed charges,
ANCHOR,7702153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,598.92,1521.48,percent of total billed charges,
ANCHOR,7776067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1820.00000,527.80000,Aetna,First Health,,1488.76,,,,,,,656.11,1488.76,percent of total billed charges,
ANCHOR,7776067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1820.00000,527.80000,Aetna,First Health,,1488.76,,,,,,,586.04,1488.76,percent of total billed charges,
STENT,7695658,CDM,278,RC,C1877,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
STENT,7695658,CDM,278,RC,C1877,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PLATE,7695889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1328.00000,385.12000,Aetna,First Health,,1086.30,,,,,,,478.74,1086.30,percent of total billed charges,
PLATE,7695889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1328.00000,385.12000,Aetna,First Health,,1086.30,,,,,,,427.62,1086.30,percent of total billed charges,
PLATE,7698174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1328.00000,385.12000,Aetna,First Health,,1086.30,,,,,,,478.74,1086.30,percent of total billed charges,
PLATE,7698174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1328.00000,385.12000,Aetna,First Health,,1086.30,,,,,,,427.62,1086.30,percent of total billed charges,
PLATE,7700037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,166.10,376.89,percent of total billed charges,
PLATE,7700037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,148.36,376.89,percent of total billed charges,
PLATE,7700161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,166.10,376.89,percent of total billed charges,
PLATE,7700161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,148.36,376.89,percent of total billed charges,
PLATE,7700331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
PLATE,7700331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
PLATE,7909416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,378.77000,109.84000,Aetna,First Health,,309.83,,,,,,,136.55,309.83,percent of total billed charges,
PLATE,7909416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,378.77000,109.84000,Aetna,First Health,,309.83,,,,,,,121.96,309.83,percent of total billed charges,
PLATE,7702989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,389.83000,113.05000,Aetna,First Health,,318.88,,,,,,,140.53,318.88,percent of total billed charges,
PLATE,7702989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,389.83000,113.05000,Aetna,First Health,,318.88,,,,,,,125.53,318.88,percent of total billed charges,
PLATE,7702991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,389.83000,113.05000,Aetna,First Health,,318.88,,,,,,,140.53,318.88,percent of total billed charges,
PLATE,7702991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,389.83000,113.05000,Aetna,First Health,,318.88,,,,,,,125.53,318.88,percent of total billed charges,
SCREW,7695542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7695542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7695579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7695579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7695854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7695854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7696444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7696444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7696661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1544.00000,447.76000,Aetna,First Health,,1262.99,,,,,,,556.61,1262.99,percent of total billed charges,
SCREW,7696661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1544.00000,447.76000,Aetna,First Health,,1262.99,,,,,,,497.17,1262.99,percent of total billed charges,
SCREW,7697127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,436.93,991.42,percent of total billed charges,
SCREW,7697127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,390.26,991.42,percent of total billed charges,
SCREW,7697378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7697378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7697504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,565.26,1282.62,percent of total billed charges,
SCREW,7697504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,504.90,1282.62,percent of total billed charges,
SCREW,7697980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,400.90000,116.26000,Aetna,First Health,,327.94,,,,,,,144.52,327.94,percent of total billed charges,
SCREW,7697980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,400.90000,116.26000,Aetna,First Health,,327.94,,,,,,,129.09,327.94,percent of total billed charges,
SCREW,7698179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7698179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7698180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7698180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7698181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,174.66,396.32,percent of total billed charges,
SCREW,7698181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,156.01,396.32,percent of total billed charges,
SCREW,7698199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
SCREW,7698199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
SCREW,7698200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
SCREW,7698200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
SCREW,7698201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
SCREW,7698201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
SCREW,7698202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
SCREW,7698202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
SCREW,7698203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
SCREW,7698203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
SCREW,7698204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
SCREW,7698204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
SCREW,7698205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
SCREW,7698205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
SCREW,7698350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
SCREW,7698350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
SCREW,7698537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7698537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7698703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7698703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7698704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7698704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7698999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7698999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7699177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7699177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7699276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,241.72,548.47,percent of total billed charges,
SCREW,7699361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,215.90,548.47,percent of total billed charges,
SCREW,7700222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,118.68,269.30,percent of total billed charges,
SCREW,7700222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,106.01,269.30,percent of total billed charges,
SCREW,7700793,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7700793,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7701616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7701930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7701930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7702178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,578.03000,167.63000,Aetna,First Health,,472.83,,,,,,,208.38,472.83,percent of total billed charges,
SCREW,7702178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,578.03000,167.63000,Aetna,First Health,,472.83,,,,,,,186.13,472.83,percent of total billed charges,
SCREW,7702180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,578.03000,167.63000,Aetna,First Health,,472.83,,,,,,,208.38,472.83,percent of total billed charges,
SCREW,7702180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,578.03000,167.63000,Aetna,First Health,,472.83,,,,,,,186.13,472.83,percent of total billed charges,
SCREW,7702223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7702225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.35000,114.07000,Aetna,First Health,,321.76,,,,,,,141.80,321.76,percent of total billed charges,
SCREW,7702378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.35000,114.07000,Aetna,First Health,,321.76,,,,,,,126.66,321.76,percent of total billed charges,
SCREW,7702379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.35000,114.07000,Aetna,First Health,,321.76,,,,,,,141.80,321.76,percent of total billed charges,
SCREW,7702379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.35000,114.07000,Aetna,First Health,,321.76,,,,,,,126.66,321.76,percent of total billed charges,
SCREW,7702380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.35000,114.07000,Aetna,First Health,,321.76,,,,,,,141.80,321.76,percent of total billed charges,
SCREW,7702380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.35000,114.07000,Aetna,First Health,,321.76,,,,,,,126.66,321.76,percent of total billed charges,
SCREW,7702381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.35000,114.07000,Aetna,First Health,,321.76,,,,,,,141.80,321.76,percent of total billed charges,
SCREW,7702381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.35000,114.07000,Aetna,First Health,,321.76,,,,,,,126.66,321.76,percent of total billed charges,
SCREW,7702382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.87000,108.71000,Aetna,First Health,,306.64,,,,,,,135.14,306.64,percent of total billed charges,
SCREW,7702382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.87000,108.71000,Aetna,First Health,,306.64,,,,,,,120.71,306.64,percent of total billed charges,
SCREW,7702383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.87000,108.71000,Aetna,First Health,,306.64,,,,,,,135.14,306.64,percent of total billed charges,
SCREW,7702383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.87000,108.71000,Aetna,First Health,,306.64,,,,,,,120.71,306.64,percent of total billed charges,
SCREW,7702384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.87000,108.71000,Aetna,First Health,,306.64,,,,,,,135.14,306.64,percent of total billed charges,
SCREW,7702384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.87000,108.71000,Aetna,First Health,,306.64,,,,,,,120.71,306.64,percent of total billed charges,
SCREW,7702385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.87000,108.71000,Aetna,First Health,,306.64,,,,,,,135.14,306.64,percent of total billed charges,
SCREW,7702385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.87000,108.71000,Aetna,First Health,,306.64,,,,,,,120.71,306.64,percent of total billed charges,
SCREW,7736279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7736279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7736609,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7736609,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7748752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7748752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7756058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,770.85000,223.55000,Aetna,First Health,,630.56,,,,,,,277.89,630.56,percent of total billed charges,
SCREW,7756058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,770.85000,223.55000,Aetna,First Health,,630.56,,,,,,,248.21,630.56,percent of total billed charges,
SCREW,7772047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7772047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7772048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7772048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7772052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7772052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7772053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7772053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7772064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7772064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
SCREW,7784185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7784185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7810069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7810069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7816127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7816127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7834035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7834035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7874120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7874120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7904802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7904802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7916928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7916928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7703092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,454.29000,131.74000,Aetna,First Health,,371.61,,,,,,,163.77,371.61,percent of total billed charges,
SCREW,7703092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,454.29000,131.74000,Aetna,First Health,,371.61,,,,,,,146.28,371.61,percent of total billed charges,
PROGRAMMER,7699770,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3732.75000,1082.50000,Aetna,First Health,,3053.39,,,,,,,1345.66,3053.39,percent of total billed charges,
PROGRAMMER,7699770,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3732.75000,1082.50000,Aetna,First Health,,3053.39,,,,,,,1201.95,3053.39,percent of total billed charges,
CATHETER,7698545,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
CATHETER,7698545,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
CATHETER,7893416,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
CATHETER,7893416,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
CATHETER,7894160,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
CATHETER,7894160,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
CATHETER,7935069,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,577.80000,167.56000,Aetna,First Health,,472.64,,,,,,,208.30,472.64,percent of total billed charges,
CATHETER,7935069,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,577.80000,167.56000,Aetna,First Health,,472.64,,,,,,,186.05,472.64,percent of total billed charges,
SCREW,7699350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7699350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7699351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7699351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7699352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7699352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7699733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7699733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7699734,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7699734,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7700816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7700816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7700817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7700817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7700818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7700818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7702616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7702616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7702617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7702617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7736125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7736125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7736205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7736205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7832056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7832056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7904847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7904847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
GUIDEWIRE,7699721,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,166.53000,48.29000,Aetna,First Health,,136.22,,,,,,,60.03,136.22,percent of total billed charges,
GUIDEWIRE,7699721,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,166.53000,48.29000,Aetna,First Health,,136.22,,,,,,,53.62,136.22,percent of total billed charges,
GRAFT,7696121,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1951.93,4429.06,percent of total billed charges,
GRAFT,7696121,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1743.47,4429.06,percent of total billed charges,
GRAFT,7696122,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1951.93,4429.06,percent of total billed charges,
GRAFT,7696122,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1743.47,4429.06,percent of total billed charges,
GRAFT,7696306,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5498.50000,1594.56000,Aetna,First Health,,4497.77,,,,,,,1982.21,4497.77,percent of total billed charges,
GRAFT,7696306,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5498.50000,1594.56000,Aetna,First Health,,4497.77,,,,,,,1770.52,4497.77,percent of total billed charges,
GRAFT,7696307,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5498.50000,1594.56000,Aetna,First Health,,4497.77,,,,,,,1982.21,4497.77,percent of total billed charges,
GRAFT,7696307,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5498.50000,1594.56000,Aetna,First Health,,4497.77,,,,,,,1770.52,4497.77,percent of total billed charges,
GRAFT,7905615,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5579.00000,1617.91000,Aetna,First Health,,4563.62,,,,,,,2011.23,4563.62,percent of total billed charges,
GRAFT,7905615,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5579.00000,1617.91000,Aetna,First Health,,4563.62,,,,,,,1796.44,4563.62,percent of total billed charges,
GUIDEWIRE,7695597,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,290.06,658.16,percent of total billed charges,
GUIDEWIRE,7695597,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,259.08,658.16,percent of total billed charges,
GUIDEWIRE,7695598,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,290.06,658.16,percent of total billed charges,
GUIDEWIRE,7695598,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,259.08,658.16,percent of total billed charges,
GRAFT,7696502,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,10962.00000,3178.98000,Aetna,First Health,,8966.92,,,,,,,3951.80,8966.92,percent of total billed charges,
GRAFT,7696502,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,10962.00000,3178.98000,Aetna,First Health,,8966.92,,,,,,,3529.76,8966.92,percent of total billed charges,
GRAFT,7702871,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1120.28,2541.98,percent of total billed charges,
GRAFT,7702871,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,First Health,,2541.98,,,,,,,1000.63,2541.98,percent of total billed charges,
ROD,7902528,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD,7902528,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ROD,7902534,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD,7902534,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
GLIDEWIRE,7695881,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,311.13000,90.23000,Aetna,First Health,,254.50,,,,,,,112.16,254.50,percent of total billed charges,
GLIDEWIRE,7695881,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,311.13000,90.23000,Aetna,First Health,,254.50,,,,,,,100.18,254.50,percent of total billed charges,
GLIDEWIRE,7703359,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
GLIDEWIRE,7703359,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
LEAD,7760132,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
LEAD,7760132,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
TISSUE EXPANDER,7697121,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697121,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697122,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697122,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697123,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697123,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697124,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697124,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697125,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697125,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697939,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7697939,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7698092,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7698092,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7698346,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7698346,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7701622,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7701622,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7702287,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7702287,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7702643,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7702643,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736051,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736051,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736248,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736248,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736306,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736306,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736308,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736308,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736310,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736310,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736311,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736311,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736312,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736312,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736314,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736314,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736366,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736366,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736317,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736317,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736319,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736319,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736320,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736320,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736321,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736321,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736322,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736322,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736323,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736323,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736324,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
TISSUE EXPANDER,7736324,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
SHUNT,7697166,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
SHUNT,7697166,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
SHUNT,7697631,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8502.00000,2465.58000,Aetna,First Health,,6954.64,,,,,,,3064.97,6954.64,percent of total billed charges,
SHUNT,7697631,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8502.00000,2465.58000,Aetna,First Health,,6954.64,,,,,,,2737.64,6954.64,percent of total billed charges,
STENT,7694670,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,418.19000,121.28000,Aetna,First Health,,342.08,,,,,,,150.76,342.08,percent of total billed charges,
STENT,7694670,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,418.19000,121.28000,Aetna,First Health,,342.08,,,,,,,134.66,342.08,percent of total billed charges,
ANCHOR,7695304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,665.84,1510.85,percent of total billed charges,
ANCHOR,7695304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,594.73,1510.85,percent of total billed charges,
ANCHOR,7697170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
ANCHOR,7697170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
ANCHOR,7784036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,First Health,,1476.49,,,,,,,650.70,1476.49,percent of total billed charges,
ANCHOR,7784036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,First Health,,1476.49,,,,,,,581.21,1476.49,percent of total billed charges,
ANCHOR,7903142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,First Health,,1476.49,,,,,,,650.70,1476.49,percent of total billed charges,
ANCHOR,7903142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,First Health,,1476.49,,,,,,,581.21,1476.49,percent of total billed charges,
ANCHOR,7935397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,First Health,,1476.49,,,,,,,650.70,1476.49,percent of total billed charges,
ANCHOR,7935397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,First Health,,1476.49,,,,,,,581.21,1476.49,percent of total billed charges,
ANCHOR,7965092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2384.00000,691.36000,Aetna,First Health,,1950.11,,,,,,,859.43,1950.11,percent of total billed charges,
ANCHOR,7965092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2384.00000,691.36000,Aetna,First Health,,1950.11,,,,,,,767.65,1950.11,percent of total billed charges,
SHEATH,7700121,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2036.00000,590.44000,Aetna,First Health,,1665.45,,,,,,,733.98,1665.45,percent of total billed charges,
SHEATH,7700121,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2036.00000,590.44000,Aetna,First Health,,1665.45,,,,,,,655.59,1665.45,percent of total billed charges,
SHEATH,7945855,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3881.50000,1125.64000,Aetna,First Health,,3175.07,,,,,,,1399.28,3175.07,percent of total billed charges,
SHEATH,7945855,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3881.50000,1125.64000,Aetna,First Health,,3175.07,,,,,,,1249.84,3175.07,percent of total billed charges,
SHEATH,7948838,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3881.50000,1125.64000,Aetna,First Health,,3175.07,,,,,,,1399.28,3175.07,percent of total billed charges,
SHEATH,7948838,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3881.50000,1125.64000,Aetna,First Health,,3175.07,,,,,,,1249.84,3175.07,percent of total billed charges,
SHEATH,7954476,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3881.50000,1125.64000,Aetna,First Health,,3175.07,,,,,,,1399.28,3175.07,percent of total billed charges,
SHEATH,7954476,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3881.50000,1125.64000,Aetna,First Health,,3175.07,,,,,,,1249.84,3175.07,percent of total billed charges,
SHEATH,7954477,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3881.50000,1125.64000,Aetna,First Health,,3175.07,,,,,,,1399.28,3175.07,percent of total billed charges,
SHEATH,7954477,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3881.50000,1125.64000,Aetna,First Health,,3175.07,,,,,,,1249.84,3175.07,percent of total billed charges,
CATHETER,7694752,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1560.80000,452.63000,Aetna,First Health,,1276.73,,,,,,,562.67,1276.73,percent of total billed charges,
CATHETER,7694752,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1560.80000,452.63000,Aetna,First Health,,1276.73,,,,,,,502.58,1276.73,percent of total billed charges,
GUIDEWIRE,7697259,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
GUIDEWIRE,7697259,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
IAB CATHETER,8135556,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
IAB CATHETER,8135556,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
IAB CATHETER,8135557,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
IAB CATHETER,8135557,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
CATHETER,8135590,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
CATHETER,8135590,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,9959.00,percent of total billed charges,
CATHETER,8135623,CDM,278,RC,C2630,HCPCS,,,facility,inpatient,,,6618.50000,1919.36000,Aetna,First Health,,5413.93,,,,,,,2385.97,5413.93,percent of total billed charges,
CATHETER,8135623,CDM,278,RC,C2630,HCPCS,,,facility,outpatient,,,6618.50000,1919.36000,Aetna,First Health,,5413.93,,,,,,,2131.16,9959.00,percent of total billed charges,
CATHETER ABLATION,8135470,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1242.82,2820.05,percent of total billed charges,
CATHETER ABLATION,8135470,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1110.10,9959.00,percent of total billed charges,
CATHETER ABLATION,8135468,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1242.82,2820.05,percent of total billed charges,
CATHETER ABLATION,8135468,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1110.10,9959.00,percent of total billed charges,
ABLATION CATHETER,8135466,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1242.82,2820.05,percent of total billed charges,
ABLATION CATHETER,8135466,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1110.10,9959.00,percent of total billed charges,
ABLATION CATHETER,8135467,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1242.82,2820.05,percent of total billed charges,
ABLATION CATHETER,8135467,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1110.10,9959.00,percent of total billed charges,
CATHETER ABLATION,8135465,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1242.82,2820.05,percent of total billed charges,
CATHETER ABLATION,8135465,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1110.10,9959.00,percent of total billed charges,
CATHETER ABLATION,8135471,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1242.82,2820.05,percent of total billed charges,
CATHETER ABLATION,8135471,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1110.10,9959.00,percent of total billed charges,
GUIDEWIRE,7694948,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,201.16,456.44,percent of total billed charges,
GUIDEWIRE,7694948,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,179.68,456.44,percent of total billed charges,
GUIDEWIRE,7848087,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,201.16,456.44,percent of total billed charges,
GUIDEWIRE,7848087,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,179.68,456.44,percent of total billed charges,
GUIDEWIRE,8135663,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,8135663,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
WIRE,8135618,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
WIRE,8135618,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
GUIDEWIRE,8135563,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,8135563,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
WIRE,8135619,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
WIRE,8135619,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
GUIDEWIRE,8135574,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,8135574,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
ANGIOJET,8135593,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2752.42,6245.43,percent of total billed charges,
ANGIOJET,8135593,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2458.47,6245.43,percent of total billed charges,
CATHETER THROMBECTOMY,8135575,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2752.42,6245.43,percent of total billed charges,
CATHETER THROMBECTOMY,8135575,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2458.47,6245.43,percent of total billed charges,
INTERBODY,8135585,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,804.83000,233.40000,Aetna,First Health,,658.35,,,,,,,290.14,658.35,percent of total billed charges,
INTERBODY,8135585,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,804.83000,233.40000,Aetna,First Health,,658.35,,,,,,,259.16,658.35,percent of total billed charges,
STENT,8135412,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8135412,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8136299,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8136299,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8136302,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8136302,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8136303,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8136303,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8136304,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8136304,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8135653,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8135653,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8135652,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8135652,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8135643,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8135643,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8135654,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8135654,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8135655,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8135655,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT CORONARY,8135415,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT CORONARY,8135415,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT CORONARY,8135416,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT CORONARY,8135416,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT CORONARY,8135417,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT CORONARY,8135417,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT CORONARY,8135418,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT CORONARY,8135418,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT CORONARY,8135419,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT CORONARY,8135419,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8135421,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8135421,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8135424,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8135424,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8135425,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8135425,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT CORONARY,8135427,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT CORONARY,8135427,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT CORONARY,8135428,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT CORONARY,8135428,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT CORONARY,8135429,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT CORONARY,8135429,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
CATHETER,8135605,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
CATHETER,8135605,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
FILTER,7695041,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
FILTER,7695041,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
FILTER,7736134,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
FILTER,7736134,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
CATHETER,7876183,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
CATHETER,7876183,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
CATHETER EMBOLIZATION,8135606,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,4735.50000,1373.29000,Aetna,First Health,,3873.64,,,,,,,1707.15,3873.64,percent of total billed charges,
CATHETER EMBOLIZATION,8135606,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,4735.50000,1373.29000,Aetna,First Health,,3873.64,,,,,,,1524.83,3873.64,percent of total billed charges,
CATHETER,8135662,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1988.00000,576.52000,Aetna,First Health,,1626.18,,,,,,,716.67,1626.18,percent of total billed charges,
CATHETER,8135662,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1988.00000,576.52000,Aetna,First Health,,1626.18,,,,,,,640.14,1626.18,percent of total billed charges,
SNARE SYSTEM,8135646,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2688.36000,779.62000,Aetna,First Health,,2199.08,,,,,,,969.15,2199.08,percent of total billed charges,
SNARE SYSTEM,8135646,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2688.36000,779.62000,Aetna,First Health,,2199.08,,,,,,,865.65,2199.08,percent of total billed charges,
CATHETER,8135438,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,35.30,80.09,percent of total billed charges,
CATHETER,8135438,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,31.53,80.09,percent of total billed charges,
CATHETER,8135522,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER,8135522,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135560,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135560,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135538,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135538,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135539,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135539,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135540,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135540,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135541,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135541,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135555,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135555,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135515,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135515,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135803,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,560.25000,162.47000,Aetna,First Health,,458.28,,,,,,,201.97,458.28,percent of total billed charges,
GUIDE CATHETER,8135803,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,560.25000,162.47000,Aetna,First Health,,458.28,,,,,,,180.40,458.28,percent of total billed charges,
GUIDE CATHETER,8135804,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,560.25000,162.47000,Aetna,First Health,,458.28,,,,,,,201.97,458.28,percent of total billed charges,
GUIDE CATHETER,8135804,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,560.25000,162.47000,Aetna,First Health,,458.28,,,,,,,180.40,458.28,percent of total billed charges,
CATHETER,7702691,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
CATHETER,7702691,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
CATHETER GUIDE,8135551,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135551,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135550,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135550,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135561,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135561,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135805,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,560.25000,162.47000,Aetna,First Health,,458.28,,,,,,,201.97,458.28,percent of total billed charges,
GUIDE CATHETER,8135805,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,560.25000,162.47000,Aetna,First Health,,458.28,,,,,,,180.40,458.28,percent of total billed charges,
GUIDE CATHETER,8135806,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,560.25000,162.47000,Aetna,First Health,,458.28,,,,,,,201.97,458.28,percent of total billed charges,
GUIDE CATHETER,8135806,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,560.25000,162.47000,Aetna,First Health,,458.28,,,,,,,180.40,458.28,percent of total billed charges,
GUIDE CATHETER,8135516,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135516,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135517,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135517,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135518,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135518,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER,8136569,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER,8136569,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135519,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135519,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135520,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135520,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135521,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135521,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135533,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135533,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135535,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135535,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135534,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135534,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135536,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135536,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135537,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135537,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135532,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135532,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135545,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135545,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135544,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135544,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135546,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135546,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135554,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135554,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135553,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
CATHETER GUIDE,8135553,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
GUIDE CATHETER,8135552,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135552,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135542,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135542,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135548,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135548,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135547,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135547,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135549,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135549,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135562,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
GUIDE CATHETER,8135562,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
CATHETER GUIDE,8135524,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135524,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135525,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135525,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135526,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135526,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135527,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135527,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135528,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135528,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135530,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135530,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135529,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135529,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135531,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135531,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135543,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135543,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8135656,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135656,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER,8135627,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
CATHETER,8135627,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
CATHETER GUIDE,8135649,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135649,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135602,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135602,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135495,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135495,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135499,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135499,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135497,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135497,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135490,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135490,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135491,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135491,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER ANGIO,8135498,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER ANGIO,8135498,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135492,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135492,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135501,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135501,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135475,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135475,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135502,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135502,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER,8135503,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER,8135503,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135504,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135504,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135488,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135488,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135482,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135482,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135474,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135474,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135505,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135505,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135483,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135483,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135486,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135486,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135485,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135485,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135487,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135487,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135506,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135506,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135478,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135478,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER,8135510,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER,8135510,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135494,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
CATHETER GUIDE,8135494,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
CATHETER GUIDE,8135479,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135479,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135484,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135484,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135507,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135507,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135508,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135508,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135509,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135509,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135512,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135512,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135513,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135513,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135476,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135476,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
GUIDE CATHETER,8135477,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
GUIDE CATHETER,8135477,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135500,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135500,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135481,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135481,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDE,8135493,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
CATHETER GUIDE,8135493,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
BALLOON SIZING,8135641,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2320.00000,672.80000,Aetna,First Health,,1897.76,,,,,,,836.36,1897.76,percent of total billed charges,
BALLOON SIZING,8135641,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2320.00000,672.80000,Aetna,First Health,,1897.76,,,,,,,747.04,1897.76,percent of total billed charges,
GUIDEWIRE,8135582,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,8135582,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
GUIDEWIRE,8135401,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,8135401,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
GUIDEWIRE,8135403,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,8135403,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
GUIDEWIRE FLP HI-TORQUE STR,8135443,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
GUIDEWIRE FLP HI-TORQUE STR,8135443,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
GUIDEWIRE,8135400,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,8135400,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
GUIDEWIRE,8135402,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,8135402,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
GUIDEWIRE,8135444,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,8135444,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
GUIDWIRE,8370413,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDWIRE,8370413,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
GUIDEWIRE,7695687,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,458.99000,133.11000,Aetna,First Health,,375.45,,,,,,,165.47,375.45,percent of total billed charges,
GUIDEWIRE,7695687,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,458.99000,133.11000,Aetna,First Health,,375.45,,,,,,,147.79,375.45,percent of total billed charges,
WIRE,8135617,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
WIRE,8135617,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
GUIDEWIRE,8136307,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
GUIDEWIRE,8136307,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
WIRE,8135620,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
WIRE,8135620,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
GUIDEWIRE,8135632,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
GUIDEWIRE,8135632,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
GUIDEWIRE,8135442,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
GUIDEWIRE,8135442,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
GUIDEWIRE,8135472,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.55000,107.46000,Aetna,First Health,,303.11,,,,,,,133.58,303.11,percent of total billed charges,
GUIDEWIRE,8135472,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.55000,107.46000,Aetna,First Health,,303.11,,,,,,,119.32,303.11,percent of total billed charges,
GUIDEWIRE,8135473,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.55000,107.46000,Aetna,First Health,,303.11,,,,,,,133.58,303.11,percent of total billed charges,
GUIDEWIRE,8135473,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.55000,107.46000,Aetna,First Health,,303.11,,,,,,,119.32,303.11,percent of total billed charges,
WIRE,8135591,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,386.51000,112.09000,Aetna,First Health,,316.17,,,,,,,139.34,316.17,percent of total billed charges,
WIRE,8135591,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,386.51000,112.09000,Aetna,First Health,,316.17,,,,,,,124.46,316.17,percent of total billed charges,
DEVICE LEAD LOCKING,8136291,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,3026.67000,877.73000,Aetna,First Health,,2475.82,,,,,,,1091.11,2475.82,percent of total billed charges,
DEVICE LEAD LOCKING,8136291,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,3026.67000,877.73000,Aetna,First Health,,2475.82,,,,,,,974.59,2475.82,percent of total billed charges,
SHEATH,8135452,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,8135452,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
SHEATH,8135455,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,8135455,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
CATHETER,7950338,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,677.74,1537.84,percent of total billed charges,
CATHETER,7950338,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,605.36,1537.84,percent of total billed charges,
CATHETER,8136293,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,670.53,1521.48,percent of total billed charges,
CATHETER,8136293,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,598.92,1521.48,percent of total billed charges,
SHEATH,8135568,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,8135568,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
SHEATH,8135453,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,8135453,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
SHEATH,8135625,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,8135625,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
SHEATH,8135630,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,8135630,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
SHEATH,8135570,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,8135570,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
CATHETER ABLATION,8135461,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
CATHETER ABLATION,8135461,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,9959.00,percent of total billed charges,
CATHETER ABLATION,8135462,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
CATHETER ABLATION,8135462,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,9959.00,percent of total billed charges,
SHEATH,8136570,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
SHEATH,8136570,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
CATHETER ABLATION,8135464,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5740.00000,1664.60000,Aetna,First Health,,4695.32,,,,,,,2069.27,4695.32,percent of total billed charges,
CATHETER ABLATION,8135464,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5740.00000,1664.60000,Aetna,First Health,,4695.32,,,,,,,1848.28,9959.00,percent of total billed charges,
INTRODUCER,8135449,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,463.74000,134.48000,Aetna,First Health,,379.34,,,,,,,167.18,379.34,percent of total billed charges,
INTRODUCER,8135449,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,463.74000,134.48000,Aetna,First Health,,379.34,,,,,,,149.32,379.34,percent of total billed charges,
SHEATH,8135584,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,478.47000,138.76000,Aetna,First Health,,391.39,,,,,,,172.49,391.39,percent of total billed charges,
SHEATH,8135584,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,478.47000,138.76000,Aetna,First Health,,391.39,,,,,,,154.07,391.39,percent of total billed charges,
INTRODUCER SHEATH,8135454,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
INTRODUCER SHEATH,8135454,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
SHEATH,7694464,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,7694464,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
INTRODUCER,8135567,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,133.35000,38.67000,Aetna,First Health,,109.08,,,,,,,48.07,109.08,percent of total billed charges,
INTRODUCER,8135567,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,133.35000,38.67000,Aetna,First Health,,109.08,,,,,,,42.94,109.08,percent of total billed charges,
INTRODUCER,8135588,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,133.35000,38.67000,Aetna,First Health,,109.08,,,,,,,48.07,109.08,percent of total billed charges,
INTRODUCER,8135588,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,133.35000,38.67000,Aetna,First Health,,109.08,,,,,,,42.94,109.08,percent of total billed charges,
CATHETER,8135707,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,3465.00000,1004.85000,Aetna,First Health,,2834.37,,,,,,,1249.13,2834.37,percent of total billed charges,
CATHETER,8135707,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,3465.00000,1004.85000,Aetna,First Health,,2834.37,,,,,,,1115.73,9959.00,percent of total billed charges,
CATHETER DECAPOLAR,8135587,CDM,278,RC,C1731,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
CATHETER DECAPOLAR,8135587,CDM,278,RC,C1731,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,9959.00,percent of total billed charges,
ROTABLATOR ROTALINK,8135448,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,4681.08000,1357.51000,Aetna,First Health,,3829.12,,,,,,,1687.53,3829.12,percent of total billed charges,
ROTABLATOR ROTALINK,8135448,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,4681.08000,1357.51000,Aetna,First Health,,3829.12,,,,,,,1507.31,3829.12,percent of total billed charges,
SHEATH,7693492,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
SHEATH,7693492,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
INTRODUCER,8135650,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,260.37,590.80,percent of total billed charges,
INTRODUCER,8135650,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,232.56,590.80,percent of total billed charges,
INTRODUCER,7694463,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
INTRODUCER,7694463,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
INTRODUCER TRANSEPTAL,8135457,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,260.37,590.80,percent of total billed charges,
INTRODUCER TRANSEPTAL,8135457,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,232.56,590.80,percent of total billed charges,
SHEATH,7694465,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
SHEATH,7694465,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
CATHETER,7960336,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,11535.00000,3345.15000,Aetna,First Health,,9435.63,,,,,,,4158.37,9435.63,percent of total billed charges,
CATHETER,7960336,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,11535.00000,3345.15000,Aetna,First Health,,9435.63,,,,,,,3714.27,9435.63,percent of total billed charges,
CATHETER,8135594,CDM,278,RC,C1759,HCPCS,,,facility,inpatient,,,13023.00000,3776.67000,Aetna,First Health,,10652.81,,,,,,,4694.79,10652.81,percent of total billed charges,
CATHETER,8135594,CDM,278,RC,C1759,HCPCS,,,facility,outpatient,,,13023.00000,3776.67000,Aetna,First Health,,10652.81,,,,,,,4193.41,10652.81,percent of total billed charges,
INTRODUCER,8135644,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3601.50000,1044.44000,Aetna,First Health,,2946.03,,,,,,,1298.34,2946.03,percent of total billed charges,
INTRODUCER,8135644,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,First Health,,2946.03,,,,,,,1159.68,2946.03,percent of total billed charges,
KIT INTRO AGILIS,8135645,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
KIT INTRO AGILIS,8135645,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BALLOON,8135633,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,5768.00000,1672.72000,Aetna,First Health,,4718.22,,,,,,,2079.36,4718.22,percent of total billed charges,
BALLOON,8135633,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,5768.00000,1672.72000,Aetna,First Health,,4718.22,,,,,,,1857.30,4718.22,percent of total billed charges,
BALLOON,8135634,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,5530.00000,1603.70000,Aetna,First Health,,4523.54,,,,,,,1993.57,4523.54,percent of total billed charges,
BALLOON,8135634,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,5530.00000,1603.70000,Aetna,First Health,,4523.54,,,,,,,1780.66,4523.54,percent of total billed charges,
GUIDEWIRE,8135635,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,211.89000,61.45000,Aetna,First Health,,173.33,,,,,,,76.39,173.33,percent of total billed charges,
GUIDEWIRE,8135635,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,211.89000,61.45000,Aetna,First Health,,173.33,,,,,,,68.23,173.33,percent of total billed charges,
GUIDEWIRE,8135451,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,190.05000,55.11000,Aetna,First Health,,155.46,,,,,,,68.51,155.46,percent of total billed charges,
GUIDEWIRE,8135451,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,190.05000,55.11000,Aetna,First Health,,155.46,,,,,,,61.20,155.46,percent of total billed charges,
GUIDEWIRE,8135636,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,68.13,154.60,percent of total billed charges,
GUIDEWIRE,8135636,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,60.86,154.60,percent of total billed charges,
SHEATH,7694462,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,7694462,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
INTRODUCER,7954681,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
INTRODUCER,7954681,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
SHEATH,8135603,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,8135603,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
CATH WOVEN FLEXIE,8136295,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
CATH WOVEN FLEXIE,8136295,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,9959.00,percent of total billed charges,
CATHETER IVUS,8135706,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
CATHETER IVUS,8135706,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
CATH WOVEN FLEXIE,8136294,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
CATH WOVEN FLEXIE,8136294,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,9959.00,percent of total billed charges,
STENT,7696339,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
STENT,7696339,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
STENT,7696332,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
STENT,7696332,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
STENT,7696338,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
STENT,7696338,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
STENT,7696345,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
STENT,7696345,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
STENT LIFESTENT,8135793,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT LIFESTENT,8135793,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT LIFESTENT,8135794,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT LIFESTENT,8135794,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT LIFESTENT,8135791,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT LIFESTENT,8135791,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT LIFESTENT,8135792,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT LIFESTENT,8135792,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
CATHETER,8135604,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
CATHETER,8135604,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
INTRODUCER,8135458,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,260.37,590.80,percent of total billed charges,
INTRODUCER,8135458,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,232.56,590.80,percent of total billed charges,
INTRODUCER,8135600,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,260.37,590.80,percent of total billed charges,
INTRODUCER,8135600,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,232.56,590.80,percent of total billed charges,
BALLOON,8135708,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135708,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135710,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135710,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135711,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135711,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135709,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135709,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135786,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135786,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135713,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135713,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135714,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135714,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135788,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135788,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135712,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135712,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135747,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135747,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135716,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135716,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135748,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135748,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135717,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135717,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135718,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135718,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135715,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135715,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135761,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135761,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135719,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135719,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135720,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135720,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135721,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135721,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135750,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135750,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135723,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135723,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135751,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135751,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135724,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135724,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135749,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135749,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135726,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135726,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135753,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135753,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135727,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135727,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135754,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135754,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135732,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135732,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135733,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135733,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON DIL OTW TREK 3.50X08MM,8135752,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON DIL OTW TREK 3.50X08MM,8135752,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135730,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135730,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135735,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135735,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135736,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135736,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135737,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135737,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135734,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135734,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135739,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135739,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135740,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135740,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135741,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135741,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135775,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135775,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135738,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135738,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135742,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135742,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135744,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135744,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135745,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135745,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135581,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
BALLOON,8135581,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
CATHETER GUIDE,8135755,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8135755,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GUIDE CATHETER,8135514,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDE CATHETER,8135514,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER VICERAL,8135607,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,175.09000,50.78000,Aetna,First Health,,143.22,,,,,,,63.12,143.22,percent of total billed charges,
CATHETER VICERAL,8135607,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,175.09000,50.78000,Aetna,First Health,,143.22,,,,,,,56.38,143.22,percent of total billed charges,
INTRODUCER,8135631,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,260.37,590.80,percent of total billed charges,
INTRODUCER,8135631,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,232.56,590.80,percent of total billed charges,
INTRODUCER,8135586,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,260.37,590.80,percent of total billed charges,
INTRODUCER,8135586,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,232.56,590.80,percent of total billed charges,
GUIDEWIRE,8135460,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,260.37,590.80,percent of total billed charges,
GUIDEWIRE,8135460,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,232.56,590.80,percent of total billed charges,
INTRODUCER SHEATH,8135459,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,260.37,590.80,percent of total billed charges,
INTRODUCER SHEATH,8135459,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,232.56,590.80,percent of total billed charges,
CATHETER,8135440,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,First Health,,1701.44,,,,,,,749.84,1701.44,percent of total billed charges,
CATHETER,8135440,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,First Health,,1701.44,,,,,,,669.76,9959.00,percent of total billed charges,
CATHETER,8135441,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,648.90,1472.40,percent of total billed charges,
CATHETER,8135441,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,579.60,9959.00,percent of total billed charges,
STENT GRAFT,7695236,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4805.10,10903.12,percent of total billed charges,
STENT GRAFT,7695236,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4291.94,10903.12,percent of total billed charges,
STENT,8151574,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11799.00000,3421.71000,Aetna,First Health,,9651.58,,,,,,,4253.54,9651.58,percent of total billed charges,
STENT,8151574,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11799.00000,3421.71000,Aetna,First Health,,9651.58,,,,,,,3799.28,9651.58,percent of total billed charges,
STENT GRAFT,7740746,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,4429.82,10051.58,percent of total billed charges,
STENT GRAFT,7740746,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,3956.74,10051.58,percent of total billed charges,
STENT GRAFT,7736631,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,4429.82,10051.58,percent of total billed charges,
STENT GRAFT,7736631,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,3956.74,10051.58,percent of total billed charges,
INTRODUCER,8135660,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
INTRODUCER,8135660,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
INTRODUCER,8135661,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
INTRODUCER,8135661,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
STYLET LOCKING LIBERATOR,8135814,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2602.00000,754.58000,Aetna,First Health,,2128.44,,,,,,,938.02,2128.44,percent of total billed charges,
STYLET LOCKING LIBERATOR,8135814,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2602.00000,754.58000,Aetna,First Health,,2128.44,,,,,,,837.84,2128.44,percent of total billed charges,
GLIDECATH,8135598,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
GLIDECATH,8135598,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
INTRODUCER SHEATH,8135589,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
INTRODUCER SHEATH,8135589,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SHEATH,8135583,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,478.47000,138.76000,Aetna,First Health,,391.39,,,,,,,172.49,391.39,percent of total billed charges,
SHEATH,8135583,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,478.47000,138.76000,Aetna,First Health,,391.39,,,,,,,154.07,391.39,percent of total billed charges,
SHEATH,8135569,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,8135569,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
WIRE ZIP,8135592,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
WIRE ZIP,8135592,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
WIRE ZIP,8135597,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,319.20000,92.57000,Aetna,First Health,,261.11,,,,,,,115.07,261.11,percent of total billed charges,
WIRE ZIP,8135597,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,319.20000,92.57000,Aetna,First Health,,261.11,,,,,,,102.78,261.11,percent of total billed charges,
WIRE ZIP,8135596,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,314.45000,91.19000,Aetna,First Health,,257.22,,,,,,,113.36,257.22,percent of total billed charges,
WIRE ZIP,8135596,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,314.45000,91.19000,Aetna,First Health,,257.22,,,,,,,101.25,257.22,percent of total billed charges,
CATHETER,8136292,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CATHETER,8136292,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9959.00,percent of total billed charges,
GUIDEWIRE,8135638,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,549.00000,159.21000,Aetna,First Health,,449.08,,,,,,,197.91,449.08,percent of total billed charges,
GUIDEWIRE,8135638,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,549.00000,159.21000,Aetna,First Health,,449.08,,,,,,,176.78,449.08,percent of total billed charges,
CATHETER,7696384,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,323.33000,93.77000,Aetna,First Health,,264.48,,,,,,,116.56,264.48,percent of total billed charges,
CATHETER,7696384,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,323.33000,93.77000,Aetna,First Health,,264.48,,,,,,,104.11,264.48,percent of total billed charges,
PACING CATHETER,8135902,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
PACING CATHETER,8135902,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,9959.00,percent of total billed charges,
CLOSURE DEVICE VASCULAR,7695242,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
CLOSURE DEVICE VASCULAR,7695242,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
CLOSURE DEVICE VASCULAR,7693641,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1452.00000,421.08000,Aetna,First Health,,1187.74,,,,,,,523.45,1187.74,percent of total billed charges,
CLOSURE DEVICE VASCULAR,7693641,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1452.00000,421.08000,Aetna,First Health,,1187.74,,,,,,,467.54,1187.74,percent of total billed charges,
SCREW,9115185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,9115185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,9115186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,9115186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,9115187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1928.00000,559.12000,Aetna,First Health,,1577.10,,,,,,,695.04,1577.10,percent of total billed charges,
SCREW,9115187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1928.00000,559.12000,Aetna,First Health,,1577.10,,,,,,,620.82,1577.10,percent of total billed charges,
STEM,9115188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26664.00000,7732.56000,Aetna,First Health,,21811.15,,,,,,,9612.37,21811.15,percent of total billed charges,
STEM,9115188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26664.00000,7732.56000,Aetna,First Health,,21811.15,,,,,,,8585.81,21811.15,percent of total billed charges,
GUIDEWIRE,7698160,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1468.00000,425.72000,Aetna,First Health,,1200.82,,,,,,,529.21,1200.82,percent of total billed charges,
GUIDEWIRE,7698160,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1468.00000,425.72000,Aetna,First Health,,1200.82,,,,,,,472.70,1200.82,percent of total billed charges,
GUIDEWIRE,7702886,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,7702886,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,7697277,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697277,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697278,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697278,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697279,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697279,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697337,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697337,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697372,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697372,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7698170,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
BALLOON,7698170,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
BALLOON,7698171,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
BALLOON,7698171,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
BALLOON,7699509,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
BALLOON,7699509,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
BALLOON,7784279,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7784279,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7962228,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON,7962228,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
PLATE,9115216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5776.12000,1675.07000,Aetna,First Health,,4724.87,,,,,,,2082.29,4724.87,percent of total billed charges,
PLATE,9115216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5776.12000,1675.07000,Aetna,First Health,,4724.87,,,,,,,1859.91,4724.87,percent of total billed charges,
PEG,7695347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7695347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7695348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7695348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PLATE,9115219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6571.85000,1905.84000,Aetna,First Health,,5375.77,,,,,,,2369.15,5375.77,percent of total billed charges,
PLATE,9115219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6571.85000,1905.84000,Aetna,First Health,,5375.77,,,,,,,2116.14,5375.77,percent of total billed charges,
PEG,7695349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7695349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7695350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7695350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7695351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7695351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7695352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7695352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7695353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7695353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7695354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7695354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7696581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7696581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7696582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7696582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7696583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7696583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
IMPLANT GEL,9114960,CDM,278,RC,C1878,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
IMPLANT GEL,9114960,CDM,278,RC,C1878,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
PEG,7696585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7696585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7696594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7696594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7696888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7696888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7697238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7697238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7697239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7697239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7697240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7697240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7697392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7697392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7698014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7698014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7698693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7698693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7698694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7698694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7698769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7698769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7736482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7736482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7878227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7878227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7903495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7903495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7908505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7908505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
GRAFT,7696364,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,6123.99,13895.77,percent of total billed charges,
GRAFT,7696364,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,5469.98,13895.77,percent of total billed charges,
GRAFT,7696365,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,6123.99,13895.77,percent of total billed charges,
GRAFT,7696365,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,5469.98,13895.77,percent of total billed charges,
GRAFT,7696366,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,6123.99,13895.77,percent of total billed charges,
GRAFT,7696366,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,5469.98,13895.77,percent of total billed charges,
STENT,7694926,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7694926,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7694933,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7694933,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7694934,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7694934,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7694947,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7694947,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7878242,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7878242,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7878244,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7878244,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7878245,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7878245,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7878246,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7878246,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7878247,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7878247,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7878248,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7878248,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7878249,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7878249,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7878250,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7878250,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7878251,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,7878251,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,7698945,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7698945,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
STENT,7880786,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7880786,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
STENT,7909379,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7909379,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
STENT,7953975,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7953975,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
GUIDEWIRE,7702889,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,322.34000,93.48000,Aetna,First Health,,263.67,,,,,,,116.20,263.67,percent of total billed charges,
GUIDEWIRE,7702889,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,322.34000,93.48000,Aetna,First Health,,263.67,,,,,,,103.79,263.67,percent of total billed charges,
ANCHOR,7697336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,608.52,1380.78,percent of total billed charges,
ANCHOR,7697336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,543.54,1380.78,percent of total billed charges,
ANCHOR,7697506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1322.00000,383.38000,Aetna,First Health,,1081.40,,,,,,,476.58,1081.40,percent of total billed charges,
ANCHOR,7697506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1322.00000,383.38000,Aetna,First Health,,1081.40,,,,,,,425.68,1081.40,percent of total billed charges,
ANCHOR,7697334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1832.00000,531.28000,Aetna,First Health,,1498.58,,,,,,,660.44,1498.58,percent of total billed charges,
ANCHOR,7697334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1832.00000,531.28000,Aetna,First Health,,1498.58,,,,,,,589.90,1498.58,percent of total billed charges,
VALVE,7927440,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,7151.42,16227.08,percent of total billed charges,
VALVE,7927440,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,6387.68,16227.08,percent of total billed charges,
ANCHOR,7697358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1432.00000,415.28000,Aetna,First Health,,1171.38,,,,,,,516.24,1171.38,percent of total billed charges,
ANCHOR,7697358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1432.00000,415.28000,Aetna,First Health,,1171.38,,,,,,,461.10,1171.38,percent of total billed charges,
LEAD,7697359,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
LEAD,7697359,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,7697379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,174.66,396.32,percent of total billed charges,
SCREW,7697379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,156.01,396.32,percent of total billed charges,
SCREW,7697427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7697427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7697428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7697428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7697588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,303.91000,88.13000,Aetna,First Health,,248.60,,,,,,,109.56,248.60,percent of total billed charges,
SCREW,7697588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,303.91000,88.13000,Aetna,First Health,,248.60,,,,,,,97.86,248.60,percent of total billed charges,
SCREW,7697884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7697884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7698861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7698861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7698862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7698862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7698863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7698863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7698898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7698898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7698899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7698899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7699447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7699447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7699448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7699448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7699540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.64000,198.26000,Aetna,First Health,,559.22,,,,,,,246.45,559.22,percent of total billed charges,
SCREW,7699540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.64000,198.26000,Aetna,First Health,,559.22,,,,,,,220.13,559.22,percent of total billed charges,
SCREW,7699887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,169.87,385.44,percent of total billed charges,
SCREW,7699887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,151.73,385.44,percent of total billed charges,
SCREW,7700133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7700133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,7701045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,283.89,644.17,percent of total billed charges,
SCREW,7701045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,253.57,644.17,percent of total billed charges,
SCREW,7701046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,283.89,644.17,percent of total billed charges,
SCREW,7701046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,253.57,644.17,percent of total billed charges,
SCREW,7701499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701552,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701552,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701553,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701553,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7701586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,7701586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,7702303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,358.86000,104.07000,Aetna,First Health,,293.55,,,,,,,129.37,293.55,percent of total billed charges,
SCREW,7702303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,358.86000,104.07000,Aetna,First Health,,293.55,,,,,,,115.55,293.55,percent of total billed charges,
SCREW,7702314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,376.68000,109.24000,Aetna,First Health,,308.12,,,,,,,135.79,308.12,percent of total billed charges,
SCREW,7702314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,376.68000,109.24000,Aetna,First Health,,308.12,,,,,,,121.29,308.12,percent of total billed charges,
SCREW,7702315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,376.68000,109.24000,Aetna,First Health,,308.12,,,,,,,135.79,308.12,percent of total billed charges,
SCREW,7702315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,376.68000,109.24000,Aetna,First Health,,308.12,,,,,,,121.29,308.12,percent of total billed charges,
SCREW,7702316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,376.68000,109.24000,Aetna,First Health,,308.12,,,,,,,135.79,308.12,percent of total billed charges,
SCREW,7702316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,376.68000,109.24000,Aetna,First Health,,308.12,,,,,,,121.29,308.12,percent of total billed charges,
SCREW,7736133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,174.66,396.32,percent of total billed charges,
SCREW,7736133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,156.01,396.32,percent of total billed charges,
SCREW,7772030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,300.28,681.35,percent of total billed charges,
SCREW,7772030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,268.21,681.35,percent of total billed charges,
SCREW,7772031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,300.28,681.35,percent of total billed charges,
SCREW,7772031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,First Health,,681.35,,,,,,,268.21,681.35,percent of total billed charges,
SCREW,7784081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7784081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7784082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7784082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7794206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
SCREW,7794206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7880755,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.45000,169.78000,Aetna,First Health,,478.90,,,,,,,211.05,478.90,percent of total billed charges,
SCREW,7880755,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.45000,169.78000,Aetna,First Health,,478.90,,,,,,,188.51,478.90,percent of total billed charges,
SCREW,7882183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7882183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7905107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7905107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7698035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7698035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7698485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7698485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,7698486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7698486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,7698487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7698487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,7698488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7698488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,7698491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7698491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,7698492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7698492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,7699274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7699274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7699389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7703168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1227.20000,355.89000,Aetna,First Health,,1003.85,,,,,,,442.41,1003.85,percent of total billed charges,
SCREW,7703168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1227.20000,355.89000,Aetna,First Health,,1003.85,,,,,,,395.16,1003.85,percent of total billed charges,
PLATE,7934062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4752.34000,1378.18000,Aetna,First Health,,3887.41,,,,,,,1713.22,3887.41,percent of total billed charges,
PLATE,7934062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4752.34000,1378.18000,Aetna,First Health,,3887.41,,,,,,,1530.25,3887.41,percent of total billed charges,
PLATE,7934956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12702.00000,3683.58000,Aetna,First Health,,10390.24,,,,,,,4579.07,10390.24,percent of total billed charges,
PLATE,7934956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12702.00000,3683.58000,Aetna,First Health,,10390.24,,,,,,,4090.04,10390.24,percent of total billed charges,
ANCHOR,7697535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1920.00000,556.80000,Aetna,First Health,,1570.56,,,,,,,692.16,1570.56,percent of total billed charges,
ANCHOR,7697535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1920.00000,556.80000,Aetna,First Health,,1570.56,,,,,,,618.24,1570.56,percent of total billed charges,
ANCHOR,7697676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1757.96000,509.81000,Aetna,First Health,,1438.01,,,,,,,633.74,1438.01,percent of total billed charges,
ANCHOR,7697676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1757.96000,509.81000,Aetna,First Health,,1438.01,,,,,,,566.06,1438.01,percent of total billed charges,
BREAST PROSTHESIS,7697385,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7697385,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,764.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7697386,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
BREAST PROSTHESIS,7697386,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,764.47,3449.91,percent of total billed charges,
BREAST PROSTHESIS,7697387,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7697387,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,764.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7698209,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7698209,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,764.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7698950,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7698950,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,764.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7698951,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7698951,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,764.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7698952,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7698952,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,764.47,3220.88,percent of total billed charges,
BREAST PROSTHESIS,7697390,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
BREAST PROSTHESIS,7697390,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
BREAST PROSTHESIS,7697938,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
BREAST PROSTHESIS,7697938,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
PLATE,7696898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2748.16000,796.97000,Aetna,First Health,,2247.99,,,,,,,990.71,2247.99,percent of total billed charges,
PLATE,7696898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2748.16000,796.97000,Aetna,First Health,,2247.99,,,,,,,884.91,2247.99,percent of total billed charges,
TRAY TIBIAL,7700074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
TRAY TIBIAL,7700074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
PLATE,7954356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE,7954356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
NAIL,7698726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,2149.26,4876.83,percent of total billed charges,
NAIL,7698726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,1919.73,4876.83,percent of total billed charges,
NAIL,7698881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,2149.26,4876.83,percent of total billed charges,
NAIL,7698881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,1919.73,4876.83,percent of total billed charges,
SCREW,7697128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,565.26,1282.62,percent of total billed charges,
SCREW,7697128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,504.90,1282.62,percent of total billed charges,
SCREW,7697419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,565.26,1282.62,percent of total billed charges,
SCREW,7697419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,504.90,1282.62,percent of total billed charges,
SCREW,7698538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
SCREW,7698538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
SCREW,7698539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
SCREW,7698539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
SCREW,7698540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
SCREW,7698540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
SCREW,7736639,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,633.60000,183.74000,Aetna,First Health,,518.28,,,,,,,228.41,518.28,percent of total billed charges,
SCREW,7736639,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,633.60000,183.74000,Aetna,First Health,,518.28,,,,,,,204.02,518.28,percent of total billed charges,
SCREW,7872101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7872101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7878569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7878569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7893525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7893525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7908716,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7908716,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7916932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7916932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7918810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7918810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7918813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7918813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7918814,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7918814,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7935610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,565.26,1282.62,percent of total billed charges,
SCREW,7935610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,504.90,1282.62,percent of total billed charges,
SCREW,7935611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,436.93,991.42,percent of total billed charges,
SCREW,7935611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,390.26,991.42,percent of total billed charges,
PLATE,7697425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
PLATE,7697425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
PLATE,7802033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3772.02000,1093.89000,Aetna,First Health,,3085.51,,,,,,,1359.81,3085.51,percent of total billed charges,
PLATE,7802033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3772.02000,1093.89000,Aetna,First Health,,3085.51,,,,,,,1214.59,3085.51,percent of total billed charges,
PLATE,7702977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2364.24000,685.63000,Aetna,First Health,,1933.95,,,,,,,852.31,1933.95,percent of total billed charges,
PLATE,7702977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2364.24000,685.63000,Aetna,First Health,,1933.95,,,,,,,761.29,1933.95,percent of total billed charges,
SCREW,7697475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7697475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7697476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7697476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7697477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7697477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7697478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7697478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7697479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7697479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7698410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7698410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7698534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7698534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7698535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7698535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7698536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7698536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7698582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7698582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7698583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7698583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7698584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7698584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7699219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7699219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7699932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7699932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7699970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7699970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7700264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7700264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7700269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7700269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7700729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7700729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7701222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701242,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701242,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7701250,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
SCREW,7701250,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
SCREW,7736056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7736056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7703108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7703108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SHOULDER GLENOSPHERE REVERSE,7748826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
SHOULDER GLENOSPHERE REVERSE,7748826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,7698291,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2669.14,6056.47,percent of total billed charges,
CAGE,7698291,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2384.09,6056.47,percent of total billed charges,
CAGE,7698454,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2669.14,6056.47,percent of total billed charges,
CAGE,7698454,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2384.09,6056.47,percent of total billed charges,
CAGE,7698544,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2669.14,6056.47,percent of total billed charges,
CAGE,7698544,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2384.09,6056.47,percent of total billed charges,
SCREW,7740563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7740563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7909411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7909411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7948215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7948215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,7948603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7948603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7948609,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7948609,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7965000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7965000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,7965001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7965001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
ROD,7698550,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD,7698550,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
ROD,7696589,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7696589,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
ROD,7696668,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7696668,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
ROD,7696696,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7696696,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
ROD,7696779,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7696779,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
ROD,7696812,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7696812,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
ROD,7696813,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7696813,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
ROD,7696814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7696814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
ROD,7696890,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7696890,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
ROD,7696941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7696941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
ROD,7697147,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7697147,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
ROD,7697193,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7697193,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
ROD,7697246,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,998.44,2265.53,percent of total billed charges,
ROD,7697246,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,First Health,,2265.53,,,,,,,891.81,2265.53,percent of total billed charges,
ROD,7697375,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7697375,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
ROD,7697413,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,703.70,1596.74,percent of total billed charges,
ROD,7697413,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,628.54,1596.74,percent of total billed charges,
ROD,7698246,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7698246,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
PLATE,7697507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8346.00000,2420.34000,Aetna,First Health,,6827.03,,,,,,,3008.73,6827.03,percent of total billed charges,
PLATE,7697507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8346.00000,2420.34000,Aetna,First Health,,6827.03,,,,,,,2687.41,6827.03,percent of total billed charges,
PLATE,7701362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1647.85,3739.08,percent of total billed charges,
PLATE,7701362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1471.86,3739.08,percent of total billed charges,
PLATE,7701363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1647.85,3739.08,percent of total billed charges,
PLATE,7701363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1471.86,3739.08,percent of total billed charges,
PLATE,7701906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.85000,1223.18000,Aetna,First Health,,3450.20,,,,,,,1520.53,3450.20,percent of total billed charges,
PLATE,7701906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.85000,1223.18000,Aetna,First Health,,3450.20,,,,,,,1358.15,3450.20,percent of total billed charges,
PLATE,7701060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6552.84000,1900.32000,Aetna,First Health,,5360.22,,,,,,,2362.30,5360.22,percent of total billed charges,
PLATE,7701060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6552.84000,1900.32000,Aetna,First Health,,5360.22,,,,,,,2110.01,5360.22,percent of total billed charges,
GUIDEWIRE,7697462,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,154.88000,44.92000,Aetna,First Health,,126.69,,,,,,,55.83,126.69,percent of total billed charges,
GUIDEWIRE,7697462,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,154.88000,44.92000,Aetna,First Health,,126.69,,,,,,,49.87,126.69,percent of total billed charges,
GUIDEWIRE,7700398,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,127.47000,36.97000,Aetna,First Health,,104.27,,,,,,,45.95,104.27,percent of total billed charges,
GUIDEWIRE,7700398,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,127.47000,36.97000,Aetna,First Health,,104.27,,,,,,,41.05,104.27,percent of total billed charges,
SCREW,7697466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,202.23,458.87,percent of total billed charges,
SCREW,7697466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,180.63,458.87,percent of total billed charges,
SCREW,7698652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,202.23,458.87,percent of total billed charges,
SCREW,7698652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,180.63,458.87,percent of total billed charges,
SCREW,7699231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,7699383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SCREW,7699410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7699410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7699411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7699411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7699685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7699685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7699686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7699686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7699687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7699687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7699688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7699688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7700364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7700364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7700365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7700365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7700366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7700366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7700660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7700660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7700661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7700661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7701596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7701596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7740527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7740527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
FEMORAL HEAD,7697625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7697625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7697626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7697626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7698057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7698057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7699372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7699372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7700243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7700243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7740765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7740765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7802092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMORAL HEAD,7802092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
FEMORAL HEAD,7904165,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMORAL HEAD,7904165,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
FEMORAL HEAD,7918998,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMORAL HEAD,7918998,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
FEMORAL HEAD,7943140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMORAL HEAD,7943140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
FEMORAL HEAD,7948757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMORAL HEAD,7948757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
FEMORAL HEAD,7964474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMORAL HEAD,7964474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7701203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,First Health,,272.14,,,,,,,119.93,272.14,percent of total billed charges,
PLATE,7701203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,First Health,,272.14,,,,,,,107.13,272.14,percent of total billed charges,
PLATE,7701536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
PLATE,7701536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
PLATE,7701537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
PLATE,7701537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
PLATE,7701539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
PLATE,7701539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
PLATE,7698442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6179.39000,1792.02000,Aetna,First Health,,5054.74,,,,,,,2227.67,5054.74,percent of total billed charges,
PLATE,7698442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6179.39000,1792.02000,Aetna,First Health,,5054.74,,,,,,,1989.76,5054.74,percent of total billed charges,
PLATE,7698443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6179.39000,1792.02000,Aetna,First Health,,5054.74,,,,,,,2227.67,5054.74,percent of total billed charges,
PLATE,7698443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6179.39000,1792.02000,Aetna,First Health,,5054.74,,,,,,,1989.76,5054.74,percent of total billed charges,
TISSUE EXPANDER,7696676,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7696676,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7696677,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7696677,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697091,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697091,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697092,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697092,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697093,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697093,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697095,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697095,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697508,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697508,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697509,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697509,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697940,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7697940,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698263,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698263,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698264,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698264,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698265,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698265,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698266,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698266,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698267,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698267,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698268,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698268,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698586,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7698586,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736305,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736305,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736307,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736307,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736309,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736309,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736313,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736313,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736315,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736315,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736316,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736316,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736318,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7736318,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7740568,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7740568,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
TISSUE EXPANDER,7808033,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TISSUE EXPANDER,7808033,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
SCREW,7695465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7695465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7695466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7695466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7697490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7697490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7697491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7697491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7697492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7697492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7697493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7697493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7697494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7697494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7697495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7697495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7697496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7697496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7697502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7697502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7697503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7697503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7697542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7697542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7697581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7697581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7697582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7697582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7697622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7697622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7697623,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7697623,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7697624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7697624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7698071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.65000,171.87000,Aetna,First Health,,484.79,,,,,,,213.65,484.79,percent of total billed charges,
SCREW,7698071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.65000,171.87000,Aetna,First Health,,484.79,,,,,,,190.83,484.79,percent of total billed charges,
SCREW,7700734,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7700734,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7701503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7701503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7701557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7701557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7702331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.10000,93.70000,Aetna,First Health,,264.30,,,,,,,116.48,264.30,percent of total billed charges,
SCREW,7702331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.10000,93.70000,Aetna,First Health,,264.30,,,,,,,104.04,264.30,percent of total billed charges,
SCREW,7702364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,179.56,407.44,percent of total billed charges,
SCREW,7702364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,160.38,407.44,percent of total billed charges,
SCREW,7702365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,179.56,407.44,percent of total billed charges,
SCREW,7702365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,160.38,407.44,percent of total billed charges,
SCREW,7702366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,179.56,407.44,percent of total billed charges,
SCREW,7702366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,160.38,407.44,percent of total billed charges,
SCREW,7702367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,179.56,407.44,percent of total billed charges,
SCREW,7702367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,160.38,407.44,percent of total billed charges,
SCREW,7702368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,179.56,407.44,percent of total billed charges,
SCREW,7702368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,160.38,407.44,percent of total billed charges,
SCREW,7702369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,179.56,407.44,percent of total billed charges,
SCREW,7702369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,160.38,407.44,percent of total billed charges,
SCREW,7702370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,179.56,407.44,percent of total billed charges,
SCREW,7702370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,160.38,407.44,percent of total billed charges,
SCREW,7702371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,179.56,407.44,percent of total billed charges,
SCREW,7702371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,160.38,407.44,percent of total billed charges,
SCREW,7702372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,179.56,407.44,percent of total billed charges,
SCREW,7702372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,First Health,,407.44,,,,,,,160.38,407.44,percent of total billed charges,
SCREW,7707466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,7707466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
SCREW,7707467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,7707467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
SCREW,7707468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,7707468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
SCREW,7707469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,7707469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
SCREW,7707470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,7707470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
SCREW,7707471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,7707471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
SCREW,7736463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7736463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7744585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7744585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7750032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,761.40000,220.81000,Aetna,First Health,,622.83,,,,,,,274.48,622.83,percent of total billed charges,
SCREW,7750032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,761.40000,220.81000,Aetna,First Health,,622.83,,,,,,,245.17,622.83,percent of total billed charges,
SCREW,7758066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7758066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7758067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7758067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7844036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7844036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7911283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7911283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7911284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7911284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7703204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7703204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7703205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7703205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7703206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7703206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7703207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7703207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7703228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7703228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
NAIL,7736671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,7736671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
NAIL,7740894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,7740894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
NAIL,7911721,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,7911721,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
NAIL,7940327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,7940327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
NAIL,7943681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,7943681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
CATHETER,7697565,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,882.00000,255.78000,Aetna,First Health,,721.48,,,,,,,317.96,721.48,percent of total billed charges,
CATHETER,7697565,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,882.00000,255.78000,Aetna,First Health,,721.48,,,,,,,284.00,721.48,percent of total billed charges,
CATHETER,7697571,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,973.85000,282.42000,Aetna,First Health,,796.61,,,,,,,351.07,796.61,percent of total billed charges,
CATHETER,7697571,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,973.85000,282.42000,Aetna,First Health,,796.61,,,,,,,313.58,796.61,percent of total billed charges,
SHEATH,7697568,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,564.30000,163.65000,Aetna,First Health,,461.60,,,,,,,203.43,461.60,percent of total billed charges,
SHEATH,7697568,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,564.30000,163.65000,Aetna,First Health,,461.60,,,,,,,181.70,461.60,percent of total billed charges,
SHEATH,7963959,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,564.30000,163.65000,Aetna,First Health,,461.60,,,,,,,203.43,461.60,percent of total billed charges,
SHEATH,7963959,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,564.30000,163.65000,Aetna,First Health,,461.60,,,,,,,181.70,461.60,percent of total billed charges,
SHEATH,7697569,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,First Health,,407.20,,,,,,,179.46,407.20,percent of total billed charges,
SHEATH,7697569,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,First Health,,407.20,,,,,,,160.29,407.20,percent of total billed charges,
FEMORAL HEAD,7900101,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7900101,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
SCREW,7698125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,728.50,1653.01,percent of total billed charges,
SCREW,7698125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,650.70,1653.01,percent of total billed charges,
SCREW,7698493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2096.00000,607.84000,Aetna,First Health,,1714.53,,,,,,,755.61,1714.53,percent of total billed charges,
SCREW,7698493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2096.00000,607.84000,Aetna,First Health,,1714.53,,,,,,,674.91,1714.53,percent of total billed charges,
SCREW,7698501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2096.00000,607.84000,Aetna,First Health,,1714.53,,,,,,,755.61,1714.53,percent of total billed charges,
SCREW,7698501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2096.00000,607.84000,Aetna,First Health,,1714.53,,,,,,,674.91,1714.53,percent of total billed charges,
SCREW,7698744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7698744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7698745,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7698745,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7698746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7698746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7699001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7699001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7699002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7699002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7699505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7699505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7699506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7699506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7758161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7758161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7758162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7758162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7921148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7921148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7921186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7921186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7937692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7937692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7697647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7697647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7697648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7697648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7697649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7697649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7697665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7697665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7697666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,596.03000,172.85000,Aetna,First Health,,487.55,,,,,,,214.87,487.55,percent of total billed charges,
SCREW,7697666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,596.03000,172.85000,Aetna,First Health,,487.55,,,,,,,191.92,487.55,percent of total billed charges,
SCREW,7698104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7698104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7698158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7698158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7698676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,169.53,384.66,percent of total billed charges,
SCREW,7698676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,151.42,384.66,percent of total billed charges,
SCREW,7698677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7698677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7698678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7698678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7698679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7698679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7698680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7698680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7698736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7698736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7698979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7698979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7699485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7699485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7699946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7699946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7700010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW,7700010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
SCREW,7700012,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7700012,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7700013,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7700013,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7700140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,169.53,384.66,percent of total billed charges,
SCREW,7700140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,151.42,384.66,percent of total billed charges,
SCREW,7700167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.65000,171.87000,Aetna,First Health,,484.79,,,,,,,213.65,484.79,percent of total billed charges,
SCREW,7700167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.65000,171.87000,Aetna,First Health,,484.79,,,,,,,190.83,484.79,percent of total billed charges,
SCREW,7700221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,358.86000,104.07000,Aetna,First Health,,293.55,,,,,,,129.37,293.55,percent of total billed charges,
SCREW,7700221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,358.86000,104.07000,Aetna,First Health,,293.55,,,,,,,115.55,293.55,percent of total billed charges,
SCREW,7700401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7700401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7700585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7700585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7701935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7701935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7701948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7701948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7701972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,169.53,384.66,percent of total billed charges,
SCREW,7701985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,151.42,384.66,percent of total billed charges,
SCREW,7701986,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,169.53,384.66,percent of total billed charges,
SCREW,7701986,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,151.42,384.66,percent of total billed charges,
SCREW,7701987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,169.53,384.66,percent of total billed charges,
SCREW,7701987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,151.42,384.66,percent of total billed charges,
SCREW,7701988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,169.53,384.66,percent of total billed charges,
SCREW,7701988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,151.42,384.66,percent of total billed charges,
SCREW,7701993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7701997,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,7701997,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7702248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7702248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7702249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7702249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7702250,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7702250,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7702251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,266.21,604.05,percent of total billed charges,
SCREW,7702251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,First Health,,604.05,,,,,,,237.78,604.05,percent of total billed charges,
SCREW,7756365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,51.10,115.95,percent of total billed charges,
SCREW,7756365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,45.64,115.95,percent of total billed charges,
SCREW,7902590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7902590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7918646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7918646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7930349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7930349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7933641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7933641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7933642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7933642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7938031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7938031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7944548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7944548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7959517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7959517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7959518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7959518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7703198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7703198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7703251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,720.00000,208.80000,Aetna,First Health,,588.96,,,,,,,259.56,588.96,percent of total billed charges,
SCREW,7703251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,720.00000,208.80000,Aetna,First Health,,588.96,,,,,,,231.84,588.96,percent of total billed charges,
PLATE,7698565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5577.88000,1617.59000,Aetna,First Health,,4562.71,,,,,,,2010.83,4562.71,percent of total billed charges,
PLATE,7698565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5577.88000,1617.59000,Aetna,First Health,,4562.71,,,,,,,1796.08,4562.71,percent of total billed charges,
PLATE,7963863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5330.64000,1545.89000,Aetna,First Health,,4360.46,,,,,,,1921.70,4360.46,percent of total billed charges,
PLATE,7963863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5330.64000,1545.89000,Aetna,First Health,,4360.46,,,,,,,1716.47,4360.46,percent of total billed charges,
MESH,7742074,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,602.80000,174.81000,Aetna,First Health,,493.09,,,,,,,217.31,493.09,percent of total billed charges,
MESH,7742074,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,602.80000,174.81000,Aetna,First Health,,493.09,,,,,,,194.10,493.09,percent of total billed charges,
PLATE,7912535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2283.20000,662.13000,Aetna,First Health,,1867.66,,,,,,,823.09,1867.66,percent of total billed charges,
PLATE,7912535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2283.20000,662.13000,Aetna,First Health,,1867.66,,,,,,,735.19,1867.66,percent of total billed charges,
PLATE,7912536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1784.00000,517.36000,Aetna,First Health,,1459.31,,,,,,,643.13,1459.31,percent of total billed charges,
PLATE,7912536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1784.00000,517.36000,Aetna,First Health,,1459.31,,,,,,,574.45,1459.31,percent of total billed charges,
SCREW,7935275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7935275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,7935276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7935276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,7935277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7935277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,7703027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7703027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
STENT,7696766,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7696766,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7698003,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7698003,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7698221,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7698221,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7698222,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7698222,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7698416,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7698416,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7698417,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7698417,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7698426,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7698426,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7700840,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7700840,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7702072,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7702072,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7702226,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7702226,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7800040,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,7800040,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STENT,7834150,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1250.70,2837.92,percent of total billed charges,
STENT,7834150,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1117.13,2837.92,percent of total billed charges,
STENT,7836195,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
STENT,7836195,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
STENT,7913593,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1250.70,2837.92,percent of total billed charges,
STENT,7913593,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1117.13,2837.92,percent of total billed charges,
STENT,7896899,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1250.70,2837.92,percent of total billed charges,
STENT,7896899,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1117.13,2837.92,percent of total billed charges,
STENT,7836186,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1250.70,2837.92,percent of total billed charges,
STENT,7836186,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1117.13,2837.92,percent of total billed charges,
INTRODUCER,7696298,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,741.19,1681.81,percent of total billed charges,
INTRODUCER,7696298,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,662.03,1681.81,percent of total billed charges,
INTRODUCER,7927545,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,741.19,1681.81,percent of total billed charges,
INTRODUCER,7927545,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,662.03,1681.81,percent of total billed charges,
INTRODUCER,7916960,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,726.53000,210.69000,Aetna,First Health,,594.30,,,,,,,261.91,594.30,percent of total billed charges,
INTRODUCER,7916960,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,726.53000,210.69000,Aetna,First Health,,594.30,,,,,,,233.94,594.30,percent of total billed charges,
INTRODUCER,7703365,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,726.53000,210.69000,Aetna,First Health,,594.30,,,,,,,261.91,594.30,percent of total billed charges,
INTRODUCER,7703365,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,726.53000,210.69000,Aetna,First Health,,594.30,,,,,,,233.94,594.30,percent of total billed charges,
PLATE,7700819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2908.00000,843.32000,Aetna,First Health,,2378.74,,,,,,,1048.33,2378.74,percent of total billed charges,
PLATE,7700819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2908.00000,843.32000,Aetna,First Health,,2378.74,,,,,,,936.38,2378.74,percent of total billed charges,
FEMORAL ADAPTER,7698422,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1843.60000,534.64000,Aetna,First Health,,1508.06,,,,,,,664.62,1508.06,percent of total billed charges,
FEMORAL ADAPTER,7698422,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1843.60000,534.64000,Aetna,First Health,,1508.06,,,,,,,593.64,1508.06,percent of total billed charges,
RING ANNULOPLASTY,7697996,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9255.00000,2683.95000,Aetna,First Health,,7570.59,,,,,,,3336.43,7570.59,percent of total billed charges,
RING ANNULOPLASTY,7697996,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9255.00000,2683.95000,Aetna,First Health,,7570.59,,,,,,,2980.11,7570.59,percent of total billed charges,
RING ANNULOPLASTY,7774236,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3790.66,8601.27,percent of total billed charges,
RING ANNULOPLASTY,7774236,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3385.83,8601.27,percent of total billed charges,
CATHETER,7698259,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1963.32000,569.36000,Aetna,First Health,,1606.00,,,,,,,707.78,1606.00,percent of total billed charges,
CATHETER,7698259,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1963.32000,569.36000,Aetna,First Health,,1606.00,,,,,,,632.19,1606.00,percent of total billed charges,
RING ANNULOPLASTY,7736622,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6545.00000,1898.05000,Aetna,First Health,,5353.81,,,,,,,2359.47,5353.81,percent of total billed charges,
RING ANNULOPLASTY,7736622,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6545.00000,1898.05000,Aetna,First Health,,5353.81,,,,,,,2107.49,5353.81,percent of total billed charges,
RING ANNULOPLASTY,7703007,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6545.00000,1898.05000,Aetna,First Health,,5353.81,,,,,,,2359.47,5353.81,percent of total billed charges,
RING ANNULOPLASTY,7703007,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6545.00000,1898.05000,Aetna,First Health,,5353.81,,,,,,,2107.49,5353.81,percent of total billed charges,
STEM AND SCREW,7698207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM AND SCREW,7698207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7697995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
PLATE,7697995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
PLATE,7736556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3441.90000,998.15000,Aetna,First Health,,2815.47,,,,,,,1240.80,2815.47,percent of total billed charges,
PLATE,7736556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3441.90000,998.15000,Aetna,First Health,,2815.47,,,,,,,1108.29,2815.47,percent of total billed charges,
PLATE,7844123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5795.30000,1680.64000,Aetna,First Health,,4740.56,,,,,,,2089.21,4740.56,percent of total billed charges,
PLATE,7844123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5795.30000,1680.64000,Aetna,First Health,,4740.56,,,,,,,1866.09,4740.56,percent of total billed charges,
STEM SPLINED KNEE,7697925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7697925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7697931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7697931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1871.68,4246.97,percent of total billed charges,
STEM SPLINED KNEE,7698223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1671.79,4246.97,percent of total billed charges,
STEM SPLINED KNEE,7698224,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698224,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7698996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7699526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7699526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7699654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7699654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7699656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7699656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7699951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7699951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7699957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7699957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7700846,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7700846,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7707545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7707545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7736465,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM SPLINED KNEE,7736465,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
TIBIAL TRAY,7697562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,3290.36,7466.05,percent of total billed charges,
TIBIAL TRAY,7697562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,2938.96,7466.05,percent of total billed charges,
TIBIAL TRAY,7697926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,3290.36,7466.05,percent of total billed charges,
TIBIAL TRAY,7697926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,2938.96,7466.05,percent of total billed charges,
TIBIAL TRAY,7698009,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,3290.36,7466.05,percent of total billed charges,
TIBIAL TRAY,7698009,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,2938.96,7466.05,percent of total billed charges,
TIBIAL TRAY,7698997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,3290.36,7466.05,percent of total billed charges,
TIBIAL TRAY,7698997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,2938.96,7466.05,percent of total billed charges,
TIBIAL TRAY,7699960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,3290.36,7466.05,percent of total billed charges,
TIBIAL TRAY,7699960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,2938.96,7466.05,percent of total billed charges,
TIBIAL TRAY,7908617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,3290.36,7466.05,percent of total billed charges,
TIBIAL TRAY,7908617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,2938.96,7466.05,percent of total billed charges,
TIBIAL TRAY,7908618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,3290.36,7466.05,percent of total billed charges,
TIBIAL TRAY,7908618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,2938.96,7466.05,percent of total billed charges,
TIBIAL TRAY,7908619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,3290.36,7466.05,percent of total billed charges,
TIBIAL TRAY,7908619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,First Health,,7466.05,,,,,,,2938.96,7466.05,percent of total billed charges,
TIBIAL CRUCIATE,7697929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3027.20000,877.89000,Aetna,First Health,,2476.25,,,,,,,1091.31,2476.25,percent of total billed charges,
TIBIAL CRUCIATE,7697929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3027.20000,877.89000,Aetna,First Health,,2476.25,,,,,,,974.76,2476.25,percent of total billed charges,
PLATE,7697989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7697989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7699749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3664.26000,1062.64000,Aetna,First Health,,2997.36,,,,,,,1320.97,2997.36,percent of total billed charges,
PLATE,7699749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3664.26000,1062.64000,Aetna,First Health,,2997.36,,,,,,,1179.89,2997.36,percent of total billed charges,
SCREW,7697934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7697934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7697935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7697935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7697952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7697952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
CORE REVISION,7697948,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4428.38000,1284.23000,Aetna,First Health,,3622.41,,,,,,,1596.43,3622.41,percent of total billed charges,
CORE REVISION,7697948,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4428.38000,1284.23000,Aetna,First Health,,3622.41,,,,,,,1425.94,3622.41,percent of total billed charges,
ACL TIGHTROPE,7697945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,839.97,1905.94,percent of total billed charges,
ACL TIGHTROPE,7697945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,750.26,1905.94,percent of total billed charges,
PLATE,7699281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1847.20,4191.43,percent of total billed charges,
PLATE,7699281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1649.93,4191.43,percent of total billed charges,
PLATE,7707517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4053.00000,1175.37000,Aetna,First Health,,3315.35,,,,,,,1461.11,3315.35,percent of total billed charges,
PLATE,7707517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4053.00000,1175.37000,Aetna,First Health,,3315.35,,,,,,,1305.07,3315.35,percent of total billed charges,
FEMORAL HEAD,7698478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1173.43,2662.59,percent of total billed charges,
FEMORAL HEAD,7698478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1048.11,2662.59,percent of total billed charges,
FEMORAL HEAD,7698790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7698790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7699257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1173.43,2662.59,percent of total billed charges,
FEMORAL HEAD,7699257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1048.11,2662.59,percent of total billed charges,
FEMORAL HEAD,7699902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7699902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7736442,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7736442,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
SCREW,7697968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7697968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7697974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7697974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7935939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7935939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7964530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7964530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7964714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7964714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
CAGE,7697973,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CAGE,7697973,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
CAGE,7697975,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CAGE,7697975,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
SCREW,7695504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7695504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7695505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7695505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7695506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7695506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7695508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7695508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7695510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7695510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7696836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7696836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7696837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7696837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7696838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7696838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7697183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
SCREW,7697183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
SCREW,7697184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
SCREW,7697184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
SCREW,7697653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7697653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7697654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7697654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7697655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7697655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7697976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7697976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7697977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7697977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7697978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7697978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7697979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7697979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7697982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7697982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7698081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7698271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7698272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7698272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7698338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7698338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7698339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7698339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7698555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,432.92,982.32,percent of total billed charges,
SCREW,7698600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,386.68,982.32,percent of total billed charges,
SCREW,7698601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,432.92,982.32,percent of total billed charges,
SCREW,7698601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,386.68,982.32,percent of total billed charges,
SCREW,7698646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7698646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7698647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7698647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7698788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7698788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7698942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
SCREW,7698942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
SCREW,7699856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,760.50000,220.54000,Aetna,First Health,,622.09,,,,,,,274.16,622.09,percent of total billed charges,
SCREW,7699856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,760.50000,220.54000,Aetna,First Health,,622.09,,,,,,,244.88,622.09,percent of total billed charges,
SCREW,7700007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,452.36,1026.43,percent of total billed charges,
SCREW,7700007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,404.05,1026.43,percent of total billed charges,
SCREW,7700608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700609,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700609,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700612,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700612,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700615,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700615,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700632,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700632,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700634,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700634,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700635,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700635,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700636,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700636,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700638,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700638,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700639,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700639,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700640,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700640,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7700645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,7700645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
SCREW,7772054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7772054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7772055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
SCREW,7772055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,7802404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7802404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7802405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7802405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7902620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,452.36,1026.43,percent of total billed charges,
SCREW,7902620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,404.05,1026.43,percent of total billed charges,
SCREW,7935882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7935882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7703062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,452.36,1026.43,percent of total billed charges,
SCREW,7703062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,404.05,1026.43,percent of total billed charges,
SCREW,7703063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,452.36,1026.43,percent of total billed charges,
SCREW,7703063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,404.05,1026.43,percent of total billed charges,
SCREW,7703064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,452.36,1026.43,percent of total billed charges,
SCREW,7703064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,First Health,,1026.43,,,,,,,404.05,1026.43,percent of total billed charges,
PIN,7895936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2498.00000,724.42000,Aetna,First Health,,2043.36,,,,,,,900.53,2043.36,percent of total billed charges,
PIN,7895936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2498.00000,724.42000,Aetna,First Health,,2043.36,,,,,,,804.36,2043.36,percent of total billed charges,
PIN,7702948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2498.00000,724.42000,Aetna,First Health,,2043.36,,,,,,,900.53,2043.36,percent of total billed charges,
PIN,7702948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2498.00000,724.42000,Aetna,First Health,,2043.36,,,,,,,804.36,2043.36,percent of total billed charges,
LINER,7699370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10658.40000,3090.94000,Aetna,First Health,,8718.57,,,,,,,3842.35,8718.57,percent of total billed charges,
LINER,7699370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10658.40000,3090.94000,Aetna,First Health,,8718.57,,,,,,,3432.00,8718.57,percent of total billed charges,
LINER,7870094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10830.00000,3140.70000,Aetna,First Health,,8858.94,,,,,,,3904.22,8858.94,percent of total billed charges,
LINER,7870094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10830.00000,3140.70000,Aetna,First Health,,8858.94,,,,,,,3487.26,8858.94,percent of total billed charges,
LINER,7943141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10830.00000,3140.70000,Aetna,First Health,,8858.94,,,,,,,3904.22,8858.94,percent of total billed charges,
LINER,7943141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10830.00000,3140.70000,Aetna,First Health,,8858.94,,,,,,,3487.26,8858.94,percent of total billed charges,
TIBIAL CONDYLAR,7698077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2389.25,5421.38,percent of total billed charges,
TIBIAL CONDYLAR,7698077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2134.09,5421.38,percent of total billed charges,
TIBIAL CONDYLAR,7698406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2389.25,5421.38,percent of total billed charges,
TIBIAL CONDYLAR,7698406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2134.09,5421.38,percent of total billed charges,
SCREW,7918355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1485.60000,430.82000,Aetna,First Health,,1215.22,,,,,,,535.56,1215.22,percent of total billed charges,
SCREW,7918355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1485.60000,430.82000,Aetna,First Health,,1215.22,,,,,,,478.36,1215.22,percent of total billed charges,
SCREW,7925241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7925241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7965449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7965449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7965450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7965450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PLATE,7698594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2649.80000,768.44000,Aetna,First Health,,2167.54,,,,,,,955.25,2167.54,percent of total billed charges,
PLATE,7698594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2649.80000,768.44000,Aetna,First Health,,2167.54,,,,,,,853.24,2167.54,percent of total billed charges,
SCREW,7696492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,631.90,1433.82,percent of total billed charges,
SCREW,7696492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,564.41,1433.82,percent of total billed charges,
SCREW,7698164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,631.90,1433.82,percent of total billed charges,
SCREW,7698164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,564.41,1433.82,percent of total billed charges,
SCREW,7699336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,631.90,1433.82,percent of total billed charges,
SCREW,7699336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,564.41,1433.82,percent of total billed charges,
SCREW,7702659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,631.90,1433.82,percent of total billed charges,
SCREW,7702659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,564.41,1433.82,percent of total billed charges,
SCREW,7903658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,631.90,1433.82,percent of total billed charges,
SCREW,7903658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,564.41,1433.82,percent of total billed charges,
SCREW,7944046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,843.86,1914.77,percent of total billed charges,
SCREW,7944046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,753.74,1914.77,percent of total billed charges,
SCREW,7946022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7946022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7947895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7947895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7953866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,843.86,1914.77,percent of total billed charges,
SCREW,7953866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,753.74,1914.77,percent of total billed charges,
SCREW,7954159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,843.86,1914.77,percent of total billed charges,
SCREW,7954159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,753.74,1914.77,percent of total billed charges,
SCREW,7957696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,843.86,1914.77,percent of total billed charges,
SCREW,7957696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,753.74,1914.77,percent of total billed charges,
SCREW,7703182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,631.90,1433.82,percent of total billed charges,
SCREW,7703182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,564.41,1433.82,percent of total billed charges,
DISTAL CENTRALIZER,7698792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
DISTAL CENTRALIZER,7698792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
DISTAL CENTRALIZER,7844124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
DISTAL CENTRALIZER,7844124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
DISTAL CENTRALIZER,7912246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
DISTAL CENTRALIZER,7912246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
COMPONENT NECK LENGTH ADAPTER,7882397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
COMPONENT NECK LENGTH ADAPTER,7882397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
PLATE,7699567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,850.50000,246.64000,Aetna,First Health,,695.71,,,,,,,306.61,695.71,percent of total billed charges,
PLATE,7699567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,850.50000,246.64000,Aetna,First Health,,695.71,,,,,,,273.86,695.71,percent of total billed charges,
PLATE,7701532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.50000,184.00000,Aetna,First Health,,519.02,,,,,,,228.74,519.02,percent of total billed charges,
PLATE,7701532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.50000,184.00000,Aetna,First Health,,519.02,,,,,,,204.31,519.02,percent of total billed charges,
PLATE,7701533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.50000,184.00000,Aetna,First Health,,519.02,,,,,,,228.74,519.02,percent of total billed charges,
PLATE,7701533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.50000,184.00000,Aetna,First Health,,519.02,,,,,,,204.31,519.02,percent of total billed charges,
SCREW,7698189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,7698189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
SCREW,7699968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,7699968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
SCREW,7858074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,7858074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
SCREW,7870095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,7870095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
SCREW,7893285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,843.86,1914.77,percent of total billed charges,
SCREW,7893285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,753.74,1914.77,percent of total billed charges,
SCREW,7937859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,7937859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
SCREW,7957756,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,577.91,1311.32,percent of total billed charges,
SCREW,7957756,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,516.19,1311.32,percent of total billed charges,
SCREW,7957757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,577.91,1311.32,percent of total billed charges,
SCREW,7957757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,516.19,1311.32,percent of total billed charges,
SCREW,7957758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,577.91,1311.32,percent of total billed charges,
SCREW,7957758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,516.19,1311.32,percent of total billed charges,
GUIDEWIRE,7696662,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,77.60,176.07,percent of total billed charges,
GUIDEWIRE,7696662,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,69.31,176.07,percent of total billed charges,
GUIDEWIRE,7697126,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,77.60,176.07,percent of total billed charges,
GUIDEWIRE,7697126,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,69.31,176.07,percent of total billed charges,
GUIDEWIRE,7697316,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,77.60,176.07,percent of total billed charges,
GUIDEWIRE,7697316,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,69.31,176.07,percent of total billed charges,
GUIDEWIRE,7698190,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,77.60,176.07,percent of total billed charges,
GUIDEWIRE,7698190,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,69.31,176.07,percent of total billed charges,
GUIDEWIRE,7699084,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,39.27,89.11,percent of total billed charges,
GUIDEWIRE,7699084,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,35.08,89.11,percent of total billed charges,
GUIDEWIRE,7700576,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,39.27,89.11,percent of total billed charges,
GUIDEWIRE,7700576,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,35.08,89.11,percent of total billed charges,
AUGMENT FEMORAL,7698022,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698022,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698023,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698023,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698025,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698025,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7698420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699813,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7699813,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7700946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7700946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7700947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7700947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7736120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7736120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7736121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7736121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7910505,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7910505,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7910507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1762.03,3998.18,percent of total billed charges,
AUGMENT FEMORAL,7910507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,First Health,,3998.18,,,,,,,1573.86,3998.18,percent of total billed charges,
COMPONENT HEAD,7698723,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
COMPONENT HEAD,7698723,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
COMPONENT HEAD,7760074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
COMPONENT HEAD,7760074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
COMPONENT HEAD,7784189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
COMPONENT HEAD,7784189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
COMPONENT HEAD,7918195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
COMPONENT HEAD,7918195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
LINER,7698724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1873.70,4251.56,percent of total billed charges,
LINER,7698724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1673.60,4251.56,percent of total billed charges,
LINER,7699790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1873.70,4251.56,percent of total billed charges,
LINER,7699790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1673.60,4251.56,percent of total billed charges,
LINER,7760072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1873.70,4251.56,percent of total billed charges,
LINER,7760072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1673.60,4251.56,percent of total billed charges,
LINER,7957715,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1873.70,4251.56,percent of total billed charges,
LINER,7957715,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1673.60,4251.56,percent of total billed charges,
EMBOLIZATION COIL,7698212,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,220.03,499.26,percent of total billed charges,
EMBOLIZATION COIL,7698212,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,196.53,499.26,percent of total billed charges,
VALVE,7696914,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,First Health,,17178.00,,,,,,,7570.50,17178.00,percent of total billed charges,
VALVE,7696914,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,First Health,,17178.00,,,,,,,6762.00,17178.00,percent of total billed charges,
VALVE,7696915,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,First Health,,17178.00,,,,,,,7570.50,17178.00,percent of total billed charges,
VALVE,7696915,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,First Health,,17178.00,,,,,,,6762.00,17178.00,percent of total billed charges,
VALVE,7736187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,First Health,,17178.00,,,,,,,7570.50,17178.00,percent of total billed charges,
VALVE,7736187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,First Health,,17178.00,,,,,,,6762.00,17178.00,percent of total billed charges,
VALVE,7768117,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,First Health,,17178.00,,,,,,,7570.50,17178.00,percent of total billed charges,
VALVE,7768117,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,First Health,,17178.00,,,,,,,6762.00,17178.00,percent of total billed charges,
VALVE,7696824,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,7620.00000,2209.80000,Aetna,First Health,,6233.16,,,,,,,2747.01,6233.16,percent of total billed charges,
VALVE,7696824,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,7620.00000,2209.80000,Aetna,First Health,,6233.16,,,,,,,2453.64,6233.16,percent of total billed charges,
VALVE,7696825,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8007.00000,2322.03000,Aetna,First Health,,6549.73,,,,,,,2886.52,6549.73,percent of total billed charges,
VALVE,7696825,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8007.00000,2322.03000,Aetna,First Health,,6549.73,,,,,,,2578.25,6549.73,percent of total billed charges,
VALVE,7696969,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8511.00000,2468.19000,Aetna,First Health,,6962.00,,,,,,,3068.22,6962.00,percent of total billed charges,
VALVE,7696969,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8511.00000,2468.19000,Aetna,First Health,,6962.00,,,,,,,2740.54,6962.00,percent of total billed charges,
VALVE,7696989,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8007.00000,2322.03000,Aetna,First Health,,6549.73,,,,,,,2886.52,6549.73,percent of total billed charges,
VALVE,7696989,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8007.00000,2322.03000,Aetna,First Health,,6549.73,,,,,,,2578.25,6549.73,percent of total billed charges,
PLUG,7695999,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
PLUG,7695999,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
PLATE,7698239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1560.40000,452.52000,Aetna,First Health,,1276.41,,,,,,,562.52,1276.41,percent of total billed charges,
PLATE,7698239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1560.40000,452.52000,Aetna,First Health,,1276.41,,,,,,,502.45,1276.41,percent of total billed charges,
HUMERAL BEARING,7700296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
HUMERAL BEARING,7700296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
HUMERAL BEARING,7794043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
HUMERAL BEARING,7794043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
HUMERAL TRAY,7700297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
HUMERAL TRAY,7700297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
FEMORAL AUGMENT,7698244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
FEMORAL AUGMENT,7698244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
FEMORAL AUGMENT,7700375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
FEMORAL AUGMENT,7700375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
FEMORAL AUGMENT,7702024,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
FEMORAL AUGMENT,7702024,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
STEM EXTENSION,7698076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1534.16,3481.12,percent of total billed charges,
STEM EXTENSION,7698076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1370.32,3481.12,percent of total billed charges,
STEM EXTENSION,7698095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1534.16,3481.12,percent of total billed charges,
STEM EXTENSION,7698095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1370.32,3481.12,percent of total billed charges,
STEM EXTENSION,7698245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7698245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7698402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7698402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7698405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1534.16,3481.12,percent of total billed charges,
STEM EXTENSION,7698405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1370.32,3481.12,percent of total billed charges,
STEM EXTENSION,7698688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7698688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7698689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7698689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7699262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1534.16,3481.12,percent of total billed charges,
STEM EXTENSION,7699262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1370.32,3481.12,percent of total billed charges,
STEM EXTENSION,7699263,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1534.16,3481.12,percent of total billed charges,
STEM EXTENSION,7699263,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1370.32,3481.12,percent of total billed charges,
STEM EXTENSION,7699649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7699649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7699891,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7699891,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7699895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7699895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7700186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7700186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7700377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7700377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7700378,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7700378,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7700854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1534.16,3481.12,percent of total billed charges,
STEM EXTENSION,7700854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1370.32,3481.12,percent of total billed charges,
STEM EXTENSION,7736358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7736358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7736684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7736684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7754284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7754284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7754285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7754285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
STEM EXTENSION,7756048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,7756048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
HIP NECK ADAPTER,7698838,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,First Health,,1308.15,,,,,,,576.51,1308.15,percent of total billed charges,
HIP NECK ADAPTER,7698838,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,First Health,,1308.15,,,,,,,514.94,1308.15,percent of total billed charges,
PLATE,7698294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3168.04000,918.73000,Aetna,First Health,,2591.46,,,,,,,1142.08,2591.46,percent of total billed charges,
PLATE,7698294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3168.04000,918.73000,Aetna,First Health,,2591.46,,,,,,,1020.11,2591.46,percent of total billed charges,
PLATE,7698295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3168.04000,918.73000,Aetna,First Health,,2591.46,,,,,,,1142.08,2591.46,percent of total billed charges,
PLATE,7698295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3168.04000,918.73000,Aetna,First Health,,2591.46,,,,,,,1020.11,2591.46,percent of total billed charges,
PLATE,7698296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3168.04000,918.73000,Aetna,First Health,,2591.46,,,,,,,1142.08,2591.46,percent of total billed charges,
PLATE,7698296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3168.04000,918.73000,Aetna,First Health,,2591.46,,,,,,,1020.11,2591.46,percent of total billed charges,
PLATE,7698297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3168.04000,918.73000,Aetna,First Health,,2591.46,,,,,,,1142.08,2591.46,percent of total billed charges,
PLATE,7698297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3168.04000,918.73000,Aetna,First Health,,2591.46,,,,,,,1020.11,2591.46,percent of total billed charges,
PLATE,7698298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3168.04000,918.73000,Aetna,First Health,,2591.46,,,,,,,1142.08,2591.46,percent of total billed charges,
PLATE,7698298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3168.04000,918.73000,Aetna,First Health,,2591.46,,,,,,,1020.11,2591.46,percent of total billed charges,
PLATE,7905598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3161.84000,916.93000,Aetna,First Health,,2586.39,,,,,,,1139.84,2586.39,percent of total billed charges,
PLATE,7905598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3161.84000,916.93000,Aetna,First Health,,2586.39,,,,,,,1018.11,2586.39,percent of total billed charges,
GLIDEWIRE,7695937,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
GLIDEWIRE,7695937,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
GUIDEWIRE,7695668,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,287.31000,83.32000,Aetna,First Health,,235.02,,,,,,,103.58,235.02,percent of total billed charges,
GUIDEWIRE,7695668,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,287.31000,83.32000,Aetna,First Health,,235.02,,,,,,,92.51,235.02,percent of total billed charges,
GUIDEWIRE,7697409,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,288.61000,83.70000,Aetna,First Health,,236.08,,,,,,,104.04,236.08,percent of total billed charges,
GUIDEWIRE,7697409,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,288.61000,83.70000,Aetna,First Health,,236.08,,,,,,,92.93,236.08,percent of total billed charges,
VALVE,7697036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20637.50000,5984.88000,Aetna,First Health,,16881.47,,,,,,,7439.82,16881.47,percent of total billed charges,
VALVE,7697036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20637.50000,5984.88000,Aetna,First Health,,16881.47,,,,,,,6645.27,16881.47,percent of total billed charges,
BALLOON,7697271,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697271,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697272,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697272,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697273,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697273,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697274,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697274,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697275,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697275,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697276,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697276,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697280,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697280,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697281,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697281,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697333,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697333,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697921,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697921,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7697922,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7697922,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7699482,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7699482,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON,7736450,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,7736450,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
GUIDEWIRE,7698743,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,165.74000,48.06000,Aetna,First Health,,135.58,,,,,,,59.75,135.58,percent of total billed charges,
GUIDEWIRE,7698743,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,165.74000,48.06000,Aetna,First Health,,135.58,,,,,,,53.37,135.58,percent of total billed charges,
GUIDEWIRE,7700025,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
GUIDEWIRE,7700025,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
GUIDEWIRE,7758163,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,164.17000,47.61000,Aetna,First Health,,134.29,,,,,,,59.18,134.29,percent of total billed charges,
GUIDEWIRE,7758163,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,164.17000,47.61000,Aetna,First Health,,134.29,,,,,,,52.86,134.29,percent of total billed charges,
GUIDEWIRE,7702895,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,364.71000,105.77000,Aetna,First Health,,298.33,,,,,,,131.48,298.33,percent of total billed charges,
GUIDEWIRE,7702895,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,364.71000,105.77000,Aetna,First Health,,298.33,,,,,,,117.44,298.33,percent of total billed charges,
GUIDEWIRE,7702897,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,192.10000,55.71000,Aetna,First Health,,157.14,,,,,,,69.25,157.14,percent of total billed charges,
GUIDEWIRE,7702897,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,192.10000,55.71000,Aetna,First Health,,157.14,,,,,,,61.86,157.14,percent of total billed charges,
CLOSURE DEVICE VASCULAR,7697488,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,504.70,1145.20,percent of total billed charges,
CLOSURE DEVICE VASCULAR,7697488,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,450.80,1145.20,percent of total billed charges,
FEMORAL HEAD,7748743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7748743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
FEMORAL HEAD,7816133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7816133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
FEMORAL HEAD,7903717,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7903717,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
FEMORAL HEAD,7905145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7905145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
FEMORAL HEAD,7913506,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7913506,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
FEMORAL HEAD,7940867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7940867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
FEMORAL HEAD,7961899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7961899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
PLATE,7699335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6188.91000,1794.78000,Aetna,First Health,,5062.53,,,,,,,2231.10,5062.53,percent of total billed charges,
PLATE,7699335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6188.91000,1794.78000,Aetna,First Health,,5062.53,,,,,,,1992.83,5062.53,percent of total billed charges,
INSERT,7762383,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,7762383,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
INSERT,7838115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7838115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,7880556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7880556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,7918548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6434.75000,1866.08000,Aetna,First Health,,5263.63,,,,,,,2319.73,5263.63,percent of total billed charges,
INSERT,7918548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6434.75000,1866.08000,Aetna,First Health,,5263.63,,,,,,,2071.99,5263.63,percent of total billed charges,
INSERT,7963936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,7963936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
SHELL,7698776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,7698776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SHELL,7699711,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
SHELL,7699711,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
SHELL,7699789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,7699789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SHELL,7699921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,7699921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SHELL,7700067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,7700067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SHELL,7741710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,7741710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SHELL,7794304,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,7794304,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SHELL,7912280,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
SHELL,7912280,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
SHELL,7940865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
SHELL,7940865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
PLATE,7698301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3285.91000,952.91000,Aetna,First Health,,2687.87,,,,,,,1184.57,2687.87,percent of total billed charges,
PLATE,7698301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3285.91000,952.91000,Aetna,First Health,,2687.87,,,,,,,1058.06,2687.87,percent of total billed charges,
PLATE,7698302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3285.91000,952.91000,Aetna,First Health,,2687.87,,,,,,,1184.57,2687.87,percent of total billed charges,
PLATE,7698302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3285.91000,952.91000,Aetna,First Health,,2687.87,,,,,,,1058.06,2687.87,percent of total billed charges,
PLATE,7698303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3285.91000,952.91000,Aetna,First Health,,2687.87,,,,,,,1184.57,2687.87,percent of total billed charges,
PLATE,7698303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3285.91000,952.91000,Aetna,First Health,,2687.87,,,,,,,1058.06,2687.87,percent of total billed charges,
PLATE,7701907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4414.20000,1280.12000,Aetna,First Health,,3610.82,,,,,,,1591.32,3610.82,percent of total billed charges,
PLATE,7701907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4414.20000,1280.12000,Aetna,First Health,,3610.82,,,,,,,1421.37,3610.82,percent of total billed charges,
PLATE,7698306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3356.50000,973.38000,Aetna,First Health,,2745.62,,,,,,,1210.02,2745.62,percent of total billed charges,
PLATE,7698306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3356.50000,973.38000,Aetna,First Health,,2745.62,,,,,,,1080.79,2745.62,percent of total billed charges,
PLATE,7698307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3356.50000,973.38000,Aetna,First Health,,2745.62,,,,,,,1210.02,2745.62,percent of total billed charges,
PLATE,7698307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3356.50000,973.38000,Aetna,First Health,,2745.62,,,,,,,1080.79,2745.62,percent of total billed charges,
PLATE,7698308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3356.50000,973.38000,Aetna,First Health,,2745.62,,,,,,,1210.02,2745.62,percent of total billed charges,
PLATE,7698308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3356.50000,973.38000,Aetna,First Health,,2745.62,,,,,,,1080.79,2745.62,percent of total billed charges,
MODULAR HEAD,7699103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
MODULAR HEAD,7699103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
WEDGE,7882869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
WEDGE,7882869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
WEDGE,7882870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2968.72,6736.23,percent of total billed charges,
WEDGE,7882870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2651.67,6736.23,percent of total billed charges,
SHEATH,7897507,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,213.26000,61.85000,Aetna,First Health,,174.45,,,,,,,76.88,174.45,percent of total billed charges,
SHEATH,7897507,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,213.26000,61.85000,Aetna,First Health,,174.45,,,,,,,68.67,174.45,percent of total billed charges,
SHEATH,7694466,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
SHEATH,7694466,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
SHEATH,7695684,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
SHEATH,7695684,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
SHEATH,7695685,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
SHEATH,7695685,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
PLATE,7696900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3863.48000,1120.41000,Aetna,First Health,,3160.33,,,,,,,1392.78,3160.33,percent of total billed charges,
PLATE,7696900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3863.48000,1120.41000,Aetna,First Health,,3160.33,,,,,,,1244.04,3160.33,percent of total billed charges,
PLATE,7697514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3863.48000,1120.41000,Aetna,First Health,,3160.33,,,,,,,1392.78,3160.33,percent of total billed charges,
PLATE,7697514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3863.48000,1120.41000,Aetna,First Health,,3160.33,,,,,,,1244.04,3160.33,percent of total billed charges,
PLATE,7702208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3863.48000,1120.41000,Aetna,First Health,,3160.33,,,,,,,1392.78,3160.33,percent of total billed charges,
PLATE,7702208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3863.48000,1120.41000,Aetna,First Health,,3160.33,,,,,,,1244.04,3160.33,percent of total billed charges,
COMPONENT DISTAL,7910250,CDM,278,RC,L8631,HCPCS,,,facility,inpatient,,,7443.00000,2158.47000,Aetna,First Health,,6088.37,,,,,,,2683.20,6088.37,percent of total billed charges,
COMPONENT DISTAL,7910250,CDM,278,RC,L8631,HCPCS,,,facility,outpatient,,,7443.00000,2158.47000,Aetna,First Health,,6088.37,,,,,,,2396.65,6088.37,percent of total billed charges,
NAIL,7695437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7695437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7696540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7696540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7696541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7696541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7696711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7696711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7696722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7696722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7697368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7697368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7697369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7697369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7697370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7697370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7697371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7697371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7698252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7698252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7698253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7698253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7698504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7698504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7699713,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7699713,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7701592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7701592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7702585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7702585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7741016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7741016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7816126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7816126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7848090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7848090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7904025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7904025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7910311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7910311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7916934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7916934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7927010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7927010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7935881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7935881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7943318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7943318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7943629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7943629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7963963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7963963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
SCREW,7698711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,First Health,,1112.38,,,,,,,490.24,1112.38,percent of total billed charges,
SCREW,7698711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,First Health,,1112.38,,,,,,,437.88,1112.38,percent of total billed charges,
SCREW,7698712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,First Health,,1112.38,,,,,,,490.24,1112.38,percent of total billed charges,
SCREW,7698712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,First Health,,1112.38,,,,,,,437.88,1112.38,percent of total billed charges,
SCREW,7699926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,First Health,,1112.38,,,,,,,490.24,1112.38,percent of total billed charges,
SCREW,7699926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,First Health,,1112.38,,,,,,,437.88,1112.38,percent of total billed charges,
SCREW,7700372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,First Health,,1112.38,,,,,,,490.24,1112.38,percent of total billed charges,
SCREW,7700372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,First Health,,1112.38,,,,,,,437.88,1112.38,percent of total billed charges,
SCREW,7700523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7700523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7700524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7700524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7700927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7700927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7700928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7700928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7701038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7701038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7701039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7701039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7701040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7701040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7701041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7701041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7701042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7701042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7701043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7701043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7701044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7701044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7701213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,7701213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,7701215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,7701215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,7768125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7768125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7828134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,7828134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,7828033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,7828033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,7828035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,7828035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,7903039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,7903039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,7916464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7916464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7916466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7916466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7917352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7917352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7917353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7917353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7917354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7917354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7920391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,7920391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,7935792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7935792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7935799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7935799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7935806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7935806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7935808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7935808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7936113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,219.00,496.94,percent of total billed charges,
SCREW,7936113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,195.62,496.94,percent of total billed charges,
SCREW,7936118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7936118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7936119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7936119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7938126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7938126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7938127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7938127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7938149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7938149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7940798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,330.96,750.96,percent of total billed charges,
SCREW,7940798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,295.61,750.96,percent of total billed charges,
SCREW,7940799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,330.96,750.96,percent of total billed charges,
SCREW,7940799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,295.61,750.96,percent of total billed charges,
SCREW,7940845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,7940845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,7965914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7965914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7965915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7965915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7698374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7698374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7698375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7698376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7698378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7699584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7699589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7699589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7700347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
SCREW,7700347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
SCREW,7700348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
SCREW,7700348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
SCREW,7700349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
SCREW,7700349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
SCREW,7700350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
SCREW,7700350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
SCREW,7702267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7702267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7702268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7702268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7702269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7702269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7702295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,118.68,269.30,percent of total billed charges,
SCREW,7702295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,106.01,269.30,percent of total billed charges,
SCREW,7702296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,118.68,269.30,percent of total billed charges,
SCREW,7702296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,106.01,269.30,percent of total billed charges,
SCREW,7702297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,118.68,269.30,percent of total billed charges,
SCREW,7702297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,106.01,269.30,percent of total billed charges,
SCREW,7702298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,118.68,269.30,percent of total billed charges,
SCREW,7702298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,106.01,269.30,percent of total billed charges,
SCREW,7702299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,118.68,269.30,percent of total billed charges,
SCREW,7702299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,106.01,269.30,percent of total billed charges,
SCREW,7702300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,118.68,269.30,percent of total billed charges,
SCREW,7702300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,106.01,269.30,percent of total billed charges,
SCREW,7702301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,118.68,269.30,percent of total billed charges,
SCREW,7702301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,First Health,,269.30,,,,,,,106.01,269.30,percent of total billed charges,
SCREW,7702352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,378.20000,109.68000,Aetna,First Health,,309.37,,,,,,,136.34,309.37,percent of total billed charges,
SCREW,7702352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,378.20000,109.68000,Aetna,First Health,,309.37,,,,,,,121.78,309.37,percent of total billed charges,
SCREW,7702353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,378.20000,109.68000,Aetna,First Health,,309.37,,,,,,,136.34,309.37,percent of total billed charges,
SCREW,7702353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,378.20000,109.68000,Aetna,First Health,,309.37,,,,,,,121.78,309.37,percent of total billed charges,
SCREW,7702354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,378.20000,109.68000,Aetna,First Health,,309.37,,,,,,,136.34,309.37,percent of total billed charges,
SCREW,7702354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,378.20000,109.68000,Aetna,First Health,,309.37,,,,,,,121.78,309.37,percent of total billed charges,
SCREW,7806286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7806286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7940792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7940792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7698389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7698390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7698390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7698391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7698391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7698392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7698392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7698393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7698393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7698394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7698394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7698395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7698395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7698414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7698414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7699271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7699271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7699272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7699272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7699273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7699273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7699275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7699275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7699619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7699619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7699620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7699620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7699621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7699621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7699801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7699801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7699818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7699818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7700056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,324.45,736.20,percent of total billed charges,
SCREW,7700056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,289.80,736.20,percent of total billed charges,
SCREW,7700566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7700566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7700567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7700567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7700568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7700568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7700569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7700569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7700570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7700570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7700918,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7700918,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7700919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7700919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7701405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7701425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7701425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,344.57,781.84,percent of total billed charges,
SCREW,7702040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,307.77,781.84,percent of total billed charges,
SCREW,7702103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7702117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7702574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7702658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7702658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7707475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1227.20000,355.89000,Aetna,First Health,,1003.85,,,,,,,442.41,1003.85,percent of total billed charges,
SCREW,7707475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1227.20000,355.89000,Aetna,First Health,,1003.85,,,,,,,395.16,1003.85,percent of total billed charges,
SCREW,7707535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7707535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7774103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7774103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7774104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7774104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7939403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7939403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
PLATE,7696305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,942.08000,273.20000,Aetna,First Health,,770.62,,,,,,,339.62,770.62,percent of total billed charges,
PLATE,7696305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,942.08000,273.20000,Aetna,First Health,,770.62,,,,,,,303.35,770.62,percent of total billed charges,
PLATE,7696430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,306.52000,88.89000,Aetna,First Health,,250.73,,,,,,,110.50,250.73,percent of total billed charges,
PLATE,7696430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,306.52000,88.89000,Aetna,First Health,,250.73,,,,,,,98.70,250.73,percent of total billed charges,
PLATE,7699884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.80000,391.73000,Aetna,First Health,,1104.95,,,,,,,486.96,1104.95,percent of total billed charges,
PLATE,7699884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.80000,391.73000,Aetna,First Health,,1104.95,,,,,,,434.96,1104.95,percent of total billed charges,
PLATE,7700454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,458.41,1040.17,percent of total billed charges,
PLATE,7700454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,409.46,1040.17,percent of total billed charges,
PLATE,7701297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1365.60000,396.02000,Aetna,First Health,,1117.06,,,,,,,492.30,1117.06,percent of total billed charges,
PLATE,7701297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1365.60000,396.02000,Aetna,First Health,,1117.06,,,,,,,439.72,1117.06,percent of total billed charges,
PLATE,7701298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1365.60000,396.02000,Aetna,First Health,,1117.06,,,,,,,492.30,1117.06,percent of total billed charges,
PLATE,7701298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1365.60000,396.02000,Aetna,First Health,,1117.06,,,,,,,439.72,1117.06,percent of total billed charges,
PLATE,7701299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1377.60000,399.50000,Aetna,First Health,,1126.88,,,,,,,496.62,1126.88,percent of total billed charges,
PLATE,7701299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1377.60000,399.50000,Aetna,First Health,,1126.88,,,,,,,443.59,1126.88,percent of total billed charges,
PLATE,7701300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1365.60000,396.02000,Aetna,First Health,,1117.06,,,,,,,492.30,1117.06,percent of total billed charges,
PLATE,7701300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1365.60000,396.02000,Aetna,First Health,,1117.06,,,,,,,439.72,1117.06,percent of total billed charges,
PLATE,7701822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,458.41,1040.17,percent of total billed charges,
PLATE,7701822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,409.46,1040.17,percent of total billed charges,
PLATE,7701828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.80000,391.73000,Aetna,First Health,,1104.95,,,,,,,486.96,1104.95,percent of total billed charges,
PLATE,7701828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.80000,391.73000,Aetna,First Health,,1104.95,,,,,,,434.96,1104.95,percent of total billed charges,
PLATE,7701851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,458.41,1040.17,percent of total billed charges,
PLATE,7701851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,409.46,1040.17,percent of total billed charges,
PLATE,7701864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.80000,391.73000,Aetna,First Health,,1104.95,,,,,,,486.96,1104.95,percent of total billed charges,
PLATE,7701864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.80000,391.73000,Aetna,First Health,,1104.95,,,,,,,434.96,1104.95,percent of total billed charges,
BIO TRANSFIX,7699074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2115.80000,613.58000,Aetna,First Health,,1730.72,,,,,,,762.75,1730.72,percent of total billed charges,
BIO TRANSFIX,7699074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2115.80000,613.58000,Aetna,First Health,,1730.72,,,,,,,681.29,1730.72,percent of total billed charges,
CABLE,7702782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2125.60000,616.42000,Aetna,First Health,,1738.74,,,,,,,766.28,1738.74,percent of total billed charges,
CABLE,7702782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2125.60000,616.42000,Aetna,First Health,,1738.74,,,,,,,684.44,1738.74,percent of total billed charges,
SCREW,7698428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,First Health,,1525.68,,,,,,,672.38,1525.68,percent of total billed charges,
SCREW,7698428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,First Health,,1525.68,,,,,,,600.57,1525.68,percent of total billed charges,
SCREW,7698429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,First Health,,1525.68,,,,,,,672.38,1525.68,percent of total billed charges,
SCREW,7698429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,First Health,,1525.68,,,,,,,600.57,1525.68,percent of total billed charges,
SCREW,7698696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,First Health,,1525.68,,,,,,,672.38,1525.68,percent of total billed charges,
SCREW,7698696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,First Health,,1525.68,,,,,,,600.57,1525.68,percent of total billed charges,
SCREW,7698697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,First Health,,1525.68,,,,,,,672.38,1525.68,percent of total billed charges,
SCREW,7698697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,First Health,,1525.68,,,,,,,600.57,1525.68,percent of total billed charges,
SCREW,7914395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1495.20000,433.61000,Aetna,First Health,,1223.07,,,,,,,539.02,1223.07,percent of total billed charges,
SCREW,7914395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1495.20000,433.61000,Aetna,First Health,,1223.07,,,,,,,481.45,1223.07,percent of total billed charges,
SCREW,7914396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1495.20000,433.61000,Aetna,First Health,,1223.07,,,,,,,539.02,1223.07,percent of total billed charges,
SCREW,7914396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1495.20000,433.61000,Aetna,First Health,,1223.07,,,,,,,481.45,1223.07,percent of total billed charges,
SCREW,7914400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1495.20000,433.61000,Aetna,First Health,,1223.07,,,,,,,539.02,1223.07,percent of total billed charges,
SCREW,7914400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1495.20000,433.61000,Aetna,First Health,,1223.07,,,,,,,481.45,1223.07,percent of total billed charges,
SCREW,7964484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,209.27,474.85,percent of total billed charges,
SCREW,7964484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,186.92,474.85,percent of total billed charges,
SCREW,7696877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7696877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7696878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7696878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7698430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
STENT,7700486,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700486,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
TIBIAL TRAY,7699328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26556.38000,7701.35000,Aetna,First Health,,21723.12,,,,,,,9573.57,21723.12,percent of total billed charges,
TIBIAL TRAY,7699328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26556.38000,7701.35000,Aetna,First Health,,21723.12,,,,,,,8551.15,21723.12,percent of total billed charges,
CATHETER GUIDE,8135489,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDE,8135489,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
BALLOON,8135743,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135743,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135725,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135725,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8135746,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135746,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
CATHETER,8135601,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
CATHETER,8135601,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SHEATH,7750461,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
SHEATH,7750461,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
RETRIEVAL DEVICE,7694845,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,First Health,,1201.64,,,,,,,529.57,1201.64,percent of total billed charges,
RETRIEVAL DEVICE,7694845,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,First Health,,1201.64,,,,,,,473.02,1201.64,percent of total billed charges,
GRAFT,7698611,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5529.37000,1603.52000,Aetna,First Health,,4523.02,,,,,,,1993.34,4523.02,percent of total billed charges,
GRAFT,7698611,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5529.37000,1603.52000,Aetna,First Health,,4523.02,,,,,,,1780.46,4523.02,percent of total billed charges,
COMPONENT FEMORAL,7698400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,9270.49,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7698400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,8280.44,21035.40,percent of total billed charges,
SCREW,7698507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7698507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7698432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1487.44000,431.36000,Aetna,First Health,,1216.73,,,,,,,536.22,1216.73,percent of total billed charges,
SCREW,7698435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1487.44000,431.36000,Aetna,First Health,,1216.73,,,,,,,478.96,1216.73,percent of total billed charges,
SCREW,7698707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7698853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7698853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7700906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,912.60000,264.65000,Aetna,First Health,,746.51,,,,,,,328.99,746.51,percent of total billed charges,
SCREW,7700906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,912.60000,264.65000,Aetna,First Health,,746.51,,,,,,,293.86,746.51,percent of total billed charges,
SCREW,7794444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7794444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7802459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7802459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7836161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7836161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7878198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7878198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7878538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7878538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7893523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7893523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7893941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7893941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7893963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7893963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918593,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918593,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7918871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7918871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7920564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7920564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7924503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7924503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7939280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7939280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7703051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7703051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7703183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,582.57,1321.89,percent of total billed charges,
SCREW,7703183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,520.35,1321.89,percent of total billed charges,
SCREW,7703185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,582.57,1321.89,percent of total billed charges,
SCREW,7703185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,520.35,1321.89,percent of total billed charges,
PLATE,7698445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6433.32000,1865.66000,Aetna,First Health,,5262.46,,,,,,,2319.21,5262.46,percent of total billed charges,
PLATE,7698445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6433.32000,1865.66000,Aetna,First Health,,5262.46,,,,,,,2071.53,5262.46,percent of total billed charges,
GUIDEWIRE,7700484,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,210.71000,61.11000,Aetna,First Health,,172.36,,,,,,,75.96,172.36,percent of total billed charges,
GUIDEWIRE,7700484,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,210.71000,61.11000,Aetna,First Health,,172.36,,,,,,,67.85,172.36,percent of total billed charges,
GUIDEWIRE,7700485,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,210.71000,61.11000,Aetna,First Health,,172.36,,,,,,,75.96,172.36,percent of total billed charges,
GUIDEWIRE,7700485,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,210.71000,61.11000,Aetna,First Health,,172.36,,,,,,,67.85,172.36,percent of total billed charges,
GUIDEWIRE,7700516,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,210.71000,61.11000,Aetna,First Health,,172.36,,,,,,,75.96,172.36,percent of total billed charges,
GUIDEWIRE,7700516,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,210.71000,61.11000,Aetna,First Health,,172.36,,,,,,,67.85,172.36,percent of total billed charges,
GUIDEWIRE,7700875,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,210.71000,61.11000,Aetna,First Health,,172.36,,,,,,,75.96,172.36,percent of total billed charges,
GUIDEWIRE,7700875,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,210.71000,61.11000,Aetna,First Health,,172.36,,,,,,,67.85,172.36,percent of total billed charges,
GUIDEWIRE,7700876,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,210.71000,61.11000,Aetna,First Health,,172.36,,,,,,,75.96,172.36,percent of total billed charges,
GUIDEWIRE,7700876,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,210.71000,61.11000,Aetna,First Health,,172.36,,,,,,,67.85,172.36,percent of total billed charges,
GUIDEWIRE,7746050,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,149.05000,43.22000,Aetna,First Health,,121.92,,,,,,,53.73,121.92,percent of total billed charges,
GUIDEWIRE,7746050,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,149.05000,43.22000,Aetna,First Health,,121.92,,,,,,,47.99,121.92,percent of total billed charges,
GUIDEWIRE,7702885,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,304.00000,88.16000,Aetna,First Health,,248.67,,,,,,,109.59,248.67,percent of total billed charges,
GUIDEWIRE,7702885,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,304.00000,88.16000,Aetna,First Health,,248.67,,,,,,,97.89,248.67,percent of total billed charges,
GUIDEWIRE,7702896,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,134.72000,39.07000,Aetna,First Health,,110.20,,,,,,,48.57,110.20,percent of total billed charges,
GUIDEWIRE,7702896,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,134.72000,39.07000,Aetna,First Health,,110.20,,,,,,,43.38,110.20,percent of total billed charges,
NAIL,7784550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7784550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
NAIL,7784551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7784551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
NAIL,7702934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7702934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
NAIL,7702935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7702935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
PLATE,7701315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1644.00000,476.76000,Aetna,First Health,,1344.79,,,,,,,592.66,1344.79,percent of total billed charges,
PLATE,7701315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1644.00000,476.76000,Aetna,First Health,,1344.79,,,,,,,529.37,1344.79,percent of total billed charges,
PLATE,7701885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2261.60000,655.86000,Aetna,First Health,,1849.99,,,,,,,815.31,1849.99,percent of total billed charges,
PLATE,7701885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2261.60000,655.86000,Aetna,First Health,,1849.99,,,,,,,728.24,1849.99,percent of total billed charges,
PLATE,7756731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1681.44000,487.62000,Aetna,First Health,,1375.42,,,,,,,606.16,1375.42,percent of total billed charges,
PLATE,7756731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1681.44000,487.62000,Aetna,First Health,,1375.42,,,,,,,541.42,1375.42,percent of total billed charges,
PLATE,7702971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1690.76000,490.32000,Aetna,First Health,,1383.04,,,,,,,609.52,1383.04,percent of total billed charges,
PLATE,7702971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1690.76000,490.32000,Aetna,First Health,,1383.04,,,,,,,544.42,1383.04,percent of total billed charges,
PLATE,7702990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.80000,244.70000,Aetna,First Health,,690.23,,,,,,,304.19,690.23,percent of total billed charges,
PLATE,7702990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.80000,244.70000,Aetna,First Health,,690.23,,,,,,,271.70,690.23,percent of total billed charges,
PLATE,7702992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,878.67000,254.81000,Aetna,First Health,,718.75,,,,,,,316.76,718.75,percent of total billed charges,
PLATE,7702992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,878.67000,254.81000,Aetna,First Health,,718.75,,,,,,,282.93,718.75,percent of total billed charges,
PLATE,7736666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2348.72000,681.13000,Aetna,First Health,,1921.25,,,,,,,846.71,1921.25,percent of total billed charges,
PLATE,7736666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2348.72000,681.13000,Aetna,First Health,,1921.25,,,,,,,756.29,1921.25,percent of total billed charges,
PLATE,7702976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2271.12000,658.62000,Aetna,First Health,,1857.78,,,,,,,818.74,1857.78,percent of total billed charges,
PLATE,7702976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2271.12000,658.62000,Aetna,First Health,,1857.78,,,,,,,731.30,1857.78,percent of total billed charges,
SCREW,7695369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,7695369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
SCREW,7695370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,7695370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
SCREW,7695371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,7695371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
SCREW,7695372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,7695372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
SCREW,7695608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,7695608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
SCREW,7696237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,7696237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
SCREW,7698815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7698815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,7701017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7701017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,7701326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,7701326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
SCREW,7702189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,7702189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
SCREW,7698490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW,7698490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
SCREW,7698649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,355.06000,102.97000,Aetna,First Health,,290.44,,,,,,,128.00,290.44,percent of total billed charges,
SCREW,7698649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,355.06000,102.97000,Aetna,First Health,,290.44,,,,,,,114.33,290.44,percent of total billed charges,
SCREW,7698673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7698673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7698674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7698675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7698864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7698864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7699176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7699776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7699879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7699879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
SCREW,7700138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7700138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7700159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7700159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7700160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7700160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7701992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7701992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7702137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7702137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7748829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,7748829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,7947921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7947921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7948044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7948044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7948046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7948046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7961903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,7961903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,7965912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7965912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
PLATE,7700368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2680.56000,777.36000,Aetna,First Health,,2192.70,,,,,,,966.34,2192.70,percent of total billed charges,
PLATE,7700368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2680.56000,777.36000,Aetna,First Health,,2192.70,,,,,,,863.14,2192.70,percent of total billed charges,
PLATE,7736139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2680.56000,777.36000,Aetna,First Health,,2192.70,,,,,,,966.34,2192.70,percent of total billed charges,
PLATE,7736139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2680.56000,777.36000,Aetna,First Health,,2192.70,,,,,,,863.14,2192.70,percent of total billed charges,
PLATE,7917331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
PLATE,7917331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
PLATE,7702986,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2699.40000,782.83000,Aetna,First Health,,2208.11,,,,,,,973.13,2208.11,percent of total billed charges,
PLATE,7702986,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2699.40000,782.83000,Aetna,First Health,,2208.11,,,,,,,869.21,2208.11,percent of total billed charges,
PLATE,7699680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7699680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7700361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7700361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7700362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7700362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7700367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2714.36000,787.16000,Aetna,First Health,,2220.35,,,,,,,978.53,2220.35,percent of total billed charges,
PLATE,7700367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2714.36000,787.16000,Aetna,First Health,,2220.35,,,,,,,874.02,2220.35,percent of total billed charges,
PLATE,7700658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7700658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7700659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7700659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7700758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7700758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7702074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3825.15000,1109.29000,Aetna,First Health,,3128.97,,,,,,,1378.97,3128.97,percent of total billed charges,
PLATE,7702074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3825.15000,1109.29000,Aetna,First Health,,3128.97,,,,,,,1231.70,3128.97,percent of total billed charges,
PLATE,7736053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3596.78000,1043.07000,Aetna,First Health,,2942.17,,,,,,,1296.64,2942.17,percent of total billed charges,
PLATE,7736053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3596.78000,1043.07000,Aetna,First Health,,2942.17,,,,,,,1158.16,2942.17,percent of total billed charges,
PLATE,7736054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3596.78000,1043.07000,Aetna,First Health,,2942.17,,,,,,,1296.64,2942.17,percent of total billed charges,
PLATE,7736054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3596.78000,1043.07000,Aetna,First Health,,2942.17,,,,,,,1158.16,2942.17,percent of total billed charges,
PLATE,7736460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7736460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7736461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7736461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7750591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7750591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7816122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7816122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7830029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7830029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7894132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7894132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7894133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7894133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7897134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
PLATE,7897134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
PLATE,7901829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1728.89,3922.97,percent of total billed charges,
PLATE,7901427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1544.25,3922.97,percent of total billed charges,
PLATE,7901428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1728.89,3922.97,percent of total billed charges,
PLATE,7901428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1544.25,3922.97,percent of total billed charges,
PLATE,7901429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1728.89,3922.97,percent of total billed charges,
PLATE,7901429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1544.25,3922.97,percent of total billed charges,
PLATE,7901430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1728.89,3922.97,percent of total billed charges,
PLATE,7901430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1544.25,3922.97,percent of total billed charges,
PLATE,7901431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5067.37000,1469.54000,Aetna,First Health,,4145.11,,,,,,,1826.79,4145.11,percent of total billed charges,
PLATE,7901433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5067.37000,1469.54000,Aetna,First Health,,4145.11,,,,,,,1631.69,4145.11,percent of total billed charges,
PLATE,7901434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5067.37000,1469.54000,Aetna,First Health,,4145.11,,,,,,,1826.79,4145.11,percent of total billed charges,
PLATE,7901434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5067.37000,1469.54000,Aetna,First Health,,4145.11,,,,,,,1631.69,4145.11,percent of total billed charges,
PLATE,7901435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5067.37000,1469.54000,Aetna,First Health,,4145.11,,,,,,,1826.79,4145.11,percent of total billed charges,
PLATE,7901435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5067.37000,1469.54000,Aetna,First Health,,4145.11,,,,,,,1631.69,4145.11,percent of total billed charges,
PLATE,7901436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5067.37000,1469.54000,Aetna,First Health,,4145.11,,,,,,,1826.79,4145.11,percent of total billed charges,
PLATE,7901436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5067.37000,1469.54000,Aetna,First Health,,4145.11,,,,,,,1631.69,4145.11,percent of total billed charges,
PLATE,7901787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1675.04,3800.78,percent of total billed charges,
PLATE,7901789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,First Health,,3800.78,,,,,,,1496.15,3800.78,percent of total billed charges,
PLATE,7901790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1728.89,3922.97,percent of total billed charges,
PLATE,7901790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1544.25,3922.97,percent of total billed charges,
PLATE,7901791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1728.89,3922.97,percent of total billed charges,
PLATE,7901791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1544.25,3922.97,percent of total billed charges,
PLATE,7901792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1728.89,3922.97,percent of total billed charges,
PLATE,7901792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1544.25,3922.97,percent of total billed charges,
PLATE,7901793,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1728.89,3922.97,percent of total billed charges,
PLATE,7901793,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1544.25,3922.97,percent of total billed charges,
CAGE,7698801,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20587.50000,5970.38000,Aetna,First Health,,16840.58,,,,,,,7421.79,16840.58,percent of total billed charges,
CAGE,7698801,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20587.50000,5970.38000,Aetna,First Health,,16840.58,,,,,,,6629.18,16840.58,percent of total billed charges,
CAGE,7698876,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20587.50000,5970.38000,Aetna,First Health,,16840.58,,,,,,,7421.79,16840.58,percent of total billed charges,
CAGE,7698876,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20587.50000,5970.38000,Aetna,First Health,,16840.58,,,,,,,6629.18,16840.58,percent of total billed charges,
CAGE,7939858,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7939858,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
ANCHOR,7698517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
ANCHOR,7698517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
STEM,7698882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7698882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7699099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7699099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7699316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7699316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7699454,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7699454,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7699904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7699904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7701637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7701637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7736439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7736439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7736440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7736440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7874343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7874343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7927420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7927420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7944502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7944502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7944503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7944503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7947859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7947859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7960004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7960004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7962616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7962616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
PLATE,7696680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.55000,1075.77000,Aetna,First Health,,3034.41,,,,,,,1337.29,3034.41,percent of total billed charges,
PLATE,7696680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.55000,1075.77000,Aetna,First Health,,3034.41,,,,,,,1194.48,3034.41,percent of total billed charges,
PLATE,7697483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.55000,1075.77000,Aetna,First Health,,3034.41,,,,,,,1337.29,3034.41,percent of total billed charges,
PLATE,7697483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.55000,1075.77000,Aetna,First Health,,3034.41,,,,,,,1194.48,3034.41,percent of total billed charges,
PLATE,7698559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7698559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
PLATE,7698561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.55000,1075.77000,Aetna,First Health,,3034.41,,,,,,,1337.29,3034.41,percent of total billed charges,
PLATE,7698561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.55000,1075.77000,Aetna,First Health,,3034.41,,,,,,,1194.48,3034.41,percent of total billed charges,
PLATE,7698562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7698562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
PLATE,7698761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1274.90,2892.83,percent of total billed charges,
PLATE,7698761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1138.74,2892.83,percent of total billed charges,
PLATE,7699934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7699934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
PLATE,7700381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2243.20000,650.53000,Aetna,First Health,,1834.94,,,,,,,808.67,1834.94,percent of total billed charges,
PLATE,7700381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2243.20000,650.53000,Aetna,First Health,,1834.94,,,,,,,722.31,1834.94,percent of total billed charges,
PLATE,7700860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1274.90,2892.83,percent of total billed charges,
PLATE,7700860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1138.74,2892.83,percent of total billed charges,
PLATE,7700861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1274.90,2892.83,percent of total billed charges,
PLATE,7700861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1138.74,2892.83,percent of total billed charges,
PLATE,7701565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1274.90,2892.83,percent of total billed charges,
PLATE,7701565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1138.74,2892.83,percent of total billed charges,
PLATE,7701898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3259.20000,945.17000,Aetna,First Health,,2666.03,,,,,,,1174.94,2666.03,percent of total billed charges,
PLATE,7701898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3259.20000,945.17000,Aetna,First Health,,2666.03,,,,,,,1049.46,2666.03,percent of total billed charges,
PLATE,7702033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.55000,1075.77000,Aetna,First Health,,3034.41,,,,,,,1337.29,3034.41,percent of total billed charges,
PLATE,7702033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.55000,1075.77000,Aetna,First Health,,3034.41,,,,,,,1194.48,3034.41,percent of total billed charges,
PLATE,7702274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4970.70000,1441.50000,Aetna,First Health,,4066.03,,,,,,,1791.94,4066.03,percent of total billed charges,
PLATE,7702274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4970.70000,1441.50000,Aetna,First Health,,4066.03,,,,,,,1600.57,4066.03,percent of total billed charges,
PLATE,7736207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7736207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
PLATE,7736493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7736493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
PLATE,7768037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7768037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
PLATE,7882263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7882263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
PLATE,7895962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7895962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
PLATE,7895963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7895963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
PLATE,7904979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1274.90,2892.83,percent of total billed charges,
PLATE,7904979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1138.74,2892.83,percent of total billed charges,
PLATE,7911285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1274.90,2892.83,percent of total billed charges,
PLATE,7911285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1138.74,2892.83,percent of total billed charges,
PLATE,7917857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7917857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
STENT,7699486,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4163.92000,1207.54000,Aetna,First Health,,3406.09,,,,,,,1501.09,3406.09,percent of total billed charges,
STENT,7699486,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4163.92000,1207.54000,Aetna,First Health,,3406.09,,,,,,,1340.78,3406.09,percent of total billed charges,
STENT,7842039,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4163.92000,1207.54000,Aetna,First Health,,3406.09,,,,,,,1501.09,3406.09,percent of total billed charges,
STENT,7842039,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4163.92000,1207.54000,Aetna,First Health,,3406.09,,,,,,,1340.78,3406.09,percent of total billed charges,
STENT,7842040,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4163.92000,1207.54000,Aetna,First Health,,3406.09,,,,,,,1501.09,3406.09,percent of total billed charges,
STENT,7842040,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4163.92000,1207.54000,Aetna,First Health,,3406.09,,,,,,,1340.78,3406.09,percent of total billed charges,
STENT,7874184,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5128.59000,1487.29000,Aetna,First Health,,4195.19,,,,,,,1848.86,4195.19,percent of total billed charges,
STENT,7874184,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5128.59000,1487.29000,Aetna,First Health,,4195.19,,,,,,,1651.41,4195.19,percent of total billed charges,
STENT,7874185,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5128.59000,1487.29000,Aetna,First Health,,4195.19,,,,,,,1848.86,4195.19,percent of total billed charges,
STENT,7874185,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5128.59000,1487.29000,Aetna,First Health,,4195.19,,,,,,,1651.41,4195.19,percent of total billed charges,
PLATE,7698566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5648.51000,1638.07000,Aetna,First Health,,4620.48,,,,,,,2036.29,4620.48,percent of total billed charges,
PLATE,7698566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5648.51000,1638.07000,Aetna,First Health,,4620.48,,,,,,,1818.82,4620.48,percent of total billed charges,
PLATE,7699334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5844.02000,1694.77000,Aetna,First Health,,4780.41,,,,,,,2106.77,4780.41,percent of total billed charges,
PLATE,7699334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5844.02000,1694.77000,Aetna,First Health,,4780.41,,,,,,,1881.77,4780.41,percent of total billed charges,
PLATE,7699363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7761.00000,2250.69000,Aetna,First Health,,6348.50,,,,,,,2797.84,6348.50,percent of total billed charges,
PLATE,7699363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7761.00000,2250.69000,Aetna,First Health,,6348.50,,,,,,,2499.04,6348.50,percent of total billed charges,
PLATE,7702001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4263.00000,1236.27000,Aetna,First Health,,3487.13,,,,,,,1536.81,3487.13,percent of total billed charges,
PLATE,7702001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4263.00000,1236.27000,Aetna,First Health,,3487.13,,,,,,,1372.69,3487.13,percent of total billed charges,
PLATE,7702002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4263.00000,1236.27000,Aetna,First Health,,3487.13,,,,,,,1536.81,3487.13,percent of total billed charges,
PLATE,7702002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4263.00000,1236.27000,Aetna,First Health,,3487.13,,,,,,,1372.69,3487.13,percent of total billed charges,
PLATE,7702003,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4263.00000,1236.27000,Aetna,First Health,,3487.13,,,,,,,1536.81,3487.13,percent of total billed charges,
PLATE,7702003,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4263.00000,1236.27000,Aetna,First Health,,3487.13,,,,,,,1372.69,3487.13,percent of total billed charges,
PLATE,7702004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4263.00000,1236.27000,Aetna,First Health,,3487.13,,,,,,,1536.81,3487.13,percent of total billed charges,
PLATE,7702004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4263.00000,1236.27000,Aetna,First Health,,3487.13,,,,,,,1372.69,3487.13,percent of total billed charges,
PLATE,7702005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4203.50000,1219.01000,Aetna,First Health,,3438.46,,,,,,,1515.36,3438.46,percent of total billed charges,
PLATE,7702005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4203.50000,1219.01000,Aetna,First Health,,3438.46,,,,,,,1353.53,3438.46,percent of total billed charges,
PLATE,7702006,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4203.50000,1219.01000,Aetna,First Health,,3438.46,,,,,,,1515.36,3438.46,percent of total billed charges,
PLATE,7702006,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4203.50000,1219.01000,Aetna,First Health,,3438.46,,,,,,,1353.53,3438.46,percent of total billed charges,
PLATE,7702007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4203.50000,1219.01000,Aetna,First Health,,3438.46,,,,,,,1515.36,3438.46,percent of total billed charges,
PLATE,7702007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4203.50000,1219.01000,Aetna,First Health,,3438.46,,,,,,,1353.53,3438.46,percent of total billed charges,
PLATE,7702009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4203.50000,1219.01000,Aetna,First Health,,3438.46,,,,,,,1515.36,3438.46,percent of total billed charges,
PLATE,7702009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4203.50000,1219.01000,Aetna,First Health,,3438.46,,,,,,,1353.53,3438.46,percent of total billed charges,
SCREW,7695804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7695804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7697432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7697432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7697629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7697629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7698568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7698568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7698857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7698857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7699467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7699467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7699574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7699574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7699575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7699575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7699576,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7699576,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7700380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7700380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7700499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7700499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7700602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7700602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7700603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7700603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7707492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,222.13000,64.42000,Aetna,First Health,,181.70,,,,,,,80.08,181.70,percent of total billed charges,
SCREW,7707492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,222.13000,64.42000,Aetna,First Health,,181.70,,,,,,,71.53,181.70,percent of total billed charges,
SCREW,7741017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7741017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7746043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7746043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7746044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
SCREW,7746044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,7756860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,149.84000,43.45000,Aetna,First Health,,122.57,,,,,,,54.02,122.57,percent of total billed charges,
SCREW,7756860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,149.84000,43.45000,Aetna,First Health,,122.57,,,,,,,48.25,122.57,percent of total billed charges,
SCREW,7784274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,102.59000,29.75000,Aetna,First Health,,83.92,,,,,,,36.98,83.92,percent of total billed charges,
SCREW,7784274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,102.59000,29.75000,Aetna,First Health,,83.92,,,,,,,33.03,83.92,percent of total billed charges,
SCREW,7828064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,102.59000,29.75000,Aetna,First Health,,83.92,,,,,,,36.98,83.92,percent of total billed charges,
SCREW,7828064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,102.59000,29.75000,Aetna,First Health,,83.92,,,,,,,33.03,83.92,percent of total billed charges,
SCREW,7856119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7856119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7893583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7893583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7896381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7896381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7905406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7905406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7905407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7905407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7905408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7905408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7905409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7905409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7913205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,222.13000,64.42000,Aetna,First Health,,181.70,,,,,,,80.08,181.70,percent of total billed charges,
SCREW,7913205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,222.13000,64.42000,Aetna,First Health,,181.70,,,,,,,71.53,181.70,percent of total billed charges,
SCREW,7913206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,222.13000,64.42000,Aetna,First Health,,181.70,,,,,,,80.08,181.70,percent of total billed charges,
SCREW,7913206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,222.13000,64.42000,Aetna,First Health,,181.70,,,,,,,71.53,181.70,percent of total billed charges,
SCREW,7913207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,222.13000,64.42000,Aetna,First Health,,181.70,,,,,,,80.08,181.70,percent of total billed charges,
SCREW,7913207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,222.13000,64.42000,Aetna,First Health,,181.70,,,,,,,71.53,181.70,percent of total billed charges,
SCREW,7703032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7703032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7703033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7703033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7703034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7703034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7703035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7703035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7703036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7703036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7703037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7703037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7882230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7882230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7703038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7703038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7703039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7703039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7703040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7703040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7703041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,7703041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
SCREW,7703232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7703232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
PIN,7698570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
PIN,7698570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
PIN,7698571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
PIN,7698571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
PIN,7698572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
PIN,7698572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
PIN,7776481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,777.47000,225.47000,Aetna,First Health,,635.97,,,,,,,280.28,635.97,percent of total billed charges,
PIN,7776481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,777.47000,225.47000,Aetna,First Health,,635.97,,,,,,,250.35,635.97,percent of total billed charges,
ROD,7910457,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7910457,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
ROD,7910458,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7910458,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
NAIL,7701071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7701112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7701112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
NAIL,7878345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,7878345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
LOCKING RING,7742072,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,205.70,466.75,percent of total billed charges,
LOCKING RING,7742072,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,183.73,466.75,percent of total billed charges,
TROCHANTERIC CLAW,7701635,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3698.10000,1072.45000,Aetna,First Health,,3025.05,,,,,,,1333.17,3025.05,percent of total billed charges,
TROCHANTERIC CLAW,7701635,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3698.10000,1072.45000,Aetna,First Health,,3025.05,,,,,,,1190.79,3025.05,percent of total billed charges,
ROD,7700864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,533.11,1209.66,percent of total billed charges,
ROD,7700864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,476.17,1209.66,percent of total billed charges,
ROD,7707459,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,533.11,1209.66,percent of total billed charges,
ROD,7707459,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,476.17,1209.66,percent of total billed charges,
ROD,7935110,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,533.11,1209.66,percent of total billed charges,
ROD,7935110,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,476.17,1209.66,percent of total billed charges,
ROD,7948616,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7948616,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD,7948617,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7948617,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD,7964998,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7964998,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
ROD,7964999,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7964999,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
SCREW,7700812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,633.51000,183.72000,Aetna,First Health,,518.21,,,,,,,228.38,518.21,percent of total billed charges,
SCREW,7700812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,633.51000,183.72000,Aetna,First Health,,518.21,,,,,,,203.99,518.21,percent of total billed charges,
SCREW,7701730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,7701730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,7701731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,7701731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,7701732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,7701732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,7701733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,7701733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,7701734,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,7701734,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
STENT,7695195,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695195,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
STENT,7695196,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695196,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
STENT,7695197,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695197,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
STENT,7695198,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695198,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
STENT,7695199,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695199,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
STENT,7695200,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695200,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
STENT,7695201,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695201,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
STENT,7695202,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695202,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
STENT,7695203,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695203,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
STENT,7695204,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695204,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
STENT,7695205,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,254.29,577.00,percent of total billed charges,
STENT,7695205,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,First Health,,577.00,,,,,,,227.13,577.00,percent of total billed charges,
LINER,7699673,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3576.63,8115.62,percent of total billed charges,
LINER,7699673,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3194.66,8115.62,percent of total billed charges,
LOCKING RING,7699674,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,First Health,,2034.20,,,,,,,896.49,2034.20,percent of total billed charges,
LOCKING RING,7699674,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,First Health,,2034.20,,,,,,,800.75,2034.20,percent of total billed charges,
STEM,7697459,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1871.68,4246.97,percent of total billed charges,
STEM,7697459,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1671.79,4246.97,percent of total billed charges,
STEM,7697460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1871.68,4246.97,percent of total billed charges,
STEM,7697460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,First Health,,4246.97,,,,,,,1671.79,4246.97,percent of total billed charges,
STEM,7699627,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7699627,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7699961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7699961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7699962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,2115.95,4801.25,percent of total billed charges,
STEM,7699962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,First Health,,4801.25,,,,,,,1889.98,4801.25,percent of total billed charges,
STEM,7882391,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
STEM,7882391,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
STEM,7812179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,7812179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
STEM,7816118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,7816118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
STEM,7909380,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,7909380,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
PLATE,7701911,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
PLATE,7701911,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
PLATE,7940795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,7940795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
PLATE,7700294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
PLATE,7700294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
PLATE,7736101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5048.37000,1464.03000,Aetna,First Health,,4129.57,,,,,,,1819.94,4129.57,percent of total billed charges,
PLATE,7736101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5048.37000,1464.03000,Aetna,First Health,,4129.57,,,,,,,1625.58,4129.57,percent of total billed charges,
PLATE,7699183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5311.78000,1540.42000,Aetna,First Health,,4345.04,,,,,,,1914.90,4345.04,percent of total billed charges,
PLATE,7699183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5311.78000,1540.42000,Aetna,First Health,,4345.04,,,,,,,1710.39,4345.04,percent of total billed charges,
PLATE,7699348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5311.78000,1540.42000,Aetna,First Health,,4345.04,,,,,,,1914.90,4345.04,percent of total billed charges,
PLATE,7699348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5311.78000,1540.42000,Aetna,First Health,,4345.04,,,,,,,1710.39,4345.04,percent of total billed charges,
PLATE,7699726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1981.68000,574.69000,Aetna,First Health,,1621.01,,,,,,,714.40,1621.01,percent of total billed charges,
PLATE,7699726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1981.68000,574.69000,Aetna,First Health,,1621.01,,,,,,,638.10,1621.01,percent of total billed charges,
PLATE,7699727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1993.88000,578.23000,Aetna,First Health,,1630.99,,,,,,,718.79,1630.99,percent of total billed charges,
PLATE,7699727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1993.88000,578.23000,Aetna,First Health,,1630.99,,,,,,,642.03,1630.99,percent of total billed charges,
PLATE,7698386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,7698386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
PLATE,7698387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,7698387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
PLATE,7698778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.22000,1054.50000,Aetna,First Health,,2974.43,,,,,,,1310.86,2974.43,percent of total billed charges,
PLATE,7698778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.22000,1054.50000,Aetna,First Health,,2974.43,,,,,,,1170.86,2974.43,percent of total billed charges,
PLATE,7699280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,7699280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
PLATE,7699282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,7699282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
PLATE,7700255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2202.84000,638.82000,Aetna,First Health,,1801.92,,,,,,,794.12,1801.92,percent of total billed charges,
PLATE,7700255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2202.84000,638.82000,Aetna,First Health,,1801.92,,,,,,,709.31,1801.92,percent of total billed charges,
PLATE,7701897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3040.40000,881.72000,Aetna,First Health,,2487.05,,,,,,,1096.06,2487.05,percent of total billed charges,
PLATE,7701897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3040.40000,881.72000,Aetna,First Health,,2487.05,,,,,,,979.01,2487.05,percent of total billed charges,
PLATE,7744536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,7744536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,7700796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,7700806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
PLATE,7700807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1996.00000,578.84000,Aetna,First Health,,1632.73,,,,,,,719.56,1632.73,percent of total billed charges,
PLATE,7700807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1996.00000,578.84000,Aetna,First Health,,1632.73,,,,,,,642.71,1632.73,percent of total billed charges,
PLATE,7701890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2789.60000,808.98000,Aetna,First Health,,2281.89,,,,,,,1005.65,2281.89,percent of total billed charges,
PLATE,7701890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2789.60000,808.98000,Aetna,First Health,,2281.89,,,,,,,898.25,2281.89,percent of total billed charges,
PLATE,7701899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2789.60000,808.98000,Aetna,First Health,,2281.89,,,,,,,1005.65,2281.89,percent of total billed charges,
PLATE,7701899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2789.60000,808.98000,Aetna,First Health,,2281.89,,,,,,,898.25,2281.89,percent of total billed charges,
PLATE,7736673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1914.20000,555.12000,Aetna,First Health,,1565.82,,,,,,,690.07,1565.82,percent of total billed charges,
PLATE,7736673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1914.20000,555.12000,Aetna,First Health,,1565.82,,,,,,,616.37,1565.82,percent of total billed charges,
STEM EXTENSION,7699186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM EXTENSION,7699186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
STEM EXTENSION,7699489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM EXTENSION,7699489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
STEM EXTENSION,7700322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM EXTENSION,7700322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
STEM EXTENSION,7702028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM EXTENSION,7702028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
STEM EXTENSION,7741331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM EXTENSION,7741331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
STEM EXTENSION,7806291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM EXTENSION,7806291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
STEM EXTENSION,7806292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM EXTENSION,7806292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
STEM EXTENSION,7699340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2680.00000,777.20000,Aetna,First Health,,2192.24,,,,,,,966.14,2192.24,percent of total billed charges,
STEM EXTENSION,7699340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2680.00000,777.20000,Aetna,First Health,,2192.24,,,,,,,862.96,2192.24,percent of total billed charges,
STEM EXTENSION,7700014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,2052.78,4657.90,percent of total billed charges,
STEM EXTENSION,7700014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,1833.55,4657.90,percent of total billed charges,
STEM EXTENSION,7736678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,2052.78,4657.90,percent of total billed charges,
STEM EXTENSION,7736678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,1833.55,4657.90,percent of total billed charges,
SHELL,7736136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7736136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SHELL,7748746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7748746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SHELL,7790172,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7790172,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SHELL,7806034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7806034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SHELL,7874290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7874290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SHELL,7882381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7882381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
PLATE,7701905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8813.70000,2555.97000,Aetna,First Health,,7209.61,,,,,,,3177.34,7209.61,percent of total billed charges,
PLATE,7701905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8813.70000,2555.97000,Aetna,First Health,,7209.61,,,,,,,2838.01,7209.61,percent of total billed charges,
PLATE,7702011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,1065.64,2418.01,percent of total billed charges,
PLATE,7702011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,951.83,2418.01,percent of total billed charges,
PLATE,7702012,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,1065.64,2418.01,percent of total billed charges,
PLATE,7702012,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,951.83,2418.01,percent of total billed charges,
PLATE,7702013,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,1065.64,2418.01,percent of total billed charges,
PLATE,7702013,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,951.83,2418.01,percent of total billed charges,
PLATE,7702014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,1065.64,2418.01,percent of total billed charges,
PLATE,7702014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,951.83,2418.01,percent of total billed charges,
PLATE,7702015,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,1065.64,2418.01,percent of total billed charges,
PLATE,7702015,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,First Health,,2418.01,,,,,,,951.83,2418.01,percent of total billed charges,
PLATE,7939424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2939.00000,852.31000,Aetna,First Health,,2404.10,,,,,,,1059.51,2404.10,percent of total billed charges,
PLATE,7939424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2939.00000,852.31000,Aetna,First Health,,2404.10,,,,,,,946.36,2404.10,percent of total billed charges,
PLATE,7696844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,794.54,1802.87,percent of total billed charges,
PLATE,7696844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,709.69,1802.87,percent of total billed charges,
PLATE,7699883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,794.54,1802.87,percent of total billed charges,
PLATE,7699883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,709.69,1802.87,percent of total billed charges,
PLATE,7894122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,794.54,1802.87,percent of total billed charges,
PLATE,7894122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,709.69,1802.87,percent of total billed charges,
PLATE,7702983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,794.54,1802.87,percent of total billed charges,
PLATE,7702983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,709.69,1802.87,percent of total billed charges,
STENT GRAFT,7740564,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21567.50000,6254.58000,Aetna,First Health,,17642.22,,,,,,,7775.08,17642.22,percent of total billed charges,
STENT GRAFT,7740564,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21567.50000,6254.58000,Aetna,First Health,,17642.22,,,,,,,6944.73,17642.22,percent of total billed charges,
STENT GRAFT,7740565,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21567.50000,6254.58000,Aetna,First Health,,17642.22,,,,,,,7775.08,17642.22,percent of total billed charges,
STENT GRAFT,7740565,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21567.50000,6254.58000,Aetna,First Health,,17642.22,,,,,,,6944.73,17642.22,percent of total billed charges,
STENT GRAFT,7744629,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21567.50000,6254.58000,Aetna,First Health,,17642.22,,,,,,,7775.08,17642.22,percent of total billed charges,
STENT GRAFT,7744629,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21567.50000,6254.58000,Aetna,First Health,,17642.22,,,,,,,6944.73,17642.22,percent of total billed charges,
COMPONENT DISTAL,7699600,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,7886.67000,2287.13000,Aetna,First Health,,6451.30,,,,,,,2843.14,6451.30,percent of total billed charges,
COMPONENT DISTAL,7699600,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,7886.67000,2287.13000,Aetna,First Health,,6451.30,,,,,,,2364.47,6451.30,percent of total billed charges,
COMPONENT DISTAL,7699601,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,8306.10000,2408.77000,Aetna,First Health,,6794.39,,,,,,,2994.35,6794.39,percent of total billed charges,
COMPONENT DISTAL,7699601,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,8306.10000,2408.77000,Aetna,First Health,,6794.39,,,,,,,2364.47,6794.39,percent of total billed charges,
COMPONENT DISTAL,7910290,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,First Health,,7082.24,,,,,,,3121.21,7082.24,percent of total billed charges,
COMPONENT DISTAL,7910290,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,First Health,,7082.24,,,,,,,2364.47,7082.24,percent of total billed charges,
STENT GRAFT,7698462,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
STENT GRAFT,7698462,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
STENT GRAFT,7698463,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
STENT GRAFT,7698463,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
STENT GRAFT,7699830,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7699830,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7699831,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
STENT GRAFT,7699831,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
STENT GRAFT,7700313,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16057.50000,4656.67000,Aetna,First Health,,13135.03,,,,,,,5788.73,13135.03,percent of total billed charges,
STENT GRAFT,7700313,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16057.50000,4656.67000,Aetna,First Health,,13135.03,,,,,,,5170.52,13135.03,percent of total billed charges,
STENT GRAFT,7768034,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7768034,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7778036,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7778036,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7778037,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7778037,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7790539,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7790539,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7818078,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7818078,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7818079,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7818079,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7826031,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7826031,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7872043,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7872043,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7882321,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7882321,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7901622,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7901622,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7902730,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7902730,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7904152,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,7904152,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,7698232,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7698232,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
STENT GRAFT,7698258,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7698258,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
STENT GRAFT,7699523,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7699523,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
STENT GRAFT,7700075,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7700075,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
STENT GRAFT,7700314,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7700314,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
STENT GRAFT,7701025,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7701025,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
STENT GRAFT,7702067,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7702067,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
STENT GRAFT,7736169,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7736169,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
STENT GRAFT,7736190,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7736190,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
STENT GRAFT,7778035,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7778035,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7790538,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7790538,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7818077,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
STENT GRAFT,7818077,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
STENT GRAFT,7826033,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7826033,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7872042,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7872042,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7876434,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7876434,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7893772,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7893772,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7901623,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7901623,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7904026,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7904026,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7904151,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7904151,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7917662,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7917662,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7926458,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7926458,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7926541,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7926541,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7929722,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33862.50000,9820.12000,Aetna,First Health,,27699.53,,,,,,,12207.43,27699.53,percent of total billed charges,
STENT GRAFT,7929722,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33862.50000,9820.12000,Aetna,First Health,,27699.53,,,,,,,10903.73,27699.53,percent of total billed charges,
STENT GRAFT,7938913,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33862.50000,9820.12000,Aetna,First Health,,27699.53,,,,,,,12207.43,27699.53,percent of total billed charges,
STENT GRAFT,7938913,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33862.50000,9820.12000,Aetna,First Health,,27699.53,,,,,,,10903.73,27699.53,percent of total billed charges,
STENT GRAFT,7939278,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7939278,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7954371,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7954371,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
STENT GRAFT,7954523,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,7954523,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
PLATE,7700342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
PLATE,7700342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
PLATE,7700344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
PLATE,7700344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
PLATE,7700345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
PLATE,7700345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
PLATE,7702987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,829.85000,240.66000,Aetna,First Health,,678.82,,,,,,,299.16,678.82,percent of total billed charges,
PLATE,7702987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,829.85000,240.66000,Aetna,First Health,,678.82,,,,,,,267.21,678.82,percent of total billed charges,
PLATE,7702988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,829.85000,240.66000,Aetna,First Health,,678.82,,,,,,,299.16,678.82,percent of total billed charges,
PLATE,7702988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,829.85000,240.66000,Aetna,First Health,,678.82,,,,,,,267.21,678.82,percent of total billed charges,
CATHETER BALLOON,7695046,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1588.00000,460.52000,Aetna,First Health,,1298.98,,,,,,,572.47,1298.98,percent of total billed charges,
CATHETER BALLOON,7695046,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1588.00000,460.52000,Aetna,First Health,,1298.98,,,,,,,511.34,1298.98,percent of total billed charges,
CATHETER BALLOON,7695329,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1652.76000,479.30000,Aetna,First Health,,1351.96,,,,,,,595.82,1351.96,percent of total billed charges,
CATHETER BALLOON,7695329,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1652.76000,479.30000,Aetna,First Health,,1351.96,,,,,,,532.19,1351.96,percent of total billed charges,
CATHETER BALLOON,7696247,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1652.76000,479.30000,Aetna,First Health,,1351.96,,,,,,,595.82,1351.96,percent of total billed charges,
CATHETER BALLOON,7696247,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1652.76000,479.30000,Aetna,First Health,,1351.96,,,,,,,532.19,1351.96,percent of total billed charges,
CATHETER BALLOON,7696514,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,7696514,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,7696702,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,7696702,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,7846239,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,7846239,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,7699042,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,7699042,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,7699417,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER BALLOON,7699417,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
CATHETER BALLOON,7700117,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER BALLOON,7700117,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
CATHETER BALLOON,7707507,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER BALLOON,7707507,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
CATHETER BALLOON,7748128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER BALLOON,7748128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER BALLOON,7905712,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER BALLOON,7905712,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
CATHETER BALLOON,7942055,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER BALLOON,7942055,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
CATHETER BALLOON,7953855,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER BALLOON,7953855,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
PLATE,7701540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
PLATE,7701540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
PLATE,7701541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
PLATE,7701541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
PLATE,7782038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,422.75000,122.60000,Aetna,First Health,,345.81,,,,,,,152.40,345.81,percent of total billed charges,
PLATE,7782038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,422.75000,122.60000,Aetna,First Health,,345.81,,,,,,,136.13,345.81,percent of total billed charges,
CATHETER BALLOON,7694653,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
CATHETER BALLOON,7694653,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
CATHETER BALLOON,7694654,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
CATHETER BALLOON,7694654,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
CATHETER BALLOON,7697874,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
CATHETER BALLOON,7697874,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
PLATE,7701901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4206.30000,1219.83000,Aetna,First Health,,3440.75,,,,,,,1516.37,3440.75,percent of total billed charges,
PLATE,7701901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4206.30000,1219.83000,Aetna,First Health,,3440.75,,,,,,,1354.43,3440.75,percent of total billed charges,
PLATE,7880276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
PLATE,7880276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
PLATE,7957718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1222.30,2773.48,percent of total billed charges,
PLATE,7957718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1091.76,2773.48,percent of total billed charges,
PLATE,7957912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1222.30,2773.48,percent of total billed charges,
PLATE,7957912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1091.76,2773.48,percent of total billed charges,
LEAD,7699768,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,7596.00000,2202.84000,Aetna,First Health,,6213.53,,,,,,,2738.36,6213.53,percent of total billed charges,
LEAD,7699768,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,7596.00000,2202.84000,Aetna,First Health,,6213.53,,,,,,,2445.91,6213.53,percent of total billed charges,
SPACER,7696146,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4705.02000,1364.46000,Aetna,First Health,,3848.71,,,,,,,1696.16,3848.71,percent of total billed charges,
SPACER,7696146,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4705.02000,1364.46000,Aetna,First Health,,3848.71,,,,,,,1515.02,3848.71,percent of total billed charges,
SPACER,7702908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4705.02000,1364.46000,Aetna,First Health,,3848.71,,,,,,,1696.16,3848.71,percent of total billed charges,
SPACER,7702908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4705.02000,1364.46000,Aetna,First Health,,3848.71,,,,,,,1515.02,3848.71,percent of total billed charges,
PLATE,7695888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,868.50000,251.86000,Aetna,First Health,,710.43,,,,,,,313.09,710.43,percent of total billed charges,
PLATE,7695888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,868.50000,251.86000,Aetna,First Health,,710.43,,,,,,,279.66,710.43,percent of total billed charges,
PLATE,7700340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,First Health,,1092.85,,,,,,,481.63,1092.85,percent of total billed charges,
PLATE,7700340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,First Health,,1092.85,,,,,,,430.19,1092.85,percent of total billed charges,
PLATE,7700341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,First Health,,1092.85,,,,,,,481.63,1092.85,percent of total billed charges,
PLATE,7700341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,First Health,,1092.85,,,,,,,430.19,1092.85,percent of total billed charges,
PLATE,7701524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,241.72,548.47,percent of total billed charges,
PLATE,7701524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,215.90,548.47,percent of total billed charges,
PLATE,7701800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,981.45000,284.62000,Aetna,First Health,,802.83,,,,,,,353.81,802.83,percent of total billed charges,
PLATE,7701826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,981.45000,284.62000,Aetna,First Health,,802.83,,,,,,,316.03,802.83,percent of total billed charges,
PLATE,7880757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,241.72,548.47,percent of total billed charges,
PLATE,7880757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,215.90,548.47,percent of total billed charges,
PLATE,7880758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,241.72,548.47,percent of total billed charges,
PLATE,7880758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,215.90,548.47,percent of total billed charges,
GRAFT,7696124,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8055.00000,2335.95000,Aetna,First Health,,6588.99,,,,,,,2903.83,6588.99,percent of total billed charges,
GRAFT,7696124,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8055.00000,2335.95000,Aetna,First Health,,6588.99,,,,,,,2593.71,6588.99,percent of total billed charges,
GRAFT,7840053,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8055.00000,2335.95000,Aetna,First Health,,6588.99,,,,,,,2903.83,6588.99,percent of total billed charges,
GRAFT,7840053,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8055.00000,2335.95000,Aetna,First Health,,6588.99,,,,,,,2593.71,6588.99,percent of total billed charges,
PLATE,7822179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5289.90000,1534.07000,Aetna,First Health,,4327.14,,,,,,,1907.01,4327.14,percent of total billed charges,
PLATE,7822179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5289.90000,1534.07000,Aetna,First Health,,4327.14,,,,,,,1703.35,4327.14,percent of total billed charges,
PLATE,7910161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5289.90000,1534.07000,Aetna,First Health,,4327.14,,,,,,,1907.01,4327.14,percent of total billed charges,
PLATE,7910161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5289.90000,1534.07000,Aetna,First Health,,4327.14,,,,,,,1703.35,4327.14,percent of total billed charges,
PLATE,7912234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5289.90000,1534.07000,Aetna,First Health,,4327.14,,,,,,,1907.01,4327.14,percent of total billed charges,
PLATE,7912234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5289.90000,1534.07000,Aetna,First Health,,4327.14,,,,,,,1703.35,4327.14,percent of total billed charges,
PLATE,7774235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2220.00000,643.80000,Aetna,First Health,,1815.96,,,,,,,800.31,1815.96,percent of total billed charges,
PLATE,7774235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2220.00000,643.80000,Aetna,First Health,,1815.96,,,,,,,714.84,1815.96,percent of total billed charges,
CABLE,7699182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1552.40000,450.20000,Aetna,First Health,,1269.86,,,,,,,559.64,1269.86,percent of total billed charges,
CABLE,7699182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1552.40000,450.20000,Aetna,First Health,,1269.86,,,,,,,499.87,1269.86,percent of total billed charges,
CATHETER,7699172,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
CATHETER,7699172,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
CATHETER DIL BALLOON,7699035,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699035,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699036,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699036,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699037,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699037,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699038,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699038,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699039,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699039,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699040,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699040,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699041,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699041,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699043,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699043,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699044,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699044,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699045,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699045,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699046,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699046,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699047,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699047,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699123,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7699123,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER DIL BALLOON,7850227,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
CATHETER DIL BALLOON,7850227,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
STENT,7694324,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7694324,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7694325,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7694325,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7694326,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7694326,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7694407,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7694407,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7695654,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7695654,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7696724,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7696724,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7696757,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7696757,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7696777,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7696777,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7696891,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7696891,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7696908,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7696908,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7756046,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7756046,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7703267,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7703267,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7703268,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7703268,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STENT,7703269,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
STENT,7703269,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
VALVE,7701325,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,6218.62,14110.50,percent of total billed charges,
VALVE,7701325,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,5554.50,14110.50,percent of total billed charges,
VALVE,7784184,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,6218.62,14110.50,percent of total billed charges,
VALVE,7784184,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,5554.50,14110.50,percent of total billed charges,
VALVE,7850228,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,6218.62,14110.50,percent of total billed charges,
VALVE,7850228,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,5554.50,14110.50,percent of total billed charges,
VALVE,7878185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,6218.62,14110.50,percent of total billed charges,
VALVE,7878185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,5554.50,14110.50,percent of total billed charges,
VALVE,7703328,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,6218.62,14110.50,percent of total billed charges,
VALVE,7703328,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,First Health,,14110.50,,,,,,,5554.50,14110.50,percent of total billed charges,
ROD,7736126,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,1128.84,percent of total billed charges,
ROD,7736126,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,444.36,1128.84,percent of total billed charges,
PIN,7699233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7699233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PIN,7699234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7699234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PIN,7699235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7699235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PIN,7699236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7699236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PIN,7699237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7699237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PIN,7699248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7699248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PIN,7700089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7700089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PIN,7701597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7701597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PIN,7954643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7954643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PIN,7954644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7954644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PIN,7954645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
PIN,7954645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
NAIL,7700226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7700226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7700418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7700418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7700501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7700501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7701330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7701330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7702596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7702596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7707474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7707474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7707504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7707504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7736502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7736502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7736548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7736548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7736670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7736670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7748067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7748067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7810034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7810034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7820144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7820144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7852132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7852132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7858270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7858270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7910126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6585.18000,1909.70000,Aetna,First Health,,5386.68,,,,,,,2373.96,5386.68,percent of total billed charges,
NAIL,7910126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6585.18000,1909.70000,Aetna,First Health,,5386.68,,,,,,,2120.43,5386.68,percent of total billed charges,
NAIL,7918386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7918386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7940866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7940866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7950389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7950389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7963861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7963861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,7964528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,7964528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
COMPONENT FEMORAL,7699823,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7699823,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
TIBIAL TRAY,7699824,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1495.17,3392.66,percent of total billed charges,
TIBIAL TRAY,7699824,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1335.49,3392.66,percent of total billed charges,
TIBIAL TRAY,7702291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1495.17,3392.66,percent of total billed charges,
TIBIAL TRAY,7702291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1335.49,3392.66,percent of total billed charges,
FEMORAL IMPLANT,7699903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
FEMORAL IMPLANT,7699903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
FEMORAL IMPLANT,7701636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
FEMORAL IMPLANT,7701636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
FEMORAL IMPLANT,7736487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
FEMORAL IMPLANT,7736487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
COMPONENT GLENOID,7699329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
COMPONENT GLENOID,7699329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
COMPONENT GLENOID,7874395,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
COMPONENT GLENOID,7874395,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
COMPONENT GLENOID,7880202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
COMPONENT GLENOID,7880202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
STEM,7699330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7699330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
STEM,7802323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7802323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
STEM,7802325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7802325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
STEM,7822250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7822250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
STEM,7828141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7828141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
STEM,7878310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7878310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
STEM,7880189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7880189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
STEM,7904044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7904044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
STEM,7908232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7908232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
STEM,7918901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7918901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
STEM,7964532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7964532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
HUMERAL HEAD,7830036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7830036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7903724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7903724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7957936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7957936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
PLATE,7699332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,First Health,,6338.19,,,,,,,2793.30,6338.19,percent of total billed charges,
PLATE,7699332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,First Health,,6338.19,,,,,,,2494.98,6338.19,percent of total billed charges,
PLATE,7699754,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,First Health,,6338.19,,,,,,,2793.30,6338.19,percent of total billed charges,
PLATE,7699754,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,First Health,,6338.19,,,,,,,2494.98,6338.19,percent of total billed charges,
PLATE,7700303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5887.49000,1707.37000,Aetna,First Health,,4815.97,,,,,,,2122.44,4815.97,percent of total billed charges,
PLATE,7700303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5887.49000,1707.37000,Aetna,First Health,,4815.97,,,,,,,1895.77,4815.97,percent of total billed charges,
PLATE,7700760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3780.14000,1096.24000,Aetna,First Health,,3092.15,,,,,,,1362.74,3092.15,percent of total billed charges,
PLATE,7700760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3780.14000,1096.24000,Aetna,First Health,,3092.15,,,,,,,1217.21,3092.15,percent of total billed charges,
PLATE,7701672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3557.47000,1031.67000,Aetna,First Health,,2910.01,,,,,,,1282.47,2910.01,percent of total billed charges,
PLATE,7701672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3557.47000,1031.67000,Aetna,First Health,,2910.01,,,,,,,1145.51,2910.01,percent of total billed charges,
PLATE,7736052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3557.47000,1031.67000,Aetna,First Health,,2910.01,,,,,,,1282.47,2910.01,percent of total billed charges,
PLATE,7736052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3557.47000,1031.67000,Aetna,First Health,,2910.01,,,,,,,1145.51,2910.01,percent of total billed charges,
PLATE,7736201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7749.00000,2247.21000,Aetna,First Health,,6338.68,,,,,,,2793.51,6338.68,percent of total billed charges,
PLATE,7736201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7749.00000,2247.21000,Aetna,First Health,,6338.68,,,,,,,2495.18,6338.68,percent of total billed charges,
PLATE,7940332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5887.49000,1707.37000,Aetna,First Health,,4815.97,,,,,,,2122.44,4815.97,percent of total billed charges,
PLATE,7940332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5887.49000,1707.37000,Aetna,First Health,,4815.97,,,,,,,1895.77,4815.97,percent of total billed charges,
PLATE,7948767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5887.49000,1707.37000,Aetna,First Health,,4815.97,,,,,,,2122.44,4815.97,percent of total billed charges,
PLATE,7948767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5887.49000,1707.37000,Aetna,First Health,,4815.97,,,,,,,1895.77,4815.97,percent of total billed charges,
PLATE,7954085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5441.56000,1578.05000,Aetna,First Health,,4451.20,,,,,,,1961.68,4451.20,percent of total billed charges,
PLATE,7954085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5441.56000,1578.05000,Aetna,First Health,,4451.20,,,,,,,1752.18,4451.20,percent of total billed charges,
PLATE,7960014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5683.83000,1648.31000,Aetna,First Health,,4649.37,,,,,,,2049.02,4649.37,percent of total billed charges,
PLATE,7960014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5683.83000,1648.31000,Aetna,First Health,,4649.37,,,,,,,1830.19,4649.37,percent of total billed charges,
PLATE,7698782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2398.36000,695.52000,Aetna,First Health,,1961.86,,,,,,,864.61,1961.86,percent of total billed charges,
PLATE,7698782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2398.36000,695.52000,Aetna,First Health,,1961.86,,,,,,,772.27,1961.86,percent of total billed charges,
PLATE,7699337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,870.20,1974.55,percent of total billed charges,
PLATE,7699337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,777.27,1974.55,percent of total billed charges,
PLATE,7699868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,870.20,1974.55,percent of total billed charges,
PLATE,7699868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,777.27,1974.55,percent of total billed charges,
PLATE,7740753,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,870.20,1974.55,percent of total billed charges,
PLATE,7740753,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,777.27,1974.55,percent of total billed charges,
PLATE,7920412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2475.20000,717.81000,Aetna,First Health,,2024.71,,,,,,,892.31,2024.71,percent of total billed charges,
PLATE,7920412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2475.20000,717.81000,Aetna,First Health,,2024.71,,,,,,,797.01,2024.71,percent of total billed charges,
INSERT,7901707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,7901707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
INSERT,7902774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,7902774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
INSERT,7902817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,7902817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
COMPONENT FEMORAL,7700416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7700416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7736287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7736287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7748820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7748820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7748901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7748901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7750089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7750089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7750119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7750119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7786147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7786147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7804038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7804038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7822235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7822235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7822242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7822242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7836169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7836169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7850226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7850226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7878479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7878479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7880274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7880274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7880669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7880669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7882255,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3940.65000,1142.79000,Aetna,First Health,,3223.45,,,,,,,1420.60,3223.45,percent of total billed charges,
COMPONENT FEMORAL,7882255,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3940.65000,1142.79000,Aetna,First Health,,3223.45,,,,,,,1268.89,3223.45,percent of total billed charges,
COMPONENT FEMORAL,7882367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7882367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7882768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7882768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7893981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7893981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7896385,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7896385,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7896742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7896742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7903725,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7903725,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7905491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7905491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
GUIDE CATHETER,7695879,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
GUIDE CATHETER,7695879,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
GUIDE CATHETER,7740758,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
GUIDE CATHETER,7740758,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
GUIDE CATHETER,7740759,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
GUIDE CATHETER,7740759,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
SPACER,7697930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
SPACER,7697930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
SPACER,7699094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
SPACER,7699094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7699367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7699367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7699628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7699628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7699655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7699655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
SPACER,7736111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
SPACER,7736111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7904695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7904695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7908620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7908620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7908621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7908621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7908622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
AUGMENT TIBIAL,7908622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
INSERT,7699747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7699747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7699814,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7699814,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
INSERT,7736288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7736288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7786148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7786148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7882511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7882511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7908184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7908184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7910433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7910433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7911548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7911548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7912139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7912139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7936054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7936054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SHELL,7701193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7701193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7736213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7736213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7876186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7876186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7896904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7896904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7902293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7902293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7911320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7911320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
COMPONENT FEMORAL,7698470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7698470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7698617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7698617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7699375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7699375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7700109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7700109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7700525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7700525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7700828,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7700828,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7701684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7701684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7778031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7778031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7816135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7816135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7893307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7893307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7897081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
COMPONENT FEMORAL,7897081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
COMPONENT PATELLA,7699532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
COMPONENT PATELLA,7699532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
COMPONENT PATELLA,7700317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
COMPONENT PATELLA,7700317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
COMPONENT PATELLA,7736219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
COMPONENT PATELLA,7736219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
PLATE,7702140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5471.97000,1586.87000,Aetna,First Health,,4476.07,,,,,,,1972.65,4476.07,percent of total billed charges,
PLATE,7702140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5471.97000,1586.87000,Aetna,First Health,,4476.07,,,,,,,1761.97,4476.07,percent of total billed charges,
PLATE,7702195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5471.97000,1586.87000,Aetna,First Health,,4476.07,,,,,,,1972.65,4476.07,percent of total billed charges,
PLATE,7702195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5471.97000,1586.87000,Aetna,First Health,,4476.07,,,,,,,1761.97,4476.07,percent of total billed charges,
PLATE,7736469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5835.87000,1692.40000,Aetna,First Health,,4773.74,,,,,,,2103.83,4773.74,percent of total billed charges,
PLATE,7736469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5835.87000,1692.40000,Aetna,First Health,,4773.74,,,,,,,1879.15,4773.74,percent of total billed charges,
NAIL CAP,7699387,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
NAIL CAP,7699387,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
NAIL CAP,7736074,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
NAIL CAP,7736074,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
NAIL CAP,7736650,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
NAIL CAP,7736650,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
PLATE,7699864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4185.72000,1213.86000,Aetna,First Health,,3423.92,,,,,,,1508.95,3423.92,percent of total billed charges,
PLATE,7699864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4185.72000,1213.86000,Aetna,First Health,,3423.92,,,,,,,1347.80,3423.92,percent of total billed charges,
SCREW,7902651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7902651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,7902652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7902652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,7902653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7902653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
ROD,7736659,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7736659,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,7701784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7701784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
SCREW,7701785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7701785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
SCREW,7701786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7701786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
SCREW,7701788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7701788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
SCREW,7701789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7701789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
SCREW,7701798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7701798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
SCREW,7701799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7701799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
PLATE,7701848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1403.60000,407.04000,Aetna,First Health,,1148.14,,,,,,,506.00,1148.14,percent of total billed charges,
PLATE,7701848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1403.60000,407.04000,Aetna,First Health,,1148.14,,,,,,,451.96,1148.14,percent of total billed charges,
PLATE,7701866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1403.60000,407.04000,Aetna,First Health,,1148.14,,,,,,,506.00,1148.14,percent of total billed charges,
PLATE,7701866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1403.60000,407.04000,Aetna,First Health,,1148.14,,,,,,,451.96,1148.14,percent of total billed charges,
PLATE,7701910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1403.60000,407.04000,Aetna,First Health,,1148.14,,,,,,,506.00,1148.14,percent of total billed charges,
PLATE,7701910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1403.60000,407.04000,Aetna,First Health,,1148.14,,,,,,,451.96,1148.14,percent of total billed charges,
PLATE,7701912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1390.40000,403.22000,Aetna,First Health,,1137.35,,,,,,,501.24,1137.35,percent of total billed charges,
PLATE,7701912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1390.40000,403.22000,Aetna,First Health,,1137.35,,,,,,,447.71,1137.35,percent of total billed charges,
PLATE,7960029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
PLATE,7960029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
STEM,7748741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7748741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7790173,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7790173,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7806035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7806035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7810032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7810032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7913647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7913647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7958151,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7958151,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
BASEPLATE,7830039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7830039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
HUMERAL HEAD,7893768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
HUMERAL HEAD,7893768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
PLATE,7699175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3745.00000,1086.05000,Aetna,First Health,,3063.41,,,,,,,1350.07,3063.41,percent of total billed charges,
PLATE,7699175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3745.00000,1086.05000,Aetna,First Health,,3063.41,,,,,,,1205.89,3063.41,percent of total billed charges,
PLATE,7699364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3776.50000,1095.18000,Aetna,First Health,,3089.18,,,,,,,1361.43,3089.18,percent of total billed charges,
PLATE,7699364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3776.50000,1095.18000,Aetna,First Health,,3089.18,,,,,,,1216.03,3089.18,percent of total billed charges,
PLATE,7699483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3745.00000,1086.05000,Aetna,First Health,,3063.41,,,,,,,1350.07,3063.41,percent of total billed charges,
PLATE,7699483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3745.00000,1086.05000,Aetna,First Health,,3063.41,,,,,,,1205.89,3063.41,percent of total billed charges,
PLATE,7700139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3801.00000,1102.29000,Aetna,First Health,,3109.22,,,,,,,1370.26,3109.22,percent of total billed charges,
PLATE,7700139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3801.00000,1102.29000,Aetna,First Health,,3109.22,,,,,,,1223.92,3109.22,percent of total billed charges,
PLATE,7701998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3801.00000,1102.29000,Aetna,First Health,,3109.22,,,,,,,1370.26,3109.22,percent of total billed charges,
PLATE,7701998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3801.00000,1102.29000,Aetna,First Health,,3109.22,,,,,,,1223.92,3109.22,percent of total billed charges,
PLATE,7701999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3801.00000,1102.29000,Aetna,First Health,,3109.22,,,,,,,1370.26,3109.22,percent of total billed charges,
PLATE,7701999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3801.00000,1102.29000,Aetna,First Health,,3109.22,,,,,,,1223.92,3109.22,percent of total billed charges,
PLATE,7702000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3801.00000,1102.29000,Aetna,First Health,,3109.22,,,,,,,1370.26,3109.22,percent of total billed charges,
PLATE,7702000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3801.00000,1102.29000,Aetna,First Health,,3109.22,,,,,,,1223.92,3109.22,percent of total billed charges,
PLATE,7702008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3745.00000,1086.05000,Aetna,First Health,,3063.41,,,,,,,1350.07,3063.41,percent of total billed charges,
PLATE,7702008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3745.00000,1086.05000,Aetna,First Health,,3063.41,,,,,,,1205.89,3063.41,percent of total billed charges,
PLATE,7702263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4130.70000,1197.90000,Aetna,First Health,,3378.91,,,,,,,1489.12,3378.91,percent of total billed charges,
PLATE,7702263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4130.70000,1197.90000,Aetna,First Health,,3378.91,,,,,,,1330.09,3378.91,percent of total billed charges,
PLATE,7910234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1368.20000,396.78000,Aetna,First Health,,1119.19,,,,,,,493.24,1119.19,percent of total billed charges,
PLATE,7910234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1368.20000,396.78000,Aetna,First Health,,1119.19,,,,,,,440.56,1119.19,percent of total billed charges,
SCREW,7702279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,62.32,141.42,percent of total billed charges,
SCREW,7702279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,55.67,141.42,percent of total billed charges,
SCREW,7702280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,62.32,141.42,percent of total billed charges,
SCREW,7702280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,55.67,141.42,percent of total billed charges,
SCREW,7741435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7741435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7744540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7744540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7744541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7744541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7744543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7744543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7794447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7794447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,7830030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7830030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7830031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7830031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7830033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7830033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7832100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7832100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7882480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7882480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
PLATE,7748068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6556.45000,1901.37000,Aetna,First Health,,5363.18,,,,,,,2363.60,5363.18,percent of total billed charges,
PLATE,7748068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6556.45000,1901.37000,Aetna,First Health,,5363.18,,,,,,,2111.18,5363.18,percent of total billed charges,
PLATE,7794301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6556.45000,1901.37000,Aetna,First Health,,5363.18,,,,,,,2363.60,5363.18,percent of total billed charges,
PLATE,7794301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6556.45000,1901.37000,Aetna,First Health,,5363.18,,,,,,,2111.18,5363.18,percent of total billed charges,
PLATE,7701818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1654.40000,479.78000,Aetna,First Health,,1353.30,,,,,,,596.41,1353.30,percent of total billed charges,
PLATE,7701818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1654.40000,479.78000,Aetna,First Health,,1353.30,,,,,,,532.72,1353.30,percent of total billed charges,
PLATE,7701868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,605.93,1374.89,percent of total billed charges,
PLATE,7701868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,541.22,1374.89,percent of total billed charges,
PLATE,7701869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,605.93,1374.89,percent of total billed charges,
PLATE,7701869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,541.22,1374.89,percent of total billed charges,
PLATE,7772159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1469.60000,426.18000,Aetna,First Health,,1202.13,,,,,,,529.79,1202.13,percent of total billed charges,
PLATE,7772159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1469.60000,426.18000,Aetna,First Health,,1202.13,,,,,,,473.21,1202.13,percent of total billed charges,
PLATE,7701883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1905.20000,552.51000,Aetna,First Health,,1558.45,,,,,,,686.82,1558.45,percent of total billed charges,
PLATE,7701883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1905.20000,552.51000,Aetna,First Health,,1558.45,,,,,,,613.47,1558.45,percent of total billed charges,
PLATE,7701887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1905.20000,552.51000,Aetna,First Health,,1558.45,,,,,,,686.82,1558.45,percent of total billed charges,
PLATE,7701887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1905.20000,552.51000,Aetna,First Health,,1558.45,,,,,,,613.47,1558.45,percent of total billed charges,
PLATE,7939414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
PLATE,7939414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
PLATE,7701838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1548.80000,449.15000,Aetna,First Health,,1266.92,,,,,,,558.34,1266.92,percent of total billed charges,
PLATE,7701838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1548.80000,449.15000,Aetna,First Health,,1266.92,,,,,,,498.71,1266.92,percent of total billed charges,
PLATE,7702784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1498.40000,434.54000,Aetna,First Health,,1225.69,,,,,,,540.17,1225.69,percent of total billed charges,
PLATE,7702784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1498.40000,434.54000,Aetna,First Health,,1225.69,,,,,,,482.48,1225.69,percent of total billed charges,
PLATE,7701867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1601.60000,464.46000,Aetna,First Health,,1310.11,,,,,,,577.38,1310.11,percent of total billed charges,
PLATE,7701867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1601.60000,464.46000,Aetna,First Health,,1310.11,,,,,,,515.72,1310.11,percent of total billed charges,
PLATE,7701871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,605.93,1374.89,percent of total billed charges,
PLATE,7701871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,541.22,1374.89,percent of total billed charges,
PLATE,7903034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1361.95,3090.35,percent of total billed charges,
PLATE,7903034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1216.50,3090.35,percent of total billed charges,
PLATE,7934085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1361.95,3090.35,percent of total billed charges,
PLATE,7934085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1216.50,3090.35,percent of total billed charges,
PLATE,7935711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1361.95,3090.35,percent of total billed charges,
PLATE,7935711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1216.50,3090.35,percent of total billed charges,
PLATE,7701892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2446.40000,709.46000,Aetna,First Health,,2001.16,,,,,,,881.93,2001.16,percent of total billed charges,
PLATE,7701892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2446.40000,709.46000,Aetna,First Health,,2001.16,,,,,,,787.74,2001.16,percent of total billed charges,
PLATE,7701893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2446.40000,709.46000,Aetna,First Health,,2001.16,,,,,,,881.93,2001.16,percent of total billed charges,
PLATE,7701893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2446.40000,709.46000,Aetna,First Health,,2001.16,,,,,,,787.74,2001.16,percent of total billed charges,
INSERT,7736080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2811.20000,815.25000,Aetna,First Health,,2299.56,,,,,,,1013.44,2299.56,percent of total billed charges,
INSERT,7736080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2811.20000,815.25000,Aetna,First Health,,2299.56,,,,,,,905.21,2299.56,percent of total billed charges,
STEM,7699000,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7699000,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7702289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7702289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7740768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7740768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7748823,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7748823,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7782039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7782039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7822248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7822248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7959957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7959957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7965297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7965297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
PLATE,7740755,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1518.00000,440.22000,Aetna,First Health,,1241.72,,,,,,,547.24,1241.72,percent of total billed charges,
PLATE,7740755,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1518.00000,440.22000,Aetna,First Health,,1241.72,,,,,,,488.80,1241.72,percent of total billed charges,
PLATE,7742071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1518.00000,440.22000,Aetna,First Health,,1241.72,,,,,,,547.24,1241.72,percent of total billed charges,
PLATE,7742071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1518.00000,440.22000,Aetna,First Health,,1241.72,,,,,,,488.80,1241.72,percent of total billed charges,
PLATE,7772035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1518.00000,440.22000,Aetna,First Health,,1241.72,,,,,,,547.24,1241.72,percent of total billed charges,
PLATE,7772035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1518.00000,440.22000,Aetna,First Health,,1241.72,,,,,,,488.80,1241.72,percent of total billed charges,
PLATE,7772040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2046.00000,593.34000,Aetna,First Health,,1673.63,,,,,,,737.58,1673.63,percent of total billed charges,
PLATE,7772040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2046.00000,593.34000,Aetna,First Health,,1673.63,,,,,,,658.81,1673.63,percent of total billed charges,
PLATE,7916933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1385.00000,401.65000,Aetna,First Health,,1132.93,,,,,,,499.29,1132.93,percent of total billed charges,
PLATE,7916933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1385.00000,401.65000,Aetna,First Health,,1132.93,,,,,,,445.97,1132.93,percent of total billed charges,
PLATE,7701878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,701.10,1590.85,percent of total billed charges,
PLATE,7701878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,626.23,1590.85,percent of total billed charges,
PLATE,7701880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,701.10,1590.85,percent of total billed charges,
PLATE,7701880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,626.23,1590.85,percent of total billed charges,
PLATE,7701888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,701.10,1590.85,percent of total billed charges,
PLATE,7701888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,626.23,1590.85,percent of total billed charges,
PLATE,7772036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1526.80000,442.77000,Aetna,First Health,,1248.92,,,,,,,550.41,1248.92,percent of total billed charges,
PLATE,7772036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1526.80000,442.77000,Aetna,First Health,,1248.92,,,,,,,491.63,1248.92,percent of total billed charges,
PLATE,7911780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7911780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7939402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,475.25,1078.39,percent of total billed charges,
PLATE,7939402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,424.50,1078.39,percent of total billed charges,
PLATE,7939431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,7939431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
PLATE,7701900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2882.00000,835.78000,Aetna,First Health,,2357.48,,,,,,,1038.96,2357.48,percent of total billed charges,
PLATE,7701900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2882.00000,835.78000,Aetna,First Health,,2357.48,,,,,,,928.00,2357.48,percent of total billed charges,
PLATE,7804059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6161.75000,1786.91000,Aetna,First Health,,5040.31,,,,,,,2221.31,5040.31,percent of total billed charges,
PLATE,7804059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6161.75000,1786.91000,Aetna,First Health,,5040.31,,,,,,,1984.08,5040.31,percent of total billed charges,
PLATE,7701909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6620.25000,1919.87000,Aetna,First Health,,5415.36,,,,,,,2386.60,5415.36,percent of total billed charges,
PLATE,7701909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6620.25000,1919.87000,Aetna,First Health,,5415.36,,,,,,,2131.72,5415.36,percent of total billed charges,
PLATE,7880554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2714.36000,787.16000,Aetna,First Health,,2220.35,,,,,,,978.53,2220.35,percent of total billed charges,
PLATE,7880554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2714.36000,787.16000,Aetna,First Health,,2220.35,,,,,,,874.02,2220.35,percent of total billed charges,
CABLE,7696191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
CABLE,7696191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
STEM,7880532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10686.00000,3098.94000,Aetna,First Health,,8741.15,,,,,,,3852.30,8741.15,percent of total billed charges,
STEM,7880532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10686.00000,3098.94000,Aetna,First Health,,8741.15,,,,,,,3440.89,8741.15,percent of total billed charges,
PLATE,7702645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,2173.83,4932.58,percent of total billed charges,
PLATE,7702645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,1941.68,4932.58,percent of total billed charges,
PLATE,7702665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,2173.83,4932.58,percent of total billed charges,
PLATE,7702665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,1941.68,4932.58,percent of total billed charges,
PLATE,7707546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,2173.83,4932.58,percent of total billed charges,
PLATE,7707546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,1941.68,4932.58,percent of total billed charges,
PLATE,7702647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7360.47000,2134.54000,Aetna,First Health,,6020.86,,,,,,,2653.45,6020.86,percent of total billed charges,
PLATE,7702647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7360.47000,2134.54000,Aetna,First Health,,6020.86,,,,,,,2370.07,6020.86,percent of total billed charges,
PLATE,7702666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7360.47000,2134.54000,Aetna,First Health,,6020.86,,,,,,,2653.45,6020.86,percent of total billed charges,
PLATE,7702666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7360.47000,2134.54000,Aetna,First Health,,6020.86,,,,,,,2370.07,6020.86,percent of total billed charges,
PLATE,7882184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7806.00000,2263.74000,Aetna,First Health,,6385.31,,,,,,,2814.06,6385.31,percent of total billed charges,
PLATE,7882184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7806.00000,2263.74000,Aetna,First Health,,6385.31,,,,,,,2513.53,6385.31,percent of total billed charges,
PLATE,7707533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7419.12000,2151.54000,Aetna,First Health,,6068.84,,,,,,,2674.59,6068.84,percent of total billed charges,
PLATE,7707533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7419.12000,2151.54000,Aetna,First Health,,6068.84,,,,,,,2388.96,6068.84,percent of total billed charges,
PLATE,7707534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7419.12000,2151.54000,Aetna,First Health,,6068.84,,,,,,,2674.59,6068.84,percent of total billed charges,
PLATE,7707534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7419.12000,2151.54000,Aetna,First Health,,6068.84,,,,,,,2388.96,6068.84,percent of total billed charges,
PLATE,7756189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6354.60000,1842.83000,Aetna,First Health,,5198.06,,,,,,,2290.83,5198.06,percent of total billed charges,
PLATE,7756189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6354.60000,1842.83000,Aetna,First Health,,5198.06,,,,,,,2046.18,5198.06,percent of total billed charges,
PLATE,7756381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7912218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7419.12000,2151.54000,Aetna,First Health,,6068.84,,,,,,,2674.59,6068.84,percent of total billed charges,
PLATE,7912218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7419.12000,2151.54000,Aetna,First Health,,6068.84,,,,,,,2388.96,6068.84,percent of total billed charges,
SCREW,7902535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
SCREW,7902535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
SCREW,7902536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
SCREW,7902536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
SCREW,7903623,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,7903623,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SCREW,7903624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,7903624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SCREW,7703084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
SCREW,7703084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
SCREW,7703085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
SCREW,7703085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
SCREW,7703086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
SCREW,7703086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
SCREW,7703088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
SCREW,7703088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
ROD,7703023,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2560.00000,742.40000,Aetna,First Health,,2094.08,,,,,,,922.88,2094.08,percent of total billed charges,
ROD,7703023,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2560.00000,742.40000,Aetna,First Health,,2094.08,,,,,,,824.32,2094.08,percent of total billed charges,
NAIL,7696239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,First Health,,3312.49,,,,,,,1459.84,3312.49,percent of total billed charges,
NAIL,7696239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,First Health,,3312.49,,,,,,,1303.94,3312.49,percent of total billed charges,
NAIL,7707537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,First Health,,3312.49,,,,,,,1459.84,3312.49,percent of total billed charges,
NAIL,7707537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,First Health,,3312.49,,,,,,,1303.94,3312.49,percent of total billed charges,
NAIL,7736076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,First Health,,4684.44,,,,,,,2064.48,4684.44,percent of total billed charges,
NAIL,7736076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,First Health,,4684.44,,,,,,,1844.00,4684.44,percent of total billed charges,
NAIL,7959985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,First Health,,4684.44,,,,,,,2064.48,4684.44,percent of total billed charges,
NAIL,7959985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,First Health,,4684.44,,,,,,,1844.00,4684.44,percent of total billed charges,
NAIL,7962255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,First Health,,4684.44,,,,,,,2064.48,4684.44,percent of total billed charges,
NAIL,7962255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,First Health,,4684.44,,,,,,,1844.00,4684.44,percent of total billed charges,
AUGMENT FEMORAL,7736086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,5404.09,12262.25,percent of total billed charges,
AUGMENT FEMORAL,7736086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,4826.95,12262.25,percent of total billed charges,
AUGMENT TIBIAL,7736360,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,5404.09,12262.25,percent of total billed charges,
AUGMENT TIBIAL,7736360,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,4826.95,12262.25,percent of total billed charges,
AUGMENT FEMORAL,7802299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,5404.09,12262.25,percent of total billed charges,
AUGMENT FEMORAL,7802299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,4826.95,12262.25,percent of total billed charges,
AUGMENT TIBIAL,7895436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,5404.09,12262.25,percent of total billed charges,
AUGMENT TIBIAL,7895436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,4826.95,12262.25,percent of total billed charges,
LINER,7736209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,526.16,1193.89,percent of total billed charges,
LINER,7736209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,469.97,1193.89,percent of total billed charges,
LINER,7740764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,526.16,1193.89,percent of total billed charges,
LINER,7740764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,469.97,1193.89,percent of total billed charges,
LINER,7820077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,526.16,1193.89,percent of total billed charges,
LINER,7820077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,469.97,1193.89,percent of total billed charges,
LINER,7905027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,526.16,1193.89,percent of total billed charges,
LINER,7905027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,469.97,1193.89,percent of total billed charges,
CATHETER CONTURA,7916983,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,10252.50000,2973.22000,Aetna,First Health,,8386.55,,,,,,,3696.03,8386.55,percent of total billed charges,
CATHETER CONTURA,7916983,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,10252.50000,2973.22000,Aetna,First Health,,8386.55,,,,,,,3301.30,8386.55,percent of total billed charges,
FEMORAL HEAD,7858119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7858119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
FEMORAL HEAD,7874327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7874327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
FEMORAL HEAD,7876325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7876325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
FEMORAL HEAD,7878333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7878333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
COMPONENT FEMORAL,7736036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7736036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7736110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7736110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7736541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
COMPONENT FEMORAL,7736541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
COMPONENT FEMORAL,7748112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7748112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7748118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
COMPONENT FEMORAL,7748118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
COMPONENT FEMORAL,7748830,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
COMPONENT FEMORAL,7748830,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
COMPONENT FEMORAL,7750113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7750113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7766057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
COMPONENT FEMORAL,7766057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
COMPONENT FEMORAL,7784192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7784192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7784272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7784272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7790168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7790168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7800033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7800033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7802101,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7802101,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7810066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7810066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7810087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7810087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7812115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7812115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7812117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7812117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7822244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7822244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7828052,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7828052,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7828057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7828057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7828060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7828060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7850198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7850198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7878482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7878482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7878567,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7878567,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7880439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7880439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7880442,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7880442,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7880443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7880443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7893983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7893983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7912219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7912219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7913879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7913879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
LINER,7878332,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7878332,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
LINER,7921280,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7921280,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CATHETER,7699487,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7699487,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7699488,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7699488,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7699651,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7699651,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7699652,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7699652,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7707506,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7707506,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7736128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7736128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7736129,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7736129,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7748747,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7748747,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7768158,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7768158,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7836194,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
CATHETER,7836194,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
CATHETER,7842038,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7842038,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7902823,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7902823,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7930132,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7930132,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7938058,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7938058,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7956684,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7956684,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
CATHETER,7956685,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER,7956685,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
PLATE,7699399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3423.00000,992.67000,Aetna,First Health,,2800.01,,,,,,,1233.99,2800.01,percent of total billed charges,
PLATE,7699399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3423.00000,992.67000,Aetna,First Health,,2800.01,,,,,,,1102.21,2800.01,percent of total billed charges,
PLATE,7736168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3423.00000,992.67000,Aetna,First Health,,2800.01,,,,,,,1233.99,2800.01,percent of total billed charges,
PLATE,7736168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3423.00000,992.67000,Aetna,First Health,,2800.01,,,,,,,1102.21,2800.01,percent of total billed charges,
PLATE,7750149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3423.00000,992.67000,Aetna,First Health,,2800.01,,,,,,,1233.99,2800.01,percent of total billed charges,
PLATE,7750149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3423.00000,992.67000,Aetna,First Health,,2800.01,,,,,,,1102.21,2800.01,percent of total billed charges,
PLATE,7828148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7828148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7900528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7900528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7900529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7900529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7900530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7900530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7900531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7900531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7900532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7900532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7900533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7900533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7901741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7901741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7901742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7901742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7901743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7901743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7901744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7901744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7901745,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7901745,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7901746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7901746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7938859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1361.95,3090.35,percent of total billed charges,
PLATE,7938859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1216.50,3090.35,percent of total billed charges,
STENT,7695216,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3414.53,7747.82,percent of total billed charges,
STENT,7695216,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3049.87,7747.82,percent of total billed charges,
STENT,7695217,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3414.53,7747.82,percent of total billed charges,
STENT,7695217,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3049.87,7747.82,percent of total billed charges,
SHELL,7736210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7736210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SHELL,7740763,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7740763,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SHELL,7820076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7820076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SHELL,7894081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7894081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SHELL,7896393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7896393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SHELL,7904042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7904042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SHELL,7905029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7905029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SHELL,7926531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7926531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SHELL,7930256,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7930256,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SHELL,7935398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7935398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
STEM,7736277,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7736277,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7748751,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7748751,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7820075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7820075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7834076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7834076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7834077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7834077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7836158,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7836158,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7836192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7836192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7850088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7850088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7850197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7850197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7858070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7858070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7893679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7893679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7896902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7896902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7897206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7897206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7905028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7905028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7905249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7905249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7944523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7944523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7736289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7736289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7802065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7802065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7804054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7804054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7804056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7804056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7806299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7806299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7822253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7822253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7822256,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7822256,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7832049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7832049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7846162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7846162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7882245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7882245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7913510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7913510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7913511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7913511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7948080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7948080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
BASEPLATE,7754104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
BASEPLATE,7754104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
BASEPLATE,7768161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
BASEPLATE,7768161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
BASEPLATE,7802060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
BASEPLATE,7802060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
SHELL,7880289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,7880289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
WEDGE,7736282,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
WEDGE,7736282,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
WEDGE,7927539,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
WEDGE,7927539,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
WEDGE,7930205,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
WEDGE,7930205,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
WEDGE,7946099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
WEDGE,7946099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
WEDGE,7954472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
WEDGE,7954472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
COMPONENT FEMORAL,7736215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7736215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7736269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7736269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7790242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7790242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7820141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7820141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7880520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7880520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7880762,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7880762,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7894082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7894082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
SHELL,7748754,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
SHELL,7748754,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
STEM,7882500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,7882500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
STEM,7911545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,7911545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
STEM,7912245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,7912245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
COMPONENT FEMORAL,7748894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7748894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7820074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7820074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7874298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7874298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7882249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7882249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7882829,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7882829,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7910430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7910430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7948081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7948081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
BASEPLATE,7748113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7748113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7750120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7750120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7784271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7784271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7786151,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7786151,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7790167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7790167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7902768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7902768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
COMPONENT PATELLA,7697552,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7697552,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7697662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7697662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7697928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7697928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7698011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7698011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7698220,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7698220,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7699630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7699630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7699861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7699861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7702131,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7702131,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7736286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7736286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7748900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7748900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7784273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7784273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7830037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7830037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT FEMORAL,7702634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7702634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7736348,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7736348,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7808034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7808034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7812122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7812122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7838063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7838063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7848089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7848089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7878301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7878301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7880673,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7880673,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7882584,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7882584,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
BASEPLATE,7748076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7748076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7748739,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7748739,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7750035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7750035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7754080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7754080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7766066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7766066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7794485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7794485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7802067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7802067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7808112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7808112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7822231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7822231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7838122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7838122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7846153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7846153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7880577,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7880577,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7880674,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7880674,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
COMPONENT FEMORAL,7748077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7748077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7750034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7750034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7766063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7766063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7766065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7766065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7766068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7766068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7808111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7808111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7822232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7822232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7834037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7834037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7838123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7838123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7878300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7878300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7880576,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7880576,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7900572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7900572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7904109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7904109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7926701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7926701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7935731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7935731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7938774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7938774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7939866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7939866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7939955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7939955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7944572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7944572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7964339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7964339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7965238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7965238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
INSERT,7748078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7748078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7748740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7748740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7750036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7750036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7754082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7754082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7766064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7766064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7766067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7766067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7766069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7766069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7790541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7790541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7794484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7794484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7802068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7802068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7808113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7808113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7822230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7822230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7834036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7834036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7846152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7846152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7858273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7858273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7866044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7866044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7876324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7876324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7878297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7878297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7878553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7878553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7880526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7880526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7880527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7880527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7880578,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7880578,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7880580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7880580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7882377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7882377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7882378,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7882378,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7882386,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7882386,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7882597,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7882597,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7882740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7882740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7897080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7897080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7900571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7900571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7904050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7904050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7904108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7904108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7905307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7905307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7905497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7905497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7906240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7906240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7909326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7909326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7910998,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7910998,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7912136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7912136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7913508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7913508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7914553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7914553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7914554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7914554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7929726,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7929726,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7935741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7935741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7938811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7938811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7943782,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7943782,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7965047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7965047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7925628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7925628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
COMPONENT PATELLA,7748738,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7748738,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7754081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7754081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7802066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7802066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7902930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7902930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT FEMORAL,7802109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,4346.82,9863.24,percent of total billed charges,
COMPONENT FEMORAL,7802109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,3882.60,9863.24,percent of total billed charges,
INSERT,7848030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7848030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7880510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7880510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7882830,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7882830,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7893865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7893865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7935804,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7935804,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STEM,7698623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7698623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7698640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7698640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7698641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7698641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7699157,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7699157,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7700107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7700107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7700173,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7700173,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7700829,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7700829,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7701021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7701021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7948370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7948370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
HUMERAL ASSEMBLY,7698634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,6398.88,14519.50,percent of total billed charges,
HUMERAL ASSEMBLY,7698634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,5715.50,14519.50,percent of total billed charges,
HUMERAL ASSEMBLY,7698784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,6398.88,14519.50,percent of total billed charges,
HUMERAL ASSEMBLY,7698784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,5715.50,14519.50,percent of total billed charges,
HUMERAL ASSEMBLY,7904738,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,6398.88,14519.50,percent of total billed charges,
HUMERAL ASSEMBLY,7904738,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,5715.50,14519.50,percent of total billed charges,
HUMERAL ASSEMBLY,7965197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,6398.88,14519.50,percent of total billed charges,
HUMERAL ASSEMBLY,7965197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,5715.50,14519.50,percent of total billed charges,
ULNAR ASSEMBLY,7698636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5948.25,13497.00,percent of total billed charges,
ULNAR ASSEMBLY,7698636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5313.00,13497.00,percent of total billed charges,
ULNAR ASSEMBLY,7698785,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5948.25,13497.00,percent of total billed charges,
ULNAR ASSEMBLY,7698785,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5313.00,13497.00,percent of total billed charges,
SCREW,7913286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,677.74,1537.84,percent of total billed charges,
SCREW,7913291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,605.36,1537.84,percent of total billed charges,
SCREW,7913292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,677.74,1537.84,percent of total billed charges,
SCREW,7913306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,605.36,1537.84,percent of total billed charges,
SCREW,7913307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7913309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7913310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7913310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7913311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7913311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7913312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7913312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7913313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7913313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7913314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7913314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7913315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7913315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7935736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,677.74,1537.84,percent of total billed charges,
SCREW,7935736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,605.36,1537.84,percent of total billed charges,
SCREW,7954748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,7954748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,7957717,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,7957717,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
PLATE,7736489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1743.52000,505.62000,Aetna,First Health,,1426.20,,,,,,,628.54,1426.20,percent of total billed charges,
PLATE,7736489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1743.52000,505.62000,Aetna,First Health,,1426.20,,,,,,,561.41,1426.20,percent of total billed charges,
PLATE,7700278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7523.40000,2181.79000,Aetna,First Health,,6154.14,,,,,,,2712.19,6154.14,percent of total billed charges,
PLATE,7700278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7523.40000,2181.79000,Aetna,First Health,,6154.14,,,,,,,2422.53,6154.14,percent of total billed charges,
PLATE,7736040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2815.80000,816.58000,Aetna,First Health,,2303.32,,,,,,,1015.10,2303.32,percent of total billed charges,
PLATE,7736040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2815.80000,816.58000,Aetna,First Health,,2303.32,,,,,,,906.69,2303.32,percent of total billed charges,
PLATE,7882614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,1223.90,2777.11,percent of total billed charges,
PLATE,7882614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,1093.19,2777.11,percent of total billed charges,
PLATE,7882616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
PLATE,7882616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
PLATE,7882617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
PLATE,7882617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
PLATE,7698902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2616.04000,758.65000,Aetna,First Health,,2139.92,,,,,,,943.08,2139.92,percent of total billed charges,
PLATE,7698902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2616.04000,758.65000,Aetna,First Health,,2139.92,,,,,,,842.36,2139.92,percent of total billed charges,
PLATE,7740524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2634.24000,763.93000,Aetna,First Health,,2154.81,,,,,,,949.64,2154.81,percent of total billed charges,
PLATE,7740524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2634.24000,763.93000,Aetna,First Health,,2154.81,,,,,,,848.23,2154.81,percent of total billed charges,
PLATE,7903161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2616.04000,758.65000,Aetna,First Health,,2139.92,,,,,,,943.08,2139.92,percent of total billed charges,
PLATE,7903161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2616.04000,758.65000,Aetna,First Health,,2139.92,,,,,,,842.36,2139.92,percent of total billed charges,
PLATE,7701016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
PLATE,7701016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
PLATE,7698768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3028.40000,878.24000,Aetna,First Health,,2477.23,,,,,,,1091.74,2477.23,percent of total billed charges,
PLATE,7698768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3028.40000,878.24000,Aetna,First Health,,2477.23,,,,,,,975.14,2477.23,percent of total billed charges,
PLATE,7699945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3028.40000,878.24000,Aetna,First Health,,2477.23,,,,,,,1091.74,2477.23,percent of total billed charges,
PLATE,7699945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3028.40000,878.24000,Aetna,First Health,,2477.23,,,,,,,975.14,2477.23,percent of total billed charges,
PLATE,7700723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3028.40000,878.24000,Aetna,First Health,,2477.23,,,,,,,1091.74,2477.23,percent of total billed charges,
PLATE,7700723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3028.40000,878.24000,Aetna,First Health,,2477.23,,,,,,,975.14,2477.23,percent of total billed charges,
STEM,7699286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4609.35,10458.95,percent of total billed charges,
STEM,7699286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4117.09,10458.95,percent of total billed charges,
INSERT,7698774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7698774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,7699288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7699288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,7699712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7699712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,7699922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7699922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,7736283,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7736283,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
PLATE,7701895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3040.40000,881.72000,Aetna,First Health,,2487.05,,,,,,,1096.06,2487.05,percent of total billed charges,
PLATE,7701895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3040.40000,881.72000,Aetna,First Health,,2487.05,,,,,,,979.01,2487.05,percent of total billed charges,
PLATE,7698913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1314.51,2982.71,percent of total billed charges,
PLATE,7698913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1174.12,2982.71,percent of total billed charges,
PLATE,7699429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
PLATE,7699429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
PLATE,7699537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1314.51,2982.71,percent of total billed charges,
PLATE,7699537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1174.12,2982.71,percent of total billed charges,
PLATE,7700862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1314.51,2982.71,percent of total billed charges,
PLATE,7700862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1174.12,2982.71,percent of total billed charges,
PLATE,7700912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1314.51,2982.71,percent of total billed charges,
PLATE,7700912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1174.12,2982.71,percent of total billed charges,
PLATE,7935366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3826.31000,1109.63000,Aetna,First Health,,3129.92,,,,,,,1379.38,3129.92,percent of total billed charges,
PLATE,7935366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3826.31000,1109.63000,Aetna,First Health,,3129.92,,,,,,,1232.07,3129.92,percent of total billed charges,
PLATE,7954642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1314.51,2982.71,percent of total billed charges,
PLATE,7954642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1174.12,2982.71,percent of total billed charges,
STEM,7700120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,7126.63,16170.84,percent of total billed charges,
STEM,7700120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,6365.54,16170.84,percent of total billed charges,
STEM,7701023,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,7126.63,16170.84,percent of total billed charges,
STEM,7701023,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,6365.54,16170.84,percent of total billed charges,
STEM,7701051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,7126.63,16170.84,percent of total billed charges,
STEM,7701051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,6365.54,16170.84,percent of total billed charges,
STEM,7736100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,7126.63,16170.84,percent of total billed charges,
STEM,7736100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,6365.54,16170.84,percent of total billed charges,
STEM,7806036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,7126.63,16170.84,percent of total billed charges,
STEM,7806036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,6365.54,16170.84,percent of total billed charges,
STEM,7893352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,7126.63,16170.84,percent of total billed charges,
STEM,7893352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,6365.54,16170.84,percent of total billed charges,
STEM,7919080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,7126.63,16170.84,percent of total billed charges,
STEM,7919080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,First Health,,16170.84,,,,,,,6365.54,16170.84,percent of total billed charges,
ROD,7736656,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7736656,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
ROD,7742177,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
ROD,7742177,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
ROD,7880508,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1818.00000,527.22000,Aetna,First Health,,1487.12,,,,,,,655.39,1487.12,percent of total billed charges,
ROD,7880508,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1818.00000,527.22000,Aetna,First Health,,1487.12,,,,,,,585.40,1487.12,percent of total billed charges,
SCREW,7741720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7741720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
ROD,7702212,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD,7702212,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
FEMORAL HEAD,7700435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7700435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7804041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7804041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7806410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7806410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7836199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7836199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7878329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7878329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7911245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7911245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7911550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7911550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7939321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7939321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
STEM,7699924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2970.88,6741.14,percent of total billed charges,
STEM,7699924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2653.60,6741.14,percent of total billed charges,
SHELL,7698351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2999.00,6804.94,percent of total billed charges,
SHELL,7698351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2678.72,6804.94,percent of total billed charges,
SHELL,7698820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2999.00,6804.94,percent of total billed charges,
SHELL,7698820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2678.72,6804.94,percent of total billed charges,
SHELL,7911242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2999.00,6804.94,percent of total billed charges,
SHELL,7911242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2678.72,6804.94,percent of total billed charges,
SHELL,7919095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2999.00,6804.94,percent of total billed charges,
SHELL,7919095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2678.72,6804.94,percent of total billed charges,
SHELL,7927540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2999.00,6804.94,percent of total billed charges,
SHELL,7927540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2678.72,6804.94,percent of total billed charges,
PLATE,7700474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2748.16000,796.97000,Aetna,First Health,,2247.99,,,,,,,990.71,2247.99,percent of total billed charges,
PLATE,7700474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2748.16000,796.97000,Aetna,First Health,,2247.99,,,,,,,884.91,2247.99,percent of total billed charges,
SCREW,7695810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7695810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7695811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7695811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7696260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7696260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7697634,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7697634,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7698858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7698858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7698988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7698988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7698989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7698989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7698990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7698990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7698991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7698991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7699430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SCREW,7699430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SCREW,7699518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7699518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7699774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7699774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7700091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7700091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7700104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SCREW,7700104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SCREW,7700116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7700116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7700230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7700230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7700356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7700356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7700399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7700399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7700605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7700605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7700730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7700730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7701501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7701501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7702188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7702188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7702626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7702626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7740883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7740883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7741014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7741014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7741338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7741338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7752054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7752054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7758260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7758260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7904803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7904803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7905400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7905400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7909350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7909350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7916708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,680.98,1545.20,percent of total billed charges,
SCREW,7916708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,608.26,1545.20,percent of total billed charges,
SCREW,7703050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7703050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7703052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7703052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7703054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7703054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7703055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7703055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7703056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7703056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7703057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7703057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
PLATE,7698865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,461.81,1047.89,percent of total billed charges,
PLATE,7698865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,412.49,1047.89,percent of total billed charges,
PLATE,7698900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,461.81,1047.89,percent of total billed charges,
PLATE,7698900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,412.49,1047.89,percent of total billed charges,
PLATE,7699971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,461.81,1047.89,percent of total billed charges,
PLATE,7699971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,412.49,1047.89,percent of total billed charges,
GUIDEWIRE,7698885,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
GUIDEWIRE,7698885,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
GUIDEWIRE,7698886,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
GUIDEWIRE,7698886,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
PLATE,7698890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,544.72,1236.00,percent of total billed charges,
PLATE,7698890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,486.54,1236.00,percent of total billed charges,
PLATE,7699660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7704.00000,2234.16000,Aetna,First Health,,6301.87,,,,,,,2777.29,6301.87,percent of total billed charges,
PLATE,7699660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7704.00000,2234.16000,Aetna,First Health,,6301.87,,,,,,,2480.69,6301.87,percent of total billed charges,
PLATE,7935779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7704.00000,2234.16000,Aetna,First Health,,6301.87,,,,,,,2777.29,6301.87,percent of total billed charges,
PLATE,7935779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7704.00000,2234.16000,Aetna,First Health,,6301.87,,,,,,,2480.69,6301.87,percent of total billed charges,
SHELL,7698284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7698284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7698957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17051.00000,4944.79000,Aetna,First Health,,13947.72,,,,,,,6146.89,13947.72,percent of total billed charges,
SHELL,7698957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17051.00000,4944.79000,Aetna,First Health,,13947.72,,,,,,,5490.42,13947.72,percent of total billed charges,
SHELL,7699129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17051.00000,4944.79000,Aetna,First Health,,13947.72,,,,,,,6146.89,13947.72,percent of total billed charges,
SHELL,7699129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17051.00000,4944.79000,Aetna,First Health,,13947.72,,,,,,,5490.42,13947.72,percent of total billed charges,
SHELL,7699942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7699942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7700670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7700670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7701058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7701058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7702193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7702193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7702245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7702245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7702259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17051.00000,4944.79000,Aetna,First Health,,13947.72,,,,,,,6146.89,13947.72,percent of total billed charges,
SHELL,7702259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17051.00000,4944.79000,Aetna,First Health,,13947.72,,,,,,,5490.42,13947.72,percent of total billed charges,
SHELL,7736443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7736443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7736578,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7736578,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7776035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7776035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7776480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7776480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7896957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7896957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7897362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7897362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7905494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7905494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7964334,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7964334,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PLATE,7700472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2451.12000,710.82000,Aetna,First Health,,2005.02,,,,,,,883.63,2005.02,percent of total billed charges,
PLATE,7700472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2451.12000,710.82000,Aetna,First Health,,2005.02,,,,,,,789.26,2005.02,percent of total billed charges,
CATHETER,7693563,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,411.11000,119.22000,Aetna,First Health,,336.29,,,,,,,148.21,336.29,percent of total billed charges,
CATHETER,7693563,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,411.11000,119.22000,Aetna,First Health,,336.29,,,,,,,132.38,336.29,percent of total billed charges,
CATHETER,7693564,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,411.11000,119.22000,Aetna,First Health,,336.29,,,,,,,148.21,336.29,percent of total billed charges,
CATHETER,7693564,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,411.11000,119.22000,Aetna,First Health,,336.29,,,,,,,132.38,336.29,percent of total billed charges,
CATHETER,7693565,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,411.11000,119.22000,Aetna,First Health,,336.29,,,,,,,148.21,336.29,percent of total billed charges,
CATHETER,7693565,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,411.11000,119.22000,Aetna,First Health,,336.29,,,,,,,132.38,336.29,percent of total billed charges,
CATHETER,7693566,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,411.11000,119.22000,Aetna,First Health,,336.29,,,,,,,148.21,336.29,percent of total billed charges,
CATHETER,7693566,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,411.11000,119.22000,Aetna,First Health,,336.29,,,,,,,132.38,336.29,percent of total billed charges,
CATHETER,7693567,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,411.11000,119.22000,Aetna,First Health,,336.29,,,,,,,148.21,336.29,percent of total billed charges,
CATHETER,7693567,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,411.11000,119.22000,Aetna,First Health,,336.29,,,,,,,132.38,336.29,percent of total billed charges,
CATHETER,7911403,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1768.00000,512.72000,Aetna,First Health,,1446.22,,,,,,,637.36,1446.22,percent of total billed charges,
CATHETER,7911403,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1768.00000,512.72000,Aetna,First Health,,1446.22,,,,,,,569.30,1446.22,percent of total billed charges,
CATHETER,7911404,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1768.00000,512.72000,Aetna,First Health,,1446.22,,,,,,,637.36,1446.22,percent of total billed charges,
CATHETER,7911404,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1768.00000,512.72000,Aetna,First Health,,1446.22,,,,,,,569.30,1446.22,percent of total billed charges,
CATHETER,7702681,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1768.00000,512.72000,Aetna,First Health,,1446.22,,,,,,,637.36,1446.22,percent of total billed charges,
CATHETER,7702681,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1768.00000,512.72000,Aetna,First Health,,1446.22,,,,,,,569.30,1446.22,percent of total billed charges,
CATHETER,7911405,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,444.86,1009.41,percent of total billed charges,
CATHETER,7911405,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,397.35,1009.41,percent of total billed charges,
CATHETER,7911406,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,444.86,1009.41,percent of total billed charges,
CATHETER,7911406,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,397.35,1009.41,percent of total billed charges,
CATHETER,7911407,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,444.86,1009.41,percent of total billed charges,
CATHETER,7911407,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,397.35,1009.41,percent of total billed charges,
GRAFT,7702881,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2959.40000,858.23000,Aetna,First Health,,2420.79,,,,,,,1066.86,2420.79,percent of total billed charges,
GRAFT,7702881,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2959.40000,858.23000,Aetna,First Health,,2420.79,,,,,,,952.93,2420.79,percent of total billed charges,
GRAFT,7736642,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,First Health,,2376.68,,,,,,,1047.43,2376.68,percent of total billed charges,
GRAFT,7736642,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,First Health,,2376.68,,,,,,,935.56,2376.68,percent of total billed charges,
GRAFT,7696029,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,First Health,,2376.68,,,,,,,1047.43,2376.68,percent of total billed charges,
GRAFT,7696029,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,First Health,,2376.68,,,,,,,935.56,2376.68,percent of total billed charges,
GRAFT,7696750,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,First Health,,2376.68,,,,,,,1047.43,2376.68,percent of total billed charges,
GRAFT,7696750,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,First Health,,2376.68,,,,,,,935.56,2376.68,percent of total billed charges,
GRAFT,7696918,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,First Health,,2376.68,,,,,,,1047.43,2376.68,percent of total billed charges,
GRAFT,7696918,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,First Health,,2376.68,,,,,,,935.56,2376.68,percent of total billed charges,
GRAFT,7702866,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3565.14000,1033.89000,Aetna,First Health,,2916.28,,,,,,,1285.23,2916.28,percent of total billed charges,
GRAFT,7702866,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3565.14000,1033.89000,Aetna,First Health,,2916.28,,,,,,,1147.98,2916.28,percent of total billed charges,
GUIDEWIRE,7702898,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,208.53000,60.47000,Aetna,First Health,,170.58,,,,,,,75.18,170.58,percent of total billed charges,
GUIDEWIRE,7702898,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,208.53000,60.47000,Aetna,First Health,,170.58,,,,,,,67.15,170.58,percent of total billed charges,
MESH,7694786,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,704.95000,204.44000,Aetna,First Health,,576.65,,,,,,,254.13,576.65,percent of total billed charges,
MESH,7694786,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,704.95000,204.44000,Aetna,First Health,,576.65,,,,,,,226.99,576.65,percent of total billed charges,
PLATE,7699933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3603.64000,1045.06000,Aetna,First Health,,2947.78,,,,,,,1299.11,2947.78,percent of total billed charges,
PLATE,7699933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3603.64000,1045.06000,Aetna,First Health,,2947.78,,,,,,,1160.37,2947.78,percent of total billed charges,
PLATE,7700393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2168.72000,628.93000,Aetna,First Health,,1774.01,,,,,,,781.82,1774.01,percent of total billed charges,
PLATE,7700393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2168.72000,628.93000,Aetna,First Health,,1774.01,,,,,,,698.33,1774.01,percent of total billed charges,
SCREW,7698326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,7698326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,7698327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,7698327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,7698328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,7698328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,7698329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,7698329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,7699878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7699878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7699885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,7699885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
SCREW,7700581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7700581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7700582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7700582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7700583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7700583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7700584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7700584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7756053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7756053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7929710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,210.49,477.61,percent of total billed charges,
SCREW,7929710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,188.01,477.61,percent of total billed charges,
SCREW,7929721,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,210.49,477.61,percent of total billed charges,
SCREW,7929721,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,188.01,477.61,percent of total billed charges,
SCREW,7954154,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,210.49,477.61,percent of total billed charges,
SCREW,7954154,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,188.01,477.61,percent of total billed charges,
SCREW,7954372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,210.49,477.61,percent of total billed charges,
SCREW,7954372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,188.01,477.61,percent of total billed charges,
STENT GRAFT,7698639,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,5546.29,12584.93,percent of total billed charges,
STENT GRAFT,7698639,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,4953.97,12584.93,percent of total billed charges,
STENT GRAFT,7698658,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,5546.29,12584.93,percent of total billed charges,
STENT GRAFT,7698658,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,4953.97,12584.93,percent of total billed charges,
STENT GRAFT,7698748,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,5546.29,12584.93,percent of total billed charges,
STENT GRAFT,7698748,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,4953.97,12584.93,percent of total billed charges,
STENT GRAFT,7698831,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,5546.29,12584.93,percent of total billed charges,
STENT GRAFT,7698831,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,4953.97,12584.93,percent of total billed charges,
STENT GRAFT,7698837,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14583.00000,4229.07000,Aetna,First Health,,11928.89,,,,,,,5257.17,11928.89,percent of total billed charges,
STENT GRAFT,7698837,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14583.00000,4229.07000,Aetna,First Health,,11928.89,,,,,,,4695.73,11928.89,percent of total billed charges,
STENT GRAFT,7700871,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,5546.29,12584.93,percent of total billed charges,
STENT GRAFT,7700871,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,4953.97,12584.93,percent of total billed charges,
STENT GRAFT,7700872,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14583.00000,4229.07000,Aetna,First Health,,11928.89,,,,,,,5257.17,11928.89,percent of total billed charges,
STENT GRAFT,7700872,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14583.00000,4229.07000,Aetna,First Health,,11928.89,,,,,,,4695.73,11928.89,percent of total billed charges,
STENT GRAFT,7909032,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,5546.29,12584.93,percent of total billed charges,
STENT GRAFT,7909032,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,4953.97,12584.93,percent of total billed charges,
STENT GRAFT,7914401,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,5546.29,12584.93,percent of total billed charges,
STENT GRAFT,7914401,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,First Health,,12584.93,,,,,,,4953.97,12584.93,percent of total billed charges,
STENT GRAFT,7698615,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7698615,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7698638,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7698638,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7698747,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7698747,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7698830,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7698830,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7698832,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7698832,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7698836,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7698836,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7700072,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7700072,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7700437,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7700437,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7700591,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7700591,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7700667,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7700667,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7700867,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7700867,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7700868,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7700868,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7700869,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7700869,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7701188,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7701188,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7702592,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,28857.38000,8368.64000,Aetna,First Health,,23605.34,,,,,,,10403.09,23605.34,percent of total billed charges,
STENT GRAFT,7702592,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,28857.38000,8368.64000,Aetna,First Health,,23605.34,,,,,,,9292.08,23605.34,percent of total billed charges,
STENT GRAFT,7740553,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7740553,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7741765,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7741765,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7794044,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7794044,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7840050,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7840050,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7905577,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7905577,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7912131,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,7912131,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,7698616,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15495.00000,4493.55000,Aetna,First Health,,12674.91,,,,,,,5585.95,12674.91,percent of total billed charges,
STENT GRAFT,7698616,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15495.00000,4493.55000,Aetna,First Health,,12674.91,,,,,,,4989.39,12674.91,percent of total billed charges,
STENT GRAFT,7699781,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15495.00000,4493.55000,Aetna,First Health,,12674.91,,,,,,,5585.95,12674.91,percent of total billed charges,
STENT GRAFT,7699781,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15495.00000,4493.55000,Aetna,First Health,,12674.91,,,,,,,4989.39,12674.91,percent of total billed charges,
STENT GRAFT,7700065,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14118.00000,4094.22000,Aetna,First Health,,11548.52,,,,,,,5089.54,11548.52,percent of total billed charges,
STENT GRAFT,7700065,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14118.00000,4094.22000,Aetna,First Health,,11548.52,,,,,,,4546.00,11548.52,percent of total billed charges,
STENT GRAFT,7700592,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15495.00000,4493.55000,Aetna,First Health,,12674.91,,,,,,,5585.95,12674.91,percent of total billed charges,
STENT GRAFT,7700592,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15495.00000,4493.55000,Aetna,First Health,,12674.91,,,,,,,4989.39,12674.91,percent of total billed charges,
STENT GRAFT,7701189,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15495.00000,4493.55000,Aetna,First Health,,12674.91,,,,,,,5585.95,12674.91,percent of total billed charges,
STENT GRAFT,7701189,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15495.00000,4493.55000,Aetna,First Health,,12674.91,,,,,,,4989.39,12674.91,percent of total billed charges,
BONE CHIPS,7812157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7795.35000,2260.65000,Aetna,First Health,,6376.60,,,,,,,2810.22,6376.60,percent of total billed charges,
BONE CHIPS,7812157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7795.35000,2260.65000,Aetna,First Health,,6376.60,,,,,,,2510.10,6376.60,percent of total billed charges,
SCREW,7696544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,619.79000,179.74000,Aetna,First Health,,506.99,,,,,,,223.43,506.99,percent of total billed charges,
SCREW,7696544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,619.79000,179.74000,Aetna,First Health,,506.99,,,,,,,199.57,506.99,percent of total billed charges,
SCREW,7696855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7696855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7697441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7697441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7697442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7697442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7697645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7697645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7698340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7698340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7698341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7698341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7698342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7698342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7698343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7698343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7698344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7698344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7698345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7698345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7698412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,7698412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,7698436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7698436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7698437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7698437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7698438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7698438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7698439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7698439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7698440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7698440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7698441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7698441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7698510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7698510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7698854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7698854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7698855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7698855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7698856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7698856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7699693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7699693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7699694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7699694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7699695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7699695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7699779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7699779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7699858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,7699858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,7699927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7699927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7699928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7699928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7699929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7699929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7699931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7699931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7700042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7700096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7700279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7700280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7700281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7700282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7700283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7700389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7700475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7700892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7700892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7701201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1304.00000,378.16000,Aetna,First Health,,1066.67,,,,,,,470.09,1066.67,percent of total billed charges,
SCREW,7701201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1304.00000,378.16000,Aetna,First Health,,1066.67,,,,,,,419.89,1066.67,percent of total billed charges,
SCREW,7701202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1304.00000,378.16000,Aetna,First Health,,1066.67,,,,,,,470.09,1066.67,percent of total billed charges,
SCREW,7701202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1304.00000,378.16000,Aetna,First Health,,1066.67,,,,,,,419.89,1066.67,percent of total billed charges,
SCREW,7701638,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7701638,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7701675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7701675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7702069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.32000,177.57000,Aetna,First Health,,500.88,,,,,,,220.74,500.88,percent of total billed charges,
SCREW,7702069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.32000,177.57000,Aetna,First Health,,500.88,,,,,,,197.17,500.88,percent of total billed charges,
SCREW,7702254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7702254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7707525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7707525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7736198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7736198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7736199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7736199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7736200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7736200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7736581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7736581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7744588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7744588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7748070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1565.16000,453.90000,Aetna,First Health,,1280.30,,,,,,,564.24,1280.30,percent of total billed charges,
SCREW,7748070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1565.16000,453.90000,Aetna,First Health,,1280.30,,,,,,,503.98,1280.30,percent of total billed charges,
SCREW,7752052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7752052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7762378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7762378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7788030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7788030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7790233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,315.11,715.00,percent of total billed charges,
SCREW,7790233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,First Health,,715.00,,,,,,,281.45,715.00,percent of total billed charges,
SCREW,7790238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,619.79000,179.74000,Aetna,First Health,,506.99,,,,,,,223.43,506.99,percent of total billed charges,
SCREW,7790238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,619.79000,179.74000,Aetna,First Health,,506.99,,,,,,,199.57,506.99,percent of total billed charges,
SCREW,7794193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7794204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,7794204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,7812125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,7812125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
SCREW,7893978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,302.94,687.39,percent of total billed charges,
SCREW,7893978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,270.59,687.39,percent of total billed charges,
SCREW,7896390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7896390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7897135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1565.16000,453.90000,Aetna,First Health,,1280.30,,,,,,,564.24,1280.30,percent of total billed charges,
SCREW,7897135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1565.16000,453.90000,Aetna,First Health,,1280.30,,,,,,,503.98,1280.30,percent of total billed charges,
SCREW,7904169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7904169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7905100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7905100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7905101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7905101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7905102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7905102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7910831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7910831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7910832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7910832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,7911043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
SCREW,7911044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,7911044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
SCREW,7911045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,7911045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
SCREW,7911047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,7911047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
SCREW,7911048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,7911061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
SCREW,7911062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7911085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7911085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7922477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,51.10,115.95,percent of total billed charges,
SCREW,7922477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,45.64,115.95,percent of total billed charges,
SCREW,7703347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1204.00000,349.16000,Aetna,First Health,,984.87,,,,,,,434.04,984.87,percent of total billed charges,
SCREW,7703347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1204.00000,349.16000,Aetna,First Health,,984.87,,,,,,,387.69,984.87,percent of total billed charges,
STENT,7699118,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,770.99000,223.59000,Aetna,First Health,,630.67,,,,,,,277.94,630.67,percent of total billed charges,
STENT,7699118,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,770.99000,223.59000,Aetna,First Health,,630.67,,,,,,,248.26,630.67,percent of total billed charges,
STENT,7699119,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,770.99000,223.59000,Aetna,First Health,,630.67,,,,,,,277.94,630.67,percent of total billed charges,
STENT,7699119,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,770.99000,223.59000,Aetna,First Health,,630.67,,,,,,,248.26,630.67,percent of total billed charges,
NAIL,7700442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5995.50000,1738.70000,Aetna,First Health,,4904.32,,,,,,,2161.38,4904.32,percent of total billed charges,
NAIL,7700442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5995.50000,1738.70000,Aetna,First Health,,4904.32,,,,,,,1930.55,4904.32,percent of total billed charges,
NAIL,7700896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,First Health,,4684.44,,,,,,,2064.48,4684.44,percent of total billed charges,
NAIL,7700896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,First Health,,4684.44,,,,,,,1844.00,4684.44,percent of total billed charges,
NAIL,7736649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5995.50000,1738.70000,Aetna,First Health,,4904.32,,,,,,,2161.38,4904.32,percent of total billed charges,
NAIL,7736649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5995.50000,1738.70000,Aetna,First Health,,4904.32,,,,,,,1930.55,4904.32,percent of total billed charges,
SCREW,7698828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2009.40000,582.73000,Aetna,First Health,,1643.69,,,,,,,724.39,1643.69,percent of total billed charges,
SCREW,7698828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2009.40000,582.73000,Aetna,First Health,,1643.69,,,,,,,647.03,1643.69,percent of total billed charges,
SCREW,7698912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2051.20000,594.85000,Aetna,First Health,,1677.88,,,,,,,739.46,1677.88,percent of total billed charges,
SCREW,7698912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2051.20000,594.85000,Aetna,First Health,,1677.88,,,,,,,660.49,1677.88,percent of total billed charges,
SCREW,7699795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,179.55000,52.07000,Aetna,First Health,,146.87,,,,,,,64.73,146.87,percent of total billed charges,
SCREW,7699795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,179.55000,52.07000,Aetna,First Health,,146.87,,,,,,,57.82,146.87,percent of total billed charges,
SCREW,7699796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,179.55000,52.07000,Aetna,First Health,,146.87,,,,,,,64.73,146.87,percent of total billed charges,
SCREW,7699796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,179.55000,52.07000,Aetna,First Health,,146.87,,,,,,,57.82,146.87,percent of total billed charges,
SCREW,7736554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2051.20000,594.85000,Aetna,First Health,,1677.88,,,,,,,739.46,1677.88,percent of total billed charges,
SCREW,7736554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2051.20000,594.85000,Aetna,First Health,,1677.88,,,,,,,660.49,1677.88,percent of total billed charges,
SCREW,7756064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7919000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7919000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7947915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2051.20000,594.85000,Aetna,First Health,,1677.88,,,,,,,739.46,1677.88,percent of total billed charges,
SCREW,7947915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2051.20000,594.85000,Aetna,First Health,,1677.88,,,,,,,660.49,1677.88,percent of total billed charges,
SCREW,7965918,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,588.34,1334.98,percent of total billed charges,
SCREW,7965918,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,525.50,1334.98,percent of total billed charges,
SCREW,7965919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,588.34,1334.98,percent of total billed charges,
SCREW,7965919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,525.50,1334.98,percent of total billed charges,
NAIL,7914555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4396.95000,1275.12000,Aetna,First Health,,3596.71,,,,,,,1585.10,3596.71,percent of total billed charges,
NAIL,7914555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4396.95000,1275.12000,Aetna,First Health,,3596.71,,,,,,,1415.82,3596.71,percent of total billed charges,
NAIL,7918958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4396.95000,1275.12000,Aetna,First Health,,3596.71,,,,,,,1585.10,3596.71,percent of total billed charges,
NAIL,7918958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4396.95000,1275.12000,Aetna,First Health,,3596.71,,,,,,,1415.82,3596.71,percent of total billed charges,
NAIL,7954009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4396.95000,1275.12000,Aetna,First Health,,3596.71,,,,,,,1585.10,3596.71,percent of total billed charges,
NAIL,7954009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4396.95000,1275.12000,Aetna,First Health,,3596.71,,,,,,,1415.82,3596.71,percent of total billed charges,
NAIL,7958130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4396.95000,1275.12000,Aetna,First Health,,3596.71,,,,,,,1585.10,3596.71,percent of total billed charges,
NAIL,7958130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4396.95000,1275.12000,Aetna,First Health,,3596.71,,,,,,,1415.82,3596.71,percent of total billed charges,
SCREW,7756396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
SCREW,7756409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
SCREW,7756409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
INSERT,7812074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,First Health,,5454.73,,,,,,,2403.95,5454.73,percent of total billed charges,
INSERT,7812074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,First Health,,5454.73,,,,,,,2147.22,5454.73,percent of total billed charges,
INSERT,7824041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7824041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7882250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7882250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7882481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7882481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7902680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7902680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7902681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7902681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7918902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7918902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7924905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7924905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7938800,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7938800,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
WEDGE,7736618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5675.25000,1645.82000,Aetna,First Health,,4642.35,,,,,,,2045.93,4642.35,percent of total billed charges,
WEDGE,7736618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5675.25000,1645.82000,Aetna,First Health,,4642.35,,,,,,,1827.43,4642.35,percent of total billed charges,
LINER,7908264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LINER,7908264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
LINER,7908265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LINER,7908265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
LINER,7908266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LINER,7908266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
LINER,7908267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LINER,7908267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
LINER,7908268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LINER,7908268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
LINER,7736655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
LINER,7736655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
LINER,7880657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
LINER,7880657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
LINER,7882521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
LINER,7882521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
LINER,7902300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LINER,7902300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
LINER,7902673,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LINER,7902673,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
LINER,7902820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LINER,7902820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
LINER,7904735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
LINER,7904735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
STEM,7880659,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8475.00000,2457.75000,Aetna,First Health,,6932.55,,,,,,,3055.24,6932.55,percent of total billed charges,
STEM,7880659,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8475.00000,2457.75000,Aetna,First Health,,6932.55,,,,,,,2728.95,6932.55,percent of total billed charges,
PEG,7740533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7740533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7740534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7740534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7740535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7740535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
PEG,7740536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,182.20,413.42,percent of total billed charges,
PEG,7740536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,First Health,,413.42,,,,,,,162.74,413.42,percent of total billed charges,
SCREW,7905325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
SCREW,7905325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
SCREW,7946100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
SCREW,7946100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
SCREW,7957759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,578.03000,167.63000,Aetna,First Health,,472.83,,,,,,,208.38,472.83,percent of total billed charges,
SCREW,7957759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,578.03000,167.63000,Aetna,First Health,,472.83,,,,,,,186.13,472.83,percent of total billed charges,
SCREW,7806051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7806051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7893606,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7893606,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7910144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7910144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7910145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7910145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7912232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7912232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7922959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7922959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7937738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7937738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7937740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,7937740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,7965484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7965484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7772043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.73000,141.15000,Aetna,First Health,,398.15,,,,,,,175.47,398.15,percent of total billed charges,
SCREW,7772043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.73000,141.15000,Aetna,First Health,,398.15,,,,,,,156.73,398.15,percent of total billed charges,
SCREW,7772044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,507.78000,147.26000,Aetna,First Health,,415.36,,,,,,,183.05,415.36,percent of total billed charges,
SCREW,7772044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,507.78000,147.26000,Aetna,First Health,,415.36,,,,,,,163.51,415.36,percent of total billed charges,
SPACER,7740780,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7740780,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,7740781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7740781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,7740782,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7740782,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,7758263,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7758263,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,7758264,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7758264,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,7937656,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7937656,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,7937657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7937657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
MESH,7774229,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8932.50000,2590.42000,Aetna,First Health,,7306.78,,,,,,,3220.17,7306.78,percent of total billed charges,
MESH,7774229,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8932.50000,2590.42000,Aetna,First Health,,7306.78,,,,,,,2876.26,7306.78,percent of total billed charges,
LINER,7740893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7740893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7810089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7810089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7832048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7832048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7880795,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7880795,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
COMPONENT FEMORAL,7698020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7838.67,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7698020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7001.53,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7698184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7838.67,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7698184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7001.53,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7698419,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7838.67,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7698419,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7001.53,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7699327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7838.67,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7699327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7001.53,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7699815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7838.67,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7699815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7001.53,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7736119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7838.67,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7736119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7001.53,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7910506,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7838.67,17786.49,percent of total billed charges,
COMPONENT FEMORAL,7910506,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,First Health,,17786.49,,,,,,,7001.53,17786.49,percent of total billed charges,
STENT,7695009,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695009,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695010,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695010,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695011,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695011,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695012,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695012,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695013,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695013,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695014,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695014,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695093,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695093,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695094,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695094,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695095,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695095,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695128,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695128,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695153,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695153,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695163,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695163,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695164,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
STENT,7695164,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
STENT,7695166,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695166,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695172,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695172,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695223,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695223,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695244,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695244,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695255,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695255,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695256,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
STENT,7695256,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
STENT,7695257,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695257,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695258,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695258,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695259,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695259,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7695278,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7695278,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7703271,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7703271,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7703272,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7703272,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
VALVE,7741658,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
VALVE,7741658,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
VALVE,7699192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
VALVE,7699192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
VALVE,7893457,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
VALVE,7893457,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
PLATE,7912217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE,7912217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
STEM,7750597,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9083.55000,2634.23000,Aetna,First Health,,7430.34,,,,,,,3274.62,7430.34,percent of total billed charges,
STEM,7750597,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9083.55000,2634.23000,Aetna,First Health,,7430.34,,,,,,,2924.90,7430.34,percent of total billed charges,
RADIAL HEAD EXT,7905611,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9083.55000,2634.23000,Aetna,First Health,,7430.34,,,,,,,3274.62,7430.34,percent of total billed charges,
RADIAL HEAD EXT,7905611,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9083.55000,2634.23000,Aetna,First Health,,7430.34,,,,,,,2924.90,7430.34,percent of total billed charges,
ANCHOR,7744591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2844.00000,824.76000,Aetna,First Health,,2326.39,,,,,,,1025.26,2326.39,percent of total billed charges,
ANCHOR,7744591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2844.00000,824.76000,Aetna,First Health,,2326.39,,,,,,,915.77,2326.39,percent of total billed charges,
MESH,7744662,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,849.81000,246.44000,Aetna,First Health,,695.14,,,,,,,306.36,695.14,percent of total billed charges,
MESH,7744662,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,849.81000,246.44000,Aetna,First Health,,695.14,,,,,,,273.64,695.14,percent of total billed charges,
MESH,7948208,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
MESH,7948208,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
COMPONENT FEMORAL,7748889,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7748889,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7782096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7782096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7790239,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7790239,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7800041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7800041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7802105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7802105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7804030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7804030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7804049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7804049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7820140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7820140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7822255,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7822255,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7828069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7828069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7838067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7838067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7838070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7838070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7838117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7838117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7838119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7838119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7874398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7874398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7876336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7876336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7876338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7876338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7878312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7878312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7878558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7878558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7880190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7880190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7880514,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7880514,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7880617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7880617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7880677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7880677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7882251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7882251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7882396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7882396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7882507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7882507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7882859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7882859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7893761,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7893761,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7896745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7896745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7896900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7896900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7900162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7900162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7900328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7900328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7911546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7911546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7912327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7912327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7912338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7912338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7913928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7913928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7917824,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7917824,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7918903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7918903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7918956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7918956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7920372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7920372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7920373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7920373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7920520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7920520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7920523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7920523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7922503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7922503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7924906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7924906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7926931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7926931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7927185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7927185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7927272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7927272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7927550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7927550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7934017,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7934017,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7935502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7935502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7935785,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7935785,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7937741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7937741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7938390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7938390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7939807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7939807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7943992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7943992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7946097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7946097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7948685,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7948685,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7962117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7962117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
BASEPLATE,7748890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7748890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7782097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7782097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7802106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7802106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7804050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7804050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7806411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7806411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7822254,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7822254,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7828068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7828068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7834148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7834148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7838069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7838069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7846160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7846160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7874397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7874397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7876337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7876337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7882503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7882503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
INSERT,7748119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7748119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7748832,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7748832,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7766059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7766059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7802091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7802091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7806370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7806370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7828051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7828051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7850200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7850200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7878323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7878323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7880663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7880663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7882371,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7882371,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7900095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7900095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7903123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7903123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7908717,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7908717,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7920750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3420.78,7762.00,percent of total billed charges,
INSERT,7920750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3055.46,7762.00,percent of total billed charges,
BASEPLATE,7748121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1495.17,3392.66,percent of total billed charges,
BASEPLATE,7748121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1335.49,3392.66,percent of total billed charges,
BASEPLATE,7766060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1495.17,3392.66,percent of total billed charges,
BASEPLATE,7766060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1335.49,3392.66,percent of total billed charges,
BASEPLATE,7784203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1495.17,3392.66,percent of total billed charges,
BASEPLATE,7784203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1335.49,3392.66,percent of total billed charges,
BASEPLATE,7882318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1495.17,3392.66,percent of total billed charges,
BASEPLATE,7882318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,First Health,,3392.66,,,,,,,1335.49,3392.66,percent of total billed charges,
COMPONENT PATELLA,7748892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7748892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7790240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7790240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7806412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7806412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT PATELLA,7893339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
COMPONENT PATELLA,7893339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
STEM,7794034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7794034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7834083,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7834083,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7858120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7858120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7858123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7858123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7866040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7866040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7866043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7866043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7874291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7874291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7880551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7880551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7882512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7882512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7893628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7893628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7893866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7893866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7903718,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7903718,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7904170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7904170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7905366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7905366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7918512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,First Health,,7901.88,,,,,,,3482.43,7901.88,percent of total billed charges,
STEM,7918512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,First Health,,7901.88,,,,,,,3110.52,7901.88,percent of total billed charges,
FEMORAL HEAD,7882389,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
FEMORAL HEAD,7882389,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
STEM,7748825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7748825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
STEM,7878188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,7878188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
TIBIAL TRAY,7858276,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
TIBIAL TRAY,7858276,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
AUGMENT FEMORAL,7750115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7750115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7834110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7834110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7834111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7834111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7882687,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7882687,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7896751,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7896751,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7935918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7935918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7943922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7943922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7944007,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7944007,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7834109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
AUGMENT FEMORAL,7834109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
AUGMENT FEMORAL,7927339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
AUGMENT FEMORAL,7927339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
AUGMENT FEMORAL,7935919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
AUGMENT FEMORAL,7935919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
AUGMENT FEMORAL,7943921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
AUGMENT FEMORAL,7943921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
BALLOON CATHETER,7750474,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750474,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7750475,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750475,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7750478,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750478,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7750482,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750482,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7750484,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750484,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7750485,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750485,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7750489,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750489,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7750491,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7750491,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7911541,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7911541,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7911542,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,7911542,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,7965172,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON CATHETER,7965172,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
BALLOON CATHETER,7965173,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON CATHETER,7965173,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
BALLOON CATHETER,7965174,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON CATHETER,7965174,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
BALLOON CATHETER,7965175,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON CATHETER,7965175,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
BALLOON CATHETER,7965176,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON CATHETER,7965176,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
BALLOON CATHETER,7965177,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON CATHETER,7965177,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
BALLOON CATHETER,7965178,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON CATHETER,7965178,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
WEDGE,7894317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5455.63000,1582.13000,Aetna,First Health,,4462.71,,,,,,,1966.75,4462.71,percent of total billed charges,
WEDGE,7894317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5455.63000,1582.13000,Aetna,First Health,,4462.71,,,,,,,1756.71,4462.71,percent of total billed charges,
WEDGE,7948114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5455.63000,1582.13000,Aetna,First Health,,4462.71,,,,,,,1966.75,4462.71,percent of total billed charges,
WEDGE,7948114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5455.63000,1582.13000,Aetna,First Health,,4462.71,,,,,,,1756.71,4462.71,percent of total billed charges,
BALLOON CATHETER,7694867,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,352.89,800.73,percent of total billed charges,
BALLOON CATHETER,7694867,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,315.20,800.73,percent of total billed charges,
BALLOON CATHETER,7695028,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,352.89,800.73,percent of total billed charges,
BALLOON CATHETER,7695028,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,315.20,800.73,percent of total billed charges,
BALLOON CATHETER,7695230,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,352.89,800.73,percent of total billed charges,
BALLOON CATHETER,7695230,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,315.20,800.73,percent of total billed charges,
BALLOON CATHETER,7695232,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,352.89,800.73,percent of total billed charges,
BALLOON CATHETER,7695232,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,315.20,800.73,percent of total billed charges,
BALLOON CATHETER,7702689,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,352.89,800.73,percent of total billed charges,
BALLOON CATHETER,7702689,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,First Health,,800.73,,,,,,,315.20,800.73,percent of total billed charges,
ACETABULAR RING,7962119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,669.60000,194.18000,Aetna,First Health,,547.73,,,,,,,241.39,547.73,percent of total billed charges,
ACETABULAR RING,7962119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,669.60000,194.18000,Aetna,First Health,,547.73,,,,,,,215.61,547.73,percent of total billed charges,
GUIDEWIRE,7918648,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
GUIDEWIRE,7918648,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
GUIDEWIRE,7927466,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,702.00000,203.58000,Aetna,First Health,,574.24,,,,,,,253.07,574.24,percent of total billed charges,
GUIDEWIRE,7927466,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,702.00000,203.58000,Aetna,First Health,,574.24,,,,,,,226.04,574.24,percent of total billed charges,
GUIDEWIRE,7930246,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,415.63000,120.53000,Aetna,First Health,,339.99,,,,,,,149.83,339.99,percent of total billed charges,
GUIDEWIRE,7930246,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,415.63000,120.53000,Aetna,First Health,,339.99,,,,,,,133.83,339.99,percent of total billed charges,
GUIDEWIRE,7933871,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
GUIDEWIRE,7933871,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
CONNECTOR,7756254,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR,7756254,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CONNECTOR,7756255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR,7756255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CONNECTOR,7756257,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR,7756257,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
CONNECTOR,7756258,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR,7756258,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
CONNECTOR,7756259,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR,7756259,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
CONNECTOR,7756260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR,7756260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
CONNECTOR,7756261,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR,7756261,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
HOOK,7756280,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756280,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756282,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756282,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756283,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756283,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756284,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756284,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756285,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756285,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756286,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756286,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756291,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756291,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756292,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756292,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756293,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756293,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756294,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756294,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
HOOK,7756366,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7756366,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
SCREW,7756296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756322,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756322,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,7756361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,7756361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
PLATE,7756188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5920.08000,1716.82000,Aetna,First Health,,4842.63,,,,,,,2134.19,4842.63,percent of total billed charges,
PLATE,7756188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5920.08000,1716.82000,Aetna,First Health,,4842.63,,,,,,,1906.27,4842.63,percent of total billed charges,
PLATE,7758261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8271.03000,2398.60000,Aetna,First Health,,6765.70,,,,,,,2981.71,6765.70,percent of total billed charges,
PLATE,7758261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8271.03000,2398.60000,Aetna,First Health,,6765.70,,,,,,,2663.27,6765.70,percent of total billed charges,
STENT,7695160,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8882.13000,2575.82000,Aetna,First Health,,7265.58,,,,,,,3202.01,7265.58,percent of total billed charges,
STENT,7695160,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8882.13000,2575.82000,Aetna,First Health,,7265.58,,,,,,,2860.05,7265.58,percent of total billed charges,
STENT,7695161,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8882.13000,2575.82000,Aetna,First Health,,7265.58,,,,,,,3202.01,7265.58,percent of total billed charges,
STENT,7695161,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8882.13000,2575.82000,Aetna,First Health,,7265.58,,,,,,,2860.05,7265.58,percent of total billed charges,
STENT,7695208,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8882.13000,2575.82000,Aetna,First Health,,7265.58,,,,,,,3202.01,7265.58,percent of total billed charges,
STENT,7695208,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8882.13000,2575.82000,Aetna,First Health,,7265.58,,,,,,,2860.05,7265.58,percent of total billed charges,
STENT,7695210,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8882.13000,2575.82000,Aetna,First Health,,7265.58,,,,,,,3202.01,7265.58,percent of total billed charges,
STENT,7695210,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8882.13000,2575.82000,Aetna,First Health,,7265.58,,,,,,,2860.05,7265.58,percent of total billed charges,
STENT,7695251,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8587.38000,2490.34000,Aetna,First Health,,7024.48,,,,,,,3095.75,7024.48,percent of total billed charges,
STENT,7695251,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8587.38000,2490.34000,Aetna,First Health,,7024.48,,,,,,,2765.14,7024.48,percent of total billed charges,
STENT,7695030,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,3356.09,7615.20,percent of total billed charges,
STENT,7695030,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,2997.67,7615.20,percent of total billed charges,
STENT,7695031,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,3356.09,7615.20,percent of total billed charges,
STENT,7695031,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,2997.67,7615.20,percent of total billed charges,
STENT,7695254,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,3356.09,7615.20,percent of total billed charges,
STENT,7695254,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,2997.67,7615.20,percent of total billed charges,
STENT,7695219,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9262.38000,2686.09000,Aetna,First Health,,7576.63,,,,,,,3339.09,7576.63,percent of total billed charges,
STENT,7695219,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9262.38000,2686.09000,Aetna,First Health,,7576.63,,,,,,,2982.49,7576.63,percent of total billed charges,
ANCHOR,7760079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,817.25,1854.41,percent of total billed charges,
ANCHOR,7760079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,729.97,1854.41,percent of total billed charges,
ANCHOR,7903162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,817.25,1854.41,percent of total billed charges,
ANCHOR,7903162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,729.97,1854.41,percent of total billed charges,
ANCHOR,7903163,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,817.25,1854.41,percent of total billed charges,
ANCHOR,7903163,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,729.97,1854.41,percent of total billed charges,
ANCHOR,7903164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,817.25,1854.41,percent of total billed charges,
ANCHOR,7903164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,729.97,1854.41,percent of total billed charges,
LINER,7957791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
LINER,7957791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
TENDON,7850189,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6373.50000,1848.31000,Aetna,First Health,,5213.52,,,,,,,2297.65,5213.52,percent of total billed charges,
TENDON,7850189,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6373.50000,1848.31000,Aetna,First Health,,5213.52,,,,,,,2052.27,5213.52,percent of total billed charges,
TENDON,7902583,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6678.00000,1936.62000,Aetna,First Health,,5462.60,,,,,,,2407.42,5462.60,percent of total billed charges,
TENDON,7902583,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6678.00000,1936.62000,Aetna,First Health,,5462.60,,,,,,,2150.32,5462.60,percent of total billed charges,
SHELL,7700535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
SHELL,7700535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SHELL,7700669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
SHELL,7700669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
STEM,7902773,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4812.68,10920.30,percent of total billed charges,
STEM,7902773,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4298.70,10920.30,percent of total billed charges,
STEM,7905312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4812.68,10920.30,percent of total billed charges,
STEM,7905312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4298.70,10920.30,percent of total billed charges,
STEM,7910286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4812.68,10920.30,percent of total billed charges,
STEM,7910286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4298.70,10920.30,percent of total billed charges,
STEM,7911000,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4812.68,10920.30,percent of total billed charges,
STEM,7911000,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4298.70,10920.30,percent of total billed charges,
STEM,7937861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4812.68,10920.30,percent of total billed charges,
STEM,7937861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4298.70,10920.30,percent of total billed charges,
STEM,7950557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4812.68,10920.30,percent of total billed charges,
STEM,7950557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4298.70,10920.30,percent of total billed charges,
CONNECTOR SPINAL,7736682,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5116.30000,1483.73000,Aetna,First Health,,4185.13,,,,,,,1844.43,4185.13,percent of total billed charges,
CONNECTOR SPINAL,7736682,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5116.30000,1483.73000,Aetna,First Health,,4185.13,,,,,,,1647.45,4185.13,percent of total billed charges,
CONNECTOR SPINAL,7736683,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5116.30000,1483.73000,Aetna,First Health,,4185.13,,,,,,,1844.43,4185.13,percent of total billed charges,
CONNECTOR SPINAL,7736683,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5116.30000,1483.73000,Aetna,First Health,,4185.13,,,,,,,1647.45,4185.13,percent of total billed charges,
CONNECTOR SPINAL,7699700,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5071.50000,1470.74000,Aetna,First Health,,4148.49,,,,,,,1828.28,4148.49,percent of total billed charges,
CONNECTOR SPINAL,7699700,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5071.50000,1470.74000,Aetna,First Health,,4148.49,,,,,,,1633.02,4148.49,percent of total billed charges,
STENT,7695020,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,308.23000,89.39000,Aetna,First Health,,252.13,,,,,,,111.12,252.13,percent of total billed charges,
STENT,7695020,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,308.23000,89.39000,Aetna,First Health,,252.13,,,,,,,99.25,252.13,percent of total billed charges,
STENT,7695021,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,308.23000,89.39000,Aetna,First Health,,252.13,,,,,,,111.12,252.13,percent of total billed charges,
STENT,7695021,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,308.23000,89.39000,Aetna,First Health,,252.13,,,,,,,99.25,252.13,percent of total billed charges,
STENT,7695022,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,308.23000,89.39000,Aetna,First Health,,252.13,,,,,,,111.12,252.13,percent of total billed charges,
STENT,7695022,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,308.23000,89.39000,Aetna,First Health,,252.13,,,,,,,99.25,252.13,percent of total billed charges,
PLATE,7895463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1303.60000,378.04000,Aetna,First Health,,1066.34,,,,,,,469.95,1066.34,percent of total billed charges,
PLATE,7895463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1303.60000,378.04000,Aetna,First Health,,1066.34,,,,,,,419.76,1066.34,percent of total billed charges,
SCREW,7929707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,347.16,787.73,percent of total billed charges,
SCREW,7929707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,310.09,787.73,percent of total billed charges,
SCREW,7935353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.27000,188.00000,Aetna,First Health,,530.28,,,,,,,233.70,530.28,percent of total billed charges,
SCREW,7935353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.27000,188.00000,Aetna,First Health,,530.28,,,,,,,208.74,530.28,percent of total billed charges,
SCREW,7935354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.27000,188.00000,Aetna,First Health,,530.28,,,,,,,233.70,530.28,percent of total billed charges,
SCREW,7935354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.27000,188.00000,Aetna,First Health,,530.28,,,,,,,208.74,530.28,percent of total billed charges,
SCREW,7950555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.27000,188.00000,Aetna,First Health,,530.28,,,,,,,233.70,530.28,percent of total billed charges,
SCREW,7950555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.27000,188.00000,Aetna,First Health,,530.28,,,,,,,208.74,530.28,percent of total billed charges,
STEM,7806296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7806296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7836183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7836183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7840125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7840125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7866037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7866037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7878326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7878326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7880196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7880196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7880198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7880198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7880653,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2741.60,6220.89,percent of total billed charges,
STEM,7880653,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2448.81,6220.89,percent of total billed charges,
STEM,7880656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2741.60,6220.89,percent of total billed charges,
STEM,7880656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2448.81,6220.89,percent of total billed charges,
STEM,7882316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2741.60,6220.89,percent of total billed charges,
STEM,7882316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2448.81,6220.89,percent of total billed charges,
STEM,7882387,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7882387,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7882525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2741.60,6220.89,percent of total billed charges,
STEM,7882525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2448.81,6220.89,percent of total billed charges,
STEM,7900099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7900099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7900100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7900100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7905536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7905536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7918510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7918510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7922573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7922573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7926699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7926699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7935847,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7935847,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STEM,7964652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7964652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
PLATE,7806050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,7806050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
PLATE,7882257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,7882257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
PLATE,7895466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3511.31000,1018.28000,Aetna,First Health,,2872.25,,,,,,,1265.83,2872.25,percent of total billed charges,
PLATE,7895466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3511.31000,1018.28000,Aetna,First Health,,2872.25,,,,,,,1130.64,2872.25,percent of total billed charges,
SCREW,7776291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7776291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7776292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
SCREW,7776292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
SCREW,7703115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
SCREW,7703115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
SHEATH,7930142,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,838.31000,243.11000,Aetna,First Health,,685.74,,,,,,,302.21,685.74,percent of total billed charges,
SHEATH,7930142,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,838.31000,243.11000,Aetna,First Health,,685.74,,,,,,,269.94,685.74,percent of total billed charges,
FEMORAL HEAD,7832050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD,7832050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
FEMORAL HEAD,7935865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD,7935865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
FEMORAL HEAD,7937715,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD,7937715,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
FEMORAL HEAD,7939847,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD,7939847,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
FEMORAL HEAD,7944260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD,7944260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
INTRODUCER,7742028,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
INTRODUCER,7742028,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
INTRODUCER,7742029,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
INTRODUCER,7742029,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
INTRODUCER,7742030,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,548.06000,158.94000,Aetna,First Health,,448.31,,,,,,,197.58,448.31,percent of total billed charges,
INTRODUCER,7742030,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,548.06000,158.94000,Aetna,First Health,,448.31,,,,,,,176.48,448.31,percent of total billed charges,
INTRODUCER,7927546,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,First Health,,407.20,,,,,,,179.46,407.20,percent of total billed charges,
INTRODUCER,7927546,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,First Health,,407.20,,,,,,,160.29,407.20,percent of total billed charges,
LINER,7700450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,957.20000,277.59000,Aetna,First Health,,782.99,,,,,,,345.07,782.99,percent of total billed charges,
LINER,7700450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,957.20000,277.59000,Aetna,First Health,,782.99,,,,,,,308.22,782.99,percent of total billed charges,
LINER,7700451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,352.03,798.78,percent of total billed charges,
LINER,7700451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,314.43,798.78,percent of total billed charges,
STENT GRAFT,7740548,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12918.00000,3746.22000,Aetna,First Health,,10566.92,,,,,,,4656.94,10566.92,percent of total billed charges,
STENT GRAFT,7740548,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12918.00000,3746.22000,Aetna,First Health,,10566.92,,,,,,,4159.60,10566.92,percent of total billed charges,
STENT GRAFT,7788042,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11799.00000,3421.71000,Aetna,First Health,,9651.58,,,,,,,4253.54,9651.58,percent of total billed charges,
STENT GRAFT,7788042,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11799.00000,3421.71000,Aetna,First Health,,9651.58,,,,,,,3799.28,9651.58,percent of total billed charges,
STENT GRAFT,7904230,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11799.00000,3421.71000,Aetna,First Health,,9651.58,,,,,,,4253.54,9651.58,percent of total billed charges,
STENT GRAFT,7904230,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11799.00000,3421.71000,Aetna,First Health,,9651.58,,,,,,,3799.28,9651.58,percent of total billed charges,
STENT GRAFT,7904231,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12918.00000,3746.22000,Aetna,First Health,,10566.92,,,,,,,4656.94,10566.92,percent of total billed charges,
STENT GRAFT,7904231,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12918.00000,3746.22000,Aetna,First Health,,10566.92,,,,,,,4159.60,10566.92,percent of total billed charges,
STENT GRAFT,7904232,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11799.00000,3421.71000,Aetna,First Health,,9651.58,,,,,,,4253.54,9651.58,percent of total billed charges,
STENT GRAFT,7904232,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11799.00000,3421.71000,Aetna,First Health,,9651.58,,,,,,,3799.28,9651.58,percent of total billed charges,
STENT GRAFT,7950032,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,7950032,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
NAIL,7695447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,714.57,1621.41,percent of total billed charges,
NAIL,7695447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,638.26,1621.41,percent of total billed charges,
NAIL,7696856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,714.57,1621.41,percent of total billed charges,
NAIL,7696856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,638.26,1621.41,percent of total billed charges,
NAIL,7697467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,714.57,1621.41,percent of total billed charges,
NAIL,7697467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,638.26,1621.41,percent of total billed charges,
NAIL,7900567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,714.57,1621.41,percent of total billed charges,
NAIL,7900567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,638.26,1621.41,percent of total billed charges,
NAIL,7902712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,700.74,1590.03,percent of total billed charges,
NAIL,7902712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,625.90,1590.03,percent of total billed charges,
NAIL,7927492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,700.74,1590.03,percent of total billed charges,
NAIL,7927492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,625.90,1590.03,percent of total billed charges,
FEMORAL ADAPTER,7784199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9226.20000,2675.60000,Aetna,First Health,,7547.03,,,,,,,3326.05,7547.03,percent of total billed charges,
FEMORAL ADAPTER,7784199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9226.20000,2675.60000,Aetna,First Health,,7547.03,,,,,,,2970.84,7547.03,percent of total billed charges,
PLATE,7858261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,7858261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
TENDON,7918863,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6544.13000,1897.80000,Aetna,First Health,,5353.10,,,,,,,2359.16,5353.10,percent of total billed charges,
TENDON,7918863,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6544.13000,1897.80000,Aetna,First Health,,5353.10,,,,,,,2107.21,5353.10,percent of total billed charges,
NAIL,7696725,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,757.22,1718.19,percent of total billed charges,
NAIL,7696725,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,676.35,1718.19,percent of total billed charges,
NAIL,7926456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,757.22,1718.19,percent of total billed charges,
NAIL,7926456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,676.35,1718.19,percent of total billed charges,
NAIL,7702747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,757.22,1718.19,percent of total billed charges,
NAIL,7702747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,676.35,1718.19,percent of total billed charges,
NAIL,7702748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,757.22,1718.19,percent of total billed charges,
NAIL,7702748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,676.35,1718.19,percent of total billed charges,
NAIL,7702749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,757.22,1718.19,percent of total billed charges,
NAIL,7702749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,676.35,1718.19,percent of total billed charges,
NAIL,7702750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,757.22,1718.19,percent of total billed charges,
NAIL,7702750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,676.35,1718.19,percent of total billed charges,
NAIL,7702751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,757.22,1718.19,percent of total billed charges,
NAIL,7702751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,676.35,1718.19,percent of total billed charges,
NAIL,7702752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,757.22,1718.19,percent of total billed charges,
NAIL,7702752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,First Health,,1718.19,,,,,,,676.35,1718.19,percent of total billed charges,
INSERT,7699092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7699092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7702257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7702257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7736116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7736116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7748827,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,7748827,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
INSERT,7748902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7748902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7784257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7784257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7784270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7784270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7786152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7786152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
WEDGE,7987916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5240.17000,1519.65000,Aetna,First Health,,4286.46,,,,,,,1889.08,4286.46,percent of total billed charges,
WEDGE,7987916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5240.17000,1519.65000,Aetna,First Health,,4286.46,,,,,,,1687.33,4286.46,percent of total billed charges,
INSERT,7806049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7806049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7822236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7822236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7822245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7822245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7876330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7876330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7876436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,7876436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
INSERT,7880660,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7880660,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7880747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7880747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7882478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7882478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7882392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,7882392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
INSERT,7893625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7893625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7902296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7902296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7902729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7902729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7902769,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7902769,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7902770,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7902770,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7912827,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7912827,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7913884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7913884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7961945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7961945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7964447,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7964447,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STEM,7868042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
STEM,7868042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
STEM,7878484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
STEM,7878484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
STEM,7880199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
STEM,7880199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
COMPONENT FEMORAL,7794298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7794298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7878295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7878295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7880791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7880791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7882385,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7882385,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7882741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7882741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7893627,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7893627,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7910169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,7910169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
STEM,7902915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,First Health,,10720.37,,,,,,,4724.57,10720.37,percent of total billed charges,
STEM,7902915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,First Health,,10720.37,,,,,,,4220.00,10720.37,percent of total billed charges,
STEM,7935355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,First Health,,10720.37,,,,,,,4724.57,10720.37,percent of total billed charges,
STEM,7935355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,First Health,,10720.37,,,,,,,4220.00,10720.37,percent of total billed charges,
STEM,7964337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,First Health,,10720.37,,,,,,,4724.57,10720.37,percent of total billed charges,
STEM,7964337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,First Health,,10720.37,,,,,,,4220.00,10720.37,percent of total billed charges,
HUMERAL HEAD,7916931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,2197.43,4986.12,percent of total billed charges,
HUMERAL HEAD,7916931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,1962.75,4986.12,percent of total billed charges,
HUMERAL HEAD,7944339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,2197.43,4986.12,percent of total billed charges,
HUMERAL HEAD,7944339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,1962.75,4986.12,percent of total billed charges,
HUMERAL HEAD,7964336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,2197.43,4986.12,percent of total billed charges,
HUMERAL HEAD,7964336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,1962.75,4986.12,percent of total billed charges,
SCREW,7790235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,7790235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SCREW,7802408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,7802408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SCREW,7802409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,7802409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SCREW,7946025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,7946025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SCREW,7954156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,7954156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SCREW,7954157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,7954157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
COMPONENT FEMORAL,7828049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7828049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7834038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7834038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7878298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7878298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7880192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7880192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7880275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7880275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7893417,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7893417,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
LINER,7874289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7874289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7846154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7846154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7866042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7866042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7954473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7954473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7957712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7957712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7958150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7958150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
COMPONENT FEMORAL,7802112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7802112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7858118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7858118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7882501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7882501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7904797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7904797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7905248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7905248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7962574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,7962574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
COMPONENT PATELLA,7911317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,605.64,1374.24,percent of total billed charges,
COMPONENT PATELLA,7911317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,540.96,1374.24,percent of total billed charges,
COMPONENT PATELLA,7927418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,605.64,1374.24,percent of total billed charges,
COMPONENT PATELLA,7927418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,540.96,1374.24,percent of total billed charges,
STENT GRAFT,7702076,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
STENT GRAFT,7702076,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
STENT GRAFT,7736492,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
STENT GRAFT,7736492,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
STENT GRAFT,7794045,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
STENT GRAFT,7794045,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
STENT GRAFT,7903410,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
STENT GRAFT,7903410,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
TIBIA ALL POLY M,7806414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
TIBIA ALL POLY M,7806414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
COMPONENT FEMORAL,7794408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7794408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7794412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7794412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7802072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7802072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7802078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7802078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7810035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7810035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7820084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7820084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7844034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7844034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7850085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7850085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7880287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7880287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7882833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7882833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7893342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7893342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7893345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7893345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7893637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7893637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7894209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7894209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7895650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7895650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7902301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7902301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7904798,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7904798,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7909378,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7909378,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7910248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7910248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7912271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7912271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7936399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7936399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7961900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,7961900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
BASEPLATE,7794409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7794409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7794413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7794413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7802073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7802073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7802076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7802076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7802079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7802079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7820082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7820082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7828065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7828065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7844033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7844033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7878327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7878327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7902128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7902128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7904741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7904741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,7912272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7912272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT PATELLA,7794411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
COMPONENT PATELLA,7794411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
COMPONENT PATELLA,7794415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
COMPONENT PATELLA,7794415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
COMPONENT PATELLA,7802074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
COMPONENT PATELLA,7802074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
COMPONENT PATELLA,7820083,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
COMPONENT PATELLA,7820083,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
INSERT,7794414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7794414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7794416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7794416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7802075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7802075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7802077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7802077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7802080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7802080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7810036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7810036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7820085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7820085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7828066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7828066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7828067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7828067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7836178,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7836178,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7844035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7844035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7876187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7876187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7878197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7878197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7880288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7880288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7880440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7880440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7880756,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7880756,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7882834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7882834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7893343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7893343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7893344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7893344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7893346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7893346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7893626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7893626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7893985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7893985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7893986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7893986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7894208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7894208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7895928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7895928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7902104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7902104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7902302,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7902302,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7903122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7903122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7904051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7904051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7904110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7904110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7904168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7904168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7904737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7904737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7904799,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7904799,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7904974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7904974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7905473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7905473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7908712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7908712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7909410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7909410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7909470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7909470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7910233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7910233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7910432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7910432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7910502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7910502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7910639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7910639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7912270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7912270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7912612,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7912612,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7913509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7913509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7913877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7913877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7913926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7913926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7917004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7917004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7917355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7917355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7918358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7918358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7918876,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7918876,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7918878,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7918878,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7919092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7919092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7920493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7920493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7920781,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7920781,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7922870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7922870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7924909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7924909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7926498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7926498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7927259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7927259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7934072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7934072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7936400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7936400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7937743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7937743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7938037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7938037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7944073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7944073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7948766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7948766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7956549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7956549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7960043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7960043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
COMPONENT FEMORAL,7935475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,7935475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
COMPONENT FEMORAL,7943705,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,7943705,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
COMPONENT FEMORAL,7954779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,7954779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
INSERT,7700185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2956.98,6709.60,percent of total billed charges,
INSERT,7700185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2641.19,6709.60,percent of total billed charges,
INSERT,7804051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7804051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7816128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7816128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7838068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7838068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7878187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7878187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7878313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7878313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7878559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7878559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7880188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7880188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7880191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7880191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7882232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7882232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7882858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7882858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7896746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7896746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7896901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7896901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7900161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7900161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7900294,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7900294,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7901614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7901614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7920813,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2956.98,6709.60,percent of total billed charges,
INSERT,7920813,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2641.19,6709.60,percent of total billed charges,
INSERT,7926552,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2956.98,6709.60,percent of total billed charges,
INSERT,7926552,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2641.19,6709.60,percent of total billed charges,
INSERT,7926708,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2956.98,6709.60,percent of total billed charges,
INSERT,7926708,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2641.19,6709.60,percent of total billed charges,
INSERT,7944035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2956.98,6709.60,percent of total billed charges,
INSERT,7944035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2641.19,6709.60,percent of total billed charges,
INSERT,7962619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2956.98,6709.60,percent of total billed charges,
INSERT,7962619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2641.19,6709.60,percent of total billed charges,
COMPONENT FEMORAL,7822233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7822233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7822234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7822234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7832047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7832047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7876326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7876326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7876327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7876327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7878195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7878195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7882595,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7882595,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
INSERT,7748891,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7748891,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7750030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7750030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7754078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7754078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7782098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7782098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7786051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7786051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7790241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7790241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7800042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7800042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7802103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7802103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7802107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7802107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7804031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7804031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7806372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7806372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7808074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7808074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7806413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7806413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7828070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7828070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7834164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7834164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7836106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7836106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7838111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7838111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7838071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7838071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7858277,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7858277,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7858278,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3850.00000,1116.50000,Aetna,First Health,,3149.30,,,,,,,1387.92,3149.30,percent of total billed charges,
INSERT,7858278,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3850.00000,1116.50000,Aetna,First Health,,3149.30,,,,,,,1239.70,3149.30,percent of total billed charges,
INSERT,7874393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7874393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7874399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7874399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7876335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7876335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7876435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7876435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7878308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7878308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7880185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7880185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7880186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7880186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7880441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7880441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7880582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7880582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7880619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7880619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7880621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7880621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7882253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7882253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7882370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7882370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7882374,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7882374,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7882375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7882375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7882506,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7882506,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7882593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7882593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7882594,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7882594,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7893770,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7893770,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7895652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7895652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7902343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7902343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7903124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7903124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7904261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7904261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7904975,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7904975,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7905013,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7905013,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7905710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7905710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7909318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7909318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7911774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7911774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7911775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7911775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7913927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7913927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7917874,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7917874,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7936194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7936194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7936195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7936195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7938370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7938370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7951930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7951930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7953913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7953913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7959515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7959515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7960314,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7960314,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SHELL,7802081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7802081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SHELL,7802084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7802084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SHELL,7836180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7836180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SHELL,7880195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7880195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SHELL,7880197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7880197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SHELL,7950462,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7950462,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SHELL,7958153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7958153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
FEMORAL IMPLANT,7880531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9201.00000,2668.29000,Aetna,First Health,,7526.42,,,,,,,3316.96,7526.42,percent of total billed charges,
FEMORAL IMPLANT,7880531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9201.00000,2668.29000,Aetna,First Health,,7526.42,,,,,,,2962.72,7526.42,percent of total billed charges,
LINER,7802110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7802110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7804055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7804055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7878307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7878307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7880248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7880248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7880675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7880675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7882504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7882504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7893703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7893703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7925893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7925893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
GUIDEWIRE,7802096,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,7802096,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
GUIDEWIRE,7802097,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,7802097,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,7696701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7696701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7696857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,7696857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,7697848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1438.48000,417.16000,Aetna,First Health,,1176.68,,,,,,,518.57,1176.68,percent of total billed charges,
SCREW,7697848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1438.48000,417.16000,Aetna,First Health,,1176.68,,,,,,,463.19,1176.68,percent of total billed charges,
SCREW,7698047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1533.36000,444.67000,Aetna,First Health,,1254.29,,,,,,,552.78,1254.29,percent of total billed charges,
SCREW,7698047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1533.36000,444.67000,Aetna,First Health,,1254.29,,,,,,,493.74,1254.29,percent of total billed charges,
SCREW,7698558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,582.57,1321.89,percent of total billed charges,
SCREW,7698558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,520.35,1321.89,percent of total billed charges,
SCREW,7698599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1565.16000,453.90000,Aetna,First Health,,1280.30,,,,,,,564.24,1280.30,percent of total billed charges,
SCREW,7698599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1565.16000,453.90000,Aetna,First Health,,1280.30,,,,,,,503.98,1280.30,percent of total billed charges,
SCREW,7699720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1428.44000,414.25000,Aetna,First Health,,1168.46,,,,,,,514.95,1168.46,percent of total billed charges,
SCREW,7699720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1428.44000,414.25000,Aetna,First Health,,1168.46,,,,,,,459.96,1168.46,percent of total billed charges,
SCREW,7700285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,480.29,1089.81,percent of total billed charges,
SCREW,7700285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,First Health,,1089.81,,,,,,,428.99,1089.81,percent of total billed charges,
SCREW,7701328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1335.80000,387.38000,Aetna,First Health,,1092.68,,,,,,,481.56,1092.68,percent of total billed charges,
SCREW,7701328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1335.80000,387.38000,Aetna,First Health,,1092.68,,,,,,,430.13,1092.68,percent of total billed charges,
SCREW,7802050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7802050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7802051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7802051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7802052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7802052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7802053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7802053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7836033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1449.16000,420.26000,Aetna,First Health,,1185.41,,,,,,,522.42,1185.41,percent of total billed charges,
SCREW,7836033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1449.16000,420.26000,Aetna,First Health,,1185.41,,,,,,,466.63,1185.41,percent of total billed charges,
SCREW,7874339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7874339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7874391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7874391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7874340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7874340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7911832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7911911,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,7911911,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,7920465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7920465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7920466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7920466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7940872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7940872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7703184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,582.57,1321.89,percent of total billed charges,
SCREW,7703184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,520.35,1321.89,percent of total billed charges,
STEM,7834082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,7834082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
STEM,7882696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,7882696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
STEM,7920120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,7920120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
STEM CENTRALIZER,7834080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
STEM CENTRALIZER,7834080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
STEM CENTRALIZER,7882695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
STEM CENTRALIZER,7882695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
STEM CENTRALIZER,7918851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
STEM CENTRALIZER,7918851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
STEM CENTRALIZER,7920119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
STEM CENTRALIZER,7920119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
STEM CENTRALIZER,7962242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
STEM CENTRALIZER,7962242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
STEM,7802083,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,7802083,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
LINER,7836179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,7836179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
LINER,7901857,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,7901857,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
LINER,7958154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,7958154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,7939326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7939326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7944350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7944350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7944351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7944351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7948242,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7948242,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7954367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7954367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7954368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7954368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7954373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7954373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7960035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7960035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7960036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7960036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7960037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7960037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7961894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7961894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
COMPONENT FEMORAL,7804047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7804047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7836188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7836188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7836191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7836191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7874294,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7874294,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7876342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7876342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7880645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7880645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7882519,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7882519,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE,7836187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BASEPLATE,7836187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
BASEPLATE,7858124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BASEPLATE,7858124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
BASEPLATE,7874293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BASEPLATE,7874293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
BASEPLATE,7880648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BASEPLATE,7880648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
SLEEVE,7698026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12638.40000,3665.14000,Aetna,First Health,,10338.21,,,,,,,4556.14,10338.21,percent of total billed charges,
SLEEVE,7698026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12638.40000,3665.14000,Aetna,First Health,,10338.21,,,,,,,4069.56,10338.21,percent of total billed charges,
SLEEVE,7816134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2302.56000,667.74000,Aetna,First Health,,1883.49,,,,,,,830.07,1883.49,percent of total billed charges,
SLEEVE,7816134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2302.56000,667.74000,Aetna,First Health,,1883.49,,,,,,,741.42,1883.49,percent of total billed charges,
SCREW,7940796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7940796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE,7697882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,920.00,2087.54,percent of total billed charges,
PLATE,7697882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,821.74,2087.54,percent of total billed charges,
PLATE,7697885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,920.00,2087.54,percent of total billed charges,
PLATE,7697885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,821.74,2087.54,percent of total billed charges,
PLATE,7702962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1641.12000,475.92000,Aetna,First Health,,1342.44,,,,,,,591.62,1342.44,percent of total billed charges,
PLATE,7702962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1641.12000,475.92000,Aetna,First Health,,1342.44,,,,,,,528.44,1342.44,percent of total billed charges,
INTRODUCER,7806235,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
INTRODUCER,7806235,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
INTRODUCER,7902105,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,451.25000,130.86000,Aetna,First Health,,369.12,,,,,,,162.68,369.12,percent of total billed charges,
INTRODUCER,7902105,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,451.25000,130.86000,Aetna,First Health,,369.12,,,,,,,145.30,369.12,percent of total billed charges,
FEMORAL HEAD,7868037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7868037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL HEAD,7876322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7876322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL HEAD,7880432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7880432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL HEAD,7900570,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7900570,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL HEAD,7910649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7910649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL HEAD,7920748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7920748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL HEAD,7926455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7926455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL HEAD,7940365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7940365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL HEAD,7942054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7942054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL HEAD,7948863,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7948863,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL HEAD,7960040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
FEMORAL HEAD,7960040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
COMPONENT FEMORAL,7876323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,7876323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
COMPONENT FEMORAL,7882379,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,7882379,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
BALLOON DILATOR,7808075,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,2887.72000,837.44000,Aetna,First Health,,2362.15,,,,,,,1041.02,2362.15,percent of total billed charges,
BALLOON DILATOR,7808075,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,2887.72000,837.44000,Aetna,First Health,,2362.15,,,,,,,929.85,2362.15,percent of total billed charges,
BALLOON DILATOR,7880678,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,2887.72000,837.44000,Aetna,First Health,,2362.15,,,,,,,1041.02,2362.15,percent of total billed charges,
BALLOON DILATOR,7880678,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,2887.72000,837.44000,Aetna,First Health,,2362.15,,,,,,,929.85,2362.15,percent of total billed charges,
LINER,7698718,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7698718,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7699116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7699116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7699954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7699954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7700241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7700241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7742073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7742073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7748756,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7748756,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7782032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7782032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7806375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7806375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7816120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7816120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7828135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7828135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7838065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7838065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7848065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7848065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7876329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7876329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7876438,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7876438,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7878481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7878481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7878561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7878561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7880533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7880533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7880665,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7880665,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7882233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7882233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7882479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7882479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7901617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7901617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7901856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7901856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7902299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7902299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7902356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7902356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7903726,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7903726,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7904734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7904734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7908599,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7908599,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7908882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7908882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7921281,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7921281,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7927347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7927347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
SHELL,7699314,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7699314,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7699451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7699451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7700029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7700029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7740523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7740523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7748114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7748114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7748755,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7748755,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7748833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7748833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7806377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7806377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7806405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7806405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7816119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7816119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7822237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7822237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7838064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7838064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7850199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7850199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7878460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7878460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7878477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7878477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7880444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7880444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7882221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7882221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7910509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7910509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7910640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7910640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7910641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7910641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7910834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7910834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7911007,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7911007,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7911287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7911287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7911777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7911777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7912826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7912826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7916925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7916925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7934070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7934070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7943250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7943250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7947858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7947858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SHELL,7950204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,7950204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
INSERT,7700841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7700841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7750090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7750090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7778029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7778029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7800032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7800032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7810088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7810088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7814060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7814060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7822246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7822246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7836105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7836105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7850175,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7850175,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7876437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7876437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7878191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7878191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7878476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7878476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7878483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7878483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7878566,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7878566,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7880187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7880187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7880251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7880251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7880581,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7880581,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7880667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7880667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7880668,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7880668,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7880670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7880670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7882372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7882372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7882373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7882373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7882849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7882849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7893982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7893982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7894126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7894126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7900129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7900129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7902127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7902127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7902346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7902346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7903362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7903362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7904048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7904048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7911776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7911776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7919093,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7919093,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BALLOON CATHETER,7695025,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1340.04000,388.61000,Aetna,First Health,,1096.15,,,,,,,483.08,1096.15,percent of total billed charges,
BALLOON CATHETER,7695025,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1340.04000,388.61000,Aetna,First Health,,1096.15,,,,,,,431.49,1096.15,percent of total billed charges,
BALLOON CATHETER,7695026,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1340.04000,388.61000,Aetna,First Health,,1096.15,,,,,,,483.08,1096.15,percent of total billed charges,
BALLOON CATHETER,7695026,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1340.04000,388.61000,Aetna,First Health,,1096.15,,,,,,,431.49,1096.15,percent of total billed charges,
BALLOON CATHETER,7695027,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1340.04000,388.61000,Aetna,First Health,,1096.15,,,,,,,483.08,1096.15,percent of total billed charges,
BALLOON CATHETER,7695027,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1340.04000,388.61000,Aetna,First Health,,1096.15,,,,,,,431.49,1096.15,percent of total billed charges,
BALLOON CATHETER,7893622,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1356.68000,393.44000,Aetna,First Health,,1109.76,,,,,,,489.08,1109.76,percent of total billed charges,
BALLOON CATHETER,7893622,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1356.68000,393.44000,Aetna,First Health,,1109.76,,,,,,,436.85,1109.76,percent of total billed charges,
STENT,7695104,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2329.43,5285.65,percent of total billed charges,
STENT,7695104,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2080.66,5285.65,percent of total billed charges,
STENT,7695105,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2329.43,5285.65,percent of total billed charges,
STENT,7695105,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2080.66,5285.65,percent of total billed charges,
STENT,7695106,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2329.43,5285.65,percent of total billed charges,
STENT,7695106,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2080.66,5285.65,percent of total billed charges,
GUIDEWIRE,7694375,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,515.04000,149.36000,Aetna,First Health,,421.30,,,,,,,185.67,421.30,percent of total billed charges,
GUIDEWIRE,7694375,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,515.04000,149.36000,Aetna,First Health,,421.30,,,,,,,165.84,421.30,percent of total billed charges,
GUIDEWIRE,7694376,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,515.04000,149.36000,Aetna,First Health,,421.30,,,,,,,185.67,421.30,percent of total billed charges,
GUIDEWIRE,7694376,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,515.04000,149.36000,Aetna,First Health,,421.30,,,,,,,165.84,421.30,percent of total billed charges,
BOLT,7695515,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7695515,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
BOLT,7695516,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7695516,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
BOLT,7695517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7695517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
BOLT,7695876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7695876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
BOLT,7695877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7695877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
BOLT,7702618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7702618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
BOLT,7740546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7740546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
BOLT,7702905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7702905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
BREAST IMPLANT,7957917,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
BREAST IMPLANT,7957917,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
BREAST IMPLANT,7965042,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
BREAST IMPLANT,7965042,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
BREAST IMPLANT,7965055,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
BREAST IMPLANT,7965055,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
BREAST IMPLANT,7965056,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
BREAST IMPLANT,7965056,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
TIBIA ADAPTER,7816101,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3266.90000,947.40000,Aetna,First Health,,2672.32,,,,,,,1177.72,2672.32,percent of total billed charges,
TIBIA ADAPTER,7816101,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3266.90000,947.40000,Aetna,First Health,,2672.32,,,,,,,1051.94,2672.32,percent of total billed charges,
STEM,7880573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,2052.78,4657.90,percent of total billed charges,
STEM,7880573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,1833.55,4657.90,percent of total billed charges,
STEM,7893764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,2052.78,4657.90,percent of total billed charges,
STEM,7893764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,1833.55,4657.90,percent of total billed charges,
STEM,7904043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,2052.78,4657.90,percent of total billed charges,
STEM,7904043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,1833.55,4657.90,percent of total billed charges,
STEM,7918194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,2052.78,4657.90,percent of total billed charges,
STEM,7918194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,First Health,,4657.90,,,,,,,1833.55,4657.90,percent of total billed charges,
SCREW,7822094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7822094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7935109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7935109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
ANCHOR,7902123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
ANCHOR,7902123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7822183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
SCREW,7822183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
SCREW,7822184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
SCREW,7822184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
SCREW,7880278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,664.20000,192.62000,Aetna,First Health,,543.32,,,,,,,239.44,543.32,percent of total billed charges,
SCREW,7880278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,664.20000,192.62000,Aetna,First Health,,543.32,,,,,,,213.87,543.32,percent of total billed charges,
SCREW,7880279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,664.20000,192.62000,Aetna,First Health,,543.32,,,,,,,239.44,543.32,percent of total billed charges,
SCREW,7880279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,664.20000,192.62000,Aetna,First Health,,543.32,,,,,,,213.87,543.32,percent of total billed charges,
SCREW,7880280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,664.20000,192.62000,Aetna,First Health,,543.32,,,,,,,239.44,543.32,percent of total billed charges,
SCREW,7880280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,664.20000,192.62000,Aetna,First Health,,543.32,,,,,,,213.87,543.32,percent of total billed charges,
SCREW,7880282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,664.20000,192.62000,Aetna,First Health,,543.32,,,,,,,239.44,543.32,percent of total billed charges,
SCREW,7880282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,664.20000,192.62000,Aetna,First Health,,543.32,,,,,,,213.87,543.32,percent of total billed charges,
COMPONENT FEMORAL,7880436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7880436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7909472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7909472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7918047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13059.00000,3787.11000,Aetna,First Health,,10682.26,,,,,,,4707.77,10682.26,percent of total billed charges,
COMPONENT FEMORAL,7918047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13059.00000,3787.11000,Aetna,First Health,,10682.26,,,,,,,4205.00,10682.26,percent of total billed charges,
LINER,7699452,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7699452,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7748115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7748115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7748834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7748834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7748879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7748879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7866111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7866111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7876332,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7876332,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7878317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7878317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7878325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7878325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7878564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7878564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7880252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7880252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7880455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7880455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7896743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7896743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7900096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7900096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7901618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7901618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7910508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7910508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7917876,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7917876,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7918630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7918630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7920411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7920411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7920820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7920820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7934071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7934071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7943251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7943251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7944261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7944261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7962118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7962118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7880530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
LINER,7880530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
INSERT,7880579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7880579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7882513,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7882513,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
LEAD,7695145,CDM,278,RC,C1777,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,5028.98,11411.10,percent of total billed charges,
LEAD,7695145,CDM,278,RC,C1777,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,4491.90,11411.10,percent of total billed charges,
SCREW,7903367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2592.00000,751.68000,Aetna,First Health,,2120.26,,,,,,,934.42,2120.26,percent of total billed charges,
SCREW,7903367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2592.00000,751.68000,Aetna,First Health,,2120.26,,,,,,,834.62,2120.26,percent of total billed charges,
PROXIMAL BODY,7927400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
PROXIMAL BODY,7927400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
PROXIMAL BODY,7944505,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
PROXIMAL BODY,7944505,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
ADAPTER,7909243,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
ADAPTER,7909243,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
KNEE IMPLANT,7908635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
KNEE IMPLANT,7908635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
COMPONENT FEMORAL,7846159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7846159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7874296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7874296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7905246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7905246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7912752,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1949.40,4423.34,percent of total billed charges,
COMPONENT FEMORAL,7912752,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,First Health,,4423.34,,,,,,,1741.21,4423.34,percent of total billed charges,
STEM,7880249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,4346.82,9863.24,percent of total billed charges,
STEM,7880249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,3882.60,9863.24,percent of total billed charges,
STEM,7896958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,4346.82,9863.24,percent of total billed charges,
STEM,7896958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,3882.60,9863.24,percent of total billed charges,
STEM,7903498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8692.80000,2520.91000,Aetna,First Health,,7110.71,,,,,,,3133.75,7110.71,percent of total billed charges,
STEM,7903498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8692.80000,2520.91000,Aetna,First Health,,7110.71,,,,,,,2799.08,7110.71,percent of total billed charges,
STEM,7925894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,4346.82,9863.24,percent of total billed charges,
STEM,7925894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,3882.60,9863.24,percent of total billed charges,
STEM,7954745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,4346.82,9863.24,percent of total billed charges,
STEM,7954745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,3882.60,9863.24,percent of total billed charges,
SHELL,7834081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,1002.19,2274.04,percent of total billed charges,
SHELL,7834081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,895.16,2274.04,percent of total billed charges,
SHELL,7846163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,1002.19,2274.04,percent of total billed charges,
SHELL,7846163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,895.16,2274.04,percent of total billed charges,
SHELL,7850194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,1002.19,2274.04,percent of total billed charges,
SHELL,7850194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,895.16,2274.04,percent of total billed charges,
SHELL,7858121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,1002.19,2274.04,percent of total billed charges,
SHELL,7858121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,895.16,2274.04,percent of total billed charges,
SHELL,7866039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,1002.19,2274.04,percent of total billed charges,
SHELL,7866039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,895.16,2274.04,percent of total billed charges,
SHELL,7866041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,1002.19,2274.04,percent of total billed charges,
SHELL,7866041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,895.16,2274.04,percent of total billed charges,
CATHETER,7834107,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,752.40000,218.20000,Aetna,First Health,,615.46,,,,,,,271.24,615.46,percent of total billed charges,
CATHETER,7834107,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,752.40000,218.20000,Aetna,First Health,,615.46,,,,,,,242.27,615.46,percent of total billed charges,
COMPONENT FEMORAL,7882690,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7882690,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7893607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7893607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7927345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7927345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7943927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7943927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7947954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7947954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
FEMORAL HEAD,7836181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
FEMORAL HEAD,7836181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
FEMORAL HEAD,7840126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
FEMORAL HEAD,7840126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
FEMORAL HEAD,7902538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
FEMORAL HEAD,7902538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
FEMORAL HEAD,7912825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
FEMORAL HEAD,7912825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
GLENOSPHERE,7701645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,2191.66,4973.03,percent of total billed charges,
GLENOSPHERE,7701645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,1957.60,4973.03,percent of total billed charges,
GLENOSPHERE,7836143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1137.20,2580.40,percent of total billed charges,
GLENOSPHERE,7836143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1015.76,2580.40,percent of total billed charges,
GLENOSPHERE,7836144,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,2191.66,4973.03,percent of total billed charges,
GLENOSPHERE,7836144,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,1957.60,4973.03,percent of total billed charges,
GLENOSPHERE,7938963,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,2191.66,4973.03,percent of total billed charges,
GLENOSPHERE,7938963,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,1957.60,4973.03,percent of total billed charges,
COMPONENT PATELLA,7858247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
COMPONENT PATELLA,7858247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
COMPONENT PATELLA,7874323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
COMPONENT PATELLA,7874323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
COMPONENT PATELLA,7920117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
COMPONENT PATELLA,7920117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
ANCHOR,7912354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,793.10,1799.60,percent of total billed charges,
ANCHOR,7912354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,708.40,1799.60,percent of total billed charges,
PLATE,7840048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9306.00000,2698.74000,Aetna,First Health,,7612.31,,,,,,,3354.81,7612.31,percent of total billed charges,
PLATE,7840048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9306.00000,2698.74000,Aetna,First Health,,7612.31,,,,,,,2996.53,7612.31,percent of total billed charges,
PLATE,7882615,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2220.00000,643.80000,Aetna,First Health,,1815.96,,,,,,,800.31,1815.96,percent of total billed charges,
PLATE,7882615,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2220.00000,643.80000,Aetna,First Health,,1815.96,,,,,,,714.84,1815.96,percent of total billed charges,
PLATE,7882618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2220.00000,643.80000,Aetna,First Health,,1815.96,,,,,,,800.31,1815.96,percent of total billed charges,
PLATE,7882618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2220.00000,643.80000,Aetna,First Health,,1815.96,,,,,,,714.84,1815.96,percent of total billed charges,
FEMORAL HEAD,7868041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7868041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7874292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7874292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7878330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7878330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7868040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7868040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7925197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7925197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
PLATE,7872038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6389.88000,1853.07000,Aetna,First Health,,5226.92,,,,,,,2303.55,5226.92,percent of total billed charges,
PLATE,7872038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6389.88000,1853.07000,Aetna,First Health,,5226.92,,,,,,,2057.54,5226.92,percent of total billed charges,
SCREW,7896380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,637.79000,184.96000,Aetna,First Health,,521.71,,,,,,,229.92,521.71,percent of total billed charges,
SCREW,7896380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,637.79000,184.96000,Aetna,First Health,,521.71,,,,,,,205.37,521.71,percent of total billed charges,
SPACER,7921022,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,865.20,1963.20,percent of total billed charges,
SPACER,7921022,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,772.80,1963.20,percent of total billed charges,
BASEPLATE,7850190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,7850190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7850191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7850191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
BASEPLATE,7878296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7878296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7882384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7882384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7882515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7882515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7938032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7938032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
SCREW,7922849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7922849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7924579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7924579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7935504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7935504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
LINER,7920115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.38000,1728.80000,Aetna,First Health,,4876.41,,,,,,,2149.08,4876.41,percent of total billed charges,
LINER,7920115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.38000,1728.80000,Aetna,First Health,,4876.41,,,,,,,1919.56,4876.41,percent of total billed charges,
SCREW,7874332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7874332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7874335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7874335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7874336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7874336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7874434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7874434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7874436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7874436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7874437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7874437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7903060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7903060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7939276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,795.98,1806.14,percent of total billed charges,
SCREW,7939276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,710.98,1806.14,percent of total billed charges,
BALLOON CATHETER,7858547,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7858547,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
BALLOON CATHETER,7893957,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7893957,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
BALLOON CATHETER,7929706,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7929706,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
BALLOON CATHETER,7957916,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7957916,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
AORTIC EXTENSION,7882344,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
AORTIC EXTENSION,7882344,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
AORTIC EXTENSION,7882346,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
AORTIC EXTENSION,7882346,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
GRAFT,7858551,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,19825.00000,5749.25000,Aetna,First Health,,16216.85,,,,,,,7146.91,16216.85,percent of total billed charges,
GRAFT,7858551,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,19825.00000,5749.25000,Aetna,First Health,,16216.85,,,,,,,6383.65,16216.85,percent of total billed charges,
PLATE,7860044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4866.75000,1411.36000,Aetna,First Health,,3981.00,,,,,,,1754.46,3981.00,percent of total billed charges,
PLATE,7860044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4866.75000,1411.36000,Aetna,First Health,,3981.00,,,,,,,1567.09,3981.00,percent of total billed charges,
PLATE,7860045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4866.75000,1411.36000,Aetna,First Health,,3981.00,,,,,,,1754.46,3981.00,percent of total billed charges,
PLATE,7860045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4866.75000,1411.36000,Aetna,First Health,,3981.00,,,,,,,1567.09,3981.00,percent of total billed charges,
PLATE,7860046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4866.75000,1411.36000,Aetna,First Health,,3981.00,,,,,,,1754.46,3981.00,percent of total billed charges,
PLATE,7860046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4866.75000,1411.36000,Aetna,First Health,,3981.00,,,,,,,1567.09,3981.00,percent of total billed charges,
PLATE,7921013,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,7921013,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
CATHETER,7695048,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
CATHETER,7695048,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
CATHETER,7920487,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
CATHETER,7920487,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
SCREW,7905302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7905302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7910511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7910511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7912274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7912274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7912275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7912275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7933869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7933869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7933870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7933870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7938779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7938779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7943928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7943928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7943929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7943929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
PLATE,7882265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3753.65000,1088.56000,Aetna,First Health,,3070.49,,,,,,,1353.19,3070.49,percent of total billed charges,
PLATE,7882265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3753.65000,1088.56000,Aetna,First Health,,3070.49,,,,,,,1208.68,3070.49,percent of total billed charges,
SLEEVE,7880433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,109.87,249.29,percent of total billed charges,
SLEEVE,7880433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,98.13,249.29,percent of total billed charges,
SLEEVE,7910648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,109.87,249.29,percent of total billed charges,
SLEEVE,7910648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,98.13,249.29,percent of total billed charges,
SLEEVE,7942053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,109.87,249.29,percent of total billed charges,
SLEEVE,7942053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,98.13,249.29,percent of total billed charges,
ANCHOR,7935738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,1117.55,2535.80,percent of total billed charges,
ANCHOR,7935738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,998.20,2535.80,percent of total billed charges,
COMPONENT TIBIAL,7940362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
COMPONENT TIBIAL,7940362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
ANCHOR,7870085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
ANCHOR,7870085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
ANCHOR,7882871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
ANCHOR,7882871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
ANCHOR,7882872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
ANCHOR,7882872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
PLATE,7872040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6571.85000,1905.84000,Aetna,First Health,,5375.77,,,,,,,2369.15,5375.77,percent of total billed charges,
PLATE,7872040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6571.85000,1905.84000,Aetna,First Health,,5375.77,,,,,,,2116.14,5375.77,percent of total billed charges,
GLENOSPHERE,7878571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,3352.65,7607.40,percent of total billed charges,
GLENOSPHERE,7878571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,2994.60,7607.40,percent of total billed charges,
STEM,7878570,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
STEM,7878570,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STEM,7893682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
STEM,7893682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STEM,7908598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
STEM,7908598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STEM,7874122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7874122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7896370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7896370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7896372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7896372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7910691,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7910691,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7911745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7911745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7911747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7911747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7912531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7912531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7913630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7913630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7913631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7913631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7924545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7924545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7926453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7926453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7927414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7927414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7927443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7927443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7927444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7927444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7933689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7933689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
STEM,7935029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,7935029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
BASEPLATE,7896384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7896384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
BASEPLATE,7910690,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7910690,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
BASEPLATE,7911746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7911746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
BASEPLATE,7912532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7912532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
BASEPLATE,7912873,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7912873,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
BASEPLATE,7913646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7913646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
BASEPLATE,7922623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7922623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
BASEPLATE,7926454,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7926454,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
BASEPLATE,7935066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7935066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
BASEPLATE,7939856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
BASEPLATE,7939856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
INSERT,7896383,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,7896383,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
INSERT,7911748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,7911748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
INSERT,7912533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,7912533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
INSERT,7918403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,7918403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
INSERT,7927415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,7927415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
INSERT,7933690,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,7933690,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
INSERT,7935031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,7935031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
INSERT,7939805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,7939805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
INSERT,7944394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,7944394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
COMPONENT FEMORAL,7896755,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,6524.15,14803.75,percent of total billed charges,
COMPONENT FEMORAL,7896755,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,5827.40,14803.75,percent of total billed charges,
COMPONENT FEMORAL,7911744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,6524.15,14803.75,percent of total billed charges,
COMPONENT FEMORAL,7911744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,5827.40,14803.75,percent of total billed charges,
COMPONENT FEMORAL,7912530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,6524.15,14803.75,percent of total billed charges,
COMPONENT FEMORAL,7912530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,5827.40,14803.75,percent of total billed charges,
COMPONENT FEMORAL,7912872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19767.50000,5732.58000,Aetna,First Health,,16169.82,,,,,,,7126.18,16169.82,percent of total billed charges,
COMPONENT FEMORAL,7912872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19767.50000,5732.58000,Aetna,First Health,,16169.82,,,,,,,6365.14,16169.82,percent of total billed charges,
COMPONENT FEMORAL,7913654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19767.50000,5732.58000,Aetna,First Health,,16169.82,,,,,,,7126.18,16169.82,percent of total billed charges,
COMPONENT FEMORAL,7913654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19767.50000,5732.58000,Aetna,First Health,,16169.82,,,,,,,6365.14,16169.82,percent of total billed charges,
COMPONENT FEMORAL,7924504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,6524.15,14803.75,percent of total billed charges,
COMPONENT FEMORAL,7924504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,5827.40,14803.75,percent of total billed charges,
COMPONENT FEMORAL,7935030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,6524.15,14803.75,percent of total billed charges,
COMPONENT FEMORAL,7935030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,5827.40,14803.75,percent of total billed charges,
PLATE,7882191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1948.00000,564.92000,Aetna,First Health,,1593.46,,,,,,,702.25,1593.46,percent of total billed charges,
PLATE,7882191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1948.00000,564.92000,Aetna,First Health,,1593.46,,,,,,,627.26,1593.46,percent of total billed charges,
PLATE,7939413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,582.57,1321.89,percent of total billed charges,
PLATE,7939413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,520.35,1321.89,percent of total billed charges,
HEART VALVE SYSTEM S,7874267,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7874267,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7874268,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7874268,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7874269,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7874269,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7874270,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7874270,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7874271,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7874271,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7902279,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7902279,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7902283,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7902283,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7902286,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7902286,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7902289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE SYSTEM S,7902289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
WEDGE,7895651,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE,7895651,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
WEDGE,7920544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE,7920544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
PLATE,7874330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12678.00000,3676.62000,Aetna,First Health,,10370.60,,,,,,,4570.42,10370.60,percent of total billed charges,
PLATE,7874330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12678.00000,3676.62000,Aetna,First Health,,10370.60,,,,,,,4082.32,10370.60,percent of total billed charges,
PLATE,7903042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12678.00000,3676.62000,Aetna,First Health,,10370.60,,,,,,,4570.42,10370.60,percent of total billed charges,
PLATE,7903042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12678.00000,3676.62000,Aetna,First Health,,10370.60,,,,,,,4082.32,10370.60,percent of total billed charges,
FEMORAL HEAD,7880200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7880200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7922504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7922504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW,7893848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7893848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
COMPONENT FEMORAL,7909471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7909471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7912140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7912140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7913429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7913429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7913911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7913911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7916712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7916712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7917663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7917663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7918410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7918410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7918905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7918905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7919169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7919169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7920348,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7920348,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7920408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7920408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7920818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7920818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7922452,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7922452,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7925272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7925272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7926706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7926706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7927210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7927210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7927450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7927450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7938090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7938090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7944016,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7944016,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7944305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7944305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7947961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7947961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7954794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,7954794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
STEM,7894010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7894010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7904260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7904260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7935866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7935866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7944196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7944196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
LINER,7880184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3850.00000,1116.50000,Aetna,First Health,,3149.30,,,,,,,1387.92,3149.30,percent of total billed charges,
LINER,7880184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3850.00000,1116.50000,Aetna,First Health,,3149.30,,,,,,,1239.70,3149.30,percent of total billed charges,
STEM,7882693,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7882693,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7893681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7893681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7905715,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7905715,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7942051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7942051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7942052,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7942052,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7944547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,7944547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
STEM,7957788,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7957788,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7957789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7957789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,7878539,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,4078.34,9254.03,percent of total billed charges,
CAGE,7878539,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,3642.79,9254.03,percent of total billed charges,
COMPONENT FEMORAL,7882398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7882398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
FEMORAL HEAD,7936397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1392.66,3160.04,percent of total billed charges,
FEMORAL HEAD,7936397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1243.93,3160.04,percent of total billed charges,
HUMERAL HEAD,7882736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7882736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7893340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7893340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
FEMORAL HEAD,7935285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7935285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
FEMORAL HEAD,7948125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7948125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
FEMORAL HEAD,7948171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7948171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
BASEPLATE,7882742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7882742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
BASEPLATE,7882744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7882744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
BASEPLATE,7908230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7908230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
BASEPLATE,7930208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7930208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
BASEPLATE,7939378,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7939378,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
BASEPLATE,7954358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7954358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
INSERT,7882743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7882743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,7882745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7882745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,7893706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7893706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,7908231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7908231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,7910168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7910168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,7930207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7930207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SLEEVE,7882261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,174.66,396.32,percent of total billed charges,
SLEEVE,7882261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,156.01,396.32,percent of total billed charges,
SLEEVE,7937957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SLEEVE,7937957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SLEEVE,7937958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SLEEVE,7937958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
COMPONENT GLENOID,7893769,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
COMPONENT GLENOID,7893769,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
COMPONENT GLENOID,7901684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
COMPONENT GLENOID,7901684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
COMPONENT GLENOID,7903564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
COMPONENT GLENOID,7903564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
COMPONENT GLENOID,7918192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
COMPONENT GLENOID,7918192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
PLATE,7939410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
PLATE,7939410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
AUGMENT TIBIAL,7882689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7882689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
AUGMENT SPACER,7896752,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
AUGMENT SPACER,7896752,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7896753,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7896753,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7902684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7902684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7902685,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7902685,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
INSERT,7927346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,7927346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,7935950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,7935950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,7943926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,7943926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,7947955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,7947955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SPACER,7921295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,2191.66,4973.03,percent of total billed charges,
SPACER,7921295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,First Health,,4973.03,,,,,,,1957.60,4973.03,percent of total billed charges,
GENERATOR,7943973,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,45787.50000,13278.37000,Aetna,First Health,,37454.18,,,,,,,16506.39,37454.18,percent of total billed charges,
GENERATOR,7943973,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,45787.50000,13278.37000,Aetna,First Health,,37454.18,,,,,,,14743.58,37454.18,percent of total billed charges,
BALLOON,7882790,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON,7882790,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON,7882793,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON,7882793,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
BALLOON,7882794,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON,7882794,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
NAIL,7926920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1913.07,4340.88,percent of total billed charges,
NAIL,7926920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1708.76,4340.88,percent of total billed charges,
NAIL,7953867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1913.07,4340.88,percent of total billed charges,
NAIL,7953867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1708.76,4340.88,percent of total billed charges,
NAIL,7956691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1913.07,4340.88,percent of total billed charges,
NAIL,7956691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1708.76,4340.88,percent of total billed charges,
NAIL,7957695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1913.07,4340.88,percent of total billed charges,
NAIL,7957695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1708.76,4340.88,percent of total billed charges,
NAIL,7959960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1913.07,4340.88,percent of total billed charges,
NAIL,7959960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1708.76,4340.88,percent of total billed charges,
NAIL,7960044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1913.07,4340.88,percent of total billed charges,
NAIL,7960044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1708.76,4340.88,percent of total billed charges,
NAIL,7963862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1913.07,4340.88,percent of total billed charges,
NAIL,7963862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,First Health,,4340.88,,,,,,,1708.76,4340.88,percent of total billed charges,
ROD,7905301,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD,7905301,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
ROD,7927019,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD,7927019,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
INSERT,7927180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3486.76,7911.70,percent of total billed charges,
INSERT,7927180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3114.38,7911.70,percent of total billed charges,
INSERT,7943247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3486.76,7911.70,percent of total billed charges,
INSERT,7943247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3114.38,7911.70,percent of total billed charges,
GRAFT,7954650,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2562.68000,743.18000,Aetna,First Health,,2096.27,,,,,,,923.85,2096.27,percent of total billed charges,
GRAFT,7954650,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2562.68000,743.18000,Aetna,First Health,,2096.27,,,,,,,825.18,2096.27,percent of total billed charges,
STENT,7700487,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700487,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700488,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700488,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700489,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700489,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700490,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700490,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700491,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700491,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700492,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700492,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700493,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700493,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700494,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700494,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700495,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700495,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700496,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700496,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700497,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700497,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700498,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700498,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700502,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700502,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
STENT,7700503,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,7700503,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
TIBIAL TRAY,7700319,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26556.38000,7701.35000,Aetna,First Health,,21723.12,,,,,,,9573.57,21723.12,percent of total billed charges,
TIBIAL TRAY,7700319,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26556.38000,7701.35000,Aetna,First Health,,21723.12,,,,,,,8551.15,21723.12,percent of total billed charges,
TIBIAL TRAY,7736122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26556.38000,7701.35000,Aetna,First Health,,21723.12,,,,,,,9573.57,21723.12,percent of total billed charges,
TIBIAL TRAY,7736122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26556.38000,7701.35000,Aetna,First Health,,21723.12,,,,,,,8551.15,21723.12,percent of total billed charges,
GRAFT,7698612,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5219.17000,1513.56000,Aetna,First Health,,4269.28,,,,,,,1881.51,4269.28,percent of total billed charges,
GRAFT,7698612,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5219.17000,1513.56000,Aetna,First Health,,4269.28,,,,,,,1680.57,4269.28,percent of total billed charges,
GRAFT,7954651,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5529.37000,1603.52000,Aetna,First Health,,4523.02,,,,,,,1993.34,4523.02,percent of total billed charges,
GRAFT,7954651,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5529.37000,1603.52000,Aetna,First Health,,4523.02,,,,,,,1780.46,4523.02,percent of total billed charges,
COMPONENT FEMORAL,7699689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,9270.49,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7699689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,8280.44,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7699890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,9270.49,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7699890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,8280.44,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7893763,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,9270.49,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7893763,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,8280.44,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7919058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,9270.49,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7919058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,8280.44,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7919078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,9270.49,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7919078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,8280.44,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7943811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,9270.49,21035.40,percent of total billed charges,
COMPONENT FEMORAL,7943811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,First Health,,21035.40,,,,,,,8280.44,21035.40,percent of total billed charges,
SCREW,7698630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7698630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7698631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7698631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7736667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7736667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
STEM,7697900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2810.33,6376.84,percent of total billed charges,
STEM,7697900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2510.20,6376.84,percent of total billed charges,
STEM,7698054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7698054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7698466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7698466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7699223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2810.33,6376.84,percent of total billed charges,
STEM,7699223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2510.20,6376.84,percent of total billed charges,
STEM,7699849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7699849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7700318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2810.33,6376.84,percent of total billed charges,
STEM,7700318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2510.20,6376.84,percent of total billed charges,
STEM,7700433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7700433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7700837,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7700837,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7701556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7701556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7736508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2810.33,6376.84,percent of total billed charges,
STEM,7736508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2510.20,6376.84,percent of total billed charges,
STEM,7838120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7838120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7872046,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7872046,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7882254,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2810.33,6376.84,percent of total billed charges,
STEM,7882254,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2510.20,6376.84,percent of total billed charges,
STEM,7882694,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7882694,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7908883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2810.33,6376.84,percent of total billed charges,
STEM,7908883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2510.20,6376.84,percent of total billed charges,
STEM,7960338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7960338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
COMPONENT PATELLA,7699851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7699851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7700106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7700106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7700172,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7700172,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7700415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7700415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7736191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7736191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ADAPTOR,7696822,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
ADAPTOR,7696822,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
TAPER,7696953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
TAPER,7696953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
TAPER,7696956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
TAPER,7696956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
TAPER,7698716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
TAPER,7698716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
TAPER,7699852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
TAPER,7699852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
GUIDEWIRE,7700441,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
GUIDEWIRE,7700441,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
STEM,7699867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17514.75000,5079.28000,Aetna,First Health,,14327.07,,,,,,,6314.07,14327.07,percent of total billed charges,
STEM,7699867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17514.75000,5079.28000,Aetna,First Health,,14327.07,,,,,,,5639.75,14327.07,percent of total billed charges,
BREAST IMPLANT,7699481,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7699481,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7700127,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7700127,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7702216,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7702216,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7702217,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7702217,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7702628,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7702628,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7702629,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7702629,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7707538,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7707538,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736152,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736152,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736162,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736162,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736225,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736225,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736226,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736226,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736227,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736227,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736228,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736228,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736229,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736229,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736230,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736230,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736231,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736231,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736368,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736368,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736369,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736369,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736371,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736371,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736372,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736372,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736373,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736373,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736374,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736374,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736375,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736375,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736376,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736376,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736377,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736377,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736379,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736379,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736380,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736380,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736381,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736381,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736384,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736384,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736385,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736385,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7736386,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736386,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736387,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736387,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7736388,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7736388,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7894171,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7894171,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7894172,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7894172,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7894173,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7894173,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7894174,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7894174,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7894268,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7894268,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7894269,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7894269,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7894270,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7894270,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7895929,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7895929,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7895930,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7895930,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7904262,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7904262,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7904263,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7904263,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7905515,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7905515,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7905516,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7905516,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7908333,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7908333,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7908334,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7908334,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7908335,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7908335,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7908336,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7908336,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7909273,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7909273,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7909274,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7909274,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7909275,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7909275,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7918818,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7918818,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7918819,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7918819,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7927141,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7927141,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7927142,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7927142,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7927143,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7927143,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7927144,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7927144,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7927145,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7927145,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,764.47,4437.65,percent of total billed charges,
BREAST IMPLANT,7935860,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7935860,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
BREAST IMPLANT,7935983,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7935983,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7935984,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7935984,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7935985,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7935985,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938152,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938152,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938153,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938153,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938154,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938154,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938155,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938155,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938156,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938156,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938157,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938157,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938334,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938334,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938335,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938335,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938336,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938336,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938651,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938651,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938652,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938652,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938653,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938653,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938654,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938654,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7938655,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7938655,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7941867,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7941867,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7941868,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7941868,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7941869,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7941869,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7941870,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7941870,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7941871,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7941871,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7941872,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7941872,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7941873,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7941873,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7941874,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7941874,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7965087,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7965087,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
COIL,7699872,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5509.00000,1597.61000,Aetna,First Health,,4506.36,,,,,,,1985.99,4506.36,percent of total billed charges,
COIL,7699872,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5509.00000,1597.61000,Aetna,First Health,,4506.36,,,,,,,1773.90,4506.36,percent of total billed charges,
COIL,7700002,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5509.00000,1597.61000,Aetna,First Health,,4506.36,,,,,,,1985.99,4506.36,percent of total billed charges,
COIL,7700002,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5509.00000,1597.61000,Aetna,First Health,,4506.36,,,,,,,1773.90,4506.36,percent of total billed charges,
COIL,7910254,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1819.44,4128.45,percent of total billed charges,
COIL,7910254,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1625.13,4128.45,percent of total billed charges,
COIL,7910255,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1819.44,4128.45,percent of total billed charges,
COIL,7910255,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1625.13,4128.45,percent of total billed charges,
COIL,7910256,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1819.44,4128.45,percent of total billed charges,
COIL,7910256,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1625.13,4128.45,percent of total billed charges,
COIL,7910289,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1819.44,4128.45,percent of total billed charges,
COIL,7910289,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1625.13,4128.45,percent of total billed charges,
COIL,7921034,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1819.44,4128.45,percent of total billed charges,
COIL,7921034,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,First Health,,4128.45,,,,,,,1625.13,4128.45,percent of total billed charges,
INSERT,7700035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2900.00000,841.00000,Aetna,First Health,,2372.20,,,,,,,1045.45,2372.20,percent of total billed charges,
INSERT,7700035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2900.00000,841.00000,Aetna,First Health,,2372.20,,,,,,,933.80,2372.20,percent of total billed charges,
INSERT,7748122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2900.00000,841.00000,Aetna,First Health,,2372.20,,,,,,,1045.45,2372.20,percent of total billed charges,
INSERT,7748122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2900.00000,841.00000,Aetna,First Health,,2372.20,,,,,,,933.80,2372.20,percent of total billed charges,
INSERT,7882317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2900.00000,841.00000,Aetna,First Health,,2372.20,,,,,,,1045.45,2372.20,percent of total billed charges,
INSERT,7882317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2900.00000,841.00000,Aetna,First Health,,2372.20,,,,,,,933.80,2372.20,percent of total billed charges,
INSERT,7882388,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2900.00000,841.00000,Aetna,First Health,,2372.20,,,,,,,1045.45,2372.20,percent of total billed charges,
INSERT,7882388,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2900.00000,841.00000,Aetna,First Health,,2372.20,,,,,,,933.80,2372.20,percent of total billed charges,
ACETABULAR CUP,7736106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4930.45000,1429.83000,Aetna,First Health,,4033.11,,,,,,,1777.43,4033.11,percent of total billed charges,
ACETABULAR CUP,7736106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4930.45000,1429.83000,Aetna,First Health,,4033.11,,,,,,,1587.60,4033.11,percent of total billed charges,
ACETABULAR CUP,7736441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7736441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
ACETABULAR CUP,7800034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7800034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
ACETABULAR CUP,7802089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7802089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
ACETABULAR CUP,7828054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7828054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
ACETABULAR CUP,7828056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7828056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
ACETABULAR CUP,7878194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7878194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
ACETABULAR CUP,7878321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7878321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
ACETABULAR CUP,7902295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7902295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
ACETABULAR CUP,7905492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7905492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
ACETABULAR CUP,7910167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7910167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
ACETABULAR CUP,7925242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7925242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
COMPONENT FEMORAL,7736515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25305.00000,7338.45000,Aetna,First Health,,20699.49,,,,,,,9122.45,20699.49,percent of total billed charges,
COMPONENT FEMORAL,7736515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25305.00000,7338.45000,Aetna,First Health,,20699.49,,,,,,,8148.21,20699.49,percent of total billed charges,
COMPONENT FEMORAL,7920814,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25305.00000,7338.45000,Aetna,First Health,,20699.49,,,,,,,9122.45,20699.49,percent of total billed charges,
COMPONENT FEMORAL,7920814,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25305.00000,7338.45000,Aetna,First Health,,20699.49,,,,,,,8148.21,20699.49,percent of total billed charges,
COMPONENT FEMORAL,7926656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25305.00000,7338.45000,Aetna,First Health,,20699.49,,,,,,,9122.45,20699.49,percent of total billed charges,
COMPONENT FEMORAL,7926656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25305.00000,7338.45000,Aetna,First Health,,20699.49,,,,,,,8148.21,20699.49,percent of total billed charges,
STEM EXTENSION,7699938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM EXTENSION,7699938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
STEM EXTENSION,7700187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM EXTENSION,7700187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
STEM EXTENSION,7756047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM EXTENSION,7756047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
INSERT,7920816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1762.40000,511.10000,Aetna,First Health,,1441.64,,,,,,,635.35,1441.64,percent of total billed charges,
INSERT,7920816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1762.40000,511.10000,Aetna,First Health,,1441.64,,,,,,,567.49,1441.64,percent of total billed charges,
CABLE,7699914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2143.88000,621.73000,Aetna,First Health,,1753.69,,,,,,,772.87,1753.69,percent of total billed charges,
CABLE,7699914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2143.88000,621.73000,Aetna,First Health,,1753.69,,,,,,,690.33,1753.69,percent of total billed charges,
SCREW,7702342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,124.63,282.79,percent of total billed charges,
SCREW,7702342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,111.32,282.79,percent of total billed charges,
SCREW,7702343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,124.63,282.79,percent of total billed charges,
SCREW,7702343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,111.32,282.79,percent of total billed charges,
SCREW,7702344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,124.63,282.79,percent of total billed charges,
SCREW,7702344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,111.32,282.79,percent of total billed charges,
SCREW,7702345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,124.63,282.79,percent of total billed charges,
SCREW,7702345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,111.32,282.79,percent of total billed charges,
SCREW,7702346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,124.63,282.79,percent of total billed charges,
SCREW,7702346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,111.32,282.79,percent of total billed charges,
SCREW,7702347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,124.63,282.79,percent of total billed charges,
SCREW,7702347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,111.32,282.79,percent of total billed charges,
SCREW,7702348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,124.63,282.79,percent of total billed charges,
SCREW,7702348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,111.32,282.79,percent of total billed charges,
SCREW,7702349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,124.63,282.79,percent of total billed charges,
SCREW,7702349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,111.32,282.79,percent of total billed charges,
SCREW,7702350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,124.63,282.79,percent of total billed charges,
SCREW,7702350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,111.32,282.79,percent of total billed charges,
SCREW,7702351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,124.63,282.79,percent of total billed charges,
SCREW,7702351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,First Health,,282.79,,,,,,,111.32,282.79,percent of total billed charges,
SCREW,7702355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,126.20,286.37,percent of total billed charges,
SCREW,7702355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,112.73,286.37,percent of total billed charges,
SCREW,7702356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,126.20,286.37,percent of total billed charges,
SCREW,7702356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,112.73,286.37,percent of total billed charges,
SCREW,7702357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,126.20,286.37,percent of total billed charges,
SCREW,7702357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,112.73,286.37,percent of total billed charges,
SCREW,7702358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,126.20,286.37,percent of total billed charges,
SCREW,7702358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,112.73,286.37,percent of total billed charges,
SCREW,7702359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,126.20,286.37,percent of total billed charges,
SCREW,7702359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,112.73,286.37,percent of total billed charges,
SCREW,7702360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,126.20,286.37,percent of total billed charges,
SCREW,7702360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,First Health,,286.37,,,,,,,112.73,286.37,percent of total billed charges,
SCREW,7702361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,351.17000,101.84000,Aetna,First Health,,287.26,,,,,,,126.60,287.26,percent of total billed charges,
SCREW,7702361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,351.17000,101.84000,Aetna,First Health,,287.26,,,,,,,113.08,287.26,percent of total billed charges,
SCREW,7702362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,353.64000,102.56000,Aetna,First Health,,289.28,,,,,,,127.49,289.28,percent of total billed charges,
SCREW,7702362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,353.64000,102.56000,Aetna,First Health,,289.28,,,,,,,113.87,289.28,percent of total billed charges,
SCREW,7702363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,353.64000,102.56000,Aetna,First Health,,289.28,,,,,,,127.49,289.28,percent of total billed charges,
SCREW,7702363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,353.64000,102.56000,Aetna,First Health,,289.28,,,,,,,113.87,289.28,percent of total billed charges,
INSERT,7699323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7699323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
INSERT,7699741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7699741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
INSERT,7700392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7700392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
INSERT,7700914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7700914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
INSERT,7736123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7736123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
INSERT,7736509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7736509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
INSERT,7784198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7784198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
INSERT,7914406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7914406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
INSERT,7926499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7926499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
INSERT,7938933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7938933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
WEDGE,7698468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7698468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7700529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7700529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7700530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7700530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7701606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7701606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7701607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7701607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7742040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7742040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7788041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7788041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
STEM,7824029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7824029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
COUPLER,7698619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3764.25000,1091.63000,Aetna,First Health,,3079.16,,,,,,,1357.01,3079.16,percent of total billed charges,
COUPLER,7698619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3764.25000,1091.63000,Aetna,First Health,,3079.16,,,,,,,1212.09,3079.16,percent of total billed charges,
COUPLER,7698620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3764.25000,1091.63000,Aetna,First Health,,3079.16,,,,,,,1357.01,3079.16,percent of total billed charges,
COUPLER,7698620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3764.25000,1091.63000,Aetna,First Health,,3079.16,,,,,,,1212.09,3079.16,percent of total billed charges,
WEDGE,7698645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7698645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7736532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7736532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7736533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7736533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7740554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7740554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7740556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7740556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7740783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7740783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7768030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7768030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7778032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7778032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7778033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7778033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7788038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7788038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7788039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7788039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7816137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7816137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7854029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7854029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7904986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7904986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
BASEPLATE,7697616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7697616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
PLATE,7697617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
PLATE,7697617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7697618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7697618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7697619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7697619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7697620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7697620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BASEPLATE,7802111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7802111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
PLATE,7913268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7913269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7913270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7913271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7913272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7913273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7913274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7913275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7913276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7913277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7913278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,7913278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,7925230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7825.50000,2269.40000,Aetna,First Health,,6401.26,,,,,,,2821.09,6401.26,percent of total billed charges,
PLATE,7925230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7825.50000,2269.40000,Aetna,First Health,,6401.26,,,,,,,2519.81,6401.26,percent of total billed charges,
PATELLA IMPLANT,7697613,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
PATELLA IMPLANT,7697613,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
PATELLA IMPLANT,7697614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
PATELLA IMPLANT,7697614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
PATELLA IMPLANT,7698403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
PATELLA IMPLANT,7698403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
PATELLA IMPLANT,7882502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
PATELLA IMPLANT,7882502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
CAGE,7696562,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,4078.34,9254.03,percent of total billed charges,
CAGE,7696562,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,3642.79,9254.03,percent of total billed charges,
CAGE,7696563,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,4078.34,9254.03,percent of total billed charges,
CAGE,7696563,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,3642.79,9254.03,percent of total billed charges,
CAGE,7697151,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,4078.34,9254.03,percent of total billed charges,
CAGE,7697151,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,3642.79,9254.03,percent of total billed charges,
CAGE,7700809,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,4078.34,9254.03,percent of total billed charges,
CAGE,7700809,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,3642.79,9254.03,percent of total billed charges,
SCREW,7696546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1554.48,3527.22,percent of total billed charges,
SCREW,7696546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1388.46,3527.22,percent of total billed charges,
SCREW,7696568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1554.48,3527.22,percent of total billed charges,
SCREW,7696568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1388.46,3527.22,percent of total billed charges,
SCREW,7696693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1554.48,3527.22,percent of total billed charges,
SCREW,7696693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1388.46,3527.22,percent of total billed charges,
SCREW,7696780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1554.48,3527.22,percent of total billed charges,
SCREW,7696780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1388.46,3527.22,percent of total billed charges,
SCREW,7697145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1554.48,3527.22,percent of total billed charges,
SCREW,7697145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1388.46,3527.22,percent of total billed charges,
SCREW,7697146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1554.48,3527.22,percent of total billed charges,
SCREW,7697146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1388.46,3527.22,percent of total billed charges,
SCREW,7930148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SCREW,7930148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,7930149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SCREW,7930149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,7930244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SCREW,7930244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,7935726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SCREW,7935726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,7935727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SCREW,7935727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,7935728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SCREW,7935728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,7935729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SCREW,7935729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,7935791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SCREW,7935791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
FEMORAL HEAD 20,7700112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD 20,7700112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
FEMORAL HEAD 20,7700534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD 20,7700534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
FEMORAL HEAD 20,7740762,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD 20,7740762,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
STEM COLLAR,7700154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9409.02000,2728.62000,Aetna,First Health,,7696.58,,,,,,,3391.95,7696.58,percent of total billed charges,
STEM COLLAR,7700154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9409.02000,2728.62000,Aetna,First Health,,7696.58,,,,,,,3029.70,7696.58,percent of total billed charges,
STEM COLLAR,7736516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9409.02000,2728.62000,Aetna,First Health,,7696.58,,,,,,,3391.95,7696.58,percent of total billed charges,
STEM COLLAR,7736516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9409.02000,2728.62000,Aetna,First Health,,7696.58,,,,,,,3029.70,7696.58,percent of total billed charges,
HIP MODULAR,7699923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
HIP MODULAR,7699923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
HIP MODULAR,7702587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
HIP MODULAR,7702587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
HIP MODULAR,7740748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
HIP MODULAR,7740748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
HIP MODULAR,7918352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
HIP MODULAR,7918352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
COMPONENT FEMORAL,7697661,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7697661,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7697927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7697927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7698019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7698019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7698219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7698219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7699095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7699095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7699525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7699525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7699950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7699950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7699963,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7699963,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7707544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7707544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908627,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908627,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7908628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
INSERT,7698225,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7698225,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7698533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8137.20000,2359.79000,Aetna,First Health,,6656.23,,,,,,,2933.46,6656.23,percent of total billed charges,
INSERT,7698533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8137.20000,2359.79000,Aetna,First Health,,6656.23,,,,,,,2620.18,6656.23,percent of total billed charges,
INSERT,7698993,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7698993,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7699093,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7699093,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7699657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7699657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
INSERT,7699952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7699952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7699956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7699956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
INSERT,7700191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7700191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
INSERT,7700849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7700849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7700950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7700950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
INSERT,7702132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7702132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
INSERT,7736112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7736112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
INSERT,7802102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8137.20000,2359.79000,Aetna,First Health,,6656.23,,,,,,,2933.46,6656.23,percent of total billed charges,
INSERT,7802102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8137.20000,2359.79000,Aetna,First Health,,6656.23,,,,,,,2620.18,6656.23,percent of total billed charges,
INSERT,7816194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7816194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
INSERT,7832096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7832096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
INSERT,7908484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908486,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908486,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908495,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908495,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7908496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
INSERT,7908497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7908497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
INSERT,7908498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7908498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
INSERT,7948695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7948695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
COMPONENT FEMORAL,7699936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4515.97,10247.05,percent of total billed charges,
COMPONENT FEMORAL,7699936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4033.68,10247.05,percent of total billed charges,
COMPONENT FEMORAL,7858546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4515.97,10247.05,percent of total billed charges,
COMPONENT FEMORAL,7858546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4033.68,10247.05,percent of total billed charges,
COMPONENT FEMORAL,7865354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4515.97,10247.05,percent of total billed charges,
COMPONENT FEMORAL,7865354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4033.68,10247.05,percent of total billed charges,
COMPONENT FEMORAL,7700156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19850.33000,5756.60000,Aetna,First Health,,16237.57,,,,,,,7156.04,16237.57,percent of total billed charges,
COMPONENT FEMORAL,7700156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19850.33000,5756.60000,Aetna,First Health,,16237.57,,,,,,,6391.81,16237.57,percent of total billed charges,
SLEEVE,7698028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12922.20000,3747.44000,Aetna,First Health,,10570.36,,,,,,,4658.45,10570.36,percent of total billed charges,
SLEEVE,7698028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12922.20000,3747.44000,Aetna,First Health,,10570.36,,,,,,,4160.95,10570.36,percent of total billed charges,
INSERT,7698250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7698250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7698465,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7698465,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7698624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7698624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7698644,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7698644,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7699228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7699228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7700016,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7700016,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7700321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7700321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7700432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7700432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7701604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7701604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7702253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7702253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7748898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7748898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7788040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7788040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7790163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7790163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7838125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7838125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7878302,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7878302,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7878303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7878303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7880250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7880250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7893308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7893308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7893704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7893704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7902710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7902710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7904694,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7904694,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7905303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7905303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7905609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7905609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7919096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7919096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
LINER,7698525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
LINER,7698525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
LINER,7699969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
LINER,7699969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
LINER,7701032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
LINER,7701032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
LINER,7702662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
LINER,7702662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
LINER,7782095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
LINER,7782095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
LINER,7818074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7818074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7937668,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
LINER,7937668,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
GUIDEWIRE,7694997,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,293.63,666.26,percent of total billed charges,
GUIDEWIRE,7694997,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,262.27,666.26,percent of total billed charges,
GUIDEWIRE,7695036,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,442.69,1004.50,percent of total billed charges,
GUIDEWIRE,7695036,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,395.42,1004.50,percent of total billed charges,
GUIDEWIRE,7695090,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,705.00000,204.45000,Aetna,First Health,,576.69,,,,,,,254.15,576.69,percent of total billed charges,
GUIDEWIRE,7695090,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,705.00000,204.45000,Aetna,First Health,,576.69,,,,,,,227.01,576.69,percent of total billed charges,
GUIDEWIRE,7695096,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,293.63,666.26,percent of total billed charges,
GUIDEWIRE,7695096,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,262.27,666.26,percent of total billed charges,
GUIDEWIRE,7695098,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,796.01000,230.84000,Aetna,First Health,,651.14,,,,,,,286.96,651.14,percent of total billed charges,
GUIDEWIRE,7695098,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,796.01000,230.84000,Aetna,First Health,,651.14,,,,,,,256.32,651.14,percent of total billed charges,
GUIDEWIRE,7695136,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,796.01000,230.84000,Aetna,First Health,,651.14,,,,,,,286.96,651.14,percent of total billed charges,
GUIDEWIRE,7695136,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,796.01000,230.84000,Aetna,First Health,,651.14,,,,,,,256.32,651.14,percent of total billed charges,
GUIDEWIRE,7878466,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,442.69,1004.50,percent of total billed charges,
GUIDEWIRE,7878466,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,395.42,1004.50,percent of total billed charges,
GUIDEWIRE,7702891,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,796.01000,230.84000,Aetna,First Health,,651.14,,,,,,,286.96,651.14,percent of total billed charges,
GUIDEWIRE,7702891,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,796.01000,230.84000,Aetna,First Health,,651.14,,,,,,,256.32,651.14,percent of total billed charges,
COIL,7702205,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5176.50000,1501.18000,Aetna,First Health,,4234.38,,,,,,,1866.13,4234.38,percent of total billed charges,
COIL,7702205,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5176.50000,1501.18000,Aetna,First Health,,4234.38,,,,,,,1666.83,4234.38,percent of total billed charges,
SPACER,7957754,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1254.66,2846.91,percent of total billed charges,
SPACER,7957754,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1120.67,2846.91,percent of total billed charges,
CAGE,7957755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1254.66,2846.91,percent of total billed charges,
CAGE,7957755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1120.67,2846.91,percent of total billed charges,
CAGE,7957911,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1254.66,2846.91,percent of total billed charges,
CAGE,7957911,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1120.67,2846.91,percent of total billed charges,
PLATE,7756708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2628.04000,762.13000,Aetna,First Health,,2149.74,,,,,,,947.41,2149.74,percent of total billed charges,
PLATE,7756708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2628.04000,762.13000,Aetna,First Health,,2149.74,,,,,,,846.23,2149.74,percent of total billed charges,
FEMORAL HEAD,7700020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7700020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
FEMORAL HEAD,7701049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7701049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
FEMORAL HEAD,7918896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7918896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
LINER,7701050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7701050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
LINER,7702258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7702258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
LINER,7741713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7741713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7806037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7806037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
LINER,7850195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7850195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7858122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7858122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7902357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7902357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
LINER,7918852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7918852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
PLATE,7702979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.00000,428.04000,Aetna,First Health,,1207.37,,,,,,,532.10,1207.37,percent of total billed charges,
PLATE,7702979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.00000,428.04000,Aetna,First Health,,1207.37,,,,,,,475.27,1207.37,percent of total billed charges,
PLATE,7700036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
PLATE,7700036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
PLATE,7700038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
PLATE,7700038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
PLATE,7700332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
PLATE,7700332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PLATE,7700335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2584.00000,749.36000,Aetna,First Health,,2113.71,,,,,,,931.53,2113.71,percent of total billed charges,
PLATE,7700335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2584.00000,749.36000,Aetna,First Health,,2113.71,,,,,,,832.05,2113.71,percent of total billed charges,
PLATE,7700653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,472.69,1072.56,percent of total billed charges,
PLATE,7700653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,422.21,1072.56,percent of total billed charges,
PLATE,7701190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,472.69,1072.56,percent of total billed charges,
PLATE,7701190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,422.21,1072.56,percent of total billed charges,
PLATE,7701191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1654.40000,479.78000,Aetna,First Health,,1353.30,,,,,,,596.41,1353.30,percent of total billed charges,
PLATE,7701191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1654.40000,479.78000,Aetna,First Health,,1353.30,,,,,,,532.72,1353.30,percent of total billed charges,
PLATE,7701817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1654.40000,479.78000,Aetna,First Health,,1353.30,,,,,,,596.41,1353.30,percent of total billed charges,
PLATE,7701817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1654.40000,479.78000,Aetna,First Health,,1353.30,,,,,,,532.72,1353.30,percent of total billed charges,
PLATE,7701842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,472.69,1072.56,percent of total billed charges,
PLATE,7701842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,422.21,1072.56,percent of total billed charges,
PLATE,7701843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,472.69,1072.56,percent of total billed charges,
PLATE,7701843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,422.21,1072.56,percent of total billed charges,
PLATE,7701844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,472.69,1072.56,percent of total billed charges,
PLATE,7701844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,422.21,1072.56,percent of total billed charges,
PLATE,7701845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,472.69,1072.56,percent of total billed charges,
PLATE,7701845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,First Health,,1072.56,,,,,,,422.21,1072.56,percent of total billed charges,
PLATE,7740888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1692.00000,490.68000,Aetna,First Health,,1384.06,,,,,,,609.97,1384.06,percent of total billed charges,
PLATE,7740888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1692.00000,490.68000,Aetna,First Health,,1384.06,,,,,,,544.82,1384.06,percent of total billed charges,
PLATE,7700092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7625.13000,2211.29000,Aetna,First Health,,6237.36,,,,,,,2748.86,6237.36,percent of total billed charges,
PLATE,7700092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7625.13000,2211.29000,Aetna,First Health,,6237.36,,,,,,,2455.29,6237.36,percent of total billed charges,
PLATE,7702623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
PLATE,7702623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
PLATE,7756389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SCREW,7698046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,661.01000,191.69000,Aetna,First Health,,540.71,,,,,,,238.29,540.71,percent of total billed charges,
SCREW,7698046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,661.01000,191.69000,Aetna,First Health,,540.71,,,,,,,212.85,540.71,percent of total billed charges,
SCREW,7700057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
SCREW,7700057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
SCREW,7700058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
SCREW,7700058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
SCREW,7702340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,717.08000,207.95000,Aetna,First Health,,586.57,,,,,,,258.51,586.57,percent of total billed charges,
SCREW,7702340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,717.08000,207.95000,Aetna,First Health,,586.57,,,,,,,230.90,586.57,percent of total billed charges,
SCREW,7702341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,727.97000,211.11000,Aetna,First Health,,595.48,,,,,,,262.43,595.48,percent of total billed charges,
SCREW,7702341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,727.97000,211.11000,Aetna,First Health,,595.48,,,,,,,234.41,595.48,percent of total billed charges,
SCREW,7741347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,649.67000,188.40000,Aetna,First Health,,531.43,,,,,,,234.21,531.43,percent of total billed charges,
SCREW,7741347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,649.67000,188.40000,Aetna,First Health,,531.43,,,,,,,209.19,531.43,percent of total billed charges,
SCREW,7750602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,783.00000,227.07000,Aetna,First Health,,640.49,,,,,,,282.27,640.49,percent of total billed charges,
SCREW,7750602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,783.00000,227.07000,Aetna,First Health,,640.49,,,,,,,252.13,640.49,percent of total billed charges,
SCREW,7822185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7822185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,7822186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7822186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,7822187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7822187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,7836141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
SCREW,7836141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
SCREW,7893728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
SCREW,7893728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
INSERT,7701579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1137.20,2580.40,percent of total billed charges,
INSERT,7701579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1015.76,2580.40,percent of total billed charges,
INSERT,7701641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1137.20,2580.40,percent of total billed charges,
INSERT,7701641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1015.76,2580.40,percent of total billed charges,
INSERT,7908615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1137.20,2580.40,percent of total billed charges,
INSERT,7908615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1015.76,2580.40,percent of total billed charges,
INSERT,7911303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1137.20,2580.40,percent of total billed charges,
INSERT,7911303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1015.76,2580.40,percent of total billed charges,
INSERT,7921307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1137.20,2580.40,percent of total billed charges,
INSERT,7921307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1015.76,2580.40,percent of total billed charges,
INSERT,7922818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1137.20,2580.40,percent of total billed charges,
INSERT,7922818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1015.76,2580.40,percent of total billed charges,
INSERT,7700068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7700068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7700069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7700069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7702589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7702589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7740749,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7740749,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7822263,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7822263,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7882222,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7882222,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7902587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7902587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7904800,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7904800,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7904982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7904982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7908234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7908234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7917872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7917872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7927537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7927537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7935784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7935784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
BASEPLATE,7701639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5109.30000,1481.70000,Aetna,First Health,,4179.41,,,,,,,1841.90,4179.41,percent of total billed charges,
BASEPLATE,7701639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5109.30000,1481.70000,Aetna,First Health,,4179.41,,,,,,,1645.19,4179.41,percent of total billed charges,
BASEPLATE,7893727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5109.30000,1481.70000,Aetna,First Health,,4179.41,,,,,,,1841.90,4179.41,percent of total billed charges,
BASEPLATE,7893727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5109.30000,1481.70000,Aetna,First Health,,4179.41,,,,,,,1645.19,4179.41,percent of total billed charges,
CUP,7701640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1906.06,4325.00,percent of total billed charges,
CUP,7701640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1702.50,4325.00,percent of total billed charges,
CUP,7836142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1906.06,4325.00,percent of total billed charges,
CUP,7836142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1702.50,4325.00,percent of total billed charges,
CUP,7910235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1906.06,4325.00,percent of total billed charges,
CUP,7910235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1702.50,4325.00,percent of total billed charges,
CUP,7911302,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1906.06,4325.00,percent of total billed charges,
CUP,7911302,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1702.50,4325.00,percent of total billed charges,
CUP,7922502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1906.06,4325.00,percent of total billed charges,
CUP,7922502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1702.50,4325.00,percent of total billed charges,
CUP,7924902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1906.06,4325.00,percent of total billed charges,
CUP,7924902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1702.50,4325.00,percent of total billed charges,
STENT GRAFT,7700870,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15217.50000,4413.08000,Aetna,First Health,,12447.92,,,,,,,5485.91,12447.92,percent of total billed charges,
STENT GRAFT,7700870,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15217.50000,4413.08000,Aetna,First Health,,12447.92,,,,,,,4900.03,12447.92,percent of total billed charges,
STENT GRAFT,7741337,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15217.50000,4413.08000,Aetna,First Health,,12447.92,,,,,,,5485.91,12447.92,percent of total billed charges,
STENT GRAFT,7741337,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15217.50000,4413.08000,Aetna,First Health,,12447.92,,,,,,,4900.03,12447.92,percent of total billed charges,
STENT GRAFT,7920566,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15217.50000,4413.08000,Aetna,First Health,,12447.92,,,,,,,5485.91,12447.92,percent of total billed charges,
STENT GRAFT,7920566,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15217.50000,4413.08000,Aetna,First Health,,12447.92,,,,,,,4900.03,12447.92,percent of total billed charges,
LEAD,7914011,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
LEAD,7914011,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
LEAD,7702928,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
LEAD,7702928,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
PLATE,7922476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,475.25,1078.39,percent of total billed charges,
PLATE,7922476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,424.50,1078.39,percent of total billed charges,
GUIDEWIRE,7882347,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
GUIDEWIRE,7882347,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
GLENOSPHERE,7882523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
GLENOSPHERE,7882523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
INSERT,7700108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7700108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7736637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7736637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7700412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7700412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7701555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7701555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7736349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7736349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7834039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7834039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7838121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7838121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7846157,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7846157,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7866086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7866086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7876341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7876341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7878346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7878346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7880524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7880524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7882596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7882596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7935725,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7935725,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7957713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7957713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HUMERAL ADAPTER TRAY,7880649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2365.78,5368.12,percent of total billed charges,
HUMERAL ADAPTER TRAY,7880649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2113.12,5368.12,percent of total billed charges,
STEM,7700245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7700245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7700537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7700537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7700905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7700905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7700910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7700910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7701059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7701059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7702286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7702286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7736095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7736095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7740761,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7740761,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7762381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7762381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7826097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7826097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7866085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7866085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7901852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7901852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7927475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7927475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7943374,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7943374,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STEM,7962116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7962116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STENT,7914036,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7914036,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7695952,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7695952,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7696244,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7696244,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7696279,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7696279,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7697117,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7697117,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7697158,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7697158,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7697236,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7697236,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7702168,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3392.17000,983.73000,Aetna,First Health,,2774.80,,,,,,,1222.88,2774.80,percent of total billed charges,
STENT,7702168,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3392.17000,983.73000,Aetna,First Health,,2774.80,,,,,,,1092.28,2774.80,percent of total billed charges,
STENT,7736035,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3392.17000,983.73000,Aetna,First Health,,2774.80,,,,,,,1222.88,2774.80,percent of total billed charges,
STENT,7736035,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3392.17000,983.73000,Aetna,First Health,,2774.80,,,,,,,1092.28,2774.80,percent of total billed charges,
STENT,7874183,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7874183,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7910539,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7910539,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7938030,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7938030,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
LINER,7700425,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7700425,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
LINER,7750107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7750107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
LINER,7822257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7822257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
LINER,7882585,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7882585,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
PLATE,7696432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,441.75000,128.11000,Aetna,First Health,,361.35,,,,,,,159.25,361.35,percent of total billed charges,
PLATE,7696432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,441.75000,128.11000,Aetna,First Health,,361.35,,,,,,,142.24,361.35,percent of total billed charges,
PLATE,7699982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1246.96000,361.62000,Aetna,First Health,,1020.01,,,,,,,449.53,1020.01,percent of total billed charges,
PLATE,7699982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1246.96000,361.62000,Aetna,First Health,,1020.01,,,,,,,401.52,1020.01,percent of total billed charges,
PLATE,7700142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1630.40000,472.82000,Aetna,First Health,,1333.67,,,,,,,587.76,1333.67,percent of total billed charges,
PLATE,7700142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1630.40000,472.82000,Aetna,First Health,,1333.67,,,,,,,524.99,1333.67,percent of total billed charges,
LINER,7874342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
LINER,7874342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
IMPLANT HEAD,7702663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1855.02,4209.18,percent of total billed charges,
IMPLANT HEAD,7702663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1656.92,4209.18,percent of total billed charges,
INSERT,7699268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2389.25,5421.38,percent of total billed charges,
INSERT,7699268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2134.09,5421.38,percent of total billed charges,
INSERT,7700168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2389.25,5421.38,percent of total billed charges,
INSERT,7700168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2134.09,5421.38,percent of total billed charges,
INSERT,7700856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2389.25,5421.38,percent of total billed charges,
INSERT,7700856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2134.09,5421.38,percent of total billed charges,
INSERT,7701613,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2389.25,5421.38,percent of total billed charges,
INSERT,7701613,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2134.09,5421.38,percent of total billed charges,
AUGMENT TIBIAL,7699414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1337.71,3035.35,percent of total billed charges,
AUGMENT TIBIAL,7699414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1194.85,3035.35,percent of total billed charges,
AUGMENT TIBIAL,7699415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1337.71,3035.35,percent of total billed charges,
AUGMENT TIBIAL,7699415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1194.85,3035.35,percent of total billed charges,
AUGMENT TIBIAL,7699439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7699439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7699894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7699894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7700166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3798.90000,1101.68000,Aetna,First Health,,3107.50,,,,,,,1369.50,3107.50,percent of total billed charges,
AUGMENT FEMORAL,7700166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3798.90000,1101.68000,Aetna,First Health,,3107.50,,,,,,,1223.25,3107.50,percent of total billed charges,
AUGMENT FEMORAL,7701599,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3798.90000,1101.68000,Aetna,First Health,,3107.50,,,,,,,1369.50,3107.50,percent of total billed charges,
AUGMENT FEMORAL,7701599,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3798.90000,1101.68000,Aetna,First Health,,3107.50,,,,,,,1223.25,3107.50,percent of total billed charges,
AUGMENT FEMORAL,7701611,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3798.90000,1101.68000,Aetna,First Health,,3107.50,,,,,,,1369.50,3107.50,percent of total billed charges,
AUGMENT FEMORAL,7701611,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3798.90000,1101.68000,Aetna,First Health,,3107.50,,,,,,,1223.25,3107.50,percent of total billed charges,
AUGMENT FEMORAL,7701612,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1337.71,3035.35,percent of total billed charges,
AUGMENT FEMORAL,7701612,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1194.85,3035.35,percent of total billed charges,
AUGMENT FEMORAL,7701619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1337.71,3035.35,percent of total billed charges,
AUGMENT FEMORAL,7701619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1194.85,3035.35,percent of total billed charges,
AUGMENT FEMORAL,7736355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7736355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7736483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1337.71,3035.35,percent of total billed charges,
AUGMENT TIBIAL,7736483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1194.85,3035.35,percent of total billed charges,
AUGMENT FEMORAL,7736675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7736675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7736679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7736679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7741332,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7741332,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7741333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7741333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7754283,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7754283,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7756049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7756049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7818166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7818166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7893765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7893765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7903722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7903722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
BASEPLATE,7699850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,4451.45,10100.66,percent of total billed charges,
BASEPLATE,7699850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,3976.06,10100.66,percent of total billed charges,
BASEPLATE,7700183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,4451.45,10100.66,percent of total billed charges,
BASEPLATE,7700183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,3976.06,10100.66,percent of total billed charges,
BASEPLATE,7700396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,4451.45,10100.66,percent of total billed charges,
BASEPLATE,7700396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,3976.06,10100.66,percent of total billed charges,
BASEPLATE,7700838,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,4451.45,10100.66,percent of total billed charges,
BASEPLATE,7700838,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,3976.06,10100.66,percent of total billed charges,
BASEPLATE,7736619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16277.50000,4720.47000,Aetna,First Health,,13315.00,,,,,,,5868.04,13315.00,percent of total billed charges,
BASEPLATE,7736619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16277.50000,4720.47000,Aetna,First Health,,13315.00,,,,,,,5241.35,13315.00,percent of total billed charges,
BASEPLATE,7897358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15688.63000,4549.70000,Aetna,First Health,,12833.30,,,,,,,5655.75,12833.30,percent of total billed charges,
BASEPLATE,7897358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15688.63000,4549.70000,Aetna,First Health,,12833.30,,,,,,,5051.74,12833.30,percent of total billed charges,
BASEPLATE,7948368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,4451.45,10100.66,percent of total billed charges,
BASEPLATE,7948368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,3976.06,10100.66,percent of total billed charges,
BASEPLATE,7956675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,4451.45,10100.66,percent of total billed charges,
BASEPLATE,7956675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,3976.06,10100.66,percent of total billed charges,
BASEPLATE,7962615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,4451.45,10100.66,percent of total billed charges,
BASEPLATE,7962615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,3976.06,10100.66,percent of total billed charges,
HUMERAL HEAD,7822261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
HUMERAL HEAD,7822261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
HUMERAL HEAD,7880529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
HUMERAL HEAD,7880529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ROD,7700196,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7700196,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
PLATE,7701882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2406.80000,697.97000,Aetna,First Health,,1968.76,,,,,,,867.65,1968.76,percent of total billed charges,
PLATE,7701882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2406.80000,697.97000,Aetna,First Health,,1968.76,,,,,,,774.99,1968.76,percent of total billed charges,
PLATE,7786158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1776.60000,515.21000,Aetna,First Health,,1453.26,,,,,,,640.46,1453.26,percent of total billed charges,
PLATE,7786158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1776.60000,515.21000,Aetna,First Health,,1453.26,,,,,,,572.07,1453.26,percent of total billed charges,
LINER,7700866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5669.30000,1644.10000,Aetna,First Health,,4637.49,,,,,,,2043.78,4637.49,percent of total billed charges,
LINER,7700866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5669.30000,1644.10000,Aetna,First Health,,4637.49,,,,,,,1825.51,4637.49,percent of total billed charges,
BONE PLUG,7700252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
BONE PLUG,7700252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
HUMERAL HEAD,7702134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,7702134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
HUMERAL HEAD,7794451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,7794451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
HUMERAL HEAD,7812181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,7812181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
HUMERAL HEAD,7882610,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,7882610,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
HUMERAL HEAD,7902537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,7902537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
HUMERAL HEAD,7926933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,7926933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
HUMERAL HEAD,7936196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,7936196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
COMPONENT FEMORAL,7701603,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7701603,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7766061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7766061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7794050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7794050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7794299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7794299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7812121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7812121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7828048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7828048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7830040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7830040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7838124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7838124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7846156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7846156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7878475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7878475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7878552,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7878552,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7882728,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7882728,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,7698941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7698941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7698943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7698943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7699581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7699581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7699646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7699646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
SCREW,7699647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7699647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
SCREW,7700267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7700267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
SCREW,7707548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7707548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
SCREW,7902106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7902106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
SCREW,7902107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7902107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
SCREW,7905474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,7905474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
SCREW,7954357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7954357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,7964526,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7964526,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,7703104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7703104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7703106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7703106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7754291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7754291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7754293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7754293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
CAGE,7937745,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CAGE,7937745,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
INSERT,7700323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7700323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7701685,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7701685,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7740555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7740555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7742042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7742042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7768029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7768029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7816139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7816139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7866102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7866102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7903719,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7903719,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7908502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7908502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7910288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
INSERT,7910288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
INSERT,7911006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7911006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7917306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7917306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7919060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7919060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7925925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7925925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7933646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7933646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7935070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7935070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7935106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7935106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7959512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
INSERT,7959512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
WEDGE,7736549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1491.35,3383.98,percent of total billed charges,
WEDGE,7736549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1332.08,3383.98,percent of total billed charges,
WEDGE,7816138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1491.35,3383.98,percent of total billed charges,
WEDGE,7816138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1332.08,3383.98,percent of total billed charges,
WEDGE,7854030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1491.35,3383.98,percent of total billed charges,
WEDGE,7854030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1332.08,3383.98,percent of total billed charges,
ROD,7844037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,1128.84,percent of total billed charges,
ROD,7844037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,444.36,1128.84,percent of total billed charges,
PLATE,7772039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.80000,525.71000,Aetna,First Health,,1482.87,,,,,,,653.51,1482.87,percent of total billed charges,
PLATE,7772039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.80000,525.71000,Aetna,First Health,,1482.87,,,,,,,583.72,1482.87,percent of total billed charges,
PLATE,7700334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
PLATE,7700334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
PLATE,7700387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,906.62000,262.92000,Aetna,First Health,,741.62,,,,,,,326.84,741.62,percent of total billed charges,
PLATE,7700387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,906.62000,262.92000,Aetna,First Health,,741.62,,,,,,,291.93,741.62,percent of total billed charges,
PLATE,7784183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1439.60000,417.48000,Aetna,First Health,,1177.59,,,,,,,518.98,1177.59,percent of total billed charges,
PLATE,7784183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1439.60000,417.48000,Aetna,First Health,,1177.59,,,,,,,463.55,1177.59,percent of total billed charges,
PLATE,7700339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.50000,184.00000,Aetna,First Health,,519.02,,,,,,,228.74,519.02,percent of total billed charges,
PLATE,7700339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.50000,184.00000,Aetna,First Health,,519.02,,,,,,,204.31,519.02,percent of total billed charges,
PLATE,7701836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1298.00000,376.42000,Aetna,First Health,,1061.76,,,,,,,467.93,1061.76,percent of total billed charges,
PLATE,7701836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1298.00000,376.42000,Aetna,First Health,,1061.76,,,,,,,417.96,1061.76,percent of total billed charges,
PLATE,7701837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,477.45,1083.36,percent of total billed charges,
PLATE,7701837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,426.46,1083.36,percent of total billed charges,
PLATE,7701840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1298.00000,376.42000,Aetna,First Health,,1061.76,,,,,,,467.93,1061.76,percent of total billed charges,
PLATE,7701840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1298.00000,376.42000,Aetna,First Health,,1061.76,,,,,,,417.96,1061.76,percent of total billed charges,
PLATE,7701852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,477.45,1083.36,percent of total billed charges,
PLATE,7701852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,426.46,1083.36,percent of total billed charges,
PLATE,7701853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,477.45,1083.36,percent of total billed charges,
PLATE,7701853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,426.46,1083.36,percent of total billed charges,
PLATE,7701854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,477.45,1083.36,percent of total billed charges,
PLATE,7701854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,426.46,1083.36,percent of total billed charges,
PLATE,7701855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,477.45,1083.36,percent of total billed charges,
PLATE,7701855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,426.46,1083.36,percent of total billed charges,
PLATE,7701856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,477.45,1083.36,percent of total billed charges,
PLATE,7701856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,426.46,1083.36,percent of total billed charges,
PLATE,7701857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,477.45,1083.36,percent of total billed charges,
PLATE,7701857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,First Health,,1083.36,,,,,,,426.46,1083.36,percent of total billed charges,
PLATE,7701858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,First Health,,1094.16,,,,,,,482.20,1094.16,percent of total billed charges,
PLATE,7701858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,First Health,,1094.16,,,,,,,430.71,1094.16,percent of total billed charges,
PLATE,7701859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,First Health,,1094.16,,,,,,,482.20,1094.16,percent of total billed charges,
PLATE,7701859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,First Health,,1094.16,,,,,,,430.71,1094.16,percent of total billed charges,
PLATE,7701860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,First Health,,1094.16,,,,,,,482.20,1094.16,percent of total billed charges,
PLATE,7701860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,First Health,,1094.16,,,,,,,430.71,1094.16,percent of total billed charges,
PLATE,7701861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,First Health,,1094.16,,,,,,,482.20,1094.16,percent of total billed charges,
PLATE,7701861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,First Health,,1094.16,,,,,,,430.71,1094.16,percent of total billed charges,
PLATE,7882264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2781.96000,806.77000,Aetna,First Health,,2275.64,,,,,,,1002.90,2275.64,percent of total billed charges,
PLATE,7882264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2781.96000,806.77000,Aetna,First Health,,2275.64,,,,,,,895.79,2275.64,percent of total billed charges,
PLATE,7897103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2781.96000,806.77000,Aetna,First Health,,2275.64,,,,,,,1002.90,2275.64,percent of total billed charges,
PLATE,7897103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2781.96000,806.77000,Aetna,First Health,,2275.64,,,,,,,895.79,2275.64,percent of total billed charges,
SCREW,7700863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
SCREW,7700863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
SCREW,7840033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7840033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7838126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7838126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7918567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7918567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7918559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7918559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
PLATE,7701577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7976.13000,2313.08000,Aetna,First Health,,6524.47,,,,,,,2875.39,6524.47,percent of total billed charges,
PLATE,7701577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7976.13000,2313.08000,Aetna,First Health,,6524.47,,,,,,,2568.31,6524.47,percent of total billed charges,
COMPONENT FEMORAL,7748758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7748758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7790501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7790501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7828137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7828137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7838062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7838062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7838114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7838114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7880438,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16243.88000,4710.73000,Aetna,First Health,,13287.49,,,,,,,5855.92,13287.49,percent of total billed charges,
COMPONENT FEMORAL,7880438,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16243.88000,4710.73000,Aetna,First Health,,13287.49,,,,,,,5230.53,13287.49,percent of total billed charges,
COMPONENT FEMORAL,7882516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7882516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7882518,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7882518,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7902616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7902616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE,7748759,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
BASEPLATE,7748759,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
BASEPLATE,7790500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
BASEPLATE,7790500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
BASEPLATE,7810065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
BASEPLATE,7810065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
BASEPLATE,7828058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
BASEPLATE,7828058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
BASEPLATE,7828061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
BASEPLATE,7828061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,7701034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7701034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7701560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7701560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7748760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7748760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7788032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7788032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7828139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7828139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7880201,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7880201,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7880437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7880437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7882517,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7882517,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7893305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7893305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7893721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7893721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7902617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7902617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7920375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7920375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7940853,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7940853,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7964529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7964529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT PATELLA,7806234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,7806234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
COMPONENT PATELLA,7828138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,7828138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
COMPONENT PATELLA,7840031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,7840031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
COMPONENT PATELLA,7880555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,7880555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
COMPONENT PATELLA,7882729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,7882729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
PLATE,7700408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3324.30000,964.05000,Aetna,First Health,,2719.28,,,,,,,1198.41,2719.28,percent of total billed charges,
PLATE,7700408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3324.30000,964.05000,Aetna,First Health,,2719.28,,,,,,,1070.42,2719.28,percent of total billed charges,
PLATE,7700555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2488.40000,721.64000,Aetna,First Health,,2035.51,,,,,,,897.07,2035.51,percent of total billed charges,
PLATE,7700555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2488.40000,721.64000,Aetna,First Health,,2035.51,,,,,,,801.26,2035.51,percent of total billed charges,
PLATE,7806346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,870.20,1974.55,percent of total billed charges,
PLATE,7806346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,777.27,1974.55,percent of total billed charges,
PLATE,7874187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2475.20000,717.81000,Aetna,First Health,,2024.71,,,,,,,892.31,2024.71,percent of total billed charges,
PLATE,7874187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2475.20000,717.81000,Aetna,First Health,,2024.71,,,,,,,797.01,2024.71,percent of total billed charges,
PLATE,7896386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2488.40000,721.64000,Aetna,First Health,,2035.51,,,,,,,897.07,2035.51,percent of total billed charges,
PLATE,7896386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2488.40000,721.64000,Aetna,First Health,,2035.51,,,,,,,801.26,2035.51,percent of total billed charges,
BASEPLATE,7736350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7736350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7748075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7748075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7748737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7748737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7748831,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BASEPLATE,7748831,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BASEPLATE,7748896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7748896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7766058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BASEPLATE,7766058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BASEPLATE,7766062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7766062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7794049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7794049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7800038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7800038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7802090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BASEPLATE,7802090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BASEPLATE,7806369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BASEPLATE,7806369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BASEPLATE,7808035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7808035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7810031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7810031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7812119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7812119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7878320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BASEPLATE,7878320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BASEPLATE,7878324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BASEPLATE,7878324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BASEPLATE,7880525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7880525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7880672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BASEPLATE,7880672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BASEPLATE,7900094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BASEPLATE,7900094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
COMPONENT FEMORAL,7736220,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2691.85,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7736220,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2404.37,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7748199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2691.85,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7748199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2404.37,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7750086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2691.85,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7750086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2404.37,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7754103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2691.85,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7754103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2404.37,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7766056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2691.85,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7766056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2404.37,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7794294,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2691.85,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7794294,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2404.37,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7802061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2691.85,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7802061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2404.37,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7814062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2691.85,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7814062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2404.37,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7834074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2691.85,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7834074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2404.37,6108.01,percent of total billed charges,
STEM,7750088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7750088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
STEM,7786157,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7786157,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
STEM,7790170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7790170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
STEM,7802062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7802062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
STEM,7806297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7806297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
STEM,7822258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7822258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
STEM,7836185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7836185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
STEM,7878199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7878199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
STEM,7878331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7878331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
STEM,7901764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7901764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
PIN,7700431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,708.30000,205.41000,Aetna,First Health,,579.39,,,,,,,255.34,579.39,percent of total billed charges,
PIN,7700431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,708.30000,205.41000,Aetna,First Health,,579.39,,,,,,,228.07,579.39,percent of total billed charges,
PIN,7927063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,179.80,407.98,percent of total billed charges,
PIN,7927063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,160.60,407.98,percent of total billed charges,
INSERT,7750118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7750118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7760130,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7760130,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7804046,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7804046,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7804048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7804048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7810067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7810067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7828059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7828059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7828062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7828062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7834112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7834112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7836190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7836190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7874295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7874295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7880647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7880647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7882803,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7882803,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7893609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.60000,2523.17000,Aetna,First Health,,7117.09,,,,,,,3136.57,7117.09,percent of total billed charges,
INSERT,7893609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.60000,2523.17000,Aetna,First Health,,7117.09,,,,,,,2801.59,7117.09,percent of total billed charges,
INSERT,7896392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7896392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7896750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7896750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7937936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7937936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7937937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7937937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7939864,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7939864,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7939865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7939865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
PLATE,7701814,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,739.17,1677.23,percent of total billed charges,
PLATE,7701814,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,660.23,1677.23,percent of total billed charges,
PLATE,7701819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,739.17,1677.23,percent of total billed charges,
PLATE,7701819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,660.23,1677.23,percent of total billed charges,
PLATE,7701821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,739.17,1677.23,percent of total billed charges,
PLATE,7701821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,660.23,1677.23,percent of total billed charges,
PLATE,7701879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,701.10,1590.85,percent of total billed charges,
PLATE,7701879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,626.23,1590.85,percent of total billed charges,
PLATE,7700461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,277.40,629.45,percent of total billed charges,
PLATE,7700461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,247.78,629.45,percent of total billed charges,
PLATE,7702400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,940.23000,272.67000,Aetna,First Health,,769.11,,,,,,,338.95,769.11,percent of total billed charges,
PLATE,7702400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,940.23000,272.67000,Aetna,First Health,,769.11,,,,,,,302.75,769.11,percent of total billed charges,
BALLOON CATHETER,7696414,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON CATHETER,7696414,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON CATHETER,7696416,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON CATHETER,7696416,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
GRAFT,7699808,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,1749.40000,507.33000,Aetna,First Health,,1431.01,,,,,,,630.66,1431.01,percent of total billed charges,
GRAFT,7699808,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,1749.40000,507.33000,Aetna,First Health,,1431.01,,,,,,,563.31,1431.01,percent of total billed charges,
STEM,7697896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2810.33,6376.84,percent of total billed charges,
STEM,7697896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,First Health,,6376.84,,,,,,,2510.20,6376.84,percent of total billed charges,
COMPONENT PATELLA,7699291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2984.00000,865.36000,Aetna,First Health,,2440.91,,,,,,,1075.73,2440.91,percent of total billed charges,
COMPONENT PATELLA,7699291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2984.00000,865.36000,Aetna,First Health,,2440.91,,,,,,,960.85,2440.91,percent of total billed charges,
TAPER,7696726,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
TAPER,7696726,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
NAIL,7699854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14143.50000,4101.62000,Aetna,First Health,,11569.38,,,,,,,5098.73,11569.38,percent of total billed charges,
NAIL,7699854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14143.50000,4101.62000,Aetna,First Health,,11569.38,,,,,,,4554.21,11569.38,percent of total billed charges,
GUIDEWIRE,7699857,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,661.50000,191.83000,Aetna,First Health,,541.11,,,,,,,238.47,541.11,percent of total billed charges,
GUIDEWIRE,7699857,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,661.50000,191.83000,Aetna,First Health,,541.11,,,,,,,213.00,541.11,percent of total billed charges,
STEM,7699866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17514.75000,5079.28000,Aetna,First Health,,14327.07,,,,,,,6314.07,14327.07,percent of total billed charges,
STEM,7699866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17514.75000,5079.28000,Aetna,First Health,,14327.07,,,,,,,5639.75,14327.07,percent of total billed charges,
SEGMENT,7699865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10274.40000,2979.58000,Aetna,First Health,,8404.46,,,,,,,3703.92,8404.46,percent of total billed charges,
SEGMENT,7699865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10274.40000,2979.58000,Aetna,First Health,,8404.46,,,,,,,3308.36,8404.46,percent of total billed charges,
BREAST IMPLANT,7699357,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
BREAST IMPLANT,7699357,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
COIL,7699871,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5509.00000,1597.61000,Aetna,First Health,,4506.36,,,,,,,1985.99,4506.36,percent of total billed charges,
COIL,7699871,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5509.00000,1597.61000,Aetna,First Health,,4506.36,,,,,,,1773.90,4506.36,percent of total billed charges,
ACETABULAR CUP,7699901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,7699901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
COMPONENT FEMORAL,7699905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25177.25000,7301.40000,Aetna,First Health,,20594.99,,,,,,,9076.40,20594.99,percent of total billed charges,
COMPONENT FEMORAL,7699905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25177.25000,7301.40000,Aetna,First Health,,20594.99,,,,,,,8107.07,20594.99,percent of total billed charges,
STEM EXTENSION,7699906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM EXTENSION,7699906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
INSERT,7699909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1914.00000,555.06000,Aetna,First Health,,1565.65,,,,,,,690.00,1565.65,percent of total billed charges,
INSERT,7699909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1914.00000,555.06000,Aetna,First Health,,1565.65,,,,,,,616.31,1565.65,percent of total billed charges,
STEM COLLAR,7699910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7982.22000,2314.84000,Aetna,First Health,,6529.46,,,,,,,2877.59,6529.46,percent of total billed charges,
STEM COLLAR,7699910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7982.22000,2314.84000,Aetna,First Health,,6529.46,,,,,,,2570.27,6529.46,percent of total billed charges,
COIL,7699900,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,850.50000,246.64000,Aetna,First Health,,695.71,,,,,,,306.61,695.71,percent of total billed charges,
COIL,7699900,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,850.50000,246.64000,Aetna,First Health,,695.71,,,,,,,273.86,695.71,percent of total billed charges,
CABLE,7696285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2143.88000,621.73000,Aetna,First Health,,1753.69,,,,,,,772.87,1753.69,percent of total billed charges,
CABLE,7696285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2143.88000,621.73000,Aetna,First Health,,1753.69,,,,,,,690.33,1753.69,percent of total billed charges,
INSERT,7698024,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,4392.57,9967.04,percent of total billed charges,
INSERT,7698024,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,First Health,,9967.04,,,,,,,3923.46,9967.04,percent of total billed charges,
WEDGE,7698467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7698467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
SHELL,7698497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
SHELL,7698497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
STEM,7698499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7698499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
COUPLER,7698051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3764.25000,1091.63000,Aetna,First Health,,3079.16,,,,,,,1357.01,3079.16,percent of total billed charges,
COUPLER,7698051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3764.25000,1091.63000,Aetna,First Health,,3079.16,,,,,,,1212.09,3079.16,percent of total billed charges,
WEDGE,7698052,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7698052,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
BASEPLATE,7697615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7697615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
PATELLA IMPLANT,7695604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
PATELLA IMPLANT,7695604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT TIBIAL,7695293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
COMPONENT TIBIAL,7695293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
PEG,7697520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
PEG,7697520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
CAGE,7696532,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,4078.34,9254.03,percent of total billed charges,
CAGE,7696532,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,First Health,,9254.03,,,,,,,3642.79,9254.03,percent of total billed charges,
SCREW,7696545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1554.48,3527.22,percent of total billed charges,
SCREW,7696545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,First Health,,3527.22,,,,,,,1388.46,3527.22,percent of total billed charges,
FEMORAL HEAD 20,7699941,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD 20,7699941,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
STEM COLLAR,7699939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9409.02000,2728.62000,Aetna,First Health,,7696.58,,,,,,,3391.95,7696.58,percent of total billed charges,
STEM COLLAR,7699939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9409.02000,2728.62000,Aetna,First Health,,7696.58,,,,,,,3029.70,7696.58,percent of total billed charges,
TAPER,7697030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,864.00000,250.56000,Aetna,First Health,,706.75,,,,,,,311.47,706.75,percent of total billed charges,
TAPER,7697030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,864.00000,250.56000,Aetna,First Health,,706.75,,,,,,,278.21,706.75,percent of total billed charges,
HIP MODULAR,7699289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
HIP MODULAR,7699289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
COMPONENT FEMORAL,7697457,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6916.19,15693.33,percent of total billed charges,
COMPONENT FEMORAL,7697457,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,First Health,,15693.33,,,,,,,6177.57,15693.33,percent of total billed charges,
INSERT,7697924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2890.63,6559.05,percent of total billed charges,
INSERT,7697924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,First Health,,6559.05,,,,,,,2581.92,6559.05,percent of total billed charges,
COMPONENT FEMORAL,7699935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4515.97,10247.05,percent of total billed charges,
COMPONENT FEMORAL,7699935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4033.68,10247.05,percent of total billed charges,
COMPONENT FEMORAL,7699937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19850.33000,5756.60000,Aetna,First Health,,16237.57,,,,,,,7156.04,16237.57,percent of total billed charges,
COMPONENT FEMORAL,7699937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19850.33000,5756.60000,Aetna,First Health,,16237.57,,,,,,,6391.81,16237.57,percent of total billed charges,
WASHER,7699940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5198.20000,1507.48000,Aetna,First Health,,4252.13,,,,,,,1873.95,4252.13,percent of total billed charges,
WASHER,7699940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5198.20000,1507.48000,Aetna,First Health,,4252.13,,,,,,,1673.82,4252.13,percent of total billed charges,
CERAMIC HEAD,7699955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
CERAMIC HEAD,7699955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SLEEVE,7697894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12922.20000,3747.44000,Aetna,First Health,,10570.36,,,,,,,4658.45,10570.36,percent of total billed charges,
SLEEVE,7697894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12922.20000,3747.44000,Aetna,First Health,,10570.36,,,,,,,4160.95,10570.36,percent of total billed charges,
INSERT,7698050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7698050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
LINER,7697880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
LINER,7697880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
PENILE IMPLANT,7699973,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
PENILE IMPLANT,7699973,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
ASSEMBLY KIT,7699975,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,2560.00000,742.40000,Aetna,First Health,,2094.08,,,,,,,922.88,2094.08,percent of total billed charges,
ASSEMBLY KIT,7699975,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,2560.00000,742.40000,Aetna,First Health,,2094.08,,,,,,,824.32,2094.08,percent of total billed charges,
GUIDEWIRE,7694358,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,293.63,666.26,percent of total billed charges,
GUIDEWIRE,7694358,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,262.27,666.26,percent of total billed charges,
COIL,7700001,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1902.00000,551.58000,Aetna,First Health,,1555.84,,,,,,,685.67,1555.84,percent of total billed charges,
COIL,7700001,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1902.00000,551.58000,Aetna,First Health,,1555.84,,,,,,,612.44,1555.84,percent of total billed charges,
COIL,7700003,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,2114.00000,613.06000,Aetna,First Health,,1729.25,,,,,,,762.10,1729.25,percent of total billed charges,
COIL,7700003,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,2114.00000,613.06000,Aetna,First Health,,1729.25,,,,,,,680.71,1729.25,percent of total billed charges,
COIL,7700004,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,2366.00000,686.14000,Aetna,First Health,,1935.39,,,,,,,852.94,1935.39,percent of total billed charges,
COIL,7700004,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,2366.00000,686.14000,Aetna,First Health,,1935.39,,,,,,,761.85,1935.39,percent of total billed charges,
EMBOSPHERE,7699998,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,485.06,1100.64,percent of total billed charges,
EMBOSPHERE,7699998,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,433.26,1100.64,percent of total billed charges,
BONE CHIPS,7699980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,544.72,1236.00,percent of total billed charges,
BONE CHIPS,7699980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,486.54,1236.00,percent of total billed charges,
PLATE,7700008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2631.12000,763.02000,Aetna,First Health,,2152.26,,,,,,,948.52,2152.26,percent of total billed charges,
PLATE,7700008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2631.12000,763.02000,Aetna,First Health,,2152.26,,,,,,,847.22,2152.26,percent of total billed charges,
FEMORAL HEAD,7698954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
FEMORAL HEAD,7698954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
LINER,7700021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7700021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
PLATE,7696428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,448.35000,130.02000,Aetna,First Health,,366.75,,,,,,,161.63,366.75,percent of total billed charges,
PLATE,7696428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,448.35000,130.02000,Aetna,First Health,,366.75,,,,,,,144.37,366.75,percent of total billed charges,
PLATE,7700041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7625.13000,2211.29000,Aetna,First Health,,6237.36,,,,,,,2748.86,6237.36,percent of total billed charges,
PLATE,7700041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7625.13000,2211.29000,Aetna,First Health,,6237.36,,,,,,,2455.29,6237.36,percent of total billed charges,
INSERT,7700061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1137.20,2580.40,percent of total billed charges,
INSERT,7700061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1015.76,2580.40,percent of total billed charges,
ACETABULAR CUP,7700063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2365.78,5368.12,percent of total billed charges,
ACETABULAR CUP,7700063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2113.12,5368.12,percent of total billed charges,
INSERT,7699293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7699293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
FEMORAL HEAD,7698288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7698288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
BASEPLATE,7700055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5109.30000,1481.70000,Aetna,First Health,,4179.41,,,,,,,1841.90,4179.41,percent of total billed charges,
BASEPLATE,7700055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5109.30000,1481.70000,Aetna,First Health,,4179.41,,,,,,,1645.19,4179.41,percent of total billed charges,
CUP,7700060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1906.06,4325.00,percent of total billed charges,
CUP,7700060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,First Health,,4325.00,,,,,,,1702.50,4325.00,percent of total billed charges,
TENDON,7700073,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
TENDON,7700073,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
STENT GRAFT,7700085,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14583.00000,4229.07000,Aetna,First Health,,11928.89,,,,,,,5257.17,11928.89,percent of total billed charges,
STENT GRAFT,7700085,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14583.00000,4229.07000,Aetna,First Health,,11928.89,,,,,,,4695.73,11928.89,percent of total billed charges,
ACUTE AC REPAIR SYSTEM,7700078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4921.88000,1427.35000,Aetna,First Health,,4026.10,,,,,,,1774.34,4026.10,percent of total billed charges,
ACUTE AC REPAIR SYSTEM,7700078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4921.88000,1427.35000,Aetna,First Health,,4026.10,,,,,,,1584.85,4026.10,percent of total billed charges,
LEAD,7784548,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
LEAD,7784548,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
PLATE,7700093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1358.68000,394.02000,Aetna,First Health,,1111.40,,,,,,,489.80,1111.40,percent of total billed charges,
PLATE,7700093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1358.68000,394.02000,Aetna,First Health,,1111.40,,,,,,,437.49,1111.40,percent of total billed charges,
GUIDEWIRE,7694996,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,293.63,666.26,percent of total billed charges,
GUIDEWIRE,7694996,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,262.27,666.26,percent of total billed charges,
GLENOSPHERE,7700102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
GLENOSPHERE,7700102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
INSERT,7698313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7698313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
HUMERAL ADAPTER TRAY,7700105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2365.78,5368.12,percent of total billed charges,
HUMERAL ADAPTER TRAY,7700105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2113.12,5368.12,percent of total billed charges,
STEM,7700110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM,7700110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
STENT,7948896,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7948896,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
LINER,7700119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7700119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
PLATE,7695862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1246.96000,361.62000,Aetna,First Health,,1020.01,,,,,,,449.53,1020.01,percent of total billed charges,
PLATE,7695862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1246.96000,361.62000,Aetna,First Health,,1020.01,,,,,,,401.52,1020.01,percent of total billed charges,
PLATE,7700143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1899.20000,550.77000,Aetna,First Health,,1553.55,,,,,,,684.66,1553.55,percent of total billed charges,
PLATE,7700143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1899.20000,550.77000,Aetna,First Health,,1553.55,,,,,,,611.54,1553.55,percent of total billed charges,
LINER,7700146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
LINER,7700146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
STEM EXTENSION,7700155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15410.25000,4468.97000,Aetna,First Health,,12605.58,,,,,,,5555.40,12605.58,percent of total billed charges,
STEM EXTENSION,7700155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15410.25000,4468.97000,Aetna,First Health,,12605.58,,,,,,,4962.10,12605.58,percent of total billed charges,
IMPLANT HEAD,7700147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1855.02,4209.18,percent of total billed charges,
IMPLANT HEAD,7700147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1656.92,4209.18,percent of total billed charges,
PLATE,7702975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2022.84000,586.62000,Aetna,First Health,,1654.68,,,,,,,729.23,1654.68,percent of total billed charges,
PLATE,7702975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2022.84000,586.62000,Aetna,First Health,,1654.68,,,,,,,651.35,1654.68,percent of total billed charges,
INSERT,7699267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2389.25,5421.38,percent of total billed charges,
INSERT,7699267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2134.09,5421.38,percent of total billed charges,
AUGMENT FEMORAL,7699266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1337.71,3035.35,percent of total billed charges,
AUGMENT FEMORAL,7699266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1194.85,3035.35,percent of total billed charges,
CATHETER,7700180,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2026.20000,587.60000,Aetna,First Health,,1657.43,,,,,,,730.45,1657.43,percent of total billed charges,
CATHETER,7700180,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2026.20000,587.60000,Aetna,First Health,,1657.43,,,,,,,652.44,1657.43,percent of total billed charges,
BASEPLATE,7699492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,4451.45,10100.66,percent of total billed charges,
BASEPLATE,7699492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,First Health,,10100.66,,,,,,,3976.06,10100.66,percent of total billed charges,
ROD,7698424,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3158.92000,916.09000,Aetna,First Health,,2584.00,,,,,,,1138.79,2584.00,percent of total billed charges,
ROD,7698424,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3158.92000,916.09000,Aetna,First Health,,2584.00,,,,,,,1017.17,2584.00,percent of total billed charges,
PLATE,7736638,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3483.90000,1010.33000,Aetna,First Health,,2849.83,,,,,,,1255.95,2849.83,percent of total billed charges,
PLATE,7736638,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3483.90000,1010.33000,Aetna,First Health,,2849.83,,,,,,,1121.82,2849.83,percent of total billed charges,
MESH,7700218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5447.68000,1579.83000,Aetna,First Health,,4456.20,,,,,,,1963.89,4456.20,percent of total billed charges,
MESH,7700218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5447.68000,1579.83000,Aetna,First Health,,4456.20,,,,,,,1754.15,4456.20,percent of total billed charges,
PLATE,7700219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1269.48000,368.15000,Aetna,First Health,,1038.43,,,,,,,457.65,1038.43,percent of total billed charges,
PLATE,7700219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1269.48000,368.15000,Aetna,First Health,,1038.43,,,,,,,408.77,1038.43,percent of total billed charges,
CONNECTING NUT,7700204,CDM,278,RC,,,,,facility,inpatient,,,153.83000,44.61000,Aetna,First Health,,125.83,,,,,,,55.46,125.83,percent of total billed charges,
CONNECTING NUT,7700204,CDM,278,RC,,,,,facility,outpatient,,,153.83000,44.61000,Aetna,First Health,,125.83,,,,,,,49.53,125.83,percent of total billed charges,
WASHER,7700209,CDM,278,RC,,,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
WASHER,7700209,CDM,278,RC,,,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
WIRE,7700211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,730.35000,211.80000,Aetna,First Health,,597.43,,,,,,,263.29,597.43,percent of total billed charges,
WIRE,7700211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,730.35000,211.80000,Aetna,First Health,,597.43,,,,,,,235.17,597.43,percent of total billed charges,
PLATE,7700229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1529.36000,443.51000,Aetna,First Health,,1251.02,,,,,,,551.33,1251.02,percent of total billed charges,
PLATE,7700229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1529.36000,443.51000,Aetna,First Health,,1251.02,,,,,,,492.45,1251.02,percent of total billed charges,
BONE GRAFT,7700239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4945.50000,1434.20000,Aetna,First Health,,4045.42,,,,,,,1782.85,4045.42,percent of total billed charges,
BONE GRAFT,7700239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4945.50000,1434.20000,Aetna,First Health,,4045.42,,,,,,,1592.45,4045.42,percent of total billed charges,
LINER,7700244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5669.30000,1644.10000,Aetna,First Health,,4637.49,,,,,,,2043.78,4637.49,percent of total billed charges,
LINER,7700244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5669.30000,1644.10000,Aetna,First Health,,4637.49,,,,,,,1825.51,4637.49,percent of total billed charges,
BONE PLUG,7699287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
BONE PLUG,7699287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
PLATE,7700254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.76000,568.62000,Aetna,First Health,,1603.90,,,,,,,706.85,1603.90,percent of total billed charges,
PLATE,7700254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.76000,568.62000,Aetna,First Health,,1603.90,,,,,,,631.36,1603.90,percent of total billed charges,
LINER,7700242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1606.00000,465.74000,Aetna,First Health,,1313.71,,,,,,,578.96,1313.71,percent of total billed charges,
LINER,7700242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1606.00000,465.74000,Aetna,First Health,,1313.71,,,,,,,517.13,1313.71,percent of total billed charges,
COMPONENT GLENOID,7700247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
COMPONENT GLENOID,7700247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
HUMERAL HEAD,7700248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,7700248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
COMPONENT FEMORAL,7700253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COMPONENT FEMORAL,7700253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,7698940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7698940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7700315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7700315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
CAGE,7700316,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CAGE,7700316,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
INSERT,7698721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7698721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
WEDGE,7700325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1491.35,3383.98,percent of total billed charges,
WEDGE,7700325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1332.08,3383.98,percent of total billed charges,
BONE CEMENT,7700326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5091.70000,1476.59000,Aetna,First Health,,4165.01,,,,,,,1835.56,4165.01,percent of total billed charges,
BONE CEMENT,7700326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5091.70000,1476.59000,Aetna,First Health,,4165.01,,,,,,,1639.53,4165.01,percent of total billed charges,
PLATE,7700330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,83.28,188.96,percent of total billed charges,
PLATE,7700330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,74.38,188.96,percent of total billed charges,
PLATE,7700333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,828.00000,240.12000,Aetna,First Health,,677.30,,,,,,,298.49,677.30,percent of total billed charges,
PLATE,7700333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,828.00000,240.12000,Aetna,First Health,,677.30,,,,,,,266.62,677.30,percent of total billed charges,
MESH,7700336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6142.50000,1781.32000,Aetna,First Health,,5024.56,,,,,,,2214.37,5024.56,percent of total billed charges,
MESH,7700336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6142.50000,1781.32000,Aetna,First Health,,5024.56,,,,,,,1977.88,5024.56,percent of total billed charges,
PLATE,7700337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,507.58,1151.74,percent of total billed charges,
PLATE,7700337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,453.38,1151.74,percent of total billed charges,
PLATE,7700338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,First Health,,1092.85,,,,,,,481.63,1092.85,percent of total billed charges,
PLATE,7700338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,First Health,,1092.85,,,,,,,430.19,1092.85,percent of total billed charges,
PLATE,7700343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
PLATE,7700343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
PLATE,7700374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9966.00000,2890.14000,Aetna,First Health,,8152.19,,,,,,,3592.74,8152.19,percent of total billed charges,
PLATE,7700374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9966.00000,2890.14000,Aetna,First Health,,8152.19,,,,,,,3209.05,8152.19,percent of total billed charges,
BONE CHIPS,7694931,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3194.00000,926.26000,Aetna,First Health,,2612.69,,,,,,,1151.44,2612.69,percent of total billed charges,
BONE CHIPS,7694931,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3194.00000,926.26000,Aetna,First Health,,2612.69,,,,,,,1028.47,2612.69,percent of total billed charges,
SCREW,7700394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,791.42000,229.51000,Aetna,First Health,,647.38,,,,,,,285.31,647.38,percent of total billed charges,
SCREW,7700394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,791.42000,229.51000,Aetna,First Health,,647.38,,,,,,,254.84,647.38,percent of total billed charges,
PLATE,7700397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7976.13000,2313.08000,Aetna,First Health,,6524.47,,,,,,,2875.39,6524.47,percent of total billed charges,
PLATE,7700397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7976.13000,2313.08000,Aetna,First Health,,6524.47,,,,,,,2568.31,6524.47,percent of total billed charges,
COMPONENT FEMORAL,7700402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7700402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE,7700403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
BASEPLATE,7700403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,7700404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7700404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT PATELLA,7700405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,7700405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
BASEPLATE,7700413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7700413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
COMPONENT FEMORAL,7700420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2691.85,6108.01,percent of total billed charges,
COMPONENT FEMORAL,7700420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,First Health,,6108.01,,,,,,,2404.37,6108.01,percent of total billed charges,
TIBIAL TRAY,7700421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
TIBIAL TRAY,7700421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STEM,7700426,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,3328.32,7552.19,percent of total billed charges,
STEM,7700426,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,First Health,,7552.19,,,,,,,2972.86,7552.19,percent of total billed charges,
PIN,7694787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.20000,255.26000,Aetna,First Health,,720.00,,,,,,,317.31,720.00,percent of total billed charges,
PIN,7694787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.20000,255.26000,Aetna,First Health,,720.00,,,,,,,283.42,720.00,percent of total billed charges,
INSERT,7700434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7700434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
TISSUE BAND FIXATE,7700447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
TISSUE BAND FIXATE,7700447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
INSERT,7905030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7905030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
PLATE,7700455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,739.17,1677.23,percent of total billed charges,
PLATE,7700455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,First Health,,1677.23,,,,,,,660.23,1677.23,percent of total billed charges,
PLATE,7696431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,348.37000,101.03000,Aetna,First Health,,284.97,,,,,,,125.59,284.97,percent of total billed charges,
PLATE,7696431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,348.37000,101.03000,Aetna,First Health,,284.97,,,,,,,112.18,284.97,percent of total billed charges,
SPACER,7696554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10755.00000,3118.95000,Aetna,First Health,,8797.59,,,,,,,3877.18,8797.59,percent of total billed charges,
SPACER,7696554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10755.00000,3118.95000,Aetna,First Health,,8797.59,,,,,,,3463.11,8797.59,percent of total billed charges,
SHEATH,7700505,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,235.94,535.36,percent of total billed charges,
SHEATH,7700505,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,210.74,535.36,percent of total billed charges,
HOOK,7700513,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1406.85,3192.24,percent of total billed charges,
HOOK,7700513,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1256.61,3192.24,percent of total billed charges,
GRAFT,7700514,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8992.80000,2607.91000,Aetna,First Health,,7356.11,,,,,,,3241.90,7356.11,percent of total billed charges,
GRAFT,7700514,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8992.80000,2607.91000,Aetna,First Health,,7356.11,,,,,,,2895.68,7356.11,percent of total billed charges,
WEDGE,7698642,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7698642,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
GRAFT STENT,7700538,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21572.50000,6256.02000,Aetna,First Health,,17646.31,,,,,,,7776.89,17646.31,percent of total billed charges,
GRAFT STENT,7700538,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21572.50000,6256.02000,Aetna,First Health,,17646.31,,,,,,,6946.35,17646.31,percent of total billed charges,
PLATE,7700571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8017.29000,2325.01000,Aetna,First Health,,6558.14,,,,,,,2890.23,6558.14,percent of total billed charges,
PLATE,7700571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8017.29000,2325.01000,Aetna,First Health,,6558.14,,,,,,,2581.57,6558.14,percent of total billed charges,
PLATE,7940870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2680.56000,777.36000,Aetna,First Health,,2192.70,,,,,,,966.34,2192.70,percent of total billed charges,
PLATE,7940870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2680.56000,777.36000,Aetna,First Health,,2192.70,,,,,,,863.14,2192.70,percent of total billed charges,
SHEATH,7700589,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,352.03,798.78,percent of total billed charges,
SHEATH,7700589,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,314.43,798.78,percent of total billed charges,
WASHER,7699692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,344.38000,99.87000,Aetna,First Health,,281.70,,,,,,,124.15,281.70,percent of total billed charges,
WASHER,7699692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,344.38000,99.87000,Aetna,First Health,,281.70,,,,,,,110.89,281.70,percent of total billed charges,
WASHER,7700646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.45000,190.66000,Aetna,First Health,,537.79,,,,,,,237.01,537.79,percent of total billed charges,
WASHER,7700646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.45000,190.66000,Aetna,First Health,,537.79,,,,,,,211.70,537.79,percent of total billed charges,
END CAP,7695434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,703.98000,204.15000,Aetna,First Health,,575.86,,,,,,,253.78,575.86,percent of total billed charges,
END CAP,7695434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,703.98000,204.15000,Aetna,First Health,,575.86,,,,,,,226.68,575.86,percent of total billed charges,
SLEEVE,7736640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2262.12000,656.01000,Aetna,First Health,,1850.41,,,,,,,815.49,1850.41,percent of total billed charges,
SLEEVE,7736640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2262.12000,656.01000,Aetna,First Health,,1850.41,,,,,,,728.40,1850.41,percent of total billed charges,
AUGMENT FEMORAL,7700663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4179.35000,1212.01000,Aetna,First Health,,3418.71,,,,,,,1506.66,3418.71,percent of total billed charges,
AUGMENT FEMORAL,7700663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4179.35000,1212.01000,Aetna,First Health,,3418.71,,,,,,,1345.75,3418.71,percent of total billed charges,
SCREW,7696715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,305.07,692.22,percent of total billed charges,
SCREW,7696715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,272.49,692.22,percent of total billed charges,
GUIDEWIRE,7700717,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,70.03,158.90,percent of total billed charges,
GUIDEWIRE,7700717,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,62.55,158.90,percent of total billed charges,
FEMORAL HEAD,7699731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7699731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
INSERT,7700727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2936.27,6662.61,percent of total billed charges,
INSERT,7700727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2622.69,6662.61,percent of total billed charges,
PIN,7700747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PIN,7700747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PIN,7698607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.00000,206.19000,Aetna,First Health,,581.60,,,,,,,256.32,581.60,percent of total billed charges,
PIN,7698607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.00000,206.19000,Aetna,First Health,,581.60,,,,,,,228.94,581.60,percent of total billed charges,
PLATE,7700728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,475.25,1078.39,percent of total billed charges,
PLATE,7700728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,424.50,1078.39,percent of total billed charges,
SCREW,7695851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7695851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7693460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,680.98,1545.20,percent of total billed charges,
SCREW,7693460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,608.26,1545.20,percent of total billed charges,
IVC RETRIEVAL,7695049,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,665.84,1510.85,percent of total billed charges,
IVC RETRIEVAL,7695049,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,594.73,1510.85,percent of total billed charges,
STEM,7700833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9500.94000,2755.27000,Aetna,First Health,,7771.77,,,,,,,3425.09,7771.77,percent of total billed charges,
STEM,7700833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9500.94000,2755.27000,Aetna,First Health,,7771.77,,,,,,,3059.30,7771.77,percent of total billed charges,
FEMORAL HEAD,7698793,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7698793,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL IMPLANT,7700835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
FEMORAL IMPLANT,7700835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
AUGMENT FEMORAL,7700844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7700844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
SHELL,7700865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10671.60000,3094.76000,Aetna,First Health,,8729.37,,,,,,,3847.11,8729.37,percent of total billed charges,
SHELL,7700865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10671.60000,3094.76000,Aetna,First Health,,8729.37,,,,,,,3436.26,8729.37,percent of total billed charges,
WASHER,7700887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,178.50000,51.76000,Aetna,First Health,,146.01,,,,,,,64.35,146.01,percent of total billed charges,
WASHER,7700887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,178.50000,51.76000,Aetna,First Health,,146.01,,,,,,,57.48,146.01,percent of total billed charges,
FEMORAL HEAD,7700889,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7700889,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
CATHETER BALLOON,7700879,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1469.76000,426.23000,Aetna,First Health,,1202.26,,,,,,,529.85,1202.26,percent of total billed charges,
CATHETER BALLOON,7700879,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1469.76000,426.23000,Aetna,First Health,,1202.26,,,,,,,473.26,1202.26,percent of total billed charges,
LINER,7700908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6485.50000,1880.79000,Aetna,First Health,,5305.14,,,,,,,2338.02,5305.14,percent of total billed charges,
LINER,7700908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6485.50000,1880.79000,Aetna,First Health,,5305.14,,,,,,,2088.33,5305.14,percent of total billed charges,
PLATE,7700888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,430.40000,124.82000,Aetna,First Health,,352.07,,,,,,,155.16,352.07,percent of total billed charges,
PLATE,7700888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,430.40000,124.82000,Aetna,First Health,,352.07,,,,,,,138.59,352.07,percent of total billed charges,
SCREW,7700920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7700920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
PLATE,7700938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8568.00000,2484.72000,Aetna,First Health,,7008.62,,,,,,,3088.76,7008.62,percent of total billed charges,
PLATE,7700938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8568.00000,2484.72000,Aetna,First Health,,7008.62,,,,,,,2758.90,7008.62,percent of total billed charges,
END CAP,7700911,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,First Health,,501.06,,,,,,,220.82,501.06,percent of total billed charges,
END CAP,7700911,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,First Health,,501.06,,,,,,,197.24,501.06,percent of total billed charges,
STEM,7700952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7700952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
END CAP,7699820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
END CAP,7699820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
NAIL,7700018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
FEMORAL HEAD,7700953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5327.42000,1544.95000,Aetna,First Health,,4357.83,,,,,,,1920.53,4357.83,percent of total billed charges,
FEMORAL HEAD,7700953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5327.42000,1544.95000,Aetna,First Health,,4357.83,,,,,,,1715.43,4357.83,percent of total billed charges,
SCREW,7695285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
SCREW,7695285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
STENT GRAFT,7736632,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,4429.82,10051.58,percent of total billed charges,
STENT GRAFT,7736632,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,3956.74,10051.58,percent of total billed charges,
GUIDEWIRE,7695364,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,241.72,548.47,percent of total billed charges,
GUIDEWIRE,7695364,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,215.90,548.47,percent of total billed charges,
END CAP,7701069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,756.00000,219.24000,Aetna,First Health,,618.41,,,,,,,272.54,618.41,percent of total billed charges,
END CAP,7701069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,756.00000,219.24000,Aetna,First Health,,618.41,,,,,,,243.43,618.41,percent of total billed charges,
PLATE,7698366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3910.52000,1134.05000,Aetna,First Health,,3198.81,,,,,,,1409.74,3198.81,percent of total billed charges,
PLATE,7698366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3910.52000,1134.05000,Aetna,First Health,,3198.81,,,,,,,1259.19,3198.81,percent of total billed charges,
PLATE,7698733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,912.60000,264.65000,Aetna,First Health,,746.51,,,,,,,328.99,746.51,percent of total billed charges,
PLATE,7698733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,912.60000,264.65000,Aetna,First Health,,746.51,,,,,,,293.86,746.51,percent of total billed charges,
PLATE,7701022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1585.24000,459.72000,Aetna,First Health,,1296.73,,,,,,,571.48,1296.73,percent of total billed charges,
PLATE,7701022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1585.24000,459.72000,Aetna,First Health,,1296.73,,,,,,,510.45,1296.73,percent of total billed charges,
WASHER,7699710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
WASHER,7699710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
PLATE,7701179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,130.14,295.30,percent of total billed charges,
PLATE,7701179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,116.24,295.30,percent of total billed charges,
PLATE,7701027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3796.45000,1100.97000,Aetna,First Health,,3105.50,,,,,,,1368.62,3105.50,percent of total billed charges,
PLATE,7701027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3796.45000,1100.97000,Aetna,First Health,,3105.50,,,,,,,1222.46,3105.50,percent of total billed charges,
PLATE,7701033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.60000,3007.76000,Aetna,First Health,,8483.97,,,,,,,3738.96,8483.97,percent of total billed charges,
PLATE,7701033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.60000,3007.76000,Aetna,First Health,,8483.97,,,,,,,3339.66,8483.97,percent of total billed charges,
PLATE,7701036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8280.00000,2401.20000,Aetna,First Health,,6773.04,,,,,,,2984.94,6773.04,percent of total billed charges,
PLATE,7701036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8280.00000,2401.20000,Aetna,First Health,,6773.04,,,,,,,2666.16,6773.04,percent of total billed charges,
GRAFT,7701037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10953.00000,3176.37000,Aetna,First Health,,8959.55,,,,,,,3948.56,8959.55,percent of total billed charges,
GRAFT,7701037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10953.00000,3176.37000,Aetna,First Health,,8959.55,,,,,,,3526.87,8959.55,percent of total billed charges,
COMPONENT GLENOID,7701056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
COMPONENT GLENOID,7701056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
GRAFT,7700873,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21020.00000,6095.80000,Aetna,First Health,,17194.36,,,,,,,7577.71,17194.36,percent of total billed charges,
GRAFT,7700873,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21020.00000,6095.80000,Aetna,First Health,,17194.36,,,,,,,6768.44,17194.36,percent of total billed charges,
GRAFT,7700874,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21240.00000,6159.60000,Aetna,First Health,,17374.32,,,,,,,7657.02,17374.32,percent of total billed charges,
GRAFT,7700874,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21240.00000,6159.60000,Aetna,First Health,,17374.32,,,,,,,6839.28,17374.32,percent of total billed charges,
WASHER,7701521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
WASHER,7701521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
WASHER,7701522,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.75000,53.29000,Aetna,First Health,,150.31,,,,,,,66.24,150.31,percent of total billed charges,
WASHER,7701522,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.75000,53.29000,Aetna,First Health,,150.31,,,,,,,59.17,150.31,percent of total billed charges,
PLATE,7701523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
PLATE,7701523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
PLATE,7701528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1784.00000,517.36000,Aetna,First Health,,1459.31,,,,,,,643.13,1459.31,percent of total billed charges,
PLATE,7701528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1784.00000,517.36000,Aetna,First Health,,1459.31,,,,,,,574.45,1459.31,percent of total billed charges,
PLATE,7701530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
PLATE,7701530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
PLATE,7701531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2288.00000,663.52000,Aetna,First Health,,1871.58,,,,,,,824.82,1871.58,percent of total billed charges,
PLATE,7701531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2288.00000,663.52000,Aetna,First Health,,1871.58,,,,,,,736.74,1871.58,percent of total billed charges,
BICEPS REPAIR,7696886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
BICEPS REPAIR,7696886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
STEM,7698165,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5787.51,13132.28,percent of total billed charges,
STEM,7698165,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5169.43,13132.28,percent of total billed charges,
PLATE,7701534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
PLATE,7701534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
COMPONENT ARTERIAL GRAFT,7701199,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,4672.50000,1355.02000,Aetna,First Health,,3822.11,,,,,,,1684.44,3822.11,percent of total billed charges,
COMPONENT ARTERIAL GRAFT,7701199,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,4672.50000,1355.02000,Aetna,First Health,,3822.11,,,,,,,1504.55,3822.11,percent of total billed charges,
ROD,7697994,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7697994,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
NUT,7701293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
NUT,7701293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
PLATE,7701294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.76000,349.96000,Aetna,First Health,,987.13,,,,,,,435.04,987.13,percent of total billed charges,
PLATE,7701294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.76000,349.96000,Aetna,First Health,,987.13,,,,,,,388.58,987.13,percent of total billed charges,
PLATE,7701301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1658.84000,481.06000,Aetna,First Health,,1356.93,,,,,,,598.01,1356.93,percent of total billed charges,
PLATE,7701301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1658.84000,481.06000,Aetna,First Health,,1356.93,,,,,,,534.15,1356.93,percent of total billed charges,
PLATE,7701303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1894.08000,549.28000,Aetna,First Health,,1549.36,,,,,,,682.82,1549.36,percent of total billed charges,
PLATE,7701303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1894.08000,549.28000,Aetna,First Health,,1549.36,,,,,,,609.89,1549.36,percent of total billed charges,
PLATE,7701304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1643.56000,476.63000,Aetna,First Health,,1344.43,,,,,,,592.50,1344.43,percent of total billed charges,
PLATE,7701304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1643.56000,476.63000,Aetna,First Health,,1344.43,,,,,,,529.23,1344.43,percent of total billed charges,
PLATE,7701305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1823.80000,528.90000,Aetna,First Health,,1491.87,,,,,,,657.48,1491.87,percent of total billed charges,
PLATE,7701305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1823.80000,528.90000,Aetna,First Health,,1491.87,,,,,,,587.26,1491.87,percent of total billed charges,
PLATE,7701308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2013.20000,583.83000,Aetna,First Health,,1646.80,,,,,,,725.76,1646.80,percent of total billed charges,
PLATE,7701308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2013.20000,583.83000,Aetna,First Health,,1646.80,,,,,,,648.25,1646.80,percent of total billed charges,
PLATE,7701312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,442.69,1004.50,percent of total billed charges,
PLATE,7701312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,395.42,1004.50,percent of total billed charges,
PLATE,7701316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
PLATE,7701316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
PLATE,7701317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1816.00000,526.64000,Aetna,First Health,,1485.49,,,,,,,654.67,1485.49,percent of total billed charges,
PLATE,7701317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1816.00000,526.64000,Aetna,First Health,,1485.49,,,,,,,584.75,1485.49,percent of total billed charges,
SCREW,7701216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,7701216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
PLATE,7701348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
AORTIC EXTENSION,7701323,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
AORTIC EXTENSION,7701323,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
ANCHOR,7701197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ANCHOR,7701197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
CABLE PLUG,7701729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
CABLE PLUG,7701729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
PLATE,7701758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5127.50000,1486.98000,Aetna,First Health,,4194.30,,,,,,,1848.46,4194.30,percent of total billed charges,
PLATE,7701758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5127.50000,1486.98000,Aetna,First Health,,4194.30,,,,,,,1651.06,4194.30,percent of total billed charges,
PLATE,7701650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1856.03,4211.47,percent of total billed charges,
PLATE,7701650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1657.82,4211.47,percent of total billed charges,
BASEPLATE,7701559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1548.17,3512.90,percent of total billed charges,
BASEPLATE,7701559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1382.83,3512.90,percent of total billed charges,
STEM,7701561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
STEM,7701561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
AUGMENT TIBIAL,7701562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7701562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
SLEEVE,7701573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1202.32000,348.67000,Aetna,First Health,,983.50,,,,,,,433.44,983.50,percent of total billed charges,
SLEEVE,7701573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1202.32000,348.67000,Aetna,First Health,,983.50,,,,,,,387.15,983.50,percent of total billed charges,
STENT GRAFT,7701400,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4805.10,10903.12,percent of total billed charges,
STENT GRAFT,7701400,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4291.94,10903.12,percent of total billed charges,
STENT GRAFT,7701401,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14706.00000,4264.74000,Aetna,First Health,,12029.51,,,,,,,5301.51,12029.51,percent of total billed charges,
STENT GRAFT,7701401,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14706.00000,4264.74000,Aetna,First Health,,12029.51,,,,,,,4735.33,12029.51,percent of total billed charges,
BALLOON,7701589,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
BALLOON,7701589,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
BASEPLATE,7698053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7698053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
ACETABULAR RING,7701608,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4135.95000,1199.43000,Aetna,First Health,,3383.21,,,,,,,1491.01,3383.21,percent of total billed charges,
ACETABULAR RING,7701608,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4135.95000,1199.43000,Aetna,First Health,,3383.21,,,,,,,1331.78,3383.21,percent of total billed charges,
LINER,7701610,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7577.10000,2197.36000,Aetna,First Health,,6198.07,,,,,,,2731.54,6198.07,percent of total billed charges,
LINER,7701610,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7577.10000,2197.36000,Aetna,First Health,,6198.07,,,,,,,2439.83,6198.07,percent of total billed charges,
PLATE,7701615,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,437.00000,126.73000,Aetna,First Health,,357.47,,,,,,,157.54,357.47,percent of total billed charges,
PLATE,7701615,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,437.00000,126.73000,Aetna,First Health,,357.47,,,,,,,140.71,357.47,percent of total billed charges,
PORT,7701621,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,2020.00000,585.80000,Aetna,First Health,,1652.36,,,,,,,728.21,1652.36,percent of total billed charges,
PORT,7701621,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,2020.00000,585.80000,Aetna,First Health,,1652.36,,,,,,,650.44,1652.36,percent of total billed charges,
GLIDEWIRE,7699835,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1682.00000,487.78000,Aetna,First Health,,1375.88,,,,,,,606.36,1375.88,percent of total billed charges,
GLIDEWIRE,7699835,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1682.00000,487.78000,Aetna,First Health,,1375.88,,,,,,,541.60,1375.88,percent of total billed charges,
COIL,7699834,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3939.25000,1142.38000,Aetna,First Health,,3222.31,,,,,,,1420.10,3222.31,percent of total billed charges,
COIL,7699834,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3939.25000,1142.38000,Aetna,First Health,,3222.31,,,,,,,1268.44,3222.31,percent of total billed charges,
BOLT,7699102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,907.31,2058.74,percent of total billed charges,
BOLT,7699102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,810.41,2058.74,percent of total billed charges,
SPACER HUMAN TISSUE,7701667,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5089.49000,1475.95000,Aetna,First Health,,4163.20,,,,,,,1834.76,4163.20,percent of total billed charges,
SPACER HUMAN TISSUE,7701667,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5089.49000,1475.95000,Aetna,First Health,,4163.20,,,,,,,1638.82,4163.20,percent of total billed charges,
PLATE,7701686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2069.36000,600.11000,Aetna,First Health,,1692.74,,,,,,,746.00,1692.74,percent of total billed charges,
PLATE,7701686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2069.36000,600.11000,Aetna,First Health,,1692.74,,,,,,,666.33,1692.74,percent of total billed charges,
PLATE,7701771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5436.27000,1576.52000,Aetna,First Health,,4446.87,,,,,,,1959.78,4446.87,percent of total billed charges,
PLATE,7701771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5436.27000,1576.52000,Aetna,First Health,,4446.87,,,,,,,1750.48,4446.87,percent of total billed charges,
PLUG,7701498,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
PLUG,7701498,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CAGE ANCHOR,7702020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE ANCHOR,7702020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,7702022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,7702022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
FEMORAL IMPLANT,7702025,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,5404.09,12262.25,percent of total billed charges,
FEMORAL IMPLANT,7702025,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,4826.95,12262.25,percent of total billed charges,
LINER,7702027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11239.20000,3259.37000,Aetna,First Health,,9193.67,,,,,,,4051.73,9193.67,percent of total billed charges,
LINER,7702027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11239.20000,3259.37000,Aetna,First Health,,9193.67,,,,,,,3619.02,9193.67,percent of total billed charges,
PLATE,7702018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
PLATE,7702018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
PLATE,7702078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,742.63,1685.08,percent of total billed charges,
PLATE,7702078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,663.32,1685.08,percent of total billed charges,
PLATE,7702083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1124.76,2552.16,percent of total billed charges,
PLATE,7702083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1004.64,2552.16,percent of total billed charges,
WASHER,7702102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
WASHER,7702102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
IMPLANT SINUS,7701623,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,5362.00000,1554.98000,Aetna,First Health,,4386.12,,,,,,,1933.00,4386.12,percent of total billed charges,
IMPLANT SINUS,7701623,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,5362.00000,1554.98000,Aetna,First Health,,4386.12,,,,,,,1726.56,4386.12,percent of total billed charges,
PLATE,7702035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3506.06000,1016.76000,Aetna,First Health,,2867.96,,,,,,,1263.93,2867.96,percent of total billed charges,
PLATE,7702035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3506.06000,1016.76000,Aetna,First Health,,2867.96,,,,,,,1128.95,2867.96,percent of total billed charges,
PLATE,7702036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,1312.94,2979.16,percent of total billed charges,
PLATE,7702036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,1172.72,2979.16,percent of total billed charges,
SCREW,7702039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,344.57,781.84,percent of total billed charges,
SCREW,7702039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,307.77,781.84,percent of total billed charges,
GUIDEWIRE,7697530,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,134.72000,39.07000,Aetna,First Health,,110.20,,,,,,,48.57,110.20,percent of total billed charges,
GUIDEWIRE,7697530,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,134.72000,39.07000,Aetna,First Health,,110.20,,,,,,,43.38,110.20,percent of total billed charges,
BALLOON CATHETER,7702066,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3381.00000,980.49000,Aetna,First Health,,2765.66,,,,,,,1218.85,2765.66,percent of total billed charges,
BALLOON CATHETER,7702066,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3381.00000,980.49000,Aetna,First Health,,2765.66,,,,,,,1088.68,2765.66,percent of total billed charges,
STEM,7700059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,7700059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
BALLOON,7975121,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7975121,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
SPACER,7700500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10755.00000,3118.95000,Aetna,First Health,,8797.59,,,,,,,3877.18,8797.59,percent of total billed charges,
SPACER,7700500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10755.00000,3118.95000,Aetna,First Health,,8797.59,,,,,,,3463.11,8797.59,percent of total billed charges,
SPACER,7741021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10755.00000,3118.95000,Aetna,First Health,,8797.59,,,,,,,3877.18,8797.59,percent of total billed charges,
SPACER,7741021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10755.00000,3118.95000,Aetna,First Health,,8797.59,,,,,,,3463.11,8797.59,percent of total billed charges,
SHEATH,7700506,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,235.94,535.36,percent of total billed charges,
SHEATH,7700506,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,210.74,535.36,percent of total billed charges,
SHEATH,7702236,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,235.94,535.36,percent of total billed charges,
SHEATH,7702236,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,210.74,535.36,percent of total billed charges,
SHEATH,7848092,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,235.94,535.36,percent of total billed charges,
SHEATH,7848092,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,210.74,535.36,percent of total billed charges,
SHEATH,7848093,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,235.94,535.36,percent of total billed charges,
SHEATH,7848093,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,210.74,535.36,percent of total billed charges,
SHEATH,7910689,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,235.94,535.36,percent of total billed charges,
SHEATH,7910689,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,First Health,,535.36,,,,,,,210.74,535.36,percent of total billed charges,
HOOK,7903627,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1406.85,3192.24,percent of total billed charges,
HOOK,7903627,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1256.61,3192.24,percent of total billed charges,
WEDGE,7698722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7698722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7700324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7700324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7700526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7700526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7700830,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7700830,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7802048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7802048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7874324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7874324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7904987,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7904987,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
INSERT,7699440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7699440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
INSERT,7699650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7699650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
INSERT,7700443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7700443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
INSERT,7700527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7700527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7700899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7700899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7736192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7736192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7736361,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7736361,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
INSERT,7790174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7790174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7802298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7802298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7812120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7812120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7818168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7818168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
INSERT,7828153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7828153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7874325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7874325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7910370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7910370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
INSERT,7922493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7922493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
INSERT,7951929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7951929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
PLATE,7772146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8017.29000,2325.01000,Aetna,First Health,,6558.14,,,,,,,2890.23,6558.14,percent of total billed charges,
PLATE,7772146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8017.29000,2325.01000,Aetna,First Health,,6558.14,,,,,,,2581.57,6558.14,percent of total billed charges,
PLATE,7938125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8017.29000,2325.01000,Aetna,First Health,,6558.14,,,,,,,2890.23,6558.14,percent of total billed charges,
PLATE,7938125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8017.29000,2325.01000,Aetna,First Health,,6558.14,,,,,,,2581.57,6558.14,percent of total billed charges,
SHEATH,7700590,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,352.03,798.78,percent of total billed charges,
SHEATH,7700590,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,314.43,798.78,percent of total billed charges,
SHEATH,7790244,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,352.03,798.78,percent of total billed charges,
SHEATH,7790244,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,314.43,798.78,percent of total billed charges,
WASHER,7700623,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,604.80000,175.39000,Aetna,First Health,,494.73,,,,,,,218.03,494.73,percent of total billed charges,
WASHER,7700623,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,604.80000,175.39000,Aetna,First Health,,494.73,,,,,,,194.75,494.73,percent of total billed charges,
END CAP,7699855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
END CAP,7699855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
SCREW,7697510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,305.07,692.22,percent of total billed charges,
SCREW,7697510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,272.49,692.22,percent of total billed charges,
SCREW,7698254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,305.07,692.22,percent of total billed charges,
SCREW,7698254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,272.49,692.22,percent of total billed charges,
SCREW,7698380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7698380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7698381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7698381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7698834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,305.07,692.22,percent of total billed charges,
SCREW,7698834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,272.49,692.22,percent of total billed charges,
SCREW,7700672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,507.58,1151.74,percent of total billed charges,
SCREW,7700680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,453.38,1151.74,percent of total billed charges,
SCREW,7700681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700689,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700689,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7700701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7700703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700713,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700713,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7700716,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7700716,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7701662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7701662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7701663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7701663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7701664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,7701664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,7702579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,305.07,692.22,percent of total billed charges,
SCREW,7702579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,272.49,692.22,percent of total billed charges,
SCREW,7702580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,305.07,692.22,percent of total billed charges,
SCREW,7702580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,272.49,692.22,percent of total billed charges,
SCREW,7750589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,305.07,692.22,percent of total billed charges,
SCREW,7750589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,272.49,692.22,percent of total billed charges,
SCREW,7770034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,7770034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,7806347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,305.07,692.22,percent of total billed charges,
SCREW,7806347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,First Health,,692.22,,,,,,,272.49,692.22,percent of total billed charges,
SCREW,7842037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
SCREW,7842037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
SCREW,7939308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,498.93,1132.11,percent of total billed charges,
SCREW,7939308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,445.65,1132.11,percent of total billed charges,
SCREW,7939310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,498.93,1132.11,percent of total billed charges,
SCREW,7939310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,445.65,1132.11,percent of total billed charges,
SCREW,7703186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,582.57,1321.89,percent of total billed charges,
SCREW,7703186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,520.35,1321.89,percent of total billed charges,
FEMORAL HEAD,7700726,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7700726,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7701609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7701609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7736196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7736196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7882390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7882390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7918138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7918138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7920116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4309.20000,1249.67000,Aetna,First Health,,3524.93,,,,,,,1553.47,3524.93,percent of total billed charges,
FEMORAL HEAD,7920116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4309.20000,1249.67000,Aetna,First Health,,3524.93,,,,,,,1387.56,3524.93,percent of total billed charges,
INSERT,7748109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7748109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PIN,7700748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PIN,7700748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PIN,7700749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PIN,7700749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PIN,7700750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,174.66,396.32,percent of total billed charges,
PIN,7700750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,156.01,396.32,percent of total billed charges,
PIN,7700751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PIN,7700751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PIN,7700902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
PIN,7700902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
PLATE,7901686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,475.25,1078.39,percent of total billed charges,
PLATE,7901686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,424.50,1078.39,percent of total billed charges,
PLATE,7926574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,475.25,1078.39,percent of total billed charges,
PLATE,7926574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,424.50,1078.39,percent of total billed charges,
PLATE,7948045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,461.81,1047.89,percent of total billed charges,
PLATE,7948045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,412.49,1047.89,percent of total billed charges,
SCREW,7695860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7695860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7697482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7697482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7700482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7700482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7700731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7700731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7700732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7700732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7700733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7700733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7701706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701713,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701713,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701716,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701716,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701717,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701717,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701721,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701721,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701724,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701724,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7701728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
SCREW,7701728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
SCREW,7736564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7736564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7784149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7784149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7804058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7804058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,7816125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7816125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7901685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7901685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7905549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7905549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7925236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,7925236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
SCREW,7926798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7926798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7926799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7926799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7926800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7926800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7930000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,7930000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
SCREW,7930326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7930326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7936055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7936055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7937790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,69.29,157.22,percent of total billed charges,
SCREW,7937790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,First Health,,157.22,,,,,,,61.89,157.22,percent of total billed charges,
SCREW,7943684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
SCREW,7943684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
SCREW,7944180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7944180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7958014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7958014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7966080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7966080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7703129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7703129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7703134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7703134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7703161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7703161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7696561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,7696561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,7696815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,680.98,1545.20,percent of total billed charges,
SCREW,7696815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,608.26,1545.20,percent of total billed charges,
SCREW,7697005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,680.98,1545.20,percent of total billed charges,
SCREW,7697005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,608.26,1545.20,percent of total billed charges,
SCREW,7697006,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,680.98,1545.20,percent of total billed charges,
SCREW,7697006,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,608.26,1545.20,percent of total billed charges,
SCREW,7698126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2108.20000,611.38000,Aetna,First Health,,1724.51,,,,,,,760.01,1724.51,percent of total billed charges,
SCREW,7698126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2108.20000,611.38000,Aetna,First Health,,1724.51,,,,,,,678.84,1724.51,percent of total billed charges,
SCREW,7698127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2196.00000,636.84000,Aetna,First Health,,1796.33,,,,,,,791.66,1796.33,percent of total billed charges,
SCREW,7698127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2196.00000,636.84000,Aetna,First Health,,1796.33,,,,,,,707.11,1796.33,percent of total billed charges,
SCREW,7698128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2196.00000,636.84000,Aetna,First Health,,1796.33,,,,,,,791.66,1796.33,percent of total billed charges,
SCREW,7698128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2196.00000,636.84000,Aetna,First Health,,1796.33,,,,,,,707.11,1796.33,percent of total billed charges,
SCREW,7698129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,701.10,1590.85,percent of total billed charges,
SCREW,7698129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,626.23,1590.85,percent of total billed charges,
SCREW,7698928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,680.98,1545.20,percent of total billed charges,
SCREW,7698928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,608.26,1545.20,percent of total billed charges,
SCREW,7700763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700773,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700773,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700775,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700775,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7700779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,7700779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7752053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1362.04000,394.99000,Aetna,First Health,,1114.15,,,,,,,491.02,1114.15,percent of total billed charges,
SCREW,7752053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1362.04000,394.99000,Aetna,First Health,,1114.15,,,,,,,438.58,1114.15,percent of total billed charges,
SCREW,7893979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1362.04000,394.99000,Aetna,First Health,,1114.15,,,,,,,491.02,1114.15,percent of total billed charges,
SCREW,7893979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1362.04000,394.99000,Aetna,First Health,,1114.15,,,,,,,438.58,1114.15,percent of total billed charges,
SCREW,7925229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,701.10,1590.85,percent of total billed charges,
SCREW,7925229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,626.23,1590.85,percent of total billed charges,
SCREW,7925231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2196.00000,636.84000,Aetna,First Health,,1796.33,,,,,,,791.66,1796.33,percent of total billed charges,
SCREW,7925231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2196.00000,636.84000,Aetna,First Health,,1796.33,,,,,,,707.11,1796.33,percent of total billed charges,
SCREW,7925232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,701.10,1590.85,percent of total billed charges,
SCREW,7925232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,First Health,,1590.85,,,,,,,626.23,1590.85,percent of total billed charges,
SCREW,7930190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,7930190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
SCREW,7936116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2000.00000,580.00000,Aetna,First Health,,1636.00,,,,,,,721.00,1636.00,percent of total billed charges,
SCREW,7936116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2000.00000,580.00000,Aetna,First Health,,1636.00,,,,,,,644.00,1636.00,percent of total billed charges,
SCREW,7700780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7700780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7700781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7700781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7700782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7700782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7700783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7700783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7700785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7700785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7700788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7700788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7700789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7700789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7700791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7700791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7700792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7700792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,7701484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,7701485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
SCREW,7701495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,7701496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
SCREW,7701496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,43.95,111.66,percent of total billed charges,
SCREW,7701652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,7701705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
SCREW,7701705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
STEM,7893924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9500.94000,2755.27000,Aetna,First Health,,7771.77,,,,,,,3425.09,7771.77,percent of total billed charges,
STEM,7893924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9500.94000,2755.27000,Aetna,First Health,,7771.77,,,,,,,3059.30,7771.77,percent of total billed charges,
FEMORAL HEAD,7700834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7700834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7736274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7736274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7736275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7736275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7736491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7736491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7834075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7834075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7840139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7840139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7866038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7866038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7880676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7880676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7880790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7880790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7893678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7893678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7896394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7896394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL IMPLANT,7736276,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
FEMORAL IMPLANT,7736276,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
AUGMENT FEMORAL,7700845,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7700845,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7700847,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7700847,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7802117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7802117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7802118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7802118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7816099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7816099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7816100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7816100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,7908634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
SHELL,7700909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10671.60000,3094.76000,Aetna,First Health,,8729.37,,,,,,,3847.11,8729.37,percent of total billed charges,
SHELL,7700909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10671.60000,3094.76000,Aetna,First Health,,8729.37,,,,,,,3436.26,8729.37,percent of total billed charges,
SHELL,7702636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10671.60000,3094.76000,Aetna,First Health,,8729.37,,,,,,,3847.11,8729.37,percent of total billed charges,
SHELL,7702636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10671.60000,3094.76000,Aetna,First Health,,8729.37,,,,,,,3436.26,8729.37,percent of total billed charges,
SHELL,7816130,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10671.60000,3094.76000,Aetna,First Health,,8729.37,,,,,,,3847.11,8729.37,percent of total billed charges,
SHELL,7816130,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10671.60000,3094.76000,Aetna,First Health,,8729.37,,,,,,,3436.26,8729.37,percent of total billed charges,
FEMORAL HEAD,7802070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7802070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
FEMORAL HEAD,7854032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7854032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
FEMORAL HEAD,7954087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7954087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
CATHETER BALLOON,7700880,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1469.76000,426.23000,Aetna,First Health,,1202.26,,,,,,,529.85,1202.26,percent of total billed charges,
CATHETER BALLOON,7700880,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1469.76000,426.23000,Aetna,First Health,,1202.26,,,,,,,473.26,1202.26,percent of total billed charges,
CATHETER BALLOON,7700881,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1469.76000,426.23000,Aetna,First Health,,1202.26,,,,,,,529.85,1202.26,percent of total billed charges,
CATHETER BALLOON,7700881,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1469.76000,426.23000,Aetna,First Health,,1202.26,,,,,,,473.26,1202.26,percent of total billed charges,
LINER,7700904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7700904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7740745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7740745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7746042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7746042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7826098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7826098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7850196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7850196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7876185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7876185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7882394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7882394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7893729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7893729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7902294,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7902294,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7902682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7902682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7904167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
LINER,7904167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
LINER,7917698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
LINER,7917698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
LINER,7918959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
LINER,7918959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
LINER,7935821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
LINER,7935821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
LINER,7702638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6485.50000,1880.79000,Aetna,First Health,,5305.14,,,,,,,2338.02,5305.14,percent of total billed charges,
LINER,7702638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6485.50000,1880.79000,Aetna,First Health,,5305.14,,,,,,,2088.33,5305.14,percent of total billed charges,
LINER,7902656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7902656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,7902821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,7902821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
SCREW,7700921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7700921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,7702159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7702159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,7736470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7736470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,7742176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7742176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,7882185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7882185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7882188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7882188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7917895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7917895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7917896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7917896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7926575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,287.47000,83.37000,Aetna,First Health,,235.15,,,,,,,103.63,235.15,percent of total billed charges,
SCREW,7926575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,287.47000,83.37000,Aetna,First Health,,235.15,,,,,,,92.57,235.15,percent of total billed charges,
PLATE,7938132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8568.00000,2484.72000,Aetna,First Health,,7008.62,,,,,,,3088.76,7008.62,percent of total billed charges,
PLATE,7938132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8568.00000,2484.72000,Aetna,First Health,,7008.62,,,,,,,2758.90,7008.62,percent of total billed charges,
STEM,7736284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7736284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7748116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7748116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7748757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7748757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7748835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7748835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7748878,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7748878,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7748880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7748880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7786153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7786153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7788034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7788034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7790536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7790536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7794486,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7794486,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7800031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7800031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7800036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7800036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7802088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7802088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7804039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7804039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7804040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7804040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7806371,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7806371,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7814061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7814061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7816121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7816121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7820081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7820081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7822241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7822241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7822243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7822243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7822247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7822247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7828053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7828053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7828055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7828055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7834041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7834041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7838066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7838066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7846134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7846134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7848066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7848066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7858125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7858125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7858274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7858274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7866112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7866112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7866115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7866115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7876333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7876333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7876334,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7876334,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878319,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878319,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878563,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878563,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7878565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7878565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7880182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7880182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7880445,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7880445,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7880523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7880523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7880666,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7880666,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7880671,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7880671,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7882509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7882509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7882510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7882510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7893771,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7893771,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7897084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7897084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7900097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7900097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7900128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7900128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7903782,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7903782,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7904976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7904976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7910510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7910510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7912138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7912138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7914035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7914035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7920821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7920821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7926709,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7926709,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7926710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7926710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7934014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7934014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7939804,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7939804,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7944550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7944550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7961897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7961897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7961901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7961901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
END CAP,7700970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
END CAP,7700970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
END CAP,7702906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
END CAP,7702906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
END CAP,7703354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
END CAP,7703354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
NAIL,7700971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700986,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700986,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700997,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700997,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7700999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7700999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7701000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7701000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7701001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7701001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7701002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7701002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7701004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7701004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7701005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7701005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7701006,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7701006,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7701007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7701007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7701008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7701008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
NAIL,7703355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1496.44,3395.52,percent of total billed charges,
NAIL,7703355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,First Health,,3395.52,,,,,,,1336.62,3395.52,percent of total billed charges,
SCREW,7695286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
SCREW,7695286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
SCREW,7903619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
SCREW,7903619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
SCREW,7703252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
SCREW,7703252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
SCREW,7903620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
SCREW,7903620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
SCREW,7903621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
SCREW,7903621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
SCREW,7903622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
SCREW,7903622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
STENT GRAFT,7701399,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,4429.82,10051.58,percent of total billed charges,
STENT GRAFT,7701399,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,3956.74,10051.58,percent of total billed charges,
STENT GRAFT,7903584,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,4429.82,10051.58,percent of total billed charges,
STENT GRAFT,7903584,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,3956.74,10051.58,percent of total billed charges,
STENT GRAFT,7905468,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,4429.82,10051.58,percent of total billed charges,
STENT GRAFT,7905468,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,3956.74,10051.58,percent of total billed charges,
GUIDEWIRE,7746048,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
GUIDEWIRE,7746048,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
GUIDEWIRE,7822089,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
GUIDEWIRE,7822089,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
GUIDEWIRE,7822091,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
GUIDEWIRE,7822091,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
PLATE,7700761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3910.52000,1134.05000,Aetna,First Health,,3198.81,,,,,,,1409.74,3198.81,percent of total billed charges,
PLATE,7700761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3910.52000,1134.05000,Aetna,First Health,,3198.81,,,,,,,1259.19,3198.81,percent of total billed charges,
PLATE,7701009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3932.22000,1140.34000,Aetna,First Health,,3216.56,,,,,,,1417.57,3216.56,percent of total billed charges,
PLATE,7701009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3932.22000,1140.34000,Aetna,First Health,,3216.56,,,,,,,1266.17,3216.56,percent of total billed charges,
PLATE,7776293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2656.00000,770.24000,Aetna,First Health,,2172.61,,,,,,,957.49,2172.61,percent of total billed charges,
PLATE,7776293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2656.00000,770.24000,Aetna,First Health,,2172.61,,,,,,,855.23,2172.61,percent of total billed charges,
PLATE,7776294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2700.00000,783.00000,Aetna,First Health,,2208.60,,,,,,,973.35,2208.60,percent of total billed charges,
PLATE,7776294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2700.00000,783.00000,Aetna,First Health,,2208.60,,,,,,,869.40,2208.60,percent of total billed charges,
PLATE,7701019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
PLATE,7701019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
WASHER,7939432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,203.23000,58.94000,Aetna,First Health,,166.24,,,,,,,73.26,166.24,percent of total billed charges,
WASHER,7939432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,203.23000,58.94000,Aetna,First Health,,166.24,,,,,,,65.44,166.24,percent of total billed charges,
PLATE,7701180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,130.14,295.30,percent of total billed charges,
PLATE,7701180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,116.24,295.30,percent of total billed charges,
PLATE,7701181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,130.14,295.30,percent of total billed charges,
PLATE,7701181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,116.24,295.30,percent of total billed charges,
PLATE,7701182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,130.14,295.30,percent of total billed charges,
PLATE,7701182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,116.24,295.30,percent of total billed charges,
CATHETER,7699827,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
CATHETER,7699827,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
CATHETER,7701028,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
CATHETER,7701028,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
CATHETER,7701029,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
CATHETER,7701029,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
CATHETER,7701030,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
CATHETER,7701030,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
PLATE,7943369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8280.00000,2401.20000,Aetna,First Health,,6773.04,,,,,,,2984.94,6773.04,percent of total billed charges,
PLATE,7943369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8280.00000,2401.20000,Aetna,First Health,,6773.04,,,,,,,2666.16,6773.04,percent of total billed charges,
WASHER,7896376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,128.05000,37.13000,Aetna,First Health,,104.74,,,,,,,46.16,104.74,percent of total billed charges,
WASHER,7896376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,128.05000,37.13000,Aetna,First Health,,104.74,,,,,,,41.23,104.74,percent of total billed charges,
PLATE,7736453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,First Health,,1208.02,,,,,,,532.39,1208.02,percent of total billed charges,
PLATE,7736453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,First Health,,1208.02,,,,,,,475.53,1208.02,percent of total billed charges,
PLATE,7740767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,First Health,,1208.02,,,,,,,532.39,1208.02,percent of total billed charges,
PLATE,7740767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,First Health,,1208.02,,,,,,,475.53,1208.02,percent of total billed charges,
PLATE,7702401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.72000,657.64000,Aetna,First Health,,1854.99,,,,,,,817.51,1854.99,percent of total billed charges,
PLATE,7702401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.72000,657.64000,Aetna,First Health,,1854.99,,,,,,,730.21,1854.99,percent of total billed charges,
PLATE,7830034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,953.52,2163.61,percent of total billed charges,
PLATE,7830034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,851.69,2163.61,percent of total billed charges,
PLATE,7958152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2072.52000,601.03000,Aetna,First Health,,1695.32,,,,,,,747.14,1695.32,percent of total billed charges,
PLATE,7958152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2072.52000,601.03000,Aetna,First Health,,1695.32,,,,,,,667.35,1695.32,percent of total billed charges,
STEM,7701194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5787.51,13132.28,percent of total billed charges,
STEM,7701194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5169.43,13132.28,percent of total billed charges,
STEM,7740766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5787.51,13132.28,percent of total billed charges,
STEM,7740766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5169.43,13132.28,percent of total billed charges,
STEM,7957822,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5787.51,13132.28,percent of total billed charges,
STEM,7957822,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5169.43,13132.28,percent of total billed charges,
STEM,7958126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5787.51,13132.28,percent of total billed charges,
STEM,7958126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5169.43,13132.28,percent of total billed charges,
PLATE,7701535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
PLATE,7701535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
PLATE,7701849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1218.80000,353.45000,Aetna,First Health,,996.98,,,,,,,439.38,996.98,percent of total billed charges,
PLATE,7701849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1218.80000,353.45000,Aetna,First Health,,996.98,,,,,,,392.45,996.98,percent of total billed charges,
PLATE,7701850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4914.00000,1425.06000,Aetna,First Health,,4019.65,,,,,,,1771.50,4019.65,percent of total billed charges,
PLATE,7701331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4914.00000,1425.06000,Aetna,First Health,,4019.65,,,,,,,1582.31,4019.65,percent of total billed charges,
PLATE,7701334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4914.00000,1425.06000,Aetna,First Health,,4019.65,,,,,,,1771.50,4019.65,percent of total billed charges,
PLATE,7701334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4914.00000,1425.06000,Aetna,First Health,,4019.65,,,,,,,1582.31,4019.65,percent of total billed charges,
PLATE,7701546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4914.00000,1425.06000,Aetna,First Health,,4019.65,,,,,,,1771.50,4019.65,percent of total billed charges,
PLATE,7701546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4914.00000,1425.06000,Aetna,First Health,,4019.65,,,,,,,1582.31,4019.65,percent of total billed charges,
PLATE,7870096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
PLATE,7870096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
PLATE,7882684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
PLATE,7882684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
PLATE,7882685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
PLATE,7882685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
ROD,7698749,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7698749,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7935273,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7935273,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7703017,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7703017,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
PLATE,7701295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.76000,349.96000,Aetna,First Health,,987.13,,,,,,,435.04,987.13,percent of total billed charges,
PLATE,7701295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.76000,349.96000,Aetna,First Health,,987.13,,,,,,,388.58,987.13,percent of total billed charges,
PLATE,7701296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.76000,349.96000,Aetna,First Health,,987.13,,,,,,,435.04,987.13,percent of total billed charges,
PLATE,7701296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.76000,349.96000,Aetna,First Health,,987.13,,,,,,,388.58,987.13,percent of total billed charges,
PLATE,7701302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1658.84000,481.06000,Aetna,First Health,,1356.93,,,,,,,598.01,1356.93,percent of total billed charges,
PLATE,7701302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1658.84000,481.06000,Aetna,First Health,,1356.93,,,,,,,534.15,1356.93,percent of total billed charges,
PLATE,7939412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1553.00000,450.37000,Aetna,First Health,,1270.35,,,,,,,559.86,1270.35,percent of total billed charges,
PLATE,7939412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1553.00000,450.37000,Aetna,First Health,,1270.35,,,,,,,500.07,1270.35,percent of total billed charges,
PLATE,7701311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.50000,259.70000,Aetna,First Health,,732.52,,,,,,,322.83,732.52,percent of total billed charges,
PLATE,7701311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.50000,259.70000,Aetna,First Health,,732.52,,,,,,,288.35,732.52,percent of total billed charges,
PLATE,7701812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1892.00000,548.68000,Aetna,First Health,,1547.66,,,,,,,682.07,1547.66,percent of total billed charges,
PLATE,7701812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1892.00000,548.68000,Aetna,First Health,,1547.66,,,,,,,609.22,1547.66,percent of total billed charges,
PLATE,7929695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1286.60000,373.11000,Aetna,First Health,,1052.44,,,,,,,463.82,1052.44,percent of total billed charges,
PLATE,7929695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1286.60000,373.11000,Aetna,First Health,,1052.44,,,,,,,414.29,1052.44,percent of total billed charges,
PLATE,7701306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1823.80000,528.90000,Aetna,First Health,,1491.87,,,,,,,657.48,1491.87,percent of total billed charges,
PLATE,7701306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1823.80000,528.90000,Aetna,First Health,,1491.87,,,,,,,587.26,1491.87,percent of total billed charges,
PLATE,7701307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1823.80000,528.90000,Aetna,First Health,,1491.87,,,,,,,657.48,1491.87,percent of total billed charges,
PLATE,7701307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1823.80000,528.90000,Aetna,First Health,,1491.87,,,,,,,587.26,1491.87,percent of total billed charges,
PLATE,7701815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1667.60000,483.60000,Aetna,First Health,,1364.10,,,,,,,601.17,1364.10,percent of total billed charges,
PLATE,7701815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1667.60000,483.60000,Aetna,First Health,,1364.10,,,,,,,536.97,1364.10,percent of total billed charges,
PLATE,7701816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1667.60000,483.60000,Aetna,First Health,,1364.10,,,,,,,601.17,1364.10,percent of total billed charges,
PLATE,7701816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1667.60000,483.60000,Aetna,First Health,,1364.10,,,,,,,536.97,1364.10,percent of total billed charges,
PLATE,7816124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.63000,103.42000,Aetna,First Health,,291.72,,,,,,,128.57,291.72,percent of total billed charges,
PLATE,7816124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.63000,103.42000,Aetna,First Health,,291.72,,,,,,,114.83,291.72,percent of total billed charges,
PLATE,7939411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1448.00000,419.92000,Aetna,First Health,,1184.46,,,,,,,522.00,1184.46,percent of total billed charges,
PLATE,7939411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1448.00000,419.92000,Aetna,First Health,,1184.46,,,,,,,466.26,1184.46,percent of total billed charges,
PLATE,7701309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2013.20000,583.83000,Aetna,First Health,,1646.80,,,,,,,725.76,1646.80,percent of total billed charges,
PLATE,7701309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2013.20000,583.83000,Aetna,First Health,,1646.80,,,,,,,648.25,1646.80,percent of total billed charges,
PLATE,7701310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2013.20000,583.83000,Aetna,First Health,,1646.80,,,,,,,725.76,1646.80,percent of total billed charges,
PLATE,7701310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2013.20000,583.83000,Aetna,First Health,,1646.80,,,,,,,648.25,1646.80,percent of total billed charges,
PLATE,7707500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1659.68000,481.31000,Aetna,First Health,,1357.62,,,,,,,598.31,1357.62,percent of total billed charges,
PLATE,7707500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1659.68000,481.31000,Aetna,First Health,,1357.62,,,,,,,534.42,1357.62,percent of total billed charges,
PLATE,7701313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,442.69,1004.50,percent of total billed charges,
PLATE,7701313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,395.42,1004.50,percent of total billed charges,
PLATE,7701318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
PLATE,7701318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
PLATE,7701319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1816.00000,526.64000,Aetna,First Health,,1485.49,,,,,,,654.67,1485.49,percent of total billed charges,
PLATE,7701319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1816.00000,526.64000,Aetna,First Health,,1485.49,,,,,,,584.75,1485.49,percent of total billed charges,
SCREW,7832046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2264.00000,656.56000,Aetna,First Health,,1851.95,,,,,,,816.17,1851.95,percent of total billed charges,
SCREW,7832046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2264.00000,656.56000,Aetna,First Health,,1851.95,,,,,,,729.01,1851.95,percent of total billed charges,
SCREW,7840045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,7840045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
SCREW,7846035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,795.98,1806.14,percent of total billed charges,
SCREW,7846035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,710.98,1806.14,percent of total billed charges,
PLATE,7701335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1583.50,3593.07,percent of total billed charges,
PLATE,7701347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,First Health,,3593.07,,,,,,,1414.38,3593.07,percent of total billed charges,
PLATE,7701349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7701361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1598.64,3627.42,percent of total billed charges,
PLATE,7701361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,First Health,,3627.42,,,,,,,1427.91,3627.42,percent of total billed charges,
PLATE,7865351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2815.80000,816.58000,Aetna,First Health,,2303.32,,,,,,,1015.10,2303.32,percent of total billed charges,
PLATE,7865351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2815.80000,816.58000,Aetna,First Health,,2303.32,,,,,,,906.69,2303.32,percent of total billed charges,
AORTIC EXTENSION,7920410,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
AORTIC EXTENSION,7920410,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
PLATE,7701365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1647.85,3739.08,percent of total billed charges,
PLATE,7701365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1471.86,3739.08,percent of total billed charges,
PLATE,7701369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1647.85,3739.08,percent of total billed charges,
PLATE,7701369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1471.86,3739.08,percent of total billed charges,
PLATE,7701370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1647.85,3739.08,percent of total billed charges,
PLATE,7701370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1471.86,3739.08,percent of total billed charges,
PLATE,7701371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1647.85,3739.08,percent of total billed charges,
PLATE,7701371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1471.86,3739.08,percent of total billed charges,
PLATE,7701372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1647.85,3739.08,percent of total billed charges,
PLATE,7701372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,First Health,,3739.08,,,,,,,1471.86,3739.08,percent of total billed charges,
PLATE,7699989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3177.36000,921.43000,Aetna,First Health,,2599.08,,,,,,,1145.44,2599.08,percent of total billed charges,
PLATE,7699989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3177.36000,921.43000,Aetna,First Health,,2599.08,,,,,,,1023.11,2599.08,percent of total billed charges,
PLATE,7701366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.00000,1380.40000,Aetna,First Health,,3893.68,,,,,,,1715.98,3893.68,percent of total billed charges,
PLATE,7701366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.00000,1380.40000,Aetna,First Health,,3893.68,,,,,,,1532.72,3893.68,percent of total billed charges,
PLATE,7701367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.00000,1380.40000,Aetna,First Health,,3893.68,,,,,,,1715.98,3893.68,percent of total billed charges,
PLATE,7701367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.00000,1380.40000,Aetna,First Health,,3893.68,,,,,,,1532.72,3893.68,percent of total billed charges,
PLATE,7701368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.00000,1380.40000,Aetna,First Health,,3893.68,,,,,,,1715.98,3893.68,percent of total billed charges,
PLATE,7701368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.00000,1380.40000,Aetna,First Health,,3893.68,,,,,,,1532.72,3893.68,percent of total billed charges,
PLATE,7701374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.00000,1380.40000,Aetna,First Health,,3893.68,,,,,,,1715.98,3893.68,percent of total billed charges,
PLATE,7701374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.00000,1380.40000,Aetna,First Health,,3893.68,,,,,,,1532.72,3893.68,percent of total billed charges,
PLATE,7701375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.00000,1380.40000,Aetna,First Health,,3893.68,,,,,,,1715.98,3893.68,percent of total billed charges,
PLATE,7701375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.00000,1380.40000,Aetna,First Health,,3893.68,,,,,,,1532.72,3893.68,percent of total billed charges,
PLATE,7702395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3607.91000,1046.29000,Aetna,First Health,,2951.27,,,,,,,1300.65,2951.27,percent of total billed charges,
PLATE,7702395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3607.91000,1046.29000,Aetna,First Health,,2951.27,,,,,,,1161.75,2951.27,percent of total billed charges,
PLATE,7702399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3607.91000,1046.29000,Aetna,First Health,,2951.27,,,,,,,1300.65,2951.27,percent of total billed charges,
PLATE,7702399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3607.91000,1046.29000,Aetna,First Health,,2951.27,,,,,,,1161.75,2951.27,percent of total billed charges,
ANCHOR,7760080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2162.00000,626.98000,Aetna,First Health,,1768.52,,,,,,,779.40,1768.52,percent of total billed charges,
ANCHOR,7760080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2162.00000,626.98000,Aetna,First Health,,1768.52,,,,,,,696.16,1768.52,percent of total billed charges,
PLATE,7701759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5127.50000,1486.98000,Aetna,First Health,,4194.30,,,,,,,1848.46,4194.30,percent of total billed charges,
PLATE,7701759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5127.50000,1486.98000,Aetna,First Health,,4194.30,,,,,,,1651.06,4194.30,percent of total billed charges,
PLATE,7701760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1856.03,4211.47,percent of total billed charges,
PLATE,7701760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1657.82,4211.47,percent of total billed charges,
PLATE,7701762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1856.03,4211.47,percent of total billed charges,
PLATE,7701762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1657.82,4211.47,percent of total billed charges,
PLATE,7701763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1856.03,4211.47,percent of total billed charges,
PLATE,7701763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1657.82,4211.47,percent of total billed charges,
PLATE,7701764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1856.03,4211.47,percent of total billed charges,
PLATE,7701764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1657.82,4211.47,percent of total billed charges,
PLATE,7701766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5127.50000,1486.98000,Aetna,First Health,,4194.30,,,,,,,1848.46,4194.30,percent of total billed charges,
PLATE,7701766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5127.50000,1486.98000,Aetna,First Health,,4194.30,,,,,,,1651.06,4194.30,percent of total billed charges,
PLATE,7701767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1856.03,4211.47,percent of total billed charges,
PLATE,7701767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1657.82,4211.47,percent of total billed charges,
PLATE,7701768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1856.03,4211.47,percent of total billed charges,
PLATE,7701768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1657.82,4211.47,percent of total billed charges,
PLATE,7701769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1856.03,4211.47,percent of total billed charges,
PLATE,7701769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1657.82,4211.47,percent of total billed charges,
PLATE,7701770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1856.03,4211.47,percent of total billed charges,
PLATE,7701770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,First Health,,4211.47,,,,,,,1657.82,4211.47,percent of total billed charges,
PLATE,7768035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5567.03000,1614.44000,Aetna,First Health,,4553.83,,,,,,,2006.91,4553.83,percent of total billed charges,
PLATE,7768035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5567.03000,1614.44000,Aetna,First Health,,4553.83,,,,,,,1792.58,4553.83,percent of total billed charges,
PLATE,7768036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5567.03000,1614.44000,Aetna,First Health,,4553.83,,,,,,,2006.91,4553.83,percent of total billed charges,
PLATE,7768036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5567.03000,1614.44000,Aetna,First Health,,4553.83,,,,,,,1792.58,4553.83,percent of total billed charges,
PLATE,7956954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5376.95000,1559.32000,Aetna,First Health,,4398.35,,,,,,,1938.39,4398.35,percent of total billed charges,
PLATE,7956954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5376.95000,1559.32000,Aetna,First Health,,4398.35,,,,,,,1731.38,4398.35,percent of total billed charges,
BASEPLATE,7750117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1548.17,3512.90,percent of total billed charges,
BASEPLATE,7750117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1382.83,3512.90,percent of total billed charges,
BASEPLATE,7760129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1548.17,3512.90,percent of total billed charges,
BASEPLATE,7760129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1382.83,3512.90,percent of total billed charges,
BASEPLATE,7893306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1548.17,3512.90,percent of total billed charges,
BASEPLATE,7893306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1382.83,3512.90,percent of total billed charges,
BASEPLATE,7940851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1548.17,3512.90,percent of total billed charges,
BASEPLATE,7940851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1382.83,3512.90,percent of total billed charges,
BASEPLATE,7943925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1548.17,3512.90,percent of total billed charges,
BASEPLATE,7943925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1382.83,3512.90,percent of total billed charges,
STEM,7882686,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
STEM,7882686,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
STEM,7940852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
STEM,7940852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
AUGMENT TIBIAL,7701563,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7701563,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7947956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7947956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7947957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7947957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
STENT GRAFT,7744660,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4805.10,10903.12,percent of total billed charges,
STENT GRAFT,7744660,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4291.94,10903.12,percent of total billed charges,
STENT GRAFT,7922551,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4805.10,10903.12,percent of total billed charges,
STENT GRAFT,7922551,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4291.94,10903.12,percent of total billed charges,
STENT GRAFT,7922552,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4805.10,10903.12,percent of total billed charges,
STENT GRAFT,7922552,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4291.94,10903.12,percent of total billed charges,
STENT GRAFT,7922553,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4805.10,10903.12,percent of total billed charges,
STENT GRAFT,7922553,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4291.94,10903.12,percent of total billed charges,
STENT GRAFT,7922554,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4805.10,10903.12,percent of total billed charges,
STENT GRAFT,7922554,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,First Health,,10903.12,,,,,,,4291.94,10903.12,percent of total billed charges,
STENT GRAFT,7701402,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14706.00000,4264.74000,Aetna,First Health,,12029.51,,,,,,,5301.51,12029.51,percent of total billed charges,
STENT GRAFT,7701402,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14706.00000,4264.74000,Aetna,First Health,,12029.51,,,,,,,4735.33,12029.51,percent of total billed charges,
STENT GRAFT,7701404,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14706.00000,4264.74000,Aetna,First Health,,12029.51,,,,,,,5301.51,12029.51,percent of total billed charges,
STENT GRAFT,7701404,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14706.00000,4264.74000,Aetna,First Health,,12029.51,,,,,,,4735.33,12029.51,percent of total billed charges,
STENT GRAFT,7910542,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14706.00000,4264.74000,Aetna,First Health,,12029.51,,,,,,,5301.51,12029.51,percent of total billed charges,
STENT GRAFT,7910542,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14706.00000,4264.74000,Aetna,First Health,,12029.51,,,,,,,4735.33,12029.51,percent of total billed charges,
BASEPLATE,7698469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7698469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7698621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7698621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7698643,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7698643,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7699229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7699229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7699376,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7699376,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7700528,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7700528,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7700883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7700883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7701554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7701554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7701602,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7701602,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7701683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7701683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7742041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7742041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7774232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7774232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
BASEPLATE,7814064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7814064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
LINER,7736195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7871.40000,2282.71000,Aetna,First Health,,6438.81,,,,,,,2837.64,6438.81,percent of total billed charges,
LINER,7736195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7871.40000,2282.71000,Aetna,First Health,,6438.81,,,,,,,2534.59,6438.81,percent of total billed charges,
PLATE,7740756,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,205.70,466.75,percent of total billed charges,
PLATE,7740756,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,First Health,,466.75,,,,,,,183.73,466.75,percent of total billed charges,
GLIDEWIRE,7701630,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1608.00000,466.32000,Aetna,First Health,,1315.34,,,,,,,579.68,1315.34,percent of total billed charges,
GLIDEWIRE,7701630,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1608.00000,466.32000,Aetna,First Health,,1315.34,,,,,,,517.78,1315.34,percent of total billed charges,
COIL,7699869,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1418.84,3219.44,percent of total billed charges,
COIL,7699869,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1267.31,3219.44,percent of total billed charges,
COIL,7701628,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1418.84,3219.44,percent of total billed charges,
COIL,7701628,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1267.31,3219.44,percent of total billed charges,
COIL,7820145,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3939.25000,1142.38000,Aetna,First Health,,3222.31,,,,,,,1420.10,3222.31,percent of total billed charges,
COIL,7820145,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3939.25000,1142.38000,Aetna,First Health,,3222.31,,,,,,,1268.44,3222.31,percent of total billed charges,
COIL,7848031,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1418.84,3219.44,percent of total billed charges,
COIL,7848031,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1267.31,3219.44,percent of total billed charges,
COIL,7874450,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1418.84,3219.44,percent of total billed charges,
COIL,7874450,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1267.31,3219.44,percent of total billed charges,
COIL,7902979,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1418.84,3219.44,percent of total billed charges,
COIL,7902979,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1267.31,3219.44,percent of total billed charges,
COIL,7935393,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1418.84,3219.44,percent of total billed charges,
COIL,7935393,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,First Health,,3219.44,,,,,,,1267.31,3219.44,percent of total billed charges,
BOLT,7701634,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,907.31,2058.74,percent of total billed charges,
BOLT,7701634,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,810.41,2058.74,percent of total billed charges,
SPACER HUMAN TISSUE,7701668,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5089.49000,1475.95000,Aetna,First Health,,4163.20,,,,,,,1834.76,4163.20,percent of total billed charges,
SPACER HUMAN TISSUE,7701668,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5089.49000,1475.95000,Aetna,First Health,,4163.20,,,,,,,1638.82,4163.20,percent of total billed charges,
SPACER HUMAN TISSUE,7701669,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5089.49000,1475.95000,Aetna,First Health,,4163.20,,,,,,,1834.76,4163.20,percent of total billed charges,
SPACER HUMAN TISSUE,7701669,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5089.49000,1475.95000,Aetna,First Health,,4163.20,,,,,,,1638.82,4163.20,percent of total billed charges,
PLATE,7756733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2066.28000,599.22000,Aetna,First Health,,1690.22,,,,,,,744.89,1690.22,percent of total billed charges,
PLATE,7756733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2066.28000,599.22000,Aetna,First Health,,1690.22,,,,,,,665.34,1690.22,percent of total billed charges,
PLATE,7912231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3945.90000,1144.31000,Aetna,First Health,,3227.75,,,,,,,1422.50,3227.75,percent of total billed charges,
PLATE,7912231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3945.90000,1144.31000,Aetna,First Health,,3227.75,,,,,,,1270.58,3227.75,percent of total billed charges,
CAGE ANCHOR,7736474,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE ANCHOR,7736474,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
FEMORAL IMPLANT,7702026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,5404.09,12262.25,percent of total billed charges,
FEMORAL IMPLANT,7702026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,4826.95,12262.25,percent of total billed charges,
PLATE,7702079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,742.63,1685.08,percent of total billed charges,
PLATE,7702079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,663.32,1685.08,percent of total billed charges,
PLATE,7702080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2216.00000,642.64000,Aetna,First Health,,1812.69,,,,,,,798.87,1812.69,percent of total billed charges,
PLATE,7702080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2216.00000,642.64000,Aetna,First Health,,1812.69,,,,,,,713.55,1812.69,percent of total billed charges,
PLATE,7702081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,742.63,1685.08,percent of total billed charges,
PLATE,7702081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,663.32,1685.08,percent of total billed charges,
PLATE,7702082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,742.63,1685.08,percent of total billed charges,
PLATE,7702082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,663.32,1685.08,percent of total billed charges,
PLATE,7774100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,742.63,1685.08,percent of total billed charges,
PLATE,7774100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,First Health,,1685.08,,,,,,,663.32,1685.08,percent of total billed charges,
PLATE,7786159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1776.60000,515.21000,Aetna,First Health,,1453.26,,,,,,,640.46,1453.26,percent of total billed charges,
PLATE,7786159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1776.60000,515.21000,Aetna,First Health,,1453.26,,,,,,,572.07,1453.26,percent of total billed charges,
PLATE,7702084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1124.76,2552.16,percent of total billed charges,
PLATE,7702084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1004.64,2552.16,percent of total billed charges,
PLATE,7702085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1124.76,2552.16,percent of total billed charges,
PLATE,7702085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1004.64,2552.16,percent of total billed charges,
PLATE,7965932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2314.80000,671.29000,Aetna,First Health,,1893.51,,,,,,,834.49,1893.51,percent of total billed charges,
PLATE,7965932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2314.80000,671.29000,Aetna,First Health,,1893.51,,,,,,,745.37,1893.51,percent of total billed charges,
IMPLANT SINUS,7701627,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
IMPLANT SINUS,7701627,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
IMPLANT SINUS,7955820,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
IMPLANT SINUS,7955820,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
PLATE,7935352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3370.12000,977.33000,Aetna,First Health,,2756.76,,,,,,,1214.93,2756.76,percent of total billed charges,
PLATE,7935352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3370.12000,977.33000,Aetna,First Health,,2756.76,,,,,,,1085.18,2756.76,percent of total billed charges,
PLATE,7964527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3638.95000,1055.30000,Aetna,First Health,,2976.66,,,,,,,1311.84,2976.66,percent of total billed charges,
PLATE,7964527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3638.95000,1055.30000,Aetna,First Health,,2976.66,,,,,,,1171.74,2976.66,percent of total billed charges,
PLATE,7896905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5816.83000,1686.88000,Aetna,First Health,,4758.17,,,,,,,2096.97,4758.17,percent of total billed charges,
PLATE,7896905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5816.83000,1686.88000,Aetna,First Health,,4758.17,,,,,,,1873.02,4758.17,percent of total billed charges,
SCREW,7794040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7794040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7794041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7794041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7812118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7812118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7866036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7866036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7916471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,344.57,781.84,percent of total billed charges,
SCREW,7916471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,307.77,781.84,percent of total billed charges,
SCREW,7916473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,344.57,781.84,percent of total billed charges,
SCREW,7916473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,307.77,781.84,percent of total billed charges,
SCREW,7916492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,344.57,781.84,percent of total billed charges,
SCREW,7916492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,307.77,781.84,percent of total billed charges,
SCREW,7933874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7933874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7939508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939513,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939513,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939515,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939515,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939516,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939516,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939522,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939522,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939526,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939526,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7939535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7939535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
STEM,7700890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,7700890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
STEM,7701580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,7701580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
STEM,7701643,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,7701643,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
STEM,7893802,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,7893802,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
STEM,7922501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,7922501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
STEM,7938914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,7938914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
BALLOON,7695947,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7695947,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7695948,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7695948,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7696058,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7696058,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7698519,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7698519,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
K WIRE,7880283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,35.30,80.09,percent of total billed charges,
K WIRE,7880283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,31.53,80.09,percent of total billed charges,
K WIRE,7701186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,99.75000,28.93000,Aetna,First Health,,81.60,,,,,,,35.96,81.60,percent of total billed charges,
K WIRE,7701186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,99.75000,28.93000,Aetna,First Health,,81.60,,,,,,,32.12,81.60,percent of total billed charges,
K WIRE,7701184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,99.75000,28.93000,Aetna,First Health,,81.60,,,,,,,35.96,81.60,percent of total billed charges,
K WIRE,7701184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,99.75000,28.93000,Aetna,First Health,,81.60,,,,,,,32.12,81.60,percent of total billed charges,
K WIRE,7701185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,99.75000,28.93000,Aetna,First Health,,81.60,,,,,,,35.96,81.60,percent of total billed charges,
K WIRE,7701185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,99.75000,28.93000,Aetna,First Health,,81.60,,,,,,,32.12,81.60,percent of total billed charges,
K WIRE,7697871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,114.45000,33.19000,Aetna,First Health,,93.62,,,,,,,41.26,93.62,percent of total billed charges,
K WIRE,7697871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,114.45000,33.19000,Aetna,First Health,,93.62,,,,,,,36.85,93.62,percent of total billed charges,
K WIRE,7699397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,94.50000,27.40000,Aetna,First Health,,77.30,,,,,,,34.07,77.30,percent of total billed charges,
K WIRE,7699397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,94.50000,27.40000,Aetna,First Health,,77.30,,,,,,,30.43,77.30,percent of total billed charges,
K WIRE,7972584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,128.63000,37.30000,Aetna,First Health,,105.22,,,,,,,46.37,105.22,percent of total billed charges,
K WIRE,7972584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,128.63000,37.30000,Aetna,First Health,,105.22,,,,,,,41.42,105.22,percent of total billed charges,
K WIRE,7806380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,128.63000,37.30000,Aetna,First Health,,105.22,,,,,,,46.37,105.22,percent of total billed charges,
K WIRE,7806380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,128.63000,37.30000,Aetna,First Health,,105.22,,,,,,,41.42,105.22,percent of total billed charges,
K WIRE,7902073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
K WIRE,7902073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
K WIRE,7908713,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
K WIRE,7908713,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,43.95,111.66,percent of total billed charges,
K WIRE,7926976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
K WIRE,7926976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,43.95,111.66,percent of total billed charges,
K WIRE,7694962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,137.88000,39.99000,Aetna,First Health,,112.79,,,,,,,49.71,112.79,percent of total billed charges,
K WIRE,7694962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,137.88000,39.99000,Aetna,First Health,,112.79,,,,,,,44.40,112.79,percent of total billed charges,
K WIRE,7694963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,137.88000,39.99000,Aetna,First Health,,112.79,,,,,,,49.71,112.79,percent of total billed charges,
K WIRE,7694963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,137.88000,39.99000,Aetna,First Health,,112.79,,,,,,,44.40,112.79,percent of total billed charges,
K WIRE,7700540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,137.88000,39.99000,Aetna,First Health,,112.79,,,,,,,49.71,112.79,percent of total billed charges,
K WIRE,7700540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,137.88000,39.99000,Aetna,First Health,,112.79,,,,,,,44.40,112.79,percent of total billed charges,
K WIRE,7695480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,88.99000,25.81000,Aetna,First Health,,72.79,,,,,,,32.08,72.79,percent of total billed charges,
K WIRE,7695480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,88.99000,25.81000,Aetna,First Health,,72.79,,,,,,,28.65,72.79,percent of total billed charges,
K WIRE,7697873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,88.99000,25.81000,Aetna,First Health,,72.79,,,,,,,32.08,72.79,percent of total billed charges,
K WIRE,7697873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,88.99000,25.81000,Aetna,First Health,,72.79,,,,,,,28.65,72.79,percent of total billed charges,
K WIRE,7695345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
K WIRE,7695345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
K WIRE,7822191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,202.65000,58.77000,Aetna,First Health,,165.77,,,,,,,73.06,165.77,percent of total billed charges,
K WIRE,7822191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,202.65000,58.77000,Aetna,First Health,,165.77,,,,,,,65.25,165.77,percent of total billed charges,
K WIRE,7700648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,51.10,115.95,percent of total billed charges,
K WIRE,7700648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,45.64,115.95,percent of total billed charges,
K WIRE,7698683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,37.85,85.89,percent of total billed charges,
K WIRE,7698683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,33.81,85.89,percent of total billed charges,
K WIRE,7700650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,51.10,115.95,percent of total billed charges,
K WIRE,7700650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,45.64,115.95,percent of total billed charges,
K WIRE,7758085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
K WIRE,7758085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
K WIRE,7911784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
K WIRE,7911784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
K WIRE,7924876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
K WIRE,7924876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
K WIRE,7740541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
K WIRE,7740541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
K WIRE,7968208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
K WIRE,7968208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
K WIRE,7968631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
K WIRE,7968631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
K WIRE,7698684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
K WIRE,7698684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,43.95,111.66,percent of total billed charges,
K WIRE,7882262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
K WIRE,7882262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
K WIRE,7925865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
K WIRE,7925865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
K WIRE,7876433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,51.10,115.95,percent of total billed charges,
K WIRE,7876433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,45.64,115.95,percent of total billed charges,
K WIRE,7698121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,235.73000,68.36000,Aetna,First Health,,192.83,,,,,,,84.98,192.83,percent of total billed charges,
K WIRE,7698121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,235.73000,68.36000,Aetna,First Health,,192.83,,,,,,,75.91,192.83,percent of total billed charges,
K WIRE,7700028,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
K WIRE,7700028,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
K WIRE,7698500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
K WIRE,7698500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
K WIRE,7699658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
K WIRE,7699658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
K WIRE,7700519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
K WIRE,7700519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
K WIRE,7700924,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
K WIRE,7700924,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
PLATE,7700917,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6218.80000,1803.45000,Aetna,First Health,,5086.98,,,,,,,2241.88,5086.98,percent of total billed charges,
PLATE,7700917,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6218.80000,1803.45000,Aetna,First Health,,5086.98,,,,,,,2002.45,5086.98,percent of total billed charges,
PLATE,7701500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3438.09000,997.05000,Aetna,First Health,,2812.36,,,,,,,1239.43,2812.36,percent of total billed charges,
PLATE,7701500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3438.09000,997.05000,Aetna,First Health,,2812.36,,,,,,,1107.06,2812.36,percent of total billed charges,
PLATE,7702154,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6218.80000,1803.45000,Aetna,First Health,,5086.98,,,,,,,2241.88,5086.98,percent of total billed charges,
PLATE,7702154,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6218.80000,1803.45000,Aetna,First Health,,5086.98,,,,,,,2002.45,5086.98,percent of total billed charges,
PLATE,7736537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3511.31000,1018.28000,Aetna,First Health,,2872.25,,,,,,,1265.83,2872.25,percent of total billed charges,
PLATE,7736537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3511.31000,1018.28000,Aetna,First Health,,2872.25,,,,,,,1130.64,2872.25,percent of total billed charges,
PLATE,7742175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6161.75000,1786.91000,Aetna,First Health,,5040.31,,,,,,,2221.31,5040.31,percent of total billed charges,
PLATE,7742175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6161.75000,1786.91000,Aetna,First Health,,5040.31,,,,,,,1984.08,5040.31,percent of total billed charges,
PLATE,7750590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5549.92000,1609.48000,Aetna,First Health,,4539.83,,,,,,,2000.75,4539.83,percent of total billed charges,
PLATE,7750590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5549.92000,1609.48000,Aetna,First Health,,4539.83,,,,,,,1787.07,4539.83,percent of total billed charges,
PLATE,7756373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7756379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7756379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,7786052,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7786052,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7790169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7790169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,7699423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2424.00000,702.96000,Aetna,First Health,,1982.83,,,,,,,873.85,1982.83,percent of total billed charges,
SCREW,7699423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2424.00000,702.96000,Aetna,First Health,,1982.83,,,,,,,780.53,1982.83,percent of total billed charges,
SCREW,7699424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2009.40000,582.73000,Aetna,First Health,,1643.69,,,,,,,724.39,1643.69,percent of total billed charges,
SCREW,7699424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2009.40000,582.73000,Aetna,First Health,,1643.69,,,,,,,647.03,1643.69,percent of total billed charges,
SCREW,7700424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,7700424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
SCREW,7958129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,795.42000,230.67000,Aetna,First Health,,650.65,,,,,,,286.75,650.65,percent of total billed charges,
SCREW,7958129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,795.42000,230.67000,Aetna,First Health,,650.65,,,,,,,256.13,650.65,percent of total billed charges,
SCREW,7958131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,795.42000,230.67000,Aetna,First Health,,650.65,,,,,,,286.75,650.65,percent of total billed charges,
SCREW,7958131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,795.42000,230.67000,Aetna,First Health,,650.65,,,,,,,256.13,650.65,percent of total billed charges,
COMPONENT TIBIAL,7699438,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8611.20000,2497.25000,Aetna,First Health,,7043.96,,,,,,,3104.34,7043.96,percent of total billed charges,
COMPONENT TIBIAL,7699438,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8611.20000,2497.25000,Aetna,First Health,,7043.96,,,,,,,2772.81,7043.96,percent of total billed charges,
PLATE,7699671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2816.00000,816.64000,Aetna,First Health,,2303.49,,,,,,,1015.17,2303.49,percent of total billed charges,
PLATE,7699671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2816.00000,816.64000,Aetna,First Health,,2303.49,,,,,,,906.75,2303.49,percent of total billed charges,
SCREW,7699395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7699446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7699446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7699519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7699519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7699520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7699520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7699521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7699521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7699705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7699705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7700084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,124.66,282.86,percent of total billed charges,
SCREW,7700084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,111.35,282.86,percent of total billed charges,
SCREW,7700409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7700409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7701776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7701776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7702019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7702019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7702264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7702264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7702317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,335.87000,97.40000,Aetna,First Health,,274.74,,,,,,,121.08,274.74,percent of total billed charges,
SCREW,7702317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,335.87000,97.40000,Aetna,First Health,,274.74,,,,,,,108.15,274.74,percent of total billed charges,
SCREW,7702318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,79.50000,23.06000,Aetna,First Health,,65.03,,,,,,,28.66,65.03,percent of total billed charges,
SCREW,7702318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,79.50000,23.06000,Aetna,First Health,,65.03,,,,,,,25.60,65.03,percent of total billed charges,
SCREW,7702319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,321.58000,93.26000,Aetna,First Health,,263.05,,,,,,,115.93,263.05,percent of total billed charges,
SCREW,7702319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,321.58000,93.26000,Aetna,First Health,,263.05,,,,,,,103.55,263.05,percent of total billed charges,
SCREW,7702320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,321.58000,93.26000,Aetna,First Health,,263.05,,,,,,,115.93,263.05,percent of total billed charges,
SCREW,7702320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,321.58000,93.26000,Aetna,First Health,,263.05,,,,,,,103.55,263.05,percent of total billed charges,
SCREW,7702620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,124.66,282.86,percent of total billed charges,
SCREW,7702620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,111.35,282.86,percent of total billed charges,
SCREW,7702627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7702627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7736060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7736060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7736536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,124.66,282.86,percent of total billed charges,
SCREW,7736536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,111.35,282.86,percent of total billed charges,
SCREW,7736535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,124.66,282.86,percent of total billed charges,
SCREW,7736535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,111.35,282.86,percent of total billed charges,
SCREW,7754160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7754160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
SCREW,7878190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7878190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7957845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7957845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7703107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7703107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7703109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7703109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7703110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7703110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7703111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7703111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7703112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7703112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
FEMORAL IMPLANT,7699453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17887.00000,5187.23000,Aetna,First Health,,14631.57,,,,,,,6448.26,14631.57,percent of total billed charges,
FEMORAL IMPLANT,7699453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17887.00000,5187.23000,Aetna,First Health,,14631.57,,,,,,,5759.61,14631.57,percent of total billed charges,
FEMORAL HEAD,7698772,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7698772,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7699455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7699455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7699925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7699925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7702246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
FEMORAL HEAD,7702246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
FEMORAL HEAD,7736165,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7736165,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7736488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7736488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7741709,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7741709,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7786156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7786156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7834040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7834040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7846133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7846133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7848088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7848088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7880291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7880291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7893914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7893914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7911286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7911286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7938992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7938992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
PLATE,7700098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
PLATE,7700098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
PLATE,7700277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6077.86000,1762.58000,Aetna,First Health,,4971.69,,,,,,,2191.07,4971.69,percent of total billed charges,
PLATE,7700277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6077.86000,1762.58000,Aetna,First Health,,4971.69,,,,,,,1957.07,4971.69,percent of total billed charges,
PLATE,7772045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4957.05000,1437.54000,Aetna,First Health,,4054.87,,,,,,,1787.02,4054.87,percent of total billed charges,
PLATE,7772045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4957.05000,1437.54000,Aetna,First Health,,4054.87,,,,,,,1596.17,4054.87,percent of total billed charges,
PLATE,7772046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5153.40000,1494.49000,Aetna,First Health,,4215.48,,,,,,,1857.80,4215.48,percent of total billed charges,
PLATE,7772046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5153.40000,1494.49000,Aetna,First Health,,4215.48,,,,,,,1659.39,4215.48,percent of total billed charges,
LINER,7699752,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7699752,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7699943,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7699943,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7700293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7700293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7701057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7701057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7701625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7701625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7702192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7702192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7707511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7707511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7736214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7736214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7736444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7736444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7736579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7736579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7760133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7760133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7820079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7820079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7822252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7822252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7834078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7834078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7878315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7878315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7893574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7893574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7896903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7896903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7905496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7905496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7954744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7954744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SHELL,7699753,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7699753,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7700536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7700536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7784547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7784547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7802064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7802064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7802108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7802108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7822251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7822251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7880511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7880511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7882505,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7882505,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SHELL,7902683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,7902683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BALLOON,7699470,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
BALLOON,7699470,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
BALLOON,7699471,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BALLOON,7699471,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
BALLOON,7699472,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BALLOON,7699472,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
BALLOON,7694928,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
BALLOON,7694928,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
BALLOON,7699473,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
BALLOON,7699473,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
BALLOON,7699474,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
BALLOON,7699474,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
BALLOON,7699475,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
BALLOON,7699475,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
BALLOON,7699476,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
BALLOON,7699476,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
BALLOON,7699477,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
BALLOON,7699477,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
BALLOON,7922462,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
BALLOON,7922462,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
BALLOON,7922463,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
BALLOON,7922463,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
TAPER,7699616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
TAPER,7699616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
TAPER,7699798,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
TAPER,7699798,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
TAPER,7700310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
TAPER,7700310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
TAPER,7700721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
TAPER,7700721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
TAPER,7699701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.80000,359.83000,Aetna,First Health,,1014.97,,,,,,,447.31,1014.97,percent of total billed charges,
TAPER,7699701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.80000,359.83000,Aetna,First Health,,1014.97,,,,,,,399.54,1014.97,percent of total billed charges,
CABLE,7698166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2000.00000,580.00000,Aetna,First Health,,1636.00,,,,,,,721.00,1636.00,percent of total billed charges,
CABLE,7698166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2000.00000,580.00000,Aetna,First Health,,1636.00,,,,,,,644.00,1636.00,percent of total billed charges,
CABLE,7702781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1890.40000,548.22000,Aetna,First Health,,1546.35,,,,,,,681.49,1546.35,percent of total billed charges,
CABLE,7702781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1890.40000,548.22000,Aetna,First Health,,1546.35,,,,,,,608.71,1546.35,percent of total billed charges,
SCREW,7698859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7698859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7698860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7698860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7701064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7701064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,7701065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7701065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,7701066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7701066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,7702578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7702578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7736467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1262.80000,366.21000,Aetna,First Health,,1032.97,,,,,,,455.24,1032.97,percent of total billed charges,
SCREW,7736467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1262.80000,366.21000,Aetna,First Health,,1032.97,,,,,,,406.62,1032.97,percent of total billed charges,
SCREW,7736468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1262.80000,366.21000,Aetna,First Health,,1032.97,,,,,,,455.24,1032.97,percent of total billed charges,
SCREW,7736468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1262.80000,366.21000,Aetna,First Health,,1032.97,,,,,,,406.62,1032.97,percent of total billed charges,
SCREW,7741344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
SCREW,7741344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,7746052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,330.96,750.96,percent of total billed charges,
SCREW,7746052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,295.61,750.96,percent of total billed charges,
SCREW,7746053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,330.96,750.96,percent of total billed charges,
SCREW,7746053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,295.61,750.96,percent of total billed charges,
SCREW,7901855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7901855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7904325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7904325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7905042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7905042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7918564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,7918564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,7934008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.32000,281.97000,Aetna,First Health,,795.36,,,,,,,350.52,795.36,percent of total billed charges,
SCREW,7934008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.32000,281.97000,Aetna,First Health,,795.36,,,,,,,313.09,795.36,percent of total billed charges,
SCREW,7934009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7934009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,7934010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7934010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
PLATE,7702398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3086.32000,895.03000,Aetna,First Health,,2524.61,,,,,,,1112.62,2524.61,percent of total billed charges,
PLATE,7702398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3086.32000,895.03000,Aetna,First Health,,2524.61,,,,,,,993.80,2524.61,percent of total billed charges,
STEM,7699702,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,8029.01,18218.40,percent of total billed charges,
STEM,7699702,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,7171.55,18218.40,percent of total billed charges,
STEM,7700722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,8029.01,18218.40,percent of total billed charges,
STEM,7700722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,7171.55,18218.40,percent of total billed charges,
STEM,7736072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,8029.01,18218.40,percent of total billed charges,
STEM,7736072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,7171.55,18218.40,percent of total billed charges,
STEM,7736616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,8029.01,18218.40,percent of total billed charges,
STEM,7736616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,7171.55,18218.40,percent of total billed charges,
STEM,7854033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,8029.01,18218.40,percent of total billed charges,
STEM,7854033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,7171.55,18218.40,percent of total billed charges,
STEM,7893454,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,8029.01,18218.40,percent of total billed charges,
STEM,7893454,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,7171.55,18218.40,percent of total billed charges,
STEM,7913413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,8029.01,18218.40,percent of total billed charges,
STEM,7913413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,First Health,,18218.40,,,,,,,7171.55,18218.40,percent of total billed charges,
HUMERAL HEAD,7695893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7695893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7697534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7697534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7698498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7698498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7699490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7699490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7707440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7707440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7736607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7736607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7802324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7802324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7816129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7816129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7822249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7822249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7828071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7828071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7828140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7828140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7874396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7874396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7880618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7880618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7882508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7882508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7918900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7918900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7962548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7962548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
SLEEVE,7699605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,First Health,,2856.56,,,,,,,1258.91,2856.56,percent of total billed charges,
SLEEVE,7699605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,First Health,,2856.56,,,,,,,1124.47,2856.56,percent of total billed charges,
SLEEVE,7700170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,First Health,,2856.56,,,,,,,1258.91,2856.56,percent of total billed charges,
SLEEVE,7700170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,First Health,,2856.56,,,,,,,1124.47,2856.56,percent of total billed charges,
SLEEVE,7812075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,First Health,,2856.56,,,,,,,1258.91,2856.56,percent of total billed charges,
SLEEVE,7812075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,First Health,,2856.56,,,,,,,1124.47,2856.56,percent of total billed charges,
INSERT,7699606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7699606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7700171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7700171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7700182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7700182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7700395,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7700395,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7700836,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7700836,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7948365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7948365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7948518,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7948518,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7951954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7951954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7957711,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7957711,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7957906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7957906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7962614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7962614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
COMPONENT FEMORAL,7699603,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,7689.47,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7699603,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,6868.26,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7700181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,7689.47,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7700181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,6868.26,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7740558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,7689.47,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7740558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,6868.26,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7897104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,7689.47,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7897104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,6868.26,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7948369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,7689.47,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7948369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,6868.26,17447.94,percent of total billed charges,
WEDGE,7699495,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1543.44,3502.17,percent of total billed charges,
WEDGE,7699495,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1378.60,3502.17,percent of total billed charges,
WEDGE,7699496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1543.44,3502.17,percent of total billed charges,
WEDGE,7699496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1378.60,3502.17,percent of total billed charges,
WEDGE,7700174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1543.44,3502.17,percent of total billed charges,
WEDGE,7700174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1378.60,3502.17,percent of total billed charges,
WEDGE,7754163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1543.44,3502.17,percent of total billed charges,
WEDGE,7754163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1378.60,3502.17,percent of total billed charges,
WEDGE,7894316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1543.44,3502.17,percent of total billed charges,
WEDGE,7894316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1378.60,3502.17,percent of total billed charges,
WEDGE,7905326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1543.44,3502.17,percent of total billed charges,
WEDGE,7905326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1378.60,3502.17,percent of total billed charges,
WEDGE,7700184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7700184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7740557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7740557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7760071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7760071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7895935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7895935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7905327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7905327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7948366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7948366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7948367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7948367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7948520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7948520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7956676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7956676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7957907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7957907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
RADIAL HEAD,7700560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2812.98,6382.85,percent of total billed charges,
RADIAL HEAD,7700560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2512.57,6382.85,percent of total billed charges,
RADIAL HEAD,7736093,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2812.98,6382.85,percent of total billed charges,
RADIAL HEAD,7736093,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2512.57,6382.85,percent of total billed charges,
STEM,7700561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
STEM,7700561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,7700363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1549.73,3516.45,percent of total billed charges,
PLATE,7700363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1384.23,3516.45,percent of total billed charges,
PLATE,7700572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1549.73,3516.45,percent of total billed charges,
PLATE,7700572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1384.23,3516.45,percent of total billed charges,
PLATE,7701847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3478.65000,1008.81000,Aetna,First Health,,2845.54,,,,,,,1254.05,2845.54,percent of total billed charges,
PLATE,7701847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3478.65000,1008.81000,Aetna,First Health,,2845.54,,,,,,,1120.13,2845.54,percent of total billed charges,
PLATE,7707485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4265.10000,1236.88000,Aetna,First Health,,3488.85,,,,,,,1537.57,3488.85,percent of total billed charges,
PLATE,7707485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4265.10000,1236.88000,Aetna,First Health,,3488.85,,,,,,,1373.36,3488.85,percent of total billed charges,
PLATE,7707491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1549.73,3516.45,percent of total billed charges,
PLATE,7707491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1384.23,3516.45,percent of total billed charges,
PLATE,7736127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2448.04000,709.93000,Aetna,First Health,,2002.50,,,,,,,882.52,2002.50,percent of total billed charges,
PLATE,7736127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2448.04000,709.93000,Aetna,First Health,,2002.50,,,,,,,788.27,2002.50,percent of total billed charges,
PLATE,7750596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1549.73,3516.45,percent of total billed charges,
PLATE,7750596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1384.23,3516.45,percent of total billed charges,
PLATE,7894137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1549.73,3516.45,percent of total billed charges,
PLATE,7894137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,First Health,,3516.45,,,,,,,1384.23,3516.45,percent of total billed charges,
STENT GRAFT,7768033,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4558.52,10343.61,percent of total billed charges,
STENT GRAFT,7768033,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4071.69,10343.61,percent of total billed charges,
STENT GRAFT,7790540,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4558.52,10343.61,percent of total billed charges,
STENT GRAFT,7790540,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4071.69,10343.61,percent of total billed charges,
STENT GRAFT,7818080,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4558.52,10343.61,percent of total billed charges,
STENT GRAFT,7818080,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4071.69,10343.61,percent of total billed charges,
STENT GRAFT,7826034,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STENT GRAFT,7826034,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
LEAD,7700290,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,2321.00000,673.09000,Aetna,First Health,,1898.58,,,,,,,836.72,1898.58,percent of total billed charges,
LEAD,7700290,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,2321.00000,673.09000,Aetna,First Health,,1898.58,,,,,,,747.36,1898.58,percent of total billed charges,
LEAD,7700291,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,2321.00000,673.09000,Aetna,First Health,,1898.58,,,,,,,836.72,1898.58,percent of total billed charges,
LEAD,7700291,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,2321.00000,673.09000,Aetna,First Health,,1898.58,,,,,,,747.36,1898.58,percent of total billed charges,
LEAD,7697447,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
LEAD,7697447,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
LEAD,7697898,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
LEAD,7697898,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
STENT,7694937,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
STENT,7694937,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
STENT,7694951,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
STENT,7694951,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
STENT,7694992,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
STENT,7694992,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
STENT,7695007,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
STENT,7695007,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
COIL,7699833,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,First Health,,3070.57,,,,,,,1353.23,3070.57,percent of total billed charges,
COIL,7699833,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,First Health,,3070.57,,,,,,,1208.71,3070.57,percent of total billed charges,
COIL,7701629,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
COIL,7701629,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COIL,7878540,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,First Health,,3070.57,,,,,,,1353.23,3070.57,percent of total billed charges,
COIL,7878540,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,First Health,,3070.57,,,,,,,1208.71,3070.57,percent of total billed charges,
COIL,7944416,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,First Health,,3070.57,,,,,,,1353.23,3070.57,percent of total billed charges,
COIL,7944416,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,First Health,,3070.57,,,,,,,1208.71,3070.57,percent of total billed charges,
RADIAL HEAD,7700476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,First Health,,18047.12,,,,,,,7953.53,18047.12,percent of total billed charges,
RADIAL HEAD,7700476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,First Health,,18047.12,,,,,,,7104.12,18047.12,percent of total billed charges,
RADIAL HEAD,7707473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,First Health,,18047.12,,,,,,,7953.53,18047.12,percent of total billed charges,
RADIAL HEAD,7707473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,First Health,,18047.12,,,,,,,7104.12,18047.12,percent of total billed charges,
RADIAL HEAD,7736088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,First Health,,18047.12,,,,,,,7953.53,18047.12,percent of total billed charges,
RADIAL HEAD,7736088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,First Health,,18047.12,,,,,,,7104.12,18047.12,percent of total billed charges,
RADIAL HEAD,7921151,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,First Health,,18047.12,,,,,,,7953.53,18047.12,percent of total billed charges,
RADIAL HEAD,7921151,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,First Health,,18047.12,,,,,,,7104.12,18047.12,percent of total billed charges,
STEM,7700477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,5515.65,12515.40,percent of total billed charges,
STEM,7700477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,4926.60,12515.40,percent of total billed charges,
STEM,7707472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,5515.65,12515.40,percent of total billed charges,
STEM,7707472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,4926.60,12515.40,percent of total billed charges,
STEM,7736089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,5515.65,12515.40,percent of total billed charges,
STEM,7736089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,4926.60,12515.40,percent of total billed charges,
STEM,7921150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,5515.65,12515.40,percent of total billed charges,
STEM,7921150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,4926.60,12515.40,percent of total billed charges,
TIBIAL TRAY,7698418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,First Health,,15018.48,,,,,,,6618.78,15018.48,percent of total billed charges,
TIBIAL TRAY,7698418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,First Health,,15018.48,,,,,,,5911.92,15018.48,percent of total billed charges,
TIBIAL TRAY,7699530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,First Health,,15018.48,,,,,,,6618.78,15018.48,percent of total billed charges,
TIBIAL TRAY,7699530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,First Health,,15018.48,,,,,,,5911.92,15018.48,percent of total billed charges,
TIBIAL TRAY,7699816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,First Health,,15018.48,,,,,,,6618.78,15018.48,percent of total billed charges,
TIBIAL TRAY,7699816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,First Health,,15018.48,,,,,,,5911.92,15018.48,percent of total billed charges,
NAIL,7696555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7696555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7696835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7696835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7697541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7697541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7697646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7697646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7698455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7698455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7698456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7698456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7699534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7699534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7699535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7699535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7699536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7699536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7700071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7700071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7700655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7700655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7701591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7701591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7736652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7736652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7740525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7740525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7776153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7776153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7782042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7782042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7840127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7840127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7935474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7935474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7944047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7944047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7954160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7954160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7961865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7961865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
SCREW,7698921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7698921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7698922,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7698922,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7698923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7698923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7699354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7699354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7700273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7700273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7700274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7700274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7700275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7700275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7700276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7700276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7700894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7700894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7700895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7700895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7700897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7700897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7702203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,202.23,458.87,percent of total billed charges,
SCREW,7702203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,180.63,458.87,percent of total billed charges,
SCREW,7736073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7736073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7736075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7736075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7741339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7741339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7741726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7741726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7802413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,619.79000,179.74000,Aetna,First Health,,506.99,,,,,,,223.43,506.99,percent of total billed charges,
SCREW,7802413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,619.79000,179.74000,Aetna,First Health,,506.99,,,,,,,199.57,506.99,percent of total billed charges,
SCREW,7806189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7806189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7812149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7812149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7812150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7812150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7812153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7812153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7848029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,7848029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,7874186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7874186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7893283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,912.60000,264.65000,Aetna,First Health,,746.51,,,,,,,328.99,746.51,percent of total billed charges,
SCREW,7893283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,912.60000,264.65000,Aetna,First Health,,746.51,,,,,,,293.86,746.51,percent of total billed charges,
SCREW,7905324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,324.45,736.20,percent of total billed charges,
SCREW,7905324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,289.80,736.20,percent of total billed charges,
SCREW,7905595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7905595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7905596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7905596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7914037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7914037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7914398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7914398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7918139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7918139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,7966078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
SCREW,7966078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
COMPONENT PATELLA,7699541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7699541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7699604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7699604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7748735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7748735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7893453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7893453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT PATELLA,7904985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,7904985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
STENT GRAFT,7740550,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,18652.27,42323.32,percent of total billed charges,
STENT GRAFT,7740550,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,16660.28,42323.32,percent of total billed charges,
STENT GRAFT,7764086,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,18652.27,42323.32,percent of total billed charges,
STENT GRAFT,7764086,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,16660.28,42323.32,percent of total billed charges,
STENT GRAFT,7764090,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,18652.27,42323.32,percent of total billed charges,
STENT GRAFT,7764090,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,16660.28,42323.32,percent of total billed charges,
STENT GRAFT,7764093,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,18652.27,42323.32,percent of total billed charges,
STENT GRAFT,7764093,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,16660.28,42323.32,percent of total billed charges,
STENT GRAFT,7764095,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,18652.27,42323.32,percent of total billed charges,
STENT GRAFT,7764095,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,16660.28,42323.32,percent of total billed charges,
STENT GRAFT,7764082,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,16524.24,37494.67,percent of total billed charges,
STENT GRAFT,7764082,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,14759.51,37494.67,percent of total billed charges,
STENT GRAFT,7764083,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,16524.24,37494.67,percent of total billed charges,
STENT GRAFT,7764083,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,14759.51,37494.67,percent of total billed charges,
STENT GRAFT,7764084,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,16524.24,37494.67,percent of total billed charges,
STENT GRAFT,7764084,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,14759.51,37494.67,percent of total billed charges,
STENT GRAFT,7764085,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,16524.24,37494.67,percent of total billed charges,
STENT GRAFT,7764085,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,14759.51,37494.67,percent of total billed charges,
STENT GRAFT,7954010,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,16524.24,37494.67,percent of total billed charges,
STENT GRAFT,7954010,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,14759.51,37494.67,percent of total billed charges,
STENT GRAFT,7954430,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,16524.24,37494.67,percent of total billed charges,
STENT GRAFT,7954430,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,14759.51,37494.67,percent of total billed charges,
PLATE,7702980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1737.32000,503.82000,Aetna,First Health,,1421.13,,,,,,,626.30,1421.13,percent of total billed charges,
PLATE,7702980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1737.32000,503.82000,Aetna,First Health,,1421.13,,,,,,,559.42,1421.13,percent of total billed charges,
PLATE,7702981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1746.60000,506.51000,Aetna,First Health,,1428.72,,,,,,,629.65,1428.72,percent of total billed charges,
PLATE,7702981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1746.60000,506.51000,Aetna,First Health,,1428.72,,,,,,,562.41,1428.72,percent of total billed charges,
PLATE,7707549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1970.08000,571.32000,Aetna,First Health,,1611.53,,,,,,,710.21,1611.53,percent of total billed charges,
PLATE,7707549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1970.08000,571.32000,Aetna,First Health,,1611.53,,,,,,,634.37,1611.53,percent of total billed charges,
PLATE,7750033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1917.32000,556.02000,Aetna,First Health,,1568.37,,,,,,,691.19,1568.37,percent of total billed charges,
PLATE,7750033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1917.32000,556.02000,Aetna,First Health,,1568.37,,,,,,,617.38,1568.37,percent of total billed charges,
PLATE,7940363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2812.00000,815.48000,Aetna,First Health,,2300.22,,,,,,,1013.73,2300.22,percent of total billed charges,
PLATE,7940363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2812.00000,815.48000,Aetna,First Health,,2300.22,,,,,,,905.46,2300.22,percent of total billed charges,
PLATE,7961993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2115.92000,613.62000,Aetna,First Health,,1730.82,,,,,,,762.79,1730.82,percent of total billed charges,
PLATE,7961993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2115.92000,613.62000,Aetna,First Health,,1730.82,,,,,,,681.33,1730.82,percent of total billed charges,
SCREW,7699558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7699558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7894136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7894136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7895467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7895467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7895468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7895468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7895469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7895469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7895961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7895961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7901854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,948.02000,274.93000,Aetna,First Health,,775.48,,,,,,,341.76,775.48,percent of total billed charges,
SCREW,7901854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,948.02000,274.93000,Aetna,First Health,,775.48,,,,,,,305.26,775.48,percent of total billed charges,
SCREW,7930310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,948.02000,274.93000,Aetna,First Health,,775.48,,,,,,,341.76,775.48,percent of total billed charges,
SCREW,7930310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,948.02000,274.93000,Aetna,First Health,,775.48,,,,,,,305.26,775.48,percent of total billed charges,
SCREW,7937841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7937841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7937842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7937842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7937843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7937843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7703187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,948.02000,274.93000,Aetna,First Health,,775.48,,,,,,,341.76,775.48,percent of total billed charges,
SCREW,7703187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,948.02000,274.93000,Aetna,First Health,,775.48,,,,,,,305.26,775.48,percent of total billed charges,
SCREW,7703191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,948.02000,274.93000,Aetna,First Health,,775.48,,,,,,,341.76,775.48,percent of total billed charges,
SCREW,7703191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,948.02000,274.93000,Aetna,First Health,,775.48,,,,,,,305.26,775.48,percent of total billed charges,
PLATE,7701809,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701809,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,7701810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
PLATE,7701824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,981.45000,284.62000,Aetna,First Health,,802.83,,,,,,,353.81,802.83,percent of total billed charges,
PLATE,7701824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,981.45000,284.62000,Aetna,First Health,,802.83,,,,,,,316.03,802.83,percent of total billed charges,
PLATE,7707529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,First Health,,1208.02,,,,,,,532.39,1208.02,percent of total billed charges,
PLATE,7707529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,First Health,,1208.02,,,,,,,475.53,1208.02,percent of total billed charges,
PLATE,7936053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,684.00000,198.36000,Aetna,First Health,,559.51,,,,,,,246.58,559.51,percent of total billed charges,
PLATE,7936053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,684.00000,198.36000,Aetna,First Health,,559.51,,,,,,,220.25,559.51,percent of total billed charges,
PLATE,7701542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4773.06000,1384.19000,Aetna,First Health,,3904.36,,,,,,,1720.69,3904.36,percent of total billed charges,
PLATE,7701542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4773.06000,1384.19000,Aetna,First Health,,3904.36,,,,,,,1536.93,3904.36,percent of total billed charges,
PLATE,7701543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4773.06000,1384.19000,Aetna,First Health,,3904.36,,,,,,,1720.69,3904.36,percent of total billed charges,
PLATE,7701543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4773.06000,1384.19000,Aetna,First Health,,3904.36,,,,,,,1536.93,3904.36,percent of total billed charges,
PLATE,7701544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4773.06000,1384.19000,Aetna,First Health,,3904.36,,,,,,,1720.69,3904.36,percent of total billed charges,
PLATE,7701544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4773.06000,1384.19000,Aetna,First Health,,3904.36,,,,,,,1536.93,3904.36,percent of total billed charges,
PLATE,7701545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4773.02000,1384.18000,Aetna,First Health,,3904.33,,,,,,,1720.67,3904.33,percent of total billed charges,
PLATE,7701545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4773.02000,1384.18000,Aetna,First Health,,3904.33,,,,,,,1536.91,3904.33,percent of total billed charges,
PLATE,7856030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2693.24000,781.04000,Aetna,First Health,,2203.07,,,,,,,970.91,2203.07,percent of total billed charges,
PLATE,7856030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2693.24000,781.04000,Aetna,First Health,,2203.07,,,,,,,867.22,2203.07,percent of total billed charges,
PLATE,7929709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1582.12000,458.81000,Aetna,First Health,,1294.17,,,,,,,570.35,1294.17,percent of total billed charges,
PLATE,7929709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1582.12000,458.81000,Aetna,First Health,,1294.17,,,,,,,509.44,1294.17,percent of total billed charges,
PLATE,7702970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1582.12000,458.81000,Aetna,First Health,,1294.17,,,,,,,570.35,1294.17,percent of total billed charges,
PLATE,7702970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1582.12000,458.81000,Aetna,First Health,,1294.17,,,,,,,509.44,1294.17,percent of total billed charges,
ROD,7697971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7697971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7698036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1224.00000,354.96000,Aetna,First Health,,1001.23,,,,,,,441.25,1001.23,percent of total billed charges,
ROD,7698036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1224.00000,354.96000,Aetna,First Health,,1001.23,,,,,,,394.13,1001.23,percent of total billed charges,
ROD,7698505,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7698505,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7900336,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7900336,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7927167,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7927167,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7935730,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
ROD,7935730,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
ROD,7937744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7937744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7937746,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7937746,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7964531,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7964531,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,7794302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,432.92,982.32,percent of total billed charges,
SCREW,7794302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,386.68,982.32,percent of total billed charges,
LINER,7699641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7699641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7736070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7736070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7736592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7736592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7736603,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7736603,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7744548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7744548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7748742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7748742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7748744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7748744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7784194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7784194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7806295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7806295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7882380,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7882380,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7893418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7893418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7893680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7893680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
SCREW,7696312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7696312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7699625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7699625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7700821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7700821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7702581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7702581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7707490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7707490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7736534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,302.94,687.39,percent of total billed charges,
SCREW,7736534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,270.59,687.39,percent of total billed charges,
SCREW,7754282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7754282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7897353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,302.94,687.39,percent of total billed charges,
SCREW,7897353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,270.59,687.39,percent of total billed charges,
SCREW,7922957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7922957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7933688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,302.94,687.39,percent of total billed charges,
SCREW,7933688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,First Health,,687.39,,,,,,,270.59,687.39,percent of total billed charges,
SCREW,7948047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7948047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7958085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7958085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7703058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
SCREW,7703058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7703223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,First Health,,501.06,,,,,,,220.82,501.06,percent of total billed charges,
SCREW,7703223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,First Health,,501.06,,,,,,,197.24,501.06,percent of total billed charges,
INSERT,7699634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7699634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7700407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7700407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7700419,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7700419,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7700423,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7700423,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7700813,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7700813,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7700907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7700907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7702241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7702241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7707441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7707441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7736236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7736236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7736218,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7736218,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7736222,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7736222,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7736270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7736270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7736677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7736677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7736685,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7736685,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7742038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7742038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7750087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7750087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7754102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7754102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7754105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7754105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7754159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7754159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7794293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7794293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7794295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7794295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7802059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7802059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7802099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7802099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7802113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7802113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7822259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7822259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7836247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7836247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7846158,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7846158,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7846161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7846161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7874297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7874297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7878314,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7878314,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7882393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7882393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7893452,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7893452,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7893541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7893541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7904846,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7904846,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7905618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7905618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7917308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7917308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7918191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7918191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7918897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7918897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7926532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7926532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7943285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7943285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7951922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7951922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
COMPONENT FEMORAL,7699632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6862.61,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7699632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6129.71,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7736359,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6862.61,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7736359,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6129.71,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7802098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6862.61,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7802098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6129.71,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7909381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6862.61,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7909381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6129.71,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7910369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6862.61,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7910369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6129.71,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7918899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6862.61,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7918899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6129.71,15571.76,percent of total billed charges,
SLEEVE,7736615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2002.36000,580.68000,Aetna,First Health,,1637.93,,,,,,,721.85,1637.93,percent of total billed charges,
SLEEVE,7736615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2002.36000,580.68000,Aetna,First Health,,1637.93,,,,,,,644.76,1637.93,percent of total billed charges,
SLEEVE,7852076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2002.80000,580.81000,Aetna,First Health,,1638.29,,,,,,,722.01,1638.29,percent of total billed charges,
SLEEVE,7852076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2002.80000,580.81000,Aetna,First Health,,1638.29,,,,,,,644.90,1638.29,percent of total billed charges,
SLEEVE,7854031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2851.37,6469.97,percent of total billed charges,
SLEEVE,7854031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2546.86,6469.97,percent of total billed charges,
SLEEVE,7874329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1935.44000,561.28000,Aetna,First Health,,1583.19,,,,,,,697.73,1583.19,percent of total billed charges,
SLEEVE,7874329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1935.44000,561.28000,Aetna,First Health,,1583.19,,,,,,,623.21,1583.19,percent of total billed charges,
SLEEVE,7913414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2002.36000,580.68000,Aetna,First Health,,1637.93,,,,,,,721.85,1637.93,percent of total billed charges,
SLEEVE,7913414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2002.36000,580.68000,Aetna,First Health,,1637.93,,,,,,,644.76,1637.93,percent of total billed charges,
SCREW,7699400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7699400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7699637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,47.83,108.52,percent of total billed charges,
SCREW,7699637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,42.72,108.52,percent of total billed charges,
SCREW,7701558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7701558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7701653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7701757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SCREW,7701757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
SCREW,7707486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,7707486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,7707487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,7707487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,7707488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,7707488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,7707489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,7707489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,7736604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,47.83,108.52,percent of total billed charges,
SCREW,7736604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,42.72,108.52,percent of total billed charges,
SCREW,7736605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,47.83,108.52,percent of total billed charges,
SCREW,7736605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,42.72,108.52,percent of total billed charges,
SCREW,7736606,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,47.83,108.52,percent of total billed charges,
SCREW,7736606,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,42.72,108.52,percent of total billed charges,
SCREW,7778030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,47.83,108.52,percent of total billed charges,
SCREW,7778030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,42.72,108.52,percent of total billed charges,
SCREW,7874333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7874333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,7874334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7874334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,7880507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7880507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7882801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7882801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SCREW,7903041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7903041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,7940331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7940331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
SHELL,7736068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7736068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SHELL,7893432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7893432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SHELL,7919003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7919003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SHELL,7926704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7926704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SHELL,7935780,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7935780,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SHELL,7948082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,7948082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
PLATE,7736478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1739.65,3947.39,percent of total billed charges,
PLATE,7736478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1553.86,3947.39,percent of total billed charges,
PLATE,7740526,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7740526,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7750595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1718.11,3898.52,percent of total billed charges,
PLATE,7750595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,First Health,,3898.52,,,,,,,1534.63,3898.52,percent of total billed charges,
PLATE,7900329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1739.65,3947.39,percent of total billed charges,
PLATE,7900329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1553.86,3947.39,percent of total billed charges,
PLATE,7900330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1739.65,3947.39,percent of total billed charges,
PLATE,7900330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1553.86,3947.39,percent of total billed charges,
PLATE,7900331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1739.65,3947.39,percent of total billed charges,
PLATE,7900331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1553.86,3947.39,percent of total billed charges,
PLATE,7900332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1739.65,3947.39,percent of total billed charges,
PLATE,7900332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1553.86,3947.39,percent of total billed charges,
PLATE,7900333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1739.65,3947.39,percent of total billed charges,
PLATE,7900333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1553.86,3947.39,percent of total billed charges,
PLATE,7900334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1739.65,3947.39,percent of total billed charges,
PLATE,7900334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1553.86,3947.39,percent of total billed charges,
PLATE,7900335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1739.65,3947.39,percent of total billed charges,
PLATE,7900335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,First Health,,3947.39,,,,,,,1553.86,3947.39,percent of total billed charges,
INSERT,7699690,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2826.49,6413.50,percent of total billed charges,
INSERT,7699690,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2524.63,6413.50,percent of total billed charges,
INSERT,7699892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2826.49,6413.50,percent of total billed charges,
INSERT,7699892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2524.63,6413.50,percent of total billed charges,
INSERT,7700376,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2826.49,6413.50,percent of total billed charges,
INSERT,7700376,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2524.63,6413.50,percent of total billed charges,
INSERT,7741334,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2826.49,6413.50,percent of total billed charges,
INSERT,7741334,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2524.63,6413.50,percent of total billed charges,
INSERT,7893766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2826.49,6413.50,percent of total billed charges,
INSERT,7893766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2524.63,6413.50,percent of total billed charges,
INSERT,7925926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2826.49,6413.50,percent of total billed charges,
INSERT,7925926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2524.63,6413.50,percent of total billed charges,
INSERT,7935561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2826.49,6413.50,percent of total billed charges,
INSERT,7935561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2524.63,6413.50,percent of total billed charges,
INSERT,7943812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2826.49,6413.50,percent of total billed charges,
INSERT,7943812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2524.63,6413.50,percent of total billed charges,
COMPONENT TIBIAL,7699691,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,5416.16,12289.66,percent of total billed charges,
COMPONENT TIBIAL,7699691,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,4837.74,12289.66,percent of total billed charges,
AUGMENT TIBIAL,7699893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,5416.16,12289.66,percent of total billed charges,
AUGMENT TIBIAL,7699893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,4837.74,12289.66,percent of total billed charges,
COMPONENT TIBIAL,7699907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,5416.16,12289.66,percent of total billed charges,
COMPONENT TIBIAL,7699907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,4837.74,12289.66,percent of total billed charges,
COMPONENT TIBIAL,7700189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,5416.16,12289.66,percent of total billed charges,
COMPONENT TIBIAL,7700189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,4837.74,12289.66,percent of total billed charges,
COMPONENT TIBIAL,7754287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,5416.16,12289.66,percent of total billed charges,
COMPONENT TIBIAL,7754287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,4837.74,12289.66,percent of total billed charges,
ROD,7699699,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
ROD,7699699,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
ROD,7736171,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
ROD,7736171,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
ROD,7756362,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7756362,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
ROD,7756363,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7756363,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
ROD,7756364,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7756364,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
PLATE,7701894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2446.40000,709.46000,Aetna,First Health,,2001.16,,,,,,,881.93,2001.16,percent of total billed charges,
PLATE,7701894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2446.40000,709.46000,Aetna,First Health,,2001.16,,,,,,,787.74,2001.16,percent of total billed charges,
WASHER,7698944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,124.66,282.86,percent of total billed charges,
WASHER,7698944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,111.35,282.86,percent of total billed charges,
WASHER,7707476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,124.66,282.86,percent of total billed charges,
WASHER,7707476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,111.35,282.86,percent of total billed charges,
WASHER,7703332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,156.61000,45.42000,Aetna,First Health,,128.11,,,,,,,56.46,128.11,percent of total billed charges,
WASHER,7703332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,156.61000,45.42000,Aetna,First Health,,128.11,,,,,,,50.43,128.11,percent of total billed charges,
GUIDEWIRE,7700891,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
GUIDEWIRE,7700891,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
GUIDEWIRE,7935737,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,299.49000,86.85000,Aetna,First Health,,244.98,,,,,,,107.97,244.98,percent of total billed charges,
GUIDEWIRE,7935737,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,299.49000,86.85000,Aetna,First Health,,244.98,,,,,,,96.44,244.98,percent of total billed charges,
PLATE,7699729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8475.00000,2457.75000,Aetna,First Health,,6932.55,,,,,,,3055.24,6932.55,percent of total billed charges,
PLATE,7699729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8475.00000,2457.75000,Aetna,First Health,,6932.55,,,,,,,2728.95,6932.55,percent of total billed charges,
PLATE,7935425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3506.06000,1016.76000,Aetna,First Health,,2867.96,,,,,,,1263.93,2867.96,percent of total billed charges,
PLATE,7935425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3506.06000,1016.76000,Aetna,First Health,,2867.96,,,,,,,1128.95,2867.96,percent of total billed charges,
FILTER,7697286,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
FILTER,7697286,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
SHELL,7699735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
SHELL,7699735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
SHELL,7880654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
SHELL,7880654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
LINER,7699255,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,First Health,,2470.36,,,,,,,1088.71,2470.36,percent of total billed charges,
LINER,7699255,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,First Health,,2470.36,,,,,,,972.44,2470.36,percent of total billed charges,
LINER,7699736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,First Health,,2470.36,,,,,,,1088.71,2470.36,percent of total billed charges,
LINER,7699736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,First Health,,2470.36,,,,,,,972.44,2470.36,percent of total billed charges,
LINER,7802041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,7802041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
LINER,7880194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,7880194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
LINER,7880652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,First Health,,2470.36,,,,,,,1088.71,2470.36,percent of total billed charges,
LINER,7880652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,First Health,,2470.36,,,,,,,972.44,2470.36,percent of total billed charges,
LINER,7880655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,First Health,,2470.36,,,,,,,1088.71,2470.36,percent of total billed charges,
LINER,7880655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,First Health,,2470.36,,,,,,,972.44,2470.36,percent of total billed charges,
LINER,7882831,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6238.58000,1809.19000,Aetna,First Health,,5103.16,,,,,,,2249.01,5103.16,percent of total billed charges,
LINER,7882831,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6238.58000,1809.19000,Aetna,First Health,,5103.16,,,,,,,2008.82,5103.16,percent of total billed charges,
LINER,7939811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6238.58000,1809.19000,Aetna,First Health,,5103.16,,,,,,,2249.01,5103.16,percent of total billed charges,
LINER,7939811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6238.58000,1809.19000,Aetna,First Health,,5103.16,,,,,,,2008.82,5103.16,percent of total billed charges,
FEMORAL HEAD,7880651,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1173.43,2662.59,percent of total billed charges,
FEMORAL HEAD,7880651,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1048.11,2662.59,percent of total billed charges,
FEMORAL HEAD,7882524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1173.43,2662.59,percent of total billed charges,
FEMORAL HEAD,7882524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,First Health,,2662.59,,,,,,,1048.11,2662.59,percent of total billed charges,
BREAST IMPLANT,7697097,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697097,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697098,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697098,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697099,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697099,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697100,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697100,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697101,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697101,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697106,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697106,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697130,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697130,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697131,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697131,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697132,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697132,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697133,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697133,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,764.47,2691.22,percent of total billed charges,
BREAST IMPLANT,7697134,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697134,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697135,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697135,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697136,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697136,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697137,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697137,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697138,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697138,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697139,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697139,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697209,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697209,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697211,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697211,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697215,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697215,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697216,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697216,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697217,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697217,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697218,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697218,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,764.47,2691.22,percent of total billed charges,
BREAST IMPLANT,7697220,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697220,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697221,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697221,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697222,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697222,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697223,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697223,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697224,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697224,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7697225,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697225,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,764.47,2691.22,percent of total billed charges,
BREAST IMPLANT,7697226,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697226,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,764.47,2691.22,percent of total billed charges,
BREAST IMPLANT,7697227,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7697227,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7698309,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7698309,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7698310,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7698310,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7698946,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7698946,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7698947,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7698947,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7698948,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7698948,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7698967,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7698967,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7702060,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7702060,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736042,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736042,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736043,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736043,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736237,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736237,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736239,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736239,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736240,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736240,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736241,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736241,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736242,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736242,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736243,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736243,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736244,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736244,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736245,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736245,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736246,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736246,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736247,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736247,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736249,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736249,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736325,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736325,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736326,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736326,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736327,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736327,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736328,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736328,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736329,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736329,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736330,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736330,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736331,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736331,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736332,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736332,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736427,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736427,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736428,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736428,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736429,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736429,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736430,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736430,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736431,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736431,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736432,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736432,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736433,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736433,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
BREAST IMPLANT,7736434,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
BREAST IMPLANT,7736434,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
FEMORAL HEAD,7699772,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7699772,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7702077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7702077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7784191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7784191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7852035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7852035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7912247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7912247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
TISSUE EXPANDER,7699765,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
TISSUE EXPANDER,7699765,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
TISSUE EXPANDER,7736362,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
TISSUE EXPANDER,7736362,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
TISSUE EXPANDER,7736363,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
TISSUE EXPANDER,7736363,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
TISSUE EXPANDER,7736364,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
TISSUE EXPANDER,7736364,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
TISSUE EXPANDER,7736365,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
TISSUE EXPANDER,7736365,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
TISSUE EXPANDER,7774110,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
TISSUE EXPANDER,7774110,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
INSERT,7698725,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7698725,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,7699791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,7699791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,7702622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,7702622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
LEAD,7699920,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
LEAD,7699920,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
CATHETER,7903656,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1838.00000,533.02000,Aetna,First Health,,1503.48,,,,,,,662.60,1503.48,percent of total billed charges,
CATHETER,7903656,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1838.00000,533.02000,Aetna,First Health,,1503.48,,,,,,,591.84,1503.48,percent of total billed charges,
CATHETER,7938338,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1838.00000,533.02000,Aetna,First Health,,1503.48,,,,,,,662.60,1503.48,percent of total billed charges,
CATHETER,7938338,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1838.00000,533.02000,Aetna,First Health,,1503.48,,,,,,,591.84,1503.48,percent of total billed charges,
SCREW,7695439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7695439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7695440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7695440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7695507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7695507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7695509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7695509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7695511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7695511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7695513,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7695513,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7695514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7695514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7696126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,First Health,,501.06,,,,,,,220.82,501.06,percent of total billed charges,
SCREW,7696126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,First Health,,501.06,,,,,,,197.24,501.06,percent of total billed charges,
SCREW,7697381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7697381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7697644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7697644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7697652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7697652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7697850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7697850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7697983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,344.57,781.84,percent of total billed charges,
SCREW,7697983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,307.77,781.84,percent of total billed charges,
SCREW,7697984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,344.57,781.84,percent of total billed charges,
SCREW,7697984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,307.77,781.84,percent of total billed charges,
SCREW,7698279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7698512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7698512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7699706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7699706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7699709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7699709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7699821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7699821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7699860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7699860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7699984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7699984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7699985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7699985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7700019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7700019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7700132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,7700132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,7700969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,733.50000,212.71000,Aetna,First Health,,600.00,,,,,,,264.43,600.00,percent of total billed charges,
SCREW,7700969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,733.50000,212.71000,Aetna,First Health,,600.00,,,,,,,236.19,600.00,percent of total billed charges,
SCREW,7702065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7702065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7702123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7702123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7702124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,7702124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,7702219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7702219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7702285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7702285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7736138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7736138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7736477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7736477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7736551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7736551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7736560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7736560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7736561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7736561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7736577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7736577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7744587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7744587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7748072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7748072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7748733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7748733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7756051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7756051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7760134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7760134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7772056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
SCREW,7772056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
SCREW,7878336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7878336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7878337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7878337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7878338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7878338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7878340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7878340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7878341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7878341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7878344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7878344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7878473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7878473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7880449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7880449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7880450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7880450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7882186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7882186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7882187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7882187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7926795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7926795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7926796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7926796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7703210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7703210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7703211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7703211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7703212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7703212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7703213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7703213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7703214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7703214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7703215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7703215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7703222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,First Health,,501.06,,,,,,,220.82,501.06,percent of total billed charges,
SCREW,7703222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,First Health,,501.06,,,,,,,197.24,501.06,percent of total billed charges,
CATHETER,7693555,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,616.94000,178.91000,Aetna,First Health,,504.66,,,,,,,222.41,504.66,percent of total billed charges,
CATHETER,7693555,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,616.94000,178.91000,Aetna,First Health,,504.66,,,,,,,198.65,504.66,percent of total billed charges,
STEM,7927341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,7927341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
STEM,7927352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,7927352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
STEM,7935917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,7935917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
STEM,7943924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,7943924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
STEM,7947959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,7947959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
BALLOON CATHETER,7905006,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1242.82,2820.05,percent of total billed charges,
BALLOON CATHETER,7905006,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1110.10,2820.05,percent of total billed charges,
STEM,7893922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2893.01,6564.45,percent of total billed charges,
STEM,7893922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2584.05,6564.45,percent of total billed charges,
SCREW,7905613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7905613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SCREW,7905614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,7905614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
PLATE,7909415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1993.80000,578.20000,Aetna,First Health,,1630.93,,,,,,,718.76,1630.93,percent of total billed charges,
PLATE,7909415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1993.80000,578.20000,Aetna,First Health,,1630.93,,,,,,,642.00,1630.93,percent of total billed charges,
PLATE,7894232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,First Health,,1515.03,,,,,,,667.69,1515.03,percent of total billed charges,
PLATE,7894232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,First Health,,1515.03,,,,,,,596.38,1515.03,percent of total billed charges,
PLATE,7894233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,First Health,,1515.03,,,,,,,667.69,1515.03,percent of total billed charges,
PLATE,7894233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,First Health,,1515.03,,,,,,,596.38,1515.03,percent of total billed charges,
SCREW,7894277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7894277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7894278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7894278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7894279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7894279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7894280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7894280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7905093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7905093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7905094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7905094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7909209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7909209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7909210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7909210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7909211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7909211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7909212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7909212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7935186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7935186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,7935825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,7935825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
PLATE,7935823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9636.00000,2794.44000,Aetna,First Health,,7882.25,,,,,,,3473.78,7882.25,percent of total billed charges,
PLATE,7935823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9636.00000,2794.44000,Aetna,First Health,,7882.25,,,,,,,3102.79,7882.25,percent of total billed charges,
PLATE,7937665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9807.00000,2844.03000,Aetna,First Health,,8022.13,,,,,,,3535.42,8022.13,percent of total billed charges,
PLATE,7937665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9807.00000,2844.03000,Aetna,First Health,,8022.13,,,,,,,3157.85,8022.13,percent of total billed charges,
PLATE,7943630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10323.00000,2993.67000,Aetna,First Health,,8444.21,,,,,,,3721.44,8444.21,percent of total billed charges,
PLATE,7943630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10323.00000,2993.67000,Aetna,First Health,,8444.21,,,,,,,3324.01,8444.21,percent of total billed charges,
WIRE,7896395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1968.80000,570.95000,Aetna,First Health,,1610.48,,,,,,,709.75,1610.48,percent of total billed charges,
WIRE,7896395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1968.80000,570.95000,Aetna,First Health,,1610.48,,,,,,,633.95,1610.48,percent of total billed charges,
SPACER HIP CEMENT,7736612,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,First Health,,3944.93,,,,,,,1738.57,3944.93,percent of total billed charges,
SPACER HIP CEMENT,7736612,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,First Health,,3944.93,,,,,,,1552.89,3944.93,percent of total billed charges,
SPACER HIP CEMENT,7895933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,First Health,,3944.93,,,,,,,1738.57,3944.93,percent of total billed charges,
SPACER HIP CEMENT,7895933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,First Health,,3944.93,,,,,,,1552.89,3944.93,percent of total billed charges,
SPACER HIP CEMENT,7930143,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,First Health,,3944.93,,,,,,,1738.57,3944.93,percent of total billed charges,
SPACER HIP CEMENT,7930143,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,First Health,,3944.93,,,,,,,1552.89,3944.93,percent of total billed charges,
PLATE,7913878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8862.00000,2569.98000,Aetna,First Health,,7249.12,,,,,,,3194.75,7249.12,percent of total billed charges,
PLATE,7913878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8862.00000,2569.98000,Aetna,First Health,,7249.12,,,,,,,2853.56,7249.12,percent of total billed charges,
SCREW,7903573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7903573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7903574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7903574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7903575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7903575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7903576,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7903576,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
PLATE,7965483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5376.00000,1559.04000,Aetna,First Health,,4397.57,,,,,,,1938.05,4397.57,percent of total billed charges,
PLATE,7965483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5376.00000,1559.04000,Aetna,First Health,,4397.57,,,,,,,1731.07,4397.57,percent of total billed charges,
INSERT,7896844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7896844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7904736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7904736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,7920525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7920525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INTRODUCER,7916958,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,490.20000,142.16000,Aetna,First Health,,400.98,,,,,,,176.72,400.98,percent of total billed charges,
INTRODUCER,7916958,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,490.20000,142.16000,Aetna,First Health,,400.98,,,,,,,157.84,400.98,percent of total billed charges,
PIN,7896876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,166.10,376.89,percent of total billed charges,
PIN,7896876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,148.36,376.89,percent of total billed charges,
SCREW,7700070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7700070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
SCREW,7762380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7762380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
SCREW,7896906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.27000,188.00000,Aetna,First Health,,530.28,,,,,,,233.70,530.28,percent of total billed charges,
SCREW,7896906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.27000,188.00000,Aetna,First Health,,530.28,,,,,,,208.74,530.28,percent of total billed charges,
SCREW,7896907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.27000,188.00000,Aetna,First Health,,530.28,,,,,,,233.70,530.28,percent of total billed charges,
SCREW,7896907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.27000,188.00000,Aetna,First Health,,530.28,,,,,,,208.74,530.28,percent of total billed charges,
SCREW,7902126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7902126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
SCREW,7904105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7904105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
STEM,7901702,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,7901702,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
STEM,7903059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,7903059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
STEM,7904739,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,7904739,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
STEM,7909386,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,7909386,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
STEM,7954793,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,7954793,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
LEAD,7897117,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
LEAD,7897117,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7965301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9144.09000,2651.79000,Aetna,First Health,,7479.87,,,,,,,3296.44,7479.87,percent of total billed charges,
INSERT,7965301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9144.09000,2651.79000,Aetna,First Health,,7479.87,,,,,,,2944.40,7479.87,percent of total billed charges,
SCREW,7929740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,7929740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
PLATE,7909412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1421.99,3226.60,percent of total billed charges,
PLATE,7909412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1270.13,3226.60,percent of total billed charges,
PLATE,7926500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1421.99,3226.60,percent of total billed charges,
PLATE,7926500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1270.13,3226.60,percent of total billed charges,
PLATE,7938383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1421.99,3226.60,percent of total billed charges,
PLATE,7938383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1270.13,3226.60,percent of total billed charges,
PLATE,7959548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1421.99,3226.60,percent of total billed charges,
PLATE,7959548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1270.13,3226.60,percent of total billed charges,
HUMERAL HEAD,7900098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7900098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7948521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7948521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
ANCHOR,7926646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
ANCHOR,7926646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
ANCHOR,7926668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
ANCHOR,7926668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
PLATE,7921187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1596.11,3621.70,percent of total billed charges,
PLATE,7921187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1425.65,3621.70,percent of total billed charges,
PLATE,7900327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,First Health,,3638.62,,,,,,,1603.57,3638.62,percent of total billed charges,
PLATE,7900327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,First Health,,3638.62,,,,,,,1432.32,3638.62,percent of total billed charges,
PLATE,7900535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1771.97,4020.72,percent of total billed charges,
PLATE,7900535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1582.73,4020.72,percent of total billed charges,
PLATE,7900536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1771.97,4020.72,percent of total billed charges,
PLATE,7900536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1582.73,4020.72,percent of total billed charges,
PLATE,7900537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1771.97,4020.72,percent of total billed charges,
PLATE,7900537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1582.73,4020.72,percent of total billed charges,
PLATE,7901767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1771.97,4020.72,percent of total billed charges,
PLATE,7901767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1582.73,4020.72,percent of total billed charges,
PLATE,7901768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1771.97,4020.72,percent of total billed charges,
PLATE,7901768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1582.73,4020.72,percent of total billed charges,
PLATE,7901769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1771.97,4020.72,percent of total billed charges,
PLATE,7901769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1582.73,4020.72,percent of total billed charges,
PLATE,7901770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1771.97,4020.72,percent of total billed charges,
PLATE,7901770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1582.73,4020.72,percent of total billed charges,
VALVE,7742036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
VALVE,7742036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
VALVE,7742037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
VALVE,7742037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
VALVE,7900568,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
VALVE,7900568,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
VALVE,7900569,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
VALVE,7900569,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
CATHETER,7902811,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
CATHETER,7902811,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
BASEPLATE,7903043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1299.40,2948.43,percent of total billed charges,
BASEPLATE,7903043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1160.63,2948.43,percent of total billed charges,
BASEPLATE,7911001,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1299.40,2948.43,percent of total billed charges,
BASEPLATE,7911001,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1160.63,2948.43,percent of total billed charges,
SCREW,7901800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,507.78000,147.26000,Aetna,First Health,,415.36,,,,,,,183.05,415.36,percent of total billed charges,
SCREW,7901800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,507.78000,147.26000,Aetna,First Health,,415.36,,,,,,,163.51,415.36,percent of total billed charges,
SHELL,7918353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,4027.94,9139.68,percent of total billed charges,
SHELL,7918353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,3597.77,9139.68,percent of total billed charges,
SHELL,7918354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,4027.94,9139.68,percent of total billed charges,
SHELL,7918354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,3597.77,9139.68,percent of total billed charges,
SHELL,7934012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,4027.94,9139.68,percent of total billed charges,
SHELL,7934012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,3597.77,9139.68,percent of total billed charges,
SHELL,7944504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,4027.94,9139.68,percent of total billed charges,
SHELL,7944504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,3597.77,9139.68,percent of total billed charges,
STEM,7935559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM,7935559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
GRIP CABLE,7902353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3493.00000,1012.97000,Aetna,First Health,,2857.27,,,,,,,1259.23,2857.27,percent of total billed charges,
GRIP CABLE,7902353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3493.00000,1012.97000,Aetna,First Health,,2857.27,,,,,,,1124.75,2857.27,percent of total billed charges,
GRIP CABLE,7902354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3493.00000,1012.97000,Aetna,First Health,,2857.27,,,,,,,1259.23,2857.27,percent of total billed charges,
GRIP CABLE,7902354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3493.00000,1012.97000,Aetna,First Health,,2857.27,,,,,,,1124.75,2857.27,percent of total billed charges,
INSERT,7935480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,7935480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
SCREW,7963956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,118.15,268.10,percent of total billed charges,
SCREW,7963956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,105.54,268.10,percent of total billed charges,
SCREW,7902672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7902672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,7935826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7935826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,7943631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7943631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,7943680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7943680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
FEMORAL HEAD,7934018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1392.66,3160.04,percent of total billed charges,
FEMORAL HEAD,7934018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1243.93,3160.04,percent of total billed charges,
CATHETER,7911423,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,556.74000,161.45000,Aetna,First Health,,455.41,,,,,,,200.70,455.41,percent of total billed charges,
CATHETER,7911423,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,556.74000,161.45000,Aetna,First Health,,455.41,,,,,,,179.27,455.41,percent of total billed charges,
PLATE,7925238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7925238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7948684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7948684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,7925237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7925237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
NAIL,7964445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,7964445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
GLENOSPHERE,7902775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
GLENOSPHERE,7902775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
GLENOSPHERE,7902814,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
GLENOSPHERE,7902814,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
BASEPLATE,7918507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2811.90,6380.40,percent of total billed charges,
BASEPLATE,7918507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2511.60,6380.40,percent of total billed charges,
COIL,7935392,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4163.25000,1207.34000,Aetna,First Health,,3405.54,,,,,,,1500.85,3405.54,percent of total billed charges,
COIL,7935392,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4163.25000,1207.34000,Aetna,First Health,,3405.54,,,,,,,1340.57,3405.54,percent of total billed charges,
ANCHOR,7910688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5344.50000,1549.90000,Aetna,First Health,,4371.80,,,,,,,1926.69,4371.80,percent of total billed charges,
ANCHOR,7910688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5344.50000,1549.90000,Aetna,First Health,,4371.80,,,,,,,1720.93,4371.80,percent of total billed charges,
ANCHOR,7919018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
ANCHOR,7919018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
ANCHOR,7939964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5179.13000,1501.95000,Aetna,First Health,,4236.53,,,,,,,1867.08,4236.53,percent of total billed charges,
ANCHOR,7939964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5179.13000,1501.95000,Aetna,First Health,,4236.53,,,,,,,1667.68,4236.53,percent of total billed charges,
COMPONENT GLENOSPHERE,7930350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT GLENOSPHERE,7930350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
COMPONENT GLENOSPHERE,7930351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT GLENOSPHERE,7930351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
SCREW,7903578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7903578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7903579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7903579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7903580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7903580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7908762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7908762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7909213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7909213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7914405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7914405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7942050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7942050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7948615,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7948615,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7958127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7958127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7958128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7958128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
PLATE,7909423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7909423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7909424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7909424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7938964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7938964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7951855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5436.69000,1576.64000,Aetna,First Health,,4447.21,,,,,,,1959.93,4447.21,percent of total billed charges,
PLATE,7951855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5436.69000,1576.64000,Aetna,First Health,,4447.21,,,,,,,1750.61,4447.21,percent of total billed charges,
GUIDEWIRE,7911817,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,First Health,,120.68,,,,,,,53.18,120.68,percent of total billed charges,
GUIDEWIRE,7911817,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,First Health,,120.68,,,,,,,47.50,120.68,percent of total billed charges,
GUIDEWIRE,7911818,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,191.63000,55.57000,Aetna,First Health,,156.75,,,,,,,69.08,156.75,percent of total billed charges,
GUIDEWIRE,7911818,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,191.63000,55.57000,Aetna,First Health,,156.75,,,,,,,61.70,156.75,percent of total billed charges,
GUIDEWIRE,7911819,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,169.58000,49.18000,Aetna,First Health,,138.72,,,,,,,61.13,138.72,percent of total billed charges,
GUIDEWIRE,7911819,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,169.58000,49.18000,Aetna,First Health,,138.72,,,,,,,54.60,138.72,percent of total billed charges,
GUIDEWIRE,7935183,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,173.67000,50.36000,Aetna,First Health,,142.06,,,,,,,62.61,142.06,percent of total billed charges,
GUIDEWIRE,7935183,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,173.67000,50.36000,Aetna,First Health,,142.06,,,,,,,55.92,142.06,percent of total billed charges,
STEM,7912135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,3136.35,7116.60,percent of total billed charges,
STEM,7912135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,2801.40,7116.60,percent of total billed charges,
STEM,7918511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,3136.35,7116.60,percent of total billed charges,
STEM,7918511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,2801.40,7116.60,percent of total billed charges,
STEM,7939848,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,3136.35,7116.60,percent of total billed charges,
STEM,7939848,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,2801.40,7116.60,percent of total billed charges,
INSERT,7912142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7912142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7913422,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7913422,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7913912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7913912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7913913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7913913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7916713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7916713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7917665,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7917665,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7917666,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7917666,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7918906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7918906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7918951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7918951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7919076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7919076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7920349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7920349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7920400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7920400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7920819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7920819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7922445,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7922445,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7924908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7924908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7926705,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7926705,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7926787,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7926787,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7927094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7927094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7927095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7927095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7927349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7927349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7927398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7927398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7927615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7927615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7933872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7933872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7935592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7935592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7935938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7935938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7938088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7938088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7938089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7938089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7938955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7938955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7939863,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7939863,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7939952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7939952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7940892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7940892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7943372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7943372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7943373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7943373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7943518,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7943518,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7944017,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7944017,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7944304,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7944304,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7944552,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7944552,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7944575,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7944575,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7947962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7947962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7948016,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7948016,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7950556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7950556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7951981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7951981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7962561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7962561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7962562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7962562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7964446,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7964446,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7964568,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7964568,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7913421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7913421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7916711,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7916711,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7917664,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7917664,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7918357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7918357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7918907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7918907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7918938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7918938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7920347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7920347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7926788,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7926788,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7939862,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7939862,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7943919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BASEPLATE,7943919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
BASEPLATE,7944307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7944307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7948814,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BASEPLATE,7948814,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
COMPONENT PATELLA,7918356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
COMPONENT PATELLA,7918356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
COMPONENT PATELLA,7944306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
COMPONENT PATELLA,7944306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
TOE IMPLANT,7912194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
TOE IMPLANT,7912194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
TOE IMPLANT,7912195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
TOE IMPLANT,7912195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
TOE IMPLANT,7912196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
TOE IMPLANT,7912196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
TOE IMPLANT,7912197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
TOE IMPLANT,7912197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
TOE IMPLANT,7912198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
TOE IMPLANT,7912198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
CAGE,7912277,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7912277,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
CAGE,7918405,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7918405,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
CAGE,7927054,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7927054,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
CAGE,7927055,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7927055,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
CAGE,7935708,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7935708,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
CAGE,7935709,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7935709,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
CAGE,7935710,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7935710,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
CAGE,7947966,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7947966,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
CAGE,7954647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
CAGE,7954647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
PLATE,7912341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5241.15000,1519.93000,Aetna,First Health,,4287.26,,,,,,,1889.43,4287.26,percent of total billed charges,
PLATE,7912341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5241.15000,1519.93000,Aetna,First Health,,4287.26,,,,,,,1687.65,4287.26,percent of total billed charges,
FEMORAL HEAD,7912823,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,First Health,,1914.12,,,,,,,843.57,1914.12,percent of total billed charges,
FEMORAL HEAD,7912823,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,First Health,,1914.12,,,,,,,753.48,1914.12,percent of total billed charges,
SPACER,7912824,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,806.18000,233.79000,Aetna,First Health,,659.46,,,,,,,290.63,659.46,percent of total billed charges,
SPACER,7912824,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,806.18000,233.79000,Aetna,First Health,,659.46,,,,,,,259.59,659.46,percent of total billed charges,
ACETABULAR RING,7912876,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,2061.39,4677.43,percent of total billed charges,
ACETABULAR RING,7912876,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,1841.24,4677.43,percent of total billed charges,
ACETABULAR RING,7912877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,2061.39,4677.43,percent of total billed charges,
ACETABULAR RING,7912877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,1841.24,4677.43,percent of total billed charges,
ACETABULAR RING,7912878,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,2061.39,4677.43,percent of total billed charges,
ACETABULAR RING,7912878,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,1841.24,4677.43,percent of total billed charges,
ACETABULAR RING,7912879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,2061.39,4677.43,percent of total billed charges,
ACETABULAR RING,7912879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,1841.24,4677.43,percent of total billed charges,
ACETABULAR RING,7912880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,2061.39,4677.43,percent of total billed charges,
ACETABULAR RING,7912880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,1841.24,4677.43,percent of total billed charges,
ACETABULAR RING,7912881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,2061.39,4677.43,percent of total billed charges,
ACETABULAR RING,7912881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,1841.24,4677.43,percent of total billed charges,
ACETABULAR RING,7912882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,2061.39,4677.43,percent of total billed charges,
ACETABULAR RING,7912882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,1841.24,4677.43,percent of total billed charges,
ACETABULAR RING,7912883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,2061.39,4677.43,percent of total billed charges,
ACETABULAR RING,7912883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,First Health,,4677.43,,,,,,,1841.24,4677.43,percent of total billed charges,
ACETABULAR RING,7912885,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,3144.73,7135.62,percent of total billed charges,
ACETABULAR RING,7912885,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,2808.89,7135.62,percent of total billed charges,
ACETABULAR RING,7912886,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,3144.73,7135.62,percent of total billed charges,
ACETABULAR RING,7912886,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,2808.89,7135.62,percent of total billed charges,
ACETABULAR RING,7912887,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,3144.73,7135.62,percent of total billed charges,
ACETABULAR RING,7912887,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,2808.89,7135.62,percent of total billed charges,
ACETABULAR RING,7912888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,3144.73,7135.62,percent of total billed charges,
ACETABULAR RING,7912888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,2808.89,7135.62,percent of total billed charges,
ACETABULAR RING,7912889,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,3144.73,7135.62,percent of total billed charges,
ACETABULAR RING,7912889,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,2808.89,7135.62,percent of total billed charges,
ACETABULAR RING,7912890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,3144.73,7135.62,percent of total billed charges,
ACETABULAR RING,7912890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,2808.89,7135.62,percent of total billed charges,
ACETABULAR RING,7912891,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,3144.73,7135.62,percent of total billed charges,
ACETABULAR RING,7912891,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,2808.89,7135.62,percent of total billed charges,
ACETABULAR RING,7912892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,3144.73,7135.62,percent of total billed charges,
ACETABULAR RING,7912892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,2808.89,7135.62,percent of total billed charges,
ACETABULAR RING,7912893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,3144.73,7135.62,percent of total billed charges,
ACETABULAR RING,7912893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,First Health,,7135.62,,,,,,,2808.89,7135.62,percent of total billed charges,
SHELL,7912895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
SHELL,7912896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
SHELL,7912897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
SHELL,7912898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
SHELL,7912899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
SHELL,7912900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
SHELL,7912901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
SHELL,7912902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
SHELL,7912903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
SHELL,7912904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7912904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
LINER,7912906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
LINER,7912920,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,7912920,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
SCREW,7912922,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,349.19,792.34,percent of total billed charges,
SCREW,7912922,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,311.90,792.34,percent of total billed charges,
SCREW,7912923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,349.19,792.34,percent of total billed charges,
SCREW,7912923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,311.90,792.34,percent of total billed charges,
SCREW,7912924,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,349.19,792.34,percent of total billed charges,
SCREW,7912924,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,311.90,792.34,percent of total billed charges,
SCREW,7912925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,349.19,792.34,percent of total billed charges,
SCREW,7912925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,311.90,792.34,percent of total billed charges,
SCREW,7912926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,349.19,792.34,percent of total billed charges,
SCREW,7912926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,311.90,792.34,percent of total billed charges,
SCREW,7912927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,349.19,792.34,percent of total billed charges,
SCREW,7912927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,311.90,792.34,percent of total billed charges,
SCREW,7912928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,349.19,792.34,percent of total billed charges,
SCREW,7912928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,311.90,792.34,percent of total billed charges,
SCREW,7912929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,349.19,792.34,percent of total billed charges,
SCREW,7912929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,311.90,792.34,percent of total billed charges,
SCREW,7912930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,349.19,792.34,percent of total billed charges,
SCREW,7912930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,First Health,,792.34,,,,,,,311.90,792.34,percent of total billed charges,
SCREW,7913083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7913083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,7913084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,7913084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
PLATE,7943316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3105.96000,900.73000,Aetna,First Health,,2540.68,,,,,,,1119.70,2540.68,percent of total billed charges,
PLATE,7943316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3105.96000,900.73000,Aetna,First Health,,2540.68,,,,,,,1000.12,2540.68,percent of total billed charges,
PLATE,7913209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
PLATE,7913209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
PLATE,7913210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
PLATE,7913210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
PLATE,7913211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
PLATE,7913211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
PLATE,7913212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
PLATE,7913212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
PLATE,7913213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
PLATE,7913213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
PLATE,7913214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
PLATE,7913214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
PLATE,7913215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
PLATE,7913215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
PLATE,7913217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
PLATE,7913217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7913218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
PLATE,7913218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7913219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
PLATE,7913219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7913220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
PLATE,7913220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7913221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
PLATE,7913221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7913222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
PLATE,7913222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7913223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
PLATE,7913223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7913224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
PLATE,7913224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7913225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
PLATE,7913225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,7913280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,7913280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,7913281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,7913281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,7913282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,7913282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,7913283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,7913283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,7913284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,7913284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,7913285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,7913285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,7929999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
SCREW,7929999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
SCREW,7940330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7940330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7959513,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7959513,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7965931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,51.67,117.24,percent of total billed charges,
SCREW,7965931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,First Health,,117.24,,,,,,,46.15,117.24,percent of total billed charges,
SCREW,7913419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7913419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
CATHETER BALLOON,7938091,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
CATHETER BALLOON,7938091,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
STEM,7916493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM,7916493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
STEM,7920815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM,7920815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
SCREW,7913876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7913876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
INSERT,7963962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7963962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
ROD,7920745,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7920745,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
PLATE,7944228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8559.00000,2482.11000,Aetna,First Health,,7001.26,,,,,,,3085.52,7001.26,percent of total billed charges,
PLATE,7944228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8559.00000,2482.11000,Aetna,First Health,,7001.26,,,,,,,2756.00,7001.26,percent of total billed charges,
STEM,7920545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2893.01,6564.45,percent of total billed charges,
STEM,7920545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2584.05,6564.45,percent of total billed charges,
STEM,7951960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2893.01,6564.45,percent of total billed charges,
STEM,7951960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2584.05,6564.45,percent of total billed charges,
NAIL,7916472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7736.40000,2243.56000,Aetna,First Health,,6328.38,,,,,,,2788.97,6328.38,percent of total billed charges,
NAIL,7916472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7736.40000,2243.56000,Aetna,First Health,,6328.38,,,,,,,2491.12,6328.38,percent of total billed charges,
AUGMENT TIBIAL,7919059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,5404.09,12262.25,percent of total billed charges,
AUGMENT TIBIAL,7919059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,4826.95,12262.25,percent of total billed charges,
STEM,7917855,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7917855,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7919094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7919094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7920121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7920121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7938821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7938821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7939279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7939279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
ANCHOR,7960333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.00000,559.99000,Aetna,First Health,,1579.56,,,,,,,696.13,1579.56,percent of total billed charges,
ANCHOR,7960333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.00000,559.99000,Aetna,First Health,,1579.56,,,,,,,621.78,1579.56,percent of total billed charges,
LINER,7926702,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7926702,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7929708,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7929708,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7935782,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7935782,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
LINER,7965002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,7965002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
SCREW,7909291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7909291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7910313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7910313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7910456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7910456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7910835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7910835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7910836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7910836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7916714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7916714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7920490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7920490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7920491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7920491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7920741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7920741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7920742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7920742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7920743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7920743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7935614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7935614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7935774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7935774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7937975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7937975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7948037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7948037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7948038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7948038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
PLATE,7938858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3506.06000,1016.76000,Aetna,First Health,,2867.96,,,,,,,1263.93,2867.96,percent of total billed charges,
PLATE,7938858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3506.06000,1016.76000,Aetna,First Health,,2867.96,,,,,,,1128.95,2867.96,percent of total billed charges,
PLATE,7938860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3370.12000,977.33000,Aetna,First Health,,2756.76,,,,,,,1214.93,2756.76,percent of total billed charges,
PLATE,7938860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3370.12000,977.33000,Aetna,First Health,,2756.76,,,,,,,1085.18,2756.76,percent of total billed charges,
ROD,7917822,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7917822,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
ROD,7918048,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7918048,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
ROD,7918049,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7918049,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
ROD,7919001,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7919001,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
ROD,7919002,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7919002,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
ROD,7921023,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7921023,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
CONNECTOR SPINAL,7910459,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7910459,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7917823,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7917823,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7930115,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7930115,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
HUMERAL HEAD,7939298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7939298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
TIGHTROPE,7935479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
TIGHTROPE,7935479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,7948607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW,7948607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
SCREW,7948608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,801.38,1818.38,percent of total billed charges,
SCREW,7948608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,715.79,1818.38,percent of total billed charges,
SHELL,7918137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,2211.03,5016.98,percent of total billed charges,
SHELL,7918137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,1974.90,5016.98,percent of total billed charges,
SHELL,7925196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,2211.03,5016.98,percent of total billed charges,
SHELL,7925196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,1974.90,5016.98,percent of total billed charges,
SHELL,7939322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,2211.03,5016.98,percent of total billed charges,
SHELL,7939322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,1974.90,5016.98,percent of total billed charges,
SHELL,7940868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,2211.03,5016.98,percent of total billed charges,
SHELL,7940868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,1974.90,5016.98,percent of total billed charges,
SHELL,7948127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,2211.03,5016.98,percent of total billed charges,
SHELL,7948127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,1974.90,5016.98,percent of total billed charges,
SHELL,7950210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,2211.03,5016.98,percent of total billed charges,
SHELL,7950210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,1974.90,5016.98,percent of total billed charges,
INSERT,7925195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
INSERT,7925195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
INSERT,7939325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
INSERT,7939325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
INSERT,7940893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
INSERT,7940893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
AUGMENT FEMORAL,7918401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7918401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
AUGMENT TIBIAL,7918402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT TIBIAL,7918402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7926452,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7926452,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
AUGMENT TIBIAL,7927413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT TIBIAL,7927413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7927416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7927416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7927417,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7927417,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
AUGMENT TIBIAL,7935028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT TIBIAL,7935028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
AUGMENT TIBIAL,7935032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT TIBIAL,7935032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7935033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7935033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
AUGMENT TIBIAL,7944415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT TIBIAL,7944415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7957819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
AUGMENT FEMORAL,7957819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
STEM,7918509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
STEM,7918509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
PLUG,7934013,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,906.12000,262.77000,Aetna,First Health,,741.21,,,,,,,326.66,741.21,percent of total billed charges,
PLUG,7934013,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,906.12000,262.77000,Aetna,First Health,,741.21,,,,,,,291.77,741.21,percent of total billed charges,
ANCHOR,7934957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,703.70,1596.74,percent of total billed charges,
ANCHOR,7934957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,First Health,,1596.74,,,,,,,628.54,1596.74,percent of total billed charges,
ANCHOR,7920543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1900.00000,551.00000,Aetna,First Health,,1554.20,,,,,,,684.95,1554.20,percent of total billed charges,
ANCHOR,7920543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1900.00000,551.00000,Aetna,First Health,,1554.20,,,,,,,611.80,1554.20,percent of total billed charges,
ANCHOR,7945868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1928.00000,559.12000,Aetna,First Health,,1577.10,,,,,,,695.04,1577.10,percent of total billed charges,
ANCHOR,7945868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1928.00000,559.12000,Aetna,First Health,,1577.10,,,,,,,620.82,1577.10,percent of total billed charges,
FEMORAL HEAD,7701620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7701620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7736464,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7736464,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7740560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7740560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7790537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7790537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7808036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7808036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7836193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7836193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7878480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7878480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7911619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7911619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7918631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7918631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7922464,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7922464,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
SCREW,7918644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SCREW,7918644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,7918645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
SCREW,7918645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
GLENOSPHERE,7959547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
GLENOSPHERE,7959547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
STEM,7930353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,7930353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
STEM,7930354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,7930354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
STEM,7935783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,7935783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
STEM,7959516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,7959516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
INSERT,7930352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7930352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7944549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7944549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
LINER,7919079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7919079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
BREAST IMPLANT,7903506,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7903506,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7903508,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7903508,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7903509,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7903509,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7903510,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7903510,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7905041,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7905041,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7905470,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7905470,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7909330,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7909330,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7909417,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7909417,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7909418,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7909418,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7909419,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7909419,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7909420,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7909420,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7909421,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7909421,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7909422,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7909422,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7920350,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7920350,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7920351,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7920351,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7920352,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7920352,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7924893,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
BREAST IMPLANT,7924893,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
BREAST IMPLANT,7924894,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7924894,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7924895,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7924895,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926565,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926565,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926566,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926566,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926567,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926567,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926568,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926568,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926877,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926877,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926878,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926878,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926879,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926879,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926880,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926880,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926895,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926895,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926896,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926896,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926897,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926897,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926966,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926966,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926967,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926967,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926968,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926968,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926969,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926969,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7926970,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7926970,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7927012,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7927012,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7927013,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7927013,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7927014,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7927014,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7927015,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7927015,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7927241,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7927241,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7927476,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7927476,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7927477,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7927477,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7927478,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7927478,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7930268,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7930268,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7930269,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7930269,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7930270,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7930270,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7930271,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7930271,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7930272,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7930272,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7935421,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7935421,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7935422,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7935422,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7948759,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7948759,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
BREAST IMPLANT,7956574,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
BREAST IMPLANT,7956574,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
AUGMENT TIBIAL,7918988,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8611.20000,2497.25000,Aetna,First Health,,7043.96,,,,,,,3104.34,7043.96,percent of total billed charges,
AUGMENT TIBIAL,7918988,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8611.20000,2497.25000,Aetna,First Health,,7043.96,,,,,,,2772.81,7043.96,percent of total billed charges,
SPACER,7920817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6114.33000,1773.16000,Aetna,First Health,,5001.52,,,,,,,2204.22,5001.52,percent of total billed charges,
SPACER,7920817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6114.33000,1773.16000,Aetna,First Health,,5001.52,,,,,,,1968.81,5001.52,percent of total billed charges,
STEM,7926703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,7926703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
LINER,7940800,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
LINER,7940800,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
LINER,7940869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
LINER,7940869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
LINER,7964473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
LINER,7964473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
GLENOSPHERE,7918990,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
GLENOSPHERE,7918990,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
GLENOSPHERE,7925895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2811.90,6380.40,percent of total billed charges,
GLENOSPHERE,7925895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2511.60,6380.40,percent of total billed charges,
THYROPLASTY IMPLANT IN KIT,7919070,CDM,278,RC,C1878,HCPCS,,,facility,inpatient,,,1984.00000,575.36000,Aetna,First Health,,1622.91,,,,,,,715.23,1622.91,percent of total billed charges,
THYROPLASTY IMPLANT IN KIT,7919070,CDM,278,RC,C1878,HCPCS,,,facility,outpatient,,,1984.00000,575.36000,Aetna,First Health,,1622.91,,,,,,,638.85,1622.91,percent of total billed charges,
FEMORAL HEAD,7923286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1645.01,3732.64,percent of total billed charges,
FEMORAL HEAD,7923286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1469.33,3732.64,percent of total billed charges,
AUGMENT ACETABULAR,7701624,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,3057.18,6936.97,percent of total billed charges,
AUGMENT ACETABULAR,7701624,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,2730.69,6936.97,percent of total billed charges,
AUGMENT ACETABULAR,7702637,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,3057.18,6936.97,percent of total billed charges,
AUGMENT ACETABULAR,7702637,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,2730.69,6936.97,percent of total billed charges,
AUGMENT ACETABULAR,7736445,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,3057.18,6936.97,percent of total billed charges,
AUGMENT ACETABULAR,7736445,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,2730.69,6936.97,percent of total billed charges,
ACETABULAR AUGMENT,7920354,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,3057.18,6936.97,percent of total billed charges,
ACETABULAR AUGMENT,7920354,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,2730.69,6936.97,percent of total billed charges,
AUGMENT ACETABULAR,7934015,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,3057.18,6936.97,percent of total billed charges,
AUGMENT ACETABULAR,7934015,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,2730.69,6936.97,percent of total billed charges,
PLATE,7920392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8037.00000,2330.73000,Aetna,First Health,,6574.27,,,,,,,2897.34,6574.27,percent of total billed charges,
PLATE,7920392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8037.00000,2330.73000,Aetna,First Health,,6574.27,,,,,,,2587.91,6574.27,percent of total billed charges,
FIXATOR,7920399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10194.00000,2956.26000,Aetna,First Health,,8338.69,,,,,,,3674.94,8338.69,percent of total billed charges,
FIXATOR,7920399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10194.00000,2956.26000,Aetna,First Health,,8338.69,,,,,,,3282.47,8338.69,percent of total billed charges,
PLATE,7939422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,839.97,1905.94,percent of total billed charges,
PLATE,7939422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,750.26,1905.94,percent of total billed charges,
ROD,7920489,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD,7920489,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
CONNECTOR SPINAL,7920492,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7920492,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7920744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7920744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW,7935160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,7935160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
SCREW,7940328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,116.29,263.86,percent of total billed charges,
SCREW,7940328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,103.87,263.86,percent of total billed charges,
SCREW,7940329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,116.29,263.86,percent of total billed charges,
SCREW,7940329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,103.87,263.86,percent of total billed charges,
SCREW,7965930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,116.29,263.86,percent of total billed charges,
SCREW,7965930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,103.87,263.86,percent of total billed charges,
STEM,7707516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3986.50000,1156.08000,Aetna,First Health,,3260.96,,,,,,,1437.13,3260.96,percent of total billed charges,
STEM,7707516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3986.50000,1156.08000,Aetna,First Health,,3260.96,,,,,,,1283.65,3260.96,percent of total billed charges,
STEM,7736156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3986.50000,1156.08000,Aetna,First Health,,3260.96,,,,,,,1437.13,3260.96,percent of total billed charges,
STEM,7736156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3986.50000,1156.08000,Aetna,First Health,,3260.96,,,,,,,1283.65,3260.96,percent of total billed charges,
SCREW,7878468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7878468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7878533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7878533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7878469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7878469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7878471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7878471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7878472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7878472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7878474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7878474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,7894276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7894276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7905095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7905095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7905096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7905096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7909208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7909208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7920746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7920746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
SCREW,7926979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7926979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7927541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,7927541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
SCREW,7927542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,7927542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
SCREW,7927543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,7927543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
SCREW,7927547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7927547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7935185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7935185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7935824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7935824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7937666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7937666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,7938857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,149.84000,43.45000,Aetna,First Health,,122.57,,,,,,,54.02,122.57,percent of total billed charges,
SCREW,7938857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,149.84000,43.45000,Aetna,First Health,,122.57,,,,,,,48.25,122.57,percent of total billed charges,
SCREW,7939441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7939488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
SCREW,7939488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,7940871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7940871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
SCREW,7944023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7944023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
SCREW,7957661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,146.42000,42.46000,Aetna,First Health,,119.77,,,,,,,52.78,119.77,percent of total billed charges,
SCREW,7957661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,146.42000,42.46000,Aetna,First Health,,119.77,,,,,,,47.15,119.77,percent of total billed charges,
SCREW,7966083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7966083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
BASEPLATE,7925897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7925897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
BASEPLATE,7935477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7935477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
BASEPLATE,7938659,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7938659,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
BASEPLATE,7939867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7939867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
BASEPLATE,7940801,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7940801,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
INSERT,7925898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7925898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,7926700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7926700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,7935476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7935476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,7938773,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7938773,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
RESERVOIR,7921207,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,8040.00000,2331.60000,Aetna,First Health,,6576.72,,,,,,,2898.42,6576.72,percent of total billed charges,
RESERVOIR,7921207,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,8040.00000,2331.60000,Aetna,First Health,,6576.72,,,,,,,2588.88,6576.72,percent of total billed charges,
STEM,7794042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7794042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7810030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7810030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7812116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7812116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7830035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7830035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7832099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7832099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7866114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7866114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7876328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7876328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7903144,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,7903144,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
STEM,7905612,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7905612,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7921279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7921279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7935564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7935564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7935724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7935724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7936197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7936197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7936394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7936394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7937839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7937839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7938036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7938036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7938809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7938809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7938810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7938810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7939803,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7939803,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7942057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7942057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7950205,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7950205,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7954086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7954086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM,7925634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7925634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
BIO TRANSFIX,7702904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1653.80000,479.60000,Aetna,First Health,,1352.81,,,,,,,596.19,1352.81,percent of total billed charges,
BIO TRANSFIX,7702904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1653.80000,479.60000,Aetna,First Health,,1352.81,,,,,,,532.52,1352.81,percent of total billed charges,
STEM,7935704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7935704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7936396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7936396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7951881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7951881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7960039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7960039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE,7924775,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924775,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1310.96,2974.66,percent of total billed charges,
PLATE,7924787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,First Health,,2974.66,,,,,,,1170.95,2974.66,percent of total billed charges,
PLATE,7924782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3930.50000,1139.84000,Aetna,First Health,,3215.15,,,,,,,1416.95,3215.15,percent of total billed charges,
PLATE,7924782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3930.50000,1139.84000,Aetna,First Health,,3215.15,,,,,,,1265.62,3215.15,percent of total billed charges,
PEG,7924788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924793,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924793,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924809,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924809,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924814,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924814,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PEG,7924843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,7924843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7908257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
SCREW,7908257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
SCREW,7924844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7924845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7924846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7924847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7924848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7924849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7924850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7924851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7924852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7924853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7924854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,7924854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,7736151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,147.26,334.15,percent of total billed charges,
SCREW,7736151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,131.54,334.15,percent of total billed charges,
SCREW,7794450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,147.26,334.15,percent of total billed charges,
SCREW,7794450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,131.54,334.15,percent of total billed charges,
SCREW,7902812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7902812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7902813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7902813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7903056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7903056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7903057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7903057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7910287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7910287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7911782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7911782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7911783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7911783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7918562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7918562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7924855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7924891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7924891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7934951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7934951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,7934952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7934952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,7934953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7934953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,7934954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7934954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,7934955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7934955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,7935505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7935505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,7935612,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7935612,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,7948694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7948694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,7959546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SCREW,7959546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
SCREW,7960030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7960030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,7960045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,7960045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,7965298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,134.94,306.18,percent of total billed charges,
SCREW,7965298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,120.52,306.18,percent of total billed charges,
SCREW,7965299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,134.94,306.18,percent of total billed charges,
SCREW,7965299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,120.52,306.18,percent of total billed charges,
STEM,7930309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7930309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7935478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7935478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7938993,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7938993,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7943783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7943783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7946098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7946098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7960154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7960154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE,7940793,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,First Health,,7023.35,,,,,,,3095.25,7023.35,percent of total billed charges,
PLATE,7940793,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,First Health,,7023.35,,,,,,,2764.69,7023.35,percent of total billed charges,
SPACER,7925239,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SPACER,7925239,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SPACER,7925240,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SPACER,7925240,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SPACER,7939859,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SPACER,7939859,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SCREW,7925370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,438.37,994.69,percent of total billed charges,
SCREW,7925424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,391.55,994.69,percent of total billed charges,
SCREW,7925425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7925451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,7925451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,7960033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,167.81,380.78,percent of total billed charges,
SCREW,7960033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,149.89,380.78,percent of total billed charges,
SCREW,7925398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,438.37,994.69,percent of total billed charges,
SCREW,7925398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,391.55,994.69,percent of total billed charges,
SCREW,7925399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,438.37,994.69,percent of total billed charges,
SCREW,7925399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,391.55,994.69,percent of total billed charges,
SCREW,7925422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,438.37,994.69,percent of total billed charges,
SCREW,7925422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,391.55,994.69,percent of total billed charges,
SCREW,7925423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,438.37,994.69,percent of total billed charges,
SCREW,7925423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,391.55,994.69,percent of total billed charges,
SCREW,7925452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,438.37,994.69,percent of total billed charges,
SCREW,7925452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,391.55,994.69,percent of total billed charges,
SCREW,7925453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,438.37,994.69,percent of total billed charges,
SCREW,7925453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,391.55,994.69,percent of total billed charges,
SCREW,7925454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,438.37,994.69,percent of total billed charges,
SCREW,7925454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,391.55,994.69,percent of total billed charges,
STEM,7927538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7927538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7957764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4558.52,10343.61,percent of total billed charges,
STEM,7957764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4071.69,10343.61,percent of total billed charges,
STEM,7925626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7925626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
COMPONENT FEMORAL,7962547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
COMPONENT FEMORAL,7962547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
COMPONENT FEMORAL,7925629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,11294.92,25628.96,percent of total billed charges,
COMPONENT FEMORAL,7925629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,10088.66,25628.96,percent of total billed charges,
STEM,7925630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7925630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
SCREW,7925799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,7925799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
PLATE,7925853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
PLATE,7925853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
PLATE,7965451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
PLATE,7965451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
GRAFT,7925855,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
GRAFT,7925855,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
SCREW,7925866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,873.04,1981.00,percent of total billed charges,
SCREW,7925866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,779.81,1981.00,percent of total billed charges,
SPACER SHOULDER,7927179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,First Health,,9245.94,,,,,,,4074.77,9245.94,percent of total billed charges,
SPACER SHOULDER,7927179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,First Health,,9245.94,,,,,,,3639.60,9245.94,percent of total billed charges,
SPACER SHOULDER,7935863,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,First Health,,9245.94,,,,,,,4074.77,9245.94,percent of total billed charges,
SPACER SHOULDER,7935863,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,First Health,,9245.94,,,,,,,3639.60,9245.94,percent of total billed charges,
SPACER SHOULDER,7943287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,First Health,,9245.94,,,,,,,4074.77,9245.94,percent of total billed charges,
SPACER SHOULDER,7943287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,First Health,,9245.94,,,,,,,3639.60,9245.94,percent of total billed charges,
STENT GRAFT,7926578,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21272.50000,6169.02000,Aetna,First Health,,17400.90,,,,,,,7668.74,17400.90,percent of total billed charges,
STENT GRAFT,7926578,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21272.50000,6169.02000,Aetna,First Health,,17400.90,,,,,,,6849.74,17400.90,percent of total billed charges,
SCREW,7926651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
SCREW,7926651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
CERVICAL DISC,7926673,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926673,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926674,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926674,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926675,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926675,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926676,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926676,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926677,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926677,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926678,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926678,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926679,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926679,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926680,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926680,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926681,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926681,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926682,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926682,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926683,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926683,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926684,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926684,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926685,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926685,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926686,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926686,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926687,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926687,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926688,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926688,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926689,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926689,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926690,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926690,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926691,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926691,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926692,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926692,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926693,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926693,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926694,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926694,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926695,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CERVICAL DISC,7926695,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
VALVE,7948018,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
VALVE,7948018,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
VALVE,7948019,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
VALVE,7948019,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
VALVE,7948020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,7480.38,16973.50,percent of total billed charges,
VALVE,7948020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,6681.50,16973.50,percent of total billed charges,
VALVE,7948021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,7480.38,16973.50,percent of total billed charges,
VALVE,7948021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,6681.50,16973.50,percent of total billed charges,
VALVE,7948022,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,7480.38,16973.50,percent of total billed charges,
VALVE,7948022,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,6681.50,16973.50,percent of total billed charges,
SCREW,7926983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,7926983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,7929739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
SCREW,7929739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
SCREW,7940791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7940791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
NAIL,7954158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2903.18,6587.52,percent of total billed charges,
NAIL,7954158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2593.13,6587.52,percent of total billed charges,
NAIL,7957821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2903.18,6587.52,percent of total billed charges,
NAIL,7957821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2593.13,6587.52,percent of total billed charges,
NAIL,7959959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2903.18,6587.52,percent of total billed charges,
NAIL,7959959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2593.13,6587.52,percent of total billed charges,
PLATE,7935159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,7935159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,7939418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,First Health,,2249.50,,,,,,,991.38,2249.50,percent of total billed charges,
PLATE,7939418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,First Health,,2249.50,,,,,,,885.50,2249.50,percent of total billed charges,
PLATE,7939429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,First Health,,2249.50,,,,,,,991.38,2249.50,percent of total billed charges,
PLATE,7939429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,First Health,,2249.50,,,,,,,885.50,2249.50,percent of total billed charges,
BALLOON CATHETER,7935113,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,577.80000,167.56000,Aetna,First Health,,472.64,,,,,,,208.30,472.64,percent of total billed charges,
BALLOON CATHETER,7935113,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,577.80000,167.56000,Aetna,First Health,,472.64,,,,,,,186.05,472.64,percent of total billed charges,
INSERT,7955061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7955061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
SCREW,7927170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7927170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
CATHETER DIALYSIS SHORT TERM,7693557,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,428.23000,124.19000,Aetna,First Health,,350.29,,,,,,,154.38,350.29,percent of total billed charges,
CATHETER DIALYSIS SHORT TERM,7693557,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,428.23000,124.19000,Aetna,First Health,,350.29,,,,,,,137.89,350.29,percent of total billed charges,
TIBIAL TRAY,7927182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3420.78,7762.00,percent of total billed charges,
TIBIAL TRAY,7927182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3055.46,7762.00,percent of total billed charges,
BASEPLATE,7939895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7939895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
COMPONENT TALAR,7736159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,7151.42,16227.08,percent of total billed charges,
COMPONENT TALAR,7736159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,6387.68,16227.08,percent of total billed charges,
COMPONENT TALAR,7736437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,7151.42,16227.08,percent of total billed charges,
COMPONENT TALAR,7736437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,6387.68,16227.08,percent of total billed charges,
COMPONENT FEMORAL,7929762,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
COMPONENT FEMORAL,7929762,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
COMPONENT FEMORAL,7947953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
COMPONENT FEMORAL,7947953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
COMPONENT FEMORAL,7948017,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
COMPONENT FEMORAL,7948017,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
FEMORAL ADAPTER,7927343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3458.00000,1002.82000,Aetna,First Health,,2828.64,,,,,,,1246.61,2828.64,percent of total billed charges,
FEMORAL ADAPTER,7927343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3458.00000,1002.82000,Aetna,First Health,,2828.64,,,,,,,1113.48,2828.64,percent of total billed charges,
AUGMENT FEMORAL,7947958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3738.75,8483.48,percent of total billed charges,
AUGMENT FEMORAL,7947958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3339.46,8483.48,percent of total billed charges,
SCREW,7927353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7927353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
SCREW,7927472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,7927472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
STEM,7927350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,7927350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
STEM,7927399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,7927399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
STEM,7935781,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,7935781,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
STEM,7944072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,7944072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
STEM,7948364,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,7948364,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
STEM,7950208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,11294.92,25628.96,percent of total billed charges,
STEM,7950208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,10088.66,25628.96,percent of total billed charges,
STEM,7959535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,7959535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
STEM,7960038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,10392.54,23581.41,percent of total billed charges,
STEM,7960038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,9282.66,23581.41,percent of total billed charges,
STEM,7960337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,7960337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
STEM,7966084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,7966084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
STEM,7966085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,7966085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
STEM,7946094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,11294.92,25628.96,percent of total billed charges,
STEM,7946094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,10088.66,25628.96,percent of total billed charges,
INSERT,7935152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7935152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7937840,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7937840,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
END CAP,7962254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
END CAP,7962254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
PLATE,7939419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3170.00000,919.30000,Aetna,First Health,,2593.06,,,,,,,1142.79,2593.06,percent of total billed charges,
PLATE,7939419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3170.00000,919.30000,Aetna,First Health,,2593.06,,,,,,,1020.74,2593.06,percent of total billed charges,
STENT GRAFT,7929724,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12426.00000,3603.54000,Aetna,First Health,,10164.47,,,,,,,4479.57,10164.47,percent of total billed charges,
STENT GRAFT,7929724,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12426.00000,3603.54000,Aetna,First Health,,10164.47,,,,,,,4001.17,10164.47,percent of total billed charges,
PLATE,7959514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1211.28,2748.48,percent of total billed charges,
PLATE,7959514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1081.92,2748.48,percent of total billed charges,
RING ANNULOPLASTY,7929753,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929753,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929754,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929754,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929757,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929757,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929758,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
RING ANNULOPLASTY,7929758,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
SCREW,7930189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,873.04,1981.00,percent of total billed charges,
SCREW,7930189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,779.81,1981.00,percent of total billed charges,
SCREW,7939812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,680.98,1545.20,percent of total billed charges,
SCREW,7939812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,First Health,,1545.20,,,,,,,608.26,1545.20,percent of total billed charges,
SPACER HIP CEMENT,7924639,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,2104.22,4774.63,percent of total billed charges,
SPACER HIP CEMENT,7924639,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,1879.50,4774.63,percent of total billed charges,
SPACER HIP CEMENT,7927098,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,2104.22,4774.63,percent of total billed charges,
SPACER HIP CEMENT,7927098,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,1879.50,4774.63,percent of total billed charges,
SPACER HIP CEMENT,7930118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,2104.22,4774.63,percent of total billed charges,
SPACER HIP CEMENT,7930118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,1879.50,4774.63,percent of total billed charges,
SPACER HIP CEMENT,7930144,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,2104.22,4774.63,percent of total billed charges,
SPACER HIP CEMENT,7930144,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,1879.50,4774.63,percent of total billed charges,
SCREW,7933665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,7933665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
ROD,7930147,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD,7930147,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
CAGE,7930183,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
CAGE,7930183,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
CAGE,7935790,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
CAGE,7935790,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
COMPONENT FEMORAL,7893923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13117.38000,3804.04000,Aetna,First Health,,10730.02,,,,,,,4728.82,10730.02,percent of total billed charges,
COMPONENT FEMORAL,7893923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13117.38000,3804.04000,Aetna,First Health,,10730.02,,,,,,,4223.80,10730.02,percent of total billed charges,
COMPONENT FEMORAL,7930202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13117.38000,3804.04000,Aetna,First Health,,10730.02,,,,,,,4728.82,10730.02,percent of total billed charges,
COMPONENT FEMORAL,7930202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13117.38000,3804.04000,Aetna,First Health,,10730.02,,,,,,,4223.80,10730.02,percent of total billed charges,
PLATE,7697162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,7697162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
ROD,7937838,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1818.00000,527.22000,Aetna,First Health,,1487.12,,,,,,,655.39,1487.12,percent of total billed charges,
ROD,7937838,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1818.00000,527.22000,Aetna,First Health,,1487.12,,,,,,,585.40,1487.12,percent of total billed charges,
ROD,7954114,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1818.00000,527.22000,Aetna,First Health,,1487.12,,,,,,,655.39,1487.12,percent of total billed charges,
ROD,7954114,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1818.00000,527.22000,Aetna,First Health,,1487.12,,,,,,,585.40,1487.12,percent of total billed charges,
ROD,7960315,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7960315,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
SCREW,7903146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,7903146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
SCREW,7903147,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,7903147,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
SCREW,7922817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,324.45,736.20,percent of total billed charges,
SCREW,7922817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,289.80,736.20,percent of total billed charges,
SCREW,7938399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,202.23,458.87,percent of total billed charges,
SCREW,7938399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,180.63,458.87,percent of total billed charges,
SCREW,7948216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
SCREW,7948216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
SCREW,7948597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7948597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7948598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7948598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7948599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7948599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7948600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7948600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7948601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7948601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7948602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7948602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7948604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7948604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7950092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7950092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7950495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7950495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7950496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7950496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7703221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,202.23,458.87,percent of total billed charges,
SCREW,7703221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,180.63,458.87,percent of total billed charges,
SCREW,7696548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1406.85,3192.24,percent of total billed charges,
SCREW,7696548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1256.61,3192.24,percent of total billed charges,
SCREW,7696549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1406.85,3192.24,percent of total billed charges,
SCREW,7696549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1256.61,3192.24,percent of total billed charges,
SCREW,7698275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1406.85,3192.24,percent of total billed charges,
SCREW,7698275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1256.61,3192.24,percent of total billed charges,
SCREW,7698811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1406.85,3192.24,percent of total billed charges,
SCREW,7698811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1256.61,3192.24,percent of total billed charges,
SCREW,7696880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1406.85,3192.24,percent of total billed charges,
SCREW,7696880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,First Health,,3192.24,,,,,,,1256.61,3192.24,percent of total billed charges,
SCREW,7965259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7965259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7965260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7965260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
STEM,7754165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7754165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7760070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7760070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7816136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7816136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7895934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7895934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7929763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7929763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7947965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7947965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,7951955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7951955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
SCREW,7905493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
SCREW,7905493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
SCREW,7933663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3670.17000,1064.35000,Aetna,First Health,,3002.20,,,,,,,1323.10,3002.20,percent of total billed charges,
SCREW,7933663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3670.17000,1064.35000,Aetna,First Health,,3002.20,,,,,,,1181.79,3002.20,percent of total billed charges,
SCREW,7933664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3670.17000,1064.35000,Aetna,First Health,,3002.20,,,,,,,1323.10,3002.20,percent of total billed charges,
SCREW,7933664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3670.17000,1064.35000,Aetna,First Health,,3002.20,,,,,,,1181.79,3002.20,percent of total billed charges,
LIGAMENT,7938959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,19710.00000,5715.90000,Aetna,First Health,,16122.78,,,,,,,7105.45,16122.78,percent of total billed charges,
LIGAMENT,7938959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,19710.00000,5715.90000,Aetna,First Health,,16122.78,,,,,,,6346.62,16122.78,percent of total billed charges,
SCREW,7935280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,7935280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
SCREW,7938400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.32000,177.57000,Aetna,First Health,,500.88,,,,,,,220.74,500.88,percent of total billed charges,
SCREW,7938400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.32000,177.57000,Aetna,First Health,,500.88,,,,,,,197.17,500.88,percent of total billed charges,
SCREW,7935279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,7935279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
STENT GRAFT,7696020,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,11078.35,25137.55,percent of total billed charges,
STENT GRAFT,7696020,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,9895.22,25137.55,percent of total billed charges,
STENT GRAFT,7696021,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,11078.35,25137.55,percent of total billed charges,
STENT GRAFT,7696021,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,9895.22,25137.55,percent of total billed charges,
STENT GRAFT,7696022,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,11078.35,25137.55,percent of total billed charges,
STENT GRAFT,7696022,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,9895.22,25137.55,percent of total billed charges,
STENT GRAFT,7696024,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,11078.35,25137.55,percent of total billed charges,
STENT GRAFT,7696024,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,9895.22,25137.55,percent of total billed charges,
STENT GRAFT,7696025,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,11078.35,25137.55,percent of total billed charges,
STENT GRAFT,7696025,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,9895.22,25137.55,percent of total billed charges,
STENT GRAFT,7696580,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,11078.35,25137.55,percent of total billed charges,
STENT GRAFT,7696580,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,9895.22,25137.55,percent of total billed charges,
STENT GRAFT,7696023,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,11078.35,25137.55,percent of total billed charges,
STENT GRAFT,7696023,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,First Health,,25137.55,,,,,,,9895.22,25137.55,percent of total billed charges,
ROD,7939316,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7939316,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
ROD,7944074,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7944074,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
HUMERAL HEAD,7935342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,2197.43,4986.12,percent of total billed charges,
HUMERAL HEAD,7935342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,1962.75,4986.12,percent of total billed charges,
HUMERAL HEAD,7939323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,2197.43,4986.12,percent of total billed charges,
HUMERAL HEAD,7939323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,1962.75,4986.12,percent of total billed charges,
ADAPTER,7699366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3266.90000,947.40000,Aetna,First Health,,2672.32,,,,,,,1177.72,2672.32,percent of total billed charges,
ADAPTER,7699366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3266.90000,947.40000,Aetna,First Health,,2672.32,,,,,,,1051.94,2672.32,percent of total billed charges,
GUIDE CATHETER,7695039,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
GUIDE CATHETER,7695039,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
GUIDE CATHETER,7700224,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
GUIDE CATHETER,7700224,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
GUIDE CATHETER,7702059,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
GUIDE CATHETER,7702059,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
GUIDE CATHETER,7914407,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
GUIDE CATHETER,7914407,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
GUIDE CATHETER,7912692,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,663.75000,192.49000,Aetna,First Health,,542.95,,,,,,,239.28,542.95,percent of total billed charges,
GUIDE CATHETER,7912692,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,663.75000,192.49000,Aetna,First Health,,542.95,,,,,,,213.73,542.95,percent of total billed charges,
GUIDE CATHETER,7695015,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,663.75000,192.49000,Aetna,First Health,,542.95,,,,,,,239.28,542.95,percent of total billed charges,
GUIDE CATHETER,7695015,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,663.75000,192.49000,Aetna,First Health,,542.95,,,,,,,213.73,542.95,percent of total billed charges,
COIL,7935394,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1902.00000,551.58000,Aetna,First Health,,1555.84,,,,,,,685.67,1555.84,percent of total billed charges,
COIL,7935394,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1902.00000,551.58000,Aetna,First Health,,1555.84,,,,,,,612.44,1555.84,percent of total billed charges,
COIL,7935391,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,First Health,,4779.78,,,,,,,2106.49,4779.78,percent of total billed charges,
COIL,7935391,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,First Health,,4779.78,,,,,,,1881.53,4779.78,percent of total billed charges,
BASEPLATE,7937860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
BASEPLATE,7937860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
BASEPLATE,7938966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
BASEPLATE,7938966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
BASEPLATE,7960153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
BASEPLATE,7960153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
AUGMENT TIBIAL,7935593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8524.20000,2472.02000,Aetna,First Health,,6972.80,,,,,,,3072.97,6972.80,percent of total billed charges,
AUGMENT TIBIAL,7935593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8524.20000,2472.02000,Aetna,First Health,,6972.80,,,,,,,2744.79,6972.80,percent of total billed charges,
HUMERAL HEAD,7935565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7935565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7950206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7950206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7956661,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7956661,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
STENT GRAFT,7965201,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7965201,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7922446,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7922446,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7925221,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7925221,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7925222,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7925222,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7935072,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7935072,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7935739,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7935739,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7937691,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7937691,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7947967,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7947967,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7956687,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7956687,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7965200,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7965200,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
CAGE,7935776,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7935776,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,7937938,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,23750.00000,6887.50000,Aetna,First Health,,19427.50,,,,,,,8561.88,19427.50,percent of total billed charges,
CAGE,7937938,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,23750.00000,6887.50000,Aetna,First Health,,19427.50,,,,,,,7647.50,19427.50,percent of total billed charges,
ROD,7945948,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7945948,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
CAGE,7946010,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7946010,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,7948523,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7948523,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,7948524,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7948524,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,7957667,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7957667,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,7935775,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7935775,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,7937874,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,23750.00000,6887.50000,Aetna,First Health,,19427.50,,,,,,,8561.88,19427.50,percent of total billed charges,
CAGE,7937874,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,23750.00000,6887.50000,Aetna,First Health,,19427.50,,,,,,,7647.50,19427.50,percent of total billed charges,
CAGE,7944052,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7944052,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
STENT GRAFT,7918350,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7918350,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7918408,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7918408,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7918946,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7918946,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7920409,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7920409,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7922453,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7922453,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7927614,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7927614,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7935740,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7935740,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7936087,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7936087,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7943307,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7943307,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7948361,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7948361,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7948914,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7948914,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7950156,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7950156,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7957958,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7957958,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7963960,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7963960,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
AORTIC EXTENSION,7700125,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16392.50000,4753.82000,Aetna,First Health,,13409.07,,,,,,,5909.50,13409.07,percent of total billed charges,
AORTIC EXTENSION,7700125,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16392.50000,4753.82000,Aetna,First Health,,13409.07,,,,,,,5278.39,13409.07,percent of total billed charges,
AORTIC EXTENSION,7701587,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16392.50000,4753.82000,Aetna,First Health,,13409.07,,,,,,,5909.50,13409.07,percent of total billed charges,
AORTIC EXTENSION,7701587,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16392.50000,4753.82000,Aetna,First Health,,13409.07,,,,,,,5278.39,13409.07,percent of total billed charges,
AORTIC EXTENSION,7788036,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
AORTIC EXTENSION,7788036,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7701588,CDM,278,RC,,,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7701588,CDM,278,RC,,,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
STENT GRAFT,7702227,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7702227,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
STENT GRAFT,7702247,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7702247,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
STENT GRAFT,7766037,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7766037,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
STENT GRAFT,7782034,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7782034,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
STENT GRAFT,7790164,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7790164,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
STENT GRAFT,7882341,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7882341,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
STENT GRAFT,7882343,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7882343,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
STENT GRAFT,7893455,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7893455,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
STENT GRAFT,7911779,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,10925.85,24791.53,percent of total billed charges,
STENT GRAFT,7911779,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,First Health,,24791.53,,,,,,,9759.01,24791.53,percent of total billed charges,
BONE MATRIX,7736081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10473.00000,3037.17000,Aetna,First Health,,8566.91,,,,,,,3775.52,8566.91,percent of total billed charges,
BONE MATRIX,7736081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10473.00000,3037.17000,Aetna,First Health,,8566.91,,,,,,,3372.31,8566.91,percent of total billed charges,
PLATE,7942776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8869.20000,2572.07000,Aetna,First Health,,7255.01,,,,,,,3197.35,7255.01,percent of total billed charges,
PLATE,7942776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8869.20000,2572.07000,Aetna,First Health,,7255.01,,,,,,,2855.88,7255.01,percent of total billed charges,
INTRODUCER IN A KIT,7935915,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1431.96000,415.27000,Aetna,First Health,,1171.34,,,,,,,516.22,1171.34,percent of total billed charges,
INTRODUCER IN A KIT,7935915,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1431.96000,415.27000,Aetna,First Health,,1171.34,,,,,,,461.09,1171.34,percent of total billed charges,
INTRODUCER IN A KIT,7935916,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1431.96000,415.27000,Aetna,First Health,,1171.34,,,,,,,516.22,1171.34,percent of total billed charges,
INTRODUCER IN A KIT,7935916,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1431.96000,415.27000,Aetna,First Health,,1171.34,,,,,,,461.09,1171.34,percent of total billed charges,
GRAFT,7840052,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13323.00000,3863.67000,Aetna,First Health,,10898.21,,,,,,,4802.94,10898.21,percent of total billed charges,
GRAFT,7840052,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13323.00000,3863.67000,Aetna,First Health,,10898.21,,,,,,,4290.01,10898.21,percent of total billed charges,
CATHETER,7694643,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,32.41,73.53,percent of total billed charges,
CATHETER,7694643,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,28.94,73.53,percent of total billed charges,
CATHETER,7694690,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,32.41,73.53,percent of total billed charges,
CATHETER,7694690,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,28.94,73.53,percent of total billed charges,
CATHETER,7702800,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,32.41,73.53,percent of total billed charges,
CATHETER,7702800,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,28.94,73.53,percent of total billed charges,
STEM,7936059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10667.67000,3093.62000,Aetna,First Health,,8726.15,,,,,,,3845.70,8726.15,percent of total billed charges,
STEM,7936059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10667.67000,3093.62000,Aetna,First Health,,8726.15,,,,,,,3434.99,8726.15,percent of total billed charges,
CONNECTOR SPINAL,7936110,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR SPINAL,7936110,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
ROD,7936112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD,7936112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
ROD,7964478,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,First Health,,1786.51,,,,,,,787.33,1786.51,percent of total billed charges,
ROD,7964478,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,First Health,,1786.51,,,,,,,703.25,1786.51,percent of total billed charges,
ROD,7964483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,First Health,,1786.51,,,,,,,787.33,1786.51,percent of total billed charges,
ROD,7964483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,First Health,,1786.51,,,,,,,703.25,1786.51,percent of total billed charges,
SCREW,7936115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1468.68,3332.53,percent of total billed charges,
SCREW,7936115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1311.83,3332.53,percent of total billed charges,
GUIDEWIRE,7936511,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,118.15,268.10,percent of total billed charges,
GUIDEWIRE,7936511,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,105.54,268.10,percent of total billed charges,
INSERT,7937698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7937698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7937934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7937934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7937935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7937935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7938775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7938775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7938776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7938776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7957707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7957707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7957708,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7957708,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7957709,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7957709,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7957710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7957710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7961898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7961898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7961942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7961942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7964338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7964338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7964340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7964340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7965236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7965236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7965237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7965237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7965257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7965257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7965258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7965258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
COMPONENT FEMORAL,7950553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7950553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
BASEPLATE,7938777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7938777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7950554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7950554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7957706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7957706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7964341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7964341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
BASEPLATE,7965239,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7965239,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
SCREW,7942654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,First Health,,275.87,,,,,,,121.58,275.87,percent of total billed charges,
SCREW,7942654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,First Health,,275.87,,,,,,,108.59,275.87,percent of total billed charges,
FEMORAL HEAD,7937809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
FEMORAL HEAD,7937809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
FEMORAL HEAD,7943249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
FEMORAL HEAD,7943249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
FEMORAL HEAD,7954790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
FEMORAL HEAD,7954790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SPINAL SPACER,7943139,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
SPINAL SPACER,7943139,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE,7950095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
BASEPLATE,7950095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
LEAD,7938910,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,15637.50000,4534.88000,Aetna,First Health,,12791.48,,,,,,,5637.32,12791.48,percent of total billed charges,
LEAD,7938910,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,15637.50000,4534.88000,Aetna,First Health,,12791.48,,,,,,,5035.27,12791.48,percent of total billed charges,
LEAD,7938911,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,15637.50000,4534.88000,Aetna,First Health,,12791.48,,,,,,,5637.32,12791.48,percent of total billed charges,
LEAD,7938911,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,15637.50000,4534.88000,Aetna,First Health,,12791.48,,,,,,,5035.27,12791.48,percent of total billed charges,
LEAD,7938912,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,15637.50000,4534.88000,Aetna,First Health,,12791.48,,,,,,,5637.32,12791.48,percent of total billed charges,
LEAD,7938912,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,15637.50000,4534.88000,Aetna,First Health,,12791.48,,,,,,,5035.27,12791.48,percent of total billed charges,
COMPONENT FEMORAL,7938995,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7938995,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7943917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7943917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7956548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7956548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7956550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
COMPONENT FEMORAL,7956550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
BASEPLATE,7939040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BASEPLATE,7939040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
SCREW,7939318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7939318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,7943289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7943289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,7943290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7943290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,7943914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7943914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,7943915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7943915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,7945952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,7945952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
CAGE,7947923,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,7947923,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
INSERT,7944265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,First Health,,4551.92,,,,,,,2006.07,4551.92,percent of total billed charges,
INSERT,7944265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,First Health,,4551.92,,,,,,,1791.83,4551.92,percent of total billed charges,
STEM,7944263,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13275.00000,3849.75000,Aetna,First Health,,10858.95,,,,,,,4785.64,10858.95,percent of total billed charges,
STEM,7944263,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13275.00000,3849.75000,Aetna,First Health,,10858.95,,,,,,,4274.55,10858.95,percent of total billed charges,
PLATE,7939416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1211.28,2748.48,percent of total billed charges,
PLATE,7939416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1081.92,2748.48,percent of total billed charges,
PLATE,7939417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1211.28,2748.48,percent of total billed charges,
PLATE,7939417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1081.92,2748.48,percent of total billed charges,
PLATE,7939430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3451.88000,1001.05000,Aetna,First Health,,2823.64,,,,,,,1244.40,2823.64,percent of total billed charges,
PLATE,7939430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3451.88000,1001.05000,Aetna,First Health,,2823.64,,,,,,,1111.51,2823.64,percent of total billed charges,
PLATE,7939427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3819.38000,1107.62000,Aetna,First Health,,3124.25,,,,,,,1376.89,3124.25,percent of total billed charges,
PLATE,7939427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3819.38000,1107.62000,Aetna,First Health,,3124.25,,,,,,,1229.84,3124.25,percent of total billed charges,
SCREW,7702333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,487.87000,141.48000,Aetna,First Health,,399.08,,,,,,,175.88,399.08,percent of total billed charges,
SCREW,7702333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,487.87000,141.48000,Aetna,First Health,,399.08,,,,,,,157.09,399.08,percent of total billed charges,
SCREW,7702334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,174.10,395.04,percent of total billed charges,
SCREW,7702334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,155.50,395.04,percent of total billed charges,
SCREW,7702335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,174.10,395.04,percent of total billed charges,
SCREW,7702335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,155.50,395.04,percent of total billed charges,
SCREW,7702336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,174.10,395.04,percent of total billed charges,
SCREW,7702336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,155.50,395.04,percent of total billed charges,
SCREW,7702337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,174.10,395.04,percent of total billed charges,
SCREW,7702337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,155.50,395.04,percent of total billed charges,
SCREW,7702338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,174.10,395.04,percent of total billed charges,
SCREW,7702338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,155.50,395.04,percent of total billed charges,
SCREW,7702339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,174.10,395.04,percent of total billed charges,
SCREW,7702339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,First Health,,395.04,,,,,,,155.50,395.04,percent of total billed charges,
SCREW,7744537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7744537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7744538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7744538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7744539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7744539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7933873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7933873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7939436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939497,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939497,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7939507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7939507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,7940850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7940850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7954155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,7954155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
ANCHOR,7961896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1595.00000,462.55000,Aetna,First Health,,1304.71,,,,,,,575.00,1304.71,percent of total billed charges,
ANCHOR,7961896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1595.00000,462.55000,Aetna,First Health,,1304.71,,,,,,,513.59,1304.71,percent of total billed charges,
CAGE,7964557,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7964557,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
CAGE,7965261,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7965261,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
BREAST IMPLANT,7941913,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,987.77,2241.32,percent of total billed charges,
BREAST IMPLANT,7941913,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,882.28,2241.32,percent of total billed charges,
BREAST IMPLANT,7941914,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,987.77,2241.32,percent of total billed charges,
BREAST IMPLANT,7941914,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,882.28,2241.32,percent of total billed charges,
SCREW,7942656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7942656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7942657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7942657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7943320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7943320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7966071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7966071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7966072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7966072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7966073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7966073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
INSERT,7953973,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,First Health,,5454.73,,,,,,,2403.95,5454.73,percent of total billed charges,
INSERT,7953973,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,First Health,,5454.73,,,,,,,2147.22,5454.73,percent of total billed charges,
PLATE SPINAL,8374458,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8374458,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STENT,7956686,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,5321.54000,1543.25000,Aetna,First Health,,4353.02,,,,,,,1918.42,4353.02,percent of total billed charges,
STENT,7956686,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,5321.54000,1543.25000,Aetna,First Health,,4353.02,,,,,,,1713.54,4353.02,percent of total billed charges,
ROD,7959984,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7959984,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
HUMERAL HEAD,7958122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15485.00000,4490.65000,Aetna,First Health,,12666.73,,,,,,,5582.34,12666.73,percent of total billed charges,
HUMERAL HEAD,7958122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15485.00000,4490.65000,Aetna,First Health,,12666.73,,,,,,,4986.17,12666.73,percent of total billed charges,
ROD,7943913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7943913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
BASEPLATE,7956551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
BASEPLATE,7956551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
STEM,7948098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM,7948098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
BASEPLATE,7950459,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7950459,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
BASEPLATE,7953899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7953899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
CAGE,7945950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,7945950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
ROD,7947924,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7947924,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
SPACER KNEE,7698662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7844.40000,2274.88000,Aetna,First Health,,6416.72,,,,,,,2827.91,6416.72,percent of total billed charges,
SPACER KNEE,7698662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7844.40000,2274.88000,Aetna,First Health,,6416.72,,,,,,,2525.90,6416.72,percent of total billed charges,
SPACER KNEE,7820086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7844.40000,2274.88000,Aetna,First Health,,6416.72,,,,,,,2827.91,6416.72,percent of total billed charges,
SPACER KNEE,7820086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7844.40000,2274.88000,Aetna,First Health,,6416.72,,,,,,,2525.90,6416.72,percent of total billed charges,
SPACER KNEE,7896396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7844.40000,2274.88000,Aetna,First Health,,6416.72,,,,,,,2827.91,6416.72,percent of total billed charges,
SPACER KNEE,7896396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7844.40000,2274.88000,Aetna,First Health,,6416.72,,,,,,,2525.90,6416.72,percent of total billed charges,
SPACER KNEE,7698663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3907.58000,1133.20000,Aetna,First Health,,3196.40,,,,,,,1408.68,3196.40,percent of total billed charges,
SPACER KNEE,7698663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3907.58000,1133.20000,Aetna,First Health,,3196.40,,,,,,,1258.24,3196.40,percent of total billed charges,
SPACER KNEE,7698904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3907.58000,1133.20000,Aetna,First Health,,3196.40,,,,,,,1408.68,3196.40,percent of total billed charges,
SPACER KNEE,7698904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3907.58000,1133.20000,Aetna,First Health,,3196.40,,,,,,,1258.24,3196.40,percent of total billed charges,
SPACER KNEE,7699312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3907.58000,1133.20000,Aetna,First Health,,3196.40,,,,,,,1408.68,3196.40,percent of total billed charges,
SPACER KNEE,7699312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3907.58000,1133.20000,Aetna,First Health,,3196.40,,,,,,,1258.24,3196.40,percent of total billed charges,
CAGE,7697937,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
CAGE,7697937,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
CAGE,7698094,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
CAGE,7698094,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
CAGE,7953908,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
CAGE,7953908,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
PLATE,7950155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7950155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7953909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7953909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7957279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7957279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7957843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7957843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,7947894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7947894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
GRAFT,7964383,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5634.61,12785.34,percent of total billed charges,
GRAFT,7964383,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5032.86,12785.34,percent of total billed charges,
PLATE,7948083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7948083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7956553,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7956553,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7957665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7957665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7964651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7964651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CAGE,7948522,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,7948522,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
CAGE,7950096,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,7950096,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
CAGE,7950461,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,7950461,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
INSERT,7948003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,7948003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,7953910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7953910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,7957666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7957666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
INSERT,7950209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
INSERT,7950209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
CUP,7948867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.58000,1439.73000,Aetna,First Health,,4061.03,,,,,,,1789.73,4061.03,percent of total billed charges,
CUP,7948867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.58000,1439.73000,Aetna,First Health,,4061.03,,,,,,,1598.59,4061.03,percent of total billed charges,
PLATE,7954785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,1072.65,2433.91,percent of total billed charges,
PLATE,7954785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,958.09,2433.91,percent of total billed charges,
PLATE,7960152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1151.87,2613.67,percent of total billed charges,
PLATE,7960152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1028.85,2613.67,percent of total billed charges,
CAGE BASE,7950501,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE BASE,7950501,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
CAGE BASE,7957820,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE BASE,7957820,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
TIBIAL CONE,7948414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
TIBIAL CONE,7948414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
TIBIAL CONE,7948693,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
TIBIAL CONE,7948693,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
TIBIAL CONE,7948696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
TIBIAL CONE,7948696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
TIBIAL CONE,7951956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
TIBIAL CONE,7951956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
TIBIAL CONE,7951957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
TIBIAL CONE,7951957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
TIBIAL CONE,7951958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
TIBIAL CONE,7951958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
TIBIAL CONE,7953974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
TIBIAL CONE,7953974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
TIBIAL CONE,7958094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
TIBIAL CONE,7958094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
TIBIAL CONE,7960042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
TIBIAL CONE,7960042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
TIBIAL CONE,7963932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
TIBIAL CONE,7963932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
TESTICULAR IMPLANT,7948611,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8499.00000,2464.71000,Aetna,First Health,,6952.18,,,,,,,3063.89,6952.18,percent of total billed charges,
TESTICULAR IMPLANT,7948611,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8499.00000,2464.71000,Aetna,First Health,,6952.18,,,,,,,2736.68,6952.18,percent of total billed charges,
BOLT,7948595,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BOLT,7948595,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
BOLT,7965009,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BOLT,7965009,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
CAGE,7948612,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,7948612,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
BALLOON CATHETER,7951862,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7951862,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
INSERT,7954524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7954524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7957705,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7957705,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
STENT GRAFT,7948865,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7948865,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7950030,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7950030,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7950031,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7950031,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7950341,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7950341,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7950342,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7950342,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7954161,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7954161,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7954162,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7954162,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7954163,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7954163,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7954164,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7954164,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7954614,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7954614,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7954682,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7954682,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
ROD,7950094,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7950094,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD,7950463,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7950463,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD,7950497,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7950497,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD,7958107,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
ROD,7958107,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
ROD,7962618,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7962618,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD,7964485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7964485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
SHELL,7955063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,608.52,1380.78,percent of total billed charges,
SHELL,7955063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,543.54,1380.78,percent of total billed charges,
SHELL,7957765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,608.52,1380.78,percent of total billed charges,
SHELL,7957765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,543.54,1380.78,percent of total billed charges,
INSERT,7950552,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7950552,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7954746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7954746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
SCREW,7954128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7954128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7954129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7954129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7954130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7954130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7954131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7954131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7954132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7954132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7954133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7954133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,7954134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7954134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SHEATH,7954475,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,First Health,,2545.62,,,,,,,1121.88,2545.62,percent of total billed charges,
SHEATH,7954475,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,First Health,,2545.62,,,,,,,1002.06,2545.62,percent of total billed charges,
STENT GRAFT,7954613,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3824.18,8677.34,percent of total billed charges,
STENT GRAFT,7954613,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3415.78,8677.34,percent of total billed charges,
SHELL,7699953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10420.80000,3022.03000,Aetna,First Health,,8524.21,,,,,,,3756.70,8524.21,percent of total billed charges,
SHELL,7699953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10420.80000,3022.03000,Aetna,First Health,,8524.21,,,,,,,3355.50,8524.21,percent of total billed charges,
SHELL,7700145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10420.80000,3022.03000,Aetna,First Health,,8524.21,,,,,,,3756.70,8524.21,percent of total billed charges,
SHELL,7700145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10420.80000,3022.03000,Aetna,First Health,,8524.21,,,,,,,3355.50,8524.21,percent of total billed charges,
STENT GRAFT,7964380,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
STENT GRAFT,7964380,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
STENT GRAFT,7964381,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
STENT GRAFT,7964381,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
STENT GRAFT,7964382,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
STENT GRAFT,7964382,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
BALLOON CATHETER,7957914,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
BALLOON CATHETER,7957914,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
SCREW,7958104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,731.09,1658.90,percent of total billed charges,
SCREW,7958104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,653.02,1658.90,percent of total billed charges,
SCREW,7958105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,731.09,1658.90,percent of total billed charges,
SCREW,7958105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,653.02,1658.90,percent of total billed charges,
SCREW,7958106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,731.09,1658.90,percent of total billed charges,
SCREW,7958106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,653.02,1658.90,percent of total billed charges,
BALLOON DILATOR,7948233,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,First Health,,7393.85,,,,,,,3258.54,7393.85,percent of total billed charges,
BALLOON DILATOR,7948233,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,First Health,,7393.85,,,,,,,2910.54,7393.85,percent of total billed charges,
BALLOON DILATOR,7948234,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,First Health,,7393.85,,,,,,,3258.54,7393.85,percent of total billed charges,
BALLOON DILATOR,7948234,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,First Health,,7393.85,,,,,,,2910.54,7393.85,percent of total billed charges,
BALLOON DILATOR,7948235,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,First Health,,7393.85,,,,,,,3258.54,7393.85,percent of total billed charges,
BALLOON DILATOR,7948235,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,First Health,,7393.85,,,,,,,2910.54,7393.85,percent of total billed charges,
BALLOON DILATOR,7948236,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,First Health,,7393.85,,,,,,,3258.54,7393.85,percent of total billed charges,
BALLOON DILATOR,7948236,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,First Health,,7393.85,,,,,,,2910.54,7393.85,percent of total billed charges,
BREAST IMPLANT,7960020,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6125.00000,1776.25000,Aetna,First Health,,5010.25,,,,,,,2208.06,5010.25,percent of total billed charges,
BREAST IMPLANT,7960020,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6125.00000,1776.25000,Aetna,First Health,,5010.25,,,,,,,1972.25,5010.25,percent of total billed charges,
CAGE,7963935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,7963935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
CAGE,7964477,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,First Health,,8255.26,,,,,,,3638.17,8255.26,percent of total billed charges,
CAGE,7964477,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,First Health,,8255.26,,,,,,,3249.62,8255.26,percent of total billed charges,
SCREW,7964480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1490.13,3381.20,percent of total billed charges,
SCREW,7964480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1330.99,3381.20,percent of total billed charges,
SCREW,7964481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1490.13,3381.20,percent of total billed charges,
SCREW,7964481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1330.99,3381.20,percent of total billed charges,
SCREW,7964482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1490.13,3381.20,percent of total billed charges,
SCREW,7964482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1330.99,3381.20,percent of total billed charges,
SCREW,7964574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1490.13,3381.20,percent of total billed charges,
SCREW,7964574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1330.99,3381.20,percent of total billed charges,
BREAST IMPLANT,7965058,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BREAST IMPLANT,7965058,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
BREAST IMPLANT,7965059,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BREAST IMPLANT,7965059,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
BREAST IMPLANT,7965060,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BREAST IMPLANT,7965060,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
BREAST IMPLANT,7965062,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
BREAST IMPLANT,7965062,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
BREAST IMPLANT,7965063,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
BREAST IMPLANT,7965063,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
PLATE,7966076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,876.74,1989.38,percent of total billed charges,
PLATE,7966076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,783.10,1989.38,percent of total billed charges,
SCREW,7903729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1527.56000,442.99000,Aetna,First Health,,1249.54,,,,,,,550.69,1249.54,percent of total billed charges,
SCREW,7903729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1527.56000,442.99000,Aetna,First Health,,1249.54,,,,,,,491.87,1249.54,percent of total billed charges,
NERVE GRAFT,7903785,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3738.75,8483.48,percent of total billed charges,
NERVE GRAFT,7903785,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3339.46,8483.48,percent of total billed charges,
NERVE GRAFT,7903786,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3738.75,8483.48,percent of total billed charges,
NERVE GRAFT,7903786,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3339.46,8483.48,percent of total billed charges,
NERVE GRAFT,7903787,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3738.75,8483.48,percent of total billed charges,
NERVE GRAFT,7903787,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3339.46,8483.48,percent of total billed charges,
NERVE GRAFT,7903788,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15675.00000,4545.75000,Aetna,First Health,,12822.15,,,,,,,5650.84,12822.15,percent of total billed charges,
NERVE GRAFT,7903788,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15675.00000,4545.75000,Aetna,First Health,,12822.15,,,,,,,5047.35,12822.15,percent of total billed charges,
NERVE GRAFT,7903789,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15675.00000,4545.75000,Aetna,First Health,,12822.15,,,,,,,5650.84,12822.15,percent of total billed charges,
NERVE GRAFT,7903789,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15675.00000,4545.75000,Aetna,First Health,,12822.15,,,,,,,5047.35,12822.15,percent of total billed charges,
NERVE GRAFT,7903790,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15675.00000,4545.75000,Aetna,First Health,,12822.15,,,,,,,5650.84,12822.15,percent of total billed charges,
NERVE GRAFT,7903790,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15675.00000,4545.75000,Aetna,First Health,,12822.15,,,,,,,5047.35,12822.15,percent of total billed charges,
NERVE GRAFT,7903792,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,21347.50000,6190.78000,Aetna,First Health,,17462.26,,,,,,,7695.77,17462.26,percent of total billed charges,
NERVE GRAFT,7903792,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,21347.50000,6190.78000,Aetna,First Health,,17462.26,,,,,,,6873.90,17462.26,percent of total billed charges,
NERVE GRAFT,7903794,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,22570.00000,6545.30000,Aetna,First Health,,18462.26,,,,,,,8136.48,18462.26,percent of total billed charges,
NERVE GRAFT,7903794,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,22570.00000,6545.30000,Aetna,First Health,,18462.26,,,,,,,7267.54,18462.26,percent of total billed charges,
NERVE GRAFT,7903779,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,25885.00000,7506.65000,Aetna,First Health,,21173.93,,,,,,,9331.54,21173.93,percent of total billed charges,
NERVE GRAFT,7903779,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,25885.00000,7506.65000,Aetna,First Health,,21173.93,,,,,,,8334.97,21173.93,percent of total billed charges,
NERVE GRAFT,7903781,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,27960.75000,8108.62000,Aetna,First Health,,22871.89,,,,,,,10079.85,22871.89,percent of total billed charges,
NERVE GRAFT,7903781,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,27960.75000,8108.62000,Aetna,First Health,,22871.89,,,,,,,9003.36,22871.89,percent of total billed charges,
SCREW,7926645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
SCREW,7926645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
SCREW,7955807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,239.14,542.62,percent of total billed charges,
SCREW,7955807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,First Health,,542.62,,,,,,,213.60,542.62,percent of total billed charges,
SCREW,7964444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
SCREW,7964444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
SCREW,7894170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,338.17,767.34,percent of total billed charges,
SCREW,7894170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,302.06,767.34,percent of total billed charges,
SCREW,7914399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,338.17,767.34,percent of total billed charges,
SCREW,7914399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,302.06,767.34,percent of total billed charges,
SCREW,7922549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7922549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7922550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7922550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7935630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7935630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,7935631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,7935631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SHELL,7910503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,7910503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SHELL,7917699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,7917699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SHELL,7918997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,7918997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SHELL,7918960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,7918960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SHELL,7935822,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,7935822,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SHELL,7948758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,7948758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SHELL,7964475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,7964475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
INSERT,7908183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7908183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7909286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7909286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7930311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7930311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7942775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,7942775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,7948613,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7948613,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7962257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7962257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
PLATE,7904845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3265.50000,946.99000,Aetna,First Health,,2671.18,,,,,,,1177.21,2671.18,percent of total billed charges,
PLATE,7904845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3265.50000,946.99000,Aetna,First Health,,2671.18,,,,,,,1051.49,2671.18,percent of total billed charges,
LINER,7993619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7993619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
INSERT,7993626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7993626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
STENT GRAFT,7993638,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18855.00000,5467.95000,Aetna,First Health,,15423.39,,,,,,,6797.23,15423.39,percent of total billed charges,
STENT GRAFT,7993638,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18855.00000,5467.95000,Aetna,First Health,,15423.39,,,,,,,6071.31,15423.39,percent of total billed charges,
SCREW,7993665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,7993665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
CONNECTOR SPINAL,7993667,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR SPINAL,7993667,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
CONNECTOR SPINAL,7993669,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR SPINAL,7993669,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
SCREW,7993664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,731.09,1658.90,percent of total billed charges,
SCREW,7993664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,653.02,1658.90,percent of total billed charges,
ROD SPINAL,7993671,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
ROD SPINAL,7993671,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
ROD SPINAL,7993672,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
ROD SPINAL,7993672,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
FEMORAL HEAD,7993748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7993748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
STENT,7993773,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,7993773,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,7993776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7993776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
STENT,7993777,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,3356.09,7615.20,percent of total billed charges,
STENT,7993777,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,2997.67,7615.20,percent of total billed charges,
HUMERAL HEAD,7993779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,7993779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
ROD SPINAL,7993811,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7993811,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
ROD SPINAL,7993813,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7993813,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW,7993926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,7993926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
PLATE,7993988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1222.30,2773.48,percent of total billed charges,
PLATE,7993988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1091.76,2773.48,percent of total billed charges,
FEMORAL HEAD,7993990,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
FEMORAL HEAD,7993990,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
LINER,7993992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,7993992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SHELL,7993994,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7993994,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,7993998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,7993998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
BREAST IMPLANT,7994180,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7994180,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7994182,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7994182,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
INSERT,7994184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7994184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
PLATE,7994255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1151.87,2613.67,percent of total billed charges,
PLATE,7994255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1028.85,2613.67,percent of total billed charges,
GENERATOR,7994294,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,48037.50000,13930.87000,Aetna,First Health,,39294.68,,,,,,,17317.52,39294.68,percent of total billed charges,
GENERATOR,7994294,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,48037.50000,13930.87000,Aetna,First Health,,39294.68,,,,,,,15468.08,39294.68,percent of total billed charges,
NAIL,8001083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4650.45,10552.20,percent of total billed charges,
NAIL,8001083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4153.80,10552.20,percent of total billed charges,
INTRODUCER,8001085,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,799.79000,231.94000,Aetna,First Health,,654.23,,,,,,,288.32,654.23,percent of total billed charges,
INTRODUCER,8001085,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,799.79000,231.94000,Aetna,First Health,,654.23,,,,,,,257.53,654.23,percent of total billed charges,
ROD SPINAL,8001414,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8001414,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW,7703200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7703200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,8001437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,8001437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
SCREW,8001439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,8001439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
COMPONENT TALAR,8001678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,7151.42,16227.08,percent of total billed charges,
COMPONENT TALAR,8001678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,6387.68,16227.08,percent of total billed charges,
INSERT,8001679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2708.08,6144.82,percent of total billed charges,
INSERT,8001679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2418.86,6144.82,percent of total billed charges,
BASEPLATE,8001680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,6518.74,14791.49,percent of total billed charges,
BASEPLATE,8001680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,5822.56,14791.49,percent of total billed charges,
STEM,8001681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4609.35,10458.95,percent of total billed charges,
STEM,8001681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4117.09,10458.95,percent of total billed charges,
COMPONENT FEMORAL,8001682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
COMPONENT FEMORAL,8001682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
FEMORAL HEAD,8001980,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,8001980,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SHELL,8002094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
SHELL,8002094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
SCREW,8002202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,8002202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
PLATE,8002204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1395.50,3166.48,percent of total billed charges,
PLATE,8002204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1246.46,3166.48,percent of total billed charges,
K WIRE,8002206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,370.50000,107.44000,Aetna,First Health,,303.07,,,,,,,133.57,303.07,percent of total billed charges,
K WIRE,8002206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,370.50000,107.44000,Aetna,First Health,,303.07,,,,,,,119.30,303.07,percent of total billed charges,
PLATE,8002387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8002387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8002389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8002389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PLATE,8003089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1222.30,2773.48,percent of total billed charges,
PLATE,8003089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1091.76,2773.48,percent of total billed charges,
CAGE,8003093,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4544.46,10311.71,percent of total billed charges,
CAGE,8003093,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4059.13,10311.71,percent of total billed charges,
NAIL,8003095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8003095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
STEM,8003091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,8003091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
PLATE,8003183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1948.00000,564.92000,Aetna,First Health,,1593.46,,,,,,,702.25,1593.46,percent of total billed charges,
PLATE,8003183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1948.00000,564.92000,Aetna,First Health,,1593.46,,,,,,,627.26,1593.46,percent of total billed charges,
INSERT,8003185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8003185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8003188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3574.03000,1036.47000,Aetna,First Health,,2923.56,,,,,,,1288.44,2923.56,percent of total billed charges,
PLATE,8003188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3574.03000,1036.47000,Aetna,First Health,,2923.56,,,,,,,1150.84,2923.56,percent of total billed charges,
SHUNT,8003300,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,18870.25000,5472.37000,Aetna,First Health,,15435.86,,,,,,,6802.73,15435.86,percent of total billed charges,
SHUNT,8003300,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,18870.25000,5472.37000,Aetna,First Health,,15435.86,,,,,,,6076.22,15435.86,percent of total billed charges,
BASEPLATE,8003302,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25875.00000,7503.75000,Aetna,First Health,,21165.75,,,,,,,9327.94,21165.75,percent of total billed charges,
BASEPLATE,8003302,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25875.00000,7503.75000,Aetna,First Health,,21165.75,,,,,,,8331.75,21165.75,percent of total billed charges,
BASEPLATE,8003303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26750.00000,7757.50000,Aetna,First Health,,21881.50,,,,,,,9643.38,21881.50,percent of total billed charges,
BASEPLATE,8003303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26750.00000,7757.50000,Aetna,First Health,,21881.50,,,,,,,8613.50,21881.50,percent of total billed charges,
STENT GRAFT,8003304,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,8003304,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
FLEXIGRAFT,8005020,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8838.00000,2563.02000,Aetna,First Health,,7229.48,,,,,,,3186.10,7229.48,percent of total billed charges,
FLEXIGRAFT,8005020,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8838.00000,2563.02000,Aetna,First Health,,7229.48,,,,,,,2845.84,7229.48,percent of total billed charges,
PLATE,8008786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4634.00000,1343.86000,Aetna,First Health,,3790.61,,,,,,,1670.56,3790.61,percent of total billed charges,
PLATE,8008786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4634.00000,1343.86000,Aetna,First Health,,3790.61,,,,,,,1492.15,3790.61,percent of total billed charges,
SCREW,8008784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,366.70000,106.34000,Aetna,First Health,,299.96,,,,,,,132.20,299.96,percent of total billed charges,
SCREW,8008784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,366.70000,106.34000,Aetna,First Health,,299.96,,,,,,,118.08,299.96,percent of total billed charges,
SHELL,8008804,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,8008804,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
LINER,8008806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8008806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SPINAL FIXATION,8008812,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,801.38,1818.38,percent of total billed charges,
SPINAL FIXATION,8008812,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,715.79,1818.38,percent of total billed charges,
SPINAL FIXATION,8008814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2337.36000,677.83000,Aetna,First Health,,1911.96,,,,,,,842.62,1911.96,percent of total billed charges,
SPINAL FIXATION,8008814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2337.36000,677.83000,Aetna,First Health,,1911.96,,,,,,,752.63,1911.96,percent of total billed charges,
CAGE,8008808,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8008808,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,8008810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,8008810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
ACETABULAR CUP,8008816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
ACETABULAR CUP,8008816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
K WIRE,8008818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
K WIRE,8008818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
COMPONENT FEMORAL,8008841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,907.31,2058.74,percent of total billed charges,
COMPONENT FEMORAL,8008841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,810.41,2058.74,percent of total billed charges,
CAGE,8009529,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,First Health,,8255.26,,,,,,,3638.17,8255.26,percent of total billed charges,
CAGE,8009529,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,First Health,,8255.26,,,,,,,3249.62,8255.26,percent of total billed charges,
SCREW,8009531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,8009531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,8009533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,8009533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
INSERT,8009723,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,8009723,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
NAIL,8061877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8061877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
SCREW,8062076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8062076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
INSERT,8062083,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8062083,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
STEM,8062084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,8062084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
COMPONENT GLENOID,8062085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT GLENOID,8062085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
HUMERAL HEAD,8062086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HUMERAL HEAD,8062086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
WEDGE,8062087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
WEDGE,8062087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
WEDGE,8062088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
WEDGE,8062088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
STEM,8062089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2365.78,5368.12,percent of total billed charges,
STEM,8062089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2113.12,5368.12,percent of total billed charges,
LINER,8062079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,8062079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
ACETABLUR AUGMENT,8062080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
ACETABLUR AUGMENT,8062080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
SHELL,8062081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,8062081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
COMPONENT FEMORAL,8062082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
COMPONENT FEMORAL,8062082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
NAIL,8067256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5971.00000,1731.59000,Aetna,First Health,,4884.28,,,,,,,2152.55,4884.28,percent of total billed charges,
NAIL,8067256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5971.00000,1731.59000,Aetna,First Health,,4884.28,,,,,,,1922.66,4884.28,percent of total billed charges,
SCREW,8067258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.00000,206.19000,Aetna,First Health,,581.60,,,,,,,256.32,581.60,percent of total billed charges,
SCREW,8067258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.00000,206.19000,Aetna,First Health,,581.60,,,,,,,228.94,581.60,percent of total billed charges,
PLATE,8067260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,920.00,2087.54,percent of total billed charges,
PLATE,8067260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,821.74,2087.54,percent of total billed charges,
SCREW,8067262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
SCREW,8067262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
ALLOGRAFT,8067264,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ALLOGRAFT,8067264,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
ALLOGRAFT,8067265,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,First Health,,1701.44,,,,,,,749.84,1701.44,percent of total billed charges,
ALLOGRAFT,8067265,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,First Health,,1701.44,,,,,,,669.76,1701.44,percent of total billed charges,
COMPONENT TIBIAL,8067384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
COMPONENT TIBIAL,8067384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,8067386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8067386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8067388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8067388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
LEAD,8067494,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,24670.00000,7154.30000,Aetna,First Health,,20180.06,,,,,,,8893.53,20180.06,percent of total billed charges,
LEAD,8067494,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,24670.00000,7154.30000,Aetna,First Health,,20180.06,,,,,,,7943.74,20180.06,percent of total billed charges,
GRAFT,8067497,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20775.00000,6024.75000,Aetna,First Health,,16993.95,,,,,,,7489.39,16993.95,percent of total billed charges,
GRAFT,8067497,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20775.00000,6024.75000,Aetna,First Health,,16993.95,,,,,,,6689.55,16993.95,percent of total billed charges,
LEAD,8067502,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,24670.00000,7154.30000,Aetna,First Health,,20180.06,,,,,,,8893.53,20180.06,percent of total billed charges,
LEAD,8067502,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,24670.00000,7154.30000,Aetna,First Health,,20180.06,,,,,,,7943.74,20180.06,percent of total billed charges,
GRAFT,8067496,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20775.00000,6024.75000,Aetna,First Health,,16993.95,,,,,,,7489.39,16993.95,percent of total billed charges,
GRAFT,8067496,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20775.00000,6024.75000,Aetna,First Health,,16993.95,,,,,,,6689.55,16993.95,percent of total billed charges,
GRAFT,8067498,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20775.00000,6024.75000,Aetna,First Health,,16993.95,,,,,,,7489.39,16993.95,percent of total billed charges,
GRAFT,8067498,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20775.00000,6024.75000,Aetna,First Health,,16993.95,,,,,,,6689.55,16993.95,percent of total billed charges,
GRAFT,8067499,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20775.00000,6024.75000,Aetna,First Health,,16993.95,,,,,,,7489.39,16993.95,percent of total billed charges,
GRAFT,8067499,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20775.00000,6024.75000,Aetna,First Health,,16993.95,,,,,,,6689.55,16993.95,percent of total billed charges,
GRAFT,8067500,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20775.00000,6024.75000,Aetna,First Health,,16993.95,,,,,,,7489.39,16993.95,percent of total billed charges,
GRAFT,8067500,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20775.00000,6024.75000,Aetna,First Health,,16993.95,,,,,,,6689.55,16993.95,percent of total billed charges,
SCREW,8067503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
SCREW,8067503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
SCREW,8067504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
SCREW,8067504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
PLATE,8067505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,208.85000,60.57000,Aetna,First Health,,170.84,,,,,,,75.29,170.84,percent of total billed charges,
PLATE,8067505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,208.85000,60.57000,Aetna,First Health,,170.84,,,,,,,67.25,170.84,percent of total billed charges,
SCREW,8067506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,70.03,158.90,percent of total billed charges,
SCREW,8067506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,62.55,158.90,percent of total billed charges,
CAGE,8067508,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8067508,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
FEMORAL HEAD,8067958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
FEMORAL HEAD,8067958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
NAIL,8067960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8067960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
SHELL,8069196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,4027.94,9139.68,percent of total billed charges,
SHELL,8069196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,3597.77,9139.68,percent of total billed charges,
SCREW,8069198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8069198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8069201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8069201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,8069203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8069203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
GLENOSPHERE,8069205,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
GLENOSPHERE,8069205,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
BASEPLATE,8069543,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
BASEPLATE,8069543,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
HUMERAL ASSEMBLY,8069772,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,6398.88,14519.50,percent of total billed charges,
HUMERAL ASSEMBLY,8069772,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,5715.50,14519.50,percent of total billed charges,
STEM,8069546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5948.25,13497.00,percent of total billed charges,
STEM,8069546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5313.00,13497.00,percent of total billed charges,
COMPONENT FEMORAL,8069547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,8069547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
SCREW,8069699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,342.48000,99.32000,Aetna,First Health,,280.15,,,,,,,123.46,280.15,percent of total billed charges,
SCREW,8069699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,342.48000,99.32000,Aetna,First Health,,280.15,,,,,,,110.28,280.15,percent of total billed charges,
SCREW,8069701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,70.03,158.90,percent of total billed charges,
SCREW,8069701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,62.55,158.90,percent of total billed charges,
SCREW,8069800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,70.03,158.90,percent of total billed charges,
SCREW,8069800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,62.55,158.90,percent of total billed charges,
STEM,8069802,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2893.01,6564.45,percent of total billed charges,
STEM,8069802,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2584.05,6564.45,percent of total billed charges,
HUMERAL HEAD,8069805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,8069805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
GUIDEWIRE,8108662,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
GUIDEWIRE,8108662,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
INSERT TIBIAL,8117183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT TIBIAL,8117183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,8117184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8117184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
COMPONENT FEMORAL,8117212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
COMPONENT FEMORAL,8117212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
STEM FEMORAL,8117214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM FEMORAL,8117214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
INSERT,8117216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8117216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
COROENT SM,8117294,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
COROENT SM,8117294,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
COROENT SM,8117296,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
COROENT SM,8117296,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
INSERT TIBIAL,8117298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT TIBIAL,8117298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
INSERT,8117324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8117324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
WEDGE FEMORAL,8117326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE FEMORAL,8117326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
CONE FEMORAL,8117363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
CONE FEMORAL,8117363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
SCREW,8117365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8117365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,8117366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8117366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
CAGE,8117461,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
CAGE,8117461,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
SPEEDBRIDGE IMPLANT SYS,8117463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8266.50000,2397.28000,Aetna,First Health,,6762.00,,,,,,,2980.07,6762.00,percent of total billed charges,
SPEEDBRIDGE IMPLANT SYS,8117463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8266.50000,2397.28000,Aetna,First Health,,6762.00,,,,,,,2661.81,6762.00,percent of total billed charges,
CATHETER PTA,8117464,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER PTA,8117464,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
STENT CATH,8117481,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT CATH,8117481,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
PLATE TIBIAL,8117483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8017.29000,2325.01000,Aetna,First Health,,6558.14,,,,,,,2890.23,6558.14,percent of total billed charges,
PLATE TIBIAL,8117483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8017.29000,2325.01000,Aetna,First Health,,6558.14,,,,,,,2581.57,6558.14,percent of total billed charges,
ROD CONTRD,8117547,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
ROD CONTRD,8117547,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
SCREW POLYAXIAL,8117673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,First Health,,2883.04,,,,,,,1270.58,2883.04,percent of total billed charges,
SCREW POLYAXIAL,8117673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,First Health,,2883.04,,,,,,,1134.89,2883.04,percent of total billed charges,
IMPLANT INNER BODY,8117675,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
IMPLANT INNER BODY,8117675,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
STENT,8117677,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
STENT,8117677,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SHELL,8117679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16087.50000,4665.38000,Aetna,First Health,,13159.58,,,,,,,5799.54,13159.58,percent of total billed charges,
SHELL,8117679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16087.50000,4665.38000,Aetna,First Health,,13159.58,,,,,,,5180.18,13159.58,percent of total billed charges,
SPACER,8117770,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4544.46,10311.71,percent of total billed charges,
SPACER,8117770,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4059.13,10311.71,percent of total billed charges,
PLATE DISTAL,8117884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6110.16000,1771.95000,Aetna,First Health,,4998.11,,,,,,,2202.71,4998.11,percent of total billed charges,
PLATE DISTAL,8117884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6110.16000,1771.95000,Aetna,First Health,,4998.11,,,,,,,1967.47,4998.11,percent of total billed charges,
PLATE BONE,8117886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,761.40000,220.81000,Aetna,First Health,,622.83,,,,,,,274.48,622.83,percent of total billed charges,
PLATE BONE,8117886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,761.40000,220.81000,Aetna,First Health,,622.83,,,,,,,245.17,622.83,percent of total billed charges,
IMPLANT RDL HEAD,8117888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8670.00000,2514.30000,Aetna,First Health,,7092.06,,,,,,,3125.53,7092.06,percent of total billed charges,
IMPLANT RDL HEAD,8117888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8670.00000,2514.30000,Aetna,First Health,,7092.06,,,,,,,2791.74,7092.06,percent of total billed charges,
NAIL,8117764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8117764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
SCREW POLYAXIAL,8117766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW POLYAXIAL,8117766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW POLYAXIAL,8117768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW POLYAXIAL,8117768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,8117772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8117772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8117907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8117907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
SCREW,8117909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8117909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
SCREW,8117911,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8117911,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
ROD,8117913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD,8117913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
ROD,8117915,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD,8117915,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SCREW,8117941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,219.00,496.94,percent of total billed charges,
SCREW,8117941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,195.62,496.94,percent of total billed charges,
SCREW SLF TAP,8118247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW SLF TAP,8118247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW CANC,8117943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW CANC,8117943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
PLATE HUMERAL,8117945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
PLATE HUMERAL,8117945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
SCREW LOCKING,8118249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW LOCKING,8118249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SLING SYS ADVANCE MALE,8119055,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,28080.00000,8143.20000,Aetna,First Health,,22969.44,,,,,,,10122.84,22969.44,percent of total billed charges,
SLING SYS ADVANCE MALE,8119055,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,28080.00000,8143.20000,Aetna,First Health,,22969.44,,,,,,,9041.76,22969.44,percent of total billed charges,
COROENT SM,8119279,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
COROENT SM,8119279,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
CONNECTOR CROSS,8119281,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR CROSS,8119281,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
ROD,8119287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,8119287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8119283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,8119283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,8119285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,8119285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
PLATE,8119541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1222.30,2773.48,percent of total billed charges,
PLATE,8119541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1091.76,2773.48,percent of total billed charges,
HEAD FEM,8119579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
HEAD FEM,8119579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
SHELL,8119916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8119916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT TIBIAL,8119918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,8119918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SHELL,8119906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11490.00000,3332.10000,Aetna,First Health,,9398.82,,,,,,,4142.15,9398.82,percent of total billed charges,
SHELL,8119906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11490.00000,3332.10000,Aetna,First Health,,9398.82,,,,,,,3699.78,9398.82,percent of total billed charges,
LINER,8119908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12276.00000,3560.04000,Aetna,First Health,,10041.77,,,,,,,4425.50,10041.77,percent of total billed charges,
LINER,8119908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12276.00000,3560.04000,Aetna,First Health,,10041.77,,,,,,,3952.87,10041.77,percent of total billed charges,
NAIL,8119910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8119910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
SHELL,8119912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,2211.03,5016.98,percent of total billed charges,
SHELL,8119912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,1974.90,5016.98,percent of total billed charges,
INSERT,8119914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
INSERT,8119914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
SCREW CANC,8120041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
SCREW CANC,8120041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
PLATE,8121090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,557.87000,161.78000,Aetna,First Health,,456.34,,,,,,,201.11,456.34,percent of total billed charges,
PLATE,8121090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,557.87000,161.78000,Aetna,First Health,,456.34,,,,,,,179.63,456.34,percent of total billed charges,
SCREW,8121091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.35000,103.34000,Aetna,First Health,,291.49,,,,,,,128.46,291.49,percent of total billed charges,
SCREW,8121091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.35000,103.34000,Aetna,First Health,,291.49,,,,,,,114.74,291.49,percent of total billed charges,
PLATE,8121092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.72000,167.25000,Aetna,First Health,,471.76,,,,,,,207.91,471.76,percent of total billed charges,
PLATE,8121092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.72000,167.25000,Aetna,First Health,,471.76,,,,,,,185.70,471.76,percent of total billed charges,
SCREW,8121093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,353.26000,102.45000,Aetna,First Health,,288.97,,,,,,,127.35,288.97,percent of total billed charges,
SCREW,8121093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,353.26000,102.45000,Aetna,First Health,,288.97,,,,,,,113.75,288.97,percent of total billed charges,
PLATE,8121094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,931.59000,270.16000,Aetna,First Health,,762.04,,,,,,,335.84,762.04,percent of total billed charges,
PLATE,8121094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,931.59000,270.16000,Aetna,First Health,,762.04,,,,,,,299.97,762.04,percent of total billed charges,
PLATE,8121095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.65000,196.81000,Aetna,First Health,,555.14,,,,,,,244.65,555.14,percent of total billed charges,
PLATE,8121095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.65000,196.81000,Aetna,First Health,,555.14,,,,,,,218.53,555.14,percent of total billed charges,
PLATE,8121096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1228.64000,356.31000,Aetna,First Health,,1005.03,,,,,,,442.92,1005.03,percent of total billed charges,
PLATE,8121096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1228.64000,356.31000,Aetna,First Health,,1005.03,,,,,,,395.62,1005.03,percent of total billed charges,
SCREW,8121097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8121097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8121098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8121098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
COMPONENT FEMORAL,8121269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,8121269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
STEM FEMORAL,8121270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM FEMORAL,8121270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
AUGMENT FEMORAL,8121271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
AUGMENT FEMORAL,8121271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
INSERT TIBIAL,8121272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,8121272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,8121291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8121291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
COMPONENT JRNY,8121292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT JRNY,8121292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
CEMENT IN TRAY,8121293,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16375.00000,4748.75000,Aetna,First Health,,13394.75,,,,,,,5903.19,13394.75,percent of total billed charges,
CEMENT IN TRAY,8121293,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16375.00000,4748.75000,Aetna,First Health,,13394.75,,,,,,,5272.75,13394.75,percent of total billed charges,
SCREW POLYAXIAL,8121294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW POLYAXIAL,8121294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW POLYAXIAL,8121295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW POLYAXIAL,8121295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
CONNECTOR AXIAL,8121296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR AXIAL,8121296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
SHOULDER REVISION,8121089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29812.50000,8645.62000,Aetna,First Health,,24386.62,,,,,,,10747.41,24386.62,percent of total billed charges,
SHOULDER REVISION,8121089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29812.50000,8645.62000,Aetna,First Health,,24386.62,,,,,,,9599.62,24386.62,percent of total billed charges,
INSERT TIBIAL,8121346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,8121346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
IMPLANT HEAD,8121347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
IMPLANT HEAD,8121347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
INSERT TIBIAL,8121348,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,8121348,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
STEM FEMORAL,8121349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM FEMORAL,8121349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
SHELL,8121350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,8121350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
LINER,8121351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,8121351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE TIBIAL,8121352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5455.70000,1582.15000,Aetna,First Health,,4462.76,,,,,,,1966.78,4462.76,percent of total billed charges,
PLATE TIBIAL,8121352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5455.70000,1582.15000,Aetna,First Health,,4462.76,,,,,,,1756.74,4462.76,percent of total billed charges,
SCREW LOCKING,8121353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,261.39,593.12,percent of total billed charges,
SCREW LOCKING,8121353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,233.48,593.12,percent of total billed charges,
PLATE,8121354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2705.64000,784.64000,Aetna,First Health,,2213.21,,,,,,,975.38,2213.21,percent of total billed charges,
PLATE,8121354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2705.64000,784.64000,Aetna,First Health,,2213.21,,,,,,,871.22,2213.21,percent of total billed charges,
SCREW CORT,8121355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW CORT,8121355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
BASEPLATE,8121356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
BASEPLATE,8121356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
SCREW CORT,8121357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW CORT,8121357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8121358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8121358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,8121359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8121359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
INSERT TIBIAL,8121360,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT TIBIAL,8121360,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
INSERT TIBIAL,8121361,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT TIBIAL,8121361,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
SCREW LOCKING,8121420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW LOCKING,8121420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW SLF TAP,8121424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW SLF TAP,8121424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
CAGE,8121416,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
CAGE,8121416,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
PLATE CERVICAL,8121418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE CERVICAL,8121418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE TIBIAL,8121422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9384.00000,2721.36000,Aetna,First Health,,7676.11,,,,,,,3382.93,7676.11,percent of total billed charges,
PLATE TIBIAL,8121422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9384.00000,2721.36000,Aetna,First Health,,7676.11,,,,,,,3021.65,7676.11,percent of total billed charges,
INTRODUCER,8121519,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,461.42000,133.81000,Aetna,First Health,,377.44,,,,,,,166.34,377.44,percent of total billed charges,
INTRODUCER,8121519,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,461.42000,133.81000,Aetna,First Health,,377.44,,,,,,,148.58,377.44,percent of total billed charges,
AUGMENT TIBIAL,8121521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
AUGMENT TIBIAL,8121521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
AUGMENT TIBIAL,8121523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
AUGMENT TIBIAL,8121523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
INSERT TIBIAL,8121525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,8121525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
STEM HUMERAL,8121572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3248.00000,941.92000,Aetna,First Health,,2656.86,,,,,,,1170.90,2656.86,percent of total billed charges,
STEM HUMERAL,8121572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3248.00000,941.92000,Aetna,First Health,,2656.86,,,,,,,1045.86,2656.86,percent of total billed charges,
WEDGE,8121574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
WEDGE,8121574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
LINER ACETABULAR,8121575,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER ACETABULAR,8121575,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CONE BODY FEM,8121576,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
CONE BODY FEM,8121576,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
PLATE,8121586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9357.00000,2713.53000,Aetna,First Health,,7654.03,,,,,,,3373.20,7654.03,percent of total billed charges,
PLATE,8121586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9357.00000,2713.53000,Aetna,First Health,,7654.03,,,,,,,3012.95,7654.03,percent of total billed charges,
INSERT TIBIAL,8121588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,8121588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SCREW BONE,8121604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,843.86,1914.77,percent of total billed charges,
SCREW BONE,8121604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,First Health,,1914.77,,,,,,,753.74,1914.77,percent of total billed charges,
PEG SMOOTH,8121606,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
PEG SMOOTH,8121606,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
PEG SMOOTH,8121608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
PEG SMOOTH,8121608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
PEG SMOOTH,8121610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
PEG SMOOTH,8121610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
CATHETER VANSCHIE,8121613,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,842.99000,244.47000,Aetna,First Health,,689.57,,,,,,,303.90,689.57,percent of total billed charges,
CATHETER VANSCHIE,8121613,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,842.99000,244.47000,Aetna,First Health,,689.57,,,,,,,271.44,689.57,percent of total billed charges,
CATHETER CODA BALLOON,8121614,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,876.74,1989.38,percent of total billed charges,
CATHETER CODA BALLOON,8121614,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,783.10,1989.38,percent of total billed charges,
ROD SPINAL,8121631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8121631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW CORT,8121868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW CORT,8121868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
PLATE,8121870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5793.90000,1680.23000,Aetna,First Health,,4739.41,,,,,,,2088.70,4739.41,percent of total billed charges,
PLATE,8121870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5793.90000,1680.23000,Aetna,First Health,,4739.41,,,,,,,1865.64,4739.41,percent of total billed charges,
COROENT SM,8121873,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
COROENT SM,8121873,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
STEM DISTAL,8121875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15325.00000,4444.25000,Aetna,First Health,,12535.85,,,,,,,5524.66,12535.85,percent of total billed charges,
STEM DISTAL,8121875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15325.00000,4444.25000,Aetna,First Health,,12535.85,,,,,,,4934.65,12535.85,percent of total billed charges,
AXLE CONN IMPLANT FEM TIB,8121877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2924.00000,847.96000,Aetna,First Health,,2391.83,,,,,,,1054.10,2391.83,percent of total billed charges,
AXLE CONN IMPLANT FEM TIB,8121877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2924.00000,847.96000,Aetna,First Health,,2391.83,,,,,,,941.53,2391.83,percent of total billed charges,
SLEEVE TIBIAL ROTATING HINGE NEUTRAL,8121879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
SLEEVE TIBIAL ROTATING HINGE NEUTRAL,8121879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
BASEPLATE TIBIAL,8121881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8265.00000,2396.85000,Aetna,First Health,,6760.77,,,,,,,2979.53,6760.77,percent of total billed charges,
BASEPLATE TIBIAL,8121881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8265.00000,2396.85000,Aetna,First Health,,6760.77,,,,,,,2661.33,6760.77,percent of total billed charges,
INSERT TIBIAL,8121883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
INSERT TIBIAL,8121883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
STEM FEMORAL,8121885,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7326.00000,2124.54000,Aetna,First Health,,5992.67,,,,,,,2641.02,5992.67,percent of total billed charges,
STEM FEMORAL,8121885,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7326.00000,2124.54000,Aetna,First Health,,5992.67,,,,,,,2358.97,5992.67,percent of total billed charges,
CAGE COROENT,8122087,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE COROENT,8122087,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
HEAD HUMERAL,8122089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
HEAD HUMERAL,8122089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
BONE CANC ASEPTIC FREEZE DRIED CHIPS,8122101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.40000,465.86000,Aetna,First Health,,1314.04,,,,,,,579.11,1314.04,percent of total billed charges,
BONE CANC ASEPTIC FREEZE DRIED CHIPS,8122101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.40000,465.86000,Aetna,First Health,,1314.04,,,,,,,517.26,1314.04,percent of total billed charges,
BONE CANC ASEPTIC FREEZE DRIED CRUSH,8122102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2319.20000,672.57000,Aetna,First Health,,1897.11,,,,,,,836.07,1897.11,percent of total billed charges,
BONE CANC ASEPTIC FREEZE DRIED CRUSH,8122102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2319.20000,672.57000,Aetna,First Health,,1897.11,,,,,,,746.78,1897.11,percent of total billed charges,
ALLOGRAFT SM 1CC,8122103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,814.73,1848.68,percent of total billed charges,
ALLOGRAFT SM 1CC,8122103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,727.72,1848.68,percent of total billed charges,
ABLATION CATHETER,8122165,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,35.30,80.09,percent of total billed charges,
ABLATION CATHETER,8122165,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,31.53,80.09,percent of total billed charges,
PLATE CLAVICLE,8122279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE CLAVICLE,8122279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
SCREW,8122281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8122281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
ROD,8122283,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
ROD,8122283,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
SCREW,8122285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8122285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
INSERT TIBIAL,8123297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT TIBIAL,8123297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT TIBIAL,8123299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT TIBIAL,8123299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
STEM,8123490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,8123490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW LOCKING,8123494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW LOCKING,8123494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
PLATE CERVICAL,8123492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE CERVICAL,8123492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
GUIDEWIRE,8123508,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,442.69,1004.50,percent of total billed charges,
GUIDEWIRE,8123508,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,395.42,1004.50,percent of total billed charges,
BALLOON,7758257,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,3510.85000,1018.15000,Aetna,First Health,,2871.88,,,,,,,1265.66,2871.88,percent of total billed charges,
BALLOON,7758257,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,3510.85000,1018.15000,Aetna,First Health,,2871.88,,,,,,,1130.49,2871.88,percent of total billed charges,
INSERT TIBIAL,8123534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,8123534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT TIBIAL,8123536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,8123536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM HUMERAL,8123539,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,8123539,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
COMPONENT FEMORAL,8123542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,8123542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
PLATE BONE,8123544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.32000,188.01000,Aetna,First Health,,530.33,,,,,,,233.72,530.33,percent of total billed charges,
PLATE BONE,8123544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.32000,188.01000,Aetna,First Health,,530.33,,,,,,,208.76,530.33,percent of total billed charges,
SCREW BONE,8123546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,84.26000,24.44000,Aetna,First Health,,68.92,,,,,,,30.38,68.92,percent of total billed charges,
SCREW BONE,8123546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,84.26000,24.44000,Aetna,First Health,,68.92,,,,,,,27.13,68.92,percent of total billed charges,
PLATE,8123548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
PLATE,8123548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW BONE,8123550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,84.30000,24.45000,Aetna,First Health,,68.96,,,,,,,30.39,68.96,percent of total billed charges,
SCREW BONE,8123550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,84.30000,24.45000,Aetna,First Health,,68.96,,,,,,,27.14,68.96,percent of total billed charges,
COMPONENT FEMORAL,8123554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,8123554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
GUIDEWIRE,8123532,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
GUIDEWIRE,8123532,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
INSERT TIBIAL,8123734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT TIBIAL,8123734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT TIBIAL,8123736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT TIBIAL,8123736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
PLATE,8123732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,836.51000,242.59000,Aetna,First Health,,684.27,,,,,,,301.56,684.27,percent of total billed charges,
PLATE,8123732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,836.51000,242.59000,Aetna,First Health,,684.27,,,,,,,269.36,684.27,percent of total billed charges,
SCREW BONE,8123738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.41000,95.53000,Aetna,First Health,,269.46,,,,,,,118.75,269.46,percent of total billed charges,
SCREW BONE,8123738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.41000,95.53000,Aetna,First Health,,269.46,,,,,,,106.07,269.46,percent of total billed charges,
STENT GRAFT,8123795,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,8123795,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
HEAD FEM,8123797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEM,8123797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SPACER,8123896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SPACER,8123896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
STEM FEMORAL,8123897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM FEMORAL,8123897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW HEX,8123906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW HEX,8123906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW HEX,8123908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW HEX,8123908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW CORT,8123953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SCREW CORT,8123953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SCREW CORT,8124275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SCREW CORT,8124275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SCREW CORT,8124277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SCREW CORT,8124277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
STENT GRAFT,8123955,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,8123955,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
INTERBODY FUSION,8123956,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
INTERBODY FUSION,8123956,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
STENT GRAFT,8124273,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,8124273,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
SHELL,8124272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8124272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
COROENT XL,8124294,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
COROENT XL,8124294,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
COROENT XL,8124296,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
COROENT XL,8124296,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
KWIRE,8124298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
KWIRE,8124298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
CEMENT BONE,8124314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,351.50000,101.93000,Aetna,First Health,,287.53,,,,,,,126.72,287.53,percent of total billed charges,
CEMENT BONE,8124314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,351.50000,101.93000,Aetna,First Health,,287.53,,,,,,,113.18,287.53,percent of total billed charges,
CEMENT BONE,8124316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
CEMENT BONE,8124316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
INSERT,8124318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8124318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
FEMORAL HEAD,8124327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,8124327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
COIL EMBOLIZATION,8124391,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,First Health,,3070.57,,,,,,,1353.23,3070.57,percent of total billed charges,
COIL EMBOLIZATION,8124391,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,First Health,,3070.57,,,,,,,1208.71,3070.57,percent of total billed charges,
SCREW CANC,8124392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
SCREW CANC,8124392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
PLATE FEMORAL,8124393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5541.90000,1607.15000,Aetna,First Health,,4533.27,,,,,,,1997.85,4533.27,percent of total billed charges,
PLATE FEMORAL,8124393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5541.90000,1607.15000,Aetna,First Health,,4533.27,,,,,,,1784.49,4533.27,percent of total billed charges,
STEM FEMORAL,8124395,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM FEMORAL,8124395,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
HEAD FEM,8124396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEM,8124396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW,8124394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,290.06,658.16,percent of total billed charges,
SCREW,8124394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,First Health,,658.16,,,,,,,259.08,658.16,percent of total billed charges,
SPHINCTEROTOME,8124413,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1932.00000,560.28000,Aetna,First Health,,1580.38,,,,,,,696.49,1580.38,percent of total billed charges,
SPHINCTEROTOME,8124413,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1932.00000,560.28000,Aetna,First Health,,1580.38,,,,,,,622.10,1580.38,percent of total billed charges,
GUIDEWIRE,8124414,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1848.00000,535.92000,Aetna,First Health,,1511.66,,,,,,,666.20,1511.66,percent of total billed charges,
GUIDEWIRE,8124414,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1848.00000,535.92000,Aetna,First Health,,1511.66,,,,,,,595.06,1511.66,percent of total billed charges,
GUIDEWIRE,8124416,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,293.63,666.26,percent of total billed charges,
GUIDEWIRE,8124416,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,262.27,666.26,percent of total billed charges,
INTRODUCER STENT,8124417,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,230.36,522.70,percent of total billed charges,
INTRODUCER STENT,8124417,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,205.76,522.70,percent of total billed charges,
GUIDEWIRE,8124420,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1276.00000,370.04000,Aetna,First Health,,1043.77,,,,,,,460.00,1043.77,percent of total billed charges,
GUIDEWIRE,8124420,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1276.00000,370.04000,Aetna,First Health,,1043.77,,,,,,,410.87,1043.77,percent of total billed charges,
GUIDEWIRE,8124421,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1276.00000,370.04000,Aetna,First Health,,1043.77,,,,,,,460.00,1043.77,percent of total billed charges,
GUIDEWIRE,8124421,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1276.00000,370.04000,Aetna,First Health,,1043.77,,,,,,,410.87,1043.77,percent of total billed charges,
STENT GRAFT,8124593,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,8124593,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,8124595,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,8124595,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
SPHERE GLENOID,8124815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
SPHERE GLENOID,8124815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
STEM HUMERAL,8124816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM HUMERAL,8124816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
COROENT TI,8124819,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,7734.60000,2243.03000,Aetna,First Health,,6326.90,,,,,,,2788.32,6326.90,percent of total billed charges,
COROENT TI,8124819,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,7734.60000,2243.03000,Aetna,First Health,,6326.90,,,,,,,2490.54,6326.90,percent of total billed charges,
INSERT TIBIAL,8124833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT TIBIAL,8124833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SPHERE GLENOID,8124835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
SPHERE GLENOID,8124835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
STEM,8124842,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30026.25000,8707.61000,Aetna,First Health,,24561.47,,,,,,,10824.46,24561.47,percent of total billed charges,
STEM,8124842,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30026.25000,8707.61000,Aetna,First Health,,24561.47,,,,,,,9668.45,24561.47,percent of total billed charges,
IMPLANT HEAD,8124843,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1855.02,4209.18,percent of total billed charges,
IMPLANT HEAD,8124843,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1656.92,4209.18,percent of total billed charges,
LINER,8124844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,3000.08,6807.40,percent of total billed charges,
LINER,8124844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,2679.68,6807.40,percent of total billed charges,
CAGE,8124845,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8124845,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,8124846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8124846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW BONE NON LCKNG,8124847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW BONE NON LCKNG,8124847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW BONE NON LCKNG,8124848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW BONE NON LCKNG,8124848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW BONE,8124849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW BONE,8124849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW BONE,8124850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW BONE,8124850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW BONE,8124851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW BONE,8124851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW BONE,8124852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW BONE,8124852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
COMPONENT FEMORAL,8124856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16598.03000,4813.43000,Aetna,First Health,,13577.19,,,,,,,5983.59,13577.19,percent of total billed charges,
COMPONENT FEMORAL,8124856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16598.03000,4813.43000,Aetna,First Health,,13577.19,,,,,,,5344.57,13577.19,percent of total billed charges,
STEM FEMORAL,8124857,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7460.70000,2163.60000,Aetna,First Health,,6102.85,,,,,,,2689.58,6102.85,percent of total billed charges,
STEM FEMORAL,8124857,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7460.70000,2163.60000,Aetna,First Health,,6102.85,,,,,,,2402.35,6102.85,percent of total billed charges,
STEM FEMORAL,8124921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2378.80000,689.85000,Aetna,First Health,,1945.86,,,,,,,857.56,1945.86,percent of total billed charges,
STEM FEMORAL,8124921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2378.80000,689.85000,Aetna,First Health,,1945.86,,,,,,,765.97,1945.86,percent of total billed charges,
SCREW,8124858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2143.80000,621.70000,Aetna,First Health,,1753.63,,,,,,,772.84,1753.63,percent of total billed charges,
SCREW,8124858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2143.80000,621.70000,Aetna,First Health,,1753.63,,,,,,,690.30,1753.63,percent of total billed charges,
PIN,8124859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2222.00000,644.38000,Aetna,First Health,,1817.60,,,,,,,801.03,1817.60,percent of total billed charges,
PIN,8124859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2222.00000,644.38000,Aetna,First Health,,1817.60,,,,,,,715.48,1817.60,percent of total billed charges,
PLUG,8124860,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5671.26000,1644.67000,Aetna,First Health,,4639.09,,,,,,,2044.49,4639.09,percent of total billed charges,
PLUG,8124860,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5671.26000,1644.67000,Aetna,First Health,,4639.09,,,,,,,1826.15,4639.09,percent of total billed charges,
BASEPLATE TIBIAL,8124861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12466.80000,3615.37000,Aetna,First Health,,10197.84,,,,,,,4494.28,10197.84,percent of total billed charges,
BASEPLATE TIBIAL,8124861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12466.80000,3615.37000,Aetna,First Health,,10197.84,,,,,,,4014.31,10197.84,percent of total billed charges,
COMPONENT FEMORAL,8124862,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23879.25000,6924.98000,Aetna,First Health,,19533.23,,,,,,,8608.47,19533.23,percent of total billed charges,
COMPONENT FEMORAL,8124862,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23879.25000,6924.98000,Aetna,First Health,,19533.23,,,,,,,7689.12,19533.23,percent of total billed charges,
ADAPTER FEMORAL,8124863,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4271.75000,1238.81000,Aetna,First Health,,3494.29,,,,,,,1539.97,3494.29,percent of total billed charges,
ADAPTER FEMORAL,8124863,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4271.75000,1238.81000,Aetna,First Health,,3494.29,,,,,,,1375.50,3494.29,percent of total billed charges,
INSERT TIBIAL,8124864,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4599.00000,1333.71000,Aetna,First Health,,3761.98,,,,,,,1657.94,3761.98,percent of total billed charges,
INSERT TIBIAL,8124864,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4599.00000,1333.71000,Aetna,First Health,,3761.98,,,,,,,1480.88,3761.98,percent of total billed charges,
AXLE CONN FEMORAL TIBIAL OSS,7698867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2398.00000,695.42000,Aetna,First Health,,1961.56,,,,,,,864.48,1961.56,percent of total billed charges,
AXLE CONN FEMORAL TIBIAL OSS,7698867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2398.00000,695.42000,Aetna,First Health,,1961.56,,,,,,,772.16,1961.56,percent of total billed charges,
COMPONENT FEMORAL,7698869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2244.00000,650.76000,Aetna,First Health,,1835.59,,,,,,,808.96,1835.59,percent of total billed charges,
COMPONENT FEMORAL,7698869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2244.00000,650.76000,Aetna,First Health,,1835.59,,,,,,,722.57,1835.59,percent of total billed charges,
COMPONENT FEMORAL,7698870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1738.00000,504.02000,Aetna,First Health,,1421.68,,,,,,,626.55,1421.68,percent of total billed charges,
COMPONENT FEMORAL,7698870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1738.00000,504.02000,Aetna,First Health,,1421.68,,,,,,,559.64,1421.68,percent of total billed charges,
COMPONENT FEMORAL,7698873,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4753.00000,1378.37000,Aetna,First Health,,3887.95,,,,,,,1713.46,3887.95,percent of total billed charges,
COMPONENT FEMORAL,7698873,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4753.00000,1378.37000,Aetna,First Health,,3887.95,,,,,,,1530.47,3887.95,percent of total billed charges,
INSERT,8124865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8124865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
WEDGE TIBIAL,8124866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
WEDGE TIBIAL,8124866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
PLATE,8124923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8124923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PIN,7698872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1583.72000,459.28000,Aetna,First Health,,1295.48,,,,,,,570.93,1295.48,percent of total billed charges,
PIN,7698872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1583.72000,459.28000,Aetna,First Health,,1295.48,,,,,,,509.96,1295.48,percent of total billed charges,
BONE GRAFT,8124959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5964.00000,1729.56000,Aetna,First Health,,4878.55,,,,,,,2150.02,4878.55,percent of total billed charges,
BONE GRAFT,8124959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5964.00000,1729.56000,Aetna,First Health,,4878.55,,,,,,,1920.41,4878.55,percent of total billed charges,
CATHETER ACCU FLO CSF,8124965,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1564.48000,453.70000,Aetna,First Health,,1279.74,,,,,,,564.00,1279.74,percent of total billed charges,
CATHETER ACCU FLO CSF,8124965,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1564.48000,453.70000,Aetna,First Health,,1279.74,,,,,,,503.76,1279.74,percent of total billed charges,
RESERVOIR,8124966,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2885.96000,836.93000,Aetna,First Health,,2360.72,,,,,,,1040.39,2360.72,percent of total billed charges,
RESERVOIR,8124966,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2885.96000,836.93000,Aetna,First Health,,2360.72,,,,,,,929.28,2360.72,percent of total billed charges,
RESERVOIR,8124967,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2885.96000,836.93000,Aetna,First Health,,2360.72,,,,,,,1040.39,2360.72,percent of total billed charges,
RESERVOIR,8124967,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2885.96000,836.93000,Aetna,First Health,,2360.72,,,,,,,929.28,2360.72,percent of total billed charges,
PLATE,8125159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8910.90000,2584.16000,Aetna,First Health,,7289.12,,,,,,,3212.38,7289.12,percent of total billed charges,
PLATE,8125159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8910.90000,2584.16000,Aetna,First Health,,7289.12,,,,,,,2869.31,7289.12,percent of total billed charges,
PLATE,8125161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2786.32000,808.03000,Aetna,First Health,,2279.21,,,,,,,1004.47,2279.21,percent of total billed charges,
PLATE,8125161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2786.32000,808.03000,Aetna,First Health,,2279.21,,,,,,,897.20,2279.21,percent of total billed charges,
PLATE,8125266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8125266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,8125268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,8125268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
TISSUE BIO AVS C PLUG,8125448,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1783.07,4045.91,percent of total billed charges,
TISSUE BIO AVS C PLUG,8125448,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1592.64,4045.91,percent of total billed charges,
TISSUE BIO AVS C PLUG,8125449,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1783.07,4045.91,percent of total billed charges,
TISSUE BIO AVS C PLUG,8125449,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1592.64,4045.91,percent of total billed charges,
TISSUE BIO AVS C PLUG,8125450,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1783.07,4045.91,percent of total billed charges,
TISSUE BIO AVS C PLUG,8125450,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1592.64,4045.91,percent of total billed charges,
TISSUE BIO AVS C PLUG,8125451,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1783.07,4045.91,percent of total billed charges,
TISSUE BIO AVS C PLUG,8125451,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1592.64,4045.91,percent of total billed charges,
TISSUE BIO AVS C PLUG,8125452,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1783.07,4045.91,percent of total billed charges,
TISSUE BIO AVS C PLUG,8125452,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,First Health,,4045.91,,,,,,,1592.64,4045.91,percent of total billed charges,
INTRODUCER,7697887,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,133.35000,38.67000,Aetna,First Health,,109.08,,,,,,,48.07,109.08,percent of total billed charges,
INTRODUCER,7697887,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,133.35000,38.67000,Aetna,First Health,,109.08,,,,,,,42.94,109.08,percent of total billed charges,
STEM FEMORAL,8125538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM FEMORAL,8125538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
INSERT TIBIAL,8125540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,8125540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SCREW,8125542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8125542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
ROD SPINAL,8125544,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8125544,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
ROD SPINAL,8125546,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8125546,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
INTERBODY,8125548,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
INTERBODY,8125548,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
BONE TENDON,7696686,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
BONE TENDON,7696686,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
WEDGE FEMORAL,8125555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE FEMORAL,8125555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
INSERT TIBIAL,8125584,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,8125584,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SPACER DISTAL,8125585,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
SPACER DISTAL,8125585,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
COMPONENT FEMORAL,8125586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,8125586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
SPACER,8125587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
SPACER,8125587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
SPACER,8125750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
SPACER,8125750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
INSERT,8125588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2708.08,6144.82,percent of total billed charges,
INSERT,8125588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2418.86,6144.82,percent of total billed charges,
BASEPLATE TIBIAL,8125589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,6518.74,14791.49,percent of total billed charges,
BASEPLATE TIBIAL,8125589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,5822.56,14791.49,percent of total billed charges,
COMPONENT FEMORAL,8125580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4515.97,10247.05,percent of total billed charges,
COMPONENT FEMORAL,8125580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4033.68,10247.05,percent of total billed charges,
COMPONENT DISTAL,8125582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25225.20000,7315.31000,Aetna,First Health,,20634.21,,,,,,,9093.68,20634.21,percent of total billed charges,
COMPONENT DISTAL,8125582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25225.20000,7315.31000,Aetna,First Health,,20634.21,,,,,,,8122.51,20634.21,percent of total billed charges,
STAPLE,8126039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5012.00000,1453.48000,Aetna,First Health,,4099.82,,,,,,,1806.83,4099.82,percent of total billed charges,
STAPLE,8126039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5012.00000,1453.48000,Aetna,First Health,,4099.82,,,,,,,1613.86,4099.82,percent of total billed charges,
IMP AUGMENT INJ,8126042,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
IMP AUGMENT INJ,8126042,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
SCREW POLYAXIAL,8126046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW POLYAXIAL,8126046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW POLYAXIAL,8126047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW POLYAXIAL,8126047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW POLYAXIAL,8126048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW POLYAXIAL,8126048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
ROD,8126049,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD,8126049,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW CANN,8126078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1608.00000,466.32000,Aetna,First Health,,1315.34,,,,,,,579.68,1315.34,percent of total billed charges,
SCREW CANN,8126078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1608.00000,466.32000,Aetna,First Health,,1315.34,,,,,,,517.78,1315.34,percent of total billed charges,
PLATE CERVICAL,8126084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE CERVICAL,8126084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
STEM,8126086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,8126086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
HEAD FEM,8126088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
HEAD FEM,8126088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
HEAD FEM,8126090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEM,8126090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
SCREW CORT,8126187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW CORT,8126187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
BASEPLATE TIBIAL,8126189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3420.78,7762.00,percent of total billed charges,
BASEPLATE TIBIAL,8126189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3055.46,7762.00,percent of total billed charges,
HEAD HUM,8126191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,2197.43,4986.12,percent of total billed charges,
HEAD HUM,8126191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,1962.75,4986.12,percent of total billed charges,
STEM HUMERAL,8126193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
STEM HUMERAL,8126193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW SLF TAP,8126197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW SLF TAP,8126197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
SCREW SLF TAP,8126199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW SLF TAP,8126199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
INSERT,8126298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3486.76,7911.70,percent of total billed charges,
INSERT,8126298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3114.38,7911.70,percent of total billed charges,
INSERT TIBIAL,8126300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT TIBIAL,8126300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
INSERT TIBIAL,8126384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT TIBIAL,8126384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
HEAD FEM,8126536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
HEAD FEM,8126536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
SHELL,8126538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,8126538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
INTERBODY DIVERGENCE,8126911,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
INTERBODY DIVERGENCE,8126911,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
SCREW FEMORAL,8126912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW FEMORAL,8126912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
PLATE DISTAL,8126913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,3076.87,6981.63,percent of total billed charges,
PLATE DISTAL,8126913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,2748.27,6981.63,percent of total billed charges,
ROD,8126914,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD,8126914,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SCREW,8126915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8126915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
SCREW BONE,8126916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW BONE,8126916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CAGE,8126917,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8126917,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE TIBIAL,8126920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5455.70000,1582.15000,Aetna,First Health,,4462.76,,,,,,,1966.78,4462.76,percent of total billed charges,
PLATE TIBIAL,8126920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5455.70000,1582.15000,Aetna,First Health,,4462.76,,,,,,,1756.74,4462.76,percent of total billed charges,
INSERT TIBIAL,8126921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT TIBIAL,8126921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
NAIL,8126922,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8126922,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
SCREW HEX,8126930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW HEX,8126930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
STENT,8126924,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3896.80000,1130.07000,Aetna,First Health,,3187.58,,,,,,,1404.80,3187.58,percent of total billed charges,
STENT,8126924,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3896.80000,1130.07000,Aetna,First Health,,3187.58,,,,,,,1254.77,3187.58,percent of total billed charges,
INSERT TIBIAL,8126926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT TIBIAL,8126926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SHELL,8126927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,8126927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
COMPONENT GLENOID,8126928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT GLENOID,8126928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
HEAD HUMERAL,8126970,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HEAD HUMERAL,8126970,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CONE FEMORAL,8126985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
CONE FEMORAL,8126985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
STEM FEMORAL,8126987,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7460.70000,2163.60000,Aetna,First Health,,6102.85,,,,,,,2689.58,6102.85,percent of total billed charges,
STEM FEMORAL,8126987,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7460.70000,2163.60000,Aetna,First Health,,6102.85,,,,,,,2402.35,6102.85,percent of total billed charges,
STEM FEMORAL,8126989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6381.55000,1850.65000,Aetna,First Health,,5220.11,,,,,,,2300.55,5220.11,percent of total billed charges,
STEM FEMORAL,8126989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6381.55000,1850.65000,Aetna,First Health,,5220.11,,,,,,,2054.86,5220.11,percent of total billed charges,
INSERT,7702915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7702915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
STEM FEMORAL,8127003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20917.50000,6066.08000,Aetna,First Health,,17110.51,,,,,,,7540.76,17110.51,percent of total billed charges,
STEM FEMORAL,8127003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20917.50000,6066.08000,Aetna,First Health,,17110.51,,,,,,,6735.44,17110.51,percent of total billed charges,
STEM FEMORAL,8127004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8397.90000,2435.39000,Aetna,First Health,,6869.48,,,,,,,3027.44,6869.48,percent of total billed charges,
STEM FEMORAL,8127004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8397.90000,2435.39000,Aetna,First Health,,6869.48,,,,,,,2704.12,6869.48,percent of total billed charges,
SPACER TIBIAL,8127005,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4564.35000,1323.66000,Aetna,First Health,,3733.64,,,,,,,1645.45,3733.64,percent of total billed charges,
SPACER TIBIAL,8127005,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4564.35000,1323.66000,Aetna,First Health,,3733.64,,,,,,,1469.72,3733.64,percent of total billed charges,
BASEPLATE TIBIAL,8127006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12466.80000,3615.37000,Aetna,First Health,,10197.84,,,,,,,4494.28,10197.84,percent of total billed charges,
BASEPLATE TIBIAL,8127006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12466.80000,3615.37000,Aetna,First Health,,10197.84,,,,,,,4014.31,10197.84,percent of total billed charges,
COMPONENT FEMORAL,8127007,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2398.00000,695.42000,Aetna,First Health,,1961.56,,,,,,,864.48,1961.56,percent of total billed charges,
COMPONENT FEMORAL,8127007,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2398.00000,695.42000,Aetna,First Health,,1961.56,,,,,,,772.16,1961.56,percent of total billed charges,
COMPONENT BRUSHING,8127008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2244.00000,650.76000,Aetna,First Health,,1835.59,,,,,,,808.96,1835.59,percent of total billed charges,
COMPONENT BRUSHING,8127008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2244.00000,650.76000,Aetna,First Health,,1835.59,,,,,,,722.57,1835.59,percent of total billed charges,
COMPONENT FEMORAL,8127009,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23136.75000,6709.66000,Aetna,First Health,,18925.86,,,,,,,8340.80,18925.86,percent of total billed charges,
COMPONENT FEMORAL,8127009,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23136.75000,6709.66000,Aetna,First Health,,18925.86,,,,,,,7450.03,18925.86,percent of total billed charges,
INSERT TIBIAL,8127010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4599.00000,1333.71000,Aetna,First Health,,3761.98,,,,,,,1657.94,3761.98,percent of total billed charges,
INSERT TIBIAL,8127010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4599.00000,1333.71000,Aetna,First Health,,3761.98,,,,,,,1480.88,3761.98,percent of total billed charges,
SPACER TIBIAL,8127011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4564.35000,1323.66000,Aetna,First Health,,3733.64,,,,,,,1645.45,3733.64,percent of total billed charges,
SPACER TIBIAL,8127011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4564.35000,1323.66000,Aetna,First Health,,3733.64,,,,,,,1469.72,3733.64,percent of total billed charges,
PLATE FEMORAL,8127012,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10323.00000,2993.67000,Aetna,First Health,,8444.21,,,,,,,3721.44,8444.21,percent of total billed charges,
PLATE FEMORAL,8127012,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10323.00000,2993.67000,Aetna,First Health,,8444.21,,,,,,,3324.01,8444.21,percent of total billed charges,
SCREW LOCKING,8127013,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW LOCKING,8127013,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW LOCKING,8127014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW LOCKING,8127014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
STEM FEMORAL,8127065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8397.90000,2435.39000,Aetna,First Health,,6869.48,,,,,,,3027.44,6869.48,percent of total billed charges,
STEM FEMORAL,8127065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8397.90000,2435.39000,Aetna,First Health,,6869.48,,,,,,,2704.12,6869.48,percent of total billed charges,
COMPONENT FEMORAL,8126999,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24250.50000,7032.64000,Aetna,First Health,,19836.91,,,,,,,8742.31,19836.91,percent of total billed charges,
COMPONENT FEMORAL,8126999,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24250.50000,7032.64000,Aetna,First Health,,19836.91,,,,,,,7808.66,19836.91,percent of total billed charges,
BASEPLATE TIBIAL,8127001,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12466.80000,3615.37000,Aetna,First Health,,10197.84,,,,,,,4494.28,10197.84,percent of total billed charges,
BASEPLATE TIBIAL,8127001,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12466.80000,3615.37000,Aetna,First Health,,10197.84,,,,,,,4014.31,10197.84,percent of total billed charges,
STEM,8127646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1257.68000,364.73000,Aetna,First Health,,1028.78,,,,,,,453.39,1028.78,percent of total billed charges,
STEM,8127646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1257.68000,364.73000,Aetna,First Health,,1028.78,,,,,,,404.97,1028.78,percent of total billed charges,
COMPONENT DISTAL,8127648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25606.63000,7425.92000,Aetna,First Health,,20946.22,,,,,,,9231.19,20946.22,percent of total billed charges,
COMPONENT DISTAL,8127648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25606.63000,7425.92000,Aetna,First Health,,20946.22,,,,,,,8245.33,20946.22,percent of total billed charges,
STEM CEMENTED,8127650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7609.95000,2206.89000,Aetna,First Health,,6224.94,,,,,,,2743.39,6224.94,percent of total billed charges,
STEM CEMENTED,8127650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7609.95000,2206.89000,Aetna,First Health,,6224.94,,,,,,,2450.40,6224.94,percent of total billed charges,
COMPONENT ROTATION CONNECT NEUTRAL MED,8127652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6613.88000,1918.03000,Aetna,First Health,,5410.15,,,,,,,2384.30,5410.15,percent of total billed charges,
COMPONENT ROTATION CONNECT NEUTRAL MED,8127652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6613.88000,1918.03000,Aetna,First Health,,5410.15,,,,,,,2129.67,5410.15,percent of total billed charges,
COMPONENT TIBIAL,8127654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16743.20000,4855.53000,Aetna,First Health,,13695.94,,,,,,,6035.92,13695.94,percent of total billed charges,
COMPONENT TIBIAL,8127654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16743.20000,4855.53000,Aetna,First Health,,13695.94,,,,,,,5391.31,13695.94,percent of total billed charges,
WEDGE TERMINAL,8127656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5240.17000,1519.65000,Aetna,First Health,,4286.46,,,,,,,1889.08,4286.46,percent of total billed charges,
WEDGE TERMINAL,8127656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5240.17000,1519.65000,Aetna,First Health,,4286.46,,,,,,,1687.33,4286.46,percent of total billed charges,
WEDGE TIBIAL,8127658,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4958.73000,1438.03000,Aetna,First Health,,4056.24,,,,,,,1787.62,4056.24,percent of total billed charges,
WEDGE TIBIAL,8127658,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4958.73000,1438.03000,Aetna,First Health,,4056.24,,,,,,,1596.71,4056.24,percent of total billed charges,
STEM CEMENTED,8127660,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,First Health,,5369.19,,,,,,,2366.25,5369.19,percent of total billed charges,
STEM CEMENTED,8127660,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,First Health,,5369.19,,,,,,,2113.54,5369.19,percent of total billed charges,
STEM,8127662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,8127662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
ROD SPINAL,8127898,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8127898,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW SLF TAP,8127900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,249.49,percent of total billed charges,
SCREW SLF TAP,8127900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,98.21,249.49,percent of total billed charges,
SCREW SLF TAP,8127902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,249.49,percent of total billed charges,
SCREW SLF TAP,8127902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,98.21,249.49,percent of total billed charges,
CONNECTOR CROSS,8127904,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
CONNECTOR CROSS,8127904,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
STEM,8132016,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8132016,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8132109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8132109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,8132104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8132104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT FEMORAL,8132107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1941.96000,563.17000,Aetna,First Health,,1588.52,,,,,,,700.08,1588.52,percent of total billed charges,
COMPONENT FEMORAL,8132107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1941.96000,563.17000,Aetna,First Health,,1588.52,,,,,,,625.31,1588.52,percent of total billed charges,
STEM,8134096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,8134096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
SCREW,8134355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8134355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8134357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8134357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
K WIRE,7920397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
K WIRE,7920397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
K WIRE,7943370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
K WIRE,7943370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
K WIRE,7703339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
K WIRE,7703339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
K WIRE,7703340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
K WIRE,7703340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
K WIRE,7698588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,325.38000,94.36000,Aetna,First Health,,266.16,,,,,,,117.30,266.16,percent of total billed charges,
K WIRE,7698588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,325.38000,94.36000,Aetna,First Health,,266.16,,,,,,,104.77,266.16,percent of total billed charges,
K WIRE,7702211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
K WIRE,7702211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
K WIRE,7918351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,68.13,154.60,percent of total billed charges,
K WIRE,7918351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,60.86,154.60,percent of total billed charges,
K WIRE,7934086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,164.17000,47.61000,Aetna,First Health,,134.29,,,,,,,59.18,134.29,percent of total billed charges,
K WIRE,7934086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,164.17000,47.61000,Aetna,First Health,,134.29,,,,,,,52.86,134.29,percent of total billed charges,
K WIRE,7698122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,235.73000,68.36000,Aetna,First Health,,192.83,,,,,,,84.98,192.83,percent of total billed charges,
K WIRE,7698122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,235.73000,68.36000,Aetna,First Health,,192.83,,,,,,,75.91,192.83,percent of total billed charges,
K WIRE,7703342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
K WIRE,7703342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
K WIRE,7698123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,316.11000,91.67000,Aetna,First Health,,258.58,,,,,,,113.96,258.58,percent of total billed charges,
K WIRE,7698123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,316.11000,91.67000,Aetna,First Health,,258.58,,,,,,,101.79,258.58,percent of total billed charges,
K WIRE,7880575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
K WIRE,7880575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
K WIRE,7903038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
K WIRE,7903038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
K WIRE,7703336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,174.66,396.32,percent of total billed charges,
K WIRE,7703336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,156.01,396.32,percent of total billed charges,
K WIRE,7698107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
K WIRE,7698107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
K WIRE,7974862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
K WIRE,7974862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
K WIRE,7699425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,307.09000,89.06000,Aetna,First Health,,251.20,,,,,,,110.71,251.20,percent of total billed charges,
K WIRE,7699425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,307.09000,89.06000,Aetna,First Health,,251.20,,,,,,,98.88,251.20,percent of total billed charges,
K WIRE,7882190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
K WIRE,7882190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
K WIRE,7895455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.25000,86.78000,Aetna,First Health,,244.79,,,,,,,107.88,244.79,percent of total billed charges,
K WIRE,7895455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.25000,86.78000,Aetna,First Health,,244.79,,,,,,,96.36,244.79,percent of total billed charges,
K WIRE,7703337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
K WIRE,7703337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
K WIRE,7699426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.51000,133.55000,Aetna,First Health,,376.70,,,,,,,166.01,376.70,percent of total billed charges,
K WIRE,7699426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.51000,133.55000,Aetna,First Health,,376.70,,,,,,,148.28,376.70,percent of total billed charges,
K WIRE,7968707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.54000,136.17000,Aetna,First Health,,384.08,,,,,,,169.27,384.08,percent of total billed charges,
K WIRE,7968707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.54000,136.17000,Aetna,First Health,,384.08,,,,,,,151.19,384.08,percent of total billed charges,
K WIRE,7896373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.54000,103.40000,Aetna,First Health,,291.65,,,,,,,128.53,291.65,percent of total billed charges,
K WIRE,7896373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.54000,103.40000,Aetna,First Health,,291.65,,,,,,,114.81,291.65,percent of total billed charges,
K WIRE,7740538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
K WIRE,7740538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
K WIRE,7694940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
K WIRE,7694940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
K WIRE,7933691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
K WIRE,7933691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
K WIRE,7701068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,166.10,376.89,percent of total billed charges,
K WIRE,7701068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,148.36,376.89,percent of total billed charges,
K WIRE,7840049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
K WIRE,7840049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
K WIRE,7703341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,167.81,380.78,percent of total billed charges,
K WIRE,7703341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,149.89,380.78,percent of total billed charges,
K WIRE,7959352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,429.73000,124.62000,Aetna,First Health,,351.52,,,,,,,154.92,351.52,percent of total billed charges,
K WIRE,7959352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,429.73000,124.62000,Aetna,First Health,,351.52,,,,,,,138.37,351.52,percent of total billed charges,
K WIRE,7897360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,448.69000,130.12000,Aetna,First Health,,367.03,,,,,,,161.75,367.03,percent of total billed charges,
K WIRE,7897360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,448.69000,130.12000,Aetna,First Health,,367.03,,,,,,,144.48,367.03,percent of total billed charges,
K WIRE,7957823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,448.69000,130.12000,Aetna,First Health,,367.03,,,,,,,161.75,367.03,percent of total billed charges,
K WIRE,7957823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,448.69000,130.12000,Aetna,First Health,,367.03,,,,,,,144.48,367.03,percent of total billed charges,
K WIRE,7695380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,777.60000,225.50000,Aetna,First Health,,636.08,,,,,,,280.32,636.08,percent of total billed charges,
K WIRE,7695380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,777.60000,225.50000,Aetna,First Health,,636.08,,,,,,,250.39,636.08,percent of total billed charges,
K WIRE,7983039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
K WIRE,7983039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
K WIRE,7944227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
K WIRE,7944227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
K WIRE,7882260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,167.81,380.78,percent of total billed charges,
K WIRE,7882260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,First Health,,380.78,,,,,,,149.89,380.78,percent of total billed charges,
K WIRE,7896374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,726.35000,210.64000,Aetna,First Health,,594.15,,,,,,,261.85,594.15,percent of total billed charges,
K WIRE,7896374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,726.35000,210.64000,Aetna,First Health,,594.15,,,,,,,233.88,594.15,percent of total billed charges,
K WIRE,7802055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1512.00000,438.48000,Aetna,First Health,,1236.82,,,,,,,545.08,1236.82,percent of total billed charges,
K WIRE,7802055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1512.00000,438.48000,Aetna,First Health,,1236.82,,,,,,,486.86,1236.82,percent of total billed charges,
K WIRE,7802057,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1512.00000,438.48000,Aetna,First Health,,1236.82,,,,,,,545.08,1236.82,percent of total billed charges,
K WIRE,7802057,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1512.00000,438.48000,Aetna,First Health,,1236.82,,,,,,,486.86,1236.82,percent of total billed charges,
K WIRE,7736082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1766.56000,512.30000,Aetna,First Health,,1445.05,,,,,,,636.84,1445.05,percent of total billed charges,
K WIRE,7736082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1766.56000,512.30000,Aetna,First Health,,1445.05,,,,,,,568.83,1445.05,percent of total billed charges,
K WIRE,7736083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1766.56000,512.30000,Aetna,First Health,,1445.05,,,,,,,636.84,1445.05,percent of total billed charges,
K WIRE,7736083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1766.56000,512.30000,Aetna,First Health,,1445.05,,,,,,,568.83,1445.05,percent of total billed charges,
CATHETER,8136154,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8136154,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
ROD,7989240,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2721.60000,789.26000,Aetna,First Health,,2226.27,,,,,,,981.14,2226.27,percent of total billed charges,
ROD,7989240,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2721.60000,789.26000,Aetna,First Health,,2226.27,,,,,,,876.36,2226.27,percent of total billed charges,
PLATE,7982409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1796.28000,520.92000,Aetna,First Health,,1469.36,,,,,,,647.56,1469.36,percent of total billed charges,
PLATE,7982409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1796.28000,520.92000,Aetna,First Health,,1469.36,,,,,,,578.40,1469.36,percent of total billed charges,
CATHETER BALLOON,7968201,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7968201,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
CATHETER BALLOON,7969560,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
CATHETER BALLOON,7969560,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
SCREW,7968433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7968433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7968432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7968432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7968505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,7968505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,7968696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,7968696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
CATHETER,7976610,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
CATHETER,7976610,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
CATHETER,7969161,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
CATHETER,7969161,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
PLATE,7982415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,564.48000,163.70000,Aetna,First Health,,461.74,,,,,,,203.50,461.74,percent of total billed charges,
PLATE,7982415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,564.48000,163.70000,Aetna,First Health,,461.74,,,,,,,181.76,461.74,percent of total billed charges,
SCREW,7982384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7982384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
STENT,7975081,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7975081,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
STENT,7975082,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7975082,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
STENT,7975084,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7975084,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
PLATE,7987301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5541.90000,1607.15000,Aetna,First Health,,4533.27,,,,,,,1997.85,4533.27,percent of total billed charges,
PLATE,7987301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5541.90000,1607.15000,Aetna,First Health,,4533.27,,,,,,,1784.49,4533.27,percent of total billed charges,
STENT,7975085,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7975085,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
STENT,7975086,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1535.87,3484.99,percent of total billed charges,
STENT,7975086,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,First Health,,3484.99,,,,,,,1371.84,3484.99,percent of total billed charges,
SCREW,7969543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7969543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7969477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7969477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7969480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7969480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7969636,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7969636,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7968823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,7968823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
NAIL,7987671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,7987671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
PLATE,7982461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.28000,468.72000,Aetna,First Health,,1322.12,,,,,,,582.67,1322.12,percent of total billed charges,
PLATE,7982461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.28000,468.72000,Aetna,First Health,,1322.12,,,,,,,520.44,1322.12,percent of total billed charges,
SCREW,7976677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7976677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
PLATE,7974654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5043.50000,1462.62000,Aetna,First Health,,4125.58,,,,,,,1818.18,4125.58,percent of total billed charges,
PLATE,7974654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5043.50000,1462.62000,Aetna,First Health,,4125.58,,,,,,,1624.01,4125.58,percent of total billed charges,
TENDON,7982852,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8280.00000,2401.20000,Aetna,First Health,,6773.04,,,,,,,2984.94,6773.04,percent of total billed charges,
TENDON,7982852,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8280.00000,2401.20000,Aetna,First Health,,6773.04,,,,,,,2666.16,6773.04,percent of total billed charges,
PLATE,7976729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7976729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7974598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7974598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SCREW,7974699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7974699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7969572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7969572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7974700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7974700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
BLOCKER,7969571,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,147.26,334.15,percent of total billed charges,
BLOCKER,7969571,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,131.54,334.15,percent of total billed charges,
SCREW,7968956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7968956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
SCREW,7968955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,7968955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
PLATE,7972009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2649.80000,768.44000,Aetna,First Health,,2167.54,,,,,,,955.25,2167.54,percent of total billed charges,
PLATE,7972009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2649.80000,768.44000,Aetna,First Health,,2167.54,,,,,,,853.24,2167.54,percent of total billed charges,
LINER,7982904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1873.70,4251.56,percent of total billed charges,
LINER,7982904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1673.60,4251.56,percent of total billed charges,
HUMERAL TRAY,7969546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
HUMERAL TRAY,7969546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
GUIDEWIRE,7972128,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,288.61000,83.70000,Aetna,First Health,,236.08,,,,,,,104.04,236.08,percent of total billed charges,
GUIDEWIRE,7972128,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,288.61000,83.70000,Aetna,First Health,,236.08,,,,,,,92.93,236.08,percent of total billed charges,
SHELL,7968729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
SHELL,7968729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
SHELL,7978437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
SHELL,7978437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
SHELL,7969312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
SHELL,7969312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
SHELL,7969311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
SHELL,7969311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
NAIL,7971940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7971940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,7972661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7972661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
SCREW,7982346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7982367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7974191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,7974191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,7982469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7982469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7982471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7982471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7982468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7982468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7982466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7982466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7982470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7982470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7982465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7982465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7982467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7982467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7982473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7982473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7982474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7982474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
SCREW,7982472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,157.15,356.57,percent of total billed charges,
SCREW,7982472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,First Health,,356.57,,,,,,,140.36,356.57,percent of total billed charges,
STEM,7971932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7971932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STEM,7982764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,7982764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
STENT,7968820,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4163.92000,1207.54000,Aetna,First Health,,3406.09,,,,,,,1501.09,3406.09,percent of total billed charges,
STENT,7968820,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4163.92000,1207.54000,Aetna,First Health,,3406.09,,,,,,,1340.78,3406.09,percent of total billed charges,
PLATE,7982426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1929.72000,559.62000,Aetna,First Health,,1578.51,,,,,,,695.66,1578.51,percent of total billed charges,
PLATE,7982426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1929.72000,559.62000,Aetna,First Health,,1578.51,,,,,,,621.37,1578.51,percent of total billed charges,
PLATE,7968107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1526.28000,442.62000,Aetna,First Health,,1248.50,,,,,,,550.22,1248.50,percent of total billed charges,
PLATE,7968107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1526.28000,442.62000,Aetna,First Health,,1248.50,,,,,,,491.46,1248.50,percent of total billed charges,
COMPONENT GLENOID,7972676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
COMPONENT GLENOID,7972676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
STEM,7972001,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4517.64,10250.85,percent of total billed charges,
STEM,7972001,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,First Health,,10250.85,,,,,,,4035.18,10250.85,percent of total billed charges,
PLATE,7982398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5689.25000,1649.88000,Aetna,First Health,,4653.81,,,,,,,2050.97,4653.81,percent of total billed charges,
PLATE,7982398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5689.25000,1649.88000,Aetna,First Health,,4653.81,,,,,,,1831.94,4653.81,percent of total billed charges,
PLATE,7976360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7976360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,7989394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
PLATE,7989394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
FEMORAL HEAD,7983033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7983033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
LINER,7989423,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7989423,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
INSERT,7968203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7968203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
INSERT,7968582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,7968582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
COMPONENT FEMORAL,7975011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,7689.47,17447.94,percent of total billed charges,
COMPONENT FEMORAL,7975011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,First Health,,17447.94,,,,,,,6868.26,17447.94,percent of total billed charges,
WEDGE,7968556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7968556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7968555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7968555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
WEDGE,7987571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,7987571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
RADIAL HEAD,7974764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2812.98,6382.85,percent of total billed charges,
RADIAL HEAD,7974764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2512.57,6382.85,percent of total billed charges,
STEM,7974765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
STEM,7974765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
ANCHOR,7969158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
ANCHOR,7969158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
COIL,7987813,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3939.25000,1142.38000,Aetna,First Health,,3222.31,,,,,,,1420.10,3222.31,percent of total billed charges,
COIL,7987813,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3939.25000,1142.38000,Aetna,First Health,,3222.31,,,,,,,1268.44,3222.31,percent of total billed charges,
NAIL,7968883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7968883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
STENT GRAFT,7986559,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,16524.24,37494.67,percent of total billed charges,
STENT GRAFT,7986559,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,14759.51,37494.67,percent of total billed charges,
SCREW,7968958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,7968958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
ROD,7969570,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
ROD,7969570,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
ROD,7976607,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7976607,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7974088,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7974088,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7974795,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
ROD,7974795,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
ROD,7969569,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
ROD,7969569,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
ROD,7974797,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
ROD,7974797,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
ROD,7974796,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
ROD,7974796,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
INSERT,7989188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,7989188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
COMPONENT FEMORAL,7978414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
COMPONENT FEMORAL,7978414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
COMPONENT FEMORAL,7974182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6862.61,15571.76,percent of total billed charges,
COMPONENT FEMORAL,7974182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,First Health,,15571.76,,,,,,,6129.71,15571.76,percent of total billed charges,
SLEEVE,7967966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2851.37,6469.97,percent of total billed charges,
SLEEVE,7967966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2546.86,6469.97,percent of total billed charges,
SLEEVE,7976758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2851.37,6469.97,percent of total billed charges,
SLEEVE,7976758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2546.86,6469.97,percent of total billed charges,
SLEEVE,7988513,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1935.44000,561.28000,Aetna,First Health,,1583.19,,,,,,,697.73,1583.19,percent of total billed charges,
SLEEVE,7988513,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1935.44000,561.28000,Aetna,First Health,,1583.19,,,,,,,623.21,1583.19,percent of total billed charges,
WASHER,7989199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,146.84000,42.58000,Aetna,First Health,,120.12,,,,,,,52.94,120.12,percent of total billed charges,
WASHER,7989199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,146.84000,42.58000,Aetna,First Health,,120.12,,,,,,,47.28,120.12,percent of total billed charges,
FEMORAL HEAD,7969324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7969324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
FEMORAL HEAD,7972313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,First Health,,4584.24,,,,,,,2020.31,4584.24,percent of total billed charges,
FEMORAL HEAD,7972313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,First Health,,4584.24,,,,,,,1804.55,4584.24,percent of total billed charges,
BONE GRAFT,7973831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8932.50000,2590.42000,Aetna,First Health,,7306.78,,,,,,,3220.17,7306.78,percent of total billed charges,
BONE GRAFT,7973831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8932.50000,2590.42000,Aetna,First Health,,7306.78,,,,,,,2876.26,7306.78,percent of total billed charges,
STEM,7982766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,7982766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
STEM,7972678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1534.16,3481.12,percent of total billed charges,
STEM,7972678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,First Health,,3481.12,,,,,,,1370.32,3481.12,percent of total billed charges,
STEM,7986565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,7986565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
STEM,7969310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7969310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PROBE CRYOABLATION,7982862,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3460.80,7852.80,percent of total billed charges,
PROBE CRYOABLATION,7982862,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3091.20,7852.80,percent of total billed charges,
SCREW,7968705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,942.98000,273.46000,Aetna,First Health,,771.36,,,,,,,339.94,771.36,percent of total billed charges,
SCREW,7968705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,942.98000,273.46000,Aetna,First Health,,771.36,,,,,,,303.64,771.36,percent of total billed charges,
SCREW,7987673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,7987673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,7987675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,7987675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
WEDGE,7968202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5675.25000,1645.82000,Aetna,First Health,,4642.35,,,,,,,2045.93,4642.35,percent of total billed charges,
WEDGE,7968202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5675.25000,1645.82000,Aetna,First Health,,4642.35,,,,,,,1827.43,4642.35,percent of total billed charges,
SCREW,7987737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,7987737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
PLATE,7976469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2475.20000,717.81000,Aetna,First Health,,2024.71,,,,,,,892.31,2024.71,percent of total billed charges,
PLATE,7976469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2475.20000,717.81000,Aetna,First Health,,2024.71,,,,,,,797.01,2024.71,percent of total billed charges,
INSERT,7969825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9144.09000,2651.79000,Aetna,First Health,,7479.87,,,,,,,3296.44,7479.87,percent of total billed charges,
INSERT,7969825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9144.09000,2651.79000,Aetna,First Health,,7479.87,,,,,,,2944.40,7479.87,percent of total billed charges,
SCREW,7969160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,124.66,282.86,percent of total billed charges,
SCREW,7969160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,First Health,,282.86,,,,,,,111.35,282.86,percent of total billed charges,
SCREW,7973842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,181.17,411.09,percent of total billed charges,
SCREW,7973842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,First Health,,411.09,,,,,,,161.82,411.09,percent of total billed charges,
SHELL,7967961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,4027.94,9139.68,percent of total billed charges,
SHELL,7967961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,3597.77,9139.68,percent of total billed charges,
SHELL,7980558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,4027.94,9139.68,percent of total billed charges,
SHELL,7980558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,3597.77,9139.68,percent of total billed charges,
STEM,7968479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1639.90,3721.04,percent of total billed charges,
STEM,7968479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,First Health,,3721.04,,,,,,,1464.76,3721.04,percent of total billed charges,
SCREW,7969680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,414.20000,120.12000,Aetna,First Health,,338.82,,,,,,,149.32,338.82,percent of total billed charges,
SCREW,7969680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,414.20000,120.12000,Aetna,First Health,,338.82,,,,,,,133.37,338.82,percent of total billed charges,
GRAFT STENT,7972276,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,44115.75000,12793.57000,Aetna,First Health,,36086.68,,,,,,,15903.73,36086.68,percent of total billed charges,
GRAFT STENT,7972276,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,44115.75000,12793.57000,Aetna,First Health,,36086.68,,,,,,,14205.27,36086.68,percent of total billed charges,
GRAFT STENT,7986556,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,44115.75000,12793.57000,Aetna,First Health,,36086.68,,,,,,,15903.73,36086.68,percent of total billed charges,
GRAFT STENT,7986556,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,44115.75000,12793.57000,Aetna,First Health,,36086.68,,,,,,,14205.27,36086.68,percent of total billed charges,
GRAFT STENT,7986557,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,44115.75000,12793.57000,Aetna,First Health,,36086.68,,,,,,,15903.73,36086.68,percent of total billed charges,
GRAFT STENT,7986557,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,44115.75000,12793.57000,Aetna,First Health,,36086.68,,,,,,,14205.27,36086.68,percent of total billed charges,
SCREW,7968101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,7968101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,7969677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7969677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7969676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7969676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
STEM,7975019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,3136.35,7116.60,percent of total billed charges,
STEM,7975019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,2801.40,7116.60,percent of total billed charges,
STEM,7980367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,3136.35,7116.60,percent of total billed charges,
STEM,7980367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,2801.40,7116.60,percent of total billed charges,
INSERT,7968633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7968633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,7982763,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,7982763,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7976427,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BASEPLATE,7976427,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
BASEPLATE,7972133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7972133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,7974589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BASEPLATE,7974589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
BASEPLATE,7974078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,7974078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PLATE,7968125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7968125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,7980871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,151.25000,43.86000,Aetna,First Health,,123.72,,,,,,,54.53,123.72,percent of total billed charges,
SCREW,7980871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,151.25000,43.86000,Aetna,First Health,,123.72,,,,,,,48.70,123.72,percent of total billed charges,
SCREW,7980876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7980876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7980877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7980877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7980870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7980870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7981159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7981159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7980872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7980872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7980874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7980874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SCREW,7980875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,63.04,143.05,percent of total billed charges,
SCREW,7980875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,First Health,,143.05,,,,,,,56.31,143.05,percent of total billed charges,
SHELL,7988517,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,4264.08,9675.51,percent of total billed charges,
SHELL,7988517,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,First Health,,9675.51,,,,,,,3808.70,9675.51,percent of total billed charges,
SCREW,7972132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
SCREW,7972132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
SCREW,7969318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,147.26,334.15,percent of total billed charges,
SCREW,7969318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,131.54,334.15,percent of total billed charges,
INSERT,7974901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7974901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7989196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,7989196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,7976719,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7976719,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7976666,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7976666,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
STEM,7974794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2893.01,6564.45,percent of total billed charges,
STEM,7974794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2584.05,6564.45,percent of total billed charges,
PLATE,7982423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2137.68000,619.93000,Aetna,First Health,,1748.62,,,,,,,770.63,1748.62,percent of total billed charges,
PLATE,7982423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2137.68000,619.93000,Aetna,First Health,,1748.62,,,,,,,688.33,1748.62,percent of total billed charges,
PLATE,7969663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2202.84000,638.82000,Aetna,First Health,,1801.92,,,,,,,794.12,1801.92,percent of total billed charges,
PLATE,7969663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2202.84000,638.82000,Aetna,First Health,,1801.92,,,,,,,709.31,1801.92,percent of total billed charges,
PLATE,7988519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1988.72000,576.73000,Aetna,First Health,,1626.77,,,,,,,716.93,1626.77,percent of total billed charges,
PLATE,7988519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1988.72000,576.73000,Aetna,First Health,,1626.77,,,,,,,640.37,1626.77,percent of total billed charges,
ROD,7983043,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,7983043,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
FEMORAL HEAD,7989425,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,7989425,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
SHELL,7972074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,1002.19,2274.04,percent of total billed charges,
SHELL,7972074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,895.16,2274.04,percent of total billed charges,
PLATE,7982422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2010.44000,583.03000,Aetna,First Health,,1644.54,,,,,,,724.76,1644.54,percent of total billed charges,
PLATE,7982422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2010.44000,583.03000,Aetna,First Health,,1644.54,,,,,,,647.36,1644.54,percent of total billed charges,
STEM,7974632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,7974632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
PLATE,7969486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.60000,706.32000,Aetna,First Health,,1992.32,,,,,,,878.03,1992.32,percent of total billed charges,
PLATE,7969486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.60000,706.32000,Aetna,First Health,,1992.32,,,,,,,784.26,1992.32,percent of total billed charges,
SLEEVE,7976433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SLEEVE,7976433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SLEEVE,7974089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SLEEVE,7974089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SLEEVE,7974594,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SLEEVE,7974594,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,7982820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7982820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
STEM,7968557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7968557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE,7974909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5398.65000,1565.61000,Aetna,First Health,,4416.10,,,,,,,1946.21,4416.10,percent of total billed charges,
PLATE,7974909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5398.65000,1565.61000,Aetna,First Health,,4416.10,,,,,,,1738.37,4416.10,percent of total billed charges,
PLATE,7982828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5398.65000,1565.61000,Aetna,First Health,,4416.10,,,,,,,1946.21,4416.10,percent of total billed charges,
PLATE,7982828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5398.65000,1565.61000,Aetna,First Health,,4416.10,,,,,,,1738.37,4416.10,percent of total billed charges,
PLATE,7987735,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8436.00000,2446.44000,Aetna,First Health,,6900.65,,,,,,,3041.18,6900.65,percent of total billed charges,
PLATE,7987735,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8436.00000,2446.44000,Aetna,First Health,,6900.65,,,,,,,2716.39,6900.65,percent of total billed charges,
SCREW,7982824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,7982824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
COMPONENT FEMORAL,7976670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,11294.92,25628.96,percent of total billed charges,
COMPONENT FEMORAL,7976670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,10088.66,25628.96,percent of total billed charges,
SPACER,7972681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9222.90000,2674.64000,Aetna,First Health,,7544.33,,,,,,,3324.86,7544.33,percent of total billed charges,
SPACER,7972681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9222.90000,2674.64000,Aetna,First Health,,7544.33,,,,,,,2969.77,7544.33,percent of total billed charges,
SPACER,7972680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9222.90000,2674.64000,Aetna,First Health,,7544.33,,,,,,,3324.86,7544.33,percent of total billed charges,
SPACER,7972680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9222.90000,2674.64000,Aetna,First Health,,7544.33,,,,,,,2969.77,7544.33,percent of total billed charges,
SCREW,7967972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,261.39,593.12,percent of total billed charges,
SCREW,7967972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,233.48,593.12,percent of total billed charges,
PLATE,7976471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,7976471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
AUGMENT FEMORAL,7987523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3738.75,8483.48,percent of total billed charges,
AUGMENT FEMORAL,7987523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3339.46,8483.48,percent of total billed charges,
SCREW,7968706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
SCREW,7968706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
STEM,7967967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,10392.54,23581.41,percent of total billed charges,
STEM,7967967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,9282.66,23581.41,percent of total billed charges,
STEM,7974701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,11294.92,25628.96,percent of total billed charges,
STEM,7974701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,10088.66,25628.96,percent of total billed charges,
STEM,7972275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,10392.54,23581.41,percent of total billed charges,
STEM,7972275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,9282.66,23581.41,percent of total billed charges,
STEM,7982870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,10392.54,23581.41,percent of total billed charges,
STEM,7982870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,9282.66,23581.41,percent of total billed charges,
TENDON,7971859,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5193.13000,1506.01000,Aetna,First Health,,4247.98,,,,,,,1872.12,4247.98,percent of total billed charges,
TENDON,7971859,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5193.13000,1506.01000,Aetna,First Health,,4247.98,,,,,,,1672.19,4247.98,percent of total billed charges,
STENT,7975083,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1250.70,2837.92,percent of total billed charges,
STENT,7975083,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,First Health,,2837.92,,,,,,,1117.13,2837.92,percent of total billed charges,
PLATE,7982429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.88000,578.52000,Aetna,First Health,,1631.81,,,,,,,719.15,1631.81,percent of total billed charges,
PLATE,7982429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.88000,578.52000,Aetna,First Health,,1631.81,,,,,,,642.35,1631.81,percent of total billed charges,
SCREW,7968561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7968561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7968478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7968478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7974025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7974025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7969479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7969479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7969478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7969478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7969635,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7969635,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7969492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,7969492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,7976608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7976608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7974083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7974083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7974084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1274.37,2891.63,percent of total billed charges,
SCREW,7974084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,First Health,,2891.63,,,,,,,1138.27,2891.63,percent of total billed charges,
SCREW,7969741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,7969741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
SCREW,7987521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,7987521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
SCREW,7987522,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,7987522,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
SCREW,7976562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,7976562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,7976533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,7976533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,7976561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,7976561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,7975068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1490.13,3381.20,percent of total billed charges,
SCREW,7975068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1330.99,3381.20,percent of total billed charges,
BASEPLATE,7976605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1299.40,2948.43,percent of total billed charges,
BASEPLATE,7976605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1160.63,2948.43,percent of total billed charges,
HUMERAL HEAD,7974631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7974631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL HEAD,7980691,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,7980691,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
STENT GRAFT,7968634,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7968634,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7969874,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7969874,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7969873,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7969873,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7969872,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7969872,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7972673,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7972673,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7969875,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7969875,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7978444,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7978444,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7969876,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7969876,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7969563,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7969563,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7974755,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7974755,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7969871,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7969871,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7989436,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,7989436,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STENT GRAFT,7968806,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7968806,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7968830,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7968830,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,7987856,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7987856,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
ROD,7968353,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,First Health,,1786.51,,,,,,,787.33,1786.51,percent of total billed charges,
ROD,7968353,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,First Health,,1786.51,,,,,,,703.25,1786.51,percent of total billed charges,
INSERT,7968480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7968480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7968558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7968558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7980368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7980368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7974903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7974903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7980369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7980369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,7974904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,7974904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
BASEPLATE,7974905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,7974905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
SCREW,7969829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,First Health,,275.87,,,,,,,121.58,275.87,percent of total billed charges,
SCREW,7969829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,First Health,,275.87,,,,,,,108.59,275.87,percent of total billed charges,
BASEPLATE,7980370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
BASEPLATE,7980370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7974599,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7974599,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7976426,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
COMPONENT FEMORAL,7976426,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
CAGE,7974799,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7974799,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
CAGE,7969631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7969631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
CAGE,7974085,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7974085,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
CAGE,7974086,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7974086,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
CAGE,7974087,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7974087,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
CAGE,7974798,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7974798,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
CAGE,7975020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7975020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
CAGE,7987303,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7987303,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
CAGE,7987801,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,7987801,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
PENILE IMPLANT,7976627,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,First Health,,27552.28,,,,,,,12142.54,27552.28,percent of total billed charges,
PENILE IMPLANT,7976627,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,First Health,,27552.28,,,,,,,10845.76,27552.28,percent of total billed charges,
STEM,7987667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM,7987667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
STEM,7988822,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM,7988822,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
INSERT,7974091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1753.28000,508.45000,Aetna,First Health,,1434.18,,,,,,,632.06,1434.18,percent of total billed charges,
INSERT,7974091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1753.28000,508.45000,Aetna,First Health,,1434.18,,,,,,,564.56,1434.18,percent of total billed charges,
COMPONENT FEMORAL,7974081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25225.20000,7315.31000,Aetna,First Health,,20634.21,,,,,,,9093.68,20634.21,percent of total billed charges,
COMPONENT FEMORAL,7974081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25225.20000,7315.31000,Aetna,First Health,,20634.21,,,,,,,8122.51,20634.21,percent of total billed charges,
CAGE,7968824,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,7968824,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
CAGE,7982819,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7982819,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
SPACER,7969568,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SPACER,7969568,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
SPACER,7969567,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SPACER,7969567,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
SCREW,7974697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,7974697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PLATE,7972314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,7972314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
INSERT,7968586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,7968586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,7974597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7974597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,7987906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,7987906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
COMPONENT GLENOID,7968610,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT GLENOID,7968610,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
SCREW,7968229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,7968229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
SCREW,7968228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,7968228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
SCREW,7968226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,7968226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
PLATE,7968232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1151.87,2613.67,percent of total billed charges,
PLATE,7968232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1028.85,2613.67,percent of total billed charges,
PLATE,7968233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1151.87,2613.67,percent of total billed charges,
PLATE,7968233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1028.85,2613.67,percent of total billed charges,
PLATE,7987811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1151.87,2613.67,percent of total billed charges,
PLATE,7987811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1028.85,2613.67,percent of total billed charges,
CAGE BASE,7968560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE BASE,7968560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
TIBIAL CONE,7973836,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
TIBIAL CONE,7973836,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
BOLT,7988470,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BOLT,7988470,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
CAGE,7988468,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,7988468,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
CAGE,7969035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,7969035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
CAGE,7969034,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,7969034,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
ROD,7973838,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7973838,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD,7969475,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7969475,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
BALLOON CATHETER,7968591,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7968591,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975104,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975104,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975105,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975105,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975108,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975108,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975092,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,544.72,1236.00,percent of total billed charges,
BALLOON CATHETER,7975092,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,486.54,1236.00,percent of total billed charges,
BALLOON CATHETER,7975097,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975097,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975098,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975098,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975100,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975100,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975101,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975101,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975107,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975107,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
VALVE,7968710,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
VALVE,7968710,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
STENT GRAFT,7968186,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
STENT GRAFT,7968186,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
SHELL,7972272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,608.52,1380.78,percent of total billed charges,
SHELL,7972272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,543.54,1380.78,percent of total billed charges,
SHELL,7968694,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,608.52,1380.78,percent of total billed charges,
SHELL,7968694,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,543.54,1380.78,percent of total billed charges,
PLATE,7969487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2528.72000,733.33000,Aetna,First Health,,2068.49,,,,,,,911.60,2068.49,percent of total billed charges,
PLATE,7969487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2528.72000,733.33000,Aetna,First Health,,2068.49,,,,,,,814.25,2068.49,percent of total billed charges,
STEM,7989363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,7989363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
FEMORAL CONE,7978455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
FEMORAL CONE,7978455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
FEMORAL CONE,7987626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
FEMORAL CONE,7987626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
ROD,7987681,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,7987681,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
PLATE,7973850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE,7973850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
SCREW,7976332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7976332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,7972073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7972073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7982818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,7982818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,7978417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7978417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
PLATE,7982402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1631.80000,473.22000,Aetna,First Health,,1334.81,,,,,,,588.26,1334.81,percent of total billed charges,
PLATE,7982402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1631.80000,473.22000,Aetna,First Health,,1334.81,,,,,,,525.44,1334.81,percent of total billed charges,
SCREW,7969164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7969164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
SCREW,7969165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,7969165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
STENT GRAFT,7969777,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
STENT GRAFT,7969777,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
FEMORAL HEAD,7969474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7969474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
FEMORAL HEAD,7972273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,7972273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
LINER,7972274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
LINER,7972274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
BALLOON CATHETER,7975093,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
BALLOON CATHETER,7975093,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
BALLOON CATHETER,7975096,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
BALLOON CATHETER,7975096,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
SCREW,7969743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,731.09,1658.90,percent of total billed charges,
SCREW,7969743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,653.02,1658.90,percent of total billed charges,
SCREW,7969744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,731.09,1658.90,percent of total billed charges,
SCREW,7969744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,First Health,,1658.90,,,,,,,653.02,1658.90,percent of total billed charges,
BASEPLATE,7968481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BASEPLATE,7968481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
CAGE,7976470,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,7976470,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
CAGE,7987258,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,7987258,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
CAGE,7987211,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,7987211,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
CAGE,7976759,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,First Health,,8255.26,,,,,,,3638.17,8255.26,percent of total billed charges,
CAGE,7976759,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,First Health,,8255.26,,,,,,,3249.62,8255.26,percent of total billed charges,
CAGE,7975064,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,First Health,,8255.26,,,,,,,3638.17,8255.26,percent of total billed charges,
CAGE,7975064,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,First Health,,8255.26,,,,,,,3249.62,8255.26,percent of total billed charges,
SCREW,7968352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1490.13,3381.20,percent of total billed charges,
SCREW,7968352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1330.99,3381.20,percent of total billed charges,
SCREW,7972587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1490.13,3381.20,percent of total billed charges,
SCREW,7972587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1330.99,3381.20,percent of total billed charges,
PENILE IMPLANT,7973837,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,First Health,,27552.28,,,,,,,12142.54,27552.28,percent of total billed charges,
PENILE IMPLANT,7973837,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,First Health,,27552.28,,,,,,,10845.76,27552.28,percent of total billed charges,
SPINAL IMPLANT,7972070,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
SPINAL IMPLANT,7972070,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
PLATE,7972072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,3076.87,6981.63,percent of total billed charges,
PLATE,7972072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,2748.27,6981.63,percent of total billed charges,
PLATE,7976653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,3076.87,6981.63,percent of total billed charges,
PLATE,7976653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,2748.27,6981.63,percent of total billed charges,
PLATE,7976671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,3076.87,6981.63,percent of total billed charges,
PLATE,7976671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,2748.27,6981.63,percent of total billed charges,
SCREW,7972071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,7972071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
PLATE,7976532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
PLATE,7976532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
PLATE,7974855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
PLATE,7974855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
CONNECTOR SPINAL,7974852,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,876.74,1989.38,percent of total billed charges,
CONNECTOR SPINAL,7974852,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,783.10,1989.38,percent of total billed charges,
CONNECTOR SPINAL,7974853,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,876.74,1989.38,percent of total billed charges,
CONNECTOR SPINAL,7974853,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,783.10,1989.38,percent of total billed charges,
CONNECTOR SPINAL,7974854,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,876.74,1989.38,percent of total billed charges,
CONNECTOR SPINAL,7974854,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,783.10,1989.38,percent of total billed charges,
MESH,7971857,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1958.96000,568.10000,Aetna,First Health,,1602.43,,,,,,,706.21,1602.43,percent of total billed charges,
MESH,7971857,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1958.96000,568.10000,Aetna,First Health,,1602.43,,,,,,,630.79,1602.43,percent of total billed charges,
SCREW,7982443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7982443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7982442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7982442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7982441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,149.85,340.02,percent of total billed charges,
SCREW,7982441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,First Health,,340.02,,,,,,,133.85,340.02,percent of total billed charges,
SCREW,7969637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,122.78,278.59,percent of total billed charges,
SCREW,7969637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,109.67,278.59,percent of total billed charges,
SCREW,7972590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7972590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7972589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,7972589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
SCREW,7968206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,7968206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
HUMERAL HEAD,7968609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HUMERAL HEAD,7968609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,7969483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1976.28000,573.12000,Aetna,First Health,,1616.60,,,,,,,712.45,1616.60,percent of total billed charges,
PLATE,7969483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1976.28000,573.12000,Aetna,First Health,,1616.60,,,,,,,636.36,1616.60,percent of total billed charges,
AUGMENT TIBIAL,7974183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1693.52,3842.72,percent of total billed charges,
AUGMENT TIBIAL,7974183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1512.66,3842.72,percent of total billed charges,
SPACER,7974137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,5416.16,12289.66,percent of total billed charges,
SPACER,7974137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,4837.74,12289.66,percent of total billed charges,
AUGMENT TIBIAL,7974138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1693.52,3842.72,percent of total billed charges,
AUGMENT TIBIAL,7974138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1512.66,3842.72,percent of total billed charges,
AUGMENT TIBIAL,7974139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1693.52,3842.72,percent of total billed charges,
AUGMENT TIBIAL,7974139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1512.66,3842.72,percent of total billed charges,
STEM,7968508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7968508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7972312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7972312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7989498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7989498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
INSERT,7968826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7968826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7968827,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7968827,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7969236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7969236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7971904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7971904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7976529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7976529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7976525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7976525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7976574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7976574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7972008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7972008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7969564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7969564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,7975048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7975048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
AUGMENT FEMORAL,7968497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT FEMORAL,7968497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7972672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1492.15,3385.78,percent of total billed charges,
AUGMENT TIBIAL,7972672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,First Health,,3385.78,,,,,,,1332.79,3385.78,percent of total billed charges,
STEM,7968728,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7968728,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7968562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7968562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7976678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7976678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7978374,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7978374,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,7989197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,7989197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
WEDGE,7980408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7980408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
WEDGE,7987573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1491.35,3383.98,percent of total billed charges,
WEDGE,7987573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1332.08,3383.98,percent of total billed charges,
STEM,7978372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2970.88,6741.14,percent of total billed charges,
STEM,7978372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2653.60,6741.14,percent of total billed charges,
COMPONENT PATELLA,7974933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,4133.49,9379.19,percent of total billed charges,
COMPONENT PATELLA,7974933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,3692.05,9379.19,percent of total billed charges,
SCREW,7982449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7982449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7982444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7982444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7982340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7982340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
SCREW,7982447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7982447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7982448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7982448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7982445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7982445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,7982446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7982446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7982450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,79.94,181.40,percent of total billed charges,
SCREW,7982450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,First Health,,181.40,,,,,,,71.41,181.40,percent of total billed charges,
SCREW,7982339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,66.00,149.75,percent of total billed charges,
SCREW,7982339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,First Health,,149.75,,,,,,,58.95,149.75,percent of total billed charges,
STEM,7989152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2920.05,6625.80,percent of total billed charges,
STEM,7989152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2608.20,6625.80,percent of total billed charges,
STENT GRAFT,7986558,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,17763.64,40306.95,percent of total billed charges,
STENT GRAFT,7986558,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,15866.55,40306.95,percent of total billed charges,
PLATE,7982406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5336.21000,1547.50000,Aetna,First Health,,4365.02,,,,,,,1923.70,4365.02,percent of total billed charges,
PLATE,7982406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5336.21000,1547.50000,Aetna,First Health,,4365.02,,,,,,,1718.26,4365.02,percent of total billed charges,
PLATE,7982407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5336.21000,1547.50000,Aetna,First Health,,4365.02,,,,,,,1923.70,4365.02,percent of total billed charges,
PLATE,7982407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5336.21000,1547.50000,Aetna,First Health,,4365.02,,,,,,,1718.26,4365.02,percent of total billed charges,
SCREW,7980873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,112.50,255.28,percent of total billed charges,
SCREW,7980873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,First Health,,255.28,,,,,,,100.49,255.28,percent of total billed charges,
PLATE,7988466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
PLATE,7988466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
SCREW,7968105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,194.62000,56.44000,Aetna,First Health,,159.20,,,,,,,70.16,159.20,percent of total billed charges,
SCREW,7968105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,194.62000,56.44000,Aetna,First Health,,159.20,,,,,,,62.67,159.20,percent of total billed charges,
PLATE,7982425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,475.25,1078.39,percent of total billed charges,
PLATE,7982425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,424.50,1078.39,percent of total billed charges,
PLATE,7982451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,475.25,1078.39,percent of total billed charges,
PLATE,7982451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,First Health,,1078.39,,,,,,,424.50,1078.39,percent of total billed charges,
LINER,7969322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,526.16,1193.89,percent of total billed charges,
LINER,7969322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,469.97,1193.89,percent of total billed charges,
COMPONENT FEMORAL,7983028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7983028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7969775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7969775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
SHELL,7969323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,7969323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
COMPONENT FEMORAL,7974902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,7974902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
INSERT,7968128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7968128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,7978443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,7978443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
STEM,7978456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,7978456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
ULNAR ASSEMBLY,7972586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5948.25,13497.00,percent of total billed charges,
ULNAR ASSEMBLY,7972586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5313.00,13497.00,percent of total billed charges,
PLATE,7980831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3739.44000,1084.44000,Aetna,First Health,,3058.86,,,,,,,1348.07,3058.86,percent of total billed charges,
PLATE,7980831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3739.44000,1084.44000,Aetna,First Health,,3058.86,,,,,,,1204.10,3058.86,percent of total billed charges,
PLATE,7980832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3739.44000,1084.44000,Aetna,First Health,,3058.86,,,,,,,1348.07,3058.86,percent of total billed charges,
PLATE,7980832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3739.44000,1084.44000,Aetna,First Health,,3058.86,,,,,,,1204.10,3058.86,percent of total billed charges,
SHELL,7969650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2999.00,6804.94,percent of total billed charges,
SHELL,7969650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2678.72,6804.94,percent of total billed charges,
SHELL,7989381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2999.00,6804.94,percent of total billed charges,
SHELL,7989381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2678.72,6804.94,percent of total billed charges,
SHELL,7982903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2999.00,6804.94,percent of total billed charges,
SHELL,7982903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,First Health,,6804.94,,,,,,,2678.72,6804.94,percent of total billed charges,
PLATE,7982452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1246.96000,361.62000,Aetna,First Health,,1020.01,,,,,,,449.53,1020.01,percent of total billed charges,
PLATE,7982452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1246.96000,361.62000,Aetna,First Health,,1020.01,,,,,,,401.52,1020.01,percent of total billed charges,
PLATE,7982454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1246.96000,361.62000,Aetna,First Health,,1020.01,,,,,,,449.53,1020.01,percent of total billed charges,
PLATE,7982454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1246.96000,361.62000,Aetna,First Health,,1020.01,,,,,,,401.52,1020.01,percent of total billed charges,
PLATE,7982462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,461.81,1047.89,percent of total billed charges,
PLATE,7982462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,412.49,1047.89,percent of total billed charges,
PLATE,7972659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5488.28000,1591.60000,Aetna,First Health,,4489.41,,,,,,,1978.52,4489.41,percent of total billed charges,
PLATE,7972659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5488.28000,1591.60000,Aetna,First Health,,4489.41,,,,,,,1767.23,4489.41,percent of total billed charges,
SCREW,7972175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,7972175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PLATE,7969681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3794.70000,1100.46000,Aetna,First Health,,3104.06,,,,,,,1367.99,3104.06,percent of total billed charges,
PLATE,7969681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3794.70000,1100.46000,Aetna,First Health,,3104.06,,,,,,,1221.89,3104.06,percent of total billed charges,
WEDGE,7987625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1543.44,3502.17,percent of total billed charges,
WEDGE,7987625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1378.60,3502.17,percent of total billed charges,
SPACER,7968243,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7968243,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,7968245,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7968245,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,7968242,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7968242,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,7968244,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,7968244,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
COMPONENT FEMORAL,7968419,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7968419,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7976526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7976526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7969565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7969565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7989194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,7989194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
BASEPLATE,7976528,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE,7976528,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
AUGMENT FEMORAL,7969314,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7969314,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7986564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7986564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7988820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7988820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7987665,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7987665,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7988818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7988818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7982765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7982765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
AUGMENT FEMORAL,7969313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
AUGMENT FEMORAL,7969313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
HOOK,7974186,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
HOOK,7974186,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
SCREW,7969739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7969739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7974189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7974189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7974188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7974188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7972674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7972674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7969320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7969320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7969740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7969740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
ROD,7969319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
ROD,7969319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
ROD,7969863,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
ROD,7969863,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
ROD,7974187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
ROD,7974187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
ROD,7972177,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
ROD,7972177,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
LINER,7982905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
LINER,7982905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STEM,7989203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4812.68,10920.30,percent of total billed charges,
STEM,7989203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,First Health,,10920.30,,,,,,,4298.70,10920.30,percent of total billed charges,
NAIL,7974760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,700.74,1590.03,percent of total billed charges,
NAIL,7974760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,625.90,1590.03,percent of total billed charges,
INSERT,7969720,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7969720,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
HUMERAL HEAD,7968124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,2197.43,4986.12,percent of total billed charges,
HUMERAL HEAD,7968124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,First Health,,4986.12,,,,,,,1962.75,4986.12,percent of total billed charges,
SCREW,7974075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,7974075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SCREW,7974076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,7974076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
INSERT,7980583,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7980583,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7974080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7974080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7972677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7972677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7976401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,7976401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,7983034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2956.98,6709.60,percent of total billed charges,
INSERT,7983034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2641.19,6709.60,percent of total billed charges,
INSERT,7972675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7972675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7976530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7976530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,7969662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,7969662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
BONE GRAFT,7973832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14724.00000,4269.96000,Aetna,First Health,,12044.23,,,,,,,5308.00,12044.23,percent of total billed charges,
BONE GRAFT,7973832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14724.00000,4269.96000,Aetna,First Health,,12044.23,,,,,,,4741.13,12044.23,percent of total billed charges,
SCREW,7968821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7968821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7968822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7968822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,7974662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1495.20000,433.61000,Aetna,First Health,,1223.07,,,,,,,539.02,1223.07,percent of total billed charges,
SCREW,7974662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1495.20000,433.61000,Aetna,First Health,,1223.07,,,,,,,481.45,1223.07,percent of total billed charges,
SCREW,7969562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,588.34,1334.98,percent of total billed charges,
SCREW,7969562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,525.50,1334.98,percent of total billed charges,
SCREW,7969561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,588.34,1334.98,percent of total billed charges,
SCREW,7969561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,525.50,1334.98,percent of total billed charges,
SCREW,7980715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,7980715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
STEM,7969030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,7969030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
STEM CENTRALIZER,7969031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
STEM CENTRALIZER,7969031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
INSERT,7969195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7969195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
NAIL,7967970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1951.93,4429.06,percent of total billed charges,
NAIL,7967970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,First Health,,4429.06,,,,,,,1743.47,4429.06,percent of total billed charges,
LINER,7981170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7981170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7976527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7976527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,7982855,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,7982855,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW,7968953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,7968953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
PROXIMAL BODY,7968122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
PROXIMAL BODY,7968122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
COMPONENT FEMORAL,7969365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7969365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7987663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,7987663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
LEAD,7968498,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
LEAD,7968498,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
ROD,7968119,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD,7968119,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ROD,7968121,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD,7968121,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
FEMORAL HEAD,7969783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7969783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7968692,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
FEMORAL HEAD,7968692,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
FEMORAL HEAD,7968695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,7968695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,7968190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,795.98,1806.14,percent of total billed charges,
SCREW,7968190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,710.98,1806.14,percent of total billed charges,
BALLOON CATHETER,7975113,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7975113,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
SCREW,7971972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7971972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
WEDGE,7989319,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE,7989319,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
FEMORAL HEAD,7980585,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7980585,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7976432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7976432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7976757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7976757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
FEMORAL HEAD,7987234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,7987234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
STEM,7968355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7968355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,7978418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7978418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7976680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7976680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,7972657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7972657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
COMPONENT PATELLA,7989190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
COMPONENT PATELLA,7989190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
BASEPLATE,7987236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
BASEPLATE,7987236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
BASEPLATE,7989148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
BASEPLATE,7989148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
BASEPLATE,7989192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
BASEPLATE,7989192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
COMPONENT FEMORAL,7978457,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7978457,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7976560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7976560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7972075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7972075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7976655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7976655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7989494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7989494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7989496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,7989496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
BASEPLATE,7978442,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,7978442,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
INSERT,7978441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,7978441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
COMPONENT GLENOID,7975049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
COMPONENT GLENOID,7975049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
PLATE,7968115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,920.57000,266.97000,Aetna,First Health,,753.03,,,,,,,331.87,753.03,percent of total billed charges,
PLATE,7968115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,920.57000,266.97000,Aetna,First Health,,753.03,,,,,,,296.42,753.03,percent of total billed charges,
AUGMENT TIBIAL,7987659,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7987659,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7987661,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
AUGMENT TIBIAL,7987661,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
INSERT,7986563,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,7986563,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,7987669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,7987669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SCREW,7987274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,588.34,1334.98,percent of total billed charges,
SCREW,7987274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,525.50,1334.98,percent of total billed charges,
SCREW,7987275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,588.34,1334.98,percent of total billed charges,
SCREW,7987275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,First Health,,1334.98,,,,,,,525.50,1334.98,percent of total billed charges,
GENERATOR,7975050,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,45787.50000,13278.37000,Aetna,First Health,,37454.18,,,,,,,16506.39,37454.18,percent of total billed charges,
GENERATOR,7975050,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,45787.50000,13278.37000,Aetna,First Health,,37454.18,,,,,,,14743.58,37454.18,percent of total billed charges,
GENERATOR,7974863,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,45787.50000,13278.37000,Aetna,First Health,,37454.18,,,,,,,16506.39,37454.18,percent of total billed charges,
GENERATOR,7974863,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,45787.50000,13278.37000,Aetna,First Health,,37454.18,,,,,,,14743.58,37454.18,percent of total billed charges,
INSERT,7974647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,7974647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
INSERT,7976667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,7976667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
GRAFT,7980763,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5529.37000,1603.52000,Aetna,First Health,,4523.02,,,,,,,1993.34,4523.02,percent of total billed charges,
GRAFT,7980763,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5529.37000,1603.52000,Aetna,First Health,,4523.02,,,,,,,1780.46,4523.02,percent of total billed charges,
BREAST IMPLANT,7968828,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7968828,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7968829,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7968829,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7969718,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7969718,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7980557,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7980557,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7973828,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7973828,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,7976720,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,7976720,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
WEDGE,7989323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7989323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
HIP MODULAR,7976363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
HIP MODULAR,7976363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
HIP MODULAR,7978373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
HIP MODULAR,7978373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
INSERT,7987862,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2852.56,6472.67,percent of total billed charges,
INSERT,7987862,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,First Health,,6472.67,,,,,,,2547.92,6472.67,percent of total billed charges,
SPACER,7968559,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1254.66,2846.91,percent of total billed charges,
SPACER,7968559,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1120.67,2846.91,percent of total billed charges,
FEMORAL HEAD,7968727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,7968727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
TENDON,7976726,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1722.29,3907.99,percent of total billed charges,
TENDON,7976726,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1538.36,3907.99,percent of total billed charges,
SCREW,7974721,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,7974721,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
STENT,7969441,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7969441,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7975073,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7975073,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7975074,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7975074,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7975075,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7975075,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7975076,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7975076,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7975077,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7975077,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
LINER,7969722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,3000.08,6807.40,percent of total billed charges,
LINER,7969722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,2679.68,6807.40,percent of total billed charges,
LINER,7978412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,3000.08,6807.40,percent of total billed charges,
LINER,7978412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,2679.68,6807.40,percent of total billed charges,
LINER,7969723,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,3000.08,6807.40,percent of total billed charges,
LINER,7969723,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,2679.68,6807.40,percent of total billed charges,
AUGMENT TIBIAL,7972679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1337.71,3035.35,percent of total billed charges,
AUGMENT TIBIAL,7972679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,First Health,,3035.35,,,,,,,1194.85,3035.35,percent of total billed charges,
ROD,7978375,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7978375,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
ROD,7989427,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,812.06,1842.63,percent of total billed charges,
ROD,7989427,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,First Health,,1842.63,,,,,,,725.34,1842.63,percent of total billed charges,
BONE GRAFT,7973829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3207.75000,930.25000,Aetna,First Health,,2623.94,,,,,,,1156.39,2623.94,percent of total billed charges,
BONE GRAFT,7973829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3207.75000,930.25000,Aetna,First Health,,2623.94,,,,,,,1032.90,2623.94,percent of total billed charges,
SCREW,7969830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,7969830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,7986470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,7986470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
INSERT,7968127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7968127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7980710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
INSERT,7980710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
INSERT,7972019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7972019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7969237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,7969237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
INSERT,7987624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
INSERT,7987624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
WEDGE,7989321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1491.35,3383.98,percent of total billed charges,
WEDGE,7989321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,First Health,,3383.98,,,,,,,1332.08,3383.98,percent of total billed charges,
PLATE,7972658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8201.94000,2378.56000,Aetna,First Health,,6709.19,,,,,,,2956.80,6709.19,percent of total billed charges,
PLATE,7972658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8201.94000,2378.56000,Aetna,First Health,,6709.19,,,,,,,2641.02,6709.19,percent of total billed charges,
BASEPLATE,7974907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
BASEPLATE,7974907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
PLATE,7982455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1358.68000,394.02000,Aetna,First Health,,1111.40,,,,,,,489.80,1111.40,percent of total billed charges,
PLATE,7982455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1358.68000,394.02000,Aetna,First Health,,1111.40,,,,,,,437.49,1111.40,percent of total billed charges,
PLATE,7982456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1358.68000,394.02000,Aetna,First Health,,1111.40,,,,,,,489.80,1111.40,percent of total billed charges,
PLATE,7982456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1358.68000,394.02000,Aetna,First Health,,1111.40,,,,,,,437.49,1111.40,percent of total billed charges,
WEDGE,7975018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,7975018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
INSERT,7971860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7971860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
INSERT,7973847,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7973847,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
INSERT,7988523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,7988523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
PLATE,7982453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,461.81,1047.89,percent of total billed charges,
PLATE,7982453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,First Health,,1047.89,,,,,,,412.49,1047.89,percent of total billed charges,
STEM,7973852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,7973852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CATHETER,7969683,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
CATHETER,7969683,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
CATHETER,7969684,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1736.00000,503.44000,Aetna,First Health,,1420.05,,,,,,,625.83,1420.05,percent of total billed charges,
CATHETER,7969684,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1736.00000,503.44000,Aetna,First Health,,1420.05,,,,,,,558.99,1420.05,percent of total billed charges,
ROD,7968605,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7968605,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7969036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7969036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD,7976664,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD,7976664,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
BASEPLATE,7974900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1548.17,3512.90,percent of total billed charges,
BASEPLATE,7974900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1382.83,3512.90,percent of total billed charges,
BASEPLATE,7986560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1548.17,3512.90,percent of total billed charges,
BASEPLATE,7986560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,First Health,,3512.90,,,,,,,1382.83,3512.90,percent of total billed charges,
STEM,7969315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
STEM,7969315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
AUGMENT TIBIAL,7983029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7983029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7986561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7986561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7986562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
AUGMENT TIBIAL,7986562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
BASEPLATE,7987575,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,7987575,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
ACETABULAR RING,7972593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4135.95000,1199.43000,Aetna,First Health,,3383.21,,,,,,,1491.01,3383.21,percent of total billed charges,
ACETABULAR RING,7972593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4135.95000,1199.43000,Aetna,First Health,,3383.21,,,,,,,1331.78,3383.21,percent of total billed charges,
LINER,7972592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7577.10000,2197.36000,Aetna,First Health,,6198.07,,,,,,,2731.54,6198.07,percent of total billed charges,
LINER,7972592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7577.10000,2197.36000,Aetna,First Health,,6198.07,,,,,,,2439.83,6198.07,percent of total billed charges,
BOLT,7971933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,907.31,2058.74,percent of total billed charges,
BOLT,7971933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,810.41,2058.74,percent of total billed charges,
BOLT,7978415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,907.31,2058.74,percent of total billed charges,
BOLT,7978415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,810.41,2058.74,percent of total billed charges,
WEDGE KNEE,7987525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE KNEE,7987525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
PLATE,7982459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1541.76000,447.11000,Aetna,First Health,,1261.16,,,,,,,555.80,1261.16,percent of total billed charges,
PLATE,7982459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1541.76000,447.11000,Aetna,First Health,,1261.16,,,,,,,496.45,1261.16,percent of total billed charges,
PLATE,7982460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1541.76000,447.11000,Aetna,First Health,,1261.16,,,,,,,555.80,1261.16,percent of total billed charges,
PLATE,7982460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1541.76000,447.11000,Aetna,First Health,,1261.16,,,,,,,496.45,1261.16,percent of total billed charges,
STENT,7974140,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
STENT,7974140,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
STENT,7974939,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,3356.09,7615.20,percent of total billed charges,
STENT,7974939,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,2997.67,7615.20,percent of total billed charges,
STENT,7974938,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,3356.09,7615.20,percent of total billed charges,
STENT,7974938,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,2997.67,7615.20,percent of total billed charges,
GUIDEWIRE,7694370,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,364.17000,105.61000,Aetna,First Health,,297.89,,,,,,,131.28,297.89,percent of total billed charges,
GUIDEWIRE,7694370,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,364.17000,105.61000,Aetna,First Health,,297.89,,,,,,,117.26,297.89,percent of total billed charges,
BALLOON,8135731,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8135731,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
ALLODERM,8141200,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2741.60,6220.89,percent of total billed charges,
ALLODERM,8141200,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,124.65,6220.89,percent of total billed charges,
CAGE,7987809,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4902.21000,1421.64000,Aetna,First Health,,4010.01,,,,,,,1767.25,4010.01,percent of total billed charges,
CAGE,7987809,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4902.21000,1421.64000,Aetna,First Health,,4010.01,,,,,,,1578.51,4010.01,percent of total billed charges,
BALLOON,8143405,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,1117.55,2535.80,percent of total billed charges,
BALLOON,8143405,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,998.20,2535.80,percent of total billed charges,
GRAFT ALLODERM,8125550,CDM,278,RC,C9359,HCPCS,,,facility,inpatient,,,4190.06000,1215.12000,Aetna,First Health,,3427.47,,,,,,,1510.52,3427.47,percent of total billed charges,
GRAFT ALLODERM,8125550,CDM,278,RC,C9359,HCPCS,,,facility,outpatient,,,4190.06000,1215.12000,Aetna,First Health,,3427.47,,,,,,,1349.20,3427.47,percent of total billed charges,
BALLOON,8143406,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,1117.55,2535.80,percent of total billed charges,
BALLOON,8143406,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,998.20,2535.80,percent of total billed charges,
BALLOON,8143407,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,1117.55,2535.80,percent of total billed charges,
BALLOON,8143407,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,998.20,2535.80,percent of total billed charges,
BALLOON,8143408,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,1117.55,2535.80,percent of total billed charges,
BALLOON,8143408,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,998.20,2535.80,percent of total billed charges,
SCREW,8167962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8167962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
ROD SPINAL,8167966,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8167966,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SCREW,8167967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8167967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
HEAD FEMORAL,8167968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
HEAD FEMORAL,8167968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
COMPONENT FEMORAL,8167969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,8167969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
ROD SPINAL,8167970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8167970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
ROD SPINAL,8167971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8167971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,8167972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8167972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,8167973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8167973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
CAGE,8168046,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8061.39000,2337.80000,Aetna,First Health,,6594.22,,,,,,,2906.13,6594.22,percent of total billed charges,
CAGE,8168046,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8061.39000,2337.80000,Aetna,First Health,,6594.22,,,,,,,2595.77,6594.22,percent of total billed charges,
SCREW,8168047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,258.04,585.50,percent of total billed charges,
SCREW,8168047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,230.48,585.50,percent of total billed charges,
SCREW,8168107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,8168107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
WEDGE,8168109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1297.08,2943.16,percent of total billed charges,
WEDGE,8168109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1158.56,2943.16,percent of total billed charges,
CEMENT,8168111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5946.50000,1724.48000,Aetna,First Health,,4864.24,,,,,,,2143.71,4864.24,percent of total billed charges,
CEMENT,8168111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5946.50000,1724.48000,Aetna,First Health,,4864.24,,,,,,,1914.77,4864.24,percent of total billed charges,
PLATE,8168113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8168113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8168115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8168115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ROD SPINAL,8168117,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8168117,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ROD SPINAL,8168119,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8168119,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CAGE,8168121,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22000.00000,6380.00000,Aetna,First Health,,17996.00,,,,,,,7931.00,17996.00,percent of total billed charges,
CAGE,8168121,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22000.00000,6380.00000,Aetna,First Health,,17996.00,,,,,,,7084.00,17996.00,percent of total billed charges,
CAGE,8168123,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22000.00000,6380.00000,Aetna,First Health,,17996.00,,,,,,,7931.00,17996.00,percent of total billed charges,
CAGE,8168123,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22000.00000,6380.00000,Aetna,First Health,,17996.00,,,,,,,7084.00,17996.00,percent of total billed charges,
SCREW,8168125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8168125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
VNS THERAPY,7946117,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,3552.50000,1030.22000,Aetna,First Health,,2905.95,,,,,,,1280.68,2905.95,percent of total billed charges,
VNS THERAPY,7946117,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,3552.50000,1030.22000,Aetna,First Health,,2905.95,,,,,,,1143.90,2905.95,percent of total billed charges,
SCREW,8168190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,258.04,585.50,percent of total billed charges,
SCREW,8168190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,230.48,585.50,percent of total billed charges,
SPACER,8168192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8061.39000,2337.80000,Aetna,First Health,,6594.22,,,,,,,2906.13,6594.22,percent of total billed charges,
SPACER,8168192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8061.39000,2337.80000,Aetna,First Health,,6594.22,,,,,,,2595.77,6594.22,percent of total billed charges,
SCREW,8168194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,258.04,585.50,percent of total billed charges,
SCREW,8168194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,230.48,585.50,percent of total billed charges,
HIP SYSTEM,8168196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
HIP SYSTEM,8168196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
CAGE,8168197,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,6060.91,13752.62,percent of total billed charges,
CAGE,8168197,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,5413.62,13752.62,percent of total billed charges,
CAGE,8168198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,6060.91,13752.62,percent of total billed charges,
CAGE,8168198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,5413.62,13752.62,percent of total billed charges,
CAGE,8168200,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,6060.91,13752.62,percent of total billed charges,
CAGE,8168200,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,5413.62,13752.62,percent of total billed charges,
BREAST IMPLANT,8168241,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8168241,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
STENT,8168239,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
STENT,8168239,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
BALLOON DILATOR,7950029,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9242.61000,2680.36000,Aetna,First Health,,7560.45,,,,,,,3331.96,7560.45,percent of total billed charges,
BALLOON DILATOR,7950029,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9242.61000,2680.36000,Aetna,First Health,,7560.45,,,,,,,2976.12,7560.45,percent of total billed charges,
ROD SPINAL,7695288,CDM,278,RC,,,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ROD SPINAL,7695288,CDM,278,RC,,,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
SCREW,7703113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,7703113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
PLATE,7772033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1293.60000,375.14000,Aetna,First Health,,1058.16,,,,,,,466.34,1058.16,percent of total billed charges,
PLATE,7772033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1293.60000,375.14000,Aetna,First Health,,1058.16,,,,,,,416.54,1058.16,percent of total billed charges,
ROD SPINAL,7912526,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,7912526,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
SCREW,7934007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,7934007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
CATHETER DILATOR,7965294,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER DILATOR,7965294,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
AUGMENT FEMORAL,7935557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,5404.09,12262.25,percent of total billed charges,
AUGMENT FEMORAL,7935557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,4826.95,12262.25,percent of total billed charges,
AUGMENT FEMORAL,7935558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,5404.09,12262.25,percent of total billed charges,
AUGMENT FEMORAL,7935558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,First Health,,12262.25,,,,,,,4826.95,12262.25,percent of total billed charges,
ROD SPINAL,7938980,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,7938980,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
ROD SPINAL,7965928,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,533.11,1209.66,percent of total billed charges,
ROD SPINAL,7965928,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,476.17,1209.66,percent of total billed charges,
SCREW,7935864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,744.07,1688.35,percent of total billed charges,
SCREW,7935864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,664.61,1688.35,percent of total billed charges,
RESOLUTION CLIP,7936052,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1329.20000,385.47000,Aetna,First Health,,1087.29,,,,,,,479.18,1087.29,percent of total billed charges,
RESOLUTION CLIP,7936052,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1329.20000,385.47000,Aetna,First Health,,1087.29,,,,,,,428.00,1087.29,percent of total billed charges,
CATHETER DILATION,7962477,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER DILATION,7962477,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
GRAFT STENT,7962543,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
GRAFT STENT,7962543,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
CAGE,7927020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CAGE,7927020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
SCREW,7696240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7696240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
INSERT,7695605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
INSERT,7695605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
SCREW,7695498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7695498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,7695499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7695499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,7695500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7695500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
PLATE,7736055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4256.46000,1234.37000,Aetna,First Health,,3481.78,,,,,,,1534.45,3481.78,percent of total billed charges,
PLATE,7736055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4256.46000,1234.37000,Aetna,First Health,,3481.78,,,,,,,1370.58,3481.78,percent of total billed charges,
PLATE,7698134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
PLATE,7698134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
ROD SPINAL,7909030,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD SPINAL,7909030,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
ROD SPINAL,7909292,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD SPINAL,7909292,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
ROD SPINAL,7866033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,7866033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
PLATE,8168368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2125.28000,616.33000,Aetna,First Health,,1738.48,,,,,,,766.16,1738.48,percent of total billed charges,
PLATE,8168368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2125.28000,616.33000,Aetna,First Health,,1738.48,,,,,,,684.34,1738.48,percent of total billed charges,
PLATE,8168370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,485.36000,140.75000,Aetna,First Health,,397.02,,,,,,,174.97,397.02,percent of total billed charges,
PLATE,8168370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,485.36000,140.75000,Aetna,First Health,,397.02,,,,,,,156.29,397.02,percent of total billed charges,
SCREW,8168405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8168405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ALLOGRAFT,8168407,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3722.04000,1079.39000,Aetna,First Health,,3044.63,,,,,,,1341.80,3044.63,percent of total billed charges,
ALLOGRAFT,8168407,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3722.04000,1079.39000,Aetna,First Health,,3044.63,,,,,,,1198.50,3044.63,percent of total billed charges,
ALLOGRAFT,8168408,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,1990.40000,577.22000,Aetna,First Health,,1628.15,,,,,,,717.54,1628.15,percent of total billed charges,
ALLOGRAFT,8168408,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,1990.40000,577.22000,Aetna,First Health,,1628.15,,,,,,,640.91,1628.15,percent of total billed charges,
SCREW,8168454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8168454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
INSERT,8168456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8168456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
COMPONENT FEMORAL,8168458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8168458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
GUIDEWIRE,8168460,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1544.00000,447.76000,Aetna,First Health,,1262.99,,,,,,,556.61,1262.99,percent of total billed charges,
GUIDEWIRE,8168460,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1544.00000,447.76000,Aetna,First Health,,1262.99,,,,,,,497.17,1262.99,percent of total billed charges,
SCREW,7695861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7695861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
COMPONENT TIBIAL,7699261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8661.15000,2511.73000,Aetna,First Health,,7084.82,,,,,,,3122.34,7084.82,percent of total billed charges,
COMPONENT TIBIAL,7699261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8661.15000,2511.73000,Aetna,First Health,,7084.82,,,,,,,2788.89,7084.82,percent of total billed charges,
COMPONENT FEMORAL,7699341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,350.41,795.10,percent of total billed charges,
COMPONENT FEMORAL,7699341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,312.98,795.10,percent of total billed charges,
COMPONENT FEMORAL,7699342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2932.00000,850.28000,Aetna,First Health,,2398.38,,,,,,,1056.99,2398.38,percent of total billed charges,
COMPONENT FEMORAL,7699342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2932.00000,850.28000,Aetna,First Health,,2398.38,,,,,,,944.10,2398.38,percent of total billed charges,
SCREW,7696592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2030.40000,588.82000,Aetna,First Health,,1660.87,,,,,,,731.96,1660.87,percent of total billed charges,
SCREW,7696592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2030.40000,588.82000,Aetna,First Health,,1660.87,,,,,,,653.79,1660.87,percent of total billed charges,
FEMORAL CONE,7699100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
FEMORAL CONE,7699100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
INSERT,7926707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7926707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ROD SPINAL,7918647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
ROD SPINAL,7918647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7965424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,870.20,1974.55,percent of total billed charges,
PLATE,7965424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,First Health,,1974.55,,,,,,,777.27,1974.55,percent of total billed charges,
GUIDEWIRE,8168527,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
GUIDEWIRE,8168527,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
ROD,8168528,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,179.80,407.98,percent of total billed charges,
ROD,8168528,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,160.60,407.98,percent of total billed charges,
STEM,8168542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,5515.65,12515.40,percent of total billed charges,
STEM,8168542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,First Health,,12515.40,,,,,,,4926.60,12515.40,percent of total billed charges,
RADIAL HEAD,8168544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23820.00000,6907.80000,Aetna,First Health,,19484.76,,,,,,,8587.11,19484.76,percent of total billed charges,
RADIAL HEAD,8168544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23820.00000,6907.80000,Aetna,First Health,,19484.76,,,,,,,7670.04,19484.76,percent of total billed charges,
ANCHOR,8168540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
ANCHOR,8168540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
COMPONENT TIBIAL,8168546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
COMPONENT TIBIAL,8168546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
INSERT,8168548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,8168548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
GLIDEWIRE,8168550,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.75000,59.38000,Aetna,First Health,,167.49,,,,,,,73.81,167.49,percent of total billed charges,
GLIDEWIRE,8168550,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.75000,59.38000,Aetna,First Health,,167.49,,,,,,,65.93,167.49,percent of total billed charges,
COMPONENT FEMORAL,8168596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15325.00000,4444.25000,Aetna,First Health,,12535.85,,,,,,,5524.66,12535.85,percent of total billed charges,
COMPONENT FEMORAL,8168596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15325.00000,4444.25000,Aetna,First Health,,12535.85,,,,,,,4934.65,12535.85,percent of total billed charges,
STEM,8168650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9258.00000,2684.82000,Aetna,First Health,,7573.04,,,,,,,3337.51,7573.04,percent of total billed charges,
STEM,8168650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9258.00000,2684.82000,Aetna,First Health,,7573.04,,,,,,,2981.08,7573.04,percent of total billed charges,
COMPONENT FEMORAL,8168598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,949.50000,275.35000,Aetna,First Health,,776.69,,,,,,,342.29,776.69,percent of total billed charges,
COMPONENT FEMORAL,8168598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,949.50000,275.35000,Aetna,First Health,,776.69,,,,,,,305.74,776.69,percent of total billed charges,
COMPONENT TIBIAL,8168600,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2752.42,6245.43,percent of total billed charges,
COMPONENT TIBIAL,8168600,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2458.47,6245.43,percent of total billed charges,
INSERT,8168602,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1932.00000,560.28000,Aetna,First Health,,1580.38,,,,,,,696.49,1580.38,percent of total billed charges,
INSERT,8168602,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1932.00000,560.28000,Aetna,First Health,,1580.38,,,,,,,622.10,1580.38,percent of total billed charges,
INSERT,8168604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4007.50000,1162.18000,Aetna,First Health,,3278.14,,,,,,,1444.70,3278.14,percent of total billed charges,
INSERT,8168604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4007.50000,1162.18000,Aetna,First Health,,3278.14,,,,,,,1290.41,3278.14,percent of total billed charges,
SCREW,8168606,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8168606,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
ROD SPINAL,8168607,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8168607,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
ROD SPINAL,8168608,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8168608,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
COMPONENT FEMORAL,8168652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,8168652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
COMPONENT TIBIAL,8168653,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,8168653,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
STENT GRAFT,7939898,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7939898,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
GRAFT,7696308,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,11445.00000,3319.05000,Aetna,First Health,,9362.01,,,,,,,4125.92,9362.01,percent of total billed charges,
GRAFT,7696308,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,11445.00000,3319.05000,Aetna,First Health,,9362.01,,,,,,,3685.29,9362.01,percent of total billed charges,
PLATE,7698080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5436.69000,1576.64000,Aetna,First Health,,4447.21,,,,,,,1959.93,4447.21,percent of total billed charges,
PLATE,7698080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5436.69000,1576.64000,Aetna,First Health,,4447.21,,,,,,,1750.61,4447.21,percent of total billed charges,
GRAFT EXTENDER,7699522,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
GRAFT EXTENDER,7699522,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
SCREW,7703201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7703201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,7703202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7703202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,7703203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,7703203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
PLATE,7702469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,980.73000,284.41000,Aetna,First Health,,802.24,,,,,,,353.55,802.24,percent of total billed charges,
PLATE,7702469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,980.73000,284.41000,Aetna,First Health,,802.24,,,,,,,315.80,802.24,percent of total billed charges,
ROD SPINAL,7910513,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,7910513,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
STENT GRAFT,7935112,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7935112,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
ROD SPINAL,7910837,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD SPINAL,7910837,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,7911046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,7911046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
ANCHOR,7694810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,814.73,1848.68,percent of total billed charges,
ANCHOR,7694810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,727.72,1848.68,percent of total billed charges,
STEM,8168757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8168757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
NAIL,8168774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8168774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
ANCHOR,8168782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4370.63000,1267.48000,Aetna,First Health,,3575.18,,,,,,,1575.61,3575.18,percent of total billed charges,
ANCHOR,8168782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4370.63000,1267.48000,Aetna,First Health,,3575.18,,,,,,,1407.34,3575.18,percent of total billed charges,
INSERT,8168783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8168783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
ROD SPINAL,8168854,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8168854,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ANCHOR,8168857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,802.11,1820.05,percent of total billed charges,
ANCHOR,8168857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,716.45,1820.05,percent of total billed charges,
STEM,8168858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,8168858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
CAGE,8168859,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8168859,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
SCREW,8168860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,122.78,278.59,percent of total billed charges,
SCREW,8168860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,109.67,278.59,percent of total billed charges,
END CAP,8168861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
END CAP,8168861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
PLATE,8168862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4039.00000,1171.31000,Aetna,First Health,,3303.90,,,,,,,1456.06,3303.90,percent of total billed charges,
PLATE,8168862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4039.00000,1171.31000,Aetna,First Health,,3303.90,,,,,,,1300.56,3303.90,percent of total billed charges,
SCREW,8168863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,927.00000,268.83000,Aetna,First Health,,758.29,,,,,,,334.18,758.29,percent of total billed charges,
SCREW,8168863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,927.00000,268.83000,Aetna,First Health,,758.29,,,,,,,298.49,758.29,percent of total billed charges,
CAGE,8168864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3444.00000,998.76000,Aetna,First Health,,2817.19,,,,,,,1241.56,2817.19,percent of total billed charges,
CAGE,8168864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3444.00000,998.76000,Aetna,First Health,,2817.19,,,,,,,1108.97,2817.19,percent of total billed charges,
SCREW,8169163,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,8169163,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,8168866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1454.17,3299.61,percent of total billed charges,
SCREW,8168866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1298.87,3299.61,percent of total billed charges,
SCREW,8168867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1454.17,3299.61,percent of total billed charges,
SCREW,8168867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1298.87,3299.61,percent of total billed charges,
SCREW,8168868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1454.17,3299.61,percent of total billed charges,
SCREW,8168868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1298.87,3299.61,percent of total billed charges,
SCREW,8168869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1454.17,3299.61,percent of total billed charges,
SCREW,8168869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1298.87,3299.61,percent of total billed charges,
SCREW,8168870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1454.17,3299.61,percent of total billed charges,
SCREW,8168870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1298.87,3299.61,percent of total billed charges,
SCREW,8168871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1454.17,3299.61,percent of total billed charges,
SCREW,8168871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,First Health,,3299.61,,,,,,,1298.87,3299.61,percent of total billed charges,
INSERT,8168872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8168872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
SCREW,8169164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,8169164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,8169165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,8169165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,8169166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,8169166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,8169167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,8169167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
TIGHTROPE,8169168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,497.78,1129.49,percent of total billed charges,
TIGHTROPE,8169168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,First Health,,1129.49,,,,,,,444.62,1129.49,percent of total billed charges,
SCREW,8169169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8169169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8169170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8169170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
GUIDEWIRE,8169047,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
GUIDEWIRE,8169047,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
ANCHOR,8169223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2099.00000,608.71000,Aetna,First Health,,1716.98,,,,,,,756.69,1716.98,percent of total billed charges,
ANCHOR,8169223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2099.00000,608.71000,Aetna,First Health,,1716.98,,,,,,,675.88,1716.98,percent of total billed charges,
PLATE,8169947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
PLATE,8169947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
SCREW,8169949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8169949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
ROD SPINAL,8169159,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
ROD SPINAL,8169159,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
NUT,8169161,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
NUT,8169161,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
SCREW,8169810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8169810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
SCREW,8169812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8169812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
ROD SPINAL,8169814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8169814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
STENT GRAFT,8169816,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,17475.69,39653.57,percent of total billed charges,
STENT GRAFT,8169816,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,15609.35,39653.57,percent of total billed charges,
STENT GRAFT,8169817,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,17475.69,39653.57,percent of total billed charges,
STENT GRAFT,8169817,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,15609.35,39653.57,percent of total billed charges,
STENT GRAFT,8169818,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,17475.69,39653.57,percent of total billed charges,
STENT GRAFT,8169818,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,15609.35,39653.57,percent of total billed charges,
STENT GRAFT,8169819,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,17475.69,39653.57,percent of total billed charges,
STENT GRAFT,8169819,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,15609.35,39653.57,percent of total billed charges,
STENT GRAFT,8169820,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,18742.40,42527.82,percent of total billed charges,
STENT GRAFT,8169820,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,16740.78,42527.82,percent of total billed charges,
STENT GRAFT,8169821,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,17475.69,39653.57,percent of total billed charges,
STENT GRAFT,8169821,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,15609.35,39653.57,percent of total billed charges,
STENT GRAFT,8169822,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,18742.40,42527.82,percent of total billed charges,
STENT GRAFT,8169822,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,16740.78,42527.82,percent of total billed charges,
STENT GRAFT,8169823,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,17475.69,39653.57,percent of total billed charges,
STENT GRAFT,8169823,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,15609.35,39653.57,percent of total billed charges,
STENT GRAFT,8169824,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51190.20000,14845.16000,Aetna,First Health,,41873.58,,,,,,,18454.07,41873.58,percent of total billed charges,
STENT GRAFT,8169824,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51190.20000,14845.16000,Aetna,First Health,,41873.58,,,,,,,16483.24,41873.58,percent of total billed charges,
STENT GRAFT,8169825,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,17475.69,39653.57,percent of total billed charges,
STENT GRAFT,8169825,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,15609.35,39653.57,percent of total billed charges,
STENT GRAFT,8169826,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,17475.69,39653.57,percent of total billed charges,
STENT GRAFT,8169826,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,15609.35,39653.57,percent of total billed charges,
STENT GRAFT,8169827,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,18742.40,42527.82,percent of total billed charges,
STENT GRAFT,8169827,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,16740.78,42527.82,percent of total billed charges,
STENT GRAFT,8169828,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,17475.69,39653.57,percent of total billed charges,
STENT GRAFT,8169828,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,15609.35,39653.57,percent of total billed charges,
STENT GRAFT,8169829,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,18742.40,42527.82,percent of total billed charges,
STENT GRAFT,8169829,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,16740.78,42527.82,percent of total billed charges,
STENT GRAFT,8169830,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,17475.69,39653.57,percent of total billed charges,
STENT GRAFT,8169830,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,First Health,,39653.57,,,,,,,15609.35,39653.57,percent of total billed charges,
STENT GRAFT,8169831,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,18742.40,42527.82,percent of total billed charges,
STENT GRAFT,8169831,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,16740.78,42527.82,percent of total billed charges,
SCREW,8169951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8169951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8169953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8169953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8169955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8169955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8169957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8169957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
ALLOGRAFT,8169919,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,21625.00000,6271.25000,Aetna,First Health,,17689.25,,,,,,,7795.81,17689.25,percent of total billed charges,
ALLOGRAFT,8169919,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,21625.00000,6271.25000,Aetna,First Health,,17689.25,,,,,,,6963.25,17689.25,percent of total billed charges,
ROD SPINAL,7920118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,7920118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
ROD SPINAL,7912362,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD SPINAL,7912362,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SLEEVE,7736071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1971.44000,571.72000,Aetna,First Health,,1612.64,,,,,,,710.70,1612.64,percent of total billed charges,
SLEEVE,7736071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1971.44000,571.72000,Aetna,First Health,,1612.64,,,,,,,634.80,1612.64,percent of total billed charges,
ROD SPINAL,7917821,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,7917821,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
PLATE,7736050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4256.46000,1234.37000,Aetna,First Health,,3481.78,,,,,,,1534.45,3481.78,percent of total billed charges,
PLATE,7736050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4256.46000,1234.37000,Aetna,First Health,,3481.78,,,,,,,1370.58,3481.78,percent of total billed charges,
HEAD FEMORAL,7800035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,7800035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
INSERT,7939307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,7939307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HEAD HUMERAL,8109156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HEAD HUMERAL,8109156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
NAIL,8117054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8117054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8117056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,1085.65,2463.42,percent of total billed charges,
NAIL,8117056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,969.71,2463.42,percent of total billed charges,
CAGE,7966221,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4544.46,10311.71,percent of total billed charges,
CAGE,7966221,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4059.13,10311.71,percent of total billed charges,
SCREW,7966223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,631.90,1433.82,percent of total billed charges,
SCREW,7966223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,First Health,,1433.82,,,,,,,564.41,1433.82,percent of total billed charges,
PLATE,7966224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.70000,1465.86000,Aetna,First Health,,4134.74,,,,,,,1822.22,4134.74,percent of total billed charges,
PLATE,7966224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.70000,1465.86000,Aetna,First Health,,4134.74,,,,,,,1627.61,4134.74,percent of total billed charges,
STEM,8170032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,8170032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
PLATE,8170045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5323.50000,1543.81000,Aetna,First Health,,4354.62,,,,,,,1919.12,4354.62,percent of total billed charges,
PLATE,8170045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5323.50000,1543.81000,Aetna,First Health,,4354.62,,,,,,,1714.17,4354.62,percent of total billed charges,
SCREW,8170048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,8170048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SPACER,8170070,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1434.61,3255.23,percent of total billed charges,
SPACER,8170070,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1281.40,3255.23,percent of total billed charges,
SPACER,8170071,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1434.61,3255.23,percent of total billed charges,
SPACER,8170071,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1281.40,3255.23,percent of total billed charges,
SPACER,8170072,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1434.61,3255.23,percent of total billed charges,
SPACER,8170072,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1281.40,3255.23,percent of total billed charges,
SCREW,8170076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8170076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,8170077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8170077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
PLATE,8170078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
PLATE,8170078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
SPACER,8170079,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1434.61,3255.23,percent of total billed charges,
SPACER,8170079,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1281.40,3255.23,percent of total billed charges,
SPACER,8170080,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1434.61,3255.23,percent of total billed charges,
SPACER,8170080,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1281.40,3255.23,percent of total billed charges,
SPACER,8170081,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1434.61,3255.23,percent of total billed charges,
SPACER,8170081,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1281.40,3255.23,percent of total billed charges,
SPACER,8170082,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1434.61,3255.23,percent of total billed charges,
SPACER,8170082,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1281.40,3255.23,percent of total billed charges,
SPACER,8170083,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1434.61,3255.23,percent of total billed charges,
SPACER,8170083,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,First Health,,3255.23,,,,,,,1281.40,3255.23,percent of total billed charges,
SCREW,7966225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
SCREW,7966225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
SCREW,7966226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7966226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,7966227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,7966227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
IMPLANT TESTICULAR,7966230,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7980.00000,2314.20000,Aetna,First Health,,6527.64,,,,,,,2876.79,6527.64,percent of total billed charges,
IMPLANT TESTICULAR,7966230,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7980.00000,2314.20000,Aetna,First Health,,6527.64,,,,,,,2569.56,6527.64,percent of total billed charges,
SCREW,7966232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
SCREW,7966232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
SCREW,7966233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
SCREW,7966233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
NAIL,7966237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,714.57,1621.41,percent of total billed charges,
NAIL,7966237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,638.26,1621.41,percent of total billed charges,
STEM,7966238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,7966238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
HEAD FEMORAL,7966239,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
HEAD FEMORAL,7966239,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
PLATE,7966240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1811.80000,525.42000,Aetna,First Health,,1482.05,,,,,,,653.15,1482.05,percent of total billed charges,
PLATE,7966240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1811.80000,525.42000,Aetna,First Health,,1482.05,,,,,,,583.40,1482.05,percent of total billed charges,
BONE STRIP,8170084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4735.50000,1373.29000,Aetna,First Health,,3873.64,,,,,,,1707.15,3873.64,percent of total billed charges,
BONE STRIP,8170084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4735.50000,1373.29000,Aetna,First Health,,3873.64,,,,,,,1524.83,3873.64,percent of total billed charges,
BONE PUTTY,8170085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
BONE PUTTY,8170085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
BONE PUTTY,8170086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2292.00000,664.68000,Aetna,First Health,,1874.86,,,,,,,826.27,1874.86,percent of total billed charges,
BONE PUTTY,8170086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2292.00000,664.68000,Aetna,First Health,,1874.86,,,,,,,738.02,1874.86,percent of total billed charges,
ADAPTER,7947960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3458.00000,1002.82000,Aetna,First Health,,2828.64,,,,,,,1246.61,2828.64,percent of total billed charges,
ADAPTER,7947960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3458.00000,1002.82000,Aetna,First Health,,2828.64,,,,,,,1113.48,2828.64,percent of total billed charges,
CONNECTOR,7697052,CDM,278,RC,,,,,facility,inpatient,,,508.25000,147.39000,Aetna,First Health,,415.75,,,,,,,183.22,415.75,percent of total billed charges,
CONNECTOR,7697052,CDM,278,RC,,,,,facility,outpatient,,,508.25000,147.39000,Aetna,First Health,,415.75,,,,,,,163.66,415.75,percent of total billed charges,
SPACER HIP CEMENT,7698840,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,2104.22,4774.63,percent of total billed charges,
SPACER HIP CEMENT,7698840,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,1879.50,4774.63,percent of total billed charges,
CAGE,8170219,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8334.00000,2416.86000,Aetna,First Health,,6817.21,,,,,,,3004.41,6817.21,percent of total billed charges,
CAGE,8170219,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8334.00000,2416.86000,Aetna,First Health,,6817.21,,,,,,,2683.55,6817.21,percent of total billed charges,
ROD SPINAL,8170221,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
ROD SPINAL,8170221,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8170223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,8170223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW,8170225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,8170225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
WEDGE,8170227,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6210.33000,1801.00000,Aetna,First Health,,5080.05,,,,,,,2238.82,5080.05,percent of total billed charges,
WEDGE,8170227,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6210.33000,1801.00000,Aetna,First Health,,5080.05,,,,,,,1999.73,5080.05,percent of total billed charges,
INSERT,8170229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,First Health,,5454.73,,,,,,,2403.95,5454.73,percent of total billed charges,
INSERT,8170229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,First Health,,5454.73,,,,,,,2147.22,5454.73,percent of total billed charges,
COMPONENT FEMORAL,8170231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,8170231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
BASEPLATE,8170233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
BASEPLATE,8170233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
CATHETER,7707526,CDM,278,RC,C1755,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
CATHETER,7707526,CDM,278,RC,C1755,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
CENTRALIZER FEMORAL,8170279,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
CENTRALIZER FEMORAL,8170279,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
STEM,8170281,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,8170281,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
GRAFT,8170361,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2270.40000,658.42000,Aetna,First Health,,1857.19,,,,,,,818.48,1857.19,percent of total billed charges,
GRAFT,8170361,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2270.40000,658.42000,Aetna,First Health,,1857.19,,,,,,,731.07,1857.19,percent of total billed charges,
VALVE SHUNT,7695715,CDM,278,RC,,,,,facility,inpatient,,,14507.85000,4207.28000,Aetna,First Health,,11867.42,,,,,,,5230.08,11867.42,percent of total billed charges,
VALVE SHUNT,7695715,CDM,278,RC,,,,,facility,outpatient,,,14507.85000,4207.28000,Aetna,First Health,,11867.42,,,,,,,4671.53,11867.42,percent of total billed charges,
SCREW,8170410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8170410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
INSERT,8170412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7932.00000,2300.28000,Aetna,First Health,,6488.38,,,,,,,2859.49,6488.38,percent of total billed charges,
INSERT,8170412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7932.00000,2300.28000,Aetna,First Health,,6488.38,,,,,,,2554.10,6488.38,percent of total billed charges,
PLATE,8170414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
PLATE,8170414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
SCREW,8170416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8170416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8170418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8170418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8170683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8170683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
PLATE,8170685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1291.62,2930.77,percent of total billed charges,
PLATE,8170685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1153.68,2930.77,percent of total billed charges,
SCREW,8170687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8170687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
HEAD FEMORAL,8170689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8170689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW,8170690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8170690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,7695472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7804.86000,2263.41000,Aetna,First Health,,6384.38,,,,,,,2813.65,6384.38,percent of total billed charges,
PLATE,7695472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7804.86000,2263.41000,Aetna,First Health,,6384.38,,,,,,,2513.16,6384.38,percent of total billed charges,
PLUG TISSUE,8170764,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15425.00000,4473.25000,Aetna,First Health,,12617.65,,,,,,,5560.71,12617.65,percent of total billed charges,
PLUG TISSUE,8170764,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15425.00000,4473.25000,Aetna,First Health,,12617.65,,,,,,,4966.85,12617.65,percent of total billed charges,
GUIDEWIRE,8170765,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,283.89,644.17,percent of total billed charges,
GUIDEWIRE,8170765,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,253.57,644.17,percent of total billed charges,
ANCHOR,8170949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2393.00000,693.97000,Aetna,First Health,,1957.47,,,,,,,862.68,1957.47,percent of total billed charges,
ANCHOR,8170949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2393.00000,693.97000,Aetna,First Health,,1957.47,,,,,,,770.55,1957.47,percent of total billed charges,
SCREW,8170951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2841.60000,824.06000,Aetna,First Health,,2324.43,,,,,,,1024.40,2324.43,percent of total billed charges,
SCREW,8170951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2841.60000,824.06000,Aetna,First Health,,2324.43,,,,,,,915.00,2324.43,percent of total billed charges,
PLATE,8170946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5727.26000,1660.91000,Aetna,First Health,,4684.90,,,,,,,2064.68,4684.90,percent of total billed charges,
PLATE,8170946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5727.26000,1660.91000,Aetna,First Health,,4684.90,,,,,,,1844.18,4684.90,percent of total billed charges,
SCREW,8170952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2841.60000,824.06000,Aetna,First Health,,2324.43,,,,,,,1024.40,2324.43,percent of total billed charges,
SCREW,8170952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2841.60000,824.06000,Aetna,First Health,,2324.43,,,,,,,915.00,2324.43,percent of total billed charges,
K WIRE,8170955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,474.05000,137.47000,Aetna,First Health,,387.77,,,,,,,170.90,387.77,percent of total billed charges,
K WIRE,8170955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,474.05000,137.47000,Aetna,First Health,,387.77,,,,,,,152.64,387.77,percent of total billed charges,
ACELLULAR DERMIS,8170967,CDM,278,RC,Q4128,HCPCS,,,facility,inpatient,,,6427.05000,1863.84000,Aetna,First Health,,5257.33,,,,,,,2316.95,5257.33,percent of total billed charges,
ACELLULAR DERMIS,8170967,CDM,278,RC,Q4128,HCPCS,,,facility,outpatient,,,6427.05000,1863.84000,Aetna,First Health,,5257.33,,,,,,,124.65,5257.33,percent of total billed charges,
BONE GRAFT,8170968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,169.53,384.66,percent of total billed charges,
BONE GRAFT,8170968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,First Health,,384.66,,,,,,,151.42,384.66,percent of total billed charges,
BONE GRAFT,8170969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,713.79,1619.64,percent of total billed charges,
BONE GRAFT,8170969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,637.56,1619.64,percent of total billed charges,
CAGE,8171026,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
CAGE,8171026,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
SCREW,8171019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8171019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
INSERT,8171068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8171068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
COMPONENT FEMORAL,8171221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,8171221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
PLATE,8171223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,1312.94,2979.16,percent of total billed charges,
PLATE,8171223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,1172.72,2979.16,percent of total billed charges,
INSERT,8171226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8171226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM,8171229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8171229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,8171230,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8334.00000,2416.86000,Aetna,First Health,,6817.21,,,,,,,3004.41,6817.21,percent of total billed charges,
CAGE,8171230,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8334.00000,2416.86000,Aetna,First Health,,6817.21,,,,,,,2683.55,6817.21,percent of total billed charges,
SCREW,8171278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,134.94,306.18,percent of total billed charges,
SCREW,8171278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,120.52,306.18,percent of total billed charges,
SCREW,8171279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,134.94,306.18,percent of total billed charges,
SCREW,8171279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,120.52,306.18,percent of total billed charges,
WEDGE,8171280,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1543.44,3502.17,percent of total billed charges,
WEDGE,8171280,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,First Health,,3502.17,,,,,,,1378.60,3502.17,percent of total billed charges,
SCREW,8171282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8171282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
INSERT,8171283,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2936.27,6662.61,percent of total billed charges,
INSERT,8171283,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2622.69,6662.61,percent of total billed charges,
SCREW,8171284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,134.94,306.18,percent of total billed charges,
SCREW,8171284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,120.52,306.18,percent of total billed charges,
NAIL,8171475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8171475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
SCREW,8171727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8171727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
SCREW,8171729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,8171729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,8171731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8171731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
COMPONENT FEMORAL,8171791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,8171791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,8171733,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8171733,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
GRAFT VASCULAR,8171610,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,14142.00000,4101.18000,Aetna,First Health,,11568.16,,,,,,,5098.19,11568.16,percent of total billed charges,
GRAFT VASCULAR,8171610,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,14142.00000,4101.18000,Aetna,First Health,,11568.16,,,,,,,4553.72,11568.16,percent of total billed charges,
SCREW,8171834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8171834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8171836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SCREW,8171836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,8171838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SCREW,8171838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CONNECTOR SPINAL,8171840,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5183.50000,1503.22000,Aetna,First Health,,4240.10,,,,,,,1868.65,4240.10,percent of total billed charges,
CONNECTOR SPINAL,8171840,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5183.50000,1503.22000,Aetna,First Health,,4240.10,,,,,,,1669.09,4240.10,percent of total billed charges,
CONNECTOR SPINAL,8171842,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5183.50000,1503.22000,Aetna,First Health,,4240.10,,,,,,,1868.65,4240.10,percent of total billed charges,
CONNECTOR SPINAL,8171842,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5183.50000,1503.22000,Aetna,First Health,,4240.10,,,,,,,1669.09,4240.10,percent of total billed charges,
SCREW,8171844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8171844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8171846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8171846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8171848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8171848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8171850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8171850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8171852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8171852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
ROD SPINAL,8171854,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
ROD SPINAL,8171854,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
CONNECTOR SPINAL,8171856,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5183.50000,1503.22000,Aetna,First Health,,4240.10,,,,,,,1868.65,4240.10,percent of total billed charges,
CONNECTOR SPINAL,8171856,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5183.50000,1503.22000,Aetna,First Health,,4240.10,,,,,,,1669.09,4240.10,percent of total billed charges,
CONNECTOR SPINAL,8171858,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3437.00000,996.73000,Aetna,First Health,,2811.47,,,,,,,1239.04,2811.47,percent of total billed charges,
CONNECTOR SPINAL,8171858,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3437.00000,996.73000,Aetna,First Health,,2811.47,,,,,,,1106.71,2811.47,percent of total billed charges,
INSERT,8171860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8171860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
GUIDEWIRE,8171862,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,191.63000,55.57000,Aetna,First Health,,156.75,,,,,,,69.08,156.75,percent of total billed charges,
GUIDEWIRE,8171862,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,191.63000,55.57000,Aetna,First Health,,156.75,,,,,,,61.70,156.75,percent of total billed charges,
SCREW,8171863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8171863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
ROD SPINAL,8171864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8171864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
AUGMENT FEMORAL,8171865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8162.25000,2367.05000,Aetna,First Health,,6676.72,,,,,,,2942.49,6676.72,percent of total billed charges,
AUGMENT FEMORAL,8171865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8162.25000,2367.05000,Aetna,First Health,,6676.72,,,,,,,2628.24,6676.72,percent of total billed charges,
PLATE,8172024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.36000,912.44000,Aetna,First Health,,2573.72,,,,,,,1134.26,2573.72,percent of total billed charges,
PLATE,8172024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.36000,912.44000,Aetna,First Health,,2573.72,,,,,,,1013.13,2573.72,percent of total billed charges,
PLATE,8172025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10152.00000,2944.08000,Aetna,First Health,,8304.34,,,,,,,3659.80,8304.34,percent of total billed charges,
PLATE,8172025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10152.00000,2944.08000,Aetna,First Health,,8304.34,,,,,,,3268.94,8304.34,percent of total billed charges,
CONNECTOR SPINAL,8172043,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,801.38,1818.38,percent of total billed charges,
CONNECTOR SPINAL,8172043,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,715.79,1818.38,percent of total billed charges,
LINER,8172044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8172044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
STEM,8172045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8172045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8172042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,8172042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
BREAST IMPLANT,8172176,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
BREAST IMPLANT,8172176,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
SCREW,8172178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.00000,537.08000,Aetna,First Health,,1514.94,,,,,,,667.65,1514.94,percent of total billed charges,
SCREW,8172178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.00000,537.08000,Aetna,First Health,,1514.94,,,,,,,596.34,1514.94,percent of total billed charges,
INSERT,8172180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,8172180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
CONNECTOR SPINAL,8172182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5502.00000,1595.58000,Aetna,First Health,,4500.64,,,,,,,1983.47,4500.64,percent of total billed charges,
CONNECTOR SPINAL,8172182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5502.00000,1595.58000,Aetna,First Health,,4500.64,,,,,,,1771.64,4500.64,percent of total billed charges,
NAIL,8172184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8172184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
ANCHOR,7925798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
ANCHOR,7925798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
CAGE,8172219,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8334.00000,2416.86000,Aetna,First Health,,6817.21,,,,,,,3004.41,6817.21,percent of total billed charges,
CAGE,8172219,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8334.00000,2416.86000,Aetna,First Health,,6817.21,,,,,,,2683.55,6817.21,percent of total billed charges,
BASEPLATE,8172221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,8172221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
INSERT,8172223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8172223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8172225,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8172225,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
SCREW,8173847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8173847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8173849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8173849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8173851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8173851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
BOLT,8180844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,475.87,1079.79,percent of total billed charges,
BOLT,8180844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,425.05,1079.79,percent of total billed charges,
ROD SPINAL,8173854,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
ROD SPINAL,8173854,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
HEAD FEMORAL,8173856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8173856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
GLENOID,8173858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31879.80000,9245.14000,Aetna,First Health,,26077.68,,,,,,,11492.67,26077.68,percent of total billed charges,
GLENOID,8173858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31879.80000,9245.14000,Aetna,First Health,,26077.68,,,,,,,10265.30,26077.68,percent of total billed charges,
PLATE,8173860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
PLATE,8173860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
BASEPLATE,8173866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5935.93000,1721.42000,Aetna,First Health,,4855.59,,,,,,,2139.90,4855.59,percent of total billed charges,
BASEPLATE,8173866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5935.93000,1721.42000,Aetna,First Health,,4855.59,,,,,,,1911.37,4855.59,percent of total billed charges,
SCREW,8173867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8173867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
SCREW,8173868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8173868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
COMPONENT GLENOID,8173869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,1075.11,2439.51,percent of total billed charges,
COMPONENT GLENOID,8173869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,960.29,2439.51,percent of total billed charges,
SCREW,8173870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8173870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
SCREW,8173871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8173871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
STEM,8173872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9705.00000,2814.45000,Aetna,First Health,,7938.69,,,,,,,3498.65,7938.69,percent of total billed charges,
STEM,8173872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9705.00000,2814.45000,Aetna,First Health,,7938.69,,,,,,,3125.01,7938.69,percent of total billed charges,
GLENOSPHERE,8173873,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,2224.35,5047.22,percent of total billed charges,
GLENOSPHERE,8173873,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,1986.80,5047.22,percent of total billed charges,
CUP HUMERAL,8173874,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.58000,1439.73000,Aetna,First Health,,4061.03,,,,,,,1789.73,4061.03,percent of total billed charges,
CUP HUMERAL,8173874,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.58000,1439.73000,Aetna,First Health,,4061.03,,,,,,,1598.59,4061.03,percent of total billed charges,
SCREW,8173875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8173875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
LINER,8181501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,8181501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SHELL,8173876,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,8173876,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
WEDGE,8173877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6210.33000,1801.00000,Aetna,First Health,,5080.05,,,,,,,2238.82,5080.05,percent of total billed charges,
WEDGE,8173877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6210.33000,1801.00000,Aetna,First Health,,5080.05,,,,,,,1999.73,5080.05,percent of total billed charges,
SHELL,8173878,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,8173878,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
ROD SPINAL,8173879,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8173879,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SPACER,8173880,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SPACER,8173880,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
COMPONENT FEMORAL,8173881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
COMPONENT FEMORAL,8173881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
STEM,8173882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2970.88,6741.14,percent of total billed charges,
STEM,8173882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2653.60,6741.14,percent of total billed charges,
SCREW,8173883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8173883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
STEM,8173884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,8173884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
PLATE,8180843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3080.08000,893.22000,Aetna,First Health,,2519.51,,,,,,,1110.37,2519.51,percent of total billed charges,
PLATE,8180843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3080.08000,893.22000,Aetna,First Health,,2519.51,,,,,,,991.79,2519.51,percent of total billed charges,
SCREW,8180845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,8180845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
IMPLANT BREAST,8181458,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
IMPLANT BREAST,8181458,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
SCREW,8181456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,475.87,1079.79,percent of total billed charges,
SCREW,8181456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,425.05,1079.79,percent of total billed charges,
STEM,8181459,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,8181459,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
COMPONENT FEMORAL,8181460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,4351.96,9874.90,percent of total billed charges,
COMPONENT FEMORAL,8181460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,3887.18,9874.90,percent of total billed charges,
STEM,8181461,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM,8181461,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
INSERT,8181462,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
INSERT,8181462,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
PLATE,8181463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1847.20,4191.43,percent of total billed charges,
PLATE,8181463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1649.93,4191.43,percent of total billed charges,
PLATE,8181464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5488.28000,1591.60000,Aetna,First Health,,4489.41,,,,,,,1978.52,4489.41,percent of total billed charges,
PLATE,8181464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5488.28000,1591.60000,Aetna,First Health,,4489.41,,,,,,,1767.23,4489.41,percent of total billed charges,
ROD SPINAL,8181465,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8181465,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SCREW,8181466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8181466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
SCREW,8181467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8181467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
SCREW,8181468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8181468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
SPACER HUMERAL,8181469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,865.20,1963.20,percent of total billed charges,
SPACER HUMERAL,8181469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,772.80,1963.20,percent of total billed charges,
WEDGE,8181476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8907.24000,2583.10000,Aetna,First Health,,7286.12,,,,,,,3211.06,7286.12,percent of total billed charges,
WEDGE,8181476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8907.24000,2583.10000,Aetna,First Health,,7286.12,,,,,,,2868.13,7286.12,percent of total billed charges,
NAIL,8181608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,8181608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
ROD SPINAL,8181609,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8181609,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8181610,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
CAGE,8181610,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
SCREW,8181611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8181611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
ROD SPINAL,8181612,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8181612,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,8181648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8181648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
COMPONENT GLENOID,8181837,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,1075.11,2439.51,percent of total billed charges,
COMPONENT GLENOID,8181837,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,960.29,2439.51,percent of total billed charges,
BASEPLATE,8181649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5935.93000,1721.42000,Aetna,First Health,,4855.59,,,,,,,2139.90,4855.59,percent of total billed charges,
BASEPLATE,8181649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5935.93000,1721.42000,Aetna,First Health,,4855.59,,,,,,,1911.37,4855.59,percent of total billed charges,
STEM,8181651,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,8181651,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
INSERT,8181839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
INSERT,8181839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
STEM,8181841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
STEM,8181841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
SCREW,8181916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8181916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ROD SPINAL,8181917,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8181917,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ROD,8181968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD,8181968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW,8181970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8181970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,8181972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8181972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
INSERT,8182193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2826.49,6413.50,percent of total billed charges,
INSERT,8182193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,First Health,,6413.50,,,,,,,2524.63,6413.50,percent of total billed charges,
INSERT,8182195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25666.15000,7443.18000,Aetna,First Health,,20994.91,,,,,,,9252.65,20994.91,percent of total billed charges,
INSERT,8182195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25666.15000,7443.18000,Aetna,First Health,,20994.91,,,,,,,8264.50,20994.91,percent of total billed charges,
BREAST IMPLANT,8204015,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
BREAST IMPLANT,8204015,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
INSERT,8213968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,8213968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
CAGE,8213970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,8213970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
CAGE,8213972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,8213972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
SCREW,8213974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8213974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,8213976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,761.40000,220.81000,Aetna,First Health,,622.83,,,,,,,274.48,622.83,percent of total billed charges,
SCREW,8213976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,761.40000,220.81000,Aetna,First Health,,622.83,,,,,,,245.17,622.83,percent of total billed charges,
SCREW,8214063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,8214063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
SCREW,8214065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,8214065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
SCREW,8214067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8214067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,8215236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,8215236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
ROD SPINAL,8215238,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2091.92000,606.66000,Aetna,First Health,,1711.19,,,,,,,754.14,1711.19,percent of total billed charges,
ROD SPINAL,8215238,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2091.92000,606.66000,Aetna,First Health,,1711.19,,,,,,,673.60,1711.19,percent of total billed charges,
SCREW,8215240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8215240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
WEDGE,8215243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE,8215243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
STEM,8215245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8215245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,8215247,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8215247,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
PLATE,8218496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8218496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8222112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,8222112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
SCREW,8222114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,8222114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
GUIDEWIRE,8222116,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
GUIDEWIRE,8222116,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CAGE,8222118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8222118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
INSERT,8223967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8223967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
ROD SPINAL,8223969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8223969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
CAGE,8223971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8223971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
TAPER,8223988,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,864.00000,250.56000,Aetna,First Health,,706.75,,,,,,,311.47,706.75,percent of total billed charges,
TAPER,8223988,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,864.00000,250.56000,Aetna,First Health,,706.75,,,,,,,278.21,706.75,percent of total billed charges,
SCREW,8224024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,370.50000,107.44000,Aetna,First Health,,303.07,,,,,,,133.57,303.07,percent of total billed charges,
SCREW,8224024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,370.50000,107.44000,Aetna,First Health,,303.07,,,,,,,119.30,303.07,percent of total billed charges,
PLATE,8224026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
PLATE,8224026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
CONNECTOR SPINAL,8224027,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2584.00000,749.36000,Aetna,First Health,,2113.71,,,,,,,931.53,2113.71,percent of total billed charges,
CONNECTOR SPINAL,8224027,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2584.00000,749.36000,Aetna,First Health,,2113.71,,,,,,,832.05,2113.71,percent of total billed charges,
PLATE,8224029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12702.00000,3683.58000,Aetna,First Health,,10390.24,,,,,,,4579.07,10390.24,percent of total billed charges,
PLATE,8224029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12702.00000,3683.58000,Aetna,First Health,,10390.24,,,,,,,4090.04,10390.24,percent of total billed charges,
PLATE,8224031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12702.00000,3683.58000,Aetna,First Health,,10390.24,,,,,,,4579.07,10390.24,percent of total billed charges,
PLATE,8224031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12702.00000,3683.58000,Aetna,First Health,,10390.24,,,,,,,4090.04,10390.24,percent of total billed charges,
COMPONENT FEMORAL,8224117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25225.20000,7315.31000,Aetna,First Health,,20634.21,,,,,,,9093.68,20634.21,percent of total billed charges,
COMPONENT FEMORAL,8224117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25225.20000,7315.31000,Aetna,First Health,,20634.21,,,,,,,8122.51,20634.21,percent of total billed charges,
INSERT,8224119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2956.98,6709.60,percent of total billed charges,
INSERT,8224119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2641.19,6709.60,percent of total billed charges,
WEDGE,8224121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,8224121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
STEM,8224123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8224123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PLATE,8224125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8224125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
LEAD NEURO STIM,8224131,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,6492.50000,1882.82000,Aetna,First Health,,5310.86,,,,,,,2340.55,5310.86,percent of total billed charges,
LEAD NEURO STIM,8224131,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,6492.50000,1882.82000,Aetna,First Health,,5310.86,,,,,,,2090.59,5310.86,percent of total billed charges,
SHEATH,8224132,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SHEATH,8224132,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SHEATH,8224133,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SHEATH,8224133,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
NAIL,8225827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8225827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,8225829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8225829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
STEM,8225831,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,8225831,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CONNECTOR SPINAL,8225833,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,1106.01,2509.62,percent of total billed charges,
CONNECTOR SPINAL,8225833,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,987.90,2509.62,percent of total billed charges,
SCREW,8225835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8225835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
STEM,8225840,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8225840,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
HEAD FEMORAL,8225841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
HEAD FEMORAL,8225841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,8225893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8225893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,8225894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8225894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,8225895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5198.20000,1507.48000,Aetna,First Health,,4252.13,,,,,,,1873.95,4252.13,percent of total billed charges,
SCREW,8225895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5198.20000,1507.48000,Aetna,First Health,,4252.13,,,,,,,1673.82,4252.13,percent of total billed charges,
STEM,8225896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM,8225896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
COMPONENT FEMORAL,8225897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4515.97,10247.05,percent of total billed charges,
COMPONENT FEMORAL,8225897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4033.68,10247.05,percent of total billed charges,
SCREW,8225898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,8225898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW,8225899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW,8225899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
NAIL,8225900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2903.18,6587.52,percent of total billed charges,
NAIL,8225900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2593.13,6587.52,percent of total billed charges,
CAGE SPINAL,8225903,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14550.00000,4219.50000,Aetna,First Health,,11901.90,,,,,,,5245.27,11901.90,percent of total billed charges,
CAGE SPINAL,8225903,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14550.00000,4219.50000,Aetna,First Health,,11901.90,,,,,,,4685.10,11901.90,percent of total billed charges,
CONNECTOR SPINAL,8225904,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5502.00000,1595.58000,Aetna,First Health,,4500.64,,,,,,,1983.47,4500.64,percent of total billed charges,
CONNECTOR SPINAL,8225904,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5502.00000,1595.58000,Aetna,First Health,,4500.64,,,,,,,1771.64,4500.64,percent of total billed charges,
CONNECTOR SPINAL,8225905,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5502.00000,1595.58000,Aetna,First Health,,4500.64,,,,,,,1983.47,4500.64,percent of total billed charges,
CONNECTOR SPINAL,8225905,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5502.00000,1595.58000,Aetna,First Health,,4500.64,,,,,,,1771.64,4500.64,percent of total billed charges,
CONNECTOR SPINAL,8225906,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
CONNECTOR SPINAL,8225906,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
CONNECTOR SPINAL,8225907,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
CONNECTOR SPINAL,8225907,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
CONNECTOR SPINAL,8225908,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
CONNECTOR SPINAL,8225908,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
PIN,8225992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
PIN,8225992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
PIN,8225994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
PIN,8225994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
PLATE,8225996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2650.40000,768.62000,Aetna,First Health,,2168.03,,,,,,,955.47,2168.03,percent of total billed charges,
PLATE,8225996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2650.40000,768.62000,Aetna,First Health,,2168.03,,,,,,,853.43,2168.03,percent of total billed charges,
SCREW,8225998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW,8225998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
SCREW,8226000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW,8226000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
INSERT,8226002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3465.42000,1004.97000,Aetna,First Health,,2834.71,,,,,,,1249.28,2834.71,percent of total billed charges,
INSERT,8226002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3465.42000,1004.97000,Aetna,First Health,,2834.71,,,,,,,1115.87,2834.71,percent of total billed charges,
HEAD FEMORAL,8226004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
HEAD FEMORAL,8226004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
LINER,8226006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,8226006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
STEM,8226008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM,8226008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
SHELL,8226010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3475.94,7887.16,percent of total billed charges,
SHELL,8226010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3104.72,7887.16,percent of total billed charges,
NAIL,8226012,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,8226012,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
STEM,8226014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM,8226014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,8226018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,266.29,604.24,percent of total billed charges,
SCREW,8226018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,237.85,604.24,percent of total billed charges,
SCREW,8226019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,266.29,604.24,percent of total billed charges,
SCREW,8226019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,237.85,604.24,percent of total billed charges,
STEM,8226020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4609.35,10458.95,percent of total billed charges,
STEM,8226020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4117.09,10458.95,percent of total billed charges,
STENT,8227867,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8227867,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
NAIL,8227868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1803.80,4092.94,percent of total billed charges,
NAIL,8227868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1611.16,4092.94,percent of total billed charges,
STEM,8228014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8228014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SCREW,8228016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8228016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
ROD,8228018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
ROD,8228018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
CAGE,8228020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8334.00000,2416.86000,Aetna,First Health,,6817.21,,,,,,,3004.41,6817.21,percent of total billed charges,
CAGE,8228020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8334.00000,2416.86000,Aetna,First Health,,6817.21,,,,,,,2683.55,6817.21,percent of total billed charges,
SCREW,8228022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8228022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8228024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8228024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8228026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8228026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
INSERT,8228028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8228028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
STEM,8228030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8228030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
STEM,8228149,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,8228149,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
GLENOSPHERE,8228150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,2224.35,5047.22,percent of total billed charges,
GLENOSPHERE,8228150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,1986.80,5047.22,percent of total billed charges,
INSERT,8228212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8228212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8228214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8228214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
SHELL,8228216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,8228216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
INSERT,8228224,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3465.42000,1004.97000,Aetna,First Health,,2834.71,,,,,,,1249.28,2834.71,percent of total billed charges,
INSERT,8228224,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3465.42000,1004.97000,Aetna,First Health,,2834.71,,,,,,,1115.87,2834.71,percent of total billed charges,
CAGE,8228218,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
CAGE,8228218,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
SCREW,8228225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8228225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
PLATE,8228368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5675.67000,1645.94000,Aetna,First Health,,4642.70,,,,,,,2046.08,4642.70,percent of total billed charges,
PLATE,8228368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5675.67000,1645.94000,Aetna,First Health,,4642.70,,,,,,,1827.57,4642.70,percent of total billed charges,
INSERT,8228370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8228370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8228397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2802.84000,812.82000,Aetna,First Health,,2292.72,,,,,,,1010.42,2292.72,percent of total billed charges,
PLATE,8228397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2802.84000,812.82000,Aetna,First Health,,2292.72,,,,,,,902.51,2292.72,percent of total billed charges,
PLATE,8228399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2497.96000,724.41000,Aetna,First Health,,2043.33,,,,,,,900.51,2043.33,percent of total billed charges,
PLATE,8228399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2497.96000,724.41000,Aetna,First Health,,2043.33,,,,,,,804.34,2043.33,percent of total billed charges,
SCREW,8228401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW,8228401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
SCREW,8228403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,266.29,604.24,percent of total billed charges,
SCREW,8228403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,237.85,604.24,percent of total billed charges,
NAIL,8228405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8228405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
STEM,8228409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18861.60000,5469.86000,Aetna,First Health,,15428.79,,,,,,,6799.61,15428.79,percent of total billed charges,
STEM,8228409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18861.60000,5469.86000,Aetna,First Health,,15428.79,,,,,,,6073.44,15428.79,percent of total billed charges,
SCREW,8228474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,8228474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
INSERT,8228476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8228476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
SHELL,8228478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,4027.94,9139.68,percent of total billed charges,
SHELL,8228478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,3597.77,9139.68,percent of total billed charges,
STEM,8228480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8228480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,8228482,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8228482,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
INSERT,8228546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8228546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
NAIL,8228552,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,8228552,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
SHELL,8228554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8228554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
COMPONENT FEMORAL,8228582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,8228582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
SCREW,8228584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8228584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8228586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8228586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ROD,8228588,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
ROD,8228588,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8229042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8229042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,8228653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,8228653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
PLATE,8228655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1151.87,2613.67,percent of total billed charges,
PLATE,8228655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1028.85,2613.67,percent of total billed charges,
SPACER,8228884,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
SPACER,8228884,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
SCREW,8228887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8228887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
SCREW,8228889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8228889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
SCREW,8228891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8228891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
ROD SPINAL,8228893,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8228893,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW,8228895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8228895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
PLATE,8228897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2760.60000,800.57000,Aetna,First Health,,2258.17,,,,,,,995.20,2258.17,percent of total billed charges,
PLATE,8228897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2760.60000,800.57000,Aetna,First Health,,2258.17,,,,,,,888.91,2258.17,percent of total billed charges,
SCREW,8228899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,303.91000,88.13000,Aetna,First Health,,248.60,,,,,,,109.56,248.60,percent of total billed charges,
SCREW,8228899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,303.91000,88.13000,Aetna,First Health,,248.60,,,,,,,97.86,248.60,percent of total billed charges,
SCREW,8229041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8229041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,8229037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8229037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,8229039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8229039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
SCREW,8229043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8229043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
SCREW,8229044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8229044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
SCREW,8229045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8229045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
PLATE,8229046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8786.25000,2548.01000,Aetna,First Health,,7187.15,,,,,,,3167.44,7187.15,percent of total billed charges,
PLATE,8229046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8786.25000,2548.01000,Aetna,First Health,,7187.15,,,,,,,2829.17,7187.15,percent of total billed charges,
SCREW,8229047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8229047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
SCREW,8229100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8229100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8229101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8229101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8229102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8229102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8229105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,8229105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
FEMORAL CONE,8229106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
FEMORAL CONE,8229106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
SCREW,8229103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8229103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
PLATE,8229256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1562.00000,452.98000,Aetna,First Health,,1277.72,,,,,,,563.10,1277.72,percent of total billed charges,
PLATE,8229256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1562.00000,452.98000,Aetna,First Health,,1277.72,,,,,,,502.96,1277.72,percent of total billed charges,
PLATE,8229254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.33000,110.30000,Aetna,First Health,,311.11,,,,,,,137.11,311.11,percent of total billed charges,
PLATE,8229254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.33000,110.30000,Aetna,First Health,,311.11,,,,,,,122.47,311.11,percent of total billed charges,
SCREW,7703078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
SCREW,7703078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
INSERT,8229924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9426.00000,2733.54000,Aetna,First Health,,7710.47,,,,,,,3398.07,7710.47,percent of total billed charges,
INSERT,8229924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9426.00000,2733.54000,Aetna,First Health,,7710.47,,,,,,,3035.17,7710.47,percent of total billed charges,
CONNECTOR SPINAL,8230051,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,1106.01,2509.62,percent of total billed charges,
CONNECTOR SPINAL,8230051,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,987.90,2509.62,percent of total billed charges,
ALLOGRAFT,8230053,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,11580.00000,3358.20000,Aetna,First Health,,9472.44,,,,,,,4174.59,9472.44,percent of total billed charges,
ALLOGRAFT,8230053,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,11580.00000,3358.20000,Aetna,First Health,,9472.44,,,,,,,3728.76,9472.44,percent of total billed charges,
COMPONENT FEMORAL,8230054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,8230054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
COMPONENT TIBIAL,8230057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,8230057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
CAGE,8230060,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8230060,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,8230062,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8230062,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
CATHETER HEMODIALYSIS,8230373,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
CATHETER HEMODIALYSIS,8230373,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
SCREW,8230375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,8230375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,8230377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,8230377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,8230379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,8230379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,8230381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,8230381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
PLATE,8230383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,684.00000,198.36000,Aetna,First Health,,559.51,,,,,,,246.58,559.51,percent of total billed charges,
PLATE,8230383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,684.00000,198.36000,Aetna,First Health,,559.51,,,,,,,220.25,559.51,percent of total billed charges,
CAGE,8230909,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,8230909,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
INSERT,8230923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8230923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT PATELLAR,8230911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
COMPONENT PATELLAR,8230911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,8230913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8230913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT FEMORAL,8230915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,8230915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
COMPONENT FEMORAL,8230918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,8230918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
STEM,8230921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8230921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SHELL,8231122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,8231122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
STEM,8231124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8231124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW,8231126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8231126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
ROD SPINAL,8231128,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8231128,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
HUMERAL TRAY,8231433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
HUMERAL TRAY,8231433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
STEM,8231434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,8231434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
PLATE,8231435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,8231435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
GRAFTLINK,8231589,CDM,278,RC,,,,,facility,inpatient,,,9135.60000,2649.32000,Aetna,First Health,,7472.92,,,,,,,3293.38,7472.92,percent of total billed charges,
GRAFTLINK,8231589,CDM,278,RC,,,,,facility,outpatient,,,9135.60000,2649.32000,Aetna,First Health,,7472.92,,,,,,,2941.66,7472.92,percent of total billed charges,
INSERT,8231590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8231590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8231594,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8231594,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
SCREW,8231596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1377.28000,399.41000,Aetna,First Health,,1126.62,,,,,,,496.51,1126.62,percent of total billed charges,
SCREW,8231596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1377.28000,399.41000,Aetna,First Health,,1126.62,,,,,,,443.48,1126.62,percent of total billed charges,
PLATE,8231598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10003.80000,2901.10000,Aetna,First Health,,8183.11,,,,,,,3606.37,8183.11,percent of total billed charges,
PLATE,8231598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10003.80000,2901.10000,Aetna,First Health,,8183.11,,,,,,,3221.22,8183.11,percent of total billed charges,
SCREW,8231600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,619.79000,179.74000,Aetna,First Health,,506.99,,,,,,,223.43,506.99,percent of total billed charges,
SCREW,8231600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,619.79000,179.74000,Aetna,First Health,,506.99,,,,,,,199.57,506.99,percent of total billed charges,
SCREW,8231602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1377.28000,399.41000,Aetna,First Health,,1126.62,,,,,,,496.51,1126.62,percent of total billed charges,
SCREW,8231602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1377.28000,399.41000,Aetna,First Health,,1126.62,,,,,,,443.48,1126.62,percent of total billed charges,
ROD SPINAL,8231604,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3211.25000,931.26000,Aetna,First Health,,2626.80,,,,,,,1157.66,2626.80,percent of total billed charges,
ROD SPINAL,8231604,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3211.25000,931.26000,Aetna,First Health,,2626.80,,,,,,,1034.02,2626.80,percent of total billed charges,
CAGE,8231606,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8304.00000,2408.16000,Aetna,First Health,,6792.67,,,,,,,2993.59,6792.67,percent of total billed charges,
CAGE,8231606,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8304.00000,2408.16000,Aetna,First Health,,6792.67,,,,,,,2673.89,6792.67,percent of total billed charges,
ROD SPINAL,8231608,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8231608,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
GRAFT STENT,8231610,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,First Health,,41219.35,,,,,,,18165.74,41219.35,percent of total billed charges,
GRAFT STENT,8231610,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,First Health,,41219.35,,,,,,,16225.71,41219.35,percent of total billed charges,
GRAFT STENT,8231612,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53270.40000,15448.42000,Aetna,First Health,,43575.19,,,,,,,19203.98,43575.19,percent of total billed charges,
GRAFT STENT,8231612,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53270.40000,15448.42000,Aetna,First Health,,43575.19,,,,,,,17153.07,43575.19,percent of total billed charges,
INSERT,8231592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8231592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
SCREW,8231615,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.60000,90.94000,Aetna,First Health,,256.52,,,,,,,113.05,256.52,percent of total billed charges,
SCREW,8231615,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.60000,90.94000,Aetna,First Health,,256.52,,,,,,,100.98,256.52,percent of total billed charges,
SCREW,8231743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8231743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SPACER,8231843,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
SPACER,8231843,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
PLATE,8231844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1174.18,2664.31,percent of total billed charges,
PLATE,8231844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,First Health,,2664.31,,,,,,,1048.79,2664.31,percent of total billed charges,
NAIL,8231845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1803.80,4092.94,percent of total billed charges,
NAIL,8231845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1611.16,4092.94,percent of total billed charges,
BLADE FOR NAIL,8231846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,700.74,1590.03,percent of total billed charges,
BLADE FOR NAIL,8231846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,625.90,1590.03,percent of total billed charges,
ANCHOR,8231877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3213.00000,931.77000,Aetna,First Health,,2628.23,,,,,,,1158.29,2628.23,percent of total billed charges,
ANCHOR,8231877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3213.00000,931.77000,Aetna,First Health,,2628.23,,,,,,,1034.59,2628.23,percent of total billed charges,
ANCHOR,8231881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2756.60000,799.41000,Aetna,First Health,,2254.90,,,,,,,993.75,2254.90,percent of total billed charges,
ANCHOR,8231881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2756.60000,799.41000,Aetna,First Health,,2254.90,,,,,,,887.63,2254.90,percent of total billed charges,
SPACER HUMERAL,8231887,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,865.20,1963.20,percent of total billed charges,
SPACER HUMERAL,8231887,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,772.80,1963.20,percent of total billed charges,
SCREW,8231891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,8231891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
PLATE,8231923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4136.27000,1199.52000,Aetna,First Health,,3383.47,,,,,,,1491.13,3383.47,percent of total billed charges,
PLATE,8231923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4136.27000,1199.52000,Aetna,First Health,,3383.47,,,,,,,1331.88,3383.47,percent of total billed charges,
SCREW,8231925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,303.91000,88.13000,Aetna,First Health,,248.60,,,,,,,109.56,248.60,percent of total billed charges,
SCREW,8231925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,303.91000,88.13000,Aetna,First Health,,248.60,,,,,,,97.86,248.60,percent of total billed charges,
PLATE,8231927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.20000,348.06000,Aetna,First Health,,981.76,,,,,,,432.67,981.76,percent of total billed charges,
PLATE,8231927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.20000,348.06000,Aetna,First Health,,981.76,,,,,,,386.46,981.76,percent of total billed charges,
STEM,8231929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,8231929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
SCREW,8231959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8231959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
SCREW,8231961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8231961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
INSERT,8231963,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8231963,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8231985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8231985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
CONNECTOR SPINAL,8231986,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2264.00000,656.56000,Aetna,First Health,,1851.95,,,,,,,816.17,1851.95,percent of total billed charges,
CONNECTOR SPINAL,8231986,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2264.00000,656.56000,Aetna,First Health,,1851.95,,,,,,,729.01,1851.95,percent of total billed charges,
SCREW,8232032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SCREW,8232032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SCREW,8232033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SCREW,8232033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
CAGE,8231987,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8231987,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
SCREW,8231988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8231988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
SPACER SPINAL,8231989,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
SPACER SPINAL,8231989,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
SCREW,8231990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8231990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8231991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8231991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
COMPONENT FEMORAL,8231992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,8231992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SHELL,8232034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
SHELL,8232034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
BUTTON SEPTAL,8232141,CDM,278,RC,L8047,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,201.16,456.44,percent of total billed charges,
BUTTON SEPTAL,8232141,CDM,278,RC,L8047,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,179.68,1561.74,percent of total billed charges,
BASEPLATE,8232143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
BASEPLATE,8232143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,8232145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8232145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE,8232147,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1303.16000,377.92000,Aetna,First Health,,1065.98,,,,,,,469.79,1065.98,percent of total billed charges,
PLATE,8232147,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1303.16000,377.92000,Aetna,First Health,,1065.98,,,,,,,419.62,1065.98,percent of total billed charges,
SCREW,8232231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SCREW,8232231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SCREW,8232232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SCREW,8232232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
ROD SPINAL,8232233,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2676.00000,776.04000,Aetna,First Health,,2188.97,,,,,,,964.70,2188.97,percent of total billed charges,
ROD SPINAL,8232233,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2676.00000,776.04000,Aetna,First Health,,2188.97,,,,,,,861.67,2188.97,percent of total billed charges,
SCREW,8232235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8232235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8232237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SCREW,8232237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SCREW,8232239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8232239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CAGE,8232240,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8232240,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CAGE,8232241,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8232241,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CAGE,8232242,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8304.00000,2408.16000,Aetna,First Health,,6792.67,,,,,,,2993.59,6792.67,percent of total billed charges,
CAGE,8232242,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8304.00000,2408.16000,Aetna,First Health,,6792.67,,,,,,,2673.89,6792.67,percent of total billed charges,
SCREW,7695494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,228.66,518.84,percent of total billed charges,
SCREW,7695494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,First Health,,518.84,,,,,,,204.24,518.84,percent of total billed charges,
PLATE,8232243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1631.80000,473.22000,Aetna,First Health,,1334.81,,,,,,,588.26,1334.81,percent of total billed charges,
PLATE,8232243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1631.80000,473.22000,Aetna,First Health,,1334.81,,,,,,,525.44,1334.81,percent of total billed charges,
STEM,8232244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,8232244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
HEAD FEMORAL,8232245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8232245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW,8232346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8232346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8232347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8232347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,8232348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8232348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,8232349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8232349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8232516,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8232516,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
PEG,8232350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8232350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PEG,8232351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8232351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PEG,8232352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8232352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PEG,8232353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8232353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PEG,8232354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8232354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
INSERT,8232355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8232355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8232356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8232356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8232357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8232357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
SHELL,8232358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,8232358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
COMPONENT FEMORAL,8232359,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
COMPONENT FEMORAL,8232359,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
SHELL,8232360,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,8232360,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
PLATE,8232502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5894.70000,1709.46000,Aetna,First Health,,4821.86,,,,,,,2125.04,4821.86,percent of total billed charges,
PLATE,8232502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5894.70000,1709.46000,Aetna,First Health,,4821.86,,,,,,,1898.09,4821.86,percent of total billed charges,
K WIRE,8232504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,51.10,115.95,percent of total billed charges,
K WIRE,8232504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,First Health,,115.95,,,,,,,45.64,115.95,percent of total billed charges,
INSERT,8232506,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8232506,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8232508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8232508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
PLATE,8232510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5864.57000,1700.73000,Aetna,First Health,,4797.22,,,,,,,2114.18,4797.22,percent of total billed charges,
PLATE,8232510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5864.57000,1700.73000,Aetna,First Health,,4797.22,,,,,,,1888.39,4797.22,percent of total billed charges,
STENT,8232517,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
STENT,8232517,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
STENT,8232513,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
STENT,8232513,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
STENT,8232515,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
STENT,8232515,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
STENT,8232514,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
STENT,8232514,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
STENT,8232518,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,322.39,731.53,percent of total billed charges,
STENT,8232518,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,287.96,731.53,percent of total billed charges,
STENT,8232519,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,322.39,731.53,percent of total billed charges,
STENT,8232519,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,287.96,731.53,percent of total billed charges,
STENT,8232520,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,322.39,731.53,percent of total billed charges,
STENT,8232520,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,287.96,731.53,percent of total billed charges,
STENT,8232521,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,322.39,731.53,percent of total billed charges,
STENT,8232521,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,287.96,731.53,percent of total billed charges,
SCREW,8232618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8232618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SPACER,8232620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SPACER,8232620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
STEM,8232622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,8232622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STEM,8232624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
STEM,8232624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
SHELL,8232626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,4027.94,9139.68,percent of total billed charges,
SHELL,8232626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,First Health,,9139.68,,,,,,,3597.77,9139.68,percent of total billed charges,
STEM,8232628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,8232628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
GUIDEWIRE,8232630,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,898.09000,260.45000,Aetna,First Health,,734.64,,,,,,,323.76,734.64,percent of total billed charges,
GUIDEWIRE,8232630,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,898.09000,260.45000,Aetna,First Health,,734.64,,,,,,,289.18,734.64,percent of total billed charges,
ROD SPINAL,8234068,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
ROD SPINAL,8234068,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
INSERT,8234070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8234070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
PLATE,8234093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1469.63,3334.68,percent of total billed charges,
PLATE,8234093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1312.67,3334.68,percent of total billed charges,
SCREW,8234094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8234094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8234095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8234095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
K WIRE,7700885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
K WIRE,7700885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
K WIRE,7993541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,442.75000,128.40000,Aetna,First Health,,362.17,,,,,,,159.61,362.17,percent of total billed charges,
K WIRE,7993541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,442.75000,128.40000,Aetna,First Health,,362.17,,,,,,,142.57,362.17,percent of total billed charges,
PLATE,8234142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3921.37000,1137.20000,Aetna,First Health,,3207.68,,,,,,,1413.65,3207.68,percent of total billed charges,
PLATE,8234142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3921.37000,1137.20000,Aetna,First Health,,3207.68,,,,,,,1262.68,3207.68,percent of total billed charges,
PLATE,8234144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3921.37000,1137.20000,Aetna,First Health,,3207.68,,,,,,,1413.65,3207.68,percent of total billed charges,
PLATE,8234144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3921.37000,1137.20000,Aetna,First Health,,3207.68,,,,,,,1262.68,3207.68,percent of total billed charges,
CAGE,8234146,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8234146,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
SCREW,8234148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW,8234148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
SCREW,8234150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW,8234150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
BASEPLATE,8234152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
BASEPLATE,8234152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
ANCHOR STAPLE,8234139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3644.38,8269.37,percent of total billed charges,
ANCHOR STAPLE,8234139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3255.18,8269.37,percent of total billed charges,
PLATE,8236008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3089.84000,896.05000,Aetna,First Health,,2527.49,,,,,,,1113.89,2527.49,percent of total billed charges,
PLATE,8236008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3089.84000,896.05000,Aetna,First Health,,2527.49,,,,,,,994.93,2527.49,percent of total billed charges,
PLATE,8236010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4486.23000,1301.01000,Aetna,First Health,,3669.74,,,,,,,1617.29,3669.74,percent of total billed charges,
PLATE,8236010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4486.23000,1301.01000,Aetna,First Health,,3669.74,,,,,,,1444.57,3669.74,percent of total billed charges,
STEM,8236012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,8236012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
ANCHOR,8236014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1734.59,3935.91,percent of total billed charges,
ANCHOR,8236014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1549.34,3935.91,percent of total billed charges,
ANCHOR,8236016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5914.13000,1715.10000,Aetna,First Health,,4837.76,,,,,,,2132.04,4837.76,percent of total billed charges,
ANCHOR,8236016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5914.13000,1715.10000,Aetna,First Health,,4837.76,,,,,,,1904.35,4837.76,percent of total billed charges,
SCREW,8236564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW,8236564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
SCREW,8236485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8236485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
PLATE,8236486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8236486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE,8237199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,3076.87,6981.63,percent of total billed charges,
PLATE,8237199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,First Health,,6981.63,,,,,,,2748.27,6981.63,percent of total billed charges,
SCREW,8237201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,8237201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
CAGE,8237203,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
CAGE,8237203,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
STENT,8237205,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,772.88000,224.14000,Aetna,First Health,,632.22,,,,,,,278.62,632.22,percent of total billed charges,
STENT,8237205,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,772.88000,224.14000,Aetna,First Health,,632.22,,,,,,,248.87,632.22,percent of total billed charges,
STENT,8237209,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
STENT,8237209,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
STEM,8237249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM,8237249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
AUGMENT FEMORAL,8237251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,8237251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
INSERT,8237253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8237253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
ANCHOR,8237277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2968.72,6736.23,percent of total billed charges,
ANCHOR,8237277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2651.67,6736.23,percent of total billed charges,
ANCHOR,8237278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
ANCHOR,8237278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
ANCHOR,8237279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
ANCHOR,8237279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
ANCHOR,8237280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
ANCHOR,8237280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
ANCHOR,8237281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
ANCHOR,8237281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
KIT MENISCAL ROOT SPACER INCLUDED IN KIT,8237287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4444.13000,1288.80000,Aetna,First Health,,3635.30,,,,,,,1602.11,3635.30,percent of total billed charges,
KIT MENISCAL ROOT SPACER INCLUDED IN KIT,8237287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4444.13000,1288.80000,Aetna,First Health,,3635.30,,,,,,,1431.01,3635.30,percent of total billed charges,
SCREW,8237400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8237400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
ROD SPINAL,8237402,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
ROD SPINAL,8237402,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
NAIL,8237404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8237404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
ROD SPINAL,8238042,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
ROD SPINAL,8238042,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,8238044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SCREW,8238044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,8238046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5320.00000,1542.80000,Aetna,First Health,,4351.76,,,,,,,1917.86,4351.76,percent of total billed charges,
SCREW,8238046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5320.00000,1542.80000,Aetna,First Health,,4351.76,,,,,,,1713.04,4351.76,percent of total billed charges,
SCREW,8238048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SCREW,8238048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,8134359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8134359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
STEM,8134361,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3184.00000,923.36000,Aetna,First Health,,2604.51,,,,,,,1147.83,2604.51,percent of total billed charges,
STEM,8134361,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3184.00000,923.36000,Aetna,First Health,,2604.51,,,,,,,1025.25,2604.51,percent of total billed charges,
INSERT,8134365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3213.00000,931.77000,Aetna,First Health,,2628.23,,,,,,,1158.29,2628.23,percent of total billed charges,
INSERT,8134365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3213.00000,931.77000,Aetna,First Health,,2628.23,,,,,,,1034.59,2628.23,percent of total billed charges,
STEM,8134371,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7746.00000,2246.34000,Aetna,First Health,,6336.23,,,,,,,2792.43,6336.23,percent of total billed charges,
STEM,8134371,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7746.00000,2246.34000,Aetna,First Health,,6336.23,,,,,,,2494.21,6336.23,percent of total billed charges,
INSERT,8134373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8134373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
ROD SPINAL,8134375,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,533.11,1209.66,percent of total billed charges,
ROD SPINAL,8134375,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,First Health,,1209.66,,,,,,,476.17,1209.66,percent of total billed charges,
CAGE,8134379,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12267.00000,3557.43000,Aetna,First Health,,10034.41,,,,,,,4422.25,10034.41,percent of total billed charges,
CAGE,8134379,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12267.00000,3557.43000,Aetna,First Health,,10034.41,,,,,,,3949.97,10034.41,percent of total billed charges,
SCREW,8134381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
SCREW,8134381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
ROD,8134924,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,536.42,1217.18,percent of total billed charges,
ROD,8134924,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,479.14,1217.18,percent of total billed charges,
SCREW,8134926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8134926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
ROD,8134927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2304.00000,668.16000,Aetna,First Health,,1884.67,,,,,,,830.59,1884.67,percent of total billed charges,
ROD,8134927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2304.00000,668.16000,Aetna,First Health,,1884.67,,,,,,,741.89,1884.67,percent of total billed charges,
SCREW,8134929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW,8134929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW,8136312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8136312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
INSERT,8136740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,8136740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
STENT GRAFT,8136572,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,8136572,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
SCREW,8136573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
SCREW,8136573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
LINER,8136574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8136574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
COMPONENT FEMORAL,7707446,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,7707446,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
LEAD KIT,8137059,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
LEAD KIT,8137059,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
SCREW,8137068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8137068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
PLATE,8137070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5013.75000,1453.99000,Aetna,First Health,,4101.25,,,,,,,1807.46,4101.25,percent of total billed charges,
PLATE,8137070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5013.75000,1453.99000,Aetna,First Health,,4101.25,,,,,,,1614.43,4101.25,percent of total billed charges,
PLATE,8137072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
PLATE,8137072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
CAGE,8136741,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8136741,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
PLATE,8136742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,8136742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
COMPONENT FEMORAL,8137074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8137074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE,8137075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BASEPLATE,8137075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
SCREW,8137076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8137076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8137077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8137077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8137078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8137078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8137079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8137079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8137080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8137080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8137081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8137081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW BONE,8137082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW BONE,8137082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8137083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8137083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8137084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8137084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,8137085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8137085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
CAGE,8137130,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8137130,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
SCREW,8137132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8137132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8137133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8137133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8137134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8137134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8137135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8137135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
PLATE,8137136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
PLATE,8137136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
BALLOON CATHETER,8137137,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,6142.50000,1781.32000,Aetna,First Health,,5024.56,,,,,,,2214.37,5024.56,percent of total billed charges,
BALLOON CATHETER,8137137,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,6142.50000,1781.32000,Aetna,First Health,,5024.56,,,,,,,1977.88,5024.56,percent of total billed charges,
BALLOON CATHETER,8137138,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,6142.50000,1781.32000,Aetna,First Health,,5024.56,,,,,,,2214.37,5024.56,percent of total billed charges,
BALLOON CATHETER,8137138,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,6142.50000,1781.32000,Aetna,First Health,,5024.56,,,,,,,1977.88,5024.56,percent of total billed charges,
BALLOON CATHETER,8137139,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,6142.50000,1781.32000,Aetna,First Health,,5024.56,,,,,,,2214.37,5024.56,percent of total billed charges,
BALLOON CATHETER,8137139,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,6142.50000,1781.32000,Aetna,First Health,,5024.56,,,,,,,1977.88,5024.56,percent of total billed charges,
BALLOON CATHETER,8137140,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
BALLOON CATHETER,8137140,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
BALLOON CATHETER,8137141,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
BALLOON CATHETER,8137141,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
BALLOON CATHETER,8137142,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,6142.50000,1781.32000,Aetna,First Health,,5024.56,,,,,,,2214.37,5024.56,percent of total billed charges,
BALLOON CATHETER,8137142,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,6142.50000,1781.32000,Aetna,First Health,,5024.56,,,,,,,1977.88,5024.56,percent of total billed charges,
SCREW,8137197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8137197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
GUIDEWIRE,8137199,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,39.27,89.11,percent of total billed charges,
GUIDEWIRE,8137199,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,35.08,89.11,percent of total billed charges,
PACEMAKER,8137190,CDM,278,RC,C2621,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
PACEMAKER,8137190,CDM,278,RC,C2621,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
PLATE,8137192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4704.00000,1364.16000,Aetna,First Health,,3847.87,,,,,,,1695.79,3847.87,percent of total billed charges,
PLATE,8137192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4704.00000,1364.16000,Aetna,First Health,,3847.87,,,,,,,1514.69,3847.87,percent of total billed charges,
SCREW,8137219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,8137219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,8137220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,8137220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
PLATE,8137221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8109.00000,2351.61000,Aetna,First Health,,6633.16,,,,,,,2923.29,6633.16,percent of total billed charges,
PLATE,8137221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8109.00000,2351.61000,Aetna,First Health,,6633.16,,,,,,,2611.10,6633.16,percent of total billed charges,
PLATE,8137218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1847.20,4191.43,percent of total billed charges,
PLATE,8137218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1649.93,4191.43,percent of total billed charges,
SCREW,8137222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,8137222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
NAIL,8137224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4518.50000,1310.36000,Aetna,First Health,,3696.13,,,,,,,1628.92,3696.13,percent of total billed charges,
NAIL,8137224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4518.50000,1310.36000,Aetna,First Health,,3696.13,,,,,,,1454.96,3696.13,percent of total billed charges,
PLATE,8137251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1469.63,3334.68,percent of total billed charges,
PLATE,8137251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1312.67,3334.68,percent of total billed charges,
SCREW,8137253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8137253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8137254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8137254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8137255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8137255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
INSERT,8137225,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8137225,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
WEDGE,8137226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7576.65000,2197.23000,Aetna,First Health,,6197.70,,,,,,,2731.38,6197.70,percent of total billed charges,
WEDGE,8137226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7576.65000,2197.23000,Aetna,First Health,,6197.70,,,,,,,2439.68,6197.70,percent of total billed charges,
SCREW,8137256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,8137256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
GRAFT,8137258,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,7610.70000,2207.10000,Aetna,First Health,,6225.55,,,,,,,2743.66,6225.55,percent of total billed charges,
GRAFT,8137258,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,7610.70000,2207.10000,Aetna,First Health,,6225.55,,,,,,,2450.65,6225.55,percent of total billed charges,
PLATE,8137284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8607.00000,2496.03000,Aetna,First Health,,7040.53,,,,,,,3102.82,7040.53,percent of total billed charges,
PLATE,8137284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8607.00000,2496.03000,Aetna,First Health,,7040.53,,,,,,,2771.45,7040.53,percent of total billed charges,
PLATE,8137299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1469.63,3334.68,percent of total billed charges,
PLATE,8137299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1312.67,3334.68,percent of total billed charges,
ANCHOR,8137403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2141.00000,620.89000,Aetna,First Health,,1751.34,,,,,,,771.83,1751.34,percent of total billed charges,
ANCHOR,8137403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2141.00000,620.89000,Aetna,First Health,,1751.34,,,,,,,689.40,1751.34,percent of total billed charges,
INSERT,8137405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8137405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8137400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4042.50000,1172.32000,Aetna,First Health,,3306.76,,,,,,,1457.32,3306.76,percent of total billed charges,
PLATE,8137400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4042.50000,1172.32000,Aetna,First Health,,3306.76,,,,,,,1301.68,3306.76,percent of total billed charges,
CAGE BASE,8137497,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE BASE,8137497,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
SCREW,8137499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.00000,516.20000,Aetna,First Health,,1456.04,,,,,,,641.69,1456.04,percent of total billed charges,
SCREW,8137499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.00000,516.20000,Aetna,First Health,,1456.04,,,,,,,573.16,1456.04,percent of total billed charges,
SCREW,8137501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.00000,516.20000,Aetna,First Health,,1456.04,,,,,,,641.69,1456.04,percent of total billed charges,
SCREW,8137501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.00000,516.20000,Aetna,First Health,,1456.04,,,,,,,573.16,1456.04,percent of total billed charges,
CAGE,8137503,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,6060.91,13752.62,percent of total billed charges,
CAGE,8137503,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,5413.62,13752.62,percent of total billed charges,
NAIL,8137735,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14143.50000,4101.62000,Aetna,First Health,,11569.38,,,,,,,5098.73,11569.38,percent of total billed charges,
NAIL,8137735,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14143.50000,4101.62000,Aetna,First Health,,11569.38,,,,,,,4554.21,11569.38,percent of total billed charges,
SHELL,8137737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8137737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW,8141080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8141080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,8141082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8141082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
PLATE,8141084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8786.25000,2548.01000,Aetna,First Health,,7187.15,,,,,,,3167.44,7187.15,percent of total billed charges,
PLATE,8141084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8786.25000,2548.01000,Aetna,First Health,,7187.15,,,,,,,2829.17,7187.15,percent of total billed charges,
SCREW,8141086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8141086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,8141088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8141088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,8141090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8141090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,8141092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8141092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,8141094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8141094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
K WIRE,8141167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,118.15,268.10,percent of total billed charges,
K WIRE,8141167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,105.54,268.10,percent of total billed charges,
SCREW,8141170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8141170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8141172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8141172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
ROD,8141174,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD,8141174,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAP,8141176,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
CAP,8141176,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SPINAL FIXATION SYSTEM,8141178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
SPINAL FIXATION SYSTEM,8141178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
SPINAL SPACER,8141180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
SPINAL SPACER,8141180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
SHELL,8141193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8141193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,8141195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8141195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT FEMORAL,8141197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,4346.82,9863.24,percent of total billed charges,
COMPONENT FEMORAL,8141197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,3882.60,9863.24,percent of total billed charges,
GRAFT STENT,8141331,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5612.98,12736.26,percent of total billed charges,
GRAFT STENT,8141331,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,First Health,,12736.26,,,,,,,5013.54,12736.26,percent of total billed charges,
INSERT,8141335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8141335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,8141337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8141337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
SPHERICAL IMPLANT,8141540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8421.00000,2442.09000,Aetna,First Health,,6888.38,,,,,,,3035.77,6888.38,percent of total billed charges,
SPHERICAL IMPLANT,8141540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8421.00000,2442.09000,Aetna,First Health,,6888.38,,,,,,,2711.56,6888.38,percent of total billed charges,
GUIDEWIRE,8141772,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,First Health,,120.68,,,,,,,53.18,120.68,percent of total billed charges,
GUIDEWIRE,8141772,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,First Health,,120.68,,,,,,,47.50,120.68,percent of total billed charges,
PLATE,8141779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
PLATE,8141779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
CAGE,8141780,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
CAGE,8141780,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8141843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,8141843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
PLATE,8142110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1395.50,3166.48,percent of total billed charges,
PLATE,8142110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1246.46,3166.48,percent of total billed charges,
HEAD HUMERAL,8142112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,8142112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL ANCHOR,8142114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,5497.62,12474.50,percent of total billed charges,
HUMERAL ANCHOR,8142114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,4910.50,12474.50,percent of total billed charges,
HEAD HUMERAL,8142116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HEAD HUMERAL,8142116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
BREAST IMPLANT,8142119,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
BREAST IMPLANT,8142119,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
IMPLANT BREAST,8142397,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
IMPLANT BREAST,8142397,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
COMPONENT FEMORAL,8142399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,8142399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
INSERT,8142400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8142400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
BASEPLATE,8142401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8077.50000,2342.48000,Aetna,First Health,,6607.40,,,,,,,2911.94,6607.40,percent of total billed charges,
BASEPLATE,8142401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8077.50000,2342.48000,Aetna,First Health,,6607.40,,,,,,,2600.95,6607.40,percent of total billed charges,
COMPONENT FEMORAL,8142402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,8142402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
INSERT,8142403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8142403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
ROD SPINE,8142404,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINE,8142404,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
WEDGE,8142405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
WEDGE,8142405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
INSERT,8142406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8142406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
COMPONENT FEMORAL,8142407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,8142407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
STEM,8142408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
STEM,8142408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
FEMORAL HEAD,8142409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,8142409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
STENT GRAFT,8142780,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,8142780,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
PLATE,8142783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
PLATE,8142783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
CAGE,8142806,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8142806,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
SPACER,8142785,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12334.50000,3577.00000,Aetna,First Health,,10089.62,,,,,,,4446.59,10089.62,percent of total billed charges,
SPACER,8142785,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12334.50000,3577.00000,Aetna,First Health,,10089.62,,,,,,,3971.71,10089.62,percent of total billed charges,
LINER,8142807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
LINER,8142807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW,8143176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,8143176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
NAIL,8143178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4518.50000,1310.36000,Aetna,First Health,,3696.13,,,,,,,1628.92,3696.13,percent of total billed charges,
NAIL,8143178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4518.50000,1310.36000,Aetna,First Health,,3696.13,,,,,,,1454.96,3696.13,percent of total billed charges,
SCREW,8143180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,8143180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
COMPONENT FEMORAL,8143226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,6524.15,14803.75,percent of total billed charges,
COMPONENT FEMORAL,8143226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,First Health,,14803.75,,,,,,,5827.40,14803.75,percent of total billed charges,
INSERT,8143222,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,8143222,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
STEM,8143224,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1553.21,3524.35,percent of total billed charges,
STEM,8143224,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,First Health,,3524.35,,,,,,,1387.34,3524.35,percent of total billed charges,
CAGE,8143276,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4920.82,11165.70,percent of total billed charges,
CAGE,8143276,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,First Health,,11165.70,,,,,,,4395.30,11165.70,percent of total billed charges,
K WIRE,8143278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
K WIRE,8143278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CAGE,8143279,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26625.00000,7721.25000,Aetna,First Health,,21779.25,,,,,,,9598.31,21779.25,percent of total billed charges,
CAGE,8143279,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26625.00000,7721.25000,Aetna,First Health,,21779.25,,,,,,,8573.25,21779.25,percent of total billed charges,
SCREW,8143280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8143280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ANCHOR,7695898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2015.00000,584.35000,Aetna,First Health,,1648.27,,,,,,,726.41,1648.27,percent of total billed charges,
ANCHOR,7695898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2015.00000,584.35000,Aetna,First Health,,1648.27,,,,,,,648.83,1648.27,percent of total billed charges,
ROD SPINAL,8143327,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8143327,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW,8143328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8143328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8143329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8143329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8143330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8143330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8143331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8143331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8143333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8143333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
PLATE,8143334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,8143334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
ANCHOR HUMERAL,8143335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,5497.62,12474.50,percent of total billed charges,
ANCHOR HUMERAL,8143335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,4910.50,12474.50,percent of total billed charges,
HUMERAL HEAD,8143336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HUMERAL HEAD,8143336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
SPACER,8143409,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
SPACER,8143409,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
CAGE,8143483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8143483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
CAP,8143484,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
CAP,8143484,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
CAP,8143485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
CAP,8143485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
SCREW,8143486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,122.78,278.59,percent of total billed charges,
SCREW,8143486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,109.67,278.59,percent of total billed charges,
CAGE,8143487,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,8143487,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
WEDGE,8143488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3942.07,8944.83,percent of total billed charges,
WEDGE,8143488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3521.07,8944.83,percent of total billed charges,
COMPONENT FEMORAL,8143489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,8143489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
NAIL,8143490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1803.80,4092.94,percent of total billed charges,
NAIL,8143490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1611.16,4092.94,percent of total billed charges,
BASEPLATE,8143491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
BASEPLATE,8143491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
SCREW,8145910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2141.00000,620.89000,Aetna,First Health,,1751.34,,,,,,,771.83,1751.34,percent of total billed charges,
SCREW,8145910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2141.00000,620.89000,Aetna,First Health,,1751.34,,,,,,,689.40,1751.34,percent of total billed charges,
SCREW,8145912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2141.00000,620.89000,Aetna,First Health,,1751.34,,,,,,,771.83,1751.34,percent of total billed charges,
SCREW,8145912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2141.00000,620.89000,Aetna,First Health,,1751.34,,,,,,,689.40,1751.34,percent of total billed charges,
SCREW,8145918,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8145918,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
COMPONENT GLENOID,8145914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
COMPONENT GLENOID,8145914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
STEM,8145916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,8145916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
WEDGE,8145925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,8145925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
SCREW,8145926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,70.03,158.90,percent of total billed charges,
SCREW,8145926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,62.55,158.90,percent of total billed charges,
EMBOSPHERE,8145924,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,485.06,1100.64,percent of total billed charges,
EMBOSPHERE,8145924,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,433.26,1100.64,percent of total billed charges,
ROD SPINAL,8145928,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
ROD SPINAL,8145928,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
SCREW,8145929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8145929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
STENT GRAFT,8146879,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,8146879,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
SCREW,8145930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8145930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
ROD SPINAL,8145931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7590.00000,2201.10000,Aetna,First Health,,6208.62,,,,,,,2736.20,6208.62,percent of total billed charges,
ROD SPINAL,8145931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7590.00000,2201.10000,Aetna,First Health,,6208.62,,,,,,,2443.98,6208.62,percent of total billed charges,
WEDGE,8145932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
WEDGE,8145932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
WEDGE,8145933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1562.05,3544.39,percent of total billed charges,
WEDGE,8145933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,First Health,,3544.39,,,,,,,1395.23,3544.39,percent of total billed charges,
INSERT,8145934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,8145934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
PLATE,8145935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1734.59,3935.91,percent of total billed charges,
PLATE,8145935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1549.34,3935.91,percent of total billed charges,
SCREW,8145936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8145936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8145937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8145937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8145938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8145938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8145939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8145939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8146880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8146880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8146881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8146881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8145940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8145940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
PIN,8145941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
PIN,8145941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
FEMORAL HEAD,8145942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,8145942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
INSERT,8145943,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8145943,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8145944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8145944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
BASEPLATE,8145945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,8145945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
STEM,8145946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8145946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
NAIL,8145947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2903.18,6587.52,percent of total billed charges,
NAIL,8145947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2593.13,6587.52,percent of total billed charges,
PLATE,8145953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
PLATE,8145953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
INSERT,8145952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8145952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
LEAD KIT NEURO STIM,8145948,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,11100.00000,3219.00000,Aetna,First Health,,9079.80,,,,,,,4001.55,9079.80,percent of total billed charges,
LEAD KIT NEURO STIM,8145948,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,11100.00000,3219.00000,Aetna,First Health,,9079.80,,,,,,,3574.20,9079.80,percent of total billed charges,
INSERT,8145954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2708.08,6144.82,percent of total billed charges,
INSERT,8145954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2418.86,6144.82,percent of total billed charges,
COMPONENT TIBIAL,8145955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,6518.74,14791.49,percent of total billed charges,
COMPONENT TIBIAL,8145955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,5822.56,14791.49,percent of total billed charges,
NAIL,8145956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8145956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
STEM,8145957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,8145957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
SHELL,8145958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8145958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
HEAD FEMORAL,8145959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
HEAD FEMORAL,8145959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SHELL,8145960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,8145960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
INSERT,8147091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8147091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HEAD HUMERAL,8147094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
HEAD HUMERAL,8147094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
BONE SUBSTITUTE IN KIT,8147338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11790.00000,3419.10000,Aetna,First Health,,9644.22,,,,,,,4250.30,9644.22,percent of total billed charges,
BONE SUBSTITUTE IN KIT,8147338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11790.00000,3419.10000,Aetna,First Health,,9644.22,,,,,,,3796.38,9644.22,percent of total billed charges,
STENT GRAFT,8147339,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,8147339,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
ROD SPINAL,8147340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8147340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8147343,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8147343,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
INSERT,8147341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8147341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
STEM,8147342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STEM,8147342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
COMPONENT HUMERAL,8147434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,5497.62,12474.50,percent of total billed charges,
COMPONENT HUMERAL,8147434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,4910.50,12474.50,percent of total billed charges,
HEAD HUMERAL,8147436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HEAD HUMERAL,8147436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
SCREW,8147479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW,8147479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
SCREW,8147481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW,8147481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
LINER,8147483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8147483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SHELL,8147603,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8147603,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
END CAP,8147650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,254.69,577.92,percent of total billed charges,
END CAP,8147650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,227.49,577.92,percent of total billed charges,
NAIL,8147652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,8147652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
CAGE,8147741,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8147741,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
PLATE,8147743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,8147743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CAGE,8147744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8147744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
INSERT,8147780,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2708.08,6144.82,percent of total billed charges,
INSERT,8147780,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2418.86,6144.82,percent of total billed charges,
COMPONENT TALAR,8147782,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,7151.42,16227.08,percent of total billed charges,
COMPONENT TALAR,8147782,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,First Health,,16227.08,,,,,,,6387.68,16227.08,percent of total billed charges,
LINER,8147785,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
LINER,8147785,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
INSERT,8147787,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8147787,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
SHELL,8147789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,8147789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
GRAFT,8147892,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4906.76000,1422.96000,Aetna,First Health,,4013.73,,,,,,,1768.89,4013.73,percent of total billed charges,
GRAFT,8147892,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4906.76000,1422.96000,Aetna,First Health,,4013.73,,,,,,,1579.98,4013.73,percent of total billed charges,
SCREW,8148049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,8148049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
SCREW,8148050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,8148050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
GLENOSPHERE,8148051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6062.00000,1757.98000,Aetna,First Health,,4958.72,,,,,,,2185.35,4958.72,percent of total billed charges,
GLENOSPHERE,8148051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6062.00000,1757.98000,Aetna,First Health,,4958.72,,,,,,,1951.96,4958.72,percent of total billed charges,
STENT GRAFT,7965251,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,7965251,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
NASAL IMPLANT,7987717,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9435.00000,2736.15000,Aetna,First Health,,7717.83,,,,,,,3401.32,7717.83,percent of total billed charges,
NASAL IMPLANT,7987717,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9435.00000,2736.15000,Aetna,First Health,,7717.83,,,,,,,3038.07,7717.83,percent of total billed charges,
GUIDWIRE,8148054,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDWIRE,8148054,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
CATHETER,8244287,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
CATHETER,8244287,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
INTRODUCER,8314043,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,351.50000,101.93000,Aetna,First Health,,287.53,,,,,,,126.72,287.53,percent of total billed charges,
INTRODUCER,8314043,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,351.50000,101.93000,Aetna,First Health,,287.53,,,,,,,113.18,287.53,percent of total billed charges,
INTRODUCER KT,8136110,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,355.59000,103.12000,Aetna,First Health,,290.87,,,,,,,128.19,290.87,percent of total billed charges,
INTRODUCER KT,8136110,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,355.59000,103.12000,Aetna,First Health,,290.87,,,,,,,114.50,290.87,percent of total billed charges,
INTRODUCER KT,8135904,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,440.80000,127.83000,Aetna,First Health,,360.57,,,,,,,158.91,360.57,percent of total billed charges,
INTRODUCER KT,8135904,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,440.80000,127.83000,Aetna,First Health,,360.57,,,,,,,141.94,360.57,percent of total billed charges,
CLOSURE DEVICE VASCULAR,8322726,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
CLOSURE DEVICE VASCULAR,8322726,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PACEMAKER,8367231,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,32175.00000,9330.75000,Aetna,First Health,,26319.15,,,,,,,11599.09,26319.15,percent of total billed charges,
PACEMAKER,8367231,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,32175.00000,9330.75000,Aetna,First Health,,26319.15,,,,,,,10360.35,26319.15,percent of total billed charges,
PACEMAKER,9226700,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
PACEMAKER,9226700,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
SHEATH,8372556,CDM,278,RC,C2629,HCPCS,,,facility,inpatient,,,12630.00000,3662.70000,Aetna,First Health,,10331.34,,,,,,,4553.11,10331.34,percent of total billed charges,
SHEATH,8372556,CDM,278,RC,C2629,HCPCS,,,facility,outpatient,,,12630.00000,3662.70000,Aetna,First Health,,10331.34,,,,,,,4066.86,10331.34,percent of total billed charges,
SHEATH,8372557,CDM,278,RC,C2629,HCPCS,,,facility,inpatient,,,12630.00000,3662.70000,Aetna,First Health,,10331.34,,,,,,,4553.11,10331.34,percent of total billed charges,
SHEATH,8372557,CDM,278,RC,C2629,HCPCS,,,facility,outpatient,,,12630.00000,3662.70000,Aetna,First Health,,10331.34,,,,,,,4066.86,10331.34,percent of total billed charges,
SHEATH,8372558,CDM,278,RC,C2629,HCPCS,,,facility,inpatient,,,12630.00000,3662.70000,Aetna,First Health,,10331.34,,,,,,,4553.11,10331.34,percent of total billed charges,
SHEATH,8372558,CDM,278,RC,C2629,HCPCS,,,facility,outpatient,,,12630.00000,3662.70000,Aetna,First Health,,10331.34,,,,,,,4066.86,10331.34,percent of total billed charges,
CATHETER,8368312,CDM,278,RC,C2630,HCPCS,,,facility,inpatient,,,9900.00000,2871.00000,Aetna,First Health,,8098.20,,,,,,,3568.95,8098.20,percent of total billed charges,
CATHETER,8368312,CDM,278,RC,C2630,HCPCS,,,facility,outpatient,,,9900.00000,2871.00000,Aetna,First Health,,8098.20,,,,,,,3187.80,9959.00,percent of total billed charges,
STENT,8415043,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415043,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415044,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415044,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415045,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415045,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415046,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415046,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415047,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415047,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415048,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415048,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415049,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415049,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415050,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415050,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415051,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415051,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415052,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415052,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415053,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415053,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415054,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415054,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415055,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415055,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415056,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415056,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415057,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415057,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415058,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415058,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415059,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415059,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415060,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415060,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
PLATE,8415308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3825.50000,1109.40000,Aetna,First Health,,3129.26,,,,,,,1379.09,3129.26,percent of total billed charges,
PLATE,8415308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3825.50000,1109.40000,Aetna,First Health,,3129.26,,,,,,,1231.81,3129.26,percent of total billed charges,
K WIRE,8415289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,83.28,188.96,percent of total billed charges,
K WIRE,8415289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,74.38,188.96,percent of total billed charges,
SCREW,8415292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,319.58,725.16,percent of total billed charges,
SCREW,8415292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,285.45,725.16,percent of total billed charges,
SCREW,8415294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,319.58,725.16,percent of total billed charges,
SCREW,8415294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,285.45,725.16,percent of total billed charges,
SCREW,8415296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,319.58,725.16,percent of total billed charges,
SCREW,8415296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,285.45,725.16,percent of total billed charges,
PIN,8415298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1864.00000,540.56000,Aetna,First Health,,1524.75,,,,,,,671.97,1524.75,percent of total billed charges,
PIN,8415298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1864.00000,540.56000,Aetna,First Health,,1524.75,,,,,,,600.21,1524.75,percent of total billed charges,
PLATE,8415300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,20217.50000,5863.08000,Aetna,First Health,,16537.92,,,,,,,7288.41,16537.92,percent of total billed charges,
PLATE,8415300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,20217.50000,5863.08000,Aetna,First Health,,16537.92,,,,,,,6510.03,16537.92,percent of total billed charges,
SCREW,8415309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8415309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
ANCHOR,8415310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,665.84,1510.85,percent of total billed charges,
ANCHOR,8415310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,594.73,1510.85,percent of total billed charges,
INSERT,8416011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8416011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8416012,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,8416012,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
CAGE,8416013,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8416013,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,8416014,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8416014,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
SCREW SPINAL,8416015,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW SPINAL,8416015,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW SPINAL,8416016,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW SPINAL,8416016,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
CATHETER,8416017,CDM,278,RC,A4340,HCPCS,,,facility,inpatient,,,137.16000,39.78000,Aetna,First Health,,112.20,,,,,,,49.45,112.20,percent of total billed charges,
CATHETER,8416017,CDM,278,RC,A4340,HCPCS,,,facility,outpatient,,,137.16000,39.78000,Aetna,First Health,,112.20,,,,,,,41.43,112.20,percent of total billed charges,
MESH,8416347,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5421.85000,1572.34000,Aetna,First Health,,4435.07,,,,,,,1954.58,4435.07,percent of total billed charges,
MESH,8416347,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5421.85000,1572.34000,Aetna,First Health,,4435.07,,,,,,,1745.84,4435.07,percent of total billed charges,
COMPONENT FEMORAL,8416349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
COMPONENT FEMORAL,8416349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
CAGE,8416351,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
CAGE,8416351,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
ROD SPINAL,8416353,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8416353,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8416355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3220.70000,934.00000,Aetna,First Health,,2634.53,,,,,,,1161.06,2634.53,percent of total billed charges,
SCREW,8416355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3220.70000,934.00000,Aetna,First Health,,2634.53,,,,,,,1037.07,2634.53,percent of total billed charges,
SCREW,8416407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW,8416407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
SCREW,8416401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW,8416401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
SCREW,8416402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8416402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8416403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8416403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8416404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8416404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
CATHETER ABLATION,7695078,CDM,278,RC,C1888,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
CATHETER ABLATION,7695078,CDM,278,RC,C1888,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
WASHER,8416418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1596.11,3621.70,percent of total billed charges,
WASHER,8416418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1425.65,3621.70,percent of total billed charges,
STEM,8416489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8416489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8416490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,8416490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,8416491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,8416491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,8416492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8416492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8416493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8416493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8416766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8416766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8416768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8416768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8416770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8416770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8416772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8416772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
NAIL,8416774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL,8416774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
NAIL,8416837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8416837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
PLATE SPINAL,8416839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8416839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8416841,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8416841,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
COMPONENT FEMORAL,8416842,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,7273.09,16503.15,percent of total billed charges,
COMPONENT FEMORAL,8416842,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,6496.35,16503.15,percent of total billed charges,
AUGMENT FEMORAL,8416844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
AUGMENT FEMORAL,8416844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
AUGMENT TIBIAL,8416846,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
AUGMENT TIBIAL,8416846,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
AUGMENT FEMORAL,8416848,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
AUGMENT FEMORAL,8416848,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
ANCHOR IN KIT,8416850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
ANCHOR IN KIT,8416850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
SPINAL FIXATION SYSTEM,8148303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
SPINAL FIXATION SYSTEM,8148303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
CAGE,8148305,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
CAGE,8148305,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
WEDGE,8148307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5455.63000,1582.13000,Aetna,First Health,,4462.71,,,,,,,1966.75,4462.71,percent of total billed charges,
WEDGE,8148307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5455.63000,1582.13000,Aetna,First Health,,4462.71,,,,,,,1756.71,4462.71,percent of total billed charges,
FEMORAL CONE,8148309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
FEMORAL CONE,8148309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
PLATE,8148311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
PLATE,8148311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
NAIL,8148313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8148313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,8148794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8148794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
MESH,8148796,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,11970.00000,3471.30000,Aetna,First Health,,9791.46,,,,,,,4315.19,9791.46,percent of total billed charges,
MESH,8148796,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,11970.00000,3471.30000,Aetna,First Health,,9791.46,,,,,,,3854.34,9791.46,percent of total billed charges,
BREAST IMPLANT,8148866,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
BREAST IMPLANT,8148866,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
INSERT,8149203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8149203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STEM,8148867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,8148867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,8148868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
INSERT,8148868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
ROD SPINAL,8148869,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
ROD SPINAL,8148869,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
SCREW,8149558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8149558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW SPINAL,8148870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW SPINAL,8148870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,8148871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8148871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,8148872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8148872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,8148873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8148873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
CONNECTOR SPINAL,8148874,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,1106.01,2509.62,percent of total billed charges,
CONNECTOR SPINAL,8148874,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,987.90,2509.62,percent of total billed charges,
CONNECTOR SPINAL,8148875,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,876.74,1989.38,percent of total billed charges,
CONNECTOR SPINAL,8148875,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,First Health,,1989.38,,,,,,,783.10,1989.38,percent of total billed charges,
SPINAL FIXATION,8148876,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
SPINAL FIXATION,8148876,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
ROD SPINAL,8148877,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8148877,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
ROD SPINAL,8149522,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8149522,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SCREW,8148878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8148878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
ROD SPINAL,8148879,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD SPINAL,8148879,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8148880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8148880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,8148881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8148881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SHELL,8149208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,8149208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
COMPONENT GLENOID,8149209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
COMPONENT GLENOID,8149209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
PLATE,8149523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3660.65000,1061.59000,Aetna,First Health,,2994.41,,,,,,,1319.66,2994.41,percent of total billed charges,
PLATE,8149523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3660.65000,1061.59000,Aetna,First Health,,2994.41,,,,,,,1178.73,2994.41,percent of total billed charges,
INSERT,8149525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8149525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
STEM,8149526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,8149526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
VALVE,8149586,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
VALVE,8149586,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
VALVE,8149587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
VALVE,8149587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
VALVE,8149588,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
VALVE,8149588,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
VALVE,8149589,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
VALVE,8149589,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
VALVE,8149590,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
VALVE,8149590,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
VALVE,8149591,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
VALVE,8149591,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
PLATE,8149592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5887.49000,1707.37000,Aetna,First Health,,4815.97,,,,,,,2122.44,4815.97,percent of total billed charges,
PLATE,8149592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5887.49000,1707.37000,Aetna,First Health,,4815.97,,,,,,,1895.77,4815.97,percent of total billed charges,
PLATE,8149593,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3638.95000,1055.30000,Aetna,First Health,,2976.66,,,,,,,1311.84,2976.66,percent of total billed charges,
PLATE,8149593,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3638.95000,1055.30000,Aetna,First Health,,2976.66,,,,,,,1171.74,2976.66,percent of total billed charges,
ROD SPINAL,8149594,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2512.00000,728.48000,Aetna,First Health,,2054.82,,,,,,,905.58,2054.82,percent of total billed charges,
ROD SPINAL,8149594,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2512.00000,728.48000,Aetna,First Health,,2054.82,,,,,,,808.86,2054.82,percent of total billed charges,
PLATE,8149595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1151.87,2613.67,percent of total billed charges,
PLATE,8149595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1028.85,2613.67,percent of total billed charges,
FEMORAL HEAD,8149683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,8149683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW,8149684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8149684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,8149685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8149685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,8149686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8149686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,8149687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8149687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
CONNECTOR SPINAL,8149688,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4039.74000,1171.52000,Aetna,First Health,,3304.51,,,,,,,1456.33,3304.51,percent of total billed charges,
CONNECTOR SPINAL,8149688,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4039.74000,1171.52000,Aetna,First Health,,3304.51,,,,,,,1300.80,3304.51,percent of total billed charges,
STEM,8149689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8149689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
CAGE,8149560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
CAGE,8149560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
SCREW,8149561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8149561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8149564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8149564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,8149565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8149565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,8149566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8149566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
ROD SPINAL,8149567,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8149567,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
GUIDEWIRE,8149569,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,164.06000,47.58000,Aetna,First Health,,134.20,,,,,,,59.14,134.20,percent of total billed charges,
GUIDEWIRE,8149569,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,164.06000,47.58000,Aetna,First Health,,134.20,,,,,,,52.83,134.20,percent of total billed charges,
SCREW,8149570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8149570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
AUGMENT FEMORAL,8149571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,8149571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
STEM,8149572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM,8149572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
INSERT,8149836,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8149836,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
LINER,8149839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,8149839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
ROD SPINAL,8149841,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8149841,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
SHELL,8149838,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6219.85000,1803.76000,Aetna,First Health,,5087.84,,,,,,,2242.26,5087.84,percent of total billed charges,
SHELL,8149838,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6219.85000,1803.76000,Aetna,First Health,,5087.84,,,,,,,2002.79,5087.84,percent of total billed charges,
PLATE,8149876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,First Health,,7023.35,,,,,,,3095.25,7023.35,percent of total billed charges,
PLATE,8149876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,First Health,,7023.35,,,,,,,2764.69,7023.35,percent of total billed charges,
WEDGE,8149878,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
WEDGE,8149878,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
STEM,8149880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM,8149880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
COMPONENT FEMORAL,8149882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,8149882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
INSERT,8149884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8149884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
WEDGE,8149886,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6210.33000,1801.00000,Aetna,First Health,,5080.05,,,,,,,2238.82,5080.05,percent of total billed charges,
WEDGE,8149886,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6210.33000,1801.00000,Aetna,First Health,,5080.05,,,,,,,1999.73,5080.05,percent of total billed charges,
SCREW,8150097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8150097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
PLATE,8150099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1469.63,3334.68,percent of total billed charges,
PLATE,8150099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1312.67,3334.68,percent of total billed charges,
SCREW,8149891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8149891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
SCREW,8149893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8149893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
SCREW,8149895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8149895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
GUIDEWIRE,8150101,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,39.27,89.11,percent of total billed charges,
GUIDEWIRE,8150101,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,35.08,89.11,percent of total billed charges,
SCREW,8150104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8150104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
GUIDEWIRE,8150106,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,39.27,89.11,percent of total billed charges,
GUIDEWIRE,8150106,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,35.08,89.11,percent of total billed charges,
HUMERAL HEAD,8150108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,8150108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
ANCHOR STAPLE,8149888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9479.25000,2748.98000,Aetna,First Health,,7754.03,,,,,,,3417.27,7754.03,percent of total billed charges,
ANCHOR STAPLE,8149888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9479.25000,2748.98000,Aetna,First Health,,7754.03,,,,,,,3052.32,7754.03,percent of total billed charges,
ANCHOR STAPLE,8150110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9479.25000,2748.98000,Aetna,First Health,,7754.03,,,,,,,3417.27,7754.03,percent of total billed charges,
ANCHOR STAPLE,8150110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9479.25000,2748.98000,Aetna,First Health,,7754.03,,,,,,,3052.32,7754.03,percent of total billed charges,
GUIDEWIRE,8150111,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
GUIDEWIRE,8150111,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,43.95,111.66,percent of total billed charges,
WEDGE,8150112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
WEDGE,8150112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
PLATE,8150113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
PLATE,8150113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SCREW,8150178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8150178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8150381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8150381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
ROD SPINAL,8150180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8150180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ROD SPINAL,8150182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8150182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
TALUS CUSTOM,8150383,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,33637.50000,9754.88000,Aetna,First Health,,27515.47,,,,,,,12126.32,27515.47,percent of total billed charges,
TALUS CUSTOM,8150383,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,33637.50000,9754.88000,Aetna,First Health,,27515.47,,,,,,,10831.27,27515.47,percent of total billed charges,
SCREW,8150837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,8150837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,8150839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,166.10,376.89,percent of total billed charges,
SCREW,8150839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,148.36,376.89,percent of total billed charges,
PLATE,8150841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,584.01,1325.16,percent of total billed charges,
PLATE,8150841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,521.64,1325.16,percent of total billed charges,
PLATE,8150843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2032.00000,589.28000,Aetna,First Health,,1662.18,,,,,,,732.54,1662.18,percent of total billed charges,
PLATE,8150843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2032.00000,589.28000,Aetna,First Health,,1662.18,,,,,,,654.30,1662.18,percent of total billed charges,
PLATE,8150845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,584.01,1325.16,percent of total billed charges,
PLATE,8150845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,521.64,1325.16,percent of total billed charges,
SCREW,8150847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,8150847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,8150849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,8150849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW,8150851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,8150851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
WEDGE,8150854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE,8150854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
BASEPLATE,8150856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
BASEPLATE,8150856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
WEDGE,8150858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE,8150858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
ROD SPINAL,8150860,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8150860,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
INSERT,8150861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8150861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
PLATE,8150934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1395.50,3166.48,percent of total billed charges,
PLATE,8150934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1246.46,3166.48,percent of total billed charges,
SCREW,8150936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,8150936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
COMPONENT PATELLA,8150937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,8150937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CUP HUMERAL,7699127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1622.36,3681.25,percent of total billed charges,
CUP HUMERAL,7699127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1449.10,3681.25,percent of total billed charges,
STEM,8150973,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2893.01,6564.45,percent of total billed charges,
STEM,8150973,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,First Health,,6564.45,,,,,,,2584.05,6564.45,percent of total billed charges,
SHELL,8150974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8150974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STRUT CORTICAL,8151005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5842.55000,1694.34000,Aetna,First Health,,4779.21,,,,,,,2106.24,4779.21,percent of total billed charges,
STRUT CORTICAL,8151005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5842.55000,1694.34000,Aetna,First Health,,4779.21,,,,,,,1881.30,4779.21,percent of total billed charges,
SHEET TISSUE,8151042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5997.32000,1739.22000,Aetna,First Health,,4905.81,,,,,,,2162.03,4905.81,percent of total billed charges,
SHEET TISSUE,8151042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5997.32000,1739.22000,Aetna,First Health,,4905.81,,,,,,,1931.14,4905.81,percent of total billed charges,
WEDGE,8151036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3585.17,8135.01,percent of total billed charges,
WEDGE,8151036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,First Health,,8135.01,,,,,,,3202.29,8135.01,percent of total billed charges,
INSERT,8151038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8151038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
WEDGE,8151040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8162.25000,2367.05000,Aetna,First Health,,6676.72,,,,,,,2942.49,6676.72,percent of total billed charges,
WEDGE,8151040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8162.25000,2367.05000,Aetna,First Health,,6676.72,,,,,,,2628.24,6676.72,percent of total billed charges,
PLATE,8151070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3437.00000,996.73000,Aetna,First Health,,2811.47,,,,,,,1239.04,2811.47,percent of total billed charges,
PLATE,8151070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3437.00000,996.73000,Aetna,First Health,,2811.47,,,,,,,1106.71,2811.47,percent of total billed charges,
ASSEMBLY COMPONENT,8151087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,6398.88,14519.50,percent of total billed charges,
ASSEMBLY COMPONENT,8151087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,5715.50,14519.50,percent of total billed charges,
SCREW,8151133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,134.94,306.18,percent of total billed charges,
SCREW,8151133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,First Health,,306.18,,,,,,,120.52,306.18,percent of total billed charges,
HUMERAL HEAD,8151147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HUMERAL HEAD,8151147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
PLATE,8151148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6637.02000,1924.74000,Aetna,First Health,,5429.08,,,,,,,2392.65,5429.08,percent of total billed charges,
PLATE,8151148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6637.02000,1924.74000,Aetna,First Health,,5429.08,,,,,,,2137.12,5429.08,percent of total billed charges,
PLATE,8151175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.95000,104.97000,Aetna,First Health,,296.08,,,,,,,130.48,296.08,percent of total billed charges,
PLATE,8151175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.95000,104.97000,Aetna,First Health,,296.08,,,,,,,116.55,296.08,percent of total billed charges,
CAGE,8151205,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2669.14,6056.47,percent of total billed charges,
CAGE,8151205,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2384.09,6056.47,percent of total billed charges,
CAGE,8151207,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
CAGE,8151207,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
INSERT,8151209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8151209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
CONNECTOR SPINAL,8151213,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
CONNECTOR SPINAL,8151213,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
HEAD HUMERAL,8151216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,8151216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
LINER,8151211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,8151211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
PLATE,8151319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
PLATE,8151319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1349.02,3427.01,percent of total billed charges,
SCREW,8151367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,8151367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,8151321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,8151321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,8151323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,8151323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
SCREW,8151325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,8151325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
INSERT,8151327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9360.00000,2714.40000,Aetna,First Health,,7656.48,,,,,,,3374.28,7656.48,percent of total billed charges,
INSERT,8151327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9360.00000,2714.40000,Aetna,First Health,,7656.48,,,,,,,3013.92,7656.48,percent of total billed charges,
CATHETER,8151330,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,108.11000,31.35000,Aetna,First Health,,88.43,,,,,,,38.97,88.43,percent of total billed charges,
CATHETER,8151330,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,108.11000,31.35000,Aetna,First Health,,88.43,,,,,,,34.81,88.43,percent of total billed charges,
ROD SPINAL,8151378,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7590.00000,2201.10000,Aetna,First Health,,6208.62,,,,,,,2736.20,6208.62,percent of total billed charges,
ROD SPINAL,8151378,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7590.00000,2201.10000,Aetna,First Health,,6208.62,,,,,,,2443.98,6208.62,percent of total billed charges,
INSERT,8151379,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8151379,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8151382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,344.57,781.84,percent of total billed charges,
SCREW,8151382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,First Health,,781.84,,,,,,,307.77,781.84,percent of total billed charges,
INSERT,8151384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8151384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HEAD HUMERAL,8151386,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,8151386,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
LINER,8151388,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4135.95000,1199.43000,Aetna,First Health,,3383.21,,,,,,,1491.01,3383.21,percent of total billed charges,
LINER,8151388,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4135.95000,1199.43000,Aetna,First Health,,3383.21,,,,,,,1331.78,3383.21,percent of total billed charges,
LINER,8151390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7577.10000,2197.36000,Aetna,First Health,,6198.07,,,,,,,2731.54,6198.07,percent of total billed charges,
LINER,8151390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7577.10000,2197.36000,Aetna,First Health,,6198.07,,,,,,,2439.83,6198.07,percent of total billed charges,
HEAD HUMERAL,8151391,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4309.20000,1249.67000,Aetna,First Health,,3524.93,,,,,,,1553.47,3524.93,percent of total billed charges,
HEAD HUMERAL,8151391,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4309.20000,1249.67000,Aetna,First Health,,3524.93,,,,,,,1387.56,3524.93,percent of total billed charges,
BALLOON CATHETER,8151462,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2588.00000,750.52000,Aetna,First Health,,2116.98,,,,,,,932.97,2116.98,percent of total billed charges,
BALLOON CATHETER,8151462,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2588.00000,750.52000,Aetna,First Health,,2116.98,,,,,,,833.34,2116.98,percent of total billed charges,
STENT,8151463,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT,8151463,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
EXCLUDER,8151465,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
EXCLUDER,8151465,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT,8151569,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT,8151569,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
HEAD HUMERAL,8151466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HEAD HUMERAL,8151466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,8151468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8151468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8151470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8151470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8151575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8151575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
ROD SPINAL,8151472,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8151472,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SHELL,8151473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,8151473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
COMPONENT FEMORAL,8151474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2851.37,6469.97,percent of total billed charges,
COMPONENT FEMORAL,8151474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2546.86,6469.97,percent of total billed charges,
STEM,8151476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,10392.54,23581.41,percent of total billed charges,
STEM,8151476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,9282.66,23581.41,percent of total billed charges,
SCREW,8151570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,240.09,544.79,percent of total billed charges,
SCREW,8151570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,,544.79,,,,,,,214.45,544.79,percent of total billed charges,
CONNECTOR SPINAL,8151573,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,801.38,1818.38,percent of total billed charges,
CONNECTOR SPINAL,8151573,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,715.79,1818.38,percent of total billed charges,
CAGE,8151647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,8151647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
ROD SPINAL,8151649,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8151649,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PLATE,8151678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3437.00000,996.73000,Aetna,First Health,,2811.47,,,,,,,1239.04,2811.47,percent of total billed charges,
PLATE,8151678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3437.00000,996.73000,Aetna,First Health,,2811.47,,,,,,,1106.71,2811.47,percent of total billed charges,
FEMORAL HEAD,8151680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,8151680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
INSERT,8151790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8151790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8151792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2708.08,6144.82,percent of total billed charges,
INSERT,8151792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2418.86,6144.82,percent of total billed charges,
TIBIAL COMPONENT,8151794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,6518.74,14791.49,percent of total billed charges,
TIBIAL COMPONENT,8151794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,5822.56,14791.49,percent of total billed charges,
GUIDE CATHETER,8151964,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
GUIDE CATHETER,8151964,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
CAGE,8151966,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8151966,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
CAGE,8151969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
CAGE,8151969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
ROD SPINAL,8151971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8151971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ROD SPINAL,8152018,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD SPINAL,8152018,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8152020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8152020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
ROD SPINAL,8152022,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD SPINAL,8152022,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
STEM,8152025,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8152025,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SCREW,8152026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8152026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
INSERT,8152115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8152115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BREAST IMPLANT,8152116,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST IMPLANT,8152116,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BREAST IMPLANT,8152117,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST IMPLANT,8152117,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BREAST IMPLANT,8152118,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BREAST IMPLANT,8152118,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
HUMERAL HEAD,8152199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20022.50000,5806.52000,Aetna,First Health,,16378.41,,,,,,,7218.11,16378.41,percent of total billed charges,
HUMERAL HEAD,8152199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20022.50000,5806.52000,Aetna,First Health,,16378.41,,,,,,,6447.24,16378.41,percent of total billed charges,
INSERT,8152200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8152200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
BREAST IMPLANT,8152230,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BREAST IMPLANT,8152230,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BREAST IMPLANT,8152232,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BREAST IMPLANT,8152232,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BREAST IMPLANT,8152234,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BREAST IMPLANT,8152234,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
INSERT,8152282,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,8152282,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
LINER,8152288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2268.31,5146.96,percent of total billed charges,
LINER,8152288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,First Health,,5146.96,,,,,,,2026.07,5146.96,percent of total billed charges,
FEMORAL HEAD,8152284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,109.87,249.29,percent of total billed charges,
FEMORAL HEAD,8152284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,98.13,249.29,percent of total billed charges,
SCREW,8152286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8152286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,8152309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8152309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
NAIL,7962617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7962617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
SCREW,7703028,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7703028,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
CAGE,8152339,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
CAGE,8152339,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
SCREW,8152341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8152341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8152343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,8152343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
NAIL,8152345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4518.50000,1310.36000,Aetna,First Health,,3696.13,,,,,,,1628.92,3696.13,percent of total billed charges,
NAIL,8152345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4518.50000,1310.36000,Aetna,First Health,,3696.13,,,,,,,1454.96,3696.13,percent of total billed charges,
INSERT,8153805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8153805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
WEDGE,8153807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
WEDGE,8153807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
SCREW,8153943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,579.01,1313.81,percent of total billed charges,
SCREW,8153943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,First Health,,1313.81,,,,,,,517.17,1313.81,percent of total billed charges,
PLATE,8153978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,954.68000,276.86000,Aetna,First Health,,780.93,,,,,,,344.16,780.93,percent of total billed charges,
PLATE,8153978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,954.68000,276.86000,Aetna,First Health,,780.93,,,,,,,307.41,780.93,percent of total billed charges,
ROD SPINAL,8154031,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
ROD SPINAL,8154031,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,8154033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8154033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8154035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8154035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
CONNECTOR SPINAL,8154037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5183.50000,1503.22000,Aetna,First Health,,4240.10,,,,,,,1868.65,4240.10,percent of total billed charges,
CONNECTOR SPINAL,8154037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5183.50000,1503.22000,Aetna,First Health,,4240.10,,,,,,,1669.09,4240.10,percent of total billed charges,
NUT,8154039,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
NUT,8154039,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
CAGE,8154041,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14550.00000,4219.50000,Aetna,First Health,,11901.90,,,,,,,5245.27,11901.90,percent of total billed charges,
CAGE,8154041,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14550.00000,4219.50000,Aetna,First Health,,11901.90,,,,,,,4685.10,11901.90,percent of total billed charges,
CAGE,8154043,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14550.00000,4219.50000,Aetna,First Health,,11901.90,,,,,,,5245.27,11901.90,percent of total billed charges,
CAGE,8154043,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14550.00000,4219.50000,Aetna,First Health,,11901.90,,,,,,,4685.10,11901.90,percent of total billed charges,
INSERT,8154045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,8154045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
COMPONENT TIBIAL,8154047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
COMPONENT TIBIAL,8154047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
PLATE,8154049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
PLATE,8154049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
ROD SPINAL,8154235,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
ROD SPINAL,8154235,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
ANCHOR,8154423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,First Health,,1476.49,,,,,,,650.70,1476.49,percent of total billed charges,
ANCHOR,8154423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,First Health,,1476.49,,,,,,,581.21,1476.49,percent of total billed charges,
ANCHOR,8154425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4738.13000,1374.06000,Aetna,First Health,,3875.79,,,,,,,1708.10,3875.79,percent of total billed charges,
ANCHOR,8154425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4738.13000,1374.06000,Aetna,First Health,,3875.79,,,,,,,1525.68,3875.79,percent of total billed charges,
SCREW,8154427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,8154427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,8154429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8154429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,8154431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8154431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,8154433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8154433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,8154435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8154435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,8154437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8154437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,8154439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8154439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,8154441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8154441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,7695820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,338.17,767.34,percent of total billed charges,
SCREW,7695820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,302.06,767.34,percent of total billed charges,
HEAD FEMORAL,8154672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
HEAD FEMORAL,8154672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INTERBODY,8154674,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
INTERBODY,8154674,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
PLATE,8154952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1876.22,4257.28,percent of total billed charges,
PLATE,8154952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1675.85,4257.28,percent of total billed charges,
K WIRE,8154954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
K WIRE,8154954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
INSERT,8154958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,8154958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
COMPONENT TIBIAL,8154960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
COMPONENT TIBIAL,8154960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
SHELL,8155075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8155075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STEM,8155077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2970.88,6741.14,percent of total billed charges,
STEM,8155077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2653.60,6741.14,percent of total billed charges,
COMPONENT FEMORAL,8155079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
COMPONENT FEMORAL,8155079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
PLATE,8155073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
PLATE,8155073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
PLATE,8155143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
PLATE,8155143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
GUIDEWIRE,8155234,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,39.27,89.11,percent of total billed charges,
GUIDEWIRE,8155234,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,35.08,89.11,percent of total billed charges,
SCREW,8155236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1448.00000,419.92000,Aetna,First Health,,1184.46,,,,,,,522.00,1184.46,percent of total billed charges,
SCREW,8155236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1448.00000,419.92000,Aetna,First Health,,1184.46,,,,,,,466.26,1184.46,percent of total billed charges,
SCREW,8155238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1448.00000,419.92000,Aetna,First Health,,1184.46,,,,,,,522.00,1184.46,percent of total billed charges,
SCREW,8155238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1448.00000,419.92000,Aetna,First Health,,1184.46,,,,,,,466.26,1184.46,percent of total billed charges,
TIGHTROPE,8155541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
TIGHTROPE,8155541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
PLATE,8155543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8155543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
SHELL,8155567,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,8155567,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
FEMORAL HEAD,8155569,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,8155569,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
STEM,8155571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,8155571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
WEDGE,8155575,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8464.50000,2454.70000,Aetna,First Health,,6923.96,,,,,,,3051.45,6923.96,percent of total billed charges,
WEDGE,8155575,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8464.50000,2454.70000,Aetna,First Health,,6923.96,,,,,,,2725.57,6923.96,percent of total billed charges,
SCREW,8155577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,209.27,474.85,percent of total billed charges,
SCREW,8155577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,186.92,474.85,percent of total billed charges,
PLATE,8155579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,608.94000,176.59000,Aetna,First Health,,498.11,,,,,,,219.52,498.11,percent of total billed charges,
PLATE,8155579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,608.94000,176.59000,Aetna,First Health,,498.11,,,,,,,196.08,498.11,percent of total billed charges,
ACETABULAR SHELL,8155657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
ACETABULAR SHELL,8155657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
FEMORAL HEAD,8155581,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,8155581,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
SCREW,8155772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8155772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8155673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8155673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8155675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8155675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8155676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8155676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
PLATE,8155678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
PLATE,8155678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
SCREW,8155680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8155680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
SCREW,8155682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8155682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
PLATE,8155684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
PLATE,8155684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
SCREW,8155686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8155686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8155688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8155688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
SCREW,8155690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8155690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
SCREW,8155692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8155692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
SCREW,8155694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8155694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
PLATE,8155696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
PLATE,8155696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
INSERT,8155698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8155698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,8155786,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8155786,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8155787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8155787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
LINER,8155789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,8155789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
STEM,8155790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,10392.54,23581.41,percent of total billed charges,
STEM,8155790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,9282.66,23581.41,percent of total billed charges,
SHELL,8155791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,8155791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
COMPONENT FEMORAL,8155792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2851.37,6469.97,percent of total billed charges,
COMPONENT FEMORAL,8155792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2546.86,6469.97,percent of total billed charges,
STENT GRAFT,8155793,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,54990.00000,15947.10000,Aetna,First Health,,44981.82,,,,,,,19823.90,44981.82,percent of total billed charges,
STENT GRAFT,8155793,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,54990.00000,15947.10000,Aetna,First Health,,44981.82,,,,,,,17706.78,44981.82,percent of total billed charges,
STENT GRAFT,8155794,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,18742.40,42527.82,percent of total billed charges,
STENT GRAFT,8155794,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,First Health,,42527.82,,,,,,,16740.78,42527.82,percent of total billed charges,
SCREW,8155796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8155796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
PLATE,8155797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1734.59,3935.91,percent of total billed charges,
PLATE,8155797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1549.34,3935.91,percent of total billed charges,
SCREW,8155798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8155798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8155799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8155799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8155800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8155800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8155801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8155801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8155802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8155802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8155803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8155803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
ANCHOR,8156032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,987.77,2241.32,percent of total billed charges,
ANCHOR,8156032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,882.28,2241.32,percent of total billed charges,
ROD SPINAL,8156200,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8156200,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8156202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8156202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ROD SPINAL,8156251,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8156251,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8156253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,8156253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
PLATE,8156255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
PLATE,8156255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
HEAD HUMERAL,8156311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,8156311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
PLATE,8156313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4190.20000,1215.16000,Aetna,First Health,,3427.58,,,,,,,1510.57,3427.58,percent of total billed charges,
PLATE,8156313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4190.20000,1215.16000,Aetna,First Health,,3427.58,,,,,,,1349.24,3427.58,percent of total billed charges,
BASEPLATE,8156315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
BASEPLATE,8156315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
STENT GRAFT,8156317,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
STENT GRAFT,8156317,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
COMPONENT FEMORAL,8157911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,8157911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
ROD SPINAL,8157912,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD SPINAL,8157912,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8157913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.00000,516.20000,Aetna,First Health,,1456.04,,,,,,,641.69,1456.04,percent of total billed charges,
SCREW,8157913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.00000,516.20000,Aetna,First Health,,1456.04,,,,,,,573.16,1456.04,percent of total billed charges,
CAGE,8157914,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,6060.91,13752.62,percent of total billed charges,
CAGE,8157914,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,5413.62,13752.62,percent of total billed charges,
CAGE,8157915,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,6060.91,13752.62,percent of total billed charges,
CAGE,8157915,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,First Health,,13752.62,,,,,,,5413.62,13752.62,percent of total billed charges,
PLATE,8157971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,1072.65,2433.91,percent of total billed charges,
PLATE,8157971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,958.09,2433.91,percent of total billed charges,
SCREW,8157970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8157970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,8158027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8158027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
ROD SPINAL,8158029,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6597.50000,1913.28000,Aetna,First Health,,5396.76,,,,,,,2378.40,5396.76,percent of total billed charges,
ROD SPINAL,8158029,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6597.50000,1913.28000,Aetna,First Health,,5396.76,,,,,,,2124.39,5396.76,percent of total billed charges,
PLATE,8158031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,8158031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
COMPONENT FEMORAL,8158033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,4351.96,9874.90,percent of total billed charges,
COMPONENT FEMORAL,8158033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,3887.18,9874.90,percent of total billed charges,
INSERT,8158035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3213.00000,931.77000,Aetna,First Health,,2628.23,,,,,,,1158.29,2628.23,percent of total billed charges,
INSERT,8158035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3213.00000,931.77000,Aetna,First Health,,2628.23,,,,,,,1034.59,2628.23,percent of total billed charges,
STEM,8158037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8158037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
SCREW,8158039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,8158039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,8158192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8158192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,8158194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8158194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
NAIL BLADE,8160717,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,714.57,1621.41,percent of total billed charges,
NAIL BLADE,8160717,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,638.26,1621.41,percent of total billed charges,
SHELL,8158235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8158235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
NAIL,8159832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4346.76000,1260.56000,Aetna,First Health,,3555.65,,,,,,,1567.01,3555.65,percent of total billed charges,
NAIL,8159832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4346.76000,1260.56000,Aetna,First Health,,3555.65,,,,,,,1399.66,3555.65,percent of total billed charges,
PLATE,8160429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
PLATE,8160429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
PLATE,8160431,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
PLATE,8160431,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
PLATE,8160433,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
PLATE,8160433,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
SPINAL IMPLANT,8160435,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
SPINAL IMPLANT,8160435,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
PLATE,8160437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1945.24000,564.12000,Aetna,First Health,,1591.21,,,,,,,701.26,1591.21,percent of total billed charges,
PLATE,8160437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1945.24000,564.12000,Aetna,First Health,,1591.21,,,,,,,626.37,1591.21,percent of total billed charges,
PLATE,8160439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1222.30,2773.48,percent of total billed charges,
PLATE,8160439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1091.76,2773.48,percent of total billed charges,
COMPONENT FEMORAL,8160441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
COMPONENT FEMORAL,8160441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
STEM,8160443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8160443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
PLATE,8160486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
PLATE,8160486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
END CAP,7695443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,762.39000,221.09000,Aetna,First Health,,623.64,,,,,,,274.84,623.64,percent of total billed charges,
END CAP,7695443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,762.39000,221.09000,Aetna,First Health,,623.64,,,,,,,245.49,623.64,percent of total billed charges,
CAGE,8160489,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8160489,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
ROD SPINAL,8160558,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8160558,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
ROD SPINAL,8160560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8160560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
SCREW,8160562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8160562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,8160564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8160564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,8160566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,8160566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,8160506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,8160506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
PLATE,8160508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8580.00000,2488.20000,Aetna,First Health,,7018.44,,,,,,,3093.09,7018.44,percent of total billed charges,
PLATE,8160508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8580.00000,2488.20000,Aetna,First Health,,7018.44,,,,,,,2762.76,7018.44,percent of total billed charges,
BONE SUBSTITUTE IN KIT,8160510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15412.50000,4469.62000,Aetna,First Health,,12607.42,,,,,,,5556.21,12607.42,percent of total billed charges,
BONE SUBSTITUTE IN KIT,8160510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15412.50000,4469.62000,Aetna,First Health,,12607.42,,,,,,,4962.82,12607.42,percent of total billed charges,
HEAD HUMERAL,7699515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,7699515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HEAD HUMERAL,7700848,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,7700848,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HEAD HUMBERAL,7701779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMBERAL,7701779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
SCREW,8160605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8160605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
GLENOSPHERE,8160607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
GLENOSPHERE,8160607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8160623,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8160623,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
SCREW,8160624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8160624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,8160625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,8160625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SCREW,8160626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,8160626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SCREW,8160627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,8160627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
ROD SPINAL,8160628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8160628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ROD SPINAL,8160630,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8160630,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CROSS CONNECTOR,8160632,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CROSS CONNECTOR,8160632,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
WEDGE,8160634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,8160634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
NAIL,8160689,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8160689,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
SCREW,8238050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SCREW,8238050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,8238052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SCREW,8238052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
ROD SPINAL,8238054,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
ROD SPINAL,8238054,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
CONNECTOR SPINAL,8238056,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5502.00000,1595.58000,Aetna,First Health,,4500.64,,,,,,,1983.47,4500.64,percent of total billed charges,
CONNECTOR SPINAL,8238056,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5502.00000,1595.58000,Aetna,First Health,,4500.64,,,,,,,1771.64,4500.64,percent of total billed charges,
ROD SPINAL,8238058,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8238058,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
LINER,8238297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1873.70,4251.56,percent of total billed charges,
LINER,8238297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1673.60,4251.56,percent of total billed charges,
INSERT,8238298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8238298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
CONNECTOR SPINAL,8238295,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7734.00000,2242.86000,Aetna,First Health,,6326.41,,,,,,,2788.11,6326.41,percent of total billed charges,
CONNECTOR SPINAL,8238295,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7734.00000,2242.86000,Aetna,First Health,,6326.41,,,,,,,2490.35,6326.41,percent of total billed charges,
WEDGE,8238389,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8238389,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
HEAD HUMERAL,8238390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HEAD HUMERAL,8238390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
HEAD FEMORAL,8238392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,8238392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
SHELL,8238393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8238393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SHELL,8238420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3475.94,7887.16,percent of total billed charges,
SHELL,8238420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3104.72,7887.16,percent of total billed charges,
SHELL,8238421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3475.94,7887.16,percent of total billed charges,
SHELL,8238421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3104.72,7887.16,percent of total billed charges,
ROD SPINAL,8238422,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8238422,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BOLT,8239859,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,907.31,2058.74,percent of total billed charges,
BOLT,8239859,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,810.41,2058.74,percent of total billed charges,
BOLT,8239861,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,907.31,2058.74,percent of total billed charges,
BOLT,8239861,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,810.41,2058.74,percent of total billed charges,
PLATE,8239863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8239863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
COMPONENT FEMORAL,8239908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,8239908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
ROD SPINAL,8240076,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8240076,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SPACER SPINAL,8240143,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21625.00000,6271.25000,Aetna,First Health,,17689.25,,,,,,,7795.81,17689.25,percent of total billed charges,
SPACER SPINAL,8240143,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21625.00000,6271.25000,Aetna,First Health,,17689.25,,,,,,,6963.25,17689.25,percent of total billed charges,
ROD SPINAL,8240070,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8240070,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8240072,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8240072,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
ROD SPINAL,8240074,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8240074,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
SPINAL IMPLANT,8240077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SPINAL IMPLANT,8240077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
PLATE,8240164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10182.00000,2952.78000,Aetna,First Health,,8328.88,,,,,,,3670.61,8328.88,percent of total billed charges,
PLATE,8240164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10182.00000,2952.78000,Aetna,First Health,,8328.88,,,,,,,3278.60,8328.88,percent of total billed charges,
PLATE,8240166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10182.00000,2952.78000,Aetna,First Health,,8328.88,,,,,,,3670.61,8328.88,percent of total billed charges,
PLATE,8240166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10182.00000,2952.78000,Aetna,First Health,,8328.88,,,,,,,3278.60,8328.88,percent of total billed charges,
SCREW,8240168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,8240168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,8240170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,8240170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,8240172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,8240172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,8240174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,648.90,1472.40,percent of total billed charges,
SCREW,8240174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,579.60,1472.40,percent of total billed charges,
SCREW,8240176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,648.90,1472.40,percent of total billed charges,
SCREW,8240176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,579.60,1472.40,percent of total billed charges,
SCREW,8240178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,8240178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,8240180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,648.90,1472.40,percent of total billed charges,
SCREW,8240180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,579.60,1472.40,percent of total billed charges,
SCREW,8240182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,648.90,1472.40,percent of total billed charges,
SCREW,8240182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,579.60,1472.40,percent of total billed charges,
SCREW,8240184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,648.90,1472.40,percent of total billed charges,
SCREW,8240184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,579.60,1472.40,percent of total billed charges,
SCREW,8240186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,648.90,1472.40,percent of total billed charges,
SCREW,8240186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,579.60,1472.40,percent of total billed charges,
ROD SPINAL,8240188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
ROD SPINAL,8240188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,8240189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SCREW,8240189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CAGE,8240190,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8240190,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
HEAD HUMERAL,8240191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HEAD HUMERAL,8240191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
SCREW,8240192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8240192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
GUIDEWIRE,8240200,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
GUIDEWIRE,8240200,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
SCREW,8240201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,169.87,385.44,percent of total billed charges,
SCREW,8240201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,151.73,385.44,percent of total billed charges,
PLATE,8240202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,605.93,1374.89,percent of total billed charges,
PLATE,8240202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,541.22,1374.89,percent of total billed charges,
NAIL,8240437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,18289.60000,5303.98000,Aetna,First Health,,14960.89,,,,,,,6593.40,14960.89,percent of total billed charges,
NAIL,8240437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,18289.60000,5303.98000,Aetna,First Health,,14960.89,,,,,,,5889.25,14960.89,percent of total billed charges,
SCREW,8240564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8240564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,8240438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8240438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,8240439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2280.00000,661.20000,Aetna,First Health,,1865.04,,,,,,,821.94,1865.04,percent of total billed charges,
SCREW,8240439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2280.00000,661.20000,Aetna,First Health,,1865.04,,,,,,,734.16,1865.04,percent of total billed charges,
SCREW,8240440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2280.00000,661.20000,Aetna,First Health,,1865.04,,,,,,,821.94,1865.04,percent of total billed charges,
SCREW,8240440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2280.00000,661.20000,Aetna,First Health,,1865.04,,,,,,,734.16,1865.04,percent of total billed charges,
ROD,8240443,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5901.28000,1711.37000,Aetna,First Health,,4827.25,,,,,,,2127.41,4827.25,percent of total billed charges,
ROD,8240443,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5901.28000,1711.37000,Aetna,First Health,,4827.25,,,,,,,1900.21,4827.25,percent of total billed charges,
GUIDEWIRE,8240447,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1451.80000,421.02000,Aetna,First Health,,1187.57,,,,,,,523.37,1187.57,percent of total billed charges,
GUIDEWIRE,8240447,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1451.80000,421.02000,Aetna,First Health,,1187.57,,,,,,,467.48,1187.57,percent of total billed charges,
SCREW,8240448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW,8240448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW,8240449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW,8240449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
ROD SPINAL,8240450,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,536.42,1217.18,percent of total billed charges,
ROD SPINAL,8240450,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,479.14,1217.18,percent of total billed charges,
K WIRE,8240567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,684.41000,198.48000,Aetna,First Health,,559.85,,,,,,,246.73,559.85,percent of total billed charges,
K WIRE,8240567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,684.41000,198.48000,Aetna,First Health,,559.85,,,,,,,220.38,559.85,percent of total billed charges,
KIT REPAIR MENISCAL ROOT ANCHOR IN KIT,8240568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5914.13000,1715.10000,Aetna,First Health,,4837.76,,,,,,,2132.04,4837.76,percent of total billed charges,
KIT REPAIR MENISCAL ROOT ANCHOR IN KIT,8240568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5914.13000,1715.10000,Aetna,First Health,,4837.76,,,,,,,1904.35,4837.76,percent of total billed charges,
SPACER,8240569,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
SPACER,8240569,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
VALVE,8240078,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
VALVE,8240078,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
PLATE,7701823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.60000,560.16000,Aetna,First Health,,1580.05,,,,,,,696.34,1580.05,percent of total billed charges,
PLATE,7701823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.60000,560.16000,Aetna,First Health,,1580.05,,,,,,,621.98,1580.05,percent of total billed charges,
SCREW,8243980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
SCREW,8243980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
LINER,8242048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3576.63,8115.62,percent of total billed charges,
LINER,8242048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3194.66,8115.62,percent of total billed charges,
LINER,8242050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3576.63,8115.62,percent of total billed charges,
LINER,8242050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3194.66,8115.62,percent of total billed charges,
HEAD FEMORAL,8242052,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1645.01,3732.64,percent of total billed charges,
HEAD FEMORAL,8242052,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1469.33,3732.64,percent of total billed charges,
CONNECTOR SPINAL,8242054,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
CONNECTOR SPINAL,8242054,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW,8242059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SCREW,8242059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
CAP,8242061,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
CAP,8242061,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
CEMENT,8242056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,432.25000,125.35000,Aetna,First Health,,353.58,,,,,,,155.83,353.58,percent of total billed charges,
CEMENT,8242056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,432.25000,125.35000,Aetna,First Health,,353.58,,,,,,,139.18,353.58,percent of total billed charges,
SCREW,8242058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8242058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8242064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,303.91000,88.13000,Aetna,First Health,,248.60,,,,,,,109.56,248.60,percent of total billed charges,
SCREW,8242064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,303.91000,88.13000,Aetna,First Health,,248.60,,,,,,,97.86,248.60,percent of total billed charges,
COVER,8242066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,814.28000,236.14000,Aetna,First Health,,666.08,,,,,,,293.55,666.08,percent of total billed charges,
COVER,8242066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,814.28000,236.14000,Aetna,First Health,,666.08,,,,,,,262.20,666.08,percent of total billed charges,
CAGE,8242062,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8242062,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
ROD SPINAL,8242069,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
ROD SPINAL,8242069,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
SPACER,8242071,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
SPACER,8242071,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
WEDGE,8242160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8242160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
STENT GRAFT,8242161,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53270.40000,15448.42000,Aetna,First Health,,43575.19,,,,,,,19203.98,43575.19,percent of total billed charges,
STENT GRAFT,8242161,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53270.40000,15448.42000,Aetna,First Health,,43575.19,,,,,,,17153.07,43575.19,percent of total billed charges,
STENT GRAFT,8242163,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,First Health,,41219.35,,,,,,,18165.74,41219.35,percent of total billed charges,
STENT GRAFT,8242163,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,First Health,,41219.35,,,,,,,16225.71,41219.35,percent of total billed charges,
CARTILAGE IMPLANT,8242166,CDM,278,RC,L8641,HCPCS,,,facility,inpatient,,,12264.00000,3556.56000,Aetna,First Health,,10031.95,,,,,,,4421.17,10031.95,percent of total billed charges,
CARTILAGE IMPLANT,8242166,CDM,278,RC,L8641,HCPCS,,,facility,outpatient,,,12264.00000,3556.56000,Aetna,First Health,,10031.95,,,,,,,428.55,10031.95,percent of total billed charges,
INSERT,8243883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8243883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,8243884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8243884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8243974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,227.47,516.15,percent of total billed charges,
SCREW,8243974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,First Health,,516.15,,,,,,,203.18,516.15,percent of total billed charges,
PLATE,8243975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1314.51,2982.71,percent of total billed charges,
PLATE,8243975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1174.12,2982.71,percent of total billed charges,
SCREW,8243976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,8243976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,8243977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,116.29,263.86,percent of total billed charges,
SCREW,8243977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,First Health,,263.86,,,,,,,103.87,263.86,percent of total billed charges,
PLATE,8243978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.10000,1821.52000,Aetna,First Health,,5137.94,,,,,,,2264.34,5137.94,percent of total billed charges,
PLATE,8243978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.10000,1821.52000,Aetna,First Health,,5137.94,,,,,,,2022.51,5137.94,percent of total billed charges,
SCREW,8243979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
SCREW,8243979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
SCREW,8244036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8244036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,8244037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8244037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
GRAFT,8243932,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
GRAFT,8243932,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
VALVE,8244035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
VALVE,8244035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
VALVE,8244026,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,7300.12,16564.50,percent of total billed charges,
VALVE,8244026,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,First Health,,16564.50,,,,,,,6520.50,16564.50,percent of total billed charges,
INSERT,8244118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8244118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
SCREW,8244119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8244119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
SCREW,8244120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8244120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
PLATE,8244121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8786.25000,2548.01000,Aetna,First Health,,7187.15,,,,,,,3167.44,7187.15,percent of total billed charges,
PLATE,8244121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8786.25000,2548.01000,Aetna,First Health,,7187.15,,,,,,,2829.17,7187.15,percent of total billed charges,
SCREW,8244122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8244122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
WEDGE,8244193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19864.05000,5760.57000,Aetna,First Health,,16248.79,,,,,,,7160.99,16248.79,percent of total billed charges,
WEDGE,8244193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19864.05000,5760.57000,Aetna,First Health,,16248.79,,,,,,,6396.22,16248.79,percent of total billed charges,
HEAD HUMERAL,8244213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HEAD HUMERAL,8244213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
CATHETER,8244214,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER,8244214,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
SCREW,8244215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8244215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,8244216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8244216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,8244217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,8244217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,8244218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,8244218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,8244219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,8244219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
PLATE,8244220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5015.50000,1454.50000,Aetna,First Health,,4102.68,,,,,,,1808.09,4102.68,percent of total billed charges,
PLATE,8244220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5015.50000,1454.50000,Aetna,First Health,,4102.68,,,,,,,1614.99,4102.68,percent of total billed charges,
STEM,8244221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
STEM,8244221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
K WIRE,8244269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
K WIRE,8244269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
ROD SPINAL,8244288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8244288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CAGE,8244289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8244289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
SCREW,8244291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,8244291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,8245842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8245842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
GENERATOR,8245843,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,64602.00000,18734.58000,Aetna,First Health,,52844.44,,,,,,,23289.02,52844.44,percent of total billed charges,
GENERATOR,8245843,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,64602.00000,18734.58000,Aetna,First Health,,52844.44,,,,,,,20801.84,52844.44,percent of total billed charges,
MEDPOR IMPLANT,8245844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,33470.24000,9706.37000,Aetna,First Health,,27378.66,,,,,,,12066.02,27378.66,percent of total billed charges,
MEDPOR IMPLANT,8245844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,33470.24000,9706.37000,Aetna,First Health,,27378.66,,,,,,,10777.42,27378.66,percent of total billed charges,
PLATE,8245845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,420.42000,121.92000,Aetna,First Health,,343.90,,,,,,,151.56,343.90,percent of total billed charges,
PLATE,8245845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,420.42000,121.92000,Aetna,First Health,,343.90,,,,,,,135.38,343.90,percent of total billed charges,
BREAST IMPLANT,8245899,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8245899,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
STEM,8245900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,8245900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
INSERT,8245962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8245962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
MESH,8245988,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,33845.63000,9815.23000,Aetna,First Health,,27685.73,,,,,,,12201.35,27685.73,percent of total billed charges,
MESH,8245988,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,33845.63000,9815.23000,Aetna,First Health,,27685.73,,,,,,,10898.29,27685.73,percent of total billed charges,
SCREW,8246037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW,8246037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
CAGE,8245996,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8245996,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
CAGE,8245997,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,8245997,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
SCREW,8245998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8245998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
NAIL,8246152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2903.18,6587.52,percent of total billed charges,
NAIL,8246152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,First Health,,6587.52,,,,,,,2593.13,6587.52,percent of total billed charges,
INSERT,8246153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8246153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ROD SPINAL,8246154,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8246154,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
WEDGE,8246155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1297.08,2943.16,percent of total billed charges,
WEDGE,8246155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1158.56,2943.16,percent of total billed charges,
PLATE,8246226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3389.09000,982.84000,Aetna,First Health,,2772.28,,,,,,,1221.77,2772.28,percent of total billed charges,
PLATE,8246226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3389.09000,982.84000,Aetna,First Health,,2772.28,,,,,,,1091.29,2772.28,percent of total billed charges,
SCREW,8246265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8246265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
ROD SPINAL,8246266,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,536.42,1217.18,percent of total billed charges,
ROD SPINAL,8246266,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,479.14,1217.18,percent of total billed charges,
SCREW,8246267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW,8246267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
INSERT,7974935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,348.46,790.68,percent of total billed charges,
INSERT,7974935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,First Health,,790.68,,,,,,,311.25,790.68,percent of total billed charges,
HEAD FEMORAL,8246426,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9455.34000,2742.05000,Aetna,First Health,,7734.47,,,,,,,3408.65,7734.47,percent of total billed charges,
HEAD FEMORAL,8246426,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9455.34000,2742.05000,Aetna,First Health,,7734.47,,,,,,,3044.62,7734.47,percent of total billed charges,
COMPONENT FEMORAL,8246427,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17212.25000,4991.55000,Aetna,First Health,,14079.62,,,,,,,6205.02,14079.62,percent of total billed charges,
COMPONENT FEMORAL,8246427,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17212.25000,4991.55000,Aetna,First Health,,14079.62,,,,,,,5542.34,14079.62,percent of total billed charges,
COMPONENT FEMORAL,8246428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14409.57000,4178.78000,Aetna,First Health,,11787.03,,,,,,,5194.65,11787.03,percent of total billed charges,
COMPONENT FEMORAL,8246428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14409.57000,4178.78000,Aetna,First Health,,11787.03,,,,,,,4639.88,11787.03,percent of total billed charges,
LINER,8246429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4372.20000,1267.94000,Aetna,First Health,,3576.46,,,,,,,1576.18,3576.46,percent of total billed charges,
LINER,8246429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4372.20000,1267.94000,Aetna,First Health,,3576.46,,,,,,,1407.85,3576.46,percent of total billed charges,
LINER,8246430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8079.30000,2343.00000,Aetna,First Health,,6608.87,,,,,,,2912.59,6608.87,percent of total billed charges,
LINER,8246430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8079.30000,2343.00000,Aetna,First Health,,6608.87,,,,,,,2601.53,6608.87,percent of total billed charges,
CAGE,8246432,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8246432,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
ROD SPINAL,8246433,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8246433,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8246434,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8246434,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
CAGE,8246492,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8246492,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
SCREW,8246493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8246493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
EMBOLIZATION COIL,8246494,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,657.86000,190.78000,Aetna,First Health,,538.13,,,,,,,237.16,538.13,percent of total billed charges,
EMBOLIZATION COIL,8246494,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,657.86000,190.78000,Aetna,First Health,,538.13,,,,,,,211.83,538.13,percent of total billed charges,
EMBOLIZATION COIL,8246495,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,657.86000,190.78000,Aetna,First Health,,538.13,,,,,,,237.16,538.13,percent of total billed charges,
EMBOLIZATION COIL,8246495,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,657.86000,190.78000,Aetna,First Health,,538.13,,,,,,,211.83,538.13,percent of total billed charges,
EMBOLIZATION COIL,8246496,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,657.86000,190.78000,Aetna,First Health,,538.13,,,,,,,237.16,538.13,percent of total billed charges,
EMBOLIZATION COIL,8246496,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,657.86000,190.78000,Aetna,First Health,,538.13,,,,,,,211.83,538.13,percent of total billed charges,
EMBOLIZATION COIL,8246497,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,657.86000,190.78000,Aetna,First Health,,538.13,,,,,,,237.16,538.13,percent of total billed charges,
EMBOLIZATION COIL,8246497,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,657.86000,190.78000,Aetna,First Health,,538.13,,,,,,,211.83,538.13,percent of total billed charges,
EMBOLIZATION COIL,8246498,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
EMBOLIZATION COIL,8246498,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
EMBOLIZATION COIL,8246499,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
EMBOLIZATION COIL,8246499,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
EMBOLIZATION COIL,8246500,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
EMBOLIZATION COIL,8246500,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
EMBOLIZATION COIL,8246501,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,220.03,499.26,percent of total billed charges,
EMBOLIZATION COIL,8246501,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,196.53,499.26,percent of total billed charges,
EMBOLIZATION COIL,8246502,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
EMBOLIZATION COIL,8246502,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
EMBOLIZATION COIL,8246503,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
EMBOLIZATION COIL,8246503,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
EMBOLIZATION COIL,8246504,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,711.95000,206.47000,Aetna,First Health,,582.38,,,,,,,256.66,582.38,percent of total billed charges,
EMBOLIZATION COIL,8246504,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,711.95000,206.47000,Aetna,First Health,,582.38,,,,,,,229.25,582.38,percent of total billed charges,
EMBOLIZATION COIL,8246505,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,711.95000,206.47000,Aetna,First Health,,582.38,,,,,,,256.66,582.38,percent of total billed charges,
EMBOLIZATION COIL,8246505,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,711.95000,206.47000,Aetna,First Health,,582.38,,,,,,,229.25,582.38,percent of total billed charges,
EMBOLIZATION COIL,8246506,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,711.95000,206.47000,Aetna,First Health,,582.38,,,,,,,256.66,582.38,percent of total billed charges,
EMBOLIZATION COIL,8246506,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,711.95000,206.47000,Aetna,First Health,,582.38,,,,,,,229.25,582.38,percent of total billed charges,
EMBOLIZATION COIL,8246507,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,711.95000,206.47000,Aetna,First Health,,582.38,,,,,,,256.66,582.38,percent of total billed charges,
EMBOLIZATION COIL,8246507,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,711.95000,206.47000,Aetna,First Health,,582.38,,,,,,,229.25,582.38,percent of total billed charges,
EMBOLIZATION COIL,8246508,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,752.72000,218.29000,Aetna,First Health,,615.72,,,,,,,271.36,615.72,percent of total billed charges,
EMBOLIZATION COIL,8246508,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,752.72000,218.29000,Aetna,First Health,,615.72,,,,,,,242.38,615.72,percent of total billed charges,
BREAST IMPLANT,8246599,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,8246599,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
BREAST IMPLANT,8246600,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,8246600,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
BREAST IMPLANT,8246601,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,8246601,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
BREAST IMPLANT,8246602,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,8246602,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
WEDGE,8246628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8246628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
LINER,8246629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
LINER,8246629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SHELL,8246630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8246630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
WEDGE,8246662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1297.08,2943.16,percent of total billed charges,
WEDGE,8246662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1158.56,2943.16,percent of total billed charges,
LINER,8246741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8246741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
SHELL,8246742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,8246742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
NAIL,8246743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8246743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
STEM,8246868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8246868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
PLATE,8246880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1222.30,2773.48,percent of total billed charges,
PLATE,8246880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1091.76,2773.48,percent of total billed charges,
INSERT,8246881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8246881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8246967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8246967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HEAD HUMERAL,8246970,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,8246970,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
WEDGE,8246972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
WEDGE,8246972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
STEM,8246974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM,8246974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
STEM,8246976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
STEM,8246976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
ANCHOR,7699542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,544.72,1236.00,percent of total billed charges,
ANCHOR,7699542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,486.54,1236.00,percent of total billed charges,
STENT,8246979,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
STENT,8246979,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
SCREW,8247054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
SCREW,8247054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
INSERT,8247055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8247055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8247067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,17067.90000,4949.69000,Aetna,First Health,,13961.54,,,,,,,6152.98,13961.54,percent of total billed charges,
PLATE,8247067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,17067.90000,4949.69000,Aetna,First Health,,13961.54,,,,,,,5495.86,13961.54,percent of total billed charges,
SHELL,8247068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11484.00000,3330.36000,Aetna,First Health,,9393.91,,,,,,,4139.98,9393.91,percent of total billed charges,
SHELL,8247068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11484.00000,3330.36000,Aetna,First Health,,9393.91,,,,,,,3697.85,9393.91,percent of total billed charges,
LINER,8247069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2365.78,5368.12,percent of total billed charges,
LINER,8247069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2113.12,5368.12,percent of total billed charges,
HEAD FEMORAL,8247070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6214.74000,1802.27000,Aetna,First Health,,5083.66,,,,,,,2240.41,5083.66,percent of total billed charges,
HEAD FEMORAL,8247070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6214.74000,1802.27000,Aetna,First Health,,5083.66,,,,,,,2001.15,5083.66,percent of total billed charges,
SCREW,8247102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8247102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8247103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8247103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8247104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8247104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8247105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8247105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8247106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8247106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8247107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8247107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
GRAFT,8247099,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
GRAFT,8247099,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
GRAFT,8247100,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5634.61,12785.34,percent of total billed charges,
GRAFT,8247100,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5032.86,12785.34,percent of total billed charges,
ROD SPINAL,8247173,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8247173,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
PLATE,8247843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1421.99,3226.60,percent of total billed charges,
PLATE,8247843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1270.13,3226.60,percent of total billed charges,
GRAFT,8247850,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5634.61,12785.34,percent of total billed charges,
GRAFT,8247850,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5032.86,12785.34,percent of total billed charges,
SCREW,8247859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8247859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8247860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8247860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW,8247861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8247861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
GRAFT STENT,8247924,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
GRAFT STENT,8247924,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
BALLOON,8247925,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
BALLOON,8247925,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
SCREW,8247926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8247926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,8247927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8247927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
ANCHOR,8247929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2756.60000,799.41000,Aetna,First Health,,2254.90,,,,,,,993.75,2254.90,percent of total billed charges,
ANCHOR,8247929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2756.60000,799.41000,Aetna,First Health,,2254.90,,,,,,,887.63,2254.90,percent of total billed charges,
ACETABULAR CUP,8247965,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1876.22,4257.28,percent of total billed charges,
ACETABULAR CUP,8247965,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1675.85,4257.28,percent of total billed charges,
SHELL,8247966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8247966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STENT,8247964,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,2182.72,4952.74,percent of total billed charges,
STENT,8247964,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,First Health,,4952.74,,,,,,,1949.61,4952.74,percent of total billed charges,
STAPLE,8247983,CDM,278,RC,C9354,HCPCS,,,facility,inpatient,,,1321.61000,383.27000,Aetna,First Health,,1081.08,,,,,,,476.44,1081.08,percent of total billed charges,
STAPLE,8247983,CDM,278,RC,C9354,HCPCS,,,facility,outpatient,,,1321.61000,383.27000,Aetna,First Health,,1081.08,,,,,,,425.56,1081.08,percent of total billed charges,
SCREW,8248004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,644.57,1462.58,percent of total billed charges,
SCREW,8248004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,First Health,,1462.58,,,,,,,575.74,1462.58,percent of total billed charges,
SCREW,8248518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8248518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
COMPONENT FEMORAL,8248508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
COMPONENT FEMORAL,8248508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
ADAPTER,8248509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5187.00000,1504.23000,Aetna,First Health,,4242.97,,,,,,,1869.91,4242.97,percent of total billed charges,
ADAPTER,8248509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5187.00000,1504.23000,Aetna,First Health,,4242.97,,,,,,,1670.21,4242.97,percent of total billed charges,
STEM,8248510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1360.00000,394.40000,Aetna,First Health,,1112.48,,,,,,,490.28,1112.48,percent of total billed charges,
STEM,8248510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1360.00000,394.40000,Aetna,First Health,,1112.48,,,,,,,437.92,1112.48,percent of total billed charges,
STEM,8248511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8248511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
STEM,8248512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1360.00000,394.40000,Aetna,First Health,,1112.48,,,,,,,490.28,1112.48,percent of total billed charges,
STEM,8248512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1360.00000,394.40000,Aetna,First Health,,1112.48,,,,,,,437.92,1112.48,percent of total billed charges,
STEM,8248513,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8248513,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
COMPONENT TIBIAL,8248514,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,8248514,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
INSERT,8248515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8248515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
PLATE,8248507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8248507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8248573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,702.00000,203.58000,Aetna,First Health,,574.24,,,,,,,253.07,574.24,percent of total billed charges,
SCREW,8248573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,702.00000,203.58000,Aetna,First Health,,574.24,,,,,,,226.04,574.24,percent of total billed charges,
ENDPLATE,8248574,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8248574,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
INSERT,8248625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8248625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
SCREW,8248626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,8248626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,8248627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,8248627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,8248628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,8248628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
NAIL,8248629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8248629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
HOLE COVER,8248630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,819.95000,237.79000,Aetna,First Health,,670.72,,,,,,,295.59,670.72,percent of total billed charges,
HOLE COVER,8248630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,819.95000,237.79000,Aetna,First Health,,670.72,,,,,,,264.02,670.72,percent of total billed charges,
SCREW,8249887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
SCREW,8249887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
COMPONENT FEMORAL,8249888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,8249888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
WEDGE,8249889,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE,8249889,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
INSERT,8249890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8249890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,8249911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8249911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8251848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8251848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
ROD SPINAL,8251849,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8251849,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
SCREW,8251850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1490.13,3381.20,percent of total billed charges,
SCREW,8251850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1330.99,3381.20,percent of total billed charges,
PLATE,8251852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6583.50000,1909.22000,Aetna,First Health,,5385.30,,,,,,,2373.35,5385.30,percent of total billed charges,
PLATE,8251852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6583.50000,1909.22000,Aetna,First Health,,5385.30,,,,,,,2119.89,5385.30,percent of total billed charges,
SCREW,8251853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
SCREW,8251853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,421.18,1069.94,percent of total billed charges,
SCREW,8251854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
SCREW,8251854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,421.18,1069.94,percent of total billed charges,
SCREW,8251855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
SCREW,8251855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,421.18,1069.94,percent of total billed charges,
SCREW,8251856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
SCREW,8251856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
SCREW,8251857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,8251857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
SPACER SPINAL,8251912,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
SPACER SPINAL,8251912,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
SPACER,8251935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SPACER,8251935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
PLATE,8251941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5568.50000,1614.86000,Aetna,First Health,,4555.03,,,,,,,2007.44,4555.03,percent of total billed charges,
PLATE,8251941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5568.50000,1614.86000,Aetna,First Health,,4555.03,,,,,,,1793.06,4555.03,percent of total billed charges,
SCREW,8251942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8251942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8251943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8251943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8251944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8251944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8251945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8251945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8251946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8251946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8253852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
SCREW,8253852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
INSERT,8253891,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8253891,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
LINER,8253892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8253892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
HEAD FEMORAL,8253893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,8253893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
ACETABULAR RING,8253894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,82.14,186.38,percent of total billed charges,
ACETABULAR RING,8253894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,First Health,,186.38,,,,,,,73.37,186.38,percent of total billed charges,
STEM,8253924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM,8253924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
SCREW,8253925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8253925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SHELL,8253926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8253926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
INSERT,8253927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8253927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STEM,8253928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8253928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
PLATE,8253929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3706.82000,1074.98000,Aetna,First Health,,3032.18,,,,,,,1336.31,3032.18,percent of total billed charges,
PLATE,8253929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3706.82000,1074.98000,Aetna,First Health,,3032.18,,,,,,,1193.60,3032.18,percent of total billed charges,
SCREW,8253930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,8253930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SPACER,8253931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
SPACER,8253931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
ROD SPINAL,8255882,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
ROD SPINAL,8255882,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
PROXIMAL CONE BODY,7698818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
PROXIMAL CONE BODY,7698818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
HEAD FEMORAL,8255883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8255883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
COMPONENT FEMORAL,8255895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
COMPONENT FEMORAL,8255895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
STEM,8255897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2970.88,6741.14,percent of total billed charges,
STEM,8255897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2653.60,6741.14,percent of total billed charges,
COMPONENT FEMORAL,8255898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
COMPONENT FEMORAL,8255898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
NAIL,8255908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,First Health,,3312.49,,,,,,,1459.84,3312.49,percent of total billed charges,
NAIL,8255908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,First Health,,3312.49,,,,,,,1303.94,3312.49,percent of total billed charges,
NAIL,8256094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,First Health,,3555.85,,,,,,,1567.09,3555.85,percent of total billed charges,
NAIL,8256094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,First Health,,3555.85,,,,,,,1399.73,3555.85,percent of total billed charges,
COMPONENT FEMORAL,8256095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
COMPONENT FEMORAL,8256095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
LINER,8256096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
LINER,8256096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
BASEPLATE,8256097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,8256097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
INSERT,8256098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8256098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8256099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8256099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
STEM,8256135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8256135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
SCREW,8256288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,8256288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
PLATE,8256289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6132.00000,1778.28000,Aetna,First Health,,5015.98,,,,,,,2210.59,5015.98,percent of total billed charges,
PLATE,8256289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6132.00000,1778.28000,Aetna,First Health,,5015.98,,,,,,,1974.50,5015.98,percent of total billed charges,
SCREW,8256290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,8256290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
PLATE,8256291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4576.29000,1327.12000,Aetna,First Health,,3743.41,,,,,,,1649.75,3743.41,percent of total billed charges,
PLATE,8256291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4576.29000,1327.12000,Aetna,First Health,,3743.41,,,,,,,1473.57,3743.41,percent of total billed charges,
INSERT,8256435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8256435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HEAD FEMORAL,8256450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
HEAD FEMORAL,8256450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
WEDGE,8256451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
WEDGE,8256451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
WEDGE,8257895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
WEDGE,8257895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
ANCHOR,8256452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
ANCHOR,8256452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
STEM,8256477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2970.88,6741.14,percent of total billed charges,
STEM,8256477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2653.60,6741.14,percent of total billed charges,
ANCHOR,8257859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.52000,391.65000,Aetna,First Health,,1104.73,,,,,,,486.86,1104.73,percent of total billed charges,
ANCHOR,8257859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.52000,391.65000,Aetna,First Health,,1104.73,,,,,,,434.87,1104.73,percent of total billed charges,
INSERT,8257860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8257860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8257861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8257861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
HEAD HUMERAL,8257868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
HEAD HUMERAL,8257868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
HEAD HUMERAL,8257869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,6038.38,13701.50,percent of total billed charges,
HEAD HUMERAL,8257869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,5393.50,13701.50,percent of total billed charges,
ANCHOR,8259906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2092.00000,606.68000,Aetna,First Health,,1711.26,,,,,,,754.17,1711.26,percent of total billed charges,
ANCHOR,8259906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2092.00000,606.68000,Aetna,First Health,,1711.26,,,,,,,673.62,1711.26,percent of total billed charges,
ANCHOR,8259913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
ANCHOR,8259913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
ANCHOR,8259914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
ANCHOR,8259914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
MESH,8259918,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
MESH,8259918,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
PLATE,8259919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1654.80000,479.89000,Aetna,First Health,,1353.63,,,,,,,596.56,1353.63,percent of total billed charges,
PLATE,8259919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1654.80000,479.89000,Aetna,First Health,,1353.63,,,,,,,532.85,1353.63,percent of total billed charges,
BREAST IMPLANT,8259920,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
BREAST IMPLANT,8259920,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
BREAST IMPLANT,8259921,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
BREAST IMPLANT,8259921,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
NAIL,8260001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8260001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
PLATE,8260002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1314.51,2982.71,percent of total billed charges,
PLATE,8260002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,First Health,,2982.71,,,,,,,1174.12,2982.71,percent of total billed charges,
SCREW,8260003,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,8260003,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,8260004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,8260004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
ANCHOR,8259993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
ANCHOR,8259993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
ANCHOR,8260035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,First Health,,1914.12,,,,,,,843.57,1914.12,percent of total billed charges,
ANCHOR,8260035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,First Health,,1914.12,,,,,,,753.48,1914.12,percent of total billed charges,
ANCHOR,8260036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2180.00000,632.20000,Aetna,First Health,,1783.24,,,,,,,785.89,1783.24,percent of total billed charges,
ANCHOR,8260036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2180.00000,632.20000,Aetna,First Health,,1783.24,,,,,,,701.96,1783.24,percent of total billed charges,
CAGE,8260037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8260037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
CAGE,8260038,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
CAGE,8260038,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
SCREW,8260039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW,8260039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
SCREW,8260040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SCREW,8260040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
STEM,8260082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,8260082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
SCREW,8260117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8260117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
ROD SPINAL,8260106,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8260106,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
SCREW CORTICAL,8260136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW CORTICAL,8260136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
PLATE,8260137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,8260137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
LEAD,8260139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
LEAD,8260139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
WEDGE,8261911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8261911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
CEMENT BONE,8260218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1857.00000,538.53000,Aetna,First Health,,1519.03,,,,,,,669.45,1519.03,percent of total billed charges,
CEMENT BONE,8260218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1857.00000,538.53000,Aetna,First Health,,1519.03,,,,,,,597.95,1519.03,percent of total billed charges,
SCREW,8260219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8260219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SCREW POLYAXIAL,8260220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW POLYAXIAL,8260220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
ROD,8260221,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
ROD,8260221,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
INSERT,8262205,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3213.00000,931.77000,Aetna,First Health,,2628.23,,,,,,,1158.29,2628.23,percent of total billed charges,
INSERT,8262205,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3213.00000,931.77000,Aetna,First Health,,2628.23,,,,,,,1034.59,2628.23,percent of total billed charges,
INSERT,8261912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8261912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8261913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8261913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8261914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8261914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8261965,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8261965,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
SCREW,8261966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8261966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
NAIL,8261967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11684.25000,3388.43000,Aetna,First Health,,9557.72,,,,,,,4212.17,9557.72,percent of total billed charges,
NAIL,8261967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11684.25000,3388.43000,Aetna,First Health,,9557.72,,,,,,,3762.33,9557.72,percent of total billed charges,
NAIL,8261968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1211.28,2748.48,percent of total billed charges,
NAIL,8261968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1081.92,2748.48,percent of total billed charges,
SCREW,7703190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1648.00000,477.92000,Aetna,First Health,,1348.06,,,,,,,594.10,1348.06,percent of total billed charges,
SCREW,7703190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1648.00000,477.92000,Aetna,First Health,,1348.06,,,,,,,530.66,1348.06,percent of total billed charges,
PLATE,8261969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3105.96000,900.73000,Aetna,First Health,,2540.68,,,,,,,1119.70,2540.68,percent of total billed charges,
PLATE,8261969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3105.96000,900.73000,Aetna,First Health,,2540.68,,,,,,,1000.12,2540.68,percent of total billed charges,
HEAD FEMORAL,8261970,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8261970,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW,8262047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4676.00000,1356.04000,Aetna,First Health,,3824.97,,,,,,,1685.70,3824.97,percent of total billed charges,
SCREW,8262047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4676.00000,1356.04000,Aetna,First Health,,3824.97,,,,,,,1505.67,3824.97,percent of total billed charges,
INSERT,8262041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8262041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
BOLT,8262043,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BOLT,8262043,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
CAGE,8262045,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8262045,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
SCREW,8262048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8262048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
PLATE,8262049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5341.63000,1549.07000,Aetna,First Health,,4369.45,,,,,,,1925.66,4369.45,percent of total billed charges,
PLATE,8262049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5341.63000,1549.07000,Aetna,First Health,,4369.45,,,,,,,1720.00,4369.45,percent of total billed charges,
SCREW,8262069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.87000,114.22000,Aetna,First Health,,322.19,,,,,,,141.99,322.19,percent of total billed charges,
SCREW,8262069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.87000,114.22000,Aetna,First Health,,322.19,,,,,,,126.83,322.19,percent of total billed charges,
SCREW,8262195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4676.00000,1356.04000,Aetna,First Health,,3824.97,,,,,,,1685.70,3824.97,percent of total billed charges,
SCREW,8262195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4676.00000,1356.04000,Aetna,First Health,,3824.97,,,,,,,1505.67,3824.97,percent of total billed charges,
INSERT,8262196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8262196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8262197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8262197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
WEDGE,8262198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4014.50000,1164.20000,Aetna,First Health,,3283.86,,,,,,,1447.23,3283.86,percent of total billed charges,
WEDGE,8262198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4014.50000,1164.20000,Aetna,First Health,,3283.86,,,,,,,1292.67,3283.86,percent of total billed charges,
COMPONENT FEMORAL,8262199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,4351.96,9874.90,percent of total billed charges,
COMPONENT FEMORAL,8262199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,3887.18,9874.90,percent of total billed charges,
COMPONENT FEMORAL,8262200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2144.00000,621.76000,Aetna,First Health,,1753.79,,,,,,,772.91,1753.79,percent of total billed charges,
COMPONENT FEMORAL,8262200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2144.00000,621.76000,Aetna,First Health,,1753.79,,,,,,,690.37,1753.79,percent of total billed charges,
BASEPLATE,8262201,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5935.93000,1721.42000,Aetna,First Health,,4855.59,,,,,,,2139.90,4855.59,percent of total billed charges,
BASEPLATE,8262201,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5935.93000,1721.42000,Aetna,First Health,,4855.59,,,,,,,1911.37,4855.59,percent of total billed charges,
GLENOSPHERE,8262202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,2224.35,5047.22,percent of total billed charges,
GLENOSPHERE,8262202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,1986.80,5047.22,percent of total billed charges,
BREAST IMPLANT,8262203,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
BREAST IMPLANT,8262203,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
BREAST IMPLANT,8262204,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
BREAST IMPLANT,8262204,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
STENT GRAFT,8262206,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,8262206,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
PLATE,8262287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8262287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8262288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8262288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8262289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8262289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
INSERT,8262290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8262290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
FHL SYSTEM ANCHOR,8262291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
FHL SYSTEM ANCHOR,8262291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
STEM,8262292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8262292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PLATE,8262293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1151.87,2613.67,percent of total billed charges,
PLATE,8262293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,First Health,,2613.67,,,,,,,1028.85,2613.67,percent of total billed charges,
PLATE,8262294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,1072.65,2433.91,percent of total billed charges,
PLATE,8262294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,958.09,2433.91,percent of total billed charges,
CAGE,8262295,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8262295,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
CROSS CONNECTOR,8262296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CROSS CONNECTOR,8262296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
ROD SPINAL,8262297,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8262297,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8262298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,8262298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
STEM,8262299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,8262299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
CAGE,8262300,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8262300,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
HEAD FEMORAL,8262386,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8262386,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
GLENOSPHERE,8265850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,2224.35,5047.22,percent of total billed charges,
GLENOSPHERE,8265850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,1986.80,5047.22,percent of total billed charges,
NAIL,8265851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8265851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
LINER,8265852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8392.50000,2433.82000,Aetna,First Health,,6865.06,,,,,,,3025.50,6865.06,percent of total billed charges,
LINER,8265852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8392.50000,2433.82000,Aetna,First Health,,6865.06,,,,,,,2702.39,6865.06,percent of total billed charges,
CAGE,8265853,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8304.00000,2408.16000,Aetna,First Health,,6792.67,,,,,,,2993.59,6792.67,percent of total billed charges,
CAGE,8265853,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8304.00000,2408.16000,Aetna,First Health,,6792.67,,,,,,,2673.89,6792.67,percent of total billed charges,
PLATE,8265854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3706.82000,1074.98000,Aetna,First Health,,3032.18,,,,,,,1336.31,3032.18,percent of total billed charges,
PLATE,8265854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3706.82000,1074.98000,Aetna,First Health,,3032.18,,,,,,,1193.60,3032.18,percent of total billed charges,
PLATE,8265855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5300.89000,1537.26000,Aetna,First Health,,4336.13,,,,,,,1910.97,4336.13,percent of total billed charges,
PLATE,8265855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5300.89000,1537.26000,Aetna,First Health,,4336.13,,,,,,,1706.89,4336.13,percent of total billed charges,
PLATE,8265856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5241.15000,1519.93000,Aetna,First Health,,4287.26,,,,,,,1889.43,4287.26,percent of total billed charges,
PLATE,8265856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5241.15000,1519.93000,Aetna,First Health,,4287.26,,,,,,,1687.65,4287.26,percent of total billed charges,
STENT,8266002,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,772.88000,224.14000,Aetna,First Health,,632.22,,,,,,,278.62,632.22,percent of total billed charges,
STENT,8266002,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,772.88000,224.14000,Aetna,First Health,,632.22,,,,,,,248.87,632.22,percent of total billed charges,
INSERT,8266013,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT,8266013,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
WEDGE,8266014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3942.07,8944.83,percent of total billed charges,
WEDGE,8266014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3521.07,8944.83,percent of total billed charges,
INSERT,8266015,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8266015,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SCREW,8266016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8266016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
BASEPLATE,8267867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
BASEPLATE,8267867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
SCREW,8267868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8267868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,8267869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8267869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
ROD SPINAL,8267870,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8267870,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
HEAD RADIAL,8269858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
HEAD RADIAL,8269858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
SCREW,8269870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8269870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8269871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8269871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
ANCHOR,8269873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3164.48000,917.70000,Aetna,First Health,,2588.54,,,,,,,1140.80,2588.54,percent of total billed charges,
ANCHOR,8269873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3164.48000,917.70000,Aetna,First Health,,2588.54,,,,,,,1018.96,2588.54,percent of total billed charges,
SCREW,8269874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,860.87,1953.38,percent of total billed charges,
SCREW,8269874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,768.94,1953.38,percent of total billed charges,
GUIDEWIRE,8269875,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,634.50000,184.00000,Aetna,First Health,,519.02,,,,,,,228.74,519.02,percent of total billed charges,
GUIDEWIRE,8269875,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,634.50000,184.00000,Aetna,First Health,,519.02,,,,,,,204.31,519.02,percent of total billed charges,
SCREW,8269876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,8269876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
SCREW,8269877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8269877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8269923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1707.44000,495.16000,Aetna,First Health,,1396.69,,,,,,,615.53,1396.69,percent of total billed charges,
SCREW,8269923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1707.44000,495.16000,Aetna,First Health,,1396.69,,,,,,,549.80,1396.69,percent of total billed charges,
PLATE,8269878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4364.50000,1265.70000,Aetna,First Health,,3570.16,,,,,,,1573.40,3570.16,percent of total billed charges,
PLATE,8269878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4364.50000,1265.70000,Aetna,First Health,,3570.16,,,,,,,1405.37,3570.16,percent of total billed charges,
PLATE,8269924,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10178.13000,2951.66000,Aetna,First Health,,8325.71,,,,,,,3669.22,8325.71,percent of total billed charges,
PLATE,8269924,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10178.13000,2951.66000,Aetna,First Health,,8325.71,,,,,,,3277.36,8325.71,percent of total billed charges,
CONNECTOR SPINAL,8269946,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,1106.01,2509.62,percent of total billed charges,
CONNECTOR SPINAL,8269946,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,987.90,2509.62,percent of total billed charges,
ROD SPINAL,8269947,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8269947,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW,8269948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8269948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
ROD SPINAL,8269949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8269949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT TIBIAL,8270039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,6518.74,14791.49,percent of total billed charges,
COMPONENT TIBIAL,8270039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,5822.56,14791.49,percent of total billed charges,
STENT GRAFT,8270040,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,8270040,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
SCREW,8270067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8270067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
INSERT,8270068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2708.08,6144.82,percent of total billed charges,
INSERT,8270068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2418.86,6144.82,percent of total billed charges,
CAGE,8270087,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8270087,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
STENT GRAFT,8270086,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,8270086,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
FIXATION STAPLE,8246415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3644.38,8269.37,percent of total billed charges,
FIXATION STAPLE,8246415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3255.18,8269.37,percent of total billed charges,
SCREW,8270126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,8270126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,8270120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,8270120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,8270122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8270122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
SCREW,8270124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8270124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
FIXATION STAPLE,8270130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3644.38,8269.37,percent of total billed charges,
FIXATION STAPLE,8270130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3255.18,8269.37,percent of total billed charges,
FIXATION STAPLE,8270131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3644.38,8269.37,percent of total billed charges,
FIXATION STAPLE,8270131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3255.18,8269.37,percent of total billed charges,
PLATE,8270173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8270173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8270250,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8270250,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
SCREW,8270251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,860.87,1953.38,percent of total billed charges,
SCREW,8270251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,768.94,1953.38,percent of total billed charges,
SCREW,8270252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,8270252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
SCREW,8270253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,8270253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
PLATE,8270329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8270329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
COMPONENT FEMORAL,8270330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,8270330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
INSERT,8270331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8270331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT TIBIAL,8270332,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,8270332,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
SCREW,8270391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8270391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
STEM,8270393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2380.26,5400.97,percent of total billed charges,
STEM,8270393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,First Health,,5400.97,,,,,,,2126.05,5400.97,percent of total billed charges,
STENT GRAFT,8271980,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,8271980,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
SCREW,8271983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,8271983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,8271985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8271985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
HEAD HUMERAL,8271987,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HEAD HUMERAL,8271987,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
ENDPLATE,8248505,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8248505,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
SCREW,7695852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,7695852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,8137506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8137506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
NAIL,8273871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,8273871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
INSERT,8273870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8273870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CATHETER,8273872,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
CATHETER,8273872,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
LEAD,8273896,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11670.00000,3384.30000,Aetna,First Health,,9546.06,,,,,,,4207.03,9546.06,percent of total billed charges,
LEAD,8273896,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11670.00000,3384.30000,Aetna,First Health,,9546.06,,,,,,,3757.74,9546.06,percent of total billed charges,
LEAD,8273897,CDM,278,RC,L8680,HCPCS,,,facility,inpatient,,,10962.00000,3178.98000,Aetna,First Health,,8966.92,,,,,,,3951.80,8966.92,percent of total billed charges,
LEAD,8273897,CDM,278,RC,L8680,HCPCS,,,facility,outpatient,,,10962.00000,3178.98000,Aetna,First Health,,8966.92,,,,,,,3529.76,8966.92,percent of total billed charges,
HEAD HUMERAL,8273904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,6038.38,13701.50,percent of total billed charges,
HEAD HUMERAL,8273904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,5393.50,13701.50,percent of total billed charges,
HEAD HUMERAL,8275870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
HEAD HUMERAL,8275870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
CAGE,8275872,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8304.00000,2408.16000,Aetna,First Health,,6792.67,,,,,,,2993.59,6792.67,percent of total billed charges,
CAGE,8275872,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8304.00000,2408.16000,Aetna,First Health,,6792.67,,,,,,,2673.89,6792.67,percent of total billed charges,
INSERT,8275873,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8275873,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
HEAD FEMORAL,8275922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9455.34000,2742.05000,Aetna,First Health,,7734.47,,,,,,,3408.65,7734.47,percent of total billed charges,
HEAD FEMORAL,8275922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9455.34000,2742.05000,Aetna,First Health,,7734.47,,,,,,,3044.62,7734.47,percent of total billed charges,
COMPONENT FEMORAL,8275923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17212.25000,4991.55000,Aetna,First Health,,14079.62,,,,,,,6205.02,14079.62,percent of total billed charges,
COMPONENT FEMORAL,8275923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17212.25000,4991.55000,Aetna,First Health,,14079.62,,,,,,,5542.34,14079.62,percent of total billed charges,
LINER,8275871,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,8275871,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
EXTENSION LEAD,8275957,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
EXTENSION LEAD,8275957,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
PLATE,8275958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5300.89000,1537.26000,Aetna,First Health,,4336.13,,,,,,,1910.97,4336.13,percent of total billed charges,
PLATE,8275958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5300.89000,1537.26000,Aetna,First Health,,4336.13,,,,,,,1706.89,4336.13,percent of total billed charges,
PLATE,8275959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1222.30,2773.48,percent of total billed charges,
PLATE,8275959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1091.76,2773.48,percent of total billed charges,
ROD SPINAL,8275983,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8275983,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
ROD SPINAL,8275984,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8275984,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
PLATE,8275985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5290.04000,1534.11000,Aetna,First Health,,4327.25,,,,,,,1907.06,4327.25,percent of total billed charges,
PLATE,8275985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5290.04000,1534.11000,Aetna,First Health,,4327.25,,,,,,,1703.39,4327.25,percent of total billed charges,
HOLE COVER,8277921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1329.12000,385.44000,Aetna,First Health,,1087.22,,,,,,,479.15,1087.22,percent of total billed charges,
HOLE COVER,8277921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1329.12000,385.44000,Aetna,First Health,,1087.22,,,,,,,427.98,1087.22,percent of total billed charges,
SCREW,8277922,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2381.84000,690.73000,Aetna,First Health,,1948.35,,,,,,,858.65,1948.35,percent of total billed charges,
SCREW,8277922,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2381.84000,690.73000,Aetna,First Health,,1948.35,,,,,,,766.95,1948.35,percent of total billed charges,
SCREW,8277925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8277925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
PLATE,8277926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5537.00000,1605.73000,Aetna,First Health,,4529.27,,,,,,,1996.09,4529.27,percent of total billed charges,
PLATE,8277926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5537.00000,1605.73000,Aetna,First Health,,4529.27,,,,,,,1782.91,4529.27,percent of total billed charges,
GUIDEWIRE,8277990,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,182.54000,52.94000,Aetna,First Health,,149.32,,,,,,,65.81,149.32,percent of total billed charges,
GUIDEWIRE,8277990,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,182.54000,52.94000,Aetna,First Health,,149.32,,,,,,,58.78,149.32,percent of total billed charges,
STEM,8278073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8278073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SCREW,8278074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8278074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8278075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8278075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ROD SPINAL,8278076,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8278076,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8278077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SCREW,8278077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SCREW,8278078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SCREW,8278078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SCREW,8278079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SCREW,8278079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SCREW,8278080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SCREW,8278080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SCREW,8278081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SCREW,8278081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SCREW,8278082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,8278082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SCREW,8278083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SCREW,8278083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SCREW,8278141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8278141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8278142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8278142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8278143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8278143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8278144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8278144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
K WIRE,8278146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
K WIRE,8278146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
SCREW,8278149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,319.58,725.16,percent of total billed charges,
SCREW,8278149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,285.45,725.16,percent of total billed charges,
CAGE,8278420,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8278420,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
PLATE,8278580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5200.41000,1508.12000,Aetna,First Health,,4253.94,,,,,,,1874.75,4253.94,percent of total billed charges,
PLATE,8278580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5200.41000,1508.12000,Aetna,First Health,,4253.94,,,,,,,1674.53,4253.94,percent of total billed charges,
PLATE,8278582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5243.91000,1520.73000,Aetna,First Health,,4289.52,,,,,,,1890.43,4289.52,percent of total billed charges,
PLATE,8278582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5243.91000,1520.73000,Aetna,First Health,,4289.52,,,,,,,1688.54,4289.52,percent of total billed charges,
PLATE,8278584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5290.04000,1534.11000,Aetna,First Health,,4327.25,,,,,,,1907.06,4327.25,percent of total billed charges,
PLATE,8278584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5290.04000,1534.11000,Aetna,First Health,,4327.25,,,,,,,1703.39,4327.25,percent of total billed charges,
HEART VALVE,8338470,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
HEART VALVE,8338470,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
HEART VALVE,8338471,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
HEART VALVE,8338471,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
HEART VALVE,8338472,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
HEART VALVE,8338472,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
HEART VALVE,8338473,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
HEART VALVE,8338473,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
HEART VALVE,8338474,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
HEART VALVE,8338474,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
HEART  VALVE,8338475,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
HEART  VALVE,8338475,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
HEART VALVE,8338865,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,9472.14,21492.95,percent of total billed charges,
HEART VALVE,8338865,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,8460.55,21492.95,percent of total billed charges,
HEART VALVE,8338866,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,9472.14,21492.95,percent of total billed charges,
HEART VALVE,8338866,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,8460.55,21492.95,percent of total billed charges,
HEART VALVE,8338867,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,9472.14,21492.95,percent of total billed charges,
HEART VALVE,8338867,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,8460.55,21492.95,percent of total billed charges,
HEART VALVE,8338868,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,9472.14,21492.95,percent of total billed charges,
HEART VALVE,8338868,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,8460.55,21492.95,percent of total billed charges,
HEART VALVE,8338869,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,9472.14,21492.95,percent of total billed charges,
HEART VALVE,8338869,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,8460.55,21492.95,percent of total billed charges,
HEART VALVE,8338870,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,9472.14,21492.95,percent of total billed charges,
HEART VALVE,8338870,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,First Health,,21492.95,,,,,,,8460.55,21492.95,percent of total billed charges,
PLATE,8338479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5743.50000,1665.61000,Aetna,First Health,,4698.18,,,,,,,2070.53,4698.18,percent of total billed charges,
PLATE,8338479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5743.50000,1665.61000,Aetna,First Health,,4698.18,,,,,,,1849.41,4698.18,percent of total billed charges,
SCREW,8338480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8338480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,8338481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8338481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8338482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8338482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,8338483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8338483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,8338484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8338484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
GRAFT,8338692,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,3212.05,7288.38,percent of total billed charges,
GRAFT,8338692,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,2869.02,7288.38,percent of total billed charges,
GRAFT,8338693,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,3212.05,7288.38,percent of total billed charges,
GRAFT,8338693,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,2869.02,7288.38,percent of total billed charges,
GRAFT,8338694,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,3212.05,7288.38,percent of total billed charges,
GRAFT,8338694,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,2869.02,7288.38,percent of total billed charges,
GRAFT,8338695,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,5028.98,11411.10,percent of total billed charges,
GRAFT,8338695,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,4491.90,11411.10,percent of total billed charges,
GRAFT,8338696,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,5028.98,11411.10,percent of total billed charges,
GRAFT,8338696,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,4491.90,11411.10,percent of total billed charges,
GRAFT,8338697,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,5028.98,11411.10,percent of total billed charges,
GRAFT,8338697,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,4491.90,11411.10,percent of total billed charges,
GRAFT,8338698,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,5028.98,11411.10,percent of total billed charges,
GRAFT,8338698,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,4491.90,11411.10,percent of total billed charges,
GRAFT,8338699,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,5028.98,11411.10,percent of total billed charges,
GRAFT,8338699,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,4491.90,11411.10,percent of total billed charges,
GRAFT,8338700,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338700,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338701,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338701,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338702,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338702,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338703,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338703,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338704,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338704,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338705,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338705,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338706,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338706,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338707,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338707,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338708,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338708,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338709,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338709,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338710,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338710,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338711,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338711,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338712,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1582.99,3591.92,percent of total billed charges,
GRAFT,8338712,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,First Health,,3591.92,,,,,,,1413.93,3591.92,percent of total billed charges,
GRAFT,8338713,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GRAFT,8338713,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
GRAFT,8338714,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GRAFT,8338714,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
GRAFT,8338715,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GRAFT,8338715,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
GRAFT,8338716,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GRAFT,8338716,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
GRAFT,8338717,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GRAFT,8338717,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
GRAFT,8338718,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GRAFT,8338718,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
GRAFT,8338719,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GRAFT,8338719,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
GRAFT,8338720,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GRAFT,8338720,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
GRAFT,8338721,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GRAFT,8338721,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
GRAFT,8338722,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GRAFT,8338722,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
CAGE,8338934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
CAGE,8338934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
COMPONENT FEMORAL,8338982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22380.50000,6490.34000,Aetna,First Health,,18307.25,,,,,,,8068.17,18307.25,percent of total billed charges,
COMPONENT FEMORAL,8338982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22380.50000,6490.34000,Aetna,First Health,,18307.25,,,,,,,7206.52,18307.25,percent of total billed charges,
SEGMENT,8338983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20917.50000,6066.08000,Aetna,First Health,,17110.51,,,,,,,7540.76,17110.51,percent of total billed charges,
SEGMENT,8338983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20917.50000,6066.08000,Aetna,First Health,,17110.51,,,,,,,6735.44,17110.51,percent of total billed charges,
SEGMENT,8338984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20917.50000,6066.08000,Aetna,First Health,,17110.51,,,,,,,7540.76,17110.51,percent of total billed charges,
SEGMENT,8338984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20917.50000,6066.08000,Aetna,First Health,,17110.51,,,,,,,6735.44,17110.51,percent of total billed charges,
SEGMENT,8338985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1203.76000,349.09000,Aetna,First Health,,984.68,,,,,,,433.96,984.68,percent of total billed charges,
SEGMENT,8338985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1203.76000,349.09000,Aetna,First Health,,984.68,,,,,,,387.61,984.68,percent of total billed charges,
STEM,8338986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6381.55000,1850.65000,Aetna,First Health,,5220.11,,,,,,,2300.55,5220.11,percent of total billed charges,
STEM,8338986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6381.55000,1850.65000,Aetna,First Health,,5220.11,,,,,,,2054.86,5220.11,percent of total billed charges,
STEM EXTENSION,8338987,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6381.55000,1850.65000,Aetna,First Health,,5220.11,,,,,,,2300.55,5220.11,percent of total billed charges,
STEM EXTENSION,8338987,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6381.55000,1850.65000,Aetna,First Health,,5220.11,,,,,,,2054.86,5220.11,percent of total billed charges,
HEART VALVE,8338725,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
HEART VALVE,8338725,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
HEART VALVE,8339241,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
HEART VALVE,8339241,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
HEART VALVE,8338726,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
HEART VALVE,8338726,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
HEART VALVE,8338727,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
HEART VALVE,8338727,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
HEART VALVE,8338728,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
HEART VALVE,8338728,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
HEART VALVE,8338729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
HEART VALVE,8338729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
HEART VALVE,8338730,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
HEART VALVE,8338730,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
HEART VALVE,8338731,CDM,278,RC,,,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
HEART VALVE,8338731,CDM,278,RC,,,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
HEART VALVE,8338732,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7885.94,17893.75,percent of total billed charges,
HEART VALVE,8338732,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,First Health,,17893.75,,,,,,,7043.75,17893.75,percent of total billed charges,
HEART VALVE,8338691,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
HEART VALVE,8338691,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
STEM,8339242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8339242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
HEAD FEMORAL,8339244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8339244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
STEM,8339245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8339245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,8339246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8339246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,8339247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8339247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8339248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8339248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ROD SPINAL,8339249,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8339249,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8339250,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8339250,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
PLATE,8339322,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,458.41,1040.17,percent of total billed charges,
PLATE,8339322,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,409.46,1040.17,percent of total billed charges,
ALLOGRAFT,8339324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
ALLOGRAFT,8339324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
BONE MATRIX,8339325,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
BONE MATRIX,8339325,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
SCREW,8340171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8340171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
RING ANNULOPLASTY,8340180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3790.66,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3385.83,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3790.66,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3385.83,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3790.66,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3385.83,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340183,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3790.66,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340183,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3385.83,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340184,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3790.66,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340184,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3385.83,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3790.66,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3385.83,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340186,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3790.66,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340186,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,First Health,,8601.27,,,,,,,3385.83,8601.27,percent of total billed charges,
RING ANNULOPLASTY,8340187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3466.21,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3096.03,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340179,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3466.21,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340179,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3096.03,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3466.21,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3096.03,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340189,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3466.21,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340189,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3096.03,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340190,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3466.21,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340190,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3096.03,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340191,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3466.21,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340191,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3096.03,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3466.21,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3096.03,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340193,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3466.21,7865.07,percent of total billed charges,
RING ANNULOPLASTY,8340193,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,First Health,,7865.07,,,,,,,3096.03,7865.07,percent of total billed charges,
ROD BLADE,8340264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2949.80000,855.44000,Aetna,First Health,,2412.94,,,,,,,1063.40,2412.94,percent of total billed charges,
ROD BLADE,8340264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2949.80000,855.44000,Aetna,First Health,,2412.94,,,,,,,949.84,2412.94,percent of total billed charges,
ANCHOR,8340307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2309.00000,669.61000,Aetna,First Health,,1888.76,,,,,,,832.39,1888.76,percent of total billed charges,
ANCHOR,8340307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2309.00000,669.61000,Aetna,First Health,,1888.76,,,,,,,743.50,1888.76,percent of total billed charges,
SCREW,8340321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8340321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
STENT GRAFT,8340323,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,8340323,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
SCREW,8340324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8340324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
COMPONENT FEMORAL,8340344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8340344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT TIBIAL,8340345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
COMPONENT TIBIAL,8340345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
SCREW,8340346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8340346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
NAIL,8342187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4650.45,10552.20,percent of total billed charges,
NAIL,8342187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4153.80,10552.20,percent of total billed charges,
LINER,8342188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,526.16,1193.89,percent of total billed charges,
LINER,8342188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,First Health,,1193.89,,,,,,,469.97,1193.89,percent of total billed charges,
SHELL,8342189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SHELL,8342189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
STEM,8342190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,8342190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
HUMERAL CUP,8342191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
HUMERAL CUP,8342191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
COMPONENT SHOULDER,8342192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT SHOULDER,8342192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
ROD SPINAL,8342255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8342255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
CAGE,8342256,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,8342256,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
CAGE,8342257,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
CAGE,8342257,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
BASEPLATE,8342258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
BASEPLATE,8342258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
COMPONENT FEMORAL,8342259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8342259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
STEM,8342260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8342260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SCREW,8342297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8342297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8342298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8342298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,8342299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8342299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,8342300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8342300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
PLATE,8342301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1469.63,3334.68,percent of total billed charges,
PLATE,8342301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1312.67,3334.68,percent of total billed charges,
ANCHOR,8342375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3451.88000,1001.05000,Aetna,First Health,,2823.64,,,,,,,1244.40,2823.64,percent of total billed charges,
ANCHOR,8342375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3451.88000,1001.05000,Aetna,First Health,,2823.64,,,,,,,1111.51,2823.64,percent of total billed charges,
ROD SPINAL,8342376,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8342376,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
LINER,8344169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8344169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
INSERT,8344170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8344170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
PLATE,8344171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,744.07,1688.35,percent of total billed charges,
PLATE,8344171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,664.61,1688.35,percent of total billed charges,
NAIL BLADE,8344210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,1085.65,2463.42,percent of total billed charges,
NAIL BLADE,8344210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,969.71,2463.42,percent of total billed charges,
NAIL,8344212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1803.80,4092.94,percent of total billed charges,
NAIL,8344212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,First Health,,4092.94,,,,,,,1611.16,4092.94,percent of total billed charges,
NAIL BLADE,8344213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,700.74,1590.03,percent of total billed charges,
NAIL BLADE,8344213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,First Health,,1590.03,,,,,,,625.90,1590.03,percent of total billed charges,
STEM EXTENSION,8344214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM EXTENSION,8344214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
WEDGE,8344215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
WEDGE,8344215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
COMPONENT TIBIAL,8344216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
COMPONENT TIBIAL,8344216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
COMPONENT FEMORAL,8344217,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,7273.09,16503.15,percent of total billed charges,
COMPONENT FEMORAL,8344217,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,6496.35,16503.15,percent of total billed charges,
STEM EXTENSION,8344218,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM EXTENSION,8344218,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
INSERT,8344219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8344219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
COMPONENT FEMORAL,8344369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
COMPONENT FEMORAL,8344369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
URINARY CONTROL PUMP,8344371,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,24250.00000,7032.50000,Aetna,First Health,,19836.50,,,,,,,8742.12,19836.50,percent of total billed charges,
URINARY CONTROL PUMP,8344371,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,24250.00000,7032.50000,Aetna,First Health,,19836.50,,,,,,,7808.50,19836.50,percent of total billed charges,
CAGE,8344373,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
CAGE,8344373,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,8344458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8344458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8344461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8344461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
INSERT,8344464,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8344464,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
LINER,8344489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8344489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
SCREW,8344796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8344796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
STEM,8344797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9522.00000,2761.38000,Aetna,First Health,,7789.00,,,,,,,3432.68,7789.00,percent of total billed charges,
STEM,8344797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9522.00000,2761.38000,Aetna,First Health,,7789.00,,,,,,,3066.08,7789.00,percent of total billed charges,
WEDGE,8344820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
WEDGE,8344820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
STEM EXTENSION,8344821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5746.30000,1666.43000,Aetna,First Health,,4700.47,,,,,,,2071.54,4700.47,percent of total billed charges,
STEM EXTENSION,8344821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5746.30000,1666.43000,Aetna,First Health,,4700.47,,,,,,,1850.31,4700.47,percent of total billed charges,
COMPONENT FEMORAL,8344840,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,8344840,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
COMPONENT FEMORAL,8344841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
COMPONENT FEMORAL,8344841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
INSERT,8344842,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8344842,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8344843,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8344843,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8344844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8344844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ANCHOR,8346169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4455.50000,1292.09000,Aetna,First Health,,3644.60,,,,,,,1606.21,3644.60,percent of total billed charges,
ANCHOR,8346169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4455.50000,1292.09000,Aetna,First Health,,3644.60,,,,,,,1434.67,3644.60,percent of total billed charges,
GRAFT STENT,8346171,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
GRAFT STENT,8346171,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
END CAP,8346208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
END CAP,8346208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
NAIL BLADE,8346209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,1085.65,2463.42,percent of total billed charges,
NAIL BLADE,8346209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,969.71,2463.42,percent of total billed charges,
ROD SPINAL,8346210,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8346210,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
LINER,8346211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8346211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
INSERT,8346212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8346212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8346213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8346213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
NAIL,8346214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8346214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
SCREW,8346215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8346215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
PLATE,8346266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7904.25000,2292.23000,Aetna,First Health,,6465.68,,,,,,,2849.48,6465.68,percent of total billed charges,
PLATE,8346266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7904.25000,2292.23000,Aetna,First Health,,6465.68,,,,,,,2545.17,6465.68,percent of total billed charges,
PLATE,8346282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
PLATE,8346282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
STEM,8346283,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,8346283,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
LINER,8346326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
LINER,8346326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
END CAP,8346327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
END CAP,8346327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8346328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,322.88,732.63,percent of total billed charges,
SCREW,8346328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,288.40,732.63,percent of total billed charges,
CAGE,8346329,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8346329,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
SCREW,8346330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,322.88,732.63,percent of total billed charges,
SCREW,8346330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,288.40,732.63,percent of total billed charges,
PLATE,8346331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8303.40000,2407.99000,Aetna,First Health,,6792.18,,,,,,,2993.38,6792.18,percent of total billed charges,
PLATE,8346331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8303.40000,2407.99000,Aetna,First Health,,6792.18,,,,,,,2673.69,6792.18,percent of total billed charges,
CAGE,8346332,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8346332,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
SCREW,8346333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,8346333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
SCREW,8346334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,8346334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
SCREW,8346429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1468.68,3332.53,percent of total billed charges,
SCREW,8346429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1311.83,3332.53,percent of total billed charges,
SCREW,8346430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1468.68,3332.53,percent of total billed charges,
SCREW,8346430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1311.83,3332.53,percent of total billed charges,
SCREW,8346431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1468.68,3332.53,percent of total billed charges,
SCREW,8346431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1311.83,3332.53,percent of total billed charges,
SCREW,8346335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,219.00,496.94,percent of total billed charges,
SCREW,8346335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,195.62,496.94,percent of total billed charges,
ROD SPINAL,8346336,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8346336,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
ROD SPINAL,8346337,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8346337,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
SCREW,8346432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1468.68,3332.53,percent of total billed charges,
SCREW,8346432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1311.83,3332.53,percent of total billed charges,
ENDPLATE,8346338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
ENDPLATE,8346338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
SHELL,8346339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8346339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
COMPONENT FEMORAL,8346433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
COMPONENT FEMORAL,8346433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
GLENOSPHERE,8346456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1779.07,4036.83,percent of total billed charges,
GLENOSPHERE,8346456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1589.07,4036.83,percent of total billed charges,
SCREW,8346915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8346915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
ROD SPINAL,8347041,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8347041,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
COMPONENT FEMORAL,8347042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,8347042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
GUIDEWIRE,8346518,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
GUIDEWIRE,8346518,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
STENT,7695649,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7695649,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7695650,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7695650,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7703279,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7703279,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7695651,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7695651,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7703280,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7703280,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7703281,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7703281,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7703282,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7703282,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7703283,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7703283,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7703284,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7703284,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7703285,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7703285,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7703286,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7703286,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7703287,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7703287,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
STENT,7703288,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
STENT,7703288,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
SHEATH,8346912,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
SHEATH,8346912,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
CATHETER BALLOON,8346507,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1574.88000,456.72000,Aetna,First Health,,1288.25,,,,,,,567.74,1288.25,percent of total billed charges,
CATHETER BALLOON,8346507,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1574.88000,456.72000,Aetna,First Health,,1288.25,,,,,,,507.11,1288.25,percent of total billed charges,
SHEATH,8346508,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
SHEATH,8346508,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
SHEATH,8346509,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,841.21000,243.95000,Aetna,First Health,,688.11,,,,,,,303.26,688.11,percent of total billed charges,
SHEATH,8346509,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,841.21000,243.95000,Aetna,First Health,,688.11,,,,,,,270.87,688.11,percent of total billed charges,
SHEATH,8346510,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
SHEATH,8346510,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
SHEATH,8346511,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
SHEATH,8346511,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
STENT,8346914,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,915.30000,265.44000,Aetna,First Health,,748.72,,,,,,,329.97,748.72,percent of total billed charges,
STENT,8346914,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,915.30000,265.44000,Aetna,First Health,,748.72,,,,,,,294.73,748.72,percent of total billed charges,
HEAD HUMERAL,8356490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HEAD HUMERAL,8356490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
INSERT,8347436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8347436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ROD SPINAL,8347437,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8347437,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
SHEATH,8347455,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,385.23000,111.72000,Aetna,First Health,,315.12,,,,,,,138.88,315.12,percent of total billed charges,
SHEATH,8347455,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,385.23000,111.72000,Aetna,First Health,,315.12,,,,,,,124.04,315.12,percent of total billed charges,
SCREW,8347508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW,8347508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
SCREW,8347509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW,8347509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
BONE VOID FILLER,8347450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5985.00000,1735.65000,Aetna,First Health,,4895.73,,,,,,,2157.59,4895.73,percent of total billed charges,
BONE VOID FILLER,8347450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5985.00000,1735.65000,Aetna,First Health,,4895.73,,,,,,,1927.17,4895.73,percent of total billed charges,
BONE VOID FILLER,8347451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11160.00000,3236.40000,Aetna,First Health,,9128.88,,,,,,,4023.18,9128.88,percent of total billed charges,
BONE VOID FILLER,8347451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11160.00000,3236.40000,Aetna,First Health,,9128.88,,,,,,,3593.52,9128.88,percent of total billed charges,
BONE VOID FILLER,8347452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,17865.00000,5180.85000,Aetna,First Health,,14613.57,,,,,,,6440.33,14613.57,percent of total billed charges,
BONE VOID FILLER,8347452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,17865.00000,5180.85000,Aetna,First Health,,14613.57,,,,,,,5752.53,14613.57,percent of total billed charges,
WEDGE,8347464,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8347464,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8347465,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8347465,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
INSERT,8347466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8347466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
WEDGE,8347467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
WEDGE,8347467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
STEM EXTENSION,8347469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM EXTENSION,8347469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
COMPONENT TIBIAL,8347470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
COMPONENT TIBIAL,8347470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
WEDGE,8347471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8347471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
HEAD FEMORAL,8347488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
HEAD FEMORAL,8347488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
PLATE,8347493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1361.95,3090.35,percent of total billed charges,
PLATE,8347493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,First Health,,3090.35,,,,,,,1216.50,3090.35,percent of total billed charges,
STEM,8347514,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8347514,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW,8347532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1468.68,3332.53,percent of total billed charges,
SCREW,8347532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1311.83,3332.53,percent of total billed charges,
SCREW,8347545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,8347545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
SCREW,8348932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,8348932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
BOLT,8348933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,907.31,2058.74,percent of total billed charges,
BOLT,8348933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,First Health,,2058.74,,,,,,,810.41,2058.74,percent of total billed charges,
LINER,8348934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8348934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,8348935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8348935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
FEMORAL HEAD,8348936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,8348936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
TRAY HUMERAL,8348937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
TRAY HUMERAL,8348937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
TRAY HUMERAL,8348938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
TRAY HUMERAL,8348938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
TIGHTROPE,8348939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3617.25000,1049.00000,Aetna,First Health,,2958.91,,,,,,,1304.02,2958.91,percent of total billed charges,
TIGHTROPE,8348939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3617.25000,1049.00000,Aetna,First Health,,2958.91,,,,,,,1164.75,2958.91,percent of total billed charges,
SCREW,8348940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8348940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
TIGHTROPE,8348941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2309.00000,669.61000,Aetna,First Health,,1888.76,,,,,,,832.39,1888.76,percent of total billed charges,
TIGHTROPE,8348941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2309.00000,669.61000,Aetna,First Health,,1888.76,,,,,,,743.50,1888.76,percent of total billed charges,
ROD SPINAL,8348942,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2612.00000,757.48000,Aetna,First Health,,2136.62,,,,,,,941.63,2136.62,percent of total billed charges,
ROD SPINAL,8348942,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2612.00000,757.48000,Aetna,First Health,,2136.62,,,,,,,841.06,2136.62,percent of total billed charges,
SCREW,8348943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8348943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,8348944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8348944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
NAIL,7695438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,7695438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
CATHETER BALLOON,8349880,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1592.00000,461.68000,Aetna,First Health,,1302.26,,,,,,,573.92,1302.26,percent of total billed charges,
CATHETER BALLOON,8349880,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1592.00000,461.68000,Aetna,First Health,,1302.26,,,,,,,512.62,1302.26,percent of total billed charges,
GRAFT,8349127,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,11175.00000,3240.75000,Aetna,First Health,,9141.15,,,,,,,4028.59,9141.15,percent of total billed charges,
GRAFT,8349127,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,11175.00000,3240.75000,Aetna,First Health,,9141.15,,,,,,,3598.35,9141.15,percent of total billed charges,
STEM,8349881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8349881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
SCREW,8349883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW,8349883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
SCREW,8349885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,322.88,732.63,percent of total billed charges,
SCREW,8349885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,288.40,732.63,percent of total billed charges,
PLATE,8349887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,8349887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8349889,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8349889,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
CAGE,8349891,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8349891,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
SCREW,8349893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,322.88,732.63,percent of total billed charges,
SCREW,8349893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,288.40,732.63,percent of total billed charges,
PLATE,8349895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,322.88,732.63,percent of total billed charges,
PLATE,8349895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,288.40,732.63,percent of total billed charges,
PLATE,8349897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,8349897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
ROD SPINAL,8349899,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2168.00000,628.72000,Aetna,First Health,,1773.42,,,,,,,781.56,1773.42,percent of total billed charges,
ROD SPINAL,8349899,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2168.00000,628.72000,Aetna,First Health,,1773.42,,,,,,,698.10,1773.42,percent of total billed charges,
SCREW,8349902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2905.68000,842.65000,Aetna,First Health,,2376.85,,,,,,,1047.50,2376.85,percent of total billed charges,
SCREW,8349902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2905.68000,842.65000,Aetna,First Health,,2376.85,,,,,,,935.63,2376.85,percent of total billed charges,
PLATE,8350290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1258.60000,364.99000,Aetna,First Health,,1029.53,,,,,,,453.73,1029.53,percent of total billed charges,
PLATE,8350290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1258.60000,364.99000,Aetna,First Health,,1029.53,,,,,,,405.27,1029.53,percent of total billed charges,
PEG,8350291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
PEG,8350291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
INSERT,8350292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8350292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ROD SPINAL,8350293,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8350293,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
BALLOON STENT,8350551,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
BALLOON STENT,8350551,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
WEDGE,8351535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8351535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8351537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
WEDGE,8351537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
WEDGE,8351539,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8351539,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
STEM,8351541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8351541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
STEM,8351543,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8351543,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
SHELL,8351545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SHELL,8351545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
INSERT,8351547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,8351547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
TRAY HUMERAL,8351549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
TRAY HUMERAL,8351549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
SHEATH,8351551,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
SHEATH,8351551,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
SHEATH,8351552,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1560.00000,452.40000,Aetna,First Health,,1276.08,,,,,,,562.38,1276.08,percent of total billed charges,
SHEATH,8351552,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1560.00000,452.40000,Aetna,First Health,,1276.08,,,,,,,502.32,1276.08,percent of total billed charges,
WEDGE,8351553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8351553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
LEAD KIT STIMULATOR,8351554,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,473.10000,137.20000,Aetna,First Health,,387.00,,,,,,,170.55,387.00,percent of total billed charges,
LEAD KIT STIMULATOR,8351554,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,473.10000,137.20000,Aetna,First Health,,387.00,,,,,,,152.34,387.00,percent of total billed charges,
LEAD TEST STIMULATOR,8351555,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,235.20000,68.21000,Aetna,First Health,,192.39,,,,,,,84.79,192.39,percent of total billed charges,
LEAD TEST STIMULATOR,8351555,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,235.20000,68.21000,Aetna,First Health,,192.39,,,,,,,75.73,192.39,percent of total billed charges,
GRAFT,8352509,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5060.13000,1467.44000,Aetna,First Health,,4139.19,,,,,,,1824.18,4139.19,percent of total billed charges,
GRAFT,8352509,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5060.13000,1467.44000,Aetna,First Health,,4139.19,,,,,,,1629.36,4139.19,percent of total billed charges,
GLENOSPHERE,8352511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1779.07,4036.83,percent of total billed charges,
GLENOSPHERE,8352511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1589.07,4036.83,percent of total billed charges,
SCREW,8355362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8355362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ROD SPINAL,8355360,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6247.50000,1811.78000,Aetna,First Health,,5110.45,,,,,,,2252.22,5110.45,percent of total billed charges,
ROD SPINAL,8355360,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6247.50000,1811.78000,Aetna,First Health,,5110.45,,,,,,,2011.69,5110.45,percent of total billed charges,
COMPONENT TIBIAL,8356363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,8356363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
SCREW,8356366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8356366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
WEDGE,8356368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
WEDGE,8356368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
INSERT,8356370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8356370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8356372,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7734.60000,2243.03000,Aetna,First Health,,6326.90,,,,,,,2788.32,6326.90,percent of total billed charges,
CAGE,8356372,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7734.60000,2243.03000,Aetna,First Health,,6326.90,,,,,,,2490.54,6326.90,percent of total billed charges,
CONNECTOR SPINAL,8356374,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,801.38,1818.38,percent of total billed charges,
CONNECTOR SPINAL,8356374,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,715.79,1818.38,percent of total billed charges,
ROD SPINAL,8356376,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8356376,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD SPINAL,8356381,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
ROD SPINAL,8356381,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
CAGE,8356491,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8304.00000,2408.16000,Aetna,First Health,,6792.67,,,,,,,2993.59,6792.67,percent of total billed charges,
CAGE,8356491,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8304.00000,2408.16000,Aetna,First Health,,6792.67,,,,,,,2673.89,6792.67,percent of total billed charges,
CAGE,8356492,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
CAGE,8356492,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
CAGE,8356493,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8356493,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
ENDPLATE,8356497,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8356497,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
ENDPLATE,8356727,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
ENDPLATE,8356727,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
GLENOSPHERE,8356556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1804.00000,523.16000,Aetna,First Health,,1475.67,,,,,,,650.34,1475.67,percent of total billed charges,
GLENOSPHERE,8356556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1804.00000,523.16000,Aetna,First Health,,1475.67,,,,,,,580.89,1475.67,percent of total billed charges,
PLATE,8356729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2496.00000,723.84000,Aetna,First Health,,2041.73,,,,,,,899.81,2041.73,percent of total billed charges,
PLATE,8356729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2496.00000,723.84000,Aetna,First Health,,2041.73,,,,,,,803.71,2041.73,percent of total billed charges,
WEDGE,8356731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
WEDGE,8356731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
STEM,8356733,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,11294.92,25628.96,percent of total billed charges,
STEM,8356733,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,10088.66,25628.96,percent of total billed charges,
ROD SPINAL,8356735,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8356735,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8356737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1640.28,3721.90,percent of total billed charges,
SCREW,8356737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1465.10,3721.90,percent of total billed charges,
SCREW,8356739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1640.28,3721.90,percent of total billed charges,
SCREW,8356739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1465.10,3721.90,percent of total billed charges,
PLATE,8356743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,434.10000,125.89000,Aetna,First Health,,355.09,,,,,,,156.49,355.09,percent of total billed charges,
PLATE,8356743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,434.10000,125.89000,Aetna,First Health,,355.09,,,,,,,139.78,355.09,percent of total billed charges,
PLATE,8356744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,906.03000,262.75000,Aetna,First Health,,741.13,,,,,,,326.62,741.13,percent of total billed charges,
PLATE,8356744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,906.03000,262.75000,Aetna,First Health,,741.13,,,,,,,291.74,741.13,percent of total billed charges,
PLATE,8356745,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,884.61000,256.54000,Aetna,First Health,,723.61,,,,,,,318.90,723.61,percent of total billed charges,
PLATE,8356745,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,884.61000,256.54000,Aetna,First Health,,723.61,,,,,,,284.84,723.61,percent of total billed charges,
BUR HOLE COVER,8356746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1484.32000,430.45000,Aetna,First Health,,1214.17,,,,,,,535.10,1214.17,percent of total billed charges,
BUR HOLE COVER,8356746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1484.32000,430.45000,Aetna,First Health,,1214.17,,,,,,,477.95,1214.17,percent of total billed charges,
PLATE,8356747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,222.34000,64.48000,Aetna,First Health,,181.87,,,,,,,80.15,181.87,percent of total billed charges,
PLATE,8356747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,222.34000,64.48000,Aetna,First Health,,181.87,,,,,,,71.59,181.87,percent of total billed charges,
INSERT,8356879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8356879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CONNECTOR SPINAL,8356880,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2264.00000,656.56000,Aetna,First Health,,1851.95,,,,,,,816.17,1851.95,percent of total billed charges,
CONNECTOR SPINAL,8356880,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2264.00000,656.56000,Aetna,First Health,,1851.95,,,,,,,729.01,1851.95,percent of total billed charges,
ROD SPINAL,8356881,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2904.00000,842.16000,Aetna,First Health,,2375.47,,,,,,,1046.89,2375.47,percent of total billed charges,
ROD SPINAL,8356881,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2904.00000,842.16000,Aetna,First Health,,2375.47,,,,,,,935.09,2375.47,percent of total billed charges,
SCREW,8356882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SCREW,8356882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166286,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166286,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
SCREW,8358401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,8358401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
PLATE,8358403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
PLATE,8358403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
NAIL,8358405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8358405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
WEDGE,8358407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8358407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
BASEPLATE,8358409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
BASEPLATE,8358409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
STEM,8358411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8358411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
INSERT,8358413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8358413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
COMPONENT FEMORAL,8358415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,7273.09,16503.15,percent of total billed charges,
COMPONENT FEMORAL,8358415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,6496.35,16503.15,percent of total billed charges,
PLATE,8358417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5510.02000,1597.91000,Aetna,First Health,,4507.20,,,,,,,1986.36,4507.20,percent of total billed charges,
PLATE,8358417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5510.02000,1597.91000,Aetna,First Health,,4507.20,,,,,,,1774.23,4507.20,percent of total billed charges,
STENT,8358420,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1356.36000,393.34000,Aetna,First Health,,1109.50,,,,,,,488.97,1109.50,percent of total billed charges,
STENT,8358420,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1356.36000,393.34000,Aetna,First Health,,1109.50,,,,,,,436.75,1109.50,percent of total billed charges,
INSERT,8358641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8358641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM,8358609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8358609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
STEM,8358610,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8358610,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
COMPONENT FEMORAL,8358611,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
COMPONENT FEMORAL,8358611,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
WEDGE,8358612,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8358612,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
WEDGE,8358613,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8358613,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
INSERT,8358639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8358639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
ROD SPINAL,8358794,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8358794,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
PLATE,8358747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5618.62000,1629.40000,Aetna,First Health,,4596.03,,,,,,,2025.51,4596.03,percent of total billed charges,
PLATE,8358747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5618.62000,1629.40000,Aetna,First Health,,4596.03,,,,,,,1809.20,4596.03,percent of total billed charges,
SCREW,8358748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8358748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
LINER,8358749,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8358749,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,8358750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8358750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
SCREW,8358751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3026.24000,877.61000,Aetna,First Health,,2475.46,,,,,,,1090.96,2475.46,percent of total billed charges,
SCREW,8358751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3026.24000,877.61000,Aetna,First Health,,2475.46,,,,,,,974.45,2475.46,percent of total billed charges,
SCREW,8358795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3026.24000,877.61000,Aetna,First Health,,2475.46,,,,,,,1090.96,2475.46,percent of total billed charges,
SCREW,8358795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3026.24000,877.61000,Aetna,First Health,,2475.46,,,,,,,974.45,2475.46,percent of total billed charges,
INSERT,8358826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8358826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
STEM,8358827,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8358827,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,8358828,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8358828,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW,8358829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2905.68000,842.65000,Aetna,First Health,,2376.85,,,,,,,1047.50,2376.85,percent of total billed charges,
SCREW,8358829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2905.68000,842.65000,Aetna,First Health,,2376.85,,,,,,,935.63,2376.85,percent of total billed charges,
HEAD FEMORAL,8360174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,1080.58,2451.91,percent of total billed charges,
HEAD FEMORAL,8360174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,First Health,,2451.91,,,,,,,965.18,2451.91,percent of total billed charges,
BOLT,8360217,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BOLT,8360217,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
CAGE,8360218,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8360218,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
INSERT,8360219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8360219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8360246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
SCREW,8360246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
SCREW,8360247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
SCREW,8360247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
ROD SPINAL,8360248,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8360248,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ROD SPINAL,8360252,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8360252,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8360253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
SCREW,8360253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
SCREW,8360254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1468.68,3332.53,percent of total billed charges,
SCREW,8360254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1311.83,3332.53,percent of total billed charges,
SCREW,8360255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1468.68,3332.53,percent of total billed charges,
SCREW,8360255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1311.83,3332.53,percent of total billed charges,
ROD SPINAL,8360316,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,First Health,,5053.19,,,,,,,2226.99,5053.19,percent of total billed charges,
ROD SPINAL,8360316,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,First Health,,5053.19,,,,,,,1989.15,5053.19,percent of total billed charges,
CAGE,8360317,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8360317,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
STENT GRAFT,8360468,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,8360468,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
INSERT,8360500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8360500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8360502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5658.28000,1640.90000,Aetna,First Health,,4628.47,,,,,,,2039.81,4628.47,percent of total billed charges,
PLATE,8360502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5658.28000,1640.90000,Aetna,First Health,,4628.47,,,,,,,1821.97,4628.47,percent of total billed charges,
LINER,8360504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
LINER,8360504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
CLIP LIGATING,8360507,CDM,278,RC,,,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
CLIP LIGATING,8360507,CDM,278,RC,,,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
CLIP LIGATING,8360508,CDM,278,RC,,,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
CLIP LIGATING,8360508,CDM,278,RC,,,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
CAGE,8360509,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,8939.50,20284.35,percent of total billed charges,
CAGE,8360509,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,7984.80,20284.35,percent of total billed charges,
WEDGE,8360572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8360572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
INSERT,8360574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8360574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM,8360576,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8360576,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
WEDGE,8360578,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8360578,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
COMPONENT FEMORAL,8360580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,7669.64,17402.95,percent of total billed charges,
COMPONENT FEMORAL,8360580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,6850.55,17402.95,percent of total billed charges,
WEDGE,8360582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8360582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
CAGE,8360584,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8360584,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
ROD SPINAL,8360585,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8360585,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,8360587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8360587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
WEDGE,8360589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,8360589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
LINER,8360591,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8360591,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CAGE,8362197,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
CAGE,8362197,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
PLATE,8362196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,8362196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
COMPONENT PATELLA,8362198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,8362198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
INSERT,8362199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8362199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
IMP BODY AEQUALIS FLEX,8362200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17125.00000,4966.25000,Aetna,First Health,,14008.25,,,,,,,6173.56,14008.25,percent of total billed charges,
IMP BODY AEQUALIS FLEX,8362200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17125.00000,4966.25000,Aetna,First Health,,14008.25,,,,,,,5514.25,14008.25,percent of total billed charges,
STEM DISTAL,8362201,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15850.00000,4596.50000,Aetna,First Health,,12965.30,,,,,,,5713.93,12965.30,percent of total billed charges,
STEM DISTAL,8362201,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15850.00000,4596.50000,Aetna,First Health,,12965.30,,,,,,,5103.70,12965.30,percent of total billed charges,
CAP AEQUALIS FLEX REVIVE LCKNG,8362202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2320.00000,672.80000,Aetna,First Health,,1897.76,,,,,,,836.36,1897.76,percent of total billed charges,
CAP AEQUALIS FLEX REVIVE LCKNG,8362202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2320.00000,672.80000,Aetna,First Health,,1897.76,,,,,,,747.04,1897.76,percent of total billed charges,
SCREW,8362203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8362203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
TRAY REVERSE,8362204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1299.40,2948.43,percent of total billed charges,
TRAY REVERSE,8362204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,First Health,,2948.43,,,,,,,1160.63,2948.43,percent of total billed charges,
SCREW CORTICAL,8362205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW CORTICAL,8362205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SHELL,8362206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
SHELL,8362206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
STEM FEMORAL,8362207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM FEMORAL,8362207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
SCREW,8362400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8362400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
GLENOID,8362432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
GLENOID,8362432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
GLENOID,8362434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
GLENOID,8362434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
SCREW,8362440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,8362440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
STEM,8362318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8362318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8362469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8362469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM FEMORAL,8362470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM FEMORAL,8362470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
GLENOID,8362471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
GLENOID,8362471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT JRNY II,8362472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT JRNY II,8362472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
INSERT JRNY II,8362473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT JRNY II,8362473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
COMPONENT FEMORAL,8362474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
COMPONENT FEMORAL,8362474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
BREAST IMPLANT,8362195,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
BREAST IMPLANT,8362195,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
STEM,8362317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8362317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
BLADE HELICAL,8362597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,1085.65,2463.42,percent of total billed charges,
BLADE HELICAL,8362597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,969.71,2463.42,percent of total billed charges,
WEDGE,8362598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
WEDGE,8362598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
INTRODUCER,8362599,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,726.53000,210.69000,Aetna,First Health,,594.30,,,,,,,261.91,594.30,percent of total billed charges,
INTRODUCER,8362599,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,726.53000,210.69000,Aetna,First Health,,594.30,,,,,,,233.94,594.30,percent of total billed charges,
SCREW,8362600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8362600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,8362601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8362601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,8362602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8362602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
BASEPLATE,8362716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
BASEPLATE,8362716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
CAGE,8362717,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8362717,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
CAGE,8362718,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8362718,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
INSERT,8362719,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8362719,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8362721,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1296.68000,376.04000,Aetna,First Health,,1060.68,,,,,,,467.45,1060.68,percent of total billed charges,
PLATE,8362721,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1296.68000,376.04000,Aetna,First Health,,1060.68,,,,,,,417.53,1060.68,percent of total billed charges,
PLATE,8362723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6191.50000,1795.54000,Aetna,First Health,,5064.65,,,,,,,2232.04,5064.65,percent of total billed charges,
PLATE,8362723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6191.50000,1795.54000,Aetna,First Health,,5064.65,,,,,,,1993.66,5064.65,percent of total billed charges,
HEAD RADIAL,8362724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10794.00000,3130.26000,Aetna,First Health,,8829.49,,,,,,,3891.24,8829.49,percent of total billed charges,
HEAD RADIAL,8362724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10794.00000,3130.26000,Aetna,First Health,,8829.49,,,,,,,3475.67,8829.49,percent of total billed charges,
STEM,8362725,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10719.00000,3108.51000,Aetna,First Health,,8768.14,,,,,,,3864.20,8768.14,percent of total billed charges,
STEM,8362725,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10719.00000,3108.51000,Aetna,First Health,,8768.14,,,,,,,3451.52,8768.14,percent of total billed charges,
SCREW,8362726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8362726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
PEG,8362727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
PEG,8362727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
PEG,8362728,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
PEG,8362728,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
PEG,8362729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,277.40,629.45,percent of total billed charges,
PEG,8362729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,247.78,629.45,percent of total billed charges,
PEG,8362730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,277.40,629.45,percent of total billed charges,
PEG,8362730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,247.78,629.45,percent of total billed charges,
LINER,8362875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8362875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
COMPONENT PATELLA,8362877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,8362877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
SCREW,8362879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
SCREW,8362879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
ROD SPINAL,8362881,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8362881,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
LINER,8362925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8362925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
PLATE,8362927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,8362927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
HEAD HUMERAL,8362929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,8362929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
GUIDEWIRE,8374338,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
GUIDEWIRE,8374338,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
GUIDEWIRE,8374347,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
GUIDEWIRE,8374347,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
STENT,8390260,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390260,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390261,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390261,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390262,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390262,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390263,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390263,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390264,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390264,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390265,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390265,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390266,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390266,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390267,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390267,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390268,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390268,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390269,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390269,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390270,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390270,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390271,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390271,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390272,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390272,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390273,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390273,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390274,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390274,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390275,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390275,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390276,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8390276,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8390277,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390277,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390278,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390278,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390279,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390279,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390280,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390280,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390281,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390281,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390282,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390282,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390283,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390283,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390284,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390284,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390285,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390285,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390286,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390286,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390287,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390287,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390288,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390288,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390289,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390289,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390290,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390290,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390291,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390291,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390292,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8390292,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8390293,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390293,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390294,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390294,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390295,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390295,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390296,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390296,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390297,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390297,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390298,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390298,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390299,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390299,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390300,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390300,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390301,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390301,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390302,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390302,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390303,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390303,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390304,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390304,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390305,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390305,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390306,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390306,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390307,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390307,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390308,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390308,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390309,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390309,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390310,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390310,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390311,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390311,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390312,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390312,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390313,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390313,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390314,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390314,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390315,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390315,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390316,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390316,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390317,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390317,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8390318,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8390318,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8402966,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8402966,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8402967,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8402967,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8402968,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8402968,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
ICM LINQ II EVENT RECORDER,8403165,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15362.50000,4455.12000,Aetna,First Health,,12566.52,,,,,,,5538.18,12566.52,percent of total billed charges,
ICM LINQ II EVENT RECORDER,8403165,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15362.50000,4455.12000,Aetna,First Health,,12566.52,,,,,,,4946.73,12566.52,percent of total billed charges,
ICM LINQ II EVENT RECORDER,8403166,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15362.50000,4455.12000,Aetna,First Health,,12566.52,,,,,,,5538.18,12566.52,percent of total billed charges,
ICM LINQ II EVENT RECORDER,8403166,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15362.50000,4455.12000,Aetna,First Health,,12566.52,,,,,,,4946.73,12566.52,percent of total billed charges,
SHEATH,8407095,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
SHEATH,8407095,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
SHEATH,8407661,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,117.60000,34.10000,Aetna,First Health,,96.20,,,,,,,42.39,96.20,percent of total billed charges,
SHEATH,8407661,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,117.60000,34.10000,Aetna,First Health,,96.20,,,,,,,37.87,96.20,percent of total billed charges,
TRAY INSERTION,8407939,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,877.41000,254.45000,Aetna,First Health,,717.72,,,,,,,316.31,717.72,percent of total billed charges,
TRAY INSERTION,8407939,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,877.41000,254.45000,Aetna,First Health,,717.72,,,,,,,282.53,9959.00,percent of total billed charges,
STENT,8409069,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8409069,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
STENT,8409070,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,886.83,2012.28,percent of total billed charges,
STENT,8409070,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,First Health,,2012.28,,,,,,,792.12,2012.28,percent of total billed charges,
PLATE,8278586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5338.94000,1548.29000,Aetna,First Health,,4367.25,,,,,,,1924.69,4367.25,percent of total billed charges,
PLATE,8278586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5338.94000,1548.29000,Aetna,First Health,,4367.25,,,,,,,1719.14,4367.25,percent of total billed charges,
PLATE,8278588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5200.41000,1508.12000,Aetna,First Health,,4253.94,,,,,,,1874.75,4253.94,percent of total billed charges,
PLATE,8278588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5200.41000,1508.12000,Aetna,First Health,,4253.94,,,,,,,1674.53,4253.94,percent of total billed charges,
PLATE,8278590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5243.91000,1520.73000,Aetna,First Health,,4289.52,,,,,,,1890.43,4289.52,percent of total billed charges,
PLATE,8278590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5243.91000,1520.73000,Aetna,First Health,,4289.52,,,,,,,1688.54,4289.52,percent of total billed charges,
PLATE,8278592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5338.94000,1548.29000,Aetna,First Health,,4367.25,,,,,,,1924.69,4367.25,percent of total billed charges,
PLATE,8278592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5338.94000,1548.29000,Aetna,First Health,,4367.25,,,,,,,1719.14,4367.25,percent of total billed charges,
CONNECTOR SPINAL,8278594,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,1106.01,2509.62,percent of total billed charges,
CONNECTOR SPINAL,8278594,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,987.90,2509.62,percent of total billed charges,
SHELL,8278596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3475.94,7887.16,percent of total billed charges,
SHELL,8278596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3104.72,7887.16,percent of total billed charges,
INSERT,8278597,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8278597,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
INSERT,8278598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8278598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
PLATE,8278599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3506.06000,1016.76000,Aetna,First Health,,2867.96,,,,,,,1263.93,2867.96,percent of total billed charges,
PLATE,8278599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3506.06000,1016.76000,Aetna,First Health,,2867.96,,,,,,,1128.95,2867.96,percent of total billed charges,
PLATE,8278600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,8278600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
END CAP,8278601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,122.78,278.59,percent of total billed charges,
END CAP,8278601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,109.67,278.59,percent of total billed charges,
END CAP,8278699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
END CAP,8278699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
END CAP,8278602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
END CAP,8278602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
CAGE,8278603,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8278603,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
SCREW,8278604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8278604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
INSERT,8278696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8278696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8278697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2544.64000,737.95000,Aetna,First Health,,2081.52,,,,,,,917.34,2081.52,percent of total billed charges,
SCREW,8278697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2544.64000,737.95000,Aetna,First Health,,2081.52,,,,,,,819.37,2081.52,percent of total billed charges,
SCREW,8278768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2544.64000,737.95000,Aetna,First Health,,2081.52,,,,,,,917.34,2081.52,percent of total billed charges,
SCREW,8278768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2544.64000,737.95000,Aetna,First Health,,2081.52,,,,,,,819.37,2081.52,percent of total billed charges,
SCREW,8278698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2544.64000,737.95000,Aetna,First Health,,2081.52,,,,,,,917.34,2081.52,percent of total billed charges,
SCREW,8278698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2544.64000,737.95000,Aetna,First Health,,2081.52,,,,,,,819.37,2081.52,percent of total billed charges,
INSERT,8278700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,8278700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
STEM,8278770,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8278770,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,8278771,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8278771,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8278769,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8278769,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT TIBIAL,8278844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
COMPONENT TIBIAL,8278844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
INSERT,8278846,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8278846,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STENT,8278848,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,772.88000,224.14000,Aetna,First Health,,632.22,,,,,,,278.62,632.22,percent of total billed charges,
STENT,8278848,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,772.88000,224.14000,Aetna,First Health,,632.22,,,,,,,248.87,632.22,percent of total billed charges,
SPACER HIP CEMENT,8280258,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,2104.22,4774.63,percent of total billed charges,
SPACER HIP CEMENT,8280258,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,First Health,,4774.63,,,,,,,1879.50,4774.63,percent of total billed charges,
INSERT,8280244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8280244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
WEDGE,8280246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8280246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
NAIL,8280249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,21775.00000,6314.75000,Aetna,First Health,,17811.95,,,,,,,7849.89,17811.95,percent of total billed charges,
NAIL,8280249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,21775.00000,6314.75000,Aetna,First Health,,17811.95,,,,,,,7011.55,17811.95,percent of total billed charges,
SHELL,8280251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8280251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SPACER SPINAL,8280253,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SPACER SPINAL,8280253,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SCREW,8280259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW,8280259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
CAGE,8280260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18032.50000,5229.42000,Aetna,First Health,,14750.58,,,,,,,6500.72,14750.58,percent of total billed charges,
CAGE,8280260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18032.50000,5229.42000,Aetna,First Health,,14750.58,,,,,,,5806.47,14750.58,percent of total billed charges,
SCREW,8280331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8280331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
SCREW,8280332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8280332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
PEG,8280422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8280422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PEG,8280423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8280423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PEG,8280424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8280424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PEG,8280425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8280425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PEG,8280426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8280426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
SCREW,8280427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8280427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
PLATE,8280428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5894.70000,1709.46000,Aetna,First Health,,4821.86,,,,,,,2125.04,4821.86,percent of total billed charges,
PLATE,8280428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5894.70000,1709.46000,Aetna,First Health,,4821.86,,,,,,,1898.09,4821.86,percent of total billed charges,
SCREW,8280429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,First Health,,1194.28,,,,,,,526.33,1194.28,percent of total billed charges,
SCREW,8280429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,First Health,,1194.28,,,,,,,470.12,1194.28,percent of total billed charges,
SPACER SPINAL,8280430,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12125.25000,3516.32000,Aetna,First Health,,9918.45,,,,,,,4371.15,9918.45,percent of total billed charges,
SPACER SPINAL,8280430,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12125.25000,3516.32000,Aetna,First Health,,9918.45,,,,,,,3904.33,9918.45,percent of total billed charges,
INSERT,8280554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8280554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SHELL,8280555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
SHELL,8280555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
PEG,8280567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
PEG,8280567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
SCREW,8280601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,8280601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
STENT GRAFT,8280680,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,8280680,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
INSERT,8280681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8280681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8280682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8280682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
SHELL,8280683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8280683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
COMPONENT PATELLA,8280712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,8280712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
INSERT,8280714,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8280714,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
HEAD FEMORAL,8280716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8280716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
COMPONENT PATELLA,8280718,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,8280718,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
HEAD FEMORAL,8280720,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1392.66,3160.04,percent of total billed charges,
HEAD FEMORAL,8280720,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1243.93,3160.04,percent of total billed charges,
STEM,8280722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,First Health,,7901.88,,,,,,,3482.43,7901.88,percent of total billed charges,
STEM,8280722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,First Health,,7901.88,,,,,,,3110.52,7901.88,percent of total billed charges,
STEM EXTENSION,8280724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3281.25000,951.56000,Aetna,First Health,,2684.06,,,,,,,1182.89,2684.06,percent of total billed charges,
STEM EXTENSION,8280724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3281.25000,951.56000,Aetna,First Health,,2684.06,,,,,,,1056.56,2684.06,percent of total billed charges,
SCREW,8282169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8282169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
GRAFT HEMI,8282173,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,34537.50000,10015.88000,Aetna,First Health,,28251.67,,,,,,,12450.77,28251.67,percent of total billed charges,
GRAFT HEMI,8282173,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,34537.50000,10015.88000,Aetna,First Health,,28251.67,,,,,,,11121.08,28251.67,percent of total billed charges,
ARTERY AORTORILIAC,8282327,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,60942.00000,17673.18000,Aetna,First Health,,49850.56,,,,,,,21969.59,49850.56,percent of total billed charges,
ARTERY AORTORILIAC,8282327,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,60942.00000,17673.18000,Aetna,First Health,,49850.56,,,,,,,19623.32,49850.56,percent of total billed charges,
WEDGE,8282328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8282328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
SCREW,8282329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8282329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
CAGE,8282331,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2360.00000,684.40000,Aetna,First Health,,1930.48,,,,,,,850.78,1930.48,percent of total billed charges,
CAGE,8282331,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2360.00000,684.40000,Aetna,First Health,,1930.48,,,,,,,759.92,1930.48,percent of total billed charges,
CAGE,8282333,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2360.00000,684.40000,Aetna,First Health,,1930.48,,,,,,,850.78,1930.48,percent of total billed charges,
CAGE,8282333,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2360.00000,684.40000,Aetna,First Health,,1930.48,,,,,,,759.92,1930.48,percent of total billed charges,
PLATE,8282335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
PLATE,8282335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
PLATE,8282337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
PLATE,8282337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,8282339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8282339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
BASEPLATE,8282341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
BASEPLATE,8282341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
STENT GRAFT,8282526,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,46811.70000,13575.39000,Aetna,First Health,,38291.97,,,,,,,16875.62,38291.97,percent of total billed charges,
STENT GRAFT,8282526,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,46811.70000,13575.39000,Aetna,First Health,,38291.97,,,,,,,15073.37,38291.97,percent of total billed charges,
PLATE,8282528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,970.29000,281.38000,Aetna,First Health,,793.70,,,,,,,349.79,793.70,percent of total billed charges,
PLATE,8282528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,970.29000,281.38000,Aetna,First Health,,793.70,,,,,,,312.43,793.70,percent of total billed charges,
PLATE,8282530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,863.19000,250.33000,Aetna,First Health,,706.09,,,,,,,311.18,706.09,percent of total billed charges,
PLATE,8282530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,863.19000,250.33000,Aetna,First Health,,706.09,,,,,,,277.95,706.09,percent of total billed charges,
MESH,8282532,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5680.26000,1647.28000,Aetna,First Health,,4646.45,,,,,,,2047.73,4646.45,percent of total billed charges,
MESH,8282532,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5680.26000,1647.28000,Aetna,First Health,,4646.45,,,,,,,1829.04,4646.45,percent of total billed charges,
SPACER HUMERAL,8282534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,865.20,1963.20,percent of total billed charges,
SPACER HUMERAL,8282534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,772.80,1963.20,percent of total billed charges,
BASEPLATE,8282536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
BASEPLATE,8282536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
COMPONENT ULNAR,8282538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
COMPONENT ULNAR,8282538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
SCREW,8282616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.06000,86.73000,Aetna,First Health,,244.63,,,,,,,107.81,244.63,percent of total billed charges,
SCREW,8282616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.06000,86.73000,Aetna,First Health,,244.63,,,,,,,96.30,244.63,percent of total billed charges,
STEM,8282617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15646.25000,4537.41000,Aetna,First Health,,12798.63,,,,,,,5640.47,12798.63,percent of total billed charges,
STEM,8282617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15646.25000,4537.41000,Aetna,First Health,,12798.63,,,,,,,5038.09,12798.63,percent of total billed charges,
HEAD FEMORAL,8282618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9455.34000,2742.05000,Aetna,First Health,,7734.47,,,,,,,3408.65,7734.47,percent of total billed charges,
HEAD FEMORAL,8282618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9455.34000,2742.05000,Aetna,First Health,,7734.47,,,,,,,3044.62,7734.47,percent of total billed charges,
SPACER FEMORAL,8282619,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1766.48000,512.28000,Aetna,First Health,,1444.98,,,,,,,636.82,1444.98,percent of total billed charges,
SPACER FEMORAL,8282619,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1766.48000,512.28000,Aetna,First Health,,1444.98,,,,,,,568.81,1444.98,percent of total billed charges,
WEDGE,8282996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8282996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
HEAD HUMERAL,8282871,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,8282871,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
HEAD HUMERAL,8282872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HEAD HUMERAL,8282872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
BLOCKER SPINAL,8282873,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
BLOCKER SPINAL,8282873,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
ROD SPINAL,8282874,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
ROD SPINAL,8282874,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
SCREW,8282875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8282875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
ROD SPINAL,8282997,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8282997,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CAGE,8282998,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,8282998,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
ANCHOR,8283043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1808.00000,524.32000,Aetna,First Health,,1478.94,,,,,,,651.78,1478.94,percent of total billed charges,
ANCHOR,8283043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1808.00000,524.32000,Aetna,First Health,,1478.94,,,,,,,582.18,1478.94,percent of total billed charges,
BREAST IMPLANT,8283365,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8283365,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
INSERT,8283362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8283362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8283363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,8283363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
SCREW,8283364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8283364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
HEAD FEMORAL,8283469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5771.50000,1673.74000,Aetna,First Health,,4721.09,,,,,,,2080.63,4721.09,percent of total billed charges,
HEAD FEMORAL,8283469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5771.50000,1673.74000,Aetna,First Health,,4721.09,,,,,,,1858.42,4721.09,percent of total billed charges,
INSERT,8283470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8283470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SHELL,8284199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8569.50000,2485.15000,Aetna,First Health,,7009.85,,,,,,,3089.30,7009.85,percent of total billed charges,
SHELL,8284199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8569.50000,2485.15000,Aetna,First Health,,7009.85,,,,,,,2759.38,7009.85,percent of total billed charges,
WEDGE,8284213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5131.18000,1488.04000,Aetna,First Health,,4197.31,,,,,,,1849.79,4197.31,percent of total billed charges,
WEDGE,8284213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5131.18000,1488.04000,Aetna,First Health,,4197.31,,,,,,,1652.24,4197.31,percent of total billed charges,
SCREW,8284214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,860.87,1953.38,percent of total billed charges,
SCREW,8284214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,768.94,1953.38,percent of total billed charges,
SCREW,8284215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,860.87,1953.38,percent of total billed charges,
SCREW,8284215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,768.94,1953.38,percent of total billed charges,
PLATE,8284216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9636.00000,2794.44000,Aetna,First Health,,7882.25,,,,,,,3473.78,7882.25,percent of total billed charges,
PLATE,8284216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9636.00000,2794.44000,Aetna,First Health,,7882.25,,,,,,,3102.79,7882.25,percent of total billed charges,
SCREW,8284217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,8284217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
PLATE,8284218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8361.00000,2424.69000,Aetna,First Health,,6839.30,,,,,,,3014.14,6839.30,percent of total billed charges,
PLATE,8284218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8361.00000,2424.69000,Aetna,First Health,,6839.30,,,,,,,2692.24,6839.30,percent of total billed charges,
SHELL,8284219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
SHELL,8284219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
BREAST IMPLANT,8286479,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8286479,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
CATHETER DIALYSIS,8284280,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
CATHETER DIALYSIS,8284280,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
CATHETER DIALYSIS,8284281,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
CATHETER DIALYSIS,8284281,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
SCREW,8284282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,8284282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
PLATE,8284308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8502.00000,2465.58000,Aetna,First Health,,6954.64,,,,,,,3064.97,6954.64,percent of total billed charges,
PLATE,8284308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8502.00000,2465.58000,Aetna,First Health,,6954.64,,,,,,,2737.64,6954.64,percent of total billed charges,
CAGE,8284415,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8284415,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
STENT GRAFT,8284416,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,First Health,,41219.35,,,,,,,18165.74,41219.35,percent of total billed charges,
STENT GRAFT,8284416,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,First Health,,41219.35,,,,,,,16225.71,41219.35,percent of total billed charges,
PLATE,7702479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,924.08000,267.98000,Aetna,First Health,,755.90,,,,,,,333.13,755.90,percent of total billed charges,
PLATE,7702479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,924.08000,267.98000,Aetna,First Health,,755.90,,,,,,,297.55,755.90,percent of total billed charges,
PLATE,8284598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5043.50000,1462.62000,Aetna,First Health,,4125.58,,,,,,,1818.18,4125.58,percent of total billed charges,
PLATE,8284598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5043.50000,1462.62000,Aetna,First Health,,4125.58,,,,,,,1624.01,4125.58,percent of total billed charges,
SCREW,8284599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8284599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8284600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8284600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
PLATE,7702468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,980.73000,284.41000,Aetna,First Health,,802.24,,,,,,,353.55,802.24,percent of total billed charges,
PLATE,7702468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,980.73000,284.41000,Aetna,First Health,,802.24,,,,,,,315.80,802.24,percent of total billed charges,
CAGE,8284788,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8284788,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8284789,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8284789,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
INSERT,8284790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8284790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
COVER BURRHOLE,7696438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.38000,143.37000,Aetna,First Health,,404.40,,,,,,,178.22,404.40,percent of total billed charges,
COVER BURRHOLE,7696438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.38000,143.37000,Aetna,First Health,,404.40,,,,,,,159.19,404.40,percent of total billed charges,
COVER BURRHOLE,7696439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.38000,143.37000,Aetna,First Health,,404.40,,,,,,,178.22,404.40,percent of total billed charges,
COVER BURRHOLE,7696439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.38000,143.37000,Aetna,First Health,,404.40,,,,,,,159.19,404.40,percent of total billed charges,
COVER BURRHOLE,7696440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,551.97000,160.07000,Aetna,First Health,,451.51,,,,,,,198.99,451.51,percent of total billed charges,
COVER BURRHOLE,7696440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,551.97000,160.07000,Aetna,First Health,,451.51,,,,,,,177.73,451.51,percent of total billed charges,
COVER BURRHOLE,7696437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.38000,143.37000,Aetna,First Health,,404.40,,,,,,,178.22,404.40,percent of total billed charges,
COVER BURRHOLE,7696437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.38000,143.37000,Aetna,First Health,,404.40,,,,,,,159.19,404.40,percent of total billed charges,
SCREW,8286421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SCREW,8286421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SCREW,8286423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SCREW,8286423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
CAGE,8286425,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11205.00000,3249.45000,Aetna,First Health,,9165.69,,,,,,,4039.40,9165.69,percent of total billed charges,
CAGE,8286425,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11205.00000,3249.45000,Aetna,First Health,,9165.69,,,,,,,3608.01,9165.69,percent of total billed charges,
COMPONENT FEMORAL,8286429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,8286429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
FIXATION STAPLE,8286426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6163.50000,1787.42000,Aetna,First Health,,5041.74,,,,,,,2221.94,5041.74,percent of total billed charges,
FIXATION STAPLE,8286426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6163.50000,1787.42000,Aetna,First Health,,5041.74,,,,,,,1984.65,5041.74,percent of total billed charges,
SCREW,8286427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,8286427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
ANCHOR,8286428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ANCHOR,8286428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
TENDON,8286430,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7656.00000,2220.24000,Aetna,First Health,,6262.61,,,,,,,2759.99,6262.61,percent of total billed charges,
TENDON,8286430,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7656.00000,2220.24000,Aetna,First Health,,6262.61,,,,,,,2465.23,6262.61,percent of total billed charges,
TENDON,7696804,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7656.00000,2220.24000,Aetna,First Health,,6262.61,,,,,,,2759.99,6262.61,percent of total billed charges,
TENDON,7696804,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7656.00000,2220.24000,Aetna,First Health,,6262.61,,,,,,,2465.23,6262.61,percent of total billed charges,
SCREW,8288272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,8288272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
STEM CENTRALIZER,8286500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
STEM CENTRALIZER,8286500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
STEM CENTRALIZER,8286501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM CENTRALIZER,8286501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
PLATE,8286502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
PLATE,8286502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW,8286503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SCREW,8286503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,8288243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8288243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8286504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8286504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8286505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8286505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8286506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,8286506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,8286507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,8286507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,8286508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,8286508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
SCREW,8286509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,434.98,987.00,percent of total billed charges,
SCREW,8286509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,First Health,,987.00,,,,,,,388.53,987.00,percent of total billed charges,
GRAFT,8286510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4803.75000,1393.09000,Aetna,First Health,,3929.47,,,,,,,1731.75,3929.47,percent of total billed charges,
GRAFT,8286510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4803.75000,1393.09000,Aetna,First Health,,3929.47,,,,,,,1546.81,3929.47,percent of total billed charges,
INSERT,8288244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8288244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ANCHOR,8290208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,794.54,1802.87,percent of total billed charges,
ANCHOR,8290208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,First Health,,1802.87,,,,,,,709.69,1802.87,percent of total billed charges,
SCREW,8290210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8290210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
POST,8290211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5369.00000,1557.01000,Aetna,First Health,,4391.84,,,,,,,1935.52,4391.84,percent of total billed charges,
POST,8290211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5369.00000,1557.01000,Aetna,First Health,,4391.84,,,,,,,1728.82,4391.84,percent of total billed charges,
SCREW,8288273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,8288273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
SCREW,8288274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,8288274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
SCREW,8288275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,8288275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
SCREW,8288276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,8288276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
GUIDEWIRE,8288278,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
GUIDEWIRE,8288278,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
PLATE,8288279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
PLATE,8288279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
NAIL,8292474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8292474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
COMPONENT GLENOID,8292475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
COMPONENT GLENOID,8292475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
COMPONENT FEMORAL,8292476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,8292476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
INSERT,8292477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8292477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8292735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8292735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
ROD SPINAL,8292737,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,1128.84,percent of total billed charges,
ROD SPINAL,8292737,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,444.36,1128.84,percent of total billed charges,
SCREW,8292739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8292739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
HEAD FEMORAL,8294177,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8294177,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
PLATE,8294170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4315.50000,1251.49000,Aetna,First Health,,3530.08,,,,,,,1555.74,3530.08,percent of total billed charges,
PLATE,8294170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4315.50000,1251.49000,Aetna,First Health,,3530.08,,,,,,,1389.59,3530.08,percent of total billed charges,
INSERT,8294228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8294228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
NAIL,8294310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8294310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
SCREW,8294311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8294311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
CAGE,8294409,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8294409,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
SHELL,8294411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
SHELL,8294411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
SCREW,8294413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8294413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,8294415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8294415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8294417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8294417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,8294419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8294419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8294421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,8294421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,8294423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8294423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,8294425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8294425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
INSERT,8294476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,8294476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
HEAD HUMERAL,8294478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
HEAD HUMERAL,8294478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
CAGE,8294480,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
CAGE,8294480,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
INSERT,8294482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8294482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SHELL,8296466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8296466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,8296470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8296470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8296471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8296471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8296472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8296472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8296473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8296473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8296474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8296474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
SCREW,8296475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8296475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8296476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8296476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
STENT GRAFT,8296477,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,8296477,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
COMPONENT PATELLAR,8296478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLAR,8296478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
INSERT,8296489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8296489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD,8296491,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,318.87000,92.47000,Aetna,First Health,,260.84,,,,,,,114.95,260.84,percent of total billed charges,
ROD,8296491,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,318.87000,92.47000,Aetna,First Health,,260.84,,,,,,,102.68,260.84,percent of total billed charges,
WIRE,8296492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,865.40000,250.97000,Aetna,First Health,,707.90,,,,,,,311.98,707.90,percent of total billed charges,
WIRE,8296492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,865.40000,250.97000,Aetna,First Health,,707.90,,,,,,,278.66,707.90,percent of total billed charges,
PLATE,8296502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6053.15000,1755.41000,Aetna,First Health,,4951.48,,,,,,,2182.16,4951.48,percent of total billed charges,
PLATE,8296502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6053.15000,1755.41000,Aetna,First Health,,4951.48,,,,,,,1949.11,4951.48,percent of total billed charges,
CUFF SYSTEM,8296835,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,22400.00000,6496.00000,Aetna,First Health,,18323.20,,,,,,,8075.20,18323.20,percent of total billed charges,
CUFF SYSTEM,8296835,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,22400.00000,6496.00000,Aetna,First Health,,18323.20,,,,,,,7212.80,18323.20,percent of total billed charges,
EXTENSION CLAMP,8296837,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
EXTENSION CLAMP,8296837,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
EXTENSION CLAMP,8296839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
EXTENSION CLAMP,8296839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
ROD SPINAL,8296841,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,First Health,,5053.19,,,,,,,2226.99,5053.19,percent of total billed charges,
ROD SPINAL,8296841,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,First Health,,5053.19,,,,,,,1989.15,5053.19,percent of total billed charges,
CONNECTOR,8296843,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
CONNECTOR,8296843,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
BREAST IMPLANT,8296844,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
BREAST IMPLANT,8296844,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
BREAST IMPLANT,8296846,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
BREAST IMPLANT,8296846,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
PLATE,8296848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7333.20000,2126.63000,Aetna,First Health,,5998.56,,,,,,,2643.62,5998.56,percent of total billed charges,
PLATE,8296848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7333.20000,2126.63000,Aetna,First Health,,5998.56,,,,,,,2361.29,5998.56,percent of total billed charges,
SCREW,8296850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8296850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
CAGE,8296866,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
CAGE,8296866,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
SCREW,8296867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8296867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
TIGHTROPE,8296868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3617.25000,1049.00000,Aetna,First Health,,2958.91,,,,,,,1304.02,2958.91,percent of total billed charges,
TIGHTROPE,8296868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3617.25000,1049.00000,Aetna,First Health,,2958.91,,,,,,,1164.75,2958.91,percent of total billed charges,
ROD SPINAL,8296869,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
ROD SPINAL,8296869,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,8296870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8296870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
CONNECTOR,8296871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5183.50000,1503.22000,Aetna,First Health,,4240.10,,,,,,,1868.65,4240.10,percent of total billed charges,
CONNECTOR,8296871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5183.50000,1503.22000,Aetna,First Health,,4240.10,,,,,,,1669.09,4240.10,percent of total billed charges,
SCREW,8296872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
SCREW,8296872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
HUMERAL CUP,8296996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1622.36,3681.25,percent of total billed charges,
HUMERAL CUP,8296996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1449.10,3681.25,percent of total billed charges,
GLENOSPHERE,8296997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
GLENOSPHERE,8296997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
EPIPHYSIS ECCENTRIC,8296998,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
EPIPHYSIS ECCENTRIC,8296998,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
SCREW,8296999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,8296999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
SCREW,8297000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,8297000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
SCREW,8297001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,8297001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
STEM,8297002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8297002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,8297003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8297003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
ANCHOR,8296969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
ANCHOR,8296969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
INSERT,8297009,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8297009,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8297115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,8297115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
PLATE,8297117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10578.00000,3067.62000,Aetna,First Health,,8652.80,,,,,,,3813.37,8652.80,percent of total billed charges,
PLATE,8297117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10578.00000,3067.62000,Aetna,First Health,,8652.80,,,,,,,3406.12,8652.80,percent of total billed charges,
INSERT,8297119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8297119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
HEAD RADIAL,8297120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10794.00000,3130.26000,Aetna,First Health,,8829.49,,,,,,,3891.24,8829.49,percent of total billed charges,
HEAD RADIAL,8297120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10794.00000,3130.26000,Aetna,First Health,,8829.49,,,,,,,3475.67,8829.49,percent of total billed charges,
SCREW,8297121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,319.58,725.16,percent of total billed charges,
SCREW,8297121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,285.45,725.16,percent of total billed charges,
PLATE,8297122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5537.00000,1605.73000,Aetna,First Health,,4529.27,,,,,,,1996.09,4529.27,percent of total billed charges,
PLATE,8297122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5537.00000,1605.73000,Aetna,First Health,,4529.27,,,,,,,1782.91,4529.27,percent of total billed charges,
SCREW,8297124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8297124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
STEM,8297125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10719.00000,3108.51000,Aetna,First Health,,8768.14,,,,,,,3864.20,8768.14,percent of total billed charges,
STEM,8297125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10719.00000,3108.51000,Aetna,First Health,,8768.14,,,,,,,3451.52,8768.14,percent of total billed charges,
SCREW,8297126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8297126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8297127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8297127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8297128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8297128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8297129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8297129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8297130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8297130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8297131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8297131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
PLATE,8297132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
PLATE,8297132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
CAGE,8297133,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11205.00000,3249.45000,Aetna,First Health,,9165.69,,,,,,,4039.40,9165.69,percent of total billed charges,
CAGE,8297133,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11205.00000,3249.45000,Aetna,First Health,,9165.69,,,,,,,3608.01,9165.69,percent of total billed charges,
HEAD HUMERAL,8297136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,8297136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
WEDGE,8297137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8907.24000,2583.10000,Aetna,First Health,,7286.12,,,,,,,3211.06,7286.12,percent of total billed charges,
WEDGE,8297137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8907.24000,2583.10000,Aetna,First Health,,7286.12,,,,,,,2868.13,7286.12,percent of total billed charges,
PLATE,8297138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5381.25000,1560.56000,Aetna,First Health,,4401.86,,,,,,,1939.94,4401.86,percent of total billed charges,
PLATE,8297138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5381.25000,1560.56000,Aetna,First Health,,4401.86,,,,,,,1732.76,4401.86,percent of total billed charges,
PLATE,8297139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4444.13000,1288.80000,Aetna,First Health,,3635.30,,,,,,,1602.11,3635.30,percent of total billed charges,
PLATE,8297139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4444.13000,1288.80000,Aetna,First Health,,3635.30,,,,,,,1431.01,3635.30,percent of total billed charges,
WEDGE,8297140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8297140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
INSERT,8297141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT,8297141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
STEM,8297142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8297142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,8297163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8297163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
INSERT,8297164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8297164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8298189,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8298189,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8297315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,195.93000,56.82000,Aetna,First Health,,160.27,,,,,,,70.63,160.27,percent of total billed charges,
SCREW,8297315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,195.93000,56.82000,Aetna,First Health,,160.27,,,,,,,63.09,160.27,percent of total billed charges,
K WIRE,8297313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
K WIRE,8297313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
SCREW,8297314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3682.00000,1067.78000,Aetna,First Health,,3011.88,,,,,,,1327.36,3011.88,percent of total billed charges,
SCREW,8297314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3682.00000,1067.78000,Aetna,First Health,,3011.88,,,,,,,1185.60,3011.88,percent of total billed charges,
SCREW,8298215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8298215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8298217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8298217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8298219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8298219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
SCREW,8298221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,8298221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,8298223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,8298223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
SCREW,8298225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,8298225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
PLATE,8298227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
PLATE,8298227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8298228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,933.62000,270.75000,Aetna,First Health,,763.70,,,,,,,336.57,763.70,percent of total billed charges,
SCREW,8298228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,933.62000,270.75000,Aetna,First Health,,763.70,,,,,,,300.63,763.70,percent of total billed charges,
SCREW,8298229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,933.62000,270.75000,Aetna,First Health,,763.70,,,,,,,336.57,763.70,percent of total billed charges,
SCREW,8298229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,933.62000,270.75000,Aetna,First Health,,763.70,,,,,,,300.63,763.70,percent of total billed charges,
SCREW,8298351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,238.73,541.70,percent of total billed charges,
SCREW,8298351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,First Health,,541.70,,,,,,,213.23,541.70,percent of total billed charges,
SCREW,8298352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,8298352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,8298353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,8298353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,8298354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW,8298354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
COVER HOLE,8229255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1329.52000,385.56000,Aetna,First Health,,1087.55,,,,,,,479.29,1087.55,percent of total billed charges,
COVER HOLE,8229255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1329.52000,385.56000,Aetna,First Health,,1087.55,,,,,,,428.11,1087.55,percent of total billed charges,
PLATE,8298486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
PLATE,8298486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,8298488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8298488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8298490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8298490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
CAGE,8298492,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8298492,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
CAGE,8298494,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8298494,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
SCREW,8298496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SCREW,8298496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SCREW,8298498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SCREW,8298498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
CAGE,8298500,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8298500,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
PLATE,8298502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,322.88,732.63,percent of total billed charges,
PLATE,8298502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,288.40,732.63,percent of total billed charges,
PLATE,8298504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,8298504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
ANCHOR,8298812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,802.11,1820.05,percent of total billed charges,
ANCHOR,8298812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,716.45,1820.05,percent of total billed charges,
PLATE,8298814,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,First Health,,3638.62,,,,,,,1603.57,3638.62,percent of total billed charges,
PLATE,8298814,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,First Health,,3638.62,,,,,,,1432.32,3638.62,percent of total billed charges,
INSERT,8298879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8298879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8298880,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8298880,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ROD SPINAL,8298881,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8298881,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8298882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8298882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SPACER,8298900,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
SPACER,8298900,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
CAGE,8298901,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8298901,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
CAGE,8298902,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8298902,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SCREW,8298903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8298903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
NAIL,8299542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8299542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
COMPONENT FEMORAL,8299544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
COMPONENT FEMORAL,8299544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SCREW,8301038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8301038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
PLATE,8299545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10383.00000,3011.07000,Aetna,First Health,,8493.29,,,,,,,3743.07,8493.29,percent of total billed charges,
PLATE,8299545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10383.00000,3011.07000,Aetna,First Health,,8493.29,,,,,,,3343.33,8493.29,percent of total billed charges,
INSERT,8299554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8299554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8299555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8299555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8299556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8299556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8300428,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8300428,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
CAGE,8300430,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8300430,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
CAP SPINAL,8300432,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
CAP SPINAL,8300432,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
CAP SPINAL,8300434,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
CAP SPINAL,8300434,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
PLATE,8300436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6437.03000,1866.74000,Aetna,First Health,,5265.49,,,,,,,2320.55,5265.49,percent of total billed charges,
PLATE,8300436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6437.03000,1866.74000,Aetna,First Health,,5265.49,,,,,,,2072.72,5265.49,percent of total billed charges,
PLATE,8300438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
PLATE,8300438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW,8301040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8301040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
CONNECTOR SPINAL,8301041,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5502.00000,1595.58000,Aetna,First Health,,4500.64,,,,,,,1983.47,4500.64,percent of total billed charges,
CONNECTOR SPINAL,8301041,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5502.00000,1595.58000,Aetna,First Health,,4500.64,,,,,,,1771.64,4500.64,percent of total billed charges,
SCREW,8301042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SCREW,8301042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,8301043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
SCREW,8301043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
SCREW,8301044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8301044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8301045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8301045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8301046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8301046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
PLATE,8301047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
PLATE,8301047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
PLATE,8301048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE,8301048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
INTRADISCAL SHIM,8301049,CDM,278,RC,,,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
INTRADISCAL SHIM,8301049,CDM,278,RC,,,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
SCREW,8301050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,8301050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
PLATE,8301051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2854.60000,827.83000,Aetna,First Health,,2335.06,,,,,,,1029.08,2335.06,percent of total billed charges,
PLATE,8301051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2854.60000,827.83000,Aetna,First Health,,2335.06,,,,,,,919.18,2335.06,percent of total billed charges,
INSERT,8305696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8305696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8305699,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8305699,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ROD SPINAL,8305701,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8305701,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8305703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,8305703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW,8305705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,8305705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
INSERT,8305707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8305707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8305709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8305709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
GUIDEWIRE,8307098,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
GUIDEWIRE,8307098,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
INSERT,8307500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8307500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INTRADISCAL SHIM,8307501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
INTRADISCAL SHIM,8307501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE,8310266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2463.52000,714.42000,Aetna,First Health,,2015.16,,,,,,,888.10,2015.16,percent of total billed charges,
PLATE,8310266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2463.52000,714.42000,Aetna,First Health,,2015.16,,,,,,,793.25,2015.16,percent of total billed charges,
ALLODERM,8310286,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2741.60,6220.89,percent of total billed charges,
ALLODERM,8310286,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,124.65,6220.89,percent of total billed charges,
COMPONENT FEMORAL,8310300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22765.50000,6602.00000,Aetna,First Health,,18622.18,,,,,,,8206.96,18622.18,percent of total billed charges,
COMPONENT FEMORAL,8310300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22765.50000,6602.00000,Aetna,First Health,,18622.18,,,,,,,7330.49,18622.18,percent of total billed charges,
INSERT,8310301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4599.00000,1333.71000,Aetna,First Health,,3761.98,,,,,,,1657.94,3761.98,percent of total billed charges,
INSERT,8310301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4599.00000,1333.71000,Aetna,First Health,,3761.98,,,,,,,1480.88,3761.98,percent of total billed charges,
CAGE,8310302,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8310302,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
CAGE,8310303,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8310303,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
PLATE,8311100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2705.64000,784.64000,Aetna,First Health,,2213.21,,,,,,,975.38,2213.21,percent of total billed charges,
PLATE,8311100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2705.64000,784.64000,Aetna,First Health,,2213.21,,,,,,,871.22,2213.21,percent of total billed charges,
VALVE,8310294,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8064.00000,2338.56000,Aetna,First Health,,6596.35,,,,,,,2907.07,6596.35,percent of total billed charges,
VALVE,8310294,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8064.00000,2338.56000,Aetna,First Health,,6596.35,,,,,,,2596.61,6596.35,percent of total billed charges,
ANCHOR IN KIT,8312094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
ANCHOR IN KIT,8312094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
VALVE,8310296,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8064.00000,2338.56000,Aetna,First Health,,6596.35,,,,,,,2907.07,6596.35,percent of total billed charges,
VALVE,8310296,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8064.00000,2338.56000,Aetna,First Health,,6596.35,,,,,,,2596.61,6596.35,percent of total billed charges,
ROD SPINAL,8312095,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8312095,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
GRAFT BONE MATRIX,8312890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14026.05000,4067.55000,Aetna,First Health,,11473.31,,,,,,,5056.39,11473.31,percent of total billed charges,
GRAFT BONE MATRIX,8312890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14026.05000,4067.55000,Aetna,First Health,,11473.31,,,,,,,4516.39,11473.31,percent of total billed charges,
SCREW,8312891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8312891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ANCHOR,8312892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ANCHOR,8312892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
ANCHOR,8312893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3065.00000,888.85000,Aetna,First Health,,2507.17,,,,,,,1104.93,2507.17,percent of total billed charges,
ANCHOR,8312893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3065.00000,888.85000,Aetna,First Health,,2507.17,,,,,,,986.93,2507.17,percent of total billed charges,
BREAST IMPLANT,8313663,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8313663,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8313665,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8313665,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8313667,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8313667,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8313669,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8313669,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8313671,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8313671,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8313673,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8313673,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
INSERT,8313681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8313681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8313682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8313682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ROD SPINAL,8313683,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8313683,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
CAGE,8313684,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2669.14,6056.47,percent of total billed charges,
CAGE,8313684,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2384.09,6056.47,percent of total billed charges,
SYSTEM SURG PROC WITH SCREW,8313608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
SYSTEM SURG PROC WITH SCREW,8313608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
MESH,8313688,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8026.80000,2327.77000,Aetna,First Health,,6565.92,,,,,,,2893.66,6565.92,percent of total billed charges,
MESH,8313688,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8026.80000,2327.77000,Aetna,First Health,,6565.92,,,,,,,2584.63,6565.92,percent of total billed charges,
SCREW,8313766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.26000,96.36000,Aetna,First Health,,271.79,,,,,,,119.78,271.79,percent of total billed charges,
SCREW,8313766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.26000,96.36000,Aetna,First Health,,271.79,,,,,,,106.99,271.79,percent of total billed charges,
WEDGE,8313898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE,8313898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
ANCHOR,8313788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
ANCHOR,8313788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
INSERT,8313940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8313940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,8314006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8314006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT TIBIAL,8314007,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
COMPONENT TIBIAL,8314007,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
COMPONENT TIBIAL,8314002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,8314002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
STEM,8314003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4609.50000,1336.76000,Aetna,First Health,,3770.57,,,,,,,1661.72,3770.57,percent of total billed charges,
STEM,8314003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4609.50000,1336.76000,Aetna,First Health,,3770.57,,,,,,,1484.26,3770.57,percent of total billed charges,
STEM,8314004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8314004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
BASEPLATE,8314044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.60000,3007.76000,Aetna,First Health,,8483.97,,,,,,,3738.96,8483.97,percent of total billed charges,
BASEPLATE,8314044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.60000,3007.76000,Aetna,First Health,,8483.97,,,,,,,3339.66,8483.97,percent of total billed charges,
GLENOSPHERE,8314045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1779.07,4036.83,percent of total billed charges,
GLENOSPHERE,8314045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1589.07,4036.83,percent of total billed charges,
PLATE,7702434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.56000,380.64000,Aetna,First Health,,1073.67,,,,,,,473.18,1073.67,percent of total billed charges,
PLATE,7702434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.56000,380.64000,Aetna,First Health,,1073.67,,,,,,,422.64,1073.67,percent of total billed charges,
GLENOSPHERE,8314118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1779.07,4036.83,percent of total billed charges,
GLENOSPHERE,8314118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1589.07,4036.83,percent of total billed charges,
BASEPLATE,8314119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.60000,3007.76000,Aetna,First Health,,8483.97,,,,,,,3738.96,8483.97,percent of total billed charges,
BASEPLATE,8314119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.60000,3007.76000,Aetna,First Health,,8483.97,,,,,,,3339.66,8483.97,percent of total billed charges,
INSERT,8314120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8314120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BASEPLATE,8314121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
BASEPLATE,8314121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
GLENOID,8314122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GLENOID,8314122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
HEAD HUMERAL,8314123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,8314123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
TENDON,8314241,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17859.38000,5179.22000,Aetna,First Health,,14608.97,,,,,,,6438.31,14608.97,percent of total billed charges,
TENDON,8314241,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17859.38000,5179.22000,Aetna,First Health,,14608.97,,,,,,,5750.72,14608.97,percent of total billed charges,
WEDGE,8314249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
WEDGE,8314249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
HEAD FEMORAL,8314250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8314250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
STEM,8318388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8318388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
HEAD HUMERAL,8314251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,8314251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STEM,8314252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,8314252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
NUT,8318440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,365.80000,106.08000,Aetna,First Health,,299.22,,,,,,,131.87,299.22,percent of total billed charges,
NUT,8318440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,365.80000,106.08000,Aetna,First Health,,299.22,,,,,,,117.79,299.22,percent of total billed charges,
BOLT,8318441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,451.44000,130.92000,Aetna,First Health,,369.28,,,,,,,162.74,369.28,percent of total billed charges,
BOLT,8318441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,451.44000,130.92000,Aetna,First Health,,369.28,,,,,,,145.36,369.28,percent of total billed charges,
INSERT,8318442,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8318442,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
LINER,8318443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10830.00000,3140.70000,Aetna,First Health,,8858.94,,,,,,,3904.22,8858.94,percent of total billed charges,
LINER,8318443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10830.00000,3140.70000,Aetna,First Health,,8858.94,,,,,,,3487.26,8858.94,percent of total billed charges,
HEAD FEMORAL,8318444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6471.50000,1876.74000,Aetna,First Health,,5293.69,,,,,,,2332.98,5293.69,percent of total billed charges,
HEAD FEMORAL,8318444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6471.50000,1876.74000,Aetna,First Health,,5293.69,,,,,,,2083.82,5293.69,percent of total billed charges,
SCREW,8320190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8320190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
CAGE,8320191,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8320191,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
SCREW,8320192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8320192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW,8320193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8320193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
ANCHOR,8320181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2024.00000,586.96000,Aetna,First Health,,1655.63,,,,,,,729.65,1655.63,percent of total billed charges,
ANCHOR,8320181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2024.00000,586.96000,Aetna,First Health,,1655.63,,,,,,,651.73,1655.63,percent of total billed charges,
SCREW,8320183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8320183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8320184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8320184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW BONE,8320185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW BONE,8320185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8320186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,8320186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
SCREW CORTICAL,8320187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW CORTICAL,8320187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW CORTICAL,8320188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW CORTICAL,8320188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SPACER,8320333,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
SPACER,8320333,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
CAGE BASE,8320305,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE BASE,8320305,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
SCREW,8320195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8320195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW CANN,8320196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW CANN,8320196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8320291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8320291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8320292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8320292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8320293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8320293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8320294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8320294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8320295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8320295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8320296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8320296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW THREADED,8320297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW THREADED,8320297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW THREADED,8320298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW THREADED,8320298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW THREADED,8320299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW THREADED,8320299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW THREADED,8320300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW THREADED,8320300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW THREADED,8320301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW THREADED,8320301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW THREADED,8320302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW THREADED,8320302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW THREADED,8320303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW THREADED,8320303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW THREADED,8320304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW THREADED,8320304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SPACER,8320346,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SPACER,8320346,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
ROD,8320879,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD,8320879,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8320885,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8320885,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
SCREW CANC,8321541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4588.50000,1330.66000,Aetna,First Health,,3753.39,,,,,,,1654.15,3753.39,percent of total billed charges,
SCREW CANC,8321541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4588.50000,1330.66000,Aetna,First Health,,3753.39,,,,,,,1477.50,3753.39,percent of total billed charges,
WEDGE FEMORAL,8321542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE FEMORAL,8321542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
ENDPLATE,8321543,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8321543,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
POUCH BIODORBABLE,8321544,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4795.00000,1390.55000,Aetna,First Health,,3922.31,,,,,,,1728.60,3922.31,percent of total billed charges,
POUCH BIODORBABLE,8321544,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4795.00000,1390.55000,Aetna,First Health,,3922.31,,,,,,,1543.99,3922.31,percent of total billed charges,
STENT,8320310,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8320310,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8320311,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8320311,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8320314,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8320314,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8320315,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8320315,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8320316,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
STENT,8320316,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
STENT,8320318,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8320318,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8320319,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8320319,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8320320,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
STENT,8320320,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
STENT,8320329,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8320329,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8320330,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8320330,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
ENDPLATE,8322727,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8322727,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
NAIL,8322728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8322728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
INSERT,8322745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8322745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
LINER,8322746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8322746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,8322747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8322747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,8322748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8322748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,8322749,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8322749,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
STEM FEMORAL,8322750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9201.00000,2668.29000,Aetna,First Health,,7526.42,,,,,,,3316.96,7526.42,percent of total billed charges,
STEM FEMORAL,8322750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9201.00000,2668.29000,Aetna,First Health,,7526.42,,,,,,,2962.72,7526.42,percent of total billed charges,
SCREW,8323236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8323236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
INSERT,8323239,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8323239,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8323240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8323240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
LINER,8324458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8324458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
STEM,8323237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11873.25000,3443.24000,Aetna,First Health,,9712.32,,,,,,,4280.31,9712.32,percent of total billed charges,
STEM,8323237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11873.25000,3443.24000,Aetna,First Health,,9712.32,,,,,,,3823.19,9712.32,percent of total billed charges,
STEM CENTRALIZER,8323238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
STEM CENTRALIZER,8323238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
INSERT,8324501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8324501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,8324502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8324502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BASEPLATE,8324503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.60000,3007.76000,Aetna,First Health,,8483.97,,,,,,,3738.96,8483.97,percent of total billed charges,
BASEPLATE,8324503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.60000,3007.76000,Aetna,First Health,,8483.97,,,,,,,3339.66,8483.97,percent of total billed charges,
SCREW,8324505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8324505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
INSERT,8324617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8324617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8324618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
PLATE,8324618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
STEM,8324619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,8324619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
INSERT,8324620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8324620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,8324621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8324621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,8324622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8324622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SCREW,8326243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
SCREW,8326243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
SCREW,8326244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
SCREW,8326244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,421.18,1069.94,percent of total billed charges,
SCREW,8326245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
SCREW,8326245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,421.18,1069.94,percent of total billed charges,
PLATE,8326246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6583.50000,1909.22000,Aetna,First Health,,5385.30,,,,,,,2373.35,5385.30,percent of total billed charges,
PLATE,8326246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6583.50000,1909.22000,Aetna,First Health,,5385.30,,,,,,,2119.89,5385.30,percent of total billed charges,
SCREW,8326247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,8326247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
SCREW,8326248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1268.00000,367.72000,Aetna,First Health,,1037.22,,,,,,,457.11,1037.22,percent of total billed charges,
SCREW,8326248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1268.00000,367.72000,Aetna,First Health,,1037.22,,,,,,,408.30,1037.22,percent of total billed charges,
SHELL,8328316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8328316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,8328335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,8328335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
STEM,8328366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,8328366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CONNECTOR SPINAL,8328336,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,1106.01,2509.62,percent of total billed charges,
CONNECTOR SPINAL,8328336,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,987.90,2509.62,percent of total billed charges,
SCREW,8328337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,8328337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
ROD SPINAL,8328381,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8328381,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER IN TRAY,8328399,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1409.20000,408.67000,Aetna,First Health,,1152.73,,,,,,,508.02,1152.73,percent of total billed charges,
CATHETER IN TRAY,8328399,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1409.20000,408.67000,Aetna,First Health,,1152.73,,,,,,,453.76,1152.73,percent of total billed charges,
COMPONENT TIBIAL,8328482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9027.00000,2617.83000,Aetna,First Health,,7384.09,,,,,,,3254.23,7384.09,percent of total billed charges,
COMPONENT TIBIAL,8328482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9027.00000,2617.83000,Aetna,First Health,,7384.09,,,,,,,2906.69,7384.09,percent of total billed charges,
BASEPLATE,8328483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17460.00000,5063.40000,Aetna,First Health,,14282.28,,,,,,,6294.33,14282.28,percent of total billed charges,
BASEPLATE,8328483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17460.00000,5063.40000,Aetna,First Health,,14282.28,,,,,,,5622.12,14282.28,percent of total billed charges,
COMPONENT FEMORAL,8328484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21873.00000,6343.17000,Aetna,First Health,,17892.11,,,,,,,7885.22,17892.11,percent of total billed charges,
COMPONENT FEMORAL,8328484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21873.00000,6343.17000,Aetna,First Health,,17892.11,,,,,,,7043.11,17892.11,percent of total billed charges,
STEM EXTENSION,8328485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5716.20000,1657.70000,Aetna,First Health,,4675.85,,,,,,,2060.69,4675.85,percent of total billed charges,
STEM EXTENSION,8328485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5716.20000,1657.70000,Aetna,First Health,,4675.85,,,,,,,1840.62,4675.85,percent of total billed charges,
SPACER,8328486,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8830.80000,2560.93000,Aetna,First Health,,7223.59,,,,,,,3183.50,7223.59,percent of total billed charges,
SPACER,8328486,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8830.80000,2560.93000,Aetna,First Health,,7223.59,,,,,,,2843.52,7223.59,percent of total billed charges,
COMPONENT TIBIAL,8328487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11201.40000,3248.41000,Aetna,First Health,,9162.75,,,,,,,4038.10,9162.75,percent of total billed charges,
COMPONENT TIBIAL,8328487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11201.40000,3248.41000,Aetna,First Health,,9162.75,,,,,,,3606.85,9162.75,percent of total billed charges,
WEDGE,8328488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5749.80000,1667.44000,Aetna,First Health,,4703.34,,,,,,,2072.80,4703.34,percent of total billed charges,
WEDGE,8328488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5749.80000,1667.44000,Aetna,First Health,,4703.34,,,,,,,1851.44,4703.34,percent of total billed charges,
STEM,8328489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STEM,8328489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
INSERT,8328490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8328490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT TIBIAL,8328491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
COMPONENT TIBIAL,8328491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
STEM,8328542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13514.40000,3919.18000,Aetna,First Health,,11054.78,,,,,,,4871.94,11054.78,percent of total billed charges,
STEM,8328542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13514.40000,3919.18000,Aetna,First Health,,11054.78,,,,,,,4351.64,11054.78,percent of total billed charges,
PLATE,8328554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
PLATE,8328554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
STENT GRAFT,8328584,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,47643.98000,13816.75000,Aetna,First Health,,38972.78,,,,,,,17175.65,38972.78,percent of total billed charges,
STENT GRAFT,8328584,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,47643.98000,13816.75000,Aetna,First Health,,38972.78,,,,,,,15341.36,38972.78,percent of total billed charges,
STENT GRAFT,8328585,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,54130.20000,15697.76000,Aetna,First Health,,44278.50,,,,,,,19513.94,44278.50,percent of total billed charges,
STENT GRAFT,8328585,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,54130.20000,15697.76000,Aetna,First Health,,44278.50,,,,,,,17429.92,44278.50,percent of total billed charges,
STENT GRAFT,8330207,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT GRAFT,8330207,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
NAIL,8330336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14143.50000,4101.62000,Aetna,First Health,,11569.38,,,,,,,5098.73,11569.38,percent of total billed charges,
NAIL,8330336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14143.50000,4101.62000,Aetna,First Health,,11569.38,,,,,,,4554.21,11569.38,percent of total billed charges,
BONE GRAFT,8330349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12528.90000,3633.38000,Aetna,First Health,,10248.64,,,,,,,4516.67,10248.64,percent of total billed charges,
BONE GRAFT,8330349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12528.90000,3633.38000,Aetna,First Health,,10248.64,,,,,,,4034.31,10248.64,percent of total billed charges,
CAGE,8330338,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8330338,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,8330339,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8330339,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
ROD SPINAL,8330340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,8330340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
PLATE,8330268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3930.50000,1139.84000,Aetna,First Health,,3215.15,,,,,,,1416.95,3215.15,percent of total billed charges,
PLATE,8330268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3930.50000,1139.84000,Aetna,First Health,,3215.15,,,,,,,1265.62,3215.15,percent of total billed charges,
GRAFT,8330425,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5689.29000,1649.89000,Aetna,First Health,,4653.84,,,,,,,2050.99,4653.84,percent of total billed charges,
GRAFT,8330425,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5689.29000,1649.89000,Aetna,First Health,,4653.84,,,,,,,1831.95,4653.84,percent of total billed charges,
WEDGE,8330394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8330394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
COMPONENT FEMORAL,8330435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8330435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE,8330436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
BASEPLATE,8330436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
SCREW,8330437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,8330437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,8330438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,8330438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
INSERT,8330494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8330494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
NAIL,8330439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330689,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330689,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5524.33000,1602.06000,Aetna,First Health,,4518.90,,,,,,,1991.52,4518.90,percent of total billed charges,
NAIL,8330690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5524.33000,1602.06000,Aetna,First Health,,4518.90,,,,,,,1778.83,4518.90,percent of total billed charges,
NAIL,8330452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5524.33000,1602.06000,Aetna,First Health,,4518.90,,,,,,,1991.52,4518.90,percent of total billed charges,
NAIL,8330452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5524.33000,1602.06000,Aetna,First Health,,4518.90,,,,,,,1778.83,4518.90,percent of total billed charges,
NAIL,8330691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5524.33000,1602.06000,Aetna,First Health,,4518.90,,,,,,,1991.52,4518.90,percent of total billed charges,
NAIL,8330691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5524.33000,1602.06000,Aetna,First Health,,4518.90,,,,,,,1778.83,4518.90,percent of total billed charges,
SCREW,8330453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,1017.48,2308.72,percent of total billed charges,
SCREW,8330463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,First Health,,2308.72,,,,,,,908.81,2308.72,percent of total billed charges,
SCREW,8330692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8330692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
SCREW,8330693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8330693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
SCREW,8330694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8330694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
GLENOSPHERE,8330695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1779.07,4036.83,percent of total billed charges,
GLENOSPHERE,8330695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1589.07,4036.83,percent of total billed charges,
HEAD HUMERAL,8330696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
HEAD HUMERAL,8330696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
ROD,8330697,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,289.57,657.06,percent of total billed charges,
ROD,8330697,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,258.65,657.06,percent of total billed charges,
INSERT,8330698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8330698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
LINER,8330765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8330765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER,8330789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8330789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
NAIL,8330859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330950,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330950,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2863.03,6496.43,percent of total billed charges,
NAIL,8330964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,First Health,,6496.43,,,,,,,2557.27,6496.43,percent of total billed charges,
NAIL,8330965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
NAIL,8330967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2963.30,6723.94,percent of total billed charges,
NAIL,8330967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,First Health,,6723.94,,,,,,,2646.83,6723.94,percent of total billed charges,
PLATE,8331246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2984.96000,865.64000,Aetna,First Health,,2441.70,,,,,,,1076.08,2441.70,percent of total billed charges,
PLATE,8331246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2984.96000,865.64000,Aetna,First Health,,2441.70,,,,,,,961.16,2441.70,percent of total billed charges,
AUGMENT FEMORAL,8331259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,8331259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
AUGMENT FEMORAL,8331260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
AUGMENT FEMORAL,8331260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
CENTRALIZER STEM,8331261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
CENTRALIZER STEM,8331261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
STEM,8331262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
STEM,8331262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
STENT GRAFT,8331286,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8331286,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT GRAFT,8331287,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8331287,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT GRAFT,8331288,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8331288,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT GRAFT,8331289,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8331289,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT GRAFT,8331290,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8331290,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT GRAFT,8331291,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8331291,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT GRAFT,8331292,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8331292,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT GRAFT,8331293,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8331293,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT GRAFT,8332177,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8332177,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT GRAFT,8331294,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8331294,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT GRAFT,8332184,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8332184,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
COMPONENT FEMORAL,8331457,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2365.78,5368.12,percent of total billed charges,
COMPONENT FEMORAL,8331457,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2113.12,5368.12,percent of total billed charges,
HOLE COVER,8169807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,830.52000,240.85000,Aetna,First Health,,679.37,,,,,,,299.40,679.37,percent of total billed charges,
HOLE COVER,8169807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,830.52000,240.85000,Aetna,First Health,,679.37,,,,,,,267.43,679.37,percent of total billed charges,
HOLE COVER,8231614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,852.08000,247.10000,Aetna,First Health,,697.00,,,,,,,307.17,697.00,percent of total billed charges,
HOLE COVER,8231614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,852.08000,247.10000,Aetna,First Health,,697.00,,,,,,,274.37,697.00,percent of total billed charges,
HOLE COVER,8169805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,842.13000,244.22000,Aetna,First Health,,688.86,,,,,,,303.59,688.86,percent of total billed charges,
HOLE COVER,8169805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,842.13000,244.22000,Aetna,First Health,,688.86,,,,,,,271.17,688.86,percent of total billed charges,
NAIL,8332171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1931.74,4383.25,percent of total billed charges,
NAIL,8332171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,First Health,,4383.25,,,,,,,1725.44,4383.25,percent of total billed charges,
CATHETER,8332191,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
CATHETER,8332191,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
STEM,8332341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18861.60000,5469.86000,Aetna,First Health,,15428.79,,,,,,,6799.61,15428.79,percent of total billed charges,
STEM,8332341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18861.60000,5469.86000,Aetna,First Health,,15428.79,,,,,,,6073.44,15428.79,percent of total billed charges,
NAIL,8332353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,1085.65,2463.42,percent of total billed charges,
NAIL,8332353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,969.71,2463.42,percent of total billed charges,
INSERT,8332491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8332491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT TIBIAL,8332516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
COMPONENT TIBIAL,8332516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,8332517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,8332517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
NAIL,8334205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,8334205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
PLATE,8334206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10152.00000,2944.08000,Aetna,First Health,,8304.34,,,,,,,3659.80,8304.34,percent of total billed charges,
PLATE,8334206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10152.00000,2944.08000,Aetna,First Health,,8304.34,,,,,,,3268.94,8304.34,percent of total billed charges,
SCREW,8334207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,8334207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,8334204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,8334204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
NAIL,8334203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2949.80000,855.44000,Aetna,First Health,,2412.94,,,,,,,1063.40,2412.94,percent of total billed charges,
NAIL,8334203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2949.80000,855.44000,Aetna,First Health,,2412.94,,,,,,,949.84,2412.94,percent of total billed charges,
SCREW,8334254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8334254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
STEM,8334312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8334312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PLATE,8334311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,564.98000,163.84000,Aetna,First Health,,462.15,,,,,,,203.68,462.15,percent of total billed charges,
PLATE,8334311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,564.98000,163.84000,Aetna,First Health,,462.15,,,,,,,181.92,462.15,percent of total billed charges,
PLATE,8334364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3575.46000,1036.88000,Aetna,First Health,,2924.73,,,,,,,1288.95,2924.73,percent of total billed charges,
PLATE,8334364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3575.46000,1036.88000,Aetna,First Health,,2924.73,,,,,,,1151.30,2924.73,percent of total billed charges,
NAIL,8334363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,1085.65,2463.42,percent of total billed charges,
NAIL,8334363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,969.71,2463.42,percent of total billed charges,
PLATE,8334391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5683.83000,1648.31000,Aetna,First Health,,4649.37,,,,,,,2049.02,4649.37,percent of total billed charges,
PLATE,8334391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5683.83000,1648.31000,Aetna,First Health,,4649.37,,,,,,,1830.19,4649.37,percent of total billed charges,
SCREW,8334390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,57.54,130.55,percent of total billed charges,
SCREW,8334390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,First Health,,130.55,,,,,,,51.39,130.55,percent of total billed charges,
ROD SPINAL,8334417,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8334417,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,8334405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
SCREW,8334405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
SCREW,8334406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
SCREW,8334406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
PIN,8334418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,513.00000,148.77000,Aetna,First Health,,419.63,,,,,,,184.94,419.63,percent of total billed charges,
PIN,8334418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,513.00000,148.77000,Aetna,First Health,,419.63,,,,,,,165.19,419.63,percent of total billed charges,
STEM,8334433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM,8334433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
INSERT,8334432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25666.15000,7443.18000,Aetna,First Health,,20994.91,,,,,,,9252.65,20994.91,percent of total billed charges,
INSERT,8334432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25666.15000,7443.18000,Aetna,First Health,,20994.91,,,,,,,8264.50,20994.91,percent of total billed charges,
PLATE,8334434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5013.75000,1453.99000,Aetna,First Health,,4101.25,,,,,,,1807.46,4101.25,percent of total billed charges,
PLATE,8334434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5013.75000,1453.99000,Aetna,First Health,,4101.25,,,,,,,1614.43,4101.25,percent of total billed charges,
PLATE,8334541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,921.29000,267.17000,Aetna,First Health,,753.62,,,,,,,332.13,753.62,percent of total billed charges,
PLATE,8334541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,921.29000,267.17000,Aetna,First Health,,753.62,,,,,,,296.66,753.62,percent of total billed charges,
PLATE,8334542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,747.59000,216.80000,Aetna,First Health,,611.53,,,,,,,269.51,611.53,percent of total billed charges,
PLATE,8334542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,747.59000,216.80000,Aetna,First Health,,611.53,,,,,,,240.72,611.53,percent of total billed charges,
NAIL BLADE,8334930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,1085.65,2463.42,percent of total billed charges,
NAIL BLADE,8334930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,969.71,2463.42,percent of total billed charges,
CAGE,8335296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8335296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
SCREW,8335282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1490.13,3381.20,percent of total billed charges,
SCREW,8335282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,First Health,,3381.20,,,,,,,1330.99,3381.20,percent of total billed charges,
CAGE,8335326,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8335326,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
ROD SPINAL,8335327,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8335327,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
COMPONENT FEMORAL,8335481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,4351.96,9874.90,percent of total billed charges,
COMPONENT FEMORAL,8335481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,3887.18,9874.90,percent of total billed charges,
AUGMENT FEMORAL,8335482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2144.00000,621.76000,Aetna,First Health,,1753.79,,,,,,,772.91,1753.79,percent of total billed charges,
AUGMENT FEMORAL,8335482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2144.00000,621.76000,Aetna,First Health,,1753.79,,,,,,,690.37,1753.79,percent of total billed charges,
NAIL BLADE,8336033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2949.80000,855.44000,Aetna,First Health,,2412.94,,,,,,,1063.40,2412.94,percent of total billed charges,
NAIL BLADE,8336033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2949.80000,855.44000,Aetna,First Health,,2412.94,,,,,,,949.84,2412.94,percent of total billed charges,
CEMENT,8336034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2980.16000,864.25000,Aetna,First Health,,2437.77,,,,,,,1074.35,2437.77,percent of total billed charges,
CEMENT,8336034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2980.16000,864.25000,Aetna,First Health,,2437.77,,,,,,,959.61,2437.77,percent of total billed charges,
CAP,8336442,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
CAP,8336442,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
CAP,8336443,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
CAP,8336443,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
CAGE,8336444,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8336444,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
NAIL BLADE,8336445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,1085.65,2463.42,percent of total billed charges,
NAIL BLADE,8336445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,969.71,2463.42,percent of total billed charges,
CAGE,8336521,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8336521,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
PLATE,8336518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1291.62,2930.77,percent of total billed charges,
PLATE,8336518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1153.68,2930.77,percent of total billed charges,
CAP,8336520,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
CAP,8336520,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
CAP,8336519,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
CAP,8336519,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
SCREW,8336554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,8336554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
NAIL,8336557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8336557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
CONNECTOR SPINAL,8336555,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3458.00000,1002.82000,Aetna,First Health,,2828.64,,,,,,,1246.61,2828.64,percent of total billed charges,
CONNECTOR SPINAL,8336555,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3458.00000,1002.82000,Aetna,First Health,,2828.64,,,,,,,1113.48,2828.64,percent of total billed charges,
HOOK,8336556,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2107.84000,611.27000,Aetna,First Health,,1724.21,,,,,,,759.88,1724.21,percent of total billed charges,
HOOK,8336556,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2107.84000,611.27000,Aetna,First Health,,1724.21,,,,,,,678.72,1724.21,percent of total billed charges,
PLATE,8336605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1734.59,3935.91,percent of total billed charges,
PLATE,8336605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1549.34,3935.91,percent of total billed charges,
GUIDEWIRE,8336745,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
GUIDEWIRE,8336745,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,43.95,111.66,percent of total billed charges,
SCREW,8336607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8336607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8336746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8336746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
GUIDEWIRE,8336604,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,39.27,89.11,percent of total billed charges,
GUIDEWIRE,8336604,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,First Health,,89.11,,,,,,,35.08,89.11,percent of total billed charges,
PLATE,8336823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4444.13000,1288.80000,Aetna,First Health,,3635.30,,,,,,,1602.11,3635.30,percent of total billed charges,
PLATE,8336823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4444.13000,1288.80000,Aetna,First Health,,3635.30,,,,,,,1431.01,3635.30,percent of total billed charges,
PLATE,8336824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1873.70,4251.56,percent of total billed charges,
PLATE,8336824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1673.60,4251.56,percent of total billed charges,
SCREW,8336825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8336825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
STAPLE,8336826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6109.74000,1771.82000,Aetna,First Health,,4997.77,,,,,,,2202.56,4997.77,percent of total billed charges,
STAPLE,8336826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6109.74000,1771.82000,Aetna,First Health,,4997.77,,,,,,,1967.34,4997.77,percent of total billed charges,
SCREW,8338169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8338169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
ROD SPINAL,8338236,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8338236,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT FEMORAL,8338244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,8338244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
HEAD FEMORAL,8338245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
HEAD FEMORAL,8338245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
HEART VALVE,8338263,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE,8338263,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
HEART VALVE,8338264,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE,8338264,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
HEART VALVE,8338394,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,27758.50,62986.00,percent of total billed charges,
HEART VALVE,8338394,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,First Health,,62986.00,,,,,,,24794.00,62986.00,percent of total billed charges,
NAIL,8338395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5971.00000,1731.59000,Aetna,First Health,,4884.28,,,,,,,2152.55,4884.28,percent of total billed charges,
NAIL,8338395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5971.00000,1731.59000,Aetna,First Health,,4884.28,,,,,,,1922.66,4884.28,percent of total billed charges,
SCREW,8338396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,8338396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,8338397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,8338397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
CAGE,8338445,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8338445,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CAGE,8338446,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8338446,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
BLOCK FEMORAL,7736497,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1991.84000,577.63000,Aetna,First Health,,1629.33,,,,,,,718.06,1629.33,percent of total billed charges,
BLOCK FEMORAL,7736497,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1991.84000,577.63000,Aetna,First Health,,1629.33,,,,,,,641.37,1629.33,percent of total billed charges,
CATHETER,8429785,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8429785,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8429787,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8429787,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8429786,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8429786,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8429788,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,8429788,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CATHETER,8435775,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,First Health,,1701.44,,,,,,,749.84,1701.44,percent of total billed charges,
CATHETER,8435775,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,First Health,,1701.44,,,,,,,669.76,9959.00,percent of total billed charges,
SUTURE SYSTEM,8446220,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1452.00000,421.08000,Aetna,First Health,,1187.74,,,,,,,523.45,1187.74,percent of total billed charges,
SUTURE SYSTEM,8446220,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1452.00000,421.08000,Aetna,First Health,,1187.74,,,,,,,467.54,1187.74,percent of total billed charges,
BALLOON CATHETER,8487989,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,1117.55,2535.80,percent of total billed charges,
BALLOON CATHETER,8487989,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,998.20,2535.80,percent of total billed charges,
MEMBRANE,8490010,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3864.00000,1120.56000,Aetna,First Health,,3160.75,,,,,,,1392.97,3160.75,percent of total billed charges,
MEMBRANE,8490010,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3864.00000,1120.56000,Aetna,First Health,,3160.75,,,,,,,1244.21,3160.75,percent of total billed charges,
SYSTEM CEREBRAL,8485955,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
SYSTEM CEREBRAL,8485955,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CATHETER BALLOON,8496707,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,277.40,629.45,percent of total billed charges,
CATHETER BALLOON,8496707,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,247.78,629.45,percent of total billed charges,
CATHETER,8511932,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4542.30,10306.80,percent of total billed charges,
CATHETER,8511932,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4057.20,10306.80,percent of total billed charges,
CATHETER,8511933,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4542.30,10306.80,percent of total billed charges,
CATHETER,8511933,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4057.20,10306.80,percent of total billed charges,
CATHETER,8511934,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4542.30,10306.80,percent of total billed charges,
CATHETER,8511934,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4057.20,10306.80,percent of total billed charges,
SHEATH,8511935,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SHEATH,8511935,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SHEATH,8511936,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SHEATH,8511936,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SHEATH,8511937,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SHEATH,8511937,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SHEATH,8511938,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SHEATH,8511938,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CATHETER,8513936,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4542.30,10306.80,percent of total billed charges,
CATHETER,8513936,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4057.20,10306.80,percent of total billed charges,
BALLOON,8663930,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
BALLOON,8663930,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CATH PACING,8683929,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,578.25000,167.69000,Aetna,First Health,,473.01,,,,,,,208.46,473.01,percent of total billed charges,
CATH PACING,8683929,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,578.25000,167.69000,Aetna,First Health,,473.01,,,,,,,186.20,9959.00,percent of total billed charges,
PACING CABLE,8683928,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,1717.80,percent of total billed charges,
PACING CABLE,8683928,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,676.20,1717.80,percent of total billed charges,
Catheter Turnpike LP 5FR 135CM,8693932,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
Catheter Turnpike LP 5FR 135CM,8693932,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
CATHETER,8701925,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,578.25000,167.69000,Aetna,First Health,,473.01,,,,,,,208.46,473.01,percent of total billed charges,
CATHETER,8701925,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,578.25000,167.69000,Aetna,First Health,,473.01,,,,,,,186.20,9959.00,percent of total billed charges,
LEAD PACING,8711945,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,1717.80,percent of total billed charges,
LEAD PACING,8711945,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,676.20,1717.80,percent of total billed charges,
SYSTEM MITRACLIP,8770104,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,72000.00000,20880.00000,Aetna,First Health,,58896.00,,,,,,,25956.00,58896.00,percent of total billed charges,
SYSTEM MITRACLIP,8770104,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,72000.00000,20880.00000,Aetna,First Health,,58896.00,,,,,,,23184.00,58896.00,percent of total billed charges,
ICD,8786164,CDM,278,RC,C1722,HCPCS,,,facility,inpatient,,,30487.50000,8841.38000,Aetna,First Health,,24938.78,,,,,,,10990.74,24938.78,percent of total billed charges,
ICD,8786164,CDM,278,RC,C1722,HCPCS,,,facility,outpatient,,,30487.50000,8841.38000,Aetna,First Health,,24938.78,,,,,,,9816.98,24938.78,percent of total billed charges,
CATHETER,8806084,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
CATHETER,8806084,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
GUIDEWIRE,8806085,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,306.38000,88.85000,Aetna,First Health,,250.62,,,,,,,110.45,250.62,percent of total billed charges,
GUIDEWIRE,8806085,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,306.38000,88.85000,Aetna,First Health,,250.62,,,,,,,98.65,250.62,percent of total billed charges,
ICM LINQ II EVENT RECORDER,8910497,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15362.50000,4455.12000,Aetna,First Health,,12566.52,,,,,,,5538.18,12566.52,percent of total billed charges,
ICM LINQ II EVENT RECORDER,8910497,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15362.50000,4455.12000,Aetna,First Health,,12566.52,,,,,,,4946.73,12566.52,percent of total billed charges,
BALLOON,8912128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,947.88,2150.82,percent of total billed charges,
BALLOON,8912128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,846.65,2150.82,percent of total billed charges,
BALLOON,8912129,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,947.88,2150.82,percent of total billed charges,
BALLOON,8912129,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,846.65,2150.82,percent of total billed charges,
BALLOON,8912130,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,947.88,2150.82,percent of total billed charges,
BALLOON,8912130,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,846.65,2150.82,percent of total billed charges,
GUIDEWIRE,8912140,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,87.57000,25.40000,Aetna,First Health,,71.63,,,,,,,31.57,71.63,percent of total billed charges,
GUIDEWIRE,8912140,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,87.57000,25.40000,Aetna,First Health,,71.63,,,,,,,28.20,71.63,percent of total billed charges,
BALLOON,8912143,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,First Health,,2814.33,,,,,,,1240.30,2814.33,percent of total billed charges,
BALLOON,8912143,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,First Health,,2814.33,,,,,,,1107.84,2814.33,percent of total billed charges,
BALLOON,8912142,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,First Health,,2814.33,,,,,,,1240.30,2814.33,percent of total billed charges,
BALLOON,8912142,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,First Health,,2814.33,,,,,,,1107.84,2814.33,percent of total billed charges,
GUIDEWIRE,8912141,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,37.85,85.89,percent of total billed charges,
GUIDEWIRE,8912141,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,33.81,85.89,percent of total billed charges,
BALLOON,8910540,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,947.88,2150.82,percent of total billed charges,
BALLOON,8910540,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,846.65,2150.82,percent of total billed charges,
BALLOON,8910541,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,947.88,2150.82,percent of total billed charges,
BALLOON,8910541,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,First Health,,2150.82,,,,,,,846.65,2150.82,percent of total billed charges,
INTRODUCER,8914218,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3601.50000,1044.44000,Aetna,First Health,,2946.03,,,,,,,1298.34,2946.03,percent of total billed charges,
INTRODUCER,8914218,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,First Health,,2946.03,,,,,,,1159.68,2946.03,percent of total billed charges,
GLIDEWIRE,8916399,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,311.13000,90.23000,Aetna,First Health,,254.50,,,,,,,112.16,254.50,percent of total billed charges,
GLIDEWIRE,8916399,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,311.13000,90.23000,Aetna,First Health,,254.50,,,,,,,100.18,254.50,percent of total billed charges,
GLIDEWIRE,8916400,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,First Health,,275.87,,,,,,,121.58,275.87,percent of total billed charges,
GLIDEWIRE,8916400,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,First Health,,275.87,,,,,,,108.59,275.87,percent of total billed charges,
CATHETER ANGIOSCLPT,8916498,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916498,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916499,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916499,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916500,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916500,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916501,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916501,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916502,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916502,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916503,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916503,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916504,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916504,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916505,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916505,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916506,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916506,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916507,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916507,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916508,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916508,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916509,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER ANGIOSCLPT,8916509,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CATHETER,8916497,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CATHETER,8916497,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
GUIDEWIRE,8916489,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,37.85,85.89,percent of total billed charges,
GUIDEWIRE,8916489,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,33.81,85.89,percent of total billed charges,
CATHETER ABLAT LASER,8916762,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
CATHETER ABLAT LASER,8916762,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
ACCESS VERSACROSS,8924175,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,First Health,,3421.28,,,,,,,1507.79,3421.28,percent of total billed charges,
ACCESS VERSACROSS,8924175,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,First Health,,3421.28,,,,,,,1346.77,3421.28,percent of total billed charges,
ACCESS VERSACROSS,8924176,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4375.00000,1268.75000,Aetna,First Health,,3578.75,,,,,,,1577.19,3578.75,percent of total billed charges,
ACCESS VERSACROSS,8924176,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4375.00000,1268.75000,Aetna,First Health,,3578.75,,,,,,,1408.75,3578.75,percent of total billed charges,
ACCESS PROC WATCHMAN,8908287,CDM,278,RC,,,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
ACCESS PROC WATCHMAN,8908287,CDM,278,RC,,,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
CATHETER PASSER,8926331,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,First Health,,3421.28,,,,,,,1507.79,3421.28,percent of total billed charges,
CATHETER PASSER,8926331,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,First Health,,3421.28,,,,,,,1346.77,3421.28,percent of total billed charges,
ACCESS VERSACROSS,8926332,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,4375.00000,1268.75000,Aetna,First Health,,3578.75,,,,,,,1577.19,3578.75,percent of total billed charges,
ACCESS VERSACROSS,8926332,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,4375.00000,1268.75000,Aetna,First Health,,3578.75,,,,,,,1408.75,3578.75,percent of total billed charges,
CATHETER,8924991,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1896.00000,549.84000,Aetna,First Health,,1550.93,,,,,,,683.51,1550.93,percent of total billed charges,
CATHETER,8924991,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1896.00000,549.84000,Aetna,First Health,,1550.93,,,,,,,610.51,1550.93,percent of total billed charges,
CATHETER,8946405,CDM,278,RC,C1759,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
CATHETER,8946405,CDM,278,RC,C1759,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
INTRODUCER,8947176,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
INTRODUCER,8947176,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
GUIDEWIRE,8916110,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,87.68000,25.43000,Aetna,First Health,,71.72,,,,,,,31.61,71.72,percent of total billed charges,
GUIDEWIRE,8916110,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,87.68000,25.43000,Aetna,First Health,,71.72,,,,,,,28.23,71.72,percent of total billed charges,
WASHER,8416985,CDM,278,RC,,,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1596.11,3621.70,percent of total billed charges,
WASHER,8416985,CDM,278,RC,,,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1425.65,3621.70,percent of total billed charges,
NAIL,8416854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL,8416854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
ROD SPINAL,8417182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8417182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8417184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,8417184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,8417186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,8417186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,8417188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,8417188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,8417190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,8417190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,8417192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,47.66,108.14,percent of total billed charges,
SCREW,8417192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,First Health,,108.14,,,,,,,42.57,108.14,percent of total billed charges,
INSERT,8417194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8417194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
MESH,8417196,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4547.55000,1318.79000,Aetna,First Health,,3719.90,,,,,,,1639.39,3719.90,percent of total billed charges,
MESH,8417196,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4547.55000,1318.79000,Aetna,First Health,,3719.90,,,,,,,1464.31,3719.90,percent of total billed charges,
SCREW SPINAL,8417198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW SPINAL,8417198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
CATHETER,8417179,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,91.88000,26.65000,Aetna,First Health,,75.16,,,,,,,33.12,75.16,percent of total billed charges,
CATHETER,8417179,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,91.88000,26.65000,Aetna,First Health,,75.16,,,,,,,29.59,75.16,percent of total billed charges,
CATHETER,8417200,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,91.88000,26.65000,Aetna,First Health,,75.16,,,,,,,33.12,75.16,percent of total billed charges,
CATHETER,8417200,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,91.88000,26.65000,Aetna,First Health,,75.16,,,,,,,29.59,75.16,percent of total billed charges,
GUIDEWIRE,8417201,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
GUIDEWIRE,8417201,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
COIL,8417202,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
COIL,8417202,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
SCREW,8417204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,8417204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,8417205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,8417205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,8417206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,8417206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,8417207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,8417207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
COMPONENT TIBIAL,8417295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
COMPONENT TIBIAL,8417295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
CAGE,8417296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8417296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
ANCHOR,8417297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,908.10,2060.54,percent of total billed charges,
ANCHOR,8417297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,811.12,2060.54,percent of total billed charges,
TISSUE,8417335,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,10281.00000,2981.49000,Aetna,First Health,,8409.86,,,,,,,3706.30,8409.86,percent of total billed charges,
TISSUE,8417335,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,10281.00000,2981.49000,Aetna,First Health,,8409.86,,,,,,,124.65,8409.86,percent of total billed charges,
AUGMENT FEMORAL,8417346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
AUGMENT FEMORAL,8417346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
INSERT,8417348,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8417348,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
NAIL,8417350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8417350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
INSERT,8417352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8417352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW SPINAL,8417344,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
SCREW SPINAL,8417344,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
STENT,8417354,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
STENT,8417354,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
STENT,8417355,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
STENT,8417355,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
STENT,8417356,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
STENT,8417356,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
SPINAL CORD STIMULATOR,8417357,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,59000.00000,17110.00000,Aetna,First Health,,48262.00,,,,,,,21269.50,48262.00,percent of total billed charges,
SPINAL CORD STIMULATOR,8417357,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,59000.00000,17110.00000,Aetna,First Health,,48262.00,,,,,,,18998.00,48262.00,percent of total billed charges,
Anchor Kit,8417448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2741.60,6220.89,percent of total billed charges,
Anchor Kit,8417448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2448.81,6220.89,percent of total billed charges,
CABLE,8417460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11584.50000,3359.50000,Aetna,First Health,,9476.12,,,,,,,4176.21,9476.12,percent of total billed charges,
CABLE,8417460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11584.50000,3359.50000,Aetna,First Health,,9476.12,,,,,,,3730.21,9476.12,percent of total billed charges,
LINER ACETABULAR,8417450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3605.00000,1045.45000,Aetna,First Health,,2948.89,,,,,,,1299.60,2948.89,percent of total billed charges,
LINER ACETABULAR,8417450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3605.00000,1045.45000,Aetna,First Health,,2948.89,,,,,,,1160.81,2948.89,percent of total billed charges,
SHEATH URETERAL,8417446,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,530.66,1204.10,percent of total billed charges,
SHEATH URETERAL,8417446,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,473.98,1204.10,percent of total billed charges,
SHEATH URETERAL,8417443,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,530.66,1204.10,percent of total billed charges,
SHEATH URETERAL,8417443,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,473.98,1204.10,percent of total billed charges,
SHEATH URETERAL,8417442,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,530.66,1204.10,percent of total billed charges,
SHEATH URETERAL,8417442,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,473.98,1204.10,percent of total billed charges,
SHEATH URETERAL,8417444,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,530.66,1204.10,percent of total billed charges,
SHEATH URETERAL,8417444,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,473.98,1204.10,percent of total billed charges,
SHEATH,8417445,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,530.66,1204.10,percent of total billed charges,
SHEATH,8417445,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,473.98,1204.10,percent of total billed charges,
SHEATH,8417572,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
SHEATH,8417572,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
SHEATH,8417573,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
SHEATH,8417573,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
PATELLA,8417574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
PATELLA,8417574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
CAGE,8417576,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8417576,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
SCREW SPINAL,8417577,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW SPINAL,8417577,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
ROD SPINAL,8417579,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8417579,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SPACER,8417923,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
SPACER,8417923,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
CONNECTOR ROD,8417938,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR ROD,8417938,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
CONNECTOR ROD,8417940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
CONNECTOR ROD,8417940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
CONNECTOR SET SCREW,8417942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
CONNECTOR SET SCREW,8417942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
CONNECTOR SPINAL,8417944,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR SPINAL,8417944,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
ROD SPINAL,8417945,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8417945,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
STEM,8417947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
STEM,8417947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
FIBERTAK KIT,8417977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
FIBERTAK KIT,8417977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
FIBERTAK,8417978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.00000,578.26000,Aetna,First Health,,1631.09,,,,,,,718.84,1631.09,percent of total billed charges,
FIBERTAK,8417978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.00000,578.26000,Aetna,First Health,,1631.09,,,,,,,642.07,1631.09,percent of total billed charges,
MINITAPE,8417979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
MINITAPE,8417979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
MINITAPE,8417980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
MINITAPE,8417980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
MINITAPE,8417981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
MINITAPE,8417981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
NAIL TIBIAL,8417982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL TIBIAL,8417982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
SCREW SPINAL,8419535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW SPINAL,8419535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
BONE GRAFT,8419543,CDM,278,RC,C9359,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
BONE GRAFT,8419543,CDM,278,RC,C9359,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
BONE GRAFT,8419544,CDM,278,RC,C9359,HCPCS,,,facility,inpatient,,,3814.86000,1106.31000,Aetna,First Health,,3120.56,,,,,,,1375.26,3120.56,percent of total billed charges,
BONE GRAFT,8419544,CDM,278,RC,C9359,HCPCS,,,facility,outpatient,,,3814.86000,1106.31000,Aetna,First Health,,3120.56,,,,,,,1228.38,3120.56,percent of total billed charges,
PATELLA,8419539,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
PATELLA,8419539,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
INSERT TIBIAL,8419540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
INSERT TIBIAL,8419540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
STEM,8419541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9378.00000,2719.62000,Aetna,First Health,,7671.20,,,,,,,3380.77,7671.20,percent of total billed charges,
STEM,8419541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9378.00000,2719.62000,Aetna,First Health,,7671.20,,,,,,,3019.72,7671.20,percent of total billed charges,
STEM,8419542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7746.00000,2246.34000,Aetna,First Health,,6336.23,,,,,,,2792.43,6336.23,percent of total billed charges,
STEM,8419542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7746.00000,2246.34000,Aetna,First Health,,6336.23,,,,,,,2494.21,6336.23,percent of total billed charges,
INSERT,8423642,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8423642,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
NAIL,8421558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8421558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
SCREW,8419617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8419617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
SCREW,8419616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8419616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
LINER,8421560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8421560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
GRAFT,8421562,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2952.00000,856.08000,Aetna,First Health,,2414.74,,,,,,,1064.20,2414.74,percent of total billed charges,
GRAFT,8421562,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2952.00000,856.08000,Aetna,First Health,,2414.74,,,,,,,950.54,2414.74,percent of total billed charges,
GUIDEWIRE,8419615,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
GUIDEWIRE,8419615,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
BREAST IMPLANT,8419619,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8419619,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
PLATE,8421595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5352.52000,1552.23000,Aetna,First Health,,4378.36,,,,,,,1929.58,4378.36,percent of total billed charges,
PLATE,8421595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5352.52000,1552.23000,Aetna,First Health,,4378.36,,,,,,,1723.51,4378.36,percent of total billed charges,
CAGE,8421597,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8421597,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
LIGAMENT,8423552,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,13680.00000,3967.20000,Aetna,First Health,,11190.24,,,,,,,4931.64,11190.24,percent of total billed charges,
LIGAMENT,8423552,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,13680.00000,3967.20000,Aetna,First Health,,11190.24,,,,,,,4404.96,11190.24,percent of total billed charges,
INSERT,8423553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8423553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,8423555,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8423555,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
PLATE SPINAL,8423557,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12747.00000,3696.63000,Aetna,First Health,,10427.05,,,,,,,4595.29,10427.05,percent of total billed charges,
PLATE SPINAL,8423557,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12747.00000,3696.63000,Aetna,First Health,,10427.05,,,,,,,4104.53,10427.05,percent of total billed charges,
SCREW SPINAL,8423559,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW SPINAL,8423559,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
PLATE,8423561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2323.88000,673.93000,Aetna,First Health,,1900.93,,,,,,,837.76,1900.93,percent of total billed charges,
PLATE,8423561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2323.88000,673.93000,Aetna,First Health,,1900.93,,,,,,,748.29,1900.93,percent of total billed charges,
SCREW,8423562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.02000,280.15000,Aetna,First Health,,790.20,,,,,,,348.25,790.20,percent of total billed charges,
SCREW,8423562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.02000,280.15000,Aetna,First Health,,790.20,,,,,,,311.06,790.20,percent of total billed charges,
STENT GRAFT,8423581,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,8423581,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
STENT GRAFT,8423582,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,8423582,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
SHEATH,8423583,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,530.66,1204.10,percent of total billed charges,
SHEATH,8423583,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,473.98,1204.10,percent of total billed charges,
CAGE,8423644,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8423644,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
SCREW SPINAL,8423650,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SPINAL,8423650,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ROD SPINAL,8423646,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
ROD SPINAL,8423646,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
SCREW,8423651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8423651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
SCREW,8423652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8423652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
SCREW,8423653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,8423653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
PLATE,8423654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8046.00000,2333.34000,Aetna,First Health,,6581.63,,,,,,,2900.58,6581.63,percent of total billed charges,
PLATE,8423654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8046.00000,2333.34000,Aetna,First Health,,6581.63,,,,,,,2590.81,6581.63,percent of total billed charges,
LINER,8425590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8425590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
COMPONENT FEMORAL,8425547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT FEMORAL,8425547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
ROD SPINAL,8425548,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8425548,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
COMPONENT TIBIAL,8425586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
COMPONENT TIBIAL,8425586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
COMPONENT PATELLA,8425588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,8425588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
GRAFT STENT,8425652,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,38137.50000,11059.88000,Aetna,First Health,,31196.47,,,,,,,13748.57,31196.47,percent of total billed charges,
GRAFT STENT,8425652,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,38137.50000,11059.88000,Aetna,First Health,,31196.47,,,,,,,12280.27,31196.47,percent of total billed charges,
ANCHOR,8425654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3685.50000,1068.79000,Aetna,First Health,,3014.74,,,,,,,1328.62,3014.74,percent of total billed charges,
ANCHOR,8425654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3685.50000,1068.79000,Aetna,First Health,,3014.74,,,,,,,1186.73,3014.74,percent of total billed charges,
SCREW,8425656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,8425656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
PLATE,8425658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3349.50000,971.35000,Aetna,First Health,,2739.89,,,,,,,1207.49,2739.89,percent of total billed charges,
PLATE,8425658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3349.50000,971.35000,Aetna,First Health,,2739.89,,,,,,,1078.54,2739.89,percent of total billed charges,
ROD SPINAL,8425660,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8425660,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PLATE,7702473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1945.24000,564.12000,Aetna,First Health,,1591.21,,,,,,,701.26,1591.21,percent of total billed charges,
PLATE,7702473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1945.24000,564.12000,Aetna,First Health,,1591.21,,,,,,,626.37,1591.21,percent of total billed charges,
SCREW,8425662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW,8425662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
SCREW,8425663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW,8425663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
SCREW,8425664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW,8425664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
SCREW,8425665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW,8425665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
SCREW,8425666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8425666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8425667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8425667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
PLATE,8425668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2357.68000,683.73000,Aetna,First Health,,1928.58,,,,,,,849.94,1928.58,percent of total billed charges,
PLATE,8425668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2357.68000,683.73000,Aetna,First Health,,1928.58,,,,,,,759.17,1928.58,percent of total billed charges,
PLATE,8425669,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2543.68000,737.67000,Aetna,First Health,,2080.73,,,,,,,917.00,2080.73,percent of total billed charges,
PLATE,8425669,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2543.68000,737.67000,Aetna,First Health,,2080.73,,,,,,,819.06,2080.73,percent of total billed charges,
PLATE,8425670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2452.20000,711.14000,Aetna,First Health,,2005.90,,,,,,,884.02,2005.90,percent of total billed charges,
PLATE,8425670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2452.20000,711.14000,Aetna,First Health,,2005.90,,,,,,,789.61,2005.90,percent of total billed charges,
SCREW,8425671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW,8425671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
SCREW,8425672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW,8425672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
SCREW,8425673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,266.29,604.24,percent of total billed charges,
SCREW,8425673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,237.85,604.24,percent of total billed charges,
SCREW,8425674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,266.29,604.24,percent of total billed charges,
SCREW,8425674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,237.85,604.24,percent of total billed charges,
SCREW,8425675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,266.29,604.24,percent of total billed charges,
SCREW,8425675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,237.85,604.24,percent of total billed charges,
COMPONENT FEMORAL,8427454,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
COMPONENT FEMORAL,8427454,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
STEM EXTENSION,8427455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM EXTENSION,8427455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
INSERT,8427456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8427456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
COMPONENT TIBIAL,8427457,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,8427457,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
STEM EXTENSION,8427458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM EXTENSION,8427458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
CAGE,8427459,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8427459,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
CAGE,8427460,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8427460,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
CAGE,8427461,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,6529.56,14816.02,percent of total billed charges,
CAGE,8427461,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,5832.23,14816.02,percent of total billed charges,
PLATE,8427463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2650.40000,768.62000,Aetna,First Health,,2168.03,,,,,,,955.47,2168.03,percent of total billed charges,
PLATE,8427463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2650.40000,768.62000,Aetna,First Health,,2168.03,,,,,,,853.43,2168.03,percent of total billed charges,
SCREW,8427464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8427464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
NAIL,8427465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8427465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
SCREW SPINAL,8427585,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW SPINAL,8427585,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW SPINAL,8427587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW SPINAL,8427587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
CAGE,8427589,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,8939.50,20284.35,percent of total billed charges,
CAGE,8427589,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,7984.80,20284.35,percent of total billed charges,
CAGE,8427591,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,8939.50,20284.35,percent of total billed charges,
CAGE,8427591,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,7984.80,20284.35,percent of total billed charges,
COVER BUR HOLE,8427596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.45000,282.01000,Aetna,First Health,,795.46,,,,,,,350.57,795.46,percent of total billed charges,
COVER BUR HOLE,8427596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.45000,282.01000,Aetna,First Health,,795.46,,,,,,,313.13,795.46,percent of total billed charges,
LIGAMENT,8427623,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,11850.00000,3436.50000,Aetna,First Health,,9693.30,,,,,,,4271.93,9693.30,percent of total billed charges,
LIGAMENT,8427623,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,11850.00000,3436.50000,Aetna,First Health,,9693.30,,,,,,,3815.70,9693.30,percent of total billed charges,
PLATE SPINAL,8427643,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE SPINAL,8427643,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
CAGE,8427645,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8427645,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
COMPONENT FEMORAL,8427647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,8427647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SCREW,8427649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,314.23,713.01,percent of total billed charges,
SCREW,8427649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,280.67,713.01,percent of total billed charges,
SCREW,8427651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,314.23,713.01,percent of total billed charges,
SCREW,8427651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,280.67,713.01,percent of total billed charges,
NAIL,8427653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5529.13000,1603.45000,Aetna,First Health,,4522.83,,,,,,,1993.25,4522.83,percent of total billed charges,
NAIL,8427653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5529.13000,1603.45000,Aetna,First Health,,4522.83,,,,,,,1780.38,4522.83,percent of total billed charges,
NAIL,8427656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7827.00000,2269.83000,Aetna,First Health,,6402.49,,,,,,,2821.63,6402.49,percent of total billed charges,
NAIL,8427656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7827.00000,2269.83000,Aetna,First Health,,6402.49,,,,,,,2520.29,6402.49,percent of total billed charges,
SCREW SPINAL,8427658,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW SPINAL,8427658,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
NAIL,8427660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7827.00000,2269.83000,Aetna,First Health,,6402.49,,,,,,,2821.63,6402.49,percent of total billed charges,
NAIL,8427660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7827.00000,2269.83000,Aetna,First Health,,6402.49,,,,,,,2520.29,6402.49,percent of total billed charges,
INSERT,8427661,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8427661,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8427663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8427663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,8427725,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
COMPONENT FEMORAL,8427725,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
WEDGE,8427727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2968.72,6736.23,percent of total billed charges,
WEDGE,8427727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2651.67,6736.23,percent of total billed charges,
SCREW,8427729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8427729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8427731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8427731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SHELL,8427733,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8427733,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
INSERT,8427735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8427735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
DERMIS TISSUE,8427738,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,418.00000,121.22000,Aetna,First Health,,341.92,,,,,,,150.69,341.92,percent of total billed charges,
DERMIS TISSUE,8427738,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,418.00000,121.22000,Aetna,First Health,,341.92,,,,,,,124.65,341.92,percent of total billed charges,
PLATE,8429562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.00000,1246.42000,Aetna,First Health,,3515.76,,,,,,,1549.43,3515.76,percent of total billed charges,
PLATE,8429562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.00000,1246.42000,Aetna,First Health,,3515.76,,,,,,,1383.96,3515.76,percent of total billed charges,
SCREW,8429563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,8429563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
SCREW,8429564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8429564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8429565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8429565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8429566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,8429566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
SCREW,8429567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,8429567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
CAGE,8429568,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8429568,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
GRAFT TISSUE,8429641,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7682.52000,2227.93000,Aetna,First Health,,6284.30,,,,,,,2769.55,6284.30,percent of total billed charges,
GRAFT TISSUE,8429641,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7682.52000,2227.93000,Aetna,First Health,,6284.30,,,,,,,2473.77,6284.30,percent of total billed charges,
GRAFT,8429643,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9499.14000,2754.75000,Aetna,First Health,,7770.30,,,,,,,3424.44,7770.30,percent of total billed charges,
GRAFT,8429643,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9499.14000,2754.75000,Aetna,First Health,,7770.30,,,,,,,3058.72,7770.30,percent of total billed charges,
GRAFT,8429644,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5034.19000,1459.92000,Aetna,First Health,,4117.97,,,,,,,1814.83,4117.97,percent of total billed charges,
GRAFT,8429644,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5034.19000,1459.92000,Aetna,First Health,,4117.97,,,,,,,1621.01,4117.97,percent of total billed charges,
COMPONENT FEMORAL,8429645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,8429645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
PLATE,8429646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4059.86000,1177.36000,Aetna,First Health,,3320.97,,,,,,,1463.58,3320.97,percent of total billed charges,
PLATE,8429646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4059.86000,1177.36000,Aetna,First Health,,3320.97,,,,,,,1307.27,3320.97,percent of total billed charges,
CAGE,8429697,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8429697,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
SCREW,8429699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8429699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
STEM,8429701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15850.00000,4596.50000,Aetna,First Health,,12965.30,,,,,,,5713.93,12965.30,percent of total billed charges,
STEM,8429701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15850.00000,4596.50000,Aetna,First Health,,12965.30,,,,,,,5103.70,12965.30,percent of total billed charges,
SPACER,8429703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,4082.66,9263.85,percent of total billed charges,
SPACER,8429703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,3646.65,9263.85,percent of total billed charges,
SCREW SPINAL,8429749,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW SPINAL,8429749,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
SCREW,8429751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8429751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8429797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW,8429797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
SCREW,8429799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW,8429799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
SCREW,8429801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW,8429801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
PLATE,8429803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1748.00000,506.92000,Aetna,First Health,,1429.86,,,,,,,630.15,1429.86,percent of total billed charges,
PLATE,8429803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1748.00000,506.92000,Aetna,First Health,,1429.86,,,,,,,562.86,1429.86,percent of total billed charges,
SCREW,8429789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,795.98,1806.14,percent of total billed charges,
SCREW,8429789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,First Health,,1806.14,,,,,,,710.98,1806.14,percent of total billed charges,
CAGE,8429790,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8429790,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
INSERT,8429805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8429805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,8429904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8429904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,8429905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8429905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW SPINAL,8431778,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW SPINAL,8431778,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
INSERT,8431898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8431898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW,8431900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8431900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SCREW,8431902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8431902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
END CAP,8431904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
END CAP,8431904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
NAIL,8431906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8431906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
STEM,8431908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8946.00000,2594.34000,Aetna,First Health,,7317.83,,,,,,,3225.03,7317.83,percent of total billed charges,
STEM,8431908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8946.00000,2594.34000,Aetna,First Health,,7317.83,,,,,,,2880.61,7317.83,percent of total billed charges,
CAGE,8431910,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8431910,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
CAGE,8432018,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
CAGE,8432018,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
PLATE,8432019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8201.94000,2378.56000,Aetna,First Health,,6709.19,,,,,,,2956.80,6709.19,percent of total billed charges,
PLATE,8432019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8201.94000,2378.56000,Aetna,First Health,,6709.19,,,,,,,2641.02,6709.19,percent of total billed charges,
SCREW,8432064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8432064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
INSERT,8432065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8432065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8432068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8432068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8433792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,8433792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CAGE,8433788,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8433788,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CAGE,8433790,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8433790,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
SCREW,8433784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8433784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,8433786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8433786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
PLATE,8433795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4258.10000,1234.85000,Aetna,First Health,,3483.13,,,,,,,1535.05,3483.13,percent of total billed charges,
PLATE,8433795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4258.10000,1234.85000,Aetna,First Health,,3483.13,,,,,,,1371.11,3483.13,percent of total billed charges,
SCREW,8433829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,8433829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW SPINAL,8433863,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW SPINAL,8433863,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
GRAFT,8433873,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,3212.05,7288.38,percent of total billed charges,
GRAFT,8433873,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,2869.02,7288.38,percent of total billed charges,
ROD SPINAL,8433864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
ROD SPINAL,8433864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
CAGE,8433940,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433940,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433942,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433942,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433944,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433944,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433945,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433945,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433946,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433946,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433947,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433947,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433948,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433948,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433952,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433952,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433954,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433954,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433955,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433955,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433956,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433956,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CAGE,8433957,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,8433957,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
PLATE,8433961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE,8433961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
COVER BURR HOLE,8433962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,814.28000,236.14000,Aetna,First Health,,666.08,,,,,,,293.55,666.08,percent of total billed charges,
COVER BURR HOLE,8433962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,814.28000,236.14000,Aetna,First Health,,666.08,,,,,,,262.20,666.08,percent of total billed charges,
INSERT,8433963,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8433963,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ROD SPINAL,8433964,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8433964,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
PLATE,8434098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4063.50000,1178.42000,Aetna,First Health,,3323.94,,,,,,,1464.89,3323.94,percent of total billed charges,
PLATE,8434098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4063.50000,1178.42000,Aetna,First Health,,3323.94,,,,,,,1308.45,3323.94,percent of total billed charges,
PLATE,8434099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1635.23,3710.45,percent of total billed charges,
PLATE,8434099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1460.59,3710.45,percent of total billed charges,
SCREW,8434100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8434100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8434101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8434101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8434102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,8434102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
SCREW,8434103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,8434103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
SCREW,8434104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,206.03,467.49,percent of total billed charges,
SCREW,8434104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,184.02,467.49,percent of total billed charges,
SCREW,8434105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,206.03,467.49,percent of total billed charges,
SCREW,8434105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,184.02,467.49,percent of total billed charges,
PLATE SPINAL,8434106,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE SPINAL,8434106,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
BONE FILLER,8435729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2424.00000,702.96000,Aetna,First Health,,1982.83,,,,,,,873.85,1982.83,percent of total billed charges,
BONE FILLER,8435729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2424.00000,702.96000,Aetna,First Health,,1982.83,,,,,,,780.53,1982.83,percent of total billed charges,
NAIL,8435761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,3062.33,6948.65,percent of total billed charges,
NAIL,8435761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,2735.29,6948.65,percent of total billed charges,
SCREW,8435763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,8435763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,8435765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,8435765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,8435767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,565.03,1282.10,percent of total billed charges,
SCREW,8435767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,504.69,1282.10,percent of total billed charges,
SCREW,8435769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW,8435769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
SCREW,8435771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW,8435771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
VALVE FOR SHUNT,8435773,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,15467.35000,4485.53000,Aetna,First Health,,12652.29,,,,,,,5575.98,12652.29,percent of total billed charges,
VALVE FOR SHUNT,8435773,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,15467.35000,4485.53000,Aetna,First Health,,12652.29,,,,,,,4980.49,12652.29,percent of total billed charges,
SCREW,8436058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1400.96000,406.28000,Aetna,First Health,,1145.99,,,,,,,505.05,1145.99,percent of total billed charges,
SCREW,8436058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1400.96000,406.28000,Aetna,First Health,,1145.99,,,,,,,451.11,1145.99,percent of total billed charges,
SCREW,8435776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1400.96000,406.28000,Aetna,First Health,,1145.99,,,,,,,505.05,1145.99,percent of total billed charges,
SCREW,8435776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1400.96000,406.28000,Aetna,First Health,,1145.99,,,,,,,451.11,1145.99,percent of total billed charges,
SCREW,8435777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1400.96000,406.28000,Aetna,First Health,,1145.99,,,,,,,505.05,1145.99,percent of total billed charges,
SCREW,8435777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1400.96000,406.28000,Aetna,First Health,,1145.99,,,,,,,451.11,1145.99,percent of total billed charges,
VALVE FOR SHUNT,8435779,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,15467.35000,4485.53000,Aetna,First Health,,12652.29,,,,,,,5575.98,12652.29,percent of total billed charges,
VALVE FOR SHUNT,8435779,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,15467.35000,4485.53000,Aetna,First Health,,12652.29,,,,,,,4980.49,12652.29,percent of total billed charges,
CAGE,8435827,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,8435827,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
SCREW,8435828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,8435828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
PLATE,8435885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,951.75000,276.01000,Aetna,First Health,,778.53,,,,,,,343.11,778.53,percent of total billed charges,
PLATE,8435885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,951.75000,276.01000,Aetna,First Health,,778.53,,,,,,,306.46,778.53,percent of total billed charges,
NEUROSTIMULATOR,8435887,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,45012.38000,13053.59000,Aetna,First Health,,36820.13,,,,,,,16226.96,36820.13,percent of total billed charges,
NEUROSTIMULATOR,8435887,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,45012.38000,13053.59000,Aetna,First Health,,36820.13,,,,,,,14493.99,36820.13,percent of total billed charges,
MESH,8435892,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
MESH,8435892,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
ROD SPINAL,8435893,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8435893,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
CRT D,8435923,CDM,278,RC,C1882,HCPCS,,,facility,inpatient,,,48825.00000,14159.25000,Aetna,First Health,,39938.85,,,,,,,17601.41,39938.85,percent of total billed charges,
CRT D,8435923,CDM,278,RC,C1882,HCPCS,,,facility,outpatient,,,48825.00000,14159.25000,Aetna,First Health,,39938.85,,,,,,,15721.65,39938.85,percent of total billed charges,
SCREW,8435989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8435989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8436060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8436060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8436062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8436062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8436064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8436064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SPACER,8436066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SPACER,8436066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
INSERT,8436068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8436068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8436070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4063.50000,1178.42000,Aetna,First Health,,3323.94,,,,,,,1464.89,3323.94,percent of total billed charges,
PLATE,8436070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4063.50000,1178.42000,Aetna,First Health,,3323.94,,,,,,,1308.45,3323.94,percent of total billed charges,
SCREW,8436071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,249.49,percent of total billed charges,
SCREW,8436071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,98.21,249.49,percent of total billed charges,
NAIL,8436151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,8436151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
ROD SPINAL,8436152,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8436152,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
GRAFT,8436244,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3292.31000,954.77000,Aetna,First Health,,2693.11,,,,,,,1186.88,2693.11,percent of total billed charges,
GRAFT,8436244,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3292.31000,954.77000,Aetna,First Health,,2693.11,,,,,,,1060.12,2693.11,percent of total billed charges,
SCREW,8436249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8436249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,8436250,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8436250,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
WIRE,8436251,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,791.78000,229.62000,Aetna,First Health,,647.68,,,,,,,285.44,647.68,percent of total billed charges,
WIRE,8436251,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,791.78000,229.62000,Aetna,First Health,,647.68,,,,,,,254.95,647.68,percent of total billed charges,
WEDGE,8436272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,8436272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
CAGE,8436291,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8436291,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
SCREW,8436292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8436292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
CAGE,8436294,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8436294,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
ROD SPINAL,8436295,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8436295,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
NAIL,8436273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8436273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
GRAFT,8436298,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3292.31000,954.77000,Aetna,First Health,,2693.11,,,,,,,1186.88,2693.11,percent of total billed charges,
GRAFT,8436298,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3292.31000,954.77000,Aetna,First Health,,2693.11,,,,,,,1060.12,2693.11,percent of total billed charges,
GRAFT,8436299,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5948.25,13497.00,percent of total billed charges,
GRAFT,8436299,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5313.00,13497.00,percent of total billed charges,
SCREW,8436419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8436419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8436420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8436420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW SPINAL,8436499,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW SPINAL,8436499,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW SPINAL,8436501,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW SPINAL,8436501,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW SPINAL,8436503,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW SPINAL,8436503,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
ROD SPINAL,8436505,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
ROD SPINAL,8436505,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
ROD SPINAL,8436507,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
ROD SPINAL,8436507,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
PLATE,8436509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,448.89,1018.57,percent of total billed charges,
PLATE,8436509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,First Health,,1018.57,,,,,,,400.95,1018.57,percent of total billed charges,
SHELL,8436529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8436529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
INSERT,8436535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8436535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,8436676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
COMPONENT FEMORAL,8436676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
GUIDE PIN,7736161,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,70.03,158.90,percent of total billed charges,
GUIDE PIN,7736161,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,62.55,158.90,percent of total billed charges,
GUIDE PIN,7702883,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,631.80000,183.22000,Aetna,First Health,,516.81,,,,,,,227.76,516.81,percent of total billed charges,
GUIDE PIN,7702883,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,631.80000,183.22000,Aetna,First Health,,516.81,,,,,,,203.44,516.81,percent of total billed charges,
STEM,8453927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8453927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SCREW SPINAL,8453928,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW SPINAL,8453928,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
INSERT,8453929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8453929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8453968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
CAGE,8453968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
CAGE,8453970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
CAGE,8453970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
CAGE,8453972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
CAGE,8453972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
CAGE,8453974,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8453974,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
INSERT,8453976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8453976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
INSERT,8453978,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8453978,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
COMPONENT FEMORAL,8453980,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,7273.09,16503.15,percent of total billed charges,
COMPONENT FEMORAL,8453980,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,6496.35,16503.15,percent of total billed charges,
PLATE SPINAL,8453982,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
PLATE SPINAL,8453982,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STENT,8453985,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1364.96000,395.84000,Aetna,First Health,,1116.54,,,,,,,492.07,1116.54,percent of total billed charges,
STENT,8453985,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1364.96000,395.84000,Aetna,First Health,,1116.54,,,,,,,439.52,1116.54,percent of total billed charges,
SHUNT,8453984,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,465.93000,135.12000,Aetna,First Health,,381.13,,,,,,,167.97,381.13,percent of total billed charges,
SHUNT,8453984,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,465.93000,135.12000,Aetna,First Health,,381.13,,,,,,,150.03,381.13,percent of total billed charges,
SCREW,8454062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8454062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,8454064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8454064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
TISSUE,8454067,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4641.00000,1345.89000,Aetna,First Health,,3796.34,,,,,,,1673.08,3796.34,percent of total billed charges,
TISSUE,8454067,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4641.00000,1345.89000,Aetna,First Health,,3796.34,,,,,,,1494.40,3796.34,percent of total billed charges,
GUIDEWIRE,8454069,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
GUIDEWIRE,8454069,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
GUIDEWIRE,8454072,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
GUIDEWIRE,8454072,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
TISSUE,8454070,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8121.00000,2355.09000,Aetna,First Health,,6642.98,,,,,,,2927.62,6642.98,percent of total billed charges,
TISSUE,8454070,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8121.00000,2355.09000,Aetna,First Health,,6642.98,,,,,,,2614.96,6642.98,percent of total billed charges,
TISSUE,8454074,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,30879.00000,8954.91000,Aetna,First Health,,25259.02,,,,,,,11131.88,25259.02,percent of total billed charges,
TISSUE,8454074,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,30879.00000,8954.91000,Aetna,First Health,,25259.02,,,,,,,9943.04,25259.02,percent of total billed charges,
PLATE SPINAL,8455806,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8455806,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW SPINAL,8455794,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW SPINAL,8455794,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE,8455796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.70000,1465.86000,Aetna,First Health,,4134.74,,,,,,,1822.22,4134.74,percent of total billed charges,
PLATE,8455796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.70000,1465.86000,Aetna,First Health,,4134.74,,,,,,,1627.61,4134.74,percent of total billed charges,
SCREW,8455798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1721.60000,499.26000,Aetna,First Health,,1408.27,,,,,,,620.64,1408.27,percent of total billed charges,
SCREW,8455798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1721.60000,499.26000,Aetna,First Health,,1408.27,,,,,,,554.36,1408.27,percent of total billed charges,
PLATE,8455800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.00000,1246.42000,Aetna,First Health,,3515.76,,,,,,,1549.43,3515.76,percent of total billed charges,
PLATE,8455800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.00000,1246.42000,Aetna,First Health,,3515.76,,,,,,,1383.96,3515.76,percent of total billed charges,
SCREW,8455802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8455802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW SPINAL,8455804,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW SPINAL,8455804,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
ANCHOR,8455928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
ANCHOR,8455928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
SCREW,8455883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8455883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,8455884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8455884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
STEM,8455920,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
STEM,8455920,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
STEM,8455922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9950.01000,2885.50000,Aetna,First Health,,8139.11,,,,,,,3586.98,8139.11,percent of total billed charges,
STEM,8455922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9950.01000,2885.50000,Aetna,First Health,,8139.11,,,,,,,3203.90,8139.11,percent of total billed charges,
STEM,8455924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9950.01000,2885.50000,Aetna,First Health,,8139.11,,,,,,,3586.98,8139.11,percent of total billed charges,
STEM,8455924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9950.01000,2885.50000,Aetna,First Health,,8139.11,,,,,,,3203.90,8139.11,percent of total billed charges,
COMPONENT FEMORAL,8455926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24194.40000,7016.38000,Aetna,First Health,,19791.02,,,,,,,8722.08,19791.02,percent of total billed charges,
COMPONENT FEMORAL,8455926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24194.40000,7016.38000,Aetna,First Health,,19791.02,,,,,,,7790.60,19791.02,percent of total billed charges,
SCREW SPINAL,8455863,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,322.88,732.63,percent of total billed charges,
SCREW SPINAL,8455863,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,288.40,732.63,percent of total billed charges,
SCREW SPINAL,8455864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW SPINAL,8455864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STEM,8455865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8455865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
COMPONENT ACETABULAR,8457766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,37485.00000,10870.65000,Aetna,First Health,,30662.73,,,,,,,13513.34,30662.73,percent of total billed charges,
COMPONENT ACETABULAR,8457766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,37485.00000,10870.65000,Aetna,First Health,,30662.73,,,,,,,12070.17,30662.73,percent of total billed charges,
ROD SPINAL,8455932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
ROD SPINAL,8455932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
STENT GRAFT,8455934,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3824.18,8677.34,percent of total billed charges,
STENT GRAFT,8455934,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3415.78,8677.34,percent of total billed charges,
MESH,8455945,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
MESH,8455945,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8456029,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW SPINAL,8456029,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
CAGE,8456031,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8061.39000,2337.80000,Aetna,First Health,,6594.22,,,,,,,2906.13,6594.22,percent of total billed charges,
CAGE,8456031,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8061.39000,2337.80000,Aetna,First Health,,6594.22,,,,,,,2595.77,6594.22,percent of total billed charges,
SCREW SPINAL,8456033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,258.04,585.50,percent of total billed charges,
SCREW SPINAL,8456033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,230.48,585.50,percent of total billed charges,
SCREW SPINAL,8456035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,258.04,585.50,percent of total billed charges,
SCREW SPINAL,8456035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,First Health,,585.50,,,,,,,230.48,585.50,percent of total billed charges,
CAGE,8456037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,6529.56,14816.02,percent of total billed charges,
CAGE,8456037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,5832.23,14816.02,percent of total billed charges,
INSERT,8456041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8456041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8456062,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8456062,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8456063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8456063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8456064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8456064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
HEAD FEMORAL,8456065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,652.82,1481.30,percent of total billed charges,
HEAD FEMORAL,8456065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,First Health,,1481.30,,,,,,,583.10,1481.30,percent of total billed charges,
COMPONENT TIBIAL,8456025,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
COMPONENT TIBIAL,8456025,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
HEAD FEMORAL,8456026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1392.66,3160.04,percent of total billed charges,
HEAD FEMORAL,8456026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1243.93,3160.04,percent of total billed charges,
LINER,8456027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8456027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CAGE,8456028,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8456028,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
HEAD RADIAL,8457767,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14803.14000,4292.91000,Aetna,First Health,,12108.97,,,,,,,5336.53,12108.97,percent of total billed charges,
HEAD RADIAL,8457767,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14803.14000,4292.91000,Aetna,First Health,,12108.97,,,,,,,4766.61,12108.97,percent of total billed charges,
SCREW,8457768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,475.87,1079.79,percent of total billed charges,
SCREW,8457768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,425.05,1079.79,percent of total billed charges,
BOLT,8457769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,475.87,1079.79,percent of total billed charges,
BOLT,8457769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,425.05,1079.79,percent of total billed charges,
NAIL,8457770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,3062.33,6948.65,percent of total billed charges,
NAIL,8457770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,2735.29,6948.65,percent of total billed charges,
SCREW,8457771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8457771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8457772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8457772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
PLATE SPINAL,8457773,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8457773,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE SPINAL,8457774,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8457774,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW SPINAL,8457775,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW SPINAL,8457775,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,8457776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,8457776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
NAIL,8457777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL,8457777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
SCREW,8458265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,860.87,1953.38,percent of total billed charges,
SCREW,8458265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,768.94,1953.38,percent of total billed charges,
CAGE,8458267,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8458267,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
STEM,8458269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8458269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8458273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8458273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
BASEPLATE,8458275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,8458275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
HUMERAL CUP,8459825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1622.36,3681.25,percent of total billed charges,
HUMERAL CUP,8459825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1449.10,3681.25,percent of total billed charges,
SPACER,8459827,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SPACER,8459827,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
GLENOSPHERE,8459829,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
GLENOSPHERE,8459829,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
SHOULDER PROSTHESIS,8459831,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
SHOULDER PROSTHESIS,8459831,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
SCREW,8459833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,8459833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
GLENOSPHERE,8459835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
GLENOSPHERE,8459835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
INSERT,8459837,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,8459837,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
SCREW,8459839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8459839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
STEM,8459842,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,3098.50,7030.71,percent of total billed charges,
STEM,8459842,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,2767.59,7030.71,percent of total billed charges,
HEMODIALYSIS CATHETER,8459816,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,694.40000,201.38000,Aetna,First Health,,568.02,,,,,,,250.33,568.02,percent of total billed charges,
HEMODIALYSIS CATHETER,8459816,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,694.40000,201.38000,Aetna,First Health,,568.02,,,,,,,223.60,568.02,percent of total billed charges,
STEM,8459901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8459901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
INSERT,8461752,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,8461752,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
STEM,8461754,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8461754,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
BASEPLATE GLENOID,8461756,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.40000,1439.68000,Aetna,First Health,,4060.88,,,,,,,1789.67,4060.88,percent of total billed charges,
BASEPLATE GLENOID,8461756,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.40000,1439.68000,Aetna,First Health,,4060.88,,,,,,,1598.54,4060.88,percent of total billed charges,
SCREW,8461758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,8461758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
GLENIOD SPHERE,8461760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
GLENIOD SPHERE,8461760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
STENT GRAFT,8461762,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,8461762,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
INSERT,8461828,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,8461828,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
COMPONENT SHOULDER,8461835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,1075.11,2439.51,percent of total billed charges,
COMPONENT SHOULDER,8461835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,960.29,2439.51,percent of total billed charges,
SCREW,8461837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8461837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
SCREW,8461839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8461839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
GUIDE PIN,7802466,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
GUIDE PIN,7802466,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
GUIDE PIN,7697028,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,594.90000,172.52000,Aetna,First Health,,486.63,,,,,,,214.46,486.63,percent of total billed charges,
GUIDE PIN,7697028,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,594.90000,172.52000,Aetna,First Health,,486.63,,,,,,,191.56,486.63,percent of total billed charges,
K WIRE,7707514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
K WIRE,7707514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
GUIDE PIN,7893937,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,457.43000,132.65000,Aetna,First Health,,374.18,,,,,,,164.90,374.18,percent of total billed charges,
GUIDE PIN,7893937,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,457.43000,132.65000,Aetna,First Health,,374.18,,,,,,,147.29,374.18,percent of total billed charges,
GUIDE PIN,7989577,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,191.63000,55.57000,Aetna,First Health,,156.75,,,,,,,69.08,156.75,percent of total billed charges,
GUIDE PIN,7989577,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,191.63000,55.57000,Aetna,First Health,,156.75,,,,,,,61.70,156.75,percent of total billed charges,
GUIDE PIN,7697154,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,142.01000,41.18000,Aetna,First Health,,116.16,,,,,,,51.19,116.16,percent of total billed charges,
GUIDE PIN,7697154,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,142.01000,41.18000,Aetna,First Health,,116.16,,,,,,,45.73,116.16,percent of total billed charges,
GUIDE PIN,7698331,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,230.21000,66.76000,Aetna,First Health,,188.31,,,,,,,82.99,188.31,percent of total billed charges,
GUIDE PIN,7698331,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,230.21000,66.76000,Aetna,First Health,,188.31,,,,,,,74.13,188.31,percent of total billed charges,
GUIDE PIN,7836032,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,202.65000,58.77000,Aetna,First Health,,165.77,,,,,,,73.06,165.77,percent of total billed charges,
GUIDE PIN,7836032,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,202.65000,58.77000,Aetna,First Health,,165.77,,,,,,,65.25,165.77,percent of total billed charges,
GUIDEWIRE,8132018,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
GUIDEWIRE,8132018,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
LINER,8436730,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,8436730,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
INSERT,8436731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8436731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
STEM,8436732,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,8436732,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
PLATE,8436733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8436733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW SPINAL,8436734,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW SPINAL,8436734,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,8436736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8436736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8436737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8436737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8436738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8436738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8436739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8436739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
PLATE,8436740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3592.75000,1041.90000,Aetna,First Health,,2938.87,,,,,,,1295.19,2938.87,percent of total billed charges,
PLATE,8436740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3592.75000,1041.90000,Aetna,First Health,,2938.87,,,,,,,1156.87,2938.87,percent of total billed charges,
NAIL,8436748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8544.84000,2478.00000,Aetna,First Health,,6989.68,,,,,,,3080.41,6989.68,percent of total billed charges,
NAIL,8436748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8544.84000,2478.00000,Aetna,First Health,,6989.68,,,,,,,2751.44,6989.68,percent of total billed charges,
SCREW,8436749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8436749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8436750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8436750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8436937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8436937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
INSERT,8437310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8437310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
TIBIAL BASE,8437311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
TIBIAL BASE,8437311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
ACETABLUAR CUP,8437313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8283.00000,2402.07000,Aetna,First Health,,6775.49,,,,,,,2986.02,6775.49,percent of total billed charges,
ACETABLUAR CUP,8437313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8283.00000,2402.07000,Aetna,First Health,,6775.49,,,,,,,2667.13,6775.49,percent of total billed charges,
ACETABULAR LINER,8437312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
ACETABULAR LINER,8437312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
Nail,8437021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4650.45,10552.20,percent of total billed charges,
Nail,8437021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4153.80,10552.20,percent of total billed charges,
Tibial Plate,8437022,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
Tibial Plate,8437022,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
BREAST IMPLANT,8437024,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8437024,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8437302,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,8437302,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
TIBAIL INSERT,8437303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
TIBAIL INSERT,8437303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ACETABULAR CUP,8437304,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1876.22,4257.28,percent of total billed charges,
ACETABULAR CUP,8437304,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1675.85,4257.28,percent of total billed charges,
SCREW,8437305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,8437305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,8437306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.25000,2383.58000,Aetna,First Health,,6723.35,,,,,,,2963.04,6723.35,percent of total billed charges,
SCREW,8437306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.25000,2383.58000,Aetna,First Health,,6723.35,,,,,,,2646.60,6723.35,percent of total billed charges,
BREAST IMPLANT,8437736,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,8437736,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
PLATE,8437941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3461.50000,1003.83000,Aetna,First Health,,2831.51,,,,,,,1247.87,2831.51,percent of total billed charges,
PLATE,8437941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3461.50000,1003.83000,Aetna,First Health,,2831.51,,,,,,,1114.60,2831.51,percent of total billed charges,
NAIL,8437943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11684.25000,3388.43000,Aetna,First Health,,9557.72,,,,,,,4212.17,9557.72,percent of total billed charges,
NAIL,8437943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11684.25000,3388.43000,Aetna,First Health,,9557.72,,,,,,,3762.33,9557.72,percent of total billed charges,
INSERT,8437942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8437942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8437940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8437940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW,8437944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8437944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
PLATE,8437945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2346.86,5325.18,percent of total billed charges,
PLATE,8437945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,First Health,,5325.18,,,,,,,2096.22,5325.18,percent of total billed charges,
ROD,8437992,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
ROD,8437992,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
SCREW,8437994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,355.06000,102.97000,Aetna,First Health,,290.44,,,,,,,128.00,290.44,percent of total billed charges,
SCREW,8437994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,355.06000,102.97000,Aetna,First Health,,290.44,,,,,,,114.33,290.44,percent of total billed charges,
SCREW,8437995,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8437995,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE,8437996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8437996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT CLUSTERHOLE,8437998,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
COMPONENT CLUSTERHOLE,8437998,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
HUMERAL HEAD,8438116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,8438116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,8438115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,355.06000,102.97000,Aetna,First Health,,290.44,,,,,,,128.00,290.44,percent of total billed charges,
SCREW,8438115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,355.06000,102.97000,Aetna,First Health,,290.44,,,,,,,114.33,290.44,percent of total billed charges,
NAIL,8438039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,1085.65,2463.42,percent of total billed charges,
NAIL,8438039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,969.71,2463.42,percent of total billed charges,
GRAFT STENT,8438263,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,16524.24,37494.67,percent of total billed charges,
GRAFT STENT,8438263,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,First Health,,37494.67,,,,,,,14759.51,37494.67,percent of total billed charges,
STEM,8438264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4609.35,10458.95,percent of total billed charges,
STEM,8438264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4117.09,10458.95,percent of total billed charges,
GRAFT STENT,8438265,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,47556.00000,13791.24000,Aetna,First Health,,38900.81,,,,,,,17143.94,38900.81,percent of total billed charges,
GRAFT STENT,8438265,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,47556.00000,13791.24000,Aetna,First Health,,38900.81,,,,,,,15313.03,38900.81,percent of total billed charges,
EXCLUDER,8438269,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,38137.50000,11059.88000,Aetna,First Health,,31196.47,,,,,,,13748.57,31196.47,percent of total billed charges,
EXCLUDER,8438269,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,38137.50000,11059.88000,Aetna,First Health,,31196.47,,,,,,,12280.27,31196.47,percent of total billed charges,
SCREW SPINE,8438270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW SPINE,8438270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
PLATE,8438266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1562.00000,452.98000,Aetna,First Health,,1277.72,,,,,,,563.10,1277.72,percent of total billed charges,
PLATE,8438266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1562.00000,452.98000,Aetna,First Health,,1277.72,,,,,,,502.96,1277.72,percent of total billed charges,
DILATOR,8438322,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,385.23000,111.72000,Aetna,First Health,,315.12,,,,,,,138.88,315.12,percent of total billed charges,
DILATOR,8438322,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,385.23000,111.72000,Aetna,First Health,,315.12,,,,,,,124.04,315.12,percent of total billed charges,
SHELL,8438315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
SHELL,8438315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
INSERT,8438323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8438323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
PLATE,8438360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,19542.50000,5667.32000,Aetna,First Health,,15985.76,,,,,,,7045.07,15985.76,percent of total billed charges,
PLATE,8438360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,19542.50000,5667.32000,Aetna,First Health,,15985.76,,,,,,,6292.69,15985.76,percent of total billed charges,
SCREW SPINE,8438361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3258.50000,944.96000,Aetna,First Health,,2665.45,,,,,,,1174.69,2665.45,percent of total billed charges,
SCREW SPINE,8438361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3258.50000,944.96000,Aetna,First Health,,2665.45,,,,,,,1049.24,2665.45,percent of total billed charges,
SCREW,8438362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3258.50000,944.96000,Aetna,First Health,,2665.45,,,,,,,1174.69,2665.45,percent of total billed charges,
SCREW,8438362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3258.50000,944.96000,Aetna,First Health,,2665.45,,,,,,,1049.24,2665.45,percent of total billed charges,
STEM,8438316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8438316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CAGE,8438317,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,8438317,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
CAGE,8438318,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,8438318,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
ROD,8438319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD,8438319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SCREW,8438320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8438320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
SCREW,8438321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8438321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
PLATE,8438438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4063.50000,1178.42000,Aetna,First Health,,3323.94,,,,,,,1464.89,3323.94,percent of total billed charges,
PLATE,8438438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4063.50000,1178.42000,Aetna,First Health,,3323.94,,,,,,,1308.45,3323.94,percent of total billed charges,
SCREW,8438439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8438439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8438440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8438440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8438441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,206.03,467.49,percent of total billed charges,
SCREW,8438441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,184.02,467.49,percent of total billed charges,
STEM,8438467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30026.25000,8707.61000,Aetna,First Health,,24561.47,,,,,,,10824.46,24561.47,percent of total billed charges,
STEM,8438467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30026.25000,8707.61000,Aetna,First Health,,24561.47,,,,,,,9668.45,24561.47,percent of total billed charges,
LINER,8438468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LINER,8438468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
LINER,8438469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER,8438469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,8438471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8438471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8438472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8438472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8438473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8438473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8438474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8438474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8438475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8438475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SHELL,8438622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
SHELL,8438622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
SCREW,8438620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,8438620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,8438619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,8438619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
FEMORAL HEAD,8438623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4004.00000,1161.16000,Aetna,First Health,,3275.27,,,,,,,1443.44,3275.27,percent of total billed charges,
FEMORAL HEAD,8438623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4004.00000,1161.16000,Aetna,First Health,,3275.27,,,,,,,1289.29,3275.27,percent of total billed charges,
LINER,8438621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8438621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
NAIL,8438624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8438624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
ADAPTOR,8438625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ADAPTOR,8438625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
ACETABULAR CUP,8439729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,37485.00000,10870.65000,Aetna,First Health,,30662.73,,,,,,,13513.34,30662.73,percent of total billed charges,
ACETABULAR CUP,8439729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,37485.00000,10870.65000,Aetna,First Health,,30662.73,,,,,,,12070.17,30662.73,percent of total billed charges,
SCREW,8438618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,249.49,percent of total billed charges,
SCREW,8438618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,98.21,249.49,percent of total billed charges,
NAIL,8439730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8439730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
PLATE,8439860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,8439860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
NAIL,8439859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7827.00000,2269.83000,Aetna,First Health,,6402.49,,,,,,,2821.63,6402.49,percent of total billed charges,
NAIL,8439859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7827.00000,2269.83000,Aetna,First Health,,6402.49,,,,,,,2520.29,6402.49,percent of total billed charges,
PLATE,8439963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,8439963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,8439964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,8439964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
IMPLANT SYSTEM,8439971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
IMPLANT SYSTEM,8439971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
SCREW,8439972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8439972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SCREW,8439973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
SCREW,8439973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
CONNECTOR,8439974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,624.39,1416.78,percent of total billed charges,
CONNECTOR,8439974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,557.70,1416.78,percent of total billed charges,
ROD,8439975,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1512.00000,438.48000,Aetna,First Health,,1236.82,,,,,,,545.08,1236.82,percent of total billed charges,
ROD,8439975,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1512.00000,438.48000,Aetna,First Health,,1236.82,,,,,,,486.86,1236.82,percent of total billed charges,
SCREW,8440204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8440204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,8440205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8440205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,8440206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8440206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
CORE,8440207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
CORE,8440207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
ENDPLATE,8440208,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8440208,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
SCREW,8440209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,8440209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,8440064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8440064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
INSERT,8440065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8440065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SCREW,8440318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8440318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8440319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8440319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
INSERT,8440320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8440320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8440321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,892.60,2025.37,percent of total billed charges,
PLATE,8440321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,797.27,2025.37,percent of total billed charges,
INSERT,8440466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8440466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8440467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,8440467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
ROD,8440427,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD,8440427,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
Screw,8440428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,330.96,750.96,percent of total billed charges,
Screw,8440428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,295.61,750.96,percent of total billed charges,
SCREW,8440429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,330.96,750.96,percent of total billed charges,
SCREW,8440429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,295.61,750.96,percent of total billed charges,
INSERT,8440465,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8440465,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,8440468,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8440468,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
CAGE,8440469,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8440469,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
SCREW,8440425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8440425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
STENT,8440502,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT,8440502,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
INSERT,8440503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8440503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
MESH,8441730,CDM,278,RC,Q4130,HCPCS,,,facility,inpatient,,,35955.00000,10426.95000,Aetna,First Health,,29411.19,,,,,,,12961.78,29411.19,percent of total billed charges,
MESH,8441730,CDM,278,RC,Q4130,HCPCS,,,facility,outpatient,,,35955.00000,10426.95000,Aetna,First Health,,29411.19,,,,,,,124.65,29411.19,percent of total billed charges,
MESH,8441731,CDM,278,RC,Q4130,HCPCS,,,facility,inpatient,,,43229.25000,12536.48000,Aetna,First Health,,35361.53,,,,,,,15584.14,35361.53,percent of total billed charges,
MESH,8441731,CDM,278,RC,Q4130,HCPCS,,,facility,outpatient,,,43229.25000,12536.48000,Aetna,First Health,,35361.53,,,,,,,124.65,35361.53,percent of total billed charges,
SCREW SPINAL,8441782,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW SPINAL,8441782,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
SCREW SPINAL,8441808,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW SPINAL,8441808,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
PLATE SPINAL,8441819,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8441819,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW SPINAL,8441821,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SPINAL,8441821,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8441823,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8441823,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
PLATE SPINAL,8441824,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1291.62,2930.77,percent of total billed charges,
PLATE SPINAL,8441824,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1153.68,2930.77,percent of total billed charges,
CAGE,8441826,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8441826,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
PLATE,8441828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.79000,278.92000,Aetna,First Health,,786.74,,,,,,,346.73,786.74,percent of total billed charges,
PLATE,8441828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.79000,278.92000,Aetna,First Health,,786.74,,,,,,,309.70,786.74,percent of total billed charges,
GUIDEWIRE,8441830,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2193.52000,636.12000,Aetna,First Health,,1794.30,,,,,,,790.76,1794.30,percent of total billed charges,
GUIDEWIRE,8441830,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2193.52000,636.12000,Aetna,First Health,,1794.30,,,,,,,706.31,1794.30,percent of total billed charges,
CAGE,8441926,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10236.00000,2968.44000,Aetna,First Health,,8373.05,,,,,,,3690.08,8373.05,percent of total billed charges,
CAGE,8441926,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10236.00000,2968.44000,Aetna,First Health,,8373.05,,,,,,,3295.99,8373.05,percent of total billed charges,
WASHER,8441977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.81000,182.93000,Aetna,First Health,,516.00,,,,,,,227.41,516.00,percent of total billed charges,
WASHER,8441977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.81000,182.93000,Aetna,First Health,,516.00,,,,,,,203.12,516.00,percent of total billed charges,
PLATE SPINAL,8441979,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
PLATE SPINAL,8441979,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
STENT GRAFT,8441889,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,8441889,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
INSERT,8441890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,8441890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
CAGE,8441922,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8441922,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
ENDPLATE,8441923,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
ENDPLATE,8441923,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
ENDPLATE,8441924,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
ENDPLATE,8441924,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
STEM,8441925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,8441925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
HEAD FEMORAL,8441983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8441983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
INSERT,8441984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8441984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8442050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8442050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
NAIL,8442051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL,8442051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
K WIRE,8442053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,230.36,522.70,percent of total billed charges,
K WIRE,8442053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,205.76,522.70,percent of total billed charges,
VASCULAR CLOSURE DEVICE,8441981,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
VASCULAR CLOSURE DEVICE,8441981,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
VASCULAR CLOSURE DEVICE,8441982,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1286.98,2920.26,percent of total billed charges,
VASCULAR CLOSURE DEVICE,8441982,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,First Health,,2920.26,,,,,,,1149.54,2920.26,percent of total billed charges,
SCREW,8442132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8442132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
LINER,8442073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8442073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
GRAFT,8442133,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,1230.00000,356.70000,Aetna,First Health,,1006.14,,,,,,,443.42,1006.14,percent of total billed charges,
GRAFT,8442133,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,1230.00000,356.70000,Aetna,First Health,,1006.14,,,,,,,396.06,1006.14,percent of total billed charges,
SCREW,8442134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,964.29,2188.05,percent of total billed charges,
SCREW,8442134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,861.31,2188.05,percent of total billed charges,
SCREW,8442135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,964.29,2188.05,percent of total billed charges,
SCREW,8442135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,861.31,2188.05,percent of total billed charges,
SCREW,8442136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,964.29,2188.05,percent of total billed charges,
SCREW,8442136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,861.31,2188.05,percent of total billed charges,
MESH,8442192,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
MESH,8442192,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SCREW,8442194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,261.39,593.12,percent of total billed charges,
SCREW,8442194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,233.48,593.12,percent of total billed charges,
INSERT,8442196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8442196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STEM,8442198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8442198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
SCREW,8442200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8442200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,8442202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2675.20000,775.81000,Aetna,First Health,,2188.31,,,,,,,964.41,2188.31,percent of total billed charges,
SCREW,8442202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2675.20000,775.81000,Aetna,First Health,,2188.31,,,,,,,861.41,2188.31,percent of total billed charges,
SCREW,8442204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8442204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
LINER,8442206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,8442206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
CAGE,8442208,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8442208,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
PLATE,8442210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
PLATE,8442210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
HEAD HUMERAL,8442211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
HEAD HUMERAL,8442211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
HEAD RADIAL,8442353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14803.14000,4292.91000,Aetna,First Health,,12108.97,,,,,,,5336.53,12108.97,percent of total billed charges,
HEAD RADIAL,8442353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14803.14000,4292.91000,Aetna,First Health,,12108.97,,,,,,,4766.61,12108.97,percent of total billed charges,
COMPONENT FEMORAL,8442390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,8442390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
SPACER,8442391,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
SPACER,8442391,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
SPACER,8442392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
SPACER,8442392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
INSERT,8442393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8442393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
PLATE,8442394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5793.90000,1680.23000,Aetna,First Health,,4739.41,,,,,,,2088.70,4739.41,percent of total billed charges,
PLATE,8442394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5793.90000,1680.23000,Aetna,First Health,,4739.41,,,,,,,1865.64,4739.41,percent of total billed charges,
SCREW,8442395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW,8442395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
SCREW,8442396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8442396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8442397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8442397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
HEAD HUMERAL,8442398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,8442398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
INSERT,8442487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8442487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
PLATE,8442489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5864.57000,1700.73000,Aetna,First Health,,4797.22,,,,,,,2114.18,4797.22,percent of total billed charges,
PLATE,8442489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5864.57000,1700.73000,Aetna,First Health,,4797.22,,,,,,,1888.39,4797.22,percent of total billed charges,
INSERT,8442493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8442493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8442494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8442494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8442495,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8442495,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BASEPLATE,8442491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BASEPLATE,8442491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
INSERT,8443806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8443806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
LINER,8443807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8443807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
GRAFT STENT,8443808,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
GRAFT STENT,8443808,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STENT GRAFT,8443809,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
STENT GRAFT,8443809,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
PLATE,8443810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8931.00000,2589.99000,Aetna,First Health,,7305.56,,,,,,,3219.63,7305.56,percent of total billed charges,
PLATE,8443810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8931.00000,2589.99000,Aetna,First Health,,7305.56,,,,,,,2875.78,7305.56,percent of total billed charges,
HEAD FEMORAL,8443812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,8443812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT FEMORAL,8443877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,8443877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
SCREW,8443869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8443869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8443871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8443871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,8443872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8443872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8443874,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
INSERT,8443874,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
INSERT,8443875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,8443875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
COMPONENT FEMORAL,8443876,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,8443876,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
ANCHOR,8443943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,839.97,1905.94,percent of total billed charges,
ANCHOR,8443943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,750.26,1905.94,percent of total billed charges,
SCREW,8443945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8443945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8443948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,8443948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
CAGE,8443873,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8443873,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
SCREW,8443947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,395.96000,114.83000,Aetna,First Health,,323.90,,,,,,,142.74,323.90,percent of total billed charges,
SCREW,8443947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,395.96000,114.83000,Aetna,First Health,,323.90,,,,,,,127.50,323.90,percent of total billed charges,
FIXATION SPINAL,8443870,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7980.00000,2314.20000,Aetna,First Health,,6527.64,,,,,,,2876.79,6527.64,percent of total billed charges,
FIXATION SPINAL,8443870,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7980.00000,2314.20000,Aetna,First Health,,6527.64,,,,,,,2569.56,6527.64,percent of total billed charges,
SHEATH,8443975,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,530.66,1204.10,percent of total billed charges,
SHEATH,8443975,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,473.98,1204.10,percent of total billed charges,
STEM,8443976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8443976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,8443978,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8443978,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
ROD SPINAL,8443980,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8443980,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
HEAD RADIAL,8444014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14803.14000,4292.91000,Aetna,First Health,,12108.97,,,,,,,5336.53,12108.97,percent of total billed charges,
HEAD RADIAL,8444014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14803.14000,4292.91000,Aetna,First Health,,12108.97,,,,,,,4766.61,12108.97,percent of total billed charges,
COMPONENT GLENOID,8445740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT GLENOID,8445740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
GRAFT STENT,8445743,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
GRAFT STENT,8445743,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
STIMULATOR NEURO,8445744,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,42836.63000,12422.62000,Aetna,First Health,,35040.36,,,,,,,15442.61,35040.36,percent of total billed charges,
STIMULATOR NEURO,8445744,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,42836.63000,12422.62000,Aetna,First Health,,35040.36,,,,,,,13793.39,35040.36,percent of total billed charges,
STEM,8445746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,8445746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
GRAFT,8445742,CDM,278,RC,Q4137,HCPCS,,,facility,inpatient,,,5436.38000,1576.55000,Aetna,First Health,,4446.96,,,,,,,1959.81,4446.96,percent of total billed charges,
GRAFT,8445742,CDM,278,RC,Q4137,HCPCS,,,facility,outpatient,,,5436.38000,1576.55000,Aetna,First Health,,4446.96,,,,,,,124.65,4446.96,percent of total billed charges,
STEM,8445747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8445747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,8445748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8445748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
BALLOON CATHETER,8445749,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,746.91000,216.60000,Aetna,First Health,,610.97,,,,,,,269.26,610.97,percent of total billed charges,
BALLOON CATHETER,8445749,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,746.91000,216.60000,Aetna,First Health,,610.97,,,,,,,240.51,610.97,percent of total billed charges,
SPINAL CORD STIM PROGRAMMER,8445984,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,3594.15000,1042.30000,Aetna,First Health,,2940.01,,,,,,,1295.69,2940.01,percent of total billed charges,
SPINAL CORD STIM PROGRAMMER,8445984,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,3594.15000,1042.30000,Aetna,First Health,,2940.01,,,,,,,1157.32,2940.01,percent of total billed charges,
BOLT SPINAL,8446058,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
BOLT SPINAL,8446058,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8446081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8446081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
INSERT,8446060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2900.00000,841.00000,Aetna,First Health,,2372.20,,,,,,,1045.45,2372.20,percent of total billed charges,
INSERT,8446060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2900.00000,841.00000,Aetna,First Health,,2372.20,,,,,,,933.80,2372.20,percent of total billed charges,
NAIL,8446062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8446062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
NAIL,8446063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8446063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
SCREW,8446064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8446064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SCREW,8446065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8446065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SCREW,8446066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8446066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
LEAD,7698132,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,2415.04000,700.36000,Aetna,First Health,,1975.50,,,,,,,870.62,1975.50,percent of total billed charges,
LEAD,7698132,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,2415.04000,700.36000,Aetna,First Health,,1975.50,,,,,,,777.64,1975.50,percent of total billed charges,
SCREW SPINAL,8446138,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW SPINAL,8446138,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
GUIDEWIRE,8446148,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,421.94000,122.36000,Aetna,First Health,,345.15,,,,,,,152.11,345.15,percent of total billed charges,
GUIDEWIRE,8446148,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,421.94000,122.36000,Aetna,First Health,,345.15,,,,,,,135.86,345.15,percent of total billed charges,
SCREW,8446149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,8446149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,8446150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,8446150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,8446151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,8446151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,8446152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,8446152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,8446153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,8446153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
GUIDEWIRE,8446195,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,607.77000,176.25000,Aetna,First Health,,497.16,,,,,,,219.10,497.16,percent of total billed charges,
GUIDEWIRE,8446195,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,607.77000,176.25000,Aetna,First Health,,497.16,,,,,,,195.70,497.16,percent of total billed charges,
CAGE,8446218,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
CAGE,8446218,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
STENT URETERAL,8446221,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
STENT URETERAL,8446221,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
STENT URETERAL,8446222,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
STENT URETERAL,8446222,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
STENT URETERAL,8446223,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
STENT URETERAL,8446223,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
STENT URETERAL,8446224,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
STENT URETERAL,8446224,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
STEM,8446283,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8446283,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8446285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8283.00000,2402.07000,Aetna,First Health,,6775.49,,,,,,,2986.02,6775.49,percent of total billed charges,
INSERT,8446285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8283.00000,2402.07000,Aetna,First Health,,6775.49,,,,,,,2667.13,6775.49,percent of total billed charges,
STEM,8447739,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8447739,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
MESH TISSUE,8447753,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,11055.00000,3205.95000,Aetna,First Health,,9042.99,,,,,,,3985.33,9042.99,percent of total billed charges,
MESH TISSUE,8447753,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,11055.00000,3205.95000,Aetna,First Health,,9042.99,,,,,,,3559.71,9042.99,percent of total billed charges,
CAGE,8447759,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8447759,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
PLATE SPINAL,8447760,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8447760,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8447761,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8447761,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
BOLT IN KIT INTRACRANIAL PRESSURE MONITOR,8447807,CDM,278,RC,A9279,HCPCS,,,facility,inpatient,,,3632.34000,1053.38000,Aetna,First Health,,2971.25,,,,,,,1309.46,2971.25,percent of total billed charges,
BOLT IN KIT INTRACRANIAL PRESSURE MONITOR,8447807,CDM,278,RC,A9279,HCPCS,,,facility,outpatient,,,3632.34000,1053.38000,Aetna,First Health,,2971.25,,,,,,,1169.61,2971.25,percent of total billed charges,
PLATE,8447895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2550.44000,739.63000,Aetna,First Health,,2086.26,,,,,,,919.43,2086.26,percent of total billed charges,
PLATE,8447895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2550.44000,739.63000,Aetna,First Health,,2086.26,,,,,,,821.24,2086.26,percent of total billed charges,
COMPONENT FEMORAL,8447911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,8447911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
INSERT,8447912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8447912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8447930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,2447.46,percent of total billed charges,
INSERT,8447930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,963.42,2447.46,percent of total billed charges,
INSERT,8447931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8447931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8448026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8448026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
NAIL,8448027,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,8448027,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
STEM,8448028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM,8448028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
INSERT,8448029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8448029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8449767,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8449767,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,8449768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8449768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
BASEPLATE,8449808,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
BASEPLATE,8449808,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
CAGE,8449842,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8449842,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW SPINAL,8449844,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW SPINAL,8449844,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
CAGE,8449809,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
CAGE,8449809,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
PLATE,8449846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3441.87000,998.14000,Aetna,First Health,,2815.45,,,,,,,1240.79,2815.45,percent of total billed charges,
PLATE,8449846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3441.87000,998.14000,Aetna,First Health,,2815.45,,,,,,,1108.28,2815.45,percent of total billed charges,
PLATE,8449850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2544.00000,737.76000,Aetna,First Health,,2080.99,,,,,,,917.11,2080.99,percent of total billed charges,
PLATE,8449850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2544.00000,737.76000,Aetna,First Health,,2080.99,,,,,,,819.17,2080.99,percent of total billed charges,
INSERT,8449851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8449851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SHELL,8449888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8449888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,8449889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,8449889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SLEEVE FEMORAL,8449922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1909.56000,553.77000,Aetna,First Health,,1562.02,,,,,,,688.40,1562.02,percent of total billed charges,
SLEEVE FEMORAL,8449922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1909.56000,553.77000,Aetna,First Health,,1562.02,,,,,,,614.88,1562.02,percent of total billed charges,
SHELL,8449924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,2211.03,5016.98,percent of total billed charges,
SHELL,8449924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,First Health,,5016.98,,,,,,,1974.90,5016.98,percent of total billed charges,
SCREW,8449891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,8449891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
INSERT,8449929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
INSERT,8449929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
PLATE SPINAL,8449931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8449931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
NAIL,8449953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL,8449953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
NAIL,8449954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8449954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
SCREW,8449987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,8449987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,8449988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,8449988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,8449989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,8449989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
PLATE,8449990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6188.91000,1794.78000,Aetna,First Health,,5062.53,,,,,,,2231.10,5062.53,percent of total billed charges,
PLATE,8449990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6188.91000,1794.78000,Aetna,First Health,,5062.53,,,,,,,1992.83,5062.53,percent of total billed charges,
KIT CATHETER INTRODUCER,8451765,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,183.75000,53.29000,Aetna,First Health,,150.31,,,,,,,66.24,150.31,percent of total billed charges,
KIT CATHETER INTRODUCER,8451765,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,183.75000,53.29000,Aetna,First Health,,150.31,,,,,,,59.17,150.31,percent of total billed charges,
PLATE,8451766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10383.00000,3011.07000,Aetna,First Health,,8493.29,,,,,,,3743.07,8493.29,percent of total billed charges,
PLATE,8451766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10383.00000,3011.07000,Aetna,First Health,,8493.29,,,,,,,3343.33,8493.29,percent of total billed charges,
SCREW,8451781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1400.96000,406.28000,Aetna,First Health,,1145.99,,,,,,,505.05,1145.99,percent of total billed charges,
SCREW,8451781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1400.96000,406.28000,Aetna,First Health,,1145.99,,,,,,,451.11,1145.99,percent of total billed charges,
SCREW,8451782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1400.96000,406.28000,Aetna,First Health,,1145.99,,,,,,,505.05,1145.99,percent of total billed charges,
SCREW,8451782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1400.96000,406.28000,Aetna,First Health,,1145.99,,,,,,,451.11,1145.99,percent of total billed charges,
GRAFT,8451783,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
GRAFT,8451783,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
COMPONENT FEMORAL,8451823,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,8451823,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
KIT FECAL MANAGEMENT,8451780,CDM,278,RC,A4330,HCPCS,,,facility,inpatient,,,673.71000,195.38000,Aetna,First Health,,551.09,,,,,,,242.87,551.09,percent of total billed charges,
KIT FECAL MANAGEMENT,8451780,CDM,278,RC,A4330,HCPCS,,,facility,outpatient,,,673.71000,195.38000,Aetna,First Health,,551.09,,,,,,,10.21,551.09,percent of total billed charges,
SCREW,8451864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,241.72,548.47,percent of total billed charges,
SCREW,8451864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,215.90,548.47,percent of total billed charges,
SCREW,8451849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,241.72,548.47,percent of total billed charges,
SCREW,8451849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,First Health,,548.47,,,,,,,215.90,548.47,percent of total billed charges,
PLATE,8451852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,18750.00000,5437.50000,Aetna,First Health,,15337.50,,,,,,,6759.38,15337.50,percent of total billed charges,
PLATE,8451852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,18750.00000,5437.50000,Aetna,First Health,,15337.50,,,,,,,6037.50,15337.50,percent of total billed charges,
COMPONENT FOSSA,8451854,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16447.50000,4769.77000,Aetna,First Health,,13454.06,,,,,,,5929.32,13454.06,percent of total billed charges,
COMPONENT FOSSA,8451854,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16447.50000,4769.77000,Aetna,First Health,,13454.06,,,,,,,5296.10,13454.06,percent of total billed charges,
SCREW,8451856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW,8451856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
SCREW,8451858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,616.50000,178.78000,Aetna,First Health,,504.30,,,,,,,222.25,504.30,percent of total billed charges,
SCREW,8451858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,616.50000,178.78000,Aetna,First Health,,504.30,,,,,,,198.51,504.30,percent of total billed charges,
SCREW,8451860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,616.50000,178.78000,Aetna,First Health,,504.30,,,,,,,222.25,504.30,percent of total billed charges,
SCREW,8451860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,616.50000,178.78000,Aetna,First Health,,504.30,,,,,,,198.51,504.30,percent of total billed charges,
STENT,8451865,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1356.36000,393.34000,Aetna,First Health,,1109.50,,,,,,,488.97,1109.50,percent of total billed charges,
STENT,8451865,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1356.36000,393.34000,Aetna,First Health,,1109.50,,,,,,,436.75,1109.50,percent of total billed charges,
SHELL,8451933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8451933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
STEM,8451953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8451953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
HEAD FEMORAL,7698926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
HEAD FEMORAL,7698926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,8451955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3465.42000,1004.97000,Aetna,First Health,,2834.71,,,,,,,1249.28,2834.71,percent of total billed charges,
INSERT,8451955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3465.42000,1004.97000,Aetna,First Health,,2834.71,,,,,,,1115.87,2834.71,percent of total billed charges,
ANCHOR,8451957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2057.00000,596.53000,Aetna,First Health,,1682.63,,,,,,,741.55,1682.63,percent of total billed charges,
ANCHOR,8451957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2057.00000,596.53000,Aetna,First Health,,1682.63,,,,,,,662.35,1682.63,percent of total billed charges,
ROD SPINAL,8451959,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8451959,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CAGE,8451961,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8451961,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
INSERT,8452047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8452047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8452008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8452008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE SPINAL,8453761,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8453761,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
HUMERAL SPOOL,8453837,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10503.00000,3045.87000,Aetna,First Health,,8591.45,,,,,,,3786.33,8591.45,percent of total billed charges,
HUMERAL SPOOL,8453837,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10503.00000,3045.87000,Aetna,First Health,,8591.45,,,,,,,3381.97,8591.45,percent of total billed charges,
STEM,8453839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,6038.38,13701.50,percent of total billed charges,
STEM,8453839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,5393.50,13701.50,percent of total billed charges,
CAGE,8453841,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8453841,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
CAGE,8453843,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8453843,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
GRAFT STENT,8453845,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
GRAFT STENT,8453845,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
CAGE,8453908,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
CAGE,8453908,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
ROD SPINAL,8362931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8362931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
ROD SPINAL,8362933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8362933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,8362935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8362935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,8362937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8362937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
PLATE,8362939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2497.96000,724.41000,Aetna,First Health,,2043.33,,,,,,,900.51,2043.33,percent of total billed charges,
PLATE,8362939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2497.96000,724.41000,Aetna,First Health,,2043.33,,,,,,,804.34,2043.33,percent of total billed charges,
SCREW,8362941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8362941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8362943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8362943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8362945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8362945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8362947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8362947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
PLATE,8362949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,8362949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,8362952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9088.80000,2635.75000,Aetna,First Health,,7434.64,,,,,,,3276.51,7434.64,percent of total billed charges,
PLATE,8362952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9088.80000,2635.75000,Aetna,First Health,,7434.64,,,,,,,2926.59,7434.64,percent of total billed charges,
INSERT,8364265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8364265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8364266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8364266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8364267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8364267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8364268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8364268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8364269,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
CAGE,8364269,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
COMPONENT FEMORAL,8364338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
COMPONENT FEMORAL,8364338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CENTRALIZER,8366269,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
CENTRALIZER,8366269,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
STEM,8366308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM,8366308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
COMPONENT FEMORAL,8366309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,11294.92,25628.96,percent of total billed charges,
COMPONENT FEMORAL,8366309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,First Health,,25628.96,,,,,,,10088.66,25628.96,percent of total billed charges,
COMPONENT GLENOID,8366342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
COMPONENT GLENOID,8366342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
GLENOSPHERE,8366343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1779.07,4036.83,percent of total billed charges,
GLENOSPHERE,8366343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1589.07,4036.83,percent of total billed charges,
SCREW,8366344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1640.28,3721.90,percent of total billed charges,
SCREW,8366344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1465.10,3721.90,percent of total billed charges,
ROD SPINAL,8366345,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8366345,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CONNECTOR SPINAL,8366346,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CONNECTOR SPINAL,8366346,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
SCREW,8366347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW,8366347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
SCREW,8366396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,8366396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
ROD SPINAL,8366397,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8366397,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
ROD SPINAL,8366923,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8366923,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SCREW,8366398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8366398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
PLATE,8366399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
PLATE,8366399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
PLATE,8366400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
PLATE,8366400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
PLATE,8366401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9885.00000,2866.65000,Aetna,First Health,,8085.93,,,,,,,3563.54,8085.93,percent of total billed charges,
PLATE,8366401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9885.00000,2866.65000,Aetna,First Health,,8085.93,,,,,,,3182.97,8085.93,percent of total billed charges,
SHELL,8366402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3475.94,7887.16,percent of total billed charges,
SHELL,8366402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3104.72,7887.16,percent of total billed charges,
PLATE,8366474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,8366474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
PLATE,8366476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,8366476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
ROD BLADE,8366470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2949.80000,855.44000,Aetna,First Health,,2412.94,,,,,,,1063.40,2412.94,percent of total billed charges,
ROD BLADE,8366470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2949.80000,855.44000,Aetna,First Health,,2412.94,,,,,,,949.84,2412.94,percent of total billed charges,
SCREW,8366478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,8366478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,8366480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8366480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,8366482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,8366482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,8366484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,8366484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,8366493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,8366493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
ROD SPINAL,8366486,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8366486,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
PLATE,8366488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1492.00000,432.68000,Aetna,First Health,,1220.46,,,,,,,537.87,1220.46,percent of total billed charges,
PLATE,8366488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1492.00000,432.68000,Aetna,First Health,,1220.46,,,,,,,480.42,1220.46,percent of total billed charges,
CAGE,8366491,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
CAGE,8366491,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
CAGE,8366492,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
CAGE,8366492,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
CAGE,8366676,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8366676,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SCREW,8366677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8366677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ROD SPINAL,8366678,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3028.00000,878.12000,Aetna,First Health,,2476.90,,,,,,,1091.59,2476.90,percent of total billed charges,
ROD SPINAL,8366678,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3028.00000,878.12000,Aetna,First Health,,2476.90,,,,,,,975.02,2476.90,percent of total billed charges,
SCREW,8366679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8366679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SCREW,8366681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8366681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SCREW,8366682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8366682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
FIBULAR SHAFT,8366684,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4183.69000,1213.27000,Aetna,First Health,,3422.26,,,,,,,1508.22,3422.26,percent of total billed charges,
FIBULAR SHAFT,8366684,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4183.69000,1213.27000,Aetna,First Health,,3422.26,,,,,,,1347.15,3422.26,percent of total billed charges,
SCREW,8366899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,8366899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
CAGE,8366901,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8366901,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
ROD SPINAL,8366903,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8366903,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
SHELL,8366905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,8366905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
STEM,8366907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8366907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
SCREW,8366914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,8366914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,8366915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,8366915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,8366910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8366910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8366911,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8366911,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8366912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8366912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8366913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8366913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
PENILE PROSTHESIS,8366966,CDM,278,RC,C2622,HCPCS,,,facility,inpatient,,,34278.75000,9940.84000,Aetna,First Health,,28040.02,,,,,,,12357.49,28040.02,percent of total billed charges,
PENILE PROSTHESIS,8366966,CDM,278,RC,C2622,HCPCS,,,facility,outpatient,,,34278.75000,9940.84000,Aetna,First Health,,28040.02,,,,,,,11037.76,28040.02,percent of total billed charges,
PENILE PROSTHESIS,8366967,CDM,278,RC,C2622,HCPCS,,,facility,inpatient,,,37136.25000,10769.51000,Aetna,First Health,,30377.45,,,,,,,13387.62,30377.45,percent of total billed charges,
PENILE PROSTHESIS,8366967,CDM,278,RC,C2622,HCPCS,,,facility,outpatient,,,37136.25000,10769.51000,Aetna,First Health,,30377.45,,,,,,,11957.87,30377.45,percent of total billed charges,
PENILE PROSTHESIS,8366968,CDM,278,RC,C2622,HCPCS,,,facility,inpatient,,,37136.25000,10769.51000,Aetna,First Health,,30377.45,,,,,,,13387.62,30377.45,percent of total billed charges,
PENILE PROSTHESIS,8366968,CDM,278,RC,C2622,HCPCS,,,facility,outpatient,,,37136.25000,10769.51000,Aetna,First Health,,30377.45,,,,,,,11957.87,30377.45,percent of total billed charges,
SCREW,8367046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8367046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8367047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,8367047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
K WIRE,8367050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,413.25000,119.84000,Aetna,First Health,,338.04,,,,,,,148.98,338.04,percent of total billed charges,
K WIRE,8367050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,413.25000,119.84000,Aetna,First Health,,338.04,,,,,,,133.07,338.04,percent of total billed charges,
ANCHOR,8367051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,451.25000,130.86000,Aetna,First Health,,369.12,,,,,,,162.68,369.12,percent of total billed charges,
ANCHOR,8367051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,451.25000,130.86000,Aetna,First Health,,369.12,,,,,,,145.30,369.12,percent of total billed charges,
SCREW,8367052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,8367052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,8367053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8367053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,8367054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,8367054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
SCREW,8367055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8367055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8367056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8367056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
K WIRE,8367057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
K WIRE,8367057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,8367062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8367062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8367063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8367063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,8367099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,8367099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,8367100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,8367100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW,8367101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
SCREW,8367101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
SCREW,8367102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,8367102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
PLATE,8367103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5323.50000,1543.81000,Aetna,First Health,,4354.62,,,,,,,1919.12,4354.62,percent of total billed charges,
PLATE,8367103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5323.50000,1543.81000,Aetna,First Health,,4354.62,,,,,,,1714.17,4354.62,percent of total billed charges,
SCREW,8367104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8367104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,8367105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8367105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
PLATE,8367106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7966.80000,2310.37000,Aetna,First Health,,6516.84,,,,,,,2872.03,6516.84,percent of total billed charges,
PLATE,8367106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7966.80000,2310.37000,Aetna,First Health,,6516.84,,,,,,,2565.31,6516.84,percent of total billed charges,
SCREW,8367107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8367107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8367108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8367108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8367109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8367109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8367110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8367110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8367111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8367111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8367112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,8367112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,8367113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,8367113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
LINER,8367174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1855.02,4209.18,percent of total billed charges,
LINER,8367174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1656.92,4209.18,percent of total billed charges,
LINER,8367175,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,3000.08,6807.40,percent of total billed charges,
LINER,8367175,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,2679.68,6807.40,percent of total billed charges,
LINER,8367176,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,3000.08,6807.40,percent of total billed charges,
LINER,8367176,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,First Health,,6807.40,,,,,,,2679.68,6807.40,percent of total billed charges,
COMPONENT FEMORAL,8367177,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,7669.64,17402.95,percent of total billed charges,
COMPONENT FEMORAL,8367177,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,6850.55,17402.95,percent of total billed charges,
STEM EXTENSION,8367178,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM EXTENSION,8367178,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
BASEPLATE,8367179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
BASEPLATE,8367179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
INSERT,8367230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8367230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
INSERT,8367739,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8367739,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CONNECTOR SPINAL,8367682,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1924.00000,557.96000,Aetna,First Health,,1573.83,,,,,,,693.60,1573.83,percent of total billed charges,
CONNECTOR SPINAL,8367682,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1924.00000,557.96000,Aetna,First Health,,1573.83,,,,,,,619.53,1573.83,percent of total billed charges,
STEM,8367684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,8367684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
PLATE,8367685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,8367685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CAGE,8367686,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
CAGE,8367686,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
SCREW,8367687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1821.97,4134.17,percent of total billed charges,
SCREW,8367687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,First Health,,4134.17,,,,,,,1627.39,4134.17,percent of total billed charges,
PLATE,8367688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5727.26000,1660.91000,Aetna,First Health,,4684.90,,,,,,,2064.68,4684.90,percent of total billed charges,
PLATE,8367688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5727.26000,1660.91000,Aetna,First Health,,4684.90,,,,,,,1844.18,4684.90,percent of total billed charges,
INSERT,8367696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
INSERT,8367696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
PLATE,8367756,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5768.00000,1672.72000,Aetna,First Health,,4718.22,,,,,,,2079.36,4718.22,percent of total billed charges,
PLATE,8367756,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5768.00000,1672.72000,Aetna,First Health,,4718.22,,,,,,,1857.30,4718.22,percent of total billed charges,
PLATE,8367757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5768.00000,1672.72000,Aetna,First Health,,4718.22,,,,,,,2079.36,4718.22,percent of total billed charges,
PLATE,8367757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5768.00000,1672.72000,Aetna,First Health,,4718.22,,,,,,,1857.30,4718.22,percent of total billed charges,
GLENOSPHERE,8367758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1779.07,4036.83,percent of total billed charges,
GLENOSPHERE,8367758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1589.07,4036.83,percent of total billed charges,
ROD SPINAL,8368294,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
ROD SPINAL,8368294,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,8368300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,8368300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CAGE,8368301,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8368301,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,8368559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW,8368559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
SCREW,8368313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW,8368313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
SCREW,8368303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW,8368303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
SCREW,8368304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW,8368304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
SCREW,8368305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8368305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8368306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8368306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8368307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8368307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
PLATE,8368308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2357.68000,683.73000,Aetna,First Health,,1928.58,,,,,,,849.94,1928.58,percent of total billed charges,
PLATE,8368308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2357.68000,683.73000,Aetna,First Health,,1928.58,,,,,,,759.17,1928.58,percent of total billed charges,
PLATE,8368309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2357.68000,683.73000,Aetna,First Health,,1928.58,,,,,,,849.94,1928.58,percent of total billed charges,
PLATE,8368309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2357.68000,683.73000,Aetna,First Health,,1928.58,,,,,,,759.17,1928.58,percent of total billed charges,
CAGE,8368314,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8368314,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
HEAD FEMORAL,8453911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5007.10000,1452.06000,Aetna,First Health,,4095.81,,,,,,,1805.06,4095.81,percent of total billed charges,
HEAD FEMORAL,8453911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5007.10000,1452.06000,Aetna,First Health,,4095.81,,,,,,,1612.29,4095.81,percent of total billed charges,
PLATE,8368316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8862.00000,2569.98000,Aetna,First Health,,7249.12,,,,,,,3194.75,7249.12,percent of total billed charges,
PLATE,8368316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8862.00000,2569.98000,Aetna,First Health,,7249.12,,,,,,,2853.56,7249.12,percent of total billed charges,
ROD SPINAL,8368319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8368319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
LINER,8368329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8368329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
COMPONENT FEMORAL,8368330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
COMPONENT FEMORAL,8368330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CAGE,8368327,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14550.00000,4219.50000,Aetna,First Health,,11901.90,,,,,,,5245.27,11901.90,percent of total billed charges,
CAGE,8368327,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14550.00000,4219.50000,Aetna,First Health,,11901.90,,,,,,,4685.10,11901.90,percent of total billed charges,
DEEP BRAIN STIMULATOR,8368328,CDM,278,RC,L8679,HCPCS,,,facility,inpatient,,,50768.40000,14722.84000,Aetna,First Health,,41528.55,,,,,,,18302.01,41528.55,percent of total billed charges,
DEEP BRAIN STIMULATOR,8368328,CDM,278,RC,L8679,HCPCS,,,facility,outpatient,,,50768.40000,14722.84000,Aetna,First Health,,41528.55,,,,,,,10323.94,41528.55,percent of total billed charges,
PLATE,8368557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2912.64000,844.67000,Aetna,First Health,,2382.54,,,,,,,1050.01,2382.54,percent of total billed charges,
PLATE,8368557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2912.64000,844.67000,Aetna,First Health,,2382.54,,,,,,,937.87,2382.54,percent of total billed charges,
STENT GRAFT,8368561,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
STENT GRAFT,8368561,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
SCREW,8368563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8368563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
COMPONENT FEMORAL,8368565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
COMPONENT FEMORAL,8368565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8370177,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8370177,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8370179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,8370179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,8370181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8370181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
BUTTON CLAVICLE,8370183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
BUTTON CLAVICLE,8370183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
PROGRAMMER DEEP BRAIN STIM,8370325,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,2173.83,4932.58,percent of total billed charges,
PROGRAMMER DEEP BRAIN STIM,8370325,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,1941.68,4932.58,percent of total billed charges,
LINER,8370186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2936.27,6662.61,percent of total billed charges,
LINER,8370186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2622.69,6662.61,percent of total billed charges,
INSERT,8370196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8370196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8370188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8370188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
GLENIOD,8370190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GLENIOD,8370190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
FEMORAL HEAD,8370192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
FEMORAL HEAD,8370192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
CATHETER,8370198,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8370198,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8370199,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8370199,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
STENT GRAFT,8370203,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,8370203,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
COMPONENT PATELLA,8370276,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,8370276,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
PLATE,8370278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,574.20000,166.52000,Aetna,First Health,,469.70,,,,,,,207.00,469.70,percent of total billed charges,
PLATE,8370278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,574.20000,166.52000,Aetna,First Health,,469.70,,,,,,,184.89,469.70,percent of total billed charges,
K WIRE,8370280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,118.15,268.10,percent of total billed charges,
K WIRE,8370280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,105.54,268.10,percent of total billed charges,
SCREW,8370282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SCREW,8370282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
ROD SPINAL,8370284,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8370284,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8370286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SCREW,8370286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
PLATE,8370319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1508.12000,437.35000,Aetna,First Health,,1233.64,,,,,,,543.68,1233.64,percent of total billed charges,
PLATE,8370319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1508.12000,437.35000,Aetna,First Health,,1233.64,,,,,,,485.61,1233.64,percent of total billed charges,
PLATE,8370365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5710.95000,1656.18000,Aetna,First Health,,4671.56,,,,,,,2058.80,4671.56,percent of total billed charges,
PLATE,8370365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5710.95000,1656.18000,Aetna,First Health,,4671.56,,,,,,,1838.93,4671.56,percent of total billed charges,
CAGE,8370390,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,6281.71,14253.65,percent of total billed charges,
CAGE,8370390,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,First Health,,14253.65,,,,,,,5610.85,14253.65,percent of total billed charges,
SCREW,8370391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SCREW,8370391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
CAGE,8370392,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,8370392,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
BASE BOLT,8370519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BASE BOLT,8370519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
ROD SPINAL,8370520,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8370520,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
CAGE,8370521,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8370521,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
SCREW,8370522,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,8370522,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
INSERT,8370523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8370523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
LINER,8370524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8370524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
ROD SPINAL,8370526,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8370526,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8370858,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8370858,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,8370794,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8370794,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
SCREW,8370795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.06000,86.73000,Aetna,First Health,,244.63,,,,,,,107.81,244.63,percent of total billed charges,
SCREW,8370795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.06000,86.73000,Aetna,First Health,,244.63,,,,,,,96.30,244.63,percent of total billed charges,
SCREW,8370822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.75000,53.29000,Aetna,First Health,,150.31,,,,,,,66.24,150.31,percent of total billed charges,
SCREW,8370822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.75000,53.29000,Aetna,First Health,,150.31,,,,,,,59.17,150.31,percent of total billed charges,
SCREW,8370859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW,8370859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
WEDGE,7694910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4344.41000,1259.88000,Aetna,First Health,,3553.73,,,,,,,1566.16,3553.73,percent of total billed charges,
WEDGE,7694910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4344.41000,1259.88000,Aetna,First Health,,3553.73,,,,,,,1398.90,3553.73,percent of total billed charges,
STRUT,8370914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4911.55000,1424.35000,Aetna,First Health,,4017.65,,,,,,,1770.61,4017.65,percent of total billed charges,
STRUT,8370914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4911.55000,1424.35000,Aetna,First Health,,4017.65,,,,,,,1581.52,4017.65,percent of total billed charges,
SCREW,8370900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SCREW,8370900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SCREW,8370901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8370901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8370902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8370902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
COMPONENT GLENOID,8370903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
COMPONENT GLENOID,8370903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
SCREW,8370904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8370904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8370905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,8370905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,8370906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8370906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE,8370909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11076.00000,3212.04000,Aetna,First Health,,9060.17,,,,,,,3992.90,9060.17,percent of total billed charges,
PLATE,8370909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11076.00000,3212.04000,Aetna,First Health,,9060.17,,,,,,,3566.47,9060.17,percent of total billed charges,
SCREW,8370910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,8370910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
STENT GRAFT,8370911,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,8370911,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
SCREW,8370912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8370912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
ROD SPINAL,8370913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8370913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ANCHOR,7893739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,6123.99,13895.77,percent of total billed charges,
ANCHOR,7893739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,5469.98,13895.77,percent of total billed charges,
GRAFT STENT,8372236,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15495.00000,4493.55000,Aetna,First Health,,12674.91,,,,,,,5585.95,12674.91,percent of total billed charges,
GRAFT STENT,8372236,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15495.00000,4493.55000,Aetna,First Health,,12674.91,,,,,,,4989.39,12674.91,percent of total billed charges,
GRAFT STENT,8372237,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,46811.70000,13575.39000,Aetna,First Health,,38291.97,,,,,,,16875.62,38291.97,percent of total billed charges,
GRAFT STENT,8372237,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,46811.70000,13575.39000,Aetna,First Health,,38291.97,,,,,,,15073.37,38291.97,percent of total billed charges,
HEAD HUMERAL,8372238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
HEAD HUMERAL,8372238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
PLATE,8372403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,8372403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
INSERT,8372405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8372405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
LEAD,8370507,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11358.00000,3293.82000,Aetna,First Health,,9290.84,,,,,,,4094.56,9290.84,percent of total billed charges,
LEAD,8370507,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11358.00000,3293.82000,Aetna,First Health,,9290.84,,,,,,,3657.28,9290.84,percent of total billed charges,
LEAD,8370508,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11358.00000,3293.82000,Aetna,First Health,,9290.84,,,,,,,4094.56,9290.84,percent of total billed charges,
LEAD,8370508,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11358.00000,3293.82000,Aetna,First Health,,9290.84,,,,,,,3657.28,9290.84,percent of total billed charges,
PROGRAMER,8370510,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,6072.50000,1761.02000,Aetna,First Health,,4967.31,,,,,,,2189.14,4967.31,percent of total billed charges,
PROGRAMER,8370510,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,6072.50000,1761.02000,Aetna,First Health,,4967.31,,,,,,,1955.35,4967.31,percent of total billed charges,
NEUROSTIMULATOR,8370512,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,29632.50000,8593.42000,Aetna,First Health,,24239.38,,,,,,,10682.52,24239.38,percent of total billed charges,
NEUROSTIMULATOR,8370512,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,29632.50000,8593.42000,Aetna,First Health,,24239.38,,,,,,,9541.67,24239.38,percent of total billed charges,
LEAD,8370513,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11358.00000,3293.82000,Aetna,First Health,,9290.84,,,,,,,4094.56,9290.84,percent of total billed charges,
LEAD,8370513,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11358.00000,3293.82000,Aetna,First Health,,9290.84,,,,,,,3657.28,9290.84,percent of total billed charges,
LEAD,8370514,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11358.00000,3293.82000,Aetna,First Health,,9290.84,,,,,,,4094.56,9290.84,percent of total billed charges,
LEAD,8370514,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11358.00000,3293.82000,Aetna,First Health,,9290.84,,,,,,,3657.28,9290.84,percent of total billed charges,
STRUT,8372239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4692.10000,1360.71000,Aetna,First Health,,3838.14,,,,,,,1691.50,3838.14,percent of total billed charges,
STRUT,8372239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4692.10000,1360.71000,Aetna,First Health,,3838.14,,,,,,,1510.86,3838.14,percent of total billed charges,
SCREW,8370908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,8370908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
CAGE,8372407,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8372407,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
STENT GRAFT,8372479,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,46811.70000,13575.39000,Aetna,First Health,,38291.97,,,,,,,16875.62,38291.97,percent of total billed charges,
STENT GRAFT,8372479,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,46811.70000,13575.39000,Aetna,First Health,,38291.97,,,,,,,15073.37,38291.97,percent of total billed charges,
SCREW,8372425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8372425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8372482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,8372482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
PLATE,8372484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3349.50000,971.35000,Aetna,First Health,,2739.89,,,,,,,1207.49,2739.89,percent of total billed charges,
PLATE,8372484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3349.50000,971.35000,Aetna,First Health,,2739.89,,,,,,,1078.54,2739.89,percent of total billed charges,
SCREW,8372486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8372486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8372488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8372488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8372490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8372490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8372492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8372492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8372546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8372546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,8372544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,8372544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
NAIL,8372549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7736.40000,2243.56000,Aetna,First Health,,6328.38,,,,,,,2788.97,6328.38,percent of total billed charges,
NAIL,8372549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7736.40000,2243.56000,Aetna,First Health,,6328.38,,,,,,,2491.12,6328.38,percent of total billed charges,
HEAD HUMERAL,8372551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
HEAD HUMERAL,8372551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
ROD SPINAL,8372553,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
ROD SPINAL,8372553,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
INSERT,8372559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8372559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,8372600,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8372600,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
SCREW,8372601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8372601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8372602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8372602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE,8372603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE,8372603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
ROD HELICAL BLADE,8372599,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,1085.65,2463.42,percent of total billed charges,
ROD HELICAL BLADE,8372599,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,First Health,,2463.42,,,,,,,969.71,2463.42,percent of total billed charges,
NEUROSTIMULATOR,7971875,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,1667.60000,483.60000,Aetna,First Health,,1364.10,,,,,,,601.17,1364.10,percent of total billed charges,
NEUROSTIMULATOR,7971875,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,1667.60000,483.60000,Aetna,First Health,,1364.10,,,,,,,536.97,1364.10,percent of total billed charges,
COMPONENT FEMORAL,8372867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
COMPONENT FEMORAL,8372867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PLATE,8372868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,646.11000,187.37000,Aetna,First Health,,528.52,,,,,,,232.92,528.52,percent of total billed charges,
PLATE,8372868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,646.11000,187.37000,Aetna,First Health,,528.52,,,,,,,208.05,528.52,percent of total billed charges,
LINER,8372882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LINER,8372882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
LINER,8372883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER,8372883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,8372884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,8372884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
RECHARGER,8372885,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,1383.26000,401.15000,Aetna,First Health,,1131.51,,,,,,,498.67,1131.51,percent of total billed charges,
RECHARGER,8372885,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,1383.26000,401.15000,Aetna,First Health,,1131.51,,,,,,,445.41,1131.51,percent of total billed charges,
LEAD EXTENSION,8372886,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,1383.26000,401.15000,Aetna,First Health,,1131.51,,,,,,,498.67,1131.51,percent of total billed charges,
LEAD EXTENSION,8372886,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,1383.26000,401.15000,Aetna,First Health,,1131.51,,,,,,,445.41,1131.51,percent of total billed charges,
SPACER TIBIAL,8374198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8830.80000,2560.93000,Aetna,First Health,,7223.59,,,,,,,3183.50,7223.59,percent of total billed charges,
SPACER TIBIAL,8374198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8830.80000,2560.93000,Aetna,First Health,,7223.59,,,,,,,2843.52,7223.59,percent of total billed charges,
STEM EXTENSION,8374200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5716.20000,1657.70000,Aetna,First Health,,4675.85,,,,,,,2060.69,4675.85,percent of total billed charges,
STEM EXTENSION,8374200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5716.20000,1657.70000,Aetna,First Health,,4675.85,,,,,,,1840.62,4675.85,percent of total billed charges,
STEM EXTENSION,8374202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15166.50000,4398.28000,Aetna,First Health,,12406.20,,,,,,,5467.52,12406.20,percent of total billed charges,
STEM EXTENSION,8374202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15166.50000,4398.28000,Aetna,First Health,,12406.20,,,,,,,4883.61,12406.20,percent of total billed charges,
PROGRAMMER,8374205,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
PROGRAMMER,8374205,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
CHARGING SYSTEM,8374206,CDM,278,RC,C1822,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
CHARGING SYSTEM,8374206,CDM,278,RC,C1822,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
GENERATOR,8374207,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,82000.00000,23780.00000,Aetna,First Health,,67076.00,,,,,,,29561.00,67076.00,percent of total billed charges,
GENERATOR,8374207,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,82000.00000,23780.00000,Aetna,First Health,,67076.00,,,,,,,26404.00,67076.00,percent of total billed charges,
GUIDEWIRE,8374260,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,471.77000,136.81000,Aetna,First Health,,385.91,,,,,,,170.07,385.91,percent of total billed charges,
GUIDEWIRE,8374260,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,471.77000,136.81000,Aetna,First Health,,385.91,,,,,,,151.91,385.91,percent of total billed charges,
GUIDEWIRE,8374261,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,441.85000,128.14000,Aetna,First Health,,361.43,,,,,,,159.29,361.43,percent of total billed charges,
GUIDEWIRE,8374261,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,441.85000,128.14000,Aetna,First Health,,361.43,,,,,,,142.28,361.43,percent of total billed charges,
SCREW,8374264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8374264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8374265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8374265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
GUIDEWIRE,8374266,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,394.44000,114.39000,Aetna,First Health,,322.65,,,,,,,142.20,322.65,percent of total billed charges,
GUIDEWIRE,8374266,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,394.44000,114.39000,Aetna,First Health,,322.65,,,,,,,127.01,322.65,percent of total billed charges,
SCREW,8374267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8374267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8374268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8374268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
GUIDE MINI GLENOID,8360506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4617.90000,1339.19000,Aetna,First Health,,3777.44,,,,,,,1664.75,3777.44,percent of total billed charges,
GUIDE MINI GLENOID,8360506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4617.90000,1339.19000,Aetna,First Health,,3777.44,,,,,,,1486.96,3777.44,percent of total billed charges,
INSERT,8374271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6681.50000,1937.63000,Aetna,First Health,,5465.47,,,,,,,2408.68,5465.47,percent of total billed charges,
INSERT,8374271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6681.50000,1937.63000,Aetna,First Health,,5465.47,,,,,,,2151.44,5465.47,percent of total billed charges,
SCREW,8374564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,8374564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
GUIDEWIRE,8374460,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,503.50000,146.01000,Aetna,First Health,,411.86,,,,,,,181.51,411.86,percent of total billed charges,
GUIDEWIRE,8374460,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,503.50000,146.01000,Aetna,First Health,,411.86,,,,,,,162.13,411.86,percent of total billed charges,
STEM,8374463,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,8374463,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
GRAFT HEAD HUMERAL,8374464,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3329.13000,965.45000,Aetna,First Health,,2723.23,,,,,,,1200.15,2723.23,percent of total billed charges,
GRAFT HEAD HUMERAL,8374464,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3329.13000,965.45000,Aetna,First Health,,2723.23,,,,,,,1071.98,2723.23,percent of total billed charges,
SCREW,8374482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,8374482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
PLATE,8374552,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7966.80000,2310.37000,Aetna,First Health,,6516.84,,,,,,,2872.03,6516.84,percent of total billed charges,
PLATE,8374552,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7966.80000,2310.37000,Aetna,First Health,,6516.84,,,,,,,2565.31,6516.84,percent of total billed charges,
SCREW,8374554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8374554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8374556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8374556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
ROD SPINAL,8374558,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8374558,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
K WIRE,8374560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,751.50000,217.93000,Aetna,First Health,,614.73,,,,,,,270.92,614.73,percent of total billed charges,
K WIRE,8374560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,751.50000,217.93000,Aetna,First Health,,614.73,,,,,,,241.98,614.73,percent of total billed charges,
ROD SPINAL,8374562,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8374562,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
INSERT,8374612,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8374612,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
LINER,8374614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5669.30000,1644.10000,Aetna,First Health,,4637.49,,,,,,,2043.78,4637.49,percent of total billed charges,
LINER,8374614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5669.30000,1644.10000,Aetna,First Health,,4637.49,,,,,,,1825.51,4637.49,percent of total billed charges,
HEAD FEMORAL,8374616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,8374616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
DEVICE ABSORBABLE FIXATION,8374661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2360.00000,684.40000,Aetna,First Health,,1930.48,,,,,,,850.78,1930.48,percent of total billed charges,
DEVICE ABSORBABLE FIXATION,8374661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2360.00000,684.40000,Aetna,First Health,,1930.48,,,,,,,759.92,1930.48,percent of total billed charges,
GRAFT BONE,8374674,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11745.00000,3406.05000,Aetna,First Health,,9607.41,,,,,,,4234.07,9607.41,percent of total billed charges,
GRAFT BONE,8374674,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11745.00000,3406.05000,Aetna,First Health,,9607.41,,,,,,,3781.89,9607.41,percent of total billed charges,
SCREW,8376204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
SCREW,8376211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
SCREW,8376213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
SCREW,8376213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
SCREW,8376214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
SCREW,8376214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
SCREW,8376215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8376221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8376221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
CAGE,8376322,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
CAGE,8376322,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
NAIL,8376243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11684.25000,3388.43000,Aetna,First Health,,9557.72,,,,,,,4212.17,9557.72,percent of total billed charges,
NAIL,8376243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11684.25000,3388.43000,Aetna,First Health,,9557.72,,,,,,,3762.33,9557.72,percent of total billed charges,
HEAD FEMORAL,8376241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8376241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
STEM,8376246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8376246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
ROD SPINAL,8376323,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8376323,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
SCREW,8376324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8376324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8376500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8376500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8376325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8376325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8376326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8376326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
COMPONENT TIBIAL,8376502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
COMPONENT TIBIAL,8376502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
INSERT,8376561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8376561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,8376664,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8376664,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
WEDGE,8376665,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8376665,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
INSERT,8376666,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8376666,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STEM,8376667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM,8376667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
COMPONENT FEMORAL,8376668,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,7273.09,16503.15,percent of total billed charges,
COMPONENT FEMORAL,8376668,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,6496.35,16503.15,percent of total billed charges,
WEDGE,8376669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8376669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
LINER,8376670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8376670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
NAIL,8376671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8376671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
MESH,8376672,CDM,278,RC,C1765,HCPCS,,,facility,inpatient,,,4795.00000,1390.55000,Aetna,First Health,,3922.31,,,,,,,1728.60,3922.31,percent of total billed charges,
MESH,8376672,CDM,278,RC,C1765,HCPCS,,,facility,outpatient,,,4795.00000,1390.55000,Aetna,First Health,,3922.31,,,,,,,1543.99,3922.31,percent of total billed charges,
CAGE,8376793,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8376793,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
HEAD FEMORAL,8376795,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
HEAD FEMORAL,8376795,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STEM,8376797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12867.00000,3731.43000,Aetna,First Health,,10525.21,,,,,,,4638.55,10525.21,percent of total billed charges,
STEM,8376797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12867.00000,3731.43000,Aetna,First Health,,10525.21,,,,,,,4143.17,10525.21,percent of total billed charges,
NAIL,8376800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11684.25000,3388.43000,Aetna,First Health,,9557.72,,,,,,,4212.17,9557.72,percent of total billed charges,
NAIL,8376800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11684.25000,3388.43000,Aetna,First Health,,9557.72,,,,,,,3762.33,9557.72,percent of total billed charges,
STENT GRAFT,8378231,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
STENT GRAFT,8378231,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
HEAD FEMORAL,8378268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
HEAD FEMORAL,8378268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
STEM,8378271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8378271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8378275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8378275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8378277,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8378277,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SPACER,8378279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10755.00000,3118.95000,Aetna,First Health,,8797.59,,,,,,,3877.18,8797.59,percent of total billed charges,
SPACER,8378279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10755.00000,3118.95000,Aetna,First Health,,8797.59,,,,,,,3463.11,8797.59,percent of total billed charges,
MESH,8378281,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,357.34000,103.63000,Aetna,First Health,,292.30,,,,,,,128.82,292.30,percent of total billed charges,
MESH,8378281,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,357.34000,103.63000,Aetna,First Health,,292.30,,,,,,,115.06,292.30,percent of total billed charges,
MESH,8378282,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1747.80000,506.86000,Aetna,First Health,,1429.70,,,,,,,630.08,1429.70,percent of total billed charges,
MESH,8378282,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1747.80000,506.86000,Aetna,First Health,,1429.70,,,,,,,562.79,1429.70,percent of total billed charges,
INSERT,8378339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
INSERT,8378339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
COMPONENT FEMORAL,8378341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8378341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT TIBIAL,8378343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
COMPONENT TIBIAL,8378343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
INSERT,8378345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8378345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
COMPONENT PATELLOFEMORAL,8378347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,4133.49,9379.19,percent of total billed charges,
COMPONENT PATELLOFEMORAL,8378347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,3692.05,9379.19,percent of total billed charges,
INSERT,8378349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2708.08,6144.82,percent of total billed charges,
INSERT,8378349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,First Health,,6144.82,,,,,,,2418.86,6144.82,percent of total billed charges,
TRAY TIBIAL,8378351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,6518.74,14791.49,percent of total billed charges,
TRAY TIBIAL,8378351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,5822.56,14791.49,percent of total billed charges,
INSERT,8378412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8378412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8380190,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8380190,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,8380192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,8380192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
INSERT,8380299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,8380299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
NAIL,8380300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4346.76000,1260.56000,Aetna,First Health,,3555.65,,,,,,,1567.01,3555.65,percent of total billed charges,
NAIL,8380300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4346.76000,1260.56000,Aetna,First Health,,3555.65,,,,,,,1399.66,3555.65,percent of total billed charges,
CAGE,8380298,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
CAGE,8380298,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
PLATE,8380374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,8380374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
PLATE,8380376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2708.00000,785.32000,Aetna,First Health,,2215.14,,,,,,,976.23,2215.14,percent of total billed charges,
PLATE,8380376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2708.00000,785.32000,Aetna,First Health,,2215.14,,,,,,,871.98,2215.14,percent of total billed charges,
COMPONENT GLENOID,8380379,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
COMPONENT GLENOID,8380379,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
STENT GRAFT,8380381,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36110.25000,10471.97000,Aetna,First Health,,29538.18,,,,,,,13017.75,29538.18,percent of total billed charges,
STENT GRAFT,8380381,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36110.25000,10471.97000,Aetna,First Health,,29538.18,,,,,,,11627.50,29538.18,percent of total billed charges,
STENT GRAFT,8380382,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36110.25000,10471.97000,Aetna,First Health,,29538.18,,,,,,,13017.75,29538.18,percent of total billed charges,
STENT GRAFT,8380382,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36110.25000,10471.97000,Aetna,First Health,,29538.18,,,,,,,11627.50,29538.18,percent of total billed charges,
STENT GRAFT,8380383,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36110.25000,10471.97000,Aetna,First Health,,29538.18,,,,,,,13017.75,29538.18,percent of total billed charges,
STENT GRAFT,8380383,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36110.25000,10471.97000,Aetna,First Health,,29538.18,,,,,,,11627.50,29538.18,percent of total billed charges,
STENT GRAFT,8380384,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36110.25000,10471.97000,Aetna,First Health,,29538.18,,,,,,,13017.75,29538.18,percent of total billed charges,
STENT GRAFT,8380384,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36110.25000,10471.97000,Aetna,First Health,,29538.18,,,,,,,11627.50,29538.18,percent of total billed charges,
STENT GRAFT,8380385,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36110.25000,10471.97000,Aetna,First Health,,29538.18,,,,,,,13017.75,29538.18,percent of total billed charges,
STENT GRAFT,8380385,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36110.25000,10471.97000,Aetna,First Health,,29538.18,,,,,,,11627.50,29538.18,percent of total billed charges,
CONNECTOR,8380428,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CONNECTOR,8380428,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
SCREW,8380429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8380429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
WEDGE,8380430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
WEDGE,8380430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
INSERT,8380472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8380472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
LEAD,8380473,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
LEAD,8380473,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
COMPONENT FEMORAL,8380474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
COMPONENT FEMORAL,8380474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
LEAD THE KIT,8380530,CDM,278,RC,L8680,HCPCS,,,facility,inpatient,,,54911.00000,15924.19000,Aetna,First Health,,44917.20,,,,,,,19795.42,44917.20,percent of total billed charges,
LEAD THE KIT,8380530,CDM,278,RC,L8680,HCPCS,,,facility,outpatient,,,54911.00000,15924.19000,Aetna,First Health,,44917.20,,,,,,,17681.34,44917.20,percent of total billed charges,
SCREW,8380523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8380523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8380524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2939.00000,852.31000,Aetna,First Health,,2404.10,,,,,,,1059.51,2404.10,percent of total billed charges,
SCREW,8380524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2939.00000,852.31000,Aetna,First Health,,2404.10,,,,,,,946.36,2404.10,percent of total billed charges,
SCREW,8380525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8380525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
INSERT,8380726,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8380726,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,8380526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1930.48,4380.39,percent of total billed charges,
INSERT,8380526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,First Health,,4380.39,,,,,,,1724.31,4380.39,percent of total billed charges,
SCREW,8380528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,8380528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
SCREW,8380529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,8380529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
PLATE,8380727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2532.08000,734.30000,Aetna,First Health,,2071.24,,,,,,,912.81,2071.24,percent of total billed charges,
PLATE,8380727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2532.08000,734.30000,Aetna,First Health,,2071.24,,,,,,,815.33,2071.24,percent of total billed charges,
STEM,8380798,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,3136.35,7116.60,percent of total billed charges,
STEM,8380798,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,2801.40,7116.60,percent of total billed charges,
STEM,8380799,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8380799,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CAGE,8380800,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8380800,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
PLATE,8380743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10494.00000,3043.26000,Aetna,First Health,,8584.09,,,,,,,3783.09,8584.09,percent of total billed charges,
PLATE,8380743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10494.00000,3043.26000,Aetna,First Health,,8584.09,,,,,,,3379.07,8584.09,percent of total billed charges,
CAGE,8380744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
CAGE,8380744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
SCREW,8380746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8380746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
WEDGE,8380821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2239.61,5081.82,percent of total billed charges,
WEDGE,8380821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,First Health,,5081.82,,,,,,,2000.42,5081.82,percent of total billed charges,
SCREW,8380844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,8380844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
ROD SPINAL,8380845,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8380845,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,8380846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8380846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,8380847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8380847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,8380853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,8380853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,8381126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8381126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,8380848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,169.10,383.69,percent of total billed charges,
SCREW,8380848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,First Health,,383.69,,,,,,,151.04,383.69,percent of total billed charges,
GRAFT WEDGE,8380861,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
GRAFT WEDGE,8380861,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
SCREW,8380855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5530.00000,1603.70000,Aetna,First Health,,4523.54,,,,,,,1993.57,4523.54,percent of total billed charges,
SCREW,8380855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5530.00000,1603.70000,Aetna,First Health,,4523.54,,,,,,,1780.66,4523.54,percent of total billed charges,
GRAFT,8380854,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9990.00000,2897.10000,Aetna,First Health,,8171.82,,,,,,,3601.39,8171.82,percent of total billed charges,
GRAFT,8380854,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9990.00000,2897.10000,Aetna,First Health,,8171.82,,,,,,,3216.78,8171.82,percent of total billed charges,
SCREW,8380894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,249.49,percent of total billed charges,
SCREW,8380894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,98.21,249.49,percent of total billed charges,
NAIL,8380895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8380895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
LINER,8381006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER,8381006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
LINER,8381092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LINER,8381092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
TIGHTROPE,8381127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,953.52,2163.61,percent of total billed charges,
TIGHTROPE,8381127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,851.69,2163.61,percent of total billed charges,
COMPONENT GLENOID,8381128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
COMPONENT GLENOID,8381128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
PLATE,8381129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1734.59,3935.91,percent of total billed charges,
PLATE,8381129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1549.34,3935.91,percent of total billed charges,
SCREW,8382209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8382209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8382211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8382211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8382213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8382213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8382261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8382261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8382262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8382262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ROD SPINAL,8382267,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1740.00000,504.60000,Aetna,First Health,,1423.32,,,,,,,627.27,1423.32,percent of total billed charges,
ROD SPINAL,8382267,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1740.00000,504.60000,Aetna,First Health,,1423.32,,,,,,,560.28,1423.32,percent of total billed charges,
INSERT,8382442,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8382442,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
WEDGE,8382443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8382443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8382444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8382444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
STEM,8382445,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM,8382445,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
STEM,8382481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,8382481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
STEM,8382483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
STEM,8382483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
LINER,8382485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6485.50000,1880.79000,Aetna,First Health,,5305.14,,,,,,,2338.02,5305.14,percent of total billed charges,
LINER,8382485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6485.50000,1880.79000,Aetna,First Health,,5305.14,,,,,,,2088.33,5305.14,percent of total billed charges,
SCREW,8382487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,8382487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SHELL,8382520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3524.61,7997.59,percent of total billed charges,
SHELL,8382520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3148.19,7997.59,percent of total billed charges,
HEAD FEMORAL,8382514,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8382514,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
ROD SPINAL,8382516,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8382516,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ANCHOR,8382558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2496.48000,723.98000,Aetna,First Health,,2042.12,,,,,,,899.98,2042.12,percent of total billed charges,
ANCHOR,8382558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2496.48000,723.98000,Aetna,First Health,,2042.12,,,,,,,803.87,2042.12,percent of total billed charges,
LINER,8382560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3576.63,8115.62,percent of total billed charges,
LINER,8382560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3194.66,8115.62,percent of total billed charges,
SCREW,8382562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8382562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
CORE,8384231,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18952.50000,5496.22000,Aetna,First Health,,15503.15,,,,,,,6832.38,15503.15,percent of total billed charges,
CORE,8384231,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18952.50000,5496.22000,Aetna,First Health,,15503.15,,,,,,,6102.70,15503.15,percent of total billed charges,
SCREW,8384233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8384233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,8384235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8384235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8384237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8384237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ENDPLATE,8384239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
ENDPLATE,8384239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
INCISION MANAGEMENT,7697583,CDM,278,RC,A6550,HCPCS,,,facility,inpatient,,,2142.80000,621.41000,Aetna,First Health,,1752.81,,,,,,,772.48,1752.81,percent of total billed charges,
INCISION MANAGEMENT,7697583,CDM,278,RC,A6550,HCPCS,,,facility,outpatient,,,2142.80000,621.41000,Aetna,First Health,,1752.81,,,,,,,31.78,1752.81,percent of total billed charges,
SHELL,8384497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8384497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,8384354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8384354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8384356,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8384356,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
STEM,8384358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
STEM,8384358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,8384363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE,8384363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
COMPONENT GLENOID,8384499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,2149.26,4876.83,percent of total billed charges,
COMPONENT GLENOID,8384499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,1919.73,4876.83,percent of total billed charges,
PLATE,8384371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8384371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
COIL EMBOLIZATION,8384501,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,First Health,,4779.78,,,,,,,2106.49,4779.78,percent of total billed charges,
COIL EMBOLIZATION,8384501,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,First Health,,4779.78,,,,,,,1881.53,4779.78,percent of total billed charges,
PLATE,8384503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1847.20,4191.43,percent of total billed charges,
PLATE,8384503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1649.93,4191.43,percent of total billed charges,
SCREW,8384505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8384505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8384507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8384507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
CONTACT EXT IN KIT,8384607,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
CONTACT EXT IN KIT,8384607,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
SCREW,8384683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8384683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8384685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8384685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SYSTEM FIXATION ORTHO,8384687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8637.00000,2504.73000,Aetna,First Health,,7065.07,,,,,,,3113.64,7065.07,percent of total billed charges,
SYSTEM FIXATION ORTHO,8384687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8637.00000,2504.73000,Aetna,First Health,,7065.07,,,,,,,2781.11,7065.07,percent of total billed charges,
ROD SPINAL,8384689,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8384689,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
ROD SPINAL,8384691,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8384691,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SCREW,8384693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8384693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8384694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8384694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8384695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8384695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8384696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8384696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8384697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8384697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8384698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8384698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8384699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8384699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
CAGE,8384721,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8384721,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
SCREW,8384803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,8384803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
ADAPTER STEM,8384804,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5187.00000,1504.23000,Aetna,First Health,,4242.97,,,,,,,1869.91,4242.97,percent of total billed charges,
ADAPTER STEM,8384804,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5187.00000,1504.23000,Aetna,First Health,,4242.97,,,,,,,1670.21,4242.97,percent of total billed charges,
INSERT,8384805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8384805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
INSERT,8384806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8384806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
INSERT,8384807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
INSERT,8384807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
COMPONENT TIBIAL,8384808,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,8384808,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
STEM,8384809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8384809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
STEM,8384810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8384810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
NAIL,8385061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8385061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
ROD SPINAL,8385063,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8385063,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CROSS CONNECTOR,8385064,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CROSS CONNECTOR,8385064,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
CROSS CONNECTOR,8385065,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CROSS CONNECTOR,8385065,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
CAGE,8385066,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8385066,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
NAIL,8386405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8386405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
SCREW,8386406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,289.57,657.06,percent of total billed charges,
SCREW,8386406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,258.65,657.06,percent of total billed charges,
PLATE,8386407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1298.00000,376.42000,Aetna,First Health,,1061.76,,,,,,,467.93,1061.76,percent of total billed charges,
PLATE,8386407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1298.00000,376.42000,Aetna,First Health,,1061.76,,,,,,,417.96,1061.76,percent of total billed charges,
SCREW,8386408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,289.57,657.06,percent of total billed charges,
SCREW,8386408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,258.65,657.06,percent of total billed charges,
STEM,8386411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
STEM,8386411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
CEMENT RESTRICTOR,8386409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
CEMENT RESTRICTOR,8386409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE,8386422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,901.40000,261.41000,Aetna,First Health,,737.35,,,,,,,324.95,737.35,percent of total billed charges,
PLATE,8386422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,901.40000,261.41000,Aetna,First Health,,737.35,,,,,,,290.25,737.35,percent of total billed charges,
SCREW,8386423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.35000,103.34000,Aetna,First Health,,291.49,,,,,,,128.46,291.49,percent of total billed charges,
SCREW,8386423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.35000,103.34000,Aetna,First Health,,291.49,,,,,,,114.74,291.49,percent of total billed charges,
PLATE,8386424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,799.52000,231.86000,Aetna,First Health,,654.01,,,,,,,288.23,654.01,percent of total billed charges,
PLATE,8386424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,799.52000,231.86000,Aetna,First Health,,654.01,,,,,,,257.45,654.01,percent of total billed charges,
INSERT,8386443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,8386443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SCREW,8386500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8386500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,8386501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW,8386501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
SCREW,8386502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8386502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,8386503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW,8386503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
SCREW,8386504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW,8386504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
SCREW,8386505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW,8386505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
STEM,8386506,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
STEM,8386506,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
SCREW,8386507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8386507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
SCREW,8386508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8386508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
CAGE,8386509,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,8386509,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
CAGE,8386510,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8386510,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
CAGE,8386740,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,8939.50,20284.35,percent of total billed charges,
CAGE,8386740,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,7984.80,20284.35,percent of total billed charges,
BREAST IMPLANT,8386801,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1432.09,3249.51,percent of total billed charges,
BREAST IMPLANT,8386801,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1279.14,3249.51,percent of total billed charges,
BREAST IMPLANT,8386802,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1432.09,3249.51,percent of total billed charges,
BREAST IMPLANT,8386802,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1279.14,3249.51,percent of total billed charges,
BREAST IMPLANT,8386803,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1432.09,3249.51,percent of total billed charges,
BREAST IMPLANT,8386803,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1279.14,3249.51,percent of total billed charges,
BREAST IMPLANT,8386804,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1432.09,3249.51,percent of total billed charges,
BREAST IMPLANT,8386804,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1279.14,3249.51,percent of total billed charges,
BREAST IMPLANT,8386805,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1432.09,3249.51,percent of total billed charges,
BREAST IMPLANT,8386805,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1279.14,3249.51,percent of total billed charges,
COMPONENT FEMORAL,8386956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,7273.09,16503.15,percent of total billed charges,
COMPONENT FEMORAL,8386956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,6496.35,16503.15,percent of total billed charges,
INSERT,8386868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8386868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
WEDGE,8386869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8386869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
STEM,8386870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8386870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
SCREW,8386871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8386871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8386872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8386872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STEM,8386958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8386958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CAGE,8386962,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8386962,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,8386972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8386972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,8386964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8386964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,8386966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8386966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
CAGE,8386968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8386968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
INSERT,8386970,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8386970,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
SCREW,8386990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8386990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
SCREW,8386991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8386991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
SCREW,8386992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8386992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
SCREW,8386993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8386993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
INTRODUCER,8386973,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,741.19,1681.81,percent of total billed charges,
INTRODUCER,8386973,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,662.03,1681.81,percent of total billed charges,
SCREW,8387220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8387220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8388188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8388188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
INSERT,8387222,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8387222,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8387224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,8387224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,8387226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,8387226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
PLATE,8387228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9088.80000,2635.75000,Aetna,First Health,,7434.64,,,,,,,3276.51,7434.64,percent of total billed charges,
PLATE,8387228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9088.80000,2635.75000,Aetna,First Health,,7434.64,,,,,,,2926.59,7434.64,percent of total billed charges,
ENDPLATE,8388189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
ENDPLATE,8388189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
FIXATOR,8388190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
FIXATOR,8388190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
ADAPTER SLEEVE,8388191,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
ADAPTER SLEEVE,8388191,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
BUTTON DIVIDER,8387230,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
BUTTON DIVIDER,8387230,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
STEM,8388336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8388336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,8388337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8388337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
INSERT,8388338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8388338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
COMPONENT TIBIAL,8388339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
COMPONENT TIBIAL,8388339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
SCREW,8388340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW,8388340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
SCREW,8388341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW,8388341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
PLATE,8388342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE,8388342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
CAGE,8388343,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8388343,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
SCREW,8388344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW,8388344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
PLATE,8388345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7362.00000,2134.98000,Aetna,First Health,,6022.12,,,,,,,2654.00,6022.12,percent of total billed charges,
PLATE,8388345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7362.00000,2134.98000,Aetna,First Health,,6022.12,,,,,,,2370.56,6022.12,percent of total billed charges,
SCREW,8388346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8388346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,8388347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8388347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
PLATE,8388442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
PLATE,8388442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
LINER,8388444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
LINER,8388444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
ADAPTER SLEEVE,8388446,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
ADAPTER SLEEVE,8388446,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
INSERT,8388448,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8388448,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
LINER,8388450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8388450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
INSERT,8388546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8388546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8388559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,8388559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8388561,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388561,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388562,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388562,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388563,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388563,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388564,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388564,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388565,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388565,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388566,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
STENT,8388566,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
STENT,8388567,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388567,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388568,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388568,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388569,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388569,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388646,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388646,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388647,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
STENT,8388647,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
STENT,8388648,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388648,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388649,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388649,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388650,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388650,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388651,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388651,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8388652,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8388652,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
CATHETER,8388653,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388653,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388654,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388654,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388655,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388655,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388656,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388656,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388657,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388657,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388658,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388658,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388659,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388659,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388660,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388660,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388661,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388661,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388662,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388662,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388663,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388663,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388664,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
CATHETER,8388664,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
CATHETER,8388665,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
CATHETER,8388665,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
CATHETER,8388666,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
CATHETER,8388666,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
CATHETER,8388667,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,8730.00000,2531.70000,Aetna,First Health,,7141.14,,,,,,,3147.16,7141.14,percent of total billed charges,
CATHETER,8388667,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,8730.00000,2531.70000,Aetna,First Health,,7141.14,,,,,,,2811.06,7141.14,percent of total billed charges,
CATHETER,8388668,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
CATHETER,8388668,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
CATHETER,8388670,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
CATHETER,8388670,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
INSERT,8388679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
INSERT,8388679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CEMENT,8388680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10590.00000,3071.10000,Aetna,First Health,,8662.62,,,,,,,3817.70,8662.62,percent of total billed charges,
CEMENT,8388680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10590.00000,3071.10000,Aetna,First Health,,8662.62,,,,,,,3409.98,8662.62,percent of total billed charges,
SCREW,8388681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,8388681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,8388682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8388682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
SCREW,8388683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8388683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
BIOCARTLIAGE,8388684,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
BIOCARTLIAGE,8388684,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
PLATE,8388704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1233.64000,357.76000,Aetna,First Health,,1009.12,,,,,,,444.73,1009.12,percent of total billed charges,
PLATE,8388704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1233.64000,357.76000,Aetna,First Health,,1009.12,,,,,,,397.23,1009.12,percent of total billed charges,
CATHETER,8388671,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
CATHETER,8388671,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
CATHETER,8388672,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
CATHETER,8388672,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
CATHETER,8388673,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,8730.00000,2531.70000,Aetna,First Health,,7141.14,,,,,,,3147.16,7141.14,percent of total billed charges,
CATHETER,8388673,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,8730.00000,2531.70000,Aetna,First Health,,7141.14,,,,,,,2811.06,7141.14,percent of total billed charges,
CATHETER,8388674,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
CATHETER,8388674,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
CATHETER,8390251,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
CATHETER,8390251,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
CATHETER,8388675,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
CATHETER,8388675,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
CATHETER,8388676,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1448.49,3286.72,percent of total billed charges,
CATHETER,8388676,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,First Health,,3286.72,,,,,,,1293.80,3286.72,percent of total billed charges,
CATHETER,8388677,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
CATHETER,8388677,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
CATHETER,8388678,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,8730.00000,2531.70000,Aetna,First Health,,7141.14,,,,,,,3147.16,7141.14,percent of total billed charges,
CATHETER,8388678,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,8730.00000,2531.70000,Aetna,First Health,,7141.14,,,,,,,2811.06,7141.14,percent of total billed charges,
GRAFT,8388690,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,7534.92000,2185.13000,Aetna,First Health,,6163.56,,,,,,,2716.34,6163.56,percent of total billed charges,
GRAFT,8388690,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,7534.92000,2185.13000,Aetna,First Health,,6163.56,,,,,,,2426.24,6163.56,percent of total billed charges,
GRAFT,8388691,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,7534.92000,2185.13000,Aetna,First Health,,6163.56,,,,,,,2716.34,6163.56,percent of total billed charges,
GRAFT,8388691,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,7534.92000,2185.13000,Aetna,First Health,,6163.56,,,,,,,2426.24,6163.56,percent of total billed charges,
GRAFT,8388692,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8965.17000,2599.90000,Aetna,First Health,,7333.51,,,,,,,3231.94,7333.51,percent of total billed charges,
GRAFT,8388692,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8965.17000,2599.90000,Aetna,First Health,,7333.51,,,,,,,2886.78,7333.51,percent of total billed charges,
GRAFT,8388693,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8965.17000,2599.90000,Aetna,First Health,,7333.51,,,,,,,3231.94,7333.51,percent of total billed charges,
GRAFT,8388693,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8965.17000,2599.90000,Aetna,First Health,,7333.51,,,,,,,2886.78,7333.51,percent of total billed charges,
GRAFT,8388694,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3317.55000,962.09000,Aetna,First Health,,2713.76,,,,,,,1195.98,2713.76,percent of total billed charges,
GRAFT,8388694,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3317.55000,962.09000,Aetna,First Health,,2713.76,,,,,,,1068.25,2713.76,percent of total billed charges,
GRAFT,8390252,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3812.73000,1105.69000,Aetna,First Health,,3118.81,,,,,,,1374.49,3118.81,percent of total billed charges,
GRAFT,8390252,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3812.73000,1105.69000,Aetna,First Health,,3118.81,,,,,,,1227.70,3118.81,percent of total billed charges,
GRAFT,8390254,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4857.30000,1408.62000,Aetna,First Health,,3973.27,,,,,,,1751.06,3973.27,percent of total billed charges,
GRAFT,8390254,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4857.30000,1408.62000,Aetna,First Health,,3973.27,,,,,,,1564.05,3973.27,percent of total billed charges,
GRAFT,8388695,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3317.55000,962.09000,Aetna,First Health,,2713.76,,,,,,,1195.98,2713.76,percent of total billed charges,
GRAFT,8388695,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3317.55000,962.09000,Aetna,First Health,,2713.76,,,,,,,1068.25,2713.76,percent of total billed charges,
GRAFT,8390256,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4857.30000,1408.62000,Aetna,First Health,,3973.27,,,,,,,1751.06,3973.27,percent of total billed charges,
GRAFT,8390256,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4857.30000,1408.62000,Aetna,First Health,,3973.27,,,,,,,1564.05,3973.27,percent of total billed charges,
GRAFT,8388696,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3317.55000,962.09000,Aetna,First Health,,2713.76,,,,,,,1195.98,2713.76,percent of total billed charges,
GRAFT,8388696,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3317.55000,962.09000,Aetna,First Health,,2713.76,,,,,,,1068.25,2713.76,percent of total billed charges,
GRAFT,8388697,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3812.73000,1105.69000,Aetna,First Health,,3118.81,,,,,,,1374.49,3118.81,percent of total billed charges,
GRAFT,8388697,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3812.73000,1105.69000,Aetna,First Health,,3118.81,,,,,,,1227.70,3118.81,percent of total billed charges,
CATHETER,8388698,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388698,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388699,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388699,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388700,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388700,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388701,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388701,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388702,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388702,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER,8388703,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,8388703,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,8390258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8390258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8390259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8390259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
BOLT CAGE,8390673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
BOLT CAGE,8390673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
CAGE,8390674,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,8390674,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
CAGE,8390675,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,8390675,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
STEM,8390676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
STEM,8390676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
LINER,8390677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LINER,8390677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
LINER,8390678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER,8390678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
CAGE,8390679,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,8939.50,20284.35,percent of total billed charges,
CAGE,8390679,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,7984.80,20284.35,percent of total billed charges,
SCREW,8390680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8390680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8390681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8390681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8390682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8390682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,8390683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8390683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,8390684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8390684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,8390685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,8390685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
PLATE,8392462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3712.24000,1076.55000,Aetna,First Health,,3036.61,,,,,,,1338.26,3036.61,percent of total billed charges,
PLATE,8392462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3712.24000,1076.55000,Aetna,First Health,,3036.61,,,,,,,1195.34,3036.61,percent of total billed charges,
PLATE,8392464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.54000,989.64000,Aetna,First Health,,2791.46,,,,,,,1230.22,2791.46,percent of total billed charges,
PLATE,8392464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.54000,989.64000,Aetna,First Health,,2791.46,,,,,,,1098.84,2791.46,percent of total billed charges,
CAGE,8392466,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8392466,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
INSERT,8392468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8392468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COIL,8392470,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,First Health,,4779.78,,,,,,,2106.49,4779.78,percent of total billed charges,
COIL,8392470,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,First Health,,4779.78,,,,,,,1881.53,4779.78,percent of total billed charges,
LINER,8392501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8392501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
HEAD FEMORAL,8392502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
HEAD FEMORAL,8392502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW,8392550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8392550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
PLATE,8392504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5447.54000,1579.79000,Aetna,First Health,,4456.09,,,,,,,1963.84,4456.09,percent of total billed charges,
PLATE,8392504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5447.54000,1579.79000,Aetna,First Health,,4456.09,,,,,,,1754.11,4456.09,percent of total billed charges,
PLATE,8392505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3514.00000,1019.06000,Aetna,First Health,,2874.45,,,,,,,1266.80,2874.45,percent of total billed charges,
PLATE,8392505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3514.00000,1019.06000,Aetna,First Health,,2874.45,,,,,,,1131.51,2874.45,percent of total billed charges,
SHEATH,8392506,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
SHEATH,8392506,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
K WIRE,8392551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
K WIRE,8392551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,8392553,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8392553,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
CAGE,8392554,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,6529.56,14816.02,percent of total billed charges,
CAGE,8392554,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,5832.23,14816.02,percent of total billed charges,
SCREW,8392555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8392555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
COMPONENT GLENOID,8392547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,2149.26,4876.83,percent of total billed charges,
COMPONENT GLENOID,8392547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,1919.73,4876.83,percent of total billed charges,
BASEPLATE,8392549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
BASEPLATE,8392549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
MESH,8392558,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1335.34000,387.25000,Aetna,First Health,,1092.31,,,,,,,481.39,1092.31,percent of total billed charges,
MESH,8392558,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1335.34000,387.25000,Aetna,First Health,,1092.31,,,,,,,429.98,1092.31,percent of total billed charges,
MESH,8392559,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1335.33000,387.25000,Aetna,First Health,,1092.30,,,,,,,481.39,1092.30,percent of total billed charges,
MESH,8392559,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1335.33000,387.25000,Aetna,First Health,,1092.30,,,,,,,429.98,1092.30,percent of total billed charges,
MESH,8392560,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1427.45000,413.96000,Aetna,First Health,,1167.65,,,,,,,514.60,1167.65,percent of total billed charges,
MESH,8392560,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1427.45000,413.96000,Aetna,First Health,,1167.65,,,,,,,459.64,1167.65,percent of total billed charges,
MESH,8392561,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1427.45000,413.96000,Aetna,First Health,,1167.65,,,,,,,514.60,1167.65,percent of total billed charges,
MESH,8392561,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1427.45000,413.96000,Aetna,First Health,,1167.65,,,,,,,459.64,1167.65,percent of total billed charges,
INSERT,8392727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8392727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
WEDGE,8392728,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
WEDGE,8392728,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
INSERT,8392729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8392729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8392730,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8392730,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8392731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8392731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,8392732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,703.26000,203.95000,Aetna,First Health,,575.27,,,,,,,253.53,575.27,percent of total billed charges,
PLATE,8392732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,703.26000,203.95000,Aetna,First Health,,575.27,,,,,,,226.45,575.27,percent of total billed charges,
SCREW,8392725,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8392725,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8392726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,6069.92,13773.08,percent of total billed charges,
SCREW,8392726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,First Health,,13773.08,,,,,,,5421.68,13773.08,percent of total billed charges,
SCREW,8394306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8394306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CAGE,8394308,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8394308,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
SCREW,8394310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8394310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
STENT,8394338,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,463.74000,134.48000,Aetna,First Health,,379.34,,,,,,,167.18,379.34,percent of total billed charges,
STENT,8394338,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,463.74000,134.48000,Aetna,First Health,,379.34,,,,,,,149.32,379.34,percent of total billed charges,
CATHETER,8394385,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
CATHETER,8394385,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
CATHETER,8394386,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
CATHETER,8394386,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
CAGE,8394350,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8394350,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
CAGE,8394351,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8394351,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
SCREW,8394377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8394377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
SCREW,8394378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8394378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
PLATE,8394379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
PLATE,8394379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SCREW,8394380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8394380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
INSERT,8394381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8394381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
LINER,8394382,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER,8394382,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
LINER,8394383,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LINER,8394383,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
SCREW,8394384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,8394384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
ROD SPINAL,8394483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,289.57,657.06,percent of total billed charges,
ROD SPINAL,8394483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,258.65,657.06,percent of total billed charges,
SCREW,8394484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,8394484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
PLATE,8394485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13755.00000,3988.95000,Aetna,First Health,,11251.59,,,,,,,4958.68,11251.59,percent of total billed charges,
PLATE,8394485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13755.00000,3988.95000,Aetna,First Health,,11251.59,,,,,,,4429.11,11251.59,percent of total billed charges,
SCREW,8394486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,8394486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SCREW,8396440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8396440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
ROD SPINAL,8396441,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8396441,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
SCREW,8396442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8396442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
CONNECTOR CROSS,8396447,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CONNECTOR CROSS,8396447,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
CAP LOCKING,8396448,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
CAP LOCKING,8396448,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
ROD SPINAL,8396449,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8396449,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
HEAD FEMORAL,8396450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
HEAD FEMORAL,8396450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
TENDON,8396598,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,First Health,,7901.88,,,,,,,3482.43,7901.88,percent of total billed charges,
TENDON,8396598,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,First Health,,7901.88,,,,,,,3110.52,7901.88,percent of total billed charges,
ANCHOR IN KIT,8396599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3850.00000,1116.50000,Aetna,First Health,,3149.30,,,,,,,1387.92,3149.30,percent of total billed charges,
ANCHOR IN KIT,8396599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3850.00000,1116.50000,Aetna,First Health,,3149.30,,,,,,,1239.70,3149.30,percent of total billed charges,
INSERT,8396655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8396655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8396656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.25000,2383.58000,Aetna,First Health,,6723.35,,,,,,,2963.04,6723.35,percent of total billed charges,
SCREW,8396656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.25000,2383.58000,Aetna,First Health,,6723.35,,,,,,,2646.60,6723.35,percent of total billed charges,
SCREW,8396657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8396657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
STENT,8396658,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,First Health,,41219.35,,,,,,,18165.74,41219.35,percent of total billed charges,
STENT,8396658,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,First Health,,41219.35,,,,,,,16225.71,41219.35,percent of total billed charges,
STEM,8396659,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,First Health,,9385.08,,,,,,,4136.09,9385.08,percent of total billed charges,
STEM,8396659,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,First Health,,9385.08,,,,,,,3694.37,9385.08,percent of total billed charges,
TRAY HUMERAL,8396660,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
TRAY HUMERAL,8396660,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
SCREW,8396661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
SCREW,8396661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
SCREW,8396662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
SCREW,8396662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
SCREW,8396664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8396664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
PLATE,8396665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2339.40000,678.43000,Aetna,First Health,,1913.63,,,,,,,843.35,1913.63,percent of total billed charges,
PLATE,8396665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2339.40000,678.43000,Aetna,First Health,,1913.63,,,,,,,753.29,1913.63,percent of total billed charges,
ROD SPINAL,8396667,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8396667,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
CAGE,8396758,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8396758,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
SCREW,8398187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8398187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW,8398188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW,8398188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
ROD SPINAL,8398189,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8398189,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
ROD SPINAL,8398190,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8398190,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
PLATE,8398191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,8398191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CAGE,8398192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
CAGE,8398192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
INSERT,8398193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8398193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT FEMORAL,8398194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
COMPONENT FEMORAL,8398194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8398195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8398195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8398265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8398265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8398266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8398266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
STEM,8398247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8398247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
INSERT,8398248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8398248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
WEDGE,8398249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8398249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
TENDON,8398291,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8280.00000,2401.20000,Aetna,First Health,,6773.04,,,,,,,2984.94,6773.04,percent of total billed charges,
TENDON,8398291,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8280.00000,2401.20000,Aetna,First Health,,6773.04,,,,,,,2666.16,6773.04,percent of total billed charges,
WEDGE,8398290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8398290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
WEDGE,8398440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
WEDGE,8398440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
NAIL,8400273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14143.50000,4101.62000,Aetna,First Health,,11569.38,,,,,,,5098.73,11569.38,percent of total billed charges,
NAIL,8400273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14143.50000,4101.62000,Aetna,First Health,,11569.38,,,,,,,4554.21,11569.38,percent of total billed charges,
PIN,8400275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,166.10,376.89,percent of total billed charges,
PIN,8400275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,First Health,,376.89,,,,,,,148.36,376.89,percent of total billed charges,
ROD SPINAL,8400277,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD SPINAL,8400277,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,8400279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,8400279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
WEDGE,8400404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
WEDGE,8400404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
WEDGE,8400406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6114.33000,1773.16000,Aetna,First Health,,5001.52,,,,,,,2204.22,5001.52,percent of total billed charges,
WEDGE,8400406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6114.33000,1773.16000,Aetna,First Health,,5001.52,,,,,,,1968.81,5001.52,percent of total billed charges,
INSERT,8400408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2956.98,6709.60,percent of total billed charges,
INSERT,8400408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,First Health,,6709.60,,,,,,,2641.19,6709.60,percent of total billed charges,
INSERT,8400410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9426.00000,2733.54000,Aetna,First Health,,7710.47,,,,,,,3398.07,7710.47,percent of total billed charges,
INSERT,8400410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9426.00000,2733.54000,Aetna,First Health,,7710.47,,,,,,,3035.17,7710.47,percent of total billed charges,
SCREW,8400402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8400402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
CAGE,8400530,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8400530,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8400531,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2669.14,6056.47,percent of total billed charges,
CAGE,8400531,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,First Health,,6056.47,,,,,,,2384.09,6056.47,percent of total billed charges,
STENT GRAFT,8400532,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,8400532,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
INSERT,8400721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8400721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
COIL,8400537,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6182.75000,1793.00000,Aetna,First Health,,5057.49,,,,,,,2228.88,5057.49,percent of total billed charges,
COIL,8400537,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6182.75000,1793.00000,Aetna,First Health,,5057.49,,,,,,,1990.85,5057.49,percent of total billed charges,
HEAD RADIAL,8400539,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14803.14000,4292.91000,Aetna,First Health,,12108.97,,,,,,,5336.53,12108.97,percent of total billed charges,
HEAD RADIAL,8400539,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14803.14000,4292.91000,Aetna,First Health,,12108.97,,,,,,,4766.61,12108.97,percent of total billed charges,
COMPONENT FEMORAL,8400540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4515.97,10247.05,percent of total billed charges,
COMPONENT FEMORAL,8400540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,First Health,,10247.05,,,,,,,4033.68,10247.05,percent of total billed charges,
CAGE,8400528,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8400528,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,8400529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,8400529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
WEDGE,8400587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8400587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
SCREW,8400589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8400589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,8400591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8400591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
WEDGE,8400711,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,8400711,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
PLATE,8400712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5352.52000,1552.23000,Aetna,First Health,,4378.36,,,,,,,1929.58,4378.36,percent of total billed charges,
PLATE,8400712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5352.52000,1552.23000,Aetna,First Health,,4378.36,,,,,,,1723.51,4378.36,percent of total billed charges,
COMPONENT FEMORAL,8400715,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8400715,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
TAK,8400716,CDM,278,RC,,,,,facility,inpatient,,,344.38000,99.87000,Aetna,First Health,,281.70,,,,,,,124.15,281.70,percent of total billed charges,
TAK,8400716,CDM,278,RC,,,,,facility,outpatient,,,344.38000,99.87000,Aetna,First Health,,281.70,,,,,,,110.89,281.70,percent of total billed charges,
TAK,8400717,CDM,278,RC,,,,,facility,inpatient,,,518.94000,150.49000,Aetna,First Health,,424.49,,,,,,,187.08,424.49,percent of total billed charges,
TAK,8400717,CDM,278,RC,,,,,facility,outpatient,,,518.94000,150.49000,Aetna,First Health,,424.49,,,,,,,167.10,424.49,percent of total billed charges,
PLATE,8400718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,3076.60,6981.02,percent of total billed charges,
PLATE,8400718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,2748.03,6981.02,percent of total billed charges,
STEM FEMORAL,8400719,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5787.51,13132.28,percent of total billed charges,
STEM FEMORAL,8400719,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5169.43,13132.28,percent of total billed charges,
HEAD FEMORAL,8400720,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5007.10000,1452.06000,Aetna,First Health,,4095.81,,,,,,,1805.06,4095.81,percent of total billed charges,
HEAD FEMORAL,8400720,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5007.10000,1452.06000,Aetna,First Health,,4095.81,,,,,,,1612.29,4095.81,percent of total billed charges,
INSERT,8400722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8400722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CATHETER,8400812,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2130.00000,617.70000,Aetna,First Health,,1742.34,,,,,,,767.87,1742.34,percent of total billed charges,
CATHETER,8400812,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2130.00000,617.70000,Aetna,First Health,,1742.34,,,,,,,685.86,1742.34,percent of total billed charges,
ROD SPINAL,8400814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8400814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8400815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
SCREW,8400815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
SCREW,8400816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8400816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,8400817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8400817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,8400818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8400818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
GUIDEWIRE,8400855,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,364.47000,105.70000,Aetna,First Health,,298.14,,,,,,,131.39,298.14,percent of total billed charges,
GUIDEWIRE,8400855,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,364.47000,105.70000,Aetna,First Health,,298.14,,,,,,,117.36,298.14,percent of total billed charges,
SCREW,8400857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8400857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
BREAST IMPLANT,8400864,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1432.09,3249.51,percent of total billed charges,
BREAST IMPLANT,8400864,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,764.47,3249.51,percent of total billed charges,
BREAST IMPLANT,8400865,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1432.09,3249.51,percent of total billed charges,
BREAST IMPLANT,8400865,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,764.47,3249.51,percent of total billed charges,
BREAST IMPLANT,8400866,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1432.09,3249.51,percent of total billed charges,
BREAST IMPLANT,8400866,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,764.47,3249.51,percent of total billed charges,
LINER,8400859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LINER,8400859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
LINER,8400860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER,8400860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,8400861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,8400861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
ROD SPINAL,8400862,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,289.57,657.06,percent of total billed charges,
ROD SPINAL,8400862,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,First Health,,657.06,,,,,,,258.65,657.06,percent of total billed charges,
ROD SPINAL,8400863,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8400863,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
GRAFT BONE,8400867,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,2940.04000,852.61000,Aetna,First Health,,2404.95,,,,,,,1059.88,2404.95,percent of total billed charges,
GRAFT BONE,8400867,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,2940.04000,852.61000,Aetna,First Health,,2404.95,,,,,,,946.69,2404.95,percent of total billed charges,
SCREW,8400986,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.25000,2383.58000,Aetna,First Health,,6723.35,,,,,,,2963.04,6723.35,percent of total billed charges,
SCREW,8400986,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.25000,2383.58000,Aetna,First Health,,6723.35,,,,,,,2646.60,6723.35,percent of total billed charges,
ROD SPINAL,8400987,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1374.05,3117.81,percent of total billed charges,
ROD SPINAL,8400987,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,First Health,,3117.81,,,,,,,1227.30,3117.81,percent of total billed charges,
ROD SPINAL,8400988,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8400988,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SCREW,8400989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
SCREW,8400989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
SCREW,8400991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,8400991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,8400994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,8400994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
COMPONENT ANKLE,8400995,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18910.00000,5483.90000,Aetna,First Health,,15468.38,,,,,,,6817.06,15468.38,percent of total billed charges,
COMPONENT ANKLE,8400995,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18910.00000,5483.90000,Aetna,First Health,,15468.38,,,,,,,6089.02,15468.38,percent of total billed charges,
SCREW,8400990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8400990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
CONNECTOR SHUNT,8402284,CDM,278,RC,,,,,facility,inpatient,,,1528.36000,443.22000,Aetna,First Health,,1250.20,,,,,,,550.97,1250.20,percent of total billed charges,
CONNECTOR SHUNT,8402284,CDM,278,RC,,,,,facility,outpatient,,,1528.36000,443.22000,Aetna,First Health,,1250.20,,,,,,,492.13,1250.20,percent of total billed charges,
STEM,8402286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8402286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CONNECTOR SPINAL,8402290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
CONNECTOR SPINAL,8402290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
ROD SPINAL,8402292,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8402292,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SHELL,8402503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,8402503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
INSERT,8402496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
INSERT,8402496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
STEM EXT,8402498,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM EXT,8402498,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
INSERT,8402500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8402500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
PLATE,8402505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
PLATE,8402505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
CAGE,8402507,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8402507,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
CAGE,8402509,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8402509,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
INSERT,8402511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8402511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BASEPLATE,8402513,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
BASEPLATE,8402513,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
PLATE,8402516,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,605.93,1374.89,percent of total billed charges,
PLATE,8402516,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,First Health,,1374.89,,,,,,,541.22,1374.89,percent of total billed charges,
INSERT,8402775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8402775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
TRAY HUMERAL,8402777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
TRAY HUMERAL,8402777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
LINER,8402779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
LINER,8402779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
HEAD HUMERAL,8402781,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
HEAD HUMERAL,8402781,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
HEAD FEMORAL,8402783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,8402783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
BONE SUBSTITUTE,7902586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13200.00000,3828.00000,Aetna,First Health,,10797.60,,,,,,,4758.60,10797.60,percent of total billed charges,
BONE SUBSTITUTE,7902586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13200.00000,3828.00000,Aetna,First Health,,10797.60,,,,,,,4250.40,10797.60,percent of total billed charges,
LINER,8402793,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LINER,8402793,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
LINER,8402794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER,8402794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,8402795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,209.27,474.85,percent of total billed charges,
SCREW,8402795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,186.92,474.85,percent of total billed charges,
SCREW,8402796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,209.27,474.85,percent of total billed charges,
SCREW,8402796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,First Health,,474.85,,,,,,,186.92,474.85,percent of total billed charges,
SCREW SPINAL,7703247,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1432.09,3249.51,percent of total billed charges,
SCREW SPINAL,7703247,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1279.14,3249.51,percent of total billed charges,
PLATE,8402935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,458.41,1040.17,percent of total billed charges,
PLATE,8402935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,409.46,1040.17,percent of total billed charges,
PLATE,8402937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,458.41,1040.17,percent of total billed charges,
PLATE,8402937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,409.46,1040.17,percent of total billed charges,
TRAY HUMERAL,8402938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
TRAY HUMERAL,8402938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
STENT GRAFT,8402940,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5676.97,12881.45,percent of total billed charges,
STENT GRAFT,8402940,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,First Health,,12881.45,,,,,,,5070.69,12881.45,percent of total billed charges,
STEM,8402942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,First Health,,9385.08,,,,,,,4136.09,9385.08,percent of total billed charges,
STEM,8402942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,First Health,,9385.08,,,,,,,3694.37,9385.08,percent of total billed charges,
WEDGE,8402943,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8402943,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
BASEPLATE,8402944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
BASEPLATE,8402944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
COMPONENT FEMORAL,8402945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,7273.09,16503.15,percent of total billed charges,
COMPONENT FEMORAL,8402945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,6496.35,16503.15,percent of total billed charges,
STEM EXTENSION,8402946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM EXTENSION,8402946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
INSERT,8402947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8402947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8402948,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8402948,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,8402949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8402949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
SCREW,8402950,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8402950,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
SCREW,8402951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8402951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
PLATE,8402969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,First Health,,7023.35,,,,,,,3095.25,7023.35,percent of total billed charges,
PLATE,8402969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,First Health,,7023.35,,,,,,,2764.69,7023.35,percent of total billed charges,
HEAD HUMERAL,8402970,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
HEAD HUMERAL,8402970,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
STEM,8402971,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,8402971,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
PLATE,8402974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
PLATE,8402974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,8402975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8402975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8402976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8402976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8402977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8402977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8402978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,8402978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
PLATE,8402979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4063.50000,1178.42000,Aetna,First Health,,3323.94,,,,,,,1464.89,3323.94,percent of total billed charges,
PLATE,8402979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4063.50000,1178.42000,Aetna,First Health,,3323.94,,,,,,,1308.45,3323.94,percent of total billed charges,
SCREW,8403159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8403159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8403161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8403161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
INSERT,8403163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8403163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8402972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8705.16000,2524.50000,Aetna,First Health,,7120.82,,,,,,,3138.21,7120.82,percent of total billed charges,
PLATE,8402972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8705.16000,2524.50000,Aetna,First Health,,7120.82,,,,,,,2803.06,7120.82,percent of total billed charges,
INSERT,8402973,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8402973,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8403248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8403248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,8403249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8403249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
INSERT,8403250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8403250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PIN,8403251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PIN,8403251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
CAGE,8403196,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8403196,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
CAGE,8403197,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8403197,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
SCREW,8403198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8403198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8403300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8403300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8403199,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8403199,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
LINER,8403201,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,8403201,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CAGE,8403202,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8403202,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
SCREW,8403474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW,8403474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
SCREW,8403773,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8403773,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
LINER,8403203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LINER,8403203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT FEMORAL,8403257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8403257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,8403472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9589.20000,2780.87000,Aetna,First Health,,7843.97,,,,,,,3456.91,7843.97,percent of total billed charges,
PLATE,8403472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9589.20000,2780.87000,Aetna,First Health,,7843.97,,,,,,,3087.72,7843.97,percent of total billed charges,
SCREW,8403475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8403475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,8403476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8403476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SHELL,8403477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
SHELL,8403477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
COMPONENT FEMORAL,8403478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,8403478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
INSERT,8403479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8403479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
LINER,8403480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8403480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
BASEPLATE,8403632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,8403632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
COMPONENT FEMORAL,8403633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,7273.09,16503.15,percent of total billed charges,
COMPONENT FEMORAL,8403633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,6496.35,16503.15,percent of total billed charges,
INSERT,8403634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8403634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BASEPLATE,8403635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
BASEPLATE,8403635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
WEDGE,8403636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
WEDGE,8403636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
WEDGE,8403637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8403637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8403638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8403638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8403639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8403639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8403640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8403640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
STEM EXT,8403641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM EXT,8403641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
STEM EXT,8403642,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM EXT,8403642,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
SCREW,8403643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW,8403643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
SCREW,8403644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW,8403644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
ROD SPINAL,8403645,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8403645,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
ROD SPINAL,8403646,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8403646,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
INSERT,8403647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8403647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8403648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8403648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
PLATE,8403738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,8403738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
CENTRALIZER STEM,8403955,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
CENTRALIZER STEM,8403955,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
STEM,8403957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
STEM,8403957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
ANCHOR ACHILLES,8403959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,3076.60,6981.02,percent of total billed charges,
ANCHOR ACHILLES,8403959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,2748.03,6981.02,percent of total billed charges,
STENT,8403961,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STENT,8403961,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
STENT,8403962,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
STENT,8403962,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
STENT,8403963,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
STENT,8403963,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
STENT,8403964,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
STENT,8403964,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
STENT,8403965,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
STENT,8403965,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
STENT,8403966,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
STENT,8403966,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
CAGE,8404338,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8404338,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
BOLT CAGE,8404339,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
BOLT CAGE,8404339,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
CAGE,8404340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,8404340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
COMPONENT FEMORAL,8404343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8404343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT TIBIAL,8404344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
COMPONENT TIBIAL,8404344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
LINER,8404336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER,8404336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
LINER,8404337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LINER,8404337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
INSERT,8404429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8404429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HEAD FEMORAL,8404440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
HEAD FEMORAL,8404440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
SCREW,8404441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,8404441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
CAGE,8404442,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,8404442,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
CAGE,8404443,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,6529.56,14816.02,percent of total billed charges,
CAGE,8404443,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,5832.23,14816.02,percent of total billed charges,
CATHETER IN KIT,8244060,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,3126.76000,906.76000,Aetna,First Health,,2557.69,,,,,,,1127.20,2557.69,percent of total billed charges,
CATHETER IN KIT,8244060,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,3126.76000,906.76000,Aetna,First Health,,2557.69,,,,,,,1006.82,2557.69,percent of total billed charges,
KWIRE,8404563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
KWIRE,8404563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
SCREW,8404565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,964.29,2188.05,percent of total billed charges,
SCREW,8404565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,861.31,2188.05,percent of total billed charges,
SCREW,8404567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,964.29,2188.05,percent of total billed charges,
SCREW,8404567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,861.31,2188.05,percent of total billed charges,
STEM,8404569,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9378.00000,2719.62000,Aetna,First Health,,7671.20,,,,,,,3380.77,7671.20,percent of total billed charges,
STEM,8404569,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9378.00000,2719.62000,Aetna,First Health,,7671.20,,,,,,,3019.72,7671.20,percent of total billed charges,
WEDGE,8404571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4014.50000,1164.20000,Aetna,First Health,,3283.86,,,,,,,1447.23,3283.86,percent of total billed charges,
WEDGE,8404571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4014.50000,1164.20000,Aetna,First Health,,3283.86,,,,,,,1292.67,3283.86,percent of total billed charges,
COMPONENT PATELLA,8404573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,8404573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
INSERT,8404575,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8404575,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8404577,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8404577,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,7969163,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,7969163,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CAGE,7986867,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
CAGE,7986867,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
CAGE,7968120,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7968120,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,7968231,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1254.66,2846.91,percent of total billed charges,
CAGE,7968231,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1120.67,2846.91,percent of total billed charges,
ROD SPINAL,7968235,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,7968235,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
SCREW,7968238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,7968238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW,7974663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,7974663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
BALLOON CATHETER,7975102,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
BALLOON CATHETER,7975102,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
BALLOON CATHETER,7975103,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975103,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975106,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975106,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7968511,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7968511,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975109,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975109,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
BALLOON CATHETER,7975110,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,7975110,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
SCREW,8404628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8404628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
HEAD FEMORAL,7974090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,7974090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
NAIL,7983040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5971.00000,1731.59000,Aetna,First Health,,4884.28,,,,,,,2152.55,4884.28,percent of total billed charges,
NAIL,7983040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5971.00000,1731.59000,Aetna,First Health,,4884.28,,,,,,,1922.66,4884.28,percent of total billed charges,
SCREW,7976361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
SCREW,7976361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
SCREW,7982826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,7982826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,7982784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7982784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
SCREW,7982785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,7982785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
COLLAGEN,7987520,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,4004.53000,1161.31000,Aetna,First Health,,3275.71,,,,,,,1443.63,3275.71,percent of total billed charges,
COLLAGEN,7987520,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,4004.53000,1161.31000,Aetna,First Health,,3275.71,,,,,,,1289.46,3275.71,percent of total billed charges,
SCREW,7968700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,728.50,1653.01,percent of total billed charges,
SCREW,7968700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,650.70,1653.01,percent of total billed charges,
SCREW,7968701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,728.50,1653.01,percent of total billed charges,
SCREW,7968701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,650.70,1653.01,percent of total billed charges,
SCREW,7968702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,728.50,1653.01,percent of total billed charges,
SCREW,7968702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,First Health,,1653.01,,,,,,,650.70,1653.01,percent of total billed charges,
SCREW,7968704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2142.40000,621.30000,Aetna,First Health,,1752.48,,,,,,,772.34,1752.48,percent of total billed charges,
SCREW,7968704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2142.40000,621.30000,Aetna,First Health,,1752.48,,,,,,,689.85,1752.48,percent of total billed charges,
SCREW,7969008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7969008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
SCREW,7969004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7969004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
SCREW,7969009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7969009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
SCREW,7969002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7969002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
SCREW,7969003,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7969003,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
SCREW,7969005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7969005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
SCREW,7969006,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,675.89,1533.65,percent of total billed charges,
SCREW,7969006,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,First Health,,1533.65,,,,,,,603.71,1533.65,percent of total billed charges,
NAIL,7969018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7969018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
NAIL,7969019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7969019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
NAIL,7969020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7969020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
NAIL,7969021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7969021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
NAIL,7969022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1386.23,3145.46,percent of total billed charges,
NAIL,7969022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,First Health,,3145.46,,,,,,,1238.19,3145.46,percent of total billed charges,
SCREW,7969026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,First Health,,2883.04,,,,,,,1270.58,2883.04,percent of total billed charges,
SCREW,7969026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,First Health,,2883.04,,,,,,,1134.89,2883.04,percent of total billed charges,
ROD SPINAL,7969027,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
ROD SPINAL,7969027,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
NAIL,7982827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7982827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7980738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7980738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7974190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7974190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7987617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7987617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7972068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7972068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
NAIL,7978326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1706.49,3872.15,percent of total billed charges,
NAIL,7978326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,First Health,,3872.15,,,,,,,1524.24,3872.15,percent of total billed charges,
SCREW,7972069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,7972069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
CATHETER,7980593,CDM,278,RC,C1714,HCPCS,,,facility,inpatient,,,13185.00000,3823.65000,Aetna,First Health,,10785.33,,,,,,,4753.19,10785.33,percent of total billed charges,
CATHETER,7980593,CDM,278,RC,C1714,HCPCS,,,facility,outpatient,,,13185.00000,3823.65000,Aetna,First Health,,10785.33,,,,,,,4245.57,10785.33,percent of total billed charges,
STENT GRAFT,7969490,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7969490,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,7969491,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,7969491,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
ROD SPINAL,7969633,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
ROD SPINAL,7969633,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
ROD SPINAL,7969545,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
ROD SPINAL,7969545,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
CAGE,7974698,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
CAGE,7974698,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
FEMORAL CONE,7982854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
FEMORAL CONE,7982854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
FEMORAL CONE,7969721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
FEMORAL CONE,7969721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
FEMORAL CONE,7974184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
FEMORAL CONE,7974184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
FEMORAL HEAD,7978413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1855.02,4209.18,percent of total billed charges,
FEMORAL HEAD,7978413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,First Health,,4209.18,,,,,,,1656.92,4209.18,percent of total billed charges,
ROD SPINAL,7969745,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
ROD SPINAL,7969745,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
ROD SPINAL,7981169,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7981169,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
ROD SPINAL,7971891,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7971891,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
ROD SPINAL,7971894,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7971894,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
SCREW,7972281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7972281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7974851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7974851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7971892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7971892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7986449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7986449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7974857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7974857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7974858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7974858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7971893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7971893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7986448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7986448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7969877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7969877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW,7971874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,7971874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SPACER SPINAL,7969834,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
SPACER SPINAL,7969834,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
SCREW,7974762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7974762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7974761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7974761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7974763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7974763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,7972130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,7972130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
CAGE,7972131,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,7972131,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
CAGE,7972183,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972183,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CAGE,7972184,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972184,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CAGE,7972185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CAGE,7972186,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972186,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CAGE,7972187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CAGE,7972188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CAGE,7972189,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972189,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CAGE,7972178,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972178,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CAGE,7972179,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972179,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CAGE,7972180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CAGE,7972181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CAGE,7972181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
ROD SPINAL,7972279,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7972279,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
ROD SPINAL,7972226,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7972226,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
ROD SPINAL,7972227,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,7972227,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
WEDGE,7972229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,First Health,,3717.89,,,,,,,1638.51,3717.89,percent of total billed charges,
WEDGE,7972229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,First Health,,3717.89,,,,,,,1463.52,3717.89,percent of total billed charges,
WEDGE,7972230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,First Health,,3717.89,,,,,,,1638.51,3717.89,percent of total billed charges,
WEDGE,7972230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,First Health,,3717.89,,,,,,,1463.52,3717.89,percent of total billed charges,
WEDGE,7972231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,First Health,,3717.89,,,,,,,1638.51,3717.89,percent of total billed charges,
WEDGE,7972231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,First Health,,3717.89,,,,,,,1463.52,3717.89,percent of total billed charges,
WEDGE,7972235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3892.18000,1128.73000,Aetna,First Health,,3183.80,,,,,,,1403.13,3183.80,percent of total billed charges,
WEDGE,7972235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3892.18000,1128.73000,Aetna,First Health,,3183.80,,,,,,,1253.28,3183.80,percent of total billed charges,
WEDGE,7972236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3892.18000,1128.73000,Aetna,First Health,,3183.80,,,,,,,1403.13,3183.80,percent of total billed charges,
WEDGE,7972236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3892.18000,1128.73000,Aetna,First Health,,3183.80,,,,,,,1253.28,3183.80,percent of total billed charges,
WEDGE,7972237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3892.18000,1128.73000,Aetna,First Health,,3183.80,,,,,,,1403.13,3183.80,percent of total billed charges,
WEDGE,7972237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3892.18000,1128.73000,Aetna,First Health,,3183.80,,,,,,,1253.28,3183.80,percent of total billed charges,
BREAST IMPLANT,7972264,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BREAST IMPLANT,7972264,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BREAST IMPLANT,7972265,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BREAST IMPLANT,7972265,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BREAST IMPLANT,7972266,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BREAST IMPLANT,7972266,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BREAST IMPLANT,7972267,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
BREAST IMPLANT,7972267,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
SCREW,7972582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,7972582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
ROD SPINAL,7980584,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,7980584,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
STENT GRAFT,7974593,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,7974593,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
PLATE,8405125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6381.73000,1850.70000,Aetna,First Health,,5220.26,,,,,,,2300.61,5220.26,percent of total billed charges,
PLATE,8405125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6381.73000,1850.70000,Aetna,First Health,,5220.26,,,,,,,2054.92,5220.26,percent of total billed charges,
CAGE,8404581,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
CAGE,8404581,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
STEM,8404582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8404582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
ANCHOR,8404583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1904.00000,552.16000,Aetna,First Health,,1557.47,,,,,,,686.39,1557.47,percent of total billed charges,
ANCHOR,8404583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1904.00000,552.16000,Aetna,First Health,,1557.47,,,,,,,613.09,1557.47,percent of total billed charges,
ROD SPINAL,8404647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
ROD SPINAL,8404647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
SCREW,8404687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8404687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8404689,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8404689,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
SCREW,8404690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8404690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
SCREW,8404691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,8404691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,8404466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,416.05000,120.65000,Aetna,First Health,,340.33,,,,,,,149.99,340.33,percent of total billed charges,
SCREW,8404466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,416.05000,120.65000,Aetna,First Health,,340.33,,,,,,,133.97,340.33,percent of total billed charges,
PLATE,8404467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5974.36000,1732.56000,Aetna,First Health,,4887.03,,,,,,,2153.76,4887.03,percent of total billed charges,
PLATE,8404467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5974.36000,1732.56000,Aetna,First Health,,4887.03,,,,,,,1923.74,4887.03,percent of total billed charges,
PLATE,8404468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1542.40000,447.30000,Aetna,First Health,,1261.68,,,,,,,556.04,1261.68,percent of total billed charges,
PLATE,8404468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1542.40000,447.30000,Aetna,First Health,,1261.68,,,,,,,496.65,1261.68,percent of total billed charges,
PLATE,8404469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.92000,466.01000,Aetna,First Health,,1314.46,,,,,,,579.29,1314.46,percent of total billed charges,
PLATE,8404469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.92000,466.01000,Aetna,First Health,,1314.46,,,,,,,517.43,1314.46,percent of total billed charges,
PLATE,8404470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1790.44000,519.23000,Aetna,First Health,,1464.58,,,,,,,645.45,1464.58,percent of total billed charges,
PLATE,8404470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1790.44000,519.23000,Aetna,First Health,,1464.58,,,,,,,576.52,1464.58,percent of total billed charges,
PLATE,8404471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2319.40000,672.63000,Aetna,First Health,,1897.27,,,,,,,836.14,1897.27,percent of total billed charges,
PLATE,8404471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2319.40000,672.63000,Aetna,First Health,,1897.27,,,,,,,746.85,1897.27,percent of total billed charges,
PLATE,8404472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1949.56000,565.37000,Aetna,First Health,,1594.74,,,,,,,702.82,1594.74,percent of total billed charges,
PLATE,8404472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1949.56000,565.37000,Aetna,First Health,,1594.74,,,,,,,627.76,1594.74,percent of total billed charges,
PLATE,8404473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7750.26000,2247.58000,Aetna,First Health,,6339.71,,,,,,,2793.97,6339.71,percent of total billed charges,
PLATE,8404473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7750.26000,2247.58000,Aetna,First Health,,6339.71,,,,,,,2495.58,6339.71,percent of total billed charges,
SCREW,8404474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2442.00000,708.18000,Aetna,First Health,,1997.56,,,,,,,880.34,1997.56,percent of total billed charges,
SCREW,8404474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2442.00000,708.18000,Aetna,First Health,,1997.56,,,,,,,786.32,1997.56,percent of total billed charges,
SCREW,8404475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2541.00000,736.89000,Aetna,First Health,,2078.54,,,,,,,916.03,2078.54,percent of total billed charges,
SCREW,8404475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2541.00000,736.89000,Aetna,First Health,,2078.54,,,,,,,818.20,2078.54,percent of total billed charges,
SCREW,8404476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2541.00000,736.89000,Aetna,First Health,,2078.54,,,,,,,916.03,2078.54,percent of total billed charges,
SCREW,8404476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2541.00000,736.89000,Aetna,First Health,,2078.54,,,,,,,818.20,2078.54,percent of total billed charges,
SCREW,8404477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,39.20,88.94,percent of total billed charges,
SCREW,8404477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,First Health,,88.94,,,,,,,35.01,88.94,percent of total billed charges,
PLATE,8404478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8404478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,8404479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8404479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,8404480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE,8404481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
SCREW,8404482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8404482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
PLATE,8404483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8404483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,8404484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE,8404485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE,8404486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE,8404487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8404487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,8404488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8404488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,8404489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8404489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,8404490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8404490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PLATE,8404491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE,8404492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE,8404493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE,8404494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE,8404495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE,8404496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE,8404496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE,8404497,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1542.49,3500.02,percent of total billed charges,
PLATE,8404497,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1377.76,3500.02,percent of total billed charges,
PLATE,8404498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1542.49,3500.02,percent of total billed charges,
PLATE,8404498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1377.76,3500.02,percent of total billed charges,
PLATE,8404499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1542.49,3500.02,percent of total billed charges,
PLATE,8404499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1377.76,3500.02,percent of total billed charges,
PLATE,8404500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1542.49,3500.02,percent of total billed charges,
PLATE,8404500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1377.76,3500.02,percent of total billed charges,
PLATE,8404501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1542.49,3500.02,percent of total billed charges,
PLATE,8404501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1377.76,3500.02,percent of total billed charges,
PLATE,8404502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1542.49,3500.02,percent of total billed charges,
PLATE,8404502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1377.76,3500.02,percent of total billed charges,
PLATE,8404503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5378.49000,1559.76000,Aetna,First Health,,4399.60,,,,,,,1938.95,4399.60,percent of total billed charges,
PLATE,8404503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5378.49000,1559.76000,Aetna,First Health,,4399.60,,,,,,,1731.87,4399.60,percent of total billed charges,
SCREW,8404504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8404504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8404505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8404505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
ROD SPINAL,8404765,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8404765,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
CAGE,8404766,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,8939.50,20284.35,percent of total billed charges,
CAGE,8404766,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,First Health,,20284.35,,,,,,,7984.80,20284.35,percent of total billed charges,
SHELL,8404767,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,8404767,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
NAIL,8404768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8404768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
SCREW,8404769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,8404769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,8404770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,8404770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
ANCHOR,8404771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,908.10,2060.54,percent of total billed charges,
ANCHOR,8404771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,811.12,2060.54,percent of total billed charges,
PLATE,8404772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
PLATE,8404772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
SCREW,8405132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8405132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
SCREW,8404773,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4453.23000,1291.44000,Aetna,First Health,,3642.74,,,,,,,1605.39,3642.74,percent of total billed charges,
SCREW,8404773,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4453.23000,1291.44000,Aetna,First Health,,3642.74,,,,,,,1433.94,3642.74,percent of total billed charges,
SCREW,8404774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4453.23000,1291.44000,Aetna,First Health,,3642.74,,,,,,,1605.39,3642.74,percent of total billed charges,
SCREW,8404774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4453.23000,1291.44000,Aetna,First Health,,3642.74,,,,,,,1433.94,3642.74,percent of total billed charges,
SCREW,8406252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4453.23000,1291.44000,Aetna,First Health,,3642.74,,,,,,,1605.39,3642.74,percent of total billed charges,
SCREW,8406252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4453.23000,1291.44000,Aetna,First Health,,3642.74,,,,,,,1433.94,3642.74,percent of total billed charges,
INSERT,8404775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8404775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8405127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8405127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8405128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8405128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
ANCHOR,8405129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.00000,559.99000,Aetna,First Health,,1579.56,,,,,,,696.13,1579.56,percent of total billed charges,
ANCHOR,8405129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.00000,559.99000,Aetna,First Health,,1579.56,,,,,,,621.78,1579.56,percent of total billed charges,
PLATE,8405131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,21239.15000,6159.35000,Aetna,First Health,,17373.62,,,,,,,7656.71,17373.62,percent of total billed charges,
PLATE,8405131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,21239.15000,6159.35000,Aetna,First Health,,17373.62,,,,,,,6839.01,17373.62,percent of total billed charges,
SCREW,8406139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8406139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
INSERT,8406140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8406140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
GLENOSPHERE,8461841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,2224.35,5047.22,percent of total billed charges,
GLENOSPHERE,8461841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,1986.80,5047.22,percent of total billed charges,
COMPONENT AUGMENT,8461843,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,3057.18,6936.97,percent of total billed charges,
COMPONENT AUGMENT,8461843,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,First Health,,6936.97,,,,,,,2730.69,6936.97,percent of total billed charges,
PLATE SPINAL,8461889,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8461889,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE SPINAL,8461969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8461969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE SPINAL,8461971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8461971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8461973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8461973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,8461975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8461975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
GUIDEWIRE,8461977,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
GUIDEWIRE,8461977,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
BASEPLATE,8461982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
BASEPLATE,8461982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT,8462085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,8462085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
NAIL,8462087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4650.45,10552.20,percent of total billed charges,
NAIL,8462087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4153.80,10552.20,percent of total billed charges,
CAGE,8462075,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8462075,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
SCREW SPINAL,8462077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
SCREW SPINAL,8462077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
SCREW SPINAL,8462079,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
SCREW SPINAL,8462079,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
ROD SPINAL,8462081,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
ROD SPINAL,8462081,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
SCREW SPINAL,8462083,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW SPINAL,8462083,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
CANNULA SPINAL,8462058,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,360.48000,104.54000,Aetna,First Health,,294.87,,,,,,,129.95,294.87,percent of total billed charges,
CANNULA SPINAL,8462058,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,360.48000,104.54000,Aetna,First Health,,294.87,,,,,,,116.07,294.87,percent of total billed charges,
CANNULA SPINAL,8462059,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,3300.01,7487.96,percent of total billed charges,
CANNULA SPINAL,8462059,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,2947.58,7487.96,percent of total billed charges,
ROD SPINAL,8462089,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
ROD SPINAL,8462089,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW,8462093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8462093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
KIT KYPHOPLASTY BALLOON,7736522,CDM,278,RC,A4215,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,3300.01,7487.96,percent of total billed charges,
KIT KYPHOPLASTY BALLOON,7736522,CDM,278,RC,A4215,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,0.14445,7487.96,percent of total billed charges,
SCREW SPINAL,8462173,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
SCREW SPINAL,8462173,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
ROD SPINAL,8462174,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
ROD SPINAL,8462174,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
CAGE,8462175,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8462175,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CAGE,8462176,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8462176,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
GUIDEWIRE,8462177,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,415.63000,120.53000,Aetna,First Health,,339.99,,,,,,,149.83,339.99,percent of total billed charges,
GUIDEWIRE,8462177,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,415.63000,120.53000,Aetna,First Health,,339.99,,,,,,,133.83,339.99,percent of total billed charges,
ROD SPINAL,8462178,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD SPINAL,8462178,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
SCREW SPINAL,8462179,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
SCREW SPINAL,8462179,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
SCREW SPINAL,8462180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
SCREW SPINAL,8462180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
SCREW SPINAL,8462181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW SPINAL,8462181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
PLATE SPINAL,8462182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE SPINAL,8462182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
SCREW,8462184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,8462184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
SCREW SPINAL,8462185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW SPINAL,8462185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
ANCHOR TENDON LIGAMENT,8462187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
ANCHOR TENDON LIGAMENT,8462187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
CAGE,8462295,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8462295,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
PLATE SPINAL,8462297,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8462297,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8463786,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
CAGE,8463786,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
PLATE SPINAL,8462287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8462287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW SPINAL,8462289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SPINAL,8462289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8462204,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8462204,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
INSERT,8462205,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2936.27,6662.61,percent of total billed charges,
INSERT,8462205,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,First Health,,6662.61,,,,,,,2622.69,6662.61,percent of total billed charges,
LINER,8462206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
LINER,8462206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
LINER,8462291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3576.63,8115.62,percent of total billed charges,
LINER,8462291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3194.66,8115.62,percent of total billed charges,
HEAD FEMORAL,8462293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,First Health,,4584.24,,,,,,,2020.31,4584.24,percent of total billed charges,
HEAD FEMORAL,8462293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,First Health,,4584.24,,,,,,,1804.55,4584.24,percent of total billed charges,
STEM,8462298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8462298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STENT,8463787,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1356.36000,393.34000,Aetna,First Health,,1109.50,,,,,,,488.97,1109.50,percent of total billed charges,
STENT,8463787,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1356.36000,393.34000,Aetna,First Health,,1109.50,,,,,,,436.75,1109.50,percent of total billed charges,
INSERT TRANSPROSTATIC,8462304,CDM,278,RC,C9739,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
INSERT TRANSPROSTATIC,8462304,CDM,278,RC,C9739,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,13568.64,percent of total billed charges,
PLATE,8463794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9589.20000,2780.87000,Aetna,First Health,,7843.97,,,,,,,3456.91,7843.97,percent of total billed charges,
PLATE,8463794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9589.20000,2780.87000,Aetna,First Health,,7843.97,,,,,,,3087.72,7843.97,percent of total billed charges,
SCREW,8463789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8463789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SCREW,8463790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8463790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
NAIL,8463791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8463791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
SHELL,8463792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,8463792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
GRAFT,8463793,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
GRAFT,8463793,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
GRAFT,8463859,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4375.00000,1268.75000,Aetna,First Health,,3578.75,,,,,,,1577.19,3578.75,percent of total billed charges,
GRAFT,8463859,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4375.00000,1268.75000,Aetna,First Health,,3578.75,,,,,,,1408.75,3578.75,percent of total billed charges,
GRAFT,8463860,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8055.00000,2335.95000,Aetna,First Health,,6588.99,,,,,,,2903.83,6588.99,percent of total billed charges,
GRAFT,8463860,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8055.00000,2335.95000,Aetna,First Health,,6588.99,,,,,,,2593.71,6588.99,percent of total billed charges,
CEMENT,8463861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1803.30000,522.96000,Aetna,First Health,,1475.10,,,,,,,650.09,1475.10,percent of total billed charges,
CEMENT,8463861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1803.30000,522.96000,Aetna,First Health,,1475.10,,,,,,,580.66,1475.10,percent of total billed charges,
SCREW SPIINAL,8463862,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW SPIINAL,8463862,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
ROD SPINAL,8463863,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8463863,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SCREW SPINAL,8463864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW SPINAL,8463864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
CAGE,8463865,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8463865,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
INSERT,8463866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8463866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,8464371,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8464371,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
SCREW,8464375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8464375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8464377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8464377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8464379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8464379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8464381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8464381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8464383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8464383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8464385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8464385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8464387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8464387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
PLATE,8464389,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,8464389,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,8464391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8464391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,8464393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8464393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
PLATE,8464353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,8464353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
PIN FIXATION,8464355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
PIN FIXATION,8464355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
GUIDEWIRE,8464357,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
GUIDEWIRE,8464357,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,43.95,111.66,percent of total billed charges,
SCREW,8464644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8464644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8464358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8464358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8464360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8464360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8464362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8464362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,8464364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8464364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,8464366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8464366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,8464368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8464368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
COMPONENT FEMORAL,8464857,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,8464857,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
STEM,8464859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8464859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
SCREW,8464861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8464861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,8464863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8464863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,8464865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8464865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,8464867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8464867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
BASEPLATE,8464869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
BASEPLATE,8464869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
INSERT,8464871,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,8464871,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
PLATE SPINAL,8464873,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
PLATE SPINAL,8464873,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
SCREW SPINAL,8464874,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW SPINAL,8464874,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
CAGE,8464876,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
CAGE,8464876,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
STENT GRAFT,8465072,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,8465072,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,8465073,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,8465073,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT GRAFT,8465074,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,38137.50000,11059.88000,Aetna,First Health,,31196.47,,,,,,,13748.57,31196.47,percent of total billed charges,
STENT GRAFT,8465074,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,38137.50000,11059.88000,Aetna,First Health,,31196.47,,,,,,,12280.27,31196.47,percent of total billed charges,
ROD SPINAL,8465075,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD SPINAL,8465075,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
SCREW SPINAL,8465076,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
SCREW SPINAL,8465076,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
SCREW,8465760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8465760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
GRAFT,8465774,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5634.61,12785.34,percent of total billed charges,
GRAFT,8465774,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,First Health,,12785.34,,,,,,,5032.86,12785.34,percent of total billed charges,
LINER,8465810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,8465810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
LINER,8465812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
LINER,8465812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
INSERT,8465814,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8465814,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT FEMORAL,8465816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,8465816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
COMPONENT TIBIAL,8465819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,8465819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
MESH,8465822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4912.43000,1424.60000,Aetna,First Health,,4018.37,,,,,,,1770.93,4018.37,percent of total billed charges,
MESH,8465822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4912.43000,1424.60000,Aetna,First Health,,4018.37,,,,,,,1581.80,4018.37,percent of total billed charges,
MESH,8465824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4912.43000,1424.60000,Aetna,First Health,,4018.37,,,,,,,1770.93,4018.37,percent of total billed charges,
MESH,8465824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4912.43000,1424.60000,Aetna,First Health,,4018.37,,,,,,,1581.80,4018.37,percent of total billed charges,
MESH,8465826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5950.04000,1725.51000,Aetna,First Health,,4867.13,,,,,,,2144.99,4867.13,percent of total billed charges,
MESH,8465826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5950.04000,1725.51000,Aetna,First Health,,4867.13,,,,,,,1915.91,4867.13,percent of total billed charges,
MESH,8465828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5950.04000,1725.51000,Aetna,First Health,,4867.13,,,,,,,2144.99,4867.13,percent of total billed charges,
MESH,8465828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5950.04000,1725.51000,Aetna,First Health,,4867.13,,,,,,,1915.91,4867.13,percent of total billed charges,
INSERT,8465830,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8465830,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8465833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.06000,86.73000,Aetna,First Health,,244.63,,,,,,,107.81,244.63,percent of total billed charges,
SCREW,8465833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.06000,86.73000,Aetna,First Health,,244.63,,,,,,,96.30,244.63,percent of total billed charges,
PLATE,8465835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1247.52000,361.78000,Aetna,First Health,,1020.47,,,,,,,449.73,1020.47,percent of total billed charges,
PLATE,8465835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1247.52000,361.78000,Aetna,First Health,,1020.47,,,,,,,401.70,1020.47,percent of total billed charges,
SCREW,8465837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,8465837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SCREW,8465839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,8465839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
PLATE,8465842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5127.50000,1486.98000,Aetna,First Health,,4194.30,,,,,,,1848.46,4194.30,percent of total billed charges,
PLATE,8465842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5127.50000,1486.98000,Aetna,First Health,,4194.30,,,,,,,1651.06,4194.30,percent of total billed charges,
PLATE SPINAL,8465922,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8465922,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ANCHOR,8465926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7357.44000,2133.66000,Aetna,First Health,,6018.39,,,,,,,2652.36,6018.39,percent of total billed charges,
ANCHOR,8465926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7357.44000,2133.66000,Aetna,First Health,,6018.39,,,,,,,2369.10,6018.39,percent of total billed charges,
ANCHOR,8465928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2464.00000,714.56000,Aetna,First Health,,2015.55,,,,,,,888.27,2015.55,percent of total billed charges,
ANCHOR,8465928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2464.00000,714.56000,Aetna,First Health,,2015.55,,,,,,,793.41,2015.55,percent of total billed charges,
GRAFT CEMENT,8465930,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,14220.00000,4123.80000,Aetna,First Health,,11631.96,,,,,,,5126.31,11631.96,percent of total billed charges,
GRAFT CEMENT,8465930,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,14220.00000,4123.80000,Aetna,First Health,,11631.96,,,,,,,4578.84,11631.96,percent of total billed charges,
PLATE,8465932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7980.00000,2314.20000,Aetna,First Health,,6527.64,,,,,,,2876.79,6527.64,percent of total billed charges,
PLATE,8465932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7980.00000,2314.20000,Aetna,First Health,,6527.64,,,,,,,2569.56,6527.64,percent of total billed charges,
PLATE,8465934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
PLATE,8465934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SCREW,8465936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,8465936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
SCREW,8465938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,8465938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
SCREW,8465940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,8465940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
SCREW,8465942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,8465942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
PLATE,8465944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
PLATE,8465944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
SCREW,8465946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,8465946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
SCREW,8465948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8465948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
INSERT,8466068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8466068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW SPINAL,8466070,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
SCREW SPINAL,8466070,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
CAGE,8466072,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8466072,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
ROD SPINAL,8466076,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD SPINAL,8466076,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
ROD SPINAL,8466077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
ROD SPINAL,8466077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
PLATE,8467762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.72000,167.25000,Aetna,First Health,,471.76,,,,,,,207.91,471.76,percent of total billed charges,
PLATE,8467762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.72000,167.25000,Aetna,First Health,,471.76,,,,,,,185.70,471.76,percent of total billed charges,
PLATE,8467764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3344.67000,969.95000,Aetna,First Health,,2735.94,,,,,,,1205.75,2735.94,percent of total billed charges,
PLATE,8467764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3344.67000,969.95000,Aetna,First Health,,2735.94,,,,,,,1076.98,2735.94,percent of total billed charges,
PLATE,8467766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1633.44000,473.70000,Aetna,First Health,,1336.15,,,,,,,588.86,1336.15,percent of total billed charges,
PLATE,8467766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1633.44000,473.70000,Aetna,First Health,,1336.15,,,,,,,525.97,1336.15,percent of total billed charges,
INSERT,8466129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8466129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT FEMORAL,8467744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,8467744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
INSERT,8466132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8466132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
SCREW,8466131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8466131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
PLATE SPINAL,8467768,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8467768,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,8467769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,172.10,390.50,percent of total billed charges,
SCREW,8467769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,First Health,,390.50,,,,,,,153.72,390.50,percent of total billed charges,
BASEPLATE,8467770,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8270.94000,2398.57000,Aetna,First Health,,6765.63,,,,,,,2981.67,6765.63,percent of total billed charges,
BASEPLATE,8467770,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8270.94000,2398.57000,Aetna,First Health,,6765.63,,,,,,,2663.24,6765.63,percent of total billed charges,
POST MODULAR,8467771,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3936.00000,1141.44000,Aetna,First Health,,3219.65,,,,,,,1418.93,3219.65,percent of total billed charges,
POST MODULAR,8467771,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3936.00000,1141.44000,Aetna,First Health,,3219.65,,,,,,,1267.39,3219.65,percent of total billed charges,
INSERT,8467777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8467777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
WEDGE,8467778,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
WEDGE,8467778,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
WEDGE,8467779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
WEDGE,8467779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
COMPONENT TIBIAL,8467780,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,8467780,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
STEM,8467772,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,8467772,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
TIBIAL TRAY,8467773,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,7417.29,16830.35,percent of total billed charges,
TIBIAL TRAY,8467773,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,6625.15,16830.35,percent of total billed charges,
PROSTHESIS ANKLE,8467774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,7786.80,17668.80,percent of total billed charges,
PROSTHESIS ANKLE,8467774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,6955.20,17668.80,percent of total billed charges,
INSERT,8467775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3360.22,7624.58,percent of total billed charges,
INSERT,8467775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3001.36,7624.58,percent of total billed charges,
STEM,8468069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
STEM,8468069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
GLENOSPHERE,8468071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5999.00000,1739.71000,Aetna,First Health,,4907.18,,,,,,,2162.64,4907.18,percent of total billed charges,
GLENOSPHERE,8468071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5999.00000,1739.71000,Aetna,First Health,,4907.18,,,,,,,1931.68,4907.18,percent of total billed charges,
SCREW,8468073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,8468073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
STEM,8468075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2348.12,5328.04,percent of total billed charges,
STEM,8468075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2097.35,5328.04,percent of total billed charges,
BASEPLATE,8468077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
BASEPLATE,8468077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
INSERT,8468079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,1049.78,2382.02,percent of total billed charges,
INSERT,8468079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,937.66,2382.02,percent of total billed charges,
PROSTHESIS SHOULDER,8468081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6083.00000,1764.07000,Aetna,First Health,,4975.89,,,,,,,2192.92,4975.89,percent of total billed charges,
PROSTHESIS SHOULDER,8468081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6083.00000,1764.07000,Aetna,First Health,,4975.89,,,,,,,1958.73,4975.89,percent of total billed charges,
WASHER,8468083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1596.11,3621.70,percent of total billed charges,
WASHER,8468083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1425.65,3621.70,percent of total billed charges,
SCREW,8468085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8468085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
NAIL,8468087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL,8468087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
SCREW,8468089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW,8468089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
SCREW,8468091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW,8468091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
SCREW,8468093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,8468093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
SCREW,8468095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,8468095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
SCREW,8468098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8468098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW SPINAL,8468272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW SPINAL,8468272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
COMPONENT FEMORAL,8467776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
COMPONENT FEMORAL,8467776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
STENT,8468160,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
STENT,8468160,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
STENT,8468161,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
STENT,8468161,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
STENT GRAFT,8468162,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT GRAFT,8468162,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
SCREW,8468273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,928.44000,269.25000,Aetna,First Health,,759.46,,,,,,,334.70,759.46,percent of total billed charges,
SCREW,8468273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,928.44000,269.25000,Aetna,First Health,,759.46,,,,,,,298.96,759.46,percent of total billed charges,
INSERT,8468274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8468274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STENT,8468480,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1356.36000,393.34000,Aetna,First Health,,1109.50,,,,,,,488.97,1109.50,percent of total billed charges,
STENT,8468480,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1356.36000,393.34000,Aetna,First Health,,1109.50,,,,,,,436.75,1109.50,percent of total billed charges,
ROD,8468481,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD,8468481,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
INSERT,8469913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,8469913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
STEM,8469914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STEM,8469914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
GLENOSPHERE,8469915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
GLENOSPHERE,8469915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
BASEPLATE,8469916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
BASEPLATE,8469916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
STEM,8469874,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8469874,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PLATE,8469912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4407.38000,1278.14000,Aetna,First Health,,3605.24,,,,,,,1588.86,3605.24,percent of total billed charges,
PLATE,8469912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4407.38000,1278.14000,Aetna,First Health,,3605.24,,,,,,,1419.18,3605.24,percent of total billed charges,
STEM,8471862,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
STEM,8471862,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
LINER,8471864,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
LINER,8471864,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
CEMENT IN KIT,7840042,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,15850.50000,4596.64000,Aetna,First Health,,12965.71,,,,,,,5714.11,12965.71,percent of total billed charges,
CEMENT IN KIT,7840042,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,15850.50000,4596.64000,Aetna,First Health,,12965.71,,,,,,,5103.86,12965.71,percent of total billed charges,
CEMENT IN KIT,8471860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15850.50000,4596.64000,Aetna,First Health,,12965.71,,,,,,,5714.11,12965.71,percent of total billed charges,
CEMENT IN KIT,8471860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15850.50000,4596.64000,Aetna,First Health,,12965.71,,,,,,,5103.86,12965.71,percent of total billed charges,
CAGE,8471774,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8471774,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
CAGE,8471776,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8471776,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
ROD SPINAL,8471778,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
ROD SPINAL,8471778,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
PLATE SPINAL,8471731,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8471731,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE SPINAL,8471730,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8471730,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE SPINAL,8471729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8471729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
GRAFT,8471780,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,17077.50000,4952.47000,Aetna,First Health,,13969.40,,,,,,,6156.44,13969.40,percent of total billed charges,
GRAFT,8471780,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,17077.50000,4952.47000,Aetna,First Health,,13969.40,,,,,,,124.65,13969.40,percent of total billed charges,
ROD SPINAL,8471896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8471896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW SPINAL,8471898,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW SPINAL,8471898,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,8471900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8471900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
SCREW,8471902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8471902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
CONNECTOR SPINAL,8471904,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,1106.01,2509.62,percent of total billed charges,
CONNECTOR SPINAL,8471904,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,First Health,,2509.62,,,,,,,987.90,2509.62,percent of total billed charges,
STEM,8473729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8473729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CAGE,8473764,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8473764,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
STENT GRAFT,8473765,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
STENT GRAFT,8473765,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
STENT GRAFT,8473766,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
STENT GRAFT,8473766,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
SPHERE GLENOID,8473771,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
SPHERE GLENOID,8473771,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
INSERT,8473772,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,8473772,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
STEM,8473773,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8473773,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
STEM,8473774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
STEM,8473774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
GLENOSPHERE,8473775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
GLENOSPHERE,8473775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
BASEPLATE,8473776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2947.09,6687.15,percent of total billed charges,
BASEPLATE,8473776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2632.35,6687.15,percent of total billed charges,
LINER,8473777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
LINER,8473777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
STEM,8473850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8473850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
BASEPLATE,8473851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8265.00000,2396.85000,Aetna,First Health,,6760.77,,,,,,,2979.53,6760.77,percent of total billed charges,
BASEPLATE,8473851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8265.00000,2396.85000,Aetna,First Health,,6760.77,,,,,,,2661.33,6760.77,percent of total billed charges,
STEM,8473852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3248.00000,941.92000,Aetna,First Health,,2656.86,,,,,,,1170.90,2656.86,percent of total billed charges,
STEM,8473852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3248.00000,941.92000,Aetna,First Health,,2656.86,,,,,,,1045.86,2656.86,percent of total billed charges,
WEDGE,8473853,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
WEDGE,8473853,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
INSERT,8473854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8473854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
WEDGE,8473855,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
WEDGE,8473855,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
INSERT,8473856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8473856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
KIT HYBRID NEW AGE,8475777,CDM,278,RC,,,,,facility,inpatient,,,28125.00000,8156.25000,Aetna,First Health,,23006.25,,,,,,,10139.06,23006.25,percent of total billed charges,
KIT HYBRID NEW AGE,8475777,CDM,278,RC,,,,,facility,outpatient,,,28125.00000,8156.25000,Aetna,First Health,,23006.25,,,,,,,9056.25,23006.25,percent of total billed charges,
SCREW SPINAL,8475778,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW SPINAL,8475778,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE,8475780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2929.08000,849.43000,Aetna,First Health,,2395.99,,,,,,,1055.93,2395.99,percent of total billed charges,
PLATE,8475780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2929.08000,849.43000,Aetna,First Health,,2395.99,,,,,,,943.16,2395.99,percent of total billed charges,
CAGE,8475895,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,713.79,1619.64,percent of total billed charges,
CAGE,8475895,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,637.56,1619.64,percent of total billed charges,
CAGE,8475896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8475896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
PLATE,8475897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3006.68000,871.94000,Aetna,First Health,,2459.46,,,,,,,1083.91,2459.46,percent of total billed charges,
PLATE,8475897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3006.68000,871.94000,Aetna,First Health,,2459.46,,,,,,,968.15,2459.46,percent of total billed charges,
CAGE,8475899,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8475899,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8475901,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
CAGE,8475901,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
CONNECTOR SPINAL,8477729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CONNECTOR SPINAL,8477729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
ROD SPINAL,8477731,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8477731,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
ROD SPINAL,8477733,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
ROD SPINAL,8477733,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SCREW,8477735,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,8477735,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW SPINAL,8477737,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SCREW SPINAL,8477737,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
CONNECTOR SPINAL,8477739,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6352.50000,1842.22000,Aetna,First Health,,5196.35,,,,,,,2290.08,5196.35,percent of total billed charges,
CONNECTOR SPINAL,8477739,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6352.50000,1842.22000,Aetna,First Health,,5196.35,,,,,,,2045.51,5196.35,percent of total billed charges,
GRAFT,8477741,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
GRAFT,8477741,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
STEM,8477742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8477742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,8477972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8477972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
CAGE,8477744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
CAGE,8477744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
CAGE,8477746,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
CAGE,8477746,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
INSERT,8477748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,8477748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
INSERT,8477750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT,8477750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,8477751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8477751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
PLATE SPINAL,8477753,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,3001.16,6809.85,percent of total billed charges,
PLATE SPINAL,8477753,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,2680.65,6809.85,percent of total billed charges,
CAGE,8477754,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8477754,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
CAGE,8477755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8477755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
SCREW SPINAL,8477756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SCREW SPINAL,8477756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
SCREW SPINAL,8477757,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SCREW SPINAL,8477757,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
PLATE SPINAL,8477758,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,3001.16,6809.85,percent of total billed charges,
PLATE SPINAL,8477758,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,2680.65,6809.85,percent of total billed charges,
SCREW,8477752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,8477752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,8477974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,8477974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,8477975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,8477975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
STEM,8477976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2348.12,5328.04,percent of total billed charges,
STEM,8477976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2097.35,5328.04,percent of total billed charges,
INSERT,8477977,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,1049.78,2382.02,percent of total billed charges,
INSERT,8477977,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,937.66,2382.02,percent of total billed charges,
INSERT,8477978,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,1049.78,2382.02,percent of total billed charges,
INSERT,8477978,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,937.66,2382.02,percent of total billed charges,
TRAY HUMERAL,8477979,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6083.00000,1764.07000,Aetna,First Health,,4975.89,,,,,,,2192.92,4975.89,percent of total billed charges,
TRAY HUMERAL,8477979,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6083.00000,1764.07000,Aetna,First Health,,4975.89,,,,,,,1958.73,4975.89,percent of total billed charges,
INSERT,8478388,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8478388,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8478389,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
CAGE,8478389,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
PLATE SPINAL,8478390,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
PLATE SPINAL,8478390,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
ANCHOR,8478391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1868.00000,541.72000,Aetna,First Health,,1528.02,,,,,,,673.41,1528.02,percent of total billed charges,
ANCHOR,8478391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1868.00000,541.72000,Aetna,First Health,,1528.02,,,,,,,601.50,1528.02,percent of total billed charges,
COMPONENT FEMORAL,8478429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
COMPONENT FEMORAL,8478429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
INSERT,8478431,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
INSERT,8478431,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
COMPONENT PATELLA,8478433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,8478433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
INSERT,8478435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8478435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
COMPONENT TIBIAL,8478392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
COMPONENT TIBIAL,8478392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
STEM,8478437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8478437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
GUIDEWIRE,8478442,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,70.03,158.90,percent of total billed charges,
GUIDEWIRE,8478442,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,First Health,,158.90,,,,,,,62.55,158.90,percent of total billed charges,
SCREW,8478443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8478443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
COMPONENT GLENOID,8478504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
COMPONENT GLENOID,8478504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
PLATE,8478506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11227.50000,3255.98000,Aetna,First Health,,9184.09,,,,,,,4047.51,9184.09,percent of total billed charges,
PLATE,8478506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11227.50000,3255.98000,Aetna,First Health,,9184.09,,,,,,,3615.26,9184.09,percent of total billed charges,
FEMORAL COMPONENT,8478636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
FEMORAL COMPONENT,8478636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
ROD SPINAL,8478629,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD SPINAL,8478629,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
CAGE,8478630,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8478630,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
K WIRE,8478631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.63000,120.53000,Aetna,First Health,,339.99,,,,,,,149.83,339.99,percent of total billed charges,
K WIRE,8478631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.63000,120.53000,Aetna,First Health,,339.99,,,,,,,133.83,339.99,percent of total billed charges,
SHIM,8478632,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SHIM,8478632,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
PROBE,8478633,CDM,278,RC,,,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
PROBE,8478633,CDM,278,RC,,,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
MAT,8478634,CDM,278,RC,,,,,facility,inpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,677.74,1537.84,percent of total billed charges,
MAT,8478634,CDM,278,RC,,,,,facility,outpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,605.36,1537.84,percent of total billed charges,
CAGE,8478635,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8478635,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
GRAFT,8478628,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,22700.00000,6583.00000,Aetna,First Health,,18568.60,,,,,,,8183.35,18568.60,percent of total billed charges,
GRAFT,8478628,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,22700.00000,6583.00000,Aetna,First Health,,18568.60,,,,,,,7309.40,18568.60,percent of total billed charges,
INSERT,8478637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8478637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
BASEPLATE,8478638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8478638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
INSERT,8478639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,8478639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
BASEPLATE,8478640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,8478640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
FEMORAL COMPONENT,8478643,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
FEMORAL COMPONENT,8478643,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
CAGE,8478641,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8478641,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
FEMORAL HEAD,8478642,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMORAL HEAD,8478642,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
FEMORAL STEM,8478644,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
FEMORAL STEM,8478644,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8478646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3360.22,7624.58,percent of total billed charges,
INSERT,8478646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3001.36,7624.58,percent of total billed charges,
DOME,8478645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,7786.80,17668.80,percent of total billed charges,
DOME,8478645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,6955.20,17668.80,percent of total billed charges,
SCREW,8478647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,8478647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
PLATE,8478648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2543.68000,737.67000,Aetna,First Health,,2080.73,,,,,,,917.00,2080.73,percent of total billed charges,
PLATE,8478648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2543.68000,737.67000,Aetna,First Health,,2080.73,,,,,,,819.06,2080.73,percent of total billed charges,
CAGE,8479730,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24750.00000,7177.50000,Aetna,First Health,,20245.50,,,,,,,8922.38,20245.50,percent of total billed charges,
CAGE,8479730,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24750.00000,7177.50000,Aetna,First Health,,20245.50,,,,,,,7969.50,20245.50,percent of total billed charges,
PEG,8481909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG,8481909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
ROD SPINAL,8481911,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8481911,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
INSERT,8481913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8481913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
COMPONENT FEMORAL,8481915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
COMPONENT FEMORAL,8481915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
COMPONENT PATELLA,8481917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,8481917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
STEM,8479731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8479731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
SCREW SPINAL,8479751,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SCREW SPINAL,8479751,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
PLATE SPINAL,8479753,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
PLATE SPINAL,8479753,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
HEAD FEMORAL,8479732,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
HEAD FEMORAL,8479732,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
STEM,8479756,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,8479756,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
STEM,8479758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8479758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
INSERT,8479760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,8479760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
NAIL,8479787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL,8479787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
SCREW,8479788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
SCREW,8479788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
NAIL,8479789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8479789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
NAIL,8479790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8479790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
SCREW,8479791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8479791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
PLATE,8479762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,4133.49,9379.19,percent of total billed charges,
PLATE,8479762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,3692.05,9379.19,percent of total billed charges,
SCREW,8479764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,436.93,991.42,percent of total billed charges,
SCREW,8479764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,390.26,991.42,percent of total billed charges,
ROD SPINAL,8479780,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8479780,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
COMPONENT TIBIAL,8479783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
COMPONENT TIBIAL,8479783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
K WIRE,8479770,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,415.63000,120.53000,Aetna,First Health,,339.99,,,,,,,149.83,339.99,percent of total billed charges,
K WIRE,8479770,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,415.63000,120.53000,Aetna,First Health,,339.99,,,,,,,133.83,339.99,percent of total billed charges,
SCREW SPINAL,8479772,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
SCREW SPINAL,8479772,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
ROD SPINAL,8479774,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD SPINAL,8479774,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
SCREW SPINAL,8479776,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW SPINAL,8479776,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
SCREW SPINAL,8479778,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8479778,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
CAGE,8479767,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8479767,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
PLATE SPINAL,8479769,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8479769,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAP END,8479795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.58000,214.48000,Aetna,First Health,,604.98,,,,,,,266.62,604.98,percent of total billed charges,
CAP END,8479795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.58000,214.48000,Aetna,First Health,,604.98,,,,,,,238.14,604.98,percent of total billed charges,
INSERT,8479784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8479784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
BASEPLATE,8479785,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8479785,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
COMPONENT FEMORAL,8479786,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
COMPONENT FEMORAL,8479786,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
LINER,8479782,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,8479782,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
HEAD FEMORAL,8479792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8479792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
HEAD FEMORAL,8479793,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8479793,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
COMPONENT ACETABULAR,8479794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1876.22,4257.28,percent of total billed charges,
COMPONENT ACETABULAR,8479794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1675.85,4257.28,percent of total billed charges,
CAGE,8479781,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CAGE,8479781,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
GRAFT,8479796,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,21437.50000,6216.88000,Aetna,First Health,,17535.88,,,,,,,7728.22,17535.88,percent of total billed charges,
GRAFT,8479796,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,21437.50000,6216.88000,Aetna,First Health,,17535.88,,,,,,,6902.88,17535.88,percent of total billed charges,
BASEPLATE,8481919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8481919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
SCREW,8481921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,964.29,2188.05,percent of total billed charges,
SCREW,8481921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,861.31,2188.05,percent of total billed charges,
PLATE,8481923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8580.00000,2488.20000,Aetna,First Health,,7018.44,,,,,,,3093.09,7018.44,percent of total billed charges,
PLATE,8481923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8580.00000,2488.20000,Aetna,First Health,,7018.44,,,,,,,2762.76,7018.44,percent of total billed charges,
SHELL,8481967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3475.94,7887.16,percent of total billed charges,
SHELL,8481967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3104.72,7887.16,percent of total billed charges,
SCREW SPINAL,8481968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
SCREW SPINAL,8481968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
ROD SPINAL,8481969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
ROD SPINAL,8481969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
INSERT,8481972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3360.22,7624.58,percent of total billed charges,
INSERT,8481972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3001.36,7624.58,percent of total billed charges,
TRAY TIBIAL,8483925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,7417.29,16830.35,percent of total billed charges,
TRAY TIBIAL,8483925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,6625.15,16830.35,percent of total billed charges,
CEMENT RESTRICTOR,8485947,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,219.00,496.94,percent of total billed charges,
CEMENT RESTRICTOR,8485947,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,195.62,496.94,percent of total billed charges,
STEM EXTENSION,8485931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6514.20000,1889.12000,Aetna,First Health,,5328.62,,,,,,,2348.37,5328.62,percent of total billed charges,
STEM EXTENSION,8485931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6514.20000,1889.12000,Aetna,First Health,,5328.62,,,,,,,2097.57,5328.62,percent of total billed charges,
STEM,8485933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17235.00000,4998.15000,Aetna,First Health,,14098.23,,,,,,,6213.22,14098.23,percent of total billed charges,
STEM,8485933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17235.00000,4998.15000,Aetna,First Health,,14098.23,,,,,,,5549.67,14098.23,percent of total billed charges,
GLENOSPHERE,8485935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7860.00000,2279.40000,Aetna,First Health,,6429.48,,,,,,,2833.53,6429.48,percent of total billed charges,
GLENOSPHERE,8485935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7860.00000,2279.40000,Aetna,First Health,,6429.48,,,,,,,2530.92,6429.48,percent of total billed charges,
SCREW,8485937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2481.20000,719.55000,Aetna,First Health,,2029.62,,,,,,,894.47,2029.62,percent of total billed charges,
SCREW,8485937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2481.20000,719.55000,Aetna,First Health,,2029.62,,,,,,,798.95,2029.62,percent of total billed charges,
HUMERAL BODY,8485939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17797.50000,5161.27000,Aetna,First Health,,14558.35,,,,,,,6416.00,14558.35,percent of total billed charges,
HUMERAL BODY,8485939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17797.50000,5161.27000,Aetna,First Health,,14558.35,,,,,,,5730.80,14558.35,percent of total billed charges,
LINER,8485941,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
LINER,8485941,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
INSERT,8485945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,8485945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
MESH,8485949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,32460.68000,9413.60000,Aetna,First Health,,26552.84,,,,,,,11702.08,26552.84,percent of total billed charges,
MESH,8485949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,32460.68000,9413.60000,Aetna,First Health,,26552.84,,,,,,,10452.34,26552.84,percent of total billed charges,
SCREW,8485951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8485951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8485953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8485953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
STENT,8487990,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
STENT,8487990,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
SCREW SPINAL,8486000,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW SPINAL,8486000,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
COMPONENT PATELLA,8486002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,8486002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
WEDGE,8486004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8486004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8486006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8486006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
STEM EXTENSION,8486008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM EXTENSION,8486008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
GLENOSPHERE,8486010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5999.00000,1739.71000,Aetna,First Health,,4907.18,,,,,,,2162.64,4907.18,percent of total billed charges,
GLENOSPHERE,8486010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5999.00000,1739.71000,Aetna,First Health,,4907.18,,,,,,,1931.68,4907.18,percent of total billed charges,
STEM,8486011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2348.12,5328.04,percent of total billed charges,
STEM,8486011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2097.35,5328.04,percent of total billed charges,
INSERT,8486012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,1049.78,2382.02,percent of total billed charges,
INSERT,8486012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,937.66,2382.02,percent of total billed charges,
STEM,8487992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8487992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
INSERT,8487994,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8487994,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
COMPONENT FEMORAL,8488006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,7669.64,17402.95,percent of total billed charges,
COMPONENT FEMORAL,8488006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,6850.55,17402.95,percent of total billed charges,
INSERT,8487996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8487996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8487998,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8487998,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SCREW,8488000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,8488000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,8488002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,8488002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
PLATE,8488004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,865.20,1963.20,percent of total billed charges,
PLATE,8488004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,772.80,1963.20,percent of total billed charges,
COMPONENT ACETABULAR,8490024,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,179.80,407.98,percent of total billed charges,
COMPONENT ACETABULAR,8490024,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,160.60,407.98,percent of total billed charges,
LINER,8489972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,8489972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
INSERT,8489973,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8489973,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
COMPONENT FEMORAL,8489974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
COMPONENT FEMORAL,8489974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
ROD SPINAL,8490019,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD SPINAL,8490019,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
CUSTOM TALAR,8488009,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,41737.50000,12103.88000,Aetna,First Health,,34141.28,,,,,,,15046.37,34141.28,percent of total billed charges,
CUSTOM TALAR,8488009,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,41737.50000,12103.88000,Aetna,First Health,,34141.28,,,,,,,13439.48,34141.28,percent of total billed charges,
PLATE SPINAL,8490021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE SPINAL,8490021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
SHELL,8493925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3475.94,7887.16,percent of total billed charges,
SHELL,8493925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3104.72,7887.16,percent of total billed charges,
SCREW,8493926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8493926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
OTOLAYNGOLOGY IMPLANT,8496708,CDM,278,RC,C1878,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
OTOLAYNGOLOGY IMPLANT,8496708,CDM,278,RC,C1878,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
INSERT,8496709,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8496709,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
FIXATION SPINAL,8496710,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FIXATION SPINAL,8496710,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
ROD SPINAL,8496711,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD SPINAL,8496711,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
CAGE,8496712,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8496712,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
SCREW SPINAL,8496713,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8496713,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8496714,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8496714,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8496715,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8496715,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
ANCHOR,8496719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3404.66000,987.35000,Aetna,First Health,,2785.01,,,,,,,1227.38,2785.01,percent of total billed charges,
ANCHOR,8496719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3404.66000,987.35000,Aetna,First Health,,2785.01,,,,,,,1096.30,2785.01,percent of total billed charges,
ANCHOR,8496722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5043.15000,1462.51000,Aetna,First Health,,4125.30,,,,,,,1818.06,4125.30,percent of total billed charges,
ANCHOR,8496722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5043.15000,1462.51000,Aetna,First Health,,4125.30,,,,,,,1623.89,4125.30,percent of total billed charges,
CAGE,8496716,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
CAGE,8496716,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
CAGE,8496717,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
CAGE,8496717,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
SCREW,8496783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8496783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
INSERT,8496784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8496784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8496786,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
CAGE,8496786,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
GRAFT,8497931,CDM,278,RC,,,,,facility,inpatient,,,19150.00000,5553.50000,Aetna,First Health,,15664.70,,,,,,,6903.57,15664.70,percent of total billed charges,
GRAFT,8497931,CDM,278,RC,,,,,facility,outpatient,,,19150.00000,5553.50000,Aetna,First Health,,15664.70,,,,,,,6166.30,15664.70,percent of total billed charges,
INSERT,8497936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8497936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW SPINAL,8497943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8497943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW SPINAL,8497945,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8497945,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW SPINAL,8497947,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW SPINAL,8497947,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
ROD SPINAL,8497949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
ROD SPINAL,8497949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
SCREW SPINAL,8497951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW SPINAL,8497951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
CONNECTOR SPINAL,8497952,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,624.39,1416.78,percent of total billed charges,
CONNECTOR SPINAL,8497952,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,557.70,1416.78,percent of total billed charges,
SCREW SPINAL,8497953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
SCREW SPINAL,8497953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
SCREW,8497954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8497954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
COMPONENT FEMORAL,8499938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,8499938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
INSERT,8499925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
INSERT,8499925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
INSERT,8499926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,8499926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
COMPONENT FEMORAL,8499927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
COMPONENT FEMORAL,8499927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
BASEPLATE,8499928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8499928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
INSERT,8499929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8499929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
SCREW,8499930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8499930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8499931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8499931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,8499932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8499932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
PLATE,8499933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3892.88000,1128.94000,Aetna,First Health,,3184.38,,,,,,,1403.38,3184.38,percent of total billed charges,
PLATE,8499933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3892.88000,1128.94000,Aetna,First Health,,3184.38,,,,,,,1253.51,3184.38,percent of total billed charges,
STEM,8499934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2348.12,5328.04,percent of total billed charges,
STEM,8499934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2097.35,5328.04,percent of total billed charges,
SCREW SPINAL,8499935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW SPINAL,8499935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
CAGE,8499936,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8499936,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
SCREW,8499937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,8499937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
INSERT,8499939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8499939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
PLATE,8502023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1211.28,2748.48,percent of total billed charges,
PLATE,8502023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1081.92,2748.48,percent of total billed charges,
SCREW,8502025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW,8502025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8502027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8502027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
PLATE,8502029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1734.59,3935.91,percent of total billed charges,
PLATE,8502029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1549.34,3935.91,percent of total billed charges,
ANCHOR,8502031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3100.40000,899.12000,Aetna,First Health,,2536.13,,,,,,,1117.69,2536.13,percent of total billed charges,
ANCHOR,8502031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3100.40000,899.12000,Aetna,First Health,,2536.13,,,,,,,998.33,2536.13,percent of total billed charges,
SCREW SPINAL,8502035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW SPINAL,8502035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
SCREW SPINAL,8502037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW SPINAL,8502037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
SCREW SPINAL,8502039,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW SPINAL,8502039,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
SCREW SPINAL,8502041,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW SPINAL,8502041,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
NERVE WRAP,8502043,CDM,278,RC,C9353,HCPCS,,,facility,inpatient,,,12045.00000,3493.05000,Aetna,First Health,,9852.81,,,,,,,4342.22,9852.81,percent of total billed charges,
NERVE WRAP,8502043,CDM,278,RC,C9353,HCPCS,,,facility,outpatient,,,12045.00000,3493.05000,Aetna,First Health,,9852.81,,,,,,,3878.49,9852.81,percent of total billed charges,
INSERT,8502033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8502033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW SPINAL,8502045,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW SPINAL,8502045,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
COMPONENT FEMORAL,8505925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
COMPONENT FEMORAL,8505925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
INSERT,8505927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8505927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
BASEPLATE,8505929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8505929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
STEM,8505931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,8505931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
AUGMENT ACETABULAR,8505933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
AUGMENT ACETABULAR,8505933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
PLATE SPINAL,8505935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8505935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8505937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,8505937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
ROD SPINAL,8505939,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
ROD SPINAL,8505939,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
SCREW SPINAL,8505941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8505941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW SPINAL,8505943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8505943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW SPINAL,8505945,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8505945,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SHUNT,8505947,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,3489.78000,1012.04000,Aetna,First Health,,2854.64,,,,,,,1258.07,2854.64,percent of total billed charges,
SHUNT,8505947,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,3489.78000,1012.04000,Aetna,First Health,,2854.64,,,,,,,1123.71,2854.64,percent of total billed charges,
PLATE,8505949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2947.09,6687.15,percent of total billed charges,
PLATE,8505949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2632.35,6687.15,percent of total billed charges,
LINER,8505951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
LINER,8505951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
GLENOSPHERE,8505953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
GLENOSPHERE,8505953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
PLATE SPINAL,8505956,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
PLATE SPINAL,8505956,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
ROD SPINAL,8505995,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8505995,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SCREW SPINAL,8509925,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW SPINAL,8509925,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
NAIL,8508000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8508000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
PLATE SPINAL,8513929,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE SPINAL,8513929,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE SPINAL,8513930,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE SPINAL,8513930,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
ENDPLATE,8513937,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8513937,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
CAGE,8513931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
CAGE,8513931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
SCREW,8513933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8513933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
CAGE,8513925,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8513925,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
SCREW SPINAL,8513927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SCREW SPINAL,8513927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
INSERT,8516822,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8516822,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
GUIDEWIRE,8516824,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
GUIDEWIRE,8516824,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,43.95,111.66,percent of total billed charges,
SCREW,8516825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8516825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8516827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8516827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,8516829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8516829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
PLATE,8516831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,8516831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
GRAFT STENT,8517955,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
GRAFT STENT,8517955,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
STEM,8517966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17095.00000,4957.55000,Aetna,First Health,,13983.71,,,,,,,6162.75,13983.71,percent of total billed charges,
STEM,8517966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17095.00000,4957.55000,Aetna,First Health,,13983.71,,,,,,,5504.59,13983.71,percent of total billed charges,
HEAD HUMERAL,8517968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,8517968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PIN GUIDE,8517970,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1596.00000,462.84000,Aetna,First Health,,1305.53,,,,,,,575.36,1305.53,percent of total billed charges,
PIN GUIDE,8517970,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1596.00000,462.84000,Aetna,First Health,,1305.53,,,,,,,513.91,1305.53,percent of total billed charges,
LUMBAR CATHETER IN KIT,8517971,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1549.28000,449.29000,Aetna,First Health,,1267.31,,,,,,,558.52,1267.31,percent of total billed charges,
LUMBAR CATHETER IN KIT,8517971,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1549.28000,449.29000,Aetna,First Health,,1267.31,,,,,,,498.87,1267.31,percent of total billed charges,
PLATE,8519925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,929.66000,269.60000,Aetna,First Health,,760.46,,,,,,,335.14,760.46,percent of total billed charges,
PLATE,8519925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,929.66000,269.60000,Aetna,First Health,,760.46,,,,,,,299.35,760.46,percent of total billed charges,
PLATE,8519926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3643.50000,1056.62000,Aetna,First Health,,2980.38,,,,,,,1313.48,2980.38,percent of total billed charges,
PLATE,8519926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3643.50000,1056.62000,Aetna,First Health,,2980.38,,,,,,,1173.21,2980.38,percent of total billed charges,
STEM,8519927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8519927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
PLATE,8522118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5233.20000,1517.63000,Aetna,First Health,,4280.76,,,,,,,1886.57,4280.76,percent of total billed charges,
PLATE,8522118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5233.20000,1517.63000,Aetna,First Health,,4280.76,,,,,,,1685.09,4280.76,percent of total billed charges,
INSERT,8522121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8522121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW,8522123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8522123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
WEDGE,8522125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
WEDGE,8522125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
INSERT,8522127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8522127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
NAIL,8522129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8522129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
STENT,8522137,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9900.00000,2871.00000,Aetna,First Health,,8098.20,,,,,,,3568.95,8098.20,percent of total billed charges,
STENT,8522137,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9900.00000,2871.00000,Aetna,First Health,,8098.20,,,,,,,3187.80,8098.20,percent of total billed charges,
BALLOON CATHETER,8522143,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON CATHETER,8522143,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PEG IN KIT,7695033,CDM,278,RC,,,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,136.99,310.84,percent of total billed charges,
PEG IN KIT,7695033,CDM,278,RC,,,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,122.36,310.84,percent of total billed charges,
WEDGE,8523925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8523925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8523927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8523927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
STEM,8523929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8523929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
HEAD FEMORAL,8523931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
HEAD FEMORAL,8523931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
COMPONENT FEMORAL,8523935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
COMPONENT FEMORAL,8523935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
STEM EXTENSION,8523937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM EXTENSION,8523937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
SCREW SPINAL,8523939,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW SPINAL,8523939,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW,8523941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8523941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8526023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
SCREW,8526023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
SCREW,8526025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,249.49,percent of total billed charges,
SCREW,8526025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,98.21,249.49,percent of total billed charges,
SCREW,8526027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,249.49,percent of total billed charges,
SCREW,8526027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,98.21,249.49,percent of total billed charges,
PLATE,8526029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2162.56000,627.14000,Aetna,First Health,,1768.97,,,,,,,779.60,1768.97,percent of total billed charges,
PLATE,8526029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2162.56000,627.14000,Aetna,First Health,,1768.97,,,,,,,696.34,1768.97,percent of total billed charges,
PLATE,8526031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1635.23,3710.45,percent of total billed charges,
PLATE,8526031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1460.59,3710.45,percent of total billed charges,
PLATE SPINAL,8526033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8526033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8527974,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
ROD SPINAL,8527974,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
ROD SPINAL,8527975,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,677.74,1537.84,percent of total billed charges,
ROD SPINAL,8527975,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,605.36,1537.84,percent of total billed charges,
SCREW SPINAL,8531935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8531935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW SPINAL,8527976,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3465.00000,1004.85000,Aetna,First Health,,2834.37,,,,,,,1249.13,2834.37,percent of total billed charges,
SCREW SPINAL,8527976,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3465.00000,1004.85000,Aetna,First Health,,2834.37,,,,,,,1115.73,2834.37,percent of total billed charges,
SCREW SPINAL,8527977,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3465.00000,1004.85000,Aetna,First Health,,2834.37,,,,,,,1249.13,2834.37,percent of total billed charges,
SCREW SPINAL,8527977,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3465.00000,1004.85000,Aetna,First Health,,2834.37,,,,,,,1115.73,2834.37,percent of total billed charges,
SCREW SPINAL,8532008,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3465.00000,1004.85000,Aetna,First Health,,2834.37,,,,,,,1249.13,2834.37,percent of total billed charges,
SCREW SPINAL,8532008,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3465.00000,1004.85000,Aetna,First Health,,2834.37,,,,,,,1115.73,2834.37,percent of total billed charges,
CAGE,8527978,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8527978,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
PLATE SPINAL,8527979,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
PLATE SPINAL,8527979,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
SCREW SPINAL,8527980,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SCREW SPINAL,8527980,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
SCREW,8527985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8527985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
STEM,8527986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8527986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
INSERT,8527987,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,8527987,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
SPACER,8527988,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7831.80000,2271.22000,Aetna,First Health,,6406.41,,,,,,,2823.36,6406.41,percent of total billed charges,
SPACER,8527988,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7831.80000,2271.22000,Aetna,First Health,,6406.41,,,,,,,2521.84,6406.41,percent of total billed charges,
STEM,8527989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8527989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
INSERT,8527991,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8527991,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
STENT,8532018,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1356.36000,393.34000,Aetna,First Health,,1109.50,,,,,,,488.97,1109.50,percent of total billed charges,
STENT,8532018,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1356.36000,393.34000,Aetna,First Health,,1109.50,,,,,,,436.75,1109.50,percent of total billed charges,
ROD SPINAL,8532010,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD SPINAL,8532010,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
SCREW SPINAL,8532012,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
SCREW SPINAL,8532012,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
INSERT,8532014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8532014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
CAGE,8532015,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
CAGE,8532015,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
SCREW,8532016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8532016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
PLATE,8532017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1395.50,3166.48,percent of total billed charges,
PLATE,8532017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1246.46,3166.48,percent of total billed charges,
CAGE,8532019,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8532019,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
SCREW,8532020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW,8532020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
MESH BAG,8532033,CDM,278,RC,C1765,HCPCS,,,facility,inpatient,,,3920.00000,1136.80000,Aetna,First Health,,3206.56,,,,,,,1413.16,3206.56,percent of total billed charges,
MESH BAG,8532033,CDM,278,RC,C1765,HCPCS,,,facility,outpatient,,,3920.00000,1136.80000,Aetna,First Health,,3206.56,,,,,,,1262.24,3206.56,percent of total billed charges,
SCREW SPINAL,8534003,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SCREW SPINAL,8534003,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
SCREW SPINAL,8534005,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SCREW SPINAL,8534005,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
CAGE,8534007,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8534007,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
BASEPLATE,8534009,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8534009,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
CAGE,8534011,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8534011,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
PLATE SPINAL,8534013,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8534013,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BASEPLATE,8534015,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8534015,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
CAGE,8533999,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8533999,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
PLATE SPINAL,8534001,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,3001.16,6809.85,percent of total billed charges,
PLATE SPINAL,8534001,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,2680.65,6809.85,percent of total billed charges,
CAGE,8539927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8539927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
NAIL,8539925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8539925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
INSERT,8539930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,1049.78,2382.02,percent of total billed charges,
INSERT,8539930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,937.66,2382.02,percent of total billed charges,
PLATE SPINAL,8539932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8539932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8542279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8542279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,8542281,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
INSERT,8542281,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ANCHOR,8547929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
ANCHOR,8547929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
INSERT,8547931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8547931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8547933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8547933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM,8551925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
STEM,8551925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
SCREW,8551927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8551927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
PLATE,8551929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4774.07000,1384.48000,Aetna,First Health,,3905.19,,,,,,,1721.05,3905.19,percent of total billed charges,
PLATE,8551929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4774.07000,1384.48000,Aetna,First Health,,3905.19,,,,,,,1537.25,3905.19,percent of total billed charges,
COMPONENT FEMORAL,8553925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
COMPONENT FEMORAL,8553925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
PLATE,8556206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,507.78000,147.26000,Aetna,First Health,,415.36,,,,,,,183.05,415.36,percent of total billed charges,
PLATE,8556206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,507.78000,147.26000,Aetna,First Health,,415.36,,,,,,,163.51,415.36,percent of total billed charges,
SCREW SPINAL,8556208,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW SPINAL,8556208,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
ANCHOR,8559938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2070.72000,600.51000,Aetna,First Health,,1693.85,,,,,,,746.49,1693.85,percent of total billed charges,
ANCHOR,8559938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2070.72000,600.51000,Aetna,First Health,,1693.85,,,,,,,666.77,1693.85,percent of total billed charges,
HEAD FEMORAL,8559940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6471.50000,1876.74000,Aetna,First Health,,5293.69,,,,,,,2332.98,5293.69,percent of total billed charges,
HEAD FEMORAL,8559940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6471.50000,1876.74000,Aetna,First Health,,5293.69,,,,,,,2083.82,5293.69,percent of total billed charges,
INSERT,8563930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8563930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM,8563932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8563932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,8563934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8563934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
PLATE,8563937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1542.49,3500.02,percent of total billed charges,
PLATE,8563937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,First Health,,3500.02,,,,,,,1377.76,3500.02,percent of total billed charges,
SCREW,8563939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8563939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
ROD SPINAL,8563941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8563941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
SCREW,8563943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,8563943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,8563945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,8563945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,8563947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,8563947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,8563949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,8563949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,8563951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,8563951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,8563953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,8563953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,8563955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,8563955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
MESH,8563957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16407.25000,4758.10000,Aetna,First Health,,13421.13,,,,,,,5914.81,13421.13,percent of total billed charges,
MESH,8563957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16407.25000,4758.10000,Aetna,First Health,,13421.13,,,,,,,5283.13,13421.13,percent of total billed charges,
ANCHOR,8563959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3064.40000,888.68000,Aetna,First Health,,2506.68,,,,,,,1104.72,2506.68,percent of total billed charges,
ANCHOR,8563959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3064.40000,888.68000,Aetna,First Health,,2506.68,,,,,,,986.74,2506.68,percent of total billed charges,
SCREW,8563967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8563967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,8563968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8563968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,8563969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8563969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
WEDGE,8566062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1297.08,2943.16,percent of total billed charges,
WEDGE,8566062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1158.56,2943.16,percent of total billed charges,
INSERT,8566063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8566063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SHELL,8566064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
SHELL,8566064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
STENT,8566065,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT,8566065,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
STEM,8567931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26499.33000,7684.81000,Aetna,First Health,,21676.45,,,,,,,9553.01,21676.45,percent of total billed charges,
STEM,8567931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26499.33000,7684.81000,Aetna,First Health,,21676.45,,,,,,,8532.78,21676.45,percent of total billed charges,
TIGHTROPE,8567934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2393.00000,693.97000,Aetna,First Health,,1957.47,,,,,,,862.68,1957.47,percent of total billed charges,
TIGHTROPE,8567934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2393.00000,693.97000,Aetna,First Health,,1957.47,,,,,,,770.55,1957.47,percent of total billed charges,
INSERT,8573942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8573942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
COMPONENT FEMORAL,8573944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
COMPONENT FEMORAL,8573944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
BASEPLATE,8573946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8573946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
INSERT,8573948,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8573948,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
COMPONENT PATELLA,8573950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,8573950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8573952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,8573952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,8573954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,8573954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
GLENOSPHERE,8573956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5999.00000,1739.71000,Aetna,First Health,,4907.18,,,,,,,2162.64,4907.18,percent of total billed charges,
GLENOSPHERE,8573956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5999.00000,1739.71000,Aetna,First Health,,4907.18,,,,,,,1931.68,4907.18,percent of total billed charges,
STEM,8573958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2348.12,5328.04,percent of total billed charges,
STEM,8573958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2097.35,5328.04,percent of total billed charges,
BOLT SPINAL,8573960,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16150.00000,4683.50000,Aetna,First Health,,13210.70,,,,,,,5822.07,13210.70,percent of total billed charges,
BOLT SPINAL,8573960,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16150.00000,4683.50000,Aetna,First Health,,13210.70,,,,,,,5200.30,13210.70,percent of total billed charges,
STEM,8573962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,4346.82,9863.24,percent of total billed charges,
STEM,8573962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,3882.60,9863.24,percent of total billed charges,
SCREW,8573965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8573965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
GLENOSPHERE,8581925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1779.07,4036.83,percent of total billed charges,
GLENOSPHERE,8581925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1589.07,4036.83,percent of total billed charges,
SCREW SPINAL,8581927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW SPINAL,8581927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
ROD SPINAL,8581929,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2588.00000,750.52000,Aetna,First Health,,2116.98,,,,,,,932.97,2116.98,percent of total billed charges,
ROD SPINAL,8581929,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2588.00000,750.52000,Aetna,First Health,,2116.98,,,,,,,833.34,2116.98,percent of total billed charges,
SCREW,8589925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,671.84,1524.46,percent of total billed charges,
SCREW,8589925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,600.09,1524.46,percent of total billed charges,
ANCHOR,8589928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2372.00000,687.88000,Aetna,First Health,,1940.30,,,,,,,855.11,1940.30,percent of total billed charges,
ANCHOR,8589928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2372.00000,687.88000,Aetna,First Health,,1940.30,,,,,,,763.78,1940.30,percent of total billed charges,
HEAD HUMERAL,8589930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,8589930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,8589932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,1049.78,2382.02,percent of total billed charges,
INSERT,8589932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,937.66,2382.02,percent of total billed charges,
PLATE,8593927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,3076.60,6981.02,percent of total billed charges,
PLATE,8593927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,2748.03,6981.02,percent of total billed charges,
PLATE SPINAL,8595953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE SPINAL,8595953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
PLATE SPINAL,8595954,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1476.25,3349.71,percent of total billed charges,
PLATE SPINAL,8595954,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,First Health,,3349.71,,,,,,,1318.59,3349.71,percent of total billed charges,
SCREW SPINAL,8595955,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW SPINAL,8595955,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
CAGE,8595956,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19125.00000,5546.25000,Aetna,First Health,,15644.25,,,,,,,6894.56,15644.25,percent of total billed charges,
CAGE,8595956,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19125.00000,5546.25000,Aetna,First Health,,15644.25,,,,,,,6158.25,15644.25,percent of total billed charges,
STEM,8595982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8595982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CONNECTOR SPINAL,8597933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3850.00000,1116.50000,Aetna,First Health,,3149.30,,,,,,,1387.92,3149.30,percent of total billed charges,
CONNECTOR SPINAL,8597933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3850.00000,1116.50000,Aetna,First Health,,3149.30,,,,,,,1239.70,3149.30,percent of total billed charges,
PLATE SPINAL,8597935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
PLATE SPINAL,8597935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
NAIL,8597937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8597937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
STEM,8597939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8597939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE,8597941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5266.80000,1527.37000,Aetna,First Health,,4308.24,,,,,,,1898.68,4308.24,percent of total billed charges,
PLATE,8597941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5266.80000,1527.37000,Aetna,First Health,,4308.24,,,,,,,1695.91,4308.24,percent of total billed charges,
PLATE,8597943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3892.88000,1128.94000,Aetna,First Health,,3184.38,,,,,,,1403.38,3184.38,percent of total billed charges,
PLATE,8597943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3892.88000,1128.94000,Aetna,First Health,,3184.38,,,,,,,1253.51,3184.38,percent of total billed charges,
CAGE,8601929,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
CAGE,8601929,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
CONNECTOR SPINAL,8601931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
CONNECTOR SPINAL,8601931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
ROD SPINAL,8601933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
ROD SPINAL,8601933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
SCREW,8601935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8601935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8601937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8601937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8601939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8601939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8601941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8601941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8601943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8601943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8601945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8601945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
PLATE,8601947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8637.00000,2504.73000,Aetna,First Health,,7065.07,,,,,,,3113.64,7065.07,percent of total billed charges,
PLATE,8601947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8637.00000,2504.73000,Aetna,First Health,,7065.07,,,,,,,2781.11,7065.07,percent of total billed charges,
GRAFT STENT,8601949,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,38137.50000,11059.88000,Aetna,First Health,,31196.47,,,,,,,13748.57,31196.47,percent of total billed charges,
GRAFT STENT,8601949,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,38137.50000,11059.88000,Aetna,First Health,,31196.47,,,,,,,12280.27,31196.47,percent of total billed charges,
INSERT,8603980,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8603980,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
BASEPLATE,8603981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
BASEPLATE,8603981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
PLATE,8603982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2947.09,6687.15,percent of total billed charges,
PLATE,8603982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2632.35,6687.15,percent of total billed charges,
BASEPLATE,8605947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8605947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
PLATE SPINAL,8605951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8605951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
STEM,8607986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,8607986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
WEDGE,8607992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
WEDGE,8607992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
ANCHOR,8607994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1435.44000,416.28000,Aetna,First Health,,1174.19,,,,,,,517.48,1174.19,percent of total billed charges,
ANCHOR,8607994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1435.44000,416.28000,Aetna,First Health,,1174.19,,,,,,,462.21,1174.19,percent of total billed charges,
CATHETER DRAINAGE,8607996,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2059.64000,597.30000,Aetna,First Health,,1684.79,,,,,,,742.50,1684.79,percent of total billed charges,
CATHETER DRAINAGE,8607996,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2059.64000,597.30000,Aetna,First Health,,1684.79,,,,,,,663.20,1684.79,percent of total billed charges,
CATHETER DRAINAGE,7694134,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1484.32000,430.45000,Aetna,First Health,,1214.17,,,,,,,535.10,1214.17,percent of total billed charges,
CATHETER DRAINAGE,7694134,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1484.32000,430.45000,Aetna,First Health,,1214.17,,,,,,,477.95,1214.17,percent of total billed charges,
ROD SPINAL,8611928,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD SPINAL,8611928,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
SCREW SPINAL,8611931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8611931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
GRAFT,8611933,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3977.89000,1153.59000,Aetna,First Health,,3253.91,,,,,,,1434.03,3253.91,percent of total billed charges,
GRAFT,8611933,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3977.89000,1153.59000,Aetna,First Health,,3253.91,,,,,,,1280.88,3253.91,percent of total billed charges,
SCREW,8611934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8611934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
INSERT,8616103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8616103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
COMPONENT PATELLA,8616105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
COMPONENT PATELLA,8616105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8616107,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,8616107,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
SCREW SPINAL,8616109,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW SPINAL,8616109,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
CONNECTOR SPINAL,8616111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR SPINAL,8616111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
CONNECTOR SPINAL,8616113,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR SPINAL,8616113,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
NAIL,8617926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8617926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,8617928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8617928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
INSERT,8619936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8619936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
FEMORAL COMPONET,8619937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
FEMORAL COMPONET,8619937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
INSERT,8619938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8619938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SPACER,8619940,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
SPACER,8619940,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
BASEPLATE,8619939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8619939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
STEM,8619943,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17235.00000,4998.15000,Aetna,First Health,,14098.23,,,,,,,6213.22,14098.23,percent of total billed charges,
STEM,8619943,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17235.00000,4998.15000,Aetna,First Health,,14098.23,,,,,,,5549.67,14098.23,percent of total billed charges,
BASEPLATE,8619944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
BASEPLATE,8619944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
HEAD,8619945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11625.00000,3371.25000,Aetna,First Health,,9509.25,,,,,,,4190.81,9509.25,percent of total billed charges,
HEAD,8619945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11625.00000,3371.25000,Aetna,First Health,,9509.25,,,,,,,3743.25,9509.25,percent of total billed charges,
NECK,8619946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3056.00000,886.24000,Aetna,First Health,,2499.81,,,,,,,1101.69,2499.81,percent of total billed charges,
NECK,8619946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3056.00000,886.24000,Aetna,First Health,,2499.81,,,,,,,984.03,2499.81,percent of total billed charges,
ANCHOR,8619947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ANCHOR,8619947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
CAGE,8623987,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
CAGE,8623987,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
ROD SPINAL,8623988,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8623988,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW SPINAL,8623989,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW SPINAL,8623989,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CONNECTOR SPINAL,8623990,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
CONNECTOR SPINAL,8623990,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
ADAPTOR SPINAL,8623991,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2700.00000,783.00000,Aetna,First Health,,2208.60,,,,,,,973.35,2208.60,percent of total billed charges,
ADAPTOR SPINAL,8623991,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2700.00000,783.00000,Aetna,First Health,,2208.60,,,,,,,869.40,2208.60,percent of total billed charges,
GLENOSPHERE,8623992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7860.00000,2279.40000,Aetna,First Health,,6429.48,,,,,,,2833.53,6429.48,percent of total billed charges,
GLENOSPHERE,8623992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7860.00000,2279.40000,Aetna,First Health,,6429.48,,,,,,,2530.92,6429.48,percent of total billed charges,
NAIL,8619948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8619948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
BILATERAL TMJ IMPLANT,8437324,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,50440.00000,14627.60000,Aetna,First Health,,41259.92,,,,,,,18183.62,41259.92,percent of total billed charges,
BILATERAL TMJ IMPLANT,8437324,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,50440.00000,14627.60000,Aetna,First Health,,41259.92,,,,,,,16241.68,41259.92,percent of total billed charges,
CEMENT,7702816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2880.00000,835.20000,Aetna,First Health,,2355.84,,,,,,,1038.24,2355.84,percent of total billed charges,
CEMENT,7702816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2880.00000,835.20000,Aetna,First Health,,2355.84,,,,,,,927.36,2355.84,percent of total billed charges,
ROD SPINAL,8627938,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
ROD SPINAL,8627938,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
GLENOSPHERE,8627940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1779.07,4036.83,percent of total billed charges,
GLENOSPHERE,8627940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1589.07,4036.83,percent of total billed charges,
INSERT,8627942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8627942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
NAIL,8627944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,8627944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
LINER,8633928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8633928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
INSERT,8633930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8633930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
STEM,8633932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10971.00000,3181.59000,Aetna,First Health,,8974.28,,,,,,,3955.05,8974.28,percent of total billed charges,
STEM,8633932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10971.00000,3181.59000,Aetna,First Health,,8974.28,,,,,,,3532.66,8974.28,percent of total billed charges,
CABLE,8633934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2892.00000,838.68000,Aetna,First Health,,2365.66,,,,,,,1042.57,2365.66,percent of total billed charges,
CABLE,8633934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2892.00000,838.68000,Aetna,First Health,,2365.66,,,,,,,931.22,2365.66,percent of total billed charges,
STEM,8633936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8633936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW SPINAL,8638435,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW SPINAL,8638435,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SHELL,8638437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,8638437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW,8638439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8638439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8638441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8638441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8638456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,132.88,301.51,percent of total billed charges,
SCREW,8638456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,First Health,,301.51,,,,,,,118.69,301.51,percent of total billed charges,
PLATE,8638443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5676.30000,1646.13000,Aetna,First Health,,4643.21,,,,,,,2046.31,4643.21,percent of total billed charges,
PLATE,8638443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5676.30000,1646.13000,Aetna,First Health,,4643.21,,,,,,,1827.77,4643.21,percent of total billed charges,
SCREW,8638445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8638445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8638447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8638447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8638449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8638449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8638451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,8638451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
CAGE,8638453,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8638453,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
BOLT SPINAL,8640003,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BOLT SPINAL,8640003,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
HEAD FEMORAL,8640005,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,8640005,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
CAGE,8640007,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8640007,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
CAGE,8640009,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8640009,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
CAGE,8640011,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8640011,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
SCREW SPINAL,8640013,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SCREW SPINAL,8640013,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
PLATE,8639993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,First Health,,5053.19,,,,,,,2226.99,5053.19,percent of total billed charges,
PLATE,8639993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,First Health,,5053.19,,,,,,,1989.15,5053.19,percent of total billed charges,
PLATE,8639995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3344.67000,969.95000,Aetna,First Health,,2735.94,,,,,,,1205.75,2735.94,percent of total billed charges,
PLATE,8639995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3344.67000,969.95000,Aetna,First Health,,2735.94,,,,,,,1076.98,2735.94,percent of total billed charges,
END CAP,8639997,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
END CAP,8639997,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
SCREW,8639999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8639999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
INSERT,8640001,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT,8640001,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
PLATE SPINAL,8643934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,4217.85,9570.60,percent of total billed charges,
PLATE SPINAL,8643934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,First Health,,9570.60,,,,,,,3767.40,9570.60,percent of total billed charges,
SCREW SPINAL,8643935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SCREW SPINAL,8643935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
STEM,8643926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7746.00000,2246.34000,Aetna,First Health,,6336.23,,,,,,,2792.43,6336.23,percent of total billed charges,
STEM,8643926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7746.00000,2246.34000,Aetna,First Health,,6336.23,,,,,,,2494.21,6336.23,percent of total billed charges,
STEM,8643927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7746.00000,2246.34000,Aetna,First Health,,6336.23,,,,,,,2792.43,6336.23,percent of total billed charges,
STEM,8643927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7746.00000,2246.34000,Aetna,First Health,,6336.23,,,,,,,2494.21,6336.23,percent of total billed charges,
STEM,8643928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6191.50000,1795.54000,Aetna,First Health,,5064.65,,,,,,,2232.04,5064.65,percent of total billed charges,
STEM,8643928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6191.50000,1795.54000,Aetna,First Health,,5064.65,,,,,,,1993.66,5064.65,percent of total billed charges,
WEDGE,8643930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
WEDGE,8643930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
WEDGE,8643931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
WEDGE,8643931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
ROD SPINAL,8643932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8643932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CEMENT,8643933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1659.30000,481.20000,Aetna,First Health,,1357.31,,,,,,,598.18,1357.31,percent of total billed charges,
CEMENT,8643933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1659.30000,481.20000,Aetna,First Health,,1357.31,,,,,,,534.29,1357.31,percent of total billed charges,
SPINAL FIXATION,8643941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
SPINAL FIXATION,8643941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW SPINAL,8643942,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8643942,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8643943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8643943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8643944,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8643944,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8643946,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8643946,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
ROD SPINAL,8643947,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,677.74,1537.84,percent of total billed charges,
ROD SPINAL,8643947,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,605.36,1537.84,percent of total billed charges,
SPINAL FIXATION,8643948,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
SPINAL FIXATION,8643948,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SPINAL FIXATION,8643949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
SPINAL FIXATION,8643949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
SCREW SPINAL,8643950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8643950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8643951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8643951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8647925,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8647925,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8643952,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8643952,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8643953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW SPINAL,8643953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
ROD SPINAL,8643954,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,677.74,1537.84,percent of total billed charges,
ROD SPINAL,8643954,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,605.36,1537.84,percent of total billed charges,
SCREW SPINAL,8643955,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW SPINAL,8643955,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW SPINAL,8643956,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
SCREW SPINAL,8643956,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW SPINAL,8643957,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
SCREW SPINAL,8643957,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
ADAPTER SPINAL,8643958,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ADAPTER SPINAL,8643958,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
INSERT,8647927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,8647927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
STEM,8647929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8647929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
STEM,8647931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2348.12,5328.04,percent of total billed charges,
STEM,8647931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2097.35,5328.04,percent of total billed charges,
SCREW,8647933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1696.00000,491.84000,Aetna,First Health,,1387.33,,,,,,,611.41,1387.33,percent of total billed charges,
SCREW,8647933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1696.00000,491.84000,Aetna,First Health,,1387.33,,,,,,,546.11,1387.33,percent of total billed charges,
GLENOSPHERE,8647935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5999.00000,1739.71000,Aetna,First Health,,4907.18,,,,,,,2162.64,4907.18,percent of total billed charges,
GLENOSPHERE,8647935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5999.00000,1739.71000,Aetna,First Health,,4907.18,,,,,,,1931.68,4907.18,percent of total billed charges,
URETHRAL BULKING SYSTEM,8516833,CDM,278,RC,L8606,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
URETHRAL BULKING SYSTEM,8516833,CDM,278,RC,L8606,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,268.67,3650.32,percent of total billed charges,
STEM,8649925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,8649925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
HEAD HUMERAL,8649928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,8649928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
SCREW SPINAL,8649931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW SPINAL,8649931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW SPINAL,8649933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW SPINAL,8649933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
TIBIAL TRAY,8649935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,7417.29,16830.35,percent of total billed charges,
TIBIAL TRAY,8649935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,6625.15,16830.35,percent of total billed charges,
COMPONENT TIBIAL,8649936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3360.22,7624.58,percent of total billed charges,
COMPONENT TIBIAL,8649936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3001.36,7624.58,percent of total billed charges,
STEM,8651983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,8651983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
INSERT,8651985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8651985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
SCREW SPINAL,8651987,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW SPINAL,8651987,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW SPINAL,8651989,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW SPINAL,8651989,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
CANNULA,7736524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,371.76000,107.81000,Aetna,First Health,,304.10,,,,,,,134.02,304.10,percent of total billed charges,
CANNULA,7736524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,371.76000,107.81000,Aetna,First Health,,304.10,,,,,,,119.71,304.10,percent of total billed charges,
INSERT,8655925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8655925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
ANCHOR,8659925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2000.00000,580.00000,Aetna,First Health,,1636.00,,,,,,,721.00,1636.00,percent of total billed charges,
ANCHOR,8659925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2000.00000,580.00000,Aetna,First Health,,1636.00,,,,,,,644.00,1636.00,percent of total billed charges,
NAIL,8659926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL,8659926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
NAIL,8659927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8659927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
ROD SPINAL,8667926,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8667926,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
LINER,8667928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,8667928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
HEAD FEMORAL,8667930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
HEAD FEMORAL,8667930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
STEM,8667932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,8667932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
COMPONENT FEMORAL,8667934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
COMPONENT FEMORAL,8667934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
INSERT,8667936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8667936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
STEM,8667938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8667938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
COMPONENT TIBIAL,8667940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,8667940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
PLATE SPINAL,8667942,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4503.52000,1306.02000,Aetna,First Health,,3683.88,,,,,,,1623.52,3683.88,percent of total billed charges,
PLATE SPINAL,8667942,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4503.52000,1306.02000,Aetna,First Health,,3683.88,,,,,,,1450.13,3683.88,percent of total billed charges,
SCREW SPINAL,8667944,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW SPINAL,8667944,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
NAIL,8667946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8667946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,8667948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8667948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
WASHER,8667950,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,219.00,496.94,percent of total billed charges,
WASHER,8667950,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,195.62,496.94,percent of total billed charges,
SCREW,8667952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1322.00000,383.38000,Aetna,First Health,,1081.40,,,,,,,476.58,1081.40,percent of total billed charges,
SCREW,8667952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1322.00000,383.38000,Aetna,First Health,,1081.40,,,,,,,425.68,1081.40,percent of total billed charges,
SCREW,8667954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1322.00000,383.38000,Aetna,First Health,,1081.40,,,,,,,476.58,1081.40,percent of total billed charges,
SCREW,8667954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1322.00000,383.38000,Aetna,First Health,,1081.40,,,,,,,425.68,1081.40,percent of total billed charges,
NAIL,8667956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8667956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
NAIL,8667957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1499.05,3401.45,percent of total billed charges,
NAIL,8667957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,First Health,,3401.45,,,,,,,1338.96,3401.45,percent of total billed charges,
ROD SPINAL,8671934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
ROD SPINAL,8671934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
ROD SPINAL,8671936,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8671936,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW SPINAL,8671938,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8671938,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW SPINAL,8671939,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8671939,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW SPINAL,8671940,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8671940,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW SPINAL,8671941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8671941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
INSERT,8671925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8671925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
HEAD HUMERAL,8679925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,8679925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
STEM,8679927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8679927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
ROD SPINAL,8679929,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
ROD SPINAL,8679929,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
SCREW SPINAL,8679931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW SPINAL,8679931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
SCREW SPINAL,8679933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
SCREW SPINAL,8679933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
CAGE,8679935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9675.00000,2805.75000,Aetna,First Health,,7914.15,,,,,,,3487.84,7914.15,percent of total billed charges,
CAGE,8679935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9675.00000,2805.75000,Aetna,First Health,,7914.15,,,,,,,3115.35,7914.15,percent of total billed charges,
CAGE,8679937,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,8679937,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
GRAFT,8679939,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4140.57000,1200.77000,Aetna,First Health,,3386.99,,,,,,,1492.68,3386.99,percent of total billed charges,
GRAFT,8679939,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4140.57000,1200.77000,Aetna,First Health,,3386.99,,,,,,,1333.26,3386.99,percent of total billed charges,
GRAFT,8679940,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4308.92000,1249.59000,Aetna,First Health,,3524.70,,,,,,,1553.37,3524.70,percent of total billed charges,
GRAFT,8679940,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4308.92000,1249.59000,Aetna,First Health,,3524.70,,,,,,,1387.47,3524.70,percent of total billed charges,
GRAFT,8679941,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4308.92000,1249.59000,Aetna,First Health,,3524.70,,,,,,,1553.37,3524.70,percent of total billed charges,
GRAFT,8679941,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4308.92000,1249.59000,Aetna,First Health,,3524.70,,,,,,,1387.47,3524.70,percent of total billed charges,
GRAFT,8679942,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4642.26000,1346.26000,Aetna,First Health,,3797.37,,,,,,,1673.53,3797.37,percent of total billed charges,
GRAFT,8679942,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4642.26000,1346.26000,Aetna,First Health,,3797.37,,,,,,,1494.81,3797.37,percent of total billed charges,
STENT,8679985,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10928.25000,3169.19000,Aetna,First Health,,8939.31,,,,,,,3939.63,8939.31,percent of total billed charges,
STENT,8679985,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10928.25000,3169.19000,Aetna,First Health,,8939.31,,,,,,,3518.90,8939.31,percent of total billed charges,
SCREW SPINAL,8682002,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8682002,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW SPINAL,8682003,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
SCREW SPINAL,8682003,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
SCREW,8682004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8682004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
PLATE,8682005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3635.63000,1054.33000,Aetna,First Health,,2973.95,,,,,,,1310.64,2973.95,percent of total billed charges,
PLATE,8682005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3635.63000,1054.33000,Aetna,First Health,,2973.95,,,,,,,1170.67,2973.95,percent of total billed charges,
NAIL,8682258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8682258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
MESH,8682253,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,11025.45000,3197.38000,Aetna,First Health,,9018.82,,,,,,,3974.67,9018.82,percent of total billed charges,
MESH,8682253,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,11025.45000,3197.38000,Aetna,First Health,,9018.82,,,,,,,3550.19,9018.82,percent of total billed charges,
ANCHOR,8682257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3990.53000,1157.25000,Aetna,First Health,,3264.25,,,,,,,1438.59,3264.25,percent of total billed charges,
ANCHOR,8682257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3990.53000,1157.25000,Aetna,First Health,,3264.25,,,,,,,1284.95,3264.25,percent of total billed charges,
MESH,8682260,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,11025.45000,3197.38000,Aetna,First Health,,9018.82,,,,,,,3974.67,9018.82,percent of total billed charges,
MESH,8682260,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,11025.45000,3197.38000,Aetna,First Health,,9018.82,,,,,,,3550.19,9018.82,percent of total billed charges,
BOLT SPINAL,8683952,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BOLT SPINAL,8683952,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
CAGE,8686213,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8686213,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
INSERT,8686214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8686214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
TIBIAL BASE,8686215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
TIBIAL BASE,8686215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
FEMORAL COMPONET,8686216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
FEMORAL COMPONET,8686216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
HUMERAL STEM,8686217,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2348.12,5328.04,percent of total billed charges,
HUMERAL STEM,8686217,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,First Health,,5328.04,,,,,,,2097.35,5328.04,percent of total billed charges,
INSERT,8686218,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,1049.78,2382.02,percent of total billed charges,
INSERT,8686218,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,First Health,,2382.02,,,,,,,937.66,2382.02,percent of total billed charges,
SCREW,8686219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,398.34000,115.52000,Aetna,First Health,,325.84,,,,,,,143.60,325.84,percent of total billed charges,
SCREW,8686219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,398.34000,115.52000,Aetna,First Health,,325.84,,,,,,,128.27,325.84,percent of total billed charges,
GLENOID,8689925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,2149.26,4876.83,percent of total billed charges,
GLENOID,8689925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,1919.73,4876.83,percent of total billed charges,
ROD SPINAL,8689927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
ROD SPINAL,8689927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
INSERT,8693925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8693925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
FEMORAL STEM,8693926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
FEMORAL STEM,8693926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
CAGE,8693927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1254.66,2846.91,percent of total billed charges,
CAGE,8693927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,First Health,,2846.91,,,,,,,1120.67,2846.91,percent of total billed charges,
ACETABLULAR INSERT,8693928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
ACETABLULAR INSERT,8693928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SPACER SPINAL,8695955,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
SPACER SPINAL,8695955,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
FEMORAL COMPONET,8697925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
FEMORAL COMPONET,8697925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
SPACER,8697927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
SPACER,8697927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
CONE,8697929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3738.75,8483.48,percent of total billed charges,
CONE,8697929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,First Health,,8483.48,,,,,,,3339.46,8483.48,percent of total billed charges,
SCREW SPINAL,8701934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,450.62,1022.50,percent of total billed charges,
SCREW SPINAL,8701934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,First Health,,1022.50,,,,,,,402.50,1022.50,percent of total billed charges,
CAGE,8701936,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
CAGE,8701936,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
SCREW,8701948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.06000,86.73000,Aetna,First Health,,244.63,,,,,,,107.81,244.63,percent of total billed charges,
SCREW,8701948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.06000,86.73000,Aetna,First Health,,244.63,,,,,,,96.30,244.63,percent of total billed charges,
CONNECTOR SPINAL,8705925,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,624.39,1416.78,percent of total billed charges,
CONNECTOR SPINAL,8705925,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,557.70,1416.78,percent of total billed charges,
STEM,8705927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,8705927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
SCREW SPINAL,8707943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW SPINAL,8707943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
CAGE,8709932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8709932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
PLATE SPINAL,8709934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1291.62,2930.77,percent of total billed charges,
PLATE SPINAL,8709934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1153.68,2930.77,percent of total billed charges,
SCREW,8709936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8709936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW,8709938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8709938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
PLATE SPINAL,8713927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8713927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8713925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8713925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8719933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
CAGE,8719933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
STEM,8719935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8719935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
SCREW,8719937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8719937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
PLATE,8719939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1211.28,2748.48,percent of total billed charges,
PLATE,8719939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,First Health,,2748.48,,,,,,,1081.92,2748.48,percent of total billed charges,
SCREW,8719940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8719940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8719942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8719942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8719944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8719944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,8719946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8719946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
INSERT,8726160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8726160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,8726162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8726162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SCREW,8726164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,8726164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
SCREW,8726166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,860.87,1953.38,percent of total billed charges,
SCREW,8726166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,768.94,1953.38,percent of total billed charges,
STEM,8726168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8726168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
STEM,8726170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8726170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
BASEPLATE,8726173,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8726173,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
COMPONENT GLENOID,8730160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,2149.26,4876.83,percent of total billed charges,
COMPONENT GLENOID,8730160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,1919.73,4876.83,percent of total billed charges,
INSERT,8730120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8730120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT TIBIAL,8732092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
COMPONENT TIBIAL,8732092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
STEM,8736084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
STEM,8736084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,8736087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8736087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
WEDGE,8740094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
WEDGE,8740094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
PLATE,8742084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5029.50000,1458.55000,Aetna,First Health,,4114.13,,,,,,,1813.13,4114.13,percent of total billed charges,
PLATE,8742084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5029.50000,1458.55000,Aetna,First Health,,4114.13,,,,,,,1619.50,4114.13,percent of total billed charges,
PLATE,8742086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,3076.60,6981.02,percent of total billed charges,
PLATE,8742086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,2748.03,6981.02,percent of total billed charges,
INSERT,8742088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8742088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,8742090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8742090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,8746097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8746097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,8750142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8750142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STEM,8754094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,8754094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
PLATE,8754096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4137.00000,1199.73000,Aetna,First Health,,3384.07,,,,,,,1491.39,3384.07,percent of total billed charges,
PLATE,8754096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4137.00000,1199.73000,Aetna,First Health,,3384.07,,,,,,,1332.11,3384.07,percent of total billed charges,
INSERT,8754098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8754098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
KIT BOX CABLE PLATE,8758089,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4973.50000,1442.31000,Aetna,First Health,,4068.32,,,,,,,1792.95,4068.32,percent of total billed charges,
KIT BOX CABLE PLATE,8758089,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4973.50000,1442.31000,Aetna,First Health,,4068.32,,,,,,,1601.47,4068.32,percent of total billed charges,
KIT BOX CABLE PLATE,8758090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5099.50000,1478.85000,Aetna,First Health,,4171.39,,,,,,,1838.37,4171.39,percent of total billed charges,
KIT BOX CABLE PLATE,8758090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5099.50000,1478.85000,Aetna,First Health,,4171.39,,,,,,,1642.04,4171.39,percent of total billed charges,
KIT BOX CABLE PLATE,8758091,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6611.50000,1917.33000,Aetna,First Health,,5408.21,,,,,,,2383.45,5408.21,percent of total billed charges,
KIT BOX CABLE PLATE,8758091,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6611.50000,1917.33000,Aetna,First Health,,5408.21,,,,,,,2128.90,5408.21,percent of total billed charges,
SCREW SPINAL,8760150,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
SCREW SPINAL,8760150,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
SCREW SPINAL,8760152,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
SCREW SPINAL,8760152,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
STENT,8760154,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT,8760154,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
STENT,8760156,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,12038.72,27316.70,percent of total billed charges,
STENT,8760156,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,First Health,,27316.70,,,,,,,10753.03,27316.70,percent of total billed charges,
SCREW,8760158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5369.00000,1557.01000,Aetna,First Health,,4391.84,,,,,,,1935.52,4391.84,percent of total billed charges,
SCREW,8760158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5369.00000,1557.01000,Aetna,First Health,,4391.84,,,,,,,1728.82,4391.84,percent of total billed charges,
STEM,8760160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8760160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
NAIL,8760162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8760162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
STEM,8760164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2811.90,6380.40,percent of total billed charges,
STEM,8760164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2511.60,6380.40,percent of total billed charges,
ANCHOR,8760166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2099.00000,608.71000,Aetna,First Health,,1716.98,,,,,,,756.69,1716.98,percent of total billed charges,
ANCHOR,8760166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2099.00000,608.71000,Aetna,First Health,,1716.98,,,,,,,675.88,1716.98,percent of total billed charges,
SCREW,8764085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5369.00000,1557.01000,Aetna,First Health,,4391.84,,,,,,,1935.52,4391.84,percent of total billed charges,
SCREW,8764085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5369.00000,1557.01000,Aetna,First Health,,4391.84,,,,,,,1728.82,4391.84,percent of total billed charges,
GLENOSPHERE,8764088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
GLENOSPHERE,8764088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
STEM,8764090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,8764090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
INSERT,8764092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8764092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
CAGE,8764094,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,8764094,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
BOLT SPINAL,8764096,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16150.00000,4683.50000,Aetna,First Health,,13210.70,,,,,,,5822.07,13210.70,percent of total billed charges,
BOLT SPINAL,8764096,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16150.00000,4683.50000,Aetna,First Health,,13210.70,,,,,,,5200.30,13210.70,percent of total billed charges,
INSERT,8764087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8764087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
SCREW,8766235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8766235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8766237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8766237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8766239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8766239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
PLATE,8766241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4634.00000,1343.86000,Aetna,First Health,,3790.61,,,,,,,1670.56,3790.61,percent of total billed charges,
PLATE,8766241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4634.00000,1343.86000,Aetna,First Health,,3790.61,,,,,,,1492.15,3790.61,percent of total billed charges,
PLATE,8766243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
PLATE,8766243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
INSERT,8766247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8766247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ROD SPINAL,8766249,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD SPINAL,8766249,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,8766245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,8766245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
PLATE,8768240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE,8768240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
WRENCH,8768242,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,3124.96000,906.24000,Aetna,First Health,,2556.22,,,,,,,1126.55,2556.22,percent of total billed charges,
WRENCH,8768242,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,3124.96000,906.24000,Aetna,First Health,,2556.22,,,,,,,1006.24,2556.22,percent of total billed charges,
SCREW,8768243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,309.75000,89.83000,Aetna,First Health,,253.38,,,,,,,111.66,253.38,percent of total billed charges,
SCREW,8768243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,309.75000,89.83000,Aetna,First Health,,253.38,,,,,,,99.74,253.38,percent of total billed charges,
DISTRACTOR,8768245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11227.35000,3255.93000,Aetna,First Health,,9183.97,,,,,,,4047.46,9183.97,percent of total billed charges,
DISTRACTOR,8768245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11227.35000,3255.93000,Aetna,First Health,,9183.97,,,,,,,3615.21,9183.97,percent of total billed charges,
CATHETER,7696349,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,356.58000,103.41000,Aetna,First Health,,291.68,,,,,,,128.55,291.68,percent of total billed charges,
CATHETER,7696349,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,356.58000,103.41000,Aetna,First Health,,291.68,,,,,,,114.82,291.68,percent of total billed charges,
LINER,8772096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,8772096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
COMPONENT FEMORAL,8772097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
COMPONENT FEMORAL,8772097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
INSERT,8772098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8772098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,8772095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT,8772095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
LINER,8776135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
LINER,8776135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STEM,8776139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17486.75000,5071.16000,Aetna,First Health,,14304.16,,,,,,,6303.97,14304.16,percent of total billed charges,
STEM,8776139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17486.75000,5071.16000,Aetna,First Health,,14304.16,,,,,,,5630.73,14304.16,percent of total billed charges,
SCREW,8776141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8776141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
NAIL,8776143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8360.52000,2424.55000,Aetna,First Health,,6838.91,,,,,,,3013.97,6838.91,percent of total billed charges,
NAIL,8776143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8360.52000,2424.55000,Aetna,First Health,,6838.91,,,,,,,2692.09,6838.91,percent of total billed charges,
SCREW,8776145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8776145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8776165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8776165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
BASEPLATE,8776147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22500.00000,6525.00000,Aetna,First Health,,18405.00,,,,,,,8111.25,18405.00,percent of total billed charges,
BASEPLATE,8776147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22500.00000,6525.00000,Aetna,First Health,,18405.00,,,,,,,7245.00,18405.00,percent of total billed charges,
SHOULDER PROSTHESIS,8776137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
SHOULDER PROSTHESIS,8776137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
BASEPLATE,8780084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,2171.47,4927.22,percent of total billed charges,
BASEPLATE,8780084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,First Health,,4927.22,,,,,,,1939.57,4927.22,percent of total billed charges,
INSERT,8780086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8780086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,8780088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8780088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,8780090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,8780090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
CAGE,8780092,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,8780092,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
CAGE,8780094,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8780094,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
LINER,8780110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1873.70,4251.56,percent of total billed charges,
LINER,8780110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,First Health,,4251.56,,,,,,,1673.60,4251.56,percent of total billed charges,
SHELL,8780111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
SHELL,8780111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
CAGE,8780112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8780112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SYSTEM IMPLANT FHL,8780113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
SYSTEM IMPLANT FHL,8780113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
SCREW SPINAL,8784138,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW SPINAL,8784138,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
CAGE,8784139,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,8784139,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
CAGE,8784141,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,8784141,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
ROD SPINAL,8784144,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
ROD SPINAL,8784144,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
SCREW,8784146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,357.44000,103.66000,Aetna,First Health,,292.39,,,,,,,128.86,292.39,percent of total billed charges,
SCREW,8784146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,357.44000,103.66000,Aetna,First Health,,292.39,,,,,,,115.10,292.39,percent of total billed charges,
SCREW,8784148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.41000,95.53000,Aetna,First Health,,269.46,,,,,,,118.75,269.46,percent of total billed charges,
SCREW,8784148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.41000,95.53000,Aetna,First Health,,269.46,,,,,,,106.07,269.46,percent of total billed charges,
SCREW,8784150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,351.60000,101.96000,Aetna,First Health,,287.61,,,,,,,126.75,287.61,percent of total billed charges,
SCREW,8784150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,351.60000,101.96000,Aetna,First Health,,287.61,,,,,,,113.22,287.61,percent of total billed charges,
COMPONENT FEMORAL,8786162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,8786162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
SCREW,8786163,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,8786163,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
COMPONENT FEMORAL,8788104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
COMPONENT FEMORAL,8788104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
LINER,8788108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8788108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
LINER,8788110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
LINER,8788110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
CAGE,8788113,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,7502.91,17024.62,percent of total billed charges,
CAGE,8788113,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,First Health,,17024.62,,,,,,,6701.62,17024.62,percent of total billed charges,
SCREW,8792085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8792085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
PLATE,8792087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.70000,1380.60000,Aetna,First Health,,3894.25,,,,,,,1716.23,3894.25,percent of total billed charges,
PLATE,8792087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.70000,1380.60000,Aetna,First Health,,3894.25,,,,,,,1532.95,3894.25,percent of total billed charges,
SCREW,8792089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW,8792089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
NAIL,8792091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8792091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
COMPONENT FEMORAL,8796087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,8796087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
INSERT,8796089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,8796089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,8796091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
INSERT,8796091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
PLATE,8796093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1715.04000,497.36000,Aetna,First Health,,1402.90,,,,,,,618.27,1402.90,percent of total billed charges,
PLATE,8796093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1715.04000,497.36000,Aetna,First Health,,1402.90,,,,,,,552.24,1402.90,percent of total billed charges,
BONE GRAFT,8796095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2936.00000,851.44000,Aetna,First Health,,2401.65,,,,,,,1058.43,2401.65,percent of total billed charges,
BONE GRAFT,8796095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2936.00000,851.44000,Aetna,First Health,,2401.65,,,,,,,945.39,2401.65,percent of total billed charges,
BONE GRAFT,8796098,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,4658.50000,1350.96000,Aetna,First Health,,3810.65,,,,,,,1679.39,3810.65,percent of total billed charges,
BONE GRAFT,8796098,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,4658.50000,1350.96000,Aetna,First Health,,3810.65,,,,,,,1500.04,3810.65,percent of total billed charges,
HEAD HUMERAL,8798136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
HEAD HUMERAL,8798136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
STEM,8798139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,8798139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
PLATE,8802084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2760.60000,800.57000,Aetna,First Health,,2258.17,,,,,,,995.20,2258.17,percent of total billed charges,
PLATE,8802084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2760.60000,800.57000,Aetna,First Health,,2258.17,,,,,,,888.91,2258.17,percent of total billed charges,
ACETABULAR AUGMENT,8802085,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
ACETABULAR AUGMENT,8802085,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
STENT,8802086,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT,8802086,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STEM,8812084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8812084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
WEDGE,8812086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1297.08,2943.16,percent of total billed charges,
WEDGE,8812086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1158.56,2943.16,percent of total billed charges,
WEDGE,8812088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
WEDGE,8812088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
INSERT,8812090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8812090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
ROD SPINAL,8812092,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8812092,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
WEDGE,8812094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
WEDGE,8812094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
STENT,8812096,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4558.52,10343.61,percent of total billed charges,
STENT,8812096,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4071.69,10343.61,percent of total billed charges,
GRAFT,8812098,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
GRAFT,8812098,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
GRAFT,8812100,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
GRAFT,8812100,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
GRAFT,8812102,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
GRAFT,8812102,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
CATHETER,8812104,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,488.12,1107.57,percent of total billed charges,
CATHETER,8812104,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,435.99,1107.57,percent of total billed charges,
CATHETER,8812105,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,488.12,1107.57,percent of total billed charges,
CATHETER,8812105,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,435.99,1107.57,percent of total billed charges,
CAGE,8824084,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8824084,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
STENT,8824086,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824086,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824088,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824088,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824090,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824090,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824092,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824092,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824094,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824094,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824096,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824096,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824098,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824098,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824100,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824100,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824102,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824102,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824104,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824104,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824106,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824106,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824108,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,160.28,363.68,percent of total billed charges,
STENT,8824108,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,First Health,,363.68,,,,,,,143.16,363.68,percent of total billed charges,
STENT,8824110,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
STENT,8824110,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
NAIL,8824112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8824112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,8824114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8824114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,8824116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8824116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,8824118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8824118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
NAIL,8824120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8824120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
PLATE,8824122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8824122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
PIN,8824128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,130.14,295.30,percent of total billed charges,
PIN,8824128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,116.24,295.30,percent of total billed charges,
SCREW,7698039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,576.80,1308.80,percent of total billed charges,
SCREW,7698039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,515.20,1308.80,percent of total billed charges,
SCREW,8828088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,576.80,1308.80,percent of total billed charges,
SCREW,8828088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,515.20,1308.80,percent of total billed charges,
ROD SPINAL,8828090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
ROD SPINAL,8828090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
ROD SPINAL,8828092,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
ROD SPINAL,8828092,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
INTRODUCER,8828094,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,First Health,,2545.62,,,,,,,1121.88,2545.62,percent of total billed charges,
INTRODUCER,8828094,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,First Health,,2545.62,,,,,,,1002.06,2545.62,percent of total billed charges,
SCREW,8828098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1239.20000,359.37000,Aetna,First Health,,1013.67,,,,,,,446.73,1013.67,percent of total billed charges,
SCREW,8828098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1239.20000,359.37000,Aetna,First Health,,1013.67,,,,,,,399.02,1013.67,percent of total billed charges,
PLATE,8828099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6373.50000,1848.31000,Aetna,First Health,,5213.52,,,,,,,2297.65,5213.52,percent of total billed charges,
PLATE,8828099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6373.50000,1848.31000,Aetna,First Health,,5213.52,,,,,,,2052.27,5213.52,percent of total billed charges,
PLATE,8828100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4668.30000,1353.81000,Aetna,First Health,,3818.67,,,,,,,1682.92,3818.67,percent of total billed charges,
PLATE,8828100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4668.30000,1353.81000,Aetna,First Health,,3818.67,,,,,,,1503.19,3818.67,percent of total billed charges,
ANCHOR,8828101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
ANCHOR,8828101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,8840084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8840084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
K WIRE,8848084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,304.48000,88.30000,Aetna,First Health,,249.06,,,,,,,109.77,249.06,percent of total billed charges,
K WIRE,8848084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,304.48000,88.30000,Aetna,First Health,,249.06,,,,,,,98.04,249.06,percent of total billed charges,
SCREW,8848087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,8848087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,8848089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,8848089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,8848091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,8848091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,8848093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8848093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8848095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8848095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8848097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8848097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
PLATE,8848099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5105.10000,1480.48000,Aetna,First Health,,4175.97,,,,,,,1840.39,4175.97,percent of total billed charges,
PLATE,8848099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5105.10000,1480.48000,Aetna,First Health,,4175.97,,,,,,,1643.84,4175.97,percent of total billed charges,
SCREW,8848102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,8848102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
PLATE SPINAL,8848104,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8848104,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
STENT,8848111,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
STENT,8848111,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
STENT,8848117,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,949.73000,275.42000,Aetna,First Health,,776.88,,,,,,,342.38,776.88,percent of total billed charges,
STENT,8848117,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,949.73000,275.42000,Aetna,First Health,,776.88,,,,,,,305.81,776.88,percent of total billed charges,
SCREW,8848106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8848106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8848112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,621.93,1411.21,percent of total billed charges,
SCREW,8848112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,First Health,,1411.21,,,,,,,555.51,1411.21,percent of total billed charges,
K WIRE,8848113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,144.06000,41.78000,Aetna,First Health,,117.84,,,,,,,51.93,117.84,percent of total billed charges,
K WIRE,8848113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,144.06000,41.78000,Aetna,First Health,,117.84,,,,,,,46.39,117.84,percent of total billed charges,
SCREW,8848107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8848107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,8848108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8848108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,8848109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8848109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
PLATE,8848110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8183.76000,2373.29000,Aetna,First Health,,6694.32,,,,,,,2950.25,6694.32,percent of total billed charges,
PLATE,8848110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8183.76000,2373.29000,Aetna,First Health,,6694.32,,,,,,,2635.17,6694.32,percent of total billed charges,
SCREW,8848114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1217.00000,352.93000,Aetna,First Health,,995.51,,,,,,,438.73,995.51,percent of total billed charges,
SCREW,8848114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1217.00000,352.93000,Aetna,First Health,,995.51,,,,,,,391.87,995.51,percent of total billed charges,
RESERVOIR,8856084,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,146.53000,42.49000,Aetna,First Health,,119.86,,,,,,,52.82,119.86,percent of total billed charges,
RESERVOIR,8856084,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,146.53000,42.49000,Aetna,First Health,,119.86,,,,,,,47.18,119.86,percent of total billed charges,
ROD SPINAL,8856085,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8856085,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
STEM,8856087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8856087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
COMPONENT FEMORAL,8856089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COMPONENT FEMORAL,8856089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SCREW SPINAL,8858268,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
SCREW SPINAL,8858268,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
INSERT,8858270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8858270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,8858272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8858272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
BOLT SPINAL,8864099,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BOLT SPINAL,8864099,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
INSERT,8864101,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8864101,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8864104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8864104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
CONNECTOR SPINAL,8864106,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,801.38,1818.38,percent of total billed charges,
CONNECTOR SPINAL,8864106,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,First Health,,1818.38,,,,,,,715.79,1818.38,percent of total billed charges,
CONNECTOR SPINAL,8864108,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
CONNECTOR SPINAL,8864108,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
ROD SPINAL,8864110,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8864110,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD SPINAL,8864112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD SPINAL,8864112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
BASEPLATE,8870084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BASEPLATE,8870084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
HEAD FEMORAL,8870085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8870085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
INSERT,8868084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8868084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
STEM,8868085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7326.00000,2124.54000,Aetna,First Health,,5992.67,,,,,,,2641.02,5992.67,percent of total billed charges,
STEM,8868085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7326.00000,2124.54000,Aetna,First Health,,5992.67,,,,,,,2358.97,5992.67,percent of total billed charges,
INSERT,8868086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8868086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,8870086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8870086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
CATHETER IN KIT,8870088,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
CATHETER IN KIT,8870088,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
CATHETER IN KIT,8870089,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,10080.00000,2923.20000,Aetna,First Health,,8245.44,,,,,,,3633.84,8245.44,percent of total billed charges,
CATHETER IN KIT,8870089,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,10080.00000,2923.20000,Aetna,First Health,,8245.44,,,,,,,3245.76,8245.44,percent of total billed charges,
CATHETER,8870090,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,18225.00000,5285.25000,Aetna,First Health,,14908.05,,,,,,,6570.11,14908.05,percent of total billed charges,
CATHETER,8870090,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,18225.00000,5285.25000,Aetna,First Health,,14908.05,,,,,,,5868.45,14908.05,percent of total billed charges,
SCREW,8874084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8874084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
PLATE,8874086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.00000,1246.42000,Aetna,First Health,,3515.76,,,,,,,1549.43,3515.76,percent of total billed charges,
PLATE,8874086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.00000,1246.42000,Aetna,First Health,,3515.76,,,,,,,1383.96,3515.76,percent of total billed charges,
PLATE,8874088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10383.00000,3011.07000,Aetna,First Health,,8493.29,,,,,,,3743.07,8493.29,percent of total billed charges,
PLATE,8874088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10383.00000,3011.07000,Aetna,First Health,,8493.29,,,,,,,3343.33,8493.29,percent of total billed charges,
ANCHOR,8874091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,First Health,,2249.50,,,,,,,991.38,2249.50,percent of total billed charges,
ANCHOR,8874091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,First Health,,2249.50,,,,,,,885.50,2249.50,percent of total billed charges,
ANCHOR,8874093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,817.25,1854.41,percent of total billed charges,
ANCHOR,8874093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,First Health,,1854.41,,,,,,,729.97,1854.41,percent of total billed charges,
INSERT,8874104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8874104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
TRAY HUMERAL,8878092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6083.00000,1764.07000,Aetna,First Health,,4975.89,,,,,,,2192.92,4975.89,percent of total billed charges,
TRAY HUMERAL,8878092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6083.00000,1764.07000,Aetna,First Health,,4975.89,,,,,,,1958.73,4975.89,percent of total billed charges,
K WIRE,8880107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
K WIRE,8880107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
PLATE,8880108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1728.89,3922.97,percent of total billed charges,
PLATE,8880108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,First Health,,3922.97,,,,,,,1544.25,3922.97,percent of total billed charges,
PLATE,8880109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1771.97,4020.72,percent of total billed charges,
PLATE,8880109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,First Health,,4020.72,,,,,,,1582.73,4020.72,percent of total billed charges,
ROD SPINAL,8886084,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD SPINAL,8886084,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
ANCHOR,8886086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10881.90000,3155.75000,Aetna,First Health,,8901.39,,,,,,,3922.92,8901.39,percent of total billed charges,
ANCHOR,8886086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10881.90000,3155.75000,Aetna,First Health,,8901.39,,,,,,,3503.97,8901.39,percent of total billed charges,
SCREW,8886088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,671.84,1524.46,percent of total billed charges,
SCREW,8886088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,600.09,1524.46,percent of total billed charges,
PIN,8886091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PIN,8886091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW,8890086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,645.57000,187.22000,Aetna,First Health,,528.08,,,,,,,232.73,528.08,percent of total billed charges,
SCREW,8890086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,645.57000,187.22000,Aetna,First Health,,528.08,,,,,,,207.87,528.08,percent of total billed charges,
SCREW,8890088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,645.57000,187.22000,Aetna,First Health,,528.08,,,,,,,232.73,528.08,percent of total billed charges,
SCREW,8890088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,645.57000,187.22000,Aetna,First Health,,528.08,,,,,,,207.87,528.08,percent of total billed charges,
STEM,8892097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8892097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
SHELL,8892099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3524.61,7997.59,percent of total billed charges,
SHELL,8892099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3148.19,7997.59,percent of total billed charges,
STEM,8892101,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8892101,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
CAGE,8904088,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8904088,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
CAGE,8904090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,6529.56,14816.02,percent of total billed charges,
CAGE,8904090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,5832.23,14816.02,percent of total billed charges,
STEM,8906084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
STEM,8906084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
WEDGE,8906088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8906088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
WEDGE,8906086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8906086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
GRAFT,8906089,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,4442.83000,1288.42000,Aetna,First Health,,3634.23,,,,,,,1601.64,3634.23,percent of total billed charges,
GRAFT,8906089,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,4442.83000,1288.42000,Aetna,First Health,,3634.23,,,,,,,1430.59,3634.23,percent of total billed charges,
GRAFT,8906090,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,3158.20000,915.88000,Aetna,First Health,,2583.41,,,,,,,1138.53,2583.41,percent of total billed charges,
GRAFT,8906090,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,3158.20000,915.88000,Aetna,First Health,,2583.41,,,,,,,1016.94,2583.41,percent of total billed charges,
GRAFT,8906091,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2363.64000,685.46000,Aetna,First Health,,1933.46,,,,,,,852.09,1933.46,percent of total billed charges,
GRAFT,8906091,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2363.64000,685.46000,Aetna,First Health,,1933.46,,,,,,,761.09,1933.46,percent of total billed charges,
GRAFT,8906092,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,3892.28000,1128.76000,Aetna,First Health,,3183.89,,,,,,,1403.17,3183.89,percent of total billed charges,
GRAFT,8906092,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,3892.28000,1128.76000,Aetna,First Health,,3183.89,,,,,,,1253.31,3183.89,percent of total billed charges,
GRAFT,8906093,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,5895.82000,1709.79000,Aetna,First Health,,4822.78,,,,,,,2125.44,4822.78,percent of total billed charges,
GRAFT,8906093,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,5895.82000,1709.79000,Aetna,First Health,,4822.78,,,,,,,1898.45,4822.78,percent of total billed charges,
GRAFT,8906094,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,1999.88000,579.97000,Aetna,First Health,,1635.90,,,,,,,720.96,1635.90,percent of total billed charges,
GRAFT,8906094,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,1999.88000,579.97000,Aetna,First Health,,1635.90,,,,,,,643.96,1635.90,percent of total billed charges,
GUIDE PIN,8908214,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1378.52000,399.77000,Aetna,First Health,,1127.63,,,,,,,496.96,1127.63,percent of total billed charges,
GUIDE PIN,8908214,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1378.52000,399.77000,Aetna,First Health,,1127.63,,,,,,,443.88,1127.63,percent of total billed charges,
SHEATH,8908230,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,127.05000,36.84000,Aetna,First Health,,103.93,,,,,,,45.80,103.93,percent of total billed charges,
SHEATH,8908230,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,127.05000,36.84000,Aetna,First Health,,103.93,,,,,,,40.91,103.93,percent of total billed charges,
COMPONENT GLENOID,8908250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
COMPONENT GLENOID,8908250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
HEAD HUMERAL,8908251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
HEAD HUMERAL,8908251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
HEAD HUMERAL,8908252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,6038.38,13701.50,percent of total billed charges,
HEAD HUMERAL,8908252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,5393.50,13701.50,percent of total billed charges,
HEAD HUMERAL,8908253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
HEAD HUMERAL,8908253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
ANCHOR,7702151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1900.00000,551.00000,Aetna,First Health,,1554.20,,,,,,,684.95,1554.20,percent of total billed charges,
ANCHOR,7702151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1900.00000,551.00000,Aetna,First Health,,1554.20,,,,,,,611.80,1554.20,percent of total billed charges,
TUBE TYMPANOSTOMY,8908291,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
TUBE TYMPANOSTOMY,8908291,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
INSERT,8908292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8908292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SCREW,8908293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8908293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
PLATE,8908294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,744.07,1688.35,percent of total billed charges,
PLATE,8908294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,664.61,1688.35,percent of total billed charges,
SCREW,8908295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8908295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
NAIL,8908296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,8908296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
NAIL,8908297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,8908297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
INSERT,8908298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8908298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
SCREW,8908334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,8908334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
SCREW,8908335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,8908335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
NAIL,8908336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,8908336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
GLENOID,8910335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28629.00000,8302.41000,Aetna,First Health,,23418.52,,,,,,,10320.75,23418.52,percent of total billed charges,
GLENOID,8910335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28629.00000,8302.41000,Aetna,First Health,,23418.52,,,,,,,9218.54,23418.52,percent of total billed charges,
PLATE,8910366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,8910366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,8910367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8910367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW,8910368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8910368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
K WIRE,8910369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.25000,162.47000,Aetna,First Health,,458.28,,,,,,,201.97,458.28,percent of total billed charges,
K WIRE,8910369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.25000,162.47000,Aetna,First Health,,458.28,,,,,,,180.40,458.28,percent of total billed charges,
SCREW,8910370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8910370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
INSERT,8910371,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8910371,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
SCREW,8910392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,664.20000,192.62000,Aetna,First Health,,543.32,,,,,,,239.44,543.32,percent of total billed charges,
SCREW,8910392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,664.20000,192.62000,Aetna,First Health,,543.32,,,,,,,213.87,543.32,percent of total billed charges,
SCREW SPINAL,8910452,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW SPINAL,8910452,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
INSERT,8910453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8910453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
BREAST IMPLANT,8910454,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7590.00000,2201.10000,Aetna,First Health,,6208.62,,,,,,,2736.20,6208.62,percent of total billed charges,
BREAST IMPLANT,8910454,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7590.00000,2201.10000,Aetna,First Health,,6208.62,,,,,,,2443.98,6208.62,percent of total billed charges,
SCREW,8910455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,8910455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,8910456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,507.58,1151.74,percent of total billed charges,
SCREW,8910456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,453.38,1151.74,percent of total billed charges,
SCREW,8910457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,8910457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
CATHETER,8910458,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,488.12,1107.57,percent of total billed charges,
CATHETER,8910458,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,435.99,1107.57,percent of total billed charges,
INSERT,8910499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8910499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
GLENOSHERE,8910500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
GLENOSHERE,8910500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
GRAFT,8910512,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4828.25000,1400.19000,Aetna,First Health,,3949.51,,,,,,,1740.58,3949.51,percent of total billed charges,
GRAFT,8910512,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4828.25000,1400.19000,Aetna,First Health,,3949.51,,,,,,,1554.70,3949.51,percent of total billed charges,
BASEPLATE,8910536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
BASEPLATE,8910536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
SPACER,8912132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,4082.66,9263.85,percent of total billed charges,
SPACER,8912132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,3646.65,9263.85,percent of total billed charges,
SPACER,8912133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,4082.66,9263.85,percent of total billed charges,
SPACER,8912133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,3646.65,9263.85,percent of total billed charges,
SCREW,8912134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8912134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
STEM PROSTHESIS,8912135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17125.00000,4966.25000,Aetna,First Health,,14008.25,,,,,,,6173.56,14008.25,percent of total billed charges,
STEM PROSTHESIS,8912135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17125.00000,4966.25000,Aetna,First Health,,14008.25,,,,,,,5514.25,14008.25,percent of total billed charges,
STEM PROSTHESIS,8912136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15850.00000,4596.50000,Aetna,First Health,,12965.30,,,,,,,5713.93,12965.30,percent of total billed charges,
STEM PROSTHESIS,8912136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15850.00000,4596.50000,Aetna,First Health,,12965.30,,,,,,,5103.70,12965.30,percent of total billed charges,
SCREW SPINAL,8912144,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW SPINAL,8912144,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW SPINAL,8912145,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW SPINAL,8912145,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
STEM,8912146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,8912146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
STEM,8912147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
STEM,8912147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
LINER,8912148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
LINER,8912148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
HEAD FEMORAL,8910542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8666.55000,2513.30000,Aetna,First Health,,7089.24,,,,,,,3124.29,7089.24,percent of total billed charges,
HEAD FEMORAL,8910542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8666.55000,2513.30000,Aetna,First Health,,7089.24,,,,,,,2790.63,7089.24,percent of total billed charges,
STENT,8858275,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858275,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858276,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858276,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858277,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858277,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858278,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858278,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858279,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858279,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858280,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858280,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858281,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858281,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858282,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858282,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858283,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858283,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858284,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858284,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858285,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858285,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858286,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858286,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858287,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858287,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858288,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858288,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858289,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858289,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858299,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858299,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858300,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858300,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858306,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858306,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858309,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858309,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858311,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858311,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858312,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858312,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858313,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858313,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858325,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858325,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858327,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858327,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858328,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858328,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858329,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858329,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858330,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858330,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
BALLOON CATHETER,8974105,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
BALLOON CATHETER,8974105,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
HEAD ADAPTER,8910543,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1505.60000,436.62000,Aetna,First Health,,1231.58,,,,,,,542.77,1231.58,percent of total billed charges,
HEAD ADAPTER,8910543,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1505.60000,436.62000,Aetna,First Health,,1231.58,,,,,,,484.80,1231.58,percent of total billed charges,
PLATE,8912137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,First Health,,2249.50,,,,,,,991.38,2249.50,percent of total billed charges,
PLATE,8912137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,First Health,,2249.50,,,,,,,885.50,2249.50,percent of total billed charges,
CAGE,8910544,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,8910544,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
PLATE,8910545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3265.50000,946.99000,Aetna,First Health,,2671.18,,,,,,,1177.21,2671.18,percent of total billed charges,
PLATE,8910545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3265.50000,946.99000,Aetna,First Health,,2671.18,,,,,,,1051.49,2671.18,percent of total billed charges,
ROD SPINAL,8910646,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8910646,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SCREW SPINAL,8910647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW SPINAL,8910647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW SPINAL,8910648,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW SPINAL,8910648,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
ANCHOR,8910679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2294.00000,665.26000,Aetna,First Health,,1876.49,,,,,,,826.99,1876.49,percent of total billed charges,
ANCHOR,8910679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2294.00000,665.26000,Aetna,First Health,,1876.49,,,,,,,738.67,1876.49,percent of total billed charges,
ANCHOR,8910680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2294.00000,665.26000,Aetna,First Health,,1876.49,,,,,,,826.99,1876.49,percent of total billed charges,
ANCHOR,8910680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2294.00000,665.26000,Aetna,First Health,,1876.49,,,,,,,738.67,1876.49,percent of total billed charges,
ANCHOR,8910681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
ANCHOR,8910681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
ROD SPINAL,8910683,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8910683,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
STEM,8910684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8910684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
GRAFT,8910711,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,31612.50000,9167.62000,Aetna,First Health,,25859.03,,,,,,,11396.31,25859.03,percent of total billed charges,
GRAFT,8910711,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,31612.50000,9167.62000,Aetna,First Health,,25859.03,,,,,,,10179.23,25859.03,percent of total billed charges,
SCREW,8910712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8910712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
COMPONENT FEMORAL,8910714,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,8910714,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
TRAY TIBIAL,8910715,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
TRAY TIBIAL,8910715,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,8910716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8910716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8916084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8916084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
GLENOSPHERE,8916176,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
GLENOSPHERE,8916176,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
ANCHOR,8916177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2412.64000,699.67000,Aetna,First Health,,1973.54,,,,,,,869.76,1973.54,percent of total billed charges,
ANCHOR,8916177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2412.64000,699.67000,Aetna,First Health,,1973.54,,,,,,,776.87,1973.54,percent of total billed charges,
ANKLE PROSTHESIS,8916290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,7786.80,17668.80,percent of total billed charges,
ANKLE PROSTHESIS,8916290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,6955.20,17668.80,percent of total billed charges,
INSERT,8916291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3360.22,7624.58,percent of total billed charges,
INSERT,8916291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3001.36,7624.58,percent of total billed charges,
LINER,7699134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,7699134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
HEAD FEMORAL,8916309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
HEAD FEMORAL,8916309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
TISSUE PATCH,8916310,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
TISSUE PATCH,8916310,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
INSERT,8916361,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8916361,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
PLATE,8916362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4641.00000,1345.89000,Aetna,First Health,,3796.34,,,,,,,1673.08,3796.34,percent of total billed charges,
PLATE,8916362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4641.00000,1345.89000,Aetna,First Health,,3796.34,,,,,,,1494.40,3796.34,percent of total billed charges,
PLATE,8916363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4641.00000,1345.89000,Aetna,First Health,,3796.34,,,,,,,1673.08,3796.34,percent of total billed charges,
PLATE,8916363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4641.00000,1345.89000,Aetna,First Health,,3796.34,,,,,,,1494.40,3796.34,percent of total billed charges,
BONE MATRIX,8916364,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
BONE MATRIX,8916364,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,8916365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4921.88000,1427.35000,Aetna,First Health,,4026.10,,,,,,,1774.34,4026.10,percent of total billed charges,
PLATE,8916365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4921.88000,1427.35000,Aetna,First Health,,4026.10,,,,,,,1584.85,4026.10,percent of total billed charges,
SCREW,8916366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8916366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8916367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8916367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8916368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8916368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8916370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8916370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8916371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8916371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8916372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8916372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
ANCHOR,8916373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,802.11,1820.05,percent of total billed charges,
ANCHOR,8916373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,716.45,1820.05,percent of total billed charges,
CARTRIDGE IMPLANT,8916346,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1640.28,3721.90,percent of total billed charges,
CARTRIDGE IMPLANT,8916346,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1465.10,3721.90,percent of total billed charges,
NAIL,8916477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8916477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
STEM,8916589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8916589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
GLEOSPHERE,8916590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7860.00000,2279.40000,Aetna,First Health,,6429.48,,,,,,,2833.53,6429.48,percent of total billed charges,
GLEOSPHERE,8916590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7860.00000,2279.40000,Aetna,First Health,,6429.48,,,,,,,2530.92,6429.48,percent of total billed charges,
CAGE,8916591,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,8916591,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
HUMERAL INSERT,8916592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
HUMERAL INSERT,8916592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
HUMERAL STEM,8916593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
HUMERAL STEM,8916593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
CATHETER,8916594,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,21225.00000,6155.25000,Aetna,First Health,,17362.05,,,,,,,7651.61,17362.05,percent of total billed charges,
CATHETER,8916594,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,21225.00000,6155.25000,Aetna,First Health,,17362.05,,,,,,,6834.45,17362.05,percent of total billed charges,
SEPARATOR,8916595,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2752.42,6245.43,percent of total billed charges,
SEPARATOR,8916595,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2458.47,6245.43,percent of total billed charges,
PLATE,8916588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2947.09,6687.15,percent of total billed charges,
PLATE,8916588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2632.35,6687.15,percent of total billed charges,
CAGE,8916647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8916647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
STEM,8916648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15850.00000,4596.50000,Aetna,First Health,,12965.30,,,,,,,5713.93,12965.30,percent of total billed charges,
STEM,8916648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15850.00000,4596.50000,Aetna,First Health,,12965.30,,,,,,,5103.70,12965.30,percent of total billed charges,
WEDGE,8914860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,8914860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
BASEPLATE,8914861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2752.96,6246.66,percent of total billed charges,
BASEPLATE,8914861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,First Health,,6246.66,,,,,,,2458.95,6246.66,percent of total billed charges,
END CAP,8916702,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
END CAP,8916702,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
NAIL,8916703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8916703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
BASEPLATE,8916646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,912.60000,264.65000,Aetna,First Health,,746.51,,,,,,,328.99,746.51,percent of total billed charges,
BASEPLATE,8916646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,912.60000,264.65000,Aetna,First Health,,746.51,,,,,,,293.86,746.51,percent of total billed charges,
VALVE AORTIC,8916479,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,14640.81,33221.03,percent of total billed charges,
VALVE AORTIC,8916479,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,13077.23,33221.03,percent of total billed charges,
VALVE AORTIC,8916481,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,14640.81,33221.03,percent of total billed charges,
VALVE AORTIC,8916481,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,13077.23,33221.03,percent of total billed charges,
VALVE AORTIC,8916483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,14640.81,33221.03,percent of total billed charges,
VALVE AORTIC,8916483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,13077.23,33221.03,percent of total billed charges,
VALVE AORTIC,8916485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,14640.81,33221.03,percent of total billed charges,
VALVE AORTIC,8916485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,13077.23,33221.03,percent of total billed charges,
VALVE AORTIC,8916487,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,14640.81,33221.03,percent of total billed charges,
VALVE AORTIC,8916487,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,13077.23,33221.03,percent of total billed charges,
SPACER,8916763,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,4082.66,9263.85,percent of total billed charges,
SPACER,8916763,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,3646.65,9263.85,percent of total billed charges,
STEM PROSTHESIS,8916764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17125.00000,4966.25000,Aetna,First Health,,14008.25,,,,,,,6173.56,14008.25,percent of total billed charges,
STEM PROSTHESIS,8916764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17125.00000,4966.25000,Aetna,First Health,,14008.25,,,,,,,5514.25,14008.25,percent of total billed charges,
STEM,8916765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15850.00000,4596.50000,Aetna,First Health,,12965.30,,,,,,,5713.93,12965.30,percent of total billed charges,
STEM,8916765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15850.00000,4596.50000,Aetna,First Health,,12965.30,,,,,,,5103.70,12965.30,percent of total billed charges,
INSERT,8916766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8916766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
COMPONENT FEMORAL,8916767,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
COMPONENT FEMORAL,8916767,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
KIT THROMBECTOMY,8916690,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,21225.00000,6155.25000,Aetna,First Health,,17362.05,,,,,,,7651.61,17362.05,percent of total billed charges,
KIT THROMBECTOMY,8916690,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,21225.00000,6155.25000,Aetna,First Health,,17362.05,,,,,,,6834.45,17362.05,percent of total billed charges,
INSERT,8916691,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,8916691,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
STEM,8914863,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1308.43,2968.93,percent of total billed charges,
STEM,8914863,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,First Health,,2968.93,,,,,,,1168.70,2968.93,percent of total billed charges,
INSERT,8916783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8916783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
STEM,8916784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8916784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
PLATE,8916785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1847.20,4191.43,percent of total billed charges,
PLATE,8916785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,First Health,,4191.43,,,,,,,1649.93,4191.43,percent of total billed charges,
SCREW,8916786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8916786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
CATHETER,8916793,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
CATHETER,8916793,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
CATHETER,8916794,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,6370.00000,1847.30000,Aetna,First Health,,5210.66,,,,,,,2296.39,5210.66,percent of total billed charges,
CATHETER,8916794,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,6370.00000,1847.30000,Aetna,First Health,,5210.66,,,,,,,2051.14,5210.66,percent of total billed charges,
SCREW,8916815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
SCREW,8916815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,8916816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1972.00000,571.88000,Aetna,First Health,,1613.10,,,,,,,710.91,1613.10,percent of total billed charges,
SCREW,8916816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1972.00000,571.88000,Aetna,First Health,,1613.10,,,,,,,634.98,1613.10,percent of total billed charges,
PLATE,8916817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10866.00000,3151.14000,Aetna,First Health,,8888.39,,,,,,,3917.19,8888.39,percent of total billed charges,
PLATE,8916817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10866.00000,3151.14000,Aetna,First Health,,8888.39,,,,,,,3498.85,8888.39,percent of total billed charges,
SCREW,8916818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,8916818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
SCREW,8916819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,8916819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
SCREW SPINAL,8916820,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW SPINAL,8916820,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW SPINAL,8916821,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1468.68,3332.53,percent of total billed charges,
SCREW SPINAL,8916821,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,First Health,,3332.53,,,,,,,1311.83,3332.53,percent of total billed charges,
SCREW,8916822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,8916822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
GUIDEWIRE,8916823,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,77.60,176.07,percent of total billed charges,
GUIDEWIRE,8916823,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,69.31,176.07,percent of total billed charges,
INSERT,8916824,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8916824,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
NASAL IMPLANT,8916699,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9435.00000,2736.15000,Aetna,First Health,,7717.83,,,,,,,3401.32,7717.83,percent of total billed charges,
NASAL IMPLANT,8916699,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9435.00000,2736.15000,Aetna,First Health,,7717.83,,,,,,,3038.07,7717.83,percent of total billed charges,
CLIP LIGATING,8914997,CDM,278,RC,,,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2947.09,6687.15,percent of total billed charges,
CLIP LIGATING,8914997,CDM,278,RC,,,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2632.35,6687.15,percent of total billed charges,
CLIP LIGATING,8914998,CDM,278,RC,,,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2947.09,6687.15,percent of total billed charges,
CLIP LIGATING,8914998,CDM,278,RC,,,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2632.35,6687.15,percent of total billed charges,
CLIP LIGATING,8916886,CDM,278,RC,,,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2947.09,6687.15,percent of total billed charges,
CLIP LIGATING,8916886,CDM,278,RC,,,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2632.35,6687.15,percent of total billed charges,
CLIP LIGATING,8916889,CDM,278,RC,,,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2947.09,6687.15,percent of total billed charges,
CLIP LIGATING,8916889,CDM,278,RC,,,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,First Health,,6687.15,,,,,,,2632.35,6687.15,percent of total billed charges,
PLATE,8916871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,First Health,,7023.35,,,,,,,3095.25,7023.35,percent of total billed charges,
PLATE,8916871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,First Health,,7023.35,,,,,,,2764.69,7023.35,percent of total billed charges,
CAGE,8916873,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8916873,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
INSERT,8916875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8916875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT,8916877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8916877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
LINER,8916879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,8916879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
COMPONENT FEMORAL,8916881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
COMPONENT FEMORAL,8916881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
CAGE,8916883,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21810.00000,6324.90000,Aetna,First Health,,17840.58,,,,,,,7862.51,17840.58,percent of total billed charges,
CAGE,8916883,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21810.00000,6324.90000,Aetna,First Health,,17840.58,,,,,,,7022.82,17840.58,percent of total billed charges,
SCREW,8916892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,8916892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
STEM,8916950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8916950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
INSERT,8916921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8916921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,8916922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8916922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SCREW,8916971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
SCREW,8916971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
SCREW,8916973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW,8916973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
SCREW SPINAL,8917021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW SPINAL,8917021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
CAGE,8917022,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,6529.56,14816.02,percent of total billed charges,
CAGE,8917022,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,5832.23,14816.02,percent of total billed charges,
PLATE SPINAL,8917023,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8917023,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8917024,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,8917024,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
BOLT SPINAL,8917025,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
BOLT SPINAL,8917025,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
SHELL,8917027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,8917027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
CAGE,8917026,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8917026,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
STEM,8917141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8917141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
INSERT,8917143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8917143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
HEAD HUMERAL,7893984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,7893984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
SCREW,8917146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8917146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8917148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8917148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,8917150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,8917150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
LINER,8918130,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
LINER,8918130,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
ANCHOR,8918131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4444.13000,1288.80000,Aetna,First Health,,3635.30,,,,,,,1602.11,3635.30,percent of total billed charges,
ANCHOR,8918131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4444.13000,1288.80000,Aetna,First Health,,3635.30,,,,,,,1431.01,3635.30,percent of total billed charges,
BASEPLATE,8918132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
BASEPLATE,8918132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
PLATE,8918133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7333.20000,2126.63000,Aetna,First Health,,5998.56,,,,,,,2643.62,5998.56,percent of total billed charges,
PLATE,8918133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7333.20000,2126.63000,Aetna,First Health,,5998.56,,,,,,,2361.29,5998.56,percent of total billed charges,
INSERT,8918135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8918135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,8918136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8918136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
PLATE,8918137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5569.76000,1615.23000,Aetna,First Health,,4556.06,,,,,,,2007.90,4556.06,percent of total billed charges,
PLATE,8918137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5569.76000,1615.23000,Aetna,First Health,,4556.06,,,,,,,1793.46,4556.06,percent of total billed charges,
SCREW,8918138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,497.63,1129.17,percent of total billed charges,
SCREW,8918138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,444.49,1129.17,percent of total billed charges,
SCREW,8918194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,497.63,1129.17,percent of total billed charges,
SCREW,8918194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,444.49,1129.17,percent of total billed charges,
CAGE,8918139,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8918139,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
STEM,8918196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8918196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
CAGE,8918198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8918198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
PROSTHESIS TOTAL ELBOW,8918200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,3136.35,7116.60,percent of total billed charges,
PROSTHESIS TOTAL ELBOW,8918200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,First Health,,7116.60,,,,,,,2801.40,7116.60,percent of total billed charges,
PROSTHESIS TOTAL ELBOW,8918202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4914.00000,1425.06000,Aetna,First Health,,4019.65,,,,,,,1771.50,4019.65,percent of total billed charges,
PROSTHESIS TOTAL ELBOW,8918202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4914.00000,1425.06000,Aetna,First Health,,4019.65,,,,,,,1582.31,4019.65,percent of total billed charges,
STEM,8918204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,5028.98,11411.10,percent of total billed charges,
STEM,8918204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,4491.90,11411.10,percent of total billed charges,
PLATE,8918206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1945.68000,564.25000,Aetna,First Health,,1591.57,,,,,,,701.42,1591.57,percent of total billed charges,
PLATE,8918206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1945.68000,564.25000,Aetna,First Health,,1591.57,,,,,,,626.51,1591.57,percent of total billed charges,
SCREW,8918208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,933.62000,270.75000,Aetna,First Health,,763.70,,,,,,,336.57,763.70,percent of total billed charges,
SCREW,8918208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,933.62000,270.75000,Aetna,First Health,,763.70,,,,,,,300.63,763.70,percent of total billed charges,
BOLT,8918210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1745.20000,506.11000,Aetna,First Health,,1427.57,,,,,,,629.14,1427.57,percent of total billed charges,
BOLT,8918210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1745.20000,506.11000,Aetna,First Health,,1427.57,,,,,,,561.95,1427.57,percent of total billed charges,
TIBIAL,8920215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,7417.29,16830.35,percent of total billed charges,
TIBIAL,8920215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,6625.15,16830.35,percent of total billed charges,
SCREW,8920216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8920216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
SCREW,8920217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8920217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW,8920218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,8920218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
PLATE,8920219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3635.63000,1054.33000,Aetna,First Health,,2973.95,,,,,,,1310.64,2973.95,percent of total billed charges,
PLATE,8920219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3635.63000,1054.33000,Aetna,First Health,,2973.95,,,,,,,1170.67,2973.95,percent of total billed charges,
CAGE,8920220,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8920220,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
SCREW,8920221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8920221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
ROD SPINAL,8920222,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8920222,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE,8920223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1635.23,3710.45,percent of total billed charges,
PLATE,8920223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1460.59,3710.45,percent of total billed charges,
PIN,8607988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,702.00000,203.58000,Aetna,First Health,,574.24,,,,,,,253.07,574.24,percent of total billed charges,
PIN,8607988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,702.00000,203.58000,Aetna,First Health,,574.24,,,,,,,226.04,574.24,percent of total billed charges,
PIN,8607990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,702.00000,203.58000,Aetna,First Health,,574.24,,,,,,,253.07,574.24,percent of total billed charges,
PIN,8607990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,702.00000,203.58000,Aetna,First Health,,574.24,,,,,,,226.04,574.24,percent of total billed charges,
BREAST IMPLANT,8918332,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,8918332,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,764.47,4509.23,percent of total billed charges,
PLATE,8920376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,744.07,1688.35,percent of total billed charges,
PLATE,8920376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,664.61,1688.35,percent of total billed charges,
PLATE,8920377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
PLATE,8920377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
ROD SPINAL,8920378,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD SPINAL,8920378,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW SPINAL,8918373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW SPINAL,8918373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW SPINAL,8918374,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW SPINAL,8918374,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
CONNECTOR SPINAL,8918375,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2087.96000,605.51000,Aetna,First Health,,1707.95,,,,,,,752.71,1707.95,percent of total billed charges,
CONNECTOR SPINAL,8918375,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2087.96000,605.51000,Aetna,First Health,,1707.95,,,,,,,672.32,1707.95,percent of total billed charges,
ANCHOR,8918376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2939.00000,852.31000,Aetna,First Health,,2404.10,,,,,,,1059.51,2404.10,percent of total billed charges,
ANCHOR,8918376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2939.00000,852.31000,Aetna,First Health,,2404.10,,,,,,,946.36,2404.10,percent of total billed charges,
INSERT,8918377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8918377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW SPINAL,8918378,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW SPINAL,8918378,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
CATHETER,8920375,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
CATHETER,8920375,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
SCREW SPINAL,8918415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW SPINAL,8918415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STEM,8918418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,6038.38,13701.50,percent of total billed charges,
STEM,8918418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,5393.50,13701.50,percent of total billed charges,
STEM,8918435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,10093.44,22902.72,percent of total billed charges,
STEM,8918435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,First Health,,22902.72,,,,,,,9015.50,22902.72,percent of total billed charges,
CAGE,8918436,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
CAGE,8918436,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
SCREW SPINAL,8918437,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SPINAL,8918437,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT FEMORAL,8918438,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,8918438,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
TRAY TIBIAL,8918439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
TRAY TIBIAL,8918439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,8920515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8920515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE,8924093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5447.54000,1579.79000,Aetna,First Health,,4456.09,,,,,,,1963.84,4456.09,percent of total billed charges,
PLATE,8924093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5447.54000,1579.79000,Aetna,First Health,,4456.09,,,,,,,1754.11,4456.09,percent of total billed charges,
INSERT,8922104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8922104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ROD SPINAL,8922113,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8922113,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
ROD SPINAL,8922114,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8922114,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
ROD SPINAL,8922105,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8922105,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
HEAD FEMORAL,8922115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
HEAD FEMORAL,8922115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
COMPONENT ACETABULAR,8922116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1876.22,4257.28,percent of total billed charges,
COMPONENT ACETABULAR,8922116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1675.85,4257.28,percent of total billed charges,
WIRE,7895653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,226.91000,65.80000,Aetna,First Health,,185.61,,,,,,,81.80,185.61,percent of total billed charges,
WIRE,7895653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,226.91000,65.80000,Aetna,First Health,,185.61,,,,,,,73.07,185.61,percent of total billed charges,
BODY PROXIMAL,8922134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17125.00000,4966.25000,Aetna,First Health,,14008.25,,,,,,,6173.56,14008.25,percent of total billed charges,
BODY PROXIMAL,8922134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17125.00000,4966.25000,Aetna,First Health,,14008.25,,,,,,,5514.25,14008.25,percent of total billed charges,
INSERT,8922138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8922138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
INSERT,8922139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14673.00000,4255.17000,Aetna,First Health,,12002.51,,,,,,,5289.62,12002.51,percent of total billed charges,
INSERT,8922139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14673.00000,4255.17000,Aetna,First Health,,12002.51,,,,,,,4724.71,12002.51,percent of total billed charges,
BASEPLATE,8922140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3420.78,7762.00,percent of total billed charges,
BASEPLATE,8922140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3055.46,7762.00,percent of total billed charges,
DOME TALAR,8922141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19900.00000,5771.00000,Aetna,First Health,,16278.20,,,,,,,7173.95,16278.20,percent of total billed charges,
DOME TALAR,8922141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19900.00000,5771.00000,Aetna,First Health,,16278.20,,,,,,,6407.80,16278.20,percent of total billed charges,
PLATE,8922142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12594.00000,3652.26000,Aetna,First Health,,10301.89,,,,,,,4540.14,10301.89,percent of total billed charges,
PLATE,8922142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12594.00000,3652.26000,Aetna,First Health,,10301.89,,,,,,,4055.27,10301.89,percent of total billed charges,
LINER,8926084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,793.10,1799.60,percent of total billed charges,
LINER,8926084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,708.40,1799.60,percent of total billed charges,
FEMER,8926085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6729.81,15270.42,percent of total billed charges,
FEMER,8926085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,First Health,,15270.42,,,,,,,6011.10,15270.42,percent of total billed charges,
LINER,8926086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8926086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
STEM,8926088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5787.51,13132.28,percent of total billed charges,
STEM,8926088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,First Health,,13132.28,,,,,,,5169.43,13132.28,percent of total billed charges,
HEAD FEMORAL,8926089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5007.10000,1452.06000,Aetna,First Health,,4095.81,,,,,,,1805.06,4095.81,percent of total billed charges,
HEAD FEMORAL,8926089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5007.10000,1452.06000,Aetna,First Health,,4095.81,,,,,,,1612.29,4095.81,percent of total billed charges,
FEMUR,8926090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
FEMUR,8926090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
INSERT TIBIAL,8926091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT TIBIAL,8926091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8926285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8926285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
ROD SPINAL,8926286,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,8926286,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
CAGE,8926287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21810.00000,6324.90000,Aetna,First Health,,17840.58,,,,,,,7862.51,17840.58,percent of total billed charges,
CAGE,8926287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21810.00000,6324.90000,Aetna,First Health,,17840.58,,,,,,,7022.82,17840.58,percent of total billed charges,
CAGE,8926288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26000.00000,7540.00000,Aetna,First Health,,21268.00,,,,,,,9373.00,21268.00,percent of total billed charges,
CAGE,8926288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26000.00000,7540.00000,Aetna,First Health,,21268.00,,,,,,,8372.00,21268.00,percent of total billed charges,
PLAE SPINAL,8926289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLAE SPINAL,8926289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8926333,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
CAGE,8926333,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
ACETABULAR SHELL,8926334,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ACETABULAR SHELL,8926334,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SCREW SPINAL,8926336,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW SPINAL,8926336,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
PLATE,8926337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7360.47000,2134.54000,Aetna,First Health,,6020.86,,,,,,,2653.45,6020.86,percent of total billed charges,
PLATE,8926337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7360.47000,2134.54000,Aetna,First Health,,6020.86,,,,,,,2370.07,6020.86,percent of total billed charges,
STEM,8924499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8924499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
GELONSPHERE,8926389,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
GELONSPHERE,8926389,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
STEM HUMERAL,8926391,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM HUMERAL,8926391,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
SCREW SPINAL,8926392,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW SPINAL,8926392,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
STEM FEMORAL,8926393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM FEMORAL,8926393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
GLENOID,8926394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
GLENOID,8926394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
INSERT,8926449,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8926449,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8926451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,8926451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
SCREW,8926452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,8926452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,8926453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8926453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
PLATE,8926454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
PLATE,8926454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,8926455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8926455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
ENDPLATE,8926456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
ENDPLATE,8926456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
PLATE,8924536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4469.50000,1296.16000,Aetna,First Health,,3656.05,,,,,,,1611.25,3656.05,percent of total billed charges,
PLATE,8924536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4469.50000,1296.16000,Aetna,First Health,,3656.05,,,,,,,1439.18,3656.05,percent of total billed charges,
SCREW,8924537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8924537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
WIRE,8924538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
WIRE,8924538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
SCREW CORT,8924587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW CORT,8924587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
STEM,8924603,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17090.00000,4956.10000,Aetna,First Health,,13979.62,,,,,,,6160.94,13979.62,percent of total billed charges,
STEM,8924603,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17090.00000,4956.10000,Aetna,First Health,,13979.62,,,,,,,5502.98,13979.62,percent of total billed charges,
INSERT,8924604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8924604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW LOCKING,7701214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW LOCKING,7701214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW SPINAL,8924605,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW SPINAL,8924605,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW,8924588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8924588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
CAGE,8924627,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8924627,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
CAGE,8924628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,8924628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
INSERT,8924629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,8924629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
GUIDE,8924630,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,7791.00000,2259.39000,Aetna,First Health,,6373.04,,,,,,,2808.66,6373.04,percent of total billed charges,
GUIDE,8924630,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,7791.00000,2259.39000,Aetna,First Health,,6373.04,,,,,,,2508.70,6373.04,percent of total billed charges,
INSERT,8924631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3420.78,7762.00,percent of total billed charges,
INSERT,8924631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3055.46,7762.00,percent of total billed charges,
CAGE,8926554,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8926554,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
INSERT,8926555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2998.40,6803.59,percent of total billed charges,
INSERT,8926555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,First Health,,6803.59,,,,,,,2678.19,6803.59,percent of total billed charges,
ROD SPINAL,8926556,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
ROD SPINAL,8926556,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
CAGE,8926557,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,8926557,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
INSERT,8926558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
INSERT,8926558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
INSERT,8926559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,8926559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
CATHETER HEMOD,7693554,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,616.94000,178.91000,Aetna,First Health,,504.66,,,,,,,222.41,504.66,percent of total billed charges,
CATHETER HEMOD,7693554,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,616.94000,178.91000,Aetna,First Health,,504.66,,,,,,,198.65,504.66,percent of total billed charges,
CONNECTOR SPINAL,8924749,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CONNECTOR SPINAL,8924749,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
ROD SPINAL,8924750,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8924750,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ROD SPINAL,8924751,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8924751,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CONNECTOR SPINAL,8924752,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7980.00000,2314.20000,Aetna,First Health,,6527.64,,,,,,,2876.79,6527.64,percent of total billed charges,
CONNECTOR SPINAL,8924752,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7980.00000,2314.20000,Aetna,First Health,,6527.64,,,,,,,2569.56,6527.64,percent of total billed charges,
SCREW SPINAL,8924753,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
SCREW SPINAL,8924753,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
SCREW SPINAL,8924754,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
SCREW SPINAL,8924754,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
SCREW SPINAL,8924755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
SCREW SPINAL,8924755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
SCREW SPINAL,8924756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
SCREW SPINAL,8924756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
SCREW SPINAL,8924757,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
SCREW SPINAL,8924757,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
SCREW SPINAL,8924758,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
SCREW SPINAL,8924758,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
SCREW SPINAL,8924759,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
SCREW SPINAL,8924759,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
SCREW SPINAL,8924760,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
SCREW SPINAL,8924760,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
SCREW SPINAL,8924761,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW SPINAL,8924761,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW SPINAL,8924762,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1640.28,3721.90,percent of total billed charges,
SCREW SPINAL,8924762,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1465.10,3721.90,percent of total billed charges,
CUP HUMERAL,8924763,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
CUP HUMERAL,8924763,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
GLENOSPHERE,8924764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1779.07,4036.83,percent of total billed charges,
GLENOSPHERE,8924764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,First Health,,4036.83,,,,,,,1589.07,4036.83,percent of total billed charges,
PLATE,7939420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
PLATE,7939420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
PLATE,7939421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4003.13000,1160.91000,Aetna,First Health,,3274.56,,,,,,,1443.13,3274.56,percent of total billed charges,
PLATE,7939421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4003.13000,1160.91000,Aetna,First Health,,3274.56,,,,,,,1289.01,3274.56,percent of total billed charges,
INSERT,8924826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8924826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SCREW,8924856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8924856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8924857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8924857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8924858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8924858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
CAGE,8924859,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
CAGE,8924859,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
IMPLANT BUNDLE UNILATERAL,8924861,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,31761.00000,9210.69000,Aetna,First Health,,25980.50,,,,,,,11449.84,25980.50,percent of total billed charges,
IMPLANT BUNDLE UNILATERAL,8924861,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,31761.00000,9210.69000,Aetna,First Health,,25980.50,,,,,,,10227.04,25980.50,percent of total billed charges,
STEM,8927024,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11412.00000,3309.48000,Aetna,First Health,,9335.02,,,,,,,4114.03,9335.02,percent of total billed charges,
STEM,8927024,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11412.00000,3309.48000,Aetna,First Health,,9335.02,,,,,,,3674.66,9335.02,percent of total billed charges,
STEM,8927062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31353.75000,9092.59000,Aetna,First Health,,25647.37,,,,,,,11303.03,25647.37,percent of total billed charges,
STEM,8927062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31353.75000,9092.59000,Aetna,First Health,,25647.37,,,,,,,10095.91,25647.37,percent of total billed charges,
INSERT,8927026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8927026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
STEM PROSTHESIS,8927027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17125.00000,4966.25000,Aetna,First Health,,14008.25,,,,,,,6173.56,14008.25,percent of total billed charges,
STEM PROSTHESIS,8927027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17125.00000,4966.25000,Aetna,First Health,,14008.25,,,,,,,5514.25,14008.25,percent of total billed charges,
CATHETER,8926653,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,694.40000,201.38000,Aetna,First Health,,568.02,,,,,,,250.33,568.02,percent of total billed charges,
CATHETER,8926653,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,694.40000,201.38000,Aetna,First Health,,568.02,,,,,,,223.60,568.02,percent of total billed charges,
CATHETER,8926655,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,694.40000,201.38000,Aetna,First Health,,568.02,,,,,,,250.33,568.02,percent of total billed charges,
CATHETER,8926655,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,694.40000,201.38000,Aetna,First Health,,568.02,,,,,,,223.60,568.02,percent of total billed charges,
CAGE,8924911,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8924911,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
PIN,8924932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1864.00000,540.56000,Aetna,First Health,,1524.75,,,,,,,671.97,1524.75,percent of total billed charges,
PIN,8924932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1864.00000,540.56000,Aetna,First Health,,1524.75,,,,,,,600.21,1524.75,percent of total billed charges,
INSERT,8924934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8924934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
INSERT,8924935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8924935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SHELL,8924936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,8924936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
PLATE,8924992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
PLATE,8924992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
SHOULDER PROSTHESIS,8924995,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SHOULDER PROSTHESIS,8924995,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
ANCHOR,8924996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2384.00000,691.36000,Aetna,First Health,,1950.11,,,,,,,859.43,1950.11,percent of total billed charges,
ANCHOR,8924996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2384.00000,691.36000,Aetna,First Health,,1950.11,,,,,,,767.65,1950.11,percent of total billed charges,
HEAD FEMORAL,8924997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,8924997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
INSERT,8945556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,8945556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
HEAD FEMORAL,8945557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5771.50000,1673.74000,Aetna,First Health,,4721.09,,,,,,,2080.63,4721.09,percent of total billed charges,
HEAD FEMORAL,8945557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5771.50000,1673.74000,Aetna,First Health,,4721.09,,,,,,,1858.42,4721.09,percent of total billed charges,
CAGE,8945558,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8945558,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
ANCHOR,8945559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3644.38,8269.37,percent of total billed charges,
ANCHOR,8945559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3255.18,8269.37,percent of total billed charges,
INSERT,8927356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8927356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
STEM,8927357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8927357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
GRAFT,8945642,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,2861.08000,829.71000,Aetna,First Health,,2340.36,,,,,,,1031.42,2340.36,percent of total billed charges,
GRAFT,8945642,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,2861.08000,829.71000,Aetna,First Health,,2340.36,,,,,,,921.27,2340.36,percent of total billed charges,
ROD SPINAL,8927379,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8927379,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CONNECTOR SPINAL,8927380,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
CONNECTOR SPINAL,8927380,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SCREW SPINAL,8927381,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW SPINAL,8927381,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
SCREW,8927382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8927382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
COMPONENT GLENOID,8927383,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,2149.26,4876.83,percent of total billed charges,
COMPONENT GLENOID,8927383,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,1919.73,4876.83,percent of total billed charges,
GRAFT,8927402,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
GRAFT,8927402,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
SCREW,8927434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,8927434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
STEM,8946406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STEM,8946406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
HEAD HUMERAL,8946407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,8946407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
GLENOID,8946408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28629.00000,8302.41000,Aetna,First Health,,23418.52,,,,,,,10320.75,23418.52,percent of total billed charges,
GLENOID,8946408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28629.00000,8302.41000,Aetna,First Health,,23418.52,,,,,,,9218.54,23418.52,percent of total billed charges,
PLATE,8946457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4595.50000,1332.70000,Aetna,First Health,,3759.12,,,,,,,1656.68,3759.12,percent of total billed charges,
PLATE,8946457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4595.50000,1332.70000,Aetna,First Health,,3759.12,,,,,,,1479.75,3759.12,percent of total billed charges,
SCREW,8946458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8946458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,8946459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,8946459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,8946460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,8946460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,8946461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,8946461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
PLATE,8946462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE,8946462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
STEM,8946463,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,8946463,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
PLATE,8946464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4469.50000,1296.16000,Aetna,First Health,,3656.05,,,,,,,1611.25,3656.05,percent of total billed charges,
PLATE,8946464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4469.50000,1296.16000,Aetna,First Health,,3656.05,,,,,,,1439.18,3656.05,percent of total billed charges,
NAIL,8948085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,8948085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
SCREW,8948086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8948086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SCREW,8948087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8948087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
PLATE,8948088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4186.88000,1214.20000,Aetna,First Health,,3424.87,,,,,,,1509.37,3424.87,percent of total billed charges,
PLATE,8948088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4186.88000,1214.20000,Aetna,First Health,,3424.87,,,,,,,1348.18,3424.87,percent of total billed charges,
BALLOON CATHETER,8948104,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,484.53,1099.42,percent of total billed charges,
BALLOON CATHETER,8948104,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,First Health,,1099.42,,,,,,,432.78,1099.42,percent of total billed charges,
STEM,8948105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8948105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
INSERT,8948106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
INSERT,8948106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
SCREW,8946531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,8946531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
SPACER,8946532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
SPACER,8946532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
SCREW,8946533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,8946533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
INSERT,8948477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8948477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
GRAFT,8948524,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3195.00000,926.55000,Aetna,First Health,,2613.51,,,,,,,1151.80,2613.51,percent of total billed charges,
GRAFT,8948524,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3195.00000,926.55000,Aetna,First Health,,2613.51,,,,,,,1028.79,2613.51,percent of total billed charges,
CAGE,8948525,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,8948525,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
SCREW SPINAL,8948526,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW SPINAL,8948526,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW SPINAL,8948527,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW SPINAL,8948527,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
STENT,8948528,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,8948528,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
ROD SPINAL,8948557,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,8948557,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
CAGE,8948588,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,8948588,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
COMPONENT FEMORAL,8948589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,8948589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
TRAY TIBIAL,8948590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
TRAY TIBIAL,8948590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INSERT,8946940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11805.00000,3423.45000,Aetna,First Health,,9656.49,,,,,,,4255.70,9656.49,percent of total billed charges,
INSERT,8946940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11805.00000,3423.45000,Aetna,First Health,,9656.49,,,,,,,3801.21,9656.49,percent of total billed charges,
ROD SPINAL,8946941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
ROD SPINAL,8946941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SCREW SPINAL,8946942,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW SPINAL,8946942,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW SPINAL,8946943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW SPINAL,8946943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
COMPONENT FEMORAL,8946944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,8946944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
TRAY TIBIAL,8946945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
TRAY TIBIAL,8946945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
DISC,8946946,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1955.71,4437.65,percent of total billed charges,
DISC,8946946,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,First Health,,4437.65,,,,,,,1746.85,4437.65,percent of total billed charges,
DISC,8946947,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11775.00000,3414.75000,Aetna,First Health,,9631.95,,,,,,,4244.89,9631.95,percent of total billed charges,
DISC,8946947,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11775.00000,3414.75000,Aetna,First Health,,9631.95,,,,,,,3791.55,9631.95,percent of total billed charges,
CAGE,8946991,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
CAGE,8946991,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
BALLOON CATHETER,8950110,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
BALLOON CATHETER,8950110,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
PIN,8950111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1496.00000,433.84000,Aetna,First Health,,1223.73,,,,,,,539.31,1223.73,percent of total billed charges,
PIN,8950111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1496.00000,433.84000,Aetna,First Health,,1223.73,,,,,,,481.71,1223.73,percent of total billed charges,
SCREW SPINAL,8950112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2236.00000,648.44000,Aetna,First Health,,1829.05,,,,,,,806.08,1829.05,percent of total billed charges,
SCREW SPINAL,8950112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2236.00000,648.44000,Aetna,First Health,,1829.05,,,,,,,719.99,1829.05,percent of total billed charges,
NAIL,8950113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8950113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
STEM,8950137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,5497.62,12474.50,percent of total billed charges,
STEM,8950137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,4910.50,12474.50,percent of total billed charges,
INSERT,8950138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8950138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
STENT,8950139,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,772.88000,224.14000,Aetna,First Health,,632.22,,,,,,,278.62,632.22,percent of total billed charges,
STENT,8950139,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,772.88000,224.14000,Aetna,First Health,,632.22,,,,,,,248.87,632.22,percent of total billed charges,
SPACER,8950143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
SPACER,8950143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
SCREW,8950136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,8950136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
STEM,8947079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,8947079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
LINER,8947080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,8947080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CAGE,8947081,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8947081,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
ROD SPINAL,8947082,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD SPINAL,8947082,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
INSERT,8947083,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8947083,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
INSERT,8947084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
INSERT,8947084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
CAGE,8947118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
CAGE,8947118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
SCREW,8947125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8947125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
STENT,8950183,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10928.25000,3169.19000,Aetna,First Health,,8939.31,,,,,,,3939.63,8939.31,percent of total billed charges,
STENT,8950183,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10928.25000,3169.19000,Aetna,First Health,,8939.31,,,,,,,3518.90,8939.31,percent of total billed charges,
INSERT,8950179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8950179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8947302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,8947302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,8947303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,8947303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,8947304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8947304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
SCREW,8947305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8947305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
GRAFT STENT,8947329,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
GRAFT STENT,8947329,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
ANCHOR,8947330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
ANCHOR,8947330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
ANCHOR,8947331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3149.00000,913.21000,Aetna,First Health,,2575.88,,,,,,,1135.21,2575.88,percent of total billed charges,
ANCHOR,8947331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3149.00000,913.21000,Aetna,First Health,,2575.88,,,,,,,1013.98,2575.88,percent of total billed charges,
STEM,8947332,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17095.00000,4957.55000,Aetna,First Health,,13983.71,,,,,,,6162.75,13983.71,percent of total billed charges,
STEM,8947332,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17095.00000,4957.55000,Aetna,First Health,,13983.71,,,,,,,5504.59,13983.71,percent of total billed charges,
BREAST IMPLANT,8947338,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
BREAST IMPLANT,8947338,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,764.47,5439.70,percent of total billed charges,
STEM,8947880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,8947880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
INSERT,8947881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8947881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
GLENOSPHERE,8947882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
GLENOSPHERE,8947882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
HOOK SPINAL,8947883,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
HOOK SPINAL,8947883,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
PLATE,8950414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4469.50000,1296.16000,Aetna,First Health,,3656.05,,,,,,,1611.25,3656.05,percent of total billed charges,
PLATE,8950414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4469.50000,1296.16000,Aetna,First Health,,3656.05,,,,,,,1439.18,3656.05,percent of total billed charges,
CAGE,8947894,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
CAGE,8947894,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
INSERT,8950431,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8950431,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CONNECTOR SPINAL,8950432,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
CONNECTOR SPINAL,8950432,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
ROD SPINAL,8950433,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
ROD SPINAL,8950433,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
INSERT,8950434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INSERT,8950434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
CAGE,8950435,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
CAGE,8950435,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
SCREW SPINAL,8950436,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SCREW SPINAL,8950436,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
SCREW SPINAL,8950437,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW SPINAL,8950437,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
ROD SPINAL,8950438,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8950438,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
ROD SPINAL,8950439,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8950439,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,8950440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8950440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8950441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8950441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8950442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8950442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
PLATE,8950443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8637.00000,2504.73000,Aetna,First Health,,7065.07,,,,,,,3113.64,7065.07,percent of total billed charges,
PLATE,8950443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8637.00000,2504.73000,Aetna,First Health,,7065.07,,,,,,,2781.11,7065.07,percent of total billed charges,
BONE PASTE,8950466,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
BONE PASTE,8950466,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1374.94,3492.86,percent of total billed charges,
ANCHOR,8950467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
ANCHOR,8950467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
ANCHOR,8950468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
ANCHOR,8950468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
STEM,8965686,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,8965686,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
ROD SPINAL,8950538,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8950538,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CAGE,8950554,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8950554,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8950564,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8950564,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
HUMERAL HEAD,8950565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6062.00000,1757.98000,Aetna,First Health,,4958.72,,,,,,,2185.35,4958.72,percent of total billed charges,
HUMERAL HEAD,8950565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6062.00000,1757.98000,Aetna,First Health,,4958.72,,,,,,,1951.96,4958.72,percent of total billed charges,
PLATE,8950566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,3076.60,6981.02,percent of total billed charges,
PLATE,8950566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,2748.03,6981.02,percent of total billed charges,
PLATE,8950752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE,8950752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
SCREW,8950753,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8950753,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
ANCHOR IN KIT,8950755,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1962.02,4451.97,percent of total billed charges,
ANCHOR IN KIT,8950755,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1752.48,4451.97,percent of total billed charges,
SCREW,8950756,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8950756,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
INSERT,8950757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8950757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
SPACER,8950758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
SPACER,8950758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
SCREW,8950759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,849.11000,246.24000,Aetna,First Health,,694.57,,,,,,,306.10,694.57,percent of total billed charges,
SCREW,8950759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,849.11000,246.24000,Aetna,First Health,,694.57,,,,,,,273.41,694.57,percent of total billed charges,
WEDGE,8950760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8950760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8950761,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8950761,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
COMPONENT FEMORAL,8965986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,7273.09,16503.15,percent of total billed charges,
COMPONENT FEMORAL,8965986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,6496.35,16503.15,percent of total billed charges,
INSERT,8965968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8965968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STEM,8965969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8965969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
MESH,8950796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,22258.15000,6454.86000,Aetna,First Health,,18207.17,,,,,,,8024.06,18207.17,percent of total billed charges,
MESH,8950796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,22258.15000,6454.86000,Aetna,First Health,,18207.17,,,,,,,7167.12,18207.17,percent of total billed charges,
INSERT,8950797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT,8950797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
INSERT,8950798,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT,8950798,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SYSTEM INTERVENTIONAL,8950799,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,14280.00000,4141.20000,Aetna,First Health,,11681.04,,,,,,,5147.94,11681.04,percent of total billed charges,
SYSTEM INTERVENTIONAL,8950799,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,14280.00000,4141.20000,Aetna,First Health,,11681.04,,,,,,,4598.16,11681.04,percent of total billed charges,
CAGE,8966251,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8966251,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
TISSUE ALLODERM,8966252,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,9387.00000,2722.23000,Aetna,First Health,,7678.57,,,,,,,3384.01,7678.57,percent of total billed charges,
TISSUE ALLODERM,8966252,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,9387.00000,2722.23000,Aetna,First Health,,7678.57,,,,,,,124.65,7678.57,percent of total billed charges,
ANCHOR,8968148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,870.25,1974.65,percent of total billed charges,
ANCHOR,8968148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,777.31,1974.65,percent of total billed charges,
ANCHOR,8968149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,870.25,1974.65,percent of total billed charges,
ANCHOR,8968149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,777.31,1974.65,percent of total billed charges,
NAIL,8968151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,8968151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
SCREW,8968152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8968152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SCREW,8968153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8968153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SHELL,8968154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8968154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
PLATE,8968155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE,8968155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
PLATE,8968156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.00000,187.92000,Aetna,First Health,,530.06,,,,,,,233.60,530.06,percent of total billed charges,
PLATE,8968156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.00000,187.92000,Aetna,First Health,,530.06,,,,,,,208.66,530.06,percent of total billed charges,
SCREW,8968157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,8968157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
INSERT,8972086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,8972086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
ANCHOR,8972087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9101.25000,2639.36000,Aetna,First Health,,7444.82,,,,,,,3281.00,7444.82,percent of total billed charges,
ANCHOR,8972087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9101.25000,2639.36000,Aetna,First Health,,7444.82,,,,,,,2930.60,7444.82,percent of total billed charges,
SCREW SPINAL,8972088,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW SPINAL,8972088,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
ROD SPINAL,8972089,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
ROD SPINAL,8972089,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
ROD SPINAL,8972302,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD SPINAL,8972302,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
INSERT,8972303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
INSERT,8972303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
FEMORAL HEAD,8972304,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,8972304,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
CAGE,8972305,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,30375.00000,8808.75000,Aetna,First Health,,24846.75,,,,,,,10950.19,24846.75,percent of total billed charges,
CAGE,8972305,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,30375.00000,8808.75000,Aetna,First Health,,24846.75,,,,,,,9780.75,24846.75,percent of total billed charges,
PLATE,8972306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2600.12000,754.03000,Aetna,First Health,,2126.90,,,,,,,937.34,2126.90,percent of total billed charges,
PLATE,8972306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2600.12000,754.03000,Aetna,First Health,,2126.90,,,,,,,837.24,2126.90,percent of total billed charges,
SCREW,8972307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,8972307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,8972308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,8972308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
CAGE,8972309,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21810.00000,6324.90000,Aetna,First Health,,17840.58,,,,,,,7862.51,17840.58,percent of total billed charges,
CAGE,8972309,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21810.00000,6324.90000,Aetna,First Health,,17840.58,,,,,,,7022.82,17840.58,percent of total billed charges,
INSERT,8974182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8974182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8974183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8974183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
PLATE SPINAL,8974184,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8974184,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STEM,8974206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8974206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,8974207,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
CAGE,8974207,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,8974208,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
CAGE,8974208,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8974210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8974210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
CAGE,8974237,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8974237,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
NAIL,8974238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8974238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
SCREW,8974253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SCREW,8974253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
BASEPLATE,8972377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
BASEPLATE,8972377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
PLATE,8972378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3416.25000,990.71000,Aetna,First Health,,2794.49,,,,,,,1231.56,2794.49,percent of total billed charges,
PLATE,8972378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3416.25000,990.71000,Aetna,First Health,,2794.49,,,,,,,1100.03,2794.49,percent of total billed charges,
CAGE,8974180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2730.79,6196.35,percent of total billed charges,
CAGE,8974180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,First Health,,6196.35,,,,,,,2439.15,6196.35,percent of total billed charges,
INSERT,8974181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8974181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
PLATE,8972394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4860.98000,1409.68000,Aetna,First Health,,3976.28,,,,,,,1752.38,3976.28,percent of total billed charges,
PLATE,8972394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4860.98000,1409.68000,Aetna,First Health,,3976.28,,,,,,,1565.24,3976.28,percent of total billed charges,
PLATE,8972395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4860.98000,1409.68000,Aetna,First Health,,3976.28,,,,,,,1752.38,3976.28,percent of total billed charges,
PLATE,8972395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4860.98000,1409.68000,Aetna,First Health,,3976.28,,,,,,,1565.24,3976.28,percent of total billed charges,
K WIRE,8972396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
K WIRE,8972396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW SPINAL,8972835,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
SCREW SPINAL,8972835,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW SPINAL,8972836,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
SCREW SPINAL,8972836,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW SPINAL,8972837,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
SCREW SPINAL,8972837,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW SPINAL,8972838,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
SCREW SPINAL,8972838,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8972839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8972839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
ROD SPINAL,8972840,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8972840,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
PLATE SPINAL,8972841,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8972841,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8972842,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8972842,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
INSERT,8972890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8972890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,8972891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8972891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW SPINAL,8972893,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW SPINAL,8972893,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
WASHER,8972915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,210.00000,60.90000,Aetna,First Health,,171.78,,,,,,,75.70,171.78,percent of total billed charges,
WASHER,8972915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,First Health,,171.78,,,,,,,67.62,171.78,percent of total billed charges,
CAGE,8972916,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,8972916,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
ROD SPINAL,8972917,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8972917,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,8972918,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,8972918,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
STENT,8972929,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8972929,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8972930,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8972930,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8972931,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8972931,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8972932,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8972932,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
STENT,8972933,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STENT,8972933,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
ANCHOR,8682255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4375.53000,1268.90000,Aetna,First Health,,3579.18,,,,,,,1577.38,3579.18,percent of total billed charges,
ANCHOR,8682255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4375.53000,1268.90000,Aetna,First Health,,3579.18,,,,,,,1408.92,3579.18,percent of total billed charges,
INSERT,8972956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8972956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,8972957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8972957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
INSERT,8972958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8972958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
GRAFT,8972960,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,17763.64,40306.95,percent of total billed charges,
GRAFT,8972960,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,First Health,,40306.95,,,,,,,15866.55,40306.95,percent of total billed charges,
HEAD FEMORAL,7699136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
HEAD FEMORAL,7699136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
CATHETER,8973019,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
CATHETER,8973019,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
BASEPLATE,8973022,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
BASEPLATE,8973022,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
BASEPLATE,8975135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
BASEPLATE,8975135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
BASEPLATE,8975136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
BASEPLATE,8975136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
BASEPLATE,8975137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
BASEPLATE,8975137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
BASEPLATE,8975138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
BASEPLATE,8975138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
BASEPLATE,8975139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
BASEPLATE,8975139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
BASEPLATE,8975140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
BASEPLATE,8975140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
BASEPLATE,8975141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
BASEPLATE,8975141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
BASEPLATE,8975142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
BASEPLATE,8975142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
BASEPLATE,8975143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,6489.00,14724.00,percent of total billed charges,
BASEPLATE,8975143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,5796.00,14724.00,percent of total billed charges,
GLENOSPHERE,8975269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
GLENOSPHERE,8975269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
ROD SPINAL,8973162,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD SPINAL,8973162,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
ANCHOR,8975270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2288.00000,663.52000,Aetna,First Health,,1871.58,,,,,,,824.82,1871.58,percent of total billed charges,
ANCHOR,8975270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2288.00000,663.52000,Aetna,First Health,,1871.58,,,,,,,736.74,1871.58,percent of total billed charges,
ANCHOR,8975271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4003.13000,1160.91000,Aetna,First Health,,3274.56,,,,,,,1443.13,3274.56,percent of total billed charges,
ANCHOR,8975271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4003.13000,1160.91000,Aetna,First Health,,3274.56,,,,,,,1289.01,3274.56,percent of total billed charges,
STEM,8975272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8975272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
STEM,8975273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,8975273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
HEAD FEMORAL,8975274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
HEAD FEMORAL,8975274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
INSERT,8973163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8973163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HEAD FEMORAL,8973161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
HEAD FEMORAL,8973161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
CATHETER,8975339,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
CATHETER,8975339,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
STEM COLLAR,8973307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6514.20000,1889.12000,Aetna,First Health,,5328.62,,,,,,,2348.37,5328.62,percent of total billed charges,
STEM COLLAR,8973307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6514.20000,1889.12000,Aetna,First Health,,5328.62,,,,,,,2097.57,5328.62,percent of total billed charges,
LINER,8973308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
LINER,8973308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
STEM PROSTHESIS,8973309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20324.25000,5894.03000,Aetna,First Health,,16625.24,,,,,,,7326.89,16625.24,percent of total billed charges,
STEM PROSTHESIS,8973309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20324.25000,5894.03000,Aetna,First Health,,16625.24,,,,,,,6544.41,16625.24,percent of total billed charges,
STEM,8973310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17235.00000,4998.15000,Aetna,First Health,,14098.23,,,,,,,6213.22,14098.23,percent of total billed charges,
STEM,8973310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17235.00000,4998.15000,Aetna,First Health,,14098.23,,,,,,,5549.67,14098.23,percent of total billed charges,
INSERT,8973311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8973311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
COMPONENT TIBIAL,8973312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
COMPONENT TIBIAL,8973312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
SCREW,8973313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2481.20000,719.55000,Aetna,First Health,,2029.62,,,,,,,894.47,2029.62,percent of total billed charges,
SCREW,8973313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2481.20000,719.55000,Aetna,First Health,,2029.62,,,,,,,798.95,2029.62,percent of total billed charges,
INSERT,8973396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8973396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
PLATE,8973397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10629.00000,3082.41000,Aetna,First Health,,8694.52,,,,,,,3831.75,8694.52,percent of total billed charges,
PLATE,8973397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10629.00000,3082.41000,Aetna,First Health,,8694.52,,,,,,,3422.54,8694.52,percent of total billed charges,
PLATE,8973398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10629.00000,3082.41000,Aetna,First Health,,8694.52,,,,,,,3831.75,8694.52,percent of total billed charges,
PLATE,8973398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10629.00000,3082.41000,Aetna,First Health,,8694.52,,,,,,,3422.54,8694.52,percent of total billed charges,
SCREW,8973399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,436.93,991.42,percent of total billed charges,
SCREW,8973399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,390.26,991.42,percent of total billed charges,
SCREW,8973400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,436.93,991.42,percent of total billed charges,
SCREW,8973400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,390.26,991.42,percent of total billed charges,
TUBE VENT,8973401,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,79.62000,23.09000,Aetna,First Health,,65.13,,,,,,,28.70,65.13,percent of total billed charges,
TUBE VENT,8973401,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,79.62000,23.09000,Aetna,First Health,,65.13,,,,,,,25.64,332.38,percent of total billed charges,
INSERT,8973402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8973402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
PLATE,8973403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5974.36000,1732.56000,Aetna,First Health,,4887.03,,,,,,,2153.76,4887.03,percent of total billed charges,
PLATE,8973403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5974.36000,1732.56000,Aetna,First Health,,4887.03,,,,,,,1923.74,4887.03,percent of total billed charges,
ANCHOR,8973404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9101.25000,2639.36000,Aetna,First Health,,7444.82,,,,,,,3281.00,7444.82,percent of total billed charges,
ANCHOR,8973404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9101.25000,2639.36000,Aetna,First Health,,7444.82,,,,,,,2930.60,7444.82,percent of total billed charges,
SCREW,8973717,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,565.26,1282.62,percent of total billed charges,
SCREW,8973717,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,504.90,1282.62,percent of total billed charges,
SCREW,8973716,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,565.26,1282.62,percent of total billed charges,
SCREW,8973716,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,504.90,1282.62,percent of total billed charges,
STEM,8975602,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,5497.62,12474.50,percent of total billed charges,
STEM,8975602,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,4910.50,12474.50,percent of total billed charges,
PLATE,8975603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9070.20000,2630.36000,Aetna,First Health,,7419.42,,,,,,,3269.81,7419.42,percent of total billed charges,
PLATE,8975603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9070.20000,2630.36000,Aetna,First Health,,7419.42,,,,,,,2920.60,7419.42,percent of total billed charges,
GRAFT,8975589,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,33072.75000,9591.10000,Aetna,First Health,,27053.51,,,,,,,11922.73,27053.51,percent of total billed charges,
GRAFT,8975589,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,33072.75000,9591.10000,Aetna,First Health,,27053.51,,,,,,,10649.43,27053.51,percent of total billed charges,
INSERT,8975592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8975592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SPACER,8975593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SPACER,8975593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW SPINAL,8975594,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SCREW SPINAL,8975594,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
SCREW SPINAL,8975595,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SCREW SPINAL,8975595,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
ROD SPINAL,8975596,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8975596,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
ROD SPINAL,8975597,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8975597,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
INSERT,8975599,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9135.00000,2649.15000,Aetna,First Health,,7472.43,,,,,,,3293.17,7472.43,percent of total billed charges,
INSERT,8975599,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9135.00000,2649.15000,Aetna,First Health,,7472.43,,,,,,,2941.47,7472.43,percent of total billed charges,
STEM,8975600,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
STEM,8975600,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STEM,8975601,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10530.00000,3053.70000,Aetna,First Health,,8613.54,,,,,,,3796.07,8613.54,percent of total billed charges,
STEM,8975601,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10530.00000,3053.70000,Aetna,First Health,,8613.54,,,,,,,3390.66,8613.54,percent of total billed charges,
LEAD KIT,8973778,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,7029.75,15951.00,percent of total billed charges,
LEAD KIT,8973778,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,6279.00,15951.00,percent of total billed charges,
STEM,8973779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,8973779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
BASEPLATE,8973780,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BASEPLATE,8973780,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
INSERT,8973781,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8973781,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
WASHER,8973782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,77.60,176.07,percent of total billed charges,
WASHER,8973782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,First Health,,176.07,,,,,,,69.31,176.07,percent of total billed charges,
PLATE,8973783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2496.00000,723.84000,Aetna,First Health,,2041.73,,,,,,,899.81,2041.73,percent of total billed charges,
PLATE,8973783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2496.00000,723.84000,Aetna,First Health,,2041.73,,,,,,,803.71,2041.73,percent of total billed charges,
BALLOON CATHETER,8973784,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,516.32,1171.57,percent of total billed charges,
BALLOON CATHETER,8973784,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,First Health,,1171.57,,,,,,,461.18,1171.57,percent of total billed charges,
PLATE,8973810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4652.13000,1349.12000,Aetna,First Health,,3805.44,,,,,,,1677.09,3805.44,percent of total billed charges,
PLATE,8973810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4652.13000,1349.12000,Aetna,First Health,,3805.44,,,,,,,1497.99,3805.44,percent of total billed charges,
PLATE,8973786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10389.00000,3012.81000,Aetna,First Health,,8498.20,,,,,,,3745.23,8498.20,percent of total billed charges,
PLATE,8973786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10389.00000,3012.81000,Aetna,First Health,,8498.20,,,,,,,3345.26,8498.20,percent of total billed charges,
STEM,8973787,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,8973787,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,8973811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8973811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8973812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,17433.30000,5055.66000,Aetna,First Health,,14260.44,,,,,,,6284.70,14260.44,percent of total billed charges,
SCREW,8973812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,17433.30000,5055.66000,Aetna,First Health,,14260.44,,,,,,,5613.52,14260.44,percent of total billed charges,
CONTROLLER PATIENT,8973827,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3578.56000,1037.78000,Aetna,First Health,,2927.26,,,,,,,1290.07,2927.26,percent of total billed charges,
CONTROLLER PATIENT,8973827,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3578.56000,1037.78000,Aetna,First Health,,2927.26,,,,,,,1152.30,2927.26,percent of total billed charges,
PLATE,8973828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5541.90000,1607.15000,Aetna,First Health,,4533.27,,,,,,,1997.85,4533.27,percent of total billed charges,
PLATE,8973828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5541.90000,1607.15000,Aetna,First Health,,4533.27,,,,,,,1784.49,4533.27,percent of total billed charges,
SCREW,8973829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8973829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
NAIL,8973830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8973830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
GLENOID,8978834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GLENOID,8978834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
HEAD HUMERAL,8978835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,8978835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,8978836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,8978836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
WASHER,8978837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
WASHER,8978837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,128.48,326.38,percent of total billed charges,
SCREW SPINAL,8982107,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SPINAL,8982107,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW SPINAL,8982108,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SPINAL,8982108,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE SPINAL,8982109,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8982109,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8982110,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
CAGE,8982110,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
CAGE,8982111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
CAGE,8982111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
CAGE,8982112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,8982112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
END CAP,8982133,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
END CAP,8982133,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
PIN,8982134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,304.17,690.19,percent of total billed charges,
PIN,8982134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,First Health,,690.19,,,,,,,271.69,690.19,percent of total billed charges,
CAGE,8981452,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
CAGE,8981452,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
CAGE,8981453,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
CAGE,8981453,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
PLATE SPINAL,8981454,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
PLATE SPINAL,8981454,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
SCREW SPINAL,8981455,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
SCREW SPINAL,8981455,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
SCREW SPINAL,8981456,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SCREW SPINAL,8981456,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
ROD SPINAL,8981457,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8981457,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
INSERT,8982310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5472.36000,1586.98000,Aetna,First Health,,4476.39,,,,,,,1972.79,4476.39,percent of total billed charges,
INSERT,8982310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5472.36000,1586.98000,Aetna,First Health,,4476.39,,,,,,,1762.10,4476.39,percent of total billed charges,
INSERT,8982311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8982311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8982312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8982312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE SPINAL,8982313,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8982313,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8982314,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8982314,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
SCREW,8982315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,795.42000,230.67000,Aetna,First Health,,650.65,,,,,,,286.75,650.65,percent of total billed charges,
SCREW,8982315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,795.42000,230.67000,Aetna,First Health,,650.65,,,,,,,256.13,650.65,percent of total billed charges,
SCREW,8982316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,795.42000,230.67000,Aetna,First Health,,650.65,,,,,,,286.75,650.65,percent of total billed charges,
SCREW,8982316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,795.42000,230.67000,Aetna,First Health,,650.65,,,,,,,256.13,650.65,percent of total billed charges,
SCREW,8982317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,795.42000,230.67000,Aetna,First Health,,650.65,,,,,,,286.75,650.65,percent of total billed charges,
SCREW,8982317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,795.42000,230.67000,Aetna,First Health,,650.65,,,,,,,256.13,650.65,percent of total billed charges,
GUIDEWIRE,8981547,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
GUIDEWIRE,8981547,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
STEM,8981548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17090.00000,4956.10000,Aetna,First Health,,13979.62,,,,,,,6160.94,13979.62,percent of total billed charges,
STEM,8981548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17090.00000,4956.10000,Aetna,First Health,,13979.62,,,,,,,5502.98,13979.62,percent of total billed charges,
GLENOSPHERE,8981549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
GLENOSPHERE,8981549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
CAGE,8982361,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8982361,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
INSERT,8982370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8982370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
PLATE,8982373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.02000,255.21000,Aetna,First Health,,719.86,,,,,,,317.25,719.86,percent of total billed charges,
PLATE,8982373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.02000,255.21000,Aetna,First Health,,719.86,,,,,,,283.37,719.86,percent of total billed charges,
PLATE,8982374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.02000,255.21000,Aetna,First Health,,719.86,,,,,,,317.25,719.86,percent of total billed charges,
PLATE,8982374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.02000,255.21000,Aetna,First Health,,719.86,,,,,,,283.37,719.86,percent of total billed charges,
PLATE,8982416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1421.99,3226.60,percent of total billed charges,
PLATE,8982416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,First Health,,3226.60,,,,,,,1270.13,3226.60,percent of total billed charges,
SCREW,8950180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,8950180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
SCREW,8950181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,8950181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
ROD SPINAL,8950182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD SPINAL,8950182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
CAGE,8947160,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,8947160,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
INSERT,8947161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8947161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW,8947162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.87000,114.22000,Aetna,First Health,,322.19,,,,,,,141.99,322.19,percent of total billed charges,
SCREW,8947162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.87000,114.22000,Aetna,First Health,,322.19,,,,,,,126.83,322.19,percent of total billed charges,
GRAFT,8947163,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,12930.00000,3749.70000,Aetna,First Health,,10576.74,,,,,,,4661.27,10576.74,percent of total billed charges,
GRAFT,8947163,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,12930.00000,3749.70000,Aetna,First Health,,10576.74,,,,,,,4163.46,10576.74,percent of total billed charges,
IMPLANT BREAST,8947165,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
IMPLANT BREAST,8947165,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
WEDGE,8947182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4958.73000,1438.03000,Aetna,First Health,,4056.24,,,,,,,1787.62,4056.24,percent of total billed charges,
WEDGE,8947182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4958.73000,1438.03000,Aetna,First Health,,4056.24,,,,,,,1596.71,4056.24,percent of total billed charges,
STEM,8947183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,First Health,,5369.19,,,,,,,2366.25,5369.19,percent of total billed charges,
STEM,8947183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,First Health,,5369.19,,,,,,,2113.54,5369.19,percent of total billed charges,
COMPONENT FEMORAL,8947184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24194.40000,7016.38000,Aetna,First Health,,19791.02,,,,,,,8722.08,19791.02,percent of total billed charges,
COMPONENT FEMORAL,8947184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24194.40000,7016.38000,Aetna,First Health,,19791.02,,,,,,,7790.60,19791.02,percent of total billed charges,
CATHETER,8947185,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
CATHETER,8947185,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
STENT,8947231,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,772.88000,224.14000,Aetna,First Health,,632.22,,,,,,,278.62,632.22,percent of total billed charges,
STENT,8947231,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,772.88000,224.14000,Aetna,First Health,,632.22,,,,,,,248.87,632.22,percent of total billed charges,
INSERT,8947232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8947232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
PLATE,7702478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,924.08000,267.98000,Aetna,First Health,,755.90,,,,,,,333.13,755.90,percent of total billed charges,
PLATE,7702478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,924.08000,267.98000,Aetna,First Health,,755.90,,,,,,,297.55,755.90,percent of total billed charges,
STEM,8982558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8982558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW SPINAL,8982559,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW SPINAL,8982559,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
ENDPLATE,8982560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8982560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
STEM,8982574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,5497.62,12474.50,percent of total billed charges,
STEM,8982574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,4910.50,12474.50,percent of total billed charges,
CAGE,8982575,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,8982575,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
SCREW SPINAL,8982576,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2949.68000,855.41000,Aetna,First Health,,2412.84,,,,,,,1063.36,2412.84,percent of total billed charges,
SCREW SPINAL,8982576,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2949.68000,855.41000,Aetna,First Health,,2412.84,,,,,,,949.80,2412.84,percent of total billed charges,
SCREW SPINAL,8982577,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW SPINAL,8982577,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
SCREW SPINAL,8982578,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW SPINAL,8982578,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
STEM,8619942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6514.20000,1889.12000,Aetna,First Health,,5328.62,,,,,,,2348.37,5328.62,percent of total billed charges,
STEM,8619942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6514.20000,1889.12000,Aetna,First Health,,5328.62,,,,,,,2097.57,5328.62,percent of total billed charges,
CAGE,8982639,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
CAGE,8982639,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
CATHETER,8982638,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,128.73000,37.33000,Aetna,First Health,,105.30,,,,,,,46.41,105.30,percent of total billed charges,
CATHETER,8982638,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,128.73000,37.33000,Aetna,First Health,,105.30,,,,,,,41.45,105.30,percent of total billed charges,
INSERT,8982732,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8982732,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
COMPONENT GLENOID,8982733,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
COMPONENT GLENOID,8982733,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
CAGE,8982734,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
CAGE,8982734,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
STEM,8981950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,3098.50,7030.71,percent of total billed charges,
STEM,8981950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,2767.59,7030.71,percent of total billed charges,
STEM,8981951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,3098.50,7030.71,percent of total billed charges,
STEM,8981951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,2767.59,7030.71,percent of total billed charges,
LINER,8981952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,First Health,,2883.04,,,,,,,1270.58,2883.04,percent of total billed charges,
LINER,8981952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,First Health,,2883.04,,,,,,,1134.89,2883.04,percent of total billed charges,
PLATE,8981953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10739.25000,3114.38000,Aetna,First Health,,8784.71,,,,,,,3871.50,8784.71,percent of total billed charges,
PLATE,8981953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10739.25000,3114.38000,Aetna,First Health,,8784.71,,,,,,,3458.04,8784.71,percent of total billed charges,
SCREW,8981954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,8981954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,8981955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,8981955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
SCREW,8981956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,8981956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
SCREW,8981957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,8981957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
SCREW,8981958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,8981958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
SCREW,8981959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,8981959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
SCREW,8981960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,8981960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
SCREW,8981961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,8981961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
COMPONENT TIBIAL,8982907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
COMPONENT TIBIAL,8982907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
SCREW,8982908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8982908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
INSERT,8982944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8982944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SCREW,8982997,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,8982997,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
CAGE,8982998,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
CAGE,8982998,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
SCREW SPINAL,8982999,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
SCREW SPINAL,8982999,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW SPINAL,8983000,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
SCREW SPINAL,8983000,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW SPINAL,8983001,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
SCREW SPINAL,8983001,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8983002,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8983002,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
INSERT,8983003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8983003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
GRAFT,8983059,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,2470.40000,716.42000,Aetna,First Health,,2020.79,,,,,,,890.58,2020.79,percent of total billed charges,
GRAFT,8983059,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,2470.40000,716.42000,Aetna,First Health,,2020.79,,,,,,,795.47,2020.79,percent of total billed charges,
GUIDEWIRE,8984230,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
GUIDEWIRE,8984230,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
GUIDEWIRE,8984231,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,612.85,1390.60,percent of total billed charges,
GUIDEWIRE,8984231,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,547.40,1390.60,percent of total billed charges,
ANKLE CUSTOM,8984234,CDM,278,RC,,,,,facility,inpatient,,,37237.50000,10798.88000,Aetna,First Health,,30460.28,,,,,,,13424.12,30460.28,percent of total billed charges,
ANKLE CUSTOM,8984234,CDM,278,RC,,,,,facility,outpatient,,,37237.50000,10798.88000,Aetna,First Health,,30460.28,,,,,,,11990.48,30460.28,percent of total billed charges,
NAIL,8984236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,24625.00000,7141.25000,Aetna,First Health,,20143.25,,,,,,,8877.31,20143.25,percent of total billed charges,
NAIL,8984236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,24625.00000,7141.25000,Aetna,First Health,,20143.25,,,,,,,7929.25,20143.25,percent of total billed charges,
NAIL,8984237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4683.00000,1358.07000,Aetna,First Health,,3830.69,,,,,,,1688.22,3830.69,percent of total billed charges,
NAIL,8984237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4683.00000,1358.07000,Aetna,First Health,,3830.69,,,,,,,1507.93,3830.69,percent of total billed charges,
SCREW,8984238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,713.79,1619.64,percent of total billed charges,
SCREW,8984238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,637.56,1619.64,percent of total billed charges,
SCREW,8984239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,713.79,1619.64,percent of total billed charges,
SCREW,8984239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,637.56,1619.64,percent of total billed charges,
SCREW,8984240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1462.00000,423.98000,Aetna,First Health,,1195.92,,,,,,,527.05,1195.92,percent of total billed charges,
SCREW,8984240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1462.00000,423.98000,Aetna,First Health,,1195.92,,,,,,,470.76,1195.92,percent of total billed charges,
SCREW,8984241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1462.00000,423.98000,Aetna,First Health,,1195.92,,,,,,,527.05,1195.92,percent of total billed charges,
SCREW,8984241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1462.00000,423.98000,Aetna,First Health,,1195.92,,,,,,,470.76,1195.92,percent of total billed charges,
CAGE,8984254,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,8984254,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
SCREW SPINAL,8984255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW SPINAL,8984255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
INSERT,8984256,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
INSERT,8984256,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
COMPONENT FEMORAL,8984257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,8984257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
PLATE MESH,8984267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4483.50000,1300.21000,Aetna,First Health,,3667.50,,,,,,,1616.30,3667.50,percent of total billed charges,
PLATE MESH,8984267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4483.50000,1300.21000,Aetna,First Health,,3667.50,,,,,,,1443.69,3667.50,percent of total billed charges,
SCREW SPINAL,8984338,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW SPINAL,8984338,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW SPINAL,8984260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW SPINAL,8984260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
PLATE,8984261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11282.40000,3271.90000,Aetna,First Health,,9229.00,,,,,,,4067.31,9229.00,percent of total billed charges,
PLATE,8984261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11282.40000,3271.90000,Aetna,First Health,,9229.00,,,,,,,3632.93,9229.00,percent of total billed charges,
PLATE,8984262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6018.60000,1745.39000,Aetna,First Health,,4923.21,,,,,,,2169.71,4923.21,percent of total billed charges,
PLATE,8984262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6018.60000,1745.39000,Aetna,First Health,,4923.21,,,,,,,1937.99,4923.21,percent of total billed charges,
INSERT,8984339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8984339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
COMPONENT RAIDAL HEAD,8984340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2812.98,6382.85,percent of total billed charges,
COMPONENT RAIDAL HEAD,8984340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2512.57,6382.85,percent of total billed charges,
SCREW,8984341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,8984341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,8984342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,8984342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
COMPONENT TIBIAL,8983208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
COMPONENT TIBIAL,8983208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
ENDPLATE,8983309,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
ENDPLATE,8983309,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
PLATE SPINAL,8983310,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8983310,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8983311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8983311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
MESH,8984495,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,20700.00000,6003.00000,Aetna,First Health,,16932.60,,,,,,,7462.35,16932.60,percent of total billed charges,
MESH,8984495,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,20700.00000,6003.00000,Aetna,First Health,,16932.60,,,,,,,6665.40,16932.60,percent of total billed charges,
SCREW SPINAL,8983438,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW SPINAL,8983438,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
SCREW SPINAL,8983439,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2425.52000,703.40000,Aetna,First Health,,1984.08,,,,,,,874.40,1984.08,percent of total billed charges,
SCREW SPINAL,8983439,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2425.52000,703.40000,Aetna,First Health,,1984.08,,,,,,,781.02,1984.08,percent of total billed charges,
CAGE,8983440,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8983440,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
CAGE,8983441,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8983441,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
CAGE,8983442,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,8983442,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
COMPONENT FEMORAL,8983443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
COMPONENT FEMORAL,8983443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
INSERT,8983444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8983444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
COMPONENT TIBIAL,8983445,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,8983445,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
SCREW,8983446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,507.58,1151.74,percent of total billed charges,
SCREW,8983446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,453.38,1151.74,percent of total billed charges,
SCREW,8983447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,8983447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
GRAFT,8983448,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17859.38000,5179.22000,Aetna,First Health,,14608.97,,,,,,,6438.31,14608.97,percent of total billed charges,
GRAFT,8983448,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17859.38000,5179.22000,Aetna,First Health,,14608.97,,,,,,,5750.72,14608.97,percent of total billed charges,
PLATE SPINAL,8984728,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE SPINAL,8984728,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW SPINAL,8984729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW SPINAL,8984729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW SPINAL,8984736,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW SPINAL,8984736,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW SPINAL,8984737,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW SPINAL,8984737,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
ROD SPINAL,8984739,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8984739,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
ROD SPINAL,8984738,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8984738,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
GLENOSPHERE,8983759,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GLENOSPHERE,8983759,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
STEM,8983760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6514.20000,1889.12000,Aetna,First Health,,5328.62,,,,,,,2348.37,5328.62,percent of total billed charges,
STEM,8983760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6514.20000,1889.12000,Aetna,First Health,,5328.62,,,,,,,2097.57,5328.62,percent of total billed charges,
SCREW,8983761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,8983761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
SCREW,8983762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,8983762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
SCREW,8983763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1551.95,3521.49,percent of total billed charges,
SCREW,8983763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,First Health,,3521.49,,,,,,,1386.21,3521.49,percent of total billed charges,
PIN,8983764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1864.00000,540.56000,Aetna,First Health,,1524.75,,,,,,,671.97,1524.75,percent of total billed charges,
PIN,8983764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1864.00000,540.56000,Aetna,First Health,,1524.75,,,,,,,600.21,1524.75,percent of total billed charges,
CAGE,8983765,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
CAGE,8983765,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
ROD SPINAL,8983766,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8983766,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
HUMERAL BODY,8983767,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20324.25000,5894.03000,Aetna,First Health,,16625.24,,,,,,,7326.89,16625.24,percent of total billed charges,
HUMERAL BODY,8983767,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20324.25000,5894.03000,Aetna,First Health,,16625.24,,,,,,,6544.41,16625.24,percent of total billed charges,
LINER,8983768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
LINER,8983768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
SCREW,8983769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,8983769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW,8983861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8983861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
SCREW SPINAL,8984805,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
SCREW SPINAL,8984805,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
PLATE SPINAL,8984806,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2365.78,5368.12,percent of total billed charges,
PLATE SPINAL,8984806,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2113.12,5368.12,percent of total billed charges,
STEM,8984807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
STEM,8984807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
INTRODUCER CATHETER,8983905,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,826.29000,239.62000,Aetna,First Health,,675.91,,,,,,,297.88,675.91,percent of total billed charges,
INTRODUCER CATHETER,8983905,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,826.29000,239.62000,Aetna,First Health,,675.91,,,,,,,266.07,675.91,percent of total billed charges,
CAGE,8984814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
CAGE,8984814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
NAIL,8984815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,8984815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
SCREW,8984816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8984816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SCREW,8984817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,8984817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
CAGE,8984818,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,8984818,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
CAGE,8984819,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,8984819,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
CAGE,8984820,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,8984820,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
ROD SPINAL,8984846,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8984846,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SCREW SPINAL,8984847,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW SPINAL,8984847,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW SPINAL,8984848,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW SPINAL,8984848,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SCREW SPINAL,8984849,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW SPINAL,8984849,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
COMPONENT FEMORAL,8983946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2851.37,6469.97,percent of total billed charges,
COMPONENT FEMORAL,8983946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,First Health,,6469.97,,,,,,,2546.86,6469.97,percent of total billed charges,
STEM,8983947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,10392.54,23581.41,percent of total billed charges,
STEM,8983947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,First Health,,23581.41,,,,,,,9282.66,23581.41,percent of total billed charges,
INSERT,8983948,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8983948,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
CAGE,8983949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
CAGE,8983949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
SCREW SPINAL,8983950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SPINAL,8983950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE SPINAL,8983951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
PLATE SPINAL,8983951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
COMPONENT FEMORAL,8983962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8983962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
SCREW SPINAL,8983963,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW SPINAL,8983963,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,8983970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8983970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8983971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8983971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
STEM,8983972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4855.03000,1407.96000,Aetna,First Health,,3971.41,,,,,,,1750.24,3971.41,percent of total billed charges,
STEM,8983972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4855.03000,1407.96000,Aetna,First Health,,3971.41,,,,,,,1563.32,3971.41,percent of total billed charges,
INSERT,8983973,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8983973,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,8983974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8983974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
GRAFT,8984011,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4277.25000,1240.40000,Aetna,First Health,,3498.79,,,,,,,1541.95,3498.79,percent of total billed charges,
GRAFT,8984011,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4277.25000,1240.40000,Aetna,First Health,,3498.79,,,,,,,1377.27,3498.79,percent of total billed charges,
GRAFT STENT,8984041,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
GRAFT STENT,8984041,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
INSERT,8984056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5344.85000,1550.01000,Aetna,First Health,,4372.09,,,,,,,1926.82,4372.09,percent of total billed charges,
INSERT,8984056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5344.85000,1550.01000,Aetna,First Health,,4372.09,,,,,,,1721.04,4372.09,percent of total billed charges,
BALLOON,8985032,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON,8985032,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
KIT QUICKSET,8985033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11227.50000,3255.98000,Aetna,First Health,,9184.09,,,,,,,4047.51,9184.09,percent of total billed charges,
KIT QUICKSET,8985033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11227.50000,3255.98000,Aetna,First Health,,9184.09,,,,,,,3615.26,9184.09,percent of total billed charges,
SCREW,8985034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8985034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
INSERT,8985035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,8985035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
ANCHOR IN KIT,8986150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1595.00000,462.55000,Aetna,First Health,,1304.71,,,,,,,575.00,1304.71,percent of total billed charges,
ANCHOR IN KIT,8986150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1595.00000,462.55000,Aetna,First Health,,1304.71,,,,,,,513.59,1304.71,percent of total billed charges,
COMPONENT GLENOID,8986159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,2149.26,4876.83,percent of total billed charges,
COMPONENT GLENOID,8986159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,1919.73,4876.83,percent of total billed charges,
LINER,8986162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER,8986162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
PLATE,8986164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14986.88000,4346.20000,Aetna,First Health,,12259.27,,,,,,,5402.77,12259.27,percent of total billed charges,
PLATE,8986164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14986.88000,4346.20000,Aetna,First Health,,12259.27,,,,,,,4825.78,12259.27,percent of total billed charges,
HIP SYSTEM,8985089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,669.60000,194.18000,Aetna,First Health,,547.73,,,,,,,241.39,547.73,percent of total billed charges,
HIP SYSTEM,8985089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,669.60000,194.18000,Aetna,First Health,,547.73,,,,,,,215.61,547.73,percent of total billed charges,
INSERT,8985090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8985090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
STEM,8985091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,8985091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
SCREW,8985093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,244.56,554.91,percent of total billed charges,
SCREW,8985093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,First Health,,554.91,,,,,,,218.44,554.91,percent of total billed charges,
KIT REV ADAPTER,8985094,CDM,278,RC,,,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
KIT REV ADAPTER,8985094,CDM,278,RC,,,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
TENDON,8985117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9101.25000,2639.36000,Aetna,First Health,,7444.82,,,,,,,3281.00,7444.82,percent of total billed charges,
TENDON,8985117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9101.25000,2639.36000,Aetna,First Health,,7444.82,,,,,,,2930.60,7444.82,percent of total billed charges,
STEM,8985118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8985118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
ROD SPINAL,8985119,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,536.42,1217.18,percent of total billed charges,
ROD SPINAL,8985119,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,479.14,1217.18,percent of total billed charges,
INSERT,8985120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8985120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
PLATE,8985121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,8985121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
SCREW,8985147,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8985147,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
INSERT,8985148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8985148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SHELL,8985163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,8985163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW SPINAL,8986243,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW SPINAL,8986243,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
CAGE,8986244,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,8986244,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
SCREW,8985203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8985203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8986284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8986284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8985204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8985204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
WEDGE,8986234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1442.18,3272.41,percent of total billed charges,
WEDGE,8986234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,First Health,,3272.41,,,,,,,1288.16,3272.41,percent of total billed charges,
PLATE,8986235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE,8986235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
SCREW,8986236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8986236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW SPINAL,8986238,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SCREW SPINAL,8986238,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
NAIL,8985205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,3062.33,6948.65,percent of total billed charges,
NAIL,8985205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,2735.29,6948.65,percent of total billed charges,
CAGE,8986240,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,7480.38,16973.50,percent of total billed charges,
CAGE,8986240,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,6681.50,16973.50,percent of total billed charges,
SCREW,8986286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8986286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
STEM,8986288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7830.00000,2270.70000,Aetna,First Health,,6404.94,,,,,,,2822.72,6404.94,percent of total billed charges,
STEM,8986288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7830.00000,2270.70000,Aetna,First Health,,6404.94,,,,,,,2521.26,6404.94,percent of total billed charges,
INSERT,8986290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8986290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8986292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8986292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8986294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8986294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
BASEPLATE,8985263,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3139.88000,910.57000,Aetna,First Health,,2568.42,,,,,,,1131.93,2568.42,percent of total billed charges,
BASEPLATE,8985263,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3139.88000,910.57000,Aetna,First Health,,2568.42,,,,,,,1011.04,2568.42,percent of total billed charges,
SCREW SPINAL,8985264,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SPINAL,8985264,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE SPINAL,8985265,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8985265,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8985266,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
CAGE,8985266,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
SCREW,8985267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,8985267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
PLATE,8985268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3349.50000,971.35000,Aetna,First Health,,2739.89,,,,,,,1207.49,2739.89,percent of total billed charges,
PLATE,8985268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3349.50000,971.35000,Aetna,First Health,,2739.89,,,,,,,1078.54,2739.89,percent of total billed charges,
NAIL,8985269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,8985269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
SCREW,8985270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8985270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
SCREW,8985271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8985271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
SCREW SPINAL,8985272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW SPINAL,8985272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PLATE SPINAL,8985273,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE SPINAL,8985273,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SHELL,8985274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,8985274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
STEM,8985275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8985275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,8986361,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
STEM,8986361,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
INSERT,8985277,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8985277,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HUMERAL HEAD,8986362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HUMERAL HEAD,8986362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
GAMMA LAG SCREW,8986363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,943.76,2141.46,percent of total billed charges,
GAMMA LAG SCREW,8986363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,842.97,2141.46,percent of total billed charges,
GAMMA NAIL,8986364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
GAMMA NAIL,8986364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
SCREW,8986430,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SCREW,8986430,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
SCREW,8986431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8986431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8986432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8986432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8986433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8986433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BASEPLATE,8986434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
BASEPLATE,8986434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1374.94,3492.86,percent of total billed charges,
GLENOSPHERE,8986435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5670.00000,1644.30000,Aetna,First Health,,4638.06,,,,,,,2044.04,4638.06,percent of total billed charges,
GLENOSPHERE,8986435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5670.00000,1644.30000,Aetna,First Health,,4638.06,,,,,,,1825.74,4638.06,percent of total billed charges,
INSERT HUMERAL,8986436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
INSERT HUMERAL,8986436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1374.94,3492.86,percent of total billed charges,
STEM HUMERAL,8986437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10530.00000,3053.70000,Aetna,First Health,,8613.54,,,,,,,3796.07,8613.54,percent of total billed charges,
STEM HUMERAL,8986437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10530.00000,3053.70000,Aetna,First Health,,8613.54,,,,,,,3390.66,8613.54,percent of total billed charges,
TRAY HUMERAL,8986438,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
TRAY HUMERAL,8986438,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
SCREW FEMORAL,8986417,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
SCREW FEMORAL,8986417,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
FEMORAL IMPLANT,8986418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
FEMORAL IMPLANT,8986418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
PLACE CLAVICLE,8986413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10578.00000,3067.62000,Aetna,First Health,,8652.80,,,,,,,3813.37,8652.80,percent of total billed charges,
PLACE CLAVICLE,8986413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10578.00000,3067.62000,Aetna,First Health,,8652.80,,,,,,,3406.12,8652.80,percent of total billed charges,
LINER ACETABULAR,8986415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8392.50000,2433.82000,Aetna,First Health,,6865.06,,,,,,,3025.50,6865.06,percent of total billed charges,
LINER ACETABULAR,8986415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8392.50000,2433.82000,Aetna,First Health,,6865.06,,,,,,,2702.39,6865.06,percent of total billed charges,
FEMOARL HEAD,8986416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
FEMOARL HEAD,8986416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
INSERT TIBIAL,8986414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,8986414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,8986439,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14547.00000,4218.63000,Aetna,First Health,,11899.45,,,,,,,5244.19,11899.45,percent of total billed charges,
CAGE,8986439,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14547.00000,4218.63000,Aetna,First Health,,11899.45,,,,,,,4684.13,11899.45,percent of total billed charges,
GLENOID,8986440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
GLENOID,8986440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
ADAPTOR,8986441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,605.64,1374.24,percent of total billed charges,
ADAPTOR,8986441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,540.96,1374.24,percent of total billed charges,
HUMERAL HEAD,8986467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,8986467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
HUMERUS,8986468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
HUMERUS,8986468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
SCREW,8986469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,671.84,1524.46,percent of total billed charges,
SCREW,8986469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,600.09,1524.46,percent of total billed charges,
SCREW,8986470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8986470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8986471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8986471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8986474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8986474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
BOLT,8986585,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BOLT,8986585,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SPACER,8986586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,20125.00000,5836.25000,Aetna,First Health,,16462.25,,,,,,,7255.06,16462.25,percent of total billed charges,
SPACER,8986586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,20125.00000,5836.25000,Aetna,First Health,,16462.25,,,,,,,6480.25,16462.25,percent of total billed charges,
SCREW,8986587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SCREW,8986587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
CATHETER,8984145,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
CATHETER,8984145,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,9959.00,percent of total billed charges,
CATHETER,8984144,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
CATHETER,8984144,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,9959.00,percent of total billed charges,
EXTENDER LEAD,8982415,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
EXTENDER LEAD,8982415,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
INTRODUCER,9072801,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,68.13,154.60,percent of total billed charges,
INTRODUCER,9072801,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,60.86,154.60,percent of total billed charges,
CATHETER ABLATION,9060901,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,25625.00000,7431.25000,Aetna,First Health,,20961.25,,,,,,,9237.81,20961.25,percent of total billed charges,
CATHETER ABLATION,9060901,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,25625.00000,7431.25000,Aetna,First Health,,20961.25,,,,,,,8251.25,20961.25,percent of total billed charges,
CATHETER ABLATION,9060902,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,25625.00000,7431.25000,Aetna,First Health,,20961.25,,,,,,,9237.81,20961.25,percent of total billed charges,
CATHETER ABLATION,9060902,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,25625.00000,7431.25000,Aetna,First Health,,20961.25,,,,,,,8251.25,20961.25,percent of total billed charges,
SHEATH,9060903,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
SHEATH,9060903,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
CATHETER TRAPPER,8402792,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2620.00000,759.80000,Aetna,First Health,,2143.16,,,,,,,944.51,2143.16,percent of total billed charges,
CATHETER TRAPPER,8402792,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2620.00000,759.80000,Aetna,First Health,,2143.16,,,,,,,843.64,2143.16,percent of total billed charges,
STENT PERIPHERAL,9056589,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT PERIPHERAL,9056589,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
Catherter D 20cm,8982174,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,1297.00000,376.13000,Aetna,First Health,,1060.95,,,,,,,467.57,1060.95,percent of total billed charges,
Catherter D 20cm,8982174,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,1297.00000,376.13000,Aetna,First Health,,1060.95,,,,,,,417.63,1060.95,percent of total billed charges,
Catheter Intravascular,9082195,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,3430.00000,994.70000,Aetna,First Health,,2805.74,,,,,,,1236.52,2805.74,percent of total billed charges,
Catheter Intravascular,9082195,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,3430.00000,994.70000,Aetna,First Health,,2805.74,,,,,,,1104.46,2805.74,percent of total billed charges,
CATHETER FINECROSS,9080273,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2770.00000,803.30000,Aetna,First Health,,2265.86,,,,,,,998.59,2265.86,percent of total billed charges,
CATHETER FINECROSS,9080273,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2770.00000,803.30000,Aetna,First Health,,2265.86,,,,,,,891.94,2265.86,percent of total billed charges,
CATHETER GUIDING,9076438,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDING,9076438,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER,8982198,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2180.00000,632.20000,Aetna,First Health,,1783.24,,,,,,,785.89,1783.24,percent of total billed charges,
CATHETER,8982198,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2180.00000,632.20000,Aetna,First Health,,1783.24,,,,,,,701.96,1783.24,percent of total billed charges,
CAT HETER EXTRACTION,9032392,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,677.74,1537.84,percent of total billed charges,
CAT HETER EXTRACTION,9032392,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,First Health,,1537.84,,,,,,,605.36,1537.84,percent of total billed charges,
INTRODUCER OPTISEAL,9042913,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
INTRODUCER OPTISEAL,9042913,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
GUIDEWIRE,9038246,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,929.30000,269.50000,Aetna,First Health,,760.17,,,,,,,335.01,760.17,percent of total billed charges,
GUIDEWIRE,9038246,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,929.30000,269.50000,Aetna,First Health,,760.17,,,,,,,299.23,760.17,percent of total billed charges,
GUIDEWIRE,9038248,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,929.30000,269.50000,Aetna,First Health,,760.17,,,,,,,335.01,760.17,percent of total billed charges,
GUIDEWIRE,9038248,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,929.30000,269.50000,Aetna,First Health,,760.17,,,,,,,299.23,760.17,percent of total billed charges,
GUIDEWIRE,9036282,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,9036282,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
GUIDEWIRE,9036283,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
GUIDEWIRE,9036283,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
ROTATIONAL ARTHRECTOMY,8983901,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,7485.00000,2170.65000,Aetna,First Health,,6122.73,,,,,,,2698.34,6122.73,percent of total billed charges,
ROTATIONAL ARTHRECTOMY,8983901,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,7485.00000,2170.65000,Aetna,First Health,,6122.73,,,,,,,2410.17,6122.73,percent of total billed charges,
ROTATIONAL ARTHRECTOMY,8983902,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,7485.00000,2170.65000,Aetna,First Health,,6122.73,,,,,,,2698.34,6122.73,percent of total billed charges,
ROTATIONAL ARTHRECTOMY,8983902,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,7485.00000,2170.65000,Aetna,First Health,,6122.73,,,,,,,2410.17,6122.73,percent of total billed charges,
ROTATIONAL ARTHRECTOMY,8983903,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,7485.00000,2170.65000,Aetna,First Health,,6122.73,,,,,,,2698.34,6122.73,percent of total billed charges,
ROTATIONAL ARTHRECTOMY,8983903,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,7485.00000,2170.65000,Aetna,First Health,,6122.73,,,,,,,2410.17,6122.73,percent of total billed charges,
INTRODUCER CATHETER,8986584,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,130.14,295.30,percent of total billed charges,
INTRODUCER CATHETER,8986584,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,116.24,295.30,percent of total billed charges,
CATHETER,8986975,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
CATHETER,8986975,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,9959.00,percent of total billed charges,
CATHETER,8986976,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3797.50000,1101.27000,Aetna,First Health,,3106.36,,,,,,,1369.00,3106.36,percent of total billed charges,
CATHETER,8986976,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3797.50000,1101.27000,Aetna,First Health,,3106.36,,,,,,,1222.80,9959.00,percent of total billed charges,
CATHETER,8990275,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3916.50000,1135.78000,Aetna,First Health,,3203.70,,,,,,,1411.90,3203.70,percent of total billed charges,
CATHETER,8990275,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3916.50000,1135.78000,Aetna,First Health,,3203.70,,,,,,,1261.11,3203.70,percent of total billed charges,
CATHETER,8990223,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3797.50000,1101.27000,Aetna,First Health,,3106.36,,,,,,,1369.00,3106.36,percent of total billed charges,
CATHETER,8990223,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3797.50000,1101.27000,Aetna,First Health,,3106.36,,,,,,,1222.80,9959.00,percent of total billed charges,
SCREW,8988116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,8988116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
ROD SPINAL,8986588,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8986588,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
CAGE,8986579,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
CAGE,8986579,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
FEMORAL IMLANT,8986580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
FEMORAL IMLANT,8986580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
INSERT,8986581,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT,8986581,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SPACER,8986583,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
SPACER,8986583,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
NAIL,8986554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8986554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
SHOULDER IMPLANT,8986631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,5497.62,12474.50,percent of total billed charges,
SHOULDER IMPLANT,8986631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,4910.50,12474.50,percent of total billed charges,
CAGE,8986632,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,8986632,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
VIRTUAL SURGICAL PLANNING BUNDLE,8986634,CDM,278,RC,,,,,facility,inpatient,,,3886.40000,1127.06000,Aetna,First Health,,3179.08,,,,,,,1401.05,3179.08,percent of total billed charges,
VIRTUAL SURGICAL PLANNING BUNDLE,8986634,CDM,278,RC,,,,,facility,outpatient,,,3886.40000,1127.06000,Aetna,First Health,,3179.08,,,,,,,1251.42,3179.08,percent of total billed charges,
BREAST IMPLANT,8985565,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8985565,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8985570,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8985570,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8985571,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8985571,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8985574,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8985574,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8985575,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8985575,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
ISOLATOR CLAMP,8986630,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,3893.40,8834.40,percent of total billed charges,
ISOLATOR CLAMP,8986630,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,3477.60,8834.40,percent of total billed charges,
ISOLATOR CLAMP,7695642,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,3893.40,8834.40,percent of total billed charges,
ISOLATOR CLAMP,7695642,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,3477.60,8834.40,percent of total billed charges,
CONNECTOR SPINE,8986680,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2401.68000,696.49000,Aetna,First Health,,1964.57,,,,,,,865.81,1964.57,percent of total billed charges,
CONNECTOR SPINE,8986680,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2401.68000,696.49000,Aetna,First Health,,1964.57,,,,,,,773.34,1964.57,percent of total billed charges,
CONNECTOR SPINE,8986681,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2401.68000,696.49000,Aetna,First Health,,1964.57,,,,,,,865.81,1964.57,percent of total billed charges,
CONNECTOR SPINE,8986681,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2401.68000,696.49000,Aetna,First Health,,1964.57,,,,,,,773.34,1964.57,percent of total billed charges,
SCREW,8986682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,122.78,278.59,percent of total billed charges,
SCREW,8986682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,109.67,278.59,percent of total billed charges,
SCREW,8986683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,8986683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
SCREW,8986684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,8986684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
SCREW,8986633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,8986633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
KWIRE,8985579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
KWIRE,8985579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8988114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SCREW,8988114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
NAIL,8988121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,2071.79,4701.05,percent of total billed charges,
NAIL,8988121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,First Health,,4701.05,,,,,,,1850.53,4701.05,percent of total billed charges,
INSERT,8988122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8988122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW SPINAL,8988125,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW SPINAL,8988125,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
SCREW SPINAL,8988126,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,254.69,577.92,percent of total billed charges,
SCREW SPINAL,8988126,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,227.49,577.92,percent of total billed charges,
SCREW SPINAL,8988127,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,254.69,577.92,percent of total billed charges,
SCREW SPINAL,8988127,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,227.49,577.92,percent of total billed charges,
INTERBODY FUSION,8988128,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
INTERBODY FUSION,8988128,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
INSERT,8988129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13050.00000,3784.50000,Aetna,First Health,,10674.90,,,,,,,4704.52,10674.90,percent of total billed charges,
INSERT,8988129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13050.00000,3784.50000,Aetna,First Health,,10674.90,,,,,,,4202.10,10674.90,percent of total billed charges,
SCREW,8988123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8988123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
GRAFT,8986773,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,13050.00000,3784.50000,Aetna,First Health,,10674.90,,,,,,,4704.52,10674.90,percent of total billed charges,
GRAFT,8986773,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,13050.00000,3784.50000,Aetna,First Health,,10674.90,,,,,,,4202.10,10674.90,percent of total billed charges,
GRAFT,8988211,CDM,278,RC,,,,,facility,inpatient,,,21125.00000,6126.25000,Aetna,First Health,,17280.25,,,,,,,7615.56,17280.25,percent of total billed charges,
GRAFT,8988211,CDM,278,RC,,,,,facility,outpatient,,,21125.00000,6126.25000,Aetna,First Health,,17280.25,,,,,,,6802.25,17280.25,percent of total billed charges,
SCREW,8988223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,8988223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
SCREW,8988224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,8988224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
PLATE,8986906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,923.31000,267.76000,Aetna,First Health,,755.27,,,,,,,332.85,755.27,percent of total billed charges,
PLATE,8986906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,923.31000,267.76000,Aetna,First Health,,755.27,,,,,,,297.31,755.27,percent of total billed charges,
CAGE,8986779,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE,8986779,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
TISSUE FASTENER,8986781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4003.13000,1160.91000,Aetna,First Health,,3274.56,,,,,,,1443.13,3274.56,percent of total billed charges,
TISSUE FASTENER,8986781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4003.13000,1160.91000,Aetna,First Health,,3274.56,,,,,,,1289.01,3274.56,percent of total billed charges,
FIBERWIRE,8986782,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,First Health,,120.68,,,,,,,53.18,120.68,percent of total billed charges,
FIBERWIRE,8986782,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,First Health,,120.68,,,,,,,47.50,120.68,percent of total billed charges,
FIBERLINK,8986783,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,210.49,477.61,percent of total billed charges,
FIBERLINK,8986783,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,First Health,,477.61,,,,,,,188.01,477.61,percent of total billed charges,
FIBERWIRE,8986784,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,First Health,,120.68,,,,,,,53.18,120.68,percent of total billed charges,
FIBERWIRE,8986784,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,First Health,,120.68,,,,,,,47.50,120.68,percent of total billed charges,
SCREW,8986785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8986785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
FIBERTAK,8986786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,953.52,2163.61,percent of total billed charges,
FIBERTAK,8986786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,851.69,2163.61,percent of total billed charges,
HUMERAL STEM,8986787,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
HUMERAL STEM,8986787,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
SPACER,8986788,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,4082.66,9263.85,percent of total billed charges,
SPACER,8986788,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,3646.65,9263.85,percent of total billed charges,
SCREW ASSEMBLY,8986789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW ASSEMBLY,8986789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
CAGE,8986790,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,8986790,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
CAGE,8986791,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE,8986791,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
SCREW,8990125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8990125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
HUMERUS,8986792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18440.00000,5347.60000,Aetna,First Health,,15083.92,,,,,,,6647.62,15083.92,percent of total billed charges,
HUMERUS,8986792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18440.00000,5347.60000,Aetna,First Health,,15083.92,,,,,,,5937.68,15083.92,percent of total billed charges,
SCREW,8986955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,254.69,577.92,percent of total billed charges,
SCREW,8986955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,227.49,577.92,percent of total billed charges,
PLATE,8986954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
PLATE,8986954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
CAGE,8986953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE,8986953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
PLATE,8986958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1378.80000,399.85000,Aetna,First Health,,1127.86,,,,,,,497.06,1127.86,percent of total billed charges,
PLATE,8986958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1378.80000,399.85000,Aetna,First Health,,1127.86,,,,,,,443.97,1127.86,percent of total billed charges,
PLATE,8986959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1357.72000,393.74000,Aetna,First Health,,1110.61,,,,,,,489.46,1110.61,percent of total billed charges,
PLATE,8986959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1357.72000,393.74000,Aetna,First Health,,1110.61,,,,,,,437.19,1110.61,percent of total billed charges,
CAGE,8986960,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
CAGE,8986960,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
STEM,8986961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM,8986961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
ACETABULAR SHELL,8986956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16087.50000,4665.38000,Aetna,First Health,,13159.58,,,,,,,5799.54,13159.58,percent of total billed charges,
ACETABULAR SHELL,8986956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16087.50000,4665.38000,Aetna,First Health,,13159.58,,,,,,,5180.18,13159.58,percent of total billed charges,
PLATE,8990126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
PLATE,8990126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
SCREW,8990127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8990127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8990128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8990128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
PLATE,8990129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4921.88000,1427.35000,Aetna,First Health,,4026.10,,,,,,,1774.34,4026.10,percent of total billed charges,
PLATE,8990129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4921.88000,1427.35000,Aetna,First Health,,4026.10,,,,,,,1584.85,4026.10,percent of total billed charges,
SCREW,8990130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8990130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
SCREW,8990131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,537.14,1218.82,percent of total billed charges,
SCREW,8990131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,First Health,,1218.82,,,,,,,479.78,1218.82,percent of total billed charges,
CAGE,8990143,CDM,278,RC,,,,,facility,inpatient,,,37237.50000,10798.88000,Aetna,First Health,,30460.28,,,,,,,13424.12,30460.28,percent of total billed charges,
CAGE,8990143,CDM,278,RC,,,,,facility,outpatient,,,37237.50000,10798.88000,Aetna,First Health,,30460.28,,,,,,,11990.48,30460.28,percent of total billed charges,
NAIL,8990134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,24625.00000,7141.25000,Aetna,First Health,,20143.25,,,,,,,8877.31,20143.25,percent of total billed charges,
NAIL,8990134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,24625.00000,7141.25000,Aetna,First Health,,20143.25,,,,,,,7929.25,20143.25,percent of total billed charges,
SCREW,8990135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4683.00000,1358.07000,Aetna,First Health,,3830.69,,,,,,,1688.22,3830.69,percent of total billed charges,
SCREW,8990135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4683.00000,1358.07000,Aetna,First Health,,3830.69,,,,,,,1507.93,3830.69,percent of total billed charges,
SCREW,8990136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,713.79,1619.64,percent of total billed charges,
SCREW,8990136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,637.56,1619.64,percent of total billed charges,
KWIRE,8990138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.75000,53.29000,Aetna,First Health,,150.31,,,,,,,66.24,150.31,percent of total billed charges,
KWIRE,8990138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.75000,53.29000,Aetna,First Health,,150.31,,,,,,,59.17,150.31,percent of total billed charges,
PLATE,8990139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7582.74000,2198.99000,Aetna,First Health,,6202.68,,,,,,,2733.58,6202.68,percent of total billed charges,
PLATE,8990139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7582.74000,2198.99000,Aetna,First Health,,6202.68,,,,,,,2441.64,6202.68,percent of total billed charges,
PLATE,8990140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,4133.49,9379.19,percent of total billed charges,
PLATE,8990140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,First Health,,9379.19,,,,,,,3692.05,9379.19,percent of total billed charges,
PLATE,8990141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,567.00000,164.43000,Aetna,First Health,,463.81,,,,,,,204.40,463.81,percent of total billed charges,
PLATE,8990141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,567.00000,164.43000,Aetna,First Health,,463.81,,,,,,,182.57,463.81,percent of total billed charges,
SCREW,8990142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,8990142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
GRAFT,8990144,CDM,278,RC,J7330,HCPCS,,,facility,inpatient,,,109212.00000,31671.48000,Aetna,First Health,,89335.42,,,,,,,39370.93,89335.42,percent of total billed charges,
GRAFT,8990144,CDM,278,RC,J7330,HCPCS,,,facility,outpatient,,,109212.00000,31671.48000,Aetna,First Health,,89335.42,,,,,,,39370.93,224509.03,percent of total billed charges,
CAGE,8987128,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,8987128,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
STRATOSPHERE,8987129,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22292.50000,6464.82000,Aetna,First Health,,18235.26,,,,,,,8036.45,18235.26,percent of total billed charges,
STRATOSPHERE,8987129,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22292.50000,6464.82000,Aetna,First Health,,18235.26,,,,,,,7178.19,18235.26,percent of total billed charges,
SCREW,8987130,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,8987130,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
SCREW,8987131,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW,8987131,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
ENDCAP,8987132,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4109.00000,1191.61000,Aetna,First Health,,3361.16,,,,,,,1481.29,3361.16,percent of total billed charges,
ENDCAP,8987132,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4109.00000,1191.61000,Aetna,First Health,,3361.16,,,,,,,1323.10,3361.16,percent of total billed charges,
SCREW,8987133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,8987133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
HUMERAL STEM,8990210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10530.00000,3053.70000,Aetna,First Health,,8613.54,,,,,,,3796.07,8613.54,percent of total billed charges,
HUMERAL STEM,8990210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10530.00000,3053.70000,Aetna,First Health,,8613.54,,,,,,,3390.66,8613.54,percent of total billed charges,
GLENOSPHERE,8990211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5670.00000,1644.30000,Aetna,First Health,,4638.06,,,,,,,2044.04,4638.06,percent of total billed charges,
GLENOSPHERE,8990211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5670.00000,1644.30000,Aetna,First Health,,4638.06,,,,,,,1825.74,4638.06,percent of total billed charges,
HUMERAL TRAY,8990212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
HUMERAL TRAY,8990212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
INSERT,8990213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
INSERT,8990213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1374.94,3492.86,percent of total billed charges,
FEMORAL HEAD,8992162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,8992162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
KWIRE,8990215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
KWIRE,8990215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
KWIRE,8990216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
KWIRE,8990216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
TIBIAL INSERT,8987180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
TIBIAL INSERT,8987180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
LINER ACETABULAR,8987181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,793.10,1799.60,percent of total billed charges,
LINER ACETABULAR,8987181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,708.40,1799.60,percent of total billed charges,
FEMORAL,8990279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
FEMORAL,8990279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
LINER,8990277,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8990277,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
INSERT,8990278,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8990278,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
SPACER,8987308,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14547.00000,4218.63000,Aetna,First Health,,11899.45,,,,,,,5244.19,11899.45,percent of total billed charges,
SPACER,8987308,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14547.00000,4218.63000,Aetna,First Health,,11899.45,,,,,,,4684.13,11899.45,percent of total billed charges,
GLENOID,8987309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9135.00000,2649.15000,Aetna,First Health,,7472.43,,,,,,,3293.17,7472.43,percent of total billed charges,
GLENOID,8987309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9135.00000,2649.15000,Aetna,First Health,,7472.43,,,,,,,2941.47,7472.43,percent of total billed charges,
HUMERAL STEM,8987310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL STEM,8987310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
ENDCAP,8987311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
ENDCAP,8987311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
TIBIAL INSERT,8992102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
TIBIAL INSERT,8992102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
TAP,8992103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,940.50000,272.74000,Aetna,First Health,,769.33,,,,,,,339.05,769.33,percent of total billed charges,
TAP,8992103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,940.50000,272.74000,Aetna,First Health,,769.33,,,,,,,302.84,769.33,percent of total billed charges,
SCREW,8992104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,8992104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
GUIDEWIRE,8987345,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,339.39000,98.42000,Aetna,First Health,,277.62,,,,,,,122.35,277.62,percent of total billed charges,
GUIDEWIRE,8987345,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,339.39000,98.42000,Aetna,First Health,,277.62,,,,,,,109.28,277.62,percent of total billed charges,
SCREW,8987346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8987346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
SCREW,8987347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8987347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,8987348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8987348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
DISTAL CENTRILIZER,8987351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
DISTAL CENTRILIZER,8987351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
POST HOFFMAN,8987341,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,756.00000,219.24000,Aetna,First Health,,618.41,,,,,,,272.54,618.41,percent of total billed charges,
POST HOFFMAN,8987341,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,756.00000,219.24000,Aetna,First Health,,618.41,,,,,,,243.43,618.41,percent of total billed charges,
SCREW,8987342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
SCREW,8987342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
WASHER,8987343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,920.00,2087.54,percent of total billed charges,
WASHER,8987343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,821.74,2087.54,percent of total billed charges,
SCREW,8987344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SCREW,8987344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
GRAFT TENDON,8987391,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1962.02,4451.97,percent of total billed charges,
GRAFT TENDON,8987391,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1752.48,4451.97,percent of total billed charges,
FEMORAL STEM,8987392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,3098.50,7030.71,percent of total billed charges,
FEMORAL STEM,8987392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,2767.59,7030.71,percent of total billed charges,
SPACER,8987484,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
SPACER,8987484,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
PLATE,8987485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4039.00000,1171.31000,Aetna,First Health,,3303.90,,,,,,,1456.06,3303.90,percent of total billed charges,
PLATE,8987485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4039.00000,1171.31000,Aetna,First Health,,3303.90,,,,,,,1300.56,3303.90,percent of total billed charges,
CAGE,8987486,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE,8987486,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
INSERT HUMERAL,8987487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT HUMERAL,8987487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
SCREW,8987488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8987488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
NAIL,8987490,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8987490,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
BREAST IMPLANT,8987469,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8987469,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
BREAST IMPLANT,8987473,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8987473,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
BREAST IMPLANT,8987474,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8987474,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
BREAST IMPLANT,8987475,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8987475,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
BREAST IMPLANT,8987480,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8987480,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
AUGMENT BLOCK,8992269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
AUGMENT BLOCK,8992269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
AUGMENT BLOCK,8992270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
AUGMENT BLOCK,8992270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
INSERT TIBIAL,8992271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,8992271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SCREW,8992272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
SCREW,8992272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
WASHER,8992273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1596.11,3621.70,percent of total billed charges,
WASHER,8992273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1425.65,3621.70,percent of total billed charges,
ROD SPINAL,8992274,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8992274,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8992275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,8992275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,8996105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW,8996105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
STEM,8996108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8996108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
SCREW,8996109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,254.69,577.92,percent of total billed charges,
SCREW,8996109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,227.49,577.92,percent of total billed charges,
PLATE,8996110,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
PLATE,8996110,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
INSERT,8996111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8996111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SPACER,8994115,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
SPACER,8994115,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
SCREW,8996112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,442.06,1003.06,percent of total billed charges,
SCREW,8996112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,First Health,,1003.06,,,,,,,394.85,1003.06,percent of total billed charges,
SCREW,8996113,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW,8996113,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
GUIDE PIN,8996114,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
GUIDE PIN,8996114,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
CROSSLINK,8994152,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2304.00000,668.16000,Aetna,First Health,,1884.67,,,,,,,830.59,1884.67,percent of total billed charges,
CROSSLINK,8994152,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2304.00000,668.16000,Aetna,First Health,,1884.67,,,,,,,741.89,1884.67,percent of total billed charges,
TISSUE EXPANDER,8975306,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
TISSUE EXPANDER,8975306,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
INSERT,8996166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8996166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
STEM,8996168,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,4276.25,9703.12,percent of total billed charges,
STEM,8996168,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,3819.56,9703.12,percent of total billed charges,
PLATE,8996169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3643.50000,1056.62000,Aetna,First Health,,2980.38,,,,,,,1313.48,2980.38,percent of total billed charges,
PLATE,8996169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3643.50000,1056.62000,Aetna,First Health,,2980.38,,,,,,,1173.21,2980.38,percent of total billed charges,
GLENOID,8996170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5670.00000,1644.30000,Aetna,First Health,,4638.06,,,,,,,2044.04,4638.06,percent of total billed charges,
GLENOID,8996170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5670.00000,1644.30000,Aetna,First Health,,4638.06,,,,,,,1825.74,4638.06,percent of total billed charges,
INSERT,8996171,CDM,278,RC,C1784,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
INSERT,8996171,CDM,278,RC,C1784,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1374.94,3492.86,percent of total billed charges,
INSERT TIBIAL,8996191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,8996191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8996192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8254.80000,2393.89000,Aetna,First Health,,6752.43,,,,,,,2975.86,6752.43,percent of total billed charges,
PLATE,8996192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8254.80000,2393.89000,Aetna,First Health,,6752.43,,,,,,,2658.05,6752.43,percent of total billed charges,
SCREW,8996193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,8996193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,8996194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,8996194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,8996195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,8996195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
FEMORAL,8996196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,4351.96,9874.90,percent of total billed charges,
FEMORAL,8996196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,3887.18,9874.90,percent of total billed charges,
SCREW,8996199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,8996199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,8996200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,8996200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,8996201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,8996201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
PLATE,8996202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4208.40000,1220.44000,Aetna,First Health,,3442.47,,,,,,,1517.13,3442.47,percent of total billed charges,
PLATE,8996202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4208.40000,1220.44000,Aetna,First Health,,3442.47,,,,,,,1355.10,3442.47,percent of total billed charges,
SCREW,8996203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,8996203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
HUMERAL STEMLESS,8996204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13530.00000,3923.70000,Aetna,First Health,,11067.54,,,,,,,4877.56,11067.54,percent of total billed charges,
HUMERAL STEMLESS,8996204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13530.00000,3923.70000,Aetna,First Health,,11067.54,,,,,,,4356.66,11067.54,percent of total billed charges,
SCREW,8994267,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,8994267,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
CAGE,8994268,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14547.00000,4218.63000,Aetna,First Health,,11899.45,,,,,,,5244.19,11899.45,percent of total billed charges,
CAGE,8994268,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14547.00000,4218.63000,Aetna,First Health,,11899.45,,,,,,,4684.13,11899.45,percent of total billed charges,
HUMERAL STEMLESS,8994269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
HUMERAL STEMLESS,8994269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
HUMERAL HEAD,8994270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,8994270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
BOLT,8994271,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BOLT,8994271,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SPACER,8994272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20125.00000,5836.25000,Aetna,First Health,,16462.25,,,,,,,7255.06,16462.25,percent of total billed charges,
SPACER,8994272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20125.00000,5836.25000,Aetna,First Health,,16462.25,,,,,,,6480.25,16462.25,percent of total billed charges,
STEM RADIAL,8994274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
STEM RADIAL,8994274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8994304,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,8994304,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
INSERT HUMERAL,8994305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT HUMERAL,8994305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
PLATE,8994319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11628.00000,3372.12000,Aetna,First Health,,9511.70,,,,,,,4191.89,9511.70,percent of total billed charges,
PLATE,8994319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11628.00000,3372.12000,Aetna,First Health,,9511.70,,,,,,,3744.22,9511.70,percent of total billed charges,
SCREW,8994306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,8994306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,8994307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,8994307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,8994308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8994308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,8994309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8994309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
GUIDE WIRE,8994310,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,126.00000,36.54000,Aetna,First Health,,103.07,,,,,,,45.42,103.07,percent of total billed charges,
GUIDE WIRE,8994310,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,126.00000,36.54000,Aetna,First Health,,103.07,,,,,,,40.57,103.07,percent of total billed charges,
SCREW,8994312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SCREW,8994312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
STAPLE,8994313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8634.00000,2503.86000,Aetna,First Health,,7062.61,,,,,,,3112.56,7062.61,percent of total billed charges,
STAPLE,8994313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8634.00000,2503.86000,Aetna,First Health,,7062.61,,,,,,,2780.15,7062.61,percent of total billed charges,
SCREW,8994320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,498.93,1132.11,percent of total billed charges,
SCREW,8994320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,445.65,1132.11,percent of total billed charges,
COUNTERSINK,8994315,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,1328.00000,385.12000,Aetna,First Health,,1086.30,,,,,,,478.74,1086.30,percent of total billed charges,
COUNTERSINK,8994315,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,1328.00000,385.12000,Aetna,First Health,,1086.30,,,,,,,427.62,1086.30,percent of total billed charges,
PLATE,8996268,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
PLATE,8996268,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
SCREW,8996269,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8996269,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,8996270,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8996270,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
FEMORAL HEAD,8994316,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,8994316,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
INSERT HUEMRAL,8994317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT HUEMRAL,8994317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
SCREW,8994321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,246.29,558.85,percent of total billed charges,
SCREW,8994321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,First Health,,558.85,,,,,,,219.99,558.85,percent of total billed charges,
SCREW,8996271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,507.58,1151.74,percent of total billed charges,
SCREW,8996271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,453.38,1151.74,percent of total billed charges,
SCREW,8996272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8996272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,8996273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,8996273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
GRAFT,8994380,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
GRAFT,8994380,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
STEM,8994381,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8994381,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
SCREW,8994416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SCREW,8994416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
SCREW,8994418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,8994418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
ROD SPINAL,8994420,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8994420,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
INSERT,8994421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8994421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
STEM,8994422,CDM,278,RC,C1772,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8994422,CDM,278,RC,C1772,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PLATE,8994423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9012.00000,2613.48000,Aetna,First Health,,7371.82,,,,,,,3248.83,7371.82,percent of total billed charges,
PLATE,8994423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9012.00000,2613.48000,Aetna,First Health,,7371.82,,,,,,,2901.86,7371.82,percent of total billed charges,
SCREW,8994424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8994424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8994425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8994425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8994426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8994426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8994427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,8994427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,8994428,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SCREW,8994428,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,8994429,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW,8994429,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
ROD,8994476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD,8994476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
CAGE,8994478,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
CAGE,8994478,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
TIBIA,8994479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
TIBIA,8994479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
INSERT GLENOID,8994480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9135.00000,2649.15000,Aetna,First Health,,7472.43,,,,,,,3293.17,7472.43,percent of total billed charges,
INSERT GLENOID,8994480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9135.00000,2649.15000,Aetna,First Health,,7472.43,,,,,,,2941.47,7472.43,percent of total billed charges,
INSTRUMENT,8994732,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,153.83000,44.61000,Aetna,First Health,,125.83,,,,,,,55.46,125.83,percent of total billed charges,
INSTRUMENT,8994732,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,153.83000,44.61000,Aetna,First Health,,125.83,,,,,,,49.53,125.83,percent of total billed charges,
FIBERTAK,8996418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2162.00000,626.98000,Aetna,First Health,,1768.52,,,,,,,779.40,1768.52,percent of total billed charges,
FIBERTAK,8996418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2162.00000,626.98000,Aetna,First Health,,1768.52,,,,,,,696.16,1768.52,percent of total billed charges,
PLATE,8996413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2587.96000,750.51000,Aetna,First Health,,2116.95,,,,,,,932.96,2116.95,percent of total billed charges,
PLATE,8996413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2587.96000,750.51000,Aetna,First Health,,2116.95,,,,,,,833.32,2116.95,percent of total billed charges,
PLATE,8996414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1239.48000,359.45000,Aetna,First Health,,1013.89,,,,,,,446.83,1013.89,percent of total billed charges,
PLATE,8996414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1239.48000,359.45000,Aetna,First Health,,1013.89,,,,,,,399.11,1013.89,percent of total billed charges,
PLATE,8996415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.79000,278.92000,Aetna,First Health,,786.74,,,,,,,346.73,786.74,percent of total billed charges,
PLATE,8996415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.79000,278.92000,Aetna,First Health,,786.74,,,,,,,309.70,786.74,percent of total billed charges,
PLATE,8996416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1325.16000,384.30000,Aetna,First Health,,1083.98,,,,,,,477.72,1083.98,percent of total billed charges,
PLATE,8996416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1325.16000,384.30000,Aetna,First Health,,1083.98,,,,,,,426.70,1083.98,percent of total billed charges,
PLATE,8996417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
PLATE,8996417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,909.33,2310.03,percent of total billed charges,
SPACER,8996419,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
SPACER,8996419,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
FEMER,8996420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
FEMER,8996420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
INSERT,8996421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8996421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8996462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8996462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,8996463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8996463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,8996464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8996464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
BASEPLATE,8997057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
BASEPLATE,8997057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1374.94,3492.86,percent of total billed charges,
GLENOSPHERE,8997058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6062.00000,1757.98000,Aetna,First Health,,4958.72,,,,,,,2185.35,4958.72,percent of total billed charges,
GLENOSPHERE,8997058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6062.00000,1757.98000,Aetna,First Health,,4958.72,,,,,,,1951.96,4958.72,percent of total billed charges,
FEMORAL COMPONENT,8997042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
FEMORAL COMPONENT,8997042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
TISSUE,8994803,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,12076.38000,3502.15000,Aetna,First Health,,9878.48,,,,,,,4353.53,9878.48,percent of total billed charges,
TISSUE,8994803,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,12076.38000,3502.15000,Aetna,First Health,,9878.48,,,,,,,3888.59,9878.48,percent of total billed charges,
INSERT,8997059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8997059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
FEMORAL NAIL,8994740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
FEMORAL NAIL,8994740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
FEMORAL NAIL,8994742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
FEMORAL NAIL,8994742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
PLATE,8997205,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4039.00000,1171.31000,Aetna,First Health,,3303.90,,,,,,,1456.06,3303.90,percent of total billed charges,
PLATE,8997205,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4039.00000,1171.31000,Aetna,First Health,,3303.90,,,,,,,1300.56,3303.90,percent of total billed charges,
KWIRE,8997206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
KWIRE,8997206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,8997210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8997210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,8997211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SCREW,8997211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
NAIL,8997212,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12204.00000,3539.16000,Aetna,First Health,,9982.87,,,,,,,4399.54,9982.87,percent of total billed charges,
NAIL,8997212,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12204.00000,3539.16000,Aetna,First Health,,9982.87,,,,,,,3929.69,9982.87,percent of total billed charges,
SCREW,8995030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8995030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,8995031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8995031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
INTERBODY FUSION,8997396,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26435.00000,7666.15000,Aetna,First Health,,21623.83,,,,,,,9529.82,21623.83,percent of total billed charges,
INTERBODY FUSION,8997396,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26435.00000,7666.15000,Aetna,First Health,,21623.83,,,,,,,8512.07,21623.83,percent of total billed charges,
SCREW,8995032,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,147.26,334.15,percent of total billed charges,
SCREW,8995032,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,131.54,334.15,percent of total billed charges,
ROD,8997397,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
ROD,8997397,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SCREW,8995033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8995033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,8995034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8995034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
PLATE,8995035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
PLATE,8995035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
INSERT,8995036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
INSERT,8995036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1374.94,3492.86,percent of total billed charges,
SCREW,8995037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8995037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW,8995082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,319.58,725.16,percent of total billed charges,
SCREW,8995082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,285.45,725.16,percent of total billed charges,
SCREW,8995083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,319.58,725.16,percent of total billed charges,
SCREW,8995083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,285.45,725.16,percent of total billed charges,
FEMORAL STEM,8995084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
FEMORAL STEM,8995084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
TIBIAL,8995111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
TIBIAL,8995111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
TIBIAL,8997394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
TIBIAL,8997394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
TIBIAL,8997395,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
TIBIAL,8997395,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
TISSUE EXPANDER,8995025,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,15102.50000,4379.72000,Aetna,First Health,,12353.84,,,,,,,5444.45,12353.84,percent of total billed charges,
TISSUE EXPANDER,8995025,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,15102.50000,4379.72000,Aetna,First Health,,12353.84,,,,,,,4863.01,12353.84,percent of total billed charges,
STEM,8997400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
STEM,8997400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
ROD,8997399,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,8997399,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ROD,8997398,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD,8997398,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
ANCHOR,8999058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,814.73,1848.68,percent of total billed charges,
ANCHOR,8999058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,727.72,1848.68,percent of total billed charges,
SURGICAL SUPPLIES,8999067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SURGICAL SUPPLIES,8999067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
SURGICAL SUPPLIES,8999069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SURGICAL SUPPLIES,8999069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
SURGICAL SUPPLIES,8999071,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,747.00000,216.63000,Aetna,First Health,,611.05,,,,,,,269.29,611.05,percent of total billed charges,
SURGICAL SUPPLIES,8999071,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,747.00000,216.63000,Aetna,First Health,,611.05,,,,,,,240.53,611.05,percent of total billed charges,
SURGICAL SUPPLIES,8999072,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,147.26,334.15,percent of total billed charges,
SURGICAL SUPPLIES,8999072,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,First Health,,334.15,,,,,,,131.54,334.15,percent of total billed charges,
KIT MINNIE TIES,7967975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,2170.21,4924.36,percent of total billed charges,
KIT MINNIE TIES,7967975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,1938.44,4924.36,percent of total billed charges,
ANCHOR SUTURE,8999056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ANCHOR SUTURE,8999056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
SUTURE TAPE,8999059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,814.73,1848.68,percent of total billed charges,
SUTURE TAPE,8999059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,727.72,1848.68,percent of total billed charges,
ANCHOR SUTURE,8999060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ANCHOR SUTURE,8999060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
ANCHOR SUTURE,8999063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,814.73,1848.68,percent of total billed charges,
ANCHOR SUTURE,8999063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,727.72,1848.68,percent of total billed charges,
ANCHOR SUTURE,8999062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,814.73,1848.68,percent of total billed charges,
ANCHOR SUTURE,8999062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,727.72,1848.68,percent of total billed charges,
SURGICAL NEEDLE,8999065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,236.85,537.43,percent of total billed charges,
SURGICAL NEEDLE,8999065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,First Health,,537.43,,,,,,,211.55,537.43,percent of total billed charges,
LOOP INFINITY,8999066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
LOOP INFINITY,8999066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
WASHER,8999068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
WASHER,8999068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
SUTURE ANCHOR,8999070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1444.00000,418.76000,Aetna,First Health,,1181.19,,,,,,,520.56,1181.19,percent of total billed charges,
SUTURE ANCHOR,8999070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1444.00000,418.76000,Aetna,First Health,,1181.19,,,,,,,464.97,1181.19,percent of total billed charges,
SCREW,8999348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,920.00,2087.54,percent of total billed charges,
SCREW,8999348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,821.74,2087.54,percent of total billed charges,
SCREW,8999350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
SCREW,8999350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
INSERT,8999353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8999353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
SPACER,8999354,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
SPACER,8999354,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
FIBERLOCK,8999355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6649.13000,1928.25000,Aetna,First Health,,5438.99,,,,,,,2397.01,5438.99,percent of total billed charges,
FIBERLOCK,8999355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6649.13000,1928.25000,Aetna,First Health,,5438.99,,,,,,,2141.02,5438.99,percent of total billed charges,
SCREW,8999356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8999356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,8999357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
SCREW,8999357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
INSERT HUMERAL,8999358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT HUMERAL,8999358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
HUMERAL HEAD,8995249,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,24062.50000,6978.12000,Aetna,First Health,,19683.12,,,,,,,8674.53,19683.12,percent of total billed charges,
HUMERAL HEAD,8995249,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,24062.50000,6978.12000,Aetna,First Health,,19683.12,,,,,,,7748.12,19683.12,percent of total billed charges,
CONNECTOR,8995285,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1596.11,3621.70,percent of total billed charges,
CONNECTOR,8995285,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1425.65,3621.70,percent of total billed charges,
SCREW,8995287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8995287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8995288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8995288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8995289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8995289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8995290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8995290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
GLENOID,8995291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
GLENOID,8995291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
STEM,8995292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,8995292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
PLATE,8995286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1777.64000,515.52000,Aetna,First Health,,1454.11,,,,,,,640.84,1454.11,percent of total billed charges,
PLATE,8995286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1777.64000,515.52000,Aetna,First Health,,1454.11,,,,,,,572.40,1454.11,percent of total billed charges,
PUTTY,8995293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
PUTTY,8995293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
SCREW,8999419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8999419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
INSERT HUMERAL,8999420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13530.00000,3923.70000,Aetna,First Health,,11067.54,,,,,,,4877.56,11067.54,percent of total billed charges,
INSERT HUMERAL,8999420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13530.00000,3923.70000,Aetna,First Health,,11067.54,,,,,,,4356.66,11067.54,percent of total billed charges,
STEM,8999421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
STEM,8999421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
LINER,8999422,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,8999422,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
BONE BLOCK,8995327,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
BONE BLOCK,8995327,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
BONE BLOCK,8995328,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,14100.00000,4089.00000,Aetna,First Health,,11533.80,,,,,,,5083.05,11533.80,percent of total billed charges,
BONE BLOCK,8995328,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,14100.00000,4089.00000,Aetna,First Health,,11533.80,,,,,,,4540.20,11533.80,percent of total billed charges,
COLLAR BUTTON,8999423,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,98.07000,28.44000,Aetna,First Health,,80.22,,,,,,,35.35,80.22,percent of total billed charges,
COLLAR BUTTON,8999423,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,98.07000,28.44000,Aetna,First Health,,80.22,,,,,,,31.58,332.38,percent of total billed charges,
RETRO CUTTER,8999456,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,1368.20000,396.78000,Aetna,First Health,,1119.19,,,,,,,493.24,1119.19,percent of total billed charges,
RETRO CUTTER,8999456,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,1368.20000,396.78000,Aetna,First Health,,1119.19,,,,,,,440.56,1119.19,percent of total billed charges,
TAP,8999455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2410.84000,699.14000,Aetna,First Health,,1972.07,,,,,,,869.11,1972.07,percent of total billed charges,
TAP,8999455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2410.84000,699.14000,Aetna,First Health,,1972.07,,,,,,,776.29,1972.07,percent of total billed charges,
PIN AXIS,8995248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1864.00000,540.56000,Aetna,First Health,,1524.75,,,,,,,671.97,1524.75,percent of total billed charges,
PIN AXIS,8995248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1864.00000,540.56000,Aetna,First Health,,1524.75,,,,,,,600.21,1524.75,percent of total billed charges,
TISSUE,8995026,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17752.50000,5148.22000,Aetna,First Health,,14521.55,,,,,,,6399.78,14521.55,percent of total billed charges,
TISSUE,8995026,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17752.50000,5148.22000,Aetna,First Health,,14521.55,,,,,,,5716.31,14521.55,percent of total billed charges,
LINER,8995379,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8995379,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BOAT FIBER,8999457,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5182.28000,1502.86000,Aetna,First Health,,4239.11,,,,,,,1868.21,4239.11,percent of total billed charges,
BOAT FIBER,8999457,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5182.28000,1502.86000,Aetna,First Health,,4239.11,,,,,,,1668.69,4239.11,percent of total billed charges,
FIBER BOAT,8999458,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8676.00000,2516.04000,Aetna,First Health,,7096.97,,,,,,,3127.70,7096.97,percent of total billed charges,
FIBER BOAT,8999458,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8676.00000,2516.04000,Aetna,First Health,,7096.97,,,,,,,2793.67,7096.97,percent of total billed charges,
NAIL,8999558,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL,8999558,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
PLATE,8999559,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10767.60000,3122.60000,Aetna,First Health,,8807.90,,,,,,,3881.72,8807.90,percent of total billed charges,
PLATE,8999559,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10767.60000,3122.60000,Aetna,First Health,,8807.90,,,,,,,3467.17,8807.90,percent of total billed charges,
SHELL,8995489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,8995489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
LINER,8995490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,8995490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
SCREW,8999562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,8999562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
SCREW,8999563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,8999563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
PLATE,8999564,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4920.30000,1426.89000,Aetna,First Health,,4024.81,,,,,,,1773.77,4024.81,percent of total billed charges,
PLATE,8999564,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4920.30000,1426.89000,Aetna,First Health,,4024.81,,,,,,,1584.34,4024.81,percent of total billed charges,
PLATE,8999565,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4197.90000,1217.39000,Aetna,First Health,,3433.88,,,,,,,1513.34,3433.88,percent of total billed charges,
PLATE,8999565,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4197.90000,1217.39000,Aetna,First Health,,3433.88,,,,,,,1351.72,3433.88,percent of total billed charges,
NAIL,8999566,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,8999566,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
SCREW,8999567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8999567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
NAIL,8999568,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8999568,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
SCREW,8999569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,8999569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SCREW,8995493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1636.00000,474.44000,Aetna,First Health,,1338.25,,,,,,,589.78,1338.25,percent of total billed charges,
SCREW,8995493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1636.00000,474.44000,Aetna,First Health,,1338.25,,,,,,,526.79,1338.25,percent of total billed charges,
ANCHOR,8999544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2871.56000,832.75000,Aetna,First Health,,2348.94,,,,,,,1035.20,2348.94,percent of total billed charges,
ANCHOR,8999544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2871.56000,832.75000,Aetna,First Health,,2348.94,,,,,,,924.64,2348.94,percent of total billed charges,
PLATE,8999546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8463.00000,2454.27000,Aetna,First Health,,6922.73,,,,,,,3050.91,6922.73,percent of total billed charges,
PLATE,8999546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8463.00000,2454.27000,Aetna,First Health,,6922.73,,,,,,,2725.09,6922.73,percent of total billed charges,
RUBY COIL,8995488,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
RUBY COIL,8995488,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
COIL,8999552,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2416.25,5482.65,percent of total billed charges,
COIL,8999552,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2158.20,5482.65,percent of total billed charges,
COIL PACKING,8999553,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
COIL PACKING,8999553,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
COIL,8999551,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
COIL,8999551,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
COIL,8999550,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
COIL,8999550,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
COIL,8999549,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
COIL,8999549,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
CAGE MODULUS,8999535,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE MODULUS,8999535,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
PLATE,8999536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6272.00000,1818.88000,Aetna,First Health,,5130.50,,,,,,,2261.06,5130.50,percent of total billed charges,
PLATE,8999536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6272.00000,1818.88000,Aetna,First Health,,5130.50,,,,,,,2019.58,5130.50,percent of total billed charges,
IMPLANT HUM HEAD,8999538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
IMPLANT HUM HEAD,8999538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
ENDPLATE,8999539,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE,8999539,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
COMPONENT FEMORAL,8999554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,8999554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
SCREW,8999541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8999541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,8999555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,365.75000,106.07000,Aetna,First Health,,299.18,,,,,,,131.85,299.18,percent of total billed charges,
SCREW,8999555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,365.75000,106.07000,Aetna,First Health,,299.18,,,,,,,117.77,299.18,percent of total billed charges,
SCREW,8999556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,365.75000,106.07000,Aetna,First Health,,299.18,,,,,,,131.85,299.18,percent of total billed charges,
SCREW,8999556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,365.75000,106.07000,Aetna,First Health,,299.18,,,,,,,117.77,299.18,percent of total billed charges,
SCREW,8999614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8999614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SCREW,8999615,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8999615,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SPACER,8999616,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3528.00000,1023.12000,Aetna,First Health,,2885.90,,,,,,,1271.84,2885.90,percent of total billed charges,
SPACER,8999616,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3528.00000,1023.12000,Aetna,First Health,,2885.90,,,,,,,1136.02,2885.90,percent of total billed charges,
SCREW,8999617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW,8999617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
HOLDER,8999618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.03000,134.86000,Aetna,First Health,,380.39,,,,,,,167.64,380.39,percent of total billed charges,
HOLDER,8999618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.03000,134.86000,Aetna,First Health,,380.39,,,,,,,149.74,380.39,percent of total billed charges,
ALPHAVENT,8910682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,309.85,703.07,percent of total billed charges,
ALPHAVENT,8910682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,276.76,703.07,percent of total billed charges,
CAGE MODULUS,8999542,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE MODULUS,8999542,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
CAGE MODULUS,8999543,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE MODULUS,8999543,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
SCREW,8999619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2099.00000,608.71000,Aetna,First Health,,1716.98,,,,,,,756.69,1716.98,percent of total billed charges,
SCREW,8999619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2099.00000,608.71000,Aetna,First Health,,1716.98,,,,,,,675.88,1716.98,percent of total billed charges,
PLATE,8999654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
PLATE,8999654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
PLATE,8999655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1143.51,2594.70,percent of total billed charges,
PLATE,8999655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,First Health,,2594.70,,,,,,,1021.38,2594.70,percent of total billed charges,
INSERT,8999656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8999656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
NAIL,8999657,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8999657,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
HEAD FEMORAL,8999658,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
HEAD FEMORAL,8999658,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
BASEPLATE,8999652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
BASEPLATE,8999652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
CAGE T LIFT,8999653,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE T LIFT,8999653,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
SCREW,8995633,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,8995633,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,8995634,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,8995634,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
PLATE,8995635,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3656.10000,1060.27000,Aetna,First Health,,2990.69,,,,,,,1318.02,2990.69,percent of total billed charges,
PLATE,8995635,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3656.10000,1060.27000,Aetna,First Health,,2990.69,,,,,,,1177.26,2990.69,percent of total billed charges,
LINER,8995636,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER,8995636,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
SPACER,8995637,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
SPACER,8995637,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
PLATE,8995638,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4487.00000,1301.23000,Aetna,First Health,,3670.37,,,,,,,1617.56,3670.37,percent of total billed charges,
PLATE,8995638,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4487.00000,1301.23000,Aetna,First Health,,3670.37,,,,,,,1444.81,3670.37,percent of total billed charges,
BASEPLATE,8995639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,8995639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
INSERT,8995640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8995640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
TIBIAL INSERT,8995681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3783.50000,1097.21000,Aetna,First Health,,3094.90,,,,,,,1363.95,3094.90,percent of total billed charges,
TIBIAL INSERT,8995681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3783.50000,1097.21000,Aetna,First Health,,3094.90,,,,,,,1218.29,3094.90,percent of total billed charges,
INBONE INSERT,8995682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11448.00000,3319.92000,Aetna,First Health,,9364.46,,,,,,,4127.00,9364.46,percent of total billed charges,
INBONE INSERT,8995682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11448.00000,3319.92000,Aetna,First Health,,9364.46,,,,,,,3686.26,9364.46,percent of total billed charges,
STEM,8999469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
STEM,8999469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
INSERT,8995696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8995696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8995697,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,722.44,1639.27,percent of total billed charges,
SCREW,8995697,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,First Health,,1639.27,,,,,,,645.29,1639.27,percent of total billed charges,
SPACER,8995698,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14547.00000,4218.63000,Aetna,First Health,,11899.45,,,,,,,5244.19,11899.45,percent of total billed charges,
SPACER,8995698,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14547.00000,4218.63000,Aetna,First Health,,11899.45,,,,,,,4684.13,11899.45,percent of total billed charges,
SPACER,8995699,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14547.00000,4218.63000,Aetna,First Health,,11899.45,,,,,,,5244.19,11899.45,percent of total billed charges,
SPACER,8995699,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14547.00000,4218.63000,Aetna,First Health,,11899.45,,,,,,,4684.13,11899.45,percent of total billed charges,
SHELL,8995700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,8995700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
IMPLANT INFINITY,8995701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11805.00000,3423.45000,Aetna,First Health,,9656.49,,,,,,,4255.70,9656.49,percent of total billed charges,
IMPLANT INFINITY,8995701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11805.00000,3423.45000,Aetna,First Health,,9656.49,,,,,,,3801.21,9656.49,percent of total billed charges,
PLATE,8999540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3209.50000,930.75000,Aetna,First Health,,2625.37,,,,,,,1157.02,2625.37,percent of total billed charges,
PLATE,8999540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3209.50000,930.75000,Aetna,First Health,,2625.37,,,,,,,1033.46,2625.37,percent of total billed charges,
SCREW,8995702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,713.79,1619.64,percent of total billed charges,
SCREW,8995702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,637.56,1619.64,percent of total billed charges,
SCREW,8995703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,713.79,1619.64,percent of total billed charges,
SCREW,8995703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,637.56,1619.64,percent of total billed charges,
CAGE,8995711,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,8995711,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
SPACER,8995712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1444.20,3276.99,percent of total billed charges,
SPACER,8995712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,First Health,,3276.99,,,,,,,1289.96,3276.99,percent of total billed charges,
STEM,8995723,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8995723,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
BLADE,8995724,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,372.07000,107.90000,Aetna,First Health,,304.35,,,,,,,134.13,304.35,percent of total billed charges,
BLADE,8995724,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,372.07000,107.90000,Aetna,First Health,,304.35,,,,,,,119.81,304.35,percent of total billed charges,
KIT,8995725,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,765.45000,221.98000,Aetna,First Health,,626.14,,,,,,,275.94,626.14,percent of total billed charges,
KIT,8995725,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,765.45000,221.98000,Aetna,First Health,,626.14,,,,,,,246.47,626.14,percent of total billed charges,
HUMERAL HEAD,8995750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
HUMERAL HEAD,8995750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
VALVE,8999892,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
VALVE,8999892,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
VALVE,8999893,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
VALVE,8999893,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
VALVE,8999894,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
VALVE,8999894,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
VALVE,8999895,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
VALVE,8999895,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
VALVE,8999896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
VALVE,8999896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
UNID TECH,8999613,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,2081.89,4723.95,percent of total billed charges,
UNID TECH,8999613,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,1859.55,4723.95,percent of total billed charges,
KWIRE,8999557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
KWIRE,8999557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
SHEATH,8995710,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,220.50000,63.94000,Aetna,First Health,,180.37,,,,,,,79.49,180.37,percent of total billed charges,
SHEATH,8995710,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,220.50000,63.94000,Aetna,First Health,,180.37,,,,,,,71.00,180.37,percent of total billed charges,
REVISION COMPLEX,8995680,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
REVISION COMPLEX,8995680,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
INSERT,8995811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,8995811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
GLENOID,8995812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
GLENOID,8995812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
IMPLANT BREAST,8995833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
IMPLANT BREAST,8995833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
IMPLANT BREAST,8995834,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
IMPLANT BREAST,8995834,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
IMPLANT BREAST,8995835,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
IMPLANT BREAST,8995835,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
SIZER BREAST,8995836,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,347.16,787.73,percent of total billed charges,
SIZER BREAST,8995836,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,310.09,787.73,percent of total billed charges,
SIZER BREAST,8995837,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,347.16,787.73,percent of total billed charges,
SIZER BREAST,8995837,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,310.09,787.73,percent of total billed charges,
SIZER BREAST,8995838,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,347.16,787.73,percent of total billed charges,
SIZER BREAST,8995838,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,310.09,787.73,percent of total billed charges,
SIZER BREAST,8995839,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,347.16,787.73,percent of total billed charges,
SIZER BREAST,8995839,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,310.09,787.73,percent of total billed charges,
SIZER BREAST,8995840,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,347.16,787.73,percent of total billed charges,
SIZER BREAST,8995840,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,310.09,787.73,percent of total billed charges,
SIZER BREAST,8995841,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,347.16,787.73,percent of total billed charges,
SIZER BREAST,8995841,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,First Health,,787.73,,,,,,,310.09,787.73,percent of total billed charges,
PLATE,8995869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,8995869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE,8995870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,8995870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8995876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8995876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW,8995877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,8995877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
GUIDEWIRE,8995878,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
GUIDEWIRE,8995878,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
INSERT,9000003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,9000003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
TUBE,8995961,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,99.27000,28.79000,Aetna,First Health,,81.20,,,,,,,35.79,81.20,percent of total billed charges,
TUBE,8995961,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,99.27000,28.79000,Aetna,First Health,,81.20,,,,,,,31.96,81.20,percent of total billed charges,
STEM,8995962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8995962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PLATE,8995963,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,4487.00000,1301.23000,Aetna,First Health,,3670.37,,,,,,,1617.56,3670.37,percent of total billed charges,
PLATE,8995963,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,4487.00000,1301.23000,Aetna,First Health,,3670.37,,,,,,,1444.81,3670.37,percent of total billed charges,
CAGE,8995964,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE,8995964,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
STRATOSPHERE,8995965,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,21107.50000,6121.17000,Aetna,First Health,,17265.94,,,,,,,7609.25,17265.94,percent of total billed charges,
STRATOSPHERE,8995965,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,21107.50000,6121.17000,Aetna,First Health,,17265.94,,,,,,,6796.61,17265.94,percent of total billed charges,
PLATE,8995966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12768.00000,3702.72000,Aetna,First Health,,10444.22,,,,,,,4602.86,10444.22,percent of total billed charges,
PLATE,8995966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12768.00000,3702.72000,Aetna,First Health,,10444.22,,,,,,,4111.30,10444.22,percent of total billed charges,
SCREW,8995967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,8995967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
SCREW,8995968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8995968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
IMMOBILIZER,8995969,CDM,278,RC,L1830,HCPCS,,,facility,inpatient,,,134.77000,39.08000,Aetna,First Health,,110.24,,,,,,,48.58,110.24,percent of total billed charges,
IMMOBILIZER,8995969,CDM,278,RC,L1830,HCPCS,,,facility,outpatient,,,134.77000,39.08000,Aetna,First Health,,110.24,,,,,,,43.40,110.24,percent of total billed charges,
ROD,8995970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
ROD,8995970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
SCREW,8995971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8995971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SCREW,8995972,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW,8995972,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
SCREW,8995973,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SCREW,8995973,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
CROSSLINK,8995974,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2304.00000,668.16000,Aetna,First Health,,1884.67,,,,,,,830.59,1884.67,percent of total billed charges,
CROSSLINK,8995974,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2304.00000,668.16000,Aetna,First Health,,1884.67,,,,,,,741.89,1884.67,percent of total billed charges,
PLATE,8995024,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,8995024,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
TIBIAL,8995038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
TIBIAL,8995038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
PLATE,8995977,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,2170.21,4924.36,percent of total billed charges,
PLATE,8995977,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,1938.44,4924.36,percent of total billed charges,
SCREW,8997061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8997061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
COMPONENT FEMORAL,8995979,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,8995979,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
INSERT,8995981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
INSERT,8995981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASE TIBIA,8995982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
BASE TIBIA,8995982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
COMPONENT FEMORAL,8995983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,8995983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
INSERT,8995984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
INSERT,8995984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PINNACLE,9000058,CDM,278,RC,,,,,facility,inpatient,,,922.05000,267.39000,Aetna,First Health,,754.24,,,,,,,332.40,754.24,percent of total billed charges,
PINNACLE,9000058,CDM,278,RC,,,,,facility,outpatient,,,922.05000,267.39000,Aetna,First Health,,754.24,,,,,,,296.90,754.24,percent of total billed charges,
INSERT,8996074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,8996074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
LINER,8996073,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,8996073,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
CAGE,8996069,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,8996069,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
GLENOID,8996070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
GLENOID,8996070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
HUMERAL HEAD,8996071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,8996071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
PLATE LOCKING,8996072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,953.52,2163.61,percent of total billed charges,
PLATE LOCKING,8996072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,851.69,2163.61,percent of total billed charges,
COMPONENT FEMORAL,9000062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2381.55,5403.91,percent of total billed charges,
COMPONENT FEMORAL,9000062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,First Health,,5403.91,,,,,,,2127.21,5403.91,percent of total billed charges,
ANCHOR,9002089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,870.25,1974.65,percent of total billed charges,
ANCHOR,9002089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,777.31,1974.65,percent of total billed charges,
SPACER,9002086,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
SPACER,9002086,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
IMPLANT RDL HEAD,9002088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
IMPLANT RDL HEAD,9002088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
CAGE,9000059,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,9000059,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
SCREW,9000060,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,9000060,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
STEM,9000061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,9000061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
TIBIAL,9002087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
TIBIAL,9002087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
GRAFT STENT,9000096,CDM,278,RC,C1784,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
GRAFT STENT,9000096,CDM,278,RC,C1784,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
STEM EXTENSION,9002161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM EXTENSION,9002161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
SCREW,9002162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,9002162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
INSERT HUMERAL,9002164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT HUMERAL,9002164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
STENT GRAFT,9002175,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21412.50000,6209.62000,Aetna,First Health,,17515.42,,,,,,,7719.21,17515.42,percent of total billed charges,
STENT GRAFT,9002175,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21412.50000,6209.62000,Aetna,First Health,,17515.42,,,,,,,6894.82,17515.42,percent of total billed charges,
SCREW,9002170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SCREW,9002170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
SCREW,9002171,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,9002171,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
LINER,9002173,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
LINER,9002173,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
LINER,9002172,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
LINER,9002172,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
INSERT,9002174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,9002174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
ENDCAP ADVANCED,9002176,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1294.88000,375.52000,Aetna,First Health,,1059.21,,,,,,,466.80,1059.21,percent of total billed charges,
ENDCAP ADVANCED,9002176,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1294.88000,375.52000,Aetna,First Health,,1059.21,,,,,,,416.95,1059.21,percent of total billed charges,
SCREW,9002177,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,565.03,1282.10,percent of total billed charges,
SCREW,9002177,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,504.69,1282.10,percent of total billed charges,
NAIL INTRAMED,9002179,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL INTRAMED,9002179,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
SCREW,9002261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,565.03,1282.10,percent of total billed charges,
SCREW,9002261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,504.69,1282.10,percent of total billed charges,
LINER,9002242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER,9002242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW,9002263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9002263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9002264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9002264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
NAIL,9002262,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,3062.33,6948.65,percent of total billed charges,
NAIL,9002262,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,2735.29,6948.65,percent of total billed charges,
STEM FEMORAL,9002241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM FEMORAL,9002241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
ROD,9002244,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD,9002244,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,9002300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,565.26,1282.62,percent of total billed charges,
SCREW,9002300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,504.90,1282.62,percent of total billed charges,
SCREW,9002301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,565.26,1282.62,percent of total billed charges,
SCREW,9002301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,504.90,1282.62,percent of total billed charges,
SCREW,9002302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,436.93,991.42,percent of total billed charges,
SCREW,9002302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,390.26,991.42,percent of total billed charges,
PLATE,9002303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3957.21,8979.19,percent of total billed charges,
PLATE,9002303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3534.59,8979.19,percent of total billed charges,
INSERT TIBIAL,9002304,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT TIBIAL,9002304,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,9002328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,614.29,1393.87,percent of total billed charges,
SCREW,9002328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,548.69,1393.87,percent of total billed charges,
SCREW,9002329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,436.93,991.42,percent of total billed charges,
SCREW,9002329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,390.26,991.42,percent of total billed charges,
PLATE,9002330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
PLATE,9002330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
INSERT TIBIAL,9000265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT TIBIAL,9000265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
INSERT,9000266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,875.21000,253.81000,Aetna,First Health,,715.92,,,,,,,315.51,715.92,percent of total billed charges,
INSERT,9000266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,875.21000,253.81000,Aetna,First Health,,715.92,,,,,,,281.82,715.92,percent of total billed charges,
STEM FEMORAL,9000267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM FEMORAL,9000267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
COMPONENT FEMORAL,9000268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,9000268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT FEMORAL,9000269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,4351.96,9874.90,percent of total billed charges,
COMPONENT FEMORAL,9000269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,3887.18,9874.90,percent of total billed charges,
SCREW,9000318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,507.58,1151.74,percent of total billed charges,
SCREW,9000318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,First Health,,1151.74,,,,,,,453.38,1151.74,percent of total billed charges,
PLATE,9000319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9070.20000,2630.36000,Aetna,First Health,,7419.42,,,,,,,3269.81,7419.42,percent of total billed charges,
PLATE,9000319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9070.20000,2630.36000,Aetna,First Health,,7419.42,,,,,,,2920.60,7419.42,percent of total billed charges,
PLATE,9000320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9752.40000,2828.20000,Aetna,First Health,,7977.46,,,,,,,3515.74,7977.46,percent of total billed charges,
PLATE,9000320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9752.40000,2828.20000,Aetna,First Health,,7977.46,,,,,,,3140.27,7977.46,percent of total billed charges,
ANCHOR,9000332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5947.41000,1724.75000,Aetna,First Health,,4864.98,,,,,,,2144.04,4864.98,percent of total billed charges,
ANCHOR,9000332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5947.41000,1724.75000,Aetna,First Health,,4864.98,,,,,,,1915.07,4864.98,percent of total billed charges,
SCREW,9000333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9000333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,9000334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9000334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
REAMER,9000352,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,565.26,1282.62,percent of total billed charges,
REAMER,9000352,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,504.90,1282.62,percent of total billed charges,
COMPONENT FEMORAL,9000342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,2133.62,4841.33,percent of total billed charges,
COMPONENT FEMORAL,9000342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,First Health,,4841.33,,,,,,,1905.76,4841.33,percent of total billed charges,
GLENOSPHERE,9000343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
GLENOSPHERE,9000343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
SCREW,9000353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,9000353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
SCREW,9002397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,9002397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,9002398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,9002398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PLATE,9002394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8523.00000,2471.67000,Aetna,First Health,,6971.81,,,,,,,3072.54,6971.81,percent of total billed charges,
PLATE,9002394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8523.00000,2471.67000,Aetna,First Health,,6971.81,,,,,,,2744.41,6971.81,percent of total billed charges,
SCREW,9002395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,9002395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
ANCHOR,9002399,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3250.45000,942.63000,Aetna,First Health,,2658.87,,,,,,,1171.79,2658.87,percent of total billed charges,
ANCHOR,9002399,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3250.45000,942.63000,Aetna,First Health,,2658.87,,,,,,,1046.64,2658.87,percent of total billed charges,
COIL,9000402,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2416.25,5482.65,percent of total billed charges,
COIL,9000402,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2158.20,5482.65,percent of total billed charges,
INSERT,9000404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,9000404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
CATHETER MICRO LANTERN,9000403,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
CATHETER MICRO LANTERN,9000403,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
BREAST IMPLANT,9002436,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,9002436,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
BREAST IMPLANT,9002437,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,9002437,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
BREAST IMPLANT,9002440,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,9002440,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
BREAST IMPLANT,9002441,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,9002441,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
NAIL,9002444,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,9002444,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
LINER,9002445,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,9002445,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
INSERT GLENOID,9002446,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9135.00000,2649.15000,Aetna,First Health,,7472.43,,,,,,,3293.17,7472.43,percent of total billed charges,
INSERT GLENOID,9002446,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9135.00000,2649.15000,Aetna,First Health,,7472.43,,,,,,,2941.47,7472.43,percent of total billed charges,
STEM FEMORAL,9002514,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM FEMORAL,9002514,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
ROD SPINAL,9000552,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,9000552,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
STEM FEMORAL,9000553,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3970.84,9010.11,percent of total billed charges,
STEM FEMORAL,9000553,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,First Health,,9010.11,,,,,,,3546.77,9010.11,percent of total billed charges,
COMPONENT FEMORAL,9000554,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17887.00000,5187.23000,Aetna,First Health,,14631.57,,,,,,,6448.26,14631.57,percent of total billed charges,
COMPONENT FEMORAL,9000554,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17887.00000,5187.23000,Aetna,First Health,,14631.57,,,,,,,5759.61,14631.57,percent of total billed charges,
REAMER,9002917,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,4532.33000,1314.38000,Aetna,First Health,,3707.45,,,,,,,1633.90,3707.45,percent of total billed charges,
REAMER,9002917,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,4532.33000,1314.38000,Aetna,First Health,,3707.45,,,,,,,1459.41,3707.45,percent of total billed charges,
SCREW,9002918,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,475.87,1079.79,percent of total billed charges,
SCREW,9002918,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,425.05,1079.79,percent of total billed charges,
BOLT,9002919,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,475.87,1079.79,percent of total billed charges,
BOLT,9002919,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,First Health,,1079.79,,,,,,,425.05,1079.79,percent of total billed charges,
TIGHTROPE,9002920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2729.00000,791.41000,Aetna,First Health,,2232.32,,,,,,,983.80,2232.32,percent of total billed charges,
TIGHTROPE,9002920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2729.00000,791.41000,Aetna,First Health,,2232.32,,,,,,,878.74,2232.32,percent of total billed charges,
COMPONENT FEMORAL,9002972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,9002972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
CEMENT RESTRICTOR,9003407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
CEMENT RESTRICTOR,9003407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
CEMENT RESTRICTOR,9003408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,178.09,404.09,percent of total billed charges,
CEMENT RESTRICTOR,9003408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,First Health,,404.09,,,,,,,159.07,404.09,percent of total billed charges,
KIT DISC W HEXALOBULAR,9003409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8022.00000,2326.38000,Aetna,First Health,,6562.00,,,,,,,2891.93,6562.00,percent of total billed charges,
KIT DISC W HEXALOBULAR,9003409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8022.00000,2326.38000,Aetna,First Health,,6562.00,,,,,,,2583.08,6562.00,percent of total billed charges,
COMPONENT HUMERAL,9003410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16445.00000,4769.05000,Aetna,First Health,,13452.01,,,,,,,5928.42,13452.01,percent of total billed charges,
COMPONENT HUMERAL,9003410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16445.00000,4769.05000,Aetna,First Health,,13452.01,,,,,,,5295.29,13452.01,percent of total billed charges,
COMPONENT ULNA,9003411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18557.50000,5381.67000,Aetna,First Health,,15180.03,,,,,,,6689.98,15180.03,percent of total billed charges,
COMPONENT ULNA,9003411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18557.50000,5381.67000,Aetna,First Health,,15180.03,,,,,,,5975.52,15180.03,percent of total billed charges,
TIBIAL TRAY,9003448,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,7417.29,16830.35,percent of total billed charges,
TIBIAL TRAY,9003448,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,6625.15,16830.35,percent of total billed charges,
CAGE,9003449,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,9003449,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
PASSER SUTURE,8423563,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
PASSER SUTURE,8423563,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
GUIDEWIRE,9003447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
GUIDEWIRE,9003447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
GRAFT TENDON,9003458,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1962.02,4451.97,percent of total billed charges,
GRAFT TENDON,9003458,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1752.48,4451.97,percent of total billed charges,
INSERT TIBIAL,9003459,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9003459,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
TISSUE EXPANDER,9003471,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
TISSUE EXPANDER,9003471,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
TISSUE EXPANDER,9003472,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
TISSUE EXPANDER,9003472,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
HEAD FEMORAL,9003502,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
HEAD FEMORAL,9003502,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
SCREW SPINAL,9000816,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SPINAL,9000816,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE,9000817,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,9000817,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,9000819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,9000819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
PLATE,9000820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1469.63,3334.68,percent of total billed charges,
PLATE,9000820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,First Health,,3334.68,,,,,,,1312.67,3334.68,percent of total billed charges,
REAMER,8342303,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,839.97,1905.94,percent of total billed charges,
REAMER,8342303,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,750.26,1905.94,percent of total billed charges,
LINER,8406040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,8406040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW,8406254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,573.57,1301.47,percent of total billed charges,
SCREW,8406254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,First Health,,1301.47,,,,,,,512.31,1301.47,percent of total billed charges,
SCREW,8406562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8406562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8406256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8406256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,7974657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,7974657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,7974655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,7974655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,7982822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,7982822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,7974658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,7974658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,7982823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,7982823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
NAIL,7976665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,7976665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
PLATE,7974757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,666.58,1512.51,percent of total billed charges,
PLATE,7974757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,First Health,,1512.51,,,,,,,595.39,1512.51,percent of total billed charges,
SCREW,7974767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW,7974767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
COMPONENT FEMORAL,7976744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
COMPONENT FEMORAL,7976744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
COMPONENT FEMORAL,7974859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
COMPONENT FEMORAL,7974859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
COMPONENT TIBIAL,7974860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
COMPONENT TIBIAL,7974860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
INSERT,7976740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7976740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,7976742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,7976742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
PLATE,8406258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8786.25000,2548.01000,Aetna,First Health,,7187.15,,,,,,,3167.44,7187.15,percent of total billed charges,
PLATE,8406258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8786.25000,2548.01000,Aetna,First Health,,7187.15,,,,,,,2829.17,7187.15,percent of total billed charges,
SCREW,8406260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,8406260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
BASEPLATE,8406262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
BASEPLATE,8406262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
INSERT,8406264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,8406264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
CATHETER,8406274,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
CATHETER,8406274,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
BREAST IMPLANT,8406266,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8406266,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
BREAST IMPLANT,8406268,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,8406268,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
CAGE,8406270,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8406270,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
STEM,8406272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM,8406272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
STENT,7975079,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7975079,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7975080,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,7975080,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
STENT,7975088,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
STENT,7975088,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
STENT,7975089,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
STENT,7975089,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
STENT,7975090,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
STENT,7975090,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
STENT,7975091,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
STENT,7975091,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
BALLOON CATHETER,7975095,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
BALLOON CATHETER,7975095,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
BALLOON CATHETER,7975120,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7975120,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
BALLOON CATHETER,7975112,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7975112,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
BALLOON CATHETER,7975111,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7975111,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
BALLOON CATHETER,7975114,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7975114,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
BALLOON CATHETER,7975115,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7975115,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
BALLOON CATHETER,7975116,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7975116,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
BALLOON CATHETER,7975117,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7975117,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
BALLOON CATHETER,7975118,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
BALLOON CATHETER,7975118,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
SCREW,7989201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,330.96,750.96,percent of total billed charges,
SCREW,7989201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,295.61,750.96,percent of total billed charges,
SHELL,7976430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7976430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SHELL,7976606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,7976606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
LINER,7976431,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,7976431,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,7976460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6167.00000,1788.43000,Aetna,First Health,,5044.61,,,,,,,2223.20,5044.61,percent of total billed charges,
SCREW,7976460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6167.00000,1788.43000,Aetna,First Health,,5044.61,,,,,,,1985.77,5044.61,percent of total billed charges,
SCREW,7978376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6167.00000,1788.43000,Aetna,First Health,,5044.61,,,,,,,2223.20,5044.61,percent of total billed charges,
SCREW,7978376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6167.00000,1788.43000,Aetna,First Health,,5044.61,,,,,,,1985.77,5044.61,percent of total billed charges,
SPINAL IMPLANT,7976654,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3631.68,8240.53,percent of total billed charges,
SPINAL IMPLANT,7976654,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,First Health,,8240.53,,,,,,,3243.83,8240.53,percent of total billed charges,
COMPONENT FEMORAL,7976669,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
COMPONENT FEMORAL,7976669,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
SCREW,7976679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7976679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
SCREW,7976708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,138.70,314.73,percent of total billed charges,
SCREW,7976708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,First Health,,314.73,,,,,,,123.89,314.73,percent of total billed charges,
STENT,7976694,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
STENT,7976694,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
STENT,7976695,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
STENT,7976695,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
STENT,7982900,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
STENT,7982900,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
STENT,7976693,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
STENT,7976693,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
STENT,7982901,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
STENT,7982901,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
STENT,7982899,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
STENT,7982899,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
SCREW,7978327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,577.91,1311.32,percent of total billed charges,
SCREW,7978327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,516.19,1311.32,percent of total billed charges,
SCREW,7978328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,577.91,1311.32,percent of total billed charges,
SCREW,7978328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,516.19,1311.32,percent of total billed charges,
SCREW,7987807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,577.91,1311.32,percent of total billed charges,
SCREW,7987807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,First Health,,1311.32,,,,,,,516.19,1311.32,percent of total billed charges,
PLATE,7980834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2616.04000,758.65000,Aetna,First Health,,2139.92,,,,,,,943.08,2139.92,percent of total billed charges,
PLATE,7980834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2616.04000,758.65000,Aetna,First Health,,2139.92,,,,,,,842.36,2139.92,percent of total billed charges,
PLATE,7980837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2781.96000,806.77000,Aetna,First Health,,2275.64,,,,,,,1002.90,2275.64,percent of total billed charges,
PLATE,7980837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2781.96000,806.77000,Aetna,First Health,,2275.64,,,,,,,895.79,2275.64,percent of total billed charges,
PLATE,7980840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2846.52000,825.49000,Aetna,First Health,,2328.45,,,,,,,1026.17,2328.45,percent of total billed charges,
PLATE,7980840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2846.52000,825.49000,Aetna,First Health,,2328.45,,,,,,,916.58,2328.45,percent of total billed charges,
SCREW,7980844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,7980844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
SCREW,7980847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,62.32,141.42,percent of total billed charges,
SCREW,7980847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,55.67,141.42,percent of total billed charges,
SCREW,7980848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,62.32,141.42,percent of total billed charges,
SCREW,7980848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,First Health,,141.42,,,,,,,55.67,141.42,percent of total billed charges,
SCREW,7980850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW,7980850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
SCREW,7980851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,188.36,427.40,percent of total billed charges,
SCREW,7980851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,First Health,,427.40,,,,,,,168.25,427.40,percent of total billed charges,
SCREW,7980853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,256.35,581.67,percent of total billed charges,
SCREW,7980865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,First Health,,581.67,,,,,,,228.97,581.67,percent of total billed charges,
SCREW,7980867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,338.17,767.34,percent of total billed charges,
SCREW,7980867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,First Health,,767.34,,,,,,,302.06,767.34,percent of total billed charges,
SCREW,7980879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7980879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7980880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7980880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7980881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,213.55,484.57,percent of total billed charges,
SCREW,7980881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,First Health,,484.57,,,,,,,190.75,484.57,percent of total billed charges,
SCREW,7982382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7982382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,7982383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,205.31,465.87,percent of total billed charges,
SCREW,7982383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,First Health,,465.87,,,,,,,183.39,465.87,percent of total billed charges,
SCREW,8406646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8406646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
PLATE,8406647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
PLATE,8406647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
SHEATH,8406648,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,5264.00000,1526.56000,Aetna,First Health,,4305.95,,,,,,,1897.67,4305.95,percent of total billed charges,
SHEATH,8406648,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,5264.00000,1526.56000,Aetna,First Health,,4305.95,,,,,,,1695.01,4305.95,percent of total billed charges,
STENT GRAFT,8406649,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,8406649,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
SCREW,7980883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,596.03000,172.85000,Aetna,First Health,,487.55,,,,,,,214.87,487.55,percent of total billed charges,
SCREW,7980883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,596.03000,172.85000,Aetna,First Health,,487.55,,,,,,,191.92,487.55,percent of total billed charges,
SCREW,7980884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7980884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7980885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7980885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7980886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7980886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7980887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,219.85,498.85,percent of total billed charges,
SCREW,7980887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,First Health,,498.85,,,,,,,196.37,498.85,percent of total billed charges,
SCREW,7980888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,596.03000,172.85000,Aetna,First Health,,487.55,,,,,,,214.87,487.55,percent of total billed charges,
SCREW,7980888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,596.03000,172.85000,Aetna,First Health,,487.55,,,,,,,191.92,487.55,percent of total billed charges,
PLATE,8406655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1560.92000,452.67000,Aetna,First Health,,1276.83,,,,,,,562.71,1276.83,percent of total billed charges,
PLATE,8406655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1560.92000,452.67000,Aetna,First Health,,1276.83,,,,,,,502.62,1276.83,percent of total billed charges,
CAGE,8406656,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8406656,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
SHELL,8406657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8406657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
BUTTON NASAL,8406658,CDM,278,RC,L8047,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,201.16,456.44,percent of total billed charges,
BUTTON NASAL,8406658,CDM,278,RC,L8047,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,179.68,1561.74,percent of total billed charges,
INSERT,8406659,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8406659,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8406660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8406660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8406661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8406661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8406644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
SCREW,8406644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
PLATE,8406645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,3076.60,6981.02,percent of total billed charges,
PLATE,8406645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,2748.03,6981.02,percent of total billed charges,
ACETABULAR AUGMENT,8406698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
ACETABULAR AUGMENT,8406698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
ACETABULAR AUGMENT,8406699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
ACETABULAR AUGMENT,8406699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
COMPONENT HEAD,8406700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
COMPONENT HEAD,8406700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SYSTEM IMPLANT KNOTLESS,8406761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7639.65000,2215.50000,Aetna,First Health,,6249.23,,,,,,,2754.09,6249.23,percent of total billed charges,
SYSTEM IMPLANT KNOTLESS,8406761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7639.65000,2215.50000,Aetna,First Health,,6249.23,,,,,,,2459.97,6249.23,percent of total billed charges,
ROD SPINAL,8406857,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8406857,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
STEM,8406858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8406858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
SCREW,7982324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7982338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7982338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
SCREW,7980905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,328.52,745.44,percent of total billed charges,
SCREW,7980905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,First Health,,745.44,,,,,,,293.44,745.44,percent of total billed charges,
STEM,8406883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,8406883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
SCREW,8406885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8406885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
CENTRALIZER FEMORAL,8158233,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
CENTRALIZER FEMORAL,8158233,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
SCREW,8169226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
SCREW,8169226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
SCREW,8169227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1204.66,2733.45,percent of total billed charges,
SCREW,8169227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,First Health,,2733.45,,,,,,,1076.00,2733.45,percent of total billed charges,
SCREW,7982343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,7982343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
SCREW,7982370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
SCREW,7982381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,260.13,590.25,percent of total billed charges,
SCREW,7982381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,First Health,,590.25,,,,,,,232.35,590.25,percent of total billed charges,
INSERT,8406915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8406915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
INSERT,8406916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8406916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,7982386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7982386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7982387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7982387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7982388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7982388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7982393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7982393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7982394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7982394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7982395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7982395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7982396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7982396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7982475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,7982475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
SCREW,7982392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7982392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,7982389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7982389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
SCREW,7982390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
SCREW,7982390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,63.55,161.43,percent of total billed charges,
PLATE,7982399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5868.45000,1701.85000,Aetna,First Health,,4800.39,,,,,,,2115.58,4800.39,percent of total billed charges,
PLATE,7982399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5868.45000,1701.85000,Aetna,First Health,,4800.39,,,,,,,1889.64,4800.39,percent of total billed charges,
PLATE,7982404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5284.58000,1532.53000,Aetna,First Health,,4322.79,,,,,,,1905.09,4322.79,percent of total billed charges,
PLATE,7982404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5284.58000,1532.53000,Aetna,First Health,,4322.79,,,,,,,1701.63,4322.79,percent of total billed charges,
PLATE,7982419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,First Health,,272.14,,,,,,,119.93,272.14,percent of total billed charges,
PLATE,7982419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,First Health,,272.14,,,,,,,107.13,272.14,percent of total billed charges,
PLATE,7982420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,First Health,,272.14,,,,,,,119.93,272.14,percent of total billed charges,
PLATE,7982420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,First Health,,272.14,,,,,,,107.13,272.14,percent of total billed charges,
PLATE,7982421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,First Health,,272.14,,,,,,,119.93,272.14,percent of total billed charges,
PLATE,7982421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,First Health,,272.14,,,,,,,107.13,272.14,percent of total billed charges,
PLATE,7982418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,358.53000,103.97000,Aetna,First Health,,293.28,,,,,,,129.25,293.28,percent of total billed charges,
PLATE,7982418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,358.53000,103.97000,Aetna,First Health,,293.28,,,,,,,115.45,293.28,percent of total billed charges,
BOLT,7982464,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,234.56,532.24,percent of total billed charges,
BOLT,7982464,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,First Health,,532.24,,,,,,,209.51,532.24,percent of total billed charges,
SCREW,7983042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,7983042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,7987623,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,873.04,1981.00,percent of total billed charges,
SCREW,7987623,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,779.81,1981.00,percent of total billed charges,
SHELL,8406919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3475.94,7887.16,percent of total billed charges,
SHELL,8406919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3104.72,7887.16,percent of total billed charges,
SCREW,8406920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,8406920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
STEM,7987918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,First Health,,5369.19,,,,,,,2366.25,5369.19,percent of total billed charges,
STEM,7987918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,First Health,,5369.19,,,,,,,2113.54,5369.19,percent of total billed charges,
COMPONENT FEMORAL,7989150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,7989150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
BONE GRAFT,7989186,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,First Health,,6650.34,,,,,,,2930.86,6650.34,percent of total billed charges,
BONE GRAFT,7989186,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,First Health,,6650.34,,,,,,,2617.86,6650.34,percent of total billed charges,
TISSUE WEDGE,7989187,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,First Health,,6650.34,,,,,,,2930.86,6650.34,percent of total billed charges,
TISSUE WEDGE,7989187,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,First Health,,6650.34,,,,,,,2617.86,6650.34,percent of total billed charges,
TISSUE WEDGE,7989184,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,First Health,,6650.34,,,,,,,2930.86,6650.34,percent of total billed charges,
TISSUE WEDGE,7989184,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,First Health,,6650.34,,,,,,,2617.86,6650.34,percent of total billed charges,
TISSUE WEDGE,7989239,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,First Health,,6650.34,,,,,,,2930.86,6650.34,percent of total billed charges,
TISSUE WEDGE,7989239,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,First Health,,6650.34,,,,,,,2617.86,6650.34,percent of total billed charges,
FEMORAL IMPLANT,7955064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
FEMORAL IMPLANT,7955064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
INSERT,7967969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,7967969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
INSERT,8407051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8407051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ROD SPINAL,8407052,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8407052,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
TIBIAL,8407057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,7417.29,16830.35,percent of total billed charges,
TIBIAL,8407057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,6625.15,16830.35,percent of total billed charges,
ANKLE PROSTHESIS,8407058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,7786.80,17668.80,percent of total billed charges,
ANKLE PROSTHESIS,8407058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,6955.20,17668.80,percent of total billed charges,
ANKLE PROSTHESIS,8407059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3360.22,7624.58,percent of total billed charges,
ANKLE PROSTHESIS,8407059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3001.36,7624.58,percent of total billed charges,
SCREW,7969162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW,7969162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,7986861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
SCREW,7986861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
STEM,7975067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STEM,7975067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
COLLAGEN,7987579,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2382.00000,690.78000,Aetna,First Health,,1948.48,,,,,,,858.71,1948.48,percent of total billed charges,
COLLAGEN,7987579,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2382.00000,690.78000,Aetna,First Health,,1948.48,,,,,,,767.00,1948.48,percent of total billed charges,
SCREW,7987622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,873.04,1981.00,percent of total billed charges,
SCREW,7987622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,First Health,,1981.00,,,,,,,779.81,1981.00,percent of total billed charges,
BALLOON,7975122,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7975122,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7975123,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7975123,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7975124,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7975124,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7975125,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7975125,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7975126,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7975126,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7975127,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7975127,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7975128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7975128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7975129,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7975129,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
BALLOON,7975130,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,234.67,532.49,percent of total billed charges,
BALLOON,7975130,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,First Health,,532.49,,,,,,,209.61,532.49,percent of total billed charges,
ROD SPINAL,8338170,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,536.42,1217.18,percent of total billed charges,
ROD SPINAL,8338170,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,479.14,1217.18,percent of total billed charges,
CONNECTOR SPINAL,8229104,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2768.00000,802.72000,Aetna,First Health,,2264.22,,,,,,,997.86,2264.22,percent of total billed charges,
CONNECTOR SPINAL,8229104,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2768.00000,802.72000,Aetna,First Health,,2264.22,,,,,,,891.30,2264.22,percent of total billed charges,
CONNECTOR SPINAL,8137223,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
CONNECTOR SPINAL,8137223,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
NAIL,8160715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8160715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
SHELL,8239907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,8239907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
ANCHOR,8259999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2324.16000,674.01000,Aetna,First Health,,1901.16,,,,,,,837.86,1901.16,percent of total billed charges,
ANCHOR,8259999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2324.16000,674.01000,Aetna,First Health,,1901.16,,,,,,,748.38,1901.16,percent of total billed charges,
COMPONENT FEMORAL,8347468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,7669.64,17402.95,percent of total billed charges,
COMPONENT FEMORAL,8347468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,6850.55,17402.95,percent of total billed charges,
ANCHOR,8320179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
ANCHOR,8320179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
INSERT,8407099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8407099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8407129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,8407129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
VALVE,8310295,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8064.00000,2338.56000,Aetna,First Health,,6596.35,,,,,,,2907.07,6596.35,percent of total billed charges,
VALVE,8310295,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8064.00000,2338.56000,Aetna,First Health,,6596.35,,,,,,,2596.61,6596.35,percent of total billed charges,
SCREW,8320189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,8320189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
LINER,8331458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8331458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
SCREW,8366680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,8366680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
INSERT,8370368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT,8370368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8407134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8407134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
SCREW,8407136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8407136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
SCREW,8407138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8407138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
NAIL,8407140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8407140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
K WIRE,8407178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
K WIRE,8407178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,8407179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8407179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8407181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8407181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8407183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8407183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8407185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8407185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
ROD SPINAL,8407187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2168.00000,628.72000,Aetna,First Health,,1773.42,,,,,,,781.56,1773.42,percent of total billed charges,
ROD SPINAL,8407187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2168.00000,628.72000,Aetna,First Health,,1773.42,,,,,,,698.10,1773.42,percent of total billed charges,
SCREW,8407228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1498.44000,434.55000,Aetna,First Health,,1225.72,,,,,,,540.19,1225.72,percent of total billed charges,
SCREW,8407228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1498.44000,434.55000,Aetna,First Health,,1225.72,,,,,,,482.50,1225.72,percent of total billed charges,
PLATE,8407230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10178.13000,2951.66000,Aetna,First Health,,8325.71,,,,,,,3669.22,8325.71,percent of total billed charges,
PLATE,8407230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10178.13000,2951.66000,Aetna,First Health,,8325.71,,,,,,,3277.36,8325.71,percent of total billed charges,
NAIL,8407232,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14143.50000,4101.62000,Aetna,First Health,,11569.38,,,,,,,5098.73,11569.38,percent of total billed charges,
NAIL,8407232,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14143.50000,4101.62000,Aetna,First Health,,11569.38,,,,,,,4554.21,11569.38,percent of total billed charges,
COMPONENT GLENOID,8407234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,2149.26,4876.83,percent of total billed charges,
COMPONENT GLENOID,8407234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,First Health,,4876.83,,,,,,,1919.73,4876.83,percent of total billed charges,
CAGE,8407236,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8407236,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
SCREW,8407222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8407222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
SCREW,8407224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8407224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
ROD SPINAL,8407226,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,8407226,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
STEM,8407315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8407315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW,8407316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8407316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
SCREW,8407317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8407317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
SCREW,8407318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8407318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
SCREW,8407319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8407319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
K WIRE,8407320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,508.25000,147.39000,Aetna,First Health,,415.75,,,,,,,183.22,415.75,percent of total billed charges,
K WIRE,8407320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,508.25000,147.39000,Aetna,First Health,,415.75,,,,,,,163.66,415.75,percent of total billed charges,
NAIL,8407321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,8407321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
ROD SPINAL,8407313,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8407313,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
INSERT,8407314,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8407314,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8407424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8407424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,8407425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,8407425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
TENDON,8407678,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
TENDON,8407678,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
NAIL,8407835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,8407835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
PLATE RIBBON,8407670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,1067.08,2421.28,percent of total billed charges,
PLATE RIBBON,8407670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,First Health,,2421.28,,,,,,,953.12,2421.28,percent of total billed charges,
CAGE,8407671,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8407671,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
CAGE,8407672,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
CAGE,8407672,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
SCREW,8407673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8407673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8407674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8407674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
ROD SPINAL,8407675,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD SPINAL,8407675,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,8407676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8407676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8407677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW,8407677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STEM,8407831,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8407831,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
INSERT,8407832,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8407832,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
FEMORAL ADAPTER,8407833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5187.00000,1504.23000,Aetna,First Health,,4242.97,,,,,,,1869.91,4242.97,percent of total billed charges,
FEMORAL ADAPTER,8407833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5187.00000,1504.23000,Aetna,First Health,,4242.97,,,,,,,1670.21,4242.97,percent of total billed charges,
COMPONENT TIBIAL,8407834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,8407834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
SPACER SPINAL,8407839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
SPACER SPINAL,8407839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
STENT GRAFT,8407930,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,8407930,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
SCREW SPINAL,8407973,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1605.20,3642.31,percent of total billed charges,
SCREW SPINAL,8407973,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,First Health,,3642.31,,,,,,,1433.77,3642.31,percent of total billed charges,
ROD SPINAL,8407932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,280.65,636.81,percent of total billed charges,
ROD SPINAL,8407932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,First Health,,636.81,,,,,,,250.68,636.81,percent of total billed charges,
SCREW,8407934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8407934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
SCREW SPINAL,8407974,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW SPINAL,8407974,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
BURR HOLE COVER,8407936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1215.20000,352.41000,Aetna,First Health,,994.03,,,,,,,438.08,994.03,percent of total billed charges,
BURR HOLE COVER,8407936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1215.20000,352.41000,Aetna,First Health,,994.03,,,,,,,391.29,994.03,percent of total billed charges,
MESH,8407965,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,8706.51000,2524.89000,Aetna,First Health,,7121.93,,,,,,,3138.70,7121.93,percent of total billed charges,
MESH,8407965,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,8706.51000,2524.89000,Aetna,First Health,,7121.93,,,,,,,2803.50,7121.93,percent of total billed charges,
SCREW,8407967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,8407967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
SCREW,8407969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,231.98,526.38,percent of total billed charges,
SCREW,8407969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,First Health,,526.38,,,,,,,207.21,526.38,percent of total billed charges,
NAIL,8407971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4518.50000,1310.36000,Aetna,First Health,,3696.13,,,,,,,1628.92,3696.13,percent of total billed charges,
NAIL,8407971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4518.50000,1310.36000,Aetna,First Health,,3696.13,,,,,,,1454.96,3696.13,percent of total billed charges,
SCREW SPINAL,8407975,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW SPINAL,8407975,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW SPINAL,8407976,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1640.28,3721.90,percent of total billed charges,
SCREW SPINAL,8407976,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1465.10,3721.90,percent of total billed charges,
SCREW SPINAL,8407977,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW SPINAL,8407977,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW SPINAL,8407978,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1640.28,3721.90,percent of total billed charges,
SCREW SPINAL,8407978,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1465.10,3721.90,percent of total billed charges,
SCREW SPINAL,8407979,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1640.28,3721.90,percent of total billed charges,
SCREW SPINAL,8407979,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1465.10,3721.90,percent of total billed charges,
SCREW SPINAL,8407980,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12942.00000,3753.18000,Aetna,First Health,,10586.56,,,,,,,4665.59,10586.56,percent of total billed charges,
SCREW SPINAL,8407980,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12942.00000,3753.18000,Aetna,First Health,,10586.56,,,,,,,4167.32,10586.56,percent of total billed charges,
SCREW SPINAL,8407981,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12942.00000,3753.18000,Aetna,First Health,,10586.56,,,,,,,4665.59,10586.56,percent of total billed charges,
SCREW SPINAL,8407981,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12942.00000,3753.18000,Aetna,First Health,,10586.56,,,,,,,4167.32,10586.56,percent of total billed charges,
CLAMP ROD TO ROD SPINAL,8407982,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2856.00000,828.24000,Aetna,First Health,,2336.21,,,,,,,1029.59,2336.21,percent of total billed charges,
CLAMP ROD TO ROD SPINAL,8407982,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2856.00000,828.24000,Aetna,First Health,,2336.21,,,,,,,919.63,2336.21,percent of total billed charges,
WEDGE,8407983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
WEDGE,8407983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
WEDGE,8408124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8408124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
INSERT,8408126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8408126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8408131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,8408131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
ROD SPINAL,8408175,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,8408175,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
CAGE,8408176,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
CAGE,8408176,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
SCREW,8408177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,8408177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
INSERT,8408178,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8408178,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,8408179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8408179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
INSERT,8408180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,8408180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,8408181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8408181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8408182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,8408182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
CAGE,8408183,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8408183,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
GUIDEWIRE,8408199,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,339.39000,98.42000,Aetna,First Health,,277.62,,,,,,,122.35,277.62,percent of total billed charges,
GUIDEWIRE,8408199,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,339.39000,98.42000,Aetna,First Health,,277.62,,,,,,,109.28,277.62,percent of total billed charges,
SCREW,8408200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW,8408200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
SCREW,8408203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW,8408203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
STENT IN A KIT,7980451,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,322.39,731.53,percent of total billed charges,
STENT IN A KIT,7980451,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,287.96,731.53,percent of total billed charges,
ROD SPINAL,8408292,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,8408292,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
SCREW,8408293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8408293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,8408294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,8408294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
PLATE,8408295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE,8408295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
ANCHOR,8408327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1940.00000,562.60000,Aetna,First Health,,1586.92,,,,,,,699.37,1586.92,percent of total billed charges,
ANCHOR,8408327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1940.00000,562.60000,Aetna,First Health,,1586.92,,,,,,,624.68,1586.92,percent of total billed charges,
COMPONENT TIBIAL,8408328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
COMPONENT TIBIAL,8408328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
SCREW SPINAL,8408341,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW SPINAL,8408341,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
PLATE,8408466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6053.15000,1755.41000,Aetna,First Health,,4951.48,,,,,,,2182.16,4951.48,percent of total billed charges,
PLATE,8408466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6053.15000,1755.41000,Aetna,First Health,,4951.48,,,,,,,1949.11,4951.48,percent of total billed charges,
COMPONENT FEMORAL,8408468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,7669.64,17402.95,percent of total billed charges,
COMPONENT FEMORAL,8408468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,6850.55,17402.95,percent of total billed charges,
INSERT,8408469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8408469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
WEDGE,8408470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8408470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8408471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8408471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
STEM,8408472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM,8408472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
HEAD FEMORAL,8408473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,8408473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
WEDGE,8408474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8408474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
COMPONENT FEMORAL,8408475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,7273.09,16503.15,percent of total billed charges,
COMPONENT FEMORAL,8408475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,First Health,,16503.15,,,,,,,6496.35,16503.15,percent of total billed charges,
INSERT,8408476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8408476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BASEPLATE,8408477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
BASEPLATE,8408477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
INSERT,8408467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8408467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SHELL,8408602,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8408602,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,8408478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,8408478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,8408479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,8408479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
SCREW,8408480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,8408480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
STEM,8408481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8408481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
PLUG VASCULAR,8408482,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
PLUG VASCULAR,8408482,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
STEM,8408604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8408604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW SPINAL,8408634,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW SPINAL,8408634,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
PLATE,8408635,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
PLATE,8408635,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
NAIL,8408636,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11684.25000,3388.43000,Aetna,First Health,,9557.72,,,,,,,4212.17,9557.72,percent of total billed charges,
NAIL,8408636,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11684.25000,3388.43000,Aetna,First Health,,9557.72,,,,,,,3762.33,9557.72,percent of total billed charges,
PLATE,8408637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
PLATE,8408637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
SCREW,8408633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,8408633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SHELL,8408695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8408695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
STEM COMPONENT,8408707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
STEM COMPONENT,8408707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
KIT HUMERAL,8408709,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
KIT HUMERAL,8408709,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
INSERT,8408785,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8408785,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM,8408786,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8408786,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
FIXATION STAPLE,7703262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,489.01000,141.81000,Aetna,First Health,,400.01,,,,,,,176.29,400.01,percent of total billed charges,
FIXATION STAPLE,7703262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,489.01000,141.81000,Aetna,First Health,,400.01,,,,,,,157.46,400.01,percent of total billed charges,
RESTRICTOR CEMENT,8408818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1215.20000,352.41000,Aetna,First Health,,994.03,,,,,,,438.08,994.03,percent of total billed charges,
RESTRICTOR CEMENT,8408818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1215.20000,352.41000,Aetna,First Health,,994.03,,,,,,,391.29,994.03,percent of total billed charges,
SPINAL CORD STIMULATOR,8408787,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
SPINAL CORD STIMULATOR,8408787,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
SHELL,8408789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8408789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
LINER,8408853,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
LINER,8408853,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
INSERT,8408851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8408851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
LINER,8408852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
LINER,8408852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
NAIL,8408900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,8408900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
CAGE,8408902,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,8408902,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
PLATE,8408928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8464.05000,2454.57000,Aetna,First Health,,6923.59,,,,,,,3051.29,6923.59,percent of total billed charges,
PLATE,8408928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8464.05000,2454.57000,Aetna,First Health,,6923.59,,,,,,,2725.42,6923.59,percent of total billed charges,
GRAFT,8408957,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,9072.00000,2630.88000,Aetna,First Health,,7420.90,,,,,,,3270.46,7420.90,percent of total billed charges,
GRAFT,8408957,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,9072.00000,2630.88000,Aetna,First Health,,7420.90,,,,,,,2921.18,7420.90,percent of total billed charges,
PLATE,8408958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2496.00000,723.84000,Aetna,First Health,,2041.73,,,,,,,899.81,2041.73,percent of total billed charges,
PLATE,8408958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2496.00000,723.84000,Aetna,First Health,,2041.73,,,,,,,803.71,2041.73,percent of total billed charges,
PLATE,8408959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2496.00000,723.84000,Aetna,First Health,,2041.73,,,,,,,899.81,2041.73,percent of total billed charges,
PLATE,8408959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2496.00000,723.84000,Aetna,First Health,,2041.73,,,,,,,803.71,2041.73,percent of total billed charges,
CAGE,8408960,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,8408960,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
SCREW SPINAL,8408999,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW SPINAL,8408999,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
ROD SPINAL,8409009,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8409009,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
COMPONENT FEMORAL,8409027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8409027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
STEM EXTENSION,8409020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1581.91,3589.46,percent of total billed charges,
STEM EXTENSION,8409020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,First Health,,3589.46,,,,,,,1412.96,3589.46,percent of total billed charges,
COMPONENT FEMORAL,8409029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8409029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE,8409030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
BASEPLATE,8409030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
HEAD FEMORAL,8409109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,8409109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
INSERT,8409111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8409111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SHELL,8409194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8271.00000,2398.59000,Aetna,First Health,,6765.68,,,,,,,2981.70,6765.68,percent of total billed charges,
SHELL,8409194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8271.00000,2398.59000,Aetna,First Health,,6765.68,,,,,,,2663.26,6765.68,percent of total billed charges,
LINER,8409195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
LINER,8409195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
LINER,8409196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10125.00000,2936.25000,Aetna,First Health,,8282.25,,,,,,,3650.06,8282.25,percent of total billed charges,
LINER,8409196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10125.00000,2936.25000,Aetna,First Health,,8282.25,,,,,,,3260.25,8282.25,percent of total billed charges,
INSERT,8409197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8409197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
COMPONENT FEMORAL,8409470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8409470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
ROD SPINAL,8409456,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD SPINAL,8409456,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
PLATE SPINAL,8409458,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE SPINAL,8409458,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
SCREW,8409460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,8409460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
SCREW,8409462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8409462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8409464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8409464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
HEAD FEMORAL,8409466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
HEAD FEMORAL,8409466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
SLEEVE FEMORAL,8409467,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3056.00000,886.24000,Aetna,First Health,,2499.81,,,,,,,1101.69,2499.81,percent of total billed charges,
SLEEVE FEMORAL,8409467,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3056.00000,886.24000,Aetna,First Health,,2499.81,,,,,,,984.03,2499.81,percent of total billed charges,
SLEEVE HUMERAL STEM,8409530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,219.98,499.14,percent of total billed charges,
SLEEVE HUMERAL STEM,8409530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,First Health,,499.14,,,,,,,196.48,499.14,percent of total billed charges,
CAGE,8409532,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE,8409532,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
PLATE SPINAL,8409534,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE SPINAL,8409534,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW SPINAL,8409536,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW SPINAL,8409536,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
SCREW SPINAL,8409538,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW SPINAL,8409538,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
SCREW SPINAL,8409540,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5530.00000,1603.70000,Aetna,First Health,,4523.54,,,,,,,1993.57,4523.54,percent of total billed charges,
SCREW SPINAL,8409540,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5530.00000,1603.70000,Aetna,First Health,,4523.54,,,,,,,1780.66,4523.54,percent of total billed charges,
INSERT,8409638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8409638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE,8409639,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
CAGE,8409639,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
BREAST IMPLANT,8409790,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
BREAST IMPLANT,8409790,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,764.47,6319.05,percent of total billed charges,
BREAST IMPLANT,8409792,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,7590.00000,2201.10000,Aetna,First Health,,6208.62,,,,,,,2736.20,6208.62,percent of total billed charges,
BREAST IMPLANT,8409792,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,7590.00000,2201.10000,Aetna,First Health,,6208.62,,,,,,,764.47,6208.62,percent of total billed charges,
BREAST IMPLANT,8409794,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,7590.00000,2201.10000,Aetna,First Health,,6208.62,,,,,,,2736.20,6208.62,percent of total billed charges,
BREAST IMPLANT,8409794,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,7590.00000,2201.10000,Aetna,First Health,,6208.62,,,,,,,764.47,6208.62,percent of total billed charges,
STEM,8409941,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8409941,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
PLATE SPINAL,8409943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE SPINAL,8409943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,8409945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8409945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8409947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8409947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
PLATE,8409949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
PLATE,8409949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,8409952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,314.23,713.01,percent of total billed charges,
SCREW,8409952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,280.67,713.01,percent of total billed charges,
SCREW,8409954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,314.23,713.01,percent of total billed charges,
SCREW,8409954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,280.67,713.01,percent of total billed charges,
SCREW,8409956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,314.23,713.01,percent of total billed charges,
SCREW,8409956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,280.67,713.01,percent of total billed charges,
NAIL,8410045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5134.01000,1488.86000,Aetna,First Health,,4199.62,,,,,,,1850.81,4199.62,percent of total billed charges,
NAIL,8410045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5134.01000,1488.86000,Aetna,First Health,,4199.62,,,,,,,1653.15,4199.62,percent of total billed charges,
SPACER SPINAL,8410049,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
SPACER SPINAL,8410049,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
COMPONENT FEMORAL,8410060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
COMPONENT FEMORAL,8410060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
INSERT,8410061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,8410061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
STEM EXTENSION,8410062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM EXTENSION,8410062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
COMPONENT TIBIAL,8410063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,8410063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
CAGE,8410064,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE,8410064,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
CONNECTOR SPINAL,8410194,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
CONNECTOR SPINAL,8410194,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
SCREW SPINAL,8410195,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW SPINAL,8410195,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
PLATE,8410196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8781.00000,2546.49000,Aetna,First Health,,7182.86,,,,,,,3165.55,7182.86,percent of total billed charges,
PLATE,8410196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8781.00000,2546.49000,Aetna,First Health,,7182.86,,,,,,,2827.48,7182.86,percent of total billed charges,
SCREW,8410230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8410230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
ABLATION CATHETER,8409329,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
ABLATION CATHETER,8409329,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,9959.00,percent of total billed charges,
CATHETER GUIDE,8410215,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8410215,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8410216,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8410216,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8410217,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8410217,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8410218,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8410218,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8410219,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8410219,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8410220,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8410220,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDE,8410221,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDE,8410221,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
GRAFT BONE,8410397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
GRAFT BONE,8410397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
SCREW,8410400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,327.18000,94.88000,Aetna,First Health,,267.63,,,,,,,117.95,267.63,percent of total billed charges,
SCREW,8410400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,327.18000,94.88000,Aetna,First Health,,267.63,,,,,,,105.35,267.63,percent of total billed charges,
SCREW,8410404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8410404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
K WIRE,8410402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,71.92,163.19,percent of total billed charges,
K WIRE,8410402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,First Health,,163.19,,,,,,,64.24,163.19,percent of total billed charges,
INSERT,8410403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8410403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE,8410509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3644.38,8269.37,percent of total billed charges,
PLATE,8410509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3255.18,8269.37,percent of total billed charges,
ANCHOR IN KIT,8410511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.00000,559.99000,Aetna,First Health,,1579.56,,,,,,,696.13,1579.56,percent of total billed charges,
ANCHOR IN KIT,8410511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.00000,559.99000,Aetna,First Health,,1579.56,,,,,,,621.78,1579.56,percent of total billed charges,
SHEATH,8410428,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
SHEATH,8410428,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
GENERATOR IN KIT,8410516,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,47362.50000,13735.12000,Aetna,First Health,,38742.53,,,,,,,17074.18,38742.53,percent of total billed charges,
GENERATOR IN KIT,8410516,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,47362.50000,13735.12000,Aetna,First Health,,38742.53,,,,,,,15250.73,38742.53,percent of total billed charges,
REMOTE CONTROL IN KIT,8410517,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
REMOTE CONTROL IN KIT,8410517,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,8410599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,8410599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
STEM,8410679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,8410679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
HEAD HUMERAL,8410680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1810.61,4108.40,percent of total billed charges,
HEAD HUMERAL,8410680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,First Health,,4108.40,,,,,,,1617.24,4108.40,percent of total billed charges,
GRAFT,8410681,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
GRAFT,8410681,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
SCREW,8410682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8410682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,8410683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8410683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
CATHETER,8410703,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CATHETER,8410703,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
CATHETER,8410704,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4558.52,10343.61,percent of total billed charges,
CATHETER,8410704,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4071.69,10343.61,percent of total billed charges,
CATHETER,8410705,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4558.52,10343.61,percent of total billed charges,
CATHETER,8410705,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,First Health,,10343.61,,,,,,,4071.69,10343.61,percent of total billed charges,
CAGE,8410910,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8410910,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
PLATE SPINAL,8410912,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1291.62,2930.77,percent of total billed charges,
PLATE SPINAL,8410912,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1153.68,2930.77,percent of total billed charges,
CAGE,8410916,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,8410916,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
INSERT,8410937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8410937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT GLENOID,8410947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
COMPONENT GLENOID,8410947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
COMPONENT TIBIAL,8411014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
COMPONENT TIBIAL,8411014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
CAGE,8411015,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,6529.56,14816.02,percent of total billed charges,
CAGE,8411015,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,5832.23,14816.02,percent of total billed charges,
SCREW SPINAL,8411016,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW SPINAL,8411016,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW SPINAL,8411017,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW SPINAL,8411017,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
INSERT,8411018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8411018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM EXTENSION,8411019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM EXTENSION,8411019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
STEM EXTENSION,8411020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM EXTENSION,8411020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
SCREW,8411021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.56000,196.78000,Aetna,First Health,,555.06,,,,,,,244.62,555.06,percent of total billed charges,
SCREW,8411021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.56000,196.78000,Aetna,First Health,,555.06,,,,,,,218.50,555.06,percent of total billed charges,
SCREW,8411022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.56000,196.78000,Aetna,First Health,,555.06,,,,,,,244.62,555.06,percent of total billed charges,
SCREW,8411022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.56000,196.78000,Aetna,First Health,,555.06,,,,,,,218.50,555.06,percent of total billed charges,
COMPONENT FEMORAL,8411023,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8411023,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
STEM,8411090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,8411090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT,8411091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
INSERT,8411091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
BASEPLATE,8411086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
BASEPLATE,8411086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
COMPONENT TIBIAL,8411087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
COMPONENT TIBIAL,8411087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
SCREW SPINAL,8411088,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW SPINAL,8411088,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
CAGE,8411089,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8411089,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
STEM,8411194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2811.90,6380.40,percent of total billed charges,
STEM,8411194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2511.60,6380.40,percent of total billed charges,
SCREW,8411195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,8411195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
PLATE,8411196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3825.50000,1109.40000,Aetna,First Health,,3129.26,,,,,,,1379.09,3129.26,percent of total billed charges,
PLATE,8411196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3825.50000,1109.40000,Aetna,First Health,,3129.26,,,,,,,1231.81,3129.26,percent of total billed charges,
SCREW,8411197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,8411197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,8411199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8411199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8411298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW,8411298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
PEG,8411186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
PEG,8411186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
PEG,8411187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
PEG,8411187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
COMPONENT TIBIAL,8411626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
COMPONENT TIBIAL,8411626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
PEG,8411189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
PEG,8411189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
PEG,8411190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
PEG,8411190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
SCREW,8411191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,8411191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
PLATE,8411192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3957.21,8979.19,percent of total billed charges,
PLATE,8411192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3534.59,8979.19,percent of total billed charges,
PLATE,8411193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8619.00000,2499.51000,Aetna,First Health,,7050.34,,,,,,,3107.15,7050.34,percent of total billed charges,
PLATE,8411193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8619.00000,2499.51000,Aetna,First Health,,7050.34,,,,,,,2775.32,7050.34,percent of total billed charges,
NASAL IMPLANT,8148052,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NASAL IMPLANT,8148052,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1374.94,3492.86,percent of total billed charges,
INSERT,8411185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8411185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,8411299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1734.59,3935.91,percent of total billed charges,
PLATE,8411299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,First Health,,3935.91,,,,,,,1549.34,3935.91,percent of total billed charges,
PLATE,8411300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
PLATE,8411300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
CAGE,8411302,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,8411302,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
BOLT SPINAL,8411303,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
BOLT SPINAL,8411303,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
CAGE,8411304,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,8411304,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
ADAPTER FEMORAL,8411305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5187.00000,1504.23000,Aetna,First Health,,4242.97,,,,,,,1869.91,4242.97,percent of total billed charges,
ADAPTER FEMORAL,8411305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5187.00000,1504.23000,Aetna,First Health,,4242.97,,,,,,,1670.21,4242.97,percent of total billed charges,
WEDGE,8411306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8411306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
WEDGE,8411307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8411307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
WEDGE,8411308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
WEDGE,8411308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
WEDGE,8411309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
WEDGE,8411309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
ROD SPINAL,8411301,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
ROD SPINAL,8411301,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,263.72,669.94,percent of total billed charges,
STEM,8411323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,5439.04,12341.58,percent of total billed charges,
STEM,8411323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,First Health,,12341.58,,,,,,,4858.18,12341.58,percent of total billed charges,
SPACER SPINAL,8411438,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
SPACER SPINAL,8411438,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
SHEATH,8411390,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
SHEATH,8411390,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
INSERT,8411463,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8411463,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,8411464,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,4351.96,9874.90,percent of total billed charges,
COMPONENT FEMORAL,8411464,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,3887.18,9874.90,percent of total billed charges,
ROD SPINAL,8411465,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,536.42,1217.18,percent of total billed charges,
ROD SPINAL,8411465,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,First Health,,1217.18,,,,,,,479.14,1217.18,percent of total billed charges,
SCREW SPINAL,8411466,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW SPINAL,8411466,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SCREW,8411467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,105.33,239.00,percent of total billed charges,
SCREW,8411467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,First Health,,239.00,,,,,,,94.08,239.00,percent of total billed charges,
SCREW,8411468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.29000,64.17000,Aetna,First Health,,181.02,,,,,,,79.78,181.02,percent of total billed charges,
SCREW,8411468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.29000,64.17000,Aetna,First Health,,181.02,,,,,,,71.26,181.02,percent of total billed charges,
SCREW,8411469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,266.29,604.24,percent of total billed charges,
SCREW,8411469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,First Health,,604.24,,,,,,,237.85,604.24,percent of total billed charges,
WEDGE,8411470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2650.40000,768.62000,Aetna,First Health,,2168.03,,,,,,,955.47,2168.03,percent of total billed charges,
WEDGE,8411470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2650.40000,768.62000,Aetna,First Health,,2168.03,,,,,,,853.43,2168.03,percent of total billed charges,
WEDGE,8411471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8411471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
INSERT,8411628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8411628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
AUGMENT FEMORAL,8411630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
AUGMENT FEMORAL,8411630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
STEM,8411632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8411632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
STEM,8411634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
STEM,8411634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
SCREW,8411636,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,8411636,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SHELL,8411640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8411640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
CAGE,8411642,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
CAGE,8411642,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
PLATE SPINAL,8411644,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1291.62,2930.77,percent of total billed charges,
PLATE SPINAL,8411644,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1153.68,2930.77,percent of total billed charges,
SCREW SPINAL,8411646,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW SPINAL,8411646,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
ROD TO ROD COUPLER,8411650,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,2348.00000,680.92000,Aetna,First Health,,1920.66,,,,,,,846.45,1920.66,percent of total billed charges,
ROD TO ROD COUPLER,8411650,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,2348.00000,680.92000,Aetna,First Health,,1920.66,,,,,,,756.06,1920.66,percent of total billed charges,
SCREW,8411731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW,8411731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
LINER,8412008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,8412008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW SPINAL,8412010,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW SPINAL,8412010,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW SPINAL,8412011,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW SPINAL,8412011,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW SPINAL,8412033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW SPINAL,8412033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
SCREW SPINAL,8412032,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1359.54,3084.88,percent of total billed charges,
SCREW SPINAL,8412032,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,First Health,,3084.88,,,,,,,1214.34,3084.88,percent of total billed charges,
TENDON,8412057,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6662.25000,1932.05000,Aetna,First Health,,5449.72,,,,,,,2401.74,5449.72,percent of total billed charges,
TENDON,8412057,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6662.25000,1932.05000,Aetna,First Health,,5449.72,,,,,,,2145.24,5449.72,percent of total billed charges,
CAGE,8412058,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
CAGE,8412058,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
INSERT,8412072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,8412072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
BASEPLATE,8412073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
BASEPLATE,8412073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
AUGMENT TIBIAL,8412074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
AUGMENT TIBIAL,8412074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
AUGMENT TIBIAL,8412119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
AUGMENT TIBIAL,8412119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
AUGMENT FEMORAL,8412120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
AUGMENT FEMORAL,8412120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
SHELL,8412110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8412110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
AUGMENT FEMORAL,8412151,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1250.39,2837.23,percent of total billed charges,
AUGMENT FEMORAL,8412151,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,First Health,,2837.23,,,,,,,1116.86,2837.23,percent of total billed charges,
ROD SPINAL,8412153,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD SPINAL,8412153,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
INFLATION DEVICE,8412155,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,222.29000,64.46000,Aetna,First Health,,181.83,,,,,,,80.14,181.83,percent of total billed charges,
INFLATION DEVICE,8412155,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,222.29000,64.46000,Aetna,First Health,,181.83,,,,,,,71.58,181.83,percent of total billed charges,
MESH,8413574,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,7749.00000,2247.21000,Aetna,First Health,,6338.68,,,,,,,2793.51,6338.68,percent of total billed charges,
MESH,8413574,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,7749.00000,2247.21000,Aetna,First Health,,6338.68,,,,,,,2495.18,6338.68,percent of total billed charges,
SCREW,8413715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8413715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
GUIDEWIRE,8413981,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,206.03,467.49,percent of total billed charges,
GUIDEWIRE,8413981,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,184.02,467.49,percent of total billed charges,
GUIDEWIRE,8413971,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,118.15,268.10,percent of total billed charges,
GUIDEWIRE,8413971,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,105.54,268.10,percent of total billed charges,
WASHER,8413972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
WASHER,8413972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
SCREW,8413817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8413817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW SPINAL,8413819,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW SPINAL,8413819,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
CAGE,8413647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8413647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
CAGE,8413649,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,8413649,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
LINER,8413651,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,8413651,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
SHELL,8413653,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,8413653,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
SHEATH,8413655,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SHEATH,8413655,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SHEATH,8413657,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SHEATH,8413657,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
MESH,8413748,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1920.00000,556.80000,Aetna,First Health,,1570.56,,,,,,,692.16,1570.56,percent of total billed charges,
MESH,8413748,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1920.00000,556.80000,Aetna,First Health,,1570.56,,,,,,,618.24,1570.56,percent of total billed charges,
TIGHTROPE,8413749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,3076.60,6981.02,percent of total billed charges,
TIGHTROPE,8413749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,2748.03,6981.02,percent of total billed charges,
INSERT,8413750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8413750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
Screw,8413718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
Screw,8413718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
CAGE,8413751,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8413751,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
CAGE,8413752,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8413752,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
CAGE,8413753,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8413753,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
PLATE,8413719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3000.44000,870.13000,Aetna,First Health,,2454.36,,,,,,,1081.66,2454.36,percent of total billed charges,
PLATE,8413719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3000.44000,870.13000,Aetna,First Health,,2454.36,,,,,,,966.14,2454.36,percent of total billed charges,
SCREW SPINAL,8413820,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW SPINAL,8413820,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
BOLT SPINAL,8413982,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
BOLT SPINAL,8413982,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW SPINAL,8413983,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SCREW SPINAL,8413983,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ROD SPINAL,8413984,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
ROD SPINAL,8413984,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW SPINAL,8413985,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW SPINAL,8413985,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
STEM,8414051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,8414051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
WEDGE,8414053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8414053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
STEM,8414055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4609.50000,1336.76000,Aetna,First Health,,3770.57,,,,,,,1661.72,3770.57,percent of total billed charges,
STEM,8414055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4609.50000,1336.76000,Aetna,First Health,,3770.57,,,,,,,1484.26,3770.57,percent of total billed charges,
SCREW,8414057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
SCREW,8414057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
WEDGE,8414059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,8414059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
WEDGE,8414060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19962.50000,5789.12000,Aetna,First Health,,16329.33,,,,,,,7196.48,16329.33,percent of total billed charges,
WEDGE,8414060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19962.50000,5789.12000,Aetna,First Health,,16329.33,,,,,,,6427.93,16329.33,percent of total billed charges,
SCREW SPINAL,8414063,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW SPINAL,8414063,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW SPINAL,8414064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW SPINAL,8414064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CAGE,8414124,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8414124,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
CAGE,8414126,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8414126,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
COMPONENT ACETABULAR,8414129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10236.00000,2968.44000,Aetna,First Health,,8373.05,,,,,,,3690.08,8373.05,percent of total billed charges,
COMPONENT ACETABULAR,8414129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10236.00000,2968.44000,Aetna,First Health,,8373.05,,,,,,,3295.99,8373.05,percent of total billed charges,
LINER,8414131,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5253.50000,1523.52000,Aetna,First Health,,4297.36,,,,,,,1893.89,4297.36,percent of total billed charges,
LINER,8414131,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5253.50000,1523.52000,Aetna,First Health,,4297.36,,,,,,,1691.63,4297.36,percent of total billed charges,
ANCHOR,8414133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
ANCHOR,8414133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,421.18,1069.94,percent of total billed charges,
STEM,8414137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,8414137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,8414138,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,8414138,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
SCREW,8414139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
SCREW,8414139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
BASEPLATE,8414222,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
BASEPLATE,8414222,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
COMPONENT FEMORAL,8414223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,7669.64,17402.95,percent of total billed charges,
COMPONENT FEMORAL,8414223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,6850.55,17402.95,percent of total billed charges,
AUGMENT FEMORAL,8414227,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5686.89,12903.95,percent of total billed charges,
AUGMENT FEMORAL,8414227,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,First Health,,12903.95,,,,,,,5079.55,12903.95,percent of total billed charges,
INSERT,8414228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8414228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,8414229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,3285.60,7455.25,percent of total billed charges,
INSERT,8414229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,First Health,,7455.25,,,,,,,2934.71,7455.25,percent of total billed charges,
BASEPLATE,8414230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
BASEPLATE,8414230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
INSERT,8414231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,8414231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
PLATE,8413818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
PLATE,8413818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
Plate,8414328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2488.40000,721.64000,Aetna,First Health,,2035.51,,,,,,,897.07,2035.51,percent of total billed charges,
Plate,8414328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2488.40000,721.64000,Aetna,First Health,,2035.51,,,,,,,801.26,2035.51,percent of total billed charges,
PLATE,8414329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.60000,706.32000,Aetna,First Health,,1992.32,,,,,,,878.03,1992.32,percent of total billed charges,
PLATE,8414329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.60000,706.32000,Aetna,First Health,,1992.32,,,,,,,784.26,1992.32,percent of total billed charges,
PLATE SPINAL,8414323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE SPINAL,8414323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
Cage,8414324,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
Cage,8414324,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
ROD SPINAL,8414325,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8414325,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SCREW SPINAL,8414436,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW SPINAL,8414436,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
Insert,8414326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
Insert,8414326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,8414327,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
CAGE,8414327,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
SCREW,8414331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,244.96,555.83,percent of total billed charges,
SCREW,8414331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,First Health,,555.83,,,,,,,218.80,555.83,percent of total billed charges,
SCREW,8414332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,8414332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
SCREW,8414437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,8414437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
COMPONENT FEMORAL,8414333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,7669.64,17402.95,percent of total billed charges,
COMPONENT FEMORAL,8414333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,6850.55,17402.95,percent of total billed charges,
PLATE,8414382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,First Health,,3638.62,,,,,,,1603.57,3638.62,percent of total billed charges,
PLATE,8414382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,First Health,,3638.62,,,,,,,1432.32,3638.62,percent of total billed charges,
COMPONENT ULNAR,8414443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
COMPONENT ULNAR,8414443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
COMPONENT HUMERAL,8414444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
COMPONENT HUMERAL,8414444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
ROD SPINAL,8414445,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD SPINAL,8414445,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SCREW SPINAL,8414441,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SPINAL,8414441,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE SPINAL,8414442,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE SPINAL,8414442,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE,8414380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,First Health,,3638.62,,,,,,,1603.57,3638.62,percent of total billed charges,
PLATE,8414380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,First Health,,3638.62,,,,,,,1432.32,3638.62,percent of total billed charges,
SCREW SPINAL,8414439,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SCREW SPINAL,8414439,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
CAGE,8414608,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,7790.40,17676.98,percent of total billed charges,
CAGE,8414608,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,First Health,,17676.98,,,,,,,6958.42,17676.98,percent of total billed charges,
COMPONENT FEMORAL,8414577,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,7669.64,17402.95,percent of total billed charges,
COMPONENT FEMORAL,8414577,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,First Health,,17402.95,,,,,,,6850.55,17402.95,percent of total billed charges,
COMPONENT TIBIAL,8414578,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,3238.01,7347.28,percent of total billed charges,
COMPONENT TIBIAL,8414578,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,First Health,,7347.28,,,,,,,2892.20,7347.28,percent of total billed charges,
WEDGE,8414579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8414579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8414580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8414580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8414609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8414609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
WEDGE,8414581,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,8414581,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
ALLOGRAFT,8414468,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
ALLOGRAFT,8414468,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
SHELL,8414630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3475.94,7887.16,percent of total billed charges,
SHELL,8414630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,First Health,,7887.16,,,,,,,3104.72,7887.16,percent of total billed charges,
COMPONENT FEMORAL,8414631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
COMPONENT FEMORAL,8414631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
SCREW,8414633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,8414633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,8414634,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,8414634,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
COMPONENT FEMORAL,8414654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,8414654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
COMPONENT TIBIAL,8414655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
COMPONENT TIBIAL,8414655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
PLATE,8414745,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2503.76000,726.09000,Aetna,First Health,,2048.08,,,,,,,902.61,2048.08,percent of total billed charges,
PLATE,8414745,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2503.76000,726.09000,Aetna,First Health,,2048.08,,,,,,,806.21,2048.08,percent of total billed charges,
SCREW,8414746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,8414746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
GUIDEWIRE,8414774,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,114.73,260.33,percent of total billed charges,
GUIDEWIRE,8414774,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,102.48,260.33,percent of total billed charges,
GRAFT STENT,8414798,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6721.52,15251.61,percent of total billed charges,
GRAFT STENT,8414798,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,First Health,,15251.61,,,,,,,6003.69,15251.61,percent of total billed charges,
TIGHTROPE,8414800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,665.84,1510.85,percent of total billed charges,
TIGHTROPE,8414800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,594.73,1510.85,percent of total billed charges,
SCREW SPINAL,8414847,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW SPINAL,8414847,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
NEUROSTIMULATOR GENERATOR,8414848,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,25042.50000,7262.32000,Aetna,First Health,,20484.76,,,,,,,9027.82,20484.76,percent of total billed charges,
NEUROSTIMULATOR GENERATOR,8414848,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,25042.50000,7262.32000,Aetna,First Health,,20484.76,,,,,,,8063.69,20484.76,percent of total billed charges,
STENT GRAFT,8414849,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,6142.92,13938.72,percent of total billed charges,
STENT GRAFT,8414849,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,First Health,,13938.72,,,,,,,5486.88,13938.72,percent of total billed charges,
CAGE,8414879,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5633.71,12783.30,percent of total billed charges,
CAGE,8414879,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,First Health,,12783.30,,,,,,,5032.06,12783.30,percent of total billed charges,
PLATE,8414882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3380.30000,980.29000,Aetna,First Health,,2765.09,,,,,,,1218.60,2765.09,percent of total billed charges,
PLATE,8414882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3380.30000,980.29000,Aetna,First Health,,2765.09,,,,,,,1088.46,2765.09,percent of total billed charges,
CATHETER,8414884,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,7029.75,15951.00,percent of total billed charges,
CATHETER,8414884,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,6279.00,15951.00,percent of total billed charges,
SHEATH,8414886,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
SHEATH,8414886,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
INTRODUCER,8414900,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
INTRODUCER,8414900,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
INSERT,8414933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,8414933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
COMPONENT FEMORAL,8414935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
COMPONENT FEMORAL,8414935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
LINER,8414937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
LINER,8414937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
LINER,8414938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
LINER,8414938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
STENT GRAFT,8414940,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3824.18,8677.34,percent of total billed charges,
STENT GRAFT,8414940,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3415.78,8677.34,percent of total billed charges,
INSERT,8414942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8899.50000,2580.86000,Aetna,First Health,,7279.79,,,,,,,3208.27,7279.79,percent of total billed charges,
INSERT,8414942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8899.50000,2580.86000,Aetna,First Health,,7279.79,,,,,,,2865.64,7279.79,percent of total billed charges,
STENT GRAFT,8414944,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3824.18,8677.34,percent of total billed charges,
STENT GRAFT,8414944,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3415.78,8677.34,percent of total billed charges,
PLATE,8415027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,3076.60,6981.02,percent of total billed charges,
PLATE,8415027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,First Health,,6981.02,,,,,,,2748.03,6981.02,percent of total billed charges,
STENT GRAFT,8415029,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,8415029,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
EXCLUDER,8415031,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,38137.50000,11059.88000,Aetna,First Health,,31196.47,,,,,,,13748.57,31196.47,percent of total billed charges,
EXCLUDER,8415031,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,38137.50000,11059.88000,Aetna,First Health,,31196.47,,,,,,,12280.27,31196.47,percent of total billed charges,
INSERT,8415025,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,8415025,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
STENT,8415033,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415033,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415034,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415034,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415035,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415035,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415036,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415036,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415037,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415037,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415038,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415038,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415039,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415039,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415040,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415040,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415041,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415041,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STENT,8415042,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1198.66,2719.85,percent of total billed charges,
STENT,8415042,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,First Health,,2719.85,,,,,,,1070.65,2719.85,percent of total billed charges,
STEM HUMERAL,9000818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM HUMERAL,9000818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
SCREW,9000866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,9000866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
PLATE,9000867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1635.23,3710.45,percent of total billed charges,
PLATE,9000867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1460.59,3710.45,percent of total billed charges,
INSERT,9000868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9000868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW SPINAL,9000869,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW SPINAL,9000869,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
CAGE,9000870,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
CAGE,9000870,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
SPACER,9000871,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,4082.66,9263.85,percent of total billed charges,
SPACER,9000871,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,3646.65,9263.85,percent of total billed charges,
INSERT,9000872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,9000872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
PIN,9000903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,430.87000,124.95000,Aetna,First Health,,352.45,,,,,,,155.33,352.45,percent of total billed charges,
PIN,9000903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,430.87000,124.95000,Aetna,First Health,,352.45,,,,,,,138.74,352.45,percent of total billed charges,
SCREW,9000904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,9000904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,9000905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,9000905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,9000906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,9000906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,9000907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,9000907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,9000908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,9000908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
STEM,9003562,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,9003562,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
ANCHOR,9000923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
ANCHOR,9000923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
SCREW,9000924,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,317.52,720.49,percent of total billed charges,
SCREW,9000924,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,First Health,,720.49,,,,,,,283.61,720.49,percent of total billed charges,
TIGHTROPE,9000925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4517.63000,1310.11000,Aetna,First Health,,3695.42,,,,,,,1628.61,3695.42,percent of total billed charges,
TIGHTROPE,9000925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4517.63000,1310.11000,Aetna,First Health,,3695.42,,,,,,,1454.68,3695.42,percent of total billed charges,
STEM,9000950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,9000950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,9000951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE,9000951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
CAGE,9000952,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,9000952,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
CAGE,9000953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,9000953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
PLATE,9000954,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3775.10000,1094.78000,Aetna,First Health,,3088.03,,,,,,,1360.92,3088.03,percent of total billed charges,
PLATE,9000954,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3775.10000,1094.78000,Aetna,First Health,,3088.03,,,,,,,1215.58,3088.03,percent of total billed charges,
NAIL,9000970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,2146.24,4869.96,percent of total billed charges,
NAIL,9000970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,1917.03,4869.96,percent of total billed charges,
ROD SPINAL,9003633,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
ROD SPINAL,9003633,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
GLENOSPHERE,9003635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
GLENOSPHERE,9003635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
LINER,9003636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1811.62,4110.70,percent of total billed charges,
LINER,9003636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1618.15,4110.70,percent of total billed charges,
SCREW,9003637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1370.40000,397.42000,Aetna,First Health,,1120.99,,,,,,,494.03,1120.99,percent of total billed charges,
SCREW,9003637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1370.40000,397.42000,Aetna,First Health,,1120.99,,,,,,,441.27,1120.99,percent of total billed charges,
INSERT,9003638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
INSERT,9003638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
STEM,9003639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,9003639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
INSERT,9003640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
INSERT,9003640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
HEART VALVE,9013416,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,80000.00000,23200.00000,Aetna,First Health,,65440.00,,,,,,,28840.00,65440.00,percent of total billed charges,
HEART VALVE,9013416,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,80000.00000,23200.00000,Aetna,First Health,,65440.00,,,,,,,25760.00,65440.00,percent of total billed charges,
HEART VALVE,9013417,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,80000.00000,23200.00000,Aetna,First Health,,65440.00,,,,,,,28840.00,65440.00,percent of total billed charges,
HEART VALVE,9013417,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,80000.00000,23200.00000,Aetna,First Health,,65440.00,,,,,,,25760.00,65440.00,percent of total billed charges,
HEART VALVE,9013418,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,80000.00000,23200.00000,Aetna,First Health,,65440.00,,,,,,,28840.00,65440.00,percent of total billed charges,
HEART VALVE,9013418,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,80000.00000,23200.00000,Aetna,First Health,,65440.00,,,,,,,25760.00,65440.00,percent of total billed charges,
HEART VALVE,9013419,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,80000.00000,23200.00000,Aetna,First Health,,65440.00,,,,,,,28840.00,65440.00,percent of total billed charges,
HEART VALVE,9013419,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,80000.00000,23200.00000,Aetna,First Health,,65440.00,,,,,,,25760.00,65440.00,percent of total billed charges,
CATHETER,9016229,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
CATHETER,9016229,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
CATHETER,9024174,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER,9024174,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
CATHETER,9024175,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER,9024175,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
CATHETER,9024176,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER,9024176,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
CATHETER,9024177,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER,9024177,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
CATHETER BALLOON,9020813,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
CATHETER BALLOON,9020813,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
CATHETER BALLOON,9020814,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
CATHETER BALLOON,9020814,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
SHEATH,9020815,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
SHEATH,9020815,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
CATHETER MAP,9020816,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
CATHETER MAP,9020816,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
CATHTER TACTI,9022252,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,5028.98,11411.10,percent of total billed charges,
CATHTER TACTI,9022252,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,4491.90,11411.10,percent of total billed charges,
CATHETER,9024095,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,609.75000,176.83000,Aetna,First Health,,498.78,,,,,,,219.81,498.78,percent of total billed charges,
CATHETER,9024095,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,609.75000,176.83000,Aetna,First Health,,498.78,,,,,,,196.34,498.78,percent of total billed charges,
BALLOON,8994744,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994744,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994745,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994745,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994746,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994746,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994747,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994747,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994748,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994748,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994749,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994749,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994750,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994750,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994751,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994751,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994752,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994752,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994753,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994753,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994754,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994754,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994755,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994755,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994756,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994756,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994757,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994757,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994758,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994758,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994759,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994759,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,8994760,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,8994760,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
CARDIAC CATHETER,8995007,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3797.50000,1101.27000,Aetna,First Health,,3106.36,,,,,,,1369.00,3106.36,percent of total billed charges,
CARDIAC CATHETER,8995007,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3797.50000,1101.27000,Aetna,First Health,,3106.36,,,,,,,1222.80,9959.00,percent of total billed charges,
CARDIAC CATHETER,8995008,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,1002.19,2274.04,percent of total billed charges,
CARDIAC CATHETER,8995008,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,First Health,,2274.04,,,,,,,895.16,9959.00,percent of total billed charges,
SHEATH,8995631,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1242.82,2820.05,percent of total billed charges,
SHEATH,8995631,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,First Health,,2820.05,,,,,,,1110.10,2820.05,percent of total billed charges,
OCCLUDER,8995632,CDM,278,RC,C1817,HCPCS,,,facility,inpatient,,,29351.25000,8511.86000,Aetna,First Health,,24009.32,,,,,,,10581.13,24009.32,percent of total billed charges,
OCCLUDER,8995632,CDM,278,RC,C1817,HCPCS,,,facility,outpatient,,,29351.25000,8511.86000,Aetna,First Health,,24009.32,,,,,,,9451.10,24009.32,percent of total billed charges,
CATHETER VENTURE,8999989,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
CATHETER VENTURE,8999989,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SNARE NEEDLES,9002185,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
SNARE NEEDLES,9002185,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
SHEATH,9002186,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
SHEATH,9002186,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SHEATH,9002187,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,1556.00000,451.24000,Aetna,First Health,,1272.81,,,,,,,560.94,1272.81,percent of total billed charges,
SHEATH,9002187,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,1556.00000,451.24000,Aetna,First Health,,1272.81,,,,,,,501.03,1272.81,percent of total billed charges,
INTRODUCER,8996067,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,260.37,590.80,percent of total billed charges,
INTRODUCER,8996067,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,First Health,,590.80,,,,,,,232.56,590.80,percent of total billed charges,
LINER,9003641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1811.62,4110.70,percent of total billed charges,
LINER,9003641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1618.15,4110.70,percent of total billed charges,
SCREW,9003642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,9003642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
SCREW,9003643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,9003643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
STEM,9003644,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,9003644,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
BASEPLATE,9003645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.40000,1439.68000,Aetna,First Health,,4060.88,,,,,,,1789.67,4060.88,percent of total billed charges,
BASEPLATE,9003645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.40000,1439.68000,Aetna,First Health,,4060.88,,,,,,,1598.54,4060.88,percent of total billed charges,
SCREW,9003646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1370.40000,397.42000,Aetna,First Health,,1120.99,,,,,,,494.03,1120.99,percent of total billed charges,
SCREW,9003646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1370.40000,397.42000,Aetna,First Health,,1120.99,,,,,,,441.27,1120.99,percent of total billed charges,
SCREW,9003647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,9003647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
INSERT,9003648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
INSERT,9003648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
LINER,9003649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1811.62,4110.70,percent of total billed charges,
LINER,9003649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1618.15,4110.70,percent of total billed charges,
SCREW,9003650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2561.60000,742.86000,Aetna,First Health,,2095.39,,,,,,,923.46,2095.39,percent of total billed charges,
SCREW,9003650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2561.60000,742.86000,Aetna,First Health,,2095.39,,,,,,,824.84,2095.39,percent of total billed charges,
INSERT,9003651,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
INSERT,9003651,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
SCREW,9000969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,398.34000,115.52000,Aetna,First Health,,325.84,,,,,,,143.60,325.84,percent of total billed charges,
SCREW,9000969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,398.34000,115.52000,Aetna,First Health,,325.84,,,,,,,128.27,325.84,percent of total billed charges,
CATHETER SET,9001025,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
CATHETER SET,9001025,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
GLENOSPHERE,9001026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
GLENOSPHERE,9001026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
TUBE,9001049,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,113.93000,33.04000,Aetna,First Health,,93.19,,,,,,,41.07,93.19,percent of total billed charges,
TUBE,9001049,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,113.93000,33.04000,Aetna,First Health,,93.19,,,,,,,36.69,332.38,percent of total billed charges,
INJECTOR NEEDLE,9001051,CDM,278,RC,A4215,HCPCS,,,facility,inpatient,,,372.92000,108.15000,Aetna,First Health,,305.05,,,,,,,134.44,305.05,percent of total billed charges,
INJECTOR NEEDLE,9001051,CDM,278,RC,A4215,HCPCS,,,facility,outpatient,,,372.92000,108.15000,Aetna,First Health,,305.05,,,,,,,0.14445,305.05,percent of total billed charges,
DOWEL,9001035,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1517.25,3442.76,percent of total billed charges,
DOWEL,9001035,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1355.22,3442.76,percent of total billed charges,
DOWEL,9001036,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1517.25,3442.76,percent of total billed charges,
DOWEL,9001036,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1355.22,3442.76,percent of total billed charges,
DOWEL,9001037,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1517.25,3442.76,percent of total billed charges,
DOWEL,9001037,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1355.22,3442.76,percent of total billed charges,
DOWEL,9001038,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1517.25,3442.76,percent of total billed charges,
DOWEL,9001038,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1355.22,3442.76,percent of total billed charges,
DOWEL,9001039,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1517.25,3442.76,percent of total billed charges,
DOWEL,9001039,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1355.22,3442.76,percent of total billed charges,
DOWEL,9001040,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1517.25,3442.76,percent of total billed charges,
DOWEL,9001040,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1355.22,3442.76,percent of total billed charges,
DOWEL,9001041,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1517.25,3442.76,percent of total billed charges,
DOWEL,9001041,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1355.22,3442.76,percent of total billed charges,
DOWEL,9001042,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1517.25,3442.76,percent of total billed charges,
DOWEL,9001042,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,First Health,,3442.76,,,,,,,1355.22,3442.76,percent of total billed charges,
ENDCAP ADVANCED,9001103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1294.88000,375.52000,Aetna,First Health,,1059.21,,,,,,,466.80,1059.21,percent of total billed charges,
ENDCAP ADVANCED,9001103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1294.88000,375.52000,Aetna,First Health,,1059.21,,,,,,,416.95,1059.21,percent of total billed charges,
SCREW,9001104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9001104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9001105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,565.03,1282.10,percent of total billed charges,
SCREW,9001105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,504.69,1282.10,percent of total billed charges,
STEM HUMERAL,9001106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17486.75000,5071.16000,Aetna,First Health,,14304.16,,,,,,,6303.97,14304.16,percent of total billed charges,
STEM HUMERAL,9001106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17486.75000,5071.16000,Aetna,First Health,,14304.16,,,,,,,5630.73,14304.16,percent of total billed charges,
SCREW,9001107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11521.50000,3341.23000,Aetna,First Health,,9424.59,,,,,,,4153.50,9424.59,percent of total billed charges,
SCREW,9001107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11521.50000,3341.23000,Aetna,First Health,,9424.59,,,,,,,3709.92,9424.59,percent of total billed charges,
SCREW,9001108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,9001108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
GLENOID,9001109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
GLENOID,9001109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
RHINOLARYNGOSCOPE,9001110,CDM,278,RC,C2631,HCPCS,,,facility,inpatient,,,320.63000,92.98000,Aetna,First Health,,262.28,,,,,,,115.59,262.28,percent of total billed charges,
RHINOLARYNGOSCOPE,9001110,CDM,278,RC,C2631,HCPCS,,,facility,outpatient,,,320.63000,92.98000,Aetna,First Health,,262.28,,,,,,,103.24,262.28,percent of total billed charges,
SCREW,9003918,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9003918,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9003919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9003919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9003920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9003920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
NAIL,9003921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL,9003921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
CENTRALIZER DISTAL,9003922,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
CENTRALIZER DISTAL,9003922,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
STEM,9003923,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
STEM,9003923,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
STEM,9003924,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,4276.25,9703.12,percent of total billed charges,
STEM,9003924,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,3819.56,9703.12,percent of total billed charges,
SCREW,9003925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9003925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW,9003913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9003913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
GRAFT STENT,9003915,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,18652.27,42323.32,percent of total billed charges,
GRAFT STENT,9003915,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,First Health,,42323.32,,,,,,,16660.28,42323.32,percent of total billed charges,
ROD,9001387,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD,9001387,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CONNECTOR,9001388,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
CONNECTOR,9001388,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
PLATE,9001389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,9001389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
MODULAR HEAD,9001404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
MODULAR HEAD,9001404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
INSERT,9001405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,9001405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
SCREW,9001406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,565.03,1282.10,percent of total billed charges,
SCREW,9001406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,504.69,1282.10,percent of total billed charges,
INSERT TIBIAL,9001408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9001408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,9004151,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4699.03000,1362.72000,Aetna,First Health,,3843.81,,,,,,,1694.00,3843.81,percent of total billed charges,
PLATE,9004151,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4699.03000,1362.72000,Aetna,First Health,,3843.81,,,,,,,1513.09,3843.81,percent of total billed charges,
CAGE,9004152,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,9004152,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
COMPONENT FEMORAL,9004154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,9004154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
END CAP,9004153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
END CAP,9004153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
SCREW,9004155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,9004155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,9004156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,9004156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,9004157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,9004157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,9004158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,9004158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,9004159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,9004159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,9004160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,9004160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,9004161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,9004161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
STEM,9004238,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,9004238,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
BASEPLATE,9004249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
BASEPLATE,9004249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
COMPONENT FEMORAL,9004250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
COMPONENT FEMORAL,9004250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SHELL,9004251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
SHELL,9004251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
CAGE,9004252,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,9004252,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
SHANK TRACTION,9004253,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1551.88000,450.05000,Aetna,First Health,,1269.44,,,,,,,559.45,1269.44,percent of total billed charges,
SHANK TRACTION,9004253,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1551.88000,450.05000,Aetna,First Health,,1269.44,,,,,,,499.71,1269.44,percent of total billed charges,
SHANK TRACTION,9004254,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1551.88000,450.05000,Aetna,First Health,,1269.44,,,,,,,559.45,1269.44,percent of total billed charges,
SHANK TRACTION,9004254,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1551.88000,450.05000,Aetna,First Health,,1269.44,,,,,,,499.71,1269.44,percent of total billed charges,
ANCHOR,9004268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5947.41000,1724.75000,Aetna,First Health,,4864.98,,,,,,,2144.04,4864.98,percent of total billed charges,
ANCHOR,9004268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5947.41000,1724.75000,Aetna,First Health,,4864.98,,,,,,,1915.07,4864.98,percent of total billed charges,
SCREW,9004269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,9004269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
CENTRALIZER DISTAL,9004272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,549.68000,159.41000,Aetna,First Health,,449.64,,,,,,,198.16,449.64,percent of total billed charges,
CENTRALIZER DISTAL,9004272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,549.68000,159.41000,Aetna,First Health,,449.64,,,,,,,177.00,449.64,percent of total billed charges,
STEM,9004273,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7380.00000,2140.20000,Aetna,First Health,,6036.84,,,,,,,2660.49,6036.84,percent of total billed charges,
STEM,9004273,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7380.00000,2140.20000,Aetna,First Health,,6036.84,,,,,,,2376.36,6036.84,percent of total billed charges,
HEAD FEMORAL,9004274,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2750.40000,797.62000,Aetna,First Health,,2249.83,,,,,,,991.52,2249.83,percent of total billed charges,
HEAD FEMORAL,9004274,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2750.40000,797.62000,Aetna,First Health,,2249.83,,,,,,,885.63,2249.83,percent of total billed charges,
PLATE,9004275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8382.00000,2430.78000,Aetna,First Health,,6856.48,,,,,,,3021.71,6856.48,percent of total billed charges,
PLATE,9004275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8382.00000,2430.78000,Aetna,First Health,,6856.48,,,,,,,2699.00,6856.48,percent of total billed charges,
PLATE,9001527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6112.16000,1772.53000,Aetna,First Health,,4999.75,,,,,,,2203.43,4999.75,percent of total billed charges,
PLATE,9001527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6112.16000,1772.53000,Aetna,First Health,,4999.75,,,,,,,1968.12,4999.75,percent of total billed charges,
TIBIAL TRAY,9001526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
TIBIAL TRAY,9001526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
CAGE,9001590,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,9001590,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
INSERT TIBIAL,9001591,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9001591,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
MESH,9001594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,49446.00000,14339.34000,Aetna,First Health,,40446.83,,,,,,,17825.28,40446.83,percent of total billed charges,
MESH,9001594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,49446.00000,14339.34000,Aetna,First Health,,40446.83,,,,,,,15921.61,40446.83,percent of total billed charges,
SCREW,9001595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,461.13000,133.73000,Aetna,First Health,,377.20,,,,,,,166.24,377.20,percent of total billed charges,
SCREW,9001595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,461.13000,133.73000,Aetna,First Health,,377.20,,,,,,,148.48,377.20,percent of total billed charges,
STEM,9001596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,6038.38,13701.50,percent of total billed charges,
STEM,9001596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,5393.50,13701.50,percent of total billed charges,
SCREW,9001611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9001611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
COVER,9001592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,830.52000,240.85000,Aetna,First Health,,679.37,,,,,,,299.40,679.37,percent of total billed charges,
COVER,9001592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,830.52000,240.85000,Aetna,First Health,,679.37,,,,,,,267.43,679.37,percent of total billed charges,
CRANIAL HALF,9001614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3920.00000,1136.80000,Aetna,First Health,,3206.56,,,,,,,1413.16,3206.56,percent of total billed charges,
CRANIAL HALF,9001614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3920.00000,1136.80000,Aetna,First Health,,3206.56,,,,,,,1262.24,3206.56,percent of total billed charges,
SCREW,9001618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW,9001618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
PLATE,9001620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8791.20000,2549.45000,Aetna,First Health,,7191.20,,,,,,,3169.23,7191.20,percent of total billed charges,
PLATE,9001620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8791.20000,2549.45000,Aetna,First Health,,7191.20,,,,,,,2830.77,7191.20,percent of total billed charges,
PLATE,9001622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7552.80000,2190.31000,Aetna,First Health,,6178.19,,,,,,,2722.78,6178.19,percent of total billed charges,
PLATE,9001622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7552.80000,2190.31000,Aetna,First Health,,6178.19,,,,,,,2432.00,6178.19,percent of total billed charges,
SCREW,9001656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9001656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,9001657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SCREW,9001657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
PLATE,9001658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9072.00000,2630.88000,Aetna,First Health,,7420.90,,,,,,,3270.46,7420.90,percent of total billed charges,
PLATE,9001658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9072.00000,2630.88000,Aetna,First Health,,7420.90,,,,,,,2921.18,7420.90,percent of total billed charges,
PLATE,9001659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
PLATE,9001659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
SCREW,9001660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,943.76,2141.46,percent of total billed charges,
SCREW,9001660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,842.97,2141.46,percent of total billed charges,
TIBIAL TRAY,9004540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,7417.29,16830.35,percent of total billed charges,
TIBIAL TRAY,9004540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,6625.15,16830.35,percent of total billed charges,
SCREW,9004541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,659.79000,191.34000,Aetna,First Health,,539.71,,,,,,,237.85,539.71,percent of total billed charges,
SCREW,9004541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,659.79000,191.34000,Aetna,First Health,,539.71,,,,,,,212.45,539.71,percent of total billed charges,
PLATE,9004542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2162.56000,627.14000,Aetna,First Health,,1768.97,,,,,,,779.60,1768.97,percent of total billed charges,
PLATE,9004542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2162.56000,627.14000,Aetna,First Health,,1768.97,,,,,,,696.34,1768.97,percent of total billed charges,
PLATE,9004543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2403.44000,697.00000,Aetna,First Health,,1966.01,,,,,,,866.44,1966.01,percent of total billed charges,
PLATE,9004543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2403.44000,697.00000,Aetna,First Health,,1966.01,,,,,,,773.91,1966.01,percent of total billed charges,
STEM,9004544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17095.00000,4957.55000,Aetna,First Health,,13983.71,,,,,,,6162.75,13983.71,percent of total billed charges,
STEM,9004544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17095.00000,4957.55000,Aetna,First Health,,13983.71,,,,,,,5504.59,13983.71,percent of total billed charges,
HUMERAL HEAD,9004545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,9004545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
NAIL,9001702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,2146.24,4869.96,percent of total billed charges,
NAIL,9001702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,1917.03,4869.96,percent of total billed charges,
SCREW,9004604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
SCREW,9004604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
WASHER,9004605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
WASHER,9004605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
PLATE,9001730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2403.60000,697.04000,Aetna,First Health,,1966.14,,,,,,,866.50,1966.14,percent of total billed charges,
PLATE,9001730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2403.60000,697.04000,Aetna,First Health,,1966.14,,,,,,,773.96,1966.14,percent of total billed charges,
WEDGE,9004615,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,10077.00000,2922.33000,Aetna,First Health,,8242.99,,,,,,,3632.76,8242.99,percent of total billed charges,
WEDGE,9004615,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,10077.00000,2922.33000,Aetna,First Health,,8242.99,,,,,,,3244.79,8242.99,percent of total billed charges,
SCREW,9004616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,9004616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
WEDGE,8986778,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,10077.00000,2922.33000,Aetna,First Health,,8242.99,,,,,,,3632.76,8242.99,percent of total billed charges,
WEDGE,8986778,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,10077.00000,2922.33000,Aetna,First Health,,8242.99,,,,,,,3244.79,8242.99,percent of total billed charges,
SCREW,9004635,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,9004635,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
GUIDEWIRE,9004634,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,179.80,407.98,percent of total billed charges,
GUIDEWIRE,9004634,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,160.60,407.98,percent of total billed charges,
NAIL,9004636,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,9004636,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
PLATE,9001837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
PLATE,9001837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
CAGE,9004637,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,9004637,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
NAIL,9004638,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL,9004638,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
PLATE,9001703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,17494.25000,5073.33000,Aetna,First Health,,14310.30,,,,,,,6306.68,14310.30,percent of total billed charges,
PLATE,9001703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,17494.25000,5073.33000,Aetna,First Health,,14310.30,,,,,,,5633.15,14310.30,percent of total billed charges,
SCREW,9001838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SCREW,9001838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
STEM,9001839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,9001839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
PLATE,9001840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,First Health,,7082.24,,,,,,,3121.21,7082.24,percent of total billed charges,
PLATE,9001840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,First Health,,7082.24,,,,,,,2787.88,7082.24,percent of total billed charges,
SCREW,9004717,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,9004717,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SCREW,9004718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,9004718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
NAIL,9004720,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2279.98,5173.44,percent of total billed charges,
NAIL,9004720,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,First Health,,5173.44,,,,,,,2036.49,5173.44,percent of total billed charges,
ROD,9004719,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1580.00000,458.20000,Aetna,First Health,,1292.44,,,,,,,569.59,1292.44,percent of total billed charges,
ROD,9004719,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1580.00000,458.20000,Aetna,First Health,,1292.44,,,,,,,508.76,1292.44,percent of total billed charges,
SPACER,9002018,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
SPACER,9002018,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
SCREW,9002019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,9002019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SPACER,9002020,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
SPACER,9002020,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
PLATE,9002021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4426.00000,1283.54000,Aetna,First Health,,3620.47,,,,,,,1595.57,3620.47,percent of total billed charges,
PLATE,9002021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4426.00000,1283.54000,Aetna,First Health,,3620.47,,,,,,,1425.17,3620.47,percent of total billed charges,
SHEATH,9002022,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,30.28,68.71,percent of total billed charges,
SHEATH,9002022,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,27.05,68.71,percent of total billed charges,
SCREW,9002023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,9002023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,9002024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,9002024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,9002025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,9002025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,9002026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,9002026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,9002027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,9002027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
PLATE,9002028,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5015.50000,1454.50000,Aetna,First Health,,4102.68,,,,,,,1808.09,4102.68,percent of total billed charges,
PLATE,9002028,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5015.50000,1454.50000,Aetna,First Health,,4102.68,,,,,,,1614.99,4102.68,percent of total billed charges,
SCREW,9002029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9002029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
PLATE,9002030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
PLATE,9002030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
POLY INSERT,9004818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3360.22,7624.58,percent of total billed charges,
POLY INSERT,9004818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3001.36,7624.58,percent of total billed charges,
NAIL,9004819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,9004819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
PLATE SPINAL,9004820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
PLATE SPINAL,9004820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
NAIL,9004821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6501.71000,1885.50000,Aetna,First Health,,5318.40,,,,,,,2343.87,5318.40,percent of total billed charges,
NAIL,9004821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6501.71000,1885.50000,Aetna,First Health,,5318.40,,,,,,,2093.55,5318.40,percent of total billed charges,
BRACE,9004822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5120.33000,1484.90000,Aetna,First Health,,4188.43,,,,,,,1845.88,4188.43,percent of total billed charges,
BRACE,9004822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5120.33000,1484.90000,Aetna,First Health,,4188.43,,,,,,,1648.75,4188.43,percent of total billed charges,
SCREW,9004823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,9004823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,9004824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
SCREW,9004824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,9006092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,964.29,2188.05,percent of total billed charges,
SCREW,9006092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,861.31,2188.05,percent of total billed charges,
PLATE,8438617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5941.78000,1723.12000,Aetna,First Health,,4860.38,,,,,,,2142.01,4860.38,percent of total billed charges,
PLATE,8438617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5941.78000,1723.12000,Aetna,First Health,,4860.38,,,,,,,1913.25,4860.38,percent of total billed charges,
SCREW,9004889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9004889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,9004890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,9004890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SPACER,9004891,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
SPACER,9004891,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
SCREW,9006180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,9006180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
STEM,9004908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,5497.62,12474.50,percent of total billed charges,
STEM,9004908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,First Health,,12474.50,,,,,,,4910.50,12474.50,percent of total billed charges,
CATHETER BALLOON,8966268,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
CATHETER BALLOON,8966268,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
STENT,8858301,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858301,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858302,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858302,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
MESH,9006217,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5462.80000,1584.21000,Aetna,First Health,,4468.57,,,,,,,1969.34,4468.57,percent of total billed charges,
MESH,9006217,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5462.80000,1584.21000,Aetna,First Health,,4468.57,,,,,,,1759.02,4468.57,percent of total billed charges,
ROD,9006250,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2512.00000,728.48000,Aetna,First Health,,2054.82,,,,,,,905.58,2054.82,percent of total billed charges,
ROD,9006250,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2512.00000,728.48000,Aetna,First Health,,2054.82,,,,,,,808.86,2054.82,percent of total billed charges,
SCREW,9006251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,9006251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
STAPLE,9006247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8634.00000,2503.86000,Aetna,First Health,,7062.61,,,,,,,3112.56,7062.61,percent of total billed charges,
STAPLE,9006247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8634.00000,2503.86000,Aetna,First Health,,7062.61,,,,,,,2780.15,7062.61,percent of total billed charges,
SCREW,9006248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,688.55,1562.38,percent of total billed charges,
SCREW,9006248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,First Health,,1562.38,,,,,,,615.02,1562.38,percent of total billed charges,
PLATE,9006249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,2170.21,4924.36,percent of total billed charges,
PLATE,9006249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,1938.44,4924.36,percent of total billed charges,
CAGE,9006282,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,9006282,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
GUIDEWIRE,9006283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1468.00000,425.72000,Aetna,First Health,,1200.82,,,,,,,529.21,1200.82,percent of total billed charges,
GUIDEWIRE,9006283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1468.00000,425.72000,Aetna,First Health,,1200.82,,,,,,,472.70,1200.82,percent of total billed charges,
GUIDEWIRE,9006284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,352.03,798.78,percent of total billed charges,
GUIDEWIRE,9006284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,314.43,798.78,percent of total billed charges,
SCREW,9006285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1276.00000,370.04000,Aetna,First Health,,1043.77,,,,,,,460.00,1043.77,percent of total billed charges,
SCREW,9006285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1276.00000,370.04000,Aetna,First Health,,1043.77,,,,,,,410.87,1043.77,percent of total billed charges,
SCREW,9006286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1276.00000,370.04000,Aetna,First Health,,1043.77,,,,,,,460.00,1043.77,percent of total billed charges,
SCREW,9006286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1276.00000,370.04000,Aetna,First Health,,1043.77,,,,,,,410.87,1043.77,percent of total billed charges,
SCREW,9006287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9006287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW,9006288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9006288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW,9006289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9006289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
STENT,8858326,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858326,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
PLATE,9006369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4426.45000,1283.67000,Aetna,First Health,,3620.84,,,,,,,1595.74,3620.84,percent of total billed charges,
PLATE,9006369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4426.45000,1283.67000,Aetna,First Health,,3620.84,,,,,,,1425.32,3620.84,percent of total billed charges,
PLATE,9006370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE,9006370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
SCREW,9006371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,9006371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,9006372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,9006372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE,9006373,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE,9006373,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
SCREW,9006374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SCREW,9006374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
PLATE,9006375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
PLATE,9006375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
SPACER,9006376,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20125.00000,5836.25000,Aetna,First Health,,16462.25,,,,,,,7255.06,16462.25,percent of total billed charges,
SPACER,9006376,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20125.00000,5836.25000,Aetna,First Health,,16462.25,,,,,,,6480.25,16462.25,percent of total billed charges,
SCREW,9006365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9006365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9006366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9006366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9006367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9006367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9006368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9006368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9005106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,9005106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW,9005107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9005107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,9005108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9005108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,9005109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9005109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,9005104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9005104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9005110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,9005110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,9005247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,9005247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
MANUAL,8400819,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
MANUAL,8400819,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
INSERT,8986398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8986398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
TISSUE,8917152,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3084.24000,894.43000,Aetna,First Health,,2522.91,,,,,,,1111.87,2522.91,percent of total billed charges,
TISSUE,8917152,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3084.24000,894.43000,Aetna,First Health,,2522.91,,,,,,,993.13,2522.91,percent of total billed charges,
STYLET KIT,8784152,CDM,278,RC,A4212,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
STYLET KIT,8784152,CDM,278,RC,A4212,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,47.33,120.25,percent of total billed charges,
GUIDEWIRE,8926092,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,8926092,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
PLATE,8455930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3984.75000,1155.58000,Aetna,First Health,,3259.53,,,,,,,1436.50,3259.53,percent of total billed charges,
PLATE,8455930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3984.75000,1155.58000,Aetna,First Health,,3259.53,,,,,,,1283.09,3259.53,percent of total billed charges,
PLATE SPINAL,8459754,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1291.62,2930.77,percent of total billed charges,
PLATE SPINAL,8459754,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,First Health,,2930.77,,,,,,,1153.68,2930.77,percent of total billed charges,
ROD SPINAL,8368315,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
ROD SPINAL,8368315,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
STENT,8858290,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858290,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858291,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858291,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858292,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858292,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858293,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858293,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858294,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858294,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858295,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858295,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858296,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858296,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858297,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858297,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858298,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858298,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858303,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858303,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858304,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858304,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858305,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858305,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858307,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858307,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858308,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858308,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858310,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858310,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858314,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858314,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858315,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858315,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858316,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858316,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858317,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858317,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858318,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858318,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858319,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858319,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858320,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858320,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858321,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858321,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858322,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858322,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858323,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858323,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STENT,8858324,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
STENT,8858324,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW,8972892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8972892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PLATE,8986582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4965.73000,1440.06000,Aetna,First Health,,4061.97,,,,,,,1790.15,4061.97,percent of total billed charges,
PLATE,8986582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4965.73000,1440.06000,Aetna,First Health,,4061.97,,,,,,,1598.97,4061.97,percent of total billed charges,
SCREW,8990214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SCREW,8990214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
STENT,8996165,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
STENT,8996165,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
STEM,8994419,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12334.50000,3577.00000,Aetna,First Health,,10089.62,,,,,,,4446.59,10089.62,percent of total billed charges,
STEM,8994419,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12334.50000,3577.00000,Aetna,First Health,,10089.62,,,,,,,3971.71,10089.62,percent of total billed charges,
GUIDEWIRE,8972888,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
GUIDEWIRE,8972888,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
GUIDEWIRE,8972889,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
GUIDEWIRE,8972889,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
ANCHOR SUTURE,8999064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ANCHOR SUTURE,8999064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
SCREW,8995975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,8995975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
IMPLANT PATELLAR,8995978,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
IMPLANT PATELLAR,8995978,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
STAPLE,9002396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9479.25000,2748.98000,Aetna,First Health,,7754.03,,,,,,,3417.27,7754.03,percent of total billed charges,
STAPLE,9002396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9479.25000,2748.98000,Aetna,First Health,,7754.03,,,,,,,3052.32,7754.03,percent of total billed charges,
SCREW,8413969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
SCREW,8413969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
BASEPLATE,9003634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.40000,1439.68000,Aetna,First Health,,4060.88,,,,,,,1789.67,4060.88,percent of total billed charges,
BASEPLATE,9003634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.40000,1439.68000,Aetna,First Health,,4060.88,,,,,,,1598.54,4060.88,percent of total billed charges,
PLATE,9003914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3644.38,8269.37,percent of total billed charges,
PLATE,9003914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,First Health,,8269.37,,,,,,,3255.18,8269.37,percent of total billed charges,
TALUS,8995692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,37237.50000,10798.88000,Aetna,First Health,,30460.28,,,,,,,13424.12,30460.28,percent of total billed charges,
TALUS,8995692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,37237.50000,10798.88000,Aetna,First Health,,30460.28,,,,,,,11990.48,30460.28,percent of total billed charges,
NAIL,9006659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
NAIL,9006659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
CAGE,9006640,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,9006640,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
GLENOID,9005307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
GLENOID,9005307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
FEMORAL CONE,9005308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
FEMORAL CONE,9005308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
HEAD FEMORAL,9005309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,9005309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
SCREW,9006718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9006718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
CAGE,9006868,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,9006868,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
LINER,9006865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5299.70000,1536.91000,Aetna,First Health,,4335.15,,,,,,,1910.54,4335.15,percent of total billed charges,
LINER,9006865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5299.70000,1536.91000,Aetna,First Health,,4335.15,,,,,,,1706.50,4335.15,percent of total billed charges,
LINER,9006866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5299.70000,1536.91000,Aetna,First Health,,4335.15,,,,,,,1910.54,4335.15,percent of total billed charges,
LINER,9006866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5299.70000,1536.91000,Aetna,First Health,,4335.15,,,,,,,1706.50,4335.15,percent of total billed charges,
LINER,9006867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
LINER,9006867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
COMPONENT FEMORAL,9005616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,9005616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
ROD,9005617,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
ROD,9005617,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ROD,9005618,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2700.00000,783.00000,Aetna,First Health,,2208.60,,,,,,,973.35,2208.60,percent of total billed charges,
ROD,9005618,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2700.00000,783.00000,Aetna,First Health,,2208.60,,,,,,,869.40,2208.60,percent of total billed charges,
ROD,9005619,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2700.00000,783.00000,Aetna,First Health,,2208.60,,,,,,,973.35,2208.60,percent of total billed charges,
ROD,9005619,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2700.00000,783.00000,Aetna,First Health,,2208.60,,,,,,,869.40,2208.60,percent of total billed charges,
SHELL,9008099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
SHELL,9008099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
PLATE,9008100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10629.00000,3082.41000,Aetna,First Health,,8694.52,,,,,,,3831.75,8694.52,percent of total billed charges,
PLATE,9008100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10629.00000,3082.41000,Aetna,First Health,,8694.52,,,,,,,3422.54,8694.52,percent of total billed charges,
SCREW,9008101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,9008101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
NAIL,9008103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL,9008103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
SCREW,9008104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9008104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
LINER,9008105,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
LINER,9008105,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SLEEVE FEMORAL,9005674,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,109.87,249.29,percent of total billed charges,
SLEEVE FEMORAL,9005674,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,98.13,249.29,percent of total billed charges,
SCREW,9005697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,498.93,1132.11,percent of total billed charges,
SCREW,9005697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,445.65,1132.11,percent of total billed charges,
PLATE,9005698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11628.00000,3372.12000,Aetna,First Health,,9511.70,,,,,,,4191.89,9511.70,percent of total billed charges,
PLATE,9005698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11628.00000,3372.12000,Aetna,First Health,,9511.70,,,,,,,3744.22,9511.70,percent of total billed charges,
HEAD HUMERAL,9005699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,7018.94,15926.46,percent of total billed charges,
HEAD HUMERAL,9005699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,6269.34,15926.46,percent of total billed charges,
SCREW,9005700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,584.01,1325.16,percent of total billed charges,
SCREW,9005700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,521.64,1325.16,percent of total billed charges,
GLENOID,9005701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GLENOID,9005701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
INSERT,9005702,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,9005702,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
CAGE,9005703,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,9005703,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
NAIL,9005704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,9005704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
GLENOSPHERE,9008228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
GLENOSPHERE,9008228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
STEM,9005744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,9005744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
COMPONENT MEDIAL,9005742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
COMPONENT MEDIAL,9005742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
STENT,9005743,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT,9005743,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
PLATE,9010119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12540.00000,3636.60000,Aetna,First Health,,10257.72,,,,,,,4520.67,10257.72,percent of total billed charges,
PLATE,9010119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12540.00000,3636.60000,Aetna,First Health,,10257.72,,,,,,,4037.88,10257.72,percent of total billed charges,
CATHETER PTA,9010120,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER PTA,9010120,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
COIL,9012139,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3939.25000,1142.38000,Aetna,First Health,,3222.31,,,,,,,1420.10,3222.31,percent of total billed charges,
COIL,9012139,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3939.25000,1142.38000,Aetna,First Health,,3222.31,,,,,,,1268.44,3222.31,percent of total billed charges,
HUMERAL HEAD,9010159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,9010159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
GLENOID,9010160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
GLENOID,9010160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
STEM,9010161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,9010161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW,9010162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,9010162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
INSERT HUMERAL,9010166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT HUMERAL,9010166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
STEM FEMORAL,9010167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM FEMORAL,9010167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
SCREW,9010165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,9010165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
ANCHOR,9010118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5947.41000,1724.75000,Aetna,First Health,,4864.98,,,,,,,2144.04,4864.98,percent of total billed charges,
ANCHOR,9010118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5947.41000,1724.75000,Aetna,First Health,,4864.98,,,,,,,1915.07,4864.98,percent of total billed charges,
SPACER,9012284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
SPACER,9012284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
MESH,9012282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.70000,2383.71000,Aetna,First Health,,6723.71,,,,,,,2963.20,6723.71,percent of total billed charges,
MESH,9012282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.70000,2383.71000,Aetna,First Health,,6723.71,,,,,,,2646.74,6723.71,percent of total billed charges,
SCREW,9012280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,210.00000,60.90000,Aetna,First Health,,171.78,,,,,,,75.70,171.78,percent of total billed charges,
SCREW,9012280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,First Health,,171.78,,,,,,,67.62,171.78,percent of total billed charges,
STEM,9012279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM,9012279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
BASEPLATE,9010320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
BASEPLATE,9010320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
COMPONENT FEMORAL,9010321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9010321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
SCREW,9010322,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,9010322,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
SCREW,9010323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
SCREW,9010323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
NAIL,9010324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL,9010324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
PIN,9010325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,764.87000,221.81000,Aetna,First Health,,625.66,,,,,,,275.74,625.66,percent of total billed charges,
PIN,9010325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,764.87000,221.81000,Aetna,First Health,,625.66,,,,,,,246.29,625.66,percent of total billed charges,
HUMERAL SHELL,9010328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
HUMERAL SHELL,9010328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
SCREW,9010326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1370.40000,397.42000,Aetna,First Health,,1120.99,,,,,,,494.03,1120.99,percent of total billed charges,
SCREW,9010326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1370.40000,397.42000,Aetna,First Health,,1120.99,,,,,,,441.27,1120.99,percent of total billed charges,
SCREW,9010327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,9010327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
STEM,9010329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,9010329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
GUIDEWIRE,9004901,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,201.16,456.44,percent of total billed charges,
GUIDEWIRE,9004901,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,179.68,456.44,percent of total billed charges,
GUIDEWIRE,9004902,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,639.47000,185.45000,Aetna,First Health,,523.09,,,,,,,230.53,523.09,percent of total billed charges,
GUIDEWIRE,9004902,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,639.47000,185.45000,Aetna,First Health,,523.09,,,,,,,205.91,523.09,percent of total billed charges,
BALLOON,9008184,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,First Health,,2814.33,,,,,,,1240.30,2814.33,percent of total billed charges,
BALLOON,9008184,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,First Health,,2814.33,,,,,,,1107.84,2814.33,percent of total billed charges,
BALLOON,9008185,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,First Health,,2814.33,,,,,,,1240.30,2814.33,percent of total billed charges,
BALLOON,9008185,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,First Health,,2814.33,,,,,,,1107.84,2814.33,percent of total billed charges,
SCREW,9012337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,9012337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
ROD SPINAL,9012338,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,9012338,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
INSERT,9012339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,9012339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
COMPONENT TIBIAL,9012340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
COMPONENT TIBIAL,9012340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
SCREW,9012387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SCREW,9012387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
PLATE,9010383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8799.00000,2551.71000,Aetna,First Health,,7197.58,,,,,,,3172.04,7197.58,percent of total billed charges,
PLATE,9010383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8799.00000,2551.71000,Aetna,First Health,,7197.58,,,,,,,2833.28,7197.58,percent of total billed charges,
COMPONENT FEMORAL,9010384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
COMPONENT FEMORAL,9010384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
SCREW,9010391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,486.57,1104.07,percent of total billed charges,
SCREW,9010391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,First Health,,1104.07,,,,,,,434.61,1104.07,percent of total billed charges,
HOOK SPINAL SM,9010392,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,2384.00000,691.36000,Aetna,First Health,,1950.11,,,,,,,859.43,1950.11,percent of total billed charges,
HOOK SPINAL SM,9010392,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,2384.00000,691.36000,Aetna,First Health,,1950.11,,,,,,,767.65,1950.11,percent of total billed charges,
HOOK SPINAL LG,9010393,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,2384.00000,691.36000,Aetna,First Health,,1950.11,,,,,,,859.43,1950.11,percent of total billed charges,
HOOK SPINAL LG,9010393,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,2384.00000,691.36000,Aetna,First Health,,1950.11,,,,,,,767.65,1950.11,percent of total billed charges,
STEM HUMERAL,8926390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17090.00000,4956.10000,Aetna,First Health,,13979.62,,,,,,,6160.94,13979.62,percent of total billed charges,
STEM HUMERAL,8926390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17090.00000,4956.10000,Aetna,First Health,,13979.62,,,,,,,5502.98,13979.62,percent of total billed charges,
SCREW,9012408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,9012408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,9012409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,9012409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
SCREW,9012410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,9012410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
SCREW,9012411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,9012411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
PLATE,9012412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9164.25000,2657.63000,Aetna,First Health,,7496.36,,,,,,,3303.71,7496.36,percent of total billed charges,
PLATE,9012412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9164.25000,2657.63000,Aetna,First Health,,7496.36,,,,,,,2950.89,7496.36,percent of total billed charges,
GUIDE PIN,9010416,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
GUIDE PIN,9010416,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
PLATE,9012416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,458.41,1040.17,percent of total billed charges,
PLATE,9012416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,409.46,1040.17,percent of total billed charges,
PLATE,9012417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,458.41,1040.17,percent of total billed charges,
PLATE,9012417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,First Health,,1040.17,,,,,,,409.46,1040.17,percent of total billed charges,
COMPONENT FEMORAL,9010449,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9010449,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
ANCHOR,9010450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,877.82,1991.83,percent of total billed charges,
ANCHOR,9010450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,First Health,,1991.83,,,,,,,784.07,1991.83,percent of total billed charges,
COMPONENT FEMORAL,9010455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,9010455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
INSERT,9010457,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,9010457,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
BASEPLATE,9010456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2277.46,5167.72,percent of total billed charges,
BASEPLATE,9010456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,First Health,,5167.72,,,,,,,2034.23,5167.72,percent of total billed charges,
STEM,9010474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24312.50000,7050.62000,Aetna,First Health,,19887.62,,,,,,,8764.66,19887.62,percent of total billed charges,
STEM,9010474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24312.50000,7050.62000,Aetna,First Health,,19887.62,,,,,,,7828.62,19887.62,percent of total billed charges,
HUMERAL TRAY,9010458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
HUMERAL TRAY,9010458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
STEM,9010453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,9010453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,9010454,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,5331.80,12098.22,percent of total billed charges,
CAGE,9010454,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,First Health,,12098.22,,,,,,,4762.38,12098.22,percent of total billed charges,
MESH,9012578,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,13734.00000,3982.86000,Aetna,First Health,,11234.41,,,,,,,4951.11,11234.41,percent of total billed charges,
MESH,9012578,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,13734.00000,3982.86000,Aetna,First Health,,11234.41,,,,,,,4422.35,11234.41,percent of total billed charges,
COMPONENT FEMORAL,9012466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9012466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
COMPONENT TIBIAL,9012619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,9012619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
COMPONENT GLENOID,9012620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,1075.11,2439.51,percent of total billed charges,
COMPONENT GLENOID,9012620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,960.29,2439.51,percent of total billed charges,
PLATE FIBULA,9010618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,First Health,,7082.24,,,,,,,3121.21,7082.24,percent of total billed charges,
PLATE FIBULA,9010618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,First Health,,7082.24,,,,,,,2787.88,7082.24,percent of total billed charges,
COMPONENT FEMORAL,9010619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9010619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
SCREW,9012649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9012649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
CAGE,9012650,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE,9012650,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,9012651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,9012651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW,9012653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9012653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
NAIL,9012654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL,9012654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
ROD CONNECTOR,8282171,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1528.00000,443.12000,Aetna,First Health,,1249.90,,,,,,,550.84,1249.90,percent of total billed charges,
ROD CONNECTOR,8282171,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1528.00000,443.12000,Aetna,First Health,,1249.90,,,,,,,492.02,1249.90,percent of total billed charges,
PLATE FIBULA,9012665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8799.00000,2551.71000,Aetna,First Health,,7197.58,,,,,,,3172.04,7197.58,percent of total billed charges,
PLATE FIBULA,9012665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8799.00000,2551.71000,Aetna,First Health,,7197.58,,,,,,,2833.28,7197.58,percent of total billed charges,
COMPONENT PATELLA,8973809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT PATELLA,8973809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
GASTRONOMY PLACEMENT,8413594,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,753.71000,218.58000,Aetna,First Health,,616.53,,,,,,,271.71,616.53,percent of total billed charges,
GASTRONOMY PLACEMENT,8413594,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,753.71000,218.58000,Aetna,First Health,,616.53,,,,,,,242.69,616.53,percent of total billed charges,
COMPONENT FEMORAL,9012705,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9012705,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
COMPONENT TIBIAL,9012706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,9012706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
COMPONENT TIBIAL,9012707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,9012707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
PLATE,9012708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8157.00000,2365.53000,Aetna,First Health,,6672.43,,,,,,,2940.60,6672.43,percent of total billed charges,
PLATE,9012708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8157.00000,2365.53000,Aetna,First Health,,6672.43,,,,,,,2626.55,6672.43,percent of total billed charges,
PLATE,9012709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7662.00000,2221.98000,Aetna,First Health,,6267.52,,,,,,,2762.15,6267.52,percent of total billed charges,
PLATE,9012709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7662.00000,2221.98000,Aetna,First Health,,6267.52,,,,,,,2467.16,6267.52,percent of total billed charges,
SCREW,9012710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,854.10000,247.69000,Aetna,First Health,,698.65,,,,,,,307.90,698.65,percent of total billed charges,
SCREW,9012710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,854.10000,247.69000,Aetna,First Health,,698.65,,,,,,,275.02,698.65,percent of total billed charges,
SCREW,9012711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,809.78000,234.84000,Aetna,First Health,,662.40,,,,,,,291.93,662.40,percent of total billed charges,
SCREW,9012711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,809.78000,234.84000,Aetna,First Health,,662.40,,,,,,,260.75,662.40,percent of total billed charges,
SCREW,9012712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9012712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE,9012681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11007.00000,3192.03000,Aetna,First Health,,9003.73,,,,,,,3968.02,9003.73,percent of total billed charges,
PLATE,9012681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11007.00000,3192.03000,Aetna,First Health,,9003.73,,,,,,,3544.25,9003.73,percent of total billed charges,
CAGE,9012744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4618.01,10478.58,percent of total billed charges,
CAGE,9012744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,First Health,,10478.58,,,,,,,4124.82,10478.58,percent of total billed charges,
JOINT,9012745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3406.72,7730.10,percent of total billed charges,
JOINT,9012745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,First Health,,7730.10,,,,,,,3042.90,7730.10,percent of total billed charges,
K WIRE,9012746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,326.52000,94.69000,Aetna,First Health,,267.09,,,,,,,117.71,267.09,percent of total billed charges,
K WIRE,9012746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,326.52000,94.69000,Aetna,First Health,,267.09,,,,,,,105.14,267.09,percent of total billed charges,
K WIRE,9012747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
K WIRE,9012747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
PLATE,9012786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5558.70000,1612.02000,Aetna,First Health,,4547.02,,,,,,,2003.91,4547.02,percent of total billed charges,
PLATE,9012786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5558.70000,1612.02000,Aetna,First Health,,4547.02,,,,,,,1789.90,4547.02,percent of total billed charges,
ROD,9012814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD,9012814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
BONE MATRIX,9012748,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,7368.00000,2136.72000,Aetna,First Health,,6027.02,,,,,,,2656.16,6027.02,percent of total billed charges,
BONE MATRIX,9012748,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,7368.00000,2136.72000,Aetna,First Health,,6027.02,,,,,,,2372.50,6027.02,percent of total billed charges,
SCREW,9012749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,498.93,1132.11,percent of total billed charges,
SCREW,9012749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,445.65,1132.11,percent of total billed charges,
SCREW,9012841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,1061.31,2408.19,percent of total billed charges,
SCREW,9012841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,947.97,2408.19,percent of total billed charges,
K WIRE,9012840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
K WIRE,9012840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
PLATE,9012842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,First Health,,7565.68,,,,,,,3334.26,7565.68,percent of total billed charges,
PLATE,9012842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,First Health,,7565.68,,,,,,,2978.18,7565.68,percent of total billed charges,
SCREW,9012845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,330.96,750.96,percent of total billed charges,
SCREW,9012845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,First Health,,750.96,,,,,,,295.61,750.96,percent of total billed charges,
SCREW,9012846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9012846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
INSERT,9010894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,9010894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
COMPONENT TIBIAL,9010896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
COMPONENT TIBIAL,9010896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
STEM,9010897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,9010897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
SCREW,9013314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,9013314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
PLATE,9013315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8052.00000,2335.08000,Aetna,First Health,,6586.54,,,,,,,2902.75,6586.54,percent of total billed charges,
PLATE,9013315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8052.00000,2335.08000,Aetna,First Health,,6586.54,,,,,,,2592.74,6586.54,percent of total billed charges,
INSERT,9013316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9013316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,9010926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,1061.31,2408.19,percent of total billed charges,
SCREW,9010926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,947.97,2408.19,percent of total billed charges,
PIN,9010927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,326.52000,94.69000,Aetna,First Health,,267.09,,,,,,,117.71,267.09,percent of total billed charges,
PIN,9010927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,326.52000,94.69000,Aetna,First Health,,267.09,,,,,,,105.14,267.09,percent of total billed charges,
SCREW,9010928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,1061.31,2408.19,percent of total billed charges,
SCREW,9010928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,947.97,2408.19,percent of total billed charges,
PLATE,9010962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
PLATE,9010962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,9013355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
SCREW,9013355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
SCREW,9013356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
SCREW,9013356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
SCREW,9013357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
SCREW,9013357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
SCREW,9013369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
SCREW,9013369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
SCREW,9013379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9013379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
COMPONENT FEMORAL,9013380,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9013380,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
COMPONENT TIBIAL,9013381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,9013381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
STEM,9013403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7460.70000,2163.60000,Aetna,First Health,,6102.85,,,,,,,2689.58,6102.85,percent of total billed charges,
STEM,9013403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7460.70000,2163.60000,Aetna,First Health,,6102.85,,,,,,,2402.35,6102.85,percent of total billed charges,
STEM,9013404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8397.90000,2435.39000,Aetna,First Health,,6869.48,,,,,,,3027.44,6869.48,percent of total billed charges,
STEM,9013404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8397.90000,2435.39000,Aetna,First Health,,6869.48,,,,,,,2704.12,6869.48,percent of total billed charges,
STEM,9013405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18371.00000,5327.59000,Aetna,First Health,,15027.48,,,,,,,6622.75,15027.48,percent of total billed charges,
STEM,9013405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18371.00000,5327.59000,Aetna,First Health,,15027.48,,,,,,,5915.46,15027.48,percent of total billed charges,
CONNECTOR,9013406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12084.00000,3504.36000,Aetna,First Health,,9884.71,,,,,,,4356.28,9884.71,percent of total billed charges,
CONNECTOR,9013406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12084.00000,3504.36000,Aetna,First Health,,9884.71,,,,,,,3891.05,9884.71,percent of total billed charges,
NAIL,9013407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13635.00000,3954.15000,Aetna,First Health,,11153.43,,,,,,,4915.42,11153.43,percent of total billed charges,
NAIL,9013407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13635.00000,3954.15000,Aetna,First Health,,11153.43,,,,,,,4390.47,11153.43,percent of total billed charges,
CONNECTOR,9013408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12084.00000,3504.36000,Aetna,First Health,,9884.71,,,,,,,4356.28,9884.71,percent of total billed charges,
CONNECTOR,9013408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12084.00000,3504.36000,Aetna,First Health,,9884.71,,,,,,,3891.05,9884.71,percent of total billed charges,
CAGE,9011127,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
CAGE,9011127,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
CAGE,9011128,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
CAGE,9011128,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
FEMORAL STEM,9013398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7326.00000,2124.54000,Aetna,First Health,,5992.67,,,,,,,2641.02,5992.67,percent of total billed charges,
FEMORAL STEM,9013398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7326.00000,2124.54000,Aetna,First Health,,5992.67,,,,,,,2358.97,5992.67,percent of total billed charges,
STEM,9013399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15425.00000,4473.25000,Aetna,First Health,,12617.65,,,,,,,5560.71,12617.65,percent of total billed charges,
STEM,9013399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15425.00000,4473.25000,Aetna,First Health,,12617.65,,,,,,,4966.85,12617.65,percent of total billed charges,
ROD,9013400,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD,9013400,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
BONE GRAFT,9013409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7620.00000,2209.80000,Aetna,First Health,,6233.16,,,,,,,2747.01,6233.16,percent of total billed charges,
BONE GRAFT,9013409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7620.00000,2209.80000,Aetna,First Health,,6233.16,,,,,,,2453.64,6233.16,percent of total billed charges,
BONE GRAFT,9013401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12090.00000,3506.10000,Aetna,First Health,,9889.62,,,,,,,4358.44,9889.62,percent of total billed charges,
BONE GRAFT,9013401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12090.00000,3506.10000,Aetna,First Health,,9889.62,,,,,,,3892.98,9889.62,percent of total billed charges,
NAIL,9011228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL,9011228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
SCREW,9011229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9011229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
ENDCAP,9011230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1294.88000,375.52000,Aetna,First Health,,1059.21,,,,,,,466.80,1059.21,percent of total billed charges,
ENDCAP,9011230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1294.88000,375.52000,Aetna,First Health,,1059.21,,,,,,,416.95,1059.21,percent of total billed charges,
SCREW,9011231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,9011231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
INSERT,9011232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13543.32000,3927.56000,Aetna,First Health,,11078.44,,,,,,,4882.37,11078.44,percent of total billed charges,
INSERT,9011232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13543.32000,3927.56000,Aetna,First Health,,11078.44,,,,,,,4360.95,11078.44,percent of total billed charges,
SPACER,9011233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5293.72000,1535.18000,Aetna,First Health,,4330.26,,,,,,,1908.39,4330.26,percent of total billed charges,
SPACER,9011233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5293.72000,1535.18000,Aetna,First Health,,4330.26,,,,,,,1704.58,4330.26,percent of total billed charges,
FEMORAL COMPONENT,9011234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25606.63000,7425.92000,Aetna,First Health,,20946.22,,,,,,,9231.19,20946.22,percent of total billed charges,
FEMORAL COMPONENT,9011234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25606.63000,7425.92000,Aetna,First Health,,20946.22,,,,,,,8245.33,20946.22,percent of total billed charges,
STEM,9011235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,First Health,,5369.19,,,,,,,2366.25,5369.19,percent of total billed charges,
STEM,9011235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,First Health,,5369.19,,,,,,,2113.54,5369.19,percent of total billed charges,
TIBIAL INSERT,9011236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
TIBIAL INSERT,9011236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT TIBIAL,9011237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9011237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT TIBIAL,9011238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9011238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CATHETER PTA,9011240,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER PTA,9011240,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
ANCHOR,9011241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,First Health,,2180.79,,,,,,,961.09,2180.79,percent of total billed charges,
ANCHOR,9011241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,First Health,,2180.79,,,,,,,858.45,2180.79,percent of total billed charges,
CAGE,9011239,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,9011239,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
HUMERAL HEAD,9013476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,9013476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
INSERT TIBIAL,9013477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9013477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
BASEPLATE,9011203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8265.00000,2396.85000,Aetna,First Health,,6760.77,,,,,,,2979.53,6760.77,percent of total billed charges,
BASEPLATE,9011203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8265.00000,2396.85000,Aetna,First Health,,6760.77,,,,,,,2661.33,6760.77,percent of total billed charges,
CATHETER PTA,9011325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
CATHETER PTA,9011325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CATHETER BALLOON,8495925,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,277.40,629.45,percent of total billed charges,
CATHETER BALLOON,8495925,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,First Health,,629.45,,,,,,,247.78,629.45,percent of total billed charges,
ROD,8417924,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3610.05,8191.45,percent of total billed charges,
ROD,8417924,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,First Health,,8191.45,,,,,,,3224.51,8191.45,percent of total billed charges,
SCREW,8429750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,8429750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,8435931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,8435931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
INSERT,8437307,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,8437307,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
LINER,8523933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6693.75000,1941.19000,Aetna,First Health,,5475.49,,,,,,,2413.10,5475.49,percent of total billed charges,
LINER,8523933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6693.75000,1941.19000,Aetna,First Health,,5475.49,,,,,,,2155.39,5475.49,percent of total billed charges,
PLATE,9004888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9210.00000,2670.90000,Aetna,First Health,,7533.78,,,,,,,3320.20,7533.78,percent of total billed charges,
PLATE,9004888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9210.00000,2670.90000,Aetna,First Health,,7533.78,,,,,,,2965.62,7533.78,percent of total billed charges,
LINER,8453910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
LINER,8453910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
SCREW,9010662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,9010662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
PLATE,9013547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.80000,244.70000,Aetna,First Health,,690.23,,,,,,,304.19,690.23,percent of total billed charges,
PLATE,9013547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.80000,244.70000,Aetna,First Health,,690.23,,,,,,,271.70,690.23,percent of total billed charges,
SHEATH,9013551,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,844.65000,244.95000,Aetna,First Health,,690.92,,,,,,,304.50,690.92,percent of total billed charges,
SHEATH,9013551,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,844.65000,244.95000,Aetna,First Health,,690.92,,,,,,,271.98,690.92,percent of total billed charges,
CONNECTOR,9013552,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
CONNECTOR,9013552,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CONNECTOR,9013553,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
CONNECTOR,9013553,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CAGE,9011344,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE,9011344,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
STEM,9011345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,793.10,1799.60,percent of total billed charges,
STEM,9011345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,First Health,,1799.60,,,,,,,708.40,1799.60,percent of total billed charges,
INTERLOCK CEMENTED,9013554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13552.50000,3930.22000,Aetna,First Health,,11085.94,,,,,,,4885.68,11085.94,percent of total billed charges,
INTERLOCK CEMENTED,9013554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13552.50000,3930.22000,Aetna,First Health,,11085.94,,,,,,,4363.90,11085.94,percent of total billed charges,
SCREW,9013548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,9013548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,9011346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,9011346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,9011347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
SCREW,9011347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
PLATE,9011348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
PLATE,9011348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
PLATE,9013549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9070.20000,2630.36000,Aetna,First Health,,7419.42,,,,,,,3269.81,7419.42,percent of total billed charges,
PLATE,9013549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9070.20000,2630.36000,Aetna,First Health,,7419.42,,,,,,,2920.60,7419.42,percent of total billed charges,
ANCHOR,9013634,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,First Health,,2180.79,,,,,,,961.09,2180.79,percent of total billed charges,
ANCHOR,9013634,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,First Health,,2180.79,,,,,,,858.45,2180.79,percent of total billed charges,
CAGE,9013621,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,9013621,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
TIBIAL TRAY,9013622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
TIBIAL TRAY,9013622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
STEM,9013623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,9013623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,9013624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,9013624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE,9011500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8607.00000,2496.03000,Aetna,First Health,,7040.53,,,,,,,3102.82,7040.53,percent of total billed charges,
PLATE,9011500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8607.00000,2496.03000,Aetna,First Health,,7040.53,,,,,,,2771.45,7040.53,percent of total billed charges,
SCREW,9011501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,113.02,256.44,percent of total billed charges,
SCREW,9011501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,First Health,,256.44,,,,,,,100.95,256.44,percent of total billed charges,
SCREW,9011502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,9011502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
GLENOID,9011503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
GLENOID,9011503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
HUMERAL HEAD,9011504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,9011504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
SCREW,9011505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9011505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW,9011506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9011506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW,9011507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9011507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW,9011508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,518.94000,150.49000,Aetna,First Health,,424.49,,,,,,,187.08,424.49,percent of total billed charges,
SCREW,9011508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,518.94000,150.49000,Aetna,First Health,,424.49,,,,,,,167.10,424.49,percent of total billed charges,
PLATE,9011509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,9011509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,9013837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,9013837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
CONNECTOR,9011537,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,624.39,1416.78,percent of total billed charges,
CONNECTOR,9011537,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,557.70,1416.78,percent of total billed charges,
SCREW,9013831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,9013831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
GUIDEWIRE,9011538,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
GUIDEWIRE,9011538,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,43.95,111.66,percent of total billed charges,
SCREW,9011539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW,9011539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
PLATE,9011540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,9011540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
SCREW,9011541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,9011541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,9011542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,9011542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,9011543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,9011543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,9011544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,9011544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SCREW,9011545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,287.14,651.54,percent of total billed charges,
SCREW,9011545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,First Health,,651.54,,,,,,,256.47,651.54,percent of total billed charges,
SHEATH,9011546,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,962.55000,279.14000,Aetna,First Health,,787.37,,,,,,,347.00,787.37,percent of total billed charges,
SHEATH,9011546,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,962.55000,279.14000,Aetna,First Health,,787.37,,,,,,,309.94,787.37,percent of total billed charges,
CAGE,9013833,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3710.01,8418.28,percent of total billed charges,
CAGE,9013833,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,First Health,,8418.28,,,,,,,3313.80,8418.28,percent of total billed charges,
CONNECTOR,9013832,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1924.00000,557.96000,Aetna,First Health,,1573.83,,,,,,,693.60,1573.83,percent of total billed charges,
CONNECTOR,9013832,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1924.00000,557.96000,Aetna,First Health,,1573.83,,,,,,,619.53,1573.83,percent of total billed charges,
GRAFT VASCULAR,9013859,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1241.07,2816.08,percent of total billed charges,
GRAFT VASCULAR,9013859,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1108.53,2816.08,percent of total billed charges,
GRAFT VASCULAR,9013860,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1241.07,2816.08,percent of total billed charges,
GRAFT VASCULAR,9013860,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1108.53,2816.08,percent of total billed charges,
GRAFT VASCULAR,9013861,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1241.07,2816.08,percent of total billed charges,
GRAFT VASCULAR,9013861,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1108.53,2816.08,percent of total billed charges,
GRAFT VASCULAR,9013862,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1241.07,2816.08,percent of total billed charges,
GRAFT VASCULAR,9013862,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1108.53,2816.08,percent of total billed charges,
GRAFT ENDOVASCULAR,9011547,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,12999.90,29497.69,percent of total billed charges,
GRAFT ENDOVASCULAR,9011547,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,First Health,,29497.69,,,,,,,11611.56,29497.69,percent of total billed charges,
SCREW,9013829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,565.03,1282.10,percent of total billed charges,
SCREW,9013829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,504.69,1282.10,percent of total billed charges,
INSERT,9013942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,9013942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
SCREW,9013941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,9013941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
GLENOID HUMERAL,9013939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
GLENOID HUMERAL,9013939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
ANCHOR,9013949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9022.50000,2616.52000,Aetna,First Health,,7380.40,,,,,,,3252.61,7380.40,percent of total billed charges,
ANCHOR,9013949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9022.50000,2616.52000,Aetna,First Health,,7380.40,,,,,,,2905.24,7380.40,percent of total billed charges,
SHEATH URETERAL,9013943,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,962.55000,279.14000,Aetna,First Health,,787.37,,,,,,,347.00,787.37,percent of total billed charges,
SHEATH URETERAL,9013943,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,962.55000,279.14000,Aetna,First Health,,787.37,,,,,,,309.94,787.37,percent of total billed charges,
SHEATH,9013944,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,844.65000,244.95000,Aetna,First Health,,690.92,,,,,,,304.50,690.92,percent of total billed charges,
SHEATH,9013944,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,844.65000,244.95000,Aetna,First Health,,690.92,,,,,,,271.98,690.92,percent of total billed charges,
SCREW,8617930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1622.28000,470.46000,Aetna,First Health,,1327.03,,,,,,,584.83,1327.03,percent of total billed charges,
SCREW,8617930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1622.28000,470.46000,Aetna,First Health,,1327.03,,,,,,,522.37,1327.03,percent of total billed charges,
DISSECTOR,9006639,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
DISSECTOR,9006639,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
PLATE,9014055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE,9014055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
SCREW,9014056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,254.69,577.92,percent of total billed charges,
SCREW,9014056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,227.49,577.92,percent of total billed charges,
NAIL,9014057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,9014057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
NAIL,9014058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9014058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
CONNECTOR,9014059,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7980.00000,2314.20000,Aetna,First Health,,6527.64,,,,,,,2876.79,6527.64,percent of total billed charges,
CONNECTOR,9014059,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7980.00000,2314.20000,Aetna,First Health,,6527.64,,,,,,,2569.56,6527.64,percent of total billed charges,
SCREW,9014060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1640.28,3721.90,percent of total billed charges,
SCREW,9014060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1465.10,3721.90,percent of total billed charges,
SCREW,9014061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,943.76,2141.46,percent of total billed charges,
SCREW,9014061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,842.97,2141.46,percent of total billed charges,
NAIL,9014062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9014062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
FEMORAL HEAD,9014065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1645.01,3732.64,percent of total billed charges,
FEMORAL HEAD,9014065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,First Health,,3732.64,,,,,,,1469.33,3732.64,percent of total billed charges,
RING LOCKING,9014066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,First Health,,2034.20,,,,,,,896.49,2034.20,percent of total billed charges,
RING LOCKING,9014066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,First Health,,2034.20,,,,,,,800.75,2034.20,percent of total billed charges,
LINER,9014067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3576.63,8115.62,percent of total billed charges,
LINER,9014067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3194.66,8115.62,percent of total billed charges,
SCREW,9014068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9014068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,9014069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9014069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
STEM,9014124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15646.25000,4537.41000,Aetna,First Health,,12798.63,,,,,,,5640.47,12798.63,percent of total billed charges,
STEM,9014124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15646.25000,4537.41000,Aetna,First Health,,12798.63,,,,,,,5038.09,12798.63,percent of total billed charges,
BOLT FIXATION,9014126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1748.32000,507.01000,Aetna,First Health,,1430.13,,,,,,,630.27,1430.13,percent of total billed charges,
BOLT FIXATION,9014126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1748.32000,507.01000,Aetna,First Health,,1430.13,,,,,,,562.96,1430.13,percent of total billed charges,
SPACER,9014128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1766.48000,512.28000,Aetna,First Health,,1444.98,,,,,,,636.82,1444.98,percent of total billed charges,
SPACER,9014128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1766.48000,512.28000,Aetna,First Health,,1444.98,,,,,,,568.81,1444.98,percent of total billed charges,
SCREW,9014130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,First Health,,1308.15,,,,,,,576.51,1308.15,percent of total billed charges,
SCREW,9014130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,First Health,,1308.15,,,,,,,514.94,1308.15,percent of total billed charges,
SCREW,9014131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,First Health,,1308.15,,,,,,,576.51,1308.15,percent of total billed charges,
SCREW,9014131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,First Health,,1308.15,,,,,,,514.94,1308.15,percent of total billed charges,
SHELL,9014132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15006.83000,4351.98000,Aetna,First Health,,12275.59,,,,,,,5409.96,12275.59,percent of total billed charges,
SHELL,9014132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15006.83000,4351.98000,Aetna,First Health,,12275.59,,,,,,,4832.20,12275.59,percent of total billed charges,
INSERT,9014133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11391.93000,3303.66000,Aetna,First Health,,9318.60,,,,,,,4106.79,9318.60,percent of total billed charges,
INSERT,9014133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11391.93000,3303.66000,Aetna,First Health,,9318.60,,,,,,,3668.20,9318.60,percent of total billed charges,
LINER,9014134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10402.77000,3016.80000,Aetna,First Health,,8509.47,,,,,,,3750.20,8509.47,percent of total billed charges,
LINER,9014134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10402.77000,3016.80000,Aetna,First Health,,8509.47,,,,,,,3349.69,8509.47,percent of total billed charges,
FEMUR MODULAR,9014135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19791.55000,5739.55000,Aetna,First Health,,16189.49,,,,,,,7134.85,16189.49,percent of total billed charges,
FEMUR MODULAR,9014135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19791.55000,5739.55000,Aetna,First Health,,16189.49,,,,,,,6372.88,16189.49,percent of total billed charges,
GLENOSPHERE,9014136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
GLENOSPHERE,9014136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
INSERT,9014137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,9014137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
SCREW,9014138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,9014138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
SCREW,9014139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,9014139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,9014140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,9014140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,9014141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,9014141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,9014142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,9014142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
FEMORAL,9014214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1297.08,2943.16,percent of total billed charges,
FEMORAL,9014214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1158.56,2943.16,percent of total billed charges,
FEMORAL CONE,9014215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,4145.39,9406.18,percent of total billed charges,
FEMORAL CONE,9014215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,First Health,,9406.18,,,,,,,3702.68,9406.18,percent of total billed charges,
SCREW,9011795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,First Health,,1308.15,,,,,,,576.51,1308.15,percent of total billed charges,
SCREW,9011795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,First Health,,1308.15,,,,,,,514.94,1308.15,percent of total billed charges,
SCREW,9014225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,254.69,577.92,percent of total billed charges,
SCREW,9014225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,227.49,577.92,percent of total billed charges,
PLATE,9014226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4487.00000,1301.23000,Aetna,First Health,,3670.37,,,,,,,1617.56,3670.37,percent of total billed charges,
PLATE,9014226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4487.00000,1301.23000,Aetna,First Health,,3670.37,,,,,,,1444.81,3670.37,percent of total billed charges,
WEDGE,9014223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
WEDGE,9014223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
INSERT,9014224,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9014224,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ANCHOR,9013830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,First Health,,2180.79,,,,,,,961.09,2180.79,percent of total billed charges,
ANCHOR,9013830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,First Health,,2180.79,,,,,,,858.45,2180.79,percent of total billed charges,
ROD SPINAL,9014237,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,2081.89,4723.95,percent of total billed charges,
ROD SPINAL,9014237,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,1859.55,4723.95,percent of total billed charges,
NAIL,9014262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,9014262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
NAIL,9014263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,9014263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
PLATE,9014264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
PLATE,9014264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
SCREW,9014265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SCREW,9014265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
PLATE,9014266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,892.60,2025.37,percent of total billed charges,
PLATE,9014266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,797.27,2025.37,percent of total billed charges,
SCREW,9014267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,9014267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
NEUROTRANSMITTER,9014316,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,54920.00000,15926.80000,Aetna,First Health,,44924.56,,,,,,,19798.66,44924.56,percent of total billed charges,
NEUROTRANSMITTER,9014316,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,54920.00000,15926.80000,Aetna,First Health,,44924.56,,,,,,,17684.24,44924.56,percent of total billed charges,
BOLT,9014318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BOLT,9014318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,9014319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,2081.89,4723.95,percent of total billed charges,
SCREW,9014319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,1859.55,4723.95,percent of total billed charges,
INSERT,9014347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,9014347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,9011849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,943.76,2141.46,percent of total billed charges,
SCREW,9011849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,842.97,2141.46,percent of total billed charges,
SCREW,9014350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,584.01,1325.16,percent of total billed charges,
SCREW,9014350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,521.64,1325.16,percent of total billed charges,
SCREW,9014351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,9014351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
SCREW,9014352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,9014352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
SHELL,9014366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,9014366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,9016093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9016093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
NAIL,9016094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1480.00000,429.20000,Aetna,First Health,,1210.64,,,,,,,533.54,1210.64,percent of total billed charges,
NAIL,9016094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1480.00000,429.20000,Aetna,First Health,,1210.64,,,,,,,476.56,1210.64,percent of total billed charges,
PLATE,9016095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,744.07,1688.35,percent of total billed charges,
PLATE,9016095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,664.61,1688.35,percent of total billed charges,
PLATE,9016096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1520.41,3449.91,percent of total billed charges,
PLATE,9016096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,First Health,,3449.91,,,,,,,1358.04,3449.91,percent of total billed charges,
TENSIONER,9016097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1595.00000,462.55000,Aetna,First Health,,1304.71,,,,,,,575.00,1304.71,percent of total billed charges,
TENSIONER,9016097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1595.00000,462.55000,Aetna,First Health,,1304.71,,,,,,,513.59,1304.71,percent of total billed charges,
LINER,9016105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,9016105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SHELL,9016106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,9016106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,9014528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5369.00000,1557.01000,Aetna,First Health,,4391.84,,,,,,,1935.52,4391.84,percent of total billed charges,
SCREW,9014528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5369.00000,1557.01000,Aetna,First Health,,4391.84,,,,,,,1728.82,4391.84,percent of total billed charges,
INSERT,9014529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9014529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,9016176,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,9016176,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT,9016175,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,9016175,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
PENILE INFLATABLE,9014587,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,37001.25000,10730.36000,Aetna,First Health,,30267.02,,,,,,,13338.95,30267.02,percent of total billed charges,
PENILE INFLATABLE,9014587,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,37001.25000,10730.36000,Aetna,First Health,,30267.02,,,,,,,11914.40,30267.02,percent of total billed charges,
FEMORAL HEAD,9016178,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9455.34000,2742.05000,Aetna,First Health,,7734.47,,,,,,,3408.65,7734.47,percent of total billed charges,
FEMORAL HEAD,9016178,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9455.34000,2742.05000,Aetna,First Health,,7734.47,,,,,,,3044.62,7734.47,percent of total billed charges,
STEM FEMORAL,9016230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM FEMORAL,9016230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
BASEPLATE,9016232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,2170.21,4924.36,percent of total billed charges,
BASEPLATE,9016232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,1938.44,4924.36,percent of total billed charges,
FEMORAL KNEE,9014678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1270.00000,368.30000,Aetna,First Health,,1038.86,,,,,,,457.83,1038.86,percent of total billed charges,
FEMORAL KNEE,9014678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1270.00000,368.30000,Aetna,First Health,,1038.86,,,,,,,408.94,1038.86,percent of total billed charges,
FEMORAL KNEE,9014679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,629.33000,182.51000,Aetna,First Health,,514.79,,,,,,,226.87,514.79,percent of total billed charges,
FEMORAL KNEE,9014679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,629.33000,182.51000,Aetna,First Health,,514.79,,,,,,,202.64,514.79,percent of total billed charges,
SCREW,9014681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,511.91,1161.56,percent of total billed charges,
SCREW,9014681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,457.24,1161.56,percent of total billed charges,
LINER,9014682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
LINER,9014682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
SCREW,9014674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1724.00000,499.96000,Aetna,First Health,,1410.23,,,,,,,621.50,1410.23,percent of total billed charges,
SCREW,9014674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1724.00000,499.96000,Aetna,First Health,,1410.23,,,,,,,555.13,1410.23,percent of total billed charges,
SCREW,9014675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1724.00000,499.96000,Aetna,First Health,,1410.23,,,,,,,621.50,1410.23,percent of total billed charges,
SCREW,9014675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1724.00000,499.96000,Aetna,First Health,,1410.23,,,,,,,555.13,1410.23,percent of total billed charges,
SCREW,9016308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,254.69,577.92,percent of total billed charges,
SCREW,9016308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,First Health,,577.92,,,,,,,227.49,577.92,percent of total billed charges,
PLATE,9014676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4497.50000,1304.27000,Aetna,First Health,,3678.95,,,,,,,1621.35,3678.95,percent of total billed charges,
PLATE,9014676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4497.50000,1304.27000,Aetna,First Health,,3678.95,,,,,,,1448.19,3678.95,percent of total billed charges,
NAIL,9014698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,9014698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
SCREW,9014752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,9014752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
SCREW,9014753,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,115.16,261.30,percent of total billed charges,
SCREW,9014753,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,First Health,,261.30,,,,,,,102.86,261.30,percent of total billed charges,
SCREW,9014754,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW,9014754,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
CUP EXETER,9014755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1876.22,4257.28,percent of total billed charges,
CUP EXETER,9014755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,First Health,,4257.28,,,,,,,1675.85,4257.28,percent of total billed charges,
STEM FEMORAL,9014756,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM FEMORAL,9014756,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
LINER,9014757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8283.00000,2402.07000,Aetna,First Health,,6775.49,,,,,,,2986.02,6775.49,percent of total billed charges,
LINER,9014757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8283.00000,2402.07000,Aetna,First Health,,6775.49,,,,,,,2667.13,6775.49,percent of total billed charges,
SCREW,9014758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,9014758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,9014700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,1061.31,2408.19,percent of total billed charges,
SCREW,9014700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,947.97,2408.19,percent of total billed charges,
PLATE,9016384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4039.00000,1171.31000,Aetna,First Health,,3303.90,,,,,,,1456.06,3303.90,percent of total billed charges,
PLATE,9016384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4039.00000,1171.31000,Aetna,First Health,,3303.90,,,,,,,1300.56,3303.90,percent of total billed charges,
WASHER,9016385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,920.00,2087.54,percent of total billed charges,
WASHER,9016385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,First Health,,2087.54,,,,,,,821.74,2087.54,percent of total billed charges,
SCREW,9016386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
SCREW,9016386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
COMPONENT,9016387,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT,9016387,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
ANCHOR,9014801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4455.50000,1292.09000,Aetna,First Health,,3644.60,,,,,,,1606.21,3644.60,percent of total billed charges,
ANCHOR,9014801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4455.50000,1292.09000,Aetna,First Health,,3644.60,,,,,,,1434.67,3644.60,percent of total billed charges,
ANCHOR,9014802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4455.50000,1292.09000,Aetna,First Health,,3644.60,,,,,,,1606.21,3644.60,percent of total billed charges,
ANCHOR,9014802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4455.50000,1292.09000,Aetna,First Health,,3644.60,,,,,,,1434.67,3644.60,percent of total billed charges,
SCREW,9014810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,9014810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,9014811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,9014811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,9016454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9016454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
NAIL,9016455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL,9016455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
STEM,9014820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
STEM,9014820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
INSERT TIBIAL,9014821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9014821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
NAIL,9014823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,9014823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
INSERT TIBIAL,9014824,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT TIBIAL,9014824,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE,9016480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2904.16000,842.21000,Aetna,First Health,,2375.60,,,,,,,1046.95,2375.60,percent of total billed charges,
PLATE,9016480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2904.16000,842.21000,Aetna,First Health,,2375.60,,,,,,,935.14,2375.60,percent of total billed charges,
SCREW,9016482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,651.73,1478.81,percent of total billed charges,
SCREW,9016482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,582.12,1478.81,percent of total billed charges,
SCREW,9016483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,9016483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SPACER,9016485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
SPACER,9016485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
PLATE,9016486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,9016486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SPACER,9014858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26000.00000,7540.00000,Aetna,First Health,,21268.00,,,,,,,9373.00,21268.00,percent of total billed charges,
SPACER,9014858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26000.00000,7540.00000,Aetna,First Health,,21268.00,,,,,,,8372.00,21268.00,percent of total billed charges,
SCREW,9014859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,9014859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
LINER,9016520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,9016520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
INSERT,9016522,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,9016522,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
INSERT,9016523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9016523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,9014877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1454.28000,421.74000,Aetna,First Health,,1189.60,,,,,,,524.27,1189.60,percent of total billed charges,
PLATE,9014877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1454.28000,421.74000,Aetna,First Health,,1189.60,,,,,,,468.28,1189.60,percent of total billed charges,
SCREW,9014886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,943.76,2141.46,percent of total billed charges,
SCREW,9014886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,842.97,2141.46,percent of total billed charges,
ROD,9014884,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,2081.89,4723.95,percent of total billed charges,
ROD,9014884,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,1859.55,4723.95,percent of total billed charges,
SCREW,9014885,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,565.03,1282.10,percent of total billed charges,
SCREW,9014885,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,504.69,1282.10,percent of total billed charges,
ROD,9016555,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,2081.89,4723.95,percent of total billed charges,
ROD,9016555,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,1859.55,4723.95,percent of total billed charges,
SCREW,9016556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,9016556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SPACER,9016557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
SPACER,9016557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
SPACER,9016558,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,9816.00,percent of total billed charges,
SPACER,9016558,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,3864.00,9816.00,percent of total billed charges,
CONE FEMORAL,9016559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
CONE FEMORAL,9016559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
SCREW,9014917,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
SCREW,9014917,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
SCREW,9014919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW,9014919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
SCREW,9014920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW,9014920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
CATHETER VERSACROSS,9014932,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1596.11,3621.70,percent of total billed charges,
CATHETER VERSACROSS,9014932,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1425.65,3621.70,percent of total billed charges,
PLATE,9016596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3024.00000,876.96000,Aetna,First Health,,2473.63,,,,,,,1090.15,2473.63,percent of total billed charges,
PLATE,9016596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3024.00000,876.96000,Aetna,First Health,,2473.63,,,,,,,973.73,2473.63,percent of total billed charges,
CONE FEMORAL,9014933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3942.07,8944.83,percent of total billed charges,
CONE FEMORAL,9014933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3521.07,8944.83,percent of total billed charges,
PLATE,9016608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,9016608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
SCREW,9016610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1955.00000,566.95000,Aetna,First Health,,1599.19,,,,,,,704.78,1599.19,percent of total billed charges,
SCREW,9016610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1955.00000,566.95000,Aetna,First Health,,1599.19,,,,,,,629.51,1599.19,percent of total billed charges,
SCREW,9016611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1955.00000,566.95000,Aetna,First Health,,1599.19,,,,,,,704.78,1599.19,percent of total billed charges,
SCREW,9016611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1955.00000,566.95000,Aetna,First Health,,1599.19,,,,,,,629.51,1599.19,percent of total billed charges,
SCREW,9016612,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,1061.31,2408.19,percent of total billed charges,
SCREW,9016612,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,947.97,2408.19,percent of total billed charges,
SCREW,9016613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,1061.31,2408.19,percent of total billed charges,
SCREW,9016613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,947.97,2408.19,percent of total billed charges,
COMPONENT TIBIAL,9016614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
COMPONENT TIBIAL,9016614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
ANCHOR,9016647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3250.45000,942.63000,Aetna,First Health,,2658.87,,,,,,,1171.79,2658.87,percent of total billed charges,
ANCHOR,9016647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3250.45000,942.63000,Aetna,First Health,,2658.87,,,,,,,1046.64,2658.87,percent of total billed charges,
SCREW,9016648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,9016648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
HEAD FEMORAL,9016650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
HEAD FEMORAL,9016650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
STEM,9016652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
STEM,9016652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
SHOULDER PROSTHESIS,9016653,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
SHOULDER PROSTHESIS,9016653,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
SHOULDER PROSTHESIS,9016654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1622.36,3681.25,percent of total billed charges,
SHOULDER PROSTHESIS,9016654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1449.10,3681.25,percent of total billed charges,
GLENOID,9016655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
GLENOID,9016655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
SHOULDER PROSTHESIS,9016657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1622.36,3681.25,percent of total billed charges,
SHOULDER PROSTHESIS,9016657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1449.10,3681.25,percent of total billed charges,
GLENOSPHERE,9016669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
GLENOSPHERE,9016669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
BASEPLATE,9016670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29351.25000,8511.86000,Aetna,First Health,,24009.32,,,,,,,10581.13,24009.32,percent of total billed charges,
BASEPLATE,9016670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29351.25000,8511.86000,Aetna,First Health,,24009.32,,,,,,,9451.10,24009.32,percent of total billed charges,
STENT,9016672,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,993.26,2253.79,percent of total billed charges,
STENT,9016672,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,First Health,,2253.79,,,,,,,887.19,2253.79,percent of total billed charges,
SCREW,9016674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW,9016674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
SCREW,9016675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW,9016675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
SPACER,9016734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
SPACER,9016734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
SPACER,9016735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
SPACER,9016735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
STEM,9016736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,9016736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,9016737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6125.67000,1776.44000,Aetna,First Health,,5010.80,,,,,,,2208.30,5010.80,percent of total billed charges,
STEM,9016737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6125.67000,1776.44000,Aetna,First Health,,5010.80,,,,,,,1972.47,5010.80,percent of total billed charges,
COUPLER FEMORAL,9016738,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4454.14000,1291.70000,Aetna,First Health,,3643.49,,,,,,,1605.72,3643.49,percent of total billed charges,
COUPLER FEMORAL,9016738,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4454.14000,1291.70000,Aetna,First Health,,3643.49,,,,,,,1434.23,3643.49,percent of total billed charges,
STEM,9016739,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,9016739,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
PLATE,9016742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,First Health,,7565.68,,,,,,,3334.26,7565.68,percent of total billed charges,
PLATE,9016742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,First Health,,7565.68,,,,,,,2978.18,7565.68,percent of total billed charges,
SCREW,9016743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,584.01,1325.16,percent of total billed charges,
SCREW,9016743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,521.64,1325.16,percent of total billed charges,
WEDGE,9016740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1238.28,2809.75,percent of total billed charges,
WEDGE,9016740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,First Health,,2809.75,,,,,,,1106.04,2809.75,percent of total billed charges,
COUPLER FEMORAL,9016741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4454.14000,1291.70000,Aetna,First Health,,3643.49,,,,,,,1605.72,3643.49,percent of total billed charges,
COUPLER FEMORAL,9016741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4454.14000,1291.70000,Aetna,First Health,,3643.49,,,,,,,1434.23,3643.49,percent of total billed charges,
PLATE,9016781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5092.50000,1476.82000,Aetna,First Health,,4165.66,,,,,,,1835.85,4165.66,percent of total billed charges,
PLATE,9016781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5092.50000,1476.82000,Aetna,First Health,,4165.66,,,,,,,1639.79,4165.66,percent of total billed charges,
PLATE,9016782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5233.20000,1517.63000,Aetna,First Health,,4280.76,,,,,,,1886.57,4280.76,percent of total billed charges,
PLATE,9016782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5233.20000,1517.63000,Aetna,First Health,,4280.76,,,,,,,1685.09,4280.76,percent of total billed charges,
ANCHOR,9016777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,802.11,1820.05,percent of total billed charges,
ANCHOR,9016777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,716.45,1820.05,percent of total billed charges,
ANCHOR,9016778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
ANCHOR,9016778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,9020086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,9020086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,9020087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,9020087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,9020088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,9020088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
SCREW,9020089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,9020089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
INSERT TIBIAL,9020090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT TIBIAL,9020090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SHEATH,9020084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.75000,192.49000,Aetna,First Health,,542.95,,,,,,,239.28,542.95,percent of total billed charges,
SHEATH,9020084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.75000,192.49000,Aetna,First Health,,542.95,,,,,,,213.73,542.95,percent of total billed charges,
SCREW,9020091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9020091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE,9018153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.88000,578.52000,Aetna,First Health,,1631.81,,,,,,,719.15,1631.81,percent of total billed charges,
PLATE,9018153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.88000,578.52000,Aetna,First Health,,1631.81,,,,,,,642.35,1631.81,percent of total billed charges,
STENT,9020138,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45099.00000,13078.71000,Aetna,First Health,,36890.98,,,,,,,16258.19,36890.98,percent of total billed charges,
STENT,9020138,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45099.00000,13078.71000,Aetna,First Health,,36890.98,,,,,,,14521.88,36890.98,percent of total billed charges,
STENT,9020139,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53951.98000,15646.07000,Aetna,First Health,,44132.72,,,,,,,19449.69,44132.72,percent of total billed charges,
STENT,9020139,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53951.98000,15646.07000,Aetna,First Health,,44132.72,,,,,,,17372.54,44132.72,percent of total billed charges,
STENT,9020140,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53951.98000,15646.07000,Aetna,First Health,,44132.72,,,,,,,19449.69,44132.72,percent of total billed charges,
STENT,9020140,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53951.98000,15646.07000,Aetna,First Health,,44132.72,,,,,,,17372.54,44132.72,percent of total billed charges,
PLATE,9020144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8502.00000,2465.58000,Aetna,First Health,,6954.64,,,,,,,3064.97,6954.64,percent of total billed charges,
PLATE,9020144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8502.00000,2465.58000,Aetna,First Health,,6954.64,,,,,,,2737.64,6954.64,percent of total billed charges,
STEM,9020142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,9020142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW,9018229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,9018229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
SCREW,9018230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,9018230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
SCREW,9018231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,9018231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
SCREW,9018232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW,9018232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
SCREW,9018233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
SCREW,9018233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SCREW,9020172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,9020172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,9020170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW,9020170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
SCREW,9020171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW,9020171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
SCREW,9020173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9020173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9020174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9020174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
PLATE,9018322,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11076.00000,3212.04000,Aetna,First Health,,9060.17,,,,,,,3992.90,9060.17,percent of total billed charges,
PLATE,9018322,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11076.00000,3212.04000,Aetna,First Health,,9060.17,,,,,,,3566.47,9060.17,percent of total billed charges,
SCREW,9018323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,9018323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
ANCHOR,9020165,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,11369.25000,3297.08000,Aetna,First Health,,9300.05,,,,,,,4098.61,9300.05,percent of total billed charges,
ANCHOR,9020165,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,11369.25000,3297.08000,Aetna,First Health,,9300.05,,,,,,,3660.90,9300.05,percent of total billed charges,
PLATE,9018325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4937.10000,1431.76000,Aetna,First Health,,4038.55,,,,,,,1779.82,4038.55,percent of total billed charges,
PLATE,9018325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4937.10000,1431.76000,Aetna,First Health,,4038.55,,,,,,,1589.75,4038.55,percent of total billed charges,
PLATE,9018332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.82000,1338.88000,Aetna,First Health,,3776.56,,,,,,,1664.36,3776.56,percent of total billed charges,
PLATE,9018332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.82000,1338.88000,Aetna,First Health,,3776.56,,,,,,,1486.62,3776.56,percent of total billed charges,
WASHER,9018333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,165.48000,47.99000,Aetna,First Health,,135.36,,,,,,,59.66,135.36,percent of total billed charges,
WASHER,9018333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,165.48000,47.99000,Aetna,First Health,,135.36,,,,,,,53.28,135.36,percent of total billed charges,
PLATE,9018334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE,9018334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
SCREW,9018335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW,9018335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
SCREW,9018336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,9018336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,9018337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW,9018337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,9018348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW,9018348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
PLATE,9018339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8934.00000,2590.86000,Aetna,First Health,,7308.01,,,,,,,3220.71,7308.01,percent of total billed charges,
PLATE,9018339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8934.00000,2590.86000,Aetna,First Health,,7308.01,,,,,,,2876.75,7308.01,percent of total billed charges,
SCREW,9018340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9018340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,9018341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9018341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
BONE MATRIX,9018347,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,8674.32000,2515.55000,Aetna,First Health,,7095.59,,,,,,,3127.09,7095.59,percent of total billed charges,
BONE MATRIX,9018347,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,8674.32000,2515.55000,Aetna,First Health,,7095.59,,,,,,,2793.13,7095.59,percent of total billed charges,
STENT ESOPAGEAL,9018345,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10928.25000,3169.19000,Aetna,First Health,,8939.31,,,,,,,3939.63,8939.31,percent of total billed charges,
STENT ESOPAGEAL,9018345,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10928.25000,3169.19000,Aetna,First Health,,8939.31,,,,,,,3518.90,8939.31,percent of total billed charges,
STENT GASTRO,9018346,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16956.28000,4917.32000,Aetna,First Health,,13870.24,,,,,,,6112.74,13870.24,percent of total billed charges,
STENT GASTRO,9018346,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16956.28000,4917.32000,Aetna,First Health,,13870.24,,,,,,,5459.92,13870.24,percent of total billed charges,
PLATE,9020277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10668.00000,3093.72000,Aetna,First Health,,8726.42,,,,,,,3845.81,8726.42,percent of total billed charges,
PLATE,9020277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10668.00000,3093.72000,Aetna,First Health,,8726.42,,,,,,,3435.10,8726.42,percent of total billed charges,
SCREW,9020278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,9020278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
CATHETER INDIGO,9018429,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,10301.29,23374.35,percent of total billed charges,
CATHETER INDIGO,9018429,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,9201.15,23374.35,percent of total billed charges,
NAIL,9018432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1643.54,3729.32,percent of total billed charges,
NAIL,9018432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,First Health,,3729.32,,,,,,,1468.02,3729.32,percent of total billed charges,
BREAST IMPLANT,9018434,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,9018434,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
BREAST IMPLANT,9018435,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,9018435,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
BREAST IMPLANT,9018436,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,9018436,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
URETHRAL DEVICE,9018430,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,12015.00000,3484.35000,Aetna,First Health,,9828.27,,,,,,,4331.41,9828.27,percent of total billed charges,
URETHRAL DEVICE,9018430,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,12015.00000,3484.35000,Aetna,First Health,,9828.27,,,,,,,3868.83,9828.27,percent of total billed charges,
URETHRAL DEVICED,9018431,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,12525.00000,3632.25000,Aetna,First Health,,10245.45,,,,,,,4515.26,10245.45,percent of total billed charges,
URETHRAL DEVICED,9018431,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,12525.00000,3632.25000,Aetna,First Health,,10245.45,,,,,,,4033.05,10245.45,percent of total billed charges,
INSERT,9018449,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT,9018449,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
COMPONENT TIBIAL,9018450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1255.44,2848.68,percent of total billed charges,
COMPONENT TIBIAL,9018450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,First Health,,2848.68,,,,,,,1121.37,2848.68,percent of total billed charges,
INSERT,9018451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5472.36000,1586.98000,Aetna,First Health,,4476.39,,,,,,,1972.79,4476.39,percent of total billed charges,
INSERT,9018451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5472.36000,1586.98000,Aetna,First Health,,4476.39,,,,,,,1762.10,4476.39,percent of total billed charges,
GRAFT VASCULAR,9018490,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1241.07,2816.08,percent of total billed charges,
GRAFT VASCULAR,9018490,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1108.53,2816.08,percent of total billed charges,
PLATE,9018519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,24077.50000,6982.48000,Aetna,First Health,,19695.40,,,,,,,8679.94,19695.40,percent of total billed charges,
PLATE,9018519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,24077.50000,6982.48000,Aetna,First Health,,19695.40,,,,,,,7752.95,19695.40,percent of total billed charges,
URETHRAL DEVICE,9020359,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
URETHRAL DEVICE,9020359,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
URETHRAL DEVICE,9020360,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
URETHRAL DEVICE,9020360,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
URETHRAL DEVICE,9020361,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
URETHRAL DEVICE,9020361,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
COLLAGEN MATRIX,9020404,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,29137.50000,8449.88000,Aetna,First Health,,23834.47,,,,,,,10504.07,23834.47,percent of total billed charges,
COLLAGEN MATRIX,9020404,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,29137.50000,8449.88000,Aetna,First Health,,23834.47,,,,,,,124.65,23834.47,percent of total billed charges,
COLLAGEN MATRIX,9020405,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,22415.00000,6500.35000,Aetna,First Health,,18335.47,,,,,,,8080.61,18335.47,percent of total billed charges,
COLLAGEN MATRIX,9020405,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,22415.00000,6500.35000,Aetna,First Health,,18335.47,,,,,,,124.65,18335.47,percent of total billed charges,
COLLAGEN MATRIX,9020406,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,7710.00000,2235.90000,Aetna,First Health,,6306.78,,,,,,,2779.45,6306.78,percent of total billed charges,
COLLAGEN MATRIX,9020406,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,7710.00000,2235.90000,Aetna,First Health,,6306.78,,,,,,,124.65,6306.78,percent of total billed charges,
CATHETER THROMBECTOMY,9018518,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,24350.00000,7061.50000,Aetna,First Health,,19918.30,,,,,,,8778.17,19918.30,percent of total billed charges,
CATHETER THROMBECTOMY,9018518,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,24350.00000,7061.50000,Aetna,First Health,,19918.30,,,,,,,7840.70,19918.30,percent of total billed charges,
INSERT TIBIAL,9020388,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9020388,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
MESH,9018557,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,174.66,396.32,percent of total billed charges,
MESH,9018557,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,First Health,,396.32,,,,,,,156.01,396.32,percent of total billed charges,
STEM,9018558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,9018558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SHELL,9018559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,9018559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,9020412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9020412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,9020456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9020456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
GRAFT VASCULAR,9020407,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1241.07,2816.08,percent of total billed charges,
GRAFT VASCULAR,9020407,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,First Health,,2816.08,,,,,,,1108.53,2816.08,percent of total billed charges,
STENT ESOPAGEAL,9019999,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10928.25000,3169.19000,Aetna,First Health,,8939.31,,,,,,,3939.63,8939.31,percent of total billed charges,
STENT ESOPAGEAL,9019999,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10928.25000,3169.19000,Aetna,First Health,,8939.31,,,,,,,3518.90,8939.31,percent of total billed charges,
INSERT,9019985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9019985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,9019992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,525.09,1191.47,percent of total billed charges,
SCREW,9019992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,469.01,1191.47,percent of total billed charges,
SCREW,9019993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,525.09,1191.47,percent of total billed charges,
SCREW,9019993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,469.01,1191.47,percent of total billed charges,
SCREW,9019994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,9019994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
SCREW,9019995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,1070.68,2429.46,percent of total billed charges,
SCREW,9019995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,First Health,,2429.46,,,,,,,956.34,2429.46,percent of total billed charges,
CONNECTOR,9019996,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
CONNECTOR,9019996,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,9019997,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
CAGE,9019997,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
INSERT,9019986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9019986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COLLAGEN MATRIX,9019998,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,32478.75000,9418.84000,Aetna,First Health,,26567.62,,,,,,,11708.59,26567.62,percent of total billed charges,
COLLAGEN MATRIX,9019998,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,32478.75000,9418.84000,Aetna,First Health,,26567.62,,,,,,,124.65,26567.62,percent of total billed charges,
SCREW,9020026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW,9020026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
PLATE,9020554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7929.00000,2299.41000,Aetna,First Health,,6485.92,,,,,,,2858.40,6485.92,percent of total billed charges,
PLATE,9020554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7929.00000,2299.41000,Aetna,First Health,,6485.92,,,,,,,2553.14,6485.92,percent of total billed charges,
PLATE,9020555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7929.00000,2299.41000,Aetna,First Health,,6485.92,,,,,,,2858.40,6485.92,percent of total billed charges,
PLATE,9020555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7929.00000,2299.41000,Aetna,First Health,,6485.92,,,,,,,2553.14,6485.92,percent of total billed charges,
SCREW,9020560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,309.85,703.07,percent of total billed charges,
SCREW,9020560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,276.76,703.07,percent of total billed charges,
SCREW,9020561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,309.85,703.07,percent of total billed charges,
SCREW,9020561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,276.76,703.07,percent of total billed charges,
SCREW,9020562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,309.85,703.07,percent of total billed charges,
SCREW,9020562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,276.76,703.07,percent of total billed charges,
SCREW,9020563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,309.85,703.07,percent of total billed charges,
SCREW,9020563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,276.76,703.07,percent of total billed charges,
SCREW,9020564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,309.85,703.07,percent of total billed charges,
SCREW,9020564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,276.76,703.07,percent of total billed charges,
SCREW,9020565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,350.41,795.10,percent of total billed charges,
SCREW,9020565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,312.98,795.10,percent of total billed charges,
SCREW,9020566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,350.41,795.10,percent of total billed charges,
SCREW,9020566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,312.98,795.10,percent of total billed charges,
KWIRE,9020567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,351.50000,101.93000,Aetna,First Health,,287.53,,,,,,,126.72,287.53,percent of total billed charges,
KWIRE,9020567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,351.50000,101.93000,Aetna,First Health,,287.53,,,,,,,113.18,287.53,percent of total billed charges,
KWIRE,9020568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,370.50000,107.44000,Aetna,First Health,,303.07,,,,,,,133.57,303.07,percent of total billed charges,
KWIRE,9020568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,370.50000,107.44000,Aetna,First Health,,303.07,,,,,,,119.30,303.07,percent of total billed charges,
KWIRE,9020569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,118.15,268.10,percent of total billed charges,
KWIRE,9020569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,First Health,,268.10,,,,,,,105.54,268.10,percent of total billed charges,
SCREW,9020570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9020570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,9020571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9020571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,9020572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9020572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,9020573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9020573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,9020574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9020574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,9020575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1484.00000,430.36000,Aetna,First Health,,1213.91,,,,,,,534.98,1213.91,percent of total billed charges,
SCREW,9020575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1484.00000,430.36000,Aetna,First Health,,1213.91,,,,,,,477.85,1213.91,percent of total billed charges,
SCREW,9020576,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1484.00000,430.36000,Aetna,First Health,,1213.91,,,,,,,534.98,1213.91,percent of total billed charges,
SCREW,9020576,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1484.00000,430.36000,Aetna,First Health,,1213.91,,,,,,,477.85,1213.91,percent of total billed charges,
SCREW,9020577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1748.00000,506.92000,Aetna,First Health,,1429.86,,,,,,,630.15,1429.86,percent of total billed charges,
SCREW,9020577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1748.00000,506.92000,Aetna,First Health,,1429.86,,,,,,,562.86,1429.86,percent of total billed charges,
SCREW,9020578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW,9020578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
SCREW,9020579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,940.50000,272.74000,Aetna,First Health,,769.33,,,,,,,339.05,769.33,percent of total billed charges,
SCREW,9020579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,940.50000,272.74000,Aetna,First Health,,769.33,,,,,,,302.84,769.33,percent of total billed charges,
SCREW,9020580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,940.50000,272.74000,Aetna,First Health,,769.33,,,,,,,339.05,769.33,percent of total billed charges,
SCREW,9020580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,940.50000,272.74000,Aetna,First Health,,769.33,,,,,,,302.84,769.33,percent of total billed charges,
STEM,9020065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STEM,9020065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
HEAD HUMERAL,9020066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,9020066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,9020081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,350.41,795.10,percent of total billed charges,
SCREW,9020081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,312.98,795.10,percent of total billed charges,
SCREW,9020068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,497.63,1129.17,percent of total billed charges,
SCREW,9020068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,444.49,1129.17,percent of total billed charges,
SPACER,9022152,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
SPACER,9022152,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
WEDGE,9022151,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1729.86,3925.17,percent of total billed charges,
WEDGE,9022151,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,First Health,,3925.17,,,,,,,1545.12,3925.17,percent of total billed charges,
LINER,9022153,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,9022153,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
STEM,9020686,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2811.90,6380.40,percent of total billed charges,
STEM,9020686,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,First Health,,6380.40,,,,,,,2511.60,6380.40,percent of total billed charges,
STEM,9020687,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,9020687,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
PLATE,9020688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3957.21,8979.19,percent of total billed charges,
PLATE,9020688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3534.59,8979.19,percent of total billed charges,
NAIL,9020683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9020683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
BREAST IMPLANT,9020734,CDM,278,RC,L8688,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
BREAST IMPLANT,9020734,CDM,278,RC,L8688,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW,9020735,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9020735,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,9020736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9020736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,9020737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9020737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,9020738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9020738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,9020739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9020739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,9020740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,9020740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
PLATE,9020741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5015.50000,1454.50000,Aetna,First Health,,4102.68,,,,,,,1808.09,4102.68,percent of total billed charges,
PLATE,9020741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5015.50000,1454.50000,Aetna,First Health,,4102.68,,,,,,,1614.99,4102.68,percent of total billed charges,
PLATE,9020742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4469.50000,1296.16000,Aetna,First Health,,3656.05,,,,,,,1611.25,3656.05,percent of total billed charges,
PLATE,9020742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4469.50000,1296.16000,Aetna,First Health,,3656.05,,,,,,,1439.18,3656.05,percent of total billed charges,
PLATE,9020743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5015.50000,1454.50000,Aetna,First Health,,4102.68,,,,,,,1808.09,4102.68,percent of total billed charges,
PLATE,9020743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5015.50000,1454.50000,Aetna,First Health,,4102.68,,,,,,,1614.99,4102.68,percent of total billed charges,
SCREW,9020744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,9020744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,9020745,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,9020745,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,9020746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,9020746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,9020747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW,9020747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW,9020684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SCREW,9020684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
SHEATH,9020799,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SHEATH,9020799,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
THROMBECTOMY CATHETER,9020800,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,10301.29,23374.35,percent of total billed charges,
THROMBECTOMY CATHETER,9020800,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,9201.15,23374.35,percent of total billed charges,
SCREW,9020802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,1075.11,2439.51,percent of total billed charges,
SCREW,9020802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,960.29,2439.51,percent of total billed charges,
MORCELLATOR,9020803,CDM,278,RC,C1782,HCPCS,,,facility,inpatient,,,1848.88000,536.18000,Aetna,First Health,,1512.38,,,,,,,666.52,1512.38,percent of total billed charges,
MORCELLATOR,9020803,CDM,278,RC,C1782,HCPCS,,,facility,outpatient,,,1848.88000,536.18000,Aetna,First Health,,1512.38,,,,,,,595.34,1512.38,percent of total billed charges,
ALLOGRAFT,9020804,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,8408.25000,2438.39000,Aetna,First Health,,6877.95,,,,,,,3031.17,6877.95,percent of total billed charges,
ALLOGRAFT,9020804,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,8408.25000,2438.39000,Aetna,First Health,,6877.95,,,,,,,2707.46,6877.95,percent of total billed charges,
SCREW,9020772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9020772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
COMPONENT FEMORAL,9020817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9020817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
SCREW,9020826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,9020826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
GRAFT,9020870,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,15487.50000,4491.38000,Aetna,First Health,,12668.77,,,,,,,5583.24,12668.77,percent of total billed charges,
GRAFT,9020870,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,15487.50000,4491.38000,Aetna,First Health,,12668.77,,,,,,,4986.98,12668.77,percent of total billed charges,
SCREW,9020871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW,9020871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
NAIL,9019984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9019984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
SHOULDER PROSTHESIS,9020901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
SHOULDER PROSTHESIS,9020901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
PLATE,9020902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10629.00000,3082.41000,Aetna,First Health,,8694.52,,,,,,,3831.75,8694.52,percent of total billed charges,
PLATE,9020902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10629.00000,3082.41000,Aetna,First Health,,8694.52,,,,,,,3422.54,8694.52,percent of total billed charges,
PLATE,9020903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10629.00000,3082.41000,Aetna,First Health,,8694.52,,,,,,,3831.75,8694.52,percent of total billed charges,
PLATE,9020903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10629.00000,3082.41000,Aetna,First Health,,8694.52,,,,,,,3422.54,8694.52,percent of total billed charges,
INSERT TIBIAL,9020904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9020904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
PLATE,9020905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,1072.65,2433.91,percent of total billed charges,
PLATE,9020905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,958.09,2433.91,percent of total billed charges,
PLATE,9020906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1626.40,3690.41,percent of total billed charges,
PLATE,9020906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,First Health,,3690.41,,,,,,,1452.70,3690.41,percent of total billed charges,
SCREW,9020907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7746.75000,2246.56000,Aetna,First Health,,6336.84,,,,,,,2792.70,6336.84,percent of total billed charges,
SCREW,9020907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7746.75000,2246.56000,Aetna,First Health,,6336.84,,,,,,,2494.45,6336.84,percent of total billed charges,
SCREW,9020920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW,9020920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
NAIL,9020921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,3062.33,6948.65,percent of total billed charges,
NAIL,9020921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,2735.29,6948.65,percent of total billed charges,
COMPONENT FEMORAL,9020922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,9020922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
INSERT TIBIAL,9020923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT TIBIAL,9020923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
BASEPLATE,9020924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,9020924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
INSERT TIBIAL,9020980,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT TIBIAL,9020980,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
INSERT,9020981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9020981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT TIBIAL,9020982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,9020982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
GLENOID XL,9020988,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
GLENOID XL,9020988,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
HUMERAL STEMLESS,9020989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
HUMERAL STEMLESS,9020989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
ANCHOR IN KIT,9020990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1962.02,4451.97,percent of total billed charges,
ANCHOR IN KIT,9020990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1752.48,4451.97,percent of total billed charges,
RESTRICTOR CEMENT,9020991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
RESTRICTOR CEMENT,9020991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
COMPONENT HUMERAL,9020992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16445.00000,4769.05000,Aetna,First Health,,13452.01,,,,,,,5928.42,13452.01,percent of total billed charges,
COMPONENT HUMERAL,9020992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16445.00000,4769.05000,Aetna,First Health,,13452.01,,,,,,,5295.29,13452.01,percent of total billed charges,
COMPONENT ULNA W BEARING,9020993,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17657.50000,5120.67000,Aetna,First Health,,14443.83,,,,,,,6365.53,14443.83,percent of total billed charges,
COMPONENT ULNA W BEARING,9020993,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17657.50000,5120.67000,Aetna,First Health,,14443.83,,,,,,,5685.72,14443.83,percent of total billed charges,
CAGE,9020998,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,9020998,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
LINER,9021050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
LINER,9021050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
CATHETER TRANSCAROTID,9021049,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,First Health,,1600.01,,,,,,,705.14,1600.01,percent of total billed charges,
CATHETER TRANSCAROTID,9021049,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,First Health,,1600.01,,,,,,,629.83,1600.01,percent of total billed charges,
CAGE,9021047,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
CAGE,9021047,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
SNARE,9022442,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
SNARE,9022442,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
NAIL,9024096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1480.00000,429.20000,Aetna,First Health,,1210.64,,,,,,,533.54,1210.64,percent of total billed charges,
NAIL,9024096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1480.00000,429.20000,Aetna,First Health,,1210.64,,,,,,,476.56,1210.64,percent of total billed charges,
NAIL,9024097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.18000,193.19000,Aetna,First Health,,544.94,,,,,,,240.16,544.94,percent of total billed charges,
NAIL,9024097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.18000,193.19000,Aetna,First Health,,544.94,,,,,,,214.51,544.94,percent of total billed charges,
COMPONENT FEMORAL,9024112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
COMPONENT FEMORAL,9024112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
SHELL,9024113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL,9024113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
PLATE,9024114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1364.92000,395.83000,Aetna,First Health,,1116.50,,,,,,,492.05,1116.50,percent of total billed charges,
PLATE,9024114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1364.92000,395.83000,Aetna,First Health,,1116.50,,,,,,,439.50,1116.50,percent of total billed charges,
SCREW,9024115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,2081.89,4723.95,percent of total billed charges,
SCREW,9024115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,1859.55,4723.95,percent of total billed charges,
GLENOSPHERE,9024116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
GLENOSPHERE,9024116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
INSERT HUMERAL,9024117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT HUMERAL,9024117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
ROD,9022444,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,475.86,1079.76,percent of total billed charges,
ROD,9022444,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,First Health,,1079.76,,,,,,,425.04,1079.76,percent of total billed charges,
SCREW,9024160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,1016.61,2306.76,percent of total billed charges,
SCREW,9024160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,First Health,,2306.76,,,,,,,908.04,2306.76,percent of total billed charges,
PENILE INFLATABLE,9021144,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,37856.25000,10978.31000,Aetna,First Health,,30966.41,,,,,,,13647.18,30966.41,percent of total billed charges,
PENILE INFLATABLE,9021144,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,37856.25000,10978.31000,Aetna,First Health,,30966.41,,,,,,,12189.71,30966.41,percent of total billed charges,
BASEPLATE,9021146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
BASEPLATE,9021146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
SCREW,9024184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1565.16000,453.90000,Aetna,First Health,,1280.30,,,,,,,564.24,1280.30,percent of total billed charges,
SCREW,9024184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1565.16000,453.90000,Aetna,First Health,,1280.30,,,,,,,503.98,1280.30,percent of total billed charges,
SCREW,9024186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1217.00000,352.93000,Aetna,First Health,,995.51,,,,,,,438.73,995.51,percent of total billed charges,
SCREW,9024186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1217.00000,352.93000,Aetna,First Health,,995.51,,,,,,,391.87,995.51,percent of total billed charges,
SCREW,9024188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,432.92,982.32,percent of total billed charges,
SCREW,9024188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,386.68,982.32,percent of total billed charges,
SCREW,9024190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,432.92,982.32,percent of total billed charges,
SCREW,9024190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,386.68,982.32,percent of total billed charges,
SCREW,9024191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,432.92,982.32,percent of total billed charges,
SCREW,9024191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,386.68,982.32,percent of total billed charges,
WASHER,9024192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,79.02,179.30,percent of total billed charges,
WASHER,9024192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,First Health,,179.30,,,,,,,70.58,179.30,percent of total billed charges,
SCREW,9024194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9024194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
PLATE,9024195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,514.43,1167.29,percent of total billed charges,
PLATE,9024195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,First Health,,1167.29,,,,,,,459.49,1167.29,percent of total billed charges,
SCREW,9024193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,432.92,982.32,percent of total billed charges,
SCREW,9024193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,First Health,,982.32,,,,,,,386.68,982.32,percent of total billed charges,
PLATE,9021356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8183.76000,2373.29000,Aetna,First Health,,6694.32,,,,,,,2950.25,6694.32,percent of total billed charges,
PLATE,9021356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8183.76000,2373.29000,Aetna,First Health,,6694.32,,,,,,,2635.17,6694.32,percent of total billed charges,
SCREW,9021357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,483.42,1096.91,percent of total billed charges,
SCREW,9021357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,First Health,,1096.91,,,,,,,431.79,1096.91,percent of total billed charges,
GUIDEWIRE,9024427,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,598.05000,173.43000,Aetna,First Health,,489.20,,,,,,,215.60,489.20,percent of total billed charges,
GUIDEWIRE,9024427,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,598.05000,173.43000,Aetna,First Health,,489.20,,,,,,,192.57,489.20,percent of total billed charges,
GUIDEWIRE,9024324,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,475.04000,137.76000,Aetna,First Health,,388.58,,,,,,,171.25,388.58,percent of total billed charges,
GUIDEWIRE,9024324,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,475.04000,137.76000,Aetna,First Health,,388.58,,,,,,,152.96,388.58,percent of total billed charges,
PLATE,9024325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.40000,730.63000,Aetna,First Health,,2060.87,,,,,,,908.24,2060.87,percent of total billed charges,
PLATE,9024325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.40000,730.63000,Aetna,First Health,,2060.87,,,,,,,811.25,2060.87,percent of total billed charges,
FEMORAL HEAD,9024434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,9024434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
LINER,9024435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,9024435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SCREW,9021600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,329.72,748.17,percent of total billed charges,
SCREW,9021600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,First Health,,748.17,,,,,,,294.51,748.17,percent of total billed charges,
SCREW,9021601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9021601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
PLATE,9021602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,582.57,1321.89,percent of total billed charges,
PLATE,9021602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,First Health,,1321.89,,,,,,,520.35,1321.89,percent of total billed charges,
SCREW,9021603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,9021603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
STEM,9024480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,9024480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
SCREW,9024481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,263.78,598.53,percent of total billed charges,
SCREW,9024481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,First Health,,598.53,,,,,,,235.61,598.53,percent of total billed charges,
SCREW,9024482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,9024482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW,9024483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,9024483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
STENT,9024484,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4163.92000,1207.54000,Aetna,First Health,,3406.09,,,,,,,1501.09,3406.09,percent of total billed charges,
STENT,9024484,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4163.92000,1207.54000,Aetna,First Health,,3406.09,,,,,,,1340.78,3406.09,percent of total billed charges,
HUMERAL CUP,9024486,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1622.36,3681.25,percent of total billed charges,
HUMERAL CUP,9024486,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,First Health,,3681.25,,,,,,,1449.10,3681.25,percent of total billed charges,
GLENOSPHERE,9024487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
GLENOSPHERE,9024487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
STEM HUMERAL,9024488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
STEM HUMERAL,9024488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
SCREW ANSIS,9024531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1491.92000,432.66000,Aetna,First Health,,1220.39,,,,,,,537.84,1220.39,percent of total billed charges,
SCREW ANSIS,9024531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1491.92000,432.66000,Aetna,First Health,,1220.39,,,,,,,480.40,1220.39,percent of total billed charges,
SCREW ANSIS,9024532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW ANSIS,9024532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
WASHER,9024533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,519.22000,150.57000,Aetna,First Health,,424.72,,,,,,,187.18,424.72,percent of total billed charges,
WASHER,9024533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,519.22000,150.57000,Aetna,First Health,,424.72,,,,,,,167.19,424.72,percent of total billed charges,
PLATE,9024530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3957.21,8979.19,percent of total billed charges,
PLATE,9024530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3534.59,8979.19,percent of total billed charges,
SUTURE CUP,9024679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.58000,1439.73000,Aetna,First Health,,4061.03,,,,,,,1789.73,4061.03,percent of total billed charges,
SUTURE CUP,9024679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.58000,1439.73000,Aetna,First Health,,4061.03,,,,,,,1598.59,4061.03,percent of total billed charges,
BASEPLATE,9021884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8270.94000,2398.57000,Aetna,First Health,,6765.63,,,,,,,2981.67,6765.63,percent of total billed charges,
BASEPLATE,9021884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8270.94000,2398.57000,Aetna,First Health,,6765.63,,,,,,,2663.24,6765.63,percent of total billed charges,
POST MODULAR,9021885,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3936.00000,1141.44000,Aetna,First Health,,3219.65,,,,,,,1418.93,3219.65,percent of total billed charges,
POST MODULAR,9021885,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3936.00000,1141.44000,Aetna,First Health,,3219.65,,,,,,,1267.39,3219.65,percent of total billed charges,
HUMERAL STEM,9024680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8734.41000,2532.98000,Aetna,First Health,,7144.75,,,,,,,3148.75,7144.75,percent of total billed charges,
HUMERAL STEM,9024680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8734.41000,2532.98000,Aetna,First Health,,7144.75,,,,,,,2812.48,7144.75,percent of total billed charges,
SCREW,9021928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW,9021928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
SCREW,9024683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,9024683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
CAGE SPACER,9024741,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE SPACER,9024741,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
PIN GLENOID,9024677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
PIN GLENOID,9024677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
REAMER GLENOID,9024678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
REAMER GLENOID,9024678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
STEM HUMERAL,9021971,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9021971,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
TRAY HUMERAL,9021972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
TRAY HUMERAL,9021972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
PLATE,9024848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,9024848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
STEM HUMERAL,9021962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,First Health,,9385.08,,,,,,,4136.09,9385.08,percent of total billed charges,
STEM HUMERAL,9021962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,First Health,,9385.08,,,,,,,3694.37,9385.08,percent of total billed charges,
SCREW,9021963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9021963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
NAIL,9021964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL,9021964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
ROD SPINAL,9021965,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2512.00000,728.48000,Aetna,First Health,,2054.82,,,,,,,905.58,2054.82,percent of total billed charges,
ROD SPINAL,9021965,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2512.00000,728.48000,Aetna,First Health,,2054.82,,,,,,,808.86,2054.82,percent of total billed charges,
RING LOCKING,9021969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,First Health,,2034.20,,,,,,,896.49,2034.20,percent of total billed charges,
RING LOCKING,9021969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,First Health,,2034.20,,,,,,,800.75,2034.20,percent of total billed charges,
HEAD FEMORAL,9021968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,First Health,,4584.24,,,,,,,2020.31,4584.24,percent of total billed charges,
HEAD FEMORAL,9021968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,First Health,,4584.24,,,,,,,1804.55,4584.24,percent of total billed charges,
LINER,9021970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3576.63,8115.62,percent of total billed charges,
LINER,9021970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,First Health,,8115.62,,,,,,,3194.66,8115.62,percent of total billed charges,
INSERT TIBIAL,9021967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9021967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
SCREW,9021966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1916.60,4348.90,percent of total billed charges,
SCREW,9021966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,First Health,,4348.90,,,,,,,1711.91,4348.90,percent of total billed charges,
STEM,9024928,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,30026.25000,8707.61000,Aetna,First Health,,24561.47,,,,,,,10824.46,24561.47,percent of total billed charges,
STEM,9024928,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,30026.25000,8707.61000,Aetna,First Health,,24561.47,,,,,,,9668.45,24561.47,percent of total billed charges,
PIN,9021961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
PIN,9021961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
CAGE,9024849,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
CAGE,9024849,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
DEFLUX INJECTION,9022306,CDM,278,RC,L8604,HCPCS,,,facility,inpatient,,,11782.38000,3416.89000,Aetna,First Health,,9637.99,,,,,,,4247.55,9637.99,percent of total billed charges,
DEFLUX INJECTION,9022306,CDM,278,RC,L8604,HCPCS,,,facility,outpatient,,,11782.38000,3416.89000,Aetna,First Health,,9637.99,,,,,,,3793.93,9637.99,percent of total billed charges,
SCREW,9024974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,9024974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
SCREW,9024975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,9024975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
SCREW,9024976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,590.14,1339.07,percent of total billed charges,
SCREW,9024976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,First Health,,1339.07,,,,,,,527.11,1339.07,percent of total billed charges,
PLATE,9024977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11054.25000,3205.73000,Aetna,First Health,,9042.38,,,,,,,3985.06,9042.38,percent of total billed charges,
PLATE,9024977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11054.25000,3205.73000,Aetna,First Health,,9042.38,,,,,,,3559.47,9042.38,percent of total billed charges,
PLATE,9024978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11054.25000,3205.73000,Aetna,First Health,,9042.38,,,,,,,3985.06,9042.38,percent of total billed charges,
PLATE,9024978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11054.25000,3205.73000,Aetna,First Health,,9042.38,,,,,,,3559.47,9042.38,percent of total billed charges,
SCREW,9024979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,9024979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
SCREW,9024980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,9024980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
SCREW,9024981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,9024981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
CATHETER TRANSCAROTID,9024982,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,First Health,,1600.01,,,,,,,705.14,1600.01,percent of total billed charges,
CATHETER TRANSCAROTID,9024982,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,First Health,,1600.01,,,,,,,629.83,1600.01,percent of total billed charges,
CAGE,9024983,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,9024983,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
CAGE,9024984,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,9024984,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
STEM,9024985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,9024985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
SCREW,9024987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW,9024987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
NAIL,9026120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9026120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
PLATE,9026122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5432.00000,1575.28000,Aetna,First Health,,4443.38,,,,,,,1958.24,4443.38,percent of total billed charges,
PLATE,9026122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5432.00000,1575.28000,Aetna,First Health,,4443.38,,,,,,,1749.10,4443.38,percent of total billed charges,
SCREW,9026124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,9026124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,9026126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,9026126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
PLATE,9026128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4329.50000,1255.55000,Aetna,First Health,,3541.53,,,,,,,1560.78,3541.53,percent of total billed charges,
PLATE,9026128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4329.50000,1255.55000,Aetna,First Health,,3541.53,,,,,,,1394.10,3541.53,percent of total billed charges,
SCREW,9026130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1736.00000,503.44000,Aetna,First Health,,1420.05,,,,,,,625.83,1420.05,percent of total billed charges,
SCREW,9026130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1736.00000,503.44000,Aetna,First Health,,1420.05,,,,,,,558.99,1420.05,percent of total billed charges,
ANCHOR,9026142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,953.52,2163.61,percent of total billed charges,
ANCHOR,9026142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,851.69,2163.61,percent of total billed charges,
BASEPLATE,9026166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
BASEPLATE,9026166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
SPACER,9026164,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,6562.00,14889.65,percent of total billed charges,
SPACER,9026164,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,5861.20,14889.65,percent of total billed charges,
INSERT HUMERAL,9026165,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT HUMERAL,9026165,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
SCREW,9025135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,453.87,1029.86,percent of total billed charges,
SCREW,9025135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,First Health,,1029.86,,,,,,,405.40,1029.86,percent of total billed charges,
CUP HUMERAL,9025176,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.58000,1439.73000,Aetna,First Health,,4061.03,,,,,,,1789.73,4061.03,percent of total billed charges,
CUP HUMERAL,9025176,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.58000,1439.73000,Aetna,First Health,,4061.03,,,,,,,1598.59,4061.03,percent of total billed charges,
STEM,9025177,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8734.41000,2532.98000,Aetna,First Health,,7144.75,,,,,,,3148.75,7144.75,percent of total billed charges,
STEM,9025177,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8734.41000,2532.98000,Aetna,First Health,,7144.75,,,,,,,2812.48,7144.75,percent of total billed charges,
SCREW,9025178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,1075.11,2439.51,percent of total billed charges,
SCREW,9025178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,First Health,,2439.51,,,,,,,960.29,2439.51,percent of total billed charges,
HEAD HUMERAL,9025179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4078.31000,1182.71000,Aetna,First Health,,3336.06,,,,,,,1470.23,3336.06,percent of total billed charges,
HEAD HUMERAL,9025179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4078.31000,1182.71000,Aetna,First Health,,3336.06,,,,,,,1313.22,3336.06,percent of total billed charges,
TRUNNION 41MM,9025180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8595.09000,2492.58000,Aetna,First Health,,7030.78,,,,,,,3098.53,7030.78,percent of total billed charges,
TRUNNION 41MM,9025180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8595.09000,2492.58000,Aetna,First Health,,7030.78,,,,,,,2767.62,7030.78,percent of total billed charges,
CAGE,9025181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8489.49000,2461.95000,Aetna,First Health,,6944.40,,,,,,,3060.46,6944.40,percent of total billed charges,
CAGE,9025181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8489.49000,2461.95000,Aetna,First Health,,6944.40,,,,,,,2733.62,6944.40,percent of total billed charges,
INSERT GLENOID,9025182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,First Health,,4551.92,,,,,,,2006.07,4551.92,percent of total billed charges,
INSERT GLENOID,9025182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,First Health,,4551.92,,,,,,,1791.83,4551.92,percent of total billed charges,
HEAD HUMERAL,9025183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,9025183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STENT,9025184,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1124.76,2552.16,percent of total billed charges,
STENT,9025184,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,First Health,,2552.16,,,,,,,1004.64,2552.16,percent of total billed charges,
SCREW,9026262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,350.41,795.10,percent of total billed charges,
SCREW,9026262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,312.98,795.10,percent of total billed charges,
SCREW,9026263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,350.41,795.10,percent of total billed charges,
SCREW,9026263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,312.98,795.10,percent of total billed charges,
SCREW,9026264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,350.41,795.10,percent of total billed charges,
SCREW,9026264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,312.98,795.10,percent of total billed charges,
SCREW,9026265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,350.41,795.10,percent of total billed charges,
SCREW,9026265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,First Health,,795.10,,,,,,,312.98,795.10,percent of total billed charges,
KWIRE,9025203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
KWIRE,9025203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
KWIRE,9025204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,304.00000,88.16000,Aetna,First Health,,248.67,,,,,,,109.59,248.67,percent of total billed charges,
KWIRE,9025204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,304.00000,88.16000,Aetna,First Health,,248.67,,,,,,,97.89,248.67,percent of total billed charges,
SCREW,9025205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9025205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,9025206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9025206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,9025207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9025207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,9025208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW,9025208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,9025209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,940.50000,272.74000,Aetna,First Health,,769.33,,,,,,,339.05,769.33,percent of total billed charges,
SCREW,9025209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,940.50000,272.74000,Aetna,First Health,,769.33,,,,,,,302.84,769.33,percent of total billed charges,
SPACER,9026289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4544.46,10311.71,percent of total billed charges,
SPACER,9026289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,First Health,,10311.71,,,,,,,4059.13,10311.71,percent of total billed charges,
PLATE,9026290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1222.76000,354.60000,Aetna,First Health,,1000.22,,,,,,,440.80,1000.22,percent of total billed charges,
PLATE,9026290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1222.76000,354.60000,Aetna,First Health,,1000.22,,,,,,,393.73,1000.22,percent of total billed charges,
INSERT,9026292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,9026292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
BLADE HELICAL,9005741,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3153.64000,914.56000,Aetna,First Health,,2579.68,,,,,,,1136.89,2579.68,percent of total billed charges,
BLADE HELICAL,9005741,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3153.64000,914.56000,Aetna,First Health,,2579.68,,,,,,,1015.47,2579.68,percent of total billed charges,
SCREW,9028094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9028094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PIN GLENOID,9028095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1379.60000,400.08000,Aetna,First Health,,1128.51,,,,,,,497.35,1128.51,percent of total billed charges,
PIN GLENOID,9028095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1379.60000,400.08000,Aetna,First Health,,1128.51,,,,,,,444.23,1128.51,percent of total billed charges,
PIN GLENOID,9028096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,896.40000,259.96000,Aetna,First Health,,733.26,,,,,,,323.15,733.26,percent of total billed charges,
PIN GLENOID,9028096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,896.40000,259.96000,Aetna,First Health,,733.26,,,,,,,288.64,733.26,percent of total billed charges,
SCREW,9028097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1246.40000,361.46000,Aetna,First Health,,1019.56,,,,,,,449.33,1019.56,percent of total billed charges,
SCREW,9028097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1246.40000,361.46000,Aetna,First Health,,1019.56,,,,,,,401.34,1019.56,percent of total billed charges,
LINER,9028098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1811.62,4110.70,percent of total billed charges,
LINER,9028098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1618.15,4110.70,percent of total billed charges,
HUMERAL TRAY,9028099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
HUMERAL TRAY,9028099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
SHELL,9028100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3524.61,7997.59,percent of total billed charges,
SHELL,9028100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3148.19,7997.59,percent of total billed charges,
SCREW,9026328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,988.40,2242.76,percent of total billed charges,
SCREW,9026328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,First Health,,2242.76,,,,,,,882.85,2242.76,percent of total billed charges,
SCREW,9028105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,565.03,1282.10,percent of total billed charges,
SCREW,9028105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,504.69,1282.10,percent of total billed charges,
NAIL,9028106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL,9028106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
STEM,9028093,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM,9028093,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
CUP REVERS CAP COATED 33 +2 LT UNIV,9028124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.58000,1439.73000,Aetna,First Health,,4061.03,,,,,,,1789.73,4061.03,percent of total billed charges,
CUP REVERS CAP COATED 33 +2 LT UNIV,9028124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.58000,1439.73000,Aetna,First Health,,4061.03,,,,,,,1598.59,4061.03,percent of total billed charges,
BASEPLATE,9028125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8270.94000,2398.57000,Aetna,First Health,,6765.63,,,,,,,2981.67,6765.63,percent of total billed charges,
BASEPLATE,9028125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8270.94000,2398.57000,Aetna,First Health,,6765.63,,,,,,,2663.24,6765.63,percent of total billed charges,
SPACER,9028126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,865.20,1963.20,percent of total billed charges,
SPACER,9028126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,772.80,1963.20,percent of total billed charges,
SPACER,9028127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1137.20,2580.40,percent of total billed charges,
SPACER,9028127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,First Health,,2580.40,,,,,,,1015.76,2580.40,percent of total billed charges,
GLENOSPHERE,9028128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,2224.35,5047.22,percent of total billed charges,
GLENOSPHERE,9028128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,First Health,,5047.22,,,,,,,1986.80,5047.22,percent of total billed charges,
PLATE,9028129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11797.20000,3421.19000,Aetna,First Health,,9650.11,,,,,,,4252.89,9650.11,percent of total billed charges,
PLATE,9028129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11797.20000,3421.19000,Aetna,First Health,,9650.11,,,,,,,3798.70,9650.11,percent of total billed charges,
STEM REDAPT,9028131,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30026.25000,8707.61000,Aetna,First Health,,24561.47,,,,,,,10824.46,24561.47,percent of total billed charges,
STEM REDAPT,9028131,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30026.25000,8707.61000,Aetna,First Health,,24561.47,,,,,,,9668.45,24561.47,percent of total billed charges,
PLATE,9028130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5023.20000,1456.73000,Aetna,First Health,,4108.98,,,,,,,1810.86,4108.98,percent of total billed charges,
PLATE,9028130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5023.20000,1456.73000,Aetna,First Health,,4108.98,,,,,,,1617.47,4108.98,percent of total billed charges,
SCREW,9028136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2389.25,5421.38,percent of total billed charges,
SCREW,9028136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,First Health,,5421.38,,,,,,,2134.09,5421.38,percent of total billed charges,
GUIDEWIRE,9028137,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,114.73,260.33,percent of total billed charges,
GUIDEWIRE,9028137,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,102.48,260.33,percent of total billed charges,
SCREW,9028143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1370.40000,397.42000,Aetna,First Health,,1120.99,,,,,,,494.03,1120.99,percent of total billed charges,
SCREW,9028143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1370.40000,397.42000,Aetna,First Health,,1120.99,,,,,,,441.27,1120.99,percent of total billed charges,
SHELL,9028144,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
SHELL,9028144,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
LINER,9028145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1811.62,4110.70,percent of total billed charges,
LINER,9028145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1618.15,4110.70,percent of total billed charges,
STEM,9028146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,9028146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
HERNIA MESH,9028141,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17565.00000,5093.85000,Aetna,First Health,,14368.17,,,,,,,6332.18,14368.17,percent of total billed charges,
HERNIA MESH,9028141,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17565.00000,5093.85000,Aetna,First Health,,14368.17,,,,,,,5655.93,14368.17,percent of total billed charges,
HERNIA MESH,9028142,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,25000.00000,7250.00000,Aetna,First Health,,20450.00,,,,,,,9012.50,20450.00,percent of total billed charges,
HERNIA MESH,9028142,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,25000.00000,7250.00000,Aetna,First Health,,20450.00,,,,,,,8050.00,20450.00,percent of total billed charges,
COVER HOLE,9028165,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,116.87000,33.89000,Aetna,First Health,,95.60,,,,,,,42.13,95.60,percent of total billed charges,
COVER HOLE,9028165,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,116.87000,33.89000,Aetna,First Health,,95.60,,,,,,,37.63,95.60,percent of total billed charges,
BRACE,9028132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
BRACE,9028132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
SCREW,9026325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9026325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,9026326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9026326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
SCREW,9026327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW,9026327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
INSERT,9028216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,9028216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
LINER,9028214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,9028214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
STEM,9028215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,9028215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM,9028237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,9028237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
SCREW,9028239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,212.19,481.47,percent of total billed charges,
SCREW,9028239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,First Health,,481.47,,,,,,,189.53,481.47,percent of total billed charges,
STEM,9028240,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,4276.25,9703.12,percent of total billed charges,
STEM,9028240,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,3819.56,9703.12,percent of total billed charges,
HELICAL BLADE,9028256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3714.83000,1077.30000,Aetna,First Health,,3038.73,,,,,,,1339.20,3038.73,percent of total billed charges,
HELICAL BLADE,9028256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3714.83000,1077.30000,Aetna,First Health,,3038.73,,,,,,,1196.18,3038.73,percent of total billed charges,
NAIL,9028257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2272.00000,658.88000,Aetna,First Health,,1858.50,,,,,,,819.06,1858.50,percent of total billed charges,
NAIL,9028257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2272.00000,658.88000,Aetna,First Health,,1858.50,,,,,,,731.58,1858.50,percent of total billed charges,
SCREW,9026449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,9026449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
INSERT,9026450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT,9026450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
ANCHOR,9026452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.90000,85.52000,Aetna,First Health,,241.23,,,,,,,106.31,241.23,percent of total billed charges,
ANCHOR,9026452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.90000,85.52000,Aetna,First Health,,241.23,,,,,,,94.96,241.23,percent of total billed charges,
CROSSLINK CONNECTOR,9026469,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2652.00000,769.08000,Aetna,First Health,,2169.34,,,,,,,956.05,2169.34,percent of total billed charges,
CROSSLINK CONNECTOR,9026469,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2652.00000,769.08000,Aetna,First Health,,2169.34,,,,,,,853.94,2169.34,percent of total billed charges,
COLLAGEN MATRIX,9026470,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,14091.00000,4086.39000,Aetna,First Health,,11526.44,,,,,,,5079.81,11526.44,percent of total billed charges,
COLLAGEN MATRIX,9026470,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,14091.00000,4086.39000,Aetna,First Health,,11526.44,,,,,,,124.65,11526.44,percent of total billed charges,
SCREW,9026484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW,9026484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
SCREW,9026485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9026485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,9026486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,9026486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SCREW,9026487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW,9026487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
SPACER,9026489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,7372.23,16728.10,percent of total billed charges,
SPACER,9026489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,First Health,,16728.10,,,,,,,6584.90,16728.10,percent of total billed charges,
GLENOSPHERE,9026490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
GLENOSPHERE,9026490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
CATHETER PTA,9026482,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER PTA,9026482,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
TISSUE MATRIX,9028292,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,13734.00000,3982.86000,Aetna,First Health,,11234.41,,,,,,,4951.11,11234.41,percent of total billed charges,
TISSUE MATRIX,9028292,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,13734.00000,3982.86000,Aetna,First Health,,11234.41,,,,,,,4422.35,11234.41,percent of total billed charges,
TISSUE MATRIX,9028293,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,15935.00000,4621.15000,Aetna,First Health,,13034.83,,,,,,,5744.57,13034.83,percent of total billed charges,
TISSUE MATRIX,9028293,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,15935.00000,4621.15000,Aetna,First Health,,13034.83,,,,,,,5131.07,13034.83,percent of total billed charges,
CATHETER TRANSCAROTID,9026518,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,First Health,,1600.01,,,,,,,705.14,1600.01,percent of total billed charges,
CATHETER TRANSCAROTID,9026518,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,First Health,,1600.01,,,,,,,629.83,1600.01,percent of total billed charges,
PIN GLENOID,9026519,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1379.60000,400.08000,Aetna,First Health,,1128.51,,,,,,,497.35,1128.51,percent of total billed charges,
PIN GLENOID,9026519,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1379.60000,400.08000,Aetna,First Health,,1128.51,,,,,,,444.23,1128.51,percent of total billed charges,
PIN FIXATION,9026520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
PIN FIXATION,9026520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
SCREW,9026569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,9026569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SCREW,9026570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,9026570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SPINAL CONNECTOR,9026571,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,624.39,1416.78,percent of total billed charges,
SPINAL CONNECTOR,9026571,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,First Health,,1416.78,,,,,,,557.70,1416.78,percent of total billed charges,
FEMORAL COMPONENT,9026572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
FEMORAL COMPONENT,9026572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
PLATE CERVICAL,9026587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
PLATE CERVICAL,9026587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
INSERT,9026596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,9026596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT TIBIAL,9026609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT TIBIAL,9026609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
STEM,9026611,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM,9026611,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
PLATE,9026637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3957.21,8979.19,percent of total billed charges,
PLATE,9026637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,First Health,,8979.19,,,,,,,3534.59,8979.19,percent of total billed charges,
SCREW,9026638,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,436.93,991.42,percent of total billed charges,
SCREW,9026638,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,First Health,,991.42,,,,,,,390.26,991.42,percent of total billed charges,
PEG SMOOTH,9026639,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
PEG SMOOTH,9026639,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
COMPONENT FEMORAL,9028396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9028396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
SPACER,9028399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,6562.00,14889.65,percent of total billed charges,
SPACER,9028399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,5861.20,14889.65,percent of total billed charges,
INSERT,9026668,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,9026668,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
LINER,9026669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1811.62,4110.70,percent of total billed charges,
LINER,9026669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1618.15,4110.70,percent of total billed charges,
HUMERAL HEAD,9026670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,9026670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
SCREW,9026675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
SCREW,9026675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
SPACER,9026676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24547.50000,7118.78000,Aetna,First Health,,20079.85,,,,,,,8849.37,20079.85,percent of total billed charges,
SPACER,9026676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24547.50000,7118.78000,Aetna,First Health,,20079.85,,,,,,,7904.30,20079.85,percent of total billed charges,
SPACER,9026677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24547.50000,7118.78000,Aetna,First Health,,20079.85,,,,,,,8849.37,20079.85,percent of total billed charges,
SPACER,9026677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24547.50000,7118.78000,Aetna,First Health,,20079.85,,,,,,,7904.30,20079.85,percent of total billed charges,
PORT INDWELLING,9030095,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
PORT INDWELLING,9030095,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
CATHETER THORACIC,9032091,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,172.23000,49.95000,Aetna,First Health,,140.88,,,,,,,62.09,140.88,percent of total billed charges,
CATHETER THORACIC,9032091,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,172.23000,49.95000,Aetna,First Health,,140.88,,,,,,,55.46,140.88,percent of total billed charges,
POLARSTEM,9028438,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
POLARSTEM,9028438,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
NAIL,9028439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9028439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
CATHETER PTA,9032084,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER PTA,9032084,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
STEM CENTRALIZER,9032086,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
STEM CENTRALIZER,9032086,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
SCREW,9032087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,860.87,1953.38,percent of total billed charges,
SCREW,9032087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,First Health,,1953.38,,,,,,,768.94,1953.38,percent of total billed charges,
NAIL,9032088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9032088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
SCREW,9030090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,9030090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
INSERT,9030091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,7259.57,16472.47,percent of total billed charges,
INSERT,9030091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,First Health,,16472.47,,,,,,,6484.27,16472.47,percent of total billed charges,
INSERT,9030092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,9030092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
COMPONENT TIBIAL,9030093,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,9030093,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
COMPONENT FEMORAL,9030096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9030096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
NAIL,9014822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,9014822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
SCREW,9020748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,964.29,2188.05,percent of total billed charges,
SCREW,9020748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,861.31,2188.05,percent of total billed charges,
PLATE,9001593,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,608.67000,176.51000,Aetna,First Health,,497.89,,,,,,,219.43,497.89,percent of total billed charges,
PLATE,9001593,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,608.67000,176.51000,Aetna,First Health,,497.89,,,,,,,195.99,497.89,percent of total billed charges,
SCREW,9032206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,9032206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
KWIRES,9032165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
KWIRES,9032165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT FEMORAL,9032166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9032166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
INSERT TIBIAL,9032167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT TIBIAL,9032167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SCREW,9032207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,648.90,1472.40,percent of total billed charges,
SCREW,9032207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,579.60,1472.40,percent of total billed charges,
PLATE CONDYLAR,9032208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2451.12000,710.82000,Aetna,First Health,,2005.02,,,,,,,883.63,2005.02,percent of total billed charges,
PLATE CONDYLAR,9032208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2451.12000,710.82000,Aetna,First Health,,2005.02,,,,,,,789.26,2005.02,percent of total billed charges,
STEM HUMERAL,9032210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9032210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
SCREW,9032211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,9032211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
INSERTER,9032212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
INSERTER,9032212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
PLATE,9032265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE,9032265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
CAGE,9032266,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
CAGE,9032266,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
INSERT,9032267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,9032267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
COMPONENT FEMORAL,9034160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,9034160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
HEAD FEMORAL,9034161,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,9034161,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
MESH,9034162,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
MESH,9034162,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
LINER,9034163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8283.00000,2402.07000,Aetna,First Health,,6775.49,,,,,,,2986.02,6775.49,percent of total billed charges,
LINER,9034163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8283.00000,2402.07000,Aetna,First Health,,6775.49,,,,,,,2667.13,6775.49,percent of total billed charges,
SPACER,9032286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1203.71,2731.30,percent of total billed charges,
SPACER,9032286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,First Health,,2731.30,,,,,,,1075.16,2731.30,percent of total billed charges,
LINER,9034199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,9034199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
STEM FEMORAL,9034200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM FEMORAL,9034200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
BASEPLATE,9034201,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,9034201,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
SCREW,9034297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,9034297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW,9034298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,943.76,2141.46,percent of total billed charges,
SCREW,9034298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,842.97,2141.46,percent of total billed charges,
TRAY TIBIAL,9032397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
TRAY TIBIAL,9032397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
BEARING TIBIAL,9032398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
BEARING TIBIAL,9032398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,9032399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW,9032399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
STEM FEMORAL,9032407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4609.35,10458.95,percent of total billed charges,
STEM FEMORAL,9032407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4117.09,10458.95,percent of total billed charges,
STRATOSPHERE,9032408,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21107.50000,6121.17000,Aetna,First Health,,17265.94,,,,,,,7609.25,17265.94,percent of total billed charges,
STRATOSPHERE,9032408,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21107.50000,6121.17000,Aetna,First Health,,17265.94,,,,,,,6796.61,17265.94,percent of total billed charges,
STEM,9032794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,9032794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
HUMERAL TRAY,9032795,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
HUMERAL TRAY,9032795,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
COMPONENT TRIATHLON ASYMMETRIC 40X11MM,9035117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,937.30,2126.80,percent of total billed charges,
COMPONENT TRIATHLON ASYMMETRIC 40X11MM,9035117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,First Health,,2126.80,,,,,,,837.20,2126.80,percent of total billed charges,
COMPONENT TIBIAL,9032844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8385.30000,2431.74000,Aetna,First Health,,6859.18,,,,,,,3022.90,6859.18,percent of total billed charges,
COMPONENT TIBIAL,9032844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8385.30000,2431.74000,Aetna,First Health,,6859.18,,,,,,,2700.07,6859.18,percent of total billed charges,
BONE STAPLE,9032845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6468.00000,1875.72000,Aetna,First Health,,5290.82,,,,,,,2331.71,5290.82,percent of total billed charges,
BONE STAPLE,9032845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6468.00000,1875.72000,Aetna,First Health,,5290.82,,,,,,,2082.70,5290.82,percent of total billed charges,
PLATE,9032846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11628.00000,3372.12000,Aetna,First Health,,9511.70,,,,,,,4191.89,9511.70,percent of total billed charges,
PLATE,9032846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11628.00000,3372.12000,Aetna,First Health,,9511.70,,,,,,,3744.22,9511.70,percent of total billed charges,
WEDGE,9035155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,9035155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
WEDGE,9035156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
WEDGE,9035156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
CAGE,9035157,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE,9035157,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
PLATE,9035158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8523.00000,2471.67000,Aetna,First Health,,6971.81,,,,,,,3072.54,6971.81,percent of total billed charges,
PLATE,9035158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8523.00000,2471.67000,Aetna,First Health,,6971.81,,,,,,,2744.41,6971.81,percent of total billed charges,
PLATE,9035144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE,9035144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT,9035182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9035182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT,9035183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9035183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW,9035184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,9035184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
PLATE,9035186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4634.00000,1343.86000,Aetna,First Health,,3790.61,,,,,,,1670.56,3790.61,percent of total billed charges,
PLATE,9035186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4634.00000,1343.86000,Aetna,First Health,,3790.61,,,,,,,1492.15,3790.61,percent of total billed charges,
BREAST IMPLANT,9035347,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,9035347,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
BREAST IMPLANT,9035348,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST IMPLANT,9035348,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,764.47,3779.16,percent of total billed charges,
SCREW,9035341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,9035341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
SCREW,9035342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,9035342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
SCREW,9035343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
SCREW,9035343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
SCREW,9035344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,9035344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW,9035345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW,9035345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
STEM,9036157,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7326.00000,2124.54000,Aetna,First Health,,5992.67,,,,,,,2641.02,5992.67,percent of total billed charges,
STEM,9036157,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7326.00000,2124.54000,Aetna,First Health,,5992.67,,,,,,,2358.97,5992.67,percent of total billed charges,
CAGE,9036168,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE,9036168,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
COMPONENT FEMORAL,9036170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
COMPONENT FEMORAL,9036170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
INSERT TIBIAL,9036171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9036171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE LOCKING,9036172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4457.57000,1292.70000,Aetna,First Health,,3646.29,,,,,,,1606.95,3646.29,percent of total billed charges,
PLATE LOCKING,9036172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4457.57000,1292.70000,Aetna,First Health,,3646.29,,,,,,,1435.34,3646.29,percent of total billed charges,
MESH,9036173,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1284.64000,372.55000,Aetna,First Health,,1050.84,,,,,,,463.11,1050.84,percent of total billed charges,
MESH,9036173,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1284.64000,372.55000,Aetna,First Health,,1050.84,,,,,,,413.65,1050.84,percent of total billed charges,
MESH,9036174,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1284.64000,372.55000,Aetna,First Health,,1050.84,,,,,,,463.11,1050.84,percent of total billed charges,
MESH,9036174,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1284.64000,372.55000,Aetna,First Health,,1050.84,,,,,,,413.65,1050.84,percent of total billed charges,
ANCHOR IN KIT,9036253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1962.02,4451.97,percent of total billed charges,
ANCHOR IN KIT,9036253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1752.48,4451.97,percent of total billed charges,
STAPLE,9036254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8634.00000,2503.86000,Aetna,First Health,,7062.61,,,,,,,3112.56,7062.61,percent of total billed charges,
STAPLE,9036254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8634.00000,2503.86000,Aetna,First Health,,7062.61,,,,,,,2780.15,7062.61,percent of total billed charges,
CAGE,9036255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,9036255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
BONE SCREW,9036257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,572.76000,166.10000,Aetna,First Health,,468.52,,,,,,,206.48,468.52,percent of total billed charges,
BONE SCREW,9036257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,572.76000,166.10000,Aetna,First Health,,468.52,,,,,,,184.43,468.52,percent of total billed charges,
SCREW BONE,9036258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1782.88000,517.04000,Aetna,First Health,,1458.40,,,,,,,642.73,1458.40,percent of total billed charges,
SCREW BONE,9036258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1782.88000,517.04000,Aetna,First Health,,1458.40,,,,,,,574.09,1458.40,percent of total billed charges,
LINER,9035410,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
LINER,9035410,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
CAGE,9035414,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,6529.56,14816.02,percent of total billed charges,
CAGE,9035414,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,First Health,,14816.02,,,,,,,5832.23,14816.02,percent of total billed charges,
PLATE,9036262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1222.30,2773.48,percent of total billed charges,
PLATE,9036262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,First Health,,2773.48,,,,,,,1091.76,2773.48,percent of total billed charges,
INSERT,9035411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9035411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
CAGE,9036296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17687.50000,5129.38000,Aetna,First Health,,14468.38,,,,,,,6376.34,14468.38,percent of total billed charges,
CAGE,9036296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17687.50000,5129.38000,Aetna,First Health,,14468.38,,,,,,,5695.38,14468.38,percent of total billed charges,
PLATE,9036300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
PLATE,9036300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SCREW,9036294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9036294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
ANCHOR IN KIT,9036295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1962.02,4451.97,percent of total billed charges,
ANCHOR IN KIT,9036295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1752.48,4451.97,percent of total billed charges,
PLATE,9036299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3689.35000,1069.91000,Aetna,First Health,,3017.89,,,,,,,1330.01,3017.89,percent of total billed charges,
PLATE,9036299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3689.35000,1069.91000,Aetna,First Health,,3017.89,,,,,,,1187.97,3017.89,percent of total billed charges,
SPACER,9036306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24547.50000,7118.78000,Aetna,First Health,,20079.85,,,,,,,8849.37,20079.85,percent of total billed charges,
SPACER,9036306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24547.50000,7118.78000,Aetna,First Health,,20079.85,,,,,,,7904.30,20079.85,percent of total billed charges,
SCREW,9035494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
SCREW,9035494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
SCREW,9035495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9035495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW,9035496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
SCREW,9035496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,9038156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW,9038156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
SPACER,9040156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24547.50000,7118.78000,Aetna,First Health,,20079.85,,,,,,,8849.37,20079.85,percent of total billed charges,
SPACER,9040156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24547.50000,7118.78000,Aetna,First Health,,20079.85,,,,,,,7904.30,20079.85,percent of total billed charges,
STEM,9040157,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM,9040157,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
NAIL,9040158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL,9040158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
SCREW,9040159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,755.39,1714.04,percent of total billed charges,
SCREW,9040159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,674.72,1714.04,percent of total billed charges,
SCREW,9038157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,755.39,1714.04,percent of total billed charges,
SCREW,9038157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,674.72,1714.04,percent of total billed charges,
PLATE,9040180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1364.70,3096.60,percent of total billed charges,
PLATE,9040180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,First Health,,3096.60,,,,,,,1218.95,3096.60,percent of total billed charges,
NAIL,9040182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL,9040182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
CAGE ANTERIOR,9040172,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,6430.42,14591.08,percent of total billed charges,
CAGE ANTERIOR,9040172,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,First Health,,14591.08,,,,,,,5743.68,14591.08,percent of total billed charges,
SCREW,9040173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW,9040173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
SCREW,9040174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SCREW,9040174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
STEM,9040175,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,9040175,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
PLATE,9040176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11076.00000,3212.04000,Aetna,First Health,,9060.17,,,,,,,3992.90,9060.17,percent of total billed charges,
PLATE,9040176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11076.00000,3212.04000,Aetna,First Health,,9060.17,,,,,,,3566.47,9060.17,percent of total billed charges,
PLATE,9040177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,9040177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
INSERT TIBIAL,9040184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9040184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
NAIL,9040185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,2146.24,4869.96,percent of total billed charges,
NAIL,9040185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,1917.03,4869.96,percent of total billed charges,
KNOTLESS AC REPAIR SYS,9040171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8156.25000,2365.31000,Aetna,First Health,,6671.81,,,,,,,2940.33,6671.81,percent of total billed charges,
KNOTLESS AC REPAIR SYS,9040171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8156.25000,2365.31000,Aetna,First Health,,6671.81,,,,,,,2626.31,6671.81,percent of total billed charges,
TIGHTROPE II,9040258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2939.84000,852.55000,Aetna,First Health,,2404.79,,,,,,,1059.81,2404.79,percent of total billed charges,
TIGHTROPE II,9040258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2939.84000,852.55000,Aetna,First Health,,2404.79,,,,,,,946.63,2404.79,percent of total billed charges,
TIGHTROPE II,9040259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2141.00000,620.89000,Aetna,First Health,,1751.34,,,,,,,771.83,1751.34,percent of total billed charges,
TIGHTROPE II,9040259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2141.00000,620.89000,Aetna,First Health,,1751.34,,,,,,,689.40,1751.34,percent of total billed charges,
COMPONENT TIBIAL,9040261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,9040261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
PLATE,9040262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1635.23,3710.45,percent of total billed charges,
PLATE,9040262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1460.59,3710.45,percent of total billed charges,
SLEEVE,9038265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SLEEVE,9038265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SHELL,9038266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,9038266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW,9038268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,9038268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
CONNECTOR THORACIC,9038269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CONNECTOR THORACIC,9038269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
ROD SPINAL,9038270,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
ROD SPINAL,9038270,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
ROD SPINAL,9038271,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
ROD SPINAL,9038271,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
MESH DYNAMIC,9040275,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5044.17000,1462.81000,Aetna,First Health,,4126.13,,,,,,,1818.42,4126.13,percent of total billed charges,
MESH DYNAMIC,9040275,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5044.17000,1462.81000,Aetna,First Health,,4126.13,,,,,,,1624.22,4126.13,percent of total billed charges,
SCREW CORT SLF TAP,9040276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,62.68,142.23,percent of total billed charges,
SCREW CORT SLF TAP,9040276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,First Health,,142.23,,,,,,,55.99,142.23,percent of total billed charges,
INSERT ASF CPS,9040300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT ASF CPS,9040300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SPACER,9040301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,6562.00,14889.65,percent of total billed charges,
SPACER,9040301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,5861.20,14889.65,percent of total billed charges,
SCREW,9042208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,9042208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
PLATE,9042193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3335.50000,967.30000,Aetna,First Health,,2728.44,,,,,,,1202.45,2728.44,percent of total billed charges,
PLATE,9042193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3335.50000,967.30000,Aetna,First Health,,2728.44,,,,,,,1074.03,2728.44,percent of total billed charges,
NAIL LONG,9042192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9042192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
STEM PSN,9042243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,2199.23,4990.21,percent of total billed charges,
STEM PSN,9042243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,First Health,,4990.21,,,,,,,1964.36,4990.21,percent of total billed charges,
SCREW,9042235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,9042235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
INSERT POLY,9042240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11448.00000,3319.92000,Aetna,First Health,,9364.46,,,,,,,4127.00,9364.46,percent of total billed charges,
INSERT POLY,9042240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11448.00000,3319.92000,Aetna,First Health,,9364.46,,,,,,,3686.26,9364.46,percent of total billed charges,
SCREW,9040346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,1061.31,2408.19,percent of total billed charges,
SCREW,9040346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,947.97,2408.19,percent of total billed charges,
SCREW,9040347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,1061.31,2408.19,percent of total billed charges,
SCREW,9040347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,947.97,2408.19,percent of total billed charges,
KWIRE,9040348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,326.52000,94.69000,Aetna,First Health,,267.09,,,,,,,117.71,267.09,percent of total billed charges,
KWIRE,9040348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,326.52000,94.69000,Aetna,First Health,,267.09,,,,,,,105.14,267.09,percent of total billed charges,
BASEPLATE,9040349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,5416.16,12289.66,percent of total billed charges,
BASEPLATE,9040349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,First Health,,12289.66,,,,,,,4837.74,12289.66,percent of total billed charges,
SPACER,9042242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,6562.00,14889.65,percent of total billed charges,
SPACER,9042242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,5861.20,14889.65,percent of total billed charges,
NAIL,9042244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,9042244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
SCREW,9042250,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,651.73,1478.81,percent of total billed charges,
SCREW,9042250,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,582.12,1478.81,percent of total billed charges,
SPACER,9042287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,4082.66,9263.85,percent of total billed charges,
SPACER,9042287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,First Health,,9263.85,,,,,,,3646.65,9263.85,percent of total billed charges,
STEM,9042288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24312.50000,7050.62000,Aetna,First Health,,19887.62,,,,,,,8764.66,19887.62,percent of total billed charges,
STEM,9042288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24312.50000,7050.62000,Aetna,First Health,,19887.62,,,,,,,7828.62,19887.62,percent of total billed charges,
ANCHOR IN KIT,9040365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,908.10,2060.54,percent of total billed charges,
ANCHOR IN KIT,9040365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,811.12,2060.54,percent of total billed charges,
SCREW,9042749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8489.49000,2461.95000,Aetna,First Health,,6944.40,,,,,,,3060.46,6944.40,percent of total billed charges,
SCREW,9042749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8489.49000,2461.95000,Aetna,First Health,,6944.40,,,,,,,2733.62,6944.40,percent of total billed charges,
HEAD HUMERAL,9042750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4078.31000,1182.71000,Aetna,First Health,,3336.06,,,,,,,1470.23,3336.06,percent of total billed charges,
HEAD HUMERAL,9042750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4078.31000,1182.71000,Aetna,First Health,,3336.06,,,,,,,1313.22,3336.06,percent of total billed charges,
TRUNNION 47MM,9042751,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.09000,2492.58000,Aetna,First Health,,7030.78,,,,,,,3098.53,7030.78,percent of total billed charges,
TRUNNION 47MM,9042751,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.09000,2492.58000,Aetna,First Health,,7030.78,,,,,,,2767.62,7030.78,percent of total billed charges,
INSERT GLENOID,9042753,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8744.73000,2535.97000,Aetna,First Health,,7153.19,,,,,,,3152.48,7153.19,percent of total billed charges,
INSERT GLENOID,9042753,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8744.73000,2535.97000,Aetna,First Health,,7153.19,,,,,,,2815.80,7153.19,percent of total billed charges,
NAIL HUMERUS,9042747,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4518.50000,1310.36000,Aetna,First Health,,3696.13,,,,,,,1628.92,3696.13,percent of total billed charges,
NAIL HUMERUS,9042747,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4518.50000,1310.36000,Aetna,First Health,,3696.13,,,,,,,1454.96,3696.13,percent of total billed charges,
VERTEBRAL PROSTHESIS,9042760,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18952.50000,5496.22000,Aetna,First Health,,15503.15,,,,,,,6832.38,15503.15,percent of total billed charges,
VERTEBRAL PROSTHESIS,9042760,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18952.50000,5496.22000,Aetna,First Health,,15503.15,,,,,,,6102.70,15503.15,percent of total billed charges,
NAIL LONG,9042761,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9042761,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
SCREW DRIVE LCKNG,9042762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW DRIVE LCKNG,9042762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
SCREW DRIVE NON LK,9042763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW DRIVE NON LK,9042763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
SCREW DRIVE NON LK,9042764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW DRIVE NON LK,9042764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
SCREW DRIVE NON LK,9042765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
SCREW DRIVE NON LK,9042765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
STEM FRACTURE,9040605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20275.00000,5879.75000,Aetna,First Health,,16584.95,,,,,,,7309.14,16584.95,percent of total billed charges,
STEM FRACTURE,9040605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20275.00000,5879.75000,Aetna,First Health,,16584.95,,,,,,,6528.55,16584.95,percent of total billed charges,
TUBE GAST,9042793,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,623.66000,180.86000,Aetna,First Health,,510.15,,,,,,,224.83,510.15,percent of total billed charges,
TUBE GAST,9042793,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,623.66000,180.86000,Aetna,First Health,,510.15,,,,,,,200.82,510.15,percent of total billed charges,
CAGE,9040628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE,9040628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
SCREW,9040629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,9040629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE,9040630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,26035.00000,7550.15000,Aetna,First Health,,21296.63,,,,,,,9385.62,21296.63,percent of total billed charges,
PLATE,9040630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,26035.00000,7550.15000,Aetna,First Health,,21296.63,,,,,,,8383.27,21296.63,percent of total billed charges,
INSERT,9042809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3486.76,7911.70,percent of total billed charges,
INSERT,9042809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,First Health,,7911.70,,,,,,,3114.38,7911.70,percent of total billed charges,
STEM,9040635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24312.50000,7050.62000,Aetna,First Health,,19887.62,,,,,,,8764.66,19887.62,percent of total billed charges,
STEM,9040635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24312.50000,7050.62000,Aetna,First Health,,19887.62,,,,,,,7828.62,19887.62,percent of total billed charges,
HEAD HUMERAL,9040637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,7018.94,15926.46,percent of total billed charges,
HEAD HUMERAL,9040637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,6269.34,15926.46,percent of total billed charges,
VERTEBRAL PROSTHESIS,9040712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
VERTEBRAL PROSTHESIS,9040712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
VERTEBRAL PROSTHESIS,9040713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
VERTEBRAL PROSTHESIS,9040713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
BONE MATRIX,9042845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
BONE MATRIX,9042845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
CAGE,9042853,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE,9042853,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
SCREW CORTICAL,9042854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW CORTICAL,9042854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
K WIRE,9042855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1248.00000,361.92000,Aetna,First Health,,1020.86,,,,,,,449.90,1020.86,percent of total billed charges,
K WIRE,9042855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1248.00000,361.92000,Aetna,First Health,,1020.86,,,,,,,401.86,1020.86,percent of total billed charges,
STEM,9042858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26499.33000,7684.81000,Aetna,First Health,,21676.45,,,,,,,9553.01,21676.45,percent of total billed charges,
STEM,9042858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26499.33000,7684.81000,Aetna,First Health,,21676.45,,,,,,,8532.78,21676.45,percent of total billed charges,
INSERT TIBIAL,9042859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9042859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
ROD TAPERED,9040757,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,987.77,2241.32,percent of total billed charges,
ROD TAPERED,9040757,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,882.28,2241.32,percent of total billed charges,
FEMORAL COMPONENT,9040758,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
FEMORAL COMPONENT,9040758,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
FEMORAL HEAD,9040759,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
FEMORAL HEAD,9040759,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
SCREW,9040787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW,9040787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
PLATE,9040788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1220.74,2769.95,percent of total billed charges,
PLATE,9040788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1090.37,2769.95,percent of total billed charges,
SCREW,9040789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,9040789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SCREW,9041052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9041052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,9041053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9041053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
BONE MATRIX,9041055,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
BONE MATRIX,9041055,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
SCREW SLF TPNG,9041057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW SLF TPNG,9041057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
SCREW SLF TPNG,9041058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW SLF TPNG,9041058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
SCREW SLF TPNG,9041059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,337.36,765.50,percent of total billed charges,
SCREW SLF TPNG,9041059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,First Health,,765.50,,,,,,,301.33,765.50,percent of total billed charges,
STEM,9041060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20748.10000,6016.95000,Aetna,First Health,,16971.95,,,,,,,7479.69,16971.95,percent of total billed charges,
STEM,9041060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20748.10000,6016.95000,Aetna,First Health,,16971.95,,,,,,,6680.89,16971.95,percent of total billed charges,
SHELL HUMERAL,9041061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
SHELL HUMERAL,9041061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
KIT QUICKSET 8CC,9041062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2968.72,6736.23,percent of total billed charges,
KIT QUICKSET 8CC,9041062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2651.67,6736.23,percent of total billed charges,
STEM HUMERAL,9043287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9043287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
SHELL ACETABULAR,9043288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
SHELL ACETABULAR,9043288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
FEMORAL HEAD,9043289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
FEMORAL HEAD,9043289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
COLLAR POLARSTEM,9043290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COLLAR POLARSTEM,9043290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
MESH BONE,9043291,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8084.88000,2344.62000,Aetna,First Health,,6613.43,,,,,,,2914.60,6613.43,percent of total billed charges,
MESH BONE,9043291,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8084.88000,2344.62000,Aetna,First Health,,6613.43,,,,,,,2603.33,6613.43,percent of total billed charges,
SCREW CORTICAL,9043292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
SCREW CORTICAL,9043292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
FOOT AND ANKLE KIT,9043293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
FOOT AND ANKLE KIT,9043293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
ANCHOR IN KIT,9043294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5546.63000,1608.52000,Aetna,First Health,,4537.14,,,,,,,1999.56,4537.14,percent of total billed charges,
ANCHOR IN KIT,9043294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5546.63000,1608.52000,Aetna,First Health,,4537.14,,,,,,,1786.01,4537.14,percent of total billed charges,
ANCHOR,9043286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,802.11,1820.05,percent of total billed charges,
ANCHOR,9043286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,716.45,1820.05,percent of total billed charges,
SCREW,9043309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,284.53,645.61,percent of total billed charges,
SCREW,9043309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,First Health,,645.61,,,,,,,254.14,645.61,percent of total billed charges,
POLARSTEM,9043310,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
POLARSTEM,9043310,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
COMPONENT TIBIAL,9043333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
COMPONENT TIBIAL,9043333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
COMPONENT FEMORAL,9043334,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9043334,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
STEM HUMERAL,9043335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9043335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM HUMERAL,9043336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17090.00000,4956.10000,Aetna,First Health,,13979.62,,,,,,,6160.94,13979.62,percent of total billed charges,
STEM HUMERAL,9043336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17090.00000,4956.10000,Aetna,First Health,,13979.62,,,,,,,5502.98,13979.62,percent of total billed charges,
SPACER,9043337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10299.30000,2986.80000,Aetna,First Health,,8424.83,,,,,,,3712.90,8424.83,percent of total billed charges,
SPACER,9043337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10299.30000,2986.80000,Aetna,First Health,,8424.83,,,,,,,3316.37,8424.83,percent of total billed charges,
STEM,9043338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20275.00000,5879.75000,Aetna,First Health,,16584.95,,,,,,,7309.14,16584.95,percent of total billed charges,
STEM,9043338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20275.00000,5879.75000,Aetna,First Health,,16584.95,,,,,,,6528.55,16584.95,percent of total billed charges,
STEM FEMORAL,9043340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM FEMORAL,9043340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
STEM,9043342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,9043342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
ANCHOR IN KIT,9041324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
ANCHOR IN KIT,9041324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
SCREW BONE,9041325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW BONE,9041325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
COMPONENT FEMORAL,9041326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9041326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
WEDGE FEMORAL,9041333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1297.08,2943.16,percent of total billed charges,
WEDGE FEMORAL,9041333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1158.56,2943.16,percent of total billed charges,
INSERT TIBIAL,9043409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9043409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW CORTICAL,9043410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW CORTICAL,9043410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
POLARSTEM,9041347,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
POLARSTEM,9041347,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SCREW CORTICAL,9043542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1448.00000,419.92000,Aetna,First Health,,1184.46,,,,,,,522.00,1184.46,percent of total billed charges,
SCREW CORTICAL,9043542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1448.00000,419.92000,Aetna,First Health,,1184.46,,,,,,,466.26,1184.46,percent of total billed charges,
TIGHTROPE KNOTLESS,9043543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.25000,2383.58000,Aetna,First Health,,6723.35,,,,,,,2963.04,6723.35,percent of total billed charges,
TIGHTROPE KNOTLESS,9043543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.25000,2383.58000,Aetna,First Health,,6723.35,,,,,,,2646.60,6723.35,percent of total billed charges,
SCREW CORTICAL,9043544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW CORTICAL,9043544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
HEAD FEMORAL,9043545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,9043545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
STEM FEMORAL,9043546,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2970.88,6741.14,percent of total billed charges,
STEM FEMORAL,9043546,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,First Health,,6741.14,,,,,,,2653.60,6741.14,percent of total billed charges,
SCREW SELF DRILL,9043547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW SELF DRILL,9043547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE TUBULAR,9043548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3853.50000,1117.51000,Aetna,First Health,,3152.16,,,,,,,1389.19,3152.16,percent of total billed charges,
PLATE TUBULAR,9043548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3853.50000,1117.51000,Aetna,First Health,,3152.16,,,,,,,1240.83,3152.16,percent of total billed charges,
SCREW NON LCKNG,9044244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW NON LCKNG,9044244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
DRESSING BIO MESHED,9043615,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,6233.50000,1807.72000,Aetna,First Health,,5099.00,,,,,,,2247.18,5099.00,percent of total billed charges,
DRESSING BIO MESHED,9043615,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,6233.50000,1807.72000,Aetna,First Health,,5099.00,,,,,,,124.65,5099.00,percent of total billed charges,
HEAD HUMERAL,9043616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,7018.94,15926.46,percent of total billed charges,
HEAD HUMERAL,9043616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,6269.34,15926.46,percent of total billed charges,
SHELL ACETABULER,9043617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3524.61,7997.59,percent of total billed charges,
SHELL ACETABULER,9043617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3148.19,7997.59,percent of total billed charges,
SCREW NON LCKNG,9044314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW NON LCKNG,9044314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW,9044317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,1017.55,2308.89,percent of total billed charges,
SCREW,9044317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,First Health,,2308.89,,,,,,,908.88,2308.89,percent of total billed charges,
CAGE TLIF,9044318,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
CAGE TLIF,9044318,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
ROD,9044319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
ROD,9044319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
PLATE,9044320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9675.00000,2805.75000,Aetna,First Health,,7914.15,,,,,,,3487.84,7914.15,percent of total billed charges,
PLATE,9044320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9675.00000,2805.75000,Aetna,First Health,,7914.15,,,,,,,3115.35,7914.15,percent of total billed charges,
CAGE SPINAL,9044321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
CAGE SPINAL,9044321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
LINER SHLDR,9044322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1811.62,4110.70,percent of total billed charges,
LINER SHLDR,9044322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1618.15,4110.70,percent of total billed charges,
GLENOSPHERE,9044323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
GLENOSPHERE,9044323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
COMPONENT FEMORAL,9044324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,9044324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
PLATE,9044325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1290.14,2927.42,percent of total billed charges,
PLATE,9044325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1152.36,2927.42,percent of total billed charges,
PIN,9044361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
PIN,9044361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
ANCHOR IN KIT,9044362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,802.11,1820.05,percent of total billed charges,
ANCHOR IN KIT,9044362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,First Health,,1820.05,,,,,,,716.45,1820.05,percent of total billed charges,
PLATE,9044364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4487.00000,1301.23000,Aetna,First Health,,3670.37,,,,,,,1617.56,3670.37,percent of total billed charges,
PLATE,9044364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4487.00000,1301.23000,Aetna,First Health,,3670.37,,,,,,,1444.81,3670.37,percent of total billed charges,
PNS SINGLE LEAD,9044373,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,6038.38,13701.50,percent of total billed charges,
PNS SINGLE LEAD,9044373,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,First Health,,13701.50,,,,,,,5393.50,13701.50,percent of total billed charges,
PNS DUAL LEAD,9044374,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,8652.00,19632.00,percent of total billed charges,
PNS DUAL LEAD,9044374,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,First Health,,19632.00,,,,,,,7728.00,19632.00,percent of total billed charges,
COMPONENT W BEARING,9044377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16445.00000,4769.05000,Aetna,First Health,,13452.01,,,,,,,5928.42,13452.01,percent of total billed charges,
COMPONENT W BEARING,9044377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16445.00000,4769.05000,Aetna,First Health,,13452.01,,,,,,,5295.29,13452.01,percent of total billed charges,
COMPONENT ULNA W BEARING,9044378,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17657.50000,5120.67000,Aetna,First Health,,14443.83,,,,,,,6365.53,14443.83,percent of total billed charges,
COMPONENT ULNA W BEARING,9044378,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17657.50000,5120.67000,Aetna,First Health,,14443.83,,,,,,,5685.72,14443.83,percent of total billed charges,
CAGE MODULUS,9043678,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE MODULUS,9043678,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
PLATE,9043697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4641.00000,1345.89000,Aetna,First Health,,3796.34,,,,,,,1673.08,3796.34,percent of total billed charges,
PLATE,9043697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4641.00000,1345.89000,Aetna,First Health,,3796.34,,,,,,,1494.40,3796.34,percent of total billed charges,
COMPONENT FEMORAL,9043698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,9043698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
LINER RETENTIVE,9043699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1811.62,4110.70,percent of total billed charges,
LINER RETENTIVE,9043699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1618.15,4110.70,percent of total billed charges,
GLENOID CEMENTED,9043701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13200.00000,3828.00000,Aetna,First Health,,10797.60,,,,,,,4758.60,10797.60,percent of total billed charges,
GLENOID CEMENTED,9043701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13200.00000,3828.00000,Aetna,First Health,,10797.60,,,,,,,4250.40,10797.60,percent of total billed charges,
SCREW CORTICAL,9043702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,826.20000,239.60000,Aetna,First Health,,675.83,,,,,,,297.85,675.83,percent of total billed charges,
SCREW CORTICAL,9043702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,826.20000,239.60000,Aetna,First Health,,675.83,,,,,,,266.04,675.83,percent of total billed charges,
PLATE,9043703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5289.90000,1534.07000,Aetna,First Health,,4327.14,,,,,,,1907.01,4327.14,percent of total billed charges,
PLATE,9043703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5289.90000,1534.07000,Aetna,First Health,,4327.14,,,,,,,1703.35,4327.14,percent of total billed charges,
SCREW CORTICAL,9043704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW CORTICAL,9043704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
SCREW LOCKING,9044428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW LOCKING,9044428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
COMPONENT TIBIAL,9044429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3725.77,8454.03,percent of total billed charges,
COMPONENT TIBIAL,9044429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,First Health,,8454.03,,,,,,,3327.87,8454.03,percent of total billed charges,
CAGE MODULUS,9043734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE MODULUS,9043734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
CONE FEMORAL,9043735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3942.07,8944.83,percent of total billed charges,
CONE FEMORAL,9043735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3521.07,8944.83,percent of total billed charges,
LINER,9043736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6693.75000,1941.19000,Aetna,First Health,,5475.49,,,,,,,2413.10,5475.49,percent of total billed charges,
LINER,9043736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6693.75000,1941.19000,Aetna,First Health,,5475.49,,,,,,,2155.39,5475.49,percent of total billed charges,
NAIL,9043737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,2146.24,4869.96,percent of total billed charges,
NAIL,9043737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,1917.03,4869.96,percent of total billed charges,
CAGE TLIF,9044638,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
CAGE TLIF,9044638,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
DISC SPINAL,9044639,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18800.00000,5452.00000,Aetna,First Health,,15378.40,,,,,,,6777.40,15378.40,percent of total billed charges,
DISC SPINAL,9044639,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18800.00000,5452.00000,Aetna,First Health,,15378.40,,,,,,,6053.60,15378.40,percent of total billed charges,
TIBIAL BEARING,9044640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
TIBIAL BEARING,9044640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW LOCKING,9044641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,261.18,592.64,percent of total billed charges,
SCREW LOCKING,9044641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,First Health,,592.64,,,,,,,233.29,592.64,percent of total billed charges,
HEAD FEMORAL,9044078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4540.73000,1316.81000,Aetna,First Health,,3714.32,,,,,,,1636.93,3714.32,percent of total billed charges,
HEAD FEMORAL,9044078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4540.73000,1316.81000,Aetna,First Health,,3714.32,,,,,,,1462.12,3714.32,percent of total billed charges,
SCREW,9044753,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SCREW,9044753,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
STEM FEMORAL,9044754,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,6507.04,14764.94,percent of total billed charges,
STEM FEMORAL,9044754,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,First Health,,14764.94,,,,,,,5812.12,14764.94,percent of total billed charges,
COLLAR POLARSTEM,9044755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COLLAR POLARSTEM,9044755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE,9044860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1746.40000,506.46000,Aetna,First Health,,1428.56,,,,,,,629.58,1428.56,percent of total billed charges,
PLATE,9044860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1746.40000,506.46000,Aetna,First Health,,1428.56,,,,,,,562.34,1428.56,percent of total billed charges,
KWIRE,9044861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
KWIRE,9044861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
SCREW BONE,9044862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,755.39,1714.04,percent of total billed charges,
SCREW BONE,9044862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,674.72,1714.04,percent of total billed charges,
ROD,9044868,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1360.00000,394.40000,Aetna,First Health,,1112.48,,,,,,,490.28,1112.48,percent of total billed charges,
ROD,9044868,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1360.00000,394.40000,Aetna,First Health,,1112.48,,,,,,,437.92,1112.48,percent of total billed charges,
STEM HUMERAL,9044140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10530.00000,3053.70000,Aetna,First Health,,8613.54,,,,,,,3796.07,8613.54,percent of total billed charges,
STEM HUMERAL,9044140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10530.00000,3053.70000,Aetna,First Health,,8613.54,,,,,,,3390.66,8613.54,percent of total billed charges,
ENDPLATE LOWER,9046257,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE LOWER,9046257,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
VERTEBRAL PROSTHESIS,9046258,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,6398.88,14519.50,percent of total billed charges,
VERTEBRAL PROSTHESIS,9046258,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,First Health,,14519.50,,,,,,,5715.50,14519.50,percent of total billed charges,
ENDPLATE UPPER,9046259,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ENDPLATE UPPER,9046259,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
NAIL LONG,9046260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9046260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
SCREW CORTICAL,9044904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1724.00000,499.96000,Aetna,First Health,,1410.23,,,,,,,621.50,1410.23,percent of total billed charges,
SCREW CORTICAL,9044904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1724.00000,499.96000,Aetna,First Health,,1410.23,,,,,,,555.13,1410.23,percent of total billed charges,
PLATE,9044905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,First Health,,7565.68,,,,,,,3334.26,7565.68,percent of total billed charges,
PLATE,9044905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,First Health,,7565.68,,,,,,,2978.18,7565.68,percent of total billed charges,
SCREW COMPRESSION,9044906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,584.01,1325.16,percent of total billed charges,
SCREW COMPRESSION,9044906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,521.64,1325.16,percent of total billed charges,
SCREW COMPRESSION,9044907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,584.01,1325.16,percent of total billed charges,
SCREW COMPRESSION,9044907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,521.64,1325.16,percent of total billed charges,
ANCHOR,9044908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3612.46000,1047.61000,Aetna,First Health,,2954.99,,,,,,,1302.29,2954.99,percent of total billed charges,
ANCHOR,9044908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3612.46000,1047.61000,Aetna,First Health,,2954.99,,,,,,,1163.21,2954.99,percent of total billed charges,
ANCHOR,9044909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
ANCHOR,9044909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
COMPONENT FEMORAL,9044910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,9044910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE TIBIAL,9044911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BASEPLATE TIBIAL,9044911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
PLATE,9044955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4039.00000,1171.31000,Aetna,First Health,,3303.90,,,,,,,1456.06,3303.90,percent of total billed charges,
PLATE,9044955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4039.00000,1171.31000,Aetna,First Health,,3303.90,,,,,,,1300.56,3303.90,percent of total billed charges,
COMPONENT FEMORAL,9044957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9044957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
PLATE,9044968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE,9044968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
BEARING PSN,9044971,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
BEARING PSN,9044971,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
CATHETER PTA,9044978,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER PTA,9044978,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
STEM HUMERAL,9044979,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15882.00000,4605.78000,Aetna,First Health,,12991.48,,,,,,,5725.46,12991.48,percent of total billed charges,
STEM HUMERAL,9044979,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15882.00000,4605.78000,Aetna,First Health,,12991.48,,,,,,,5114.00,12991.48,percent of total billed charges,
HEAD HUMERAL,9044980,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,9044980,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
COLLAR POLARSTEM,9044981,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COLLAR POLARSTEM,9044981,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
COMPONENT FEMORAL,9044982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9044982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
CATHETER  VENTRICULAR,9044984,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2781.76000,806.71000,Aetna,First Health,,2275.48,,,,,,,1002.82,2275.48,percent of total billed charges,
CATHETER  VENTRICULAR,9044984,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2781.76000,806.71000,Aetna,First Health,,2275.48,,,,,,,895.73,2275.48,percent of total billed charges,
CAGE SCREW,9045005,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
CAGE SCREW,9045005,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
HEAD HUMERAL,9045006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4078.31000,1182.71000,Aetna,First Health,,3336.06,,,,,,,1470.23,3336.06,percent of total billed charges,
HEAD HUMERAL,9045006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4078.31000,1182.71000,Aetna,First Health,,3336.06,,,,,,,1313.22,3336.06,percent of total billed charges,
PLATE,9045007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,868.08,1969.74,percent of total billed charges,
PLATE,9045007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,First Health,,1969.74,,,,,,,775.38,1969.74,percent of total billed charges,
INSERT FLEX,9046388,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1430.54,3245.99,percent of total billed charges,
INSERT FLEX,9046388,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,First Health,,3245.99,,,,,,,1277.76,3245.99,percent of total billed charges,
HEAD FEMORAL,9045040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2750.40000,797.62000,Aetna,First Health,,2249.83,,,,,,,991.52,2249.83,percent of total billed charges,
HEAD FEMORAL,9045040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2750.40000,797.62000,Aetna,First Health,,2249.83,,,,,,,885.63,2249.83,percent of total billed charges,
LINER,9045032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER,9045032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
SCREW ACETABULAR,9045033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,47.83,108.52,percent of total billed charges,
SCREW ACETABULAR,9045033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,First Health,,108.52,,,,,,,42.72,108.52,percent of total billed charges,
SCREW CHAMFERED,9045034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5369.00000,1557.01000,Aetna,First Health,,4391.84,,,,,,,1935.52,4391.84,percent of total billed charges,
SCREW CHAMFERED,9045034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5369.00000,1557.01000,Aetna,First Health,,4391.84,,,,,,,1728.82,4391.84,percent of total billed charges,
STEM HUMERAL,9045035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9045035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
SCREW CANNULATED,9046385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW CANNULATED,9046385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW CANNULATED,9046386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,651.73,1478.81,percent of total billed charges,
SCREW CANNULATED,9046386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,582.12,1478.81,percent of total billed charges,
PLATE,9046387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2312.00000,670.48000,Aetna,First Health,,1891.22,,,,,,,833.48,1891.22,percent of total billed charges,
PLATE,9046387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2312.00000,670.48000,Aetna,First Health,,1891.22,,,,,,,744.46,1891.22,percent of total billed charges,
INSERT POLY,9045041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14673.00000,4255.17000,Aetna,First Health,,12002.51,,,,,,,5289.62,12002.51,percent of total billed charges,
INSERT POLY,9045041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14673.00000,4255.17000,Aetna,First Health,,12002.51,,,,,,,4724.71,12002.51,percent of total billed charges,
SCREW COMPRESSION,9045042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,1061.31,2408.19,percent of total billed charges,
SCREW COMPRESSION,9045042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,947.97,2408.19,percent of total billed charges,
SCREW COMPRESSION,9045043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,1061.31,2408.19,percent of total billed charges,
SCREW COMPRESSION,9045043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,First Health,,2408.19,,,,,,,947.97,2408.19,percent of total billed charges,
STEM ULNAR,9046434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15307.50000,4439.17000,Aetna,First Health,,12521.53,,,,,,,5518.35,12521.53,percent of total billed charges,
STEM ULNAR,9046434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15307.50000,4439.17000,Aetna,First Health,,12521.53,,,,,,,4929.02,12521.53,percent of total billed charges,
PLATE SPINAL,9046435,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE SPINAL,9046435,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
SPACER INNER BODY,9046436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SPACER INNER BODY,9046436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
STEM HUMERAL,9046433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20222.50000,5864.52000,Aetna,First Health,,16542.01,,,,,,,7290.21,16542.01,percent of total billed charges,
STEM HUMERAL,9046433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20222.50000,5864.52000,Aetna,First Health,,16542.01,,,,,,,6511.65,16542.01,percent of total billed charges,
SPACER INTERBODY,9046473,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8334.00000,2416.86000,Aetna,First Health,,6817.21,,,,,,,3004.41,6817.21,percent of total billed charges,
SPACER INTERBODY,9046473,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8334.00000,2416.86000,Aetna,First Health,,6817.21,,,,,,,2683.55,6817.21,percent of total billed charges,
PLATE ACP,9046474,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE ACP,9046474,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
LINER,9046475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8392.50000,2433.82000,Aetna,First Health,,6865.06,,,,,,,3025.50,6865.06,percent of total billed charges,
LINER,9046475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8392.50000,2433.82000,Aetna,First Health,,6865.06,,,,,,,2702.39,6865.06,percent of total billed charges,
ANCHOR,9046476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2015.00000,584.35000,Aetna,First Health,,1648.27,,,,,,,726.41,1648.27,percent of total billed charges,
ANCHOR,9046476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2015.00000,584.35000,Aetna,First Health,,1648.27,,,,,,,648.83,1648.27,percent of total billed charges,
VERTEBRAL PROSTHESIS,9046516,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19000.00000,5510.00000,Aetna,First Health,,15542.00,,,,,,,6849.50,15542.00,percent of total billed charges,
VERTEBRAL PROSTHESIS,9046516,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19000.00000,5510.00000,Aetna,First Health,,15542.00,,,,,,,6118.00,15542.00,percent of total billed charges,
SCREW,9046517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,9046517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW SELF DRILL,9046518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SELF DRILL,9046518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ENDPLATE UPPER,9046519,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,First Health,,3421.28,,,,,,,1507.79,3421.28,percent of total billed charges,
ENDPLATE UPPER,9046519,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,First Health,,3421.28,,,,,,,1346.77,3421.28,percent of total billed charges,
ENDPLATE LOWER,9046520,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,First Health,,3421.28,,,,,,,1507.79,3421.28,percent of total billed charges,
ENDPLATE LOWER,9046520,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,First Health,,3421.28,,,,,,,1346.77,3421.28,percent of total billed charges,
SPINAL CEMENT SYSTEM,9046530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5418.18000,1571.27000,Aetna,First Health,,4432.07,,,,,,,1953.25,4432.07,percent of total billed charges,
SPINAL CEMENT SYSTEM,9046530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5418.18000,1571.27000,Aetna,First Health,,4432.07,,,,,,,1744.65,4432.07,percent of total billed charges,
SCREW POLYAXIAL,9046521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4453.23000,1291.44000,Aetna,First Health,,3642.74,,,,,,,1605.39,3642.74,percent of total billed charges,
SCREW POLYAXIAL,9046521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4453.23000,1291.44000,Aetna,First Health,,3642.74,,,,,,,1433.94,3642.74,percent of total billed charges,
NAIL LONG,9045244,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9045244,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
STEM FEMORAL,9045259,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7326.00000,2124.54000,Aetna,First Health,,5992.67,,,,,,,2641.02,5992.67,percent of total billed charges,
STEM FEMORAL,9045259,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7326.00000,2124.54000,Aetna,First Health,,5992.67,,,,,,,2358.97,5992.67,percent of total billed charges,
PLATE ACP,9045260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1290.14,2927.42,percent of total billed charges,
PLATE ACP,9045260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1152.36,2927.42,percent of total billed charges,
NAIL RETRO T2,9045261,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL RETRO T2,9045261,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
SCREW COMPRESSION,9045262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,860.66,1952.89,percent of total billed charges,
SCREW COMPRESSION,9045262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,First Health,,1952.89,,,,,,,768.74,1952.89,percent of total billed charges,
NAIL LONG,9045263,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9045263,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
SPINAL DISC,9046560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18800.00000,5452.00000,Aetna,First Health,,15378.40,,,,,,,6777.40,15378.40,percent of total billed charges,
SPINAL DISC,9046560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18800.00000,5452.00000,Aetna,First Health,,15378.40,,,,,,,6053.60,15378.40,percent of total billed charges,
BONE ANCHOR,9046561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3250.45000,942.63000,Aetna,First Health,,2658.87,,,,,,,1171.79,2658.87,percent of total billed charges,
BONE ANCHOR,9046561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3250.45000,942.63000,Aetna,First Health,,2658.87,,,,,,,1046.64,2658.87,percent of total billed charges,
XBRAID NO NEEDLE,9045328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
XBRAID NO NEEDLE,9045328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
HUMERUS PROXIMAL,9045329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16585.00000,4809.65000,Aetna,First Health,,13566.53,,,,,,,5978.89,13566.53,percent of total billed charges,
HUMERUS PROXIMAL,9045329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16585.00000,4809.65000,Aetna,First Health,,13566.53,,,,,,,5340.37,13566.53,percent of total billed charges,
STENT GRAFT,9045245,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3824.18,8677.34,percent of total billed charges,
STENT GRAFT,9045245,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3415.78,8677.34,percent of total billed charges,
STENT GRAFT,9045246,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9045246,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,9045247,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9045247,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,9045248,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9045248,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,9045249,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9045249,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,9045250,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9045250,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,9045251,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9045251,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,9045252,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9045252,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,9045253,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9045253,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,9045254,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9045254,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,9045255,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9045255,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
SCREW COMPRESSION,9045340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SCREW COMPRESSION,9045340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
SCREW COMPRESSION,9045341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,563.82,1279.35,percent of total billed charges,
SCREW COMPRESSION,9045341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,First Health,,1279.35,,,,,,,503.61,1279.35,percent of total billed charges,
BONE ANCHOR,9045342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1962.02,4451.97,percent of total billed charges,
BONE ANCHOR,9045342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1752.48,4451.97,percent of total billed charges,
NAIL LONG,9045343,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9045343,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
ANCHOR KNOTLESS,9045385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3542.18000,1027.23000,Aetna,First Health,,2897.50,,,,,,,1276.96,2897.50,percent of total billed charges,
ANCHOR KNOTLESS,9045385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3542.18000,1027.23000,Aetna,First Health,,2897.50,,,,,,,1140.58,2897.50,percent of total billed charges,
SCREW LOCKING,9045380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW LOCKING,9045380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW LOCKING,9045381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW LOCKING,9045381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
SCREW RELINE,9045382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,525.09,1191.47,percent of total billed charges,
SCREW RELINE,9045382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,469.01,1191.47,percent of total billed charges,
SCREW SELF DRILL,9045383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,498.93,1132.11,percent of total billed charges,
SCREW SELF DRILL,9045383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,445.65,1132.11,percent of total billed charges,
ANCHOR KNOTLESS,9045504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
ANCHOR KNOTLESS,9045504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
STEM FEMORAL,9046736,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM FEMORAL,9046736,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE TIBIAL,9045687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6270.39000,1818.41000,Aetna,First Health,,5129.18,,,,,,,2260.48,5129.18,percent of total billed charges,
PLATE TIBIAL,9045687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6270.39000,1818.41000,Aetna,First Health,,5129.18,,,,,,,2019.07,5129.18,percent of total billed charges,
CAGE ANCHOR,9047089,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CAGE ANCHOR,9047089,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STEM PRESSFIT,9047090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM PRESSFIT,9047090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
GLENOSPHERE INHANCE,9045896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
GLENOSPHERE INHANCE,9045896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
LINER HUMERAL,9045897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1811.62,4110.70,percent of total billed charges,
LINER HUMERAL,9045897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1618.15,4110.70,percent of total billed charges,
CATHETER PERITONEAL,9045903,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1963.32000,569.36000,Aetna,First Health,,1606.00,,,,,,,707.78,1606.00,percent of total billed charges,
CATHETER PERITONEAL,9045903,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1963.32000,569.36000,Aetna,First Health,,1606.00,,,,,,,632.19,1606.00,percent of total billed charges,
INTRODUCER SHEATH,9046017,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,5602.49000,1624.72000,Aetna,First Health,,4582.84,,,,,,,2019.70,4582.84,percent of total billed charges,
INTRODUCER SHEATH,9046017,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,5602.49000,1624.72000,Aetna,First Health,,4582.84,,,,,,,1804.00,4582.84,percent of total billed charges,
SCREW SPINAL,9045992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
SCREW SPINAL,9045992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
PLATE SPINAL,9045993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,461.44,1047.04,percent of total billed charges,
PLATE SPINAL,9045993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,First Health,,1047.04,,,,,,,412.16,1047.04,percent of total billed charges,
CAGE,9045994,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16137.50000,4679.88000,Aetna,First Health,,13200.48,,,,,,,5817.57,13200.48,percent of total billed charges,
CAGE,9045994,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16137.50000,4679.88000,Aetna,First Health,,13200.48,,,,,,,5196.27,13200.48,percent of total billed charges,
SCREW CORTICAL,9045995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW CORTICAL,9045995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
SCREW,9046001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,755.39,1714.04,percent of total billed charges,
SCREW,9046001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,674.72,1714.04,percent of total billed charges,
SCREW,9046002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,755.39,1714.04,percent of total billed charges,
SCREW,9046002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,674.72,1714.04,percent of total billed charges,
COMPONENT FEMORAL,9046003,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
COMPONENT FEMORAL,9046003,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
WEDGE TIBIAL,9046020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19627.50000,5691.98000,Aetna,First Health,,16055.30,,,,,,,7075.71,16055.30,percent of total billed charges,
WEDGE TIBIAL,9046020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19627.50000,5691.98000,Aetna,First Health,,16055.30,,,,,,,6320.06,16055.30,percent of total billed charges,
STEM HUMERAL,9046050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20222.50000,5864.52000,Aetna,First Health,,16542.01,,,,,,,7290.21,16542.01,percent of total billed charges,
STEM HUMERAL,9046050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20222.50000,5864.52000,Aetna,First Health,,16542.01,,,,,,,6511.65,16542.01,percent of total billed charges,
CAGE TLIF,9046051,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
CAGE TLIF,9046051,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
SCREW,9046052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
SCREW,9046052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
BEARING TIBIAL,9046053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
BEARING TIBIAL,9046053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
FIXATION HALF PIN,9046054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,370.50000,107.44000,Aetna,First Health,,303.07,,,,,,,133.57,303.07,percent of total billed charges,
FIXATION HALF PIN,9046054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,370.50000,107.44000,Aetna,First Health,,303.07,,,,,,,119.30,303.07,percent of total billed charges,
FIXATION PIN,9046055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,370.50000,107.44000,Aetna,First Health,,303.07,,,,,,,133.57,303.07,percent of total billed charges,
FIXATION PIN,9046055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,370.50000,107.44000,Aetna,First Health,,303.07,,,,,,,119.30,303.07,percent of total billed charges,
SCREW LOCKING,9046060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW LOCKING,9046060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW LOCKING,9046061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW LOCKING,9046061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
PLATE,9046062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
PLATE,9046062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
NAIL LONG,9046063,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9046063,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
SCREW,9047256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9047256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE TUBULAR,9047257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2652.00000,769.08000,Aetna,First Health,,2169.34,,,,,,,956.05,2169.34,percent of total billed charges,
PLATE TUBULAR,9047257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2652.00000,769.08000,Aetna,First Health,,2169.34,,,,,,,853.94,2169.34,percent of total billed charges,
PLATE OFFSET,9047258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3076.00000,892.04000,Aetna,First Health,,2516.17,,,,,,,1108.90,2516.17,percent of total billed charges,
PLATE OFFSET,9047258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3076.00000,892.04000,Aetna,First Health,,2516.17,,,,,,,990.47,2516.17,percent of total billed charges,
PLATE HUMERAL,9047259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3446.74,7820.90,percent of total billed charges,
PLATE HUMERAL,9047259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,First Health,,7820.90,,,,,,,3078.64,7820.90,percent of total billed charges,
CATHETER GUIDEZILLA,9048181,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,First Health,,1525.57,,,,,,,672.33,1525.57,percent of total billed charges,
CATHETER GUIDEZILLA,9048181,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,First Health,,1525.57,,,,,,,600.53,1525.57,percent of total billed charges,
SCREW CANNULATED,9047274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW CANNULATED,9047274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW CANNULATED,9047275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW CANNULATED,9047275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW LAG,9048167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3141.20000,910.95000,Aetna,First Health,,2569.50,,,,,,,1132.40,2569.50,percent of total billed charges,
SCREW LAG,9048167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3141.20000,910.95000,Aetna,First Health,,2569.50,,,,,,,1011.47,2569.50,percent of total billed charges,
SCREW NON LCKNG,9048168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,288.76,655.22,percent of total billed charges,
SCREW NON LCKNG,9048168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,First Health,,655.22,,,,,,,257.92,655.22,percent of total billed charges,
SCREW LCKG,9048169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW LCKG,9048169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
HEAD FEMORAL,9048170,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1272.79,2888.06,percent of total billed charges,
HEAD FEMORAL,9048170,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,First Health,,2888.06,,,,,,,1136.86,2888.06,percent of total billed charges,
MESH REINFORCED,9048174,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,13800.00000,4002.00000,Aetna,First Health,,11288.40,,,,,,,4974.90,11288.40,percent of total billed charges,
MESH REINFORCED,9048174,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,13800.00000,4002.00000,Aetna,First Health,,11288.40,,,,,,,4443.60,11288.40,percent of total billed charges,
NAIL TIBIAL,9048171,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL TIBIAL,9048171,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
SCREW LCKG,9048172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW LCKG,9048172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
ANKLE PROSTHESIS,9048176,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3360.22,7624.58,percent of total billed charges,
ANKLE PROSTHESIS,9048176,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3001.36,7624.58,percent of total billed charges,
SCREW CANNULATED,9048177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,651.73,1478.81,percent of total billed charges,
SCREW CANNULATED,9048177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,582.12,1478.81,percent of total billed charges,
ANCHOR IN KIT,9048178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,866.64,1966.47,percent of total billed charges,
ANCHOR IN KIT,9048178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,774.09,1966.47,percent of total billed charges,
STAPLE BONE FIXATION,9048182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9015.00000,2614.35000,Aetna,First Health,,7374.27,,,,,,,3249.91,7374.27,percent of total billed charges,
STAPLE BONE FIXATION,9048182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9015.00000,2614.35000,Aetna,First Health,,7374.27,,,,,,,2902.83,7374.27,percent of total billed charges,
STAPLE EASYFUSE,9048183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8634.00000,2503.86000,Aetna,First Health,,7062.61,,,,,,,3112.56,7062.61,percent of total billed charges,
STAPLE EASYFUSE,9048183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8634.00000,2503.86000,Aetna,First Health,,7062.61,,,,,,,2780.15,7062.61,percent of total billed charges,
SCREW BONE,9048243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
SCREW BONE,9048243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
ANCHOR Y KNOT,9048175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
ANCHOR Y KNOT,9048175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
FEMORAL COMPONENT,9048221,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
FEMORAL COMPONENT,9048221,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
FIBERSTITCH,9048255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.84000,797.74000,Aetna,First Health,,2250.19,,,,,,,991.68,2250.19,percent of total billed charges,
FIBERSTITCH,9048255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.84000,797.74000,Aetna,First Health,,2250.19,,,,,,,885.77,2250.19,percent of total billed charges,
SCREW SPINAL,9048276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1664.25,3776.30,percent of total billed charges,
SCREW SPINAL,9048276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,First Health,,3776.30,,,,,,,1486.51,3776.30,percent of total billed charges,
LINER ACETB,9048277,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1362.69,3092.04,percent of total billed charges,
LINER ACETB,9048277,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,First Health,,3092.04,,,,,,,1217.16,3092.04,percent of total billed charges,
PLATE COMPRESSION,9048278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3265.50000,946.99000,Aetna,First Health,,2671.18,,,,,,,1177.21,2671.18,percent of total billed charges,
PLATE COMPRESSION,9048278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3265.50000,946.99000,Aetna,First Health,,2671.18,,,,,,,1051.49,2671.18,percent of total billed charges,
PLATE CERVICAL,9048279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
PLATE CERVICAL,9048279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
CATHETER VALVULOPLASTY,9050253,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
CATHETER VALVULOPLASTY,9050253,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
SCREW CANNULATED,9048292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW CANNULATED,9048292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
ANCHOR STIMULATOR,9048293,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,558.23000,161.89000,Aetna,First Health,,456.63,,,,,,,201.24,456.63,percent of total billed charges,
ANCHOR STIMULATOR,9048293,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,558.23000,161.89000,Aetna,First Health,,456.63,,,,,,,179.75,456.63,percent of total billed charges,
LEAD OCTRODE,9048309,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LEAD OCTRODE,9048309,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
GUIDEWIRE,9048310,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,597.15000,173.17000,Aetna,First Health,,488.47,,,,,,,215.27,488.47,percent of total billed charges,
GUIDEWIRE,9048310,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,597.15000,173.17000,Aetna,First Health,,488.47,,,,,,,192.28,488.47,percent of total billed charges,
TOTAL HIP KIT,9048311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1740.00000,504.60000,Aetna,First Health,,1423.32,,,,,,,627.27,1423.32,percent of total billed charges,
TOTAL HIP KIT,9048311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1740.00000,504.60000,Aetna,First Health,,1423.32,,,,,,,560.28,1423.32,percent of total billed charges,
ANCHOR SUTURE,9048331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,764.26,1734.16,percent of total billed charges,
ANCHOR SUTURE,9048331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,First Health,,1734.16,,,,,,,682.64,1734.16,percent of total billed charges,
SCREW COMPRESSION,9048332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW COMPRESSION,9048332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
NAIL FEMORAL,9048333,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL FEMORAL,9048333,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
VASCULAR HEMASHIELD,9048334,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,848.93000,246.19000,Aetna,First Health,,694.42,,,,,,,306.04,694.42,percent of total billed charges,
VASCULAR HEMASHIELD,9048334,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,848.93000,246.19000,Aetna,First Health,,694.42,,,,,,,273.36,694.42,percent of total billed charges,
SCREW LAG,9050283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,943.76,2141.46,percent of total billed charges,
SCREW LAG,9050283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,842.97,2141.46,percent of total billed charges,
STEM HIP,9048472,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,892.60,2025.37,percent of total billed charges,
STEM HIP,9048472,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,First Health,,2025.37,,,,,,,797.27,2025.37,percent of total billed charges,
FEMORAL HEAD,9048473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,929.25000,269.48000,Aetna,First Health,,760.13,,,,,,,334.99,760.13,percent of total billed charges,
FEMORAL HEAD,9048473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,929.25000,269.48000,Aetna,First Health,,760.13,,,,,,,299.22,760.13,percent of total billed charges,
ROD THORACOLUMBAR,9048474,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD THORACOLUMBAR,9048474,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
GLENOSPHERE,9048475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1956.97,4440.51,percent of total billed charges,
GLENOSPHERE,9048475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,First Health,,4440.51,,,,,,,1747.98,4440.51,percent of total billed charges,
PLATE SACRAL,9048476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE SACRAL,9048476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
SCREW THORACOLUMBAR,9048477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW THORACOLUMBAR,9048477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE LUMBAR,9048478,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE LUMBAR,9048478,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
TRUSS OSTEOTOMY,9048479,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,6518.74,14791.49,percent of total billed charges,
TRUSS OSTEOTOMY,9048479,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,First Health,,14791.49,,,,,,,5822.56,14791.49,percent of total billed charges,
INSERT,9048503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,9048503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
SCREW CORTICAL,9048506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW CORTICAL,9048506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
PLATE HUMERUS,9048507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5676.30000,1646.13000,Aetna,First Health,,4643.21,,,,,,,2046.31,4643.21,percent of total billed charges,
PLATE HUMERUS,9048507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5676.30000,1646.13000,Aetna,First Health,,4643.21,,,,,,,1827.77,4643.21,percent of total billed charges,
KWIRE,9048508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
KWIRE,9048508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,96.66,245.56,percent of total billed charges,
SCREW,9048525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,671.84,1524.46,percent of total billed charges,
SCREW,9048525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,600.09,1524.46,percent of total billed charges,
COMPONENT TIBIAL,9048522,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9048522,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9048523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9048523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW CORTICAL,9048530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW CORTICAL,9048530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE ACP,9048531,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1290.14,2927.42,percent of total billed charges,
PLATE ACP,9048531,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1152.36,2927.42,percent of total billed charges,
NAIL LONG,9048532,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9048532,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
PLATE DISTAL,9048533,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5289.90000,1534.07000,Aetna,First Health,,4327.14,,,,,,,1907.01,4327.14,percent of total billed charges,
PLATE DISTAL,9048533,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5289.90000,1534.07000,Aetna,First Health,,4327.14,,,,,,,1703.35,4327.14,percent of total billed charges,
SCREW CORTICAL,9048534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW CORTICAL,9048534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
LINER ACETABULAR,9048537,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER ACETABULAR,9048537,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
POLARSTEM,9048538,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
POLARSTEM,9048538,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SHELL  ACETABULAR,9048539,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3524.61,7997.59,percent of total billed charges,
SHELL  ACETABULAR,9048539,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,First Health,,7997.59,,,,,,,3148.19,7997.59,percent of total billed charges,
COMPONENT FEMORAL,9048540,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
COMPONENT FEMORAL,9048540,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
CATHETER STINGRAY,9052182,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,9819.00000,2847.51000,Aetna,First Health,,8031.94,,,,,,,3539.75,8031.94,percent of total billed charges,
CATHETER STINGRAY,9052182,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,9819.00000,2847.51000,Aetna,First Health,,8031.94,,,,,,,3161.72,8031.94,percent of total billed charges,
GUIDEWIRE,9052183,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,9052183,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER MICRO,9052184,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,First Health,,2296.94,,,,,,,1012.28,2296.94,percent of total billed charges,
CATHETER MICRO,9052184,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,First Health,,2296.94,,,,,,,904.18,2296.94,percent of total billed charges,
SCREW COMPRESSION,9048625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW COMPRESSION,9048625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
BONE CEMENT,9048627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
BONE CEMENT,9048627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
PLATE ACP,9048628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE ACP,9048628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
DISC INTERVERTEBRAL,9048629,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18800.00000,5452.00000,Aetna,First Health,,15378.40,,,,,,,6777.40,15378.40,percent of total billed charges,
DISC INTERVERTEBRAL,9048629,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18800.00000,5452.00000,Aetna,First Health,,15378.40,,,,,,,6053.60,15378.40,percent of total billed charges,
STEM FEMORAL,9048637,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4609.35,10458.95,percent of total billed charges,
STEM FEMORAL,9048637,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4117.09,10458.95,percent of total billed charges,
HEAD FEMORAL,9048638,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,9048638,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
COMPONENT FEMORAL,9052185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
COMPONENT FEMORAL,9052185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
COMPONENT TIBIAL,9052186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
COMPONENT TIBIAL,9052186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
MICROCATHETER CARAVEL,9044895,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
MICROCATHETER CARAVEL,9044895,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
MICROCATHETER CORSAIR,9044896,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
MICROCATHETER CORSAIR,9044896,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
GUIDEWIRE FIELDER,9044897,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE FIELDER,9044897,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
GUIDEWIRE GLADIUS,9044898,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE GLADIUS,9044898,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER METACROSS,9045502,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1712.00000,496.48000,Aetna,First Health,,1400.42,,,,,,,617.18,1400.42,percent of total billed charges,
CATHETER METACROSS,9045502,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1712.00000,496.48000,Aetna,First Health,,1400.42,,,,,,,551.26,1400.42,percent of total billed charges,
CATHETER METACROSS,9045503,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1712.00000,496.48000,Aetna,First Health,,1400.42,,,,,,,617.18,1400.42,percent of total billed charges,
CATHETER METACROSS,9045503,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1712.00000,496.48000,Aetna,First Health,,1400.42,,,,,,,551.26,1400.42,percent of total billed charges,
CATHETER NAVICROSS,9045501,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,488.12,1107.57,percent of total billed charges,
CATHETER NAVICROSS,9045501,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,435.99,1107.57,percent of total billed charges,
TIBIAL TRAY,9052187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
TIBIAL TRAY,9052187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW POLYAXIAL,9052188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW POLYAXIAL,9052188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
SCREW POLYAXIAL,9052189,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1153.60,2617.60,percent of total billed charges,
SCREW POLYAXIAL,9052189,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1030.40,2617.60,percent of total billed charges,
CERVICAL DISC,9048639,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
CERVICAL DISC,9048639,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
SCREW MULTI AXIAL,9052191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW MULTI AXIAL,9052191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
HEAD FEMORAL,9054159,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,9054159,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
STENT GRAFT,9048827,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45099.00000,13078.71000,Aetna,First Health,,36890.98,,,,,,,16258.19,36890.98,percent of total billed charges,
STENT GRAFT,9048827,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45099.00000,13078.71000,Aetna,First Health,,36890.98,,,,,,,14521.88,36890.98,percent of total billed charges,
NAIL LONG,9048828,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9048828,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
STEM HUMERAL,9048829,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9048829,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
STEM FRACTURE,9048830,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20275.00000,5879.75000,Aetna,First Health,,16584.95,,,,,,,7309.14,16584.95,percent of total billed charges,
STEM FRACTURE,9048830,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20275.00000,5879.75000,Aetna,First Health,,16584.95,,,,,,,6528.55,16584.95,percent of total billed charges,
SCREW ANTERIOR,9048824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW ANTERIOR,9048824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CAGE ANTERIOR,9048825,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE ANTERIOR,9048825,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
CAGE ANTERIOR,9048826,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE ANTERIOR,9048826,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
GRAFT ENDOVASCULAR,9048832,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,9569.47,21713.81,percent of total billed charges,
GRAFT ENDOVASCULAR,9048832,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,First Health,,21713.81,,,,,,,8547.49,21713.81,percent of total billed charges,
ROD REVERSE,9048833,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
ROD REVERSE,9048833,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
STEM TIBIAL,9054178,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
STEM TIBIAL,9054178,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
NOVOSORB BTM,9048877,CDM,278,RC,Q4104,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
NOVOSORB BTM,9048877,CDM,278,RC,Q4104,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,56.25,7975.50,percent of total billed charges,
PANCREATIC STENT,9048890,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,457.90000,132.79000,Aetna,First Health,,374.56,,,,,,,165.07,374.56,percent of total billed charges,
PANCREATIC STENT,9048890,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,457.90000,132.79000,Aetna,First Health,,374.56,,,,,,,147.44,374.56,percent of total billed charges,
WEDGE,9048886,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
WEDGE,9048886,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
COMPONENT FEMORAL,9048887,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9048887,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
COMPONENT TIBIAL,9048888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9048888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
LINER ACETABULAR,9048889,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER ACETABULAR,9048889,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
GUIDEPIN,9054203,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,266.70,605.16,percent of total billed charges,
GUIDEPIN,9054203,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,First Health,,605.16,,,,,,,238.22,605.16,percent of total billed charges,
SCREW CANCELLOUS,9054204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1419.20000,411.57000,Aetna,First Health,,1160.91,,,,,,,511.62,1160.91,percent of total billed charges,
SCREW CANCELLOUS,9054204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1419.20000,411.57000,Aetna,First Health,,1160.91,,,,,,,456.98,1160.91,percent of total billed charges,
NAIL,9054206,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8571.60000,2485.76000,Aetna,First Health,,7011.57,,,,,,,3090.06,7011.57,percent of total billed charges,
NAIL,9054206,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8571.60000,2485.76000,Aetna,First Health,,7011.57,,,,,,,2760.06,7011.57,percent of total billed charges,
SCREW DISTAL,9054207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW DISTAL,9054207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW DISTAL,9054208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW DISTAL,9054208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW DISTAL,9054209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW DISTAL,9054209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
SCREW DISTAL,9054210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,336.78,764.18,percent of total billed charges,
SCREW DISTAL,9054210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,First Health,,764.18,,,,,,,300.81,764.18,percent of total billed charges,
PATELLAR TRIATHLON,9054211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
PATELLAR TRIATHLON,9054211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
TIBIAL INSERT,9054212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
TIBIAL INSERT,9054212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
TIBIAL INSERT,9054213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
TIBIAL INSERT,9054213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SHEATH PROTRIEVE,9054300,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,5137.12,11656.50,percent of total billed charges,
SHEATH PROTRIEVE,9054300,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,First Health,,11656.50,,,,,,,4588.50,11656.50,percent of total billed charges,
PLUG PORT,9048979,CDM,278,RC,L9900,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
PLUG PORT,9048979,CDM,278,RC,L9900,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW COMPRESSION,9048996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW COMPRESSION,9048996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW COMPRESSION,9048997,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW COMPRESSION,9048997,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW COMPRESSION,9048998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW COMPRESSION,9048998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
PLATE CLAVICLE,9048999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE CLAVICLE,9048999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
STEM HUMERAL,9049000,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9049000,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
PLATE ACP,9049001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1220.74,2769.95,percent of total billed charges,
PLATE ACP,9049001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1090.37,2769.95,percent of total billed charges,
GLENOID HYBRID,9049002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13200.00000,3828.00000,Aetna,First Health,,10797.60,,,,,,,4758.60,10797.60,percent of total billed charges,
GLENOID HYBRID,9049002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13200.00000,3828.00000,Aetna,First Health,,10797.60,,,,,,,4250.40,10797.60,percent of total billed charges,
STEM HUMERAL,9049003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9049003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
ANCHOR SWIVELOCK,9049004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2415.68000,700.55000,Aetna,First Health,,1976.03,,,,,,,870.85,1976.03,percent of total billed charges,
ANCHOR SWIVELOCK,9049004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2415.68000,700.55000,Aetna,First Health,,1976.03,,,,,,,777.85,1976.03,percent of total billed charges,
NAIL FEMORAL,9049006,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL FEMORAL,9049006,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
CAGE LORDOTIC,9049008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE LORDOTIC,9049008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
CAGE LUMBAR,9049009,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE LUMBAR,9049009,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
CAGE LUMBAR,9049010,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE LUMBAR,9049010,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
STENT GRAFT,9056157,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3824.18,8677.34,percent of total billed charges,
STENT GRAFT,9056157,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3415.78,8677.34,percent of total billed charges,
AUGMENT DISTAL,9056478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
AUGMENT DISTAL,9056478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
BREAST PROSTHESIS,9049037,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST PROSTHESIS,9049037,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
BREAST PROSTHESIS,9049038,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST PROSTHESIS,9049038,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
BREAST PROSTHESIS,9049039,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST PROSTHESIS,9049039,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
TIBIAL INSERT,9056479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
TIBIAL INSERT,9056479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
COMPONENT FEMORAL,9056480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,4351.96,9874.90,percent of total billed charges,
COMPONENT FEMORAL,9056480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,First Health,,9874.90,,,,,,,3887.18,9874.90,percent of total billed charges,
SCREW SPINAL,9049426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW SPINAL,9049426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
TIGHTROPE,9049427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
TIGHTROPE,9049427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
TIBIAL INSERT,9056531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
TIBIAL INSERT,9056531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
TIBIAL INSERT,9056532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
TIBIAL INSERT,9056532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT FEMORAL,9056533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23136.75000,6709.66000,Aetna,First Health,,18925.86,,,,,,,8340.80,18925.86,percent of total billed charges,
COMPONENT FEMORAL,9056533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23136.75000,6709.66000,Aetna,First Health,,18925.86,,,,,,,7450.03,18925.86,percent of total billed charges,
TIBIAL INSERT,9056534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4599.00000,1333.71000,Aetna,First Health,,3761.98,,,,,,,1657.94,3761.98,percent of total billed charges,
TIBIAL INSERT,9056534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4599.00000,1333.71000,Aetna,First Health,,3761.98,,,,,,,1480.88,3761.98,percent of total billed charges,
BASEPLATE TIBIAL,9056535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12272.10000,3558.91000,Aetna,First Health,,10038.58,,,,,,,4424.09,10038.58,percent of total billed charges,
BASEPLATE TIBIAL,9056535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12272.10000,3558.91000,Aetna,First Health,,10038.58,,,,,,,3951.62,10038.58,percent of total billed charges,
INTRPHALANGEAL,9056536,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
INTRPHALANGEAL,9056536,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
COMPONENT FEMORAL,9056537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20917.50000,6066.08000,Aetna,First Health,,17110.51,,,,,,,7540.76,17110.51,percent of total billed charges,
COMPONENT FEMORAL,9056537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20917.50000,6066.08000,Aetna,First Health,,17110.51,,,,,,,6735.44,17110.51,percent of total billed charges,
CATHETER PTA,9056538,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER PTA,9056538,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER PTA,9056539,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER PTA,9056539,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
CATHETER PTA,9049432,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER PTA,9049432,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW SELF TAP,9049433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW SELF TAP,9049433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW SELF DRILL,9056599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SELF DRILL,9056599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
CATHETER VENTRICULAR,9056600,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1462.52000,424.13000,Aetna,First Health,,1196.34,,,,,,,527.24,1196.34,percent of total billed charges,
CATHETER VENTRICULAR,9056600,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1462.52000,424.13000,Aetna,First Health,,1196.34,,,,,,,470.93,1196.34,percent of total billed charges,
SCREW LOCKING,9056601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW LOCKING,9056601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
TIBIAL COMPONENT,9056602,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
TIBIAL COMPONENT,9056602,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW LOCKING,9058158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW LOCKING,9058158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
BREAST IMPLANT,9058159,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,9058159,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,764.47,4509.23,percent of total billed charges,
BREAST IMPLANT,9058160,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,9058160,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,764.47,4509.23,percent of total billed charges,
BREAST IMPLANT,9058161,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,9058161,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,764.47,4509.23,percent of total billed charges,
NEUROSTIM,9056616,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
NEUROSTIM,9056616,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
NEUROSTIMULATOR,9056617,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
NEUROSTIMULATOR,9056617,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
PULSE GENERATOR,9056618,CDM,278,RC,C1822,HCPCS,,,facility,inpatient,,,97342.00000,28229.18000,Aetna,First Health,,79625.76,,,,,,,35091.79,79625.76,percent of total billed charges,
PULSE GENERATOR,9056618,CDM,278,RC,C1822,HCPCS,,,facility,outpatient,,,97342.00000,28229.18000,Aetna,First Health,,79625.76,,,,,,,31344.12,79625.76,percent of total billed charges,
STEM HUMERAL,9056619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18255.00000,5293.95000,Aetna,First Health,,14932.59,,,,,,,6580.93,14932.59,percent of total billed charges,
STEM HUMERAL,9056619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18255.00000,5293.95000,Aetna,First Health,,14932.59,,,,,,,5878.11,14932.59,percent of total billed charges,
ELBOW PROSTHESIS,9056620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10503.00000,3045.87000,Aetna,First Health,,8591.45,,,,,,,3786.33,8591.45,percent of total billed charges,
ELBOW PROSTHESIS,9056620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10503.00000,3045.87000,Aetna,First Health,,8591.45,,,,,,,3381.97,8591.45,percent of total billed charges,
TRANSARTICULAR FIXATION,9056660,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
TRANSARTICULAR FIXATION,9056660,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
TRANSARTICULAR FIXATION,9056661,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
TRANSARTICULAR FIXATION,9056661,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
TRANSARTICULAR FIXATION,9056662,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
TRANSARTICULAR FIXATION,9056662,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
STEM ULNAR,9058235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15307.50000,4439.17000,Aetna,First Health,,12521.53,,,,,,,5518.35,12521.53,percent of total billed charges,
STEM ULNAR,9058235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15307.50000,4439.17000,Aetna,First Health,,12521.53,,,,,,,4929.02,12521.53,percent of total billed charges,
HEAD FEMORAL,9056676,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
HEAD FEMORAL,9056676,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SCREW MATRIX,9056678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,671.84,1524.46,percent of total billed charges,
SCREW MATRIX,9056678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,600.09,1524.46,percent of total billed charges,
SCREW LOCKING,9056679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW LOCKING,9056679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
PLATE HOOK,9056681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4315.50000,1251.49000,Aetna,First Health,,3530.08,,,,,,,1555.74,3530.08,percent of total billed charges,
PLATE HOOK,9056681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4315.50000,1251.49000,Aetna,First Health,,3530.08,,,,,,,1389.59,3530.08,percent of total billed charges,
SCREW KREULOCK,9056683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW KREULOCK,9056683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
NAIL FEMUR,9056685,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL FEMUR,9056685,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
INSERT TIBIAL,9056686,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT TIBIAL,9056686,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
SPINAL CORD STIMULATION,9056797,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,52152.00000,15124.08000,Aetna,First Health,,42660.34,,,,,,,18800.80,42660.34,percent of total billed charges,
SPINAL CORD STIMULATION,9056797,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,52152.00000,15124.08000,Aetna,First Health,,42660.34,,,,,,,16792.94,42660.34,percent of total billed charges,
CATHETER CEREBROFLO,9056845,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,3297.65000,956.32000,Aetna,First Health,,2697.48,,,,,,,1188.80,2697.48,percent of total billed charges,
CATHETER CEREBROFLO,9056845,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,3297.65000,956.32000,Aetna,First Health,,2697.48,,,,,,,1061.84,2697.48,percent of total billed charges,
ADVANTAGE WASHER,9056850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1282.80000,372.01000,Aetna,First Health,,1049.33,,,,,,,462.45,1049.33,percent of total billed charges,
ADVANTAGE WASHER,9056850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1282.80000,372.01000,Aetna,First Health,,1049.33,,,,,,,413.06,1049.33,percent of total billed charges,
GUIDE CABLE,9056851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1541.52000,447.04000,Aetna,First Health,,1260.96,,,,,,,555.72,1260.96,percent of total billed charges,
GUIDE CABLE,9056851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1541.52000,447.04000,Aetna,First Health,,1260.96,,,,,,,496.37,1260.96,percent of total billed charges,
CAP ORTHO LOCK,9056852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1714.00000,497.06000,Aetna,First Health,,1402.05,,,,,,,617.90,1402.05,percent of total billed charges,
CAP ORTHO LOCK,9056852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1714.00000,497.06000,Aetna,First Health,,1402.05,,,,,,,551.91,1402.05,percent of total billed charges,
PLATE INTERNAL FIXATION,9056853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14589.18000,4230.86000,Aetna,First Health,,11933.95,,,,,,,5259.40,11933.95,percent of total billed charges,
PLATE INTERNAL FIXATION,9056853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14589.18000,4230.86000,Aetna,First Health,,11933.95,,,,,,,4697.72,11933.95,percent of total billed charges,
NAIL,9058335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL,9058335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
PLATE ACP,9056982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1220.74,2769.95,percent of total billed charges,
PLATE ACP,9056982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1090.37,2769.95,percent of total billed charges,
DEEP BRAIN STIMIULATOR,9056983,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,2173.83,4932.58,percent of total billed charges,
DEEP BRAIN STIMIULATOR,9056983,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,First Health,,4932.58,,,,,,,1941.68,4932.58,percent of total billed charges,
BRAIN STIMULATOR RECHARGE,9056985,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,7824.69000,2269.16000,Aetna,First Health,,6400.60,,,,,,,2820.80,6400.60,percent of total billed charges,
BRAIN STIMULATOR RECHARGE,9056985,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,7824.69000,2269.16000,Aetna,First Health,,6400.60,,,,,,,2519.55,6400.60,percent of total billed charges,
NAIL LONG,9056987,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9056987,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
TIBIAL PROSTHESIS,9056988,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,7417.29,16830.35,percent of total billed charges,
TIBIAL PROSTHESIS,9056988,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,First Health,,16830.35,,,,,,,6625.15,16830.35,percent of total billed charges,
TIBIAL COMPONENT,9056989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
TIBIAL COMPONENT,9056989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
SCREW HEADLESS,9056990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW HEADLESS,9056990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
ROD STRAIGHT,9056992,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD STRAIGHT,9056992,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
TIBIAL COMPONENT,9057001,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
TIBIAL COMPONENT,9057001,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
NAIL LONG,9057003,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9057003,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
NEUROSTIMULATOR SYSTEM,9056984,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,62965.20000,18259.91000,Aetna,First Health,,51505.53,,,,,,,22698.95,51505.53,percent of total billed charges,
NEUROSTIMULATOR SYSTEM,9056984,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,62965.20000,18259.91000,Aetna,First Health,,51505.53,,,,,,,20274.79,51505.53,percent of total billed charges,
STEM STANDARD,9060249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20275.00000,5879.75000,Aetna,First Health,,16584.95,,,,,,,7309.14,16584.95,percent of total billed charges,
STEM STANDARD,9060249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20275.00000,5879.75000,Aetna,First Health,,16584.95,,,,,,,6528.55,16584.95,percent of total billed charges,
INSERT HUMERAL,9060250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT HUMERAL,9060250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STEM OFFSET,9060251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1390.00000,403.10000,Aetna,First Health,,1137.02,,,,,,,501.10,1137.02,percent of total billed charges,
STEM OFFSET,9060251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1390.00000,403.10000,Aetna,First Health,,1137.02,,,,,,,447.58,1137.02,percent of total billed charges,
SCREW LUMBAR,9060256,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW LUMBAR,9060256,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
INSERT TIBIAL,9060257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT TIBIAL,9060257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
INSERT BEARING,9057010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT BEARING,9057010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BASEPLATE TIBIAL,9057011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
BASEPLATE TIBIAL,9057011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
ANKLE PROSTHESIS,9057026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11805.00000,3423.45000,Aetna,First Health,,9656.49,,,,,,,4255.70,9656.49,percent of total billed charges,
ANKLE PROSTHESIS,9057026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11805.00000,3423.45000,Aetna,First Health,,9656.49,,,,,,,3801.21,9656.49,percent of total billed charges,
COLLAR POLARSTEM,9057027,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COLLAR POLARSTEM,9057027,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SCREW CORTICAL,9060288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,142.13,322.50,percent of total billed charges,
SCREW CORTICAL,9060288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,First Health,,322.50,,,,,,,126.95,322.50,percent of total billed charges,
PLATE 3 HOLE,9060295,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1586.60000,460.11000,Aetna,First Health,,1297.84,,,,,,,571.97,1297.84,percent of total billed charges,
PLATE 3 HOLE,9060295,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1586.60000,460.11000,Aetna,First Health,,1297.84,,,,,,,510.89,1297.84,percent of total billed charges,
CATHETER VENTRICULOPERITONEAL,9060337,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,3290.18000,954.15000,Aetna,First Health,,2691.37,,,,,,,1186.11,2691.37,percent of total billed charges,
CATHETER VENTRICULOPERITONEAL,9060337,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,3290.18000,954.15000,Aetna,First Health,,2691.37,,,,,,,1059.44,2691.37,percent of total billed charges,
PLATE MANDIBULAR,9060338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3291.96000,954.67000,Aetna,First Health,,2692.82,,,,,,,1186.75,2692.82,percent of total billed charges,
PLATE MANDIBULAR,9060338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3291.96000,954.67000,Aetna,First Health,,2692.82,,,,,,,1060.01,2692.82,percent of total billed charges,
LINER ACETABULAR,9057181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER ACETABULAR,9057181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
SCREW ACP,9057182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW ACP,9057182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
PLATE ACP,9057183,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1220.74,2769.95,percent of total billed charges,
PLATE ACP,9057183,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1090.37,2769.95,percent of total billed charges,
STEM FEMORAL,9060340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM FEMORAL,9060340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
STEM FEMORAL,9060341,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM FEMORAL,9060341,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
INSERT CROSS LINK,9060343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11448.00000,3319.92000,Aetna,First Health,,9364.46,,,,,,,4127.00,9364.46,percent of total billed charges,
INSERT CROSS LINK,9060343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11448.00000,3319.92000,Aetna,First Health,,9364.46,,,,,,,3686.26,9364.46,percent of total billed charges,
PLATE TALAR,9060344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12519.00000,3630.51000,Aetna,First Health,,10240.54,,,,,,,4513.10,10240.54,percent of total billed charges,
PLATE TALAR,9060344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12519.00000,3630.51000,Aetna,First Health,,10240.54,,,,,,,4031.12,10240.54,percent of total billed charges,
DOME TALAR,9060345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19900.00000,5771.00000,Aetna,First Health,,16278.20,,,,,,,7173.95,16278.20,percent of total billed charges,
DOME TALAR,9060345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19900.00000,5771.00000,Aetna,First Health,,16278.20,,,,,,,6407.80,16278.20,percent of total billed charges,
SCREW LOCKING,9057188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW LOCKING,9057188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
SCREW COMPRESSION,9057189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,584.01,1325.16,percent of total billed charges,
SCREW COMPRESSION,9057189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,521.64,1325.16,percent of total billed charges,
COMPONENT FEMORAL,9057190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,2100.81,4766.90,percent of total billed charges,
COMPONENT FEMORAL,9057190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,First Health,,4766.90,,,,,,,1876.45,4766.90,percent of total billed charges,
INSERT TIBIAL,9057191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT TIBIAL,9057191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
CAGE SPACER,9057192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
CAGE SPACER,9057192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
LINER LIPPED,9057193,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13668.00000,3963.72000,Aetna,First Health,,11180.42,,,,,,,4927.31,11180.42,percent of total billed charges,
LINER LIPPED,9057193,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13668.00000,3963.72000,Aetna,First Health,,11180.42,,,,,,,4401.10,11180.42,percent of total billed charges,
CATHETER PTA,9057236,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER PTA,9057236,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
BASEPLATE GLENOID,9057250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5778.50000,1675.76000,Aetna,First Health,,4726.81,,,,,,,2083.15,4726.81,percent of total billed charges,
BASEPLATE GLENOID,9057250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5778.50000,1675.76000,Aetna,First Health,,4726.81,,,,,,,1860.68,4726.81,percent of total billed charges,
CAGE LUMBAR,9057251,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE LUMBAR,9057251,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
PLATE LOCKING,9057252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3825.50000,1109.40000,Aetna,First Health,,3129.26,,,,,,,1379.09,3129.26,percent of total billed charges,
PLATE LOCKING,9057252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3825.50000,1109.40000,Aetna,First Health,,3129.26,,,,,,,1231.81,3129.26,percent of total billed charges,
SCREW LOCKING,9057253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW LOCKING,9057253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW LOCKING,9057254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW LOCKING,9057254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
ANCHOR,9057264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3132.80000,908.51000,Aetna,First Health,,2562.63,,,,,,,1129.37,2562.63,percent of total billed charges,
ANCHOR,9057264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3132.80000,908.51000,Aetna,First Health,,2562.63,,,,,,,1008.76,2562.63,percent of total billed charges,
ANCHOR,9057265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3132.80000,908.51000,Aetna,First Health,,2562.63,,,,,,,1129.37,2562.63,percent of total billed charges,
ANCHOR,9057265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3132.80000,908.51000,Aetna,First Health,,2562.63,,,,,,,1008.76,2562.63,percent of total billed charges,
STEM FRACTURE,9057290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20275.00000,5879.75000,Aetna,First Health,,16584.95,,,,,,,7309.14,16584.95,percent of total billed charges,
STEM FRACTURE,9057290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20275.00000,5879.75000,Aetna,First Health,,16584.95,,,,,,,6528.55,16584.95,percent of total billed charges,
NAIL LONG,9057291,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9057291,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
PLATE HUMERUS,9057292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7966.80000,2310.37000,Aetna,First Health,,6516.84,,,,,,,2872.03,6516.84,percent of total billed charges,
PLATE HUMERUS,9057292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7966.80000,2310.37000,Aetna,First Health,,6516.84,,,,,,,2565.31,6516.84,percent of total billed charges,
SCREW CORTICAL,9057293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,258.91,587.49,percent of total billed charges,
SCREW CORTICAL,9057293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,First Health,,587.49,,,,,,,231.26,587.49,percent of total billed charges,
NAIL FEMORAL,9060433,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL FEMORAL,9060433,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
SCREW LOCKING,9060434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW LOCKING,9060434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW SELF TAP,9057295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SELF TAP,9057295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW LOCKING,9057336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW LOCKING,9057336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW LOCKING,9057337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW LOCKING,9057337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
PLATE SPINAL,9057334,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE SPINAL,9057334,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
ANCHOR SUTURE,9057333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2597.28000,753.21000,Aetna,First Health,,2124.58,,,,,,,936.32,2124.58,percent of total billed charges,
ANCHOR SUTURE,9057333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2597.28000,753.21000,Aetna,First Health,,2124.58,,,,,,,836.32,2124.58,percent of total billed charges,
PLATE LOCKING,9057338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1635.23,3710.45,percent of total billed charges,
PLATE LOCKING,9057338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1460.59,3710.45,percent of total billed charges,
SCREW POLYAXIAL,9057339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW POLYAXIAL,9057339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
SCREW POLYAXIAL,9057340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW POLYAXIAL,9057340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
ROD STRAIGHT,9057341,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,301.74,684.67,percent of total billed charges,
ROD STRAIGHT,9057341,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,First Health,,684.67,,,,,,,269.51,684.67,percent of total billed charges,
CONNECTOR QUARTEX,9057342,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CONNECTOR QUARTEX,9057342,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
SCREW COMPRESSION,9057343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW COMPRESSION,9057343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW COMPRESSION,9057344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW COMPRESSION,9057344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW COMPRESSION,9057345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW COMPRESSION,9057345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
ROD SPINAL,9060516,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,9060516,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
POLARSTEM,9060535,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
POLARSTEM,9060535,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
INSERT,9060534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9060534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HUMERAL STEM,9060536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,670.53,1521.48,percent of total billed charges,
HUMERAL STEM,9060536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,598.92,1521.48,percent of total billed charges,
HEAD HUMERAL ADAPTOR,9060538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
HEAD HUMERAL ADAPTOR,9060538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,282.56,717.79,percent of total billed charges,
HOLE COVER ACETABULAR,7987260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,116.87000,33.89000,Aetna,First Health,,95.60,,,,,,,42.13,95.60,percent of total billed charges,
HOLE COVER ACETABULAR,7987260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,116.87000,33.89000,Aetna,First Health,,95.60,,,,,,,37.63,95.60,percent of total billed charges,
TIBIAL INSERT,9060638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
TIBIAL INSERT,9060638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,9060639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,9060639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE TIBIAL,9060640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE TIBIAL,9060640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COLLAR POLARSTEM,9060641,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COLLAR POLARSTEM,9060641,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
INSERT,8994318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,8994318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
BASEPLATE,9060650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8270.94000,2398.57000,Aetna,First Health,,6765.63,,,,,,,2981.67,6765.63,percent of total billed charges,
BASEPLATE,9060650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8270.94000,2398.57000,Aetna,First Health,,6765.63,,,,,,,2663.24,6765.63,percent of total billed charges,
NAIL LONG,9060651,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9060651,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
CATHETER PTA,9057724,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,225.74,512.22,percent of total billed charges,
CATHETER PTA,9057724,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,First Health,,512.22,,,,,,,201.63,512.22,percent of total billed charges,
PLATE ACP,9057727,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1220.74,2769.95,percent of total billed charges,
PLATE ACP,9057727,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1090.37,2769.95,percent of total billed charges,
STEM ULNAR,9057588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15307.50000,4439.17000,Aetna,First Health,,12521.53,,,,,,,5518.35,12521.53,percent of total billed charges,
STEM ULNAR,9057588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15307.50000,4439.17000,Aetna,First Health,,12521.53,,,,,,,4929.02,12521.53,percent of total billed charges,
SCREW CORTICAL,9057589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW CORTICAL,9057589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW CORTICAL,9057590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW CORTICAL,9057590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
STENT GRAFT,9057728,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,47556.00000,13791.24000,Aetna,First Health,,38900.81,,,,,,,17143.94,38900.81,percent of total billed charges,
STENT GRAFT,9057728,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,47556.00000,13791.24000,Aetna,First Health,,38900.81,,,,,,,15313.03,38900.81,percent of total billed charges,
SCREW IFUSE,9057729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
SCREW IFUSE,9057729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
TIBIAL INSERT,9057805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
TIBIAL INSERT,9057805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
STEM CONICAL,9060959,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,4276.25,9703.12,percent of total billed charges,
STEM CONICAL,9060959,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,3819.56,9703.12,percent of total billed charges,
SHELL TRIDENT,9060960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,3155.82,7160.77,percent of total billed charges,
SHELL TRIDENT,9060960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,First Health,,7160.77,,,,,,,2818.79,7160.77,percent of total billed charges,
SCREW BONE,9060961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,755.39,1714.04,percent of total billed charges,
SCREW BONE,9060961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,674.72,1714.04,percent of total billed charges,
SCREW BONE,9060962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,755.39,1714.04,percent of total billed charges,
SCREW BONE,9060962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,674.72,1714.04,percent of total billed charges,
SCREW BONE,9060963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,755.39,1714.04,percent of total billed charges,
SCREW BONE,9060963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,First Health,,1714.04,,,,,,,674.72,1714.04,percent of total billed charges,
SPACER,9060964,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,6562.00,14889.65,percent of total billed charges,
SPACER,9060964,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,5861.20,14889.65,percent of total billed charges,
ROD COVERED,9060965,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD COVERED,9060965,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
COMPONENT FEMORAL,9060966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9060966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
STENT GRAFT,9060967,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,9060967,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
TIBIAL INSERT,9057964,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
TIBIAL INSERT,9057964,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
STEM HUMERAL,9057965,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29128.50000,8447.26000,Aetna,First Health,,23827.11,,,,,,,10500.82,23827.11,percent of total billed charges,
STEM HUMERAL,9057965,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29128.50000,8447.26000,Aetna,First Health,,23827.11,,,,,,,9379.38,23827.11,percent of total billed charges,
SCREW RELINE,9061011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,525.09,1191.47,percent of total billed charges,
SCREW RELINE,9061011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,469.01,1191.47,percent of total billed charges,
SPACER CATALYFT,9061012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,6562.00,14889.65,percent of total billed charges,
SPACER CATALYFT,9061012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,First Health,,14889.65,,,,,,,5861.20,14889.65,percent of total billed charges,
CATHETER PTA,9062157,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER PTA,9062157,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
BONE CEMENT,9062158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
BONE CEMENT,9062158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
COMPONENT TIBIAL,9062159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9062159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9062160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9062160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
SCREW CANNULATED,9062161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,663.32,1505.12,percent of total billed charges,
SCREW CANNULATED,9062161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,First Health,,1505.12,,,,,,,592.48,1505.12,percent of total billed charges,
BONE CEMENT,9062162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
BONE CEMENT,9062162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
STEM HUMERAL,9062163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,First Health,,23827.85,,,,,,,10501.15,23827.85,percent of total billed charges,
STEM HUMERAL,9062163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,First Health,,23827.85,,,,,,,9379.67,23827.85,percent of total billed charges,
INSERT HUMERAL,9062164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT HUMERAL,9062164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
PLATE COVERED,9057987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1224.56000,355.12000,Aetna,First Health,,1001.69,,,,,,,441.45,1001.69,percent of total billed charges,
PLATE COVERED,9057987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1224.56000,355.12000,Aetna,First Health,,1001.69,,,,,,,394.31,1001.69,percent of total billed charges,
PLATE BONE,9057988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,734.58000,213.03000,Aetna,First Health,,600.89,,,,,,,264.82,600.89,percent of total billed charges,
PLATE BONE,9057988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,734.58000,213.03000,Aetna,First Health,,600.89,,,,,,,236.53,600.89,percent of total billed charges,
COMPONENT TIBIAL,9057981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9057981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
GLENOSPHERE,9057982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
GLENOSPHERE,9057982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
PLATE DISTAL,9057983,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5793.90000,1680.23000,Aetna,First Health,,4739.41,,,,,,,2088.70,4739.41,percent of total billed charges,
PLATE DISTAL,9057983,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5793.90000,1680.23000,Aetna,First Health,,4739.41,,,,,,,1865.64,4739.41,percent of total billed charges,
SCREW NON LOCKING,9057984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,169.87,385.44,percent of total billed charges,
SCREW NON LOCKING,9057984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,151.73,385.44,percent of total billed charges,
STEM CEMENTED,9057985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM CEMENTED,9057985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
STEM EXT,9057986,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19627.50000,5691.98000,Aetna,First Health,,16055.30,,,,,,,7075.71,16055.30,percent of total billed charges,
STEM EXT,9057986,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19627.50000,5691.98000,Aetna,First Health,,16055.30,,,,,,,6320.06,16055.30,percent of total billed charges,
HEAD HUMERAL,9064207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4078.31000,1182.71000,Aetna,First Health,,3336.06,,,,,,,1470.23,3336.06,percent of total billed charges,
HEAD HUMERAL,9064207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4078.31000,1182.71000,Aetna,First Health,,3336.06,,,,,,,1313.22,3336.06,percent of total billed charges,
TRUNNION 39MM,9064208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.09000,2492.58000,Aetna,First Health,,7030.78,,,,,,,3098.53,7030.78,percent of total billed charges,
TRUNNION 39MM,9064208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.09000,2492.58000,Aetna,First Health,,7030.78,,,,,,,2767.62,7030.78,percent of total billed charges,
COLLAR POLARSTEM,9064209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
COLLAR POLARSTEM,9064209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,9064210,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6826.97,15490.88,percent of total billed charges,
CAGE,9064210,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,First Health,,15490.88,,,,,,,6097.88,15490.88,percent of total billed charges,
NAIL FEMORAL,9064211,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL FEMORAL,9064211,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
PLATE LOCKING,9064212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5015.50000,1454.50000,Aetna,First Health,,4102.68,,,,,,,1808.09,4102.68,percent of total billed charges,
PLATE LOCKING,9064212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5015.50000,1454.50000,Aetna,First Health,,4102.68,,,,,,,1614.99,4102.68,percent of total billed charges,
STEM RADIAL,9064213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
STEM RADIAL,9064213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
BONE SCREW,9062270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
BONE SCREW,9062270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
BONE SCREW,9062271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,965.85,2191.59,percent of total billed charges,
BONE SCREW,9062271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,First Health,,2191.59,,,,,,,862.70,2191.59,percent of total billed charges,
SPACER INTERBODY,9062272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
SPACER INTERBODY,9062272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
PLATE LONG,9062273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11004.00000,3191.16000,Aetna,First Health,,9001.27,,,,,,,3966.94,9001.27,percent of total billed charges,
PLATE LONG,9062273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11004.00000,3191.16000,Aetna,First Health,,9001.27,,,,,,,3543.29,9001.27,percent of total billed charges,
ANKLE PROSTHESIS,9062274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3360.22,7624.58,percent of total billed charges,
ANKLE PROSTHESIS,9062274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3001.36,7624.58,percent of total billed charges,
SCREW SELF TAP,9062276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW SELF TAP,9062276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
HUMERAL HEAD,9062279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,9062279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
STEM HUMERAL,9062280,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9062280,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
CATHETER PTA,9062440,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,469.01,1064.22,percent of total billed charges,
CATHETER PTA,9062440,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,418.92,1064.22,percent of total billed charges,
POSTFREE DISTRACTION,9064429,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
POSTFREE DISTRACTION,9064429,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
COLLAR BUTTON,9066156,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,86.50000,25.08000,Aetna,First Health,,70.76,,,,,,,31.18,70.76,percent of total billed charges,
COLLAR BUTTON,9066156,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,86.50000,25.08000,Aetna,First Health,,70.76,,,,,,,27.85,332.38,percent of total billed charges,
NAIL LONG,9068180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL LONG,9068180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
MESH DYNAMIC,9068181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5039.65000,1461.50000,Aetna,First Health,,4122.43,,,,,,,1816.79,4122.43,percent of total billed charges,
MESH DYNAMIC,9068181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5039.65000,1461.50000,Aetna,First Health,,4122.43,,,,,,,1622.77,4122.43,percent of total billed charges,
PLATE CERVICAL,9068182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE CERVICAL,9068182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
STEM LATITUDE,9068186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15307.50000,4439.17000,Aetna,First Health,,12521.53,,,,,,,5518.35,12521.53,percent of total billed charges,
STEM LATITUDE,9068186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15307.50000,4439.17000,Aetna,First Health,,12521.53,,,,,,,4929.02,12521.53,percent of total billed charges,
ROD HEX,9068187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
ROD HEX,9068187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
LINER ACETABULAR,9068188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8283.00000,2402.07000,Aetna,First Health,,6775.49,,,,,,,2986.02,6775.49,percent of total billed charges,
LINER ACETABULAR,9068188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8283.00000,2402.07000,Aetna,First Health,,6775.49,,,,,,,2667.13,6775.49,percent of total billed charges,
PLATE ARCHON,9068196,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,1072.65,2433.91,percent of total billed charges,
PLATE ARCHON,9068196,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,First Health,,2433.91,,,,,,,958.09,2433.91,percent of total billed charges,
SCREW CORTICAL,9068197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,305.63,693.50,percent of total billed charges,
SCREW CORTICAL,9068197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,First Health,,693.50,,,,,,,272.99,693.50,percent of total billed charges,
STEM FEMORAL,9068287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM FEMORAL,9068287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
MESH DYNAMIC,9068286,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8020.47000,2325.94000,Aetna,First Health,,6560.74,,,,,,,2891.38,6560.74,percent of total billed charges,
MESH DYNAMIC,9068286,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8020.47000,2325.94000,Aetna,First Health,,6560.74,,,,,,,2582.59,6560.74,percent of total billed charges,
MESH HERNIA,9068288,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,12487.50000,3621.37000,Aetna,First Health,,10214.77,,,,,,,4501.74,10214.77,percent of total billed charges,
MESH HERNIA,9068288,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,12487.50000,3621.37000,Aetna,First Health,,10214.77,,,,,,,4020.97,10214.77,percent of total billed charges,
CAGE,9068289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5835.59,13241.38,percent of total billed charges,
CAGE,9068289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,First Health,,13241.38,,,,,,,5212.38,13241.38,percent of total billed charges,
CAGE INTERBODY,9068290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1411.24,3202.21,percent of total billed charges,
CAGE INTERBODY,9068290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,First Health,,3202.21,,,,,,,1260.53,3202.21,percent of total billed charges,
BASEPLATE TIBIAL,9068291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1880.01,4265.87,percent of total billed charges,
BASEPLATE TIBIAL,9068291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,First Health,,4265.87,,,,,,,1679.23,4265.87,percent of total billed charges,
COMPONENT FEMORAL,9068292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9068292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
PLATE LEFT,9068293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1361.16000,394.74000,Aetna,First Health,,1113.43,,,,,,,490.70,1113.43,percent of total billed charges,
PLATE LEFT,9068293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1361.16000,394.74000,Aetna,First Health,,1113.43,,,,,,,438.29,1113.43,percent of total billed charges,
PLATE RIGHT,9068294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1361.16000,394.74000,Aetna,First Health,,1113.43,,,,,,,490.70,1113.43,percent of total billed charges,
PLATE RIGHT,9068294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1361.16000,394.74000,Aetna,First Health,,1113.43,,,,,,,438.29,1113.43,percent of total billed charges,
SCREW POLYAXIAL,9068295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW POLYAXIAL,9068295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
STEM DISTAL,9068296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,4276.25,9703.12,percent of total billed charges,
STEM DISTAL,9068296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,3819.56,9703.12,percent of total billed charges,
NAIL LONG,9068297,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9068297,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
BIRTHING KIT,9072244,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3920.00000,1136.80000,Aetna,First Health,,3206.56,,,,,,,1413.16,3206.56,percent of total billed charges,
BIRTHING KIT,9072244,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3920.00000,1136.80000,Aetna,First Health,,3206.56,,,,,,,1262.24,3206.56,percent of total billed charges,
SCREW SELF DRILL,9068352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SELF DRILL,9068352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ANCHOR,9068353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2226.68000,645.74000,Aetna,First Health,,1821.42,,,,,,,802.72,1821.42,percent of total billed charges,
ANCHOR,9068353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2226.68000,645.74000,Aetna,First Health,,1821.42,,,,,,,716.99,1821.42,percent of total billed charges,
NAIL FEMORAL,9068484,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL FEMORAL,9068484,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
NAIL LONG,9068485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9068485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
SCREW SELF TAP,9068486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW SELF TAP,9068486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
ENDCAP,9068487,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4109.00000,1191.61000,Aetna,First Health,,3361.16,,,,,,,1481.29,3361.16,percent of total billed charges,
ENDCAP,9068487,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4109.00000,1191.61000,Aetna,First Health,,3361.16,,,,,,,1323.10,3361.16,percent of total billed charges,
STRATOSPHERE,9068488,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22292.50000,6464.82000,Aetna,First Health,,18235.26,,,,,,,8036.45,18235.26,percent of total billed charges,
STRATOSPHERE,9068488,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22292.50000,6464.82000,Aetna,First Health,,18235.26,,,,,,,7178.19,18235.26,percent of total billed charges,
GRAFT AORTIC,9068489,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,19155.53,43465.25,percent of total billed charges,
GRAFT AORTIC,9068489,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,First Health,,43465.25,,,,,,,17109.79,43465.25,percent of total billed charges,
PLATE SPINAL,9068490,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
PLATE SPINAL,9068490,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
PLATE LOCKING,9068525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7582.74000,2198.99000,Aetna,First Health,,6202.68,,,,,,,2733.58,6202.68,percent of total billed charges,
PLATE LOCKING,9068525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7582.74000,2198.99000,Aetna,First Health,,6202.68,,,,,,,2441.64,6202.68,percent of total billed charges,
COMPONENT TIBIAL,9068526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9068526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9068527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9068527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
NAIL TIBIAL,9068528,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL TIBIAL,9068528,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
SCREW LOCKING,9068529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,565.03,1282.10,percent of total billed charges,
SCREW LOCKING,9068529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,First Health,,1282.10,,,,,,,504.69,1282.10,percent of total billed charges,
INTRODUCER,9074228,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
INTRODUCER,9074228,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
NAIL TIBIAL,9072296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL TIBIAL,9072296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
COIL HELICAL,9072297,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,First Health,,4779.78,,,,,,,2106.49,4779.78,percent of total billed charges,
COIL HELICAL,9072297,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,First Health,,4779.78,,,,,,,1881.53,4779.78,percent of total billed charges,
PLATE ACETABULAR,9074161,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2928.00000,849.12000,Aetna,First Health,,2395.10,,,,,,,1055.54,2395.10,percent of total billed charges,
PLATE ACETABULAR,9074161,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2928.00000,849.12000,Aetna,First Health,,2395.10,,,,,,,942.82,2395.10,percent of total billed charges,
SCREW CANNULATED,9074162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,651.73,1478.81,percent of total billed charges,
SCREW CANNULATED,9074162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,582.12,1478.81,percent of total billed charges,
SPHERE EMBOLIZATION,9074163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SPHERE EMBOLIZATION,9074163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SHEATH INTRODUCER,9072299,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
SHEATH INTRODUCER,9072299,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW POLYAXIAL,9072300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW POLYAXIAL,9072300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW SELF TAP,9072301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
SCREW SELF TAP,9072301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
SCREW LOCKING,9074238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW LOCKING,9074238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW HEADLESS,9074239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW HEADLESS,9074239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
COMPONENT TIBIAL,9074240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9074240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
STEM HUMERAL,9074241,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9074241,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
CONNECTOR,9074242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2520.00000,730.80000,Aetna,First Health,,2061.36,,,,,,,908.46,2061.36,percent of total billed charges,
CONNECTOR,9074242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2520.00000,730.80000,Aetna,First Health,,2061.36,,,,,,,811.44,2061.36,percent of total billed charges,
PLATE CLAVICLE,9074243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.22000,1054.50000,Aetna,First Health,,2974.43,,,,,,,1310.86,2974.43,percent of total billed charges,
PLATE CLAVICLE,9074243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.22000,1054.50000,Aetna,First Health,,2974.43,,,,,,,1170.86,2974.43,percent of total billed charges,
K WIRE,9074405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,230.36,522.70,percent of total billed charges,
K WIRE,9074405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,205.76,522.70,percent of total billed charges,
BASEPLATE GLENOID,9074396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5778.50000,1675.76000,Aetna,First Health,,4726.81,,,,,,,2083.15,4726.81,percent of total billed charges,
BASEPLATE GLENOID,9074396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5778.50000,1675.76000,Aetna,First Health,,4726.81,,,,,,,1860.68,4726.81,percent of total billed charges,
NAIL LONG,9074397,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9074397,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
PLATE ACP,9074398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE ACP,9074398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
PEG LOCKING,9074399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PEG LOCKING,9074399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
STEM FEMORAL,9074400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9258.00000,2684.82000,Aetna,First Health,,7573.04,,,,,,,3337.51,7573.04,percent of total billed charges,
STEM FEMORAL,9074400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9258.00000,2684.82000,Aetna,First Health,,7573.04,,,,,,,2981.08,7573.04,percent of total billed charges,
SCREW BONE,9074406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,327.69,743.56,percent of total billed charges,
SCREW BONE,9074406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,First Health,,743.56,,,,,,,292.70,743.56,percent of total billed charges,
HEAD FEMORAL,9074407,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,9074407,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
COMPONENT TIBIAL,9074505,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
COMPONENT TIBIAL,9074505,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
PLATE ACETABULAR,9072507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2312.00000,670.48000,Aetna,First Health,,1891.22,,,,,,,833.48,1891.22,percent of total billed charges,
PLATE ACETABULAR,9072507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2312.00000,670.48000,Aetna,First Health,,1891.22,,,,,,,744.46,1891.22,percent of total billed charges,
PLATE SPRING,9072508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1510.56000,438.06000,Aetna,First Health,,1235.64,,,,,,,544.56,1235.64,percent of total billed charges,
PLATE SPRING,9072508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1510.56000,438.06000,Aetna,First Health,,1235.64,,,,,,,486.40,1235.64,percent of total billed charges,
CATHETER,8986318,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4542.30,10306.80,percent of total billed charges,
CATHETER,8986318,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4057.20,10306.80,percent of total billed charges,
PATELLAR TRIATHLON,9072675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
PATELLAR TRIATHLON,9072675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
TISSUE MATRIX,9074519,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,4543.00000,1317.47000,Aetna,First Health,,3716.17,,,,,,,1637.75,3716.17,percent of total billed charges,
TISSUE MATRIX,9074519,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,4543.00000,1317.47000,Aetna,First Health,,3716.17,,,,,,,124.65,3716.17,percent of total billed charges,
SCREW COUNTERSINK,9072682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,First Health,,1194.28,,,,,,,526.33,1194.28,percent of total billed charges,
SCREW COUNTERSINK,9072682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,First Health,,1194.28,,,,,,,470.12,1194.28,percent of total billed charges,
PLATE,9072529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2196.64000,637.03000,Aetna,First Health,,1796.85,,,,,,,791.89,1796.85,percent of total billed charges,
PLATE,9072529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2196.64000,637.03000,Aetna,First Health,,1796.85,,,,,,,707.32,1796.85,percent of total billed charges,
SPACER,9072530,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
SPACER,9072530,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
SPACER,9072531,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
SPACER,9072531,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
PLATE LOCKING,9072532,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,865.20,1963.20,percent of total billed charges,
PLATE LOCKING,9072532,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,772.80,1963.20,percent of total billed charges,
SCREW LUMBAR,9072533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW LUMBAR,9072533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SHEATH GUIDING,9072597,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,First Health,,1194.28,,,,,,,526.33,1194.28,percent of total billed charges,
SHEATH GUIDING,9072597,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,First Health,,1194.28,,,,,,,470.12,1194.28,percent of total billed charges,
CATHETER,9072598,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1560.00000,452.40000,Aetna,First Health,,1276.08,,,,,,,562.38,1276.08,percent of total billed charges,
CATHETER,9072598,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1560.00000,452.40000,Aetna,First Health,,1276.08,,,,,,,502.32,1276.08,percent of total billed charges,
PATELLAR TRIATHLON,9072676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
PATELLAR TRIATHLON,9072676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
SCREW LOCKING,9072683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW LOCKING,9072683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
STENT GRAFT,9072684,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9072684,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
SCREW COMPRESSION,9072685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW COMPRESSION,9072685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
HUMERAL STEMLESS,9072686,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
HUMERAL STEMLESS,9072686,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,4830.00,12270.00,percent of total billed charges,
HUMERAL HEAD,9072687,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,9072687,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
SYNDESMOTIC FIXATION DEVICE,8380191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4658.50000,1350.96000,Aetna,First Health,,3810.65,,,,,,,1679.39,3810.65,percent of total billed charges,
SYNDESMOTIC FIXATION DEVICE,8380191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4658.50000,1350.96000,Aetna,First Health,,3810.65,,,,,,,1500.04,3810.65,percent of total billed charges,
NAIL FEMORAL,9072778,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL FEMORAL,9072778,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
TISSUE MATRIX,9072795,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17725.00000,5140.25000,Aetna,First Health,,14499.05,,,,,,,6389.86,14499.05,percent of total billed charges,
TISSUE MATRIX,9072795,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17725.00000,5140.25000,Aetna,First Health,,14499.05,,,,,,,5707.45,14499.05,percent of total billed charges,
INSERT TIBIAL,9074747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9074747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE GLENOID,9072796,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,2170.21,4924.36,percent of total billed charges,
PLATE GLENOID,9072796,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,1938.44,4924.36,percent of total billed charges,
CAP END,9072797,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
CAP END,9072797,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
CAGE SPINAL,9072798,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,6331.28,14366.12,percent of total billed charges,
CAGE SPINAL,9072798,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,First Health,,14366.12,,,,,,,5655.12,14366.12,percent of total billed charges,
SCREW CANNULATED,9072799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,122.78,278.59,percent of total billed charges,
SCREW CANNULATED,9072799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,109.67,278.59,percent of total billed charges,
ROD SPINAL,9078170,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,2081.89,4723.95,percent of total billed charges,
ROD SPINAL,9078170,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,First Health,,4723.95,,,,,,,1859.55,4723.95,percent of total billed charges,
SCREW POLYAXIAL,9078168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4453.23000,1291.44000,Aetna,First Health,,3642.74,,,,,,,1605.39,3642.74,percent of total billed charges,
SCREW POLYAXIAL,9078168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4453.23000,1291.44000,Aetna,First Health,,3642.74,,,,,,,1433.94,3642.74,percent of total billed charges,
STEM HUMERAL,9078169,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
STEM HUMERAL,9078169,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
PLATE FRACTURE,9078171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3764.81000,1091.79000,Aetna,First Health,,3079.61,,,,,,,1357.21,3079.61,percent of total billed charges,
PLATE FRACTURE,9078171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3764.81000,1091.79000,Aetna,First Health,,3079.61,,,,,,,1212.27,3079.61,percent of total billed charges,
SHOULDER GUIDE,9076189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4617.90000,1339.19000,Aetna,First Health,,3777.44,,,,,,,1664.75,3777.44,percent of total billed charges,
SHOULDER GUIDE,9076189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4617.90000,1339.19000,Aetna,First Health,,3777.44,,,,,,,1486.96,3777.44,percent of total billed charges,
PLATE TIBIAL,9076190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9384.00000,2721.36000,Aetna,First Health,,7676.11,,,,,,,3382.93,7676.11,percent of total billed charges,
PLATE TIBIAL,9076190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9384.00000,2721.36000,Aetna,First Health,,7676.11,,,,,,,3021.65,7676.11,percent of total billed charges,
CATHETER GUIDING,9076434,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDING,9076434,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
CATHETER GUIDING,9076435,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDING,9076435,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDING,9076436,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDING,9076436,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDING,9076437,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,80.83,183.42,percent of total billed charges,
CATHETER GUIDING,9076437,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,First Health,,183.42,,,,,,,72.20,183.42,percent of total billed charges,
INSERT TIBIAL,9076327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT TIBIAL,9076327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
ANCHOR KNOTLESS,9076336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1609.36000,466.71000,Aetna,First Health,,1316.46,,,,,,,580.17,1316.46,percent of total billed charges,
ANCHOR KNOTLESS,9076336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1609.36000,466.71000,Aetna,First Health,,1316.46,,,,,,,518.21,1316.46,percent of total billed charges,
ANCHOR IN KIT,9076337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5043.15000,1462.51000,Aetna,First Health,,4125.30,,,,,,,1818.06,4125.30,percent of total billed charges,
ANCHOR IN KIT,9076337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5043.15000,1462.51000,Aetna,First Health,,4125.30,,,,,,,1623.89,4125.30,percent of total billed charges,
INSERT HUMERAL,9076329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT HUMERAL,9076329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
STEM HUMERAL,9076330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,First Health,,23827.85,,,,,,,10501.15,23827.85,percent of total billed charges,
STEM HUMERAL,9076330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,First Health,,23827.85,,,,,,,9379.67,23827.85,percent of total billed charges,
COMPONENT FEMORAL,9076338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9076338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
STEM HUMERAL,9076331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,First Health,,23827.85,,,,,,,10501.15,23827.85,percent of total billed charges,
STEM HUMERAL,9076331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,First Health,,23827.85,,,,,,,9379.67,23827.85,percent of total billed charges,
CATHETER THROMBECTOMY,9076340,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,10301.29,23374.35,percent of total billed charges,
CATHETER THROMBECTOMY,9076340,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,9201.15,23374.35,percent of total billed charges,
SCREW SELF TAP,9076341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,303.91000,88.13000,Aetna,First Health,,248.60,,,,,,,109.56,248.60,percent of total billed charges,
SCREW SELF TAP,9076341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,303.91000,88.13000,Aetna,First Health,,248.60,,,,,,,97.86,248.60,percent of total billed charges,
SCREW RELINE,9078601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW RELINE,9078601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
ROD CERVICAL,9078602,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD CERVICAL,9078602,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
SCREW CERVICAL,9078603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3270.75000,948.52000,Aetna,First Health,,2675.47,,,,,,,1179.11,2675.47,percent of total billed charges,
SCREW CERVICAL,9078603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3270.75000,948.52000,Aetna,First Health,,2675.47,,,,,,,1053.18,2675.47,percent of total billed charges,
NAIL LONG,9078605,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9078605,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
INSERT TIBIAL,9078606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9078606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
COMPONENT TIBIAL,9078607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3223.50000,934.82000,Aetna,First Health,,2636.82,,,,,,,1162.07,2636.82,percent of total billed charges,
COMPONENT TIBIAL,9078607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3223.50000,934.82000,Aetna,First Health,,2636.82,,,,,,,1037.97,2636.82,percent of total billed charges,
COMPONENT FEMORAL,9078608,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,9078608,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
NAIL FEMORAL,9078609,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,714.57,1621.41,percent of total billed charges,
NAIL FEMORAL,9078609,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,638.26,1621.41,percent of total billed charges,
STEM FEMORAL,9078701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM FEMORAL,9078701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
INSERT TIBIAL,9076721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9076721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
PIN FIXATION,9078700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
PIN FIXATION,9078700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
PLATE FRACTURE,9076737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4084.64000,1184.55000,Aetna,First Health,,3341.24,,,,,,,1472.51,3341.24,percent of total billed charges,
PLATE FRACTURE,9076737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4084.64000,1184.55000,Aetna,First Health,,3341.24,,,,,,,1315.25,3341.24,percent of total billed charges,
PLATE VARIABLE,9076738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7804.26000,2263.24000,Aetna,First Health,,6383.88,,,,,,,2813.44,6383.88,percent of total billed charges,
PLATE VARIABLE,9076738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7804.26000,2263.24000,Aetna,First Health,,6383.88,,,,,,,2512.97,6383.88,percent of total billed charges,
NAIL LONG,9082199,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9082199,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
COVER CATHETER,9078752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
COVER CATHETER,9078752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
CATHETER GUIDING,9078753,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
CATHETER GUIDING,9078753,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
GUIDEWIRE KIT,9078754,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,12375.00000,3588.75000,Aetna,First Health,,10122.75,,,,,,,4461.19,10122.75,percent of total billed charges,
GUIDEWIRE KIT,9078754,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,12375.00000,3588.75000,Aetna,First Health,,10122.75,,,,,,,3984.75,10122.75,percent of total billed charges,
GUIDEWIRE KIT,9078755,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
GUIDEWIRE KIT,9078755,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
CATHETER GUIDE,9078759,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
CATHETER GUIDE,9078759,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
SCREW CANNULATED,9076790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,321.21,728.84,percent of total billed charges,
SCREW CANNULATED,9076790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,,728.84,,,,,,,286.90,728.84,percent of total billed charges,
PLATE ORTHOLOC,9076791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11628.00000,3372.12000,Aetna,First Health,,9511.70,,,,,,,4191.89,9511.70,percent of total billed charges,
PLATE ORTHOLOC,9076791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11628.00000,3372.12000,Aetna,First Health,,9511.70,,,,,,,3744.22,9511.70,percent of total billed charges,
NAIL LONG,9080167,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9080167,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
PLATE FEMUR,9080169,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,34292.70000,9944.88000,Aetna,First Health,,28051.43,,,,,,,12362.52,28051.43,percent of total billed charges,
PLATE FEMUR,9080169,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,34292.70000,9944.88000,Aetna,First Health,,28051.43,,,,,,,11042.25,28051.43,percent of total billed charges,
SCREW CORTICAL,9080170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW CORTICAL,9080170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW CORTICAL,9080171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW CORTICAL,9080171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW NON CANNULATED,9080172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.00000,537.08000,Aetna,First Health,,1514.94,,,,,,,667.65,1514.94,percent of total billed charges,
SCREW NON CANNULATED,9080172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.00000,537.08000,Aetna,First Health,,1514.94,,,,,,,596.34,1514.94,percent of total billed charges,
SCREW NON CANNULATED,9080173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.00000,537.08000,Aetna,First Health,,1514.94,,,,,,,667.65,1514.94,percent of total billed charges,
SCREW NON CANNULATED,9080173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.00000,537.08000,Aetna,First Health,,1514.94,,,,,,,596.34,1514.94,percent of total billed charges,
SCREW,9080174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2992.44000,867.81000,Aetna,First Health,,2447.82,,,,,,,1078.77,2447.82,percent of total billed charges,
SCREW,9080174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2992.44000,867.81000,Aetna,First Health,,2447.82,,,,,,,963.57,2447.82,percent of total billed charges,
SCREW POLYAXIAL,9082198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,1059.87,2404.92,percent of total billed charges,
SCREW POLYAXIAL,9082198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,First Health,,2404.92,,,,,,,946.68,2404.92,percent of total billed charges,
COMPONENT FEMORAL,9082200,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,9082200,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
INSERT CONSTRAINED,9082201,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT CONSTRAINED,9082201,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
INSERT TIBIAL,9082202,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
INSERT TIBIAL,9082202,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
BONE SCREW SPINAL,9080198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
BONE SCREW SPINAL,9080198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
NAIL LONG,9076789,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4650.45,10552.20,percent of total billed charges,
NAIL LONG,9076789,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,First Health,,10552.20,,,,,,,4153.80,10552.20,percent of total billed charges,
SCREW RELINE,9080175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW RELINE,9080175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
SCREW RELINE,9080176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW RELINE,9080176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
INSERT TIBIAL,9082280,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9082280,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
HEAD GLENOID,9082282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1924.17,4366.07,percent of total billed charges,
HEAD GLENOID,9082282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,First Health,,4366.07,,,,,,,1718.67,4366.07,percent of total billed charges,
PLATE FACIAL,9080274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,24616.08000,7138.66000,Aetna,First Health,,20135.95,,,,,,,8874.10,20135.95,percent of total billed charges,
PLATE FACIAL,9080274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,24616.08000,7138.66000,Aetna,First Health,,20135.95,,,,,,,7926.38,20135.95,percent of total billed charges,
BONE SCREW,9080275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.41000,95.53000,Aetna,First Health,,269.46,,,,,,,118.75,269.46,percent of total billed charges,
BONE SCREW,9080275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.41000,95.53000,Aetna,First Health,,269.46,,,,,,,106.07,269.46,percent of total billed charges,
PLATE MANDIBULAR,9080276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4243.86000,1230.72000,Aetna,First Health,,3471.48,,,,,,,1529.91,3471.48,percent of total billed charges,
PLATE MANDIBULAR,9080276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4243.86000,1230.72000,Aetna,First Health,,3471.48,,,,,,,1366.52,3471.48,percent of total billed charges,
PLATE BONE,9080277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1228.96000,356.40000,Aetna,First Health,,1005.29,,,,,,,443.04,1005.29,percent of total billed charges,
PLATE BONE,9080277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1228.96000,356.40000,Aetna,First Health,,1005.29,,,,,,,395.73,1005.29,percent of total billed charges,
INSERT CONSTRAINED,9080279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT CONSTRAINED,9080279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
SCREW LOCKING,9080281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,826.20000,239.60000,Aetna,First Health,,675.83,,,,,,,297.85,675.83,percent of total billed charges,
SCREW LOCKING,9080281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,826.20000,239.60000,Aetna,First Health,,675.83,,,,,,,266.04,675.83,percent of total billed charges,
NAIL FEMORAL,9080282,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL FEMORAL,9080282,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
ROD SPINAL,9080283,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,9080283,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
ROD SPINAL,9080284,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD SPINAL,9080284,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
SCREW SELF TAP,9076788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW SELF TAP,9076788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
TIBIAL LEFT TALLO,9082160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,41737.50000,12103.88000,Aetna,First Health,,34141.28,,,,,,,15046.37,34141.28,percent of total billed charges,
TIBIAL LEFT TALLO,9082160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,41737.50000,12103.88000,Aetna,First Health,,34141.28,,,,,,,13439.48,34141.28,percent of total billed charges,
SCREW CORTICAL,9080351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW CORTICAL,9080351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW CORTICAL,9080352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW CORTICAL,9080352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW CORTICAL,9080353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW CORTICAL,9080353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW CORTICAL,9080354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW CORTICAL,9080354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
NAIL LONG,9080368,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL LONG,9080368,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
PLATE LOCKING,9080369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,865.40000,250.97000,Aetna,First Health,,707.90,,,,,,,311.98,707.90,percent of total billed charges,
PLATE LOCKING,9080369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,865.40000,250.97000,Aetna,First Health,,707.90,,,,,,,278.66,707.90,percent of total billed charges,
PLATE CRANIO,9080375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2155.44000,625.08000,Aetna,First Health,,1763.15,,,,,,,777.04,1763.15,percent of total billed charges,
PLATE CRANIO,9080375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2155.44000,625.08000,Aetna,First Health,,1763.15,,,,,,,694.05,1763.15,percent of total billed charges,
INTERSTIM STIMULATOR LEAD,9082367,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,235.20000,68.21000,Aetna,First Health,,192.39,,,,,,,84.79,192.39,percent of total billed charges,
INTERSTIM STIMULATOR LEAD,9082367,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,235.20000,68.21000,Aetna,First Health,,192.39,,,,,,,75.73,192.39,percent of total billed charges,
INTERSTIM STIMULATOR TEST,9082368,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,314.45000,91.19000,Aetna,First Health,,257.22,,,,,,,113.36,257.22,percent of total billed charges,
INTERSTIM STIMULATOR TEST,9082368,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,314.45000,91.19000,Aetna,First Health,,257.22,,,,,,,101.25,257.22,percent of total billed charges,
SCREW CORTICAL,9082371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW CORTICAL,9082371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
PLATE LATERAL,9082372,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3299.59000,956.88000,Aetna,First Health,,2699.06,,,,,,,1189.50,2699.06,percent of total billed charges,
PLATE LATERAL,9082372,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3299.59000,956.88000,Aetna,First Health,,2699.06,,,,,,,1062.47,2699.06,percent of total billed charges,
PLATE DORSAL,9082373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3299.59000,956.88000,Aetna,First Health,,2699.06,,,,,,,1189.50,2699.06,percent of total billed charges,
PLATE DORSAL,9082373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3299.59000,956.88000,Aetna,First Health,,2699.06,,,,,,,1062.47,2699.06,percent of total billed charges,
SCREW BONE,9082374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW BONE,9082374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW AXS,9082396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.35000,103.34000,Aetna,First Health,,291.49,,,,,,,128.46,291.49,percent of total billed charges,
SCREW AXS,9082396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.35000,103.34000,Aetna,First Health,,291.49,,,,,,,114.74,291.49,percent of total billed charges,
INSERT,9082404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT,9082404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
ROD CERVICAL,9080470,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD CERVICAL,9080470,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
ROD CONTOURED,9080471,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,674.86,1531.30,percent of total billed charges,
ROD CONTOURED,9080471,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,First Health,,1531.30,,,,,,,602.78,1531.30,percent of total billed charges,
PLATE ACP,9080525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE ACP,9080525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
COIL RUBY,9080519,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
COIL RUBY,9080519,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
COIL RUBY,9080520,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
COIL RUBY,9080520,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
COIL RUBY,9080521,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
COIL RUBY,9080521,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
COIL PACKING,9080522,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
COIL PACKING,9080522,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
STEM CEMENTED,9080523,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12966.00000,3760.14000,Aetna,First Health,,10606.19,,,,,,,4674.24,10606.19,percent of total billed charges,
STEM CEMENTED,9080523,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12966.00000,3760.14000,Aetna,First Health,,10606.19,,,,,,,4175.05,10606.19,percent of total billed charges,
TIBIAL HINGE,9080524,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14424.00000,4182.96000,Aetna,First Health,,11798.83,,,,,,,5199.85,11798.83,percent of total billed charges,
TIBIAL HINGE,9080524,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14424.00000,4182.96000,Aetna,First Health,,11798.83,,,,,,,4644.53,11798.83,percent of total billed charges,
STEM RADIAL,9080526,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10719.00000,3108.51000,Aetna,First Health,,8768.14,,,,,,,3864.20,8768.14,percent of total billed charges,
STEM RADIAL,9080526,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10719.00000,3108.51000,Aetna,First Health,,8768.14,,,,,,,3451.52,8768.14,percent of total billed charges,
HEAD RADIAL,9080527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10794.00000,3130.26000,Aetna,First Health,,8829.49,,,,,,,3891.24,8829.49,percent of total billed charges,
HEAD RADIAL,9080527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10794.00000,3130.26000,Aetna,First Health,,8829.49,,,,,,,3475.67,8829.49,percent of total billed charges,
SPACER SPINAL,9080528,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3444.00000,998.76000,Aetna,First Health,,2817.19,,,,,,,1241.56,2817.19,percent of total billed charges,
SPACER SPINAL,9080528,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3444.00000,998.76000,Aetna,First Health,,2817.19,,,,,,,1108.97,2817.19,percent of total billed charges,
PLATE CERVICAL,9080529,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE CERVICAL,9080529,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
INSERT PSN,9080530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT PSN,9080530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT TIBIAL,9080537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT TIBIAL,9080537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
INSERT TIBIAL,9080538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT TIBIAL,9080538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,9080539,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,9080539,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE TIBIAL,9080540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE TIBIAL,9080540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,9080542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9080542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
INTRODUCER ANSEL,9080652,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
INTRODUCER ANSEL,9080652,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
STEM HUMERAL,9080630,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10530.00000,3053.70000,Aetna,First Health,,8613.54,,,,,,,3796.07,8613.54,percent of total billed charges,
STEM HUMERAL,9080630,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10530.00000,3053.70000,Aetna,First Health,,8613.54,,,,,,,3390.66,8613.54,percent of total billed charges,
PLATE GLENOID,9080631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,2170.21,4924.36,percent of total billed charges,
PLATE GLENOID,9080631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,1938.44,4924.36,percent of total billed charges,
STEM FEMORAL,9080632,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM FEMORAL,9080632,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SCREW SELF DRILL,9080633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,202.23,458.87,percent of total billed charges,
SCREW SELF DRILL,9080633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,180.63,458.87,percent of total billed charges,
PLATE RIGHT,9080641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1552.00000,450.08000,Aetna,First Health,,1269.54,,,,,,,559.50,1269.54,percent of total billed charges,
PLATE RIGHT,9080641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1552.00000,450.08000,Aetna,First Health,,1269.54,,,,,,,499.74,1269.54,percent of total billed charges,
PLATE LEFT,9080642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1481.28000,429.57000,Aetna,First Health,,1211.69,,,,,,,534.00,1211.69,percent of total billed charges,
PLATE LEFT,9080642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1481.28000,429.57000,Aetna,First Health,,1211.69,,,,,,,476.97,1211.69,percent of total billed charges,
SCREW CERVICAL,9080643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3270.75000,948.52000,Aetna,First Health,,2675.47,,,,,,,1179.11,2675.47,percent of total billed charges,
SCREW CERVICAL,9080643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3270.75000,948.52000,Aetna,First Health,,2675.47,,,,,,,1053.18,2675.47,percent of total billed charges,
ROD CERVICAL,9080644,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD CERVICAL,9080644,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
SCREW LOCKING,9080645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,122.78,278.59,percent of total billed charges,
SCREW LOCKING,9080645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,First Health,,278.59,,,,,,,109.67,278.59,percent of total billed charges,
PLATE TIBIAL,9080646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8481.00000,2459.49000,Aetna,First Health,,6937.46,,,,,,,3057.40,6937.46,percent of total billed charges,
PLATE TIBIAL,9080646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8481.00000,2459.49000,Aetna,First Health,,6937.46,,,,,,,2730.88,6937.46,percent of total billed charges,
SCREW LOCKING,9080647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW LOCKING,9080647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW LOCKING,9080649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW LOCKING,9080649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
SCREW LOCKING,9080650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW LOCKING,9080650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
GUIDE WIRE,9080651,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2047.56000,593.79000,Aetna,First Health,,1674.90,,,,,,,738.15,1674.90,percent of total billed charges,
GUIDE WIRE,9080651,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2047.56000,593.79000,Aetna,First Health,,1674.90,,,,,,,659.31,1674.90,percent of total billed charges,
PLATE,9080653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2904.16000,842.21000,Aetna,First Health,,2375.60,,,,,,,1046.95,2375.60,percent of total billed charges,
PLATE,9080653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2904.16000,842.21000,Aetna,First Health,,2375.60,,,,,,,935.14,2375.60,percent of total billed charges,
INSERT HUMERAL,9082582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT HUMERAL,9082582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
FEMORAL HEAD,9082584,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1787.90,4056.87,percent of total billed charges,
FEMORAL HEAD,9082584,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,First Health,,4056.87,,,,,,,1596.96,4056.87,percent of total billed charges,
SLEEVE MATRIX,9082585,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,109.87,249.29,percent of total billed charges,
SLEEVE MATRIX,9082585,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,First Health,,249.29,,,,,,,98.13,249.29,percent of total billed charges,
INSERT TIBIAL,9082583,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
INSERT TIBIAL,9082583,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
ANCHOR IN KIT,9082586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
ANCHOR IN KIT,9082586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
CONNECTOR,9082587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2798.76000,811.64000,Aetna,First Health,,2289.39,,,,,,,1008.95,2289.39,percent of total billed charges,
CONNECTOR,9082587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2798.76000,811.64000,Aetna,First Health,,2289.39,,,,,,,901.20,2289.39,percent of total billed charges,
SCREW,9082588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9082588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
SCREW,9082589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9082589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
ROD SPINAL,9082590,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD SPINAL,9082590,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
ROD SPINAL,9082591,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD SPINAL,9082591,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
BONE SCREW,9082592,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
BONE SCREW,9082592,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
SCREW,9082593,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9082593,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
ROD CERVICAL,9082594,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD CERVICAL,9082594,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
SCREW RELINE,9082595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW RELINE,9082595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
TISSUE ALLOGRAFT,9082597,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
TISSUE ALLOGRAFT,9082597,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
CATHETER NON BALLOON,9082599,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2047.44000,593.76000,Aetna,First Health,,1674.81,,,,,,,738.10,1674.81,percent of total billed charges,
CATHETER NON BALLOON,9082599,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2047.44000,593.76000,Aetna,First Health,,1674.81,,,,,,,659.28,1674.81,percent of total billed charges,
ROD HEX,9080746,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1740.00000,504.60000,Aetna,First Health,,1423.32,,,,,,,627.27,1423.32,percent of total billed charges,
ROD HEX,9080746,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1740.00000,504.60000,Aetna,First Health,,1423.32,,,,,,,560.28,1423.32,percent of total billed charges,
CATHETER GUIDING,9084241,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,1976.00000,573.04000,Aetna,First Health,,1616.37,,,,,,,712.35,1616.37,percent of total billed charges,
CATHETER GUIDING,9084241,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,1976.00000,573.04000,Aetna,First Health,,1616.37,,,,,,,636.27,1616.37,percent of total billed charges,
PULSE GENERATOR,9084221,CDM,278,RC,C1826,HCPCS,,,facility,inpatient,,,53948.00000,15644.92000,Aetna,First Health,,44129.46,,,,,,,19448.25,44129.46,percent of total billed charges,
PULSE GENERATOR,9084221,CDM,278,RC,C1826,HCPCS,,,facility,outpatient,,,53948.00000,15644.92000,Aetna,First Health,,44129.46,,,,,,,17371.26,44129.46,percent of total billed charges,
DEVICE PROGRAMMER,9084222,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3594.15000,1042.30000,Aetna,First Health,,2940.01,,,,,,,1295.69,2940.01,percent of total billed charges,
DEVICE PROGRAMMER,9084222,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3594.15000,1042.30000,Aetna,First Health,,2940.01,,,,,,,1157.32,2940.01,percent of total billed charges,
SCREW LOCKING,9084225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,830.25000,240.77000,Aetna,First Health,,679.14,,,,,,,299.31,679.14,percent of total billed charges,
SCREW LOCKING,9084225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,830.25000,240.77000,Aetna,First Health,,679.14,,,,,,,267.34,679.14,percent of total billed charges,
SCREW CORTEX,9084226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW CORTEX,9084226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW CORTEX,9084227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW CORTEX,9084227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW LOCKING,9084229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,608.52,1380.78,percent of total billed charges,
SCREW LOCKING,9084229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,543.54,1380.78,percent of total billed charges,
SCREW LOCKING,9084230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW LOCKING,9084230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW LOCKING,9084231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW LOCKING,9084231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW LOCKING,9084232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW LOCKING,9084232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW LOCKING,9084233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW LOCKING,9084233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
STENT GRAFT,9084237,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3824.18,8677.34,percent of total billed charges,
STENT GRAFT,9084237,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3415.78,8677.34,percent of total billed charges,
CAGE MODULUS,9084238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE MODULUS,9084238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
WEDGE TIBIAL,9084239,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
WEDGE TIBIAL,9084239,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
INSERT TIBIAL,9084240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2720.51,6173.04,percent of total billed charges,
INSERT TIBIAL,9084240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,First Health,,6173.04,,,,,,,2429.97,6173.04,percent of total billed charges,
PIN FIXATION,9084244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1343.60000,389.64000,Aetna,First Health,,1099.06,,,,,,,484.37,1099.06,percent of total billed charges,
PIN FIXATION,9084244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1343.60000,389.64000,Aetna,First Health,,1099.06,,,,,,,432.64,1099.06,percent of total billed charges,
BONE SCREW,9084246,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
BONE SCREW,9084246,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
SCREW LOCKING,9084247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,518.94000,150.49000,Aetna,First Health,,424.49,,,,,,,187.08,424.49,percent of total billed charges,
SCREW LOCKING,9084247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,518.94000,150.49000,Aetna,First Health,,424.49,,,,,,,167.10,424.49,percent of total billed charges,
BONE PIN,9084248,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6289.50000,1823.96000,Aetna,First Health,,5144.81,,,,,,,2267.36,5144.81,percent of total billed charges,
BONE PIN,9084248,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6289.50000,1823.96000,Aetna,First Health,,5144.81,,,,,,,2025.22,5144.81,percent of total billed charges,
NAIL STRAIGHT,9084249,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12204.00000,3539.16000,Aetna,First Health,,9982.87,,,,,,,4399.54,9982.87,percent of total billed charges,
NAIL STRAIGHT,9084249,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12204.00000,3539.16000,Aetna,First Health,,9982.87,,,,,,,3929.69,9982.87,percent of total billed charges,
SCREW CORTEX,9082849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
SCREW CORTEX,9082849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
PLATE FEMORAL,9084236,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13170.00000,3819.30000,Aetna,First Health,,10773.06,,,,,,,4747.78,10773.06,percent of total billed charges,
PLATE FEMORAL,9084236,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13170.00000,3819.30000,Aetna,First Health,,10773.06,,,,,,,4240.74,10773.06,percent of total billed charges,
INTRODUCER,9084715,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
INTRODUCER,9084715,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
BREAST IMPLANT,9084333,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST IMPLANT,9084333,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,764.47,4222.93,percent of total billed charges,
BREAT IMPLANT,9084334,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAT IMPLANT,9084334,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,764.47,4222.93,percent of total billed charges,
BREAST IMPLANT,9084335,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST IMPLANT,9084335,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,764.47,4222.93,percent of total billed charges,
BREAST IMPLANT,9084336,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST IMPLANT,9084336,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,764.47,4222.93,percent of total billed charges,
BREAST IMPLANT,9084337,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST IMPLANT,9084337,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,764.47,4222.93,percent of total billed charges,
BREAST IMPLANT,9084338,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST IMPLANT,9084338,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,764.47,4222.93,percent of total billed charges,
BREAST IMPLANT,9084339,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST IMPLANT,9084339,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,764.47,4222.93,percent of total billed charges,
SCREW CORTICAL,9083222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW CORTICAL,9083222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
GLENOID HYBRID,9082850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13200.00000,3828.00000,Aetna,First Health,,10797.60,,,,,,,4758.60,10797.60,percent of total billed charges,
GLENOID HYBRID,9082850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13200.00000,3828.00000,Aetna,First Health,,10797.60,,,,,,,4250.40,10797.60,percent of total billed charges,
BALLOON PTA,9084716,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON PTA,9084716,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON PTA,9084717,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON PTA,9084717,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
BALLOON PTA,9084718,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
BALLOON PTA,9084718,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
INSERT TIBIAL,9084804,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9084804,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INSERT TIBIAL,9084803,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9084803,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
NAIL LEFT,9084801,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4346.76000,1260.56000,Aetna,First Health,,3555.65,,,,,,,1567.01,3555.65,percent of total billed charges,
NAIL LEFT,9084801,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4346.76000,1260.56000,Aetna,First Health,,3555.65,,,,,,,1399.66,3555.65,percent of total billed charges,
FEMORAL COMPONENT,9083417,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
FEMORAL COMPONENT,9083417,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
STEM,9084799,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20291.63000,5884.57000,Aetna,First Health,,16598.55,,,,,,,7315.13,16598.55,percent of total billed charges,
STEM,9084799,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20291.63000,5884.57000,Aetna,First Health,,16598.55,,,,,,,6533.90,16598.55,percent of total billed charges,
HEAD FEMORAL,9084800,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7579.59000,2198.08000,Aetna,First Health,,6200.10,,,,,,,2732.44,6200.10,percent of total billed charges,
HEAD FEMORAL,9084800,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7579.59000,2198.08000,Aetna,First Health,,6200.10,,,,,,,2440.63,6200.10,percent of total billed charges,
BLADE SPIRAL,9083371,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1869.28000,542.09000,Aetna,First Health,,1529.07,,,,,,,673.88,1529.07,percent of total billed charges,
BLADE SPIRAL,9083371,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1869.28000,542.09000,Aetna,First Health,,1529.07,,,,,,,601.91,1529.07,percent of total billed charges,
SHOULDER INTERSPACE,9083373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SHOULDER INTERSPACE,9083373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SHOULDER INTERSPACE,9084820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SHOULDER INTERSPACE,9084820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW CORTICAL,9084821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2188.00000,634.52000,Aetna,First Health,,1789.78,,,,,,,788.77,1789.78,percent of total billed charges,
SCREW CORTICAL,9084821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2188.00000,634.52000,Aetna,First Health,,1789.78,,,,,,,704.54,1789.78,percent of total billed charges,
SCREW CORTICAL,9084822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2188.00000,634.52000,Aetna,First Health,,1789.78,,,,,,,788.77,1789.78,percent of total billed charges,
SCREW CORTICAL,9084822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2188.00000,634.52000,Aetna,First Health,,1789.78,,,,,,,704.54,1789.78,percent of total billed charges,
SCREW CORTICAL,9084823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
SCREW CORTICAL,9084823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
SCREW CORTICAL,9084824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
SCREW CORTICAL,9084824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
SCREW CORTICAL,9084825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
SCREW CORTICAL,9084825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
SCREW CORTICAL,9084826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
SCREW CORTICAL,9084826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
SCREW CORTICAL,9084827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,348.78,791.41,percent of total billed charges,
SCREW CORTICAL,9084827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,First Health,,791.41,,,,,,,311.54,791.41,percent of total billed charges,
PLATE T SHAPE,9084828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4371.50000,1267.73000,Aetna,First Health,,3575.89,,,,,,,1575.93,3575.89,percent of total billed charges,
PLATE T SHAPE,9084828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4371.50000,1267.73000,Aetna,First Health,,3575.89,,,,,,,1407.62,3575.89,percent of total billed charges,
STENT GRAFT,9084830,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3824.18,8677.34,percent of total billed charges,
STENT GRAFT,9084830,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3415.78,8677.34,percent of total billed charges,
PLATE TIBIAL,9083422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8151.00000,2363.79000,Aetna,First Health,,6667.52,,,,,,,2938.44,6667.52,percent of total billed charges,
PLATE TIBIAL,9083422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8151.00000,2363.79000,Aetna,First Health,,6667.52,,,,,,,2624.62,6667.52,percent of total billed charges,
CONNECTOR,9083423,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1924.00000,557.96000,Aetna,First Health,,1573.83,,,,,,,693.60,1573.83,percent of total billed charges,
CONNECTOR,9083423,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1924.00000,557.96000,Aetna,First Health,,1573.83,,,,,,,619.53,1573.83,percent of total billed charges,
STEM FEMORAL,9083424,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2649.68,6012.30,percent of total billed charges,
STEM FEMORAL,9083424,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,First Health,,6012.30,,,,,,,2366.70,6012.30,percent of total billed charges,
NAIL RETRO,9083425,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL RETRO,9083425,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
SCREW LOCKING,9083426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,566.71,1285.90,percent of total billed charges,
SCREW LOCKING,9083426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,First Health,,1285.90,,,,,,,506.18,1285.90,percent of total billed charges,
SINUS PROPEL,9083257,CDM,278,RC,J7402,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SINUS PROPEL,9083257,CDM,278,RC,J7402,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,10.93,4222.93,percent of total billed charges,
LINER ACETABULAR,9083372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11239.20000,3259.37000,Aetna,First Health,,9193.67,,,,,,,4051.73,9193.67,percent of total billed charges,
LINER ACETABULAR,9083372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11239.20000,3259.37000,Aetna,First Health,,9193.67,,,,,,,3619.02,9193.67,percent of total billed charges,
MESH,8988111,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1722.29,3907.99,percent of total billed charges,
MESH,8988111,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,First Health,,3907.99,,,,,,,1538.36,3907.99,percent of total billed charges,
TRANSARTICULAR FIXATION,9083510,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
TRANSARTICULAR FIXATION,9083510,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
SCREW,9083511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,9083511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
SCREW STANDARD,9084965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW STANDARD,9084965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
PLATE,9084966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7893.00000,2288.97000,Aetna,First Health,,6456.47,,,,,,,2845.43,6456.47,percent of total billed charges,
PLATE,9084966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7893.00000,2288.97000,Aetna,First Health,,6456.47,,,,,,,2541.55,6456.47,percent of total billed charges,
FEMORAL HEAD,9084968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
FEMORAL HEAD,9084968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SHELL,8440424,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,8440424,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
SCREW NON CANNULATED,9083686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW NON CANNULATED,9083686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
SCREW NON CANNULATED,9083687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,258.86,587.38,percent of total billed charges,
SCREW NON CANNULATED,9083687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,First Health,,587.38,,,,,,,231.22,587.38,percent of total billed charges,
FEMORAL ARTERY,9083688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23797.50000,6901.28000,Aetna,First Health,,19466.35,,,,,,,8579.00,19466.35,percent of total billed charges,
FEMORAL ARTERY,9083688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23797.50000,6901.28000,Aetna,First Health,,19466.35,,,,,,,7662.80,19466.35,percent of total billed charges,
NAIL TROCHANTERIC,9085007,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,2146.24,4869.96,percent of total billed charges,
NAIL TROCHANTERIC,9085007,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,1917.03,4869.96,percent of total billed charges,
DISC SPINAL,9085009,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18800.00000,5452.00000,Aetna,First Health,,15378.40,,,,,,,6777.40,15378.40,percent of total billed charges,
DISC SPINAL,9085009,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18800.00000,5452.00000,Aetna,First Health,,15378.40,,,,,,,6053.60,15378.40,percent of total billed charges,
HEAD FEMORAL,9085010,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,9085010,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
LINER ACETABULAR,9085011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER ACETABULAR,9085011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
STENT GRAFT,9085012,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9085012,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
STENT GRAFT,9085013,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
STENT GRAFT,9085013,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
SPACER,9085016,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
SPACER,9085016,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
STEM FEMORAL,9085053,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
STEM FEMORAL,9085053,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
PUTTY,9083755,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,2984.00000,865.36000,Aetna,First Health,,2440.91,,,,,,,1075.73,2440.91,percent of total billed charges,
PUTTY,9083755,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,2984.00000,865.36000,Aetna,First Health,,2440.91,,,,,,,960.85,2440.91,percent of total billed charges,
PUTTY,9083756,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,7920.00000,2296.80000,Aetna,First Health,,6478.56,,,,,,,2855.16,6478.56,percent of total billed charges,
PUTTY,9083756,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,7920.00000,2296.80000,Aetna,First Health,,6478.56,,,,,,,2550.24,6478.56,percent of total billed charges,
BONE MATRIX,9083757,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,9135.00000,2649.15000,Aetna,First Health,,7472.43,,,,,,,3293.17,7472.43,percent of total billed charges,
BONE MATRIX,9083757,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,9135.00000,2649.15000,Aetna,First Health,,7472.43,,,,,,,124.65,7472.43,percent of total billed charges,
BONE MATRIX LARGE,9083758,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,13500.00000,3915.00000,Aetna,First Health,,11043.00,,,,,,,4866.75,11043.00,percent of total billed charges,
BONE MATRIX LARGE,9083758,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,13500.00000,3915.00000,Aetna,First Health,,11043.00,,,,,,,124.65,11043.00,percent of total billed charges,
STEM HIP,9083759,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
STEM HIP,9083759,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
PLATE TIBIAL,9083760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10635.00000,3084.15000,Aetna,First Health,,8699.43,,,,,,,3833.92,8699.43,percent of total billed charges,
PLATE TIBIAL,9083760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10635.00000,3084.15000,Aetna,First Health,,8699.43,,,,,,,3424.47,8699.43,percent of total billed charges,
SCREW LOCKING,9083761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW LOCKING,9083761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
SCREW LOCKING,9083762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,498.93,1132.11,percent of total billed charges,
SCREW LOCKING,9083762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,445.65,1132.11,percent of total billed charges,
SCREW LOCKING,9083763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,498.93,1132.11,percent of total billed charges,
SCREW LOCKING,9083763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,First Health,,1132.11,,,,,,,445.65,1132.11,percent of total billed charges,
SCREW LOCKING,9083764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW LOCKING,9083764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW LOCKING,9083765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW LOCKING,9083765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW LOCKING,9083766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW LOCKING,9083766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
STEM DISTAL,9085055,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,4276.25,9703.12,percent of total billed charges,
STEM DISTAL,9085055,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,3819.56,9703.12,percent of total billed charges,
SPACER CERVICAL,9085182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
SPACER CERVICAL,9085182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SCREW COMPRESSION,9085176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW COMPRESSION,9085176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW COMPRESSION,9085177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW COMPRESSION,9085177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW LOCKING,9085178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,518.94000,150.49000,Aetna,First Health,,424.49,,,,,,,187.08,424.49,percent of total billed charges,
SCREW LOCKING,9085178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,518.94000,150.49000,Aetna,First Health,,424.49,,,,,,,167.10,424.49,percent of total billed charges,
SCREW RELINE,9085180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW RELINE,9085180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
SCREW RELINE,9085181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW RELINE,9085181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
ROD SPINAL,9083945,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4609.61000,1336.79000,Aetna,First Health,,3770.66,,,,,,,1661.76,3770.66,percent of total billed charges,
ROD SPINAL,9083945,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4609.61000,1336.79000,Aetna,First Health,,3770.66,,,,,,,1484.29,3770.66,percent of total billed charges,
SCREW SPINAL,9083946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,872.10000,252.91000,Aetna,First Health,,713.38,,,,,,,314.39,713.38,percent of total billed charges,
SCREW SPINAL,9083946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,872.10000,252.91000,Aetna,First Health,,713.38,,,,,,,280.82,713.38,percent of total billed charges,
SCREW SPINAL,9083947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,872.10000,252.91000,Aetna,First Health,,713.38,,,,,,,314.39,713.38,percent of total billed charges,
SCREW SPINAL,9083947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,872.10000,252.91000,Aetna,First Health,,713.38,,,,,,,280.82,713.38,percent of total billed charges,
SCREW SPINAL,9083948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,872.10000,252.91000,Aetna,First Health,,713.38,,,,,,,314.39,713.38,percent of total billed charges,
SCREW SPINAL,9083948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,872.10000,252.91000,Aetna,First Health,,713.38,,,,,,,280.82,713.38,percent of total billed charges,
PLATE SPINAL,9083949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8799.18000,2551.76000,Aetna,First Health,,7197.73,,,,,,,3172.10,7197.73,percent of total billed charges,
PLATE SPINAL,9083949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8799.18000,2551.76000,Aetna,First Health,,7197.73,,,,,,,2833.34,7197.73,percent of total billed charges,
PLATE ACP,9083950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
PLATE ACP,9083950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
EXCLUDER,9083970,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16562.50000,4803.12000,Aetna,First Health,,13548.12,,,,,,,5970.78,13548.12,percent of total billed charges,
EXCLUDER,9083970,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16562.50000,4803.12000,Aetna,First Health,,13548.12,,,,,,,5333.12,13548.12,percent of total billed charges,
NAIL LONG,9083971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9083971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
STEM FEMORAL,9083972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12867.00000,3731.43000,Aetna,First Health,,10525.21,,,,,,,4638.55,10525.21,percent of total billed charges,
STEM FEMORAL,9083972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12867.00000,3731.43000,Aetna,First Health,,10525.21,,,,,,,4143.17,10525.21,percent of total billed charges,
SPACER,9083973,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,9083973,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,9083974,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,9083974,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
PLATE ACP,9083975,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1290.14,2927.42,percent of total billed charges,
PLATE ACP,9083975,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1152.36,2927.42,percent of total billed charges,
PLATE LOCKING,9083976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5915.35000,1715.45000,Aetna,First Health,,4838.76,,,,,,,2132.48,4838.76,percent of total billed charges,
PLATE LOCKING,9083976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5915.35000,1715.45000,Aetna,First Health,,4838.76,,,,,,,1904.74,4838.76,percent of total billed charges,
SCREW CORTICAL,9083977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,141.10,320.17,percent of total billed charges,
SCREW CORTICAL,9083977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,First Health,,320.17,,,,,,,126.03,320.17,percent of total billed charges,
TIGHTROPE,9085244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3453.35000,1001.47000,Aetna,First Health,,2824.84,,,,,,,1244.93,2824.84,percent of total billed charges,
TIGHTROPE,9085244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3453.35000,1001.47000,Aetna,First Health,,2824.84,,,,,,,1111.98,2824.84,percent of total billed charges,
CATHETER,9086283,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4542.30,10306.80,percent of total billed charges,
CATHETER,9086283,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4057.20,10306.80,percent of total billed charges,
SCREW,9085395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,359.91000,104.37000,Aetna,First Health,,294.41,,,,,,,129.75,294.41,percent of total billed charges,
SCREW,9085395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,359.91000,104.37000,Aetna,First Health,,294.41,,,,,,,115.89,294.41,percent of total billed charges,
SCREW,9085398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,395.11000,114.58000,Aetna,First Health,,323.20,,,,,,,142.44,323.20,percent of total billed charges,
SCREW,9085398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,395.11000,114.58000,Aetna,First Health,,323.20,,,,,,,127.23,323.20,percent of total billed charges,
SCREW,9085399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.14000,110.82000,Aetna,First Health,,312.59,,,,,,,137.76,312.59,percent of total billed charges,
SCREW,9085399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.14000,110.82000,Aetna,First Health,,312.59,,,,,,,123.05,312.59,percent of total billed charges,
SCREW,9085400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.14000,110.82000,Aetna,First Health,,312.59,,,,,,,137.76,312.59,percent of total billed charges,
SCREW,9085400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.14000,110.82000,Aetna,First Health,,312.59,,,,,,,123.05,312.59,percent of total billed charges,
NAIL,9086326,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9086326,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
SPACER,9086327,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SPACER,9086327,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
LINER,9086306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINER,9086306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
PLATE,9085405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2697.20000,782.19000,Aetna,First Health,,2206.31,,,,,,,972.34,2206.31,percent of total billed charges,
PLATE,9085405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2697.20000,782.19000,Aetna,First Health,,2206.31,,,,,,,868.50,2206.31,percent of total billed charges,
SCREW,9086305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
SCREW,9086305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,583.46,1482.22,percent of total billed charges,
STENT,9084022,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,3356.09,7615.20,percent of total billed charges,
STENT,9084022,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,2997.67,7615.20,percent of total billed charges,
STENT,9084023,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,3356.09,7615.20,percent of total billed charges,
STENT,9084023,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,First Health,,7615.20,,,,,,,2997.67,7615.20,percent of total billed charges,
ROD,9086227,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
ROD,9086227,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
SCREW,9086228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,300.12,680.99,percent of total billed charges,
SCREW,9086228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,First Health,,680.99,,,,,,,268.06,680.99,percent of total billed charges,
SCREW,9085381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,108.65,246.54,percent of total billed charges,
SCREW,9085381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,First Health,,246.54,,,,,,,97.05,246.54,percent of total billed charges,
SCREW,9085382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,9085382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
STEM,9085383,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,9085383,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
NAIL,9085384,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9085384,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
HUMERAL HEAD,9085385,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL HEAD,9085385,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
SUTURE ANCHOR,9085386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
SUTURE ANCHOR,9085386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
SUTURE ANCHOR,9085387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
SUTURE ANCHOR,9085387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
NAIL,9085388,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,9085388,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
SCREW,9086256,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
SCREW,9086256,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
SCREW,9086257,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
SCREW,9086257,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
SCREW,9086258,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,340.67,773.01,percent of total billed charges,
SCREW,9086258,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,First Health,,773.01,,,,,,,304.29,773.01,percent of total billed charges,
ROD,9086259,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
ROD,9086259,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
PLATE,9086260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2365.78,5368.12,percent of total billed charges,
PLATE,9086260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,First Health,,5368.12,,,,,,,2113.12,5368.12,percent of total billed charges,
CONNECTOR,9086261,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,1031.03,2339.48,percent of total billed charges,
CONNECTOR,9086261,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,First Health,,2339.48,,,,,,,920.92,2339.48,percent of total billed charges,
FEMORAL COMPONET,9086255,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
FEMORAL COMPONET,9086255,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
CATHETER,9086316,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,2156.00000,625.24000,Aetna,First Health,,1763.61,,,,,,,777.24,1763.61,percent of total billed charges,
CATHETER,9086316,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,2156.00000,625.24000,Aetna,First Health,,1763.61,,,,,,,694.23,9959.00,percent of total billed charges,
CATHETER,9086317,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
CATHETER,9086317,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,9959.00,percent of total billed charges,
CATHETER,9086318,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
CATHETER,9086318,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,9959.00,percent of total billed charges,
CATHETER,9086319,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
CATHETER,9086319,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,9959.00,percent of total billed charges,
CATHETER,9086320,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,4861.50000,1409.83000,Aetna,First Health,,3976.71,,,,,,,1752.57,3976.71,percent of total billed charges,
CATHETER,9086320,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,4861.50000,1409.83000,Aetna,First Health,,3976.71,,,,,,,1565.40,9959.00,percent of total billed charges,
CATHETER,9086321,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,5587.75,12679.00,percent of total billed charges,
CATHETER,9086321,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,First Health,,12679.00,,,,,,,4991.00,12679.00,percent of total billed charges,
CATHETER,9086322,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,15572.50000,4516.02000,Aetna,First Health,,12738.31,,,,,,,5613.89,12738.31,percent of total billed charges,
CATHETER,9086322,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,15572.50000,4516.02000,Aetna,First Health,,12738.31,,,,,,,5014.35,12738.31,percent of total billed charges,
CATHETER,9086323,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,11160.00000,3236.40000,Aetna,First Health,,9128.88,,,,,,,4023.18,9128.88,percent of total billed charges,
CATHETER,9086323,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,11160.00000,3236.40000,Aetna,First Health,,9128.88,,,,,,,3593.52,9959.00,percent of total billed charges,
CATHETER,9086324,CDM,278,RC,C1759,HCPCS,,,facility,inpatient,,,10731.00000,3111.99000,Aetna,First Health,,8777.96,,,,,,,3868.53,8777.96,percent of total billed charges,
CATHETER,9086324,CDM,278,RC,C1759,HCPCS,,,facility,outpatient,,,10731.00000,3111.99000,Aetna,First Health,,8777.96,,,,,,,3455.38,8777.96,percent of total billed charges,
SHEATH,9086325,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4483.50000,1300.21000,Aetna,First Health,,3667.50,,,,,,,1616.30,3667.50,percent of total billed charges,
SHEATH,9086325,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4483.50000,1300.21000,Aetna,First Health,,3667.50,,,,,,,1443.69,3667.50,percent of total billed charges,
FEMORAL COMPONET,9086303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
FEMORAL COMPONET,9086303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
SWIVELOCK,9086304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3948.00000,1144.92000,Aetna,First Health,,3229.46,,,,,,,1423.25,3229.46,percent of total billed charges,
SWIVELOCK,9086304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3948.00000,1144.92000,Aetna,First Health,,3229.46,,,,,,,1271.26,3229.46,percent of total billed charges,
SCREW,9085343,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9085343,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
FEMORAL STEM,9086328,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
FEMORAL STEM,9086328,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
MIDFACE,9085401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,2170.21,4924.36,percent of total billed charges,
MIDFACE,9085401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,First Health,,4924.36,,,,,,,1938.44,4924.36,percent of total billed charges,
TRANSARTICULAR FIXATION,9086454,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
TRANSARTICULAR FIXATION,9086454,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
SCREW,9086452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9086452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,9086453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3024.48000,877.10000,Aetna,First Health,,2474.02,,,,,,,1090.33,2474.02,percent of total billed charges,
SCREW,9086453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3024.48000,877.10000,Aetna,First Health,,2474.02,,,,,,,973.88,2474.02,percent of total billed charges,
STENT,9086444,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,4429.82,10051.58,percent of total billed charges,
STENT,9086444,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,First Health,,10051.58,,,,,,,3956.74,10051.58,percent of total billed charges,
NAIL,9086451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9086451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
SCREW,9086449,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,9086449,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
CAGE,9086448,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,7025.24,15940.77,percent of total billed charges,
CAGE,9086448,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,First Health,,15940.77,,,,,,,6274.98,15940.77,percent of total billed charges,
STEM,9086447,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26499.33000,7684.81000,Aetna,First Health,,21676.45,,,,,,,9553.01,21676.45,percent of total billed charges,
STEM,9086447,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26499.33000,7684.81000,Aetna,First Health,,21676.45,,,,,,,8532.78,21676.45,percent of total billed charges,
NAIL,9086446,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,714.57,1621.41,percent of total billed charges,
NAIL,9086446,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,638.26,1621.41,percent of total billed charges,
NAIL,9086445,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,714.57,1621.41,percent of total billed charges,
NAIL,9086445,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,First Health,,1621.41,,,,,,,638.26,1621.41,percent of total billed charges,
SCREW,9085675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,290.38,658.90,percent of total billed charges,
SCREW,9085675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,First Health,,658.90,,,,,,,259.37,658.90,percent of total billed charges,
Stent Graft,9086443,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4774.82,10834.41,percent of total billed charges,
Stent Graft,9086443,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,First Health,,10834.41,,,,,,,4264.89,10834.41,percent of total billed charges,
PLATE,9086442,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1290.14,2927.42,percent of total billed charges,
PLATE,9086442,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1152.36,2927.42,percent of total billed charges,
PLATE,9085674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1337.14,3034.07,percent of total billed charges,
PLATE,9085674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,First Health,,3034.07,,,,,,,1194.34,3034.07,percent of total billed charges,
FEMORAL STEM,9086480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
FEMORAL STEM,9086480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW,9086481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,651.73,1478.81,percent of total billed charges,
SCREW,9086481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,582.12,1478.81,percent of total billed charges,
FEMORAL NAIL,9086482,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
FEMORAL NAIL,9086482,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
GLIDECATH,9088194,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
GLIDECATH,9088194,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
SCREW,9088202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2099.00000,608.71000,Aetna,First Health,,1716.98,,,,,,,756.69,1716.98,percent of total billed charges,
SCREW,9088202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2099.00000,608.71000,Aetna,First Health,,1716.98,,,,,,,675.88,1716.98,percent of total billed charges,
HUMERAL HEAD,9088203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HUMERAL HEAD,9088203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
HUMERAL STEM,9088204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
HUMERAL STEM,9088204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
SCREW,9090210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
SCREW,9090210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
SCREW,9090211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9090211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW,9090212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9090212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW,9090213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9090213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW,9090214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9090214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
PLATE,9090215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12177.00000,3531.33000,Aetna,First Health,,9960.79,,,,,,,4389.81,9960.79,percent of total billed charges,
PLATE,9090215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12177.00000,3531.33000,Aetna,First Health,,9960.79,,,,,,,3920.99,9960.79,percent of total billed charges,
CATHETER,9090338,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,13050.00000,3784.50000,Aetna,First Health,,10674.90,,,,,,,4704.52,10674.90,percent of total billed charges,
CATHETER,9090338,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,13050.00000,3784.50000,Aetna,First Health,,10674.90,,,,,,,4202.10,10674.90,percent of total billed charges,
SHEATH,9090339,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
SHEATH,9090339,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
CATHETER,9088277,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,179.80,407.98,percent of total billed charges,
CATHETER,9088277,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,160.60,9959.00,percent of total billed charges,
INTRODUCER,9088278,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,304.48000,88.30000,Aetna,First Health,,249.06,,,,,,,109.77,249.06,percent of total billed charges,
INTRODUCER,9088278,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,304.48000,88.30000,Aetna,First Health,,249.06,,,,,,,98.04,249.06,percent of total billed charges,
MICROCATHETER,9088279,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
MICROCATHETER,9088279,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
GUIDEWIRE,9088280,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,9088280,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
GUIDEWIRE,9088281,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
GUIDEWIRE,9088281,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CATHETER,9088282,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
CATHETER,9088282,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,9959.00,percent of total billed charges,
SHEATH,9088283,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4483.50000,1300.21000,Aetna,First Health,,3667.50,,,,,,,1616.30,3667.50,percent of total billed charges,
SHEATH,9088283,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4483.50000,1300.21000,Aetna,First Health,,3667.50,,,,,,,1443.69,3667.50,percent of total billed charges,
GUIDEWIRE,9088284,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,107.63000,31.21000,Aetna,First Health,,88.04,,,,,,,38.80,88.04,percent of total billed charges,
GUIDEWIRE,9088284,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,107.63000,31.21000,Aetna,First Health,,88.04,,,,,,,34.66,88.04,percent of total billed charges,
INTRODUCER,9088285,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3601.50000,1044.44000,Aetna,First Health,,2946.03,,,,,,,1298.34,2946.03,percent of total billed charges,
INTRODUCER,9088285,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,First Health,,2946.03,,,,,,,1159.68,2946.03,percent of total billed charges,
INNATE,9088270,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8004.00000,2321.16000,Aetna,First Health,,6547.27,,,,,,,2885.44,6547.27,percent of total billed charges,
INNATE,9088270,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8004.00000,2321.16000,Aetna,First Health,,6547.27,,,,,,,2577.29,6547.27,percent of total billed charges,
SCREW,9090295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,284.67,645.94,percent of total billed charges,
SCREW,9090295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,First Health,,645.94,,,,,,,254.27,645.94,percent of total billed charges,
INSERT,9090297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12330.00000,3575.70000,Aetna,First Health,,10085.94,,,,,,,4444.97,10085.94,percent of total billed charges,
INSERT,9090297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12330.00000,3575.70000,Aetna,First Health,,10085.94,,,,,,,3970.26,10085.94,percent of total billed charges,
BASEPLATE,9088262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14673.60000,4255.34000,Aetna,First Health,,12003.00,,,,,,,5289.83,12003.00,percent of total billed charges,
BASEPLATE,9088262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14673.60000,4255.34000,Aetna,First Health,,12003.00,,,,,,,4724.90,12003.00,percent of total billed charges,
FEMORAL NAIL,9090298,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
FEMORAL NAIL,9090298,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
PLATE,9090299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8221.02000,2384.10000,Aetna,First Health,,6724.79,,,,,,,2963.68,6724.79,percent of total billed charges,
PLATE,9090299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8221.02000,2384.10000,Aetna,First Health,,6724.79,,,,,,,2647.17,6724.79,percent of total billed charges,
SCREW,9090300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,651.73,1478.81,percent of total billed charges,
SCREW,9090300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,582.12,1478.81,percent of total billed charges,
TIGHTROPE,9090358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1595.00000,462.55000,Aetna,First Health,,1304.71,,,,,,,575.00,1304.71,percent of total billed charges,
TIGHTROPE,9090358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1595.00000,462.55000,Aetna,First Health,,1304.71,,,,,,,513.59,1304.71,percent of total billed charges,
SCREW,9088310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,9088310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SCREW,9088311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,9088311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
SCREW,9088312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
SCREW,9088312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
PLATE,9088313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8157.09000,2365.56000,Aetna,First Health,,6672.50,,,,,,,2940.63,6672.50,percent of total billed charges,
PLATE,9088313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8157.09000,2365.56000,Aetna,First Health,,6672.50,,,,,,,2626.58,6672.50,percent of total billed charges,
FOBERTAPE,9088314,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
FOBERTAPE,9088314,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
SCREW,9088315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9088315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
CATHETER BALLOON,9088411,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER BALLOON,9088411,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
CATHETER BALLOON,9088412,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER BALLOON,9088412,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
CATHETER BALLOON,9088413,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER BALLOON,9088413,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
CATHETER BALLOON,9088414,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER BALLOON,9088414,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
CATHETER BALLOON,9088415,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER BALLOON,9088415,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
CATHETER BALLOON,9088416,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER BALLOON,9088416,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
CARDIOVERTER ICD,9090495,CDM,278,RC,C1721,HCPCS,,,facility,inpatient,,,41726.25000,12100.61000,Aetna,First Health,,34132.07,,,,,,,15042.31,34132.07,percent of total billed charges,
CARDIOVERTER ICD,9090495,CDM,278,RC,C1721,HCPCS,,,facility,outpatient,,,41726.25000,12100.61000,Aetna,First Health,,34132.07,,,,,,,13435.85,34132.07,percent of total billed charges,
BONE STAPLE,9090504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
BONE STAPLE,9090504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
SCREW LOCKING,9090384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW LOCKING,9090384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW LOCKING,9090385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW LOCKING,9090385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
K WIRE,9088410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,352.03,798.78,percent of total billed charges,
K WIRE,9088410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,First Health,,798.78,,,,,,,314.43,798.78,percent of total billed charges,
CATHETER VENTRICULAR,9090447,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1624.61000,471.14000,Aetna,First Health,,1328.93,,,,,,,585.67,1328.93,percent of total billed charges,
CATHETER VENTRICULAR,9090447,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1624.61000,471.14000,Aetna,First Health,,1328.93,,,,,,,523.12,1328.93,percent of total billed charges,
CAGE ANTERIOR,9090448,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE ANTERIOR,9090448,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
STEM HUMERAL,9090449,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3062.00000,887.98000,Aetna,First Health,,2504.72,,,,,,,1103.85,2504.72,percent of total billed charges,
STEM HUMERAL,9090449,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3062.00000,887.98000,Aetna,First Health,,2504.72,,,,,,,985.96,2504.72,percent of total billed charges,
INSERT,9090451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,9090451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
PLATE,9090452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,First Health,,7565.68,,,,,,,3334.26,7565.68,percent of total billed charges,
PLATE,9090452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,First Health,,7565.68,,,,,,,2978.18,7565.68,percent of total billed charges,
SCREW CORTICAL,9090453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW CORTICAL,9090453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
KWIRE,9088534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,82.90,188.10,percent of total billed charges,
KWIRE,9088534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,First Health,,188.10,,,,,,,74.04,188.10,percent of total billed charges,
PLATE LOCKING,9088535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,1312.94,2979.16,percent of total billed charges,
PLATE LOCKING,9088535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,1172.72,2979.16,percent of total billed charges,
PLATE ACETABULAR,9088536,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,741.19,1681.81,percent of total billed charges,
PLATE ACETABULAR,9088536,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,First Health,,1681.81,,,,,,,662.03,1681.81,percent of total billed charges,
SCREW,9088539,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,517.64000,150.12000,Aetna,First Health,,423.43,,,,,,,186.61,423.43,percent of total billed charges,
SCREW,9088539,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,517.64000,150.12000,Aetna,First Health,,423.43,,,,,,,166.68,423.43,percent of total billed charges,
STEM HUMERAL,9088541,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9088541,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
PLATE FIBULA,9090503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8799.00000,2551.71000,Aetna,First Health,,7197.58,,,,,,,3172.04,7197.58,percent of total billed charges,
PLATE FIBULA,9090503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8799.00000,2551.71000,Aetna,First Health,,7197.58,,,,,,,2833.28,7197.58,percent of total billed charges,
SCREW HEADLESS,9088558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1588.54,3604.52,percent of total billed charges,
SCREW HEADLESS,9088558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,First Health,,3604.52,,,,,,,1418.89,3604.52,percent of total billed charges,
COMPONENT FEMORAL,9088560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2927.35,6642.36,percent of total billed charges,
COMPONENT FEMORAL,9088560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,First Health,,6642.36,,,,,,,2614.72,6642.36,percent of total billed charges,
NOVOSORB BTM,9040254,CDM,278,RC,A2006,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
NOVOSORB BTM,9040254,CDM,278,RC,A2006,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,124.65,4222.93,percent of total billed charges,
INSERT TIBIAL,9088621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
INSERT TIBIAL,9088621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
FEMORAL HEAD,9090502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
FEMORAL HEAD,9090502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
Anchor,9088706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2099.00000,608.71000,Aetna,First Health,,1716.98,,,,,,,756.69,1716.98,percent of total billed charges,
Anchor,9088706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2099.00000,608.71000,Aetna,First Health,,1716.98,,,,,,,675.88,1716.98,percent of total billed charges,
GRAFT,9088611,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
GRAFT,9088611,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
HUMERAL STEM,9090450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
HUMERAL STEM,9090450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
SCREW LOCKING,9090383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1528.00000,443.12000,Aetna,First Health,,1249.90,,,,,,,550.84,1249.90,percent of total billed charges,
SCREW LOCKING,9090383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1528.00000,443.12000,Aetna,First Health,,1249.90,,,,,,,492.02,1249.90,percent of total billed charges,
PLATE,9088734,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10569.00000,3065.01000,Aetna,First Health,,8645.44,,,,,,,3810.12,8645.44,percent of total billed charges,
PLATE,9088734,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10569.00000,3065.01000,Aetna,First Health,,8645.44,,,,,,,3403.22,8645.44,percent of total billed charges,
SCREW,9091159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9091159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SPACER,9088612,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,6601.66,14979.62,percent of total billed charges,
SPACER,9088612,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,First Health,,14979.62,,,,,,,5896.62,14979.62,percent of total billed charges,
TIBIAL NAIL,9088732,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
TIBIAL NAIL,9088732,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
INSERT,9088698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9088698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,9088607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5534.45000,1604.99000,Aetna,First Health,,4527.18,,,,,,,1995.17,4527.18,percent of total billed charges,
PLATE,9088607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5534.45000,1604.99000,Aetna,First Health,,4527.18,,,,,,,1782.09,4527.18,percent of total billed charges,
FEMORAL COMPONENT,9088704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
FEMORAL COMPONENT,9088704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
STEM,9088703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,4276.25,9703.12,percent of total billed charges,
STEM,9088703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,First Health,,9703.12,,,,,,,3819.56,9703.12,percent of total billed charges,
SCREW,9091164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9091164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
SCREW,9088735,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9088735,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
ROD,9088737,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD,9088737,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
SCREW,9088736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9088736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
PLATE,9088741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1343.76,3049.09,percent of total billed charges,
PLATE,9088741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,First Health,,3049.09,,,,,,,1200.26,3049.09,percent of total billed charges,
SCREW,9088738,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,958.93,2175.88,percent of total billed charges,
SCREW,9088738,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,First Health,,2175.88,,,,,,,856.52,2175.88,percent of total billed charges,
INSERT,9088742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12330.00000,3575.70000,Aetna,First Health,,10085.94,,,,,,,4444.97,10085.94,percent of total billed charges,
INSERT,9088742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12330.00000,3575.70000,Aetna,First Health,,10085.94,,,,,,,3970.26,10085.94,percent of total billed charges,
INSERT,9088740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11448.00000,3319.92000,Aetna,First Health,,9364.46,,,,,,,4127.00,9364.46,percent of total billed charges,
INSERT,9088740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11448.00000,3319.92000,Aetna,First Health,,9364.46,,,,,,,3686.26,9364.46,percent of total billed charges,
BREAST IMPLANT,9090638,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST IMPLANT,9090638,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,764.47,4222.93,percent of total billed charges,
BREAST IMPLANT,9090639,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
BREAST IMPLANT,9090639,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,764.47,4222.93,percent of total billed charges,
SPINAL ROD,9088699,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
SPINAL ROD,9088699,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SPINAL ROD,9088700,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
SPINAL ROD,9088700,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
SCREW,9088721,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,9088721,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
PUTTY,9088726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11925.00000,3458.25000,Aetna,First Health,,9754.65,,,,,,,4298.96,9754.65,percent of total billed charges,
PUTTY,9088726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11925.00000,3458.25000,Aetna,First Health,,9754.65,,,,,,,3839.85,9754.65,percent of total billed charges,
SCREW,9091168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,572.76000,166.10000,Aetna,First Health,,468.52,,,,,,,206.48,468.52,percent of total billed charges,
SCREW,9091168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,572.76000,166.10000,Aetna,First Health,,468.52,,,,,,,184.43,468.52,percent of total billed charges,
SCREW,9088739,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,9088739,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
CAGE,9091292,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,6083.44,13803.75,percent of total billed charges,
CAGE,9091292,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,First Health,,13803.75,,,,,,,5433.75,13803.75,percent of total billed charges,
SCREW,9088912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9088912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW,9088913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9088913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW,9088914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9088914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
PLATE,9088915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11412.00000,3309.48000,Aetna,First Health,,9335.02,,,,,,,4114.03,9335.02,percent of total billed charges,
PLATE,9088915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11412.00000,3309.48000,Aetna,First Health,,9335.02,,,,,,,3674.66,9335.02,percent of total billed charges,
SCREW,9088916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9088916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
ANCHOR,9088917,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,908.10,2060.54,percent of total billed charges,
ANCHOR,9088917,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,811.12,2060.54,percent of total billed charges,
PLATE,9088971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2963.20000,859.33000,Aetna,First Health,,2423.90,,,,,,,1068.23,2423.90,percent of total billed charges,
PLATE,9088971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2963.20000,859.33000,Aetna,First Health,,2423.90,,,,,,,954.15,2423.90,percent of total billed charges,
ANCHOR,9088972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3810.21000,1104.96000,Aetna,First Health,,3116.75,,,,,,,1373.58,3116.75,percent of total billed charges,
ANCHOR,9088972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3810.21000,1104.96000,Aetna,First Health,,3116.75,,,,,,,1226.89,3116.75,percent of total billed charges,
CAGE LUMBAR,9091362,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE LUMBAR,9091362,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
PLATE HUMERAL,9088973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11829.00000,3430.41000,Aetna,First Health,,9676.12,,,,,,,4264.35,9676.12,percent of total billed charges,
PLATE HUMERAL,9088973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11829.00000,3430.41000,Aetna,First Health,,9676.12,,,,,,,3808.94,9676.12,percent of total billed charges,
SCREW LOCKING,9088974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW LOCKING,9088974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW,9088975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9088975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
PLATE LOCKING,9088977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4469.50000,1296.16000,Aetna,First Health,,3656.05,,,,,,,1611.25,3656.05,percent of total billed charges,
PLATE LOCKING,9088977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4469.50000,1296.16000,Aetna,First Health,,3656.05,,,,,,,1439.18,3656.05,percent of total billed charges,
SCREW CORTICAL,9088978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW CORTICAL,9088978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW CANCELLOUS,9088979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW CANCELLOUS,9088979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
SCREW CANCELLOUS,9088980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
SCREW CANCELLOUS,9088980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
WEDGE,9088981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1786.32,4053.30,percent of total billed charges,
WEDGE,9088981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,First Health,,4053.30,,,,,,,1595.55,4053.30,percent of total billed charges,
INSERT,9088982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1305.91,2963.20,percent of total billed charges,
INSERT,9088982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,First Health,,2963.20,,,,,,,1166.44,2963.20,percent of total billed charges,
SCREW LOCKING,9088983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,472.98,1073.22,percent of total billed charges,
SCREW LOCKING,9088983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,First Health,,1073.22,,,,,,,422.46,1073.22,percent of total billed charges,
INSERT,9088984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1186.05,2691.22,percent of total billed charges,
INSERT,9088984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,First Health,,2691.22,,,,,,,1059.38,2691.22,percent of total billed charges,
NAIL TIBIAL,9088985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL TIBIAL,9088985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
SHEATH,9091385,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SHEATH,9091385,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
ROD SPINAL,9091439,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,9091439,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
ROD SPINAL,9091440,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,915.67,2077.72,percent of total billed charges,
ROD SPINAL,9091440,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,First Health,,2077.72,,,,,,,817.88,2077.72,percent of total billed charges,
PLATE,9092591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7741.50000,2245.04000,Aetna,First Health,,6332.55,,,,,,,2790.81,6332.55,percent of total billed charges,
PLATE,9092591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7741.50000,2245.04000,Aetna,First Health,,6332.55,,,,,,,2492.76,6332.55,percent of total billed charges,
BASEPLATE,9091635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
BASEPLATE,9091635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
COMPONENT TIBIAL,9091636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
COMPONENT TIBIAL,9091636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
NAIL TIBIAL,9091637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL TIBIAL,9091637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
STENT URETERAL,9092609,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,445.58,1011.05,percent of total billed charges,
STENT URETERAL,9092609,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,397.99,1011.05,percent of total billed charges,
GUIDEWIRE,9091711,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,9091711,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
STENT GRAFT,9091686,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3824.18,8677.34,percent of total billed charges,
STENT GRAFT,9091686,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,First Health,,8677.34,,,,,,,3415.78,8677.34,percent of total billed charges,
COMPONENT FEMORAL,9092694,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9092694,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
INSERT HUMERAL,9092685,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT HUMERAL,9092685,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
PLATE TIBIAL,9092686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10218.00000,2963.22000,Aetna,First Health,,8358.32,,,,,,,3683.59,8358.32,percent of total billed charges,
PLATE TIBIAL,9092686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10218.00000,2963.22000,Aetna,First Health,,8358.32,,,,,,,3290.20,8358.32,percent of total billed charges,
SCREW LOCKING,9092687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW LOCKING,9092687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
SCREW LOCKING,9092688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW LOCKING,9092688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
SCREW LOCKING,9092689,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW LOCKING,9092689,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW MULTIAXIAL,9092690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,895.48,2031.91,percent of total billed charges,
SCREW MULTIAXIAL,9092690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,First Health,,2031.91,,,,,,,799.85,2031.91,percent of total billed charges,
SCREW BONE,9092691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW BONE,9092691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
SCREW BONE,9092692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
SCREW BONE,9092692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
PLATE BONE,9092693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
PLATE BONE,9092693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
GUIDEWIRE,9094190,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
GUIDEWIRE,9094190,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
STEM FEMORAL,9092608,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM FEMORAL,9092608,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
CRYO PROBE,9091657,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,10200.00000,2958.00000,Aetna,First Health,,8343.60,,,,,,,3677.10,8343.60,percent of total billed charges,
CRYO PROBE,9091657,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,10200.00000,2958.00000,Aetna,First Health,,8343.60,,,,,,,3284.40,8343.60,percent of total billed charges,
INSERT PSN,9076339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT PSN,9076339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ZIPFIX STERNAL,9094192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2456.00000,712.24000,Aetna,First Health,,2009.01,,,,,,,885.39,2009.01,percent of total billed charges,
ZIPFIX STERNAL,9094192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2456.00000,712.24000,Aetna,First Health,,2009.01,,,,,,,790.83,2009.01,percent of total billed charges,
POST MODULAR,9094194,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3936.00000,1141.44000,Aetna,First Health,,3219.65,,,,,,,1418.93,3219.65,percent of total billed charges,
POST MODULAR,9094194,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3936.00000,1141.44000,Aetna,First Health,,3219.65,,,,,,,1267.39,3219.65,percent of total billed charges,
SHELL ACETABULAR,9094195,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16087.50000,4665.38000,Aetna,First Health,,13159.58,,,,,,,5799.54,13159.58,percent of total billed charges,
SHELL ACETABULAR,9094195,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16087.50000,4665.38000,Aetna,First Health,,13159.58,,,,,,,5180.18,13159.58,percent of total billed charges,
LINER ACETABULAR,9094196,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
LINER ACETABULAR,9094196,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
INSERT DUAL,9094197,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
INSERT DUAL,9094197,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
STEM MONOBLOCK,9094198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26499.33000,7684.81000,Aetna,First Health,,21676.45,,,,,,,9553.01,21676.45,percent of total billed charges,
STEM MONOBLOCK,9094198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26499.33000,7684.81000,Aetna,First Health,,21676.45,,,,,,,8532.78,21676.45,percent of total billed charges,
INSERT TIBIAL,9094199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT TIBIAL,9094199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
CAGE ANTERIOR,9094201,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE ANTERIOR,9094201,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
SCREW,9094203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
SCREW,9094203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,111.65,283.64,percent of total billed charges,
WASHER,9094204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,519.22000,150.57000,Aetna,First Health,,424.72,,,,,,,187.18,424.72,percent of total billed charges,
WASHER,9094204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,519.22000,150.57000,Aetna,First Health,,424.72,,,,,,,167.19,424.72,percent of total billed charges,
SHELL,9094205,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,4286.20,9725.69,percent of total billed charges,
SHELL,9094205,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,First Health,,9725.69,,,,,,,3828.45,9725.69,percent of total billed charges,
LINER DUAL,9094206,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
LINER DUAL,9094206,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
LINER INSERT,9094207,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
LINER INSERT,9094207,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
BONE MATRIX,9094208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13193.73000,3826.18000,Aetna,First Health,,10792.47,,,,,,,4756.34,10792.47,percent of total billed charges,
BONE MATRIX,9094208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13193.73000,3826.18000,Aetna,First Health,,10792.47,,,,,,,4248.38,10792.47,percent of total billed charges,
HEAD HUMERAL,9094210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HEAD HUMERAL,9094210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
BASEPLATE,9094212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,9094212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
SCREW,9094214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
SCREW,9094214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
STEM HUMERAL,9094215,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9094215,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
PIN SELF DRILL,7968102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PIN SELF DRILL,7968102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
BEARING TIBIAL,9091721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
BEARING TIBIAL,9091721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE CLAVICLE,9092804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5029.50000,1458.55000,Aetna,First Health,,4114.13,,,,,,,1813.13,4114.13,percent of total billed charges,
PLATE CLAVICLE,9092804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5029.50000,1458.55000,Aetna,First Health,,4114.13,,,,,,,1619.50,4114.13,percent of total billed charges,
SHEATH,9091380,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,10080.00000,2923.20000,Aetna,First Health,,8245.44,,,,,,,3633.84,8245.44,percent of total billed charges,
SHEATH,9091380,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,10080.00000,2923.20000,Aetna,First Health,,8245.44,,,,,,,3245.76,8245.44,percent of total billed charges,
SHEATH,9091381,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,10080.00000,2923.20000,Aetna,First Health,,8245.44,,,,,,,3633.84,8245.44,percent of total billed charges,
SHEATH,9091381,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,10080.00000,2923.20000,Aetna,First Health,,8245.44,,,,,,,3245.76,8245.44,percent of total billed charges,
SHEATH,9091382,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,8385.00000,2431.65000,Aetna,First Health,,6858.93,,,,,,,3022.79,6858.93,percent of total billed charges,
SHEATH,9091382,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,8385.00000,2431.65000,Aetna,First Health,,6858.93,,,,,,,2699.97,6858.93,percent of total billed charges,
SHEATH,9091384,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SHEATH,9091384,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
PLATE TIBIAL,9092805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5404.11000,1567.19000,Aetna,First Health,,4420.56,,,,,,,1948.18,4420.56,percent of total billed charges,
PLATE TIBIAL,9092805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5404.11000,1567.19000,Aetna,First Health,,4420.56,,,,,,,1740.12,4420.56,percent of total billed charges,
SHEATH,9091386,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
SHEATH,9091386,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
LLD ACCESSORY,9091387,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,3026.67000,877.73000,Aetna,First Health,,2475.82,,,,,,,1091.11,2475.82,percent of total billed charges,
LLD ACCESSORY,9091387,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,3026.67000,877.73000,Aetna,First Health,,2475.82,,,,,,,974.59,2475.82,percent of total billed charges,
DEVICE LEAD LOCKING,9091388,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,3026.67000,877.73000,Aetna,First Health,,2475.82,,,,,,,1091.11,2475.82,percent of total billed charges,
DEVICE LEAD LOCKING,9091388,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,3026.67000,877.73000,Aetna,First Health,,2475.82,,,,,,,974.59,2475.82,percent of total billed charges,
LLD DEVICE,9091389,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,3026.67000,877.73000,Aetna,First Health,,2475.82,,,,,,,1091.11,2475.82,percent of total billed charges,
LLD DEVICE,9091389,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,3026.67000,877.73000,Aetna,First Health,,2475.82,,,,,,,974.59,2475.82,percent of total billed charges,
KIT ACCESSORY,9091390,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,283.89,644.17,percent of total billed charges,
KIT ACCESSORY,9091390,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,253.57,644.17,percent of total billed charges,
SCREW,9092834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,9092834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
ROD SPINAL,9092829,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD SPINAL,9092829,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
SCREW,9094459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.90000,232.55000,Aetna,First Health,,655.95,,,,,,,289.08,655.95,percent of total billed charges,
SCREW,9094459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.90000,232.55000,Aetna,First Health,,655.95,,,,,,,258.21,655.95,percent of total billed charges,
PLATE MINI,9092833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2779.04000,805.92000,Aetna,First Health,,2273.25,,,,,,,1001.84,2273.25,percent of total billed charges,
PLATE MINI,9092833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2779.04000,805.92000,Aetna,First Health,,2273.25,,,,,,,894.85,2273.25,percent of total billed charges,
PLATE,9094461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2936.00000,851.44000,Aetna,First Health,,2401.65,,,,,,,1058.43,2401.65,percent of total billed charges,
PLATE,9094461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2936.00000,851.44000,Aetna,First Health,,2401.65,,,,,,,945.39,2401.65,percent of total billed charges,
HEAD FEMORAL,9094501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9455.34000,2742.05000,Aetna,First Health,,7734.47,,,,,,,3408.65,7734.47,percent of total billed charges,
HEAD FEMORAL,9094501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9455.34000,2742.05000,Aetna,First Health,,7734.47,,,,,,,3044.62,7734.47,percent of total billed charges,
INSERT,9094478,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,9094478,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
RESTRICTOR,9094479,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
RESTRICTOR,9094479,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
STEM HUMERAL,9094480,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,First Health,,23827.85,,,,,,,10501.15,23827.85,percent of total billed charges,
STEM HUMERAL,9094480,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,First Health,,23827.85,,,,,,,9379.67,23827.85,percent of total billed charges,
STENT,9094544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,9094544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
SCREW,9092831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,671.84,1524.46,percent of total billed charges,
SCREW,9092831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,First Health,,1524.46,,,,,,,600.09,1524.46,percent of total billed charges,
SCREW,9092967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9092967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
SCREW,9092970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1603.68,3638.87,percent of total billed charges,
SCREW,9092970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,First Health,,3638.87,,,,,,,1432.42,3638.87,percent of total billed charges,
SPACER,9094580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18915.00000,5485.35000,Aetna,First Health,,15472.47,,,,,,,6818.86,15472.47,percent of total billed charges,
SPACER,9094580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18915.00000,5485.35000,Aetna,First Health,,15472.47,,,,,,,6090.63,15472.47,percent of total billed charges,
SHEATH,9094581,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
SHEATH,9094581,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
SHEATH,9091383,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,8385.00000,2431.65000,Aetna,First Health,,6858.93,,,,,,,3022.79,6858.93,percent of total billed charges,
SHEATH,9091383,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,8385.00000,2431.65000,Aetna,First Health,,6858.93,,,,,,,2699.97,6858.93,percent of total billed charges,
HEAD FEMORAL,9092828,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1392.66,3160.04,percent of total billed charges,
HEAD FEMORAL,9092828,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,First Health,,3160.04,,,,,,,1243.93,3160.04,percent of total billed charges,
PLATE MANDIBLE,9092832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,18751.75000,5438.01000,Aetna,First Health,,15338.93,,,,,,,6760.01,15338.93,percent of total billed charges,
PLATE MANDIBLE,9092832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,18751.75000,5438.01000,Aetna,First Health,,15338.93,,,,,,,6038.06,15338.93,percent of total billed charges,
SCREW LOCKING,9094458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.90000,232.55000,Aetna,First Health,,655.95,,,,,,,289.08,655.95,percent of total billed charges,
SCREW LOCKING,9094458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.90000,232.55000,Aetna,First Health,,655.95,,,,,,,258.21,655.95,percent of total billed charges,
PLATE,9094460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3790.50000,1099.24000,Aetna,First Health,,3100.63,,,,,,,1366.48,3100.63,percent of total billed charges,
PLATE,9094460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3790.50000,1099.24000,Aetna,First Health,,3100.63,,,,,,,1220.54,3100.63,percent of total billed charges,
NAIL,9093007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL,9093007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
NAIL LONG,9094670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9094670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
PIN,9094671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,405.33000,117.55000,Aetna,First Health,,331.56,,,,,,,146.12,331.56,percent of total billed charges,
PIN,9094671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,405.33000,117.55000,Aetna,First Health,,331.56,,,,,,,130.52,331.56,percent of total billed charges,
INSERT TIBIAL,9094674,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9094674,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
COMPONENT FEMORAL,9094675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,3011.98,6834.39,percent of total billed charges,
COMPONENT FEMORAL,9094675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,First Health,,6834.39,,,,,,,2690.31,6834.39,percent of total billed charges,
PLATE TIBIAL,9094677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10635.00000,3084.15000,Aetna,First Health,,8699.43,,,,,,,3833.92,8699.43,percent of total billed charges,
PLATE TIBIAL,9094677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10635.00000,3084.15000,Aetna,First Health,,8699.43,,,,,,,3424.47,8699.43,percent of total billed charges,
SCREW,9094678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW,9094678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
SCREW,9094679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW,9094679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
SCREW,9094680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW,9094680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
SCREW,9094681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9094681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW,9094682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,179.80,407.98,percent of total billed charges,
SCREW,9094682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,160.60,407.98,percent of total billed charges,
INSERT TIBIAL,9094683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1659.20,3764.84,percent of total billed charges,
INSERT TIBIAL,9094683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,First Health,,3764.84,,,,,,,1482.01,3764.84,percent of total billed charges,
GRAFT TISSUE,9094676,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4828.25000,1400.19000,Aetna,First Health,,3949.51,,,,,,,1740.58,3949.51,percent of total billed charges,
GRAFT TISSUE,9094676,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4828.25000,1400.19000,Aetna,First Health,,3949.51,,,,,,,1554.70,3949.51,percent of total billed charges,
STEM HUMERAL,9093072,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM HUMERAL,9093072,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
NAIL FEMORAL,9093073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL FEMORAL,9093073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
SCREW,9094763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1457.00000,422.53000,Aetna,First Health,,1191.83,,,,,,,525.25,1191.83,percent of total billed charges,
SCREW,9094763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1457.00000,422.53000,Aetna,First Health,,1191.83,,,,,,,469.15,1191.83,percent of total billed charges,
STEM FEMORAL,9094764,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM FEMORAL,9094764,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
VALVE W SIPHONGUARD,7917826,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,15615.75000,4528.57000,Aetna,First Health,,12773.68,,,,,,,5629.48,12773.68,percent of total billed charges,
VALVE W SIPHONGUARD,7917826,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,15615.75000,4528.57000,Aetna,First Health,,12773.68,,,,,,,5028.27,12773.68,percent of total billed charges,
RESTRICTOR,9048626,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
RESTRICTOR,9048626,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
CAGE,9094883,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,4380.07,9938.70,percent of total billed charges,
CAGE,9094883,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,First Health,,9938.70,,,,,,,3912.30,9938.70,percent of total billed charges,
SCREW,9093184,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4088.00000,1185.52000,Aetna,First Health,,3343.98,,,,,,,1473.72,3343.98,percent of total billed charges,
SCREW,9093184,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4088.00000,1185.52000,Aetna,First Health,,3343.98,,,,,,,1316.34,3343.98,percent of total billed charges,
STENT,9086253,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,9086253,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
IMPLANT COLLAR,9094837,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
IMPLANT COLLAR,9094837,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
SPACER,9094882,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
SPACER,9094882,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BEARING,9094884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
BEARING,9094884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ANCHOR,8366494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2264.53,5138.37,percent of total billed charges,
ANCHOR,8366494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,First Health,,5138.37,,,,,,,2022.68,5138.37,percent of total billed charges,
SHELL,9093190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHELL,9093190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SLEEVE,9094817,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3056.00000,886.24000,Aetna,First Health,,2499.81,,,,,,,1101.69,2499.81,percent of total billed charges,
SLEEVE,9094817,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3056.00000,886.24000,Aetna,First Health,,2499.81,,,,,,,984.03,2499.81,percent of total billed charges,
FEMORAL HEAM,9094818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11625.00000,3371.25000,Aetna,First Health,,9509.25,,,,,,,4190.81,9509.25,percent of total billed charges,
FEMORAL HEAM,9094818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11625.00000,3371.25000,Aetna,First Health,,9509.25,,,,,,,3743.25,9509.25,percent of total billed charges,
SCREW,9093197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,314.23,713.01,percent of total billed charges,
SCREW,9093197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,280.67,713.01,percent of total billed charges,
SCREW,9093198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,314.23,713.01,percent of total billed charges,
SCREW,9093198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,280.67,713.01,percent of total billed charges,
SCREW,9093199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,314.23,713.01,percent of total billed charges,
SCREW,9093199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,First Health,,713.01,,,,,,,280.67,713.01,percent of total billed charges,
SCREW,9094839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4676.00000,1356.04000,Aetna,First Health,,3824.97,,,,,,,1685.70,3824.97,percent of total billed charges,
SCREW,9094839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4676.00000,1356.04000,Aetna,First Health,,3824.97,,,,,,,1505.67,3824.97,percent of total billed charges,
SCREW,9094838,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4676.00000,1356.04000,Aetna,First Health,,3824.97,,,,,,,1685.70,3824.97,percent of total billed charges,
SCREW,9094838,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4676.00000,1356.04000,Aetna,First Health,,3824.97,,,,,,,1505.67,3824.97,percent of total billed charges,
ACETABULAR LINER,9094898,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
ACETABULAR LINER,9094898,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
FEMORAL COMPONENET,9094899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1925.04000,558.26000,Aetna,First Health,,1574.68,,,,,,,693.98,1574.68,percent of total billed charges,
FEMORAL COMPONENET,9094899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1925.04000,558.26000,Aetna,First Health,,1574.68,,,,,,,619.86,1574.68,percent of total billed charges,
FEMORAL SLEEVE,9094897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30026.25000,8707.61000,Aetna,First Health,,24561.47,,,,,,,10824.46,24561.47,percent of total billed charges,
FEMORAL SLEEVE,9094897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30026.25000,8707.61000,Aetna,First Health,,24561.47,,,,,,,9668.45,24561.47,percent of total billed charges,
ACETABULAR SHELL,9094896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13716.60000,3977.81000,Aetna,First Health,,11220.18,,,,,,,4944.83,11220.18,percent of total billed charges,
ACETABULAR SHELL,9094896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13716.60000,3977.81000,Aetna,First Health,,11220.18,,,,,,,4416.75,11220.18,percent of total billed charges,
CATHETER GUIDING,9094880,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER GUIDING,9094880,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
ANCHOR IN KIT,9094779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,870.25,1974.65,percent of total billed charges,
ANCHOR IN KIT,9094779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,777.31,1974.65,percent of total billed charges,
INSERT,9094819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT,9094819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
BONE SCREW,9094961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,651.38000,188.90000,Aetna,First Health,,532.83,,,,,,,234.82,532.83,percent of total billed charges,
BONE SCREW,9094961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,651.38000,188.90000,Aetna,First Health,,532.83,,,,,,,209.74,532.83,percent of total billed charges,
BONE SCREW,9094962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,570.38000,165.41000,Aetna,First Health,,466.57,,,,,,,205.62,466.57,percent of total billed charges,
BONE SCREW,9094962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,570.38000,165.41000,Aetna,First Health,,466.57,,,,,,,183.66,466.57,percent of total billed charges,
SCREW,9088691,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,525.09,1191.47,percent of total billed charges,
SCREW,9088691,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,First Health,,1191.47,,,,,,,469.01,1191.47,percent of total billed charges,
ANCHOR,8999061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2092.00000,606.68000,Aetna,First Health,,1711.26,,,,,,,754.17,1711.26,percent of total billed charges,
ANCHOR,8999061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2092.00000,606.68000,Aetna,First Health,,1711.26,,,,,,,673.62,1711.26,percent of total billed charges,
BEARING TIBIAL,9092969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
BEARING TIBIAL,9092969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
INTRODUCER,9098366,CDM,278,RC,C1817,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
INTRODUCER,9098366,CDM,278,RC,C1817,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
CATHETER GUIDING,9094877,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,5320.00000,1542.80000,Aetna,First Health,,4351.76,,,,,,,1917.86,4351.76,percent of total billed charges,
CATHETER GUIDING,9094877,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,5320.00000,1542.80000,Aetna,First Health,,4351.76,,,,,,,1713.04,4351.76,percent of total billed charges,
CATHETER GUIDING,9094878,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER GUIDING,9094878,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
CATHETER GUIDING,9094879,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER GUIDING,9094879,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
CATHETER GUIDING,9094881,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER GUIDING,9094881,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
CATHETER,9095000,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
CATHETER,9095000,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CATHETER,9095001,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
CATHETER,9095001,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
CATHETER,9095003,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
CATHETER,9095003,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
PLATE,9093359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5390.00000,1563.10000,Aetna,First Health,,4409.02,,,,,,,1943.10,4409.02,percent of total billed charges,
PLATE,9093359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5390.00000,1563.10000,Aetna,First Health,,4409.02,,,,,,,1735.58,4409.02,percent of total billed charges,
CATHETER,9095019,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,11247.00000,3261.63000,Aetna,First Health,,9200.05,,,,,,,4054.54,9200.05,percent of total billed charges,
CATHETER,9095019,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,11247.00000,3261.63000,Aetna,First Health,,9200.05,,,,,,,3621.53,9200.05,percent of total billed charges,
CAROTID CATHETER,9095008,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,14217.00000,4122.93000,Aetna,First Health,,11629.51,,,,,,,5125.23,11629.51,percent of total billed charges,
CAROTID CATHETER,9095008,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,14217.00000,4122.93000,Aetna,First Health,,11629.51,,,,,,,4577.87,11629.51,percent of total billed charges,
GLIDE CATHETER,9095020,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,347.61000,100.81000,Aetna,First Health,,284.34,,,,,,,125.31,284.34,percent of total billed charges,
GLIDE CATHETER,9095020,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,347.61000,100.81000,Aetna,First Health,,284.34,,,,,,,111.93,284.34,percent of total billed charges,
HOOK CATHETER,9095021,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,326.07,739.88,percent of total billed charges,
HOOK CATHETER,9095021,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,First Health,,739.88,,,,,,,291.25,739.88,percent of total billed charges,
CATHETER,9095022,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,309.46000,89.74000,Aetna,First Health,,253.14,,,,,,,111.56,253.14,percent of total billed charges,
CATHETER,9095022,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,309.46000,89.74000,Aetna,First Health,,253.14,,,,,,,99.65,253.14,percent of total billed charges,
CATHETER,9095023,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,309.46000,89.74000,Aetna,First Health,,253.14,,,,,,,111.56,253.14,percent of total billed charges,
CATHETER,9095023,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,309.46000,89.74000,Aetna,First Health,,253.14,,,,,,,99.65,253.14,percent of total billed charges,
SCREW,9095024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9095024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,9095025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9095025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
SCREW,9095026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,711.58,1614.63,percent of total billed charges,
SCREW,9095026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,First Health,,1614.63,,,,,,,635.59,1614.63,percent of total billed charges,
ALLOGRAFT,9093360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,First Health,,1701.44,,,,,,,749.84,1701.44,percent of total billed charges,
ALLOGRAFT,9093360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,First Health,,1701.44,,,,,,,669.76,1701.44,percent of total billed charges,
ALLOGRAFT,9095028,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ALLOGRAFT,9095028,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
NAIL,9095005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2918.97,6623.35,percent of total billed charges,
NAIL,9095005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,First Health,,6623.35,,,,,,,2607.23,6623.35,percent of total billed charges,
INSERT,9095006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT,9095006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
HUMERAL TRAY,9095007,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,2088.20,4738.27,percent of total billed charges,
HUMERAL TRAY,9095007,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,First Health,,4738.27,,,,,,,1865.18,4738.27,percent of total billed charges,
PLATE,9094889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5120.50000,1484.94000,Aetna,First Health,,4188.57,,,,,,,1845.94,4188.57,percent of total billed charges,
PLATE,9094889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5120.50000,1484.94000,Aetna,First Health,,4188.57,,,,,,,1648.80,4188.57,percent of total billed charges,
PLATE,9094890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5390.00000,1563.10000,Aetna,First Health,,4409.02,,,,,,,1943.10,4409.02,percent of total billed charges,
PLATE,9094890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5390.00000,1563.10000,Aetna,First Health,,4409.02,,,,,,,1735.58,4409.02,percent of total billed charges,
SCREW,9094891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW,9094891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
SCREW,9094892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW,9094892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
PLATE,9095004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1220.74,2769.95,percent of total billed charges,
PLATE,9095004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1090.37,2769.95,percent of total billed charges,
GLENOSPHERE,9093446,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8449.50000,2450.36000,Aetna,First Health,,6911.69,,,,,,,3046.04,6911.69,percent of total billed charges,
GLENOSPHERE,9093446,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8449.50000,2450.36000,Aetna,First Health,,6911.69,,,,,,,2720.74,6911.69,percent of total billed charges,
HUMERAL INSERT,9093447,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
HUMERAL INSERT,9093447,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
CATHETER,9095002,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
CATHETER,9095002,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
SHEATH,9046200,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
SHEATH,9046200,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
CATHETER,9046201,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,7029.75,15951.00,percent of total billed charges,
CATHETER,9046201,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,6279.00,15951.00,percent of total billed charges,
CATHETER,9093628,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5530.00000,1603.70000,Aetna,First Health,,4523.54,,,,,,,1993.57,4523.54,percent of total billed charges,
CATHETER,9093628,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5530.00000,1603.70000,Aetna,First Health,,4523.54,,,,,,,1780.66,9959.00,percent of total billed charges,
CATHETER,9093629,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5768.00000,1672.72000,Aetna,First Health,,4718.22,,,,,,,2079.36,4718.22,percent of total billed charges,
CATHETER,9093629,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5768.00000,1672.72000,Aetna,First Health,,4718.22,,,,,,,1857.30,9959.00,percent of total billed charges,
CATHETER,9093840,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5530.00000,1603.70000,Aetna,First Health,,4523.54,,,,,,,1993.57,4523.54,percent of total billed charges,
CATHETER,9093840,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5530.00000,1603.70000,Aetna,First Health,,4523.54,,,,,,,1780.66,9959.00,percent of total billed charges,
SCREW,9101005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW,9101005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PLATE,9101064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1220.74,2769.95,percent of total billed charges,
PLATE,9101064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,First Health,,2769.95,,,,,,,1090.37,2769.95,percent of total billed charges,
SPACER,9101065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
SPACER,9101065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
WASHER,9101066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
WASHER,9101066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
SCREW,9099399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3024.48000,877.10000,Aetna,First Health,,2474.02,,,,,,,1090.33,2474.02,percent of total billed charges,
SCREW,9099399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3024.48000,877.10000,Aetna,First Health,,2474.02,,,,,,,973.88,2474.02,percent of total billed charges,
STEM,9099400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14670.00000,4254.30000,Aetna,First Health,,12000.06,,,,,,,5288.53,12000.06,percent of total billed charges,
STEM,9099400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14670.00000,4254.30000,Aetna,First Health,,12000.06,,,,,,,4723.74,12000.06,percent of total billed charges,
COMPONENT ULNAR,9099401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
COMPONENT ULNAR,9099401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
SHELL,9101112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1131.97,2568.52,percent of total billed charges,
SHELL,9101112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,First Health,,2568.52,,,,,,,1011.08,2568.52,percent of total billed charges,
LINER ACETABULAR,9101113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
LINER ACETABULAR,9101113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
INSERT,9101114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT,9101114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
GLENOSPHERE,9101115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
GLENOSPHERE,9101115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
NAIL,9101116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,9101116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
PLATE,9101117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
PLATE,9101117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
INSERT TIBIAL,9101118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
INSERT TIBIAL,9101118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
SCREW,9101119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,943.76,2141.46,percent of total billed charges,
SCREW,9101119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,842.97,2141.46,percent of total billed charges,
STEM,9101129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,9101129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
ANCHOR,9101131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,839.97,1905.94,percent of total billed charges,
ANCHOR,9101131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,750.26,1905.94,percent of total billed charges,
GLENOID COMPONENT,9101132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
GLENOID COMPONENT,9101132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
HUMERAL SYSTEM,9101133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17100.00000,4959.00000,Aetna,First Health,,13987.80,,,,,,,6164.55,13987.80,percent of total billed charges,
HUMERAL SYSTEM,9101133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17100.00000,4959.00000,Aetna,First Health,,13987.80,,,,,,,5506.20,13987.80,percent of total billed charges,
HUMERAL HEAD,9101134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HUMERAL HEAD,9101134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
STENT TRANSCAROTID,9101135,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
STENT TRANSCAROTID,9101135,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
FEMUR PROSTHESIS,9103526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
FEMUR PROSTHESIS,9103526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
PLATE DISTAL,9103527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5029.50000,1458.55000,Aetna,First Health,,4114.13,,,,,,,1813.13,4114.13,percent of total billed charges,
PLATE DISTAL,9103527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5029.50000,1458.55000,Aetna,First Health,,4114.13,,,,,,,1619.50,4114.13,percent of total billed charges,
HEAD HUMERAL,9103528,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4078.31000,1182.71000,Aetna,First Health,,3336.06,,,,,,,1470.23,3336.06,percent of total billed charges,
HEAD HUMERAL,9103528,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4078.31000,1182.71000,Aetna,First Health,,3336.06,,,,,,,1313.22,3336.06,percent of total billed charges,
TRUNNION 45MM,9103529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.09000,2492.58000,Aetna,First Health,,7030.78,,,,,,,3098.53,7030.78,percent of total billed charges,
TRUNNION 45MM,9103529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.09000,2492.58000,Aetna,First Health,,7030.78,,,,,,,2767.62,7030.78,percent of total billed charges,
HEAD HUMERAL,9103530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,7018.94,15926.46,percent of total billed charges,
HEAD HUMERAL,9103530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,6269.34,15926.46,percent of total billed charges,
PLATE LOCKING,9103531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8382.00000,2430.78000,Aetna,First Health,,6856.48,,,,,,,3021.71,6856.48,percent of total billed charges,
PLATE LOCKING,9103531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8382.00000,2430.78000,Aetna,First Health,,6856.48,,,,,,,2699.00,6856.48,percent of total billed charges,
SCREW LOCKING,9103532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW LOCKING,9103532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
PATELLA PROSTHESIS,9103533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
PATELLA PROSTHESIS,9103533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
COMPONENT FEMORAL,9103534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9103534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
STEM HUMERAL,9101267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9101267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
SPACER,9101268,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,6646.72,15081.88,percent of total billed charges,
SPACER,9101268,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,First Health,,15081.88,,,,,,,5936.88,15081.88,percent of total billed charges,
PATELLA PROSTHESIS,9101269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
PATELLA PROSTHESIS,9101269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
BONE SCREW,9101270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
BONE SCREW,9101270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
COMPONENT FEMORAL,9101271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9101271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
INSERT,9101272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT,9101272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SPACER,9101273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1165.86,2645.41,percent of total billed charges,
SPACER,9101273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,First Health,,2645.41,,,,,,,1041.35,2645.41,percent of total billed charges,
CATHETER SHOCKWAVE,9093507,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4542.30,10306.80,percent of total billed charges,
CATHETER SHOCKWAVE,9093507,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4057.20,10306.80,percent of total billed charges,
CATHETER SHOCKWAVE,9093508,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4542.30,10306.80,percent of total billed charges,
CATHETER SHOCKWAVE,9093508,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,First Health,,10306.80,,,,,,,4057.20,10306.80,percent of total billed charges,
SCREW LOCKING,9101313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW LOCKING,9101313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW COMPRESSION,9101314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW COMPRESSION,9101314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
SCREW LOCKING,9101315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW LOCKING,9101315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
PLATE DISTAL,9101316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13596.00000,3942.84000,Aetna,First Health,,11121.53,,,,,,,4901.36,11121.53,percent of total billed charges,
PLATE DISTAL,9101316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13596.00000,3942.84000,Aetna,First Health,,11121.53,,,,,,,4377.91,11121.53,percent of total billed charges,
BEARING ACETABULAR,9101311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1533.03,3478.55,percent of total billed charges,
BEARING ACETABULAR,9101311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,First Health,,3478.55,,,,,,,1369.31,3478.55,percent of total billed charges,
HEAD FEMORAL,9101312,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,9101312,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
CVAC ASPIRATOR SYS,9101531,CDM,278,RC,C1747,HCPCS,,,facility,inpatient,,,12735.00000,3693.15000,Aetna,First Health,,10417.23,,,,,,,4590.97,10417.23,percent of total billed charges,
CVAC ASPIRATOR SYS,9101531,CDM,278,RC,C1747,HCPCS,,,facility,outpatient,,,12735.00000,3693.15000,Aetna,First Health,,10417.23,,,,,,,4100.67,10417.23,percent of total billed charges,
CAGE,9101365,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE,9101365,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
SCREW,9103708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,9103708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,9103709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,9103709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
COMPONENT FEMORAL,9103707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
COMPONENT FEMORAL,9103707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2559.90,6503.10,percent of total billed charges,
GRAFT TISSUE,9101292,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,19478.25000,5648.69000,Aetna,First Health,,15933.21,,,,,,,7021.91,15933.21,percent of total billed charges,
GRAFT TISSUE,9101292,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,19478.25000,5648.69000,Aetna,First Health,,15933.21,,,,,,,6272.00,15933.21,percent of total billed charges,
ENDPLATE,9104149,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
ENDPLATE,9104149,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
ENDPLATE,9104150,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
ENDPLATE,9104150,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
INLAY,9104151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
INLAY,9104151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,9104158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,9104158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
SCREW,9104159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
SCREW,9104159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
HEAD FEMORAL,9104153,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,634.48,1439.68,percent of total billed charges,
HEAD FEMORAL,9104153,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,First Health,,1439.68,,,,,,,566.72,1439.68,percent of total billed charges,
STEM FEMORAL,9104154,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,4346.82,9863.24,percent of total billed charges,
STEM FEMORAL,9104154,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,First Health,,9863.24,,,,,,,3882.60,9863.24,percent of total billed charges,
PLATE FEMUR,9104155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16255.00000,4713.95000,Aetna,First Health,,13296.59,,,,,,,5859.93,13296.59,percent of total billed charges,
PLATE FEMUR,9104155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16255.00000,4713.95000,Aetna,First Health,,13296.59,,,,,,,5234.11,13296.59,percent of total billed charges,
SCREW LOCKING,9104156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,608.52,1380.78,percent of total billed charges,
SCREW LOCKING,9104156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,543.54,1380.78,percent of total billed charges,
SCREW LOCKING,9104157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,608.52,1380.78,percent of total billed charges,
SCREW LOCKING,9104157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,First Health,,1380.78,,,,,,,543.54,1380.78,percent of total billed charges,
SCREW CORTEX,9104160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW CORTEX,9104160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
SCREW LOCKING,9104161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW LOCKING,9104161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
PLATE,9104406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6240.50000,1809.74000,Aetna,First Health,,5104.73,,,,,,,2249.70,5104.73,percent of total billed charges,
PLATE,9104406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6240.50000,1809.74000,Aetna,First Health,,5104.73,,,,,,,2009.44,5104.73,percent of total billed charges,
ANCHOR IN KIT,9104407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2477.00000,718.33000,Aetna,First Health,,2026.19,,,,,,,892.96,2026.19,percent of total billed charges,
ANCHOR IN KIT,9104407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2477.00000,718.33000,Aetna,First Health,,2026.19,,,,,,,797.59,2026.19,percent of total billed charges,
LINER,9104408,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
LINER,9104408,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
STEM FEMORAL,9104217,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9723.00000,2819.67000,Aetna,First Health,,7953.41,,,,,,,3505.14,7953.41,percent of total billed charges,
STEM FEMORAL,9104217,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9723.00000,2819.67000,Aetna,First Health,,7953.41,,,,,,,3130.81,7953.41,percent of total billed charges,
SPACER,9104218,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
SPACER,9104218,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
SPACER,9104219,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
SPACER,9104219,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
SCREW CORTICAL,9104415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,236.04,535.59,percent of total billed charges,
SCREW CORTICAL,9104415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,First Health,,535.59,,,,,,,210.83,535.59,percent of total billed charges,
STEM,9104416,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,3098.50,7030.71,percent of total billed charges,
STEM,9104416,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,First Health,,7030.71,,,,,,,2767.59,7030.71,percent of total billed charges,
ROD SPINAL,9104458,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD SPINAL,9104458,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
ROD SPINAL,9104459,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD SPINAL,9104459,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
SCREW,9104460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9104460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
SCREW,9104461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9104461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
PLATE,9104462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5540.50000,1606.74000,Aetna,First Health,,4532.13,,,,,,,1997.35,4532.13,percent of total billed charges,
PLATE,9104462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5540.50000,1606.74000,Aetna,First Health,,4532.13,,,,,,,1784.04,4532.13,percent of total billed charges,
PLATE,9104464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16255.00000,4713.95000,Aetna,First Health,,13296.59,,,,,,,5859.93,13296.59,percent of total billed charges,
PLATE,9104464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16255.00000,4713.95000,Aetna,First Health,,13296.59,,,,,,,5234.11,13296.59,percent of total billed charges,
SCREW,9104465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9104465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW,9104466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9104466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
ANCHOR,9094663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,908.10,2060.54,percent of total billed charges,
ANCHOR,9094663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,811.12,2060.54,percent of total billed charges,
FEMORAL STEM,9104580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3825.27,8679.80,percent of total billed charges,
FEMORAL STEM,9104580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,First Health,,8679.80,,,,,,,3416.74,8679.80,percent of total billed charges,
NAIL TIBIAL,9104594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,2209.32,5013.11,percent of total billed charges,
NAIL TIBIAL,9104594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,First Health,,5013.11,,,,,,,1973.38,5013.11,percent of total billed charges,
SCREW,9104595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,943.76,2141.46,percent of total billed charges,
SCREW,9104595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,First Health,,2141.46,,,,,,,842.97,2141.46,percent of total billed charges,
VERTEBRAL PROSTHESIS,9104629,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
VERTEBRAL PROSTHESIS,9104629,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
HEAD HUMERAL,9104630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,7018.94,15926.46,percent of total billed charges,
HEAD HUMERAL,9104630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,6269.34,15926.46,percent of total billed charges,
PLATE,9104636,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5266.80000,1527.37000,Aetna,First Health,,4308.24,,,,,,,1898.68,4308.24,percent of total billed charges,
PLATE,9104636,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5266.80000,1527.37000,Aetna,First Health,,4308.24,,,,,,,1695.91,4308.24,percent of total billed charges,
PENILE PUMP,9104628,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,45663.75000,13242.49000,Aetna,First Health,,37352.95,,,,,,,16461.78,37352.95,percent of total billed charges,
PENILE PUMP,9104628,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,45663.75000,13242.49000,Aetna,First Health,,37352.95,,,,,,,14703.73,37352.95,percent of total billed charges,
PENILE PUMP KIT,9104627,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1703.36,3865.05,percent of total billed charges,
PENILE PUMP KIT,9104627,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,First Health,,3865.05,,,,,,,1521.45,3865.05,percent of total billed charges,
SCREW,9104673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9104673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
INSERT TIBIAL,9104674,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
INSERT TIBIAL,9104674,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE,9106475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,9106475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
LINER,9106476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
LINER,9106476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
HEAD FEMORAL,9106477,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
HEAD FEMORAL,9106477,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
SHELL PRIME,9106479,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
SHELL PRIME,9106479,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
LINER,9106480,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1167.12,2648.28,percent of total billed charges,
LINER,9106480,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,First Health,,2648.28,,,,,,,1042.47,2648.28,percent of total billed charges,
GRAFT,9012704,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,3212.05,7288.38,percent of total billed charges,
GRAFT,9012704,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,2869.02,7288.38,percent of total billed charges,
ANCHOR SUTURE,9104730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,866.64,1966.47,percent of total billed charges,
ANCHOR SUTURE,9104730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,774.09,1966.47,percent of total billed charges,
INSERT,9104731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,9104731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
COMPONENT FEMORAL,9104732,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
COMPONENT FEMORAL,9104732,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
SPACER,9108393,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
SPACER,9108393,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
STAPLE EASYFUSE,9010164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8634.00000,2503.86000,Aetna,First Health,,7062.61,,,,,,,3112.56,7062.61,percent of total billed charges,
STAPLE EASYFUSE,9010164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8634.00000,2503.86000,Aetna,First Health,,7062.61,,,,,,,2780.15,7062.61,percent of total billed charges,
CATHETER LASER,9005676,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,11247.00000,3261.63000,Aetna,First Health,,9200.05,,,,,,,4054.54,9200.05,percent of total billed charges,
CATHETER LASER,9005676,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,11247.00000,3261.63000,Aetna,First Health,,9200.05,,,,,,,3621.53,9200.05,percent of total billed charges,
CATHETER LASER,9005677,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,11247.00000,3261.63000,Aetna,First Health,,9200.05,,,,,,,4054.54,9200.05,percent of total billed charges,
CATHETER LASER,9005677,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,11247.00000,3261.63000,Aetna,First Health,,9200.05,,,,,,,3621.53,9200.05,percent of total billed charges,
CATHETER LASER,9005678,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,11247.00000,3261.63000,Aetna,First Health,,9200.05,,,,,,,4054.54,9200.05,percent of total billed charges,
CATHETER LASER,9005678,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,11247.00000,3261.63000,Aetna,First Health,,9200.05,,,,,,,3621.53,9200.05,percent of total billed charges,
CATHETER LASER,9005679,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,11247.00000,3261.63000,Aetna,First Health,,9200.05,,,,,,,4054.54,9200.05,percent of total billed charges,
CATHETER LASER,9005679,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,11247.00000,3261.63000,Aetna,First Health,,9200.05,,,,,,,3621.53,9200.05,percent of total billed charges,
STEM,9021126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16237.50000,4708.88000,Aetna,First Health,,13282.27,,,,,,,5853.62,13282.27,percent of total billed charges,
STEM,9021126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16237.50000,4708.88000,Aetna,First Health,,13282.27,,,,,,,5228.48,13282.27,percent of total billed charges,
LINER HUMERAL,9056621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1811.62,4110.70,percent of total billed charges,
LINER HUMERAL,9056621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,First Health,,4110.70,,,,,,,1618.15,4110.70,percent of total billed charges,
SCREW CORTICAL,9080350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,598.43,1357.88,percent of total billed charges,
SCREW CORTICAL,9080350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,534.52,1357.88,percent of total billed charges,
SCREW,9091160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9091160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
GRAFT HUMERUS,9094313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,29335.50000,8507.30000,Aetna,First Health,,23996.44,,,,,,,10575.45,23996.44,percent of total billed charges,
GRAFT HUMERUS,9094313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,29335.50000,8507.30000,Aetna,First Health,,23996.44,,,,,,,9446.03,23996.44,percent of total billed charges,
HUMERAL HEAD,8997060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,8997060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,9010895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
SCREW,9010895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
COMPONENT PATELLA,9050225,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
COMPONENT PATELLA,9050225,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,2705.53,percent of total billed charges,
HEAD HUMERAL,9060537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,9060537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
INSERT PSN ASF,9076188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT PSN ASF,9076188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
LINE ACETABULAR,9080349,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,2519.44,percent of total billed charges,
LINE ACETABULAR,9080349,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,991.76,2519.44,percent of total billed charges,
STEM HUMERAL,9083638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9083638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
INTRODUCER,9104736,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,30.28,68.71,percent of total billed charges,
INTRODUCER,9104736,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,27.05,68.71,percent of total billed charges,
NAIL LONG,9108403,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9108403,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
PLATE,9104804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2770.80000,803.53000,Aetna,First Health,,2266.51,,,,,,,998.87,2266.51,percent of total billed charges,
PLATE,9104804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2770.80000,803.53000,Aetna,First Health,,2266.51,,,,,,,892.20,2266.51,percent of total billed charges,
PLATE,9104805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3012.88000,873.74000,Aetna,First Health,,2464.54,,,,,,,1086.14,2464.54,percent of total billed charges,
PLATE,9104805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3012.88000,873.74000,Aetna,First Health,,2464.54,,,,,,,970.15,2464.54,percent of total billed charges,
NAIL LONG,9108398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL LONG,9108398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
INSERT TIBIAL,9104823,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9104823,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
SPACER,9104824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
SPACER,9104824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
COMPONENT RADIAL,9108483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2812.98,6382.85,percent of total billed charges,
COMPONENT RADIAL,9108483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,First Health,,6382.85,,,,,,,2512.57,6382.85,percent of total billed charges,
PLATE,9108484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2302.69,5224.98,percent of total billed charges,
PLATE,9108484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,First Health,,5224.98,,,,,,,2056.78,5224.98,percent of total billed charges,
SCREW,9108485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,309.85,703.07,percent of total billed charges,
SCREW,9108485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,276.76,703.07,percent of total billed charges,
SCREW,9104855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,261.39,593.12,percent of total billed charges,
SCREW,9104855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,First Health,,593.12,,,,,,,233.48,593.12,percent of total billed charges,
STEM,9104859,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,9104859,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
SCREW,9104850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,309.85,703.07,percent of total billed charges,
SCREW,9104850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,276.76,703.07,percent of total billed charges,
SCREW,9104851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,9104851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,9104852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,9104852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,9104853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,9104853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
SCREW,9104854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,454.23,1030.68,percent of total billed charges,
SCREW,9104854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,First Health,,1030.68,,,,,,,405.72,1030.68,percent of total billed charges,
Screw,9104856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
Screw,9104856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
PLATE,9104858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
PLATE,9104858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,9104860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16255.00000,4713.95000,Aetna,First Health,,13296.59,,,,,,,5859.93,13296.59,percent of total billed charges,
PLATE,9104860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16255.00000,4713.95000,Aetna,First Health,,13296.59,,,,,,,5234.11,13296.59,percent of total billed charges,
SCREW,9104861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
SCREW,9104861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
SCREW,9104862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
SCREW,9104862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
SCREW,9104863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
SCREW,9104863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
SCREW,9104864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
SCREW,9104864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
SCREW,9104865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
SCREW,9104865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
SCREW,9104866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9104866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW,9104867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9104867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW,9104868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9104868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW,9108598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,201.16,456.44,percent of total billed charges,
SCREW,9108598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,179.68,456.44,percent of total billed charges,
SCREW,9108599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,201.16,456.44,percent of total billed charges,
SCREW,9108599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,179.68,456.44,percent of total billed charges,
BASEPLATE,9104953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9894.00000,2869.26000,Aetna,First Health,,8093.29,,,,,,,3566.79,8093.29,percent of total billed charges,
BASEPLATE,9104953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9894.00000,2869.26000,Aetna,First Health,,8093.29,,,,,,,3185.87,8093.29,percent of total billed charges,
CEMENT TIBIAL,9108632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4963.00000,1439.27000,Aetna,First Health,,4059.73,,,,,,,1789.16,4059.73,percent of total billed charges,
CEMENT TIBIAL,9108632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4963.00000,1439.27000,Aetna,First Health,,4059.73,,,,,,,1598.09,4059.73,percent of total billed charges,
STEM FEMORAL,9104954,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM FEMORAL,9104954,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
SCREW,9104955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,9104955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
BASEPLATE,9104956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
BASEPLATE,9104956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
COMPONENT FEMORAL,9104957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,9104957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
INSERT TIBIAL,9104958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
INSERT TIBIAL,9104958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
STEM,9104959,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,9104959,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
SCREW,9104960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1962.02,4451.97,percent of total billed charges,
SCREW,9104960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1752.48,4451.97,percent of total billed charges,
SCREW,9108633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1356.00000,393.24000,Aetna,First Health,,1109.21,,,,,,,488.84,1109.21,percent of total billed charges,
SCREW,9108633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1356.00000,393.24000,Aetna,First Health,,1109.21,,,,,,,436.63,1109.21,percent of total billed charges,
VASCULAR GRAFT,9108634,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,6123.99,13895.77,percent of total billed charges,
VASCULAR GRAFT,9108634,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,First Health,,13895.77,,,,,,,5469.98,13895.77,percent of total billed charges,
PLATE,9104994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1463.63,3321.08,percent of total billed charges,
PLATE,9104994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,First Health,,3321.08,,,,,,,1307.32,3321.08,percent of total billed charges,
PLATE,9108550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,744.07,1688.35,percent of total billed charges,
PLATE,9108550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,664.61,1688.35,percent of total billed charges,
SCREW,9108685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,9108685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
SPACER,9108686,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
SPACER,9108686,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
COMPONENT GLENOID,9108688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
COMPONENT GLENOID,9108688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
HEAD HUMERAL,9108689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
HEAD HUMERAL,9108689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
STEM HUMERAL,9108690,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM HUMERAL,9108690,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
GUIDE PIN,9108691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
GUIDE PIN,9108691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,9108692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,309.85,703.07,percent of total billed charges,
SCREW,9108692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,276.76,703.07,percent of total billed charges,
SCREW,9108693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,9108693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
SPACER,9108700,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
SPACER,9108700,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
SPACER,9108694,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
SPACER,9108694,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
SCREW,9108701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9108701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
SCREW,9108702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9108702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
SPACER,9108703,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,6308.75,14315.00,percent of total billed charges,
SPACER,9108703,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,First Health,,14315.00,,,,,,,5635.00,14315.00,percent of total billed charges,
PLATE,9108704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1410.01,3199.40,percent of total billed charges,
PLATE,9108704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,First Health,,3199.40,,,,,,,1259.42,3199.40,percent of total billed charges,
SCREW,9108705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9108705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
SCREW,9108706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9108706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
GRAFT TISSUE,9108687,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17725.00000,5140.25000,Aetna,First Health,,14499.05,,,,,,,6389.86,14499.05,percent of total billed charges,
GRAFT TISSUE,9108687,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17725.00000,5140.25000,Aetna,First Health,,14499.05,,,,,,,5707.45,14499.05,percent of total billed charges,
INSERT,9105022,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,9105022,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
GRAFT TISSUE,9114686,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT TISSUE,9114686,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
ROD,9110106,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
ROD,9110106,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE,9116392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.00000,1121.43000,Aetna,First Health,,3163.21,,,,,,,1394.05,3163.21,percent of total billed charges,
PLATE,9116392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.00000,1121.43000,Aetna,First Health,,3163.21,,,,,,,1245.17,3163.21,percent of total billed charges,
MESH,9116414,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,13776.00000,3995.04000,Aetna,First Health,,11268.77,,,,,,,4966.25,11268.77,percent of total billed charges,
MESH,9116414,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,13776.00000,3995.04000,Aetna,First Health,,11268.77,,,,,,,4435.87,11268.77,percent of total billed charges,
SCREW,9116416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9116416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
SCREW,9116415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1134.13,2573.43,percent of total billed charges,
SCREW,9116415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,First Health,,2573.43,,,,,,,1013.01,2573.43,percent of total billed charges,
TIBIAL INSERT,9114752,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
TIBIAL INSERT,9114752,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
HUMERAL SHELL,9114810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,3298.57,7484.70,percent of total billed charges,
HUMERAL SHELL,9114810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,First Health,,7484.70,,,,,,,2946.30,7484.70,percent of total billed charges,
STEM,9114811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,9114811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
ARTICULARTING SURFACE,9116537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
ARTICULARTING SURFACE,9116537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
OCCLUDER,9116492,CDM,278,RC,C1817,HCPCS,,,facility,inpatient,,,29351.25000,8511.86000,Aetna,First Health,,24009.32,,,,,,,10581.13,24009.32,percent of total billed charges,
OCCLUDER,9116492,CDM,278,RC,C1817,HCPCS,,,facility,outpatient,,,29351.25000,8511.86000,Aetna,First Health,,24009.32,,,,,,,9451.10,24009.32,percent of total billed charges,
OCCLUDER,9116493,CDM,278,RC,C1817,HCPCS,,,facility,inpatient,,,29351.25000,8511.86000,Aetna,First Health,,24009.32,,,,,,,10581.13,24009.32,percent of total billed charges,
OCCLUDER,9116493,CDM,278,RC,C1817,HCPCS,,,facility,outpatient,,,29351.25000,8511.86000,Aetna,First Health,,24009.32,,,,,,,9451.10,24009.32,percent of total billed charges,
GRAFT,9110107,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,36816.75000,10676.86000,Aetna,First Health,,30116.10,,,,,,,13272.44,30116.10,percent of total billed charges,
GRAFT,9110107,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,36816.75000,10676.86000,Aetna,First Health,,30116.10,,,,,,,11854.99,30116.10,percent of total billed charges,
VALVE,9116394,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116394,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116395,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116395,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116396,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116396,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116397,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116397,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116398,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116398,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116399,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116399,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116400,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116400,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116401,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116401,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116402,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116402,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116403,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116403,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116404,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116404,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116405,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116405,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116406,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116406,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116407,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116407,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116408,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5691.39,12914.17,percent of total billed charges,
VALVE,9116408,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,First Health,,12914.17,,,,,,,5083.57,12914.17,percent of total billed charges,
VALVE,9116409,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21687.50000,6289.38000,Aetna,First Health,,17740.38,,,,,,,7818.34,17740.38,percent of total billed charges,
VALVE,9116409,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21687.50000,6289.38000,Aetna,First Health,,17740.38,,,,,,,6983.38,17740.38,percent of total billed charges,
VALVE,9116410,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21687.50000,6289.38000,Aetna,First Health,,17740.38,,,,,,,7818.34,17740.38,percent of total billed charges,
VALVE,9116410,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21687.50000,6289.38000,Aetna,First Health,,17740.38,,,,,,,6983.38,17740.38,percent of total billed charges,
VALVE,9116411,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21687.50000,6289.38000,Aetna,First Health,,17740.38,,,,,,,7818.34,17740.38,percent of total billed charges,
VALVE,9116411,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21687.50000,6289.38000,Aetna,First Health,,17740.38,,,,,,,6983.38,17740.38,percent of total billed charges,
VAVLE,9116412,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21687.50000,6289.38000,Aetna,First Health,,17740.38,,,,,,,7818.34,17740.38,percent of total billed charges,
VAVLE,9116412,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21687.50000,6289.38000,Aetna,First Health,,17740.38,,,,,,,6983.38,17740.38,percent of total billed charges,
VALVE,9116413,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21687.50000,6289.38000,Aetna,First Health,,17740.38,,,,,,,7818.34,17740.38,percent of total billed charges,
VALVE,9116413,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21687.50000,6289.38000,Aetna,First Health,,17740.38,,,,,,,6983.38,17740.38,percent of total billed charges,
PLATE,9116494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,744.07,1688.35,percent of total billed charges,
PLATE,9116494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,First Health,,1688.35,,,,,,,664.61,1688.35,percent of total billed charges,
STRUT,9116495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,3050.80,6922.49,percent of total billed charges,
STRUT,9116495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,First Health,,6922.49,,,,,,,2724.99,6922.49,percent of total billed charges,
PROGRAMMER,9116655,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3594.15000,1042.30000,Aetna,First Health,,2940.01,,,,,,,1295.69,2940.01,percent of total billed charges,
PROGRAMMER,9116655,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3594.15000,1042.30000,Aetna,First Health,,2940.01,,,,,,,1157.32,2940.01,percent of total billed charges,
SPACER,9116661,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
SPACER,9116661,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
NAIL,9114979,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,7609.00000,2206.61000,Aetna,First Health,,6224.16,,,,,,,2743.04,6224.16,percent of total billed charges,
NAIL,9114979,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,7609.00000,2206.61000,Aetna,First Health,,6224.16,,,,,,,2450.10,6224.16,percent of total billed charges,
ANCHOR,9114980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.00000,559.99000,Aetna,First Health,,1579.56,,,,,,,696.13,1579.56,percent of total billed charges,
ANCHOR,9114980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.00000,559.99000,Aetna,First Health,,1579.56,,,,,,,621.78,1579.56,percent of total billed charges,
ANCHOR,9116670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,First Health,,2180.79,,,,,,,961.09,2180.79,percent of total billed charges,
ANCHOR,9116670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,First Health,,2180.79,,,,,,,858.45,2180.79,percent of total billed charges,
INSERT,9116797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,9116797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
TIBIAL CONE,9116796,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
TIBIAL CONE,9116796,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
TIBIAL CONE,9116795,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,6128.50,13906.00,percent of total billed charges,
TIBIAL CONE,9116795,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,First Health,,13906.00,,,,,,,5474.00,13906.00,percent of total billed charges,
STEM,9115103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10719.00000,3108.51000,Aetna,First Health,,8768.14,,,,,,,3864.20,8768.14,percent of total billed charges,
STEM,9115103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10719.00000,3108.51000,Aetna,First Health,,8768.14,,,,,,,3451.52,8768.14,percent of total billed charges,
PLATE,9115105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2436.00000,706.44000,Aetna,First Health,,1992.65,,,,,,,878.18,1992.65,percent of total billed charges,
PLATE,9115105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2436.00000,706.44000,Aetna,First Health,,1992.65,,,,,,,784.39,1992.65,percent of total billed charges,
PLATE,9115106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
PLATE,9115106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
BASEPLATE,9115107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,961.81,2182.42,percent of total billed charges,
BASEPLATE,9115107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,First Health,,2182.42,,,,,,,859.10,2182.42,percent of total billed charges,
FEMORAL IMPLANT,9115108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,5249.60,11911.72,percent of total billed charges,
FEMORAL IMPLANT,9115108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,First Health,,11911.72,,,,,,,4688.96,11911.72,percent of total billed charges,
SCREW,9115109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,9115109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
HUMERAL HEAD,9116835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
HUMERAL HEAD,9116835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
STEM,9116836,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,9116836,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
SCREW,9115104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,309.85,703.07,percent of total billed charges,
SCREW,9115104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,First Health,,703.07,,,,,,,276.76,703.07,percent of total billed charges,
UROLIFT 2,9056981,CDM,278,RC,C9739,HCPCS,,,facility,inpatient,,,5075.00000,1471.75000,Aetna,First Health,,4151.35,,,,,,,1829.54,4151.35,percent of total billed charges,
UROLIFT 2,9056981,CDM,278,RC,C9739,HCPCS,,,facility,outpatient,,,5075.00000,1471.75000,Aetna,First Health,,4151.35,,,,,,,1634.15,13568.64,percent of total billed charges,
UROLIFT,8916347,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1640.28,3721.90,percent of total billed charges,
UROLIFT,8916347,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,First Health,,3721.90,,,,,,,1465.10,3721.90,percent of total billed charges,
BIOBRACE,9116838,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,16997.50000,4929.27000,Aetna,First Health,,13903.95,,,,,,,6127.60,13903.95,percent of total billed charges,
BIOBRACE,9116838,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,16997.50000,4929.27000,Aetna,First Health,,13903.95,,,,,,,5473.19,13903.95,percent of total billed charges,
WIRE,9114812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,730.35000,211.80000,Aetna,First Health,,597.43,,,,,,,263.29,597.43,percent of total billed charges,
WIRE,9114812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,730.35000,211.80000,Aetna,First Health,,597.43,,,,,,,235.17,597.43,percent of total billed charges,
WIRE,9116503,CDM,278,RC,,,,,facility,inpatient,,,625.05000,181.26000,Aetna,First Health,,511.29,,,,,,,225.33,511.29,percent of total billed charges,
WIRE,9116503,CDM,278,RC,,,,,facility,outpatient,,,625.05000,181.26000,Aetna,First Health,,511.29,,,,,,,201.27,511.29,percent of total billed charges,
SCREW,9115181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
SCREW,9115181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
SCREW,9115182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW,9115182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
PLATE,9115183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1635.23,3710.45,percent of total billed charges,
PLATE,9115183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,First Health,,3710.45,,,,,,,1460.59,3710.45,percent of total billed charges,
SCREW,9115184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW,9115184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
NEUROSTIMULATOR,9108707,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,7596.00000,2202.84000,Aetna,First Health,,6213.53,,,,,,,2738.36,6213.53,percent of total billed charges,
NEUROSTIMULATOR,9108707,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,7596.00000,2202.84000,Aetna,First Health,,6213.53,,,,,,,2445.91,6213.53,percent of total billed charges,
PLATE,9108758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8254.80000,2393.89000,Aetna,First Health,,6752.43,,,,,,,2975.86,6752.43,percent of total billed charges,
PLATE,9108758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8254.80000,2393.89000,Aetna,First Health,,6752.43,,,,,,,2658.05,6752.43,percent of total billed charges,
SPACER,9108760,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SPACER,9108760,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
SPACER,9108761,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1567.72,3557.28,percent of total billed charges,
SPACER,9108761,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,First Health,,3557.28,,,,,,,1400.30,3557.28,percent of total billed charges,
PLATE,9108762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1290.14,2927.42,percent of total billed charges,
PLATE,9108762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1152.36,2927.42,percent of total billed charges,
IMPLANTABLE TISSUE MARKER,9011866,CDM,278,RC,A4648,HCPCS,,,facility,inpatient,,,93.66000,27.16000,Aetna,First Health,,76.61,,,,,,,33.76,76.61,percent of total billed charges,
IMPLANTABLE TISSUE MARKER,9011866,CDM,278,RC,A4648,HCPCS,,,facility,outpatient,,,93.66000,27.16000,Aetna,First Health,,76.61,,,,,,,30.16,76.61,percent of total billed charges,
HEAD HUMERAL,9105164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,2057.21,4667.95,percent of total billed charges,
HEAD HUMERAL,9105164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,First Health,,4667.95,,,,,,,1837.51,4667.95,percent of total billed charges,
INSERT HUMERAL,9108784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT HUMERAL,9108784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
SCREW,9108785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,9108785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
PLATE,9108786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4238.50000,1229.16000,Aetna,First Health,,3467.09,,,,,,,1527.98,3467.09,percent of total billed charges,
PLATE,9108786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4238.50000,1229.16000,Aetna,First Health,,3467.09,,,,,,,1364.80,3467.09,percent of total billed charges,
PLATE,9108787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5715.50000,1657.50000,Aetna,First Health,,4675.28,,,,,,,2060.44,4675.28,percent of total billed charges,
PLATE,9108787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5715.50000,1657.50000,Aetna,First Health,,4675.28,,,,,,,1840.39,4675.28,percent of total billed charges,
SCREW,9108788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,9108788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
PLATE,9108789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3296.76000,956.06000,Aetna,First Health,,2696.75,,,,,,,1188.48,2696.75,percent of total billed charges,
PLATE,9108789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3296.76000,956.06000,Aetna,First Health,,2696.75,,,,,,,1061.56,2696.75,percent of total billed charges,
ANNULOPLASTY RING,9105111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105113,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105113,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105114,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105114,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105115,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105115,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105116,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105116,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105117,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3623.03,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105117,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,First Health,,8220.90,,,,,,,3236.10,8220.90,percent of total billed charges,
ANNULOPLASTY RING,9105118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3460.80,7852.80,percent of total billed charges,
ANNULOPLASTY RING,9105118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3091.20,7852.80,percent of total billed charges,
ANNULOPLASTY RING,9105119,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3460.80,7852.80,percent of total billed charges,
ANNULOPLASTY RING,9105119,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3091.20,7852.80,percent of total billed charges,
ANNULOPLASTY RING,9105120,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3460.80,7852.80,percent of total billed charges,
ANNULOPLASTY RING,9105120,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3091.20,7852.80,percent of total billed charges,
ANNULOPLASTY RING,9108755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3460.80,7852.80,percent of total billed charges,
ANNULOPLASTY RING,9108755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3091.20,7852.80,percent of total billed charges,
ANNULOPLASTY RING,9108756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3460.80,7852.80,percent of total billed charges,
ANNULOPLASTY RING,9108756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,First Health,,7852.80,,,,,,,3091.20,7852.80,percent of total billed charges,
PLATE TIBIAL,9105247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5539.91000,1606.57000,Aetna,First Health,,4531.65,,,,,,,1997.14,4531.65,percent of total billed charges,
PLATE TIBIAL,9105247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5539.91000,1606.57000,Aetna,First Health,,4531.65,,,,,,,1783.85,4531.65,percent of total billed charges,
SCREW,9105248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,47.26,107.23,percent of total billed charges,
SCREW,9105248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,First Health,,107.23,,,,,,,42.21,107.23,percent of total billed charges,
SCREW,9105331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3024.48000,877.10000,Aetna,First Health,,2474.02,,,,,,,1090.33,2474.02,percent of total billed charges,
SCREW,9105331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3024.48000,877.10000,Aetna,First Health,,2474.02,,,,,,,973.88,2474.02,percent of total billed charges,
BALLOON,9105335,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
BALLOON,9105335,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
BALLOON,9105353,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
BALLOON,9105353,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
BALLOON,9105354,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
BALLOON,9105354,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
BONE GRAFT,9105355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8676.00000,2516.04000,Aetna,First Health,,7096.97,,,,,,,3127.70,7096.97,percent of total billed charges,
BONE GRAFT,9105355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8676.00000,2516.04000,Aetna,First Health,,7096.97,,,,,,,2793.67,7096.97,percent of total billed charges,
GUIDEWIRE,9105356,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
GUIDEWIRE,9105356,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
PLATE,9105336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2936.00000,851.44000,Aetna,First Health,,2401.65,,,,,,,1058.43,2401.65,percent of total billed charges,
PLATE,9105336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2936.00000,851.44000,Aetna,First Health,,2401.65,,,,,,,945.39,2401.65,percent of total billed charges,
SCREW,9108940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.90000,232.55000,Aetna,First Health,,655.95,,,,,,,289.08,655.95,percent of total billed charges,
SCREW,9108940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.90000,232.55000,Aetna,First Health,,655.95,,,,,,,258.21,655.95,percent of total billed charges,
STEM,9105362,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM,9105362,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
SCREW,9105358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,9105358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
NAIL,9105361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9105361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
NAIL,9105360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,3018.47,6849.11,percent of total billed charges,
NAIL,9105360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,First Health,,6849.11,,,,,,,2696.11,6849.11,percent of total billed charges,
PENILE PROSTHESIS,9105434,CDM,278,RC,C2622,HCPCS,,,facility,inpatient,,,56810.00000,16474.90000,Aetna,First Health,,46470.58,,,,,,,20480.01,46470.58,percent of total billed charges,
PENILE PROSTHESIS,9105434,CDM,278,RC,C2622,HCPCS,,,facility,outpatient,,,56810.00000,16474.90000,Aetna,First Health,,46470.58,,,,,,,18292.82,46470.58,percent of total billed charges,
PENILE PROSTHESIS,9109055,CDM,278,RC,C2622,HCPCS,,,facility,inpatient,,,56810.00000,16474.90000,Aetna,First Health,,46470.58,,,,,,,20480.01,46470.58,percent of total billed charges,
PENILE PROSTHESIS,9109055,CDM,278,RC,C2622,HCPCS,,,facility,outpatient,,,56810.00000,16474.90000,Aetna,First Health,,46470.58,,,,,,,18292.82,46470.58,percent of total billed charges,
STENT,9109056,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6300.00000,1827.00000,Aetna,First Health,,5153.40,,,,,,,2271.15,5153.40,percent of total billed charges,
STENT,9109056,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6300.00000,1827.00000,Aetna,First Health,,5153.40,,,,,,,2028.60,5153.40,percent of total billed charges,
ROD,9109061,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,First Health,,5053.19,,,,,,,2226.99,5053.19,percent of total billed charges,
ROD,9109061,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,First Health,,5053.19,,,,,,,1989.15,5053.19,percent of total billed charges,
FEMORAL STEM,9109062,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
FEMORAL STEM,9109062,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
FEMORAL STEM,9109063,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
FEMORAL STEM,9109063,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
FEMORAL STEM,9109064,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
FEMORAL STEM,9109064,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
SCREW,9109065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,893.46,2027.33,percent of total billed charges,
SCREW,9109065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,First Health,,2027.33,,,,,,,798.04,2027.33,percent of total billed charges,
CAGE,9109067,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17357.50000,5033.67000,Aetna,First Health,,14198.43,,,,,,,6257.38,14198.43,percent of total billed charges,
CAGE,9109067,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17357.50000,5033.67000,Aetna,First Health,,14198.43,,,,,,,5589.11,14198.43,percent of total billed charges,
SCREW,9105357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,9105357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW,9105359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,9105359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SHEATH GUIDING,9109114,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1802.68000,522.78000,Aetna,First Health,,1474.59,,,,,,,649.87,1474.59,percent of total billed charges,
SHEATH GUIDING,9109114,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1802.68000,522.78000,Aetna,First Health,,1474.59,,,,,,,580.46,1474.59,percent of total billed charges,
PLATE,9109115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5979.82000,1734.15000,Aetna,First Health,,4891.49,,,,,,,2155.73,4891.49,percent of total billed charges,
PLATE,9109115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5979.82000,1734.15000,Aetna,First Health,,4891.49,,,,,,,1925.50,4891.49,percent of total billed charges,
PLATE,9112392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5835.87000,1692.40000,Aetna,First Health,,4773.74,,,,,,,2103.83,4773.74,percent of total billed charges,
PLATE,9112392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5835.87000,1692.40000,Aetna,First Health,,4773.74,,,,,,,1879.15,4773.74,percent of total billed charges,
PLATE,9112393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,9112393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
PLATE,9112394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1261.75,2863.00,percent of total billed charges,
PLATE,9112394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,First Health,,2863.00,,,,,,,1127.00,2863.00,percent of total billed charges,
SPACER,9109167,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
SPACER,9109167,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
SPACER,9109168,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
SPACER,9109168,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
COMPONENT FEMORAL,9109169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
COMPONENT FEMORAL,9109169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
BASEPLATE,9109170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,9109170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
COMPONENT FEMORAL,9109171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,9109171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
CATHETER,9112469,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
CATHETER,9112469,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,9959.00,percent of total billed charges,
KNEE WEDGE,9109423,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
KNEE WEDGE,9109423,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
KNEE WEDGE,9112483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1718.50,3899.41,percent of total billed charges,
KNEE WEDGE,9112483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,First Health,,3899.41,,,,,,,1534.97,3899.41,percent of total billed charges,
INSERT,9112484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT,9112484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
ROD,9112485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD,9112485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
COMPONENT FEMORAL,9112492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,9112492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
INSERT,9112493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1538.07,3490.00,percent of total billed charges,
INSERT,9112493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,First Health,,3490.00,,,,,,,1373.81,3490.00,percent of total billed charges,
GLENOID TAP,9109428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
GLENOID TAP,9109428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
TAPER KIT,9109429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10410.00000,3018.90000,Aetna,First Health,,8515.38,,,,,,,3752.80,8515.38,percent of total billed charges,
TAPER KIT,9109429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10410.00000,3018.90000,Aetna,First Health,,8515.38,,,,,,,3352.02,8515.38,percent of total billed charges,
CRYO PROBE,9091656,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,9900.00000,2871.00000,Aetna,First Health,,8098.20,,,,,,,3568.95,8098.20,percent of total billed charges,
CRYO PROBE,9091656,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,9900.00000,2871.00000,Aetna,First Health,,8098.20,,,,,,,3187.80,8098.20,percent of total billed charges,
PLATE,9109495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12231.00000,3546.99000,Aetna,First Health,,10004.96,,,,,,,4409.28,10004.96,percent of total billed charges,
PLATE,9109495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12231.00000,3546.99000,Aetna,First Health,,10004.96,,,,,,,3938.38,10004.96,percent of total billed charges,
SCREW,9114428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9114428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW,9114429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9114429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
PLATE,9114430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12231.00000,3546.99000,Aetna,First Health,,10004.96,,,,,,,4409.28,10004.96,percent of total billed charges,
PLATE,9114430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12231.00000,3546.99000,Aetna,First Health,,10004.96,,,,,,,3938.38,10004.96,percent of total billed charges,
SCREW,9114431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9114431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
SCREW,9114432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,40.67,92.29,percent of total billed charges,
SCREW,9114432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,First Health,,92.29,,,,,,,36.33,92.29,percent of total billed charges,
PLATE,9109496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,878.67000,254.81000,Aetna,First Health,,718.75,,,,,,,316.76,718.75,percent of total billed charges,
PLATE,9109496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,878.67000,254.81000,Aetna,First Health,,718.75,,,,,,,282.93,718.75,percent of total billed charges,
ROD,9109508,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
ROD,9109508,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
STENT GRAFT,9114457,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,4391.97,9965.69,percent of total billed charges,
STENT GRAFT,9114457,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,First Health,,9965.69,,,,,,,3922.93,9965.69,percent of total billed charges,
COMPONENT FEMORAL,9114458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,2184.09,4955.85,percent of total billed charges,
COMPONENT FEMORAL,9114458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,First Health,,4955.85,,,,,,,1950.84,4955.85,percent of total billed charges,
STEM FEMORAL,9114459,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM FEMORAL,9114459,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
POLARSTEM,9114463,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
POLARSTEM,9114463,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
BONE CHIP,9114504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3832.50000,1111.42000,Aetna,First Health,,3134.99,,,,,,,1381.62,3134.99,percent of total billed charges,
BONE CHIP,9114504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3832.50000,1111.42000,Aetna,First Health,,3134.99,,,,,,,1234.07,3134.99,percent of total billed charges,
STENT,9109539,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15676.38000,4546.15000,Aetna,First Health,,12823.28,,,,,,,5651.33,12823.28,percent of total billed charges,
STENT,9109539,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15676.38000,4546.15000,Aetna,First Health,,12823.28,,,,,,,5047.79,12823.28,percent of total billed charges,
STENT,9109538,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15676.38000,4546.15000,Aetna,First Health,,12823.28,,,,,,,5651.33,12823.28,percent of total billed charges,
STENT,9109538,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15676.38000,4546.15000,Aetna,First Health,,12823.28,,,,,,,5047.79,12823.28,percent of total billed charges,
STENT,9114470,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16956.28000,4917.32000,Aetna,First Health,,13870.24,,,,,,,6112.74,13870.24,percent of total billed charges,
STENT,9114470,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16956.28000,4917.32000,Aetna,First Health,,13870.24,,,,,,,5459.92,13870.24,percent of total billed charges,
STENT,9114471,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16956.28000,4917.32000,Aetna,First Health,,13870.24,,,,,,,6112.74,13870.24,percent of total billed charges,
STENT,9114471,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16956.28000,4917.32000,Aetna,First Health,,13870.24,,,,,,,5459.92,13870.24,percent of total billed charges,
INTRODUCER,9109542,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,60.56,137.42,percent of total billed charges,
INTRODUCER,9109542,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,54.10,137.42,percent of total billed charges,
STENT,9114472,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16956.28000,4917.32000,Aetna,First Health,,13870.24,,,,,,,6112.74,13870.24,percent of total billed charges,
STENT,9114472,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16956.28000,4917.32000,Aetna,First Health,,13870.24,,,,,,,5459.92,13870.24,percent of total billed charges,
STENT GRAFT,7969878,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,4284.00000,1242.36000,Aetna,First Health,,3504.31,,,,,,,1544.38,3504.31,percent of total billed charges,
STENT GRAFT,7969878,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,4284.00000,1242.36000,Aetna,First Health,,3504.31,,,,,,,1379.45,3504.31,percent of total billed charges,
SPINE SEALANT,8366683,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,3000.00000,870.00000,Aetna,First Health,,2454.00,,,,,,,1081.50,2454.00,percent of total billed charges,
SPINE SEALANT,8366683,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,3000.00000,870.00000,Aetna,First Health,,2454.00,,,,,,,966.00,2454.00,percent of total billed charges,
PLATE LOCKING,9109991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,544.72,1236.00,percent of total billed charges,
PLATE LOCKING,9109991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,486.54,1236.00,percent of total billed charges,
DILATOR,9109992,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1514.64000,439.25000,Aetna,First Health,,1238.98,,,,,,,546.03,1238.98,percent of total billed charges,
DILATOR,9109992,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1514.64000,439.25000,Aetna,First Health,,1238.98,,,,,,,487.71,1238.98,percent of total billed charges,
SCREW,9114581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9114581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
ROD SPINAL,9114583,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
ROD SPINAL,9114583,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,9110015,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
SCREW,9110015,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
SCREW,9114589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1955.00000,566.95000,Aetna,First Health,,1599.19,,,,,,,704.78,1599.19,percent of total billed charges,
SCREW,9114589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1955.00000,566.95000,Aetna,First Health,,1599.19,,,,,,,629.51,1599.19,percent of total billed charges,
SCREW,9114594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4882.50000,1415.92000,Aetna,First Health,,3993.89,,,,,,,1760.14,3993.89,percent of total billed charges,
SCREW,9114594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4882.50000,1415.92000,Aetna,First Health,,3993.89,,,,,,,1572.16,3993.89,percent of total billed charges,
SCREW,9110038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,9110038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
INSERT TIBIAL,9110037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
INSERT TIBIAL,9110037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
VASCULAR CLOSURE,9114590,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1360.00000,394.40000,Aetna,First Health,,1112.48,,,,,,,490.28,1112.48,percent of total billed charges,
VASCULAR CLOSURE,9114590,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1360.00000,394.40000,Aetna,First Health,,1112.48,,,,,,,437.92,1112.48,percent of total billed charges,
BONE ANCHOR,9114582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5362.88000,1555.24000,Aetna,First Health,,4386.84,,,,,,,1933.32,4386.84,percent of total billed charges,
BONE ANCHOR,9114582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5362.88000,1555.24000,Aetna,First Health,,4386.84,,,,,,,1726.85,4386.84,percent of total billed charges,
SHEATH,9110039,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,530.66,1204.10,percent of total billed charges,
SHEATH,9110039,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,473.98,1204.10,percent of total billed charges,
SHEATH URETHRAL,9110040,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,530.66,1204.10,percent of total billed charges,
SHEATH URETHRAL,9110040,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,473.98,1204.10,percent of total billed charges,
SHEATH URETHRAL,9110041,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,530.66,1204.10,percent of total billed charges,
SHEATH URETHRAL,9110041,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,First Health,,1204.10,,,,,,,473.98,1204.10,percent of total billed charges,
AUGMENT BLOCK FEMORAL,9114677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1297.08,2943.16,percent of total billed charges,
AUGMENT BLOCK FEMORAL,9114677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1158.56,2943.16,percent of total billed charges,
INSERT TIBIAL,9114678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9114678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
STEM,9114679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1972.08000,571.90000,Aetna,First Health,,1613.16,,,,,,,710.93,1613.16,percent of total billed charges,
STEM,9114679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1972.08000,571.90000,Aetna,First Health,,1613.16,,,,,,,635.01,1613.16,percent of total billed charges,
HEAD HUMERAL,9110095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,7018.94,15926.46,percent of total billed charges,
HEAD HUMERAL,9110095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,First Health,,15926.46,,,,,,,6269.34,15926.46,percent of total billed charges,
PLATE,9110096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1274.90,2892.83,percent of total billed charges,
PLATE,9110096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,First Health,,2892.83,,,,,,,1138.74,2892.83,percent of total billed charges,
STEM FEMORAL,9110098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2952.49,6699.42,percent of total billed charges,
STEM FEMORAL,9110098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,First Health,,6699.42,,,,,,,2637.18,6699.42,percent of total billed charges,
FEMORAL COMPONENT,9114688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,3309.39,7509.24,percent of total billed charges,
FEMORAL COMPONENT,9114688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,First Health,,7509.24,,,,,,,2955.96,7509.24,percent of total billed charges,
ROD,9114689,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD,9114689,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
SCREW,9114690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3270.75000,948.52000,Aetna,First Health,,2675.47,,,,,,,1179.11,2675.47,percent of total billed charges,
SCREW,9114690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3270.75000,948.52000,Aetna,First Health,,2675.47,,,,,,,1053.18,2675.47,percent of total billed charges,
GRAFT TISSUE,9114681,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT TISSUE,9114681,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
GRAFT TISSUE,9114682,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT TISSUE,9114682,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
GRAFT TISSUE,9114683,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT TISSUE,9114683,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
GRAFT,9114684,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT,9114684,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
GRAFT TISSUE,9114685,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT TISSUE,9114685,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
GENERATOR,9188859,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,56.93000,16.51000,Aetna,First Health,,46.57,,,,,,,20.52,46.57,percent of total billed charges,
GENERATOR,9188859,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,56.93000,16.51000,Aetna,First Health,,46.57,,,,,,,18.33,46.57,percent of total billed charges,
LEAD,9188860,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,12375.00000,3588.75000,Aetna,First Health,,10122.75,,,,,,,4461.19,10122.75,percent of total billed charges,
LEAD,9188860,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,12375.00000,3588.75000,Aetna,First Health,,10122.75,,,,,,,3984.75,10122.75,percent of total billed charges,
SCREW,9188861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,9188861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
SCREW,9188862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,9188862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
SCREW,9188863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,9188863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
SCREW,9188864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,281.25,638.18,percent of total billed charges,
SCREW,9188864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,First Health,,638.18,,,,,,,251.21,638.18,percent of total billed charges,
CATHETER,9192619,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
CATHETER,9192619,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
CATHETER,9192620,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
CATHETER,9192620,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
CATHETER,9192621,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
CATHETER,9192621,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
CATHETER,9192622,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,464.32,1053.58,percent of total billed charges,
CATHETER,9192622,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,First Health,,1053.58,,,,,,,414.74,1053.58,percent of total billed charges,
CATHETER,9192623,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
CATHETER,9192623,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
CATHETER,9192624,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
CATHETER,9192624,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
CATHETER,9192625,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
CATHETER,9192625,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
CATHETER,9192626,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
CATHETER,9192626,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
CATHETER,9192627,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
CATHETER,9192627,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
CATHETER,9192628,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
CATHETER,9192628,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
CATHETER,9192629,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,435.48,988.14,percent of total billed charges,
CATHETER,9192629,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,First Health,,988.14,,,,,,,388.98,988.14,percent of total billed charges,
278058466,9192618,CDM,278,RC,C9806,HCPCS,,,facility,inpatient,,,2724.00000,789.96000,Aetna,First Health,,2228.23,,,,,,,982.00,2228.23,percent of total billed charges,
278058466,9192618,CDM,278,RC,C9806,HCPCS,,,facility,outpatient,,,2724.00000,789.96000,Aetna,First Health,,2228.23,,,,,,,877.13,2228.23,percent of total billed charges,
SHEALTH,9198531,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,516.60000,149.81000,Aetna,First Health,,422.58,,,,,,,186.23,422.58,percent of total billed charges,
SHEALTH,9198531,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,516.60000,149.81000,Aetna,First Health,,422.58,,,,,,,166.35,422.58,percent of total billed charges,
PIN,7968103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,202.78,460.12,percent of total billed charges,
PIN,7968103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,First Health,,460.12,,,,,,,181.12,460.12,percent of total billed charges,
INTRODUCER,9200516,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3601.50000,1044.44000,Aetna,First Health,,2946.03,,,,,,,1298.34,2946.03,percent of total billed charges,
INTRODUCER,9200516,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,First Health,,2946.03,,,,,,,1159.68,2946.03,percent of total billed charges,
CATHETER,9200517,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,5028.98,11411.10,percent of total billed charges,
CATHETER,9200517,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,First Health,,11411.10,,,,,,,4491.90,11411.10,percent of total billed charges,
SCREW,9200489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,497.63,1129.17,percent of total billed charges,
SCREW,9200489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,First Health,,1129.17,,,,,,,444.49,1129.17,percent of total billed charges,
CATHETER,9206443,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5858.12,13292.50,percent of total billed charges,
CATHETER,9206443,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,5232.50,13292.50,percent of total billed charges,
NASAL PACKING,9206436,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,895.50000,259.70000,Aetna,First Health,,732.52,,,,,,,322.83,732.52,percent of total billed charges,
NASAL PACKING,9206436,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,895.50000,259.70000,Aetna,First Health,,732.52,,,,,,,288.35,732.52,percent of total billed charges,
STENT,9206527,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,182.11,413.22,percent of total billed charges,
STENT,9206527,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,162.66,413.22,percent of total billed charges,
STENT,9206528,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,182.11,413.22,percent of total billed charges,
STENT,9206528,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,162.66,413.22,percent of total billed charges,
GRAFT,9206529,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,19487.00000,5651.23000,Aetna,First Health,,15940.37,,,,,,,7025.06,15940.37,percent of total billed charges,
GRAFT,9206529,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,19487.00000,5651.23000,Aetna,First Health,,15940.37,,,,,,,6274.81,15940.37,percent of total billed charges,
GRAFT,9206530,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,19487.00000,5651.23000,Aetna,First Health,,15940.37,,,,,,,7025.06,15940.37,percent of total billed charges,
GRAFT,9206530,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,19487.00000,5651.23000,Aetna,First Health,,15940.37,,,,,,,6274.81,15940.37,percent of total billed charges,
GLIDESHEATH,9212619,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
GLIDESHEATH,9212619,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
GLIDESHEATH,9212618,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
GLIDESHEATH,9212618,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
SEALANT,9212684,CDM,278,RC,C2615,HCPCS,,,facility,inpatient,,,4582.90000,1329.04000,Aetna,First Health,,3748.81,,,,,,,1652.14,3748.81,percent of total billed charges,
SEALANT,9212684,CDM,278,RC,C2615,HCPCS,,,facility,outpatient,,,4582.90000,1329.04000,Aetna,First Health,,3748.81,,,,,,,1475.69,3748.81,percent of total billed charges,
STENT,9212685,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,326.04000,94.55000,Aetna,First Health,,266.70,,,,,,,117.54,266.70,percent of total billed charges,
STENT,9212685,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,326.04000,94.55000,Aetna,First Health,,266.70,,,,,,,104.98,266.70,percent of total billed charges,
SPACER,9214430,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SPACER,9214430,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
GENERATOR,9214431,CDM,278,RC,C1822,HCPCS,,,facility,inpatient,,,62000.00000,17980.00000,Aetna,First Health,,50716.00,,,,,,,22351.00,50716.00,percent of total billed charges,
GENERATOR,9214431,CDM,278,RC,C1822,HCPCS,,,facility,outpatient,,,62000.00000,17980.00000,Aetna,First Health,,50716.00,,,,,,,19964.00,50716.00,percent of total billed charges,
SCREW,9214433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
SCREW,9214433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
STENT,9218439,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3839.32,8711.70,percent of total billed charges,
STENT,9218439,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,First Health,,8711.70,,,,,,,3429.30,8711.70,percent of total billed charges,
BREAST IMPLANT,9218440,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1432.09,3249.51,percent of total billed charges,
BREAST IMPLANT,9218440,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,First Health,,3249.51,,,,,,,1279.14,3249.51,percent of total billed charges,
CATHETER,9218445,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,5320.00000,1542.80000,Aetna,First Health,,4351.76,,,,,,,1917.86,4351.76,percent of total billed charges,
CATHETER,9218445,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,5320.00000,1542.80000,Aetna,First Health,,4351.76,,,,,,,1713.04,4351.76,percent of total billed charges,
CATHETER,9218446,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
CATHETER,9218446,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
FUSION IMPLANT KIT,9220488,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,76000.00000,22040.00000,Aetna,First Health,,62168.00,,,,,,,27398.00,62168.00,percent of total billed charges,
FUSION IMPLANT KIT,9220488,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,76000.00000,22040.00000,Aetna,First Health,,62168.00,,,,,,,24472.00,62168.00,percent of total billed charges,
CATHETER,9218441,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,275.78,625.77,percent of total billed charges,
CATHETER,9218441,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,First Health,,625.77,,,,,,,246.33,625.77,percent of total billed charges,
WIRE,9218485,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,609.75000,176.83000,Aetna,First Health,,498.78,,,,,,,219.81,498.78,percent of total billed charges,
WIRE,9218485,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,609.75000,176.83000,Aetna,First Health,,498.78,,,,,,,196.34,498.78,percent of total billed charges,
CARTIMAX FA,9218486,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5948.25,13497.00,percent of total billed charges,
CARTIMAX FA,9218486,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,First Health,,13497.00,,,,,,,5313.00,13497.00,percent of total billed charges,
MONITOR,9218506,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
MONITOR,9218506,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
STENT,9218507,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
STENT,9218507,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
STENT,9218510,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
STENT,9218510,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
STENT,9218511,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
STENT,9218511,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
STENT,9220538,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,322.39,731.53,percent of total billed charges,
STENT,9220538,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,287.96,731.53,percent of total billed charges,
STENT,9220539,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220539,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220540,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220540,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220541,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220541,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220542,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220542,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220543,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220543,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220544,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220544,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220545,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220545,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220546,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,182.11,413.22,percent of total billed charges,
STENT,9220546,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,162.66,413.22,percent of total billed charges,
STENT,9220547,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,182.11,413.22,percent of total billed charges,
STENT,9220547,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,162.66,413.22,percent of total billed charges,
STENT,9220548,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,182.11,413.22,percent of total billed charges,
STENT,9220548,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,162.66,413.22,percent of total billed charges,
STENT,9220549,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,182.11,413.22,percent of total billed charges,
STENT,9220549,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,162.66,413.22,percent of total billed charges,
STENT,9220550,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,182.11,413.22,percent of total billed charges,
STENT,9220550,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,162.66,413.22,percent of total billed charges,
STENT,9220551,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220551,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220552,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220552,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220553,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220553,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220554,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220554,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
STENT,9220555,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,165.12,374.68,percent of total billed charges,
STENT,9220555,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,First Health,,374.68,,,,,,,147.49,374.68,percent of total billed charges,
SHEATH,9220575,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2744.00000,795.76000,Aetna,First Health,,2244.59,,,,,,,989.21,2244.59,percent of total billed charges,
SHEATH,9220575,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2744.00000,795.76000,Aetna,First Health,,2244.59,,,,,,,883.57,2244.59,percent of total billed charges,
BALLOON,9224458,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,7948.35000,2305.02000,Aetna,First Health,,6501.75,,,,,,,2865.38,6501.75,percent of total billed charges,
BALLOON,9224458,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,7948.35000,2305.02000,Aetna,First Health,,6501.75,,,,,,,2559.37,6501.75,percent of total billed charges,
SHEATH,9228506,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,620.06,1406.96,percent of total billed charges,
SHEATH,9228506,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,First Health,,1406.96,,,,,,,553.84,1406.96,percent of total billed charges,
STENT,9086252,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,9086252,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
STENT,9086254,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT,9086254,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
SHEATH,9226566,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
SHEATH,9226566,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STENT,9226567,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
STENT,9226567,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
GUIDEWIRE,8135967,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,81.95000,23.77000,Aetna,First Health,,67.04,,,,,,,29.54,67.04,percent of total billed charges,
GUIDEWIRE,8135967,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,81.95000,23.77000,Aetna,First Health,,67.04,,,,,,,26.39,67.04,percent of total billed charges,
UROLOGICAL SET,9226530,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,128.43,291.41,percent of total billed charges,
UROLOGICAL SET,9226530,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,First Health,,291.41,,,,,,,114.71,291.41,percent of total billed charges,
FASTEMER KIT,9226565,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,18987.50000,5506.38000,Aetna,First Health,,15531.77,,,,,,,6844.99,15531.77,percent of total billed charges,
FASTEMER KIT,9226565,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,18987.50000,5506.38000,Aetna,First Health,,15531.77,,,,,,,6113.98,15531.77,percent of total billed charges,
HUMERUS,9230523,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,20332.50000,5896.42000,Aetna,First Health,,16631.99,,,,,,,7329.87,16631.99,percent of total billed charges,
HUMERUS,9230523,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,20332.50000,5896.42000,Aetna,First Health,,16631.99,,,,,,,6547.06,16631.99,percent of total billed charges,
CATHETER,9230555,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
CATHETER,9230555,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
CATHETER,9230556,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
CATHETER,9230556,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
CATHETER,9230557,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
CATHETER,9230557,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
CATHETER,9230558,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
CATHETER,9230558,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
ADAPTER,9115189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12915.00000,3745.35000,Aetna,First Health,,10564.47,,,,,,,4655.86,10564.47,percent of total billed charges,
ADAPTER,9115189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12915.00000,3745.35000,Aetna,First Health,,10564.47,,,,,,,4158.63,10564.47,percent of total billed charges,
TIBIAL COMPONENT,9115190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13543.32000,3927.56000,Aetna,First Health,,11078.44,,,,,,,4882.37,11078.44,percent of total billed charges,
TIBIAL COMPONENT,9115190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13543.32000,3927.56000,Aetna,First Health,,11078.44,,,,,,,4360.95,11078.44,percent of total billed charges,
TIBIAL STEM,9115191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19962.50000,5789.12000,Aetna,First Health,,16329.33,,,,,,,7196.48,16329.33,percent of total billed charges,
TIBIAL STEM,9115191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19962.50000,5789.12000,Aetna,First Health,,16329.33,,,,,,,6427.93,16329.33,percent of total billed charges,
TIBIAL CONE,9115179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26499.33000,7684.81000,Aetna,First Health,,21676.45,,,,,,,9553.01,21676.45,percent of total billed charges,
TIBIAL CONE,9115179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26499.33000,7684.81000,Aetna,First Health,,21676.45,,,,,,,8532.78,21676.45,percent of total billed charges,
ANCHOR,9115170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,908.10,2060.54,percent of total billed charges,
ANCHOR,9115170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,811.12,2060.54,percent of total billed charges,
PENILE PROSTHESIS,9115163,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,46425.00000,13463.25000,Aetna,First Health,,37975.65,,,,,,,16736.21,37975.65,percent of total billed charges,
PENILE PROSTHESIS,9115163,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,46425.00000,13463.25000,Aetna,First Health,,37975.65,,,,,,,14948.85,37975.65,percent of total billed charges,
HIP STEM,9115171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
HIP STEM,9115171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,2898.00,7362.00,percent of total billed charges,
TIBIAL TRAY,9115172,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
TIBIAL TRAY,9115172,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
FEMORAL COMPENENT,9115173,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
FEMORAL COMPENENT,9115173,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
TIBAIL INSERT,9115174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
TIBAIL INSERT,9115174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
NAIL,9115214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6501.71000,1885.50000,Aetna,First Health,,5318.40,,,,,,,2343.87,5318.40,percent of total billed charges,
NAIL,9115214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6501.71000,1885.50000,Aetna,First Health,,5318.40,,,,,,,2093.55,5318.40,percent of total billed charges,
NAIL,9115215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6501.71000,1885.50000,Aetna,First Health,,5318.40,,,,,,,2343.87,5318.40,percent of total billed charges,
NAIL,9115215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6501.71000,1885.50000,Aetna,First Health,,5318.40,,,,,,,2093.55,5318.40,percent of total billed charges,
PLATE,9115217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6175.37000,1790.86000,Aetna,First Health,,5051.45,,,,,,,2226.22,5051.45,percent of total billed charges,
PLATE,9115217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6175.37000,1790.86000,Aetna,First Health,,5051.45,,,,,,,1988.47,5051.45,percent of total billed charges,
PLATE,9115218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6376.30000,1849.13000,Aetna,First Health,,5215.81,,,,,,,2298.66,5215.81,percent of total billed charges,
PLATE,9115218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6376.30000,1849.13000,Aetna,First Health,,5215.81,,,,,,,2053.17,5215.81,percent of total billed charges,
SCREW,9115164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,9115164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
STENT,9115165,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,82.01000,23.78000,Aetna,First Health,,67.08,,,,,,,29.56,67.08,percent of total billed charges,
STENT,9115165,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,82.01000,23.78000,Aetna,First Health,,67.08,,,,,,,26.41,67.08,percent of total billed charges,
STENT,9115166,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,82.01000,23.78000,Aetna,First Health,,67.08,,,,,,,29.56,67.08,percent of total billed charges,
STENT,9115166,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,82.01000,23.78000,Aetna,First Health,,67.08,,,,,,,26.41,67.08,percent of total billed charges,
STENT,9115167,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,82.01000,23.78000,Aetna,First Health,,67.08,,,,,,,29.56,67.08,percent of total billed charges,
STENT,9115167,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,82.01000,23.78000,Aetna,First Health,,67.08,,,,,,,26.41,67.08,percent of total billed charges,
STENT,9115168,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,82.01000,23.78000,Aetna,First Health,,67.08,,,,,,,29.56,67.08,percent of total billed charges,
STENT,9115168,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,82.01000,23.78000,Aetna,First Health,,67.08,,,,,,,26.41,67.08,percent of total billed charges,
STENT,9115169,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,82.01000,23.78000,Aetna,First Health,,67.08,,,,,,,29.56,67.08,percent of total billed charges,
STENT,9115169,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,82.01000,23.78000,Aetna,First Health,,67.08,,,,,,,26.41,67.08,percent of total billed charges,
PLATE,9115192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2697.20000,782.19000,Aetna,First Health,,2206.31,,,,,,,972.34,2206.31,percent of total billed charges,
PLATE,9115192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2697.20000,782.19000,Aetna,First Health,,2206.31,,,,,,,868.50,2206.31,percent of total billed charges,
SCREW,9115194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
SCREW,9115194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
SCREW,9115196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,121.73,276.22,percent of total billed charges,
SCREW,9115196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,First Health,,276.22,,,,,,,108.73,276.22,percent of total billed charges,
IMPLANT SYSTEM,9118491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1962.02,4451.97,percent of total billed charges,
IMPLANT SYSTEM,9118491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,First Health,,4451.97,,,,,,,1752.48,4451.97,percent of total billed charges,
STEM,9117121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,9117121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
PLATE,9118487,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1290.14,2927.42,percent of total billed charges,
PLATE,9118487,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1152.36,2927.42,percent of total billed charges,
HEAD,9118492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
HEAD,9118492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
STEM,9118493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
STEM,9118493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
STEM,9118494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,9118494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
INSERT,9117139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT,9117139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
GLENOID,9117140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
GLENOID,9117140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,4652.38,percent of total billed charges,
HUMERUS,9117141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17100.00000,4959.00000,Aetna,First Health,,13987.80,,,,,,,6164.55,13987.80,percent of total billed charges,
HUMERUS,9117141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17100.00000,4959.00000,Aetna,First Health,,13987.80,,,,,,,5506.20,13987.80,percent of total billed charges,
HUMERAL HEAD,9117142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HUMERAL HEAD,9117142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
NEEDLE,9117161,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,509.49000,147.75000,Aetna,First Health,,416.76,,,,,,,183.67,416.76,percent of total billed charges,
NEEDLE,9117161,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,509.49000,147.75000,Aetna,First Health,,416.76,,,,,,,164.06,416.76,percent of total billed charges,
NEEDLE,9117162,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,601.83000,174.53000,Aetna,First Health,,492.30,,,,,,,216.96,492.30,percent of total billed charges,
NEEDLE,9117162,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,601.83000,174.53000,Aetna,First Health,,492.30,,,,,,,193.79,492.30,percent of total billed charges,
NEEDLE,9117163,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,469.35000,136.11000,Aetna,First Health,,383.93,,,,,,,169.20,383.93,percent of total billed charges,
NEEDLE,9117163,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,469.35000,136.11000,Aetna,First Health,,383.93,,,,,,,151.13,383.93,percent of total billed charges,
NEEDLE,9117164,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,469.35000,136.11000,Aetna,First Health,,383.93,,,,,,,169.20,383.93,percent of total billed charges,
NEEDLE,9117164,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,469.35000,136.11000,Aetna,First Health,,383.93,,,,,,,151.13,383.93,percent of total billed charges,
COMPONENT,9117118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24194.40000,7016.38000,Aetna,First Health,,19791.02,,,,,,,8722.08,19791.02,percent of total billed charges,
COMPONENT,9117118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24194.40000,7016.38000,Aetna,First Health,,19791.02,,,,,,,7790.60,19791.02,percent of total billed charges,
TIBIAL SPACER,9118484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5293.72000,1535.18000,Aetna,First Health,,4330.26,,,,,,,1908.39,4330.26,percent of total billed charges,
TIBIAL SPACER,9118484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5293.72000,1535.18000,Aetna,First Health,,4330.26,,,,,,,1704.58,4330.26,percent of total billed charges,
BREAST IMPLANT,9117143,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,9117143,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
TIBIAL INSERT,9117240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
TIBIAL INSERT,9117240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,9117241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
SCREW,9117241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
SCREW,9117242,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,641.62,1455.88,percent of total billed charges,
SCREW,9117242,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,First Health,,1455.88,,,,,,,573.10,1455.88,percent of total billed charges,
FEMORAL BLADE,9117228,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3153.64000,914.56000,Aetna,First Health,,2579.68,,,,,,,1136.89,2579.68,percent of total billed charges,
FEMORAL BLADE,9117228,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3153.64000,914.56000,Aetna,First Health,,2579.68,,,,,,,1015.47,2579.68,percent of total billed charges,
SCREW,9117233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,66.74,151.43,percent of total billed charges,
SCREW,9117233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,First Health,,151.43,,,,,,,59.61,151.43,percent of total billed charges,
PLATE,9117243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1292.00000,374.68000,Aetna,First Health,,1056.86,,,,,,,465.77,1056.86,percent of total billed charges,
PLATE,9117243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1292.00000,374.68000,Aetna,First Health,,1056.86,,,,,,,416.02,1056.86,percent of total billed charges,
AUGMENT WEDGE,9120435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1297.08,2943.16,percent of total billed charges,
AUGMENT WEDGE,9120435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,First Health,,2943.16,,,,,,,1158.56,2943.16,percent of total billed charges,
CONE,9120436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3942.07,8944.83,percent of total billed charges,
CONE,9120436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,First Health,,8944.83,,,,,,,3521.07,8944.83,percent of total billed charges,
INSERT,9117288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1848.00000,535.92000,Aetna,First Health,,1511.66,,,,,,,666.20,1511.66,percent of total billed charges,
INSERT,9117288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1848.00000,535.92000,Aetna,First Health,,1511.66,,,,,,,595.06,1511.66,percent of total billed charges,
INSERT,9117289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,9117289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SPACER,9120488,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
SPACER,9120488,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
END CAP,9120489,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,769.31,1745.61,percent of total billed charges,
END CAP,9120489,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,First Health,,1745.61,,,,,,,687.15,1745.61,percent of total billed charges,
STEM,9117290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,10838.66,24593.69,percent of total billed charges,
STEM,9117290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,First Health,,24593.69,,,,,,,9681.13,24593.69,percent of total billed charges,
SHELL,9120490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1646.58,3736.22,percent of total billed charges,
SHELL,9120490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,First Health,,3736.22,,,,,,,1470.73,3736.22,percent of total billed charges,
STEM,9122408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,9122408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,9122409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,9122409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
ANCHOR,9122410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.84000,578.50000,Aetna,First Health,,1631.78,,,,,,,719.14,1631.78,percent of total billed charges,
ANCHOR,9122410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.84000,578.50000,Aetna,First Health,,1631.78,,,,,,,642.34,1631.78,percent of total billed charges,
SCREW,9120523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9120523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
SCREW,9120524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9120524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
GENERATOR,9120525,CDM,278,RC,L8679,HCPCS,,,facility,inpatient,,,47652.75000,13819.30000,Aetna,First Health,,38979.95,,,,,,,17178.82,38979.95,percent of total billed charges,
GENERATOR,9120525,CDM,278,RC,L8679,HCPCS,,,facility,outpatient,,,47652.75000,13819.30000,Aetna,First Health,,38979.95,,,,,,,10323.94,38979.95,percent of total billed charges,
PLATE,9124447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5760.00000,1670.40000,Aetna,First Health,,4711.68,,,,,,,2076.48,4711.68,percent of total billed charges,
PLATE,9124447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5760.00000,1670.40000,Aetna,First Health,,4711.68,,,,,,,1854.72,4711.68,percent of total billed charges,
STEM,9124448,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,9124448,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
STEM,9124449,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,9124449,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
SPACER,9124631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2795.68,6343.59,percent of total billed charges,
SPACER,9124631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,First Health,,6343.59,,,,,,,2497.11,6343.59,percent of total billed charges,
ARTICULAR SURFACE,9126396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
ARTICULAR SURFACE,9126396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
PLATE,9126392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8736.00000,2533.44000,Aetna,First Health,,7146.05,,,,,,,3149.33,7146.05,percent of total billed charges,
PLATE,9126392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8736.00000,2533.44000,Aetna,First Health,,7146.05,,,,,,,2812.99,7146.05,percent of total billed charges,
SCREW,9126393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,9126393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
ANCHOR,9126394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,665.24000,192.92000,Aetna,First Health,,544.17,,,,,,,239.82,544.17,percent of total billed charges,
ANCHOR,9126394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,665.24000,192.92000,Aetna,First Health,,544.17,,,,,,,214.21,544.17,percent of total billed charges,
ANCHOR,9126395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,665.24000,192.92000,Aetna,First Health,,544.17,,,,,,,239.82,544.17,percent of total billed charges,
ANCHOR,9126395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,665.24000,192.92000,Aetna,First Health,,544.17,,,,,,,214.21,544.17,percent of total billed charges,
PLATE,9126431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1289.24000,373.88000,Aetna,First Health,,1054.60,,,,,,,464.77,1054.60,percent of total billed charges,
PLATE,9126431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1289.24000,373.88000,Aetna,First Health,,1054.60,,,,,,,415.14,1054.60,percent of total billed charges,
INSERT,9126426,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9144.09000,2651.79000,Aetna,First Health,,7479.87,,,,,,,3296.44,7479.87,percent of total billed charges,
INSERT,9126426,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9144.09000,2651.79000,Aetna,First Health,,7479.87,,,,,,,2944.40,7479.87,percent of total billed charges,
FEMORAL WEDGE,9126427,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5675.25000,1645.82000,Aetna,First Health,,4642.35,,,,,,,2045.93,4642.35,percent of total billed charges,
FEMORAL WEDGE,9126427,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5675.25000,1645.82000,Aetna,First Health,,4642.35,,,,,,,1827.43,4642.35,percent of total billed charges,
STEM,9126428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
STEM,9126428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
SCREW,9126430,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
SCREW,9126430,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
SCREW,9128416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
SCREW,9128416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
SCREW,9128417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
SCREW,9128417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
SCREW,9128418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,517.68,1174.65,percent of total billed charges,
SCREW,9128418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,First Health,,1174.65,,,,,,,462.39,1174.65,percent of total billed charges,
SCREW,9128419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,116.44,264.21,percent of total billed charges,
SCREW,9128419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,104.01,264.21,percent of total billed charges,
GUIDEWIRE,9128420,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,695.12000,201.58000,Aetna,First Health,,568.61,,,,,,,250.59,568.61,percent of total billed charges,
GUIDEWIRE,9128420,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,695.12000,201.58000,Aetna,First Health,,568.61,,,,,,,223.83,568.61,percent of total billed charges,
NAIL,9128421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9128421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
FEMORAL HEAD,9128423,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
FEMORAL HEAD,9128423,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
STEM,9128474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
STEM,9128474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
CAGE,9128472,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6180.00000,1792.20000,Aetna,First Health,,5055.24,,,,,,,2227.89,5055.24,percent of total billed charges,
CAGE,9128472,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6180.00000,1792.20000,Aetna,First Health,,5055.24,,,,,,,1989.96,5055.24,percent of total billed charges,
TIBIAL INSERT,9117174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
TIBIAL INSERT,9117174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
SCREW,9128473,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,9128473,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
SCREW,9132397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2675.00000,775.75000,Aetna,First Health,,2188.15,,,,,,,964.34,2188.15,percent of total billed charges,
SCREW,9132397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2675.00000,775.75000,Aetna,First Health,,2188.15,,,,,,,861.35,2188.15,percent of total billed charges,
SCREW,9132398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,964.29,2188.05,percent of total billed charges,
SCREW,9132398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,First Health,,2188.05,,,,,,,861.31,2188.05,percent of total billed charges,
SCREW,9134415,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
SCREW,9134415,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
SCREW,9130453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,549.40,1246.63,percent of total billed charges,
SCREW,9130453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,First Health,,1246.63,,,,,,,490.73,1246.63,percent of total billed charges,
LINER,9134411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1341.24,3043.37,percent of total billed charges,
LINER,9134411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,First Health,,3043.37,,,,,,,1198.00,3043.37,percent of total billed charges,
ANCHOR,9134412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
ANCHOR,9134412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,217.35,552.15,percent of total billed charges,
LOCKING PEG,9134475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
LOCKING PEG,9134475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
SCREW,9134476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW,9134476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
SCREW,9134477,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,235.55,534.48,percent of total billed charges,
SCREW,9134477,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,First Health,,534.48,,,,,,,210.39,534.48,percent of total billed charges,
LINER,9132455,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,3950.94,percent of total billed charges,
LINER,9132455,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1555.26,3950.94,percent of total billed charges,
SCREW,9132458,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
SCREW,9132458,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1352.40,3435.60,percent of total billed charges,
HUMERAL COMPONENT,9132459,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,16445.00000,4769.05000,Aetna,First Health,,13452.01,,,,,,,5928.42,13452.01,percent of total billed charges,
HUMERAL COMPONENT,9132459,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,16445.00000,4769.05000,Aetna,First Health,,13452.01,,,,,,,5295.29,13452.01,percent of total billed charges,
ULNA COMPONENT,9132460,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,17657.50000,5120.67000,Aetna,First Health,,14443.83,,,,,,,6365.53,14443.83,percent of total billed charges,
ULNA COMPONENT,9132460,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,17657.50000,5120.67000,Aetna,First Health,,14443.83,,,,,,,5685.72,14443.83,percent of total billed charges,
LOCKING PEG,9134474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1797.99,4079.78,percent of total billed charges,
LOCKING PEG,9134474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,First Health,,4079.78,,,,,,,1605.97,4079.78,percent of total billed charges,
NAIL,9142526,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,2146.24,4869.96,percent of total billed charges,
NAIL,9142526,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,First Health,,4869.96,,,,,,,1917.03,4869.96,percent of total billed charges,
SPACER,9142534,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
SPACER,9142534,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
STEM,9142535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.28000,961.43000,Aetna,First Health,,2711.90,,,,,,,1195.16,2711.90,percent of total billed charges,
STEM,9142535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.28000,961.43000,Aetna,First Health,,2711.90,,,,,,,1067.52,2711.90,percent of total billed charges,
SCREW,9142165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,502.05,1139.18,percent of total billed charges,
SCREW,9142165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,First Health,,1139.18,,,,,,,448.43,1139.18,percent of total billed charges,
NAIL,9142523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2264.03,5137.25,percent of total billed charges,
NAIL,9142523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,First Health,,5137.25,,,,,,,2022.24,5137.25,percent of total billed charges,
ANCHOR,9142525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,411.68000,119.39000,Aetna,First Health,,336.75,,,,,,,148.41,336.75,percent of total billed charges,
ANCHOR,9142525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,411.68000,119.39000,Aetna,First Health,,336.75,,,,,,,132.56,336.75,percent of total billed charges,
SCREW,9142532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,202.23,458.87,percent of total billed charges,
SCREW,9142532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,First Health,,458.87,,,,,,,180.63,458.87,percent of total billed charges,
STEM,9142533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,4163.77,9447.90,percent of total billed charges,
STEM,9142533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,First Health,,9447.90,,,,,,,3719.10,9447.90,percent of total billed charges,
HUMERAL INSERT,9142584,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.54000,1344.89000,Aetna,First Health,,3793.51,,,,,,,1671.83,3793.51,percent of total billed charges,
HUMERAL INSERT,9142584,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.54000,1344.89000,Aetna,First Health,,3793.51,,,,,,,1493.29,3793.51,percent of total billed charges,
GUIDEWIRE,9142610,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,100.33000,29.10000,Aetna,First Health,,82.07,,,,,,,36.17,82.07,percent of total billed charges,
GUIDEWIRE,9142610,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,100.33000,29.10000,Aetna,First Health,,82.07,,,,,,,32.31,82.07,percent of total billed charges,
CATHETER,9142164,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
CATHETER,9142164,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
MEMBRANE,9150429,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,7407.00000,2148.03000,Aetna,First Health,,6058.93,,,,,,,2670.22,6058.93,percent of total billed charges,
MEMBRANE,9150429,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,7407.00000,2148.03000,Aetna,First Health,,6058.93,,,,,,,2385.05,6058.93,percent of total billed charges,
PATCH,9145019,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2968.72,6736.23,percent of total billed charges,
PATCH,9145019,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2651.67,6736.23,percent of total billed charges,
PATCH,9145020,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
PATCH,9145020,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
NAIL,9154548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,175.52,398.27,percent of total billed charges,
NAIL,9154548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,First Health,,398.27,,,,,,,156.78,398.27,percent of total billed charges,
KNEE AUGMENT,9154549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1722.60000,499.55000,Aetna,First Health,,1409.09,,,,,,,621.00,1409.09,percent of total billed charges,
KNEE AUGMENT,9154549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1722.60000,499.55000,Aetna,First Health,,1409.09,,,,,,,554.68,1409.09,percent of total billed charges,
AUGMENT FEM DIST,9154550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,442.46000,128.31000,Aetna,First Health,,361.93,,,,,,,159.51,361.93,percent of total billed charges,
AUGMENT FEM DIST,9154550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,442.46000,128.31000,Aetna,First Health,,361.93,,,,,,,142.47,361.93,percent of total billed charges,
NAIL,9154551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.63000,120.53000,Aetna,First Health,,339.99,,,,,,,149.83,339.99,percent of total billed charges,
NAIL,9154551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.63000,120.53000,Aetna,First Health,,339.99,,,,,,,133.83,339.99,percent of total billed charges,
KNEE SPACER,9154553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1730.00000,501.70000,Aetna,First Health,,1415.14,,,,,,,623.66,1415.14,percent of total billed charges,
KNEE SPACER,9154553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1730.00000,501.70000,Aetna,First Health,,1415.14,,,,,,,557.06,1415.14,percent of total billed charges,
ROD,9154556,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2578.00000,747.62000,Aetna,First Health,,2108.80,,,,,,,929.37,2108.80,percent of total billed charges,
ROD,9154556,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2578.00000,747.62000,Aetna,First Health,,2108.80,,,,,,,830.12,2108.80,percent of total billed charges,
SNARE,9158405,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1535.96000,445.43000,Aetna,First Health,,1256.42,,,,,,,553.71,1256.42,percent of total billed charges,
SNARE,9158405,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1535.96000,445.43000,Aetna,First Health,,1256.42,,,,,,,494.58,1256.42,percent of total billed charges,
SCREW,9160489,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1558.26,3535.80,percent of total billed charges,
SCREW,9160489,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,First Health,,3535.80,,,,,,,1391.85,3535.80,percent of total billed charges,
CATHETER,9168404,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,776.12000,225.07000,Aetna,First Health,,634.87,,,,,,,279.79,634.87,percent of total billed charges,
CATHETER,9168404,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,776.12000,225.07000,Aetna,First Health,,634.87,,,,,,,249.91,634.87,percent of total billed charges,
STENT KIT,9168405,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,322.39,731.53,percent of total billed charges,
STENT KIT,9168405,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,First Health,,731.53,,,,,,,287.96,731.53,percent of total billed charges,
STENT,9168406,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,182.11,413.22,percent of total billed charges,
STENT,9168406,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,162.66,413.22,percent of total billed charges,
STENT,9168407,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,182.11,413.22,percent of total billed charges,
STENT,9168407,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,First Health,,413.22,,,,,,,162.66,413.22,percent of total billed charges,
DELIVERY SYSTEM,9168408,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,473.91000,137.43000,Aetna,First Health,,387.66,,,,,,,170.84,387.66,percent of total billed charges,
DELIVERY SYSTEM,9168408,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,473.91000,137.43000,Aetna,First Health,,387.66,,,,,,,152.60,387.66,percent of total billed charges,
DELIVERY SYSTEM,9168409,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,473.91000,137.43000,Aetna,First Health,,387.66,,,,,,,170.84,387.66,percent of total billed charges,
DELIVERY SYSTEM,9168409,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,473.91000,137.43000,Aetna,First Health,,387.66,,,,,,,152.60,387.66,percent of total billed charges,
ANCHOR,9176421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,953.52,2163.61,percent of total billed charges,
ANCHOR,9176421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,First Health,,2163.61,,,,,,,851.69,2163.61,percent of total billed charges,
GUIDEWIRE,8170945,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1595.00000,462.55000,Aetna,First Health,,1304.71,,,,,,,575.00,1304.71,percent of total billed charges,
GUIDEWIRE,8170945,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1595.00000,462.55000,Aetna,First Health,,1304.71,,,,,,,513.59,1304.71,percent of total billed charges,
CATHETER,9176422,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,23600.00000,6844.00000,Aetna,First Health,,19304.80,,,,,,,8507.80,19304.80,percent of total billed charges,
CATHETER,9176422,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,23600.00000,6844.00000,Aetna,First Health,,19304.80,,,,,,,7599.20,19304.80,percent of total billed charges,
URETERSCOPE,9176468,CDM,278,RC,C1747,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
URETERSCOPE,9176468,CDM,278,RC,C1747,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
PACEMAKER,9178558,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,14640.81,33221.03,percent of total billed charges,
PACEMAKER,9178558,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,13077.23,33221.03,percent of total billed charges,
PACEMAKER,9178560,CDM,278,RC,C1605,HCPCS,,,facility,inpatient,,,112500.00000,32625.00000,Aetna,First Health,,92025.00,,,,,,,40556.25,92025.00,percent of total billed charges,
PACEMAKER,9178560,CDM,278,RC,C1605,HCPCS,,,facility,outpatient,,,112500.00000,32625.00000,Aetna,First Health,,92025.00,,,,,,,36225.00,92025.00,percent of total billed charges,
PACEMAKER,9178559,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,36900.00000,10701.00000,Aetna,First Health,,30184.20,,,,,,,13302.45,30184.20,percent of total billed charges,
PACEMAKER,9178559,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,36900.00000,10701.00000,Aetna,First Health,,30184.20,,,,,,,11881.80,30184.20,percent of total billed charges,
PULMONARY VALVE,9178561,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,53228.25000,15436.19000,Aetna,First Health,,43540.71,,,,,,,19188.78,43540.71,percent of total billed charges,
PULMONARY VALVE,9178561,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,53228.25000,15436.19000,Aetna,First Health,,43540.71,,,,,,,17139.50,43540.71,percent of total billed charges,
PULMONARY VALVE,9178562,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,53228.25000,15436.19000,Aetna,First Health,,43540.71,,,,,,,19188.78,43540.71,percent of total billed charges,
PULMONARY VALVE,9178562,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,53228.25000,15436.19000,Aetna,First Health,,43540.71,,,,,,,17139.50,43540.71,percent of total billed charges,
PULMONARY VALVE,9178563,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,35887.50000,10407.38000,Aetna,First Health,,29355.97,,,,,,,12937.44,29355.97,percent of total billed charges,
PULMONARY VALVE,9178563,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,35887.50000,10407.38000,Aetna,First Health,,29355.97,,,,,,,11555.77,29355.97,percent of total billed charges,
AORTIC VALVE,9178564,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,53228.25000,15436.19000,Aetna,First Health,,43540.71,,,,,,,19188.78,43540.71,percent of total billed charges,
AORTIC VALVE,9178564,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,53228.25000,15436.19000,Aetna,First Health,,43540.71,,,,,,,17139.50,43540.71,percent of total billed charges,
AORTIC VALVE,9178565,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
AORTIC VALVE,9178565,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
AORTIC VALVE,9178566,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,12694.11,28803.83,percent of total billed charges,
AORTIC VALVE,9178566,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,First Health,,28803.83,,,,,,,11338.42,28803.83,percent of total billed charges,
PUMP,9180544,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,63112.50000,18302.62000,Aetna,First Health,,51626.03,,,,,,,22752.06,51626.03,percent of total billed charges,
PUMP,9180544,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,63112.50000,18302.62000,Aetna,First Health,,51626.03,,,,,,,20322.22,51626.03,percent of total billed charges,
GRAFT,9180602,CDM,278,RC,Q4125,HCPCS,,,facility,inpatient,,,7987.50000,2316.38000,Aetna,First Health,,6533.77,,,,,,,2879.49,6533.77,percent of total billed charges,
GRAFT,9180602,CDM,278,RC,Q4125,HCPCS,,,facility,outpatient,,,7987.50000,2316.38000,Aetna,First Health,,6533.77,,,,,,,124.65,6533.77,percent of total billed charges,
INSERT,9182564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT,9182564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
TIBIAL TRAY,9180630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3420.78,7762.00,percent of total billed charges,
TIBIAL TRAY,9180630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,First Health,,7762.00,,,,,,,3055.46,7762.00,percent of total billed charges,
SCREW,9180628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.80000,818.03000,Aetna,First Health,,2307.41,,,,,,,1016.90,2307.41,percent of total billed charges,
SCREW,9180628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.80000,818.03000,Aetna,First Health,,2307.41,,,,,,,908.30,2307.41,percent of total billed charges,
SCREW,9180626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,235.47,534.30,percent of total billed charges,
SCREW,9180626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,First Health,,534.30,,,,,,,210.32,534.30,percent of total billed charges,
IMPLANT,9180624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13059.00000,3787.11000,Aetna,First Health,,10682.26,,,,,,,4707.77,10682.26,percent of total billed charges,
IMPLANT,9180624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13059.00000,3787.11000,Aetna,First Health,,10682.26,,,,,,,4205.00,10682.26,percent of total billed charges,
VENT TUBE,9115121,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,109.25000,31.68000,Aetna,First Health,,89.37,,,,,,,39.38,89.37,percent of total billed charges,
VENT TUBE,9115121,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,109.25000,31.68000,Aetna,First Health,,89.37,,,,,,,35.18,332.38,percent of total billed charges,
BONE GRAFT,9182690,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,12879.00000,3734.91000,Aetna,First Health,,10535.02,,,,,,,4642.88,10535.02,percent of total billed charges,
BONE GRAFT,9182690,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,12879.00000,3734.91000,Aetna,First Health,,10535.02,,,,,,,4147.04,10535.02,percent of total billed charges,
URETERAL SHEATH,9180777,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
URETERAL SHEATH,9180777,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
UTERERAL SHEATH,9180778,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,872.41,1979.56,percent of total billed charges,
UTERERAL SHEATH,9180778,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,First Health,,1979.56,,,,,,,779.24,1979.56,percent of total billed charges,
BALLOON,9186523,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,9186523,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,9186524,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,9186524,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,9186525,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,9186525,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
Catheter,9142528,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
Catheter,9142528,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
Introducer,9142529,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
Introducer,9142529,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
Pacemaker,9142530,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,34762.50000,10081.12000,Aetna,First Health,,28435.72,,,,,,,12531.88,28435.72,percent of total billed charges,
Pacemaker,9142530,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,34762.50000,10081.12000,Aetna,First Health,,28435.72,,,,,,,11193.52,28435.72,percent of total billed charges,
Pacemaker,9142531,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,11193.52,25398.90,percent of total billed charges,
Pacemaker,9142531,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,First Health,,25398.90,,,,,,,9998.10,25398.90,percent of total billed charges,
Introducer,9142527,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
Introducer,9142527,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,914.48,2323.12,percent of total billed charges,
catheter guide,9142162,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
catheter guide,9142162,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
DILATION CATHETER,9182729,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
DILATION CATHETER,9182729,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
BALLOON,9186526,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,9186526,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,9186527,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,9186527,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,9186528,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,9186528,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,9186529,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,9186529,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
BALLOON,9186530,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
BALLOON,9186530,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
TISSUE REINFORCED MATRIX,9188444,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,24450.00000,7090.50000,Aetna,First Health,,20000.10,,,,,,,8814.23,20000.10,percent of total billed charges,
TISSUE REINFORCED MATRIX,9188444,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,24450.00000,7090.50000,Aetna,First Health,,20000.10,,,,,,,7872.90,20000.10,percent of total billed charges,
BREAST IMPLANT,9186566,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,9186566,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
BREAST IMPLANT,9186567,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1987.26,4509.23,percent of total billed charges,
BREAST IMPLANT,9186567,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,First Health,,4509.23,,,,,,,1775.03,4509.23,percent of total billed charges,
CATHETER,9188868,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER,9188868,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
GENERATOR,9188835,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,67050.00000,19444.50000,Aetna,First Health,,54846.90,,,,,,,24171.53,54846.90,percent of total billed charges,
GENERATOR,9188835,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,67050.00000,19444.50000,Aetna,First Health,,54846.90,,,,,,,21590.10,54846.90,percent of total billed charges,
LEAD,9188836,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2920.05,6625.80,percent of total billed charges,
LEAD,9188836,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,First Health,,6625.80,,,,,,,2608.20,6625.80,percent of total billed charges,
ANNULOPLASTY RING,9188706,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,3352.65,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188706,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,2994.60,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188707,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,3352.65,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188707,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,2994.60,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188708,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,3352.65,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188708,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,2994.60,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188700,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,3352.65,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188700,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,2994.60,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188701,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,3352.65,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188701,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,2994.60,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188702,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,3352.65,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188702,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,2994.60,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188703,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,3352.65,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188703,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,2994.60,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188704,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,3352.65,7607.40,percent of total billed charges,
ANNULOPLASTY RING,9188704,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,First Health,,7607.40,,,,,,,2994.60,7607.40,percent of total billed charges,
CATHETER,9202429,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2456.00000,712.24000,Aetna,First Health,,2009.01,,,,,,,885.39,2009.01,percent of total billed charges,
CATHETER,9202429,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2456.00000,712.24000,Aetna,First Health,,2009.01,,,,,,,790.83,2009.01,percent of total billed charges,
CATHETER,9188971,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1484.00000,430.36000,Aetna,First Health,,1213.91,,,,,,,534.98,1213.91,percent of total billed charges,
CATHETER,9188971,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1484.00000,430.36000,Aetna,First Health,,1213.91,,,,,,,477.85,1213.91,percent of total billed charges,
CATHETER,9200469,CDM,278,RC,C1759,HCPCS,,,facility,inpatient,,,4165.00000,1207.85000,Aetna,First Health,,3406.97,,,,,,,1501.48,3406.97,percent of total billed charges,
CATHETER,9200469,CDM,278,RC,C1759,HCPCS,,,facility,outpatient,,,4165.00000,1207.85000,Aetna,First Health,,3406.97,,,,,,,1341.13,3406.97,percent of total billed charges,
CATHETER,9200468,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,4287.00000,1243.23000,Aetna,First Health,,3506.77,,,,,,,1545.46,3506.77,percent of total billed charges,
CATHETER,9200468,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,4287.00000,1243.23000,Aetna,First Health,,3506.77,,,,,,,1380.41,9959.00,percent of total billed charges,
CATHETER,9200467,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,633.83000,183.81000,Aetna,First Health,,518.47,,,,,,,228.50,518.47,percent of total billed charges,
CATHETER,9200467,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,633.83000,183.81000,Aetna,First Health,,518.47,,,,,,,204.09,9959.00,percent of total billed charges,
CATHETER,9200466,CDM,278,RC,C1731,HCPCS,,,facility,inpatient,,,1338.76000,388.24000,Aetna,First Health,,1095.11,,,,,,,482.62,1095.11,percent of total billed charges,
CATHETER,9200466,CDM,278,RC,C1731,HCPCS,,,facility,outpatient,,,1338.76000,388.24000,Aetna,First Health,,1095.11,,,,,,,431.08,9959.00,percent of total billed charges,
CATHETER,9200465,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,2050.34,4652.38,percent of total billed charges,
CATHETER,9200465,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,First Health,,4652.38,,,,,,,1831.38,9959.00,percent of total billed charges,
CATHETER,9200464,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
CATHETER,9200464,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,9959.00,percent of total billed charges,
CATHETER,9200463,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,206.27000,59.82000,Aetna,First Health,,168.73,,,,,,,74.36,168.73,percent of total billed charges,
CATHETER,9200463,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,206.27000,59.82000,Aetna,First Health,,168.73,,,,,,,66.42,9959.00,percent of total billed charges,
INTRODUCER,9200462,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2696.52000,781.99000,Aetna,First Health,,2205.75,,,,,,,972.10,2205.75,percent of total billed charges,
INTRODUCER,9200462,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2696.52000,781.99000,Aetna,First Health,,2205.75,,,,,,,868.28,2205.75,percent of total billed charges,
CATHETER,9200461,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
CATHETER,9200461,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,9959.00,percent of total billed charges,
INTRODUCER,9200460,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
INTRODUCER,9200460,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,888.72,2257.68,percent of total billed charges,
CATHETER,9202430,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
CATHETER,9202430,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,9959.00,percent of total billed charges,
CATHETER,9200459,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,733.50000,212.71000,Aetna,First Health,,600.00,,,,,,,264.43,600.00,percent of total billed charges,
CATHETER,9200459,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,733.50000,212.71000,Aetna,First Health,,600.00,,,,,,,236.19,9959.00,percent of total billed charges,
CATHETER,9206538,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,699.53000,202.86000,Aetna,First Health,,572.22,,,,,,,252.18,572.22,percent of total billed charges,
CATHETER,9206538,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,699.53000,202.86000,Aetna,First Health,,572.22,,,,,,,225.25,9959.00,percent of total billed charges,
CATHETER,9206539,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1192.35,2705.53,percent of total billed charges,
CATHETER,9206539,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,First Health,,2705.53,,,,,,,1065.02,9959.00,percent of total billed charges,
CATHETER,9206540,CDM,278,RC,C1759,HCPCS,,,facility,inpatient,,,5628.00000,1632.12000,Aetna,First Health,,4603.70,,,,,,,2028.89,4603.70,percent of total billed charges,
CATHETER,9206540,CDM,278,RC,C1759,HCPCS,,,facility,outpatient,,,5628.00000,1632.12000,Aetna,First Health,,4603.70,,,,,,,1812.22,4603.70,percent of total billed charges,
CATHETER,9212435,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
CATHETER,9212435,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,9959.00,percent of total billed charges,
CATHETER,9212436,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
CATHETER,9212436,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,9959.00,percent of total billed charges,
CATHETER,9212437,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER,9212437,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
CATHETER,9212438,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER,9212438,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
CATHETER,9212439,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER,9212439,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
CATHETER,9212440,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER,9212440,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
CATHETER,9212441,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER,9212441,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
CATHETER,9212442,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER,9212442,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
CATHETER,9212443,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER,9212443,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
CATHETER,9212444,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,77.79,176.51,percent of total billed charges,
CATHETER,9212444,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,First Health,,176.51,,,,,,,69.48,176.51,percent of total billed charges,
INTRODUCER,9212620,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,774.90000,224.72000,Aetna,First Health,,633.87,,,,,,,279.35,633.87,percent of total billed charges,
INTRODUCER,9212620,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,774.90000,224.72000,Aetna,First Health,,633.87,,,,,,,249.52,633.87,percent of total billed charges,
CATHETER,9210522,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,9888.00000,2867.52000,Aetna,First Health,,8088.38,,,,,,,3564.62,8088.38,percent of total billed charges,
CATHETER,9210522,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,9888.00000,2867.52000,Aetna,First Health,,8088.38,,,,,,,3183.94,9959.00,percent of total billed charges,
CATHETER,9210558,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,13002.00000,3770.58000,Aetna,First Health,,10635.64,,,,,,,4687.22,10635.64,percent of total billed charges,
CATHETER,9210558,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,13002.00000,3770.58000,Aetna,First Health,,10635.64,,,,,,,4186.64,10635.64,percent of total billed charges,
PACEMAKER,9210766,CDM,278,RC,C1824,HCPCS,,,facility,inpatient,,,64000.00000,18560.00000,Aetna,First Health,,52352.00,,,,,,,23072.00,52352.00,percent of total billed charges,
PACEMAKER,9210766,CDM,278,RC,C1824,HCPCS,,,facility,outpatient,,,64000.00000,18560.00000,Aetna,First Health,,52352.00,,,,,,,20608.00,52352.00,percent of total billed charges,
OCCLUDERS,9220446,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,14235.24,32300.78,percent of total billed charges,
OCCLUDERS,9220446,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,12714.98,32300.78,percent of total billed charges,
OCCLUDER,9220447,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,14235.24,32300.78,percent of total billed charges,
OCCLUDER,9220447,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,12714.98,32300.78,percent of total billed charges,
OCCLUDER,9220448,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,14235.24,32300.78,percent of total billed charges,
OCCLUDER,9220448,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,12714.98,32300.78,percent of total billed charges,
SHEATH,9220459,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SHEATH,9220459,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
OCCLUDER,9224436,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,14235.24,32300.78,percent of total billed charges,
OCCLUDER,9224436,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,12714.98,32300.78,percent of total billed charges,
OCCLUDER,9224437,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,14235.24,32300.78,percent of total billed charges,
OCCLUDER,9224437,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,12714.98,32300.78,percent of total billed charges,
OCCLUDER,9224438,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,14235.24,32300.78,percent of total billed charges,
OCCLUDER,9224438,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,12714.98,32300.78,percent of total billed charges,
OCCLUDER,9224439,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,14235.24,32300.78,percent of total billed charges,
OCCLUDER,9224439,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,12714.98,32300.78,percent of total billed charges,
OCCLUDER,9224440,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,14235.24,32300.78,percent of total billed charges,
OCCLUDER,9224440,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,First Health,,32300.78,,,,,,,12714.98,32300.78,percent of total billed charges,
CATHETER,9230559,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3731.18,8466.30,percent of total billed charges,
CATHETER,9230559,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,First Health,,8466.30,,,,,,,3332.70,8466.30,percent of total billed charges,
ENDOCATHETER,9230566,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9984.00000,2895.36000,Aetna,First Health,,8166.91,,,,,,,3599.23,8166.91,percent of total billed charges,
ENDOCATHETER,9230566,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9984.00000,2895.36000,Aetna,First Health,,8166.91,,,,,,,3214.85,8166.91,percent of total billed charges,
ENDOCATHETER,9230567,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9984.00000,2895.36000,Aetna,First Health,,8166.91,,,,,,,3599.23,8166.91,percent of total billed charges,
ENDOCATHETER,9230567,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9984.00000,2895.36000,Aetna,First Health,,8166.91,,,,,,,3214.85,8166.91,percent of total billed charges,
GRAFT BONE,9230560,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,6107.50000,1771.18000,Aetna,First Health,,4995.94,,,,,,,2201.75,4995.94,percent of total billed charges,
GRAFT BONE,9230560,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,6107.50000,1771.18000,Aetna,First Health,,4995.94,,,,,,,1966.62,4995.94,percent of total billed charges,
GRAFT BONE,9230561,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,12795.00000,3710.55000,Aetna,First Health,,10466.31,,,,,,,4612.60,10466.31,percent of total billed charges,
GRAFT BONE,9230561,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,12795.00000,3710.55000,Aetna,First Health,,10466.31,,,,,,,4119.99,10466.31,percent of total billed charges,
GRAFT BONE,9230562,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,16850.00000,4886.50000,Aetna,First Health,,13783.30,,,,,,,6074.43,13783.30,percent of total billed charges,
GRAFT BONE,9230562,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,16850.00000,4886.50000,Aetna,First Health,,13783.30,,,,,,,5425.70,13783.30,percent of total billed charges,
GRAFT BONE,9230563,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,19937.50000,5781.88000,Aetna,First Health,,16308.88,,,,,,,7187.47,16308.88,percent of total billed charges,
GRAFT BONE,9230563,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,19937.50000,5781.88000,Aetna,First Health,,16308.88,,,,,,,6419.88,16308.88,percent of total billed charges,
NEUROSTIMULATOR,9230473,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,115.50000,33.49000,Aetna,First Health,,94.48,,,,,,,41.64,94.48,percent of total billed charges,
NEUROSTIMULATOR,9230473,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,115.50000,33.49000,Aetna,First Health,,94.48,,,,,,,37.19,94.48,percent of total billed charges,
CATHETER,9230647,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,23600.00000,6844.00000,Aetna,First Health,,19304.80,,,,,,,8507.80,19304.80,percent of total billed charges,
CATHETER,9230647,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,23600.00000,6844.00000,Aetna,First Health,,19304.80,,,,,,,7599.20,19304.80,percent of total billed charges,
GUIDEWIRE,9230648,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1580.88000,458.46000,Aetna,First Health,,1293.16,,,,,,,569.91,1293.16,percent of total billed charges,
GUIDEWIRE,9230648,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1580.88000,458.46000,Aetna,First Health,,1293.16,,,,,,,509.04,1293.16,percent of total billed charges,
GUIDEWIRE,9230649,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,796.01000,230.84000,Aetna,First Health,,651.14,,,,,,,286.96,651.14,percent of total billed charges,
GUIDEWIRE,9230649,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,796.01000,230.84000,Aetna,First Health,,651.14,,,,,,,256.32,651.14,percent of total billed charges,
TISSUE HELIX PRO,9230650,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2160.68000,626.60000,Aetna,First Health,,1767.44,,,,,,,778.93,1767.44,percent of total billed charges,
TISSUE HELIX PRO,9230650,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2160.68000,626.60000,Aetna,First Health,,1767.44,,,,,,,695.74,1767.44,percent of total billed charges,
TENDON,9230670,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,3893.40,8834.40,percent of total billed charges,
TENDON,9230670,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,3477.60,8834.40,percent of total billed charges,
CATHETER,9194482,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194482,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194483,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194483,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194484,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194484,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194485,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194485,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194486,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194486,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194487,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194487,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194488,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194488,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194489,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194489,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194490,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194490,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194491,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194491,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194492,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194492,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9194493,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9194493,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192476,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192476,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192477,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192477,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192478,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192478,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192479,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192479,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192480,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192480,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192481,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192481,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192482,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192482,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192483,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192483,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192484,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192484,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192485,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192485,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192486,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192486,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192487,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192487,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192488,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192488,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192489,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192489,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192490,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192490,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
CATHETER,9192491,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,6714.31,15235.25,percent of total billed charges,
CATHETER,9192491,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,First Health,,15235.25,,,,,,,5997.25,15235.25,percent of total billed charges,
GUIDEWIRE HORNET,9068267,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,648.00000,187.92000,Aetna,First Health,,530.06,,,,,,,233.60,530.06,percent of total billed charges,
GUIDEWIRE HORNET,9068267,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,648.00000,187.92000,Aetna,First Health,,530.06,,,,,,,208.66,530.06,percent of total billed charges,
DILATOR VERCROSS,9068268,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1596.11,3621.70,percent of total billed charges,
DILATOR VERCROSS,9068268,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,First Health,,3621.70,,,,,,,1425.65,3621.70,percent of total billed charges,
DEVICE CLOSURE WATCHMAN,9117235,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,45112.50000,13082.62000,Aetna,First Health,,36902.03,,,,,,,16263.06,36902.03,percent of total billed charges,
DEVICE CLOSURE WATCHMAN,9117235,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,45112.50000,13082.62000,Aetna,First Health,,36902.03,,,,,,,14526.23,36902.03,percent of total billed charges,
ACCESS WATCHMAN,9117236,CDM,278,RC,C1817,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
ACCESS WATCHMAN,9117236,CDM,278,RC,C1817,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
AUGMENT TENT,9093621,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1693.52,3842.72,percent of total billed charges,
AUGMENT TENT,9093621,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,First Health,,3842.72,,,,,,,1512.66,3842.72,percent of total billed charges,
BEARING,9093511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
BEARING,9093511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
GENERATOR,9093509,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,14640.81,33221.03,percent of total billed charges,
GENERATOR,9093509,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,First Health,,33221.03,,,,,,,13077.23,33221.03,percent of total billed charges,
GUIDEWIRE,9093627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,690.62000,200.28000,Aetna,First Health,,564.93,,,,,,,248.97,564.93,percent of total billed charges,
GUIDEWIRE,9093627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,690.62000,200.28000,Aetna,First Health,,564.93,,,,,,,222.38,564.93,percent of total billed charges,
IMPLANT ANKLE,9093618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3360.22,7624.58,percent of total billed charges,
IMPLANT ANKLE,9093618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,First Health,,7624.58,,,,,,,3001.36,7624.58,percent of total billed charges,
INSERT EVOLUTION,9095262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2844.34,6454.02,percent of total billed charges,
INSERT EVOLUTION,9095262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,First Health,,6454.02,,,,,,,2540.58,6454.02,percent of total billed charges,
INSERT JRNY,9093516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4884.13,11082.44,percent of total billed charges,
INSERT JRNY,9093516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,First Health,,11082.44,,,,,,,4362.52,11082.44,percent of total billed charges,
KIT ACCESSORY,9093644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,231.46000,67.12000,Aetna,First Health,,189.33,,,,,,,83.44,189.33,percent of total billed charges,
KIT ACCESSORY,9093644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,231.46000,67.12000,Aetna,First Health,,189.33,,,,,,,74.53,189.33,percent of total billed charges,
PLATE BONE,9095247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5012.00000,1453.48000,Aetna,First Health,,4099.82,,,,,,,1806.83,4099.82,percent of total billed charges,
PLATE BONE,9095247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5012.00000,1453.48000,Aetna,First Health,,4099.82,,,,,,,1613.86,4099.82,percent of total billed charges,
PLATE DIST,9093641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5540.50000,1606.74000,Aetna,First Health,,4532.13,,,,,,,1997.35,4532.13,percent of total billed charges,
PLATE DIST,9093641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5540.50000,1606.74000,Aetna,First Health,,4532.13,,,,,,,1784.04,4532.13,percent of total billed charges,
PLATE LUMBAR,9093643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE LUMBAR,9093643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
PLATE POST,9095243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10989.00000,3186.81000,Aetna,First Health,,8989.00,,,,,,,3961.53,8989.00,percent of total billed charges,
PLATE POST,9095243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10989.00000,3186.81000,Aetna,First Health,,8989.00,,,,,,,3538.46,8989.00,percent of total billed charges,
PLATE VOLAR,9095245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4819.50000,1397.66000,Aetna,First Health,,3942.35,,,,,,,1737.43,3942.35,percent of total billed charges,
PLATE VOLAR,9095245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4819.50000,1397.66000,Aetna,First Health,,3942.35,,,,,,,1551.88,3942.35,percent of total billed charges,
SCREW CANN,9095244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW CANN,9095244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW TORX,9093620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW TORX,9093620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
SCREW BONE,9093515,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,186.65,423.52,percent of total billed charges,
SCREW BONE,9093515,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,First Health,,423.52,,,,,,,166.72,423.52,percent of total billed charges,
SCREW BONE,9093514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
SCREW BONE,9093514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
SCREW,9093625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,510.47,1158.29,percent of total billed charges,
SCREW,9093625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,First Health,,1158.29,,,,,,,455.95,1158.29,percent of total billed charges,
SCREW,9093626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,651.73,1478.81,percent of total billed charges,
SCREW,9093626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,First Health,,1478.81,,,,,,,582.12,1478.81,percent of total billed charges,
SCREW,9095241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,9095241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
SCREW,9093642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW,9093642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
SCREW,9095242,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9095242,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW,9095240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4676.00000,1356.04000,Aetna,First Health,,3824.97,,,,,,,1685.70,3824.97,percent of total billed charges,
SCREW,9095240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4676.00000,1356.04000,Aetna,First Health,,3824.97,,,,,,,1505.67,3824.97,percent of total billed charges,
STEM,9095261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1748.79,3968.12,percent of total billed charges,
STEM,9095261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,First Health,,3968.12,,,,,,,1562.02,3968.12,percent of total billed charges,
STEM FEMORAL,9093510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM FEMORAL,9093510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
STEM,9093512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM,9093512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
ANCHOR,9095421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,839.97,1905.94,percent of total billed charges,
ANCHOR,9095421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,First Health,,1905.94,,,,,,,750.26,1905.94,percent of total billed charges,
PATELLA PROSTHESIS,9095424,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
PATELLA PROSTHESIS,9095424,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
BASEPLATE,9095428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10410.00000,3018.90000,Aetna,First Health,,8515.38,,,,,,,3752.80,8515.38,percent of total billed charges,
BASEPLATE,9095428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10410.00000,3018.90000,Aetna,First Health,,8515.38,,,,,,,3352.02,8515.38,percent of total billed charges,
SCREW,9095429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4882.50000,1415.92000,Aetna,First Health,,3993.89,,,,,,,1760.14,3993.89,percent of total billed charges,
SCREW,9095429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4882.50000,1415.92000,Aetna,First Health,,3993.89,,,,,,,1572.16,3993.89,percent of total billed charges,
SCREW,9095430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,9095430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
SCREW,9095431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,9095431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
SCREW,9095432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,9095432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
SCREW,9093732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
SCREW,9093732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
SCREW,9093733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
SCREW,9093733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
WEDGE,9093734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4050.38000,1174.61000,Aetna,First Health,,3313.21,,,,,,,1460.16,3313.21,percent of total billed charges,
WEDGE,9093734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4050.38000,1174.61000,Aetna,First Health,,3313.21,,,,,,,1304.22,3313.21,percent of total billed charges,
FEMORAL,9093735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,66260.00000,19215.40000,Aetna,First Health,,54200.68,,,,,,,23886.73,54200.68,percent of total billed charges,
FEMORAL,9093735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,66260.00000,19215.40000,Aetna,First Health,,54200.68,,,,,,,21335.72,54200.68,percent of total billed charges,
STENT,9093736,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
STENT,9093736,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3381.00,8589.00,percent of total billed charges,
CAGE,9093737,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
CAGE,9093737,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
ROD,9093738,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,468.65,1063.40,percent of total billed charges,
ROD,9093738,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,First Health,,1063.40,,,,,,,418.60,1063.40,percent of total billed charges,
SCREW,9093767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,55.36,125.61,percent of total billed charges,
SCREW,9093767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,First Health,,125.61,,,,,,,49.45,125.61,percent of total billed charges,
NAIL,9095609,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,3206.47,7275.72,percent of total billed charges,
NAIL,9095609,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,First Health,,7275.72,,,,,,,2864.04,7275.72,percent of total billed charges,
PLATE,9095602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7743.00000,2245.47000,Aetna,First Health,,6333.77,,,,,,,2791.35,6333.77,percent of total billed charges,
PLATE,9095602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7743.00000,2245.47000,Aetna,First Health,,6333.77,,,,,,,2493.25,6333.77,percent of total billed charges,
PLATE,9095603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8163.00000,2367.27000,Aetna,First Health,,6677.33,,,,,,,2942.76,6677.33,percent of total billed charges,
PLATE,9095603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8163.00000,2367.27000,Aetna,First Health,,6677.33,,,,,,,2628.49,6677.33,percent of total billed charges,
SCREW,9095604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9095604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW,9095605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9095605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
SCREW,9095606,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,527.77,1197.55,percent of total billed charges,
SCREW,9095606,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,First Health,,1197.55,,,,,,,471.41,1197.55,percent of total billed charges,
BASEPLATE,9095607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
BASEPLATE,9095607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
PLATE,9095610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1290.14,2927.42,percent of total billed charges,
PLATE,9095610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,First Health,,2927.42,,,,,,,1152.36,2927.42,percent of total billed charges,
SCREW,9093880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
SCREW,9093880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
PLATE,9093881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,3168.80,7190.22,percent of total billed charges,
PLATE,9093881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,First Health,,7190.22,,,,,,,2830.38,7190.22,percent of total billed charges,
CAGE,9093882,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE,9093882,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
SPINAL BOLT,9095703,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
SPINAL BOLT,9095703,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
HUMERAL AUGMENT,9095704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8176.92000,2371.31000,Aetna,First Health,,6688.72,,,,,,,2947.78,6688.72,percent of total billed charges,
HUMERAL AUGMENT,9095704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8176.92000,2371.31000,Aetna,First Health,,6688.72,,,,,,,2632.97,6688.72,percent of total billed charges,
CATHETER,9094999,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
CATHETER,9094999,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,260.82,662.58,percent of total billed charges,
DEFIBRILLATOR,9093889,CDM,278,RC,C1722,HCPCS,,,facility,inpatient,,,36346.50000,10540.48000,Aetna,First Health,,29731.44,,,,,,,13102.91,29731.44,percent of total billed charges,
DEFIBRILLATOR,9093889,CDM,278,RC,C1722,HCPCS,,,facility,outpatient,,,36346.50000,10540.48000,Aetna,First Health,,29731.44,,,,,,,11703.57,29731.44,percent of total billed charges,
ROD,9095744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
ROD,9095744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
URETHRAL SLING,9095705,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,3892.00000,1128.68000,Aetna,First Health,,3183.66,,,,,,,1403.07,3183.66,percent of total billed charges,
URETHRAL SLING,9095705,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,3892.00000,1128.68000,Aetna,First Health,,3183.66,,,,,,,1253.22,3183.66,percent of total billed charges,
TIBIAL GRAFT,9093902,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9606.00000,2785.74000,Aetna,First Health,,7857.71,,,,,,,3462.96,7857.71,percent of total billed charges,
TIBIAL GRAFT,9093902,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9606.00000,2785.74000,Aetna,First Health,,7857.71,,,,,,,3093.13,7857.71,percent of total billed charges,
ANCHOR,9095748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2415.68000,700.55000,Aetna,First Health,,1976.03,,,,,,,870.85,1976.03,percent of total billed charges,
ANCHOR,9095748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2415.68000,700.55000,Aetna,First Health,,1976.03,,,,,,,777.85,1976.03,percent of total billed charges,
HUMERAL HEAD,9095749,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
HUMERAL HEAD,9095749,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
STEM HUMERAL,9093903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3866.36,8773.05,percent of total billed charges,
STEM HUMERAL,9093903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,First Health,,8773.05,,,,,,,3453.45,8773.05,percent of total billed charges,
GUIDEWIRE,7939434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,29.34,66.57,percent of total billed charges,
GUIDEWIRE,7939434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,First Health,,66.57,,,,,,,26.20,66.57,percent of total billed charges,
ANCHOR,8999057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2092.00000,606.68000,Aetna,First Health,,1711.26,,,,,,,754.17,1711.26,percent of total billed charges,
ANCHOR,8999057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2092.00000,606.68000,Aetna,First Health,,1711.26,,,,,,,673.62,1711.26,percent of total billed charges,
INSERT TIBIAL,9094029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
INSERT TIBIAL,9094029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2001.55,5084.69,percent of total billed charges,
COMPONENT FEMORAL,9094030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,5446.25,12357.93,percent of total billed charges,
COMPONENT FEMORAL,9094030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,First Health,,12357.93,,,,,,,4864.61,12357.93,percent of total billed charges,
SCREW,9094031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1721.60000,499.26000,Aetna,First Health,,1408.27,,,,,,,620.64,1408.27,percent of total billed charges,
SCREW,9094031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1721.60000,499.26000,Aetna,First Health,,1408.27,,,,,,,554.36,1408.27,percent of total billed charges,
SCREW,9094032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1721.60000,499.26000,Aetna,First Health,,1408.27,,,,,,,620.64,1408.27,percent of total billed charges,
SCREW,9094032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1721.60000,499.26000,Aetna,First Health,,1408.27,,,,,,,554.36,1408.27,percent of total billed charges,
SCREW,9094033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1721.60000,499.26000,Aetna,First Health,,1408.27,,,,,,,620.64,1408.27,percent of total billed charges,
SCREW,9094033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1721.60000,499.26000,Aetna,First Health,,1408.27,,,,,,,554.36,1408.27,percent of total billed charges,
ANCHOR,9094034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4339.16000,1258.36000,Aetna,First Health,,3549.43,,,,,,,1564.27,3549.43,percent of total billed charges,
ANCHOR,9094034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4339.16000,1258.36000,Aetna,First Health,,3549.43,,,,,,,1397.21,3549.43,percent of total billed charges,
ANCHOR,9094035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4339.16000,1258.36000,Aetna,First Health,,3549.43,,,,,,,1564.27,3549.43,percent of total billed charges,
ANCHOR,9094035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4339.16000,1258.36000,Aetna,First Health,,3549.43,,,,,,,1397.21,3549.43,percent of total billed charges,
SCREW,9094040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
SCREW,9094040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
HEAD FEMORAL,9094042,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1293.29,2934.57,percent of total billed charges,
HEAD FEMORAL,9094042,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,First Health,,2934.57,,,,,,,1155.17,2934.57,percent of total billed charges,
SCREW,9094043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1356.00000,393.24000,Aetna,First Health,,1109.21,,,,,,,488.84,1109.21,percent of total billed charges,
SCREW,9094043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1356.00000,393.24000,Aetna,First Health,,1109.21,,,,,,,436.63,1109.21,percent of total billed charges,
SCREW,9094044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1356.00000,393.24000,Aetna,First Health,,1109.21,,,,,,,488.84,1109.21,percent of total billed charges,
SCREW,9094044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1356.00000,393.24000,Aetna,First Health,,1109.21,,,,,,,436.63,1109.21,percent of total billed charges,
KWIRE,9094046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
KWIRE,9094046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
VASCULAR GRAFT,9012701,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,10242.00000,2970.18000,Aetna,First Health,,8377.96,,,,,,,3692.24,8377.96,percent of total billed charges,
VASCULAR GRAFT,9012701,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,10242.00000,2970.18000,Aetna,First Health,,8377.96,,,,,,,3297.92,8377.96,percent of total billed charges,
GRAFT,9012702,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,3212.05,7288.38,percent of total billed charges,
GRAFT,9012702,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,First Health,,7288.38,,,,,,,2869.02,7288.38,percent of total billed charges,
LINER,9094041,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1545.64,3507.18,percent of total billed charges,
LINER,9094041,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,First Health,,3507.18,,,,,,,1380.58,3507.18,percent of total billed charges,
GRAFT TIBIAL,9096189,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9606.00000,2785.74000,Aetna,First Health,,7857.71,,,,,,,3462.96,7857.71,percent of total billed charges,
GRAFT TIBIAL,9096189,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9606.00000,2785.74000,Aetna,First Health,,7857.71,,,,,,,3093.13,7857.71,percent of total billed charges,
SCREW,9096339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,235.23,533.75,percent of total billed charges,
SCREW,9096339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,First Health,,533.75,,,,,,,210.10,533.75,percent of total billed charges,
ADAPTER,9096340,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,3559.50000,1032.25000,Aetna,First Health,,2911.67,,,,,,,1283.20,2911.67,percent of total billed charges,
ADAPTER,9096340,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,3559.50000,1032.25000,Aetna,First Health,,2911.67,,,,,,,1146.16,2911.67,percent of total billed charges,
PLATE CERVICAL,9098323,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1556.00000,451.24000,Aetna,First Health,,1272.81,,,,,,,560.94,1272.81,percent of total billed charges,
PLATE CERVICAL,9098323,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1556.00000,451.24000,Aetna,First Health,,1272.81,,,,,,,501.03,1272.81,percent of total billed charges,
BONE ANCHOR,9095416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3451.88000,1001.05000,Aetna,First Health,,2823.64,,,,,,,1244.40,2823.64,percent of total billed charges,
BONE ANCHOR,9095416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3451.88000,1001.05000,Aetna,First Health,,2823.64,,,,,,,1111.51,2823.64,percent of total billed charges,
SCREW,9098324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.25000,86.78000,Aetna,First Health,,244.79,,,,,,,107.88,244.79,percent of total billed charges,
SCREW,9098324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.25000,86.78000,Aetna,First Health,,244.79,,,,,,,96.36,244.79,percent of total billed charges,
SCREW,9098325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.25000,86.78000,Aetna,First Health,,244.79,,,,,,,107.88,244.79,percent of total billed charges,
SCREW,9098325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.25000,86.78000,Aetna,First Health,,244.79,,,,,,,96.36,244.79,percent of total billed charges,
SCREW,9098326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,605.28,1373.42,percent of total billed charges,
SCREW,9098326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,First Health,,1373.42,,,,,,,540.64,1373.42,percent of total billed charges,
GRANITE IMPLANT SYSTEM,9098367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
GRANITE IMPLANT SYSTEM,9098367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
CATHETER,9096386,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
CATHETER,9096386,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
SHEATH,9096387,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
SHEATH,9096387,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
INSERT,9096366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
INSERT,9096366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1493.28,3793.47,percent of total billed charges,
COMPONENT,9096367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3514.88,7975.50,percent of total billed charges,
COMPONENT,9096367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,First Health,,7975.50,,,,,,,3139.50,7975.50,percent of total billed charges,
SPACER,9098375,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5677.88,12883.50,percent of total billed charges,
SPACER,9098375,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,First Health,,12883.50,,,,,,,5071.50,12883.50,percent of total billed charges,
HEAD HUMERAL,9098373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1560.00000,452.40000,Aetna,First Health,,1276.08,,,,,,,562.38,1276.08,percent of total billed charges,
HEAD HUMERAL,9098373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1560.00000,452.40000,Aetna,First Health,,1276.08,,,,,,,502.32,1276.08,percent of total billed charges,
HEAD HUMERAL,9098374,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
HEAD HUMERAL,9098374,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
HEAD HUMERAL SYSTEM,9098376,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17100.00000,4959.00000,Aetna,First Health,,13987.80,,,,,,,6164.55,13987.80,percent of total billed charges,
HEAD HUMERAL SYSTEM,9098376,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17100.00000,4959.00000,Aetna,First Health,,13987.80,,,,,,,5506.20,13987.80,percent of total billed charges,
PATELLA PROSTHESIS,9098377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
PATELLA PROSTHESIS,9098377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
TISSUE MATRIX,9098378,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,21555.00000,6250.95000,Aetna,First Health,,17631.99,,,,,,,7770.58,17631.99,percent of total billed charges,
TISSUE MATRIX,9098378,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,21555.00000,6250.95000,Aetna,First Health,,17631.99,,,,,,,124.65,17631.99,percent of total billed charges,
BREAST PROSTHESIS,9098379,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1665.51,3779.16,percent of total billed charges,
BREAST PROSTHESIS,9098379,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,First Health,,3779.16,,,,,,,1487.64,3779.16,percent of total billed charges,
STEM FEMORAL,9096354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM FEMORAL,9096354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
POLARSTEM,9096451,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1709.67,3879.36,percent of total billed charges,
POLARSTEM,9096451,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,First Health,,3879.36,,,,,,,1527.09,3879.36,percent of total billed charges,
PLATE,9096452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1394.23,3163.61,percent of total billed charges,
PLATE,9096452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,First Health,,3163.61,,,,,,,1245.34,3163.61,percent of total billed charges,
SCREW,9098389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
SCREW,9098389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
NAIL FEMORAL,9096454,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2839.07,6442.04,percent of total billed charges,
NAIL FEMORAL,9096454,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,First Health,,6442.04,,,,,,,2535.87,6442.04,percent of total billed charges,
NAIL FEMORAL,9098390,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,3062.33,6948.65,percent of total billed charges,
NAIL FEMORAL,9098390,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,First Health,,6948.65,,,,,,,2735.29,6948.65,percent of total billed charges,
STEM FEMORAL,9096453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4921.94,11168.23,percent of total billed charges,
STEM FEMORAL,9096453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,First Health,,11168.23,,,,,,,4396.29,11168.23,percent of total billed charges,
STENT SCAFFOLD,9086251,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
STENT SCAFFOLD,9086251,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
PATELLA PROSTHESIS,9098469,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
PATELLA PROSTHESIS,9098469,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
PLATE,9098470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3493.00000,1012.97000,Aetna,First Health,,2857.27,,,,,,,1259.23,2857.27,percent of total billed charges,
PLATE,9098470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3493.00000,1012.97000,Aetna,First Health,,2857.27,,,,,,,1124.75,2857.27,percent of total billed charges,
ROD SPINAL,9098471,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,332.11,753.57,percent of total billed charges,
ROD SPINAL,9098471,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,First Health,,753.57,,,,,,,296.64,753.57,percent of total billed charges,
SCREW,9098454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,584.01,1325.16,percent of total billed charges,
SCREW,9098454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,First Health,,1325.16,,,,,,,521.64,1325.16,percent of total billed charges,
STEM FEMORAL,9098483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1195.19,2711.98,percent of total billed charges,
STEM FEMORAL,9098483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,First Health,,2711.98,,,,,,,1067.55,2711.98,percent of total billed charges,
COMPONENT TIBIAL,9098484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23400.00000,6786.00000,Aetna,First Health,,19141.20,,,,,,,8435.70,19141.20,percent of total billed charges,
COMPONENT TIBIAL,9098484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23400.00000,6786.00000,Aetna,First Health,,19141.20,,,,,,,7534.80,19141.20,percent of total billed charges,
FEMORAL ASSEMBLY,9098485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,40878.00000,11854.62000,Aetna,First Health,,33438.20,,,,,,,14736.52,33438.20,percent of total billed charges,
FEMORAL ASSEMBLY,9098485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,40878.00000,11854.62000,Aetna,First Health,,33438.20,,,,,,,13162.72,33438.20,percent of total billed charges,
ROD,9098455,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,483.07,1096.12,percent of total billed charges,
ROD,9098455,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,First Health,,1096.12,,,,,,,431.48,1096.12,percent of total billed charges,
SPACER,9098515,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,3297.49,7482.25,percent of total billed charges,
SPACER,9098515,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,First Health,,7482.25,,,,,,,2945.33,7482.25,percent of total billed charges,
CATHETER,9098516,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28732.50000,8332.42000,Aetna,First Health,,23503.19,,,,,,,10358.07,23503.19,percent of total billed charges,
CATHETER,9098516,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28732.50000,8332.42000,Aetna,First Health,,23503.19,,,,,,,9251.86,23503.19,percent of total billed charges,
CATHETER SINUS,9035115,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,199.54,452.76,percent of total billed charges,
CATHETER SINUS,9035115,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,First Health,,452.76,,,,,,,178.23,452.76,percent of total billed charges,
PLATE,9100567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2703.75,6135.00,percent of total billed charges,
PLATE,9100567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,2415.00,6135.00,percent of total billed charges,
INSERT HUMERAL,9098523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,3305.93,7501.39,percent of total billed charges,
INSERT HUMERAL,9098523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,First Health,,7501.39,,,,,,,2952.87,7501.39,percent of total billed charges,
GLENOSPHERE,9098620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,2176.52,4938.68,percent of total billed charges,
GLENOSPHERE,9098620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,First Health,,4938.68,,,,,,,1944.08,4938.68,percent of total billed charges,
AUGMENT TIBIAL,9098621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1758.88,3991.02,percent of total billed charges,
AUGMENT TIBIAL,9098621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,First Health,,3991.02,,,,,,,1571.04,3991.02,percent of total billed charges,
GLENOID TAP,9098622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,901.25,2045.00,percent of total billed charges,
GLENOID TAP,9098622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,First Health,,2045.00,,,,,,,805.00,2045.00,percent of total billed charges,
CONE TIBIAL,9098624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,6579.12,14928.50,percent of total billed charges,
CONE TIBIAL,9098624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,First Health,,14928.50,,,,,,,5876.50,14928.50,percent of total billed charges,
SCREW,9098625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,322.88,732.63,percent of total billed charges,
SCREW,9098625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,First Health,,732.63,,,,,,,288.40,732.63,percent of total billed charges,
AUGMENT TIBIAL,9098882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5798.10000,1681.45000,Aetna,First Health,,4742.85,,,,,,,2090.22,4742.85,percent of total billed charges,
AUGMENT TIBIAL,9098882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5798.10000,1681.45000,Aetna,First Health,,4742.85,,,,,,,1866.99,4742.85,percent of total billed charges,
BASEPLATE,9098883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14673.60000,4255.34000,Aetna,First Health,,12003.00,,,,,,,5289.83,12003.00,percent of total billed charges,
BASEPLATE,9098883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14673.60000,4255.34000,Aetna,First Health,,12003.00,,,,,,,4724.90,12003.00,percent of total billed charges,
AUGMENT TIBIAL,9098884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5798.10000,1681.45000,Aetna,First Health,,4742.85,,,,,,,2090.22,4742.85,percent of total billed charges,
AUGMENT TIBIAL,9098884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5798.10000,1681.45000,Aetna,First Health,,4742.85,,,,,,,1866.99,4742.85,percent of total billed charges,
INSERT,9098885,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12330.00000,3575.70000,Aetna,First Health,,10085.94,,,,,,,4444.97,10085.94,percent of total billed charges,
INSERT,9098885,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12330.00000,3575.70000,Aetna,First Health,,10085.94,,,,,,,3970.26,10085.94,percent of total billed charges,
CAGE LUMBAR,9098886,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,7191.98,16319.10,percent of total billed charges,
CAGE LUMBAR,9098886,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,First Health,,16319.10,,,,,,,6423.90,16319.10,percent of total billed charges,
PLATE LOCKING,9098887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,865.20,1963.20,percent of total billed charges,
PLATE LOCKING,9098887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,First Health,,1963.20,,,,,,,772.80,1963.20,percent of total billed charges,
INSERT TIBIAL,9098888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1602.42,3636.01,percent of total billed charges,
INSERT TIBIAL,9098888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,First Health,,3636.01,,,,,,,1431.29,3636.01,percent of total billed charges,
ULNAR PROXIMAL,9098891,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,18232.50000,5287.42000,Aetna,First Health,,14914.18,,,,,,,6572.82,14914.18,percent of total billed charges,
ULNAR PROXIMAL,9098891,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,18232.50000,5287.42000,Aetna,First Health,,14914.18,,,,,,,5870.86,14914.18,percent of total billed charges,
MESH,9100774,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3640.00000,1055.60000,Aetna,First Health,,2977.52,,,,,,,1312.22,2977.52,percent of total billed charges,
MESH,9100774,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3640.00000,1055.60000,Aetna,First Health,,2977.52,,,,,,,1172.08,2977.52,percent of total billed charges,
BREAST EXPANDER,8975307,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
BREAST EXPANDER,8975307,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
BREAST EXPANDER,8975308,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
BREAST EXPANDER,8975308,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
STEM FEMORAL,9100992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4609.35,10458.95,percent of total billed charges,
STEM FEMORAL,9100992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,First Health,,10458.95,,,,,,,4117.09,10458.95,percent of total billed charges,
INSERT,9099194,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,3190.43,7239.30,percent of total billed charges,
INSERT,9099194,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,First Health,,7239.30,,,,,,,2849.70,7239.30,percent of total billed charges,
NAIL,9100991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6501.71000,1885.50000,Aetna,First Health,,5318.40,,,,,,,2343.87,5318.40,percent of total billed charges,
NAIL,9100991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6501.71000,1885.50000,Aetna,First Health,,5318.40,,,,,,,2093.55,5318.40,percent of total billed charges,
GRAFT TISSUE,9100946,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT TISSUE,9100946,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
GRAFT TISSUE,9100947,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT TISSUE,9100947,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
GRAFT TISSUE,9100948,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT TISSUE,9100948,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
GRAFT TISSUE,9100973,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT TISSUE,9100973,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
GRAFT TISSUE,9100974,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
GRAFT TISSUE,9100974,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
BONE SCREW SPINAL,9100976,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
BONE SCREW SPINAL,9100976,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
BONE SCREW SPINAL,9100977,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,4055.62,9202.50,percent of total billed charges,
BONE SCREW SPINAL,9100977,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,First Health,,9202.50,,,,,,,3622.50,9202.50,percent of total billed charges,
PATELLA PROSTHESIS,9099192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,951.72,2159.52,percent of total billed charges,
PATELLA PROSTHESIS,9099192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,First Health,,2159.52,,,,,,,850.08,2159.52,percent of total billed charges,
FEMORAL AUGMENT,9099193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1505.27,3415.56,percent of total billed charges,
FEMORAL AUGMENT,9099193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,First Health,,3415.56,,,,,,,1344.51,3415.56,percent of total billed charges,
SPACER,9100981,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,9100981,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
SPACER,9100982,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1780.46,4039.98,percent of total billed charges,
SPACER,9100982,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,First Health,,4039.98,,,,,,,1590.31,4039.98,percent of total billed charges,
CATHETER GUIDING,9101048,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDING,9101048,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
CATHETER GUIDING,9101049,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,85.17,193.25,percent of total billed charges,
CATHETER GUIDING,9101049,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,First Health,,193.25,,,,,,,76.07,193.25,percent of total billed charges,
PLATE,9099300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1492.00000,432.68000,Aetna,First Health,,1220.46,,,,,,,537.87,1220.46,percent of total billed charges,
PLATE,9099300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1492.00000,432.68000,Aetna,First Health,,1220.46,,,,,,,480.42,1220.46,percent of total billed charges,
SHEATH,9220460,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
SHEATH,9220460,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
TEMP PACER LEAD,7694843,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,154.11,349.69,percent of total billed charges,
TEMP PACER LEAD,7694843,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,First Health,,349.69,,,,,,,137.66,349.69,percent of total billed charges,
SCREW,8986412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
SCREW,8986412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
BLOCK CHARGE EPIDURAL,8437018,CDM,278,RC,,,,,facility,inpatient,,,1911.00000,554.19000,Aetna,First Health,,1563.20,,,,,,,688.92,1563.20,percent of total billed charges,
BLOCK CHARGE EPIDURAL,8437018,CDM,278,RC,,,,,facility,outpatient,,,1911.00000,554.19000,Aetna,First Health,,1563.20,,,,,,,615.34,1563.20,percent of total billed charges,
NEUROSURGICAL PROCEDURE KIT,9042870,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,3082.28,6993.90,percent of total billed charges,
NEUROSURGICAL PROCEDURE KIT,9042870,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,First Health,,6993.90,,,,,,,2753.10,6993.90,percent of total billed charges,
Kyphoplasty Balloon 10mm,8438480,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,3300.01,7487.96,percent of total billed charges,
Kyphoplasty Balloon 10mm,8438480,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,2947.58,7487.96,percent of total billed charges,
Kyphoplasty Balloon 15mm,8438482,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,3300.01,7487.96,percent of total billed charges,
Kyphoplasty Balloon 15mm,8438482,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,2947.58,7487.96,percent of total billed charges,
Catheter Guide H 6Fr,8438484,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
Catheter Guide H 6Fr,8438484,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
Catheter Guide M 6Fr,8438486,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
Catheter Guide M 6Fr,8438486,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
Catheter Guide R 6Fr,8438488,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
Catheter Guide R 6Fr,8438488,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
Kyphoplasty Avaflex Kit,8438490,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9472.89000,2747.14000,Aetna,First Health,,7748.82,,,,,,,3414.98,7748.82,percent of total billed charges,
Kyphoplasty Avaflex Kit,8438490,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9472.89000,2747.14000,Aetna,First Health,,7748.82,,,,,,,3050.27,7748.82,percent of total billed charges,
Tissue Location Device Additional Clip,8438498,CDM,278,RC,C1819,HCPCS,,,facility,inpatient,,,456.57000,132.41000,Aetna,First Health,,373.47,,,,,,,164.59,373.47,percent of total billed charges,
Tissue Location Device Additional Clip,8438498,CDM,278,RC,C1819,HCPCS,,,facility,outpatient,,,456.57000,132.41000,Aetna,First Health,,373.47,,,,,,,147.02,373.47,percent of total billed charges,
Tissue Location Device Wire,8442299,CDM,278,RC,C1819,HCPCS,,,facility,inpatient,,,315.88000,91.61000,Aetna,First Health,,258.39,,,,,,,113.87,258.39,percent of total billed charges,
Tissue Location Device Wire,8442299,CDM,278,RC,C1819,HCPCS,,,facility,outpatient,,,315.88000,91.61000,Aetna,First Health,,258.39,,,,,,,101.71,258.39,percent of total billed charges,
Tissue Location Device Additional Wire,8442302,CDM,278,RC,C1819,HCPCS,,,facility,inpatient,,,315.88000,91.61000,Aetna,First Health,,258.39,,,,,,,113.87,258.39,percent of total billed charges,
Tissue Location Device Additional Wire,8442302,CDM,278,RC,C1819,HCPCS,,,facility,outpatient,,,315.88000,91.61000,Aetna,First Health,,258.39,,,,,,,101.71,258.39,percent of total billed charges,
Tissue Location Device Clip,8438496,CDM,278,RC,C1819,HCPCS,,,facility,inpatient,,,456.57000,132.41000,Aetna,First Health,,373.47,,,,,,,164.59,373.47,percent of total billed charges,
Tissue Location Device Clip,8438496,CDM,278,RC,C1819,HCPCS,,,facility,outpatient,,,456.57000,132.41000,Aetna,First Health,,373.47,,,,,,,147.02,373.47,percent of total billed charges,
AN STENT NEPH 8F,607049,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
AN STENT NEPH 8F,607049,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
AN INTRODUCER MET,607028,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,287.85000,83.48000,Aetna,First Health,,235.46,,,,,,,103.77,235.46,percent of total billed charges,
AN INTRODUCER MET,607028,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,287.85000,83.48000,Aetna,First Health,,235.46,,,,,,,92.69,235.46,percent of total billed charges,
AN GUIDEWIRE 035 X 150 GSS,606961,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
AN GUIDEWIRE 035 X 150 GSS,606961,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
AN GUIDEWIRE 038 X 150 G,606959,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.75000,59.38000,Aetna,First Health,,167.49,,,,,,,73.81,167.49,percent of total billed charges,
AN GUIDEWIRE 038 X 150 G,606959,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.75000,59.38000,Aetna,First Health,,167.49,,,,,,,65.93,167.49,percent of total billed charges,
AN GUIDEWIRE 035 X 260 G,606958,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,First Health,,275.87,,,,,,,121.58,275.87,percent of total billed charges,
AN GUIDEWIRE 035 X 260 G,606958,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,First Health,,275.87,,,,,,,108.59,275.87,percent of total billed charges,
Guidewire GSS,606960,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,368.13000,106.76000,Aetna,First Health,,301.13,,,,,,,132.71,301.13,percent of total billed charges,
Guidewire GSS,606960,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,368.13000,106.76000,Aetna,First Health,,301.13,,,,,,,118.54,301.13,percent of total billed charges,
Guidewire B,606968,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,131.20000,38.05000,Aetna,First Health,,107.32,,,,,,,47.30,107.32,percent of total billed charges,
Guidewire B,606968,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,131.20000,38.05000,Aetna,First Health,,107.32,,,,,,,42.25,107.32,percent of total billed charges,
Filter Retrieval T,8126645,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,665.84,1510.85,percent of total billed charges,
Filter Retrieval T,8126645,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,First Health,,1510.85,,,,,,,594.73,1510.85,percent of total billed charges,
Introducer D 5F,8126713,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,473.62000,137.35000,Aetna,First Health,,387.42,,,,,,,170.74,387.42,percent of total billed charges,
Introducer D 5F,8126713,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,473.62000,137.35000,Aetna,First Health,,387.42,,,,,,,152.51,387.42,percent of total billed charges,
Guidewire BMW 190cm,8126661,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
Guidewire BMW 190cm,8126661,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
Guidewire Meier 180cm,8126695,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,375.25000,108.82000,Aetna,First Health,,306.95,,,,,,,135.28,306.95,percent of total billed charges,
Guidewire Meier 180cm,8126695,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,375.25000,108.82000,Aetna,First Health,,306.95,,,,,,,120.83,306.95,percent of total billed charges,
Guidewire N,3232842,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.71000,107.51000,Aetna,First Health,,303.24,,,,,,,133.64,303.24,percent of total billed charges,
Guidewire N,3232842,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.71000,107.51000,Aetna,First Health,,303.24,,,,,,,119.37,303.24,percent of total billed charges,
Guidewire Nitrex 80cm,8126701,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.71000,107.51000,Aetna,First Health,,303.24,,,,,,,133.64,303.24,percent of total billed charges,
Guidewire Nitrex 80cm,8126701,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.71000,107.51000,Aetna,First Health,,303.24,,,,,,,119.37,303.24,percent of total billed charges,
Guidewire J 145cm,8126685,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,100.33000,29.10000,Aetna,First Health,,82.07,,,,,,,36.17,82.07,percent of total billed charges,
Guidewire J 145cm,8126685,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,100.33000,29.10000,Aetna,First Health,,82.07,,,,,,,32.31,82.07,percent of total billed charges,
Stent Ureteral 6F x 22cm,8126801,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
Stent Ureteral 6F x 22cm,8126801,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
Stent Dual Lumen Ureteral 10F,8126791,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,381.71000,110.70000,Aetna,First Health,,312.24,,,,,,,137.61,312.24,percent of total billed charges,
Stent Dual Lumen Ureteral 10F,8126791,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,381.71000,110.70000,Aetna,First Health,,312.24,,,,,,,122.91,312.24,percent of total billed charges,
AN DRAIN PERITONEAL,3232850,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2706.00000,784.74000,Aetna,First Health,,2213.51,,,,,,,975.51,2213.51,percent of total billed charges,
AN DRAIN PERITONEAL,3232850,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2706.00000,784.74000,Aetna,First Health,,2213.51,,,,,,,871.33,2213.51,percent of total billed charges,
Drain Peritoneal,8126821,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2706.00000,784.74000,Aetna,First Health,,2213.51,,,,,,,975.51,2213.51,percent of total billed charges,
Drain Peritoneal,8126821,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2706.00000,784.74000,Aetna,First Health,,2213.51,,,,,,,871.33,2213.51,percent of total billed charges,
Drain Pleural,8126823,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2706.00000,784.74000,Aetna,First Health,,2213.51,,,,,,,975.51,2213.51,percent of total billed charges,
Drain Pleural,8126823,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2706.00000,784.74000,Aetna,First Health,,2213.51,,,,,,,871.33,2213.51,percent of total billed charges,
Transjugular Liver Access 200,8126325,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,814.73,1848.68,percent of total billed charges,
Transjugular Liver Access 200,8126325,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,First Health,,1848.68,,,,,,,727.72,1848.68,percent of total billed charges,
Sheath PA 9F x 30cm,8126777,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,350.55000,101.66000,Aetna,First Health,,286.75,,,,,,,126.37,286.75,percent of total billed charges,
Sheath PA 9F x 30cm,8126777,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,350.55000,101.66000,Aetna,First Health,,286.75,,,,,,,112.88,286.75,percent of total billed charges,
Introducer L 5F,8126717,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,341.34000,98.99000,Aetna,First Health,,279.22,,,,,,,123.05,279.22,percent of total billed charges,
Introducer L 5F,8126717,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,341.34000,98.99000,Aetna,First Health,,279.22,,,,,,,109.91,279.22,percent of total billed charges,
Drain APD,8126831,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
Drain APD,8126831,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
AN GUIDEWIRE 018 X 150 G,3601876,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
AN GUIDEWIRE 018 X 150 G,3601876,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
Guidewire Angled 150cm,8126655,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
Guidewire Angled 150cm,8126655,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
AN GUIDEWIRE 018 X 260 G,3601878,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,501.13000,145.33000,Aetna,First Health,,409.92,,,,,,,180.66,409.92,percent of total billed charges,
AN GUIDEWIRE 018 X 260 G,3601878,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,501.13000,145.33000,Aetna,First Health,,409.92,,,,,,,161.36,409.92,percent of total billed charges,
Guidewire Glidewire 260cm,8126681,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,501.13000,145.33000,Aetna,First Health,,409.92,,,,,,,180.66,409.92,percent of total billed charges,
Guidewire Glidewire 260cm,8126681,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,501.13000,145.33000,Aetna,First Health,,409.92,,,,,,,161.36,409.92,percent of total billed charges,
Guidewire G,3601880,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.75000,59.38000,Aetna,First Health,,167.49,,,,,,,73.81,167.49,percent of total billed charges,
Guidewire G,3601880,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.75000,59.38000,Aetna,First Health,,167.49,,,,,,,65.93,167.49,percent of total billed charges,
Guidewire Glide 150cm,8126671,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.75000,59.38000,Aetna,First Health,,167.49,,,,,,,73.81,167.49,percent of total billed charges,
Guidewire Glide 150cm,8126671,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.75000,59.38000,Aetna,First Health,,167.49,,,,,,,65.93,167.49,percent of total billed charges,
AN GUIDEWIRE 038 X 150 GSS,3601882,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
AN GUIDEWIRE 038 X 150 GSS,3601882,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
Introducer A,3601886,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,508.25000,147.39000,Aetna,First Health,,415.75,,,,,,,183.22,415.75,percent of total billed charges,
Introducer A,3601886,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,508.25000,147.39000,Aetna,First Health,,415.75,,,,,,,163.66,415.75,percent of total billed charges,
AN PORT 6 FS,3601894,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,576.80,1308.80,percent of total billed charges,
AN PORT 6 FS,3601894,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,515.20,1308.80,percent of total billed charges,
Central Line 6FR PP,8126456,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,576.80,1308.80,percent of total billed charges,
Central Line 6FR PP,8126456,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,515.20,1308.80,percent of total billed charges,
AN PORT 8 F,3601896,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,576.80,1308.80,percent of total billed charges,
AN PORT 8 F,3601896,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,515.20,1308.80,percent of total billed charges,
Central Line 8FR PP,8126458,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,576.80,1308.80,percent of total billed charges,
Central Line 8FR PP,8126458,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,First Health,,1308.80,,,,,,,515.20,1308.80,percent of total billed charges,
Sheath Curved 10F,8126763,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,542.21000,157.24000,Aetna,First Health,,443.53,,,,,,,195.47,443.53,percent of total billed charges,
Sheath Curved 10F,8126763,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,542.21000,157.24000,Aetna,First Health,,443.53,,,,,,,174.59,443.53,percent of total billed charges,
AN DRAINAGE YC,3687840,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,145.48000,42.19000,Aetna,First Health,,119.00,,,,,,,52.45,119.00,percent of total billed charges,
AN DRAINAGE YC,3687840,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,145.48000,42.19000,Aetna,First Health,,119.00,,,,,,,46.84,119.00,percent of total billed charges,
Introducer MS,5565840,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,293.55000,85.13000,Aetna,First Health,,240.12,,,,,,,105.82,240.12,percent of total billed charges,
Introducer MS,5565840,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,293.55000,85.13000,Aetna,First Health,,240.12,,,,,,,94.52,240.12,percent of total billed charges,
Introducer Micropuncture With Sheath,8126721,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,293.55000,85.13000,Aetna,First Health,,240.12,,,,,,,105.82,240.12,percent of total billed charges,
Introducer Micropuncture With Sheath,8126721,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,293.55000,85.13000,Aetna,First Health,,240.12,,,,,,,94.52,240.12,percent of total billed charges,
Catheter 65cm,9057682,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
Catheter 65cm,9057682,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
Catheter SF 5F 90cm,8126449,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,35.30,80.09,percent of total billed charges,
Catheter SF 5F 90cm,8126449,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,31.53,80.09,percent of total billed charges,
Catheter C 16F,8126372,CDM,278,RC,A4344,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,32.41,73.53,percent of total billed charges,
Catheter C 16F,8126372,CDM,278,RC,A4344,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,20.67,73.53,percent of total billed charges,
Filter UC,8126647,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5718.83000,1658.46000,Aetna,First Health,,4678.00,,,,,,,2061.64,4678.00,percent of total billed charges,
Filter UC,8126647,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5718.83000,1658.46000,Aetna,First Health,,4678.00,,,,,,,1841.46,4678.00,percent of total billed charges,
Filter T,8126643,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5100.20000,1479.06000,Aetna,First Health,,4171.96,,,,,,,1838.62,4171.96,percent of total billed charges,
Filter T,8126643,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5100.20000,1479.06000,Aetna,First Health,,4171.96,,,,,,,1642.26,4171.96,percent of total billed charges,
Guidewire Transend 190cm,8126709,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1141.93,percent of total billed charges,
Guidewire Transend 190cm,8126709,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,449.51,1141.93,percent of total billed charges,
Guidewire J 80cm,8126693,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,95.76000,27.77000,Aetna,First Health,,78.33,,,,,,,34.52,78.33,percent of total billed charges,
Guidewire J 80cm,8126693,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,95.76000,27.77000,Aetna,First Health,,78.33,,,,,,,30.83,78.33,percent of total billed charges,
AN GUIDEWIRE 035 X 80 A,5563886,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,160.07000,46.42000,Aetna,First Health,,130.94,,,,,,,57.71,130.94,percent of total billed charges,
AN GUIDEWIRE 035 X 80 A,5563886,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,160.07000,46.42000,Aetna,First Health,,130.94,,,,,,,51.54,130.94,percent of total billed charges,
Guidewire Amplatz,8126653,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,160.07000,46.42000,Aetna,First Health,,130.94,,,,,,,57.71,130.94,percent of total billed charges,
Guidewire Amplatz,8126653,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,160.07000,46.42000,Aetna,First Health,,130.94,,,,,,,51.54,130.94,percent of total billed charges,
Guidewire B,5563888,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,155.87000,45.20000,Aetna,First Health,,127.50,,,,,,,56.19,127.50,percent of total billed charges,
Guidewire B,5563888,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,155.87000,45.20000,Aetna,First Health,,127.50,,,,,,,50.19,127.50,percent of total billed charges,
Guidewire Bentson,8126659,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,155.87000,45.20000,Aetna,First Health,,127.50,,,,,,,56.19,127.50,percent of total billed charges,
Guidewire Bentson,8126659,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,155.87000,45.20000,Aetna,First Health,,127.50,,,,,,,50.19,127.50,percent of total billed charges,
AN GUIDEWIRE CSS,5563890,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,231.68000,67.19000,Aetna,First Health,,189.51,,,,,,,83.52,189.51,percent of total billed charges,
AN GUIDEWIRE CSS,5563890,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,231.68000,67.19000,Aetna,First Health,,189.51,,,,,,,74.60,189.51,percent of total billed charges,
Guidewire Cope,8126667,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,231.68000,67.19000,Aetna,First Health,,189.51,,,,,,,83.52,189.51,percent of total billed charges,
Guidewire Cope,8126667,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,231.68000,67.19000,Aetna,First Health,,189.51,,,,,,,74.60,189.51,percent of total billed charges,
Guidewire GDA,8126683,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,442.69,1004.50,percent of total billed charges,
Guidewire GDA,8126683,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,First Health,,1004.50,,,,,,,395.42,1004.50,percent of total billed charges,
Guidewire PP,8126705,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,489.25000,141.88000,Aetna,First Health,,400.21,,,,,,,176.37,400.21,percent of total billed charges,
Guidewire PP,8126705,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,489.25000,141.88000,Aetna,First Health,,400.21,,,,,,,157.54,400.21,percent of total billed charges,
Catheter Marker 150cm,8126432,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2020.00000,585.80000,Aetna,First Health,,1652.36,,,,,,,728.21,1652.36,percent of total billed charges,
Catheter Marker 150cm,8126432,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2020.00000,585.80000,Aetna,First Health,,1652.36,,,,,,,650.44,1652.36,percent of total billed charges,
Catheter R 150cm,8126430,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,706.58,1603.28,percent of total billed charges,
Catheter R 150cm,8126430,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,First Health,,1603.28,,,,,,,631.12,1603.28,percent of total billed charges,
Sheath PA 7F x 11cm,8126771,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,127.05000,36.84000,Aetna,First Health,,103.93,,,,,,,45.80,103.93,percent of total billed charges,
Sheath PA 7F x 11cm,8126771,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,127.05000,36.84000,Aetna,First Health,,103.93,,,,,,,40.91,103.93,percent of total billed charges,
AN SHEATH 9 CURVED,5565870,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,542.21000,157.24000,Aetna,First Health,,443.53,,,,,,,195.47,443.53,percent of total billed charges,
AN SHEATH 9 CURVED,5565870,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,542.21000,157.24000,Aetna,First Health,,443.53,,,,,,,174.59,443.53,percent of total billed charges,
Sheath Curved 9F,8126765,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,542.21000,157.24000,Aetna,First Health,,443.53,,,,,,,195.47,443.53,percent of total billed charges,
Sheath Curved 9F,8126765,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,542.21000,157.24000,Aetna,First Health,,443.53,,,,,,,174.59,443.53,percent of total billed charges,
Sheath BT 9F 35cm,8126761,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
Sheath BT 9F 35cm,8126761,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
Snare A 25mm,8126783,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
Snare A 25mm,8126783,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
Snare E 18 to 30,8126787,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,First Health,,1201.64,,,,,,,529.57,1201.64,percent of total billed charges,
Snare E 18 to 30,8126787,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,First Health,,1201.64,,,,,,,473.02,1201.64,percent of total billed charges,
Balloon 4 x 4 x 75,8126335,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
Balloon 4 x 4 x 75,8126335,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
Kyphoplasty Balloon 11 x 10cm,8126723,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,3300.01,7487.96,percent of total billed charges,
Kyphoplasty Balloon 11 x 10cm,8126723,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,2947.58,7487.96,percent of total billed charges,
Kyphoplasty Balloon 11 x 15cm,8126725,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,3300.01,7487.96,percent of total billed charges,
Kyphoplasty Balloon 11 x 15cm,8126725,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,2947.58,7487.96,percent of total billed charges,
Guidewire GSS,7926852,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,190.05000,55.11000,Aetna,First Health,,155.46,,,,,,,68.51,155.46,percent of total billed charges,
Guidewire GSS,7926852,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,190.05000,55.11000,Aetna,First Health,,155.46,,,,,,,61.20,155.46,percent of total billed charges,
Guidewire Glide SS 80cm,8126679,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,190.05000,55.11000,Aetna,First Health,,155.46,,,,,,,68.51,155.46,percent of total billed charges,
Guidewire Glide SS 80cm,8126679,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,190.05000,55.11000,Aetna,First Health,,155.46,,,,,,,61.20,155.46,percent of total billed charges,
AN GUIDEWIRE GLIDE 035 X 80 G,7926854,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
AN GUIDEWIRE GLIDE 035 X 80 G,7926854,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
Guidewire Glide 80cm,8126673,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
Guidewire Glide 80cm,8126673,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
Catheter SF 5F 65cm,8126446,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,35.30,80.09,percent of total billed charges,
Catheter SF 5F 65cm,8126446,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,31.53,80.09,percent of total billed charges,
Catheter C 20F,8126376,CDM,278,RC,A4344,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,32.41,73.53,percent of total billed charges,
Catheter C 20F,8126376,CDM,278,RC,A4344,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,First Health,,73.53,,,,,,,20.67,73.53,percent of total billed charges,
Catheter C 22F,8126378,CDM,278,RC,A4344,HCPCS,,,facility,inpatient,,,123.27000,35.75000,Aetna,First Health,,100.83,,,,,,,44.44,100.83,percent of total billed charges,
Catheter C 22F,8126378,CDM,278,RC,A4344,HCPCS,,,facility,outpatient,,,123.27000,35.75000,Aetna,First Health,,100.83,,,,,,,20.67,100.83,percent of total billed charges,
Catheter C 18F,8126374,CDM,278,RC,A4344,HCPCS,,,facility,inpatient,,,85.68000,24.85000,Aetna,First Health,,70.09,,,,,,,30.89,70.09,percent of total billed charges,
Catheter C 18F,8126374,CDM,278,RC,A4344,HCPCS,,,facility,outpatient,,,85.68000,24.85000,Aetna,First Health,,70.09,,,,,,,20.67,70.09,percent of total billed charges,
Catheter O 5F,8126416,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,35.30,80.09,percent of total billed charges,
Catheter O 5F,8126416,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,31.53,80.09,percent of total billed charges,
Guidewire J 145cm,8126687,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,103.69000,30.07000,Aetna,First Health,,84.82,,,,,,,37.38,84.82,percent of total billed charges,
Guidewire J 145cm,8126687,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,103.69000,30.07000,Aetna,First Health,,84.82,,,,,,,33.39,84.82,percent of total billed charges,
Catheter S2 5F,8126442,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,114.98000,33.34000,Aetna,First Health,,94.05,,,,,,,41.45,94.05,percent of total billed charges,
Catheter S2 5F,8126442,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,114.98000,33.34000,Aetna,First Health,,94.05,,,,,,,37.02,94.05,percent of total billed charges,
Catheter S3 5F,8126444,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,114.98000,33.34000,Aetna,First Health,,94.05,,,,,,,41.45,94.05,percent of total billed charges,
Catheter S3 5F,8126444,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,114.98000,33.34000,Aetna,First Health,,94.05,,,,,,,37.02,94.05,percent of total billed charges,
Catheter S1 5F,8126440,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,158.55000,45.98000,Aetna,First Health,,129.69,,,,,,,57.16,129.69,percent of total billed charges,
Catheter S1 5F,8126440,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,158.55000,45.98000,Aetna,First Health,,129.69,,,,,,,51.05,129.69,percent of total billed charges,
Sheath BT 6F 11cm,8126745,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
Sheath BT 6F 11cm,8126745,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
Sheath BT 5F 11cm,8126741,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
Sheath BT 5F 11cm,8126741,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
Sheath BT 7F 11cm,8126751,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
Sheath BT 7F 11cm,8126751,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
Sheath BT 8F 11cm,8126753,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
Sheath BT 8F 11cm,8126753,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
Sheath BT 9F 11cm,8126759,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,50.16,113.81,percent of total billed charges,
Sheath BT 9F 11cm,8126759,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,First Health,,113.81,,,,,,,44.80,113.81,percent of total billed charges,
Guidewire J 260cm,8126689,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,160.76000,46.62000,Aetna,First Health,,131.50,,,,,,,57.95,131.50,percent of total billed charges,
Guidewire J 260cm,8126689,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,160.76000,46.62000,Aetna,First Health,,131.50,,,,,,,51.76,131.50,percent of total billed charges,
Guidewire Coons,8126665,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,156.19000,45.30000,Aetna,First Health,,127.76,,,,,,,56.31,127.76,percent of total billed charges,
Guidewire Coons,8126665,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,156.19000,45.30000,Aetna,First Health,,127.76,,,,,,,50.29,127.76,percent of total billed charges,
Sheath BT 6F 23cm,8126747,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
Sheath BT 6F 23cm,8126747,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
Sheath BT 7F 23cm,8126749,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
Sheath BT 7F 23cm,8126749,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
Sheath BT 9F 23cm,8126757,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
Sheath BT 9F 23cm,8126757,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
Sheath BT 8F 23cm,8126755,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,61.62,139.83,percent of total billed charges,
Sheath BT 8F 23cm,8126755,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,First Health,,139.83,,,,,,,55.04,139.83,percent of total billed charges,
Guidewire A,606807,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,214.62000,62.24000,Aetna,First Health,,175.56,,,,,,,77.37,175.56,percent of total billed charges,
Guidewire A,606807,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,214.62000,62.24000,Aetna,First Health,,175.56,,,,,,,69.11,175.56,percent of total billed charges,
Guidewire Amplatz,8126651,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,214.62000,62.24000,Aetna,First Health,,175.56,,,,,,,77.37,175.56,percent of total billed charges,
Guidewire Amplatz,8126651,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,214.62000,62.24000,Aetna,First Health,,175.56,,,,,,,69.11,175.56,percent of total billed charges,
Guidewire Nible,8126697,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,83.28,188.96,percent of total billed charges,
Guidewire Nible,8126697,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,74.38,188.96,percent of total billed charges,
Feeding Tube Cecostomy Adapter,8126629,CDM,278,RC,,,,,facility,inpatient,,,220.45000,63.93000,Aetna,First Health,,180.33,,,,,,,79.47,180.33,percent of total billed charges,
Feeding Tube Cecostomy Adapter,8126629,CDM,278,RC,,,,,facility,outpatient,,,220.45000,63.93000,Aetna,First Health,,180.33,,,,,,,70.98,180.33,percent of total billed charges,
Guidewire Nitinol,8126699,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.71000,107.51000,Aetna,First Health,,303.24,,,,,,,133.64,303.24,percent of total billed charges,
Guidewire Nitinol,8126699,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.71000,107.51000,Aetna,First Health,,303.24,,,,,,,119.37,303.24,percent of total billed charges,
Catheter Glide 5F 100cm,8126412,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
Catheter Glide 5F 100cm,8126412,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
Catheter Glide 5F 65cm,8126364,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
Catheter Glide 5F 65cm,8126364,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
Catheter Straight 5F 65cm,8126395,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
Catheter Straight 5F 65cm,8126395,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
Catheter Angeled 4F 65cm,8126393,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
Catheter Angeled 4F 65cm,8126393,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
Drain Mini Pig 6F,8126844,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,119.87,271.99,percent of total billed charges,
Drain Mini Pig 6F,8126844,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,First Health,,271.99,,,,,,,107.06,271.99,percent of total billed charges,
Catheter 6F 55cm,8126414,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
Catheter 6F 55cm,8126414,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
Catheter 6F 55cm,8126397,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
Catheter 6F 55cm,8126397,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
Kyphoplasty Canulla,8126731,CDM,278,RC,,,,,facility,inpatient,,,371.76000,107.81000,Aetna,First Health,,304.10,,,,,,,134.02,304.10,percent of total billed charges,
Kyphoplasty Canulla,8126731,CDM,278,RC,,,,,facility,outpatient,,,371.76000,107.81000,Aetna,First Health,,304.10,,,,,,,119.71,304.10,percent of total billed charges,
Sheath PA 7F x 30cm,8126773,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,350.55000,101.66000,Aetna,First Health,,286.75,,,,,,,126.37,286.75,percent of total billed charges,
Sheath PA 7F x 30cm,8126773,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,350.55000,101.66000,Aetna,First Health,,286.75,,,,,,,112.88,286.75,percent of total billed charges,
Drain 8F x 45cm,8126835,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
Drain 8F x 45cm,8126835,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
Guidewire BMW,8126663,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,251.45,570.55,percent of total billed charges,
Guidewire BMW,8126663,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,First Health,,570.55,,,,,,,224.59,570.55,percent of total billed charges,
Drain Bililary 8F,8126842,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
Drain Bililary 8F,8126842,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
Central Line M 12F x 20cm,8126468,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,428.23000,124.19000,Aetna,First Health,,350.29,,,,,,,154.38,350.29,percent of total billed charges,
Central Line M 12F x 20cm,8126468,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,428.23000,124.19000,Aetna,First Health,,350.29,,,,,,,137.89,350.29,percent of total billed charges,
Central Line M 12F x 24cm,8126470,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,428.23000,124.19000,Aetna,First Health,,350.29,,,,,,,154.38,350.29,percent of total billed charges,
Central Line M 12F x 24cm,8126470,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,428.23000,124.19000,Aetna,First Health,,350.29,,,,,,,137.89,350.29,percent of total billed charges,
Drain 12F,8126827,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
Drain 12F,8126827,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
Drain 10F,8126825,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
Drain 10F,8126825,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
Drain 14F,8126829,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
Drain 14F,8126829,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
Drain 8F,8126833,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,234.19,531.39,percent of total billed charges,
Drain 8F,8126833,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,First Health,,531.39,,,,,,,209.18,531.39,percent of total billed charges,
Embolization Coil,8126884,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,220.03,499.26,percent of total billed charges,
Embolization Coil,8126884,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,196.53,499.26,percent of total billed charges,
Embolization Coil,8126579,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,220.03,499.26,percent of total billed charges,
Embolization Coil,8126579,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,196.53,499.26,percent of total billed charges,
Embolization Coil,8126585,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,220.03,499.26,percent of total billed charges,
Embolization Coil,8126585,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,196.53,499.26,percent of total billed charges,
Embolization Coil,8126581,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,220.03,499.26,percent of total billed charges,
Embolization Coil,8126581,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,First Health,,499.26,,,,,,,196.53,499.26,percent of total billed charges,
Embolization Coil,8126587,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
Embolization Coil,8126587,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
Embolization Coil,8126583,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
Embolization Coil,8126583,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
Embolization Coil,8126589,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
Embolization Coil,8126589,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
Embolization Coil,8126593,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
Embolization Coil,8126593,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
Embolization Coil,8126591,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,229.53,520.83,percent of total billed charges,
Embolization Coil,8126591,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,First Health,,520.83,,,,,,,205.02,520.83,percent of total billed charges,
Stent Nephroureteral 8F x 24cm,8126795,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
Stent Nephroureteral 8F x 24cm,8126795,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
Stent Nephroureteral 8F x 26cm,8126797,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
Stent Nephroureteral 8F x 26cm,8126797,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
Stent Nephroureteral 8F x 28cm,8126799,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,217.38,493.25,percent of total billed charges,
Stent Nephroureteral 8F x 28cm,8126799,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,First Health,,493.25,,,,,,,194.17,493.25,percent of total billed charges,
Central Line Triple Lumen,8126813,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
Central Line Triple Lumen,8126813,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
Stent Ureteral 6F x 24cm,8126803,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
Stent Ureteral 6F x 24cm,8126803,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
Stent Ureteral 6F x 26cm,8126805,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
Stent Ureteral 6F x 26cm,8126805,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
Stent Ureteral 6F x 28 cm,8126807,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,265.53,602.51,percent of total billed charges,
Stent Ureteral 6F x 28 cm,8126807,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,First Health,,602.51,,,,,,,237.17,602.51,percent of total billed charges,
Catheter PICC Single Lumen 4F,8126418,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,864.00000,250.56000,Aetna,First Health,,706.75,,,,,,,311.47,706.75,percent of total billed charges,
Catheter PICC Single Lumen 4F,8126418,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,864.00000,250.56000,Aetna,First Health,,706.75,,,,,,,278.21,706.75,percent of total billed charges,
Central Line PICC 5F,8126478,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,261.59,593.57,percent of total billed charges,
Central Line PICC 5F,8126478,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,First Health,,593.57,,,,,,,233.65,593.57,percent of total billed charges,
Embolization Coil Pusher,8126595,CDM,278,RC,,,,,facility,inpatient,,,985.50000,285.79000,Aetna,First Health,,806.14,,,,,,,355.27,806.14,percent of total billed charges,
Embolization Coil Pusher,8126595,CDM,278,RC,,,,,facility,outpatient,,,985.50000,285.79000,Aetna,First Health,,806.14,,,,,,,317.33,806.14,percent of total billed charges,
Sheath PA 9F x 11cm,8126775,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,124.43000,36.08000,Aetna,First Health,,101.78,,,,,,,44.86,101.78,percent of total billed charges,
Sheath PA 9F x 11cm,8126775,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,124.43000,36.08000,Aetna,First Health,,101.78,,,,,,,40.07,101.78,percent of total billed charges,
Balloon 5 x 4 x 75,8126337,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
Balloon 5 x 4 x 75,8126337,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
Balloon 6 x 4 x 75,8126339,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
Balloon 6 x 4 x 75,8126339,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
Balloon 7 x 4 x 75,8126341,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
Balloon 7 x 4 x 75,8126341,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
Balloon 8 x 4 x 75,8126343,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
Balloon 8 x 4 x 75,8126343,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
Balloon 9 x 4 x 75,8126346,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
Balloon 9 x 4 x 75,8126346,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
Balloon 10 x 4 x 75,8126329,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
Balloon 10 x 4 x 75,8126329,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
Balloon 12 x 4 x 75,8126331,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
Balloon 12 x 4 x 75,8126331,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
Balloon 3 x 4 x 75,8126333,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,356.89,809.82,percent of total billed charges,
Balloon 3 x 4 x 75,8126333,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,First Health,,809.82,,,,,,,318.78,809.82,percent of total billed charges,
Catheter U 5F 135x5cm,8126451,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,444.86,1009.41,percent of total billed charges,
Catheter U 5F 135x5cm,8126451,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,397.35,1009.41,percent of total billed charges,
Central Line PICC 6F,8126480,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,928.80000,269.35000,Aetna,First Health,,759.76,,,,,,,334.83,759.76,percent of total billed charges,
Central Line PICC 6F,8126480,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,928.80000,269.35000,Aetna,First Health,,759.76,,,,,,,299.07,759.76,percent of total billed charges,
Catheter CS,8126382,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1312.92000,380.75000,Aetna,First Health,,1073.97,,,,,,,473.31,1073.97,percent of total billed charges,
Catheter CS,8126382,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1312.92000,380.75000,Aetna,First Health,,1073.97,,,,,,,422.76,1073.97,percent of total billed charges,
Feeding Tube Cecostomy 24cm,8126625,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1311.96000,380.47000,Aetna,First Health,,1073.18,,,,,,,472.96,1073.18,percent of total billed charges,
Feeding Tube Cecostomy 24cm,8126625,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1311.96000,380.47000,Aetna,First Health,,1073.18,,,,,,,422.45,1073.18,percent of total billed charges,
Feeding Tube Cecostomy 20cm,8126623,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1301.96000,377.57000,Aetna,First Health,,1065.00,,,,,,,469.36,1065.00,percent of total billed charges,
Feeding Tube Cecostomy 20cm,8126623,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1301.96000,377.57000,Aetna,First Health,,1065.00,,,,,,,419.23,1065.00,percent of total billed charges,
Chest Tube Thoracic Vent,8126817,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1352.00000,392.08000,Aetna,First Health,,1105.94,,,,,,,487.40,1105.94,percent of total billed charges,
Chest Tube Thoracic Vent,8126817,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1352.00000,392.08000,Aetna,First Health,,1105.94,,,,,,,435.34,1105.94,percent of total billed charges,
Embolization Particles 300 to 500,8126617,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,485.06,1100.64,percent of total billed charges,
Embolization Particles 300 to 500,8126617,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,433.26,1100.64,percent of total billed charges,
Embolization Particles 500 to 700,8126619,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,485.06,1100.64,percent of total billed charges,
Embolization Particles 500 to 700,8126619,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,433.26,1100.64,percent of total billed charges,
Embolization Particles 700 to 900,8126621,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,485.06,1100.64,percent of total billed charges,
Embolization Particles 700 to 900,8126621,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,433.26,1100.64,percent of total billed charges,
Embolization Particles 100 to 300,8126615,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,485.06,1100.64,percent of total billed charges,
Embolization Particles 100 to 300,8126615,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,First Health,,1100.64,,,,,,,433.26,1100.64,percent of total billed charges,
Central Line Tunneled P 6F,8126815,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1444.00000,418.76000,Aetna,First Health,,1181.19,,,,,,,520.56,1181.19,percent of total billed charges,
Central Line Tunneled P 6F,8126815,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1444.00000,418.76000,Aetna,First Health,,1181.19,,,,,,,464.97,1181.19,percent of total billed charges,
Guidewire Fathom,8126669,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1740.00000,504.60000,Aetna,First Health,,1423.32,,,,,,,627.27,1423.32,percent of total billed charges,
Guidewire Fathom,8126669,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1740.00000,504.60000,Aetna,First Health,,1423.32,,,,,,,560.28,1423.32,percent of total billed charges,
Sheath PA 12F x 11cm,8126769,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,122.87000,35.63000,Aetna,First Health,,100.51,,,,,,,44.29,100.51,percent of total billed charges,
Sheath PA 12F x 11cm,8126769,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,122.87000,35.63000,Aetna,First Health,,100.51,,,,,,,39.56,100.51,percent of total billed charges,
Snare A 35mm,8126785,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
Snare A 35mm,8126785,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
Snare A 10mm,8126781,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
Snare A 10mm,8126781,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,483.00,1227.00,percent of total billed charges,
Snare Ensnare,8126789,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,First Health,,1201.64,,,,,,,529.57,1201.64,percent of total billed charges,
Snare Ensnare,8126789,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,First Health,,1201.64,,,,,,,473.02,1201.64,percent of total billed charges,
Transponder Implants,8126733,CDM,278,RC,A4648,HCPCS,,,facility,inpatient,,,2224.00000,644.96000,Aetna,First Health,,1819.23,,,,,,,801.75,1819.23,percent of total billed charges,
Transponder Implants,8126733,CDM,278,RC,A4648,HCPCS,,,facility,outpatient,,,2224.00000,644.96000,Aetna,First Health,,1819.23,,,,,,,716.13,1819.23,percent of total billed charges,
Catheter R 135cm,8126428,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,987.77,2241.32,percent of total billed charges,
Catheter R 135cm,8126428,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,882.28,2241.32,percent of total billed charges,
Catheter R 115cm,8126426,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,987.77,2241.32,percent of total billed charges,
Catheter R 115cm,8126426,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,First Health,,2241.32,,,,,,,882.28,2241.32,percent of total billed charges,
Kyphoplasty HV Cement,8126729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3806.69000,1103.94000,Aetna,First Health,,3113.87,,,,,,,1372.31,3113.87,percent of total billed charges,
Kyphoplasty HV Cement,8126729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3806.69000,1103.94000,Aetna,First Health,,3113.87,,,,,,,1225.75,3113.87,percent of total billed charges,
Stent W 8 x 40cm,8126518,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3960.25000,1148.47000,Aetna,First Health,,3239.48,,,,,,,1427.67,3239.48,percent of total billed charges,
Stent W 8 x 40cm,8126518,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3960.25000,1148.47000,Aetna,First Health,,3239.48,,,,,,,1275.20,3239.48,percent of total billed charges,
Stent W 10 x 68cm,8126502,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4707.99000,1365.32000,Aetna,First Health,,3851.14,,,,,,,1697.23,3851.14,percent of total billed charges,
Stent W 10 x 68cm,8126502,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4707.99000,1365.32000,Aetna,First Health,,3851.14,,,,,,,1515.97,3851.14,percent of total billed charges,
Filter UT,8126649,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5100.20000,1479.06000,Aetna,First Health,,4171.96,,,,,,,1838.62,4171.96,percent of total billed charges,
Filter UT,8126649,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5100.20000,1479.06000,Aetna,First Health,,4171.96,,,,,,,1642.26,4171.96,percent of total billed charges,
Stent W Uncovered 10 x 60cm,8126496,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2329.43,5285.65,percent of total billed charges,
Stent W Uncovered 10 x 60cm,8126496,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2080.66,5285.65,percent of total billed charges,
Stent W Uncovered 10 x 80cm,8126498,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2329.43,5285.65,percent of total billed charges,
Stent W Uncovered 10 x 80cm,8126498,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,First Health,,5285.65,,,,,,,2080.66,5285.65,percent of total billed charges,
Stent W Full Covered 10 x 80cm,8126486,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3414.53,7747.82,percent of total billed charges,
Stent W Full Covered 10 x 80cm,8126486,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3049.87,7747.82,percent of total billed charges,
Stent W Full Covered 10 x 60cm,8126484,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3414.53,7747.82,percent of total billed charges,
Stent W Full Covered 10 x 60cm,8126484,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3049.87,7747.82,percent of total billed charges,
Stent Wallfex Part Covered 10 x 60cm,8126492,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9262.38000,2686.09000,Aetna,First Health,,7576.63,,,,,,,3339.09,7576.63,percent of total billed charges,
Stent Wallfex Part Covered 10 x 60cm,8126492,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9262.38000,2686.09000,Aetna,First Health,,7576.63,,,,,,,2982.49,7576.63,percent of total billed charges,
Stent W Part Covered 10 x 80cm,8126488,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9262.38000,2686.09000,Aetna,First Health,,7576.63,,,,,,,3339.09,7576.63,percent of total billed charges,
Stent W Part Covered 10 x 80cm,8126488,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9262.38000,2686.09000,Aetna,First Health,,7576.63,,,,,,,2982.49,7576.63,percent of total billed charges,
Stent W Full Covered 10 x 40cm,8126482,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3414.53,7747.82,percent of total billed charges,
Stent W Full Covered 10 x 40cm,8126482,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,First Health,,7747.82,,,,,,,3049.87,7747.82,percent of total billed charges,
Stent V 6 x 2 x 75cm,8126809,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18667.50000,5413.58000,Aetna,First Health,,15270.01,,,,,,,6729.63,15270.01,percent of total billed charges,
Stent V 6 x 2 x 75cm,8126809,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18667.50000,5413.58000,Aetna,First Health,,15270.01,,,,,,,6010.94,15270.01,percent of total billed charges,
Stent V 8 x 2 x 75cm,8126811,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17740.00000,5144.60000,Aetna,First Health,,14511.32,,,,,,,6395.27,14511.32,percent of total billed charges,
Stent V 8 x 2 x 75cm,8126811,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17740.00000,5144.60000,Aetna,First Health,,14511.32,,,,,,,5712.28,14511.32,percent of total billed charges,
Central Line G 8F,8126460,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,981.00000,284.49000,Aetna,First Health,,802.46,,,,,,,353.65,802.46,percent of total billed charges,
Central Line G 8F,8126460,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,981.00000,284.49000,Aetna,First Health,,802.46,,,,,,,315.88,802.46,percent of total billed charges,
Central Line Groshong,8126462,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,First Health,,1194.28,,,,,,,526.33,1194.28,percent of total billed charges,
Central Line Groshong,8126462,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,First Health,,1194.28,,,,,,,470.12,1194.28,percent of total billed charges,
Guidewire NS,8442312,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,549.41000,159.33000,Aetna,First Health,,449.42,,,,,,,198.06,449.42,percent of total billed charges,
Guidewire NS,8442312,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,549.41000,159.33000,Aetna,First Health,,449.42,,,,,,,176.91,449.42,percent of total billed charges,
Introducer CT,8442315,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,136.45000,39.57000,Aetna,First Health,,111.62,,,,,,,49.19,111.62,percent of total billed charges,
Introducer CT,8442315,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,136.45000,39.57000,Aetna,First Health,,111.62,,,,,,,43.94,111.62,percent of total billed charges,
Guidewire Glide 0 point18 x 150cm,8647979,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,140.41,318.61,percent of total billed charges,
Guidewire Glide 0 point18 x 150cm,8647979,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,First Health,,318.61,,,,,,,125.42,318.61,percent of total billed charges,
Sheath V 6Fr x 4cm,8982449,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,175.88000,51.01000,Aetna,First Health,,143.87,,,,,,,63.40,143.87,percent of total billed charges,
Sheath V 6Fr x 4cm,8982449,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,175.88000,51.01000,Aetna,First Health,,143.87,,,,,,,56.63,143.87,percent of total billed charges,
Introducer Micropuncture S,8981676,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,191.36000,55.49000,Aetna,First Health,,156.53,,,,,,,68.99,156.53,percent of total billed charges,
Introducer Micropuncture S,8981676,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,191.36000,55.49000,Aetna,First Health,,156.53,,,,,,,61.62,156.53,percent of total billed charges,
Catheter Q 65cm,8982187,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1252.00000,363.08000,Aetna,First Health,,1024.14,,,,,,,451.35,1024.14,percent of total billed charges,
Catheter Q 65cm,8982187,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1252.00000,363.08000,Aetna,First Health,,1024.14,,,,,,,403.14,1024.14,percent of total billed charges,
Catheter Q 90cm,8981433,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1252.00000,363.08000,Aetna,First Health,,1024.14,,,,,,,451.35,1024.14,percent of total billed charges,
Catheter Q 90cm,8981433,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1252.00000,363.08000,Aetna,First Health,,1024.14,,,,,,,403.14,1024.14,percent of total billed charges,
Catheter Q 135cm,8982185,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1252.00000,363.08000,Aetna,First Health,,1024.14,,,,,,,451.35,1024.14,percent of total billed charges,
Catheter Q 135cm,8982185,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1252.00000,363.08000,Aetna,First Health,,1024.14,,,,,,,403.14,1024.14,percent of total billed charges,
Embo Coil PH 4mm x 20cm,8982267,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embo Coil PH 4mm x 20cm,8982267,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Embo Coil Prestige Complex 4mm x 35cm,8981505,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil Prestige Complex 4mm x 35cm,8981505,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embo Coil PH 4mm x 40cm,8981521,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil PH 4mm x 40cm,8981521,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embo Coil Prestige Complex 5mm x 17cm,8981507,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embo Coil Prestige Complex 5mm x 17cm,8981507,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Embo Coil Prestige Complex 5mm x 40cm,8981509,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil Prestige Complex 5mm x 40cm,8981509,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embo Coil PH 5mm x 40cm,8982269,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil PH 5mm x 40cm,8982269,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embo Coil PC 6mm x 20cm,8981511,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embo Coil PC 6mm x 20cm,8981511,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Embo Coil PC 6mm x 35cm,8982243,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil PC 6mm x 35cm,8982243,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil PC 6mm x 50cm,8982245,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil PC 6mm x 50cm,8982245,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PH 6mm x 50cm,8981523,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil PH 6mm x 50cm,8981523,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embo Coil PC 7mm x 20cm,8982247,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embo Coil PC 7mm x 20cm,8982247,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Embo Coil PC 7mm x 50cm,8981513,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil PC 7mm x 50cm,8981513,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PH 7mm x 50cm,8982271,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil PH 7mm x 50cm,8982271,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embo Coil PC 8mm x 45cm,8982249,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil PC 8mm x 45cm,8982249,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embo Coil PC 8mm x 65cm,8981515,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil PC 8mm x 65cm,8981515,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PH 8mm x 65cm,8982275,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil PH 8mm x 65cm,8982275,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PC 9mm x 30cm,8981517,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil PC 9mm x 30cm,8981517,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil PC 9mm x 65cm,8982251,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil PC 9mm x 65cm,8982251,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PC 10mm x 45cm,8982209,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil PC 10mm x 45cm,8982209,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embolization Coil PC 10mmx45cm,8982211,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embolization Coil PC 10mmx45cm,8982211,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PH 10mm x 65cm,8982261,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil PH 10mm x 65cm,8982261,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PC 12mm x 45cm,8981485,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil PC 12mm x 45cm,8981485,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embolization Coil PC 12mmx65cm,8981487,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embolization Coil PC 12mmx65cm,8981487,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PC 14mm x 45cm,8982217,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil PC 14mm x 45cm,8982217,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embo Coil Prestige Complex 14mm x 65cm,8982219,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil Prestige Complex 14mm x 65cm,8982219,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PC 16mm x 65cm,8981491,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil PC 16mm x 65cm,8981491,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PC 18mm x 65cm,8981495,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil PC 18mm x 65cm,8981495,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PC 20mm x 65cm,8982225,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil PC 20mm x 65cm,8982225,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil PC 22mm x 65cm,8981497,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil PC 22mm x 65cm,8981497,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embo Coil Prestige Complex 24mm x 65cm,8981501,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embo Coil Prestige Complex 24mm x 65cm,8981501,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embolization Coil,9005469,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embolization Coil,9005469,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Embolization Coil,9005473,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embolization Coil,9005473,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Embolization Coil,9006815,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embolization Coil,9006815,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Transjugular 19G,9005542,CDM,278,RC,A4215,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
Transjugular 19G,9005542,CDM,278,RC,A4215,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,0.14445,2257.68,percent of total billed charges,
Transjugular 18G,9005544,CDM,278,RC,A4215,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
Transjugular 18G,9005544,CDM,278,RC,A4215,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,0.14445,2257.68,percent of total billed charges,
Drain 16F,9005567,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,647.24000,187.70000,Aetna,First Health,,529.44,,,,,,,233.33,529.44,percent of total billed charges,
Drain 16F,9005567,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,647.24000,187.70000,Aetna,First Health,,529.44,,,,,,,208.41,529.44,percent of total billed charges,
Catheter M 5Frx80cm,8981431,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.97000,28.41000,Aetna,First Health,,80.14,,,,,,,35.32,80.14,percent of total billed charges,
Catheter M 5Frx80cm,8981431,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.97000,28.41000,Aetna,First Health,,80.14,,,,,,,31.55,80.14,percent of total billed charges,
Catheter O 5Frx65cm,8982183,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,176.72000,51.25000,Aetna,First Health,,144.56,,,,,,,63.71,144.56,percent of total billed charges,
Catheter O 5Frx65cm,8982183,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,176.72000,51.25000,Aetna,First Health,,144.56,,,,,,,56.90,144.56,percent of total billed charges,
Catheter JB1 5Fr x 65cm,8982181,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,128.73000,37.33000,Aetna,First Health,,105.30,,,,,,,46.41,105.30,percent of total billed charges,
Catheter JB1 5Fr x 65cm,8982181,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,128.73000,37.33000,Aetna,First Health,,105.30,,,,,,,41.45,105.30,percent of total billed charges,
Catheter J 5Frx100,8982179,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,297.35000,86.23000,Aetna,First Health,,243.23,,,,,,,107.19,243.23,percent of total billed charges,
Catheter J 5Frx100,8982179,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,297.35000,86.23000,Aetna,First Health,,243.23,,,,,,,95.75,243.23,percent of total billed charges,
Embolization Coil,9006833,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embolization Coil,9006833,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil PC 4mm x 13cm,8982239,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embo Coil PC 4mm x 13cm,8982239,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Embo Coil PH 8mm x 30cm,8982273,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil PH 8mm x 30cm,8982273,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Stent PDP 8Fr x 28cm,8981706,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
Stent PDP 8Fr x 28cm,8981706,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
Guidewire 0 035 x 75cm,8981652,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
Guidewire 0 035 x 75cm,8981652,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
Sheath DS 1 point 25mm,8981435,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12435.00000,3606.15000,Aetna,First Health,,10171.83,,,,,,,4482.82,10171.83,percent of total billed charges,
Sheath DS 1 point 25mm,8981435,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12435.00000,3606.15000,Aetna,First Health,,10171.83,,,,,,,4004.07,10171.83,percent of total billed charges,
Guidewire VF Tip 0 point 018 x 335cm,8981658,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,720.00000,208.80000,Aetna,First Health,,588.96,,,,,,,259.56,588.96,percent of total billed charges,
Guidewire VF Tip 0 point 018 x 335cm,8981658,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,720.00000,208.80000,Aetna,First Health,,588.96,,,,,,,231.84,588.96,percent of total billed charges,
Sheath FB 6Fr x 40cm,8982428,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,463.74000,134.48000,Aetna,First Health,,379.34,,,,,,,167.18,379.34,percent of total billed charges,
Sheath FB 6Fr x 40cm,8982428,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,463.74000,134.48000,Aetna,First Health,,379.34,,,,,,,149.32,379.34,percent of total billed charges,
Sheath FB 8Fr x 40cm,8982431,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,463.74000,134.48000,Aetna,First Health,,379.34,,,,,,,167.18,379.34,percent of total billed charges,
Sheath FB 8Fr x 40cm,8982431,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,463.74000,134.48000,Aetna,First Health,,379.34,,,,,,,149.32,379.34,percent of total billed charges,
Sheath Ch 14Fr x 45cm,8981682,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,856.94000,248.51000,Aetna,First Health,,700.98,,,,,,,308.93,700.98,percent of total billed charges,
Sheath Ch 14Fr x 45cm,8981682,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,856.94000,248.51000,Aetna,First Health,,700.98,,,,,,,275.93,700.98,percent of total billed charges,
Catheter A 5Frx65cm,8981417,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,54.89,124.54,percent of total billed charges,
Catheter A 5Frx65cm,8981417,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,First Health,,124.54,,,,,,,49.02,124.54,percent of total billed charges,
Catheter B 5Frx100cm,8982170,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,89.25000,25.88000,Aetna,First Health,,73.01,,,,,,,32.17,73.01,percent of total billed charges,
Catheter B 5Frx100cm,8982170,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,89.25000,25.88000,Aetna,First Health,,73.01,,,,,,,28.74,73.01,percent of total billed charges,
Drain Biliary R 10Fr,8982189,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,422.75000,122.60000,Aetna,First Health,,345.81,,,,,,,152.40,345.81,percent of total billed charges,
Drain Biliary R 10Fr,8982189,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,422.75000,122.60000,Aetna,First Health,,345.81,,,,,,,136.13,345.81,percent of total billed charges,
Drain Biliary R 12Fr,8981437,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,422.75000,122.60000,Aetna,First Health,,345.81,,,,,,,152.40,345.81,percent of total billed charges,
Drain Biliary R 12Fr,8981437,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,422.75000,122.60000,Aetna,First Health,,345.81,,,,,,,136.13,345.81,percent of total billed charges,
Drain Biliary R 14Fr,8981439,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,422.75000,122.60000,Aetna,First Health,,345.81,,,,,,,152.40,345.81,percent of total billed charges,
Drain Biliary R 14Fr,8981439,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,422.75000,122.60000,Aetna,First Health,,345.81,,,,,,,136.13,345.81,percent of total billed charges,
Drain Biliary R 8Fr,8981441,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,422.75000,122.60000,Aetna,First Health,,345.81,,,,,,,152.40,345.81,percent of total billed charges,
Drain Biliary R 8Fr,8981441,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,422.75000,122.60000,Aetna,First Health,,345.81,,,,,,,136.13,345.81,percent of total billed charges,
Sheath D 8Fr x 45cm,8981688,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
Sheath D 8Fr x 45cm,8981688,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
Sheath D 8Fr x 65cm,8981690,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,663.75000,192.49000,Aetna,First Health,,542.95,,,,,,,239.28,542.95,percent of total billed charges,
Sheath D 8Fr x 65cm,8981690,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,663.75000,192.49000,Aetna,First Health,,542.95,,,,,,,213.73,542.95,percent of total billed charges,
Sheath D 8Fr x 90cm,8981692,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
Sheath D 8Fr x 90cm,8981692,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
Stent Biliary VH 10mm x 6cm,8981704,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
Stent Biliary VH 10mm x 6cm,8981704,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
Stent Biliary VH 10mm x 8cm,8982455,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12045.00000,3493.05000,Aetna,First Health,,9852.81,,,,,,,4342.22,9852.81,percent of total billed charges,
Stent Biliary VH 10mm x 8cm,8982455,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12045.00000,3493.05000,Aetna,First Health,,9852.81,,,,,,,3878.49,9852.81,percent of total billed charges,
Stent Biliary VNH 10mm x 6cm,8982453,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4596.38,10429.50,percent of total billed charges,
Stent Biliary VNH 10mm x 6cm,8982453,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,First Health,,10429.50,,,,,,,4105.50,10429.50,percent of total billed charges,
Stent Biliary VNH 10mm x 8cm,8982457,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12960.00000,3758.40000,Aetna,First Health,,10601.28,,,,,,,4672.08,10601.28,percent of total billed charges,
Stent Biliary VNH 10mm x 8cm,8982457,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12960.00000,3758.40000,Aetna,First Health,,10601.28,,,,,,,4173.12,10601.28,percent of total billed charges,
Embo Coil RCSD 3mm x 5cm,8981618,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil RCSD 3mm x 5cm,8981618,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil RCSD 3mm x 12cm,8981614,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil RCSD 3mm x 12cm,8981614,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil RCSD 3mm x 20cm,8981616,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil RCSD 3mm x 20cm,8981616,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil RCSD 4mm x 10cm,8982399,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil RCSD 4mm x 10cm,8982399,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil RCSD 4mm x 20cm,8981622,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil RCSD 4mm x 20cm,8981622,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil RCSD 4mm x 35cm,8981624,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 4mm x 35cm,8981624,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil Ruby Complex Std 5mm x 12cm,8981626,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil Ruby Complex Std 5mm x 12cm,8981626,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil RCSD 5mm x 30cm,8982401,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 5mm x 30cm,8982401,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCSD 6mm x 20cm,8982403,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil RCSD 6mm x 20cm,8982403,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil RCSD 6mm x 30cm,8982405,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 6mm x 30cm,8982405,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
EMBO COIL,8981628,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
EMBO COIL,8981628,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil RCSD 8mm x 25cm,8981630,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil RCSD 8mm x 25cm,8981630,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil RCSD 8mm x 40cm,8981632,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 8mm x 40cm,8981632,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCSD 10mm x 35cm,8981600,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 10mm x 35cm,8981600,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCSD 12mm x 60cm,8981602,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 12mm x 60cm,8981602,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCSD 14mm x 60cm,8981604,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 14mm x 60cm,8981604,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCSD 16mm x 60cm,8982393,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 16mm x 60cm,8982393,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCSD 18mm x 60cm,8982395,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 18mm x 60cm,8982395,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCSD 20mm x 60cm,8981606,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil RCSD 20mm x 60cm,8981606,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil P 5cm,8982197,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil P 5cm,8982197,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil P 60cm,8981451,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil P 60cm,8981451,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCSD 28mm x 60cm,8981610,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 28mm x 60cm,8981610,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil Ruby Complex Std 32mm x 60cm,8981612,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil Ruby Complex Std 32mm x 60cm,8981612,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCSD 36mm x 60cm,8982397,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 36mm x 60cm,8982397,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCSD 40mm x 60cm,8981620,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 40mm x 60cm,8981620,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCS 2mm x 1cm,8981586,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil RCS 2mm x 1cm,8981586,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil RCS 2mm x 2cm,8981588,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil RCS 2mm x 2cm,8981588,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil RCS 2mm x 4cm,8982385,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil RCS 2mm x 4cm,8982385,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil RCS 3mm x 5cm,8981592,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil RCS 3mm x 5cm,8981592,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil RCS 3mm x 15cm,8981590,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil RCS 3mm x 15cm,8981590,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil RCS 4mm x 6cm,8981596,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil RCS 4mm x 6cm,8981596,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil Ruby Complex Soft 4mm x 15cm,8981594,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil Ruby Complex Soft 4mm x 15cm,8981594,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil RCS 6mm x 20cm,8981598,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil RCS 6mm x 20cm,8981598,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil RCS 6mm x 30cm,8982387,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCS 6mm x 30cm,8982387,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil Ruby Complex Soft 8mm x 35cm,8982389,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil Ruby Complex Soft 8mm x 35cm,8982389,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCS 8mm x 60cm,8982391,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCS 8mm x 60cm,8982391,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil Ruby Complex RCS 16MM X 50CM,8981573,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil Ruby Complex RCS 16MM X 50CM,8981573,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil RCS 20mm x 60cm,8981580,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCS 20mm x 60cm,8981580,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embolization Coil PD 8 10mm x 60cm,8982283,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2416.25,5482.65,percent of total billed charges,
Embolization Coil PD 8 10mm x 60cm,8982283,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2158.20,5482.65,percent of total billed charges,
Embolization Coil PD 10 to 12mm x 60cm,8981525,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2416.25,5482.65,percent of total billed charges,
Embolization Coil PD 10 to 12mm x 60cm,8981525,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2158.20,5482.65,percent of total billed charges,
Embolization Coil PD 12 to14mm x 60cm,8981527,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2416.25,5482.65,percent of total billed charges,
Embolization Coil PD 12 to14mm x 60cm,8981527,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2158.20,5482.65,percent of total billed charges,
Embolization Coil PD 3 x 20cm,8981529,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2416.25,5482.65,percent of total billed charges,
Embolization Coil PD 3 x 20cm,8981529,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2158.20,5482.65,percent of total billed charges,
Embolization Coil PD 3 25 4mm x 30cm,8982277,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2416.25,5482.65,percent of total billed charges,
Embolization Coil PD 3 25 4mm x 30cm,8982277,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2158.20,5482.65,percent of total billed charges,
Embolization Coil PD 4 5mm x 30cm,8982279,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2416.25,5482.65,percent of total billed charges,
Embolization Coil PD 4 5mm x 30cm,8982279,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2158.20,5482.65,percent of total billed charges,
Embolization Coil PD 5 6mm x 50cm,8982281,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2416.25,5482.65,percent of total billed charges,
Embolization Coil PD 5 6mm x 50cm,8982281,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2158.20,5482.65,percent of total billed charges,
Embolization Coil PD 6 to 8mm x 60cm,8981531,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2416.25,5482.65,percent of total billed charges,
Embolization Coil PD 6 to 8mm x 60cm,8981531,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,First Health,,5482.65,,,,,,,2158.20,5482.65,percent of total billed charges,
Embo Coil P 15cm,8982193,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil P 15cm,8982193,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil P30cm,8981449,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil P30cm,8981449,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embo Coil P 45cm,8982195,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil P 45cm,8982195,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Separator L200CM,8982422,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
Separator L200CM,8982422,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
Balloon M 5x40 135cm,8982159,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 5x40 135cm,8982159,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 6x20mm 135cm,8981401,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 6x20mm 135cm,8981401,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 6x20mm 75cm,8981403,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 6x20mm 75cm,8981403,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 6x40mm 75cm,8981405,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 6x40mm 75cm,8981405,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 6x100mm 75cm,8981399,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 6x100mm 75cm,8981399,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 7x20mm 75cm,8981407,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 7x20mm 75cm,8981407,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 7x40mm 135cm,8982161,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 7x40mm 135cm,8982161,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 7x40mm 75cm,8981409,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 7x40mm 75cm,8981409,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 7x80mm 75cm,8982163,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 7x80mm 75cm,8982163,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 8x20mm 75cm,8981411,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 8x20mm 75cm,8981411,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 8x40 135cm,8981413,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 8x40 135cm,8981413,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 8x40mm 75cm,8982166,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 8x40mm 75cm,8982166,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 9x40mm 75cm,8981415,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 9x40mm 75cm,8981415,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 10x20mm 75cm,8982155,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 10x20mm 75cm,8982155,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Ballloon M 10x40mm 135cm,8981393,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Ballloon M 10x40mm 135cm,8981393,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 10x40mm 75CM,8981395,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 10x40mm 75CM,8981395,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 12x40mm 75cm,8981397,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 12x40mm 75cm,8981397,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Stent VSEA 100 x 10mm,8981708,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
Stent VSEA 100 x 10mm,8981708,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
Stent VSEA  60 x 12mm,8981718,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
Stent VSEA  60 x 12mm,8981718,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
Stent VSEA 100 x 12mm,8981710,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
Stent VSEA 100 x 12mm,8981710,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
Stent VSEA 150 x 12mm,8981716,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,3001.16,6809.85,percent of total billed charges,
Stent VSEA 150 x 12mm,8981716,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,2680.65,6809.85,percent of total billed charges,
Stent VSEA 60 x 14mm,8982465,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
Stent VSEA 60 x 14mm,8982465,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
Stent VSEA 120 x 14mm,8981712,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
Stent VSEA 120 x 14mm,8981712,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
Stent VSEA 150 x 14mm,8982461,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,3001.16,6809.85,percent of total billed charges,
Stent VSEA 150 x 14mm,8982461,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,First Health,,6809.85,,,,,,,2680.65,6809.85,percent of total billed charges,
Stent VSEA 180 x 16mm,8982463,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
Stent VSEA 180 x 16mm,8982463,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
Stent VSEA 120 x 16mm,8982459,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
Stent VSEA 120 x 16mm,8982459,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
Stent VSEA 80 x 20mm,8982467,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
Stent VSEA 80 x 20mm,8982467,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
Stent VSEA 120 x 20mm,8981714,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2784.86,6319.05,percent of total billed charges,
Stent VSEA 120 x 20mm,8981714,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,First Health,,6319.05,,,,,,,2487.45,6319.05,percent of total billed charges,
Sheath PA 18Fr,8982434,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,325.33000,94.35000,Aetna,First Health,,266.12,,,,,,,117.28,266.12,percent of total billed charges,
Sheath PA 18Fr,8982434,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,325.33000,94.35000,Aetna,First Health,,266.12,,,,,,,104.76,266.12,percent of total billed charges,
Introducer Micropuncture 5Fr,8981674,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,316.78000,91.87000,Aetna,First Health,,259.13,,,,,,,114.20,259.13,percent of total billed charges,
Introducer Micropuncture 5Fr,8981674,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,316.78000,91.87000,Aetna,First Health,,259.13,,,,,,,102.00,259.13,percent of total billed charges,
Balloon M 4x20mm 135cm,8982157,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 4x20mm 135cm,8982157,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Catheter I 140cm,8982413,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
Catheter I 140cm,8982413,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
catheter 6fr,9057624,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2757.82,6257.70,percent of total billed charges,
catheter 6fr,9057624,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,First Health,,6257.70,,,,,,,2463.30,6257.70,percent of total billed charges,
Separator I 200cm,8982420,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
Separator I 200cm,8982420,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
Sperator 4,9060678,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1324.84,3006.15,percent of total billed charges,
Sperator 4,9060678,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,First Health,,3006.15,,,,,,,1183.35,3006.15,percent of total billed charges,
Separator I 150cm,8981672,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2752.42,6245.43,percent of total billed charges,
Separator I 150cm,8981672,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,First Health,,6245.43,,,,,,,2458.47,6245.43,percent of total billed charges,
Catheter I 12Fr 100cm XTORQ,8982411,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,21225.00000,6155.25000,Aetna,First Health,,17362.05,,,,,,,7651.61,17362.05,percent of total billed charges,
Catheter I 12Fr 100cm XTORQ,8982411,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,21225.00000,6155.25000,Aetna,First Health,,17362.05,,,,,,,6834.45,17362.05,percent of total billed charges,
Catheter I 12Fr 115cm HTORQ,8981660,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,21225.00000,6155.25000,Aetna,First Health,,17362.05,,,,,,,7651.61,17362.05,percent of total billed charges,
Catheter I 12Fr 115cm HTORQ,8981660,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,21225.00000,6155.25000,Aetna,First Health,,17362.05,,,,,,,6834.45,17362.05,percent of total billed charges,
Catheter I 8Fr 115cm XTORQ,8981662,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,18725.00000,5430.25000,Aetna,First Health,,15317.05,,,,,,,6750.36,15317.05,percent of total billed charges,
Catheter I 8Fr 115cm XTORQ,8981662,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,18725.00000,5430.25000,Aetna,First Health,,15317.05,,,,,,,6029.45,15317.05,percent of total billed charges,
Guidewire NS 0 018 x 60cm,8981656,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.71000,107.51000,Aetna,First Health,,303.24,,,,,,,133.64,303.24,percent of total billed charges,
Guidewire NS 0 018 x 60cm,8981656,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.71000,107.51000,Aetna,First Health,,303.24,,,,,,,119.37,303.24,percent of total billed charges,
Guidewire NA 0 018 x 60cm,8981654,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.71000,107.51000,Aetna,First Health,,303.24,,,,,,,133.64,303.24,percent of total billed charges,
Guidewire NA 0 018 x 60cm,8981654,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.71000,107.51000,Aetna,First Health,,303.24,,,,,,,119.37,303.24,percent of total billed charges,
Drain 18F,9005569,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,647.24000,187.70000,Aetna,First Health,,529.44,,,,,,,233.33,529.44,percent of total billed charges,
Drain 18F,9005569,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,647.24000,187.70000,Aetna,First Health,,529.44,,,,,,,208.41,529.44,percent of total billed charges,
Drain 16F,9006729,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,513.24000,148.84000,Aetna,First Health,,419.83,,,,,,,185.02,419.83,percent of total billed charges,
Drain 16F,9006729,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,513.24000,148.84000,Aetna,First Health,,419.83,,,,,,,165.26,419.83,percent of total billed charges,
Drain 18F,9006731,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.76000,188.43000,Aetna,First Health,,531.50,,,,,,,234.24,531.50,percent of total billed charges,
Drain 18F,9006731,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.76000,188.43000,Aetna,First Health,,531.50,,,,,,,209.22,531.50,percent of total billed charges,
Drain 20F,9006733,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.76000,188.43000,Aetna,First Health,,531.50,,,,,,,234.24,531.50,percent of total billed charges,
Drain 20F,9006733,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.76000,188.43000,Aetna,First Health,,531.50,,,,,,,209.22,531.50,percent of total billed charges,
catheter 150cm,9021389,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,488.12,1107.57,percent of total billed charges,
catheter 150cm,9021389,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,435.99,1107.57,percent of total billed charges,
catheter 150cm,9024294,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,488.12,1107.57,percent of total billed charges,
catheter 150cm,9024294,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,435.99,1107.57,percent of total billed charges,
Guidewire 150cm,9021274,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,206.03,467.49,percent of total billed charges,
Guidewire 150cm,9021274,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,184.02,467.49,percent of total billed charges,
Guidewire 300cm,9024215,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,206.03,467.49,percent of total billed charges,
Guidewire 300cm,9024215,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,First Health,,467.49,,,,,,,184.02,467.49,percent of total billed charges,
stent,9021310,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
stent,9021310,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
stent,9021312,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
stent,9021312,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
Stent,9021314,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
Stent,9021314,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
stent,9021320,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
stent,9021320,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
stent,9021324,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
stent,9021324,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
Guidewire 300cm,9021270,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,283.89,644.17,percent of total billed charges,
Guidewire 300cm,9021270,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,First Health,,644.17,,,,,,,253.57,644.17,percent of total billed charges,
Guidewire 300cm,9024211,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
Guidewire 300cm,9024211,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
Guidewire 300cm,9021266,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
Guidewire 300cm,9021266,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
Guidewire 300cm,9021272,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,308.23,699.39,percent of total billed charges,
Guidewire 300cm,9021272,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,First Health,,699.39,,,,,,,275.31,699.39,percent of total billed charges,
Guidewire 300cm,9021268,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2412.00000,699.48000,Aetna,First Health,,1973.02,,,,,,,869.53,1973.02,percent of total billed charges,
Guidewire 300cm,9021268,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2412.00000,699.48000,Aetna,First Health,,1973.02,,,,,,,776.66,1973.02,percent of total billed charges,
Guidewire 300cm,9024217,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,201.16,456.44,percent of total billed charges,
Guidewire 300cm,9024217,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,179.68,456.44,percent of total billed charges,
Sheath 6F,9005475,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
Sheath 6F,9005475,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
Sheath 8F,9005477,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,172.95,392.44,percent of total billed charges,
Sheath 8F,9005477,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,First Health,,392.44,,,,,,,154.48,392.44,percent of total billed charges,
Sheath 10F,9005471,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,First Health,,407.20,,,,,,,179.46,407.20,percent of total billed charges,
Sheath 10F,9005471,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,First Health,,407.20,,,,,,,160.29,407.20,percent of total billed charges,
Snare 2mm,9021304,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
Snare 2mm,9021304,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
Snare 7mm,9021306,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
Snare 7mm,9021306,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
Sheath 22F,9006817,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,325.33000,94.35000,Aetna,First Health,,266.12,,,,,,,117.28,266.12,percent of total billed charges,
Sheath 22F,9006817,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,325.33000,94.35000,Aetna,First Health,,266.12,,,,,,,104.76,266.12,percent of total billed charges,
Sheath 12F,9005465,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,355.59000,103.12000,Aetna,First Health,,290.87,,,,,,,128.19,290.87,percent of total billed charges,
Sheath 12F,9005465,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,355.59000,103.12000,Aetna,First Health,,290.87,,,,,,,114.50,290.87,percent of total billed charges,
Stent 8F,9006715,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,716.18000,207.69000,Aetna,First Health,,585.84,,,,,,,258.18,585.84,percent of total billed charges,
Stent 8F,9006715,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,716.18000,207.69000,Aetna,First Health,,585.84,,,,,,,230.61,585.84,percent of total billed charges,
Stent 8F,9006713,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,753.71000,218.58000,Aetna,First Health,,616.53,,,,,,,271.71,616.53,percent of total billed charges,
Stent 8F,9006713,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,753.71000,218.58000,Aetna,First Health,,616.53,,,,,,,242.69,616.53,percent of total billed charges,
Stent 8F,9005387,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,716.18000,207.69000,Aetna,First Health,,585.84,,,,,,,258.18,585.84,percent of total billed charges,
Stent 8F,9005387,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,716.18000,207.69000,Aetna,First Health,,585.84,,,,,,,230.61,585.84,percent of total billed charges,
Stent 8F,9005379,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,906.71000,262.95000,Aetna,First Health,,741.69,,,,,,,326.87,741.69,percent of total billed charges,
Stent 8F,9005379,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,906.71000,262.95000,Aetna,First Health,,741.69,,,,,,,291.96,741.69,percent of total billed charges,
Stent 8F,9006711,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,834.48000,242.00000,Aetna,First Health,,682.60,,,,,,,300.83,682.60,percent of total billed charges,
Stent 8F,9006711,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,834.48000,242.00000,Aetna,First Health,,682.60,,,,,,,268.70,682.60,percent of total billed charges,
Stent 8F,9005373,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,834.48000,242.00000,Aetna,First Health,,682.60,,,,,,,300.83,682.60,percent of total billed charges,
Stent 8F,9005373,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,834.48000,242.00000,Aetna,First Health,,682.60,,,,,,,268.70,682.60,percent of total billed charges,
Catheter CVSL,9005395,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1364.00000,395.56000,Aetna,First Health,,1115.75,,,,,,,491.72,1115.75,percent of total billed charges,
Catheter CVSL,9005395,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1364.00000,395.56000,Aetna,First Health,,1115.75,,,,,,,439.21,1115.75,percent of total billed charges,
Sheath 24F,9006837,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,325.33000,94.35000,Aetna,First Health,,266.12,,,,,,,117.28,266.12,percent of total billed charges,
Sheath 24F,9006837,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,325.33000,94.35000,Aetna,First Health,,266.12,,,,,,,104.76,266.12,percent of total billed charges,
Introducer 4F,9021288,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,191.36000,55.49000,Aetna,First Health,,156.53,,,,,,,68.99,156.53,percent of total billed charges,
Introducer 4F,9021288,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,191.36000,55.49000,Aetna,First Health,,156.53,,,,,,,61.62,156.53,percent of total billed charges,
Introducer,9021279,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,145.55,330.27,percent of total billed charges,
Introducer,9021279,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,First Health,,330.27,,,,,,,130.01,330.27,percent of total billed charges,
Drain R 8 point 5Fr,8981447,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,410.02000,118.91000,Aetna,First Health,,335.40,,,,,,,147.81,335.40,percent of total billed charges,
Drain R 8 point 5Fr,8981447,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,410.02000,118.91000,Aetna,First Health,,335.40,,,,,,,132.03,335.40,percent of total billed charges,
Catheter,9072200,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
Catheter,9072200,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
Sheath P 6Fr x 10cm RO II,8981696,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,178.50000,51.76000,Aetna,First Health,,146.01,,,,,,,64.35,146.01,percent of total billed charges,
Sheath P 6Fr x 10cm RO II,8981696,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,178.50000,51.76000,Aetna,First Health,,146.01,,,,,,,57.48,146.01,percent of total billed charges,
Sheath P 6Fr x 25cm RO II,8981698,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,220.50000,63.94000,Aetna,First Health,,180.37,,,,,,,79.49,180.37,percent of total billed charges,
Sheath P 6Fr x 25cm RO II,8981698,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,220.50000,63.94000,Aetna,First Health,,180.37,,,,,,,71.00,180.37,percent of total billed charges,
Sheath P 7Fr x 10cm,8982442,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,86.63000,25.12000,Aetna,First Health,,70.86,,,,,,,31.23,70.86,percent of total billed charges,
Sheath P 7Fr x 10cm,8982442,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,86.63000,25.12000,Aetna,First Health,,70.86,,,,,,,27.89,70.86,percent of total billed charges,
Sheath P 8Fr x 10cm,8981700,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,86.63000,25.12000,Aetna,First Health,,70.86,,,,,,,31.23,70.86,percent of total billed charges,
Sheath P 8Fr x 10cm,8981700,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,86.63000,25.12000,Aetna,First Health,,70.86,,,,,,,27.89,70.86,percent of total billed charges,
Sheath P 8Fr x 25cm,8982445,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
Sheath P 8Fr x 25cm,8982445,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
Sheath P 9Fr x 10cm,8982447,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,86.63000,25.12000,Aetna,First Health,,70.86,,,,,,,31.23,70.86,percent of total billed charges,
Sheath P 9Fr x 10cm,8982447,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,86.63000,25.12000,Aetna,First Health,,70.86,,,,,,,27.89,70.86,percent of total billed charges,
Sheath P 10Fr x 10cm,8982437,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,86.63000,25.12000,Aetna,First Health,,70.86,,,,,,,31.23,70.86,percent of total billed charges,
Sheath P 10Fr x 10cm,8982437,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,86.63000,25.12000,Aetna,First Health,,70.86,,,,,,,27.89,70.86,percent of total billed charges,
Sheath P 10Fr x 25cm,8981694,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
Sheath P 10Fr x 25cm,8981694,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
Tramsponders BC,8982168,CDM,278,RC,,,,,facility,inpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,735.42,1668.72,percent of total billed charges,
Tramsponders BC,8982168,CDM,278,RC,,,,,facility,outpatient,,,2040.00000,591.60000,Aetna,First Health,,1668.72,,,,,,,656.88,1668.72,percent of total billed charges,
Dialysis 15cm,9005548,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,1297.00000,376.13000,Aetna,First Health,,1060.95,,,,,,,467.57,1060.95,percent of total billed charges,
Dialysis 15cm,9005548,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,1297.00000,376.13000,Aetna,First Health,,1060.95,,,,,,,417.63,1060.95,percent of total billed charges,
Dialysis 20cm,9006872,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,1297.00000,376.13000,Aetna,First Health,,1060.95,,,,,,,467.57,1060.95,percent of total billed charges,
Dialysis 20cm,9006872,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,1297.00000,376.13000,Aetna,First Health,,1060.95,,,,,,,417.63,1060.95,percent of total billed charges,
Dialysis 24cm,9006870,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,1297.00000,376.13000,Aetna,First Health,,1060.95,,,,,,,467.57,1060.95,percent of total billed charges,
Dialysis 24cm,9006870,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,1297.00000,376.13000,Aetna,First Health,,1060.95,,,,,,,417.63,1060.95,percent of total billed charges,
Dialysis 30cm,9005546,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,1297.00000,376.13000,Aetna,First Health,,1060.95,,,,,,,467.57,1060.95,percent of total billed charges,
Dialysis 30cm,9005546,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,1297.00000,376.13000,Aetna,First Health,,1060.95,,,,,,,417.63,1060.95,percent of total billed charges,
stent,9021333,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9735.00000,2823.15000,Aetna,First Health,,7963.23,,,,,,,3509.47,7963.23,percent of total billed charges,
stent,9021333,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9735.00000,2823.15000,Aetna,First Health,,7963.23,,,,,,,3134.67,7963.23,percent of total billed charges,
Stent,9021328,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
Stent,9021328,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
stent,9021335,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9735.00000,2823.15000,Aetna,First Health,,7963.23,,,,,,,3509.47,7963.23,percent of total billed charges,
stent,9021335,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9735.00000,2823.15000,Aetna,First Health,,7963.23,,,,,,,3134.67,7963.23,percent of total billed charges,
Stent,9024254,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
Stent,9024254,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
Embolization Coil,9005461,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embolization Coil,9005461,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embo Coil PC 11mm x 37cm,8982213,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embo Coil PC 11mm x 37cm,8982213,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embo Coil PC 12mm x 40cm,8982215,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil PC 12mm x 40cm,8982215,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embolization Coil,9021258,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1734.91,3936.62,percent of total billed charges,
Embolization Coil,9021258,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,First Health,,3936.62,,,,,,,1549.62,3936.62,percent of total billed charges,
Embolization Coil,9024207,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embolization Coil,9024207,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Balloon,9072202,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon,9072202,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon,9068355,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon,9068355,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon,9068357,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon,9068357,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon,9068359,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon,9068359,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Catheter 5fr,8126436,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,88.20000,25.58000,Aetna,First Health,,72.15,,,,,,,31.80,72.15,percent of total billed charges,
Catheter 5fr,8126436,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,88.20000,25.58000,Aetna,First Health,,72.15,,,,,,,28.40,72.15,percent of total billed charges,
Catheter 5fr,8126438,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,88.20000,25.58000,Aetna,First Health,,72.15,,,,,,,31.80,72.15,percent of total billed charges,
Catheter 5fr,8126438,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,88.20000,25.58000,Aetna,First Health,,72.15,,,,,,,28.40,72.15,percent of total billed charges,
Embo Coil PC 1mm x 3cm,9082493,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil PC 1mm x 3cm,9082493,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Sheath Ch 16fr x 13cm,9080603,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,731.21000,212.05000,Aetna,First Health,,598.13,,,,,,,263.60,598.13,percent of total billed charges,
Sheath Ch 16fr x 13cm,9080603,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,731.21000,212.05000,Aetna,First Health,,598.13,,,,,,,235.45,598.13,percent of total billed charges,
catheter 5F,9021383,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,171.24,388.55,percent of total billed charges,
catheter 5F,9021383,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,First Health,,388.55,,,,,,,152.95,388.55,percent of total billed charges,
Closure Device,9005565,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,346.76,786.82,percent of total billed charges,
Closure Device,9005565,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,First Health,,786.82,,,,,,,309.73,786.82,percent of total billed charges,
Guidewire 75cm,9005371,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
Guidewire 75cm,9005371,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
Stent 8Fr,9057656,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
Stent 8Fr,9057656,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
Guidewire Amplatz,9060712,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
Guidewire Amplatz,9060712,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
Stent H,9057634,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
Stent H,9057634,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
Catheter 90cm,9060718,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,297.35000,86.23000,Aetna,First Health,,243.23,,,,,,,107.19,243.23,percent of total billed charges,
Catheter 90cm,9060718,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,297.35000,86.23000,Aetna,First Health,,243.23,,,,,,,95.75,243.23,percent of total billed charges,
cactheter 16fr,9057626,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,10301.29,23374.35,percent of total billed charges,
cactheter 16fr,9057626,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,9201.15,23374.35,percent of total billed charges,
Stent V,9057628,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9735.00000,2823.15000,Aetna,First Health,,7963.23,,,,,,,3509.47,7963.23,percent of total billed charges,
Stent V,9057628,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9735.00000,2823.15000,Aetna,First Health,,7963.23,,,,,,,3134.67,7963.23,percent of total billed charges,
Stent V,9057630,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9735.00000,2823.15000,Aetna,First Health,,7963.23,,,,,,,3509.47,7963.23,percent of total billed charges,
Stent V,9057630,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9735.00000,2823.15000,Aetna,First Health,,7963.23,,,,,,,3134.67,7963.23,percent of total billed charges,
Viabahn Stent,9060684,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
Viabahn Stent,9060684,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
Bone Cement,9057644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.84000,487.15000,Aetna,First Health,,1374.11,,,,,,,605.58,1374.11,percent of total billed charges,
Bone Cement,9057644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.84000,487.15000,Aetna,First Health,,1374.11,,,,,,,540.91,1374.11,percent of total billed charges,
Spine Needle,9057646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15850.50000,4596.64000,Aetna,First Health,,12965.71,,,,,,,5714.11,12965.71,percent of total billed charges,
Spine Needle,9057646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15850.50000,4596.64000,Aetna,First Health,,12965.71,,,,,,,5103.86,12965.71,percent of total billed charges,
Snare,9057658,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
Snare,9057658,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
Snare,9057660,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
Snare,9057660,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,875.84,2224.96,percent of total billed charges,
Snare,9060708,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,807.52,1832.32,percent of total billed charges,
Snare,9060708,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,First Health,,1832.32,,,,,,,721.28,1832.32,percent of total billed charges,
catheter 150cm,9057664,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,488.12,1107.57,percent of total billed charges,
catheter 150cm,9057664,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,435.99,1107.57,percent of total billed charges,
catheter 90cm,9057666,CDM,278,RC,C1877,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,488.12,1107.57,percent of total billed charges,
catheter 90cm,9057666,CDM,278,RC,C1877,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,First Health,,1107.57,,,,,,,435.99,1107.57,percent of total billed charges,
Guidewire Amplatz,9060714,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,106.17,240.90,percent of total billed charges,
Guidewire Amplatz,9060714,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,First Health,,240.90,,,,,,,94.83,240.90,percent of total billed charges,
Guidewire Bentson,9057668,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,148.68000,43.12000,Aetna,First Health,,121.62,,,,,,,53.60,121.62,percent of total billed charges,
Guidewire Bentson,9057668,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,148.68000,43.12000,Aetna,First Health,,121.62,,,,,,,47.87,121.62,percent of total billed charges,
Guidewire Glide,9060716,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1294.00000,375.26000,Aetna,First Health,,1058.49,,,,,,,466.49,1058.49,percent of total billed charges,
Guidewire Glide,9060716,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1294.00000,375.26000,Aetna,First Health,,1058.49,,,,,,,416.67,1058.49,percent of total billed charges,
Guidewire Glide,9057670,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,1122.30,percent of total billed charges,
Guidewire Glide,9057670,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,441.78,1122.30,percent of total billed charges,
Guidewire Rosen,9057672,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,103.79000,30.10000,Aetna,First Health,,84.90,,,,,,,37.42,84.90,percent of total billed charges,
Guidewire Rosen,9057672,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,103.79000,30.10000,Aetna,First Health,,84.90,,,,,,,33.42,84.90,percent of total billed charges,
Guidewire Guide,9057674,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1608.00000,466.32000,Aetna,First Health,,1315.34,,,,,,,579.68,1315.34,percent of total billed charges,
Guidewire Guide,9057674,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1608.00000,466.32000,Aetna,First Health,,1315.34,,,,,,,517.78,1315.34,percent of total billed charges,
Guidewire Guide,9057676,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1682.00000,487.78000,Aetna,First Health,,1375.88,,,,,,,606.36,1375.88,percent of total billed charges,
Guidewire Guide,9057676,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1682.00000,487.78000,Aetna,First Health,,1375.88,,,,,,,541.60,1375.88,percent of total billed charges,
Guidewire Sportacore,9057678,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,201.16,456.44,percent of total billed charges,
Guidewire Sportacore,9057678,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,First Health,,456.44,,,,,,,179.68,456.44,percent of total billed charges,
catheter 6fr,9057680,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,156.96,356.15,percent of total billed charges,
catheter 6fr,9057680,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,First Health,,356.15,,,,,,,140.20,356.15,percent of total billed charges,
Embolization Coil,9006808,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embolization Coil,9006808,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Catheter 130 cm,9005412,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,First Health,,2296.94,,,,,,,1012.28,2296.94,percent of total billed charges,
Catheter 130 cm,9005412,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,First Health,,2296.94,,,,,,,904.18,2296.94,percent of total billed charges,
Catheter 150 cm,9006759,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,First Health,,2296.94,,,,,,,1012.28,2296.94,percent of total billed charges,
Catheter 150 cm,9006759,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,First Health,,2296.94,,,,,,,904.18,2296.94,percent of total billed charges,
catheter 5F,9021375,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,219.00,496.94,percent of total billed charges,
catheter 5F,9021375,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,First Health,,496.94,,,,,,,195.62,496.94,percent of total billed charges,
catheter 5F,9024306,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1768.00000,512.72000,Aetna,First Health,,1446.22,,,,,,,637.36,1446.22,percent of total billed charges,
catheter 5F,9024306,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1768.00000,512.72000,Aetna,First Health,,1446.22,,,,,,,569.30,1446.22,percent of total billed charges,
Catheter 5F,9024308,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,444.86,1009.41,percent of total billed charges,
Catheter 5F,9024308,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,397.35,1009.41,percent of total billed charges,
catheter 5F,9024310,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,444.86,1009.41,percent of total billed charges,
catheter 5F,9024310,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,397.35,1009.41,percent of total billed charges,
catheter 5F,9024304,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,444.86,1009.41,percent of total billed charges,
catheter 5F,9024304,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,397.35,1009.41,percent of total billed charges,
Catheter 5F,9005377,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,444.86,1009.41,percent of total billed charges,
Catheter 5F,9005377,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,397.35,1009.41,percent of total billed charges,
Catheter 5F,9005375,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,444.86,1009.41,percent of total billed charges,
Catheter 5F,9005375,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,First Health,,1009.41,,,,,,,397.35,1009.41,percent of total billed charges,
Sheath 12F,9005631,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,461.42000,133.81000,Aetna,First Health,,377.44,,,,,,,166.34,377.44,percent of total billed charges,
Sheath 12F,9005631,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,461.42000,133.81000,Aetna,First Health,,377.44,,,,,,,148.58,377.44,percent of total billed charges,
Catheter 5F 70 cm,9006642,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1508.00000,437.32000,Aetna,First Health,,1233.54,,,,,,,543.63,1233.54,percent of total billed charges,
Catheter 5F 70 cm,9006642,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1508.00000,437.32000,Aetna,First Health,,1233.54,,,,,,,485.58,1233.54,percent of total billed charges,
Catheter 5F 70 cm,9005297,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,439.85000,127.56000,Aetna,First Health,,359.80,,,,,,,158.57,359.80,percent of total billed charges,
Catheter 5F 70 cm,9005297,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,439.85000,127.56000,Aetna,First Health,,359.80,,,,,,,141.63,359.80,percent of total billed charges,
Catheter Pigtail 5Fr x 90cm:Catheter Pigtail 5Fr x 90cm,9005393,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,176.72000,51.25000,Aetna,First Health,,144.56,,,,,,,63.71,144.56,percent of total billed charges,
Catheter Pigtail 5Fr x 90cm:Catheter Pigtail 5Fr x 90cm,9005393,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,176.72000,51.25000,Aetna,First Health,,144.56,,,,,,,56.90,144.56,percent of total billed charges,
Catheter 130 cm,9005414,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1667.20000,483.49000,Aetna,First Health,,1363.77,,,,,,,601.03,1363.77,percent of total billed charges,
Catheter 130 cm,9005414,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1667.20000,483.49000,Aetna,First Health,,1363.77,,,,,,,536.84,1363.77,percent of total billed charges,
Sheath 10F,9005467,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,461.42000,133.81000,Aetna,First Health,,377.44,,,,,,,166.34,377.44,percent of total billed charges,
Sheath 10F,9005467,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,461.42000,133.81000,Aetna,First Health,,377.44,,,,,,,148.58,377.44,percent of total billed charges,
Guidewire 200cm,9024213,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1740.00000,504.60000,Aetna,First Health,,1423.32,,,,,,,627.27,1423.32,percent of total billed charges,
Guidewire 200cm,9024213,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1740.00000,504.60000,Aetna,First Health,,1423.32,,,,,,,560.28,1423.32,percent of total billed charges,
Stent 8F,9005385,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
Stent 8F,9005385,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
Stent 8F,9005383,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
Stent 8F,9005383,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
Stent 8F,9005381,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,296.87,673.62,percent of total billed charges,
Stent 8F,9005381,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,First Health,,673.62,,,,,,,265.17,673.62,percent of total billed charges,
Stent 8F,9006717,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
Stent 8F,9006717,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
Stent 8F,9005391,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
Stent 8F,9005391,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
Stent 8F,9005389,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
Stent 8F,9005389,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,234.74,596.32,percent of total billed charges,
Balloon 15 mm,9005633,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9689.58000,2809.98000,Aetna,First Health,,7926.08,,,,,,,3493.09,7926.08,percent of total billed charges,
Balloon 15 mm,9005633,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9689.58000,2809.98000,Aetna,First Health,,7926.08,,,,,,,3120.04,7926.08,percent of total billed charges,
Balloon 20 mm,9005635,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9689.58000,2809.98000,Aetna,First Health,,7926.08,,,,,,,3493.09,7926.08,percent of total billed charges,
Balloon 20 mm,9005635,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9689.58000,2809.98000,Aetna,First Health,,7926.08,,,,,,,3120.04,7926.08,percent of total billed charges,
Guidewire 260 cm,9006896,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,114.73,260.33,percent of total billed charges,
Guidewire 260 cm,9006896,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,First Health,,260.33,,,,,,,102.48,260.33,percent of total billed charges,
Drain 5F,9024269,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,81.38,184.66,percent of total billed charges,
Drain 5F,9024269,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,First Health,,184.66,,,,,,,72.69,184.66,percent of total billed charges,
catheter 130cm,9024292,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1667.20000,483.49000,Aetna,First Health,,1363.77,,,,,,,601.03,1363.77,percent of total billed charges,
catheter 130cm,9024292,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1667.20000,483.49000,Aetna,First Health,,1363.77,,,,,,,536.84,1363.77,percent of total billed charges,
catheter 130cm,9021385,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1667.20000,483.49000,Aetna,First Health,,1363.77,,,,,,,601.03,1363.77,percent of total billed charges,
catheter 130cm,9021385,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1667.20000,483.49000,Aetna,First Health,,1363.77,,,,,,,536.84,1363.77,percent of total billed charges,
stent,9021326,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
stent,9021326,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
Sheath 7F,9021302,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
Sheath 7F,9021302,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,50.72,128.84,percent of total billed charges,
Sheath 5F,9021300,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,86.63000,25.12000,Aetna,First Health,,70.86,,,,,,,31.23,70.86,percent of total billed charges,
Sheath 5F,9021300,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,86.63000,25.12000,Aetna,First Health,,70.86,,,,,,,27.89,70.86,percent of total billed charges,
Balloon AXT,9005295,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,227.12,515.34,percent of total billed charges,
Balloon AXT,9005295,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,First Health,,515.34,,,,,,,202.86,515.34,percent of total billed charges,
Balloon 7F,9024288,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon 7F,9024288,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon 6F,9021367,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon 6F,9021367,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon 5F,9024285,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon 5F,9024285,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon 4F,9021365,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon 4F,9021365,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Stent 8F,9006679,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 8F,9006679,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 8F,9006677,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 8F,9006677,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 8F,9005323,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 8F,9005323,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 7F,9006671,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 7F,9006671,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 7F,9005321,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 7F,9005321,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 7F,9006669,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 7F,9006669,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 6F,9005319,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 6F,9005319,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 8F,9006667,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 8F,9006667,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 8F,9005317,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 8F,9005317,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 8F,9005315,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 8F,9005315,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 9F,9005313,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 9F,9005313,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 7F,9006665,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 7F,9006665,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 7F,9006663,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 7F,9006663,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 7F,9006661,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 7F,9006661,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Stent 9F,9005311,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
Stent 9F,9005311,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,689.08,1750.52,percent of total billed charges,
Port,9060844,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,713.79,1619.64,percent of total billed charges,
Port,9060844,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,First Health,,1619.64,,,,,,,637.56,1619.64,percent of total billed charges,
Sheath Intro Dryseal 16frx33cm,9076761,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,First Health,,2545.62,,,,,,,1121.88,2545.62,percent of total billed charges,
Sheath Intro Dryseal 16frx33cm,9076761,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,First Health,,2545.62,,,,,,,1002.06,2545.62,percent of total billed charges,
Glidesheath Slender SS 6frx10cm,9078785,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,137.85,312.79,percent of total billed charges,
Glidesheath Slender SS 6frx10cm,9078785,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,First Health,,312.79,,,,,,,123.13,312.79,percent of total billed charges,
Embo Coil PC 11mm x 45cm,9080605,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embo Coil PC 11mm x 45cm,9080605,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Balloon M 10x80x75,9082505,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 10x80x75,9082505,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon M 12x80mm 75cm,9082507,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon M 12x80mm 75cm,9082507,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Catheter I 16fr HTORQ,9082509,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,10301.29,23374.35,percent of total billed charges,
Catheter I 16fr HTORQ,9082509,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,9201.15,23374.35,percent of total billed charges,
Catheter I 16fr HTORQ,9082511,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,10301.29,23374.35,percent of total billed charges,
Catheter I 16fr HTORQ,9082511,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,9201.15,23374.35,percent of total billed charges,
Kyphoplasty Cement,9080725,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4078.45000,1182.75000,Aetna,First Health,,3336.17,,,,,,,1470.28,3336.17,percent of total billed charges,
Kyphoplasty Cement,9080725,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4078.45000,1182.75000,Aetna,First Health,,3336.17,,,,,,,1313.26,3336.17,percent of total billed charges,
Sheath 11fr,9082608,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,30.28,68.71,percent of total billed charges,
Sheath 11fr,9082608,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,27.05,68.71,percent of total billed charges,
Sheath 6fr 45cm,9082610,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
Sheath 6fr 45cm,9082610,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
Sheath 6fr 45cm Rdc,9080761,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
Sheath 6fr 45cm Rdc,9080761,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
Sheath 6fr 65cm Str,9082612,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,663.75000,192.49000,Aetna,First Health,,542.95,,,,,,,239.28,542.95,percent of total billed charges,
Sheath 6fr 65cm Str,9082612,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,663.75000,192.49000,Aetna,First Health,,542.95,,,,,,,213.73,542.95,percent of total billed charges,
Sheath 6fr 90cm Str,9080763,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,257.94,585.28,percent of total billed charges,
Sheath 6fr 90cm Str,9080763,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,First Health,,585.28,,,,,,,230.39,585.28,percent of total billed charges,
Sheath 7fr 45cm,9080765,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,220.63,500.62,percent of total billed charges,
Sheath 7fr 45cm,9080765,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,First Health,,500.62,,,,,,,197.06,500.62,percent of total billed charges,
Sheath 12fr,9082614,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,490.20000,142.16000,Aetna,First Health,,400.98,,,,,,,176.72,400.98,percent of total billed charges,
Sheath 12fr,9082614,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,490.20000,142.16000,Aetna,First Health,,400.98,,,,,,,157.84,400.98,percent of total billed charges,
Sheath 16fr long,9082616,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,726.53000,210.69000,Aetna,First Health,,594.30,,,,,,,261.91,594.30,percent of total billed charges,
Sheath 16fr long,9082616,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,726.53000,210.69000,Aetna,First Health,,594.30,,,,,,,233.94,594.30,percent of total billed charges,
Sheath 5fr,9091681,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,30.28,68.71,percent of total billed charges,
Sheath 5fr,9091681,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,27.05,68.71,percent of total billed charges,
Catheter 6fr,9092643,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,879.62,1995.92,percent of total billed charges,
Catheter 6fr,9092643,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,First Health,,1995.92,,,,,,,785.68,1995.92,percent of total billed charges,
Catheter 5fr,9091685,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,83.28,188.96,percent of total billed charges,
Catheter 5fr,9091685,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,74.38,188.96,percent of total billed charges,
Balloon Kit,9092884,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,3300.01,7487.96,percent of total billed charges,
Balloon Kit,9092884,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,First Health,,7487.96,,,,,,,2947.58,7487.96,percent of total billed charges,
Introducer,9094448,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,220.50000,63.94000,Aetna,First Health,,180.37,,,,,,,79.49,180.37,percent of total billed charges,
Introducer,9094448,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,220.50000,63.94000,Aetna,First Health,,180.37,,,,,,,71.00,180.37,percent of total billed charges,
Balloon 75cm,9092886,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon 75cm,9092886,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Nephroureteral Stent,9093110,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,719.51000,208.66000,Aetna,First Health,,588.56,,,,,,,259.38,588.56,percent of total billed charges,
Nephroureteral Stent,9093110,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,719.51000,208.66000,Aetna,First Health,,588.56,,,,,,,231.68,588.56,percent of total billed charges,
Nephroureteral Stent,9094741,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,762.71000,221.19000,Aetna,First Health,,623.90,,,,,,,274.96,623.90,percent of total billed charges,
Nephroureteral Stent,9094741,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,762.71000,221.19000,Aetna,First Health,,623.90,,,,,,,245.59,623.90,percent of total billed charges,
Micropuncture 4Fr,9095032,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,61.51,139.58,percent of total billed charges,
Micropuncture 4Fr,9095032,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,First Health,,139.58,,,,,,,54.94,139.58,percent of total billed charges,
Catheter 5fr,9093367,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
Catheter 5fr,9093367,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
Catheter 5Fr,9093369,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
Catheter 5Fr,9093369,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
Catheter 6Fr,9093371,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
Catheter 6Fr,9093371,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
Catheter 6Fr,9095034,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
Catheter 6Fr,9095034,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
Catheter 5Fr,9095036,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
Catheter 5Fr,9095036,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
Catheter 6Fr,9093373,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
Catheter 6Fr,9093373,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
Catheter 6Fr,9093375,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
Catheter 6Fr,9093375,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
Catheter 100cm,9109954,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,58.67,133.13,percent of total billed charges,
Catheter 100cm,9109954,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,First Health,,133.13,,,,,,,52.41,133.13,percent of total billed charges,
Thrombectomy Supplies,9114554,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,31612.00000,9167.48000,Aetna,First Health,,25858.62,,,,,,,11396.13,25858.62,percent of total billed charges,
Thrombectomy Supplies,9114554,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,31612.00000,9167.48000,Aetna,First Health,,25858.62,,,,,,,10179.06,25858.62,percent of total billed charges,
Balloon,9116448,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon,9116448,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Balloon,9114758,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,519.12,1177.92,percent of total billed charges,
Balloon,9114758,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,First Health,,1177.92,,,,,,,463.68,1177.92,percent of total billed charges,
Catheter,9114754,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,7480.38,16973.50,percent of total billed charges,
Catheter,9114754,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,6681.50,16973.50,percent of total billed charges,
Catheter,9116446,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,7480.38,16973.50,percent of total billed charges,
Catheter,9116446,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,6681.50,16973.50,percent of total billed charges,
Line 4Fr,9150394,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,684.00000,198.36000,Aetna,First Health,,559.51,,,,,,,246.58,559.51,percent of total billed charges,
Line 4Fr,9150394,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,684.00000,198.36000,Aetna,First Health,,559.51,,,,,,,220.25,559.51,percent of total billed charges,
Line 5Fr,9150396,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,319.58,725.16,percent of total billed charges,
Line 5Fr,9150396,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,First Health,,725.16,,,,,,,285.45,725.16,percent of total billed charges,
Line 5Fr,9145005,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,447.02,1014.32,percent of total billed charges,
Line 5Fr,9145005,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,First Health,,1014.32,,,,,,,399.28,1014.32,percent of total billed charges,
Kyphoplasty S 5 point 8mm,8981680,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13832.88000,4011.54000,Aetna,First Health,,11315.30,,,,,,,4986.75,11315.30,percent of total billed charges,
Kyphoplasty S 5 point 8mm,8981680,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13832.88000,4011.54000,Aetna,First Health,,11315.30,,,,,,,4454.19,11315.30,percent of total billed charges,
Kyphoplasty S 5 0mm,8981678,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13832.88000,4011.54000,Aetna,First Health,,11315.30,,,,,,,4986.75,11315.30,percent of total billed charges,
Kyphoplasty S 5 0mm,8981678,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13832.88000,4011.54000,Aetna,First Health,,11315.30,,,,,,,4454.19,11315.30,percent of total billed charges,
Kyphoplasty S 4 2mm,8982424,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13832.88000,4011.54000,Aetna,First Health,,11315.30,,,,,,,4986.75,11315.30,percent of total billed charges,
Kyphoplasty S 4 2mm,8982424,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13832.88000,4011.54000,Aetna,First Health,,11315.30,,,,,,,4454.19,11315.30,percent of total billed charges,
Embolization CoilPC 1 5mmx3cm,8982205,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embolization CoilPC 1 5mmx3cm,8982205,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil PC 1 5mm x 8cm,8982207,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil PC 1 5mm x 8cm,8982207,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil PC 2mm x 4cm,8982231,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil PC 2mm x 4cm,8982231,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil PC 2mm x 6cm,8981503,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil PC 2mm x 6cm,8981503,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil PC 2mm x 8cm,8982233,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil PC 2mm x 8cm,8982233,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embolization Coil PH 2mm x 8 cm,8982263,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embolization Coil PH 2mm x 8 cm,8982263,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil PC 3mm x 10cm,8982235,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embo Coil PC 3mm x 10cm,8982235,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Embo Coil PH 3mm x 15cm,8982265,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embo Coil PH 3mm x 15cm,8982265,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Embo Coil PC 3mm x 20cm,8982237,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embo Coil PC 3mm x 20cm,8982237,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Embo Coil Prestige Complex 4mm x 20cm,8982241,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embo Coil Prestige Complex 4mm x 20cm,8982241,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Embo Coil PC 2mm x 12cm,8982229,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1356.38,3077.72,percent of total billed charges,
Embo Coil PC 2mm x 12cm,8982229,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,First Health,,3077.72,,,,,,,1211.53,3077.72,percent of total billed charges,
Catheter 16 Fr,9021379,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,10301.29,23374.35,percent of total billed charges,
Catheter 16 Fr,9021379,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,First Health,,23374.35,,,,,,,9201.15,23374.35,percent of total billed charges,
Embolization Coil,9024205,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embolization Coil,9024205,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embo Coil RCSD 24mm x 60cm,8981608,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1861.08,4222.93,percent of total billed charges,
Embo Coil RCSD 24mm x 60cm,8981608,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,First Health,,4222.93,,,,,,,1662.33,4222.93,percent of total billed charges,
Embolization Coil,9005463,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embolization Coil,9005463,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
Embolization Coil,9006806,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1608.73,3650.32,percent of total billed charges,
Embolization Coil,9006806,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,First Health,,3650.32,,,,,,,1436.92,3650.32,percent of total billed charges,
Embolization Coil,9006831,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1230.21,2791.43,percent of total billed charges,
Embolization Coil,9006831,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,First Health,,2791.43,,,,,,,1098.83,2791.43,percent of total billed charges,
Closure Device,8947189,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,504.70,1145.20,percent of total billed charges,
Closure Device,8947189,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,450.80,1145.20,percent of total billed charges,
Closure Device,8950251,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,504.70,1145.20,percent of total billed charges,
Closure Device,8950251,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,450.80,1145.20,percent of total billed charges,
Catheter,8947191,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
Catheter,8947191,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
Catheter,8950253,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
Catheter,8950253,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
Catheter,8947193,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
Catheter,8947193,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
Microcatheter,8950255,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1838.00000,533.02000,Aetna,First Health,,1503.48,,,,,,,662.60,1503.48,percent of total billed charges,
Microcatheter,8950255,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1838.00000,533.02000,Aetna,First Health,,1503.48,,,,,,,591.84,1503.48,percent of total billed charges,
Microcatheter,8950257,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,First Health,,2296.94,,,,,,,1012.28,2296.94,percent of total billed charges,
Microcatheter,8950257,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,First Health,,2296.94,,,,,,,904.18,2296.94,percent of total billed charges,
Vena Cava Filter,8947195,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
Vena Cava Filter,8947195,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
Guidewire,8947197,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,577.47000,167.47000,Aetna,First Health,,472.37,,,,,,,208.18,472.37,percent of total billed charges,
Guidewire,8947197,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,577.47000,167.47000,Aetna,First Health,,472.37,,,,,,,185.95,472.37,percent of total billed charges,
Guidewire,8950261,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,728.10000,211.15000,Aetna,First Health,,595.59,,,,,,,262.48,595.59,percent of total billed charges,
Guidewire,8950261,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,728.10000,211.15000,Aetna,First Health,,595.59,,,,,,,234.45,595.59,percent of total billed charges,
Ablation Antenna,8982145,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,12941.10000,3752.92000,Aetna,First Health,,10585.82,,,,,,,4665.27,10585.82,percent of total billed charges,
Ablation Antenna,8982145,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,12941.10000,3752.92000,Aetna,First Health,,10585.82,,,,,,,4167.03,10585.82,percent of total billed charges,
Ablation Antenna,8982147,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,12941.10000,3752.92000,Aetna,First Health,,10585.82,,,,,,,4665.27,10585.82,percent of total billed charges,
Ablation Antenna,8982147,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,12941.10000,3752.92000,Aetna,First Health,,10585.82,,,,,,,4167.03,10585.82,percent of total billed charges,
Ablation Antenna,8981389,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,13914.45000,4035.19000,Aetna,First Health,,11382.02,,,,,,,5016.16,11382.02,percent of total billed charges,
Ablation Antenna,8981389,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,13914.45000,4035.19000,Aetna,First Health,,11382.02,,,,,,,4480.45,11382.02,percent of total billed charges,
Drain Catheter,8981443,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,410.02000,118.91000,Aetna,First Health,,335.40,,,,,,,147.81,335.40,percent of total billed charges,
Drain Catheter,8981443,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,410.02000,118.91000,Aetna,First Health,,335.40,,,,,,,132.03,335.40,percent of total billed charges,
Drain Catheter 12Fr,8982191,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,410.02000,118.91000,Aetna,First Health,,335.40,,,,,,,147.81,335.40,percent of total billed charges,
Drain Catheter 12Fr,8982191,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,410.02000,118.91000,Aetna,First Health,,335.40,,,,,,,132.03,335.40,percent of total billed charges,
Drain catheter 14Fr,8981445,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,410.02000,118.91000,Aetna,First Health,,335.40,,,,,,,147.81,335.40,percent of total billed charges,
Drain catheter 14Fr,8981445,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,410.02000,118.91000,Aetna,First Health,,335.40,,,,,,,132.03,335.40,percent of total billed charges,
Vascular G Plug 8mm,8981648,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
Vascular G Plug 8mm,8981648,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
Vascular Plug G 10mm,8981636,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
Vascular Plug G 10mm,8981636,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
Vascular G Plug 12mm,8981638,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
Vascular G Plug 12mm,8981638,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
Vascular G Plug 14mm,8981640,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
Vascular G Plug 14mm,8981640,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
Vascular G Plug 16mm,8981642,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
Vascular G Plug 16mm,8981642,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
Vascular G Plug 18mm,8981644,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
Vascular G Plug 18mm,8981644,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
Vascular G Plug 20mm,8982407,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
Vascular G Plug 20mm,8982407,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
Vascular G Plug 22mm,8981646,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1632.70,3704.72,percent of total billed charges,
Vascular G Plug 22mm,8981646,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,First Health,,3704.72,,,,,,,1458.34,3704.72,percent of total billed charges,
Stent,8982469,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18667.50000,5413.58000,Aetna,First Health,,15270.01,,,,,,,6729.63,15270.01,percent of total billed charges,
Stent,8982469,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18667.50000,5413.58000,Aetna,First Health,,15270.01,,,,,,,6010.94,15270.01,percent of total billed charges,
Stent,8982471,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,19530.00000,5663.70000,Aetna,First Health,,15975.54,,,,,,,7040.56,15975.54,percent of total billed charges,
Stent,8982471,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,19530.00000,5663.70000,Aetna,First Health,,15975.54,,,,,,,6288.66,15975.54,percent of total billed charges,
Stent,8982473,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18667.50000,5413.58000,Aetna,First Health,,15270.01,,,,,,,6729.63,15270.01,percent of total billed charges,
Stent,8982473,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18667.50000,5413.58000,Aetna,First Health,,15270.01,,,,,,,6010.94,15270.01,percent of total billed charges,
Stent,8981720,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,19235.00000,5578.15000,Aetna,First Health,,15734.23,,,,,,,6934.22,15734.23,percent of total billed charges,
Stent,8981720,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,19235.00000,5578.15000,Aetna,First Health,,15734.23,,,,,,,6193.67,15734.23,percent of total billed charges,
Stent,8982475,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17740.00000,5144.60000,Aetna,First Health,,14511.32,,,,,,,6395.27,14511.32,percent of total billed charges,
Stent,8982475,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17740.00000,5144.60000,Aetna,First Health,,14511.32,,,,,,,5712.28,14511.32,percent of total billed charges,
Closure Device,8982149,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,504.70,1145.20,percent of total billed charges,
Closure Device,8982149,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,450.80,1145.20,percent of total billed charges,
Closure Device,8982151,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,504.70,1145.20,percent of total billed charges,
Closure Device,8982151,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,First Health,,1145.20,,,,,,,450.80,1145.20,percent of total billed charges,
Vena Cava Filter,8982409,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
Vena Cava Filter,8982409,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
Vena Cava Filter,8981650,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
Vena Cava Filter,8981650,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2141.30,5439.70,percent of total billed charges,
Catheter,8981427,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
Catheter,8981427,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
Catheter,8981429,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
Catheter,8981429,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
Catheter,8982177,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,759.93,1724.34,percent of total billed charges,
Catheter,8982177,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,678.78,1724.34,percent of total billed charges,
Sheath,8981684,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
Sheath,8981684,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
Catheter,8981419,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,7029.75,15951.00,percent of total billed charges,
Catheter,8981419,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,6279.00,15951.00,percent of total billed charges,
Sheath,8981686,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2974.12,6748.50,percent of total billed charges,
Sheath,8981686,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,First Health,,6748.50,,,,,,,2656.50,6748.50,percent of total billed charges,
Sheath,8982451,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,175.88000,51.01000,Aetna,First Health,,143.87,,,,,,,63.40,143.87,percent of total billed charges,
Sheath,8982451,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,175.88000,51.01000,Aetna,First Health,,143.87,,,,,,,56.63,143.87,percent of total billed charges,
Balloon,8982153,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,222.77,505.47,percent of total billed charges,
Balloon,8982153,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,198.98,505.47,percent of total billed charges,
Balloon,8981391,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,222.77,505.47,percent of total billed charges,
Balloon,8981391,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,198.98,505.47,percent of total billed charges,
Embolization Coil,9021260,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1482.56,3364.03,percent of total billed charges,
Embolization Coil,9021260,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,First Health,,3364.03,,,,,,,1324.22,3364.03,percent of total billed charges,
stent,9021308,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
stent,9021308,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
Stent,9160396,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
Stent,9160396,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
stent,9021318,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
stent,9021318,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
stent,9021322,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
stent,9021322,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
catheter radial,9021413,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
catheter radial,9021413,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
catheter radial,9021415,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,111.30,252.56,percent of total billed charges,
catheter radial,9021415,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,First Health,,252.56,,,,,,,99.42,252.56,percent of total billed charges,
stent,9024226,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
stent,9024226,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,978.88,2486.72,percent of total billed charges,
Gastrostomy Tube,9021298,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,753.71000,218.58000,Aetna,First Health,,616.53,,,,,,,271.71,616.53,percent of total billed charges,
Gastrostomy Tube,9021298,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,753.71000,218.58000,Aetna,First Health,,616.53,,,,,,,242.69,616.53,percent of total billed charges,
Gastrostomy,9060686,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,753.71000,218.58000,Aetna,First Health,,616.53,,,,,,,271.71,616.53,percent of total billed charges,
Gastrostomy,9060686,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,753.71000,218.58000,Aetna,First Health,,616.53,,,,,,,242.69,616.53,percent of total billed charges,
catheter 12F,9021371,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,7029.75,15951.00,percent of total billed charges,
catheter 12F,9021371,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,6279.00,15951.00,percent of total billed charges,
catheter 5F,9024209,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
catheter 5F,9024209,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
Cryo,9057636,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,7935.00000,2301.15000,Aetna,First Health,,6490.83,,,,,,,2860.57,6490.83,percent of total billed charges,
Cryo,9057636,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,First Health,,6490.83,,,,,,,2555.07,6490.83,percent of total billed charges,
Introducer 5F,9005540,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,780.75000,226.42000,Aetna,First Health,,638.65,,,,,,,281.46,638.65,percent of total billed charges,
Introducer 5F,9005540,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,780.75000,226.42000,Aetna,First Health,,638.65,,,,,,,251.40,638.65,percent of total billed charges,
Balloon A,9021399,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021399,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021391,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021391,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021393,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021393,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9024271,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1419.47,3220.88,percent of total billed charges,
Balloon A,9024271,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,First Health,,3220.88,,,,,,,1267.88,3220.88,percent of total billed charges,
Balloon A,9021349,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021349,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021395,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021395,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9024275,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9024275,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021397,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021397,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021341,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021341,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021343,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021343,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021345,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021345,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021347,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021347,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9024273,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9024273,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021351,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021351,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021353,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021353,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9024277,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9024277,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9024279,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9024279,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021355,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021355,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9024281,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9024281,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Balloon A,9021359,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,210.89,478.53,percent of total billed charges,
Balloon A,9021359,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,188.37,478.53,percent of total billed charges,
Introducer,9021284,CDM,278,RC,,,,,facility,inpatient,,,2456.00000,712.24000,Aetna,First Health,,2009.01,,,,,,,885.39,2009.01,percent of total billed charges,
Introducer,9021284,CDM,278,RC,,,,,facility,outpatient,,,2456.00000,712.24000,Aetna,First Health,,2009.01,,,,,,,790.83,2009.01,percent of total billed charges,
Catheter CVTL,9005397,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,591.22,1341.52,percent of total billed charges,
Catheter CVTL,9005397,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,First Health,,1341.52,,,,,,,528.08,1341.52,percent of total billed charges,
Balloon 7F,9024283,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 7F,9024283,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
Balloon 7F,9021361,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 7F,9021361,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
Balloon 8F,9021363,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 8F,9021363,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
catheter 130cm,9021387,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3477.25000,1008.40000,Aetna,First Health,,2844.39,,,,,,,1253.55,2844.39,percent of total billed charges,
catheter 130cm,9021387,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3477.25000,1008.40000,Aetna,First Health,,2844.39,,,,,,,1119.67,2844.39,percent of total billed charges,
Balloon 15cm,9021337,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,4977.00000,1443.33000,Aetna,First Health,,4071.19,,,,,,,1794.21,4071.19,percent of total billed charges,
Balloon 15cm,9021337,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,4977.00000,1443.33000,Aetna,First Health,,4071.19,,,,,,,1602.59,4071.19,percent of total billed charges,
Drain Resolve 6 5Fr,9021377,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,410.02000,118.91000,Aetna,First Health,,335.40,,,,,,,147.81,335.40,percent of total billed charges,
Drain Resolve 6 5Fr,9021377,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,410.02000,118.91000,Aetna,First Health,,335.40,,,,,,,132.03,335.40,percent of total billed charges,
Inflation Device,9021262,CDM,278,RC,,,,,facility,inpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,62.46,141.72,percent of total billed charges,
Inflation Device,9021262,CDM,278,RC,,,,,facility,outpatient,,,173.25000,50.24000,Aetna,First Health,,141.72,,,,,,,55.79,141.72,percent of total billed charges,
stent,9021330,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
stent,9021330,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
Stent V,9060682,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3947.47,8957.10,percent of total billed charges,
Stent V,9060682,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,First Health,,8957.10,,,,,,,3525.90,8957.10,percent of total billed charges,
Catheter Kit,9060680,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,10080.00000,2923.20000,Aetna,First Health,,8245.44,,,,,,,3633.84,8245.44,percent of total billed charges,
Catheter Kit,9060680,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,10080.00000,2923.20000,Aetna,First Health,,8245.44,,,,,,,3245.76,8245.44,percent of total billed charges,
Thrombectomy catheter,9024222,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,6370.00000,1847.30000,Aetna,First Health,,5210.66,,,,,,,2296.39,5210.66,percent of total billed charges,
Thrombectomy catheter,9024222,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,6370.00000,1847.30000,Aetna,First Health,,5210.66,,,,,,,2051.14,5210.66,percent of total billed charges,
Sheath V 7Fr x 4cm,8981702,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,175.88000,51.01000,Aetna,First Health,,143.87,,,,,,,63.40,143.87,percent of total billed charges,
Sheath V 7Fr x 4cm,8981702,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,175.88000,51.01000,Aetna,First Health,,143.87,,,,,,,56.63,143.87,percent of total billed charges,
Balloon 120cm,9021405,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 120cm,9021405,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
Balloon 120cm,9024300,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 120cm,9024300,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
Balloon 120cm,9021409,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
Balloon 120cm,9021409,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
Balloon 75cm,9021401,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 75cm,9021401,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
Balloon 120cm,9024296,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 120cm,9024296,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
Balloon 75cm,9024298,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 75cm,9024298,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
Balloon 120cm,9021403,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 120cm,9021403,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
Balloon 75cm,9021407,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 75cm,9021407,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
Balloon 75cm,9024302,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,547.96,1243.36,percent of total billed charges,
Balloon 75cm,9024302,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,First Health,,1243.36,,,,,,,489.44,1243.36,percent of total billed charges,
Balloon 75cm,9021411,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,555.17,1259.72,percent of total billed charges,
Balloon 75cm,9021411,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,First Health,,1259.72,,,,,,,495.88,1259.72,percent of total billed charges,
Balloon 4F,9021381,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,222.77,505.47,percent of total billed charges,
Balloon 4F,9021381,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,198.98,505.47,percent of total billed charges,
Balloon 4F,9024290,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,222.77,505.47,percent of total billed charges,
Balloon 4F,9024290,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,First Health,,505.47,,,,,,,198.98,505.47,percent of total billed charges,
Vena Cava Filter,9021264,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
Vena Cava Filter,9021264,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
catheter 125cm,9057632,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,9900.00000,2871.00000,Aetna,First Health,,8098.20,,,,,,,3568.95,8098.20,percent of total billed charges,
catheter 125cm,9057632,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,9900.00000,2871.00000,Aetna,First Health,,8098.20,,,,,,,3187.80,8098.20,percent of total billed charges,
Markers,9182905,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,332.56,754.61,percent of total billed charges,
Markers,9182905,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,First Health,,754.61,,,,,,,297.05,754.61,percent of total billed charges,
Stent 8fr,9182907,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,906.71000,262.95000,Aetna,First Health,,741.69,,,,,,,326.87,741.69,percent of total billed charges,
Stent 8fr,9182907,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,906.71000,262.95000,Aetna,First Health,,741.69,,,,,,,291.96,741.69,percent of total billed charges,
Catheter 4fr,9182909,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,131.00,297.24,percent of total billed charges,
Catheter 4fr,9182909,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,First Health,,297.24,,,,,,,117.01,297.24,percent of total billed charges,
Catheter XL,9196882,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,7480.38,16973.50,percent of total billed charges,
Catheter XL,9196882,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,First Health,,16973.50,,,,,,,6681.50,16973.50,percent of total billed charges,
Embolization,9212545,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
Embolization,9212545,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
Embolization,9210585,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
Embolization,9210585,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
Embolization,9210851,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
Embolization,9210851,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,1887.72,4795.52,percent of total billed charges,
Stent Nephroureteral 8F x 22cm,8126793,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,215.76,489.57,percent of total billed charges,
Stent Nephroureteral 8F x 22cm,8126793,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,First Health,,489.57,,,,,,,192.72,489.57,percent of total billed charges,
Transjugular RTPS 100,8126327,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2579.96000,748.19000,Aetna,First Health,,2110.41,,,,,,,930.08,2110.41,percent of total billed charges,
Transjugular RTPS 100,8126327,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2579.96000,748.19000,Aetna,First Health,,2110.41,,,,,,,830.75,2110.41,percent of total billed charges,
Guidewire GSS,8126675,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,123.29,279.76,percent of total billed charges,
Guidewire GSS,8126675,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,110.12,279.76,percent of total billed charges,
Guidewire Glide SS,8126677,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,368.13000,106.76000,Aetna,First Health,,301.13,,,,,,,132.71,301.13,percent of total billed charges,
Guidewire Glide SS,8126677,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,368.13000,106.76000,Aetna,First Health,,301.13,,,,,,,118.54,301.13,percent of total billed charges,
Venipuncture,7892200,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Venipuncture,7892200,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
Blood Drawn from Central Line Yes,7897018,CDM,300,RC,36592,HCPCS,,,facility,inpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,160.20,218.41,percent of total billed charges,
Blood Drawn from Central Line Yes,7897018,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,106.80,2860.00,percent of total billed charges,
Blood Collection From Line,7903646,CDM,300,RC,36592,HCPCS,,,facility,inpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,160.20,218.41,percent of total billed charges,
Blood Collection From Line,7903646,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,106.80,2860.00,percent of total billed charges,
Blood Draw from line,8290500,CDM,300,RC,36592,HCPCS,,,facility,inpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,160.20,218.41,percent of total billed charges,
Blood Draw from line,8290500,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,106.80,2860.00,percent of total billed charges,
Blood Draw from Line PICC or Central Line,8997131,CDM,300,RC,36592,HCPCS,,,facility,inpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,160.20,218.41,percent of total billed charges,
Blood Draw from Line PICC or Central Line,8997131,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,106.80,2860.00,percent of total billed charges,
Blood draw from line PICC or Central line,9088523,CDM,300,RC,36592,HCPCS,,,facility,inpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,160.20,218.41,percent of total billed charges,
Blood draw from line PICC or Central line,9088523,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,106.80,2860.00,percent of total billed charges,
Blood draw from line bce,9088530,CDM,300,RC,36592,HCPCS,,,facility,inpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,160.20,218.41,percent of total billed charges,
Blood draw from line bce,9088530,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,106.80,2860.00,percent of total billed charges,
Venipuncture,7957594,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Venipuncture,7957594,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
Venipuncture,8290498,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Venipuncture,8290498,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
Venipuncture,8997130,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Venipuncture,8997130,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
Venipuncture bce,9088531,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Venipuncture bce,9088531,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
Venipuncture,9120409,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Venipuncture,9120409,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
Blood collection from device Port a Cath,8290499,CDM,300,RC,36591,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Blood collection from device Port a Cath,8290499,CDM,300,RC,36591,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,4.00,2860.00,percent of total billed charges,
Blood Collection from Device Port a Cath,8997132,CDM,300,RC,36591,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Blood Collection from Device Port a Cath,8997132,CDM,300,RC,36591,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,4.00,2860.00,percent of total billed charges,
Blood Collection from Device Port a Cath,9088529,CDM,300,RC,36591,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Blood Collection from Device Port a Cath,9088529,CDM,300,RC,36591,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,4.00,2860.00,percent of total billed charges,
Blood collection from device Port a Cath,9090464,CDM,300,RC,36591,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Blood collection from device Port a Cath,9090464,CDM,300,RC,36591,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,4.00,2860.00,percent of total billed charges,
NB Metabolic Lab,7932190,CDM,300,RC,,,,,facility,inpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,179.40,244.58,percent of total billed charges,
NB Metabolic Lab,7932190,CDM,300,RC,,,,,facility,outpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,107.79,244.58,percent of total billed charges,
ER Venipuncture,602334,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
ER Venipuncture,602334,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
ER Venipuncture,7897012,CDM,300,RC,36591,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
ER Venipuncture,7897012,CDM,300,RC,36591,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,4.00,2860.00,percent of total billed charges,
Allergen Food Pistachio IgE,9142392,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Allergen Food Pistachio IgE,9142392,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,4.84,125.15,percent of total billed charges,
FINGERSTICK,636686,CDM,300,RC,36416,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
FINGERSTICK,636686,CDM,300,RC,36416,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
FINGERSTICK,638310,CDM,300,RC,36416,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
FINGERSTICK,638310,CDM,300,RC,36416,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
FINGERSTICK,638674,CDM,300,RC,36416,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
FINGERSTICK,638674,CDM,300,RC,36416,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
VENIPUNCTURE,596672,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
VENIPUNCTURE,596672,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
VENIPUNCTURE,636689,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
VENIPUNCTURE,636689,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
VENIPUNCTURE,638313,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
VENIPUNCTURE,638313,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
VENIPUNCTURE,638677,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
VENIPUNCTURE,638677,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
VENIPUNCTURE,646764,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
VENIPUNCTURE,646764,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
VENIPUNCTURE,646778,CDM,300,RC,36415,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
VENIPUNCTURE,646778,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,21.02,percent of total billed charges,
PLATELET COUNT BLOOD COUNT,596022,CDM,300,RC,85049,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
PLATELET COUNT BLOOD COUNT,596022,CDM,300,RC,85049,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,4.15,81.80,percent of total billed charges,
AUTOMATED PLATELET COUNT,8246770,CDM,300,RC,85049,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
AUTOMATED PLATELET COUNT,8246770,CDM,300,RC,85049,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,4.15,81.80,percent of total billed charges,
NASAL EOSINOPHIL,596034,CDM,300,RC,89190,HCPCS,,,facility,inpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,39.00,53.17,percent of total billed charges,
NASAL EOSINOPHIL,596034,CDM,300,RC,89190,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,5.37,53.17,percent of total billed charges,
HEPARIN INDUCED THROMBOCYTOPENIA,5831839,CDM,300,RC,86022,HCPCS,,,facility,inpatient,,,544.00000,157.76000,Aetna,First Health,,444.99,,,,,,,326.40,444.99,percent of total billed charges,
HEPARIN INDUCED THROMBOCYTOPENIA,5831839,CDM,300,RC,86022,HCPCS,,,facility,outpatient,,,544.00000,157.76000,Aetna,First Health,,444.99,,,,,,,17.03,444.99,percent of total billed charges,
OBSTETRIC PANEL,627340,CDM,300,RC,80055,HCPCS,,,facility,inpatient,,,532.00000,154.28000,Aetna,First Health,,435.18,,,,,,,319.20,435.18,percent of total billed charges,
OBSTETRIC PANEL,627340,CDM,300,RC,80055,HCPCS,,,facility,outpatient,,,532.00000,154.28000,Aetna,First Health,,435.18,,,,,,,38.90,435.18,percent of total billed charges,
BONE MARROW STAIN ONLY,636197,CDM,300,RC,88313,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,144.60,197.14,percent of total billed charges,
BONE MARROW STAIN ONLY,636197,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,53.93,353.14,percent of total billed charges,
BUFFY COAT SLIDE,596025,CDM,300,RC,85009,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
BUFFY COAT SLIDE,596025,CDM,300,RC,85009,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,4.70,94.89,percent of total billed charges,
HEMOGRAM NO DIFFERENTIAL,596023,CDM,300,RC,85027,HCPCS,,,facility,inpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,84.60,115.34,percent of total billed charges,
HEMOGRAM NO DIFFERENTIAL,596023,CDM,300,RC,85027,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,5.99,115.34,percent of total billed charges,
CBC WITH DIFFERENTIAL,594812,CDM,300,RC,85025,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
CBC WITH DIFFERENTIAL,594812,CDM,300,RC,85025,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,7.20,144.79,percent of total billed charges,
BLD SMEAR MICRO EXAM,596033,CDM,300,RC,85007,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
BLD SMEAR MICRO EXAM,596033,CDM,300,RC,85007,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,3.52,64.62,percent of total billed charges,
EOSINOPHIL COUNT,596035,CDM,300,RC,87205,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
EOSINOPHIL COUNT,596035,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,3.96,85.07,percent of total billed charges,
EOSINOPHIL COUNT,602303,CDM,300,RC,87205,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
EOSINOPHIL COUNT,602303,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,3.96,85.07,percent of total billed charges,
FETAL STAIN,614648,CDM,300,RC,85460,HCPCS,,,facility,inpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,152.40,207.77,percent of total billed charges,
FETAL STAIN,614648,CDM,300,RC,85460,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,7.17,207.77,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,596021,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,596021,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,597370,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,597370,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,7946077,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,7946077,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
HEMATOCRIT,8246794,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
HEMATOCRIT,8246794,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,8367779,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,8367779,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT OTHER,596046,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT OTHER,596046,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT OTHER,604204,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT OTHER,604204,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
CSF HEMATOCRIT,636145,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
CSF HEMATOCRIT,636145,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMOGLOBIN,596020,CDM,300,RC,85018,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
BLOOD COUNT HEMOGLOBIN,596020,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMOGLOBIN,597371,CDM,300,RC,85018,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
BLOOD COUNT HEMOGLOBIN,597371,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMOGLOBIN,7946075,CDM,300,RC,85018,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
BLOOD COUNT HEMOGLOBIN,7946075,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
HEMOGLOBIN,8246793,CDM,300,RC,85018,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
HEMOGLOBIN,8246793,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
BLOOOD COUNT HEMOGLOBIN,8367791,CDM,300,RC,85018,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
BLOOOD COUNT HEMOGLOBIN,8367791,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
THROMBIN TIME,604090,CDM,300,RC,85670,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
THROMBIN TIME,604090,CDM,300,RC,85670,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,5.35,119.43,percent of total billed charges,
WHITE BLOOD CELL COUNT,596024,CDM,300,RC,85048,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
WHITE BLOOD CELL COUNT,596024,CDM,300,RC,85048,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,2.36,73.62,percent of total billed charges,
ESR WESTERGREN SED RATE,596039,CDM,300,RC,85652,HCPCS,,,facility,inpatient,,,126.00000,36.54000,Aetna,First Health,,103.07,,,,,,,75.60,103.07,percent of total billed charges,
ESR WESTERGREN SED RATE,596039,CDM,300,RC,85652,HCPCS,,,facility,outpatient,,,126.00000,36.54000,Aetna,First Health,,103.07,,,,,,,2.50,103.07,percent of total billed charges,
FIBRIN DIMER SPLIT PRODUCTS,596406,CDM,300,RC,85378,HCPCS,,,facility,inpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,138.00,188.14,percent of total billed charges,
FIBRIN DIMER SPLIT PRODUCTS,596406,CDM,300,RC,85378,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,9.01,188.14,percent of total billed charges,
FIBRIN DIMER SPLIT PRODUCTS,658963,CDM,300,RC,85378,HCPCS,,,facility,inpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,138.00,188.14,percent of total billed charges,
FIBRIN DIMER SPLIT PRODUCTS,658963,CDM,300,RC,85378,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,9.01,188.14,percent of total billed charges,
Fibrin Dimer,8246772,CDM,300,RC,85378,HCPCS,,,facility,inpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,138.00,188.14,percent of total billed charges,
Fibrin Dimer,8246772,CDM,300,RC,85378,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,9.01,188.14,percent of total billed charges,
Fibrin Dimer Split Products,9012084,CDM,300,RC,85378,HCPCS,,,facility,inpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,138.00,188.14,percent of total billed charges,
Fibrin Dimer Split Products,9012084,CDM,300,RC,85378,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,9.01,188.14,percent of total billed charges,
PROTHROMBIN TIME,2892835,CDM,300,RC,85610,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
PROTHROMBIN TIME,2892835,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME,596412,CDM,300,RC,85610,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
PROTHROMBIN TIME,596412,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME,658920,CDM,300,RC,85610,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
PROTHROMBIN TIME,658920,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME,658961,CDM,300,RC,85610,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
PROTHROMBIN TIME,658961,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME,8246801,CDM,300,RC,85610,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
PROTHROMBIN TIME,8246801,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME,8433729,CDM,300,RC,85610,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
PROTHROMBIN TIME,8433729,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME 1 TO 1 MIX,613104,CDM,300,RC,85611,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
PROTHROMBIN TIME 1 TO 1 MIX,613104,CDM,300,RC,85611,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,3.66,81.80,percent of total billed charges,
HEPARIN ASSAY,2892836,CDM,300,RC,85520,HCPCS,,,facility,inpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,136.80,186.50,percent of total billed charges,
HEPARIN ASSAY,2892836,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,12.13,186.50,percent of total billed charges,
HEPARIN ASSAY,596407,CDM,300,RC,85520,HCPCS,,,facility,inpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,136.80,186.50,percent of total billed charges,
HEPARIN ASSAY,596407,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,12.13,186.50,percent of total billed charges,
HEPARIN ASSAY,596408,CDM,300,RC,85520,HCPCS,,,facility,inpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,136.80,186.50,percent of total billed charges,
HEPARIN ASSAY,596408,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,12.13,186.50,percent of total billed charges,
PARTIAL THROMBOPLASTIN TIME,596414,CDM,300,RC,85730,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
PARTIAL THROMBOPLASTIN TIME,596414,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,5.57,94.07,percent of total billed charges,
PARTIAL THROMBOPLASTIN TIME,658921,CDM,300,RC,85730,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
PARTIAL THROMBOPLASTIN TIME,658921,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,5.57,94.07,percent of total billed charges,
PARTIAL THROMBOPLASTIN TIME,658962,CDM,300,RC,85730,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
PARTIAL THROMBOPLASTIN TIME,658962,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,5.57,94.07,percent of total billed charges,
THROMBOPLASTIN TIME PARTIAL,8246799,CDM,300,RC,85730,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
THROMBOPLASTIN TIME PARTIAL,8246799,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,5.57,94.07,percent of total billed charges,
APTT 1 TO 1 MIX,613105,CDM,300,RC,85732,HCPCS,,,facility,inpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,79.20,107.98,percent of total billed charges,
APTT 1 TO 1 MIX,613105,CDM,300,RC,85732,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,5.99,107.98,percent of total billed charges,
IMMATURE PLT FRACTION,8170610,CDM,300,RC,85055,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
IMMATURE PLT FRACTION,8170610,CDM,300,RC,85055,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,23.12,159.51,percent of total billed charges,
COMPLETE CBC W AUTO DIFF WBC,8134949,CDM,300,RC,85025,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
COMPLETE CBC W AUTO DIFF WBC,8134949,CDM,300,RC,85025,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,7.20,144.79,percent of total billed charges,
Hematocrit Addl,8229413,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,GY,54.81,,,,,,,40.20,54.81,percent of total billed charges,
Hematocrit Addl,8229413,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,GY,54.81,,,,,,,2.19,54.81,percent of total billed charges,
Hemoglobin Addl,8229202,CDM,300,RC,85018,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,GY,54.81,,,,,,,40.20,54.81,percent of total billed charges,
Hemoglobin Addl,8229202,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,GY,54.81,,,,,,,2.19,54.81,percent of total billed charges,
CBC without Diff Addl,8229204,CDM,300,RC,85025,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,GY,144.79,,,,,,,106.20,144.79,percent of total billed charges,
CBC without Diff Addl,8229204,CDM,300,RC,85025,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,GY,144.79,,,,,,,7.20,144.79,percent of total billed charges,
Heparin Assay Addl,8229205,CDM,300,RC,85520,HCPCS,,,facility,inpatient,,,228.00000,66.12000,Aetna,First Health,GY,186.50,,,,,,,136.80,186.50,percent of total billed charges,
Heparin Assay Addl,8229205,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,First Health,GY,186.50,,,,,,,12.13,186.50,percent of total billed charges,
Eosinophil count Addl,8230229,CDM,300,RC,87205,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
Eosinophil count Addl,8230229,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,3.96,85.07,percent of total billed charges,
RETICULOCYTE,596037,CDM,300,RC,85045,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
RETICULOCYTE,596037,CDM,300,RC,85045,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,3.70,94.07,percent of total billed charges,
FIBRINOGEN,596405,CDM,300,RC,85384,HCPCS,,,facility,inpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,103.80,141.51,percent of total billed charges,
FIBRINOGEN,596405,CDM,300,RC,85384,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,9.01,141.51,percent of total billed charges,
FIBRINOGEN,658958,CDM,300,RC,85384,HCPCS,,,facility,inpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,103.80,141.51,percent of total billed charges,
FIBRINOGEN,658958,CDM,300,RC,85384,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,9.01,141.51,percent of total billed charges,
FIBRINOGEN ACTIVITY,8246773,CDM,300,RC,85384,HCPCS,,,facility,inpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,103.80,141.51,percent of total billed charges,
FIBRINOGEN ACTIVITY,8246773,CDM,300,RC,85384,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,9.01,141.51,percent of total billed charges,
OB Panel w HIV,9002332,CDM,300,RC,80081,HCPCS,,,facility,inpatient,,,640.00000,185.60000,Aetna,First Health,,523.52,,,,,,,384.00,523.52,percent of total billed charges,
OB Panel w HIV,9002332,CDM,300,RC,80081,HCPCS,,,facility,outpatient,,,640.00000,185.60000,Aetna,First Health,,523.52,,,,,,,69.39,523.52,percent of total billed charges,
BACTERIAL CULTURE MEDICAL DEVICE,593517,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE MEDICAL DEVICE,593517,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE RESPIRATORY,593516,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE RESPIRATORY,593516,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE RESPIRATORY,593524,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE RESPIRATORY,593524,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE WOUND,593521,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE WOUND,593521,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BETA STREP CULTURE,593535,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
BETA STREP CULTURE,593535,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,6.15,94.89,percent of total billed charges,
BETA STREP A SCREEN,7902430,CDM,300,RC,87430,HCPCS,,,facility,inpatient,,,99.00000,28.71000,Aetna,First Health,,80.98,,,,,,,59.40,80.98,percent of total billed charges,
BETA STREP A SCREEN,7902430,CDM,300,RC,87430,HCPCS,,,facility,outpatient,,,99.00000,28.71000,Aetna,First Health,,80.98,,,,,,,15.58,80.98,percent of total billed charges,
BACTERIAL CULTURE BLOOD,593510,CDM,300,RC,87040,HCPCS,,,facility,inpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,163.80,223.31,percent of total billed charges,
BACTERIAL CULTURE BLOOD,593510,CDM,300,RC,87040,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,9.57,223.31,percent of total billed charges,
Bacterial Culture for Blood,8948141,CDM,300,RC,87040,HCPCS,,,facility,inpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,163.80,223.31,percent of total billed charges,
Bacterial Culture for Blood,8948141,CDM,300,RC,87040,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,9.57,223.31,percent of total billed charges,
Bacterial Culture Blood,9114569,CDM,300,RC,87040,HCPCS,,,facility,inpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,163.80,223.31,percent of total billed charges,
Bacterial Culture Blood,9114569,CDM,300,RC,87040,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,9.57,223.31,percent of total billed charges,
BACTERIAL CULTURE FECES,593565,CDM,300,RC,87045,HCPCS,,,facility,inpatient,,,414.00000,120.06000,Aetna,First Health,,338.65,,,,,,,248.40,338.65,percent of total billed charges,
BACTERIAL CULTURE FECES,593565,CDM,300,RC,87045,HCPCS,,,facility,outpatient,,,414.00000,120.06000,Aetna,First Health,,338.65,,,,,,,8.76,338.65,percent of total billed charges,
0081271 Sickle Solubility Bill ARUP,3190954,CDM,300,RC,85660,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
0081271 Sickle Solubility Bill ARUP,3190954,CDM,300,RC,85660,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,5.11,94.07,percent of total billed charges,
Crypto,3190980,CDM,300,RC,87328,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
Crypto,3190980,CDM,300,RC,87328,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,12.81,116.97,percent of total billed charges,
CAMPYLOBACTER BY EIA,7902416,CDM,300,RC,87449,HCPCS,,,facility,inpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,127.80,174.23,percent of total billed charges,
CAMPYLOBACTER BY EIA,7902416,CDM,300,RC,87449,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,11.10,174.23,percent of total billed charges,
PH GASTRIC,7902422,CDM,300,RC,83986,HCPCS,,,facility,inpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,76.20,103.89,percent of total billed charges,
PH GASTRIC,7902422,CDM,300,RC,83986,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,3.32,103.89,percent of total billed charges,
87899 Dir IA Shiga Toxin,2532898,CDM,300,RC,87427,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
87899 Dir IA Shiga Toxin,2532898,CDM,300,RC,87427,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,11.10,132.52,percent of total billed charges,
87427 Shiga like toxin ag eia,3373839,CDM,300,RC,87427,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
87427 Shiga like toxin ag eia,3373839,CDM,300,RC,87427,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,11.10,132.52,percent of total billed charges,
DIRECT IMMUNOASSAY SHIGA TOXIN,7902429,CDM,300,RC,87427,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
DIRECT IMMUNOASSAY SHIGA TOXIN,7902429,CDM,300,RC,87427,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,11.10,132.52,percent of total billed charges,
Shiga like Toxin CSCTRULE,8948136,CDM,300,RC,87427,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
Shiga like Toxin CSCTRULE,8948136,CDM,300,RC,87427,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,11.10,132.52,percent of total billed charges,
LACTOFERRIN FECAL QUAL,7902420,CDM,300,RC,83630,HCPCS,,,facility,inpatient,,,249.00000,72.21000,Aetna,First Health,,203.68,,,,,,,149.40,203.68,percent of total billed charges,
LACTOFERRIN FECAL QUAL,7902420,CDM,300,RC,83630,HCPCS,,,facility,outpatient,,,249.00000,72.21000,Aetna,First Health,,203.68,,,,,,,15.52,203.68,percent of total billed charges,
BIOCHEMICAL YEAST,7972033,CDM,300,RC,87106,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
BIOCHEMICAL YEAST,7972033,CDM,300,RC,87106,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,9.57,40.90,percent of total billed charges,
BIOCHEMICAL OTHER,620801,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,620801,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7972034,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7972034,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7972035,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7972035,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7972036,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7972036,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7980772,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7980772,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7989523,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7989523,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7989524,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7989524,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7989525,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7989525,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,7.49,143.15,percent of total billed charges,
RapID Staphylococci Identification,8260120,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
RapID Staphylococci Identification,8260120,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,7.49,143.15,percent of total billed charges,
RESTISTANCE TESTING,7741537,CDM,300,RC,87147,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
RESTISTANCE TESTING,7741537,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,4.80,85.07,percent of total billed charges,
MACROSCOPIC PARASITE EXAM,7897023,CDM,300,RC,87169,HCPCS,,,facility,inpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,42.60,58.08,percent of total billed charges,
MACROSCOPIC PARASITE EXAM,7897023,CDM,300,RC,87169,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,4.00,58.08,percent of total billed charges,
CRYPTOCOCCUS ANTIGEN,7902419,CDM,300,RC,87327,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
CRYPTOCOCCUS ANTIGEN,7902419,CDM,300,RC,87327,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,12.44,144.79,percent of total billed charges,
MALARIA ANTIGEN SCREEN,7926831,CDM,300,RC,87899,HCPCS,,,facility,inpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,96.60,131.70,percent of total billed charges,
MALARIA ANTIGEN SCREEN,7926831,CDM,300,RC,87899,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,14.89,131.70,percent of total billed charges,
INFECTIOUS AGENT AG DETECTION,8228698,CDM,300,RC,87899,HCPCS,,,facility,inpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,96.60,131.70,percent of total billed charges,
INFECTIOUS AGENT AG DETECTION,8228698,CDM,300,RC,87899,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,14.89,131.70,percent of total billed charges,
INFECTIOUS AGENT AG DETECTION,8228699,CDM,300,RC,87899,HCPCS,,,facility,inpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,96.60,131.70,percent of total billed charges,
INFECTIOUS AGENT AG DETECTION,8228699,CDM,300,RC,87899,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,14.89,131.70,percent of total billed charges,
BLOOD CULTURE FOR FUNGUS,593542,CDM,300,RC,87103,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,202.80,276.48,percent of total billed charges,
BLOOD CULTURE FOR FUNGUS,593542,CDM,300,RC,87103,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,10.17,276.48,percent of total billed charges,
CONCENTRATION INFECTIOUS AGENT,649079,CDM,300,RC,87015,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
CONCENTRATION INFECTIOUS AGENT,649079,CDM,300,RC,87015,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,6.19,73.62,percent of total billed charges,
MONONUCLEOSIS SCREEN,7902425,CDM,300,RC,86308,HCPCS,,,facility,inpatient,,,113.00000,32.77000,Aetna,First Health,,92.43,,,,,,,67.80,92.43,percent of total billed charges,
MONONUCLEOSIS SCREEN,7902425,CDM,300,RC,86308,HCPCS,,,facility,outpatient,,,113.00000,32.77000,Aetna,First Health,,92.43,,,,,,,4.80,92.43,percent of total billed charges,
BACTERIAL CULTURE BODY FLUID,593511,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE BODY FLUID,593511,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
CULTURE BLOOD CATHETER,593537,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
CULTURE BLOOD CATHETER,593537,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE EAR,593513,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE EAR,593513,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE EYE,593514,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE EYE,593514,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
GENITAL CULTURE,593515,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
GENITAL CULTURE,593515,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE TISSUE,593519,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE TISSUE,593519,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE OTHER,593512,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE OTHER,593512,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE OTHER,593536,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE OTHER,593536,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE THROAT NOSE,593518,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BACTERIAL CULTURE THROAT NOSE,593518,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE URINE,593520,CDM,300,RC,87086,HCPCS,,,facility,inpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,138.00,188.14,percent of total billed charges,
BACTERIAL CULTURE URINE,593520,CDM,300,RC,87086,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,7.48,188.14,percent of total billed charges,
BACTERIAL CULTURE ANAEROBIC,593509,CDM,300,RC,87075,HCPCS,,,facility,inpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,184.80,251.94,percent of total billed charges,
BACTERIAL CULTURE ANAEROBIC,593509,CDM,300,RC,87075,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,8.78,251.94,percent of total billed charges,
FUNGUS CULTURE,593563,CDM,300,RC,87102,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
FUNGUS CULTURE,593563,CDM,300,RC,87102,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,7.80,265.85,percent of total billed charges,
RESPIRATORY SYNC VIRUS ANTIGEN,7902427,CDM,300,RC,87420,HCPCS,,,facility,inpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,129.00,175.87,percent of total billed charges,
RESPIRATORY SYNC VIRUS ANTIGEN,7902427,CDM,300,RC,87420,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,12.90,175.87,percent of total billed charges,
Influ B,636324,CDM,300,RC,87804,HCPCS,,,facility,inpatient,,,167.00000,48.43000,Aetna,First Health,,136.61,,,,,,,100.20,136.61,percent of total billed charges,
Influ B,636324,CDM,300,RC,87804,HCPCS,,,facility,outpatient,,,167.00000,48.43000,Aetna,First Health,,136.61,,,,,,,15.35,136.61,percent of total billed charges,
Influ Ag,648082,CDM,300,RC,87804,HCPCS,,,facility,inpatient,,,167.00000,48.43000,Aetna,First Health,,136.61,,,,,,,100.20,136.61,percent of total billed charges,
Influ Ag,648082,CDM,300,RC,87804,HCPCS,,,facility,outpatient,,,167.00000,48.43000,Aetna,First Health,,136.61,,,,,,,15.35,136.61,percent of total billed charges,
Gonorrhea Culture,593564,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
Gonorrhea Culture,593564,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,6.15,94.89,percent of total billed charges,
Giardia,644366,CDM,300,RC,87329,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
Giardia,644366,CDM,300,RC,87329,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,11.10,116.97,percent of total billed charges,
Crypto,644367,CDM,300,RC,87329,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
Crypto,644367,CDM,300,RC,87329,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,11.10,116.97,percent of total billed charges,
GIARDIA ANTIGEN SCREEN,7902423,CDM,300,RC,87329,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
GIARDIA ANTIGEN SCREEN,7902423,CDM,300,RC,87329,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,11.10,116.97,percent of total billed charges,
GRAM STAIN,593522,CDM,300,RC,87205,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
GRAM STAIN,593522,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,3.96,85.07,percent of total billed charges,
GRAM STAIN,594243,CDM,300,RC,87205,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
GRAM STAIN,594243,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,3.96,85.07,percent of total billed charges,
GRAM STAIN,6155895,CDM,300,RC,87205,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
GRAM STAIN,6155895,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,3.96,85.07,percent of total billed charges,
ID EXTRA ADD ON,620793,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,71.40,97.34,percent of total billed charges,
ID EXTRA ADD ON,620793,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,7.49,97.34,percent of total billed charges,
API AEROBIC IDENTIFICATION,7980328,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,71.40,97.34,percent of total billed charges,
API AEROBIC IDENTIFICATION,7980328,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,7.49,97.34,percent of total billed charges,
TISSUE GRINDING CHARGE,620800,CDM,300,RC,87176,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
TISSUE GRINDING CHARGE,620800,CDM,300,RC,87176,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,5.45,59.71,percent of total billed charges,
BETA LACTAMASE,593980,CDM,300,RC,87185,HCPCS,,,facility,inpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,42.60,58.08,percent of total billed charges,
BETA LACTAMASE,593980,CDM,300,RC,87185,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,4.41,58.08,percent of total billed charges,
MOLD IDENTIFICATION CHARGE,644330,CDM,300,RC,87107,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,85.20,116.16,percent of total billed charges,
MOLD IDENTIFICATION CHARGE,644330,CDM,300,RC,87107,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,9.57,116.16,percent of total billed charges,
FECAL OCCULT BLOOD NEOPLASM SCREENING,7902421,CDM,300,RC,82270,HCPCS,,,facility,inpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,39.00,53.17,percent of total billed charges,
FECAL OCCULT BLOOD NEOPLASM SCREENING,7902421,CDM,300,RC,82270,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,3.37,53.17,percent of total billed charges,
GASTRIC BLOOD,7902426,CDM,300,RC,82271,HCPCS,,,facility,inpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,39.00,53.17,percent of total billed charges,
GASTRIC BLOOD,7902426,CDM,300,RC,82271,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,4.03,53.17,percent of total billed charges,
HELICOBACTER PYLORI SCREEN UREASE,7902418,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
HELICOBACTER PYLORI SCREEN UREASE,7902418,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,6.15,94.89,percent of total billed charges,
SUSCEPTIBILITY INDIVIDUAL,294945,CDM,300,RC,87181,HCPCS,,,facility,inpatient,,,81.00000,23.49000,Aetna,First Health,,66.26,,,,,,,48.60,66.26,percent of total billed charges,
SUSCEPTIBILITY INDIVIDUAL,294945,CDM,300,RC,87181,HCPCS,,,facility,outpatient,,,81.00000,23.49000,Aetna,First Health,,66.26,,,,,,,4.41,66.26,percent of total billed charges,
MINIMUM INHIBITORY CONCENTRATION,294946,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,115.80,157.87,percent of total billed charges,
MINIMUM INHIBITORY CONCENTRATION,294946,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,8.02,157.87,percent of total billed charges,
WET PREP SALINE,593529,CDM,300,RC,87210,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
WET PREP SALINE,593529,CDM,300,RC,87210,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,5.40,89.16,percent of total billed charges,
CULTURE SCREENING ONLY,1429845,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
CULTURE SCREENING ONLY,1429845,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,6.15,94.89,percent of total billed charges,
CULTURE SCREENING ONLY,1429846,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
CULTURE SCREENING ONLY,1429846,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,6.15,94.89,percent of total billed charges,
CULTURE SCREENING ONLY,593532,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
CULTURE SCREENING ONLY,593532,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,6.15,94.89,percent of total billed charges,
C difficile Toxin Assay,8155516,CDM,300,RC,87324,HCPCS,,,facility,inpatient,,,252.00000,73.08000,Aetna,First Health,,206.14,,,,,,,151.20,206.14,percent of total billed charges,
C difficile Toxin Assay,8155516,CDM,300,RC,87324,HCPCS,,,facility,outpatient,,,252.00000,73.08000,Aetna,First Health,,206.14,,,,,,,11.10,206.14,percent of total billed charges,
FECAL OCCULT BLOOD GI BLEED,8214084,CDM,300,RC,82272,HCPCS,,,facility,inpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,34.20,46.63,percent of total billed charges,
FECAL OCCULT BLOOD GI BLEED,8214084,CDM,300,RC,82272,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,3.92,46.63,percent of total billed charges,
BLOOD CULTURE FOR BACTERIA,8134952,CDM,300,RC,87040,HCPCS,,,facility,inpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,163.80,223.31,percent of total billed charges,
BLOOD CULTURE FOR BACTERIA,8134952,CDM,300,RC,87040,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,9.57,223.31,percent of total billed charges,
SHIGA LIKE TOXIN AG IA,8134953,CDM,300,RC,87427,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
SHIGA LIKE TOXIN AG IA,8134953,CDM,300,RC,87427,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,11.10,132.52,percent of total billed charges,
Culture Anaerobic Addl,8229218,CDM,300,RC,87075,HCPCS,,,facility,inpatient,,,308.00000,89.32000,Aetna,First Health,GY,251.94,,,,,,,184.80,251.94,percent of total billed charges,
Culture Anaerobic Addl,8229218,CDM,300,RC,87075,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,First Health,GY,251.94,,,,,,,8.78,251.94,percent of total billed charges,
Fungus Culture Addl,8229878,CDM,300,RC,87102,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,GY,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Fungus Culture Addl,8229878,CDM,300,RC,87102,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,GY,265.85,,,,,,,7.80,265.85,percent of total billed charges,
AFB Stain Addl,8229214,CDM,300,RC,87206,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GY,99.80,,,,,,,73.20,99.80,percent of total billed charges,
AFB Stain Addl,8229214,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GY,99.80,,,,,,,5.00,99.80,percent of total billed charges,
Culture Body Fluid Addl,8230210,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Culture Body Fluid Addl,8230210,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
Culture Blood catheter Addl,8230211,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Culture Blood catheter Addl,8230211,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
Culture Miscellaneous Addl,8230217,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Culture Miscellaneous Addl,8230217,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
Culture Ear addl,8230213,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Culture Ear addl,8230213,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
Culture Eye addl,8230214,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Culture Eye addl,8230214,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
Genital Culture Addl,8230215,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Genital Culture Addl,8230215,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
Culture Medical Device Addl,8230216,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Culture Medical Device Addl,8230216,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
Culture Respiratory Addl,8230218,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Culture Respiratory Addl,8230218,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
CULTURE OTHR SPECIMN AEROBIC,8230219,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
CULTURE OTHR SPECIMN AEROBIC,8230219,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
Culture Tissue Addl,8230220,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Culture Tissue Addl,8230220,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
Culture Wound Addl,8230221,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Culture Wound Addl,8230221,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,7.99,229.04,percent of total billed charges,
Bacterial Culture Anaerobic Addl,8230222,CDM,300,RC,87075,HCPCS,,,facility,inpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,184.80,251.94,percent of total billed charges,
Bacterial Culture Anaerobic Addl,8230222,CDM,300,RC,87075,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,8.78,251.94,percent of total billed charges,
Fungus Culture Addl,8230223,CDM,300,RC,87102,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Fungus Culture Addl,8230223,CDM,300,RC,87102,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,7.80,265.85,percent of total billed charges,
Culture Screening only Addl,8230225,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
Culture Screening only Addl,8230225,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,6.15,94.89,percent of total billed charges,
Beta Strep Culture Addl,8230226,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
Beta Strep Culture Addl,8230226,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,6.15,94.89,percent of total billed charges,
Helicobacter pylori screen Addl,8230227,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
Helicobacter pylori screen Addl,8230227,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,6.15,94.89,percent of total billed charges,
Gram Stain Addl,8230228,CDM,300,RC,87205,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
Gram Stain Addl,8230228,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,3.96,85.07,percent of total billed charges,
AFB Stain Addl,8230230,CDM,300,RC,87206,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
AFB Stain Addl,8230230,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,5.00,99.80,percent of total billed charges,
AFB Culture Addl,8230235,CDM,300,RC,87116,HCPCS,,,facility,inpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,152.40,207.77,percent of total billed charges,
AFB Culture Addl,8230235,CDM,300,RC,87116,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,10.01,207.77,percent of total billed charges,
AFB Stain Only,593533,CDM,300,RC,87206,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
AFB Stain Only,593533,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,5.00,99.80,percent of total billed charges,
AFB STAIN ONLY,594242,CDM,300,RC,87206,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
AFB STAIN ONLY,594242,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,5.00,99.80,percent of total billed charges,
KIRBY BAUER,294944,CDM,300,RC,87184,HCPCS,,,facility,inpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,76.20,103.89,percent of total billed charges,
KIRBY BAUER,294944,CDM,300,RC,87184,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,6.93,103.89,percent of total billed charges,
Fungus Culture Skin Hair Nails,8326250,CDM,300,RC,87101,HCPCS,,,facility,inpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,103.80,141.51,percent of total billed charges,
Fungus Culture Skin Hair Nails,8326250,CDM,300,RC,87101,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,7.15,141.51,percent of total billed charges,
Influenza Antigen A and B,7902424,CDM,300,RC,87400,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
Influenza Antigen A and B,7902424,CDM,300,RC,87400,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,7.98,88.34,percent of total billed charges,
87400 Influenza Antigen,8408268,CDM,300,RC,87400,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
87400 Influenza Antigen,8408268,CDM,300,RC,87400,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,7.98,88.34,percent of total billed charges,
Concentrated Infectious Agent,9010371,CDM,300,RC,88108,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Concentrated Infectious Agent,9010371,CDM,300,RC,88108,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,34.46,213.50,percent of total billed charges,
Bacterial Culture Respiratory,9028384,CDM,300,RC,87071,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Bacterial Culture Respiratory,9028384,CDM,300,RC,87071,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,9.17,229.04,percent of total billed charges,
Bacterial Culture Respiratory,9194450,CDM,300,RC,87071,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Bacterial Culture Respiratory,9194450,CDM,300,RC,87071,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,9.17,229.04,percent of total billed charges,
C DIFFICILE TOXIN BY IMMUNOASSAY,9226551,CDM,300,RC,87324,HCPCS,,,facility,inpatient,,,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,108.60,148.06,percent of total billed charges,
C DIFFICILE TOXIN BY IMMUNOASSAY,9226551,CDM,300,RC,87324,HCPCS,,,facility,outpatient,,,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,11.10,148.06,percent of total billed charges,
C DIFF ANTIGEN TOXIN,9230468,CDM,300,RC,87449,HCPCS,,,facility,inpatient,,,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,122.40,166.87,percent of total billed charges,
C DIFF ANTIGEN TOXIN,9230468,CDM,300,RC,87449,HCPCS,,,facility,outpatient,,,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,11.10,166.87,percent of total billed charges,
hCG Urine,3018937,CDM,300,RC,81025,HCPCS,,,facility,inpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
hCG Urine,3018937,CDM,300,RC,81025,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,7.98,108.79,percent of total billed charges,
hCG Urine,4631840,CDM,300,RC,81025,HCPCS,,,facility,inpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
hCG Urine,4631840,CDM,300,RC,81025,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,7.98,108.79,percent of total billed charges,
Hepatitis C Antibody,9049011,CDM,300,RC,86803,HCPCS,,,facility,inpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,125.40,170.96,percent of total billed charges,
Hepatitis C Antibody,9049011,CDM,300,RC,86803,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,13.23,170.96,percent of total billed charges,
HEPATITIS C AB TEST,9090233,CDM,300,RC,86803,HCPCS,,,facility,inpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,125.40,170.96,percent of total billed charges,
HEPATITIS C AB TEST,9090233,CDM,300,RC,86803,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,13.23,170.96,percent of total billed charges,
CALCIUM IONIZED,599730,CDM,300,RC,82330,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
CALCIUM IONIZED,599730,CDM,300,RC,82330,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,8.54,144.79,percent of total billed charges,
Calcium,8246774,CDM,300,RC,82330,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
Calcium,8246774,CDM,300,RC,82330,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,8.54,144.79,percent of total billed charges,
CALCIUM IONIZED,8367782,CDM,300,RC,82330,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
CALCIUM IONIZED,8367782,CDM,300,RC,82330,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,8.54,144.79,percent of total billed charges,
HEPATITIS B CORE ANTIBODY IGM,605665,CDM,300,RC,86705,HCPCS,,,facility,inpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,129.00,175.87,percent of total billed charges,
HEPATITIS B CORE ANTIBODY IGM,605665,CDM,300,RC,86705,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,10.91,175.87,percent of total billed charges,
HEPATITIS B SURF AG,605664,CDM,300,RC,87340,HCPCS,,,facility,inpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,111.60,152.15,percent of total billed charges,
HEPATITIS B SURF AG,605664,CDM,300,RC,87340,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,9.58,152.15,percent of total billed charges,
Hepatitis B surface Antigen,9088219,CDM,300,RC,87340,HCPCS,,,facility,inpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,111.60,152.15,percent of total billed charges,
Hepatitis B surface Antigen,9088219,CDM,300,RC,87340,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,9.58,152.15,percent of total billed charges,
HEPATITIS B SURFACE ANTIBODY,605666,CDM,300,RC,86706,HCPCS,,,facility,inpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,105.60,143.97,percent of total billed charges,
HEPATITIS B SURFACE ANTIBODY,605666,CDM,300,RC,86706,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,9.96,143.97,percent of total billed charges,
HEP B SURFACE ANTIBODY,9088217,CDM,300,RC,86706,HCPCS,,,facility,inpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,105.60,143.97,percent of total billed charges,
HEP B SURFACE ANTIBODY,9088217,CDM,300,RC,86706,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,9.96,143.97,percent of total billed charges,
HEPATITIS A IGM ANTIBODY,605667,CDM,300,RC,86709,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
HEPATITIS A IGM ANTIBODY,605667,CDM,300,RC,86709,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,10.43,159.51,percent of total billed charges,
HEPATITIS PANEL ACUTE,599697,CDM,300,RC,80074,HCPCS,,,facility,inpatient,,,649.00000,188.21000,Aetna,First Health,,530.88,,,,,,,389.40,530.88,percent of total billed charges,
HEPATITIS PANEL ACUTE,599697,CDM,300,RC,80074,HCPCS,,,facility,outpatient,,,649.00000,188.21000,Aetna,First Health,,530.88,,,,,,,44.16,530.88,percent of total billed charges,
UREA NITROGEN URINE,596767,CDM,300,RC,84540,HCPCS,,,facility,inpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,52.20,71.17,percent of total billed charges,
UREA NITROGEN URINE,596767,CDM,300,RC,84540,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,5.15,71.17,percent of total billed charges,
UREA NITROGEN URINE,596768,CDM,300,RC,84540,HCPCS,,,facility,inpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,52.20,71.17,percent of total billed charges,
UREA NITROGEN URINE,596768,CDM,300,RC,84540,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,5.15,71.17,percent of total billed charges,
ALBUMIN LEVEL,596689,CDM,300,RC,82040,HCPCS,,,facility,inpatient,,,81.00000,23.49000,Aetna,First Health,,66.26,,,,,,,48.60,66.26,percent of total billed charges,
ALBUMIN LEVEL,596689,CDM,300,RC,82040,HCPCS,,,facility,outpatient,,,81.00000,23.49000,Aetna,First Health,,66.26,,,,,,,4.59,66.26,percent of total billed charges,
ALBUMIN LEVEL,597161,CDM,300,RC,82040,HCPCS,,,facility,inpatient,,,81.00000,23.49000,Aetna,First Health,,66.26,,,,,,,48.60,66.26,percent of total billed charges,
ALBUMIN LEVEL,597161,CDM,300,RC,82040,HCPCS,,,facility,outpatient,,,81.00000,23.49000,Aetna,First Health,,66.26,,,,,,,4.59,66.26,percent of total billed charges,
ALBUMIN LEVEL,599684,CDM,300,RC,82040,HCPCS,,,facility,inpatient,,,81.00000,23.49000,Aetna,First Health,,66.26,,,,,,,48.60,66.26,percent of total billed charges,
ALBUMIN LEVEL,599684,CDM,300,RC,82040,HCPCS,,,facility,outpatient,,,81.00000,23.49000,Aetna,First Health,,66.26,,,,,,,4.59,66.26,percent of total billed charges,
PTH INTACT,2872841,CDM,300,RC,83970,HCPCS,,,facility,inpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,218.40,297.75,percent of total billed charges,
PTH INTACT,2872841,CDM,300,RC,83970,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,38.26,297.75,percent of total billed charges,
PTH INTACT,605514,CDM,300,RC,83970,HCPCS,,,facility,inpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,218.40,297.75,percent of total billed charges,
PTH INTACT,605514,CDM,300,RC,83970,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,38.26,297.75,percent of total billed charges,
PTH INTACT,8324476,CDM,300,RC,83970,HCPCS,,,facility,inpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,218.40,297.75,percent of total billed charges,
PTH INTACT,8324476,CDM,300,RC,83970,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,38.26,297.75,percent of total billed charges,
FETAL MEMBRANE RUPTURE,1976824,CDM,300,RC,84112,HCPCS,,,facility,inpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,152.40,207.77,percent of total billed charges,
FETAL MEMBRANE RUPTURE,1976824,CDM,300,RC,84112,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,90.95,259.99,percent of total billed charges,
ARTERIAL BLOOD GAS FOR CLIENT,2126824,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
ARTERIAL BLOOD GAS FOR CLIENT,2126824,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
Arterial Blood Gas Client Addl,8229334,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,GY,258.49,,,,,,,189.60,258.49,percent of total billed charges,
Arterial Blood Gas Client Addl,8229334,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,GY,258.49,,,,,,,7.68,258.49,percent of total billed charges,
LDL CHOLESTEROL LIPOPROTEIN,2548834,CDM,300,RC,83721,HCPCS,,,facility,inpatient,,,110.00000,31.90000,Aetna,First Health,,89.98,,,,,,,66.00,89.98,percent of total billed charges,
LDL CHOLESTEROL LIPOPROTEIN,2548834,CDM,300,RC,83721,HCPCS,,,facility,outpatient,,,110.00000,31.90000,Aetna,First Health,,89.98,,,,,,,9.73,89.98,percent of total billed charges,
HEP B CORE AB TOTAL,3060839,CDM,300,RC,86704,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
HEP B CORE AB TOTAL,3060839,CDM,300,RC,86704,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,11.18,94.07,percent of total billed charges,
Hep B Core Antibody Total,8410737,CDM,300,RC,86704,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
Hep B Core Antibody Total,8410737,CDM,300,RC,86704,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,11.18,94.07,percent of total billed charges,
HEP B CORE ANTIBODY TOTAL,9088218,CDM,300,RC,86704,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
HEP B CORE ANTIBODY TOTAL,9088218,CDM,300,RC,86704,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,11.18,94.07,percent of total billed charges,
SYPHILIS ANTIBODY,7962633,CDM,300,RC,86780,HCPCS,,,facility,inpatient,,,114.00000,33.06000,Aetna,First Health,,93.25,,,,,,,68.40,93.25,percent of total billed charges,
SYPHILIS ANTIBODY,7962633,CDM,300,RC,86780,HCPCS,,,facility,outpatient,,,114.00000,33.06000,Aetna,First Health,,93.25,,,,,,,12.28,93.25,percent of total billed charges,
86780 Syphilis Antibody,7962635,CDM,300,RC,86780,HCPCS,,,facility,inpatient,,,114.00000,33.06000,Aetna,First Health,,93.25,,,,,,,68.40,93.25,percent of total billed charges,
86780 Syphilis Antibody,7962635,CDM,300,RC,86780,HCPCS,,,facility,outpatient,,,114.00000,33.06000,Aetna,First Health,,93.25,,,,,,,12.28,93.25,percent of total billed charges,
PROCALCITONIN,7976685,CDM,300,RC,84145,HCPCS,,,facility,inpatient,,,433.00000,125.57000,Aetna,First Health,,354.19,,,,,,,259.80,354.19,percent of total billed charges,
PROCALCITONIN,7976685,CDM,300,RC,84145,HCPCS,,,facility,outpatient,,,433.00000,125.57000,Aetna,First Health,,354.19,,,,,,,25.23,354.19,percent of total billed charges,
86335 Urine Immunofixation,8117511,CDM,300,RC,86335,HCPCS,,,facility,inpatient,,,302.00000,87.58000,Aetna,First Health,,247.04,,,,,,,181.20,247.04,percent of total billed charges,
86335 Urine Immunofixation,8117511,CDM,300,RC,86335,HCPCS,,,facility,outpatient,,,302.00000,87.58000,Aetna,First Health,,247.04,,,,,,,27.21,247.04,percent of total billed charges,
RPR Qualitative,8122550,CDM,300,RC,86592,HCPCS,,,facility,inpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,84.60,115.34,percent of total billed charges,
RPR Qualitative,8122550,CDM,300,RC,86592,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,3.96,115.34,percent of total billed charges,
RPR Qualitative,8122551,CDM,300,RC,86592,HCPCS,,,facility,inpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,84.60,115.34,percent of total billed charges,
RPR Qualitative,8122551,CDM,300,RC,86592,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,3.96,115.34,percent of total billed charges,
RPR TITER 1,8122547,CDM,300,RC,86593,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,85.20,116.16,percent of total billed charges,
RPR TITER 1,8122547,CDM,300,RC,86593,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,4.08,116.16,percent of total billed charges,
VITAMIN D 25 HYDROXY,5981857,CDM,300,RC,82306,HCPCS,,,facility,inpatient,,,221.00000,64.09000,Aetna,First Health,,180.78,,,,,,,132.60,180.78,percent of total billed charges,
VITAMIN D 25 HYDROXY,5981857,CDM,300,RC,82306,HCPCS,,,facility,outpatient,,,221.00000,64.09000,Aetna,First Health,,180.78,,,,,,,27.44,180.78,percent of total billed charges,
PROTEIN E PHORESIS SERUM,7023839,CDM,300,RC,84165,HCPCS,,,facility,inpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,115.20,157.06,percent of total billed charges,
PROTEIN E PHORESIS SERUM,7023839,CDM,300,RC,84165,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,9.96,157.06,percent of total billed charges,
IMMUNOFIX E PHORESIS SERUM,7023840,CDM,300,RC,86334,HCPCS,,,facility,inpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,157.20,214.32,percent of total billed charges,
IMMUNOFIX E PHORESIS SERUM,7023840,CDM,300,RC,86334,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,20.71,214.32,percent of total billed charges,
HIV AG AND ANTIBODIES,7732029,CDM,300,RC,87389,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
HIV AG AND ANTIBODIES,7732029,CDM,300,RC,87389,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,22.32,144.79,percent of total billed charges,
BETA HYDROXYBUTYRATE,7911344,CDM,300,RC,82010,HCPCS,,,facility,inpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,103.20,140.70,percent of total billed charges,
BETA HYDROXYBUTYRATE,7911344,CDM,300,RC,82010,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,7.57,140.70,percent of total billed charges,
URINE DRUG SCREEN,7921223,CDM,300,RC,80306,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
URINE DRUG SCREEN,7921223,CDM,300,RC,80306,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,15.89,85.07,percent of total billed charges,
ELECTROLYTE PANEL,596657,CDM,300,RC,80051,HCPCS,,,facility,inpatient,,,271.00000,78.59000,Aetna,First Health,,221.68,,,,,,,162.60,221.68,percent of total billed charges,
ELECTROLYTE PANEL,596657,CDM,300,RC,80051,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,First Health,,221.68,,,,,,,6.50,221.68,percent of total billed charges,
ELECTROLYTE PANEL,658418,CDM,300,RC,80051,HCPCS,,,facility,inpatient,,,271.00000,78.59000,Aetna,First Health,,221.68,,,,,,,162.60,221.68,percent of total billed charges,
ELECTROLYTE PANEL,658418,CDM,300,RC,80051,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,First Health,,221.68,,,,,,,6.50,221.68,percent of total billed charges,
BASIC METABOLIC PANEL,596652,CDM,300,RC,80048,HCPCS,,,facility,inpatient,,,311.00000,90.19000,Aetna,First Health,,254.40,,,,,,,186.60,254.40,percent of total billed charges,
BASIC METABOLIC PANEL,596652,CDM,300,RC,80048,HCPCS,,,facility,outpatient,,,311.00000,90.19000,Aetna,First Health,,254.40,,,,,,,7.84,254.40,percent of total billed charges,
HEPATIC FUNCTION PANEL,596653,CDM,300,RC,80076,HCPCS,,,facility,inpatient,,,268.00000,77.72000,Aetna,First Health,,219.22,,,,,,,160.80,219.22,percent of total billed charges,
HEPATIC FUNCTION PANEL,596653,CDM,300,RC,80076,HCPCS,,,facility,outpatient,,,268.00000,77.72000,Aetna,First Health,,219.22,,,,,,,7.57,219.22,percent of total billed charges,
HEPATIC FUNCTION PANEL,8948137,CDM,300,RC,80076,HCPCS,,,facility,inpatient,,,268.00000,77.72000,Aetna,First Health,,219.22,,,,,,,160.80,219.22,percent of total billed charges,
HEPATIC FUNCTION PANEL,8948137,CDM,300,RC,80076,HCPCS,,,facility,outpatient,,,268.00000,77.72000,Aetna,First Health,,219.22,,,,,,,7.57,219.22,percent of total billed charges,
METHEMOGLOBIN,596781,CDM,300,RC,83050,HCPCS,,,facility,inpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,76.20,103.89,percent of total billed charges,
METHEMOGLOBIN,596781,CDM,300,RC,83050,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,7.60,103.89,percent of total billed charges,
ACETAMINOPHEN LEVEL,596679,CDM,300,RC,80143,HCPCS,,,facility,inpatient,,,225.00000,65.25000,Aetna,First Health,,184.05,,,,,,,135.00,184.05,percent of total billed charges,
ACETAMINOPHEN LEVEL,596679,CDM,300,RC,80143,HCPCS,,,facility,outpatient,,,225.00000,65.25000,Aetna,First Health,,184.05,,,,,,,17.28,184.05,percent of total billed charges,
ALBUMIN LEVEL BODY FLUID,596669,CDM,300,RC,82042,HCPCS,,,facility,inpatient,,,89.00000,25.81000,Aetna,First Health,,72.80,,,,,,,53.40,72.80,percent of total billed charges,
ALBUMIN LEVEL BODY FLUID,596669,CDM,300,RC,82042,HCPCS,,,facility,outpatient,,,89.00000,25.81000,Aetna,First Health,,72.80,,,,,,,3.83,72.80,percent of total billed charges,
ALBUMIN LEVEL BODY FLUID,596804,CDM,300,RC,82042,HCPCS,,,facility,inpatient,,,89.00000,25.81000,Aetna,First Health,,72.80,,,,,,,53.40,72.80,percent of total billed charges,
ALBUMIN LEVEL BODY FLUID,596804,CDM,300,RC,82042,HCPCS,,,facility,outpatient,,,89.00000,25.81000,Aetna,First Health,,72.80,,,,,,,3.83,72.80,percent of total billed charges,
Albumin Level,635102,CDM,300,RC,82042,HCPCS,,,facility,inpatient,,,89.00000,25.81000,Aetna,First Health,,72.80,,,,,,,53.40,72.80,percent of total billed charges,
Albumin Level,635102,CDM,300,RC,82042,HCPCS,,,facility,outpatient,,,89.00000,25.81000,Aetna,First Health,,72.80,,,,,,,3.83,72.80,percent of total billed charges,
ETHANOL BLOOD,596773,CDM,300,RC,82077,HCPCS,,,facility,inpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,105.60,143.97,percent of total billed charges,
ETHANOL BLOOD,596773,CDM,300,RC,82077,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,16.01,143.97,percent of total billed charges,
ALKALINE PHOSPHATASE,596735,CDM,300,RC,84075,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
ALKALINE PHOSPHATASE,596735,CDM,300,RC,84075,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,4.80,111.25,percent of total billed charges,
ALKALINE PHOSPHATASE,599670,CDM,300,RC,84075,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
ALKALINE PHOSPHATASE,599670,CDM,300,RC,84075,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,4.80,111.25,percent of total billed charges,
AMMONIA LEVEL,596691,CDM,300,RC,82140,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
AMMONIA LEVEL,596691,CDM,300,RC,82140,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,13.50,164.42,percent of total billed charges,
AMYLASE BLOOD,596692,CDM,300,RC,82150,HCPCS,,,facility,inpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,103.20,140.70,percent of total billed charges,
AMYLASE BLOOD,596692,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,6.00,140.70,percent of total billed charges,
AMYLASE RANDOM URINE,596658,CDM,300,RC,82150,HCPCS,,,facility,inpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,103.20,140.70,percent of total billed charges,
AMYLASE RANDOM URINE,596658,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,6.00,140.70,percent of total billed charges,
AMYLASE RANDOM URINE,596659,CDM,300,RC,82150,HCPCS,,,facility,inpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,103.20,140.70,percent of total billed charges,
AMYLASE RANDOM URINE,596659,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,6.00,140.70,percent of total billed charges,
Amylase Random Urine,613077,CDM,300,RC,82150,HCPCS,,,facility,inpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,103.20,140.70,percent of total billed charges,
Amylase Random Urine,613077,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,6.00,140.70,percent of total billed charges,
BODY FLUID AMYLASE,596799,CDM,300,RC,82150,HCPCS,,,facility,inpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,103.20,140.70,percent of total billed charges,
BODY FLUID AMYLASE,596799,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,6.00,140.70,percent of total billed charges,
BHCG QUANTITATIVE,3339839,CDM,300,RC,84702,HCPCS,,,facility,inpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,111.60,152.15,percent of total billed charges,
BHCG QUANTITATIVE,3339839,CDM,300,RC,84702,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,13.96,152.15,percent of total billed charges,
BHCG QUANTITATIVE,596775,CDM,300,RC,84702,HCPCS,,,facility,inpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,111.60,152.15,percent of total billed charges,
BHCG QUANTITATIVE,596775,CDM,300,RC,84702,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,13.96,152.15,percent of total billed charges,
BILIRUBIN TOTAL,596693,CDM,300,RC,82247,HCPCS,,,facility,inpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,73.80,100.61,percent of total billed charges,
BILIRUBIN TOTAL,596693,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,4.66,100.61,percent of total billed charges,
BILIRUBIN TOTAL,599673,CDM,300,RC,82247,HCPCS,,,facility,inpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,73.80,100.61,percent of total billed charges,
BILIRUBIN TOTAL,599673,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,4.66,100.61,percent of total billed charges,
BILIRUBIN TOTAL,8324477,CDM,300,RC,82247,HCPCS,,,facility,inpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,73.80,100.61,percent of total billed charges,
BILIRUBIN TOTAL,8324477,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,4.66,100.61,percent of total billed charges,
BILIRUBIN TOTAL,8324478,CDM,300,RC,82247,HCPCS,,,facility,inpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,73.80,100.61,percent of total billed charges,
BILIRUBIN TOTAL,8324478,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,4.66,100.61,percent of total billed charges,
BILIRUBIN DIRECT,596694,CDM,300,RC,82248,HCPCS,,,facility,inpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,73.80,100.61,percent of total billed charges,
BILIRUBIN DIRECT,596694,CDM,300,RC,82248,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,4.66,100.61,percent of total billed charges,
BILIRUBIN DIRECT,8324561,CDM,300,RC,82248,HCPCS,,,facility,inpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,73.80,100.61,percent of total billed charges,
BILIRUBIN DIRECT,8324561,CDM,300,RC,82248,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,4.66,100.61,percent of total billed charges,
COMPREHENSIVE METABOLIC PANEL,596650,CDM,300,RC,80053,HCPCS,,,facility,inpatient,,,445.00000,129.05000,Aetna,First Health,,364.01,,,,,,,267.00,364.01,percent of total billed charges,
COMPREHENSIVE METABOLIC PANEL,596650,CDM,300,RC,80053,HCPCS,,,facility,outpatient,,,445.00000,129.05000,Aetna,First Health,,364.01,,,,,,,9.79,364.01,percent of total billed charges,
COMPREHENSIVE METABOLIC PANEL,797800,CDM,300,RC,80053,HCPCS,,,facility,inpatient,,,445.00000,129.05000,Aetna,First Health,,364.01,,,,,,,267.00,364.01,percent of total billed charges,
COMPREHENSIVE METABOLIC PANEL,797800,CDM,300,RC,80053,HCPCS,,,facility,outpatient,,,445.00000,129.05000,Aetna,First Health,,364.01,,,,,,,9.79,364.01,percent of total billed charges,
ARTERIAL BLOOD GASES,596708,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,596708,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,596713,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,596713,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,596717,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,596717,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,6345842,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,6345842,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,8367784,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,8367784,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
Arterial Blood Gases,9100397,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
Arterial Blood Gases,9100397,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
VENOUS BLOOD GASES,596709,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
VENOUS BLOOD GASES,596709,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
VENOUS BLOOD GASES,596715,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
VENOUS BLOOD GASES,596715,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
VENOUS BLOOD GASES,596716,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
VENOUS BLOOD GASES,596716,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
B TYPE NATRIURETIC PEPTIDE,596721,CDM,300,RC,83880,HCPCS,,,facility,inpatient,,,313.00000,90.77000,Aetna,First Health,,256.03,,,,,,,187.80,256.03,percent of total billed charges,
B TYPE NATRIURETIC PEPTIDE,596721,CDM,300,RC,83880,HCPCS,,,facility,outpatient,,,313.00000,90.77000,Aetna,First Health,,256.03,,,,,,,36.39,256.03,percent of total billed charges,
BLOOD UREA NITROGEN,596648,CDM,300,RC,84520,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BLOOD UREA NITROGEN,596648,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.67,73.62,percent of total billed charges,
BLOOD UREA NITROGEN,596765,CDM,300,RC,84520,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BLOOD UREA NITROGEN,596765,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.67,73.62,percent of total billed charges,
BLOOD UREA NITROGEN,599674,CDM,300,RC,84520,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BLOOD UREA NITROGEN,599674,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.67,73.62,percent of total billed charges,
BLOOD UREA NITROGEN,599688,CDM,300,RC,84520,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BLOOD UREA NITROGEN,599688,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.67,73.62,percent of total billed charges,
UREA NITROGEN CLEAR,596766,CDM,300,RC,84545,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
UREA NITROGEN CLEAR,596766,CDM,300,RC,84545,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,6.19,128.43,percent of total billed charges,
CRP CARDIO AND INFLAMMATORY,628517,CDM,300,RC,86141,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
CRP CARDIO AND INFLAMMATORY,628517,CDM,300,RC,86141,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,12.01,143.15,percent of total billed charges,
CALCIUM LEVEL TOTAL,596695,CDM,300,RC,82310,HCPCS,,,facility,inpatient,,,95.00000,27.55000,Aetna,First Health,,77.71,,,,,,,57.00,77.71,percent of total billed charges,
CALCIUM LEVEL TOTAL,596695,CDM,300,RC,82310,HCPCS,,,facility,outpatient,,,95.00000,27.55000,Aetna,First Health,,77.71,,,,,,,4.78,77.71,percent of total billed charges,
CALCIUM LEVEL TOTAL,599675,CDM,300,RC,82310,HCPCS,,,facility,inpatient,,,95.00000,27.55000,Aetna,First Health,,77.71,,,,,,,57.00,77.71,percent of total billed charges,
CALCIUM LEVEL TOTAL,599675,CDM,300,RC,82310,HCPCS,,,facility,outpatient,,,95.00000,27.55000,Aetna,First Health,,77.71,,,,,,,4.78,77.71,percent of total billed charges,
CALCIUM LEVEL TOTAL,599689,CDM,300,RC,82310,HCPCS,,,facility,inpatient,,,95.00000,27.55000,Aetna,First Health,,77.71,,,,,,,57.00,77.71,percent of total billed charges,
CALCIUM LEVEL TOTAL,599689,CDM,300,RC,82310,HCPCS,,,facility,outpatient,,,95.00000,27.55000,Aetna,First Health,,77.71,,,,,,,4.78,77.71,percent of total billed charges,
CALCIUM,8324545,CDM,300,RC,82310,HCPCS,,,facility,inpatient,,,95.00000,27.55000,Aetna,First Health,,77.71,,,,,,,57.00,77.71,percent of total billed charges,
CALCIUM,8324545,CDM,300,RC,82310,HCPCS,,,facility,outpatient,,,95.00000,27.55000,Aetna,First Health,,77.71,,,,,,,4.78,77.71,percent of total billed charges,
CANCER ANTIGEN 125 II,605670,CDM,300,RC,86304,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
CANCER ANTIGEN 125 II,605670,CDM,300,RC,86304,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,13.15,208.59,percent of total billed charges,
CARCINOEMBRYONIC ANTIGEN,596697,CDM,300,RC,82378,HCPCS,,,facility,inpatient,,,252.00000,73.08000,Aetna,First Health,,206.14,,,,,,,151.20,206.14,percent of total billed charges,
CARCINOEMBRYONIC ANTIGEN,596697,CDM,300,RC,82378,HCPCS,,,facility,outpatient,,,252.00000,73.08000,Aetna,First Health,,206.14,,,,,,,17.57,206.14,percent of total billed charges,
DIGOXIN LEVEL,596776,CDM,300,RC,80162,HCPCS,,,facility,inpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,118.20,161.15,percent of total billed charges,
DIGOXIN LEVEL,596776,CDM,300,RC,80162,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,12.31,161.15,percent of total billed charges,
DIGOXIN LEVEL,596777,CDM,300,RC,80162,HCPCS,,,facility,inpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,118.20,161.15,percent of total billed charges,
DIGOXIN LEVEL,596777,CDM,300,RC,80162,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,12.31,161.15,percent of total billed charges,
DIGOXIN LEVEL,596778,CDM,300,RC,80162,HCPCS,,,facility,inpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,118.20,161.15,percent of total billed charges,
DIGOXIN LEVEL,596778,CDM,300,RC,80162,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,12.31,161.15,percent of total billed charges,
CARBON DIOXIDE BLOOD,596710,CDM,300,RC,82374,HCPCS,,,facility,inpatient,,,196.00000,56.84000,Aetna,First Health,,160.33,,,,,,,117.60,160.33,percent of total billed charges,
CARBON DIOXIDE BLOOD,596710,CDM,300,RC,82374,HCPCS,,,facility,outpatient,,,196.00000,56.84000,Aetna,First Health,,160.33,,,,,,,4.52,160.33,percent of total billed charges,
CARBON MONOXIDE QUANT,596774,CDM,300,RC,82375,HCPCS,,,facility,inpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,103.80,141.51,percent of total billed charges,
CARBON MONOXIDE QUANT,596774,CDM,300,RC,82375,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,7.68,141.51,percent of total billed charges,
Carbon Monoxide,9100400,CDM,300,RC,82375,HCPCS,,,facility,inpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,103.80,141.51,percent of total billed charges,
Carbon Monoxide,9100400,CDM,300,RC,82375,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,7.68,141.51,percent of total billed charges,
CHLORIDE BLOOD,596698,CDM,300,RC,82435,HCPCS,,,facility,inpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,34.20,46.63,percent of total billed charges,
CHLORIDE BLOOD,596698,CDM,300,RC,82435,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,4.26,46.63,percent of total billed charges,
CHLORIDE URINE,596661,CDM,300,RC,82436,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
CHLORIDE URINE,596661,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,5.34,79.35,percent of total billed charges,
CHLORIDE URINE,596699,CDM,300,RC,82436,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
CHLORIDE URINE,596699,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,5.34,79.35,percent of total billed charges,
CHLORIDE URINE,602500,CDM,300,RC,82436,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
CHLORIDE URINE,602500,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,5.34,79.35,percent of total billed charges,
CHLORIDE URINE,613070,CDM,300,RC,82436,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
CHLORIDE URINE,613070,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,5.34,79.35,percent of total billed charges,
CHLORIDE URINE,636118,CDM,300,RC,82436,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
CHLORIDE URINE,636118,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,5.34,79.35,percent of total billed charges,
CHOLESTEROL,596701,CDM,300,RC,82465,HCPCS,,,facility,inpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,56.40,76.89,percent of total billed charges,
CHOLESTEROL,596701,CDM,300,RC,82465,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,4.04,76.89,percent of total billed charges,
CHOLESTEROL,596810,CDM,300,RC,82465,HCPCS,,,facility,inpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,56.40,76.89,percent of total billed charges,
CHOLESTEROL,596810,CDM,300,RC,82465,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,4.04,76.89,percent of total billed charges,
CHOLESTEROL,599683,CDM,300,RC,82465,HCPCS,,,facility,inpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,56.40,76.89,percent of total billed charges,
CHOLESTEROL,599683,CDM,300,RC,82465,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,4.04,76.89,percent of total billed charges,
COMPLEMENT COMPONENT C3,605614,CDM,300,RC,86160,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
COMPLEMENT COMPONENT C3,605614,CDM,300,RC,86160,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.12,164.42,percent of total billed charges,
COMPLEMENT C3,8324479,CDM,300,RC,86160,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
COMPLEMENT C3,8324479,CDM,300,RC,86160,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.12,164.42,percent of total billed charges,
COMPLEMENT COMPONENT C4,605615,CDM,300,RC,86160,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
COMPLEMENT COMPONENT C4,605615,CDM,300,RC,86160,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.12,164.42,percent of total billed charges,
COMPLEMENT 4,8324506,CDM,300,RC,86160,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
COMPLEMENT 4,8324506,CDM,300,RC,86160,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.12,164.42,percent of total billed charges,
CORTISOL TOTAL,599748,CDM,300,RC,82533,HCPCS,,,facility,inpatient,,,222.00000,64.38000,Aetna,First Health,,181.60,,,,,,,133.20,181.60,percent of total billed charges,
CORTISOL TOTAL,599748,CDM,300,RC,82533,HCPCS,,,facility,outpatient,,,222.00000,64.38000,Aetna,First Health,,181.60,,,,,,,15.11,181.60,percent of total billed charges,
CORTISOL TOTAL,873798,CDM,300,RC,82533,HCPCS,,,facility,inpatient,,,222.00000,64.38000,Aetna,First Health,,181.60,,,,,,,133.20,181.60,percent of total billed charges,
CORTISOL TOTAL,873798,CDM,300,RC,82533,HCPCS,,,facility,outpatient,,,222.00000,64.38000,Aetna,First Health,,181.60,,,,,,,15.11,181.60,percent of total billed charges,
CORTISOL TOTAL,873799,CDM,300,RC,82533,HCPCS,,,facility,inpatient,,,222.00000,64.38000,Aetna,First Health,,181.60,,,,,,,133.20,181.60,percent of total billed charges,
CORTISOL TOTAL,873799,CDM,300,RC,82533,HCPCS,,,facility,outpatient,,,222.00000,64.38000,Aetna,First Health,,181.60,,,,,,,15.11,181.60,percent of total billed charges,
CREATININE BLOOD,596705,CDM,300,RC,82565,HCPCS,,,facility,inpatient,,,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,57.60,78.53,percent of total billed charges,
CREATININE BLOOD,596705,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,4.75,78.53,percent of total billed charges,
CREATININE BLOOD,599676,CDM,300,RC,82565,HCPCS,,,facility,inpatient,,,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,57.60,78.53,percent of total billed charges,
CREATININE BLOOD,599676,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,4.75,78.53,percent of total billed charges,
CREATININE BLOOD,599691,CDM,300,RC,82565,HCPCS,,,facility,inpatient,,,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,57.60,78.53,percent of total billed charges,
CREATININE BLOOD,599691,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,4.75,78.53,percent of total billed charges,
CREATININE BLOOD,7948676,CDM,300,RC,82565,HCPCS,,,facility,inpatient,,,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,57.60,78.53,percent of total billed charges,
CREATININE BLOOD,7948676,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,4.75,78.53,percent of total billed charges,
CREATININE CLEARANCE,1019800,CDM,300,RC,82575,HCPCS,,,facility,inpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,152.40,207.77,percent of total billed charges,
CREATININE CLEARANCE,1019800,CDM,300,RC,82575,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,8.77,207.77,percent of total billed charges,
CREATININE CLEARANCE,596706,CDM,300,RC,82575,HCPCS,,,facility,inpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,152.40,207.77,percent of total billed charges,
CREATININE CLEARANCE,596706,CDM,300,RC,82575,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,8.77,207.77,percent of total billed charges,
CREATININE OTHER,1545907,CDM,300,RC,82570,HCPCS,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
CREATININE OTHER,1545907,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,4.80,86.71,percent of total billed charges,
CREATININE OTHER,596662,CDM,300,RC,82570,HCPCS,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
CREATININE OTHER,596662,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,4.80,86.71,percent of total billed charges,
CREATININE OTHER,596663,CDM,300,RC,82570,HCPCS,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
CREATININE OTHER,596663,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,4.80,86.71,percent of total billed charges,
CREATININE OTHER,596802,CDM,300,RC,82570,HCPCS,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
CREATININE OTHER,596802,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,4.80,86.71,percent of total billed charges,
Creatinine Random Urine,613068,CDM,300,RC,82570,HCPCS,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
Creatinine Random Urine,613068,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,4.80,86.71,percent of total billed charges,
Body Fluid Creatinine,613078,CDM,300,RC,82570,HCPCS,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
Body Fluid Creatinine,613078,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,4.80,86.71,percent of total billed charges,
CREATININE OTHER,663099,CDM,300,RC,82570,HCPCS,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
CREATININE OTHER,663099,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,4.80,86.71,percent of total billed charges,
CREATININE,8336480,CDM,300,RC,82570,HCPCS,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
CREATININE,8336480,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,4.80,86.71,percent of total billed charges,
CK Isoenzyme,613102,CDM,300,RC,82553,HCPCS,,,facility,inpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,123.00,167.69,percent of total billed charges,
CK Isoenzyme,613102,CDM,300,RC,82553,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,10.71,167.69,percent of total billed charges,
PHENYTOIN DILANTIN LEVEL,596784,CDM,300,RC,80185,HCPCS,,,facility,inpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,128.40,175.05,percent of total billed charges,
PHENYTOIN DILANTIN LEVEL,596784,CDM,300,RC,80185,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,12.29,175.05,percent of total billed charges,
PHENYTOIN DILANTIN LEVEL,596785,CDM,300,RC,80185,HCPCS,,,facility,inpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,128.40,175.05,percent of total billed charges,
PHENYTOIN DILANTIN LEVEL,596785,CDM,300,RC,80185,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,12.29,175.05,percent of total billed charges,
ESTRADIOL,604448,CDM,300,RC,82670,HCPCS,,,facility,inpatient,,,289.00000,83.81000,Aetna,First Health,,236.40,,,,,,,173.40,236.40,percent of total billed charges,
ESTRADIOL,604448,CDM,300,RC,82670,HCPCS,,,facility,outpatient,,,289.00000,83.81000,Aetna,First Health,,236.40,,,,,,,25.90,236.40,percent of total billed charges,
FERRITIN,604594,CDM,300,RC,82728,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,121.80,166.05,percent of total billed charges,
FERRITIN,604594,CDM,300,RC,82728,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,12.64,166.05,percent of total billed charges,
Ferritin Level,9082180,CDM,300,RC,82728,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,121.80,166.05,percent of total billed charges,
Ferritin Level,9082180,CDM,300,RC,82728,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,12.64,166.05,percent of total billed charges,
FETAL FIBRONECTIN FFN,596707,CDM,300,RC,82731,HCPCS,,,facility,inpatient,,,564.00000,163.56000,Aetna,First Health,,461.35,,,,,,,338.40,461.35,percent of total billed charges,
FETAL FIBRONECTIN FFN,596707,CDM,300,RC,82731,HCPCS,,,facility,outpatient,,,564.00000,163.56000,Aetna,First Health,,461.35,,,,,,,59.71,461.35,percent of total billed charges,
FOLIC ACID SERUM,604597,CDM,300,RC,82746,HCPCS,,,facility,inpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,110.40,150.51,percent of total billed charges,
FOLIC ACID SERUM,604597,CDM,300,RC,82746,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,13.63,150.51,percent of total billed charges,
GAMMA GLUTAMYL TRANSPEPTIDASE,596729,CDM,300,RC,82977,HCPCS,,,facility,inpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,76.20,103.89,percent of total billed charges,
GAMMA GLUTAMYL TRANSPEPTIDASE,596729,CDM,300,RC,82977,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,6.67,103.89,percent of total billed charges,
GLUCOSE LEVEL OTHER,596718,CDM,300,RC,82945,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
GLUCOSE LEVEL OTHER,596718,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE LEVEL OTHER,596753,CDM,300,RC,82945,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
GLUCOSE LEVEL OTHER,596753,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,596749,CDM,300,RC,82947,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,596749,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,599677,CDM,300,RC,82947,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,599677,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,599692,CDM,300,RC,82947,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,599692,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,7911339,CDM,300,RC,82947,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,7911339,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE BLOOD,8367783,CDM,300,RC,82947,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
GLUCOSE BLOOD,8367783,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
CEREBRAL SPINAL FLUID GLUCOSE,596815,CDM,300,RC,82945,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
CEREBRAL SPINAL FLUID GLUCOSE,596815,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
BODY FLUID GLUCOSE,596793,CDM,300,RC,82945,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BODY FLUID GLUCOSE,596793,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE 3 HOUR,596825,CDM,300,RC,82952,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
GLUCOSE 3 HOUR,596825,CDM,300,RC,82952,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.64,73.62,percent of total billed charges,
GLUCOSE 3 HOUR,7854056,CDM,300,RC,82952,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
GLUCOSE 3 HOUR,7854056,CDM,300,RC,82952,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.64,73.62,percent of total billed charges,
Glucose Tol Test,7844075,CDM,300,RC,82951,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
Glucose Tol Test,7844075,CDM,300,RC,82951,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,11.93,73.62,percent of total billed charges,
Glucose Tol Test,7844076,CDM,300,RC,82951,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
Glucose Tol Test,7844076,CDM,300,RC,82951,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,11.93,73.62,percent of total billed charges,
Glucose 1 Hour Gestational,7844074,CDM,300,RC,82950,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
Glucose 1 Hour Gestational,7844074,CDM,300,RC,82950,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,4.41,73.62,percent of total billed charges,
HAPTOGLOBIN,605486,CDM,300,RC,83010,HCPCS,,,facility,inpatient,,,190.00000,55.10000,Aetna,First Health,,155.42,,,,,,,114.00,155.42,percent of total billed charges,
HAPTOGLOBIN,605486,CDM,300,RC,83010,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,First Health,,155.42,,,,,,,11.66,155.42,percent of total billed charges,
IMMUNOGLOBULIN G,605477,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,99.00,134.97,percent of total billed charges,
IMMUNOGLOBULIN G,605477,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,8.18,134.97,percent of total billed charges,
IMMUNOGLOBULIN G,605478,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,99.00,134.97,percent of total billed charges,
IMMUNOGLOBULIN G,605478,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,8.18,134.97,percent of total billed charges,
IgA,1175851,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,99.00,134.97,percent of total billed charges,
IgA,1175851,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,8.18,134.97,percent of total billed charges,
IMMUNOGLOBULIN A,605476,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,99.00,134.97,percent of total billed charges,
IMMUNOGLOBULIN A,605476,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,8.18,134.97,percent of total billed charges,
IMMUNOGLOBULIN A,613038,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,99.00,134.97,percent of total billed charges,
IMMUNOGLOBULIN A,613038,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,8.18,134.97,percent of total billed charges,
IMMUNOGLOBULIN M,604615,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,99.00,134.97,percent of total billed charges,
IMMUNOGLOBULIN M,604615,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,8.18,134.97,percent of total billed charges,
IMMUNOGLOBULIN M,613037,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,99.00,134.97,percent of total billed charges,
IMMUNOGLOBULIN M,613037,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,8.18,134.97,percent of total billed charges,
IRON TOTAL,596722,CDM,300,RC,83540,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
IRON TOTAL,596722,CDM,300,RC,83540,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,5.99,110.43,percent of total billed charges,
IRON TOTAL,596723,CDM,300,RC,83540,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
IRON TOTAL,596723,CDM,300,RC,83540,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,5.99,110.43,percent of total billed charges,
Iron Level,8347449,CDM,300,RC,83540,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
Iron Level,8347449,CDM,300,RC,83540,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,5.99,110.43,percent of total billed charges,
UIBC,613082,CDM,300,RC,83550,HCPCS,,,facility,inpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,82.20,112.07,percent of total billed charges,
UIBC,613082,CDM,300,RC,83550,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,8.11,112.07,percent of total billed charges,
HDL CHOLESTEROL,596700,CDM,300,RC,83718,HCPCS,,,facility,inpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,82.20,112.07,percent of total billed charges,
HDL CHOLESTEROL,596700,CDM,300,RC,83718,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,7.59,112.07,percent of total billed charges,
HDL CHOLESTEROL,596728,CDM,300,RC,83718,HCPCS,,,facility,inpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,82.20,112.07,percent of total billed charges,
HDL CHOLESTEROL,596728,CDM,300,RC,83718,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,7.59,112.07,percent of total billed charges,
RENAL FUNCTION PANEL,596651,CDM,300,RC,80069,HCPCS,,,facility,inpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,154.80,211.04,percent of total billed charges,
RENAL FUNCTION PANEL,596651,CDM,300,RC,80069,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,8.04,211.04,percent of total billed charges,
LACTATE,2942846,CDM,300,RC,83605,HCPCS,,,facility,inpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,109.20,148.88,percent of total billed charges,
LACTATE,2942846,CDM,300,RC,83605,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,10.72,148.88,percent of total billed charges,
LACTATE,596724,CDM,300,RC,83605,HCPCS,,,facility,inpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,109.20,148.88,percent of total billed charges,
LACTATE,596724,CDM,300,RC,83605,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,10.72,148.88,percent of total billed charges,
LACTATE,6345860,CDM,300,RC,83605,HCPCS,,,facility,inpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,109.20,148.88,percent of total billed charges,
LACTATE,6345860,CDM,300,RC,83605,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,10.72,148.88,percent of total billed charges,
BODY FLUID LD,596795,CDM,300,RC,83615,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
BODY FLUID LD,596795,CDM,300,RC,83615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,5.60,112.88,percent of total billed charges,
LACTATE DEHYDROGENASE,596725,CDM,300,RC,83615,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
LACTATE DEHYDROGENASE,596725,CDM,300,RC,83615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,5.60,112.88,percent of total billed charges,
LIPASE,596726,CDM,300,RC,83690,HCPCS,,,facility,inpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
LIPASE,596726,CDM,300,RC,83690,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,6.19,108.79,percent of total billed charges,
LIPID PANEL CHOL TRIG HDL LDL,596727,CDM,300,RC,80061,HCPCS,,,facility,inpatient,,,309.00000,89.61000,Aetna,First Health,,252.76,,,,,,,185.40,252.76,percent of total billed charges,
LIPID PANEL CHOL TRIG HDL LDL,596727,CDM,300,RC,80061,HCPCS,,,facility,outpatient,,,309.00000,89.61000,Aetna,First Health,,252.76,,,,,,,12.41,252.76,percent of total billed charges,
METABOLIC PANEL TOTAL CA,8134945,CDM,300,RC,80048,HCPCS,,,facility,inpatient,,,311.00000,90.19000,Aetna,First Health,,254.40,,,,,,,186.60,254.40,percent of total billed charges,
METABOLIC PANEL TOTAL CA,8134945,CDM,300,RC,80048,HCPCS,,,facility,outpatient,,,311.00000,90.19000,Aetna,First Health,,254.40,,,,,,,7.84,254.40,percent of total billed charges,
HEPATIC FUNCTION PANEL,8134944,CDM,300,RC,80076,HCPCS,,,facility,inpatient,,,268.00000,77.72000,Aetna,First Health,,219.22,,,,,,,160.80,219.22,percent of total billed charges,
HEPATIC FUNCTION PANEL,8134944,CDM,300,RC,80076,HCPCS,,,facility,outpatient,,,268.00000,77.72000,Aetna,First Health,,219.22,,,,,,,7.57,219.22,percent of total billed charges,
CREATINE MB FRACTION,8134946,CDM,300,RC,82553,HCPCS,,,facility,inpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,123.00,167.69,percent of total billed charges,
CREATINE MB FRACTION,8134946,CDM,300,RC,82553,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,10.71,167.69,percent of total billed charges,
ASSAY GLUCOSE BLOOD QUANT,8142650,CDM,300,RC,82947,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
ASSAY GLUCOSE BLOOD QUANT,8142650,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
ASSAY OF TROPONIN QUANT,8134948,CDM,300,RC,84484,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
ASSAY OF TROPONIN QUANT,8134948,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.39,164.42,percent of total billed charges,
LITHIUM LEVEL,596779,CDM,300,RC,80178,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
LITHIUM LEVEL,596779,CDM,300,RC,80178,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,6.13,94.07,percent of total billed charges,
LITHIUM LEVEL,596780,CDM,300,RC,80178,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
LITHIUM LEVEL,596780,CDM,300,RC,80178,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,6.13,94.07,percent of total billed charges,
Myoglobin,613103,CDM,300,RC,83874,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
Myoglobin,613103,CDM,300,RC,83874,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,11.98,144.79,percent of total billed charges,
MAGNESIUM LEVEL,596791,CDM,300,RC,83735,HCPCS,,,facility,inpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,71.40,97.34,percent of total billed charges,
MAGNESIUM LEVEL,596791,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,6.21,97.34,percent of total billed charges,
MAGNESIUM LEVEL,596792,CDM,300,RC,83735,HCPCS,,,facility,inpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,71.40,97.34,percent of total billed charges,
MAGNESIUM LEVEL,596792,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,6.21,97.34,percent of total billed charges,
MAGNESIUM LEVEL,599678,CDM,300,RC,83735,HCPCS,,,facility,inpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,71.40,97.34,percent of total billed charges,
MAGNESIUM LEVEL,599678,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,6.21,97.34,percent of total billed charges,
MAGNESIUM LEVEL,599693,CDM,300,RC,83735,HCPCS,,,facility,inpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,71.40,97.34,percent of total billed charges,
MAGNESIUM LEVEL,599693,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,6.21,97.34,percent of total billed charges,
MICROALBUMIN CREATININE RATIO,1073830,CDM,300,RC,82043,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
MICROALBUMIN CREATININE RATIO,1073830,CDM,300,RC,82043,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,3.83,124.34,percent of total billed charges,
MICROALBUMIN CREATININE RATIO,1073831,CDM,300,RC,82043,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
MICROALBUMIN CREATININE RATIO,1073831,CDM,300,RC,82043,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,3.83,124.34,percent of total billed charges,
MICROALBUMIN CREATININE RATIO,628526,CDM,300,RC,82043,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
MICROALBUMIN CREATININE RATIO,628526,CDM,300,RC,82043,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,3.83,124.34,percent of total billed charges,
MICROALBUMIN,8326170,CDM,300,RC,82043,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
MICROALBUMIN,8326170,CDM,300,RC,82043,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,3.83,124.34,percent of total billed charges,
OSMOLALITY BLOOD,596731,CDM,300,RC,83930,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
OSMOLALITY BLOOD,596731,CDM,300,RC,83930,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,6.13,112.88,percent of total billed charges,
BODY FLUID PH,596794,CDM,300,RC,83986,HCPCS,,,facility,inpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,76.20,103.89,percent of total billed charges,
BODY FLUID PH,596794,CDM,300,RC,83986,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,3.32,103.89,percent of total billed charges,
PHOSPHOROUS URINE,596666,CDM,300,RC,84105,HCPCS,,,facility,inpatient,,,103.00000,29.87000,Aetna,First Health,,84.25,,,,,,,61.80,84.25,percent of total billed charges,
PHOSPHOROUS URINE,596666,CDM,300,RC,84105,HCPCS,,,facility,outpatient,,,103.00000,29.87000,Aetna,First Health,,84.25,,,,,,,5.36,84.25,percent of total billed charges,
PHOSPHOROUS URINE,596737,CDM,300,RC,84105,HCPCS,,,facility,inpatient,,,103.00000,29.87000,Aetna,First Health,,84.25,,,,,,,61.80,84.25,percent of total billed charges,
PHOSPHOROUS URINE,596737,CDM,300,RC,84105,HCPCS,,,facility,outpatient,,,103.00000,29.87000,Aetna,First Health,,84.25,,,,,,,5.36,84.25,percent of total billed charges,
Acetaminophen Level Addl,8229179,CDM,300,RC,80143,HCPCS,,,facility,inpatient,,,225.00000,65.25000,Aetna,First Health,GY,184.05,,,,,,,135.00,184.05,percent of total billed charges,
Acetaminophen Level Addl,8229179,CDM,300,RC,80143,HCPCS,,,facility,outpatient,,,225.00000,65.25000,Aetna,First Health,GY,184.05,,,,,,,17.28,184.05,percent of total billed charges,
Ethanol Addl,8229177,CDM,300,RC,82077,HCPCS,,,facility,inpatient,,,176.00000,51.04000,Aetna,First Health,GY,143.97,,,,,,,105.60,143.97,percent of total billed charges,
Ethanol Addl,8229177,CDM,300,RC,82077,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,First Health,GY,143.97,,,,,,,16.01,143.97,percent of total billed charges,
hCG Quant Addl,8229417,CDM,300,RC,84702,HCPCS,,,facility,inpatient,,,185.00000,53.65000,Aetna,First Health,GY,151.33,,,,,,,111.00,151.33,percent of total billed charges,
hCG Quant Addl,8229417,CDM,300,RC,84702,HCPCS,,,facility,outpatient,,,185.00000,53.65000,Aetna,First Health,GY,151.33,,,,,,,13.96,151.33,percent of total billed charges,
Arterial Blood gas Addl,8229333,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,GY,258.49,,,,,,,189.60,258.49,percent of total billed charges,
Arterial Blood gas Addl,8229333,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,GY,258.49,,,,,,,7.68,258.49,percent of total billed charges,
Venous Blood Gas Addl,8229336,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,GY,258.49,,,,,,,189.60,258.49,percent of total billed charges,
Venous Blood Gas Addl,8229336,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,GY,258.49,,,,,,,7.68,258.49,percent of total billed charges,
BUN Addl,8229401,CDM,300,RC,84520,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BUN Addl,8229401,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,3.67,73.62,percent of total billed charges,
Glucose Blood Addl,8229363,CDM,300,RC,82947,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,54.00,73.62,percent of total billed charges,
Glucose Blood Addl,8229363,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,3.65,73.62,percent of total billed charges,
Potassium Level Addl,8229375,CDM,300,RC,84132,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,GY,50.72,,,,,,,37.20,50.72,percent of total billed charges,
Potassium Level Addl,8229375,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,GY,50.72,,,,,,,4.41,50.72,percent of total billed charges,
Salicylate Level Addl,8229178,CDM,300,RC,80179,HCPCS,,,facility,inpatient,,,204.00000,59.16000,Aetna,First Health,GY,166.87,,,,,,,122.40,166.87,percent of total billed charges,
Salicylate Level Addl,8229178,CDM,300,RC,80179,HCPCS,,,facility,outpatient,,,204.00000,59.16000,Aetna,First Health,GY,166.87,,,,,,,17.28,166.87,percent of total billed charges,
Sodium Addl,8229415,CDM,300,RC,84295,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,GY,68.71,,,,,,,50.40,68.71,percent of total billed charges,
Sodium Addl,8229415,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,GY,68.71,,,,,,,4.46,68.71,percent of total billed charges,
METABOLIC PANEL TOTAL CA Addl,8229168,CDM,300,RC,80048,HCPCS,,,facility,inpatient,,,311.00000,90.19000,Aetna,First Health,GY,254.40,,,,,,,186.60,254.40,percent of total billed charges,
METABOLIC PANEL TOTAL CA Addl,8229168,CDM,300,RC,80048,HCPCS,,,facility,outpatient,,,311.00000,90.19000,Aetna,First Health,GY,254.40,,,,,,,7.84,254.40,percent of total billed charges,
ELECTROLYTE PANEL Addl,8229169,CDM,300,RC,80051,HCPCS,,,facility,inpatient,,,271.00000,78.59000,Aetna,First Health,GY,221.68,,,,,,,162.60,221.68,percent of total billed charges,
ELECTROLYTE PANEL Addl,8229169,CDM,300,RC,80051,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,First Health,GY,221.68,,,,,,,6.50,221.68,percent of total billed charges,
Bili Total Addl,8229184,CDM,300,RC,82247,HCPCS,,,facility,inpatient,,,123.00000,35.67000,Aetna,First Health,GY,100.61,,,,,,,73.80,100.61,percent of total billed charges,
Bili Total Addl,8229184,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,First Health,GY,100.61,,,,,,,4.66,100.61,percent of total billed charges,
Chloride Addl,8229186,CDM,300,RC,82435,HCPCS,,,facility,inpatient,,,57.00000,16.53000,Aetna,First Health,GY,46.63,,,,,,,34.20,46.63,percent of total billed charges,
Chloride Addl,8229186,CDM,300,RC,82435,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,First Health,GY,46.63,,,,,,,4.26,46.63,percent of total billed charges,
Creatinine Blood Addl,8229187,CDM,300,RC,82565,HCPCS,,,facility,inpatient,,,96.00000,27.84000,Aetna,First Health,GY,78.53,,,,,,,57.60,78.53,percent of total billed charges,
Creatinine Blood Addl,8229187,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,96.00000,27.84000,Aetna,First Health,GY,78.53,,,,,,,4.75,78.53,percent of total billed charges,
Body fluid glucose Addl,8229189,CDM,300,RC,82945,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,54.00,73.62,percent of total billed charges,
Body fluid glucose Addl,8229189,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,3.65,73.62,percent of total billed charges,
T4 Addl,8229194,CDM,300,RC,84436,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,GY,116.16,,,,,,,85.20,116.16,percent of total billed charges,
T4 Addl,8229194,CDM,300,RC,84436,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,GY,116.16,,,,,,,6.37,116.16,percent of total billed charges,
AST Addl,8229195,CDM,300,RC,84450,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,GY,61.35,,,,,,,45.00,61.35,percent of total billed charges,
AST Addl,8229195,CDM,300,RC,84450,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,GY,61.35,,,,,,,4.80,61.35,percent of total billed charges,
ALT Addl,8229196,CDM,300,RC,84460,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,GY,62.99,,,,,,,46.20,62.99,percent of total billed charges,
ALT Addl,8229196,CDM,300,RC,84460,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,GY,62.99,,,,,,,4.91,62.99,percent of total billed charges,
Troponin I Addl,8229950,CDM,300,RC,84484,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
Troponin I Addl,8229950,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.39,164.42,percent of total billed charges,
POTASSIUM LEVEL,596740,CDM,300,RC,84132,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM LEVEL,596740,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.41,50.72,percent of total billed charges,
POTASSIUM LEVEL,658420,CDM,300,RC,84132,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM LEVEL,658420,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.41,50.72,percent of total billed charges,
POTASSIUM LEVEL,7946072,CDM,300,RC,84132,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM LEVEL,7946072,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.41,50.72,percent of total billed charges,
POTASSIUM BLOOD,8367781,CDM,300,RC,84132,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM BLOOD,8367781,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.41,50.72,percent of total billed charges,
POTASSIUM URINE,596667,CDM,300,RC,84133,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM URINE,596667,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.39,50.72,percent of total billed charges,
POTASSIUM URINE,596738,CDM,300,RC,84133,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM URINE,596738,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.39,50.72,percent of total billed charges,
POTASSIUM URINE,602501,CDM,300,RC,84133,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM URINE,602501,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.39,50.72,percent of total billed charges,
POTASSIUM URINE,610827,CDM,300,RC,84133,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM URINE,610827,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.39,50.72,percent of total billed charges,
POTASSIUM URINE,613069,CDM,300,RC,84133,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM URINE,613069,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.39,50.72,percent of total billed charges,
PREALBUMIN,596739,CDM,300,RC,84134,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,100.80,137.42,percent of total billed charges,
PREALBUMIN,596739,CDM,300,RC,84134,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,13.52,137.42,percent of total billed charges,
CREATININE KINASE TOTAL,596703,CDM,300,RC,82550,HCPCS,,,facility,inpatient,,,196.00000,56.84000,Aetna,First Health,,160.33,,,,,,,117.60,160.33,percent of total billed charges,
CREATININE KINASE TOTAL,596703,CDM,300,RC,82550,HCPCS,,,facility,outpatient,,,196.00000,56.84000,Aetna,First Health,,160.33,,,,,,,6.04,160.33,percent of total billed charges,
CK Total,613100,CDM,300,RC,82550,HCPCS,,,facility,inpatient,,,196.00000,56.84000,Aetna,First Health,,160.33,,,,,,,117.60,160.33,percent of total billed charges,
CK Total,613100,CDM,300,RC,82550,HCPCS,,,facility,outpatient,,,196.00000,56.84000,Aetna,First Health,,160.33,,,,,,,6.04,160.33,percent of total billed charges,
SYNOVIAL FLUID GLUCOSE,596817,CDM,300,RC,82945,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
SYNOVIAL FLUID GLUCOSE,596817,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
URINE OSMOLALITY,596732,CDM,300,RC,83935,HCPCS,,,facility,inpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,82.20,112.07,percent of total billed charges,
URINE OSMOLALITY,596732,CDM,300,RC,83935,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,6.32,112.07,percent of total billed charges,
URINE OSMOLALITY,596733,CDM,300,RC,83935,HCPCS,,,facility,inpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,82.20,112.07,percent of total billed charges,
URINE OSMOLALITY,596733,CDM,300,RC,83935,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,6.32,112.07,percent of total billed charges,
PHOSPHOROUS BLOOD,596736,CDM,300,RC,84100,HCPCS,,,facility,inpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,56.40,76.89,percent of total billed charges,
PHOSPHOROUS BLOOD,596736,CDM,300,RC,84100,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,4.40,76.89,percent of total billed charges,
PHOSPHOROUS BLOOD,599679,CDM,300,RC,84100,HCPCS,,,facility,inpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,56.40,76.89,percent of total billed charges,
PHOSPHOROUS BLOOD,599679,CDM,300,RC,84100,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,4.40,76.89,percent of total billed charges,
PHOSPHOROUS BLOOD,599694,CDM,300,RC,84100,HCPCS,,,facility,inpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,56.40,76.89,percent of total billed charges,
PHOSPHOROUS BLOOD,599694,CDM,300,RC,84100,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,4.40,76.89,percent of total billed charges,
CEREBRAL SPINAL FLUID PROTEIN,596814,CDM,300,RC,84157,HCPCS,,,facility,inpatient,,,93.00000,26.97000,Aetna,First Health,,76.07,,,,,,,55.80,76.07,percent of total billed charges,
CEREBRAL SPINAL FLUID PROTEIN,596814,CDM,300,RC,84157,HCPCS,,,facility,outpatient,,,93.00000,26.97000,Aetna,First Health,,76.07,,,,,,,3.71,76.07,percent of total billed charges,
BODY FLUID PROTEIN,596812,CDM,300,RC,84157,HCPCS,,,facility,inpatient,,,93.00000,26.97000,Aetna,First Health,,76.07,,,,,,,55.80,76.07,percent of total billed charges,
BODY FLUID PROTEIN,596812,CDM,300,RC,84157,HCPCS,,,facility,outpatient,,,93.00000,26.97000,Aetna,First Health,,76.07,,,,,,,3.71,76.07,percent of total billed charges,
BODY FLUID PROTEIN,656538,CDM,300,RC,84157,HCPCS,,,facility,inpatient,,,93.00000,26.97000,Aetna,First Health,,76.07,,,,,,,55.80,76.07,percent of total billed charges,
BODY FLUID PROTEIN,656538,CDM,300,RC,84157,HCPCS,,,facility,outpatient,,,93.00000,26.97000,Aetna,First Health,,76.07,,,,,,,3.71,76.07,percent of total billed charges,
PROTEIN URINE,596744,CDM,300,RC,84156,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
PROTEIN URINE,596744,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN URINE,596745,CDM,300,RC,84156,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
PROTEIN URINE,596745,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN URINE,596746,CDM,300,RC,84156,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
PROTEIN URINE,596746,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN URINE,663098,CDM,300,RC,84156,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
PROTEIN URINE,663098,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,3.40,89.16,percent of total billed charges,
ASPARTATE AMINOTRANSFERASE,596758,CDM,300,RC,84450,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
ASPARTATE AMINOTRANSFERASE,596758,CDM,300,RC,84450,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,4.80,61.35,percent of total billed charges,
ASPARTATE AMINOTRANSFERASE,599672,CDM,300,RC,84450,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
ASPARTATE AMINOTRANSFERASE,599672,CDM,300,RC,84450,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,4.80,61.35,percent of total billed charges,
HEMOGLOBIN A1C,605755,CDM,300,RC,83036,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
HEMOGLOBIN A1C,605755,CDM,300,RC,83036,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,9.00,127.61,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN DIAGNOS,596741,CDM,300,RC,84153,HCPCS,,,facility,inpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,128.40,175.05,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN DIAGNOS,596741,CDM,300,RC,84153,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,17.05,175.05,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN DIAGNOS,646394,CDM,300,RC,84153,HCPCS,,,facility,inpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,128.40,175.05,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN DIAGNOS,646394,CDM,300,RC,84153,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,17.05,175.05,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN SCREEN,596742,CDM,300,RC,G0103,HCPCS,,,facility,inpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,128.40,175.05,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN SCREEN,596742,CDM,300,RC,G0103,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,17.90,175.05,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN FREE,629514,CDM,300,RC,84154,HCPCS,,,facility,inpatient,,,190.00000,55.10000,Aetna,First Health,,155.42,,,,,,,114.00,155.42,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN FREE,629514,CDM,300,RC,84154,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,First Health,,155.42,,,,,,,17.05,155.42,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN FREE,849798,CDM,300,RC,84154,HCPCS,,,facility,inpatient,,,190.00000,55.10000,Aetna,First Health,,155.42,,,,,,,114.00,155.42,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN FREE,849798,CDM,300,RC,84154,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,First Health,,155.42,,,,,,,17.05,155.42,percent of total billed charges,
PROTEIN TOTAL,596743,CDM,300,RC,84155,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
PROTEIN TOTAL,596743,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN TOTAL,597159,CDM,300,RC,84155,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
PROTEIN TOTAL,597159,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN TOTAL,599680,CDM,300,RC,84155,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
PROTEIN TOTAL,599680,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN TOTAL,613072,CDM,300,RC,84155,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
PROTEIN TOTAL,613072,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN URINE,8326171,CDM,300,RC,84156,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
PROTEIN URINE,8326171,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,3.40,89.16,percent of total billed charges,
RHEUMATOID FACTOR,605674,CDM,300,RC,86431,HCPCS,,,facility,inpatient,,,125.00000,36.25000,Aetna,First Health,,102.25,,,,,,,75.00,102.25,percent of total billed charges,
RHEUMATOID FACTOR,605674,CDM,300,RC,86431,HCPCS,,,facility,outpatient,,,125.00000,36.25000,Aetna,First Health,,102.25,,,,,,,5.25,102.25,percent of total billed charges,
SALICYLATE LEVEL,596786,CDM,300,RC,80179,HCPCS,,,facility,inpatient,,,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,122.40,166.87,percent of total billed charges,
SALICYLATE LEVEL,596786,CDM,300,RC,80179,HCPCS,,,facility,outpatient,,,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,17.28,166.87,percent of total billed charges,
SODIUM LEVEL,596747,CDM,300,RC,84295,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM LEVEL,596747,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.46,68.71,percent of total billed charges,
SODIUM LEVEL,656682,CDM,300,RC,84295,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM LEVEL,656682,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.46,68.71,percent of total billed charges,
SODIUM LEVEL,658421,CDM,300,RC,84295,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM LEVEL,658421,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.46,68.71,percent of total billed charges,
SODIUM LEVEL,7946073,CDM,300,RC,84295,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM LEVEL,7946073,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.46,68.71,percent of total billed charges,
SODIUM BLOOD,8367780,CDM,300,RC,84295,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM BLOOD,8367780,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.46,68.71,percent of total billed charges,
ALANINE AMINOTRANSFERASE,596759,CDM,300,RC,84460,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
ALANINE AMINOTRANSFERASE,596759,CDM,300,RC,84460,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,4.91,62.99,percent of total billed charges,
ALANINE AMINOTRANSFERASE,599671,CDM,300,RC,84460,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
ALANINE AMINOTRANSFERASE,599671,CDM,300,RC,84460,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,4.91,62.99,percent of total billed charges,
Coronavirus 19 SARS CoV 2 IgG,8338457,CDM,300,RC,86769,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
Coronavirus 19 SARS CoV 2 IgG,8338457,CDM,300,RC,86769,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,39.06,132.52,percent of total billed charges,
SODIUM URINE,596665,CDM,300,RC,84300,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM URINE,596665,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.69,68.71,percent of total billed charges,
SODIUM URINE,596670,CDM,300,RC,84300,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM URINE,596670,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.69,68.71,percent of total billed charges,
SODIUM URINE,596748,CDM,300,RC,84300,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM URINE,596748,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.69,68.71,percent of total billed charges,
SODIUM URINE,602502,CDM,300,RC,84300,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM URINE,602502,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.69,68.71,percent of total billed charges,
SODIUM URINE,610828,CDM,300,RC,84300,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM URINE,610828,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.69,68.71,percent of total billed charges,
Sodium Random Urine,617727,CDM,300,RC,84300,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
Sodium Random Urine,617727,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.69,68.71,percent of total billed charges,
THYROXINE TOTAL,596720,CDM,300,RC,84436,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,85.20,116.16,percent of total billed charges,
THYROXINE TOTAL,596720,CDM,300,RC,84436,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,6.37,116.16,percent of total billed charges,
THYROXINE TOTAL,663030,CDM,300,RC,84436,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,85.20,116.16,percent of total billed charges,
THYROXINE TOTAL,663030,CDM,300,RC,84436,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,6.37,116.16,percent of total billed charges,
FREE THYROXINE,596756,CDM,300,RC,84439,HCPCS,,,facility,inpatient,,,232.00000,67.28000,Aetna,First Health,,189.78,,,,,,,139.20,189.78,percent of total billed charges,
FREE THYROXINE,596756,CDM,300,RC,84439,HCPCS,,,facility,outpatient,,,232.00000,67.28000,Aetna,First Health,,189.78,,,,,,,8.36,189.78,percent of total billed charges,
T3 TOTAL,605607,CDM,300,RC,84480,HCPCS,,,facility,inpatient,,,190.00000,55.10000,Aetna,First Health,,155.42,,,,,,,114.00,155.42,percent of total billed charges,
T3 TOTAL,605607,CDM,300,RC,84480,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,First Health,,155.42,,,,,,,13.14,155.42,percent of total billed charges,
T3 FREE,604473,CDM,300,RC,84481,HCPCS,,,facility,inpatient,,,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,151.80,206.95,percent of total billed charges,
T3 FREE,604473,CDM,300,RC,84481,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,15.71,206.95,percent of total billed charges,
Total Volume 24 Hr Urine,613071,CDM,300,RC,81050,HCPCS,,,facility,inpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,24.00,32.72,percent of total billed charges,
Total Volume 24 Hr Urine,613071,CDM,300,RC,81050,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,3.38,32.72,percent of total billed charges,
TOTAL VOLUME TIMED URINE,644493,CDM,300,RC,81050,HCPCS,,,facility,inpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,24.00,32.72,percent of total billed charges,
TOTAL VOLUME TIMED URINE,644493,CDM,300,RC,81050,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,3.38,32.72,percent of total billed charges,
TRANSFERRIN,606218,CDM,300,RC,84466,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,96.00,130.88,percent of total billed charges,
TRANSFERRIN,606218,CDM,300,RC,84466,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,11.82,130.88,percent of total billed charges,
TRIGLYCERIDES,596760,CDM,300,RC,84478,HCPCS,,,facility,inpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,72.00,98.16,percent of total billed charges,
TRIGLYCERIDES,596760,CDM,300,RC,84478,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,5.33,98.16,percent of total billed charges,
TRIGLYCERIDES,596811,CDM,300,RC,84478,HCPCS,,,facility,inpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,72.00,98.16,percent of total billed charges,
TRIGLYCERIDES,596811,CDM,300,RC,84478,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,5.33,98.16,percent of total billed charges,
TRIGLYCERIDES,599681,CDM,300,RC,84478,HCPCS,,,facility,inpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,72.00,98.16,percent of total billed charges,
TRIGLYCERIDES,599681,CDM,300,RC,84478,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,5.33,98.16,percent of total billed charges,
TRIGLYCERIDES,599695,CDM,300,RC,84478,HCPCS,,,facility,inpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,72.00,98.16,percent of total billed charges,
TRIGLYCERIDES,599695,CDM,300,RC,84478,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,5.33,98.16,percent of total billed charges,
VANCOMYCIN LEVEL,596685,CDM,300,RC,80202,HCPCS,,,facility,inpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,157.20,214.32,percent of total billed charges,
VANCOMYCIN LEVEL,596685,CDM,300,RC,80202,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,12.56,214.32,percent of total billed charges,
VANCOMYCIN LEVEL,596686,CDM,300,RC,80202,HCPCS,,,facility,inpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,157.20,214.32,percent of total billed charges,
VANCOMYCIN LEVEL,596686,CDM,300,RC,80202,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,12.56,214.32,percent of total billed charges,
VANCOMYCIN LEVEL,7948500,CDM,300,RC,80202,HCPCS,,,facility,inpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,157.20,214.32,percent of total billed charges,
VANCOMYCIN LEVEL,7948500,CDM,300,RC,80202,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,12.56,214.32,percent of total billed charges,
Troponin I,613101,CDM,300,RC,84484,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
Troponin I,613101,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.39,164.42,percent of total billed charges,
Troponin I  HighSensitivity,8926116,CDM,300,RC,84484,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
Troponin I  HighSensitivity,8926116,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.39,164.42,percent of total billed charges,
Troponin I CSCTRULE,8948140,CDM,300,RC,84484,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
Troponin I CSCTRULE,8948140,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.39,164.42,percent of total billed charges,
THYROID STIMULATING HORMONE,596757,CDM,300,RC,84443,HCPCS,,,facility,inpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,129.00,175.87,percent of total billed charges,
THYROID STIMULATING HORMONE,596757,CDM,300,RC,84443,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,15.57,175.87,percent of total billed charges,
THYROID STIMULATING HORMONE,663031,CDM,300,RC,84443,HCPCS,,,facility,inpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,129.00,175.87,percent of total billed charges,
THYROID STIMULATING HORMONE,663031,CDM,300,RC,84443,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,15.57,175.87,percent of total billed charges,
THYROID STIMULATING HORMONE,8324475,CDM,300,RC,84443,HCPCS,,,facility,inpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,129.00,175.87,percent of total billed charges,
THYROID STIMULATING HORMONE,8324475,CDM,300,RC,84443,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,15.57,175.87,percent of total billed charges,
URIC ACID BLOOD,596769,CDM,300,RC,84550,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
URIC ACID BLOOD,596769,CDM,300,RC,84550,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,4.19,112.88,percent of total billed charges,
VALPROIC ACID LEVEL,596674,CDM,300,RC,80164,HCPCS,,,facility,inpatient,,,282.00000,81.78000,Aetna,First Health,,230.68,,,,,,,169.20,230.68,percent of total billed charges,
VALPROIC ACID LEVEL,596674,CDM,300,RC,80164,HCPCS,,,facility,outpatient,,,282.00000,81.78000,Aetna,First Health,,230.68,,,,,,,12.56,230.68,percent of total billed charges,
VALPROIC ACID LEVEL,596675,CDM,300,RC,80164,HCPCS,,,facility,inpatient,,,282.00000,81.78000,Aetna,First Health,,230.68,,,,,,,169.20,230.68,percent of total billed charges,
VALPROIC ACID LEVEL,596675,CDM,300,RC,80164,HCPCS,,,facility,outpatient,,,282.00000,81.78000,Aetna,First Health,,230.68,,,,,,,12.56,230.68,percent of total billed charges,
VITAMIN B12,599751,CDM,300,RC,82607,HCPCS,,,facility,inpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,118.20,161.15,percent of total billed charges,
VITAMIN B12,599751,CDM,300,RC,82607,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,13.98,161.15,percent of total billed charges,
ASSAY ALKALINE PHOSPHATASE Addl,8229192,CDM,300,RC,84075,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,GY,111.25,,,,,,,81.60,111.25,percent of total billed charges,
ASSAY ALKALINE PHOSPHATASE Addl,8229192,CDM,300,RC,84075,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,GY,111.25,,,,,,,4.80,111.25,percent of total billed charges,
CRYSTALLIZATION TEST AMNIO,1810824,CDM,300,RC,Q0114,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
CRYSTALLIZATION TEST AMNIO,1810824,CDM,300,RC,Q0114,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,9.03,99.80,percent of total billed charges,
diff,1461798,CDM,300,RC,89051,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,121.80,166.05,percent of total billed charges,
diff,1461798,CDM,300,RC,89051,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,5.19,166.05,percent of total billed charges,
diff,614938,CDM,300,RC,89051,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,121.80,166.05,percent of total billed charges,
diff,614938,CDM,300,RC,89051,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,5.19,166.05,percent of total billed charges,
Diff,646173,CDM,300,RC,89051,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,121.80,166.05,percent of total billed charges,
Diff,646173,CDM,300,RC,89051,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,5.19,166.05,percent of total billed charges,
Cell Count Fluid No Diff,595908,CDM,300,RC,89050,HCPCS,,,facility,inpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,94.80,129.24,percent of total billed charges,
Cell Count Fluid No Diff,595908,CDM,300,RC,89050,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,4.38,129.24,percent of total billed charges,
CELL COUNT FLUID NO DIFF,646174,CDM,300,RC,89050,HCPCS,,,facility,inpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,94.80,129.24,percent of total billed charges,
CELL COUNT FLUID NO DIFF,646174,CDM,300,RC,89050,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,4.38,129.24,percent of total billed charges,
BILE FLUID ANALYSIS,597206,CDM,300,RC,89060,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
BILE FLUID ANALYSIS,597206,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,6.80,99.80,percent of total billed charges,
FECAL VOLUME 24 HR,605908,CDM,300,RC,81050,HCPCS,,,facility,inpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,24.00,32.72,percent of total billed charges,
FECAL VOLUME 24 HR,605908,CDM,300,RC,81050,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,3.38,32.72,percent of total billed charges,
HEMOSIDERIN,604439,CDM,300,RC,83070,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
HEMOSIDERIN,604439,CDM,300,RC,83070,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,4.41,44.17,percent of total billed charges,
BODY FLUID CRYSTAL,596047,CDM,300,RC,89060,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
BODY FLUID CRYSTAL,596047,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,6.80,99.80,percent of total billed charges,
BODY FLUID CRYSTAL,596050,CDM,300,RC,89060,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
BODY FLUID CRYSTAL,596050,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,6.80,99.80,percent of total billed charges,
BILL UA PLUS MC,605152,CDM,300,RC,81001,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BILL UA PLUS MC,605152,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,2.94,73.62,percent of total billed charges,
BILL UA PLUS MC,614931,CDM,300,RC,81001,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BILL UA PLUS MC,614931,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,2.94,73.62,percent of total billed charges,
BILL UA PLUS MC,8569925,CDM,300,RC,81001,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BILL UA PLUS MC,8569925,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,2.94,73.62,percent of total billed charges,
UA Scope Foley,8878110,CDM,300,RC,81001,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
UA Scope Foley,8878110,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,2.94,73.62,percent of total billed charges,
BILL UA PLUS MC,8995880,CDM,300,RC,81001,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BILL UA PLUS MC,8995880,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,2.94,73.62,percent of total billed charges,
URINALYSIS WITHOUT MICRO,599584,CDM,300,RC,81003,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
URINALYSIS WITHOUT MICRO,599584,CDM,300,RC,81003,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,2.09,44.17,percent of total billed charges,
Urinalysis Auto without Scope,605214,CDM,300,RC,81003,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
Urinalysis Auto without Scope,605214,CDM,300,RC,81003,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,2.09,44.17,percent of total billed charges,
UA w Micro Addl,8229181,CDM,300,RC,81001,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,54.00,73.62,percent of total billed charges,
UA w Micro Addl,8229181,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,2.94,73.62,percent of total billed charges,
UA no micro Addl,8229182,CDM,300,RC,81003,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,GY,44.17,,,,,,,32.40,44.17,percent of total billed charges,
UA no micro Addl,8229182,CDM,300,RC,81003,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,GY,44.17,,,,,,,2.09,44.17,percent of total billed charges,
Body Fluid Cell Count Addl,8229215,CDM,300,RC,89051,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,GY,166.05,,,,,,,121.80,166.05,percent of total billed charges,
Body Fluid Cell Count Addl,8229215,CDM,300,RC,89051,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,GY,166.05,,,,,,,5.19,166.05,percent of total billed charges,
Synovial Crystals Addl,8229216,CDM,300,RC,89060,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GY,99.80,,,,,,,73.20,99.80,percent of total billed charges,
Synovial Crystals Addl,8229216,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GY,99.80,,,,,,,6.80,99.80,percent of total billed charges,
Bill UA w Mic Addl,8230203,CDM,300,RC,81001,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
Bill UA w Mic Addl,8230203,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,2.94,73.62,percent of total billed charges,
Urinalysis WO micro Addl,8230204,CDM,300,RC,81003,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
Urinalysis WO micro Addl,8230204,CDM,300,RC,81003,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,2.09,44.17,percent of total billed charges,
DIFF Fluid  Addl,8230231,CDM,300,RC,89051,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,121.80,166.05,percent of total billed charges,
DIFF Fluid  Addl,8230231,CDM,300,RC,89051,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,5.19,166.05,percent of total billed charges,
Bile Fluid Analysis Addl,8230232,CDM,300,RC,89060,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
Bile Fluid Analysis Addl,8230232,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,6.80,99.80,percent of total billed charges,
Fern Test Addl,8230234,CDM,300,RC,89060,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
Fern Test Addl,8230234,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,6.80,99.80,percent of total billed charges,
URINE MICROSCOPIC ONLY,605193,CDM,300,RC,81015,HCPCS,,,facility,inpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,38.40,52.35,percent of total billed charges,
URINE MICROSCOPIC ONLY,605193,CDM,300,RC,81015,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,2.83,52.35,percent of total billed charges,
Body Fluid Crystal Addl,8230233,CDM,300,RC,89060,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
Body Fluid Crystal Addl,8230233,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,6.80,99.80,percent of total billed charges,
BAL Differential Cell Count,9180652,CDM,300,RC,88106,HCPCS,,,facility,inpatient,,,226.00000,65.54000,Aetna,First Health,,184.87,,,,,,,135.60,184.87,percent of total billed charges,
BAL Differential Cell Count,9180652,CDM,300,RC,88106,HCPCS,,,facility,outpatient,,,226.00000,65.54000,Aetna,First Health,,184.87,,,,,,,21.51,184.87,percent of total billed charges,
BLOOD ALCOHOL CLINICAL REF LAB,596008,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,1650.00000,478.50000,Aetna,First Health,,1349.70,,,,,,,990.00,1349.70,percent of total billed charges,
BLOOD ALCOHOL CLINICAL REF LAB,596008,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,1650.00000,478.50000,Aetna,First Health,,1349.70,,,,,,,106.08,1349.70,percent of total billed charges,
TOX NON DOT,596010,CDM,300,RC,99001,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,74.40,101.43,percent of total billed charges,
TOX NON DOT,596010,CDM,300,RC,99001,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,13.00,101.43,percent of total billed charges,
TOX DOT,596011,CDM,300,RC,99001,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,74.40,101.43,percent of total billed charges,
TOX DOT,596011,CDM,300,RC,99001,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,13.00,101.43,percent of total billed charges,
TOXICOLOGY SPECIMEN COLLECTION,596016,CDM,300,RC,99001,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,74.40,101.43,percent of total billed charges,
TOXICOLOGY SPECIMEN COLLECTION,596016,CDM,300,RC,99001,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,13.00,101.43,percent of total billed charges,
BREATH ALCOHOL SCREENING,596012,CDM,300,RC,82075,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
BREATH ALCOHOL SCREENING,596012,CDM,300,RC,82075,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,16.04,79.50,percent of total billed charges,
TOXICOLOGY MRO SERVICES,660740,CDM,300,RC,,,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
TOXICOLOGY MRO SERVICES,660740,CDM,300,RC,,,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,9.73,22.09,percent of total billed charges,
BREATH ALCOHOL CONFIRMATION,596014,CDM,300,RC,82075,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
BREATH ALCOHOL CONFIRMATION,596014,CDM,300,RC,82075,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,16.04,79.50,percent of total billed charges,
BREATH ALCOHOL COURT TIME,596015,CDM,300,RC,,,,,facility,inpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
BREATH ALCOHOL COURT TIME,596015,CDM,300,RC,,,,,facility,outpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,14.06,31.90,percent of total billed charges,
TOX NON DOT STAT NKC,771798,CDM,300,RC,80305,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
TOX NON DOT STAT NKC,771798,CDM,300,RC,80305,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,11.68,121.06,percent of total billed charges,
CHLORIDE BLOOD POINT OF CARE,1663806,CDM,300,RC,82435,HCPCS,,,facility,inpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,34.20,46.63,percent of total billed charges,
CHLORIDE BLOOD POINT OF CARE,1663806,CDM,300,RC,82435,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,4.26,46.63,percent of total billed charges,
BLOOD GAS POINT OF CARE,1545821,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,1545821,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,2760856,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,2760856,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,2776876,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,2776876,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,5705843,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,5705843,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,6649840,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,6649840,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,6649846,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,6649846,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,6649850,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,6649850,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,7.68,258.49,percent of total billed charges,
HEMATOCRIT POINT OF CARE,1667821,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
HEMATOCRIT POINT OF CARE,1667821,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
POTASSIUM BLOOD POINT OF CARE,1545814,CDM,300,RC,84132,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM BLOOD POINT OF CARE,1545814,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.41,50.72,percent of total billed charges,
POTASSIUM BLOOD POINT OF CARE,2764840,CDM,300,RC,84132,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
POTASSIUM BLOOD POINT OF CARE,2764840,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,4.41,50.72,percent of total billed charges,
SODIUM BLOOD POINT OF CARE,1545813,CDM,300,RC,84295,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM BLOOD POINT OF CARE,1545813,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.46,68.71,percent of total billed charges,
SODIUM BLOOD POINT OF CARE,2802842,CDM,300,RC,84295,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,50.40,68.71,percent of total billed charges,
SODIUM BLOOD POINT OF CARE,2802842,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,,68.71,,,,,,,4.46,68.71,percent of total billed charges,
ACTIVATED CLOTTING TIME,636253,CDM,300,RC,85347,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
ACTIVATED CLOTTING TIME,636253,CDM,300,RC,85347,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,3.97,65.44,percent of total billed charges,
Activated Clotting Time,8948131,CDM,300,RC,85347,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
Activated Clotting Time,8948131,CDM,300,RC,85347,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,3.97,65.44,percent of total billed charges,
HEPCON ACT BILL ONLY TEST,599591,CDM,300,RC,85347,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
HEPCON ACT BILL ONLY TEST,599591,CDM,300,RC,85347,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,3.97,65.44,percent of total billed charges,
Hepcon Activated Clotting Time,8948132,CDM,300,RC,85347,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
Hepcon Activated Clotting Time,8948132,CDM,300,RC,85347,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,3.97,65.44,percent of total billed charges,
IONIZED CALCIUM POINT OF CARE,1661804,CDM,300,RC,82330,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
IONIZED CALCIUM POINT OF CARE,1661804,CDM,300,RC,82330,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,8.54,144.79,percent of total billed charges,
IONIZED CALCIUM POINT OF CARE,2764851,CDM,300,RC,82330,HCPCS,,,facility,inpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
IONIZED CALCIUM POINT OF CARE,2764851,CDM,300,RC,82330,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,8.54,144.79,percent of total billed charges,
HEPARIN ASSAY,599594,CDM,300,RC,85520,HCPCS,,,facility,inpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,136.80,186.50,percent of total billed charges,
HEPARIN ASSAY,599594,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,12.13,186.50,percent of total billed charges,
HEPARIN DOSE RESPONSE,599597,CDM,300,RC,85530,HCPCS,,,facility,inpatient,,,44.00000,12.76000,Aetna,First Health,,35.99,,,,,,,26.40,35.99,percent of total billed charges,
HEPARIN DOSE RESPONSE,599597,CDM,300,RC,85530,HCPCS,,,facility,outpatient,,,44.00000,12.76000,Aetna,First Health,,35.99,,,,,,,12.13,35.99,percent of total billed charges,
GLUCOSE BLOOD POINT OF CARE,1545817,CDM,300,RC,82947,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
GLUCOSE BLOOD POINT OF CARE,1545817,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.65,73.62,percent of total billed charges,
Glucose Point of Care Addl,8229364,CDM,300,RC,82947,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,54.00,73.62,percent of total billed charges,
Glucose Point of Care Addl,8229364,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,3.65,73.62,percent of total billed charges,
BLOOD UREA NITROGEN POINT OF CARE,1667809,CDM,300,RC,84520,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
BLOOD UREA NITROGEN POINT OF CARE,1667809,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,3.67,73.62,percent of total billed charges,
TROPONIN POINT OF CARE,1780824,CDM,300,RC,84484,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
TROPONIN POINT OF CARE,1780824,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.39,164.42,percent of total billed charges,
POC Troponin iSTAT CSCTRULE,8948139,CDM,300,RC,84484,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
POC Troponin iSTAT CSCTRULE,8948139,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.39,164.42,percent of total billed charges,
LACTATE POINT OF CARE,4813839,CDM,300,RC,83605,HCPCS,,,facility,inpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,109.20,148.88,percent of total billed charges,
LACTATE POINT OF CARE,4813839,CDM,300,RC,83605,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,10.72,148.88,percent of total billed charges,
HEMOGLOBIN POINT OF CARE,2760860,CDM,300,RC,85018,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
HEMOGLOBIN POINT OF CARE,2760860,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
HEMOGLOBIN POINT OF CARE,7919068,CDM,300,RC,85018,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
HEMOGLOBIN POINT OF CARE,7919068,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,2.19,54.81,percent of total billed charges,
BHCG POC,7935639,CDM,300,RC,84702,HCPCS,,,facility,inpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,111.60,152.15,percent of total billed charges,
BHCG POC,7935639,CDM,300,RC,84702,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,13.96,152.15,percent of total billed charges,
COAGULATION TIME ACTIVATED,8134950,CDM,300,RC,85347,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
COAGULATION TIME ACTIVATED,8134950,CDM,300,RC,85347,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,3.97,65.44,percent of total billed charges,
Blood Gas Point of Care Addl,8229335,CDM,300,RC,82803,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,GY,258.49,,,,,,,189.60,258.49,percent of total billed charges,
Blood Gas Point of Care Addl,8229335,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,GY,258.49,,,,,,,7.68,258.49,percent of total billed charges,
Hematocrit Point of Care Addl,8229414,CDM,300,RC,85014,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,GY,54.81,,,,,,,40.20,54.81,percent of total billed charges,
Hematocrit Point of Care Addl,8229414,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,GY,54.81,,,,,,,2.19,54.81,percent of total billed charges,
Sodium Point of Care Addl,8229416,CDM,300,RC,84295,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,First Health,GY,68.71,,,,,,,50.40,68.71,percent of total billed charges,
Sodium Point of Care Addl,8229416,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,First Health,GY,68.71,,,,,,,4.46,68.71,percent of total billed charges,
Blood Urea Nitrogen Point of Care Addl,8229402,CDM,300,RC,84520,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,54.00,73.62,percent of total billed charges,
Blood Urea Nitrogen Point of Care Addl,8229402,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,GY,73.62,,,,,,,3.67,73.62,percent of total billed charges,
Hemoglobin Point of Care Addl,8229203,CDM,300,RC,85018,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,GY,54.81,,,,,,,40.20,54.81,percent of total billed charges,
Hemoglobin Point of Care Addl,8229203,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,GY,54.81,,,,,,,2.19,54.81,percent of total billed charges,
HCG QUANT Point of Care Addl,8229418,CDM,300,RC,84702,HCPCS,,,facility,inpatient,,,186.00000,53.94000,Aetna,First Health,GY,152.15,,,,,,,111.60,152.15,percent of total billed charges,
HCG QUANT Point of Care Addl,8229418,CDM,300,RC,84702,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,First Health,GY,152.15,,,,,,,13.96,152.15,percent of total billed charges,
Potassium Point of Care Addl,8229193,CDM,300,RC,84132,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,GY,50.72,,,,,,,37.20,50.72,percent of total billed charges,
Potassium Point of Care Addl,8229193,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,GY,50.72,,,,,,,4.41,50.72,percent of total billed charges,
Troponin I Point of Care Addl,8229951,CDM,300,RC,84484,HCPCS,,,facility,inpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,120.60,164.42,percent of total billed charges,
Troponin I Point of Care Addl,8229951,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,First Health,,164.42,,,,,,,11.39,164.42,percent of total billed charges,
RF CONSULT HEM PATH,624903,CDM,300,RC,88325,HCPCS,,,facility,inpatient,,,379.00000,109.91000,Aetna,First Health,,310.02,,,,,,,227.40,310.02,percent of total billed charges,
RF CONSULT HEM PATH,624903,CDM,300,RC,88325,HCPCS,,,facility,outpatient,,,379.00000,109.91000,Aetna,First Health,,310.02,,,,,,,150.47,452.20,percent of total billed charges,
RF CONSULT WORK UP,624904,CDM,300,RC,88323,HCPCS,,,facility,inpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,144.00,196.32,percent of total billed charges,
RF CONSULT WORK UP,624904,CDM,300,RC,88323,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,46.92,196.32,percent of total billed charges,
RF BILL IHC MAWD,624905,CDM,300,RC,88342,HCPCS,,,facility,inpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,144.00,196.32,percent of total billed charges,
RF BILL IHC MAWD,624905,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,84.70,452.20,percent of total billed charges,
RF CONSULT,624906,CDM,300,RC,88321,HCPCS,,,facility,inpatient,,,379.00000,109.91000,Aetna,First Health,,310.02,,,,,,,227.40,310.02,percent of total billed charges,
RF CONSULT,624906,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,379.00000,109.91000,Aetna,First Health,,310.02,,,,,,,34.46,310.02,percent of total billed charges,
Tiss Cult,613075,CDM,300,RC,88237,HCPCS,,,facility,inpatient,,,249.00000,72.21000,Aetna,First Health,,203.68,,,,,,,149.40,203.68,percent of total billed charges,
Tiss Cult,613075,CDM,300,RC,88237,HCPCS,,,facility,outpatient,,,249.00000,72.21000,Aetna,First Health,,203.68,,,,,,,32.36,380.94,percent of total billed charges,
RECEPTOR ASSAY PROGESTERONE,1061799,CDM,300,RC,88360,HCPCS,,,facility,inpatient,,,311.00000,90.19000,Aetna,First Health,,254.40,,,,,,,186.60,254.40,percent of total billed charges,
RECEPTOR ASSAY PROGESTERONE,1061799,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,311.00000,90.19000,Aetna,First Health,,254.40,,,,,,,104.47,452.20,percent of total billed charges,
RECEPTOR ASSAY ESTROGEN,1061798,CDM,300,RC,88360,HCPCS,,,facility,inpatient,,,311.00000,90.19000,Aetna,First Health,,254.40,,,,,,,186.60,254.40,percent of total billed charges,
RECEPTOR ASSAY ESTROGEN,1061798,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,311.00000,90.19000,Aetna,First Health,,254.40,,,,,,,104.47,452.20,percent of total billed charges,
RF BILL SURG LEVEL IV,624897,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,444.00000,128.76000,Aetna,First Health,,363.19,,,,,,,266.40,363.19,percent of total billed charges,
RF BILL SURG LEVEL IV,624897,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,444.00000,128.76000,Aetna,First Health,,363.19,,,,,,,46.92,363.19,percent of total billed charges,
RF Surg Level IV,8948127,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,123.00,167.69,percent of total billed charges,
RF Surg Level IV,8948127,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,46.92,167.69,percent of total billed charges,
RF BILL GROUP II MAWD,6155847,CDM,300,RC,88313,HCPCS,,,facility,inpatient,,,199.00000,57.71000,Aetna,First Health,,162.78,,,,,,,119.40,162.78,percent of total billed charges,
RF BILL GROUP II MAWD,6155847,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,199.00000,57.71000,Aetna,First Health,,162.78,,,,,,,53.93,353.14,percent of total billed charges,
RF BILL SURG IPX MAYO,624902,CDM,300,RC,88342,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
RF BILL SURG IPX MAYO,624902,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,84.70,452.20,percent of total billed charges,
RF BILL SURG CONSULT MD ANDERSON,624910,CDM,300,RC,88321,HCPCS,,,facility,inpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,357.00,486.71,percent of total billed charges,
RF BILL SURG CONSULT MD ANDERSON,624910,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,34.46,486.71,percent of total billed charges,
RF GROUP II MAYO,624908,CDM,300,RC,88313,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
RF GROUP II MAYO,624908,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,53.93,353.14,percent of total billed charges,
RF BILL SURG CONSULT KU,624907,CDM,300,RC,88321,HCPCS,,,facility,inpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,357.00,486.71,percent of total billed charges,
RF BILL SURG CONSULT KU,624907,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,34.46,486.71,percent of total billed charges,
RF BILL SURG CONSULT UNIV OF NE,624911,CDM,300,RC,88321,HCPCS,,,facility,inpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,357.00,486.71,percent of total billed charges,
RF BILL SURG CONSULT UNIV OF NE,624911,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,34.46,486.71,percent of total billed charges,
RF BILL SURG CONSULT ST LUKES,624912,CDM,300,RC,88321,HCPCS,,,facility,inpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,357.00,486.71,percent of total billed charges,
RF BILL SURG CONSULT ST LUKES,624912,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,34.46,486.71,percent of total billed charges,
RF BILL SURG CONSULT MASS GEN,624913,CDM,300,RC,88321,HCPCS,,,facility,inpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,357.00,486.71,percent of total billed charges,
RF BILL SURG CONSULT MASS GEN,624913,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,34.46,486.71,percent of total billed charges,
RF BILL CYTO NONGYN SMR MAWD,645753,CDM,300,RC,88104,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
RF BILL CYTO NONGYN SMR MAWD,645753,CDM,300,RC,88104,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,34.46,159.51,percent of total billed charges,
RF BILL CYTO NONGYN TECH MAWD,644293,CDM,300,RC,88112,HCPCS,,,facility,inpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,99.00,134.97,percent of total billed charges,
RF BILL CYTO NONGYN TECH MAWD,644293,CDM,300,RC,88112,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,46.92,176.63,percent of total billed charges,
RF BILL SURG ERT,644294,CDM,300,RC,87230,HCPCS,,,facility,inpatient,,,163.00000,47.27000,Aetna,First Health,,133.33,,,,,,,97.80,133.33,percent of total billed charges,
RF BILL SURG ERT,644294,CDM,300,RC,87230,HCPCS,,,facility,outpatient,,,163.00000,47.27000,Aetna,First Health,,133.33,,,,,,,18.30,133.33,percent of total billed charges,
RF BILL SURG IHC MAWD,652163,CDM,300,RC,88361,HCPCS,,,facility,inpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,148.80,202.86,percent of total billed charges,
RF BILL SURG IHC MAWD,652163,CDM,300,RC,88361,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,116.56,951.40,percent of total billed charges,
RF ISH MAYO,652158,CDM,300,RC,88365,HCPCS,,,facility,inpatient,,,823.00000,238.67000,Aetna,First Health,,673.21,,,,,,,493.80,673.21,percent of total billed charges,
RF ISH MAYO,652158,CDM,300,RC,88365,HCPCS,,,facility,outpatient,,,823.00000,238.67000,Aetna,First Health,,673.21,,,,,,,121.31,673.21,percent of total billed charges,
HER 2 NEU,4375839,CDM,300,RC,83950,HCPCS,,,facility,inpatient,,,575.00000,166.75000,Aetna,First Health,,470.35,,,,,,,345.00,470.35,percent of total billed charges,
HER 2 NEU,4375839,CDM,300,RC,83950,HCPCS,,,facility,outpatient,,,575.00000,166.75000,Aetna,First Health,,470.35,,,,,,,59.71,470.35,percent of total billed charges,
RF BILL ISH MANUAL MAWD,5789839,CDM,300,RC,88368,HCPCS,,,facility,inpatient,,,234.00000,67.86000,Aetna,First Health,,191.41,,,,,,,140.40,191.41,percent of total billed charges,
RF BILL ISH MANUAL MAWD,5789839,CDM,300,RC,88368,HCPCS,,,facility,outpatient,,,234.00000,67.86000,Aetna,First Health,,191.41,,,,,,,109.98,951.40,percent of total billed charges,
RF BILL SPECIAL STAIN NEPHROPATH,6327841,CDM,300,RC,88312,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,144.60,197.14,percent of total billed charges,
RF BILL SPECIAL STAIN NEPHROPATH,6327841,CDM,300,RC,88312,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,46.92,197.14,percent of total billed charges,
RF BILL CYTO SMEAR MAWD,6155842,CDM,300,RC,88160,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,121.80,166.05,percent of total billed charges,
RF BILL CYTO SMEAR MAWD,6155842,CDM,300,RC,88160,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,21.51,166.05,percent of total billed charges,
RF BILL NEEDLE ASP INTERP MAWD,6155844,CDM,300,RC,88173,HCPCS,,,facility,inpatient,,,271.00000,78.59000,Aetna,First Health,,221.68,,,,,,,162.60,221.68,percent of total billed charges,
RF BILL NEEDLE ASP INTERP MAWD,6155844,CDM,300,RC,88173,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,First Health,,221.68,,,,,,,46.92,221.68,percent of total billed charges,
RF BILL SURG LEVEL IV MAWD,6155846,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
RF BILL SURG LEVEL IV MAWD,6155846,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,46.92,150.74,percent of total billed charges,
Micro Analysis MAWD CSCTRULE,8948126,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
Micro Analysis MAWD CSCTRULE,8948126,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,46.92,150.74,percent of total billed charges,
RF BILL TUMOR IHC MAWD,6155848,CDM,300,RC,88360,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
RF BILL TUMOR IHC MAWD,6155848,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,104.47,452.20,percent of total billed charges,
RF BILL HPV DNA AMP PROBE MAWD,6155839,CDM,300,RC,87624,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
RF BILL HPV DNA AMP PROBE MAWD,6155839,CDM,300,RC,87624,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,32.53,116.97,percent of total billed charges,
RF BILL CV PATH INTERP MAWD,6155840,CDM,300,RC,88141,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
RF BILL CV PATH INTERP MAWD,6155840,CDM,300,RC,88141,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,21.36,128.43,percent of total billed charges,
RF BILL CV AUTO FLUID MAWD,6155841,CDM,300,RC,88175,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,80.40,109.61,percent of total billed charges,
RF BILL CV AUTO FLUID MAWD,6155841,CDM,300,RC,88175,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,24.67,109.61,percent of total billed charges,
RF BILL FNA ADEQUACY MAWD,6155843,CDM,300,RC,88172,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
RF BILL FNA ADEQUACY MAWD,6155843,CDM,300,RC,88172,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,49.26,452.20,percent of total billed charges,
RF BILL FNA ADDL INTERP MAWD,6155845,CDM,300,RC,88177,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
RF BILL FNA ADDL INTERP MAWD,6155845,CDM,300,RC,88177,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,26.63,111.25,percent of total billed charges,
RF BILL MICRODISSECTION MAWD,6155849,CDM,300,RC,88381,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,183.00,249.49,percent of total billed charges,
RF BILL MICRODISSECTION MAWD,6155849,CDM,300,RC,88381,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,306.33,percent of total billed charges,
RF BILL STAIN ON TISS BLOCK MAYO,6323843,CDM,300,RC,88314,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
RF BILL STAIN ON TISS BLOCK MAYO,6323843,CDM,300,RC,88314,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,91.46,208.59,percent of total billed charges,
RF BILL STAINS GROUP III MAYO,6323844,CDM,300,RC,88319,HCPCS,,,facility,inpatient,,,270.00000,78.30000,Aetna,First Health,,220.86,,,,,,,162.00,220.86,percent of total billed charges,
RF BILL STAINS GROUP III MAYO,6323844,CDM,300,RC,88319,HCPCS,,,facility,outpatient,,,270.00000,78.30000,Aetna,First Health,,220.86,,,,,,,126.90,2138.50,percent of total billed charges,
RF BILL IRON LIVER TISSUE MAYO,6323845,CDM,300,RC,83540,HCPCS,,,facility,inpatient,,,263.00000,76.27000,Aetna,First Health,,215.13,,,,,,,157.80,215.13,percent of total billed charges,
RF BILL IRON LIVER TISSUE MAYO,6323845,CDM,300,RC,83540,HCPCS,,,facility,outpatient,,,263.00000,76.27000,Aetna,First Health,,215.13,,,,,,,5.99,215.13,percent of total billed charges,
RF BILL SURG LEVEL IV MAYO,6323842,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,323.40,440.90,percent of total billed charges,
RF BILL SURG LEVEL IV MAYO,6323842,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,46.92,440.90,percent of total billed charges,
RF Surg Level IV Mayo,8948128,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,323.40,440.90,percent of total billed charges,
RF Surg Level IV Mayo,8948128,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,46.92,440.90,percent of total billed charges,
RF BILL IHC MAYO,646653,CDM,300,RC,88342,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
RF BILL IHC MAYO,646653,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,84.70,452.20,percent of total billed charges,
RF BILL C TRACH MAWD,6271840,CDM,300,RC,87491,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
RF BILL C TRACH MAWD,6271840,CDM,300,RC,87491,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,32.53,116.97,percent of total billed charges,
RF BILL N GORNORRHOEAE MAWD,6271839,CDM,300,RC,87591,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
RF BILL N GORNORRHOEAE MAWD,6271839,CDM,300,RC,87591,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,32.53,116.97,percent of total billed charges,
RF MOL CYTOGEN DNA PROBE MAYO,3233446,CDM,300,RC,88271,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
RF MOL CYTOGEN DNA PROBE MAYO,3233446,CDM,300,RC,88271,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,19.86,125.97,percent of total billed charges,
RF MOL CYTOGEN DNA PROBE MAYO,3247839,CDM,300,RC,88271,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
RF MOL CYTOGEN DNA PROBE MAYO,3247839,CDM,300,RC,88271,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,19.86,125.97,percent of total billed charges,
RF MOL CYTOGEN DNA PROBE MAYO,6471839,CDM,300,RC,88271,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
RF MOL CYTOGEN DNA PROBE MAYO,6471839,CDM,300,RC,88271,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,19.86,125.97,percent of total billed charges,
RF BILL SURG IHC NEPHROPATH,624909,CDM,300,RC,88342,HCPCS,,,facility,inpatient,,,270.00000,78.30000,Aetna,First Health,,220.86,,,,,,,162.00,220.86,percent of total billed charges,
RF BILL SURG IHC NEPHROPATH,624909,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,270.00000,78.30000,Aetna,First Health,,220.86,,,,,,,84.70,452.20,percent of total billed charges,
RF BILL SURG LEVEL IV NEPHROPATH,2894853,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,123.00,167.69,percent of total billed charges,
RF BILL SURG LEVEL IV NEPHROPATH,2894853,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,46.92,167.69,percent of total billed charges,
RF Surg Level IV Neph,8948129,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,123.00,167.69,percent of total billed charges,
RF Surg Level IV Neph,8948129,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,46.92,167.69,percent of total billed charges,
Immunoassay Other,657701,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
Immunoassay Other,657701,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,16.01,126.79,percent of total billed charges,
ARSENIC BLOOD,657782,CDM,300,RC,82175,HCPCS,,,facility,inpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,34.20,46.63,percent of total billed charges,
ARSENIC BLOOD,657782,CDM,300,RC,82175,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,17.58,50.27,percent of total billed charges,
BILL TOUCH PREP FROZEN SECTION,592817,CDM,300,RC,88331,HCPCS,,,facility,inpatient,,,220.00000,63.80000,Aetna,First Health,,179.96,,,,,,,132.00,179.96,percent of total billed charges,
BILL TOUCH PREP FROZEN SECTION,592817,CDM,300,RC,88331,HCPCS,,,facility,outpatient,,,220.00000,63.80000,Aetna,First Health,,179.96,,,,,,,85.33,452.20,percent of total billed charges,
RF BILL HER 2 IHC CSI,7965322,CDM,300,RC,88361,HCPCS,,,facility,inpatient,,,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,137.40,187.32,percent of total billed charges,
RF BILL HER 2 IHC CSI,7965322,CDM,300,RC,88361,HCPCS,,,facility,outpatient,,,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,107.63,951.40,percent of total billed charges,
RF BILL ALK FISH MAWD,7965323,CDM,300,RC,88377,HCPCS,,,facility,inpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,300.00,409.00,percent of total billed charges,
RF BILL ALK FISH MAWD,7965323,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,150.47,452.20,percent of total billed charges,
RF BILL PD L1 CSI,7965324,CDM,300,RC,88360,HCPCS,,,facility,inpatient,,,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,137.40,187.32,percent of total billed charges,
RF BILL PD L1 CSI,7965324,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,104.47,452.20,percent of total billed charges,
RF BILL C KIT CSI,7968015,CDM,300,RC,81272,HCPCS,,,facility,inpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,218.40,297.75,percent of total billed charges,
RF BILL C KIT CSI,7968015,CDM,300,RC,81272,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,171.08,873.20,percent of total billed charges,
ISH FIRST PROBE,7987316,CDM,300,RC,88365,HCPCS,,,facility,inpatient,,,388.00000,112.52000,Aetna,First Health,,317.38,,,,,,,232.80,317.38,percent of total billed charges,
ISH FIRST PROBE,7987316,CDM,300,RC,88365,HCPCS,,,facility,outpatient,,,388.00000,112.52000,Aetna,First Health,,317.38,,,,,,,121.31,452.20,percent of total billed charges,
ISH ADDITIONAL PROBE,7987317,CDM,300,RC,88364,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,189.60,258.49,percent of total billed charges,
ISH ADDITIONAL PROBE,7987317,CDM,300,RC,88364,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,,258.49,,,,,,,113.92,258.49,percent of total billed charges,
MORPHOMETRIC IHC MANUAL,7987315,CDM,300,RC,88360,HCPCS,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
MORPHOMETRIC IHC MANUAL,7987315,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,104.47,452.20,percent of total billed charges,
RF BILL SURG EM NEPHROPATH,2894856,CDM,300,RC,88348,HCPCS,,,facility,inpatient,,,674.00000,195.46000,Aetna,First Health,,551.33,,,,,,,404.40,551.33,percent of total billed charges,
RF BILL SURG EM NEPHROPATH,2894856,CDM,300,RC,88348,HCPCS,,,facility,outpatient,,,674.00000,195.46000,Aetna,First Health,,551.33,,,,,,,316.78,2138.50,percent of total billed charges,
RF BILL SURG DIF NEPHROPATH,2894855,CDM,300,RC,88346,HCPCS,,,facility,inpatient,,,288.00000,83.52000,Aetna,First Health,,235.58,,,,,,,172.80,235.58,percent of total billed charges,
RF BILL SURG DIF NEPHROPATH,2894855,CDM,300,RC,88346,HCPCS,,,facility,outpatient,,,288.00000,83.52000,Aetna,First Health,,235.58,,,,,,,88.98,452.20,percent of total billed charges,
RF BILL SURG STN II NEPHROPATH,2894854,CDM,300,RC,88313,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
RF BILL SURG STN II NEPHROPATH,2894854,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,53.93,353.14,percent of total billed charges,
RF BILL GROUP I MAWD,5789840,CDM,300,RC,88312,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
RF BILL GROUP I MAWD,5789840,CDM,300,RC,88312,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,46.92,194.68,percent of total billed charges,
RF GROUP I MICRO MAYO,6409842,CDM,300,RC,88312,HCPCS,,,facility,inpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,138.00,188.14,percent of total billed charges,
RF GROUP I MICRO MAYO,6409842,CDM,300,RC,88312,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,46.92,188.14,percent of total billed charges,
RF ISH MANUAL MAYO,6409844,CDM,300,RC,88368,HCPCS,,,facility,inpatient,,,339.00000,98.31000,Aetna,First Health,,277.30,,,,,,,203.40,277.30,percent of total billed charges,
RF ISH MANUAL MAYO,6409844,CDM,300,RC,88368,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,First Health,,277.30,,,,,,,140.64,951.40,percent of total billed charges,
RF DIF MAYO,6409845,CDM,300,RC,88346,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
RF DIF MAYO,6409845,CDM,300,RC,88346,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,72.85,452.20,percent of total billed charges,
RF IN SITU HYBRID MAYO,6471840,CDM,300,RC,88275,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
RF IN SITU HYBRID MAYO,6471840,CDM,300,RC,88275,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,47.45,135.65,percent of total billed charges,
RF CYTO MOLE INTERP MAYO,6471841,CDM,300,RC,88291,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,80.40,109.61,percent of total billed charges,
RF CYTO MOLE INTERP MAYO,6471841,CDM,300,RC,88291,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,25.72,109.61,percent of total billed charges,
KRAS GENE ANALYSIS MAWD ZB4S1,7005842,CDM,300,RC,81275,HCPCS,,,facility,inpatient,,,424.00000,122.96000,Aetna,First Health,,346.83,,,,,,,254.40,346.83,percent of total billed charges,
KRAS GENE ANALYSIS MAWD ZB4S1,7005842,CDM,300,RC,81275,HCPCS,,,facility,outpatient,,,424.00000,122.96000,Aetna,First Health,,346.83,,,,,,,179.15,512.11,percent of total billed charges,
MICROSATELLITE INSTABILITY MAWD ZB4S5,7005843,CDM,300,RC,81301,HCPCS,,,facility,inpatient,,,653.00000,189.37000,Aetna,First Health,,534.15,,,,,,,391.80,534.15,percent of total billed charges,
MICROSATELLITE INSTABILITY MAWD ZB4S5,7005843,CDM,300,RC,81301,HCPCS,,,facility,outpatient,,,653.00000,189.37000,Aetna,First Health,,534.15,,,,,,,306.91,923.68,percent of total billed charges,
BRAF GENE ANALYSIS MAWD ZB4S2,7005844,CDM,300,RC,81210,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
BRAF GENE ANALYSIS MAWD ZB4S2,7005844,CDM,300,RC,81210,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,131.60,464.81,percent of total billed charges,
EGFR GENE ANALYSIS MAWD ZB4S3,7005841,CDM,300,RC,81235,HCPCS,,,facility,inpatient,,,424.00000,122.96000,Aetna,First Health,,346.83,,,,,,,254.40,346.83,percent of total billed charges,
EGFR GENE ANALYSIS MAWD ZB4S3,7005841,CDM,300,RC,81235,HCPCS,,,facility,outpatient,,,424.00000,122.96000,Aetna,First Health,,346.83,,,,,,,199.28,1154.35,percent of total billed charges,
ROS1 BY FISH MAWD,7523981,CDM,300,RC,88377,HCPCS,,,facility,inpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,300.00,409.00,percent of total billed charges,
ROS1 BY FISH MAWD,7523981,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,150.47,452.20,percent of total billed charges,
Immunohistochemistry quant,7719216,CDM,300,RC,88360,HCPCS,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Immunohistochemistry quant,7719216,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,104.47,452.20,percent of total billed charges,
MULTIPLEX ANTIBODY STAIN,7806064,CDM,300,RC,88344,HCPCS,,,facility,inpatient,,,339.00000,98.31000,Aetna,First Health,,277.30,,,,,,,203.40,277.30,percent of total billed charges,
MULTIPLEX ANTIBODY STAIN,7806064,CDM,300,RC,88344,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,First Health,,277.30,,,,,,,159.33,951.40,percent of total billed charges,
RF BILL IHC ADDL NEPHROPATH,7806063,CDM,300,RC,88341,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
RF BILL IHC ADDL NEPHROPATH,7806063,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,85.80,194.68,percent of total billed charges,
RF BILL IHC ADDL NEPHROPATH,7806067,CDM,300,RC,88341,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
RF BILL IHC ADDL NEPHROPATH,7806067,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,85.80,194.68,percent of total billed charges,
RF BILL IHC ADDL MAWD,7806068,CDM,300,RC,88341,HCPCS,,,facility,inpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,142.20,193.87,percent of total billed charges,
RF BILL IHC ADDL MAWD,7806068,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,85.44,193.87,percent of total billed charges,
RF BILL IHC ADDL MAYO,7806069,CDM,300,RC,88341,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
RF BILL IHC ADDL MAYO,7806069,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,91.93,208.59,percent of total billed charges,
ADDITIONAL IHC ANTIBODY STAIN,7806070,CDM,300,RC,88341,HCPCS,,,facility,inpatient,,,379.00000,109.91000,Aetna,First Health,,310.02,,,,,,,227.40,310.02,percent of total billed charges,
ADDITIONAL IHC ANTIBODY STAIN,7806070,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,379.00000,109.91000,Aetna,First Health,,310.02,,,,,,,96.30,310.02,percent of total billed charges,
RF BILL ISH ADDL MAYO,7806072,CDM,300,RC,88364,HCPCS,,,facility,inpatient,,,823.00000,238.67000,Aetna,First Health,,673.21,,,,,,,493.80,673.21,percent of total billed charges,
RF BILL ISH ADDL MAYO,7806072,CDM,300,RC,88364,HCPCS,,,facility,outpatient,,,823.00000,238.67000,Aetna,First Health,,673.21,,,,,,,139.10,673.21,percent of total billed charges,
RF BILL MORPH ISH ADDL MAWD,7806074,CDM,300,RC,88373,HCPCS,,,facility,inpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,96.60,131.70,percent of total billed charges,
RF BILL MORPH ISH ADDL MAWD,7806074,CDM,300,RC,88373,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,58.04,131.70,percent of total billed charges,
RF BILL MORPH ISH ADDL MAYO,7806075,CDM,300,RC,88373,HCPCS,,,facility,inpatient,,,336.00000,97.44000,Aetna,First Health,,274.85,,,,,,,201.60,274.85,percent of total billed charges,
RF BILL MORPH ISH ADDL MAYO,7806075,CDM,300,RC,88373,HCPCS,,,facility,outpatient,,,336.00000,97.44000,Aetna,First Health,,274.85,,,,,,,86.20,274.85,percent of total billed charges,
RF BILL MORPH ISH MULTI MAYO,7806076,CDM,300,RC,88374,HCPCS,,,facility,inpatient,,,336.00000,97.44000,Aetna,First Health,,274.85,,,,,,,201.60,274.85,percent of total billed charges,
RF BILL MORPH ISH MULTI MAYO,7806076,CDM,300,RC,88374,HCPCS,,,facility,outpatient,,,336.00000,97.44000,Aetna,First Health,,274.85,,,,,,,150.47,452.20,percent of total billed charges,
RF BILL MORPH ISH MULTI MAWD,7806077,CDM,300,RC,88374,HCPCS,,,facility,inpatient,,,428.00000,124.12000,Aetna,First Health,,350.10,,,,,,,256.80,350.10,percent of total billed charges,
RF BILL MORPH ISH MULTI MAWD,7806077,CDM,300,RC,88374,HCPCS,,,facility,outpatient,,,428.00000,124.12000,Aetna,First Health,,350.10,,,,,,,150.47,452.20,percent of total billed charges,
RF BILL MAN ISH ADDL MAYO,7806081,CDM,300,RC,88369,HCPCS,,,facility,inpatient,,,290.00000,84.10000,Aetna,First Health,,237.22,,,,,,,174.00,237.22,percent of total billed charges,
RF BILL MAN ISH ADDL MAYO,7806081,CDM,300,RC,88369,HCPCS,,,facility,outpatient,,,290.00000,84.10000,Aetna,First Health,,237.22,,,,,,,104.55,237.22,percent of total billed charges,
RF BILL MORPH ISH ADDL MAWD,7806079,CDM,300,RC,88369,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
RF BILL MORPH ISH ADDL MAWD,7806079,CDM,300,RC,88369,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,100.94,229.04,percent of total billed charges,
RF BILL MAN ISH MULTI MAYO,7806200,CDM,300,RC,88377,HCPCS,,,facility,inpatient,,,1046.00000,303.34000,Aetna,First Health,,855.63,,,,,,,627.60,855.63,percent of total billed charges,
RF BILL MAN ISH MULTI MAYO,7806200,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,1046.00000,303.34000,Aetna,First Health,,855.63,,,,,,,150.47,855.63,percent of total billed charges,
RF BILL MAN ISH MULTI MAWD,7806201,CDM,300,RC,88377,HCPCS,,,facility,inpatient,,,609.00000,176.61000,Aetna,First Health,,498.16,,,,,,,365.40,498.16,percent of total billed charges,
RF BILL MAN ISH MULTI MAWD,7806201,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,609.00000,176.61000,Aetna,First Health,,498.16,,,,,,,150.47,498.16,percent of total billed charges,
RF BILL DIAGNOSTIC IHC CSI,7838032,CDM,300,RC,88342,HCPCS,,,facility,inpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,110.40,150.51,percent of total billed charges,
RF BILL DIAGNOSTIC IHC CSI,7838032,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,84.70,452.20,percent of total billed charges,
RF BILL IHC ADDL CSI,7838033,CDM,300,RC,88341,HCPCS,,,facility,inpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,110.40,150.51,percent of total billed charges,
RF BILL IHC ADDL CSI,7838033,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,66.33,150.51,percent of total billed charges,
Manual Multiplix Stain CSI,7894064,CDM,300,RC,88377,HCPCS,,,facility,inpatient,,,408.00000,118.32000,Aetna,First Health,,333.74,,,,,,,244.80,333.74,percent of total billed charges,
Manual Multiplix Stain CSI,7894064,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,408.00000,118.32000,Aetna,First Health,,333.74,,,,,,,150.47,452.20,percent of total billed charges,
FISH CSI,7935096,CDM,300,RC,88377,HCPCS,,,facility,inpatient,,,408.00000,118.32000,Aetna,First Health,,333.74,,,,,,,244.80,333.74,percent of total billed charges,
FISH CSI,7935096,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,408.00000,118.32000,Aetna,First Health,,333.74,,,,,,,150.47,452.20,percent of total billed charges,
MORPH ANALYSIS MANUAL CSI,7894032,CDM,300,RC,88360,HCPCS,,,facility,inpatient,,,221.00000,64.09000,Aetna,First Health,,180.78,,,,,,,132.60,180.78,percent of total billed charges,
MORPH ANALYSIS MANUAL CSI,7894032,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,221.00000,64.09000,Aetna,First Health,,180.78,,,,,,,103.87,452.20,percent of total billed charges,
IN SITU HYBRIDIZATION CSI,7894034,CDM,300,RC,88365,HCPCS,,,facility,inpatient,,,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,148.20,202.05,percent of total billed charges,
IN SITU HYBRIDIZATION CSI,7894034,CDM,300,RC,88365,HCPCS,,,facility,outpatient,,,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,116.09,452.20,percent of total billed charges,
NRAS GENE ANALYSIS MAWD ZB4S4,7894030,CDM,300,RC,81311,HCPCS,,,facility,inpatient,,,424.00000,122.96000,Aetna,First Health,,346.83,,,,,,,254.40,346.83,percent of total billed charges,
NRAS GENE ANALYSIS MAWD ZB4S4,7894030,CDM,300,RC,81311,HCPCS,,,facility,outpatient,,,424.00000,122.96000,Aetna,First Health,,346.83,,,,,,,199.28,783.84,percent of total billed charges,
BILL TOUCH PREP ADDL,7911714,CDM,300,RC,88334,HCPCS,,,facility,inpatient,,,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,108.60,148.06,percent of total billed charges,
BILL TOUCH PREP ADDL,7911714,CDM,300,RC,88334,HCPCS,,,facility,outpatient,,,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,44.26,148.06,percent of total billed charges,
IMMUNOFLUORESCENCE ADDL NEPHRO,7959502,CDM,300,RC,88350,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
IMMUNOFLUORESCENCE ADDL NEPHRO,7959502,CDM,300,RC,88350,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,100.94,229.04,percent of total billed charges,
CYTO GYN THIN PREP,592813,CDM,300,RC,G0123,HCPCS,,,facility,inpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,71.40,97.34,percent of total billed charges,
CYTO GYN THIN PREP,592813,CDM,300,RC,G0123,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,18.78,97.34,percent of total billed charges,
CYTO NON GYN SMEAR,295380,CDM,300,RC,88104,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CYTO NON GYN SMEAR,295380,CDM,300,RC,88104,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,34.46,126.79,percent of total billed charges,
TISSUE EXAM BY PATHOLOGIST,8134955,CDM,300,RC,88304,HCPCS,,,facility,inpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,184.80,251.94,percent of total billed charges,
TISSUE EXAM BY PATHOLOGIST,8134955,CDM,300,RC,88304,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,46.92,251.94,percent of total billed charges,
TISSUE EXAM BY PATHOLOGIST,8134956,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
TISSUE EXAM BY PATHOLOGIST,8134956,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,46.92,348.47,percent of total billed charges,
TISSUE EXAM BY PATHOLOGIST,8134957,CDM,300,RC,88307,HCPCS,,,facility,inpatient,,,618.00000,179.22000,Aetna,First Health,,505.52,,,,,,,370.80,505.52,percent of total billed charges,
TISSUE EXAM BY PATHOLOGIST,8134957,CDM,300,RC,88307,HCPCS,,,facility,outpatient,,,618.00000,179.22000,Aetna,First Health,,505.52,,,,,,,174.61,951.40,percent of total billed charges,
Surg BM Clot Addl,8229955,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
Surg BM Clot Addl,8229955,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,46.92,348.47,percent of total billed charges,
Surg Level IV Addl,8229956,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
Surg Level IV Addl,8229956,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,46.92,348.47,percent of total billed charges,
RF Bill Surg Level IV MAWD Addl,8229957,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,105.60,143.97,percent of total billed charges,
RF Bill Surg Level IV MAWD Addl,8229957,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,46.92,150.74,percent of total billed charges,
RF Bill Surg Level IV Addl,8229958,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,447.00000,129.63000,Aetna,First Health,,365.65,,,,,,,268.20,365.65,percent of total billed charges,
RF Bill Surg Level IV Addl,8229958,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,447.00000,129.63000,Aetna,First Health,,365.65,,,,,,,46.92,365.65,percent of total billed charges,
RF Bill Surg Level IV Nephropath Addl,8229959,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,123.00,167.69,percent of total billed charges,
RF Bill Surg Level IV Nephropath Addl,8229959,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,46.92,167.69,percent of total billed charges,
RF Bill Surg Level IV Mayo Addl,8229960,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,418.20,570.15,percent of total billed charges,
RF Bill Surg Level IV Mayo Addl,8229960,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,46.92,570.15,percent of total billed charges,
Bill Surg Decal Addl,8230236,CDM,300,RC,88311,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
Bill Surg Decal Addl,8230236,CDM,300,RC,88311,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,17.63,59.71,percent of total billed charges,
SURG LEVEL I,295346,CDM,300,RC,88300,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
SURG LEVEL I,295346,CDM,300,RC,88300,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,19.63,111.25,percent of total billed charges,
SURG LEVEL II,295348,CDM,300,RC,88302,HCPCS,,,facility,inpatient,,,223.00000,64.67000,Aetna,First Health,,182.41,,,,,,,133.80,182.41,percent of total billed charges,
SURG LEVEL II,295348,CDM,300,RC,88302,HCPCS,,,facility,outpatient,,,223.00000,64.67000,Aetna,First Health,,182.41,,,,,,,34.46,182.41,percent of total billed charges,
SURG LEVEL III,295350,CDM,300,RC,88304,HCPCS,,,facility,inpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,184.80,251.94,percent of total billed charges,
SURG LEVEL III,295350,CDM,300,RC,88304,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,46.92,251.94,percent of total billed charges,
Surg Level III,8948122,CDM,300,RC,88304,HCPCS,,,facility,inpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,184.80,251.94,percent of total billed charges,
Surg Level III,8948122,CDM,300,RC,88304,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,46.92,251.94,percent of total billed charges,
SURG LEVEL IV,295352,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
SURG LEVEL IV,295352,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,46.92,348.47,percent of total billed charges,
Surg Level IV,8948125,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
Surg Level IV,8948125,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,46.92,348.47,percent of total billed charges,
SURG LEVEL V,295354,CDM,300,RC,88307,HCPCS,,,facility,inpatient,,,618.00000,179.22000,Aetna,First Health,,505.52,,,,,,,370.80,505.52,percent of total billed charges,
SURG LEVEL V,295354,CDM,300,RC,88307,HCPCS,,,facility,outpatient,,,618.00000,179.22000,Aetna,First Health,,505.52,,,,,,,174.61,951.40,percent of total billed charges,
Surg Level V,8948123,CDM,300,RC,88307,HCPCS,,,facility,inpatient,,,618.00000,179.22000,Aetna,First Health,,505.52,,,,,,,370.80,505.52,percent of total billed charges,
Surg Level V,8948123,CDM,300,RC,88307,HCPCS,,,facility,outpatient,,,618.00000,179.22000,Aetna,First Health,,505.52,,,,,,,174.61,951.40,percent of total billed charges,
SURG LEVEL VI,295356,CDM,300,RC,88309,HCPCS,,,facility,inpatient,,,825.00000,239.25000,Aetna,First Health,,674.85,,,,,,,495.00,674.85,percent of total billed charges,
SURG LEVEL VI,295356,CDM,300,RC,88309,HCPCS,,,facility,outpatient,,,825.00000,239.25000,Aetna,First Health,,674.85,,,,,,,244.61,2138.50,percent of total billed charges,
SURG DECAL,295360,CDM,300,RC,88311,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
SURG DECAL,295360,CDM,300,RC,88311,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,17.63,59.71,percent of total billed charges,
SURG CONSULT,295358,CDM,300,RC,88321,HCPCS,,,facility,inpatient,,,216.00000,62.64000,Aetna,First Health,,176.69,,,,,,,129.60,176.69,percent of total billed charges,
SURG CONSULT,295358,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,216.00000,62.64000,Aetna,First Health,,176.69,,,,,,,34.46,176.69,percent of total billed charges,
SURG CONSULT SLIDES W PREP,592821,CDM,300,RC,88323,HCPCS,,,facility,inpatient,,,388.00000,112.52000,Aetna,First Health,,317.38,,,,,,,232.80,317.38,percent of total billed charges,
SURG CONSULT SLIDES W PREP,592821,CDM,300,RC,88323,HCPCS,,,facility,outpatient,,,388.00000,112.52000,Aetna,First Health,,317.38,,,,,,,46.92,317.38,percent of total billed charges,
SURG CONSULT COMPREHENSIVE,592819,CDM,300,RC,88325,HCPCS,,,facility,inpatient,,,2485.00000,720.65000,Aetna,First Health,,2032.73,,,,,,,1491.00,2032.73,percent of total billed charges,
SURG CONSULT COMPREHENSIVE,592819,CDM,300,RC,88325,HCPCS,,,facility,outpatient,,,2485.00000,720.65000,Aetna,First Health,,2032.73,,,,,,,150.47,2032.73,percent of total billed charges,
SURG DIF,594645,CDM,300,RC,88346,HCPCS,,,facility,inpatient,,,339.00000,98.31000,Aetna,First Health,,277.30,,,,,,,203.40,277.30,percent of total billed charges,
SURG DIF,594645,CDM,300,RC,88346,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,First Health,,277.30,,,,,,,88.98,452.20,percent of total billed charges,
SURG STAINS GROUP I MICRO,295362,CDM,300,RC,88312,HCPCS,,,facility,inpatient,,,216.00000,62.64000,Aetna,First Health,,176.69,,,,,,,129.60,176.69,percent of total billed charges,
SURG STAINS GROUP I MICRO,295362,CDM,300,RC,88312,HCPCS,,,facility,outpatient,,,216.00000,62.64000,Aetna,First Health,,176.69,,,,,,,46.92,176.69,percent of total billed charges,
SURG STAINS GROUP II OTHER,295364,CDM,300,RC,88313,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,96.00,130.88,percent of total billed charges,
SURG STAINS GROUP II OTHER,295364,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,53.93,353.14,percent of total billed charges,
SURG IHC FIRST ANTIBODY,295366,CDM,300,RC,88342,HCPCS,,,facility,inpatient,,,279.00000,80.91000,Aetna,First Health,,228.22,,,,,,,167.40,228.22,percent of total billed charges,
SURG IHC FIRST ANTIBODY,295366,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,279.00000,80.91000,Aetna,First Health,,228.22,,,,,,,84.70,452.20,percent of total billed charges,
Prostate Biopsy Two Methods,8948107,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Two Methods,8948107,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Three Methods,8948108,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Three Methods,8948108,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Four Methods,8948109,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Four Methods,8948109,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Five Methods,8948110,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Five Methods,8948110,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Six Methods,8948111,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Six Methods,8948111,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Seven Methods,8948112,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Seven Methods,8948112,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Eight Methods,8948113,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Eight Methods,8948113,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Nine Methods,8948114,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Nine Methods,8948114,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Ten Methods,8948115,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Ten Methods,8948115,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Eleven Methods,8948116,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Eleven Methods,8948116,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Twelve Methods,8948117,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Twelve Methods,8948117,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Thirteen Methods,8948118,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Thirteen Methods,8948118,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Fourteen Methods,8948119,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Fourteen Methods,8948119,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Fifteen Methods,8948120,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Fifteen Methods,8948120,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Sixteen Methods,8948121,CDM,300,RC,G0416,HCPCS,,,facility,inpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,483.00,658.49,percent of total billed charges,
Prostate Biopsy Sixteen Methods,8948121,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,First Health,,658.49,,,,,,,315.85,807.79,percent of total billed charges,
CYTO FNA INTERP,295388,CDM,300,RC,88173,HCPCS,,,facility,inpatient,,,329.00000,95.41000,Aetna,First Health,,269.12,,,,,,,197.40,269.12,percent of total billed charges,
CYTO FNA INTERP,295388,CDM,300,RC,88173,HCPCS,,,facility,outpatient,,,329.00000,95.41000,Aetna,First Health,,269.12,,,,,,,46.92,269.12,percent of total billed charges,
CYTO NON GYN CONC TECH,592809,CDM,300,RC,88108,HCPCS,,,facility,inpatient,,,271.00000,78.59000,Aetna,First Health,,221.68,,,,,,,162.60,221.68,percent of total billed charges,
CYTO NON GYN CONC TECH,592809,CDM,300,RC,88108,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,First Health,,221.68,,,,,,,34.46,221.68,percent of total billed charges,
CYTO NON GYN OTHER SOURCE,656038,CDM,300,RC,88160,HCPCS,,,facility,inpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,76.20,103.89,percent of total billed charges,
CYTO NON GYN OTHER SOURCE,656038,CDM,300,RC,88160,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,21.51,103.89,percent of total billed charges,
SURG TOUCH PREP,594561,CDM,300,RC,88333,HCPCS,,,facility,inpatient,,,811.00000,235.19000,Aetna,First Health,,663.40,,,,,,,486.60,663.40,percent of total billed charges,
SURG TOUCH PREP,594561,CDM,300,RC,88333,HCPCS,,,facility,outpatient,,,811.00000,235.19000,Aetna,First Health,,663.40,,,,,,,84.98,2138.50,percent of total billed charges,
SURG B M CLOT,594641,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
SURG B M CLOT,594641,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,46.92,348.47,percent of total billed charges,
Bone Marrow Clot,8948124,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
Bone Marrow Clot,8948124,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,46.92,348.47,percent of total billed charges,
SURG TRANSFUSION REACTION,597052,CDM,300,RC,86078,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
SURG TRANSFUSION REACTION,597052,CDM,300,RC,86078,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,51.71,452.20,percent of total billed charges,
88365 RF Bill ISH Initial Stain MAWD,9114584,CDM,300,RC,88365,HCPCS,,,facility,inpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,163.80,223.31,percent of total billed charges,
88365 RF Bill ISH Initial Stain MAWD,9114584,CDM,300,RC,88365,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,121.31,452.20,percent of total billed charges,
88364 RF Bill ISH Addl Stain MAWD,9110010,CDM,300,RC,88364,HCPCS,,,facility,inpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,163.80,223.31,percent of total billed charges,
88364 RF Bill ISH Addl Stain MAWD,9110010,CDM,300,RC,88364,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,98.42,223.31,percent of total billed charges,
CROSSMATCH ELECTRONIC,4574097,CDM,300,RC,86923,HCPCS,,,facility,inpatient,,,171.00000,49.59000,Aetna,First Health,,139.88,,,,,,,102.60,139.88,percent of total billed charges,
CROSSMATCH ELECTRONIC,4574097,CDM,300,RC,86923,HCPCS,,,facility,outpatient,,,171.00000,49.59000,Aetna,First Health,,139.88,,,,,,,80.37,452.20,percent of total billed charges,
BB BILL GRAD SEP REFERENCE,5987846,CDM,300,RC,86972,HCPCS,,,facility,inpatient,,,371.00000,107.59000,Aetna,First Health,,303.48,,,,,,,222.60,303.48,percent of total billed charges,
BB BILL GRAD SEP REFERENCE,5987846,CDM,300,RC,86972,HCPCS,,,facility,outpatient,,,371.00000,107.59000,Aetna,First Health,,303.48,,,,,,,75.96,452.20,percent of total billed charges,
BB BILL INHIBITION REFERENCE,5987847,CDM,300,RC,86977,HCPCS,,,facility,inpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,144.00,196.32,percent of total billed charges,
BB BILL INHIBITION REFERENCE,5987847,CDM,300,RC,86977,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,75.96,452.20,percent of total billed charges,
BB BILL AB PNL ADS REFERENCE,5987849,CDM,300,RC,86870,HCPCS,,,facility,inpatient,,,272.00000,78.88000,Aetna,First Health,,222.50,,,,,,,163.20,222.50,percent of total billed charges,
BB BILL AB PNL ADS REFERENCE,5987849,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,272.00000,78.88000,Aetna,First Health,,222.50,,,,,,,28.92,951.40,percent of total billed charges,
BB BILL AB SCREEN RARE REFERENCE,5987850,CDM,300,RC,86850,HCPCS,,,facility,inpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,130.80,178.32,percent of total billed charges,
BB BILL AB SCREEN RARE REFERENCE,5987850,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,9.77,178.32,percent of total billed charges,
BB BILL PRE WARM REFERENCE,5987851,CDM,300,RC,86999,HCPCS,,,facility,inpatient,,,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,78.60,107.16,percent of total billed charges,
BB BILL PRE WARM REFERENCE,5987851,CDM,300,RC,86999,HCPCS,,,facility,outpatient,,,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,21.51,107.16,percent of total billed charges,
DIRECT COOMBS SOLID PHASE,662025,CDM,300,RC,86880,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
DIRECT COOMBS SOLID PHASE,662025,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,5.39,61.35,percent of total billed charges,
DIRECT COOMBS SOLID PHASE,662059,CDM,300,RC,86880,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
DIRECT COOMBS SOLID PHASE,662059,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,5.39,61.35,percent of total billed charges,
BB BILL AB ID RARE REFERENCE,5987853,CDM,300,RC,86870,HCPCS,,,facility,inpatient,,,242.00000,70.18000,Aetna,First Health,,197.96,,,,,,,145.20,197.96,percent of total billed charges,
BB BILL AB ID RARE REFERENCE,5987853,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,242.00000,70.18000,Aetna,First Health,,197.96,,,,,,,28.92,951.40,percent of total billed charges,
BB BILL SALINE RPLMT REFERENCE,5987854,CDM,300,RC,86999,HCPCS,,,facility,inpatient,,,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,78.60,107.16,percent of total billed charges,
BB BILL SALINE RPLMT REFERENCE,5987854,CDM,300,RC,86999,HCPCS,,,facility,outpatient,,,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,21.51,107.16,percent of total billed charges,
BB BILL PRETREAT CHEM DRUG REFERE,5987855,CDM,300,RC,86975,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,228.00,310.84,percent of total billed charges,
BB BILL PRETREAT CHEM DRUG REFERE,5987855,CDM,300,RC,86975,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,75.96,1185.74,percent of total billed charges,
BB BILL AB ID REFERENCE,5987844,CDM,300,RC,86870,HCPCS,,,facility,inpatient,,,242.00000,70.18000,Aetna,First Health,,197.96,,,,,,,145.20,197.96,percent of total billed charges,
BB BILL AB ID REFERENCE,5987844,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,242.00000,70.18000,Aetna,First Health,,197.96,,,,,,,28.92,951.40,percent of total billed charges,
BB BILL AB SCREEN REFERENCE,5987843,CDM,300,RC,86850,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
BB BILL AB SCREEN REFERENCE,5987843,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,9.77,118.61,percent of total billed charges,
BB BILL ANTIGEN TYPE PT REFERENCE,5987840,CDM,300,RC,86905,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
BB BILL ANTIGEN TYPE PT REFERENCE,5987840,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,3.83,358.78,percent of total billed charges,
BB BILL DAT POLY REFERENCE,5987841,CDM,300,RC,86880,HCPCS,,,facility,inpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,30.60,41.72,percent of total billed charges,
BB BILL DAT POLY REFERENCE,5987841,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,5.39,59.24,percent of total billed charges,
BB BILL ELUTION REFERENCE,5987842,CDM,300,RC,86860,HCPCS,,,facility,inpatient,,,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,148.20,202.05,percent of total billed charges,
BB BILL ELUTION REFERENCE,5987842,CDM,300,RC,86860,HCPCS,,,facility,outpatient,,,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,33.03,452.20,percent of total billed charges,
BB BILL RH TYPE REFERENCE,595629,CDM,300,RC,86901,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
BB BILL RH TYPE REFERENCE,595629,CDM,300,RC,86901,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,2.99,121.06,percent of total billed charges,
BB BILL ABO TYPING REFERENCE,5987839,CDM,300,RC,86900,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
BB BILL ABO TYPING REFERENCE,5987839,CDM,300,RC,86900,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,2.99,128.57,percent of total billed charges,
PLASMA EXCHANGE THERAPEUTIC,595633,CDM,300,RC,36514,HCPCS,,,facility,inpatient,,,3737.00000,1083.73000,Aetna,First Health,,3056.87,,,,,,,2242.20,3056.87,percent of total billed charges,
PLASMA EXCHANGE THERAPEUTIC,595633,CDM,300,RC,36514,HCPCS,,,facility,outpatient,,,3737.00000,1083.73000,Aetna,First Health,,3056.87,,,,,,,1439.38,3509.86,percent of total billed charges,
BB BILL PRETREATMENT REFERENCE,595630,CDM,300,RC,86971,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
BB BILL PRETREATMENT REFERENCE,595630,CDM,300,RC,86971,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,17.35,452.20,percent of total billed charges,
BLOOD TYPE ABO,595784,CDM,300,RC,86900,HCPCS,,,facility,inpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
BLOOD TYPE ABO,595784,CDM,300,RC,86900,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,2.99,128.57,percent of total billed charges,
BLOOD TYPE ABO,594592,CDM,300,RC,86900,HCPCS,,,facility,inpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
BLOOD TYPE ABO,594592,CDM,300,RC,86900,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,2.99,128.57,percent of total billed charges,
BLOOD TYPE ABO,7964598,CDM,300,RC,86900,HCPCS,,,facility,inpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
BLOOD TYPE ABO,7964598,CDM,300,RC,86900,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,2.99,128.57,percent of total billed charges,
BLOOD TYPE RH,636655,CDM,300,RC,86901,HCPCS,,,facility,inpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,39.60,53.99,percent of total billed charges,
BLOOD TYPE RH,636655,CDM,300,RC,86901,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,2.99,53.99,percent of total billed charges,
PRETREATMENT ENZYMES,638994,CDM,300,RC,86971,HCPCS,,,facility,inpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,195.60,266.67,percent of total billed charges,
PRETREATMENT ENZYMES,638994,CDM,300,RC,86971,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,17.35,452.20,percent of total billed charges,
Pretreatment,642407,CDM,300,RC,86971,HCPCS,,,facility,inpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,195.60,266.67,percent of total billed charges,
Pretreatment,642407,CDM,300,RC,86971,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,17.35,452.20,percent of total billed charges,
ANTIBODY ID SERUM,639127,CDM,300,RC,86870,HCPCS,,,facility,inpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,195.60,266.67,percent of total billed charges,
ANTIBODY ID SERUM,639127,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,28.92,951.40,percent of total billed charges,
ANTIBODY ID SERUM,639128,CDM,300,RC,86870,HCPCS,,,facility,inpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,195.60,266.67,percent of total billed charges,
ANTIBODY ID SERUM,639128,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,28.92,951.40,percent of total billed charges,
ANTIBODY ID SERUM,639129,CDM,300,RC,86870,HCPCS,,,facility,inpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,195.60,266.67,percent of total billed charges,
ANTIBODY ID SERUM,639129,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,28.92,951.40,percent of total billed charges,
ANTIBODY ID SERUM,639130,CDM,300,RC,86870,HCPCS,,,facility,inpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,195.60,266.67,percent of total billed charges,
ANTIBODY ID SERUM,639130,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,28.92,951.40,percent of total billed charges,
Panel,639136,CDM,300,RC,86870,HCPCS,,,facility,inpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,195.60,266.67,percent of total billed charges,
Panel,639136,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,28.92,951.40,percent of total billed charges,
AB SCRN INC TECH,2212824,CDM,300,RC,86850,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,70.20,95.71,percent of total billed charges,
AB SCRN INC TECH,2212824,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,9.77,95.71,percent of total billed charges,
AB SCRN INC TECH,594607,CDM,300,RC,86850,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,70.20,95.71,percent of total billed charges,
AB SCRN INC TECH,594607,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,9.77,95.71,percent of total billed charges,
AB SCRN INC TECH,594609,CDM,300,RC,86850,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,70.20,95.71,percent of total billed charges,
AB SCRN INC TECH,594609,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,9.77,95.71,percent of total billed charges,
AB SCRN INC TECH,595595,CDM,300,RC,86850,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,70.20,95.71,percent of total billed charges,
AB SCRN INC TECH,595595,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,9.77,95.71,percent of total billed charges,
AB SCRN INC TECH,639057,CDM,300,RC,86850,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,70.20,95.71,percent of total billed charges,
AB SCRN INC TECH,639057,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,9.77,95.71,percent of total billed charges,
AB SCRN INC TECH,7964596,CDM,300,RC,86850,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,70.20,95.71,percent of total billed charges,
AB SCRN INC TECH,7964596,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,9.77,95.71,percent of total billed charges,
RBC ANTIBODY SCREEN,8441798,CDM,300,RC,86850,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,70.20,95.71,percent of total billed charges,
RBC ANTIBODY SCREEN,8441798,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,9.77,95.71,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,639120,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,639120,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,641259,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,641259,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,641260,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,641260,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,641261,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,641261,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
Antigen Type per unit,641296,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,309.00000,89.61000,Aetna,First Health,,252.76,,,,,,,185.40,252.76,percent of total billed charges,
Antigen Type per unit,641296,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,309.00000,89.61000,Aetna,First Health,,252.76,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648144,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648144,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648145,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648145,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648146,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648146,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648147,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648147,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648148,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648148,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648149,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648149,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648150,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648150,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648151,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648151,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,6.35,358.78,percent of total billed charges,
ANTIGEN TYPE PATIENT,639119,CDM,300,RC,86905,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
ANTIGEN TYPE PATIENT,639119,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,3.83,358.78,percent of total billed charges,
ANTIGEN TYPE PATIENT,641250,CDM,300,RC,86905,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
ANTIGEN TYPE PATIENT,641250,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,3.83,358.78,percent of total billed charges,
ANTIGEN TYPE PATIENT,641251,CDM,300,RC,86905,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
ANTIGEN TYPE PATIENT,641251,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,3.83,358.78,percent of total billed charges,
ANTIGEN TYPE PATIENT,641252,CDM,300,RC,86905,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
ANTIGEN TYPE PATIENT,641252,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,3.83,358.78,percent of total billed charges,
Antigen Type patient,641295,CDM,300,RC,86905,HCPCS,,,facility,inpatient,,,309.00000,89.61000,Aetna,First Health,,252.76,,,,,,,185.40,252.76,percent of total billed charges,
Antigen Type patient,641295,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,309.00000,89.61000,Aetna,First Health,,252.76,,,,,,,3.83,358.78,percent of total billed charges,
COOMBS DIRECT,595458,CDM,300,RC,86880,HCPCS,,,facility,inpatient,,,85.00000,24.65000,Aetna,First Health,,69.53,,,,,,,51.00,69.53,percent of total billed charges,
COOMBS DIRECT,595458,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,85.00000,24.65000,Aetna,First Health,,69.53,,,,,,,5.39,69.53,percent of total billed charges,
COOMBS DIRECT,595794,CDM,300,RC,86880,HCPCS,,,facility,inpatient,,,85.00000,24.65000,Aetna,First Health,,69.53,,,,,,,51.00,69.53,percent of total billed charges,
COOMBS DIRECT,595794,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,85.00000,24.65000,Aetna,First Health,,69.53,,,,,,,5.39,69.53,percent of total billed charges,
COOMBS DIRECT,7964626,CDM,300,RC,86880,HCPCS,,,facility,inpatient,,,85.00000,24.65000,Aetna,First Health,,69.53,,,,,,,51.00,69.53,percent of total billed charges,
COOMBS DIRECT,7964626,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,85.00000,24.65000,Aetna,First Health,,69.53,,,,,,,5.39,69.53,percent of total billed charges,
COOMBS DIRECT,7964680,CDM,300,RC,86880,HCPCS,,,facility,inpatient,,,85.00000,24.65000,Aetna,First Health,,69.53,,,,,,,51.00,69.53,percent of total billed charges,
COOMBS DIRECT,7964680,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,85.00000,24.65000,Aetna,First Health,,69.53,,,,,,,5.39,69.53,percent of total billed charges,
CROSSMATCH IS TECHNIQUE,592980,CDM,300,RC,86920,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
CROSSMATCH IS TECHNIQUE,592980,CDM,300,RC,86920,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH IS TECHNIQUE,595426,CDM,300,RC,86920,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
CROSSMATCH IS TECHNIQUE,595426,CDM,300,RC,86920,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH IS TECHNIQUE,639021,CDM,300,RC,86920,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
CROSSMATCH IS TECHNIQUE,639021,CDM,300,RC,86920,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595819,CDM,300,RC,86921,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595819,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595820,CDM,300,RC,86921,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595820,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595802,CDM,300,RC,86921,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595802,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595806,CDM,300,RC,86921,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595806,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,7964622,CDM,300,RC,86921,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,7964622,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,7964677,CDM,300,RC,86921,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,7964677,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH IC TECHNIQUE,639022,CDM,300,RC,86922,HCPCS,,,facility,inpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,97.20,132.52,percent of total billed charges,
CROSSMATCH IC TECHNIQUE,639022,CDM,300,RC,86922,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,First Health,,132.52,,,,,,,34.70,452.20,percent of total billed charges,
ELUTION,595619,CDM,300,RC,86860,HCPCS,,,facility,inpatient,,,164.00000,47.56000,Aetna,First Health,,134.15,,,,,,,98.40,134.15,percent of total billed charges,
ELUTION,595619,CDM,300,RC,86860,HCPCS,,,facility,outpatient,,,164.00000,47.56000,Aetna,First Health,,134.15,,,,,,,33.03,452.20,percent of total billed charges,
IRRADIATED,636050,CDM,300,RC,86945,HCPCS,,,facility,inpatient,,,171.00000,49.59000,Aetna,First Health,,139.88,,,,,,,102.60,139.88,percent of total billed charges,
IRRADIATED,636050,CDM,300,RC,86945,HCPCS,,,facility,outpatient,,,171.00000,49.59000,Aetna,First Health,,139.88,,,,,,,34.46,139.88,percent of total billed charges,
FETAL SCREEN,595602,CDM,300,RC,86941,HCPCS,,,facility,inpatient,,,164.00000,47.56000,Aetna,First Health,,134.15,,,,,,,98.40,134.15,percent of total billed charges,
FETAL SCREEN,595602,CDM,300,RC,86941,HCPCS,,,facility,outpatient,,,164.00000,47.56000,Aetna,First Health,,134.15,,,,,,,11.23,134.15,percent of total billed charges,
THAWING FEE,638906,CDM,300,RC,86927,HCPCS,,,facility,inpatient,,,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,159.00,216.77,percent of total billed charges,
THAWING FEE,638906,CDM,300,RC,86927,HCPCS,,,facility,outpatient,,,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,2.75,452.20,percent of total billed charges,
HEA PANEL ADD ON CBC ZB04H,7974998,CDM,300,RC,81403,HCPCS,,,facility,inpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,218.40,297.75,percent of total billed charges,
HEA PANEL ADD ON CBC ZB04H,7974998,CDM,300,RC,81403,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,171.08,490.78,percent of total billed charges,
PLATELET ANTIBODY SCREEN IRL,7989144,CDM,300,RC,86022,HCPCS,,,facility,inpatient,,,287.00000,83.23000,Aetna,First Health,,234.77,,,,,,,172.20,234.77,percent of total billed charges,
PLATELET ANTIBODY SCREEN IRL,7989144,CDM,300,RC,86022,HCPCS,,,facility,outpatient,,,287.00000,83.23000,Aetna,First Health,,234.77,,,,,,,17.03,234.77,percent of total billed charges,
PLATELET ANTIBODY SCREEN IRL,596410,CDM,300,RC,86023,HCPCS,,,facility,inpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,130.80,178.32,percent of total billed charges,
PLATELET ANTIBODY SCREEN IRL,596410,CDM,300,RC,86023,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,11.55,178.32,percent of total billed charges,
PLATELET BOUND IGG IRL,657858,CDM,300,RC,86023,HCPCS,,,facility,inpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,130.80,178.32,percent of total billed charges,
PLATELET BOUND IGG IRL,657858,CDM,300,RC,86023,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,11.55,178.32,percent of total billed charges,
WBC DEPLETION,5291840,CDM,300,RC,36511,HCPCS,,,facility,inpatient,,,5086.00000,1474.94000,Aetna,First Health,,4160.35,,,,,,,3051.60,4160.35,percent of total billed charges,
WBC DEPLETION,5291840,CDM,300,RC,36511,HCPCS,,,facility,outpatient,,,5086.00000,1474.94000,Aetna,First Health,,4160.35,,,,,,,1439.38,4160.35,percent of total billed charges,
BB BILL COM SEROLOGIC PAN REFEREN,6633842,CDM,300,RC,86906,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,100.80,137.42,percent of total billed charges,
BB BILL COM SEROLOGIC PAN REFEREN,6633842,CDM,300,RC,86906,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,First Health,,137.42,,,,,,,7.75,137.42,percent of total billed charges,
BB BILL NEAT UNTYPED REFERENCE,6605847,CDM,300,RC,86904,HCPCS,,,facility,inpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,148.80,202.86,percent of total billed charges,
BB BILL NEAT UNTYPED REFERENCE,6605847,CDM,300,RC,86904,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,6.19,202.86,percent of total billed charges,
BB BILL NEAT AG NEG REFERENCE,6605850,CDM,300,RC,86904,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
BB BILL NEAT AG NEG REFERENCE,6605850,CDM,300,RC,86904,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,6.19,121.88,percent of total billed charges,
BB BILL IAT REFERENCE,6605851,CDM,300,RC,86885,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
BB BILL IAT REFERENCE,6605851,CDM,300,RC,86885,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,5.72,170.93,percent of total billed charges,
BB BILL SEROLOGIC PANEL REFERENCE,6633840,CDM,300,RC,86905,HCPCS,,,facility,inpatient,,,88.00000,25.52000,Aetna,First Health,,71.98,,,,,,,52.80,71.98,percent of total billed charges,
BB BILL SEROLOGIC PANEL REFERENCE,6633840,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,88.00000,25.52000,Aetna,First Health,,71.98,,,,,,,3.83,358.78,percent of total billed charges,
BB BILL AUTO AB ID REFERENCE,6969839,CDM,300,RC,86940,HCPCS,,,facility,inpatient,,,49.00000,14.21000,Aetna,First Health,,40.08,,,,,,,29.40,40.08,percent of total billed charges,
BB BILL AUTO AB ID REFERENCE,6969839,CDM,300,RC,86940,HCPCS,,,facility,outpatient,,,49.00000,14.21000,Aetna,First Health,,40.08,,,,,,,8.13,40.08,percent of total billed charges,
BB BILL AUTO AB ID REFERENCE,6969840,CDM,300,RC,86940,HCPCS,,,facility,inpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,30.60,41.72,percent of total billed charges,
BB BILL AUTO AB ID REFERENCE,6969840,CDM,300,RC,86940,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,8.13,41.72,percent of total billed charges,
BB BILL AB ID REFERENCE,6969841,CDM,300,RC,86941,HCPCS,,,facility,inpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,42.60,58.08,percent of total billed charges,
BB BILL AB ID REFERENCE,6969841,CDM,300,RC,86941,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,11.23,58.08,percent of total billed charges,
BB BILL RED CELL EXCHANGE,7141839,CDM,300,RC,36512,HCPCS,,,facility,inpatient,,,3631.00000,1052.99000,Aetna,First Health,,2970.16,,,,,,,2178.60,2970.16,percent of total billed charges,
BB BILL RED CELL EXCHANGE,7141839,CDM,300,RC,36512,HCPCS,,,facility,outpatient,,,3631.00000,1052.99000,Aetna,First Health,,2970.16,,,,,,,1439.38,3509.86,percent of total billed charges,
BB BILL EGA TREATMENT REFERENCE,7734603,CDM,300,RC,86970,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
BB BILL EGA TREATMENT REFERENCE,7734603,CDM,300,RC,86970,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,52.15,156.59,percent of total billed charges,
BB BILL ANTIBODY TITRATION REF,5103840,CDM,300,RC,86886,HCPCS,,,facility,inpatient,,,217.00000,62.93000,Aetna,First Health,,177.51,,,,,,,130.20,177.51,percent of total billed charges,
BB BILL ANTIBODY TITRATION REF,5103840,CDM,300,RC,86886,HCPCS,,,facility,outpatient,,,217.00000,62.93000,Aetna,First Health,,177.51,,,,,,,5.18,177.51,percent of total billed charges,
RBC Pretrtmt inc w enzyme,8232065,CDM,300,RC,86971,HCPCS,,,facility,inpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,195.60,266.67,percent of total billed charges,
RBC Pretrtmt inc w enzyme,8232065,CDM,300,RC,86971,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,First Health,,266.67,,,,,,,17.35,452.20,percent of total billed charges,
RBC typing adsorption,8232066,CDM,300,RC,86905,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
RBC typing adsorption,8232066,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,3.83,358.78,percent of total billed charges,
Typed Donor Units 7 Percent,8471788,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
Typed Donor Units 7 Percent,8471788,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,6.35,358.78,percent of total billed charges,
Typed Donor Units 4 to 6 percent,8471794,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,157.20,214.32,percent of total billed charges,
Typed Donor Units 4 to 6 percent,8471794,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,6.35,358.78,percent of total billed charges,
Typed Donor Units 3 Percent,8471800,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,328.00000,95.12000,Aetna,First Health,,268.30,,,,,,,196.80,268.30,percent of total billed charges,
Typed Donor Units 3 Percent,8471800,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,328.00000,95.12000,Aetna,First Health,,268.30,,,,,,,6.35,358.78,percent of total billed charges,
Typed Donor Units 2 percent,8471801,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,440.00000,127.60000,Aetna,First Health,,359.92,,,,,,,264.00,359.92,percent of total billed charges,
Typed Donor Units 2 percent,8471801,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,440.00000,127.60000,Aetna,First Health,,359.92,,,,,,,6.35,359.92,percent of total billed charges,
Typed Donor Units 1 percentc,8471812,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,515.00000,149.35000,Aetna,First Health,,421.27,,,,,,,309.00,421.27,percent of total billed charges,
Typed Donor Units 1 percentc,8471812,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,515.00000,149.35000,Aetna,First Health,,421.27,,,,,,,6.35,421.27,percent of total billed charges,
Typed Donor Units less than 1 percent,8471818,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,573.00000,166.17000,Aetna,First Health,,468.71,,,,,,,343.80,468.71,percent of total billed charges,
Typed Donor Units less than 1 percent,8471818,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,573.00000,166.17000,Aetna,First Health,,468.71,,,,,,,6.35,468.71,percent of total billed charges,
Low Incident Antigen Unit,8471824,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,166.00000,48.14000,Aetna,First Health,,135.79,,,,,,,99.60,135.79,percent of total billed charges,
Low Incident Antigen Unit,8471824,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,166.00000,48.14000,Aetna,First Health,,135.79,,,,,,,6.35,358.78,percent of total billed charges,
Rare Antigen Unit,8471830,CDM,300,RC,86902,HCPCS,,,facility,inpatient,,,431.00000,124.99000,Aetna,First Health,,352.56,,,,,,,258.60,352.56,percent of total billed charges,
Rare Antigen Unit,8471830,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,431.00000,124.99000,Aetna,First Health,,352.56,,,,,,,6.35,358.78,percent of total billed charges,
Bill Genotype RHD weak partial D CBC Z00A2,8987502,CDM,300,RC,81403,HCPCS,,,facility,inpatient,,,455.00000,131.95000,Aetna,First Health,,372.19,,,,,,,273.00,372.19,percent of total billed charges,
Bill Genotype RHD weak partial D CBC Z00A2,8987502,CDM,300,RC,81403,HCPCS,,,facility,outpatient,,,455.00000,131.95000,Aetna,First Health,,372.19,,,,,,,171.68,490.78,percent of total billed charges,
Genotype RHD CBC Z00A2,9093819,CDM,300,RC,81403,HCPCS,,,facility,inpatient,,,473.00000,137.17000,Aetna,First Health,,386.91,,,,,,,283.80,386.91,percent of total billed charges,
Genotype RHD CBC Z00A2,9093819,CDM,300,RC,81403,HCPCS,,,facility,outpatient,,,473.00000,137.17000,Aetna,First Health,,386.91,,,,,,,171.68,490.78,percent of total billed charges,
Rh genotyping RHD Grifols Z0019,9093830,CDM,300,RC,0198U,HCPCS,,,facility,inpatient,,,509.00000,147.61000,Aetna,First Health,,416.36,,,,,,,305.40,416.36,percent of total billed charges,
Rh genotyping RHD Grifols Z0019,9093830,CDM,300,RC,0198U,HCPCS,,,facility,outpatient,,,509.00000,147.61000,Aetna,First Health,,416.36,,,,,,,203.60,636.48,percent of total billed charges,
ENTEROVIRUS PCR,4793840,CDM,300,RC,87498,HCPCS,,,facility,inpatient,,,302.00000,87.58000,Aetna,First Health,,247.04,,,,,,,181.20,247.04,percent of total billed charges,
ENTEROVIRUS PCR,4793840,CDM,300,RC,87498,HCPCS,,,facility,outpatient,,,302.00000,87.58000,Aetna,First Health,,247.04,,,,,,,32.53,247.04,percent of total billed charges,
Bordetella pertussis parapertussis PCR,8471758,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,125.40,170.96,percent of total billed charges,
Bordetella pertussis parapertussis PCR,8471758,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,32.53,170.96,percent of total billed charges,
Bordetella PCR,8471763,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,125.40,170.96,percent of total billed charges,
Bordetella PCR,8471763,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,32.53,170.96,percent of total billed charges,
C DIFF AMPLIFIED PROBE,4793839,CDM,300,RC,87493,HCPCS,,,facility,inpatient,,,223.00000,64.67000,Aetna,First Health,,182.41,,,,,,,133.80,182.41,percent of total billed charges,
C DIFF AMPLIFIED PROBE,4793839,CDM,300,RC,87493,HCPCS,,,facility,outpatient,,,223.00000,64.67000,Aetna,First Health,,182.41,,,,,,,34.55,182.41,percent of total billed charges,
87798 Respiratory Pathogens Gr 3,7971880,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,125.40,170.96,percent of total billed charges,
87798 Respiratory Pathogens Gr 3,7971880,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,32.53,170.96,percent of total billed charges,
INFLUENZA AB RAPID PCR,7969531,CDM,300,RC,87502,HCPCS,,,facility,inpatient,,,445.00000,129.05000,Aetna,First Health,,364.01,,,,,,,267.00,364.01,percent of total billed charges,
INFLUENZA AB RAPID PCR,7969531,CDM,300,RC,87502,HCPCS,,,facility,outpatient,,,445.00000,129.05000,Aetna,First Health,,364.01,,,,,,,88.81,364.01,percent of total billed charges,
Strep Group A Rapid PCR,8125256,CDM,300,RC,87651,HCPCS,,,facility,inpatient,,,207.00000,60.03000,Aetna,First Health,,169.33,,,,,,,124.20,169.33,percent of total billed charges,
Strep Group A Rapid PCR,8125256,CDM,300,RC,87651,HCPCS,,,facility,outpatient,,,207.00000,60.03000,Aetna,First Health,,169.33,,,,,,,32.53,169.33,percent of total billed charges,
Strep Group B PCR,8125257,CDM,300,RC,87150,HCPCS,,,facility,inpatient,,,272.00000,78.88000,Aetna,First Health,,222.50,,,,,,,163.20,222.50,percent of total billed charges,
Strep Group B PCR,8125257,CDM,300,RC,87150,HCPCS,,,facility,outpatient,,,272.00000,78.88000,Aetna,First Health,,222.50,,,,,,,32.53,222.50,percent of total billed charges,
Blood Culture DNA RNA AMPLIFIED PROBE,8370648,CDM,300,RC,87150,HCPCS,,,facility,inpatient,,,272.00000,78.88000,Aetna,First Health,,222.50,,,,,,,163.20,222.50,percent of total billed charges,
Blood Culture DNA RNA AMPLIFIED PROBE,8370648,CDM,300,RC,87150,HCPCS,,,facility,outpatient,,,272.00000,78.88000,Aetna,First Health,,222.50,,,,,,,32.53,222.50,percent of total billed charges,
Blood Culture DNA RNA AMPLIFIED PROBE,8370649,CDM,300,RC,87150,HCPCS,,,facility,inpatient,,,272.00000,78.88000,Aetna,First Health,,222.50,,,,,,,163.20,222.50,percent of total billed charges,
Blood Culture DNA RNA AMPLIFIED PROBE,8370649,CDM,300,RC,87150,HCPCS,,,facility,outpatient,,,272.00000,78.88000,Aetna,First Health,,222.50,,,,,,,32.53,222.50,percent of total billed charges,
Blood Culture DNA RNA AMPLIFIED PROBE,8370650,CDM,300,RC,87150,HCPCS,,,facility,inpatient,,,272.00000,78.88000,Aetna,First Health,,222.50,,,,,,,163.20,222.50,percent of total billed charges,
Blood Culture DNA RNA AMPLIFIED PROBE,8370650,CDM,300,RC,87150,HCPCS,,,facility,outpatient,,,272.00000,78.88000,Aetna,First Health,,222.50,,,,,,,32.53,222.50,percent of total billed charges,
MRSA DNA AMP PROBE,4793841,CDM,300,RC,87641,HCPCS,,,facility,inpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,150.00,204.50,percent of total billed charges,
MRSA DNA AMP PROBE,4793841,CDM,300,RC,87641,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,32.53,204.50,percent of total billed charges,
C TRACHOMATIC DNA PROBE,7935464,CDM,300,RC,87491,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
C TRACHOMATIC DNA PROBE,7935464,CDM,300,RC,87491,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,32.53,128.43,percent of total billed charges,
N GONORRHOEAE DNA PROBE,7935468,CDM,300,RC,87591,HCPCS,,,facility,inpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,94.80,129.24,percent of total billed charges,
N GONORRHOEAE DNA PROBE,7935468,CDM,300,RC,87591,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,32.53,129.24,percent of total billed charges,
Encephalitis Panel CSF by PCR,8338740,CDM,300,RC,87483,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,1264.80,1724.34,percent of total billed charges,
Encephalitis Panel CSF by PCR,8338740,CDM,300,RC,87483,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,First Health,,1724.34,,,,,,,386.35,1724.34,percent of total billed charges,
COV 2019 CORONAVIRUS,8336076,CDM,300,RC,87635,HCPCS,,,facility,inpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,110.40,150.51,percent of total billed charges,
COV 2019 CORONAVIRUS,8336076,CDM,300,RC,87635,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,47.57,150.51,percent of total billed charges,
Influenza A and B  and RSV PCR,8328328,CDM,300,RC,87631,HCPCS,,,facility,inpatient,,,531.00000,153.99000,Aetna,First Health,,434.36,,,,,,,318.60,434.36,percent of total billed charges,
Influenza A and B  and RSV PCR,8328328,CDM,300,RC,87631,HCPCS,,,facility,outpatient,,,531.00000,153.99000,Aetna,First Health,,434.36,,,,,,,132.22,434.36,percent of total billed charges,
RSV RAPID PCR,8366451,CDM,300,RC,87634,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,121.80,166.05,percent of total billed charges,
RSV RAPID PCR,8366451,CDM,300,RC,87634,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,65.08,186.03,percent of total billed charges,
Infectious disease bacterial or viral respiratory tract inf,8370647,CDM,300,RC,87633,HCPCS,,,facility,inpatient,,,1848.00000,535.92000,Aetna,First Health,,1511.66,,,,,,,1108.80,1511.66,percent of total billed charges,
Infectious disease bacterial or viral respiratory tract inf,8370647,CDM,300,RC,87633,HCPCS,,,facility,outpatient,,,1848.00000,535.92000,Aetna,First Health,,1511.66,,,,,,,386.35,1511.66,percent of total billed charges,
Influenza CoVID 19 RSV PCR,8398214,CDM,300,RC,87637,HCPCS,,,facility,inpatient,,,531.00000,153.99000,Aetna,First Health,,434.36,,,,,,,318.60,434.36,percent of total billed charges,
Influenza CoVID 19 RSV PCR,8398214,CDM,300,RC,87637,HCPCS,,,facility,outpatient,,,531.00000,153.99000,Aetna,First Health,,434.36,,,,,,,132.22,434.36,percent of total billed charges,
N gonorrhoeae DNA PROBE,8453852,CDM,300,RC,87591,HCPCS,,,facility,inpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,94.80,129.24,percent of total billed charges,
N gonorrhoeae DNA PROBE,8453852,CDM,300,RC,87591,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,32.53,129.24,percent of total billed charges,
C trachomatis DNA PROBE,8453851,CDM,300,RC,87491,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
C trachomatis DNA PROBE,8453851,CDM,300,RC,87491,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,32.53,128.43,percent of total billed charges,
Enteric Pathogen Panel PCR,8914517,CDM,300,RC,87507,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,486.00,662.58,percent of total billed charges,
Enteric Pathogen Panel PCR,8914517,CDM,300,RC,87507,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,380.70,1104.47,percent of total billed charges,
Trichomonas vaginalis probe,8995201,CDM,300,RC,87661,HCPCS,,,facility,inpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,128.40,175.05,percent of total billed charges,
Trichomonas vaginalis probe,8995201,CDM,300,RC,87661,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,32.53,175.05,percent of total billed charges,
Bacterial Vaginitis Probe,8995202,CDM,300,RC,81515,HCPCS,,,facility,inpatient,,,277.00000,80.33000,Aetna,First Health,,226.59,,,,,,,166.20,226.59,percent of total billed charges,
Bacterial Vaginitis Probe,8995202,CDM,300,RC,81515,HCPCS,,,facility,outpatient,,,277.00000,80.33000,Aetna,First Health,,226.59,,,,,,,130.19,696.92,percent of total billed charges,
HBV Quant by NAAT,8143458,CDM,300,RC,87517,HCPCS,,,facility,inpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,154.80,211.04,percent of total billed charges,
HBV Quant by NAAT,8143458,CDM,300,RC,87517,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,39.72,211.04,percent of total billed charges,
ADRENOCORTICOTROPHIC,3184886,CDM,300,RC,82024,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
ADRENOCORTICOTROPHIC,3184886,CDM,300,RC,82024,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,35.80,110.43,percent of total billed charges,
HEPATITIS DELTA ANTIBODY,7784330,CDM,300,RC,86692,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
HEPATITIS DELTA ANTIBODY,7784330,CDM,300,RC,86692,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,15.90,121.88,percent of total billed charges,
ACETONE SERUM,597253,CDM,300,RC,80320,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,113.40,154.60,percent of total billed charges,
ACETONE SERUM,597253,CDM,300,RC,80320,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,0.01485,154.60,percent of total billed charges,
Isopropanol Blood,8239842,CDM,300,RC,80320,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,113.40,154.60,percent of total billed charges,
Isopropanol Blood,8239842,CDM,300,RC,80320,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,0.01485,154.60,percent of total billed charges,
ALDOSTERONE 24 HOUR,3206893,CDM,300,RC,82088,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
ALDOSTERONE 24 HOUR,3206893,CDM,300,RC,82088,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,37.78,128.43,percent of total billed charges,
BK VIRUS QUANT,3214920,CDM,300,RC,87799,HCPCS,,,facility,inpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,138.00,188.14,percent of total billed charges,
BK VIRUS QUANT,3214920,CDM,300,RC,87799,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,39.72,188.14,percent of total billed charges,
PLATELIA ASPERGILLUS ANTIGEN,3214896,CDM,300,RC,87305,HCPCS,,,facility,inpatient,,,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,108.60,148.06,percent of total billed charges,
PLATELIA ASPERGILLUS ANTIGEN,3214896,CDM,300,RC,87305,HCPCS,,,facility,outpatient,,,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,11.10,148.06,percent of total billed charges,
HEPATITIS A TOTAL,3192844,CDM,300,RC,86708,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
HEPATITIS A TOTAL,3192844,CDM,300,RC,86708,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,11.48,120.25,percent of total billed charges,
NEUROLOGY ABS BY IFA,759805,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,126.00000,36.54000,Aetna,First Health,,103.07,,,,,,,75.60,103.07,percent of total billed charges,
NEUROLOGY ABS BY IFA,759805,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,126.00000,36.54000,Aetna,First Health,,103.07,,,,,,,11.18,103.07,percent of total billed charges,
HEPATITIS BE ANTIGEN,3206839,CDM,300,RC,87350,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
HEPATITIS BE ANTIGEN,3206839,CDM,300,RC,87350,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,10.69,122.70,percent of total billed charges,
CATECHOLAMINES URINE,3188946,CDM,300,RC,82384,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
CATECHOLAMINES URINE,3188946,CDM,300,RC,82384,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,23.41,114.52,percent of total billed charges,
TISSUE CULTURE BM BLOOD CSI,7844100,CDM,300,RC,88237,HCPCS,,,facility,inpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,118.20,161.15,percent of total billed charges,
TISSUE CULTURE BM BLOOD CSI,7844100,CDM,300,RC,88237,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,32.36,380.94,percent of total billed charges,
CORTISOL URINE FREE,3206876,CDM,300,RC,82530,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
CORTISOL URINE FREE,3206876,CDM,300,RC,82530,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,15.49,124.34,percent of total billed charges,
VARICELLA ZOSTER VIRUS ANTIBODIES,3216840,CDM,300,RC,86787,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
VARICELLA ZOSTER VIRUS ANTIBODIES,3216840,CDM,300,RC,86787,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,11.94,63.80,percent of total billed charges,
VARICELLA ZOSTER VIRUS ANTIBODIES,991819,CDM,300,RC,86787,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
VARICELLA ZOSTER VIRUS ANTIBODIES,991819,CDM,300,RC,86787,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,11.94,63.80,percent of total billed charges,
HEPATITIS BE ANTIBODY,3196842,CDM,300,RC,86707,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,90.60,123.52,percent of total billed charges,
HEPATITIS BE ANTIBODY,3196842,CDM,300,RC,86707,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,10.72,123.52,percent of total billed charges,
EPSTEIN BARR CAPSID VCA,3188874,CDM,300,RC,86665,HCPCS,,,facility,inpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,25.80,35.17,percent of total billed charges,
EPSTEIN BARR CAPSID VCA,3188874,CDM,300,RC,86665,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,16.82,48.07,percent of total billed charges,
HCV Quant by NAAT with Reflex to Sequencing,8119533,CDM,300,RC,87522,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
HCV Quant by NAAT with Reflex to Sequencing,8119533,CDM,300,RC,87522,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,39.72,194.68,percent of total billed charges,
3000572 Hepatitis C Virus by Quantitative NAAT ARUP,8124828,CDM,300,RC,87522,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
3000572 Hepatitis C Virus by Quantitative NAAT ARUP,8124828,CDM,300,RC,87522,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,39.72,194.68,percent of total billed charges,
FRUCTOSAMINE,3192850,CDM,300,RC,82985,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
FRUCTOSAMINE,3192850,CDM,300,RC,82985,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,15.53,118.61,percent of total billed charges,
BLASTOMIC,613051,CDM,300,RC,86612,HCPCS,,,facility,inpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,22.20,30.27,percent of total billed charges,
BLASTOMIC,613051,CDM,300,RC,86612,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,6.68,34.19,percent of total billed charges,
FUNGAL ANTIBODY PANEL,3214839,CDM,300,RC,86698,HCPCS,,,facility,inpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,24.00,32.72,percent of total billed charges,
FUNGAL ANTIBODY PANEL,3214839,CDM,300,RC,86698,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,12.78,36.54,percent of total billed charges,
HELICOBACTER PYLORI AG DETECTION,7243847,CDM,300,RC,87338,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
HELICOBACTER PYLORI AG DETECTION,7243847,CDM,300,RC,87338,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,13.33,126.79,percent of total billed charges,
HEPATITIS B SURF AG NEUTRAL,3481850,CDM,300,RC,87341,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
HEPATITIS B SURF AG NEUTRAL,3481850,CDM,300,RC,87341,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,9.58,117.79,percent of total billed charges,
ASSAY OF SERUM ALBUMIN,613062,CDM,300,RC,82040,HCPCS,,,facility,inpatient,,,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,13.20,18.00,percent of total billed charges,
ASSAY OF SERUM ALBUMIN,613062,CDM,300,RC,82040,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,4.59,18.00,percent of total billed charges,
HERPES SIMPLEX ANTIBODY,3184945,CDM,300,RC,86695,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
HERPES SIMPLEX ANTIBODY,3184945,CDM,300,RC,86695,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,12.23,127.61,percent of total billed charges,
Herp 1,613113,CDM,300,RC,86695,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
Herp 1,613113,CDM,300,RC,86695,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,12.23,127.61,percent of total billed charges,
HERPES SIMPLEX 2,3184946,CDM,300,RC,86696,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
HERPES SIMPLEX 2,3184946,CDM,300,RC,86696,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,17.94,126.79,percent of total billed charges,
HISTOPLASMA ANTIGEN URINE,3190989,CDM,300,RC,87385,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
HISTOPLASMA ANTIGEN URINE,3190989,CDM,300,RC,87385,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,12.29,159.51,percent of total billed charges,
HLA B27 ANTIGEN,3218879,CDM,300,RC,86812,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
HLA B27 ANTIGEN,3218879,CDM,300,RC,86812,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,23.93,114.52,percent of total billed charges,
IGG SUBCLASS,1549815,CDM,300,RC,82787,HCPCS,,,facility,inpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,25.80,35.17,percent of total billed charges,
IGG SUBCLASS,1549815,CDM,300,RC,82787,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,7.44,35.17,percent of total billed charges,
ALDOSTERONE,3184848,CDM,300,RC,82088,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
ALDOSTERONE,3184848,CDM,300,RC,82088,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,37.78,127.61,percent of total billed charges,
LIPOPROTEIN A,3214932,CDM,300,RC,83695,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
LIPOPROTEIN A,3214932,CDM,300,RC,83695,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,13.28,127.61,percent of total billed charges,
MUMPS VIRUS ANTIBODY IGG,3178879,CDM,300,RC,86735,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
MUMPS VIRUS ANTIBODY IGG,3178879,CDM,300,RC,86735,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,12.10,127.61,percent of total billed charges,
LIPASE FLUID,4349840,CDM,300,RC,83690,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
LIPASE FLUID,4349840,CDM,300,RC,83690,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,6.19,127.61,percent of total billed charges,
Thyroglobulin,6061984,CDM,300,RC,84432,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
Thyroglobulin,6061984,CDM,300,RC,84432,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,14.88,159.51,percent of total billed charges,
THYROGLOBULIN LC MS MS,6145846,CDM,300,RC,84432,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
THYROGLOBULIN LC MS MS,6145846,CDM,300,RC,84432,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,14.88,159.51,percent of total billed charges,
BILIRUBIN TOTAL FLUID,1153806,CDM,300,RC,82247,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
BILIRUBIN TOTAL FLUID,1153806,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,4.66,126.79,percent of total billed charges,
GROWTH HORMONE,3206873,CDM,300,RC,83003,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,90.60,123.52,percent of total billed charges,
GROWTH HORMONE,3206873,CDM,300,RC,83003,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,15.45,123.52,percent of total billed charges,
HISTAMINE PLASMA,7243843,CDM,300,RC,83088,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
HISTAMINE PLASMA,7243843,CDM,300,RC,83088,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,27.38,111.25,percent of total billed charges,
HISTONE AB,7243839,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
HISTONE AB,7243839,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,10.69,120.25,percent of total billed charges,
ALKALINE PHOSPHATASE,613044,CDM,300,RC,84075,HCPCS,,,facility,inpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,24.00,32.72,percent of total billed charges,
ALKALINE PHOSPHATASE,613044,CDM,300,RC,84075,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,4.80,32.72,percent of total billed charges,
ALK PHOSE ISOENZYMES,3191024,CDM,300,RC,84080,HCPCS,,,facility,inpatient,,,113.00000,32.77000,Aetna,First Health,,92.43,,,,,,,67.80,92.43,percent of total billed charges,
ALK PHOSE ISOENZYMES,3191024,CDM,300,RC,84080,HCPCS,,,facility,outpatient,,,113.00000,32.77000,Aetna,First Health,,92.43,,,,,,,13.70,92.43,percent of total billed charges,
HIV 1 Quant by NAAT,8146997,CDM,300,RC,87536,HCPCS,,,facility,inpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,147.00,200.41,percent of total billed charges,
HIV 1 Quant by NAAT,8146997,CDM,300,RC,87536,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,78.89,225.51,percent of total billed charges,
HIV 1 QUANT,8275875,CDM,300,RC,87536,HCPCS,,,facility,inpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,147.00,200.41,percent of total billed charges,
HIV 1 QUANT,8275875,CDM,300,RC,87536,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,78.89,225.51,percent of total billed charges,
HIV 1 GENOTYPING WITH VIRTUAL PHE,8442363,CDM,300,RC,87901,HCPCS,,,facility,inpatient,,,379.00000,109.91000,Aetna,First Health,,310.02,,,,,,,227.40,310.02,percent of total billed charges,
HIV 1 GENOTYPING WITH VIRTUAL PHE,8442363,CDM,300,RC,87901,HCPCS,,,facility,outpatient,,,379.00000,109.91000,Aetna,First Health,,310.02,,,,,,,178.13,682.24,percent of total billed charges,
IMMUNOGLOBULIN D,3207059,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
IMMUNOGLOBULIN D,3207059,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,8.18,128.43,percent of total billed charges,
IMMUNOGLOBULIN G SUBCLASSES PANEL,3208996,CDM,300,RC,82787,HCPCS,,,facility,inpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,25.80,35.17,percent of total billed charges,
IMMUNOGLOBULIN G SUBCLASSES PANEL,3208996,CDM,300,RC,82787,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,7.44,35.17,percent of total billed charges,
ALPHA FETOPROTEIN NONPREG,3180842,CDM,300,RC,82105,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
ALPHA FETOPROTEIN NONPREG,3180842,CDM,300,RC,82105,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,15.54,121.06,percent of total billed charges,
Maternal Serum Screen AFP,8161657,CDM,300,RC,82105,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
Maternal Serum Screen AFP,8161657,CDM,300,RC,82105,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,15.54,121.06,percent of total billed charges,
ALUMINUM,7177840,CDM,300,RC,82108,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
ALUMINUM,7177840,CDM,300,RC,82108,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,23.62,121.06,percent of total billed charges,
RF INSULIN TOTAL,3184845,CDM,300,RC,83525,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,3184845,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,10.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748031,CDM,300,RC,83525,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748031,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,10.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748032,CDM,300,RC,83525,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748032,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,10.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748033,CDM,300,RC,83525,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748033,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,10.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748034,CDM,300,RC,83525,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748034,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,10.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748035,CDM,300,RC,83525,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748035,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,10.60,127.61,percent of total billed charges,
Insulin Random ARUP,8170373,CDM,300,RC,83525,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
Insulin Random ARUP,8170373,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,10.60,127.61,percent of total billed charges,
INSULIN ANTIBODIES,7177850,CDM,300,RC,86337,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
INSULIN ANTIBODIES,7177850,CDM,300,RC,86337,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,19.85,121.88,percent of total billed charges,
INTRINSIC FACTOR BLOCKING ANTIBDY,3218856,CDM,300,RC,86340,HCPCS,,,facility,inpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,94.80,129.24,percent of total billed charges,
INTRINSIC FACTOR BLOCKING ANTIBDY,3218856,CDM,300,RC,86340,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,13.98,129.24,percent of total billed charges,
EPSTEIN BARR VIRUS DNA QT REAL TM,3198952,CDM,300,RC,87799,HCPCS,,,facility,inpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,130.80,178.32,percent of total billed charges,
EPSTEIN BARR VIRUS DNA QT REAL TM,3198952,CDM,300,RC,87799,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,39.72,178.32,percent of total billed charges,
LAMOTRIGINE LEVEL,3198911,CDM,300,RC,80175,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
LAMOTRIGINE LEVEL,3198911,CDM,300,RC,80175,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,12.29,124.34,percent of total billed charges,
AMYLASE ISOENZYMES,3209005,CDM,300,RC,82150,HCPCS,,,facility,inpatient,,,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,45.60,62.17,percent of total billed charges,
AMYLASE ISOENZYMES,3209005,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,6.00,62.17,percent of total billed charges,
CHLAMYDIA,7790508,CDM,300,RC,86631,HCPCS,,,facility,inpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
CHLAMYDIA,7790508,CDM,300,RC,86631,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,10.81,31.32,percent of total billed charges,
CHLAMYDIA,7790527,CDM,300,RC,86631,HCPCS,,,facility,inpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
CHLAMYDIA,7790527,CDM,300,RC,86631,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,10.81,31.32,percent of total billed charges,
ALBUMIN CSF,1453800,CDM,300,RC,82042,HCPCS,,,facility,inpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,21.00,28.63,percent of total billed charges,
ALBUMIN CSF,1453800,CDM,300,RC,82042,HCPCS,,,facility,outpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,3.83,28.63,percent of total billed charges,
EHRLICHIA,1453801,CDM,300,RC,86666,HCPCS,,,facility,inpatient,,,68.00000,19.72000,Aetna,First Health,,55.62,,,,,,,40.80,55.62,percent of total billed charges,
EHRLICHIA,1453801,CDM,300,RC,86666,HCPCS,,,facility,outpatient,,,68.00000,19.72000,Aetna,First Health,,55.62,,,,,,,9.43,55.62,percent of total billed charges,
EHRLICHIA,3188904,CDM,300,RC,86666,HCPCS,,,facility,inpatient,,,68.00000,19.72000,Aetna,First Health,,55.62,,,,,,,40.80,55.62,percent of total billed charges,
EHRLICHIA,3188904,CDM,300,RC,86666,HCPCS,,,facility,outpatient,,,68.00000,19.72000,Aetna,First Health,,55.62,,,,,,,9.43,55.62,percent of total billed charges,
LDH,1453805,CDM,300,RC,83615,HCPCS,,,facility,inpatient,,,49.00000,14.21000,Aetna,First Health,,40.08,,,,,,,29.40,40.08,percent of total billed charges,
LDH,1453805,CDM,300,RC,83615,HCPCS,,,facility,outpatient,,,49.00000,14.21000,Aetna,First Health,,40.08,,,,,,,5.60,40.08,percent of total billed charges,
JC VIRUS PCR,3214941,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,146.40,199.59,percent of total billed charges,
JC VIRUS PCR,3214941,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,32.53,199.59,percent of total billed charges,
AMYLASE ISO,759806,CDM,300,RC,82150,HCPCS,,,facility,inpatient,,,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,45.60,62.17,percent of total billed charges,
AMYLASE ISO,759806,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,6.00,62.17,percent of total billed charges,
CARDIOLIPID ANTIBODY,3190994,CDM,300,RC,86147,HCPCS,,,facility,inpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,28.80,39.26,percent of total billed charges,
CARDIOLIPID ANTIBODY,3190994,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,22.56,67.44,percent of total billed charges,
CARDIO AB,613048,CDM,300,RC,86147,HCPCS,,,facility,inpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,28.80,39.26,percent of total billed charges,
CARDIO AB,613048,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,22.56,67.44,percent of total billed charges,
CARDIOLIPIN ANTIBODY,8256399,CDM,300,RC,86147,HCPCS,,,facility,inpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,28.80,39.26,percent of total billed charges,
CARDIOLIPIN ANTIBODY,8256399,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,22.56,67.44,percent of total billed charges,
RESPIRATORY SYNCYTIAL VIRUS,3218874,CDM,300,RC,87280,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
RESPIRATORY SYNCYTIAL VIRUS,3218874,CDM,300,RC,87280,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,12.44,111.25,percent of total billed charges,
LEAD BLD,3188848,CDM,300,RC,83655,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
LEAD BLD,3188848,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,11.23,125.97,percent of total billed charges,
LEAD BLD,7933752,CDM,300,RC,83655,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
LEAD BLD,7933752,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,11.23,125.97,percent of total billed charges,
BETA D GLUCAN,7111839,CDM,300,RC,87449,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,138.60,188.96,percent of total billed charges,
BETA D GLUCAN,7111839,CDM,300,RC,87449,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,11.10,188.96,percent of total billed charges,
IMMUNOASSAY TUMOR OTHER,8366174,CDM,300,RC,86316,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
IMMUNOASSAY TUMOR OTHER,8366174,CDM,300,RC,86316,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,13.15,118.61,percent of total billed charges,
IMMUNOASSAY TUMOR OTHER,8461765,CDM,300,RC,86316,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
IMMUNOASSAY TUMOR OTHER,8461765,CDM,300,RC,86316,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,13.15,118.61,percent of total billed charges,
IMMUNOASSAY TUMOR OTHER,8461767,CDM,300,RC,86316,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
IMMUNOASSAY TUMOR OTHER,8461767,CDM,300,RC,86316,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,13.15,118.61,percent of total billed charges,
KAPPA LAMBDA LIGHT CHAINS,3214904,CDM,300,RC,83521,HCPCS,,,facility,inpatient,,,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,49.80,67.89,percent of total billed charges,
KAPPA LAMBDA LIGHT CHAINS,3214904,CDM,300,RC,83521,HCPCS,,,facility,outpatient,,,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,16.01,67.89,percent of total billed charges,
KAPPA LAMBDA LIGHT CHAIN,1549817,CDM,300,RC,83521,HCPCS,,,facility,inpatient,,,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,49.80,67.89,percent of total billed charges,
KAPPA LAMBDA LIGHT CHAIN,1549817,CDM,300,RC,83521,HCPCS,,,facility,outpatient,,,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,16.01,67.89,percent of total billed charges,
C TRACH N GONORRHOEAE BY AMD,3200851,CDM,300,RC,87491,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
C TRACH N GONORRHOEAE BY AMD,3200851,CDM,300,RC,87491,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,32.53,92.99,percent of total billed charges,
N GONOR DNA AMP PROBE,1714802,CDM,300,RC,87591,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
N GONOR DNA AMP PROBE,1714802,CDM,300,RC,87591,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,32.53,92.99,percent of total billed charges,
IMMUNOASSAY QUANT NOS,1429800,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,24.60,33.54,percent of total billed charges,
IMMUNOASSAY QUANT NOS,1429800,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,16.01,45.77,percent of total billed charges,
IMMUNOASSAY QUANT NOS,5391874,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,24.60,33.54,percent of total billed charges,
IMMUNOASSAY QUANT NOS,5391874,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,16.01,45.77,percent of total billed charges,
CARDIOLIPIN ANTIBODIES SCREEN,3178845,CDM,300,RC,86147,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
CARDIOLIPIN ANTIBODIES SCREEN,3178845,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,23.60,119.43,percent of total billed charges,
CARDIOLIPIN ANTIBODY,8256309,CDM,300,RC,86147,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
CARDIOLIPIN ANTIBODY,8256309,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,23.60,119.43,percent of total billed charges,
CARDIOLIPIN ANTIBODY,8256316,CDM,300,RC,86147,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
CARDIOLIPIN ANTIBODY,8256316,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,23.60,119.43,percent of total billed charges,
PHOSPHOLIPIDS,3206858,CDM,300,RC,84311,HCPCS,,,facility,inpatient,,,159.00000,46.11000,Aetna,First Health,,130.06,,,,,,,95.40,130.06,percent of total billed charges,
PHOSPHOLIPIDS,3206858,CDM,300,RC,84311,HCPCS,,,facility,outpatient,,,159.00000,46.11000,Aetna,First Health,,130.06,,,,,,,7.51,130.06,percent of total billed charges,
GBM ANTIBODY,3190853,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
GBM ANTIBODY,3190853,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,10.69,111.25,percent of total billed charges,
ANGIOTENSIN 1 CONVERTING,3188943,CDM,300,RC,82164,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
ANGIOTENSIN 1 CONVERTING,3188943,CDM,300,RC,82164,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,13.53,126.79,percent of total billed charges,
ANGIOTENSIN 1 CONVERTING,3196845,CDM,300,RC,82164,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
ANGIOTENSIN 1 CONVERTING,3196845,CDM,300,RC,82164,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,13.53,126.79,percent of total billed charges,
SJOGREN ANTIBODIES SSA AND SSB,3214893,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,45.00000,13.05000,Aetna,First Health,,36.81,,,,,,,27.00,36.81,percent of total billed charges,
SJOGREN ANTIBODIES SSA AND SSB,3214893,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,45.00000,13.05000,Aetna,First Health,,36.81,,,,,,,16.62,47.51,percent of total billed charges,
SJOGREN ANTIBODIES SSA AND SSB,3214992,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,45.00000,13.05000,Aetna,First Health,,36.81,,,,,,,27.00,36.81,percent of total billed charges,
SJOGREN ANTIBODIES SSA AND SSB,3214992,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,45.00000,13.05000,Aetna,First Health,,36.81,,,,,,,16.62,47.51,percent of total billed charges,
LIDOCAINE LEVEL,599708,CDM,300,RC,80176,HCPCS,,,facility,inpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
LIDOCAINE LEVEL,599708,CDM,300,RC,80176,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,13.62,108.79,percent of total billed charges,
LIVER KIDNEY LKM1 AB IGM,3216879,CDM,300,RC,86376,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
LIVER KIDNEY LKM1 AB IGM,3216879,CDM,300,RC,86376,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,13.49,122.70,percent of total billed charges,
PLATELET NEUTRALIZATION LUPUS ANT,3341841,CDM,300,RC,85597,HCPCS,,,facility,inpatient,,,44.00000,12.76000,Aetna,First Health,,35.99,,,,,,,26.40,35.99,percent of total billed charges,
PLATELET NEUTRALIZATION LUPUS ANT,3341841,CDM,300,RC,85597,HCPCS,,,facility,outpatient,,,44.00000,12.76000,Aetna,First Health,,35.99,,,,,,,16.67,47.65,percent of total billed charges,
Lyme disease C6 Peptide Ab,9011398,CDM,300,RC,86618,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
Lyme disease C6 Peptide Ab,9011398,CDM,300,RC,86618,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,15.79,119.43,percent of total billed charges,
Lyme 1st Tier Testing,9044144,CDM,300,RC,86618,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
Lyme 1st Tier Testing,9044144,CDM,300,RC,86618,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,15.79,119.43,percent of total billed charges,
50255 Borrelia burgdorferi Ab IgG by Immunoblot ARUP,8117903,CDM,300,RC,86617,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
50255 Borrelia burgdorferi Ab IgG by Immunoblot ARUP,8117903,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,14.36,124.34,percent of total billed charges,
B Burgdorferi Ab IgG IgM CSCTRULE,8948133,CDM,300,RC,86617,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
B Burgdorferi Ab IgG IgM CSCTRULE,8948133,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,14.36,124.34,percent of total billed charges,
PTT LUPUS,613046,CDM,300,RC,85730,HCPCS,,,facility,inpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,25.20,34.36,percent of total billed charges,
PTT LUPUS,613046,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,5.57,34.36,percent of total billed charges,
CHLAMYDIA IGM,7790528,CDM,300,RC,86632,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
CHLAMYDIA IGM,7790528,CDM,300,RC,86632,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,11.75,33.60,percent of total billed charges,
ANA REFLEX BILL,3173065,CDM,300,RC,86039,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
ANA REFLEX BILL,3173065,CDM,300,RC,86039,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,10.34,119.43,percent of total billed charges,
Antinuclear Ab with HEp2 Substrate IgG by IFA,8146939,CDM,300,RC,86039,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
Antinuclear Ab with HEp2 Substrate IgG by IFA,8146939,CDM,300,RC,86039,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,10.34,119.43,percent of total billed charges,
Antinuclear Ab with HEp2 Substrate IgG by IFA,8146989,CDM,300,RC,86039,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
Antinuclear Ab with HEp2 Substrate IgG by IFA,8146989,CDM,300,RC,86039,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,10.34,119.43,percent of total billed charges,
ANA SCREEN,3173050,CDM,300,RC,86038,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
ANA SCREEN,3173050,CDM,300,RC,86038,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,11.21,124.34,percent of total billed charges,
THYROID PEROXIDASE AND THRYOGLOB,3188926,CDM,300,RC,86376,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
THYROID PEROXIDASE AND THRYOGLOB,3188926,CDM,300,RC,86376,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,13.49,59.71,percent of total billed charges,
METHYLMALONIC ACID,3190886,CDM,300,RC,83921,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
METHYLMALONIC ACID,3190886,CDM,300,RC,83921,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,19.66,110.43,percent of total billed charges,
THYROGLOBULIN ANTIBODY,3196864,CDM,300,RC,86800,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
THYROGLOBULIN ANTIBODY,3196864,CDM,300,RC,86800,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,14.75,127.61,percent of total billed charges,
THYROGLOBULIN ANTIBODY,6061848,CDM,300,RC,86800,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
THYROGLOBULIN ANTIBODY,6061848,CDM,300,RC,86800,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,14.75,127.61,percent of total billed charges,
METANEPHRINSE FRACTIONED URINE,6875878,CDM,300,RC,83835,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
METANEPHRINSE FRACTIONED URINE,6875878,CDM,300,RC,83835,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,15.71,111.25,percent of total billed charges,
METANEPHRINES PLASMA,3192856,CDM,300,RC,83835,HCPCS,,,facility,inpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,79.20,107.98,percent of total billed charges,
METANEPHRINES PLASMA,3192856,CDM,300,RC,83835,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,15.71,107.98,percent of total billed charges,
MAGNESIUM OTHER,3214929,CDM,300,RC,83735,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
MAGNESIUM OTHER,3214929,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,6.21,118.61,percent of total billed charges,
MAGNESIUM OTHER,3218843,CDM,300,RC,83735,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
MAGNESIUM OTHER,3218843,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,6.21,118.61,percent of total billed charges,
METHANOL,604347,CDM,300,RC,80320,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,113.40,154.60,percent of total billed charges,
METHANOL,604347,CDM,300,RC,80320,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,0.01485,154.60,percent of total billed charges,
TREPONEMA PALLIDUM,3198917,CDM,300,RC,86780,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
TREPONEMA PALLIDUM,3198917,CDM,300,RC,86780,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,12.28,118.61,percent of total billed charges,
TREPONEMA PALLIDUM,3521842,CDM,300,RC,86780,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
TREPONEMA PALLIDUM,3521842,CDM,300,RC,86780,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,12.28,120.25,percent of total billed charges,
METHOTREXATE LEVEL,605916,CDM,300,RC,80204,HCPCS,,,facility,inpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,84.60,115.34,percent of total billed charges,
METHOTREXATE LEVEL,605916,CDM,300,RC,80204,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,35.75,115.34,percent of total billed charges,
PROTHROMBIN TIME,3178898,CDM,300,RC,85610,HCPCS,,,facility,inpatient,,,31.00000,8.99000,Aetna,First Health,,25.36,,,,,,,18.60,25.36,percent of total billed charges,
PROTHROMBIN TIME,3178898,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,31.00000,8.99000,Aetna,First Health,,25.36,,,,,,,3.98,25.36,percent of total billed charges,
PTT SUB PLASMA FRACT,3186863,CDM,300,RC,85732,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
PTT SUB PLASMA FRACT,3186863,CDM,300,RC,85732,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,5.99,22.09,percent of total billed charges,
HEPARIN NEUT,3186866,CDM,300,RC,85525,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
HEPARIN NEUT,3186866,CDM,300,RC,85525,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,10.98,40.90,percent of total billed charges,
FACTOR V LEIDEN ZB10C,3178848,CDM,300,RC,81241,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
FACTOR V LEIDEN ZB10C,3178848,CDM,300,RC,81241,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,68.01,194.43,percent of total billed charges,
FACTOR V LEIDEN ZB10C,7730126,CDM,300,RC,81241,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
FACTOR V LEIDEN ZB10C,7730126,CDM,300,RC,81241,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,68.01,194.43,percent of total billed charges,
STONE ANALYSIS,7724048,CDM,300,RC,82365,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
STONE ANALYSIS,7724048,CDM,300,RC,82365,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,11.96,125.97,percent of total billed charges,
HERPES SIMPLEX 2 AG,3180854,CDM,300,RC,87273,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
HERPES SIMPLEX 2 AG,3180854,CDM,300,RC,87273,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,11.10,57.26,percent of total billed charges,
HERPES SIMPLEX I AG,3180875,CDM,300,RC,87274,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
HERPES SIMPLEX I AG,3180875,CDM,300,RC,87274,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,11.10,57.26,percent of total billed charges,
VARICELLA ZOSTER AG,3180876,CDM,300,RC,87290,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
VARICELLA ZOSTER AG,3180876,CDM,300,RC,87290,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,12.44,64.62,percent of total billed charges,
Virus Inoculate,3186853,CDM,300,RC,87253,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
Virus Inoculate,3186853,CDM,300,RC,87253,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,18.73,111.25,percent of total billed charges,
Culture HSV w Reflex Typing,8387024,CDM,300,RC,87253,HCPCS,,,facility,inpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,34.80,47.44,percent of total billed charges,
Culture HSV w Reflex Typing,8387024,CDM,300,RC,87253,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,18.73,53.53,percent of total billed charges,
MITOCHONDRIAL ANTIBODIES,3180910,CDM,300,RC,86381,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
MITOCHONDRIAL ANTIBODIES,3180910,CDM,300,RC,86381,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,23.60,121.06,percent of total billed charges,
BETA 2 MICROGLOBULIN BLOOD,3184862,CDM,300,RC,82232,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
BETA 2 MICROGLOBULIN BLOOD,3184862,CDM,300,RC,82232,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,15.00,121.06,percent of total billed charges,
CHLORIDE URINE SUPERSAT PROF,7507978,CDM,300,RC,82436,HCPCS,,,facility,inpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
CHLORIDE URINE SUPERSAT PROF,7507978,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,5.34,15.24,percent of total billed charges,
ACETYLCHOLINE BINDING AG,3188940,CDM,300,RC,86041,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,85.20,116.16,percent of total billed charges,
ACETYLCHOLINE BINDING AG,3188940,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,17.06,116.16,percent of total billed charges,
HEMOCHROMATOSIS MUTATIONS ZB10H,3190955,CDM,300,RC,81256,HCPCS,,,facility,inpatient,,,242.00000,70.18000,Aetna,First Health,,197.96,,,,,,,145.20,197.96,percent of total billed charges,
HEMOCHROMATOSIS MUTATIONS ZB10H,3190955,CDM,300,RC,81256,HCPCS,,,facility,outpatient,,,242.00000,70.18000,Aetna,First Health,,197.96,,,,,,,60.58,197.96,percent of total billed charges,
HEMOGLOBIN EVALUATION,3188851,CDM,300,RC,83021,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
HEMOGLOBIN EVALUATION,3188851,CDM,300,RC,83021,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,11.66,111.25,percent of total billed charges,
HEMOGLOBIN EVALUATION,3190839,CDM,300,RC,83021,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
HEMOGLOBIN EVALUATION,3190839,CDM,300,RC,83021,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,11.66,111.25,percent of total billed charges,
HGB EVALUATION PANEL,8265873,CDM,300,RC,83021,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
HGB EVALUATION PANEL,8265873,CDM,300,RC,83021,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,11.66,111.25,percent of total billed charges,
IMMUNOGLOB SERUM CRYOPRECIP,3190956,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,9.00,12.27,percent of total billed charges,
IMMUNOGLOB SERUM CRYOPRECIP,3190956,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,7.05,24.64,percent of total billed charges,
IMMUNOGLOB SERUM CRYOPRECIP,3190975,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,9.00,12.27,percent of total billed charges,
IMMUNOGLOB SERUM CRYOPRECIP,3190975,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,7.05,24.64,percent of total billed charges,
LYME DIS DNA AMP PROBE,3191041,CDM,300,RC,87476,HCPCS,,,facility,inpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,118.20,161.15,percent of total billed charges,
LYME DIS DNA AMP PROBE,3191041,CDM,300,RC,87476,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,32.53,161.15,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3481847,CDM,300,RC,86258,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3481847,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,11.18,118.61,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3481848,CDM,300,RC,86258,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3481848,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,11.18,118.61,percent of total billed charges,
THIOPURINE METHYLTRANSFERASE,3196893,CDM,300,RC,84433,HCPCS,,,facility,inpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,138.00,188.14,percent of total billed charges,
THIOPURINE METHYLTRANSFERASE,3196893,CDM,300,RC,84433,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,20.55,188.14,percent of total billed charges,
ESTROGEN FRACTIONATED,3198904,CDM,300,RC,82671,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
ESTROGEN FRACTIONATED,3198904,CDM,300,RC,82671,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,29.94,117.79,percent of total billed charges,
JAK2 MUTATION QUAL ZB1HR,3200855,CDM,300,RC,81270,HCPCS,,,facility,inpatient,,,275.00000,79.75000,Aetna,First Health,,224.95,,,,,,,165.00,224.95,percent of total billed charges,
JAK2 MUTATION QUAL ZB1HR,3200855,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,275.00000,79.75000,Aetna,First Health,,224.95,,,,,,,84.96,242.90,percent of total billed charges,
PHENYTOIN TOTAL,3207134,CDM,300,RC,80185,HCPCS,,,facility,inpatient,,,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,41.40,56.44,percent of total billed charges,
PHENYTOIN TOTAL,3207134,CDM,300,RC,80185,HCPCS,,,facility,outpatient,,,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,12.29,56.44,percent of total billed charges,
VARICELLA ZOSTER BY PCR,3216846,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,118.20,161.15,percent of total billed charges,
VARICELLA ZOSTER BY PCR,3216846,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,32.53,161.15,percent of total billed charges,
DRUG CONF FENTANYL METAB UR,3232944,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,112.20,152.97,percent of total billed charges,
DRUG CONF FENTANYL METAB UR,3232944,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,74.80,257.47,percent of total billed charges,
OSTEOCALCIN BY ECIA,3216851,CDM,300,RC,83937,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
OSTEOCALCIN BY ECIA,3216851,CDM,300,RC,83937,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,27.68,121.88,percent of total billed charges,
BILE ACIDS FRACT AND TOTAL,3218892,CDM,300,RC,83789,HCPCS,,,facility,inpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,94.80,129.24,percent of total billed charges,
BILE ACIDS FRACT AND TOTAL,3218892,CDM,300,RC,83789,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,11.66,129.24,percent of total billed charges,
PSEUDOCHOLINESTERASE TOTAL,3218840,CDM,300,RC,82480,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
PSEUDOCHOLINESTERASE TOTAL,3218840,CDM,300,RC,82480,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,5.09,121.88,percent of total billed charges,
COLLAGEN CROSSLINKS,3218903,CDM,300,RC,82523,HCPCS,,,facility,inpatient,,,169.00000,49.01000,Aetna,First Health,,138.24,,,,,,,101.40,138.24,percent of total billed charges,
COLLAGEN CROSSLINKS,3218903,CDM,300,RC,82523,HCPCS,,,facility,outpatient,,,169.00000,49.01000,Aetna,First Health,,138.24,,,,,,,17.31,138.24,percent of total billed charges,
PORPHOBIL DEAMINASE RBC,3218906,CDM,300,RC,82657,HCPCS,,,facility,inpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,115.20,157.06,percent of total billed charges,
PORPHOBIL DEAMINASE RBC,3218906,CDM,300,RC,82657,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,11.66,157.06,percent of total billed charges,
PORPHYRINS TOTAL PLASMA,5785839,CDM,300,RC,84311,HCPCS,,,facility,inpatient,,,277.00000,80.33000,Aetna,First Health,,226.59,,,,,,,166.20,226.59,percent of total billed charges,
PORPHYRINS TOTAL PLASMA,5785839,CDM,300,RC,84311,HCPCS,,,facility,outpatient,,,277.00000,80.33000,Aetna,First Health,,226.59,,,,,,,7.51,226.59,percent of total billed charges,
PORPHYRINS FRACTION PLASMA,3247840,CDM,300,RC,82542,HCPCS,,,facility,inpatient,,,307.00000,89.03000,Aetna,First Health,,251.13,,,,,,,184.20,251.13,percent of total billed charges,
PORPHYRINS FRACTION PLASMA,3247840,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,307.00000,89.03000,Aetna,First Health,,251.13,,,,,,,11.66,251.13,percent of total billed charges,
PORPHYRINS FRACTION PLASMA,6537839,CDM,300,RC,82542,HCPCS,,,facility,inpatient,,,307.00000,89.03000,Aetna,First Health,,251.13,,,,,,,184.20,251.13,percent of total billed charges,
PORPHYRINS FRACTION PLASMA,6537839,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,307.00000,89.03000,Aetna,First Health,,251.13,,,,,,,11.66,251.13,percent of total billed charges,
DNA ANTIBODY,3184889,CDM,300,RC,86225,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
DNA ANTIBODY,3184889,CDM,300,RC,86225,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,12.74,119.43,percent of total billed charges,
ANNA IFA TITER,3327846,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,72.00,98.16,percent of total billed charges,
ANNA IFA TITER,3327846,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,11.18,98.16,percent of total billed charges,
SICKLE SOLUBILITY TEST,1605803,CDM,300,RC,85660,HCPCS,,,facility,inpatient,,,129.00000,37.41000,Aetna,First Health,,105.52,,,,,,,77.40,105.52,percent of total billed charges,
SICKLE SOLUBILITY TEST,1605803,CDM,300,RC,85660,HCPCS,,,facility,outpatient,,,129.00000,37.41000,Aetna,First Health,,105.52,,,,,,,5.11,105.52,percent of total billed charges,
PURKINSE CELL AB TITER IGG,3327848,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,72.00,98.16,percent of total billed charges,
PURKINSE CELL AB TITER IGG,3327848,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,11.18,98.16,percent of total billed charges,
ENDOMYSIAL AB IGA TITER,3327850,CDM,300,RC,86231,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
ENDOMYSIAL AB IGA TITER,3327850,CDM,300,RC,86231,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,11.21,111.25,percent of total billed charges,
EPSTEIN BARR ANTIBODY,3427839,CDM,300,RC,86663,HCPCS,,,facility,inpatient,,,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,18.00,24.54,percent of total billed charges,
EPSTEIN BARR ANTIBODY,3427839,CDM,300,RC,86663,HCPCS,,,facility,outpatient,,,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,12.16,34.77,percent of total billed charges,
PSA ULTRASENSITIVE,3481849,CDM,300,RC,84153,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
PSA ULTRASENSITIVE,3481849,CDM,300,RC,84153,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,17.05,125.97,percent of total billed charges,
CARDIOLIPID ANTIBODY,3973871,CDM,300,RC,86147,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
CARDIOLIPID ANTIBODY,3973871,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,23.60,67.44,percent of total billed charges,
CARDIOLIPID ANTIBODY,7726055,CDM,300,RC,86147,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
CARDIOLIPID ANTIBODY,7726055,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,23.60,67.44,percent of total billed charges,
CARCINOEMBRYONIC AG BODY FL,4349839,CDM,300,RC,82378,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
CARCINOEMBRYONIC AG BODY FL,4349839,CDM,300,RC,82378,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,17.57,124.34,percent of total billed charges,
BLOOD PLATELET AGGREGATION,4563839,CDM,300,RC,85576,HCPCS,,,facility,inpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,39.60,53.99,percent of total billed charges,
BLOOD PLATELET AGGREGATION,4563839,CDM,300,RC,85576,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,23.09,66.01,percent of total billed charges,
BLOOD PLATELET AGGREGATION,4563841,CDM,300,RC,85576,HCPCS,,,facility,inpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,39.60,53.99,percent of total billed charges,
BLOOD PLATELET AGGREGATION,4563841,CDM,300,RC,85576,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,23.09,66.01,percent of total billed charges,
HEXAGONAL PHOSPHOLIPID,3180845,CDM,300,RC,85598,HCPCS,,,facility,inpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,115.20,157.06,percent of total billed charges,
HEXAGONAL PHOSPHOLIPID,3180845,CDM,300,RC,85598,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,16.67,157.06,percent of total billed charges,
HEXAGONAL PHOSPHOLIPID,3341842,CDM,300,RC,85598,HCPCS,,,facility,inpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,115.20,157.06,percent of total billed charges,
HEXAGONAL PHOSPHOLIPID,3341842,CDM,300,RC,85598,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,16.67,157.06,percent of total billed charges,
WEST NILE VIRUS AB BLOOD IGM,657873,CDM,300,RC,86788,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
WEST NILE VIRUS AB BLOOD IGM,657873,CDM,300,RC,86788,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,15.63,62.99,percent of total billed charges,
DEHYDROEPIANDROSTERONE DHEA,4937943,CDM,300,RC,82626,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
DEHYDROEPIANDROSTERONE DHEA,4937943,CDM,300,RC,82626,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,23.42,110.43,percent of total billed charges,
DS DNA ANTIBODY 1GG TITER,3327845,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
DS DNA ANTIBODY 1GG TITER,3327845,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,11.18,111.25,percent of total billed charges,
MYCOPLASMA AB IGM,5235839,CDM,300,RC,86738,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
MYCOPLASMA AB IGM,5235839,CDM,300,RC,86738,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,12.28,118.61,percent of total billed charges,
3000400 QuantiFERON TB Gold Plus 1 Tube ARUP,8118233,CDM,300,RC,86480,HCPCS,,,facility,inpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,79.20,107.98,percent of total billed charges,
3000400 QuantiFERON TB Gold Plus 1 Tube ARUP,8118233,CDM,300,RC,86480,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,57.45,164.25,percent of total billed charges,
IMMUNOASSAY QUANT NOS,5391853,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
IMMUNOASSAY QUANT NOS,5391853,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,8.46,45.77,percent of total billed charges,
IMMUNOASSAY QUANT NOS,5391855,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
IMMUNOASSAY QUANT NOS,5391855,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,8.46,45.77,percent of total billed charges,
C REACTIVE PROTEIN,5391856,CDM,300,RC,86140,HCPCS,,,facility,inpatient,,,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
C REACTIVE PROTEIN,5391856,CDM,300,RC,86140,HCPCS,,,facility,outpatient,,,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.82,13.73,percent of total billed charges,
BB BILL ANTIGEN TYPE REFERENCE,595625,CDM,300,RC,86905,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
BB BILL ANTIGEN TYPE REFERENCE,595625,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,3.83,358.78,percent of total billed charges,
BB BILL RH PHENOTYPING REFERENCE,5987845,CDM,300,RC,86906,HCPCS,,,facility,inpatient,,,281.00000,81.49000,Aetna,First Health,,229.86,,,,,,,168.60,229.86,percent of total billed charges,
BB BILL RH PHENOTYPING REFERENCE,5987845,CDM,300,RC,86906,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,First Health,,229.86,,,,,,,7.75,229.86,percent of total billed charges,
BB BILL AB SCREEN ADS REFERENCE,5987848,CDM,300,RC,86850,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,96.00,130.88,percent of total billed charges,
BB BILL AB SCREEN ADS REFERENCE,5987848,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,9.77,130.88,percent of total billed charges,
MUMPS ANTIBODY,3210841,CDM,300,RC,86735,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
MUMPS ANTIBODY,3210841,CDM,300,RC,86735,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,12.10,120.25,percent of total billed charges,
MYCOPLASMA AB IGG,3206842,CDM,300,RC,86738,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
MYCOPLASMA AB IGG,3206842,CDM,300,RC,86738,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,12.28,118.61,percent of total billed charges,
BRUCELLA IGG IGM EIA,3232941,CDM,300,RC,86622,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
BRUCELLA IGG IGM EIA,3232941,CDM,300,RC,86622,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,8.28,120.25,percent of total billed charges,
C PEPTIDE,3188901,CDM,300,RC,84681,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
C PEPTIDE,3188901,CDM,300,RC,84681,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,19.29,119.43,percent of total billed charges,
MYELIN BASIC PROTEIN CSF,3190889,CDM,300,RC,83873,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
MYELIN BASIC PROTEIN CSF,3190889,CDM,300,RC,83873,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,15.94,112.88,percent of total billed charges,
CALCITONIN LEVEL,3209019,CDM,300,RC,82308,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
CALCITONIN LEVEL,3209019,CDM,300,RC,82308,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,24.83,128.43,percent of total billed charges,
CANCER ANTIGEN 15 3,3216854,CDM,300,RC,86300,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
CANCER ANTIGEN 15 3,3216854,CDM,300,RC,86300,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,13.15,121.06,percent of total billed charges,
CARBOHYDRATE AG 19 9,3180848,CDM,300,RC,86301,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
CARBOHYDRATE AG 19 9,3180848,CDM,300,RC,86301,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,13.15,119.43,percent of total billed charges,
CA 27 29 BIOMIRA,3180839,CDM,300,RC,86300,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
CA 27 29 BIOMIRA,3180839,CDM,300,RC,86300,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,13.15,119.43,percent of total billed charges,
MYOGLOBIN,3191015,CDM,300,RC,83874,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
MYOGLOBIN,3191015,CDM,300,RC,83874,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,11.98,120.25,percent of total billed charges,
MYOGLOBIN,7950123,CDM,300,RC,83874,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
MYOGLOBIN,7950123,CDM,300,RC,83874,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,11.98,120.25,percent of total billed charges,
OSMOLALITY FECES ZB4GK,3209061,CDM,300,RC,84999,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
OSMOLALITY FECES ZB4GK,3209061,CDM,300,RC,84999,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,56.24,127.61,percent of total billed charges,
CATECHOLAMINES PLASMA,3196848,CDM,300,RC,82384,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
CATECHOLAMINES PLASMA,3196848,CDM,300,RC,82384,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,23.41,118.61,percent of total billed charges,
NICOTINE BLOOD,4129840,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
NICOTINE BLOOD,4129840,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,55.20,257.47,percent of total billed charges,
NICOTINE AND METABOLITES URINE,7286008,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
NICOTINE AND METABOLITES URINE,7286008,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,57.60,257.47,percent of total billed charges,
OLIGOCLONAL BANDING,3188966,CDM,300,RC,83916,HCPCS,,,facility,inpatient,,,159.00000,46.11000,Aetna,First Health,,130.06,,,,,,,95.40,130.06,percent of total billed charges,
OLIGOCLONAL BANDING,3188966,CDM,300,RC,83916,HCPCS,,,facility,outpatient,,,159.00000,46.11000,Aetna,First Health,,130.06,,,,,,,25.39,130.06,percent of total billed charges,
OXCARBAZEPINE,3198933,CDM,300,RC,80183,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
OXCARBAZEPINE,3198933,CDM,300,RC,80183,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,12.29,110.43,percent of total billed charges,
CERULOPLASMIN,3182883,CDM,300,RC,82390,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CERULOPLASMIN,3182883,CDM,300,RC,82390,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,9.96,126.79,percent of total billed charges,
PARVOVIRUS B19 IGG ONLY,3218859,CDM,300,RC,86747,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
PARVOVIRUS B19 IGG ONLY,3218859,CDM,300,RC,86747,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,13.94,121.06,percent of total billed charges,
PARVOVIRUS B19 IGM ONLY,3218860,CDM,300,RC,86747,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
PARVOVIRUS B19 IGM ONLY,3218860,CDM,300,RC,86747,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,13.94,121.06,percent of total billed charges,
PARVOVIRUS B19 IGG AND IGM,3209022,CDM,300,RC,86747,HCPCS,,,facility,inpatient,,,68.00000,19.72000,Aetna,First Health,,55.62,,,,,,,40.80,55.62,percent of total billed charges,
PARVOVIRUS B19 IGG AND IGM,3209022,CDM,300,RC,86747,HCPCS,,,facility,outpatient,,,68.00000,19.72000,Aetna,First Health,,55.62,,,,,,,13.94,55.62,percent of total billed charges,
PARVOVIRUS AB,613110,CDM,300,RC,86747,HCPCS,,,facility,inpatient,,,68.00000,19.72000,Aetna,First Health,,55.62,,,,,,,40.80,55.62,percent of total billed charges,
PARVOVIRUS AB,613110,CDM,300,RC,86747,HCPCS,,,facility,outpatient,,,68.00000,19.72000,Aetna,First Health,,55.62,,,,,,,13.94,55.62,percent of total billed charges,
TISSUE PLASMINOGEN ACTIVATOR,3481842,CDM,300,RC,85415,HCPCS,,,facility,inpatient,,,170.00000,49.30000,Aetna,First Health,,139.06,,,,,,,102.00,139.06,percent of total billed charges,
TISSUE PLASMINOGEN ACTIVATOR,3481842,CDM,300,RC,85415,HCPCS,,,facility,outpatient,,,170.00000,49.30000,Aetna,First Health,,139.06,,,,,,,15.93,139.06,percent of total billed charges,
PLASMINOGEN ACTIVATOR INHIBITOR,3207065,CDM,300,RC,85415,HCPCS,,,facility,inpatient,,,170.00000,49.30000,Aetna,First Health,,139.06,,,,,,,102.00,139.06,percent of total billed charges,
PLASMINOGEN ACTIVATOR INHIBITOR,3207065,CDM,300,RC,85415,HCPCS,,,facility,outpatient,,,170.00000,49.30000,Aetna,First Health,,139.06,,,,,,,15.93,139.06,percent of total billed charges,
CLOZAPINE,7933960,CDM,300,RC,80159,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
CLOZAPINE,7933960,CDM,300,RC,80159,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,18.68,128.43,percent of total billed charges,
PHENYBARB,613087,CDM,300,RC,80184,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
PHENYBARB,613087,CDM,300,RC,80184,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,14.18,58.90,percent of total billed charges,
PORPHOBILINOGEN 24 HOUR,3209040,CDM,300,RC,84110,HCPCS,,,facility,inpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,84.60,115.34,percent of total billed charges,
PORPHOBILINOGEN 24 HOUR,3209040,CDM,300,RC,84110,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,7.83,115.34,percent of total billed charges,
PORPHYRINS URINE,3196981,CDM,300,RC,84120,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
PORPHYRINS URINE,3196981,CDM,300,RC,84120,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,13.64,111.25,percent of total billed charges,
FECAL POTASSIUM ZB4GR,3196881,CDM,300,RC,84999,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
FECAL POTASSIUM ZB4GR,3196881,CDM,300,RC,84999,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,52.99,120.25,percent of total billed charges,
COPPER,3170880,CDM,300,RC,82525,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
COPPER,3170880,CDM,300,RC,82525,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,11.51,125.15,percent of total billed charges,
COPPER,3192847,CDM,300,RC,82525,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
COPPER,3192847,CDM,300,RC,82525,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,11.51,125.15,percent of total billed charges,
PRIMIDONE,3209045,CDM,300,RC,80188,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
PRIMIDONE,3209045,CDM,300,RC,80188,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,15.38,64.62,percent of total billed charges,
COUMADIN,3216883,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,115.20,157.06,percent of total billed charges,
COUMADIN,3216883,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,76.80,257.47,percent of total billed charges,
VARICELLA ZOSTER VIRUS IGG ANTIBD,3198895,CDM,300,RC,86787,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
VARICELLA ZOSTER VIRUS IGG ANTIBD,3198895,CDM,300,RC,86787,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,11.94,118.61,percent of total billed charges,
VARICELLA ZOSTER ANTIBODY,8260154,CDM,300,RC,86787,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
VARICELLA ZOSTER ANTIBODY,8260154,CDM,300,RC,86787,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,11.94,118.61,percent of total billed charges,
IMMUNOGLOBULIN G CSF,3188909,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,24.60,33.54,percent of total billed charges,
IMMUNOGLOBULIN G CSF,3188909,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,8.18,33.54,percent of total billed charges,
IMMUNOGLOBULIN A,8147425,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,24.60,33.54,percent of total billed charges,
IMMUNOGLOBULIN A,8147425,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,8.18,33.54,percent of total billed charges,
CYCLOSPORIN LEVEL,605905,CDM,300,RC,80158,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
CYCLOSPORIN LEVEL,605905,CDM,300,RC,80158,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,11.64,117.79,percent of total billed charges,
CYTOMEGALOVIRUS IGG,3196860,CDM,300,RC,86644,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
CYTOMEGALOVIRUS IGG,3196860,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,13.34,118.61,percent of total billed charges,
CMV IGG,613063,CDM,300,RC,86644,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
CMV IGG,613063,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,13.34,118.61,percent of total billed charges,
CMV IgG,635122,CDM,300,RC,86644,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
CMV IgG,635122,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,13.34,118.61,percent of total billed charges,
CYTOMEGALOVIRUS IGM,3190842,CDM,300,RC,86645,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
CYTOMEGALOVIRUS IGM,3190842,CDM,300,RC,86645,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,15.63,118.61,percent of total billed charges,
Cytomegalovirus by Quant NAAT Plasma,8984933,CDM,300,RC,87497,HCPCS,,,facility,inpatient,,,270.00000,78.30000,Aetna,First Health,,220.86,,,,,,,162.00,220.86,percent of total billed charges,
Cytomegalovirus by Quant NAAT Plasma,8984933,CDM,300,RC,87497,HCPCS,,,facility,outpatient,,,270.00000,78.30000,Aetna,First Health,,220.86,,,,,,,39.72,220.86,percent of total billed charges,
PROTEIN S ANTIGEN,3191021,CDM,300,RC,85305,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
PROTEIN S ANTIGEN,3191021,CDM,300,RC,85305,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,10.76,128.43,percent of total billed charges,
PROTEIN C ANTIGEN,3191018,CDM,300,RC,85302,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
PROTEIN C ANTIGEN,3191018,CDM,300,RC,85302,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,11.13,128.43,percent of total billed charges,
CRYOGLOBULIN SERUM,3191102,CDM,300,RC,82595,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CRYOGLOBULIN SERUM,3191102,CDM,300,RC,82595,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,5.99,126.79,percent of total billed charges,
ACTIVATED PROTEIN C RESISTANCE,3198901,CDM,300,RC,85307,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
ACTIVATED PROTEIN C RESISTANCE,3198901,CDM,300,RC,85307,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,14.20,127.61,percent of total billed charges,
ACTIVATED PROTEIN C RESISTANCE,7726056,CDM,300,RC,85307,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
ACTIVATED PROTEIN C RESISTANCE,7726056,CDM,300,RC,85307,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,14.20,127.61,percent of total billed charges,
C1 INHIBITOR FUNCTIONAL,3208993,CDM,300,RC,86161,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
C1 INHIBITOR FUNCTIONAL,3208993,CDM,300,RC,86161,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,11.12,110.43,percent of total billed charges,
PTH RELATED PROTEIN,7732383,CDM,300,RC,83519,HCPCS,,,facility,inpatient,,,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,108.60,148.06,percent of total billed charges,
PTH RELATED PROTEIN,7732383,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,17.06,148.06,percent of total billed charges,
RAPAMYCIN,3196869,CDM,300,RC,80195,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
RAPAMYCIN,3196869,CDM,300,RC,80195,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,11.77,121.88,percent of total billed charges,
IMMUNE COMPLEX C1Q,7177855,CDM,300,RC,86332,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
IMMUNE COMPLEX C1Q,7177855,CDM,300,RC,86332,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,22.59,125.15,percent of total billed charges,
PLASMA RENIN ACTIVITY,3184851,CDM,300,RC,84244,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
PLASMA RENIN ACTIVITY,3184851,CDM,300,RC,84244,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,20.38,125.97,percent of total billed charges,
Cyclic Citrullinated Peptide Ab,9011531,CDM,300,RC,86200,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
Cyclic Citrullinated Peptide Ab,9011531,CDM,300,RC,86200,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,12.01,122.70,percent of total billed charges,
RISTOCETIN COFACTOR,7856055,CDM,300,RC,85245,HCPCS,,,facility,inpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,83.40,113.70,percent of total billed charges,
RISTOCETIN COFACTOR,7856055,CDM,300,RC,85245,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,21.27,113.70,percent of total billed charges,
ROCKY MT SPOTTED FEVER ANTIBODIES,3192863,CDM,300,RC,86757,HCPCS,,,facility,inpatient,,,82.00000,23.78000,Aetna,First Health,,67.08,,,,,,,49.20,67.08,percent of total billed charges,
ROCKY MT SPOTTED FEVER ANTIBODIES,3192863,CDM,300,RC,86757,HCPCS,,,facility,outpatient,,,82.00000,23.78000,Aetna,First Health,,67.08,,,,,,,17.94,67.08,percent of total billed charges,
ROCKY MT SPOTTED FEVER ANTIBODIES,3192883,CDM,300,RC,86757,HCPCS,,,facility,inpatient,,,82.00000,23.78000,Aetna,First Health,,67.08,,,,,,,49.20,67.08,percent of total billed charges,
ROCKY MT SPOTTED FEVER ANTIBODIES,3192883,CDM,300,RC,86757,HCPCS,,,facility,outpatient,,,82.00000,23.78000,Aetna,First Health,,67.08,,,,,,,17.94,67.08,percent of total billed charges,
RMSF,647051,CDM,300,RC,86757,HCPCS,,,facility,inpatient,,,82.00000,23.78000,Aetna,First Health,,67.08,,,,,,,49.20,67.08,percent of total billed charges,
RMSF,647051,CDM,300,RC,86757,HCPCS,,,facility,outpatient,,,82.00000,23.78000,Aetna,First Health,,67.08,,,,,,,17.94,67.08,percent of total billed charges,
DHEA SULFATE,3190859,CDM,300,RC,82627,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
DHEA SULFATE,3190859,CDM,300,RC,82627,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,20.61,127.61,percent of total billed charges,
REFLEX RMSF TYPHUS FEVER IGM,646393,CDM,300,RC,86757,HCPCS,,,facility,inpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,42.60,58.08,percent of total billed charges,
REFLEX RMSF TYPHUS FEVER IGM,646393,CDM,300,RC,86757,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,17.94,58.08,percent of total billed charges,
ROTAVIRUS EIA,3214901,CDM,300,RC,87425,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
ROTAVIRUS EIA,3214901,CDM,300,RC,87425,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,11.10,121.06,percent of total billed charges,
RUBELLA VIRUS AB AGM,3481840,CDM,300,RC,86762,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
RUBELLA VIRUS AB AGM,3481840,CDM,300,RC,86762,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,13.34,118.61,percent of total billed charges,
RUBELLA VIRUS IGG AB,6033839,CDM,300,RC,86762,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
RUBELLA VIRUS IGG AB,6033839,CDM,300,RC,86762,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,13.34,127.61,percent of total billed charges,
Rubeola A,613116,CDM,300,RC,86765,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Rubeola A,613116,CDM,300,RC,86765,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,11.94,125.15,percent of total billed charges,
RUBEOLA A,6557840,CDM,300,RC,86765,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
RUBEOLA A,6557840,CDM,300,RC,86765,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,11.94,125.15,percent of total billed charges,
SEROTONIN BLOOD,3209050,CDM,300,RC,84260,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,85.20,116.16,percent of total billed charges,
SEROTONIN BLOOD,3209050,CDM,300,RC,84260,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,24.77,116.16,percent of total billed charges,
SEROTONIN BLOOD,7948571,CDM,300,RC,84260,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,85.20,116.16,percent of total billed charges,
SEROTONIN BLOOD,7948571,CDM,300,RC,84260,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,24.77,116.16,percent of total billed charges,
HIAA 24 HOUR URINE,3188931,CDM,300,RC,83497,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
HIAA 24 HOUR URINE,3188931,CDM,300,RC,83497,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,11.96,125.15,percent of total billed charges,
SMOOTH MUSCLE ACTIN ANTIBODY,7954688,CDM,300,RC,86015,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
SMOOTH MUSCLE ACTIN ANTIBODY,7954688,CDM,300,RC,86015,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,11.18,120.25,percent of total billed charges,
SOMATOMEDIN C,7971977,CDM,300,RC,84305,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
SOMATOMEDIN C,7971977,CDM,300,RC,84305,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,19.70,124.34,percent of total billed charges,
FECAL SODIUM,3196878,CDM,300,RC,84302,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
FECAL SODIUM,3196878,CDM,300,RC,84302,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,4.50,120.25,percent of total billed charges,
STRIATED MUSCLE AB SCREEN,7119839,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
STRIATED MUSCLE AB SCREEN,7119839,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,11.18,122.70,percent of total billed charges,
STRIATED MUSCLE AB TITER,3255842,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,33.60,45.81,percent of total billed charges,
STRIATED MUSCLE AB TITER,3255842,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,11.18,45.81,percent of total billed charges,
Striated Muscle Ab Titer,759803,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,33.60,45.81,percent of total billed charges,
Striated Muscle Ab Titer,759803,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,11.18,45.81,percent of total billed charges,
FLUORESCENT AB NONINFECTIOUS,6875890,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,84.60,115.34,percent of total billed charges,
FLUORESCENT AB NONINFECTIOUS,6875890,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,11.18,115.34,percent of total billed charges,
Reflex PCCA/ANNA by IFA Serum ARUP,9117301,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,84.60,115.34,percent of total billed charges,
Reflex PCCA/ANNA by IFA Serum ARUP,9117301,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,11.18,115.34,percent of total billed charges,
VITAMIN B1 THIAMIN PYROPHOSPH,3192868,CDM,300,RC,84425,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
VITAMIN B1 THIAMIN PYROPHOSPH,3192868,CDM,300,RC,84425,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,19.68,119.43,percent of total billed charges,
DRUG SCREEN CMH GASTRIC ADD ON,605880,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,151.80,206.95,percent of total billed charges,
DRUG SCREEN CMH GASTRIC ADD ON,605880,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,101.20,257.47,percent of total billed charges,
THYROID PEROXIDASE ANTIBODIES,3196865,CDM,300,RC,86376,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
THYROID PEROXIDASE ANTIBODIES,3196865,CDM,300,RC,86376,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,13.49,127.61,percent of total billed charges,
DRUG SCREEN CMH URINE ONLY,605869,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,151.80,206.95,percent of total billed charges,
DRUG SCREEN CMH URINE ONLY,605869,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,101.20,257.47,percent of total billed charges,
PNEUMOCYSTIS JIROVECII PCR,7111864,CDM,300,RC,87594,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,193.80,264.21,percent of total billed charges,
PNEUMOCYSTIS JIROVECII PCR,7111864,CDM,300,RC,87594,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,32.53,264.21,percent of total billed charges,
Thyroid Stimulating Immunoglobulin,8310218,CDM,300,RC,84445,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
Thyroid Stimulating Immunoglobulin,8310218,CDM,300,RC,84445,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,47.14,134.78,percent of total billed charges,
EHRLICHIA CHAFF AB IFA,7794104,CDM,300,RC,86666,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
EHRLICHIA CHAFF AB IFA,7794104,CDM,300,RC,86666,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,9.43,121.06,percent of total billed charges,
TOBRAMYCIN LEVEL,596683,CDM,300,RC,80200,HCPCS,,,facility,inpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,84.60,115.34,percent of total billed charges,
TOBRAMYCIN LEVEL,596683,CDM,300,RC,80200,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,14.96,115.34,percent of total billed charges,
TOBRAMYCIN LEVEL,596684,CDM,300,RC,80200,HCPCS,,,facility,inpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,84.60,115.34,percent of total billed charges,
TOBRAMYCIN LEVEL,596684,CDM,300,RC,80200,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,14.96,115.34,percent of total billed charges,
TOPIRAMATE LEVEL,3216863,CDM,300,RC,80201,HCPCS,,,facility,inpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,83.40,113.70,percent of total billed charges,
TOPIRAMATE LEVEL,3216863,CDM,300,RC,80201,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,11.05,113.70,percent of total billed charges,
TYPHUS ANTIBODY WITH REFLEX,3192906,CDM,300,RC,86757,HCPCS,,,facility,inpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,42.60,58.08,percent of total billed charges,
TYPHUS ANTIBODY WITH REFLEX,3192906,CDM,300,RC,86757,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,17.94,58.08,percent of total billed charges,
SM AND RNP ANTIBODIES,3200854,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
SM AND RNP ANTIBODIES,3200854,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,16.62,121.06,percent of total billed charges,
ENA AB,3200852,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
ENA AB,3200852,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,16.62,121.06,percent of total billed charges,
THROMBIN TIME,3186865,CDM,300,RC,85670,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
THROMBIN TIME,3186865,CDM,300,RC,85670,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,5.35,20.45,percent of total billed charges,
ESTRONE LEVEL,7897073,CDM,300,RC,82679,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
ESTRONE LEVEL,7897073,CDM,300,RC,82679,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,23.13,117.79,percent of total billed charges,
ESTRIOL,7913612,CDM,300,RC,82677,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
ESTRIOL,7913612,CDM,300,RC,82677,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,22.41,121.06,percent of total billed charges,
PLASMINOGEN ACTIVITY,3178876,CDM,300,RC,85420,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
PLASMINOGEN ACTIVITY,3178876,CDM,300,RC,85420,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,6.06,126.79,percent of total billed charges,
EB CAPSID VCA,613056,CDM,300,RC,86665,HCPCS,,,facility,inpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,25.80,35.17,percent of total billed charges,
EB CAPSID VCA,613056,CDM,300,RC,86665,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,16.82,48.07,percent of total billed charges,
EB V NUCLEAR ANTIGEN,613058,CDM,300,RC,86664,HCPCS,,,facility,inpatient,,,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
EB V NUCLEAR ANTIGEN,613058,CDM,300,RC,86664,HCPCS,,,facility,outpatient,,,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,14.17,40.52,percent of total billed charges,
ERYTHROPOIETIN,7953965,CDM,300,RC,82668,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,80.40,109.61,percent of total billed charges,
ERYTHROPOIETIN,7953965,CDM,300,RC,82668,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,17.42,109.61,percent of total billed charges,
ETHYLENE GLYCOL LEVEL,661848,CDM,300,RC,82693,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,138.60,188.96,percent of total billed charges,
ETHYLENE GLYCOL LEVEL,661848,CDM,300,RC,82693,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,13.81,188.96,percent of total billed charges,
TOXOPLASMA ANTIBODY,3214848,CDM,300,RC,86778,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
TOXOPLASMA ANTIBODY,3214848,CDM,300,RC,86778,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,13.36,63.80,percent of total billed charges,
TOXOPLASMA ANTIBODY IGG,613117,CDM,300,RC,86777,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
TOXOPLASMA ANTIBODY IGG,613117,CDM,300,RC,86777,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,13.34,63.80,percent of total billed charges,
FECAL FAT QUALITATIVE,3188843,CDM,300,RC,82705,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
FECAL FAT QUALITATIVE,3188843,CDM,300,RC,82705,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,4.73,124.34,percent of total billed charges,
FECAL LIPIDS TOTAL,3521839,CDM,300,RC,82710,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
FECAL LIPIDS TOTAL,3521839,CDM,300,RC,82710,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,15.57,120.25,percent of total billed charges,
FECAL LIPIDS TOTAL,3521840,CDM,300,RC,82710,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
FECAL LIPIDS TOTAL,3521840,CDM,300,RC,82710,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,15.57,120.25,percent of total billed charges,
FECAL LIPIDS TOTAL,3521841,CDM,300,RC,82710,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
FECAL LIPIDS TOTAL,3521841,CDM,300,RC,82710,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,15.57,120.25,percent of total billed charges,
BB BILL THAW REFERENCE,5987852,CDM,300,RC,86999,HCPCS,,,facility,inpatient,,,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,78.60,107.16,percent of total billed charges,
BB BILL THAW REFERENCE,5987852,CDM,300,RC,86999,HCPCS,,,facility,outpatient,,,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,21.51,107.16,percent of total billed charges,
BB BILL DILUTION REFERENCE,5987856,CDM,300,RC,86976,HCPCS,,,facility,inpatient,,,210.00000,60.90000,Aetna,First Health,,171.78,,,,,,,126.00,171.78,percent of total billed charges,
BB BILL DILUTION REFERENCE,5987856,CDM,300,RC,86976,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,First Health,,171.78,,,,,,,21.51,171.78,percent of total billed charges,
BB BILL PRETREAT WITH DRUGS REFER,5987857,CDM,300,RC,86970,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
BB BILL PRETREAT WITH DRUGS REFER,5987857,CDM,300,RC,86970,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,52.15,156.59,percent of total billed charges,
BB BILL ABSORPTION REFERENCE,595623,CDM,300,RC,86978,HCPCS,,,facility,inpatient,,,282.00000,81.78000,Aetna,First Health,,230.68,,,,,,,169.20,230.68,percent of total billed charges,
BB BILL ABSORPTION REFERENCE,595623,CDM,300,RC,86978,HCPCS,,,facility,outpatient,,,282.00000,81.78000,Aetna,First Health,,230.68,,,,,,,52.15,230.68,percent of total billed charges,
TISSUE TRANSGLUTAMINASE ANTIBODY,3184854,CDM,300,RC,86364,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
TISSUE TRANSGLUTAMINASE ANTIBODY,3184854,CDM,300,RC,86364,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,10.69,120.25,percent of total billed charges,
TISSUE TRANSGLUTAMINASE ANTIBODY,3481845,CDM,300,RC,86364,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
TISSUE TRANSGLUTAMINASE ANTIBODY,3481845,CDM,300,RC,86364,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,10.69,120.25,percent of total billed charges,
TISSUE TRANSGLUTAMINASE ANTIBODY,3481846,CDM,300,RC,86364,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
TISSUE TRANSGLUTAMINASE ANTIBODY,3481846,CDM,300,RC,86364,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,10.69,120.25,percent of total billed charges,
SOLUBLE TRANSFERRIN RECEPTOR,3214917,CDM,300,RC,84238,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
SOLUBLE TRANSFERRIN RECEPTOR,3214917,CDM,300,RC,84238,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,33.90,128.43,percent of total billed charges,
COLD AGGLUTININS,7111844,CDM,300,RC,86157,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
COLD AGGLUTININS,7111844,CDM,300,RC,86157,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,7.47,121.06,percent of total billed charges,
CYTOMEGALOVIRUS BY PCR,7121843,CDM,300,RC,87496,HCPCS,,,facility,inpatient,,,270.00000,78.30000,Aetna,First Health,,220.86,,,,,,,162.00,220.86,percent of total billed charges,
CYTOMEGALOVIRUS BY PCR,7121843,CDM,300,RC,87496,HCPCS,,,facility,outpatient,,,270.00000,78.30000,Aetna,First Health,,220.86,,,,,,,32.53,220.86,percent of total billed charges,
M TUBERCULOSIS AMP PROBE,7726075,CDM,300,RC,87564,HCPCS,,,facility,inpatient,,,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,189.00,257.67,percent of total billed charges,
M TUBERCULOSIS AMP PROBE,7726075,CDM,300,RC,87564,HCPCS,,,facility,outpatient,,,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,71.16,257.67,percent of total billed charges,
M TUBERCULOSIS AMP PROBE,9101340,CDM,300,RC,87564,HCPCS,,,facility,inpatient,,,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,189.00,257.67,percent of total billed charges,
M TUBERCULOSIS AMP PROBE,9101340,CDM,300,RC,87564,HCPCS,,,facility,outpatient,,,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,71.16,257.67,percent of total billed charges,
ASSAY FOR CALPROTECTIN FECAL,8366173,CDM,300,RC,83993,HCPCS,,,facility,inpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,142.20,193.87,percent of total billed charges,
ASSAY FOR CALPROTECTIN FECAL,8366173,CDM,300,RC,83993,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,18.20,193.87,percent of total billed charges,
HISTOPLASMA ANTIGEN SERUM,7111851,CDM,300,RC,87385,HCPCS,,,facility,inpatient,,,191.00000,55.39000,Aetna,First Health,,156.24,,,,,,,114.60,156.24,percent of total billed charges,
HISTOPLASMA ANTIGEN SERUM,7111851,CDM,300,RC,87385,HCPCS,,,facility,outpatient,,,191.00000,55.39000,Aetna,First Health,,156.24,,,,,,,12.29,156.24,percent of total billed charges,
THYROGLOBULIN CIA,6145847,CDM,300,RC,84432,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
THYROGLOBULIN CIA,6145847,CDM,300,RC,84432,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,14.88,127.61,percent of total billed charges,
IRON LIVER TISSUE,8280333,CDM,300,RC,83540,HCPCS,,,facility,inpatient,,,263.00000,76.27000,Aetna,First Health,,215.13,,,,,,,157.80,215.13,percent of total billed charges,
IRON LIVER TISSUE,8280333,CDM,300,RC,83540,HCPCS,,,facility,outpatient,,,263.00000,76.27000,Aetna,First Health,,215.13,,,,,,,5.99,215.13,percent of total billed charges,
VOLTAGE GATED CALCIUM CHANNEL AB,6297841,CDM,300,RC,86596,HCPCS,,,facility,inpatient,,,313.00000,90.77000,Aetna,First Health,,256.03,,,,,,,187.80,256.03,percent of total billed charges,
VOLTAGE GATED CALCIUM CHANNEL AB,6297841,CDM,300,RC,86596,HCPCS,,,facility,outpatient,,,313.00000,90.77000,Aetna,First Health,,256.03,,,,,,,11.18,256.03,percent of total billed charges,
TRICYCLIC ANTIDEPRESSANT DETECTIO,3206890,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
TRICYCLIC ANTIDEPRESSANT DETECTIO,3206890,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,58.00,257.47,percent of total billed charges,
CHYMOTRYPSIN STOOL,7177859,CDM,300,RC,84311,HCPCS,,,facility,inpatient,,,275.00000,79.75000,Aetna,First Health,,224.95,,,,,,,165.00,224.95,percent of total billed charges,
CHYMOTRYPSIN STOOL,7177859,CDM,300,RC,84311,HCPCS,,,facility,outpatient,,,275.00000,79.75000,Aetna,First Health,,224.95,,,,,,,7.51,224.95,percent of total billed charges,
LEVETIRACETAM LEVEL,3207062,CDM,300,RC,80177,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
LEVETIRACETAM LEVEL,3207062,CDM,300,RC,80177,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,12.29,122.70,percent of total billed charges,
LEGION PNEUMOPHILIA AG,3210840,CDM,300,RC,87278,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
LEGION PNEUMOPHILIA AG,3210840,CDM,300,RC,87278,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,14.46,118.61,percent of total billed charges,
GLYCOPROTEIN ANTIBODY,3207191,CDM,300,RC,86146,HCPCS,,,facility,inpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,94.80,129.24,percent of total billed charges,
GLYCOPROTEIN ANTIBODY,3207191,CDM,300,RC,86146,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,23.60,129.24,percent of total billed charges,
ANDROSTENEDIONE,3232940,CDM,300,RC,82157,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
ANDROSTENEDIONE,3232940,CDM,300,RC,82157,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,27.14,117.79,percent of total billed charges,
IMMUNODIF OUCHTERLONY,2340824,CDM,300,RC,86331,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
IMMUNODIF OUCHTERLONY,2340824,CDM,300,RC,86331,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,11.10,31.75,percent of total billed charges,
IMMUNODIF OUCHTERLONY,3206845,CDM,300,RC,86331,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
IMMUNODIF OUCHTERLONY,3206845,CDM,300,RC,86331,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,11.10,31.75,percent of total billed charges,
ENZYME ACTIVITY IN PERIPHERAL RBC,2386825,CDM,300,RC,84433,HCPCS,,,facility,inpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,179.40,244.58,percent of total billed charges,
ENZYME ACTIVITY IN PERIPHERAL RBC,2386825,CDM,300,RC,84433,HCPCS,,,facility,outpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,20.55,244.58,percent of total billed charges,
CHEMILUMINESCENT ASSAY,2388833,CDM,300,RC,82397,HCPCS,,,facility,inpatient,,,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,9.00,12.27,percent of total billed charges,
CHEMILUMINESCENT ASSAY,2388833,CDM,300,RC,82397,HCPCS,,,facility,outpatient,,,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,7.05,37.42,percent of total billed charges,
MYELOPEROXIDASE AB,3186908,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,39.00,53.17,percent of total billed charges,
MYELOPEROXIDASE AB,3186908,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,10.69,53.17,percent of total billed charges,
PROTEINASE 3 AB,2460826,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
PROTEINASE 3 AB,2460826,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,10.69,54.81,percent of total billed charges,
TRYPTASE,3216876,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,90.60,123.52,percent of total billed charges,
TRYPTASE,3216876,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,16.01,123.52,percent of total billed charges,
88305 Surg IV Arkana,8070002,CDM,300,RC,88305,HCPCS,,,facility,inpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,123.00,167.69,percent of total billed charges,
88305 Surg IV Arkana,8070002,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,46.92,167.69,percent of total billed charges,
VANILLYLMANDELIC ACID URINE 24 HR,3190879,CDM,300,RC,84585,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,90.60,123.52,percent of total billed charges,
VANILLYLMANDELIC ACID URINE 24 HR,3190879,CDM,300,RC,84585,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,14.37,123.52,percent of total billed charges,
VDRL CSF,3184881,CDM,300,RC,86592,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
VDRL CSF,3184881,CDM,300,RC,86592,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,3.96,125.15,percent of total billed charges,
VDRL CSF,7969183,CDM,300,RC,86592,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
VDRL CSF,7969183,CDM,300,RC,86592,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,3.96,125.15,percent of total billed charges,
VASOACTIVE INTESTINAL POLYPEPT,3209053,CDM,300,RC,84586,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
VASOACTIVE INTESTINAL POLYPEPT,3209053,CDM,300,RC,84586,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,32.75,118.61,percent of total billed charges,
VIRAL AB,613114,CDM,300,RC,86788,HCPCS,,,facility,inpatient,,,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,49.80,67.89,percent of total billed charges,
VIRAL AB,613114,CDM,300,RC,86788,HCPCS,,,facility,outpatient,,,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,15.63,67.89,percent of total billed charges,
VISCOSITY SERUM,3214884,CDM,300,RC,85810,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
VISCOSITY SERUM,3214884,CDM,300,RC,85810,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,10.81,118.61,percent of total billed charges,
VITAMIN A RETINOL,3216866,CDM,300,RC,84590,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
VITAMIN A RETINOL,3216866,CDM,300,RC,84590,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,10.76,121.06,percent of total billed charges,
VITAMIN B6,3191033,CDM,300,RC,84207,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
VITAMIN B6,3191033,CDM,300,RC,84207,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,26.05,122.70,percent of total billed charges,
FOLIC ACID RBC,3190865,CDM,300,RC,82747,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
FOLIC ACID RBC,3190865,CDM,300,RC,82747,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,16.37,125.97,percent of total billed charges,
VITAMIN E TOCOPHEROL,3209056,CDM,300,RC,84446,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
VITAMIN E TOCOPHEROL,3209056,CDM,300,RC,84446,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,13.14,126.79,percent of total billed charges,
VITAMIN D 1 25 DIHYDROXY,3182847,CDM,300,RC,82652,HCPCS,,,facility,inpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,94.80,129.24,percent of total billed charges,
VITAMIN D 1 25 DIHYDROXY,3182847,CDM,300,RC,82652,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,35.69,129.24,percent of total billed charges,
ASPERGILL,613050,CDM,300,RC,86606,HCPCS,,,facility,inpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,25.80,35.17,percent of total billed charges,
ASPERGILL,613050,CDM,300,RC,86606,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,13.96,39.88,percent of total billed charges,
COCCIDIOIDES ANTIBODY CF,613052,CDM,300,RC,86635,HCPCS,,,facility,inpatient,,,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,19.80,26.99,percent of total billed charges,
COCCIDIOIDES ANTIBODY CF,613052,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,6.68,30.40,percent of total billed charges,
COCCIDIOIDES ANTIBODY CF,8142380,CDM,300,RC,86635,HCPCS,,,facility,inpatient,,,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,19.80,26.99,percent of total billed charges,
COCCIDIOIDES ANTIBODY CF,8142380,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,6.68,30.40,percent of total billed charges,
SR CA URINE,613088,CDM,300,RC,82340,HCPCS,,,facility,inpatient,,,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
SR CA URINE,613088,CDM,300,RC,82340,HCPCS,,,facility,outpatient,,,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.59,15.98,percent of total billed charges,
SR OXALATE,613089,CDM,300,RC,83945,HCPCS,,,facility,inpatient,,,38.00000,11.02000,Aetna,First Health,,31.08,,,,,,,22.80,31.08,percent of total billed charges,
SR OXALATE,613089,CDM,300,RC,83945,HCPCS,,,facility,outpatient,,,38.00000,11.02000,Aetna,First Health,,31.08,,,,,,,13.40,38.29,percent of total billed charges,
URIC ACID OTHER SOURCE,613090,CDM,300,RC,84560,HCPCS,,,facility,inpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
URIC ACID OTHER SOURCE,613090,CDM,300,RC,84560,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,4.71,13.46,percent of total billed charges,
SR CITRATE,613091,CDM,300,RC,82507,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
SR CITRATE,613091,CDM,300,RC,82507,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,25.77,73.67,percent of total billed charges,
SR PH UR,613092,CDM,300,RC,83986,HCPCS,,,facility,inpatient,,,9.00000,2.61000,Aetna,First Health,,7.36,,,,,,,5.40,7.36,percent of total billed charges,
SR PH UR,613092,CDM,300,RC,83986,HCPCS,,,facility,outpatient,,,9.00000,2.61000,Aetna,First Health,,7.36,,,,,,,3.32,9.49,percent of total billed charges,
SR SODIUM URINE,613094,CDM,300,RC,84300,HCPCS,,,facility,inpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
SR SODIUM URINE,613094,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,4.69,13.41,percent of total billed charges,
SR SULFATE URINE,613095,CDM,300,RC,84392,HCPCS,,,facility,inpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
SR SULFATE URINE,613095,CDM,300,RC,84392,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,5.09,14.55,percent of total billed charges,
SR PO4 URINE,613096,CDM,300,RC,84105,HCPCS,,,facility,inpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
SR PO4 URINE,613096,CDM,300,RC,84105,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,5.36,15.32,percent of total billed charges,
SR MG URINE,613097,CDM,300,RC,83735,HCPCS,,,facility,inpatient,,,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
SR MG URINE,613097,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,6.21,17.75,percent of total billed charges,
GASTRIN,3188898,CDM,300,RC,82941,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
GASTRIN,3188898,CDM,300,RC,82941,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,16.35,121.88,percent of total billed charges,
SR POTASSIUM URINE,613099,CDM,300,RC,84133,HCPCS,,,facility,inpatient,,,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,7.20,9.82,percent of total billed charges,
SR POTASSIUM URINE,613099,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,4.39,12.53,percent of total billed charges,
HYDROXYPROGESTERONE,3214935,CDM,300,RC,83498,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
HYDROXYPROGESTERONE,3214935,CDM,300,RC,83498,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,25.18,128.43,percent of total billed charges,
ALLERGY EVALUATION,657931,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
ALLERGY EVALUATION,657931,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,4.70,13.83,percent of total billed charges,
ARGINE VASOPRESSIN,3214890,CDM,300,RC,84588,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
ARGINE VASOPRESSIN,3214890,CDM,300,RC,84588,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,31.47,112.88,percent of total billed charges,
CELIAC DISEASE DIAGNOSTIC PANEL,7281858,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
CELIAC DISEASE DIAGNOSTIC PANEL,7281858,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,8.18,120.25,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7904829,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7904829,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,10.69,58.90,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7904832,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7904832,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,10.69,58.90,percent of total billed charges,
LEAD BLOOD,7798031,CDM,300,RC,83655,HCPCS,,,facility,inpatient,,,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,137.40,187.32,percent of total billed charges,
LEAD BLOOD,7798031,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,11.23,187.32,percent of total billed charges,
HEAVY METALS EVALUATION BLOOD,3207054,CDM,300,RC,83825,HCPCS,,,facility,inpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,28.80,39.26,percent of total billed charges,
HEAVY METALS EVALUATION BLOOD,3207054,CDM,300,RC,83825,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,15.07,43.09,percent of total billed charges,
JO 1 ANTIBODY,3216873,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
JO 1 ANTIBODY,3216873,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,16.62,128.43,percent of total billed charges,
SCLERODERMA ANTIBODIES,3196866,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
SCLERODERMA ANTIBODIES,3196866,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,16.62,121.06,percent of total billed charges,
WEST NILE VIRUS AB BLOOD IGG,3188888,CDM,300,RC,86789,HCPCS,,,facility,inpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,39.60,53.99,percent of total billed charges,
WEST NILE VIRUS AB BLOOD IGG,3188888,CDM,300,RC,86789,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,13.34,53.99,percent of total billed charges,
GLUCAGON,3214938,CDM,300,RC,82943,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
GLUCAGON,3214938,CDM,300,RC,82943,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,13.25,127.61,percent of total billed charges,
Culture Varicella Zoster Virus,8387017,CDM,300,RC,87252,HCPCS,,,facility,inpatient,,,45.00000,13.05000,Aetna,First Health,,36.81,,,,,,,27.00,36.81,percent of total billed charges,
Culture Varicella Zoster Virus,8387017,CDM,300,RC,87252,HCPCS,,,facility,outpatient,,,45.00000,13.05000,Aetna,First Health,,36.81,,,,,,,21.15,69.09,percent of total billed charges,
GLUTAMIC ACID DECARBOXYLASE,3191100,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
GLUTAMIC ACID DECARBOXYLASE,3191100,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,21.85,118.61,percent of total billed charges,
Encephalopathy Panel Serum,8916115,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
Encephalopathy Panel Serum,8916115,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,21.85,99.80,percent of total billed charges,
Autoimmune Dementia Paraneoplastic Eval Serum,9004978,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
Autoimmune Dementia Paraneoplastic Eval Serum,9004978,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,21.85,99.80,percent of total billed charges,
PROTHROMBIN F2 G20210A ZB10B,3180904,CDM,300,RC,81240,HCPCS,,,facility,inpatient,,,167.00000,48.43000,Aetna,First Health,,136.61,,,,,,,100.20,136.61,percent of total billed charges,
PROTHROMBIN F2 G20210A ZB10B,3180904,CDM,300,RC,81240,HCPCS,,,facility,outpatient,,,167.00000,48.43000,Aetna,First Health,,136.61,,,,,,,60.89,174.08,percent of total billed charges,
COAG FACTOR V ACTIVITY,3209012,CDM,300,RC,85220,HCPCS,,,facility,inpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,94.80,129.24,percent of total billed charges,
COAG FACTOR V ACTIVITY,3209012,CDM,300,RC,85220,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,16.37,129.24,percent of total billed charges,
COAG FACTOR VIII ACTIVITY,3209015,CDM,300,RC,85240,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
COAG FACTOR VIII ACTIVITY,3209015,CDM,300,RC,85240,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,16.59,128.43,percent of total billed charges,
Factor VIII,613066,CDM,300,RC,85240,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
Factor VIII,613066,CDM,300,RC,85240,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,16.59,128.43,percent of total billed charges,
PLATELET AGGREGATION,596409,CDM,300,RC,85576,HCPCS,,,facility,inpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,25.80,35.17,percent of total billed charges,
PLATELET AGGREGATION,596409,CDM,300,RC,85576,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,20.21,66.01,percent of total billed charges,
PLATELET AGGREGATION,8229030,CDM,300,RC,85576,HCPCS,,,facility,inpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,25.80,35.17,percent of total billed charges,
PLATELET AGGREGATION,8229030,CDM,300,RC,85576,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,20.21,66.01,percent of total billed charges,
ANTITHROMBIN III ACT,3178945,CDM,300,RC,85300,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
ANTITHROMBIN III ACT,3178945,CDM,300,RC,85300,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,3.83,128.43,percent of total billed charges,
COMPLEMENT TOTAL CH50,8335518,CDM,300,RC,86162,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,90.60,123.52,percent of total billed charges,
COMPLEMENT TOTAL CH50,8335518,CDM,300,RC,86162,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,18.84,123.52,percent of total billed charges,
DELTA AMINOLEVULINIC ACID 24 HOUR,3218887,CDM,300,RC,82135,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,80.40,109.61,percent of total billed charges,
DELTA AMINOLEVULINIC ACID 24 HOUR,3218887,CDM,300,RC,82135,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,15.25,109.61,percent of total billed charges,
ALDOLASE,3184839,CDM,300,RC,82085,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
ALDOLASE,3184839,CDM,300,RC,82085,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,9.00,126.79,percent of total billed charges,
IMMUNOGLOBULIN G SUBCLASS 4,7917340,CDM,300,RC,82787,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,90.60,123.52,percent of total billed charges,
IMMUNOGLOBULIN G SUBCLASS 4,7917340,CDM,300,RC,82787,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,7.44,123.52,percent of total billed charges,
RPR TITER,7969189,CDM,300,RC,86593,HCPCS,,,facility,inpatient,,,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
RPR TITER,7969189,CDM,300,RC,86593,HCPCS,,,facility,outpatient,,,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,4.08,29.45,percent of total billed charges,
5 A DIHYDROTESTOSTERONE 1,7948142,CDM,300,RC,82642,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
5 A DIHYDROTESTOSTERONE 1,7948142,CDM,300,RC,82642,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,27.14,117.79,percent of total billed charges,
ASPERGILLUS ANTIBODY BY CF,7946089,CDM,300,RC,86606,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
ASPERGILLUS ANTIBODY BY CF,7946089,CDM,300,RC,86606,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,13.96,118.61,percent of total billed charges,
COENZYME Q10 TOTAL,7948396,CDM,300,RC,82542,HCPCS,,,facility,inpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,115.20,157.06,percent of total billed charges,
COENZYME Q10 TOTAL,7948396,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,11.66,157.06,percent of total billed charges,
SUBSTANCE P,7948552,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
SUBSTANCE P,7948552,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,16.01,194.68,percent of total billed charges,
FLUOXETINE AND METABOLITE,7953933,CDM,300,RC,84311,HCPCS,,,facility,inpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,144.00,196.32,percent of total billed charges,
FLUOXETINE AND METABOLITE,7953933,CDM,300,RC,84311,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,7.51,196.32,percent of total billed charges,
TICK BORNE DISEASE PANEL PCR,7955046,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
TICK BORNE DISEASE PANEL PCR,7955046,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,32.53,92.99,percent of total billed charges,
TICK BORNE DISEASE PANEL PCR,7955053,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
TICK BORNE DISEASE PANEL PCR,7955053,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,32.53,92.99,percent of total billed charges,
5 NUCLEOTIDASE,7962058,CDM,300,RC,83915,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
5 NUCLEOTIDASE,7962058,CDM,300,RC,83915,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,10.34,121.06,percent of total billed charges,
DENGUE VIRUS BY PCR,7964316,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
DENGUE VIRUS BY PCR,7964316,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,32.53,92.99,percent of total billed charges,
87798 Dengue Virus Subtypes,8920419,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
87798 Dengue Virus Subtypes,8920419,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,32.53,92.99,percent of total billed charges,
CHIKUNGUNYA BY PCR,7964360,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,284.00000,82.36000,Aetna,First Health,,232.31,,,,,,,170.40,232.31,percent of total billed charges,
CHIKUNGUNYA BY PCR,7964360,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,284.00000,82.36000,Aetna,First Health,,232.31,,,,,,,32.53,232.31,percent of total billed charges,
APOE FOR ALZHEIMER RISK ZB2UW,7964309,CDM,300,RC,81401,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,144.60,197.14,percent of total billed charges,
APOE FOR ALZHEIMER RISK ZB2UW,7964309,CDM,300,RC,81401,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,113.27,363.05,percent of total billed charges,
THYROGLOBULIN LC MS,7964305,CDM,300,RC,84432,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
THYROGLOBULIN LC MS,7964305,CDM,300,RC,84432,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,14.88,159.51,percent of total billed charges,
HCV NS5A DRUG RESISTANCE,7954211,CDM,300,RC,87902,HCPCS,,,facility,inpatient,,,799.00000,231.71000,Aetna,First Health,,653.58,,,,,,,479.40,653.58,percent of total billed charges,
HCV NS5A DRUG RESISTANCE,7954211,CDM,300,RC,87902,HCPCS,,,facility,outpatient,,,799.00000,231.71000,Aetna,First Health,,653.58,,,,,,,238.66,682.24,percent of total billed charges,
HCV RNA GENOTYPE,3190862,CDM,300,RC,87902,HCPCS,,,facility,inpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,146.40,199.59,percent of total billed charges,
HCV RNA GENOTYPE,3190862,CDM,300,RC,87902,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,114.68,682.24,percent of total billed charges,
HCV RNA GENOTYPE,7964392,CDM,300,RC,87902,HCPCS,,,facility,inpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,146.40,199.59,percent of total billed charges,
HCV RNA GENOTYPE,7964392,CDM,300,RC,87902,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,114.68,682.24,percent of total billed charges,
PROTEIN ELECTRO FRACTIONATION,7966155,CDM,300,RC,84165,HCPCS,,,facility,inpatient,,,112.00000,32.48000,Aetna,First Health,,91.62,,,,,,,67.20,91.62,percent of total billed charges,
PROTEIN ELECTRO FRACTIONATION,7966155,CDM,300,RC,84165,HCPCS,,,facility,outpatient,,,112.00000,32.48000,Aetna,First Health,,91.62,,,,,,,9.96,91.62,percent of total billed charges,
AFP TOTAL AND L3 PERCENT,7964461,CDM,300,RC,82107,HCPCS,,,facility,inpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,128.40,175.05,percent of total billed charges,
AFP TOTAL AND L3 PERCENT,7964461,CDM,300,RC,82107,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,First Health,,175.05,,,,,,,59.71,175.05,percent of total billed charges,
S PNEUMONIAE ABS IGG,7948308,CDM,300,RC,86581,HCPCS,,,facility,inpatient,,,183.00000,53.07000,Aetna,First Health,,149.69,,,,,,,109.80,149.69,percent of total billed charges,
S PNEUMONIAE ABS IGG,7948308,CDM,300,RC,86581,HCPCS,,,facility,outpatient,,,183.00000,53.07000,Aetna,First Health,,149.69,,,,,,,86.01,243.88,percent of total billed charges,
98519 Itraconazole Quantitative by LC MS MS ARUP,7966306,CDM,300,RC,80189,HCPCS,,,facility,inpatient,,,167.00000,48.43000,Aetna,First Health,,136.61,,,,,,,100.20,136.61,percent of total billed charges,
98519 Itraconazole Quantitative by LC MS MS ARUP,7966306,CDM,300,RC,80189,HCPCS,,,facility,outpatient,,,167.00000,48.43000,Aetna,First Health,,136.61,,,,,,,25.13,136.61,percent of total billed charges,
80055 Carotene Serum Total ARUP,7966296,CDM,300,RC,82380,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
80055 Carotene Serum Total ARUP,7966296,CDM,300,RC,82380,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,8.55,121.88,percent of total billed charges,
ALPHA GAL FOOD PANEL,7966191,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,13.20,18.00,percent of total billed charges,
ALPHA GAL FOOD PANEL,7966191,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,4.84,18.00,percent of total billed charges,
2013107 HIV Types 1 and 2 Ab Differentiation Supplemental AR,7966166,CDM,300,RC,86701,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
2013107 HIV Types 1 and 2 Ab Differentiation Supplemental AR,7966166,CDM,300,RC,86701,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,8.24,81.80,percent of total billed charges,
DYSAUTONOMIA EVAL BY RIA,7966179,CDM,300,RC,86702,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
DYSAUTONOMIA EVAL BY RIA,7966179,CDM,300,RC,86702,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,12.54,121.88,percent of total billed charges,
2014546 Norovirus Groups 1 and 2 by PCR ARUP,7966326,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
2014546 Norovirus Groups 1 and 2 by PCR ARUP,7966326,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,32.53,128.43,percent of total billed charges,
87798 Norovirus Groups,8918452,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
87798 Norovirus Groups,8918452,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,32.53,128.43,percent of total billed charges,
VITAMIN K SERUM,7968785,CDM,300,RC,84597,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
VITAMIN K SERUM,7968785,CDM,300,RC,84597,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,12.72,112.88,percent of total billed charges,
SELENIUM URINE,7968792,CDM,300,RC,84255,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
SELENIUM URINE,7968792,CDM,300,RC,84255,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,23.67,122.70,percent of total billed charges,
PARVOVIRUS B19 QUANT BY PCR,7969209,CDM,300,RC,87799,HCPCS,,,facility,inpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,146.40,199.59,percent of total billed charges,
PARVOVIRUS B19 QUANT BY PCR,7969209,CDM,300,RC,87799,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,39.72,199.59,percent of total billed charges,
CMV AB IGG AVIDITY,7971965,CDM,300,RC,86644,HCPCS,,,facility,inpatient,,,221.00000,64.09000,Aetna,First Health,,180.78,,,,,,,132.60,180.78,percent of total billed charges,
CMV AB IGG AVIDITY,7971965,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,221.00000,64.09000,Aetna,First Health,,180.78,,,,,,,13.34,180.78,percent of total billed charges,
HEA CBC ZB04H,7974997,CDM,300,RC,81403,HCPCS,,,facility,inpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,218.40,297.75,percent of total billed charges,
HEA CBC ZB04H,7974997,CDM,300,RC,81403,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,171.08,490.78,percent of total billed charges,
MECONIUM DRUG SCREEN,7994150,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,79.20,107.98,percent of total billed charges,
MECONIUM DRUG SCREEN,7994150,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,52.80,257.47,percent of total billed charges,
COCAINE AND METABOLITES,7998873,CDM,300,RC,80353,HCPCS,,,facility,inpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,118.20,161.15,percent of total billed charges,
COCAINE AND METABOLITES,7998873,CDM,300,RC,80353,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,First Health,,161.15,,,,,,,0.01485,161.15,percent of total billed charges,
AMPHETAMINE DRUG SCREENING,7994261,CDM,300,RC,80324,HCPCS,,,facility,inpatient,,,99.00000,28.71000,Aetna,First Health,,80.98,,,,,,,59.40,80.98,percent of total billed charges,
AMPHETAMINE DRUG SCREENING,7994261,CDM,300,RC,80324,HCPCS,,,facility,outpatient,,,99.00000,28.71000,Aetna,First Health,,80.98,,,,,,,0.01485,80.98,percent of total billed charges,
80359 methlenedioxyamphetamine,7994282,CDM,300,RC,80359,HCPCS,,,facility,inpatient,,,99.00000,28.71000,Aetna,First Health,,80.98,,,,,,,59.40,80.98,percent of total billed charges,
80359 methlenedioxyamphetamine,7994282,CDM,300,RC,80359,HCPCS,,,facility,outpatient,,,99.00000,28.71000,Aetna,First Health,,80.98,,,,,,,0.01485,80.98,percent of total billed charges,
PCP CONFIRMATION MECONIUM,8001651,CDM,300,RC,83992,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,138.60,188.96,percent of total billed charges,
PCP CONFIRMATION MECONIUM,8001651,CDM,300,RC,83992,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,19.56,188.96,percent of total billed charges,
CARBOXY THC CONFIRMATION,8001663,CDM,300,RC,80349,HCPCS,,,facility,inpatient,,,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,115.80,157.87,percent of total billed charges,
CARBOXY THC CONFIRMATION,8001663,CDM,300,RC,80349,HCPCS,,,facility,outpatient,,,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,0.01485,157.87,percent of total billed charges,
OPIATE CONFIRMATION,8001345,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
OPIATE CONFIRMATION,8001345,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,46.00,257.47,percent of total billed charges,
80365 Oxycodone Confirmation,8001369,CDM,300,RC,80365,HCPCS,,,facility,inpatient,,,99.00000,28.71000,Aetna,First Health,,80.98,,,,,,,59.40,80.98,percent of total billed charges,
80365 Oxycodone Confirmation,8001369,CDM,300,RC,80365,HCPCS,,,facility,outpatient,,,99.00000,28.71000,Aetna,First Health,,80.98,,,,,,,0.01485,80.98,percent of total billed charges,
HMGCR ANTIBODY,7976407,CDM,300,RC,82397,HCPCS,,,facility,inpatient,,,234.00000,67.86000,Aetna,First Health,,191.41,,,,,,,140.40,191.41,percent of total billed charges,
HMGCR ANTIBODY,7976407,CDM,300,RC,82397,HCPCS,,,facility,outpatient,,,234.00000,67.86000,Aetna,First Health,,191.41,,,,,,,13.09,191.41,percent of total billed charges,
PERTUSSIS PARAPETUSSIS,7976416,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,111.00000,32.19000,Aetna,First Health,,90.80,,,,,,,66.60,90.80,percent of total billed charges,
PERTUSSIS PARAPETUSSIS,7976416,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,111.00000,32.19000,Aetna,First Health,,90.80,,,,,,,32.53,92.99,percent of total billed charges,
87798 Bordetella pertussis parapertussis,8920417,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,111.00000,32.19000,Aetna,First Health,,90.80,,,,,,,66.60,90.80,percent of total billed charges,
87798 Bordetella pertussis parapertussis,8920417,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,111.00000,32.19000,Aetna,First Health,,90.80,,,,,,,32.53,92.99,percent of total billed charges,
ADAMTS13 INHIBITOR,7980427,CDM,300,RC,85335,HCPCS,,,facility,inpatient,,,291.00000,84.39000,Aetna,First Health,,238.04,,,,,,,174.60,238.04,percent of total billed charges,
ADAMTS13 INHIBITOR,7980427,CDM,300,RC,85335,HCPCS,,,facility,outpatient,,,291.00000,84.39000,Aetna,First Health,,238.04,,,,,,,11.64,238.04,percent of total billed charges,
ADAMTS13 ANTIBODY,7980433,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,436.00000,126.44000,Aetna,First Health,,356.65,,,,,,,261.60,356.65,percent of total billed charges,
ADAMTS13 ANTIBODY,7980433,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,436.00000,126.44000,Aetna,First Health,,356.65,,,,,,,16.01,356.65,percent of total billed charges,
Alpha Internexin CBA Serum,8914135,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
Alpha Internexin CBA Serum,8914135,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
PNH INTERPRETATION CSI,7987163,CDM,300,RC,88187,HCPCS,,,facility,inpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,79.20,107.98,percent of total billed charges,
PNH INTERPRETATION CSI,7987163,CDM,300,RC,88187,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,47.59,107.98,percent of total billed charges,
REFLEX NO AQP4 TITER MAYO,8002080,CDM,300,RC,86053,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
REFLEX NO AQP4 TITER MAYO,8002080,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,34.98,99.98,percent of total billed charges,
REFLEX NO AQP4 TITER MAYO,8003386,CDM,300,RC,86053,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
REFLEX NO AQP4 TITER MAYO,8003386,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,34.98,99.98,percent of total billed charges,
GAD65 AB SERUM MAYO,7993976,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,327.00000,94.83000,Aetna,First Health,,267.49,,,,,,,196.20,267.49,percent of total billed charges,
GAD65 AB SERUM MAYO,7993976,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,327.00000,94.83000,Aetna,First Health,,267.49,,,,,,,21.85,267.49,percent of total billed charges,
PROTEIN WESTERN BLOT TEST,8278514,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,298.00000,86.42000,Aetna,First Health,,243.76,,,,,,,178.80,243.76,percent of total billed charges,
PROTEIN WESTERN BLOT TEST,8278514,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,298.00000,86.42000,Aetna,First Health,,243.76,,,,,,,23.95,243.76,percent of total billed charges,
NMDA R AB CBA,8002088,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
NMDA R AB CBA,8002088,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
NMDA R AB CBA,8003284,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
NMDA R AB CBA,8003284,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8002166,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8002166,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8002172,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8002172,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8003290,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8003290,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8003296,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8003296,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
mGluR1 Ab CBA Serum,8914181,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
mGluR1 Ab CBA Serum,8914181,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
DPPX Ab CBA Serum,8916164,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
DPPX Ab CBA Serum,8916164,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
IgLON5 CBA Serum,8916184,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
IgLON5 CBA Serum,8916184,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
NIF Heavy Chain CBA Serum,8916205,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
NIF Heavy Chain CBA Serum,8916205,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
NIF Light Chain CBA Serum,8916221,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
NIF Light Chain CBA Serum,8916221,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,11.18,417.18,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8002375,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8002375,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8002381,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8002381,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8002542,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8002542,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8003356,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8003356,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8003368,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8003368,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8003374,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8003374,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
GFAP IFA Titer Serum,8914158,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
GFAP IFA Titer Serum,8914158,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
IgLON5 IFA Titer Serum,8914175,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
IgLON5 IFA Titer Serum,8914175,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
DPPX Ab IFA Titer Serum,8916172,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
DPPX Ab IFA Titer Serum,8916172,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
NIF IFA Titer Serum,8916213,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
NIF IFA Titer Serum,8916213,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
Neurochondrin IFA Titer CSF,9000407,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
Neurochondrin IFA Titer CSF,9000407,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
AP3B2 IFA Titer CSF,9002421,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
AP3B2 IFA Titer CSF,9002421,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
Septin 7 IFA Titer CSF,9002426,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
Septin 7 IFA Titer CSF,9002426,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
CRMP 5 IGG WBLOT SERUM,8003392,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,385.00000,111.65000,Aetna,First Health,,314.93,,,,,,,231.00,314.93,percent of total billed charges,
CRMP 5 IGG WBLOT SERUM,8003392,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,385.00000,111.65000,Aetna,First Health,,314.93,,,,,,,23.95,314.93,percent of total billed charges,
CRMWC CRMP 5 IgG Western Blot CSF MAYO,8002062,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,491.00000,142.39000,Aetna,First Health,,401.64,,,,,,,294.60,401.64,percent of total billed charges,
CRMWC CRMP 5 IgG Western Blot CSF MAYO,8002062,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,491.00000,142.39000,Aetna,First Health,,401.64,,,,,,,23.95,401.64,percent of total billed charges,
GD65C GAD65 Ab Assay CSF MAYO,7994174,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,527.00000,152.83000,Aetna,First Health,,431.09,,,,,,,316.20,431.09,percent of total billed charges,
GD65C GAD65 Ab Assay CSF MAYO,7994174,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,527.00000,152.83000,Aetna,First Health,,431.09,,,,,,,21.85,431.09,percent of total billed charges,
VGKCC VGKC complex Ab IPA CSF MAYO,8002572,CDM,300,RC,83519,HCPCS,,,facility,inpatient,,,395.00000,114.55000,Aetna,First Health,,323.11,,,,,,,237.00,323.11,percent of total billed charges,
VGKCC VGKC complex Ab IPA CSF MAYO,8002572,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,First Health,,323.11,,,,,,,17.06,323.11,percent of total billed charges,
MOGFS Myelin Oligodendrocyte Glycoprotein IgG1 Serum MAYO,7993982,CDM,300,RC,86363,HCPCS,,,facility,inpatient,,,982.00000,284.78000,Aetna,First Health,,803.28,,,,,,,589.20,803.28,percent of total billed charges,
MOGFS Myelin Oligodendrocyte Glycoprotein IgG1 Serum MAYO,7993982,CDM,300,RC,86363,HCPCS,,,facility,outpatient,,,982.00000,284.78000,Aetna,First Health,,803.28,,,,,,,34.98,803.28,percent of total billed charges,
TOXACARA ANTIBODY BY ELISA,8070812,CDM,300,RC,86682,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
TOXACARA ANTIBODY BY ELISA,8070812,CDM,300,RC,86682,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,12.06,212.68,percent of total billed charges,
2013436 Spinal Muscular Atrophy SMA Copy Number Analysis A,8119034,CDM,300,RC,81329,HCPCS,,,facility,inpatient,,,370.00000,107.30000,Aetna,First Health,,302.66,,,,,,,222.00,302.66,percent of total billed charges,
2013436 Spinal Muscular Atrophy SMA Copy Number Analysis A,8119034,CDM,300,RC,81329,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,First Health,,302.66,,,,,,,127.00,363.05,percent of total billed charges,
Saccharomyces cerevisiae Abs  IgG and IgA,8117644,CDM,300,RC,86671,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
Saccharomyces cerevisiae Abs  IgG and IgA,8117644,CDM,300,RC,86671,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,6.68,63.80,percent of total billed charges,
S CEREBISIAE AB,8117647,CDM,300,RC,86671,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
S CEREBISIAE AB,8117647,CDM,300,RC,86671,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,6.68,63.80,percent of total billed charges,
2001601 RNA Polymerase III Antibody IgG ARUP,8117752,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,164.00000,47.56000,Aetna,First Health,,134.15,,,,,,,98.40,134.15,percent of total billed charges,
2001601 RNA Polymerase III Antibody IgG ARUP,8117752,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,164.00000,47.56000,Aetna,First Health,,134.15,,,,,,,10.69,134.15,percent of total billed charges,
2003040 PM Scl 100 Antibody IgG by Immunoblot ARUP,8117758,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
2003040 PM Scl 100 Antibody IgG by Immunoblot ARUP,8117758,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,16.62,143.15,percent of total billed charges,
2005287 Chromatin Antibody IgG ARUP,8117733,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
2005287 Chromatin Antibody IgG ARUP,8117733,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,10.69,125.97,percent of total billed charges,
2012173 Fibrillarin U3 RNP Antibody IgG ARUP,8117746,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,150.00,204.50,percent of total billed charges,
2012173 Fibrillarin U3 RNP Antibody IgG ARUP,8117746,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,16.62,204.50,percent of total billed charges,
PCABP Purkinje Cell Cytoplasmic Ab Type 1 MAYO,8119030,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
PCABP Purkinje Cell Cytoplasmic Ab Type 1 MAYO,8119030,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,11.18,126.79,percent of total billed charges,
Acetylcholine receptor binding antibody,8403757,CDM,300,RC,86041,HCPCS,,,facility,inpatient,,,322.00000,93.38000,Aetna,First Health,,263.40,,,,,,,193.20,263.40,percent of total billed charges,
Acetylcholine receptor binding antibody,8403757,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,322.00000,93.38000,Aetna,First Health,,263.40,,,,,,,17.06,263.40,percent of total billed charges,
GANG AChR Ganglionic Neuronal Ab Serum MAYO,8119022,CDM,300,RC,83519,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
GANG AChR Ganglionic Neuronal Ab Serum MAYO,8119022,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,17.06,126.79,percent of total billed charges,
VGKC Neuronal V G Kplus Channel Ab Serum MAYO,8119026,CDM,300,RC,83519,HCPCS,,,facility,inpatient,,,395.00000,114.55000,Aetna,First Health,,323.11,,,,,,,237.00,323.11,percent of total billed charges,
VGKC Neuronal V G Kplus Channel Ab Serum MAYO,8119026,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,First Health,,323.11,,,,,,,17.06,323.11,percent of total billed charges,
2006898 Hepatitis C Virus High Resolution Genotype by Sequen,8119572,CDM,300,RC,87902,HCPCS,,,facility,inpatient,,,461.00000,133.69000,Aetna,First Health,,377.10,,,,,,,276.60,377.10,percent of total billed charges,
2006898 Hepatitis C Virus High Resolution Genotype by Sequen,8119572,CDM,300,RC,87902,HCPCS,,,facility,outpatient,,,461.00000,133.69000,Aetna,First Health,,377.10,,,,,,,216.67,682.24,percent of total billed charges,
ENCEPHALOPATHY AUTOIMMUNE PANEL CSF,8278733,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
ENCEPHALOPATHY AUTOIMMUNE PANEL CSF,8278733,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,21.85,99.80,percent of total billed charges,
EPILEPSY ABS,8280225,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
EPILEPSY ABS,8280225,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,11.18,121.88,percent of total billed charges,
PCAB2 Purkinje Cell Cytoplasmic Ab Type 2 MAYO,8122525,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,127.20,173.42,percent of total billed charges,
PCAB2 Purkinje Cell Cytoplasmic Ab Type 2 MAYO,8122525,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,11.18,173.42,percent of total billed charges,
PCATR Purkinje Cell Cytoplasmic Ab Type Tr MAYO,8122530,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,127.20,173.42,percent of total billed charges,
PCATR Purkinje Cell Cytoplasmic Ab Type Tr MAYO,8122530,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,11.18,173.42,percent of total billed charges,
ANN3S Anti Neuronal Ab Type 3 MAYO,8122535,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,127.20,173.42,percent of total billed charges,
ANN3S Anti Neuronal Ab Type 3 MAYO,8122535,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,11.18,173.42,percent of total billed charges,
ANN2S Anti Neuronal Nuclear Ab Type 2 MAYO,8122558,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,127.20,173.42,percent of total billed charges,
ANN2S Anti Neuronal Nuclear Ab Type 2 MAYO,8122558,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,11.18,173.42,percent of total billed charges,
FYABW Yo Antibody by Western Blot MAYO,8123708,CDM,300,RC,84181,HCPCS,,,facility,inpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,69.00,94.07,percent of total billed charges,
FYABW Yo Antibody by Western Blot MAYO,8123708,CDM,300,RC,84181,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,First Health,,94.07,,,,,,,15.79,94.07,percent of total billed charges,
FYABT Yo Antibody Titer MAYO,8123702,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,46.00000,13.34000,Aetna,First Health,,37.63,,,,,,,27.60,37.63,percent of total billed charges,
FYABT Yo Antibody Titer MAYO,8123702,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,46.00000,13.34000,Aetna,First Health,,37.63,,,,,,,11.18,37.63,percent of total billed charges,
2007081 Cotinine Screen Urine ARUP,8123943,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
2007081 Cotinine Screen Urine ARUP,8123943,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,61.60,257.47,percent of total billed charges,
ALLERGENS FOOD FISH,7948720,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,14.40,19.63,percent of total billed charges,
ALLERGENS FOOD FISH,7948720,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,4.84,19.63,percent of total billed charges,
ALLERGENS FOOD FISH,7948735,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,14.40,19.63,percent of total billed charges,
ALLERGENS FOOD FISH,7948735,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,4.84,19.63,percent of total billed charges,
ALLERGENS FOOD FISH,7974731,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,14.40,19.63,percent of total billed charges,
ALLERGENS FOOD FISH,7974731,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,4.84,19.63,percent of total billed charges,
86003 Allergens Food Fish IgE ARUP,7974746,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,14.40,19.63,percent of total billed charges,
86003 Allergens Food Fish IgE ARUP,7974746,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,4.84,19.63,percent of total billed charges,
"Allergen, Food, Fish Profile 2 IgE",9090538,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,14.40,19.63,percent of total billed charges,
"Allergen, Food, Fish Profile 2 IgE",9090538,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,4.84,19.63,percent of total billed charges,
HLA B 57 01 ABACAVIR SENSITIVITY ZB10D,7950194,CDM,300,RC,81381,HCPCS,,,facility,inpatient,,,226.00000,65.54000,Aetna,First Health,,184.87,,,,,,,135.60,184.87,percent of total billed charges,
HLA B 57 01 ABACAVIR SENSITIVITY ZB10D,7950194,CDM,300,RC,81381,HCPCS,,,facility,outpatient,,,226.00000,65.54000,Aetna,First Health,,184.87,,,,,,,106.22,450.24,percent of total billed charges,
FACTOR IX ACTIVITY,7948820,CDM,300,RC,85250,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
FACTOR IX ACTIVITY,7948820,CDM,300,RC,85250,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,17.65,118.61,percent of total billed charges,
PANCREASTATIN,7948530,CDM,300,RC,83519,HCPCS,,,facility,inpatient,,,281.00000,81.49000,Aetna,First Health,,229.86,,,,,,,168.60,229.86,percent of total billed charges,
PANCREASTATIN,7948530,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,First Health,,229.86,,,,,,,17.06,229.86,percent of total billed charges,
LIBRIUM AND NORDIAZEPAM,7948796,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
LIBRIUM AND NORDIAZEPAM,7948796,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,58.00,257.47,percent of total billed charges,
FACTOR X ACTIVITY,7948807,CDM,300,RC,85260,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
FACTOR X ACTIVITY,7948807,CDM,300,RC,85260,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,16.59,111.25,percent of total billed charges,
CLOMIPRAMINE AND METABOLITE,7948577,CDM,300,RC,80335,HCPCS,,,facility,inpatient,,,159.00000,46.11000,Aetna,First Health,,130.06,,,,,,,95.40,130.06,percent of total billed charges,
CLOMIPRAMINE AND METABOLITE,7948577,CDM,300,RC,80335,HCPCS,,,facility,outpatient,,,159.00000,46.11000,Aetna,First Health,,130.06,,,,,,,0.01485,130.06,percent of total billed charges,
2014069 Zika Virus by PCR Urine ARUP,7966045,CDM,300,RC,87662,HCPCS,,,facility,inpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,179.40,244.58,percent of total billed charges,
2014069 Zika Virus by PCR Urine ARUP,7966045,CDM,300,RC,87662,HCPCS,,,facility,outpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,47.57,244.58,percent of total billed charges,
2014065 Zika Virus by PCR Blood ARUP,7966055,CDM,300,RC,87662,HCPCS,,,facility,inpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,179.40,244.58,percent of total billed charges,
2014065 Zika Virus by PCR Blood ARUP,7966055,CDM,300,RC,87662,HCPCS,,,facility,outpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,47.57,244.58,percent of total billed charges,
GLUCOSE 6 PHOSPHATE,3214911,CDM,300,RC,82955,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
GLUCOSE 6 PHOSPHATE,3214911,CDM,300,RC,82955,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,8.99,125.97,percent of total billed charges,
FOLLICLE STIMULATING HORMONE,6029839,CDM,300,RC,83001,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
FOLLICLE STIMULATING HORMONE,6029839,CDM,300,RC,83001,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,17.22,126.79,percent of total billed charges,
PROLACTIN,6025840,CDM,300,RC,84146,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
PROLACTIN,6025840,CDM,300,RC,84146,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,17.96,118.61,percent of total billed charges,
HOMOCYSTEINE,6035855,CDM,300,RC,83090,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
HOMOCYSTEINE,6035855,CDM,300,RC,83090,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,16.61,125.97,percent of total billed charges,
THEOPHYLLINE LEVEL,5981853,CDM,300,RC,80198,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
THEOPHYLLINE LEVEL,5981853,CDM,300,RC,80198,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,13.11,112.88,percent of total billed charges,
LUTEINIZING HORMONE,6035848,CDM,300,RC,83002,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
LUTEINIZING HORMONE,6035848,CDM,300,RC,83002,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,17.17,128.43,percent of total billed charges,
PHENOBARBITAL LEVEL,6059849,CDM,300,RC,80184,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
PHENOBARBITAL LEVEL,6059849,CDM,300,RC,80184,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,14.18,125.97,percent of total billed charges,
CARBAMAZEPINE TEGRETOL LEVEL,6063844,CDM,300,RC,80156,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
CARBAMAZEPINE TEGRETOL LEVEL,6063844,CDM,300,RC,80156,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,13.50,127.61,percent of total billed charges,
GENTAMICIN ASSAY,6059839,CDM,300,RC,80170,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
GENTAMICIN ASSAY,6059839,CDM,300,RC,80170,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,15.18,118.61,percent of total billed charges,
GENTAMICIN ASSAY,6059844,CDM,300,RC,80170,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
GENTAMICIN ASSAY,6059844,CDM,300,RC,80170,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,15.18,118.61,percent of total billed charges,
PROGESTERONE,7127839,CDM,300,RC,84144,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
PROGESTERONE,7127839,CDM,300,RC,84144,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,19.33,127.61,percent of total billed charges,
88348 EM Arkana 1,8070005,CDM,300,RC,88348,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,511.20,696.94,percent of total billed charges,
88348 EM Arkana 1,8070005,CDM,300,RC,88348,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,393.37,2138.50,percent of total billed charges,
88346 DIF Arkana,8070004,CDM,300,RC,88346,HCPCS,,,facility,inpatient,,,288.00000,83.52000,Aetna,First Health,,235.58,,,,,,,172.80,235.58,percent of total billed charges,
88346 DIF Arkana,8070004,CDM,300,RC,88346,HCPCS,,,facility,outpatient,,,288.00000,83.52000,Aetna,First Health,,235.58,,,,,,,88.98,452.20,percent of total billed charges,
88313 STN II Arkana,8070003,CDM,300,RC,88313,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
88313 STN II Arkana,8070003,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,53.93,353.14,percent of total billed charges,
87081 Legionella Culture ARUP,8387247,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
87081 Legionella Culture ARUP,8387247,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,6.15,114.52,percent of total billed charges,
MOPATH LVI II CROHNS PROG ZB25L,6509840,CDM,300,RC,81401,HCPCS,,,facility,inpatient,,,357.00000,103.53000,Aetna,First Health,,292.03,,,,,,,214.20,292.03,percent of total billed charges,
MOPATH LVI II CROHNS PROG ZB25L,6509840,CDM,300,RC,81401,HCPCS,,,facility,outpatient,,,357.00000,103.53000,Aetna,First Health,,292.03,,,,,,,127.00,363.05,percent of total billed charges,
ZB23L MOPATH LVI II TPMT GENETICS ZB23L,2386824,CDM,300,RC,81335,HCPCS,,,facility,inpatient,,,537.00000,155.73000,Aetna,First Health,,439.27,,,,,,,322.20,439.27,percent of total billed charges,
ZB23L MOPATH LVI II TPMT GENETICS ZB23L,2386824,CDM,300,RC,81335,HCPCS,,,facility,outpatient,,,537.00000,155.73000,Aetna,First Health,,439.27,,,,,,,162.05,463.25,percent of total billed charges,
MOPATH LVI II NOD2 CARD15 ZB23M,2386832,CDM,300,RC,81401,HCPCS,,,facility,inpatient,,,442.00000,128.18000,Aetna,First Health,,361.56,,,,,,,265.20,361.56,percent of total billed charges,
MOPATH LVI II NOD2 CARD15 ZB23M,2386832,CDM,300,RC,81401,HCPCS,,,facility,outpatient,,,442.00000,128.18000,Aetna,First Health,,361.56,,,,,,,127.00,363.05,percent of total billed charges,
MOPATH LVI I LACOTYPE ZB25N,2386831,CDM,300,RC,81400,HCPCS,,,facility,inpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,241.80,329.65,percent of total billed charges,
MOPATH LVI I LACOTYPE ZB25N,2386831,CDM,300,RC,81400,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,59.29,329.65,percent of total billed charges,
IBD SGI DIAGNOSTIC ZB25M,6509844,CDM,300,RC,81479,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
IBD SGI DIAGNOSTIC ZB25M,6509844,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,9.73,22.09,percent of total billed charges,
HLA TYPING CELIAC GENETICS ZB25K,2386829,CDM,300,RC,81382,HCPCS,,,facility,inpatient,,,442.00000,128.18000,Aetna,First Health,,361.56,,,,,,,265.20,361.56,percent of total billed charges,
HLA TYPING CELIAC GENETICS ZB25K,2386829,CDM,300,RC,81382,HCPCS,,,facility,outpatient,,,442.00000,128.18000,Aetna,First Health,,361.56,,,,,,,114.65,361.56,percent of total billed charges,
HLA TYPING CELIAC GENETICS ZB25K,6509851,CDM,300,RC,81382,HCPCS,,,facility,inpatient,,,442.00000,128.18000,Aetna,First Health,,361.56,,,,,,,265.20,361.56,percent of total billed charges,
HLA TYPING CELIAC GENETICS ZB25K,6509851,CDM,300,RC,81382,HCPCS,,,facility,outpatient,,,442.00000,128.18000,Aetna,First Health,,361.56,,,,,,,114.65,361.56,percent of total billed charges,
MTHFR 2 MUTATIONS ZB10E,3209030,CDM,300,RC,81291,HCPCS,,,facility,inpatient,,,206.00000,59.74000,Aetna,First Health,,168.51,,,,,,,123.60,168.51,percent of total billed charges,
MTHFR 2 MUTATIONS ZB10E,3209030,CDM,300,RC,81291,HCPCS,,,facility,outpatient,,,206.00000,59.74000,Aetna,First Health,,168.51,,,,,,,60.57,173.15,percent of total billed charges,
BB BILL ABSORBED AG NEG REFERNCE,6605849,CDM,300,RC,86904,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
BB BILL ABSORBED AG NEG REFERNCE,6605849,CDM,300,RC,86904,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,6.19,121.88,percent of total billed charges,
RESP VIRUS MINI PANEL,4107839,CDM,300,RC,87631,HCPCS,,,facility,inpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,178.20,242.95,percent of total billed charges,
RESP VIRUS MINI PANEL,4107839,CDM,300,RC,87631,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,First Health,,242.95,,,,,,,132.22,377.97,percent of total billed charges,
MYELIN ASSOC GLYCO AB,7117856,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
MYELIN ASSOC GLYCO AB,7117856,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,10.69,126.79,percent of total billed charges,
GANGLIOSIDE ANTIBODIES,3218861,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,28.20,38.45,percent of total billed charges,
GANGLIOSIDE ANTIBODIES,3218861,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,10.69,38.45,percent of total billed charges,
GANGLIOSIDE ANTIBODIES,7897158,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,28.20,38.45,percent of total billed charges,
GANGLIOSIDE ANTIBODIES,7897158,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,10.69,38.45,percent of total billed charges,
GANGLIOSIDE ANTIBODIES,7900269,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,28.20,38.45,percent of total billed charges,
GANGLIOSIDE ANTIBODIES,7900269,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,10.69,38.45,percent of total billed charges,
ACHR Blocking,7117846,CDM,300,RC,86042,HCPCS,,,facility,inpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,52.20,71.17,percent of total billed charges,
ACHR Blocking,7117846,CDM,300,RC,86042,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,17.06,71.17,percent of total billed charges,
ACETYLCHOLINE REC AB MODULATING,3255839,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
ACETYLCHOLINE REC AB MODULATING,3255839,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,10.69,122.70,percent of total billed charges,
TITIN ANTIBODY,7117847,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,34.80,47.44,percent of total billed charges,
TITIN ANTIBODY,7117847,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,10.69,47.44,percent of total billed charges,
MUSK QUANT ANTIBODY,7117860,CDM,300,RC,86366,HCPCS,,,facility,inpatient,,,935.00000,271.15000,Aetna,First Health,,764.83,,,,,,,561.00,764.83,percent of total billed charges,
MUSK QUANT ANTIBODY,7117860,CDM,300,RC,86366,HCPCS,,,facility,outpatient,,,935.00000,271.15000,Aetna,First Health,,764.83,,,,,,,17.06,764.83,percent of total billed charges,
MUSK QUANT ANTIBODY,8001931,CDM,300,RC,86366,HCPCS,,,facility,inpatient,,,935.00000,271.15000,Aetna,First Health,,764.83,,,,,,,561.00,764.83,percent of total billed charges,
MUSK QUANT ANTIBODY,8001931,CDM,300,RC,86366,HCPCS,,,facility,outpatient,,,935.00000,271.15000,Aetna,First Health,,764.83,,,,,,,17.06,764.83,percent of total billed charges,
SULFATIDE AUTOANTIBODY,7117864,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
SULFATIDE AUTOANTIBODY,7117864,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,16.01,420.45,percent of total billed charges,
SULFATIDE AUTOANTIBODY,7117866,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
SULFATIDE AUTOANTIBODY,7117866,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,16.01,420.45,percent of total billed charges,
SULFATIDE AUTOANTIBODY,8005030,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
SULFATIDE AUTOANTIBODY,8005030,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,16.01,420.45,percent of total billed charges,
TRB GENE REARRANGEMENT MAYO ZB1Z7,7159845,CDM,300,RC,81340,HCPCS,,,facility,inpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,396.60,540.70,percent of total billed charges,
TRB GENE REARRANGEMENT MAYO ZB1Z7,7159845,CDM,300,RC,81340,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,193.67,553.64,percent of total billed charges,
TRG GENE REARRAGEMENT MAYO ZB1Z7,7159846,CDM,300,RC,81342,HCPCS,,,facility,inpatient,,,638.00000,185.02000,Aetna,First Health,,521.88,,,,,,,382.80,521.88,percent of total billed charges,
TRG GENE REARRAGEMENT MAYO ZB1Z7,7159846,CDM,300,RC,81342,HCPCS,,,facility,outpatient,,,638.00000,185.02000,Aetna,First Health,,521.88,,,,,,,186.79,533.98,percent of total billed charges,
BB BILL SUPER DAT REFERENCE,7165847,CDM,300,RC,86999,HCPCS,,,facility,inpatient,,,337.00000,97.73000,Aetna,First Health,,275.67,,,,,,,202.20,275.67,percent of total billed charges,
BB BILL SUPER DAT REFERENCE,7165847,CDM,300,RC,86999,HCPCS,,,facility,outpatient,,,337.00000,97.73000,Aetna,First Health,,275.67,,,,,,,21.51,275.67,percent of total billed charges,
88184 Flow First Marker,7728001,CDM,300,RC,88184,HCPCS,,,facility,inpatient,,,339.00000,98.31000,Aetna,First Health,,277.30,,,,,,,203.40,277.30,percent of total billed charges,
88184 Flow First Marker,7728001,CDM,300,RC,88184,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,First Health,,277.30,,,,,,,47.66,951.40,percent of total billed charges,
FLOW CYTOMETRY FIRST MARKER,7838048,CDM,300,RC,88184,HCPCS,,,facility,inpatient,,,339.00000,98.31000,Aetna,First Health,,277.30,,,,,,,203.40,277.30,percent of total billed charges,
FLOW CYTOMETRY FIRST MARKER,7838048,CDM,300,RC,88184,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,First Health,,277.30,,,,,,,47.66,951.40,percent of total billed charges,
FLOW CYTOMETRY ADDL MARKER,7281839,CDM,300,RC,88185,HCPCS,,,facility,inpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,16.80,22.90,percent of total billed charges,
FLOW CYTOMETRY ADDL MARKER,7281839,CDM,300,RC,88185,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,10.09,36.19,percent of total billed charges,
B CELLS TOTAL COUNT,7303845,CDM,300,RC,86355,HCPCS,,,facility,inpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,34.80,47.44,percent of total billed charges,
B CELLS TOTAL COUNT,7303845,CDM,300,RC,86355,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,27.26,99.98,percent of total billed charges,
B Cell Subset Analysis,9001557,CDM,300,RC,86355,HCPCS,,,facility,inpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,34.80,47.44,percent of total billed charges,
B Cell Subset Analysis,9001557,CDM,300,RC,86355,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,27.26,99.98,percent of total billed charges,
NATURAL KILLER CELLS TOTAL,7303841,CDM,300,RC,86357,HCPCS,,,facility,inpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,34.80,47.44,percent of total billed charges,
NATURAL KILLER CELLS TOTAL,7303841,CDM,300,RC,86357,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,27.26,99.98,percent of total billed charges,
T CELLS TOTAL COUNT,7303842,CDM,300,RC,86359,HCPCS,,,facility,inpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,39.60,53.99,percent of total billed charges,
T CELLS TOTAL COUNT,7303842,CDM,300,RC,86359,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,31.02,99.98,percent of total billed charges,
T CELLS TOTAL COUNT,7303846,CDM,300,RC,86359,HCPCS,,,facility,inpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,39.60,53.99,percent of total billed charges,
T CELLS TOTAL COUNT,7303846,CDM,300,RC,86359,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,31.02,99.98,percent of total billed charges,
T CELLS ABS CD4 CD8 W RATIO,7303843,CDM,300,RC,86360,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
T CELLS ABS CD4 CD8 W RATIO,7303843,CDM,300,RC,86360,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,37.60,124.50,percent of total billed charges,
MONONUCLEAR CELL AG QUANT,7303844,CDM,300,RC,86356,HCPCS,,,facility,inpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,28.80,39.26,percent of total billed charges,
MONONUCLEAR CELL AG QUANT,7303844,CDM,300,RC,86356,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,22.56,70.97,percent of total billed charges,
MONONUCLEAR CELL AG QUANT,7303847,CDM,300,RC,86356,HCPCS,,,facility,inpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,28.80,39.26,percent of total billed charges,
MONONUCLEAR CELL AG QUANT,7303847,CDM,300,RC,86356,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,22.56,70.97,percent of total billed charges,
T CELLS ABSOLUTE CD4 COUNT,7303848,CDM,300,RC,86361,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
T CELLS ABSOLUTE CD4 COUNT,7303848,CDM,300,RC,86361,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,22.87,116.97,percent of total billed charges,
CALCIUM URINE,7383839,CDM,300,RC,82340,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CALCIUM URINE,7383839,CDM,300,RC,82340,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,5.59,126.79,percent of total billed charges,
GASTRIC PARIETAL CELL ANTIBODY,7850078,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
GASTRIC PARIETAL CELL ANTIBODY,7850078,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,10.69,127.61,percent of total billed charges,
21 Hydroxylase Autoantibodies Serum,8310209,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
21 Hydroxylase Autoantibodies Serum,8310209,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,10.69,117.79,percent of total billed charges,
BB BILL COLD AB TITER REFERENCE,7734601,CDM,300,RC,86157,HCPCS,,,facility,inpatient,,,217.00000,62.93000,Aetna,First Health,,177.51,,,,,,,130.20,177.51,percent of total billed charges,
BB BILL COLD AB TITER REFERENCE,7734601,CDM,300,RC,86157,HCPCS,,,facility,outpatient,,,217.00000,62.93000,Aetna,First Health,,177.51,,,,,,,7.47,177.51,percent of total billed charges,
PLATELET ASSOCIATED ABS,7435839,CDM,300,RC,86023,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
PLATELET ASSOCIATED ABS,7435839,CDM,300,RC,86023,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,11.55,64.62,percent of total billed charges,
PLATELET ASSOCIATED ABS,7435876,CDM,300,RC,86023,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
PLATELET ASSOCIATED ABS,7435876,CDM,300,RC,86023,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,11.55,64.62,percent of total billed charges,
HEPARIN DEPENDANT PLATELET AB,7726074,CDM,300,RC,86022,HCPCS,,,facility,inpatient,,,277.00000,80.33000,Aetna,First Health,,226.59,,,,,,,166.20,226.59,percent of total billed charges,
HEPARIN DEPENDANT PLATELET AB,7726074,CDM,300,RC,86022,HCPCS,,,facility,outpatient,,,277.00000,80.33000,Aetna,First Health,,226.59,,,,,,,17.03,226.59,percent of total billed charges,
MALARIA PCR,7744345,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
MALARIA PCR,7744345,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,32.53,92.99,percent of total billed charges,
MALARIA PCR,7744374,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
MALARIA PCR,7744374,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,32.53,92.99,percent of total billed charges,
RUBEOLA ABS IGG AND IGM,7744346,CDM,300,RC,86765,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
RUBEOLA ABS IGG AND IGM,7744346,CDM,300,RC,86765,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,11.94,62.99,percent of total billed charges,
RUBEOLA ABS IGG AND IGM,7798057,CDM,300,RC,86765,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
RUBEOLA ABS IGG AND IGM,7798057,CDM,300,RC,86765,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,11.94,62.99,percent of total billed charges,
Ova and Parasite Exam Fecal,8310280,CDM,300,RC,87177,HCPCS,,,facility,inpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,28.80,39.26,percent of total billed charges,
Ova and Parasite Exam Fecal,8310280,CDM,300,RC,87177,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,8.25,39.26,percent of total billed charges,
TRICHROME STAIN,7742206,CDM,300,RC,87209,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
TRICHROME STAIN,7742206,CDM,300,RC,87209,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,16.67,79.35,percent of total billed charges,
AMIKACIN,7754130,CDM,300,RC,80150,HCPCS,,,facility,inpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,110.40,150.51,percent of total billed charges,
AMIKACIN,7754130,CDM,300,RC,80150,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,13.98,150.51,percent of total billed charges,
AMIKACIN,7754136,CDM,300,RC,80150,HCPCS,,,facility,inpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,110.40,150.51,percent of total billed charges,
AMIKACIN,7754136,CDM,300,RC,80150,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,13.98,150.51,percent of total billed charges,
Amikacin Level,8999857,CDM,300,RC,80150,HCPCS,,,facility,inpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,110.40,150.51,percent of total billed charges,
Amikacin Level,8999857,CDM,300,RC,80150,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,13.98,150.51,percent of total billed charges,
LEUKOCYTE ALKALINE PHOSPHATASE,7748188,CDM,300,RC,85540,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
LEUKOCYTE ALKALINE PHOSPHATASE,7748188,CDM,300,RC,85540,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,7.97,127.61,percent of total billed charges,
ARSENIC BLOOD,7754140,CDM,300,RC,82175,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
ARSENIC BLOOD,7754140,CDM,300,RC,82175,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,17.58,122.70,percent of total billed charges,
CHLAMYDIA PNEUMONIAE,7798038,CDM,300,RC,87486,HCPCS,,,facility,inpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,146.40,199.59,percent of total billed charges,
CHLAMYDIA PNEUMONIAE,7798038,CDM,300,RC,87486,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,32.53,199.59,percent of total billed charges,
HAEMOPHILIUS INFLUENZA B AB,7794096,CDM,300,RC,86317,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
HAEMOPHILIUS INFLUENZA B AB,7794096,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,13.89,119.43,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7776198,CDM,300,RC,86615,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7776198,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,11.10,112.88,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786197,CDM,300,RC,86615,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786197,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,11.10,112.88,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786198,CDM,300,RC,86615,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786198,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,11.10,112.88,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786199,CDM,300,RC,86615,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786199,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,11.10,112.88,percent of total billed charges,
DENGUE FEVER,7794372,CDM,300,RC,86790,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
DENGUE FEVER,7794372,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,11.94,59.71,percent of total billed charges,
DENGUE FEVER,7794379,CDM,300,RC,86790,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
DENGUE FEVER,7794379,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,11.94,59.71,percent of total billed charges,
EHRLICHIA AND ANAPLASMA PCR,7756747,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
EHRLICHIA AND ANAPLASMA PCR,7756747,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,25.38,92.99,percent of total billed charges,
EHRLICHIA AND ANAPLASMA PCR,7768113,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
EHRLICHIA AND ANAPLASMA PCR,7768113,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,25.38,92.99,percent of total billed charges,
TESTOSTERONE TOTAL,3182886,CDM,300,RC,84403,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
TESTOSTERONE TOTAL,3182886,CDM,300,RC,84403,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,23.93,118.61,percent of total billed charges,
TESTOSTERONE FREE ADULT MALE,7768187,CDM,300,RC,84402,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
TESTOSTERONE FREE ADULT MALE,7768187,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,23.61,120.25,percent of total billed charges,
CULTURE CHLAMYDIA,7776186,CDM,300,RC,87110,HCPCS,,,facility,inpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,63.00,85.89,percent of total billed charges,
CULTURE CHLAMYDIA,7776186,CDM,300,RC,87110,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,14.11,85.89,percent of total billed charges,
CULTURE TYPING CHLAMYDIA,7776191,CDM,300,RC,87140,HCPCS,,,facility,inpatient,,,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,18.00,24.54,percent of total billed charges,
CULTURE TYPING CHLAMYDIA,7776191,CDM,300,RC,87140,HCPCS,,,facility,outpatient,,,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,5.16,24.54,percent of total billed charges,
DIPTHERIA OR TETANUS AB,7790463,CDM,300,RC,86317,HCPCS,,,facility,inpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,42.60,58.08,percent of total billed charges,
DIPTHERIA OR TETANUS AB,7790463,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,13.89,58.08,percent of total billed charges,
DIPTHERIA OR TETANUS AB,7790468,CDM,300,RC,86317,HCPCS,,,facility,inpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,42.60,58.08,percent of total billed charges,
DIPTHERIA OR TETANUS AB,7790468,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,13.89,58.08,percent of total billed charges,
ENTEROVIRUS ANTIBODY,7794160,CDM,300,RC,86658,HCPCS,,,facility,inpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,25.20,34.36,percent of total billed charges,
ENTEROVIRUS ANTIBODY,7794160,CDM,300,RC,86658,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,6.68,34.53,percent of total billed charges,
COCCIDIODES ANTIBODY,7790214,CDM,300,RC,86635,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
COCCIDIODES ANTIBODY,7790214,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,6.68,118.61,percent of total billed charges,
COCCIDIODES ANTIBODY,8141154,CDM,300,RC,86635,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
COCCIDIODES ANTIBODY,8141154,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,6.68,118.61,percent of total billed charges,
YERSINIA ANTIBODY,7786194,CDM,300,RC,86793,HCPCS,,,facility,inpatient,,,110.00000,31.90000,Aetna,First Health,,89.98,,,,,,,66.00,89.98,percent of total billed charges,
YERSINIA ANTIBODY,7786194,CDM,300,RC,86793,HCPCS,,,facility,outpatient,,,110.00000,31.90000,Aetna,First Health,,89.98,,,,,,,12.23,89.98,percent of total billed charges,
YERSINIA ANTIBODY,7786236,CDM,300,RC,86793,HCPCS,,,facility,inpatient,,,110.00000,31.90000,Aetna,First Health,,89.98,,,,,,,66.00,89.98,percent of total billed charges,
YERSINIA ANTIBODY,7786236,CDM,300,RC,86793,HCPCS,,,facility,outpatient,,,110.00000,31.90000,Aetna,First Health,,89.98,,,,,,,12.23,89.98,percent of total billed charges,
WEST NILE VIRUS CSF,7790486,CDM,300,RC,86788,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
WEST NILE VIRUS CSF,7790486,CDM,300,RC,86788,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,15.63,128.43,percent of total billed charges,
STREPTOCOCCUS PNEUMO AG CSF,7794108,CDM,300,RC,87899,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
STREPTOCOCCUS PNEUMO AG CSF,7794108,CDM,300,RC,87899,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,14.89,118.61,percent of total billed charges,
TETANUS ANTIBODY,7784307,CDM,300,RC,86317,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
TETANUS ANTIBODY,7784307,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,13.89,122.70,percent of total billed charges,
LISTERIA ANTIBODY,7784303,CDM,300,RC,86723,HCPCS,,,facility,inpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,111.60,152.15,percent of total billed charges,
LISTERIA ANTIBODY,7784303,CDM,300,RC,86723,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,12.23,152.15,percent of total billed charges,
GIARDIA LAMBLIA AB,7784163,CDM,300,RC,86674,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
GIARDIA LAMBLIA AB,7784163,CDM,300,RC,86674,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,13.65,59.71,percent of total billed charges,
GIARDIA LAMBLIA AB,7784167,CDM,300,RC,86674,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
GIARDIA LAMBLIA AB,7784167,CDM,300,RC,86674,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,13.65,59.71,percent of total billed charges,
HEPATITIS E VIRUS AB,7852056,CDM,300,RC,86790,HCPCS,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
HEPATITIS E VIRUS AB,7852056,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,11.94,86.71,percent of total billed charges,
HEPATITIS E VIRUS AB,7876561,CDM,300,RC,86790,HCPCS,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
HEPATITIS E VIRUS AB,7876561,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,11.94,86.71,percent of total billed charges,
LEGIONELLA,7856061,CDM,300,RC,87541,HCPCS,,,facility,inpatient,,,125.00000,36.25000,Aetna,First Health,,102.25,,,,,,,75.00,102.25,percent of total billed charges,
LEGIONELLA,7856061,CDM,300,RC,87541,HCPCS,,,facility,outpatient,,,125.00000,36.25000,Aetna,First Health,,102.25,,,,,,,32.53,102.25,percent of total billed charges,
LEGIONELLA AMPLIFIED PROBE,7856071,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,129.00000,37.41000,Aetna,First Health,,105.52,,,,,,,77.40,105.52,percent of total billed charges,
LEGIONELLA AMPLIFIED PROBE,7856071,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,129.00000,37.41000,Aetna,First Health,,105.52,,,,,,,32.53,105.52,percent of total billed charges,
PROTEIN C,7726054,CDM,300,RC,85303,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
PROTEIN C,7726054,CDM,300,RC,85303,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,12.83,57.26,percent of total billed charges,
PROTEIN S,7726064,CDM,300,RC,85306,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
PROTEIN S,7726064,CDM,300,RC,85306,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,14.20,63.80,percent of total billed charges,
MATERNAL SERUM SCREEN ZB1OC,7980982,CDM,300,RC,81511,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
MATERNAL SERUM SCREEN ZB1OC,7980982,CDM,300,RC,81511,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,68.62,406.77,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794352,CDM,300,RC,86790,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794352,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,11.94,128.43,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794353,CDM,300,RC,86790,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794353,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,11.94,128.43,percent of total billed charges,
HEPATITIS E VIRUS QUANT BY PCR,7800074,CDM,300,RC,87799,HCPCS,,,facility,inpatient,,,351.00000,101.79000,Aetna,First Health,,287.12,,,,,,,210.60,287.12,percent of total billed charges,
HEPATITIS E VIRUS QUANT BY PCR,7800074,CDM,300,RC,87799,HCPCS,,,facility,outpatient,,,351.00000,101.79000,Aetna,First Health,,287.12,,,,,,,39.72,287.12,percent of total billed charges,
CHROMIUM SERUM,7896929,CDM,300,RC,82495,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
CHROMIUM SERUM,7896929,CDM,300,RC,82495,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,18.80,124.34,percent of total billed charges,
HEPATITIS DELTA ANTIGEN,7808094,CDM,300,RC,87380,HCPCS,,,facility,inpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,127.80,174.23,percent of total billed charges,
HEPATITIS DELTA ANTIGEN,7808094,CDM,300,RC,87380,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,17.02,174.23,percent of total billed charges,
HEMOGLOBIN A1C REFERENCE,3481841,CDM,300,RC,83036,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
HEMOGLOBIN A1C REFERENCE,3481841,CDM,300,RC,83036,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,9.00,118.61,percent of total billed charges,
ANTI NMDA ANTIBODY IGG CSF,7822217,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,277.00000,80.33000,Aetna,First Health,,226.59,,,,,,,166.20,226.59,percent of total billed charges,
ANTI NMDA ANTIBODY IGG CSF,7822217,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,277.00000,80.33000,Aetna,First Health,,226.59,,,,,,,11.18,226.59,percent of total billed charges,
2006311 N methyl D Aspartate Receptor Bill ARUP,7822223,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,90.60,123.52,percent of total billed charges,
2006311 N methyl D Aspartate Receptor Bill ARUP,7822223,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,11.18,123.52,percent of total billed charges,
TOXOPLASMA GONDII PCR,7820119,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,146.40,199.59,percent of total billed charges,
TOXOPLASMA GONDII PCR,7820119,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,First Health,,199.59,,,,,,,32.53,199.59,percent of total billed charges,
NMO AQP4 IGG CBA CSF,7935085,CDM,300,RC,86053,HCPCS,,,facility,inpatient,,,625.00000,181.25000,Aetna,First Health,,511.25,,,,,,,375.00,511.25,percent of total billed charges,
NMO AQP4 IGG CBA CSF,7935085,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,625.00000,181.25000,Aetna,First Health,,511.25,,,,,,,34.98,511.25,percent of total billed charges,
NMO AQP4 IGG CBA CSF,8002074,CDM,300,RC,86053,HCPCS,,,facility,inpatient,,,625.00000,181.25000,Aetna,First Health,,511.25,,,,,,,375.00,511.25,percent of total billed charges,
NMO AQP4 IGG CBA CSF,8002074,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,625.00000,181.25000,Aetna,First Health,,511.25,,,,,,,34.98,511.25,percent of total billed charges,
NMO AQP4 IGG CBA CSF,8003380,CDM,300,RC,86053,HCPCS,,,facility,inpatient,,,625.00000,181.25000,Aetna,First Health,,511.25,,,,,,,375.00,511.25,percent of total billed charges,
NMO AQP4 IGG CBA CSF,8003380,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,625.00000,181.25000,Aetna,First Health,,511.25,,,,,,,34.98,511.25,percent of total billed charges,
FHSAG MVista Histoplasma Ag CSF MAYO,8117653,CDM,300,RC,87385,HCPCS,,,facility,inpatient,,,217.00000,62.93000,Aetna,First Health,,177.51,,,,,,,130.20,177.51,percent of total billed charges,
FHSAG MVista Histoplasma Ag CSF MAYO,8117653,CDM,300,RC,87385,HCPCS,,,facility,outpatient,,,217.00000,62.93000,Aetna,First Health,,177.51,,,,,,,12.29,177.51,percent of total billed charges,
88280 Additional Karotypes CSI,7844059,CDM,300,RC,88280,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
88280 Additional Karotypes CSI,7844059,CDM,300,RC,88280,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,31.02,125.15,percent of total billed charges,
TISSUE CULTURE LYMPHOCYTE CSI,7844058,CDM,300,RC,88230,HCPCS,,,facility,inpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,142.20,193.87,percent of total billed charges,
TISSUE CULTURE LYMPHOCYTE CSI,7844058,CDM,300,RC,88230,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,32.36,308.70,percent of total billed charges,
CHROMOSOME ANALYSIS CSI,7844060,CDM,300,RC,88264,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
CHROMOSOME ANALYSIS CSI,7844060,CDM,300,RC,88264,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,68.15,383.22,percent of total billed charges,
B CELL GENE ARRANGEMENT CSI ZB4I7,7844048,CDM,300,RC,81261,HCPCS,,,facility,inpatient,,,224.00000,64.96000,Aetna,First Health,,183.23,,,,,,,134.40,183.23,percent of total billed charges,
B CELL GENE ARRANGEMENT CSI ZB4I7,7844048,CDM,300,RC,81261,HCPCS,,,facility,outpatient,,,224.00000,64.96000,Aetna,First Health,,183.23,,,,,,,105.28,524.67,percent of total billed charges,
BCR ABL QUNAT ANALYSIS CSI ZB4IC,7844117,CDM,300,RC,81206,HCPCS,,,facility,inpatient,,,256.00000,74.24000,Aetna,First Health,,209.41,,,,,,,153.60,209.41,percent of total billed charges,
BCR ABL QUNAT ANALYSIS CSI ZB4IC,7844117,CDM,300,RC,81206,HCPCS,,,facility,outpatient,,,256.00000,74.24000,Aetna,First Health,,209.41,,,,,,,120.32,434.49,percent of total billed charges,
JAK2 MUTATION CSI ZB4ID,7844107,CDM,300,RC,81270,HCPCS,,,facility,inpatient,,,289.00000,83.81000,Aetna,First Health,,236.40,,,,,,,173.40,236.40,percent of total billed charges,
JAK2 MUTATION CSI ZB4ID,7844107,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,289.00000,83.81000,Aetna,First Health,,236.40,,,,,,,84.96,242.90,percent of total billed charges,
JAK2 MUTATION CSI ZB4ID,9104196,CDM,300,RC,81270,HCPCS,,,facility,inpatient,,,289.00000,83.81000,Aetna,First Health,,236.40,,,,,,,173.40,236.40,percent of total billed charges,
JAK2 MUTATION CSI ZB4ID,9104196,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,289.00000,83.81000,Aetna,First Health,,236.40,,,,,,,84.96,242.90,percent of total billed charges,
T CELL GENE ARRANGEMENT CSI ZB4IG,7846211,CDM,300,RC,81342,HCPCS,,,facility,inpatient,,,371.00000,107.59000,Aetna,First Health,,303.48,,,,,,,222.60,303.48,percent of total billed charges,
T CELL GENE ARRANGEMENT CSI ZB4IG,7846211,CDM,300,RC,81342,HCPCS,,,facility,outpatient,,,371.00000,107.59000,Aetna,First Health,,303.48,,,,,,,174.37,533.98,percent of total billed charges,
MORPH ANALYSIS CSI,7894065,CDM,300,RC,88361,HCPCS,,,facility,inpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,148.80,202.86,percent of total billed charges,
MORPH ANALYSIS CSI,7894065,CDM,300,RC,88361,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,116.56,951.40,percent of total billed charges,
SSA ANTIBODY IGG,7852142,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
SSA ANTIBODY IGG,7852142,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,16.62,60.53,percent of total billed charges,
ENA ANTIBODY IGG,7880415,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
ENA ANTIBODY IGG,7880415,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,16.62,60.53,percent of total billed charges,
ENA ANTIBODY,8262186,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
ENA ANTIBODY,8262186,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,16.62,60.53,percent of total billed charges,
NUCLEAR ANTIGEN ANTIBODY,8344447,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
NUCLEAR ANTIGEN ANTIBODY,8344447,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,16.62,60.53,percent of total billed charges,
HPV HIGH RISK CSI,7894031,CDM,300,RC,87624,HCPCS,,,facility,inpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,147.00,200.41,percent of total billed charges,
HPV HIGH RISK CSI,7894031,CDM,300,RC,87624,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,32.53,200.41,percent of total billed charges,
COCCIDIOIDES AB PANEL,7790212,CDM,300,RC,86635,HCPCS,,,facility,inpatient,,,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,41.40,56.44,percent of total billed charges,
COCCIDIOIDES AB PANEL,7790212,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,6.68,56.44,percent of total billed charges,
COCCIDIOIDES AB PANEL,7897016,CDM,300,RC,86635,HCPCS,,,facility,inpatient,,,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,41.40,56.44,percent of total billed charges,
COCCIDIOIDES AB PANEL,7897016,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,6.68,56.44,percent of total billed charges,
HEPATITIS BE AG PANEL,7896938,CDM,300,RC,87350,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
HEPATITIS BE AG PANEL,7896938,CDM,300,RC,87350,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,10.69,57.26,percent of total billed charges,
HEPATITIS BE AB PANEL,7896944,CDM,300,RC,86707,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
HEPATITIS BE AB PANEL,7896944,CDM,300,RC,86707,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,10.72,57.26,percent of total billed charges,
IODINE SERUM,7897099,CDM,300,RC,83018,HCPCS,,,facility,inpatient,,,191.00000,55.39000,Aetna,First Health,,156.24,,,,,,,114.60,156.24,percent of total billed charges,
IODINE SERUM,7897099,CDM,300,RC,83018,HCPCS,,,facility,outpatient,,,191.00000,55.39000,Aetna,First Health,,156.24,,,,,,,20.35,156.24,percent of total billed charges,
COBALT BLOOD,7896954,CDM,300,RC,83018,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
COBALT BLOOD,7896954,CDM,300,RC,83018,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,20.35,125.97,percent of total billed charges,
MANGANESE RBC,7897152,CDM,300,RC,83785,HCPCS,,,facility,inpatient,,,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,148.20,202.05,percent of total billed charges,
MANGANESE RBC,7897152,CDM,300,RC,83785,HCPCS,,,facility,outpatient,,,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,24.71,202.05,percent of total billed charges,
ALPHA 1 ANTITRYPSIN TOTAL,7902337,CDM,300,RC,82103,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
ALPHA 1 ANTITRYPSIN TOTAL,7902337,CDM,300,RC,82103,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,12.46,65.44,percent of total billed charges,
ALPHA 1 ANTITRYPSIN TOTAL,7902388,CDM,300,RC,82103,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
ALPHA 1 ANTITRYPSIN TOTAL,7902388,CDM,300,RC,82103,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,12.46,65.44,percent of total billed charges,
ALPHA 1 ANTITRYPSIN PHENOTYPE,7897147,CDM,300,RC,82104,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
ALPHA 1 ANTITRYPSIN PHENOTYPE,7897147,CDM,300,RC,82104,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,13.40,112.88,percent of total billed charges,
0089006 A1A Phenotype Reflex Bill ARUP,7902410,CDM,300,RC,82104,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
0089006 A1A Phenotype Reflex Bill ARUP,7902410,CDM,300,RC,82104,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,13.40,112.88,percent of total billed charges,
ALPHA 1 ANTITRYPSIIN SERPINA 1 ZB1HO,7902405,CDM,300,RC,81332,HCPCS,,,facility,inpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,152.40,207.77,percent of total billed charges,
ALPHA 1 ANTITRYPSIIN SERPINA 1 ZB1HO,7902405,CDM,300,RC,81332,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,40.47,207.77,percent of total billed charges,
ENA ANTIBODIES,7902896,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,16.80,22.90,percent of total billed charges,
ENA ANTIBODIES,7902896,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,13.16,47.51,percent of total billed charges,
ENA ANTIBODIES,7902903,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,16.80,22.90,percent of total billed charges,
ENA ANTIBODIES,7902903,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,13.16,47.51,percent of total billed charges,
ENA ANTIBODIES,7903251,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,16.80,22.90,percent of total billed charges,
ENA ANTIBODIES,7903251,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,13.16,47.51,percent of total billed charges,
RIBOSOMAL P PROTEIN ANTIBODY,7902949,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
RIBOSOMAL P PROTEIN ANTIBODY,7902949,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,10.69,128.43,percent of total billed charges,
CENTROMERE ANTIBODY IGG,7903167,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,90.60,123.52,percent of total billed charges,
CENTROMERE ANTIBODY IGG,7903167,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,10.69,123.52,percent of total billed charges,
BCR ABL MINOR POINT BREAK ZBG82,7903078,CDM,300,RC,81207,HCPCS,,,facility,inpatient,,,436.00000,126.44000,Aetna,First Health,,356.65,,,,,,,261.60,356.65,percent of total billed charges,
BCR ABL MINOR POINT BREAK ZBG82,7903078,CDM,300,RC,81207,HCPCS,,,facility,outpatient,,,436.00000,126.44000,Aetna,First Health,,356.65,,,,,,,134.27,383.83,percent of total billed charges,
NATALIZUB ANTIBODIES,7903086,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,487.00000,141.23000,Aetna,First Health,,398.37,,,,,,,292.20,398.37,percent of total billed charges,
NATALIZUB ANTIBODIES,7903086,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,487.00000,141.23000,Aetna,First Health,,398.37,,,,,,,10.69,398.37,percent of total billed charges,
IMMUNOHISTOCHEMICAL CSI,7903706,CDM,300,RC,88342,HCPCS,,,facility,inpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,148.80,202.86,percent of total billed charges,
IMMUNOHISTOCHEMICAL CSI,7903706,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,84.70,452.20,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7903758,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,33.60,45.81,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7903758,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,10.69,45.81,percent of total billed charges,
FLUORESCENT AB TITER,7902944,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
FLUORESCENT AB TITER,7902944,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,11.18,119.43,percent of total billed charges,
FLUORESCENT AB TITER,7954692,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
FLUORESCENT AB TITER,7954692,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,11.18,119.43,percent of total billed charges,
AMPHIPHYSIN ANTIBODY,7905259,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,236.00000,68.44000,Aetna,First Health,,193.05,,,,,,,141.60,193.05,percent of total billed charges,
AMPHIPHYSIN ANTIBODY,7905259,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,236.00000,68.44000,Aetna,First Health,,193.05,,,,,,,10.69,193.05,percent of total billed charges,
REVERSE T3,7905840,CDM,300,RC,84482,HCPCS,,,facility,inpatient,,,159.00000,46.11000,Aetna,First Health,,130.06,,,,,,,95.40,130.06,percent of total billed charges,
REVERSE T3,7905840,CDM,300,RC,84482,HCPCS,,,facility,outpatient,,,159.00000,46.11000,Aetna,First Health,,130.06,,,,,,,14.61,130.06,percent of total billed charges,
PARANEOPLASTIC EVAL CSF M,7905683,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
PARANEOPLASTIC EVAL CSF M,7905683,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,11.18,85.07,percent of total billed charges,
PARANEOPLASTIC EVAL CSF M,8001942,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,62.40,85.07,percent of total billed charges,
PARANEOPLASTIC EVAL CSF M,8001942,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,First Health,,85.07,,,,,,,11.18,85.07,percent of total billed charges,
ALLERGEN FOOD IGE,7908250,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
ALLERGEN FOOD IGE,7908250,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,4.84,18.81,percent of total billed charges,
ALLERGEN FOOD IGE,7935663,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
ALLERGEN FOOD IGE,7935663,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,4.84,18.81,percent of total billed charges,
Allergen Food Peanut Components IgE ARUP,7976373,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
Allergen Food Peanut Components IgE ARUP,7976373,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,4.84,18.81,percent of total billed charges,
"Allergen, Food, Tree Nuts Components Reflex",9101323,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
"Allergen, Food, Tree Nuts Components Reflex",9101323,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,4.84,18.81,percent of total billed charges,
GAMMAGLOBULIN IGE,7908197,CDM,300,RC,82785,HCPCS,,,facility,inpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,25.20,34.36,percent of total billed charges,
GAMMAGLOBULIN IGE,7908197,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,8.18,43.62,percent of total billed charges,
ALLERGEN ENVIRONMENTAL,7910592,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
ALLERGEN ENVIRONMENTAL,7910592,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,4.84,13.83,percent of total billed charges,
ALLERGEN ENVIRONMENTAL,7910627,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
ALLERGEN ENVIRONMENTAL,7910627,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,4.84,13.83,percent of total billed charges,
ALLERGEN FOOD MILK IGE,8256168,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
ALLERGEN FOOD MILK IGE,8256168,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,4.84,13.83,percent of total billed charges,
ALLERGEN QUALITATIVE,7910628,CDM,300,RC,86005,HCPCS,,,facility,inpatient,,,21.00000,6.09000,Aetna,First Health,,17.18,,,,,,,12.60,17.18,percent of total billed charges,
ALLERGEN QUALITATIVE,7910628,CDM,300,RC,86005,HCPCS,,,facility,outpatient,,,21.00000,6.09000,Aetna,First Health,,17.18,,,,,,,7.39,21.12,percent of total billed charges,
PREGNENOLONE,7908525,CDM,300,RC,84140,HCPCS,,,facility,inpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,83.40,113.70,percent of total billed charges,
PREGNENOLONE,7908525,CDM,300,RC,84140,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,19.16,113.70,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7908698,CDM,300,RC,86698,HCPCS,,,facility,inpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,28.20,38.45,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7908698,CDM,300,RC,86698,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,12.78,38.45,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7908706,CDM,300,RC,86698,HCPCS,,,facility,inpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,28.20,38.45,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7908706,CDM,300,RC,86698,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,12.78,38.45,percent of total billed charges,
BONE SPECIFIC AIK PHOSPHATASE,7908692,CDM,300,RC,84080,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,90.60,123.52,percent of total billed charges,
BONE SPECIFIC AIK PHOSPHATASE,7908692,CDM,300,RC,84080,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,13.70,123.52,percent of total billed charges,
ANTI MULLERIAN HORMONE,7908686,CDM,300,RC,82166,HCPCS,,,facility,inpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,109.20,148.88,percent of total billed charges,
ANTI MULLERIAN HORMONE,7908686,CDM,300,RC,82166,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,35.80,148.88,percent of total billed charges,
ALLERGEN FOOD ALPHA GAL IGE,7910154,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
ALLERGEN FOOD ALPHA GAL IGE,7910154,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,4.84,116.97,percent of total billed charges,
AMINO ACID QUANT BLOOD,7910858,CDM,300,RC,82139,HCPCS,,,facility,inpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,147.00,200.41,percent of total billed charges,
AMINO ACID QUANT BLOOD,7910858,CDM,300,RC,82139,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,15.64,200.41,percent of total billed charges,
IMMUNOFLUORESCENT INITIAL,7910656,CDM,300,RC,88346,HCPCS,,,facility,inpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,208.20,283.85,percent of total billed charges,
IMMUNOFLUORESCENT INITIAL,7910656,CDM,300,RC,88346,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,88.98,452.20,percent of total billed charges,
IMMUNOFLUORESCENCE EACH ADDL,7910658,CDM,300,RC,88350,HCPCS,,,facility,inpatient,,,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,159.00,216.77,percent of total billed charges,
IMMUNOFLUORESCENCE EACH ADDL,7910658,CDM,300,RC,88350,HCPCS,,,facility,outpatient,,,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,95.53,216.77,percent of total billed charges,
CHROMATOGRAPHY W MASS SPEC,1425800,CDM,300,RC,82542,HCPCS,,,facility,inpatient,,,367.00000,106.43000,Aetna,First Health,,300.21,,,,,,,220.20,300.21,percent of total billed charges,
CHROMATOGRAPHY W MASS SPEC,1425800,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,First Health,,300.21,,,,,,,11.66,300.21,percent of total billed charges,
BARTONELLA SEROLOGY,7910483,CDM,300,RC,86611,HCPCS,,,facility,inpatient,,,38.00000,11.02000,Aetna,First Health,,31.08,,,,,,,22.80,31.08,percent of total billed charges,
BARTONELLA SEROLOGY,7910483,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,38.00000,11.02000,Aetna,First Health,,31.08,,,,,,,9.43,31.08,percent of total billed charges,
BARTONELLA SEROLOGY,7910496,CDM,300,RC,86611,HCPCS,,,facility,inpatient,,,38.00000,11.02000,Aetna,First Health,,31.08,,,,,,,22.80,31.08,percent of total billed charges,
BARTONELLA SEROLOGY,7910496,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,38.00000,11.02000,Aetna,First Health,,31.08,,,,,,,9.43,31.08,percent of total billed charges,
ARSENIC URINE,7911488,CDM,300,RC,82175,HCPCS,,,facility,inpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
ARSENIC URINE,7911488,CDM,300,RC,82175,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,17.58,50.27,percent of total billed charges,
LEAD URINE,7911529,CDM,300,RC,83655,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
LEAD URINE,7911529,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,11.23,32.09,percent of total billed charges,
MERCURY URINE,7911530,CDM,300,RC,83825,HCPCS,,,facility,inpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,20.40,27.81,percent of total billed charges,
MERCURY URINE,7911530,CDM,300,RC,83825,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,15.07,43.09,percent of total billed charges,
CADMIUM URINE,7911531,CDM,300,RC,82300,HCPCS,,,facility,inpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,28.80,39.26,percent of total billed charges,
CADMIUM URINE,7911531,CDM,300,RC,82300,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,21.92,62.65,percent of total billed charges,
ARSENIC FRACTIONATED URINE,7911571,CDM,300,RC,82175,HCPCS,,,facility,inpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,144.00,196.32,percent of total billed charges,
ARSENIC FRACTIONATED URINE,7911571,CDM,300,RC,82175,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,17.58,196.32,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7910781,CDM,300,RC,86698,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7910781,CDM,300,RC,86698,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,12.78,63.80,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7910784,CDM,300,RC,86698,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7910784,CDM,300,RC,86698,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,12.78,63.80,percent of total billed charges,
EVEROLIMUS,7910774,CDM,300,RC,80169,HCPCS,,,facility,inpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,129.00,175.87,percent of total billed charges,
EVEROLIMUS,7910774,CDM,300,RC,80169,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,12.73,175.87,percent of total billed charges,
PROINSULIN INTACT,7910825,CDM,300,RC,84206,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
PROINSULIN INTACT,7910825,CDM,300,RC,84206,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,22.41,114.52,percent of total billed charges,
TSH RECEPTOR,7910852,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,85.20,116.16,percent of total billed charges,
TSH RECEPTOR,7910852,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,16.01,116.16,percent of total billed charges,
17 KETOSTEROIDS URINE,7911699,CDM,300,RC,83586,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
17 KETOSTEROIDS URINE,7911699,CDM,300,RC,83586,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,11.87,112.88,percent of total billed charges,
HELMINTH ANTIBODY,7912096,CDM,300,RC,86682,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
HELMINTH ANTIBODY,7912096,CDM,300,RC,86682,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,12.06,127.61,percent of total billed charges,
HELMINTH ANTIBODY,7912102,CDM,300,RC,86682,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
HELMINTH ANTIBODY,7912102,CDM,300,RC,86682,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,12.06,127.61,percent of total billed charges,
CYTOMEGALOVIRUS IGM,7911390,CDM,300,RC,86645,HCPCS,,,facility,inpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,22.20,30.27,percent of total billed charges,
CYTOMEGALOVIRUS IGM,7911390,CDM,300,RC,86645,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,15.63,44.65,percent of total billed charges,
HSV ANTIBODIES,7911389,CDM,300,RC,86694,HCPCS,,,facility,inpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
HSV ANTIBODIES,7911389,CDM,300,RC,86694,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,13.34,38.13,percent of total billed charges,
RUBELLA ANTIBODIES,7911393,CDM,300,RC,86762,HCPCS,,,facility,inpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
RUBELLA ANTIBODIES,7911393,CDM,300,RC,86762,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,13.34,38.13,percent of total billed charges,
TOXOPLASMA IGM,7911382,CDM,300,RC,86778,HCPCS,,,facility,inpatient,,,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,19.20,26.18,percent of total billed charges,
TOXOPLASMA IGM,7911382,CDM,300,RC,86778,HCPCS,,,facility,outpatient,,,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,13.36,38.19,percent of total billed charges,
CMV IGG,7911456,CDM,300,RC,86644,HCPCS,,,facility,inpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
CMV IGG,7911456,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,13.34,38.13,percent of total billed charges,
TOXOPLASMA IGG,7911462,CDM,300,RC,86777,HCPCS,,,facility,inpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
TOXOPLASMA IGG,7911462,CDM,300,RC,86777,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,13.34,38.13,percent of total billed charges,
INHIBIN B A,7911733,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,142.20,193.87,percent of total billed charges,
INHIBIN B A,7911733,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,16.01,193.87,percent of total billed charges,
INHIBIN B A,7912090,CDM,300,RC,86336,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
INHIBIN B A,7912090,CDM,300,RC,86336,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,13.30,111.25,percent of total billed charges,
Q FEVER ANTIBODIES,7904951,CDM,300,RC,86638,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
Q FEVER ANTIBODIES,7904951,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,6.68,57.26,percent of total billed charges,
Q FEVER ANTIBODIES,7905150,CDM,300,RC,86638,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
Q FEVER ANTIBODIES,7905150,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,6.68,57.26,percent of total billed charges,
Q FEVER ANTIBODIES,7912072,CDM,300,RC,86638,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
Q FEVER ANTIBODIES,7912072,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,6.68,57.26,percent of total billed charges,
REFLEX Q FEVER IGG ANTIBODIES,7904960,CDM,300,RC,86638,HCPCS,,,facility,inpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,24.60,33.54,percent of total billed charges,
REFLEX Q FEVER IGG ANTIBODIES,7904960,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,6.68,33.54,percent of total billed charges,
REFLEX Q FEVER IGG ANTIBODIES,7904964,CDM,300,RC,86638,HCPCS,,,facility,inpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,24.60,33.54,percent of total billed charges,
REFLEX Q FEVER IGG ANTIBODIES,7904964,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,6.68,33.54,percent of total billed charges,
REFLEX Q FEVER IGM ANTIBODIES,7905189,CDM,300,RC,86638,HCPCS,,,facility,inpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,24.60,33.54,percent of total billed charges,
REFLEX Q FEVER IGM ANTIBODIES,7905189,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,6.68,33.54,percent of total billed charges,
REFLEX Q FEVER IGM ANTIBODIES,7905193,CDM,300,RC,86638,HCPCS,,,facility,inpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,24.60,33.54,percent of total billed charges,
REFLEX Q FEVER IGM ANTIBODIES,7905193,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,First Health,,33.54,,,,,,,6.68,33.54,percent of total billed charges,
PLATELET AGGREGATION P2Y12,7912254,CDM,300,RC,85576,HCPCS,,,facility,inpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,147.00,200.41,percent of total billed charges,
PLATELET AGGREGATION P2Y12,7912254,CDM,300,RC,85576,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,23.09,200.41,percent of total billed charges,
C DIFFICULE CYTOTOXIN CELL,7912598,CDM,300,RC,87230,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
C DIFFICULE CYTOTOXIN CELL,7912598,CDM,300,RC,87230,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,18.30,111.25,percent of total billed charges,
VITAMIN C ASCORBIC ACID PLASMA,7912841,CDM,300,RC,82180,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
VITAMIN C ASCORBIC ACID PLASMA,7912841,CDM,300,RC,82180,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,5.46,127.61,percent of total billed charges,
OXALATE URINE,7913603,CDM,300,RC,83945,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
OXALATE URINE,7913603,CDM,300,RC,83945,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,13.40,125.97,percent of total billed charges,
VITAMIN B2 RIBOFLAVIN,7913827,CDM,300,RC,84252,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
VITAMIN B2 RIBOFLAVIN,7913827,CDM,300,RC,84252,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,18.77,125.15,percent of total billed charges,
BARTONELLA HENSELAE ABS,7916456,CDM,300,RC,86611,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
BARTONELLA HENSELAE ABS,7916456,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,9.43,63.80,percent of total billed charges,
BARTONELLA HENSELAE ABS,7916459,CDM,300,RC,86611,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
BARTONELLA HENSELAE ABS,7916459,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,9.43,63.80,percent of total billed charges,
ZONISAMIDE,7916507,CDM,300,RC,80203,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
ZONISAMIDE,7916507,CDM,300,RC,80203,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,12.29,125.97,percent of total billed charges,
C1 ESTERASE INHIBITOR,7916635,CDM,300,RC,86160,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
C1 ESTERASE INHIBITOR,7916635,CDM,300,RC,86160,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,11.12,110.43,percent of total billed charges,
ALLERGENS IGE,7916858,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
ALLERGENS IGE,7916858,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,4.70,13.83,percent of total billed charges,
ALLERGENS IGE,7916919,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
ALLERGENS IGE,7916919,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,4.70,13.83,percent of total billed charges,
Hypersensitivity Pneumonitis Extended Panel,8171764,CDM,300,RC,86005,HCPCS,,,facility,inpatient,,,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,7.20,9.82,percent of total billed charges,
Hypersensitivity Pneumonitis Extended Panel,8171764,CDM,300,RC,86005,HCPCS,,,facility,outpatient,,,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,5.64,21.12,percent of total billed charges,
IMMUNODIFFUSION GEL,7917271,CDM,300,RC,86331,HCPCS,,,facility,inpatient,,,19.00000,5.51000,Aetna,First Health,,15.54,,,,,,,11.40,15.54,percent of total billed charges,
IMMUNODIFFUSION GEL,7917271,CDM,300,RC,86331,HCPCS,,,facility,outpatient,,,19.00000,5.51000,Aetna,First Health,,15.54,,,,,,,8.93,31.75,percent of total billed charges,
ASPERGILLUS ANTIBODY,7917270,CDM,300,RC,86606,HCPCS,,,facility,inpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
ASPERGILLUS ANTIBODY,7917270,CDM,300,RC,86606,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,10.81,39.88,percent of total billed charges,
PROTEIN S FREE AG,7948300,CDM,300,RC,85306,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
PROTEIN S FREE AG,7948300,CDM,300,RC,85306,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,14.20,118.61,percent of total billed charges,
Bird Fanciers Precipitin Panel I MAYO,7921273,CDM,300,RC,86331,HCPCS,,,facility,inpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
Bird Fanciers Precipitin Panel I MAYO,7921273,CDM,300,RC,86331,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,10.81,31.75,percent of total billed charges,
86331 Immunodiffusion Ouchterlony,7934944,CDM,300,RC,86331,HCPCS,,,facility,inpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
86331 Immunodiffusion Ouchterlony,7934944,CDM,300,RC,86331,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,10.81,31.75,percent of total billed charges,
BABESIA SPECIES BY PCR,7921226,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,70.20,95.71,percent of total billed charges,
BABESIA SPECIES BY PCR,7921226,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,32.53,95.71,percent of total billed charges,
88350 IF Additional Arkana,8070006,CDM,300,RC,88350,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
88350 IF Additional Arkana,8070006,CDM,300,RC,88350,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,100.94,229.04,percent of total billed charges,
VORICONAZOLE QUANT,7933863,CDM,300,RC,80285,HCPCS,,,facility,inpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,96.60,131.70,percent of total billed charges,
VORICONAZOLE QUANT,7933863,CDM,300,RC,80285,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,First Health,,131.70,,,,,,,25.13,131.70,percent of total billed charges,
CYSTIC FIBROSIS VARIANTS PANEL ZB2XT,7935002,CDM,300,RC,81220,HCPCS,,,facility,inpatient,,,560.00000,162.40000,Aetna,First Health,,458.08,,,,,,,336.00,458.08,percent of total billed charges,
CYSTIC FIBROSIS VARIANTS PANEL ZB2XT,7935002,CDM,300,RC,81220,HCPCS,,,facility,outpatient,,,560.00000,162.40000,Aetna,First Health,,458.08,,,,,,,263.20,1474.99,percent of total billed charges,
GABAPENTIN,7934996,CDM,300,RC,80171,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
GABAPENTIN,7934996,CDM,300,RC,80171,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,20.09,124.34,percent of total billed charges,
APOLIPOPROTEIN E GENOTYPING CR ZB2UV,7934987,CDM,300,RC,81401,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,144.60,197.14,percent of total billed charges,
APOLIPOPROTEIN E GENOTYPING CR ZB2UV,7934987,CDM,300,RC,81401,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,113.27,363.05,percent of total billed charges,
FLUORESCENT AGENT SCREEN,7935373,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,39.00,53.17,percent of total billed charges,
FLUORESCENT AGENT SCREEN,7935373,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,11.18,53.17,percent of total billed charges,
"Paraneoplastic Autoantibody Eval, Serum",8002684,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,113.00000,32.77000,Aetna,First Health,,92.43,,,,,,,67.80,92.43,percent of total billed charges,
"Paraneoplastic Autoantibody Eval, Serum",8002684,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,113.00000,32.77000,Aetna,First Health,,92.43,,,,,,,11.18,92.43,percent of total billed charges,
FELBAMATE,7945916,CDM,300,RC,80167,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
FELBAMATE,7945916,CDM,300,RC,80167,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,17.28,125.15,percent of total billed charges,
ADAMTS13 ACTIVITY,7945931,CDM,300,RC,85397,HCPCS,,,facility,inpatient,,,259.00000,75.11000,Aetna,First Health,,211.86,,,,,,,155.40,211.86,percent of total billed charges,
ADAMTS13 ACTIVITY,7945931,CDM,300,RC,85397,HCPCS,,,facility,outpatient,,,259.00000,75.11000,Aetna,First Health,,211.86,,,,,,,28.60,211.86,percent of total billed charges,
ADAMTS13 ACTIVITY,7980423,CDM,300,RC,85397,HCPCS,,,facility,inpatient,,,259.00000,75.11000,Aetna,First Health,,211.86,,,,,,,155.40,211.86,percent of total billed charges,
ADAMTS13 ACTIVITY,7980423,CDM,300,RC,85397,HCPCS,,,facility,outpatient,,,259.00000,75.11000,Aetna,First Health,,211.86,,,,,,,28.60,211.86,percent of total billed charges,
AMITRIPTYLINE AND NORTRIPTYLINE,7945963,CDM,300,RC,80335,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
AMITRIPTYLINE AND NORTRIPTYLINE,7945963,CDM,300,RC,80335,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,0.01485,112.88,percent of total billed charges,
HYPOGLYCEMIA PANEL URINE,7950203,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,246.00000,71.34000,Aetna,First Health,,201.23,,,,,,,147.60,201.23,percent of total billed charges,
HYPOGLYCEMIA PANEL URINE,7950203,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,246.00000,71.34000,Aetna,First Health,,201.23,,,,,,,98.40,257.47,percent of total billed charges,
ALLERGENS FOOD IGG,7950256,CDM,300,RC,86001,HCPCS,,,facility,inpatient,,,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,19.20,26.18,percent of total billed charges,
ALLERGENS FOOD IGG,7950256,CDM,300,RC,86001,HCPCS,,,facility,outpatient,,,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,6.95,26.18,percent of total billed charges,
ALLERGENS FOOD IGG,7950314,CDM,300,RC,86001,HCPCS,,,facility,inpatient,,,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,19.20,26.18,percent of total billed charges,
ALLERGENS FOOD IGG,7950314,CDM,300,RC,86001,HCPCS,,,facility,outpatient,,,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,6.95,26.18,percent of total billed charges,
IMMUNOGLOBULIN QUANT,7954564,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
IMMUNOGLOBULIN QUANT,7954564,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,8.18,126.79,percent of total billed charges,
IMMUNOGLOBULIN QUANT,7954568,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
IMMUNOGLOBULIN QUANT,7954568,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,8.18,126.79,percent of total billed charges,
IMMUNOGLOBULIN QUANT,7954572,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
IMMUNOGLOBULIN QUANT,7954572,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,8.18,126.79,percent of total billed charges,
DNASE B ANTIBODY,7177863,CDM,300,RC,86215,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
DNASE B ANTIBODY,7177863,CDM,300,RC,86215,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,12.29,118.61,percent of total billed charges,
STREPTOLYSIN O ANTIBODY,3198898,CDM,300,RC,86060,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
STREPTOLYSIN O ANTIBODY,3198898,CDM,300,RC,86060,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,6.77,118.61,percent of total billed charges,
COAG FACTOR VII ACTIVITY,3214887,CDM,300,RC,85230,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
COAG FACTOR VII ACTIVITY,3214887,CDM,300,RC,85230,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,16.59,112.88,percent of total billed charges,
HEMOGLOBIN PLASMA FREE,7475959,CDM,300,RC,83051,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
HEMOGLOBIN PLASMA FREE,7475959,CDM,300,RC,83051,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,5.46,120.25,percent of total billed charges,
MALARIA SMEAR,7935889,CDM,300,RC,87207,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,80.40,109.61,percent of total billed charges,
MALARIA SMEAR,7935889,CDM,300,RC,87207,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,5.55,109.61,percent of total billed charges,
ALPHA 1 ANTITRYPSIN,3184842,CDM,300,RC,82103,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
ALPHA 1 ANTITRYPSIN,3184842,CDM,300,RC,82103,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,12.46,117.79,percent of total billed charges,
DRUG SCREEN CMH BLOOD ADD ON,605879,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,221.00000,64.09000,Aetna,First Health,,180.78,,,,,,,132.60,180.78,percent of total billed charges,
DRUG SCREEN CMH BLOOD ADD ON,605879,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,221.00000,64.09000,Aetna,First Health,,180.78,,,,,,,88.40,257.47,percent of total billed charges,
LACTATE DEHYDROGENASE ISOENZ,3191002,CDM,300,RC,83625,HCPCS,,,facility,inpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,63.00,85.89,percent of total billed charges,
LACTATE DEHYDROGENASE ISOENZ,3191002,CDM,300,RC,83625,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,8.63,85.89,percent of total billed charges,
Somatostatin Quantitative Plasma ARUP,8141145,CDM,300,RC,84307,HCPCS,,,facility,inpatient,,,290.00000,84.10000,Aetna,First Health,,237.22,,,,,,,174.00,237.22,percent of total billed charges,
Somatostatin Quantitative Plasma ARUP,8141145,CDM,300,RC,84307,HCPCS,,,facility,outpatient,,,290.00000,84.10000,Aetna,First Health,,237.22,,,,,,,16.94,237.22,percent of total billed charges,
AMPHETAMINE DRUG SCREENING,8142281,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
AMPHETAMINE DRUG SCREENING,8142281,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,55.20,257.47,percent of total billed charges,
Beta 2 Transferrin ARUP,8141113,CDM,300,RC,86335,HCPCS,,,facility,inpatient,,,210.00000,60.90000,Aetna,First Health,,171.78,,,,,,,126.00,171.78,percent of total billed charges,
Beta 2 Transferrin ARUP,8141113,CDM,300,RC,86335,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,First Health,,171.78,,,,,,,27.21,171.78,percent of total billed charges,
Methylenedioxyamphetamine,8142685,CDM,300,RC,80359,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Methylenedioxyamphetamine,8142685,CDM,300,RC,80359,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,0.01485,61.35,percent of total billed charges,
HSV Subtype by PCR,8147023,CDM,300,RC,87529,HCPCS,,,facility,inpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,71.40,97.34,percent of total billed charges,
HSV Subtype by PCR,8147023,CDM,300,RC,87529,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,32.53,97.34,percent of total billed charges,
87529 HSV Subtype,8920421,CDM,300,RC,87529,HCPCS,,,facility,inpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,71.40,97.34,percent of total billed charges,
87529 HSV Subtype,8920421,CDM,300,RC,87529,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,32.53,97.34,percent of total billed charges,
Relapsing Fever Borrelia Sp by PCR,8147237,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,257.00000,74.53000,Aetna,First Health,,210.23,,,,,,,154.20,210.23,percent of total billed charges,
Relapsing Fever Borrelia Sp by PCR,8147237,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,257.00000,74.53000,Aetna,First Health,,210.23,,,,,,,32.53,210.23,percent of total billed charges,
Prostate Health Index,8147279,CDM,300,RC,84153,HCPCS,,,facility,inpatient,,,200.00000,58.00000,Aetna,First Health,,163.60,,,,,,,120.00,163.60,percent of total billed charges,
Prostate Health Index,8147279,CDM,300,RC,84153,HCPCS,,,facility,outpatient,,,200.00000,58.00000,Aetna,First Health,,163.60,,,,,,,17.05,163.60,percent of total billed charges,
86008 Peanut Components IgE,8152009,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
86008 Peanut Components IgE,8152009,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,16.62,58.90,percent of total billed charges,
86008 Allergen Food Nut Component,8918476,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
86008 Allergen Food Nut Component,8918476,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,16.62,58.90,percent of total billed charges,
Allergen Food Nut Components,8920423,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
Allergen Food Nut Components,8920423,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,16.62,58.90,percent of total billed charges,
HTLV I and II Antibodies with Reflex to Confirmation,8169045,CDM,300,RC,86790,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
HTLV I and II Antibodies with Reflex to Confirmation,8169045,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,11.94,119.43,percent of total billed charges,
HTLV Types I II Western Blot ARUP,8169127,CDM,300,RC,86689,HCPCS,,,facility,inpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,123.00,167.69,percent of total billed charges,
HTLV Types I II Western Blot ARUP,8169127,CDM,300,RC,86689,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,First Health,,167.69,,,,,,,17.94,167.69,percent of total billed charges,
Trypanosoma cruzi Ab,8161538,CDM,300,RC,86753,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
Trypanosoma cruzi Ab,8161538,CDM,300,RC,86753,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,7.68,126.79,percent of total billed charges,
Islet Antigen 2 IA 2 Autoantibody Serum,8172076,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,263.00000,76.27000,Aetna,First Health,,215.13,,,,,,,157.80,215.13,percent of total billed charges,
Islet Antigen 2 IA 2 Autoantibody Serum,8172076,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,263.00000,76.27000,Aetna,First Health,,215.13,,,,,,,21.85,215.13,percent of total billed charges,
DETECT AGENT NOS DNA AMP,8161858,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,275.00000,79.75000,Aetna,First Health,,224.95,,,,,,,165.00,224.95,percent of total billed charges,
DETECT AGENT NOS DNA AMP,8161858,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,275.00000,79.75000,Aetna,First Health,,224.95,,,,,,,32.53,224.95,percent of total billed charges,
Allergen Occupational Latex IgE Enhanced ARUP,8168799,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Allergen Occupational Latex IgE Enhanced ARUP,8168799,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,4.84,125.15,percent of total billed charges,
Allergen Food Chocolate,8978805,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Allergen Food Chocolate,8978805,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,4.84,125.15,percent of total billed charges,
Allergen Food  Peanut with Reflex to Components,9001682,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Allergen Food  Peanut with Reflex to Components,9001682,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,4.84,125.15,percent of total billed charges,
Allergen Food Sesame Seed,9044143,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Allergen Food Sesame Seed,9044143,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,4.84,125.15,percent of total billed charges,
Cashew IgE,9092972,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Cashew IgE,9092972,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,4.84,125.15,percent of total billed charges,
Walnut IgE,9094760,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Walnut IgE,9094760,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,4.84,125.15,percent of total billed charges,
Benzodiazepines Urine Quantitatitve ARUP,8168808,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
Benzodiazepines Urine Quantitatitve ARUP,8168808,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,59.60,257.47,percent of total billed charges,
Phencyclidine PCP Urine Quantitative ARUP,8169150,CDM,300,RC,83992,HCPCS,,,facility,inpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,112.20,152.97,percent of total billed charges,
Phencyclidine PCP Urine Quantitative ARUP,8169150,CDM,300,RC,83992,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,19.56,152.97,percent of total billed charges,
Cocaine Metabolite Urine Quantitative ARUP,8169136,CDM,300,RC,80353,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
Cocaine Metabolite Urine Quantitative ARUP,8169136,CDM,300,RC,80353,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,0.01485,117.79,percent of total billed charges,
80365 Oxycodone Urine,8172066,CDM,300,RC,80365,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
80365 Oxycodone Urine,8172066,CDM,300,RC,80365,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,0.01485,54.81,percent of total billed charges,
Drug Confirmation Opiates Urine,3196861,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
Drug Confirmation Opiates Urine,3196861,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,46.40,257.47,percent of total billed charges,
Flunitrazepam and Metabolites Urine,8170446,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,279.00000,80.91000,Aetna,First Health,,228.22,,,,,,,167.40,228.22,percent of total billed charges,
Flunitrazepam and Metabolites Urine,8170446,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,279.00000,80.91000,Aetna,First Health,,228.22,,,,,,,106.08,257.47,percent of total billed charges,
Gamma Hydroxybutyric Acid GHB Urine Screen,8171656,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,291.00000,84.39000,Aetna,First Health,,238.04,,,,,,,174.60,238.04,percent of total billed charges,
Gamma Hydroxybutyric Acid GHB Urine Screen,8171656,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,291.00000,84.39000,Aetna,First Health,,238.04,,,,,,,106.08,257.47,percent of total billed charges,
Gamma Hydroxybutyric Acid Confirmation,8171683,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Gamma Hydroxybutyric Acid Confirmation,8171683,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.40000,257.47,percent of total billed charges,
Allergens Hymenoptera Bee Venom Profile ARUP,8170382,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
Allergens Hymenoptera Bee Venom Profile ARUP,8170382,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,4.84,22.09,percent of total billed charges,
86003 Allergen Bee Venom,8170399,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
86003 Allergen Bee Venom,8170399,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,4.84,22.09,percent of total billed charges,
ALLERGEN SPECIFIC IGE,8280608,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
ALLERGEN SPECIFIC IGE,8280608,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,4.84,22.09,percent of total billed charges,
Allergens Food  Mollusks Profile IgE,9080484,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
Allergens Food  Mollusks Profile IgE,9080484,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,4.84,22.09,percent of total billed charges,
86003 Mollusks IgE,9082418,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
86003 Mollusks IgE,9082418,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,4.84,22.09,percent of total billed charges,
HERPES SIMPLEX ANTIBODY,3209018,CDM,300,RC,86695,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
HERPES SIMPLEX ANTIBODY,3209018,CDM,300,RC,86695,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,12.23,50.72,percent of total billed charges,
HERPES SIMPLEX 2,646387,CDM,300,RC,86696,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
HERPES SIMPLEX 2,646387,CDM,300,RC,86696,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,17.94,73.62,percent of total billed charges,
IMMUNOGLOBULIN E,3190845,CDM,300,RC,82785,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
IMMUNOGLOBULIN E,3190845,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,8.18,126.79,percent of total billed charges,
VIRUS ISOL SHELL VIAL EACH,3186843,CDM,300,RC,87254,HCPCS,,,facility,inpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,20.40,27.81,percent of total billed charges,
VIRUS ISOL SHELL VIAL EACH,3186843,CDM,300,RC,87254,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,15.98,51.83,percent of total billed charges,
SJOGREN ANTIBODIES SSA AND SSB,3216839,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
SJOGREN ANTIBODIES SSA AND SSB,3216839,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,16.62,121.06,percent of total billed charges,
LYME DISEASE IGG AND IGM WB,3188883,CDM,300,RC,86617,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
LYME DISEASE IGG AND IGM WB,3188883,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,14.36,58.90,percent of total billed charges,
LYME DISEASE IGG AND IGM WB,613054,CDM,300,RC,86617,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
LYME DISEASE IGG AND IGM WB,613054,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,14.36,58.90,percent of total billed charges,
LYME DISEASE IGG AND IGM WB,8948134,CDM,300,RC,86617,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
LYME DISEASE IGG AND IGM WB,8948134,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,14.36,58.90,percent of total billed charges,
Reflex Lyme Standard 2 Tier CSF 2nd Tier,9043530,CDM,300,RC,86617,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
Reflex Lyme Standard 2 Tier CSF 2nd Tier,9043530,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,14.36,58.90,percent of total billed charges,
Lyme Ab IB,9044145,CDM,300,RC,86617,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
Lyme Ab IB,9044145,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,14.36,58.90,percent of total billed charges,
RUSSELL VIPER VENOM,3178851,CDM,300,RC,85613,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
RUSSELL VIPER VENOM,3178851,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,8.88,54.81,percent of total billed charges,
RUSSELL VIPER VENOM,3186893,CDM,300,RC,85613,HCPCS,,,facility,inpatient,,,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,13.20,18.00,percent of total billed charges,
RUSSELL VIPER VENOM,3186893,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,8.88,25.39,percent of total billed charges,
dRVVT Mix and Confirm Bill,9041356,CDM,300,RC,85613,HCPCS,,,facility,inpatient,,,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,13.20,18.00,percent of total billed charges,
dRVVT Mix and Confirm Bill,9041356,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,8.88,25.39,percent of total billed charges,
85613 dRVVT Confirm,9041360,CDM,300,RC,85613,HCPCS,,,facility,inpatient,,,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,13.20,18.00,percent of total billed charges,
85613 dRVVT Confirm,9041360,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,8.88,25.39,percent of total billed charges,
RUSSELL VIPER VENOM,3186864,CDM,300,RC,85613,HCPCS,,,facility,inpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,28.20,38.45,percent of total billed charges,
RUSSELL VIPER VENOM,3186864,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,8.88,38.45,percent of total billed charges,
THYROGLOBULIN ANTIBODY,613060,CDM,300,RC,86800,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
THYROGLOBULIN ANTIBODY,613060,CDM,300,RC,86800,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,14.75,64.62,percent of total billed charges,
ACETYLCHOLINE BINDING AG,7117839,CDM,300,RC,86041,HCPCS,,,facility,inpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,52.20,71.17,percent of total billed charges,
ACETYLCHOLINE BINDING AG,7117839,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,17.06,71.17,percent of total billed charges,
HEMOGLOBIN EVALUATION,7281867,CDM,300,RC,83020,HCPCS,,,facility,inpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,25.20,34.36,percent of total billed charges,
HEMOGLOBIN EVALUATION,7281867,CDM,300,RC,83020,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,8.54,34.36,percent of total billed charges,
SEX HORMONE BINDING GLOBULIN,3216882,CDM,300,RC,84270,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
SEX HORMONE BINDING GLOBULIN,3216882,CDM,300,RC,84270,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,20.15,121.06,percent of total billed charges,
GLYCOPROTEIN ANTIBODY,2164824,CDM,300,RC,86146,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
GLYCOPROTEIN ANTIBODY,2164824,CDM,300,RC,86146,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,23.60,67.44,percent of total billed charges,
GLYCOPROTEIN ANTIBODY,3207190,CDM,300,RC,86146,HCPCS,,,facility,inpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,42.00,57.26,percent of total billed charges,
GLYCOPROTEIN ANTIBODY,3207190,CDM,300,RC,86146,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,23.60,67.44,percent of total billed charges,
URIC ACID OTHER SOURCE,5721862,CDM,300,RC,84560,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
URIC ACID OTHER SOURCE,5721862,CDM,300,RC,84560,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,4.71,125.97,percent of total billed charges,
CITRATE ACID URINE,7177867,CDM,300,RC,82507,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
CITRATE ACID URINE,7177867,CDM,300,RC,82507,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,25.77,120.25,percent of total billed charges,
LEAD BLOOD,657783,CDM,300,RC,83655,HCPCS,,,facility,inpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,22.20,30.27,percent of total billed charges,
LEAD BLOOD,657783,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,11.23,32.09,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786195,CDM,300,RC,86615,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786195,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,11.10,40.90,percent of total billed charges,
2001784 B pertussis Abs IgG IgM w Reflex ARUP,7786196,CDM,300,RC,86615,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
2001784 B pertussis Abs IgG IgM w Reflex ARUP,7786196,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,11.10,40.90,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786250,CDM,300,RC,86615,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786250,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,11.10,40.90,percent of total billed charges,
COCCIDIODES ANTIBODY,7790213,CDM,300,RC,86635,HCPCS,,,facility,inpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,20.40,27.81,percent of total billed charges,
COCCIDIODES ANTIBODY,7790213,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,6.68,30.40,percent of total billed charges,
COCCIDIODES ANTIBODY,7790255,CDM,300,RC,86635,HCPCS,,,facility,inpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,20.40,27.81,percent of total billed charges,
COCCIDIODES ANTIBODY,7790255,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,6.68,30.40,percent of total billed charges,
PROTEIN C,3178939,CDM,300,RC,85303,HCPCS,,,facility,inpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
PROTEIN C,3178939,CDM,300,RC,85303,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,12.83,108.79,percent of total billed charges,
PROTEIN C FUNCTIONAL,8263982,CDM,300,RC,85303,HCPCS,,,facility,inpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
PROTEIN C FUNCTIONAL,8263982,CDM,300,RC,85303,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,12.83,108.79,percent of total billed charges,
PROTEIN S,3178951,CDM,300,RC,85306,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
PROTEIN S,3178951,CDM,300,RC,85306,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,14.20,121.88,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7903261,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7903261,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,8.46,30.55,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794351,CDM,300,RC,86790,HCPCS,,,facility,inpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,78.00,106.34,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794351,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,11.94,106.34,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794363,CDM,300,RC,86790,HCPCS,,,facility,inpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,78.00,106.34,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794363,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,11.94,106.34,percent of total billed charges,
HEPATITIS E VIRUS AB,7784142,CDM,300,RC,86790,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
HEPATITIS E VIRUS AB,7784142,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,11.94,119.43,percent of total billed charges,
LAB IGG CBA MAYO,8002615,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,295.00000,85.55000,Aetna,First Health,,241.31,,,,,,,177.00,241.31,percent of total billed charges,
LAB IGG CBA MAYO,8002615,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,295.00000,85.55000,Aetna,First Health,,241.31,,,,,,,11.18,241.31,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8002650,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,295.00000,85.55000,Aetna,First Health,,241.31,,,,,,,177.00,241.31,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8002650,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,295.00000,85.55000,Aetna,First Health,,241.31,,,,,,,11.18,241.31,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8003398,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,295.00000,85.55000,Aetna,First Health,,241.31,,,,,,,177.00,241.31,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8003398,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,295.00000,85.55000,Aetna,First Health,,241.31,,,,,,,11.18,241.31,percent of total billed charges,
IGG CBA MAYO,8003404,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,295.00000,85.55000,Aetna,First Health,,241.31,,,,,,,177.00,241.31,percent of total billed charges,
IGG CBA MAYO,8003404,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,295.00000,85.55000,Aetna,First Health,,241.31,,,,,,,11.18,241.31,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3192839,CDM,300,RC,86258,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3192839,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,11.18,63.80,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3192884,CDM,300,RC,86258,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3192884,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,11.18,63.80,percent of total billed charges,
Inhibitor Assay PT,8239986,CDM,300,RC,85610,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,90.60,123.52,percent of total billed charges,
Inhibitor Assay PT,8239986,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,,123.52,,,,,,,3.98,123.52,percent of total billed charges,
PT Inhibitor Screen,8239995,CDM,300,RC,85611,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
PT Inhibitor Screen,8239995,CDM,300,RC,85611,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,3.66,22.09,percent of total billed charges,
PTT Inhibitor Screen,8240012,CDM,300,RC,85730,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
PTT Inhibitor Screen,8240012,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,5.57,119.43,percent of total billed charges,
PTT Inhibitor Screen,8240031,CDM,300,RC,85732,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
PTT Inhibitor Screen,8240031,CDM,300,RC,85732,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,5.99,22.09,percent of total billed charges,
PTT Inhibitor 1 Hour Incubation,8240046,CDM,300,RC,85730,HCPCS,,,facility,inpatient,,,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
PTT Inhibitor 1 Hour Incubation,8240046,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,5.57,15.93,percent of total billed charges,
85732 PTT Inhibitor Screen Incubation,2238839,CDM,300,RC,85732,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
85732 PTT Inhibitor Screen Incubation,2238839,CDM,300,RC,85732,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,5.99,22.09,percent of total billed charges,
PTT Inhibitor Screen Incubation,8240062,CDM,300,RC,85732,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
PTT Inhibitor Screen Incubation,8240062,CDM,300,RC,85732,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,5.99,22.09,percent of total billed charges,
Allergen Region 8 Respiratory Panel IgE,8239878,CDM,300,RC,82785,HCPCS,,,facility,inpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,16.80,22.90,percent of total billed charges,
Allergen Region 8 Respiratory Panel IgE,8239878,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,8.18,43.62,percent of total billed charges,
Immunoglobulin E,8239929,CDM,300,RC,82785,HCPCS,,,facility,inpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,16.80,22.90,percent of total billed charges,
Immunoglobulin E,8239929,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,8.18,43.62,percent of total billed charges,
HUMAN EPIDIDYMIS PROTEIN 4,8247887,CDM,300,RC,86305,HCPCS,,,facility,inpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,147.00,200.41,percent of total billed charges,
HUMAN EPIDIDYMIS PROTEIN 4,8247887,CDM,300,RC,86305,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,19.29,200.41,percent of total billed charges,
ALLERGEN EGG IGE,8247908,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
ALLERGEN EGG IGE,8247908,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,4.84,13.91,percent of total billed charges,
ALLERGENS FOOD,8262162,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
ALLERGENS FOOD,8262162,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,4.84,13.91,percent of total billed charges,
Allergen Food 10 IgE,9085018,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
Allergen Food 10 IgE,9085018,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,4.84,13.91,percent of total billed charges,
86003 Allergen Food Tree Nut IgE,9085486,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
86003 Allergen Food Tree Nut IgE,9085486,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,4.84,13.91,percent of total billed charges,
"Allergens, Food, Tree Nuts Profile IgE",9086331,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
"Allergens, Food, Tree Nuts Profile IgE",9086331,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,4.84,13.91,percent of total billed charges,
ALLERGEN FOOD COMPONENT IGE,8247896,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,59.00000,17.11000,Aetna,First Health,,48.26,,,,,,,35.40,48.26,percent of total billed charges,
ALLERGEN FOOD COMPONENT IGE,8247896,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,59.00000,17.11000,Aetna,First Health,,48.26,,,,,,,16.62,48.26,percent of total billed charges,
ALLERGEN Food COMPONENT IGE,8247907,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,59.00000,17.11000,Aetna,First Health,,48.26,,,,,,,35.40,48.26,percent of total billed charges,
ALLERGEN Food COMPONENT IGE,8247907,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,59.00000,17.11000,Aetna,First Health,,48.26,,,,,,,16.62,48.26,percent of total billed charges,
17 Hydroxypregnenolone Quant by LC MS MS,8256185,CDM,300,RC,84143,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
17 Hydroxypregnenolone Quant by LC MS MS,8256185,CDM,300,RC,84143,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,21.15,114.52,percent of total billed charges,
CADMIUM,8256343,CDM,300,RC,82300,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
CADMIUM,8256343,CDM,300,RC,82300,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,21.92,121.88,percent of total billed charges,
APTT,8256401,CDM,300,RC,85730,HCPCS,,,facility,inpatient,,,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,7.20,9.82,percent of total billed charges,
APTT,8256401,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,5.57,15.93,percent of total billed charges,
RUSSELL VIPER VENOM,8256402,CDM,300,RC,85613,HCPCS,,,facility,inpatient,,,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
RUSSELL VIPER VENOM,8256402,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,8.46,25.39,percent of total billed charges,
ANTITHROMBIN ANTIGEN,8256352,CDM,300,RC,85301,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
ANTITHROMBIN ANTIGEN,8256352,CDM,300,RC,85301,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,10.02,127.61,percent of total billed charges,
THC METABOLITE,8256239,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
THC METABOLITE,8256239,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,57.60,257.47,percent of total billed charges,
Marijuana Metabolite Umbilical Cord Qual,8858104,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
Marijuana Metabolite Umbilical Cord Qual,8858104,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,54.00,257.47,percent of total billed charges,
BILE ACIDS TOTAL,8256194,CDM,300,RC,82239,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
BILE ACIDS TOTAL,8256194,CDM,300,RC,82239,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,15.87,121.06,percent of total billed charges,
PHOSPHATIDYLSERINE ANTIBODY,8256361,CDM,300,RC,86148,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
PHOSPHATIDYLSERINE ANTIBODY,8256361,CDM,300,RC,86148,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,14.89,42.59,percent of total billed charges,
PHOSPHATIDYLSERINE ANTIBODY,8256368,CDM,300,RC,86148,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
PHOSPHATIDYLSERINE ANTIBODY,8256368,CDM,300,RC,86148,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,14.89,42.59,percent of total billed charges,
FOLLICLE STIMULATION HORMONE,8256298,CDM,300,RC,83001,HCPCS,,,facility,inpatient,,,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,45.60,62.17,percent of total billed charges,
FOLLICLE STIMULATION HORMONE,8256298,CDM,300,RC,83001,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,17.22,62.17,percent of total billed charges,
Luteinizing Hormone and Follicle Stimulating Hormone,8256271,CDM,300,RC,83002,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Luteinizing Hormone and Follicle Stimulating Hormone,8256271,CDM,300,RC,83002,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,17.17,61.35,percent of total billed charges,
ALCOHOLS BIOMARKERS 1OR 2,8256155,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
ALCOHOLS BIOMARKERS 1OR 2,8256155,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,58.80,257.47,percent of total billed charges,
HEPATITIS B SURFACE AB,8260195,CDM,300,RC,86706,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
HEPATITIS B SURFACE AB,8260195,CDM,300,RC,86706,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,9.96,126.79,percent of total billed charges,
MERCURY,8260166,CDM,300,RC,83825,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
MERCURY,8260166,CDM,300,RC,83825,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,15.07,118.61,percent of total billed charges,
ASSAY NEPHELOMETRY NOT SPEC,8134947,CDM,300,RC,83883,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
ASSAY NEPHELOMETRY NOT SPEC,8134947,CDM,300,RC,83883,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,12.61,112.88,percent of total billed charges,
LYME DISEASE ANTIBODY,8134951,CDM,300,RC,86617,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
LYME DISEASE ANTIBODY,8134951,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,14.36,120.25,percent of total billed charges,
TISSUE CULTURE BONE MARROW,8134954,CDM,300,RC,88237,HCPCS,,,facility,inpatient,,,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,122.40,166.87,percent of total billed charges,
TISSUE CULTURE BONE MARROW,8134954,CDM,300,RC,88237,HCPCS,,,facility,outpatient,,,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,32.36,380.94,percent of total billed charges,
Ehrlichia Addl,8229208,CDM,300,RC,86666,HCPCS,,,facility,inpatient,,,66.00000,19.14000,Aetna,First Health,GY,53.99,,,,,,,39.60,53.99,percent of total billed charges,
Ehrlichia Addl,8229208,CDM,300,RC,86666,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,First Health,GY,53.99,,,,,,,9.43,53.99,percent of total billed charges,
Methotrexate Level Addl,8229175,CDM,300,RC,80299,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,GY,111.25,,,,,,,81.60,111.25,percent of total billed charges,
Methotrexate Level Addl,8229175,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,GY,111.25,,,,,,,17.28,111.25,percent of total billed charges,
Mycoplasma pneumoniae Ab Addl,8229211,CDM,300,RC,86738,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,GY,114.52,,,,,,,84.00,114.52,percent of total billed charges,
Mycoplasma pneumoniae Ab Addl,8229211,CDM,300,RC,86738,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,GY,114.52,,,,,,,12.28,114.52,percent of total billed charges,
Mycoplasma pneumoniae Ab Addl,8229210,CDM,300,RC,86738,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,GY,114.52,,,,,,,84.00,114.52,percent of total billed charges,
Mycoplasma pneumoniae Ab Addl,8229210,CDM,300,RC,86738,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,GY,114.52,,,,,,,12.28,114.52,percent of total billed charges,
Warfarin Level Addl,8229171,CDM,300,RC,80299,HCPCS,,,facility,inpatient,,,185.00000,53.65000,Aetna,First Health,GY,151.33,,,,,,,111.00,151.33,percent of total billed charges,
Warfarin Level Addl,8229171,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,185.00000,53.65000,Aetna,First Health,GY,151.33,,,,,,,17.28,151.33,percent of total billed charges,
Drug Screen CMH Urine Addl,8229180,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,243.00000,70.47000,Aetna,First Health,GY,198.77,,,,,,,145.80,198.77,percent of total billed charges,
Drug Screen CMH Urine Addl,8229180,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,243.00000,70.47000,Aetna,First Health,GY,198.77,,,,,,,87.60,198.77,percent of total billed charges,
Ehrlichia Addl,8229209,CDM,300,RC,86666,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,GY,116.97,,,,,,,85.80,116.97,percent of total billed charges,
Ehrlichia Addl,8229209,CDM,300,RC,86666,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,GY,116.97,,,,,,,9.43,116.97,percent of total billed charges,
Itraconizole Quant Addl,8229174,CDM,300,RC,80299,HCPCS,,,facility,inpatient,,,161.00000,46.69000,Aetna,First Health,GY,131.70,,,,,,,96.60,131.70,percent of total billed charges,
Itraconizole Quant Addl,8229174,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,First Health,GY,131.70,,,,,,,17.28,131.70,percent of total billed charges,
Bartonella Addl,8229206,CDM,300,RC,86611,HCPCS,,,facility,inpatient,,,37.00000,10.73000,Aetna,First Health,GY,30.27,,,,,,,22.20,30.27,percent of total billed charges,
Bartonella Addl,8229206,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,First Health,GY,30.27,,,,,,,9.43,30.27,percent of total billed charges,
Bartonella Addl,8229207,CDM,300,RC,86611,HCPCS,,,facility,inpatient,,,76.00000,22.04000,Aetna,First Health,GY,62.17,,,,,,,45.60,62.17,percent of total billed charges,
Bartonella Addl,8229207,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,First Health,GY,62.17,,,,,,,9.43,62.17,percent of total billed charges,
Voriconazole Quant Addl,8229172,CDM,300,RC,80299,HCPCS,,,facility,inpatient,,,161.00000,46.69000,Aetna,First Health,GY,131.70,,,,,,,96.60,131.70,percent of total billed charges,
Voriconazole Quant Addl,8229172,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,First Health,GY,131.70,,,,,,,17.28,131.70,percent of total billed charges,
T3 Uptake Addl,8229197,CDM,300,RC,84479,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,GY,121.06,,,,,,,88.80,121.06,percent of total billed charges,
T3 Uptake Addl,8229197,CDM,300,RC,84479,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,GY,121.06,,,,,,,5.99,121.06,percent of total billed charges,
Kappa Lambda Light Chain Addl,8230207,CDM,300,RC,83883,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Kappa Lambda Light Chain Addl,8230207,CDM,300,RC,83883,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,12.61,112.88,percent of total billed charges,
Assay Nephelometry Not Spec Addl,8230208,CDM,300,RC,83883,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Assay Nephelometry Not Spec Addl,8230208,CDM,300,RC,83883,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,12.61,112.88,percent of total billed charges,
Kappa Lambda Quant Addl,8230209,CDM,300,RC,83883,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Kappa Lambda Quant Addl,8230209,CDM,300,RC,83883,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,12.61,112.88,percent of total billed charges,
Legionella Culture Addl,8230224,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
Legionella Culture Addl,8230224,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,6.15,114.52,percent of total billed charges,
87081 Carbapenem Resistant Organism,8388216,CDM,300,RC,87081,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
87081 Carbapenem Resistant Organism,8388216,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,6.15,114.52,percent of total billed charges,
Allergens Food Common Adult Food IgE Addl,8231054,CDM,300,RC,82785,HCPCS,,,facility,inpatient,,,42.00000,12.18000,Aetna,First Health,GY,34.36,,,,,,,25.20,34.36,percent of total billed charges,
Allergens Food Common Adult Food IgE Addl,8231054,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,First Health,GY,34.36,,,,,,,8.18,34.36,percent of total billed charges,
ALLERGENS LATEX CROSS REACTIVE FOOD PANEL IGE,8280364,CDM,300,RC,82785,HCPCS,,,facility,inpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,25.20,34.36,percent of total billed charges,
ALLERGENS LATEX CROSS REACTIVE FOOD PANEL IGE,8280364,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,8.18,43.62,percent of total billed charges,
Immunoglobulin E Addl,8231055,CDM,300,RC,82785,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,GY,121.88,,,,,,,89.40,121.88,percent of total billed charges,
Immunoglobulin E Addl,8231055,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,GY,121.88,,,,,,,8.18,121.88,percent of total billed charges,
Lupus Anticoagulant Reflexive Panel Addl,8231057,CDM,300,RC,85613,HCPCS,,,facility,inpatient,,,65.00000,18.85000,Aetna,First Health,GY,53.17,,,,,,,39.00,53.17,percent of total billed charges,
Lupus Anticoagulant Reflexive Panel Addl,8231057,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,First Health,GY,53.17,,,,,,,8.88,53.17,percent of total billed charges,
DRVVT 1to1 Mix Bill Addl,8231058,CDM,300,RC,85613,HCPCS,,,facility,inpatient,,,22.00000,6.38000,Aetna,First Health,GY,18.00,,,,,,,13.20,18.00,percent of total billed charges,
DRVVT 1to1 Mix Bill Addl,8231058,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,First Health,GY,18.00,,,,,,,7.93,19.63,percent of total billed charges,
DRVVT Confirmation Bill Addl,8231059,CDM,300,RC,85613,HCPCS,,,facility,inpatient,,,32.00000,9.28000,Aetna,First Health,GY,26.18,,,,,,,19.20,26.18,percent of total billed charges,
DRVVT Confirmation Bill Addl,8231059,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,32.00000,9.28000,Aetna,First Health,GY,26.18,,,,,,,8.88,26.18,percent of total billed charges,
FACTOR VIII ACTIVITY,7935654,CDM,300,RC,85240,HCPCS,,,facility,inpatient,,,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,36.00,49.08,percent of total billed charges,
FACTOR VIII ACTIVITY,7935654,CDM,300,RC,85240,HCPCS,,,facility,outpatient,,,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,16.59,49.08,percent of total billed charges,
VON WILLEBRAND FACTOR ANTIGEN,7935648,CDM,300,RC,85246,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
VON WILLEBRAND FACTOR ANTIGEN,7935648,CDM,300,RC,85246,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,21.27,62.99,percent of total billed charges,
von Willebrand Panel with Reflex,9093115,CDM,300,RC,85246,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
von Willebrand Panel with Reflex,9093115,CDM,300,RC,85246,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,21.27,62.99,percent of total billed charges,
RISTOCETIN COFACTOR,7935655,CDM,300,RC,85245,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
RISTOCETIN COFACTOR,7935655,CDM,300,RC,85245,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,21.27,62.99,percent of total billed charges,
86671 S cerevisiae Antibody,7944540,CDM,300,RC,86671,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
86671 S cerevisiae Antibody,7944540,CDM,300,RC,86671,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,6.68,63.80,percent of total billed charges,
PHENYTOIN FREE,3206883,CDM,300,RC,80186,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
PHENYTOIN FREE,3206883,CDM,300,RC,80186,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,12.75,58.90,percent of total billed charges,
Protein,613045,CDM,300,RC,84156,HCPCS,,,facility,inpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,22.20,30.27,percent of total billed charges,
Protein,613045,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,3.40,30.27,percent of total billed charges,
Protein Electrophoresis Serum ARUP,7954220,CDM,300,RC,84155,HCPCS,,,facility,inpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,22.20,30.27,percent of total billed charges,
Protein Electrophoresis Serum ARUP,7954220,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,3.40,30.27,percent of total billed charges,
BARBITURATES,8260173,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,166.00000,48.14000,Aetna,First Health,,135.79,,,,,,,99.60,135.79,percent of total billed charges,
BARBITURATES,8260173,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,166.00000,48.14000,Aetna,First Health,,135.79,,,,,,,66.40,257.47,percent of total billed charges,
METHADONE,8260204,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
METHADONE,8260204,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,60.00,257.47,percent of total billed charges,
ZINC PROTOPORPHYINS,8261907,CDM,300,RC,84202,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
ZINC PROTOPORPHYINS,8261907,CDM,300,RC,84202,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,13.31,125.97,percent of total billed charges,
LEAD,8261920,CDM,300,RC,83655,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
LEAD,8261920,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,11.23,50.72,percent of total billed charges,
PROTOPORPHRYIN RBC,8261928,CDM,300,RC,84202,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
PROTOPORPHRYIN RBC,8261928,CDM,300,RC,84202,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,13.31,59.71,percent of total billed charges,
JAK2 V617F Mutation by ddPCR Quant ARUP ZB20D,8441771,CDM,300,RC,81270,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,351.00,478.53,percent of total billed charges,
JAK2 V617F Mutation by ddPCR Quant ARUP ZB20D,8441771,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,First Health,,478.53,,,,,,,84.96,478.53,percent of total billed charges,
EPSTEIN BARR CAPSID VCA,8261886,CDM,300,RC,86665,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
EPSTEIN BARR CAPSID VCA,8261886,CDM,300,RC,86665,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,16.82,118.61,percent of total billed charges,
RUBELLA ANTIBODY,8261893,CDM,300,RC,86762,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
RUBELLA ANTIBODY,8261893,CDM,300,RC,86762,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,13.34,62.99,percent of total billed charges,
RUBELLA ANTIBODY,8261896,CDM,300,RC,86762,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
RUBELLA ANTIBODY,8261896,CDM,300,RC,86762,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,13.34,62.99,percent of total billed charges,
ALPHA THALASSEMIA HBA1 AND HBA2 BILL ZB2QF,8265946,CDM,300,RC,81259,HCPCS,,,facility,inpatient,,,1139.00000,330.31000,Aetna,First Health,,931.70,,,,,,,683.40,931.70,percent of total billed charges,
ALPHA THALASSEMIA HBA1 AND HBA2 BILL ZB2QF,8265946,CDM,300,RC,81259,HCPCS,,,facility,outpatient,,,1139.00000,330.31000,Aetna,First Health,,931.70,,,,,,,535.33,1590.00,percent of total billed charges,
FACTOR XIII ACTIVITY,8264144,CDM,300,RC,85290,HCPCS,,,facility,inpatient,,,242.00000,70.18000,Aetna,First Health,,197.96,,,,,,,145.20,197.96,percent of total billed charges,
FACTOR XIII ACTIVITY,8264144,CDM,300,RC,85290,HCPCS,,,facility,outpatient,,,242.00000,70.18000,Aetna,First Health,,197.96,,,,,,,15.15,197.96,percent of total billed charges,
ALPHA GLOBIN HBA1 AND HBA2 DD ZB2R0,8265964,CDM,300,RC,81269,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,228.00,310.84,percent of total billed charges,
ALPHA GLOBIN HBA1 AND HBA2 DD ZB2R0,8265964,CDM,300,RC,81269,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,First Health,,310.84,,,,,,,178.60,536.36,percent of total billed charges,
BETA GLOBIN GENE SEQUENCING ZB2QI,8265937,CDM,300,RC,81364,HCPCS,,,facility,inpatient,,,1000.00000,290.00000,Aetna,First Health,,818.00,,,,,,,600.00,818.00,percent of total billed charges,
BETA GLOBIN GENE SEQUENCING ZB2QI,8265937,CDM,300,RC,81364,HCPCS,,,facility,outpatient,,,1000.00000,290.00000,Aetna,First Health,,818.00,,,,,,,300.88,860.14,percent of total billed charges,
BETA GLOBIN DEL DUP ZB34A,8265973,CDM,300,RC,81363,HCPCS,,,facility,inpatient,,,858.00000,248.82000,Aetna,First Health,,701.84,,,,,,,514.80,701.84,percent of total billed charges,
BETA GLOBIN DEL DUP ZB34A,8265973,CDM,300,RC,81363,HCPCS,,,facility,outpatient,,,858.00000,248.82000,Aetna,First Health,,701.84,,,,,,,187.62,701.84,percent of total billed charges,
PHOSPHOLIPASE A2 RECEPTOR,8265846,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,234.00000,67.86000,Aetna,First Health,,191.41,,,,,,,140.40,191.41,percent of total billed charges,
PHOSPHOLIPASE A2 RECEPTOR,8265846,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,234.00000,67.86000,Aetna,First Health,,191.41,,,,,,,11.18,191.41,percent of total billed charges,
PHOSPHOLIPASE A2 RECEPTOR AB TITER,8265864,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
PHOSPHOLIPASE A2 RECEPTOR AB TITER,8265864,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,11.18,194.68,percent of total billed charges,
FACTOR II,8264135,CDM,300,RC,85210,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
FACTOR II,8264135,CDM,300,RC,85210,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,12.03,124.34,percent of total billed charges,
ASSAY OF BLOOD LIPOPROTEIN,8280653,CDM,300,RC,83721,HCPCS,,,facility,inpatient,,,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
ASSAY OF BLOOD LIPOPROTEIN,8280653,CDM,300,RC,83721,HCPCS,,,facility,outpatient,,,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,9.73,29.45,percent of total billed charges,
ANCA ASSOCIATE VASCULITIS PROFILE,8442123,CDM,300,RC,86036,HCPCS,,,facility,inpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,30.60,41.72,percent of total billed charges,
ANCA ASSOCIATE VASCULITIS PROFILE,8442123,CDM,300,RC,86036,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,11.18,41.72,percent of total billed charges,
CREATINE KINASE MB,8263974,CDM,300,RC,82553,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
CREATINE KINASE MB,8263974,CDM,300,RC,82553,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,10.71,122.70,percent of total billed charges,
CREATINE MB FRACTION,8948138,CDM,300,RC,82553,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
CREATINE MB FRACTION,8948138,CDM,300,RC,82553,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,10.71,122.70,percent of total billed charges,
TESTOSTERONE FREE,8271845,CDM,300,RC,84402,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
TESTOSTERONE FREE,8271845,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,23.61,120.25,percent of total billed charges,
TESTOSTERONE FREE,8275891,CDM,300,RC,84402,HCPCS,,,facility,inpatient,,,49.00000,14.21000,Aetna,First Health,,40.08,,,,,,,29.40,40.08,percent of total billed charges,
TESTOSTERONE FREE,8275891,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,49.00000,14.21000,Aetna,First Health,,40.08,,,,,,,23.03,67.50,percent of total billed charges,
TESTOSTERONE TOTAL,8275884,CDM,300,RC,84403,HCPCS,,,facility,inpatient,,,49.00000,14.21000,Aetna,First Health,,40.08,,,,,,,29.40,40.08,percent of total billed charges,
TESTOSTERONE TOTAL,8275884,CDM,300,RC,84403,HCPCS,,,facility,outpatient,,,49.00000,14.21000,Aetna,First Health,,40.08,,,,,,,23.03,68.40,percent of total billed charges,
THYROXINE FREE,8270389,CDM,300,RC,84439,HCPCS,,,facility,inpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,83.40,113.70,percent of total billed charges,
THYROXINE FREE,8270389,CDM,300,RC,84439,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,8.36,113.70,percent of total billed charges,
HSV TYPING,8277910,CDM,300,RC,87140,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
HSV TYPING,8277910,CDM,300,RC,87140,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,5.16,61.35,percent of total billed charges,
Herpes Simplex Virus Typing,8387181,CDM,300,RC,87140,HCPCS,,,facility,inpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,43.20,58.90,percent of total billed charges,
Herpes Simplex Virus Typing,8387181,CDM,300,RC,87140,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,5.16,58.90,percent of total billed charges,
ESTRADIOL BY TMS,8270382,CDM,300,RC,82670,HCPCS,,,facility,inpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,83.40,113.70,percent of total billed charges,
ESTRADIOL BY TMS,8270382,CDM,300,RC,82670,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,25.90,113.70,percent of total billed charges,
PNEUMOCYSTIC CARANII AG IF,3209027,CDM,300,RC,87015,HCPCS,,,facility,inpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,31.20,42.54,percent of total billed charges,
PNEUMOCYSTIC CARANII AG IF,3209027,CDM,300,RC,87015,HCPCS,,,facility,outpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,6.19,42.54,percent of total billed charges,
P JIROVECII,8270277,CDM,300,RC,87281,HCPCS,,,facility,inpatient,,,93.00000,26.97000,Aetna,First Health,,76.07,,,,,,,55.80,76.07,percent of total billed charges,
P JIROVECII,8270277,CDM,300,RC,87281,HCPCS,,,facility,outpatient,,,93.00000,26.97000,Aetna,First Health,,76.07,,,,,,,11.10,76.07,percent of total billed charges,
TESTOSTERONE FREE,3190870,CDM,300,RC,84402,HCPCS,,,facility,inpatient,,,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,33.00,44.99,percent of total billed charges,
TESTOSTERONE FREE,3190870,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,23.61,67.50,percent of total billed charges,
TESTOSTERONE FREE,3481853,CDM,300,RC,84402,HCPCS,,,facility,inpatient,,,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,33.00,44.99,percent of total billed charges,
TESTOSTERONE FREE,3481853,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,23.61,67.50,percent of total billed charges,
TESTOSTERONE FREE,4907839,CDM,300,RC,84402,HCPCS,,,facility,inpatient,,,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,33.00,44.99,percent of total billed charges,
TESTOSTERONE FREE,4907839,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,23.61,67.50,percent of total billed charges,
TESTOSTERONE TOTAL,8270312,CDM,300,RC,84403,HCPCS,,,facility,inpatient,,,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,33.00,44.99,percent of total billed charges,
TESTOSTERONE TOTAL,8270312,CDM,300,RC,84403,HCPCS,,,facility,outpatient,,,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,23.93,68.40,percent of total billed charges,
SHGB,8270313,CDM,300,RC,84270,HCPCS,,,facility,inpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,28.20,38.45,percent of total billed charges,
SHGB,8270313,CDM,300,RC,84270,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,20.15,57.58,percent of total billed charges,
CNS DEMYELINATING DISEASE EVAL PANEL,8277875,CDM,300,RC,86363,HCPCS,,,facility,inpatient,,,759.00000,220.11000,Aetna,First Health,,620.86,,,,,,,455.40,620.86,percent of total billed charges,
CNS DEMYELINATING DISEASE EVAL PANEL,8277875,CDM,300,RC,86363,HCPCS,,,facility,outpatient,,,759.00000,220.11000,Aetna,First Health,,620.86,,,,,,,34.98,620.86,percent of total billed charges,
AUTOIMMUNE MYELOPATHY EVAL CSF,8278488,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
AUTOIMMUNE MYELOPATHY EVAL CSF,8278488,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,21.85,194.68,percent of total billed charges,
ASSAY OF CPK IN BLOOD,8280607,CDM,300,RC,82552,HCPCS,,,facility,inpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,63.00,85.89,percent of total billed charges,
ASSAY OF CPK IN BLOOD,8280607,CDM,300,RC,82552,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,11.51,85.89,percent of total billed charges,
ASSAY OF CK CPK,8280652,CDM,300,RC,82550,HCPCS,,,facility,inpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,31.20,42.54,percent of total billed charges,
ASSAY OF CK CPK,8280652,CDM,300,RC,82550,HCPCS,,,facility,outpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,6.04,42.54,percent of total billed charges,
ENCEPHALOPATHY ABS,8278756,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,36.60,49.90,percent of total billed charges,
ENCEPHALOPATHY ABS,8278756,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,11.18,49.90,percent of total billed charges,
ASSAY OF CHROMIUM,8280575,CDM,300,RC,82495,HCPCS,,,facility,inpatient,,,544.00000,157.76000,Aetna,First Health,,444.99,,,,,,,326.40,444.99,percent of total billed charges,
ASSAY OF CHROMIUM,8280575,CDM,300,RC,82495,HCPCS,,,facility,outpatient,,,544.00000,157.76000,Aetna,First Health,,444.99,,,,,,,18.80,444.99,percent of total billed charges,
ASSAY OF ARSENIC,8286211,CDM,300,RC,82175,HCPCS,,,facility,inpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,25.20,34.36,percent of total billed charges,
ASSAY OF ARSENIC,8286211,CDM,300,RC,82175,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,17.58,50.27,percent of total billed charges,
ASSAY OF CADMIUM,8286181,CDM,300,RC,82300,HCPCS,,,facility,inpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,31.20,42.54,percent of total billed charges,
ASSAY OF CADMIUM,8286181,CDM,300,RC,82300,HCPCS,,,facility,outpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,21.92,62.65,percent of total billed charges,
ASSAY OF LEAD,8286212,CDM,300,RC,83655,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
ASSAY OF LEAD,8286212,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,11.23,32.09,percent of total billed charges,
ASSAY OF MERCURY,8286213,CDM,300,RC,83825,HCPCS,,,facility,inpatient,,,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
ASSAY OF MERCURY,8286213,CDM,300,RC,83825,HCPCS,,,facility,outpatient,,,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,15.07,43.09,percent of total billed charges,
Urine Protein,8310239,CDM,300,RC,84156,HCPCS,,,facility,inpatient,,,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,9.00,12.27,percent of total billed charges,
Urine Protein,8310239,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,3.40,12.27,percent of total billed charges,
84156 Total Protein Urine,8975473,CDM,300,RC,84156,HCPCS,,,facility,inpatient,,,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,9.00,12.27,percent of total billed charges,
84156 Total Protein Urine,8975473,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,3.40,12.27,percent of total billed charges,
Immunofixation,8310248,CDM,300,RC,86335,HCPCS,,,facility,inpatient,,,113.00000,32.77000,Aetna,First Health,,92.43,,,,,,,67.80,92.43,percent of total billed charges,
Immunofixation,8310248,CDM,300,RC,86335,HCPCS,,,facility,outpatient,,,113.00000,32.77000,Aetna,First Health,,92.43,,,,,,,27.21,92.43,percent of total billed charges,
Immunoassay Quant Urine,8310249,CDM,300,RC,83521,HCPCS,,,facility,inpatient,,,68.00000,19.72000,Aetna,First Health,,55.62,,,,,,,40.80,55.62,percent of total billed charges,
Immunoassay Quant Urine,8310249,CDM,300,RC,83521,HCPCS,,,facility,outpatient,,,68.00000,19.72000,Aetna,First Health,,55.62,,,,,,,16.01,55.62,percent of total billed charges,
Coronavirus 2019 SARS Cov2,8334462,CDM,300,RC,87635,HCPCS,,,facility,inpatient,,,198.00000,57.42000,Aetna,First Health,,161.96,,,,,,,118.80,161.96,percent of total billed charges,
Coronavirus 2019 SARS Cov2,8334462,CDM,300,RC,87635,HCPCS,,,facility,outpatient,,,198.00000,57.42000,Aetna,First Health,,161.96,,,,,,,47.57,161.96,percent of total billed charges,
HERPES SIMPLEX NES ANTBDY,8286182,CDM,300,RC,86694,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
HERPES SIMPLEX NES ANTBDY,8286182,CDM,300,RC,86694,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,13.34,121.88,percent of total billed charges,
Culture Cytomegalovirus Rapid,8387022,CDM,300,RC,87254,HCPCS,,,facility,inpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,105.00,143.15,percent of total billed charges,
Culture Cytomegalovirus Rapid,8387022,CDM,300,RC,87254,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,First Health,,143.15,,,,,,,18.13,143.15,percent of total billed charges,
Serum Protein Electrophoresis with Reflex ARUP,7954544,CDM,300,RC,84155,HCPCS,,,facility,inpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,22.20,30.27,percent of total billed charges,
Serum Protein Electrophoresis with Reflex ARUP,7954544,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,3.40,30.27,percent of total billed charges,
SPEP,8344350,CDM,300,RC,84165,HCPCS,,,facility,inpatient,,,112.00000,32.48000,Aetna,First Health,,91.62,,,,,,,67.20,91.62,percent of total billed charges,
SPEP,8344350,CDM,300,RC,84165,HCPCS,,,facility,outpatient,,,112.00000,32.48000,Aetna,First Health,,91.62,,,,,,,9.96,91.62,percent of total billed charges,
Immunofix Electrophoresis Bill,7954558,CDM,300,RC,86334,HCPCS,,,facility,inpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,76.20,103.89,percent of total billed charges,
Immunofix Electrophoresis Bill,7954558,CDM,300,RC,86334,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,20.71,103.89,percent of total billed charges,
GIARDIA AG IA,8372350,CDM,300,RC,87329,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
GIARDIA AG IA,8372350,CDM,300,RC,87329,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,11.10,122.70,percent of total billed charges,
CRYPTOSPORIDIUM AG IA,8372351,CDM,300,RC,87328,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
CRYPTOSPORIDIUM AG IA,8372351,CDM,300,RC,87328,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,12.81,128.43,percent of total billed charges,
PROTEIN WESTERN BLOT TEST,8372349,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,59.00000,17.11000,Aetna,First Health,,48.26,,,,,,,35.40,48.26,percent of total billed charges,
PROTEIN WESTERN BLOT TEST,8372349,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,59.00000,17.11000,Aetna,First Health,,48.26,,,,,,,23.95,77.41,percent of total billed charges,
PROTEIN WESTERN BLOT TEST,8372367,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,59.00000,17.11000,Aetna,First Health,,48.26,,,,,,,35.40,48.26,percent of total billed charges,
PROTEIN WESTERN BLOT TEST,8372367,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,59.00000,17.11000,Aetna,First Health,,48.26,,,,,,,23.95,77.41,percent of total billed charges,
AFB Culture,8387232,CDM,300,RC,87116,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
AFB Culture,8387232,CDM,300,RC,87116,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,10.01,116.97,percent of total billed charges,
87206 AFB Stain ARUP,8388172,CDM,300,RC,87206,HCPCS,,,facility,inpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,20.40,27.81,percent of total billed charges,
87206 AFB Stain ARUP,8388172,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,5.00,27.81,percent of total billed charges,
SMEAR FLUORESCENT ACID STAI,8396254,CDM,300,RC,87206,HCPCS,,,facility,inpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,20.40,27.81,percent of total billed charges,
SMEAR FLUORESCENT ACID STAI,8396254,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,5.00,27.81,percent of total billed charges,
Bill AFB Concentration 2010182 ARUP,8388840,CDM,300,RC,87015,HCPCS,,,facility,inpatient,,,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,19.80,26.99,percent of total billed charges,
Bill AFB Concentration 2010182 ARUP,8388840,CDM,300,RC,87015,HCPCS,,,facility,outpatient,,,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,6.19,26.99,percent of total billed charges,
Bill M tuberculosis by DNA Probe 60459 ARUP,8388846,CDM,300,RC,87149,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
Bill M tuberculosis by DNA Probe 60459 ARUP,8388846,CDM,300,RC,87149,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,15.50,53.13,percent of total billed charges,
Bill AFB ID by DNA Sequencing 61208 ARUP,8388852,CDM,300,RC,87153,HCPCS,,,facility,inpatient,,,266.00000,77.14000,Aetna,First Health,,217.59,,,,,,,159.60,217.59,percent of total billed charges,
Bill AFB ID by DNA Sequencing 61208 ARUP,8388852,CDM,300,RC,87153,HCPCS,,,facility,outpatient,,,266.00000,77.14000,Aetna,First Health,,217.59,,,,,,,106.93,305.70,percent of total billed charges,
Bill M tuberculosis Susceptibility 60409 ARUP,8388858,CDM,300,RC,87188,HCPCS,,,facility,inpatient,,,349.00000,101.21000,Aetna,First Health,,285.48,,,,,,,209.40,285.48,percent of total billed charges,
Bill M tuberculosis Susceptibility 60409 ARUP,8388858,CDM,300,RC,87188,HCPCS,,,facility,outpatient,,,349.00000,101.21000,Aetna,First Health,,285.48,,,,,,,6.16,285.48,percent of total billed charges,
Bill Single Drug Susceptibility by Broth Dilution 62229 ARUP,8388864,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
Bill Single Drug Susceptibility by Broth Dilution 62229 ARUP,8388864,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,8.02,159.51,percent of total billed charges,
Bill AFB Nocardia Susceptibility by Broth Dilution,8388910,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
Bill AFB Nocardia Susceptibility by Broth Dilution,8388910,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,8.02,159.51,percent of total billed charges,
Bill AFB Isolation 60725 ARUP,8388877,CDM,300,RC,87015,HCPCS,,,facility,inpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,184.80,251.94,percent of total billed charges,
Bill AFB Isolation 60725 ARUP,8388877,CDM,300,RC,87015,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,6.19,251.94,percent of total billed charges,
Bill Ethambutol Resistance by Sequencing 2011789 ARUP,8388883,CDM,300,RC,87153,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,193.80,264.21,percent of total billed charges,
Bill Ethambutol Resistance by Sequencing 2011789 ARUP,8388883,CDM,300,RC,87153,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,106.93,305.70,percent of total billed charges,
Bill Fungal ID by MALDI TOF 2007693 ARUP,8388634,CDM,300,RC,83789,HCPCS,,,facility,inpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,112.20,152.97,percent of total billed charges,
Bill Fungal ID by MALDI TOF 2007693 ARUP,8388634,CDM,300,RC,83789,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,11.66,152.97,percent of total billed charges,
Bill AFB ID by MALDI 2009960 ARUP,8388889,CDM,300,RC,83789,HCPCS,,,facility,inpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,112.20,152.97,percent of total billed charges,
Bill AFB ID by MALDI 2009960 ARUP,8388889,CDM,300,RC,83789,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,11.66,152.97,percent of total billed charges,
87070 Unusual Organism Culture ARUP,8387278,CDM,300,RC,87070,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
87070 Unusual Organism Culture ARUP,8387278,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,7.99,122.70,percent of total billed charges,
87252 Respiratory Viral Culture,8388192,CDM,300,RC,87252,HCPCS,,,facility,inpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,109.20,148.88,percent of total billed charges,
87252 Respiratory Viral Culture,8388192,CDM,300,RC,87252,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,First Health,,148.88,,,,,,,24.16,148.88,percent of total billed charges,
87252 Non Respiratory Viral Culture,8388202,CDM,300,RC,87252,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
87252 Non Respiratory Viral Culture,8388202,CDM,300,RC,87252,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,24.16,125.97,percent of total billed charges,
Bill Tuberculosis species ID 2014218 ARUP,8388896,CDM,300,RC,87150,HCPCS,,,facility,inpatient,,,320.00000,92.80000,Aetna,First Health,,261.76,,,,,,,192.00,261.76,percent of total billed charges,
Bill Tuberculosis species ID 2014218 ARUP,8388896,CDM,300,RC,87150,HCPCS,,,facility,outpatient,,,320.00000,92.80000,Aetna,First Health,,261.76,,,,,,,32.53,261.76,percent of total billed charges,
Bill Histoplasma capsulatum DNA Probe ARUP,8388640,CDM,300,RC,87149,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Bill Histoplasma capsulatum DNA Probe ARUP,8388640,CDM,300,RC,87149,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,15.50,229.04,percent of total billed charges,
Bill Blastomyces dermatitdis DNA Probe ARUP,8388902,CDM,300,RC,87149,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Bill Blastomyces dermatitdis DNA Probe ARUP,8388902,CDM,300,RC,87149,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,15.50,229.04,percent of total billed charges,
Bill Coccidioides immitis DNA Probe ARUP,8388916,CDM,300,RC,87149,HCPCS,,,facility,inpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,168.00,229.04,percent of total billed charges,
Bill Coccidioides immitis DNA Probe ARUP,8388916,CDM,300,RC,87149,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,First Health,,229.04,,,,,,,15.50,229.04,percent of total billed charges,
Bill Viral Culture ID 2006696 ARUP,8388592,CDM,300,RC,87253,HCPCS,,,facility,inpatient,,,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,31.80,43.35,percent of total billed charges,
Bill Viral Culture ID 2006696 ARUP,8388592,CDM,300,RC,87253,HCPCS,,,facility,outpatient,,,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,18.73,53.53,percent of total billed charges,
DNA RNA SEQUENCING,8396257,CDM,300,RC,87153,HCPCS,,,facility,inpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,144.00,196.32,percent of total billed charges,
DNA RNA SEQUENCING,8396257,CDM,300,RC,87153,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,106.93,305.70,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396266,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396266,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,8.02,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396273,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396273,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,8.02,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396275,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396275,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,8.02,159.51,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396251,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396251,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396252,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396252,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396256,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396256,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396258,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396258,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396260,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396260,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396264,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396264,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396265,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396265,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396268,CDM,300,RC,87077,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396268,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,7.49,126.79,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396269,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396269,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,8.02,118.61,percent of total billed charges,
MICROBE SUSCEPTIBLE ENZYME,8396271,CDM,300,RC,87185,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
MICROBE SUSCEPTIBLE ENZYME,8396271,CDM,300,RC,87185,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,4.41,125.15,percent of total billed charges,
MICROBE SUSCEPTIBLE DISK,8396272,CDM,300,RC,87184,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
MICROBE SUSCEPTIBLE DISK,8396272,CDM,300,RC,87184,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,6.93,120.25,percent of total billed charges,
MICROBE SUSCEPTIBLE DISK,8396274,CDM,300,RC,87184,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
MICROBE SUSCEPTIBLE DISK,8396274,CDM,300,RC,87184,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,6.93,120.25,percent of total billed charges,
DNA RNA SEQUENCING,8396262,CDM,300,RC,87153,HCPCS,,,facility,inpatient,,,287.00000,83.23000,Aetna,First Health,,234.77,,,,,,,172.20,234.77,percent of total billed charges,
DNA RNA SEQUENCING,8396262,CDM,300,RC,87153,HCPCS,,,facility,outpatient,,,287.00000,83.23000,Aetna,First Health,,234.77,,,,,,,106.93,305.70,percent of total billed charges,
MICROBE SUSCEPTIBLE DIFFUSE,8396279,CDM,300,RC,87181,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE DIFFUSE,8396279,CDM,300,RC,87181,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,4.41,159.51,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396253,CDM,300,RC,83789,HCPCS,,,facility,inpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,112.20,152.97,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396253,CDM,300,RC,83789,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,11.66,152.97,percent of total billed charges,
CULTURE ANAEROBE IDENT EACH,8396255,CDM,300,RC,83789,HCPCS,,,facility,inpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,112.20,152.97,percent of total billed charges,
CULTURE ANAEROBE IDENT EACH,8396255,CDM,300,RC,83789,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,11.66,152.97,percent of total billed charges,
MR STAPH DNA AMP PROBE,8396281,CDM,300,RC,87641,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,144.60,197.14,percent of total billed charges,
MR STAPH DNA AMP PROBE,8396281,CDM,300,RC,87641,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,32.53,197.14,percent of total billed charges,
MICROBE SUSCEPTIBLE ENZYME,8396276,CDM,300,RC,87184,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
MICROBE SUSCEPTIBLE ENZYME,8396276,CDM,300,RC,87184,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,6.93,120.25,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396277,CDM,300,RC,87147,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396277,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,4.80,117.79,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396267,CDM,300,RC,87147,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396267,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,4.80,121.88,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396270,CDM,300,RC,87147,HCPCS,,,facility,inpatient,,,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,131.40,179.14,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396270,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,4.80,179.14,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396259,CDM,300,RC,87147,HCPCS,,,facility,inpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,82.20,112.07,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396259,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,First Health,,112.07,,,,,,,4.80,112.07,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396263,CDM,300,RC,87147,HCPCS,,,facility,inpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,86.40,117.79,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396263,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,4.80,117.79,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396280,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,279.00000,80.91000,Aetna,First Health,,228.22,,,,,,,167.40,228.22,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396280,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,279.00000,80.91000,Aetna,First Health,,228.22,,,,,,,8.02,228.22,percent of total billed charges,
FUNGI IDENTIFICATION YEAST,8396278,CDM,300,RC,87106,HCPCS,,,facility,inpatient,,,207.00000,60.03000,Aetna,First Health,,169.33,,,,,,,124.20,169.33,percent of total billed charges,
FUNGI IDENTIFICATION YEAST,8396278,CDM,300,RC,87106,HCPCS,,,facility,outpatient,,,207.00000,60.03000,Aetna,First Health,,169.33,,,,,,,9.57,169.33,percent of total billed charges,
FUNGI IDENTIFICATION MOLD,8396261,CDM,300,RC,87107,HCPCS,,,facility,inpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,144.00,196.32,percent of total billed charges,
FUNGI IDENTIFICATION MOLD,8396261,CDM,300,RC,87107,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,9.57,196.32,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396469,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,136.80,186.50,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396469,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,8.02,186.50,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396560,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396560,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,8.02,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MLC,8396561,CDM,300,RC,87187,HCPCS,,,facility,inpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,117.00,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MLC,8396561,CDM,300,RC,87187,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,First Health,,159.51,,,,,,,9.53,159.51,percent of total billed charges,
Herpes Simplex Virus by PCR Neonate,8398281,CDM,300,RC,87529,HCPCS,,,facility,inpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,142.20,193.87,percent of total billed charges,
Herpes Simplex Virus by PCR Neonate,8398281,CDM,300,RC,87529,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,32.53,193.87,percent of total billed charges,
IMMUNOASSAY QUANT NOS NONAB,8410360,CDM,300,RC,83529,HCPCS,,,facility,inpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,127.20,173.42,percent of total billed charges,
IMMUNOASSAY QUANT NOS NONAB,8410360,CDM,300,RC,83529,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,16.01,173.42,percent of total billed charges,
Immunofixation Electrophoresis Serum,8414194,CDM,300,RC,86334,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Immunofixation Electrophoresis Serum,8414194,CDM,300,RC,86334,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,20.71,125.15,percent of total billed charges,
Lysozyme Serum,8414204,CDM,300,RC,85549,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Lysozyme Serum,8414204,CDM,300,RC,85549,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,17.39,125.15,percent of total billed charges,
Bill 88280 Cytogenetics CSI,8415387,CDM,300,RC,88280,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Bill 88280 Cytogenetics CSI,8415387,CDM,300,RC,88280,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,31.02,125.15,percent of total billed charges,
Bill 88368 FISH CSI,8415380,CDM,300,RC,88368,HCPCS,,,facility,inpatient,,,277.00000,80.33000,Aetna,First Health,,226.59,,,,,,,166.20,226.59,percent of total billed charges,
Bill 88368 FISH CSI,8415380,CDM,300,RC,88368,HCPCS,,,facility,outpatient,,,277.00000,80.33000,Aetna,First Health,,226.59,,,,,,,130.19,951.40,percent of total billed charges,
T Cell receptor Beta Gene Rearrangement CSI ZB4IH,8415408,CDM,300,RC,81340,HCPCS,,,facility,inpatient,,,425.00000,123.25000,Aetna,First Health,,347.65,,,,,,,255.00,347.65,percent of total billed charges,
T Cell receptor Beta Gene Rearrangement CSI ZB4IH,8415408,CDM,300,RC,81340,HCPCS,,,facility,outpatient,,,425.00000,123.25000,Aetna,First Health,,347.65,,,,,,,193.67,553.64,percent of total billed charges,
IDH IDH2 Mutation Detection CSI ZBA8A,8415399,CDM,300,RC,81479,HCPCS,,,facility,inpatient,,,451.00000,130.79000,Aetna,First Health,,368.92,,,,,,,270.60,368.92,percent of total billed charges,
IDH IDH2 Mutation Detection CSI ZBA8A,8415399,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,451.00000,130.79000,Aetna,First Health,,368.92,,,,,,,162.59,368.92,percent of total billed charges,
B Cell IGK Gene Rearrangement CSI ZB4I6,8415440,CDM,300,RC,81264,HCPCS,,,facility,inpatient,,,256.00000,74.24000,Aetna,First Health,,209.41,,,,,,,153.60,209.41,percent of total billed charges,
B Cell IGK Gene Rearrangement CSI ZB4I6,8415440,CDM,300,RC,81264,HCPCS,,,facility,outpatient,,,256.00000,74.24000,Aetna,First Health,,209.41,,,,,,,120.32,457.73,percent of total billed charges,
Bill 88182 Flow Cytometry Marker CSI,8415393,CDM,300,RC,88182,HCPCS,,,facility,inpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,148.80,202.86,percent of total billed charges,
Bill 88182 Flow Cytometry Marker CSI,8415393,CDM,300,RC,88182,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,46.92,202.86,percent of total billed charges,
Bill 88261 Cytogenetics CSI,8415374,CDM,300,RC,88261,HCPCS,,,facility,inpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,142.20,193.87,percent of total billed charges,
Bill 88261 Cytogenetics CSI,8415374,CDM,300,RC,88261,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,111.39,700.50,percent of total billed charges,
MYD88 Mutation Analysis CSI ZBA0X,8415570,CDM,300,RC,81479,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
MYD88 Mutation Analysis CSI ZBA0X,8415570,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,91.93,208.59,percent of total billed charges,
MGMT Promoter Methylation CSI ZB2O2,8415564,CDM,300,RC,81287,HCPCS,,,facility,inpatient,,,298.00000,86.42000,Aetna,First Health,,243.76,,,,,,,178.80,243.76,percent of total billed charges,
MGMT Promoter Methylation CSI ZB2O2,8415564,CDM,300,RC,81287,HCPCS,,,facility,outpatient,,,298.00000,86.42000,Aetna,First Health,,243.76,,,,,,,115.55,330.30,percent of total billed charges,
IGVH Mutation Analysis CSI ZBX4C,8415485,CDM,300,RC,81263,HCPCS,,,facility,inpatient,,,587.00000,170.23000,Aetna,First Health,,480.17,,,,,,,352.20,480.17,percent of total billed charges,
IGVH Mutation Analysis CSI ZBX4C,8415485,CDM,300,RC,81263,HCPCS,,,facility,outpatient,,,587.00000,170.23000,Aetna,First Health,,480.17,,,,,,,273.02,780.48,percent of total billed charges,
MPL Mutation CSI ZB51I,8415578,CDM,300,RC,81338,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,138.60,188.96,percent of total billed charges,
MPL Mutation CSI ZB51I,8415578,CDM,300,RC,81338,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,108.57,398.37,percent of total billed charges,
Hematology Complete Profile CSI Z01VW,8415585,CDM,300,RC,81455,HCPCS,,,facility,inpatient,,,3230.00000,936.70000,Aetna,First Health,,2642.14,,,,,,,1938.00,2642.14,percent of total billed charges,
Hematology Complete Profile CSI Z01VW,8415585,CDM,300,RC,81455,HCPCS,,,facility,outpatient,,,3230.00000,936.70000,Aetna,First Health,,2642.14,,,,,,,1518.10,7736.94,percent of total billed charges,
CALR Mutation CSI ZB51H,8415680,CDM,300,RC,81219,HCPCS,,,facility,inpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,127.80,174.23,percent of total billed charges,
CALR Mutation CSI ZB51H,8415680,CDM,300,RC,81219,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,100.11,322.32,percent of total billed charges,
PDGFRA CSI ZB3Y2,8415686,CDM,300,RC,81314,HCPCS,,,facility,inpatient,,,383.00000,111.07000,Aetna,First Health,,313.29,,,,,,,229.80,313.29,percent of total billed charges,
PDGFRA CSI ZB3Y2,8415686,CDM,300,RC,81314,HCPCS,,,facility,outpatient,,,383.00000,111.07000,Aetna,First Health,,313.29,,,,,,,180.01,873.20,percent of total billed charges,
Bill 88230 Cytogenetics CSI,8415798,CDM,300,RC,88230,HCPCS,,,facility,inpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,142.20,193.87,percent of total billed charges,
Bill 88230 Cytogenetics CSI,8415798,CDM,300,RC,88230,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,32.36,308.70,percent of total billed charges,
Bill 88285 Cytogenetics CSI,8415804,CDM,300,RC,88285,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Bill 88285 Cytogenetics CSI,8415804,CDM,300,RC,88285,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,24.95,125.15,percent of total billed charges,
Bill 88271 Cytogentics CSI,8415812,CDM,300,RC,88271,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
Bill 88271 Cytogentics CSI,8415812,CDM,300,RC,88271,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,19.86,125.97,percent of total billed charges,
STRIATED MUSCLE AB SCREEN,7117845,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,34.80,47.44,percent of total billed charges,
STRIATED MUSCLE AB SCREEN,7117845,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,11.18,47.44,percent of total billed charges,
Striated Muscle Ab Scr,759802,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,34.80,47.44,percent of total billed charges,
Striated Muscle Ab Scr,759802,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,11.18,47.44,percent of total billed charges,
SYPHILIS TEST NON TREP QUANT,3184947,CDM,300,RC,86593,HCPCS,,,facility,inpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,25.20,34.36,percent of total billed charges,
SYPHILIS TEST NON TREP QUANT,3184947,CDM,300,RC,86593,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,4.08,34.36,percent of total billed charges,
SYPHILIS TEST NON TREP QUANT,7904119,CDM,300,RC,86593,HCPCS,,,facility,inpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,25.20,34.36,percent of total billed charges,
SYPHILIS TEST NON TREP QUANT,7904119,CDM,300,RC,86593,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,4.08,34.36,percent of total billed charges,
Allergen IgE,7966184,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
Allergen IgE,7966184,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,16.62,60.53,percent of total billed charges,
FRANCISELLA TULARENSIS,8366175,CDM,300,RC,86668,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
FRANCISELLA TULARENSIS,8366175,CDM,300,RC,86668,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,10.64,64.62,percent of total billed charges,
FRANCISELLA TULARENSIS,8366187,CDM,300,RC,86668,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
FRANCISELLA TULARENSIS,8366187,CDM,300,RC,86668,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,10.64,64.62,percent of total billed charges,
MG Evaluation with MuSK Reflex,8433930,CDM,300,RC,86041,HCPCS,,,facility,inpatient,,,322.00000,93.38000,Aetna,First Health,,263.40,,,,,,,193.20,263.40,percent of total billed charges,
MG Evaluation with MuSK Reflex,8433930,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,322.00000,93.38000,Aetna,First Health,,263.40,,,,,,,17.06,263.40,percent of total billed charges,
MPO and PR3 Abs with Reflex,8442361,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
MPO and PR3 Abs with Reflex,8442361,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,10.69,54.81,percent of total billed charges,
MPO Antibodies,8526022,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
MPO Antibodies,8526022,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,10.69,54.81,percent of total billed charges,
Lacosamide,8461766,CDM,300,RC,80235,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,144.60,197.14,percent of total billed charges,
Lacosamide,8461766,CDM,300,RC,80235,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,25.13,197.14,percent of total billed charges,
83516 Immunoassay NonAb,8464205,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
83516 Immunoassay NonAb,8464205,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,10.69,30.55,percent of total billed charges,
86235 Nuclear Ab Ag,8464206,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,38.00000,11.02000,Aetna,First Health,,31.08,,,,,,,22.80,31.08,percent of total billed charges,
86235 Nuclear Ab Ag,8464206,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,38.00000,11.02000,Aetna,First Health,,31.08,,,,,,,16.62,47.51,percent of total billed charges,
MOGTS MOG FACS IgG1 Titer Serum MAYO,7994144,CDM,300,RC,86363,HCPCS,,,facility,inpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,58.20,79.35,percent of total billed charges,
MOGTS MOG FACS IgG1 Titer Serum MAYO,7994144,CDM,300,RC,86363,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,First Health,,79.35,,,,,,,34.98,99.98,percent of total billed charges,
86053 CNS Demyelinating Eval Panel,8277878,CDM,300,RC,86053,HCPCS,,,facility,inpatient,,,759.00000,220.11000,Aetna,First Health,,620.86,,,,,,,455.40,620.86,percent of total billed charges,
86053 CNS Demyelinating Eval Panel,8277878,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,759.00000,220.11000,Aetna,First Health,,620.86,,,,,,,34.98,620.86,percent of total billed charges,
Pancreatic Elastase Fecal by Immunoassay,8366177,CDM,300,RC,82653,HCPCS,,,facility,inpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,142.20,193.87,percent of total billed charges,
Pancreatic Elastase Fecal by Immunoassay,8366177,CDM,300,RC,82653,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,First Health,,193.87,,,,,,,21.29,193.87,percent of total billed charges,
Anti Neutrophil Cytoplasmic Ab IgG,8442362,CDM,300,RC,86036,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
Anti Neutrophil Cytoplasmic Ab IgG,8442362,CDM,300,RC,86036,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,11.18,122.70,percent of total billed charges,
NMO Antibodies,8526041,CDM,300,RC,86053,HCPCS,,,facility,inpatient,,,417.00000,120.93000,Aetna,First Health,,341.11,,,,,,,250.20,341.11,percent of total billed charges,
NMO Antibodies,8526041,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,417.00000,120.93000,Aetna,First Health,,341.11,,,,,,,34.98,341.11,percent of total billed charges,
Thyroid Hormone,8750084,CDM,300,RC,84479,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
Thyroid Hormone,8750084,CDM,300,RC,84479,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,5.99,60.53,percent of total billed charges,
84436 Thyroxine Total,8750094,CDM,300,RC,84436,HCPCS,,,facility,inpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
84436 Thyroxine Total,8750094,CDM,300,RC,84436,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,6.37,62.99,percent of total billed charges,
Alpha Defensin Synovial Fluid,8890092,CDM,300,RC,83518,HCPCS,,,facility,inpatient,,,804.00000,233.16000,Aetna,First Health,,657.67,,,,,,,482.40,657.67,percent of total billed charges,
Alpha Defensin Synovial Fluid,8890092,CDM,300,RC,83518,HCPCS,,,facility,outpatient,,,804.00000,233.16000,Aetna,First Health,,657.67,,,,,,,8.94,657.67,percent of total billed charges,
Bacterial Detection by PCR,8868088,CDM,300,RC,87801,HCPCS,,,facility,inpatient,,,491.00000,142.39000,Aetna,First Health,,401.64,,,,,,,294.60,401.64,percent of total billed charges,
Bacterial Detection by PCR,8868088,CDM,300,RC,87801,HCPCS,,,facility,outpatient,,,491.00000,142.39000,Aetna,First Health,,401.64,,,,,,,65.08,401.64,percent of total billed charges,
Cortisol Free by ED LC MS MS,8910302,CDM,300,RC,82530,HCPCS,,,facility,inpatient,,,167.00000,48.43000,Aetna,First Health,,136.61,,,,,,,100.20,136.61,percent of total billed charges,
Cortisol Free by ED LC MS MS,8910302,CDM,300,RC,82530,HCPCS,,,facility,outpatient,,,167.00000,48.43000,Aetna,First Health,,136.61,,,,,,,15.49,136.61,percent of total billed charges,
WEST NILE VIRUS AB CSF IGG IGM,3190848,CDM,300,RC,86789,HCPCS,,,facility,inpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,42.60,58.08,percent of total billed charges,
WEST NILE VIRUS AB CSF IGG IGM,3190848,CDM,300,RC,86789,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,13.34,58.08,percent of total billed charges,
WEST NILE VIRUS RNA RT PCR CSF,3196903,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,268.00000,77.72000,Aetna,First Health,,219.22,,,,,,,160.80,219.22,percent of total billed charges,
WEST NILE VIRUS RNA RT PCR CSF,3196903,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,268.00000,77.72000,Aetna,First Health,,219.22,,,,,,,32.53,219.22,percent of total billed charges,
Kratom Screen with Reflex to Confirmation Urine,8910290,CDM,300,RC,80307,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
Kratom Screen with Reflex to Confirmation Urine,8910290,CDM,300,RC,80307,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,57.61,208.59,percent of total billed charges,
Kratom Confirmation Quant Urine,8910300,CDM,300,RC,80323,HCPCS,,,facility,inpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,54.00,73.62,percent of total billed charges,
Kratom Confirmation Quant Urine,8910300,CDM,300,RC,80323,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,First Health,,73.62,,,,,,,0.01485,73.62,percent of total billed charges,
Bath Salts Qualitative Panel Urine,8908352,CDM,300,RC,80371,HCPCS,,,facility,inpatient,,,216.00000,62.64000,Aetna,First Health,,176.69,,,,,,,129.60,176.69,percent of total billed charges,
Bath Salts Qualitative Panel Urine,8908352,CDM,300,RC,80371,HCPCS,,,facility,outpatient,,,216.00000,62.64000,Aetna,First Health,,176.69,,,,,,,0.01485,176.69,percent of total billed charges,
Synthetic Cannabinoid Metabolites Qualitative,8908344,CDM,300,RC,80352,HCPCS,,,facility,inpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,112.20,152.97,percent of total billed charges,
Synthetic Cannabinoid Metabolites Qualitative,8908344,CDM,300,RC,80352,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,First Health,,152.97,,,,,,,0.01485,152.97,percent of total billed charges,
Bath Salts Qual Panel,8914725,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,159.00,216.77,percent of total billed charges,
Bath Salts Qual Panel,8914725,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,106.00,257.47,percent of total billed charges,
Imipramine and Desipramine Serum or Plasma,8914841,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
Imipramine and Desipramine Serum or Plasma,8914841,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,62.80,257.47,percent of total billed charges,
ANNA 1 Immunoblot Serum,8916154,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,136.80,186.50,percent of total billed charges,
ANNA 1 Immunoblot Serum,8916154,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,23.95,186.50,percent of total billed charges,
ANNA 2 Immunoblot Serum,8916156,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,136.80,186.50,percent of total billed charges,
ANNA 2 Immunoblot Serum,8916156,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,23.95,186.50,percent of total billed charges,
PCA 1 Immunoblot Serum,8916228,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,136.80,186.50,percent of total billed charges,
PCA 1 Immunoblot Serum,8916228,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,23.95,186.50,percent of total billed charges,
PCA Tr Immunoblot Serum,8916237,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,136.80,186.50,percent of total billed charges,
PCA Tr Immunoblot Serum,8916237,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,23.95,186.50,percent of total billed charges,
ZINC LEVEL SERUM,3196875,CDM,300,RC,84630,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
ZINC LEVEL SERUM,3196875,CDM,300,RC,84630,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,10.56,125.97,percent of total billed charges,
Pancreatic Polypeptide,8914867,CDM,300,RC,83519,HCPCS,,,facility,inpatient,,,249.00000,72.21000,Aetna,First Health,,203.68,,,,,,,149.40,203.68,percent of total billed charges,
Pancreatic Polypeptide,8914867,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,249.00000,72.21000,Aetna,First Health,,203.68,,,,,,,17.06,203.68,percent of total billed charges,
Tricyclic Antidepressants Quant,8915034,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
Tricyclic Antidepressants Quant,8915034,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,58.00,257.47,percent of total billed charges,
Stachybotrys chartarum atra Panel,8918182,CDM,300,RC,86001,HCPCS,,,facility,inpatient,,,92.00000,26.68000,Aetna,First Health,,75.26,,,,,,,55.20,75.26,percent of total billed charges,
Stachybotrys chartarum atra Panel,8918182,CDM,300,RC,86001,HCPCS,,,facility,outpatient,,,92.00000,26.68000,Aetna,First Health,,75.26,,,,,,,6.95,75.26,percent of total billed charges,
86003 Stachybotrys chartarum atra Panel,8918190,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,36.60,49.90,percent of total billed charges,
86003 Stachybotrys chartarum atra Panel,8918190,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,4.84,49.90,percent of total billed charges,
Brivaracetam Quantitative Serum or Plasma,8918191,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,236.00000,68.44000,Aetna,First Health,,193.05,,,,,,,141.60,193.05,percent of total billed charges,
Brivaracetam Quantitative Serum or Plasma,8918191,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,236.00000,68.44000,Aetna,First Health,,193.05,,,,,,,94.40,257.47,percent of total billed charges,
F tularensis Ab by Agglutination,8366176,CDM,300,RC,86000,HCPCS,,,facility,inpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,28.80,39.26,percent of total billed charges,
F tularensis Ab by Agglutination,8366176,CDM,300,RC,86000,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,6.47,39.26,percent of total billed charges,
Interleukin 2 Receptor Soluble Serum,8920458,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,127.20,173.42,percent of total billed charges,
Interleukin 2 Receptor Soluble Serum,8920458,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,First Health,,173.42,,,,,,,16.01,173.42,percent of total billed charges,
Aspergillus Species by PCR,8968088,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,198.00000,57.42000,Aetna,First Health,,161.96,,,,,,,118.80,161.96,percent of total billed charges,
Aspergillus Species by PCR,8968088,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,198.00000,57.42000,Aetna,First Health,,161.96,,,,,,,32.53,161.96,percent of total billed charges,
87798 Aspergillus Species,8968098,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,198.00000,57.42000,Aetna,First Health,,161.96,,,,,,,118.80,161.96,percent of total billed charges,
87798 Aspergillus Species,8968098,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,198.00000,57.42000,Aetna,First Health,,161.96,,,,,,,32.53,161.96,percent of total billed charges,
Orthopoxvirus Monkeypox by PCR,8927075,CDM,300,RC,87593,HCPCS,,,facility,inpatient,,,224.00000,64.96000,Aetna,First Health,,183.23,,,,,,,134.40,183.23,percent of total billed charges,
Orthopoxvirus Monkeypox by PCR,8927075,CDM,300,RC,87593,HCPCS,,,facility,outpatient,,,224.00000,64.96000,Aetna,First Health,,183.23,,,,,,,47.57,183.23,percent of total billed charges,
87255 HSV Culture,8277896,CDM,300,RC,87255,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
87255 HSV Culture,8277896,CDM,300,RC,87255,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,31.38,111.25,percent of total billed charges,
Culture Herpes Simplex Virus,8387023,CDM,300,RC,87255,HCPCS,,,facility,inpatient,,,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,78.60,107.16,percent of total billed charges,
Culture Herpes Simplex Virus,8387023,CDM,300,RC,87255,HCPCS,,,facility,outpatient,,,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,31.38,107.16,percent of total billed charges,
82172 Apolipoprotein,8950563,CDM,300,RC,82172,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
82172 Apolipoprotein,8950563,CDM,300,RC,82172,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,19.55,63.80,percent of total billed charges,
Apolipoprotein BA Ratio,8965749,CDM,300,RC,82172,HCPCS,,,facility,inpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,46.80,63.80,percent of total billed charges,
Apolipoprotein BA Ratio,8965749,CDM,300,RC,82172,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,19.55,63.80,percent of total billed charges,
Cortisol Saliva,8968106,CDM,300,RC,82533,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
Cortisol Saliva,8968106,CDM,300,RC,82533,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,15.11,124.34,percent of total billed charges,
84166 Protein Electrophoresis Urine,8975474,CDM,300,RC,84166,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
84166 Protein Electrophoresis Urine,8975474,CDM,300,RC,84166,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,16.53,60.53,percent of total billed charges,
Monoclonal Protein Study 24 Hour Urine,8973314,CDM,300,RC,86335,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,73.20,99.80,percent of total billed charges,
Monoclonal Protein Study 24 Hour Urine,8973314,CDM,300,RC,86335,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,,99.80,,,,,,,27.21,99.80,percent of total billed charges,
NIPT ARUP Z01UZ,8978826,CDM,300,RC,81420,HCPCS,,,facility,inpatient,,,680.00000,197.20000,Aetna,First Health,,556.24,,,,,,,408.00,556.24,percent of total billed charges,
NIPT ARUP Z01UZ,8978826,CDM,300,RC,81420,HCPCS,,,facility,outpatient,,,680.00000,197.20000,Aetna,First Health,,556.24,,,,,,,319.60,2011.48,percent of total billed charges,
Kratom Umbilical Cord Tissue Qual,8984925,CDM,300,RC,80323,HCPCS,,,facility,inpatient,,,298.00000,86.42000,Aetna,First Health,,243.76,,,,,,,178.80,243.76,percent of total billed charges,
Kratom Umbilical Cord Tissue Qual,8984925,CDM,300,RC,80323,HCPCS,,,facility,outpatient,,,298.00000,86.42000,Aetna,First Health,,243.76,,,,,,,0.01485,243.76,percent of total billed charges,
Hypoglycemia Panel Serum or Plasma,8984934,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,130.80,178.32,percent of total billed charges,
Hypoglycemia Panel Serum or Plasma,8984934,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,87.20,257.47,percent of total billed charges,
Measles Virus PCR Throat,9042908,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,792.00000,229.68000,Aetna,First Health,,647.86,,,,,,,475.20,647.86,percent of total billed charges,
Measles Virus PCR Throat,9042908,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,First Health,,647.86,,,,,,,32.53,647.86,percent of total billed charges,
AMH with Menopausal Status,9044141,CDM,300,RC,82166,HCPCS,,,facility,inpatient,,,216.00000,62.64000,Aetna,First Health,,176.69,,,,,,,129.60,176.69,percent of total billed charges,
AMH with Menopausal Status,9044141,CDM,300,RC,82166,HCPCS,,,facility,outpatient,,,216.00000,62.64000,Aetna,First Health,,176.69,,,,,,,35.80,176.69,percent of total billed charges,
Allergen Food Sesame rSes i 1 Component,9044142,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
Allergen Food Sesame rSes i 1 Component,9044142,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,16.62,125.15,percent of total billed charges,
Adalimumab Ab to Adalimumab Quant,9044146,CDM,300,RC,80145,HCPCS,,,facility,inpatient,,,385.00000,111.65000,Aetna,First Health,,314.93,,,,,,,231.00,314.93,percent of total billed charges,
Adalimumab Ab to Adalimumab Quant,9044146,CDM,300,RC,80145,HCPCS,,,facility,outpatient,,,385.00000,111.65000,Aetna,First Health,,314.93,,,,,,,35.75,314.93,percent of total billed charges,
Adalimumab Ab to Quant,9046333,CDM,300,RC,82397,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,85.20,116.16,percent of total billed charges,
Adalimumab Ab to Quant,9046333,CDM,300,RC,82397,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,13.09,116.16,percent of total billed charges,
Infliximab,9044147,CDM,300,RC,80230,HCPCS,,,facility,inpatient,,,385.00000,111.65000,Aetna,First Health,,314.93,,,,,,,231.00,314.93,percent of total billed charges,
Infliximab,9044147,CDM,300,RC,80230,HCPCS,,,facility,outpatient,,,385.00000,111.65000,Aetna,First Health,,314.93,,,,,,,35.75,314.93,percent of total billed charges,
82397 Infliximab,9044992,CDM,300,RC,82397,HCPCS,,,facility,inpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,85.20,116.16,percent of total billed charges,
82397 Infliximab,9044992,CDM,300,RC,82397,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,First Health,,116.16,,,,,,,13.09,116.16,percent of total billed charges,
BCR ABL1 Minor Quant ARUP ZBG82,7900258,CDM,300,RC,81207,HCPCS,,,facility,inpatient,,,436.00000,126.44000,Aetna,First Health,,356.65,,,,,,,261.60,356.65,percent of total billed charges,
BCR ABL1 Minor Quant ARUP ZBG82,7900258,CDM,300,RC,81207,HCPCS,,,facility,outpatient,,,436.00000,126.44000,Aetna,First Health,,356.65,,,,,,,134.27,383.83,percent of total billed charges,
Reflexed to PTT Ratio Treated Bill ARUP,9041349,CDM,300,RC,85730,HCPCS,,,facility,inpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,28.80,39.26,percent of total billed charges,
Reflexed to PTT Ratio Treated Bill ARUP,9041349,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,5.57,39.26,percent of total billed charges,
Reflexed to dRVVT Screen Ratio Treated Bill,9041351,CDM,300,RC,85613,HCPCS,,,facility,inpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,28.20,38.45,percent of total billed charges,
Reflexed to dRVVT Screen Ratio Treated Bill,9041351,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,First Health,,38.45,,,,,,,8.88,38.45,percent of total billed charges,
Reflex to Anti Xa Qual Interp Bill,9043438,CDM,300,RC,85520,HCPCS,,,facility,inpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,39.00,53.17,percent of total billed charges,
Reflex to Anti Xa Qual Interp Bill,9043438,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,12.13,53.17,percent of total billed charges,
Hepzyme Treatment Bill,9043443,CDM,300,RC,85525,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
Hepzyme Treatment Bill,9043443,CDM,300,RC,85525,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,10.98,40.90,percent of total billed charges,
Lyme Disease Reflexive Panel CSF,7756197,CDM,300,RC,86618,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
Lyme Disease Reflexive Panel CSF,7756197,CDM,300,RC,86618,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,15.79,125.97,percent of total billed charges,
Culture Blood Fungus,9058156,CDM,300,RC,87103,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
Culture Blood Fungus,9058156,CDM,300,RC,87103,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,10.17,114.52,percent of total billed charges,
Bill SusceptibilityNocardiaBrothDilution,9058162,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,118.00000,34.22000,Aetna,First Health,,96.52,,,,,,,70.80,96.52,percent of total billed charges,
Bill SusceptibilityNocardiaBrothDilution,9058162,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,118.00000,34.22000,Aetna,First Health,,96.52,,,,,,,8.02,96.52,percent of total billed charges,
Aldosterone 3005949 ARUP,9074651,CDM,300,RC,82088,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
Aldosterone 3005949 ARUP,9074651,CDM,300,RC,82088,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,37.78,128.43,percent of total billed charges,
Renin Activity,9074657,CDM,300,RC,84244,HCPCS,,,facility,inpatient,,,222.00000,64.38000,Aetna,First Health,,181.60,,,,,,,133.20,181.60,percent of total billed charges,
Renin Activity,9074657,CDM,300,RC,84244,HCPCS,,,facility,outpatient,,,222.00000,64.38000,Aetna,First Health,,181.60,,,,,,,20.38,181.60,percent of total billed charges,
Body Fluid Urea Nitrogen,9076716,CDM,300,RC,84540,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
Body Fluid Urea Nitrogen,9076716,CDM,300,RC,84540,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,5.15,126.79,percent of total billed charges,
TSPOT TB,9083466,CDM,300,RC,86481,HCPCS,,,facility,inpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,83.40,113.70,percent of total billed charges,
TSPOT TB,9083466,CDM,300,RC,86481,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,First Health,,113.70,,,,,,,65.33,265.00,percent of total billed charges,
Tacrolimus by Tandem Mass Spectrometry,9082381,CDM,300,RC,80197,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
Tacrolimus by Tandem Mass Spectrometry,9082381,CDM,300,RC,80197,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,11.64,110.43,percent of total billed charges,
86003 Crustacean IgE,9080478,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
86003 Crustacean IgE,9080478,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,4.84,31.90,percent of total billed charges,
Allergens Food Crustacean Profile IgE,9082412,CDM,300,RC,86003,HCPCS,,,facility,inpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
Allergens Food Crustacean Profile IgE,9082412,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,4.84,31.90,percent of total billed charges,
HLA B 58 01 Typing ARUP ZO1AK,8990305,CDM,300,RC,81381,HCPCS,,,facility,inpatient,,,408.00000,118.32000,Aetna,First Health,,333.74,,,,,,,244.80,333.74,percent of total billed charges,
HLA B 58 01 Typing ARUP ZO1AK,8990305,CDM,300,RC,81381,HCPCS,,,facility,outpatient,,,408.00000,118.32000,Aetna,First Health,,333.74,,,,,,,157.50,450.24,percent of total billed charges,
86039 ANA Ab Titer,8990299,CDM,300,RC,86039,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
86039 ANA Ab Titer,8990299,CDM,300,RC,86039,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,10.34,54.81,percent of total billed charges,
86235 ENA Abs,8987202,CDM,300,RC,86235,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
86235 ENA Abs,8987202,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,16.62,64.62,percent of total billed charges,
Comprehensive Systemic Sclerosis Panel,8990291,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,40.20,54.81,percent of total billed charges,
Comprehensive Systemic Sclerosis Panel,8990291,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,10.69,54.81,percent of total billed charges,
HLA B Genotype ARUP ZB6W2,8990306,CDM,300,RC,81380,HCPCS,,,facility,inpatient,,,417.00000,120.93000,Aetna,First Health,,341.11,,,,,,,250.20,341.11,percent of total billed charges,
HLA B Genotype ARUP ZB6W2,8990306,CDM,300,RC,81380,HCPCS,,,facility,outpatient,,,417.00000,120.93000,Aetna,First Health,,341.11,,,,,,,164.32,469.71,percent of total billed charges,
B Cell Gene Rearrangement IGH Neogenomics ZBQ39,8987410,CDM,300,RC,81261,HCPCS,,,facility,inpatient,,,404.00000,117.16000,Aetna,First Health,,330.47,,,,,,,242.40,330.47,percent of total billed charges,
B Cell Gene Rearrangement IGH Neogenomics ZBQ39,8987410,CDM,300,RC,81261,HCPCS,,,facility,outpatient,,,404.00000,117.16000,Aetna,First Health,,330.47,,,,,,,183.54,524.67,percent of total billed charges,
B Cell Gene Rearrangement IGK Neogenomics ZBQ39,8987411,CDM,300,RC,81264,HCPCS,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
B Cell Gene Rearrangement IGK Neogenomics ZBQ39,8987411,CDM,300,RC,81264,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,155.10,457.73,percent of total billed charges,
TRB Gene Rearrangement Neogenomics ZB4T6,8987412,CDM,300,RC,81340,HCPCS,,,facility,inpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,396.60,540.70,percent of total billed charges,
TRB Gene Rearrangement Neogenomics ZB4T6,8987412,CDM,300,RC,81340,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,193.67,553.64,percent of total billed charges,
TRG Gene Rearrangement Neogenomics ZBY91,8987417,CDM,300,RC,81342,HCPCS,,,facility,inpatient,,,421.00000,122.09000,Aetna,First Health,,344.38,,,,,,,252.60,344.38,percent of total billed charges,
TRG Gene Rearrangement Neogenomics ZBY91,8987417,CDM,300,RC,81342,HCPCS,,,facility,outpatient,,,421.00000,122.09000,Aetna,First Health,,344.38,,,,,,,186.79,533.98,percent of total billed charges,
CALR Mutation Analysis Neogenomics ZBX2Z,8992189,CDM,300,RC,81219,HCPCS,,,facility,inpatient,,,513.00000,148.77000,Aetna,First Health,,419.63,,,,,,,307.80,419.63,percent of total billed charges,
CALR Mutation Analysis Neogenomics ZBX2Z,8992189,CDM,300,RC,81219,HCPCS,,,facility,outpatient,,,513.00000,148.77000,Aetna,First Health,,419.63,,,,,,,112.75,419.63,percent of total billed charges,
KIT c KIT Neogenomics ZBQ09,8992194,CDM,300,RC,81272,HCPCS,,,facility,inpatient,,,445.00000,129.05000,Aetna,First Health,,364.01,,,,,,,267.00,364.01,percent of total billed charges,
KIT c KIT Neogenomics ZBQ09,8992194,CDM,300,RC,81272,HCPCS,,,facility,outpatient,,,445.00000,129.05000,Aetna,First Health,,364.01,,,,,,,209.15,873.20,percent of total billed charges,
CXCR4 Mutation Analysis Neogenomics ZB41R,8992196,CDM,300,RC,81479,HCPCS,,,facility,inpatient,,,573.00000,166.17000,Aetna,First Health,,468.71,,,,,,,343.80,468.71,percent of total billed charges,
CXCR4 Mutation Analysis Neogenomics ZB41R,8992196,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,573.00000,166.17000,Aetna,First Health,,468.71,,,,,,,206.57,468.71,percent of total billed charges,
IDH and IDH2 Mutation Analysis Neogenomics ZBQ14,8992198,CDM,300,RC,81479,HCPCS,,,facility,inpatient,,,486.00000,140.94000,Aetna,First Health,,397.55,,,,,,,291.60,397.55,percent of total billed charges,
IDH and IDH2 Mutation Analysis Neogenomics ZBQ14,8992198,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,486.00000,140.94000,Aetna,First Health,,397.55,,,,,,,175.20,397.55,percent of total billed charges,
IgVH Mutation Analysis Neogenomics ZBO89,8992199,CDM,300,RC,81263,HCPCS,,,facility,inpatient,,,614.00000,178.06000,Aetna,First Health,,502.25,,,,,,,368.40,502.25,percent of total billed charges,
IgVH Mutation Analysis Neogenomics ZBO89,8992199,CDM,300,RC,81263,HCPCS,,,facility,outpatient,,,614.00000,178.06000,Aetna,First Health,,502.25,,,,,,,273.02,780.48,percent of total billed charges,
JAK2 V617F Mutation Analysis Neogenomics ZBY95,8992200,CDM,300,RC,81270,HCPCS,,,facility,inpatient,,,427.00000,123.83000,Aetna,First Health,,349.29,,,,,,,256.20,349.29,percent of total billed charges,
JAK2 V617F Mutation Analysis Neogenomics ZBY95,8992200,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,427.00000,123.83000,Aetna,First Health,,349.29,,,,,,,84.96,349.29,percent of total billed charges,
JAK2 V617F Mutation Analysis Neogenomics ZBY95,9090321,CDM,300,RC,81270,HCPCS,,,facility,inpatient,,,427.00000,123.83000,Aetna,First Health,,349.29,,,,,,,256.20,349.29,percent of total billed charges,
JAK2 V617F Mutation Analysis Neogenomics ZBY95,9090321,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,427.00000,123.83000,Aetna,First Health,,349.29,,,,,,,84.96,349.29,percent of total billed charges,
JAK2 Exon 12 14 Mutation Analysis Neogenomics ZBY94,8987442,CDM,300,RC,81279,HCPCS,,,facility,inpatient,,,513.00000,148.77000,Aetna,First Health,,419.63,,,,,,,307.80,419.63,percent of total billed charges,
JAK2 Exon 12 14 Mutation Analysis Neogenomics ZBY94,8987442,CDM,300,RC,81279,HCPCS,,,facility,outpatient,,,513.00000,148.77000,Aetna,First Health,,419.63,,,,,,,171.68,490.78,percent of total billed charges,
MGMT Promoter Methylation Analysis Neogenomic ZBX6H,8992205,CDM,300,RC,81287,HCPCS,,,facility,inpatient,,,588.00000,170.52000,Aetna,First Health,,480.98,,,,,,,352.80,480.98,percent of total billed charges,
MGMT Promoter Methylation Analysis Neogenomic ZBX6H,8992205,CDM,300,RC,81287,HCPCS,,,facility,outpatient,,,588.00000,170.52000,Aetna,First Health,,480.98,,,,,,,115.55,480.98,percent of total billed charges,
MPL Mutation Neogenomics ZB3EP,8987449,CDM,300,RC,81339,HCPCS,,,facility,inpatient,,,406.00000,117.74000,Aetna,First Health,,332.11,,,,,,,243.60,332.11,percent of total billed charges,
MPL Mutation Neogenomics ZB3EP,8987449,CDM,300,RC,81339,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,First Health,,332.11,,,,,,,171.68,490.78,percent of total billed charges,
MYD88 Mutation Neogenomics ZBZR7,8987450,CDM,300,RC,81305,HCPCS,,,facility,inpatient,,,532.00000,154.28000,Aetna,First Health,,435.18,,,,,,,319.20,435.18,percent of total billed charges,
MYD88 Mutation Neogenomics ZBZR7,8987450,CDM,300,RC,81305,HCPCS,,,facility,outpatient,,,532.00000,154.28000,Aetna,First Health,,435.18,,,,,,,162.60,464.81,percent of total billed charges,
PDGFRa Mutation Neogenomics ZBQ20,8987452,CDM,300,RC,81314,HCPCS,,,facility,inpatient,,,734.00000,212.86000,Aetna,First Health,,600.41,,,,,,,440.40,600.41,percent of total billed charges,
PDGFRa Mutation Neogenomics ZBQ20,8987452,CDM,300,RC,81314,HCPCS,,,facility,outpatient,,,734.00000,212.86000,Aetna,First Health,,600.41,,,,,,,305.46,873.20,percent of total billed charges,
PIK3CA Mutation Neogenomics ZB3EJ,8987458,CDM,300,RC,81309,HCPCS,,,facility,inpatient,,,702.00000,203.58000,Aetna,First Health,,574.24,,,,,,,421.20,574.24,percent of total billed charges,
PIK3CA Mutation Neogenomics ZB3EJ,8987458,CDM,300,RC,81309,HCPCS,,,facility,outpatient,,,702.00000,203.58000,Aetna,First Health,,574.24,,,,,,,254.77,728.30,percent of total billed charges,
SF3B1 Mutation Neogenomics ZBQ28,8992216,CDM,300,RC,81347,HCPCS,,,facility,inpatient,,,434.00000,125.86000,Aetna,First Health,,355.01,,,,,,,260.40,355.01,percent of total billed charges,
SF3B1 Mutation Neogenomics ZBQ28,8992216,CDM,300,RC,81347,HCPCS,,,facility,outpatient,,,434.00000,125.86000,Aetna,First Health,,355.01,,,,,,,179.15,512.11,percent of total billed charges,
STAT3 Mutation Neogenomics ZB7B9,8992217,CDM,300,RC,81405,HCPCS,,,facility,inpatient,,,665.00000,192.85000,Aetna,First Health,,543.97,,,,,,,399.00,543.97,percent of total billed charges,
STAT3 Mutation Neogenomics ZB7B9,8992217,CDM,300,RC,81405,HCPCS,,,facility,outpatient,,,665.00000,192.85000,Aetna,First Health,,543.97,,,,,,,279.36,798.58,percent of total billed charges,
88377 FISH Neogenomics,8992223,CDM,300,RC,88377,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
88377 FISH Neogenomics,8992223,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,150.47,452.20,percent of total billed charges,
Bill 88368 FISH Neogenomics,8992229,CDM,300,RC,88368,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
Bill 88368 FISH Neogenomics,8992229,CDM,300,RC,88368,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,119.85,951.40,percent of total billed charges,
Bill 88369 FISH Neogenomics,8987468,CDM,300,RC,88369,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
Bill 88369 FISH Neogenomics,8987468,CDM,300,RC,88369,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,91.93,208.59,percent of total billed charges,
Bill 88367 FISH Neogenomics,8992235,CDM,300,RC,88367,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
Bill 88367 FISH Neogenomics,8992235,CDM,300,RC,88367,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,119.85,951.40,percent of total billed charges,
Bill 88374 FISH Neogenomics,8992236,CDM,300,RC,88374,HCPCS,,,facility,inpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,306.00,417.18,percent of total billed charges,
Bill 88374 FISH Neogenomics,8992236,CDM,300,RC,88374,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,First Health,,417.18,,,,,,,150.47,452.20,percent of total billed charges,
BCR ABL1 Quant Major BP ARUP ZBG81,7913833,CDM,300,RC,81206,HCPCS,,,facility,inpatient,,,493.00000,142.97000,Aetna,First Health,,403.27,,,,,,,295.80,403.27,percent of total billed charges,
BCR ABL1 Quant Major BP ARUP ZBG81,7913833,CDM,300,RC,81206,HCPCS,,,facility,outpatient,,,493.00000,142.97000,Aetna,First Health,,403.27,,,,,,,151.99,434.49,percent of total billed charges,
Babesia Species by PCR,7921216,CDM,300,RC,87469,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,70.20,95.71,percent of total billed charges,
Babesia Species by PCR,7921216,CDM,300,RC,87469,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,,95.71,,,,,,,32.53,95.71,percent of total billed charges,
87468 Tick Borne Disease Panel,8997407,CDM,300,RC,87468,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
87468 Tick Borne Disease Panel,8997407,CDM,300,RC,87468,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,32.53,92.99,percent of total billed charges,
87484 Tick Borne Disease Panel,8995146,CDM,300,RC,87484,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
87484 Tick Borne Disease Panel,8995146,CDM,300,RC,87484,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,32.53,92.99,percent of total billed charges,
87469 Tick Borne Disease Panel,8997408,CDM,300,RC,87469,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
87469 Tick Borne Disease Panel,8997408,CDM,300,RC,87469,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,32.53,92.99,percent of total billed charges,
87468 Ehrlichia and Anaplasma by PCR,8997417,CDM,300,RC,87468,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
87468 Ehrlichia and Anaplasma by PCR,8997417,CDM,300,RC,87468,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,25.38,92.99,percent of total billed charges,
87484 Ehrlichia and Anaplasma by PCR,8997418,CDM,300,RC,87484,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
87484 Ehrlichia and Anaplasma by PCR,8997418,CDM,300,RC,87484,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,25.38,92.99,percent of total billed charges,
BCR ABL Major Break Point ARUP ZB078,7900203,CDM,300,RC,81206,HCPCS,,,facility,inpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,99.00,134.97,percent of total billed charges,
BCR ABL Major Break Point ARUP ZB078,7900203,CDM,300,RC,81206,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,First Health,,134.97,,,,,,,77.55,434.49,percent of total billed charges,
81207 BCR ABL Minor BP ARUP ZB078,8999667,CDM,300,RC,81207,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
81207 BCR ABL Minor BP ARUP ZB078,8999667,CDM,300,RC,81207,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,68.15,383.83,percent of total billed charges,
81208 BCR ABL ARUP ZB078,8999666,CDM,300,RC,81208,HCPCS,,,facility,inpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,129.00,175.87,percent of total billed charges,
81208 BCR ABL ARUP ZB078,8999666,CDM,300,RC,81208,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,First Health,,175.87,,,,,,,101.05,568.74,percent of total billed charges,
Epstein Barr  Qualitative PCR,8999941,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,110.40,150.51,percent of total billed charges,
Epstein Barr  Qualitative PCR,8999941,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,First Health,,150.51,,,,,,,32.53,150.51,percent of total billed charges,
BK Virus by Quantitative NAAT Urine,9002090,CDM,300,RC,87799,HCPCS,,,facility,inpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,138.00,188.14,percent of total billed charges,
BK Virus by Quantitative NAAT Urine,9002090,CDM,300,RC,87799,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,First Health,,188.14,,,,,,,39.72,188.14,percent of total billed charges,
86317 14 3 3 Protein Tau CSF,9002104,CDM,300,RC,86317,HCPCS,,,facility,inpatient,,,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,19.80,26.99,percent of total billed charges,
86317 14 3 3 Protein Tau CSF,9002104,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,13.89,39.72,percent of total billed charges,
14 3 3 Protein Tau Total CSF,9000099,CDM,300,RC,0035U,HCPCS,,,facility,inpatient,,,1056.00000,306.24000,Aetna,First Health,,863.81,,,,,,,633.60,863.81,percent of total billed charges,
14 3 3 Protein Tau Total CSF,9000099,CDM,300,RC,0035U,HCPCS,,,facility,outpatient,,,1056.00000,306.24000,Aetna,First Health,,863.81,,,,,,,422.40,1217.23,percent of total billed charges,
86356 B Cell Subset Analysis,9004382,CDM,300,RC,86356,HCPCS,,,facility,inpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,25.80,35.17,percent of total billed charges,
86356 B Cell Subset Analysis,9004382,CDM,300,RC,86356,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,20.21,70.97,percent of total billed charges,
Phosphatidylethanol Peth Whole Blood,9004392,CDM,300,RC,G0480,HCPCS,,,facility,inpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,152.40,207.77,percent of total billed charges,
Phosphatidylethanol Peth Whole Blood,9004392,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,First Health,,207.77,,,,,,,101.60,257.47,percent of total billed charges,
Autoimmune Stiff Person Disorders CSF,9001747,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,147.00,200.41,percent of total billed charges,
Autoimmune Stiff Person Disorders CSF,9001747,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,21.85,200.41,percent of total billed charges,
Autoimmune Stiff Person Disorders Serum,9004577,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,147.00,200.41,percent of total billed charges,
Autoimmune Stiff Person Disorders Serum,9004577,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,First Health,,200.41,,,,,,,21.85,200.41,percent of total billed charges,
84182 Autoimmune Stiff Person Disorders,9004584,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,306.00000,88.74000,Aetna,First Health,,250.31,,,,,,,183.60,250.31,percent of total billed charges,
84182 Autoimmune Stiff Person Disorders,9004584,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,306.00000,88.74000,Aetna,First Health,,250.31,,,,,,,23.95,250.31,percent of total billed charges,
"DPPX IgG Ab Titer, CSF",9001764,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,189.00,257.67,percent of total billed charges,
"DPPX IgG Ab Titer, CSF",9001764,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,11.18,257.67,percent of total billed charges,
"DPPX IgG Ab Titer, Serum",9004599,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,189.00,257.67,percent of total billed charges,
"DPPX IgG Ab Titer, Serum",9004599,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,11.18,257.67,percent of total billed charges,
86255 Autoimmune Stiff Person Disorders,9001734,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,129.00000,37.41000,Aetna,First Health,,105.52,,,,,,,77.40,105.52,percent of total billed charges,
86255 Autoimmune Stiff Person Disorders,9001734,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,129.00000,37.41000,Aetna,First Health,,105.52,,,,,,,11.18,105.52,percent of total billed charges,
MuSK Ab IgG with Reflex to Titer Serum,9002034,CDM,300,RC,86366,HCPCS,,,facility,inpatient,,,536.00000,155.44000,Aetna,First Health,,438.45,,,,,,,321.60,438.45,percent of total billed charges,
MuSK Ab IgG with Reflex to Titer Serum,9002034,CDM,300,RC,86366,HCPCS,,,facility,outpatient,,,536.00000,155.44000,Aetna,First Health,,438.45,,,,,,,17.06,438.45,percent of total billed charges,
MuSK IgG Ab Titer Serum,9002038,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
MuSK IgG Ab Titer Serum,9002038,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,11.18,212.68,percent of total billed charges,
Myasthenia Gravis Reflexive Panel,9002040,CDM,300,RC,86041,HCPCS,,,facility,inpatient,,,91.00000,26.39000,Aetna,First Health,,74.44,,,,,,,54.60,74.44,percent of total billed charges,
Myasthenia Gravis Reflexive Panel,9002040,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,91.00000,26.39000,Aetna,First Health,,74.44,,,,,,,17.06,74.44,percent of total billed charges,
83516 Myasthenia Gravis Reflexive Panel,9004779,CDM,300,RC,86042,HCPCS,,,facility,inpatient,,,91.00000,26.39000,Aetna,First Health,,74.44,,,,,,,54.60,74.44,percent of total billed charges,
83516 Myasthenia Gravis Reflexive Panel,9004779,CDM,300,RC,86042,HCPCS,,,facility,outpatient,,,91.00000,26.39000,Aetna,First Health,,74.44,,,,,,,17.06,74.44,percent of total billed charges,
Drug Detection Umbilical Cord Qual,8858115,CDM,300,RC,G0482,HCPCS,,,facility,inpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,144.00,196.32,percent of total billed charges,
Drug Detection Umbilical Cord Qual,8858115,CDM,300,RC,G0482,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,First Health,,196.32,,,,,,,96.00,447.17,percent of total billed charges,
Fatty Acids Profile Essential,9010208,CDM,300,RC,82542,HCPCS,,,facility,inpatient,,,617.00000,178.93000,Aetna,First Health,,504.71,,,,,,,370.20,504.71,percent of total billed charges,
Fatty Acids Profile Essential,9010208,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,617.00000,178.93000,Aetna,First Health,,504.71,,,,,,,11.66,504.71,percent of total billed charges,
HIV Types 1 and 2 Ab Differentiation,9005680,CDM,300,RC,86701,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,60.00,81.80,percent of total billed charges,
HIV Types 1 and 2 Ab Differentiation,9005680,CDM,300,RC,86701,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,8.24,81.80,percent of total billed charges,
86702 HIV2 Ab,9005685,CDM,300,RC,86702,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
86702 HIV2 Ab,9005685,CDM,300,RC,86702,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,12.54,121.88,percent of total billed charges,
JC Virus Ab by ELISA,9008200,CDM,300,RC,86711,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
JC Virus Ab by ELISA,9008200,CDM,300,RC,86711,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,15.66,112.88,percent of total billed charges,
JC Virus Inhibition Assay,9008214,CDM,300,RC,86711,HCPCS,,,facility,inpatient,,,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
JC Virus Inhibition Assay,9008214,CDM,300,RC,86711,HCPCS,,,facility,outpatient,,,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.47000,44.76,percent of total billed charges,
MOG Antibody IgG,9012473,CDM,300,RC,86362,HCPCS,,,facility,inpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,154.80,211.04,percent of total billed charges,
MOG Antibody IgG,9012473,CDM,300,RC,86362,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,11.18,211.04,percent of total billed charges,
86362 MOG by CBA,9012506,CDM,300,RC,86362,HCPCS,,,facility,inpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,154.80,211.04,percent of total billed charges,
86362 MOG by CBA,9012506,CDM,300,RC,86362,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,11.18,211.04,percent of total billed charges,
Autoimmune CNS Demyelinating Disease Reflexive Panel,9012503,CDM,300,RC,86052,HCPCS,,,facility,inpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,154.80,211.04,percent of total billed charges,
Autoimmune CNS Demyelinating Disease Reflexive Panel,9012503,CDM,300,RC,86052,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,11.18,211.04,percent of total billed charges,
MOG Ab IgG Titer,9010459,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,160.20,218.41,percent of total billed charges,
MOG Ab IgG Titer,9010459,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,11.18,218.41,percent of total billed charges,
Aquaporin 4 IgG Titer,9012491,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,103.20,140.70,percent of total billed charges,
Aquaporin 4 IgG Titer,9012491,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,11.18,140.70,percent of total billed charges,
Aquaporin 4 IgG Serum,9012486,CDM,300,RC,86052,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,193.80,264.21,percent of total billed charges,
Aquaporin 4 IgG Serum,9012486,CDM,300,RC,86052,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,First Health,,264.21,,,,,,,11.18,264.21,percent of total billed charges,
87900 HIV Drug Resistance,9010834,CDM,300,RC,87900,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,113.40,154.60,percent of total billed charges,
87900 HIV Drug Resistance,9010834,CDM,300,RC,87900,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,88.83,345.43,percent of total billed charges,
87906 HIV Drug Resistance,9010835,CDM,300,RC,87906,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,113.40,154.60,percent of total billed charges,
87906 HIV Drug Resistance,9010835,CDM,300,RC,87906,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,88.83,341.13,percent of total billed charges,
CYTOMEGALOVIRUS IGG,3190856,CDM,300,RC,86644,HCPCS,,,facility,inpatient,,,63.00000,18.27000,Aetna,First Health,,51.53,,,,,,,37.80,51.53,percent of total billed charges,
CYTOMEGALOVIRUS IGG,3190856,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,63.00000,18.27000,Aetna,First Health,,51.53,,,,,,,13.34,51.53,percent of total billed charges,
CYTOMEGALOVIRUS IGM,635121,CDM,300,RC,86645,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
CYTOMEGALOVIRUS IGM,635121,CDM,300,RC,86645,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,15.63,60.53,percent of total billed charges,
RUBEOLA A,7744347,CDM,300,RC,86765,HCPCS,,,facility,inpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,88.80,121.06,percent of total billed charges,
RUBEOLA A,7744347,CDM,300,RC,86765,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,First Health,,121.06,,,,,,,11.94,121.06,percent of total billed charges,
VITAMIN B1 Plasma,8271856,CDM,300,RC,84425,HCPCS,,,facility,inpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,81.60,111.25,percent of total billed charges,
VITAMIN B1 Plasma,8271856,CDM,300,RC,84425,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,First Health,,111.25,,,,,,,19.68,111.25,percent of total billed charges,
GAMMAGLOBULIN,2386830,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,63.00000,18.27000,Aetna,First Health,,51.53,,,,,,,37.80,51.53,percent of total billed charges,
GAMMAGLOBULIN,2386830,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,63.00000,18.27000,Aetna,First Health,,51.53,,,,,,,8.18,51.53,percent of total billed charges,
86258 Prometheus Celiac Panel,9010847,CDM,300,RC,86258,HCPCS,,,facility,inpatient,,,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,49.80,67.89,percent of total billed charges,
86258 Prometheus Celiac Panel,9010847,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,11.18,67.89,percent of total billed charges,
86364 Prometheus Celiac Panel,9010848,CDM,300,RC,86364,HCPCS,,,facility,inpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,47.40,64.62,percent of total billed charges,
86364 Prometheus Celiac Panel,9010848,CDM,300,RC,86364,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,First Health,,64.62,,,,,,,10.69,64.62,percent of total billed charges,
86231 Prometheus Celiac Panel,9010849,CDM,300,RC,86231,HCPCS,,,facility,inpatient,,,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,49.80,67.89,percent of total billed charges,
86231 Prometheus Celiac Panel,9010849,CDM,300,RC,86231,HCPCS,,,facility,outpatient,,,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,11.21,67.89,percent of total billed charges,
EPILEPSY EVAL CSF,8280203,CDM,300,RC,86341,HCPCS,,,facility,inpatient,,,279.00000,80.91000,Aetna,First Health,,228.22,,,,,,,167.40,228.22,percent of total billed charges,
EPILEPSY EVAL CSF,8280203,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,279.00000,80.91000,Aetna,First Health,,228.22,,,,,,,21.85,228.22,percent of total billed charges,
Acetylcholine Clocking Antibody,3196839,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
Acetylcholine Clocking Antibody,3196839,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,10.69,116.97,percent of total billed charges,
Testosterone Female or Child,3210839,CDM,300,RC,84403,HCPCS,,,facility,inpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,91.20,124.34,percent of total billed charges,
Testosterone Female or Child,3210839,CDM,300,RC,84403,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,First Health,,124.34,,,,,,,23.93,124.34,percent of total billed charges,
ANCA ANTIBODY,8264168,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
ANCA ANTIBODY,8264168,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,10.69,40.90,percent of total billed charges,
86008 Milk Components,9013243,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
86008 Milk Components,9013243,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,16.62,60.53,percent of total billed charges,
Rfx Allergen Food Peanut Components IgE,9050255,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
Rfx Allergen Food Peanut Components IgE,9050255,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,16.62,60.53,percent of total billed charges,
86008 Reflex Peanut Components IgE,9050261,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
86008 Reflex Peanut Components IgE,9050261,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,16.62,60.53,percent of total billed charges,
86008 Hazelnut component,9101389,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,44.40,60.53,percent of total billed charges,
86008 Hazelnut component,9101389,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,16.62,60.53,percent of total billed charges,
HELMINTH ANTIBODY,7913622,CDM,300,RC,86682,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
HELMINTH ANTIBODY,7913622,CDM,300,RC,86682,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,12.06,114.52,percent of total billed charges,
86258 Prometheus Celiac Plus,9013269,CDM,300,RC,86258,HCPCS,,,facility,inpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,30.60,41.72,percent of total billed charges,
86258 Prometheus Celiac Plus,9013269,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,11.18,41.72,percent of total billed charges,
Prometheus Celiac Plus,2386828,CDM,300,RC,86364,HCPCS,,,facility,inpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,30.60,41.72,percent of total billed charges,
Prometheus Celiac Plus,2386828,CDM,300,RC,86364,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,10.69,41.72,percent of total billed charges,
86231 Prometheus Celiac Plus,9010883,CDM,300,RC,86231,HCPCS,,,facility,inpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,30.60,41.72,percent of total billed charges,
86231 Prometheus Celiac Plus,9010883,CDM,300,RC,86231,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,11.21,41.72,percent of total billed charges,
82784 Prometheus Celiac Plus,9013270,CDM,300,RC,82784,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
82784 Prometheus Celiac Plus,9013270,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,8.18,24.64,percent of total billed charges,
81382 Prometheus Celiac Plus ZB25K,9010884,CDM,300,RC,81382,HCPCS,,,facility,inpatient,,,537.00000,155.73000,Aetna,First Health,,439.27,,,,,,,322.20,439.27,percent of total billed charges,
81382 Prometheus Celiac Plus ZB25K,9010884,CDM,300,RC,81382,HCPCS,,,facility,outpatient,,,537.00000,155.73000,Aetna,First Health,,439.27,,,,,,,114.65,439.27,percent of total billed charges,
Reflex Lyme Modified 2 Tier Testing,9013646,CDM,300,RC,86618,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
Reflex Lyme Modified 2 Tier Testing,9013646,CDM,300,RC,86618,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,15.79,59.71,percent of total billed charges,
86618 Lyme Modified Two Tier Testing,9013647,CDM,300,RC,86618,HCPCS,,,facility,inpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,43.80,59.71,percent of total billed charges,
86618 Lyme Modified Two Tier Testing,9013647,CDM,300,RC,86618,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,First Health,,59.71,,,,,,,15.79,59.71,percent of total billed charges,
Thiopurine Metabolites,9013653,CDM,300,RC,80299,HCPCS,,,facility,inpatient,,,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,131.40,179.14,percent of total billed charges,
Thiopurine Metabolites,9013653,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,17.28,179.14,percent of total billed charges,
Voltage Gated Potassium Channel Ab,9011734,CDM,300,RC,83519,HCPCS,,,facility,inpatient,,,354.00000,102.66000,Aetna,First Health,,289.57,,,,,,,212.40,289.57,percent of total billed charges,
Voltage Gated Potassium Channel Ab,9011734,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,354.00000,102.66000,Aetna,First Health,,289.57,,,,,,,17.06,289.57,percent of total billed charges,
VGKC Ab with Reflex,9014540,CDM,300,RC,83519,HCPCS,,,facility,inpatient,,,354.00000,102.66000,Aetna,First Health,,289.57,,,,,,,212.40,289.57,percent of total billed charges,
VGKC Ab with Reflex,9014540,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,354.00000,102.66000,Aetna,First Health,,289.57,,,,,,,17.06,289.57,percent of total billed charges,
Bill 88342 IHC Initial Stain Neogenomics,9014173,CDM,300,RC,88342,HCPCS,,,facility,inpatient,,,252.00000,73.08000,Aetna,First Health,,206.14,,,,,,,151.20,206.14,percent of total billed charges,
Bill 88342 IHC Initial Stain Neogenomics,9014173,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,252.00000,73.08000,Aetna,First Health,,206.14,,,,,,,84.70,452.20,percent of total billed charges,
Bill 88341 IHC Additional Stain Neogenomics,9011763,CDM,300,RC,88341,HCPCS,,,facility,inpatient,,,252.00000,73.08000,Aetna,First Health,,206.14,,,,,,,151.20,206.14,percent of total billed charges,
Bill 88341 IHC Additional Stain Neogenomics,9011763,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,252.00000,73.08000,Aetna,First Health,,206.14,,,,,,,90.85,206.14,percent of total billed charges,
Bill 88364 IHC by ISH Additional Neogenomics,9011770,CDM,300,RC,88364,HCPCS,,,facility,inpatient,,,428.00000,124.12000,Aetna,First Health,,350.10,,,,,,,256.80,350.10,percent of total billed charges,
Bill 88364 IHC by ISH Additional Neogenomics,9011770,CDM,300,RC,88364,HCPCS,,,facility,outpatient,,,428.00000,124.12000,Aetna,First Health,,350.10,,,,,,,139.10,350.10,percent of total billed charges,
Bill 88365 IHC by ISH Neogenomics,9014186,CDM,300,RC,88365,HCPCS,,,facility,inpatient,,,428.00000,124.12000,Aetna,First Health,,350.10,,,,,,,256.80,350.10,percent of total billed charges,
Bill 88365 IHC by ISH Neogenomics,9014186,CDM,300,RC,88365,HCPCS,,,facility,outpatient,,,428.00000,124.12000,Aetna,First Health,,350.10,,,,,,,121.31,452.20,percent of total billed charges,
Bill 88360 IHC Quant Neogenomics,9014192,CDM,300,RC,88360,HCPCS,,,facility,inpatient,,,306.00000,88.74000,Aetna,First Health,,250.31,,,,,,,183.60,250.31,percent of total billed charges,
Bill 88360 IHC Quant Neogenomics,9014192,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,306.00000,88.74000,Aetna,First Health,,250.31,,,,,,,104.47,452.20,percent of total billed charges,
Vitamin B3,9014320,CDM,300,RC,84591,HCPCS,,,facility,inpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,154.80,211.04,percent of total billed charges,
Vitamin B3,9014320,CDM,300,RC,84591,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,15.43,211.04,percent of total billed charges,
"Copper, Liver, Tissue",9011890,CDM,300,RC,82525,HCPCS,,,facility,inpatient,,,268.00000,77.72000,Aetna,First Health,,219.22,,,,,,,160.80,219.22,percent of total billed charges,
"Copper, Liver, Tissue",9011890,CDM,300,RC,82525,HCPCS,,,facility,outpatient,,,268.00000,77.72000,Aetna,First Health,,219.22,,,,,,,11.51,219.22,percent of total billed charges,
86255 LGI1 and CASPRA2 IgG,9014551,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,113.40,154.60,percent of total billed charges,
86255 LGI1 and CASPRA2 IgG,9014551,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,11.18,154.60,percent of total billed charges,
"LGI1 and CASPR2 Abs, IgG by CBA-IFA with Reflex to Titer, Se",9016155,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,113.40,154.60,percent of total billed charges,
"LGI1 and CASPR2 Abs, IgG by CBA-IFA with Reflex to Titer, Se",9016155,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,,154.60,,,,,,,11.18,154.60,percent of total billed charges,
CASPR2 IgG Titer,9014558,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,131.40,179.14,percent of total billed charges,
CASPR2 IgG Titer,9014558,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,11.18,179.14,percent of total billed charges,
LGI1 Ab IgG Titer,9016167,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,242.00000,70.18000,Aetna,First Health,,197.96,,,,,,,145.20,197.96,percent of total billed charges,
LGI1 Ab IgG Titer,9016167,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,242.00000,70.18000,Aetna,First Health,,197.96,,,,,,,11.18,197.96,percent of total billed charges,
LipoFit by NMR,9016179,CDM,300,RC,83704,HCPCS,,,facility,inpatient,,,102.00000,29.58000,Aetna,First Health,,83.44,,,,,,,61.20,83.44,percent of total billed charges,
LipoFit by NMR,9016179,CDM,300,RC,83704,HCPCS,,,facility,outpatient,,,102.00000,29.58000,Aetna,First Health,,83.44,,,,,,,23.54,90.60,percent of total billed charges,
80061 LipoFit by NMR,9014577,CDM,300,RC,80061,HCPCS,,,facility,inpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
80061 LipoFit by NMR,9014577,CDM,300,RC,80061,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,12.41,35.48,percent of total billed charges,
NMDA Receptor Ab,9016218,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,232.00000,67.28000,Aetna,First Health,,189.78,,,,,,,139.20,189.78,percent of total billed charges,
NMDA Receptor Ab,9016218,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,232.00000,67.28000,Aetna,First Health,,189.78,,,,,,,11.18,189.78,percent of total billed charges,
Autoimmune Neuromuscular Junction Reflexive Panel,9016248,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
Autoimmune Neuromuscular Junction Reflexive Panel,9016248,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,11.18,110.43,percent of total billed charges,
83519 Autoimmune Neuromuscular Junction Panel,9014619,CDM,300,RC,83519,HCPCS,,,facility,inpatient,,,202.00000,58.58000,Aetna,First Health,,165.24,,,,,,,121.20,165.24,percent of total billed charges,
83519 Autoimmune Neuromuscular Junction Panel,9014619,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,202.00000,58.58000,Aetna,First Health,,165.24,,,,,,,17.06,165.24,percent of total billed charges,
83516 Autoimmune Neuromuscular Junction Panel,9014620,CDM,300,RC,83516,HCPCS,,,facility,inpatient,,,121.00000,35.09000,Aetna,First Health,,98.98,,,,,,,72.60,98.98,percent of total billed charges,
83516 Autoimmune Neuromuscular Junction Panel,9014620,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,121.00000,35.09000,Aetna,First Health,,98.98,,,,,,,10.69,98.98,percent of total billed charges,
86596 Autoimmune Neuromuscular Junction Panel,9016262,CDM,300,RC,86596,HCPCS,,,facility,inpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,81.00,110.43,percent of total billed charges,
86596 Autoimmune Neuromuscular Junction Panel,9016262,CDM,300,RC,86596,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,First Health,,110.43,,,,,,,11.18,110.43,percent of total billed charges,
AChR Modulation Flow Cytometry Serum,8433966,CDM,300,RC,86043,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,138.60,188.96,percent of total billed charges,
AChR Modulation Flow Cytometry Serum,8433966,CDM,300,RC,86043,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,11.18,188.96,percent of total billed charges,
86041 Autoimmune Neuromuscular Junction Panel,9042795,CDM,300,RC,86041,HCPCS,,,facility,inpatient,,,202.00000,58.58000,Aetna,First Health,,165.24,,,,,,,121.20,165.24,percent of total billed charges,
86041 Autoimmune Neuromuscular Junction Panel,9042795,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,202.00000,58.58000,Aetna,First Health,,165.24,,,,,,,17.06,165.24,percent of total billed charges,
86042 Autoimmune Neuromuscular Junction Panel,9040626,CDM,300,RC,86042,HCPCS,,,facility,inpatient,,,202.00000,58.58000,Aetna,First Health,,165.24,,,,,,,121.20,165.24,percent of total billed charges,
86042 Autoimmune Neuromuscular Junction Panel,9040626,CDM,300,RC,86042,HCPCS,,,facility,outpatient,,,202.00000,58.58000,Aetna,First Health,,165.24,,,,,,,17.06,165.24,percent of total billed charges,
BCR ABL1 Diagnostic Non Standard p230 Qual Neogenomics ZB49L,9090307,CDM,300,RC,81208,HCPCS,,,facility,inpatient,,,412.00000,119.48000,Aetna,First Health,,337.02,,,,,,,247.20,337.02,percent of total billed charges,
BCR ABL1 Diagnostic Non Standard p230 Qual Neogenomics ZB49L,9090307,CDM,300,RC,81208,HCPCS,,,facility,outpatient,,,412.00000,119.48000,Aetna,First Health,,337.02,,,,,,,193.64,568.74,percent of total billed charges,
BCR ABL1 Kinase Domain Mutation Analysis Neogenomics ZBY98,9090317,CDM,300,RC,81170,HCPCS,,,facility,inpatient,,,731.00000,211.99000,Aetna,First Health,,597.96,,,,,,,438.60,597.96,percent of total billed charges,
BCR ABL1 Kinase Domain Mutation Analysis Neogenomics ZBY98,9090317,CDM,300,RC,81170,HCPCS,,,facility,outpatient,,,731.00000,211.99000,Aetna,First Health,,597.96,,,,,,,278.10,795.00,percent of total billed charges,
Mumps Virus Qualitative PCR,9088663,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,150.00,204.50,percent of total billed charges,
Mumps Virus Qualitative PCR,9088663,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,32.53,204.50,percent of total billed charges,
HIV 1 and 2 by Qualitative NAAT,9092926,CDM,300,RC,87535,HCPCS,,,facility,inpatient,,,118.00000,34.22000,Aetna,First Health,,96.52,,,,,,,70.80,96.52,percent of total billed charges,
HIV 1 and 2 by Qualitative NAAT,9092926,CDM,300,RC,87535,HCPCS,,,facility,outpatient,,,118.00000,34.22000,Aetna,First Health,,96.52,,,,,,,32.53,96.52,percent of total billed charges,
KLHL11Ab IgG CBA IFA Serum,9103694,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
KLHL11Ab IgG CBA IFA Serum,9103694,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,11.18,305.93,percent of total billed charges,
KLHL11 Ab IgG CBA IFA CSF,9103695,CDM,300,RC,86255,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
KLHL11 Ab IgG CBA IFA CSF,9103695,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,11.18,305.93,percent of total billed charges,
KLHL11 Ab IgG CBA IFA Titer CSF,9103699,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,435.00000,126.15000,Aetna,First Health,,355.83,,,,,,,261.00,355.83,percent of total billed charges,
KLHL11 Ab IgG CBA IFA Titer CSF,9103699,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,435.00000,126.15000,Aetna,First Health,,355.83,,,,,,,11.18,355.83,percent of total billed charges,
KLHL11 Ab IgG CBA IFA Titer Serum,9103700,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,435.00000,126.15000,Aetna,First Health,,355.83,,,,,,,261.00,355.83,percent of total billed charges,
KLHL11 Ab IgG CBA IFA Titer Serum,9103700,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,435.00000,126.15000,Aetna,First Health,,355.83,,,,,,,11.18,355.83,percent of total billed charges,
Coxsackie A Antibodies,9103525,CDM,300,RC,86658,HCPCS,,,facility,inpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,20.40,27.81,percent of total billed charges,
Coxsackie A Antibodies,9103525,CDM,300,RC,86658,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,6.68,34.53,percent of total billed charges,
86658 Coxsackie Ab,9103535,CDM,300,RC,86658,HCPCS,,,facility,inpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,20.40,27.81,percent of total billed charges,
86658 Coxsackie Ab,9103535,CDM,300,RC,86658,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,6.68,34.53,percent of total billed charges,
84182 Protein Western Blot,9104887,CDM,300,RC,84182,HCPCS,,,facility,inpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,38.40,52.35,percent of total billed charges,
84182 Protein Western Blot,9104887,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,23.95,77.41,percent of total billed charges,
Extended Myositis Panel,8464159,CDM,300,RC,86039,HCPCS,,,facility,inpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
Extended Myositis Panel,8464159,CDM,300,RC,86039,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,10.34,29.57,percent of total billed charges,
Vaginosis Panel by TMA,8344406,CDM,300,RC,81513,HCPCS,,,facility,inpatient,,,164.00000,47.56000,Aetna,First Health,,134.15,,,,,,,98.40,134.15,percent of total billed charges,
Vaginosis Panel by TMA,8344406,CDM,300,RC,81513,HCPCS,,,facility,outpatient,,,164.00000,47.56000,Aetna,First Health,,134.15,,,,,,,77.08,377.97,percent of total billed charges,
87481 Candida Species by TMA,8344420,CDM,300,RC,87481,HCPCS,,,facility,inpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,24.00,32.72,percent of total billed charges,
87481 Candida Species by TMA,8344420,CDM,300,RC,87481,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,18.80,92.99,percent of total billed charges,
87661 Trichomonas vaginalis by TMA,8344421,CDM,300,RC,87661,HCPCS,,,facility,inpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,24.00,32.72,percent of total billed charges,
87661 Trichomonas vaginalis by TMA,8344421,CDM,300,RC,87661,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,18.80,92.99,percent of total billed charges,
"Alzheimer?s Disease Evaluation, CSF",8346295,CDM,300,RC,84393,HCPCS,,,facility,inpatient,,,732.00000,212.28000,Aetna,First Health,,598.78,,,,,,,439.20,598.78,percent of total billed charges,
"Alzheimer?s Disease Evaluation, CSF",8346295,CDM,300,RC,84393,HCPCS,,,facility,outpatient,,,732.00000,212.28000,Aetna,First Health,,598.78,,,,,,,128.92,598.78,percent of total billed charges,
84394 Alzheimer's Disease Eval,9101318,CDM,300,RC,84394,HCPCS,,,facility,inpatient,,,732.00000,212.28000,Aetna,First Health,,598.78,,,,,,,439.20,598.78,percent of total billed charges,
84394 Alzheimer's Disease Eval,9101318,CDM,300,RC,84394,HCPCS,,,facility,outpatient,,,732.00000,212.28000,Aetna,First Health,,598.78,,,,,,,128.92,598.78,percent of total billed charges,
82234 Alzheimer's Disease Eval,9103652,CDM,300,RC,82234,HCPCS,,,facility,inpatient,,,732.00000,212.28000,Aetna,First Health,,598.78,,,,,,,439.20,598.78,percent of total billed charges,
82234 Alzheimer's Disease Eval,9103652,CDM,300,RC,82234,HCPCS,,,facility,outpatient,,,732.00000,212.28000,Aetna,First Health,,598.78,,,,,,,128.92,598.78,percent of total billed charges,
Bill erm41Molecular Detection,9101347,CDM,300,RC,87999,HCPCS,,,facility,inpatient,,,663.00000,192.27000,Aetna,First Health,,542.33,,,,,,,397.80,542.33,percent of total billed charges,
Bill erm41Molecular Detection,9101347,CDM,300,RC,87999,HCPCS,,,facility,outpatient,,,663.00000,192.27000,Aetna,First Health,,542.33,,,,,,,239.01,542.33,percent of total billed charges,
JAK2 Exon 12 Analysis CSI ZB6SB,9104403,CDM,300,RC,81279,HCPCS,,,facility,inpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,127.80,174.23,percent of total billed charges,
JAK2 Exon 12 Analysis CSI ZB6SB,9104403,CDM,300,RC,81279,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,100.11,490.78,percent of total billed charges,
"14 3 3 eta Protein, Serum",8247878,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
"14 3 3 eta Protein, Serum",8247878,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,16.01,126.79,percent of total billed charges,
5 Flucytosine Serum,9092959,CDM,300,RC,80299,HCPCS,,,facility,inpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,127.80,174.23,percent of total billed charges,
5 Flucytosine Serum,9092959,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,17.28,174.23,percent of total billed charges,
Cystatin and Creatinine with eGFR,9092950,CDM,300,RC,82610,HCPCS,,,facility,inpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,72.00,98.16,percent of total billed charges,
Cystatin and Creatinine with eGFR,9092950,CDM,300,RC,82610,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,17.17,98.16,percent of total billed charges,
82565 Cystatin and Creatinine with eGFR,9092951,CDM,300,RC,82565,HCPCS,,,facility,inpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,20.40,27.81,percent of total billed charges,
82565 Cystatin and Creatinine with eGFR,9092951,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,4.75,27.81,percent of total billed charges,
Cashew Component rAna o3,9094578,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
Cashew Component rAna o3,9094578,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,16.62,122.70,percent of total billed charges,
Walnut Component IgE,9094762,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
Walnut Component IgE,9094762,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,16.62,122.70,percent of total billed charges,
Walnut Component IgE,9094766,CDM,300,RC,86008,HCPCS,,,facility,inpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,90.00,122.70,percent of total billed charges,
Walnut Component IgE,9094766,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,First Health,,122.70,,,,,,,16.62,122.70,percent of total billed charges,
von Willebrand Factor Multimers,9093122,CDM,300,RC,85247,HCPCS,,,facility,inpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,103.20,140.70,percent of total billed charges,
von Willebrand Factor Multimers,9093122,CDM,300,RC,85247,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,First Health,,140.70,,,,,,,21.27,140.70,percent of total billed charges,
87538 HIV 2 Probe,9093843,CDM,300,RC,87538,HCPCS,,,facility,inpatient,,,118.00000,34.22000,Aetna,First Health,,96.52,,,,,,,70.80,96.52,percent of total billed charges,
87538 HIV 2 Probe,9093843,CDM,300,RC,87538,HCPCS,,,facility,outpatient,,,118.00000,34.22000,Aetna,First Health,,96.52,,,,,,,32.53,96.52,percent of total billed charges,
Osmotic Fragility Erythrocyte,9105265,CDM,300,RC,85555,HCPCS,,,facility,inpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,111.60,152.15,percent of total billed charges,
Osmotic Fragility Erythrocyte,9105265,CDM,300,RC,85555,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,First Health,,152.15,,,,,,,6.92,152.15,percent of total billed charges,
RBC Band 3 Protein Reduction in Hereditary Spherocytosis,9105266,CDM,300,RC,88184,HCPCS,,,facility,inpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,154.80,211.04,percent of total billed charges,
RBC Band 3 Protein Reduction in Hereditary Spherocytosis,9105266,CDM,300,RC,88184,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,First Health,,211.04,,,,,,,47.66,951.40,percent of total billed charges,
Solid Tumor Profile NGS Z01SA,9108886,CDM,300,RC,81479,HCPCS,,,facility,inpatient,,,3230.00000,936.70000,Aetna,First Health,,2642.14,,,,,,,1938.00,2642.14,percent of total billed charges,
Solid Tumor Profile NGS Z01SA,9108886,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,3230.00000,936.70000,Aetna,First Health,,2642.14,,,,,,,1164.41,2642.14,percent of total billed charges,
HPV High Risk Rflx to Genotype,9109069,CDM,300,RC,87624,HCPCS,,,facility,inpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,91.80,125.15,percent of total billed charges,
HPV High Risk Rflx to Genotype,9109069,CDM,300,RC,87624,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,32.53,125.15,percent of total billed charges,
HPV Genotype 16 18.45,9109070,CDM,300,RC,87625,HCPCS,,,facility,inpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,87.00,118.61,percent of total billed charges,
HPV Genotype 16 18.45,9109070,CDM,300,RC,87625,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,First Health,,118.61,,,,,,,37.59,118.61,percent of total billed charges,
PAP Pathologist Review,9109013,CDM,300,RC,88141,HCPCS,,,facility,inpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,94.80,129.24,percent of total billed charges,
PAP Pathologist Review,9109013,CDM,300,RC,88141,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,First Health,,129.24,,,,,,,21.36,129.24,percent of total billed charges,
Neurofilament Lighe Chain Plasma,9109513,CDM,300,RC,0361U,HCPCS,,,facility,inpatient,,,1461.00000,423.69000,Aetna,First Health,,1195.10,,,,,,,876.60,1195.10,percent of total billed charges,
Neurofilament Lighe Chain Plasma,9109513,CDM,300,RC,0361U,HCPCS,,,facility,outpatient,,,1461.00000,423.69000,Aetna,First Health,,1195.10,,,,,,,526.69,1195.10,percent of total billed charges,
Powassan Virus PCR Serum,9118490,CDM,300,RC,87798,HCPCS,,,facility,inpatient,,,911.00000,264.19000,Aetna,First Health,,745.20,,,,,,,546.60,745.20,percent of total billed charges,
Powassan Virus PCR Serum,9118490,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,911.00000,264.19000,Aetna,First Health,,745.20,,,,,,,32.53,745.20,percent of total billed charges,
"Phospho Tau 217,Plasma",9122399,CDM,300,RC,84393,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
"Phospho Tau 217,Plasma",9122399,CDM,300,RC,84393,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,128.92,593.05,percent of total billed charges,
"Anti Mutated Citrullinated Vimentin,Ab",9122398,CDM,300,RC,83520,HCPCS,,,facility,inpatient,,,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,151.80,206.95,percent of total billed charges,
"Anti Mutated Citrullinated Vimentin,Ab",9122398,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,16.01,206.95,percent of total billed charges,
Hemoglobin S Sickle Solubility,9122395,CDM,300,RC,85660,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,80.40,109.61,percent of total billed charges,
Hemoglobin S Sickle Solubility,9122395,CDM,300,RC,85660,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,5.11,109.61,percent of total billed charges,
Chromosome Analysis Peripheral Blood,3232942,CDM,300,RC,88262,HCPCS,,,facility,inpatient,,,288.00000,83.52000,Aetna,First Health,,235.58,,,,,,,172.80,235.58,percent of total billed charges,
Chromosome Analysis Peripheral Blood,3232942,CDM,300,RC,88262,HCPCS,,,facility,outpatient,,,288.00000,83.52000,Aetna,First Health,,235.58,,,,,,,116.33,332.55,percent of total billed charges,
88230 Tissue Cult Lymph,9132514,CDM,300,RC,88230,HCPCS,,,facility,inpatient,,,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,159.00,216.77,percent of total billed charges,
88230 Tissue Cult Lymph,9132514,CDM,300,RC,88230,HCPCS,,,facility,outpatient,,,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,32.36,308.70,percent of total billed charges,
Bill Lymph Non Neo Processing Fee 93267,9132524,CDM,300,RC,88230,HCPCS,,,facility,inpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,69.60,94.89,percent of total billed charges,
Bill Lymph Non Neo Processing Fee 93267,9132524,CDM,300,RC,88230,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,32.36,308.70,percent of total billed charges,
Bill Counts 5 1 Karyotype 93261,9132525,CDM,300,RC,88261,HCPCS,,,facility,inpatient,,,264.00000,76.56000,Aetna,First Health,,215.95,,,,,,,158.40,215.95,percent of total billed charges,
Bill Counts 5 1 Karyotype 93261,9132525,CDM,300,RC,88261,HCPCS,,,facility,outpatient,,,264.00000,76.56000,Aetna,First Health,,215.95,,,,,,,124.08,700.50,percent of total billed charges,
Bill/Interp and Reporting 93252,9132526,CDM,300,RC,88291,HCPCS,,,facility,inpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,63.00,85.89,percent of total billed charges,
Bill/Interp and Reporting 93252,9132526,CDM,300,RC,88291,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,First Health,,85.89,,,,,,,25.72,85.89,percent of total billed charges,
Bill 88369 FISH-CSI,9132395,CDM,300,RC,88369,HCPCS,,,facility,inpatient,,,223.00000,64.67000,Aetna,First Health,,182.41,,,,,,,133.80,182.41,percent of total billed charges,
Bill 88369 FISH-CSI,9132395,CDM,300,RC,88369,HCPCS,,,facility,outpatient,,,223.00000,64.67000,Aetna,First Health,,182.41,,,,,,,80.39,182.41,percent of total billed charges,
Neisseria gonorrhoeae by TMA,8297037,CDM,300,RC,87591,HCPCS,,,facility,inpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,89.40,121.88,percent of total billed charges,
Neisseria gonorrhoeae by TMA,8297037,CDM,300,RC,87591,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,First Health,,121.88,,,,,,,32.53,121.88,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,9132532,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,150.00,204.50,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,9132532,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,8.02,204.50,percent of total billed charges,
"Vedolizumab Quant w Antibodies, Serum",9132502,CDM,300,RC,80280,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
"Vedolizumab Quant w Antibodies, Serum",9132502,CDM,300,RC,80280,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,35.75,288.75,percent of total billed charges,
82397 Vedolizumab,9142151,CDM,300,RC,82397,HCPCS,,,facility,inpatient,,,128.00000,37.12000,Aetna,First Health,,104.70,,,,,,,76.80,104.70,percent of total billed charges,
82397 Vedolizumab,9142151,CDM,300,RC,82397,HCPCS,,,facility,outpatient,,,128.00000,37.12000,Aetna,First Health,,104.70,,,,,,,13.09,104.70,percent of total billed charges,
Bill/Susceptibility single drug by broth dilution,9142228,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,121.80,166.05,percent of total billed charges,
Bill/Susceptibility single drug by broth dilution,9142228,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,8.02,166.05,percent of total billed charges,
Bill/Susceptibility broth dilution auto read,9142229,CDM,300,RC,87186,HCPCS,,,facility,inpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,121.80,166.05,percent of total billed charges,
Bill/Susceptibility broth dilution auto read,9142229,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,First Health,,166.05,,,,,,,8.02,166.05,percent of total billed charges,
APOLIPOPROTEIN B,8356387,CDM,300,RC,82172,HCPCS,,,facility,inpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,87.60,119.43,percent of total billed charges,
APOLIPOPROTEIN B,8356387,CDM,300,RC,82172,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,First Health,,119.43,,,,,,,19.55,119.43,percent of total billed charges,
Helicobacter pylori Urea Breath Test,8342253,CDM,300,RC,83013,HCPCS,,,facility,inpatient,,,183.00000,53.07000,Aetna,First Health,,149.69,,,,,,,109.80,149.69,percent of total billed charges,
Helicobacter pylori Urea Breath Test,8342253,CDM,300,RC,83013,HCPCS,,,facility,outpatient,,,183.00000,53.07000,Aetna,First Health,,149.69,,,,,,,62.44,178.50,percent of total billed charges,
Amyloid Beta,9176399,CDM,300,RC,83519,HCPCS,,,facility,inpatient,,,527.00000,152.83000,Aetna,First Health,,431.09,,,,,,,316.20,431.09,percent of total billed charges,
Amyloid Beta,9176399,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,527.00000,152.83000,Aetna,First Health,,431.09,,,,,,,17.06,431.09,percent of total billed charges,
Copeptin proAVP,8451941,CDM,300,RC,84588,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,93.00,126.79,percent of total billed charges,
Copeptin proAVP,8451941,CDM,300,RC,84588,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,31.47,126.79,percent of total billed charges,
PAP Digital Imaging Review,9190449,CDM,300,RC,88175,HCPCS,,,facility,inpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,93.60,127.61,percent of total billed charges,
PAP Digital Imaging Review,9190449,CDM,300,RC,88175,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,First Health,,127.61,,,,,,,24.67,127.61,percent of total billed charges,
Leishmania Ab IgG,9180614,CDM,300,RC,86717,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
Leishmania Ab IgG,9180614,CDM,300,RC,86717,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,7.68,88.34,percent of total billed charges,
Valproic Acid Total,8356297,CDM,300,RC,80164,HCPCS,,,facility,inpatient,,,86.00000,24.94000,Aetna,First Health,,70.35,,,,,,,51.60,70.35,percent of total billed charges,
Valproic Acid Total,8356297,CDM,300,RC,80164,HCPCS,,,facility,outpatient,,,86.00000,24.94000,Aetna,First Health,,70.35,,,,,,,12.56,70.35,percent of total billed charges,
PAP Manual Review,9190450,CDM,300,RC,88142,HCPCS,,,facility,inpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
PAP Manual Review,9190450,CDM,300,RC,88142,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,10.39,128.43,percent of total billed charges,
HPV Screen PCR,9192443,CDM,300,RC,87626,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
HPV Screen PCR,9192443,CDM,300,RC,87626,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,65.08,305.93,percent of total billed charges,
Prion Markers 1433 Gamma Bill,9210716,CDM,300,RC,86317,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
Prion Markers 1433 Gamma Bill,9210716,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,13.89,114.52,percent of total billed charges,
Prion Markers Total Tau Bill,9210715,CDM,300,RC,86317,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
Prion Markers Total Tau Bill,9210715,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,13.89,114.52,percent of total billed charges,
REFLEX LYMPHOCYTE NON NEOPLASIC BILL,9222442,CDM,300,RC,88230,HCPCS,,,facility,inpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,150.00,204.50,percent of total billed charges,
REFLEX LYMPHOCYTE NON NEOPLASIC BILL,9222442,CDM,300,RC,88230,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,32.36,308.70,percent of total billed charges,
"REFLEX COUNT 5,1 KARYOTYPE BILL",9222443,CDM,300,RC,88261,HCPCS,,,facility,inpatient,,,249.00000,72.21000,Aetna,First Health,,203.68,,,,,,,149.40,203.68,percent of total billed charges,
"REFLEX COUNT 5,1 KARYOTYPE BILL",9222443,CDM,300,RC,88261,HCPCS,,,facility,outpatient,,,249.00000,72.21000,Aetna,First Health,,203.68,,,,,,,117.03,700.50,percent of total billed charges,
REFLEX INTERPRETATION AND REPORTING BILL,9222444,CDM,300,RC,88291,HCPCS,,,facility,inpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,150.00,204.50,percent of total billed charges,
REFLEX INTERPRETATION AND REPORTING BILL,9222444,CDM,300,RC,88291,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,First Health,,204.50,,,,,,,25.72,204.50,percent of total billed charges,
Fatty Acids Profile,9178429,CDM,300,RC,82542,HCPCS,,,facility,inpatient,,,617.00000,178.93000,Aetna,First Health,,504.71,,,,,,,370.20,504.71,percent of total billed charges,
Fatty Acids Profile,9178429,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,617.00000,178.93000,Aetna,First Health,,504.71,,,,,,,11.66,504.71,percent of total billed charges,
81405 Prometheus IBD sgi diagnositic ZB25M,9180514,CDM,300,RC,81405,HCPCS,,,facility,inpatient,,,302.00000,87.58000,Aetna,First Health,,247.04,,,,,,,181.20,247.04,percent of total billed charges,
81405 Prometheus IBD sgi diagnositic ZB25M,9180514,CDM,300,RC,81405,HCPCS,,,facility,outpatient,,,302.00000,87.58000,Aetna,First Health,,247.04,,,,,,,141.94,798.58,percent of total billed charges,
80165 Valproic Acid Free,9184458,CDM,300,RC,80165,HCPCS,,,facility,inpatient,,,86.00000,24.94000,Aetna,First Health,,70.35,,,,,,,51.60,70.35,percent of total billed charges,
80165 Valproic Acid Free,9184458,CDM,300,RC,80165,HCPCS,,,facility,outpatient,,,86.00000,24.94000,Aetna,First Health,,70.35,,,,,,,12.56,70.35,percent of total billed charges,
T Uptake ARUP,9002340,CDM,300,RC,84479,HCPCS,,,facility,inpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
T Uptake ARUP,9002340,CDM,300,RC,84479,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,5.99,125.97,percent of total billed charges,
mGluR1 Ab IFA Titer Serum,8914185,CDM,300,RC,86256,HCPCS,,,facility,inpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,64.80,88.34,percent of total billed charges,
mGluR1 Ab IFA Titer Serum,8914185,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,11.18,88.34,percent of total billed charges,
THERAPIST ABG DRAW,8070818,CDM,300,RC,36600,HCPCS,,,facility,inpatient,,,190.00000,55.10000,Aetna,First Health,,155.42,,,,,,,114.00,155.42,percent of total billed charges,
THERAPIST ABG DRAW,8070818,CDM,300,RC,36600,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,First Health,,155.42,,,,,,,76.00,2860.00,percent of total billed charges,
DYSAUTONOMIA EVAL BY RIA,8121236,CDM,300,RC,,,,,facility,inpatient,,,221.00000,64.09000,Aetna,First Health,,180.78,,,,,,,132.60,180.78,percent of total billed charges,
DYSAUTONOMIA EVAL BY RIA,8121236,CDM,300,RC,,,,,facility,outpatient,,,221.00000,64.09000,Aetna,First Health,,180.78,,,,,,,79.67,180.78,percent of total billed charges,
Pain Management Fluoro 320,8151453,CDM,320,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
Pain Management Fluoro 320,8151453,CDM,320,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,981.60,percent of total billed charges,
Fluoro Guidance,8062811,CDM,320,RC,,,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,900.00,1227.00,percent of total billed charges,
Fluoro Guidance,8062811,CDM,320,RC,,,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
RA Mandible Minimum 4 Views,613973,CDM,320,RC,70110,HCPCS,,,facility,inpatient,,,588.00000,170.52000,Aetna,First Health,,480.98,,,,,,,352.80,480.98,percent of total billed charges,
RA Mandible Minimum 4 Views,613973,CDM,320,RC,70110,HCPCS,,,facility,outpatient,,,588.00000,170.52000,Aetna,First Health,,480.98,,,,,,,23.44,480.98,percent of total billed charges,
RA Orbits Foreign Body,614071,CDM,320,RC,70030,HCPCS,,,facility,inpatient,,,313.00000,90.77000,Aetna,First Health,,256.03,,,,,,,187.80,256.03,percent of total billed charges,
RA Orbits Foreign Body,614071,CDM,320,RC,70030,HCPCS,,,facility,outpatient,,,313.00000,90.77000,Aetna,First Health,,256.03,,,,,,,15.64,256.03,percent of total billed charges,
RA Sinuses 1 or 2 Views,614223,CDM,320,RC,70210,HCPCS,,,facility,inpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,241.80,329.65,percent of total billed charges,
RA Sinuses 1 or 2 Views,614223,CDM,320,RC,70210,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,23.44,329.65,percent of total billed charges,
RA Sinuses Minimum 3 Views,614229,CDM,320,RC,70220,HCPCS,,,facility,inpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,396.60,540.70,percent of total billed charges,
RA Sinuses Minimum 3 Views,614229,CDM,320,RC,70220,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,29.48,540.70,percent of total billed charges,
RA Neck Soft Tissue,614040,CDM,320,RC,70360,HCPCS,,,facility,inpatient,,,393.00000,113.97000,Aetna,First Health,,321.47,,,,,,,235.80,321.47,percent of total billed charges,
RA Neck Soft Tissue,614040,CDM,320,RC,70360,HCPCS,,,facility,outpatient,,,393.00000,113.97000,Aetna,First Health,,321.47,,,,,,,15.64,321.47,percent of total billed charges,
RA Chest Single View,8001025,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest Single View,8001025,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Ribs Unilateral Right,7920867,CDM,320,RC,71101,HCPCS,,,facility,inpatient,,,572.00000,165.88000,Aetna,First Health,RT,467.90,,,,,,,343.20,467.90,percent of total billed charges,
RA Ribs Unilateral Right,7920867,CDM,320,RC,71101,HCPCS,,,facility,outpatient,,,572.00000,165.88000,Aetna,First Health,RT,467.90,,,,,,,25.22,467.90,percent of total billed charges,
RA Ribs Unilateral Left,7920859,CDM,320,RC,71101,HCPCS,,,facility,inpatient,,,572.00000,165.88000,Aetna,First Health,LT,467.90,,,,,,,343.20,467.90,percent of total billed charges,
RA Ribs Unilateral Left,7920859,CDM,320,RC,71101,HCPCS,,,facility,outpatient,,,572.00000,165.88000,Aetna,First Health,LT,467.90,,,,,,,25.22,467.90,percent of total billed charges,
RA Mandible Less than 4 Views,613979,CDM,320,RC,70100,HCPCS,,,facility,inpatient,,,413.00000,119.77000,Aetna,First Health,,337.83,,,,,,,247.80,337.83,percent of total billed charges,
RA Mandible Less than 4 Views,613979,CDM,320,RC,70100,HCPCS,,,facility,outpatient,,,413.00000,119.77000,Aetna,First Health,,337.83,,,,,,,19.19,337.83,percent of total billed charges,
RA Ribs Bilateral w PA Chest,7920875,CDM,320,RC,71111,HCPCS,,,facility,inpatient,,,763.00000,221.27000,Aetna,First Health,,624.13,,,,,,,457.80,624.13,percent of total billed charges,
RA Ribs Bilateral w PA Chest,7920875,CDM,320,RC,71111,HCPCS,,,facility,outpatient,,,763.00000,221.27000,Aetna,First Health,,624.13,,,,,,,33.74,624.13,percent of total billed charges,
RA Sternum Minimum 2 Views,614259,CDM,320,RC,71120,HCPCS,,,facility,inpatient,,,454.00000,131.66000,Aetna,First Health,,371.37,,,,,,,272.40,371.37,percent of total billed charges,
RA Sternum Minimum 2 Views,614259,CDM,320,RC,71120,HCPCS,,,facility,outpatient,,,454.00000,131.66000,Aetna,First Health,,371.37,,,,,,,24.51,371.37,percent of total billed charges,
RA Ankle 2 Views Right,2052836,CDM,320,RC,73600,HCPCS,,,facility,inpatient,,,395.00000,114.55000,Aetna,First Health,RT,323.11,,,,,,,237.00,323.11,percent of total billed charges,
RA Ankle 2 Views Right,2052836,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,First Health,RT,323.11,,,,,,,18.12,323.11,percent of total billed charges,
RA Ankle 2 Views Left,2052834,CDM,320,RC,73600,HCPCS,,,facility,inpatient,,,395.00000,114.55000,Aetna,First Health,LT,323.11,,,,,,,237.00,323.11,percent of total billed charges,
RA Ankle 2 Views Left,2052834,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,First Health,LT,323.11,,,,,,,18.12,323.11,percent of total billed charges,
RA Facial Bones 1 or 2 Views,613736,CDM,320,RC,70140,HCPCS,,,facility,inpatient,,,473.00000,137.17000,Aetna,First Health,,386.91,,,,,,,283.80,386.91,percent of total billed charges,
RA Facial Bones 1 or 2 Views,613736,CDM,320,RC,70140,HCPCS,,,facility,outpatient,,,473.00000,137.17000,Aetna,First Health,,386.91,,,,,,,23.44,386.91,percent of total billed charges,
RA Spine 1 View,2052838,CDM,320,RC,72020,HCPCS,,,facility,inpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,241.80,329.65,percent of total billed charges,
RA Spine 1 View,2052838,CDM,320,RC,72020,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,15.64,329.65,percent of total billed charges,
RA Spine 1 View,6043847,CDM,320,RC,72020,HCPCS,,,facility,inpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,241.80,329.65,percent of total billed charges,
RA Spine 1 View,6043847,CDM,320,RC,72020,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,15.64,329.65,percent of total billed charges,
RA Spine 1 View,613633,CDM,320,RC,72020,HCPCS,,,facility,inpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,241.80,329.65,percent of total billed charges,
RA Spine 1 View,613633,CDM,320,RC,72020,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,15.64,329.65,percent of total billed charges,
RA Spine 1 View,7908918,CDM,320,RC,72020,HCPCS,,,facility,inpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,241.80,329.65,percent of total billed charges,
RA Spine 1 View,7908918,CDM,320,RC,72020,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,15.64,329.65,percent of total billed charges,
RA Facial Bones Minimum 3 Views,613734,CDM,320,RC,70150,HCPCS,,,facility,inpatient,,,692.00000,200.68000,Aetna,First Health,,566.06,,,,,,,415.20,566.06,percent of total billed charges,
RA Facial Bones Minimum 3 Views,613734,CDM,320,RC,70150,HCPCS,,,facility,outpatient,,,692.00000,200.68000,Aetna,First Health,,566.06,,,,,,,29.48,566.06,percent of total billed charges,
RA Nasal Bones Minimum 3 Views,614036,CDM,320,RC,70160,HCPCS,,,facility,inpatient,,,470.00000,136.30000,Aetna,First Health,,384.46,,,,,,,282.00,384.46,percent of total billed charges,
RA Nasal Bones Minimum 3 Views,614036,CDM,320,RC,70160,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,First Health,,384.46,,,,,,,19.19,384.46,percent of total billed charges,
RA Sterno Clavicular Joints Minimum 3V,614255,CDM,320,RC,71130,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Sterno Clavicular Joints Minimum 3V,614255,CDM,320,RC,71130,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,,312.48,,,,,,,26.65,312.48,percent of total billed charges,
RA Hip Arthrogram Left,7253886,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Hip Arthrogram Left,7253886,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Hip Arthrogram Left,7957020,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Hip Arthrogram Left,7957020,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Orbits Minimum 4 Views,614063,CDM,320,RC,70200,HCPCS,,,facility,inpatient,,,556.00000,161.24000,Aetna,First Health,,454.81,,,,,,,333.60,454.81,percent of total billed charges,
RA Orbits Minimum 4 Views,614063,CDM,320,RC,70200,HCPCS,,,facility,outpatient,,,556.00000,161.24000,Aetna,First Health,,454.81,,,,,,,29.48,454.81,percent of total billed charges,
RA Skull Less than 4 Views,614237,CDM,320,RC,70250,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
RA Skull Less than 4 Views,614237,CDM,320,RC,70250,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,23.44,420.45,percent of total billed charges,
RA Skull Minimum 4 Views,614233,CDM,320,RC,70260,HCPCS,,,facility,inpatient,,,733.00000,212.57000,Aetna,First Health,,599.59,,,,,,,439.80,599.59,percent of total billed charges,
RA Skull Minimum 4 Views,614233,CDM,320,RC,70260,HCPCS,,,facility,outpatient,,,733.00000,212.57000,Aetna,First Health,,599.59,,,,,,,33.74,599.59,percent of total billed charges,
RA Temporal Mandibular Joint,614269,CDM,320,RC,70330,HCPCS,,,facility,inpatient,,,556.00000,161.24000,Aetna,First Health,,454.81,,,,,,,333.60,454.81,percent of total billed charges,
RA Temporal Mandibular Joint,614269,CDM,320,RC,70330,HCPCS,,,facility,outpatient,,,556.00000,161.24000,Aetna,First Health,,454.81,,,,,,,31.62,454.81,percent of total billed charges,
RA Thoracolumbar 2 Views,3661907,CDM,320,RC,72080,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
RA Thoracolumbar 2 Views,3661907,CDM,320,RC,72080,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,25.22,420.45,percent of total billed charges,
RA Osseous Survery Complete,613998,CDM,320,RC,77075,HCPCS,,,facility,inpatient,,,733.00000,212.57000,Aetna,First Health,,599.59,,,,,,,439.80,599.59,percent of total billed charges,
RA Osseous Survery Complete,613998,CDM,320,RC,77075,HCPCS,,,facility,outpatient,,,733.00000,212.57000,Aetna,First Health,,599.59,,,,,,,93.38,599.59,percent of total billed charges,
RA Osseous Survey Complete,661540,CDM,320,RC,77075,HCPCS,,,facility,inpatient,,,733.00000,212.57000,Aetna,First Health,,599.59,,,,,,,439.80,599.59,percent of total billed charges,
RA Osseous Survey Complete,661540,CDM,320,RC,77075,HCPCS,,,facility,outpatient,,,733.00000,212.57000,Aetna,First Health,,599.59,,,,,,,93.38,599.59,percent of total billed charges,
RA Bone Mineral Analysis Dexa,7544174,CDM,320,RC,77075,HCPCS,,,facility,inpatient,,,733.00000,212.57000,Aetna,First Health,,599.59,,,,,,,439.80,599.59,percent of total billed charges,
RA Bone Mineral Analysis Dexa,7544174,CDM,320,RC,77075,HCPCS,,,facility,outpatient,,,733.00000,212.57000,Aetna,First Health,,599.59,,,,,,,93.38,599.59,percent of total billed charges,
RA Knee 3 Views Left,7253922,CDM,320,RC,73562,HCPCS,,,facility,inpatient,,,464.00000,134.56000,Aetna,First Health,LT,379.55,,,,,,,278.40,379.55,percent of total billed charges,
RA Knee 3 Views Left,7253922,CDM,320,RC,73562,HCPCS,,,facility,outpatient,,,464.00000,134.56000,Aetna,First Health,LT,379.55,,,,,,,21.67,379.55,percent of total billed charges,
RA Knee Right 4 or More Views,7235923,CDM,320,RC,73564,HCPCS,,,facility,inpatient,,,560.00000,162.40000,Aetna,First Health,RT,458.08,,,,,,,336.00,458.08,percent of total billed charges,
RA Knee Right 4 or More Views,7235923,CDM,320,RC,73564,HCPCS,,,facility,outpatient,,,560.00000,162.40000,Aetna,First Health,RT,458.08,,,,,,,23.44,458.08,percent of total billed charges,
RA Knee Left 4 or More Views,7235919,CDM,320,RC,73564,HCPCS,,,facility,inpatient,,,560.00000,162.40000,Aetna,First Health,LT,458.08,,,,,,,336.00,458.08,percent of total billed charges,
RA Knee Left 4 or More Views,7235919,CDM,320,RC,73564,HCPCS,,,facility,outpatient,,,560.00000,162.40000,Aetna,First Health,LT,458.08,,,,,,,23.44,458.08,percent of total billed charges,
RA Ribs Unilateral Right 2 Views,7920871,CDM,320,RC,71100,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,RT,360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Ribs Unilateral Right 2 Views,7920871,CDM,320,RC,71100,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,RT,360.74,,,,,,,21.67,360.74,percent of total billed charges,
RA Ribs Unilateral Left 2 Views,7920863,CDM,320,RC,71100,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,LT,360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Ribs Unilateral Left 2 Views,7920863,CDM,320,RC,71100,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,LT,360.74,,,,,,,21.67,360.74,percent of total billed charges,
RA Ribs Bilateral 3 Views,7920879,CDM,320,RC,71110,HCPCS,,,facility,inpatient,,,529.00000,153.41000,Aetna,First Health,,432.72,,,,,,,317.40,432.72,percent of total billed charges,
RA Ribs Bilateral 3 Views,7920879,CDM,320,RC,71110,HCPCS,,,facility,outpatient,,,529.00000,153.41000,Aetna,First Health,,432.72,,,,,,,29.48,432.72,percent of total billed charges,
RA Thoracic Spine 2 Views,7790074,CDM,320,RC,72070,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
RA Thoracic Spine 2 Views,7790074,CDM,320,RC,72070,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,24.51,420.45,percent of total billed charges,
RA Scoliosis Study 2 or 3 Views,614199,CDM,320,RC,72082,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,,360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Scoliosis Study 2 or 3 Views,614199,CDM,320,RC,72082,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,,360.74,,,,,,,65.38,360.74,percent of total billed charges,
RA Lumbar Spine Minimum 6 Views,7903303,CDM,320,RC,72114,HCPCS,,,facility,inpatient,,,880.00000,255.20000,Aetna,First Health,,719.84,,,,,,,528.00,719.84,percent of total billed charges,
RA Lumbar Spine Minimum 6 Views,7903303,CDM,320,RC,72114,HCPCS,,,facility,outpatient,,,880.00000,255.20000,Aetna,First Health,,719.84,,,,,,,44.41,719.84,percent of total billed charges,
RA Cervical Spine 6 or more Views,6439864,CDM,320,RC,72052,HCPCS,,,facility,inpatient,,,821.00000,238.09000,Aetna,First Health,,671.58,,,,,,,492.60,671.58,percent of total billed charges,
RA Cervical Spine 6 or more Views,6439864,CDM,320,RC,72052,HCPCS,,,facility,outpatient,,,821.00000,238.09000,Aetna,First Health,,671.58,,,,,,,42.28,671.58,percent of total billed charges,
RA Ankle Arthrogram Left,7253859,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Ankle Arthrogram Left,7253859,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Ankle Arthrogram Left,7957003,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Ankle Arthrogram Left,7957003,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Joint Aspiration Left,7253898,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Joint Aspiration Left,7253898,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Ankle Arthrogram Right,7235862,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Ankle Arthrogram Right,7235862,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Ankle Arthrogram Right,7957005,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Ankle Arthrogram Right,7957005,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Elbow Right Minimum 3 Views,7235866,CDM,320,RC,73080,HCPCS,,,facility,inpatient,,,443.00000,128.47000,Aetna,First Health,RT,362.37,,,,,,,265.80,362.37,percent of total billed charges,
RA Elbow Right Minimum 3 Views,7235866,CDM,320,RC,73080,HCPCS,,,facility,outpatient,,,443.00000,128.47000,Aetna,First Health,RT,362.37,,,,,,,21.67,362.37,percent of total billed charges,
RA Elbow Arthrogram Right,7235868,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Elbow Arthrogram Right,7235868,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Elbow Arthrogram Right,7957014,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Elbow Arthrogram Right,7957014,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Foot 2 Views Right,7235872,CDM,320,RC,73620,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,RT,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Foot 2 Views Right,7235872,CDM,320,RC,73620,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,RT,312.48,,,,,,,18.12,312.48,percent of total billed charges,
RA Hand 2 Views Right,7253879,CDM,320,RC,73120,HCPCS,,,facility,inpatient,,,367.00000,106.43000,Aetna,First Health,RT,300.21,,,,,,,220.20,300.21,percent of total billed charges,
RA Hand 2 Views Right,7253879,CDM,320,RC,73120,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,First Health,RT,300.21,,,,,,,18.12,300.21,percent of total billed charges,
RA Hip Arthrogram Right,7235878,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Hip Arthrogram Right,7235878,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Hip Arthrogram Right,7957022,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Hip Arthrogram Right,7957022,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Joint Aspiration Right,7235890,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Joint Aspiration Right,7235890,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Knee Arthrogram Right,7235894,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Knee Arthrogram Right,7235894,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Knee Arthrogram Right,7957030,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Knee Arthrogram Right,7957030,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Shoulder Arthrogram Right,7235898,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Shoulder Arthrogram Right,7235898,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Shoulder Arthrogram Right,7957038,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Shoulder Arthrogram Right,7957038,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Shoulder 1 View Right,7235902,CDM,320,RC,73020,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,RT,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Shoulder 1 View Right,7235902,CDM,320,RC,73020,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,RT,312.48,,,,,,,17.41,312.48,percent of total billed charges,
RA Wrist 2 Views Right,7235906,CDM,320,RC,73100,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,RT,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Wrist 2 Views Right,7235906,CDM,320,RC,73100,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,RT,312.48,,,,,,,18.12,312.48,percent of total billed charges,
RA Wrist Arthrogram Right,7235911,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Wrist Arthrogram Right,7235911,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Wrist Arthrogram Right,7957046,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Wrist Arthrogram Right,7957046,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Joint Injection Fluoroscopy Guide,7286039,CDM,320,RC,,,,,facility,inpatient,,,5214.00000,1512.06000,Aetna,First Health,,4265.05,,,,,,,3128.40,4265.05,percent of total billed charges,
RA Joint Injection Fluoroscopy Guide,7286039,CDM,320,RC,,,,,facility,outpatient,,,5214.00000,1512.06000,Aetna,First Health,,4265.05,,,,,,,1879.65,4265.05,percent of total billed charges,
RA Cervical Spine 2 or 3 Views,7790082,CDM,320,RC,72040,HCPCS,,,facility,inpatient,,,674.00000,195.46000,Aetna,First Health,,551.33,,,,,,,404.40,551.33,percent of total billed charges,
RA Cervical Spine 2 or 3 Views,7790082,CDM,320,RC,72040,HCPCS,,,facility,outpatient,,,674.00000,195.46000,Aetna,First Health,,551.33,,,,,,,22.73,551.33,percent of total billed charges,
RA Cervical Spine 4 or 5 Views,613625,CDM,320,RC,72050,HCPCS,,,facility,inpatient,,,821.00000,238.09000,Aetna,First Health,,671.58,,,,,,,492.60,671.58,percent of total billed charges,
RA Cervical Spine 4 or 5 Views,613625,CDM,320,RC,72050,HCPCS,,,facility,outpatient,,,821.00000,238.09000,Aetna,First Health,,671.58,,,,,,,33.74,671.58,percent of total billed charges,
RA Thoracic Spine 3 Views,7790078,CDM,320,RC,72072,HCPCS,,,facility,inpatient,,,600.00000,174.00000,Aetna,First Health,,490.80,,,,,,,360.00,490.80,percent of total billed charges,
RA Thoracic Spine 3 Views,7790078,CDM,320,RC,72072,HCPCS,,,facility,outpatient,,,600.00000,174.00000,Aetna,First Health,,490.80,,,,,,,27.71,490.80,percent of total billed charges,
RA Lumbar Spine 2 or 3 Views,7903293,CDM,320,RC,72100,HCPCS,,,facility,inpatient,,,572.00000,165.88000,Aetna,First Health,,467.90,,,,,,,343.20,467.90,percent of total billed charges,
RA Lumbar Spine 2 or 3 Views,7903293,CDM,320,RC,72100,HCPCS,,,facility,outpatient,,,572.00000,165.88000,Aetna,First Health,,467.90,,,,,,,25.22,467.90,percent of total billed charges,
RA Lumbar Spine Minimum 4 Views,7903299,CDM,320,RC,72110,HCPCS,,,facility,inpatient,,,808.00000,234.32000,Aetna,First Health,,660.94,,,,,,,484.80,660.94,percent of total billed charges,
RA Lumbar Spine Minimum 4 Views,7903299,CDM,320,RC,72110,HCPCS,,,facility,outpatient,,,808.00000,234.32000,Aetna,First Health,,660.94,,,,,,,34.46,660.94,percent of total billed charges,
RA Lumbar Spine Bending 2 or 3 Views,613952,CDM,320,RC,72120,HCPCS,,,facility,inpatient,,,572.00000,165.88000,Aetna,First Health,,467.90,,,,,,,343.20,467.90,percent of total billed charges,
RA Lumbar Spine Bending 2 or 3 Views,613952,CDM,320,RC,72120,HCPCS,,,facility,outpatient,,,572.00000,165.88000,Aetna,First Health,,467.90,,,,,,,33.74,467.90,percent of total billed charges,
RA Pelvis 1 or 2 Views,613831,CDM,320,RC,72170,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Pelvis 1 or 2 Views,613831,CDM,320,RC,72170,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,19.19,348.47,percent of total billed charges,
RA Pelvis 1 or 2 Views,7908906,CDM,320,RC,72170,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Pelvis 1 or 2 Views,7908906,CDM,320,RC,72170,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,19.19,348.47,percent of total billed charges,
RA Ankle Left 1 View,7938559,CDM,320,RC,73600,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,"LT,52",258.49,,,,,,,189.60,258.49,percent of total billed charges,
RA Ankle Left 1 View,7938559,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,"LT,52",258.49,,,,,,,18.12,258.49,percent of total billed charges,
RA Ankle Right 1 View,7938563,CDM,320,RC,73600,HCPCS,,,facility,inpatient,,,316.00000,91.64000,Aetna,First Health,"RT,52",258.49,,,,,,,189.60,258.49,percent of total billed charges,
RA Ankle Right 1 View,7938563,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,First Health,"RT,52",258.49,,,,,,,18.12,258.49,percent of total billed charges,
RA Elbow Left 1 View,7938567,CDM,320,RC,73070,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,"52,LT",249.49,,,,,,,183.00,249.49,percent of total billed charges,
RA Elbow Left 1 View,7938567,CDM,320,RC,73070,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,"52,LT",249.49,,,,,,,19.19,249.49,percent of total billed charges,
RA Elbow Right 1 View,7938571,CDM,320,RC,73070,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,"52,RT",249.49,,,,,,,183.00,249.49,percent of total billed charges,
RA Elbow Right 1 View,7938571,CDM,320,RC,73070,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,"52,RT",249.49,,,,,,,19.19,249.49,percent of total billed charges,
RA Foot Left 1 View,7938575,CDM,320,RC,73620,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,"52,LT",249.49,,,,,,,183.00,249.49,percent of total billed charges,
RA Foot Left 1 View,7938575,CDM,320,RC,73620,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,"52,LT",249.49,,,,,,,18.12,249.49,percent of total billed charges,
RA Foot Right 1 View,7938579,CDM,320,RC,73620,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,"52,RT",249.49,,,,,,,183.00,249.49,percent of total billed charges,
RA Foot Right 1 View,7938579,CDM,320,RC,73620,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,"52,RT",249.49,,,,,,,18.12,249.49,percent of total billed charges,
RA Forearm Left 1 View,7938583,CDM,320,RC,73090,HCPCS,,,facility,inpatient,,,340.00000,98.60000,Aetna,First Health,"LT,52",278.12,,,,,,,204.00,278.12,percent of total billed charges,
RA Forearm Left 1 View,7938583,CDM,320,RC,73090,HCPCS,,,facility,outpatient,,,340.00000,98.60000,Aetna,First Health,"LT,52",278.12,,,,,,,19.19,278.12,percent of total billed charges,
RA Forearm Right 1 View,7938587,CDM,320,RC,73090,HCPCS,,,facility,inpatient,,,340.00000,98.60000,Aetna,First Health,"52,RT",278.12,,,,,,,204.00,278.12,percent of total billed charges,
RA Forearm Right 1 View,7938587,CDM,320,RC,73090,HCPCS,,,facility,outpatient,,,340.00000,98.60000,Aetna,First Health,"52,RT",278.12,,,,,,,19.19,278.12,percent of total billed charges,
RA Hand Left 1 View,7938591,CDM,320,RC,73120,HCPCS,,,facility,inpatient,,,293.00000,84.97000,Aetna,First Health,"52,LT",239.67,,,,,,,175.80,239.67,percent of total billed charges,
RA Hand Left 1 View,7938591,CDM,320,RC,73120,HCPCS,,,facility,outpatient,,,293.00000,84.97000,Aetna,First Health,"52,LT",239.67,,,,,,,18.12,283.84,percent of total billed charges,
RA Hand Right 1 View,7938595,CDM,320,RC,73120,HCPCS,,,facility,inpatient,,,293.00000,84.97000,Aetna,First Health,"RT,52",239.67,,,,,,,175.80,239.67,percent of total billed charges,
RA Hand Right 1 View,7938595,CDM,320,RC,73120,HCPCS,,,facility,outpatient,,,293.00000,84.97000,Aetna,First Health,"RT,52",239.67,,,,,,,18.12,283.84,percent of total billed charges,
RA Humerus Left 1 View,7938599,CDM,320,RC,73060,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,"52,LT",360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Humerus Left 1 View,7938599,CDM,320,RC,73060,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,"52,LT",360.74,,,,,,,21.67,360.74,percent of total billed charges,
RA Humerus Right 1 View,7938603,CDM,320,RC,73060,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,"52,RT",360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Humerus Right 1 View,7938603,CDM,320,RC,73060,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,"52,RT",360.74,,,,,,,21.67,360.74,percent of total billed charges,
RA Lower Leg Left 1 View,7938607,CDM,320,RC,73590,HCPCS,,,facility,inpatient,,,357.00000,103.53000,Aetna,First Health,"52,LT",292.03,,,,,,,214.20,292.03,percent of total billed charges,
RA Lower Leg Left 1 View,7938607,CDM,320,RC,73590,HCPCS,,,facility,outpatient,,,357.00000,103.53000,Aetna,First Health,"52,LT",292.03,,,,,,,19.19,292.03,percent of total billed charges,
RA Lower Leg Right 1 View,7938611,CDM,320,RC,73590,HCPCS,,,facility,inpatient,,,357.00000,103.53000,Aetna,First Health,"52,RT",292.03,,,,,,,214.20,292.03,percent of total billed charges,
RA Lower Leg Right 1 View,7938611,CDM,320,RC,73590,HCPCS,,,facility,outpatient,,,357.00000,103.53000,Aetna,First Health,"52,RT",292.03,,,,,,,19.19,292.03,percent of total billed charges,
RA Wrist Left 1 View,7938615,CDM,320,RC,73100,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,"LT,52",249.49,,,,,,,183.00,249.49,percent of total billed charges,
RA Wrist Left 1 View,7938615,CDM,320,RC,73100,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,"LT,52",249.49,,,,,,,18.12,249.49,percent of total billed charges,
RA Wrist Right 1 View,7938619,CDM,320,RC,73100,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,"RT,52",249.49,,,,,,,183.00,249.49,percent of total billed charges,
RA Wrist Right 1 View,7938619,CDM,320,RC,73100,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,"RT,52",249.49,,,,,,,18.12,249.49,percent of total billed charges,
RA Clavicle Left 1 View,7938623,CDM,320,RC,73000,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,"LT,52",360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Clavicle Left 1 View,7938623,CDM,320,RC,73000,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,"LT,52",360.74,,,,,,,19.19,360.74,percent of total billed charges,
RA Clavicle Right 1 View,7938627,CDM,320,RC,73000,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,"52,RT",360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Clavicle Right 1 View,7938627,CDM,320,RC,73000,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,"52,RT",360.74,,,,,,,19.19,360.74,percent of total billed charges,
RA Fingers Left 1 View,7938631,CDM,320,RC,73140,HCPCS,,,facility,inpatient,,,281.00000,81.49000,Aetna,First Health,"52,LT",229.86,,,,,,,168.60,229.86,percent of total billed charges,
RA Fingers Left 1 View,7938631,CDM,320,RC,73140,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,First Health,"52,LT",229.86,,,,,,,15.64,235.00,percent of total billed charges,
RA Fingers Right 1 View,7938635,CDM,320,RC,73140,HCPCS,,,facility,inpatient,,,281.00000,81.49000,Aetna,First Health,"52,RT",229.86,,,,,,,168.60,229.86,percent of total billed charges,
RA Fingers Right 1 View,7938635,CDM,320,RC,73140,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,First Health,"52,RT",229.86,,,,,,,15.64,235.00,percent of total billed charges,
RA Heel Left 1 View,7938639,CDM,320,RC,73650,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,"LT,52",249.49,,,,,,,183.00,249.49,percent of total billed charges,
RA Heel Left 1 View,7938639,CDM,320,RC,73650,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,"LT,52",249.49,,,,,,,17.41,249.49,percent of total billed charges,
RA Heel Right 1 View,7938643,CDM,320,RC,73650,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,"RT,52",249.49,,,,,,,183.00,249.49,percent of total billed charges,
RA Heel Right 1 View,7938643,CDM,320,RC,73650,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,"RT,52",249.49,,,,,,,17.41,249.49,percent of total billed charges,
RA Lower Extremity Infant Left 1 View,7938436,CDM,320,RC,73592,HCPCS,,,facility,inpatient,,,271.00000,78.59000,Aetna,First Health,"52,LT",221.68,,,,,,,162.60,221.68,percent of total billed charges,
RA Lower Extremity Infant Left 1 View,7938436,CDM,320,RC,73592,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,First Health,"52,LT",221.68,,,,,,,18.12,235.00,percent of total billed charges,
RA Lower Extremity Infant Right 1 View,7938440,CDM,320,RC,73592,HCPCS,,,facility,inpatient,,,271.00000,78.59000,Aetna,First Health,"RT,52",221.68,,,,,,,162.60,221.68,percent of total billed charges,
RA Lower Extremity Infant Right 1 View,7938440,CDM,320,RC,73592,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,First Health,"RT,52",221.68,,,,,,,18.12,235.00,percent of total billed charges,
RA Toes Left 1 View,7938445,CDM,320,RC,73660,HCPCS,,,facility,inpatient,,,271.00000,78.59000,Aetna,First Health,"LT,52",221.68,,,,,,,162.60,221.68,percent of total billed charges,
RA Toes Left 1 View,7938445,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,First Health,"LT,52",221.68,,,,,,,15.64,235.00,percent of total billed charges,
RA Toes Right 1 View,7938449,CDM,320,RC,73660,HCPCS,,,facility,inpatient,,,271.00000,78.59000,Aetna,First Health,"52,RT",221.68,,,,,,,162.60,221.68,percent of total billed charges,
RA Toes Right 1 View,7938449,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,First Health,"52,RT",221.68,,,,,,,15.64,235.00,percent of total billed charges,
RA Upper Extremity Infant Left 1 View,7938452,CDM,320,RC,73092,HCPCS,,,facility,inpatient,,,281.00000,81.49000,Aetna,First Health,"52,LT",229.86,,,,,,,168.60,229.86,percent of total billed charges,
RA Upper Extremity Infant Left 1 View,7938452,CDM,320,RC,73092,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,First Health,"52,LT",229.86,,,,,,,18.12,283.84,percent of total billed charges,
RA Upper Extremity Infant LT Minimum 2V,7938457,CDM,320,RC,73092,HCPCS,,,facility,inpatient,,,352.00000,102.08000,Aetna,First Health,"RT,52",287.94,,,,,,,211.20,287.94,percent of total billed charges,
RA Upper Extremity Infant LT Minimum 2V,7938457,CDM,320,RC,73092,HCPCS,,,facility,outpatient,,,352.00000,102.08000,Aetna,First Health,"RT,52",287.94,,,,,,,18.12,287.94,percent of total billed charges,
RA Pelvis Minimum 3 Views,7908910,CDM,320,RC,72190,HCPCS,,,facility,inpatient,,,542.00000,157.18000,Aetna,First Health,,443.36,,,,,,,325.20,443.36,percent of total billed charges,
RA Pelvis Minimum 3 Views,7908910,CDM,320,RC,72190,HCPCS,,,facility,outpatient,,,542.00000,157.18000,Aetna,First Health,,443.36,,,,,,,25.22,443.36,percent of total billed charges,
RA Sacro  Iliac Joints 1 or 2 Views,654419,CDM,320,RC,72200,HCPCS,,,facility,inpatient,,,367.00000,106.43000,Aetna,First Health,,300.21,,,,,,,220.20,300.21,percent of total billed charges,
RA Sacro  Iliac Joints 1 or 2 Views,654419,CDM,320,RC,72200,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,First Health,,300.21,,,,,,,19.19,300.21,percent of total billed charges,
RA Sacro Iliac Joints 3 Views,614173,CDM,320,RC,72202,HCPCS,,,facility,inpatient,,,470.00000,136.30000,Aetna,First Health,,384.46,,,,,,,282.00,384.46,percent of total billed charges,
RA Sacro Iliac Joints 3 Views,614173,CDM,320,RC,72202,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,First Health,,384.46,,,,,,,23.44,384.46,percent of total billed charges,
RA Sacrum and Coccyx Minimum 2 Views,614181,CDM,320,RC,72220,HCPCS,,,facility,inpatient,,,470.00000,136.30000,Aetna,First Health,,384.46,,,,,,,282.00,384.46,percent of total billed charges,
RA Sacrum and Coccyx Minimum 2 Views,614181,CDM,320,RC,72220,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,First Health,,384.46,,,,,,,21.67,384.46,percent of total billed charges,
RA Knee 4 views Bilat,8156274,CDM,320,RC,73564,HCPCS,,,facility,inpatient,,,1120.00000,324.80000,Aetna,First Health,,916.16,,,,,,,672.00,916.16,percent of total billed charges,
RA Knee 4 views Bilat,8156274,CDM,320,RC,73564,HCPCS,,,facility,outpatient,,,1120.00000,324.80000,Aetna,First Health,,916.16,,,,,,,23.44,916.16,percent of total billed charges,
RA Femur Min 2 Views Bilat,8156282,CDM,320,RC,73552,HCPCS,,,facility,inpatient,,,924.00000,267.96000,Aetna,First Health,,755.83,,,,,,,554.40,755.83,percent of total billed charges,
RA Femur Min 2 Views Bilat,8156282,CDM,320,RC,73552,HCPCS,,,facility,outpatient,,,924.00000,267.96000,Aetna,First Health,,755.83,,,,,,,32.46,755.83,percent of total billed charges,
RA Lower Extremity Infant Bilat Min 2V,8160991,CDM,320,RC,73592,HCPCS,,,facility,inpatient,,,678.00000,196.62000,Aetna,First Health,,554.60,,,,,,,406.80,554.60,percent of total billed charges,
RA Lower Extremity Infant Bilat Min 2V,8160991,CDM,320,RC,73592,HCPCS,,,facility,outpatient,,,678.00000,196.62000,Aetna,First Health,,554.60,,,,,,,18.12,554.60,percent of total billed charges,
RA Shunt Survey,624996,CDM,320,RC,70250,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
RA Shunt Survey,624996,CDM,320,RC,70250,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,23.44,420.45,percent of total billed charges,
RA Shunt Survey Spine,8001064,CDM,320,RC,72020,HCPCS,,,facility,inpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,241.80,329.65,percent of total billed charges,
RA Shunt Survey Spine,8001064,CDM,320,RC,72020,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,15.64,329.65,percent of total billed charges,
RA Shunt Survey Chest,8001065,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Shunt Survey Chest,8001065,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Shunt Survey Abdomen,8001066,CDM,320,RC,74018,HCPCS,,,facility,inpatient,,,412.00000,119.48000,Aetna,First Health,,337.02,,,,,,,247.20,337.02,percent of total billed charges,
RA Shunt Survey Abdomen,8001066,CDM,320,RC,74018,HCPCS,,,facility,outpatient,,,412.00000,119.48000,Aetna,First Health,,337.02,,,,,,,26.31,337.02,percent of total billed charges,
RA Sitzmark Study Initial Day,7974965,CDM,320,RC,74019,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
RA Sitzmark Study Initial Day,7974965,CDM,320,RC,74019,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,48.77,420.45,percent of total billed charges,
RA Chest 1 View,6043855,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest 1 View,6043855,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,6043859,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest 1 View,6043859,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,613659,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest 1 View,613659,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,641725,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest 1 View,641725,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,642145,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest 1 View,642145,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,7903287,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest 1 View,7903287,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,7903291,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest 1 View,7903291,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,7903307,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest 1 View,7903307,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,7903311,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest 1 View,7903311,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,7908818,CDM,320,RC,71045,HCPCS,,,facility,inpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,211.80,288.75,percent of total billed charges,
RA Chest 1 View,7908818,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,First Health,,288.75,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 2 Views,6043867,CDM,320,RC,71046,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Chest 2 Views,6043867,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,613639,CDM,320,RC,71046,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Chest 2 Views,613639,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,613651,CDM,320,RC,71046,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Chest 2 Views,613651,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,613653,CDM,320,RC,71046,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Chest 2 Views,613653,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,613661,CDM,320,RC,71046,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Chest 2 Views,613661,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,614117,CDM,320,RC,71046,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Chest 2 Views,614117,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,7908822,CDM,320,RC,71046,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Chest 2 Views,7908822,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 4 Views,613645,CDM,320,RC,71048,HCPCS,,,facility,inpatient,,,533.00000,154.57000,Aetna,First Health,,435.99,,,,,,,319.80,435.99,percent of total billed charges,
RA Chest 4 Views,613645,CDM,320,RC,71048,HCPCS,,,facility,outpatient,,,533.00000,154.57000,Aetna,First Health,,435.99,,,,,,,93.38,435.99,percent of total billed charges,
RA Abdomen 1 View,6043851,CDM,320,RC,74018,HCPCS,,,facility,inpatient,,,412.00000,119.48000,Aetna,First Health,,337.02,,,,,,,247.20,337.02,percent of total billed charges,
RA Abdomen 1 View,6043851,CDM,320,RC,74018,HCPCS,,,facility,outpatient,,,412.00000,119.48000,Aetna,First Health,,337.02,,,,,,,26.31,337.02,percent of total billed charges,
RA Abdomen 1 View,613564,CDM,320,RC,74018,HCPCS,,,facility,inpatient,,,412.00000,119.48000,Aetna,First Health,,337.02,,,,,,,247.20,337.02,percent of total billed charges,
RA Abdomen 1 View,613564,CDM,320,RC,74018,HCPCS,,,facility,outpatient,,,412.00000,119.48000,Aetna,First Health,,337.02,,,,,,,26.31,337.02,percent of total billed charges,
RA Abdomen 2 Views,613566,CDM,320,RC,74019,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
RA Abdomen 2 Views,613566,CDM,320,RC,74019,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,48.77,420.45,percent of total billed charges,
RA Abdomen 2 Views,7900404,CDM,320,RC,74019,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
RA Abdomen 2 Views,7900404,CDM,320,RC,74019,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,48.77,420.45,percent of total billed charges,
RA Abdomen 3 Views,1099805,CDM,320,RC,74021,HCPCS,,,facility,inpatient,,,542.00000,157.18000,Aetna,First Health,,443.36,,,,,,,325.20,443.36,percent of total billed charges,
RA Abdomen 3 Views,1099805,CDM,320,RC,74021,HCPCS,,,facility,outpatient,,,542.00000,157.18000,Aetna,First Health,,443.36,,,,,,,57.11,443.36,percent of total billed charges,
RA ERCP,7575990,CDM,320,RC,,,,,facility,inpatient,,,1217.00000,352.93000,Aetna,First Health,,995.51,,,,,,,730.20,995.51,percent of total billed charges,
RA ERCP,7575990,CDM,320,RC,,,,,facility,outpatient,,,1217.00000,352.93000,Aetna,First Health,,995.51,,,,,,,438.73,995.51,percent of total billed charges,
RA Knees Bilateral AP Standing Only,7920883,CDM,320,RC,73565,HCPCS,,,facility,inpatient,,,406.00000,117.74000,Aetna,First Health,,332.11,,,,,,,243.60,332.11,percent of total billed charges,
RA Knees Bilateral AP Standing Only,7920883,CDM,320,RC,73565,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,First Health,,332.11,,,,,,,18.12,332.11,percent of total billed charges,
RA Scoliosis Study 1 View,7908914,CDM,320,RC,72081,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,,360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Scoliosis Study 1 View,7908914,CDM,320,RC,72081,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,,360.74,,,,,,,36.00,360.74,percent of total billed charges,
RA Hip Right 1 View,7908830,CDM,320,RC,73501,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,RT,276.48,,,,,,,202.80,276.48,percent of total billed charges,
RA Hip Right 1 View,7908830,CDM,320,RC,73501,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,RT,276.48,,,,,,,28.91,276.48,percent of total billed charges,
RA Hip Right 1 View,7908854,CDM,320,RC,73501,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,RT,276.48,,,,,,,202.80,276.48,percent of total billed charges,
RA Hip Right 1 View,7908854,CDM,320,RC,73501,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,RT,276.48,,,,,,,28.91,276.48,percent of total billed charges,
RA Hip Left 2 or 3 Views,7908834,CDM,320,RC,73502,HCPCS,,,facility,inpatient,,,395.00000,114.55000,Aetna,First Health,LT,323.11,,,,,,,237.00,323.11,percent of total billed charges,
RA Hip Left 2 or 3 Views,7908834,CDM,320,RC,73502,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,First Health,LT,323.11,,,,,,,42.59,323.11,percent of total billed charges,
RA Hip Left 2 or 3 Views,7908858,CDM,320,RC,73502,HCPCS,,,facility,inpatient,,,395.00000,114.55000,Aetna,First Health,LT,323.11,,,,,,,237.00,323.11,percent of total billed charges,
RA Hip Left 2 or 3 Views,7908858,CDM,320,RC,73502,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,First Health,LT,323.11,,,,,,,42.59,323.11,percent of total billed charges,
RA Hip Right 2 or 3 Views,7908838,CDM,320,RC,73502,HCPCS,,,facility,inpatient,,,395.00000,114.55000,Aetna,First Health,RT,323.11,,,,,,,237.00,323.11,percent of total billed charges,
RA Hip Right 2 or 3 Views,7908838,CDM,320,RC,73502,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,First Health,RT,323.11,,,,,,,42.59,323.11,percent of total billed charges,
RA HIp Right 2 or 3 Views,7908862,CDM,320,RC,73502,HCPCS,,,facility,inpatient,,,395.00000,114.55000,Aetna,First Health,RT,323.11,,,,,,,237.00,323.11,percent of total billed charges,
RA HIp Right 2 or 3 Views,7908862,CDM,320,RC,73502,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,First Health,RT,323.11,,,,,,,42.59,323.11,percent of total billed charges,
RA Hips Bilateral 2 Views,7908842,CDM,320,RC,73521,HCPCS,,,facility,inpatient,,,790.00000,229.10000,Aetna,First Health,,646.22,,,,,,,474.00,646.22,percent of total billed charges,
RA Hips Bilateral 2 Views,7908842,CDM,320,RC,73521,HCPCS,,,facility,outpatient,,,790.00000,229.10000,Aetna,First Health,,646.22,,,,,,,40.05,646.22,percent of total billed charges,
RA Hips Bilateral 3 to 4 Views,7908846,CDM,320,RC,73522,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,729.60,994.69,percent of total billed charges,
RA Hips Bilateral 3 to 4 Views,7908846,CDM,320,RC,73522,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,47.65,994.69,percent of total billed charges,
RA Femur Left 1 View,7908866,CDM,320,RC,73551,HCPCS,,,facility,inpatient,,,367.00000,106.43000,Aetna,First Health,LT,300.21,,,,,,,220.20,300.21,percent of total billed charges,
RA Femur Left 1 View,7908866,CDM,320,RC,73551,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,First Health,LT,300.21,,,,,,,27.38,300.21,percent of total billed charges,
RA Femur Right 1 View,7908870,CDM,320,RC,73551,HCPCS,,,facility,inpatient,,,367.00000,106.43000,Aetna,First Health,RT,300.21,,,,,,,220.20,300.21,percent of total billed charges,
RA Femur Right 1 View,7908870,CDM,320,RC,73551,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,First Health,RT,300.21,,,,,,,27.38,300.21,percent of total billed charges,
RA Femur Left Minimum 2 Views,7908874,CDM,320,RC,73552,HCPCS,,,facility,inpatient,,,462.00000,133.98000,Aetna,First Health,LT,377.92,,,,,,,277.20,377.92,percent of total billed charges,
RA Femur Left Minimum 2 Views,7908874,CDM,320,RC,73552,HCPCS,,,facility,outpatient,,,462.00000,133.98000,Aetna,First Health,LT,377.92,,,,,,,32.46,377.92,percent of total billed charges,
RA Femur Right Minimum 2 Views,7908878,CDM,320,RC,73552,HCPCS,,,facility,inpatient,,,462.00000,133.98000,Aetna,First Health,RT,377.92,,,,,,,277.20,377.92,percent of total billed charges,
RA Femur Right Minimum 2 Views,7908878,CDM,320,RC,73552,HCPCS,,,facility,outpatient,,,462.00000,133.98000,Aetna,First Health,RT,377.92,,,,,,,32.46,377.92,percent of total billed charges,
RA Hip Left 1 View,7908826,CDM,320,RC,73501,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,LT,276.48,,,,,,,202.80,276.48,percent of total billed charges,
RA Hip Left 1 View,7908826,CDM,320,RC,73501,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,LT,276.48,,,,,,,28.91,276.48,percent of total billed charges,
RA Hip Left 1 View,7908850,CDM,320,RC,73501,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,LT,276.48,,,,,,,202.80,276.48,percent of total billed charges,
RA Hip Left 1 View,7908850,CDM,320,RC,73501,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,LT,276.48,,,,,,,28.91,276.48,percent of total billed charges,
RA Clavicle Right,613667,CDM,320,RC,73000,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,RT,360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Clavicle Right,613667,CDM,320,RC,73000,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,RT,360.74,,,,,,,19.19,360.74,percent of total billed charges,
RA Clavicle Left,613665,CDM,320,RC,73000,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,LT,360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Clavicle Left,613665,CDM,320,RC,73000,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,LT,360.74,,,,,,,19.19,360.74,percent of total billed charges,
RA Scapula Right,614193,CDM,320,RC,73010,HCPCS,,,facility,inpatient,,,470.00000,136.30000,Aetna,First Health,RT,384.46,,,,,,,282.00,384.46,percent of total billed charges,
RA Scapula Right,614193,CDM,320,RC,73010,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,First Health,RT,384.46,,,,,,,19.19,384.46,percent of total billed charges,
RA Scapula Left,614191,CDM,320,RC,73010,HCPCS,,,facility,inpatient,,,470.00000,136.30000,Aetna,First Health,LT,384.46,,,,,,,282.00,384.46,percent of total billed charges,
RA Scapula Left,614191,CDM,320,RC,73010,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,First Health,LT,384.46,,,,,,,19.19,384.46,percent of total billed charges,
RA Shoulder 1 View Left,7253910,CDM,320,RC,73020,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,LT,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Shoulder 1 View Left,7253910,CDM,320,RC,73020,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,LT,312.48,,,,,,,17.41,312.48,percent of total billed charges,
RA Shoulder Right Minimum 2 Views,7912750,CDM,320,RC,73030,HCPCS,,,facility,inpatient,,,485.00000,140.65000,Aetna,First Health,RT,396.73,,,,,,,291.00,396.73,percent of total billed charges,
RA Shoulder Right Minimum 2 Views,7912750,CDM,320,RC,73030,HCPCS,,,facility,outpatient,,,485.00000,140.65000,Aetna,First Health,RT,396.73,,,,,,,21.67,396.73,percent of total billed charges,
RA Shoulder Left Minimum 2 Views,7912746,CDM,320,RC,73030,HCPCS,,,facility,inpatient,,,485.00000,140.65000,Aetna,First Health,LT,396.73,,,,,,,291.00,396.73,percent of total billed charges,
RA Shoulder Left Minimum 2 Views,7912746,CDM,320,RC,73030,HCPCS,,,facility,outpatient,,,485.00000,140.65000,Aetna,First Health,LT,396.73,,,,,,,21.67,396.73,percent of total billed charges,
RA Shoulder Arthrogram Left,7253906,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Shoulder Arthrogram Left,7253906,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Shoulder Arthrogram Left,7957036,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Shoulder Arthrogram Left,7957036,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Acromio Clavicular Joints,613570,CDM,320,RC,73050,HCPCS,,,facility,inpatient,,,431.00000,124.99000,Aetna,First Health,,352.56,,,,,,,258.60,352.56,percent of total billed charges,
RA Acromio Clavicular Joints,613570,CDM,320,RC,73050,HCPCS,,,facility,outpatient,,,431.00000,124.99000,Aetna,First Health,,352.56,,,,,,,25.22,352.56,percent of total billed charges,
RA Humerus Right Minimum 2 Views,613839,CDM,320,RC,73060,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,RT,360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Humerus Right Minimum 2 Views,613839,CDM,320,RC,73060,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,RT,360.74,,,,,,,21.67,360.74,percent of total billed charges,
RA Humerus Left Minimum 2 Views,613835,CDM,320,RC,73060,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,LT,360.74,,,,,,,264.60,360.74,percent of total billed charges,
RA Humerus Left Minimum 2 Views,613835,CDM,320,RC,73060,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,LT,360.74,,,,,,,21.67,360.74,percent of total billed charges,
RA Elbow Right 2 Views,7912726,CDM,320,RC,73070,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,RT,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Elbow Right 2 Views,7912726,CDM,320,RC,73070,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,RT,312.48,,,,,,,19.19,312.48,percent of total billed charges,
RA Elbow Left 2 Views,7912722,CDM,320,RC,73070,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,LT,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Elbow Left 2 Views,7912722,CDM,320,RC,73070,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,LT,312.48,,,,,,,19.19,312.48,percent of total billed charges,
RA Elbow Left Minimum 3 Views,7253867,CDM,320,RC,73080,HCPCS,,,facility,inpatient,,,443.00000,128.47000,Aetna,First Health,LT,362.37,,,,,,,265.80,362.37,percent of total billed charges,
RA Elbow Left Minimum 3 Views,7253867,CDM,320,RC,73080,HCPCS,,,facility,outpatient,,,443.00000,128.47000,Aetna,First Health,LT,362.37,,,,,,,21.67,362.37,percent of total billed charges,
RA Elbow Arthrogram Left,7253871,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Elbow Arthrogram Left,7253871,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Elbow Arthrogram Left,7957012,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Elbow Arthrogram Left,7957012,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Forearm Right 2 Views,613781,CDM,320,RC,73090,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,RT,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Forearm Right 2 Views,613781,CDM,320,RC,73090,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,RT,348.47,,,,,,,19.19,348.47,percent of total billed charges,
RA Forearm Left 2 Views,613779,CDM,320,RC,73090,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,LT,348.47,,,,,,,255.60,348.47,percent of total billed charges,
RA Forearm Left 2 Views,613779,CDM,320,RC,73090,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,LT,348.47,,,,,,,19.19,348.47,percent of total billed charges,
RA Upper Extremity Infant RT Minimum 2V,614295,CDM,320,RC,73092,HCPCS,,,facility,inpatient,,,352.00000,102.08000,Aetna,First Health,RT,287.94,,,,,,,211.20,287.94,percent of total billed charges,
RA Upper Extremity Infant RT Minimum 2V,614295,CDM,320,RC,73092,HCPCS,,,facility,outpatient,,,352.00000,102.08000,Aetna,First Health,RT,287.94,,,,,,,18.12,287.94,percent of total billed charges,
RA Upper Extremity Infant LT Minimum 2V,614291,CDM,320,RC,73092,HCPCS,,,facility,inpatient,,,352.00000,102.08000,Aetna,First Health,LT,287.94,,,,,,,211.20,287.94,percent of total billed charges,
RA Upper Extremity Infant LT Minimum 2V,614291,CDM,320,RC,73092,HCPCS,,,facility,outpatient,,,352.00000,102.08000,Aetna,First Health,LT,287.94,,,,,,,18.12,287.94,percent of total billed charges,
RA Wrist 2 Views Left,7253914,CDM,320,RC,73100,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,LT,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Wrist 2 Views Left,7253914,CDM,320,RC,73100,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,LT,312.48,,,,,,,18.12,312.48,percent of total billed charges,
RA Wrist Right Minimum 3 Views,7912771,CDM,320,RC,73110,HCPCS,,,facility,inpatient,,,454.00000,131.66000,Aetna,First Health,RT,371.37,,,,,,,272.40,371.37,percent of total billed charges,
RA Wrist Right Minimum 3 Views,7912771,CDM,320,RC,73110,HCPCS,,,facility,outpatient,,,454.00000,131.66000,Aetna,First Health,RT,371.37,,,,,,,19.55,371.37,percent of total billed charges,
RA Wrist Left Minimum 3 Views,7912767,CDM,320,RC,73110,HCPCS,,,facility,inpatient,,,454.00000,131.66000,Aetna,First Health,LT,371.37,,,,,,,272.40,371.37,percent of total billed charges,
RA Wrist Left Minimum 3 Views,7912767,CDM,320,RC,73110,HCPCS,,,facility,outpatient,,,454.00000,131.66000,Aetna,First Health,LT,371.37,,,,,,,19.55,371.37,percent of total billed charges,
RA Wrist Arthrogram Left,7253918,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Wrist Arthrogram Left,7253918,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Wrist Arthrogram Left,7957044,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Wrist Arthrogram Left,7957044,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Hand 2 Views Left,7253881,CDM,320,RC,73120,HCPCS,,,facility,inpatient,,,367.00000,106.43000,Aetna,First Health,LT,300.21,,,,,,,220.20,300.21,percent of total billed charges,
RA Hand 2 Views Left,7253881,CDM,320,RC,73120,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,First Health,LT,300.21,,,,,,,18.12,300.21,percent of total billed charges,
RA Hand Right Minimum 3 Views,7912742,CDM,320,RC,73130,HCPCS,,,facility,inpatient,,,454.00000,131.66000,Aetna,First Health,RT,371.37,,,,,,,272.40,371.37,percent of total billed charges,
RA Hand Right Minimum 3 Views,7912742,CDM,320,RC,73130,HCPCS,,,facility,outpatient,,,454.00000,131.66000,Aetna,First Health,RT,371.37,,,,,,,19.55,371.37,percent of total billed charges,
RA Hand Left Minimum 3 Views,7912738,CDM,320,RC,73130,HCPCS,,,facility,inpatient,,,454.00000,131.66000,Aetna,First Health,LT,371.37,,,,,,,272.40,371.37,percent of total billed charges,
RA Hand Left Minimum 3 Views,7912738,CDM,320,RC,73130,HCPCS,,,facility,outpatient,,,454.00000,131.66000,Aetna,First Health,LT,371.37,,,,,,,19.55,371.37,percent of total billed charges,
RA Fingers Right Minimum 2 Views,613749,CDM,320,RC,73140,HCPCS,,,facility,inpatient,,,352.00000,102.08000,Aetna,First Health,RT,287.94,,,,,,,211.20,287.94,percent of total billed charges,
RA Fingers Right Minimum 2 Views,613749,CDM,320,RC,73140,HCPCS,,,facility,outpatient,,,352.00000,102.08000,Aetna,First Health,RT,287.94,,,,,,,15.64,287.94,percent of total billed charges,
RA Fingers Left Minimum 2 Views,613753,CDM,320,RC,73140,HCPCS,,,facility,inpatient,,,352.00000,102.08000,Aetna,First Health,LT,287.94,,,,,,,211.20,287.94,percent of total billed charges,
RA Fingers Left Minimum 2 Views,613753,CDM,320,RC,73140,HCPCS,,,facility,outpatient,,,352.00000,102.08000,Aetna,First Health,LT,287.94,,,,,,,15.64,287.94,percent of total billed charges,
RA Knee Right 1 or 2 Views,7908894,CDM,320,RC,73560,HCPCS,,,facility,inpatient,,,406.00000,117.74000,Aetna,First Health,RT,332.11,,,,,,,243.60,332.11,percent of total billed charges,
RA Knee Right 1 or 2 Views,7908894,CDM,320,RC,73560,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,First Health,RT,332.11,,,,,,,19.19,332.11,percent of total billed charges,
RA Knee Right 1 or 2 Views,7908902,CDM,320,RC,73560,HCPCS,,,facility,inpatient,,,406.00000,117.74000,Aetna,First Health,RT,332.11,,,,,,,243.60,332.11,percent of total billed charges,
RA Knee Right 1 or 2 Views,7908902,CDM,320,RC,73560,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,First Health,RT,332.11,,,,,,,19.19,332.11,percent of total billed charges,
RA Knee Left 1 or 2 Views,7908890,CDM,320,RC,73560,HCPCS,,,facility,inpatient,,,406.00000,117.74000,Aetna,First Health,LT,332.11,,,,,,,243.60,332.11,percent of total billed charges,
RA Knee Left 1 or 2 Views,7908890,CDM,320,RC,73560,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,First Health,LT,332.11,,,,,,,19.19,332.11,percent of total billed charges,
RA Knee Left 1 or 2 Views,7908898,CDM,320,RC,73560,HCPCS,,,facility,inpatient,,,406.00000,117.74000,Aetna,First Health,LT,332.11,,,,,,,243.60,332.11,percent of total billed charges,
RA Knee Left 1 or 2 Views,7908898,CDM,320,RC,73560,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,First Health,LT,332.11,,,,,,,19.19,332.11,percent of total billed charges,
RA Knee 3 Views Right,7235915,CDM,320,RC,73562,HCPCS,,,facility,inpatient,,,464.00000,134.56000,Aetna,First Health,RT,379.55,,,,,,,278.40,379.55,percent of total billed charges,
RA Knee 3 Views Right,7235915,CDM,320,RC,73562,HCPCS,,,facility,outpatient,,,464.00000,134.56000,Aetna,First Health,RT,379.55,,,,,,,21.67,379.55,percent of total billed charges,
RA Knee Arthrogram Left,7253902,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Knee Arthrogram Left,7253902,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Knee Arthrogram Left,7957028,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Knee Arthrogram Left,7957028,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Lower Leg Right 2 Views,613935,CDM,320,RC,73590,HCPCS,,,facility,inpatient,,,447.00000,129.63000,Aetna,First Health,RT,365.65,,,,,,,268.20,365.65,percent of total billed charges,
RA Lower Leg Right 2 Views,613935,CDM,320,RC,73590,HCPCS,,,facility,outpatient,,,447.00000,129.63000,Aetna,First Health,RT,365.65,,,,,,,19.19,365.65,percent of total billed charges,
RA Lower Leg Left 2 Views,613928,CDM,320,RC,73590,HCPCS,,,facility,inpatient,,,447.00000,129.63000,Aetna,First Health,LT,365.65,,,,,,,268.20,365.65,percent of total billed charges,
RA Lower Leg Left 2 Views,613928,CDM,320,RC,73590,HCPCS,,,facility,outpatient,,,447.00000,129.63000,Aetna,First Health,LT,365.65,,,,,,,19.19,365.65,percent of total billed charges,
RA Lower Extremity Infant RT Minimum 2V,613921,CDM,320,RC,73592,HCPCS,,,facility,inpatient,,,339.00000,98.31000,Aetna,First Health,RT,277.30,,,,,,,203.40,277.30,percent of total billed charges,
RA Lower Extremity Infant RT Minimum 2V,613921,CDM,320,RC,73592,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,First Health,RT,277.30,,,,,,,18.12,277.30,percent of total billed charges,
RA Lower Extremity Infant LT Minimum 2V,613917,CDM,320,RC,73592,HCPCS,,,facility,inpatient,,,339.00000,98.31000,Aetna,First Health,LT,277.30,,,,,,,203.40,277.30,percent of total billed charges,
RA Lower Extremity Infant LT Minimum 2V,613917,CDM,320,RC,73592,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,First Health,LT,277.30,,,,,,,18.12,277.30,percent of total billed charges,
RA Ankle Right Minimum 3 Views,7912716,CDM,320,RC,73610,HCPCS,,,facility,inpatient,,,470.00000,136.30000,Aetna,First Health,RT,384.46,,,,,,,282.00,384.46,percent of total billed charges,
RA Ankle Right Minimum 3 Views,7912716,CDM,320,RC,73610,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,First Health,RT,384.46,,,,,,,19.55,384.46,percent of total billed charges,
RA Ankle Left Minimum 3 Views,7912712,CDM,320,RC,73610,HCPCS,,,facility,inpatient,,,470.00000,136.30000,Aetna,First Health,LT,384.46,,,,,,,282.00,384.46,percent of total billed charges,
RA Ankle Left Minimum 3 Views,7912712,CDM,320,RC,73610,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,First Health,LT,384.46,,,,,,,19.55,384.46,percent of total billed charges,
RA Foot 2 Views Left,7253875,CDM,320,RC,73620,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,LT,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Foot 2 Views Left,7253875,CDM,320,RC,73620,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,LT,312.48,,,,,,,18.12,312.48,percent of total billed charges,
RA Foot Right Minimum 3 Views,7912734,CDM,320,RC,73630,HCPCS,,,facility,inpatient,,,470.00000,136.30000,Aetna,First Health,RT,384.46,,,,,,,282.00,384.46,percent of total billed charges,
RA Foot Right Minimum 3 Views,7912734,CDM,320,RC,73630,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,First Health,RT,384.46,,,,,,,19.55,384.46,percent of total billed charges,
RA Foot Left Minimum 3 Views,7912730,CDM,320,RC,73630,HCPCS,,,facility,inpatient,,,470.00000,136.30000,Aetna,First Health,LT,384.46,,,,,,,282.00,384.46,percent of total billed charges,
RA Foot Left Minimum 3 Views,7912730,CDM,320,RC,73630,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,First Health,LT,384.46,,,,,,,19.55,384.46,percent of total billed charges,
RA Heel Right Minimum 2 Views,613809,CDM,320,RC,73650,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,RT,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Heel Right Minimum 2 Views,613809,CDM,320,RC,73650,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,RT,312.48,,,,,,,17.41,312.48,percent of total billed charges,
RA Heel Left Minimum 2 Views,613805,CDM,320,RC,73650,HCPCS,,,facility,inpatient,,,382.00000,110.78000,Aetna,First Health,LT,312.48,,,,,,,229.20,312.48,percent of total billed charges,
RA Heel Left Minimum 2 Views,613805,CDM,320,RC,73650,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,First Health,LT,312.48,,,,,,,17.41,312.48,percent of total billed charges,
RA Toes Right Minimum 2 Views,614281,CDM,320,RC,73660,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,RT,276.48,,,,,,,202.80,276.48,percent of total billed charges,
RA Toes Right Minimum 2 Views,614281,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,RT,276.48,,,,,,,15.64,276.48,percent of total billed charges,
RA Toes Left Minimum 2 Views,614279,CDM,320,RC,73660,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,LT,276.48,,,,,,,202.80,276.48,percent of total billed charges,
RA Toes Left Minimum 2 Views,614279,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,LT,276.48,,,,,,,15.64,276.48,percent of total billed charges,
Fluoroscopy with xray,8147154,CDM,320,RC,76000,HCPCS,,,facility,inpatient,,,300.00000,87.00000,Aetna,First Health,,245.40,,,,,,,180.00,245.40,percent of total billed charges,
Fluoroscopy with xray,8147154,CDM,320,RC,76000,HCPCS,,,facility,outpatient,,,300.00000,87.00000,Aetna,First Health,,245.40,,,,,,,49.03,672.09,percent of total billed charges,
RA Acute Abd Series,6043863,CDM,320,RC,74022,HCPCS,,,facility,inpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,396.60,540.70,percent of total billed charges,
RA Acute Abd Series,6043863,CDM,320,RC,74022,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,27.71,540.70,percent of total billed charges,
RA Acute Abd Series,613574,CDM,320,RC,74022,HCPCS,,,facility,inpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,396.60,540.70,percent of total billed charges,
RA Acute Abd Series,613574,CDM,320,RC,74022,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,27.71,540.70,percent of total billed charges,
RA Knee 1 or 2 Views Bilat,8149643,CDM,320,RC,73560,HCPCS,,,facility,inpatient,,,812.00000,235.48000,Aetna,First Health,,664.22,,,,,,,487.20,664.22,percent of total billed charges,
RA Knee 1 or 2 Views Bilat,8149643,CDM,320,RC,73560,HCPCS,,,facility,outpatient,,,812.00000,235.48000,Aetna,First Health,,664.22,,,,,,,19.19,664.22,percent of total billed charges,
RA Shoulder Min 2 Views Bilat,8149651,CDM,320,RC,73030,HCPCS,,,facility,inpatient,,,970.00000,281.30000,Aetna,First Health,,793.46,,,,,,,582.00,793.46,percent of total billed charges,
RA Shoulder Min 2 Views Bilat,8149651,CDM,320,RC,73030,HCPCS,,,facility,outpatient,,,970.00000,281.30000,Aetna,First Health,,793.46,,,,,,,21.67,793.46,percent of total billed charges,
RA Lower Leg Bilat 2 View,8149659,CDM,320,RC,73590,HCPCS,,,facility,inpatient,,,894.00000,259.26000,Aetna,First Health,,731.29,,,,,,,536.40,731.29,percent of total billed charges,
RA Lower Leg Bilat 2 View,8149659,CDM,320,RC,73590,HCPCS,,,facility,outpatient,,,894.00000,259.26000,Aetna,First Health,,731.29,,,,,,,19.19,731.29,percent of total billed charges,
RA Knee 3 Views Bilat,8149667,CDM,320,RC,73562,HCPCS,,,facility,inpatient,,,928.00000,269.12000,Aetna,First Health,,759.10,,,,,,,556.80,759.10,percent of total billed charges,
RA Knee 3 Views Bilat,8149667,CDM,320,RC,73562,HCPCS,,,facility,outpatient,,,928.00000,269.12000,Aetna,First Health,,759.10,,,,,,,21.67,759.10,percent of total billed charges,
RA Elbow 2 Views Bilat,9004148,CDM,320,RC,73070,HCPCS,,,facility,inpatient,,,764.00000,221.56000,Aetna,First Health,,624.95,,,,,,,458.40,624.95,percent of total billed charges,
RA Elbow 2 Views Bilat,9004148,CDM,320,RC,73070,HCPCS,,,facility,outpatient,,,764.00000,221.56000,Aetna,First Health,,624.95,,,,,,,19.19,624.95,percent of total billed charges,
RA Ankle Min 3 Views Bilat,8150262,CDM,320,RC,73610,HCPCS,,,facility,inpatient,,,940.00000,272.60000,Aetna,First Health,,768.92,,,,,,,564.00,768.92,percent of total billed charges,
RA Ankle Min 3 Views Bilat,8150262,CDM,320,RC,73610,HCPCS,,,facility,outpatient,,,940.00000,272.60000,Aetna,First Health,,768.92,,,,,,,19.55,768.92,percent of total billed charges,
RA Fluoro,8150218,CDM,320,RC,,,,,facility,inpatient,,,1188.00000,344.52000,Aetna,First Health,,971.78,,,,,,,712.80,971.78,percent of total billed charges,
RA Fluoro,8150218,CDM,320,RC,,,,,facility,outpatient,,,1188.00000,344.52000,Aetna,First Health,,971.78,,,,,,,428.27,971.78,percent of total billed charges,
RA Wrist Min 3 Views Bilat,8150662,CDM,320,RC,73110,HCPCS,,,facility,inpatient,,,908.00000,263.32000,Aetna,First Health,,742.74,,,,,,,544.80,742.74,percent of total billed charges,
RA Wrist Min 3 Views Bilat,8150662,CDM,320,RC,73110,HCPCS,,,facility,outpatient,,,908.00000,263.32000,Aetna,First Health,,742.74,,,,,,,19.55,742.74,percent of total billed charges,
RA Hand Min 3 Views Bilat,8152094,CDM,320,RC,73130,HCPCS,,,facility,inpatient,,,908.00000,263.32000,Aetna,First Health,,742.74,,,,,,,544.80,742.74,percent of total billed charges,
RA Hand Min 3 Views Bilat,8152094,CDM,320,RC,73130,HCPCS,,,facility,outpatient,,,908.00000,263.32000,Aetna,First Health,,742.74,,,,,,,19.55,742.74,percent of total billed charges,
RA Foot Min 3 Views Bilat,8152093,CDM,320,RC,73630,HCPCS,,,facility,inpatient,,,940.00000,272.60000,Aetna,First Health,,768.92,,,,,,,564.00,768.92,percent of total billed charges,
RA Foot Min 3 Views Bilat,8152093,CDM,320,RC,73630,HCPCS,,,facility,outpatient,,,940.00000,272.60000,Aetna,First Health,,768.92,,,,,,,19.55,768.92,percent of total billed charges,
RA Hip Bilat 2 Views,8228484,CDM,320,RC,73521,HCPCS,,,facility,inpatient,,,790.00000,229.10000,Aetna,First Health,,646.22,,,,,,,474.00,646.22,percent of total billed charges,
RA Hip Bilat 2 Views,8228484,CDM,320,RC,73521,HCPCS,,,facility,outpatient,,,790.00000,229.10000,Aetna,First Health,,646.22,,,,,,,40.05,646.22,percent of total billed charges,
RA Hand Bilat 2 View,8228592,CDM,320,RC,73120,HCPCS,,,facility,inpatient,,,734.00000,212.86000,Aetna,First Health,,600.41,,,,,,,440.40,600.41,percent of total billed charges,
RA Hand Bilat 2 View,8228592,CDM,320,RC,73120,HCPCS,,,facility,outpatient,,,734.00000,212.86000,Aetna,First Health,,600.41,,,,,,,18.12,600.41,percent of total billed charges,
RA Modified Barium Swallow,613518,CDM,320,RC,74230,HCPCS,,,facility,inpatient,,,1030.00000,298.70000,Aetna,First Health,,842.54,,,,,,,618.00,842.54,percent of total billed charges,
RA Modified Barium Swallow,613518,CDM,320,RC,74230,HCPCS,,,facility,outpatient,,,1030.00000,298.70000,Aetna,First Health,,842.54,,,,,,,49.03,842.54,percent of total billed charges,
RA Upper GI Single Contrast,7900284,CDM,320,RC,74240,HCPCS,,,facility,inpatient,,,1583.00000,459.07000,Aetna,First Health,,1294.89,,,,,,,949.80,1294.89,percent of total billed charges,
RA Upper GI Single Contrast,7900284,CDM,320,RC,74240,HCPCS,,,facility,outpatient,,,1583.00000,459.07000,Aetna,First Health,,1294.89,,,,,,,54.72,1294.89,percent of total billed charges,
RA Small Bowel Follow Thru,614245,CDM,320,RC,74250,HCPCS,,,facility,inpatient,,,1174.00000,340.46000,Aetna,First Health,,960.33,,,,,,,704.40,960.33,percent of total billed charges,
RA Small Bowel Follow Thru,614245,CDM,320,RC,74250,HCPCS,,,facility,outpatient,,,1174.00000,340.46000,Aetna,First Health,,960.33,,,,,,,49.03,960.33,percent of total billed charges,
Small Bowel Follow Thru,8284744,CDM,320,RC,74248,HCPCS,,,facility,inpatient,,,1174.00000,340.46000,Aetna,First Health,,960.33,,,,,,,704.40,960.33,percent of total billed charges,
Small Bowel Follow Thru,8284744,CDM,320,RC,74248,HCPCS,,,facility,outpatient,,,1174.00000,340.46000,Aetna,First Health,,960.33,,,,,,,120.48,960.33,percent of total billed charges,
RA Barium Enema,613588,CDM,320,RC,74270,HCPCS,,,facility,inpatient,,,1541.00000,446.89000,Aetna,First Health,,1260.54,,,,,,,924.60,1260.54,percent of total billed charges,
RA Barium Enema,613588,CDM,320,RC,74270,HCPCS,,,facility,outpatient,,,1541.00000,446.89000,Aetna,First Health,,1260.54,,,,,,,64.29,1260.54,percent of total billed charges,
RA Barium Enema,613688,CDM,320,RC,74270,HCPCS,,,facility,inpatient,,,1541.00000,446.89000,Aetna,First Health,,1260.54,,,,,,,924.60,1260.54,percent of total billed charges,
RA Barium Enema,613688,CDM,320,RC,74270,HCPCS,,,facility,outpatient,,,1541.00000,446.89000,Aetna,First Health,,1260.54,,,,,,,64.29,1260.54,percent of total billed charges,
RA Barium Enema Air Contrast,613590,CDM,320,RC,74280,HCPCS,,,facility,inpatient,,,1541.00000,446.89000,Aetna,First Health,,1260.54,,,,,,,924.60,1260.54,percent of total billed charges,
RA Barium Enema Air Contrast,613590,CDM,320,RC,74280,HCPCS,,,facility,outpatient,,,1541.00000,446.89000,Aetna,First Health,,1260.54,,,,,,,84.20,1260.54,percent of total billed charges,
RA Esophagus Single Contrast,8284688,CDM,320,RC,74220,HCPCS,,,facility,inpatient,,,742.00000,215.18000,Aetna,First Health,,606.96,,,,,,,445.20,606.96,percent of total billed charges,
RA Esophagus Single Contrast,8284688,CDM,320,RC,74220,HCPCS,,,facility,outpatient,,,742.00000,215.18000,Aetna,First Health,,606.96,,,,,,,44.41,606.96,percent of total billed charges,
RA Esophagus Double Contrast,8284686,CDM,320,RC,74221,HCPCS,,,facility,inpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,457.20,623.32,percent of total billed charges,
RA Esophagus Double Contrast,8284686,CDM,320,RC,74221,HCPCS,,,facility,outpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,156.31,623.32,percent of total billed charges,
RA Upper GI Double Contrast w SBFT,8284708,CDM,320,RC,74246,HCPCS,,,facility,inpatient,,,1466.00000,425.14000,Aetna,First Health,,1199.19,,,,,,,879.60,1199.19,percent of total billed charges,
RA Upper GI Double Contrast w SBFT,8284708,CDM,320,RC,74246,HCPCS,,,facility,outpatient,,,1466.00000,425.14000,Aetna,First Health,,1199.19,,,,,,,61.81,1199.19,percent of total billed charges,
RA Upper GI Double Contrast,8284704,CDM,320,RC,74246,HCPCS,,,facility,inpatient,,,1466.00000,425.14000,Aetna,First Health,,1199.19,,,,,,,879.60,1199.19,percent of total billed charges,
RA Upper GI Double Contrast,8284704,CDM,320,RC,74246,HCPCS,,,facility,outpatient,,,1466.00000,425.14000,Aetna,First Health,,1199.19,,,,,,,61.81,1199.19,percent of total billed charges,
RA Upper GI Single Contrast w SBFT,8284710,CDM,320,RC,74240,HCPCS,,,facility,inpatient,,,1583.00000,459.07000,Aetna,First Health,,1294.89,,,,,,,949.80,1294.89,percent of total billed charges,
RA Upper GI Single Contrast w SBFT,8284710,CDM,320,RC,74240,HCPCS,,,facility,outpatient,,,1583.00000,459.07000,Aetna,First Health,,1294.89,,,,,,,54.72,1294.89,percent of total billed charges,
RA Intro Gastrointestinal Tube,642503,CDM,320,RC,,,,,facility,inpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,1021.80,1393.05,percent of total billed charges,
RA Intro Gastrointestinal Tube,642503,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,First Health,,1393.05,,,,,,,613.93,1393.05,percent of total billed charges,
RA Fingers Bilat Min 2 Views,8248016,CDM,320,RC,73140,HCPCS,,,facility,inpatient,,,704.00000,204.16000,Aetna,First Health,,575.87,,,,,,,422.40,575.87,percent of total billed charges,
RA Fingers Bilat Min 2 Views,8248016,CDM,320,RC,73140,HCPCS,,,facility,outpatient,,,704.00000,204.16000,Aetna,First Health,,575.87,,,,,,,15.64,575.87,percent of total billed charges,
RA Foot 2 Views Bilat,8246100,CDM,320,RC,73620,HCPCS,,,facility,inpatient,,,764.00000,221.56000,Aetna,First Health,,624.95,,,,,,,458.40,624.95,percent of total billed charges,
RA Foot 2 Views Bilat,8246100,CDM,320,RC,73620,HCPCS,,,facility,outpatient,,,764.00000,221.56000,Aetna,First Health,,624.95,,,,,,,18.12,624.95,percent of total billed charges,
RA Heel Bilat 2 Views,8263933,CDM,320,RC,73650,HCPCS,,,facility,inpatient,,,764.00000,221.56000,Aetna,First Health,,624.95,,,,,,,458.40,624.95,percent of total billed charges,
RA Heel Bilat 2 Views,8263933,CDM,320,RC,73650,HCPCS,,,facility,outpatient,,,764.00000,221.56000,Aetna,First Health,,624.95,,,,,,,17.41,624.95,percent of total billed charges,
RA Forearm Bilat,8270108,CDM,320,RC,73090,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,511.20,696.94,percent of total billed charges,
RA Forearm Bilat,8270108,CDM,320,RC,73090,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,19.19,696.94,percent of total billed charges,
RA Hip Bilat 3 to 4 Views,8409336,CDM,320,RC,73522,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,729.60,994.69,percent of total billed charges,
RA Hip Bilat 3 to 4 Views,8409336,CDM,320,RC,73522,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,First Health,,994.69,,,,,,,47.65,994.69,percent of total billed charges,
RA Intravenous Pyelogram,613887,CDM,320,RC,74400,HCPCS,,,facility,inpatient,,,1470.00000,426.30000,Aetna,First Health,,1202.46,,,,,,,882.00,1202.46,percent of total billed charges,
RA Intravenous Pyelogram,613887,CDM,320,RC,74400,HCPCS,,,facility,outpatient,,,1470.00000,426.30000,Aetna,First Health,,1202.46,,,,,,,63.58,1202.46,percent of total billed charges,
RA Loopogram,613909,CDM,320,RC,,,,,facility,inpatient,,,2010.00000,582.90000,Aetna,First Health,,1644.18,,,,,,,1206.00,1644.18,percent of total billed charges,
RA Loopogram,613909,CDM,320,RC,,,,,facility,outpatient,,,2010.00000,582.90000,Aetna,First Health,,1644.18,,,,,,,724.61,1644.18,percent of total billed charges,
RA Cystogram,613672,CDM,320,RC,,,,,facility,inpatient,,,1685.00000,488.65000,Aetna,First Health,,1378.33,,,,,,,1011.00,1378.33,percent of total billed charges,
RA Cystogram,613672,CDM,320,RC,,,,,facility,outpatient,,,1685.00000,488.65000,Aetna,First Health,,1378.33,,,,,,,607.44,1378.33,percent of total billed charges,
RA Urethrogram Retrograde,614303,CDM,320,RC,,,,,facility,inpatient,,,2343.00000,679.47000,Aetna,First Health,,1916.57,,,,,,,1405.80,1916.57,percent of total billed charges,
RA Urethrogram Retrograde,614303,CDM,320,RC,,,,,facility,outpatient,,,2343.00000,679.47000,Aetna,First Health,,1916.57,,,,,,,844.65,1916.57,percent of total billed charges,
RA Urethrogram Voiding,614307,CDM,320,RC,,,,,facility,inpatient,,,1772.00000,513.88000,Aetna,First Health,,1449.50,,,,,,,1063.20,1449.50,percent of total billed charges,
RA Urethrogram Voiding,614307,CDM,320,RC,,,,,facility,outpatient,,,1772.00000,513.88000,Aetna,First Health,,1449.50,,,,,,,638.81,1449.50,percent of total billed charges,
RA Urethrogram Voiding,614315,CDM,320,RC,,,,,facility,inpatient,,,1772.00000,513.88000,Aetna,First Health,,1449.50,,,,,,,1063.20,1449.50,percent of total billed charges,
RA Urethrogram Voiding,614315,CDM,320,RC,,,,,facility,outpatient,,,1772.00000,513.88000,Aetna,First Health,,1449.50,,,,,,,638.81,1449.50,percent of total billed charges,
RA Joint Survey,8456050,CDM,320,RC,77074,HCPCS,,,facility,inpatient,,,572.00000,165.88000,Aetna,First Health,,467.90,,,,,,,343.20,467.90,percent of total billed charges,
RA Joint Survey,8456050,CDM,320,RC,77074,HCPCS,,,facility,outpatient,,,572.00000,165.88000,Aetna,First Health,,467.90,,,,,,,73.11,467.90,percent of total billed charges,
RA Hysterosalpingogram,613846,CDM,320,RC,,,,,facility,inpatient,,,1787.00000,518.23000,Aetna,First Health,,1461.77,,,,,,,1072.20,1461.77,percent of total billed charges,
RA Hysterosalpingogram,613846,CDM,320,RC,,,,,facility,outpatient,,,1787.00000,518.23000,Aetna,First Health,,1461.77,,,,,,,644.21,1461.77,percent of total billed charges,
RA Toes 1 view bilat,9088259,CDM,320,RC,73660,HCPCS,,,facility,inpatient,,,676.00000,196.04000,Aetna,First Health,,552.97,,,,,,,405.60,552.97,percent of total billed charges,
RA Toes 1 view bilat,9088259,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,676.00000,196.04000,Aetna,First Health,,552.97,,,,,,,15.64,552.97,percent of total billed charges,
RA Ankle 2 Views Bilat,9109874,CDM,320,RC,73600,HCPCS,,,facility,inpatient,,,790.00000,229.10000,Aetna,First Health,,646.22,,,,,,,474.00,646.22,percent of total billed charges,
RA Ankle 2 Views Bilat,9109874,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,790.00000,229.10000,Aetna,First Health,,646.22,,,,,,,18.12,646.22,percent of total billed charges,
RA Ankle 1 Views Bilat,9114505,CDM,320,RC,73600,HCPCS,,,facility,inpatient,,,632.00000,183.28000,Aetna,First Health,,516.98,,,,,,,379.20,516.98,percent of total billed charges,
RA Ankle 1 Views Bilat,9114505,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,632.00000,183.28000,Aetna,First Health,,516.98,,,,,,,18.12,516.98,percent of total billed charges,
RA Toes 2 Views Bilat bce,9089061,CDM,320,RC,73660,HCPCS,,,facility,inpatient,,,676.00000,196.04000,Aetna,First Health,,552.97,,,,,,,405.60,552.97,percent of total billed charges,
RA Toes 2 Views Bilat bce,9089061,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,676.00000,196.04000,Aetna,First Health,,552.97,,,,,,,15.64,552.97,percent of total billed charges,
RA Timed Esophagram with Pill,9158470,CDM,320,RC,74220,HCPCS,,,facility,inpatient,,,742.00000,215.18000,Aetna,First Health,,606.96,,,,,,,445.20,606.96,percent of total billed charges,
RA Timed Esophagram with Pill,9158470,CDM,320,RC,74220,HCPCS,,,facility,outpatient,,,742.00000,215.18000,Aetna,First Health,,606.96,,,,,,,44.41,606.96,percent of total billed charges,
RA Fluoroscopy with Image,8146789,CDM,320,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
RA Fluoroscopy with Image,8146789,CDM,320,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,981.60,percent of total billed charges,
RA Fluoroscopy with Images,8147064,CDM,320,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
RA Fluoroscopy with Images,8147064,CDM,320,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,981.60,percent of total billed charges,
RA Bone Age,613604,CDM,320,RC,77072,HCPCS,,,facility,inpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,241.80,329.65,percent of total billed charges,
RA Bone Age,613604,CDM,320,RC,77072,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,First Health,,329.65,,,,,,,23.67,329.65,percent of total billed charges,
RA Bone Length,642501,CDM,320,RC,77073,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
RA Bone Length,642501,CDM,320,RC,77073,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,50.13,420.45,percent of total billed charges,
RA Sinus Tract Injection,642505,CDM,320,RC,,,,,facility,inpatient,,,1117.00000,323.93000,Aetna,First Health,,913.71,,,,,,,670.20,913.71,percent of total billed charges,
RA Sinus Tract Injection,642505,CDM,320,RC,,,,,facility,outpatient,,,1117.00000,323.93000,Aetna,First Health,,913.71,,,,,,,402.68,913.71,percent of total billed charges,
RA Bone Survey Infant,613617,CDM,320,RC,77076,HCPCS,,,facility,inpatient,,,485.00000,140.65000,Aetna,First Health,,396.73,,,,,,,291.00,396.73,percent of total billed charges,
RA Bone Survey Infant,613617,CDM,320,RC,77076,HCPCS,,,facility,outpatient,,,485.00000,140.65000,Aetna,First Health,,396.73,,,,,,,68.24,396.73,percent of total billed charges,
RA Bone Survey Infant Less than 1 year,7544178,CDM,320,RC,77076,HCPCS,,,facility,inpatient,,,485.00000,140.65000,Aetna,First Health,,396.73,,,,,,,291.00,396.73,percent of total billed charges,
RA Bone Survey Infant Less than 1 year,7544178,CDM,320,RC,77076,HCPCS,,,facility,outpatient,,,485.00000,140.65000,Aetna,First Health,,396.73,,,,,,,68.24,396.73,percent of total billed charges,
Bone Length Study,613891,CDM,320,RC,77073,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
Bone Length Study,613891,CDM,320,RC,77073,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,50.13,420.45,percent of total billed charges,
RA Bone Mineral Analysis Dexa,613612,CDM,320,RC,77080,HCPCS,,,facility,inpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,396.60,540.70,percent of total billed charges,
RA Bone Mineral Analysis Dexa,613612,CDM,320,RC,77080,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,93.38,540.70,percent of total billed charges,
Radiologic Guidance,613353,CDM,320,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
Radiologic Guidance,613353,CDM,320,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
RA Fluoroscopy,648719,CDM,320,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
RA Fluoroscopy,648719,CDM,320,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,981.60,percent of total billed charges,
RA Fluoroscopy with Images,613763,CDM,320,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
RA Fluoroscopy with Images,613763,CDM,320,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,981.60,percent of total billed charges,
Chemo Infusion Concurrent Drug,9094186,CDM,330,RC,96549,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,540.00,736.20,percent of total billed charges,
Chemo Infusion Concurrent Drug,9094186,CDM,330,RC,96549,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,40.51,736.20,percent of total billed charges,
Chemo Infusion Sequential Drug,9092698,CDM,330,RC,96417,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,540.00,736.20,percent of total billed charges,
Chemo Infusion Sequential Drug,9092698,CDM,330,RC,96417,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,62.50,736.20,percent of total billed charges,
Chemo Infusion Each Hour,9094185,CDM,330,RC,96415,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,540.00,736.20,percent of total billed charges,
Chemo Infusion Each Hour,9094185,CDM,330,RC,96415,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,62.50,736.20,percent of total billed charges,
Chemo Infusion First Hr First Drg,9092657,CDM,330,RC,96413,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,900.00,1227.00,percent of total billed charges,
Chemo Infusion First Hr First Drg,9092657,CDM,330,RC,96413,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,291.24,1227.00,percent of total billed charges,
Chemo Infusion Gt 8Hrs Using Pump,9094319,CDM,330,RC,96416,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,1080.00,1472.40,percent of total billed charges,
Chemo Infusion Gt 8Hrs Using Pump,9094319,CDM,330,RC,96416,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,291.24,1472.40,percent of total billed charges,
Chemo Iv Push Each Addl Drug,9094318,CDM,330,RC,96411,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,540.00,736.20,percent of total billed charges,
Chemo Iv Push Each Addl Drug,9094318,CDM,330,RC,96411,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,62.50,736.20,percent of total billed charges,
Chemo Iv Push Initial Or Single,9091696,CDM,330,RC,96409,HCPCS,,,facility,inpatient,,,950.00000,275.50000,Aetna,First Health,,777.10,,,,,,,570.00,777.10,percent of total billed charges,
Chemo Iv Push Initial Or Single,9091696,CDM,330,RC,96409,HCPCS,,,facility,outpatient,,,950.00000,275.50000,Aetna,First Health,,777.10,,,,,,,291.24,930.39,percent of total billed charges,
Chemo Refill And Maint Port Pump,7295869,CDM,330,RC,96521,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Chemo Refill And Maint Port Pump,7295869,CDM,330,RC,96521,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,185.00,654.40,percent of total billed charges,
Chemo Refill And Maint Port Pump,7957586,CDM,330,RC,96521,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Chemo Refill And Maint Port Pump,7957586,CDM,330,RC,96521,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,185.00,654.40,percent of total billed charges,
Chemo Refill And Maint Port Pump,8061981,CDM,330,RC,96521,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Chemo Refill And Maint Port Pump,8061981,CDM,330,RC,96521,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,185.00,654.40,percent of total billed charges,
Chemo Refill Implanted Pump,7295868,CDM,330,RC,96522,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Chemo Refill Implanted Pump,7295868,CDM,330,RC,96522,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,185.00,654.40,percent of total billed charges,
Chemo Refill Implanted Pump,7957587,CDM,330,RC,96522,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Chemo Refill Implanted Pump,7957587,CDM,330,RC,96522,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,185.00,654.40,percent of total billed charges,
Chemo Refill Implanted Pump,8061982,CDM,330,RC,96522,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Chemo Refill Implanted Pump,8061982,CDM,330,RC,96522,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,185.00,654.40,percent of total billed charges,
Initial Chemo Sub Q Im Hormonal AntiNeopl,9092753,CDM,330,RC,96402,HCPCS,,,facility,inpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,300.00,409.00,percent of total billed charges,
Initial Chemo Sub Q Im Hormonal AntiNeopl,9092753,CDM,330,RC,96402,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,62.50,409.00,percent of total billed charges,
Chemo Sub Q Im Hormonal AntiNeopl,9094165,CDM,330,RC,96402,HCPCS,,,facility,inpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,300.00,409.00,percent of total billed charges,
Chemo Sub Q Im Hormonal AntiNeopl,9094165,CDM,330,RC,96402,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,62.50,409.00,percent of total billed charges,
Initial Chemo SubQ IM NonHormonal AntiNeopl,9092750,CDM,330,RC,96401,HCPCS,,,facility,inpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,300.00,409.00,percent of total billed charges,
Initial Chemo SubQ IM NonHormonal AntiNeopl,9092750,CDM,330,RC,96401,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,62.50,409.00,percent of total billed charges,
Chemo SubQ IM NonHormonal AntiNeopl,9094164,CDM,330,RC,96401,HCPCS,,,facility,inpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,300.00,409.00,percent of total billed charges,
Chemo SubQ IM NonHormonal AntiNeopl,9094164,CDM,330,RC,96401,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,62.50,409.00,percent of total billed charges,
Chemo Inf Init Hr Of Pts Own Med,9094160,CDM,330,RC,96413,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,FB,1227.00,,,,,,,900.00,1227.00,percent of total billed charges,
Chemo Inf Init Hr Of Pts Own Med,9094160,CDM,330,RC,96413,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,FB,1227.00,,,,,,,291.24,1227.00,percent of total billed charges,
Chemo Inf Ea Hr Of Pts Own Med,9092755,CDM,330,RC,96415,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,FB,736.20,,,,,,,540.00,736.20,percent of total billed charges,
Chemo Inf Ea Hr Of Pts Own Med,9092755,CDM,330,RC,96415,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,FB,736.20,,,,,,,62.50,736.20,percent of total billed charges,
Chemo Push Initial of Pts Own Med,9094159,CDM,330,RC,96409,HCPCS,,,facility,inpatient,,,950.00000,275.50000,Aetna,First Health,FB,777.10,,,,,,,570.00,777.10,percent of total billed charges,
Chemo Push Initial of Pts Own Med,9094159,CDM,330,RC,96409,HCPCS,,,facility,outpatient,,,950.00000,275.50000,Aetna,First Health,FB,777.10,,,,,,,291.24,885.31,percent of total billed charges,
Chemo Push Addl Med Of Pts Own,9092754,CDM,330,RC,96411,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,FB,736.20,,,,,,,540.00,736.20,percent of total billed charges,
Chemo Push Addl Med Of Pts Own,9092754,CDM,330,RC,96411,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,FB,736.20,,,,,,,62.50,736.20,percent of total billed charges,
Chemo SubQ Hormonal AntiNeopl of Pts Own Med,9094316,CDM,330,RC,96402,HCPCS,,,facility,inpatient,,,500.00000,145.00000,Aetna,First Health,FB,409.00,,,,,,,300.00,409.00,percent of total billed charges,
Chemo SubQ Hormonal AntiNeopl of Pts Own Med,9094316,CDM,330,RC,96402,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,First Health,FB,409.00,,,,,,,62.50,409.00,percent of total billed charges,
Chemo SubQ Hormonal AntiNeopl of Pts Own Med,9094317,CDM,330,RC,96402,HCPCS,,,facility,inpatient,,,500.00000,145.00000,Aetna,First Health,FB,409.00,,,,,,,300.00,409.00,percent of total billed charges,
Chemo SubQ Hormonal AntiNeopl of Pts Own Med,9094317,CDM,330,RC,96402,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,First Health,FB,409.00,,,,,,,62.50,409.00,percent of total billed charges,
Chemo SubQ IM NonHormone AntiNeopl of Pts Own Med,9092751,CDM,330,RC,96401,HCPCS,,,facility,inpatient,,,500.00000,145.00000,Aetna,First Health,FB,409.00,,,,,,,300.00,409.00,percent of total billed charges,
Chemo SubQ IM NonHormone AntiNeopl of Pts Own Med,9092751,CDM,330,RC,96401,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,First Health,FB,409.00,,,,,,,62.50,409.00,percent of total billed charges,
Chemo SubQ IM NonHormone AntiNeopl of Pts Own Med,9092752,CDM,330,RC,96401,HCPCS,,,facility,inpatient,,,500.00000,145.00000,Aetna,First Health,FB,409.00,,,,,,,300.00,409.00,percent of total billed charges,
Chemo SubQ IM NonHormone AntiNeopl of Pts Own Med,9092752,CDM,330,RC,96401,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,First Health,FB,409.00,,,,,,,62.50,409.00,percent of total billed charges,
Chemo Infusion Sequential Drug Pts Own Med,9186697,CDM,330,RC,96417,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,540.00,736.20,percent of total billed charges,
Chemo Infusion Sequential Drug Pts Own Med,9186697,CDM,330,RC,96417,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,62.50,736.20,percent of total billed charges,
Chemo Infusion Concurrent Drug Pts Own Med,9188729,CDM,330,RC,96549,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,540.00,736.20,percent of total billed charges,
Chemo Infusion Concurrent Drug Pts Own Med,9188729,CDM,330,RC,96549,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,First Health,,736.20,,,,,,,40.51,736.20,percent of total billed charges,
Chemo IV Infusion 8Hrs or More,9186782,CDM,330,RC,96416,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,1080.00,1472.40,percent of total billed charges,
Chemo IV Infusion 8Hrs or More,9186782,CDM,330,RC,96416,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,291.24,1472.40,percent of total billed charges,
Chemo Extended IV Infusion w CADD,9188634,CDM,330,RC,G0498,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,1080.00,1472.40,percent of total billed charges,
Chemo Extended IV Infusion w CADD,9188634,CDM,330,RC,G0498,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,First Health,,1472.40,,,,,,,291.24,1472.40,percent of total billed charges,
With Intrathecal Chemo,9078314,CDM,331,RC,,,,,facility,inpatient,,,1140.00000,330.60000,Aetna,First Health,,932.52,,,,,,,684.00,932.52,percent of total billed charges,
With Intrathecal Chemo,9078314,CDM,331,RC,,,,,facility,outpatient,,,1140.00000,330.60000,Aetna,First Health,,932.52,,,,,,,410.97,932.52,percent of total billed charges,
IGRT,2452825,CDM,333,RC,77387,HCPCS,,,facility,inpatient,,,1828.00000,530.12000,Aetna,First Health,,1495.30,,,,,,,1096.80,1495.30,percent of total billed charges,
IGRT,2452825,CDM,333,RC,77387,HCPCS,,,facility,outpatient,,,1828.00000,530.12000,Aetna,First Health,,1495.30,,,,,,,219.84,1495.30,percent of total billed charges,
MLC Device Design And Construct,3172896,CDM,333,RC,77338,HCPCS,,,facility,inpatient,,,3301.00000,957.29000,Aetna,First Health,,2700.22,,,,,,,1980.60,2700.22,percent of total billed charges,
MLC Device Design And Construct,3172896,CDM,333,RC,77338,HCPCS,,,facility,outpatient,,,3301.00000,957.29000,Aetna,First Health,,2700.22,,,,,,,229.63,2700.22,percent of total billed charges,
Treatment Stereo Brain,8062056,CDM,333,RC,77372,HCPCS,,,facility,inpatient,,,21448.00000,6219.92000,Aetna,First Health,,17544.46,,,,,,,12868.80,17544.46,percent of total billed charges,
Treatment Stereo Brain,8062056,CDM,333,RC,77372,HCPCS,,,facility,outpatient,,,21448.00000,6219.92000,Aetna,First Health,,17544.46,,,,,,,1596.68,20403.84,percent of total billed charges,
Treatment Stereo Body,8062057,CDM,333,RC,77373,HCPCS,,,facility,inpatient,,,8758.00000,2539.82000,Aetna,First Health,,7164.04,,,,,,,5254.80,7164.04,percent of total billed charges,
Treatment Stereo Body,8062057,CDM,333,RC,77373,HCPCS,,,facility,outpatient,,,8758.00000,2539.82000,Aetna,First Health,,7164.04,,,,,,,1541.79,7164.04,percent of total billed charges,
Simulation 4D,8062058,CDM,333,RC,77293,HCPCS,,,facility,inpatient,,,5052.00000,1465.08000,Aetna,First Health,,4132.54,,,,,,,3031.20,4132.54,percent of total billed charges,
Simulation 4D,8062058,CDM,333,RC,77293,HCPCS,,,facility,outpatient,,,5052.00000,1465.08000,Aetna,First Health,,4132.54,,,,,,,503.50,4132.54,percent of total billed charges,
IMRT Complex,8062059,CDM,333,RC,77386,HCPCS,,,facility,inpatient,,,4600.00000,1334.00000,Aetna,First Health,,3762.80,,,,,,,2760.00,3762.80,percent of total billed charges,
IMRT Complex,8062059,CDM,333,RC,77386,HCPCS,,,facility,outpatient,,,4600.00000,1334.00000,Aetna,First Health,,3762.80,,,,,,,1544.00,3762.80,percent of total billed charges,
IMRT Complex Prostate Or Breast,8062060,CDM,333,RC,77385,HCPCS,,,facility,inpatient,,,4600.00000,1334.00000,Aetna,First Health,,3762.80,,,,,,,2760.00,3762.80,percent of total billed charges,
IMRT Complex Prostate Or Breast,8062060,CDM,333,RC,77385,HCPCS,,,facility,outpatient,,,4600.00000,1334.00000,Aetna,First Health,,3762.80,,,,,,,1544.00,3762.80,percent of total billed charges,
Radiotherapy Dose Plan Imrt B,8062061,CDM,333,RC,77301,HCPCS,,,facility,inpatient,,,23288.00000,6753.52000,Aetna,First Health,,19049.58,,,,,,,13972.80,19049.58,percent of total billed charges,
Radiotherapy Dose Plan Imrt B,8062061,CDM,333,RC,77301,HCPCS,,,facility,outpatient,,,23288.00000,6753.52000,Aetna,First Health,,19049.58,,,,,,,1047.77,19049.58,percent of total billed charges,
Simulation Simple w GZ CTR,9192549,CDM,333,RC,77280,HCPCS,,,facility,inpatient,,,3810.00000,1104.90000,Aetna,First Health,GZ,3116.58,,,,,,,2286.00,3116.58,percent of total billed charges,
Simulation Simple w GZ CTR,9192549,CDM,333,RC,77280,HCPCS,,,facility,outpatient,,,3810.00000,1104.90000,Aetna,First Health,GZ,3116.58,,,,,,,116.59,3116.58,percent of total billed charges,
Manual Calculations w XU CTR,9194578,CDM,333,RC,77300,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,XU,1011.05,,,,,,,741.60,1011.05,percent of total billed charges,
Manual Calculations w XU CTR,9194578,CDM,333,RC,77300,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,XU,1011.05,,,,,,,50.10,1011.05,percent of total billed charges,
Isodose Planning Complex w GZ CTR,9192550,CDM,333,RC,77307,HCPCS,,,facility,inpatient,,,2510.00000,727.90000,Aetna,First Health,GZ,2053.18,,,,,,,1506.00,2053.18,percent of total billed charges,
Isodose Planning Complex w GZ CTR,9192550,CDM,333,RC,77307,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,First Health,GZ,2053.18,,,,,,,189.84,2053.18,percent of total billed charges,
Treatment Device Complex w XU CTR,9194580,CDM,333,RC,77334,HCPCS,,,facility,inpatient,,,2510.00000,727.90000,Aetna,First Health,XU,2053.18,,,,,,,1506.00,2053.18,percent of total billed charges,
Treatment Device Complex w XU CTR,9194580,CDM,333,RC,77334,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,First Health,XU,2053.18,,,,,,,121.87,2053.18,percent of total billed charges,
Isodose Planning Complex w XU CTR,9194579,CDM,333,RC,77307,HCPCS,,,facility,inpatient,,,2510.00000,727.90000,Aetna,First Health,XU,2053.18,,,,,,,1506.00,2053.18,percent of total billed charges,
Isodose Planning Complex w XU CTR,9194579,CDM,333,RC,77307,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,First Health,XU,2053.18,,,,,,,189.84,2053.18,percent of total billed charges,
Physics QA Support w GZ CTR,9194581,CDM,333,RC,77336,HCPCS,,,facility,inpatient,,,1368.00000,396.72000,Aetna,First Health,GZ,1119.02,,,,,,,820.80,1119.02,percent of total billed charges,
Physics QA Support w GZ CTR,9194581,CDM,333,RC,77336,HCPCS,,,facility,outpatient,,,1368.00000,396.72000,Aetna,First Health,GZ,1119.02,,,,,,,111.92,1119.02,percent of total billed charges,
Physics QA Support w XU CTR,9194582,CDM,333,RC,77336,HCPCS,,,facility,inpatient,,,1368.00000,396.72000,Aetna,First Health,XU,1119.02,,,,,,,820.80,1119.02,percent of total billed charges,
Physics QA Support w XU CTR,9194582,CDM,333,RC,77336,HCPCS,,,facility,outpatient,,,1368.00000,396.72000,Aetna,First Health,XU,1119.02,,,,,,,111.92,1119.02,percent of total billed charges,
MLC Device Design and Construct w XU CTR,9194583,CDM,333,RC,77338,HCPCS,,,facility,inpatient,,,3301.00000,957.29000,Aetna,First Health,XU,2700.22,,,,,,,1980.60,2700.22,percent of total billed charges,
MLC Device Design and Construct w XU CTR,9194583,CDM,333,RC,77338,HCPCS,,,facility,outpatient,,,3301.00000,957.29000,Aetna,First Health,XU,2700.22,,,,,,,229.63,2700.22,percent of total billed charges,
Simulation Simple,602781,CDM,333,RC,77280,HCPCS,,,facility,inpatient,,,3810.00000,1104.90000,Aetna,First Health,,3116.58,,,,,,,2286.00,3116.58,percent of total billed charges,
Simulation Simple,602781,CDM,333,RC,77280,HCPCS,,,facility,outpatient,,,3810.00000,1104.90000,Aetna,First Health,,3116.58,,,,,,,116.59,3116.58,percent of total billed charges,
Simulation Complex,602785,CDM,333,RC,77290,HCPCS,,,facility,inpatient,,,6002.00000,1740.58000,Aetna,First Health,,4909.64,,,,,,,3601.20,4909.64,percent of total billed charges,
Simulation Complex,602785,CDM,333,RC,77290,HCPCS,,,facility,outpatient,,,6002.00000,1740.58000,Aetna,First Health,,4909.64,,,,,,,244.44,4909.64,percent of total billed charges,
3D Isodose Plan,602787,CDM,333,RC,77295,HCPCS,,,facility,inpatient,,,11874.00000,3443.46000,Aetna,First Health,,9712.93,,,,,,,7124.40,9712.93,percent of total billed charges,
3D Isodose Plan,602787,CDM,333,RC,77295,HCPCS,,,facility,outpatient,,,11874.00000,3443.46000,Aetna,First Health,,9712.93,,,,,,,1047.77,9712.93,percent of total billed charges,
Manual Calculations,602789,CDM,333,RC,77300,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,741.60,1011.05,percent of total billed charges,
Manual Calculations,602789,CDM,333,RC,77300,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,First Health,,1011.05,,,,,,,50.10,1011.05,percent of total billed charges,
Radiotherapy Dose Plan Imrt,647071,CDM,333,RC,77301,HCPCS,,,facility,inpatient,,,13159.00000,3816.11000,Aetna,First Health,,10764.06,,,,,,,7895.40,10764.06,percent of total billed charges,
Radiotherapy Dose Plan Imrt,647071,CDM,333,RC,77301,HCPCS,,,facility,outpatient,,,13159.00000,3816.11000,Aetna,First Health,,10764.06,,,,,,,1047.77,10764.06,percent of total billed charges,
Isodose Planning Simple,602791,CDM,333,RC,77306,HCPCS,,,facility,inpatient,,,1190.00000,345.10000,Aetna,First Health,,973.42,,,,,,,714.00,973.42,percent of total billed charges,
Isodose Planning Simple,602791,CDM,333,RC,77306,HCPCS,,,facility,outpatient,,,1190.00000,345.10000,Aetna,First Health,,973.42,,,,,,,109.99,977.09,percent of total billed charges,
ISODOSE PLANNING COMPLEX,602795,CDM,333,RC,77307,HCPCS,,,facility,inpatient,,,2510.00000,727.90000,Aetna,First Health,,2053.18,,,,,,,1506.00,2053.18,percent of total billed charges,
ISODOSE PLANNING COMPLEX,602795,CDM,333,RC,77307,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,First Health,,2053.18,,,,,,,189.84,2053.18,percent of total billed charges,
Special Treatment Port Plan,602797,CDM,333,RC,77321,HCPCS,,,facility,inpatient,,,1555.00000,450.95000,Aetna,First Health,,1271.99,,,,,,,933.00,1271.99,percent of total billed charges,
Special Treatment Port Plan,602797,CDM,333,RC,77321,HCPCS,,,facility,outpatient,,,1555.00000,450.95000,Aetna,First Health,,1271.99,,,,,,,151.36,1271.99,percent of total billed charges,
Treatment Device Simple,602807,CDM,333,RC,77332,HCPCS,,,facility,inpatient,,,1368.00000,396.72000,Aetna,First Health,,1119.02,,,,,,,820.80,1119.02,percent of total billed charges,
Treatment Device Simple,602807,CDM,333,RC,77332,HCPCS,,,facility,outpatient,,,1368.00000,396.72000,Aetna,First Health,,1119.02,,,,,,,50.10,1119.02,percent of total billed charges,
Treatment Device Intermediate,602809,CDM,333,RC,77333,HCPCS,,,facility,inpatient,,,1694.00000,491.26000,Aetna,First Health,,1385.69,,,,,,,1016.40,1385.69,percent of total billed charges,
Treatment Device Intermediate,602809,CDM,333,RC,77333,HCPCS,,,facility,outpatient,,,1694.00000,491.26000,Aetna,First Health,,1385.69,,,,,,,71.41,1385.69,percent of total billed charges,
Treatment Device Complex,602811,CDM,333,RC,77334,HCPCS,,,facility,inpatient,,,2510.00000,727.90000,Aetna,First Health,,2053.18,,,,,,,1506.00,2053.18,percent of total billed charges,
Treatment Device Complex,602811,CDM,333,RC,77334,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,First Health,,2053.18,,,,,,,121.87,2053.18,percent of total billed charges,
Physics QA Support,602813,CDM,333,RC,77336,HCPCS,,,facility,inpatient,,,1368.00000,396.72000,Aetna,First Health,,1119.02,,,,,,,820.80,1119.02,percent of total billed charges,
Physics QA Support,602813,CDM,333,RC,77336,HCPCS,,,facility,outpatient,,,1368.00000,396.72000,Aetna,First Health,,1119.02,,,,,,,111.92,1119.02,percent of total billed charges,
Physics Special Consult,602815,CDM,333,RC,77370,HCPCS,,,facility,inpatient,,,2192.00000,635.68000,Aetna,First Health,,1793.06,,,,,,,1315.20,1793.06,percent of total billed charges,
Physics Special Consult,602815,CDM,333,RC,77370,HCPCS,,,facility,outpatient,,,2192.00000,635.68000,Aetna,First Health,,1793.06,,,,,,,116.59,1793.06,percent of total billed charges,
Daily Treatment Simple,602817,CDM,333,RC,77402,HCPCS,,,facility,inpatient,,,913.00000,264.77000,Aetna,First Health,,746.83,,,,,,,547.80,746.83,percent of total billed charges,
Daily Treatment Simple,602817,CDM,333,RC,77402,HCPCS,,,facility,outpatient,,,913.00000,264.77000,Aetna,First Health,,746.83,,,,,,,67.13,746.83,percent of total billed charges,
Daily Treatment Complex,602821,CDM,333,RC,77412,HCPCS,,,facility,inpatient,,,2510.00000,727.90000,Aetna,First Health,,2053.18,,,,,,,1506.00,2053.18,percent of total billed charges,
Daily Treatment Complex,602821,CDM,333,RC,77412,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,First Health,,2053.18,,,,,,,87.75,2053.18,percent of total billed charges,
Port Films Verified,602823,CDM,333,RC,77417,HCPCS,,,facility,inpatient,,,550.00000,159.50000,Aetna,First Health,,449.90,,,,,,,330.00,449.90,percent of total billed charges,
Port Films Verified,602823,CDM,333,RC,77417,HCPCS,,,facility,outpatient,,,550.00000,159.50000,Aetna,First Health,,449.90,,,,,,,22.37,449.90,percent of total billed charges,
Special Treatment,602825,CDM,333,RC,77470,HCPCS,,,facility,inpatient,,,5482.00000,1589.78000,Aetna,First Health,,4484.28,,,,,,,3289.20,4484.28,percent of total billed charges,
Special Treatment,602825,CDM,333,RC,77470,HCPCS,,,facility,outpatient,,,5482.00000,1589.78000,Aetna,First Health,,4484.28,,,,,,,418.18,4484.28,percent of total billed charges,
CAR NM RESTING MYOCARDIAL PERFUSI,7363901,CDM,341,RC,78451,HCPCS,,,facility,inpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,2554.80,3483.04,percent of total billed charges,
CAR NM RESTING MYOCARDIAL PERFUSI,7363901,CDM,341,RC,78451,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,141.62,3646.69,percent of total billed charges,
CAR NM MUGA,7363902,CDM,341,RC,78472,HCPCS,,,facility,inpatient,,,3703.00000,1073.87000,Aetna,First Health,,3029.05,,,,,,,2221.80,3029.05,percent of total billed charges,
CAR NM MUGA,7363902,CDM,341,RC,78472,HCPCS,,,facility,outpatient,,,3703.00000,1073.87000,Aetna,First Health,,3029.05,,,,,,,207.13,3029.05,percent of total billed charges,
CAR NM SPECT MYOCARDIAL IMAGING,7363898,CDM,341,RC,78452,HCPCS,,,facility,inpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,2554.80,3483.04,percent of total billed charges,
CAR NM SPECT MYOCARDIAL IMAGING,7363898,CDM,341,RC,78452,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,273.63,3646.69,percent of total billed charges,
CAR NM SPECT MYOCARDIAL IMAGING,7363899,CDM,341,RC,78452,HCPCS,,,facility,inpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,2554.80,3483.04,percent of total billed charges,
CAR NM SPECT MYOCARDIAL IMAGING,7363899,CDM,341,RC,78452,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,273.63,3646.69,percent of total billed charges,
CAR NM SPECT MYOCARDIAL IMAGING,7363900,CDM,341,RC,78452,HCPCS,,,facility,inpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,2554.80,3483.04,percent of total billed charges,
CAR NM SPECT MYOCARDIAL IMAGING,7363900,CDM,341,RC,78452,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,273.63,3646.69,percent of total billed charges,
CAR NM THALLIUM VIABILITY,7363897,CDM,341,RC,78452,HCPCS,,,facility,inpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,2554.80,3483.04,percent of total billed charges,
CAR NM THALLIUM VIABILITY,7363897,CDM,341,RC,78452,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,273.63,3646.69,percent of total billed charges,
NM VQ Scan,1557808,CDM,341,RC,78582,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM VQ Scan,1557808,CDM,341,RC,78582,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,249.86,2777.11,percent of total billed charges,
NM Bone Marrow,3661942,CDM,341,RC,78104,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Bone Marrow,3661942,CDM,341,RC,78104,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,152.77,2099.81,percent of total billed charges,
NM GB Biliary Tract w CCK,3661944,CDM,341,RC,78227,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM GB Biliary Tract w CCK,3661944,CDM,341,RC,78227,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,269.54,2777.11,percent of total billed charges,
NM Adrenal,7286032,CDM,341,RC,78075,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Adrenal,7286032,CDM,341,RC,78075,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,203.59,3646.69,percent of total billed charges,
NM Shunt Right to Left,8148515,CDM,341,RC,78428,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Shunt Right to Left,8148515,CDM,341,RC,78428,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,84.91,2777.11,percent of total billed charges,
NM DATScan Exam,8155221,CDM,341,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
NM DATScan Exam,8155221,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
NM GB Biliary Tract w Boost,8876098,CDM,341,RC,78226,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM GB Biliary Tract w Boost,8876098,CDM,341,RC,78226,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,269.54,2777.11,percent of total billed charges,
NM Cerebral Flow Study,624515,CDM,341,RC,78601,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Cerebral Flow Study,624515,CDM,341,RC,78601,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,127.55,2777.11,percent of total billed charges,
NM Cisternogram,624530,CDM,341,RC,78630,HCPCS,,,facility,inpatient,,,2952.00000,856.08000,Aetna,First Health,,2414.74,,,,,,,1771.20,2414.74,percent of total billed charges,
NM Cisternogram,624530,CDM,341,RC,78630,HCPCS,,,facility,outpatient,,,2952.00000,856.08000,Aetna,First Health,,2414.74,,,,,,,189.02,2414.74,percent of total billed charges,
NM CSF Shunt Evaluation,624538,CDM,341,RC,78645,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM CSF Shunt Evaluation,624538,CDM,341,RC,78645,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,128.62,2777.11,percent of total billed charges,
NM CSF Shunt Evaluation,624540,CDM,341,RC,78645,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM CSF Shunt Evaluation,624540,CDM,341,RC,78645,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,128.62,2777.11,percent of total billed charges,
NM GI Bleeding Scan,624563,CDM,341,RC,78278,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM GI Bleeding Scan,624563,CDM,341,RC,78278,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,182.28,2777.11,percent of total billed charges,
NM Liver Spleen Scan,624574,CDM,341,RC,78215,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Liver Spleen Scan,624574,CDM,341,RC,78215,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,109.80,2099.81,percent of total billed charges,
NM Meckels Imaging,624588,CDM,341,RC,78290,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Meckels Imaging,624588,CDM,341,RC,78290,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,114.40,2777.11,percent of total billed charges,
NM Metastatic Body Survey,624592,CDM,341,RC,78018,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Metastatic Body Survey,624592,CDM,341,RC,78018,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,203.59,2777.11,percent of total billed charges,
NM Thyroid Carcinoma Whole Body,624608,CDM,341,RC,78018,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Thyroid Carcinoma Whole Body,624608,CDM,341,RC,78018,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,203.59,2777.11,percent of total billed charges,
NM Thyroid Whole Body Thyrogen,624670,CDM,341,RC,78018,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Thyroid Whole Body Thyrogen,624670,CDM,341,RC,78018,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,203.59,2777.11,percent of total billed charges,
NM Thyroid Whole Body Thyrogen,8297157,CDM,341,RC,78018,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Thyroid Whole Body Thyrogen,8297157,CDM,341,RC,78018,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,203.59,2777.11,percent of total billed charges,
NM Parathyroid Planar Imaging,624603,CDM,341,RC,78070,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Parathyroid Planar Imaging,624603,CDM,341,RC,78070,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,156.09,2777.11,percent of total billed charges,
NM Parathyroid Planar Imaging,655844,CDM,341,RC,78070,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Parathyroid Planar Imaging,655844,CDM,341,RC,78070,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,156.09,2777.11,percent of total billed charges,
NM Pulmonary Perfusion,624610,CDM,341,RC,78580,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Pulmonary Perfusion,624610,CDM,341,RC,78580,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,128.62,2777.11,percent of total billed charges,
NM Pulmonary Ventilation,624612,CDM,341,RC,78579,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Pulmonary Ventilation,624612,CDM,341,RC,78579,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,161.47,2099.81,percent of total billed charges,
NM Renal Mag 3,624629,CDM,341,RC,78707,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Renal Mag 3,624629,CDM,341,RC,78707,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,167.35,2777.11,percent of total billed charges,
NM Thyroid Uptake,624683,CDM,341,RC,78012,HCPCS,,,facility,inpatient,,,1839.00000,533.31000,Aetna,First Health,,1504.30,,,,,,,1103.40,1504.30,percent of total billed charges,
NM Thyroid Uptake,624683,CDM,341,RC,78012,HCPCS,,,facility,outpatient,,,1839.00000,533.31000,Aetna,First Health,,1504.30,,,,,,,102.90,1504.30,percent of total billed charges,
NM Bone Scan Whole Body,1557804,CDM,341,RC,78306,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Bone Scan Whole Body,1557804,CDM,341,RC,78306,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,159.89,2777.11,percent of total billed charges,
NM Bone Scan Whole Body,624504,CDM,341,RC,78306,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Bone Scan Whole Body,624504,CDM,341,RC,78306,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,159.89,2777.11,percent of total billed charges,
NM Thyroid Uptake and Scan,624685,CDM,341,RC,78014,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Thyroid Uptake and Scan,624685,CDM,341,RC,78014,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,320.23,2777.11,percent of total billed charges,
NM Tc99M Thyroid,624664,CDM,341,RC,78013,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Tc99M Thyroid,624664,CDM,341,RC,78013,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,254.38,2777.11,percent of total billed charges,
NM RBC Blood Volume,624618,CDM,341,RC,78121,HCPCS,,,facility,inpatient,,,3380.00000,980.20000,Aetna,First Health,,2764.84,,,,,,,2028.00,2764.84,percent of total billed charges,
NM RBC Blood Volume,624618,CDM,341,RC,78121,HCPCS,,,facility,outpatient,,,3380.00000,980.20000,Aetna,First Health,,2764.84,,,,,,,108.73,2764.84,percent of total billed charges,
NM Thyroid Thyrogen Carcinoma Therapy,7917891,CDM,341,RC,79005,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Thyroid Thyrogen Carcinoma Therapy,7917891,CDM,341,RC,79005,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,98.42,2777.11,percent of total billed charges,
NM GB Biliary Tract wo CCK,624561,CDM,341,RC,78226,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM GB Biliary Tract wo CCK,624561,CDM,341,RC,78226,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,269.54,2777.11,percent of total billed charges,
NM Localize Inflamation Whole Body,624518,CDM,341,RC,78802,HCPCS,,,facility,inpatient,,,3887.00000,1127.23000,Aetna,First Health,,3179.57,,,,,,,2332.20,3179.57,percent of total billed charges,
NM Localize Inflamation Whole Body,624518,CDM,341,RC,78802,HCPCS,,,facility,outpatient,,,3887.00000,1127.23000,Aetna,First Health,,3179.57,,,,,,,207.84,3484.44,percent of total billed charges,
NM Indium WBC Imaging,624568,CDM,341,RC,78802,HCPCS,,,facility,inpatient,,,3887.00000,1127.23000,Aetna,First Health,,3179.57,,,,,,,2332.20,3179.57,percent of total billed charges,
NM Indium WBC Imaging,624568,CDM,341,RC,78802,HCPCS,,,facility,outpatient,,,3887.00000,1127.23000,Aetna,First Health,,3179.57,,,,,,,207.84,3484.44,percent of total billed charges,
NM Testicular Scan with Flow,624668,CDM,341,RC,78761,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Testicular Scan with Flow,624668,CDM,341,RC,78761,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,120.09,2099.81,percent of total billed charges,
NM Lymphoscintigrapy,624583,CDM,341,RC,78195,HCPCS,,,facility,inpatient,,,4470.00000,1296.30000,Aetna,First Health,,3656.46,,,,,,,2682.00,3656.46,percent of total billed charges,
NM Lymphoscintigrapy,624583,CDM,341,RC,78195,HCPCS,,,facility,outpatient,,,4470.00000,1296.30000,Aetna,First Health,,3656.46,,,,,,,152.77,3656.46,percent of total billed charges,
NM Liver Imaging SPECT,624621,CDM,341,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
NM Liver Imaging SPECT,624621,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
NM SPECT Liver,624657,CDM,341,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
NM SPECT Liver,624657,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
NM Salivary Gland,624636,CDM,341,RC,78231,HCPCS,,,facility,inpatient,,,1839.00000,533.31000,Aetna,First Health,,1504.30,,,,,,,1103.40,1504.30,percent of total billed charges,
NM Salivary Gland,624636,CDM,341,RC,78231,HCPCS,,,facility,outpatient,,,1839.00000,533.31000,Aetna,First Health,,1504.30,,,,,,,119.03,1504.30,percent of total billed charges,
NM Esophageal Reflux Aspiration,624546,CDM,341,RC,78262,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Esophageal Reflux Aspiration,624546,CDM,341,RC,78262,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,159.17,2099.81,percent of total billed charges,
NM Gastric Emptying,7943875,CDM,341,RC,78264,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Gastric Emptying,7943875,CDM,341,RC,78264,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,154.91,2777.11,percent of total billed charges,
NM Shunt Patency,624649,CDM,341,RC,78291,HCPCS,,,facility,inpatient,,,1839.00000,533.31000,Aetna,First Health,,1504.30,,,,,,,1103.40,1504.30,percent of total billed charges,
NM Shunt Patency,624649,CDM,341,RC,78291,HCPCS,,,facility,outpatient,,,1839.00000,533.31000,Aetna,First Health,,1504.30,,,,,,,114.76,1504.30,percent of total billed charges,
NM 3 Phase Bone Scan,624494,CDM,341,RC,78315,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM 3 Phase Bone Scan,624494,CDM,341,RC,78315,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,179.07,2777.11,percent of total billed charges,
NM SPECT Bone,624652,CDM,341,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
NM SPECT Bone,624652,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
NM SPECT Bone,8001078,CDM,341,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
NM SPECT Bone,8001078,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
NM Split Function Lung,624662,CDM,341,RC,78597,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Split Function Lung,624662,CDM,341,RC,78597,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,182.07,2777.11,percent of total billed charges,
NM Cystogram,624544,CDM,341,RC,78740,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Cystogram,624544,CDM,341,RC,78740,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,79.94,2099.81,percent of total billed charges,
NM Renal w Lasix,624631,CDM,341,RC,78708,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Renal w Lasix,624631,CDM,341,RC,78708,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,167.35,2777.11,percent of total billed charges,
NM SPECT Tumor,624659,CDM,341,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
NM SPECT Tumor,624659,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
NM SPECT Tumor,8001079,CDM,341,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
NM SPECT Tumor,8001079,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
NM Spect Tumor,8001077,CDM,341,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
NM Spect Tumor,8001077,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
NM Octreoscan Tumor Img,624601,CDM,341,RC,78804,HCPCS,,,facility,inpatient,,,4224.00000,1224.96000,Aetna,First Health,,3455.23,,,,,,,2534.40,3455.23,percent of total billed charges,
NM Octreoscan Tumor Img,624601,CDM,341,RC,78804,HCPCS,,,facility,outpatient,,,4224.00000,1224.96000,Aetna,First Health,,3455.23,,,,,,,404.97,3484.44,percent of total billed charges,
NM Tumor Localization Whole Body,624692,CDM,341,RC,78804,HCPCS,,,facility,inpatient,,,4224.00000,1224.96000,Aetna,First Health,,3455.23,,,,,,,2534.40,3455.23,percent of total billed charges,
NM Tumor Localization Whole Body,624692,CDM,341,RC,78804,HCPCS,,,facility,outpatient,,,4224.00000,1224.96000,Aetna,First Health,,3455.23,,,,,,,404.97,3484.44,percent of total billed charges,
NM Lymphoma Imaging Bexxar,661243,CDM,341,RC,78804,HCPCS,,,facility,inpatient,,,4224.00000,1224.96000,Aetna,First Health,,3455.23,,,,,,,2534.40,3455.23,percent of total billed charges,
NM Lymphoma Imaging Bexxar,661243,CDM,341,RC,78804,HCPCS,,,facility,outpatient,,,4224.00000,1224.96000,Aetna,First Health,,3455.23,,,,,,,404.97,3484.44,percent of total billed charges,
NM Gallium Citrate Imaging,624553,CDM,341,RC,78802,HCPCS,,,facility,inpatient,,,3887.00000,1127.23000,Aetna,First Health,,3179.57,,,,,,,2332.20,3179.57,percent of total billed charges,
NM Gallium Citrate Imaging,624553,CDM,341,RC,78802,HCPCS,,,facility,outpatient,,,3887.00000,1127.23000,Aetna,First Health,,3179.57,,,,,,,207.84,3484.44,percent of total billed charges,
NM Lymphoma Imaging,624579,CDM,341,RC,78802,HCPCS,,,facility,inpatient,,,3887.00000,1127.23000,Aetna,First Health,,3179.57,,,,,,,2332.20,3179.57,percent of total billed charges,
NM Lymphoma Imaging,624579,CDM,341,RC,78802,HCPCS,,,facility,outpatient,,,3887.00000,1127.23000,Aetna,First Health,,3179.57,,,,,,,207.84,3484.44,percent of total billed charges,
NM Lymphoma Zevalin Imaging,7544149,CDM,341,RC,78802,HCPCS,,,facility,inpatient,,,3887.00000,1127.23000,Aetna,First Health,,3179.57,,,,,,,2332.20,3179.57,percent of total billed charges,
NM Lymphoma Zevalin Imaging,7544149,CDM,341,RC,78802,HCPCS,,,facility,outpatient,,,3887.00000,1127.23000,Aetna,First Health,,3179.57,,,,,,,207.84,3484.44,percent of total billed charges,
NM Radium Therapy,7858138,CDM,342,RC,79101,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Radium Therapy,7858138,CDM,342,RC,79101,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,98.42,2099.81,percent of total billed charges,
NM Lutcieum Prostate Therapy,9083669,CDM,342,RC,79101,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Lutcieum Prostate Therapy,9083669,CDM,342,RC,79101,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,98.42,2099.81,percent of total billed charges,
NM Lutathera Therapy,9083667,CDM,342,RC,79101,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Lutathera Therapy,9083667,CDM,342,RC,79101,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,98.42,2099.81,percent of total billed charges,
NM Radiopharm Therapy Oral Administration,624681,CDM,342,RC,79005,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Radiopharm Therapy Oral Administration,624681,CDM,342,RC,79005,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,98.42,2777.11,percent of total billed charges,
NM Radiopharm Therapy IV Admin,624507,CDM,342,RC,79101,HCPCS,,,facility,inpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,1540.20,2099.81,percent of total billed charges,
NM Radiopharm Therapy IV Admin,624507,CDM,342,RC,79101,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,First Health,,2099.81,,,,,,,98.42,2099.81,percent of total billed charges,
CAR NM SESTIMIBI RADIOPHARM,7363927,CDM,343,RC,A9500,HCPCS,,,facility,inpatient,,,430.00000,124.70000,Aetna,First Health,,351.74,,,,,,,258.00,351.74,percent of total billed charges,
CAR NM SESTIMIBI RADIOPHARM,7363927,CDM,343,RC,A9500,HCPCS,,,facility,outpatient,,,430.00000,124.70000,Aetna,First Health,,351.74,,,,,,,155.01,351.74,percent of total billed charges,
CAR NM SESTIMIBI RADIOPHARM,7371907,CDM,343,RC,A9500,HCPCS,,,facility,inpatient,,,430.00000,124.70000,Aetna,First Health,,351.74,,,,,,,258.00,351.74,percent of total billed charges,
CAR NM SESTIMIBI RADIOPHARM,7371907,CDM,343,RC,A9500,HCPCS,,,facility,outpatient,,,430.00000,124.70000,Aetna,First Health,,351.74,,,,,,,155.01,351.74,percent of total billed charges,
CAR NM Sestimibi Radiopharm,8147827,CDM,343,RC,A9500,HCPCS,,,facility,inpatient,,,430.00000,124.70000,Aetna,First Health,,351.74,,,,,,,258.00,351.74,percent of total billed charges,
CAR NM Sestimibi Radiopharm,8147827,CDM,343,RC,A9500,HCPCS,,,facility,outpatient,,,430.00000,124.70000,Aetna,First Health,,351.74,,,,,,,155.01,351.74,percent of total billed charges,
CAR NM THALLIUM CHLORIDE 4,7363926,CDM,343,RC,A9505,HCPCS,,,facility,inpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,103.80,141.51,percent of total billed charges,
CAR NM THALLIUM CHLORIDE 4,7363926,CDM,343,RC,A9505,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,62.37,141.51,percent of total billed charges,
Radiopharmaceutical Thallium,7371909,CDM,343,RC,A9505,HCPCS,,,facility,inpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,103.80,141.51,percent of total billed charges,
Radiopharmaceutical Thallium,7371909,CDM,343,RC,A9505,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,62.37,141.51,percent of total billed charges,
CAR NM RUBIDIUM PER STUDY DOSE,7363928,CDM,343,RC,A9555,HCPCS,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
CAR NM RUBIDIUM PER STUDY DOSE,7363928,CDM,343,RC,A9555,HCPCS,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,741.11,percent of total billed charges,
CAR NM RUBIDIUM PER STUDY DOSE,7371908,CDM,343,RC,A9555,HCPCS,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
CAR NM RUBIDIUM PER STUDY DOSE,7371908,CDM,343,RC,A9555,HCPCS,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,741.11,percent of total billed charges,
CAR NM Rubidium per Study Dose,8147826,CDM,343,RC,A9555,HCPCS,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
CAR NM Rubidium per Study Dose,8147826,CDM,343,RC,A9555,HCPCS,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,741.11,percent of total billed charges,
CAR NM TC99M LABELED RBC,7504000,CDM,343,RC,A9560,HCPCS,,,facility,inpatient,,,961.00000,278.69000,Aetna,First Health,,786.10,,,,,,,576.60,786.10,percent of total billed charges,
CAR NM TC99M LABELED RBC,7504000,CDM,343,RC,A9560,HCPCS,,,facility,outpatient,,,961.00000,278.69000,Aetna,First Health,,786.10,,,,,,,346.44,786.10,percent of total billed charges,
CAR PET F18 FDG,7371910,CDM,343,RC,A9552,HCPCS,,,facility,inpatient,,,915.00000,265.35000,Aetna,First Health,,748.47,,,,,,,549.00,748.47,percent of total billed charges,
CAR PET F18 FDG,7371910,CDM,343,RC,A9552,HCPCS,,,facility,outpatient,,,915.00000,265.35000,Aetna,First Health,,748.47,,,,,,,329.86,748.47,percent of total billed charges,
CAR NM 99 MTC Pyrophosphate,8227890,CDM,343,RC,A9538,HCPCS,,,facility,inpatient,,,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,108.60,148.06,percent of total billed charges,
CAR NM 99 MTC Pyrophosphate,8227890,CDM,343,RC,A9538,HCPCS,,,facility,outpatient,,,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,18.51,148.06,percent of total billed charges,
Radiopharmaceutical Technetium 99 HDP,9132430,CDM,343,RC,A9561,HCPCS,,,facility,inpatient,,,194.00000,56.26000,Aetna,First Health,,158.69,,,,,,,116.40,158.69,percent of total billed charges,
Radiopharmaceutical Technetium 99 HDP,9132430,CDM,343,RC,A9561,HCPCS,,,facility,outpatient,,,194.00000,56.26000,Aetna,First Health,,158.69,,,,,,,69.94,158.69,percent of total billed charges,
NM INDIUM LABELED WBC,3601884,CDM,343,RC,A9570,HCPCS,,,facility,inpatient,,,13784.00000,3997.36000,Aetna,First Health,,11275.31,,,,,,,8270.40,11275.31,percent of total billed charges,
NM INDIUM LABELED WBC,3601884,CDM,343,RC,A9570,HCPCS,,,facility,outpatient,,,13784.00000,3997.36000,Aetna,First Health,,11275.31,,,,,,,956.10,11275.31,percent of total billed charges,
NM TC 99M DTPA GT 25MCI,3601910,CDM,343,RC,A9539,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,202.80,276.48,percent of total billed charges,
NM TC 99M DTPA GT 25MCI,3601910,CDM,343,RC,A9539,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,121.85,276.48,percent of total billed charges,
NM TC99M LABELED RBC,3609840,CDM,343,RC,A9560,HCPCS,,,facility,inpatient,,,966.00000,280.14000,Aetna,First Health,,790.19,,,,,,,579.60,790.19,percent of total billed charges,
NM TC99M LABELED RBC,3609840,CDM,343,RC,A9560,HCPCS,,,facility,outpatient,,,966.00000,280.14000,Aetna,First Health,,790.19,,,,,,,348.24,790.19,percent of total billed charges,
PET F18 SODIUM FLUORIDE,6439844,CDM,343,RC,A9552,HCPCS,,,facility,inpatient,,,551.00000,159.79000,Aetna,First Health,,450.72,,,,,,,330.60,450.72,percent of total billed charges,
PET F18 SODIUM FLUORIDE,6439844,CDM,343,RC,A9552,HCPCS,,,facility,outpatient,,,551.00000,159.79000,Aetna,First Health,,450.72,,,,,,,198.64,450.72,percent of total billed charges,
Gallium Dotatate,8119563,CDM,343,RC,A9587,HCPCS,,,facility,inpatient,,,14793.00000,4289.97000,Aetna,First Health,,12100.67,,,,,,,8875.80,12100.67,percent of total billed charges,
Gallium Dotatate,8119563,CDM,343,RC,A9587,HCPCS,,,facility,outpatient,,,14793.00000,4289.97000,Aetna,First Health,,12100.67,,,,,,,49.63,12100.67,percent of total billed charges,
Sestamibi,8182173,CDM,343,RC,A9500,HCPCS,,,facility,inpatient,,,385.00000,111.65000,Aetna,First Health,,314.93,,,,,,,231.00,314.93,percent of total billed charges,
Sestamibi,8182173,CDM,343,RC,A9500,HCPCS,,,facility,outpatient,,,385.00000,111.65000,Aetna,First Health,,314.93,,,,,,,138.79,314.93,percent of total billed charges,
NM TC99M MDP,7909457,CDM,343,RC,A9503,HCPCS,,,facility,inpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,103.80,141.51,percent of total billed charges,
NM TC99M MDP,7909457,CDM,343,RC,A9503,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,First Health,,141.51,,,,,,,62.37,141.51,percent of total billed charges,
Ioflupane,8148517,CDM,343,RC,A9584,HCPCS,,,facility,inpatient,,,12320.00000,3572.80000,Aetna,First Health,,10077.76,,,,,,,7392.00,10077.76,percent of total billed charges,
Ioflupane,8148517,CDM,343,RC,A9584,HCPCS,,,facility,outpatient,,,12320.00000,3572.80000,Aetna,First Health,,10077.76,,,,,,,1387.74,10077.76,percent of total billed charges,
NM Copper CU64,8412046,CDM,343,RC,A9592,HCPCS,,,facility,inpatient,,,14055.00000,4075.95000,Aetna,First Health,,11496.99,,,,,,,8433.00,11496.99,percent of total billed charges,
NM Copper CU64,8412046,CDM,343,RC,A9592,HCPCS,,,facility,outpatient,,,14055.00000,4075.95000,Aetna,First Health,,11496.99,,,,,,,594.28,11496.99,percent of total billed charges,
Tc99m Timanocept,8478382,CDM,343,RC,A9520,HCPCS,,,facility,inpatient,,,1302.00000,377.58000,Aetna,First Health,,1065.04,,,,,,,781.20,1065.04,percent of total billed charges,
Tc99m Timanocept,8478382,CDM,343,RC,A9520,HCPCS,,,facility,outpatient,,,1302.00000,377.58000,Aetna,First Health,,1065.04,,,,,,,469.37,1065.04,percent of total billed charges,
Piflufolastat F 18,8457867,CDM,343,RC,A9595,HCPCS,,,facility,inpatient,,,20838.00000,6043.02000,Aetna,First Health,,17045.48,,,,,,,12502.80,17045.48,percent of total billed charges,
Piflufolastat F 18,8457867,CDM,343,RC,A9595,HCPCS,,,facility,outpatient,,,20838.00000,6043.02000,Aetna,First Health,,17045.48,,,,,,,308.18,17045.48,percent of total billed charges,
NM SOD PERT 30MCI,607137,CDM,343,RC,A9512,HCPCS,,,facility,inpatient,,,171.00000,49.59000,Aetna,First Health,,139.88,,,,,,,102.60,139.88,percent of total billed charges,
NM SOD PERT 30MCI,607137,CDM,343,RC,A9512,HCPCS,,,facility,outpatient,,,171.00000,49.59000,Aetna,First Health,,139.88,,,,,,,1.46,139.88,percent of total billed charges,
NM SOD PERT 20MCI,607136,CDM,343,RC,A9512,HCPCS,,,facility,inpatient,,,171.00000,49.59000,Aetna,First Health,,139.88,,,,,,,102.60,139.88,percent of total billed charges,
NM SOD PERT 20MCI,607136,CDM,343,RC,A9512,HCPCS,,,facility,outpatient,,,171.00000,49.59000,Aetna,First Health,,139.88,,,,,,,1.46,139.88,percent of total billed charges,
NM SULFUR COLLIOD 8MCI,607155,CDM,343,RC,A9541,HCPCS,,,facility,inpatient,,,506.00000,146.74000,Aetna,First Health,,413.91,,,,,,,303.60,413.91,percent of total billed charges,
NM SULFUR COLLIOD 8MCI,607155,CDM,343,RC,A9541,HCPCS,,,facility,outpatient,,,506.00000,146.74000,Aetna,First Health,,413.91,,,,,,,182.41,413.91,percent of total billed charges,
NM SULFUR COLLIOD ULTRAFILTERED,607154,CDM,343,RC,A9541,HCPCS,,,facility,inpatient,,,833.00000,241.57000,Aetna,First Health,,681.39,,,,,,,499.80,681.39,percent of total billed charges,
NM SULFUR COLLIOD ULTRAFILTERED,607154,CDM,343,RC,A9541,HCPCS,,,facility,outpatient,,,833.00000,241.57000,Aetna,First Health,,681.39,,,,,,,300.30,681.39,percent of total billed charges,
NM 99M TC MAA RADIOPHARM,606365,CDM,343,RC,A9540,HCPCS,,,facility,inpatient,,,877.00000,254.33000,Aetna,First Health,,717.39,,,,,,,526.20,717.39,percent of total billed charges,
NM 99M TC MAA RADIOPHARM,606365,CDM,343,RC,A9540,HCPCS,,,facility,outpatient,,,877.00000,254.33000,Aetna,First Health,,717.39,,,,,,,316.16,717.39,percent of total billed charges,
NM TC99M DTPA LT 25MCI,606366,CDM,343,RC,A9539,HCPCS,,,facility,inpatient,,,586.00000,169.94000,Aetna,First Health,,479.35,,,,,,,351.60,479.35,percent of total billed charges,
NM TC99M DTPA LT 25MCI,606366,CDM,343,RC,A9539,HCPCS,,,facility,outpatient,,,586.00000,169.94000,Aetna,First Health,,479.35,,,,,,,211.25,479.35,percent of total billed charges,
NM 99MTC MEBROFENIN,606800,CDM,343,RC,A9537,HCPCS,,,facility,inpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,160.20,218.41,percent of total billed charges,
NM 99MTC MEBROFENIN,606800,CDM,343,RC,A9537,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,First Health,,218.41,,,,,,,9.30,218.41,percent of total billed charges,
NM IODINE 131 DIAGNOSTIC CAPSULE,606997,CDM,343,RC,A9528,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,138.60,188.96,percent of total billed charges,
NM IODINE 131 DIAGNOSTIC CAPSULE,606997,CDM,343,RC,A9528,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,83.28,188.96,percent of total billed charges,
NM I123 DIAG CAP RADIOPHARM,606995,CDM,343,RC,A9516,HCPCS,,,facility,inpatient,,,446.00000,129.34000,Aetna,First Health,,364.83,,,,,,,267.60,364.83,percent of total billed charges,
NM I123 DIAG CAP RADIOPHARM,606995,CDM,343,RC,A9516,HCPCS,,,facility,outpatient,,,446.00000,129.34000,Aetna,First Health,,364.83,,,,,,,160.78,364.83,percent of total billed charges,
NM INDIUM 111 DTPA,607006,CDM,343,RC,A9548,HCPCS,,,facility,inpatient,,,12556.00000,3641.24000,Aetna,First Health,,10270.81,,,,,,,7533.60,10270.81,percent of total billed charges,
NM INDIUM 111 DTPA,607006,CDM,343,RC,A9548,HCPCS,,,facility,outpatient,,,12556.00000,3641.24000,Aetna,First Health,,10270.81,,,,,,,663.07,10270.81,percent of total billed charges,
NM INDIUM III PENTEREOTIDE,607007,CDM,343,RC,A9572,HCPCS,,,facility,inpatient,,,14172.00000,4109.88000,Aetna,First Health,,11592.70,,,,,,,8503.20,11592.70,percent of total billed charges,
NM INDIUM III PENTEREOTIDE,607007,CDM,343,RC,A9572,HCPCS,,,facility,outpatient,,,14172.00000,4109.88000,Aetna,First Health,,11592.70,,,,,,,2000.94,18497.83,percent of total billed charges,
NM MIBG,607027,CDM,343,RC,A9582,HCPCS,,,facility,inpatient,,,14967.00000,4340.43000,Aetna,First Health,,12243.01,,,,,,,8980.20,12243.01,percent of total billed charges,
NM MIBG,607027,CDM,343,RC,A9582,HCPCS,,,facility,outpatient,,,14967.00000,4340.43000,Aetna,First Health,,12243.01,,,,,,,1923.35,27007.42,percent of total billed charges,
NM GALLIUM CITRATE TO 4MCI,606950,CDM,343,RC,A9556,HCPCS,,,facility,inpatient,,,410.00000,118.90000,Aetna,First Health,,335.38,,,,,,,246.00,335.38,percent of total billed charges,
NM GALLIUM CITRATE TO 4MCI,606950,CDM,343,RC,A9556,HCPCS,,,facility,outpatient,,,410.00000,118.90000,Aetna,First Health,,335.38,,,,,,,147.81,499.52,percent of total billed charges,
NM EACH ADDL GALLIUM CITRATE,606934,CDM,343,RC,A9556,HCPCS,,,facility,inpatient,,,387.00000,112.23000,Aetna,First Health,,316.57,,,,,,,232.20,316.57,percent of total billed charges,
NM EACH ADDL GALLIUM CITRATE,606934,CDM,343,RC,A9556,HCPCS,,,facility,outpatient,,,387.00000,112.23000,Aetna,First Health,,316.57,,,,,,,139.51,499.52,percent of total billed charges,
NM RENAL MAG 3 ISOTOPE,607022,CDM,343,RC,A9562,HCPCS,,,facility,inpatient,,,1929.00000,559.41000,Aetna,First Health,,1577.92,,,,,,,1157.40,1577.92,percent of total billed charges,
NM RENAL MAG 3 ISOTOPE,607022,CDM,343,RC,A9562,HCPCS,,,facility,outpatient,,,1929.00000,559.41000,Aetna,First Health,,1577.92,,,,,,,695.40,2867.29,percent of total billed charges,
NM 99MTC CERETEC WHITE BLOOD CELL,606907,CDM,343,RC,A9569,HCPCS,,,facility,inpatient,,,14285.00000,4142.65000,Aetna,First Health,,11685.13,,,,,,,8571.00,11685.13,percent of total billed charges,
NM 99MTC CERETEC WHITE BLOOD CELL,606907,CDM,343,RC,A9569,HCPCS,,,facility,outpatient,,,14285.00000,4142.65000,Aetna,First Health,,11685.13,,,,,,,934.13,11685.13,percent of total billed charges,
NM TETROFOSMIN,607169,CDM,343,RC,A9502,HCPCS,,,facility,inpatient,,,348.00000,100.92000,Aetna,First Health,,284.66,,,,,,,208.80,284.66,percent of total billed charges,
NM TETROFOSMIN,607169,CDM,343,RC,A9502,HCPCS,,,facility,outpatient,,,348.00000,100.92000,Aetna,First Health,,284.66,,,,,,,112.62,360.67,percent of total billed charges,
NM Non HEU Source TC-99m per dose,9090500,CDM,343,RC,Q9969,HCPCS,,,facility,inpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,21.00,28.63,percent of total billed charges,
NM Non HEU Source TC-99m per dose,9090500,CDM,343,RC,Q9969,HCPCS,,,facility,outpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,12.62,28.63,percent of total billed charges,
NM Gallium Citrate 1mCi,9083633,CDM,343,RC,A9556,HCPCS,,,facility,inpatient,,,233.28000,67.65000,Aetna,First Health,,190.82,,,,,,,139.97,190.82,percent of total billed charges,
NM Gallium Citrate 1mCi,9083633,CDM,343,RC,A9556,HCPCS,,,facility,outpatient,,,233.28000,67.65000,Aetna,First Health,,190.82,,,,,,,84.10,499.52,percent of total billed charges,
F18 Flucicovine,8119561,CDM,343,RC,A9588,HCPCS,,,facility,inpatient,,,17587.00000,5100.23000,Aetna,First Health,,14386.17,,,,,,,10552.20,14386.17,percent of total billed charges,
F18 Flucicovine,8119561,CDM,343,RC,A9588,HCPCS,,,facility,outpatient,,,17587.00000,5100.23000,Aetna,First Health,,14386.17,,,,,,,322.27,14386.17,percent of total billed charges,
PET FI8 FLORBETAPIR,7926833,CDM,343,RC,A9586,HCPCS,,,facility,inpatient,,,13794.00000,4000.26000,Aetna,First Health,,11283.49,,,,,,,8276.40,11283.49,percent of total billed charges,
PET FI8 FLORBETAPIR,7926833,CDM,343,RC,A9586,HCPCS,,,facility,outpatient,,,13794.00000,4000.26000,Aetna,First Health,,11283.49,,,,,,,1825.64,11283.49,percent of total billed charges,
Gallium Ga68 Gozetotide Diagnostic,8973054,CDM,343,RC,A9596,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,9750.00,13292.50,percent of total billed charges,
Gallium Ga68 Gozetotide Diagnostic,8973054,CDM,343,RC,A9596,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,First Health,,13292.50,,,,,,,478.52,13292.50,percent of total billed charges,
PET F18 FDG,606944,CDM,343,RC,A9552,HCPCS,,,facility,inpatient,,,554.00000,160.66000,Aetna,First Health,,453.17,,,,,,,332.40,453.17,percent of total billed charges,
PET F18 FDG,606944,CDM,343,RC,A9552,HCPCS,,,facility,outpatient,,,554.00000,160.66000,Aetna,First Health,,453.17,,,,,,,199.72,453.17,percent of total billed charges,
F18 Posluma,9116450,CDM,343,RC,A9608,HCPCS,,,facility,inpatient,,,18082.88000,5244.04000,Aetna,First Health,,14791.80,,,,,,,10849.73,14791.80,percent of total billed charges,
F18 Posluma,9116450,CDM,343,RC,A9608,HCPCS,,,facility,outpatient,,,18082.88000,5244.04000,Aetna,First Health,,14791.80,,,,,,,671.22,14791.80,percent of total billed charges,
NM IODINE 131 THYROGEN WB CAPSULE,3977840,CDM,344,RC,A9528,HCPCS,,,facility,inpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,357.00,486.71,percent of total billed charges,
NM IODINE 131 THYROGEN WB CAPSULE,3977840,CDM,344,RC,A9528,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,First Health,,486.71,,,,,,,214.50,486.71,percent of total billed charges,
NM IODINE 131 1MCI FOR 100MCI,606998,CDM,344,RC,A9517,HCPCS,,,facility,inpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,30.60,41.72,percent of total billed charges,
NM IODINE 131 1MCI FOR 100MCI,606998,CDM,344,RC,A9517,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,18.93,54.16,percent of total billed charges,
NM Iodine 131 1mCi for 100mCi,8001058,CDM,344,RC,A9517,HCPCS,,,facility,inpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,30.60,41.72,percent of total billed charges,
NM Iodine 131 1mCi for 100mCi,8001058,CDM,344,RC,A9517,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,18.93,54.16,percent of total billed charges,
NM IODINE 131 1MCI FOR 50MCI,607000,CDM,344,RC,A9517,HCPCS,,,facility,inpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,31.20,42.54,percent of total billed charges,
NM IODINE 131 1MCI FOR 50MCI,607000,CDM,344,RC,A9517,HCPCS,,,facility,outpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,19.30,54.16,percent of total billed charges,
NM Iodine 131 1mCi for 50mCi,8001059,CDM,344,RC,A9517,HCPCS,,,facility,inpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,31.20,42.54,percent of total billed charges,
NM Iodine 131 1mCi for 50mCi,8001059,CDM,344,RC,A9517,HCPCS,,,facility,outpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,19.30,54.16,percent of total billed charges,
NM IODINE 131 1MCI FOR 10MCI,606999,CDM,344,RC,A9517,HCPCS,,,facility,inpatient,,,107.00000,31.03000,Aetna,First Health,,87.53,,,,,,,64.20,87.53,percent of total billed charges,
NM IODINE 131 1MCI FOR 10MCI,606999,CDM,344,RC,A9517,HCPCS,,,facility,outpatient,,,107.00000,31.03000,Aetna,First Health,,87.53,,,,,,,21.44,87.53,percent of total billed charges,
NM Iodine 131 1mCi for 10mCi,8001060,CDM,344,RC,A9517,HCPCS,,,facility,inpatient,,,107.00000,31.03000,Aetna,First Health,,87.53,,,,,,,64.20,87.53,percent of total billed charges,
NM Iodine 131 1mCi for 10mCi,8001060,CDM,344,RC,A9517,HCPCS,,,facility,outpatient,,,107.00000,31.03000,Aetna,First Health,,87.53,,,,,,,21.44,87.53,percent of total billed charges,
NM IODINE 131 1MCI FOR 5MCI,607001,CDM,344,RC,A9517,HCPCS,,,facility,inpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,72.00,98.16,percent of total billed charges,
NM IODINE 131 1MCI FOR 5MCI,607001,CDM,344,RC,A9517,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,21.44,98.16,percent of total billed charges,
NM Iodine 131 1mCi for 5mCi,8001061,CDM,344,RC,A9517,HCPCS,,,facility,inpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,72.00,98.16,percent of total billed charges,
NM Iodine 131 1mCi for 5mCi,8001061,CDM,344,RC,A9517,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,21.44,98.16,percent of total billed charges,
NM RADIUM 223 1 UCI,7858034,CDM,344,RC,A9606,HCPCS,,,facility,inpatient,,,892.00000,258.68000,Aetna,First Health,,729.66,,,,,,,535.20,729.66,percent of total billed charges,
NM RADIUM 223 1 UCI,7858034,CDM,344,RC,A9606,HCPCS,,,facility,outpatient,,,892.00000,258.68000,Aetna,First Health,,729.66,,,,,,,171.92,729.66,percent of total billed charges,
NM EACH ADDL IODINE,606935,CDM,344,RC,A9517,HCPCS,,,facility,inpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,52.20,71.17,percent of total billed charges,
NM EACH ADDL IODINE,606935,CDM,344,RC,A9517,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,21.44,71.17,percent of total billed charges,
NM METASTRON,607026,CDM,344,RC,A9600,HCPCS,,,facility,inpatient,,,26176.00000,7591.04000,Aetna,First Health,,21411.97,,,,,,,15705.60,21411.97,percent of total billed charges,
NM METASTRON,607026,CDM,344,RC,A9600,HCPCS,,,facility,outpatient,,,26176.00000,7591.04000,Aetna,First Health,,21411.97,,,,,,,4146.34,21411.97,percent of total billed charges,
Lutetium LU VipiVotide,9084991,CDM,344,RC,A9607,HCPCS,,,facility,inpatient,,,796.53000,230.99000,Aetna,First Health,,651.56,,,,,,,477.92,651.56,percent of total billed charges,
Lutetium LU VipiVotide,9084991,CDM,344,RC,A9607,HCPCS,,,facility,outpatient,,,796.53000,230.99000,Aetna,First Health,,651.56,,,,,,,259.32,842.27,percent of total billed charges,
Lutetium Lu 177 dotatate,9083671,CDM,344,RC,A9513,HCPCS,,,facility,inpatient,,,978.18000,283.67000,Aetna,First Health,,800.15,,,,,,,586.91,800.15,percent of total billed charges,
Lutetium Lu 177 dotatate,9083671,CDM,344,RC,A9513,HCPCS,,,facility,outpatient,,,978.18000,283.67000,Aetna,First Health,,800.15,,,,,,,320.77,1034.31,percent of total billed charges,
CAR NM Amyloidosis Planar,8227929,CDM,349,RC,78800,HCPCS,,,facility,inpatient,,,3220.00000,933.80000,Aetna,First Health,,2633.96,,,,,,,1932.00,2633.96,percent of total billed charges,
CAR NM Amyloidosis Planar,8227929,CDM,349,RC,78800,HCPCS,,,facility,outpatient,,,3220.00000,933.80000,Aetna,First Health,,2633.96,,,,,,,127.55,2633.96,percent of total billed charges,
Card Amyloidosis,9134447,CDM,349,RC,78800,HCPCS,,,facility,inpatient,,,3220.00000,933.80000,Aetna,First Health,,2633.96,,,,,,,1932.00,2633.96,percent of total billed charges,
Card Amyloidosis,9134447,CDM,349,RC,78800,HCPCS,,,facility,outpatient,,,3220.00000,933.80000,Aetna,First Health,,2633.96,,,,,,,127.55,2633.96,percent of total billed charges,
CAR NM Amyloidosis Planar W Spect,8227928,CDM,349,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
CAR NM Amyloidosis Planar W Spect,8227928,CDM,349,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
Card Amyloid w Spect,9134448,CDM,349,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
Card Amyloid w Spect,9134448,CDM,349,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
NM Cardiac Amyloidosis,8436578,CDM,349,RC,78800,HCPCS,,,facility,inpatient,,,3220.00000,933.80000,Aetna,First Health,,2633.96,,,,,,,1932.00,2633.96,percent of total billed charges,
NM Cardiac Amyloidosis,8436578,CDM,349,RC,78800,HCPCS,,,facility,outpatient,,,3220.00000,933.80000,Aetna,First Health,,2633.96,,,,,,,127.55,2633.96,percent of total billed charges,
NM Cardiac Amyloidosis SPECT,8436176,CDM,349,RC,78803,HCPCS,,,facility,inpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,2914.80,3973.84,percent of total billed charges,
NM Cardiac Amyloidosis SPECT,8436176,CDM,349,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,First Health,,3973.84,,,,,,,245.86,3973.84,percent of total billed charges,
NM Sentinal Node Non Imag,624647,CDM,349,RC,,,,,facility,inpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,2037.00,2777.11,percent of total billed charges,
NM Sentinal Node Non Imag,624647,CDM,349,RC,,,,,facility,outpatient,,,3395.00000,984.55000,Aetna,First Health,,2777.11,,,,,,,1223.90,2777.11,percent of total billed charges,
CT Colonography w Contrast,7741559,CDM,350,RC,74262,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Colonography w Contrast,7741559,CDM,350,RC,74262,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Colonography wo Contrast,7741561,CDM,350,RC,74261,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Colonography wo Contrast,7741561,CDM,350,RC,74261,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Orbits w Contrast,1443807,CDM,351,RC,70481,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Orbits w Contrast,1443807,CDM,351,RC,70481,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Orbit Ear Fossa w Contrast,654668,CDM,351,RC,70481,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Orbit Ear Fossa w Contrast,654668,CDM,351,RC,70481,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Head wo Contrast,3110839,CDM,351,RC,70450,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Head wo Contrast,3110839,CDM,351,RC,70450,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Head wo Contrast,613391,CDM,351,RC,70450,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Head wo Contrast,613391,CDM,351,RC,70450,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Head wo Contrast,7523980,CDM,351,RC,70450,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Head wo Contrast,7523980,CDM,351,RC,70450,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Head w Contrast,613383,CDM,351,RC,70460,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Head w Contrast,613383,CDM,351,RC,70460,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Head w Contrast,7523978,CDM,351,RC,70460,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Head w Contrast,7523978,CDM,351,RC,70460,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Head w wo Contrast,613387,CDM,351,RC,70470,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Head w wo Contrast,613387,CDM,351,RC,70470,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Head w wo Contrast,7523979,CDM,351,RC,70470,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Head w wo Contrast,7523979,CDM,351,RC,70470,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Soft Tissue Neck wo Contrast,613702,CDM,351,RC,70490,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Soft Tissue Neck wo Contrast,613702,CDM,351,RC,70490,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Soft Tissue Neck w Contrast,613694,CDM,351,RC,70491,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Soft Tissue Neck w Contrast,613694,CDM,351,RC,70491,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Soft Tissue Neck w wo Contrast,613700,CDM,351,RC,70492,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Soft Tissue Neck w wo Contrast,613700,CDM,351,RC,70492,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Head,1513815,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Head,1513815,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Head,2300825,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Head,2300825,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CTA HEAD W CONTRAST,3136871,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CTA HEAD W CONTRAST,3136871,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Head,7938005,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Head,7938005,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Head,7988045,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Head,7988045,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Maxillofacial w Contrast,613481,CDM,351,RC,70487,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Maxillofacial w Contrast,613481,CDM,351,RC,70487,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Sinuses w Contrast,7285917,CDM,351,RC,70487,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Sinuses w Contrast,7285917,CDM,351,RC,70487,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Maxillofacial wo Contrast,613485,CDM,351,RC,70486,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Maxillofacial wo Contrast,613485,CDM,351,RC,70486,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Sinuses wo Contrast,613674,CDM,351,RC,70486,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Sinuses wo Contrast,613674,CDM,351,RC,70486,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Stealth Sinuses wo Contrast,7920891,CDM,351,RC,70486,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Stealth Sinuses wo Contrast,7920891,CDM,351,RC,70486,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Angio Neck,2300826,CDM,351,RC,70498,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Neck,2300826,CDM,351,RC,70498,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Neck,8001036,CDM,351,RC,70498,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Neck,8001036,CDM,351,RC,70498,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Neck BCE,9040800,CDM,351,RC,70498,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Neck BCE,9040800,CDM,351,RC,70498,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Perfusion,8366954,CDM,351,RC,0042T,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Perfusion,8366954,CDM,351,RC,0042T,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,771.47,1750.52,percent of total billed charges,
CT Angio Perfusion Head Code Stroke,8366931,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Perfusion Head Code Stroke,8366931,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Perfusion Head and Neck Code Stroke,8366933,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Perfusion Head and Neck Code Stroke,8366933,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Venous Head Code Stroke,8416708,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Venous Head Code Stroke,8416708,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Venous Head and Neck Code Stroke,8416712,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Venous Head and Neck Code Stroke,8416712,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Prfn Venous Head Code Stroke,8416702,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Prfn Venous Head Code Stroke,8416702,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Perf Venous Head Neck Code Stroke,8416681,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Perf Venous Head Neck Code Stroke,8416681,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Prfn Venous Head and Neck Code Stroke CT Exam 1,8416704,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Prfn Venous Head and Neck Code Stroke CT Exam 1,8416704,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Venous Head and Neck,8416710,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Venous Head and Neck,8416710,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Venous Head,8416706,CDM,351,RC,70496,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Venous Head,8416706,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Parathyroid 4D Neck w wo Contrast,8910355,CDM,351,RC,70492,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Parathyroid 4D Neck w wo Contrast,8910355,CDM,351,RC,70492,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Orbits wo Contrast,613708,CDM,351,RC,70480,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Orbits wo Contrast,613708,CDM,351,RC,70480,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Orbit Ear Fossa wo Contrast,654658,CDM,351,RC,70480,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Orbit Ear Fossa wo Contrast,654658,CDM,351,RC,70480,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Orbits w wo Contrast,613714,CDM,351,RC,70482,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Orbits w wo Contrast,613714,CDM,351,RC,70482,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Orbit Ear Fossa w wo Contrast,654622,CDM,351,RC,70482,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Orbit Ear Fossa w wo Contrast,654622,CDM,351,RC,70482,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Sinuses w wo Contrast,654666,CDM,351,RC,70488,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Sinuses w wo Contrast,654666,CDM,351,RC,70488,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Maxillofacial w wo Contrast,654689,CDM,351,RC,70488,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Maxillofacial w wo Contrast,654689,CDM,351,RC,70488,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Upper Extremity Right w Contrast,1053802,CDM,352,RC,73201,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Upper Extremity Right w Contrast,1053802,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,221.71,1516.57,percent of total billed charges,
CT Upper Extremity Right w Contrast,7913755,CDM,352,RC,73201,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Upper Extremity Right w Contrast,7913755,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,221.71,1516.57,percent of total billed charges,
CT Upper Extremity Right w Contrast,7991376,CDM,352,RC,73201,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Upper Extremity Right w Contrast,7991376,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,221.71,1516.57,percent of total billed charges,
CT Upper Extremity Right w Contrast,7991400,CDM,352,RC,73201,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Upper Extremity Right w Contrast,7991400,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,221.71,1516.57,percent of total billed charges,
CT Upper Extremity Right w wo Contrast,1053808,CDM,352,RC,73202,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,RT,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Upper Extremity Right w wo Contrast,1053808,CDM,352,RC,73202,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,RT,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Upper Extremity Left w Contrast,1053822,CDM,352,RC,73201,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Upper Extremity Left w Contrast,1053822,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,221.71,1516.57,percent of total billed charges,
CT Upper Extremity Left w Contrast,7913751,CDM,352,RC,73201,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Upper Extremity Left w Contrast,7913751,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,221.71,1516.57,percent of total billed charges,
CT Upper Extremity Left w Contrast,7991372,CDM,352,RC,73201,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Upper Extremity Left w Contrast,7991372,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,221.71,1516.57,percent of total billed charges,
CT Wrist Left Post Arthrogram,7991396,CDM,352,RC,73201,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Wrist Left Post Arthrogram,7991396,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,221.71,1516.57,percent of total billed charges,
CT Upper Extremity Left w wo Contrast,1083812,CDM,352,RC,73202,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,LT,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Upper Extremity Left w wo Contrast,1083812,CDM,352,RC,73202,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,LT,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Lower Extremity Right w Contrast,1053824,CDM,352,RC,73701,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Lower Extremity Right w Contrast,1053824,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Lower Extremity Right w Contrast,7991368,CDM,352,RC,73701,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Lower Extremity Right w Contrast,7991368,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Lower Extremity Right w Contrast,7991384,CDM,352,RC,73701,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Lower Extremity Right w Contrast,7991384,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Lower Extremity Right w Contrast,7991392,CDM,352,RC,73701,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Lower Extremity Right w Contrast,7991392,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,RT,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Lower Extremity Right w wo Contrast,1083816,CDM,352,RC,73702,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,RT,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Lower Extremity Right w wo Contrast,1083816,CDM,352,RC,73702,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,RT,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Lower Extremity Left w Contrast,1063831,CDM,352,RC,73701,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Lower Extremity Left w Contrast,1063831,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Lower Extremity Left w Contrast,7991364,CDM,352,RC,73701,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Lower Extremity Left w Contrast,7991364,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Lower Extremity w Contrast,7991380,CDM,352,RC,73701,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Lower Extremity w Contrast,7991380,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Lower Extremity Left w Contrast,7991388,CDM,352,RC,73701,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Lower Extremity Left w Contrast,7991388,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,LT,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Lower Extremity Left w wo Contrast,1063833,CDM,352,RC,73702,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,LT,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Lower Extremity Left w wo Contrast,1063833,CDM,352,RC,73702,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,LT,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Chest Partial During Coronary w wo Contrast,7976458,CDM,352,RC,71270,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Chest Partial During Coronary w wo Contrast,7976458,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Chest Partial During Coronary w wo Contrast,8166094,CDM,352,RC,71270,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Chest Partial During Coronary w wo Contrast,8166094,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Chest Partial During Coronary w Contrast,7976457,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Chest Partial During Coronary w Contrast,7976457,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Chest Partial During Coronary w Contrast,8166092,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Chest Partial During Coronary w Contrast,8166092,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Chest Partial During Coronary wo Contrast,7976459,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Chest Partial During Coronary wo Contrast,7976459,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Chest Partial During Coronary wo Contrast,8166093,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Chest Partial During Coronary wo Contrast,8166093,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Coronary Angio without Evaluation,7976456,CDM,352,RC,75574,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Coronary Angio without Evaluation,7976456,CDM,352,RC,75574,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,313.58,1750.52,percent of total billed charges,
CT Coronary Angio wo Evaluation,8166096,CDM,352,RC,75574,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Coronary Angio wo Evaluation,8166096,CDM,352,RC,75574,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,313.58,1750.52,percent of total billed charges,
CT Coronary Angio with Evaluation,7976455,CDM,352,RC,75574,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Coronary Angio with Evaluation,7976455,CDM,352,RC,75574,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,313.58,1750.52,percent of total billed charges,
CT Coronary Angio w Evaluation,8166095,CDM,352,RC,75574,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Coronary Angio w Evaluation,8166095,CDM,352,RC,75574,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,313.58,1750.52,percent of total billed charges,
CT Angio Abdomen Pelvis,1513813,CDM,352,RC,74174,HCPCS,,,facility,inpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,2567.40,3500.22,percent of total billed charges,
CT Angio Abdomen Pelvis,1513813,CDM,352,RC,74174,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,313.58,3500.22,percent of total billed charges,
CT Angio Abd Pelv w Contrast,8001028,CDM,352,RC,74174,HCPCS,,,facility,inpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,2567.40,3500.22,percent of total billed charges,
CT Angio Abd Pelv w Contrast,8001028,CDM,352,RC,74174,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,313.58,3500.22,percent of total billed charges,
CT Abdomen wo Contrast,613231,CDM,352,RC,74150,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Abdomen wo Contrast,613231,CDM,352,RC,74150,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Abdomen wo Contrast,7920887,CDM,352,RC,74150,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Abdomen wo Contrast,7920887,CDM,352,RC,74150,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Abdomen wo Contrast,8001030,CDM,352,RC,74150,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Abdomen wo Contrast,8001030,CDM,352,RC,74150,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Abdomen w Contrast,613317,CDM,352,RC,74160,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Abdomen w Contrast,613317,CDM,352,RC,74160,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Abdomen w Contrast,7920895,CDM,352,RC,74160,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Abdomen w Contrast,7920895,CDM,352,RC,74160,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Abdomen w Contrast,8001031,CDM,352,RC,74160,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Abdomen w Contrast,8001031,CDM,352,RC,74160,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Abdomen w wo Contrast,613321,CDM,352,RC,74170,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Abdomen w wo Contrast,613321,CDM,352,RC,74170,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Abdomen w wo Contrast,7903279,CDM,352,RC,74170,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Abdomen w wo Contrast,7903279,CDM,352,RC,74170,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Abdomen w wo Contrast,8001032,CDM,352,RC,74170,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Abdomen w wo Contrast,8001032,CDM,352,RC,74170,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Pelvis wo Contrast,613368,CDM,352,RC,72192,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Pelvis wo Contrast,613368,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT PELVIS WO CONTRAST,7790106,CDM,352,RC,72192,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT PELVIS WO CONTRAST,7790106,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Pelvis w Contrast,613726,CDM,352,RC,72193,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Pelvis w Contrast,613726,CDM,352,RC,72193,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Pelvis w wo Contrast,613728,CDM,352,RC,72194,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Pelvis w wo Contrast,613728,CDM,352,RC,72194,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Chest wo Contrast,1371811,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Chest wo Contrast,1371811,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Chest wo Contrast,1371823,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Chest wo Contrast,1371823,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Chest wo Contrast,2052850,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Chest wo Contrast,2052850,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Chest wo Contrast,613224,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Chest wo Contrast,613224,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Chest wo Contrast,7900400,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Chest wo Contrast,7900400,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Chest wo Contrast,7913760,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Chest wo Contrast,7913760,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Chest w Contrast,1371817,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Chest w Contrast,1371817,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Chest w Contrast,1371819,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Chest w Contrast,1371819,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Chest w Contrast,1447807,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Chest w Contrast,1447807,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Chest w Contrast,1447813,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Chest w Contrast,1447813,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Chest w Contrast,3136873,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Chest w Contrast,3136873,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Chest w Contrast,3661973,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Chest w Contrast,3661973,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Chest w Contrast,613431,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Chest w Contrast,613431,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Chest w wo Contrast,1371809,CDM,352,RC,71270,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Chest w wo Contrast,1371809,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Chest w wo Contrast,1371813,CDM,352,RC,71270,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Chest w wo Contrast,1371813,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Chest w wo Contrast,1447809,CDM,352,RC,71270,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Chest w wo Contrast,1447809,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Chest w wo Contrast,1447811,CDM,352,RC,71270,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Chest w wo Contrast,1447811,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Chest w wo Contrast,613435,CDM,352,RC,71270,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Chest w wo Contrast,613435,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Cervical Spine wo Contrast,613359,CDM,352,RC,72125,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Cervical Spine wo Contrast,613359,CDM,352,RC,72125,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Cervical Spine w wo Contrast,613408,CDM,352,RC,72127,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Cervical Spine w wo Contrast,613408,CDM,352,RC,72127,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Thoracic Spine wo Contrast,613889,CDM,352,RC,72128,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Thoracic Spine wo Contrast,613889,CDM,352,RC,72128,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Thoracic Spine w wo Contrast,613885,CDM,352,RC,72130,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Thoracic Spine w wo Contrast,613885,CDM,352,RC,72130,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT LUMBAR SPINE WO CONTRAST,613629,CDM,352,RC,72131,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT LUMBAR SPINE WO CONTRAST,613629,CDM,352,RC,72131,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lumbar Spine wo Contrast,613647,CDM,352,RC,72131,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lumbar Spine wo Contrast,613647,CDM,352,RC,72131,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lumbar Spine w wo Contrast,613643,CDM,352,RC,72133,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Lumbar Spine w wo Contrast,613643,CDM,352,RC,72133,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Chest,1411836,CDM,352,RC,71275,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Chest,1411836,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Chest,1513811,CDM,352,RC,71275,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Chest,1513811,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Chest,1513817,CDM,352,RC,71275,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Chest,1513817,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Chest,2052853,CDM,352,RC,71275,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Chest,2052853,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Chest,7908926,CDM,352,RC,71275,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Chest,7908926,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Chest,989820,CDM,352,RC,71275,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Chest,989820,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Lumbar Spine w Contrast,613623,CDM,352,RC,72132,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Lumbar Spine w Contrast,613623,CDM,352,RC,72132,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,265.06,1516.57,percent of total billed charges,
CT Lumbar Spine w Contrast,613637,CDM,352,RC,72132,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Lumbar Spine w Contrast,613637,CDM,352,RC,72132,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,265.06,1516.57,percent of total billed charges,
CT Thoracic Spine w Contrast,613841,CDM,352,RC,72129,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Thoracic Spine w Contrast,613841,CDM,352,RC,72129,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Thoracic Spine w Contrast,613881,CDM,352,RC,72129,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Thoracic Spine w Contrast,613881,CDM,352,RC,72129,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Cervical Spine w Contrast,613401,CDM,352,RC,72126,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Cervical Spine w Contrast,613401,CDM,352,RC,72126,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,265.06,1516.57,percent of total billed charges,
CT Cervical Spine w Contrast,613414,CDM,352,RC,72126,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Cervical Spine w Contrast,613414,CDM,352,RC,72126,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,265.06,1516.57,percent of total billed charges,
CT Angio Abdomen,2300824,CDM,352,RC,74175,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Abdomen,2300824,CDM,352,RC,74175,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Abdomen,2300827,CDM,352,RC,74175,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Abdomen,2300827,CDM,352,RC,74175,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Abdomen w Contrast,8001034,CDM,352,RC,74175,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Abdomen w Contrast,8001034,CDM,352,RC,74175,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Lower Extremity Left wo Contrast,1063835,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Left wo Contrast,1063835,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Left wo Contrast,5841882,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Left wo Contrast,5841882,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613351,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613351,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613487,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613487,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613499,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613499,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613558,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613558,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613596,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613596,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613608,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Left wo Contrast,613608,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Ankle Left Prophecy,7943866,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Ankle Left Prophecy,7943866,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Ankle Right Prophecy,7943870,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Ankle Right Prophecy,7943870,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity wo Contrast,8001035,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity wo Contrast,8001035,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Left wo Contrast,8148236,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Left wo Contrast,8148236,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Right wo Contrast,1053826,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Right wo Contrast,1053826,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Right wo Contrast,5841884,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Right wo Contrast,5841884,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Right wo Contrast,613355,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Right wo Contrast,613355,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Right wo Contrast,613489,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Right wo Contrast,613489,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Right wo Contrast,613504,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Right wo Contrast,613504,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Right wo Contrast,613560,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Right wo Contrast,613560,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Right wo Contrast,613598,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Right wo Contrast,613598,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremtiy Right wo Contrast,613610,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremtiy Right wo Contrast,613610,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity wo Contrast,8001037,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity wo Contrast,8001037,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Right wo Contrast,8148237,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Right wo Contrast,8148237,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Angio Runoff,2300828,CDM,352,RC,75635,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Runoff,2300828,CDM,352,RC,75635,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Upper Extremity Left,5543848,CDM,352,RC,73206,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,LT,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Upper Extremity Left,5543848,CDM,352,RC,73206,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,LT,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Upper Extremity Right,5543844,CDM,352,RC,73206,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,RT,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Upper Extremity Right,5543844,CDM,352,RC,73206,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,RT,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Abd Pel wo Contrast,1371825,CDM,352,RC,74176,HCPCS,,,facility,inpatient,,,3139.00000,910.31000,Aetna,First Health,,2567.70,,,,,,,1883.40,2567.70,percent of total billed charges,
CT Abd Pel wo Contrast,1371825,CDM,352,RC,74176,HCPCS,,,facility,outpatient,,,3139.00000,910.31000,Aetna,First Health,,2567.70,,,,,,,123.60,2567.70,percent of total billed charges,
CT Abd Pelv wo Contrast,8001043,CDM,352,RC,74176,HCPCS,,,facility,inpatient,,,3139.00000,910.31000,Aetna,First Health,,2567.70,,,,,,,1883.40,2567.70,percent of total billed charges,
CT Abd Pelv wo Contrast,8001043,CDM,352,RC,74176,HCPCS,,,facility,outpatient,,,3139.00000,910.31000,Aetna,First Health,,2567.70,,,,,,,123.60,2567.70,percent of total billed charges,
CT Abd Pel w Contrast,1371821,CDM,352,RC,74177,HCPCS,,,facility,inpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,2224.80,3033.14,percent of total billed charges,
CT Abd Pel w Contrast,1371821,CDM,352,RC,74177,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,235.67,3033.14,percent of total billed charges,
CT Abd Pelv w Contrast,7285879,CDM,352,RC,74177,HCPCS,,,facility,inpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,2224.80,3033.14,percent of total billed charges,
CT Abd Pelv w Contrast,7285879,CDM,352,RC,74177,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,235.67,3033.14,percent of total billed charges,
CT Abd Pel w Contrast,7920899,CDM,352,RC,74177,HCPCS,,,facility,inpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,2224.80,3033.14,percent of total billed charges,
CT Abd Pel w Contrast,7920899,CDM,352,RC,74177,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,235.67,3033.14,percent of total billed charges,
CT Abd Pel w Contrast,8001044,CDM,352,RC,74177,HCPCS,,,facility,inpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,2224.80,3033.14,percent of total billed charges,
CT Abd Pel w Contrast,8001044,CDM,352,RC,74177,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,235.67,3033.14,percent of total billed charges,
CT Abd Pel w wo Contrast,1371815,CDM,352,RC,74178,HCPCS,,,facility,inpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,2567.40,3500.22,percent of total billed charges,
CT Abd Pel w wo Contrast,1371815,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,311.43,3500.22,percent of total billed charges,
CT Abd Pel w wo Contrast,1447817,CDM,352,RC,74178,HCPCS,,,facility,inpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,2567.40,3500.22,percent of total billed charges,
CT Abd Pel w wo Contrast,1447817,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,311.43,3500.22,percent of total billed charges,
CT Abd Pelv w wo Contrast,7285922,CDM,352,RC,74178,HCPCS,,,facility,inpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,2567.40,3500.22,percent of total billed charges,
CT Abd Pelv w wo Contrast,7285922,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,311.43,3500.22,percent of total billed charges,
CT Abd Pelv w wo Contrast,8001045,CDM,352,RC,74178,HCPCS,,,facility,inpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,2567.40,3500.22,percent of total billed charges,
CT Abd Pelv w wo Contrast,8001045,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,311.43,3500.22,percent of total billed charges,
CT Lung Cancer Screening,8320177,CDM,352,RC,71271,HCPCS,,,facility,inpatient,,,1499.00000,434.71000,Aetna,First Health,,1226.18,,,,,,,899.40,1226.18,percent of total billed charges,
CT Lung Cancer Screening,8320177,CDM,352,RC,71271,HCPCS,,,facility,outpatient,,,1499.00000,434.71000,Aetna,First Health,,1226.18,,,,,,,93.38,1474.00,percent of total billed charges,
CT Heart TAVR wo Contrast,7938008,CDM,352,RC,75571,HCPCS,,,facility,inpatient,,,1494.00000,433.26000,Aetna,First Health,,1222.09,,,,,,,896.40,1222.09,percent of total billed charges,
CT Heart TAVR wo Contrast,7938008,CDM,352,RC,75571,HCPCS,,,facility,outpatient,,,1494.00000,433.26000,Aetna,First Health,,1222.09,,,,,,,56.24,1474.00,percent of total billed charges,
CT Lower Extremity Bilat wo Contrast,613556,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,1881.60,2565.25,percent of total billed charges,
CT Lower Extremity Bilat wo Contrast,613556,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,93.38,2565.25,percent of total billed charges,
CT Lower Extremity Bilat wo Contrast,613592,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,1881.60,2565.25,percent of total billed charges,
CT Lower Extremity Bilat wo Contrast,613592,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,93.38,2565.25,percent of total billed charges,
CT Lower Extremity Bilat wo Contrast,8148159,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,1881.60,2565.25,percent of total billed charges,
CT Lower Extremity Bilat wo Contrast,8148159,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,93.38,2565.25,percent of total billed charges,
CT Upper Extremity Bilat wo Contrast,613862,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,1881.60,2565.25,percent of total billed charges,
CT Upper Extremity Bilat wo Contrast,613862,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,93.38,2565.25,percent of total billed charges,
CT Upper Extremity Bilat wo Contrast,8148158,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,1881.60,2565.25,percent of total billed charges,
CT Upper Extremity Bilat wo Contrast,8148158,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,93.38,2565.25,percent of total billed charges,
CT Angio Lower Extremity Right,7991332,CDM,352,RC,73706,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,RT,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Lower Extremity Right,7991332,CDM,352,RC,73706,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,RT,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Lower Extremity Left,7991336,CDM,352,RC,73706,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,LT,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Lower Extremity Left,7991336,CDM,352,RC,73706,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,LT,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Heart TAVR w Contrast,7858050,CDM,352,RC,75572,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Heart TAVR w Contrast,7858050,CDM,352,RC,75572,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,161.98,1516.57,percent of total billed charges,
CT TAVR Angio Chest,7858048,CDM,352,RC,71275,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT TAVR Angio Chest,7858048,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Chest wo Contrast High Resolution,8246688,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Chest wo Contrast High Resolution,8246688,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Chest w Contrast High Resolution,8246684,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Chest w Contrast High Resolution,8246684,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Hip Stryker Left wo Contrast,8282227,CDM,352,RC,72192,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Hip Stryker Left wo Contrast,8282227,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Hip Stryker Right wo Contrast,8282231,CDM,352,RC,72192,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Hip Stryker Right wo Contrast,8282231,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Hip Stryker Bilateral wo Contrast,8282223,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,1881.60,2565.25,percent of total billed charges,
CT Hip Stryker Bilateral wo Contrast,8282223,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,93.38,2565.25,percent of total billed charges,
CT TAVR Chest w Contrast,8282210,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT TAVR Chest w Contrast,8282210,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Lower Extremity LT Partial,8282190,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,"LT,52",1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity LT Partial,8282190,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,"LT,52",1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity RT Partial,8282189,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,"RT,52",1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity RT Partial,8282189,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,"RT,52",1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Angio Chest Abd w or wo Pel w Contrast,8436129,CDM,352,RC,71275,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Chest Abd w or wo Pel w Contrast,8436129,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Chest Abd Pel w or wo Contrast,8436133,CDM,352,RC,71275,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Chest Abd Pel w or wo Contrast,8436133,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Abd w wo Pel w contrast,1447815,CDM,352,RC,74178,HCPCS,,,facility,inpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,2567.40,3500.22,percent of total billed charges,
CT Abd w wo Pel w contrast,1447815,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,311.43,3500.22,percent of total billed charges,
CT Abd w wo Pel w Contrast,8436171,CDM,352,RC,74178,HCPCS,,,facility,inpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,2567.40,3500.22,percent of total billed charges,
CT Abd w wo Pel w Contrast,8436171,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,First Health,,3500.22,,,,,,,311.43,3500.22,percent of total billed charges,
CT Hip Right for Torsion wo Contrast,8438392,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Hip Right for Torsion wo Contrast,8438392,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Hip Left forTorsion wo Contrast,8438390,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Hip Left forTorsion wo Contrast,8438390,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Device Right,8475816,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Device Right,8475816,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Device LT,8475814,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Device LT,8475814,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Device RT,8475812,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,3136.00000,909.44000,Aetna,First Health,RT,2565.25,,,,,,,1881.60,2565.25,percent of total billed charges,
CT Lower Extremity Device RT,8475812,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,First Health,RT,2565.25,,,,,,,93.38,2565.25,percent of total billed charges,
CT Lower Extremity Device RT,8475782,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,"RT,52",1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Device RT,8475782,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,"RT,52",1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Lower Extremity Device LT,8475783,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,"LT,52",1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Lower Extremity Device LT,8475783,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,"LT,52",1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Pelvis Anteversion,8515979,CDM,352,RC,72192,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Pelvis Anteversion,8515979,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Hip Right w Partial Knee Eval,8515992,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Hip Right w Partial Knee Eval,8515992,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Hip Left w Partial Knee Eval,8515988,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Hip Left w Partial Knee Eval,8515988,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Hip Bilat w Partial Knee Eval,8515984,CDM,352,RC,73700,HCPCS,,,facility,inpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,1881.60,2565.25,percent of total billed charges,
CT Hip Bilat w Partial Knee Eval,8515984,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,93.38,2565.25,percent of total billed charges,
CT Upper Extremity Bilat w Contrast,8442476,CDM,352,RC,73201,HCPCS,,,facility,inpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,2224.80,3033.14,percent of total billed charges,
CT Upper Extremity Bilat w Contrast,8442476,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,221.71,3033.14,percent of total billed charges,
CT Watchman Chest w Contrast,8975193,CDM,352,RC,71260,HCPCS,,,facility,inpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,1112.40,1516.57,percent of total billed charges,
CT Watchman Chest w Contrast,8975193,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,First Health,,1516.57,,,,,,,156.31,1516.57,percent of total billed charges,
CT Watchman Chest wo Contrast,8975211,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Watchman Chest wo Contrast,8975211,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Angio Pelvis:CT Exam 1,9093171,CDM,352,RC,72191,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Pelvis:CT Exam 1,9093171,CDM,352,RC,72191,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
Radiology:CT Angio Pelvis,9094802,CDM,352,RC,72191,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
Radiology:CT Angio Pelvis,9094802,CDM,352,RC,72191,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Hip Ortho Bilateral MAKO,9034211,CDM,352,RC,72192,HCPCS,,,facility,inpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,1881.60,2565.25,percent of total billed charges,
CT Hip Ortho Bilateral MAKO,9034211,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,First Health,,2565.25,,,,,,,93.38,2565.25,percent of total billed charges,
CT Hip Ortho Left MAKO,9034213,CDM,352,RC,72192,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Hip Ortho Left MAKO,9034213,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Hip Ortho Right MAKO,9032366,CDM,352,RC,72192,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Hip Ortho Right MAKO,9032366,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Post Bariatric CT Abd Pel w Contrast:CT Exam 1,9045933,CDM,352,RC,74177,HCPCS,,,facility,inpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,2224.80,3033.14,percent of total billed charges,
CT Post Bariatric CT Abd Pel w Contrast:CT Exam 1,9045933,CDM,352,RC,74177,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,First Health,,3033.14,,,,,,,235.67,3033.14,percent of total billed charges,
CT Angio Runoff,9202440,CDM,352,RC,75635,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Runoff,9202440,CDM,352,RC,75635,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Angio Chest,9202519,CDM,352,RC,71275,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,1284.00,1750.52,percent of total billed charges,
CT Angio Chest,9202519,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,First Health,,1750.52,,,,,,,156.31,1750.52,percent of total billed charges,
CT Upper Extremity Right wo Contrast,1083810,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Right wo Contrast,1083810,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613446,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613446,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613475,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613475,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613514,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613514,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613532,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613532,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613572,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613572,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613871,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613871,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613911,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Right wo Contrast,613911,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Right wo Contrast,8148235,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Right wo Contrast,8148235,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Shoulder Biomet Zimmer Right,8153827,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Shoulder Biomet Zimmer Right,8153827,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,RT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Left wo Contrast,1083814,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Left wo Contrast,1083814,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613442,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613442,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613469,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613469,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613512,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613512,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613530,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613530,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613568,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613568,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613866,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613866,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613907,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Left wo Contrast,613907,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Upper Extremity Left wo Contrast,8148234,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Upper Extremity Left wo Contrast,8148234,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Shoulder Biomet Zimmer Left,8153825,CDM,352,RC,73200,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,940.80,1282.62,percent of total billed charges,
CT Shoulder Biomet Zimmer Left,8153825,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,First Health,LT,1282.62,,,,,,,93.38,1474.00,percent of total billed charges,
CT Chest Low Dose Follow Up,9072581,CDM,352,RC,71250,HCPCS,,,facility,inpatient,,,1882.00000,545.78000,Aetna,First Health,,1539.48,,,,,,,1129.20,1539.48,percent of total billed charges,
CT Chest Low Dose Follow Up,9072581,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1882.00000,545.78000,Aetna,First Health,,1539.48,,,,,,,93.38,1539.48,percent of total billed charges,
CT Ablation Guidance,8001027,CDM,359,RC,,,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,2322.60,3166.48,percent of total billed charges,
CT Ablation Guidance,8001027,CDM,359,RC,,,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,First Health,,3166.48,,,,,,,1395.50,3166.48,percent of total billed charges,
CT Guide for Needle Biopsy,8001033,CDM,359,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
CT Guide for Needle Biopsy,8001033,CDM,359,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
CT Guided Thoracentesis,6439868,CDM,359,RC,,,,,facility,inpatient,,,4208.00000,1220.32000,Aetna,First Health,,3442.14,,,,,,,2524.80,3442.14,percent of total billed charges,
CT Guided Thoracentesis,6439868,CDM,359,RC,,,,,facility,outpatient,,,4208.00000,1220.32000,Aetna,First Health,,3442.14,,,,,,,1516.98,3442.14,percent of total billed charges,
CT Denver Drain Placement Pleural,6439876,CDM,359,RC,,,,,facility,inpatient,,,5923.00000,1717.67000,Aetna,First Health,,4845.01,,,,,,,3553.80,4845.01,percent of total billed charges,
CT Denver Drain Placement Pleural,6439876,CDM,359,RC,,,,,facility,outpatient,,,5923.00000,1717.67000,Aetna,First Health,,4845.01,,,,,,,2135.24,4845.01,percent of total billed charges,
CT Guided Chest Tube Placement,7069842,CDM,359,RC,,,,,facility,inpatient,,,5400.00000,1566.00000,Aetna,First Health,,4417.20,,,,,,,3240.00,4417.20,percent of total billed charges,
CT Guided Chest Tube Placement,7069842,CDM,359,RC,,,,,facility,outpatient,,,5400.00000,1566.00000,Aetna,First Health,,4417.20,,,,,,,1946.70,4417.20,percent of total billed charges,
CT Guided Chest Tube Placement,8001054,CDM,359,RC,,,,,facility,inpatient,,,5400.00000,1566.00000,Aetna,First Health,,4417.20,,,,,,,3240.00,4417.20,percent of total billed charges,
CT Guided Chest Tube Placement,8001054,CDM,359,RC,,,,,facility,outpatient,,,5400.00000,1566.00000,Aetna,First Health,,4417.20,,,,,,,1946.70,4417.20,percent of total billed charges,
CT Guided Injection,7285909,CDM,359,RC,,,,,facility,inpatient,,,2881.00000,835.49000,Aetna,First Health,,2356.66,,,,,,,1728.60,2356.66,percent of total billed charges,
CT Guided Injection,7285909,CDM,359,RC,,,,,facility,outpatient,,,2881.00000,835.49000,Aetna,First Health,,2356.66,,,,,,,1038.60,2356.66,percent of total billed charges,
CT Guided Wire Localization,7285913,CDM,359,RC,,,,,facility,inpatient,,,2643.00000,766.47000,Aetna,First Health,,2161.97,,,,,,,1585.80,2161.97,percent of total billed charges,
CT Guided Wire Localization,7285913,CDM,359,RC,,,,,facility,outpatient,,,2643.00000,766.47000,Aetna,First Health,,2161.97,,,,,,,952.80,2161.97,percent of total billed charges,
CT Denver Drain Placement Peritoneal,7544100,CDM,359,RC,,,,,facility,inpatient,,,5286.00000,1532.94000,Aetna,First Health,,4323.95,,,,,,,3171.60,4323.95,percent of total billed charges,
CT Denver Drain Placement Peritoneal,7544100,CDM,359,RC,,,,,facility,outpatient,,,5286.00000,1532.94000,Aetna,First Health,,4323.95,,,,,,,1905.60,4323.95,percent of total billed charges,
CT Guidance IR,9038230,CDM,359,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
CT Guidance IR,9038230,CDM,359,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,981.60,percent of total billed charges,
CT Guidance,9158419,CDM,359,RC,,,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,900.00,1227.00,percent of total billed charges,
CT Guidance,9158419,CDM,359,RC,,,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
CT Guidance,8001026,CDM,359,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
CT Guidance,8001026,CDM,359,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,981.60,percent of total billed charges,
EXTREMITY BLOCK CHARGE,9088208,CDM,360,RC,,,,,facility,inpatient,,,2545.00000,738.05000,Aetna,First Health,,2081.81,,,,,,,1527.00,2081.81,percent of total billed charges,
EXTREMITY BLOCK CHARGE,9088208,CDM,360,RC,,,,,facility,outpatient,,,2545.00000,738.05000,Aetna,First Health,,2081.81,,,,,,,917.47,4908.00,percent of total billed charges,
BLOCK CHARGE JOINT,8404436,CDM,360,RC,,,,,facility,inpatient,,,2533.00000,734.57000,Aetna,First Health,,2071.99,,,,,,,1519.80,2071.99,percent of total billed charges,
BLOCK CHARGE JOINT,8404436,CDM,360,RC,,,,,facility,outpatient,,,2533.00000,734.57000,Aetna,First Health,,2071.99,,,,,,,913.15,4908.00,percent of total billed charges,
BLOCK EXTREMITY,9098451,CDM,360,RC,,,,,facility,inpatient,,,2533.00000,734.57000,Aetna,First Health,,2071.99,,,,,,,1519.80,2071.99,percent of total billed charges,
BLOCK EXTREMITY,9098451,CDM,360,RC,,,,,facility,outpatient,,,2533.00000,734.57000,Aetna,First Health,,2071.99,,,,,,,913.15,4908.00,percent of total billed charges,
BLOCK OTHER,9098452,CDM,360,RC,,,,,facility,inpatient,,,2533.00000,734.57000,Aetna,First Health,,2071.99,,,,,,,1519.80,2071.99,percent of total billed charges,
BLOCK OTHER,9098452,CDM,360,RC,,,,,facility,outpatient,,,2533.00000,734.57000,Aetna,First Health,,2071.99,,,,,,,913.15,4908.00,percent of total billed charges,
Apply Low Sub Feet Addl 25,8411844,CDM,360,RC,C5276,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,1020.00,1390.60,percent of total billed charges,
Apply Low Sub Feet Addl 25,8411844,CDM,360,RC,C5276,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,315.00,1717.00,percent of total billed charges,
FEMORAL NERVE BLOCK,7720094,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
FEMORAL NERVE BLOCK,7720094,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
FEMORAL NERVE BLOCK,7950175,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
FEMORAL NERVE BLOCK,7950175,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOOD PATCH,7720070,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOOD PATCH,7720070,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
OB Blood Patch,9020353,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
OB Blood Patch,9020353,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
INTERSCALENE BLOCK,7720100,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
INTERSCALENE BLOCK,7720100,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE,7950176,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE,7950176,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
CENTRAL LINE PLACEMENT,7720074,CDM,360,RC,,,,,facility,inpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,1045.80,1425.77,percent of total billed charges,
CENTRAL LINE PLACEMENT,7720074,CDM,360,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,628.35,4908.00,percent of total billed charges,
Surgery Procedure Level 1,8981724,CDM,360,RC,,,,,facility,inpatient,,,10213.00000,2961.77000,Aetna,First Health,,8354.23,,,,,,,6127.80,8354.23,percent of total billed charges,
Surgery Procedure Level 1,8981724,CDM,360,RC,,,,,facility,outpatient,,,10213.00000,2961.77000,Aetna,First Health,,8354.23,,,,,,,1232.85,8354.23,percent of total billed charges,
Surgery Procedure Level 2,8981723,CDM,360,RC,,,,,facility,inpatient,,,11131.00000,3227.99000,Aetna,First Health,,9105.16,,,,,,,6678.60,9105.16,percent of total billed charges,
Surgery Procedure Level 2,8981723,CDM,360,RC,,,,,facility,outpatient,,,11131.00000,3227.99000,Aetna,First Health,,9105.16,,,,,,,1232.85,9105.16,percent of total billed charges,
Surgery Procedure Level 3,8981722,CDM,360,RC,,,,,facility,inpatient,,,11358.00000,3293.82000,Aetna,First Health,,9290.84,,,,,,,6814.80,9290.84,percent of total billed charges,
Surgery Procedure Level 3,8981722,CDM,360,RC,,,,,facility,outpatient,,,11358.00000,3293.82000,Aetna,First Health,,9290.84,,,,,,,1232.85,9290.84,percent of total billed charges,
Surgery Procedure Level 4,8982482,CDM,360,RC,,,,,facility,inpatient,,,11585.00000,3359.65000,Aetna,First Health,,9476.53,,,,,,,6951.00,9476.53,percent of total billed charges,
Surgery Procedure Level 4,8982482,CDM,360,RC,,,,,facility,outpatient,,,11585.00000,3359.65000,Aetna,First Health,,9476.53,,,,,,,1232.85,9476.53,percent of total billed charges,
Surgery Procedure Level 5,8982481,CDM,360,RC,,,,,facility,inpatient,,,11819.00000,3427.51000,Aetna,First Health,,9667.94,,,,,,,7091.40,9667.94,percent of total billed charges,
Surgery Procedure Level 5,8982481,CDM,360,RC,,,,,facility,outpatient,,,11819.00000,3427.51000,Aetna,First Health,,9667.94,,,,,,,1232.85,9667.94,percent of total billed charges,
Surgery Procedure Level 1 Add On,8981721,CDM,360,RC,,,,,facility,inpatient,,,1930.00000,559.70000,Aetna,First Health,,1578.74,,,,,,,1158.00,1578.74,percent of total billed charges,
Surgery Procedure Level 1 Add On,8981721,CDM,360,RC,,,,,facility,outpatient,,,1930.00000,559.70000,Aetna,First Health,,1578.74,,,,,,,695.76,4908.00,percent of total billed charges,
Surgery Procedure Level 2 Add On,8161222,CDM,360,RC,,,,,facility,inpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,1242.60,1694.08,percent of total billed charges,
Surgery Procedure Level 2 Add On,8161222,CDM,360,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,746.60,4908.00,percent of total billed charges,
Surgery Procedure Level 3 Add On,8981725,CDM,360,RC,,,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,1260.00,1717.80,percent of total billed charges,
Surgery Procedure Level 3 Add On,8981725,CDM,360,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,4908.00,percent of total billed charges,
Surgery Procedure Level 4 Add On,8168892,CDM,360,RC,,,,,facility,inpatient,,,2255.00000,653.95000,Aetna,First Health,,1844.59,,,,,,,1353.00,1844.59,percent of total billed charges,
Surgery Procedure Level 4 Add On,8168892,CDM,360,RC,,,,,facility,outpatient,,,2255.00000,653.95000,Aetna,First Health,,1844.59,,,,,,,812.93,4908.00,percent of total billed charges,
Surgery Procedure Level 5 Add On,8981727,CDM,360,RC,,,,,facility,inpatient,,,2370.00000,687.30000,Aetna,First Health,,1938.66,,,,,,,1422.00,1938.66,percent of total billed charges,
Surgery Procedure Level 5 Add On,8981727,CDM,360,RC,,,,,facility,outpatient,,,2370.00000,687.30000,Aetna,First Health,,1938.66,,,,,,,854.38,4908.00,percent of total billed charges,
SUPRACLAVICULAR BLOCK,7950179,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
SUPRACLAVICULAR BLOCK,7950179,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
POPLITEAL BLOCK,7950178,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
POPLITEAL BLOCK,7950178,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
AXILLARY BLOCK,7950174,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
AXILLARY BLOCK,7950174,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
ADDUCTOR CANCAL BLOCK,7950173,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
ADDUCTOR CANCAL BLOCK,7950173,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
TAP BLOCK CHARGE,7987721,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
TAP BLOCK CHARGE,7987721,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
INTERSCALENE BLOCK,7950177,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
INTERSCALENE BLOCK,7950177,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE FASCIA ILIAC BLOCK,8146878,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE FASCIA ILIAC BLOCK,8146878,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE ADDUCTOR CANAL CONTINUES,8146877,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE ADDUCTOR CANAL CONTINUES,8146877,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE SUPRACLAVICULAR CONTINUES,8150938,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE SUPRACLAVICULAR CONTINUES,8150938,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE ERECTOR SPINAE,8154827,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE ERECTOR SPINAE,8154827,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
INTERCOSTAL BRACHIAL BLOCK,8247187,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
INTERCOSTAL BRACHIAL BLOCK,8247187,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
PENG BLOCK,8503930,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
PENG BLOCK,8503930,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE SUPERFICIAL CERVICAL PLEXUS,8972084,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE SUPERFICIAL CERVICAL PLEXUS,8972084,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE INFRACLAVICULAR NERVE,9002009,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE INFRACLAVICULAR NERVE,9002009,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE ERECTOR SPINAE CONTINUOUS,9004817,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE ERECTOR SPINAE CONTINUOUS,9004817,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE MEDIAN NERVE BLOCK,9020750,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE MEDIAN NERVE BLOCK,9020750,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE RADIAL,9021136,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE RADIAL,9021136,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
MUSCULOCUTANEOUS BLOCK,9032195,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
MUSCULOCUTANEOUS BLOCK,9032195,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
ULNAR NERVE BLOCK,9032196,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
ULNAR NERVE BLOCK,9032196,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BLOCK CHARGE LATERAL FEMORAL,9046064,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE LATERAL FEMORAL,9046064,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
BRACHIAL PLUXUS,9046065,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BRACHIAL PLUXUS,9046065,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
LEFT LATERAL FEMORAL,9046066,CDM,360,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
LEFT LATERAL FEMORAL,9046066,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
IntraOp Monitoring  Ea Addtl 15,9106484,CDM,360,RC,G0453,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
IntraOp Monitoring  Ea Addtl 15,9106484,CDM,360,RC,G0453,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.04,4908.00,percent of total billed charges,
ULTRASOUND IMAGES SAVED,9226702,CDM,360,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
ULTRASOUND IMAGES SAVED,9226702,CDM,360,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,4908.00,percent of total billed charges,
ANES Ultrasound Guidance Block Line Placement Epidural,8435934,CDM,360,RC,,,,,facility,inpatient,,,425.00000,123.25000,Aetna,First Health,,347.65,,,,,,,255.00,347.65,percent of total billed charges,
ANES Ultrasound Guidance Block Line Placement Epidural,8435934,CDM,360,RC,,,,,facility,outpatient,,,425.00000,123.25000,Aetna,First Health,,347.65,,,,,,,153.21,4908.00,percent of total billed charges,
RA Retrograde Pyelogram,614157,CDM,360,RC,,,,,facility,inpatient,,,2096.00000,607.84000,Aetna,First Health,,1714.53,,,,,,,1257.60,1714.53,percent of total billed charges,
RA Retrograde Pyelogram,614157,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,607.84000,Aetna,First Health,,1714.53,,,,,,,755.61,4908.00,percent of total billed charges,
Sono Guided Asp Inj Intermediate Jnt LT,9092773,CDM,360,RC,,,,,facility,inpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,1198.20,1633.55,percent of total billed charges,
Sono Guided Asp Inj Intermediate Jnt LT,9092773,CDM,360,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,719.92,4908.00,percent of total billed charges,
Liver Ablation CT Guided,9076300,CDM,360,RC,,,,,facility,inpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,10138.80,13822.56,percent of total billed charges,
Liver Ablation CT Guided,9076300,CDM,360,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,1232.85,13822.56,percent of total billed charges,
Bone Marrow Biopsy And Aspiration,1327800,CDM,361,RC,,,,,facility,inpatient,,,2593.00000,751.97000,Aetna,First Health,,2121.07,,,,,,,1555.80,2121.07,percent of total billed charges,
Bone Marrow Biopsy And Aspiration,1327800,CDM,361,RC,,,,,facility,outpatient,,,2593.00000,751.97000,Aetna,First Health,,2121.07,,,,,,,934.78,4908.00,percent of total billed charges,
Bone Marrow Biopsy And Aspiration,7295870,CDM,361,RC,,,,,facility,inpatient,,,2593.00000,751.97000,Aetna,First Health,,2121.07,,,,,,,1555.80,2121.07,percent of total billed charges,
Bone Marrow Biopsy And Aspiration,7295870,CDM,361,RC,,,,,facility,outpatient,,,2593.00000,751.97000,Aetna,First Health,,2121.07,,,,,,,934.78,4908.00,percent of total billed charges,
Bone Marrow Biopsy And Aspiration,7957595,CDM,361,RC,,,,,facility,inpatient,,,2593.00000,751.97000,Aetna,First Health,,2121.07,,,,,,,1555.80,2121.07,percent of total billed charges,
Bone Marrow Biopsy And Aspiration,7957595,CDM,361,RC,,,,,facility,outpatient,,,2593.00000,751.97000,Aetna,First Health,,2121.07,,,,,,,934.78,4908.00,percent of total billed charges,
Paracentesis,1327817,CDM,361,RC,,,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,1656.00,2257.68,percent of total billed charges,
Paracentesis,1327817,CDM,361,RC,,,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,4908.00,percent of total billed charges,
Paracentesis,7295846,CDM,361,RC,,,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,1656.00,2257.68,percent of total billed charges,
Paracentesis,7295846,CDM,361,RC,,,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,4908.00,percent of total billed charges,
Lumbar Puncture,1327812,CDM,361,RC,,,,,facility,inpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,1242.60,1694.08,percent of total billed charges,
Lumbar Puncture,1327812,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,746.60,4908.00,percent of total billed charges,
Lumbar Puncture,7275857,CDM,361,RC,,,,,facility,inpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,1242.60,1694.08,percent of total billed charges,
Lumbar Puncture,7275857,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,746.60,4908.00,percent of total billed charges,
Lumbar Puncture,7295861,CDM,361,RC,,,,,facility,inpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,1242.60,1694.08,percent of total billed charges,
Lumbar Puncture,7295861,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,746.60,4908.00,percent of total billed charges,
Lumbar Puncture,7942791,CDM,361,RC,,,,,facility,inpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,1242.60,1694.08,percent of total billed charges,
Lumbar Puncture,7942791,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,746.60,4908.00,percent of total billed charges,
Thoracentesis,1327819,CDM,361,RC,,,,,facility,inpatient,,,3008.00000,872.32000,Aetna,First Health,,2460.54,,,,,,,1804.80,2460.54,percent of total billed charges,
Thoracentesis,1327819,CDM,361,RC,,,,,facility,outpatient,,,3008.00000,872.32000,Aetna,First Health,,2460.54,,,,,,,1084.38,4908.00,percent of total billed charges,
Thoracentesis,7295848,CDM,361,RC,,,,,facility,inpatient,,,3008.00000,872.32000,Aetna,First Health,,2460.54,,,,,,,1804.80,2460.54,percent of total billed charges,
Thoracentesis,7295848,CDM,361,RC,,,,,facility,outpatient,,,3008.00000,872.32000,Aetna,First Health,,2460.54,,,,,,,1084.38,4908.00,percent of total billed charges,
INSERT CHEST TUBE,7295863,CDM,361,RC,,,,,facility,inpatient,,,1522.00000,441.38000,Aetna,First Health,,1245.00,,,,,,,913.20,1245.00,percent of total billed charges,
INSERT CHEST TUBE,7295863,CDM,361,RC,,,,,facility,outpatient,,,1522.00000,441.38000,Aetna,First Health,,1245.00,,,,,,,548.68,4908.00,percent of total billed charges,
Insert Chest Tube,7942785,CDM,361,RC,,,,,facility,inpatient,,,1522.00000,441.38000,Aetna,First Health,,1245.00,,,,,,,913.20,1245.00,percent of total billed charges,
Insert Chest Tube,7942785,CDM,361,RC,,,,,facility,outpatient,,,1522.00000,441.38000,Aetna,First Health,,1245.00,,,,,,,548.68,4908.00,percent of total billed charges,
Insert Laryngoscopy And Or Trach,7295862,CDM,361,RC,,,,,facility,inpatient,,,2535.00000,735.15000,Aetna,First Health,,2073.63,,,,,,,1521.00,2073.63,percent of total billed charges,
Insert Laryngoscopy And Or Trach,7295862,CDM,361,RC,,,,,facility,outpatient,,,2535.00000,735.15000,Aetna,First Health,,2073.63,,,,,,,913.87,4908.00,percent of total billed charges,
Flexible Cystoscopy,7295865,CDM,361,RC,,,,,facility,inpatient,,,3037.00000,880.73000,Aetna,First Health,,2484.27,,,,,,,1822.20,2484.27,percent of total billed charges,
Flexible Cystoscopy,7295865,CDM,361,RC,,,,,facility,outpatient,,,3037.00000,880.73000,Aetna,First Health,,2484.27,,,,,,,1094.84,4908.00,percent of total billed charges,
Flexible Cystoscopy,8171790,CDM,361,RC,,,,,facility,inpatient,,,3037.00000,880.73000,Aetna,First Health,,2484.27,,,,,,,1822.20,2484.27,percent of total billed charges,
Flexible Cystoscopy,8171790,CDM,361,RC,,,,,facility,outpatient,,,3037.00000,880.73000,Aetna,First Health,,2484.27,,,,,,,1094.84,4908.00,percent of total billed charges,
Replace Central Venous Catheter,7295852,CDM,361,RC,,,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,828.00,1128.84,percent of total billed charges,
Replace Central Venous Catheter,7295852,CDM,361,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,4908.00,percent of total billed charges,
Replace Central Venous Catheter,7957592,CDM,361,RC,,,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,828.00,1128.84,percent of total billed charges,
Replace Central Venous Catheter,7957592,CDM,361,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,4908.00,percent of total billed charges,
Insert Central Venous Catheter,7295864,CDM,361,RC,,,,,facility,inpatient,,,1801.00000,522.29000,Aetna,First Health,,1473.22,,,,,,,1080.60,1473.22,percent of total billed charges,
Insert Central Venous Catheter,7295864,CDM,361,RC,,,,,facility,outpatient,,,1801.00000,522.29000,Aetna,First Health,,1473.22,,,,,,,649.26,4908.00,percent of total billed charges,
Aspiration Or Arthrocentesis,7295871,CDM,361,RC,,,,,facility,inpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,1045.80,1425.77,percent of total billed charges,
Aspiration Or Arthrocentesis,7295871,CDM,361,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,628.35,4908.00,percent of total billed charges,
Place Dialysis Catheter,7457912,CDM,361,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
Place Dialysis Catheter,7457912,CDM,361,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,4908.00,percent of total billed charges,
Place dialysis catheter,8171789,CDM,361,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
Place dialysis catheter,8171789,CDM,361,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,4908.00,percent of total billed charges,
Place Central Line,8156502,CDM,361,RC,,,,,facility,inpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,1045.80,1425.77,percent of total billed charges,
Place Central Line,8156502,CDM,361,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,628.35,4908.00,percent of total billed charges,
Place Icp Monitoring Device,7457910,CDM,361,RC,,,,,facility,inpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,697.20,950.52,percent of total billed charges,
Place Icp Monitoring Device,7457910,CDM,361,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,418.90,4908.00,percent of total billed charges,
Lumbar Drain,7457908,CDM,361,RC,,,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,142.80,194.68,percent of total billed charges,
Lumbar Drain,7457908,CDM,361,RC,,,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,85.80,4908.00,percent of total billed charges,
Place Intracerebral Drain,7457909,CDM,361,RC,,,,,facility,inpatient,,,3052.00000,885.08000,Aetna,First Health,,2496.54,,,,,,,1831.20,2496.54,percent of total billed charges,
Place Intracerebral Drain,7457909,CDM,361,RC,,,,,facility,outpatient,,,3052.00000,885.08000,Aetna,First Health,,2496.54,,,,,,,1100.25,4908.00,percent of total billed charges,
Drain Abscess Cyst Or Lesion,7295867,CDM,361,RC,,,,,facility,inpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,457.20,623.32,percent of total billed charges,
Drain Abscess Cyst Or Lesion,7295867,CDM,361,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,274.70,4908.00,percent of total billed charges,
Drain abscess cyst or lesion,8171372,CDM,361,RC,,,,,facility,inpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,457.20,623.32,percent of total billed charges,
Drain abscess cyst or lesion,8171372,CDM,361,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,274.70,4908.00,percent of total billed charges,
Epidural,8172036,CDM,361,RC,,,,,facility,inpatient,,,2324.00000,673.96000,Aetna,First Health,,1901.03,,,,,,,1394.40,1901.03,percent of total billed charges,
Epidural,8172036,CDM,361,RC,,,,,facility,outpatient,,,2324.00000,673.96000,Aetna,First Health,,1901.03,,,,,,,837.80,4908.00,percent of total billed charges,
Treatment Of Hypothermia,7457916,CDM,361,RC,,,,,facility,inpatient,,,3631.00000,1052.99000,Aetna,First Health,,2970.16,,,,,,,2178.60,2970.16,percent of total billed charges,
Treatment Of Hypothermia,7457916,CDM,361,RC,,,,,facility,outpatient,,,3631.00000,1052.99000,Aetna,First Health,,2970.16,,,,,,,1308.98,4908.00,percent of total billed charges,
Pleural Drainage And Cath Place,6847839,CDM,361,RC,,,,,facility,inpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,697.20,950.52,percent of total billed charges,
Pleural Drainage And Cath Place,6847839,CDM,361,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,418.90,4908.00,percent of total billed charges,
Pleural Drainage And Cath Place,7295854,CDM,361,RC,,,,,facility,inpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,697.20,950.52,percent of total billed charges,
Pleural Drainage And Cath Place,7295854,CDM,361,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,418.90,4908.00,percent of total billed charges,
Denver Drain Exchange,7457913,CDM,361,RC,,,,,facility,inpatient,,,509.00000,147.61000,Aetna,First Health,,416.36,,,,,,,305.40,416.36,percent of total billed charges,
Denver Drain Exchange,7457913,CDM,361,RC,,,,,facility,outpatient,,,509.00000,147.61000,Aetna,First Health,,416.36,,,,,,,183.49,4908.00,percent of total billed charges,
Denver Drain Exchange,7957588,CDM,361,RC,,,,,facility,inpatient,,,509.00000,147.61000,Aetna,First Health,,416.36,,,,,,,305.40,416.36,percent of total billed charges,
Denver Drain Exchange,7957588,CDM,361,RC,,,,,facility,outpatient,,,509.00000,147.61000,Aetna,First Health,,416.36,,,,,,,183.49,4908.00,percent of total billed charges,
Biopsy,7902565,CDM,361,RC,,,,,facility,inpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1848.00,2519.44,percent of total billed charges,
Biopsy,7902565,CDM,361,RC,,,,,facility,outpatient,,,3080.00000,893.20000,Aetna,First Health,,2519.44,,,,,,,1110.34,4908.00,percent of total billed charges,
REMOVE IAB,7902567,CDM,361,RC,,,,,facility,inpatient,,,5695.00000,1651.55000,Aetna,First Health,,4658.51,,,,,,,3417.00,4658.51,percent of total billed charges,
REMOVE IAB,7902567,CDM,361,RC,,,,,facility,outpatient,,,5695.00000,1651.55000,Aetna,First Health,,4658.51,,,,,,,2053.05,4908.00,percent of total billed charges,
Orthopedic Treatment,7457900,CDM,361,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7457900,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,4908.00,percent of total billed charges,
Orthopedic Treatment,7457917,CDM,361,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7457917,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,4908.00,percent of total billed charges,
Orthopedic Treatment,7894476,CDM,361,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894476,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,4908.00,percent of total billed charges,
Orthopedic Treatment,7894477,CDM,361,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894477,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,4908.00,percent of total billed charges,
Orthopedic Treatment,7894482,CDM,361,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894482,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,4908.00,percent of total billed charges,
Swan Ganz Insertion,7295849,CDM,361,RC,,,,,facility,inpatient,,,3994.00000,1158.26000,Aetna,First Health,,3267.09,,,,,,,2396.40,3267.09,percent of total billed charges,
Swan Ganz Insertion,7295849,CDM,361,RC,,,,,facility,outpatient,,,3994.00000,1158.26000,Aetna,First Health,,3267.09,,,,,,,1439.84,4908.00,percent of total billed charges,
Swan Ganz Insertion,7457906,CDM,361,RC,,,,,facility,inpatient,,,3994.00000,1158.26000,Aetna,First Health,,3267.09,,,,,,,2396.40,3267.09,percent of total billed charges,
Swan Ganz Insertion,7457906,CDM,361,RC,,,,,facility,outpatient,,,3994.00000,1158.26000,Aetna,First Health,,3267.09,,,,,,,1439.84,4908.00,percent of total billed charges,
Place Ventriculostomy,7457905,CDM,361,RC,,,,,facility,inpatient,,,2906.00000,842.74000,Aetna,First Health,,2377.11,,,,,,,1743.60,2377.11,percent of total billed charges,
Place Ventriculostomy,7457905,CDM,361,RC,,,,,facility,outpatient,,,2906.00000,842.74000,Aetna,First Health,,2377.11,,,,,,,1047.61,4908.00,percent of total billed charges,
Plasma Exchange,8141860,CDM,361,RC,,,,,facility,inpatient,,,1664.00000,482.56000,Aetna,First Health,,1361.15,,,,,,,998.40,1361.15,percent of total billed charges,
Plasma Exchange,8141860,CDM,361,RC,,,,,facility,outpatient,,,1664.00000,482.56000,Aetna,First Health,,1361.15,,,,,,,599.87,4908.00,percent of total billed charges,
NB Circumcision,7939799,CDM,361,RC,,,,,facility,inpatient,,,1545.00000,448.05000,Aetna,First Health,,1263.81,,,,,,,927.00,1263.81,percent of total billed charges,
NB Circumcision,7939799,CDM,361,RC,,,,,facility,outpatient,,,1545.00000,448.05000,Aetna,First Health,,1263.81,,,,,,,556.97,4908.00,percent of total billed charges,
NB Circumcision,7987281,CDM,361,RC,,,,,facility,inpatient,,,1545.00000,448.05000,Aetna,First Health,,1263.81,,,,,,,927.00,1263.81,percent of total billed charges,
NB Circumcision,7987281,CDM,361,RC,,,,,facility,outpatient,,,1545.00000,448.05000,Aetna,First Health,,1263.81,,,,,,,556.97,4908.00,percent of total billed charges,
NB Insert Venous Umbilical Cath,7942789,CDM,361,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
NB Insert Venous Umbilical Cath,7942789,CDM,361,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,4908.00,percent of total billed charges,
NB Intubation,7942790,CDM,361,RC,,,,,facility,inpatient,,,2276.00000,660.04000,Aetna,First Health,,1861.77,,,,,,,1365.60,1861.77,percent of total billed charges,
NB Intubation,7942790,CDM,361,RC,,,,,facility,outpatient,,,2276.00000,660.04000,Aetna,First Health,,1861.77,,,,,,,820.50,4908.00,percent of total billed charges,
NB Needle Aspiration,7942793,CDM,361,RC,,,,,facility,inpatient,,,872.00000,252.88000,Aetna,First Health,,713.30,,,,,,,523.20,713.30,percent of total billed charges,
NB Needle Aspiration,7942793,CDM,361,RC,,,,,facility,outpatient,,,872.00000,252.88000,Aetna,First Health,,713.30,,,,,,,314.36,4908.00,percent of total billed charges,
NB Exchange Transfusion Partial,7943093,CDM,361,RC,,,,,facility,inpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,1045.80,1425.77,percent of total billed charges,
NB Exchange Transfusion Partial,7943093,CDM,361,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,628.35,4908.00,percent of total billed charges,
NB Skin Tag Removal,7942794,CDM,361,RC,,,,,facility,inpatient,,,289.00000,83.81000,Aetna,First Health,,236.40,,,,,,,173.40,236.40,percent of total billed charges,
NB Skin Tag Removal,7942794,CDM,361,RC,,,,,facility,outpatient,,,289.00000,83.81000,Aetna,First Health,,236.40,,,,,,,104.18,4908.00,percent of total billed charges,
NB Frenulectomy Or Frenectomy,7942783,CDM,361,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
NB Frenulectomy Or Frenectomy,7942783,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,4908.00,percent of total billed charges,
NB Insert Arterial Umbilical Cath,7942784,CDM,361,RC,,,,,facility,inpatient,,,518.00000,150.22000,Aetna,First Health,,423.72,,,,,,,310.80,423.72,percent of total billed charges,
NB Insert Arterial Umbilical Cath,7942784,CDM,361,RC,,,,,facility,outpatient,,,518.00000,150.22000,Aetna,First Health,,423.72,,,,,,,186.74,4908.00,percent of total billed charges,
Insert Picc Line,7894580,CDM,361,RC,,,,,facility,inpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,2220.00,3026.60,percent of total billed charges,
Insert Picc Line,7894580,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,1333.85,4908.00,percent of total billed charges,
Insert Picc Line,7942786,CDM,361,RC,,,,,facility,inpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,2220.00,3026.60,percent of total billed charges,
Insert Picc Line,7942786,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,1333.85,4908.00,percent of total billed charges,
Insert Picc Line,7942788,CDM,361,RC,,,,,facility,inpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,2220.00,3026.60,percent of total billed charges,
Insert Picc Line,7942788,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,1333.85,4908.00,percent of total billed charges,
PICC Insertion Successful,8950541,CDM,361,RC,,,,,facility,inpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,2220.00,3026.60,percent of total billed charges,
PICC Insertion Successful,8950541,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,1333.85,4908.00,percent of total billed charges,
PICC insertion by VAT team successful,9094037,CDM,361,RC,,,,,facility,inpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,2220.00,3026.60,percent of total billed charges,
PICC insertion by VAT team successful,9094037,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,1333.85,4908.00,percent of total billed charges,
Midline Insertion,7920029,CDM,361,RC,,,,,facility,inpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,823.20,1122.30,percent of total billed charges,
Midline Insertion,7920029,CDM,361,RC,,,,,facility,outpatient,,,1372.00000,397.88000,Aetna,First Health,,1122.30,,,,,,,494.61,4908.00,percent of total billed charges,
Insert Laryngoscopy And Or Trach,2152832,CDM,361,RC,,,,,facility,inpatient,,,2535.00000,735.15000,Aetna,First Health,,2073.63,,,,,,,1521.00,2073.63,percent of total billed charges,
Insert Laryngoscopy And Or Trach,2152832,CDM,361,RC,,,,,facility,outpatient,,,2535.00000,735.15000,Aetna,First Health,,2073.63,,,,,,,913.87,4908.00,percent of total billed charges,
Orthopedic Treatment,7275862,CDM,361,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7275862,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,4908.00,percent of total billed charges,
Orthopedic Treatment,7894475,CDM,361,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894475,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,4908.00,percent of total billed charges,
Orthopedic Treatment,7894504,CDM,361,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894504,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,4908.00,percent of total billed charges,
Orthopedic Treatment,7894505,CDM,361,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894505,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,4908.00,percent of total billed charges,
I And D Complex,602594,CDM,361,RC,10061,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,1860.00,2535.80,percent of total billed charges,
I And D Complex,602594,CDM,361,RC,10061,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,93.72,2860.00,percent of total billed charges,
I And D Complex,7958310,CDM,361,RC,10061,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,1860.00,2535.80,percent of total billed charges,
I And D Complex,7958310,CDM,361,RC,10061,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,93.72,2860.00,percent of total billed charges,
Chemical Cautery Of Wound,602652,CDM,361,RC,17250,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,1020.00,1390.60,percent of total billed charges,
Chemical Cautery Of Wound,602652,CDM,361,RC,17250,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,99.00,2860.00,percent of total billed charges,
Chemical Cautery Of Wound,7958354,CDM,361,RC,17250,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,1020.00,1390.60,percent of total billed charges,
Chemical Cautery Of Wound,7958354,CDM,361,RC,17250,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,99.00,2860.00,percent of total billed charges,
I And D Simple,602592,CDM,361,RC,10060,HCPCS,,,facility,inpatient,,,1013.00000,293.77000,Aetna,First Health,,828.63,,,,,,,607.80,828.63,percent of total billed charges,
I And D Simple,602592,CDM,361,RC,10060,HCPCS,,,facility,outpatient,,,1013.00000,293.77000,Aetna,First Health,,828.63,,,,,,,93.72,2860.00,percent of total billed charges,
I And D Simple,7958308,CDM,361,RC,10060,HCPCS,,,facility,inpatient,,,1013.00000,293.77000,Aetna,First Health,,828.63,,,,,,,607.80,828.63,percent of total billed charges,
I And D Simple,7958308,CDM,361,RC,10060,HCPCS,,,facility,outpatient,,,1013.00000,293.77000,Aetna,First Health,,828.63,,,,,,,93.72,2860.00,percent of total billed charges,
Debridement Skin Subq First 20 Cm,4201840,CDM,361,RC,11042,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Debridement Skin Subq First 20 Cm,4201840,CDM,361,RC,11042,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,182.16,2860.00,percent of total billed charges,
Debridement Skin Subq First 20 Cm,7958311,CDM,361,RC,11042,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Debridement Skin Subq First 20 Cm,7958311,CDM,361,RC,11042,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,182.16,2860.00,percent of total billed charges,
Debridement Skin Subq Addl 20 Cm,4201839,CDM,361,RC,11045,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Debridement Skin Subq Addl 20 Cm,4201839,CDM,361,RC,11045,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,182.16,2860.00,percent of total billed charges,
Debridement Skin Subq Addl 20 Cm,7958313,CDM,361,RC,11045,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Debridement Skin Subq Addl 20 Cm,7958313,CDM,361,RC,11045,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,182.16,2860.00,percent of total billed charges,
Debridement Muscle Fascia First20,4201841,CDM,361,RC,11043,HCPCS,,,facility,inpatient,,,1866.00000,541.14000,Aetna,First Health,,1526.39,,,,,,,1119.60,1526.39,percent of total billed charges,
Debridement Muscle Fascia First20,4201841,CDM,361,RC,11043,HCPCS,,,facility,outpatient,,,1866.00000,541.14000,Aetna,First Health,,1526.39,,,,,,,182.16,2860.00,percent of total billed charges,
Debridement Muscle Fascia First20,7958315,CDM,361,RC,11043,HCPCS,,,facility,inpatient,,,1866.00000,541.14000,Aetna,First Health,,1526.39,,,,,,,1119.60,1526.39,percent of total billed charges,
Debridement Muscle Fascia First20,7958315,CDM,361,RC,11043,HCPCS,,,facility,outpatient,,,1866.00000,541.14000,Aetna,First Health,,1526.39,,,,,,,182.16,2860.00,percent of total billed charges,
Excision Of Nail,3172901,CDM,361,RC,11750,HCPCS,,,facility,inpatient,,,1050.00000,304.50000,Aetna,First Health,,858.90,,,,,,,630.00,858.90,percent of total billed charges,
Excision Of Nail,3172901,CDM,361,RC,11750,HCPCS,,,facility,outpatient,,,1050.00000,304.50000,Aetna,First Health,,858.90,,,,,,,291.72,2860.00,percent of total billed charges,
Excision Of Nail,7958352,CDM,361,RC,11750,HCPCS,,,facility,inpatient,,,1050.00000,304.50000,Aetna,First Health,,858.90,,,,,,,630.00,858.90,percent of total billed charges,
Excision Of Nail,7958352,CDM,361,RC,11750,HCPCS,,,facility,outpatient,,,1050.00000,304.50000,Aetna,First Health,,858.90,,,,,,,291.72,2860.00,percent of total billed charges,
Trim Of Nondys Nails,602624,CDM,361,RC,11719,HCPCS,,,facility,inpatient,,,345.00000,100.05000,Aetna,First Health,,282.21,,,,,,,207.00,282.21,percent of total billed charges,
Trim Of Nondys Nails,602624,CDM,361,RC,11719,HCPCS,,,facility,outpatient,,,345.00000,100.05000,Aetna,First Health,,282.21,,,,,,,25.74,4908.00,percent of total billed charges,
Trim Of Nondys Nails,7958344,CDM,361,RC,11719,HCPCS,,,facility,inpatient,,,345.00000,100.05000,Aetna,First Health,,282.21,,,,,,,207.00,282.21,percent of total billed charges,
Trim Of Nondys Nails,7958344,CDM,361,RC,11719,HCPCS,,,facility,outpatient,,,345.00000,100.05000,Aetna,First Health,,282.21,,,,,,,25.74,4908.00,percent of total billed charges,
Debride Of Nails 1 To 5,602626,CDM,361,RC,11720,HCPCS,,,facility,inpatient,,,345.00000,100.05000,Aetna,First Health,,282.21,,,,,,,207.00,282.21,percent of total billed charges,
Debride Of Nails 1 To 5,602626,CDM,361,RC,11720,HCPCS,,,facility,outpatient,,,345.00000,100.05000,Aetna,First Health,,282.21,,,,,,,52.15,2860.00,percent of total billed charges,
Debride Of Nails 1 To 5,7958346,CDM,361,RC,11720,HCPCS,,,facility,inpatient,,,345.00000,100.05000,Aetna,First Health,,282.21,,,,,,,207.00,282.21,percent of total billed charges,
Debride Of Nails 1 To 5,7958346,CDM,361,RC,11720,HCPCS,,,facility,outpatient,,,345.00000,100.05000,Aetna,First Health,,282.21,,,,,,,52.15,2860.00,percent of total billed charges,
Debride Of Nails 6 Plus,602628,CDM,361,RC,11721,HCPCS,,,facility,inpatient,,,418.00000,121.22000,Aetna,First Health,,341.92,,,,,,,250.80,341.92,percent of total billed charges,
Debride Of Nails 6 Plus,602628,CDM,361,RC,11721,HCPCS,,,facility,outpatient,,,418.00000,121.22000,Aetna,First Health,,341.92,,,,,,,52.15,2860.00,percent of total billed charges,
Debride Of Nails 6 Plus,7958348,CDM,361,RC,11721,HCPCS,,,facility,inpatient,,,418.00000,121.22000,Aetna,First Health,,341.92,,,,,,,250.80,341.92,percent of total billed charges,
Debride Of Nails 6 Plus,7958348,CDM,361,RC,11721,HCPCS,,,facility,outpatient,,,418.00000,121.22000,Aetna,First Health,,341.92,,,,,,,52.15,2860.00,percent of total billed charges,
Avul Of Nail Plate Single,602630,CDM,361,RC,11730,HCPCS,,,facility,inpatient,,,623.00000,180.67000,Aetna,First Health,,509.61,,,,,,,373.80,509.61,percent of total billed charges,
Avul Of Nail Plate Single,602630,CDM,361,RC,11730,HCPCS,,,facility,outpatient,,,623.00000,180.67000,Aetna,First Health,,509.61,,,,,,,58.08,2860.00,percent of total billed charges,
Avul Of Nail Plate Single,7958350,CDM,361,RC,11730,HCPCS,,,facility,inpatient,,,623.00000,180.67000,Aetna,First Health,,509.61,,,,,,,373.80,509.61,percent of total billed charges,
Avul Of Nail Plate Single,7958350,CDM,361,RC,11730,HCPCS,,,facility,outpatient,,,623.00000,180.67000,Aetna,First Health,,509.61,,,,,,,58.08,2860.00,percent of total billed charges,
Debridement Muscle Fascia Addl 20,4283839,CDM,361,RC,11046,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Debridement Muscle Fascia Addl 20,4283839,CDM,361,RC,11046,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,182.16,2860.00,percent of total billed charges,
Debridement Muscle Fascia Addl 20,7958316,CDM,361,RC,11046,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Debridement Muscle Fascia Addl 20,7958316,CDM,361,RC,11046,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,182.16,2860.00,percent of total billed charges,
Debridement Bone First 20 Sq Cm,4205845,CDM,361,RC,11044,HCPCS,,,facility,inpatient,,,4865.00000,1410.85000,Aetna,First Health,,3979.57,,,,,,,2919.00,3979.57,percent of total billed charges,
Debridement Bone First 20 Sq Cm,4205845,CDM,361,RC,11044,HCPCS,,,facility,outpatient,,,4865.00000,1410.85000,Aetna,First Health,,3979.57,,,,,,,545.82,4324.56,percent of total billed charges,
Debridement Bone First 20 Sq Cm,7958317,CDM,361,RC,11044,HCPCS,,,facility,inpatient,,,4865.00000,1410.85000,Aetna,First Health,,3979.57,,,,,,,2919.00,3979.57,percent of total billed charges,
Debridement Bone First 20 Sq Cm,7958317,CDM,361,RC,11044,HCPCS,,,facility,outpatient,,,4865.00000,1410.85000,Aetna,First Health,,3979.57,,,,,,,545.82,4324.56,percent of total billed charges,
Debridement Bone Addl 20 Sq Cm,7389880,CDM,361,RC,11047,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,1448.40,1974.65,percent of total billed charges,
Debridement Bone Addl 20 Sq Cm,7389880,CDM,361,RC,11047,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,315.00,2860.00,percent of total billed charges,
Debridement Bone Addl 20 Sq Cm,7958318,CDM,361,RC,11047,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,1448.40,1974.65,percent of total billed charges,
Debridement Bone Addl 20 Sq Cm,7958318,CDM,361,RC,11047,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,First Health,,1974.65,,,,,,,315.00,2860.00,percent of total billed charges,
Dress Debride P Thick Burn Medium,5385843,CDM,361,RC,16025,HCPCS,,,facility,inpatient,,,776.00000,225.04000,Aetna,First Health,,634.77,,,,,,,465.60,634.77,percent of total billed charges,
Dress Debride P Thick Burn Medium,5385843,CDM,361,RC,16025,HCPCS,,,facility,outpatient,,,776.00000,225.04000,Aetna,First Health,,634.77,,,,,,,99.00,2860.00,percent of total billed charges,
Dress Debride P Thick Burn Medium,7959587,CDM,361,RC,16025,HCPCS,,,facility,inpatient,,,776.00000,225.04000,Aetna,First Health,,634.77,,,,,,,465.60,634.77,percent of total billed charges,
Dress Debride P Thick Burn Medium,7959587,CDM,361,RC,16025,HCPCS,,,facility,outpatient,,,776.00000,225.04000,Aetna,First Health,,634.77,,,,,,,99.00,2860.00,percent of total billed charges,
Dress Debride P Thick Burn Small,5385844,CDM,361,RC,16020,HCPCS,,,facility,inpatient,,,550.00000,159.50000,Aetna,First Health,,449.90,,,,,,,330.00,449.90,percent of total billed charges,
Dress Debride P Thick Burn Small,5385844,CDM,361,RC,16020,HCPCS,,,facility,outpatient,,,550.00000,159.50000,Aetna,First Health,,449.90,,,,,,,99.00,2860.00,percent of total billed charges,
Dress Debride P Thick Burn Small,7959586,CDM,361,RC,16020,HCPCS,,,facility,inpatient,,,550.00000,159.50000,Aetna,First Health,,449.90,,,,,,,330.00,449.90,percent of total billed charges,
Dress Debride P Thick Burn Small,7959586,CDM,361,RC,16020,HCPCS,,,facility,outpatient,,,550.00000,159.50000,Aetna,First Health,,449.90,,,,,,,99.00,2860.00,percent of total billed charges,
Amputation Partial Toe Rt,8137559,CDM,361,RC,28825,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
Amputation Partial Toe Rt,8137559,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
WHC Partial Toe Amputation Right,8411590,CDM,361,RC,28825,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
WHC Partial Toe Amputation Right,8411590,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
Partial Toe Amp RT,8411834,CDM,361,RC,28825,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
Partial Toe Amp RT,8411834,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
Apply High Sub T A L Init 25,7417872,CDM,361,RC,15271,HCPCS,,,facility,inpatient,,,5800.00000,1682.00000,Aetna,First Health,,4744.40,,,,,,,3480.00,4744.40,percent of total billed charges,
Apply High Sub T A L Init 25,7417872,CDM,361,RC,15271,HCPCS,,,facility,outpatient,,,5800.00000,1682.00000,Aetna,First Health,,4744.40,,,,,,,215.16,4882.38,percent of total billed charges,
Apply High Sub T A L Init 25,7958321,CDM,361,RC,15271,HCPCS,,,facility,inpatient,,,5800.00000,1682.00000,Aetna,First Health,,4744.40,,,,,,,3480.00,4744.40,percent of total billed charges,
Apply High Sub T A L Init 25,7958321,CDM,361,RC,15271,HCPCS,,,facility,outpatient,,,5800.00000,1682.00000,Aetna,First Health,,4744.40,,,,,,,215.16,4882.38,percent of total billed charges,
Apply High Sub T A L Addl 25,7417873,CDM,361,RC,15272,HCPCS,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Apply High Sub T A L Addl 25,7417873,CDM,361,RC,15272,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,78.54,3926.40,percent of total billed charges,
Apply High Sub T A L Addl 25,7958325,CDM,361,RC,15272,HCPCS,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Apply High Sub T A L Addl 25,7958325,CDM,361,RC,15272,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,78.54,3926.40,percent of total billed charges,
Apply High Sub T A L Init 100,7417874,CDM,361,RC,15273,HCPCS,,,facility,inpatient,,,9400.00000,2726.00000,Aetna,First Health,,7689.20,,,,,,,5640.00,7689.20,percent of total billed charges,
Apply High Sub T A L Init 100,7417874,CDM,361,RC,15273,HCPCS,,,facility,outpatient,,,9400.00000,2726.00000,Aetna,First Health,,7689.20,,,,,,,328.02,9771.45,percent of total billed charges,
Apply High Sub T A L Init 100,7958329,CDM,361,RC,15273,HCPCS,,,facility,inpatient,,,9400.00000,2726.00000,Aetna,First Health,,7689.20,,,,,,,5640.00,7689.20,percent of total billed charges,
Apply High Sub T A L Init 100,7958329,CDM,361,RC,15273,HCPCS,,,facility,outpatient,,,9400.00000,2726.00000,Aetna,First Health,,7689.20,,,,,,,328.02,9771.45,percent of total billed charges,
Apply High Sub T A L Addl 100,7417875,CDM,361,RC,15274,HCPCS,,,facility,inpatient,,,9400.00000,2726.00000,Aetna,First Health,,7689.20,,,,,,,5640.00,7689.20,percent of total billed charges,
Apply High Sub T A L Addl 100,7417875,CDM,361,RC,15274,HCPCS,,,facility,outpatient,,,9400.00000,2726.00000,Aetna,First Health,,7689.20,,,,,,,215.16,7689.20,percent of total billed charges,
Apply High Sub T A L Addl 100,7958333,CDM,361,RC,15274,HCPCS,,,facility,inpatient,,,9400.00000,2726.00000,Aetna,First Health,,7689.20,,,,,,,5640.00,7689.20,percent of total billed charges,
Apply High Sub T A L Addl 100,7958333,CDM,361,RC,15274,HCPCS,,,facility,outpatient,,,9400.00000,2726.00000,Aetna,First Health,,7689.20,,,,,,,215.16,7689.20,percent of total billed charges,
Apply High Sub F H F Init 25,7417876,CDM,361,RC,15275,HCPCS,,,facility,inpatient,,,1991.00000,577.39000,Aetna,First Health,,1628.64,,,,,,,1194.60,1628.64,percent of total billed charges,
Apply High Sub F H F Init 25,7417876,CDM,361,RC,15275,HCPCS,,,facility,outpatient,,,1991.00000,577.39000,Aetna,First Health,,1628.64,,,,,,,215.16,4882.38,percent of total billed charges,
Apply High Sub F H F Addl 25,7417877,CDM,361,RC,15276,HCPCS,,,facility,inpatient,,,1991.00000,577.39000,Aetna,First Health,,1628.64,,,,,,,1194.60,1628.64,percent of total billed charges,
Apply High Sub F H F Addl 25,7417877,CDM,361,RC,15276,HCPCS,,,facility,outpatient,,,1991.00000,577.39000,Aetna,First Health,,1628.64,,,,,,,78.54,2860.00,percent of total billed charges,
Resection Metatarsal,7958301,CDM,361,RC,28140,HCPCS,,,facility,inpatient,,,9559.00000,2772.11000,Aetna,First Health,,7819.26,,,,,,,5735.40,7819.26,percent of total billed charges,
Resection Metatarsal,7958301,CDM,361,RC,28140,HCPCS,,,facility,outpatient,,,9559.00000,2772.11000,Aetna,First Health,,7819.26,,,,,,,1458.60,8660.15,percent of total billed charges,
Amputation Full Toe Rt,8137558,CDM,361,RC,28820,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
Amputation Full Toe Rt,8137558,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
WHC Full toe Amputation Right,8411594,CDM,361,RC,28820,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
WHC Full toe Amputation Right,8411594,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
Full Toe Amputation RT,8411832,CDM,361,RC,28820,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
Full Toe Amputation RT,8411832,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,RT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
Amputation Full Toe Lt,8137557,CDM,361,RC,28820,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
Amputation Full Toe Lt,8137557,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
WHC Full Toe Amputation Left,8411592,CDM,361,RC,28820,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
WHC Full Toe Amputation Left,8411592,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
Full Toe Amputation LT,8411833,CDM,361,RC,28820,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
Full Toe Amputation LT,8411833,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
Amputation Partial Toe Lt,8137556,CDM,361,RC,28825,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
Amputation Partial Toe Lt,8137556,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
WHC Partial Toe Amputation Left,8411588,CDM,361,RC,28825,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
WHC Partial Toe Amputation Left,8411588,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
Partial Toe Amp LT,8411835,CDM,361,RC,28825,HCPCS,,,facility,inpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,5070.00,6912.10,percent of total billed charges,
Partial Toe Amp LT,8411835,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,First Health,LT,6912.10,,,,,,,1458.60,8660.15,percent of total billed charges,
Application Total Contact Cast Lt,7943797,CDM,361,RC,29445,HCPCS,,,facility,inpatient,,,792.00000,229.68000,Aetna,First Health,LT,647.86,,,,,,,475.20,647.86,percent of total billed charges,
Application Total Contact Cast Lt,7943797,CDM,361,RC,29445,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,First Health,LT,647.86,,,,,,,169.62,4908.00,percent of total billed charges,
Application Total Contact Cast Lt,7958322,CDM,361,RC,29445,HCPCS,,,facility,inpatient,,,792.00000,229.68000,Aetna,First Health,LT,647.86,,,,,,,475.20,647.86,percent of total billed charges,
Application Total Contact Cast Lt,7958322,CDM,361,RC,29445,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,First Health,LT,647.86,,,,,,,169.62,4908.00,percent of total billed charges,
Aspiration or Inject Joint Bursa,8137560,CDM,361,RC,20605,HCPCS,,,facility,inpatient,,,2533.00000,734.57000,Aetna,First Health,,2071.99,,,,,,,1519.80,2071.99,percent of total billed charges,
Aspiration or Inject Joint Bursa,8137560,CDM,361,RC,20605,HCPCS,,,facility,outpatient,,,2533.00000,734.57000,Aetna,First Health,,2071.99,,,,,,,172.26,2860.00,percent of total billed charges,
Tangential Biopsy Of Skin Single Lesion,8153919,CDM,361,RC,11102,HCPCS,,,facility,inpatient,,,1390.00000,403.10000,Aetna,First Health,,1137.02,,,,,,,834.00,1137.02,percent of total billed charges,
Tangential Biopsy Of Skin Single Lesion,8153919,CDM,361,RC,11102,HCPCS,,,facility,outpatient,,,1390.00000,403.10000,Aetna,First Health,,1137.02,,,,,,,174.47,2860.00,percent of total billed charges,
WHC Tangential Biopsy Single Lesion,8156015,CDM,361,RC,11102,HCPCS,,,facility,inpatient,,,1390.00000,403.10000,Aetna,First Health,,1137.02,,,,,,,834.00,1137.02,percent of total billed charges,
WHC Tangential Biopsy Single Lesion,8156015,CDM,361,RC,11102,HCPCS,,,facility,outpatient,,,1390.00000,403.10000,Aetna,First Health,,1137.02,,,,,,,174.47,2860.00,percent of total billed charges,
Tangential Biopsy Of Skin Each Addl,8153925,CDM,361,RC,11103,HCPCS,,,facility,inpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,208.20,283.85,percent of total billed charges,
Tangential Biopsy Of Skin Each Addl,8153925,CDM,361,RC,11103,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,125.09,2860.00,percent of total billed charges,
WHC Tangential Biopsy Addl Lesion,8156017,CDM,361,RC,11103,HCPCS,,,facility,inpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,208.20,283.85,percent of total billed charges,
WHC Tangential Biopsy Addl Lesion,8156017,CDM,361,RC,11103,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,125.09,2860.00,percent of total billed charges,
Punch Biopsy Of Skin Single Lesion,8153931,CDM,361,RC,11104,HCPCS,,,facility,inpatient,,,1432.00000,415.28000,Aetna,First Health,,1171.38,,,,,,,859.20,1171.38,percent of total billed charges,
Punch Biopsy Of Skin Single Lesion,8153931,CDM,361,RC,11104,HCPCS,,,facility,outpatient,,,1432.00000,415.28000,Aetna,First Health,,1171.38,,,,,,,315.00,2860.00,percent of total billed charges,
WHC Punch Biopsy Of Skin Single Lesion,8156019,CDM,361,RC,11104,HCPCS,,,facility,inpatient,,,1432.00000,415.28000,Aetna,First Health,,1171.38,,,,,,,859.20,1171.38,percent of total billed charges,
WHC Punch Biopsy Of Skin Single Lesion,8156019,CDM,361,RC,11104,HCPCS,,,facility,outpatient,,,1432.00000,415.28000,Aetna,First Health,,1171.38,,,,,,,315.00,2860.00,percent of total billed charges,
Punch Biopsy Of Skin Ea Addl,8153937,CDM,361,RC,11105,HCPCS,,,facility,inpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,208.20,283.85,percent of total billed charges,
Punch Biopsy Of Skin Ea Addl,8153937,CDM,361,RC,11105,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,125.09,2860.00,percent of total billed charges,
WHC Punch Biopsy Of Skin Each Addl,8156021,CDM,361,RC,11105,HCPCS,,,facility,inpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,208.20,283.85,percent of total billed charges,
WHC Punch Biopsy Of Skin Each Addl,8156021,CDM,361,RC,11105,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,125.09,2860.00,percent of total billed charges,
Incisional Biopsy Of Skin Single Lesion,8153950,CDM,361,RC,11106,HCPCS,,,facility,inpatient,,,1867.00000,541.43000,Aetna,First Health,,1527.21,,,,,,,1120.20,1527.21,percent of total billed charges,
Incisional Biopsy Of Skin Single Lesion,8153950,CDM,361,RC,11106,HCPCS,,,facility,outpatient,,,1867.00000,541.43000,Aetna,First Health,,1527.21,,,,,,,537.48,2860.00,percent of total billed charges,
WHC Incisional Bx Of Skin Single Lesion,8156023,CDM,361,RC,11106,HCPCS,,,facility,inpatient,,,1867.00000,541.43000,Aetna,First Health,,1527.21,,,,,,,1120.20,1527.21,percent of total billed charges,
WHC Incisional Bx Of Skin Single Lesion,8156023,CDM,361,RC,11106,HCPCS,,,facility,outpatient,,,1867.00000,541.43000,Aetna,First Health,,1527.21,,,,,,,537.48,2860.00,percent of total billed charges,
Incisional Biopsy Of Skin Ea Addl,8153956,CDM,361,RC,11107,HCPCS,,,facility,inpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,208.20,283.85,percent of total billed charges,
Incisional Biopsy Of Skin Ea Addl,8153956,CDM,361,RC,11107,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,125.09,2860.00,percent of total billed charges,
WHC Incisional Bx Of Skin Each Addl,8156025,CDM,361,RC,11107,HCPCS,,,facility,inpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,208.20,283.85,percent of total billed charges,
WHC Incisional Bx Of Skin Each Addl,8156025,CDM,361,RC,11107,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,First Health,,283.85,,,,,,,125.09,2860.00,percent of total billed charges,
Apply High Sub Feet Addl 100,8411851,CDM,361,RC,15278,HCPCS,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Apply High Sub Feet Addl 100,8411851,CDM,361,RC,15278,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,215.16,3926.40,percent of total billed charges,
WHC I and D of hematoma seroma or fluid collection,8411602,CDM,361,RC,10140,HCPCS,,,facility,inpatient,,,3329.00000,965.41000,Aetna,First Health,,2723.12,,,,,,,1997.40,2723.12,percent of total billed charges,
WHC I and D of hematoma seroma or fluid collection,8411602,CDM,361,RC,10140,HCPCS,,,facility,outpatient,,,3329.00000,965.41000,Aetna,First Health,,2723.12,,,,,,,866.58,4324.56,percent of total billed charges,
I and D Hematoma,8411852,CDM,361,RC,10140,HCPCS,,,facility,inpatient,,,3329.00000,965.41000,Aetna,First Health,,2723.12,,,,,,,1997.40,2723.12,percent of total billed charges,
I and D Hematoma,8411852,CDM,361,RC,10140,HCPCS,,,facility,outpatient,,,3329.00000,965.41000,Aetna,First Health,,2723.12,,,,,,,866.58,4324.56,percent of total billed charges,
WHC Paring cutting benign hyperkeratotic lesion,8411604,CDM,361,RC,11055,HCPCS,,,facility,inpatient,,,520.00000,150.80000,Aetna,First Health,,425.36,,,,,,,312.00,425.36,percent of total billed charges,
WHC Paring cutting benign hyperkeratotic lesion,8411604,CDM,361,RC,11055,HCPCS,,,facility,outpatient,,,520.00000,150.80000,Aetna,First Health,,425.36,,,,,,,58.08,2860.00,percent of total billed charges,
Trim Skin Lesion,8411854,CDM,361,RC,11055,HCPCS,,,facility,inpatient,,,520.00000,150.80000,Aetna,First Health,,425.36,,,,,,,312.00,425.36,percent of total billed charges,
Trim Skin Lesion,8411854,CDM,361,RC,11055,HCPCS,,,facility,outpatient,,,520.00000,150.80000,Aetna,First Health,,425.36,,,,,,,58.08,2860.00,percent of total billed charges,
WHC Pare cut benign hyperkeratotic les 2 to 4,8411606,CDM,361,RC,11056,HCPCS,,,facility,inpatient,,,665.00000,192.85000,Aetna,First Health,,543.97,,,,,,,399.00,543.97,percent of total billed charges,
WHC Pare cut benign hyperkeratotic les 2 to 4,8411606,CDM,361,RC,11056,HCPCS,,,facility,outpatient,,,665.00000,192.85000,Aetna,First Health,,543.97,,,,,,,58.08,2860.00,percent of total billed charges,
Trim Skin Lesion 2 to 4,8411855,CDM,361,RC,11056,HCPCS,,,facility,inpatient,,,665.00000,192.85000,Aetna,First Health,,543.97,,,,,,,399.00,543.97,percent of total billed charges,
Trim Skin Lesion 2 to 4,8411855,CDM,361,RC,11056,HCPCS,,,facility,outpatient,,,665.00000,192.85000,Aetna,First Health,,543.97,,,,,,,58.08,2860.00,percent of total billed charges,
Avul of Nail Plate Add On,8411620,CDM,361,RC,11732,HCPCS,,,facility,inpatient,,,455.00000,131.95000,Aetna,First Health,,372.19,,,,,,,273.00,372.19,percent of total billed charges,
Avul of Nail Plate Add On,8411620,CDM,361,RC,11732,HCPCS,,,facility,outpatient,,,455.00000,131.95000,Aetna,First Health,,372.19,,,,,,,58.08,2860.00,percent of total billed charges,
Avulsion of Nail Plate Add On,8411849,CDM,361,RC,11732,HCPCS,,,facility,inpatient,,,455.00000,131.95000,Aetna,First Health,,372.19,,,,,,,273.00,372.19,percent of total billed charges,
Avulsion of Nail Plate Add On,8411849,CDM,361,RC,11732,HCPCS,,,facility,outpatient,,,455.00000,131.95000,Aetna,First Health,,372.19,,,,,,,58.08,2860.00,percent of total billed charges,
Apply High Sub Feet Initial 100,7958323,CDM,361,RC,15277,HCPCS,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Apply High Sub Feet Initial 100,7958323,CDM,361,RC,15277,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,328.02,4882.38,percent of total billed charges,
Apply High Sub Feet Initial 100,8411850,CDM,361,RC,15277,HCPCS,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Apply High Sub Feet Initial 100,8411850,CDM,361,RC,15277,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,328.02,4882.38,percent of total billed charges,
Apply High Sub Feet Addl 100,7958327,CDM,361,RC,15278,HCPCS,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Apply High Sub Feet Addl 100,7958327,CDM,361,RC,15278,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,215.16,3926.40,percent of total billed charges,
Apply Low Sub Legs Initial 25,8411842,CDM,361,RC,C5271,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,1020.00,1390.60,percent of total billed charges,
Apply Low Sub Legs Initial 25,8411842,CDM,361,RC,C5271,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,315.00,2209.00,percent of total billed charges,
Apply Low Sub Feet Initital 25,8411843,CDM,361,RC,C5275,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,1020.00,1390.60,percent of total billed charges,
Apply Low Sub Feet Initital 25,8411843,CDM,361,RC,C5275,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,315.00,2209.00,percent of total billed charges,
Apply Low Sub Legs Addl 25,8411841,CDM,361,RC,C5272,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,1020.00,1390.60,percent of total billed charges,
Apply Low Sub Legs Addl 25,8411841,CDM,361,RC,C5272,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,First Health,,1390.60,,,,,,,315.00,1717.00,percent of total billed charges,
Apply Low Sub Legs Initial 100,8411848,CDM,361,RC,C5273,HCPCS,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Apply Low Sub Legs Initial 100,8411848,CDM,361,RC,C5273,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,1730.40,4882.38,percent of total billed charges,
Apply Low Sub Feet Initial 100,8411846,CDM,361,RC,C5277,HCPCS,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Apply Low Sub Feet Initial 100,8411846,CDM,361,RC,C5277,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,315.00,3926.40,percent of total billed charges,
Apply Low Sub Legs Addl 100,8411847,CDM,361,RC,C5274,HCPCS,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Apply Low Sub Legs Addl 100,8411847,CDM,361,RC,C5274,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,315.00,3926.40,percent of total billed charges,
Apply Low Sub Feet Addl 100,8411845,CDM,361,RC,C5278,HCPCS,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Apply Low Sub Feet Addl 100,8411845,CDM,361,RC,C5278,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,315.00,3926.40,percent of total billed charges,
Dress Debride P Thick Burn L,8411784,CDM,361,RC,16030,HCPCS,,,facility,inpatient,,,1034.00000,299.86000,Aetna,First Health,,845.81,,,,,,,620.40,845.81,percent of total billed charges,
Dress Debride P Thick Burn L,8411784,CDM,361,RC,16030,HCPCS,,,facility,outpatient,,,1034.00000,299.86000,Aetna,First Health,,845.81,,,,,,,99.00,2860.00,percent of total billed charges,
WHC Biopsy of Bone,8411608,CDM,361,RC,20220,HCPCS,,,facility,inpatient,,,4250.00000,1232.50000,Aetna,First Health,,3476.50,,,,,,,2550.00,3476.50,percent of total billed charges,
WHC Biopsy of Bone,8411608,CDM,361,RC,20220,HCPCS,,,facility,outpatient,,,4250.00000,1232.50000,Aetna,First Health,,3476.50,,,,,,,545.82,4324.56,percent of total billed charges,
Biopsy of Bone,8411839,CDM,361,RC,20220,HCPCS,,,facility,inpatient,,,4250.00000,1232.50000,Aetna,First Health,,3476.50,,,,,,,2550.00,3476.50,percent of total billed charges,
Biopsy of Bone,8411839,CDM,361,RC,20220,HCPCS,,,facility,outpatient,,,4250.00000,1232.50000,Aetna,First Health,,3476.50,,,,,,,545.82,4324.56,percent of total billed charges,
Remove Foregn Body Simple,8411830,CDM,361,RC,10120,HCPCS,,,facility,inpatient,,,1050.00000,304.50000,Aetna,First Health,,858.90,,,,,,,630.00,858.90,percent of total billed charges,
Remove Foregn Body Simple,8411830,CDM,361,RC,10120,HCPCS,,,facility,outpatient,,,1050.00000,304.50000,Aetna,First Health,,858.90,,,,,,,182.16,2860.00,percent of total billed charges,
Remove Foreign Body Complex,8411831,CDM,361,RC,10121,HCPCS,,,facility,inpatient,,,2524.00000,731.96000,Aetna,First Health,,2064.63,,,,,,,1514.40,2064.63,percent of total billed charges,
Remove Foreign Body Complex,8411831,CDM,361,RC,10121,HCPCS,,,facility,outpatient,,,2524.00000,731.96000,Aetna,First Health,,2064.63,,,,,,,936.91,4324.56,percent of total billed charges,
Deep Muscle Biopsy,9040169,CDM,361,RC,20205,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,4500.00,6135.00,percent of total billed charges,
Deep Muscle Biopsy,9040169,CDM,361,RC,20205,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,1122.66,7639.06,percent of total billed charges,
Deep Muscle Biopsy,9043763,CDM,361,RC,20205,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,4500.00,6135.00,percent of total billed charges,
Deep Muscle Biopsy,9043763,CDM,361,RC,20205,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,First Health,,6135.00,,,,,,,1122.66,7639.06,percent of total billed charges,
WHC Excision of Benign Lesion scalp neck hands feet,9021658,CDM,361,RC,11421,HCPCS,,,facility,inpatient,,,4500.00000,1305.00000,Aetna,First Health,,3681.00,,,,,,,2700.00,3681.00,percent of total billed charges,
WHC Excision of Benign Lesion scalp neck hands feet,9021658,CDM,361,RC,11421,HCPCS,,,facility,outpatient,,,4500.00000,1305.00000,Aetna,First Health,,3681.00,,,,,,,545.82,3681.00,percent of total billed charges,
WHC Excision Benign Lesion trunk arm legs,9022163,CDM,361,RC,11406,HCPCS,,,facility,inpatient,,,4500.00000,1305.00000,Aetna,First Health,,3681.00,,,,,,,2700.00,3681.00,percent of total billed charges,
WHC Excision Benign Lesion trunk arm legs,9022163,CDM,361,RC,11406,HCPCS,,,facility,outpatient,,,4500.00000,1305.00000,Aetna,First Health,,3681.00,,,,,,,1122.66,4324.56,percent of total billed charges,
WHC Excision Benign Lesion,9024453,CDM,361,RC,11406,HCPCS,,,facility,inpatient,,,4500.00000,1305.00000,Aetna,First Health,,3681.00,,,,,,,2700.00,3681.00,percent of total billed charges,
WHC Excision Benign Lesion,9024453,CDM,361,RC,11406,HCPCS,,,facility,outpatient,,,4500.00000,1305.00000,Aetna,First Health,,3681.00,,,,,,,1122.66,4324.56,percent of total billed charges,
WHC Excision Malignant Lesion Trunk Arms Legs,9010174,CDM,361,RC,11604,HCPCS,,,facility,inpatient,,,4500.00000,1305.00000,Aetna,First Health,,3681.00,,,,,,,2700.00,3681.00,percent of total billed charges,
WHC Excision Malignant Lesion Trunk Arms Legs,9010174,CDM,361,RC,11604,HCPCS,,,facility,outpatient,,,4500.00000,1305.00000,Aetna,First Health,,3681.00,,,,,,,545.82,3681.00,percent of total billed charges,
TPA Administation Or Declot,599448,CDM,361,RC,,,,,facility,inpatient,,,707.00000,205.03000,Aetna,First Health,,578.33,,,,,,,424.20,578.33,percent of total billed charges,
TPA Administation Or Declot,599448,CDM,361,RC,,,,,facility,outpatient,,,707.00000,205.03000,Aetna,First Health,,578.33,,,,,,,254.87,4908.00,percent of total billed charges,
TPA Administation Or Declot,7902208,CDM,361,RC,,,,,facility,inpatient,,,707.00000,205.03000,Aetna,First Health,,578.33,,,,,,,424.20,578.33,percent of total billed charges,
TPA Administation Or Declot,7902208,CDM,361,RC,,,,,facility,outpatient,,,707.00000,205.03000,Aetna,First Health,,578.33,,,,,,,254.87,4908.00,percent of total billed charges,
TPA Administation Or Declot,7902275,CDM,361,RC,,,,,facility,inpatient,,,707.00000,205.03000,Aetna,First Health,,578.33,,,,,,,424.20,578.33,percent of total billed charges,
TPA Administation Or Declot,7902275,CDM,361,RC,,,,,facility,outpatient,,,707.00000,205.03000,Aetna,First Health,,578.33,,,,,,,254.87,4908.00,percent of total billed charges,
LITHOTRIPSY,7720029,CDM,361,RC,,,,,facility,inpatient,,,16035.00000,4650.15000,Aetna,First Health,,13116.63,,,,,,,9621.00,13116.63,percent of total billed charges,
LITHOTRIPSY,7720029,CDM,361,RC,,,,,facility,outpatient,,,16035.00000,4650.15000,Aetna,First Health,,13116.63,,,,,,,4610.00,13116.63,percent of total billed charges,
RA Epidural Injection,613706,CDM,361,RC,,,,,facility,inpatient,,,2761.00000,800.69000,Aetna,First Health,,2258.50,,,,,,,1656.60,2258.50,percent of total billed charges,
RA Epidural Injection,613706,CDM,361,RC,,,,,facility,outpatient,,,2761.00000,800.69000,Aetna,First Health,,2258.50,,,,,,,995.34,4908.00,percent of total billed charges,
AN Ablation Bone Tumor,8147143,CDM,361,RC,,,,,facility,inpatient,,,7428.00000,2154.12000,Aetna,First Health,,6076.10,,,,,,,4456.80,6076.10,percent of total billed charges,
AN Ablation Bone Tumor,8147143,CDM,361,RC,,,,,facility,outpatient,,,7428.00000,2154.12000,Aetna,First Health,,6076.10,,,,,,,2677.79,6076.10,percent of total billed charges,
Injection for Hysterosalpingogram,8001040,CDM,361,RC,,,,,facility,inpatient,,,1451.00000,420.79000,Aetna,First Health,,1186.92,,,,,,,870.60,1186.92,percent of total billed charges,
Injection for Hysterosalpingogram,8001040,CDM,361,RC,,,,,facility,outpatient,,,1451.00000,420.79000,Aetna,First Health,,1186.92,,,,,,,523.09,4908.00,percent of total billed charges,
Injection for Arthrogram,8001041,CDM,361,RC,,,,,facility,inpatient,,,1451.00000,420.79000,Aetna,First Health,,1186.92,,,,,,,870.60,1186.92,percent of total billed charges,
Injection for Arthrogram,8001041,CDM,361,RC,,,,,facility,outpatient,,,1451.00000,420.79000,Aetna,First Health,,1186.92,,,,,,,523.09,4908.00,percent of total billed charges,
Injection for Procedure,8001042,CDM,361,RC,,,,,facility,inpatient,,,1451.00000,420.79000,Aetna,First Health,,1186.92,,,,,,,870.60,1186.92,percent of total billed charges,
Injection for Procedure,8001042,CDM,361,RC,,,,,facility,outpatient,,,1451.00000,420.79000,Aetna,First Health,,1186.92,,,,,,,523.09,4908.00,percent of total billed charges,
RA Myelogram Cervical,9062217,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
RA Myelogram Cervical,9062217,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
RA Myelogram Thoracic,9062220,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
RA Myelogram Thoracic,9062220,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
RA Myelogram Lumbar,9062219,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
RA Myelogram Lumbar,9062219,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
RA Myelogram Cervical Thoracic,9062218,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
RA Myelogram Cervical Thoracic,9062218,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
RA Myelogram Thoracic Lumbar,9062221,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
RA Myelogram Thoracic Lumbar,9062221,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
RA Myelogram Cervical Lumbar,9064201,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
RA Myelogram Cervical Lumbar,9064201,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
RA Myelogram Total Spine,9064202,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
RA Myelogram Total Spine,9064202,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
RA Lumbar Puncture,624491,CDM,361,RC,,,,,facility,inpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,1242.60,1694.08,percent of total billed charges,
RA Lumbar Puncture,624491,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,746.60,4908.00,percent of total billed charges,
AN Axillary Biopsy Right,8001069,CDM,361,RC,,,,,facility,inpatient,,,3000.00000,870.00000,Aetna,First Health,,2454.00,,,,,,,1800.00,2454.00,percent of total billed charges,
AN Axillary Biopsy Right,8001069,CDM,361,RC,,,,,facility,outpatient,,,3000.00000,870.00000,Aetna,First Health,,2454.00,,,,,,,1081.50,4908.00,percent of total billed charges,
Each Additional Lesion Fine Needle,8154200,CDM,361,RC,,,,,facility,inpatient,,,3317.00000,961.93000,Aetna,First Health,,2713.31,,,,,,,1990.20,2713.31,percent of total billed charges,
Each Additional Lesion Fine Needle,8154200,CDM,361,RC,,,,,facility,outpatient,,,3317.00000,961.93000,Aetna,First Health,,2713.31,,,,,,,1195.78,4908.00,percent of total billed charges,
RA Gall Bladder Operative,613785,CDM,361,RC,,,,,facility,inpatient,,,1089.00000,315.81000,Aetna,First Health,,890.80,,,,,,,653.40,890.80,percent of total billed charges,
RA Gall Bladder Operative,613785,CDM,361,RC,,,,,facility,outpatient,,,1089.00000,315.81000,Aetna,First Health,,890.80,,,,,,,392.58,4908.00,percent of total billed charges,
AN Percutaneous Cholangiogram,2888832,CDM,361,RC,,,,,facility,inpatient,,,4374.00000,1268.46000,Aetna,First Health,,3577.93,,,,,,,2624.40,3577.93,percent of total billed charges,
AN Percutaneous Cholangiogram,2888832,CDM,361,RC,,,,,facility,outpatient,,,4374.00000,1268.46000,Aetna,First Health,,3577.93,,,,,,,1576.83,4908.00,percent of total billed charges,
AN Nephrostogram,2888831,CDM,361,RC,,,,,facility,inpatient,,,5254.00000,1523.66000,Aetna,First Health,,4297.77,,,,,,,3152.40,4297.77,percent of total billed charges,
AN Nephrostogram,2888831,CDM,361,RC,,,,,facility,outpatient,,,5254.00000,1523.66000,Aetna,First Health,,4297.77,,,,,,,1894.07,4908.00,percent of total billed charges,
Radiologic Guidance,8001074,CDM,361,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
Radiologic Guidance,8001074,CDM,361,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,4908.00,percent of total billed charges,
AN Bone Biopsy,7918032,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
AN Bone Biopsy,7918032,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
AN Biopsy Abdominal Mass,3661971,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
AN Biopsy Abdominal Mass,3661971,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Biopsy Renal,9198582,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Biopsy Renal,9198582,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Biopsy Other,9196961,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Biopsy Other,9196961,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
SONO GUIDED BREAST LOC ADDL SITE,6043878,CDM,361,RC,,,,,facility,inpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1795.20,2447.46,percent of total billed charges,
SONO GUIDED BREAST LOC ADDL SITE,6043878,CDM,361,RC,,,,,facility,outpatient,,,2992.00000,867.68000,Aetna,First Health,,2447.46,,,,,,,1078.62,4908.00,percent of total billed charges,
Sono Breast Limited Bilateral,654595,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
Sono Breast Limited Bilateral,654595,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
SONO GUIDED BREAST BIOPSY ADDL,6043876,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
SONO GUIDED BREAST BIOPSY ADDL,6043876,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
Sono Guided Breast Localization,654590,CDM,361,RC,,,,,facility,inpatient,,,3863.00000,1120.27000,Aetna,First Health,,3159.93,,,,,,,2317.80,3159.93,percent of total billed charges,
Sono Guided Breast Localization,654590,CDM,361,RC,,,,,facility,outpatient,,,3863.00000,1120.27000,Aetna,First Health,,3159.93,,,,,,,1392.61,4908.00,percent of total billed charges,
SONO GUIDED MAMMOTOME BIOPSY ADDL,6043874,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
SONO GUIDED MAMMOTOME BIOPSY ADDL,6043874,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
Sono Guide Inject Tendon Ligament Left,7991406,CDM,361,RC,,,,,facility,inpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,1242.60,1694.08,percent of total billed charges,
Sono Guide Inject Tendon Ligament Left,7991406,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,746.60,4908.00,percent of total billed charges,
Sono Guide Inject Tendon Ligament Right,7991410,CDM,361,RC,,,,,facility,inpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,1242.60,1694.08,percent of total billed charges,
Sono Guide Inject Tendon Ligament Right,7991410,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,746.60,4908.00,percent of total billed charges,
Sono Guided Breast Localization Right,8181312,CDM,361,RC,,,,,facility,inpatient,,,4211.00000,1221.19000,Aetna,First Health,,3444.60,,,,,,,2526.60,3444.60,percent of total billed charges,
Sono Guided Breast Localization Right,8181312,CDM,361,RC,,,,,facility,outpatient,,,4211.00000,1221.19000,Aetna,First Health,,3444.60,,,,,,,1518.07,4908.00,percent of total billed charges,
Sono Guided Breast Localization Left,8181320,CDM,361,RC,,,,,facility,inpatient,,,4211.00000,1221.19000,Aetna,First Health,,3444.60,,,,,,,2526.60,3444.60,percent of total billed charges,
Sono Guided Breast Localization Left,8181320,CDM,361,RC,,,,,facility,outpatient,,,4211.00000,1221.19000,Aetna,First Health,,3444.60,,,,,,,1518.07,4908.00,percent of total billed charges,
Sono Guided Breast Localization Bilateral,8181322,CDM,361,RC,,,,,facility,inpatient,,,8422.00000,2442.38000,Aetna,First Health,,6889.20,,,,,,,5053.20,6889.20,percent of total billed charges,
Sono Guided Breast Localization Bilateral,8181322,CDM,361,RC,,,,,facility,outpatient,,,8422.00000,2442.38000,Aetna,First Health,,6889.20,,,,,,,3036.13,6889.20,percent of total billed charges,
Sono Amniocentesis,7913740,CDM,361,RC,,,,,facility,inpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,697.20,950.52,percent of total billed charges,
Sono Amniocentesis,7913740,CDM,361,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,418.90,4908.00,percent of total billed charges,
Sono Cordocentesis,7913744,CDM,361,RC,,,,,facility,inpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,697.20,950.52,percent of total billed charges,
Sono Cordocentesis,7913744,CDM,361,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,418.90,4908.00,percent of total billed charges,
Sono Guided Asp Inj Small Joint LT,9092776,CDM,361,RC,,,,,facility,inpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,1198.20,1633.55,percent of total billed charges,
Sono Guided Asp Inj Small Joint LT,9092776,CDM,361,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,719.92,4908.00,percent of total billed charges,
Sono Guided Asp Inj Small Joint RT,9092777,CDM,361,RC,,,,,facility,inpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,1198.20,1633.55,percent of total billed charges,
Sono Guided Asp Inj Small Joint RT,9092777,CDM,361,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,719.92,4908.00,percent of total billed charges,
Sono Guided Asp/Inj Intermediate Right,9094377,CDM,361,RC,,,,,facility,inpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,1198.20,1633.55,percent of total billed charges,
Sono Guided Asp/Inj Intermediate Right,9094377,CDM,361,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,719.92,4908.00,percent of total billed charges,
Sono Guided Asp Inj Major Joint Left,9092774,CDM,361,RC,,,,,facility,inpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,1198.20,1633.55,percent of total billed charges,
Sono Guided Asp Inj Major Joint Left,9092774,CDM,361,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,719.92,4908.00,percent of total billed charges,
Sono Guided Asp Inj Major Joint RT,9092775,CDM,361,RC,,,,,facility,inpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,1198.20,1633.55,percent of total billed charges,
Sono Guided Asp Inj Major Joint RT,9092775,CDM,361,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,First Health,,1633.55,,,,,,,719.92,4908.00,percent of total billed charges,
Sono Guided Addl Lesion Fine Needle,8154198,CDM,361,RC,,,,,facility,inpatient,,,3682.00000,1067.78000,Aetna,First Health,,3011.88,,,,,,,2209.20,3011.88,percent of total billed charges,
Sono Guided Addl Lesion Fine Needle,8154198,CDM,361,RC,,,,,facility,outpatient,,,3682.00000,1067.78000,Aetna,First Health,,3011.88,,,,,,,1327.36,4908.00,percent of total billed charges,
Sono Guide Injection Tendon Ligament Bilateral,8436137,CDM,361,RC,,,,,facility,inpatient,,,1972.00000,571.88000,Aetna,First Health,,1613.10,,,,,,,1183.20,1613.10,percent of total billed charges,
Sono Guide Injection Tendon Ligament Bilateral,8436137,CDM,361,RC,,,,,facility,outpatient,,,1972.00000,571.88000,Aetna,First Health,,1613.10,,,,,,,710.91,4908.00,percent of total billed charges,
Sono Guided Asp Injection Intermediate Joint Bilateral,9094376,CDM,361,RC,,,,,facility,inpatient,,,1832.00000,531.28000,Aetna,First Health,,1498.58,,,,,,,1099.20,1498.58,percent of total billed charges,
Sono Guided Asp Injection Intermediate Joint Bilateral,9094376,CDM,361,RC,,,,,facility,outpatient,,,1832.00000,531.28000,Aetna,First Health,,1498.58,,,,,,,660.44,4908.00,percent of total billed charges,
Sono Guided Asp Inj Major Joint Left,9094378,CDM,361,RC,,,,,facility,inpatient,,,1832.00000,531.28000,Aetna,First Health,,1498.58,,,,,,,1099.20,1498.58,percent of total billed charges,
Sono Guided Asp Inj Major Joint Left,9094378,CDM,361,RC,,,,,facility,outpatient,,,1832.00000,531.28000,Aetna,First Health,,1498.58,,,,,,,660.44,4908.00,percent of total billed charges,
Sono Guide Inject Tendon Ligament Right,8436172,CDM,361,RC,,,,,facility,inpatient,,,1972.00000,571.88000,Aetna,First Health,,1613.10,,,,,,,1183.20,1613.10,percent of total billed charges,
Sono Guide Inject Tendon Ligament Right,8436172,CDM,361,RC,,,,,facility,outpatient,,,1972.00000,571.88000,Aetna,First Health,,1613.10,,,,,,,710.91,4908.00,percent of total billed charges,
Sono Guided Asp Injection Intermediate Joint Right,8436173,CDM,361,RC,,,,,facility,inpatient,,,1599.00000,463.71000,Aetna,First Health,,1307.98,,,,,,,959.40,1307.98,percent of total billed charges,
Sono Guided Asp Injection Intermediate Joint Right,8436173,CDM,361,RC,,,,,facility,outpatient,,,1599.00000,463.71000,Aetna,First Health,,1307.98,,,,,,,576.44,4908.00,percent of total billed charges,
Sono Guided Asp/Inj Small Joint Left,9094379,CDM,361,RC,,,,,facility,inpatient,,,1832.00000,531.28000,Aetna,First Health,,1498.58,,,,,,,1099.20,1498.58,percent of total billed charges,
Sono Guided Asp/Inj Small Joint Left,9094379,CDM,361,RC,,,,,facility,outpatient,,,1832.00000,531.28000,Aetna,First Health,,1498.58,,,,,,,660.44,4908.00,percent of total billed charges,
Sono Guided Asp Injection Small Joint Right,8436174,CDM,361,RC,,,,,facility,inpatient,,,1900.00000,551.00000,Aetna,First Health,,1554.20,,,,,,,1140.00,1554.20,percent of total billed charges,
Sono Guided Asp Injection Small Joint Right,8436174,CDM,361,RC,,,,,facility,outpatient,,,1900.00000,551.00000,Aetna,First Health,,1554.20,,,,,,,684.95,4908.00,percent of total billed charges,
Sono Guided Asp Injection Major Joint Right,8436175,CDM,361,RC,,,,,facility,inpatient,,,1900.00000,551.00000,Aetna,First Health,,1554.20,,,,,,,1140.00,1554.20,percent of total billed charges,
Sono Guided Asp Injection Major Joint Right,8436175,CDM,361,RC,,,,,facility,outpatient,,,1900.00000,551.00000,Aetna,First Health,,1554.20,,,,,,,684.95,4908.00,percent of total billed charges,
Sono Guided Breast Loc Bilat Pellet,8945730,CDM,361,RC,,,,,facility,inpatient,,,7086.00000,2054.94000,Aetna,First Health,,5796.35,,,,,,,4251.60,5796.35,percent of total billed charges,
Sono Guided Breast Loc Bilat Pellet,8945730,CDM,361,RC,,,,,facility,outpatient,,,7086.00000,2054.94000,Aetna,First Health,,5796.35,,,,,,,2554.50,5796.35,percent of total billed charges,
Sono Guided Breast Loc Left Pellet,8927458,CDM,361,RC,,,,,facility,inpatient,,,4211.00000,1221.19000,Aetna,First Health,,3444.60,,,,,,,2526.60,3444.60,percent of total billed charges,
Sono Guided Breast Loc Left Pellet,8927458,CDM,361,RC,,,,,facility,outpatient,,,4211.00000,1221.19000,Aetna,First Health,,3444.60,,,,,,,1518.07,4908.00,percent of total billed charges,
Sono Guided Breast Loc Right Pellet,8927460,CDM,361,RC,,,,,facility,inpatient,,,3544.00000,1027.76000,Aetna,First Health,,2898.99,,,,,,,2126.40,2898.99,percent of total billed charges,
Sono Guided Breast Loc Right Pellet,8927460,CDM,361,RC,,,,,facility,outpatient,,,3544.00000,1027.76000,Aetna,First Health,,2898.99,,,,,,,1277.61,4908.00,percent of total billed charges,
Sono Guided Breast Biopsy Left,9158474,CDM,361,RC,,,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,1260.00,1717.80,percent of total billed charges,
Sono Guided Breast Biopsy Left,9158474,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,4908.00,percent of total billed charges,
Sono Guided Breast Biopsy Right,9160461,CDM,361,RC,,,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,1260.00,1717.80,percent of total billed charges,
Sono Guided Breast Biopsy Right,9160461,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,4908.00,percent of total billed charges,
Sono Guided Breast Biopsy Bilateral,9160465,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
Sono Guided Breast Biopsy Bilateral,9160465,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
Sono Guided Breast Cyst Aspiration LT,9158489,CDM,361,RC,,,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,1260.00,1717.80,percent of total billed charges,
Sono Guided Breast Cyst Aspiration LT,9158489,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,4908.00,percent of total billed charges,
Sono Guided Breast Cyst Aspiration RT,9158491,CDM,361,RC,,,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,1260.00,1717.80,percent of total billed charges,
Sono Guided Breast Cyst Aspiration RT,9158491,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,4908.00,percent of total billed charges,
Sono Guided Breast Cyst Aspiration Bilat,9158493,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
Sono Guided Breast Cyst Aspiration Bilat,9158493,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
Sono Guided Mammotome Biopsy LT,9160467,CDM,361,RC,,,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,1260.00,1717.80,percent of total billed charges,
Sono Guided Mammotome Biopsy LT,9160467,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,4908.00,percent of total billed charges,
Sono Guided Mammotome Biopsy RT,9160479,CDM,361,RC,,,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,1260.00,1717.80,percent of total billed charges,
Sono Guided Mammotome Biopsy RT,9160479,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,4908.00,percent of total billed charges,
Sono Guided Mammotome Biopsy Bilat,9160481,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
Sono Guided Mammotome Biopsy Bilat,9160481,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
Sono Guided Localization,9198651,CDM,361,RC,,,,,facility,inpatient,,,1332.00000,386.28000,Aetna,First Health,,1089.58,,,,,,,799.20,1089.58,percent of total billed charges,
Sono Guided Localization,9198651,CDM,361,RC,,,,,facility,outpatient,,,1332.00000,386.28000,Aetna,First Health,,1089.58,,,,,,,480.19,4908.00,percent of total billed charges,
Sono Guided Thoracentesis,9198606,CDM,361,RC,,,,,facility,inpatient,,,4208.00000,1220.32000,Aetna,First Health,,3442.14,,,,,,,2524.80,3442.14,percent of total billed charges,
Sono Guided Thoracentesis,9198606,CDM,361,RC,,,,,facility,outpatient,,,4208.00000,1220.32000,Aetna,First Health,,3442.14,,,,,,,1516.98,4908.00,percent of total billed charges,
Sono Paracentesis with Guidance,614061,CDM,361,RC,,,,,facility,inpatient,,,3960.00000,1148.40000,Aetna,First Health,,3239.28,,,,,,,2376.00,3239.28,percent of total billed charges,
Sono Paracentesis with Guidance,614061,CDM,361,RC,,,,,facility,outpatient,,,3960.00000,1148.40000,Aetna,First Health,,3239.28,,,,,,,1427.58,4908.00,percent of total billed charges,
Sono Guided Paracentesis,9196891,CDM,361,RC,,,,,facility,inpatient,,,4197.00000,1217.13000,Aetna,First Health,,3433.15,,,,,,,2518.20,3433.15,percent of total billed charges,
Sono Guided Paracentesis,9196891,CDM,361,RC,,,,,facility,outpatient,,,4197.00000,1217.13000,Aetna,First Health,,3433.15,,,,,,,1513.02,4908.00,percent of total billed charges,
Sono Guided Thyroid Needle Biopsy,9196929,CDM,361,RC,,,,,facility,inpatient,,,4908.00000,1423.32000,Aetna,First Health,,4014.74,,,,,,,2944.80,4014.74,percent of total billed charges,
Sono Guided Thyroid Needle Biopsy,9196929,CDM,361,RC,,,,,facility,outpatient,,,4908.00000,1423.32000,Aetna,First Health,,4014.74,,,,,,,1769.33,4908.00,percent of total billed charges,
Biopsy,9198641,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Biopsy,9198641,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Biopsy Pancreas,9198542,CDM,361,RC,,,,,facility,inpatient,,,2593.00000,751.97000,Aetna,First Health,,2121.07,,,,,,,1555.80,2121.07,percent of total billed charges,
Biopsy Pancreas,9198542,CDM,361,RC,,,,,facility,outpatient,,,2593.00000,751.97000,Aetna,First Health,,2121.07,,,,,,,934.78,4908.00,percent of total billed charges,
Biopsy Abdominal Mass,9196946,CDM,361,RC,,,,,facility,inpatient,,,2593.00000,751.97000,Aetna,First Health,,2121.07,,,,,,,1555.80,2121.07,percent of total billed charges,
Biopsy Abdominal Mass,9196946,CDM,361,RC,,,,,facility,outpatient,,,2593.00000,751.97000,Aetna,First Health,,2121.07,,,,,,,934.78,4908.00,percent of total billed charges,
Biopsy Renal Mass,9196918,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Biopsy Renal Mass,9196918,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Biopsy Renal,3661953,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Biopsy Renal,3661953,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
AN Biopsy Other,3661967,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
AN Biopsy Other,3661967,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
AN Bone Marrow Biopsy,7918036,CDM,361,RC,,,,,facility,inpatient,,,4656.00000,1350.24000,Aetna,First Health,,3808.61,,,,,,,2793.60,3808.61,percent of total billed charges,
AN Bone Marrow Biopsy,7918036,CDM,361,RC,,,,,facility,outpatient,,,4656.00000,1350.24000,Aetna,First Health,,3808.61,,,,,,,1678.49,4908.00,percent of total billed charges,
AN Biopsy Bone Marrow,8001038,CDM,361,RC,,,,,facility,inpatient,,,4656.00000,1350.24000,Aetna,First Health,,3808.61,,,,,,,2793.60,3808.61,percent of total billed charges,
AN Biopsy Bone Marrow,8001038,CDM,361,RC,,,,,facility,outpatient,,,4656.00000,1350.24000,Aetna,First Health,,3808.61,,,,,,,1678.49,4908.00,percent of total billed charges,
CT Guided Pleura Biopsy,3661955,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
CT Guided Pleura Biopsy,3661955,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
CT Guided Addl Lesion Fine Needle,8154202,CDM,361,RC,,,,,facility,inpatient,,,3926.00000,1138.54000,Aetna,First Health,,3211.47,,,,,,,2355.60,3211.47,percent of total billed charges,
CT Guided Addl Lesion Fine Needle,8154202,CDM,361,RC,,,,,facility,outpatient,,,3926.00000,1138.54000,Aetna,First Health,,3211.47,,,,,,,1415.32,4908.00,percent of total billed charges,
Biopsy Bone,3661965,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Biopsy Bone,3661965,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
CT Guided Lung Biopsy,3661959,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
CT Guided Lung Biopsy,3661959,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Biopsy Liver,3661961,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Biopsy Liver,3661961,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Biopsy Pancreas,3661957,CDM,361,RC,,,,,facility,inpatient,,,3000.00000,870.00000,Aetna,First Health,,2454.00,,,,,,,1800.00,2454.00,percent of total billed charges,
Biopsy Pancreas,3661957,CDM,361,RC,,,,,facility,outpatient,,,3000.00000,870.00000,Aetna,First Health,,2454.00,,,,,,,1081.50,4908.00,percent of total billed charges,
Biopsy Renal Mass,3661951,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Biopsy Renal Mass,3661951,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
MR Guided Mammotome Biopsy,3661945,CDM,361,RC,,,,,facility,inpatient,,,6889.00000,1997.81000,Aetna,First Health,,5635.20,,,,,,,4133.40,5635.20,percent of total billed charges,
MR Guided Mammotome Biopsy,3661945,CDM,361,RC,,,,,facility,outpatient,,,6889.00000,1997.81000,Aetna,First Health,,5635.20,,,,,,,2483.48,5635.20,percent of total billed charges,
MAMMO GUIDED BREAST LOC ADDL SITE,6043882,CDM,361,RC,,,,,facility,inpatient,,,4075.00000,1181.75000,Aetna,First Health,,3333.35,,,,,,,2445.00,3333.35,percent of total billed charges,
MAMMO GUIDED BREAST LOC ADDL SITE,6043882,CDM,361,RC,,,,,facility,outpatient,,,4075.00000,1181.75000,Aetna,First Health,,3333.35,,,,,,,1469.04,4908.00,percent of total billed charges,
MAMMO GUIDED BREAST BIOPSY ADDL,6043880,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
MAMMO GUIDED BREAST BIOPSY ADDL,6043880,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
MM Biopsy Breast Stereotactic Left,9158515,CDM,361,RC,,,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,1260.00,1717.80,percent of total billed charges,
MM Biopsy Breast Stereotactic Left,9158515,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,4908.00,percent of total billed charges,
MM Biopsy Breast Stereotactic Right,9162392,CDM,361,RC,,,,,facility,inpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,1260.00,1717.80,percent of total billed charges,
MM Biopsy Breast Stereotactic Right,9162392,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,First Health,,1717.80,,,,,,,757.05,4908.00,percent of total billed charges,
MM Biopsy Breast Stereotactic Bilat,9162394,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
MM Biopsy Breast Stereotactic Bilat,9162394,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
MM Preop Breast Localization Left,9162400,CDM,361,RC,,,,,facility,inpatient,,,4211.00000,1221.19000,Aetna,First Health,,3444.60,,,,,,,2526.60,3444.60,percent of total billed charges,
MM Preop Breast Localization Left,9162400,CDM,361,RC,,,,,facility,outpatient,,,4211.00000,1221.19000,Aetna,First Health,,3444.60,,,,,,,1518.07,4908.00,percent of total billed charges,
MM Preop Breast Localization Right,9162401,CDM,361,RC,,,,,facility,inpatient,,,4211.00000,1221.19000,Aetna,First Health,,3444.60,,,,,,,2526.60,3444.60,percent of total billed charges,
MM Preop Breast Localization Right,9162401,CDM,361,RC,,,,,facility,outpatient,,,4211.00000,1221.19000,Aetna,First Health,,3444.60,,,,,,,1518.07,4908.00,percent of total billed charges,
MM Preop Breast Localization Bilat,9164395,CDM,361,RC,,,,,facility,inpatient,,,8422.00000,2442.38000,Aetna,First Health,,6889.20,,,,,,,5053.20,6889.20,percent of total billed charges,
MM Preop Breast Localization Bilat,9164395,CDM,361,RC,,,,,facility,outpatient,,,8422.00000,2442.38000,Aetna,First Health,,6889.20,,,,,,,3036.13,6889.20,percent of total billed charges,
AN Kyphoplasty Each Add Vertebrae,1053806,CDM,361,RC,,,,,facility,inpatient,,,17570.00000,5095.30000,Aetna,First Health,,14372.26,,,,,,,10542.00,14372.26,percent of total billed charges,
AN Kyphoplasty Each Add Vertebrae,1053806,CDM,361,RC,,,,,facility,outpatient,,,17570.00000,5095.30000,Aetna,First Health,,14372.26,,,,,,,4610.00,14372.26,percent of total billed charges,
AN Ablation Bone,3661989,CDM,361,RC,,,,,facility,inpatient,,,8178.00000,2371.62000,Aetna,First Health,,6689.60,,,,,,,4906.80,6689.60,percent of total billed charges,
AN Ablation Bone,3661989,CDM,361,RC,,,,,facility,outpatient,,,8178.00000,2371.62000,Aetna,First Health,,6689.60,,,,,,,2948.17,6689.60,percent of total billed charges,
AFC GENERIC ADD-ON,9076525,CDM,361,RC,,,,,facility,inpatient,,,8178.00000,2371.62000,Aetna,First Health,,6689.60,,,,,,,4906.80,6689.60,percent of total billed charges,
AFC GENERIC ADD-ON,9076525,CDM,361,RC,,,,,facility,outpatient,,,8178.00000,2371.62000,Aetna,First Health,,6689.60,,,,,,,2948.17,6689.60,percent of total billed charges,
AN Ablation Liver,3661991,CDM,361,RC,,,,,facility,inpatient,,,8178.00000,2371.62000,Aetna,First Health,,6689.60,,,,,,,4906.80,6689.60,percent of total billed charges,
AN Ablation Liver,3661991,CDM,361,RC,,,,,facility,outpatient,,,8178.00000,2371.62000,Aetna,First Health,,6689.60,,,,,,,2948.17,6689.60,percent of total billed charges,
AN Ablation Renal Bilateral,3661995,CDM,361,RC,,,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,10800.00,14724.00,percent of total billed charges,
AN Ablation Renal Bilateral,3661995,CDM,361,RC,,,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,4610.00,14724.00,percent of total billed charges,
AN Port A Cath Removal,2044835,CDM,361,RC,,,,,facility,inpatient,,,5040.00000,1461.60000,Aetna,First Health,,4122.72,,,,,,,3024.00,4122.72,percent of total billed charges,
AN Port A Cath Removal,2044835,CDM,361,RC,,,,,facility,outpatient,,,5040.00000,1461.60000,Aetna,First Health,,4122.72,,,,,,,1816.92,4908.00,percent of total billed charges,
Sono Guided MammoSite Placement,2032825,CDM,361,RC,,,,,facility,inpatient,,,30000.00000,8700.00000,Aetna,First Health,,24540.00,,,,,,,18000.00,24540.00,percent of total billed charges,
Sono Guided MammoSite Placement,2032825,CDM,361,RC,,,,,facility,outpatient,,,30000.00000,8700.00000,Aetna,First Health,,24540.00,,,,,,,4610.00,24540.00,percent of total billed charges,
AN Dialysis Cath Placement Temporary,3665839,CDM,361,RC,,,,,facility,inpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,6480.00,8834.40,percent of total billed charges,
AN Dialysis Cath Placement Temporary,3665839,CDM,361,RC,,,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,3893.40,8834.40,percent of total billed charges,
AN Tunneled Line Removal,3661981,CDM,361,RC,,,,,facility,inpatient,,,3563.00000,1033.27000,Aetna,First Health,,2914.53,,,,,,,2137.80,2914.53,percent of total billed charges,
AN Tunneled Line Removal,3661981,CDM,361,RC,,,,,facility,outpatient,,,3563.00000,1033.27000,Aetna,First Health,,2914.53,,,,,,,1284.46,4908.00,percent of total billed charges,
AN Ureteral Stent Placement,3661979,CDM,361,RC,,,,,facility,inpatient,,,11040.00000,3201.60000,Aetna,First Health,,9030.72,,,,,,,6624.00,9030.72,percent of total billed charges,
AN Ureteral Stent Placement,3661979,CDM,361,RC,,,,,facility,outpatient,,,11040.00000,3201.60000,Aetna,First Health,,9030.72,,,,,,,3979.92,9030.72,percent of total billed charges,
AN IVC Filter Removal,2890858,CDM,361,RC,,,,,facility,inpatient,,,11437.00000,3316.73000,Aetna,First Health,,9355.47,,,,,,,6862.20,9355.47,percent of total billed charges,
AN IVC Filter Removal,2890858,CDM,361,RC,,,,,facility,outpatient,,,11437.00000,3316.73000,Aetna,First Health,,9355.47,,,,,,,4123.04,9355.47,percent of total billed charges,
AN Central Line Placement,2890847,CDM,361,RC,,,,,facility,inpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,5976.00,8147.28,percent of total billed charges,
AN Central Line Placement,2890847,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,3590.58,8147.28,percent of total billed charges,
AN Chest Tube Placement,3661939,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
AN Chest Tube Placement,3661939,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
AN Transjugular Liver Biopsy,3662005,CDM,361,RC,,,,,facility,inpatient,,,6073.00000,1761.17000,Aetna,First Health,,4967.71,,,,,,,3643.80,4967.71,percent of total billed charges,
AN Transjugular Liver Biopsy,3662005,CDM,361,RC,,,,,facility,outpatient,,,6073.00000,1761.17000,Aetna,First Health,,4967.71,,,,,,,2189.32,4967.71,percent of total billed charges,
AN JTube Exchange,2890854,CDM,361,RC,,,,,facility,inpatient,,,7747.00000,2246.63000,Aetna,First Health,,6337.05,,,,,,,4648.20,6337.05,percent of total billed charges,
AN JTube Exchange,2890854,CDM,361,RC,,,,,facility,outpatient,,,7747.00000,2246.63000,Aetna,First Health,,6337.05,,,,,,,2792.79,6337.05,percent of total billed charges,
AN Nephrostomy Tube Placement,3662003,CDM,361,RC,,,,,facility,inpatient,,,6360.00000,1844.40000,Aetna,First Health,,5202.48,,,,,,,3816.00,5202.48,percent of total billed charges,
AN Nephrostomy Tube Placement,3662003,CDM,361,RC,,,,,facility,outpatient,,,6360.00000,1844.40000,Aetna,First Health,,5202.48,,,,,,,2292.78,5202.48,percent of total billed charges,
AN Nephrostomy Tube Placement,8001039,CDM,361,RC,,,,,facility,inpatient,,,6360.00000,1844.40000,Aetna,First Health,,5202.48,,,,,,,3816.00,5202.48,percent of total billed charges,
AN Nephrostomy Tube Placement,8001039,CDM,361,RC,,,,,facility,outpatient,,,6360.00000,1844.40000,Aetna,First Health,,5202.48,,,,,,,2292.78,5202.48,percent of total billed charges,
AN Dialysis Cath Placement Permanent,3661999,CDM,361,RC,,,,,facility,inpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,6480.00,8834.40,percent of total billed charges,
AN Dialysis Cath Placement Permanent,3661999,CDM,361,RC,,,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,3893.40,8834.40,percent of total billed charges,
AN Ablation Pulmonary,3661993,CDM,361,RC,,,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,10800.00,14724.00,percent of total billed charges,
AN Ablation Pulmonary,3661993,CDM,361,RC,,,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,First Health,,14724.00,,,,,,,4610.00,14724.00,percent of total billed charges,
AN VERTEBROPLASTY EACH ADDL LEVEL,7265840,CDM,361,RC,,,,,facility,inpatient,,,15198.00000,4407.42000,Aetna,First Health,,12431.96,,,,,,,9118.80,12431.96,percent of total billed charges,
AN VERTEBROPLASTY EACH ADDL LEVEL,7265840,CDM,361,RC,,,,,facility,outpatient,,,15198.00000,4407.42000,Aetna,First Health,,12431.96,,,,,,,4610.00,12431.96,percent of total billed charges,
AN Cecostomy Tube Exchange,6825867,CDM,361,RC,,,,,facility,inpatient,,,11432.00000,3315.28000,Aetna,First Health,,9351.38,,,,,,,6859.20,9351.38,percent of total billed charges,
AN Cecostomy Tube Exchange,6825867,CDM,361,RC,,,,,facility,outpatient,,,11432.00000,3315.28000,Aetna,First Health,,9351.38,,,,,,,4121.24,9351.38,percent of total billed charges,
AN Tube Check,2890843,CDM,361,RC,,,,,facility,inpatient,,,1678.00000,486.62000,Aetna,First Health,,1372.60,,,,,,,1006.80,1372.60,percent of total billed charges,
AN Tube Check,2890843,CDM,361,RC,,,,,facility,outpatient,,,1678.00000,486.62000,Aetna,First Health,,1372.60,,,,,,,604.92,4908.00,percent of total billed charges,
AN Gastrostomy Tube Exchange,7285861,CDM,361,RC,,,,,facility,inpatient,,,11432.00000,3315.28000,Aetna,First Health,,9351.38,,,,,,,6859.20,9351.38,percent of total billed charges,
AN Gastrostomy Tube Exchange,7285861,CDM,361,RC,,,,,facility,outpatient,,,11432.00000,3315.28000,Aetna,First Health,,9351.38,,,,,,,4121.24,9351.38,percent of total billed charges,
AN GJ Tube Exchnage,7285865,CDM,361,RC,,,,,facility,inpatient,,,5911.00000,1714.19000,Aetna,First Health,,4835.20,,,,,,,3546.60,4835.20,percent of total billed charges,
AN GJ Tube Exchnage,7285865,CDM,361,RC,,,,,facility,outpatient,,,5911.00000,1714.19000,Aetna,First Health,,4835.20,,,,,,,2130.92,4908.00,percent of total billed charges,
AN Fluoro Guided Beacon Placement Liver,7920903,CDM,361,RC,,,,,facility,inpatient,,,5230.00000,1516.70000,Aetna,First Health,,4278.14,,,,,,,3138.00,4278.14,percent of total billed charges,
AN Fluoro Guided Beacon Placement Liver,7920903,CDM,361,RC,,,,,facility,outpatient,,,5230.00000,1516.70000,Aetna,First Health,,4278.14,,,,,,,1885.41,4908.00,percent of total billed charges,
AN Biopsy and Aspriation,3661963,CDM,361,RC,,,,,facility,inpatient,,,11237.00000,3258.73000,Aetna,First Health,,9191.87,,,,,,,6742.20,9191.87,percent of total billed charges,
AN Biopsy and Aspriation,3661963,CDM,361,RC,,,,,facility,outpatient,,,11237.00000,3258.73000,Aetna,First Health,,9191.87,,,,,,,4050.94,9191.87,percent of total billed charges,
AN Gastrostomy Tube Placement,8945702,CDM,361,RC,,,,,facility,inpatient,,,6000.00000,1740.00000,Aetna,First Health,,4908.00,,,,,,,3600.00,4908.00,percent of total billed charges,
AN Gastrostomy Tube Placement,8945702,CDM,361,RC,,,,,facility,outpatient,,,6000.00000,1740.00000,Aetna,First Health,,4908.00,,,,,,,2163.00,4908.00,percent of total billed charges,
AN GJ Tube Placement,8945704,CDM,361,RC,,,,,facility,inpatient,,,6000.00000,1740.00000,Aetna,First Health,,4908.00,,,,,,,3600.00,4908.00,percent of total billed charges,
AN GJ Tube Placement,8945704,CDM,361,RC,,,,,facility,outpatient,,,6000.00000,1740.00000,Aetna,First Health,,4908.00,,,,,,,2163.00,4908.00,percent of total billed charges,
AN Gastrostomy to GJ Conversion,8945698,CDM,361,RC,,,,,facility,inpatient,,,6000.00000,1740.00000,Aetna,First Health,,4908.00,,,,,,,3600.00,4908.00,percent of total billed charges,
AN Gastrostomy to GJ Conversion,8945698,CDM,361,RC,,,,,facility,outpatient,,,6000.00000,1740.00000,Aetna,First Health,,4908.00,,,,,,,2163.00,4908.00,percent of total billed charges,
AN Injection,8927432,CDM,361,RC,,,,,facility,inpatient,,,1999.00000,579.71000,Aetna,First Health,,1635.18,,,,,,,1199.40,1635.18,percent of total billed charges,
AN Injection,8927432,CDM,361,RC,,,,,facility,outpatient,,,1999.00000,579.71000,Aetna,First Health,,1635.18,,,,,,,720.64,4908.00,percent of total billed charges,
AN Sacroplasty Unilateral,8975125,CDM,361,RC,,,,,facility,inpatient,,,22800.00000,6612.00000,Aetna,First Health,,18650.40,,,,,,,13680.00,18650.40,percent of total billed charges,
AN Sacroplasty Unilateral,8975125,CDM,361,RC,,,,,facility,outpatient,,,22800.00000,6612.00000,Aetna,First Health,,18650.40,,,,,,,4610.00,18650.40,percent of total billed charges,
AN Sacroplasty Bilateral,8973008,CDM,361,RC,,,,,facility,inpatient,,,22800.00000,6612.00000,Aetna,First Health,,18650.40,,,,,,,13680.00,18650.40,percent of total billed charges,
AN Sacroplasty Bilateral,8973008,CDM,361,RC,,,,,facility,outpatient,,,22800.00000,6612.00000,Aetna,First Health,,18650.40,,,,,,,4610.00,18650.40,percent of total billed charges,
AN Lymphangiogram,8975131,CDM,361,RC,,,,,facility,inpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,5976.00,8147.28,percent of total billed charges,
AN Lymphangiogram,8975131,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,3590.58,8147.28,percent of total billed charges,
Biliary Drain Check Change Upsize,9078237,CDM,361,RC,,,,,facility,inpatient,,,5306.00000,1538.74000,Aetna,First Health,,4340.31,,,,,,,3183.60,4340.31,percent of total billed charges,
Biliary Drain Check Change Upsize,9078237,CDM,361,RC,,,,,facility,outpatient,,,5306.00000,1538.74000,Aetna,First Health,,4340.31,,,,,,,1912.81,4908.00,percent of total billed charges,
Biliary Drain Removal,9076228,CDM,361,RC,,,,,facility,inpatient,,,2718.00000,788.22000,Aetna,First Health,,2223.32,,,,,,,1630.80,2223.32,percent of total billed charges,
Biliary Drain Removal,9076228,CDM,361,RC,,,,,facility,outpatient,,,2718.00000,788.22000,Aetna,First Health,,2223.32,,,,,,,979.84,4908.00,percent of total billed charges,
Biliary Dilation,9076230,CDM,361,RC,,,,,facility,inpatient,,,1742.00000,505.18000,Aetna,First Health,,1424.96,,,,,,,1045.20,1424.96,percent of total billed charges,
Biliary Dilation,9076230,CDM,361,RC,,,,,facility,outpatient,,,1742.00000,505.18000,Aetna,First Health,,1424.96,,,,,,,627.99,4908.00,percent of total billed charges,
Biliary Stent Placement,9078239,CDM,361,RC,,,,,facility,inpatient,,,18301.00000,5307.29000,Aetna,First Health,,14970.22,,,,,,,10980.60,14970.22,percent of total billed charges,
Biliary Stent Placement,9078239,CDM,361,RC,,,,,facility,outpatient,,,18301.00000,5307.29000,Aetna,First Health,,14970.22,,,,,,,4610.00,14970.22,percent of total billed charges,
Biliary Stone Removal,9076232,CDM,361,RC,,,,,facility,inpatient,,,7026.00000,2037.54000,Aetna,First Health,,5747.27,,,,,,,4215.60,5747.27,percent of total billed charges,
Biliary Stone Removal,9076232,CDM,361,RC,,,,,facility,outpatient,,,7026.00000,2037.54000,Aetna,First Health,,5747.27,,,,,,,2532.87,5747.27,percent of total billed charges,
Biliary Biopsy,9078241,CDM,361,RC,,,,,facility,inpatient,,,3000.00000,870.00000,Aetna,First Health,,2454.00,,,,,,,1800.00,2454.00,percent of total billed charges,
Biliary Biopsy,9078241,CDM,361,RC,,,,,facility,outpatient,,,3000.00000,870.00000,Aetna,First Health,,2454.00,,,,,,,1081.50,4908.00,percent of total billed charges,
TIPS Placement,9078243,CDM,361,RC,,,,,facility,inpatient,,,7874.00000,2283.46000,Aetna,First Health,,6440.93,,,,,,,4724.40,6440.93,percent of total billed charges,
TIPS Placement,9078243,CDM,361,RC,,,,,facility,outpatient,,,7874.00000,2283.46000,Aetna,First Health,,6440.93,,,,,,,2838.58,6440.93,percent of total billed charges,
Thoracic augment,9076242,CDM,361,RC,,,,,facility,inpatient,,,19172.00000,5559.88000,Aetna,First Health,,15682.70,,,,,,,11503.20,15682.70,percent of total billed charges,
Thoracic augment,9076242,CDM,361,RC,,,,,facility,outpatient,,,19172.00000,5559.88000,Aetna,First Health,,15682.70,,,,,,,4610.00,15682.70,percent of total billed charges,
Lumbar Augment,9078256,CDM,361,RC,,,,,facility,inpatient,,,17430.00000,5054.70000,Aetna,First Health,,14257.74,,,,,,,10458.00,14257.74,percent of total billed charges,
Lumbar Augment,9078256,CDM,361,RC,,,,,facility,outpatient,,,17430.00000,5054.70000,Aetna,First Health,,14257.74,,,,,,,4610.00,14257.74,percent of total billed charges,
Sacral augment,9076244,CDM,361,RC,,,,,facility,inpatient,,,17430.00000,5054.70000,Aetna,First Health,,14257.74,,,,,,,10458.00,14257.74,percent of total billed charges,
Sacral augment,9076244,CDM,361,RC,,,,,facility,outpatient,,,17430.00000,5054.70000,Aetna,First Health,,14257.74,,,,,,,4610.00,14257.74,percent of total billed charges,
Liver Ablation,9076246,CDM,361,RC,,,,,facility,inpatient,,,7502.00000,2175.58000,Aetna,First Health,,6136.64,,,,,,,4501.20,6136.64,percent of total billed charges,
Liver Ablation,9076246,CDM,361,RC,,,,,facility,outpatient,,,7502.00000,2175.58000,Aetna,First Health,,6136.64,,,,,,,2704.47,6136.64,percent of total billed charges,
Right Nephrostomy Tube Check,9078258,CDM,361,RC,,,,,facility,inpatient,,,4208.00000,1220.32000,Aetna,First Health,,3442.14,,,,,,,2524.80,3442.14,percent of total billed charges,
Right Nephrostomy Tube Check,9078258,CDM,361,RC,,,,,facility,outpatient,,,4208.00000,1220.32000,Aetna,First Health,,3442.14,,,,,,,1516.98,4908.00,percent of total billed charges,
Left Nephrostomy Tube Check,9076248,CDM,361,RC,,,,,facility,inpatient,,,4208.00000,1220.32000,Aetna,First Health,,3442.14,,,,,,,2524.80,3442.14,percent of total billed charges,
Left Nephrostomy Tube Check,9076248,CDM,361,RC,,,,,facility,outpatient,,,4208.00000,1220.32000,Aetna,First Health,,3442.14,,,,,,,1516.98,4908.00,percent of total billed charges,
Bilateral Nephrostomy Tube Check,9078260,CDM,361,RC,,,,,facility,inpatient,,,4208.00000,1220.32000,Aetna,First Health,,3442.14,,,,,,,2524.80,3442.14,percent of total billed charges,
Bilateral Nephrostomy Tube Check,9078260,CDM,361,RC,,,,,facility,outpatient,,,4208.00000,1220.32000,Aetna,First Health,,3442.14,,,,,,,1516.98,4908.00,percent of total billed charges,
Right Nephrostomy Tube Exchange,9078262,CDM,361,RC,,,,,facility,inpatient,,,5777.00000,1675.33000,Aetna,First Health,,4725.59,,,,,,,3466.20,4725.59,percent of total billed charges,
Right Nephrostomy Tube Exchange,9078262,CDM,361,RC,,,,,facility,outpatient,,,5777.00000,1675.33000,Aetna,First Health,,4725.59,,,,,,,2082.61,4908.00,percent of total billed charges,
Left Nephrostomy Tube Exchange,9078264,CDM,361,RC,,,,,facility,inpatient,,,5777.00000,1675.33000,Aetna,First Health,,4725.59,,,,,,,3466.20,4725.59,percent of total billed charges,
Left Nephrostomy Tube Exchange,9078264,CDM,361,RC,,,,,facility,outpatient,,,5777.00000,1675.33000,Aetna,First Health,,4725.59,,,,,,,2082.61,4908.00,percent of total billed charges,
Bilateral Nephrostomy Tube Exchange,9078266,CDM,361,RC,,,,,facility,inpatient,,,11031.00000,3198.99000,Aetna,First Health,,9023.36,,,,,,,6618.60,9023.36,percent of total billed charges,
Bilateral Nephrostomy Tube Exchange,9078266,CDM,361,RC,,,,,facility,outpatient,,,11031.00000,3198.99000,Aetna,First Health,,9023.36,,,,,,,3976.68,9023.36,percent of total billed charges,
Cholecystostomy Tube Placement,9076250,CDM,361,RC,,,,,facility,inpatient,,,3269.00000,948.01000,Aetna,First Health,,2674.04,,,,,,,1961.40,2674.04,percent of total billed charges,
Cholecystostomy Tube Placement,9076250,CDM,361,RC,,,,,facility,outpatient,,,3269.00000,948.01000,Aetna,First Health,,2674.04,,,,,,,1178.47,4908.00,percent of total billed charges,
Cholecystostomy Check Change Upsize,9078272,CDM,361,RC,,,,,facility,inpatient,,,3269.00000,948.01000,Aetna,First Health,,2674.04,,,,,,,1961.40,2674.04,percent of total billed charges,
Cholecystostomy Check Change Upsize,9078272,CDM,361,RC,,,,,facility,outpatient,,,3269.00000,948.01000,Aetna,First Health,,2674.04,,,,,,,1178.47,4908.00,percent of total billed charges,
Abscess Drain Check Change Upsize,9078274,CDM,361,RC,,,,,facility,inpatient,,,1465.00000,424.85000,Aetna,First Health,,1198.37,,,,,,,879.00,1198.37,percent of total billed charges,
Abscess Drain Check Change Upsize,9078274,CDM,361,RC,,,,,facility,outpatient,,,1465.00000,424.85000,Aetna,First Health,,1198.37,,,,,,,528.13,4908.00,percent of total billed charges,
Abscess Drain Check Change Upsize,9078783,CDM,361,RC,,,,,facility,inpatient,,,1465.00000,424.85000,Aetna,First Health,,1198.37,,,,,,,879.00,1198.37,percent of total billed charges,
Abscess Drain Check Change Upsize,9078783,CDM,361,RC,,,,,facility,outpatient,,,1465.00000,424.85000,Aetna,First Health,,1198.37,,,,,,,528.13,4908.00,percent of total billed charges,
Thoracic Kyphoplasty,9076292,CDM,361,RC,,,,,facility,inpatient,,,20710.00000,6005.90000,Aetna,First Health,,16940.78,,,,,,,12426.00,16940.78,percent of total billed charges,
Thoracic Kyphoplasty,9076292,CDM,361,RC,,,,,facility,outpatient,,,20710.00000,6005.90000,Aetna,First Health,,16940.78,,,,,,,4610.00,16940.78,percent of total billed charges,
Lumbar Kyphoplasty,9076294,CDM,361,RC,,,,,facility,inpatient,,,20710.00000,6005.90000,Aetna,First Health,,16940.78,,,,,,,12426.00,16940.78,percent of total billed charges,
Lumbar Kyphoplasty,9076294,CDM,361,RC,,,,,facility,outpatient,,,20710.00000,6005.90000,Aetna,First Health,,16940.78,,,,,,,4610.00,16940.78,percent of total billed charges,
Each Additional Level for Kyphoplasty,9078304,CDM,361,RC,,,,,facility,inpatient,,,15960.00000,4628.40000,Aetna,First Health,,13055.28,,,,,,,9576.00,13055.28,percent of total billed charges,
Each Additional Level for Kyphoplasty,9078304,CDM,361,RC,,,,,facility,outpatient,,,15960.00000,4628.40000,Aetna,First Health,,13055.28,,,,,,,4610.00,13055.28,percent of total billed charges,
Liver Ablation Sono Guided,9076298,CDM,361,RC,,,,,facility,inpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,10138.80,13822.56,percent of total billed charges,
Liver Ablation Sono Guided,9076298,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,4610.00,13822.56,percent of total billed charges,
Thyroid Ablation Sono Guided,9076296,CDM,361,RC,,,,,facility,inpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,10138.80,13822.56,percent of total billed charges,
Thyroid Ablation Sono Guided,9076296,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,4610.00,13822.56,percent of total billed charges,
Renal Unilateral Ablation Sono Gudied,9078306,CDM,361,RC,,,,,facility,inpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,10138.80,13822.56,percent of total billed charges,
Renal Unilateral Ablation Sono Gudied,9078306,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,4610.00,13822.56,percent of total billed charges,
Cholecystostomy Tube Placement CT Guided,9078278,CDM,361,RC,,,,,facility,inpatient,,,5308.00000,1539.32000,Aetna,First Health,,4341.94,,,,,,,3184.80,4341.94,percent of total billed charges,
Cholecystostomy Tube Placement CT Guided,9078278,CDM,361,RC,,,,,facility,outpatient,,,5308.00000,1539.32000,Aetna,First Health,,4341.94,,,,,,,1913.53,4908.00,percent of total billed charges,
Cholecystostomy Check Change Upsize,9076254,CDM,361,RC,,,,,facility,inpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,5976.00,8147.28,percent of total billed charges,
Cholecystostomy Check Change Upsize,9076254,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,3590.58,8147.28,percent of total billed charges,
Abcess Drain Check Change or Upsize,9076256,CDM,361,RC,,,,,facility,inpatient,,,5354.00000,1552.66000,Aetna,First Health,,4379.57,,,,,,,3212.40,4379.57,percent of total billed charges,
Abcess Drain Check Change or Upsize,9076256,CDM,361,RC,,,,,facility,outpatient,,,5354.00000,1552.66000,Aetna,First Health,,4379.57,,,,,,,1930.12,4908.00,percent of total billed charges,
Abcess Drain Placement CT Guided,9076258,CDM,361,RC,,,,,facility,inpatient,,,6343.00000,1839.47000,Aetna,First Health,,5188.57,,,,,,,3805.80,5188.57,percent of total billed charges,
Abcess Drain Placement CT Guided,9076258,CDM,361,RC,,,,,facility,outpatient,,,6343.00000,1839.47000,Aetna,First Health,,5188.57,,,,,,,2286.65,5188.57,percent of total billed charges,
Drain Check Change or Upsize,9076260,CDM,361,RC,,,,,facility,inpatient,,,3269.00000,948.01000,Aetna,First Health,,2674.04,,,,,,,1961.40,2674.04,percent of total billed charges,
Drain Check Change or Upsize,9076260,CDM,361,RC,,,,,facility,outpatient,,,3269.00000,948.01000,Aetna,First Health,,2674.04,,,,,,,1178.47,4908.00,percent of total billed charges,
Drain Placement,9078280,CDM,361,RC,,,,,facility,inpatient,,,3269.00000,948.01000,Aetna,First Health,,2674.04,,,,,,,1961.40,2674.04,percent of total billed charges,
Drain Placement,9078280,CDM,361,RC,,,,,facility,outpatient,,,3269.00000,948.01000,Aetna,First Health,,2674.04,,,,,,,1178.47,4908.00,percent of total billed charges,
Aspiration Renal Cyst CT Guided,9078282,CDM,361,RC,,,,,facility,inpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,1209.60,1649.09,percent of total billed charges,
Aspiration Renal Cyst CT Guided,9078282,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,726.77,4908.00,percent of total billed charges,
Aspiration Seroma CT Guided,9078284,CDM,361,RC,,,,,facility,inpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,1209.60,1649.09,percent of total billed charges,
Aspiration Seroma CT Guided,9078284,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,726.77,4908.00,percent of total billed charges,
Aspiration Abdominal CT Guided,9076262,CDM,361,RC,,,,,facility,inpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,1209.60,1649.09,percent of total billed charges,
Aspiration Abdominal CT Guided,9076262,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,726.77,4908.00,percent of total billed charges,
Aspiration Groin CT Guided,9076264,CDM,361,RC,,,,,facility,inpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,1209.60,1649.09,percent of total billed charges,
Aspiration Groin CT Guided,9076264,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,726.77,4908.00,percent of total billed charges,
Aspiration Renal Cyst Sono Guided,9078286,CDM,361,RC,,,,,facility,inpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,1209.60,1649.09,percent of total billed charges,
Aspiration Renal Cyst Sono Guided,9078286,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,726.77,4908.00,percent of total billed charges,
Renal Bilateral Sono Guided,9076324,CDM,361,RC,,,,,facility,inpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,10138.80,13822.56,percent of total billed charges,
Renal Bilateral Sono Guided,9076324,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,4610.00,13822.56,percent of total billed charges,
Renal Unilateral Ablation CT Gudied,9076302,CDM,361,RC,,,,,facility,inpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,10138.80,13822.56,percent of total billed charges,
Renal Unilateral Ablation CT Gudied,9076302,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,4610.00,13822.56,percent of total billed charges,
Renal Bilateral CT Guided,9078322,CDM,361,RC,,,,,facility,inpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,10138.80,13822.56,percent of total billed charges,
Renal Bilateral CT Guided,9078322,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,4610.00,13822.56,percent of total billed charges,
Bone Ablation CT Guided,9076304,CDM,361,RC,,,,,facility,inpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,10138.80,13822.56,percent of total billed charges,
Bone Ablation CT Guided,9076304,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,4610.00,13822.56,percent of total billed charges,
Lung Unilateral Ablation CT Guided,9078308,CDM,361,RC,,,,,facility,inpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,10138.80,13822.56,percent of total billed charges,
Lung Unilateral Ablation CT Guided,9078308,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,4610.00,13822.56,percent of total billed charges,
Lung Bilateral Ablation CT Guided,9076326,CDM,361,RC,,,,,facility,inpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,10138.80,13822.56,percent of total billed charges,
Lung Bilateral Ablation CT Guided,9076326,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,First Health,,13822.56,,,,,,,4610.00,13822.56,percent of total billed charges,
Parathyroid Sampling,9076226,CDM,361,RC,,,,,facility,inpatient,,,3842.00000,1114.18000,Aetna,First Health,,3142.76,,,,,,,2305.20,3142.76,percent of total billed charges,
Parathyroid Sampling,9076226,CDM,361,RC,,,,,facility,outpatient,,,3842.00000,1114.18000,Aetna,First Health,,3142.76,,,,,,,1385.04,4908.00,percent of total billed charges,
Adrenal Vein Sampling,9078233,CDM,361,RC,,,,,facility,inpatient,,,3842.00000,1114.18000,Aetna,First Health,,3142.76,,,,,,,2305.20,3142.76,percent of total billed charges,
Adrenal Vein Sampling,9078233,CDM,361,RC,,,,,facility,outpatient,,,3842.00000,1114.18000,Aetna,First Health,,3142.76,,,,,,,1385.04,4908.00,percent of total billed charges,
Line Replacement,9076252,CDM,361,RC,,,,,facility,inpatient,,,1747.00000,506.63000,Aetna,First Health,,1429.05,,,,,,,1048.20,1429.05,percent of total billed charges,
Line Replacement,9076252,CDM,361,RC,,,,,facility,outpatient,,,1747.00000,506.63000,Aetna,First Health,,1429.05,,,,,,,629.79,4908.00,percent of total billed charges,
Bilateral Nephrostomy Tube Placememt,9078270,CDM,361,RC,,,,,facility,inpatient,,,11031.00000,3198.99000,Aetna,First Health,,9023.36,,,,,,,6618.60,9023.36,percent of total billed charges,
Bilateral Nephrostomy Tube Placememt,9078270,CDM,361,RC,,,,,facility,outpatient,,,11031.00000,3198.99000,Aetna,First Health,,9023.36,,,,,,,3976.68,9023.36,percent of total billed charges,
Each Additional Drain,9076316,CDM,361,RC,,,,,facility,inpatient,,,2059.00000,597.11000,Aetna,First Health,,1684.26,,,,,,,1235.40,1684.26,percent of total billed charges,
Each Additional Drain,9076316,CDM,361,RC,,,,,facility,outpatient,,,2059.00000,597.11000,Aetna,First Health,,1684.26,,,,,,,742.27,4908.00,percent of total billed charges,
Ea Additional Drain CT,9078318,CDM,361,RC,,,,,facility,inpatient,,,3996.00000,1158.84000,Aetna,First Health,,3268.73,,,,,,,2397.60,3268.73,percent of total billed charges,
Ea Additional Drain CT,9078318,CDM,361,RC,,,,,facility,outpatient,,,3996.00000,1158.84000,Aetna,First Health,,3268.73,,,,,,,1440.56,4908.00,percent of total billed charges,
Each Additional Chest Tube,9078320,CDM,361,RC,,,,,facility,inpatient,,,2646.00000,767.34000,Aetna,First Health,,2164.43,,,,,,,1587.60,2164.43,percent of total billed charges,
Each Additional Chest Tube,9078320,CDM,361,RC,,,,,facility,outpatient,,,2646.00000,767.34000,Aetna,First Health,,2164.43,,,,,,,953.88,4908.00,percent of total billed charges,
EA Additional Chest Tube CT,9076318,CDM,361,RC,,,,,facility,inpatient,,,2646.00000,767.34000,Aetna,First Health,,2164.43,,,,,,,1587.60,2164.43,percent of total billed charges,
EA Additional Chest Tube CT,9076318,CDM,361,RC,,,,,facility,outpatient,,,2646.00000,767.34000,Aetna,First Health,,2164.43,,,,,,,953.88,4908.00,percent of total billed charges,
Aspiration Disc,9076320,CDM,361,RC,,,,,facility,inpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,1209.60,1649.09,percent of total billed charges,
Aspiration Disc,9076320,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,726.77,4908.00,percent of total billed charges,
Aspiration Disc CT Guided,9076322,CDM,361,RC,,,,,facility,inpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,1209.60,1649.09,percent of total billed charges,
Aspiration Disc CT Guided,9076322,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,726.77,4908.00,percent of total billed charges,
Axillary Bilateral Biopsy,9076272,CDM,361,RC,,,,,facility,inpatient,,,6000.00000,1740.00000,Aetna,First Health,,4908.00,,,,,,,3600.00,4908.00,percent of total billed charges,
Axillary Bilateral Biopsy,9076272,CDM,361,RC,,,,,facility,outpatient,,,6000.00000,1740.00000,Aetna,First Health,,4908.00,,,,,,,2163.00,4908.00,percent of total billed charges,
Axillary Left Biopsy,9076268,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Axillary Left Biopsy,9076268,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Right Cervical Biopsy,9078296,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Right Cervical Biopsy,9078296,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Right Groin Biopsy,9078292,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Right Groin Biopsy,9078292,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Right Inguinal Biopsy,9076278,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Right Inguinal Biopsy,9076278,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Right Supraclavicular Biopsy,9076284,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Right Supraclavicular Biopsy,9076284,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Right Nephrostomy Tube Placement,9076647,CDM,361,RC,,,,,facility,inpatient,,,5777.00000,1675.33000,Aetna,First Health,,4725.59,,,,,,,3466.20,4725.59,percent of total billed charges,
Right Nephrostomy Tube Placement,9076647,CDM,361,RC,,,,,facility,outpatient,,,5777.00000,1675.33000,Aetna,First Health,,4725.59,,,,,,,2082.61,4908.00,percent of total billed charges,
Left Nephrostomy Tube Placement,9076651,CDM,361,RC,,,,,facility,inpatient,,,5777.00000,1675.33000,Aetna,First Health,,4725.59,,,,,,,3466.20,4725.59,percent of total billed charges,
Left Nephrostomy Tube Placement,9076651,CDM,361,RC,,,,,facility,outpatient,,,5777.00000,1675.33000,Aetna,First Health,,4725.59,,,,,,,2082.61,4908.00,percent of total billed charges,
AN Lumbar Puncture,9074544,CDM,361,RC,,,,,facility,inpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,1242.60,1694.08,percent of total billed charges,
AN Lumbar Puncture,9074544,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,746.60,4908.00,percent of total billed charges,
AFC GENERIC ADD-ON,9076366,CDM,361,RC,,,,,facility,inpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,1242.60,1694.08,percent of total billed charges,
AFC GENERIC ADD-ON,9076366,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,First Health,,1694.08,,,,,,,746.60,4908.00,percent of total billed charges,
Pseudo Aneurysm Treatment,9076288,CDM,361,RC,,,,,facility,inpatient,,,2256.00000,654.24000,Aetna,First Health,,1845.41,,,,,,,1353.60,1845.41,percent of total billed charges,
Pseudo Aneurysm Treatment,9076288,CDM,361,RC,,,,,facility,outpatient,,,2256.00000,654.24000,Aetna,First Health,,1845.41,,,,,,,813.29,4908.00,percent of total billed charges,
Sono Guided Thrombin Injection,9198609,CDM,361,RC,,,,,facility,inpatient,,,2256.00000,654.24000,Aetna,First Health,,1845.41,,,,,,,1353.60,1845.41,percent of total billed charges,
Sono Guided Thrombin Injection,9198609,CDM,361,RC,,,,,facility,outpatient,,,2256.00000,654.24000,Aetna,First Health,,1845.41,,,,,,,813.29,4908.00,percent of total billed charges,
Sono Guided Denver Drain Placement Peritoneal,9198625,CDM,361,RC,,,,,facility,inpatient,,,8292.00000,2404.68000,Aetna,First Health,,6782.86,,,,,,,4975.20,6782.86,percent of total billed charges,
Sono Guided Denver Drain Placement Peritoneal,9198625,CDM,361,RC,,,,,facility,outpatient,,,8292.00000,2404.68000,Aetna,First Health,,6782.86,,,,,,,2989.27,6782.86,percent of total billed charges,
Sono Guided Denver Drain Placement Pleural,9198632,CDM,361,RC,,,,,facility,inpatient,,,8292.00000,2404.68000,Aetna,First Health,,6782.86,,,,,,,4975.20,6782.86,percent of total billed charges,
Sono Guided Denver Drain Placement Pleural,9198632,CDM,361,RC,,,,,facility,outpatient,,,8292.00000,2404.68000,Aetna,First Health,,6782.86,,,,,,,2989.27,6782.86,percent of total billed charges,
AN Denver Drain Removal,9074596,CDM,361,RC,,,,,facility,inpatient,,,2718.00000,788.22000,Aetna,First Health,,2223.32,,,,,,,1630.80,2223.32,percent of total billed charges,
AN Denver Drain Removal,9074596,CDM,361,RC,,,,,facility,outpatient,,,2718.00000,788.22000,Aetna,First Health,,2223.32,,,,,,,979.84,4908.00,percent of total billed charges,
Stent placement,9078223,CDM,361,RC,,,,,facility,inpatient,,,7907.00000,2293.03000,Aetna,First Health,,6467.93,,,,,,,4744.20,6467.93,percent of total billed charges,
Stent placement,9078223,CDM,361,RC,,,,,facility,outpatient,,,7907.00000,2293.03000,Aetna,First Health,,6467.93,,,,,,,2850.47,6467.93,percent of total billed charges,
Thrombectomy,9076308,CDM,361,RC,,,,,facility,inpatient,,,18840.00000,5463.60000,Aetna,First Health,,15411.12,,,,,,,11304.00,15411.12,percent of total billed charges,
Thrombectomy,9076308,CDM,361,RC,,,,,facility,outpatient,,,18840.00000,5463.60000,Aetna,First Health,,15411.12,,,,,,,4610.00,15411.12,percent of total billed charges,
Y90 Treatment,9076310,CDM,361,RC,,,,,facility,inpatient,,,712.00000,206.48000,Aetna,First Health,,582.42,,,,,,,427.20,582.42,percent of total billed charges,
Y90 Treatment,9076310,CDM,361,RC,,,,,facility,outpatient,,,712.00000,206.48000,Aetna,First Health,,582.42,,,,,,,256.68,4908.00,percent of total billed charges,
Y90 Mapping,9078310,CDM,361,RC,,,,,facility,inpatient,,,31446.00000,9119.34000,Aetna,First Health,,25722.83,,,,,,,18867.60,25722.83,percent of total billed charges,
Y90 Mapping,9078310,CDM,361,RC,,,,,facility,outpatient,,,31446.00000,9119.34000,Aetna,First Health,,25722.83,,,,,,,4610.00,25722.83,percent of total billed charges,
Trans Arterial Chemo Embolization,9076312,CDM,361,RC,,,,,facility,inpatient,,,25200.00000,7308.00000,Aetna,First Health,,20613.60,,,,,,,15120.00,20613.60,percent of total billed charges,
Trans Arterial Chemo Embolization,9076312,CDM,361,RC,,,,,facility,outpatient,,,25200.00000,7308.00000,Aetna,First Health,,20613.60,,,,,,,4610.00,20613.60,percent of total billed charges,
Retrograde Transvenous Obliteration,9078312,CDM,361,RC,,,,,facility,inpatient,,,25200.00000,7308.00000,Aetna,First Health,,20613.60,,,,,,,15120.00,20613.60,percent of total billed charges,
Retrograde Transvenous Obliteration,9078312,CDM,361,RC,,,,,facility,outpatient,,,25200.00000,7308.00000,Aetna,First Health,,20613.60,,,,,,,4610.00,20613.60,percent of total billed charges,
TIPS Check and Treat,9076234,CDM,361,RC,,,,,facility,inpatient,,,3386.00000,981.94000,Aetna,First Health,,2769.75,,,,,,,2031.60,2769.75,percent of total billed charges,
TIPS Check and Treat,9076234,CDM,361,RC,,,,,facility,outpatient,,,3386.00000,981.94000,Aetna,First Health,,2769.75,,,,,,,1220.65,4908.00,percent of total billed charges,
TIPS Takedown,9076314,CDM,361,RC,,,,,facility,inpatient,,,16338.00000,4738.02000,Aetna,First Health,,13364.48,,,,,,,9802.80,13364.48,percent of total billed charges,
TIPS Takedown,9076314,CDM,361,RC,,,,,facility,outpatient,,,16338.00000,4738.02000,Aetna,First Health,,13364.48,,,,,,,4610.00,13364.48,percent of total billed charges,
Blood Patch,9078316,CDM,361,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
Blood Patch,9078316,CDM,361,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,4908.00,percent of total billed charges,
Myelogram Cervical,9078248,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
Myelogram Cervical,9078248,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
Myelogram Thoracic,9078250,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
Myelogram Thoracic,9078250,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
Myelogram Lumbar,9076236,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
Myelogram Lumbar,9076236,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
Myelogram Total,9078254,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
Myelogram Total,9078254,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
Portacath Replacement,9078276,CDM,361,RC,,,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,2898.00,3950.94,percent of total billed charges,
Portacath Replacement,9078276,CDM,361,RC,,,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,First Health,,3950.94,,,,,,,1741.21,4908.00,percent of total billed charges,
Aspiration Seroma Sono Guided,9076266,CDM,361,RC,,,,,facility,inpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,1209.60,1649.09,percent of total billed charges,
Aspiration Seroma Sono Guided,9076266,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,726.77,4908.00,percent of total billed charges,
Aspiration Abdominal Sono Guided,9078288,CDM,361,RC,,,,,facility,inpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,1209.60,1649.09,percent of total billed charges,
Aspiration Abdominal Sono Guided,9078288,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,726.77,4908.00,percent of total billed charges,
Aspiration Groin Sono Guided,9078290,CDM,361,RC,,,,,facility,inpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,1209.60,1649.09,percent of total billed charges,
Aspiration Groin Sono Guided,9078290,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,First Health,,1649.09,,,,,,,726.77,4908.00,percent of total billed charges,
Arteriogram,9076306,CDM,361,RC,,,,,facility,inpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,5976.00,8147.28,percent of total billed charges,
Arteriogram,9076306,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,3590.58,8147.28,percent of total billed charges,
Angioplasty,9078221,CDM,361,RC,,,,,facility,inpatient,,,9151.00000,2653.79000,Aetna,First Health,,7485.52,,,,,,,5490.60,7485.52,percent of total billed charges,
Angioplasty,9078221,CDM,361,RC,,,,,facility,outpatient,,,9151.00000,2653.79000,Aetna,First Health,,7485.52,,,,,,,3298.94,7485.52,percent of total billed charges,
Thrombolysis,9078225,CDM,361,RC,,,,,facility,inpatient,,,4576.00000,1327.04000,Aetna,First Health,,3743.17,,,,,,,2745.60,3743.17,percent of total billed charges,
Thrombolysis,9078225,CDM,361,RC,,,,,facility,outpatient,,,4576.00000,1327.04000,Aetna,First Health,,3743.17,,,,,,,1649.65,4908.00,percent of total billed charges,
Axillary Right Biopsy,9076270,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Axillary Right Biopsy,9076270,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Left Groin Biopsy,9076274,CDM,361,RC,,,,,facility,inpatient,,,4849.00000,1406.21000,Aetna,First Health,,3966.48,,,,,,,2909.40,3966.48,percent of total billed charges,
Left Groin Biopsy,9076274,CDM,361,RC,,,,,facility,outpatient,,,4849.00000,1406.21000,Aetna,First Health,,3966.48,,,,,,,1748.06,4908.00,percent of total billed charges,
Bilateral Groin Biopsy,9076276,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Bilateral Groin Biopsy,9076276,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Left Inguinal Biopsy,9076280,CDM,361,RC,,,,,facility,inpatient,,,4849.00000,1406.21000,Aetna,First Health,,3966.48,,,,,,,2909.40,3966.48,percent of total billed charges,
Left Inguinal Biopsy,9076280,CDM,361,RC,,,,,facility,outpatient,,,4849.00000,1406.21000,Aetna,First Health,,3966.48,,,,,,,1748.06,4908.00,percent of total billed charges,
Bilateral Inguinal Biopsy,9078294,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Bilateral Inguinal Biopsy,9078294,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Left Cervical Lymph Node Biopsy,9076282,CDM,361,RC,,,,,facility,inpatient,,,4849.00000,1406.21000,Aetna,First Health,,3966.48,,,,,,,2909.40,3966.48,percent of total billed charges,
Left Cervical Lymph Node Biopsy,9076282,CDM,361,RC,,,,,facility,outpatient,,,4849.00000,1406.21000,Aetna,First Health,,3966.48,,,,,,,1748.06,4908.00,percent of total billed charges,
Bilateral Cervical Biopsy,9078298,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Bilateral Cervical Biopsy,9078298,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Left Supraclavicular Biopsy,9078300,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
Left Supraclavicular Biopsy,9078300,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
Bilateral Supraclavicular Biopsy,9076286,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Bilateral Supraclavicular Biopsy,9076286,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Myelogram Cervical/Lumbar,9076238,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
Myelogram Cervical/Lumbar,9076238,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
Myelogram Cervical/Thoracic,9076240,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
Myelogram Cervical/Thoracic,9076240,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
Myelogram Thoracic/Lumbar,9078252,CDM,361,RC,,,,,facility,inpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,2719.20,3707.18,percent of total billed charges,
Myelogram Thoracic/Lumbar,9078252,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,First Health,,3707.18,,,,,,,1633.79,4908.00,percent of total billed charges,
Embolization,9078227,CDM,361,RC,,,,,facility,inpatient,,,25200.00000,7308.00000,Aetna,First Health,,20613.60,,,,,,,15120.00,20613.60,percent of total billed charges,
Embolization,9078227,CDM,361,RC,,,,,facility,outpatient,,,25200.00000,7308.00000,Aetna,First Health,,20613.60,,,,,,,4610.00,20613.60,percent of total billed charges,
Aortogram with Runoff,9076218,CDM,361,RC,,,,,facility,inpatient,,,8716.00000,2527.64000,Aetna,First Health,,7129.69,,,,,,,5229.60,7129.69,percent of total billed charges,
Aortogram with Runoff,9076218,CDM,361,RC,,,,,facility,outpatient,,,8716.00000,2527.64000,Aetna,First Health,,7129.69,,,,,,,3142.12,7129.69,percent of total billed charges,
Venogram,9078229,CDM,361,RC,,,,,facility,inpatient,,,4578.00000,1327.62000,Aetna,First Health,,3744.80,,,,,,,2746.80,3744.80,percent of total billed charges,
Venogram,9078229,CDM,361,RC,,,,,facility,outpatient,,,4578.00000,1327.62000,Aetna,First Health,,3744.80,,,,,,,1650.37,4908.00,percent of total billed charges,
Foreign Body Retreival,9078231,CDM,361,RC,,,,,facility,inpatient,,,7576.00000,2197.04000,Aetna,First Health,,6197.17,,,,,,,4545.60,6197.17,percent of total billed charges,
Foreign Body Retreival,9078231,CDM,361,RC,,,,,facility,outpatient,,,7576.00000,2197.04000,Aetna,First Health,,6197.17,,,,,,,2731.15,6197.17,percent of total billed charges,
Venous Pressures,9076220,CDM,361,RC,,,,,facility,inpatient,,,5710.00000,1655.90000,Aetna,First Health,,4670.78,,,,,,,3426.00,4670.78,percent of total billed charges,
Venous Pressures,9076220,CDM,361,RC,,,,,facility,outpatient,,,5710.00000,1655.90000,Aetna,First Health,,4670.78,,,,,,,2058.45,4908.00,percent of total billed charges,
IVC Filter Removal,9076222,CDM,361,RC,,,,,facility,inpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,6480.00,8834.40,percent of total billed charges,
IVC Filter Removal,9076222,CDM,361,RC,,,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,First Health,,8834.40,,,,,,,3893.40,8834.40,percent of total billed charges,
IVC Filter Placement,9076224,CDM,361,RC,,,,,facility,inpatient,,,9517.00000,2759.93000,Aetna,First Health,,7784.91,,,,,,,5710.20,7784.91,percent of total billed charges,
IVC Filter Placement,9076224,CDM,361,RC,,,,,facility,outpatient,,,9517.00000,2759.93000,Aetna,First Health,,7784.91,,,,,,,3430.88,7784.91,percent of total billed charges,
Biliary Drain Placement,9078235,CDM,361,RC,,,,,facility,inpatient,,,5572.00000,1615.88000,Aetna,First Health,,4557.90,,,,,,,3343.20,4557.90,percent of total billed charges,
Biliary Drain Placement,9078235,CDM,361,RC,,,,,facility,outpatient,,,5572.00000,1615.88000,Aetna,First Health,,4557.90,,,,,,,2008.71,4908.00,percent of total billed charges,
Suprapubic Catheter Placement CT Guided,9078805,CDM,361,RC,,,,,facility,inpatient,,,6343.00000,1839.47000,Aetna,First Health,,5188.57,,,,,,,3805.80,5188.57,percent of total billed charges,
Suprapubic Catheter Placement CT Guided,9078805,CDM,361,RC,,,,,facility,outpatient,,,6343.00000,1839.47000,Aetna,First Health,,5188.57,,,,,,,2286.65,5188.57,percent of total billed charges,
Each Additional Nephrostomy Tube,9076806,CDM,361,RC,,,,,facility,inpatient,,,4007.00000,1162.03000,Aetna,First Health,,3277.73,,,,,,,2404.20,3277.73,percent of total billed charges,
Each Additional Nephrostomy Tube,9076806,CDM,361,RC,,,,,facility,outpatient,,,4007.00000,1162.03000,Aetna,First Health,,3277.73,,,,,,,1444.52,4908.00,percent of total billed charges,
Each Additional Ureteral Stent,9076808,CDM,361,RC,,,,,facility,inpatient,,,6955.00000,2016.95000,Aetna,First Health,,5689.19,,,,,,,4173.00,5689.19,percent of total billed charges,
Each Additional Ureteral Stent,9076808,CDM,361,RC,,,,,facility,outpatient,,,6955.00000,2016.95000,Aetna,First Health,,5689.19,,,,,,,2507.28,5689.19,percent of total billed charges,
Abscess Drain Placement,9082487,CDM,361,RC,,,,,facility,inpatient,,,3269.00000,948.01000,Aetna,First Health,,2674.04,,,,,,,1961.40,2674.04,percent of total billed charges,
Abscess Drain Placement,9082487,CDM,361,RC,,,,,facility,outpatient,,,3269.00000,948.01000,Aetna,First Health,,2674.04,,,,,,,1178.47,4908.00,percent of total billed charges,
Nephrostomy Tube Removal Right,9080599,CDM,361,RC,,,,,facility,inpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,1511.40,2060.54,percent of total billed charges,
Nephrostomy Tube Removal Right,9080599,CDM,361,RC,,,,,facility,outpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,908.10,4908.00,percent of total billed charges,
Nephrostomy Tube Removal Left,9082489,CDM,361,RC,,,,,facility,inpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,1511.40,2060.54,percent of total billed charges,
Nephrostomy Tube Removal Left,9082489,CDM,361,RC,,,,,facility,outpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,908.10,4908.00,percent of total billed charges,
Nephrostomy Tube Removal Bilateral,9082491,CDM,361,RC,,,,,facility,inpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,1511.40,2060.54,percent of total billed charges,
Nephrostomy Tube Removal Bilateral,9082491,CDM,361,RC,,,,,facility,outpatient,,,2519.00000,730.51000,Aetna,First Health,,2060.54,,,,,,,908.10,4908.00,percent of total billed charges,
Submandibular Biopsy,9080601,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Submandibular Biopsy,9080601,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Sono Guided Parotid Mass Biopsy,9196916,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
Sono Guided Parotid Mass Biopsy,9196916,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
Drain Removal:Drain Removal,9083655,CDM,361,RC,,,,,facility,inpatient,,,2718.00000,788.22000,Aetna,First Health,,2223.32,,,,,,,1630.80,2223.32,percent of total billed charges,
Drain Removal:Drain Removal,9083655,CDM,361,RC,,,,,facility,outpatient,,,2718.00000,788.22000,Aetna,First Health,,2223.32,,,,,,,979.84,4908.00,percent of total billed charges,
Sono Guided Chest Tube Placement,9196930,CDM,361,RC,,,,,facility,inpatient,,,5400.00000,1566.00000,Aetna,First Health,,4417.20,,,,,,,3240.00,4417.20,percent of total billed charges,
Sono Guided Chest Tube Placement,9196930,CDM,361,RC,,,,,facility,outpatient,,,5400.00000,1566.00000,Aetna,First Health,,4417.20,,,,,,,1946.70,4908.00,percent of total billed charges,
Bone Biopsy,9094511,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
Bone Biopsy,9094511,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
Bone Biopsy CT Guided,9094513,CDM,361,RC,,,,,facility,inpatient,,,5200.00000,1508.00000,Aetna,First Health,,4253.60,,,,,,,3120.00,4253.60,percent of total billed charges,
Bone Biopsy CT Guided,9094513,CDM,361,RC,,,,,facility,outpatient,,,5200.00000,1508.00000,Aetna,First Health,,4253.60,,,,,,,1874.60,4908.00,percent of total billed charges,
Liver Biopsy CT Guided,9092928,CDM,361,RC,,,,,facility,inpatient,,,5200.00000,1508.00000,Aetna,First Health,,4253.60,,,,,,,3120.00,4253.60,percent of total billed charges,
Liver Biopsy CT Guided,9092928,CDM,361,RC,,,,,facility,outpatient,,,5200.00000,1508.00000,Aetna,First Health,,4253.60,,,,,,,1874.60,4908.00,percent of total billed charges,
Renal Biopsy CT Guided,9092930,CDM,361,RC,,,,,facility,inpatient,,,5200.00000,1508.00000,Aetna,First Health,,4253.60,,,,,,,3120.00,4253.60,percent of total billed charges,
Renal Biopsy CT Guided,9092930,CDM,361,RC,,,,,facility,outpatient,,,5200.00000,1508.00000,Aetna,First Health,,4253.60,,,,,,,1874.60,4908.00,percent of total billed charges,
Lung Biopsy CT Guided,9092932,CDM,361,RC,,,,,facility,inpatient,,,5200.00000,1508.00000,Aetna,First Health,,4253.60,,,,,,,3120.00,4253.60,percent of total billed charges,
Lung Biopsy CT Guided,9092932,CDM,361,RC,,,,,facility,outpatient,,,5200.00000,1508.00000,Aetna,First Health,,4253.60,,,,,,,1874.60,4908.00,percent of total billed charges,
Cholangiogram,9095030,CDM,361,RC,,,,,facility,inpatient,,,4570.00000,1325.30000,Aetna,First Health,,3738.26,,,,,,,2742.00,3738.26,percent of total billed charges,
Cholangiogram,9095030,CDM,361,RC,,,,,facility,outpatient,,,4570.00000,1325.30000,Aetna,First Health,,3738.26,,,,,,,1647.48,4908.00,percent of total billed charges,
Vertebroplasty,9108866,CDM,361,RC,,,,,facility,inpatient,,,20898.00000,6060.42000,Aetna,First Health,,17094.56,,,,,,,12538.80,17094.56,percent of total billed charges,
Vertebroplasty,9108866,CDM,361,RC,,,,,facility,outpatient,,,20898.00000,6060.42000,Aetna,First Health,,17094.56,,,,,,,4610.00,17094.56,percent of total billed charges,
Fluoro Guidance,9158417,CDM,361,RC,,,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,900.00,1227.00,percent of total billed charges,
Fluoro Guidance,9158417,CDM,361,RC,,,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,4908.00,percent of total billed charges,
Ablation,9158456,CDM,361,RC,,,,,facility,inpatient,,,14082.00000,4083.78000,Aetna,First Health,,11519.08,,,,,,,8449.20,11519.08,percent of total billed charges,
Ablation,9158456,CDM,361,RC,,,,,facility,outpatient,,,14082.00000,4083.78000,Aetna,First Health,,11519.08,,,,,,,4610.00,11519.08,percent of total billed charges,
Ablation,9158458,CDM,361,RC,,,,,facility,inpatient,,,14082.00000,4083.78000,Aetna,First Health,,11519.08,,,,,,,8449.20,11519.08,percent of total billed charges,
Ablation,9158458,CDM,361,RC,,,,,facility,outpatient,,,14082.00000,4083.78000,Aetna,First Health,,11519.08,,,,,,,4610.00,11519.08,percent of total billed charges,
Fistulogram with Stent Placement,9210579,CDM,361,RC,,,,,facility,inpatient,,,7907.00000,2293.03000,Aetna,First Health,,6467.93,,,,,,,4744.20,6467.93,percent of total billed charges,
Fistulogram with Stent Placement,9210579,CDM,361,RC,,,,,facility,outpatient,,,7907.00000,2293.03000,Aetna,First Health,,6467.93,,,,,,,2850.47,6467.93,percent of total billed charges,
Fistulogram with Angioplasty,9210581,CDM,361,RC,,,,,facility,inpatient,,,9151.00000,2653.79000,Aetna,First Health,,7485.52,,,,,,,5490.60,7485.52,percent of total billed charges,
Fistulogram with Angioplasty,9210581,CDM,361,RC,,,,,facility,outpatient,,,9151.00000,2653.79000,Aetna,First Health,,7485.52,,,,,,,3298.94,7485.52,percent of total billed charges,
Fistulogram,9210583,CDM,361,RC,,,,,facility,inpatient,,,4578.00000,1327.62000,Aetna,First Health,,3744.80,,,,,,,2746.80,3744.80,percent of total billed charges,
Fistulogram,9210583,CDM,361,RC,,,,,facility,outpatient,,,4578.00000,1327.62000,Aetna,First Health,,3744.80,,,,,,,1650.37,4908.00,percent of total billed charges,
AN PICC Line Reposition,661600,CDM,361,RC,,,,,facility,inpatient,,,5040.00000,1461.60000,Aetna,First Health,,4122.72,,,,,,,3024.00,4122.72,percent of total billed charges,
AN PICC Line Reposition,661600,CDM,361,RC,,,,,facility,outpatient,,,5040.00000,1461.60000,Aetna,First Health,,4122.72,,,,,,,1816.92,4908.00,percent of total billed charges,
AN PICC Line Replacement,661598,CDM,361,RC,,,,,facility,inpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,2220.00,3026.60,percent of total billed charges,
AN PICC Line Replacement,661598,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,1333.85,4908.00,percent of total billed charges,
AN PICC Line Placement,613309,CDM,361,RC,,,,,facility,inpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,2220.00,3026.60,percent of total billed charges,
AN PICC Line Placement,613309,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,First Health,,3026.60,,,,,,,1333.85,4908.00,percent of total billed charges,
AN Tunneled Line Placement,661602,CDM,361,RC,,,,,facility,inpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,5976.00,8147.28,percent of total billed charges,
AN Tunneled Line Placement,661602,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,3590.58,8147.28,percent of total billed charges,
AN Fluoro Guided Biopsy,642078,CDM,361,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
AN Fluoro Guided Biopsy,642078,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,4908.00,percent of total billed charges,
AN Vertebroplasty Thoracic,613299,CDM,361,RC,,,,,facility,inpatient,,,20898.00000,6060.42000,Aetna,First Health,,17094.56,,,,,,,12538.80,17094.56,percent of total billed charges,
AN Vertebroplasty Thoracic,613299,CDM,361,RC,,,,,facility,outpatient,,,20898.00000,6060.42000,Aetna,First Health,,17094.56,,,,,,,4610.00,17094.56,percent of total billed charges,
AN Vertebroplasty Lumbar,613554,CDM,361,RC,,,,,facility,inpatient,,,20898.00000,6060.42000,Aetna,First Health,,17094.56,,,,,,,12538.80,17094.56,percent of total billed charges,
AN Vertebroplasty Lumbar,613554,CDM,361,RC,,,,,facility,outpatient,,,20898.00000,6060.42000,Aetna,First Health,,17094.56,,,,,,,4610.00,17094.56,percent of total billed charges,
AN Port A Cath Insertion,661604,CDM,361,RC,,,,,facility,inpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,5976.00,8147.28,percent of total billed charges,
AN Port A Cath Insertion,661604,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,First Health,,8147.28,,,,,,,3590.58,8147.28,percent of total billed charges,
RA Tube Check,614287,CDM,361,RC,,,,,facility,inpatient,,,1597.00000,463.13000,Aetna,First Health,,1306.35,,,,,,,958.20,1306.35,percent of total billed charges,
RA Tube Check,614287,CDM,361,RC,,,,,facility,outpatient,,,1597.00000,463.13000,Aetna,First Health,,1306.35,,,,,,,575.72,4908.00,percent of total billed charges,
AN Biopsy Deep Bone,613204,CDM,361,RC,,,,,facility,inpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,2400.00,3272.00,percent of total billed charges,
AN Biopsy Deep Bone,613204,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,First Health,,3272.00,,,,,,,1442.00,4908.00,percent of total billed charges,
AN IVC Filter Placement,613275,CDM,361,RC,,,,,facility,inpatient,,,17160.00000,4976.40000,Aetna,First Health,,14036.88,,,,,,,10296.00,14036.88,percent of total billed charges,
AN IVC Filter Placement,613275,CDM,361,RC,,,,,facility,outpatient,,,17160.00000,4976.40000,Aetna,First Health,,14036.88,,,,,,,4610.00,14036.88,percent of total billed charges,
Insert Laryngoscopy And Or Trach,8062055,CDM,361,RC,31575,HCPCS,,,facility,inpatient,,,2791.00000,809.39000,Aetna,First Health,,2283.04,,,,,,,1674.60,2283.04,percent of total billed charges,
Insert Laryngoscopy And Or Trach,8062055,CDM,361,RC,31575,HCPCS,,,facility,outpatient,,,2791.00000,809.39000,Aetna,First Health,,2283.04,,,,,,,122.76,4061.89,percent of total billed charges,
Biopsy Done With Bronchoscopy,5465959,CDM,361,RC,,,,,facility,inpatient,,,4444.00000,1288.76000,Aetna,First Health,,3635.19,,,,,,,2666.40,3635.19,percent of total billed charges,
Biopsy Done With Bronchoscopy,5465959,CDM,361,RC,,,,,facility,outpatient,,,4444.00000,1288.76000,Aetna,First Health,,3635.19,,,,,,,1602.06,4908.00,percent of total billed charges,
Biopsy Done With Bronchoscopy,5571857,CDM,361,RC,,,,,facility,inpatient,,,4444.00000,1288.76000,Aetna,First Health,,3635.19,,,,,,,2666.40,3635.19,percent of total billed charges,
Biopsy Done With Bronchoscopy,5571857,CDM,361,RC,,,,,facility,outpatient,,,4444.00000,1288.76000,Aetna,First Health,,3635.19,,,,,,,1602.06,4908.00,percent of total billed charges,
Trach Tube Change,4417847,CDM,361,RC,,,,,facility,inpatient,,,276.00000,80.04000,Aetna,First Health,,225.77,,,,,,,165.60,225.77,percent of total billed charges,
Trach Tube Change,4417847,CDM,361,RC,,,,,facility,outpatient,,,276.00000,80.04000,Aetna,First Health,,225.77,,,,,,,99.50,4908.00,percent of total billed charges,
Bronchoscopy,5571840,CDM,361,RC,,,,,facility,inpatient,,,4444.00000,1288.76000,Aetna,First Health,,3635.19,,,,,,,2666.40,3635.19,percent of total billed charges,
Bronchoscopy,5571840,CDM,361,RC,,,,,facility,outpatient,,,4444.00000,1288.76000,Aetna,First Health,,3635.19,,,,,,,1602.06,4908.00,percent of total billed charges,
Bronchoscopy,7900308,CDM,361,RC,,,,,facility,inpatient,,,4444.00000,1288.76000,Aetna,First Health,,3635.19,,,,,,,2666.40,3635.19,percent of total billed charges,
Bronchoscopy,7900308,CDM,361,RC,,,,,facility,outpatient,,,4444.00000,1288.76000,Aetna,First Health,,3635.19,,,,,,,1602.06,4908.00,percent of total billed charges,
Conscious Sedation,8995219,CDM,370,RC,99152,HCPCS,,,facility,inpatient,,,438.00000,127.02000,Aetna,First Health,,358.28,,,,,,,262.80,358.28,percent of total billed charges,
Conscious Sedation,8995219,CDM,370,RC,99152,HCPCS,,,facility,outpatient,,,438.00000,127.02000,Aetna,First Health,,358.28,,,,,,,157.90,358.28,percent of total billed charges,
Conscious Sedation Initial 15 Mins,9010086,CDM,370,RC,99153,HCPCS,,,facility,inpatient,,,438.00000,127.02000,Aetna,First Health,,358.28,,,,,,,262.80,358.28,percent of total billed charges,
Conscious Sedation Initial 15 Mins,9010086,CDM,370,RC,99153,HCPCS,,,facility,outpatient,,,438.00000,127.02000,Aetna,First Health,,358.28,,,,,,,157.90,358.28,percent of total billed charges,
Conscious Sedation Initial 15 Mins,9012097,CDM,370,RC,99152,HCPCS,,,facility,inpatient,,,438.00000,127.02000,Aetna,First Health,,358.28,,,,,,,262.80,358.28,percent of total billed charges,
Conscious Sedation Initial 15 Mins,9012097,CDM,370,RC,99152,HCPCS,,,facility,outpatient,,,438.00000,127.02000,Aetna,First Health,,358.28,,,,,,,157.90,358.28,percent of total billed charges,
Conscious Sedatin Addl 15 Mins,9010088,CDM,370,RC,99153,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,144.60,197.14,percent of total billed charges,
Conscious Sedatin Addl 15 Mins,9010088,CDM,370,RC,99153,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,86.88,197.14,percent of total billed charges,
Mat Anesthesia With Supplies,7939784,CDM,370,RC,,,,,facility,inpatient,,,2599.00000,753.71000,Aetna,First Health,,2125.98,,,,,,,1559.40,2125.98,percent of total billed charges,
Mat Anesthesia With Supplies,7939784,CDM,370,RC,,,,,facility,outpatient,,,2599.00000,753.71000,Aetna,First Health,,2125.98,,,,,,,936.94,2125.98,percent of total billed charges,
Anesthesia General 30 min,8147913,CDM,370,RC,,,,,facility,inpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,836.40,1140.29,percent of total billed charges,
Anesthesia General 30 min,8147913,CDM,370,RC,,,,,facility,outpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,502.54,1140.29,percent of total billed charges,
Anesthesia General Ea Addl 15 min,8147908,CDM,370,RC,,,,,facility,inpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,63.60,86.71,percent of total billed charges,
Anesthesia General Ea Addl 15 min,8147908,CDM,370,RC,,,,,facility,outpatient,,,106.00000,30.74000,Aetna,First Health,,86.71,,,,,,,38.21,86.71,percent of total billed charges,
MODERATE SEDATION,7720028,CDM,370,RC,,,,,facility,inpatient,,,890.00000,258.10000,Aetna,First Health,,728.02,,,,,,,534.00,728.02,percent of total billed charges,
MODERATE SEDATION,7720028,CDM,370,RC,,,,,facility,outpatient,,,890.00000,258.10000,Aetna,First Health,,728.02,,,,,,,320.85,728.02,percent of total billed charges,
Cath Lab Conscious Sedation Initial 15 Mins,9012134,CDM,370,RC,99152,HCPCS,,,facility,inpatient,,,438.00000,127.02000,Aetna,First Health,,358.28,,,,,,,262.80,358.28,percent of total billed charges,
Cath Lab Conscious Sedation Initial 15 Mins,9012134,CDM,370,RC,99152,HCPCS,,,facility,outpatient,,,438.00000,127.02000,Aetna,First Health,,358.28,,,,,,,157.90,358.28,percent of total billed charges,
Cath Lab Conscious Sedation Addl 15 Mins,9012133,CDM,370,RC,99153,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,144.60,197.14,percent of total billed charges,
Cath Lab Conscious Sedation Addl 15 Mins,9012133,CDM,370,RC,99153,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,86.88,197.14,percent of total billed charges,
LRPC Washed,4327839,CDM,390,RC,P9022,HCPCS,,,facility,inpatient,,,679.00000,196.91000,Aetna,First Health,,555.42,,,,,,,407.40,555.42,percent of total billed charges,
LRPC Washed,4327839,CDM,390,RC,P9022,HCPCS,,,facility,outpatient,,,679.00000,196.91000,Aetna,First Health,,555.42,,,,,,,252.04,1059.29,percent of total billed charges,
LRPC QUAD IRRAD,2644864,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,684.00000,198.36000,Aetna,First Health,,559.51,,,,,,,410.40,559.51,percent of total billed charges,
LRPC QUAD IRRAD,2644864,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,684.00000,198.36000,Aetna,First Health,,559.51,,,,,,,224.60,682.75,percent of total billed charges,
CRYOPRECIPITATE,1856825,CDM,390,RC,P9012,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
CRYOPRECIPITATE,1856825,CDM,390,RC,P9012,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,40.46,169.67,percent of total billed charges,
CRYOPRECIPITATE,7962047,CDM,390,RC,P9012,HCPCS,,,facility,inpatient,,,113.00000,32.77000,Aetna,First Health,,92.43,,,,,,,67.80,92.43,percent of total billed charges,
CRYOPRECIPITATE,7962047,CDM,390,RC,P9012,HCPCS,,,facility,outpatient,,,113.00000,32.77000,Aetna,First Health,,92.43,,,,,,,41.95,169.67,percent of total billed charges,
Fresh Frozen Plasma,1427804,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Fresh Frozen Plasma,1427804,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,1870826,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
FRESH FROZEN PLASMA,1870826,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,1870828,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
FRESH FROZEN PLASMA,1870828,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,1870829,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
FRESH FROZEN PLASMA,1870829,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,2350824,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
FRESH FROZEN PLASMA,2350824,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,2350825,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
FRESH FROZEN PLASMA,2350825,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma CPD Th,3599840,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma CPD Th,3599840,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma CPDA 1 Th,3599844,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma CPDA 1 Th,3599844,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma CP2D Th,3599848,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma CP2D Th,3599848,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apher ACD A Th,3599856,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Apher ACD A Th,3599856,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apher NaCitrate Th,3599864,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Apher NaCitrate Th,3599864,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Fresh Frozen Plasma,3599872,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Fresh Frozen Plasma,3599872,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma CPDA 1 Th,3683841,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma CPDA 1 Th,3683841,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apheresis ACD A Th,4313841,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Apheresis ACD A Th,4313841,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apheresis ACD A Dv Th,4313842,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Apheresis ACD A Dv Th,4313842,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,614777,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
FRESH FROZEN PLASMA,614777,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma CP2D,6241845,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma CP2D,6241845,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,638930,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
FRESH FROZEN PLASMA,638930,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,7251842,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
FRESH FROZEN PLASMA,7251842,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,7251844,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
FRESH FROZEN PLASMA,7251844,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7734036,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7734036,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7734038,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7734038,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7734039,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7734039,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7734042,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7734042,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7738959,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7738959,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7742092,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7742092,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7742093,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7742093,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7754301,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7754301,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apheresis,7846077,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Apheresis,7846077,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apheresis,7846079,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Apheresis,7846079,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7852108,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7852108,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7852109,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7852109,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7852110,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7852110,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph 1st ACD A Frz 24h Th,7852111,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph 1st ACD A Frz 24h Th,7852111,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7852112,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph,7852112,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Thawed,8282307,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Thawed,8282307,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Thawed,8282308,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Thawed,8282308,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338191,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338191,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338192,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338192,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338193,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338193,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338197,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338197,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Convalescent Plasma COVID 19,8380456,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Convalescent Plasma COVID 19,8380456,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph ACD-A Frz 24h Th Dv E2284,9112429,CDM,390,RC,P9059,HCPCS,,,facility,inpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,82.80,112.88,percent of total billed charges,
Plasma Aph ACD-A Frz 24h Th Dv E2284,9112429,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,First Health,,112.88,,,,,,,51.23,189.76,percent of total billed charges,
PLATELETS PHERESIS LEUKORED REDUC,2502825,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
PLATELETS PHERESIS LEUKORED REDUC,2502825,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
PLATELETS PHERESIS LEUKORED REDUC,614807,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
PLATELETS PHERESIS LEUKORED REDUC,614807,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
PLATELETS PHERESIS LEUKORED REDUC,614808,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
PLATELETS PHERESIS LEUKORED REDUC,614808,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Platelets pheresis leukocytes reduced each unit,8282343,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Platelets pheresis leukocytes reduced each unit,8282343,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Platelets pheresis leukocytes reduced each unit,8282344,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Platelets pheresis leukocytes reduced each unit,8282344,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR less than 3 X log 11,8372252,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Aph Plt ACDA LR less than 3 X log 11,8372252,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR Bact Monitor 7D,8436691,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Aph Plt ACDA LR Bact Monitor 7D,8436691,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 1 Bact Monitor 7D,8436741,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Aph Plt ACDA LR 1 Bact Monitor 7D,8436741,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 1st less than 3E11 Bact Monitor7D,8436751,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Aph Plt ACDA LR 1st less than 3E11 Bact Monitor7D,8436751,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 2nd less than 3E11 Bact Monitor7D,8436752,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Aph Plt ACDA LR 2nd less than 3E11 Bact Monitor7D,8436752,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR Bact Monitor 7D,8436755,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Aph Plt ACDA LR Bact Monitor 7D,8436755,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 2 Bact Monitor 7D,8436757,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Aph Plt ACDA LR 2 Bact Monitor 7D,8436757,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 3rd less than 3E11 Bact Monitor7D,8436759,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Aph Plt ACDA LR 3rd less than 3E11 Bact Monitor7D,8436759,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 3 Bact Monitor 7D,8436762,CDM,390,RC,P9035,HCPCS,,,facility,inpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,942.00,1284.26,percent of total billed charges,
Aph Plt ACDA LR 3 Bact Monitor 7D,8436762,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,First Health,,1284.26,,,,,,,427.71,1300.12,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,2502826,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,2502826,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
Plate pheres leukoredu irrad,2644865,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Plate pheres leukoredu irrad,2644865,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607839,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607839,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607840,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607840,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607841,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607841,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607842,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607842,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607843,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607843,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 3 Bact Monitor 7D,8436753,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Aph Plt ACDA LR Irr 3 Bact Monitor 7D,8436753,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr less than 3E11 Bact Monitor7D,8436754,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Aph Plt ACDA LR Irr less than 3E11 Bact Monitor7D,8436754,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 2nd less than 3E11 Bact Monit,8436756,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Aph Plt ACDA LR Irr 2nd less than 3E11 Bact Monit,8436756,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 3rd less than 3E11 Bact Monit,8436758,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Aph Plt ACDA LR Irr 3rd less than 3E11 Bact Monit,8436758,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 1st less than 3E11 Bact Monit,8436760,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Aph Plt ACDA LR Irr 1st less than 3E11 Bact Monit,8436760,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr Bact Monitor 7D,8436761,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Aph Plt ACDA LR Irr Bact Monitor 7D,8436761,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 1 Bact Monitor 7D,8436763,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Aph Plt ACDA LR Irr 1 Bact Monitor 7D,8436763,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 2 Bact Monitor 7D,8436764,CDM,390,RC,P9037,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Aph Plt ACDA LR Irr 2 Bact Monitor 7D,8436764,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1803.40,percent of total billed charges,
LRPC IRRAD,1037811,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
LRPC IRRAD,1037811,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
LRPC IRRAD,1037812,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
LRPC IRRAD,1037812,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
LRPC IRRAD,2644838,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
LRPC IRRAD,2644838,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
LRPC IRRAD,614792,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
LRPC IRRAD,614792,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
LRPC Aph Irr AS1,7782063,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
LRPC Aph Irr AS1,7782063,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
LRPC IRRAD,7968682,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
LRPC IRRAD,7968682,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
LRPC IRRAD,7991271,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
LRPC IRRAD,7991271,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
LRPC Irradiated,8166085,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
LRPC Irradiated,8166085,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074168,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074168,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074171,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074171,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074175,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074175,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074180,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074180,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074185,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074185,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074186,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074186,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074189,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074189,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074190,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074190,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074194,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074194,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074195,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074195,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074200,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074200,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074205,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074205,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074210,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074210,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074214,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074214,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074217,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074217,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074218,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074218,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074220,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074220,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074221,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074221,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074223,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074223,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074226,CDM,390,RC,P9040,HCPCS,,,facility,inpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,471.60,642.95,percent of total billed charges,
RBC leukoreduced irradiated,9074226,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,First Health,,642.95,,,,,,,224.60,682.75,percent of total billed charges,
LRPC,614787,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
LRPC,614787,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,614788,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
LRPC,614788,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,7782064,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
LRPC,7782064,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,791798,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
LRPC,791798,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,791799,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
LRPC,791799,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,7968681,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
LRPC,7968681,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,7968815,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
LRPC,7968815,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282272,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282272,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282273,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282273,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282274,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282274,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282275,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282275,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282276,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282276,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
LRPC CPD 500mL,8986922,CDM,390,RC,P9016,HCPCS,,,facility,inpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,398.40,543.15,percent of total billed charges,
LRPC CPD 500mL,8986922,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,First Health,,543.15,,,,,,,159.80,543.15,percent of total billed charges,
Split Fee,2644858,CDM,390,RC,86985,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,96.00,130.88,percent of total billed charges,
Split Fee,2644858,CDM,390,RC,86985,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,30.37,457.39,percent of total billed charges,
Split Fee LRPC Irrad 1st,2644860,CDM,390,RC,86985,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,96.00,130.88,percent of total billed charges,
Split Fee LRPC Irrad 1st,2644860,CDM,390,RC,86985,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,30.37,457.39,percent of total billed charges,
SPLIT BLOOD PRODUCTS,2644861,CDM,390,RC,86985,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,96.00,130.88,percent of total billed charges,
SPLIT BLOOD PRODUCTS,2644861,CDM,390,RC,86985,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,,130.88,,,,,,,30.37,457.39,percent of total billed charges,
RBC Deglyc LR,6699839,CDM,390,RC,P9039,HCPCS,,,facility,inpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,829.80,1131.29,percent of total billed charges,
RBC Deglyc LR,6699839,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,306.86,1744.90,percent of total billed charges,
RBC Deglyc,7153865,CDM,390,RC,P9039,HCPCS,,,facility,inpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,829.80,1131.29,percent of total billed charges,
RBC Deglyc,7153865,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,306.86,1744.90,percent of total billed charges,
RBC Deglyc Aph LR,8148752,CDM,390,RC,P9039,HCPCS,,,facility,inpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,829.80,1131.29,percent of total billed charges,
RBC Deglyc Aph LR,8148752,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,306.86,1744.90,percent of total billed charges,
RBC Deglyc Aph LR,8148753,CDM,390,RC,P9039,HCPCS,,,facility,inpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,829.80,1131.29,percent of total billed charges,
RBC Deglyc Aph LR,8148753,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,306.86,1744.90,percent of total billed charges,
RBC Deglyc Aph LR,8148754,CDM,390,RC,P9039,HCPCS,,,facility,inpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,829.80,1131.29,percent of total billed charges,
RBC Deglyc Aph LR,8148754,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,306.86,1744.90,percent of total billed charges,
RBC Deglyc Aph LR Irr,8148755,CDM,390,RC,P9057,HCPCS,,,facility,inpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,829.80,1131.29,percent of total billed charges,
RBC Deglyc Aph LR Irr,8148755,CDM,390,RC,P9057,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,414.40,1295.51,percent of total billed charges,
RBC Deglyc Aph LR Irr,8148756,CDM,390,RC,P9057,HCPCS,,,facility,inpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,829.80,1131.29,percent of total billed charges,
RBC Deglyc Aph LR Irr,8148756,CDM,390,RC,P9057,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,414.40,1295.51,percent of total billed charges,
RBC Deglyc Aph LR Irr,8148757,CDM,390,RC,P9057,HCPCS,,,facility,inpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,829.80,1131.29,percent of total billed charges,
RBC Deglyc Aph LR Irr,8148757,CDM,390,RC,P9057,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,414.40,1295.51,percent of total billed charges,
RBC deglycerolized,9074209,CDM,390,RC,P9039,HCPCS,,,facility,inpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,829.80,1131.29,percent of total billed charges,
RBC deglycerolized,9074209,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,306.86,1744.90,percent of total billed charges,
RBC deglycerolized,9074215,CDM,390,RC,P9039,HCPCS,,,facility,inpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,829.80,1131.29,percent of total billed charges,
RBC deglycerolized,9074215,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,First Health,,1131.29,,,,,,,306.86,1744.90,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294242,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294242,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294243,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294243,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294244,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294244,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294245,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294245,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294246,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294246,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294247,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294247,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294248,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294248,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294249,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294249,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294250,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294250,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8438587,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8438587,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Aph Plt ACDA less than PASC LR 3,8438595,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Aph Plt ACDA less than PASC LR 3,8438595,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8438596,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8438596,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8438597,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8438597,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440034,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440034,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440035,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440035,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440036,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440036,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440037,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440037,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440532,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440532,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440533,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440533,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440534,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440534,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440535,CDM,390,RC,P9073,HCPCS,,,facility,inpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,686.40,935.79,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440535,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,First Health,,935.79,,,,,,,424.65,1567.49,percent of total billed charges,
Cryoprecipitatereducedplasma,9011157,CDM,390,RC,P9044,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
Cryoprecipitatereducedplasma,9011157,CDM,390,RC,P9044,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,54.57,393.15,percent of total billed charges,
Cryoprecipitatereducedplasma,9011158,CDM,390,RC,P9044,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
Cryoprecipitatereducedplasma,9011158,CDM,390,RC,P9044,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,54.57,393.15,percent of total billed charges,
Cryoprecipitatereducedplasma,9114412,CDM,390,RC,P9044,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,88.20,120.25,percent of total billed charges,
Cryoprecipitatereducedplasma,9114412,CDM,390,RC,P9044,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,First Health,,120.25,,,,,,,54.57,393.15,percent of total billed charges,
Transfusion Of Blood Products,1327806,CDM,391,RC,36430,HCPCS,,,facility,inpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,1527.60,2082.63,percent of total billed charges,
Transfusion Of Blood Products,1327806,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,383.87,2860.00,percent of total billed charges,
Transfusion Of Blood Products,7457914,CDM,391,RC,36430,HCPCS,,,facility,inpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,1527.60,2082.63,percent of total billed charges,
Transfusion Of Blood Products,7457914,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,383.87,2860.00,percent of total billed charges,
Transfusion Of Blood Products,7942782,CDM,391,RC,36430,HCPCS,,,facility,inpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,1527.60,2082.63,percent of total billed charges,
Transfusion Of Blood Products,7942782,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,383.87,2860.00,percent of total billed charges,
Transfusion Of Blood Products,7957584,CDM,391,RC,36430,HCPCS,,,facility,inpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,1527.60,2082.63,percent of total billed charges,
Transfusion Of Blood Products,7957584,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,383.87,2860.00,percent of total billed charges,
Transfusion of Blood Products,8924116,CDM,391,RC,36430,HCPCS,,,facility,inpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,1527.60,2082.63,percent of total billed charges,
Transfusion of Blood Products,8924116,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,383.87,2860.00,percent of total billed charges,
Transfusion of Blood Product,8997125,CDM,391,RC,36430,HCPCS,,,facility,inpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,1527.60,2082.63,percent of total billed charges,
Transfusion of Blood Product,8997125,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,383.87,2860.00,percent of total billed charges,
ER Transfusion Of Blood Products,602490,CDM,391,RC,36430,HCPCS,,,facility,inpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,1527.60,2082.63,percent of total billed charges,
ER Transfusion Of Blood Products,602490,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,First Health,,2082.63,,,,,,,383.87,2860.00,percent of total billed charges,
Mammo Bilateral Diagnostic Digital,1299805,CDM,401,RC,77066,HCPCS,,,facility,inpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,218.40,297.75,percent of total billed charges,
Mammo Bilateral Diagnostic Digital,1299805,CDM,401,RC,77066,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,135.12,307.99,percent of total billed charges,
Mammo Bilateral Diagnostic Digital,7910092,CDM,401,RC,77066,HCPCS,,,facility,inpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,218.40,297.75,percent of total billed charges,
Mammo Bilateral Diagnostic Digital,7910092,CDM,401,RC,77066,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,First Health,,297.75,,,,,,,135.12,307.99,percent of total billed charges,
Mammo Unilateral Right Diagnostic Digital,7846196,CDM,401,RC,77065,HCPCS,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,RT,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Mammo Unilateral Right Diagnostic Digital,7846196,CDM,401,RC,77065,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,RT,269.94,,,,,,,108.86,269.94,percent of total billed charges,
Mammmo Unilateral Right Diagnostic Digital,7910104,CDM,401,RC,77065,HCPCS,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,RT,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Mammmo Unilateral Right Diagnostic Digital,7910104,CDM,401,RC,77065,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,RT,269.94,,,,,,,108.86,269.94,percent of total billed charges,
Mammo Unilateral Left Diagnostic Digital,7846194,CDM,401,RC,77065,HCPCS,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,LT,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Mammo Unilateral Left Diagnostic Digital,7846194,CDM,401,RC,77065,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,LT,269.94,,,,,,,108.86,269.94,percent of total billed charges,
Mammo Unilateral Left Diagnostic Digital,7910100,CDM,401,RC,77065,HCPCS,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,LT,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Mammo Unilateral Left Diagnostic Digital,7910100,CDM,401,RC,77065,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,LT,269.94,,,,,,,108.86,269.94,percent of total billed charges,
Mammo Left Diagnostic Tomosynthesis,8001062,CDM,401,RC,G0279,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
Mammo Left Diagnostic Tomosynthesis,8001062,CDM,401,RC,G0279,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,29.70,80.73,percent of total billed charges,
Mammo Right Diagnostic Tomosynthesis,8001063,CDM,401,RC,G0279,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
Mammo Right Diagnostic Tomosynthesis,8001063,CDM,401,RC,G0279,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,29.70,80.73,percent of total billed charges,
Mammo Bilateral Diagnostic Tomosynthesis,8001068,CDM,401,RC,G0279,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
Mammo Bilateral Diagnostic Tomosynthesis,8001068,CDM,401,RC,G0279,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,29.70,80.73,percent of total billed charges,
Echo Guidance by Anesthesia,8786161,CDM,402,RC,,,,,facility,inpatient,,,425.00000,123.25000,Aetna,First Health,,347.65,,,,,,,255.00,347.65,percent of total billed charges,
Echo Guidance by Anesthesia,8786161,CDM,402,RC,,,,,facility,outpatient,,,425.00000,123.25000,Aetna,First Health,,347.65,,,,,,,153.21,347.65,percent of total billed charges,
Sono Neonatal Head,7762494,CDM,402,RC,76506,HCPCS,,,facility,inpatient,,,1011.00000,293.19000,Aetna,First Health,,827.00,,,,,,,606.60,827.00,percent of total billed charges,
Sono Neonatal Head,7762494,CDM,402,RC,76506,HCPCS,,,facility,outpatient,,,1011.00000,293.19000,Aetna,First Health,,827.00,,,,,,,53.29,827.00,percent of total billed charges,
Sono Soft Tissue Lower Back,7900438,CDM,402,RC,76705,HCPCS,,,facility,inpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,829.20,1130.48,percent of total billed charges,
Sono Soft Tissue Lower Back,7900438,CDM,402,RC,76705,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Abdomen Limited,7900442,CDM,402,RC,76705,HCPCS,,,facility,inpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,829.20,1130.48,percent of total billed charges,
Sono Abdomen Limited,7900442,CDM,402,RC,76705,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Vaginal OB,7762498,CDM,402,RC,76817,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono Vaginal OB,7762498,CDM,402,RC,76817,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,56.16,1219.64,percent of total billed charges,
Sono OB Transvaginal,7774178,CDM,402,RC,76817,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transvaginal,7774178,CDM,402,RC,76817,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,56.16,1219.64,percent of total billed charges,
Sono OB Transvaginal,7774182,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transvaginal,7774182,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,53.29,1219.64,percent of total billed charges,
SONO OB TRANSVAGINAL,7818042,CDM,402,RC,76817,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
SONO OB TRANSVAGINAL,7818042,CDM,402,RC,76817,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,56.16,1219.64,percent of total billed charges,
Sono OB Transvaginal,8001029,CDM,402,RC,76817,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transvaginal,8001029,CDM,402,RC,76817,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,56.16,1219.64,percent of total billed charges,
Sono Pelvis Limited,7900177,CDM,402,RC,76857,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Pelvis Limited,7900177,CDM,402,RC,76857,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,62.92,870.35,percent of total billed charges,
Sono Pelvis Limited,7900181,CDM,402,RC,76857,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Pelvis Limited,7900181,CDM,402,RC,76857,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,62.92,870.35,percent of total billed charges,
Sono Pelvis Limited,7900434,CDM,402,RC,76857,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Pelvis Limited,7900434,CDM,402,RC,76857,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,62.92,870.35,percent of total billed charges,
Sono Obstetrical Follow Up,7774186,CDM,402,RC,76816,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,7774186,CDM,402,RC,76816,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,41.57,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,7774190,CDM,402,RC,76816,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,7774190,CDM,402,RC,76816,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,41.57,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,7774194,CDM,402,RC,76816,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,7774194,CDM,402,RC,76816,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,41.57,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,7913724,CDM,402,RC,76816,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,7913724,CDM,402,RC,76816,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,41.57,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,8001052,CDM,402,RC,76816,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,8001052,CDM,402,RC,76816,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,41.57,696.94,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762477,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762477,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762478,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762478,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762482,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762482,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762484,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762484,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB 12 to 14 Weeks Twins,7900194,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB 12 to 14 Weeks Twins,7900194,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7900197,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7900197,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB less than 14 weeks,8148590,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB less than 14 weeks,8148590,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB less than 14 Weeks,8148592,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB less than 14 Weeks,8148592,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB less than 14 weeks w TV,8148593,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB less than 14 weeks w TV,8148593,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB less than 14 weeks,8158019,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB less than 14 weeks,8158019,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono Guidance,8001053,CDM,402,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
Sono Guidance,8001053,CDM,402,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,981.60,percent of total billed charges,
Sono Guided Localization,8001076,CDM,402,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
Sono Guided Localization,8001076,CDM,402,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,981.60,percent of total billed charges,
SONO OB PELVIS LT14WKS ADDL,7145842,CDM,402,RC,76802,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
SONO OB PELVIS LT14WKS ADDL,7145842,CDM,402,RC,76802,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,41.51,348.47,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks Additional,8001055,CDM,402,RC,76802,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks Additional,8001055,CDM,402,RC,76802,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,41.51,348.47,percent of total billed charges,
Sono OB Detailed,7913715,CDM,402,RC,76811,HCPCS,,,facility,inpatient,,,1379.00000,399.91000,Aetna,First Health,,1128.02,,,,,,,827.40,1128.02,percent of total billed charges,
Sono OB Detailed,7913715,CDM,402,RC,76811,HCPCS,,,facility,outpatient,,,1379.00000,399.91000,Aetna,First Health,,1128.02,,,,,,,96.14,1128.02,percent of total billed charges,
SONO OB DETAILED ADDITIONAL,7913716,CDM,402,RC,76812,HCPCS,,,facility,inpatient,,,613.00000,177.77000,Aetna,First Health,,501.43,,,,,,,367.80,501.43,percent of total billed charges,
SONO OB DETAILED ADDITIONAL,7913716,CDM,402,RC,76812,HCPCS,,,facility,outpatient,,,613.00000,177.77000,Aetna,First Health,,501.43,,,,,,,51.52,501.43,percent of total billed charges,
Sono OB Detailed Additional Fetus,8001056,CDM,402,RC,76812,HCPCS,,,facility,inpatient,,,613.00000,177.77000,Aetna,First Health,,501.43,,,,,,,367.80,501.43,percent of total billed charges,
Sono OB Detailed Additional Fetus,8001056,CDM,402,RC,76812,HCPCS,,,facility,outpatient,,,613.00000,177.77000,Aetna,First Health,,501.43,,,,,,,51.52,501.43,percent of total billed charges,
Sono Abdominal Aortic Aneurysm Screening,6095843,CDM,402,RC,76706,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,383.40,522.70,percent of total billed charges,
Sono Abdominal Aortic Aneurysm Screening,6095843,CDM,402,RC,76706,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,93.38,522.70,percent of total billed charges,
Sono Abdominal Aortic Aneurysm Screening,8150278,CDM,402,RC,76706,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,383.40,522.70,percent of total billed charges,
Sono Abdominal Aortic Aneurysm Screening,8150278,CDM,402,RC,76706,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,93.38,522.70,percent of total billed charges,
Sono Obstetrical Biophysical Profile,8001057,CDM,402,RC,76819,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono Obstetrical Biophysical Profile,8001057,CDM,402,RC,76819,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,60.74,1219.64,percent of total billed charges,
Sono Hips Infant with Manipulation,7964738,CDM,402,RC,76885,HCPCS,,,facility,inpatient,,,388.00000,112.52000,Aetna,First Health,,317.38,,,,,,,232.80,317.38,percent of total billed charges,
Sono Hips Infant with Manipulation,7964738,CDM,402,RC,76885,HCPCS,,,facility,outpatient,,,388.00000,112.52000,Aetna,First Health,,317.38,,,,,,,57.54,317.38,percent of total billed charges,
Sono Hips Infant without Manipulation,7964742,CDM,402,RC,76886,HCPCS,,,facility,inpatient,,,388.00000,112.52000,Aetna,First Health,,317.38,,,,,,,232.80,317.38,percent of total billed charges,
Sono Hips Infant without Manipulation,7964742,CDM,402,RC,76886,HCPCS,,,facility,outpatient,,,388.00000,112.52000,Aetna,First Health,,317.38,,,,,,,53.29,317.38,percent of total billed charges,
Sono Extremity Complete Bilateral,7917956,CDM,402,RC,76881,HCPCS,,,facility,inpatient,,,2458.00000,712.82000,Aetna,First Health,,2010.64,,,,,,,1474.80,2010.64,percent of total billed charges,
Sono Extremity Complete Bilateral,7917956,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,2458.00000,712.82000,Aetna,First Health,,2010.64,,,,,,,80.94,2010.64,percent of total billed charges,
Sono Extremity Complete Bilateral,7918015,CDM,402,RC,76881,HCPCS,,,facility,inpatient,,,2458.00000,712.82000,Aetna,First Health,,2010.64,,,,,,,1474.80,2010.64,percent of total billed charges,
Sono Extremity Complete Bilateral,7918015,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,2458.00000,712.82000,Aetna,First Health,,2010.64,,,,,,,80.94,2010.64,percent of total billed charges,
Sono Extremity Complete Bilat,8148163,CDM,402,RC,76881,HCPCS,,,facility,inpatient,,,2458.00000,712.82000,Aetna,First Health,,2010.64,,,,,,,1474.80,2010.64,percent of total billed charges,
Sono Extremity Complete Bilat,8148163,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,2458.00000,712.82000,Aetna,First Health,,2010.64,,,,,,,80.94,2010.64,percent of total billed charges,
Sono Breast Limited Bilateral,7790371,CDM,402,RC,76642,HCPCS,,,facility,inpatient,,,1332.00000,386.28000,Aetna,First Health,,1089.58,,,,,,,799.20,1089.58,percent of total billed charges,
Sono Breast Limited Bilateral,7790371,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,First Health,,1089.58,,,,,,,77.31,1089.58,percent of total billed charges,
Sono Breaat Limited Bilat,8148162,CDM,402,RC,76642,HCPCS,,,facility,inpatient,,,1332.00000,386.28000,Aetna,First Health,,1089.58,,,,,,,799.20,1089.58,percent of total billed charges,
Sono Breaat Limited Bilat,8148162,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,First Health,,1089.58,,,,,,,77.31,1089.58,percent of total billed charges,
Sono Breast Complete Bilateral,7790367,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,1782.00000,516.78000,Aetna,First Health,,1457.68,,,,,,,1069.20,1457.68,percent of total billed charges,
Sono Breast Complete Bilateral,7790367,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,1782.00000,516.78000,Aetna,First Health,,1457.68,,,,,,,93.38,1457.68,percent of total billed charges,
Sono Breast Bilat Complete,8148161,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,1782.00000,516.78000,Aetna,First Health,,1457.68,,,,,,,1069.20,1457.68,percent of total billed charges,
Sono Breast Bilat Complete,8148161,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,1782.00000,516.78000,Aetna,First Health,,1457.68,,,,,,,93.38,1457.68,percent of total billed charges,
Sono Breast Automated Complete Bilat,9060801,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,1782.00000,516.78000,Aetna,First Health,,1457.68,,,,,,,1069.20,1457.68,percent of total billed charges,
Sono Breast Automated Complete Bilat,9060801,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,1782.00000,516.78000,Aetna,First Health,,1457.68,,,,,,,93.38,1457.68,percent of total billed charges,
Sono Extremity Limited Bilateral,7856090,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,1022.40,1393.87,percent of total billed charges,
Sono Extremity Limited Bilateral,7856090,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,9.63,1393.87,percent of total billed charges,
Sono Extremity Limited Bilateral,7917991,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,1022.40,1393.87,percent of total billed charges,
Sono Extremity Limited Bilateral,7917991,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,9.63,1393.87,percent of total billed charges,
Sono Extremity Bilateral Limited,7918003,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,1022.40,1393.87,percent of total billed charges,
Sono Extremity Bilateral Limited,7918003,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,9.63,1393.87,percent of total billed charges,
Sono Extremity Bilateral Limited,7938015,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,1022.40,1393.87,percent of total billed charges,
Sono Extremity Bilateral Limited,7938015,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,9.63,1393.87,percent of total billed charges,
Sono Extremity Bilat Limited,8148160,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,1022.40,1393.87,percent of total billed charges,
Sono Extremity Bilat Limited,8148160,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,First Health,,1393.87,,,,,,,9.63,1393.87,percent of total billed charges,
Sono Axilla Breast Bilateral,8181328,CDM,402,RC,76642,HCPCS,,,facility,inpatient,,,1332.00000,386.28000,Aetna,First Health,,1089.58,,,,,,,799.20,1089.58,percent of total billed charges,
Sono Axilla Breast Bilateral,8181328,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,First Health,,1089.58,,,,,,,77.31,1089.58,percent of total billed charges,
Sono Axilla Breast Right,8181324,CDM,402,RC,76642,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,RT,544.79,,,,,,,399.60,544.79,percent of total billed charges,
Sono Axilla Breast Right,8181324,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,RT,544.79,,,,,,,77.89,544.79,percent of total billed charges,
Sono Axilla Breast Left,8181326,CDM,402,RC,76642,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,First Health,LT,544.79,,,,,,,399.60,544.79,percent of total billed charges,
Sono Axilla Breast Left,8181326,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,First Health,LT,544.79,,,,,,,77.89,544.79,percent of total billed charges,
Sono Chest Upper Back Limited,7900426,CDM,402,RC,76604,HCPCS,,,facility,inpatient,,,961.00000,278.69000,Aetna,First Health,,786.10,,,,,,,576.60,786.10,percent of total billed charges,
Sono Chest Upper Back Limited,7900426,CDM,402,RC,76604,HCPCS,,,facility,outpatient,,,961.00000,278.69000,Aetna,First Health,,786.10,,,,,,,49.03,786.10,percent of total billed charges,
Sono Chest Upper Back Limited,7900430,CDM,402,RC,76604,HCPCS,,,facility,inpatient,,,961.00000,278.69000,Aetna,First Health,,786.10,,,,,,,576.60,786.10,percent of total billed charges,
Sono Chest Upper Back Limited,7900430,CDM,402,RC,76604,HCPCS,,,facility,outpatient,,,961.00000,278.69000,Aetna,First Health,,786.10,,,,,,,49.03,786.10,percent of total billed charges,
Sono Retroperitoneal Limited,613948,CDM,402,RC,76775,HCPCS,,,facility,inpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,829.20,1130.48,percent of total billed charges,
Sono Retroperitoneal Limited,613948,CDM,402,RC,76775,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Retroperitoneal Limited,7900185,CDM,402,RC,76775,HCPCS,,,facility,inpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,829.20,1130.48,percent of total billed charges,
Sono Retroperitoneal Limited,7900185,CDM,402,RC,76775,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Extremity Right Limited,7790347,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,RT,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Extremity Right Limited,7790347,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,RT,696.94,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Limited Right,7917995,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,RT,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Extremity Limited Right,7917995,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,RT,696.94,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Right Limited,7918007,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,RT,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Extremity Right Limited,7918007,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,RT,696.94,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Limited Right,7949919,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,RT,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Extremity Limited Right,7949919,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,RT,696.94,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Right Limited,8148239,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,RT,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Extremity Right Limited,8148239,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,RT,696.94,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Left Limited,7790351,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,LT,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Extremity Left Limited,7790351,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,LT,696.94,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Limited Left,7917999,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,LT,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Extremity Limited Left,7917999,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,LT,696.94,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Left Limited,7918011,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,LT,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Extremity Left Limited,7918011,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,LT,696.94,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Limited Left,7949916,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,LT,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Extremity Limited Left,7949916,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,LT,696.94,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Left Limited,8148238,CDM,402,RC,76882,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,LT,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Sono Extremity Left Limited,8148238,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,LT,696.94,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Complete Right,7917983,CDM,402,RC,76881,HCPCS,,,facility,inpatient,,,1229.00000,356.41000,Aetna,First Health,RT,1005.32,,,,,,,737.40,1005.32,percent of total billed charges,
Sono Extremity Complete Right,7917983,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,First Health,RT,1005.32,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Extremity Right Complete,7918019,CDM,402,RC,76881,HCPCS,,,facility,inpatient,,,1229.00000,356.41000,Aetna,First Health,RT,1005.32,,,,,,,737.40,1005.32,percent of total billed charges,
Sono Extremity Right Complete,7918019,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,First Health,RT,1005.32,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Extremity Complete Right,8148243,CDM,402,RC,76881,HCPCS,,,facility,inpatient,,,1229.00000,356.41000,Aetna,First Health,RT,1005.32,,,,,,,737.40,1005.32,percent of total billed charges,
Sono Extremity Complete Right,8148243,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,First Health,RT,1005.32,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Extremity Complete Left,7917987,CDM,402,RC,76881,HCPCS,,,facility,inpatient,,,1229.00000,356.41000,Aetna,First Health,LT,1005.32,,,,,,,737.40,1005.32,percent of total billed charges,
Sono Extremity Complete Left,7917987,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,First Health,LT,1005.32,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Extremity Left Complete,7918023,CDM,402,RC,76881,HCPCS,,,facility,inpatient,,,1229.00000,356.41000,Aetna,First Health,LT,1005.32,,,,,,,737.40,1005.32,percent of total billed charges,
Sono Extremity Left Complete,7918023,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,First Health,LT,1005.32,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Extremity Complete Left,8148242,CDM,402,RC,76881,HCPCS,,,facility,inpatient,,,1229.00000,356.41000,Aetna,First Health,LT,1005.32,,,,,,,737.40,1005.32,percent of total billed charges,
Sono Extremity Complete Left,8148242,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,First Health,LT,1005.32,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Perinatal OB Fetal MCA Doppler,7913736,CDM,402,RC,76821,HCPCS,,,facility,inpatient,,,484.00000,140.36000,Aetna,First Health,,395.91,,,,,,,290.40,395.91,percent of total billed charges,
Sono Perinatal OB Fetal MCA Doppler,7913736,CDM,402,RC,76821,HCPCS,,,facility,outpatient,,,484.00000,140.36000,Aetna,First Health,,395.91,,,,,,,61.43,663.49,percent of total billed charges,
Sono Perinatal Fetal MCA Doppler,7913748,CDM,402,RC,76821,HCPCS,,,facility,inpatient,,,484.00000,140.36000,Aetna,First Health,,395.91,,,,,,,290.40,395.91,percent of total billed charges,
Sono Perinatal Fetal MCA Doppler,7913748,CDM,402,RC,76821,HCPCS,,,facility,outpatient,,,484.00000,140.36000,Aetna,First Health,,395.91,,,,,,,61.43,663.49,percent of total billed charges,
SONO OB TRANSABD GT14WKS ADDL,7145844,CDM,402,RC,76810,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
SONO OB TRANSABD GT14WKS ADDL,7145844,CDM,402,RC,76810,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,44.95,348.47,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks Additional,8001070,CDM,402,RC,76810,HCPCS,,,facility,inpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,255.60,348.47,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks Additional,8001070,CDM,402,RC,76810,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,First Health,,348.47,,,,,,,44.95,348.47,percent of total billed charges,
Sono OB Transabd GT 14 Weeks,7762470,CDM,402,RC,76805,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transabd GT 14 Weeks,7762470,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7762472,CDM,402,RC,76805,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7762472,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7762473,CDM,402,RC,76805,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7762473,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7762474,CDM,402,RC,76805,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7762474,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabd GT 14 Weeks,7762483,CDM,402,RC,76805,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transabd GT 14 Weeks,7762483,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7790356,CDM,402,RC,76805,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7790356,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7790360,CDM,402,RC,76805,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7790360,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7790364,CDM,402,RC,76805,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7790364,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,79.23,1219.64,percent of total billed charges,
SONO OB UMBILICAL DOPPLER,7844138,CDM,402,RC,76820,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,383.40,522.70,percent of total billed charges,
SONO OB UMBILICAL DOPPLER,7844138,CDM,402,RC,76820,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,61.43,522.70,percent of total billed charges,
Sono OB Umbilical Doppler,7913732,CDM,402,RC,76820,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,383.40,522.70,percent of total billed charges,
Sono OB Umbilical Doppler,7913732,CDM,402,RC,76820,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,61.43,522.70,percent of total billed charges,
Sono Umbilical Doppler,8001072,CDM,402,RC,76820,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,383.40,522.70,percent of total billed charges,
Sono Umbilical Doppler,8001072,CDM,402,RC,76820,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,61.43,522.70,percent of total billed charges,
Sono Breast Complete Left,7790331,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,LT,728.84,,,,,,,534.60,728.84,percent of total billed charges,
Sono Breast Complete Left,7790331,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,LT,728.84,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Left Complete,8148240,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,LT,728.84,,,,,,,534.60,728.84,percent of total billed charges,
Sono Breast Left Complete,8148240,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,LT,728.84,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast LT Complete,8245914,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,LT,728.84,,,,,,,534.60,728.84,percent of total billed charges,
Sono Breast LT Complete,8245914,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,LT,728.84,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Automated Complete LT,9057731,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,LT,728.84,,,,,,,534.60,728.84,percent of total billed charges,
Sono Breast Automated Complete LT,9057731,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,LT,728.84,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Limited,7790335,CDM,402,RC,76642,HCPCS,,,facility,inpatient,,,1332.00000,386.28000,Aetna,First Health,LT,1089.58,,,,,,,799.20,1089.58,percent of total billed charges,
Sono Breast Limited,7790335,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,First Health,LT,1089.58,,,,,,,77.89,1089.58,percent of total billed charges,
Sono Breast Limited Left,8148697,CDM,402,RC,76642,HCPCS,,,facility,inpatient,,,1332.00000,386.28000,Aetna,First Health,LT,1089.58,,,,,,,799.20,1089.58,percent of total billed charges,
Sono Breast Limited Left,8148697,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,First Health,LT,1089.58,,,,,,,77.89,1089.58,percent of total billed charges,
Sono Breast LT Limited,8245960,CDM,402,RC,76642,HCPCS,,,facility,inpatient,,,1332.00000,386.28000,Aetna,First Health,LT,1089.58,,,,,,,799.20,1089.58,percent of total billed charges,
Sono Breast LT Limited,8245960,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,First Health,LT,1089.58,,,,,,,77.89,1089.58,percent of total billed charges,
Sono Breast Complete Right,7790339,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,RT,728.84,,,,,,,534.60,728.84,percent of total billed charges,
Sono Breast Complete Right,7790339,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,RT,728.84,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Right Complete,8148241,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,RT,728.84,,,,,,,534.60,728.84,percent of total billed charges,
Sono Breast Right Complete,8148241,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,RT,728.84,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast RT Complete,8245915,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,RT,728.84,,,,,,,534.60,728.84,percent of total billed charges,
Sono Breast RT Complete,8245915,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,RT,728.84,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Automated Complete RT,9060802,CDM,402,RC,76641,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,First Health,RT,728.84,,,,,,,534.60,728.84,percent of total billed charges,
Sono Breast Automated Complete RT,9060802,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,First Health,RT,728.84,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Limited,7790343,CDM,402,RC,76642,HCPCS,,,facility,inpatient,,,1332.00000,386.28000,Aetna,First Health,RT,1089.58,,,,,,,799.20,1089.58,percent of total billed charges,
Sono Breast Limited,7790343,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,First Health,RT,1089.58,,,,,,,77.89,1089.58,percent of total billed charges,
Sono Breast Limited Right,8148704,CDM,402,RC,76642,HCPCS,,,facility,inpatient,,,1332.00000,386.28000,Aetna,First Health,RT,1089.58,,,,,,,799.20,1089.58,percent of total billed charges,
Sono Breast Limited Right,8148704,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,First Health,RT,1089.58,,,,,,,77.89,1089.58,percent of total billed charges,
Sono Temporal Artery Doppler Right,8973070,CDM,402,RC,93882,HCPCS,,,facility,inpatient,,,978.00000,283.62000,Aetna,First Health,,800.00,,,,,,,586.80,800.00,percent of total billed charges,
Sono Temporal Artery Doppler Right,8973070,CDM,402,RC,93882,HCPCS,,,facility,outpatient,,,978.00000,283.62000,Aetna,First Health,,800.00,,,,,,,93.38,800.00,percent of total billed charges,
Sono Temporal Artery Doppler Left,8973068,CDM,402,RC,93882,HCPCS,,,facility,inpatient,,,978.00000,283.62000,Aetna,First Health,,800.00,,,,,,,586.80,800.00,percent of total billed charges,
Sono Temporal Artery Doppler Left,8973068,CDM,402,RC,93882,HCPCS,,,facility,outpatient,,,978.00000,283.62000,Aetna,First Health,,800.00,,,,,,,93.38,800.00,percent of total billed charges,
Sono Temporal Artery Doppler Left,8975182,CDM,402,RC,93882,HCPCS,,,facility,inpatient,,,978.00000,283.62000,Aetna,First Health,,800.00,,,,,,,586.80,800.00,percent of total billed charges,
Sono Temporal Artery Doppler Left,8975182,CDM,402,RC,93882,HCPCS,,,facility,outpatient,,,978.00000,283.62000,Aetna,First Health,,800.00,,,,,,,93.38,800.00,percent of total billed charges,
Sono Temporal Artery Doppler Bilateral,8973066,CDM,402,RC,93882,HCPCS,,,facility,inpatient,,,978.00000,283.62000,Aetna,First Health,,800.00,,,,,,,586.80,800.00,percent of total billed charges,
Sono Temporal Artery Doppler Bilateral,8973066,CDM,402,RC,93882,HCPCS,,,facility,outpatient,,,978.00000,283.62000,Aetna,First Health,,800.00,,,,,,,93.38,800.00,percent of total billed charges,
Sono Obstetrical Limited,7762486,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762486,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762488,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762488,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762490,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762490,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762491,CDM,402,RC,76820,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762491,CDM,402,RC,76820,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,61.43,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762496,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762496,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762497,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762497,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774174,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774174,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774198,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774198,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774202,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774202,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774206,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774206,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774210,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774210,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774226,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774226,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7808059,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7808059,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7808063,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7808063,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7846226,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7846226,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7846228,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7846228,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7900201,CDM,402,RC,76801,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7900201,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,79.23,870.35,percent of total billed charges,
Sono Obstetrical Limited,7913720,CDM,402,RC,76815,HCPCS,,,facility,inpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,638.40,870.35,percent of total billed charges,
Sono Obstetrical Limited,7913720,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,First Health,,870.35,,,,,,,53.29,870.35,percent of total billed charges,
Sono Abdomen,2052844,CDM,402,RC,76700,HCPCS,,,facility,inpatient,,,1895.00000,549.55000,Aetna,First Health,,1550.11,,,,,,,1137.00,1550.11,percent of total billed charges,
Sono Abdomen,2052844,CDM,402,RC,76700,HCPCS,,,facility,outpatient,,,1895.00000,549.55000,Aetna,First Health,,1550.11,,,,,,,74.25,1550.11,percent of total billed charges,
Sono Abdomen,2052848,CDM,402,RC,76700,HCPCS,,,facility,inpatient,,,1895.00000,549.55000,Aetna,First Health,,1550.11,,,,,,,1137.00,1550.11,percent of total billed charges,
Sono Abdomen,2052848,CDM,402,RC,76700,HCPCS,,,facility,outpatient,,,1895.00000,549.55000,Aetna,First Health,,1550.11,,,,,,,74.25,1550.11,percent of total billed charges,
Sono Abdomen,613923,CDM,402,RC,76700,HCPCS,,,facility,inpatient,,,1895.00000,549.55000,Aetna,First Health,,1550.11,,,,,,,1137.00,1550.11,percent of total billed charges,
Sono Abdomen,613923,CDM,402,RC,76700,HCPCS,,,facility,outpatient,,,1895.00000,549.55000,Aetna,First Health,,1550.11,,,,,,,74.25,1550.11,percent of total billed charges,
Sono Retroperitoneal Complete,614089,CDM,402,RC,76770,HCPCS,,,facility,inpatient,,,1895.00000,549.55000,Aetna,First Health,,1550.11,,,,,,,1137.00,1550.11,percent of total billed charges,
Sono Retroperitoneal Complete,614089,CDM,402,RC,76770,HCPCS,,,facility,outpatient,,,1895.00000,549.55000,Aetna,First Health,,1550.11,,,,,,,74.25,1550.11,percent of total billed charges,
Sono Retroperitoneal Complete,7900416,CDM,402,RC,76770,HCPCS,,,facility,inpatient,,,1895.00000,549.55000,Aetna,First Health,,1550.11,,,,,,,1137.00,1550.11,percent of total billed charges,
Sono Retroperitoneal Complete,7900416,CDM,402,RC,76770,HCPCS,,,facility,outpatient,,,1895.00000,549.55000,Aetna,First Health,,1550.11,,,,,,,74.25,1550.11,percent of total billed charges,
Sono Vaginal Non OB,1519811,CDM,402,RC,76830,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono Vaginal Non OB,1519811,CDM,402,RC,76830,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,57.54,1219.64,percent of total billed charges,
Sono Vaginal NonOB,8001075,CDM,402,RC,76830,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono Vaginal NonOB,8001075,CDM,402,RC,76830,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,57.54,1219.64,percent of total billed charges,
Sono Vaginal Non OB,8148208,CDM,402,RC,76830,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Sono Vaginal Non OB,8148208,CDM,402,RC,76830,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,57.54,1219.64,percent of total billed charges,
Sono Soft Tissue Head and Neck,614125,CDM,402,RC,76536,HCPCS,,,facility,inpatient,,,1278.00000,370.62000,Aetna,First Health,,1045.40,,,,,,,766.80,1045.40,percent of total billed charges,
Sono Soft Tissue Head and Neck,614125,CDM,402,RC,76536,HCPCS,,,facility,outpatient,,,1278.00000,370.62000,Aetna,First Health,,1045.40,,,,,,,53.29,1045.40,percent of total billed charges,
Sono Soft Tissue Head and Neck,614159,CDM,402,RC,76536,HCPCS,,,facility,inpatient,,,1278.00000,370.62000,Aetna,First Health,,1045.40,,,,,,,766.80,1045.40,percent of total billed charges,
Sono Soft Tissue Head and Neck,614159,CDM,402,RC,76536,HCPCS,,,facility,outpatient,,,1278.00000,370.62000,Aetna,First Health,,1045.40,,,,,,,53.29,1045.40,percent of total billed charges,
Sono Soft Tissue Head and Neck,7900422,CDM,402,RC,76536,HCPCS,,,facility,inpatient,,,1278.00000,370.62000,Aetna,First Health,,1045.40,,,,,,,766.80,1045.40,percent of total billed charges,
Sono Soft Tissue Head and Neck,7900422,CDM,402,RC,76536,HCPCS,,,facility,outpatient,,,1278.00000,370.62000,Aetna,First Health,,1045.40,,,,,,,53.29,1045.40,percent of total billed charges,
Sono Testicle with Doppler,614153,CDM,402,RC,76870,HCPCS,,,facility,inpatient,,,1174.00000,340.46000,Aetna,First Health,,960.33,,,,,,,704.40,960.33,percent of total billed charges,
Sono Testicle with Doppler,614153,CDM,402,RC,76870,HCPCS,,,facility,outpatient,,,1174.00000,340.46000,Aetna,First Health,,960.33,,,,,,,57.54,960.33,percent of total billed charges,
Sono Abdomen Limited,2052846,CDM,402,RC,76705,HCPCS,,,facility,inpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,829.20,1130.48,percent of total billed charges,
Sono Abdomen Limited,2052846,CDM,402,RC,76705,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Abdomen Limited,613937,CDM,402,RC,76705,HCPCS,,,facility,inpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,829.20,1130.48,percent of total billed charges,
Sono Abdomen Limited,613937,CDM,402,RC,76705,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Abdomen Limited,614143,CDM,402,RC,76705,HCPCS,,,facility,inpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,829.20,1130.48,percent of total billed charges,
Sono Abdomen Limited,614143,CDM,402,RC,76705,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,First Health,,1130.48,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Pelvis,613975,CDM,402,RC,76856,HCPCS,,,facility,inpatient,,,1062.00000,307.98000,Aetna,First Health,,868.72,,,,,,,637.20,868.72,percent of total billed charges,
Sono Pelvis,613975,CDM,402,RC,76856,HCPCS,,,facility,outpatient,,,1062.00000,307.98000,Aetna,First Health,,868.72,,,,,,,57.54,868.72,percent of total billed charges,
Sono Pelvis,7740859,CDM,402,RC,76856,HCPCS,,,facility,inpatient,,,1062.00000,307.98000,Aetna,First Health,,868.72,,,,,,,637.20,868.72,percent of total billed charges,
Sono Pelvis,7740859,CDM,402,RC,76856,HCPCS,,,facility,outpatient,,,1062.00000,307.98000,Aetna,First Health,,868.72,,,,,,,57.54,868.72,percent of total billed charges,
Sono Pelvis Limited,7900418,CDM,402,RC,76857,HCPCS,,,facility,inpatient,,,1062.00000,307.98000,Aetna,First Health,,868.72,,,,,,,637.20,868.72,percent of total billed charges,
Sono Pelvis Limited,7900418,CDM,402,RC,76857,HCPCS,,,facility,outpatient,,,1062.00000,307.98000,Aetna,First Health,,868.72,,,,,,,62.92,868.72,percent of total billed charges,
Sono Guidance in Surgery,646951,CDM,402,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
Sono Guidance in Surgery,646951,CDM,402,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,432.60,981.60,percent of total billed charges,
Sono Carotid Duplex,614000,CDM,402,RC,93880,HCPCS,,,facility,inpatient,,,1943.00000,563.47000,Aetna,First Health,,1589.37,,,,,,,1165.80,1589.37,percent of total billed charges,
Sono Carotid Duplex,614000,CDM,402,RC,93880,HCPCS,,,facility,outpatient,,,1943.00000,563.47000,Aetna,First Health,,1589.37,,,,,,,212.24,1589.37,percent of total billed charges,
Sono Pseudoaneurysm Compression,614135,CDM,402,RC,76936,HCPCS,,,facility,inpatient,,,1180.00000,342.20000,Aetna,First Health,,965.24,,,,,,,708.00,965.24,percent of total billed charges,
Sono Pseudoaneurysm Compression,614135,CDM,402,RC,76936,HCPCS,,,facility,outpatient,,,1180.00000,342.20000,Aetna,First Health,,965.24,,,,,,,150.37,965.24,percent of total billed charges,
Sono Chest,614006,CDM,402,RC,76604,HCPCS,,,facility,inpatient,,,961.00000,278.69000,Aetna,First Health,,786.10,,,,,,,576.60,786.10,percent of total billed charges,
Sono Chest,614006,CDM,402,RC,76604,HCPCS,,,facility,outpatient,,,961.00000,278.69000,Aetna,First Health,,786.10,,,,,,,49.03,786.10,percent of total billed charges,
Ultrasound Guidance,9160404,CDM,402,RC,,,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,900.00,1227.00,percent of total billed charges,
Ultrasound Guidance,9160404,CDM,402,RC,,,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,540.75,1227.00,percent of total billed charges,
MM Mammo Same Day Screening 3D,8159811,CDM,403,RC,77067,HCPCS,,,facility,inpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,169.80,231.49,percent of total billed charges,
MM Mammo Same Day Screening 3D,8159811,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,105.05,247.47,percent of total billed charges,
Mammo Screening Digital,1299801,CDM,403,RC,77067,HCPCS,,,facility,inpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,169.80,231.49,percent of total billed charges,
Mammo Screening Digital,1299801,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,105.05,247.47,percent of total billed charges,
Mammogram Screening Digital,7910096,CDM,403,RC,77067,HCPCS,,,facility,inpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,169.80,231.49,percent of total billed charges,
Mammogram Screening Digital,7910096,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,105.05,247.47,percent of total billed charges,
MM Mammo 3D Screening with Sono As Needed,8380179,CDM,403,RC,77067,HCPCS,,,facility,inpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,169.80,231.49,percent of total billed charges,
MM Mammo 3D Screening with Sono As Needed,8380179,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,105.05,247.47,percent of total billed charges,
Mammo Screening Tomosynthesis,8001067,CDM,403,RC,77063,HCPCS,,,facility,inpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
Mammo Screening Tomosynthesis,8001067,CDM,403,RC,77063,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,29.70,101.41,percent of total billed charges,
MM Mammo 3D Screening Left,9162396,CDM,403,RC,77067,HCPCS,,,facility,inpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,169.80,231.49,percent of total billed charges,
MM Mammo 3D Screening Left,9162396,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,105.05,247.47,percent of total billed charges,
MM Mammo 3D Screening Right,9164392,CDM,403,RC,77067,HCPCS,,,facility,inpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,169.80,231.49,percent of total billed charges,
MM Mammo 3D Screening Right,9164392,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,105.05,247.47,percent of total billed charges,
MM Screening Digital Left,9162402,CDM,403,RC,77067,HCPCS,,,facility,inpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,169.80,231.49,percent of total billed charges,
MM Screening Digital Left,9162402,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,105.05,247.47,percent of total billed charges,
MM Screening Digital Right,9162404,CDM,403,RC,77067,HCPCS,,,facility,inpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,169.80,231.49,percent of total billed charges,
MM Screening Digital Right,9162404,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,105.05,247.47,percent of total billed charges,
CAR NM PET CT FDG VIABILITY,7363918,CDM,404,RC,78429,HCPCS,,,facility,inpatient,,,10558.00000,3061.82000,Aetna,First Health,,8636.44,,,,,,,6334.80,8636.44,percent of total billed charges,
CAR NM PET CT FDG VIABILITY,7363918,CDM,404,RC,78429,HCPCS,,,facility,outpatient,,,10558.00000,3061.82000,Aetna,First Health,,8636.44,,,,,,,1280.72,8636.44,percent of total billed charges,
CAR NM PET CT CARDIAC,7363919,CDM,404,RC,78431,HCPCS,,,facility,inpatient,,,14948.00000,4334.92000,Aetna,First Health,,12227.46,,,,,,,8968.80,12227.46,percent of total billed charges,
CAR NM PET CT CARDIAC,7363919,CDM,404,RC,78431,HCPCS,,,facility,outpatient,,,14948.00000,4334.92000,Aetna,First Health,,12227.46,,,,,,,1474.00,12227.46,percent of total billed charges,
CAR NM PET CT Cardiac,8298200,CDM,404,RC,78431,HCPCS,,,facility,inpatient,,,14948.00000,4334.92000,Aetna,First Health,,12227.46,,,,,,,8968.80,12227.46,percent of total billed charges,
CAR NM PET CT Cardiac,8298200,CDM,404,RC,78431,HCPCS,,,facility,outpatient,,,14948.00000,4334.92000,Aetna,First Health,,12227.46,,,,,,,1474.00,12227.46,percent of total billed charges,
CAR NM PET CT CARDIAC SINGLE STDY,7524082,CDM,404,RC,78430,HCPCS,,,facility,inpatient,,,13963.00000,4049.27000,Aetna,First Health,,11421.73,,,,,,,8377.80,11421.73,percent of total billed charges,
CAR NM PET CT CARDIAC SINGLE STDY,7524082,CDM,404,RC,78430,HCPCS,,,facility,outpatient,,,13963.00000,4049.27000,Aetna,First Health,,11421.73,,,,,,,1280.72,11421.73,percent of total billed charges,
PET CT Mycocardial Blood Flow,8148537,CDM,404,RC,78434,HCPCS,,,facility,inpatient,,,3934.00000,1140.86000,Aetna,First Health,,3218.01,,,,,,,2360.40,3218.01,percent of total billed charges,
PET CT Mycocardial Blood Flow,8148537,CDM,404,RC,78434,HCPCS,,,facility,outpatient,,,3934.00000,1140.86000,Aetna,First Health,,3218.01,,,,,,,1418.21,3218.01,percent of total billed charges,
PET CT Mycocardial Blood Flow,8298199,CDM,404,RC,78434,HCPCS,,,facility,inpatient,,,3934.00000,1140.86000,Aetna,First Health,,3218.01,,,,,,,2360.40,3218.01,percent of total billed charges,
PET CT Mycocardial Blood Flow,8298199,CDM,404,RC,78434,HCPCS,,,facility,outpatient,,,3934.00000,1140.86000,Aetna,First Health,,3218.01,,,,,,,1418.21,3218.01,percent of total billed charges,
FDG Viability with Rb Study,8290448,CDM,404,RC,78433,HCPCS,,,facility,inpatient,,,13963.00000,4049.27000,Aetna,First Health,,11421.73,,,,,,,8377.80,11421.73,percent of total billed charges,
FDG Viability with Rb Study,8290448,CDM,404,RC,78433,HCPCS,,,facility,outpatient,,,13963.00000,4049.27000,Aetna,First Health,,11421.73,,,,,,,1474.00,11421.73,percent of total billed charges,
PET CT Sarcoidosis Study,8997039,CDM,404,RC,78433,HCPCS,,,facility,inpatient,,,13963.00000,4049.27000,Aetna,First Health,,11421.73,,,,,,,8377.80,11421.73,percent of total billed charges,
PET CT Sarcoidosis Study,8997039,CDM,404,RC,78433,HCPCS,,,facility,outpatient,,,13963.00000,4049.27000,Aetna,First Health,,11421.73,,,,,,,1474.00,11421.73,percent of total billed charges,
PET CT Dotatate Skull Thigh,8121821,CDM,404,RC,78815,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT Dotatate Skull Thigh,8121821,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT Brain Metabolic Eval Initial,3136854,CDM,404,RC,78608,HCPCS,,,facility,inpatient,,,9962.00000,2888.98000,Aetna,First Health,PI,8148.92,,,,,,,5977.20,8148.92,percent of total billed charges,
PET CT Brain Metabolic Eval Initial,3136854,CDM,404,RC,78608,HCPCS,,,facility,outpatient,,,9962.00000,2888.98000,Aetna,First Health,PI,8148.92,,,,,,,1280.72,8148.92,percent of total billed charges,
PET CT Brain Metabolic Eval Restaging,3136856,CDM,404,RC,78608,HCPCS,,,facility,inpatient,,,9962.00000,2888.98000,Aetna,First Health,PS,8148.92,,,,,,,5977.20,8148.92,percent of total billed charges,
PET CT Brain Metabolic Eval Restaging,3136856,CDM,404,RC,78608,HCPCS,,,facility,outpatient,,,9962.00000,2888.98000,Aetna,First Health,PS,8148.92,,,,,,,1280.72,8148.92,percent of total billed charges,
PET CT Tumor Imaging Limited Initial,3136866,CDM,404,RC,78814,HCPCS,,,facility,inpatient,,,9962.00000,2888.98000,Aetna,First Health,PI,8148.92,,,,,,,5977.20,8148.92,percent of total billed charges,
PET CT Tumor Imaging Limited Initial,3136866,CDM,404,RC,78814,HCPCS,,,facility,outpatient,,,9962.00000,2888.98000,Aetna,First Health,PI,8148.92,,,,,,,1280.72,8148.92,percent of total billed charges,
PET CT Tumor Imaging Limited Restaging,3136868,CDM,404,RC,78814,HCPCS,,,facility,inpatient,,,9962.00000,2888.98000,Aetna,First Health,PS,8148.92,,,,,,,5977.20,8148.92,percent of total billed charges,
PET CT Tumor Imaging Limited Restaging,3136868,CDM,404,RC,78814,HCPCS,,,facility,outpatient,,,9962.00000,2888.98000,Aetna,First Health,PS,8148.92,,,,,,,1280.72,8148.92,percent of total billed charges,
PET CT Tumor Image Skull Thigh Initial,3136858,CDM,404,RC,78815,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT Tumor Image Skull Thigh Initial,3136858,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT Tumor Image Skull Thigh Restaging,3136860,CDM,404,RC,78815,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT Tumor Image Skull Thigh Restaging,3136860,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT Tumor Image Whole Body Initial,3136862,CDM,404,RC,78816,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT Tumor Image Whole Body Initial,3136862,CDM,404,RC,78816,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT Whole Body Bone Scan Initial,7544165,CDM,404,RC,78816,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT Whole Body Bone Scan Initial,7544165,CDM,404,RC,78816,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT Tumor Image Whole Body Restaging,3136864,CDM,404,RC,78816,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT Tumor Image Whole Body Restaging,3136864,CDM,404,RC,78816,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT Whole Body Bone Scan Restaging,7544170,CDM,404,RC,78816,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT Whole Body Bone Scan Restaging,7544170,CDM,404,RC,78816,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT Dotatate Skull Thigh Restaging,8237892,CDM,404,RC,78815,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT Dotatate Skull Thigh Restaging,8237892,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET Exam,8237905,CDM,404,RC,78815,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET Exam,8237905,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT Beta Amyloid Imaging,7918028,CDM,404,RC,78814,HCPCS,,,facility,inpatient,,,9962.00000,2888.98000,Aetna,First Health,Q1,8148.92,,,,,,,5977.20,8148.92,percent of total billed charges,
PET CT Beta Amyloid Imaging,7918028,CDM,404,RC,78814,HCPCS,,,facility,outpatient,,,9962.00000,2888.98000,Aetna,First Health,Q1,8148.92,,,,,,,1280.72,8148.92,percent of total billed charges,
PET Exam,8237915,CDM,404,RC,78815,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET Exam,8237915,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT Dotatate Skull Thigh Initial,8237883,CDM,404,RC,78815,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT Dotatate Skull Thigh Initial,8237883,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT Trailblazer Brain,8435857,CDM,404,RC,,,,,facility,inpatient,,,6000.00000,1740.00000,Aetna,First Health,,4908.00,,,,,,,3600.00,4908.00,percent of total billed charges,
PET CT Trailblazer Brain,8435857,CDM,404,RC,,,,,facility,outpatient,,,6000.00000,1740.00000,Aetna,First Health,,4908.00,,,,,,,2163.00,4908.00,percent of total billed charges,
PET CT F18 PSMA Skull to Thigh Initial,8456055,CDM,404,RC,78815,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT F18 PSMA Skull to Thigh Initial,8456055,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PI,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
PET CT F 18 PSMA Skull to Thigh Restaging,8456060,CDM,404,RC,78815,HCPCS,,,facility,inpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,7903.20,10774.70,percent of total billed charges,
PET CT F 18 PSMA Skull to Thigh Restaging,8456060,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,First Health,PS,10774.70,,,,,,,1280.72,10774.70,percent of total billed charges,
Pentamidine Treatment,5571854,CDM,410,RC,94642,HCPCS,,,facility,inpatient,,,528.00000,153.12000,Aetna,First Health,,431.90,,,,,,,316.80,431.90,percent of total billed charges,
Pentamidine Treatment,5571854,CDM,410,RC,94642,HCPCS,,,facility,outpatient,,,528.00000,153.12000,Aetna,First Health,,431.90,,,,,,,190.00,542.88,percent of total billed charges,
Pentamidine Treatment,715807,CDM,410,RC,94642,HCPCS,,,facility,inpatient,,,528.00000,153.12000,Aetna,First Health,,431.90,,,,,,,316.80,431.90,percent of total billed charges,
Pentamidine Treatment,715807,CDM,410,RC,94642,HCPCS,,,facility,outpatient,,,528.00000,153.12000,Aetna,First Health,,431.90,,,,,,,190.00,542.88,percent of total billed charges,
Pentamidine Treatment,7892189,CDM,410,RC,94642,HCPCS,,,facility,inpatient,,,528.00000,153.12000,Aetna,First Health,,431.90,,,,,,,316.80,431.90,percent of total billed charges,
Pentamidine Treatment,7892189,CDM,410,RC,94642,HCPCS,,,facility,outpatient,,,528.00000,153.12000,Aetna,First Health,,431.90,,,,,,,190.00,542.88,percent of total billed charges,
Surfactant Administration,5460081,CDM,410,RC,94610,HCPCS,,,facility,inpatient,,,303.00000,87.87000,Aetna,First Health,,247.85,,,,,,,181.80,247.85,percent of total billed charges,
Surfactant Administration,5460081,CDM,410,RC,94610,HCPCS,,,facility,outpatient,,,303.00000,87.87000,Aetna,First Health,,247.85,,,,,,,112.47,542.88,percent of total billed charges,
Surfactant Administration,7796098,CDM,410,RC,94610,HCPCS,,,facility,inpatient,,,303.00000,87.87000,Aetna,First Health,,247.85,,,,,,,181.80,247.85,percent of total billed charges,
Surfactant Administration,7796098,CDM,410,RC,94610,HCPCS,,,facility,outpatient,,,303.00000,87.87000,Aetna,First Health,,247.85,,,,,,,112.47,542.88,percent of total billed charges,
SURFACTANT ADMINISTRATION,7796105,CDM,410,RC,94610,HCPCS,,,facility,inpatient,,,303.00000,87.87000,Aetna,First Health,,247.85,,,,,,,181.80,247.85,percent of total billed charges,
SURFACTANT ADMINISTRATION,7796105,CDM,410,RC,94610,HCPCS,,,facility,outpatient,,,303.00000,87.87000,Aetna,First Health,,247.85,,,,,,,112.47,542.88,percent of total billed charges,
P D And V Subsequent,3191092,CDM,410,RC,94668,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
P D And V Subsequent,3191092,CDM,410,RC,94668,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,96.51,344.05,percent of total billed charges,
P D And V Subsequent,7944218,CDM,410,RC,94668,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
P D And V Subsequent,7944218,CDM,410,RC,94668,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,96.51,344.05,percent of total billed charges,
P D And V Subsequent,7945905,CDM,410,RC,94668,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
P D And V Subsequent,7945905,CDM,410,RC,94668,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,96.51,344.05,percent of total billed charges,
Cpap Bipap Set Up And 1St Day,612607,CDM,410,RC,94660,HCPCS,,,facility,inpatient,,,1968.00000,570.72000,Aetna,First Health,,1609.82,,,,,,,1180.80,1609.82,percent of total billed charges,
Cpap Bipap Set Up And 1St Day,612607,CDM,410,RC,94660,HCPCS,,,facility,outpatient,,,1968.00000,570.72000,Aetna,First Health,,1609.82,,,,,,,178.59,1609.82,percent of total billed charges,
Cpap Bipap Set Up And 1St Day,7892318,CDM,410,RC,94660,HCPCS,,,facility,inpatient,,,1968.00000,570.72000,Aetna,First Health,,1609.82,,,,,,,1180.80,1609.82,percent of total billed charges,
Cpap Bipap Set Up And 1St Day,7892318,CDM,410,RC,94660,HCPCS,,,facility,outpatient,,,1968.00000,570.72000,Aetna,First Health,,1609.82,,,,,,,178.59,1609.82,percent of total billed charges,
Mechanical Chest Wall Oscillation,7403872,CDM,410,RC,94669,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Mechanical Chest Wall Oscillation,7403872,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Mechanical Chest Wall Oscillation,7944172,CDM,410,RC,94669,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Mechanical Chest Wall Oscillation,7944172,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Mechanical Chest Wall Oscillation,7944173,CDM,410,RC,94669,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Mechanical Chest Wall Oscillation,7944173,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Mechanical Chest Wall Oscillation,7945901,CDM,410,RC,94669,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Mechanical Chest Wall Oscillation,7945901,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Mechanical Chest Wall Oscillation,7945906,CDM,410,RC,94669,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Mechanical Chest Wall Oscillation,7945906,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Mechanical Chest Wall Oscillation,8150442,CDM,410,RC,94669,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Mechanical Chest Wall Oscillation,8150442,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Continuous Vent Set Up And First Day,7892198,CDM,410,RC,94002,HCPCS,,,facility,inpatient,,,2383.00000,691.07000,Aetna,First Health,,1949.29,,,,,,,1429.80,1949.29,percent of total billed charges,
Continuous Vent Set Up And First Day,7892198,CDM,410,RC,94002,HCPCS,,,facility,outpatient,,,2383.00000,691.07000,Aetna,First Health,,1949.29,,,,,,,190.00,1949.29,percent of total billed charges,
Continuous Vent Daily,612627,CDM,410,RC,94003,HCPCS,,,facility,inpatient,,,2383.00000,691.07000,Aetna,First Health,,1949.29,,,,,,,1429.80,1949.29,percent of total billed charges,
Continuous Vent Daily,612627,CDM,410,RC,94003,HCPCS,,,facility,outpatient,,,2383.00000,691.07000,Aetna,First Health,,1949.29,,,,,,,190.00,1949.29,percent of total billed charges,
Continuous Vent Daily,7892196,CDM,410,RC,94003,HCPCS,,,facility,inpatient,,,2383.00000,691.07000,Aetna,First Health,,1949.29,,,,,,,1429.80,1949.29,percent of total billed charges,
Continuous Vent Daily,7892196,CDM,410,RC,94003,HCPCS,,,facility,outpatient,,,2383.00000,691.07000,Aetna,First Health,,1949.29,,,,,,,190.00,1949.29,percent of total billed charges,
P D And V Initial,613013,CDM,410,RC,94667,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
P D And V Initial,613013,CDM,410,RC,94667,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,96.51,344.05,percent of total billed charges,
P D And V Initial,7944217,CDM,410,RC,94667,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
P D And V Initial,7944217,CDM,410,RC,94667,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,96.51,344.05,percent of total billed charges,
P D And V Initial,7945900,CDM,410,RC,94667,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
P D And V Initial,7945900,CDM,410,RC,94667,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,96.51,344.05,percent of total billed charges,
ED Continuous 1-Hour,9036250,CDM,410,RC,94644,HCPCS,,,facility,inpatient,,,233.00000,67.57000,Aetna,First Health,,190.59,,,,,,,139.80,190.59,percent of total billed charges,
ED Continuous 1-Hour,9036250,CDM,410,RC,94644,HCPCS,,,facility,outpatient,,,233.00000,67.57000,Aetna,First Health,,190.59,,,,,,,86.49,344.05,percent of total billed charges,
ED Cont. Subsequent Hour,9036249,CDM,410,RC,94645,HCPCS,,,facility,inpatient,,,233.00000,67.57000,Aetna,First Health,,190.59,,,,,,,139.80,190.59,percent of total billed charges,
ED Cont. Subsequent Hour,9036249,CDM,410,RC,94645,HCPCS,,,facility,outpatient,,,233.00000,67.57000,Aetna,First Health,,190.59,,,,,,,84.00,225.00,percent of total billed charges,
INTUBATION ASSIST,5460062,CDM,410,RC,31500,HCPCS,,,facility,inpatient,,,1599.00000,463.71000,Aetna,First Health,,1307.98,,,,,,,959.40,1307.98,percent of total billed charges,
INTUBATION ASSIST,5460062,CDM,410,RC,31500,HCPCS,,,facility,outpatient,,,1599.00000,463.71000,Aetna,First Health,,1307.98,,,,,,,190.00,2860.00,percent of total billed charges,
Cpap Bipap Subsequent Day,612745,CDM,410,RC,94660,HCPCS,,,facility,inpatient,,,1968.00000,570.72000,Aetna,First Health,,1609.82,,,,,,,1180.80,1609.82,percent of total billed charges,
Cpap Bipap Subsequent Day,612745,CDM,410,RC,94660,HCPCS,,,facility,outpatient,,,1968.00000,570.72000,Aetna,First Health,,1609.82,,,,,,,178.59,1609.82,percent of total billed charges,
Cpap Bipap Subsequent Day,7892317,CDM,410,RC,94660,HCPCS,,,facility,inpatient,,,1968.00000,570.72000,Aetna,First Health,,1609.82,,,,,,,1180.80,1609.82,percent of total billed charges,
Cpap Bipap Subsequent Day,7892317,CDM,410,RC,94660,HCPCS,,,facility,outpatient,,,1968.00000,570.72000,Aetna,First Health,,1609.82,,,,,,,178.59,1609.82,percent of total billed charges,
Hyperbaric Oxy Therapy 30 Min,602684,CDM,413,RC,G0277,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,780.60,1064.22,percent of total billed charges,
Hyperbaric Oxy Therapy 30 Min,602684,CDM,413,RC,G0277,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,121.09,1064.22,percent of total billed charges,
Hyperbaric Oxy Therapy 30 Min,7958302,CDM,413,RC,G0277,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,780.60,1064.22,percent of total billed charges,
Hyperbaric Oxy Therapy 30 Min,7958302,CDM,413,RC,G0277,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,First Health,,1064.22,,,,,,,121.09,1064.22,percent of total billed charges,
PTS Woundcare Select Deb Ea Adl20,4925828,CDM,420,RC,97598,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,GP,570.15,,,,,,,418.20,570.15,percent of total billed charges,
PTS Woundcare Select Deb Ea Adl20,4925828,CDM,420,RC,97598,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,GP,570.15,,,,,,,59.03,1717.00,percent of total billed charges,
PTS Woundcare Nonselective Debrid,4938021,CDM,420,RC,97602,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,GP,552.15,,,,,,,405.00,552.15,percent of total billed charges,
PTS Woundcare Nonselective Debrid,4938021,CDM,420,RC,97602,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,GP,552.15,,,,,,,97.85,552.15,percent of total billed charges,
PTS Therapeutic Exercise 15 Min,4925759,CDM,420,RC,97110,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,GP,130.88,,,,,,,96.00,130.88,percent of total billed charges,
PTS Therapeutic Exercise 15 Min,4925759,CDM,420,RC,97110,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,GP,130.88,,,,,,,26.07,225.00,percent of total billed charges,
PTS Fluidotherapy,4938080,CDM,420,RC,97022,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,GP,101.43,,,,,,,74.40,101.43,percent of total billed charges,
PTS Fluidotherapy,4938080,CDM,420,RC,97022,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,GP,101.43,,,,,,,13.96,225.00,percent of total billed charges,
PTS Electrical Stim Attend 15Min,4925764,CDM,420,RC,97032,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Electrical Stim Attend 15Min,4925764,CDM,420,RC,97032,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,12.94,225.00,percent of total billed charges,
PTS Aquatic Therapy 15 Min,4925761,CDM,420,RC,97113,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Aquatic Therapy 15 Min,4925761,CDM,420,RC,97113,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,30.28,225.00,percent of total billed charges,
PTS Orthotic Initial Train 15Min,4925757,CDM,420,RC,97760,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Orthotic Initial Train 15Min,4925757,CDM,420,RC,97760,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,29.55,225.00,percent of total billed charges,
PTS Prosthetic Init Train 15Min,4925782,CDM,420,RC,97761,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,GP,123.52,,,,,,,90.60,123.52,percent of total billed charges,
PTS Prosthetic Init Train 15Min,4925782,CDM,420,RC,97761,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,GP,123.52,,,,,,,27.08,225.00,percent of total billed charges,
PTS Adl Management Train 15 Min,4925778,CDM,420,RC,97535,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Adl Management Train 15 Min,4925778,CDM,420,RC,97535,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,28.51,225.00,percent of total billed charges,
PTS Wheelchair Management 15 Min,4925787,CDM,420,RC,97542,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Wheelchair Management 15 Min,4925787,CDM,420,RC,97542,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,26.73,225.00,percent of total billed charges,
PTS Therapeutic Activities 15 Min,4925768,CDM,420,RC,97530,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,GP,130.88,,,,,,,96.00,130.88,percent of total billed charges,
PTS Therapeutic Activities 15 Min,4925768,CDM,420,RC,97530,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,GP,130.88,,,,,,,27.79,225.00,percent of total billed charges,
PTS Manual Therapy 15 Min,4925774,CDM,420,RC,97140,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Manual Therapy 15 Min,4925774,CDM,420,RC,97140,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,24.62,225.00,percent of total billed charges,
PTS Massage 15 Min,4925784,CDM,420,RC,97124,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Massage 15 Min,4925784,CDM,420,RC,97124,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,21.30,225.00,percent of total billed charges,
PTS Neuromuscular Re Ed 15 Min,4925780,CDM,420,RC,97112,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Neuromuscular Re Ed 15 Min,4925780,CDM,420,RC,97112,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,27.80,225.00,percent of total billed charges,
PTS Gait Training 15 Min,4925762,CDM,420,RC,97116,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Gait Training 15 Min,4925762,CDM,420,RC,97116,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,23.49,225.00,percent of total billed charges,
PTS Iontophoresis 15 Min,4925770,CDM,420,RC,97033,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Iontophoresis 15 Min,4925770,CDM,420,RC,97033,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,16.94,225.00,percent of total billed charges,
PTS ORTHOTIC PROSTH CHECKOUT 15MIN,4925766,CDM,420,RC,97763,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,GP,123.52,,,,,,,90.60,123.52,percent of total billed charges,
PTS ORTHOTIC PROSTH CHECKOUT 15MIN,4925766,CDM,420,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,GP,123.52,,,,,,,44.95,225.00,percent of total billed charges,
PTS Electrical Stim Unattended,4939850,CDM,420,RC,G0283,HCPCS,,,facility,inpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,105.60,143.97,percent of total billed charges,
PTS Electrical Stim Unattended,4939850,CDM,420,RC,G0283,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,17.84,225.00,percent of total billed charges,
PTS Canalith Repositioning,4938085,CDM,420,RC,95992,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,GP,249.49,,,,,,,183.00,249.49,percent of total billed charges,
PTS Canalith Repositioning,4938085,CDM,420,RC,95992,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,GP,249.49,,,,,,,40.55,249.49,percent of total billed charges,
PTS Work Task Analysis 15 Min,4925789,CDM,420,RC,97537,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,GP,101.43,,,,,,,74.40,101.43,percent of total billed charges,
PTS Work Task Analysis 15 Min,4925789,CDM,420,RC,97537,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,GP,101.43,,,,,,,26.02,225.00,percent of total billed charges,
PTS Vasopneumatic Device,4937972,CDM,420,RC,97016,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,GP,101.43,,,,,,,74.40,101.43,percent of total billed charges,
PTS Vasopneumatic Device,4937972,CDM,420,RC,97016,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,GP,101.43,,,,,,,10.55,225.00,percent of total billed charges,
PTS Ultrasound 15 Min,4925776,CDM,420,RC,97035,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Ultrasound 15 Min,4925776,CDM,420,RC,97035,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,11.57,225.00,percent of total billed charges,
PTS Traction Mechanical,4937999,CDM,420,RC,97012,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,73.20,99.80,percent of total billed charges,
PTS Traction Mechanical,4937999,CDM,420,RC,97012,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GP,99.80,,,,,,,12.94,225.00,percent of total billed charges,
PTS Paraffin Bath,4938013,CDM,420,RC,97018,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,GP,101.43,,,,,,,74.40,101.43,percent of total billed charges,
PTS Paraffin Bath,4938013,CDM,420,RC,97018,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,GP,101.43,,,,,,,5.52,225.00,percent of total billed charges,
PT Group,4937992,CDM,420,RC,97150,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GP,95.71,,,,,,,70.20,95.71,percent of total billed charges,
PT Group,4937992,CDM,420,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GP,95.71,,,,,,,16.60,225.00,percent of total billed charges,
PT Group,4937993,CDM,420,RC,97150,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GP,95.71,,,,,,,70.20,95.71,percent of total billed charges,
PT Group,4937993,CDM,420,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GP,95.71,,,,,,,16.60,225.00,percent of total billed charges,
PT Group,4937994,CDM,420,RC,97150,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GP,95.71,,,,,,,70.20,95.71,percent of total billed charges,
PT Group,4937994,CDM,420,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GP,95.71,,,,,,,16.60,225.00,percent of total billed charges,
PT Group,4937995,CDM,420,RC,97150,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GP,95.71,,,,,,,70.20,95.71,percent of total billed charges,
PT Group,4937995,CDM,420,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GP,95.71,,,,,,,16.60,225.00,percent of total billed charges,
PT Group Therapy,8263920,CDM,420,RC,97150,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GP,95.71,,,,,,,70.20,95.71,percent of total billed charges,
PT Group Therapy,8263920,CDM,420,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GP,95.71,,,,,,,16.60,225.00,percent of total billed charges,
PT Aquatic Therapy by assistant,8282687,CDM,420,RC,97113,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Aquatic Therapy by assistant,8282687,CDM,420,RC,97113,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,30.28,225.00,percent of total billed charges,
PT Canalith Repositioning by assistant,8283329,CDM,420,RC,95992,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,"CQ,GP",249.49,,,,,,,183.00,249.49,percent of total billed charges,
PT Canalith Repositioning by assistant,8283329,CDM,420,RC,95992,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,"CQ,GP",249.49,,,,,,,40.55,249.49,percent of total billed charges,
PT Elec Stim Attended by assistant,8282679,CDM,420,RC,97032,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Elec Stim Attended by assistant,8282679,CDM,420,RC,97032,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,12.94,225.00,percent of total billed charges,
PT Elec Stim Unattended by assistant,8283351,CDM,420,RC,G0283,HCPCS,,,facility,inpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,105.60,143.97,percent of total billed charges,
PT Elec Stim Unattended by assistant,8283351,CDM,420,RC,G0283,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,17.84,225.00,percent of total billed charges,
PT Fluidotherapy by assistant,8283433,CDM,420,RC,97022,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,"CQ,GP",101.43,,,,,,,74.40,101.43,percent of total billed charges,
PT Fluidotherapy by assistant,8283433,CDM,420,RC,97022,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,"CQ,GP",101.43,,,,,,,13.96,225.00,percent of total billed charges,
PT Gait Training by assistant,8282689,CDM,420,RC,97116,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Gait Training by assistant,8282689,CDM,420,RC,97116,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,23.49,225.00,percent of total billed charges,
PT Iontophoresis by assistant,8282681,CDM,420,RC,97033,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Iontophoresis by assistant,8282681,CDM,420,RC,97033,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,16.94,225.00,percent of total billed charges,
PT Manual Therapy Charge Units by assistant,8282693,CDM,420,RC,97140,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Manual Therapy Charge Units by assistant,8282693,CDM,420,RC,97140,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,24.62,225.00,percent of total billed charges,
PT Massage by assistant,8282691,CDM,420,RC,97124,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Massage by assistant,8282691,CDM,420,RC,97124,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,21.30,225.00,percent of total billed charges,
PT Neuromusc Re Education by assistant,8282697,CDM,420,RC,97112,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Neuromusc Re Education by assistant,8282697,CDM,420,RC,97112,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,27.80,225.00,percent of total billed charges,
PT Orthotic Fit Train by assistant,8282703,CDM,420,RC,97760,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Orthotic Fit Train by assistant,8282703,CDM,420,RC,97760,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,29.55,225.00,percent of total billed charges,
PT Orthotic Prosthetic Check by assistant,8282707,CDM,420,RC,97763,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,"CQ,GP",123.52,,,,,,,90.60,123.52,percent of total billed charges,
PT Orthotic Prosthetic Check by assistant,8282707,CDM,420,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,"CQ,GP",123.52,,,,,,,44.95,225.00,percent of total billed charges,
PT Prosthetic Training by assistant,8282705,CDM,420,RC,97761,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,"CQ,GP",123.52,,,,,,,90.60,123.52,percent of total billed charges,
PT Prosthetic Training by assistant,8282705,CDM,420,RC,97761,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,"CQ,GP",123.52,,,,,,,27.08,225.00,percent of total billed charges,
PT Self Care Home Management Charge Units by assistant,8282699,CDM,420,RC,97535,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Self Care Home Management Charge Units by assistant,8282699,CDM,420,RC,97535,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,28.51,225.00,percent of total billed charges,
PT Ther Act Functional Mobiliity by assistant,8282695,CDM,420,RC,97530,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,"GP,CQ",130.88,,,,,,,96.00,130.88,percent of total billed charges,
PT Ther Act Functional Mobiliity by assistant,8282695,CDM,420,RC,97530,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,"GP,CQ",130.88,,,,,,,27.79,225.00,percent of total billed charges,
PT Therapeutic Exercise Charge Units by assistant,8282685,CDM,420,RC,97110,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,"CQ,GP",130.88,,,,,,,96.00,130.88,percent of total billed charges,
PT Therapeutic Exercise Charge Units by assistant,8282685,CDM,420,RC,97110,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,"CQ,GP",130.88,,,,,,,26.07,225.00,percent of total billed charges,
PT Traction Mechanical by assistant,8283315,CDM,420,RC,97012,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Traction Mechanical by assistant,8283315,CDM,420,RC,97012,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,12.94,225.00,percent of total billed charges,
PT Ultrasound by assistant,8282683,CDM,420,RC,97035,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Ultrasound by assistant,8282683,CDM,420,RC,97035,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CQ,GP",99.80,,,,,,,11.57,225.00,percent of total billed charges,
PT Wheelchair Management Assistant Units,8282701,CDM,420,RC,97542,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,73.20,99.80,percent of total billed charges,
PT Wheelchair Management Assistant Units,8282701,CDM,420,RC,97542,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"GP,CQ",99.80,,,,,,,26.73,225.00,percent of total billed charges,
Dry Needling 3 or More Muscles,8686212,CDM,420,RC,20561,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,GP,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Dry Needling 3 or More Muscles,8686212,CDM,420,RC,20561,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,GP,61.35,,,,,,,45.00,2860.00,percent of total billed charges,
Dry Needling 1 or 2 Muscles,8686204,CDM,420,RC,20560,HCPCS,,,facility,inpatient,,,40.00000,11.60000,Aetna,First Health,GP,32.72,,,,,,,24.00,32.72,percent of total billed charges,
Dry Needling 1 or 2 Muscles,8686204,CDM,420,RC,20560,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,First Health,GP,32.72,,,,,,,24.00,2860.00,percent of total billed charges,
PT Caregiver Training Initial 30 Charge,9040367,CDM,420,RC,97550,HCPCS,,,facility,inpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,148.80,202.86,percent of total billed charges,
PT Caregiver Training Initial 30 Charge,9040367,CDM,420,RC,97550,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,57.09,225.00,percent of total billed charges,
PT Caregiver Training Initial 30 Charge,9042293,CDM,420,RC,97550,HCPCS,,,facility,inpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,148.80,202.86,percent of total billed charges,
PT Caregiver Training Initial 30 Charge,9042293,CDM,420,RC,97550,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,57.09,225.00,percent of total billed charges,
PT Caregiver Training Addl 15 Unit,9040369,CDM,420,RC,97551,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,74.40,101.43,percent of total billed charges,
PT Caregiver Training Addl 15 Unit,9040369,CDM,420,RC,97551,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,30.25,225.00,percent of total billed charges,
PT Caregiver Training Addl 15 Unit,9042295,CDM,420,RC,97551,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,74.40,101.43,percent of total billed charges,
PT Caregiver Training Addl 15 Unit,9042295,CDM,420,RC,97551,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,30.25,225.00,percent of total billed charges,
PT NO PT PRSNT TRAIN INITIAL 30,9101500,CDM,420,RC,G0541,HCPCS,,,facility,inpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,78.00,106.34,percent of total billed charges,
PT NO PT PRSNT TRAIN INITIAL 30,9101500,CDM,420,RC,G0541,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,28.97,225.00,percent of total billed charges,
PT NO PT PRSNT TRAIN INITIAL 30 BY ASSIST,9103988,CDM,420,RC,G0541,HCPCS,,,facility,inpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,78.00,106.34,percent of total billed charges,
PT NO PT PRSNT TRAIN INITIAL 30 BY ASSIST,9103988,CDM,420,RC,G0541,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,28.97,225.00,percent of total billed charges,
PT NO PT PRSNT TRAIN ADD 15,9101412,CDM,420,RC,G0542,HCPCS,,,facility,inpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,38.40,52.35,percent of total billed charges,
PT NO PT PRSNT TRAIN ADD 15,9101412,CDM,420,RC,G0542,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,30.08,225.00,percent of total billed charges,
PT NO PT PRSNT TRAIN ADD 15 BY ASSIST,9103753,CDM,420,RC,G0542,HCPCS,,,facility,inpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,38.40,52.35,percent of total billed charges,
PT NO PT PRSNT TRAIN ADD 15 BY ASSIST,9103753,CDM,420,RC,G0542,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,30.08,225.00,percent of total billed charges,
PT GROUP TRAIN WO PATEINT,9104029,CDM,420,RC,G0543,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
PT GROUP TRAIN WO PATEINT,9104029,CDM,420,RC,G0543,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,25.38,225.00,percent of total billed charges,
PT GROUP TRAIN WO PATEINT BY ASSIST,9101529,CDM,420,RC,G0543,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
PT GROUP TRAIN WO PATEINT BY ASSIST,9101529,CDM,420,RC,G0543,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,25.38,225.00,percent of total billed charges,
PTS Re Evaluation,5039840,CDM,424,RC,97164,HCPCS,,,facility,inpatient,,,213.00000,61.77000,Aetna,First Health,GP,174.23,,,,,,,127.80,174.23,percent of total billed charges,
PTS Re Evaluation,5039840,CDM,424,RC,97164,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,First Health,GP,174.23,,,,,,,61.07,225.00,percent of total billed charges,
PTS Evaluation Low Complexity,7941922,CDM,424,RC,97161,HCPCS,,,facility,inpatient,,,313.00000,90.77000,Aetna,First Health,GP,256.03,,,,,,,187.80,256.03,percent of total billed charges,
PTS Evaluation Low Complexity,7941922,CDM,424,RC,97161,HCPCS,,,facility,outpatient,,,313.00000,90.77000,Aetna,First Health,GP,256.03,,,,,,,88.77,256.03,percent of total billed charges,
PTS Evaluation Moderate Complex,7941923,CDM,424,RC,97162,HCPCS,,,facility,inpatient,,,340.00000,98.60000,Aetna,First Health,GP,278.12,,,,,,,204.00,278.12,percent of total billed charges,
PTS Evaluation Moderate Complex,7941923,CDM,424,RC,97162,HCPCS,,,facility,outpatient,,,340.00000,98.60000,Aetna,First Health,GP,278.12,,,,,,,88.77,278.12,percent of total billed charges,
PTS Evaluation High Complexity,7941921,CDM,424,RC,97163,HCPCS,,,facility,inpatient,,,328.00000,95.12000,Aetna,First Health,GP,268.30,,,,,,,196.80,268.30,percent of total billed charges,
PTS Evaluation High Complexity,7941921,CDM,424,RC,97163,HCPCS,,,facility,outpatient,,,328.00000,95.12000,Aetna,First Health,GP,268.30,,,,,,,88.77,268.30,percent of total billed charges,
OTS Therapeutic Exercise 15 Min,4922244,CDM,430,RC,97110,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,GO,130.88,,,,,,,96.00,130.88,percent of total billed charges,
OTS Therapeutic Exercise 15 Min,4922244,CDM,430,RC,97110,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,GO,130.88,,,,,,,26.07,225.00,percent of total billed charges,
OTS Iontophoresis 15 Min,4922263,CDM,430,RC,97033,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Iontophoresis 15 Min,4922263,CDM,430,RC,97033,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,16.94,225.00,percent of total billed charges,
OTS Fluidotherapy,4941868,CDM,430,RC,97022,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,GO,101.43,,,,,,,74.40,101.43,percent of total billed charges,
OTS Fluidotherapy,4941868,CDM,430,RC,97022,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,GO,101.43,,,,,,,13.96,225.00,percent of total billed charges,
OTS Electrical Stim Attend 15Min,4922258,CDM,430,RC,97032,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Electrical Stim Attend 15Min,4922258,CDM,430,RC,97032,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,12.94,225.00,percent of total billed charges,
OTS Aquatic Therapy 15 Min,4922266,CDM,430,RC,97113,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Aquatic Therapy 15 Min,4922266,CDM,430,RC,97113,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,30.28,225.00,percent of total billed charges,
OTS Orthotic Initial Train 15Min,4922248,CDM,430,RC,97760,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Orthotic Initial Train 15Min,4922248,CDM,430,RC,97760,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,29.55,225.00,percent of total billed charges,
OT Orthotic Prosthetic Manage Train Units,8185049,CDM,430,RC,97763,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,GO,123.52,,,,,,,90.60,123.52,percent of total billed charges,
OT Orthotic Prosthetic Manage Train Units,8185049,CDM,430,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,GO,123.52,,,,,,,44.95,225.00,percent of total billed charges,
OTS Adl Management Train 15Min,4922250,CDM,430,RC,97535,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Adl Management Train 15Min,4922250,CDM,430,RC,97535,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,28.51,225.00,percent of total billed charges,
OTS Cognitive Treatment Initital 15 min,4922270,CDM,430,RC,97129,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Cognitive Treatment Initital 15 min,4922270,CDM,430,RC,97129,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,19.86,225.00,percent of total billed charges,
OT Cognitive Treatment Initial Charge,8282841,CDM,430,RC,97129,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Cognitive Treatment Initial Charge,8282841,CDM,430,RC,97129,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,19.86,225.00,percent of total billed charges,
OTS Electrical Stim Unattended,4941874,CDM,430,RC,G0283,HCPCS,,,facility,inpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,105.60,143.97,percent of total billed charges,
OTS Electrical Stim Unattended,4941874,CDM,430,RC,G0283,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,17.84,225.00,percent of total billed charges,
OTS Therapeutic Activities 15 Min,4922256,CDM,430,RC,97530,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,GO,130.88,,,,,,,96.00,130.88,percent of total billed charges,
OTS Therapeutic Activities 15 Min,4922256,CDM,430,RC,97530,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,GO,130.88,,,,,,,27.79,225.00,percent of total billed charges,
OTS Manual Therapy 15 Min,4922252,CDM,430,RC,97140,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Manual Therapy 15 Min,4922252,CDM,430,RC,97140,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,24.62,225.00,percent of total billed charges,
OTS L Dex Measurement,4958179,CDM,430,RC,93702,HCPCS,,,facility,inpatient,,,185.00000,53.65000,Aetna,First Health,GO,151.33,,,,,,,111.00,151.33,percent of total billed charges,
OTS L Dex Measurement,4958179,CDM,430,RC,93702,HCPCS,,,facility,outpatient,,,185.00000,53.65000,Aetna,First Health,GO,151.33,,,,,,,86.95,417.59,percent of total billed charges,
OTS Work Task Analysis 15 Min,4922276,CDM,430,RC,97537,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,GO,101.43,,,,,,,74.40,101.43,percent of total billed charges,
OTS Work Task Analysis 15 Min,4922276,CDM,430,RC,97537,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,GO,101.43,,,,,,,26.02,225.00,percent of total billed charges,
OTS Wound Care Selective Lt 20 Cm,4932425,CDM,430,RC,97597,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,GO,570.15,,,,,,,418.20,570.15,percent of total billed charges,
OTS Wound Care Selective Lt 20 Cm,4932425,CDM,430,RC,97597,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,GO,570.15,,,,,,,46.38,1717.00,percent of total billed charges,
OTS Ultrasound 15 Min,4922268,CDM,430,RC,97035,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Ultrasound 15 Min,4922268,CDM,430,RC,97035,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,11.57,225.00,percent of total billed charges,
OTS Wound Care Nonselective,4941877,CDM,430,RC,97602,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,GO,552.15,,,,,,,405.00,552.15,percent of total billed charges,
OTS Wound Care Nonselective,4941877,CDM,430,RC,97602,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,GO,552.15,,,,,,,97.85,552.15,percent of total billed charges,
OTS Orthotic Prosth Train 15min,4922260,CDM,430,RC,97763,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,GO,123.52,,,,,,,90.60,123.52,percent of total billed charges,
OTS Orthotic Prosth Train 15min,4922260,CDM,430,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,GO,123.52,,,,,,,44.95,225.00,percent of total billed charges,
OTS Vasopneumatic Device,4941846,CDM,430,RC,97016,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,GO,101.43,,,,,,,74.40,101.43,percent of total billed charges,
OTS Vasopneumatic Device,4941846,CDM,430,RC,97016,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,GO,101.43,,,,,,,10.55,225.00,percent of total billed charges,
OTS Paraffin Bath,4941848,CDM,430,RC,97018,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,GO,101.43,,,,,,,74.40,101.43,percent of total billed charges,
OTS Paraffin Bath,4941848,CDM,430,RC,97018,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,GO,101.43,,,,,,,5.52,225.00,percent of total billed charges,
OTS Multi Layer Com Afhf Bilat,7939211,CDM,430,RC,29584,HCPCS,,,facility,inpatient,,,1093.00000,316.97000,Aetna,First Health,"GO,50",894.07,,,,,,,655.80,894.07,percent of total billed charges,
OTS Multi Layer Com Afhf Bilat,7939211,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,1093.00000,316.97000,Aetna,First Health,"GO,50",894.07,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Multi Layer Comp Afhf Rt,7939209,CDM,430,RC,29584,HCPCS,,,facility,inpatient,,,546.00000,158.34000,Aetna,First Health,"GO,RT",446.63,,,,,,,327.60,446.63,percent of total billed charges,
OTS Multi Layer Comp Afhf Rt,7939209,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,546.00000,158.34000,Aetna,First Health,"GO,RT",446.63,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Multi Layer Comp Afhf Lt,7939210,CDM,430,RC,29584,HCPCS,,,facility,inpatient,,,546.00000,158.34000,Aetna,First Health,"GO,LT",446.63,,,,,,,327.60,446.63,percent of total billed charges,
OTS Multi Layer Comp Afhf Lt,7939210,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,546.00000,158.34000,Aetna,First Health,"GO,LT",446.63,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Multi Layer Comp Lef Bilat,7939226,CDM,430,RC,29581,HCPCS,,,facility,inpatient,,,1196.00000,346.84000,Aetna,First Health,"50,GO",978.33,,,,,,,717.60,978.33,percent of total billed charges,
OTS Multi Layer Comp Lef Bilat,7939226,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,First Health,"50,GO",978.33,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Multi Layer Comp Lef Rt,7939224,CDM,430,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,"RT,GO",489.16,,,,,,,358.80,489.16,percent of total billed charges,
OTS Multi Layer Comp Lef Rt,7939224,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,"RT,GO",489.16,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Multi Layer Compress Lef Lt,7939225,CDM,430,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,"GO,LT",489.16,,,,,,,358.80,489.16,percent of total billed charges,
OTS Multi Layer Compress Lef Lt,7939225,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,"GO,LT",489.16,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Massage 15 Min,4922246,CDM,430,RC,97124,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Massage 15 Min,4922246,CDM,430,RC,97124,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,21.30,225.00,percent of total billed charges,
OTS Neuromuscular Re Ed 15 Min,4922265,CDM,430,RC,97112,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Neuromuscular Re Ed 15 Min,4922265,CDM,430,RC,97112,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,27.80,225.00,percent of total billed charges,
OTS Wheelchair Management 15 Min,4922254,CDM,430,RC,97542,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Wheelchair Management 15 Min,4922254,CDM,430,RC,97542,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,26.73,225.00,percent of total billed charges,
OTS Prosthetic Init Train 15Min,4922272,CDM,430,RC,97761,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,GO,123.52,,,,,,,90.60,123.52,percent of total billed charges,
OTS Prosthetic Init Train 15Min,4922272,CDM,430,RC,97761,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,GO,123.52,,,,,,,27.08,225.00,percent of total billed charges,
OTS Wound Care Selective Gt 20Cm,4922296,CDM,430,RC,97598,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,GO,570.15,,,,,,,418.20,570.15,percent of total billed charges,
OTS Wound Care Selective Gt 20Cm,4922296,CDM,430,RC,97598,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,GO,570.15,,,,,,,59.03,1717.00,percent of total billed charges,
OT Group,4941857,CDM,430,RC,97150,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GO,95.71,,,,,,,70.20,95.71,percent of total billed charges,
OT Group,4941857,CDM,430,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GO,95.71,,,,,,,16.60,225.00,percent of total billed charges,
OT Group,4941860,CDM,430,RC,97150,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GO,95.71,,,,,,,70.20,95.71,percent of total billed charges,
OT Group,4941860,CDM,430,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GO,95.71,,,,,,,16.60,225.00,percent of total billed charges,
OT Group,4941863,CDM,430,RC,97150,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GO,95.71,,,,,,,70.20,95.71,percent of total billed charges,
OT Group,4941863,CDM,430,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GO,95.71,,,,,,,16.60,225.00,percent of total billed charges,
OT Group,4943849,CDM,430,RC,97150,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GO,95.71,,,,,,,70.20,95.71,percent of total billed charges,
OT Group,4943849,CDM,430,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GO,95.71,,,,,,,16.60,225.00,percent of total billed charges,
OT Group Therapy Charge,8236128,CDM,430,RC,97150,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GO,95.71,,,,,,,70.20,95.71,percent of total billed charges,
OT Group Therapy Charge,8236128,CDM,430,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GO,95.71,,,,,,,16.60,225.00,percent of total billed charges,
OTS Cognitive Treatment ea Addl 15 min,8282791,CDM,430,RC,97130,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,73.20,99.80,percent of total billed charges,
OTS Cognitive Treatment ea Addl 15 min,8282791,CDM,430,RC,97130,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GO,99.80,,,,,,,18.97,225.00,percent of total billed charges,
OTS Biofeedback Perianal Initial 15 min,8283272,CDM,430,RC,90912,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,First Health,GO,154.60,,,,,,,113.40,154.60,percent of total billed charges,
OTS Biofeedback Perianal Initial 15 min,8283272,CDM,430,RC,90912,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,First Health,GO,154.60,,,,,,,88.83,225.00,percent of total billed charges,
OTS Biofeedback Perianal Addl 15 min,8282775,CDM,430,RC,90913,HCPCS,,,facility,inpatient,,,190.00000,55.10000,Aetna,First Health,GO,155.42,,,,,,,114.00,155.42,percent of total billed charges,
OTS Biofeedback Perianal Addl 15 min,8282775,CDM,430,RC,90913,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,First Health,GO,155.42,,,,,,,89.30,225.00,percent of total billed charges,
L Dex measurement by assistant,8283077,CDM,430,RC,93702,HCPCS,,,facility,inpatient,,,185.00000,53.65000,Aetna,First Health,"GO,CO",151.33,,,,,,,111.00,151.33,percent of total billed charges,
L Dex measurement by assistant,8283077,CDM,430,RC,93702,HCPCS,,,facility,outpatient,,,185.00000,53.65000,Aetna,First Health,"GO,CO",151.33,,,,,,,86.95,417.59,percent of total billed charges,
Manual Therapy Techniques by assistant,8282755,CDM,430,RC,97140,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
Manual Therapy Techniques by assistant,8282755,CDM,430,RC,97140,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,24.62,225.00,percent of total billed charges,
Neuromuscular Reeducation by assistant,8282751,CDM,430,RC,97112,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
Neuromuscular Reeducation by assistant,8282751,CDM,430,RC,97112,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,27.80,225.00,percent of total billed charges,
OT  Compression Pump by assistant,8283097,CDM,430,RC,97016,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,"GO,CO",101.43,,,,,,,74.40,101.43,percent of total billed charges,
OT  Compression Pump by assistant,8283097,CDM,430,RC,97016,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,"GO,CO",101.43,,,,,,,10.55,225.00,percent of total billed charges,
OT Active Wound Care by assistant,8283006,CDM,430,RC,97597,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,"GO,CO",570.15,,,,,,,418.20,570.15,percent of total billed charges,
OT Active Wound Care by assistant,8283006,CDM,430,RC,97597,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,"GO,CO",570.15,,,,,,,46.38,1717.00,percent of total billed charges,
OT Aquatic Therapy by assistant,8282797,CDM,430,RC,97113,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Aquatic Therapy by assistant,8282797,CDM,430,RC,97113,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,30.28,225.00,percent of total billed charges,
OT Rt Leg ankle foot by assistant,8282805,CDM,430,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,"RT,GO,CO",489.16,,,,,,,358.80,489.16,percent of total billed charges,
OT Rt Leg ankle foot by assistant,8282805,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,"RT,GO,CO",489.16,,,,,,,97.85,2860.00,percent of total billed charges,
OT B Leg ankle foot by assistant,8282809,CDM,430,RC,29581,HCPCS,,,facility,inpatient,,,1196.00000,346.84000,Aetna,First Health,"50,GO,CO",978.33,,,,,,,717.60,978.33,percent of total billed charges,
OT B Leg ankle foot by assistant,8282809,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,First Health,"50,GO,CO",978.33,,,,,,,97.85,2860.00,percent of total billed charges,
OT B Upperarm forearm hand fingers by assistant,8282815,CDM,430,RC,29584,HCPCS,,,facility,inpatient,,,1093.00000,316.97000,Aetna,First Health,"CO,50,GO",894.07,,,,,,,655.80,894.07,percent of total billed charges,
OT B Upperarm forearm hand fingers by assistant,8282815,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,1093.00000,316.97000,Aetna,First Health,"CO,50,GO",894.07,,,,,,,97.85,2860.00,percent of total billed charges,
OT Cognitive Skills Dev Assistant Units,8290456,CDM,430,RC,97129,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Cognitive Skills Dev Assistant Units,8290456,CDM,430,RC,97129,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,19.86,225.00,percent of total billed charges,
OT Cognitive Tx addl by assistant,8282793,CDM,430,RC,97130,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"GO,CO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Cognitive Tx addl by assistant,8282793,CDM,430,RC,97130,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"GO,CO",99.80,,,,,,,18.97,225.00,percent of total billed charges,
OT Debridement Each additional 20 cm charge by assistant,8283014,CDM,430,RC,97598,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,"CO,GO",570.15,,,,,,,418.20,570.15,percent of total billed charges,
OT Debridement Each additional 20 cm charge by assistant,8283014,CDM,430,RC,97598,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,"CO,GO",570.15,,,,,,,59.03,1717.00,percent of total billed charges,
OT Electrical Stim Attended Charge Units by assistant,8282743,CDM,430,RC,97032,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Electrical Stim Attended Charge Units by assistant,8282743,CDM,430,RC,97032,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,12.94,225.00,percent of total billed charges,
OT Rt upperarm forearm hand fingers by assistant,8282811,CDM,430,RC,29584,HCPCS,,,facility,inpatient,,,546.00000,158.34000,Aetna,First Health,"GO,RT,CO",446.63,,,,,,,327.60,446.63,percent of total billed charges,
OT Rt upperarm forearm hand fingers by assistant,8282811,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,546.00000,158.34000,Aetna,First Health,"GO,RT,CO",446.63,,,,,,,97.85,2860.00,percent of total billed charges,
OT Electrical Stim Unattended by assistant,8282733,CDM,430,RC,G0283,HCPCS,,,facility,inpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,84.00,114.52,percent of total billed charges,
OT Electrical Stim Unattended by assistant,8282733,CDM,430,RC,G0283,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,First Health,,114.52,,,,,,,17.84,225.00,percent of total billed charges,
OT Fluidotherapy by assistant,8283155,CDM,430,RC,97022,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,"CO,GO",101.43,,,,,,,74.40,101.43,percent of total billed charges,
OT Fluidotherapy by assistant,8283155,CDM,430,RC,97022,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,"CO,GO",101.43,,,,,,,13.96,225.00,percent of total billed charges,
OT Iontophoresis by assistant,8282745,CDM,430,RC,97033,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Iontophoresis by assistant,8282745,CDM,430,RC,97033,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,16.94,225.00,percent of total billed charges,
OT Lt Leg ankle foot by assistant,8282807,CDM,430,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,"LT,GO,CO",489.16,,,,,,,358.80,489.16,percent of total billed charges,
OT Lt Leg ankle foot by assistant,8282807,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,"LT,GO,CO",489.16,,,,,,,97.85,2860.00,percent of total billed charges,
OT Lt Upperarm forearm hand fingers by assistant,8282813,CDM,430,RC,29584,HCPCS,,,facility,inpatient,,,546.00000,158.34000,Aetna,First Health,"CO,LT,GO",446.63,,,,,,,327.60,446.63,percent of total billed charges,
OT Lt Upperarm forearm hand fingers by assistant,8282813,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,546.00000,158.34000,Aetna,First Health,"CO,LT,GO",446.63,,,,,,,97.85,2860.00,percent of total billed charges,
OT Massage by assistant,8282753,CDM,430,RC,97124,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"GO,CO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Massage by assistant,8282753,CDM,430,RC,97124,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"GO,CO",99.80,,,,,,,21.30,225.00,percent of total billed charges,
OT Orthotic Fit and Training Charge Units by assistant,8282765,CDM,430,RC,97760,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"GO,CO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Orthotic Fit and Training Charge Units by assistant,8282765,CDM,430,RC,97760,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"GO,CO",99.80,,,,,,,29.55,225.00,percent of total billed charges,
OT Orthotic Prosthetic Checkout Charge Units by assistant,8282769,CDM,430,RC,97763,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,"CO,GO",123.52,,,,,,,90.60,123.52,percent of total billed charges,
OT Orthotic Prosthetic Checkout Charge Units by assistant,8282769,CDM,430,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,"CO,GO",123.52,,,,,,,44.95,225.00,percent of total billed charges,
OT Paraffin Bath by assistant,8283132,CDM,430,RC,97018,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,"CO,GO",101.43,,,,,,,74.40,101.43,percent of total billed charges,
OT Paraffin Bath by assistant,8283132,CDM,430,RC,97018,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,"CO,GO",101.43,,,,,,,5.52,225.00,percent of total billed charges,
OT Prosthetic Training by assistant,8282767,CDM,430,RC,97761,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,"GO,CO",123.52,,,,,,,90.60,123.52,percent of total billed charges,
OT Prosthetic Training by assistant,8282767,CDM,430,RC,97761,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,"GO,CO",123.52,,,,,,,27.08,225.00,percent of total billed charges,
OT Self Care Home Management by Assistant,8282761,CDM,430,RC,97535,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Self Care Home Management by Assistant,8282761,CDM,430,RC,97535,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,28.51,225.00,percent of total billed charges,
OT Ther Act Functional Mobility by Assistant,8282757,CDM,430,RC,97530,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,"CO,GO",130.88,,,,,,,96.00,130.88,percent of total billed charges,
OT Ther Act Functional Mobility by Assistant,8282757,CDM,430,RC,97530,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,"CO,GO",130.88,,,,,,,27.79,225.00,percent of total billed charges,
OT Ultrasound by Assistant,8282747,CDM,430,RC,97035,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Ultrasound by Assistant,8282747,CDM,430,RC,97035,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,11.57,225.00,percent of total billed charges,
OT Wheelchair Mgmt Training by Assistant,8282763,CDM,430,RC,97542,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,73.20,99.80,percent of total billed charges,
OT Wheelchair Mgmt Training by Assistant,8282763,CDM,430,RC,97542,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,"CO,GO",99.80,,,,,,,26.73,225.00,percent of total billed charges,
OT Work Task Analysis Unit by Assistant,8282779,CDM,430,RC,97537,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,"CO,GO",101.43,,,,,,,74.40,101.43,percent of total billed charges,
OT Work Task Analysis Unit by Assistant,8282779,CDM,430,RC,97537,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,"CO,GO",101.43,,,,,,,26.02,225.00,percent of total billed charges,
OT Orthotic Prosthetic Checkout Charge Units by Assistant,8283004,CDM,430,RC,97763,HCPCS,,,facility,inpatient,,,151.00000,43.79000,Aetna,First Health,"CO,GO",123.52,,,,,,,90.60,123.52,percent of total billed charges,
OT Orthotic Prosthetic Checkout Charge Units by Assistant,8283004,CDM,430,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,First Health,"CO,GO",123.52,,,,,,,44.95,225.00,percent of total billed charges,
OT Therapeutic Exercise by Assistant,8282749,CDM,430,RC,97110,HCPCS,,,facility,inpatient,,,160.00000,46.40000,Aetna,First Health,"CO,GO",130.88,,,,,,,96.00,130.88,percent of total billed charges,
OT Therapeutic Exercise by Assistant,8282749,CDM,430,RC,97110,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,First Health,"CO,GO",130.88,,,,,,,26.07,225.00,percent of total billed charges,
Dry Needling 1 or 2 Muscles,9192644,CDM,430,RC,20560,HCPCS,,,facility,inpatient,,,40.00000,11.60000,Aetna,First Health,GO,32.72,,,,,,,24.00,32.72,percent of total billed charges,
Dry Needling 1 or 2 Muscles,9192644,CDM,430,RC,20560,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,First Health,GO,32.72,,,,,,,24.00,2860.00,percent of total billed charges,
Dry Needling 3 or More Muscles,9196676,CDM,430,RC,20561,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,GO,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Dry Needling 3 or More Muscles,9196676,CDM,430,RC,20561,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,GO,61.35,,,,,,,45.00,2860.00,percent of total billed charges,
OT Caregiver Training Initial 30 Charge,9040371,CDM,430,RC,97550,HCPCS,,,facility,inpatient,,,248.00000,71.92000,Aetna,First Health,"GO,CO",202.86,,,,,,,148.80,202.86,percent of total billed charges,
OT Caregiver Training Initial 30 Charge,9040371,CDM,430,RC,97550,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,First Health,"GO,CO",202.86,,,,,,,97.85,225.00,percent of total billed charges,
OT Caregiver Training Initial 30 Charge,9042297,CDM,430,RC,97550,HCPCS,,,facility,inpatient,,,248.00000,71.92000,Aetna,First Health,GO,202.86,,,,,,,148.80,202.86,percent of total billed charges,
OT Caregiver Training Initial 30 Charge,9042297,CDM,430,RC,97550,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,First Health,GO,202.86,,,,,,,97.85,225.00,percent of total billed charges,
OT Caregiver Training Addl 15 Unit,9040374,CDM,430,RC,97551,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,74.40,101.43,percent of total billed charges,
OT Caregiver Training Addl 15 Unit,9040374,CDM,430,RC,97551,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,30.25,225.00,percent of total billed charges,
OT Caregiver Training Addl 15 Unit,9040376,CDM,430,RC,97551,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,74.40,101.43,percent of total billed charges,
OT Caregiver Training Addl 15 Unit,9040376,CDM,430,RC,97551,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,30.25,225.00,percent of total billed charges,
OT NO PT PRSNT TRAIN INITIAL 30,9104046,CDM,430,RC,G0541,HCPCS,,,facility,inpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,78.00,106.34,percent of total billed charges,
OT NO PT PRSNT TRAIN INITIAL 30,9104046,CDM,430,RC,G0541,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,28.97,225.00,percent of total billed charges,
OT NO PT PRSNT TRAIN INITIAL 30 BY ASSIST,9101665,CDM,430,RC,G0541,HCPCS,,,facility,inpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,78.00,106.34,percent of total billed charges,
OT NO PT PRSNT TRAIN INITIAL 30 BY ASSIST,9101665,CDM,430,RC,G0541,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,28.97,225.00,percent of total billed charges,
OT NO PT PRSNT TRAIN ADD 15,9103749,CDM,430,RC,G0542,HCPCS,,,facility,inpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,38.40,52.35,percent of total billed charges,
OT NO PT PRSNT TRAIN ADD 15,9103749,CDM,430,RC,G0542,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,30.08,225.00,percent of total billed charges,
OT NO PT PRSNT TRAIN ADD 15 BY ASSIST,9103751,CDM,430,RC,G0542,HCPCS,,,facility,inpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,38.40,52.35,percent of total billed charges,
OT NO PT PRSNT TRAIN ADD 15 BY ASSIST,9103751,CDM,430,RC,G0542,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,30.08,225.00,percent of total billed charges,
OT GROUP TRAIN WO PATEINT,9101769,CDM,430,RC,G0543,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
OT GROUP TRAIN WO PATEINT,9101769,CDM,430,RC,G0543,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,25.38,225.00,percent of total billed charges,
OT GROUP TRAIN WO PATEINT BY ASSIST,9101782,CDM,430,RC,G0543,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
OT GROUP TRAIN WO PATEINT BY ASSIST,9101782,CDM,430,RC,G0543,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,25.38,225.00,percent of total billed charges,
OTS Re Evaluation,4941851,CDM,434,RC,97168,HCPCS,,,facility,inpatient,,,213.00000,61.77000,Aetna,First Health,GO,174.23,,,,,,,127.80,174.23,percent of total billed charges,
OTS Re Evaluation,4941851,CDM,434,RC,97168,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,First Health,GO,174.23,,,,,,,62.80,225.00,percent of total billed charges,
OTS Evaluation Low Complexity,7941933,CDM,434,RC,97165,HCPCS,,,facility,inpatient,,,313.00000,90.77000,Aetna,First Health,GO,256.03,,,,,,,187.80,256.03,percent of total billed charges,
OTS Evaluation Low Complexity,7941933,CDM,434,RC,97165,HCPCS,,,facility,outpatient,,,313.00000,90.77000,Aetna,First Health,GO,256.03,,,,,,,91.04,256.03,percent of total billed charges,
OTS Evaluation Moderate Complex,7941934,CDM,434,RC,97166,HCPCS,,,facility,inpatient,,,320.00000,92.80000,Aetna,First Health,GO,261.76,,,,,,,192.00,261.76,percent of total billed charges,
OTS Evaluation Moderate Complex,7941934,CDM,434,RC,97166,HCPCS,,,facility,outpatient,,,320.00000,92.80000,Aetna,First Health,GO,261.76,,,,,,,91.04,261.76,percent of total billed charges,
OTS Evaluation High Complexity,7941932,CDM,434,RC,97167,HCPCS,,,facility,inpatient,,,328.00000,95.12000,Aetna,First Health,GO,268.30,,,,,,,196.80,268.30,percent of total billed charges,
OTS Evaluation High Complexity,7941932,CDM,434,RC,97167,HCPCS,,,facility,outpatient,,,328.00000,95.12000,Aetna,First Health,GO,268.30,,,,,,,91.04,268.30,percent of total billed charges,
ST Group 30 Mins,4937857,CDM,440,RC,92508,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GN,95.71,,,,,,,70.20,95.71,percent of total billed charges,
ST Group 30 Mins,4937857,CDM,440,RC,92508,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GN,95.71,,,,,,,21.33,225.00,percent of total billed charges,
STS Eval Swallow,7542256,CDM,440,RC,92610,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,GN,420.45,,,,,,,308.40,420.45,percent of total billed charges,
STS Eval Swallow,7542256,CDM,440,RC,92610,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,GN,420.45,,,,,,,75.57,420.45,percent of total billed charges,
STS Video Swallow Study,7542261,CDM,440,RC,92611,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,GN,420.45,,,,,,,308.40,420.45,percent of total billed charges,
STS Video Swallow Study,7542261,CDM,440,RC,92611,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,GN,420.45,,,,,,,80.49,420.45,percent of total billed charges,
STS Video Swallow Study,8994299,CDM,440,RC,92611,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,308.40,420.45,percent of total billed charges,
STS Video Swallow Study,8994299,CDM,440,RC,92611,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,,420.45,,,,,,,80.49,420.45,percent of total billed charges,
ST Aphasia Assessment,4936753,CDM,440,RC,96105,HCPCS,,,facility,inpatient,,,531.00000,153.99000,Aetna,First Health,GN,434.36,,,,,,,318.60,434.36,percent of total billed charges,
ST Aphasia Assessment,4936753,CDM,440,RC,96105,HCPCS,,,facility,outpatient,,,531.00000,153.99000,Aetna,First Health,GN,434.36,,,,,,,69.19,434.36,percent of total billed charges,
STS Aphasia Assessment Hr,7467870,CDM,440,RC,96105,HCPCS,,,facility,inpatient,,,531.00000,153.99000,Aetna,First Health,GN,434.36,,,,,,,318.60,434.36,percent of total billed charges,
STS Aphasia Assessment Hr,7467870,CDM,440,RC,96105,HCPCS,,,facility,outpatient,,,531.00000,153.99000,Aetna,First Health,GN,434.36,,,,,,,69.19,434.36,percent of total billed charges,
ST Group 15 Mins,4916255,CDM,440,RC,92508,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GN,95.71,,,,,,,70.20,95.71,percent of total billed charges,
ST Group 15 Mins,4916255,CDM,440,RC,92508,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GN,95.71,,,,,,,21.33,225.00,percent of total billed charges,
ST Group 15 Mins,4937856,CDM,440,RC,92508,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GN,95.71,,,,,,,70.20,95.71,percent of total billed charges,
ST Group 15 Mins,4937856,CDM,440,RC,92508,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GN,95.71,,,,,,,21.33,225.00,percent of total billed charges,
STS Cognitive Treatment Initial 15 min,7467871,CDM,440,RC,97129,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GN,99.80,,,,,,,73.20,99.80,percent of total billed charges,
STS Cognitive Treatment Initial 15 min,7467871,CDM,440,RC,97129,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GN,99.80,,,,,,,19.86,225.00,percent of total billed charges,
STS Cognitive Treatment Initial 15 min,8282823,CDM,440,RC,97129,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GN,99.80,,,,,,,73.20,99.80,percent of total billed charges,
STS Cognitive Treatment Initial 15 min,8282823,CDM,440,RC,97129,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GN,99.80,,,,,,,19.86,225.00,percent of total billed charges,
STS Eval Cognition,7467869,CDM,440,RC,96125,HCPCS,,,facility,inpatient,,,458.00000,132.82000,Aetna,First Health,GN,374.64,,,,,,,274.80,374.64,percent of total billed charges,
STS Eval Cognition,7467869,CDM,440,RC,96125,HCPCS,,,facility,outpatient,,,458.00000,132.82000,Aetna,First Health,GN,374.64,,,,,,,88.00,374.64,percent of total billed charges,
SLP Cog Perf Testing Unit,8215280,CDM,440,RC,96125,HCPCS,,,facility,inpatient,,,458.00000,132.82000,Aetna,First Health,GN,374.64,,,,,,,274.80,374.64,percent of total billed charges,
SLP Cog Perf Testing Unit,8215280,CDM,440,RC,96125,HCPCS,,,facility,outpatient,,,458.00000,132.82000,Aetna,First Health,GN,374.64,,,,,,,88.00,374.64,percent of total billed charges,
STS Eval Voice Prosthesis,7951877,CDM,440,RC,92597,HCPCS,,,facility,inpatient,,,377.00000,109.33000,Aetna,First Health,GN,308.39,,,,,,,226.20,308.39,percent of total billed charges,
STS Eval Voice Prosthesis,7951877,CDM,440,RC,92597,HCPCS,,,facility,outpatient,,,377.00000,109.33000,Aetna,First Health,GN,308.39,,,,,,,64.66,308.39,percent of total billed charges,
STS Swallow Treament,7922814,CDM,440,RC,92526,HCPCS,,,facility,inpatient,,,445.00000,129.05000,Aetna,First Health,GN,364.01,,,,,,,267.00,364.01,percent of total billed charges,
STS Swallow Treament,7922814,CDM,440,RC,92526,HCPCS,,,facility,outpatient,,,445.00000,129.05000,Aetna,First Health,GN,364.01,,,,,,,75.05,364.01,percent of total billed charges,
STS Eval Voice,7922811,CDM,440,RC,92524,HCPCS,,,facility,inpatient,,,535.00000,155.15000,Aetna,First Health,GN,437.63,,,,,,,321.00,437.63,percent of total billed charges,
STS Eval Voice,7922811,CDM,440,RC,92524,HCPCS,,,facility,outpatient,,,535.00000,155.15000,Aetna,First Health,GN,437.63,,,,,,,97.03,437.63,percent of total billed charges,
STS Eval Language Only,7922805,CDM,440,RC,92523,HCPCS,,,facility,inpatient,,,740.00000,214.60000,Aetna,First Health,GN,605.32,,,,,,,444.00,605.32,percent of total billed charges,
STS Eval Language Only,7922805,CDM,440,RC,92523,HCPCS,,,facility,outpatient,,,740.00000,214.60000,Aetna,First Health,GN,605.32,,,,,,,97.85,605.32,percent of total billed charges,
STS Eval Speech And Language,7922808,CDM,440,RC,92523,HCPCS,,,facility,inpatient,,,740.00000,214.60000,Aetna,First Health,GN,605.32,,,,,,,444.00,605.32,percent of total billed charges,
STS Eval Speech And Language,7922808,CDM,440,RC,92523,HCPCS,,,facility,outpatient,,,740.00000,214.60000,Aetna,First Health,GN,605.32,,,,,,,97.85,605.32,percent of total billed charges,
STS EVAL SOUND PRODUCTION,7922798,CDM,440,RC,92522,HCPCS,,,facility,inpatient,,,367.00000,106.43000,Aetna,First Health,GN,300.21,,,,,,,220.20,300.21,percent of total billed charges,
STS EVAL SOUND PRODUCTION,7922798,CDM,440,RC,92522,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,First Health,GN,300.21,,,,,,,97.85,300.21,percent of total billed charges,
STS Eval Fluency,7922795,CDM,440,RC,92521,HCPCS,,,facility,inpatient,,,441.00000,127.89000,Aetna,First Health,GN,360.74,,,,,,,264.60,360.74,percent of total billed charges,
STS Eval Fluency,7922795,CDM,440,RC,92521,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,First Health,GN,360.74,,,,,,,97.85,360.74,percent of total billed charges,
STS Speech Treatment,7922792,CDM,440,RC,92507,HCPCS,,,facility,inpatient,,,290.00000,84.10000,Aetna,First Health,GN,237.22,,,,,,,174.00,237.22,percent of total billed charges,
STS Speech Treatment,7922792,CDM,440,RC,92507,HCPCS,,,facility,outpatient,,,290.00000,84.10000,Aetna,First Health,GN,237.22,,,,,,,59.17,237.22,percent of total billed charges,
STS Cognitive Treatment Ea Addl 15 min,8282825,CDM,440,RC,97130,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GN,99.80,,,,,,,73.20,99.80,percent of total billed charges,
STS Cognitive Treatment Ea Addl 15 min,8282825,CDM,440,RC,97130,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GN,99.80,,,,,,,18.97,225.00,percent of total billed charges,
STS Community Work Reintegration,8282829,CDM,440,RC,97537,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,GN,101.43,,,,,,,74.40,101.43,percent of total billed charges,
STS Community Work Reintegration,8282829,CDM,440,RC,97537,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,GN,101.43,,,,,,,26.02,225.00,percent of total billed charges,
STS Self Care Home Skills,8282827,CDM,440,RC,97535,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,First Health,GN,99.80,,,,,,,73.20,99.80,percent of total billed charges,
STS Self Care Home Skills,8282827,CDM,440,RC,97535,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,First Health,GN,99.80,,,,,,,28.51,225.00,percent of total billed charges,
SLP Group Therapy,8263914,CDM,440,RC,92508,HCPCS,,,facility,inpatient,,,117.00000,33.93000,Aetna,First Health,GN,95.71,,,,,,,70.20,95.71,percent of total billed charges,
SLP Group Therapy,8263914,CDM,440,RC,92508,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,First Health,GN,95.71,,,,,,,21.33,225.00,percent of total billed charges,
SLP Caregiver Training Initial 30 Charge,9040378,CDM,440,RC,97550,HCPCS,,,facility,inpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,148.80,202.86,percent of total billed charges,
SLP Caregiver Training Initial 30 Charge,9040378,CDM,440,RC,97550,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,First Health,,202.86,,,,,,,57.09,225.00,percent of total billed charges,
SLP Caregiver Training Addl 15 Unit,9042299,CDM,440,RC,97551,HCPCS,,,facility,inpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,74.40,101.43,percent of total billed charges,
SLP Caregiver Training Addl 15 Unit,9042299,CDM,440,RC,97551,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,30.25,225.00,percent of total billed charges,
ST Endoscopy Swallow Fees Vid,9042187,CDM,440,RC,92612,HCPCS,,,facility,inpatient,,,514.00000,149.06000,Aetna,First Health,GN,420.45,,,,,,,308.40,420.45,percent of total billed charges,
ST Endoscopy Swallow Fees Vid,9042187,CDM,440,RC,92612,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,First Health,GN,420.45,,,,,,,97.85,466.24,percent of total billed charges,
SLP NO PT PRSNT TRAIN INITIAL 30,9101795,CDM,440,RC,G0541,HCPCS,,,facility,inpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,78.00,106.34,percent of total billed charges,
SLP NO PT PRSNT TRAIN INITIAL 30,9101795,CDM,440,RC,G0541,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,28.97,225.00,percent of total billed charges,
SLP NO PT PRSNT TRAIN ADD 15,9101414,CDM,440,RC,G0542,HCPCS,,,facility,inpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,38.40,52.35,percent of total billed charges,
SLP NO PT PRSNT TRAIN ADD 15,9101414,CDM,440,RC,G0542,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,First Health,,52.35,,,,,,,30.08,225.00,percent of total billed charges,
SLP GROUP TRAIN WO PATEINT,9101806,CDM,440,RC,G0543,HCPCS,,,facility,inpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
SLP GROUP TRAIN WO PATEINT,9101806,CDM,440,RC,G0543,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,13.43,225.00,percent of total billed charges,
ER Bladder Scan,7275875,CDM,450,RC,51798,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
ER Bladder Scan,7275875,CDM,450,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,52.15,2860.00,percent of total billed charges,
INTEGUMENTRY PROCEDURE,7275860,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
INTEGUMENTRY PROCEDURE,7275860,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
INTEGUMENTRY PROCEDURE,7295866,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
INTEGUMENTRY PROCEDURE,7295866,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
ER Orthopedic Treatment,7982969,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
ER Orthopedic Treatment,7982969,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894478,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894478,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894481,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894481,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894489,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894489,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
ER Declot Implanted Device,7901654,CDM,450,RC,36593,HCPCS,,,facility,inpatient,,,1110.00000,321.90000,Aetna,First Health,,907.98,,,,,,,666.00,907.98,percent of total billed charges,
ER Declot Implanted Device,7901654,CDM,450,RC,36593,HCPCS,,,facility,outpatient,,,1110.00000,321.90000,Aetna,First Health,,907.98,,,,,,,291.24,2860.00,percent of total billed charges,
ER Ent Procedure,7275856,CDM,450,RC,,,,,facility,inpatient,,,518.00000,150.22000,Aetna,First Health,,423.72,,,,,,,310.80,423.72,percent of total billed charges,
ER Ent Procedure,7275856,CDM,450,RC,,,,,facility,outpatient,,,518.00000,150.22000,Aetna,First Health,,423.72,,,,,,,186.74,1462.32,percent of total billed charges,
Gastric Procedure,7275861,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Gastric Procedure,7275861,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
ER Insert Ng Tube,7901656,CDM,450,RC,43752,HCPCS,,,facility,inpatient,,,1133.00000,328.57000,Aetna,First Health,,926.79,,,,,,,679.80,926.79,percent of total billed charges,
ER Insert Ng Tube,7901656,CDM,450,RC,43752,HCPCS,,,facility,outpatient,,,1133.00000,328.57000,Aetna,First Health,,926.79,,,,,,,350.38,2860.00,percent of total billed charges,
ER Optic Treatment,7275849,CDM,450,RC,,,,,facility,inpatient,,,433.00000,125.57000,Aetna,First Health,,354.19,,,,,,,259.80,354.19,percent of total billed charges,
ER Optic Treatment,7275849,CDM,450,RC,,,,,facility,outpatient,,,433.00000,125.57000,Aetna,First Health,,354.19,,,,,,,156.10,1462.32,percent of total billed charges,
ER Tongue And Mouth Surgery,7275850,CDM,450,RC,,,,,facility,inpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,457.20,623.32,percent of total billed charges,
ER Tongue And Mouth Surgery,7275850,CDM,450,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,274.70,1462.32,percent of total billed charges,
ER Thoracentesis,7901658,CDM,450,RC,,,,,facility,inpatient,,,3008.00000,872.32000,Aetna,First Health,,2460.54,,,,,,,1804.80,2460.54,percent of total billed charges,
ER Thoracentesis,7901658,CDM,450,RC,,,,,facility,outpatient,,,3008.00000,872.32000,Aetna,First Health,,2460.54,,,,,,,1084.38,2460.54,percent of total billed charges,
ER Insert Chest Tube,7918377,CDM,450,RC,,,,,facility,inpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,837.60,1141.93,percent of total billed charges,
ER Insert Chest Tube,7918377,CDM,450,RC,,,,,facility,outpatient,,,1396.00000,404.84000,Aetna,First Health,,1141.93,,,,,,,503.26,1462.32,percent of total billed charges,
Insert replace trach intubation tube,7901657,CDM,450,RC,,,,,facility,inpatient,,,2276.00000,660.04000,Aetna,First Health,,1861.77,,,,,,,1365.60,1861.77,percent of total billed charges,
Insert replace trach intubation tube,7901657,CDM,450,RC,,,,,facility,outpatient,,,2276.00000,660.04000,Aetna,First Health,,1861.77,,,,,,,820.50,1861.77,percent of total billed charges,
Injection SubQ IM,7261847,CDM,450,RC,96372,HCPCS,,,facility,inpatient,,,375.00000,108.75000,Aetna,First Health,,306.75,,,,,,,225.00,306.75,percent of total billed charges,
Injection SubQ IM,7261847,CDM,450,RC,96372,HCPCS,,,facility,outpatient,,,375.00000,108.75000,Aetna,First Health,,306.75,,,,,,,62.50,1462.32,percent of total billed charges,
IV Infusion Concurrent Drug,1431866,CDM,450,RC,96368,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
IV Infusion Concurrent Drug,1431866,CDM,450,RC,96368,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,134.83,1462.32,percent of total billed charges,
ED IV Infusion Concurrent Drug,1445823,CDM,450,RC,96368,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
ED IV Infusion Concurrent Drug,1445823,CDM,450,RC,96368,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,134.83,1462.32,percent of total billed charges,
IV Infusion Initial First Hr,7261843,CDM,450,RC,96365,HCPCS,,,facility,inpatient,,,662.00000,191.98000,Aetna,First Health,,541.52,,,,,,,397.20,541.52,percent of total billed charges,
IV Infusion Initial First Hr,7261843,CDM,450,RC,96365,HCPCS,,,facility,outpatient,,,662.00000,191.98000,Aetna,First Health,,541.52,,,,,,,185.00,1462.32,percent of total billed charges,
IV Infusion First Drug Ea Hr,7261844,CDM,450,RC,96366,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
IV Infusion First Drug Ea Hr,7261844,CDM,450,RC,96366,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,40.51,1462.32,percent of total billed charges,
IV Infusion Sequential Drug,7261845,CDM,450,RC,96367,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
IV Infusion Sequential Drug,7261845,CDM,450,RC,96367,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,62.50,1462.32,percent of total billed charges,
IV Push,7261849,CDM,450,RC,96375,HCPCS,,,facility,inpatient,,,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,223.80,305.11,percent of total billed charges,
IV Push,7261849,CDM,450,RC,96375,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,40.51,1462.32,percent of total billed charges,
IV Push Initial,7261848,CDM,450,RC,96374,HCPCS,,,facility,inpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,396.60,540.70,percent of total billed charges,
IV Push Initial,7261848,CDM,450,RC,96374,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,185.00,1462.32,percent of total billed charges,
ED IV Push Initial,927805,CDM,450,RC,96374,HCPCS,,,facility,inpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,396.60,540.70,percent of total billed charges,
ED IV Push Initial,927805,CDM,450,RC,96374,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,First Health,,540.70,,,,,,,185.00,1462.32,percent of total billed charges,
ER Integumentry Procedure,2144850,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
ER Integumentry Procedure,2144850,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
ER Integumentry Procedure,7275858,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
ER Integumentry Procedure,7275858,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
ER Integumentry Procedure,7275863,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
ER Integumentry Procedure,7275863,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
IV Push Sequential,7261850,CDM,450,RC,96376,HCPCS,,,facility,inpatient,,,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,223.80,305.11,percent of total billed charges,
IV Push Sequential,7261850,CDM,450,RC,96376,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,134.47,1462.32,percent of total billed charges,
Orthopedic Treatment,7894479,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894479,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894487,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894487,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894488,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894488,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894494,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
Orthopedic Treatment,7894494,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
ER Orthopedic Treatment,7902957,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
ER Orthopedic Treatment,7902957,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
Urinary catheter insertion Foley,7959496,CDM,450,RC,51702,HCPCS,,,facility,inpatient,,,387.00000,112.23000,Aetna,First Health,,316.57,,,,,,,232.20,316.57,percent of total billed charges,
Urinary catheter insertion Foley,7959496,CDM,450,RC,51702,HCPCS,,,facility,outpatient,,,387.00000,112.23000,Aetna,First Health,,316.57,,,,,,,113.19,2860.00,percent of total billed charges,
ER Insert Cath Straight,7959497,CDM,450,RC,51701,HCPCS,,,facility,inpatient,,,239.00000,69.31000,Aetna,First Health,,195.50,,,,,,,143.40,195.50,percent of total billed charges,
ER Insert Cath Straight,7959497,CDM,450,RC,51701,HCPCS,,,facility,outpatient,,,239.00000,69.31000,Aetna,First Health,,195.50,,,,,,,95.60,2860.00,percent of total billed charges,
ER Declot Implanted Device,7902973,CDM,450,RC,,,,,facility,inpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,726.00,989.78,percent of total billed charges,
ER Declot Implanted Device,7902973,CDM,450,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,1462.32,percent of total billed charges,
ER Anoscopy,3030879,CDM,450,RC,,,,,facility,inpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,457.20,623.32,percent of total billed charges,
ER Anoscopy,3030879,CDM,450,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,274.70,1462.32,percent of total billed charges,
ER Anoscopy,7275878,CDM,450,RC,,,,,facility,inpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,457.20,623.32,percent of total billed charges,
ER Anoscopy,7275878,CDM,450,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,274.70,1462.32,percent of total billed charges,
ER Cardiac Procedure,7275854,CDM,450,RC,,,,,facility,inpatient,,,2450.00000,710.50000,Aetna,First Health,,2004.10,,,,,,,1470.00,2004.10,percent of total billed charges,
ER Cardiac Procedure,7275854,CDM,450,RC,,,,,facility,outpatient,,,2450.00000,710.50000,Aetna,First Health,,2004.10,,,,,,,883.23,2004.10,percent of total billed charges,
ER Cardiac Procedure,7902968,CDM,450,RC,,,,,facility,inpatient,,,2450.00000,710.50000,Aetna,First Health,,2004.10,,,,,,,1470.00,2004.10,percent of total billed charges,
ER Cardiac Procedure,7902968,CDM,450,RC,,,,,facility,outpatient,,,2450.00000,710.50000,Aetna,First Health,,2004.10,,,,,,,883.23,2004.10,percent of total billed charges,
ER Ent Procedure,7902955,CDM,450,RC,,,,,facility,inpatient,,,518.00000,150.22000,Aetna,First Health,,423.72,,,,,,,310.80,423.72,percent of total billed charges,
ER Ent Procedure,7902955,CDM,450,RC,,,,,facility,outpatient,,,518.00000,150.22000,Aetna,First Health,,423.72,,,,,,,186.74,1462.32,percent of total billed charges,
ER Gastric Procedure,2152825,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
ER Gastric Procedure,2152825,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
ER Gastric Procedure,7275869,CDM,450,RC,,,,,facility,inpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,543.60,741.11,percent of total billed charges,
ER Gastric Procedure,7275869,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,1462.32,percent of total billed charges,
ER Hazmat Decontamination,602332,CDM,450,RC,,,,,facility,inpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,1045.80,1425.77,percent of total billed charges,
ER Hazmat Decontamination,602332,CDM,450,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,628.35,1462.32,percent of total billed charges,
ER Hazmat Decontamination,7275866,CDM,450,RC,,,,,facility,inpatient,,,1562.00000,452.98000,Aetna,First Health,,1277.72,,,,,,,937.20,1277.72,percent of total billed charges,
ER Hazmat Decontamination,7275866,CDM,450,RC,,,,,facility,outpatient,,,1562.00000,452.98000,Aetna,First Health,,1277.72,,,,,,,563.10,1462.32,percent of total billed charges,
ER Incision Of Windpipe,2152827,CDM,450,RC,,,,,facility,inpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,1045.80,1425.77,percent of total billed charges,
ER Incision Of Windpipe,2152827,CDM,450,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,First Health,,1425.77,,,,,,,628.35,1462.32,percent of total billed charges,
ER Insert Ng Tube,2152835,CDM,450,RC,43752,HCPCS,,,facility,inpatient,,,1133.00000,328.57000,Aetna,First Health,,926.79,,,,,,,679.80,926.79,percent of total billed charges,
ER Insert Ng Tube,2152835,CDM,450,RC,43752,HCPCS,,,facility,outpatient,,,1133.00000,328.57000,Aetna,First Health,,926.79,,,,,,,350.38,2860.00,percent of total billed charges,
ER Insert Ng Tube,5757849,CDM,450,RC,43752,HCPCS,,,facility,inpatient,,,1133.00000,328.57000,Aetna,First Health,,926.79,,,,,,,679.80,926.79,percent of total billed charges,
ER Insert Ng Tube,5757849,CDM,450,RC,43752,HCPCS,,,facility,outpatient,,,1133.00000,328.57000,Aetna,First Health,,926.79,,,,,,,350.38,2860.00,percent of total billed charges,
ER Optic Treatment,602382,CDM,450,RC,,,,,facility,inpatient,,,433.00000,125.57000,Aetna,First Health,,354.19,,,,,,,259.80,354.19,percent of total billed charges,
ER Optic Treatment,602382,CDM,450,RC,,,,,facility,outpatient,,,433.00000,125.57000,Aetna,First Health,,354.19,,,,,,,156.10,1462.32,percent of total billed charges,
ER Puncture Peritoneal Cavity,2152841,CDM,450,RC,,,,,facility,inpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,457.20,623.32,percent of total billed charges,
ER Puncture Peritoneal Cavity,2152841,CDM,450,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,274.70,1462.32,percent of total billed charges,
ER Tongue And Mouth Surgery,2152851,CDM,450,RC,,,,,facility,inpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,457.20,623.32,percent of total billed charges,
ER Tongue And Mouth Surgery,2152851,CDM,450,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,First Health,,623.32,,,,,,,274.70,1462.32,percent of total billed charges,
ER Urinary Procedure,2152834,CDM,450,RC,,,,,facility,inpatient,,,1639.00000,475.31000,Aetna,First Health,,1340.70,,,,,,,983.40,1340.70,percent of total billed charges,
ER Urinary Procedure,2152834,CDM,450,RC,,,,,facility,outpatient,,,1639.00000,475.31000,Aetna,First Health,,1340.70,,,,,,,590.86,1462.32,percent of total billed charges,
ER Urinary Procedure,2152837,CDM,450,RC,,,,,facility,inpatient,,,1639.00000,475.31000,Aetna,First Health,,1340.70,,,,,,,983.40,1340.70,percent of total billed charges,
ER Urinary Procedure,2152837,CDM,450,RC,,,,,facility,outpatient,,,1639.00000,475.31000,Aetna,First Health,,1340.70,,,,,,,590.86,1462.32,percent of total billed charges,
ER Insert Central Venous Catheter,2152831,CDM,450,RC,,,,,facility,inpatient,,,1801.00000,522.29000,Aetna,First Health,,1473.22,,,,,,,1080.60,1473.22,percent of total billed charges,
ER Insert Central Venous Catheter,2152831,CDM,450,RC,,,,,facility,outpatient,,,1801.00000,522.29000,Aetna,First Health,,1473.22,,,,,,,649.26,1473.22,percent of total billed charges,
ER Insert Chest Tube,2152830,CDM,450,RC,,,,,facility,inpatient,,,1522.00000,441.38000,Aetna,First Health,,1245.00,,,,,,,913.20,1245.00,percent of total billed charges,
ER Insert Chest Tube,2152830,CDM,450,RC,,,,,facility,outpatient,,,1522.00000,441.38000,Aetna,First Health,,1245.00,,,,,,,548.68,1462.32,percent of total billed charges,
ER Spinal Fluid Tap,2152848,CDM,450,RC,,,,,facility,inpatient,,,982.00000,284.78000,Aetna,First Health,,803.28,,,,,,,589.20,803.28,percent of total billed charges,
ER Spinal Fluid Tap,2152848,CDM,450,RC,,,,,facility,outpatient,,,982.00000,284.78000,Aetna,First Health,,803.28,,,,,,,354.01,1462.32,percent of total billed charges,
IV Hydration Initial 1st hr,8997071,CDM,450,RC,96360,HCPCS,,,facility,inpatient,,,575.00000,166.75000,Aetna,First Health,,470.35,,,,,,,345.00,470.35,percent of total billed charges,
IV Hydration Initial 1st hr,8997071,CDM,450,RC,96360,HCPCS,,,facility,outpatient,,,575.00000,166.75000,Aetna,First Health,,470.35,,,,,,,185.00,1462.32,percent of total billed charges,
IV Hydration Addl Ea Hr,8994799,CDM,450,RC,96361,HCPCS,,,facility,inpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,224.40,305.93,percent of total billed charges,
IV Hydration Addl Ea Hr,8994799,CDM,450,RC,96361,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,First Health,,305.93,,,,,,,40.51,1462.32,percent of total billed charges,
Change of Cystostomy Tube Simple,9011808,CDM,450,RC,51705,HCPCS,,,facility,inpatient,,,302.00000,87.58000,Aetna,First Health,,247.04,,,,,,,181.20,247.04,percent of total billed charges,
Change of Cystostomy Tube Simple,9011808,CDM,450,RC,51705,HCPCS,,,facility,outpatient,,,302.00000,87.58000,Aetna,First Health,,247.04,,,,,,,120.80,2860.00,percent of total billed charges,
ER Level 1,7261851,CDM,450,RC,99281,HCPCS,,,facility,inpatient,,,480.00000,139.20000,Aetna,First Health,,392.64,,,,,,,288.00,392.64,percent of total billed charges,
ER Level 1,7261851,CDM,450,RC,99281,HCPCS,,,facility,outpatient,,,480.00000,139.20000,Aetna,First Health,,392.64,,,,,,,77.31,1462.32,percent of total billed charges,
ER Level 2,7261852,CDM,450,RC,99282,HCPCS,,,facility,inpatient,,,790.00000,229.10000,Aetna,First Health,,646.22,,,,,,,474.00,646.22,percent of total billed charges,
ER Level 2,7261852,CDM,450,RC,99282,HCPCS,,,facility,outpatient,,,790.00000,229.10000,Aetna,First Health,,646.22,,,,,,,139.04,1462.32,percent of total billed charges,
ER Level 3,7261853,CDM,450,RC,99283,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,900.00,1227.00,percent of total billed charges,
ER Level 3,7261853,CDM,450,RC,99283,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,First Health,,1227.00,,,,,,,243.12,2478.00,percent of total billed charges,
ER Level 4,7261854,CDM,450,RC,99284,HCPCS,,,facility,inpatient,,,2315.00000,671.35000,Aetna,First Health,,1893.67,,,,,,,1389.00,1893.67,percent of total billed charges,
ER Level 4,7261854,CDM,450,RC,99284,HCPCS,,,facility,outpatient,,,2315.00000,671.35000,Aetna,First Health,,1893.67,,,,,,,373.89,3070.00,percent of total billed charges,
ER Level 5,7261855,CDM,450,RC,99285,HCPCS,,,facility,inpatient,,,3646.00000,1057.34000,Aetna,First Health,,2982.43,,,,,,,2187.60,2982.43,percent of total billed charges,
ER Level 5,7261855,CDM,450,RC,99285,HCPCS,,,facility,outpatient,,,3646.00000,1057.34000,Aetna,First Health,,2982.43,,,,,,,538.34,3070.00,percent of total billed charges,
ER Level 6,7261856,CDM,450,RC,99291,HCPCS,,,facility,inpatient,,,5253.00000,1523.37000,Aetna,First Health,,4296.95,,,,,,,3151.80,4296.95,percent of total billed charges,
ER Level 6,7261856,CDM,450,RC,99291,HCPCS,,,facility,outpatient,,,5253.00000,1523.37000,Aetna,First Health,,4296.95,,,,,,,739.86,4296.95,percent of total billed charges,
Sane Level 1,602472,CDM,450,RC,99499,HCPCS,,,facility,inpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,157.20,214.32,percent of total billed charges,
Sane Level 1,602472,CDM,450,RC,99499,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,First Health,,214.32,,,,,,,94.45,1462.32,percent of total billed charges,
Sane Level 2,602474,CDM,450,RC,99499,HCPCS,,,facility,inpatient,,,797.00000,231.13000,Aetna,First Health,,651.95,,,,,,,478.20,651.95,percent of total billed charges,
Sane Level 2,602474,CDM,450,RC,99499,HCPCS,,,facility,outpatient,,,797.00000,231.13000,Aetna,First Health,,651.95,,,,,,,287.32,1462.32,percent of total billed charges,
Sane Level 3,602476,CDM,450,RC,99499,HCPCS,,,facility,inpatient,,,1934.00000,560.86000,Aetna,First Health,,1582.01,,,,,,,1160.40,1582.01,percent of total billed charges,
Sane Level 3,602476,CDM,450,RC,99499,HCPCS,,,facility,outpatient,,,1934.00000,560.86000,Aetna,First Health,,1582.01,,,,,,,697.21,1582.01,percent of total billed charges,
OTHER BLOCK CHARGE,9088206,CDM,460,RC,,,,,facility,inpatient,,,2545.00000,738.05000,Aetna,First Health,,2081.81,,,,,,,1527.00,2081.81,percent of total billed charges,
OTHER BLOCK CHARGE,9088206,CDM,460,RC,,,,,facility,outpatient,,,2545.00000,738.05000,Aetna,First Health,,2081.81,,,,,,,917.47,2081.81,percent of total billed charges,
Stress Test 6 Minutes Simple,7860031,CDM,460,RC,94618,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Stress Test 6 Minutes Simple,7860031,CDM,460,RC,94618,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,113.19,696.94,percent of total billed charges,
Demo Eval Gen Neb Inh Device,5466009,CDM,460,RC,94664,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Demo Eval Gen Neb Inh Device,5466009,CDM,460,RC,94664,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Evaluate Patient Use of Inhaler,657753,CDM,460,RC,94664,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Evaluate Patient Use of Inhaler,657753,CDM,460,RC,94664,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Aerobika Daily Charge,8996766,CDM,460,RC,94664,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Aerobika Daily Charge,8996766,CDM,460,RC,94664,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Vital Capacity Test,3191093,CDM,460,RC,94150,HCPCS,,,facility,inpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,179.40,244.58,percent of total billed charges,
Vital Capacity Test,3191093,CDM,460,RC,94150,HCPCS,,,facility,outpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,110.99,417.59,percent of total billed charges,
Vital Capacity Test,5471878,CDM,460,RC,94150,HCPCS,,,facility,inpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,179.40,244.58,percent of total billed charges,
Vital Capacity Test,5471878,CDM,460,RC,94150,HCPCS,,,facility,outpatient,,,299.00000,86.71000,Aetna,First Health,,244.58,,,,,,,110.99,417.59,percent of total billed charges,
Sm Volume Nebulizer First Daily,5389871,CDM,460,RC,94640,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Sm Volume Nebulizer First Daily,5389871,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.84,542.88,percent of total billed charges,
Sm Volume Nebulizer First Daily,7637985,CDM,460,RC,94640,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Sm Volume Nebulizer First Daily,7637985,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.84,542.88,percent of total billed charges,
Sm Volume Nebulizer First Daily,9190478,CDM,460,RC,94640,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Sm Volume Nebulizer First Daily,9190478,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.84,542.88,percent of total billed charges,
Nitrogen Washout Or Frc,5389884,CDM,460,RC,94727,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Nitrogen Washout Or Frc,5389884,CDM,460,RC,94727,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,137.38,593.05,percent of total billed charges,
Nitrogen Washout Or Frc,5471883,CDM,460,RC,94727,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Nitrogen Washout Or Frc,5471883,CDM,460,RC,94727,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,137.38,593.05,percent of total billed charges,
Thoracic Gas Volume,5389885,CDM,460,RC,94726,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Thoracic Gas Volume,5389885,CDM,460,RC,94726,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,269.12,840.96,percent of total billed charges,
Thoracic Gas Volume,5471879,CDM,460,RC,94726,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Thoracic Gas Volume,5471879,CDM,460,RC,94726,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,269.12,840.96,percent of total billed charges,
Resistance To Airflow W N2 Volume,7967854,CDM,460,RC,94726,HCPCS,,,facility,inpatient,,,1450.00000,420.50000,Aetna,First Health,,1186.10,,,,,,,870.00,1186.10,percent of total billed charges,
Resistance To Airflow W N2 Volume,7967854,CDM,460,RC,94726,HCPCS,,,facility,outpatient,,,1450.00000,420.50000,Aetna,First Health,,1186.10,,,,,,,273.42,1186.10,percent of total billed charges,
Sm Volume Nebulizer Subseq Daily,5389872,CDM,460,RC,94640,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Sm Volume Nebulizer Subseq Daily,5389872,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.84,542.88,percent of total billed charges,
Sm Volume Nebulizer Subseq Daily,7637984,CDM,460,RC,94640,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Sm Volume Nebulizer Subseq Daily,7637984,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.84,542.88,percent of total billed charges,
Exercise Oximetry,7930098,CDM,460,RC,94618,HCPCS,,,facility,inpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,511.20,696.94,percent of total billed charges,
Exercise Oximetry,7930098,CDM,460,RC,94618,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,First Health,,696.94,,,,,,,113.19,696.94,percent of total billed charges,
Spirometry,5471881,CDM,460,RC,94010,HCPCS,,,facility,inpatient,,,644.00000,186.76000,Aetna,First Health,,526.79,,,,,,,386.40,526.79,percent of total billed charges,
Spirometry,5471881,CDM,460,RC,94010,HCPCS,,,facility,outpatient,,,644.00000,186.76000,Aetna,First Health,,526.79,,,,,,,137.38,526.79,percent of total billed charges,
Spirometry,5471888,CDM,460,RC,94010,HCPCS,,,facility,inpatient,,,644.00000,186.76000,Aetna,First Health,,526.79,,,,,,,386.40,526.79,percent of total billed charges,
Spirometry,5471888,CDM,460,RC,94010,HCPCS,,,facility,outpatient,,,644.00000,186.76000,Aetna,First Health,,526.79,,,,,,,137.38,526.79,percent of total billed charges,
Spirometry,612663,CDM,460,RC,94010,HCPCS,,,facility,inpatient,,,644.00000,186.76000,Aetna,First Health,,526.79,,,,,,,386.40,526.79,percent of total billed charges,
Spirometry,612663,CDM,460,RC,94010,HCPCS,,,facility,outpatient,,,644.00000,186.76000,Aetna,First Health,,526.79,,,,,,,137.38,526.79,percent of total billed charges,
Spirometry,612735,CDM,460,RC,94010,HCPCS,,,facility,inpatient,,,644.00000,186.76000,Aetna,First Health,,526.79,,,,,,,386.40,526.79,percent of total billed charges,
Spirometry,612735,CDM,460,RC,94010,HCPCS,,,facility,outpatient,,,644.00000,186.76000,Aetna,First Health,,526.79,,,,,,,137.38,526.79,percent of total billed charges,
Spirometry Pre And Post,5471880,CDM,460,RC,94060,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,491.40,669.94,percent of total billed charges,
Spirometry Pre And Post,5471880,CDM,460,RC,94060,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,273.42,840.96,percent of total billed charges,
Spirometry Pre And Post,612667,CDM,460,RC,94060,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,491.40,669.94,percent of total billed charges,
Spirometry Pre And Post,612667,CDM,460,RC,94060,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,273.42,840.96,percent of total billed charges,
Diffusion Capacity,5471886,CDM,460,RC,94729,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,491.40,669.94,percent of total billed charges,
Diffusion Capacity,5471886,CDM,460,RC,94729,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
Diffusion Capacity,612671,CDM,460,RC,94729,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,491.40,669.94,percent of total billed charges,
Diffusion Capacity,612671,CDM,460,RC,94729,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,First Health,,669.94,,,,,,,295.25,669.94,percent of total billed charges,
Resistance To Airflow,5471882,CDM,460,RC,94726,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Resistance To Airflow,5471882,CDM,460,RC,94726,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,269.12,840.96,percent of total billed charges,
Resistance To Airflow,612677,CDM,460,RC,94726,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Resistance To Airflow,612677,CDM,460,RC,94726,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,269.12,840.96,percent of total billed charges,
Methacoline Challenge,5471884,CDM,460,RC,94070,HCPCS,,,facility,inpatient,,,2087.00000,605.23000,Aetna,First Health,,1707.17,,,,,,,1252.20,1707.17,percent of total billed charges,
Methacoline Challenge,5471884,CDM,460,RC,94070,HCPCS,,,facility,outpatient,,,2087.00000,605.23000,Aetna,First Health,,1707.17,,,,,,,273.42,1707.17,percent of total billed charges,
Sm Volume Nebulizer Initial,8244299,CDM,460,RC,94640,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,GZ,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Sm Volume Nebulizer Initial,8244299,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,GZ,61.35,,,,,,,27.04,542.88,percent of total billed charges,
Continuous High Freq Oscillation Initial,8414037,CDM,460,RC,94669,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Continuous High Freq Oscillation Initial,8414037,CDM,460,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Continuous High Freq Oscillation Subsequent,8414038,CDM,460,RC,94669,HCPCS,,,facility,inpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,176.40,240.49,percent of total billed charges,
Continuous High Freq Oscillation Subsequent,8414038,CDM,460,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,First Health,,240.49,,,,,,,109.13,542.88,percent of total billed charges,
Maximum Voluntary Ventilation,5471885,CDM,460,RC,94200,HCPCS,,,facility,inpatient,,,370.00000,107.30000,Aetna,First Health,,302.66,,,,,,,222.00,302.66,percent of total billed charges,
Maximum Voluntary Ventilation,5471885,CDM,460,RC,94200,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,First Health,,302.66,,,,,,,52.15,302.66,percent of total billed charges,
Maximum Voluntary Ventilation,5757855,CDM,460,RC,94200,HCPCS,,,facility,inpatient,,,370.00000,107.30000,Aetna,First Health,,302.66,,,,,,,222.00,302.66,percent of total billed charges,
Maximum Voluntary Ventilation,5757855,CDM,460,RC,94200,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,First Health,,302.66,,,,,,,52.15,302.66,percent of total billed charges,
Maximum Voluntary Ventilation,612701,CDM,460,RC,94200,HCPCS,,,facility,inpatient,,,370.00000,107.30000,Aetna,First Health,,302.66,,,,,,,222.00,302.66,percent of total billed charges,
Maximum Voluntary Ventilation,612701,CDM,460,RC,94200,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,First Health,,302.66,,,,,,,52.15,302.66,percent of total billed charges,
Metered Treatment Initial,7944332,CDM,460,RC,94640,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,45.00,61.35,percent of total billed charges,
Metered Treatment Initial,7944332,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.84,542.88,percent of total billed charges,
Nocturnal Oximetry,5111861,CDM,460,RC,94762,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Nocturnal Oximetry,5111861,CDM,460,RC,94762,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,128.88,593.05,percent of total billed charges,
Nocturnal Oximetry,5470370,CDM,460,RC,94762,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Nocturnal Oximetry,5470370,CDM,460,RC,94762,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,128.88,593.05,percent of total billed charges,
Continuous Pulse Ox,5571843,CDM,460,RC,94762,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Continuous Pulse Ox,5571843,CDM,460,RC,94762,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,128.88,593.05,percent of total billed charges,
Continuous Pulse Ox,5745855,CDM,460,RC,94762,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Continuous Pulse Ox,5745855,CDM,460,RC,94762,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,128.88,593.05,percent of total billed charges,
Continuous Pulse Ox,5745857,CDM,460,RC,94762,HCPCS,,,facility,inpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,435.00,593.05,percent of total billed charges,
Continuous Pulse Ox,5745857,CDM,460,RC,94762,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,First Health,,593.05,,,,,,,128.88,593.05,percent of total billed charges,
CEN Positional Nystagmus,617804,CDM,471,RC,92542,HCPCS,,,facility,inpatient,,,409.00000,118.61000,Aetna,First Health,,334.56,,,,,,,245.40,334.56,percent of total billed charges,
CEN Positional Nystagmus,617804,CDM,471,RC,92542,HCPCS,,,facility,outpatient,,,409.00000,118.61000,Aetna,First Health,,334.56,,,,,,,53.64,344.05,percent of total billed charges,
CEN Oscillating Tracking,617803,CDM,471,RC,92545,HCPCS,,,facility,inpatient,,,409.00000,118.61000,Aetna,First Health,,334.56,,,,,,,245.40,334.56,percent of total billed charges,
CEN Oscillating Tracking,617803,CDM,471,RC,92545,HCPCS,,,facility,outpatient,,,409.00000,118.61000,Aetna,First Health,,334.56,,,,,,,37.89,831.14,percent of total billed charges,
Cardioversion,1327801,CDM,480,RC,,,,,facility,inpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,2237.40,3050.32,percent of total billed charges,
Cardioversion,1327801,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,1344.30,3050.32,percent of total billed charges,
Cardioversion,7295845,CDM,480,RC,,,,,facility,inpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,2237.40,3050.32,percent of total billed charges,
Cardioversion,7295845,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,1344.30,3050.32,percent of total billed charges,
Tilt Table,7860029,CDM,480,RC,93660,HCPCS,,,facility,inpatient,,,4683.00000,1358.07000,Aetna,First Health,,3830.69,,,,,,,2809.80,3830.69,percent of total billed charges,
Tilt Table,7860029,CDM,480,RC,93660,HCPCS,,,facility,outpatient,,,4683.00000,1358.07000,Aetna,First Health,,3830.69,,,,,,,373.76,3830.69,percent of total billed charges,
Cardioversion,7289842,CDM,480,RC,,,,,facility,inpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,2237.40,3050.32,percent of total billed charges,
Cardioversion,7289842,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,1344.30,3050.32,percent of total billed charges,
Cardioversion,7401840,CDM,480,RC,,,,,facility,inpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,2237.40,3050.32,percent of total billed charges,
Cardioversion,7401840,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,1344.30,3050.32,percent of total billed charges,
Cardioversion,8147861,CDM,480,RC,,,,,facility,inpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,2237.40,3050.32,percent of total billed charges,
Cardioversion,8147861,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,1344.30,3050.32,percent of total billed charges,
COLOR FLOW,8003078,CDM,480,RC,93325,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,852.00,1161.56,percent of total billed charges,
COLOR FLOW,8003078,CDM,480,RC,93325,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,287.88,1161.56,percent of total billed charges,
Color Flow,8147860,CDM,480,RC,93325,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,852.00,1161.56,percent of total billed charges,
Color Flow,8147860,CDM,480,RC,93325,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,287.88,1161.56,percent of total billed charges,
Echo Intracardiac,7289846,CDM,480,RC,,,,,facility,inpatient,,,10727.00000,3110.83000,Aetna,First Health,,8774.69,,,,,,,6436.20,8774.69,percent of total billed charges,
Echo Intracardiac,7289846,CDM,480,RC,,,,,facility,outpatient,,,10727.00000,3110.83000,Aetna,First Health,,8774.69,,,,,,,3867.08,8774.69,percent of total billed charges,
Myocardial Strain Imaging,7993616,CDM,480,RC,93356,HCPCS,,,facility,inpatient,,,985.00000,285.65000,Aetna,First Health,,805.73,,,,,,,591.00,805.73,percent of total billed charges,
Myocardial Strain Imaging,7993616,CDM,480,RC,93356,HCPCS,,,facility,outpatient,,,985.00000,285.65000,Aetna,First Health,,805.73,,,,,,,355.09,805.73,percent of total billed charges,
Cardioversion External Elective,8062919,CDM,480,RC,,,,,facility,inpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,2237.40,3050.32,percent of total billed charges,
Cardioversion External Elective,8062919,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,First Health,,3050.32,,,,,,,1344.30,3050.32,percent of total billed charges,
Resuscitation,5463843,CDM,480,RC,92950,HCPCS,,,facility,inpatient,,,2675.00000,775.75000,Aetna,First Health,,2188.15,,,,,,,1605.00,2188.15,percent of total billed charges,
Resuscitation,5463843,CDM,480,RC,92950,HCPCS,,,facility,outpatient,,,2675.00000,775.75000,Aetna,First Health,,2188.15,,,,,,,216.27,2188.15,percent of total billed charges,
Resuscitation,612639,CDM,480,RC,92950,HCPCS,,,facility,inpatient,,,2675.00000,775.75000,Aetna,First Health,,2188.15,,,,,,,1605.00,2188.15,percent of total billed charges,
Resuscitation,612639,CDM,480,RC,92950,HCPCS,,,facility,outpatient,,,2675.00000,775.75000,Aetna,First Health,,2188.15,,,,,,,216.27,2188.15,percent of total billed charges,
NB Resuscitation,8994591,CDM,480,RC,99465,HCPCS,,,facility,inpatient,,,2675.00000,775.75000,Aetna,First Health,,2188.15,,,,,,,1605.00,2188.15,percent of total billed charges,
NB Resuscitation,8994591,CDM,480,RC,99465,HCPCS,,,facility,outpatient,,,2675.00000,775.75000,Aetna,First Health,,2188.15,,,,,,,574.59,2188.15,percent of total billed charges,
IVC Filter Placement W Venogram,8062812,CDM,481,RC,,,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,9000.00,12270.00,percent of total billed charges,
IVC Filter Placement W Venogram,8062812,CDM,481,RC,,,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
IVC Filter Removal,8062813,CDM,481,RC,,,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,5400.00,7362.00,percent of total billed charges,
IVC Filter Removal,8062813,CDM,481,RC,,,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,10865.00,percent of total billed charges,
Insert Arterial Impella,8142185,CDM,481,RC,,,,,facility,inpatient,,,12397.00000,3595.13000,Aetna,First Health,,10140.75,,,,,,,7438.20,10140.75,percent of total billed charges,
Insert Arterial Impella,8142185,CDM,481,RC,,,,,facility,outpatient,,,12397.00000,3595.13000,Aetna,First Health,,10140.75,,,,,,,4469.12,10865.00,percent of total billed charges,
Balloon Aortic Valvuloplasty,8062816,CDM,481,RC,,,,,facility,inpatient,,,21281.00000,6171.49000,Aetna,First Health,,17407.86,,,,,,,12768.60,17407.86,percent of total billed charges,
Balloon Aortic Valvuloplasty,8062816,CDM,481,RC,,,,,facility,outpatient,,,21281.00000,6171.49000,Aetna,First Health,,17407.86,,,,,,,7671.80,17407.86,percent of total billed charges,
Implant LAA Closure Device,8062817,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Implant LAA Closure Device,8062817,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Reprogramming Of Icd,8062818,CDM,481,RC,,,,,facility,inpatient,,,646.00000,187.34000,Aetna,First Health,,528.43,,,,,,,387.60,528.43,percent of total billed charges,
Reprogramming Of Icd,8062818,CDM,481,RC,,,,,facility,outpatient,,,646.00000,187.34000,Aetna,First Health,,528.43,,,,,,,232.88,10865.00,percent of total billed charges,
Closure Patent Ductus,8062819,CDM,481,RC,,,,,facility,inpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,27600.00,37628.00,percent of total billed charges,
Closure Patent Ductus,8062819,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,9200.00,37628.00,percent of total billed charges,
Heart Cath Rt W Sensor Implant,8142184,CDM,481,RC,,,,,facility,inpatient,,,87400.00000,25346.00000,Aetna,First Health,,71493.20,,,,,,,52440.00,71493.20,percent of total billed charges,
Heart Cath Rt W Sensor Implant,8142184,CDM,481,RC,,,,,facility,outpatient,,,87400.00000,25346.00000,Aetna,First Health,,71493.20,,,,,,,9200.00,71493.20,percent of total billed charges,
Place Stent Addtl Nonlower,8062884,CDM,481,RC,,,,,facility,inpatient,,,41323.00000,11983.67000,Aetna,First Health,,33802.21,,,,,,,24793.80,33802.21,percent of total billed charges,
Place Stent Addtl Nonlower,8062884,CDM,481,RC,,,,,facility,outpatient,,,41323.00000,11983.67000,Aetna,First Health,,33802.21,,,,,,,9200.00,33802.21,percent of total billed charges,
Place Stent and PTCA Single Major AR,8062968,CDM,481,RC,,,,,facility,inpatient,,,41323.00000,11983.67000,Aetna,First Health,,33802.21,,,,,,,24793.80,33802.21,percent of total billed charges,
Place Stent and PTCA Single Major AR,8062968,CDM,481,RC,,,,,facility,outpatient,,,41323.00000,11983.67000,Aetna,First Health,,33802.21,,,,,,,9200.00,33802.21,percent of total billed charges,
Place Stent,8142488,CDM,481,RC,,,,,facility,inpatient,,,41323.00000,11983.67000,Aetna,First Health,,33802.21,,,,,,,24793.80,33802.21,percent of total billed charges,
Place Stent,8142488,CDM,481,RC,,,,,facility,outpatient,,,41323.00000,11983.67000,Aetna,First Health,,33802.21,,,,,,,9200.00,33802.21,percent of total billed charges,
Reposition Ventricular Lead w Anti Micobial Pouch,8225890,CDM,481,RC,,,,,facility,inpatient,,,16298.00000,4726.42000,Aetna,First Health,,13331.76,,,,,,,9778.80,13331.76,percent of total billed charges,
Reposition Ventricular Lead w Anti Micobial Pouch,8225890,CDM,481,RC,,,,,facility,outpatient,,,16298.00000,4726.42000,Aetna,First Health,,13331.76,,,,,,,5875.43,13331.76,percent of total billed charges,
TAVR Procedure,8436576,CDM,481,RC,,,,,facility,inpatient,,,29604.00000,8585.16000,Aetna,First Health,,24216.07,,,,,,,17762.40,24216.07,percent of total billed charges,
TAVR Procedure,8436576,CDM,481,RC,,,,,facility,outpatient,,,29604.00000,8585.16000,Aetna,First Health,,24216.07,,,,,,,9200.00,24216.07,percent of total billed charges,
Transcatheter Mitral Valve Repair,8948552,CDM,481,RC,,,,,facility,inpatient,,,29604.00000,8585.16000,Aetna,First Health,,24216.07,,,,,,,17762.40,24216.07,percent of total billed charges,
Transcatheter Mitral Valve Repair,8948552,CDM,481,RC,,,,,facility,outpatient,,,29604.00000,8585.16000,Aetna,First Health,,24216.07,,,,,,,9200.00,24216.07,percent of total billed charges,
Intravascular Lithotripsy,9000387,CDM,481,RC,,,,,facility,inpatient,,,32811.00000,9515.19000,Aetna,First Health,,26839.40,,,,,,,19686.60,26839.40,percent of total billed charges,
Intravascular Lithotripsy,9000387,CDM,481,RC,,,,,facility,outpatient,,,32811.00000,9515.19000,Aetna,First Health,,26839.40,,,,,,,9200.00,26839.40,percent of total billed charges,
INSERT OR REPLACE SUBQ DEFIBRILLATOR,9090469,CDM,481,RC,,,,,facility,inpatient,,,60000.00000,17400.00000,Aetna,First Health,,49080.00,,,,,,,36000.00,49080.00,percent of total billed charges,
INSERT OR REPLACE SUBQ DEFIBRILLATOR,9090469,CDM,481,RC,,,,,facility,outpatient,,,60000.00000,17400.00000,Aetna,First Health,,49080.00,,,,,,,9200.00,49080.00,percent of total billed charges,
Device Interrogation,8997182,CDM,481,RC,,,,,facility,inpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,183.00,249.49,percent of total billed charges,
Device Interrogation,8997182,CDM,481,RC,,,,,facility,outpatient,,,305.00000,88.45000,Aetna,First Health,,249.49,,,,,,,109.95,10865.00,percent of total billed charges,
Pacemaker Leadless Insert Or Repl,8156532,CDM,481,RC,,,,,facility,inpatient,,,51000.00000,14790.00000,Aetna,First Health,,41718.00,,,,,,,30600.00,41718.00,percent of total billed charges,
Pacemaker Leadless Insert Or Repl,8156532,CDM,481,RC,,,,,facility,outpatient,,,51000.00000,14790.00000,Aetna,First Health,,41718.00,,,,,,,9200.00,41718.00,percent of total billed charges,
Insert or Replace Cardiac Modulation,9210779,CDM,481,RC,,,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,7200.00,9816.00,percent of total billed charges,
Insert or Replace Cardiac Modulation,9210779,CDM,481,RC,,,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,First Health,,9816.00,,,,,,,4326.00,10865.00,percent of total billed charges,
Insert Drug Coated Balloon,9198712,CDM,481,RC,,,,,facility,inpatient,,,41323.00000,11983.67000,Aetna,First Health,,33802.21,,,,,,,24793.80,33802.21,percent of total billed charges,
Insert Drug Coated Balloon,9198712,CDM,481,RC,,,,,facility,outpatient,,,41323.00000,11983.67000,Aetna,First Health,,33802.21,,,,,,,9200.00,33802.21,percent of total billed charges,
Pericardiocentesis Initl,8062820,CDM,481,RC,,,,,facility,inpatient,,,8109.00000,2351.61000,Aetna,First Health,,6633.16,,,,,,,4865.40,6633.16,percent of total billed charges,
Pericardiocentesis Initl,8062820,CDM,481,RC,,,,,facility,outpatient,,,8109.00000,2351.61000,Aetna,First Health,,6633.16,,,,,,,2923.29,10865.00,percent of total billed charges,
Pericardiocentesis Subsequent,8062821,CDM,481,RC,,,,,facility,inpatient,,,1992.00000,577.68000,Aetna,First Health,,1629.46,,,,,,,1195.20,1629.46,percent of total billed charges,
Pericardiocentesis Subsequent,8062821,CDM,481,RC,,,,,facility,outpatient,,,1992.00000,577.68000,Aetna,First Health,,1629.46,,,,,,,718.12,10865.00,percent of total billed charges,
Insert Replace PM Atrial,8062822,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Insert Replace PM Atrial,8062822,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Insert Replace PM Ventr,8062823,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Insert Replace PM Ventr,8062823,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Insert Replace PM Atrial And Ventr,8062824,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Insert Replace PM Atrial And Ventr,8062824,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Insert Replace Temp Single PM,8062825,CDM,481,RC,,,,,facility,inpatient,,,26450.00000,7670.50000,Aetna,First Health,,21636.10,,,,,,,15870.00,21636.10,percent of total billed charges,
Insert Replace Temp Single PM,8062825,CDM,481,RC,,,,,facility,outpatient,,,26450.00000,7670.50000,Aetna,First Health,,21636.10,,,,,,,9200.00,21636.10,percent of total billed charges,
Insertgen Only Existing Single,8062826,CDM,481,RC,,,,,facility,inpatient,,,28000.00000,8120.00000,Aetna,First Health,,22904.00,,,,,,,16800.00,22904.00,percent of total billed charges,
Insertgen Only Existing Single,8062826,CDM,481,RC,,,,,facility,outpatient,,,28000.00000,8120.00000,Aetna,First Health,,22904.00,,,,,,,9200.00,22904.00,percent of total billed charges,
Insert Gen Only Existing Dual,8062827,CDM,481,RC,,,,,facility,inpatient,,,32200.00000,9338.00000,Aetna,First Health,,26339.60,,,,,,,19320.00,26339.60,percent of total billed charges,
Insert Gen Only Existing Dual,8062827,CDM,481,RC,,,,,facility,outpatient,,,32200.00000,9338.00000,Aetna,First Health,,26339.60,,,,,,,9200.00,26339.60,percent of total billed charges,
Upgrade Single Pm To Dual Pm,8062828,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Upgrade Single Pm To Dual Pm,8062828,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Reposition Rt Ventr Atrial Lead,8062829,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
Reposition Rt Ventr Atrial Lead,8062829,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
Insert Lead One,8062830,CDM,481,RC,,,,,facility,inpatient,,,26450.00000,7670.50000,Aetna,First Health,,21636.10,,,,,,,15870.00,21636.10,percent of total billed charges,
Insert Lead One,8062830,CDM,481,RC,,,,,facility,outpatient,,,26450.00000,7670.50000,Aetna,First Health,,21636.10,,,,,,,9200.00,21636.10,percent of total billed charges,
Insert Lead Two,8062831,CDM,481,RC,,,,,facility,inpatient,,,26450.00000,7670.50000,Aetna,First Health,,21636.10,,,,,,,15870.00,21636.10,percent of total billed charges,
Insert Lead Two,8062831,CDM,481,RC,,,,,facility,outpatient,,,26450.00000,7670.50000,Aetna,First Health,,21636.10,,,,,,,9200.00,21636.10,percent of total billed charges,
Repair Lead One,8062832,CDM,481,RC,,,,,facility,inpatient,,,14879.00000,4314.91000,Aetna,First Health,,12171.02,,,,,,,8927.40,12171.02,percent of total billed charges,
Repair Lead One,8062832,CDM,481,RC,,,,,facility,outpatient,,,14879.00000,4314.91000,Aetna,First Health,,12171.02,,,,,,,5363.88,12171.02,percent of total billed charges,
Insert Gen Only Existing Multiple,8062833,CDM,481,RC,,,,,facility,inpatient,,,51000.00000,14790.00000,Aetna,First Health,,41718.00,,,,,,,30600.00,41718.00,percent of total billed charges,
Insert Gen Only Existing Multiple,8062833,CDM,481,RC,,,,,facility,outpatient,,,51000.00000,14790.00000,Aetna,First Health,,41718.00,,,,,,,9200.00,41718.00,percent of total billed charges,
Revision Relocate Of Skin Pocket,8062805,CDM,481,RC,,,,,facility,inpatient,,,8109.00000,2351.61000,Aetna,First Health,,6633.16,,,,,,,4865.40,6633.16,percent of total billed charges,
Revision Relocate Of Skin Pocket,8062805,CDM,481,RC,,,,,facility,outpatient,,,8109.00000,2351.61000,Aetna,First Health,,6633.16,,,,,,,2923.29,10865.00,percent of total billed charges,
Revision Relocate Of Skin Pocket,8062806,CDM,481,RC,,,,,facility,inpatient,,,6131.00000,1777.99000,Aetna,First Health,,5015.16,,,,,,,3678.60,5015.16,percent of total billed charges,
Revision Relocate Of Skin Pocket,8062806,CDM,481,RC,,,,,facility,outpatient,,,6131.00000,1777.99000,Aetna,First Health,,5015.16,,,,,,,2210.23,10865.00,percent of total billed charges,
Add Lt Ventr Lead to Existing Pm,8062834,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Add Lt Ventr Lead to Existing Pm,8062834,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Insert Lt Ventr Lead At Time Of P,8062835,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Insert Lt Ventr Lead At Time Of P,8062835,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Reposition Lt Ventricular Lead,8062836,CDM,481,RC,,,,,facility,inpatient,,,11263.00000,3266.27000,Aetna,First Health,,9213.13,,,,,,,6757.80,9213.13,percent of total billed charges,
Reposition Lt Ventricular Lead,8062836,CDM,481,RC,,,,,facility,outpatient,,,11263.00000,3266.27000,Aetna,First Health,,9213.13,,,,,,,4060.31,10865.00,percent of total billed charges,
Replace Pm Gen Existng Single,8062837,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Replace Pm Gen Existng Single,8062837,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Replace Pm Gen Existng Dual Lead,8062838,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Replace Pm Gen Existng Dual Lead,8062838,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Replace Pm Gen Existng Multple,8062839,CDM,481,RC,,,,,facility,inpatient,,,58650.00000,17008.50000,Aetna,First Health,,47975.70,,,,,,,35190.00,47975.70,percent of total billed charges,
Replace Pm Gen Existng Multple,8062839,CDM,481,RC,,,,,facility,outpatient,,,58650.00000,17008.50000,Aetna,First Health,,47975.70,,,,,,,9200.00,47975.70,percent of total billed charges,
Insert Of Icd Gen Only Dual,8062840,CDM,481,RC,,,,,facility,inpatient,,,62000.00000,17980.00000,Aetna,First Health,,50716.00,,,,,,,37200.00,50716.00,percent of total billed charges,
Insert Of Icd Gen Only Dual,8062840,CDM,481,RC,,,,,facility,outpatient,,,62000.00000,17980.00000,Aetna,First Health,,50716.00,,,,,,,9200.00,50716.00,percent of total billed charges,
Insert Of Icd Gen Only Multiple,8062841,CDM,481,RC,,,,,facility,inpatient,,,86000.00000,24940.00000,Aetna,First Health,,70348.00,,,,,,,51600.00,70348.00,percent of total billed charges,
Insert Of Icd Gen Only Multiple,8062841,CDM,481,RC,,,,,facility,outpatient,,,86000.00000,24940.00000,Aetna,First Health,,70348.00,,,,,,,9200.00,70348.00,percent of total billed charges,
Remove Perm Pm Pulse Gen Only,8062842,CDM,481,RC,,,,,facility,inpatient,,,26450.00000,7670.50000,Aetna,First Health,,21636.10,,,,,,,15870.00,21636.10,percent of total billed charges,
Remove Perm Pm Pulse Gen Only,8062842,CDM,481,RC,,,,,facility,outpatient,,,26450.00000,7670.50000,Aetna,First Health,,21636.10,,,,,,,9200.00,21636.10,percent of total billed charges,
Remove Transv Lead Single,8062843,CDM,481,RC,,,,,facility,inpatient,,,12649.00000,3668.21000,Aetna,First Health,,10346.88,,,,,,,7589.40,10346.88,percent of total billed charges,
Remove Transv Lead Single,8062843,CDM,481,RC,,,,,facility,outpatient,,,12649.00000,3668.21000,Aetna,First Health,,10346.88,,,,,,,4559.96,10865.00,percent of total billed charges,
Remove Of Transv Lead Dual,8062844,CDM,481,RC,,,,,facility,inpatient,,,12766.00000,3702.14000,Aetna,First Health,,10442.59,,,,,,,7659.60,10442.59,percent of total billed charges,
Remove Of Transv Lead Dual,8062844,CDM,481,RC,,,,,facility,outpatient,,,12766.00000,3702.14000,Aetna,First Health,,10442.59,,,,,,,4602.14,10865.00,percent of total billed charges,
Insert Of Icd Gen Only Single,8062845,CDM,481,RC,,,,,facility,inpatient,,,62000.00000,17980.00000,Aetna,First Health,,50716.00,,,,,,,37200.00,50716.00,percent of total billed charges,
Insert Of Icd Gen Only Single,8062845,CDM,481,RC,,,,,facility,outpatient,,,62000.00000,17980.00000,Aetna,First Health,,50716.00,,,,,,,9200.00,50716.00,percent of total billed charges,
Remove ICD Gen Only,8062846,CDM,481,RC,,,,,facility,inpatient,,,14895.00000,4319.55000,Aetna,First Health,,12184.11,,,,,,,8937.00,12184.11,percent of total billed charges,
Remove ICD Gen Only,8062846,CDM,481,RC,,,,,facility,outpatient,,,14895.00000,4319.55000,Aetna,First Health,,12184.11,,,,,,,5369.65,12184.11,percent of total billed charges,
Remove Electrode Transvenous,8062847,CDM,481,RC,,,,,facility,inpatient,,,12649.00000,3668.21000,Aetna,First Health,,10346.88,,,,,,,7589.40,10346.88,percent of total billed charges,
Remove Electrode Transvenous,8062847,CDM,481,RC,,,,,facility,outpatient,,,12649.00000,3668.21000,Aetna,First Health,,10346.88,,,,,,,4559.96,10865.00,percent of total billed charges,
Insert Pulse Gen And Lead,8062848,CDM,481,RC,,,,,facility,inpatient,,,98900.00000,28681.00000,Aetna,First Health,,80900.20,,,,,,,59340.00,80900.20,percent of total billed charges,
Insert Pulse Gen And Lead,8062848,CDM,481,RC,,,,,facility,outpatient,,,98900.00000,28681.00000,Aetna,First Health,,80900.20,,,,,,,9200.00,80900.20,percent of total billed charges,
Replace Icd Gen Existng Single,8062849,CDM,481,RC,,,,,facility,inpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,42780.00,58323.40,percent of total billed charges,
Replace Icd Gen Existng Single,8062849,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,9200.00,58323.40,percent of total billed charges,
Replace Icd Gen Existng Dual,8062850,CDM,481,RC,,,,,facility,inpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,42780.00,58323.40,percent of total billed charges,
Replace Icd Gen Existng Dual,8062850,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,9200.00,58323.40,percent of total billed charges,
Replace Icd Gen Existng Multiple,8062851,CDM,481,RC,,,,,facility,inpatient,,,98900.00000,28681.00000,Aetna,First Health,,80900.20,,,,,,,59340.00,80900.20,percent of total billed charges,
Replace Icd Gen Existng Multiple,8062851,CDM,481,RC,,,,,facility,outpatient,,,98900.00000,28681.00000,Aetna,First Health,,80900.20,,,,,,,9200.00,80900.20,percent of total billed charges,
Insert Loop Event Recorder,8062852,CDM,481,RC,,,,,facility,inpatient,,,20268.00000,5877.72000,Aetna,First Health,,16579.22,,,,,,,12160.80,16579.22,percent of total billed charges,
Insert Loop Event Recorder,8062852,CDM,481,RC,,,,,facility,outpatient,,,20268.00000,5877.72000,Aetna,First Health,,16579.22,,,,,,,7306.61,16579.22,percent of total billed charges,
Remove Loop Recorder,8062853,CDM,481,RC,,,,,facility,inpatient,,,8109.00000,2351.61000,Aetna,First Health,,6633.16,,,,,,,4865.40,6633.16,percent of total billed charges,
Remove Loop Recorder,8062853,CDM,481,RC,,,,,facility,outpatient,,,8109.00000,2351.61000,Aetna,First Health,,6633.16,,,,,,,2923.29,10865.00,percent of total billed charges,
Insert Balloon Pump,8062854,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
Insert Balloon Pump,8062854,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
Remove Balloon Pump,8062855,CDM,481,RC,,,,,facility,inpatient,,,6690.00000,1940.10000,Aetna,First Health,,5472.42,,,,,,,4014.00,5472.42,percent of total billed charges,
Remove Balloon Pump,8062855,CDM,481,RC,,,,,facility,outpatient,,,6690.00000,1940.10000,Aetna,First Health,,5472.42,,,,,,,2411.74,10865.00,percent of total billed charges,
Reposition At Separate Session,8062856,CDM,481,RC,,,,,facility,inpatient,,,12649.00000,3668.21000,Aetna,First Health,,10346.88,,,,,,,7589.40,10346.88,percent of total billed charges,
Reposition At Separate Session,8062856,CDM,481,RC,,,,,facility,outpatient,,,12649.00000,3668.21000,Aetna,First Health,,10346.88,,,,,,,4559.96,10865.00,percent of total billed charges,
Brachiocephalic Initl Vessel,8062857,CDM,481,RC,,,,,facility,inpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,7355.40,10027.86,percent of total billed charges,
Brachiocephalic Initl Vessel,8062857,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,4419.37,10865.00,percent of total billed charges,
Brachiocephalic Each Additl Vesse,8062858,CDM,481,RC,,,,,facility,inpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,7355.40,10027.86,percent of total billed charges,
Brachiocephalic Each Additl Vesse,8062858,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,4419.37,10865.00,percent of total billed charges,
Place Cath Rt Or Pulm Art,8062859,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Place Cath Rt Or Pulm Art,8062859,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Place Catheter Rt Or Lt Pulm Art,8062860,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Place Catheter Rt Or Lt Pulm Art,8062860,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Place Catheter Segmntl Pulm Art,8062861,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Place Catheter Segmntl Pulm Art,8062861,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Place Catheter In Artery Brachial,8062862,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Place Catheter In Artery Brachial,8062862,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Place Catheter in Extremity,8062863,CDM,481,RC,,,,,facility,inpatient,,,6082.00000,1763.78000,Aetna,First Health,,4975.08,,,,,,,3649.20,4975.08,percent of total billed charges,
Place Catheter in Extremity,8062863,CDM,481,RC,,,,,facility,outpatient,,,6082.00000,1763.78000,Aetna,First Health,,4975.08,,,,,,,2192.56,10865.00,percent of total billed charges,
Place Catheter In Femoral Or Brac,8062864,CDM,481,RC,,,,,facility,inpatient,,,6082.00000,1763.78000,Aetna,First Health,,4975.08,,,,,,,3649.20,4975.08,percent of total billed charges,
Place Catheter In Femoral Or Brac,8062864,CDM,481,RC,,,,,facility,outpatient,,,6082.00000,1763.78000,Aetna,First Health,,4975.08,,,,,,,2192.56,10865.00,percent of total billed charges,
Each 1St Order Above Diaghram,8062865,CDM,481,RC,,,,,facility,inpatient,,,6082.00000,1763.78000,Aetna,First Health,,4975.08,,,,,,,3649.20,4975.08,percent of total billed charges,
Each 1St Order Above Diaghram,8062865,CDM,481,RC,,,,,facility,outpatient,,,6082.00000,1763.78000,Aetna,First Health,,4975.08,,,,,,,2192.56,10865.00,percent of total billed charges,
Initial 2nd Order Above Diaphragm,8062866,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Initial 2nd Order Above Diaphragm,8062866,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Initl 3rd Order Above Diaghram,8062867,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Initl 3rd Order Above Diaghram,8062867,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Addtl 2nd Order Above Diaphragm,8062868,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Addtl 2nd Order Above Diaphragm,8062868,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Nonselect Great Vessels,8062869,CDM,481,RC,,,,,facility,inpatient,,,18241.00000,5289.89000,Aetna,First Health,,14921.14,,,,,,,10944.60,14921.14,percent of total billed charges,
Nonselect Great Vessels,8062869,CDM,481,RC,,,,,facility,outpatient,,,18241.00000,5289.89000,Aetna,First Health,,14921.14,,,,,,,6575.88,14921.14,percent of total billed charges,
Carotid Intracranial Unilat,8062870,CDM,481,RC,,,,,facility,inpatient,,,18022.00000,5226.38000,Aetna,First Health,,14742.00,,,,,,,10813.20,14742.00,percent of total billed charges,
Carotid Intracranial Unilat,8062870,CDM,481,RC,,,,,facility,outpatient,,,18022.00000,5226.38000,Aetna,First Health,,14742.00,,,,,,,6496.93,14742.00,percent of total billed charges,
Vertebral Unilatw Select,8062871,CDM,481,RC,,,,,facility,inpatient,,,13793.00000,3999.97000,Aetna,First Health,,11282.67,,,,,,,8275.80,11282.67,percent of total billed charges,
Vertebral Unilatw Select,8062871,CDM,481,RC,,,,,facility,outpatient,,,13793.00000,3999.97000,Aetna,First Health,,11282.67,,,,,,,4972.38,11282.67,percent of total billed charges,
Each 1st Order Below Diaphragm,8062872,CDM,481,RC,,,,,facility,inpatient,,,6082.00000,1763.78000,Aetna,First Health,,4975.08,,,,,,,3649.20,4975.08,percent of total billed charges,
Each 1st Order Below Diaphragm,8062872,CDM,481,RC,,,,,facility,outpatient,,,6082.00000,1763.78000,Aetna,First Health,,4975.08,,,,,,,2192.56,10865.00,percent of total billed charges,
Initl 2nd Order Above Diaghram,8062873,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Initl 2nd Order Above Diaghram,8062873,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Initl 3rd Order Above Diaghram,8062874,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Initl 3rd Order Above Diaghram,8062874,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Addtl 2nd Order Below Diaphragm,8062875,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Addtl 2nd Order Below Diaphragm,8062875,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Renal Select Unilat,8062876,CDM,481,RC,,,,,facility,inpatient,,,10727.00000,3110.83000,Aetna,First Health,,8774.69,,,,,,,6436.20,8774.69,percent of total billed charges,
Renal Select Unilat,8062876,CDM,481,RC,,,,,facility,outpatient,,,10727.00000,3110.83000,Aetna,First Health,,8774.69,,,,,,,3867.08,10865.00,percent of total billed charges,
Renal Select Bilat,8062877,CDM,481,RC,,,,,facility,inpatient,,,19153.00000,5554.37000,Aetna,First Health,,15667.15,,,,,,,11491.80,15667.15,percent of total billed charges,
Renal Select Bilat,8062877,CDM,481,RC,,,,,facility,outpatient,,,19153.00000,5554.37000,Aetna,First Health,,15667.15,,,,,,,6904.66,15667.15,percent of total billed charges,
1st Art Thrombect Initl Vessel,8062878,CDM,481,RC,,,,,facility,inpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,27600.00,37628.00,percent of total billed charges,
1st Art Thrombect Initl Vessel,8062878,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,9200.00,37628.00,percent of total billed charges,
1st Art Thrombect 2nd Vessel,8062879,CDM,481,RC,,,,,facility,inpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,7355.40,10027.86,percent of total billed charges,
1st Art Thrombect 2nd Vessel,8062879,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,4419.37,10865.00,percent of total billed charges,
2nd Arterial Thrombectomy,8062880,CDM,481,RC,,,,,facility,inpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,7355.40,10027.86,percent of total billed charges,
2nd Arterial Thrombectomy,8062880,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,4419.37,10865.00,percent of total billed charges,
Perc Retrieval Of Foreign Body,8062881,CDM,481,RC,,,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,5400.00,7362.00,percent of total billed charges,
Perc Retrieval Of Foreign Body,8062881,CDM,481,RC,,,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,10865.00,percent of total billed charges,
Infusion For Other Than Thrombo,8062882,CDM,481,RC,,,,,facility,inpatient,,,5364.00000,1555.56000,Aetna,First Health,,4387.75,,,,,,,3218.40,4387.75,percent of total billed charges,
Infusion For Other Than Thrombo,8062882,CDM,481,RC,,,,,facility,outpatient,,,5364.00000,1555.56000,Aetna,First Health,,4387.75,,,,,,,1933.72,10865.00,percent of total billed charges,
Place Stent Initl Vessel Nonlower,8062883,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Place Stent Initl Vessel Nonlower,8062883,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Angioplasty Only Iliac Artery Init,8062885,CDM,481,RC,,,,,facility,inpatient,,,23409.00000,6788.61000,Aetna,First Health,,19148.56,,,,,,,14045.40,19148.56,percent of total billed charges,
Angioplasty Only Iliac Artery Init,8062885,CDM,481,RC,,,,,facility,outpatient,,,23409.00000,6788.61000,Aetna,First Health,,19148.56,,,,,,,8438.94,19148.56,percent of total billed charges,
Place Stent Wwo Angio Iliac Art,8062886,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Place Stent Wwo Angio Iliac Art,8062886,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Angioplasty Iliac Artery Addtl,8062887,CDM,481,RC,,,,,facility,inpatient,,,16858.00000,4888.82000,Aetna,First Health,,13789.84,,,,,,,10114.80,13789.84,percent of total billed charges,
Angioplasty Iliac Artery Addtl,8062887,CDM,481,RC,,,,,facility,outpatient,,,16858.00000,4888.82000,Aetna,First Health,,13789.84,,,,,,,6077.31,13789.84,percent of total billed charges,
Place Stent Wwo Angio Iliac Addtl,8062888,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Place Stent Wwo Angio Iliac Addtl,8062888,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Angio Only Fem Pop Artery Unilat,8062889,CDM,481,RC,,,,,facility,inpatient,,,23409.00000,6788.61000,Aetna,First Health,,19148.56,,,,,,,14045.40,19148.56,percent of total billed charges,
Angio Only Fem Pop Artery Unilat,8062889,CDM,481,RC,,,,,facility,outpatient,,,23409.00000,6788.61000,Aetna,First Health,,19148.56,,,,,,,8438.94,19148.56,percent of total billed charges,
Atherect Only Fem Pop W Angio,8062890,CDM,481,RC,,,,,facility,inpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,27600.00,37628.00,percent of total billed charges,
Atherect Only Fem Pop W Angio,8062890,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,9200.00,37628.00,percent of total billed charges,
Place Stent Wwo Angio Fem Pop,8062891,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Place Stent Wwo Angio Fem Pop,8062891,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Place Stent and Atherect Wwo Angio,8062892,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Place Stent and Atherect Wwo Angio,8062892,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Angio Only Tibial Peroneal Art,8062893,CDM,481,RC,,,,,facility,inpatient,,,29000.00000,8410.00000,Aetna,First Health,,23722.00,,,,,,,17400.00,23722.00,percent of total billed charges,
Angio Only Tibial Peroneal Art,8062893,CDM,481,RC,,,,,facility,outpatient,,,29000.00000,8410.00000,Aetna,First Health,,23722.00,,,,,,,9200.00,23722.00,percent of total billed charges,
Atherct Tib Per W Angio Initl,8062894,CDM,481,RC,,,,,facility,inpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,27600.00,37628.00,percent of total billed charges,
Atherct Tib Per W Angio Initl,8062894,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,9200.00,37628.00,percent of total billed charges,
Place Stent Wwo Angio Tib Per Ini,8062895,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Place Stent Wwo Angio Tib Per Ini,8062895,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Place Stent W Atherect Wwo Angio,8062807,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Place Stent W Atherect Wwo Angio,8062807,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Angio Only Tibial Peroneal Art Ea,8062896,CDM,481,RC,,,,,facility,inpatient,,,16858.00000,4888.82000,Aetna,First Health,,13789.84,,,,,,,10114.80,13789.84,percent of total billed charges,
Angio Only Tibial Peroneal Art Ea,8062896,CDM,481,RC,,,,,facility,outpatient,,,16858.00000,4888.82000,Aetna,First Health,,13789.84,,,,,,,6077.31,13789.84,percent of total billed charges,
Atherct Only Tib Per Addtl Vessel,8062897,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Atherct Only Tib Per Addtl Vessel,8062897,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Place Stent Wwo Angio Tib Per Add,8062898,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Place Stent Wwo Angio Tib Per Add,8062898,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Place Stent W Atherect Wwo Angio,8062808,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Place Stent W Atherect Wwo Angio,8062808,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
IVUS Noncoronary Initl Vessel,8062899,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
IVUS Noncoronary Initl Vessel,8062899,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
IVUS Noncoronary Addtl Vessel,8062900,CDM,481,RC,,,,,facility,inpatient,,,8045.00000,2333.05000,Aetna,First Health,,6580.81,,,,,,,4827.00,6580.81,percent of total billed charges,
IVUS Noncoronary Addtl Vessel,8062900,CDM,481,RC,,,,,facility,outpatient,,,8045.00000,2333.05000,Aetna,First Health,,6580.81,,,,,,,2900.22,10865.00,percent of total billed charges,
Descend Thoracic Aorto Single,8062901,CDM,481,RC,,,,,facility,inpatient,,,8300.00000,2407.00000,Aetna,First Health,,6789.40,,,,,,,4980.00,6789.40,percent of total billed charges,
Descend Thoracic Aorto Single,8062901,CDM,481,RC,,,,,facility,outpatient,,,8300.00000,2407.00000,Aetna,First Health,,6789.40,,,,,,,2992.15,10865.00,percent of total billed charges,
Descend Thoracic Aorto Multiple,8062902,CDM,481,RC,,,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,9000.00,12270.00,percent of total billed charges,
Descend Thoracic Aorto Multiple,8062902,CDM,481,RC,,,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,First Health,,12270.00,,,,,,,5407.50,12270.00,percent of total billed charges,
Abd Aortogram,8062903,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
Abd Aortogram,8062903,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
Abd Aortogrm W Bilat Runoff,8062904,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
Abd Aortogrm W Bilat Runoff,8062904,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
Unilat Extremity Upper Or Lower,8062905,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
Unilat Extremity Upper Or Lower,8062905,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
Bilateral Extremity Upper or Lower,8062906,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
Bilateral Extremity Upper or Lower,8062906,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
Pulm Angiogram Unilat Select,8062907,CDM,481,RC,,,,,facility,inpatient,,,8892.00000,2578.68000,Aetna,First Health,,7273.66,,,,,,,5335.20,7273.66,percent of total billed charges,
Pulm Angiogram Unilat Select,8062907,CDM,481,RC,,,,,facility,outpatient,,,8892.00000,2578.68000,Aetna,First Health,,7273.66,,,,,,,3205.57,10865.00,percent of total billed charges,
Pulm Angiogram Bilat Select,8062908,CDM,481,RC,,,,,facility,inpatient,,,8892.00000,2578.68000,Aetna,First Health,,7273.66,,,,,,,5335.20,7273.66,percent of total billed charges,
Pulm Angiogram Bilat Select,8062908,CDM,481,RC,,,,,facility,outpatient,,,8892.00000,2578.68000,Aetna,First Health,,7273.66,,,,,,,3205.57,10865.00,percent of total billed charges,
Pulm Angiogram Nonselect,8062909,CDM,481,RC,,,,,facility,inpatient,,,8300.00000,2407.00000,Aetna,First Health,,6789.40,,,,,,,4980.00,6789.40,percent of total billed charges,
Pulm Angiogram Nonselect,8062909,CDM,481,RC,,,,,facility,outpatient,,,8300.00000,2407.00000,Aetna,First Health,,6789.40,,,,,,,2992.15,10865.00,percent of total billed charges,
Internal Mammary,8062910,CDM,481,RC,,,,,facility,inpatient,,,8300.00000,2407.00000,Aetna,First Health,,6789.40,,,,,,,4980.00,6789.40,percent of total billed charges,
Internal Mammary,8062910,CDM,481,RC,,,,,facility,outpatient,,,8300.00000,2407.00000,Aetna,First Health,,6789.40,,,,,,,2992.15,10865.00,percent of total billed charges,
Inferior Venocavogram,8062911,CDM,481,RC,,,,,facility,inpatient,,,22987.00000,6666.23000,Aetna,First Health,,18803.37,,,,,,,13792.20,18803.37,percent of total billed charges,
Inferior Venocavogram,8062911,CDM,481,RC,,,,,facility,outpatient,,,22987.00000,6666.23000,Aetna,First Health,,18803.37,,,,,,,8286.81,18803.37,percent of total billed charges,
Superior Venocavogram,8062912,CDM,481,RC,,,,,facility,inpatient,,,22987.00000,6666.23000,Aetna,First Health,,18803.37,,,,,,,13792.20,18803.37,percent of total billed charges,
Superior Venocavogram,8062912,CDM,481,RC,,,,,facility,outpatient,,,22987.00000,6666.23000,Aetna,First Health,,18803.37,,,,,,,8286.81,18803.37,percent of total billed charges,
PTCA Single Artery Or Branch,8062914,CDM,481,RC,,,,,facility,inpatient,,,21281.00000,6171.49000,Aetna,First Health,,17407.86,,,,,,,12768.60,17407.86,percent of total billed charges,
PTCA Single Artery Or Branch,8062914,CDM,481,RC,,,,,facility,outpatient,,,21281.00000,6171.49000,Aetna,First Health,,17407.86,,,,,,,7671.80,17407.86,percent of total billed charges,
PTCA Each Addtl Branch,8062915,CDM,481,RC,,,,,facility,inpatient,,,21281.00000,6171.49000,Aetna,First Health,,17407.86,,,,,,,12768.60,17407.86,percent of total billed charges,
PTCA Each Addtl Branch,8062915,CDM,481,RC,,,,,facility,outpatient,,,21281.00000,6171.49000,Aetna,First Health,,17407.86,,,,,,,7671.80,17407.86,percent of total billed charges,
Atherect And Ptca Art Or Branch,8062916,CDM,481,RC,,,,,facility,inpatient,,,41323.00000,11983.67000,Aetna,First Health,,33802.21,,,,,,,24793.80,33802.21,percent of total billed charges,
Atherect And Ptca Art Or Branch,8062916,CDM,481,RC,,,,,facility,outpatient,,,41323.00000,11983.67000,Aetna,First Health,,33802.21,,,,,,,9200.00,33802.21,percent of total billed charges,
Atherect And Ptca Addtl Branch,8062917,CDM,481,RC,,,,,facility,inpatient,,,31246.00000,9061.34000,Aetna,First Health,,25559.23,,,,,,,18747.60,25559.23,percent of total billed charges,
Atherect And Ptca Addtl Branch,8062917,CDM,481,RC,,,,,facility,outpatient,,,31246.00000,9061.34000,Aetna,First Health,,25559.23,,,,,,,9200.00,25559.23,percent of total billed charges,
Resuscitation,8062918,CDM,481,RC,,,,,facility,inpatient,,,2675.00000,775.75000,Aetna,First Health,,2188.15,,,,,,,1605.00,2188.15,percent of total billed charges,
Resuscitation,8062918,CDM,481,RC,,,,,facility,outpatient,,,2675.00000,775.75000,Aetna,First Health,,2188.15,,,,,,,964.34,10865.00,percent of total billed charges,
Coronary Thrombectomy,8062920,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
Coronary Thrombectomy,8062920,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
Intracoronary Thrombolysis,8062921,CDM,481,RC,,,,,facility,inpatient,,,8045.00000,2333.05000,Aetna,First Health,,6580.81,,,,,,,4827.00,6580.81,percent of total billed charges,
Intracoronary Thrombolysis,8062921,CDM,481,RC,,,,,facility,outpatient,,,8045.00000,2333.05000,Aetna,First Health,,6580.81,,,,,,,2900.22,10865.00,percent of total billed charges,
IVUS Initial Vessel,8062922,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
IVUS Initial Vessel,8062922,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
IVUS Addtl Vessel,8062923,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
IVUS Addtl Vessel,8062923,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
Pulm Artery Angio Single Vessel,8062924,CDM,481,RC,,,,,facility,inpatient,,,29000.00000,8410.00000,Aetna,First Health,,23722.00,,,,,,,17400.00,23722.00,percent of total billed charges,
Pulm Artery Angio Single Vessel,8062924,CDM,481,RC,,,,,facility,outpatient,,,29000.00000,8410.00000,Aetna,First Health,,23722.00,,,,,,,9200.00,23722.00,percent of total billed charges,
Pulm Artery Angio Addtl Vessel,8062925,CDM,481,RC,,,,,facility,inpatient,,,14879.00000,4314.91000,Aetna,First Health,,12171.02,,,,,,,8927.40,12171.02,percent of total billed charges,
Pulm Artery Angio Addtl Vessel,8062925,CDM,481,RC,,,,,facility,outpatient,,,14879.00000,4314.91000,Aetna,First Health,,12171.02,,,,,,,5363.88,12171.02,percent of total billed charges,
Eval Implantable Loop Recorder System,8062926,CDM,481,RC,,,,,facility,inpatient,,,646.00000,187.34000,Aetna,First Health,,528.43,,,,,,,387.60,528.43,percent of total billed charges,
Eval Implantable Loop Recorder System,8062926,CDM,481,RC,,,,,facility,outpatient,,,646.00000,187.34000,Aetna,First Health,,528.43,,,,,,,232.88,10865.00,percent of total billed charges,
Eval Of Implantable System,8062927,CDM,481,RC,,,,,facility,inpatient,,,646.00000,187.34000,Aetna,First Health,,528.43,,,,,,,387.60,528.43,percent of total billed charges,
Eval Of Implantable System,8062927,CDM,481,RC,,,,,facility,outpatient,,,646.00000,187.34000,Aetna,First Health,,528.43,,,,,,,232.88,10865.00,percent of total billed charges,
Heart Cath Rt,8062928,CDM,481,RC,,,,,facility,inpatient,,,20005.00000,5801.45000,Aetna,First Health,,16364.09,,,,,,,12003.00,16364.09,percent of total billed charges,
Heart Cath Rt,8062928,CDM,481,RC,,,,,facility,outpatient,,,20005.00000,5801.45000,Aetna,First Health,,16364.09,,,,,,,7211.80,16364.09,percent of total billed charges,
Heart Cath Lt,8062929,CDM,481,RC,,,,,facility,inpatient,,,25965.00000,7529.85000,Aetna,First Health,,21239.37,,,,,,,15579.00,21239.37,percent of total billed charges,
Heart Cath Lt,8062929,CDM,481,RC,,,,,facility,outpatient,,,25965.00000,7529.85000,Aetna,First Health,,21239.37,,,,,,,9200.00,21239.37,percent of total billed charges,
Heart Cath Rt And Lt,8062930,CDM,481,RC,,,,,facility,inpatient,,,28778.00000,8345.62000,Aetna,First Health,,23540.40,,,,,,,17266.80,23540.40,percent of total billed charges,
Heart Cath Rt And Lt,8062930,CDM,481,RC,,,,,facility,outpatient,,,28778.00000,8345.62000,Aetna,First Health,,23540.40,,,,,,,9200.00,23540.40,percent of total billed charges,
Heart Cath Cors,8062931,CDM,481,RC,,,,,facility,inpatient,,,22984.00000,6665.36000,Aetna,First Health,,18800.91,,,,,,,13790.40,18800.91,percent of total billed charges,
Heart Cath Cors,8062931,CDM,481,RC,,,,,facility,outpatient,,,22984.00000,6665.36000,Aetna,First Health,,18800.91,,,,,,,8285.73,18800.91,percent of total billed charges,
Heart Cath Cors And Grafts,8062932,CDM,481,RC,,,,,facility,inpatient,,,25965.00000,7529.85000,Aetna,First Health,,21239.37,,,,,,,15579.00,21239.37,percent of total billed charges,
Heart Cath Cors And Grafts,8062932,CDM,481,RC,,,,,facility,outpatient,,,25965.00000,7529.85000,Aetna,First Health,,21239.37,,,,,,,9200.00,21239.37,percent of total billed charges,
Heart Cath Rt And Cors,8062933,CDM,481,RC,,,,,facility,inpatient,,,30806.00000,8933.74000,Aetna,First Health,,25199.31,,,,,,,18483.60,25199.31,percent of total billed charges,
Heart Cath Rt And Cors,8062933,CDM,481,RC,,,,,facility,outpatient,,,30806.00000,8933.74000,Aetna,First Health,,25199.31,,,,,,,9200.00,25199.31,percent of total billed charges,
Heart Cath Rt And Cors And Grafts,8062934,CDM,481,RC,,,,,facility,inpatient,,,35061.00000,10167.69000,Aetna,First Health,,28679.90,,,,,,,21036.60,28679.90,percent of total billed charges,
Heart Cath Rt And Cors And Grafts,8062934,CDM,481,RC,,,,,facility,outpatient,,,35061.00000,10167.69000,Aetna,First Health,,28679.90,,,,,,,9200.00,28679.90,percent of total billed charges,
Heart Cath Lt And Cors,8062935,CDM,481,RC,,,,,facility,inpatient,,,32225.00000,9345.25000,Aetna,First Health,,26360.05,,,,,,,19335.00,26360.05,percent of total billed charges,
Heart Cath Lt And Cors,8062935,CDM,481,RC,,,,,facility,outpatient,,,32225.00000,9345.25000,Aetna,First Health,,26360.05,,,,,,,9200.00,26360.05,percent of total billed charges,
Heart Cath Lt And Cors And Grafts,8062936,CDM,481,RC,,,,,facility,inpatient,,,34048.00000,9873.92000,Aetna,First Health,,27851.26,,,,,,,20428.80,27851.26,percent of total billed charges,
Heart Cath Lt And Cors And Grafts,8062936,CDM,481,RC,,,,,facility,outpatient,,,34048.00000,9873.92000,Aetna,First Health,,27851.26,,,,,,,9200.00,27851.26,percent of total billed charges,
Heart Cath Rt And Lt And Cors,8062937,CDM,481,RC,,,,,facility,inpatient,,,36279.00000,10520.91000,Aetna,First Health,,29676.22,,,,,,,21767.40,29676.22,percent of total billed charges,
Heart Cath Rt And Lt And Cors,8062937,CDM,481,RC,,,,,facility,outpatient,,,36279.00000,10520.91000,Aetna,First Health,,29676.22,,,,,,,9200.00,29676.22,percent of total billed charges,
Heart Cath Rt And Lt And Cors And Grafts,8062938,CDM,481,RC,,,,,facility,inpatient,,,39320.00000,11402.80000,Aetna,First Health,,32163.76,,,,,,,23592.00,32163.76,percent of total billed charges,
Heart Cath Rt And Lt And Cors And Grafts,8062938,CDM,481,RC,,,,,facility,outpatient,,,39320.00000,11402.80000,Aetna,First Health,,32163.76,,,,,,,9200.00,32163.76,percent of total billed charges,
Heart Cath Rt And Lt Retro,8062939,CDM,481,RC,,,,,facility,inpatient,,,22067.00000,6399.43000,Aetna,First Health,,18050.81,,,,,,,13240.20,18050.81,percent of total billed charges,
Heart Cath Rt And Lt Retro,8062939,CDM,481,RC,,,,,facility,outpatient,,,22067.00000,6399.43000,Aetna,First Health,,18050.81,,,,,,,7955.15,18050.81,percent of total billed charges,
Heart Cath Rt And Lt Trans,8062940,CDM,481,RC,,,,,facility,inpatient,,,27890.00000,8088.10000,Aetna,First Health,,22814.02,,,,,,,16734.00,22814.02,percent of total billed charges,
Heart Cath Rt And Lt Trans,8062940,CDM,481,RC,,,,,facility,outpatient,,,27890.00000,8088.10000,Aetna,First Health,,22814.02,,,,,,,9200.00,22814.02,percent of total billed charges,
Select Rt Ventric Rt Atrial Angio,8062941,CDM,481,RC,,,,,facility,inpatient,,,6082.00000,1763.78000,Aetna,First Health,,4975.08,,,,,,,3649.20,4975.08,percent of total billed charges,
Select Rt Ventric Rt Atrial Angio,8062941,CDM,481,RC,,,,,facility,outpatient,,,6082.00000,1763.78000,Aetna,First Health,,4975.08,,,,,,,2192.56,10865.00,percent of total billed charges,
Closure Atrial Septal Defect,8062942,CDM,481,RC,,,,,facility,inpatient,,,52900.00000,15341.00000,Aetna,First Health,,43272.20,,,,,,,31740.00,43272.20,percent of total billed charges,
Closure Atrial Septal Defect,8062942,CDM,481,RC,,,,,facility,outpatient,,,52900.00000,15341.00000,Aetna,First Health,,43272.20,,,,,,,9200.00,43272.20,percent of total billed charges,
Closure Ventricular Septal Defect,8062943,CDM,481,RC,,,,,facility,inpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,27600.00,37628.00,percent of total billed charges,
Closure Ventricular Septal Defect,8062943,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,9200.00,37628.00,percent of total billed charges,
Bundle of HIS Recording,8062944,CDM,481,RC,,,,,facility,inpatient,,,23000.00000,6670.00000,Aetna,First Health,,18814.00,,,,,,,13800.00,18814.00,percent of total billed charges,
Bundle of HIS Recording,8062944,CDM,481,RC,,,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,First Health,,18814.00,,,,,,,8291.50,18814.00,percent of total billed charges,
Intraatrial Recording,8062945,CDM,481,RC,,,,,facility,inpatient,,,23000.00000,6670.00000,Aetna,First Health,,18814.00,,,,,,,13800.00,18814.00,percent of total billed charges,
Intraatrial Recording,8062945,CDM,481,RC,,,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,First Health,,18814.00,,,,,,,8291.50,18814.00,percent of total billed charges,
Rt Ventricular Recording,8062946,CDM,481,RC,,,,,facility,inpatient,,,9194.00000,2666.26000,Aetna,First Health,,7520.69,,,,,,,5516.40,7520.69,percent of total billed charges,
Rt Ventricular Recording,8062946,CDM,481,RC,,,,,facility,outpatient,,,9194.00000,2666.26000,Aetna,First Health,,7520.69,,,,,,,3314.44,10865.00,percent of total billed charges,
Mapping of Tachycardia,8062947,CDM,481,RC,,,,,facility,inpatient,,,17023.00000,4936.67000,Aetna,First Health,,13924.81,,,,,,,10213.80,13924.81,percent of total billed charges,
Mapping of Tachycardia,8062947,CDM,481,RC,,,,,facility,outpatient,,,17023.00000,4936.67000,Aetna,First Health,,13924.81,,,,,,,6136.79,13924.81,percent of total billed charges,
Intraatrial Pacing,8062948,CDM,481,RC,,,,,facility,inpatient,,,23000.00000,6670.00000,Aetna,First Health,,18814.00,,,,,,,13800.00,18814.00,percent of total billed charges,
Intraatrial Pacing,8062948,CDM,481,RC,,,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,First Health,,18814.00,,,,,,,8291.50,18814.00,percent of total billed charges,
Intraventricular Pacing,8062949,CDM,481,RC,,,,,facility,inpatient,,,20000.00000,5800.00000,Aetna,First Health,,16360.00,,,,,,,12000.00,16360.00,percent of total billed charges,
Intraventricular Pacing,8062949,CDM,481,RC,,,,,facility,outpatient,,,20000.00000,5800.00000,Aetna,First Health,,16360.00,,,,,,,7210.00,16360.00,percent of total billed charges,
3D Mapping Of Tachycardia,8062950,CDM,481,RC,,,,,facility,inpatient,,,17023.00000,4936.67000,Aetna,First Health,,13924.81,,,,,,,10213.80,13924.81,percent of total billed charges,
3D Mapping Of Tachycardia,8062950,CDM,481,RC,,,,,facility,outpatient,,,17023.00000,4936.67000,Aetna,First Health,,13924.81,,,,,,,6136.79,13924.81,percent of total billed charges,
Induction Of Arrhythmia,8062951,CDM,481,RC,,,,,facility,inpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,6382.80,8701.88,percent of total billed charges,
Induction Of Arrhythmia,8062951,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,First Health,,8701.88,,,,,,,3835.00,10865.00,percent of total billed charges,
Rt Atria Rt Ventric And HIS Bundle,8062809,CDM,481,RC,,,,,facility,inpatient,,,20000.00000,5800.00000,Aetna,First Health,,16360.00,,,,,,,12000.00,16360.00,percent of total billed charges,
Rt Atria Rt Ventric And HIS Bundle,8062809,CDM,481,RC,,,,,facility,outpatient,,,20000.00000,5800.00000,Aetna,First Health,,16360.00,,,,,,,7210.00,16360.00,percent of total billed charges,
Rt Atria Rt Ventric And HIS Bundle,8062810,CDM,481,RC,,,,,facility,inpatient,,,23409.00000,6788.61000,Aetna,First Health,,19148.56,,,,,,,14045.40,19148.56,percent of total billed charges,
Rt Atria Rt Ventric And HIS Bundle,8062810,CDM,481,RC,,,,,facility,outpatient,,,23409.00000,6788.61000,Aetna,First Health,,19148.56,,,,,,,8438.94,19148.56,percent of total billed charges,
Lt Atrial Pacing From Cor Sinus,8062952,CDM,481,RC,,,,,facility,inpatient,,,21281.00000,6171.49000,Aetna,First Health,,17407.86,,,,,,,12768.60,17407.86,percent of total billed charges,
Lt Atrial Pacing From Cor Sinus,8062952,CDM,481,RC,,,,,facility,outpatient,,,21281.00000,6171.49000,Aetna,First Health,,17407.86,,,,,,,7671.80,17407.86,percent of total billed charges,
Lt Ventricular Pacing and Recording,8062953,CDM,481,RC,,,,,facility,inpatient,,,12185.00000,3533.65000,Aetna,First Health,,9967.33,,,,,,,7311.00,9967.33,percent of total billed charges,
Lt Ventricular Pacing and Recording,8062953,CDM,481,RC,,,,,facility,outpatient,,,12185.00000,3533.65000,Aetna,First Health,,9967.33,,,,,,,4392.69,10865.00,percent of total billed charges,
Stimulation and Pace After Iv Drug,8062954,CDM,481,RC,,,,,facility,inpatient,,,16115.00000,4673.35000,Aetna,First Health,,13182.07,,,,,,,9669.00,13182.07,percent of total billed charges,
Stimulation and Pace After Iv Drug,8062954,CDM,481,RC,,,,,facility,outpatient,,,16115.00000,4673.35000,Aetna,First Health,,13182.07,,,,,,,5809.46,13182.07,percent of total billed charges,
Ep Eval Of Single Or Dual Icd Lea,8062955,CDM,481,RC,,,,,facility,inpatient,,,12185.00000,3533.65000,Aetna,First Health,,9967.33,,,,,,,7311.00,9967.33,percent of total billed charges,
Ep Eval Of Single Or Dual Icd Lea,8062955,CDM,481,RC,,,,,facility,outpatient,,,12185.00000,3533.65000,Aetna,First Health,,9967.33,,,,,,,4392.69,10865.00,percent of total billed charges,
Ep Eval Of Single Or Dual Icdlead,8062956,CDM,481,RC,,,,,facility,inpatient,,,12185.00000,3533.65000,Aetna,First Health,,9967.33,,,,,,,7311.00,9967.33,percent of total billed charges,
Ep Eval Of Single Or Dual Icdlead,8062956,CDM,481,RC,,,,,facility,outpatient,,,12185.00000,3533.65000,Aetna,First Health,,9967.33,,,,,,,4392.69,10865.00,percent of total billed charges,
Ep Eval Of Single Or Dual Icd Gen,8062957,CDM,481,RC,,,,,facility,inpatient,,,12185.00000,3533.65000,Aetna,First Health,,9967.33,,,,,,,7311.00,9967.33,percent of total billed charges,
Ep Eval Of Single Or Dual Icd Gen,8062957,CDM,481,RC,,,,,facility,outpatient,,,12185.00000,3533.65000,Aetna,First Health,,9967.33,,,,,,,4392.69,10865.00,percent of total billed charges,
Ablation AV Node Function Block,8062958,CDM,481,RC,,,,,facility,inpatient,,,23000.00000,6670.00000,Aetna,First Health,,18814.00,,,,,,,13800.00,18814.00,percent of total billed charges,
Ablation AV Node Function Block,8062958,CDM,481,RC,,,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,First Health,,18814.00,,,,,,,8291.50,18814.00,percent of total billed charges,
Ablation Svt W Comp Ep Study,8062959,CDM,481,RC,,,,,facility,inpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,42780.00,58323.40,percent of total billed charges,
Ablation Svt W Comp Ep Study,8062959,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,9200.00,58323.40,percent of total billed charges,
Ablation VT W Comp EP Study,8062960,CDM,481,RC,,,,,facility,inpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,42780.00,58323.40,percent of total billed charges,
Ablation VT W Comp EP Study,8062960,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,9200.00,58323.40,percent of total billed charges,
Ablation Separate Mechanism Of Ar,8062961,CDM,481,RC,,,,,facility,inpatient,,,20661.00000,5991.69000,Aetna,First Health,,16900.70,,,,,,,12396.60,16900.70,percent of total billed charges,
Ablation Separate Mechanism Of Ar,8062961,CDM,481,RC,,,,,facility,outpatient,,,20661.00000,5991.69000,Aetna,First Health,,16900.70,,,,,,,7448.29,16900.70,percent of total billed charges,
Ablation By Pulm Isolation W Ep S,8062962,CDM,481,RC,,,,,facility,inpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,42780.00,58323.40,percent of total billed charges,
Ablation By Pulm Isolation W Ep S,8062962,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,9200.00,58323.40,percent of total billed charges,
Addtl Ablation Of Lt Or Rt Atrium,8062963,CDM,481,RC,,,,,facility,inpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,42780.00,58323.40,percent of total billed charges,
Addtl Ablation Of Lt Or Rt Atrium,8062963,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,First Health,,58323.40,,,,,,,9200.00,58323.40,percent of total billed charges,
Intraccardiac Echocardiogram,8062964,CDM,481,RC,,,,,facility,inpatient,,,14186.00000,4113.94000,Aetna,First Health,,11604.15,,,,,,,8511.60,11604.15,percent of total billed charges,
Intraccardiac Echocardiogram,8062964,CDM,481,RC,,,,,facility,outpatient,,,14186.00000,4113.94000,Aetna,First Health,,11604.15,,,,,,,5114.05,11604.15,percent of total billed charges,
Brachiocephalic Trunk And Branches,8062966,CDM,481,RC,,,,,facility,inpatient,,,29000.00000,8410.00000,Aetna,First Health,,23722.00,,,,,,,17400.00,23722.00,percent of total billed charges,
Brachiocephalic Trunk And Branches,8062966,CDM,481,RC,,,,,facility,outpatient,,,29000.00000,8410.00000,Aetna,First Health,,23722.00,,,,,,,9200.00,23722.00,percent of total billed charges,
Periph Atherectomy Iliac Artery,8062967,CDM,481,RC,,,,,facility,inpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,27600.00,37628.00,percent of total billed charges,
Periph Atherectomy Iliac Artery,8062967,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,9200.00,37628.00,percent of total billed charges,
Place Stent AndPtca Each Addtl Bran,8062969,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Place Stent AndPtca Each Addtl Bran,8062969,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Atherect And Place Stent And Ptca Art,8062970,CDM,481,RC,,,,,facility,inpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,27600.00,37628.00,percent of total billed charges,
Atherect And Place Stent And Ptca Art,8062970,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,First Health,,37628.00,,,,,,,9200.00,37628.00,percent of total billed charges,
Atherect And Place Stent And Ptca Addt,8062971,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Atherect And Place Stent And Ptca Addt,8062971,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Perc Revasc Of Bypass Graft,8062972,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Perc Revasc Of Bypass Graft,8062972,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Perc Revasc Of Branch Of Bypass,8062973,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Perc Revasc Of Branch Of Bypass,8062973,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Revasc Of Occlusion During Acute,8062974,CDM,481,RC,,,,,facility,inpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,23612.40,32191.57,percent of total billed charges,
Revasc Of Occlusion During Acute,8062974,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,First Health,,32191.57,,,,,,,9200.00,32191.57,percent of total billed charges,
Revasc Of Chronic Occlusion,8062975,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Revasc Of Chronic Occlusion,8062975,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Revasc Chronic Occlusion Addtl,8062976,CDM,481,RC,,,,,facility,inpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,17854.20,24341.23,percent of total billed charges,
Revasc Chronic Occlusion Addtl,8062976,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,First Health,,24341.23,,,,,,,9200.00,24341.23,percent of total billed charges,
Placement of Closure Device,8062977,CDM,481,RC,,,,,facility,inpatient,,,1532.00000,444.28000,Aetna,First Health,,1253.18,,,,,,,919.20,1253.18,percent of total billed charges,
Placement of Closure Device,8062977,CDM,481,RC,,,,,facility,outpatient,,,1532.00000,444.28000,Aetna,First Health,,1253.18,,,,,,,552.29,10865.00,percent of total billed charges,
Nonselect Renal S At Time Of Cath,8062978,CDM,481,RC,,,,,facility,inpatient,,,6131.00000,1777.99000,Aetna,First Health,,5015.16,,,,,,,3678.60,5015.16,percent of total billed charges,
Nonselect Renal S At Time Of Cath,8062978,CDM,481,RC,,,,,facility,outpatient,,,6131.00000,1777.99000,Aetna,First Health,,5015.16,,,,,,,2210.23,10865.00,percent of total billed charges,
Nonselect Iliac S At Time Of Cath,8062979,CDM,481,RC,,,,,facility,inpatient,,,10132.00000,2938.28000,Aetna,First Health,,8287.98,,,,,,,6079.20,8287.98,percent of total billed charges,
Nonselect Iliac S At Time Of Cath,8062979,CDM,481,RC,,,,,facility,outpatient,,,10132.00000,2938.28000,Aetna,First Health,,8287.98,,,,,,,3652.59,10865.00,percent of total billed charges,
Supravalvular Aortography,8062987,CDM,481,RC,,,,,facility,inpatient,,,19678.00000,5706.62000,Aetna,First Health,,16096.60,,,,,,,11806.80,16096.60,percent of total billed charges,
Supravalvular Aortography,8062987,CDM,481,RC,,,,,facility,outpatient,,,19678.00000,5706.62000,Aetna,First Health,,16096.60,,,,,,,7093.92,16096.60,percent of total billed charges,
Pulm Angiogram,8062988,CDM,481,RC,,,,,facility,inpatient,,,14879.00000,4314.91000,Aetna,First Health,,12171.02,,,,,,,8927.40,12171.02,percent of total billed charges,
Pulm Angiogram,8062988,CDM,481,RC,,,,,facility,outpatient,,,14879.00000,4314.91000,Aetna,First Health,,12171.02,,,,,,,5363.88,12171.02,percent of total billed charges,
Lt Cath Transseptal,8062989,CDM,481,RC,,,,,facility,inpatient,,,19923.00000,5777.67000,Aetna,First Health,,16297.01,,,,,,,11953.80,16297.01,percent of total billed charges,
Lt Cath Transseptal,8062989,CDM,481,RC,,,,,facility,outpatient,,,19923.00000,5777.67000,Aetna,First Health,,16297.01,,,,,,,7182.24,16297.01,percent of total billed charges,
Place Line,8062990,CDM,481,RC,,,,,facility,inpatient,,,20268.00000,5877.72000,Aetna,First Health,,16579.22,,,,,,,12160.80,16579.22,percent of total billed charges,
Place Line,8062990,CDM,481,RC,,,,,facility,outpatient,,,20268.00000,5877.72000,Aetna,First Health,,16579.22,,,,,,,7306.61,16579.22,percent of total billed charges,
Visceral Renal Initl Vessel,8062991,CDM,481,RC,,,,,facility,inpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,7355.40,10027.86,percent of total billed charges,
Visceral Renal Initl Vessel,8062991,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,4419.37,10865.00,percent of total billed charges,
Visceral Renal Each Addtl Vessel,8062992,CDM,481,RC,,,,,facility,inpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,7355.40,10027.86,percent of total billed charges,
Visceral Renal Each Addtl Vessel,8062992,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,First Health,,10027.86,,,,,,,4419.37,10865.00,percent of total billed charges,
FFR IFR Measure,8062995,CDM,481,RC,,,,,facility,inpatient,,,8515.00000,2469.35000,Aetna,First Health,,6965.27,,,,,,,5109.00,6965.27,percent of total billed charges,
FFR IFR Measure,8062995,CDM,481,RC,,,,,facility,outpatient,,,8515.00000,2469.35000,Aetna,First Health,,6965.27,,,,,,,3069.66,10865.00,percent of total billed charges,
Injection Proc For Extrem Veno,8062996,CDM,481,RC,,,,,facility,inpatient,,,8045.00000,2333.05000,Aetna,First Health,,6580.81,,,,,,,4827.00,6580.81,percent of total billed charges,
Injection Proc For Extrem Veno,8062996,CDM,481,RC,,,,,facility,outpatient,,,8045.00000,2333.05000,Aetna,First Health,,6580.81,,,,,,,2900.22,10865.00,percent of total billed charges,
Venography Extrem Unilat,8062997,CDM,481,RC,,,,,facility,inpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,2758.80,3761.16,percent of total billed charges,
Venography Extrem Unilat,8062997,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,First Health,,3761.16,,,,,,,1657.58,10865.00,percent of total billed charges,
Treadmill Bruce Thallium Stress,7762029,CDM,482,RC,93017,HCPCS,,,facility,inpatient,,,3247.00000,941.63000,Aetna,First Health,,2656.05,,,,,,,1948.20,2656.05,percent of total billed charges,
Treadmill Bruce Thallium Stress,7762029,CDM,482,RC,93017,HCPCS,,,facility,outpatient,,,3247.00000,941.63000,Aetna,First Health,,2656.05,,,,,,,216.27,2656.05,percent of total billed charges,
Treadmill Bruce Thallium Stress,7866069,CDM,482,RC,93017,HCPCS,,,facility,inpatient,,,3247.00000,941.63000,Aetna,First Health,,2656.05,,,,,,,1948.20,2656.05,percent of total billed charges,
Treadmill Bruce Thallium Stress,7866069,CDM,482,RC,93017,HCPCS,,,facility,outpatient,,,3247.00000,941.63000,Aetna,First Health,,2656.05,,,,,,,216.27,2656.05,percent of total billed charges,
Pharmacological Stress,7866071,CDM,482,RC,93017,HCPCS,,,facility,inpatient,,,3247.00000,941.63000,Aetna,First Health,,2656.05,,,,,,,1948.20,2656.05,percent of total billed charges,
Pharmacological Stress,7866071,CDM,482,RC,93017,HCPCS,,,facility,outpatient,,,3247.00000,941.63000,Aetna,First Health,,2656.05,,,,,,,216.27,2656.05,percent of total billed charges,
Pharmalogical Stress,8298340,CDM,482,RC,93017,HCPCS,,,facility,inpatient,,,3247.00000,941.63000,Aetna,First Health,,2656.05,,,,,,,1948.20,2656.05,percent of total billed charges,
Pharmalogical Stress,8298340,CDM,482,RC,93017,HCPCS,,,facility,outpatient,,,3247.00000,941.63000,Aetna,First Health,,2656.05,,,,,,,216.27,2656.05,percent of total billed charges,
Tee Cardoversion,8403239,CDM,483,RC,93312,HCPCS,,,facility,inpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,3702.60,5047.88,percent of total billed charges,
Tee Cardoversion,8403239,CDM,483,RC,93312,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,481.44,5047.88,percent of total billed charges,
Echo Limited Wo Contrast,7289844,CDM,483,RC,93308,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Echo Limited Wo Contrast,7289844,CDM,483,RC,93308,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,212.24,1219.64,percent of total billed charges,
3D Tee,8927197,CDM,483,RC,93319,HCPCS,,,facility,inpatient,,,1113.00000,322.77000,Aetna,First Health,,910.43,,,,,,,667.80,910.43,percent of total billed charges,
3D Tee,8927197,CDM,483,RC,93319,HCPCS,,,facility,outpatient,,,1113.00000,322.77000,Aetna,First Health,,910.43,,,,,,,401.24,910.43,percent of total billed charges,
Complete Echo,7289848,CDM,483,RC,93306,HCPCS,,,facility,inpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,3702.60,5047.88,percent of total billed charges,
Complete Echo,7289848,CDM,483,RC,93306,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,481.44,5047.88,percent of total billed charges,
Complete Echo With Contrast,7289847,CDM,483,RC,C8929,HCPCS,,,facility,inpatient,,,7615.00000,2208.35000,Aetna,First Health,,6229.07,,,,,,,4569.00,6229.07,percent of total billed charges,
Complete Echo With Contrast,7289847,CDM,483,RC,C8929,HCPCS,,,facility,outpatient,,,7615.00000,2208.35000,Aetna,First Health,,6229.07,,,,,,,693.72,6229.07,percent of total billed charges,
Dobutamine Stress Echo,7289858,CDM,483,RC,93351,HCPCS,,,facility,inpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,3702.60,5047.88,percent of total billed charges,
Dobutamine Stress Echo,7289858,CDM,483,RC,93351,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,481.44,5047.88,percent of total billed charges,
Dobut Stress Echo With Contrast,7289856,CDM,483,RC,C8930,HCPCS,,,facility,inpatient,,,7615.00000,2208.35000,Aetna,First Health,,6229.07,,,,,,,4569.00,6229.07,percent of total billed charges,
Dobut Stress Echo With Contrast,7289856,CDM,483,RC,C8930,HCPCS,,,facility,outpatient,,,7615.00000,2208.35000,Aetna,First Health,,6229.07,,,,,,,693.72,6229.07,percent of total billed charges,
Exercise Stress Echo,7289854,CDM,483,RC,93351,HCPCS,,,facility,inpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,3702.60,5047.88,percent of total billed charges,
Exercise Stress Echo,7289854,CDM,483,RC,93351,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,481.44,5047.88,percent of total billed charges,
Exercise Stress Echo,8151169,CDM,483,RC,93351,HCPCS,,,facility,inpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,3702.60,5047.88,percent of total billed charges,
Exercise Stress Echo,8151169,CDM,483,RC,93351,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,481.44,5047.88,percent of total billed charges,
Exercise Echo Stress Only,7289855,CDM,483,RC,93351,HCPCS,,,facility,inpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,3702.60,5047.88,percent of total billed charges,
Exercise Echo Stress Only,7289855,CDM,483,RC,93351,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,481.44,5047.88,percent of total billed charges,
Exercise Stress Echo W Contrast,7289853,CDM,483,RC,C8930,HCPCS,,,facility,inpatient,,,7615.00000,2208.35000,Aetna,First Health,,6229.07,,,,,,,4569.00,6229.07,percent of total billed charges,
Exercise Stress Echo W Contrast,7289853,CDM,483,RC,C8930,HCPCS,,,facility,outpatient,,,7615.00000,2208.35000,Aetna,First Health,,6229.07,,,,,,,693.72,6229.07,percent of total billed charges,
Echo Doppler Limited,8404520,CDM,483,RC,93321,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Echo Doppler Limited,8404520,CDM,483,RC,93321,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,143.40,1219.64,percent of total billed charges,
Echo Limited With Contrast,7289843,CDM,483,RC,C8924,HCPCS,,,facility,inpatient,,,2355.00000,682.95000,Aetna,First Health,,1926.39,,,,,,,1413.00,1926.39,percent of total billed charges,
Echo Limited With Contrast,7289843,CDM,483,RC,C8924,HCPCS,,,facility,outpatient,,,2355.00000,682.95000,Aetna,First Health,,1926.39,,,,,,,313.58,1926.39,percent of total billed charges,
SPECTRAL DOPPLER,8003079,CDM,483,RC,93320,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
SPECTRAL DOPPLER,8003079,CDM,483,RC,93320,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,498.63,1219.64,percent of total billed charges,
Transesophageal Echo Intraop,7289859,CDM,483,RC,93318,HCPCS,,,facility,inpatient,,,5366.00000,1556.14000,Aetna,First Health,,4389.39,,,,,,,3219.60,4389.39,percent of total billed charges,
Transesophageal Echo Intraop,7289859,CDM,483,RC,93318,HCPCS,,,facility,outpatient,,,5366.00000,1556.14000,Aetna,First Health,,4389.39,,,,,,,296.50,4389.39,percent of total billed charges,
Dobut Stress Echo Stress Only,7289857,CDM,483,RC,93351,HCPCS,,,facility,inpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,3702.60,5047.88,percent of total billed charges,
Dobut Stress Echo Stress Only,7289857,CDM,483,RC,93351,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,481.44,5047.88,percent of total billed charges,
Transesophageal Echo Wo,7289861,CDM,483,RC,93312,HCPCS,,,facility,inpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,3702.60,5047.88,percent of total billed charges,
Transesophageal Echo Wo,7289861,CDM,483,RC,93312,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,481.44,5047.88,percent of total billed charges,
Transesophageal Echo Wo,8999424,CDM,483,RC,93312,HCPCS,,,facility,inpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,3702.60,5047.88,percent of total billed charges,
Transesophageal Echo Wo,8999424,CDM,483,RC,93312,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,First Health,,5047.88,,,,,,,481.44,5047.88,percent of total billed charges,
Transesophageal Echo Guidance,7963889,CDM,483,RC,93355,HCPCS,,,facility,inpatient,,,5366.00000,1556.14000,Aetna,First Health,,4389.39,,,,,,,3219.60,4389.39,percent of total billed charges,
Transesophageal Echo Guidance,7963889,CDM,483,RC,93355,HCPCS,,,facility,outpatient,,,5366.00000,1556.14000,Aetna,First Health,,4389.39,,,,,,,479.00,4389.39,percent of total billed charges,
Echo Pediatric Complete,8400321,CDM,483,RC,93320,HCPCS,,,facility,inpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,894.60,1219.64,percent of total billed charges,
Echo Pediatric Complete,8400321,CDM,483,RC,93320,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,First Health,,1219.64,,,,,,,498.63,1219.64,percent of total billed charges,
Echo Pediatric Limited,8400322,CDM,483,RC,93320,HCPCS,,,facility,inpatient,,,1016.00000,294.64000,Aetna,First Health,,831.09,,,,,,,609.60,831.09,percent of total billed charges,
Echo Pediatric Limited,8400322,CDM,483,RC,93320,HCPCS,,,facility,outpatient,,,1016.00000,294.64000,Aetna,First Health,,831.09,,,,,,,366.27,831.09,percent of total billed charges,
Sclerotherapy,9099344,CDM,490,RC,,,,,facility,inpatient,,,4316.00000,1251.64000,Aetna,First Health,,3530.49,,,,,,,2589.60,3530.49,percent of total billed charges,
Sclerotherapy,9099344,CDM,490,RC,,,,,facility,outpatient,,,4316.00000,1251.64000,Aetna,First Health,,3530.49,,,,,,,1232.85,4908.00,percent of total billed charges,
Sclerotherapy Intravascular,9099346,CDM,490,RC,,,,,facility,inpatient,,,1062.00000,307.98000,Aetna,First Health,,868.72,,,,,,,637.20,868.72,percent of total billed charges,
Sclerotherapy Intravascular,9099346,CDM,490,RC,,,,,facility,outpatient,,,1062.00000,307.98000,Aetna,First Health,,868.72,,,,,,,382.85,4908.00,percent of total billed charges,
Vertebroplasty,9108868,CDM,490,RC,,,,,facility,inpatient,,,20898.00000,6060.42000,Aetna,First Health,,17094.56,,,,,,,12538.80,17094.56,percent of total billed charges,
Vertebroplasty,9108868,CDM,490,RC,,,,,facility,outpatient,,,20898.00000,6060.42000,Aetna,First Health,,17094.56,,,,,,,1232.85,17094.56,percent of total billed charges,
Aspiration,9116452,CDM,490,RC,,,,,facility,inpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,1008.00,1374.24,percent of total billed charges,
Aspiration,9116452,CDM,490,RC,,,,,facility,outpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,605.64,4908.00,percent of total billed charges,
Aspiration,9114763,CDM,490,RC,,,,,facility,inpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,1008.00,1374.24,percent of total billed charges,
Aspiration,9114763,CDM,490,RC,,,,,facility,outpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,605.64,4908.00,percent of total billed charges,
Aspiration,9114761,CDM,490,RC,,,,,facility,inpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,1008.00,1374.24,percent of total billed charges,
Aspiration,9114761,CDM,490,RC,,,,,facility,outpatient,,,1680.00000,487.20000,Aetna,First Health,,1374.24,,,,,,,605.64,4908.00,percent of total billed charges,
Clinic Visit,7417968,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Clinic Visit,7417968,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,7874157,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Clinic Visit,7874157,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,8270107,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Clinic Visit,8270107,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit Charge Transitional Care,8997126,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Clinic Visit Charge Transitional Care,8997126,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,9084099,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Clinic Visit,9084099,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,9085347,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Clinic Visit,9085347,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
Insert Cath Foley Indwelling,7957589,CDM,510,RC,,,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,205.20,279.76,percent of total billed charges,
Insert Cath Foley Indwelling,7957589,CDM,510,RC,,,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,100.00,279.76,percent of total billed charges,
Insert Foley Catheter Indwelling,8997123,CDM,510,RC,,,,,facility,inpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,205.20,279.76,percent of total billed charges,
Insert Foley Catheter Indwelling,8997123,CDM,510,RC,,,,,facility,outpatient,,,342.00000,99.18000,Aetna,First Health,,279.76,,,,,,,100.00,279.76,percent of total billed charges,
Insert Cath For Urine Collection,7957590,CDM,510,RC,P9612,HCPCS,,,facility,inpatient,,,44.00000,12.76000,Aetna,First Health,,35.99,,,,,,,26.40,35.99,percent of total billed charges,
Insert Cath For Urine Collection,7957590,CDM,510,RC,P9612,HCPCS,,,facility,outpatient,,,44.00000,12.76000,Aetna,First Health,,35.99,,,,,,,8.43,1717.00,percent of total billed charges,
Insert Cath for Urine Collection,8997122,CDM,510,RC,P9612,HCPCS,,,facility,inpatient,,,44.00000,12.76000,Aetna,First Health,,35.99,,,,,,,26.40,35.99,percent of total billed charges,
Insert Cath for Urine Collection,8997122,CDM,510,RC,P9612,HCPCS,,,facility,outpatient,,,44.00000,12.76000,Aetna,First Health,,35.99,,,,,,,8.43,1717.00,percent of total billed charges,
Declot Vascular Device EG Ultaplace,8997080,CDM,510,RC,36593,HCPCS,,,facility,inpatient,,,1110.00000,321.90000,Aetna,First Health,,907.98,,,,,,,666.00,907.98,percent of total billed charges,
Declot Vascular Device EG Ultaplace,8997080,CDM,510,RC,36593,HCPCS,,,facility,outpatient,,,1110.00000,321.90000,Aetna,First Health,,907.98,,,,,,,291.24,2860.00,percent of total billed charges,
Insert Cath Foley Indwelling,8151096,CDM,510,RC,51702,HCPCS,,,facility,inpatient,,,387.00000,112.23000,Aetna,First Health,,316.57,,,,,,,232.20,316.57,percent of total billed charges,
Insert Cath Foley Indwelling,8151096,CDM,510,RC,51702,HCPCS,,,facility,outpatient,,,387.00000,112.23000,Aetna,First Health,,316.57,,,,,,,113.19,2860.00,percent of total billed charges,
Clinic Visit,7419867,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Clinic Visit,7419867,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,7959538,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Clinic Visit,7959538,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
CLINIC VISIT,7692067,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
CLINIC VISIT,7692067,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
PMS CLINIC VISIT,7826049,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
PMS CLINIC VISIT,7826049,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit PreOp,9010378,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Clinic Visit PreOp,9010378,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
CLINIC VISIT,9010380,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
CLINIC VISIT,9010380,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
NM Attempted Proced,624502,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
NM Attempted Proced,624502,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,8062792,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
Clinic Visit,8062792,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
CLINIC VISIT,7960082,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
CLINIC VISIT,7960082,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
CLINIC VISIT,9010381,CDM,510,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
CLINIC VISIT,9010381,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
MR Upper Extremity Joint Lt wo Contrast,613773,CDM,610,RC,73221,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Joint Lt wo Contrast,613773,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt wo Contrast,614275,CDM,610,RC,73221,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Joint Lt wo Contrast,614275,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt wo Contrast,614421,CDM,610,RC,73221,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Joint Lt wo Contrast,614421,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,6117877,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,6117877,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,613657,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,613657,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,614024,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,614024,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,614075,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,614075,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,7741567,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,7741567,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,7840082,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,7840082,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,7991360,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,7991360,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,8148232,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Rt wo Contrast,8148232,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Left w wo Contrast,1053853,CDM,610,RC,73720,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Left w wo Contrast,1053853,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Left w wo Contrast,613848,CDM,610,RC,73720,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Left w wo Contrast,613848,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Left w wo Contrast,614175,CDM,610,RC,73720,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Left w wo Contrast,614175,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Left w wo Contrast,614399,CDM,610,RC,73720,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Left w wo Contrast,614399,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Breast Right wo Contrast,7938485,CDM,610,RC,77046,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Breast Right wo Contrast,7938485,CDM,610,RC,77046,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Breast Bilateral wo Contrast,2532851,CDM,610,RC,77047,HCPCS,,,facility,inpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,2820.00,3844.60,percent of total billed charges,
MR Breast Bilateral wo Contrast,2532851,CDM,610,RC,77047,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,212.24,3844.60,percent of total billed charges,
MRI Breast Right w Contrast,7938477,CDM,610,RC,C8903,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MRI Breast Right w Contrast,7938477,CDM,610,RC,C8903,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,156.31,1966.47,percent of total billed charges,
MR Breast Bilateral w Contrast,2532848,CDM,610,RC,C8906,HCPCS,,,facility,inpatient,,,4808.00000,1394.32000,Aetna,First Health,,3932.94,,,,,,,2884.80,3932.94,percent of total billed charges,
MR Breast Bilateral w Contrast,2532848,CDM,610,RC,C8906,HCPCS,,,facility,outpatient,,,4808.00000,1394.32000,Aetna,First Health,,3932.94,,,,,,,313.58,3932.94,percent of total billed charges,
MR Breast Right w wo Contrast,7938481,CDM,610,RC,C8905,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Breast Right w wo Contrast,7938481,CDM,610,RC,C8905,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2059.72,percent of total billed charges,
MR Breast Bilateral w wo Contrast,2532849,CDM,610,RC,C8908,HCPCS,,,facility,inpatient,,,5036.00000,1460.44000,Aetna,First Health,,4119.45,,,,,,,3021.60,4119.45,percent of total billed charges,
MR Breast Bilateral w wo Contrast,2532849,CDM,610,RC,C8908,HCPCS,,,facility,outpatient,,,5036.00000,1460.44000,Aetna,First Health,,4119.45,,,,,,,313.58,4119.45,percent of total billed charges,
MR Abdomen w Contrast,7520020,CDM,610,RC,74182,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Abdomen w Contrast,7520020,CDM,610,RC,74182,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Temporal Mandibular Joint,614329,CDM,610,RC,70336,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Temporal Mandibular Joint,614329,CDM,610,RC,70336,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Guided Breast Localization,3661947,CDM,610,RC,,,,,facility,inpatient,,,5568.00000,1614.72000,Aetna,First Health,,4554.62,,,,,,,3340.80,4554.62,percent of total billed charges,
MR Guided Breast Localization,3661947,CDM,610,RC,,,,,facility,outpatient,,,5568.00000,1614.72000,Aetna,First Health,,4554.62,,,,,,,2007.26,4554.62,percent of total billed charges,
MR Chest wo Contrast,7544137,CDM,610,RC,71550,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Chest wo Contrast,7544137,CDM,610,RC,71550,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Chest wo Contrast,7734636,CDM,610,RC,71550,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Chest wo Contrast,7734636,CDM,610,RC,71550,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Orbit Face Neck w Contrast,7524014,CDM,610,RC,70542,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Orbit Face Neck w Contrast,7524014,CDM,610,RC,70542,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Orbit Face Neck w Contrast,7544104,CDM,610,RC,70542,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Orbit Face Neck w Contrast,7544104,CDM,610,RC,70542,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Orbits w Contrast,8001046,CDM,610,RC,70542,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Orbits w Contrast,8001046,CDM,610,RC,70542,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Right Partial,8001047,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,1790.00000,519.10000,Aetna,First Health,RT,1464.22,,,,,,,1074.00,1464.22,percent of total billed charges,
MR Lower Extremity Joint Right Partial,8001047,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,1790.00000,519.10000,Aetna,First Health,RT,1464.22,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Left Partial,8001048,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,1790.00000,519.10000,Aetna,First Health,LT,1464.22,,,,,,,1074.00,1464.22,percent of total billed charges,
MR Lower Extremity Joint Left Partial,8001048,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,1790.00000,519.10000,Aetna,First Health,LT,1464.22,,,,,,,212.24,2209.00,percent of total billed charges,
MRCP done with MR Abdomen,8001049,CDM,610,RC,76376,HCPCS,,,facility,inpatient,,,3180.00000,922.20000,Aetna,First Health,,2601.24,,,,,,,1908.00,2601.24,percent of total billed charges,
MRCP done with MR Abdomen,8001049,CDM,610,RC,76376,HCPCS,,,facility,outpatient,,,3180.00000,922.20000,Aetna,First Health,,2601.24,,,,,,,124.81,2601.24,percent of total billed charges,
MR Breast CAD,8001050,CDM,610,RC,C8937,HCPCS,,,facility,inpatient,,,266.00000,77.14000,Aetna,First Health,,217.59,,,,,,,159.60,217.59,percent of total billed charges,
MR Breast CAD,8001050,CDM,610,RC,C8937,HCPCS,,,facility,outpatient,,,266.00000,77.14000,Aetna,First Health,,217.59,,,,,,,95.89,217.59,percent of total billed charges,
MR Orbit Face Neck wo Contrast,7285970,CDM,610,RC,70540,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Orbit Face Neck wo Contrast,7285970,CDM,610,RC,70540,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Orbit Face Neck wo Contrast,7524018,CDM,610,RC,70540,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Orbit Face Neck wo Contrast,7524018,CDM,610,RC,70540,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Orbits wo Contrast,8001051,CDM,610,RC,70540,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Orbits wo Contrast,8001051,CDM,610,RC,70540,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Pelvis wo Contrast,7285978,CDM,610,RC,72195,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Pelvis wo Contrast,7285978,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Pelvis wo Contrast,7285986,CDM,610,RC,72195,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Pelvis wo Contrast,7285986,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Pelvis wo Contrast,7285994,CDM,610,RC,72195,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Pelvis wo Contrast,7285994,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Pelvis wo Contrast,7523989,CDM,610,RC,72195,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Pelvis wo Contrast,7523989,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Pelvis wo Contrast,7964754,CDM,610,RC,72195,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Pelvis wo Contrast,7964754,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Pelvis wo Contrast,7964766,CDM,610,RC,72197,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Pelvis wo Contrast,7964766,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,313.58,2209.00,percent of total billed charges,
MR Chest w Contrast,7586019,CDM,610,RC,71551,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Chest w Contrast,7586019,CDM,610,RC,71551,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,497.61,2209.00,percent of total billed charges,
MR Chest w wo Contrast,7586017,CDM,610,RC,71552,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Chest w wo Contrast,7586017,CDM,610,RC,71552,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Chest w wo Contrast,7734632,CDM,610,RC,71552,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Chest w wo Contrast,7734632,CDM,610,RC,71552,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w wo Contrast,7285998,CDM,610,RC,72197,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Pelvis w wo Contrast,7285998,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w wo Contrast,7523994,CDM,610,RC,72197,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Pelvis w wo Contrast,7523994,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w wo Contrast,7523998,CDM,610,RC,72197,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Pelvis w wo Contrast,7523998,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w wo Contrast,7524002,CDM,610,RC,72197,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Pelvis w wo Contrast,7524002,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w wo Contrast,7964750,CDM,610,RC,72197,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Pelvis w wo Contrast,7964750,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w wo Contrast,7964762,CDM,610,RC,72197,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Pelvis w wo Contrast,7964762,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Cardiac wo Contrast,7285942,CDM,610,RC,75557,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Cardiac wo Contrast,7285942,CDM,610,RC,75557,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,613627,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,613627,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,614004,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,614004,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,614046,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,614046,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,7285926,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,7285926,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,7285954,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,7285954,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,7285962,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,7285962,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,7991340,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Lt w Contrast,7991340,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint LT w Contrast,8148229,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint LT w Contrast,8148229,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,613641,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,613641,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,614012,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,614012,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,614067,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,614067,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,7285930,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,7285930,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,7285958,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,7285958,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,7285966,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,7285966,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,7991352,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,7991352,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,8148230,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Joint Rt w Contrast,8148230,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt wo Contrast,613765,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Lt wo Contrast,613765,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt w Contrast,614297,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Lt w Contrast,614297,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt w Contrast,614417,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Lt w Contrast,614417,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt w Contrast,7285946,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Lt w Contrast,7285946,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt w Contrast,7286002,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Lt w Contrast,7286002,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt w Contrast,7286019,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Lt w Contrast,7286019,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,613777,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,613777,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,614305,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,614305,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,614423,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,614423,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,7285950,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,7285950,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,7286006,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,7286006,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,7286023,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Joint Rt w Contrast,7286023,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,495.89,2209.00,percent of total billed charges,
MR Breast Left w Contrast,7938461,CDM,610,RC,C8903,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Breast Left w Contrast,7938461,CDM,610,RC,C8903,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,156.31,1966.47,percent of total billed charges,
MR Breast Left wo Contrast,7938471,CDM,610,RC,77046,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Breast Left wo Contrast,7938471,CDM,610,RC,77046,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Breast Left w wo Contrast,7938467,CDM,610,RC,C8905,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Breast Left w wo Contrast,7938467,CDM,610,RC,C8905,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2059.72,percent of total billed charges,
MR Pelvis w Contrast,7285982,CDM,610,RC,72196,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Pelvis w Contrast,7285982,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w Contrast,7285990,CDM,610,RC,72196,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Pelvis w Contrast,7285990,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w Contrast,7544106,CDM,610,RC,72196,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Pelvis w Contrast,7544106,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w Contrast,7544112,CDM,610,RC,72196,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Pelvis w Contrast,7544112,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w Contrast,7964746,CDM,610,RC,72196,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Pelvis w Contrast,7964746,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Pelvis w Contrast,7964758,CDM,610,RC,72196,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Pelvis w Contrast,7964758,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Bilat w wo Contrast,613987,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,5036.00000,1460.44000,Aetna,First Health,,4119.45,,,,,,,3021.60,4119.45,percent of total billed charges,
MR Lower Extremity Joint Bilat w wo Contrast,613987,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,5036.00000,1460.44000,Aetna,First Health,,4119.45,,,,,,,313.58,4119.45,percent of total billed charges,
MR Lower Extremity w wo Contrast,8148157,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,5036.00000,1460.44000,Aetna,First Health,,4119.45,,,,,,,3021.60,4119.45,percent of total billed charges,
MR Lower Extremity w wo Contrast,8148157,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,5036.00000,1460.44000,Aetna,First Health,,4119.45,,,,,,,313.58,4119.45,percent of total billed charges,
MR Lower Extremity Joint Bilat wo Contrast,613996,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,2820.00,3844.60,percent of total billed charges,
MR Lower Extremity Joint Bilat wo Contrast,613996,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,212.24,3844.60,percent of total billed charges,
MR Lower Extremity Joint Bilat wo Contrast,8148284,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,2820.00,3844.60,percent of total billed charges,
MR Lower Extremity Joint Bilat wo Contrast,8148284,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,212.24,3844.60,percent of total billed charges,
MR Lower Extremity Joint Bilat w Contrast,613983,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,4808.00000,1394.32000,Aetna,First Health,,3932.94,,,,,,,2884.80,3932.94,percent of total billed charges,
MR Lower Extremity Joint Bilat w Contrast,613983,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,4808.00000,1394.32000,Aetna,First Health,,3932.94,,,,,,,495.89,3932.94,percent of total billed charges,
MR Lower Extremity Joint Bilot w Contrast,8148154,CDM,610,RC,73722,HCPCS,,,facility,inpatient,,,4808.00000,1394.32000,Aetna,First Health,,3932.94,,,,,,,2884.80,3932.94,percent of total billed charges,
MR Lower Extremity Joint Bilot w Contrast,8148154,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,4808.00000,1394.32000,Aetna,First Health,,3932.94,,,,,,,495.89,3932.94,percent of total billed charges,
MR Cardiac w wo Contrast,614221,CDM,610,RC,75561,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Cardiac w wo Contrast,614221,CDM,610,RC,75561,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Cardiac w wo Contrast,7926863,CDM,610,RC,75561,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Cardiac w wo Contrast,7926863,CDM,610,RC,75561,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Orbit Face Neck w wo Contrast,7285974,CDM,610,RC,70543,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Orbit Face Neck w wo Contrast,7285974,CDM,610,RC,70543,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Orbit Face Neck w wo Contrast,7544141,CDM,610,RC,70543,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Orbit Face Neck w wo Contrast,7544141,CDM,610,RC,70543,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Orbits w wo Contrast,8001073,CDM,610,RC,70543,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Orbits w wo Contrast,8001073,CDM,610,RC,70543,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt wo Contrast,613787,CDM,610,RC,73221,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Joint Rt wo Contrast,613787,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt wo Contrast,614323,CDM,610,RC,73221,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Joint Rt wo Contrast,614323,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt wo Contrast,614427,CDM,610,RC,73221,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Joint Rt wo Contrast,614427,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Right wo Contrast,613522,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Right wo Contrast,613522,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Right wo Contrast,613751,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Right wo Contrast,613751,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Right wo Contrast,613825,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Right wo Contrast,613825,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Right wo Contrast,613977,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Right wo Contrast,613977,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Right wo Contrast,614271,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Right wo Contrast,614271,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Right wo Contrast,614347,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Right wo Contrast,614347,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Right wo Contrast,614371,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Right wo Contrast,614371,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Right w Contrast,613743,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Right w Contrast,613743,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w Contrast,613813,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Right w Contrast,613813,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w Contrast,613961,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Right w Contrast,613961,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w Contrast,614103,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Right w Contrast,614103,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w Contrast,614263,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Right w Contrast,614263,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w Contrast,614343,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Right w Contrast,614343,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w Contrast,614367,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Right w Contrast,614367,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left wo Contrast,613520,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Left wo Contrast,613520,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Left wo Contrast,613738,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Left wo Contrast,613738,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Left wo Contrast,613807,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Left wo Contrast,613807,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Left wo Contrast,613950,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Left wo Contrast,613950,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Left wo Contrast,614261,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Left wo Contrast,614261,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Left wo Contrast,614341,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Left wo Contrast,614341,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Left wo Contrast,614365,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Upper Extremity Left wo Contrast,614365,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Upper Extremity Left w Contrast,613724,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Left w Contrast,613724,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w Contrast,613797,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Left w Contrast,613797,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity w Contrast,613933,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity w Contrast,613933,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w Contrast,614093,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Left w Contrast,614093,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w Contrast,614251,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Left w Contrast,614251,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w Contrast,614337,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Left w Contrast,614337,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w Contrast,614361,CDM,610,RC,73219,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Upper Extremity Left w Contrast,614361,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt w wo Contrast,613783,CDM,610,RC,73223,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Joint Rt w wo Contrast,613783,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt w wo Contrast,614311,CDM,610,RC,73223,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Joint Rt w wo Contrast,614311,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Joint Rt w wo Contrast,614425,CDM,610,RC,73223,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Joint Rt w wo Contrast,614425,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt w wo Contrast,613769,CDM,610,RC,73223,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Joint Lt w wo Contrast,613769,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt w wo Contrast,614301,CDM,610,RC,73223,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Joint Lt w wo Contrast,614301,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Joint Lt w wo Contrast,614419,CDM,610,RC,73223,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Joint Lt w wo Contrast,614419,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,613747,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,613747,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,613819,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,613819,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Hand Right w wo Contrast,613967,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Hand Right w wo Contrast,613967,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,614109,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,614109,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,614267,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,614267,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,614345,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,614345,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,614369,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Right w wo Contrast,614369,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,613732,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,613732,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,613801,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,613801,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity w wo Contrast,613939,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity w wo Contrast,613939,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,614095,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,614095,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,614257,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,614257,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,614339,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,614339,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,614363,CDM,610,RC,73220,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Upper Extremity Left w wo Contrast,614363,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w wo Contrast,613649,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Joint Rt w wo Contrast,613649,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w wo Contrast,614018,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Joint Rt w wo Contrast,614018,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w wo Contrast,614073,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Joint Rt w wo Contrast,614073,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w wo Contrast,7991356,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Joint Rt w wo Contrast,7991356,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Rt w wo Contrast,8148233,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Joint Rt w wo Contrast,8148233,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w wo Contrast,613631,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Joint Lt w wo Contrast,613631,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w wo Contrast,614008,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Joint Lt w wo Contrast,614008,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w wo Contrast,614053,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Joint Lt w wo Contrast,614053,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt w wo Contrast,7991344,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Joint Lt w wo Contrast,7991344,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint LT w wo Contrast,8148497,CDM,610,RC,73723,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Joint LT w wo Contrast,8148497,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,LT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,6117875,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,6117875,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,613635,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,613635,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,614010,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,614010,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,614059,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,614059,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,7741565,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,7741565,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,7840076,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,7840076,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,7991348,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint Lt wo Contrast,7991348,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Joint LT wo Contrast,8148231,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Joint LT wo Contrast,8148231,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Right wo Contrast,1063803,CDM,610,RC,73718,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Right wo Contrast,1063803,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Right wo Contrast,613858,CDM,610,RC,73718,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Right wo Contrast,613858,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Right wo Contrast,614195,CDM,610,RC,73718,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Right wo Contrast,614195,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Right wo Contrast,614407,CDM,610,RC,73718,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Right wo Contrast,614407,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Right w Contrast,613854,CDM,610,RC,73719,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Right w Contrast,613854,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Right w Contrast,614187,CDM,610,RC,73719,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Right w Contrast,614187,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Right w Contrast,614403,CDM,610,RC,73719,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Right w Contrast,614403,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Right w Contrast,7586023,CDM,610,RC,73719,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Right w Contrast,7586023,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,RT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Right w wo Contrast,1063805,CDM,610,RC,73720,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Right w wo Contrast,1063805,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Right w wo Contrast,613856,CDM,610,RC,73720,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Right w wo Contrast,613856,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Right w wo Contrast,614189,CDM,610,RC,73720,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Right w wo Contrast,614189,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Right w wo Contrast,614405,CDM,610,RC,73720,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lower Extremity Right w wo Contrast,614405,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,RT,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Left wo Contrast,1053851,CDM,610,RC,73718,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Left wo Contrast,1053851,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Left wo Contrast,613852,CDM,610,RC,73718,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Left wo Contrast,613852,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremty Left wo Contrast,614183,CDM,610,RC,73718,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremty Left wo Contrast,614183,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Left wo Contrast,614401,CDM,610,RC,73718,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lower Extremity Left wo Contrast,614401,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lower Extremity Left w Contrast,613843,CDM,610,RC,73719,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Left w Contrast,613843,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Left w Contrast,614169,CDM,610,RC,73719,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Left w Contrast,614169,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Left w Contrast,614397,CDM,610,RC,73719,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Left w Contrast,614397,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lower Extremity Left w Contrast,7586021,CDM,610,RC,73719,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lower Extremity Left w Contrast,7586021,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,LT,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Abdomen w wo Contrast,7520024,CDM,610,RC,74183,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Abdomen w wo Contrast,7520024,CDM,610,RC,74183,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Abdomen w wo Contrast,927861,CDM,610,RC,74183,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Abdomen w wo Contrast,927861,CDM,610,RC,74183,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Abdomen wo Contrast,613524,CDM,610,RC,74181,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Abdomen wo Contrast,613524,CDM,610,RC,74181,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Abdomen wo Contrast,614215,CDM,610,RC,74181,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Abdomen wo Contrast,614215,CDM,610,RC,74181,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Abdomen wo Contrast,7520018,CDM,610,RC,74181,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Abdomen wo Contrast,7520018,CDM,610,RC,74181,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Abdomen wo Contrast,7903283,CDM,610,RC,74181,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Abdomen wo Contrast,7903283,CDM,610,RC,74181,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Abdomen w Contrast,613526,CDM,610,RC,74182,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Abdomen w Contrast,613526,CDM,610,RC,74182,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MRI Lower Extremity wo Contrast Bilat,8150244,CDM,610,RC,73718,HCPCS,,,facility,inpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,2820.00,3844.60,percent of total billed charges,
MRI Lower Extremity wo Contrast Bilat,8150244,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,212.24,3844.60,percent of total billed charges,
MRI Lower Extremity w wo Contrast Bilat,8150674,CDM,610,RC,73720,HCPCS,,,facility,inpatient,,,5036.00000,1460.44000,Aetna,First Health,,4119.45,,,,,,,3021.60,4119.45,percent of total billed charges,
MRI Lower Extremity w wo Contrast Bilat,8150674,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,5036.00000,1460.44000,Aetna,First Health,,4119.45,,,,,,,313.58,4119.45,percent of total billed charges,
MRI Breast LT w wo Cont w CAD,8153990,CDM,610,RC,77048,HCPCS,,,facility,inpatient,,,2784.00000,807.36000,Aetna,First Health,LT,2277.31,,,,,,,1670.40,2277.31,percent of total billed charges,
MRI Breast LT w wo Cont w CAD,8153990,CDM,610,RC,77048,HCPCS,,,facility,outpatient,,,2784.00000,807.36000,Aetna,First Health,LT,2277.31,,,,,,,421.18,2277.31,percent of total billed charges,
MRI Breast RT w wo Cont w CAD,8153968,CDM,610,RC,77048,HCPCS,,,facility,inpatient,,,2784.00000,807.36000,Aetna,First Health,RT,2277.31,,,,,,,1670.40,2277.31,percent of total billed charges,
MRI Breast RT w wo Cont w CAD,8153968,CDM,610,RC,77048,HCPCS,,,facility,outpatient,,,2784.00000,807.36000,Aetna,First Health,RT,2277.31,,,,,,,421.18,2277.31,percent of total billed charges,
MRI Breast Bil w wo Cont w CAD,8153999,CDM,610,RC,77049,HCPCS,,,facility,inpatient,,,5568.00000,1614.72000,Aetna,First Health,,4554.62,,,,,,,3340.80,4554.62,percent of total billed charges,
MRI Breast Bil w wo Cont w CAD,8153999,CDM,610,RC,77049,HCPCS,,,facility,outpatient,,,5568.00000,1614.72000,Aetna,First Health,,4554.62,,,,,,,419.13,4554.62,percent of total billed charges,
MR Upper Extremity Joint Bilat wo Contrast,8161791,CDM,610,RC,73221,HCPCS,,,facility,inpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,2820.00,3844.60,percent of total billed charges,
MR Upper Extremity Joint Bilat wo Contrast,8161791,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,212.24,3844.60,percent of total billed charges,
MRI Breast Lt for Bilat Study,8171067,CDM,610,RC,C8905,HCPCS,,,facility,inpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,2820.00,3844.60,percent of total billed charges,
MRI Breast Lt for Bilat Study,8171067,CDM,610,RC,C8905,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,313.58,3844.60,percent of total billed charges,
MRI Breast Rt for Bilat Study,8171066,CDM,610,RC,C8905,HCPCS,,,facility,inpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,2820.00,3844.60,percent of total billed charges,
MRI Breast Rt for Bilat Study,8171066,CDM,610,RC,C8905,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,313.58,3844.60,percent of total billed charges,
MR Hip Left wo Contrast Extended,8246692,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Hip Left wo Contrast Extended,8246692,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,LT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Hip Right wo Contrast Extended,8246696,CDM,610,RC,73721,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Hip Right wo Contrast Extended,8246696,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,RT,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MRI Upper Extremity Joint Bilat w Contrast,8284388,CDM,610,RC,73222,HCPCS,,,facility,inpatient,,,4808.00000,1394.32000,Aetna,First Health,,3932.94,,,,,,,2884.80,3932.94,percent of total billed charges,
MRI Upper Extremity Joint Bilat w Contrast,8284388,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,4808.00000,1394.32000,Aetna,First Health,,3932.94,,,,,,,495.89,3932.94,percent of total billed charges,
MR Rectal Staging w or wo Contrast,8452000,CDM,610,RC,72197,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Rectal Staging w or wo Contrast,8452000,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Rectal Staging wo Contrast,8452002,CDM,610,RC,72195,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Rectal Staging wo Contrast,8452002,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Rectal Staging w Contrast,8451998,CDM,610,RC,72196,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Rectal Staging w Contrast,8451998,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Upper Extremity WO contrast Bilat,9134465,CDM,610,RC,73218,HCPCS,,,facility,inpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,2820.00,3844.60,percent of total billed charges,
MR Upper Extremity WO contrast Bilat,9134465,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,First Health,,3844.60,,,,,,,212.24,3844.60,percent of total billed charges,
MR Brain wo Contrast,2890862,CDM,611,RC,70551,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Brain wo Contrast,2890862,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Brain wo Contrast,613682,CDM,611,RC,70551,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Brain wo Contrast,613682,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Brain wo Contrast,7285934,CDM,611,RC,70551,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Brain wo Contrast,7285934,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Brain wo Contrast,7812062,CDM,611,RC,70551,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Brain wo Contrast,7812062,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Brain wo Contrast,7949881,CDM,611,RC,70551,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Brain wo Contrast,7949881,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Brain wo Contrast,7956997,CDM,611,RC,70551,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Brain wo Contrast,7956997,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Brain wo Contrast,8121791,CDM,611,RC,70551,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Brain wo Contrast,8121791,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Brain w Contrast,613676,CDM,611,RC,70552,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Brain w Contrast,613676,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w Contrast,613678,CDM,611,RC,70552,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Brain w Contrast,613678,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w Contrast,7524006,CDM,611,RC,70552,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Brain w Contrast,7524006,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w Contrast,7524010,CDM,611,RC,70552,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Brain w Contrast,7524010,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w Contrast,7812058,CDM,611,RC,70552,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Brain w Contrast,7812058,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w Contrast,7956995,CDM,611,RC,70552,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Brain w Contrast,7956995,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w Contrast,8121783,CDM,611,RC,70552,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Brain w Contrast,8121783,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w wo Contrast,2890860,CDM,611,RC,70553,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Brain w wo Contrast,2890860,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w wo Contrast,613680,CDM,611,RC,70553,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Brain w wo Contrast,613680,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w wo Contrast,7285938,CDM,611,RC,70553,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Brain w wo Contrast,7285938,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w wo Contrast,7812066,CDM,611,RC,70553,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Brain w wo Contrast,7812066,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w wo Contrast,7908922,CDM,611,RC,70553,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Brain w wo Contrast,7908922,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w wo Contrast,7949877,CDM,611,RC,70553,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Brain w wo Contrast,7949877,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w wo Contrast,7949885,CDM,611,RC,70553,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Brain w wo Contrast,7949885,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Brain w wo Contrast,8121787,CDM,611,RC,70553,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Brain w wo Contrast,8121787,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Trailblazer Brain wo Contrast,8435861,CDM,611,RC,,,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Trailblazer Brain wo Contrast,8435861,CDM,611,RC,,,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,847.17,1922.30,percent of total billed charges,
MR Cervical Spine wo Contrast,613696,CDM,612,RC,72141,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Cervical Spine wo Contrast,613696,CDM,612,RC,72141,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Cervical Spine w Contrast,613684,CDM,612,RC,72142,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Cervical Spine w Contrast,613684,CDM,612,RC,72142,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Thoracic Spine wo Contrast,614335,CDM,612,RC,72146,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Thoracic Spine wo Contrast,614335,CDM,612,RC,72146,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Thoracic Spine w Contrast,614331,CDM,612,RC,72147,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Thoracic Spine w Contrast,614331,CDM,612,RC,72147,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lumbar Spine wo Contrast,614207,CDM,612,RC,72148,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Lumbar Spine wo Contrast,614207,CDM,612,RC,72148,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Lumbar Spine w Contrast,614197,CDM,612,RC,72149,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Lumbar Spine w Contrast,614197,CDM,612,RC,72149,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Cervical Spine w wo Contrast,613690,CDM,612,RC,72156,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Cervical Spine w wo Contrast,613690,CDM,612,RC,72156,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Thoracic Spine w wo Contrast,614333,CDM,612,RC,72157,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Thoracic Spine w wo Contrast,614333,CDM,612,RC,72157,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Lumbar Spine w wo Contrast,614201,CDM,612,RC,72158,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Lumbar Spine w wo Contrast,614201,CDM,612,RC,72158,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Angio Head wo Contrast,613419,CDM,615,RC,70544,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Angio Head wo Contrast,613419,CDM,615,RC,70544,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Angio Head wo Contrast,613542,CDM,615,RC,70544,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Angio Head wo Contrast,613542,CDM,615,RC,70544,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Angio Head wo Contrast,614409,CDM,615,RC,70544,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Angio Head wo Contrast,614409,CDM,615,RC,70544,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Angio Neck wo Contrast,613440,CDM,615,RC,70547,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Angio Neck wo Contrast,613440,CDM,615,RC,70547,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Angio Neck w Contrast,655779,CDM,615,RC,70548,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Angio Neck w Contrast,655779,CDM,615,RC,70548,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Angio Neck w wo Contrast,613437,CDM,615,RC,70549,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Angio Neck w wo Contrast,613437,CDM,615,RC,70549,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Angio Head w Contrast,8440452,CDM,615,RC,70545,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Angio Head w Contrast,8440452,CDM,615,RC,70545,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,2209.00,percent of total billed charges,
MR Angio Head w and wo Contrast,8440454,CDM,615,RC,70546,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Angio Head w and wo Contrast,8440454,CDM,615,RC,70546,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2209.00,percent of total billed charges,
MR Angio Head wo Contrast,8440456,CDM,615,RC,70544,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Angio Head wo Contrast,8440456,CDM,615,RC,70544,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,2209.00,percent of total billed charges,
MR Angio Lower Extremity Left w or wo Contrast,1063829,CDM,616,RC,C8914,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Angio Lower Extremity Left w or wo Contrast,1063829,CDM,616,RC,C8914,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Lower Extremity Right w or wo Contrast,7586002,CDM,616,RC,C8912,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Angio Lower Extremity Right w or wo Contrast,7586002,CDM,616,RC,C8912,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,1966.47,percent of total billed charges,
MR Angio Lower Extremity Right w or wo Contrast,7586003,CDM,616,RC,C8913,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Angio Lower Extremity Right w or wo Contrast,7586003,CDM,616,RC,C8913,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,212.24,1966.47,percent of total billed charges,
MR Angio Lower Extremity Left w or wo Contrast,7586005,CDM,616,RC,C8912,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Angio Lower Extremity Left w or wo Contrast,7586005,CDM,616,RC,C8912,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,1966.47,percent of total billed charges,
MR Angio Lower Extremity Left w or wo Contrast,7586007,CDM,616,RC,C8913,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Angio Lower Extremity Left w or wo Contrast,7586007,CDM,616,RC,C8913,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,212.24,1966.47,percent of total billed charges,
MR Angio Lower Extremity Right w or wo Contrast,1083818,CDM,616,RC,C8914,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Angio Lower Extremity Right w or wo Contrast,1083818,CDM,616,RC,C8914,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Upper Extremity Left w Contrast,7544133,CDM,618,RC,C8934,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Angio Upper Extremity Left w Contrast,7544133,CDM,618,RC,C8934,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,1966.47,percent of total billed charges,
MR Angio Upper Extremity Right w Contrast,7544129,CDM,618,RC,C8934,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Angio Upper Extremity Right w Contrast,7544129,CDM,618,RC,C8934,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,1966.47,percent of total billed charges,
MR Angio Abdomen wo Contrast,3136869,CDM,618,RC,C8901,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Angio Abdomen wo Contrast,3136869,CDM,618,RC,C8901,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,1922.30,percent of total billed charges,
MR Angio Chest w Contrast,613538,CDM,618,RC,C8909,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Angio Chest w Contrast,613538,CDM,618,RC,C8909,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,1966.47,percent of total billed charges,
MR Angio Abdomen w wo Contrast,7585994,CDM,618,RC,C8902,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Angio Abdomen w wo Contrast,7585994,CDM,618,RC,C8902,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Chest w wo Contrast,7585998,CDM,618,RC,C8911,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Angio Chest w wo Contrast,7585998,CDM,618,RC,C8911,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Chest wo Contrast,7585996,CDM,618,RC,C8910,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Angio Chest wo Contrast,7585996,CDM,618,RC,C8910,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,1922.30,percent of total billed charges,
MR Angio Upper Extremity Left wo Contrast,7586009,CDM,618,RC,C8935,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Angio Upper Extremity Left wo Contrast,7586009,CDM,618,RC,C8935,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,1922.30,percent of total billed charges,
MR Angio Upper Extremity Left w wo Contrast,7586011,CDM,618,RC,C8936,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Angio Upper Extremity Left w wo Contrast,7586011,CDM,618,RC,C8936,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Upper Extremity Right wo Contrast,7586013,CDM,618,RC,C8935,HCPCS,,,facility,inpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,1410.00,1922.30,percent of total billed charges,
MR Angio Upper Extremity Right wo Contrast,7586013,CDM,618,RC,C8935,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,First Health,,1922.30,,,,,,,212.24,1922.30,percent of total billed charges,
MR Angio Upper Extremity Right w wo Contrast,7586015,CDM,618,RC,C8936,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Angio Upper Extremity Right w wo Contrast,7586015,CDM,618,RC,C8936,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Spinal Canal,613602,CDM,618,RC,C8931,HCPCS,,,facility,inpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,1510.80,2059.72,percent of total billed charges,
MR Angio Spinal Canal,613602,CDM,618,RC,C8931,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,First Health,,2059.72,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Abdomen w Contrast,613405,CDM,618,RC,C8900,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,1442.40,1966.47,percent of total billed charges,
MR Angio Abdomen w Contrast,613405,CDM,618,RC,C8900,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,First Health,,1966.47,,,,,,,313.58,1966.47,percent of total billed charges,
COLLAGEN POWDER,9026163,CDM,623,RC,A6010,HCPCS,,,facility,inpatient,,,5670.00000,1644.30000,Aetna,First Health,,4638.06,,,,,,,3402.00,4638.06,percent of total billed charges,
COLLAGEN POWDER,9026163,CDM,623,RC,A6010,HCPCS,,,facility,outpatient,,,5670.00000,1644.30000,Aetna,First Health,,4638.06,,,,,,,44.14,4638.06,percent of total billed charges,
COLLAGEN POWDER,9026162,CDM,623,RC,A6010,HCPCS,,,facility,inpatient,,,2020.00000,585.80000,Aetna,First Health,,1652.36,,,,,,,1212.00,1652.36,percent of total billed charges,
COLLAGEN POWDER,9026162,CDM,623,RC,A6010,HCPCS,,,facility,outpatient,,,2020.00000,585.80000,Aetna,First Health,,1652.36,,,,,,,44.14,1652.36,percent of total billed charges,
COLLAGEN POWDER,9090501,CDM,623,RC,A6010,HCPCS,,,facility,inpatient,,,399.48000,115.85000,Aetna,First Health,,326.77,,,,,,,239.69,326.77,percent of total billed charges,
COLLAGEN POWDER,9090501,CDM,623,RC,A6010,HCPCS,,,facility,outpatient,,,399.48000,115.85000,Aetna,First Health,,326.77,,,,,,,44.14,326.77,percent of total billed charges,
COLLAGEN POWDER,9091189,CDM,623,RC,A6010,HCPCS,,,facility,inpatient,,,671.85000,194.84000,Aetna,First Health,,549.57,,,,,,,403.11,549.57,percent of total billed charges,
COLLAGEN POWDER,9091189,CDM,623,RC,A6010,HCPCS,,,facility,outpatient,,,671.85000,194.84000,Aetna,First Health,,549.57,,,,,,,44.14,549.57,percent of total billed charges,
COLLAGEN DRESSING,9096351,CDM,623,RC,A6010,HCPCS,,,facility,inpatient,,,121.48000,35.23000,Aetna,First Health,,99.37,,,,,,,72.89,99.37,percent of total billed charges,
COLLAGEN DRESSING,9096351,CDM,623,RC,A6010,HCPCS,,,facility,outpatient,,,121.48000,35.23000,Aetna,First Health,,99.37,,,,,,,43.79,99.37,percent of total billed charges,
Contrast Visipaque 320 1Ml,8062814,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
Contrast Visipaque 320 1Ml,8062814,CDM,636,RC,Q9967,HCPCS,,,facility,outpatient,,,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.14445,1.64,percent of total billed charges,
Contrast Visipaque 320 1Ml Wasted,8062815,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
Contrast Visipaque 320 1Ml Wasted,8062815,CDM,636,RC,Q9967,HCPCS,,,facility,outpatient,,,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.14445,1.64,percent of total billed charges,
DERMIS,7902709,CDM,636,RC,Q4125,HCPCS,,,facility,inpatient,,,13200.00000,3828.00000,Aetna,First Health,,10797.60,,,,,,,4758.60,10797.60,percent of total billed charges,
DERMIS,7902709,CDM,636,RC,Q4125,HCPCS,,,facility,outpatient,,,13200.00000,3828.00000,Aetna,First Health,,10797.60,,,,,,,124.65,10797.60,percent of total billed charges,
ALLODERM 1CM FOR 2X4CM,7694892,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,670.53,1521.48,percent of total billed charges,
ALLODERM 1CM FOR 2X4CM,7694892,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,First Health,,1521.48,,,,,,,124.65,1521.48,percent of total billed charges,
ALLODERM 1CM FOR 4X12CM,7694423,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,8589.00000,2490.81000,Aetna,First Health,,7025.80,,,,,,,3096.33,7025.80,percent of total billed charges,
ALLODERM 1CM FOR 4X12CM,7694423,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,8589.00000,2490.81000,Aetna,First Health,,7025.80,,,,,,,124.65,7025.80,percent of total billed charges,
ALLODERM 1CM FOR 4X16CM,7697282,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,9387.00000,2722.23000,Aetna,First Health,,7678.57,,,,,,,3384.01,7678.57,percent of total billed charges,
ALLODERM 1CM FOR 4X16CM,7697282,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,9387.00000,2722.23000,Aetna,First Health,,7678.57,,,,,,,124.65,7678.57,percent of total billed charges,
ALLODERM 1CM FOR 6X12CM,7697300,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,10281.00000,2981.49000,Aetna,First Health,,8409.86,,,,,,,3706.30,8409.86,percent of total billed charges,
ALLODERM 1CM FOR 6X12CM,7697300,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,10281.00000,2981.49000,Aetna,First Health,,8409.86,,,,,,,124.65,8409.86,percent of total billed charges,
ALLODERM 1CM,7810033,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,17857.50000,5178.67000,Aetna,First Health,,14607.43,,,,,,,6437.63,14607.43,percent of total billed charges,
ALLODERM 1CM,7810033,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,17857.50000,5178.67000,Aetna,First Health,,14607.43,,,,,,,124.65,14607.43,percent of total billed charges,
ALLODERM 1CM,7790162,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,17467.50000,5065.58000,Aetna,First Health,,14288.42,,,,,,,6297.03,14288.42,percent of total billed charges,
ALLODERM 1CM,7790162,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,17467.50000,5065.58000,Aetna,First Health,,14288.42,,,,,,,124.65,14288.42,percent of total billed charges,
AMNIOMATRIX 1CM FOR 2X12CM,7736490,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,5207.30000,1510.12000,Aetna,First Health,,4259.57,,,,,,,1877.23,4259.57,percent of total billed charges,
AMNIOMATRIX 1CM FOR 2X12CM,7736490,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,5207.30000,1510.12000,Aetna,First Health,,4259.57,,,,,,,55.68,4259.57,percent of total billed charges,
MATRIX,7700390,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,1842.25000,534.25000,Aetna,First Health,,1506.96,,,,,,,664.13,1506.96,percent of total billed charges,
MATRIX,7700390,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,1842.25000,534.25000,Aetna,First Health,,1506.96,,,,,,,55.68,1506.96,percent of total billed charges,
GRAFT,7926786,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,1763.24000,511.34000,Aetna,First Health,,1442.33,,,,,,,635.65,1442.33,percent of total billed charges,
GRAFT,7926786,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,1763.24000,511.34000,Aetna,First Health,,1442.33,,,,,,,55.68,1442.33,percent of total billed charges,
MATRIX,7694915,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,2837.32000,822.82000,Aetna,First Health,,2320.93,,,,,,,1022.85,2320.93,percent of total billed charges,
MATRIX,7694915,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,2837.32000,822.82000,Aetna,First Health,,2320.93,,,,,,,55.68,2320.93,percent of total billed charges,
MATRIX,7699911,CDM,636,RC,Q4104,HCPCS,,,facility,inpatient,,,10110.36000,2932.00000,Aetna,First Health,,8270.27,,,,,,,3644.78,8270.27,percent of total billed charges,
MATRIX,7699911,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,10110.36000,2932.00000,Aetna,First Health,,8270.27,,,,,,,56.25,8270.27,percent of total billed charges,
MATRIX,7902347,CDM,636,RC,Q4104,HCPCS,,,facility,inpatient,,,34995.83000,10148.79000,Aetna,First Health,,28626.59,,,,,,,12616.00,28626.59,percent of total billed charges,
MATRIX,7902347,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,34995.83000,10148.79000,Aetna,First Health,,28626.59,,,,,,,56.25,28626.59,percent of total billed charges,
STRATTICE,7697305,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,50790.00000,14729.10000,Aetna,First Health,,41546.22,,,,,,,18309.79,41546.22,percent of total billed charges,
STRATTICE,7697305,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,50790.00000,14729.10000,Aetna,First Health,,41546.22,,,,,,,124.65,41546.22,percent of total billed charges,
STRATTICE,7696116,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,17432.50000,5055.42000,Aetna,First Health,,14259.78,,,,,,,6284.42,14259.78,percent of total billed charges,
STRATTICE,7696116,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,17432.50000,5055.42000,Aetna,First Health,,14259.78,,,,,,,124.65,14259.78,percent of total billed charges,
STRATTICE,7696117,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,30136.50000,8739.58000,Aetna,First Health,,24651.66,,,,,,,10864.21,24651.66,percent of total billed charges,
STRATTICE,7696117,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,30136.50000,8739.58000,Aetna,First Health,,24651.66,,,,,,,124.65,24651.66,percent of total billed charges,
STRATTICE,7696397,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,11559.00000,3352.11000,Aetna,First Health,,9455.26,,,,,,,4167.02,9455.26,percent of total billed charges,
STRATTICE,7696397,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,11559.00000,3352.11000,Aetna,First Health,,9455.26,,,,,,,124.65,9455.26,percent of total billed charges,
STRATTICE,7700822,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,2240.87,5084.69,percent of total billed charges,
STRATTICE,7700822,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,First Health,,5084.69,,,,,,,124.65,5084.69,percent of total billed charges,
STRATTICE,7696115,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,14298.00000,4146.42000,Aetna,First Health,,11695.76,,,,,,,5154.43,11695.76,percent of total billed charges,
STRATTICE,7696115,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,14298.00000,4146.42000,Aetna,First Health,,11695.76,,,,,,,124.65,11695.76,percent of total billed charges,
GRAFT JACKET,7702862,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,10821.00000,3138.09000,Aetna,First Health,,8851.58,,,,,,,3900.97,8851.58,percent of total billed charges,
GRAFT JACKET,7702862,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,10821.00000,3138.09000,Aetna,First Health,,8851.58,,,,,,,97.38,8851.58,percent of total billed charges,
NERVE GUIDE,7696718,CDM,636,RC,C9352,HCPCS,,,facility,inpatient,,,9672.30000,2804.97000,Aetna,First Health,,7911.94,,,,,,,3486.86,7911.94,percent of total billed charges,
NERVE GUIDE,7696718,CDM,636,RC,C9352,HCPCS,,,facility,outpatient,,,9672.30000,2804.97000,Aetna,First Health,,7911.94,,,,,,,3486.86,7911.94,percent of total billed charges,
NERVE PROTECTOR,7903795,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
NERVE PROTECTOR,7903795,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
NERVE PROTECTOR,7903800,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2968.72,6736.23,percent of total billed charges,
NERVE PROTECTOR,7903800,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2968.72,6736.23,percent of total billed charges,
NERVE WRAP,7700814,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,9303.00000,2697.87000,Aetna,First Health,,7609.85,,,,,,,3353.73,7609.85,percent of total billed charges,
NERVE WRAP,7700814,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,9303.00000,2697.87000,Aetna,First Health,,7609.85,,,,,,,3353.73,7609.85,percent of total billed charges,
NERVE WRAP,7701054,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,9739.80000,2824.54000,Aetna,First Health,,7967.16,,,,,,,3511.20,7967.16,percent of total billed charges,
NERVE WRAP,7701054,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,9739.80000,2824.54000,Aetna,First Health,,7967.16,,,,,,,3511.20,7967.16,percent of total billed charges,
BONE PUTTY,7694973,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,2488.20000,721.58000,Aetna,First Health,,2035.35,,,,,,,897.00,2035.35,percent of total billed charges,
BONE PUTTY,7694973,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,2488.20000,721.58000,Aetna,First Health,,2035.35,,,,,,,897.00,2035.35,percent of total billed charges,
BONE PUTTY,7696227,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,2923.32000,847.76000,Aetna,First Health,,2391.28,,,,,,,1053.86,2391.28,percent of total billed charges,
BONE PUTTY,7696227,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,2923.32000,847.76000,Aetna,First Health,,2391.28,,,,,,,1053.86,2391.28,percent of total billed charges,
BONE PUTTY,7703390,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,695.07000,201.57000,Aetna,First Health,,568.57,,,,,,,250.57,568.57,percent of total billed charges,
BONE PUTTY,7703390,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,695.07000,201.57000,Aetna,First Health,,568.57,,,,,,,250.57,568.57,percent of total billed charges,
BONE PUTTY,7694904,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,3543.51000,1027.62000,Aetna,First Health,,2898.59,,,,,,,1277.44,2898.59,percent of total billed charges,
BONE PUTTY,7694904,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,3543.51000,1027.62000,Aetna,First Health,,2898.59,,,,,,,1277.44,2898.59,percent of total billed charges,
BONE FILLER,7844126,CDM,636,RC,C9359,HCPCS,,,facility,inpatient,,,10080.00000,2923.20000,Aetna,First Health,,8245.44,,,,,,,3633.84,8245.44,percent of total billed charges,
BONE FILLER,7844126,CDM,636,RC,C9359,HCPCS,,,facility,outpatient,,,10080.00000,2923.20000,Aetna,First Health,,8245.44,,,,,,,3633.84,8245.44,percent of total billed charges,
BONE FILLER,7700201,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,9503.34000,2755.97000,Aetna,First Health,,7773.73,,,,,,,3425.95,7773.73,percent of total billed charges,
BONE FILLER,7700201,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,9503.34000,2755.97000,Aetna,First Health,,7773.73,,,,,,,3425.95,7773.73,percent of total billed charges,
BONE PUTTY,7700517,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
BONE PUTTY,7700517,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,First Health,,717.79,,,,,,,316.34,717.79,percent of total billed charges,
ALLODERM 1CM FOR 16X20CM,7937654,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,35158.50000,10195.96000,Aetna,First Health,,28759.65,,,,,,,12674.64,28759.65,percent of total billed charges,
ALLODERM 1CM FOR 16X20CM,7937654,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,35158.50000,10195.96000,Aetna,First Health,,28759.65,,,,,,,124.65,28759.65,percent of total billed charges,
BONE FILLER,7916969,CDM,636,RC,C9362,HCPCS,,,facility,inpatient,,,5178.60000,1501.79000,Aetna,First Health,,4236.09,,,,,,,1866.89,4236.09,percent of total billed charges,
BONE FILLER,7916969,CDM,636,RC,C9362,HCPCS,,,facility,outpatient,,,5178.60000,1501.79000,Aetna,First Health,,4236.09,,,,,,,1866.89,4236.09,percent of total billed charges,
GRAFT JACKET,7702861,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,2865.97,6503.10,percent of total billed charges,
GRAFT JACKET,7702861,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,First Health,,6503.10,,,,,,,97.38,6503.10,percent of total billed charges,
GRAFT JACKET,7804029,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,10002.00000,2900.58000,Aetna,First Health,,8181.64,,,,,,,3605.72,8181.64,percent of total billed charges,
GRAFT JACKET,7804029,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,10002.00000,2900.58000,Aetna,First Health,,8181.64,,,,,,,97.38,8181.64,percent of total billed charges,
SEALANT,7950499,CDM,636,RC,,,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
SEALANT,7950499,CDM,636,RC,,,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,First Health,,3427.01,,,,,,,1510.31,3427.01,percent of total billed charges,
MESH,7944205,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,70184.00000,20353.36000,Aetna,First Health,,57410.51,,,,,,,25301.33,57410.51,percent of total billed charges,
MESH,7944205,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,70184.00000,20353.36000,Aetna,First Health,,57410.51,,,,,,,124.65,57410.51,percent of total billed charges,
NERVE CONNECT,7903764,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903764,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903771,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,5250.00000,1522.50000,Aetna,First Health,,4294.50,,,,,,,1892.62,4294.50,percent of total billed charges,
NERVE CONNECT,7903771,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,5250.00000,1522.50000,Aetna,First Health,,4294.50,,,,,,,1892.62,4294.50,percent of total billed charges,
PUTTY,7948221,CDM,636,RC,C9359,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
PUTTY,7948221,CDM,636,RC,C9359,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,243.34,552.15,percent of total billed charges,
PUTTY,7948222,CDM,636,RC,C9359,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
PUTTY,7948222,CDM,636,RC,C9359,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,First Health,,2224.96,,,,,,,980.56,2224.96,percent of total billed charges,
PUTTY,7948223,CDM,636,RC,C9359,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
PUTTY,7948223,CDM,636,RC,C9359,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,First Health,,3793.47,,,,,,,1671.82,3793.47,percent of total billed charges,
ALLODERM 1CM,7950033,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,18230.00000,5286.70000,Aetna,First Health,,14912.14,,,,,,,6571.91,14912.14,percent of total billed charges,
ALLODERM 1CM,7950033,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,18230.00000,5286.70000,Aetna,First Health,,14912.14,,,,,,,124.65,14912.14,percent of total billed charges,
ALLODERM 1CM FOR 16X20CM,7950035,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,35158.50000,10195.96000,Aetna,First Health,,28759.65,,,,,,,12674.64,28759.65,percent of total billed charges,
ALLODERM 1CM FOR 16X20CM,7950035,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,35158.50000,10195.96000,Aetna,First Health,,28759.65,,,,,,,124.65,28759.65,percent of total billed charges,
BONE PUTTY,7950502,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,2224.00000,644.96000,Aetna,First Health,,1819.23,,,,,,,801.75,1819.23,percent of total billed charges,
BONE PUTTY,7950502,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,2224.00000,644.96000,Aetna,First Health,,1819.23,,,,,,,801.75,1819.23,percent of total billed charges,
BONE PUTTY,7950503,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,6520.50000,1890.94000,Aetna,First Health,,5333.77,,,,,,,2350.64,5333.77,percent of total billed charges,
BONE PUTTY,7950503,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,6520.50000,1890.94000,Aetna,First Health,,5333.77,,,,,,,2350.64,5333.77,percent of total billed charges,
BONE PUTTY,7950504,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,9621.00000,2790.09000,Aetna,First Health,,7869.98,,,,,,,3468.37,7869.98,percent of total billed charges,
BONE PUTTY,7950504,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,9621.00000,2790.09000,Aetna,First Health,,7869.98,,,,,,,3468.37,7869.98,percent of total billed charges,
ALLODERM 1CM FOR 8X16CM,7955810,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,17077.50000,4952.47000,Aetna,First Health,,13969.40,,,,,,,6156.44,13969.40,percent of total billed charges,
ALLODERM 1CM FOR 8X16CM,7955810,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,17077.50000,4952.47000,Aetna,First Health,,13969.40,,,,,,,124.65,13969.40,percent of total billed charges,
TENDON PROTECTOR,7964375,CDM,636,RC,C9356,HCPCS,,,facility,inpatient,,,11354.40000,3292.78000,Aetna,First Health,,9287.90,,,,,,,4093.26,9287.90,percent of total billed charges,
TENDON PROTECTOR,7964375,CDM,636,RC,C9356,HCPCS,,,facility,outpatient,,,11354.40000,3292.78000,Aetna,First Health,,9287.90,,,,,,,4093.26,9287.90,percent of total billed charges,
ALLODERM 1CM FOR 16X20CM,7972596,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,36816.75000,10676.86000,Aetna,First Health,,30116.10,,,,,,,13272.44,30116.10,percent of total billed charges,
ALLODERM 1CM FOR 16X20CM,7972596,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,36816.75000,10676.86000,Aetna,First Health,,30116.10,,,,,,,124.65,30116.10,percent of total billed charges,
ALLODERM 1CM FOR 4X12CM,7974910,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,5659.50000,1641.26000,Aetna,First Health,,4629.47,,,,,,,2040.25,4629.47,percent of total billed charges,
ALLODERM 1CM FOR 4X12CM,7974910,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,5659.50000,1641.26000,Aetna,First Health,,4629.47,,,,,,,124.65,4629.47,percent of total billed charges,
ALLODERM 1CM FOR 4X12CM,7697299,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2741.60,6220.89,percent of total billed charges,
ALLODERM 1CM FOR 4X12CM,7697299,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,124.65,6220.89,percent of total billed charges,
ALLODERM 1CM FOR 4X12CM,7736636,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,2741.60,6220.89,percent of total billed charges,
ALLODERM 1CM FOR 4X12CM,7736636,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,First Health,,6220.89,,,,,,,124.65,6220.89,percent of total billed charges,
STRATTICE,7700823,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,17432.50000,5055.42000,Aetna,First Health,,14259.78,,,,,,,6284.42,14259.78,percent of total billed charges,
STRATTICE,7700823,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,17432.50000,5055.42000,Aetna,First Health,,14259.78,,,,,,,124.65,14259.78,percent of total billed charges,
STRATTICE,7700824,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,30136.50000,8739.58000,Aetna,First Health,,24651.66,,,,,,,10864.21,24651.66,percent of total billed charges,
STRATTICE,7700824,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,30136.50000,8739.58000,Aetna,First Health,,24651.66,,,,,,,124.65,24651.66,percent of total billed charges,
NERVE GUIDE,7696719,CDM,636,RC,C9352,HCPCS,,,facility,inpatient,,,9672.30000,2804.97000,Aetna,First Health,,7911.94,,,,,,,3486.86,7911.94,percent of total billed charges,
NERVE GUIDE,7696719,CDM,636,RC,C9352,HCPCS,,,facility,outpatient,,,9672.30000,2804.97000,Aetna,First Health,,7911.94,,,,,,,3486.86,7911.94,percent of total billed charges,
NERVE GUIDE,7696720,CDM,636,RC,C9352,HCPCS,,,facility,inpatient,,,9672.30000,2804.97000,Aetna,First Health,,7911.94,,,,,,,3486.86,7911.94,percent of total billed charges,
NERVE GUIDE,7696720,CDM,636,RC,C9352,HCPCS,,,facility,outpatient,,,9672.30000,2804.97000,Aetna,First Health,,7911.94,,,,,,,3486.86,7911.94,percent of total billed charges,
NERVE GUIDE,7696721,CDM,636,RC,C9352,HCPCS,,,facility,inpatient,,,9672.30000,2804.97000,Aetna,First Health,,7911.94,,,,,,,3486.86,7911.94,percent of total billed charges,
NERVE GUIDE,7696721,CDM,636,RC,C9352,HCPCS,,,facility,outpatient,,,9672.30000,2804.97000,Aetna,First Health,,7911.94,,,,,,,3486.86,7911.94,percent of total billed charges,
NERVE PROTECTOR,7903796,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
NERVE PROTECTOR,7903796,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
NERVE PROTECTOR,7903797,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
NERVE PROTECTOR,7903797,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
NERVE PROTECTOR,7903798,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
NERVE PROTECTOR,7903798,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
NERVE PROTECTOR,7903799,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
NERVE PROTECTOR,7903799,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,First Health,,5439.70,,,,,,,2397.32,5439.70,percent of total billed charges,
NERVE PROTECTOR,7903801,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,11448.00000,3319.92000,Aetna,First Health,,9364.46,,,,,,,4127.00,9364.46,percent of total billed charges,
NERVE PROTECTOR,7903801,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,11448.00000,3319.92000,Aetna,First Health,,9364.46,,,,,,,4127.00,9364.46,percent of total billed charges,
NERVE PROTECTOR,7903802,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2968.72,6736.23,percent of total billed charges,
NERVE PROTECTOR,7903802,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,First Health,,6736.23,,,,,,,2968.72,6736.23,percent of total billed charges,
NERVE PROTECTOR,7903803,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,9525.00000,2762.25000,Aetna,First Health,,7791.45,,,,,,,3433.76,7791.45,percent of total billed charges,
NERVE PROTECTOR,7903803,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,9525.00000,2762.25000,Aetna,First Health,,7791.45,,,,,,,3433.76,7791.45,percent of total billed charges,
NERVE WRAP,7707509,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,9739.80000,2824.54000,Aetna,First Health,,7967.16,,,,,,,3511.20,7967.16,percent of total billed charges,
NERVE WRAP,7707509,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,9739.80000,2824.54000,Aetna,First Health,,7967.16,,,,,,,3511.20,7967.16,percent of total billed charges,
BONE PUTTY,7694891,CDM,636,RC,C9359,HCPCS,,,facility,inpatient,,,2648.00000,767.92000,Aetna,First Health,,2166.06,,,,,,,954.60,2166.06,percent of total billed charges,
BONE PUTTY,7694891,CDM,636,RC,C9359,HCPCS,,,facility,outpatient,,,2648.00000,767.92000,Aetna,First Health,,2166.06,,,,,,,954.60,2166.06,percent of total billed charges,
NERVE CONNECT,7903774,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,8832.00000,2561.28000,Aetna,First Health,,7224.58,,,,,,,3183.94,7224.58,percent of total billed charges,
NERVE CONNECT,7903774,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,8832.00000,2561.28000,Aetna,First Health,,7224.58,,,,,,,3183.94,7224.58,percent of total billed charges,
NERVE CONNECT,7903775,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,8832.00000,2561.28000,Aetna,First Health,,7224.58,,,,,,,3183.94,7224.58,percent of total billed charges,
NERVE CONNECT,7903775,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,8832.00000,2561.28000,Aetna,First Health,,7224.58,,,,,,,3183.94,7224.58,percent of total billed charges,
ALLODERM 1CM FOR 6X12CM,7982869,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,10281.00000,2981.49000,Aetna,First Health,,8409.86,,,,,,,3706.30,8409.86,percent of total billed charges,
ALLODERM 1CM FOR 6X12CM,7982869,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,10281.00000,2981.49000,Aetna,First Health,,8409.86,,,,,,,124.65,8409.86,percent of total billed charges,
TISSUE ALLODERM,8124397,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,36816.75000,10676.86000,Aetna,First Health,,30116.10,,,,,,,13272.44,30116.10,percent of total billed charges,
TISSUE ALLODERM,8124397,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,36816.75000,10676.86000,Aetna,First Health,,30116.10,,,,,,,124.65,30116.10,percent of total billed charges,
ACELLULAR DERMIS,8170966,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,7559.10000,2192.14000,Aetna,First Health,,6183.34,,,,,,,2725.06,6183.34,percent of total billed charges,
ACELLULAR DERMIS,8170966,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,7559.10000,2192.14000,Aetna,First Health,,6183.34,,,,,,,124.65,6183.34,percent of total billed charges,
MESH,8228673,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,30831.75000,8941.21000,Aetna,First Health,,25220.37,,,,,,,11114.85,25220.37,percent of total billed charges,
MESH,8228673,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,30831.75000,8941.21000,Aetna,First Health,,25220.37,,,,,,,124.65,25220.37,percent of total billed charges,
MESH,8228674,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,44313.75000,12850.99000,Aetna,First Health,,36248.65,,,,,,,15975.11,36248.65,percent of total billed charges,
MESH,8228674,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,44313.75000,12850.99000,Aetna,First Health,,36248.65,,,,,,,124.65,36248.65,percent of total billed charges,
ALLODERM 1CM,8145963,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,38133.00000,11058.57000,Aetna,First Health,,31192.79,,,,,,,13746.95,31192.79,percent of total billed charges,
ALLODERM 1CM,8145963,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,38133.00000,11058.57000,Aetna,First Health,,31192.79,,,,,,,124.65,31192.79,percent of total billed charges,
NERVE CONNECT,7903765,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903765,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903766,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903766,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903767,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903767,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903768,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903768,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903769,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903769,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903770,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903770,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,First Health,,3492.86,,,,,,,1539.34,3492.86,percent of total billed charges,
NERVE CONNECT,7903772,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,5250.00000,1522.50000,Aetna,First Health,,4294.50,,,,,,,1892.62,4294.50,percent of total billed charges,
NERVE CONNECT,7903772,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,5250.00000,1522.50000,Aetna,First Health,,4294.50,,,,,,,1892.62,4294.50,percent of total billed charges,
NERVE CONNECT,7903773,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,8832.00000,2561.28000,Aetna,First Health,,7224.58,,,,,,,3183.94,7224.58,percent of total billed charges,
NERVE CONNECT,7903773,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,8832.00000,2561.28000,Aetna,First Health,,7224.58,,,,,,,3183.94,7224.58,percent of total billed charges,
IMPLANT NERVE CONN,7903776,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,5250.00000,1522.50000,Aetna,First Health,,4294.50,,,,,,,1892.62,4294.50,percent of total billed charges,
IMPLANT NERVE CONN,7903776,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,5250.00000,1522.50000,Aetna,First Health,,4294.50,,,,,,,1892.62,4294.50,percent of total billed charges,
NERVE CONNECT,7903777,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,5250.00000,1522.50000,Aetna,First Health,,4294.50,,,,,,,1892.62,4294.50,percent of total billed charges,
NERVE CONNECT,7903777,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,5250.00000,1522.50000,Aetna,First Health,,4294.50,,,,,,,1892.62,4294.50,percent of total billed charges,
PUTTY,8478440,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
PUTTY,8478440,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,First Health,,2323.12,,,,,,,1023.82,2323.12,percent of total billed charges,
putty,8478441,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
putty,8478441,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,First Health,,4795.52,,,,,,,2113.43,4795.52,percent of total billed charges,
NERVE WRAP,9024733,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,7933.95000,2300.85000,Aetna,First Health,,6489.97,,,,,,,2860.19,6489.97,percent of total billed charges,
NERVE WRAP,9024733,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,7933.95000,2300.85000,Aetna,First Health,,6489.97,,,,,,,2860.19,6489.97,percent of total billed charges,
NERVE WRAP,9024737,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,8859.60000,2569.28000,Aetna,First Health,,7247.15,,,,,,,3193.89,7247.15,percent of total billed charges,
NERVE WRAP,9024737,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,8859.60000,2569.28000,Aetna,First Health,,7247.15,,,,,,,3193.89,7247.15,percent of total billed charges,
NERVE WRAP,9024734,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,7933.95000,2300.85000,Aetna,First Health,,6489.97,,,,,,,2860.19,6489.97,percent of total billed charges,
NERVE WRAP,9024734,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,7933.95000,2300.85000,Aetna,First Health,,6489.97,,,,,,,2860.19,6489.97,percent of total billed charges,
NERVE WRAP,9024735,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,10030.05000,2908.71000,Aetna,First Health,,8204.58,,,,,,,3615.83,8204.58,percent of total billed charges,
NERVE WRAP,9024735,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,10030.05000,2908.71000,Aetna,First Health,,8204.58,,,,,,,3615.83,8204.58,percent of total billed charges,
NERVE WRAP,9024736,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,7933.95000,2300.85000,Aetna,First Health,,6489.97,,,,,,,2860.19,6489.97,percent of total billed charges,
NERVE WRAP,9024736,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,7933.95000,2300.85000,Aetna,First Health,,6489.97,,,,,,,2860.19,6489.97,percent of total billed charges,
SEALANT,8182180,CDM,636,RC,C9250,HCPCS,,,facility,inpatient,,,837.32000,242.82000,Aetna,First Health,,684.93,,,,,,,301.85,684.93,percent of total billed charges,
SEALANT,8182180,CDM,636,RC,C9250,HCPCS,,,facility,outpatient,,,837.32000,242.82000,Aetna,First Health,,684.93,,,,,,,142.48,824.94,percent of total billed charges,
SEALANT,8182192,CDM,636,RC,C9250,HCPCS,,,facility,inpatient,,,1972.08000,571.90000,Aetna,First Health,,1613.16,,,,,,,710.93,1613.16,percent of total billed charges,
SEALANT,8182192,CDM,636,RC,C9250,HCPCS,,,facility,outpatient,,,1972.08000,571.90000,Aetna,First Health,,1613.16,,,,,,,142.48,1613.16,percent of total billed charges,
Apligraft 1 Sq Cm Used,2330824,CDM,636,RC,Q4101,HCPCS,,,facility,inpatient,,,101.00000,29.29000,Aetna,First Health,,82.62,,,,,,,36.41,82.62,percent of total billed charges,
Apligraft 1 Sq Cm Used,2330824,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,101.00000,29.29000,Aetna,First Health,,82.62,,,,,,,37.37,128.39,percent of total billed charges,
Apligraft 1 Sq Cm Used,7958341,CDM,636,RC,Q4101,HCPCS,,,facility,inpatient,,,101.00000,29.29000,Aetna,First Health,,82.62,,,,,,,36.41,82.62,percent of total billed charges,
Apligraft 1 Sq Cm Used,7958341,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,101.00000,29.29000,Aetna,First Health,,82.62,,,,,,,37.37,128.39,percent of total billed charges,
Primatrix Per Sq Cm,7417871,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,298.00000,86.42000,Aetna,First Health,,243.76,,,,,,,107.43,243.76,percent of total billed charges,
Primatrix Per Sq Cm,7417871,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,298.00000,86.42000,Aetna,First Health,,243.76,,,,,,,110.26,243.76,percent of total billed charges,
Kerecis 1 Sq Cm Used,7940831,CDM,636,RC,Q4158,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,86.88,197.14,percent of total billed charges,
Kerecis 1 Sq Cm Used,7940831,CDM,636,RC,Q4158,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,89.17,197.14,percent of total billed charges,
Kerecis 1 Sq Cm Used,7958353,CDM,636,RC,Q4158,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,86.88,197.14,percent of total billed charges,
Kerecis 1 Sq Cm Used,7958353,CDM,636,RC,Q4158,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,89.17,197.14,percent of total billed charges,
KERECIS 1 SQ CM USED,7958356,CDM,636,RC,Q4158,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,86.88,197.14,percent of total billed charges,
KERECIS 1 SQ CM USED,7958356,CDM,636,RC,Q4158,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,First Health,,197.14,,,,,,,89.17,197.14,percent of total billed charges,
Omnigraft 1 sqcm Used,8411612,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,460.00000,133.40000,Aetna,First Health,,376.28,,,,,,,165.83,376.28,percent of total billed charges,
Omnigraft 1 sqcm Used,8411612,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,460.00000,133.40000,Aetna,First Health,,376.28,,,,,,,55.68,376.28,percent of total billed charges,
Omnigraft per 1sqcm Used,8411836,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,460.00000,133.40000,Aetna,First Health,,376.28,,,,,,,165.83,376.28,percent of total billed charges,
Omnigraft per 1sqcm Used,8411836,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,460.00000,133.40000,Aetna,First Health,,376.28,,,,,,,55.68,376.28,percent of total billed charges,
NM THYROGEN SINGLE DOSE,607176,CDM,636,RC,J3240,HCPCS,,,facility,inpatient,,,7140.00000,2070.60000,Aetna,First Health,,5840.52,,,,,,,2573.97,5840.52,percent of total billed charges,
NM THYROGEN SINGLE DOSE,607176,CDM,636,RC,J3240,HCPCS,,,facility,outpatient,,,7140.00000,2070.60000,Aetna,First Health,,5840.52,,,,,,,2046.99,6555.47,percent of total billed charges,
NM CHOLECYSTOKINEN 5MCG,651559,CDM,636,RC,J2805,HCPCS,,,facility,inpatient,,,396.36000,114.94000,Aetna,First Health,,324.22,,,,,,,142.89,324.22,percent of total billed charges,
NM CHOLECYSTOKINEN 5MCG,651559,CDM,636,RC,J2805,HCPCS,,,facility,outpatient,,,396.36000,114.94000,Aetna,First Health,,324.22,,,,,,,106.06,339.64,percent of total billed charges,
Embolization,9158415,CDM,636,RC,,,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
Embolization,9158415,CDM,636,RC,,,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
Embolization,9160402,CDM,636,RC,,,,,facility,inpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
Embolization,9160402,CDM,636,RC,,,,,facility,outpatient,,,810.00000,234.90000,Aetna,First Health,,662.58,,,,,,,292.00,662.58,percent of total billed charges,
Embolization,9158411,CDM,636,RC,,,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,7029.75,15951.00,percent of total billed charges,
Embolization,9158411,CDM,636,RC,,,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,7029.75,15951.00,percent of total billed charges,
Embolization,9160400,CDM,636,RC,,,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
Embolization,9160400,CDM,636,RC,,,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
Embolization,9158413,CDM,636,RC,,,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,7029.75,15951.00,percent of total billed charges,
Embolization,9158413,CDM,636,RC,,,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,First Health,,15951.00,,,,,,,7029.75,15951.00,percent of total billed charges,
Embolization,9160398,CDM,636,RC,,,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
Embolization,9160398,CDM,636,RC,,,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,First Health,,8589.00,,,,,,,3785.25,8589.00,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,8724036,CDM,636,RC,J0780,HCPCS,,,facility,inpatient,,,35.48000,10.29000,Aetna,First Health,,29.02,,,,,,,12.79,29.02,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,8724036,CDM,636,RC,J0780,HCPCS,,,facility,outpatient,,,35.48000,10.29000,Aetna,First Health,,29.02,,,,,,,2.43,29.02,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,8724382,CDM,636,RC,J7517,HCPCS,,,facility,inpatient,,,11.37000,3.30000,Aetna,First Health,,9.30,,,,,,,4.10,9.30,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,8724382,CDM,636,RC,J7517,HCPCS,,,facility,outpatient,,,11.37000,3.30000,Aetna,First Health,,9.30,,,,,,,0.14445,9.30,percent of total billed charges,
Linezolid 600mg P,8723689,CDM,636,RC,J2020,HCPCS,,,facility,inpatient,,,481.17000,139.54000,Aetna,First Health,,393.60,,,,,,,173.46,393.60,percent of total billed charges,
Linezolid 600mg P,8723689,CDM,636,RC,J2020,HCPCS,,,facility,outpatient,,,481.17000,139.54000,Aetna,First Health,,393.60,,,,,,,2.64,393.60,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,8723407,CDM,636,RC,J1327,HCPCS,,,facility,inpatient,,,187.52000,54.38000,Aetna,First Health,,153.39,,,,,,,67.60,153.39,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,8723407,CDM,636,RC,J1327,HCPCS,,,facility,outpatient,,,187.52000,54.38000,Aetna,First Health,,153.39,,,,,,,3.52,153.39,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),8724204,CDM,636,RC,J2469,HCPCS,,,facility,inpatient,,,160.58000,46.57000,Aetna,First Health,,131.35,,,,,,,57.89,131.35,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),8724204,CDM,636,RC,J2469,HCPCS,,,facility,outpatient,,,160.58000,46.57000,Aetna,First Health,,131.35,,,,,,,0.33705,131.35,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),8724290,CDM,636,RC,J0706,HCPCS,,,facility,inpatient,,,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,82.55,187.32,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),8724290,CDM,636,RC,J0706,HCPCS,,,facility,outpatient,,,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,1.40,187.32,percent of total billed charges,
Bortezomib 3.5mg Inj,8724142,CDM,636,RC,J9041,HCPCS,,,facility,inpatient,,,531.49000,154.13000,Aetna,First Health,,434.76,,,,,,,191.60,434.76,percent of total billed charges,
Bortezomib 3.5mg Inj,8724142,CDM,636,RC,J9041,HCPCS,,,facility,outpatient,,,531.49000,154.13000,Aetna,First Health,,434.76,,,,,,,2.58,434.76,percent of total billed charges,
Methacholine Challenge Kit,8724337,CDM,636,RC,J7674,HCPCS,,,facility,inpatient,,,3613.45000,1047.90000,Aetna,First Health,,2955.80,,,,,,,1302.65,2955.80,percent of total billed charges,
Methacholine Challenge Kit,8724337,CDM,636,RC,J7674,HCPCS,,,facility,outpatient,,,3613.45000,1047.90000,Aetna,First Health,,2955.80,,,,,,,1.83,2955.80,percent of total billed charges,
DAPTOmycin 500 mg Inj,8724270,CDM,636,RC,J0878,HCPCS,,,facility,inpatient,,,476.98000,138.32000,Aetna,First Health,,390.17,,,,,,,171.95,390.17,percent of total billed charges,
DAPTOmycin 500 mg Inj,8724270,CDM,636,RC,J0878,HCPCS,,,facility,outpatient,,,476.98000,138.32000,Aetna,First Health,,390.17,,,,,,,0.02889,390.17,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),8723849,CDM,636,RC,J0360,HCPCS,,,facility,inpatient,,,90.26000,26.18000,Aetna,First Health,,73.83,,,,,,,32.54,73.83,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),8723849,CDM,636,RC,J0360,HCPCS,,,facility,outpatient,,,90.26000,26.18000,Aetna,First Health,,73.83,,,,,,,4.23,73.83,percent of total billed charges,
acetaZOLAMIDE 500mg I,8724111,CDM,636,RC,J1120,HCPCS,,,facility,inpatient,,,399.64000,115.90000,Aetna,First Health,,326.91,,,,,,,144.07,326.91,percent of total billed charges,
acetaZOLAMIDE 500mg I,8724111,CDM,636,RC,J1120,HCPCS,,,facility,outpatient,,,399.64000,115.90000,Aetna,First Health,,326.91,,,,,,,24.64,326.91,percent of total billed charges,
Calcium Gluconate 1g/10mL I,8723427,CDM,636,RC,J0612,HCPCS,,,facility,inpatient,,,101.42000,29.41000,Aetna,First Health,,82.96,,,,,,,36.56,82.96,percent of total billed charges,
Calcium Gluconate 1g/10mL I,8723427,CDM,636,RC,J0612,HCPCS,,,facility,outpatient,,,101.42000,29.41000,Aetna,First Health,,82.96,,,,,,,0.02889,82.96,percent of total billed charges,
Fluorouracil 500mg/10mL I,8723452,CDM,636,RC,J9190,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.04,61.35,percent of total billed charges,
Fluorouracil 500mg/10mL I,8723452,CDM,636,RC,J9190,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,1.87,61.35,percent of total billed charges,
Glucagon 1mg/1mL Inj,8725579,CDM,636,RC,J1610,HCPCS,,,facility,inpatient,,,1155.32000,335.04000,Aetna,First Health,,945.05,,,,,,,416.49,945.05,percent of total billed charges,
Glucagon 1mg/1mL Inj,8725579,CDM,636,RC,J1610,HCPCS,,,facility,outpatient,,,1155.32000,335.04000,Aetna,First Health,,945.05,,,,,,,158.76,945.05,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),8725523,CDM,636,RC,J1740,HCPCS,,,facility,inpatient,,,1862.37000,540.09000,Aetna,First Health,,1523.42,,,,,,,671.38,1523.42,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),8725523,CDM,636,RC,J1740,HCPCS,,,facility,outpatient,,,1862.37000,540.09000,Aetna,First Health,,1523.42,,,,,,,12.65,1523.42,percent of total billed charges,
Abatacept 250mg I(Orencia),8724477,CDM,636,RC,J0129,HCPCS,,,facility,inpatient,,,11216.23000,3252.71000,Aetna,First Health,,9174.88,,,,,,,4043.45,9174.88,percent of total billed charges,
Abatacept 250mg I(Orencia),8724477,CDM,636,RC,J0129,HCPCS,,,facility,outpatient,,,11216.23000,3252.71000,Aetna,First Health,,9174.88,,,,,,,43.11,9174.88,percent of total billed charges,
Tetanus IG 250U I(Bay-Tet),8723983,CDM,636,RC,J1670,HCPCS,,,facility,inpatient,,,2406.70000,697.94000,Aetna,First Health,,1968.68,,,,,,,867.62,1968.68,percent of total billed charges,
Tetanus IG 250U I(Bay-Tet),8723983,CDM,636,RC,J1670,HCPCS,,,facility,outpatient,,,2406.70000,697.94000,Aetna,First Health,,1968.68,,,,,,,566.76,1968.68,percent of total billed charges,
NS 250 mL,8723687,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,100.34000,29.10000,Aetna,First Health,,82.08,,,,,,,36.17,82.08,percent of total billed charges,
NS 250 mL,8723687,CDM,636,RC,J7050,HCPCS,,,facility,outpatient,,,100.34000,29.10000,Aetna,First Health,,82.08,,,,,,,0.63558,82.08,percent of total billed charges,
NS 50mL,8723597,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
NS 50mL,8723597,CDM,636,RC,J7050,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,0.63558,40.90,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),8724476,CDM,636,RC,J1953,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),8724476,CDM,636,RC,J1953,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,0.03852,40.90,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),8724693,CDM,636,RC,J3486,HCPCS,,,facility,inpatient,,,209.89000,60.87000,Aetna,First Health,,171.69,,,,,,,75.67,171.69,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),8724693,CDM,636,RC,J3486,HCPCS,,,facility,outpatient,,,209.89000,60.87000,Aetna,First Health,,171.69,,,,,,,8.81,171.69,percent of total billed charges,
Dexrazoxane 500mg Inj,8724687,CDM,636,RC,J1190,HCPCS,,,facility,inpatient,,,3059.80000,887.34000,Aetna,First Health,,2502.92,,,,,,,1103.06,2502.92,percent of total billed charges,
Dexrazoxane 500mg Inj,8724687,CDM,636,RC,J1190,HCPCS,,,facility,outpatient,,,3059.80000,887.34000,Aetna,First Health,,2502.92,,,,,,,55.86,2502.92,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),8724836,CDM,636,RC,J3489,HCPCS,,,facility,inpatient,,,423.00000,122.67000,Aetna,First Health,,346.01,,,,,,,152.49,346.01,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),8724836,CDM,636,RC,J3489,HCPCS,,,facility,outpatient,,,423.00000,122.67000,Aetna,First Health,,346.01,,,,,,,4.89,346.01,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,8724822,CDM,636,RC,J3489,HCPCS,,,facility,inpatient,,,2818.80000,817.45000,Aetna,First Health,,2305.78,,,,,,,1016.18,2305.78,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,8724822,CDM,636,RC,J3489,HCPCS,,,facility,outpatient,,,2818.80000,817.45000,Aetna,First Health,,2305.78,,,,,,,4.89,2305.78,percent of total billed charges,
Meropenem 1g I (Merrem),8724818,CDM,636,RC,J2185,HCPCS,,,facility,inpatient,,,56.73000,16.45000,Aetna,First Health,,46.41,,,,,,,20.45,46.41,percent of total billed charges,
Meropenem 1g I (Merrem),8724818,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,,,56.73000,16.45000,Aetna,First Health,,46.41,,,,,,,0.36594,46.41,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,8724441,CDM,636,RC,J1652,HCPCS,,,facility,inpatient,,,290.30000,84.19000,Aetna,First Health,,237.47,,,,,,,104.65,237.47,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,8724441,CDM,636,RC,J1652,HCPCS,,,facility,outpatient,,,290.30000,84.19000,Aetna,First Health,,237.47,,,,,,,0.84744,237.47,percent of total billed charges,
romiPLOStim 250mcg Inj,8724902,CDM,636,RC,J2802,HCPCS,,,facility,inpatient,,,11158.05000,3235.83000,Aetna,First Health,,9127.28,,,,,,,4022.48,9127.28,percent of total billed charges,
romiPLOStim 250mcg Inj,8724902,CDM,636,RC,J2802,HCPCS,,,facility,outpatient,,,11158.05000,3235.83000,Aetna,First Health,,9127.28,,,,,,,10.64,9127.28,percent of total billed charges,
NS 100mL(Mini-Bag+),8723638,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,67.07000,19.45000,Aetna,First Health,,54.86,,,,,,,24.18,54.86,percent of total billed charges,
NS 100mL(Mini-Bag+),8723638,CDM,636,RC,J7050,HCPCS,,,facility,outpatient,,,67.07000,19.45000,Aetna,First Health,,54.86,,,,,,,0.63558,54.86,percent of total billed charges,
Sodium Chloride 3% IVPB 250mL,8724011,CDM,636,RC,J7131,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Sodium Chloride 3% IVPB 250mL,8724011,CDM,636,RC,J7131,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,0.14445,81.80,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),8724917,CDM,636,RC,J2785,HCPCS,,,facility,inpatient,,,1187.00000,344.23000,Aetna,First Health,,970.97,,,,,,,427.91,970.97,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),8724917,CDM,636,RC,J2785,HCPCS,,,facility,outpatient,,,1187.00000,344.23000,Aetna,First Health,,970.97,,,,,,,2.58,970.97,percent of total billed charges,
DOPamine 400mg/D5W 250mL,8723999,CDM,636,RC,J1265,HCPCS,,,facility,inpatient,,,144.90000,42.02000,Aetna,First Health,,118.53,,,,,,,52.24,118.53,percent of total billed charges,
DOPamine 400mg/D5W 250mL,8723999,CDM,636,RC,J1265,HCPCS,,,facility,outpatient,,,144.90000,42.02000,Aetna,First Health,,118.53,,,,,,,0.77040,118.53,percent of total billed charges,
azaCITIDine 100mg Inj,8724713,CDM,636,RC,J9025,HCPCS,,,facility,inpatient,,,2966.30000,860.23000,Aetna,First Health,,2426.43,,,,,,,1069.35,2426.43,percent of total billed charges,
azaCITIDine 100mg Inj,8724713,CDM,636,RC,J9025,HCPCS,,,facility,outpatient,,,2966.30000,860.23000,Aetna,First Health,,2426.43,,,,,,,0.44298,2426.43,percent of total billed charges,
Iron Dextran 100mg/2mL I(Infed),8724027,CDM,636,RC,J1750,HCPCS,,,facility,inpatient,,,558.67000,162.01000,Aetna,First Health,,456.99,,,,,,,201.40,456.99,percent of total billed charges,
Iron Dextran 100mg/2mL I(Infed),8724027,CDM,636,RC,J1750,HCPCS,,,facility,outpatient,,,558.67000,162.01000,Aetna,First Health,,456.99,,,,,,,17.41,456.99,percent of total billed charges,
levoFLOXacin  750mg/150mL P,8724502,CDM,636,RC,J1956,HCPCS,,,facility,inpatient,,,77.19000,22.39000,Aetna,First Health,,63.14,,,,,,,27.83,63.14,percent of total billed charges,
levoFLOXacin  750mg/150mL P,8724502,CDM,636,RC,J1956,HCPCS,,,facility,outpatient,,,77.19000,22.39000,Aetna,First Health,,63.14,,,,,,,2.08,63.14,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),8723448,CDM,636,RC,J2597,HCPCS,,,facility,inpatient,,,5787.53000,1678.38000,Aetna,First Health,,4734.20,,,,,,,2086.40,4734.20,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),8723448,CDM,636,RC,J2597,HCPCS,,,facility,outpatient,,,5787.53000,1678.38000,Aetna,First Health,,4734.20,,,,,,,3.28,4734.20,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,8724282,CDM,636,RC,J9264,HCPCS,,,facility,inpatient,,,7866.10000,2281.17000,Aetna,First Health,,6434.47,,,,,,,2835.73,6434.47,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,8724282,CDM,636,RC,J9264,HCPCS,,,facility,outpatient,,,7866.10000,2281.17000,Aetna,First Health,,6434.47,,,,,,,7.88,6434.47,percent of total billed charges,
Goserelin 10.8 mg Impl,8724420,CDM,636,RC,J9202,HCPCS,,,facility,inpatient,,,8294.30000,2405.35000,Aetna,First Health,,6784.74,,,,,,,2990.10,6784.74,percent of total billed charges,
Goserelin 10.8 mg Impl,8724420,CDM,636,RC,J9202,HCPCS,,,facility,outpatient,,,8294.30000,2405.35000,Aetna,First Health,,6784.74,,,,,,,748.73,6784.74,percent of total billed charges,
Bendamustine 100mg I(Treanda),8724842,CDM,636,RC,J9033,HCPCS,,,facility,inpatient,,,3157.00000,915.53000,Aetna,First Health,,2582.43,,,,,,,1138.10,2582.43,percent of total billed charges,
Bendamustine 100mg I(Treanda),8724842,CDM,636,RC,J9033,HCPCS,,,facility,outpatient,,,3157.00000,915.53000,Aetna,First Health,,2582.43,,,,,,,1.97,2582.43,percent of total billed charges,
Vancomycin HCl 1g Inj,8723994,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,,,88.76000,25.74000,Aetna,First Health,,72.61,,,,,,,32.00,72.61,percent of total billed charges,
Vancomycin HCl 1g Inj,8723994,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,,,88.76000,25.74000,Aetna,First Health,,72.61,,,,,,,0.02889,72.61,percent of total billed charges,
"NS 1,000mL",8723973,CDM,636,RC,J7030,HCPCS,,,facility,inpatient,,,100.04000,29.01000,Aetna,First Health,,81.83,,,,,,,36.06,81.83,percent of total billed charges,
"NS 1,000mL",8723973,CDM,636,RC,J7030,HCPCS,,,facility,outpatient,,,100.04000,29.01000,Aetna,First Health,,81.83,,,,,,,1.92,81.83,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,8723525,CDM,636,RC,J2590,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,8723525,CDM,636,RC,J2590,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,1.00,20.45,percent of total billed charges,
DOBUTamine 250mg/D5W 250mL,8724254,CDM,636,RC,J1250,HCPCS,,,facility,inpatient,,,230.35000,66.80000,Aetna,First Health,,188.43,,,,,,,83.04,188.43,percent of total billed charges,
DOBUTamine 250mg/D5W 250mL,8724254,CDM,636,RC,J1250,HCPCS,,,facility,outpatient,,,230.35000,66.80000,Aetna,First Health,,188.43,,,,,,,7.72,188.43,percent of total billed charges,
NS 250mL PVC Free,8724365,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,102.04000,29.59000,Aetna,First Health,,83.47,,,,,,,36.79,83.47,percent of total billed charges,
NS 250mL PVC Free,8724365,CDM,636,RC,J7050,HCPCS,,,facility,outpatient,,,102.04000,29.59000,Aetna,First Health,,83.47,,,,,,,0.63558,83.47,percent of total billed charges,
NS 100mL,8723637,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,50.41000,14.62000,Aetna,First Health,,41.24,,,,,,,18.17,41.24,percent of total billed charges,
NS 100mL,8723637,CDM,636,RC,J7050,HCPCS,,,facility,outpatient,,,50.41000,14.62000,Aetna,First Health,,41.24,,,,,,,0.63558,41.24,percent of total billed charges,
Acyclovir 50mg/mL Inj 20mL,8725520,CDM,636,RC,J0133,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,85.80,194.68,percent of total billed charges,
Acyclovir 50mg/mL Inj 20mL,8725520,CDM,636,RC,J0133,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,0.11556,194.68,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),8724371,CDM,636,RC,J1756,HCPCS,,,facility,inpatient,,,563.09000,163.30000,Aetna,First Health,,460.61,,,,,,,202.99,460.61,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),8724371,CDM,636,RC,J1756,HCPCS,,,facility,outpatient,,,563.09000,163.30000,Aetna,First Health,,460.61,,,,,,,0.23112,460.61,percent of total billed charges,
NICU- Oxacillin 100mg/mL IV Infusion,8725013,CDM,636,RC,J2700,HCPCS,,,facility,inpatient,,,112.15000,32.52000,Aetna,First Health,,91.74,,,,,,,40.43,91.74,percent of total billed charges,
NICU- Oxacillin 100mg/mL IV Infusion,8725013,CDM,636,RC,J2700,HCPCS,,,facility,outpatient,,,112.15000,32.52000,Aetna,First Health,,91.74,,,,,,,0.54891,91.74,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",8725006,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,100.10000,29.03000,Aetna,First Health,,81.88,,,,,,,36.09,81.88,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",8725006,CDM,636,RC,J1644,HCPCS,,,facility,outpatient,,,100.10000,29.03000,Aetna,First Health,,81.88,,,,,,,0.17334,81.88,percent of total billed charges,
Lidocaine 2g / D5W 250mL,8723686,CDM,636,RC,J2002,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Lidocaine 2g / D5W 250mL,8723686,CDM,636,RC,J2002,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,37.00,81.80,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,8724318,CDM,636,RC,J0132,HCPCS,,,facility,inpatient,,,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,335.26,760.74,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,8724318,CDM,636,RC,J0132,HCPCS,,,facility,outpatient,,,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,0.35631,760.74,percent of total billed charges,
methylPREDNISolone NaSucc 40mg PF Inj,8725812,CDM,636,RC,J2919,HCPCS,,,facility,inpatient,,,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,14.89,33.78,percent of total billed charges,
methylPREDNISolone NaSucc 40mg PF Inj,8725812,CDM,636,RC,J2919,HCPCS,,,facility,outpatient,,,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,0.25038,33.78,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,8724405,CDM,636,RC,J3475,HCPCS,,,facility,inpatient,,,80.42000,23.32000,Aetna,First Health,,65.78,,,,,,,28.99,65.78,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,8724405,CDM,636,RC,J3475,HCPCS,,,facility,outpatient,,,80.42000,23.32000,Aetna,First Health,,65.78,,,,,,,0.39483,65.78,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),8724275,CDM,636,RC,J0694,HCPCS,,,facility,inpatient,,,102.33000,29.68000,Aetna,First Health,,83.71,,,,,,,36.89,83.71,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),8724275,CDM,636,RC,J0694,HCPCS,,,facility,outpatient,,,102.33000,29.68000,Aetna,First Health,,83.71,,,,,,,4.56,83.71,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,8723821,CDM,636,RC,J2919,HCPCS,,,facility,inpatient,,,66.92000,19.41000,Aetna,First Health,,54.74,,,,,,,24.12,54.74,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,8723821,CDM,636,RC,J2919,HCPCS,,,facility,outpatient,,,66.92000,19.41000,Aetna,First Health,,54.74,,,,,,,0.25038,54.74,percent of total billed charges,
"Heparin I(10,000/10mL)",8723969,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
"Heparin I(10,000/10mL)",8723969,CDM,636,RC,J1644,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.17334,20.45,percent of total billed charges,
Furosemide 100mg I,8723430,CDM,636,RC,J1938,HCPCS,,,facility,inpatient,,,56.05000,16.25000,Aetna,First Health,,45.85,,,,,,,20.21,45.85,percent of total billed charges,
Furosemide 100mg I,8723430,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,,,56.05000,16.25000,Aetna,First Health,,45.85,,,,,,,0.01926,45.85,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,8723508,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,61.33000,17.79000,Aetna,First Health,,50.17,,,,,,,22.11,50.17,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,8723508,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,61.33000,17.79000,Aetna,First Health,,50.17,,,,,,,0.04815,50.17,percent of total billed charges,
ROPivacaine 0.2% Epidural,8723449,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,369.40000,107.13000,Aetna,First Health,,302.17,,,,,,,133.17,302.17,percent of total billed charges,
ROPivacaine 0.2% Epidural,8723449,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,369.40000,107.13000,Aetna,First Health,,302.17,,,,,,,0.04815,302.17,percent of total billed charges,
ROPivacaine 0.5% 30mL I,8723548,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,11.66,26.46,percent of total billed charges,
ROPivacaine 0.5% 30mL I,8723548,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,0.04815,26.46,percent of total billed charges,
levoFLOXacin  500mg/100mL P,8723628,CDM,636,RC,J1956,HCPCS,,,facility,inpatient,,,110.89000,32.16000,Aetna,First Health,,90.71,,,,,,,39.98,90.71,percent of total billed charges,
levoFLOXacin  500mg/100mL P,8723628,CDM,636,RC,J1956,HCPCS,,,facility,outpatient,,,110.89000,32.16000,Aetna,First Health,,90.71,,,,,,,2.08,90.71,percent of total billed charges,
KCl 10mEq / 100mL IVPB,8723631,CDM,636,RC,J3480,HCPCS,,,facility,inpatient,,,50.05000,14.51000,Aetna,First Health,,40.94,,,,,,,18.04,40.94,percent of total billed charges,
KCl 10mEq / 100mL IVPB,8723631,CDM,636,RC,J3480,HCPCS,,,facility,outpatient,,,50.05000,14.51000,Aetna,First Health,,40.94,,,,,,,0.11556,40.94,percent of total billed charges,
KCl 20mEq/Water 100mL,8723632,CDM,636,RC,J3480,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
KCl 20mEq/Water 100mL,8723632,CDM,636,RC,J3480,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,0.11556,40.90,percent of total billed charges,
DOBUTamine 1g/D5W 250mL,8723992,CDM,636,RC,J1250,HCPCS,,,facility,inpatient,,,291.07000,84.41000,Aetna,First Health,,238.10,,,,,,,104.93,238.10,percent of total billed charges,
DOBUTamine 1g/D5W 250mL,8723992,CDM,636,RC,J1250,HCPCS,,,facility,outpatient,,,291.07000,84.41000,Aetna,First Health,,238.10,,,,,,,7.72,238.10,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),8723676,CDM,636,RC,J1450,HCPCS,,,facility,inpatient,,,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,51.48,116.81,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),8723676,CDM,636,RC,J1450,HCPCS,,,facility,outpatient,,,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,4.31,116.81,percent of total billed charges,
Vancomycin HCl 1g /200mL  IVPB,8724496,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,102.02,231.49,percent of total billed charges,
Vancomycin HCl 1g /200mL  IVPB,8724496,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,0.02889,231.49,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,8724465,CDM,636,RC,J3475,HCPCS,,,facility,inpatient,,,130.80000,37.93000,Aetna,First Health,,106.99,,,,,,,47.15,106.99,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,8724465,CDM,636,RC,J3475,HCPCS,,,facility,outpatient,,,130.80000,37.93000,Aetna,First Health,,106.99,,,,,,,0.39483,106.99,percent of total billed charges,
Atropine 1mg/10mL IS,8723397,CDM,636,RC,J0461,HCPCS,,,facility,inpatient,,,58.26000,16.90000,Aetna,First Health,,47.66,,,,,,,21.00,47.66,percent of total billed charges,
Atropine 1mg/10mL IS,8723397,CDM,636,RC,J0461,HCPCS,,,facility,outpatient,,,58.26000,16.90000,Aetna,First Health,,47.66,,,,,,,0.09630,47.66,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,8723831,CDM,636,RC,J2919,HCPCS,,,facility,inpatient,,,1585.55000,459.81000,Aetna,First Health,,1296.98,,,,,,,571.59,1296.98,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,8723831,CDM,636,RC,J2919,HCPCS,,,facility,outpatient,,,1585.55000,459.81000,Aetna,First Health,,1296.98,,,,,,,0.25038,1296.98,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),8724112,CDM,636,RC,J1885,HCPCS,,,facility,inpatient,,,33.62000,9.75000,Aetna,First Health,,27.50,,,,,,,12.12,27.50,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),8724112,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,33.62000,9.75000,Aetna,First Health,,27.50,,,,,,,0.31779,27.50,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),8724356,CDM,636,RC,J2250,HCPCS,,,facility,inpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,12.62,28.63,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),8724356,CDM,636,RC,J2250,HCPCS,,,facility,outpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,0.13482,28.63,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,8725560,CDM,636,RC,J2710,HCPCS,,,facility,inpatient,,,105.16000,30.50000,Aetna,First Health,,86.02,,,,,,,37.91,86.02,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,8725560,CDM,636,RC,J2710,HCPCS,,,facility,outpatient,,,105.16000,30.50000,Aetna,First Health,,86.02,,,,,,,0.92448,86.02,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,8723829,CDM,636,RC,J2919,HCPCS,,,facility,inpatient,,,320.97000,93.08000,Aetna,First Health,,262.55,,,,,,,115.71,262.55,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,8723829,CDM,636,RC,J2919,HCPCS,,,facility,outpatient,,,320.97000,93.08000,Aetna,First Health,,262.55,,,,,,,0.25038,262.55,percent of total billed charges,
Potassium Cl 2mEq/mL I,8723498,CDM,636,RC,J3480,HCPCS,,,facility,inpatient,,,100.67000,29.19000,Aetna,First Health,,82.35,,,,,,,36.29,82.35,percent of total billed charges,
Potassium Cl 2mEq/mL I,8723498,CDM,636,RC,J3480,HCPCS,,,facility,outpatient,,,100.67000,29.19000,Aetna,First Health,,82.35,,,,,,,0.11556,82.35,percent of total billed charges,
Magnesium SO4 10g/20mL I,8723425,CDM,636,RC,J3475,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Magnesium SO4 10g/20mL I,8723425,CDM,636,RC,J3475,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,0.39483,81.80,percent of total billed charges,
Atropine SO4 1mg/mL 1mL I,8724028,CDM,636,RC,J0461,HCPCS,,,facility,inpatient,,,80.20000,23.26000,Aetna,First Health,,65.60,,,,,,,28.91,65.60,percent of total billed charges,
Atropine SO4 1mg/mL 1mL I,8724028,CDM,636,RC,J0461,HCPCS,,,facility,outpatient,,,80.20000,23.26000,Aetna,First Health,,65.60,,,,,,,0.09630,65.60,percent of total billed charges,
Aminophylline 500mg/20mL I,8723512,CDM,636,RC,J0280,HCPCS,,,facility,inpatient,,,118.92000,34.49000,Aetna,First Health,,97.28,,,,,,,42.87,97.28,percent of total billed charges,
Aminophylline 500mg/20mL I,8723512,CDM,636,RC,J0280,HCPCS,,,facility,outpatient,,,118.92000,34.49000,Aetna,First Health,,97.28,,,,,,,10.02,97.28,percent of total billed charges,
Factor VIIa I (NovoSeven RT),8725010,CDM,636,RC,J7189,HCPCS,,,facility,inpatient,,,19410.87000,5629.15000,Aetna,First Health,,15878.09,,,,,,,6997.62,15878.09,percent of total billed charges,
Factor VIIa I (NovoSeven RT),8725010,CDM,636,RC,J7189,HCPCS,,,facility,outpatient,,,19410.87000,5629.15000,Aetna,First Health,,15878.09,,,,,,,2.52,15878.09,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",8723434,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,41.49000,12.03000,Aetna,First Health,,33.94,,,,,,,14.96,33.94,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",8723434,CDM,636,RC,J1644,HCPCS,,,facility,outpatient,,,41.49000,12.03000,Aetna,First Health,,33.94,,,,,,,0.17334,33.94,percent of total billed charges,
ceFAZolin 1g/ Water Syr (Ancef),8725050,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,22.35,50.72,percent of total billed charges,
ceFAZolin 1g/ Water Syr (Ancef),8725050,CDM,636,RC,J0690,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,0.79929,50.72,percent of total billed charges,
ceFAZolin 2g/ Water  Syr (Ancef),8725049,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,95.00000,27.55000,Aetna,First Health,,77.71,,,,,,,34.25,77.71,percent of total billed charges,
ceFAZolin 2g/ Water  Syr (Ancef),8725049,CDM,636,RC,J0690,HCPCS,,,facility,outpatient,,,95.00000,27.55000,Aetna,First Health,,77.71,,,,,,,0.79929,77.71,percent of total billed charges,
"Epoetin 3,000 unit/mL Inj",8725038,CDM,636,RC,J0885,HCPCS,,,facility,inpatient,,,298.90000,86.68000,Aetna,First Health,,244.50,,,,,,,107.75,244.50,percent of total billed charges,
"Epoetin 3,000 unit/mL Inj",8725038,CDM,636,RC,J0885,HCPCS,,,facility,outpatient,,,298.90000,86.68000,Aetna,First Health,,244.50,,,,,,,7.45,244.50,percent of total billed charges,
"Heparin 30,000u/NS 1,030mL  P",8725043,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
"Heparin 30,000u/NS 1,030mL  P",8725043,CDM,636,RC,J1644,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,0.17334,81.80,percent of total billed charges,
chlorproMAZINE 25mg/mL 2mL I(Thoraz,8723854,CDM,636,RC,J3230,HCPCS,,,facility,inpatient,,,205.46000,59.58000,Aetna,First Health,,168.07,,,,,,,74.07,168.07,percent of total billed charges,
chlorproMAZINE 25mg/mL 2mL I(Thoraz,8723854,CDM,636,RC,J3230,HCPCS,,,facility,outpatient,,,205.46000,59.58000,Aetna,First Health,,168.07,,,,,,,22.89,168.07,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,8723503,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,8723503,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.00963,20.45,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",8723504,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,25.98000,7.53000,Aetna,First Health,,21.25,,,,,,,9.37,21.25,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",8723504,CDM,636,RC,J2004,HCPCS,,,facility,outpatient,,,25.98000,7.53000,Aetna,First Health,,21.25,,,,,,,0.00963,21.25,percent of total billed charges,
Lidocaine HCl 1% 50mL I,8723579,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,36.55000,10.60000,Aetna,First Health,,29.90,,,,,,,13.18,29.90,percent of total billed charges,
Lidocaine HCl 1% 50mL I,8723579,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,36.55000,10.60000,Aetna,First Health,,29.90,,,,,,,0.00963,29.90,percent of total billed charges,
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",8723580,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,83.15000,24.11000,Aetna,First Health,,68.02,,,,,,,29.98,68.02,percent of total billed charges,
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",8723580,CDM,636,RC,J2004,HCPCS,,,facility,outpatient,,,83.15000,24.11000,Aetna,First Health,,68.02,,,,,,,0.00963,68.02,percent of total billed charges,
Lidocaine HCl 2% 20mL I,8723505,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,9.66,21.92,percent of total billed charges,
Lidocaine HCl 2% 20mL I,8723505,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,0.00963,21.92,percent of total billed charges,
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",8723507,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,29.05000,8.42000,Aetna,First Health,,23.76,,,,,,,10.47,23.76,percent of total billed charges,
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",8723507,CDM,636,RC,J2004,HCPCS,,,facility,outpatient,,,29.05000,8.42000,Aetna,First Health,,23.76,,,,,,,0.00963,23.76,percent of total billed charges,
cycloPHOSphamide 500mg I,8724350,CDM,636,RC,J9075,HCPCS,,,facility,inpatient,,,3143.79000,911.70000,Aetna,First Health,,2571.62,,,,,,,1133.34,2571.62,percent of total billed charges,
cycloPHOSphamide 500mg I,8724350,CDM,636,RC,J9075,HCPCS,,,facility,outpatient,,,3143.79000,911.70000,Aetna,First Health,,2571.62,,,,,,,0.56817,2571.62,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,8723995,CDM,636,RC,J0165,HCPCS,,,facility,inpatient,,,95.55000,27.71000,Aetna,First Health,,78.16,,,,,,,34.45,78.16,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,8723995,CDM,636,RC,J0165,HCPCS,,,facility,outpatient,,,95.55000,27.71000,Aetna,First Health,,78.16,,,,,,,0.41409,78.16,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 500mL MDV,8725093,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 500mL MDV,8725093,CDM,636,RC,Q9967,HCPCS,,,facility,outpatient,,,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,0.14445,3.89,percent of total billed charges,
RAD- Iohexol 240mg/mL Inj 10mL,8725103,CDM,636,RC,Q9966,HCPCS,,,facility,inpatient,,,266.75000,77.36000,Aetna,First Health,,218.20,,,,,,,96.16,218.20,percent of total billed charges,
RAD- Iohexol 240mg/mL Inj 10mL,8725103,CDM,636,RC,Q9966,HCPCS,,,facility,outpatient,,,266.75000,77.36000,Aetna,First Health,,218.20,,,,,,,0.38520,218.20,percent of total billed charges,
Lacosamide 200mg/20mL I,8725007,CDM,636,RC,C9254,HCPCS,,,facility,inpatient,,,587.65000,170.42000,Aetna,First Health,,480.70,,,,,,,211.85,480.70,percent of total billed charges,
Lacosamide 200mg/20mL I,8725007,CDM,636,RC,C9254,HCPCS,,,facility,outpatient,,,587.65000,170.42000,Aetna,First Health,,480.70,,,,,,,0.37557,480.70,percent of total billed charges,
RAD- Iohexol 300mg/mL Inj 50mL,8724981,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,274.30000,79.55000,Aetna,First Health,,224.38,,,,,,,98.89,224.38,percent of total billed charges,
RAD- Iohexol 300mg/mL Inj 50mL,8724981,CDM,636,RC,Q9967,HCPCS,,,facility,outpatient,,,274.30000,79.55000,Aetna,First Health,,224.38,,,,,,,0.14445,224.38,percent of total billed charges,
RAD- iodixanol 270mg/mL I 50mL,8724982,CDM,636,RC,Q9966,HCPCS,,,facility,inpatient,,,293.25000,85.04000,Aetna,First Health,,239.88,,,,,,,105.72,239.88,percent of total billed charges,
RAD- iodixanol 270mg/mL I 50mL,8724982,CDM,636,RC,Q9966,HCPCS,,,facility,outpatient,,,293.25000,85.04000,Aetna,First Health,,239.88,,,,,,,0.38520,239.88,percent of total billed charges,
"Heparin 30,000 unit/30mL",8723554,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
"Heparin 30,000 unit/30mL",8723554,CDM,636,RC,J1644,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,0.17334,81.80,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),8724121,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,106.10000,30.77000,Aetna,First Health,,86.79,,,,,,,38.25,86.79,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),8724121,CDM,636,RC,J0690,HCPCS,,,facility,outpatient,,,106.10000,30.77000,Aetna,First Health,,86.79,,,,,,,0.79929,86.79,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),8723967,CDM,636,RC,J1938,HCPCS,,,facility,inpatient,,,26.85000,7.79000,Aetna,First Health,,21.96,,,,,,,9.68,21.96,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),8723967,CDM,636,RC,J1938,HCPCS,,,facility,outpatient,,,26.85000,7.79000,Aetna,First Health,,21.96,,,,,,,0.01926,21.96,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),8723390,CDM,636,RC,Q2009,HCPCS,,,facility,inpatient,,,243.85000,70.72000,Aetna,First Health,,199.47,,,,,,,87.91,199.47,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),8723390,CDM,636,RC,Q2009,HCPCS,,,facility,outpatient,,,243.85000,70.72000,Aetna,First Health,,199.47,,,,,,,1.34,199.47,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,8724353,CDM,636,RC,J9045,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.04,61.35,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,8724353,CDM,636,RC,J9045,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,2.82,61.35,percent of total billed charges,
Lidocaine HCl 1% 10mL IS PF - Anesthesia,8985542,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Lidocaine HCl 1% 10mL IS PF - Anesthesia,8985542,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.00963,20.45,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,8723946,CDM,636,RC,J7509,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,8723946,CDM,636,RC,J7509,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.13482,8.18,percent of total billed charges,
Gemcitabine 2000mg Inj,8994849,CDM,636,RC,J9201,HCPCS,,,facility,inpatient,,,632.10000,183.31000,Aetna,First Health,,517.06,,,,,,,227.87,517.06,percent of total billed charges,
Gemcitabine 2000mg Inj,8994849,CDM,636,RC,J9201,HCPCS,,,facility,outpatient,,,632.10000,183.31000,Aetna,First Health,,517.06,,,,,,,3.46,517.06,percent of total billed charges,
Ondansetron 4mg T(Zofran),8724794,CDM,636,RC,Q0162,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Ondansetron 4mg T(Zofran),8724794,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.00963,8.18,percent of total billed charges,
Fosaprepitant 150mg I (Emend),8724913,CDM,636,RC,J1453,HCPCS,,,facility,inpatient,,,477.54000,138.49000,Aetna,First Health,,390.63,,,,,,,172.15,390.63,percent of total billed charges,
Fosaprepitant 150mg I (Emend),8724913,CDM,636,RC,J1453,HCPCS,,,facility,outpatient,,,477.54000,138.49000,Aetna,First Health,,390.63,,,,,,,0.10593,390.63,percent of total billed charges,
Acetaminophen 1g/100mL Inj,8725196,CDM,636,RC,J0131,HCPCS,,,facility,inpatient,,,141.14000,40.93000,Aetna,First Health,,115.45,,,,,,,50.88,115.45,percent of total billed charges,
Acetaminophen 1g/100mL Inj,8725196,CDM,636,RC,J0131,HCPCS,,,facility,outpatient,,,141.14000,40.93000,Aetna,First Health,,115.45,,,,,,,0.05778,115.45,percent of total billed charges,
Mepivacaine 2% PF I 20mL,8725225,CDM,636,RC,J0670,HCPCS,,,facility,inpatient,,,33.35000,9.67000,Aetna,First Health,,27.28,,,,,,,12.02,27.28,percent of total billed charges,
Mepivacaine 2% PF I 20mL,8725225,CDM,636,RC,J0670,HCPCS,,,facility,outpatient,,,33.35000,9.67000,Aetna,First Health,,27.28,,,,,,,3.61,27.28,percent of total billed charges,
Immune Globulin 20g/200mL I,8724539,CDM,636,RC,J1569,HCPCS,,,facility,inpatient,,,25330.85000,7345.95000,Aetna,First Health,,20720.64,,,,,,,9131.77,20720.64,percent of total billed charges,
Immune Globulin 20g/200mL I,8724539,CDM,636,RC,J1569,HCPCS,,,facility,outpatient,,,25330.85000,7345.95000,Aetna,First Health,,20720.64,,,,,,,45.54,20720.64,percent of total billed charges,
levOCARNitine 200mg/1mL I 5mL Vial,8724714,CDM,636,RC,J1955,HCPCS,,,facility,inpatient,,,238.85000,69.27000,Aetna,First Health,,195.38,,,,,,,86.11,195.38,percent of total billed charges,
levOCARNitine 200mg/1mL I 5mL Vial,8724714,CDM,636,RC,J1955,HCPCS,,,facility,outpatient,,,238.85000,69.27000,Aetna,First Health,,195.38,,,,,,,22.41,195.38,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,8724685,CDM,636,RC,J1205,HCPCS,,,facility,inpatient,,,1376.05000,399.05000,Aetna,First Health,,1125.61,,,,,,,496.07,1125.61,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,8724685,CDM,636,RC,J1205,HCPCS,,,facility,outpatient,,,1376.05000,399.05000,Aetna,First Health,,1125.61,,,,,,,55.98,1125.61,percent of total billed charges,
Sodium Thiosulfate 12.5g/50mL Inj,8724690,CDM,636,RC,J0209,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,179.80,407.98,percent of total billed charges,
Sodium Thiosulfate 12.5g/50mL Inj,8724690,CDM,636,RC,J0209,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,0.88000,407.98,percent of total billed charges,
TACROLIMUS 5MG/ML INJ,8724691,CDM,636,RC,J7525,HCPCS,,,facility,inpatient,,,4849.80000,1406.44000,Aetna,First Health,,3967.14,,,,,,,1748.35,3967.14,percent of total billed charges,
TACROLIMUS 5MG/ML INJ,8724691,CDM,636,RC,J7525,HCPCS,,,facility,outpatient,,,4849.80000,1406.44000,Aetna,First Health,,3967.14,,,,,,,252.74,3967.14,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),8725327,CDM,636,RC,90675,HCPCS,,,facility,inpatient,,,1877.50000,544.47000,Aetna,First Health,,1535.80,,,,,,,676.84,1535.80,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),8725327,CDM,636,RC,90675,HCPCS,,,facility,outpatient,,,1877.50000,544.47000,Aetna,First Health,,1535.80,,,,,,,307.92,1535.80,percent of total billed charges,
NICU- Calcium Gluconate 0.465mEq/mL Inj,8725329,CDM,636,RC,J0612,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
NICU- Calcium Gluconate 0.465mEq/mL Inj,8725329,CDM,636,RC,J0612,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,0.02889,81.80,percent of total billed charges,
fentaNYL 10mcg/mL Cont Inf.,8725259,CDM,636,RC,J3010,HCPCS,,,facility,inpatient,,,212.50000,61.62000,Aetna,First Health,,173.82,,,,,,,76.61,173.82,percent of total billed charges,
fentaNYL 10mcg/mL Cont Inf.,8725259,CDM,636,RC,J3010,HCPCS,,,facility,outpatient,,,212.50000,61.62000,Aetna,First Health,,173.82,,,,,,,1.15,173.82,percent of total billed charges,
Dianeal LCA Soln 1.5% 2000mL,8724960,CDM,636,RC,A4722,HCPCS,,,facility,inpatient,,,230.52000,66.85000,Aetna,First Health,,188.57,,,,,,,83.10,188.57,percent of total billed charges,
Dianeal LCA Soln 1.5% 2000mL,8724960,CDM,636,RC,A4722,HCPCS,,,facility,outpatient,,,230.52000,66.85000,Aetna,First Health,,188.57,,,,,,,83.10,188.57,percent of total billed charges,
Dianeal LCA Soln 2.5% 2000mL,8724961,CDM,636,RC,A4722,HCPCS,,,facility,inpatient,,,255.32000,74.04000,Aetna,First Health,,208.85,,,,,,,92.04,208.85,percent of total billed charges,
Dianeal LCA Soln 2.5% 2000mL,8724961,CDM,636,RC,A4722,HCPCS,,,facility,outpatient,,,255.32000,74.04000,Aetna,First Health,,208.85,,,,,,,92.04,208.85,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,8723830,CDM,636,RC,J1050,HCPCS,,,facility,inpatient,,,305.78000,88.68000,Aetna,First Health,,250.13,,,,,,,110.23,250.13,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,8723830,CDM,636,RC,J1050,HCPCS,,,facility,outpatient,,,305.78000,88.68000,Aetna,First Health,,250.13,,,,,,,0.40446,250.13,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),8725278,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),8725278,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.44298,20.45,percent of total billed charges,
Atropine SO4 0.4mg/mL 1mL I,8725289,CDM,636,RC,J0461,HCPCS,,,facility,inpatient,,,51.10000,14.82000,Aetna,First Health,,41.80,,,,,,,18.42,41.80,percent of total billed charges,
Atropine SO4 0.4mg/mL 1mL I,8725289,CDM,636,RC,J0461,HCPCS,,,facility,outpatient,,,51.10000,14.82000,Aetna,First Health,,41.80,,,,,,,0.09630,41.80,percent of total billed charges,
NICU- Acyclovir 7mg/mL IV,8724945,CDM,636,RC,J0133,HCPCS,,,facility,inpatient,,,313.78000,91.00000,Aetna,First Health,,256.67,,,,,,,113.12,256.67,percent of total billed charges,
NICU- Acyclovir 7mg/mL IV,8724945,CDM,636,RC,J0133,HCPCS,,,facility,outpatient,,,313.78000,91.00000,Aetna,First Health,,256.67,,,,,,,0.11556,256.67,percent of total billed charges,
Penicillin GK 3MU/50mL P,8724497,CDM,636,RC,J2540,HCPCS,,,facility,inpatient,,,121.25000,35.16000,Aetna,First Health,,99.18,,,,,,,43.71,99.18,percent of total billed charges,
Penicillin GK 3MU/50mL P,8724497,CDM,636,RC,J2540,HCPCS,,,facility,outpatient,,,121.25000,35.16000,Aetna,First Health,,99.18,,,,,,,0.75114,99.18,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,8725274,CDM,636,RC,J1953,HCPCS,,,facility,inpatient,,,178.05000,51.63000,Aetna,First Health,,145.64,,,,,,,64.19,145.64,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,8725274,CDM,636,RC,J1953,HCPCS,,,facility,outpatient,,,178.05000,51.63000,Aetna,First Health,,145.64,,,,,,,0.03852,145.64,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,8724438,CDM,636,RC,J2543,HCPCS,,,facility,inpatient,,,64.17000,18.61000,Aetna,First Health,,52.49,,,,,,,23.13,52.49,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,8724438,CDM,636,RC,J2543,HCPCS,,,facility,outpatient,,,64.17000,18.61000,Aetna,First Health,,52.49,,,,,,,1.05,52.49,percent of total billed charges,
Phenylephrine 25mg/NS 250mL PF PB,8725397,CDM,636,RC,J2371,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Phenylephrine 25mg/NS 250mL PF PB,8725397,CDM,636,RC,J2371,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,37.00,81.80,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,8725400,CDM,636,RC,J0165,HCPCS,,,facility,inpatient,,,806.25000,233.81000,Aetna,First Health,,659.51,,,,,,,290.65,659.51,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,8725400,CDM,636,RC,J0165,HCPCS,,,facility,outpatient,,,806.25000,233.81000,Aetna,First Health,,659.51,,,,,,,0.41409,659.51,percent of total billed charges,
EPINEPHrine 0.15mg Syringe,8725399,CDM,636,RC,J0165,HCPCS,,,facility,inpatient,,,806.25000,233.81000,Aetna,First Health,,659.51,,,,,,,290.65,659.51,percent of total billed charges,
EPINEPHrine 0.15mg Syringe,8725399,CDM,636,RC,J0165,HCPCS,,,facility,outpatient,,,806.25000,233.81000,Aetna,First Health,,659.51,,,,,,,0.41409,659.51,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,8725439,CDM,636,RC,J2371,HCPCS,,,facility,inpatient,,,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,45.96,104.30,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,8725439,CDM,636,RC,J2371,HCPCS,,,facility,outpatient,,,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,47.17,104.30,percent of total billed charges,
fentaNYL 10mcg/mL /NS PCA 100mL,8924969,CDM,636,RC,J3010,HCPCS,,,facility,inpatient,,,246.73000,71.55000,Aetna,First Health,,201.83,,,,,,,88.95,201.83,percent of total billed charges,
fentaNYL 10mcg/mL /NS PCA 100mL,8924969,CDM,636,RC,J3010,HCPCS,,,facility,outpatient,,,246.73000,71.55000,Aetna,First Health,,201.83,,,,,,,1.15,201.83,percent of total billed charges,
HYDROmorphone 0.2mg/mL /NS PCA,8725503,CDM,636,RC,J1171,HCPCS,,,facility,inpatient,,,205.72000,59.66000,Aetna,First Health,,168.28,,,,,,,74.16,168.28,percent of total billed charges,
HYDROmorphone 0.2mg/mL /NS PCA,8725503,CDM,636,RC,J1171,HCPCS,,,facility,outpatient,,,205.72000,59.66000,Aetna,First Health,,168.28,,,,,,,0.13482,168.28,percent of total billed charges,
Morphine 1mg/mL / NS PCA,8924968,CDM,636,RC,J2270,HCPCS,,,facility,inpatient,,,151.52000,43.94000,Aetna,First Health,,123.94,,,,,,,54.62,123.94,percent of total billed charges,
Morphine 1mg/mL / NS PCA,8924968,CDM,636,RC,J2270,HCPCS,,,facility,outpatient,,,151.52000,43.94000,Aetna,First Health,,123.94,,,,,,,2.93,123.94,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),8723514,CDM,636,RC,J2704,HCPCS,,,facility,inpatient,,,37.16000,10.78000,Aetna,First Health,,30.40,,,,,,,13.40,30.40,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),8723514,CDM,636,RC,J2704,HCPCS,,,facility,outpatient,,,37.16000,10.78000,Aetna,First Health,,30.40,,,,,,,0.08667,30.40,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),8723647,CDM,636,RC,J2704,HCPCS,,,facility,inpatient,,,307.53000,89.18000,Aetna,First Health,,251.56,,,,,,,110.86,251.56,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),8723647,CDM,636,RC,J2704,HCPCS,,,facility,outpatient,,,307.53000,89.18000,Aetna,First Health,,251.56,,,,,,,0.08667,251.56,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),8723585,CDM,636,RC,J2704,HCPCS,,,facility,inpatient,,,135.35000,39.25000,Aetna,First Health,,110.72,,,,,,,48.79,110.72,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),8723585,CDM,636,RC,J2704,HCPCS,,,facility,outpatient,,,135.35000,39.25000,Aetna,First Health,,110.72,,,,,,,0.08667,110.72,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,8924970,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,922.30000,267.47000,Aetna,First Health,,754.44,,,,,,,332.49,754.44,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,8924970,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,922.30000,267.47000,Aetna,First Health,,754.44,,,,,,,0.04815,754.44,percent of total billed charges,
Vancomycin HCl 750mg Inj,8725512,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,,,94.45000,27.39000,Aetna,First Health,,77.26,,,,,,,34.05,77.26,percent of total billed charges,
Vancomycin HCl 750mg Inj,8725512,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,,,94.45000,27.39000,Aetna,First Health,,77.26,,,,,,,0.02889,77.26,percent of total billed charges,
ceFAZolin 3g/ NS 115mL P (Ancef),8725528,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,87.40000,25.35000,Aetna,First Health,,71.49,,,,,,,31.51,71.49,percent of total billed charges,
ceFAZolin 3g/ NS 115mL P (Ancef),8725528,CDM,636,RC,J0690,HCPCS,,,facility,outpatient,,,87.40000,25.35000,Aetna,First Health,,71.49,,,,,,,0.79929,71.49,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),8723553,CDM,636,RC,J1642,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),8723553,CDM,636,RC,J1642,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.01926,20.45,percent of total billed charges,
Meropenem 500mg I (Merrem),8725539,CDM,636,RC,J2185,HCPCS,,,facility,inpatient,,,50.23000,14.57000,Aetna,First Health,,41.09,,,,,,,18.11,41.09,percent of total billed charges,
Meropenem 500mg I (Merrem),8725539,CDM,636,RC,J2185,HCPCS,,,facility,outpatient,,,50.23000,14.57000,Aetna,First Health,,41.09,,,,,,,0.36594,41.09,percent of total billed charges,
EPINEPHrine 4 mg/NS 250mL IVPB,8726013,CDM,636,RC,J0165,HCPCS,,,facility,inpatient,,,212.50000,61.62000,Aetna,First Health,,173.82,,,,,,,76.61,173.82,percent of total billed charges,
EPINEPHrine 4 mg/NS 250mL IVPB,8726013,CDM,636,RC,J0165,HCPCS,,,facility,outpatient,,,212.50000,61.62000,Aetna,First Health,,173.82,,,,,,,0.41409,173.82,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,8723399,CDM,636,RC,J0168,HCPCS,,,facility,inpatient,,,63.80000,18.50000,Aetna,First Health,,52.19,,,,,,,23.00,52.19,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,8723399,CDM,636,RC,J0168,HCPCS,,,facility,outpatient,,,63.80000,18.50000,Aetna,First Health,,52.19,,,,,,,2.89,52.19,percent of total billed charges,
Denosumab 60mg/1mL IS(Prolia),8725582,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,7661.75000,2221.91000,Aetna,First Health,,6267.31,,,,,,,2762.06,6267.31,percent of total billed charges,
Denosumab 60mg/1mL IS(Prolia),8725582,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,7661.75000,2221.91000,Aetna,First Health,,6267.31,,,,,,,28.37,6267.31,percent of total billed charges,
Acyclovir 50mg/mL Inj 10mL,8725662,CDM,636,RC,J0133,HCPCS,,,facility,inpatient,,,180.50000,52.34000,Aetna,First Health,,147.65,,,,,,,65.07,147.65,percent of total billed charges,
Acyclovir 50mg/mL Inj 10mL,8725662,CDM,636,RC,J0133,HCPCS,,,facility,outpatient,,,180.50000,52.34000,Aetna,First Health,,147.65,,,,,,,0.11556,147.65,percent of total billed charges,
Magnesium Sulf 50% I 10mL,8725663,CDM,636,RC,J3475,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Magnesium Sulf 50% I 10mL,8725663,CDM,636,RC,J3475,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,0.39483,81.80,percent of total billed charges,
ROPivacaine 0.5% 20mL I,8725666,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,98.75000,28.64000,Aetna,First Health,,80.78,,,,,,,35.60,80.78,percent of total billed charges,
ROPivacaine 0.5% 20mL I,8725666,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,98.75000,28.64000,Aetna,First Health,,80.78,,,,,,,0.04815,80.78,percent of total billed charges,
Ceftolozane-Tazobactam 1.5g Inj,8725675,CDM,636,RC,J0695,HCPCS,,,facility,inpatient,,,1442.40000,418.30000,Aetna,First Health,,1179.88,,,,,,,519.99,1179.88,percent of total billed charges,
Ceftolozane-Tazobactam 1.5g Inj,8725675,CDM,636,RC,J0695,HCPCS,,,facility,outpatient,,,1442.40000,418.30000,Aetna,First Health,,1179.88,,,,,,,8.62,1179.88,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,8725683,CDM,636,RC,J0330,HCPCS,,,facility,inpatient,,,148.24000,42.99000,Aetna,First Health,,121.26,,,,,,,53.44,121.26,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,8725683,CDM,636,RC,J0330,HCPCS,,,facility,outpatient,,,148.24000,42.99000,Aetna,First Health,,121.26,,,,,,,0.93411,121.26,percent of total billed charges,
RAD- iodixanol 270mg/mL I 100mL,8725707,CDM,636,RC,Q9966,HCPCS,,,facility,inpatient,,,526.85000,152.79000,Aetna,First Health,,430.96,,,,,,,189.93,430.96,percent of total billed charges,
RAD- iodixanol 270mg/mL I 100mL,8725707,CDM,636,RC,Q9966,HCPCS,,,facility,outpatient,,,526.85000,152.79000,Aetna,First Health,,430.96,,,,,,,0.38520,430.96,percent of total billed charges,
RHo (D) Immune Globulin 300mcg/2mL Inj,8725718,CDM,636,RC,J2791,HCPCS,,,facility,inpatient,,,799.05000,231.72000,Aetna,First Health,,653.62,,,,,,,288.06,653.62,percent of total billed charges,
RHo (D) Immune Globulin 300mcg/2mL Inj,8725718,CDM,636,RC,J2791,HCPCS,,,facility,outpatient,,,799.05000,231.72000,Aetna,First Health,,653.62,,,,,,,4.65,653.62,percent of total billed charges,
Methylene Blue 0.5% 10mL I,8725737,CDM,636,RC,Q9968,HCPCS,,,facility,inpatient,,,1133.96000,328.85000,Aetna,First Health,,927.58,,,,,,,408.79,927.58,percent of total billed charges,
Methylene Blue 0.5% 10mL I,8725737,CDM,636,RC,Q9968,HCPCS,,,facility,outpatient,,,1133.96000,328.85000,Aetna,First Health,,927.58,,,,,,,5.42,927.58,percent of total billed charges,
hydrOXYzine HCl 50mg/1mL Inj,8723781,CDM,636,RC,J3410,HCPCS,,,facility,inpatient,,,200.78000,58.23000,Aetna,First Health,,164.24,,,,,,,72.38,164.24,percent of total billed charges,
hydrOXYzine HCl 50mg/1mL Inj,8723781,CDM,636,RC,J3410,HCPCS,,,facility,outpatient,,,200.78000,58.23000,Aetna,First Health,,164.24,,,,,,,12.52,164.24,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,8725753,CDM,636,RC,J1171,HCPCS,,,facility,inpatient,,,35.04000,10.16000,Aetna,First Health,,28.66,,,,,,,12.63,28.66,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,8725753,CDM,636,RC,J1171,HCPCS,,,facility,outpatient,,,35.04000,10.16000,Aetna,First Health,,28.66,,,,,,,0.13482,28.66,percent of total billed charges,
Panitumumab 100mg/5mL I(Vectibix),8724846,CDM,636,RC,J9303,HCPCS,,,facility,inpatient,,,9969.95000,2891.29000,Aetna,First Health,,8155.42,,,,,,,3594.17,8155.42,percent of total billed charges,
Panitumumab 100mg/5mL I(Vectibix),8724846,CDM,636,RC,J9303,HCPCS,,,facility,outpatient,,,9969.95000,2891.29000,Aetna,First Health,,8155.42,,,,,,,167.24,8155.42,percent of total billed charges,
Pertuzumab 420 mg/14 mL I(Perjeta),8725277,CDM,636,RC,J9306,HCPCS,,,facility,inpatient,,,37017.65000,10735.12000,Aetna,First Health,,30280.44,,,,,,,13344.86,30280.44,percent of total billed charges,
Pertuzumab 420 mg/14 mL I(Perjeta),8725277,CDM,636,RC,J9306,HCPCS,,,facility,outpatient,,,37017.65000,10735.12000,Aetna,First Health,,30280.44,,,,,,,16.38,30280.44,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),8724151,CDM,636,RC,J0583,HCPCS,,,facility,inpatient,,,7562.21000,2193.04000,Aetna,First Health,,6185.89,,,,,,,2726.18,6185.89,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),8724151,CDM,636,RC,J0583,HCPCS,,,facility,outpatient,,,7562.21000,2193.04000,Aetna,First Health,,6185.89,,,,,,,0.15408,6185.89,percent of total billed charges,
DOXOrubicin 10mg/5mL I,8723898,CDM,636,RC,J9000,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.04,61.35,percent of total billed charges,
DOXOrubicin 10mg/5mL I,8723898,CDM,636,RC,J9000,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,2.68,61.35,percent of total billed charges,
DOXOrubicin 50mg/25mL I,8723870,CDM,636,RC,J9000,HCPCS,,,facility,inpatient,,,189.40000,54.93000,Aetna,First Health,,154.93,,,,,,,68.28,154.93,percent of total billed charges,
DOXOrubicin 50mg/25mL I,8723870,CDM,636,RC,J9000,HCPCS,,,facility,outpatient,,,189.40000,54.93000,Aetna,First Health,,154.93,,,,,,,2.68,154.93,percent of total billed charges,
Methotrexate Na 250mg/10mL I PF,8723451,CDM,636,RC,J9260,HCPCS,,,facility,inpatient,,,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,32.34,73.37,percent of total billed charges,
Methotrexate Na 250mg/10mL I PF,8723451,CDM,636,RC,J9260,HCPCS,,,facility,outpatient,,,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,2.48,73.37,percent of total billed charges,
Methotrexate 1g/40mL I PF,8724347,CDM,636,RC,J9260,HCPCS,,,facility,inpatient,,,343.60000,99.64000,Aetna,First Health,,281.06,,,,,,,123.87,281.06,percent of total billed charges,
Methotrexate 1g/40mL I PF,8724347,CDM,636,RC,J9260,HCPCS,,,facility,outpatient,,,343.60000,99.64000,Aetna,First Health,,281.06,,,,,,,2.48,281.06,percent of total billed charges,
vinCRIStine 2mg/2mL Inj,8723899,CDM,636,RC,J9370,HCPCS,,,facility,inpatient,,,141.39000,41.00000,Aetna,First Health,,115.66,,,,,,,50.97,115.66,percent of total billed charges,
vinCRIStine 2mg/2mL Inj,8723899,CDM,636,RC,J9370,HCPCS,,,facility,outpatient,,,141.39000,41.00000,Aetna,First Health,,115.66,,,,,,,7.85,115.66,percent of total billed charges,
Mepolizumab 100mg Inj,8725764,CDM,636,RC,J2182,HCPCS,,,facility,inpatient,,,14425.17000,4183.30000,Aetna,First Health,,11799.79,,,,,,,5200.27,11799.79,percent of total billed charges,
Mepolizumab 100mg Inj,8725764,CDM,636,RC,J2182,HCPCS,,,facility,outpatient,,,14425.17000,4183.30000,Aetna,First Health,,11799.79,,,,,,,30.71,11799.79,percent of total billed charges,
Vedolizumab 300mg I(Entyvio),8725765,CDM,636,RC,J3380,HCPCS,,,facility,inpatient,,,67578.40000,19597.74000,Aetna,First Health,,55279.13,,,,,,,24362.01,55279.13,percent of total billed charges,
Vedolizumab 300mg I(Entyvio),8725765,CDM,636,RC,J3380,HCPCS,,,facility,outpatient,,,67578.40000,19597.74000,Aetna,First Health,,55279.13,,,,,,,20.58,55279.13,percent of total billed charges,
Alteplase 10mg/10mL Bolus Syringe,8725714,CDM,636,RC,J2997,HCPCS,,,facility,inpatient,,,4529.45000,1313.54000,Aetna,First Health,,3705.09,,,,,,,1632.87,3705.09,percent of total billed charges,
Alteplase 10mg/10mL Bolus Syringe,8725714,CDM,636,RC,J2997,HCPCS,,,facility,outpatient,,,4529.45000,1313.54000,Aetna,First Health,,3705.09,,,,,,,90.36,3705.09,percent of total billed charges,
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),8725767,CDM,636,RC,Q9950,HCPCS,,,facility,inpatient,,,746.49000,216.48000,Aetna,First Health,,610.63,,,,,,,269.11,610.63,percent of total billed charges,
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),8725767,CDM,636,RC,Q9950,HCPCS,,,facility,outpatient,,,746.49000,216.48000,Aetna,First Health,,610.63,,,,,,,17.50,610.63,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 10mL",8725771,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,9.12,20.70,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 10mL",8725771,CDM,636,RC,J2004,HCPCS,,,facility,outpatient,,,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,0.00963,20.70,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,8725786,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,8725786,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.00963,20.45,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,8725794,CDM,636,RC,J1596,HCPCS,,,facility,inpatient,,,70.87000,20.55000,Aetna,First Health,,57.97,,,,,,,25.55,57.97,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,8725794,CDM,636,RC,J1596,HCPCS,,,facility,outpatient,,,70.87000,20.55000,Aetna,First Health,,57.97,,,,,,,0.36594,57.97,percent of total billed charges,
Trastuzumab 150mg I(Herceptin),8725817,CDM,636,RC,J9355,HCPCS,,,facility,inpatient,,,8602.45000,2494.71000,Aetna,First Health,,7036.80,,,,,,,3101.18,7036.80,percent of total billed charges,
Trastuzumab 150mg I(Herceptin),8725817,CDM,636,RC,J9355,HCPCS,,,facility,outpatient,,,8602.45000,2494.71000,Aetna,First Health,,7036.80,,,,,,,70.76,7036.80,percent of total billed charges,
Alteplase 0.5mg/1mL Inj Syr,8725820,CDM,636,RC,J2997,HCPCS,,,facility,inpatient,,,385.60000,111.82000,Aetna,First Health,,315.42,,,,,,,139.01,315.42,percent of total billed charges,
Alteplase 0.5mg/1mL Inj Syr,8725820,CDM,636,RC,J2997,HCPCS,,,facility,outpatient,,,385.60000,111.82000,Aetna,First Health,,315.42,,,,,,,90.36,315.42,percent of total billed charges,
Labor Room Epidural 100mL,8725822,CDM,636,RC,J3010,HCPCS,,,facility,inpatient,,,204.43000,59.28000,Aetna,First Health,,167.22,,,,,,,73.70,167.22,percent of total billed charges,
Labor Room Epidural 100mL,8725822,CDM,636,RC,J3010,HCPCS,,,facility,outpatient,,,204.43000,59.28000,Aetna,First Health,,167.22,,,,,,,1.15,167.22,percent of total billed charges,
Denosumab 120mg/1.7mL I (Xgeva),8725825,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,13933.80000,4040.80000,Aetna,First Health,,11397.85,,,,,,,5023.13,11397.85,percent of total billed charges,
Denosumab 120mg/1.7mL I (Xgeva),8725825,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,13933.80000,4040.80000,Aetna,First Health,,11397.85,,,,,,,28.37,11397.85,percent of total billed charges,
Dalbavancin 500mg I (Dalvance),8725826,CDM,636,RC,J0875,HCPCS,,,facility,inpatient,,,12996.75000,3769.06000,Aetna,First Health,,10631.34,,,,,,,4685.33,10631.34,percent of total billed charges,
Dalbavancin 500mg I (Dalvance),8725826,CDM,636,RC,J0875,HCPCS,,,facility,outpatient,,,12996.75000,3769.06000,Aetna,First Health,,10631.34,,,,,,,15.01,10631.34,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,8725605,CDM,636,RC,A9585,HCPCS,,,facility,inpatient,,,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,19.11,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,8725605,CDM,636,RC,A9585,HCPCS,,,facility,outpatient,,,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,0.26964,43.35,percent of total billed charges,
RAD- Gadoxetate 181.43mg/mL I 10mL,8725236,CDM,636,RC,A9581,HCPCS,,,facility,inpatient,,,740.75000,214.82000,Aetna,First Health,,605.93,,,,,,,267.04,605.93,percent of total billed charges,
RAD- Gadoxetate 181.43mg/mL I 10mL,8725236,CDM,636,RC,A9581,HCPCS,,,facility,outpatient,,,740.75000,214.82000,Aetna,First Health,,605.93,,,,,,,14.20,605.93,percent of total billed charges,
RAD- iodixanol 320mg/mL Inj 100mL,8725698,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,506.20000,146.80000,Aetna,First Health,,414.07,,,,,,,182.49,414.07,percent of total billed charges,
RAD- iodixanol 320mg/mL Inj 100mL,8725698,CDM,636,RC,Q9967,HCPCS,,,facility,outpatient,,,506.20000,146.80000,Aetna,First Health,,414.07,,,,,,,0.14445,414.07,percent of total billed charges,
RAD- Iohexol 180mg/mL Inj 10mL,8725699,CDM,636,RC,Q9965,HCPCS,,,facility,inpatient,,,245.62000,71.23000,Aetna,First Health,,200.92,,,,,,,88.55,200.92,percent of total billed charges,
RAD- Iohexol 180mg/mL Inj 10mL,8725699,CDM,636,RC,Q9965,HCPCS,,,facility,outpatient,,,245.62000,71.23000,Aetna,First Health,,200.92,,,,,,,1.00,200.92,percent of total billed charges,
RAD- Iohexol 180mg/mL Inj 20mL,8725700,CDM,636,RC,Q9965,HCPCS,,,facility,inpatient,,,311.35000,90.29000,Aetna,First Health,,254.68,,,,,,,112.24,254.68,percent of total billed charges,
RAD- Iohexol 180mg/mL Inj 20mL,8725700,CDM,636,RC,Q9965,HCPCS,,,facility,outpatient,,,311.35000,90.29000,Aetna,First Health,,254.68,,,,,,,1.00,254.68,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 100mL,8725760,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,551.91000,160.05000,Aetna,First Health,,451.46,,,,,,,198.96,451.46,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 100mL,8725760,CDM,636,RC,Q9967,HCPCS,,,facility,outpatient,,,551.91000,160.05000,Aetna,First Health,,451.46,,,,,,,0.14445,451.46,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 50mL,8725607,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,408.30000,118.41000,Aetna,First Health,,333.99,,,,,,,147.19,333.99,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 50mL,8725607,CDM,636,RC,Q9967,HCPCS,,,facility,outpatient,,,408.30000,118.41000,Aetna,First Health,,333.99,,,,,,,0.14445,333.99,percent of total billed charges,
Pfizer Covid Vaccine Medication Dose 1,8429711,CDM,636,RC,91300,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Pfizer Covid Vaccine Medication Dose 1,8429711,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Pfizer Covid Vaccine Medication Dose 2,8429710,CDM,636,RC,91300,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Pfizer Covid Vaccine Medication Dose 2,8429710,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
PEMEtrexed 500mg Rec Inj,8724346,CDM,636,RC,J9305,HCPCS,,,facility,inpatient,,,682.28000,197.86000,Aetna,First Health,,558.11,,,,,,,245.96,558.11,percent of total billed charges,
PEMEtrexed 500mg Rec Inj,8724346,CDM,636,RC,J9305,HCPCS,,,facility,outpatient,,,682.28000,197.86000,Aetna,First Health,,558.11,,,,,,,3.46,558.11,percent of total billed charges,
NICU- Ampicillin 100mg/mL IV Syr,8725452,CDM,636,RC,J0290,HCPCS,,,facility,inpatient,,,35.91000,10.41000,Aetna,First Health,,29.37,,,,,,,12.95,29.37,percent of total billed charges,
NICU- Ampicillin 100mg/mL IV Syr,8725452,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,,,35.91000,10.41000,Aetna,First Health,,29.37,,,,,,,0.56817,29.37,percent of total billed charges,
Prothrombin Complex-Human I(Kcentra),8725461,CDM,636,RC,J7168,HCPCS,,,facility,inpatient,,,21.57000,6.26000,Aetna,First Health,,17.64,,,,,,,7.78,17.64,percent of total billed charges,
Prothrombin Complex-Human I(Kcentra),8725461,CDM,636,RC,J7168,HCPCS,,,facility,outpatient,,,21.57000,6.26000,Aetna,First Health,,17.64,,,,,,,2.09,17.64,percent of total billed charges,
Aztreonam 2g I (Azactam),8725498,CDM,636,RC,J0457,HCPCS,,,facility,inpatient,,,591.49000,171.53000,Aetna,First Health,,483.84,,,,,,,213.23,483.84,percent of total billed charges,
Aztreonam 2g I (Azactam),8725498,CDM,636,RC,J0457,HCPCS,,,facility,outpatient,,,591.49000,171.53000,Aetna,First Health,,483.84,,,,,,,2.15,483.84,percent of total billed charges,
CISplatin 10mg/10mL I,8725650,CDM,636,RC,J9060,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.04,61.35,percent of total billed charges,
CISplatin 10mg/10mL I,8725650,CDM,636,RC,J9060,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,2.03,61.35,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,8725629,CDM,636,RC,J9181,HCPCS,,,facility,inpatient,,,4.87000,1.41000,Aetna,First Health,,3.98,,,,,,,1.76,3.98,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,8725629,CDM,636,RC,J9181,HCPCS,,,facility,outpatient,,,4.87000,1.41000,Aetna,First Health,,3.98,,,,,,,1.00,3.98,percent of total billed charges,
PACLitaxel 1mg Inj,8725644,CDM,636,RC,J9267,HCPCS,,,facility,inpatient,,,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,4.56,10.35,percent of total billed charges,
PACLitaxel 1mg Inj,8725644,CDM,636,RC,J9267,HCPCS,,,facility,outpatient,,,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,0.09630,10.35,percent of total billed charges,
vinBLAStine 1mg/mL Inj,8725636,CDM,636,RC,J9360,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.04,61.35,percent of total billed charges,
vinBLAStine 1mg/mL Inj,8725636,CDM,636,RC,J9360,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,4.99,61.35,percent of total billed charges,
Mesna 200mg/2mL I (Mesnex),8725643,CDM,636,RC,J9209,HCPCS,,,facility,inpatient,,,135.30000,39.24000,Aetna,First Health,,110.68,,,,,,,48.78,110.68,percent of total billed charges,
Mesna 200mg/2mL I (Mesnex),8725643,CDM,636,RC,J9209,HCPCS,,,facility,outpatient,,,135.30000,39.24000,Aetna,First Health,,110.68,,,,,,,1.64,110.68,percent of total billed charges,
NS 250mL Inj IVR,8725555,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,100.96000,29.28000,Aetna,First Health,,82.59,,,,,,,36.40,82.59,percent of total billed charges,
NS 250mL Inj IVR,8725555,CDM,636,RC,J7050,HCPCS,,,facility,outpatient,,,100.96000,29.28000,Aetna,First Health,,82.59,,,,,,,0.63558,82.59,percent of total billed charges,
NS 100mL Inj,8725556,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,50.62000,14.68000,Aetna,First Health,,41.41,,,,,,,18.25,41.41,percent of total billed charges,
NS 100mL Inj,8725556,CDM,636,RC,J7050,HCPCS,,,facility,outpatient,,,50.62000,14.68000,Aetna,First Health,,41.41,,,,,,,0.63558,41.41,percent of total billed charges,
NICU- cefTAZidime 50mg/mL IS,8725569,CDM,636,RC,J0713,HCPCS,,,facility,inpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,18.75,42.54,percent of total billed charges,
NICU- cefTAZidime 50mg/mL IS,8725569,CDM,636,RC,J0713,HCPCS,,,facility,outpatient,,,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,1.42,42.54,percent of total billed charges,
idaruCIZUmab  2.5g/50mL I(Praxbind),8725584,CDM,636,RC,C9399,HCPCS,,,facility,inpatient,,,18555.70000,5381.15000,Aetna,First Health,,15178.56,,,,,,,6689.33,15178.56,percent of total billed charges,
idaruCIZUmab  2.5g/50mL I(Praxbind),8725584,CDM,636,RC,C9399,HCPCS,,,facility,outpatient,,,18555.70000,5381.15000,Aetna,First Health,,15178.56,,,,,,,6689.33,15178.56,percent of total billed charges,
ROPivacaine 0.5% (5mg/1mL) I,8725588,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
ROPivacaine 0.5% (5mg/1mL) I,8725588,CDM,636,RC,J2795,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.04815,20.45,percent of total billed charges,
Vasopressin 20units/1mL- For IV Set,8725589,CDM,636,RC,J2598,HCPCS,,,facility,inpatient,,,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,176.65,400.82,percent of total billed charges,
Vasopressin 20units/1mL- For IV Set,8725589,CDM,636,RC,J2598,HCPCS,,,facility,outpatient,,,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,0.51039,400.82,percent of total billed charges,
Hyaluronidase 150units/1mL Inj.,8725611,CDM,636,RC,J3470,HCPCS,,,facility,inpatient,,,330.30000,95.79000,Aetna,First Health,,270.19,,,,,,,119.07,270.19,percent of total billed charges,
Hyaluronidase 150units/1mL Inj.,8725611,CDM,636,RC,J3470,HCPCS,,,facility,outpatient,,,330.30000,95.79000,Aetna,First Health,,270.19,,,,,,,30.63,270.19,percent of total billed charges,
Ondansetron 2mg/2.5 mL Oral Soln,8725924,CDM,636,RC,Q0162,HCPCS,,,facility,inpatient,,,84.90000,24.62000,Aetna,First Health,,69.45,,,,,,,30.61,69.45,percent of total billed charges,
Ondansetron 2mg/2.5 mL Oral Soln,8725924,CDM,636,RC,Q0162,HCPCS,,,facility,outpatient,,,84.90000,24.62000,Aetna,First Health,,69.45,,,,,,,0.00963,69.45,percent of total billed charges,
metroNIDAZOLE 500mg P,8723633,CDM,636,RC,J1836,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
metroNIDAZOLE 500mg P,8723633,CDM,636,RC,J1836,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,0.02889,40.90,percent of total billed charges,
Nitroglycerin 50mg/10mL I,8723429,CDM,636,RC,J2305,HCPCS,,,facility,inpatient,,,158.65000,46.01000,Aetna,First Health,,129.78,,,,,,,57.19,129.78,percent of total billed charges,
Nitroglycerin 50mg/10mL I,8723429,CDM,636,RC,J2305,HCPCS,,,facility,outpatient,,,158.65000,46.01000,Aetna,First Health,,129.78,,,,,,,1.46,129.78,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,8723550,CDM,636,RC,J2401,HCPCS,,,facility,inpatient,,,143.45000,41.60000,Aetna,First Health,,117.34,,,,,,,51.71,117.34,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,8723550,CDM,636,RC,J2401,HCPCS,,,facility,outpatient,,,143.45000,41.60000,Aetna,First Health,,117.34,,,,,,,0.03852,117.34,percent of total billed charges,
Promethazine HCl 25mg/1mL I,8722806,CDM,636,RC,J2550,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Promethazine HCl 25mg/1mL I,8722806,CDM,636,RC,J2550,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,3.82,20.45,percent of total billed charges,
Mag Sulfate 40g/Water 1000mL,8725828,CDM,636,RC,J3475,HCPCS,,,facility,inpatient,,,961.36000,278.79000,Aetna,First Health,,786.39,,,,,,,346.57,786.39,percent of total billed charges,
Mag Sulfate 40g/Water 1000mL,8725828,CDM,636,RC,J3475,HCPCS,,,facility,outpatient,,,961.36000,278.79000,Aetna,First Health,,786.39,,,,,,,0.39483,786.39,percent of total billed charges,
Rabies Immune Glob 300IU/1mL Inj,8725832,CDM,636,RC,90375,HCPCS,,,facility,inpatient,,,3019.15000,875.55000,Aetna,First Health,,2469.66,,,,,,,1088.40,2469.66,percent of total billed charges,
Rabies Immune Glob 300IU/1mL Inj,8725832,CDM,636,RC,90375,HCPCS,,,facility,outpatient,,,3019.15000,875.55000,Aetna,First Health,,2469.66,,,,,,,269.59,2469.66,percent of total billed charges,
Ocrelizumab 300mg/10mL I(Ocrevus),8725847,CDM,636,RC,J2350,HCPCS,,,facility,inpatient,,,148801.95000,43152.57000,Aetna,First Health,,121720.00,,,,,,,53643.10,121720.00,percent of total billed charges,
Ocrelizumab 300mg/10mL I(Ocrevus),8725847,CDM,636,RC,J2350,HCPCS,,,facility,outpatient,,,148801.95000,43152.57000,Aetna,First Health,,121720.00,,,,,,,57.13,121720.00,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,8723547,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,75.30000,21.84000,Aetna,First Health,,61.60,,,,,,,27.15,61.60,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,8723547,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,75.30000,21.84000,Aetna,First Health,,61.60,,,,,,,0.00963,61.60,percent of total billed charges,
Ceftazidime-Avibactam2-0.5g Inj,8725843,CDM,636,RC,J0714,HCPCS,,,facility,inpatient,,,3181.46000,922.62000,Aetna,First Health,,2602.43,,,,,,,1146.92,2602.43,percent of total billed charges,
Ceftazidime-Avibactam2-0.5g Inj,8725843,CDM,636,RC,J0714,HCPCS,,,facility,outpatient,,,3181.46000,922.62000,Aetna,First Health,,2602.43,,,,,,,100.84,2602.43,percent of total billed charges,
Eculizumab- Pt Own Supply,8725899,CDM,636,RC,J1299,HCPCS,,,facility,inpatient,,,372.90000,108.14000,Aetna,First Health,,305.03,,,,,,,134.43,305.03,percent of total billed charges,
Eculizumab- Pt Own Supply,8725899,CDM,636,RC,J1299,HCPCS,,,facility,outpatient,,,372.90000,108.14000,Aetna,First Health,,305.03,,,,,,,43.36,305.03,percent of total billed charges,
Lidocaine HCl 1% 10mL Inj,8725850,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Lidocaine HCl 1% 10mL Inj,8725850,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.00963,20.45,percent of total billed charges,
"NICU- PENICILLIN GK 100,000 UNIT/ML IM",8725865,CDM,636,RC,J2540,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
"NICU- PENICILLIN GK 100,000 UNIT/ML IM",8725865,CDM,636,RC,J2540,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.75114,20.45,percent of total billed charges,
Alpha 1-Proteinase Inhbitor Human 10mg I(Prolastin),8725866,CDM,636,RC,J0256,HCPCS,,,facility,inpatient,,,28.07000,8.14000,Aetna,First Health,,22.96,,,,,,,10.12,22.96,percent of total billed charges,
Alpha 1-Proteinase Inhbitor Human 10mg I(Prolastin),8725866,CDM,636,RC,J0256,HCPCS,,,facility,outpatient,,,28.07000,8.14000,Aetna,First Health,,22.96,,,,,,,5.17,22.96,percent of total billed charges,
Ocrelizumab- Pt Own Supply,8725879,CDM,636,RC,J2350,HCPCS,,,facility,inpatient,,,0.09000,0.03000,Aetna,First Health,,0.07362,,,,,,,0.03245,0.07362,percent of total billed charges,
Ocrelizumab- Pt Own Supply,8725879,CDM,636,RC,J2350,HCPCS,,,facility,outpatient,,,0.09000,0.03000,Aetna,First Health,,0.07362,,,,,,,0.03330,182.94,percent of total billed charges,
inFLIXimab- Pt Own Supply,8725880,CDM,636,RC,J1745,HCPCS,,,facility,inpatient,,,0.01000,,Aetna,First Health,,0.00818,,,,,,,0.00361,0.00818,percent of total billed charges,
inFLIXimab- Pt Own Supply,8725880,CDM,636,RC,J1745,HCPCS,,,facility,outpatient,,,0.01000,,Aetna,First Health,,0.00818,,,,,,,0.00370,99.98,percent of total billed charges,
Natalizumab - Pt Own Supply,8725881,CDM,636,RC,J2323,HCPCS,,,facility,inpatient,,,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05407,0.12270,percent of total billed charges,
Natalizumab - Pt Own Supply,8725881,CDM,636,RC,J2323,HCPCS,,,facility,outpatient,,,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05550,75.59,percent of total billed charges,
Benralizumab- Pt Own Supply,8725886,CDM,636,RC,J0517,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Benralizumab- Pt Own Supply,8725886,CDM,636,RC,J0517,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,505.68,percent of total billed charges,
Brivaracetam 10mg/mL Inj 5mL,8725877,CDM,636,RC,,,,,facility,inpatient,,,568.30000,164.81000,Aetna,First Health,,464.87,,,,,,,204.87,464.87,percent of total billed charges,
Brivaracetam 10mg/mL Inj 5mL,8725877,CDM,636,RC,,,,,facility,outpatient,,,568.30000,164.81000,Aetna,First Health,,464.87,,,,,,,204.87,464.87,percent of total billed charges,
Omalizumab 150mg- Pt Own Supply,8726081,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Omalizumab 150mg- Pt Own Supply,8726081,CDM,636,RC,J2357,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,140.32,percent of total billed charges,
Omalizumab 75mg- Pt Own Supply,8726080,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Omalizumab 75mg- Pt Own Supply,8726080,CDM,636,RC,J2357,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,140.32,percent of total billed charges,
Omalizumab 150mg/mL IS(Xolair),8725885,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,5831.85000,1691.24000,Aetna,First Health,,4770.45,,,,,,,2102.38,4770.45,percent of total billed charges,
Omalizumab 150mg/mL IS(Xolair),8725885,CDM,636,RC,J2357,HCPCS,,,facility,outpatient,,,5831.85000,1691.24000,Aetna,First Health,,4770.45,,,,,,,43.82,4770.45,percent of total billed charges,
Omalizumab 75mg/0.5mL IS(Xolair),8725882,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,3010.95000,873.18000,Aetna,First Health,,2462.96,,,,,,,1085.45,2462.96,percent of total billed charges,
Omalizumab 75mg/0.5mL IS(Xolair),8725882,CDM,636,RC,J2357,HCPCS,,,facility,outpatient,,,3010.95000,873.18000,Aetna,First Health,,2462.96,,,,,,,43.82,2462.96,percent of total billed charges,
Sodium Chloride 3% IV 500mL,8725889,CDM,636,RC,J7131,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
Sodium Chloride 3% IV 500mL,8725889,CDM,636,RC,J7131,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,0.14445,81.80,percent of total billed charges,
Haloperidol Decanoate 100mg/1mL Inj,8725890,CDM,636,RC,J1631,HCPCS,,,facility,inpatient,,,187.52000,54.38000,Aetna,First Health,,153.39,,,,,,,67.60,153.39,percent of total billed charges,
Haloperidol Decanoate 100mg/1mL Inj,8725890,CDM,636,RC,J1631,HCPCS,,,facility,outpatient,,,187.52000,54.38000,Aetna,First Health,,153.39,,,,,,,3.79,153.39,percent of total billed charges,
Pegfilgrastim-cbqv 6mg/0.6mL Inj Syr,8725937,CDM,636,RC,Q5111,HCPCS,,,facility,inpatient,,,16823.20000,4878.73000,Aetna,First Health,,13761.38,,,,,,,6064.76,13761.38,percent of total billed charges,
Pegfilgrastim-cbqv 6mg/0.6mL Inj Syr,8725937,CDM,636,RC,Q5111,HCPCS,,,facility,outpatient,,,16823.20000,4878.73000,Aetna,First Health,,13761.38,,,,,,,156.00,13761.38,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),8725561,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),8725561,CDM,636,RC,J0696,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.44298,20.45,percent of total billed charges,
Lidocaine 0.5% 50mL PF I,8724335,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,92.45000,26.81000,Aetna,First Health,,75.62,,,,,,,33.33,75.62,percent of total billed charges,
Lidocaine 0.5% 50mL PF I,8724335,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,92.45000,26.81000,Aetna,First Health,,75.62,,,,,,,0.00963,75.62,percent of total billed charges,
Argatroban 50mg/50mL I,8726133,CDM,636,RC,J0883,HCPCS,,,facility,inpatient,,,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,335.26,760.74,percent of total billed charges,
Argatroban 50mg/50mL I,8726133,CDM,636,RC,J0883,HCPCS,,,facility,outpatient,,,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,0.58743,760.74,percent of total billed charges,
Levothyroxine 100 mcg Inj (20mcg/mL),8726143,CDM,636,RC,J0651,HCPCS,,,facility,inpatient,,,778.80000,225.85000,Aetna,First Health,,637.06,,,,,,,280.76,637.06,percent of total billed charges,
Levothyroxine 100 mcg Inj (20mcg/mL),8726143,CDM,636,RC,J0651,HCPCS,,,facility,outpatient,,,778.80000,225.85000,Aetna,First Health,,637.06,,,,,,,6.68,637.06,percent of total billed charges,
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,8726096,CDM,636,RC,J0612,HCPCS,,,facility,inpatient,,,186.01000,53.94000,Aetna,First Health,,152.16,,,,,,,67.06,152.16,percent of total billed charges,
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,8726096,CDM,636,RC,J0612,HCPCS,,,facility,outpatient,,,186.01000,53.94000,Aetna,First Health,,152.16,,,,,,,0.02889,152.16,percent of total billed charges,
Milrinone 20mg/D5W 100mL,8726113,CDM,636,RC,J2260,HCPCS,,,facility,inpatient,,,153.41000,44.49000,Aetna,First Health,,125.49,,,,,,,55.30,125.49,percent of total billed charges,
Milrinone 20mg/D5W 100mL,8726113,CDM,636,RC,J2260,HCPCS,,,facility,outpatient,,,153.41000,44.49000,Aetna,First Health,,125.49,,,,,,,1.30,125.49,percent of total billed charges,
Dupilumab 200mg- Pt Own Supply,8726116,CDM,636,RC,C9399,HCPCS,,,facility,inpatient,,,0.04000,0.01000,Aetna,First Health,,0.03272,,,,,,,0.01442,0.03272,percent of total billed charges,
Dupilumab 200mg- Pt Own Supply,8726116,CDM,636,RC,C9399,HCPCS,,,facility,outpatient,,,0.04000,0.01000,Aetna,First Health,,0.03272,,,,,,,0.01442,0.03272,percent of total billed charges,
Midazolam 100mg/NS 100mL IV,8726120,CDM,636,RC,J2250,HCPCS,,,facility,inpatient,,,223.53000,64.82000,Aetna,First Health,,182.85,,,,,,,80.58,182.85,percent of total billed charges,
Midazolam 100mg/NS 100mL IV,8726120,CDM,636,RC,J2250,HCPCS,,,facility,outpatient,,,223.53000,64.82000,Aetna,First Health,,182.85,,,,,,,0.13482,182.85,percent of total billed charges,
Pembrolizumab 25mg/mL Inj 4mL,8726129,CDM,636,RC,J9271,HCPCS,,,facility,inpatient,,,31410.25000,9108.97000,Aetna,First Health,,25693.58,,,,,,,11323.40,25693.58,percent of total billed charges,
Pembrolizumab 25mg/mL Inj 4mL,8726129,CDM,636,RC,J9271,HCPCS,,,facility,outpatient,,,31410.25000,9108.97000,Aetna,First Health,,25693.58,,,,,,,57.52,25693.58,percent of total billed charges,
Nalbuphine 10mg/mL I (Nubain),8725074,CDM,636,RC,J2300,HCPCS,,,facility,inpatient,,,29.76000,8.63000,Aetna,First Health,,24.34,,,,,,,10.73,24.34,percent of total billed charges,
Nalbuphine 10mg/mL I (Nubain),8725074,CDM,636,RC,J2300,HCPCS,,,facility,outpatient,,,29.76000,8.63000,Aetna,First Health,,24.34,,,,,,,3.32,24.34,percent of total billed charges,
Tezepelumab-ekko 210mg Inj (Tezspire),8924941,CDM,636,RC,J2356,HCPCS,,,facility,inpatient,,,17595.95000,5102.83000,Aetna,First Health,,14393.49,,,,,,,6343.34,14393.49,percent of total billed charges,
Tezepelumab-ekko 210mg Inj (Tezspire),8924941,CDM,636,RC,J2356,HCPCS,,,facility,outpatient,,,17595.95000,5102.83000,Aetna,First Health,,14393.49,,,,,,,17.16,14393.49,percent of total billed charges,
Pneumococcal 20-Valent Conjugate Vaccine,8924967,CDM,636,RC,90677,HCPCS,,,facility,inpatient,,,1264.62000,366.74000,Aetna,First Health,,1034.46,,,,,,,455.90,1034.46,percent of total billed charges,
Pneumococcal 20-Valent Conjugate Vaccine,8924967,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,1264.62000,366.74000,Aetna,First Health,,1034.46,,,,,,,301.32,1034.46,percent of total billed charges,
romiPLOStim 125mcg Inj,8924973,CDM,636,RC,J2802,HCPCS,,,facility,inpatient,,,5674.10000,1645.49000,Aetna,First Health,,4641.41,,,,,,,2045.51,4641.41,percent of total billed charges,
romiPLOStim 125mcg Inj,8924973,CDM,636,RC,J2802,HCPCS,,,facility,outpatient,,,5674.10000,1645.49000,Aetna,First Health,,4641.41,,,,,,,10.64,4641.41,percent of total billed charges,
ceFAZolin 2g Inj (Ancef),8924974,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,58.50000,16.96000,Aetna,First Health,,47.85,,,,,,,21.09,47.85,percent of total billed charges,
ceFAZolin 2g Inj (Ancef),8924974,CDM,636,RC,J0690,HCPCS,,,facility,outpatient,,,58.50000,16.96000,Aetna,First Health,,47.85,,,,,,,0.79929,47.85,percent of total billed charges,
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,8924975,CDM,636,RC,J1953,HCPCS,,,facility,inpatient,,,385.93000,111.92000,Aetna,First Health,,315.69,,,,,,,139.13,315.69,percent of total billed charges,
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,8924975,CDM,636,RC,J1953,HCPCS,,,facility,outpatient,,,385.93000,111.92000,Aetna,First Health,,315.69,,,,,,,0.03852,315.69,percent of total billed charges,
leuprolide 22.5mg/3 month(Eligard),8947246,CDM,636,RC,J9217,HCPCS,,,facility,inpatient,,,5588.60000,1620.69000,Aetna,First Health,,4571.47,,,,,,,2014.69,4571.47,percent of total billed charges,
leuprolide 22.5mg/3 month(Eligard),8947246,CDM,636,RC,J9217,HCPCS,,,facility,outpatient,,,5588.60000,1620.69000,Aetna,First Health,,4571.47,,,,,,,164.46,4571.47,percent of total billed charges,
ravulizumab-cwvz- Pt Own Supply,8970141,CDM,636,RC,J1303,HCPCS,,,facility,inpatient,,,0.13000,0.04000,Aetna,First Health,,0.10634,,,,,,,0.04686,0.10634,percent of total billed charges,
ravulizumab-cwvz- Pt Own Supply,8970141,CDM,636,RC,J1303,HCPCS,,,facility,outpatient,,,0.13000,0.04000,Aetna,First Health,,0.10634,,,,,,,0.04810,693.28,percent of total billed charges,
Oxytocin 30 unit/500 mL-NaCl 0.9%,8975604,CDM,636,RC,J2590,HCPCS,,,facility,inpatient,,,278.63000,80.80000,Aetna,First Health,,227.92,,,,,,,100.45,227.92,percent of total billed charges,
Oxytocin 30 unit/500 mL-NaCl 0.9%,8975604,CDM,636,RC,J2590,HCPCS,,,facility,outpatient,,,278.63000,80.80000,Aetna,First Health,,227.92,,,,,,,1.00,227.92,percent of total billed charges,
micafungin 100mg Inj,8984065,CDM,636,RC,J2248,HCPCS,,,facility,inpatient,,,441.20000,127.95000,Aetna,First Health,,360.90,,,,,,,159.05,360.90,percent of total billed charges,
micafungin 100mg Inj,8984065,CDM,636,RC,J2248,HCPCS,,,facility,outpatient,,,441.20000,127.95000,Aetna,First Health,,360.90,,,,,,,0.24075,360.90,percent of total billed charges,
Lurbinectedin 4mg Inj (Zepzelca),8985202,CDM,636,RC,J9223,HCPCS,,,facility,inpatient,,,58579.00000,16987.91000,Aetna,First Health,,47917.62,,,,,,,21117.73,47917.62,percent of total billed charges,
Lurbinectedin 4mg Inj (Zepzelca),8985202,CDM,636,RC,J9223,HCPCS,,,facility,outpatient,,,58579.00000,16987.91000,Aetna,First Health,,47917.62,,,,,,,202.98,47917.62,percent of total billed charges,
Pegfilgrastim-apgf 6 mg/0.6 mL Inj Syr,8986793,CDM,636,RC,Q5122,HCPCS,,,facility,inpatient,,,30805.00000,8933.45000,Aetna,First Health,,25198.49,,,,,,,11105.20,25198.49,percent of total billed charges,
Pegfilgrastim-apgf 6 mg/0.6 mL Inj Syr,8986793,CDM,636,RC,Q5122,HCPCS,,,facility,outpatient,,,30805.00000,8933.45000,Aetna,First Health,,25198.49,,,,,,,128.13,25198.49,percent of total billed charges,
Trastuzumab- qyyp 420mg Inj,8986794,CDM,636,RC,Q5116,HCPCS,,,facility,inpatient,,,18498.85000,5364.67000,Aetna,First Health,,15132.06,,,,,,,6668.84,15132.06,percent of total billed charges,
Trastuzumab- qyyp 420mg Inj,8986794,CDM,636,RC,Q5116,HCPCS,,,facility,outpatient,,,18498.85000,5364.67000,Aetna,First Health,,15132.06,,,,,,,7.91,15132.06,percent of total billed charges,
Trastuzumab- qyyp 150mg Inj,8986795,CDM,636,RC,Q5116,HCPCS,,,facility,inpatient,,,6726.95000,1950.82000,Aetna,First Health,,5502.65,,,,,,,2425.07,5502.65,percent of total billed charges,
Trastuzumab- qyyp 150mg Inj,8986795,CDM,636,RC,Q5116,HCPCS,,,facility,outpatient,,,6726.95000,1950.82000,Aetna,First Health,,5502.65,,,,,,,7.91,5502.65,percent of total billed charges,
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,8986952,CDM,636,RC,Q5108,HCPCS,,,facility,inpatient,,,9823.39000,2848.78000,Aetna,First Health,,8035.53,,,,,,,3541.33,8035.53,percent of total billed charges,
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,8986952,CDM,636,RC,Q5108,HCPCS,,,facility,outpatient,,,9823.39000,2848.78000,Aetna,First Health,,8035.53,,,,,,,95.21,8035.53,percent of total billed charges,
Filgrastim- aafi 300mcg Inj Syr,8988270,CDM,636,RC,Q5110,HCPCS,,,facility,inpatient,,,1125.83000,326.49000,Aetna,First Health,,920.93,,,,,,,405.86,920.93,percent of total billed charges,
Filgrastim- aafi 300mcg Inj Syr,8988270,CDM,636,RC,Q5110,HCPCS,,,facility,outpatient,,,1125.83000,326.49000,Aetna,First Health,,920.93,,,,,,,0.26964,920.93,percent of total billed charges,
Filgrastim- aafi 480mcg Inj Syr,8986962,CDM,636,RC,Q5110,HCPCS,,,facility,inpatient,,,1586.00000,459.94000,Aetna,First Health,,1297.35,,,,,,,571.75,1297.35,percent of total billed charges,
Filgrastim- aafi 480mcg Inj Syr,8986962,CDM,636,RC,Q5110,HCPCS,,,facility,outpatient,,,1586.00000,459.94000,Aetna,First Health,,1297.35,,,,,,,0.26964,1297.35,percent of total billed charges,
Diatrizoate Meglumine 30% I 100mL,8995784,CDM,636,RC,Q9958,HCPCS,,,facility,inpatient,,,309.00000,89.61000,Aetna,First Health,,252.76,,,,,,,111.39,252.76,percent of total billed charges,
Diatrizoate Meglumine 30% I 100mL,8995784,CDM,636,RC,Q9958,HCPCS,,,facility,outpatient,,,309.00000,89.61000,Aetna,First Health,,252.76,,,,,,,0.06741,252.76,percent of total billed charges,
Methocarbamol 1g/10mL Inj,8723383,CDM,636,RC,J2800,HCPCS,,,facility,inpatient,,,76.80000,22.27000,Aetna,First Health,,62.82,,,,,,,27.69,62.82,percent of total billed charges,
Methocarbamol 1g/10mL Inj,8723383,CDM,636,RC,J2800,HCPCS,,,facility,outpatient,,,76.80000,22.27000,Aetna,First Health,,62.82,,,,,,,4.37,62.82,percent of total billed charges,
Inclisiran 284mg/1.5 mL IS (Leqvio),9000458,CDM,636,RC,J1306,HCPCS,,,facility,inpatient,,,13629.70000,3952.61000,Aetna,First Health,,11149.09,,,,,,,4913.51,11149.09,percent of total billed charges,
Inclisiran 284mg/1.5 mL IS (Leqvio),9000458,CDM,636,RC,J1306,HCPCS,,,facility,outpatient,,,13629.70000,3952.61000,Aetna,First Health,,11149.09,,,,,,,12.22,11149.09,percent of total billed charges,
inFLIXimab - axxq 100mg Inj,9000600,CDM,636,RC,Q5121,HCPCS,,,facility,inpatient,,,3787.00000,1098.23000,Aetna,First Health,,3097.77,,,,,,,1365.21,3097.77,percent of total billed charges,
inFLIXimab - axxq 100mg Inj,9000600,CDM,636,RC,Q5121,HCPCS,,,facility,outpatient,,,3787.00000,1098.23000,Aetna,First Health,,3097.77,,,,,,,22.93,3097.77,percent of total billed charges,
Eravacycline 100mg REC Inj,9003760,CDM,636,RC,J0122,HCPCS,,,facility,inpatient,,,997.00000,289.13000,Aetna,First Health,,815.55,,,,,,,359.42,815.55,percent of total billed charges,
Eravacycline 100mg REC Inj,9003760,CDM,636,RC,J0122,HCPCS,,,facility,outpatient,,,997.00000,289.13000,Aetna,First Health,,815.55,,,,,,,1.24,815.55,percent of total billed charges,
inFLIXimab - abda 100mg Inj,9004122,CDM,636,RC,Q5104,HCPCS,,,facility,inpatient,,,5611.45000,1627.32000,Aetna,First Health,,4590.17,,,,,,,2022.93,4590.17,percent of total billed charges,
inFLIXimab - abda 100mg Inj,9004122,CDM,636,RC,Q5104,HCPCS,,,facility,outpatient,,,5611.45000,1627.32000,Aetna,First Health,,4590.17,,,,,,,26.72,4590.17,percent of total billed charges,
Fluorouracil 2.5g/50mL Inj,9005006,CDM,636,RC,J9190,HCPCS,,,facility,inpatient,,,140.65000,40.79000,Aetna,First Health,,115.05,,,,,,,50.70,115.05,percent of total billed charges,
Fluorouracil 2.5g/50mL Inj,9005006,CDM,636,RC,J9190,HCPCS,,,facility,outpatient,,,140.65000,40.79000,Aetna,First Health,,115.05,,,,,,,1.87,115.05,percent of total billed charges,
Methotrexate 50mg/2mL Inj,9006348,CDM,636,RC,J9260,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.04,61.35,percent of total billed charges,
Methotrexate 50mg/2mL Inj,9006348,CDM,636,RC,J9260,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,2.48,61.35,percent of total billed charges,
Dupilumab 300mg/2mL Inj,9010087,CDM,636,RC,C9399,HCPCS,,,facility,inpatient,,,8144.80000,2361.99000,Aetna,First Health,,6662.45,,,,,,,2936.20,6662.45,percent of total billed charges,
Dupilumab 300mg/2mL Inj,9010087,CDM,636,RC,C9399,HCPCS,,,facility,outpatient,,,8144.80000,2361.99000,Aetna,First Health,,6662.45,,,,,,,2936.20,6662.45,percent of total billed charges,
golimumab 50mg/4mL Inj,9011879,CDM,636,RC,J1602,HCPCS,,,facility,inpatient,,,14581.20000,4228.55000,Aetna,First Health,,11927.42,,,,,,,5256.52,11927.42,percent of total billed charges,
golimumab 50mg/4mL Inj,9011879,CDM,636,RC,J1602,HCPCS,,,facility,outpatient,,,14581.20000,4228.55000,Aetna,First Health,,11927.42,,,,,,,11.20,11927.42,percent of total billed charges,
cangrelor 50mg Inj,9025117,CDM,636,RC,C9460,HCPCS,,,facility,inpatient,,,7395.65000,2144.74000,Aetna,First Health,,6049.64,,,,,,,2666.13,6049.64,percent of total billed charges,
cangrelor 50mg Inj,9025117,CDM,636,RC,C9460,HCPCS,,,facility,outpatient,,,7395.65000,2144.74000,Aetna,First Health,,6049.64,,,,,,,19.94,6049.64,percent of total billed charges,
Certolizumab Pegol Lypholized Kit,9024406,CDM,636,RC,J0717,HCPCS,,,facility,inpatient,,,19375.20000,5618.81000,Aetna,First Health,,15848.91,,,,,,,6984.76,15848.91,percent of total billed charges,
Certolizumab Pegol Lypholized Kit,9024406,CDM,636,RC,J0717,HCPCS,,,facility,outpatient,,,19375.20000,5618.81000,Aetna,First Health,,15848.91,,,,,,,3.73,15848.91,percent of total billed charges,
Lecanemab - irmb 500mg Inj,9021927,CDM,636,RC,J0174,HCPCS,,,facility,inpatient,,,4822.13000,1398.42000,Aetna,First Health,,3944.50,,,,,,,1738.38,3944.50,percent of total billed charges,
Lecanemab - irmb 500mg Inj,9021927,CDM,636,RC,J0174,HCPCS,,,facility,outpatient,,,4822.13000,1398.42000,Aetna,First Health,,3944.50,,,,,,,1.28,3944.50,percent of total billed charges,
Lecanemab - irmb 200mg Inj,9024790,CDM,636,RC,J0174,HCPCS,,,facility,inpatient,,,2071.06000,600.61000,Aetna,First Health,,1694.13,,,,,,,746.62,1694.13,percent of total billed charges,
Lecanemab - irmb 200mg Inj,9024790,CDM,636,RC,J0174,HCPCS,,,facility,outpatient,,,2071.06000,600.61000,Aetna,First Health,,1694.13,,,,,,,1.28,1694.13,percent of total billed charges,
Morphine 5mg/10mL PF I,8723436,CDM,636,RC,J2274,HCPCS,,,facility,inpatient,,,198.64000,57.61000,Aetna,First Health,,162.49,,,,,,,71.61,162.49,percent of total billed charges,
Morphine 5mg/10mL PF I,8723436,CDM,636,RC,J2274,HCPCS,,,facility,outpatient,,,198.64000,57.61000,Aetna,First Health,,162.49,,,,,,,13.00,162.49,percent of total billed charges,
Morphine 10mg/10mL PF,8723433,CDM,636,RC,J2274,HCPCS,,,facility,inpatient,,,199.18000,57.76000,Aetna,First Health,,162.93,,,,,,,71.80,162.93,percent of total billed charges,
Morphine 10mg/10mL PF,8723433,CDM,636,RC,J2274,HCPCS,,,facility,outpatient,,,199.18000,57.76000,Aetna,First Health,,162.93,,,,,,,13.00,162.93,percent of total billed charges,
Mannitol 25% I 50mL,8723584,CDM,636,RC,J2150,HCPCS,,,facility,inpatient,,,32.53000,9.43000,Aetna,First Health,,26.61,,,,,,,11.73,26.61,percent of total billed charges,
Mannitol 25% I 50mL,8723584,CDM,636,RC,J2150,HCPCS,,,facility,outpatient,,,32.53000,9.43000,Aetna,First Health,,26.61,,,,,,,11.73,26.61,percent of total billed charges,
Pembrolizumab 100mg/4mL Inj - Pt Own Supply,9044858,CDM,636,RC,J9271,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Pembrolizumab 100mg/4mL Inj - Pt Own Supply,9044858,CDM,636,RC,J9271,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,184.21,percent of total billed charges,
Pertuzumab 420 mg Inj- Pt Own Supply,9044856,CDM,636,RC,J9306,HCPCS,,,facility,inpatient,,,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05407,0.12270,percent of total billed charges,
Pertuzumab 420 mg Inj- Pt Own Supply,9044856,CDM,636,RC,J9306,HCPCS,,,facility,outpatient,,,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05550,52.46,percent of total billed charges,
riTUXimab-pvvr 100mg- Pt Own Supply,9046659,CDM,636,RC,Q5119,HCPCS,,,facility,inpatient,,,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
riTUXimab-pvvr 100mg- Pt Own Supply,9046659,CDM,636,RC,Q5119,HCPCS,,,facility,outpatient,,,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,40.92,percent of total billed charges,
nirsevimab - alip 50mg/0.5mL PF IS,9044695,CDM,636,RC,90380,HCPCS,,,facility,inpatient,,,2405.65000,697.64000,Aetna,First Health,,1967.82,,,,,,,867.24,1967.82,percent of total billed charges,
nirsevimab - alip 50mg/0.5mL PF IS,9044695,CDM,636,RC,90380,HCPCS,,,facility,outpatient,,,2405.65000,697.64000,Aetna,First Health,,1967.82,,,,,,,600.62,1967.82,percent of total billed charges,
daratumumab-hyaluronidase fihj Inj - Pt Own Supply,9044863,CDM,636,RC,J9144,HCPCS,,,facility,inpatient,,,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05407,0.12270,percent of total billed charges,
daratumumab-hyaluronidase fihj Inj - Pt Own Supply,9044863,CDM,636,RC,J9144,HCPCS,,,facility,outpatient,,,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05550,169.81,percent of total billed charges,
Nivolumab 120mg Inj - Pt Own Supply,9074454,CDM,636,RC,J9299,HCPCS,,,facility,inpatient,,,0.13000,0.04000,Aetna,First Health,,0.10634,,,,,,,0.04686,0.10634,percent of total billed charges,
Nivolumab 120mg Inj - Pt Own Supply,9074454,CDM,636,RC,J9299,HCPCS,,,facility,outpatient,,,0.13000,0.04000,Aetna,First Health,,0.10634,,,,,,,0.04810,103.53,percent of total billed charges,
Nivolumab 240mg Inj - Pt Own Supply,9046662,CDM,636,RC,J9299,HCPCS,,,facility,inpatient,,,0.25000,0.07000,Aetna,First Health,,0.20450,,,,,,,0.09012,0.20450,percent of total billed charges,
Nivolumab 240mg Inj - Pt Own Supply,9046662,CDM,636,RC,J9299,HCPCS,,,facility,outpatient,,,0.25000,0.07000,Aetna,First Health,,0.20450,,,,,,,0.09250,103.53,percent of total billed charges,
riTUXimab-pvvr 500mg- Pt Own Supply,9057005,CDM,636,RC,Q5119,HCPCS,,,facility,inpatient,,,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.18025,0.40900,percent of total billed charges,
riTUXimab-pvvr 500mg- Pt Own Supply,9057005,CDM,636,RC,Q5119,HCPCS,,,facility,outpatient,,,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.18500,40.92,percent of total billed charges,
Tezepelumab-ekko - Pt Own Supply,9044865,CDM,636,RC,J2356,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Tezepelumab-ekko - Pt Own Supply,9044865,CDM,636,RC,J2356,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,54.96,percent of total billed charges,
Denosumab 120mg Inj - Pt Own Supply,9046522,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Denosumab 120mg Inj - Pt Own Supply,9046522,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,90.85,percent of total billed charges,
Alpha 1-Proteinase inhibitor human 10mg I(Zemaira),9060183,CDM,636,RC,J0256,HCPCS,,,facility,inpatient,,,44.41000,12.88000,Aetna,First Health,,36.33,,,,,,,16.01,36.33,percent of total billed charges,
Alpha 1-Proteinase inhibitor human 10mg I(Zemaira),9060183,CDM,636,RC,J0256,HCPCS,,,facility,outpatient,,,44.41000,12.88000,Aetna,First Health,,36.33,,,,,,,5.17,36.33,percent of total billed charges,
Dupilumab 300mg- Pt Own Supply,9057587,CDM,636,RC,C9399,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Dupilumab 300mg- Pt Own Supply,9057587,CDM,636,RC,C9399,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Romosozumag-aqqg 105mg - Pt Own Supply,9068266,CDM,636,RC,J3111,HCPCS,,,facility,inpatient,,,0.03000,0.01000,Aetna,First Health,,0.02454,,,,,,,0.01081,0.02454,percent of total billed charges,
Romosozumag-aqqg 105mg - Pt Own Supply,9068266,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,0.03000,0.01000,Aetna,First Health,,0.02454,,,,,,,0.01110,37.35,percent of total billed charges,
omalizumab 300mg/2mL IS(Xolair),9068278,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,11473.65000,3327.36000,Aetna,First Health,,9385.45,,,,,,,4136.25,9385.45,percent of total billed charges,
omalizumab 300mg/2mL IS(Xolair),9068278,CDM,636,RC,J2357,HCPCS,,,facility,outpatient,,,11473.65000,3327.36000,Aetna,First Health,,9385.45,,,,,,,43.82,9385.45,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 1mL I,9068276,CDM,636,RC,J3010,HCPCS,,,facility,inpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,12.62,28.63,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 1mL I,9068276,CDM,636,RC,J3010,HCPCS,,,facility,outpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,1.15,28.63,percent of total billed charges,
Trastuzumab- dkst 150mg Inj,9074395,CDM,636,RC,Q5114,HCPCS,,,facility,inpatient,,,5265.75000,1527.07000,Aetna,First Health,,4307.38,,,,,,,1898.30,4307.38,percent of total billed charges,
Trastuzumab- dkst 150mg Inj,9074395,CDM,636,RC,Q5114,HCPCS,,,facility,outpatient,,,5265.75000,1527.07000,Aetna,First Health,,4307.38,,,,,,,36.31,4307.38,percent of total billed charges,
Trastuzumab- dkst 420mg Inj,9074394,CDM,636,RC,Q5114,HCPCS,,,facility,inpatient,,,14362.30000,4165.07000,Aetna,First Health,,11748.36,,,,,,,5177.61,11748.36,percent of total billed charges,
Trastuzumab- dkst 420mg Inj,9074394,CDM,636,RC,Q5114,HCPCS,,,facility,outpatient,,,14362.30000,4165.07000,Aetna,First Health,,11748.36,,,,,,,36.31,11748.36,percent of total billed charges,
Canakinumab 150 mg/mL - Pt Own Supply,9072486,CDM,636,RC,J0638,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Canakinumab 150 mg/mL - Pt Own Supply,9072486,CDM,636,RC,J0638,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,455.63,percent of total billed charges,
Lecanemab-irmb 200mg- Pt Own Supply,9074459,CDM,636,RC,J0174,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Lecanemab-irmb 200mg- Pt Own Supply,9074459,CDM,636,RC,J0174,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,4.10,percent of total billed charges,
Lecanemab-irmb 500mg- Pt Own Supply,9072487,CDM,636,RC,J0174,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Lecanemab-irmb 500mg- Pt Own Supply,9072487,CDM,636,RC,J0174,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,4.10,percent of total billed charges,
Omalizumab 300mg- Pt Own Supply,9072488,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Omalizumab 300mg- Pt Own Supply,9072488,CDM,636,RC,J2357,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,140.32,percent of total billed charges,
durvalumab 500mg/10mL Inj - Pt Own Supply,9076540,CDM,636,RC,J9173,HCPCS,,,facility,inpatient,,,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
durvalumab 500mg/10mL Inj - Pt Own Supply,9076540,CDM,636,RC,J9173,HCPCS,,,facility,outpatient,,,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,266.06,percent of total billed charges,
Benralizumab 30mg IS (Fasenra),9076702,CDM,636,RC,J0517,HCPCS,,,facility,inpatient,,,22806.20000,6613.80000,Aetna,First Health,,18655.47,,,,,,,8221.64,18655.47,percent of total billed charges,
Benralizumab 30mg IS (Fasenra),9076702,CDM,636,RC,J0517,HCPCS,,,facility,outpatient,,,22806.20000,6613.80000,Aetna,First Health,,18655.47,,,,,,,157.90,18655.47,percent of total billed charges,
Phytonadione 1mg/0.5mL Inj - Alum Free,9080753,CDM,636,RC,J3430,HCPCS,,,facility,inpatient,,,144.14000,41.80000,Aetna,First Health,,117.91,,,,,,,51.96,117.91,percent of total billed charges,
Phytonadione 1mg/0.5mL Inj - Alum Free,9080753,CDM,636,RC,J3430,HCPCS,,,facility,outpatient,,,144.14000,41.80000,Aetna,First Health,,117.91,,,,,,,2.71,117.91,percent of total billed charges,
Ublituximab - xiiy 150mg- Pt Own Supply,9082778,CDM,636,RC,J2329,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.04,61.35,percent of total billed charges,
Ublituximab - xiiy 150mg- Pt Own Supply,9082778,CDM,636,RC,J2329,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.75,216.44,percent of total billed charges,
polatuzumab vedotin - piiq 30mg I(Polivy),9085020,CDM,636,RC,J9309,HCPCS,,,facility,inpatient,,,28901.85000,8381.54000,Aetna,First Health,,23641.71,,,,,,,10419.12,23641.71,percent of total billed charges,
polatuzumab vedotin - piiq 30mg I(Polivy),9085020,CDM,636,RC,J9309,HCPCS,,,facility,outpatient,,,28901.85000,8381.54000,Aetna,First Health,,23641.71,,,,,,,131.71,23641.71,percent of total billed charges,
polatuzumab vedotin - piiq 140mg I(Polivy),9085021,CDM,636,RC,J9309,HCPCS,,,facility,inpatient,,,134189.20000,38914.87000,Aetna,First Health,,109766.77,,,,,,,48375.21,109766.77,percent of total billed charges,
polatuzumab vedotin - piiq 140mg I(Polivy),9085021,CDM,636,RC,J9309,HCPCS,,,facility,outpatient,,,134189.20000,38914.87000,Aetna,First Health,,109766.77,,,,,,,131.71,109766.77,percent of total billed charges,
ipilimumab 50mg/10mL I(Yervoy),9085022,CDM,636,RC,J9228,HCPCS,,,facility,inpatient,,,64907.71000,18823.24000,Aetna,First Health,,53094.51,,,,,,,23399.23,53094.51,percent of total billed charges,
ipilimumab 50mg/10mL I(Yervoy),9085022,CDM,636,RC,J9228,HCPCS,,,facility,outpatient,,,64907.71000,18823.24000,Aetna,First Health,,53094.51,,,,,,,179.99,53094.51,percent of total billed charges,
"Influenza Virus Vaccine, Inact Trivalent Inj",9083697,CDM,636,RC,90656,HCPCS,,,facility,inpatient,,,126.05000,36.55000,Aetna,First Health,,103.11,,,,,,,45.44,103.11,percent of total billed charges,
"Influenza Virus Vaccine, Inact Trivalent Inj",9083697,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,126.05000,36.55000,Aetna,First Health,,103.11,,,,,,,14.13,103.11,percent of total billed charges,
durvalumab 500mg/10mL (Imfinzi),9085110,CDM,636,RC,J9173,HCPCS,,,facility,inpatient,,,30229.52000,8766.56000,Aetna,First Health,,24727.75,,,,,,,10897.74,24727.75,percent of total billed charges,
durvalumab 500mg/10mL (Imfinzi),9085110,CDM,636,RC,J9173,HCPCS,,,facility,outpatient,,,30229.52000,8766.56000,Aetna,First Health,,24727.75,,,,,,,83.08,24727.75,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",8723506,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,37.03000,10.74000,Aetna,First Health,,30.29,,,,,,,13.35,30.29,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",8723506,CDM,636,RC,J2004,HCPCS,,,facility,outpatient,,,37.03000,10.74000,Aetna,First Health,,30.29,,,,,,,0.00963,30.29,percent of total billed charges,
belimumab 120mg REC Inj(Benlysta),9024968,CDM,636,RC,J0490,HCPCS,,,facility,inpatient,,,3672.70000,1065.08000,Aetna,First Health,,3004.27,,,,,,,1324.01,3004.27,percent of total billed charges,
belimumab 120mg REC Inj(Benlysta),9024968,CDM,636,RC,J0490,HCPCS,,,facility,outpatient,,,3672.70000,1065.08000,Aetna,First Health,,3004.27,,,,,,,55.05,3004.27,percent of total billed charges,
belimumab 400mg REC Inj (Benlysta),9022076,CDM,636,RC,J0490,HCPCS,,,facility,inpatient,,,11840.30000,3433.69000,Aetna,First Health,,9685.37,,,,,,,4268.43,9685.37,percent of total billed charges,
belimumab 400mg REC Inj (Benlysta),9022076,CDM,636,RC,J0490,HCPCS,,,facility,outpatient,,,11840.30000,3433.69000,Aetna,First Health,,9685.37,,,,,,,55.05,9685.37,percent of total billed charges,
"daratumumab-hyaluronidase fihj 1800 mg-30,000 units/15 mL I",9041323,CDM,636,RC,J9144,HCPCS,,,facility,inpatient,,,54309.25000,15749.68000,Aetna,First Health,,44424.97,,,,,,,19578.48,44424.97,percent of total billed charges,
"daratumumab-hyaluronidase fihj 1800 mg-30,000 units/15 mL I",9041323,CDM,636,RC,J9144,HCPCS,,,facility,outpatient,,,54309.25000,15749.68000,Aetna,First Health,,44424.97,,,,,,,53.02,44424.97,percent of total billed charges,
Denosumab 60mg/1mL - Pt Own Supply,9043569,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Denosumab 60mg/1mL - Pt Own Supply,9043569,CDM,636,RC,J0897,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,90.85,percent of total billed charges,
NICU- DexAMETHasone 0.1mg/mL IV in D5W,9044404,CDM,636,RC,J1100,HCPCS,,,facility,inpatient,,,98.20000,28.48000,Aetna,First Health,,80.33,,,,,,,35.40,80.33,percent of total billed charges,
NICU- DexAMETHasone 0.1mg/mL IV in D5W,9044404,CDM,636,RC,J1100,HCPCS,,,facility,outpatient,,,98.20000,28.48000,Aetna,First Health,,80.33,,,,,,,0.10593,80.33,percent of total billed charges,
"Influenza Virus Vaccine, Inact High-Dose-Trivalent PF Inj",9086429,CDM,636,RC,90662,HCPCS,,,facility,inpatient,,,450.80000,130.73000,Aetna,First Health,,368.75,,,,,,,162.51,368.75,percent of total billed charges,
"Influenza Virus Vaccine, Inact High-Dose-Trivalent PF Inj",9086429,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,450.80000,130.73000,Aetna,First Health,,368.75,,,,,,,94.53,368.75,percent of total billed charges,
inFLIXimab - axxq - Pt Own Supply,9044864,CDM,636,RC,Q5121,HCPCS,,,facility,inpatient,,,0.03000,0.01000,Aetna,First Health,,0.02454,,,,,,,0.01081,0.02454,percent of total billed charges,
inFLIXimab - axxq - Pt Own Supply,9044864,CDM,636,RC,Q5121,HCPCS,,,facility,outpatient,,,0.03000,0.01000,Aetna,First Health,,0.02454,,,,,,,0.01110,73.43,percent of total billed charges,
cemiplimab - rwlc 350 mg/7 mL Soln,9091655,CDM,636,RC,J9119,HCPCS,,,facility,inpatient,,,58082.12000,16843.81000,Aetna,First Health,,47511.17,,,,,,,20938.60,47511.17,percent of total billed charges,
cemiplimab - rwlc 350 mg/7 mL Soln,9091655,CDM,636,RC,J9119,HCPCS,,,facility,outpatient,,,58082.12000,16843.81000,Aetna,First Health,,47511.17,,,,,,,27.63,47511.17,percent of total billed charges,
Nivolumab 120mg/12mL I(Opdivo),9094916,CDM,636,RC,J9299,HCPCS,,,facility,inpatient,,,21458.95000,6223.10000,Aetna,First Health,,17553.42,,,,,,,7735.95,17553.42,percent of total billed charges,
Nivolumab 120mg/12mL I(Opdivo),9094916,CDM,636,RC,J9299,HCPCS,,,facility,outpatient,,,21458.95000,6223.10000,Aetna,First Health,,17553.42,,,,,,,32.33,17553.42,percent of total billed charges,
efgartigimod alfa-hyaluronidase qvfc Inj - Pt Own Supply,9093230,CDM,636,RC,J9334,HCPCS,,,facility,inpatient,,,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
efgartigimod alfa-hyaluronidase qvfc Inj - Pt Own Supply,9093230,CDM,636,RC,J9334,HCPCS,,,facility,outpatient,,,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,105.23,percent of total billed charges,
Bevacizumab - adcd 400mg Inj,9093250,CDM,636,RC,Q5129,HCPCS,,,facility,inpatient,,,14818.85000,4297.47000,Aetna,First Health,,12121.82,,,,,,,5342.20,12121.82,percent of total billed charges,
Bevacizumab - adcd 400mg Inj,9093250,CDM,636,RC,Q5129,HCPCS,,,facility,outpatient,,,14818.85000,4297.47000,Aetna,First Health,,12121.82,,,,,,,36.75,12121.82,percent of total billed charges,
Bevacizumab - adcd 100mg Inj,9093249,CDM,636,RC,Q5129,HCPCS,,,facility,inpatient,,,4375.00000,1268.75000,Aetna,First Health,,3578.75,,,,,,,1577.19,3578.75,percent of total billed charges,
Bevacizumab - adcd 100mg Inj,9093249,CDM,636,RC,Q5129,HCPCS,,,facility,outpatient,,,4375.00000,1268.75000,Aetna,First Health,,3578.75,,,,,,,36.75,3578.75,percent of total billed charges,
enfortumab vedotin-ejfv 30mg I(Padcev),9100469,CDM,636,RC,J9177,HCPCS,,,facility,inpatient,,,22939.90000,6652.57000,Aetna,First Health,,18764.84,,,,,,,8269.83,18764.84,percent of total billed charges,
enfortumab vedotin-ejfv 30mg I(Padcev),9100469,CDM,636,RC,J9177,HCPCS,,,facility,outpatient,,,22939.90000,6652.57000,Aetna,First Health,,18764.84,,,,,,,35.36,18764.84,percent of total billed charges,
enfortumab vedotin-ejfv 20mg I(Padcev),9098881,CDM,636,RC,J9177,HCPCS,,,facility,inpatient,,,15355.60000,4453.12000,Aetna,First Health,,12560.88,,,,,,,5535.69,12560.88,percent of total billed charges,
enfortumab vedotin-ejfv 20mg I(Padcev),9098881,CDM,636,RC,J9177,HCPCS,,,facility,outpatient,,,15355.60000,4453.12000,Aetna,First Health,,12560.88,,,,,,,35.36,12560.88,percent of total billed charges,
atezolizumab 840mg/14mL Inj(Tecentriq),9101837,CDM,636,RC,J9022,HCPCS,,,facility,inpatient,,,47444.65000,13758.95000,Aetna,First Health,,38809.72,,,,,,,17103.80,38809.72,percent of total billed charges,
atezolizumab 840mg/14mL Inj(Tecentriq),9101837,CDM,636,RC,J9022,HCPCS,,,facility,outpatient,,,47444.65000,13758.95000,Aetna,First Health,,38809.72,,,,,,,90.44,38809.72,percent of total billed charges,
Panitumumab 400mg/20mL I(Vectibix),9104162,CDM,636,RC,J9303,HCPCS,,,facility,inpatient,,,39318.65000,11402.41000,Aetna,First Health,,32162.66,,,,,,,14174.37,32162.66,percent of total billed charges,
Panitumumab 400mg/20mL I(Vectibix),9104162,CDM,636,RC,J9303,HCPCS,,,facility,outpatient,,,39318.65000,11402.41000,Aetna,First Health,,32162.66,,,,,,,167.24,32162.66,percent of total billed charges,
PHENobarbital 130mg/1mL  Inj,8724035,CDM,636,RC,J2560,HCPCS,,,facility,inpatient,,,513.70000,148.97000,Aetna,First Health,,420.21,,,,,,,185.19,420.21,percent of total billed charges,
PHENobarbital 130mg/1mL  Inj,8724035,CDM,636,RC,J2560,HCPCS,,,facility,outpatient,,,513.70000,148.97000,Aetna,First Health,,420.21,,,,,,,28.00,420.21,percent of total billed charges,
tocilizumab- Pt Own Supply,9104640,CDM,636,RC,J3262,HCPCS,,,facility,inpatient,,,0.12000,0.03000,Aetna,First Health,,0.09816,,,,,,,0.04326,0.09816,percent of total billed charges,
tocilizumab- Pt Own Supply,9104640,CDM,636,RC,J3262,HCPCS,,,facility,outpatient,,,0.12000,0.03000,Aetna,First Health,,0.09816,,,,,,,0.04440,17.30,percent of total billed charges,
hemin 350mg Inj,9110073,CDM,636,RC,J1640,HCPCS,,,facility,inpatient,,,78958.55000,22897.98000,Aetna,First Health,,64588.09,,,,,,,28464.56,64588.09,percent of total billed charges,
hemin 350mg Inj,9110073,CDM,636,RC,J1640,HCPCS,,,facility,outpatient,,,78958.55000,22897.98000,Aetna,First Health,,64588.09,,,,,,,34.00,64588.09,percent of total billed charges,
risankizumab-rzaa- Pt Own Supply,9120431,CDM,636,RC,J2327,HCPCS,,,facility,inpatient,,,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
risankizumab-rzaa- Pt Own Supply,9120431,CDM,636,RC,J2327,HCPCS,,,facility,outpatient,,,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,46.04,percent of total billed charges,
romiPLOStim 125mcg I - Pt Own Supply,9120516,CDM,636,RC,J2802,HCPCS,,,facility,inpatient,,,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
romiPLOStim 125mcg I - Pt Own Supply,9120516,CDM,636,RC,J2802,HCPCS,,,facility,outpatient,,,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,34.08,percent of total billed charges,
pertuz/trastuz/hyal 10mL I-Maint. Dose,9124637,CDM,636,RC,J9316,HCPCS,,,facility,inpatient,,,66983.75000,19425.29000,Aetna,First Health,,54792.71,,,,,,,24147.64,54792.71,percent of total billed charges,
pertuz/trastuz/hyal 10mL I-Maint. Dose,9124637,CDM,636,RC,J9316,HCPCS,,,facility,outpatient,,,66983.75000,19425.29000,Aetna,First Health,,54792.71,,,,,,,58.70,54792.71,percent of total billed charges,
donanemab - azbt 350mg I,9142540,CDM,636,RC,J0175,HCPCS,,,facility,inpatient,,,5242.69000,1520.38000,Aetna,First Health,,4288.52,,,,,,,1889.99,4288.52,percent of total billed charges,
donanemab - azbt 350mg I,9142540,CDM,636,RC,J0175,HCPCS,,,facility,outpatient,,,5242.69000,1520.38000,Aetna,First Health,,4288.52,,,,,,,4.02,4288.52,percent of total billed charges,
guselkumab 200mg I - Pt Own Supply,9142543,CDM,636,RC,J1628,HCPCS,,,facility,inpatient,,,0.20000,0.06000,Aetna,First Health,,0.16360,,,,,,,0.07210,0.16360,percent of total billed charges,
guselkumab 200mg I - Pt Own Supply,9142543,CDM,636,RC,J1628,HCPCS,,,facility,outpatient,,,0.20000,0.06000,Aetna,First Health,,0.16360,,,,,,,0.07400,224.95,percent of total billed charges,
Dalbavancin 500mg I - Pt Own Supply,9160458,CDM,636,RC,J0875,HCPCS,,,facility,inpatient,,,0.03000,0.01000,Aetna,First Health,,0.02454,,,,,,,0.01081,0.02454,percent of total billed charges,
Dalbavancin 500mg I - Pt Own Supply,9160458,CDM,636,RC,J0875,HCPCS,,,facility,outpatient,,,0.03000,0.01000,Aetna,First Health,,0.02454,,,,,,,0.01110,48.08,percent of total billed charges,
Tremelimumab- actl- Pt Own Supply,9160457,CDM,636,RC,J9347,HCPCS,,,facility,inpatient,,,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05407,0.12270,percent of total billed charges,
Tremelimumab- actl- Pt Own Supply,9160457,CDM,636,RC,J9347,HCPCS,,,facility,outpatient,,,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05550,441.07,percent of total billed charges,
Dupilumab 200mg/1.14mL Inj,9176537,CDM,636,RC,C9399,HCPCS,,,facility,inpatient,,,8144.80000,2361.99000,Aetna,First Health,,6662.45,,,,,,,2936.20,6662.45,percent of total billed charges,
Dupilumab 200mg/1.14mL Inj,9176537,CDM,636,RC,C9399,HCPCS,,,facility,outpatient,,,8144.80000,2361.99000,Aetna,First Health,,6662.45,,,,,,,2936.20,6662.45,percent of total billed charges,
PACLItaxel PROTein-bound 100mg - Pt Own Supply,9182618,CDM,636,RC,J9264,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
PACLItaxel PROTein-bound 100mg - Pt Own Supply,9182618,CDM,636,RC,J9264,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,25.23,percent of total billed charges,
Bortezomib 3.5mg Inj- Pt Own Supply,9184441,CDM,636,RC,J9041,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.04,61.35,percent of total billed charges,
Bortezomib 3.5mg Inj- Pt Own Supply,9184441,CDM,636,RC,J9041,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,2.58,61.35,percent of total billed charges,
cemiplimab-rwlc 350mg/7mL I - Pt Own Supply,9184513,CDM,636,RC,J9119,HCPCS,,,facility,inpatient,,,25.09000,7.28000,Aetna,First Health,,20.52,,,,,,,9.04,20.52,percent of total billed charges,
cemiplimab-rwlc 350mg/7mL I - Pt Own Supply,9184513,CDM,636,RC,J9119,HCPCS,,,facility,outpatient,,,25.09000,7.28000,Aetna,First Health,,20.52,,,,,,,9.28,88.48,percent of total billed charges,
Atezolizumab 1200 mg- Pt Own Supply(Tecentriq),9208476,CDM,636,RC,J9022,HCPCS,,,facility,inpatient,,,0.20000,0.06000,Aetna,First Health,,0.16360,,,,,,,0.07210,0.16360,percent of total billed charges,
Atezolizumab 1200 mg- Pt Own Supply(Tecentriq),9208476,CDM,636,RC,J9022,HCPCS,,,facility,outpatient,,,0.20000,0.06000,Aetna,First Health,,0.16360,,,,,,,0.07400,289.62,percent of total billed charges,
Elotuzumab 300mg-Pt Own Supply,9212500,CDM,636,RC,J9176,HCPCS,,,facility,inpatient,,,0.02000,0.01000,Aetna,First Health,,0.01636,,,,,,,0.00721,0.01636,percent of total billed charges,
Elotuzumab 300mg-Pt Own Supply,9212500,CDM,636,RC,J9176,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Aetna,First Health,,0.01636,,,,,,,0.00740,24.80,percent of total billed charges,
Iron Sucrose 200mg/NS,9210781,CDM,636,RC,J1756,HCPCS,,,facility,inpatient,,,968.30000,280.81000,Aetna,First Health,,792.07,,,,,,,349.07,792.07,percent of total billed charges,
Iron Sucrose 200mg/NS,9210781,CDM,636,RC,J1756,HCPCS,,,facility,outpatient,,,968.30000,280.81000,Aetna,First Health,,792.07,,,,,,,0.23112,792.07,percent of total billed charges,
Iron Sucrose 300mg/NS,9216514,CDM,636,RC,J1756,HCPCS,,,facility,inpatient,,,1413.55000,409.93000,Aetna,First Health,,1156.28,,,,,,,509.58,1156.28,percent of total billed charges,
Iron Sucrose 300mg/NS,9216514,CDM,636,RC,J1756,HCPCS,,,facility,outpatient,,,1413.55000,409.93000,Aetna,First Health,,1156.28,,,,,,,0.23112,1156.28,percent of total billed charges,
DENOSUMAB-BBDZ 60MG/1ML(JUBBONTI),9218509,CDM,636,RC,Q5136,HCPCS,,,facility,inpatient,,,6580.90000,1908.46000,Aetna,First Health,,5383.18,,,,,,,2372.41,5383.18,percent of total billed charges,
DENOSUMAB-BBDZ 60MG/1ML(JUBBONTI),9218509,CDM,636,RC,Q5136,HCPCS,,,facility,outpatient,,,6580.90000,1908.46000,Aetna,First Health,,5383.18,,,,,,,27.19,5383.18,percent of total billed charges,
BEVACIZUMAB - BVZR 400MG INJ,9220617,CDM,636,RC,Q5118,HCPCS,,,facility,inpatient,,,13436.45000,3896.57000,Aetna,First Health,,10991.02,,,,,,,4843.84,10991.02,percent of total billed charges,
BEVACIZUMAB - BVZR 400MG INJ,9220617,CDM,636,RC,Q5118,HCPCS,,,facility,outpatient,,,13436.45000,3896.57000,Aetna,First Health,,10991.02,,,,,,,24.85,10991.02,percent of total billed charges,
BEVACIZUMAB - BVZR 100MG INJ,9220616,CDM,636,RC,Q5118,HCPCS,,,facility,inpatient,,,3499.40000,1014.83000,Aetna,First Health,,2862.51,,,,,,,1261.53,2862.51,percent of total billed charges,
BEVACIZUMAB - BVZR 100MG INJ,9220616,CDM,636,RC,Q5118,HCPCS,,,facility,outpatient,,,3499.40000,1014.83000,Aetna,First Health,,2862.51,,,,,,,24.85,2862.51,percent of total billed charges,
DENOSUMAB-BMWO 60MG/1ML(STOBOCLO),9226539,CDM,636,RC,Q5157,HCPCS,,,facility,inpatient,,,7288.15000,2113.56000,Aetna,First Health,,5961.71,,,,,,,2627.38,5961.71,percent of total billed charges,
DENOSUMAB-BMWO 60MG/1ML(STOBOCLO),9226539,CDM,636,RC,Q5157,HCPCS,,,facility,outpatient,,,7288.15000,2113.56000,Aetna,First Health,,5961.71,,,,,,,28.13,5961.71,percent of total billed charges,
CEFAZOLIN 3G INJ (ANCEF),9230530,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,84.25000,24.43000,Aetna,First Health,,68.92,,,,,,,30.37,68.92,percent of total billed charges,
CEFAZOLIN 3G INJ (ANCEF),9230530,CDM,636,RC,J0690,HCPCS,,,facility,outpatient,,,84.25000,24.43000,Aetna,First Health,,68.92,,,,,,,0.79929,68.92,percent of total billed charges,
IFOSFAMIDE 1G INJ (IFEX),8724327,CDM,636,RC,J9208,HCPCS,,,facility,inpatient,,,525.65000,152.44000,Aetna,First Health,,429.98,,,,,,,189.50,429.98,percent of total billed charges,
IFOSFAMIDE 1G INJ (IFEX),8724327,CDM,636,RC,J9208,HCPCS,,,facility,outpatient,,,525.65000,152.44000,Aetna,First Health,,429.98,,,,,,,23.92,429.98,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),8723629,CDM,636,RC,J1450,HCPCS,,,facility,inpatient,,,67.70000,19.63000,Aetna,First Health,,55.38,,,,,,,24.41,55.38,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),8723629,CDM,636,RC,J1450,HCPCS,,,facility,outpatient,,,67.70000,19.63000,Aetna,First Health,,55.38,,,,,,,4.31,55.38,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,8723853,CDM,636,RC,J1200,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,8723853,CDM,636,RC,J1200,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.68373,20.45,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),8724123,CDM,636,RC,J1110,HCPCS,,,facility,inpatient,,,775.35000,224.85000,Aetna,First Health,,634.24,,,,,,,279.51,634.24,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),8724123,CDM,636,RC,J1110,HCPCS,,,facility,outpatient,,,775.35000,224.85000,Aetna,First Health,,634.24,,,,,,,54.97,634.24,percent of total billed charges,
Morphine 10mg/1mL PF Inj,8725868,CDM,636,RC,J2274,HCPCS,,,facility,inpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,12.62,28.63,percent of total billed charges,
Morphine 10mg/1mL PF Inj,8725868,CDM,636,RC,J2274,HCPCS,,,facility,outpatient,,,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,12.95,41.63,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,8723402,CDM,636,RC,J0330,HCPCS,,,facility,inpatient,,,127.55000,36.99000,Aetna,First Health,,104.34,,,,,,,45.98,104.34,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,8723402,CDM,636,RC,J0330,HCPCS,,,facility,outpatient,,,127.55000,36.99000,Aetna,First Health,,104.34,,,,,,,0.93411,104.34,percent of total billed charges,
"Epoetin alfa - epbx 3,000units/mL PF Inj",8725942,CDM,636,RC,Q5106,HCPCS,,,facility,inpatient,,,213.30000,61.86000,Aetna,First Health,,174.48,,,,,,,76.89,174.48,percent of total billed charges,
"Epoetin alfa - epbx 3,000units/mL PF Inj",8725942,CDM,636,RC,Q5106,HCPCS,,,facility,outpatient,,,213.30000,61.86000,Aetna,First Health,,174.48,,,,,,,7.29,174.48,percent of total billed charges,
"Epoetin alfa - epbx 4,000units/mL PF Inj",8725943,CDM,636,RC,Q5106,HCPCS,,,facility,inpatient,,,274.40000,79.58000,Aetna,First Health,,224.46,,,,,,,98.92,224.46,percent of total billed charges,
"Epoetin alfa - epbx 4,000units/mL PF Inj",8725943,CDM,636,RC,Q5106,HCPCS,,,facility,outpatient,,,274.40000,79.58000,Aetna,First Health,,224.46,,,,,,,7.29,224.46,percent of total billed charges,
"Epoetin alfa - epbx 10,000units/mL PF Inj",8725944,CDM,636,RC,Q5106,HCPCS,,,facility,inpatient,,,646.93000,187.61000,Aetna,First Health,,529.19,,,,,,,233.22,529.19,percent of total billed charges,
"Epoetin alfa - epbx 10,000units/mL PF Inj",8725944,CDM,636,RC,Q5106,HCPCS,,,facility,outpatient,,,646.93000,187.61000,Aetna,First Health,,529.19,,,,,,,7.29,529.19,percent of total billed charges,
"Epoetin alfa - epbx 40,000units/mL PF Inj",8725945,CDM,636,RC,Q5106,HCPCS,,,facility,inpatient,,,1947.75000,564.85000,Aetna,First Health,,1593.26,,,,,,,702.16,1593.26,percent of total billed charges,
"Epoetin alfa - epbx 40,000units/mL PF Inj",8725945,CDM,636,RC,Q5106,HCPCS,,,facility,outpatient,,,1947.75000,564.85000,Aetna,First Health,,1593.26,,,,,,,7.29,1593.26,percent of total billed charges,
Nivolumab 40mg/4mL I(Opdivo),8725946,CDM,636,RC,J9299,HCPCS,,,facility,inpatient,,,7335.80000,2127.38000,Aetna,First Health,,6000.68,,,,,,,2644.56,6000.68,percent of total billed charges,
Nivolumab 40mg/4mL I(Opdivo),8725946,CDM,636,RC,J9299,HCPCS,,,facility,outpatient,,,7335.80000,2127.38000,Aetna,First Health,,6000.68,,,,,,,32.33,6000.68,percent of total billed charges,
Mepolizumab 100mg/1mL IS (Nucala),8725948,CDM,636,RC,J2182,HCPCS,,,facility,inpatient,,,15327.20000,4444.89000,Aetna,First Health,,12537.65,,,,,,,5525.46,12537.65,percent of total billed charges,
Mepolizumab 100mg/1mL IS (Nucala),8725948,CDM,636,RC,J2182,HCPCS,,,facility,outpatient,,,15327.20000,4444.89000,Aetna,First Health,,12537.65,,,,,,,30.71,12537.65,percent of total billed charges,
Levonorgestrel 52mg IUD(Mirena),8725956,CDM,636,RC,J7298,HCPCS,,,facility,inpatient,,,7689.45000,2229.94000,Aetna,First Health,,6289.97,,,,,,,2772.05,6289.97,percent of total billed charges,
Levonorgestrel 52mg IUD(Mirena),8725956,CDM,636,RC,J7298,HCPCS,,,facility,outpatient,,,7689.45000,2229.94000,Aetna,First Health,,6289.97,,,,,,,1336.79,6289.97,percent of total billed charges,
Mepolizumab Syringe- Pt Own Supply,9013953,CDM,636,RC,J2182,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Mepolizumab Syringe- Pt Own Supply,9013953,CDM,636,RC,J2182,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,98.35,percent of total billed charges,
dexaMETHasone 1mg Tab UD,8726003,CDM,636,RC,J8540,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
dexaMETHasone 1mg Tab UD,8726003,CDM,636,RC,J8540,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.00963,8.18,percent of total billed charges,
Insulin(R) 100unit/100mL NS,8726015,CDM,636,RC,J1815,HCPCS,,,facility,inpatient,,,351.00000,101.79000,Aetna,First Health,,287.12,,,,,,,126.54,287.12,percent of total billed charges,
Insulin(R) 100unit/100mL NS,8726015,CDM,636,RC,J1815,HCPCS,,,facility,outpatient,,,351.00000,101.79000,Aetna,First Health,,287.12,,,,,,,0.26001,287.12,percent of total billed charges,
Dianeal LCA Soln 1.5% 6000mL,8725976,CDM,636,RC,A4726,HCPCS,,,facility,inpatient,,,415.75000,120.57000,Aetna,First Health,,340.08,,,,,,,149.88,340.08,percent of total billed charges,
Dianeal LCA Soln 1.5% 6000mL,8725976,CDM,636,RC,A4726,HCPCS,,,facility,outpatient,,,415.75000,120.57000,Aetna,First Health,,340.08,,,,,,,149.88,340.08,percent of total billed charges,
Dianeal LCA Soln 2.5% 6000mL,8725977,CDM,636,RC,A4726,HCPCS,,,facility,inpatient,,,423.85000,122.92000,Aetna,First Health,,346.71,,,,,,,152.80,346.71,percent of total billed charges,
Dianeal LCA Soln 2.5% 6000mL,8725977,CDM,636,RC,A4726,HCPCS,,,facility,outpatient,,,423.85000,122.92000,Aetna,First Health,,346.71,,,,,,,152.80,346.71,percent of total billed charges,
Dianeal LCA Soln 4.25% 6000mL,8725978,CDM,636,RC,A4726,HCPCS,,,facility,inpatient,,,434.65000,126.05000,Aetna,First Health,,355.54,,,,,,,156.69,355.54,percent of total billed charges,
Dianeal LCA Soln 4.25% 6000mL,8725978,CDM,636,RC,A4726,HCPCS,,,facility,outpatient,,,434.65000,126.05000,Aetna,First Health,,355.54,,,,,,,156.69,355.54,percent of total billed charges,
Remdesivir 100mg Inj,8726025,CDM,636,RC,J0248,HCPCS,,,facility,inpatient,,,4757.95000,1379.81000,Aetna,First Health,,3892.00,,,,,,,1715.24,3892.00,percent of total billed charges,
Remdesivir 100mg Inj,8726025,CDM,636,RC,J0248,HCPCS,,,facility,outpatient,,,4757.95000,1379.81000,Aetna,First Health,,3892.00,,,,,,,6.64,3892.00,percent of total billed charges,
Minocycline HCl 100mg Inj,8726028,CDM,636,RC,J2265,HCPCS,,,facility,inpatient,,,2048.20000,593.98000,Aetna,First Health,,1675.43,,,,,,,738.38,1675.43,percent of total billed charges,
Minocycline HCl 100mg Inj,8726028,CDM,636,RC,J2265,HCPCS,,,facility,outpatient,,,2048.20000,593.98000,Aetna,First Health,,1675.43,,,,,,,2.67,1675.43,percent of total billed charges,
eptinezumab - jjmr 100mg Inj,8726031,CDM,636,RC,J3032,HCPCS,,,facility,inpatient,,,10951.00000,3175.79000,Aetna,First Health,,8957.92,,,,,,,3947.84,8957.92,percent of total billed charges,
eptinezumab - jjmr 100mg Inj,8726031,CDM,636,RC,J3032,HCPCS,,,facility,outpatient,,,10951.00000,3175.79000,Aetna,First Health,,8957.92,,,,,,,19.74,8957.92,percent of total billed charges,
atezolizumab 1200 mg/20 mL Inj (Tecentriq),8726040,CDM,636,RC,J9022,HCPCS,,,facility,inpatient,,,60946.80000,17674.57000,Aetna,First Health,,49854.48,,,,,,,21971.32,49854.48,percent of total billed charges,
atezolizumab 1200 mg/20 mL Inj (Tecentriq),8726040,CDM,636,RC,J9022,HCPCS,,,facility,outpatient,,,60946.80000,17674.57000,Aetna,First Health,,49854.48,,,,,,,90.44,49854.48,percent of total billed charges,
eptinezumab-jjmr 100mg Inj - Pt Own Supply,8726041,CDM,636,RC,J3032,HCPCS,,,facility,inpatient,,,0.02000,0.01000,Aetna,First Health,,0.01636,,,,,,,0.00721,0.01636,percent of total billed charges,
eptinezumab-jjmr 100mg Inj - Pt Own Supply,8726041,CDM,636,RC,J3032,HCPCS,,,facility,outpatient,,,0.02000,0.01000,Aetna,First Health,,0.01636,,,,,,,0.00740,63.22,percent of total billed charges,
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,8726046,CDM,636,RC,J1953,HCPCS,,,facility,inpatient,,,306.22000,88.80000,Aetna,First Health,,250.49,,,,,,,110.39,250.49,percent of total billed charges,
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,8726046,CDM,636,RC,J1953,HCPCS,,,facility,outpatient,,,306.22000,88.80000,Aetna,First Health,,250.49,,,,,,,0.03852,250.49,percent of total billed charges,
Etonogestrel 68 mg Implant,8726048,CDM,636,RC,J7307,HCPCS,,,facility,inpatient,,,6567.80000,1904.66000,Aetna,First Health,,5372.46,,,,,,,2367.69,5372.46,percent of total billed charges,
Etonogestrel 68 mg Implant,8726048,CDM,636,RC,J7307,HCPCS,,,facility,outpatient,,,6567.80000,1904.66000,Aetna,First Health,,5372.46,,,,,,,1336.20,5372.46,percent of total billed charges,
Romosozumab-aqqg 105mg Inj Syr (Evenity),8726059,CDM,636,RC,J3111,HCPCS,,,facility,inpatient,,,5350.83000,1551.74000,Aetna,First Health,,4376.98,,,,,,,1928.97,4376.98,percent of total billed charges,
Romosozumab-aqqg 105mg Inj Syr (Evenity),8726059,CDM,636,RC,J3111,HCPCS,,,facility,outpatient,,,5350.83000,1551.74000,Aetna,First Health,,4376.98,,,,,,,11.66,4376.98,percent of total billed charges,
riTUXimab - pvvr 500mg/50mL Inj,8726072,CDM,636,RC,Q5119,HCPCS,,,facility,inpatient,,,25991.80000,7537.62000,Aetna,First Health,,21261.29,,,,,,,9370.04,21261.29,percent of total billed charges,
riTUXimab - pvvr 500mg/50mL Inj,8726072,CDM,636,RC,Q5119,HCPCS,,,facility,outpatient,,,25991.80000,7537.62000,Aetna,First Health,,21261.29,,,,,,,12.78,21261.29,percent of total billed charges,
riTUXimab - pvvr 100mg/10mL Inj,8726071,CDM,636,RC,Q5119,HCPCS,,,facility,inpatient,,,5348.00000,1550.92000,Aetna,First Health,,4374.66,,,,,,,1927.95,4374.66,percent of total billed charges,
riTUXimab - pvvr 100mg/10mL Inj,8726071,CDM,636,RC,Q5119,HCPCS,,,facility,outpatient,,,5348.00000,1550.92000,Aetna,First Health,,4374.66,,,,,,,12.78,4374.66,percent of total billed charges,
"Epoetin alfa - epbx 20,000 units/mL Inj",8726083,CDM,636,RC,Q5106,HCPCS,,,facility,inpatient,,,1656.87000,480.49000,Aetna,First Health,,1355.32,,,,,,,597.30,1355.32,percent of total billed charges,
"Epoetin alfa - epbx 20,000 units/mL Inj",8726083,CDM,636,RC,Q5106,HCPCS,,,facility,outpatient,,,1656.87000,480.49000,Aetna,First Health,,1355.32,,,,,,,7.29,1355.32,percent of total billed charges,
Immune Globulin 5g/50mL I,8726085,CDM,636,RC,J1569,HCPCS,,,facility,inpatient,,,6600.53000,1914.15000,Aetna,First Health,,5399.23,,,,,,,2379.49,5399.23,percent of total billed charges,
Immune Globulin 5g/50mL I,8726085,CDM,636,RC,J1569,HCPCS,,,facility,outpatient,,,6600.53000,1914.15000,Aetna,First Health,,5399.23,,,,,,,45.54,5399.23,percent of total billed charges,
Immune Globulin 10g/100mL I,8724540,CDM,636,RC,J1569,HCPCS,,,facility,inpatient,,,12758.95000,3700.10000,Aetna,First Health,,10436.82,,,,,,,4599.60,10436.82,percent of total billed charges,
Immune Globulin 10g/100mL I,8724540,CDM,636,RC,J1569,HCPCS,,,facility,outpatient,,,12758.95000,3700.10000,Aetna,First Health,,10436.82,,,,,,,45.54,10436.82,percent of total billed charges,
Immune Globulin 30g/300mL I,8726086,CDM,636,RC,J1569,HCPCS,,,facility,inpatient,,,37902.80000,10991.81000,Aetna,First Health,,31004.49,,,,,,,13663.96,31004.49,percent of total billed charges,
Immune Globulin 30g/300mL I,8726086,CDM,636,RC,J1569,HCPCS,,,facility,outpatient,,,37902.80000,10991.81000,Aetna,First Health,,31004.49,,,,,,,45.54,31004.49,percent of total billed charges,
Doxercalciferol 4mcg/2mL Inj,8726087,CDM,636,RC,J1270,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Doxercalciferol 4mcg/2mL Inj,8726087,CDM,636,RC,J1270,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.29853,20.45,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,8723634,CDM,636,RC,J1580,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,8723634,CDM,636,RC,J1580,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,2.09,40.90,percent of total billed charges,
Albumin 5% 250mL I,8723688,CDM,636,RC,P9045,HCPCS,,,facility,inpatient,,,937.27000,271.81000,Aetna,First Health,,766.69,,,,,,,337.89,766.69,percent of total billed charges,
Albumin 5% 250mL I,8723688,CDM,636,RC,P9045,HCPCS,,,facility,outpatient,,,937.27000,271.81000,Aetna,First Health,,766.69,,,,,,,51.12,766.69,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,8723709,CDM,636,RC,J2305,HCPCS,,,facility,inpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,75.34,170.96,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,8723709,CDM,636,RC,J2305,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,First Health,,170.96,,,,,,,1.46,170.96,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",8723545,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,98.20000,28.48000,Aetna,First Health,,80.33,,,,,,,35.40,80.33,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",8723545,CDM,636,RC,J2004,HCPCS,,,facility,outpatient,,,98.20000,28.48000,Aetna,First Health,,80.33,,,,,,,0.00963,80.33,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",8723713,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,36.05,81.80,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",8723713,CDM,636,RC,J1644,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,First Health,,81.80,,,,,,,0.17334,81.80,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,8723412,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,37.73000,10.94000,Aetna,First Health,,30.86,,,,,,,13.60,30.86,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,8723412,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,37.73000,10.94000,Aetna,First Health,,30.86,,,,,,,0.00963,30.86,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,8724336,CDM,636,RC,J9045,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,27.04,61.35,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,8724336,CDM,636,RC,J9045,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,First Health,,61.35,,,,,,,2.82,61.35,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,8723592,CDM,636,RC,J0736,HCPCS,,,facility,inpatient,,,112.45000,32.61000,Aetna,First Health,,91.98,,,,,,,40.54,91.98,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,8723592,CDM,636,RC,J0736,HCPCS,,,facility,outpatient,,,112.45000,32.61000,Aetna,First Health,,91.98,,,,,,,1.84,91.98,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,8723593,CDM,636,RC,J0736,HCPCS,,,facility,inpatient,,,133.15000,38.61000,Aetna,First Health,,108.92,,,,,,,48.00,108.92,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,8723593,CDM,636,RC,J0736,HCPCS,,,facility,outpatient,,,133.15000,38.61000,Aetna,First Health,,108.92,,,,,,,1.84,108.92,percent of total billed charges,
BUMETANIDE MDV I - IV ROOM USE,8723568,CDM,636,RC,J1939,HCPCS,,,facility,inpatient,,,2.37000,0.69000,Aetna,First Health,,1.94,,,,,,,0.85438,1.94,percent of total billed charges,
BUMETANIDE MDV I - IV ROOM USE,8723568,CDM,636,RC,J1939,HCPCS,,,facility,outpatient,,,2.37000,0.69000,Aetna,First Health,,1.94,,,,,,,0.34668,1.94,percent of total billed charges,
Lidocaine HCl 2% 50mL I,8723581,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,9.64,21.88,percent of total billed charges,
Lidocaine HCl 2% 50mL I,8723581,CDM,636,RC,J2003,HCPCS,,,facility,outpatient,,,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,0.00963,21.88,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),8724130,CDM,636,RC,J3360,HCPCS,,,facility,inpatient,,,286.67000,83.13000,Aetna,First Health,,234.50,,,,,,,103.34,234.50,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),8724130,CDM,636,RC,J3360,HCPCS,,,facility,outpatient,,,286.67000,83.13000,Aetna,First Health,,234.50,,,,,,,6.44,234.50,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),8725053,CDM,636,RC,J1885,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),8725053,CDM,636,RC,J1885,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.31779,20.45,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,8723832,CDM,636,RC,J1010,HCPCS,,,facility,inpatient,,,68.66000,19.91000,Aetna,First Health,,56.16,,,,,,,24.75,56.16,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,8723832,CDM,636,RC,J1010,HCPCS,,,facility,outpatient,,,68.66000,19.91000,Aetna,First Health,,56.16,,,,,,,0.11556,56.16,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),8723437,CDM,636,RC,J1805,HCPCS,,,facility,inpatient,,,46.55000,13.50000,Aetna,First Health,,38.08,,,,,,,16.78,38.08,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),8723437,CDM,636,RC,J1805,HCPCS,,,facility,outpatient,,,46.55000,13.50000,Aetna,First Health,,38.08,,,,,,,0.20223,38.08,percent of total billed charges,
RITUXIMAB 100MG/10ML I,8723450,CDM,636,RC,J9312,HCPCS,,,facility,inpatient,,,6951.55000,2015.95000,Aetna,First Health,,5686.37,,,,,,,2506.03,5686.37,percent of total billed charges,
RITUXIMAB 100MG/10ML I,8723450,CDM,636,RC,J9312,HCPCS,,,facility,outpatient,,,6951.55000,2015.95000,Aetna,First Health,,5686.37,,,,,,,72.00,5686.37,percent of total billed charges,
RiTUXimab 500mg/50mL I,8723602,CDM,636,RC,J9312,HCPCS,,,facility,inpatient,,,34009.75000,9862.83000,Aetna,First Health,,27819.98,,,,,,,12260.51,27819.98,percent of total billed charges,
RiTUXimab 500mg/50mL I,8723602,CDM,636,RC,J9312,HCPCS,,,facility,outpatient,,,34009.75000,9862.83000,Aetna,First Health,,27819.98,,,,,,,72.00,27819.98,percent of total billed charges,
Albumin 25% 50mL I,8723603,CDM,636,RC,P9047,HCPCS,,,facility,inpatient,,,527.80000,153.06000,Aetna,First Health,,431.74,,,,,,,190.27,431.74,percent of total billed charges,
Albumin 25% 50mL I,8723603,CDM,636,RC,P9047,HCPCS,,,facility,outpatient,,,527.80000,153.06000,Aetna,First Health,,431.74,,,,,,,51.12,431.74,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),8723833,CDM,636,RC,J1010,HCPCS,,,facility,inpatient,,,113.05000,32.78000,Aetna,First Health,,92.47,,,,,,,40.75,92.47,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),8723833,CDM,636,RC,J1010,HCPCS,,,facility,outpatient,,,113.05000,32.78000,Aetna,First Health,,92.47,,,,,,,0.11556,92.47,percent of total billed charges,
Tenecteplase 50mg Inj,9002120,CDM,636,RC,J3101,HCPCS,,,facility,inpatient,,,33246.30000,9641.43000,Aetna,First Health,,27195.47,,,,,,,11985.29,27195.47,percent of total billed charges,
Tenecteplase 50mg Inj,9002120,CDM,636,RC,J3101,HCPCS,,,facility,outpatient,,,33246.30000,9641.43000,Aetna,First Health,,27195.47,,,,,,,180.05,27195.47,percent of total billed charges,
Haemophilus B Conj (PRP-T) Vac I,8724246,CDM,636,RC,90648,HCPCS,,,facility,inpatient,,,84.05000,24.37000,Aetna,First Health,,68.75,,,,,,,30.30,68.75,percent of total billed charges,
Haemophilus B Conj (PRP-T) Vac I,8724246,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,84.05000,24.37000,Aetna,First Health,,68.75,,,,,,,14.65,68.75,percent of total billed charges,
Oxaliplatin 100mg/20mL I,8724448,CDM,636,RC,J9263,HCPCS,,,facility,inpatient,,,2733.30000,792.66000,Aetna,First Health,,2235.84,,,,,,,985.35,2235.84,percent of total billed charges,
Oxaliplatin 100mg/20mL I,8724448,CDM,636,RC,J9263,HCPCS,,,facility,outpatient,,,2733.30000,792.66000,Aetna,First Health,,2235.84,,,,,,,0.04815,2235.84,percent of total billed charges,
levoFLOXacin  250mg/50mL P,8724203,CDM,636,RC,J1956,HCPCS,,,facility,inpatient,,,52.17000,15.13000,Aetna,First Health,,42.68,,,,,,,18.81,42.68,percent of total billed charges,
levoFLOXacin  250mg/50mL P,8724203,CDM,636,RC,J1956,HCPCS,,,facility,outpatient,,,52.17000,15.13000,Aetna,First Health,,42.68,,,,,,,2.08,42.68,percent of total billed charges,
Tetanus-Diphtheria Toxoids 0.5mL IS,8724243,CDM,636,RC,90714,HCPCS,,,facility,inpatient,,,246.17000,71.39000,Aetna,First Health,,201.37,,,,,,,88.74,201.37,percent of total billed charges,
Tetanus-Diphtheria Toxoids 0.5mL IS,8724243,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,246.17000,71.39000,Aetna,First Health,,201.37,,,,,,,37.53,201.37,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),8724743,CDM,636,RC,J2359,HCPCS,,,facility,inpatient,,,218.66000,63.41000,Aetna,First Health,,178.86,,,,,,,78.83,178.86,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),8724743,CDM,636,RC,J2359,HCPCS,,,facility,outpatient,,,218.66000,63.41000,Aetna,First Health,,178.86,,,,,,,0.78003,178.86,percent of total billed charges,
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),8724773,CDM,636,RC,90700,HCPCS,,,facility,inpatient,,,185.15000,53.69000,Aetna,First Health,,151.45,,,,,,,66.75,151.45,percent of total billed charges,
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),8724773,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,185.15000,53.69000,Aetna,First Health,,151.45,,,,,,,32.84,151.45,percent of total billed charges,
Octreotide 20mg I Kit (SandoSTATIN LAR),8724780,CDM,636,RC,J2353,HCPCS,,,facility,inpatient,,,18581.35000,5388.59000,Aetna,First Health,,15199.54,,,,,,,6698.58,15199.54,percent of total billed charges,
Octreotide 20mg I Kit (SandoSTATIN LAR),8724780,CDM,636,RC,J2353,HCPCS,,,facility,outpatient,,,18581.35000,5388.59000,Aetna,First Health,,15199.54,,,,,,,191.80,15199.54,percent of total billed charges,
Hydroxocobalamin 5g Kit,8725860,CDM,636,RC,J3424,HCPCS,,,facility,inpatient,,,4863.10000,1410.30000,Aetna,First Health,,3978.02,,,,,,,1753.15,3978.02,percent of total billed charges,
Hydroxocobalamin 5g Kit,8725860,CDM,636,RC,J3424,HCPCS,,,facility,outpatient,,,4863.10000,1410.30000,Aetna,First Health,,3978.02,,,,,,,5.44,3978.02,percent of total billed charges,
Erythromycin Lact.500mg I,8724886,CDM,636,RC,J1364,HCPCS,,,facility,inpatient,,,1474.00000,427.46000,Aetna,First Health,,1205.73,,,,,,,531.38,1205.73,percent of total billed charges,
Erythromycin Lact.500mg I,8724886,CDM,636,RC,J1364,HCPCS,,,facility,outpatient,,,1474.00000,427.46000,Aetna,First Health,,1205.73,,,,,,,19.41,1205.73,percent of total billed charges,
Goserelin 3.6mg Impl,8724925,CDM,636,RC,J9202,HCPCS,,,facility,inpatient,,,2889.45000,837.94000,Aetna,First Health,,2363.57,,,,,,,1041.65,2363.57,percent of total billed charges,
Goserelin 3.6mg Impl,8724925,CDM,636,RC,J9202,HCPCS,,,facility,outpatient,,,2889.45000,837.94000,Aetna,First Health,,2363.57,,,,,,,748.73,2397.81,percent of total billed charges,
NICU- Gentamicin Sulf 5mg/mL IV,8724934,CDM,636,RC,J1580,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
NICU- Gentamicin Sulf 5mg/mL IV,8724934,CDM,636,RC,J1580,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,2.09,40.90,percent of total billed charges,
NICU- Vancomycin 5mg/mL IV,8724940,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,,,138.95000,40.30000,Aetna,First Health,,113.66,,,,,,,50.09,113.66,percent of total billed charges,
NICU- Vancomycin 5mg/mL IV,8724940,CDM,636,RC,J3373,HCPCS,,,facility,outpatient,,,138.95000,40.30000,Aetna,First Health,,113.66,,,,,,,0.02889,113.66,percent of total billed charges,
NICU- Ampicillin 500mg/2mL IM,8724939,CDM,636,RC,J0290,HCPCS,,,facility,inpatient,,,53.20000,15.43000,Aetna,First Health,,43.52,,,,,,,19.18,43.52,percent of total billed charges,
NICU- Ampicillin 500mg/2mL IM,8724939,CDM,636,RC,J0290,HCPCS,,,facility,outpatient,,,53.20000,15.43000,Aetna,First Health,,43.52,,,,,,,0.56817,43.52,percent of total billed charges,
"NICU- Penicillin GK 50,000 unit/mL IV",8724943,CDM,636,RC,J2540,HCPCS,,,facility,inpatient,,,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,10.81,24.54,percent of total billed charges,
"NICU- Penicillin GK 50,000 unit/mL IV",8724943,CDM,636,RC,J2540,HCPCS,,,facility,outpatient,,,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,0.75114,24.54,percent of total billed charges,
Azithromycin 500mg/NS 250mL P,8725030,CDM,636,RC,J0456,HCPCS,,,facility,inpatient,,,177.50000,51.47000,Aetna,First Health,,145.19,,,,,,,63.99,145.19,percent of total billed charges,
Azithromycin 500mg/NS 250mL P,8725030,CDM,636,RC,J0456,HCPCS,,,facility,outpatient,,,177.50000,51.47000,Aetna,First Health,,145.19,,,,,,,1.96,145.19,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,8725037,CDM,636,RC,J2371,HCPCS,,,facility,inpatient,,,25.57000,7.42000,Aetna,First Health,,20.92,,,,,,,9.22,20.92,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,8725037,CDM,636,RC,J2371,HCPCS,,,facility,outpatient,,,25.57000,7.42000,Aetna,First Health,,20.92,,,,,,,9.46,20.92,percent of total billed charges,
RAD- Iohexol 240mg/mL Inj 20mL,8724317,CDM,636,RC,Q9966,HCPCS,,,facility,inpatient,,,279.55000,81.07000,Aetna,First Health,,228.67,,,,,,,100.78,228.67,percent of total billed charges,
RAD- Iohexol 240mg/mL Inj 20mL,8724317,CDM,636,RC,Q9966,HCPCS,,,facility,outpatient,,,279.55000,81.07000,Aetna,First Health,,228.67,,,,,,,0.38520,228.67,percent of total billed charges,
niCARdipine 25mg/10mL I,8724338,CDM,636,RC,J2404,HCPCS,,,facility,inpatient,,,213.92000,62.04000,Aetna,First Health,,174.99,,,,,,,77.12,174.99,percent of total billed charges,
niCARdipine 25mg/10mL I,8724338,CDM,636,RC,J2404,HCPCS,,,facility,outpatient,,,213.92000,62.04000,Aetna,First Health,,174.99,,,,,,,0.06741,174.99,percent of total billed charges,
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,8725282,CDM,636,RC,90715,HCPCS,,,facility,inpatient,,,293.70000,85.17000,Aetna,First Health,,240.25,,,,,,,105.88,240.25,percent of total billed charges,
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,8725282,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,293.70000,85.17000,Aetna,First Health,,240.25,,,,,,,38.22,240.25,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),8724436,CDM,636,RC,J1805,HCPCS,,,facility,inpatient,,,2058.68000,597.02000,Aetna,First Health,,1684.00,,,,,,,742.15,1684.00,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),8724436,CDM,636,RC,J1805,HCPCS,,,facility,outpatient,,,2058.68000,597.02000,Aetna,First Health,,1684.00,,,,,,,0.20223,1684.00,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,8724443,CDM,636,RC,J1652,HCPCS,,,facility,inpatient,,,591.17000,171.44000,Aetna,First Health,,483.58,,,,,,,213.12,483.58,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,8724443,CDM,636,RC,J1652,HCPCS,,,facility,outpatient,,,591.17000,171.44000,Aetna,First Health,,483.58,,,,,,,0.84744,483.58,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML I,8724444,CDM,636,RC,J1652,HCPCS,,,facility,inpatient,,,417.50000,121.07000,Aetna,First Health,,341.51,,,,,,,150.51,341.51,percent of total billed charges,
FONDAPARINUX 10 MG/0.8 ML I,8724444,CDM,636,RC,J1652,HCPCS,,,facility,outpatient,,,417.50000,121.07000,Aetna,First Health,,341.51,,,,,,,0.84744,341.51,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),8723955,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),8723955,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),8723953,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),8723953,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),8723954,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),8723954,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),8723958,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),8723958,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),8724802,CDM,637,RC,,,,,facility,inpatient,,,117.61000,34.11000,Aetna,First Health,,96.20,,,,,,,70.57,96.20,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),8724802,CDM,637,RC,,,,,facility,outpatient,,,117.61000,34.11000,Aetna,First Health,,96.20,,,,,,,42.40,96.20,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),8724801,CDM,637,RC,,,,,facility,inpatient,,,139.75000,40.53000,Aetna,First Health,,114.32,,,,,,,83.85,114.32,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),8724801,CDM,637,RC,,,,,facility,outpatient,,,139.75000,40.53000,Aetna,First Health,,114.32,,,,,,,50.38,114.32,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),8724796,CDM,637,RC,,,,,facility,inpatient,,,126.87000,36.79000,Aetna,First Health,,103.78,,,,,,,76.12,103.78,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),8724796,CDM,637,RC,,,,,facility,outpatient,,,126.87000,36.79000,Aetna,First Health,,103.78,,,,,,,45.74,103.78,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,8724152,CDM,637,RC,J2354,HCPCS,,,facility,inpatient,,,298.60000,86.59000,Aetna,First Health,,244.25,,,,,,,179.16,244.25,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,8724152,CDM,637,RC,J2354,HCPCS,,,facility,outpatient,,,298.60000,86.59000,Aetna,First Health,,244.25,,,,,,,0.63558,244.25,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),8723957,CDM,637,RC,,,,,facility,inpatient,,,30.70000,8.90000,Aetna,First Health,,25.11,,,,,,,18.42,25.11,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),8723957,CDM,637,RC,,,,,facility,outpatient,,,30.70000,8.90000,Aetna,First Health,,25.11,,,,,,,11.07,25.11,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",8724321,CDM,637,RC,,,,,facility,inpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",8724321,CDM,637,RC,,,,,facility,outpatient,,,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,5.05,11.45,percent of total billed charges,
methylPREDNISolone 16 mg T(Medrol),8724428,CDM,637,RC,J7509,HCPCS,,,facility,inpatient,,,25.10000,7.28000,Aetna,First Health,,20.53,,,,,,,15.06,20.53,percent of total billed charges,
methylPREDNISolone 16 mg T(Medrol),8724428,CDM,637,RC,J7509,HCPCS,,,facility,outpatient,,,25.10000,7.28000,Aetna,First Health,,20.53,,,,,,,0.13482,20.53,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),8724045,CDM,637,RC,,,,,facility,inpatient,,,16.58000,4.81000,Aetna,First Health,,13.56,,,,,,,9.95,13.56,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),8724045,CDM,637,RC,,,,,facility,outpatient,,,16.58000,4.81000,Aetna,First Health,,13.56,,,,,,,5.98,13.56,percent of total billed charges,
Insulin Reg - TPN/PPN Use,8725011,CDM,637,RC,J1815,HCPCS,,,facility,inpatient,,,237.58000,68.90000,Aetna,First Health,,194.34,,,,,,,142.55,194.34,percent of total billed charges,
Insulin Reg - TPN/PPN Use,8725011,CDM,637,RC,J1815,HCPCS,,,facility,outpatient,,,237.58000,68.90000,Aetna,First Health,,194.34,,,,,,,0.26001,194.34,percent of total billed charges,
Haloperidol 1mg T(Haldol),8724041,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Haloperidol 1mg T(Haldol),8724041,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,8723778,CDM,637,RC,,,,,facility,inpatient,,,544.85000,158.01000,Aetna,First Health,,445.69,,,,,,,326.91,445.69,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,8723778,CDM,637,RC,,,,,facility,outpatient,,,544.85000,158.01000,Aetna,First Health,,445.69,,,,,,,196.42,445.69,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,8725554,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,8725554,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Haloperidol 1mg/0.5mL LC UD,8725145,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Haloperidol 1mg/0.5mL LC UD,8725145,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Haloperidol 0.5mg/0.25mL LC UD,8725146,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Haloperidol 0.5mg/0.25mL LC UD,8725146,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Magic Mouthwash 5mL  L UD,8725147,CDM,637,RC,,,,,facility,inpatient,,,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,13.47,18.36,percent of total billed charges,
Magic Mouthwash 5mL  L UD,8725147,CDM,637,RC,,,,,facility,outpatient,,,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,8.09,18.36,percent of total billed charges,
Magic Mouthwash 15mL L UD,8725148,CDM,637,RC,,,,,facility,inpatient,,,67.25000,19.50000,Aetna,First Health,,55.01,,,,,,,40.35,55.01,percent of total billed charges,
Magic Mouthwash 15mL L UD,8725148,CDM,637,RC,,,,,facility,outpatient,,,67.25000,19.50000,Aetna,First Health,,55.01,,,,,,,24.24,55.01,percent of total billed charges,
Potassium Cl 10mEq/7.5 mL L UD,8725152,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Potassium Cl 10mEq/7.5 mL L UD,8725152,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),8725154,CDM,637,RC,,,,,facility,inpatient,,,174.43000,50.58000,Aetna,First Health,,142.68,,,,,,,104.66,142.68,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),8725154,CDM,637,RC,,,,,facility,outpatient,,,174.43000,50.58000,Aetna,First Health,,142.68,,,,,,,62.88,142.68,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,8725165,CDM,637,RC,,,,,facility,inpatient,,,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,29.01,39.55,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,8725165,CDM,637,RC,,,,,facility,outpatient,,,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,17.43,39.55,percent of total billed charges,
oxyBUTYnin 5mg/5mL L UD,8725164,CDM,637,RC,,,,,facility,inpatient,,,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,11.07,15.09,percent of total billed charges,
oxyBUTYnin 5mg/5mL L UD,8725164,CDM,637,RC,,,,,facility,outpatient,,,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,6.65,15.09,percent of total billed charges,
Valproic Acid 250 mg/5 mL Liq UD,8725163,CDM,637,RC,,,,,facility,inpatient,,,219.67000,63.70000,Aetna,First Health,,179.69,,,,,,,131.80,179.69,percent of total billed charges,
Valproic Acid 250 mg/5 mL Liq UD,8725163,CDM,637,RC,,,,,facility,outpatient,,,219.67000,63.70000,Aetna,First Health,,179.69,,,,,,,79.19,179.69,percent of total billed charges,
Ticagrelor 90mg T,8725174,CDM,637,RC,,,,,facility,inpatient,,,65.85000,19.10000,Aetna,First Health,,53.87,,,,,,,39.51,53.87,percent of total billed charges,
Ticagrelor 90mg T,8725174,CDM,637,RC,,,,,facility,outpatient,,,65.85000,19.10000,Aetna,First Health,,53.87,,,,,,,23.74,53.87,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,8725178,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,8725178,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,8725177,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,8725177,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
prednisoLONE Sod Phos 15mg/5mL L UD,8725175,CDM,637,RC,J7510,HCPCS,,,facility,inpatient,,,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,6.69,9.12,percent of total billed charges,
prednisoLONE Sod Phos 15mg/5mL L UD,8725175,CDM,637,RC,J7510,HCPCS,,,facility,outpatient,,,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,0.88596,9.12,percent of total billed charges,
Furosemide 40mg T(Lasix),8724012,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Furosemide 40mg T(Lasix),8724012,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,8725172,CDM,637,RC,,,,,facility,inpatient,,,30.86000,8.95000,Aetna,First Health,,25.24,,,,,,,18.52,25.24,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,8725172,CDM,637,RC,,,,,facility,outpatient,,,30.86000,8.95000,Aetna,First Health,,25.24,,,,,,,11.13,25.24,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,8725171,CDM,637,RC,,,,,facility,inpatient,,,25.75000,7.47000,Aetna,First Health,,21.06,,,,,,,15.45,21.06,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,8725171,CDM,637,RC,,,,,facility,outpatient,,,25.75000,7.47000,Aetna,First Health,,21.06,,,,,,,9.28,21.06,percent of total billed charges,
Diphenoxylate - Atrop 5mL UD Oral Liq,8725170,CDM,637,RC,,,,,facility,inpatient,,,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,33.60,45.81,percent of total billed charges,
Diphenoxylate - Atrop 5mL UD Oral Liq,8725170,CDM,637,RC,,,,,facility,outpatient,,,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,20.19,45.81,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,8725169,CDM,637,RC,,,,,facility,inpatient,,,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,8.85,12.07,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,8725169,CDM,637,RC,,,,,facility,outpatient,,,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,5.32,12.07,percent of total billed charges,
Tolvaptan 15mg T (Samsca),8725227,CDM,637,RC,,,,,facility,inpatient,,,2963.62000,859.45000,Aetna,First Health,,2424.24,,,,,,,1778.17,2424.24,percent of total billed charges,
Tolvaptan 15mg T (Samsca),8725227,CDM,637,RC,,,,,facility,outpatient,,,2963.62000,859.45000,Aetna,First Health,,2424.24,,,,,,,1068.39,2424.24,percent of total billed charges,
Benzocaine 20% Top Spray 0.5mL UD,8725180,CDM,637,RC,,,,,facility,inpatient,,,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,22.86,31.17,percent of total billed charges,
Benzocaine 20% Top Spray 0.5mL UD,8725180,CDM,637,RC,,,,,facility,outpatient,,,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,13.74,31.17,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),8725190,CDM,637,RC,,,,,facility,inpatient,,,161.35000,46.79000,Aetna,First Health,,131.98,,,,,,,96.81,131.98,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),8725190,CDM,637,RC,,,,,facility,outpatient,,,161.35000,46.79000,Aetna,First Health,,131.98,,,,,,,58.17,131.98,percent of total billed charges,
Losartan 100mg T (Cozaar),8725197,CDM,637,RC,,,,,facility,inpatient,,,10.12000,2.93000,Aetna,First Health,,8.28,,,,,,,6.07,8.28,percent of total billed charges,
Losartan 100mg T (Cozaar),8725197,CDM,637,RC,,,,,facility,outpatient,,,10.12000,2.93000,Aetna,First Health,,8.28,,,,,,,3.65,8.28,percent of total billed charges,
NICU- Ferrous Sulfate 2.25mg/0.15mL L UD,8725200,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
NICU- Ferrous Sulfate 2.25mg/0.15mL L UD,8725200,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
NICU- Ferrous Sulfate 3.75mg/0.25mL L UD,8725201,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
NICU- Ferrous Sulfate 3.75mg/0.25mL L UD,8725201,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),8725205,CDM,637,RC,,,,,facility,inpatient,,,11.86000,3.44000,Aetna,First Health,,9.70,,,,,,,7.12,9.70,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),8725205,CDM,637,RC,,,,,facility,outpatient,,,11.86000,3.44000,Aetna,First Health,,9.70,,,,,,,4.28,9.70,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),8725206,CDM,637,RC,,,,,facility,inpatient,,,52.63000,15.26000,Aetna,First Health,,43.05,,,,,,,31.58,43.05,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),8725206,CDM,637,RC,,,,,facility,outpatient,,,52.63000,15.26000,Aetna,First Health,,43.05,,,,,,,18.97,43.05,percent of total billed charges,
Cetirizine 5 mg Tab,8725207,CDM,637,RC,,,,,facility,inpatient,,,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
Cetirizine 5 mg Tab,8725207,CDM,637,RC,,,,,facility,outpatient,,,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),8725216,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),8725216,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),8725215,CDM,637,RC,,,,,facility,inpatient,,,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,6.51,8.88,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),8725215,CDM,637,RC,,,,,facility,outpatient,,,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
Escitalopram 5mg T(Lexapro),8725221,CDM,637,RC,,,,,facility,inpatient,,,29.40000,8.53000,Aetna,First Health,,24.05,,,,,,,17.64,24.05,percent of total billed charges,
Escitalopram 5mg T(Lexapro),8725221,CDM,637,RC,,,,,facility,outpatient,,,29.40000,8.53000,Aetna,First Health,,24.05,,,,,,,10.60,24.05,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,8725214,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,8725214,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),8725220,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),8725220,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),8725219,CDM,637,RC,,,,,facility,inpatient,,,24.10000,6.99000,Aetna,First Health,,19.71,,,,,,,14.46,19.71,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),8725219,CDM,637,RC,,,,,facility,outpatient,,,24.10000,6.99000,Aetna,First Health,,19.71,,,,,,,8.69,19.71,percent of total billed charges,
Modafinil 100mg T(Provigil),8725209,CDM,637,RC,,,,,facility,inpatient,,,112.22000,32.54000,Aetna,First Health,,91.80,,,,,,,67.33,91.80,percent of total billed charges,
Modafinil 100mg T(Provigil),8725209,CDM,637,RC,,,,,facility,outpatient,,,112.22000,32.54000,Aetna,First Health,,91.80,,,,,,,40.46,91.80,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),8725210,CDM,637,RC,Q0169,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),8725210,CDM,637,RC,Q0169,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.24075,8.18,percent of total billed charges,
Sertraline HCl 25mg T,8725211,CDM,637,RC,,,,,facility,inpatient,,,10.24000,2.97000,Aetna,First Health,,8.38,,,,,,,6.14,8.38,percent of total billed charges,
Sertraline HCl 25mg T,8725211,CDM,637,RC,,,,,facility,outpatient,,,10.24000,2.97000,Aetna,First Health,,8.38,,,,,,,3.69,8.38,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,8725213,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,8725213,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),8725231,CDM,637,RC,,,,,facility,inpatient,,,88.19000,25.58000,Aetna,First Health,,72.14,,,,,,,52.91,72.14,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),8725231,CDM,637,RC,,,,,facility,outpatient,,,88.19000,25.58000,Aetna,First Health,,72.14,,,,,,,31.79,72.14,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),8725237,CDM,637,RC,,,,,facility,inpatient,,,161.35000,46.79000,Aetna,First Health,,131.98,,,,,,,96.81,131.98,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),8725237,CDM,637,RC,,,,,facility,outpatient,,,161.35000,46.79000,Aetna,First Health,,131.98,,,,,,,58.17,131.98,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,8725240,CDM,637,RC,,,,,facility,inpatient,,,1531.90000,444.25000,Aetna,First Health,,1253.09,,,,,,,919.14,1253.09,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,8725240,CDM,637,RC,,,,,facility,outpatient,,,1531.90000,444.25000,Aetna,First Health,,1253.09,,,,,,,552.25,1253.09,percent of total billed charges,
Fluticasone Prop 250mcg/INH Diskus,8725241,CDM,637,RC,,,,,facility,inpatient,,,1858.45000,538.95000,Aetna,First Health,,1520.21,,,,,,,1115.07,1520.21,percent of total billed charges,
Fluticasone Prop 250mcg/INH Diskus,8725241,CDM,637,RC,,,,,facility,outpatient,,,1858.45000,538.95000,Aetna,First Health,,1520.21,,,,,,,669.97,1520.21,percent of total billed charges,
Morphine 5mg/1.25 mL Oral Liq,8725247,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Morphine 5mg/1.25 mL Oral Liq,8725247,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Cetirizine 5mg/5mL L UD,8725139,CDM,637,RC,,,,,facility,inpatient,,,17.51000,5.08000,Aetna,First Health,,14.32,,,,,,,10.51,14.32,percent of total billed charges,
Cetirizine 5mg/5mL L UD,8725139,CDM,637,RC,,,,,facility,outpatient,,,17.51000,5.08000,Aetna,First Health,,14.32,,,,,,,6.31,14.32,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),8723909,CDM,637,RC,J7509,HCPCS,,,facility,inpatient,,,12.09000,3.51000,Aetna,First Health,,9.89,,,,,,,7.25,9.89,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),8723909,CDM,637,RC,J7509,HCPCS,,,facility,outpatient,,,12.09000,3.51000,Aetna,First Health,,9.89,,,,,,,0.13482,9.89,percent of total billed charges,
SITagliptin 50 mg T(Januvia),8724507,CDM,637,RC,,,,,facility,inpatient,,,93.50000,27.12000,Aetna,First Health,,76.48,,,,,,,56.10,76.48,percent of total billed charges,
SITagliptin 50 mg T(Januvia),8724507,CDM,637,RC,,,,,facility,outpatient,,,93.50000,27.12000,Aetna,First Health,,76.48,,,,,,,33.71,76.48,percent of total billed charges,
Desmopressin 0.1 mg Tab,8724514,CDM,637,RC,,,,,facility,inpatient,,,37.45000,10.86000,Aetna,First Health,,30.63,,,,,,,22.47,30.63,percent of total billed charges,
Desmopressin 0.1 mg Tab,8724514,CDM,637,RC,,,,,facility,outpatient,,,37.45000,10.86000,Aetna,First Health,,30.63,,,,,,,13.50,30.63,percent of total billed charges,
cycloSPORINE 25mg C(SandIMMUNE),8723933,CDM,637,RC,J7515,HCPCS,,,facility,inpatient,,,36.46000,10.57000,Aetna,First Health,,29.82,,,,,,,21.88,29.82,percent of total billed charges,
cycloSPORINE 25mg C(SandIMMUNE),8723933,CDM,637,RC,J7515,HCPCS,,,facility,outpatient,,,36.46000,10.57000,Aetna,First Health,,29.82,,,,,,,0.51039,29.82,percent of total billed charges,
cycloSPORINE 100mg C(SandIMMUNE),8723934,CDM,637,RC,J7502,HCPCS,,,facility,inpatient,,,125.05000,36.26000,Aetna,First Health,,102.29,,,,,,,75.03,102.29,percent of total billed charges,
cycloSPORINE 100mg C(SandIMMUNE),8723934,CDM,637,RC,J7502,HCPCS,,,facility,outpatient,,,125.05000,36.26000,Aetna,First Health,,102.29,,,,,,,1.74,102.29,percent of total billed charges,
Cilostazol 100 mg Tab,8724522,CDM,637,RC,,,,,facility,inpatient,,,15.89000,4.61000,Aetna,First Health,,13.00,,,,,,,9.53,13.00,percent of total billed charges,
Cilostazol 100 mg Tab,8724522,CDM,637,RC,,,,,facility,outpatient,,,15.89000,4.61000,Aetna,First Health,,13.00,,,,,,,5.73,13.00,percent of total billed charges,
Cabergoline 0.5 mg Tab,8724527,CDM,637,RC,J8515,HCPCS,,,facility,inpatient,,,256.25000,74.31000,Aetna,First Health,,209.61,,,,,,,153.75,209.61,percent of total billed charges,
Cabergoline 0.5 mg Tab,8724527,CDM,637,RC,J8515,HCPCS,,,facility,outpatient,,,256.25000,74.31000,Aetna,First Health,,209.61,,,,,,,17.65,209.61,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),8724530,CDM,637,RC,,,,,facility,inpatient,,,226.10000,65.57000,Aetna,First Health,,184.95,,,,,,,135.66,184.95,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),8724530,CDM,637,RC,,,,,facility,outpatient,,,226.10000,65.57000,Aetna,First Health,,184.95,,,,,,,81.51,184.95,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),8724532,CDM,637,RC,,,,,facility,inpatient,,,220.72000,64.01000,Aetna,First Health,,180.55,,,,,,,132.43,180.55,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),8724532,CDM,637,RC,,,,,facility,outpatient,,,220.72000,64.01000,Aetna,First Health,,180.55,,,,,,,79.57,180.55,percent of total billed charges,
Dipyridamole 25mg T(Persantine),8724031,CDM,637,RC,,,,,facility,inpatient,,,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
Dipyridamole 25mg T(Persantine),8724031,CDM,637,RC,,,,,facility,outpatient,,,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,8724538,CDM,637,RC,,,,,facility,inpatient,,,967.25000,280.50000,Aetna,First Health,,791.21,,,,,,,580.35,791.21,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,8724538,CDM,637,RC,,,,,facility,outpatient,,,967.25000,280.50000,Aetna,First Health,,791.21,,,,,,,348.69,791.21,percent of total billed charges,
Alfuzosin 10 mg ER Tab,8724543,CDM,637,RC,,,,,facility,inpatient,,,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Alfuzosin 10 mg ER Tab,8724543,CDM,637,RC,,,,,facility,outpatient,,,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
Aliskiren 150mg T(Tekturna),8724795,CDM,637,RC,,,,,facility,inpatient,,,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,31.80,43.35,percent of total billed charges,
Aliskiren 150mg T(Tekturna),8724795,CDM,637,RC,,,,,facility,outpatient,,,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,19.11,43.35,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,8724728,CDM,637,RC,,,,,facility,inpatient,,,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,11.28,15.38,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,8724728,CDM,637,RC,,,,,facility,outpatient,,,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,6.78,15.38,percent of total billed charges,
Baclofen 20mg T,8724548,CDM,637,RC,,,,,facility,inpatient,,,16.34000,4.74000,Aetna,First Health,,13.37,,,,,,,9.80,13.37,percent of total billed charges,
Baclofen 20mg T,8724548,CDM,637,RC,,,,,facility,outpatient,,,16.34000,4.74000,Aetna,First Health,,13.37,,,,,,,5.89,13.37,percent of total billed charges,
Bisoprolol 5 mg Tab,8724550,CDM,637,RC,,,,,facility,inpatient,,,15.42000,4.47000,Aetna,First Health,,12.61,,,,,,,9.25,12.61,percent of total billed charges,
Bisoprolol 5 mg Tab,8724550,CDM,637,RC,,,,,facility,outpatient,,,15.42000,4.47000,Aetna,First Health,,12.61,,,,,,,5.56,12.61,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,8724552,CDM,637,RC,,,,,facility,inpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,105.60,143.97,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,8724552,CDM,637,RC,,,,,facility,outpatient,,,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,63.45,143.97,percent of total billed charges,
Minocycline HCl 50mg C,8724555,CDM,637,RC,,,,,facility,inpatient,,,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,7.23,9.86,percent of total billed charges,
Minocycline HCl 50mg C,8724555,CDM,637,RC,,,,,facility,outpatient,,,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,4.34,9.86,percent of total billed charges,
Haloperidol 5mg T(Haldol),8724043,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Haloperidol 5mg T(Haldol),8724043,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Famciclovir 250 mg T (Famvir),8724571,CDM,637,RC,,,,,facility,inpatient,,,44.80000,12.99000,Aetna,First Health,,36.65,,,,,,,26.88,36.65,percent of total billed charges,
Famciclovir 250 mg T (Famvir),8724571,CDM,637,RC,,,,,facility,outpatient,,,44.80000,12.99000,Aetna,First Health,,36.65,,,,,,,16.15,36.65,percent of total billed charges,
Glimepiride 1mg T (Amaryl),8724575,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Glimepiride 1mg T (Amaryl),8724575,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Hydrocortisone 5mg T,8724788,CDM,637,RC,,,,,facility,inpatient,,,13.66000,3.96000,Aetna,First Health,,11.17,,,,,,,8.20,11.17,percent of total billed charges,
Hydrocortisone 5mg T,8724788,CDM,637,RC,,,,,facility,outpatient,,,13.66000,3.96000,Aetna,First Health,,11.17,,,,,,,4.92,11.17,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),8724582,CDM,637,RC,,,,,facility,inpatient,,,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),8724582,CDM,637,RC,,,,,facility,outpatient,,,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
Ivermectin 3 mg T(Stomectol),8724584,CDM,637,RC,,,,,facility,inpatient,,,35.20000,10.21000,Aetna,First Health,,28.79,,,,,,,21.12,28.79,percent of total billed charges,
Ivermectin 3 mg T(Stomectol),8724584,CDM,637,RC,,,,,facility,outpatient,,,35.20000,10.21000,Aetna,First Health,,28.79,,,,,,,12.69,28.79,percent of total billed charges,
Leflunomide 10 mg T(Arava),8724588,CDM,637,RC,,,,,facility,inpatient,,,66.22000,19.20000,Aetna,First Health,,54.17,,,,,,,39.73,54.17,percent of total billed charges,
Leflunomide 10 mg T(Arava),8724588,CDM,637,RC,,,,,facility,outpatient,,,66.22000,19.20000,Aetna,First Health,,54.17,,,,,,,23.87,54.17,percent of total billed charges,
Letrozole 2.5 mg T(Femara),8724589,CDM,637,RC,,,,,facility,inpatient,,,128.30000,37.21000,Aetna,First Health,,104.95,,,,,,,76.98,104.95,percent of total billed charges,
Letrozole 2.5 mg T(Femara),8724589,CDM,637,RC,,,,,facility,outpatient,,,128.30000,37.21000,Aetna,First Health,,104.95,,,,,,,46.25,104.95,percent of total billed charges,
Lithium Carb 450mg ER T,8724591,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Lithium Carb 450mg ER T,8724591,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Lithium Carb 150mg C,8724592,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Lithium Carb 150mg C,8724592,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),8724596,CDM,637,RC,,,,,facility,inpatient,,,53.13000,15.41000,Aetna,First Health,,43.46,,,,,,,31.88,43.46,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),8724596,CDM,637,RC,,,,,facility,outpatient,,,53.13000,15.41000,Aetna,First Health,,43.46,,,,,,,19.15,43.46,percent of total billed charges,
Meloxicam 7.5 mg T,8724597,CDM,637,RC,,,,,facility,inpatient,,,21.95000,6.37000,Aetna,First Health,,17.96,,,,,,,13.17,17.96,percent of total billed charges,
Meloxicam 7.5 mg T,8724597,CDM,637,RC,,,,,facility,outpatient,,,21.95000,6.37000,Aetna,First Health,,17.96,,,,,,,7.91,17.96,percent of total billed charges,
Methenamine Hippurate 1 g T,8724599,CDM,637,RC,,,,,facility,inpatient,,,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,8.91,12.15,percent of total billed charges,
Methenamine Hippurate 1 g T,8724599,CDM,637,RC,,,,,facility,outpatient,,,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,5.35,12.15,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),8724605,CDM,637,RC,J7518,HCPCS,,,facility,inpatient,,,35.14000,10.19000,Aetna,First Health,,28.74,,,,,,,21.08,28.74,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),8724605,CDM,637,RC,J7518,HCPCS,,,facility,outpatient,,,35.14000,10.19000,Aetna,First Health,,28.74,,,,,,,0.30816,28.74,percent of total billed charges,
Nitazoxanide 500mg Tab,8724609,CDM,637,RC,,,,,facility,inpatient,,,1011.85000,293.44000,Aetna,First Health,,827.69,,,,,,,607.11,827.69,percent of total billed charges,
Nitazoxanide 500mg Tab,8724609,CDM,637,RC,,,,,facility,outpatient,,,1011.85000,293.44000,Aetna,First Health,,827.69,,,,,,,364.77,827.69,percent of total billed charges,
Norethindrone 5mg T,8724610,CDM,637,RC,,,,,facility,inpatient,,,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,11.28,15.38,percent of total billed charges,
Norethindrone 5mg T,8724610,CDM,637,RC,,,,,facility,outpatient,,,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,6.78,15.38,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),8724613,CDM,637,RC,,,,,facility,inpatient,,,216.35000,62.74000,Aetna,First Health,,176.97,,,,,,,129.81,176.97,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),8724613,CDM,637,RC,,,,,facility,outpatient,,,216.35000,62.74000,Aetna,First Health,,176.97,,,,,,,77.99,176.97,percent of total billed charges,
PARoxetine 10mg T(Paxil),8724615,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
PARoxetine 10mg T(Paxil),8724615,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),8724621,CDM,637,RC,,,,,facility,inpatient,,,20.04000,5.81000,Aetna,First Health,,16.39,,,,,,,12.02,16.39,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),8724621,CDM,637,RC,,,,,facility,outpatient,,,20.04000,5.81000,Aetna,First Health,,16.39,,,,,,,7.22,16.39,percent of total billed charges,
Potassium  Citrate 10mEq ER T,8724710,CDM,637,RC,,,,,facility,inpatient,,,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,10.44,14.23,percent of total billed charges,
Potassium  Citrate 10mEq ER T,8724710,CDM,637,RC,,,,,facility,outpatient,,,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,6.27,14.23,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),8724623,CDM,637,RC,,,,,facility,inpatient,,,10.14000,2.94000,Aetna,First Health,,8.29,,,,,,,6.08,8.29,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),8724623,CDM,637,RC,,,,,facility,outpatient,,,10.14000,2.94000,Aetna,First Health,,8.29,,,,,,,3.66,8.29,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),8724624,CDM,637,RC,,,,,facility,inpatient,,,20.56000,5.96000,Aetna,First Health,,16.82,,,,,,,12.34,16.82,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),8724624,CDM,637,RC,,,,,facility,outpatient,,,20.56000,5.96000,Aetna,First Health,,16.82,,,,,,,7.41,16.82,percent of total billed charges,
Progesterone 100mg C(Prometrium),8724625,CDM,637,RC,,,,,facility,inpatient,,,16.91000,4.90000,Aetna,First Health,,13.83,,,,,,,10.15,13.83,percent of total billed charges,
Progesterone 100mg C(Prometrium),8724625,CDM,637,RC,,,,,facility,outpatient,,,16.91000,4.90000,Aetna,First Health,,13.83,,,,,,,6.10,13.83,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),8724626,CDM,637,RC,,,,,facility,inpatient,,,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,42.48,57.91,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),8724626,CDM,637,RC,,,,,facility,outpatient,,,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),8724630,CDM,637,RC,,,,,facility,inpatient,,,176.90000,51.30000,Aetna,First Health,,144.70,,,,,,,106.14,144.70,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),8724630,CDM,637,RC,,,,,facility,outpatient,,,176.90000,51.30000,Aetna,First Health,,144.70,,,,,,,63.77,144.70,percent of total billed charges,
Riluzole 50mg T(Rilutek),8724637,CDM,637,RC,,,,,facility,inpatient,,,258.10000,74.85000,Aetna,First Health,,211.13,,,,,,,154.86,211.13,percent of total billed charges,
Riluzole 50mg T(Rilutek),8724637,CDM,637,RC,,,,,facility,outpatient,,,258.10000,74.85000,Aetna,First Health,,211.13,,,,,,,93.05,211.13,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),8724640,CDM,637,RC,,,,,facility,inpatient,,,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),8724640,CDM,637,RC,,,,,facility,outpatient,,,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),8724641,CDM,637,RC,,,,,facility,inpatient,,,10.77000,3.12000,Aetna,First Health,,8.81,,,,,,,6.46,8.81,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),8724641,CDM,637,RC,,,,,facility,outpatient,,,10.77000,3.12000,Aetna,First Health,,8.81,,,,,,,3.88,8.81,percent of total billed charges,
Sertraline 100mg T,8724647,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Sertraline 100mg T,8724647,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),8724650,CDM,637,RC,,,,,facility,inpatient,,,24.52000,7.11000,Aetna,First Health,,20.06,,,,,,,14.71,20.06,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),8724650,CDM,637,RC,,,,,facility,outpatient,,,24.52000,7.11000,Aetna,First Health,,20.06,,,,,,,8.84,20.06,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),8724652,CDM,637,RC,,,,,facility,inpatient,,,180.45000,52.33000,Aetna,First Health,,147.61,,,,,,,108.27,147.61,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),8724652,CDM,637,RC,,,,,facility,outpatient,,,180.45000,52.33000,Aetna,First Health,,147.61,,,,,,,65.05,147.61,percent of total billed charges,
Emtricitabine-Tenofovir 200-300mg T(Truvada),8724655,CDM,637,RC,,,,,facility,inpatient,,,465.65000,135.04000,Aetna,First Health,,380.90,,,,,,,279.39,380.90,percent of total billed charges,
Emtricitabine-Tenofovir 200-300mg T(Truvada),8724655,CDM,637,RC,,,,,facility,outpatient,,,465.65000,135.04000,Aetna,First Health,,380.90,,,,,,,167.87,380.90,percent of total billed charges,
Tenofovir 300mg T(Viread),8724658,CDM,637,RC,,,,,facility,inpatient,,,281.70000,81.69000,Aetna,First Health,,230.43,,,,,,,169.02,230.43,percent of total billed charges,
Tenofovir 300mg T(Viread),8724658,CDM,637,RC,,,,,facility,outpatient,,,281.70000,81.69000,Aetna,First Health,,230.43,,,,,,,101.55,230.43,percent of total billed charges,
Terbinafine 250mg T(LamISIL),8724659,CDM,637,RC,,,,,facility,inpatient,,,92.26000,26.76000,Aetna,First Health,,75.47,,,,,,,55.36,75.47,percent of total billed charges,
Terbinafine 250mg T(LamISIL),8724659,CDM,637,RC,,,,,facility,outpatient,,,92.26000,26.76000,Aetna,First Health,,75.47,,,,,,,33.26,75.47,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),8724663,CDM,637,RC,,,,,facility,inpatient,,,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,12.42,16.93,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),8724663,CDM,637,RC,,,,,facility,outpatient,,,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,7.46,16.93,percent of total billed charges,
Torsemide 5mg T,8724664,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Torsemide 5mg T,8724664,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),8724668,CDM,637,RC,,,,,facility,inpatient,,,438.23000,127.09000,Aetna,First Health,,358.47,,,,,,,262.94,358.47,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),8724668,CDM,637,RC,,,,,facility,outpatient,,,438.23000,127.09000,Aetna,First Health,,358.47,,,,,,,157.98,358.47,percent of total billed charges,
Voriconazole 200mg T(VFEND),8724670,CDM,637,RC,,,,,facility,inpatient,,,523.50000,151.82000,Aetna,First Health,,428.22,,,,,,,314.10,428.22,percent of total billed charges,
Voriconazole 200mg T(VFEND),8724670,CDM,637,RC,,,,,facility,outpatient,,,523.50000,151.82000,Aetna,First Health,,428.22,,,,,,,188.72,428.22,percent of total billed charges,
Zonisamide 100mg C,8724672,CDM,637,RC,,,,,facility,inpatient,,,12.23000,3.55000,Aetna,First Health,,10.00,,,,,,,7.34,10.00,percent of total billed charges,
Zonisamide 100mg C,8724672,CDM,637,RC,,,,,facility,outpatient,,,12.23000,3.55000,Aetna,First Health,,10.00,,,,,,,4.41,10.00,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,8724678,CDM,637,RC,,,,,facility,inpatient,,,413.90000,120.03000,Aetna,First Health,,338.57,,,,,,,248.34,338.57,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,8724678,CDM,637,RC,,,,,facility,outpatient,,,413.90000,120.03000,Aetna,First Health,,338.57,,,,,,,149.21,338.57,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,8724680,CDM,637,RC,,,,,facility,inpatient,,,350.70000,101.70000,Aetna,First Health,,286.87,,,,,,,210.42,286.87,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,8724680,CDM,637,RC,,,,,facility,outpatient,,,350.70000,101.70000,Aetna,First Health,,286.87,,,,,,,126.43,286.87,percent of total billed charges,
Ketoconazole 2% Top Shampoo 120mL,8724696,CDM,637,RC,,,,,facility,inpatient,,,214.05000,62.07000,Aetna,First Health,,175.09,,,,,,,128.43,175.09,percent of total billed charges,
Ketoconazole 2% Top Shampoo 120mL,8724696,CDM,637,RC,,,,,facility,outpatient,,,214.05000,62.07000,Aetna,First Health,,175.09,,,,,,,77.17,175.09,percent of total billed charges,
Mesalamine 1000mg Supp (Canasa),8724698,CDM,637,RC,,,,,facility,inpatient,,,290.20000,84.16000,Aetna,First Health,,237.38,,,,,,,174.12,237.38,percent of total billed charges,
Mesalamine 1000mg Supp (Canasa),8724698,CDM,637,RC,,,,,facility,outpatient,,,290.20000,84.16000,Aetna,First Health,,237.38,,,,,,,104.62,237.38,percent of total billed charges,
Testosterone 1% TG 2.5G UD,8724705,CDM,637,RC,,,,,facility,inpatient,,,82.70000,23.98000,Aetna,First Health,,67.65,,,,,,,49.62,67.65,percent of total billed charges,
Testosterone 1% TG 2.5G UD,8724705,CDM,637,RC,,,,,facility,outpatient,,,82.70000,23.98000,Aetna,First Health,,67.65,,,,,,,29.81,67.65,percent of total billed charges,
Triamcinolone 0.025% TC 80g,8724706,CDM,637,RC,,,,,facility,inpatient,,,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,47.37,64.58,percent of total billed charges,
Triamcinolone 0.025% TC 80g,8724706,CDM,637,RC,,,,,facility,outpatient,,,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,28.46,64.58,percent of total billed charges,
Triamcinolone 0.1% TC 80g,8724707,CDM,637,RC,,,,,facility,inpatient,,,103.05000,29.88000,Aetna,First Health,,84.29,,,,,,,61.83,84.29,percent of total billed charges,
Triamcinolone 0.1% TC 80g,8724707,CDM,637,RC,,,,,facility,outpatient,,,103.05000,29.88000,Aetna,First Health,,84.29,,,,,,,37.15,84.29,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,8724731,CDM,637,RC,,,,,facility,inpatient,,,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,8724731,CDM,637,RC,,,,,facility,outpatient,,,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
Levalbuterol HFA 45 mcg/inh,8724738,CDM,637,RC,,,,,facility,inpatient,,,488.10000,141.55000,Aetna,First Health,,399.27,,,,,,,292.86,399.27,percent of total billed charges,
Levalbuterol HFA 45 mcg/inh,8724738,CDM,637,RC,,,,,facility,outpatient,,,488.10000,141.55000,Aetna,First Health,,399.27,,,,,,,175.96,399.27,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),8725279,CDM,637,RC,,,,,facility,inpatient,,,36.77000,10.66000,Aetna,First Health,,30.08,,,,,,,22.06,30.08,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),8725279,CDM,637,RC,,,,,facility,outpatient,,,36.77000,10.66000,Aetna,First Health,,30.08,,,,,,,13.26,30.08,percent of total billed charges,
Fluticasone Prop 50mcg/INH Diskus,8725285,CDM,637,RC,,,,,facility,inpatient,,,1467.30000,425.52000,Aetna,First Health,,1200.25,,,,,,,880.38,1200.25,percent of total billed charges,
Fluticasone Prop 50mcg/INH Diskus,8725285,CDM,637,RC,,,,,facility,outpatient,,,1467.30000,425.52000,Aetna,First Health,,1200.25,,,,,,,528.96,1200.25,percent of total billed charges,
"NICU- Nystatin 100,000unit/1mL L",8725290,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
"NICU- Nystatin 100,000unit/1mL L",8725290,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Apixaban 2.5mg Tab (Eliquis),8725299,CDM,637,RC,,,,,facility,inpatient,,,85.90000,24.91000,Aetna,First Health,,70.27,,,,,,,51.54,70.27,percent of total billed charges,
Apixaban 2.5mg Tab (Eliquis),8725299,CDM,637,RC,,,,,facility,outpatient,,,85.90000,24.91000,Aetna,First Health,,70.27,,,,,,,30.97,70.27,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),8725300,CDM,637,RC,,,,,facility,inpatient,,,85.90000,24.91000,Aetna,First Health,,70.27,,,,,,,51.54,70.27,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),8725300,CDM,637,RC,,,,,facility,outpatient,,,85.90000,24.91000,Aetna,First Health,,70.27,,,,,,,30.97,70.27,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),8725302,CDM,637,RC,,,,,facility,inpatient,,,161.35000,46.79000,Aetna,First Health,,131.98,,,,,,,96.81,131.98,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),8725302,CDM,637,RC,,,,,facility,outpatient,,,161.35000,46.79000,Aetna,First Health,,131.98,,,,,,,58.17,131.98,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,8725305,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,8725305,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Lurasidone 40mg T(Latuda),8725348,CDM,637,RC,,,,,facility,inpatient,,,317.62000,92.11000,Aetna,First Health,,259.81,,,,,,,190.57,259.81,percent of total billed charges,
Lurasidone 40mg T(Latuda),8725348,CDM,637,RC,,,,,facility,outpatient,,,317.62000,92.11000,Aetna,First Health,,259.81,,,,,,,114.50,259.81,percent of total billed charges,
Gabapentin 300mg/6mL Oral Liq UD,8725337,CDM,637,RC,,,,,facility,inpatient,,,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
Gabapentin 300mg/6mL Oral Liq UD,8725337,CDM,637,RC,,,,,facility,outpatient,,,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Naltrexone 50mg Tab,8725342,CDM,637,RC,,,,,facility,inpatient,,,17.88000,5.19000,Aetna,First Health,,14.63,,,,,,,10.73,14.63,percent of total billed charges,
Naltrexone 50mg Tab,8725342,CDM,637,RC,,,,,facility,outpatient,,,17.88000,5.19000,Aetna,First Health,,14.63,,,,,,,6.45,14.63,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,8725377,CDM,637,RC,,,,,facility,inpatient,,,90.35000,26.20000,Aetna,First Health,,73.91,,,,,,,54.21,73.91,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,8725377,CDM,637,RC,,,,,facility,outpatient,,,90.35000,26.20000,Aetna,First Health,,73.91,,,,,,,32.57,73.91,percent of total billed charges,
Mineral Oil 100% Enema,8725368,CDM,637,RC,,,,,facility,inpatient,,,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,11.13,15.17,percent of total billed charges,
Mineral Oil 100% Enema,8725368,CDM,637,RC,,,,,facility,outpatient,,,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,6.69,15.17,percent of total billed charges,
Cholestyramine 4g Lt Pkt,8725963,CDM,637,RC,,,,,facility,inpatient,,,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,14.25,19.43,percent of total billed charges,
Cholestyramine 4g Lt Pkt,8725963,CDM,637,RC,,,,,facility,outpatient,,,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.56,19.43,percent of total billed charges,
Aprepitant 40mg C (Emend),8725265,CDM,637,RC,J8501,HCPCS,,,facility,inpatient,,,704.45000,204.29000,Aetna,First Health,,576.24,,,,,,,422.67,576.24,percent of total billed charges,
Aprepitant 40mg C (Emend),8725265,CDM,637,RC,J8501,HCPCS,,,facility,outpatient,,,704.45000,204.29000,Aetna,First Health,,576.24,,,,,,,2.67,576.24,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",8723759,CDM,637,RC,,,,,facility,inpatient,,,261.50000,75.83000,Aetna,First Health,,213.91,,,,,,,156.90,213.91,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",8723759,CDM,637,RC,,,,,facility,outpatient,,,261.50000,75.83000,Aetna,First Health,,213.91,,,,,,,94.27,213.91,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),8723483,CDM,637,RC,,,,,facility,inpatient,,,107.50000,31.17000,Aetna,First Health,,87.94,,,,,,,64.50,87.94,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),8723483,CDM,637,RC,,,,,facility,outpatient,,,107.50000,31.17000,Aetna,First Health,,87.94,,,,,,,38.75,87.94,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,8724057,CDM,637,RC,,,,,facility,inpatient,,,1042.25000,302.25000,Aetna,First Health,,852.56,,,,,,,625.35,852.56,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,8724057,CDM,637,RC,,,,,facility,outpatient,,,1042.25000,302.25000,Aetna,First Health,,852.56,,,,,,,375.73,852.56,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,8723474,CDM,637,RC,,,,,facility,inpatient,,,639.25000,185.38000,Aetna,First Health,,522.91,,,,,,,383.55,522.91,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,8723474,CDM,637,RC,,,,,facility,outpatient,,,639.25000,185.38000,Aetna,First Health,,522.91,,,,,,,230.45,522.91,percent of total billed charges,
Levothyroxine Sodium 50mcg T,8724019,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Levothyroxine Sodium 50mcg T,8724019,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),8723855,CDM,637,RC,,,,,facility,inpatient,,,376.35000,109.14000,Aetna,First Health,,307.85,,,,,,,225.81,307.85,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),8723855,CDM,637,RC,,,,,facility,outpatient,,,376.35000,109.14000,Aetna,First Health,,307.85,,,,,,,135.67,307.85,percent of total billed charges,
Erythromycin 0.5% 3.5g Ophth Oint,8722117,CDM,637,RC,,,,,facility,inpatient,,,134.55000,39.02000,Aetna,First Health,,110.06,,,,,,,80.73,110.06,percent of total billed charges,
Erythromycin 0.5% 3.5g Ophth Oint,8722117,CDM,637,RC,,,,,facility,outpatient,,,134.55000,39.02000,Aetna,First Health,,110.06,,,,,,,48.51,110.06,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),8723948,CDM,637,RC,Q0161,HCPCS,,,facility,inpatient,,,36.10000,10.47000,Aetna,First Health,,29.53,,,,,,,21.66,29.53,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),8723948,CDM,637,RC,Q0161,HCPCS,,,facility,outpatient,,,36.10000,10.47000,Aetna,First Health,,29.53,,,,,,,2.07,29.53,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),8723949,CDM,637,RC,Q0161,HCPCS,,,facility,inpatient,,,44.44000,12.89000,Aetna,First Health,,36.35,,,,,,,26.66,36.35,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),8723949,CDM,637,RC,Q0161,HCPCS,,,facility,outpatient,,,44.44000,12.89000,Aetna,First Health,,36.35,,,,,,,2.07,36.35,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),8723943,CDM,637,RC,Q0177,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),8723943,CDM,637,RC,Q0177,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.21186,8.18,percent of total billed charges,
Thyroid 30mg T,8724054,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Thyroid 30mg T,8724054,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Buprenorphine 8mg SL Tab,8724792,CDM,637,RC,J0571,HCPCS,,,facility,inpatient,,,38.55000,11.18000,Aetna,First Health,,31.53,,,,,,,23.13,31.53,percent of total billed charges,
Buprenorphine 8mg SL Tab,8724792,CDM,637,RC,J0571,HCPCS,,,facility,outpatient,,,38.55000,11.18000,Aetna,First Health,,31.53,,,,,,,2.08,31.53,percent of total billed charges,
Thyroid 120mg T,8724025,CDM,637,RC,,,,,facility,inpatient,,,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,8.64,11.78,percent of total billed charges,
Thyroid 120mg T,8724025,CDM,637,RC,,,,,facility,outpatient,,,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,5.19,11.78,percent of total billed charges,
Methylnaltrexone 12mg/0.6mL I,8724855,CDM,637,RC,J2212,HCPCS,,,facility,inpatient,,,867.05000,251.44000,Aetna,First Health,,709.25,,,,,,,520.23,709.25,percent of total billed charges,
Methylnaltrexone 12mg/0.6mL I,8724855,CDM,637,RC,J2212,HCPCS,,,facility,outpatient,,,867.05000,251.44000,Aetna,First Health,,709.25,,,,,,,1.54,709.25,percent of total billed charges,
predniSONE 10mg T,8723926,CDM,637,RC,J7512,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
predniSONE 10mg T,8723926,CDM,637,RC,J7512,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.00963,8.18,percent of total billed charges,
predniSONE 50mg T,8723928,CDM,637,RC,J7512,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
predniSONE 50mg T,8723928,CDM,637,RC,J7512,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.00963,8.18,percent of total billed charges,
predniSONE 5mg/mL L(Pred Intensol),8723863,CDM,637,RC,J7512,HCPCS,,,facility,inpatient,,,36.85000,10.69000,Aetna,First Health,,30.14,,,,,,,22.11,30.14,percent of total billed charges,
predniSONE 5mg/mL L(Pred Intensol),8723863,CDM,637,RC,J7512,HCPCS,,,facility,outpatient,,,36.85000,10.69000,Aetna,First Health,,30.14,,,,,,,0.00963,30.14,percent of total billed charges,
predniSONE 20mg T,8723927,CDM,637,RC,J7512,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
predniSONE 20mg T,8723927,CDM,637,RC,J7512,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.00963,8.18,percent of total billed charges,
predniSONE 2.5mg T,8723924,CDM,637,RC,J7512,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
predniSONE 2.5mg T,8723924,CDM,637,RC,J7512,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.00963,8.18,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),8723774,CDM,637,RC,Q0177,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),8723774,CDM,637,RC,Q0177,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.21186,8.18,percent of total billed charges,
Fosfomycin 3g Packet,8725719,CDM,637,RC,,,,,facility,inpatient,,,652.93000,189.35000,Aetna,First Health,,534.10,,,,,,,391.76,534.10,percent of total billed charges,
Fosfomycin 3g Packet,8725719,CDM,637,RC,,,,,facility,outpatient,,,652.93000,189.35000,Aetna,First Health,,534.10,,,,,,,235.38,534.10,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,8725732,CDM,637,RC,,,,,facility,inpatient,,,178.89000,51.88000,Aetna,First Health,,146.33,,,,,,,107.33,146.33,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,8725732,CDM,637,RC,,,,,facility,outpatient,,,178.89000,51.88000,Aetna,First Health,,146.33,,,,,,,64.49,146.33,percent of total billed charges,
Mycophenolate Mofetil 500mg/2.5mL Susp,8725730,CDM,637,RC,,,,,facility,inpatient,,,160.40000,46.52000,Aetna,First Health,,131.21,,,,,,,96.24,131.21,percent of total billed charges,
Mycophenolate Mofetil 500mg/2.5mL Susp,8725730,CDM,637,RC,,,,,facility,outpatient,,,160.40000,46.52000,Aetna,First Health,,131.21,,,,,,,57.82,131.21,percent of total billed charges,
PARoxetine 20mg/10mL Oral Liq.,8725728,CDM,637,RC,,,,,facility,inpatient,,,60.80000,17.63000,Aetna,First Health,,49.73,,,,,,,36.48,49.73,percent of total billed charges,
PARoxetine 20mg/10mL Oral Liq.,8725728,CDM,637,RC,,,,,facility,outpatient,,,60.80000,17.63000,Aetna,First Health,,49.73,,,,,,,21.92,49.73,percent of total billed charges,
Haloperidol 5mg/2.5mL LC UD,8725724,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Haloperidol 5mg/2.5mL LC UD,8725724,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Tetracaine HCl 0.5% 4mL Ophth Soln,8725742,CDM,637,RC,,,,,facility,inpatient,,,117.95000,34.21000,Aetna,First Health,,96.48,,,,,,,70.77,96.48,percent of total billed charges,
Tetracaine HCl 0.5% 4mL Ophth Soln,8725742,CDM,637,RC,,,,,facility,outpatient,,,117.95000,34.21000,Aetna,First Health,,96.48,,,,,,,42.52,96.48,percent of total billed charges,
Sulfamethoxazole-Trimethoprim DS 800-160mg T,8725738,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Sulfamethoxazole-Trimethoprim DS 800-160mg T,8725738,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Buprenorphine 2mg SL Tab,8725739,CDM,637,RC,J0571,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Buprenorphine 2mg SL Tab,8725739,CDM,637,RC,J0571,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,2.08,20.45,percent of total billed charges,
Ferric Subsulfate 8mL TS(Monsel's),8725743,CDM,637,RC,,,,,facility,inpatient,,,99.90000,28.97000,Aetna,First Health,,81.72,,,,,,,59.94,81.72,percent of total billed charges,
Ferric Subsulfate 8mL TS(Monsel's),8725743,CDM,637,RC,,,,,facility,outpatient,,,99.90000,28.97000,Aetna,First Health,,81.72,,,,,,,36.01,81.72,percent of total billed charges,
Patiromer 8.4g REC Packet (Veltassa),8725762,CDM,637,RC,,,,,facility,inpatient,,,386.15000,111.98000,Aetna,First Health,,315.87,,,,,,,231.69,315.87,percent of total billed charges,
Patiromer 8.4g REC Packet (Veltassa),8725762,CDM,637,RC,,,,,facility,outpatient,,,386.15000,111.98000,Aetna,First Health,,315.87,,,,,,,139.21,315.87,percent of total billed charges,
Mupirocin/Nystatin/Betameth/Antifungal Oint.,8725775,CDM,637,RC,,,,,facility,inpatient,,,603.95000,175.15000,Aetna,First Health,,494.03,,,,,,,362.37,494.03,percent of total billed charges,
Mupirocin/Nystatin/Betameth/Antifungal Oint.,8725775,CDM,637,RC,,,,,facility,outpatient,,,603.95000,175.15000,Aetna,First Health,,494.03,,,,,,,217.72,494.03,percent of total billed charges,
Ciproflox-Fluoc 0.3-0.025% Otic Soln,8725777,CDM,637,RC,,,,,facility,inpatient,,,164.75000,47.78000,Aetna,First Health,,134.77,,,,,,,98.85,134.77,percent of total billed charges,
Ciproflox-Fluoc 0.3-0.025% Otic Soln,8725777,CDM,637,RC,,,,,facility,outpatient,,,164.75000,47.78000,Aetna,First Health,,134.77,,,,,,,59.39,134.77,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),8723951,CDM,637,RC,,,,,facility,inpatient,,,110.40000,32.02000,Aetna,First Health,,90.31,,,,,,,66.24,90.31,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),8723951,CDM,637,RC,,,,,facility,outpatient,,,110.40000,32.02000,Aetna,First Health,,90.31,,,,,,,39.80,90.31,percent of total billed charges,
Vortioxetine 10mg Tab,8725797,CDM,637,RC,,,,,facility,inpatient,,,145.65000,42.24000,Aetna,First Health,,119.14,,,,,,,87.39,119.14,percent of total billed charges,
Vortioxetine 10mg Tab,8725797,CDM,637,RC,,,,,facility,outpatient,,,145.65000,42.24000,Aetna,First Health,,119.14,,,,,,,52.51,119.14,percent of total billed charges,
Insulin Regular (Concentrated) U-500 Pen/Needle,8725800,CDM,637,RC,J1815,HCPCS,,,facility,inpatient,,,1333.85000,386.82000,Aetna,First Health,,1091.09,,,,,,,800.31,1091.09,percent of total billed charges,
Insulin Regular (Concentrated) U-500 Pen/Needle,8725800,CDM,637,RC,J1815,HCPCS,,,facility,outpatient,,,1333.85000,386.82000,Aetna,First Health,,1091.09,,,,,,,0.26001,1091.09,percent of total billed charges,
Ticagrelor 60mg Tab,8725801,CDM,637,RC,,,,,facility,inpatient,,,65.85000,19.10000,Aetna,First Health,,53.87,,,,,,,39.51,53.87,percent of total billed charges,
Ticagrelor 60mg Tab,8725801,CDM,637,RC,,,,,facility,outpatient,,,65.85000,19.10000,Aetna,First Health,,53.87,,,,,,,23.74,53.87,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,8725802,CDM,637,RC,,,,,facility,inpatient,,,35.30000,10.24000,Aetna,First Health,,28.88,,,,,,,21.18,28.88,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,8725802,CDM,637,RC,,,,,facility,outpatient,,,35.30000,10.24000,Aetna,First Health,,28.88,,,,,,,12.73,28.88,percent of total billed charges,
Sodium Hypochlor 0.125% TS 473mL,8725818,CDM,637,RC,,,,,facility,inpatient,,,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,78.60,107.16,percent of total billed charges,
Sodium Hypochlor 0.125% TS 473mL,8725818,CDM,637,RC,,,,,facility,outpatient,,,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,47.23,107.16,percent of total billed charges,
Mupirocin 2% Top Oint 1g UD,8725819,CDM,637,RC,,,,,facility,inpatient,,,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,21.78,29.69,percent of total billed charges,
Mupirocin 2% Top Oint 1g UD,8725819,CDM,637,RC,,,,,facility,outpatient,,,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,13.09,29.69,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,8724143,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,8724143,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
SITagliptin 25 mg T (Januvia),8725370,CDM,637,RC,,,,,facility,inpatient,,,93.50000,27.12000,Aetna,First Health,,76.48,,,,,,,56.10,76.48,percent of total billed charges,
SITagliptin 25 mg T (Januvia),8725370,CDM,637,RC,,,,,facility,outpatient,,,93.50000,27.12000,Aetna,First Health,,76.48,,,,,,,33.71,76.48,percent of total billed charges,
Ammonium Lactate 12% Lotion,8725387,CDM,637,RC,,,,,facility,inpatient,,,129.15000,37.45000,Aetna,First Health,,105.64,,,,,,,77.49,105.64,percent of total billed charges,
Ammonium Lactate 12% Lotion,8725387,CDM,637,RC,,,,,facility,outpatient,,,129.15000,37.45000,Aetna,First Health,,105.64,,,,,,,46.56,105.64,percent of total billed charges,
Mycophenolate Mofetil 250mg Oral Liq,8725661,CDM,637,RC,J7517,HCPCS,,,facility,inpatient,,,80.20000,23.26000,Aetna,First Health,,65.60,,,,,,,48.12,65.60,percent of total billed charges,
Mycophenolate Mofetil 250mg Oral Liq,8725661,CDM,637,RC,J7517,HCPCS,,,facility,outpatient,,,80.20000,23.26000,Aetna,First Health,,65.60,,,,,,,0.14445,65.60,percent of total billed charges,
PHENobarbital 40mg/10mL Soln,8725391,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
PHENobarbital 40mg/10mL Soln,8725391,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
LORazepam 1mg/0.5mL Oral Conc,8725390,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
LORazepam 1mg/0.5mL Oral Conc,8725390,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Gabapentin 100mg/2mL Oral Liq UD,8725388,CDM,637,RC,,,,,facility,inpatient,,,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,7.08,9.65,percent of total billed charges,
Gabapentin 100mg/2mL Oral Liq UD,8725388,CDM,637,RC,,,,,facility,outpatient,,,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,4.25,9.65,percent of total billed charges,
Gabapentin 200mg/4mL Oral Liq UD,8725389,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Gabapentin 200mg/4mL Oral Liq UD,8725389,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Mirabegron 25mg ER T,8725444,CDM,637,RC,,,,,facility,inpatient,,,117.35000,34.03000,Aetna,First Health,,95.99,,,,,,,70.41,95.99,percent of total billed charges,
Mirabegron 25mg ER T,8725444,CDM,637,RC,,,,,facility,outpatient,,,117.35000,34.03000,Aetna,First Health,,95.99,,,,,,,42.30,95.99,percent of total billed charges,
Linaclotide 145mcg C(Linzess),8725445,CDM,637,RC,,,,,facility,inpatient,,,160.85000,46.65000,Aetna,First Health,,131.58,,,,,,,96.51,131.58,percent of total billed charges,
Linaclotide 145mcg C(Linzess),8725445,CDM,637,RC,,,,,facility,outpatient,,,160.85000,46.65000,Aetna,First Health,,131.58,,,,,,,57.99,131.58,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,8725450,CDM,637,RC,,,,,facility,inpatient,,,86.25000,25.01000,Aetna,First Health,,70.55,,,,,,,51.75,70.55,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,8725450,CDM,637,RC,,,,,facility,outpatient,,,86.25000,25.01000,Aetna,First Health,,70.55,,,,,,,31.09,70.55,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),8725455,CDM,637,RC,,,,,facility,inpatient,,,255.60000,74.12000,Aetna,First Health,,209.08,,,,,,,153.36,209.08,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),8725455,CDM,637,RC,,,,,facility,outpatient,,,255.60000,74.12000,Aetna,First Health,,209.08,,,,,,,92.14,209.08,percent of total billed charges,
Lurasidone 20 mg T(Latuda),8725458,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Lurasidone 20 mg T(Latuda),8725458,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Papaverine HCl 60mg/2mL I,8725463,CDM,637,RC,J2440,HCPCS,,,facility,inpatient,,,385.70000,111.85000,Aetna,First Health,,315.50,,,,,,,231.42,315.50,percent of total billed charges,
Papaverine HCl 60mg/2mL I,8725463,CDM,637,RC,J2440,HCPCS,,,facility,outpatient,,,385.70000,111.85000,Aetna,First Health,,315.50,,,,,,,43.34,315.50,percent of total billed charges,
Silodosin 4mg Cap,8725508,CDM,637,RC,,,,,facility,inpatient,,,63.55000,18.43000,Aetna,First Health,,51.98,,,,,,,38.13,51.98,percent of total billed charges,
Silodosin 4mg Cap,8725508,CDM,637,RC,,,,,facility,outpatient,,,63.55000,18.43000,Aetna,First Health,,51.98,,,,,,,22.91,51.98,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),8725510,CDM,637,RC,,,,,facility,inpatient,,,103.55000,30.03000,Aetna,First Health,,84.70,,,,,,,62.13,84.70,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),8725510,CDM,637,RC,,,,,facility,outpatient,,,103.55000,30.03000,Aetna,First Health,,84.70,,,,,,,37.33,84.70,percent of total billed charges,
Methadone 100mg/10mL Oral Conc,8725513,CDM,637,RC,,,,,facility,inpatient,,,67.60000,19.60000,Aetna,First Health,,55.30,,,,,,,40.56,55.30,percent of total billed charges,
Methadone 100mg/10mL Oral Conc,8725513,CDM,637,RC,,,,,facility,outpatient,,,67.60000,19.60000,Aetna,First Health,,55.30,,,,,,,24.37,55.30,percent of total billed charges,
Methadone 50mg/5mL Oral Conc,8725514,CDM,637,RC,,,,,facility,inpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
Methadone 50mg/5mL Oral Conc,8725514,CDM,637,RC,,,,,facility,outpatient,,,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,47.95,108.79,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,8725527,CDM,637,RC,J8540,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,8725527,CDM,637,RC,J8540,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.00963,8.18,percent of total billed charges,
GI Cocktail 50mL UD - ED Use,8726033,CDM,637,RC,,,,,facility,inpatient,,,48.15000,13.96000,Aetna,First Health,,39.39,,,,,,,28.89,39.39,percent of total billed charges,
GI Cocktail 50mL UD - ED Use,8726033,CDM,637,RC,,,,,facility,outpatient,,,48.15000,13.96000,Aetna,First Health,,39.39,,,,,,,17.36,39.39,percent of total billed charges,
Hydrocortisone 2.5%-Pramox 1% Top Oint,8725533,CDM,637,RC,,,,,facility,inpatient,,,1789.25000,518.88000,Aetna,First Health,,1463.61,,,,,,,1073.55,1463.61,percent of total billed charges,
Hydrocortisone 2.5%-Pramox 1% Top Oint,8725533,CDM,637,RC,,,,,facility,outpatient,,,1789.25000,518.88000,Aetna,First Health,,1463.61,,,,,,,645.02,1463.61,percent of total billed charges,
Tapentadol 50mg Tab UD,8725541,CDM,637,RC,,,,,facility,inpatient,,,116.90000,33.90000,Aetna,First Health,,95.62,,,,,,,70.14,95.62,percent of total billed charges,
Tapentadol 50mg Tab UD,8725541,CDM,637,RC,,,,,facility,outpatient,,,116.90000,33.90000,Aetna,First Health,,95.62,,,,,,,42.14,95.62,percent of total billed charges,
Balsam Peru-Castor Oil Topical Oint,8726101,CDM,637,RC,,,,,facility,inpatient,,,236.85000,68.69000,Aetna,First Health,,193.74,,,,,,,142.11,193.74,percent of total billed charges,
Balsam Peru-Castor Oil Topical Oint,8726101,CDM,637,RC,,,,,facility,outpatient,,,236.85000,68.69000,Aetna,First Health,,193.74,,,,,,,85.38,193.74,percent of total billed charges,
Fidaxomicin 200mg T(Dificid),8725559,CDM,637,RC,,,,,facility,inpatient,,,1871.50000,542.74000,Aetna,First Health,,1530.89,,,,,,,1122.90,1530.89,percent of total billed charges,
Fidaxomicin 200mg T(Dificid),8725559,CDM,637,RC,,,,,facility,outpatient,,,1871.50000,542.74000,Aetna,First Health,,1530.89,,,,,,,674.68,1530.89,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),8725563,CDM,637,RC,,,,,facility,inpatient,,,58.15000,16.86000,Aetna,First Health,,47.57,,,,,,,34.89,47.57,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),8725563,CDM,637,RC,,,,,facility,outpatient,,,58.15000,16.86000,Aetna,First Health,,47.57,,,,,,,20.96,47.57,percent of total billed charges,
Ivabradine 5mg Tab,8725567,CDM,637,RC,,,,,facility,inpatient,,,88.72000,25.73000,Aetna,First Health,,72.57,,,,,,,53.23,72.57,percent of total billed charges,
Ivabradine 5mg Tab,8725567,CDM,637,RC,,,,,facility,outpatient,,,88.72000,25.73000,Aetna,First Health,,72.57,,,,,,,31.98,72.57,percent of total billed charges,
Milnacipran 50mg T(Savella),8725571,CDM,637,RC,,,,,facility,inpatient,,,72.50000,21.02000,Aetna,First Health,,59.30,,,,,,,43.50,59.30,percent of total billed charges,
Milnacipran 50mg T(Savella),8725571,CDM,637,RC,,,,,facility,outpatient,,,72.50000,21.02000,Aetna,First Health,,59.30,,,,,,,26.14,59.30,percent of total billed charges,
Sacubitril-Valsartan 24-26mg Tab,8725575,CDM,637,RC,,,,,facility,inpatient,,,99.22000,28.77000,Aetna,First Health,,81.16,,,,,,,59.53,81.16,percent of total billed charges,
Sacubitril-Valsartan 24-26mg Tab,8725575,CDM,637,RC,,,,,facility,outpatient,,,99.22000,28.77000,Aetna,First Health,,81.16,,,,,,,35.77,81.16,percent of total billed charges,
Sacubitril-Valsartan 49-51mg Tab,8725576,CDM,637,RC,,,,,facility,inpatient,,,94.62000,27.44000,Aetna,First Health,,77.40,,,,,,,56.77,77.40,percent of total billed charges,
Sacubitril-Valsartan 49-51mg Tab,8725576,CDM,637,RC,,,,,facility,outpatient,,,94.62000,27.44000,Aetna,First Health,,77.40,,,,,,,34.11,77.40,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,8725577,CDM,637,RC,,,,,facility,inpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,58.75,80.09,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,8725577,CDM,637,RC,,,,,facility,outpatient,,,97.91000,28.39000,Aetna,First Health,,80.09,,,,,,,35.30,80.09,percent of total billed charges,
HYDROmorphone 5mg/5mL Oral Soln,8725651,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
HYDROmorphone 5mg/5mL Oral Soln,8725651,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Vilazodone 20mg T(Viibryd),8725667,CDM,637,RC,,,,,facility,inpatient,,,78.01000,22.62000,Aetna,First Health,,63.81,,,,,,,46.81,63.81,percent of total billed charges,
Vilazodone 20mg T(Viibryd),8725667,CDM,637,RC,,,,,facility,outpatient,,,78.01000,22.62000,Aetna,First Health,,63.81,,,,,,,28.12,63.81,percent of total billed charges,
miSOPROStol 25mcg/0.25 Tab,8725665,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
miSOPROStol 25mcg/0.25 Tab,8725665,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
NICU- Morphine 0.4mg/mLOral Liq,8725710,CDM,637,RC,,,,,facility,inpatient,,,39.60000,11.48000,Aetna,First Health,,32.39,,,,,,,23.76,32.39,percent of total billed charges,
NICU- Morphine 0.4mg/mLOral Liq,8725710,CDM,637,RC,,,,,facility,outpatient,,,39.60000,11.48000,Aetna,First Health,,32.39,,,,,,,14.28,32.39,percent of total billed charges,
Cholestyramine 5g/ZincOxide 20% TP,8725705,CDM,637,RC,,,,,facility,inpatient,,,77.35000,22.43000,Aetna,First Health,,63.27,,,,,,,46.41,63.27,percent of total billed charges,
Cholestyramine 5g/ZincOxide 20% TP,8725705,CDM,637,RC,,,,,facility,outpatient,,,77.35000,22.43000,Aetna,First Health,,63.27,,,,,,,27.88,63.27,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,8723462,CDM,637,RC,,,,,facility,inpatient,,,75.36000,21.85000,Aetna,First Health,,61.64,,,,,,,45.22,61.64,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,8723462,CDM,637,RC,,,,,facility,outpatient,,,75.36000,21.85000,Aetna,First Health,,61.64,,,,,,,27.17,61.64,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,8723535,CDM,637,RC,,,,,facility,inpatient,,,64.69000,18.76000,Aetna,First Health,,52.92,,,,,,,38.81,52.92,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,8723535,CDM,637,RC,,,,,facility,outpatient,,,64.69000,18.76000,Aetna,First Health,,52.92,,,,,,,23.32,52.92,percent of total billed charges,
Amoxicillin 250mg/5mL L,8723645,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Amoxicillin 250mg/5mL L,8723645,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Nystatin Oral Susp 5mL UD,8723609,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Nystatin Oral Susp 5mL UD,8723609,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Microfibrillar 1g TP(Avitene),8724093,CDM,637,RC,,,,,facility,inpatient,,,1758.20000,509.88000,Aetna,First Health,,1438.21,,,,,,,1054.92,1438.21,percent of total billed charges,
Microfibrillar 1g TP(Avitene),8724093,CDM,637,RC,,,,,facility,outpatient,,,1758.20000,509.88000,Aetna,First Health,,1438.21,,,,,,,633.83,1438.21,percent of total billed charges,
Furosemide 40mg/4mL (Lasix),8726122,CDM,637,RC,,,,,facility,inpatient,,,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,13.08,17.83,percent of total billed charges,
Furosemide 40mg/4mL (Lasix),8726122,CDM,637,RC,,,,,facility,outpatient,,,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,7.86,17.83,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),8723484,CDM,637,RC,,,,,facility,inpatient,,,377.20000,109.39000,Aetna,First Health,,308.55,,,,,,,226.32,308.55,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),8723484,CDM,637,RC,,,,,facility,outpatient,,,377.20000,109.39000,Aetna,First Health,,308.55,,,,,,,135.98,308.55,percent of total billed charges,
Desvenlafaxine 100mg ER T,8725839,CDM,637,RC,,,,,facility,inpatient,,,79.95000,23.19000,Aetna,First Health,,65.40,,,,,,,47.97,65.40,percent of total billed charges,
Desvenlafaxine 100mg ER T,8725839,CDM,637,RC,,,,,facility,outpatient,,,79.95000,23.19000,Aetna,First Health,,65.40,,,,,,,28.82,65.40,percent of total billed charges,
Dolutegravir 50mg Tab,8725841,CDM,637,RC,,,,,facility,inpatient,,,605.50000,175.60000,Aetna,First Health,,495.30,,,,,,,363.30,495.30,percent of total billed charges,
Dolutegravir 50mg Tab,8725841,CDM,637,RC,,,,,facility,outpatient,,,605.50000,175.60000,Aetna,First Health,,495.30,,,,,,,218.28,495.30,percent of total billed charges,
elviteg/cobic/emtrici/teno 150-150-200-10mg T,8725851,CDM,637,RC,,,,,facility,inpatient,,,1031.05000,299.00000,Aetna,First Health,,843.40,,,,,,,618.63,843.40,percent of total billed charges,
elviteg/cobic/emtrici/teno 150-150-200-10mg T,8725851,CDM,637,RC,,,,,facility,outpatient,,,1031.05000,299.00000,Aetna,First Health,,843.40,,,,,,,371.69,843.40,percent of total billed charges,
Emtricitabine-Tenofovir 200-25mg Tab,8725852,CDM,637,RC,,,,,facility,inpatient,,,575.60000,166.92000,Aetna,First Health,,470.84,,,,,,,345.36,470.84,percent of total billed charges,
Emtricitabine-Tenofovir 200-25mg Tab,8725852,CDM,637,RC,,,,,facility,outpatient,,,575.60000,166.92000,Aetna,First Health,,470.84,,,,,,,207.50,470.84,percent of total billed charges,
LinaCLOtide 72mcg C (Linzess),8725846,CDM,637,RC,,,,,facility,inpatient,,,160.85000,46.65000,Aetna,First Health,,131.58,,,,,,,96.51,131.58,percent of total billed charges,
LinaCLOtide 72mcg C (Linzess),8725846,CDM,637,RC,,,,,facility,outpatient,,,160.85000,46.65000,Aetna,First Health,,131.58,,,,,,,57.99,131.58,percent of total billed charges,
Mesalamine 800mg EC Tab,8725845,CDM,637,RC,,,,,facility,inpatient,,,74.44000,21.59000,Aetna,First Health,,60.89,,,,,,,44.66,60.89,percent of total billed charges,
Mesalamine 800mg EC Tab,8725845,CDM,637,RC,,,,,facility,outpatient,,,74.44000,21.59000,Aetna,First Health,,60.89,,,,,,,26.84,60.89,percent of total billed charges,
Zonisamide 25mg Cap,8725842,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Zonisamide 25mg Cap,8725842,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Bromocriptine 2.5mg Tab,8725836,CDM,637,RC,,,,,facility,inpatient,,,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,17.58,23.97,percent of total billed charges,
Bromocriptine 2.5mg Tab,8725836,CDM,637,RC,,,,,facility,outpatient,,,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,10.56,23.97,percent of total billed charges,
NUTR- Isosource 1.5 (250mL),8725909,CDM,637,RC,,,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
NUTR- Isosource 1.5 (250mL),8725909,CDM,637,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
NUTR- Isosource 1.5 (1L),8725910,CDM,637,RC,,,,,facility,inpatient,,,65.15000,18.89000,Aetna,First Health,,53.29,,,,,,,39.09,53.29,percent of total billed charges,
NUTR- Isosource 1.5 (1L),8725910,CDM,637,RC,,,,,facility,outpatient,,,65.15000,18.89000,Aetna,First Health,,53.29,,,,,,,23.49,53.29,percent of total billed charges,
Potassium Chloride 20mEq ER T,8725856,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Potassium Chloride 20mEq ER T,8725856,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Abacavir/Dolut/Lamiv 600-50-300mg T,8725869,CDM,637,RC,,,,,facility,inpatient,,,959.95000,278.39000,Aetna,First Health,,785.24,,,,,,,575.97,785.24,percent of total billed charges,
Abacavir/Dolut/Lamiv 600-50-300mg T,8725869,CDM,637,RC,,,,,facility,outpatient,,,959.95000,278.39000,Aetna,First Health,,785.24,,,,,,,346.06,785.24,percent of total billed charges,
Spacer for Inhaler,8725893,CDM,637,RC,,,,,facility,inpatient,,,143.05000,41.48000,Aetna,First Health,,117.01,,,,,,,85.83,117.01,percent of total billed charges,
Spacer for Inhaler,8725893,CDM,637,RC,,,,,facility,outpatient,,,143.05000,41.48000,Aetna,First Health,,117.01,,,,,,,51.57,117.01,percent of total billed charges,
NUTR- Novasource Renal (237mL),8725913,CDM,637,RC,,,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
NUTR- Novasource Renal (237mL),8725913,CDM,637,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
NUTR- Novasource Renal(1L),8725914,CDM,637,RC,,,,,facility,inpatient,,,161.80000,46.92000,Aetna,First Health,,132.35,,,,,,,97.08,132.35,percent of total billed charges,
NUTR- Novasource Renal(1L),8725914,CDM,637,RC,,,,,facility,outpatient,,,161.80000,46.92000,Aetna,First Health,,132.35,,,,,,,58.33,132.35,percent of total billed charges,
NUTR- Nutren 2.0 (250mL),8725915,CDM,637,RC,,,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
NUTR- Nutren 2.0 (250mL),8725915,CDM,637,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
NUTR- Nutren 2.0 (1L),8725928,CDM,637,RC,,,,,facility,inpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,30.00,40.90,percent of total billed charges,
NUTR- Nutren 2.0 (1L),8725928,CDM,637,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
NUTR- Peptamen 1.5 (1L),8725918,CDM,637,RC,,,,,facility,inpatient,,,321.75000,93.31000,Aetna,First Health,,263.19,,,,,,,193.05,263.19,percent of total billed charges,
NUTR- Peptamen 1.5 (1L),8725918,CDM,637,RC,,,,,facility,outpatient,,,321.75000,93.31000,Aetna,First Health,,263.19,,,,,,,115.99,263.19,percent of total billed charges,
NUTR- Peptamen AF (1L),8725919,CDM,637,RC,,,,,facility,inpatient,,,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,189.39,258.20,percent of total billed charges,
NUTR- Peptamen AF (1L),8725919,CDM,637,RC,,,,,facility,outpatient,,,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,113.79,258.20,percent of total billed charges,
NUTR- Peptamen Intense VHP(1L),8725920,CDM,637,RC,,,,,facility,inpatient,,,345.90000,100.31000,Aetna,First Health,,282.95,,,,,,,207.54,282.95,percent of total billed charges,
NUTR- Peptamen Intense VHP(1L),8725920,CDM,637,RC,,,,,facility,outpatient,,,345.90000,100.31000,Aetna,First Health,,282.95,,,,,,,124.70,282.95,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,8726012,CDM,637,RC,,,,,facility,inpatient,,,14.09000,4.09000,Aetna,First Health,,11.53,,,,,,,8.45,11.53,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,8726012,CDM,637,RC,,,,,facility,outpatient,,,14.09000,4.09000,Aetna,First Health,,11.53,,,,,,,5.08,11.53,percent of total billed charges,
Albuterol 90 mcg/Inh,8724355,CDM,637,RC,,,,,facility,inpatient,,,592.70000,171.88000,Aetna,First Health,,484.83,,,,,,,355.62,484.83,percent of total billed charges,
Albuterol 90 mcg/Inh,8724355,CDM,637,RC,,,,,facility,outpatient,,,592.70000,171.88000,Aetna,First Health,,484.83,,,,,,,213.67,484.83,percent of total billed charges,
Opium 10% (Deod Opium Tinc),8723654,CDM,637,RC,,,,,facility,inpatient,,,50.20000,14.56000,Aetna,First Health,,41.06,,,,,,,30.12,41.06,percent of total billed charges,
Opium 10% (Deod Opium Tinc),8723654,CDM,637,RC,,,,,facility,outpatient,,,50.20000,14.56000,Aetna,First Health,,41.06,,,,,,,18.10,41.06,percent of total billed charges,
prednisoLONE 0.12% 5mL Ophth Susp(Pred Mild),8724116,CDM,637,RC,,,,,facility,inpatient,,,1164.05000,337.57000,Aetna,First Health,,952.19,,,,,,,698.43,952.19,percent of total billed charges,
prednisoLONE 0.12% 5mL Ophth Susp(Pred Mild),8724116,CDM,637,RC,,,,,facility,outpatient,,,1164.05000,337.57000,Aetna,First Health,,952.19,,,,,,,419.64,952.19,percent of total billed charges,
Lithium Carb 300mg CR T,8723984,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Lithium Carb 300mg CR T,8723984,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Empagliflozin 10mg Tab,8726130,CDM,637,RC,,,,,facility,inpatient,,,180.70000,52.40000,Aetna,First Health,,147.81,,,,,,,108.42,147.81,percent of total billed charges,
Empagliflozin 10mg Tab,8726130,CDM,637,RC,,,,,facility,outpatient,,,180.70000,52.40000,Aetna,First Health,,147.81,,,,,,,65.14,147.81,percent of total billed charges,
benzocaine-menthol Topical Spray,8726097,CDM,637,RC,,,,,facility,inpatient,,,45.55000,13.21000,Aetna,First Health,,37.26,,,,,,,27.33,37.26,percent of total billed charges,
benzocaine-menthol Topical Spray,8726097,CDM,637,RC,,,,,facility,outpatient,,,45.55000,13.21000,Aetna,First Health,,37.26,,,,,,,16.42,37.26,percent of total billed charges,
Zinc Oxide 20% Topical Paste,8726108,CDM,637,RC,,,,,facility,inpatient,,,680.60000,197.37000,Aetna,First Health,,556.73,,,,,,,408.36,556.73,percent of total billed charges,
Zinc Oxide 20% Topical Paste,8726108,CDM,637,RC,,,,,facility,outpatient,,,680.60000,197.37000,Aetna,First Health,,556.73,,,,,,,245.36,556.73,percent of total billed charges,
naloxegol 25mg Tab UD,8726109,CDM,637,RC,,,,,facility,inpatient,,,123.40000,35.79000,Aetna,First Health,,100.94,,,,,,,74.04,100.94,percent of total billed charges,
naloxegol 25mg Tab UD,8726109,CDM,637,RC,,,,,facility,outpatient,,,123.40000,35.79000,Aetna,First Health,,100.94,,,,,,,44.49,100.94,percent of total billed charges,
Brivaracetam 25 mg Tab,8726111,CDM,637,RC,,,,,facility,inpatient,,,233.95000,67.85000,Aetna,First Health,,191.37,,,,,,,140.37,191.37,percent of total billed charges,
Brivaracetam 25 mg Tab,8726111,CDM,637,RC,,,,,facility,outpatient,,,233.95000,67.85000,Aetna,First Health,,191.37,,,,,,,84.34,191.37,percent of total billed charges,
brimonidine 0.2% Ophth Soln,8726144,CDM,637,RC,,,,,facility,inpatient,,,85.00000,24.65000,Aetna,First Health,,69.53,,,,,,,51.00,69.53,percent of total billed charges,
brimonidine 0.2% Ophth Soln,8726144,CDM,637,RC,,,,,facility,outpatient,,,85.00000,24.65000,Aetna,First Health,,69.53,,,,,,,30.64,69.53,percent of total billed charges,
Gentamicin 0.1% TC,8726147,CDM,637,RC,,,,,facility,inpatient,,,339.95000,98.59000,Aetna,First Health,,278.08,,,,,,,203.97,278.08,percent of total billed charges,
Gentamicin 0.1% TC,8726147,CDM,637,RC,,,,,facility,outpatient,,,339.95000,98.59000,Aetna,First Health,,278.08,,,,,,,122.55,278.08,percent of total billed charges,
bictegr/emtric/tenofov 50-200-25 mg Tab,8924939,CDM,637,RC,,,,,facility,inpatient,,,1031.05000,299.00000,Aetna,First Health,,843.40,,,,,,,618.63,843.40,percent of total billed charges,
bictegr/emtric/tenofov 50-200-25 mg Tab,8924939,CDM,637,RC,,,,,facility,outpatient,,,1031.05000,299.00000,Aetna,First Health,,843.40,,,,,,,371.69,843.40,percent of total billed charges,
Rivaroxaban 2.5mg T(Xarelto),8924943,CDM,637,RC,,,,,facility,inpatient,,,80.70000,23.40000,Aetna,First Health,,66.01,,,,,,,48.42,66.01,percent of total billed charges,
Rivaroxaban 2.5mg T(Xarelto),8924943,CDM,637,RC,,,,,facility,outpatient,,,80.70000,23.40000,Aetna,First Health,,66.01,,,,,,,29.09,66.01,percent of total billed charges,
Entecavir 0.5mg Tab,8924945,CDM,637,RC,,,,,facility,inpatient,,,195.24000,56.62000,Aetna,First Health,,159.71,,,,,,,117.14,159.71,percent of total billed charges,
Entecavir 0.5mg Tab,8924945,CDM,637,RC,,,,,facility,outpatient,,,195.24000,56.62000,Aetna,First Health,,159.71,,,,,,,70.38,159.71,percent of total billed charges,
darun/cobic/emtric/tenof 800-150-200-10mg T,8924947,CDM,637,RC,,,,,facility,inpatient,,,1142.85000,331.43000,Aetna,First Health,,934.85,,,,,,,685.71,934.85,percent of total billed charges,
darun/cobic/emtric/tenof 800-150-200-10mg T,8924947,CDM,637,RC,,,,,facility,outpatient,,,1142.85000,331.43000,Aetna,First Health,,934.85,,,,,,,412.00,934.85,percent of total billed charges,
Empagliflozin 25mg Tab,8924948,CDM,637,RC,,,,,facility,inpatient,,,180.70000,52.40000,Aetna,First Health,,147.81,,,,,,,108.42,147.81,percent of total billed charges,
Empagliflozin 25mg Tab,8924948,CDM,637,RC,,,,,facility,outpatient,,,180.70000,52.40000,Aetna,First Health,,147.81,,,,,,,65.14,147.81,percent of total billed charges,
Tacrolimus 1mg ER T(Envarsus XR),8924949,CDM,637,RC,J7503,HCPCS,,,facility,inpatient,,,59.44000,17.24000,Aetna,First Health,,48.62,,,,,,,35.66,48.62,percent of total billed charges,
Tacrolimus 1mg ER T(Envarsus XR),8924949,CDM,637,RC,J7503,HCPCS,,,facility,outpatient,,,59.44000,17.24000,Aetna,First Health,,48.62,,,,,,,1.80,48.62,percent of total billed charges,
LamoTRIgine 25mg ODT,8924950,CDM,637,RC,,,,,facility,inpatient,,,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,38.01,51.82,percent of total billed charges,
LamoTRIgine 25mg ODT,8924950,CDM,637,RC,,,,,facility,outpatient,,,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,22.84,51.82,percent of total billed charges,
Tenofovir 25mg T(Vemlidy),8924952,CDM,637,RC,,,,,facility,inpatient,,,411.30000,119.28000,Aetna,First Health,,336.44,,,,,,,246.78,336.44,percent of total billed charges,
Tenofovir 25mg T(Vemlidy),8924952,CDM,637,RC,,,,,facility,outpatient,,,411.30000,119.28000,Aetna,First Health,,336.44,,,,,,,148.27,336.44,percent of total billed charges,
Cariprazine 1.5mg C(Vraylar),8924954,CDM,637,RC,,,,,facility,inpatient,,,409.40000,118.73000,Aetna,First Health,,334.89,,,,,,,245.64,334.89,percent of total billed charges,
Cariprazine 1.5mg C(Vraylar),8924954,CDM,637,RC,,,,,facility,outpatient,,,409.40000,118.73000,Aetna,First Health,,334.89,,,,,,,147.59,334.89,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,8924957,CDM,637,RC,,,,,facility,inpatient,,,60.82000,17.64000,Aetna,First Health,,49.75,,,,,,,36.49,49.75,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,8924957,CDM,637,RC,,,,,facility,outpatient,,,60.82000,17.64000,Aetna,First Health,,49.75,,,,,,,21.93,49.75,percent of total billed charges,
Metoprolol 12.5mg T(Lopressor),8924976,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Metoprolol 12.5mg T(Lopressor),8924976,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Indomethacin 100mg Rectal Supp,8975006,CDM,637,RC,,,,,facility,inpatient,,,1809.00000,524.61000,Aetna,First Health,,1479.76,,,,,,,1085.40,1479.76,percent of total billed charges,
Indomethacin 100mg Rectal Supp,8975006,CDM,637,RC,,,,,facility,outpatient,,,1809.00000,524.61000,Aetna,First Health,,1479.76,,,,,,,652.14,1479.76,percent of total billed charges,
Torsemide 100mg T,8972940,CDM,637,RC,,,,,facility,inpatient,,,20.50000,5.94000,Aetna,First Health,,16.77,,,,,,,12.30,16.77,percent of total billed charges,
Torsemide 100mg T,8972940,CDM,637,RC,,,,,facility,outpatient,,,20.50000,5.94000,Aetna,First Health,,16.77,,,,,,,7.39,16.77,percent of total billed charges,
sodium polystyrene sulfonate 15g Oral Rec Pwd,8985000,CDM,637,RC,,,,,facility,inpatient,,,111.95000,32.47000,Aetna,First Health,,91.58,,,,,,,67.17,91.58,percent of total billed charges,
sodium polystyrene sulfonate 15g Oral Rec Pwd,8985000,CDM,637,RC,,,,,facility,outpatient,,,111.95000,32.47000,Aetna,First Health,,91.58,,,,,,,40.36,91.58,percent of total billed charges,
artemether-lumefantrine 20mg-120mg Tab,8985001,CDM,637,RC,,,,,facility,inpatient,,,47.75000,13.85000,Aetna,First Health,,39.06,,,,,,,28.65,39.06,percent of total billed charges,
artemether-lumefantrine 20mg-120mg Tab,8985001,CDM,637,RC,,,,,facility,outpatient,,,47.75000,13.85000,Aetna,First Health,,39.06,,,,,,,17.21,39.06,percent of total billed charges,
Insulin Regular - 5 unit/ 0.05 mL,8995649,CDM,637,RC,J1815,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Insulin Regular - 5 unit/ 0.05 mL,8995649,CDM,637,RC,J1815,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.26001,20.45,percent of total billed charges,
Lidocaine 4% TD Patch,9001413,CDM,637,RC,,,,,facility,inpatient,,,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,6.39,8.71,percent of total billed charges,
Lidocaine 4% TD Patch,9001413,CDM,637,RC,,,,,facility,outpatient,,,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,3.84,8.71,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,9001639,CDM,637,RC,,,,,facility,inpatient,,,111.70000,32.39000,Aetna,First Health,,91.37,,,,,,,67.02,91.37,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,9001639,CDM,637,RC,,,,,facility,outpatient,,,111.70000,32.39000,Aetna,First Health,,91.37,,,,,,,40.27,91.37,percent of total billed charges,
Zonisamide 100 mg/5 mL Oral Susp,9004505,CDM,637,RC,,,,,facility,inpatient,,,118.03000,34.23000,Aetna,First Health,,96.55,,,,,,,70.82,96.55,percent of total billed charges,
Zonisamide 100 mg/5 mL Oral Susp,9004505,CDM,637,RC,,,,,facility,outpatient,,,118.03000,34.23000,Aetna,First Health,,96.55,,,,,,,42.55,96.55,percent of total billed charges,
Paliperidone 1.5mg ER T(Invega),9021075,CDM,637,RC,,,,,facility,inpatient,,,216.10000,62.67000,Aetna,First Health,,176.77,,,,,,,129.66,176.77,percent of total billed charges,
Paliperidone 1.5mg ER T(Invega),9021075,CDM,637,RC,,,,,facility,outpatient,,,216.10000,62.67000,Aetna,First Health,,176.77,,,,,,,77.90,176.77,percent of total billed charges,
NUTR- PROSource TF20 60mL,9024836,CDM,637,RC,,,,,facility,inpatient,,,22.55000,6.54000,Aetna,First Health,,18.45,,,,,,,13.53,18.45,percent of total billed charges,
NUTR- PROSource TF20 60mL,9024836,CDM,637,RC,,,,,facility,outpatient,,,22.55000,6.54000,Aetna,First Health,,18.45,,,,,,,8.13,18.45,percent of total billed charges,
Digoxin 125mcg/2.5mL (0.125mg/2.5mL) L UD,8723986,CDM,637,RC,,,,,facility,inpatient,,,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,7.41,10.10,percent of total billed charges,
Digoxin 125mcg/2.5mL (0.125mg/2.5mL) L UD,8723986,CDM,637,RC,,,,,facility,outpatient,,,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,4.45,10.10,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,8723867,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,8723867,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),8723947,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),8723947,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,8723619,CDM,637,RC,,,,,facility,inpatient,,,51.35000,14.89000,Aetna,First Health,,42.00,,,,,,,30.81,42.00,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,8723619,CDM,637,RC,,,,,facility,outpatient,,,51.35000,14.89000,Aetna,First Health,,42.00,,,,,,,18.51,42.00,percent of total billed charges,
dapagliflozin 10mg Tab UD,9061017,CDM,637,RC,,,,,facility,inpatient,,,169.85000,49.26000,Aetna,First Health,,138.94,,,,,,,101.91,138.94,percent of total billed charges,
dapagliflozin 10mg Tab UD,9061017,CDM,637,RC,,,,,facility,outpatient,,,169.85000,49.26000,Aetna,First Health,,138.94,,,,,,,61.23,138.94,percent of total billed charges,
NUTR- Juven 23g/1 packet,9072160,CDM,637,RC,,,,,facility,inpatient,,,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,9.15,12.47,percent of total billed charges,
NUTR- Juven 23g/1 packet,9072160,CDM,637,RC,,,,,facility,outpatient,,,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,5.50,12.47,percent of total billed charges,
Droxidopa 100mg Cap,9072465,CDM,637,RC,,,,,facility,inpatient,,,251.65000,72.98000,Aetna,First Health,,205.85,,,,,,,150.99,205.85,percent of total billed charges,
Droxidopa 100mg Cap,9072465,CDM,637,RC,,,,,facility,outpatient,,,251.65000,72.98000,Aetna,First Health,,205.85,,,,,,,90.72,205.85,percent of total billed charges,
Insulin Regular human recomb. Inj Pen,9076665,CDM,637,RC,J1815,HCPCS,,,facility,inpatient,,,116.35000,33.74000,Aetna,First Health,,95.17,,,,,,,69.81,95.17,percent of total billed charges,
Insulin Regular human recomb. Inj Pen,9076665,CDM,637,RC,J1815,HCPCS,,,facility,outpatient,,,116.35000,33.74000,Aetna,First Health,,95.17,,,,,,,0.26001,95.17,percent of total billed charges,
Insulin Aspart Dispensing Pen,9078750,CDM,637,RC,J1815,HCPCS,,,facility,inpatient,,,175.62000,50.93000,Aetna,First Health,,143.66,,,,,,,105.37,143.66,percent of total billed charges,
Insulin Aspart Dispensing Pen,9078750,CDM,637,RC,J1815,HCPCS,,,facility,outpatient,,,175.62000,50.93000,Aetna,First Health,,143.66,,,,,,,0.26001,143.66,percent of total billed charges,
sirolimus 0.5 mg Tab,9080759,CDM,637,RC,J7520,HCPCS,,,facility,inpatient,,,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,36.00,49.08,percent of total billed charges,
sirolimus 0.5 mg Tab,9080759,CDM,637,RC,J7520,HCPCS,,,facility,outpatient,,,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,0.93411,49.08,percent of total billed charges,
clonazePAM 2mg T(KlonoPIN),9040372,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
clonazePAM 2mg T(KlonoPIN),9040372,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
PHENobarbital 32.4 mg Tab,9041249,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
PHENobarbital 32.4 mg Tab,9041249,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Levothyroxine Sodium 125mcg T,8724020,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Levothyroxine Sodium 125mcg T,8724020,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
busPIRone 10mg T,8723936,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
busPIRone 10mg T,8723936,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
mirabegron 50mg ER T,9091179,CDM,637,RC,,,,,facility,inpatient,,,117.35000,34.03000,Aetna,First Health,,95.99,,,,,,,70.41,95.99,percent of total billed charges,
mirabegron 50mg ER T,9091179,CDM,637,RC,,,,,facility,outpatient,,,117.35000,34.03000,Aetna,First Health,,95.99,,,,,,,42.30,95.99,percent of total billed charges,
lacosamide 50mg/5mL Oral Soln,9091712,CDM,637,RC,,,,,facility,inpatient,,,78.91000,22.88000,Aetna,First Health,,64.55,,,,,,,47.35,64.55,percent of total billed charges,
lacosamide 50mg/5mL Oral Soln,9091712,CDM,637,RC,,,,,facility,outpatient,,,78.91000,22.88000,Aetna,First Health,,64.55,,,,,,,28.45,64.55,percent of total billed charges,
cloBAZam 10mg Tab UD,9091697,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
cloBAZam 10mg Tab UD,9091697,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
PHENobarbital 64.8mg Tab,9104311,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
PHENobarbital 64.8mg Tab,9104311,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
PHENobarbital 97.2 mg Tab,9104486,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
PHENobarbital 97.2 mg Tab,9104486,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Cefpodoxime 200mg Tab,9124632,CDM,637,RC,,,,,facility,inpatient,,,59.90000,17.37000,Aetna,First Health,,49.00,,,,,,,35.94,49.00,percent of total billed charges,
Cefpodoxime 200mg Tab,9124632,CDM,637,RC,,,,,facility,outpatient,,,59.90000,17.37000,Aetna,First Health,,49.00,,,,,,,21.59,49.00,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,8723856,CDM,637,RC,,,,,facility,inpatient,,,217.30000,63.02000,Aetna,First Health,,177.75,,,,,,,130.38,177.75,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,8723856,CDM,637,RC,,,,,facility,outpatient,,,217.30000,63.02000,Aetna,First Health,,177.75,,,,,,,78.34,177.75,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,8723786,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,8723786,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,8723669,CDM,637,RC,,,,,facility,inpatient,,,15.30000,4.44000,Aetna,First Health,,12.52,,,,,,,9.18,12.52,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,8723669,CDM,637,RC,,,,,facility,outpatient,,,15.30000,4.44000,Aetna,First Health,,12.52,,,,,,,5.52,12.52,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,8723930,CDM,637,RC,,,,,facility,inpatient,,,12.49000,3.62000,Aetna,First Health,,10.22,,,,,,,7.49,10.22,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,8723930,CDM,637,RC,,,,,facility,outpatient,,,12.49000,3.62000,Aetna,First Health,,10.22,,,,,,,4.50,10.22,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),8723937,CDM,637,RC,,,,,facility,inpatient,,,10.38000,3.01000,Aetna,First Health,,8.49,,,,,,,6.23,8.49,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),8723937,CDM,637,RC,,,,,facility,outpatient,,,10.38000,3.01000,Aetna,First Health,,8.49,,,,,,,3.74,8.49,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),8723942,CDM,637,RC,,,,,facility,inpatient,,,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,8.34,11.37,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),8723942,CDM,637,RC,,,,,facility,outpatient,,,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,5.01,11.37,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,8723551,CDM,637,RC,,,,,facility,inpatient,,,28.45000,8.25000,Aetna,First Health,,23.27,,,,,,,17.07,23.27,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,8723551,CDM,637,RC,,,,,facility,outpatient,,,28.45000,8.25000,Aetna,First Health,,23.27,,,,,,,10.26,23.27,percent of total billed charges,
guaiFENesin 600mg ER T,8724010,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
guaiFENesin 600mg ER T,8724010,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),8723912,CDM,637,RC,,,,,facility,inpatient,,,14.86000,4.31000,Aetna,First Health,,12.16,,,,,,,8.92,12.16,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),8723912,CDM,637,RC,,,,,facility,outpatient,,,14.86000,4.31000,Aetna,First Health,,12.16,,,,,,,5.36,12.16,percent of total billed charges,
Levothyroxine Sodium 25mcg T,8724013,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Levothyroxine Sodium 25mcg T,8724013,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),8723472,CDM,637,RC,,,,,facility,inpatient,,,303.75000,88.09000,Aetna,First Health,,248.47,,,,,,,182.25,248.47,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),8723472,CDM,637,RC,,,,,facility,outpatient,,,303.75000,88.09000,Aetna,First Health,,248.47,,,,,,,109.50,248.47,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,8723920,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,8723920,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",8723764,CDM,637,RC,,,,,facility,inpatient,,,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,7.20,9.82,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",8723764,CDM,637,RC,,,,,facility,outpatient,,,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,4.33,9.82,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),8723612,CDM,637,RC,,,,,facility,inpatient,,,171.95000,49.87000,Aetna,First Health,,140.66,,,,,,,103.17,140.66,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),8723612,CDM,637,RC,,,,,facility,outpatient,,,171.95000,49.87000,Aetna,First Health,,140.66,,,,,,,61.99,140.66,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),8723938,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),8723938,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Tiotropium 2.5mcg/1INH Aerosol,8725949,CDM,637,RC,,,,,facility,inpatient,,,587.20000,170.29000,Aetna,First Health,,480.33,,,,,,,352.32,480.33,percent of total billed charges,
Tiotropium 2.5mcg/1INH Aerosol,8725949,CDM,637,RC,,,,,facility,outpatient,,,587.20000,170.29000,Aetna,First Health,,480.33,,,,,,,211.69,480.33,percent of total billed charges,
Insulin Isophane (NPH) Inj,8725962,CDM,637,RC,J1815,HCPCS,,,facility,inpatient,,,9.16000,2.66000,Aetna,First Health,,7.49,,,,,,,5.50,7.49,percent of total billed charges,
Insulin Isophane (NPH) Inj,8725962,CDM,637,RC,J1815,HCPCS,,,facility,outpatient,,,9.16000,2.66000,Aetna,First Health,,7.49,,,,,,,0.26001,7.49,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",8725995,CDM,637,RC,,,,,facility,inpatient,,,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,21.90,29.86,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",8725995,CDM,637,RC,,,,,facility,outpatient,,,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,13.16,29.86,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,8726011,CDM,637,RC,,,,,facility,inpatient,,,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,7.41,10.10,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,8726011,CDM,637,RC,,,,,facility,outpatient,,,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,4.45,10.10,percent of total billed charges,
Loxapine Succinate 10mg,8726038,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Loxapine Succinate 10mg,8726038,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
dexaMETHasone 6mg Tab UD,8726064,CDM,637,RC,J8540,HCPCS,,,facility,inpatient,,,14.88000,4.32000,Aetna,First Health,,12.17,,,,,,,8.93,12.17,percent of total billed charges,
dexaMETHasone 6mg Tab UD,8726064,CDM,637,RC,J8540,HCPCS,,,facility,outpatient,,,14.88000,4.32000,Aetna,First Health,,12.17,,,,,,,0.00963,12.17,percent of total billed charges,
Norgestimate-ethinyl estradiol,8726079,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Norgestimate-ethinyl estradiol,8726079,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sus(Cortispor,8723420,CDM,637,RC,,,,,facility,inpatient,,,1042.25000,302.25000,Aetna,First Health,,852.56,,,,,,,625.35,852.56,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sus(Cortispor,8723420,CDM,637,RC,,,,,facility,outpatient,,,1042.25000,302.25000,Aetna,First Health,,852.56,,,,,,,375.73,852.56,percent of total billed charges,
Cefixime 400mg C (Suprax),8725430,CDM,637,RC,,,,,facility,inpatient,,,166.55000,48.30000,Aetna,First Health,,136.24,,,,,,,99.93,136.24,percent of total billed charges,
Cefixime 400mg C (Suprax),8725430,CDM,637,RC,,,,,facility,outpatient,,,166.55000,48.30000,Aetna,First Health,,136.24,,,,,,,60.04,136.24,percent of total billed charges,
Ibuprofen 800mg T(Motrin),8724052,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Ibuprofen 800mg T(Motrin),8724052,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),8723990,CDM,637,RC,,,,,facility,inpatient,,,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,6.39,8.71,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),8723990,CDM,637,RC,,,,,facility,outpatient,,,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,3.84,8.71,percent of total billed charges,
Levothyroxine Sodium 175mcg T,8724022,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Levothyroxine Sodium 175mcg T,8724022,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Terazosin 1mg C(Hytrin),8724046,CDM,637,RC,,,,,facility,inpatient,,,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,6.84,9.33,percent of total billed charges,
Terazosin 1mg C(Hytrin),8724046,CDM,637,RC,,,,,facility,outpatient,,,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,4.11,9.33,percent of total billed charges,
Terazosin 5mg C(Hytrin),8724047,CDM,637,RC,,,,,facility,inpatient,,,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,6.84,9.33,percent of total billed charges,
Terazosin 5mg C(Hytrin),8724047,CDM,637,RC,,,,,facility,outpatient,,,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,4.11,9.33,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),8723701,CDM,637,RC,,,,,facility,inpatient,,,14.51000,4.21000,Aetna,First Health,,11.87,,,,,,,8.71,11.87,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),8723701,CDM,637,RC,,,,,facility,outpatient,,,14.51000,4.21000,Aetna,First Health,,11.87,,,,,,,5.23,11.87,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),8724090,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),8724090,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,8723769,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,8723769,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),8723756,CDM,637,RC,J3030,HCPCS,,,facility,inpatient,,,72.54000,21.04000,Aetna,First Health,,59.34,,,,,,,43.52,59.34,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),8723756,CDM,637,RC,J3030,HCPCS,,,facility,outpatient,,,72.54000,21.04000,Aetna,First Health,,59.34,,,,,,,26.15,273.24,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),8724462,CDM,637,RC,,,,,facility,inpatient,,,135.95000,39.43000,Aetna,First Health,,111.21,,,,,,,81.57,111.21,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),8724462,CDM,637,RC,,,,,facility,outpatient,,,135.95000,39.43000,Aetna,First Health,,111.21,,,,,,,49.01,111.21,percent of total billed charges,
rOPINIRole 1 mg T(Requip),8724481,CDM,637,RC,,,,,facility,inpatient,,,10.16000,2.95000,Aetna,First Health,,8.31,,,,,,,6.10,8.31,percent of total billed charges,
rOPINIRole 1 mg T(Requip),8724481,CDM,637,RC,,,,,facility,outpatient,,,10.16000,2.95000,Aetna,First Health,,8.31,,,,,,,3.66,8.31,percent of total billed charges,
rOPINIRole 2 mg T(Requip),8724482,CDM,637,RC,,,,,facility,inpatient,,,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
rOPINIRole 2 mg T(Requip),8724482,CDM,637,RC,,,,,facility,outpatient,,,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Divalproex 500 mg ER T/24hr,8724485,CDM,637,RC,,,,,facility,inpatient,,,14.29000,4.14000,Aetna,First Health,,11.69,,,,,,,8.57,11.69,percent of total billed charges,
Divalproex 500 mg ER T/24hr,8724485,CDM,637,RC,,,,,facility,outpatient,,,14.29000,4.14000,Aetna,First Health,,11.69,,,,,,,5.15,11.69,percent of total billed charges,
rifAXIMin 200 mg T(Xifaxan),8724490,CDM,637,RC,,,,,facility,inpatient,,,95.40000,27.67000,Aetna,First Health,,78.04,,,,,,,57.24,78.04,percent of total billed charges,
rifAXIMin 200 mg T(Xifaxan),8724490,CDM,637,RC,,,,,facility,outpatient,,,95.40000,27.67000,Aetna,First Health,,78.04,,,,,,,34.39,78.04,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),8724494,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),8724494,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),8724493,CDM,637,RC,,,,,facility,inpatient,,,14.24000,4.13000,Aetna,First Health,,11.65,,,,,,,8.54,11.65,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),8724493,CDM,637,RC,,,,,facility,outpatient,,,14.24000,4.13000,Aetna,First Health,,11.65,,,,,,,5.13,11.65,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),8724500,CDM,637,RC,,,,,facility,inpatient,,,48.42000,14.04000,Aetna,First Health,,39.61,,,,,,,29.05,39.61,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),8724500,CDM,637,RC,,,,,facility,outpatient,,,48.42000,14.04000,Aetna,First Health,,39.61,,,,,,,17.46,39.61,percent of total billed charges,
Cephalexin 250mg/5mL L,8723646,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Cephalexin 250mg/5mL L,8723646,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),8723381,CDM,637,RC,,,,,facility,inpatient,,,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,55.53,75.71,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),8723381,CDM,637,RC,,,,,facility,outpatient,,,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,33.36,75.71,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,8723767,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,8723767,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),8724349,CDM,637,RC,,,,,facility,inpatient,,,10.78000,3.13000,Aetna,First Health,,8.82,,,,,,,6.47,8.82,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),8724349,CDM,637,RC,,,,,facility,outpatient,,,10.78000,3.13000,Aetna,First Health,,8.82,,,,,,,3.89,8.82,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,8723770,CDM,637,RC,,,,,facility,inpatient,,,15.49000,4.49000,Aetna,First Health,,12.67,,,,,,,9.29,12.67,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,8723770,CDM,637,RC,,,,,facility,outpatient,,,15.49000,4.49000,Aetna,First Health,,12.67,,,,,,,5.58,12.67,percent of total billed charges,
busPIRone 5mg T(Buspar),8723935,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
busPIRone 5mg T(Buspar),8723935,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),8724061,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),8724061,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),8723907,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),8723907,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Temazepam 7.5mg C(Restoril),8724103,CDM,637,RC,,,,,facility,inpatient,,,41.96000,12.17000,Aetna,First Health,,34.32,,,,,,,25.18,34.32,percent of total billed charges,
Temazepam 7.5mg C(Restoril),8724103,CDM,637,RC,,,,,facility,outpatient,,,41.96000,12.17000,Aetna,First Health,,34.32,,,,,,,15.13,34.32,percent of total billed charges,
Na Citrate-Citric Acid 30mL L(Bicit,8723544,CDM,637,RC,,,,,facility,inpatient,,,43.74000,12.68000,Aetna,First Health,,35.78,,,,,,,26.24,35.78,percent of total billed charges,
Na Citrate-Citric Acid 30mL L(Bicit,8723544,CDM,637,RC,,,,,facility,outpatient,,,43.74000,12.68000,Aetna,First Health,,35.78,,,,,,,15.77,35.78,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),8725039,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),8725039,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),8724009,CDM,637,RC,,,,,facility,inpatient,,,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,7.08,9.65,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),8724009,CDM,637,RC,,,,,facility,outpatient,,,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,4.25,9.65,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,8725073,CDM,637,RC,,,,,facility,inpatient,,,389.92000,113.08000,Aetna,First Health,,318.95,,,,,,,233.95,318.95,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,8725073,CDM,637,RC,,,,,facility,outpatient,,,389.92000,113.08000,Aetna,First Health,,318.95,,,,,,,140.57,318.95,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),8725072,CDM,637,RC,,,,,facility,inpatient,,,74.23000,21.53000,Aetna,First Health,,60.72,,,,,,,44.54,60.72,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),8725072,CDM,637,RC,,,,,facility,outpatient,,,74.23000,21.53000,Aetna,First Health,,60.72,,,,,,,26.76,60.72,percent of total billed charges,
Buprenorphine-Naloxone 8-2mg SLT,8725067,CDM,637,RC,J0574,HCPCS,,,facility,inpatient,,,83.40000,24.19000,Aetna,First Health,,68.22,,,,,,,50.04,68.22,percent of total billed charges,
Buprenorphine-Naloxone 8-2mg SLT,8725067,CDM,637,RC,J0574,HCPCS,,,facility,outpatient,,,83.40000,24.19000,Aetna,First Health,,68.22,,,,,,,9.80,68.22,percent of total billed charges,
Buprenorphine-Naloxone 2-0.5mg SLTab,8725066,CDM,637,RC,J0572,HCPCS,,,facility,inpatient,,,32.36000,9.38000,Aetna,First Health,,26.47,,,,,,,19.42,26.47,percent of total billed charges,
Buprenorphine-Naloxone 2-0.5mg SLTab,8725066,CDM,637,RC,J0572,HCPCS,,,facility,outpatient,,,32.36000,9.38000,Aetna,First Health,,26.47,,,,,,,5.48,26.47,percent of total billed charges,
Desvenlafaxine 50 mg ER T,8725065,CDM,637,RC,,,,,facility,inpatient,,,19.17000,5.56000,Aetna,First Health,,15.68,,,,,,,11.50,15.68,percent of total billed charges,
Desvenlafaxine 50 mg ER T,8725065,CDM,637,RC,,,,,facility,outpatient,,,19.17000,5.56000,Aetna,First Health,,15.68,,,,,,,6.91,15.68,percent of total billed charges,
Vancomycin 125mg/2.5mL Oral Soln,8725810,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Vancomycin 125mg/2.5mL Oral Soln,8725810,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),8725095,CDM,637,RC,,,,,facility,inpatient,,,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,18.15,24.74,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),8725095,CDM,637,RC,,,,,facility,outpatient,,,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,10.91,24.74,percent of total billed charges,
Lisinopril 20mg T (Zestril),8725089,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Lisinopril 20mg T (Zestril),8725089,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),8725096,CDM,637,RC,,,,,facility,inpatient,,,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),8725096,CDM,637,RC,,,,,facility,outpatient,,,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),8725097,CDM,637,RC,,,,,facility,inpatient,,,16.01000,4.64000,Aetna,First Health,,13.10,,,,,,,9.61,13.10,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),8725097,CDM,637,RC,,,,,facility,outpatient,,,16.01000,4.64000,Aetna,First Health,,13.10,,,,,,,5.77,13.10,percent of total billed charges,
Lacosamide 50mg T (Vimpat),8725099,CDM,637,RC,,,,,facility,inpatient,,,25.54000,7.41000,Aetna,First Health,,20.89,,,,,,,15.32,20.89,percent of total billed charges,
Lacosamide 50mg T (Vimpat),8725099,CDM,637,RC,,,,,facility,outpatient,,,25.54000,7.41000,Aetna,First Health,,20.89,,,,,,,9.21,20.89,percent of total billed charges,
Donepezil 23mg T (Aricept),8725100,CDM,637,RC,,,,,facility,inpatient,,,73.75000,21.39000,Aetna,First Health,,60.33,,,,,,,44.25,60.33,percent of total billed charges,
Donepezil 23mg T (Aricept),8725100,CDM,637,RC,,,,,facility,outpatient,,,73.75000,21.39000,Aetna,First Health,,60.33,,,,,,,26.59,60.33,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),8724322,CDM,637,RC,,,,,facility,inpatient,,,164.35000,47.66000,Aetna,First Health,,134.44,,,,,,,98.61,134.44,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),8724322,CDM,637,RC,,,,,facility,outpatient,,,164.35000,47.66000,Aetna,First Health,,134.44,,,,,,,59.25,134.44,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,8725133,CDM,637,RC,,,,,facility,inpatient,,,53.06000,15.39000,Aetna,First Health,,43.40,,,,,,,31.84,43.40,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,8725133,CDM,637,RC,,,,,facility,outpatient,,,53.06000,15.39000,Aetna,First Health,,43.40,,,,,,,19.13,43.40,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,8725140,CDM,637,RC,,,,,facility,inpatient,,,21.66000,6.28000,Aetna,First Health,,17.72,,,,,,,13.00,17.72,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,8725140,CDM,637,RC,,,,,facility,outpatient,,,21.66000,6.28000,Aetna,First Health,,17.72,,,,,,,7.81,17.72,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),8724323,CDM,637,RC,,,,,facility,inpatient,,,163.75000,47.49000,Aetna,First Health,,133.95,,,,,,,98.25,133.95,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),8724323,CDM,637,RC,,,,,facility,outpatient,,,163.75000,47.49000,Aetna,First Health,,133.95,,,,,,,59.03,133.95,percent of total billed charges,
Metoclopramide 5mg/5mL L UD,8725125,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Metoclopramide 5mg/5mL L UD,8725125,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,8725130,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,8725130,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,8725135,CDM,637,RC,,,,,facility,inpatient,,,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,19.32,26.34,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,8725135,CDM,637,RC,,,,,facility,outpatient,,,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,8725136,CDM,637,RC,,,,,facility,inpatient,,,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,6.24,8.51,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,8725136,CDM,637,RC,,,,,facility,outpatient,,,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,8725137,CDM,637,RC,,,,,facility,inpatient,,,119.46000,34.64000,Aetna,First Health,,97.72,,,,,,,71.68,97.72,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,8725137,CDM,637,RC,,,,,facility,outpatient,,,119.46000,34.64000,Aetna,First Health,,97.72,,,,,,,43.07,97.72,percent of total billed charges,
predniSONE 1mg T,8723929,CDM,637,RC,J7512,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
predniSONE 1mg T,8723929,CDM,637,RC,J7512,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.00963,8.18,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),8724051,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),8724051,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),8725313,CDM,637,RC,,,,,facility,inpatient,,,31.35000,9.09000,Aetna,First Health,,25.64,,,,,,,18.81,25.64,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),8725313,CDM,637,RC,,,,,facility,outpatient,,,31.35000,9.09000,Aetna,First Health,,25.64,,,,,,,11.30,25.64,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),8723939,CDM,637,RC,,,,,facility,inpatient,,,13.66000,3.96000,Aetna,First Health,,11.17,,,,,,,8.20,11.17,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),8723939,CDM,637,RC,,,,,facility,outpatient,,,13.66000,3.96000,Aetna,First Health,,11.17,,,,,,,4.92,11.17,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),8723772,CDM,637,RC,,,,,facility,inpatient,,,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,7.08,9.65,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),8723772,CDM,637,RC,,,,,facility,outpatient,,,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,4.25,9.65,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),8723959,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),8723959,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Oral Colonic Lavage 4000 mL,8723755,CDM,637,RC,,,,,facility,inpatient,,,149.55000,43.37000,Aetna,First Health,,122.33,,,,,,,89.73,122.33,percent of total billed charges,
Oral Colonic Lavage 4000 mL,8723755,CDM,637,RC,,,,,facility,outpatient,,,149.55000,43.37000,Aetna,First Health,,122.33,,,,,,,53.91,122.33,percent of total billed charges,
Sucralfate 1g/10mL L UD,8723443,CDM,637,RC,,,,,facility,inpatient,,,74.33000,21.56000,Aetna,First Health,,60.80,,,,,,,44.60,60.80,percent of total billed charges,
Sucralfate 1g/10mL L UD,8723443,CDM,637,RC,,,,,facility,outpatient,,,74.33000,21.56000,Aetna,First Health,,60.80,,,,,,,26.80,60.80,percent of total billed charges,
Insulin Glargine (LanTUS),8723408,CDM,637,RC,J1815,HCPCS,,,facility,inpatient,,,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,4.86,6.63,percent of total billed charges,
Insulin Glargine (LanTUS),8723408,CDM,637,RC,J1815,HCPCS,,,facility,outpatient,,,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,0.26001,6.63,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,8723530,CDM,637,RC,,,,,facility,inpatient,,,3285.40000,952.77000,Aetna,First Health,,2687.46,,,,,,,1971.24,2687.46,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,8723530,CDM,637,RC,,,,,facility,outpatient,,,3285.40000,952.77000,Aetna,First Health,,2687.46,,,,,,,1184.39,2687.46,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,8723528,CDM,637,RC,,,,,facility,inpatient,,,2121.15000,615.13000,Aetna,First Health,,1735.10,,,,,,,1272.69,1735.10,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,8723528,CDM,637,RC,,,,,facility,outpatient,,,2121.15000,615.13000,Aetna,First Health,,1735.10,,,,,,,764.67,1735.10,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,8723529,CDM,637,RC,,,,,facility,inpatient,,,2566.35000,744.24000,Aetna,First Health,,2099.27,,,,,,,1539.81,2099.27,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,8723529,CDM,637,RC,,,,,facility,outpatient,,,2566.35000,744.24000,Aetna,First Health,,2099.27,,,,,,,925.17,2099.27,percent of total billed charges,
Midazolam HCl 5mg/2.5mL L UD,8723655,CDM,637,RC,,,,,facility,inpatient,,,51.20000,14.85000,Aetna,First Health,,41.88,,,,,,,30.72,41.88,percent of total billed charges,
Midazolam HCl 5mg/2.5mL L UD,8723655,CDM,637,RC,,,,,facility,outpatient,,,51.20000,14.85000,Aetna,First Health,,41.88,,,,,,,18.46,41.88,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,8725315,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,8725315,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,8723963,CDM,637,RC,,,,,facility,inpatient,,,44.22000,12.82000,Aetna,First Health,,36.17,,,,,,,26.53,36.17,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,8723963,CDM,637,RC,,,,,facility,outpatient,,,44.22000,12.82000,Aetna,First Health,,36.17,,,,,,,15.94,36.17,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,8724147,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,8724147,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Salmeterol 50 mcg Pwd/Inh,8724155,CDM,637,RC,,,,,facility,inpatient,,,2866.45000,831.27000,Aetna,First Health,,2344.76,,,,,,,1719.87,2344.76,percent of total billed charges,
Salmeterol 50 mcg Pwd/Inh,8724155,CDM,637,RC,,,,,facility,outpatient,,,2866.45000,831.27000,Aetna,First Health,,2344.76,,,,,,,1033.36,2344.76,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,8724156,CDM,637,RC,,,,,facility,inpatient,,,677.25000,196.40000,Aetna,First Health,,553.99,,,,,,,406.35,553.99,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,8724156,CDM,637,RC,,,,,facility,outpatient,,,677.25000,196.40000,Aetna,First Health,,553.99,,,,,,,244.15,553.99,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,8724182,CDM,637,RC,J7510,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,8724182,CDM,637,RC,J7510,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.88596,8.18,percent of total billed charges,
Valsartan 80 mg T(Diovan),8724194,CDM,637,RC,,,,,facility,inpatient,,,10.37000,3.01000,Aetna,First Health,,8.48,,,,,,,6.22,8.48,percent of total billed charges,
Valsartan 80 mg T(Diovan),8724194,CDM,637,RC,,,,,facility,outpatient,,,10.37000,3.01000,Aetna,First Health,,8.48,,,,,,,3.74,8.48,percent of total billed charges,
Valsartan 160 mg T(Diovan),8724197,CDM,637,RC,,,,,facility,inpatient,,,10.78000,3.13000,Aetna,First Health,,8.82,,,,,,,6.47,8.82,percent of total billed charges,
Valsartan 160 mg T(Diovan),8724197,CDM,637,RC,,,,,facility,outpatient,,,10.78000,3.13000,Aetna,First Health,,8.82,,,,,,,3.89,8.82,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),8724195,CDM,637,RC,,,,,facility,inpatient,,,79.07000,22.93000,Aetna,First Health,,64.68,,,,,,,47.44,64.68,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),8724195,CDM,637,RC,,,,,facility,outpatient,,,79.07000,22.93000,Aetna,First Health,,64.68,,,,,,,28.50,64.68,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),8724199,CDM,637,RC,,,,,facility,inpatient,,,31.04000,9.00000,Aetna,First Health,,25.39,,,,,,,18.62,25.39,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),8724199,CDM,637,RC,,,,,facility,outpatient,,,31.04000,9.00000,Aetna,First Health,,25.39,,,,,,,11.19,25.39,percent of total billed charges,
Escitalopram 20 mg T(lexapro),8724198,CDM,637,RC,,,,,facility,inpatient,,,32.39000,9.39000,Aetna,First Health,,26.50,,,,,,,19.43,26.50,percent of total billed charges,
Escitalopram 20 mg T(lexapro),8724198,CDM,637,RC,,,,,facility,outpatient,,,32.39000,9.39000,Aetna,First Health,,26.50,,,,,,,11.68,26.50,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,8724207,CDM,637,RC,,,,,facility,inpatient,,,89.06000,25.83000,Aetna,First Health,,72.85,,,,,,,53.44,72.85,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,8724207,CDM,637,RC,,,,,facility,outpatient,,,89.06000,25.83000,Aetna,First Health,,72.85,,,,,,,32.11,72.85,percent of total billed charges,
metFORMIN 500mg ER T,8724213,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
metFORMIN 500mg ER T,8724213,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Azithromycin 100mg/5mL L,8724221,CDM,637,RC,,,,,facility,inpatient,,,82.35000,23.88000,Aetna,First Health,,67.36,,,,,,,49.41,67.36,percent of total billed charges,
Azithromycin 100mg/5mL L,8724221,CDM,637,RC,,,,,facility,outpatient,,,82.35000,23.88000,Aetna,First Health,,67.36,,,,,,,29.69,67.36,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,8724222,CDM,637,RC,J7515,HCPCS,,,facility,inpatient,,,14.72000,4.27000,Aetna,First Health,,12.04,,,,,,,8.83,12.04,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,8724222,CDM,637,RC,J7515,HCPCS,,,facility,outpatient,,,14.72000,4.27000,Aetna,First Health,,12.04,,,,,,,0.51039,12.04,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,8724223,CDM,637,RC,J7502,HCPCS,,,facility,inpatient,,,62.45000,18.11000,Aetna,First Health,,51.08,,,,,,,37.47,51.08,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,8724223,CDM,637,RC,J7502,HCPCS,,,facility,outpatient,,,62.45000,18.11000,Aetna,First Health,,51.08,,,,,,,1.74,51.08,percent of total billed charges,
Hydroxychloroquine 200mg T,8724224,CDM,637,RC,,,,,facility,inpatient,,,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Hydroxychloroquine 200mg T,8724224,CDM,637,RC,,,,,facility,outpatient,,,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),8724225,CDM,637,RC,,,,,facility,inpatient,,,79.05000,22.92000,Aetna,First Health,,64.66,,,,,,,47.43,64.66,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),8724225,CDM,637,RC,,,,,facility,outpatient,,,79.05000,22.92000,Aetna,First Health,,64.66,,,,,,,28.50,64.66,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),8724226,CDM,637,RC,,,,,facility,inpatient,,,34.84000,10.10000,Aetna,First Health,,28.50,,,,,,,20.90,28.50,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),8724226,CDM,637,RC,,,,,facility,outpatient,,,34.84000,10.10000,Aetna,First Health,,28.50,,,,,,,12.56,28.50,percent of total billed charges,
Metoprolol 25mg T(Lopressor),8724227,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Metoprolol 25mg T(Lopressor),8724227,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Triamcinolone 0.1% TO 80g,8724234,CDM,637,RC,,,,,facility,inpatient,,,89.80000,26.04000,Aetna,First Health,,73.46,,,,,,,53.88,73.46,percent of total billed charges,
Triamcinolone 0.1% TO 80g,8724234,CDM,637,RC,,,,,facility,outpatient,,,89.80000,26.04000,Aetna,First Health,,73.46,,,,,,,32.37,73.46,percent of total billed charges,
Triamcinolone 0.1% TC 15g,8724237,CDM,637,RC,,,,,facility,inpatient,,,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,24.78,33.78,percent of total billed charges,
Triamcinolone 0.1% TC 15g,8724237,CDM,637,RC,,,,,facility,outpatient,,,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,14.89,33.78,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),8724248,CDM,637,RC,,,,,facility,inpatient,,,17.26000,5.01000,Aetna,First Health,,14.12,,,,,,,10.36,14.12,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),8724248,CDM,637,RC,,,,,facility,outpatient,,,17.26000,5.01000,Aetna,First Health,,14.12,,,,,,,6.22,14.12,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),8724249,CDM,637,RC,,,,,facility,inpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,78.75,107.36,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),8724249,CDM,637,RC,,,,,facility,outpatient,,,131.25000,38.06000,Aetna,First Health,,107.36,,,,,,,47.32,107.36,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),8724251,CDM,637,RC,,,,,facility,inpatient,,,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,33.54,45.73,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),8724251,CDM,637,RC,,,,,facility,outpatient,,,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,20.15,45.73,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),8724252,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),8724252,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,8724261,CDM,637,RC,,,,,facility,inpatient,,,10.96000,3.18000,Aetna,First Health,,8.97,,,,,,,6.58,8.97,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,8724261,CDM,637,RC,,,,,facility,outpatient,,,10.96000,3.18000,Aetna,First Health,,8.97,,,,,,,3.95,8.97,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),8724255,CDM,637,RC,,,,,facility,inpatient,,,276.80000,80.27000,Aetna,First Health,,226.42,,,,,,,166.08,226.42,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),8724255,CDM,637,RC,,,,,facility,outpatient,,,276.80000,80.27000,Aetna,First Health,,226.42,,,,,,,99.79,226.42,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),8724262,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),8724262,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
lamoTRIgine 100mg Tablet,8724263,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
lamoTRIgine 100mg Tablet,8724263,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),8724264,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),8724264,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),8724265,CDM,637,RC,,,,,facility,inpatient,,,18.60000,5.39000,Aetna,First Health,,15.21,,,,,,,11.16,15.21,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),8724265,CDM,637,RC,,,,,facility,outpatient,,,18.60000,5.39000,Aetna,First Health,,15.21,,,,,,,6.71,15.21,percent of total billed charges,
Topiramate 25 mg T(Topamax),8724266,CDM,637,RC,,,,,facility,inpatient,,,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Topiramate 25 mg T(Topamax),8724266,CDM,637,RC,,,,,facility,outpatient,,,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Topiramate 100 mg T(Topamax),8724267,CDM,637,RC,,,,,facility,inpatient,,,49.32000,14.30000,Aetna,First Health,,40.34,,,,,,,29.59,40.34,percent of total billed charges,
Topiramate 100 mg T(Topamax),8724267,CDM,637,RC,,,,,facility,outpatient,,,49.32000,14.30000,Aetna,First Health,,40.34,,,,,,,17.78,40.34,percent of total billed charges,
Etodolac 200 mg C (Lodine),8724271,CDM,637,RC,,,,,facility,inpatient,,,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
Etodolac 200 mg C (Lodine),8724271,CDM,637,RC,,,,,facility,outpatient,,,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),8724273,CDM,637,RC,,,,,facility,inpatient,,,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,21.72,29.61,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),8724273,CDM,637,RC,,,,,facility,outpatient,,,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,13.05,29.61,percent of total billed charges,
Dapsone 100 mg Tab,8724274,CDM,637,RC,,,,,facility,inpatient,,,21.45000,6.22000,Aetna,First Health,,17.55,,,,,,,12.87,17.55,percent of total billed charges,
Dapsone 100 mg Tab,8724274,CDM,637,RC,,,,,facility,outpatient,,,21.45000,6.22000,Aetna,First Health,,17.55,,,,,,,7.73,17.55,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),8724276,CDM,637,RC,,,,,facility,inpatient,,,748.45000,217.05000,Aetna,First Health,,612.23,,,,,,,449.07,612.23,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),8724276,CDM,637,RC,,,,,facility,outpatient,,,748.45000,217.05000,Aetna,First Health,,612.23,,,,,,,269.82,612.23,percent of total billed charges,
SUMAtriptan 20mg/spray NS,8724760,CDM,637,RC,,,,,facility,inpatient,,,413.95000,120.05000,Aetna,First Health,,338.61,,,,,,,248.37,338.61,percent of total billed charges,
SUMAtriptan 20mg/spray NS,8724760,CDM,637,RC,,,,,facility,outpatient,,,413.95000,120.05000,Aetna,First Health,,338.61,,,,,,,149.23,338.61,percent of total billed charges,
levoFLOXacin  25mg/mL L,8724823,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
levoFLOXacin  25mg/mL L,8724823,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
K-Phos-Na Phos Neutral 250mg T,8724811,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
K-Phos-Na Phos Neutral 250mg T,8724811,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,8724814,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,8724814,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,8724849,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,8724849,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Dextroamphetamine 5mg T,8724815,CDM,637,RC,S0160,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Dextroamphetamine 5mg T,8724815,CDM,637,RC,S0160,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,2.79,20.45,percent of total billed charges,
carBAMazepine 100 mg ER C,8724283,CDM,637,RC,,,,,facility,inpatient,,,13.95000,4.05000,Aetna,First Health,,11.41,,,,,,,8.37,11.41,percent of total billed charges,
carBAMazepine 100 mg ER C,8724283,CDM,637,RC,,,,,facility,outpatient,,,13.95000,4.05000,Aetna,First Health,,11.41,,,,,,,5.03,11.41,percent of total billed charges,
cycloSPORINE Microemul 100mg/1mL L,8724724,CDM,637,RC,J7502,HCPCS,,,facility,inpatient,,,108.95000,31.60000,Aetna,First Health,,89.12,,,,,,,65.37,89.12,percent of total billed charges,
cycloSPORINE Microemul 100mg/1mL L,8724724,CDM,637,RC,J7502,HCPCS,,,facility,outpatient,,,108.95000,31.60000,Aetna,First Health,,89.12,,,,,,,1.74,89.12,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,8724859,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,8724859,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,8724867,CDM,637,RC,,,,,facility,inpatient,,,980.15000,284.24000,Aetna,First Health,,801.76,,,,,,,588.09,801.76,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,8724867,CDM,637,RC,,,,,facility,outpatient,,,980.15000,284.24000,Aetna,First Health,,801.76,,,,,,,353.34,801.76,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,8724869,CDM,637,RC,,,,,facility,inpatient,,,102.00000,29.58000,Aetna,First Health,,83.44,,,,,,,61.20,83.44,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,8724869,CDM,637,RC,,,,,facility,outpatient,,,102.00000,29.58000,Aetna,First Health,,83.44,,,,,,,36.77,83.44,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),8724884,CDM,637,RC,,,,,facility,inpatient,,,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),8724884,CDM,637,RC,,,,,facility,outpatient,,,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,12.98,29.45,percent of total billed charges,
fluvoxaMINE 100mg T,8724885,CDM,637,RC,,,,,facility,inpatient,,,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,11.19,15.26,percent of total billed charges,
fluvoxaMINE 100mg T,8724885,CDM,637,RC,,,,,facility,outpatient,,,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,6.72,15.26,percent of total billed charges,
LamiVUDine 10mg/1mL Oral L(Epivir),8724891,CDM,637,RC,,,,,facility,inpatient,,,8.34000,2.42000,Aetna,First Health,,6.82,,,,,,,5.00,6.82,percent of total billed charges,
LamiVUDine 10mg/1mL Oral L(Epivir),8724891,CDM,637,RC,,,,,facility,outpatient,,,8.34000,2.42000,Aetna,First Health,,6.82,,,,,,,3.01,6.82,percent of total billed charges,
Raltegravir 400mg T (Isentress),8724896,CDM,637,RC,,,,,facility,inpatient,,,289.15000,83.85000,Aetna,First Health,,236.52,,,,,,,173.49,236.52,percent of total billed charges,
Raltegravir 400mg T (Isentress),8724896,CDM,637,RC,,,,,facility,outpatient,,,289.15000,83.85000,Aetna,First Health,,236.52,,,,,,,104.24,236.52,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),8724897,CDM,637,RC,,,,,facility,inpatient,,,373.35000,108.27000,Aetna,First Health,,305.40,,,,,,,224.01,305.40,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),8724897,CDM,637,RC,,,,,facility,outpatient,,,373.35000,108.27000,Aetna,First Health,,305.40,,,,,,,134.59,305.40,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),8724909,CDM,637,RC,,,,,facility,inpatient,,,226.10000,65.57000,Aetna,First Health,,184.95,,,,,,,135.66,184.95,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),8724909,CDM,637,RC,,,,,facility,outpatient,,,226.10000,65.57000,Aetna,First Health,,184.95,,,,,,,81.51,184.95,percent of total billed charges,
Fenofibrate 160mg T(Tricor),8724932,CDM,637,RC,,,,,facility,inpatient,,,33.74000,9.78000,Aetna,First Health,,27.60,,,,,,,20.24,27.60,percent of total billed charges,
Fenofibrate 160mg T(Tricor),8724932,CDM,637,RC,,,,,facility,outpatient,,,33.74000,9.78000,Aetna,First Health,,27.60,,,,,,,12.16,27.60,percent of total billed charges,
Nebivolol 5mg T (Bystolic),8724920,CDM,637,RC,,,,,facility,inpatient,,,26.21000,7.60000,Aetna,First Health,,21.44,,,,,,,15.73,21.44,percent of total billed charges,
Nebivolol 5mg T (Bystolic),8724920,CDM,637,RC,,,,,facility,outpatient,,,26.21000,7.60000,Aetna,First Health,,21.44,,,,,,,9.45,21.44,percent of total billed charges,
NICU- Chlorothiazide 50mg/mL L,8724930,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
NICU- Chlorothiazide 50mg/mL L,8724930,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
NICU- FERROUS SULFATE 15MG/1ML L,8724935,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
NICU- FERROUS SULFATE 15MG/1ML L,8724935,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Cephalexin 125mg/2.5mL L,8723652,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Cephalexin 125mg/2.5mL L,8723652,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,8724954,CDM,637,RC,,,,,facility,inpatient,,,23.98000,6.95000,Aetna,First Health,,19.62,,,,,,,14.39,19.62,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,8724954,CDM,637,RC,,,,,facility,outpatient,,,23.98000,6.95000,Aetna,First Health,,19.62,,,,,,,8.64,19.62,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),8724292,CDM,637,RC,,,,,facility,inpatient,,,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,42.48,57.91,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),8724292,CDM,637,RC,,,,,facility,outpatient,,,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),8724295,CDM,637,RC,,,,,facility,inpatient,,,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,9.90,13.50,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),8724295,CDM,637,RC,,,,,facility,outpatient,,,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
Dronedarone 400mg T,8724977,CDM,637,RC,,,,,facility,inpatient,,,104.48000,30.30000,Aetna,First Health,,85.46,,,,,,,62.69,85.46,percent of total billed charges,
Dronedarone 400mg T,8724977,CDM,637,RC,,,,,facility,outpatient,,,104.48000,30.30000,Aetna,First Health,,85.46,,,,,,,37.67,85.46,percent of total billed charges,
Prasugrel 10mg T,8724978,CDM,637,RC,,,,,facility,inpatient,,,118.06000,34.24000,Aetna,First Health,,96.57,,,,,,,70.84,96.57,percent of total billed charges,
Prasugrel 10mg T,8724978,CDM,637,RC,,,,,facility,outpatient,,,118.06000,34.24000,Aetna,First Health,,96.57,,,,,,,42.56,96.57,percent of total billed charges,
Prasugrel 5mg T,8724979,CDM,637,RC,,,,,facility,inpatient,,,116.90000,33.90000,Aetna,First Health,,95.62,,,,,,,70.14,95.62,percent of total billed charges,
Prasugrel 5mg T,8724979,CDM,637,RC,,,,,facility,outpatient,,,116.90000,33.90000,Aetna,First Health,,95.62,,,,,,,42.14,95.62,percent of total billed charges,
Magic Mouthwash 10mL L UD,8724980,CDM,637,RC,,,,,facility,inpatient,,,44.85000,13.01000,Aetna,First Health,,36.69,,,,,,,26.91,36.69,percent of total billed charges,
Magic Mouthwash 10mL L UD,8724980,CDM,637,RC,,,,,facility,outpatient,,,44.85000,13.01000,Aetna,First Health,,36.69,,,,,,,16.17,36.69,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),8724993,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),8724993,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,8724995,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,8724995,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),8724297,CDM,637,RC,,,,,facility,inpatient,,,64.98000,18.84000,Aetna,First Health,,53.15,,,,,,,38.99,53.15,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),8724297,CDM,637,RC,,,,,facility,outpatient,,,64.98000,18.84000,Aetna,First Health,,53.15,,,,,,,23.43,53.15,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),8725026,CDM,637,RC,,,,,facility,inpatient,,,82.15000,23.82000,Aetna,First Health,,67.20,,,,,,,49.29,67.20,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),8725026,CDM,637,RC,,,,,facility,outpatient,,,82.15000,23.82000,Aetna,First Health,,67.20,,,,,,,29.62,67.20,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),8724302,CDM,637,RC,,,,,facility,inpatient,,,28.03000,8.13000,Aetna,First Health,,22.93,,,,,,,16.82,22.93,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),8724302,CDM,637,RC,,,,,facility,outpatient,,,28.03000,8.13000,Aetna,First Health,,22.93,,,,,,,10.10,22.93,percent of total billed charges,
Midodrine 5 mg T(Proamatine),8724303,CDM,637,RC,,,,,facility,inpatient,,,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,6.54,8.92,percent of total billed charges,
Midodrine 5 mg T(Proamatine),8724303,CDM,637,RC,,,,,facility,outpatient,,,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),8724306,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),8724306,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Torsemide 20mg T,8724312,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Torsemide 20mg T,8724312,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,8724319,CDM,637,RC,,,,,facility,inpatient,,,1651.65000,478.98000,Aetna,First Health,,1351.05,,,,,,,990.99,1351.05,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,8724319,CDM,637,RC,,,,,facility,outpatient,,,1651.65000,478.98000,Aetna,First Health,,1351.05,,,,,,,595.42,1351.05,percent of total billed charges,
Lisinopril 40 mg T(Zestril),8724325,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Lisinopril 40 mg T(Zestril),8724325,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
fentaNYL 12 mcg/hr TD,8724326,CDM,637,RC,,,,,facility,inpatient,,,154.23000,44.73000,Aetna,First Health,,126.16,,,,,,,92.54,126.16,percent of total billed charges,
fentaNYL 12 mcg/hr TD,8724326,CDM,637,RC,,,,,facility,outpatient,,,154.23000,44.73000,Aetna,First Health,,126.16,,,,,,,55.60,126.16,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),8724328,CDM,637,RC,,,,,facility,inpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),8724328,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),8724369,CDM,637,RC,,,,,facility,inpatient,,,54.84000,15.90000,Aetna,First Health,,44.86,,,,,,,32.90,44.86,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),8724369,CDM,637,RC,,,,,facility,outpatient,,,54.84000,15.90000,Aetna,First Health,,44.86,,,,,,,19.77,44.86,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),8724370,CDM,637,RC,,,,,facility,inpatient,,,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,33.36,45.48,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),8724370,CDM,637,RC,,,,,facility,outpatient,,,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,20.04,45.48,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),8724373,CDM,637,RC,,,,,facility,inpatient,,,10.24000,2.97000,Aetna,First Health,,8.38,,,,,,,6.14,8.38,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),8724373,CDM,637,RC,,,,,facility,outpatient,,,10.24000,2.97000,Aetna,First Health,,8.38,,,,,,,3.69,8.38,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),8724374,CDM,637,RC,,,,,facility,inpatient,,,24.20000,7.02000,Aetna,First Health,,19.80,,,,,,,14.52,19.80,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),8724374,CDM,637,RC,,,,,facility,outpatient,,,24.20000,7.02000,Aetna,First Health,,19.80,,,,,,,8.72,19.80,percent of total billed charges,
Nitroglycerin 2% TO 1g,8724368,CDM,637,RC,,,,,facility,inpatient,,,21.45000,6.22000,Aetna,First Health,,17.55,,,,,,,12.87,17.55,percent of total billed charges,
Nitroglycerin 2% TO 1g,8724368,CDM,637,RC,,,,,facility,outpatient,,,21.45000,6.22000,Aetna,First Health,,17.55,,,,,,,7.73,17.55,percent of total billed charges,
Imatinib 100 mg T(Gleevac),8724375,CDM,637,RC,,,,,facility,inpatient,,,685.70000,198.85000,Aetna,First Health,,560.90,,,,,,,411.42,560.90,percent of total billed charges,
Imatinib 100 mg T(Gleevac),8724375,CDM,637,RC,,,,,facility,outpatient,,,685.70000,198.85000,Aetna,First Health,,560.90,,,,,,,247.19,560.90,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),8724377,CDM,637,RC,,,,,facility,inpatient,,,21.31000,6.18000,Aetna,First Health,,17.43,,,,,,,12.79,17.43,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),8724377,CDM,637,RC,,,,,facility,outpatient,,,21.31000,6.18000,Aetna,First Health,,17.43,,,,,,,7.68,17.43,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),8724378,CDM,637,RC,J7507,HCPCS,,,facility,inpatient,,,10.14000,2.94000,Aetna,First Health,,8.29,,,,,,,6.08,8.29,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),8724378,CDM,637,RC,J7507,HCPCS,,,facility,outpatient,,,10.14000,2.94000,Aetna,First Health,,8.29,,,,,,,0.19260,8.29,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),8724379,CDM,637,RC,J7507,HCPCS,,,facility,inpatient,,,31.60000,9.16000,Aetna,First Health,,25.85,,,,,,,18.96,25.85,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),8724379,CDM,637,RC,J7507,HCPCS,,,facility,outpatient,,,31.60000,9.16000,Aetna,First Health,,25.85,,,,,,,0.19260,25.85,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),8724380,CDM,637,RC,,,,,facility,inpatient,,,216.77000,62.86000,Aetna,First Health,,177.32,,,,,,,130.06,177.32,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),8724380,CDM,637,RC,,,,,facility,outpatient,,,216.77000,62.86000,Aetna,First Health,,177.32,,,,,,,78.15,177.32,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),8724384,CDM,637,RC,,,,,facility,inpatient,,,23.45000,6.80000,Aetna,First Health,,19.18,,,,,,,14.07,19.18,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),8724384,CDM,637,RC,,,,,facility,outpatient,,,23.45000,6.80000,Aetna,First Health,,19.18,,,,,,,8.45,19.18,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),8724385,CDM,637,RC,,,,,facility,inpatient,,,23.45000,6.80000,Aetna,First Health,,19.18,,,,,,,14.07,19.18,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),8724385,CDM,637,RC,,,,,facility,outpatient,,,23.45000,6.80000,Aetna,First Health,,19.18,,,,,,,8.45,19.18,percent of total billed charges,
Entacapone 200 mg T(Comtan),8724386,CDM,637,RC,,,,,facility,inpatient,,,33.44000,9.70000,Aetna,First Health,,27.35,,,,,,,20.06,27.35,percent of total billed charges,
Entacapone 200 mg T(Comtan),8724386,CDM,637,RC,,,,,facility,outpatient,,,33.44000,9.70000,Aetna,First Health,,27.35,,,,,,,12.06,27.35,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),8724388,CDM,637,RC,,,,,facility,inpatient,,,42.85000,12.43000,Aetna,First Health,,35.05,,,,,,,25.71,35.05,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),8724388,CDM,637,RC,,,,,facility,outpatient,,,42.85000,12.43000,Aetna,First Health,,35.05,,,,,,,15.45,35.05,percent of total billed charges,
Eplerenone 25 mg T(Inspra),8724389,CDM,637,RC,,,,,facility,inpatient,,,35.32000,10.24000,Aetna,First Health,,28.89,,,,,,,21.19,28.89,percent of total billed charges,
Eplerenone 25 mg T(Inspra),8724389,CDM,637,RC,,,,,facility,outpatient,,,35.32000,10.24000,Aetna,First Health,,28.89,,,,,,,12.73,28.89,percent of total billed charges,
Colesevelam 625 mg T(Welchol),8724390,CDM,637,RC,,,,,facility,inpatient,,,23.74000,6.88000,Aetna,First Health,,19.42,,,,,,,14.24,19.42,percent of total billed charges,
Colesevelam 625 mg T(Welchol),8724390,CDM,637,RC,,,,,facility,outpatient,,,23.74000,6.88000,Aetna,First Health,,19.42,,,,,,,8.56,19.42,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),8724395,CDM,637,RC,,,,,facility,inpatient,,,11.86000,3.44000,Aetna,First Health,,9.70,,,,,,,7.12,9.70,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),8724395,CDM,637,RC,,,,,facility,outpatient,,,11.86000,3.44000,Aetna,First Health,,9.70,,,,,,,4.28,9.70,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),8724396,CDM,637,RC,,,,,facility,inpatient,,,12.34000,3.58000,Aetna,First Health,,10.09,,,,,,,7.40,10.09,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),8724396,CDM,637,RC,,,,,facility,outpatient,,,12.34000,3.58000,Aetna,First Health,,10.09,,,,,,,4.45,10.09,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),8724399,CDM,637,RC,,,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),8724399,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,8724400,CDM,637,RC,,,,,facility,inpatient,,,12.52000,3.63000,Aetna,First Health,,10.24,,,,,,,7.51,10.24,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,8724400,CDM,637,RC,,,,,facility,outpatient,,,12.52000,3.63000,Aetna,First Health,,10.24,,,,,,,4.51,10.24,percent of total billed charges,
Pregabalin 25mg C(Lyrica),8724406,CDM,637,RC,,,,,facility,inpatient,,,26.28000,7.62000,Aetna,First Health,,21.50,,,,,,,15.77,21.50,percent of total billed charges,
Pregabalin 25mg C(Lyrica),8724406,CDM,637,RC,,,,,facility,outpatient,,,26.28000,7.62000,Aetna,First Health,,21.50,,,,,,,9.47,21.50,percent of total billed charges,
Pregabalin 50mg C(Lyrica),8724407,CDM,637,RC,,,,,facility,inpatient,,,30.70000,8.90000,Aetna,First Health,,25.11,,,,,,,18.42,25.11,percent of total billed charges,
Pregabalin 50mg C(Lyrica),8724407,CDM,637,RC,,,,,facility,outpatient,,,30.70000,8.90000,Aetna,First Health,,25.11,,,,,,,11.07,25.11,percent of total billed charges,
Pregabalin 75mg C(Lyrica),8724408,CDM,637,RC,,,,,facility,inpatient,,,28.15000,8.16000,Aetna,First Health,,23.03,,,,,,,16.89,23.03,percent of total billed charges,
Pregabalin 75mg C(Lyrica),8724408,CDM,637,RC,,,,,facility,outpatient,,,28.15000,8.16000,Aetna,First Health,,23.03,,,,,,,10.15,23.03,percent of total billed charges,
Pregabalin 100mg C(Lyrica),8724409,CDM,637,RC,,,,,facility,inpatient,,,28.93000,8.39000,Aetna,First Health,,23.66,,,,,,,17.36,23.66,percent of total billed charges,
Pregabalin 100mg C(Lyrica),8724409,CDM,637,RC,,,,,facility,outpatient,,,28.93000,8.39000,Aetna,First Health,,23.66,,,,,,,10.43,23.66,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,8725811,CDM,637,RC,,,,,facility,inpatient,,,96.05000,27.85000,Aetna,First Health,,78.57,,,,,,,57.63,78.57,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,8725811,CDM,637,RC,,,,,facility,outpatient,,,96.05000,27.85000,Aetna,First Health,,78.57,,,,,,,34.63,78.57,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),8724413,CDM,637,RC,,,,,facility,inpatient,,,33.84000,9.81000,Aetna,First Health,,27.68,,,,,,,20.30,27.68,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),8724413,CDM,637,RC,,,,,facility,outpatient,,,33.84000,9.81000,Aetna,First Health,,27.68,,,,,,,12.20,27.68,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),8724423,CDM,637,RC,,,,,facility,inpatient,,,26.11000,7.57000,Aetna,First Health,,21.36,,,,,,,15.67,21.36,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),8724423,CDM,637,RC,,,,,facility,outpatient,,,26.11000,7.57000,Aetna,First Health,,21.36,,,,,,,9.41,21.36,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),8724424,CDM,637,RC,,,,,facility,inpatient,,,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,6.21,8.47,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),8724424,CDM,637,RC,,,,,facility,outpatient,,,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,3.73,8.47,percent of total billed charges,
Ramipril 1.25 mg C(Altace),8724427,CDM,637,RC,,,,,facility,inpatient,,,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,6.51,8.88,percent of total billed charges,
Ramipril 1.25 mg C(Altace),8724427,CDM,637,RC,,,,,facility,outpatient,,,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),8724429,CDM,637,RC,,,,,facility,inpatient,,,13.50000,3.91000,Aetna,First Health,,11.04,,,,,,,8.10,11.04,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),8724429,CDM,637,RC,,,,,facility,outpatient,,,13.50000,3.91000,Aetna,First Health,,11.04,,,,,,,4.87,11.04,percent of total billed charges,
Memantine HCl 5mg T(Namenda),8724430,CDM,637,RC,,,,,facility,inpatient,,,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
Memantine HCl 5mg T(Namenda),8724430,CDM,637,RC,,,,,facility,outpatient,,,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
Memantine HCl 10mg T(Namenda),8724431,CDM,637,RC,,,,,facility,inpatient,,,10.11000,2.93000,Aetna,First Health,,8.27,,,,,,,6.07,8.27,percent of total billed charges,
Memantine HCl 10mg T(Namenda),8724431,CDM,637,RC,,,,,facility,outpatient,,,10.11000,2.93000,Aetna,First Health,,8.27,,,,,,,3.64,8.27,percent of total billed charges,
ER Trauma Activation,7904020,CDM,682,RC,G0390,HCPCS,,,facility,inpatient,,,8281.00000,2401.49000,Aetna,First Health,,6773.86,,,,,,,4968.60,6773.86,percent of total billed charges,
ER Trauma Activation,7904020,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,8281.00000,2401.49000,Aetna,First Health,,6773.86,,,,,,,1335.06,6773.86,percent of total billed charges,
ER Trauma Alert,7904019,CDM,682,RC,,,,,facility,inpatient,,,7821.00000,2268.09000,Aetna,First Health,,6397.58,,,,,,,4692.60,6397.58,percent of total billed charges,
ER Trauma Alert,7904019,CDM,682,RC,,,,,facility,outpatient,,,7821.00000,2268.09000,Aetna,First Health,,6397.58,,,,,,,2819.47,6397.58,percent of total billed charges,
Trauma Activation Level 1,8625952,CDM,682,RC,G0390,HCPCS,,,facility,inpatient,,,7200.00000,2088.00000,Aetna,First Health,,5889.60,,,,,,,4320.00,5889.60,percent of total billed charges,
Trauma Activation Level 1,8625952,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,7200.00000,2088.00000,Aetna,First Health,,5889.60,,,,,,,1335.06,5889.60,percent of total billed charges,
Trauma Activation Level 2,8625953,CDM,682,RC,G0390,HCPCS,,,facility,inpatient,,,6800.00000,1972.00000,Aetna,First Health,,5562.40,,,,,,,4080.00,5562.40,percent of total billed charges,
Trauma Activation Level 2,8625953,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,6800.00000,1972.00000,Aetna,First Health,,5562.40,,,,,,,1335.06,5562.40,percent of total billed charges,
Trauma Activation I with Critical Care,9010915,CDM,682,RC,G0390,HCPCS,,,facility,inpatient,,,7200.00000,2088.00000,Aetna,First Health,,5889.60,,,,,,,4320.00,5889.60,percent of total billed charges,
Trauma Activation I with Critical Care,9010915,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,7200.00000,2088.00000,Aetna,First Health,,5889.60,,,,,,,1335.06,5889.60,percent of total billed charges,
Trauma Activation 1 W Critical Care W Prehospital Notice,9101301,CDM,682,RC,G0390,HCPCS,,,facility,inpatient,,,7200.00000,2088.00000,Aetna,First Health,,5889.60,,,,,,,4320.00,5889.60,percent of total billed charges,
Trauma Activation 1 W Critical Care W Prehospital Notice,9101301,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,7200.00000,2088.00000,Aetna,First Health,,5889.60,,,,,,,1335.06,5889.60,percent of total billed charges,
Trauma Activation I without Critical Care,9010916,CDM,682,RC,,,,,facility,inpatient,,,7200.00000,2088.00000,Aetna,First Health,,5889.60,,,,,,,4320.00,5889.60,percent of total billed charges,
Trauma Activation I without Critical Care,9010916,CDM,682,RC,,,,,facility,outpatient,,,7200.00000,2088.00000,Aetna,First Health,,5889.60,,,,,,,2595.60,5889.60,percent of total billed charges,
Trauma Activation 1 WO Critical Care W Prehospital N,9101299,CDM,682,RC,,,,,facility,inpatient,,,7200.00000,2088.00000,Aetna,First Health,,5889.60,,,,,,,4320.00,5889.60,percent of total billed charges,
Trauma Activation 1 WO Critical Care W Prehospital N,9101299,CDM,682,RC,,,,,facility,outpatient,,,7200.00000,2088.00000,Aetna,First Health,,5889.60,,,,,,,2595.60,5889.60,percent of total billed charges,
Trauma Activation II with Critical Care,9010917,CDM,682,RC,G0390,HCPCS,,,facility,inpatient,,,6800.00000,1972.00000,Aetna,First Health,,5562.40,,,,,,,4080.00,5562.40,percent of total billed charges,
Trauma Activation II with Critical Care,9010917,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,6800.00000,1972.00000,Aetna,First Health,,5562.40,,,,,,,1335.06,5562.40,percent of total billed charges,
Trauma Activation 2 W Critical Care W Prehospital Notice,9101297,CDM,682,RC,G0390,HCPCS,,,facility,inpatient,,,6800.00000,1972.00000,Aetna,First Health,,5562.40,,,,,,,4080.00,5562.40,percent of total billed charges,
Trauma Activation 2 W Critical Care W Prehospital Notice,9101297,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,6800.00000,1972.00000,Aetna,First Health,,5562.40,,,,,,,1335.06,5562.40,percent of total billed charges,
Trauma Activation II without Critical Care,9010918,CDM,682,RC,,,,,facility,inpatient,,,6800.00000,1972.00000,Aetna,First Health,,5562.40,,,,,,,4080.00,5562.40,percent of total billed charges,
Trauma Activation II without Critical Care,9010918,CDM,682,RC,,,,,facility,outpatient,,,6800.00000,1972.00000,Aetna,First Health,,5562.40,,,,,,,2451.40,5562.40,percent of total billed charges,
Trauma Activation 2 WO Critical Care W Prehospital Notice,9103634,CDM,682,RC,,,,,facility,inpatient,,,6800.00000,1972.00000,Aetna,First Health,,5562.40,,,,,,,4080.00,5562.40,percent of total billed charges,
Trauma Activation 2 WO Critical Care W Prehospital Notice,9103634,CDM,682,RC,,,,,facility,outpatient,,,6800.00000,1972.00000,Aetna,First Health,,5562.40,,,,,,,2451.40,5562.40,percent of total billed charges,
Mat Recovery,7939185,CDM,710,RC,,,,,facility,inpatient,,,1624.00000,470.96000,Aetna,First Health,,1328.43,,,,,,,974.40,1328.43,percent of total billed charges,
Mat Recovery,7939185,CDM,710,RC,,,,,facility,outpatient,,,1624.00000,470.96000,Aetna,First Health,,1328.43,,,,,,,585.45,1328.43,percent of total billed charges,
Mat Recovery,7939255,CDM,710,RC,,,,,facility,inpatient,,,1624.00000,470.96000,Aetna,First Health,,1328.43,,,,,,,974.40,1328.43,percent of total billed charges,
Mat Recovery,7939255,CDM,710,RC,,,,,facility,outpatient,,,1624.00000,470.96000,Aetna,First Health,,1328.43,,,,,,,585.45,1328.43,percent of total billed charges,
MC C Section Recovery,889798,CDM,710,RC,,,,,facility,inpatient,,,1624.00000,470.96000,Aetna,First Health,,1328.43,,,,,,,974.40,1328.43,percent of total billed charges,
MC C Section Recovery,889798,CDM,710,RC,,,,,facility,outpatient,,,1624.00000,470.96000,Aetna,First Health,,1328.43,,,,,,,585.45,1328.43,percent of total billed charges,
PACU 1 to 30 Min,8161131,CDM,710,RC,,,,,facility,inpatient,,,750.00000,217.50000,Aetna,First Health,,613.50,,,,,,,450.00,613.50,percent of total billed charges,
PACU 1 to 30 Min,8161131,CDM,710,RC,,,,,facility,outpatient,,,750.00000,217.50000,Aetna,First Health,,613.50,,,,,,,270.38,613.50,percent of total billed charges,
PACU each Addl 15 min,8161132,CDM,710,RC,,,,,facility,inpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,56.40,76.89,percent of total billed charges,
PACU each Addl 15 min,8161132,CDM,710,RC,,,,,facility,outpatient,,,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,33.89,76.89,percent of total billed charges,
Mat Amnioinfusion,7932241,CDM,720,RC,59070,HCPCS,,,facility,inpatient,,,1066.00000,309.14000,Aetna,First Health,,871.99,,,,,,,639.60,871.99,percent of total billed charges,
Mat Amnioinfusion,7932241,CDM,720,RC,59070,HCPCS,,,facility,outpatient,,,1066.00000,309.14000,Aetna,First Health,,871.99,,,,,,,267.10,2860.00,percent of total billed charges,
Mat Treat Postpartum Hemmo,7942646,CDM,720,RC,,,,,facility,inpatient,,,1036.00000,300.44000,Aetna,First Health,,847.45,,,,,,,621.60,847.45,percent of total billed charges,
Mat Treat Postpartum Hemmo,7942646,CDM,720,RC,,,,,facility,outpatient,,,1036.00000,300.44000,Aetna,First Health,,847.45,,,,,,,373.48,847.45,percent of total billed charges,
Mat Treat Postpartum Hemmo,7954815,CDM,720,RC,,,,,facility,inpatient,,,1036.00000,300.44000,Aetna,First Health,,847.45,,,,,,,621.60,847.45,percent of total billed charges,
Mat Treat Postpartum Hemmo,7954815,CDM,720,RC,,,,,facility,outpatient,,,1036.00000,300.44000,Aetna,First Health,,847.45,,,,,,,373.48,847.45,percent of total billed charges,
Intrauterine Pressure Catheter,9005280,CDM,720,RC,59050,HCPCS,,,facility,inpatient,,,400.00000,116.00000,Aetna,First Health,,327.20,,,,,,,240.00,327.20,percent of total billed charges,
Intrauterine Pressure Catheter,9005280,CDM,720,RC,59050,HCPCS,,,facility,outpatient,,,400.00000,116.00000,Aetna,First Health,,327.20,,,,,,,144.20,2860.00,percent of total billed charges,
Fetal Scalp Electrode,9005275,CDM,720,RC,59050,HCPCS,,,facility,inpatient,,,400.00000,116.00000,Aetna,First Health,,327.20,,,,,,,240.00,327.20,percent of total billed charges,
Fetal Scalp Electrode,9005275,CDM,720,RC,59050,HCPCS,,,facility,outpatient,,,400.00000,116.00000,Aetna,First Health,,327.20,,,,,,,144.20,2860.00,percent of total billed charges,
Mat Cervical Ripening,7939789,CDM,720,RC,,,,,facility,inpatient,,,1036.00000,300.44000,Aetna,First Health,,847.45,,,,,,,621.60,847.45,percent of total billed charges,
Mat Cervical Ripening,7939789,CDM,720,RC,,,,,facility,outpatient,,,1036.00000,300.44000,Aetna,First Health,,847.45,,,,,,,373.48,847.45,percent of total billed charges,
Mat Labor Room 0 To 4 Hours,8158159,CDM,721,RC,,,,,facility,inpatient,,,1617.00000,468.93000,Aetna,First Health,,1322.71,,,,,,,970.20,1322.71,percent of total billed charges,
Mat Labor Room 0 To 4 Hours,8158159,CDM,721,RC,,,,,facility,outpatient,,,1617.00000,468.93000,Aetna,First Health,,1322.71,,,,,,,582.93,1322.71,percent of total billed charges,
Mat Labor Room Each Addl Hour,8158160,CDM,721,RC,,,,,facility,inpatient,,,433.00000,125.57000,Aetna,First Health,,354.19,,,,,,,259.80,354.19,percent of total billed charges,
Mat Labor Room Each Addl Hour,8158160,CDM,721,RC,,,,,facility,outpatient,,,433.00000,125.57000,Aetna,First Health,,354.19,,,,,,,156.10,354.19,percent of total billed charges,
Mat Vaginal Delivery,7936480,CDM,722,RC,,,,,facility,inpatient,,,7581.00000,2198.49000,Aetna,First Health,,6201.26,,,,,,,4548.60,6201.26,percent of total billed charges,
Mat Vaginal Delivery,7936480,CDM,722,RC,,,,,facility,outpatient,,,7581.00000,2198.49000,Aetna,First Health,,6201.26,,,,,,,2732.95,6201.26,percent of total billed charges,
Mat Vaginal Delivery,7936481,CDM,722,RC,,,,,facility,inpatient,,,7581.00000,2198.49000,Aetna,First Health,,6201.26,,,,,,,4548.60,6201.26,percent of total billed charges,
Mat Vaginal Delivery,7936481,CDM,722,RC,,,,,facility,outpatient,,,7581.00000,2198.49000,Aetna,First Health,,6201.26,,,,,,,2732.95,6201.26,percent of total billed charges,
Mat Vaginal Delivery,7936482,CDM,722,RC,,,,,facility,inpatient,,,7581.00000,2198.49000,Aetna,First Health,,6201.26,,,,,,,4548.60,6201.26,percent of total billed charges,
Mat Vaginal Delivery,7936482,CDM,722,RC,,,,,facility,outpatient,,,7581.00000,2198.49000,Aetna,First Health,,6201.26,,,,,,,2732.95,6201.26,percent of total billed charges,
Mat Vaginal Delivery,7936483,CDM,722,RC,,,,,facility,inpatient,,,7581.00000,2198.49000,Aetna,First Health,,6201.26,,,,,,,4548.60,6201.26,percent of total billed charges,
Mat Vaginal Delivery,7936483,CDM,722,RC,,,,,facility,outpatient,,,7581.00000,2198.49000,Aetna,First Health,,6201.26,,,,,,,2732.95,6201.26,percent of total billed charges,
Vaginal Manual Extraction,9005272,CDM,722,RC,59414,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1920.00,2617.60,percent of total billed charges,
Vaginal Manual Extraction,9005272,CDM,722,RC,59414,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,First Health,,2617.60,,,,,,,1187.84,8486.44,percent of total billed charges,
RT Attendance at Delivery,8996890,CDM,722,RC,99464,HCPCS,,,facility,inpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,79.20,107.98,percent of total billed charges,
RT Attendance at Delivery,8996890,CDM,722,RC,99464,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,47.59,107.98,percent of total billed charges,
EKG,2154824,CDM,730,RC,93005,HCPCS,,,facility,inpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,402.60,548.88,percent of total billed charges,
EKG,2154824,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,52.15,563.00,percent of total billed charges,
ED EKG,8347478,CDM,730,RC,93005,HCPCS,,,facility,inpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,402.60,548.88,percent of total billed charges,
ED EKG,8347478,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,52.15,563.00,percent of total billed charges,
ED EKG,8347481,CDM,730,RC,93005,HCPCS,,,facility,inpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,402.60,548.88,percent of total billed charges,
ED EKG,8347481,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,52.15,563.00,percent of total billed charges,
ED EKG,927801,CDM,730,RC,93005,HCPCS,,,facility,inpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,402.60,548.88,percent of total billed charges,
ED EKG,927801,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,52.15,563.00,percent of total billed charges,
EKG,599382,CDM,730,RC,93005,HCPCS,,,facility,inpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,402.60,548.88,percent of total billed charges,
EKG,599382,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,52.15,563.00,percent of total billed charges,
EKG,8347445,CDM,730,RC,93005,HCPCS,,,facility,inpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,402.60,548.88,percent of total billed charges,
EKG,8347445,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,52.15,563.00,percent of total billed charges,
EKG After Hours,8347490,CDM,730,RC,93005,HCPCS,,,facility,inpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,402.60,548.88,percent of total billed charges,
EKG After Hours,8347490,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,52.15,563.00,percent of total billed charges,
Cardiology EKG,8356873,CDM,730,RC,93005,HCPCS,,,facility,inpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,402.60,548.88,percent of total billed charges,
Cardiology EKG,8356873,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,First Health,,548.88,,,,,,,52.15,563.00,percent of total billed charges,
Rhythym Strip Tracing,599396,CDM,730,RC,93041,HCPCS,,,facility,inpatient,,,640.00000,185.60000,Aetna,First Health,,523.52,,,,,,,384.00,523.52,percent of total billed charges,
Rhythym Strip Tracing,599396,CDM,730,RC,93041,HCPCS,,,facility,outpatient,,,640.00000,185.60000,Aetna,First Health,,523.52,,,,,,,52.15,563.00,percent of total billed charges,
Rhythm Strip Tracing,9101084,CDM,730,RC,93041,HCPCS,,,facility,inpatient,,,640.00000,185.60000,Aetna,First Health,,523.52,,,,,,,384.00,523.52,percent of total billed charges,
Rhythm Strip Tracing,9101084,CDM,730,RC,93041,HCPCS,,,facility,outpatient,,,640.00000,185.60000,Aetna,First Health,,523.52,,,,,,,52.15,563.00,percent of total billed charges,
Holter Recording,599392,CDM,731,RC,93225,HCPCS,,,facility,inpatient,,,659.00000,191.11000,Aetna,First Health,,539.06,,,,,,,395.40,539.06,percent of total billed charges,
Holter Recording,599392,CDM,731,RC,93225,HCPCS,,,facility,outpatient,,,659.00000,191.11000,Aetna,First Health,,539.06,,,,,,,113.19,563.00,percent of total billed charges,
CEK Holter Recording,617798,CDM,731,RC,93225,HCPCS,,,facility,inpatient,,,659.00000,191.11000,Aetna,First Health,,539.06,,,,,,,395.40,539.06,percent of total billed charges,
CEK Holter Recording,617798,CDM,731,RC,93225,HCPCS,,,facility,outpatient,,,659.00000,191.11000,Aetna,First Health,,539.06,,,,,,,113.19,563.00,percent of total billed charges,
Holter Recording,7936142,CDM,731,RC,93225,HCPCS,,,facility,inpatient,,,659.00000,191.11000,Aetna,First Health,,539.06,,,,,,,395.40,539.06,percent of total billed charges,
Holter Recording,7936142,CDM,731,RC,93225,HCPCS,,,facility,outpatient,,,659.00000,191.11000,Aetna,First Health,,539.06,,,,,,,113.19,563.00,percent of total billed charges,
Holter Scanning,599394,CDM,731,RC,93226,HCPCS,,,facility,inpatient,,,2587.00000,750.23000,Aetna,First Health,,2116.17,,,,,,,1552.20,2116.17,percent of total billed charges,
Holter Scanning,599394,CDM,731,RC,93226,HCPCS,,,facility,outpatient,,,2587.00000,750.23000,Aetna,First Health,,2116.17,,,,,,,52.15,2116.17,percent of total billed charges,
CEK Holter Scanning,617799,CDM,731,RC,93226,HCPCS,,,facility,inpatient,,,2587.00000,750.23000,Aetna,First Health,,2116.17,,,,,,,1552.20,2116.17,percent of total billed charges,
CEK Holter Scanning,617799,CDM,731,RC,93226,HCPCS,,,facility,outpatient,,,2587.00000,750.23000,Aetna,First Health,,2116.17,,,,,,,52.15,2116.17,percent of total billed charges,
Holter Scanning,7897215,CDM,731,RC,93226,HCPCS,,,facility,inpatient,,,2587.00000,750.23000,Aetna,First Health,,2116.17,,,,,,,1552.20,2116.17,percent of total billed charges,
Holter Scanning,7897215,CDM,731,RC,93226,HCPCS,,,facility,outpatient,,,2587.00000,750.23000,Aetna,First Health,,2116.17,,,,,,,52.15,2116.17,percent of total billed charges,
Holter Acquisition Scanning,7936143,CDM,731,RC,93226,HCPCS,,,facility,inpatient,,,2587.00000,750.23000,Aetna,First Health,,2116.17,,,,,,,1552.20,2116.17,percent of total billed charges,
Holter Acquisition Scanning,7936143,CDM,731,RC,93226,HCPCS,,,facility,outpatient,,,2587.00000,750.23000,Aetna,First Health,,2116.17,,,,,,,52.15,2116.17,percent of total billed charges,
Holter Acquisition Scanning bce,8994534,CDM,731,RC,93226,HCPCS,,,facility,inpatient,,,2587.00000,750.23000,Aetna,First Health,,2116.17,,,,,,,1552.20,2116.17,percent of total billed charges,
Holter Acquisition Scanning bce,8994534,CDM,731,RC,93226,HCPCS,,,facility,outpatient,,,2587.00000,750.23000,Aetna,First Health,,2116.17,,,,,,,52.15,2116.17,percent of total billed charges,
EEG 41 to 60 Mins,8999433,CDM,740,RC,95812,HCPCS,,,facility,inpatient,,,2096.00000,607.84000,Aetna,First Health,,1714.53,,,,,,,1257.60,1714.53,percent of total billed charges,
EEG 41 to 60 Mins,8999433,CDM,740,RC,95812,HCPCS,,,facility,outpatient,,,2096.00000,607.84000,Aetna,First Health,,1714.53,,,,,,,216.27,1714.53,percent of total billed charges,
EEG 41 to 60 Mins,9001531,CDM,740,RC,95812,HCPCS,,,facility,inpatient,,,2096.00000,607.84000,Aetna,First Health,,1714.53,,,,,,,1257.60,1714.53,percent of total billed charges,
EEG 41 to 60 Mins,9001531,CDM,740,RC,95812,HCPCS,,,facility,outpatient,,,2096.00000,607.84000,Aetna,First Health,,1714.53,,,,,,,216.27,1714.53,percent of total billed charges,
EEG 61 to 119 Mins,8995349,CDM,740,RC,95813,HCPCS,,,facility,inpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,1708.20,2328.85,percent of total billed charges,
EEG 61 to 119 Mins,8995349,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,216.27,2328.85,percent of total billed charges,
EEG 61 to 119 Mins,9001530,CDM,740,RC,95813,HCPCS,,,facility,inpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,1708.20,2328.85,percent of total billed charges,
EEG 61 to 119 Mins,9001530,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,216.27,2328.85,percent of total billed charges,
EEG 20 to 40 Mins Awake,8995348,CDM,740,RC,95816,HCPCS,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
EEG 20 to 40 Mins Awake,8995348,CDM,740,RC,95816,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 20 to 40 Min Awake,9001532,CDM,740,RC,95816,HCPCS,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
EEG 20 to 40 Min Awake,9001532,CDM,740,RC,95816,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 20 to 40 Mins Awake and Asleep or Asleep,8995347,CDM,740,RC,95819,HCPCS,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
EEG 20 to 40 Mins Awake and Asleep or Asleep,8995347,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 20 to 40 Min Awake and Asleep or Asleep,9001529,CDM,740,RC,95819,HCPCS,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
EEG 20 to 40 Min Awake and Asleep or Asleep,9001529,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 2 to 12 Hrs 8 plus Channel No Video,9001533,CDM,740,RC,95705,HCPCS,,,facility,inpatient,,,1232.00000,357.28000,Aetna,First Health,,1007.78,,,,,,,739.20,1007.78,percent of total billed charges,
EEG 2 to 12 Hrs 8 plus Channel No Video,9001533,CDM,740,RC,95705,HCPCS,,,facility,outpatient,,,1232.00000,357.28000,Aetna,First Health,,1007.78,,,,,,,216.27,1007.78,percent of total billed charges,
EEG 2 to 12 Hours 8 or More Channels No Video,9004109,CDM,740,RC,95705,HCPCS,,,facility,inpatient,,,1232.00000,357.28000,Aetna,First Health,,1007.78,,,,,,,739.20,1007.78,percent of total billed charges,
EEG 2 to 12 Hours 8 or More Channels No Video,9004109,CDM,740,RC,95705,HCPCS,,,facility,outpatient,,,1232.00000,357.28000,Aetna,First Health,,1007.78,,,,,,,216.27,1007.78,percent of total billed charges,
EEG Greater Than 12 Hrs,9001528,CDM,740,RC,95708,HCPCS,,,facility,inpatient,,,2466.00000,715.14000,Aetna,First Health,,2017.19,,,,,,,1479.60,2017.19,percent of total billed charges,
EEG Greater Than 12 Hrs,9001528,CDM,740,RC,95708,HCPCS,,,facility,outpatient,,,2466.00000,715.14000,Aetna,First Health,,2017.19,,,,,,,373.76,2017.19,percent of total billed charges,
EEG Greater Than 12 Hours,9004110,CDM,740,RC,95708,HCPCS,,,facility,inpatient,,,2466.00000,715.14000,Aetna,First Health,,2017.19,,,,,,,1479.60,2017.19,percent of total billed charges,
EEG Greater Than 12 Hours,9004110,CDM,740,RC,95708,HCPCS,,,facility,outpatient,,,2466.00000,715.14000,Aetna,First Health,,2017.19,,,,,,,373.76,2017.19,percent of total billed charges,
EEG,599346,CDM,740,RC,95819,HCPCS,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
EEG,599346,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,216.27,1766.06,percent of total billed charges,
EEG,7957125,CDM,740,RC,95819,HCPCS,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
EEG,7957125,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,216.27,1766.06,percent of total billed charges,
EEG Awake and Asleep,8282899,CDM,740,RC,95819,HCPCS,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
EEG Awake and Asleep,8282899,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,216.27,1766.06,percent of total billed charges,
Visual Evoked Potentials,599350,CDM,740,RC,95930,HCPCS,,,facility,inpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,1337.40,1823.32,percent of total billed charges,
Visual Evoked Potentials,599350,CDM,740,RC,95930,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,216.27,1823.32,percent of total billed charges,
Visual Evoked Potentials,7957297,CDM,740,RC,95930,HCPCS,,,facility,inpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,1337.40,1823.32,percent of total billed charges,
Visual Evoked Potentials,7957297,CDM,740,RC,95930,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,216.27,1823.32,percent of total billed charges,
EEG More Than 1 Hr,599360,CDM,740,RC,95813,HCPCS,,,facility,inpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,1708.20,2328.85,percent of total billed charges,
EEG More Than 1 Hr,599360,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,216.27,2328.85,percent of total billed charges,
EEG More Than 1 Hr,7957142,CDM,740,RC,95813,HCPCS,,,facility,inpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,1708.20,2328.85,percent of total billed charges,
EEG More Than 1 Hr,7957142,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,216.27,2328.85,percent of total billed charges,
EEG More Than 1 Hr,7957300,CDM,740,RC,95813,HCPCS,,,facility,inpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,1708.20,2328.85,percent of total billed charges,
EEG More Than 1 Hr,7957300,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,216.27,2328.85,percent of total billed charges,
EEG 61 to 119mins,8426932,CDM,740,RC,95813,HCPCS,,,facility,inpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,1708.20,2328.85,percent of total billed charges,
EEG 61 to 119mins,8426932,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,216.27,2328.85,percent of total billed charges,
EEG Cerebral Death,599364,CDM,740,RC,95824,HCPCS,,,facility,inpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,1501.20,2046.64,percent of total billed charges,
EEG Cerebral Death,599364,CDM,740,RC,95824,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,373.76,2046.64,percent of total billed charges,
EEG Cerebral Death,7957298,CDM,740,RC,95824,HCPCS,,,facility,inpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,1501.20,2046.64,percent of total billed charges,
EEG Cerebral Death,7957298,CDM,740,RC,95824,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,373.76,2046.64,percent of total billed charges,
EEG During Surgery,599366,CDM,740,RC,95955,HCPCS,,,facility,inpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,1501.20,2046.64,percent of total billed charges,
EEG During Surgery,599366,CDM,740,RC,95955,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,901.97,2046.64,percent of total billed charges,
EEG During Surgery,7957301,CDM,740,RC,95955,HCPCS,,,facility,inpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,1501.20,2046.64,percent of total billed charges,
EEG During Surgery,7957301,CDM,740,RC,95955,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,901.97,2046.64,percent of total billed charges,
EEG Ambulatory Each 24 Hours,7957295,CDM,740,RC,95708,HCPCS,,,facility,inpatient,,,2466.00000,715.14000,Aetna,First Health,,2017.19,,,,,,,1479.60,2017.19,percent of total billed charges,
EEG Ambulatory Each 24 Hours,7957295,CDM,740,RC,95708,HCPCS,,,facility,outpatient,,,2466.00000,715.14000,Aetna,First Health,,2017.19,,,,,,,373.76,2017.19,percent of total billed charges,
EEG Ambulatory Each 24 Hours,8159873,CDM,740,RC,95708,HCPCS,,,facility,inpatient,,,2466.00000,715.14000,Aetna,First Health,,2017.19,,,,,,,1479.60,2017.19,percent of total billed charges,
EEG Ambulatory Each 24 Hours,8159873,CDM,740,RC,95708,HCPCS,,,facility,outpatient,,,2466.00000,715.14000,Aetna,First Health,,2017.19,,,,,,,373.76,2017.19,percent of total billed charges,
EEG Coma Or Sleep Only,7846076,CDM,740,RC,95822,HCPCS,,,facility,inpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,1501.20,2046.64,percent of total billed charges,
EEG Coma Or Sleep Only,7846076,CDM,740,RC,95822,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,216.27,2046.64,percent of total billed charges,
EEG Coma Or Sleep Only,7957299,CDM,740,RC,95822,HCPCS,,,facility,inpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,1501.20,2046.64,percent of total billed charges,
EEG Coma Or Sleep Only,7957299,CDM,740,RC,95822,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,First Health,,2046.64,,,,,,,216.27,2046.64,percent of total billed charges,
EEG Extended Monitoring 41 to 60Min,7963895,CDM,740,RC,95812,HCPCS,,,facility,inpatient,,,1897.00000,550.13000,Aetna,First Health,,1551.75,,,,,,,1138.20,1551.75,percent of total billed charges,
EEG Extended Monitoring 41 to 60Min,7963895,CDM,740,RC,95812,HCPCS,,,facility,outpatient,,,1897.00000,550.13000,Aetna,First Health,,1551.75,,,,,,,216.27,1551.75,percent of total billed charges,
EEG 20 to 40mins awake and sleepy,8426922,CDM,740,RC,95819,HCPCS,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
EEG 20 to 40mins awake and sleepy,8426922,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,216.27,1766.06,percent of total billed charges,
EEG Attended,7963896,CDM,740,RC,95700,HCPCS,,,facility,inpatient,,,5625.00000,1631.25000,Aetna,First Health,,4601.25,,,,,,,3375.00,4601.25,percent of total billed charges,
EEG Attended,7963896,CDM,740,RC,95700,HCPCS,,,facility,outpatient,,,5625.00000,1631.25000,Aetna,First Health,,4601.25,,,,,,,137.38,4601.25,percent of total billed charges,
LTM EEG set up by EEG Tech,8414878,CDM,740,RC,95700,HCPCS,,,facility,inpatient,,,5625.00000,1631.25000,Aetna,First Health,,4601.25,,,,,,,3375.00,4601.25,percent of total billed charges,
LTM EEG set up by EEG Tech,8414878,CDM,740,RC,95700,HCPCS,,,facility,outpatient,,,5625.00000,1631.25000,Aetna,First Health,,4601.25,,,,,,,137.38,4601.25,percent of total billed charges,
EEG Unattended,7963897,CDM,740,RC,95714,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,2185.20,2979.16,percent of total billed charges,
EEG Unattended,7963897,CDM,740,RC,95714,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,373.76,2979.16,percent of total billed charges,
EEG Unattended,8166241,CDM,740,RC,95714,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,2185.20,2979.16,percent of total billed charges,
EEG Unattended,8166241,CDM,740,RC,95714,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,373.76,2979.16,percent of total billed charges,
LTM w Video 95714,8414876,CDM,740,RC,95714,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,2185.20,2979.16,percent of total billed charges,
LTM w Video 95714,8414876,CDM,740,RC,95714,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,373.76,2979.16,percent of total billed charges,
LTM w Video 95714,8427295,CDM,740,RC,95714,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,2185.20,2979.16,percent of total billed charges,
LTM w Video 95714,8427295,CDM,740,RC,95714,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,373.76,2979.16,percent of total billed charges,
LTM EEG set up by EEG Tech,8426945,CDM,740,RC,95700,HCPCS,,,facility,inpatient,,,5625.00000,1631.25000,Aetna,First Health,,4601.25,,,,,,,3375.00,4601.25,percent of total billed charges,
LTM EEG set up by EEG Tech,8426945,CDM,740,RC,95700,HCPCS,,,facility,outpatient,,,5625.00000,1631.25000,Aetna,First Health,,4601.25,,,,,,,137.38,4601.25,percent of total billed charges,
EEG Awake and Drowsy,8282900,CDM,740,RC,95816,HCPCS,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
EEG Awake and Drowsy,8282900,CDM,740,RC,95816,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 20 to 40mins awake and drowsy,8426917,CDM,740,RC,95816,HCPCS,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
EEG 20 to 40mins awake and drowsy,8426917,CDM,740,RC,95816,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 12 to 26 Hours,8410991,CDM,740,RC,95714,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,2185.20,2979.16,percent of total billed charges,
EEG 12 to 26 Hours,8410991,CDM,740,RC,95714,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,First Health,,2979.16,,,,,,,373.76,2979.16,percent of total billed charges,
EEG 2 to 12 Hours,8410992,CDM,740,RC,95711,HCPCS,,,facility,inpatient,,,3239.00000,939.31000,Aetna,First Health,,2649.50,,,,,,,1943.40,2649.50,percent of total billed charges,
EEG 2 to 12 Hours,8410992,CDM,740,RC,95711,HCPCS,,,facility,outpatient,,,3239.00000,939.31000,Aetna,First Health,,2649.50,,,,,,,216.27,2649.50,percent of total billed charges,
LTM w Video 95711,8414877,CDM,740,RC,95711,HCPCS,,,facility,inpatient,,,3239.00000,939.31000,Aetna,First Health,,2649.50,,,,,,,1943.40,2649.50,percent of total billed charges,
LTM w Video 95711,8414877,CDM,740,RC,95711,HCPCS,,,facility,outpatient,,,3239.00000,939.31000,Aetna,First Health,,2649.50,,,,,,,216.27,2649.50,percent of total billed charges,
LTM w Video 95711,8427296,CDM,740,RC,95711,HCPCS,,,facility,inpatient,,,3239.00000,939.31000,Aetna,First Health,,2649.50,,,,,,,1943.40,2649.50,percent of total billed charges,
LTM w Video 95711,8427296,CDM,740,RC,95711,HCPCS,,,facility,outpatient,,,3239.00000,939.31000,Aetna,First Health,,2649.50,,,,,,,216.27,2649.50,percent of total billed charges,
EEG 2 to 12hrs 8 less than channels no video,8426927,CDM,740,RC,95705,HCPCS,,,facility,inpatient,,,1232.00000,357.28000,Aetna,First Health,,1007.78,,,,,,,739.20,1007.78,percent of total billed charges,
EEG 2 to 12hrs 8 less than channels no video,8426927,CDM,740,RC,95705,HCPCS,,,facility,outpatient,,,1232.00000,357.28000,Aetna,First Health,,1007.78,,,,,,,216.27,1007.78,percent of total billed charges,
EEG 12 to 26hrs 8 less than channels no video,8426912,CDM,740,RC,95708,HCPCS,,,facility,inpatient,,,2466.00000,715.14000,Aetna,First Health,,2017.19,,,,,,,1479.60,2017.19,percent of total billed charges,
EEG 12 to 26hrs 8 less than channels no video,8426912,CDM,740,RC,95708,HCPCS,,,facility,outpatient,,,2466.00000,715.14000,Aetna,First Health,,2017.19,,,,,,,373.76,2017.19,percent of total billed charges,
ANOSCOPY SN,7691983,CDM,750,RC,,,,,facility,inpatient,,,692.00000,200.68000,Aetna,First Health,,566.06,,,,,,,415.20,566.06,percent of total billed charges,
ANOSCOPY SN,7691983,CDM,750,RC,,,,,facility,outpatient,,,692.00000,200.68000,Aetna,First Health,,566.06,,,,,,,249.47,566.06,percent of total billed charges,
Anoscopy SN,8328370,CDM,750,RC,,,,,facility,inpatient,,,692.00000,200.68000,Aetna,First Health,,566.06,,,,,,,415.20,566.06,percent of total billed charges,
Anoscopy SN,8328370,CDM,750,RC,,,,,facility,outpatient,,,692.00000,200.68000,Aetna,First Health,,566.06,,,,,,,249.47,566.06,percent of total billed charges,
STRICTUREPLASTY,9182901,CDM,750,RC,,,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,828.00,1128.84,percent of total billed charges,
STRICTUREPLASTY,9182901,CDM,750,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,1128.84,percent of total billed charges,
TRIGGER POINT PROCEDURE,7692085,CDM,750,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
TRIGGER POINT PROCEDURE,7692085,CDM,750,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
ENTEROSCOPY,7692008,CDM,750,RC,,,,,facility,inpatient,,,3799.00000,1101.71000,Aetna,First Health,,3107.58,,,,,,,2279.40,3107.58,percent of total billed charges,
ENTEROSCOPY,7692008,CDM,750,RC,,,,,facility,outpatient,,,3799.00000,1101.71000,Aetna,First Health,,3107.58,,,,,,,1369.54,3107.58,percent of total billed charges,
ILEOPSCOPY,7692020,CDM,750,RC,,,,,facility,inpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,1760.40,2400.01,percent of total billed charges,
ILEOPSCOPY,7692020,CDM,750,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,1057.71,2400.01,percent of total billed charges,
EGD,7692013,CDM,750,RC,,,,,facility,inpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,1035.60,1411.87,percent of total billed charges,
EGD,7692013,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,622.22,1411.87,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Removal with Esopha,7756871,CDM,750,RC,,,,,facility,inpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,1035.60,1411.87,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Removal with Esopha,7756871,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,622.22,1411.87,percent of total billed charges,
EGD,8246767,CDM,750,RC,,,,,facility,inpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,1035.60,1411.87,percent of total billed charges,
EGD,8246767,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,622.22,1411.87,percent of total billed charges,
COLONOSCOPY,7692005,CDM,750,RC,,,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
COLONOSCOPY,7692005,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,778.32,1766.06,percent of total billed charges,
COLONOSCOPY,7923326,CDM,750,RC,,,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
COLONOSCOPY,7923326,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,778.32,1766.06,percent of total billed charges,
COLONOSCOPY,8246766,CDM,750,RC,,,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
COLONOSCOPY,8246766,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,778.32,1766.06,percent of total billed charges,
Colonoscopy Screening SN,8786157,CDM,750,RC,,,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
Colonoscopy Screening SN,8786157,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,778.32,1766.06,percent of total billed charges,
ERCP,7691986,CDM,750,RC,,,,,facility,inpatient,,,6904.00000,2002.16000,Aetna,First Health,,5647.47,,,,,,,4142.40,5647.47,percent of total billed charges,
ERCP,7691986,CDM,750,RC,,,,,facility,outpatient,,,6904.00000,2002.16000,Aetna,First Health,,5647.47,,,,,,,2488.89,5647.47,percent of total billed charges,
ERCP,9212541,CDM,750,RC,,,,,facility,inpatient,,,6904.00000,2002.16000,Aetna,First Health,,5647.47,,,,,,,4142.40,5647.47,percent of total billed charges,
ERCP,9212541,CDM,750,RC,,,,,facility,outpatient,,,6904.00000,2002.16000,Aetna,First Health,,5647.47,,,,,,,2488.89,5647.47,percent of total billed charges,
CAPSULE ENDOSCOPY,7692006,CDM,750,RC,91110,HCPCS,,,facility,inpatient,,,5067.00000,1469.43000,Aetna,First Health,,4144.81,,,,,,,3040.20,4144.81,percent of total billed charges,
CAPSULE ENDOSCOPY,7692006,CDM,750,RC,91110,HCPCS,,,facility,outpatient,,,5067.00000,1469.43000,Aetna,First Health,,4144.81,,,,,,,682.44,4144.81,percent of total billed charges,
EG TUBE PLACEMENT OTHER,7692047,CDM,750,RC,,,,,facility,inpatient,,,1553.00000,450.37000,Aetna,First Health,,1270.35,,,,,,,931.80,1270.35,percent of total billed charges,
EG TUBE PLACEMENT OTHER,7692047,CDM,750,RC,,,,,facility,outpatient,,,1553.00000,450.37000,Aetna,First Health,,1270.35,,,,,,,559.86,1270.35,percent of total billed charges,
EG TUBE PLACEMENT OTHER,9000946,CDM,750,RC,,,,,facility,inpatient,,,1553.00000,450.37000,Aetna,First Health,,1270.35,,,,,,,931.80,1270.35,percent of total billed charges,
EG TUBE PLACEMENT OTHER,9000946,CDM,750,RC,,,,,facility,outpatient,,,1553.00000,450.37000,Aetna,First Health,,1270.35,,,,,,,559.86,1270.35,percent of total billed charges,
LOWER ENDOSCOPY WITH ULTRASOUND,7692027,CDM,750,RC,,,,,facility,inpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,3106.80,4235.60,percent of total billed charges,
LOWER ENDOSCOPY WITH ULTRASOUND,7692027,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,1866.67,4235.60,percent of total billed charges,
UPPER ENDOSCOPY WITH ULTRASOUND,7692031,CDM,750,RC,,,,,facility,inpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,3106.80,4235.60,percent of total billed charges,
UPPER ENDOSCOPY WITH ULTRASOUND,7692031,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,1866.67,4235.60,percent of total billed charges,
Upper Endoscopy w Ultrasound,8153962,CDM,750,RC,,,,,facility,inpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,3106.80,4235.60,percent of total billed charges,
Upper Endoscopy w Ultrasound,8153962,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,1866.67,4235.60,percent of total billed charges,
UPPER ENDOSCOPIC ULTRASOUND,8246852,CDM,750,RC,,,,,facility,inpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,3106.80,4235.60,percent of total billed charges,
UPPER ENDOSCOPIC ULTRASOUND,8246852,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,1866.67,4235.60,percent of total billed charges,
EUS NEEDLE ASPIRATION,7692030,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EUS NEEDLE ASPIRATION,7692030,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EUS NEEDLE ASPIRATION,7692036,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EUS NEEDLE ASPIRATION,7692036,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EUS FINE NEEDLE BIOPSY,9154468,CDM,750,RC,,,,,facility,inpatient,,,1267.00000,367.43000,Aetna,First Health,,1036.41,,,,,,,760.20,1036.41,percent of total billed charges,
EUS FINE NEEDLE BIOPSY,9154468,CDM,750,RC,,,,,facility,outpatient,,,1267.00000,367.43000,Aetna,First Health,,1036.41,,,,,,,456.75,1036.41,percent of total billed charges,
EUS FINE NEEDLE BIOPSY,9154469,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EUS FINE NEEDLE BIOPSY,9154469,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
Ultrasound Upper Endoscopic Celiac Plexis Block,7692034,CDM,750,RC,,,,,facility,inpatient,,,706.00000,204.74000,Aetna,First Health,,577.51,,,,,,,423.60,577.51,percent of total billed charges,
Ultrasound Upper Endoscopic Celiac Plexis Block,7692034,CDM,750,RC,,,,,facility,outpatient,,,706.00000,204.74000,Aetna,First Health,,577.51,,,,,,,254.51,577.51,percent of total billed charges,
EUS BLOCK OR NEUROLYSIS,7692035,CDM,750,RC,,,,,facility,inpatient,,,706.00000,204.74000,Aetna,First Health,,577.51,,,,,,,423.60,577.51,percent of total billed charges,
EUS BLOCK OR NEUROLYSIS,7692035,CDM,750,RC,,,,,facility,outpatient,,,706.00000,204.74000,Aetna,First Health,,577.51,,,,,,,254.51,577.51,percent of total billed charges,
BALLOON ENTEROSCOPY,7692007,CDM,750,RC,,,,,facility,inpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,3106.80,4235.60,percent of total billed charges,
BALLOON ENTEROSCOPY,7692007,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,1866.67,4235.60,percent of total billed charges,
COLONOSCOPY WITH POLYP OR BIOPSY,7147843,CDM,750,RC,,,,,facility,inpatient,,,3539.00000,1026.31000,Aetna,First Health,,2894.90,,,,,,,2123.40,2894.90,percent of total billed charges,
COLONOSCOPY WITH POLYP OR BIOPSY,7147843,CDM,750,RC,,,,,facility,outpatient,,,3539.00000,1026.31000,Aetna,First Health,,2894.90,,,,,,,1275.81,2894.90,percent of total billed charges,
EGD WITH POLYP OR BIOPSY,7147841,CDM,750,RC,,,,,facility,inpatient,,,3107.00000,901.03000,Aetna,First Health,,2541.53,,,,,,,1864.20,2541.53,percent of total billed charges,
EGD WITH POLYP OR BIOPSY,7147841,CDM,750,RC,,,,,facility,outpatient,,,3107.00000,901.03000,Aetna,First Health,,2541.53,,,,,,,1120.07,2541.53,percent of total billed charges,
EGD WITH DILATION,7147840,CDM,750,RC,,,,,facility,inpatient,,,2470.00000,716.30000,Aetna,First Health,,2020.46,,,,,,,1482.00,2020.46,percent of total billed charges,
EGD WITH DILATION,7147840,CDM,750,RC,,,,,facility,outpatient,,,2470.00000,716.30000,Aetna,First Health,,2020.46,,,,,,,890.43,2020.46,percent of total billed charges,
COL APC PROCEDURE,7691996,CDM,750,RC,,,,,facility,inpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,2071.80,2824.55,percent of total billed charges,
COL APC PROCEDURE,7691996,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,1244.81,2824.55,percent of total billed charges,
EG APC PROCEDURE,7692037,CDM,750,RC,,,,,facility,inpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,2071.80,2824.55,percent of total billed charges,
EG APC PROCEDURE,7692037,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,1244.81,2824.55,percent of total billed charges,
COL BICAP,7691997,CDM,750,RC,,,,,facility,inpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,726.00,989.78,percent of total billed charges,
COL BICAP,7691997,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,989.78,percent of total billed charges,
EG BICAP,7692038,CDM,750,RC,,,,,facility,inpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,726.00,989.78,percent of total billed charges,
EG BICAP,7692038,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,989.78,percent of total billed charges,
COL DILITATION,7692001,CDM,750,RC,,,,,facility,inpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,726.00,989.78,percent of total billed charges,
COL DILITATION,7692001,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,989.78,percent of total billed charges,
EG DILITATION,7692042,CDM,750,RC,,,,,facility,inpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,726.00,989.78,percent of total billed charges,
EG DILITATION,7692042,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,989.78,percent of total billed charges,
ERC DILITATION,7691987,CDM,750,RC,,,,,facility,inpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,726.00,989.78,percent of total billed charges,
ERC DILITATION,7691987,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,989.78,percent of total billed charges,
COL MUCOSAL RESECTION,7692002,CDM,750,RC,,,,,facility,inpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,2071.80,2824.55,percent of total billed charges,
COL MUCOSAL RESECTION,7692002,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,1244.81,2824.55,percent of total billed charges,
EG MUCOSAL RESECTION,7692044,CDM,750,RC,,,,,facility,inpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,2071.80,2824.55,percent of total billed charges,
EG MUCOSAL RESECTION,7692044,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,1244.81,2824.55,percent of total billed charges,
COL FOREIGN BODY REMOVAL,7692003,CDM,750,RC,,,,,facility,inpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,697.20,950.52,percent of total billed charges,
COL FOREIGN BODY REMOVAL,7692003,CDM,750,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,418.90,950.52,percent of total billed charges,
EG FOREIGN BODY REMOVAL,7692043,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EG FOREIGN BODY REMOVAL,7692043,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EG VARIX LIGATION,7692009,CDM,750,RC,,,,,facility,inpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,2071.80,2824.55,percent of total billed charges,
EG VARIX LIGATION,7692009,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,1244.81,2824.55,percent of total billed charges,
ERC SCLEROTHERAPY,7691991,CDM,750,RC,,,,,facility,inpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,697.20,950.52,percent of total billed charges,
ERC SCLEROTHERAPY,7691991,CDM,750,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,418.90,950.52,percent of total billed charges,
EG SCLEROTHERAPY,7692045,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EG SCLEROTHERAPY,7692045,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
COL SCLEROTHERAPY,7692004,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
COL SCLEROTHERAPY,7692004,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
ERC POLYPECTOMY OR BIOPSY,7691988,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
ERC POLYPECTOMY OR BIOPSY,7691988,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
ERC POLYPECTOMY OR BIOPSY,7692028,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
ERC POLYPECTOMY OR BIOPSY,7692028,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
ERC POLYPECTOMY OR BIOPSY,7692032,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
ERC POLYPECTOMY OR BIOPSY,7692032,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EG POLYPECTOMY OR BIOPSY,7692039,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EG POLYPECTOMY OR BIOPSY,7692039,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
COL POLYPECTOMY OR BIOPSY,7691998,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
COL POLYPECTOMY OR BIOPSY,7691998,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
ERC STENT PLACEMENT,7691993,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
ERC STENT PLACEMENT,7691993,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EG STENT PLACEMENT,7692046,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EG STENT PLACEMENT,7692046,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
ESOPHAGOSCOPY,7692014,CDM,750,RC,,,,,facility,inpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,1087.20,1482.22,percent of total billed charges,
ESOPHAGOSCOPY,7692014,CDM,750,RC,,,,,facility,outpatient,,,1812.00000,525.48000,Aetna,First Health,,1482.22,,,,,,,653.23,1482.22,percent of total billed charges,
LOCAL STEROID INJECTION SOFT TISSUE,7772187,CDM,750,RC,,,,,facility,inpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,435.60,593.87,percent of total billed charges,
LOCAL STEROID INJECTION SOFT TISSUE,7772187,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,261.72,593.87,percent of total billed charges,
ERC CAUTERY,7880398,CDM,750,RC,,,,,facility,inpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,435.60,593.87,percent of total billed charges,
ERC CAUTERY,7880398,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,261.72,593.87,percent of total billed charges,
COL STENT PLACEMENT,7741221,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
COL STENT PLACEMENT,7741221,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
ERC LITHOTRIPSY,7901473,CDM,750,RC,,,,,facility,inpatient,,,3306.00000,958.74000,Aetna,First Health,,2704.31,,,,,,,1983.60,2704.31,percent of total billed charges,
ERC LITHOTRIPSY,7901473,CDM,750,RC,,,,,facility,outpatient,,,3306.00000,958.74000,Aetna,First Health,,2704.31,,,,,,,1191.81,2704.31,percent of total billed charges,
Upper Endoscopy w Ultrasound FNA and or Biopsy,8117252,CDM,750,RC,,,,,facility,inpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,3934.80,5364.44,percent of total billed charges,
Upper Endoscopy w Ultrasound FNA and or Biopsy,8117252,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,2364.16,5364.44,percent of total billed charges,
Upper Endoscopy w Ultrasound FNA and or Biopsy,8150640,CDM,750,RC,,,,,facility,inpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,3934.80,5364.44,percent of total billed charges,
Upper Endoscopy w Ultrasound FNA and or Biopsy,8150640,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,2364.16,5364.44,percent of total billed charges,
Lower Endoscopy w Ultrasound FNA and or Biopsy,8150653,CDM,750,RC,,,,,facility,inpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,3934.80,5364.44,percent of total billed charges,
Lower Endoscopy w Ultrasound FNA and or Biopsy,8150653,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,2364.16,5364.44,percent of total billed charges,
Lower Endoscopy w Ultrasound FNA and or Biopsy,9154557,CDM,750,RC,,,,,facility,inpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,3934.80,5364.44,percent of total billed charges,
Lower Endoscopy w Ultrasound FNA and or Biopsy,9154557,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,2364.16,5364.44,percent of total billed charges,
PH CAPSULE MONITORING,7691985,CDM,750,RC,91035,HCPCS,,,facility,inpatient,,,4247.00000,1231.63000,Aetna,First Health,,3474.05,,,,,,,2548.20,3474.05,percent of total billed charges,
PH CAPSULE MONITORING,7691985,CDM,750,RC,91035,HCPCS,,,facility,outpatient,,,4247.00000,1231.63000,Aetna,First Health,,3474.05,,,,,,,269.28,3474.05,percent of total billed charges,
ESOPHAGEAL MANOMETRY WITH IMPEDANCE TEST,8143316,CDM,750,RC,91034,HCPCS,,,facility,inpatient,,,2634.00000,763.86000,Aetna,First Health,,2154.61,,,,,,,1580.40,2154.61,percent of total billed charges,
ESOPHAGEAL MANOMETRY WITH IMPEDANCE TEST,8143316,CDM,750,RC,91034,HCPCS,,,facility,outpatient,,,2634.00000,763.86000,Aetna,First Health,,2154.61,,,,,,,269.28,2154.61,percent of total billed charges,
EGD,8149948,CDM,750,RC,,,,,facility,inpatient,,,1452.00000,421.08000,Aetna,First Health,,1187.74,,,,,,,871.20,1187.74,percent of total billed charges,
EGD,8149948,CDM,750,RC,,,,,facility,outpatient,,,1452.00000,421.08000,Aetna,First Health,,1187.74,,,,,,,523.45,1187.74,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Placement with Esop,7756868,CDM,750,RC,,,,,facility,inpatient,,,5593.00000,1621.97000,Aetna,First Health,,4575.07,,,,,,,3355.80,4575.07,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Placement with Esop,7756868,CDM,750,RC,,,,,facility,outpatient,,,5593.00000,1621.97000,Aetna,First Health,,4575.07,,,,,,,2016.28,4575.07,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Replacement with Es,7756869,CDM,750,RC,,,,,facility,inpatient,,,5593.00000,1621.97000,Aetna,First Health,,4575.07,,,,,,,3355.80,4575.07,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Replacement with Es,7756869,CDM,750,RC,,,,,facility,outpatient,,,5593.00000,1621.97000,Aetna,First Health,,4575.07,,,,,,,2016.28,4575.07,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Replacement without,7756870,CDM,750,RC,,,,,facility,inpatient,,,5593.00000,1621.97000,Aetna,First Health,,4575.07,,,,,,,3355.80,4575.07,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Replacement without,7756870,CDM,750,RC,,,,,facility,outpatient,,,5593.00000,1621.97000,Aetna,First Health,,4575.07,,,,,,,2016.28,4575.07,percent of total billed charges,
Esophageal pH with Impedance Test,8496862,CDM,750,RC,91034,HCPCS,,,facility,inpatient,,,2634.00000,763.86000,Aetna,First Health,,2154.61,,,,,,,1580.40,2154.61,percent of total billed charges,
Esophageal pH with Impedance Test,8496862,CDM,750,RC,91034,HCPCS,,,facility,outpatient,,,2634.00000,763.86000,Aetna,First Health,,2154.61,,,,,,,269.28,2154.61,percent of total billed charges,
Radiofrequency Ablation GI Lab,8414865,CDM,750,RC,,,,,facility,inpatient,,,5695.00000,1651.55000,Aetna,First Health,,4658.51,,,,,,,3417.00,4658.51,percent of total billed charges,
Radiofrequency Ablation GI Lab,8414865,CDM,750,RC,,,,,facility,outpatient,,,5695.00000,1651.55000,Aetna,First Health,,4658.51,,,,,,,2053.05,4658.51,percent of total billed charges,
Upper EUS,9182825,CDM,750,RC,,,,,facility,inpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,3106.80,4235.60,percent of total billed charges,
Upper EUS,9182825,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,1866.67,4235.60,percent of total billed charges,
Lower EUS,9184442,CDM,750,RC,,,,,facility,inpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,3106.80,4235.60,percent of total billed charges,
Lower EUS,9184442,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,1866.67,4235.60,percent of total billed charges,
EUS STENT,9182826,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EUS STENT,9182826,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EUS DILATION,9180597,CDM,750,RC,,,,,facility,inpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,726.00,989.78,percent of total billed charges,
EUS DILATION,9180597,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,989.78,percent of total billed charges,
EUS DILATION,9182827,CDM,750,RC,,,,,facility,inpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,726.00,989.78,percent of total billed charges,
EUS DILATION,9182827,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,989.78,percent of total billed charges,
EUS BIOPSY,9184443,CDM,750,RC,,,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,828.00,1128.84,percent of total billed charges,
EUS BIOPSY,9184443,CDM,750,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,1128.84,percent of total billed charges,
EUS NECROSECTOMY,9184444,CDM,750,RC,,,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,828.00,1128.84,percent of total billed charges,
EUS NECROSECTOMY,9184444,CDM,750,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,1128.84,percent of total billed charges,
EUS CAUTERY,7535999,CDM,750,RC,,,,,facility,inpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,435.60,593.87,percent of total billed charges,
EUS CAUTERY,7535999,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,261.72,593.87,percent of total billed charges,
EUS CAUTERY,9186573,CDM,750,RC,,,,,facility,inpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,435.60,593.87,percent of total billed charges,
EUS CAUTERY,9186573,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,261.72,593.87,percent of total billed charges,
EUD STENT UPPER,9182472,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EUD STENT UPPER,9182472,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
Upper EUS with Stent,9184518,CDM,750,RC,,,,,facility,inpatient,,,6559.00000,1902.11000,Aetna,First Health,,5365.26,,,,,,,3935.40,5365.26,percent of total billed charges,
Upper EUS with Stent,9184518,CDM,750,RC,,,,,facility,outpatient,,,6559.00000,1902.11000,Aetna,First Health,,5365.26,,,,,,,2364.52,5365.26,percent of total billed charges,
Upper EUS With Dilation,9182937,CDM,750,RC,,,,,facility,inpatient,,,6388.00000,1852.52000,Aetna,First Health,,5225.38,,,,,,,3832.80,5225.38,percent of total billed charges,
Upper EUS With Dilation,9182937,CDM,750,RC,,,,,facility,outpatient,,,6388.00000,1852.52000,Aetna,First Health,,5225.38,,,,,,,2302.87,5225.38,percent of total billed charges,
Upper EUS with Dilation,9182938,CDM,750,RC,,,,,facility,inpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,3934.80,5364.44,percent of total billed charges,
Upper EUS with Dilation,9182938,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,2364.16,5364.44,percent of total billed charges,
Upper EUS with Necrosectomy,9182939,CDM,750,RC,,,,,facility,inpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,3934.80,5364.44,percent of total billed charges,
Upper EUS with Necrosectomy,9182939,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,2364.16,5364.44,percent of total billed charges,
EUS NECROSECTOMY UPPER,9186439,CDM,750,RC,,,,,facility,inpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,3934.80,5364.44,percent of total billed charges,
EUS NECROSECTOMY UPPER,9186439,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,2364.16,5364.44,percent of total billed charges,
Upper EUS With Cautery,9184519,CDM,750,RC,,,,,facility,inpatient,,,5904.00000,1712.16000,Aetna,First Health,,4829.47,,,,,,,3542.40,4829.47,percent of total billed charges,
Upper EUS With Cautery,9184519,CDM,750,RC,,,,,facility,outpatient,,,5904.00000,1712.16000,Aetna,First Health,,4829.47,,,,,,,2128.39,4829.47,percent of total billed charges,
Lower EUS With Stent,9182940,CDM,750,RC,,,,,facility,inpatient,,,6559.00000,1902.11000,Aetna,First Health,,5365.26,,,,,,,3935.40,5365.26,percent of total billed charges,
Lower EUS With Stent,9182940,CDM,750,RC,,,,,facility,outpatient,,,6559.00000,1902.11000,Aetna,First Health,,5365.26,,,,,,,2364.52,5365.26,percent of total billed charges,
Lower EUS With Dilation,9182941,CDM,750,RC,,,,,facility,inpatient,,,6388.00000,1852.52000,Aetna,First Health,,5225.38,,,,,,,3832.80,5225.38,percent of total billed charges,
Lower EUS With Dilation,9182941,CDM,750,RC,,,,,facility,outpatient,,,6388.00000,1852.52000,Aetna,First Health,,5225.38,,,,,,,2302.87,5225.38,percent of total billed charges,
Lower EUS With Biopsy,9184520,CDM,750,RC,,,,,facility,inpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,3934.80,5364.44,percent of total billed charges,
Lower EUS With Biopsy,9184520,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,2364.16,5364.44,percent of total billed charges,
Lower EUS With Necrosectomy,9182942,CDM,750,RC,,,,,facility,inpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,3934.80,5364.44,percent of total billed charges,
Lower EUS With Necrosectomy,9182942,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,2364.16,5364.44,percent of total billed charges,
EUS NECROSECTOMY LOWER,9186440,CDM,750,RC,,,,,facility,inpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,3934.80,5364.44,percent of total billed charges,
EUS NECROSECTOMY LOWER,9186440,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,First Health,,5364.44,,,,,,,2364.16,5364.44,percent of total billed charges,
Lower EUS With Cautery,9184521,CDM,750,RC,,,,,facility,inpatient,,,5904.00000,1712.16000,Aetna,First Health,,4829.47,,,,,,,3542.40,4829.47,percent of total billed charges,
Lower EUS With Cautery,9184521,CDM,750,RC,,,,,facility,outpatient,,,5904.00000,1712.16000,Aetna,First Health,,4829.47,,,,,,,2128.39,4829.47,percent of total billed charges,
Neurolysis Celiac Plexus,9196728,CDM,750,RC,,,,,facility,inpatient,,,3063.00000,888.27000,Aetna,First Health,,2505.53,,,,,,,1837.80,2505.53,percent of total billed charges,
Neurolysis Celiac Plexus,9196728,CDM,750,RC,,,,,facility,outpatient,,,3063.00000,888.27000,Aetna,First Health,,2505.53,,,,,,,1104.21,2505.53,percent of total billed charges,
Block Celiac Plexus,9196768,CDM,750,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
Block Celiac Plexus,9196768,CDM,750,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1095.92,2486.72,percent of total billed charges,
CAPSULE ENDOSCOPY,9202443,CDM,750,RC,91110,HCPCS,,,facility,inpatient,,,5067.00000,1469.43000,Aetna,First Health,,4144.81,,,,,,,3040.20,4144.81,percent of total billed charges,
CAPSULE ENDOSCOPY,9202443,CDM,750,RC,91110,HCPCS,,,facility,outpatient,,,5067.00000,1469.43000,Aetna,First Health,,4144.81,,,,,,,682.44,4144.81,percent of total billed charges,
FUNDOPLICATION TRANSORAL INCISIONLESS (TIF),9228447,CDM,750,RC,,,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,5400.00,7362.00,percent of total billed charges,
FUNDOPLICATION TRANSORAL INCISIONLESS (TIF),9228447,CDM,750,RC,,,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
FUNDOPLICATION TRANSORAL INCISIONLESS (TIF),9228448,CDM,750,RC,,,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,5400.00,7362.00,percent of total billed charges,
FUNDOPLICATION TRANSORAL INCISIONLESS (TIF),9228448,CDM,750,RC,,,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,First Health,,7362.00,,,,,,,3244.50,7362.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC GASTRIC (POEM)????????? ??????,9228449,CDM,750,RC,,,,,facility,inpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,8400.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC GASTRIC (POEM)????????? ??????,9228449,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC GASTRIC?(POEM)?????? ????????,9226454,CDM,750,RC,,,,,facility,inpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,8400.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC GASTRIC?(POEM)?????? ????????,9226454,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC ZENKER?S (POEM),9226451,CDM,750,RC,,,,,facility,inpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,8400.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC ZENKER?S (POEM),9226451,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC ZENKER?S (POEM),9226455,CDM,750,RC,,,,,facility,inpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,8400.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC ZENKER?S (POEM),9226455,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC (POEM),9226452,CDM,750,RC,,,,,facility,inpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,8400.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC (POEM),9226452,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC (POEM),9226456,CDM,750,RC,,,,,facility,inpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,8400.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC (POEM),9226456,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC DIVERTICULUM (POEM)?,9226453,CDM,750,RC,,,,,facility,inpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,8400.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC DIVERTICULUM (POEM)?,9226453,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC DIVERTICULUM (POEM)?,9226457,CDM,750,RC,,,,,facility,inpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,8400.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC DIVERTICULUM (POEM)?,9226457,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,First Health,,11452.00,,,,,,,5047.00,11452.00,percent of total billed charges,
EGD W ENDOFLIP,9228463,CDM,750,RC,,,,,facility,inpatient,,,1018.00000,295.22000,Aetna,First Health,,832.72,,,,,,,610.80,832.72,percent of total billed charges,
EGD W ENDOFLIP,9228463,CDM,750,RC,,,,,facility,outpatient,,,1018.00000,295.22000,Aetna,First Health,,832.72,,,,,,,366.99,832.72,percent of total billed charges,
EGD W ENDOFLIP,9228464,CDM,750,RC,,,,,facility,inpatient,,,1018.00000,295.22000,Aetna,First Health,,832.72,,,,,,,610.80,832.72,percent of total billed charges,
EGD W ENDOFLIP,9228464,CDM,750,RC,,,,,facility,outpatient,,,1018.00000,295.22000,Aetna,First Health,,832.72,,,,,,,366.99,832.72,percent of total billed charges,
COLON ENDOSCOPIC SUBMUCOSAL DISSECTION,9226513,CDM,750,RC,,,,,facility,inpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,2071.80,2824.55,percent of total billed charges,
COLON ENDOSCOPIC SUBMUCOSAL DISSECTION,9226513,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,1244.81,2824.55,percent of total billed charges,
COLON ENDOSCOPIC SUBMUCOSAL DISSECTION,9228483,CDM,750,RC,,,,,facility,inpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,2071.80,2824.55,percent of total billed charges,
COLON ENDOSCOPIC SUBMUCOSAL DISSECTION,9228483,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,1244.81,2824.55,percent of total billed charges,
UPPER ENDOSCOPIC SUBMUCOSAL DISSECTION,9228484,CDM,750,RC,,,,,facility,inpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,2071.80,2824.55,percent of total billed charges,
UPPER ENDOSCOPIC SUBMUCOSAL DISSECTION,9228484,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,1244.81,2824.55,percent of total billed charges,
UPPER ENDOSCOPIC SUBMUCOSAL DISSECTION,9226520,CDM,750,RC,,,,,facility,inpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,2071.80,2824.55,percent of total billed charges,
UPPER ENDOSCOPIC SUBMUCOSAL DISSECTION,9226520,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,1244.81,2824.55,percent of total billed charges,
EGD W/ STRICTUREPLASTY,9184486,CDM,750,RC,,,,,facility,inpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,1035.60,1411.87,percent of total billed charges,
EGD W/ STRICTUREPLASTY,9184486,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,622.22,1411.87,percent of total billed charges,
EGD WITH DEBRIDEMENT,9188442,CDM,750,RC,,,,,facility,inpatient,,,3106.00000,900.74000,Aetna,First Health,,2540.71,,,,,,,1863.60,2540.71,percent of total billed charges,
EGD WITH DEBRIDEMENT,9188442,CDM,750,RC,,,,,facility,outpatient,,,3106.00000,900.74000,Aetna,First Health,,2540.71,,,,,,,1119.71,2540.71,percent of total billed charges,
OVERSTITCH,9118499,CDM,750,RC,,,,,facility,inpatient,,,11000.00000,3190.00000,Aetna,First Health,,8998.00,,,,,,,6600.00,8998.00,percent of total billed charges,
OVERSTITCH,9118499,CDM,750,RC,,,,,facility,outpatient,,,11000.00000,3190.00000,Aetna,First Health,,8998.00,,,,,,,3965.50,8998.00,percent of total billed charges,
EGD W OVERSTICH,9206506,CDM,750,RC,,,,,facility,inpatient,,,12583.00000,3649.07000,Aetna,First Health,,10292.89,,,,,,,7549.80,10292.89,percent of total billed charges,
EGD W OVERSTICH,9206506,CDM,750,RC,,,,,facility,outpatient,,,12583.00000,3649.07000,Aetna,First Health,,10292.89,,,,,,,4536.17,10292.89,percent of total billed charges,
EUS CAUTERY UPPER,9188538,CDM,750,RC,,,,,facility,inpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,435.60,593.87,percent of total billed charges,
EUS CAUTERY UPPER,9188538,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,261.72,593.87,percent of total billed charges,
EUS STENT PLACEMENT LOWER,9188536,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EUS STENT PLACEMENT LOWER,9188536,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EUS STENT REMOVAL LOWER,9188537,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EUS STENT REMOVAL LOWER,9188537,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EUS CYSTOGASTROSTOMY,9180586,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EUS CYSTOGASTROSTOMY,9180586,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EUS STENT REMOVAL UPPER,9188520,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EUS STENT REMOVAL UPPER,9188520,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
COLONOSCOPY,9186430,CDM,750,RC,,,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
COLONOSCOPY,9186430,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,778.32,1766.06,percent of total billed charges,
Colonoscopy Screening SN,9210514,CDM,750,RC,,,,,facility,inpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,1295.40,1766.06,percent of total billed charges,
Colonoscopy Screening SN,9210514,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,First Health,,1766.06,,,,,,,778.32,1766.06,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Placement with Esop,9186436,CDM,750,RC,,,,,facility,inpatient,,,5593.00000,1621.97000,Aetna,First Health,,4575.07,,,,,,,3355.80,4575.07,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Placement with Esop,9186436,CDM,750,RC,,,,,facility,outpatient,,,5593.00000,1621.97000,Aetna,First Health,,4575.07,,,,,,,2016.28,4575.07,percent of total billed charges,
Upper Endoscopic Foreign Body Removal,9186438,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
Upper Endoscopic Foreign Body Removal,9186438,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EG STENT PLACEMENT,9188435,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
EG STENT PLACEMENT,9188435,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
EGD,9186433,CDM,750,RC,,,,,facility,inpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,1035.60,1411.87,percent of total billed charges,
EGD,9186433,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,622.22,1411.87,percent of total billed charges,
Enteroscopy,9186431,CDM,750,RC,,,,,facility,inpatient,,,3799.00000,1101.71000,Aetna,First Health,,3107.58,,,,,,,2279.40,3107.58,percent of total billed charges,
Enteroscopy,9186431,CDM,750,RC,,,,,facility,outpatient,,,3799.00000,1101.71000,Aetna,First Health,,3107.58,,,,,,,1369.54,3107.58,percent of total billed charges,
ESOPHAGEAL MANOMETRYR,9188432,CDM,750,RC,91010,HCPCS,,,facility,inpatient,,,2635.00000,764.15000,Aetna,First Health,,2155.43,,,,,,,1581.00,2155.43,percent of total billed charges,
ESOPHAGEAL MANOMETRYR,9188432,CDM,750,RC,91010,HCPCS,,,facility,outpatient,,,2635.00000,764.15000,Aetna,First Health,,2155.43,,,,,,,269.28,2155.43,percent of total billed charges,
PARACENTESIS,9186435,CDM,750,RC,,,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,1656.00,2257.68,percent of total billed charges,
PARACENTESIS,9186435,CDM,750,RC,,,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
SIGMOIDOSCOPY,9188433,CDM,750,RC,,,,,facility,inpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,1035.60,1411.87,percent of total billed charges,
SIGMOIDOSCOPY,9188433,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,622.22,1411.87,percent of total billed charges,
LOWER ENDOSCOPY WITH ULTRASOUND,9186437,CDM,750,RC,,,,,facility,inpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,3106.80,4235.60,percent of total billed charges,
LOWER ENDOSCOPY WITH ULTRASOUND,9186437,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,1866.67,4235.60,percent of total billed charges,
UPPER ENDOSCOPY WITH ULTRASOUND,9188434,CDM,750,RC,,,,,facility,inpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,3106.80,4235.60,percent of total billed charges,
UPPER ENDOSCOPY WITH ULTRASOUND,9188434,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,First Health,,4235.60,,,,,,,1866.67,4235.60,percent of total billed charges,
ERCP,9186845,CDM,750,RC,,,,,facility,inpatient,,,6904.00000,2002.16000,Aetna,First Health,,5647.47,,,,,,,4142.40,5647.47,percent of total billed charges,
ERCP,9186845,CDM,750,RC,,,,,facility,outpatient,,,6904.00000,2002.16000,Aetna,First Health,,5647.47,,,,,,,2488.89,5647.47,percent of total billed charges,
ENTEROSCOPY  BIOPSY,9196830,CDM,750,RC,,,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,828.00,1128.84,percent of total billed charges,
ENTEROSCOPY  BIOPSY,9196830,CDM,750,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,1128.84,percent of total billed charges,
ENTEROSCOPY  CAUTERY,9196831,CDM,750,RC,,,,,facility,inpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,435.60,593.87,percent of total billed charges,
ENTEROSCOPY  CAUTERY,9196831,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,261.72,593.87,percent of total billed charges,
ENTEROSCOPY  DILATION,9196832,CDM,750,RC,,,,,facility,inpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,726.00,989.78,percent of total billed charges,
ENTEROSCOPY  DILATION,9196832,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,989.78,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE BIOPSY,9198527,CDM,750,RC,,,,,facility,inpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,828.00,1128.84,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE BIOPSY,9198527,CDM,750,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,First Health,,1128.84,,,,,,,497.49,1128.84,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE CAUTERY,9196833,CDM,750,RC,,,,,facility,inpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,435.60,593.87,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE CAUTERY,9196833,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,261.72,593.87,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE DILATION,9196834,CDM,750,RC,,,,,facility,inpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,726.00,989.78,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE DILATION,9196834,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,989.78,percent of total billed charges,
EGD CAUTERY,9198528,CDM,750,RC,,,,,facility,inpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,435.60,593.87,percent of total billed charges,
EGD CAUTERY,9198528,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,261.72,593.87,percent of total billed charges,
EGD CAUTERY,9198529,CDM,750,RC,,,,,facility,inpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,435.60,593.87,percent of total billed charges,
EGD CAUTERY,9198529,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,First Health,,593.87,,,,,,,261.72,593.87,percent of total billed charges,
COLONOSCOPY STENT,9196835,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
COLONOSCOPY STENT,9196835,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
COLONOSCOPY STENT,9196836,CDM,750,RC,,,,,facility,inpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,828.60,1129.66,percent of total billed charges,
COLONOSCOPY STENT,9196836,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,First Health,,1129.66,,,,,,,497.85,1129.66,percent of total billed charges,
ENTEROSCOPY WITH BIOPSY,9208477,CDM,750,RC,,,,,facility,inpatient,,,5179.00000,1501.91000,Aetna,First Health,,4236.42,,,,,,,3107.40,4236.42,percent of total billed charges,
ENTEROSCOPY WITH BIOPSY,9208477,CDM,750,RC,,,,,facility,outpatient,,,5179.00000,1501.91000,Aetna,First Health,,4236.42,,,,,,,1867.03,4236.42,percent of total billed charges,
ENTEROSCOPY  WITH CAUTERY,9208478,CDM,750,RC,,,,,facility,inpatient,,,4525.00000,1312.25000,Aetna,First Health,,3701.45,,,,,,,2715.00,3701.45,percent of total billed charges,
ENTEROSCOPY  WITH CAUTERY,9208478,CDM,750,RC,,,,,facility,outpatient,,,4525.00000,1312.25000,Aetna,First Health,,3701.45,,,,,,,1631.26,3701.45,percent of total billed charges,
ENTEROSCOPY WITH DILATION,9206473,CDM,750,RC,,,,,facility,inpatient,,,5009.00000,1452.61000,Aetna,First Health,,4097.36,,,,,,,3005.40,4097.36,percent of total billed charges,
ENTEROSCOPY WITH DILATION,9206473,CDM,750,RC,,,,,facility,outpatient,,,5009.00000,1452.61000,Aetna,First Health,,4097.36,,,,,,,1805.74,4097.36,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE WITH BIOPSY,9208479,CDM,750,RC,,,,,facility,inpatient,,,3106.00000,900.74000,Aetna,First Health,,2540.71,,,,,,,1863.60,2540.71,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE WITH BIOPSY,9208479,CDM,750,RC,,,,,facility,outpatient,,,3106.00000,900.74000,Aetna,First Health,,2540.71,,,,,,,1119.71,2540.71,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE WITH CAUTERY,9206474,CDM,750,RC,,,,,facility,inpatient,,,2452.00000,711.08000,Aetna,First Health,,2005.74,,,,,,,1471.20,2005.74,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE WITH CAUTERY,9206474,CDM,750,RC,,,,,facility,outpatient,,,2452.00000,711.08000,Aetna,First Health,,2005.74,,,,,,,883.95,2005.74,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE WITH DILATION,9206475,CDM,750,RC,,,,,facility,inpatient,,,2936.00000,851.44000,Aetna,First Health,,2401.65,,,,,,,1761.60,2401.65,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE WITH DILATION,9206475,CDM,750,RC,,,,,facility,outpatient,,,2936.00000,851.44000,Aetna,First Health,,2401.65,,,,,,,1058.43,2401.65,percent of total billed charges,
EGD WITH CAUTERY INPATIENT,9206500,CDM,750,RC,,,,,facility,inpatient,,,2452.00000,711.08000,Aetna,First Health,,2005.74,,,,,,,1471.20,2005.74,percent of total billed charges,
EGD WITH CAUTERY INPATIENT,9206500,CDM,750,RC,,,,,facility,outpatient,,,2452.00000,711.08000,Aetna,First Health,,2005.74,,,,,,,883.95,2005.74,percent of total billed charges,
COLONOSCOPY WITH STENT OUTPATIENT,9208480,CDM,750,RC,,,,,facility,inpatient,,,3540.00000,1026.60000,Aetna,First Health,,2895.72,,,,,,,2124.00,2895.72,percent of total billed charges,
COLONOSCOPY WITH STENT OUTPATIENT,9208480,CDM,750,RC,,,,,facility,outpatient,,,3540.00000,1026.60000,Aetna,First Health,,2895.72,,,,,,,1276.17,2895.72,percent of total billed charges,
COLONOSCOPY WITH STENT INPATIENT,9208490,CDM,750,RC,,,,,facility,inpatient,,,3540.00000,1026.60000,Aetna,First Health,,2895.72,,,,,,,2124.00,2895.72,percent of total billed charges,
COLONOSCOPY WITH STENT INPATIENT,9208490,CDM,750,RC,,,,,facility,outpatient,,,3540.00000,1026.60000,Aetna,First Health,,2895.72,,,,,,,1276.17,2895.72,percent of total billed charges,
Endoscopic Mucosal Resection Outpatient,9212530,CDM,750,RC,,,,,facility,inpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,2071.80,2824.55,percent of total billed charges,
Endoscopic Mucosal Resection Outpatient,9212530,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,First Health,,2824.55,,,,,,,1244.81,2824.55,percent of total billed charges,
SIGMOIDOSCOPY,7692025,CDM,750,RC,,,,,facility,inpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,1035.60,1411.87,percent of total billed charges,
SIGMOIDOSCOPY,7692025,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,622.22,1411.87,percent of total billed charges,
COL HEMORRHOID BANDING,7692019,CDM,750,RC,,,,,facility,inpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,697.20,950.52,percent of total billed charges,
COL HEMORRHOID BANDING,7692019,CDM,750,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,First Health,,950.52,,,,,,,418.90,950.52,percent of total billed charges,
ESOPHAGEAL MANOMETRYR,7692021,CDM,750,RC,91010,HCPCS,,,facility,inpatient,,,2635.00000,764.15000,Aetna,First Health,,2155.43,,,,,,,1581.00,2155.43,percent of total billed charges,
ESOPHAGEAL MANOMETRYR,7692021,CDM,750,RC,91010,HCPCS,,,facility,outpatient,,,2635.00000,764.15000,Aetna,First Health,,2155.43,,,,,,,269.28,2155.43,percent of total billed charges,
PH MONITORING,7692026,CDM,750,RC,91034,HCPCS,,,facility,inpatient,,,2316.00000,671.64000,Aetna,First Health,,1894.49,,,,,,,1389.60,1894.49,percent of total billed charges,
PH MONITORING,7692026,CDM,750,RC,91034,HCPCS,,,facility,outpatient,,,2316.00000,671.64000,Aetna,First Health,,1894.49,,,,,,,269.28,1894.49,percent of total billed charges,
LIVER BIOPSY,7691984,CDM,750,RC,,,,,facility,inpatient,,,2901.00000,841.29000,Aetna,First Health,,2373.02,,,,,,,1740.60,2373.02,percent of total billed charges,
LIVER BIOPSY,7691984,CDM,750,RC,,,,,facility,outpatient,,,2901.00000,841.29000,Aetna,First Health,,2373.02,,,,,,,1045.81,2373.02,percent of total billed charges,
ERC SPHINCTEROTOMY,7691992,CDM,750,RC,,,,,facility,inpatient,,,2589.00000,750.81000,Aetna,First Health,,2117.80,,,,,,,1553.40,2117.80,percent of total billed charges,
ERC SPHINCTEROTOMY,7691992,CDM,750,RC,,,,,facility,outpatient,,,2589.00000,750.81000,Aetna,First Health,,2117.80,,,,,,,933.33,2117.80,percent of total billed charges,
EGD WITH TUBE INSERTION,7692010,CDM,750,RC,,,,,facility,inpatient,,,3279.00000,950.91000,Aetna,First Health,,2682.22,,,,,,,1967.40,2682.22,percent of total billed charges,
EGD WITH TUBE INSERTION,7692010,CDM,750,RC,,,,,facility,outpatient,,,3279.00000,950.91000,Aetna,First Health,,2682.22,,,,,,,1182.08,2682.22,percent of total billed charges,
ERC STONE EXTRACTION,7691995,CDM,750,RC,,,,,facility,inpatient,,,3306.00000,958.74000,Aetna,First Health,,2704.31,,,,,,,1983.60,2704.31,percent of total billed charges,
ERC STONE EXTRACTION,7691995,CDM,750,RC,,,,,facility,outpatient,,,3306.00000,958.74000,Aetna,First Health,,2704.31,,,,,,,1191.81,2704.31,percent of total billed charges,
EG PEG TUBE REMOVAL WITH SCOPE,7692011,CDM,750,RC,,,,,facility,inpatient,,,3279.00000,950.91000,Aetna,First Health,,2682.22,,,,,,,1967.40,2682.22,percent of total billed charges,
EG PEG TUBE REMOVAL WITH SCOPE,7692011,CDM,750,RC,,,,,facility,outpatient,,,3279.00000,950.91000,Aetna,First Health,,2682.22,,,,,,,1182.08,2682.22,percent of total billed charges,
PEG TUBE REPLACE SIMPLE,7692017,CDM,750,RC,,,,,facility,inpatient,,,1132.00000,328.28000,Aetna,First Health,,925.98,,,,,,,679.20,925.98,percent of total billed charges,
PEG TUBE REPLACE SIMPLE,7692017,CDM,750,RC,,,,,facility,outpatient,,,1132.00000,328.28000,Aetna,First Health,,925.98,,,,,,,408.09,925.98,percent of total billed charges,
PEG TUBE INSERT,8246768,CDM,750,RC,,,,,facility,inpatient,,,1132.00000,328.28000,Aetna,First Health,,925.98,,,,,,,679.20,925.98,percent of total billed charges,
PEG TUBE INSERT,8246768,CDM,750,RC,,,,,facility,outpatient,,,1132.00000,328.28000,Aetna,First Health,,925.98,,,,,,,408.09,925.98,percent of total billed charges,
EG JEJUNAL TUBE INSERTION,7692012,CDM,750,RC,,,,,facility,inpatient,,,1452.00000,421.08000,Aetna,First Health,,1187.74,,,,,,,871.20,1187.74,percent of total billed charges,
EG JEJUNAL TUBE INSERTION,7692012,CDM,750,RC,,,,,facility,outpatient,,,1452.00000,421.08000,Aetna,First Health,,1187.74,,,,,,,523.45,1187.74,percent of total billed charges,
PARACENTESIS,7692022,CDM,750,RC,,,,,facility,inpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,1656.00,2257.68,percent of total billed charges,
PARACENTESIS,7692022,CDM,750,RC,,,,,facility,outpatient,,,2760.00000,800.40000,Aetna,First Health,,2257.68,,,,,,,994.98,2257.68,percent of total billed charges,
Apply multilayer Compression Lt,8282369,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,LT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply multilayer Compression Lt,8282369,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,LT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Left Dressing,8997128,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,LT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply Multilayer Compression Left Dressing,8997128,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,LT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Rt,8282371,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply Multilayer Compression Rt,8282371,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Right Dressing,8997129,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply Multilayer Compression Right Dressing,8997129,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilat,8282370,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,717.60,978.33,percent of total billed charges,
Apply Multilayer Compression Bilat,8282370,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilateral Dressing,8997127,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,717.60,978.33,percent of total billed charges,
Apply Multilayer Compression Bilateral Dressing,8997127,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,138.56,2860.00,percent of total billed charges,
BLOCK CHARGE,8999490,CDM,761,RC,,,,,facility,inpatient,,,2533.00000,734.57000,Aetna,First Health,,2071.99,,,,,,,1519.80,2071.99,percent of total billed charges,
BLOCK CHARGE,8999490,CDM,761,RC,,,,,facility,outpatient,,,2533.00000,734.57000,Aetna,First Health,,2071.99,,,,,,,100.00,2071.99,percent of total billed charges,
Neg Press Wnd Tx Lt 50Cm,1099798,CDM,761,RC,97605,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Neg Press Wnd Tx Lt 50Cm,1099798,CDM,761,RC,97605,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,32.86,570.15,percent of total billed charges,
Neg Press Wnd Tx Lt 50Cm,7959854,CDM,761,RC,97605,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Neg Press Wnd Tx Lt 50Cm,7959854,CDM,761,RC,97605,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,32.86,570.15,percent of total billed charges,
Neg Press Wnd Tx LT 50CM,8282403,CDM,761,RC,97605,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Neg Press Wnd Tx LT 50CM,8282403,CDM,761,RC,97605,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,32.86,570.15,percent of total billed charges,
Neg Press Wnd Tx Gt 50Cm,1099799,CDM,761,RC,97606,HCPCS,,,facility,inpatient,,,1244.00000,360.76000,Aetna,First Health,,1017.59,,,,,,,746.40,1017.59,percent of total billed charges,
Neg Press Wnd Tx Gt 50Cm,1099799,CDM,761,RC,97606,HCPCS,,,facility,outpatient,,,1244.00000,360.76000,Aetna,First Health,,1017.59,,,,,,,35.39,1066.38,percent of total billed charges,
Neg Press Wnd Tx Gt 50Cm,7959855,CDM,761,RC,97606,HCPCS,,,facility,inpatient,,,1244.00000,360.76000,Aetna,First Health,,1017.59,,,,,,,746.40,1017.59,percent of total billed charges,
Neg Press Wnd Tx Gt 50Cm,7959855,CDM,761,RC,97606,HCPCS,,,facility,outpatient,,,1244.00000,360.76000,Aetna,First Health,,1017.59,,,,,,,35.39,1066.38,percent of total billed charges,
Neg Press Wnd Tx GT 50 CM,8282404,CDM,761,RC,97606,HCPCS,,,facility,inpatient,,,1244.00000,360.76000,Aetna,First Health,,1017.59,,,,,,,746.40,1017.59,percent of total billed charges,
Neg Press Wnd Tx GT 50 CM,8282404,CDM,761,RC,97606,HCPCS,,,facility,outpatient,,,1244.00000,360.76000,Aetna,First Health,,1017.59,,,,,,,35.39,1066.38,percent of total billed charges,
Application Total Contact Cast Rt,1655829,CDM,761,RC,29445,HCPCS,,,facility,inpatient,,,792.00000,229.68000,Aetna,First Health,RT,647.86,,,,,,,475.20,647.86,percent of total billed charges,
Application Total Contact Cast Rt,1655829,CDM,761,RC,29445,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,First Health,RT,647.86,,,,,,,285.52,2860.00,percent of total billed charges,
Application Total Contact Cast Rt,7958320,CDM,761,RC,29445,HCPCS,,,facility,inpatient,,,792.00000,229.68000,Aetna,First Health,RT,647.86,,,,,,,475.20,647.86,percent of total billed charges,
Application Total Contact Cast Rt,7958320,CDM,761,RC,29445,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,First Health,RT,647.86,,,,,,,285.52,2860.00,percent of total billed charges,
Debridement Open Wound First 20Cm,4201842,CDM,761,RC,97597,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Debridement Open Wound First 20Cm,4201842,CDM,761,RC,97597,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,46.38,1717.00,percent of total billed charges,
Debridement Open Wound First 20Cm,7958307,CDM,761,RC,97597,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Debridement Open Wound First 20Cm,7958307,CDM,761,RC,97597,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,46.38,1717.00,percent of total billed charges,
Nonselective Debridement,1792826,CDM,761,RC,97602,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,405.00,552.15,percent of total billed charges,
Nonselective Debridement,1792826,CDM,761,RC,97602,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,100.00,552.15,percent of total billed charges,
Nonselective Debridement,7958319,CDM,761,RC,97602,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,405.00,552.15,percent of total billed charges,
Nonselective Debridement,7958319,CDM,761,RC,97602,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,100.00,552.15,percent of total billed charges,
Nonselective Debridement,8282400,CDM,761,RC,97602,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,405.00,552.15,percent of total billed charges,
Nonselective Debridement,8282400,CDM,761,RC,97602,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,First Health,,552.15,,,,,,,100.00,552.15,percent of total billed charges,
Debridement Open Wound Addl 20 Cm,4205848,CDM,761,RC,97598,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Debridement Open Wound Addl 20 Cm,4205848,CDM,761,RC,97598,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,59.03,1717.00,percent of total billed charges,
Debridement Open Wound Addl 20 Cm,7958309,CDM,761,RC,97598,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Debridement Open Wound Addl 20 Cm,7958309,CDM,761,RC,97598,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,,570.15,,,,,,,59.03,1717.00,percent of total billed charges,
Apply Unna Boot Bilateral,3172898,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,836.40,1140.29,percent of total billed charges,
Apply Unna Boot Bilateral,3172898,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Unna Boot Bilateral,7958330,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,836.40,1140.29,percent of total billed charges,
Apply Unna Boot Bilateral,7958330,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Unna Boot Bilateral,7958336,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,836.40,1140.29,percent of total billed charges,
Apply Unna Boot Bilateral,7958336,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Unna Boot Bilat,8148068,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,836.40,1140.29,percent of total billed charges,
Apply Unna Boot Bilat,8148068,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Unna Boot Bilateral,8282406,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,836.40,1140.29,percent of total billed charges,
Apply Unna Boot Bilateral,8282406,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,138.56,2860.00,percent of total billed charges,
WHC Apply Unna Boot Iimmpregnated Wrap Bilat,8411618,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,836.40,1140.29,percent of total billed charges,
WHC Apply Unna Boot Iimmpregnated Wrap Bilat,8411618,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Una Boot Impregnated Wrap Bilat,8411856,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,836.40,1140.29,percent of total billed charges,
Apply Una Boot Impregnated Wrap Bilat,8411856,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,First Health,,1140.29,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Multilayer Compression Rt,3172899,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply Multilayer Compression Rt,3172899,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Rt,7935309,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply Multilayer Compression Rt,7935309,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Rt,7958338,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply Multilayer Compression Rt,7958338,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Rt,8148228,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply Multilayer Compression Rt,8148228,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Unil,8282407,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply Multilayer Compression Unil,8282407,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,RT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilat,3172900,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,717.60,978.33,percent of total billed charges,
Apply Multilayer Compression Bilat,3172900,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilat,7958342,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,717.60,978.33,percent of total billed charges,
Apply Multilayer Compression Bilat,7958342,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilat,8148067,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,717.60,978.33,percent of total billed charges,
Apply Multilayer Compression Bilat,8148067,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilateral,8282408,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,717.60,978.33,percent of total billed charges,
Apply Multilayer Compression Bilateral,8282408,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,First Health,,978.33,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Unna Boot Rt,7935311,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Apply Unna Boot Rt,7935311,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Rt,7958326,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Apply Unna Boot Rt,7958326,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Rt,7958332,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Apply Unna Boot Rt,7958332,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Unilateral,8282405,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Apply Unna Boot Unilateral,8282405,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
WHC Apply Unna Boot Impregnated Wrap RT,8411614,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
WHC Apply Unna Boot Impregnated Wrap RT,8411614,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Impregnated Wrap RT,8411858,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Apply Unna Boot Impregnated Wrap RT,8411858,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,RT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
Neg Press Wnd Tx W Pico Lt 50Cm,7917314,CDM,761,RC,97607,HCPCS,,,facility,inpatient,,,1188.00000,344.52000,Aetna,First Health,,971.78,,,,,,,712.80,971.78,percent of total billed charges,
Neg Press Wnd Tx W Pico Lt 50Cm,7917314,CDM,761,RC,97607,HCPCS,,,facility,outpatient,,,1188.00000,344.52000,Aetna,First Health,,971.78,,,,,,,100.00,1066.38,percent of total billed charges,
Neg Press Wnd Tx W Pico Lt 50Cm,7959856,CDM,761,RC,97607,HCPCS,,,facility,inpatient,,,1188.00000,344.52000,Aetna,First Health,,971.78,,,,,,,712.80,971.78,percent of total billed charges,
Neg Press Wnd Tx W Pico Lt 50Cm,7959856,CDM,761,RC,97607,HCPCS,,,facility,outpatient,,,1188.00000,344.52000,Aetna,First Health,,971.78,,,,,,,100.00,1066.38,percent of total billed charges,
Neg Press Wnd Tx W Incisional Wound Bac LT 50 CM,8282401,CDM,761,RC,97607,HCPCS,,,facility,inpatient,,,1188.00000,344.52000,Aetna,First Health,,971.78,,,,,,,712.80,971.78,percent of total billed charges,
Neg Press Wnd Tx W Incisional Wound Bac LT 50 CM,8282401,CDM,761,RC,97607,HCPCS,,,facility,outpatient,,,1188.00000,344.52000,Aetna,First Health,,971.78,,,,,,,100.00,1066.38,percent of total billed charges,
Neg Press Wnd Tx W Pico Gt 50Cm,7917315,CDM,761,RC,97608,HCPCS,,,facility,inpatient,,,1213.00000,351.77000,Aetna,First Health,,992.23,,,,,,,727.80,992.23,percent of total billed charges,
Neg Press Wnd Tx W Pico Gt 50Cm,7917315,CDM,761,RC,97608,HCPCS,,,facility,outpatient,,,1213.00000,351.77000,Aetna,First Health,,992.23,,,,,,,100.00,1066.38,percent of total billed charges,
Neg Press Wnd Tx W Pico Gt 50Cm,7959857,CDM,761,RC,97608,HCPCS,,,facility,inpatient,,,1213.00000,351.77000,Aetna,First Health,,992.23,,,,,,,727.80,992.23,percent of total billed charges,
Neg Press Wnd Tx W Pico Gt 50Cm,7959857,CDM,761,RC,97608,HCPCS,,,facility,outpatient,,,1213.00000,351.77000,Aetna,First Health,,992.23,,,,,,,100.00,1066.38,percent of total billed charges,
Negative pressure wound tx with incisional wound greater,8298387,CDM,761,RC,97608,HCPCS,,,facility,inpatient,,,1213.00000,351.77000,Aetna,First Health,,992.23,,,,,,,727.80,992.23,percent of total billed charges,
Negative pressure wound tx with incisional wound greater,8298387,CDM,761,RC,97608,HCPCS,,,facility,outpatient,,,1213.00000,351.77000,Aetna,First Health,,992.23,,,,,,,100.00,1066.38,percent of total billed charges,
Apply Unna Boot Lt,7935312,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,LT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Apply Unna Boot Lt,7935312,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,LT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Lt,7958328,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,LT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Apply Unna Boot Lt,7958328,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,LT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Lt,7958334,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,LT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Apply Unna Boot Lt,7958334,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,LT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
WHC Apply Unna Boot Impregnated Wrap LT,8411616,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,LT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
WHC Apply Unna Boot Impregnated Wrap LT,8411616,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,LT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Una Boot Impregnated Wrap LT,8411857,CDM,761,RC,29580,HCPCS,,,facility,inpatient,,,697.00000,202.13000,Aetna,First Health,LT,570.15,,,,,,,418.20,570.15,percent of total billed charges,
Apply Una Boot Impregnated Wrap LT,8411857,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,First Health,LT,570.15,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Lt,7935310,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,LT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply Multilayer Compression Lt,7935310,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,LT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Lt,7958340,CDM,761,RC,29581,HCPCS,,,facility,inpatient,,,598.00000,173.42000,Aetna,First Health,LT,489.16,,,,,,,358.80,489.16,percent of total billed charges,
Apply Multilayer Compression Lt,7958340,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,First Health,LT,489.16,,,,,,,207.83,2860.00,percent of total billed charges,
Application Total Contact Cast Bilat,7958324,CDM,761,RC,29445,HCPCS,,,facility,inpatient,,,1584.00000,459.36000,Aetna,First Health,,1295.71,,,,,,,950.40,1295.71,percent of total billed charges,
Application Total Contact Cast Bilat,7958324,CDM,761,RC,29445,HCPCS,,,facility,outpatient,,,1584.00000,459.36000,Aetna,First Health,,1295.71,,,,,,,233.19,2860.00,percent of total billed charges,
GENICULAR NERVE BLOCK,7902230,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
GENICULAR NERVE BLOCK,7902230,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
Pain Mgmt Px w Fluoro bce,8151063,CDM,761,RC,,,,,facility,inpatient,,,4140.00000,1200.60000,Aetna,First Health,,3386.52,,,,,,,2484.00,3386.52,percent of total billed charges,
Pain Mgmt Px w Fluoro bce,8151063,CDM,761,RC,,,,,facility,outpatient,,,4140.00000,1200.60000,Aetna,First Health,,3386.52,,,,,,,100.00,3386.52,percent of total billed charges,
Pain Management Block,8151452,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
Pain Management Block,8151452,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
PMS ASPIRATION FLUID,8388545,CDM,761,RC,,,,,facility,inpatient,,,1508.00000,437.32000,Aetna,First Health,,1233.54,,,,,,,904.80,1233.54,percent of total billed charges,
PMS ASPIRATION FLUID,8388545,CDM,761,RC,,,,,facility,outpatient,,,1508.00000,437.32000,Aetna,First Health,,1233.54,,,,,,,100.00,1233.54,percent of total billed charges,
BLOCK OBTURATOR AND FEMORAL NERVE,8152281,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK OBTURATOR AND FEMORAL NERVE,8152281,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
Injection Sternal Costalcondral Joint,7882891,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
Injection Sternal Costalcondral Joint,7882891,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
Ultrasound Guidance SN,8999446,CDM,761,RC,,,,,facility,inpatient,,,1358.00000,393.82000,Aetna,First Health,,1110.84,,,,,,,814.80,1110.84,percent of total billed charges,
Ultrasound Guidance SN,8999446,CDM,761,RC,,,,,facility,outpatient,,,1358.00000,393.82000,Aetna,First Health,,1110.84,,,,,,,100.00,1110.84,percent of total billed charges,
Medial Nerve Block Bilat,9182680,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
Medial Nerve Block Bilat,9182680,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
PMS RADIOFREQUENCY ABLATION BILAT,9182681,CDM,761,RC,,,,,facility,inpatient,,,12540.00000,3636.60000,Aetna,First Health,,10257.72,,,,,,,7524.00,10257.72,percent of total billed charges,
PMS RADIOFREQUENCY ABLATION BILAT,9182681,CDM,761,RC,,,,,facility,outpatient,,,12540.00000,3636.60000,Aetna,First Health,,10257.72,,,,,,,100.00,10257.72,percent of total billed charges,
PMS TRANSFORMINAL INJECTION BILAT,9180801,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
PMS TRANSFORMINAL INJECTION BILAT,9180801,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
SI JOINT INJECTION BILAT,9182682,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
SI JOINT INJECTION BILAT,9182682,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
HIP INJECTION BILAT,9180802,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
HIP INJECTION BILAT,9180802,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
FACET JOINT INJECTION BILAT,9182683,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
FACET JOINT INJECTION BILAT,9182683,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
CELIAC PEXUS BLOCK BILAT,9182684,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
CELIAC PEXUS BLOCK BILAT,9182684,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
GENICULAR NERVE BLOCK BILAT,9180803,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
GENICULAR NERVE BLOCK BILAT,9180803,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
OCCIPITAL NERVE BLOCK BILAT,9182685,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
OCCIPITAL NERVE BLOCK BILAT,9182685,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
SELECTIVE NERVE ROOT INJECTION BILAT,9182686,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
SELECTIVE NERVE ROOT INJECTION BILAT,9182686,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
BURSA BLOCK BILAT,9182687,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
BURSA BLOCK BILAT,9182687,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
KNEE INJECTION BILAT,9180804,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
KNEE INJECTION BILAT,9180804,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
Ilioiinguinal Nerve Block Bilat,9192510,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
Ilioiinguinal Nerve Block Bilat,9192510,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
Coccygeal Joint Injection Bilat,9194523,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
Coccygeal Joint Injection Bilat,9194523,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
Shoulder Injection Bilat,9194524,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
Shoulder Injection Bilat,9194524,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
Thermal Ablation Each Additional Vertebral Body,9046250,CDM,761,RC,,,,,facility,inpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,2880.00,3926.40,percent of total billed charges,
Thermal Ablation Each Additional Vertebral Body,9046250,CDM,761,RC,,,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,First Health,,3926.40,,,,,,,100.00,3926.40,percent of total billed charges,
NEUROSURGICAL PROCEDURE KIT,9042872,CDM,761,RC,C1889,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,1860.00,2535.80,percent of total billed charges,
NEUROSURGICAL PROCEDURE KIT,9042872,CDM,761,RC,C1889,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,First Health,,2535.80,,,,,,,100.00,2535.80,percent of total billed charges,
PAIN NERVE STIMULATION,9060237,CDM,761,RC,,,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,12960.00,17668.80,percent of total billed charges,
PAIN NERVE STIMULATION,9060237,CDM,761,RC,,,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,100.00,17668.80,percent of total billed charges,
INTRACEPT,9046199,CDM,761,RC,,,,,facility,inpatient,,,19200.00000,5568.00000,Aetna,First Health,,15705.60,,,,,,,11520.00,15705.60,percent of total billed charges,
INTRACEPT,9046199,CDM,761,RC,,,,,facility,outpatient,,,19200.00000,5568.00000,Aetna,First Health,,15705.60,,,,,,,100.00,15705.60,percent of total billed charges,
PAIN MANAGEMENT FLUORO IMAGING,9228443,CDM,761,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
PAIN MANAGEMENT FLUORO IMAGING,9228443,CDM,761,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,100.00,981.60,percent of total billed charges,
UNILATERAL JOINT BLOCK,9222435,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL JOINT BLOCK,9222435,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
JOINT BLOCK BILATERAL,9220565,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
JOINT BLOCK BILATERAL,9220565,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
PERIFORMIS INJECTION,7692062,CDM,761,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
PERIFORMIS INJECTION,7692062,CDM,761,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,100.00,3435.60,percent of total billed charges,
KNEE INJECTION,7692088,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
KNEE INJECTION,7692088,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
FEMORAL NERVE BLOCK,7764039,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
FEMORAL NERVE BLOCK,7764039,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
BLOOD PATCH,7692078,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOOD PATCH,7692078,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
SYMPATHETIC NERVE BLOCK,7692060,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
SYMPATHETIC NERVE BLOCK,7692060,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
Block Thoracic Sympathetic,7965420,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
Block Thoracic Sympathetic,7965420,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
CERVICAL EPIDURAL BLOCK,7692081,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
CERVICAL EPIDURAL BLOCK,7692081,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
LUMBAR EPIDURAL BLOCK,7692082,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
LUMBAR EPIDURAL BLOCK,7692082,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
THORACIC EPIDURAL BLOCK,7692083,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
THORACIC EPIDURAL BLOCK,7692083,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
CAUDAL EPIDURAL BLOCK,7692080,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
CAUDAL EPIDURAL BLOCK,7692080,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
OCCIPITAL NERVE BLOCK,7692048,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
OCCIPITAL NERVE BLOCK,7692048,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
OCCIPITAL NERVE BLOCK,7692061,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
OCCIPITAL NERVE BLOCK,7692061,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
TRIGEMINAL NERVE BLOCK,7692065,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
TRIGEMINAL NERVE BLOCK,7692065,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
ILIOIINGUINAL NERVE BLOCK,7692056,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
ILIOIINGUINAL NERVE BLOCK,7692056,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
STELLATE BLOCK,7692064,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
STELLATE BLOCK,7692064,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
INTERSCALENE BLOCK,7692058,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
INTERSCALENE BLOCK,7692058,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
INTERCOSTAL BLOCK,7692057,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
INTERCOSTAL BLOCK,7692057,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
FACET JOINT INJECTION,7692053,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
FACET JOINT INJECTION,7692053,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
INTRATHECAL INJECTION,7692087,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
INTRATHECAL INJECTION,7692087,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
ABLATION,7692098,CDM,761,RC,,,,,facility,inpatient,,,6270.00000,1818.30000,Aetna,First Health,,5128.86,,,,,,,3762.00,5128.86,percent of total billed charges,
ABLATION,7692098,CDM,761,RC,,,,,facility,outpatient,,,6270.00000,1818.30000,Aetna,First Health,,5128.86,,,,,,,100.00,5128.86,percent of total billed charges,
PMS RADIOFREQUENCY ABLATION,7692099,CDM,761,RC,,,,,facility,inpatient,,,6270.00000,1818.30000,Aetna,First Health,,5128.86,,,,,,,3762.00,5128.86,percent of total billed charges,
PMS RADIOFREQUENCY ABLATION,7692099,CDM,761,RC,,,,,facility,outpatient,,,6270.00000,1818.30000,Aetna,First Health,,5128.86,,,,,,,100.00,5128.86,percent of total billed charges,
PMS TRANSFORMINAL INJECTION,7692084,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
PMS TRANSFORMINAL INJECTION,7692084,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
PMS TRANSFORMINAL NERVE INJECTION,7966345,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
PMS TRANSFORMINAL NERVE INJECTION,7966345,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
MEDIAL NERVE BLOCK,7691978,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
MEDIAL NERVE BLOCK,7691978,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
PMS MEDIAL NERVE INJECTION,7966342,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
PMS MEDIAL NERVE INJECTION,7966342,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
SELECTIVE NERVE ROOT INJECTION,7692063,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
SELECTIVE NERVE ROOT INJECTION,7692063,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
CELIAC PEXUS BLOCK,7692052,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
CELIAC PEXUS BLOCK,7692052,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
ANALYZE PUMP WO PROGRAMMING,7692069,CDM,761,RC,,,,,facility,inpatient,,,960.00000,278.40000,Aetna,First Health,,785.28,,,,,,,576.00,785.28,percent of total billed charges,
ANALYZE PUMP WO PROGRAMMING,7692069,CDM,761,RC,,,,,facility,outpatient,,,960.00000,278.40000,Aetna,First Health,,785.28,,,,,,,100.00,785.28,percent of total billed charges,
VERTEBROPLASTY,7692105,CDM,761,RC,22510,HCPCS,,,facility,inpatient,,,32252.00000,9353.08000,Aetna,First Health,,26382.14,,,,,,,19351.20,26382.14,percent of total billed charges,
VERTEBROPLASTY,7692105,CDM,761,RC,22510,HCPCS,,,facility,outpatient,,,32252.00000,9353.08000,Aetna,First Health,,26382.14,,,,,,,2848.95,26382.14,percent of total billed charges,
ANALYZE PUMP WITH PROGRAMMING,7692072,CDM,761,RC,,,,,facility,inpatient,,,1398.00000,405.42000,Aetna,First Health,,1143.56,,,,,,,838.80,1143.56,percent of total billed charges,
ANALYZE PUMP WITH PROGRAMMING,7692072,CDM,761,RC,,,,,facility,outpatient,,,1398.00000,405.42000,Aetna,First Health,,1143.56,,,,,,,100.00,1143.56,percent of total billed charges,
HIP INJECTION,7692054,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
HIP INJECTION,7692054,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
EPIDURAL CATHETER INSERTION,7692096,CDM,761,RC,,,,,facility,inpatient,,,7111.00000,2062.19000,Aetna,First Health,,5816.80,,,,,,,4266.60,5816.80,percent of total billed charges,
EPIDURAL CATHETER INSERTION,7692096,CDM,761,RC,,,,,facility,outpatient,,,7111.00000,2062.19000,Aetna,First Health,,5816.80,,,,,,,100.00,5816.80,percent of total billed charges,
SHOULDER INJECTION,7692100,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
SHOULDER INJECTION,7692100,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
INSERT TEMP SPINAL STIM,7692086,CDM,761,RC,,,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,12960.00,17668.80,percent of total billed charges,
INSERT TEMP SPINAL STIM,7692086,CDM,761,RC,,,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,100.00,17668.80,percent of total billed charges,
INSERT TEMP SPINAL STIM,7692095,CDM,761,RC,,,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,12960.00,17668.80,percent of total billed charges,
INSERT TEMP SPINAL STIM,7692095,CDM,761,RC,,,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,First Health,,17668.80,,,,,,,100.00,17668.80,percent of total billed charges,
PMS VERTEBROPLASTY ADDTL LEVEL,7742108,CDM,761,RC,,,,,facility,inpatient,,,13943.00000,4043.47000,Aetna,First Health,,11405.37,,,,,,,8365.80,11405.37,percent of total billed charges,
PMS VERTEBROPLASTY ADDTL LEVEL,7742108,CDM,761,RC,,,,,facility,outpatient,,,13943.00000,4043.47000,Aetna,First Health,,11405.37,,,,,,,100.00,11405.37,percent of total billed charges,
PMS ABLATION ADDL,7742107,CDM,761,RC,,,,,facility,inpatient,,,5320.00000,1542.80000,Aetna,First Health,,4351.76,,,,,,,3192.00,4351.76,percent of total billed charges,
PMS ABLATION ADDL,7742107,CDM,761,RC,,,,,facility,outpatient,,,5320.00000,1542.80000,Aetna,First Health,,4351.76,,,,,,,100.00,4351.76,percent of total billed charges,
DISCOGRAM,7692066,CDM,761,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
DISCOGRAM,7692066,CDM,761,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,100.00,3435.60,percent of total billed charges,
DISCOGRAM,7692090,CDM,761,RC,62290,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
DISCOGRAM,7692090,CDM,761,RC,62290,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,1514.10,3435.60,percent of total billed charges,
DISCOGRAM,7692104,CDM,761,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
DISCOGRAM,7692104,CDM,761,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,100.00,3435.60,percent of total billed charges,
Injection for Discogram,8147111,CDM,761,RC,,,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,2520.00,3435.60,percent of total billed charges,
Injection for Discogram,8147111,CDM,761,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,First Health,,3435.60,,,,,,,100.00,3435.60,percent of total billed charges,
MILD PROCEDURE BILAT INIT,7692092,CDM,761,RC,,,,,facility,inpatient,,,22800.00000,6612.00000,Aetna,First Health,,18650.40,,,,,,,13680.00,18650.40,percent of total billed charges,
MILD PROCEDURE BILAT INIT,7692092,CDM,761,RC,,,,,facility,outpatient,,,22800.00000,6612.00000,Aetna,First Health,,18650.40,,,,,,,100.00,18650.40,percent of total billed charges,
PMS MILD PROCEDURE BILAT ADDTL,7742105,CDM,761,RC,,,,,facility,inpatient,,,16337.00000,4737.73000,Aetna,First Health,,13363.67,,,,,,,9802.20,13363.67,percent of total billed charges,
PMS MILD PROCEDURE BILAT ADDTL,7742105,CDM,761,RC,,,,,facility,outpatient,,,16337.00000,4737.73000,Aetna,First Health,,13363.67,,,,,,,100.00,13363.67,percent of total billed charges,
MILD PROCEDURE UNILAT INITIAL,7692093,CDM,761,RC,,,,,facility,inpatient,,,11400.00000,3306.00000,Aetna,First Health,,9325.20,,,,,,,6840.00,9325.20,percent of total billed charges,
MILD PROCEDURE UNILAT INITIAL,7692093,CDM,761,RC,,,,,facility,outpatient,,,11400.00000,3306.00000,Aetna,First Health,,9325.20,,,,,,,100.00,9325.20,percent of total billed charges,
PMS MILD PROCEDURE UNILAT ADDTL,7742106,CDM,761,RC,C1889,HCPCS,,,facility,inpatient,,,8168.00000,2368.72000,Aetna,First Health,,6681.42,,,,,,,4900.80,6681.42,percent of total billed charges,
PMS MILD PROCEDURE UNILAT ADDTL,7742106,CDM,761,RC,C1889,HCPCS,,,facility,outpatient,,,8168.00000,2368.72000,Aetna,First Health,,6681.42,,,,,,,100.00,6681.42,percent of total billed charges,
PMS DISCOGRAM ADDITIONAL LEVEL,7742103,CDM,761,RC,,,,,facility,inpatient,,,2470.00000,716.30000,Aetna,First Health,,2020.46,,,,,,,1482.00,2020.46,percent of total billed charges,
PMS DISCOGRAM ADDITIONAL LEVEL,7742103,CDM,761,RC,,,,,facility,outpatient,,,2470.00000,716.30000,Aetna,First Health,,2020.46,,,,,,,100.00,2020.46,percent of total billed charges,
PMS KYPHOPLASTY ADDITIONAL LEVEL,7742104,CDM,761,RC,,,,,facility,inpatient,,,17570.00000,5095.30000,Aetna,First Health,,14372.26,,,,,,,10542.00,14372.26,percent of total billed charges,
PMS KYPHOPLASTY ADDITIONAL LEVEL,7742104,CDM,761,RC,,,,,facility,outpatient,,,17570.00000,5095.30000,Aetna,First Health,,14372.26,,,,,,,100.00,14372.26,percent of total billed charges,
PMS ADDITIONAL LEVEL,7703402,CDM,761,RC,,,,,facility,inpatient,,,1518.00000,440.22000,Aetna,First Health,,1241.72,,,,,,,910.80,1241.72,percent of total billed charges,
PMS ADDITIONAL LEVEL,7703402,CDM,761,RC,,,,,facility,outpatient,,,1518.00000,440.22000,Aetna,First Health,,1241.72,,,,,,,100.00,1241.72,percent of total billed charges,
COCCYGEAL JOINT INJECTION,7692074,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
COCCYGEAL JOINT INJECTION,7692074,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
CLINIC PUMP DYE STUDY,7692071,CDM,761,RC,G0463,HCPCS,,,facility,inpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,156.60,213.50,percent of total billed charges,
CLINIC PUMP DYE STUDY,7692071,CDM,761,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,First Health,,213.50,,,,,,,96.88,343.96,percent of total billed charges,
GANGLIA IMPAR BLOCK,7692077,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
GANGLIA IMPAR BLOCK,7692077,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
ILEOINGUINAL HYPOGAST BLOCK,7692055,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
ILEOINGUINAL HYPOGAST BLOCK,7692055,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
ILEOINGUINAL HYPOGAST BLOCK,7692103,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
ILEOINGUINAL HYPOGAST BLOCK,7692103,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
ANALYZE AND REFILL PUMP,7692073,CDM,761,RC,,,,,facility,inpatient,,,1710.00000,495.90000,Aetna,First Health,,1398.78,,,,,,,1026.00,1398.78,percent of total billed charges,
ANALYZE AND REFILL PUMP,7692073,CDM,761,RC,,,,,facility,outpatient,,,1710.00000,495.90000,Aetna,First Health,,1398.78,,,,,,,100.00,1398.78,percent of total billed charges,
KYPHOPLASTY,7692089,CDM,761,RC,,,,,facility,inpatient,,,22800.00000,6612.00000,Aetna,First Health,,18650.40,,,,,,,13680.00,18650.40,percent of total billed charges,
KYPHOPLASTY,7692089,CDM,761,RC,,,,,facility,outpatient,,,22800.00000,6612.00000,Aetna,First Health,,18650.40,,,,,,,100.00,18650.40,percent of total billed charges,
EPIDURAL CATHETER INJECTION,7692075,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
EPIDURAL CATHETER INJECTION,7692075,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
SI JOINT INJECTION,7692079,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
SI JOINT INJECTION,7692079,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
PMS SI JOINT INJECTION,7966344,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
PMS SI JOINT INJECTION,7966344,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
BIER BLOCK,7692050,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BIER BLOCK,7692050,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
BURSA BLOCK,7692051,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BURSA BLOCK,7692051,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
JOINT BLOCK,7692059,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
JOINT BLOCK,7692059,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
JOINT BLOCK,7692102,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
JOINT BLOCK,7692102,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
SPHENOPALATINE BLOCK,7692101,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
SPHENOPALATINE BLOCK,7692101,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
ANKLE INJECTION,7692049,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
ANKLE INJECTION,7692049,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
EPIDURAL WITH RACZ,7692076,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
EPIDURAL WITH RACZ,7692076,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
INSERT PUMP TRIAL INTRATHECAL,7692097,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
INSERT PUMP TRIAL INTRATHECAL,7692097,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
ABLATION COOLED,7744602,CDM,761,RC,,,,,facility,inpatient,,,9500.00000,2755.00000,Aetna,First Health,,7771.00,,,,,,,5700.00,7771.00,percent of total billed charges,
ABLATION COOLED,7744602,CDM,761,RC,,,,,facility,outpatient,,,9500.00000,2755.00000,Aetna,First Health,,7771.00,,,,,,,100.00,7771.00,percent of total billed charges,
PMS ABLATION COOLED,8413679,CDM,761,RC,,,,,facility,inpatient,,,9500.00000,2755.00000,Aetna,First Health,,7771.00,,,,,,,5700.00,7771.00,percent of total billed charges,
PMS ABLATION COOLED,8413679,CDM,761,RC,,,,,facility,outpatient,,,9500.00000,2755.00000,Aetna,First Health,,7771.00,,,,,,,100.00,7771.00,percent of total billed charges,
UNILATERAL MEDIAL NERVE BLOCK,9198672,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL MEDIAL NERVE BLOCK,9198672,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL PMS RADIOFREQUENCY ABLATION,9198673,CDM,761,RC,,,,,facility,inpatient,,,6270.00000,1818.30000,Aetna,First Health,,5128.86,,,,,,,3762.00,5128.86,percent of total billed charges,
UNILATERAL PMS RADIOFREQUENCY ABLATION,9198673,CDM,761,RC,,,,,facility,outpatient,,,6270.00000,1818.30000,Aetna,First Health,,5128.86,,,,,,,100.00,5128.86,percent of total billed charges,
Unilateral PMS Transforminal Injection,9198680,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
Unilateral PMS Transforminal Injection,9198680,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL SI JOINT INJECTION,9198681,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL SI JOINT INJECTION,9198681,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL HIP INJECTION,9198682,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL HIP INJECTION,9198682,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL FACET JOINT INJECTION,9198674,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL FACET JOINT INJECTION,9198674,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL CELIAC PEXUS BLOCK,9198683,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL CELIAC PEXUS BLOCK,9198683,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL GENICULAR NERVE BLOCK,9198675,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL GENICULAR NERVE BLOCK,9198675,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL OCCIPITAL NERVE BLOCK,9198676,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL OCCIPITAL NERVE BLOCK,9198676,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL SELECTIVE NERVE ROOT INJECTION,9198684,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL SELECTIVE NERVE ROOT INJECTION,9198684,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL BURSA BLOCK,9198685,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL BURSA BLOCK,9198685,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL KNEE INJECTION,9198677,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL KNEE INJECTION,9198677,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL ILIOIINGUINAL NERVE BLOCK,9198678,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL ILIOIINGUINAL NERVE BLOCK,9198678,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL COCCYGEAL JOINT INJECTION,9198679,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
UNILATERAL COCCYGEAL JOINT INJECTION,9198679,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
Unilateral Shoulder Injection,9198686,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
Unilateral Shoulder Injection,9198686,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
MEDIAL NERVE BLOCK  BILATERAL,9212560,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
MEDIAL NERVE BLOCK  BILATERAL,9212560,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
PMS RADIOFREQUENCY ABALATION  BILATERAL,9210618,CDM,761,RC,,,,,facility,inpatient,,,12540.00000,3636.60000,Aetna,First Health,,10257.72,,,,,,,7524.00,10257.72,percent of total billed charges,
PMS RADIOFREQUENCY ABALATION  BILATERAL,9210618,CDM,761,RC,,,,,facility,outpatient,,,12540.00000,3636.60000,Aetna,First Health,,10257.72,,,,,,,100.00,10257.72,percent of total billed charges,
PMS TRANSFORMINAL INJECTION  BILATERAL,9212561,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
PMS TRANSFORMINAL INJECTION  BILATERAL,9212561,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
SI JOINT INJECTION  BILATERAL,9212562,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
SI JOINT INJECTION  BILATERAL,9212562,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
HIP INJECTION  BILATERAL,9212563,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
HIP INJECTION  BILATERAL,9212563,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
FACET JOINT INJECTION  BILATERAL,9210619,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
FACET JOINT INJECTION  BILATERAL,9210619,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
CELIAC PEXUS BLOCK  BILATERAL,9212564,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
CELIAC PEXUS BLOCK  BILATERAL,9212564,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
GENICULAR NERVE BLOCK  BILATERAL,9210620,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
GENICULAR NERVE BLOCK  BILATERAL,9210620,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
OCCIPITAL NERVE BLOCK  BILATERAL,9210621,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
OCCIPITAL NERVE BLOCK  BILATERAL,9210621,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
SELECTIVE NERVE ROOT INJECTION  BILATERAL,9212565,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
SELECTIVE NERVE ROOT INJECTION  BILATERAL,9212565,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
BURSA BLOCK  BILATERAL,9212566,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
BURSA BLOCK  BILATERAL,9212566,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
KNEE INJECTION  BILATERAL,9212567,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
KNEE INJECTION  BILATERAL,9212567,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
ILIOIINGUINAL NERVE BLOCK  BILATERAL,9212568,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
ILIOIINGUINAL NERVE BLOCK  BILATERAL,9212568,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
COCCYGEAL JOINT INJECTION  BILATERAL,9210622,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
COCCYGEAL JOINT INJECTION  BILATERAL,9210622,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
SHOULDER INJECTION  BILATERAL,9210623,CDM,761,RC,,,,,facility,inpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,3648.00,4973.44,percent of total billed charges,
SHOULDER INJECTION  BILATERAL,9210623,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,First Health,,4973.44,,,,,,,100.00,4973.44,percent of total billed charges,
BLOCK CHARGE RECTUS SHEATH,8414116,CDM,761,RC,,,,,facility,inpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,1824.00,2486.72,percent of total billed charges,
BLOCK CHARGE RECTUS SHEATH,8414116,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,First Health,,2486.72,,,,,,,100.00,2486.72,percent of total billed charges,
RA Steroid Injection Right,7943878,CDM,761,RC,,,,,facility,inpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,1760.40,2400.01,percent of total billed charges,
RA Steroid Injection Right,7943878,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,100.00,2400.01,percent of total billed charges,
RA Steroid Injection Left,7943882,CDM,761,RC,,,,,facility,inpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,1760.40,2400.01,percent of total billed charges,
RA Steroid Injection Left,7943882,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,100.00,2400.01,percent of total billed charges,
RA Steroid Injection Right,7943886,CDM,761,RC,,,,,facility,inpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,1760.40,2400.01,percent of total billed charges,
RA Steroid Injection Right,7943886,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,100.00,2400.01,percent of total billed charges,
RA Steroid Injection,7957052,CDM,761,RC,,,,,facility,inpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,1760.40,2400.01,percent of total billed charges,
RA Steroid Injection,7957052,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,100.00,2400.01,percent of total billed charges,
RA Steroid Injection,7957054,CDM,761,RC,,,,,facility,inpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,1760.40,2400.01,percent of total billed charges,
RA Steroid Injection,7957054,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,100.00,2400.01,percent of total billed charges,
RA Steroid Injection Left,8147184,CDM,761,RC,,,,,facility,inpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,1760.40,2400.01,percent of total billed charges,
RA Steroid Injection Left,8147184,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,First Health,,2400.01,,,,,,,100.00,2400.01,percent of total billed charges,
RA Foot Steroid Injection,9005754,CDM,761,RC,,,,,facility,inpatient,,,2266.00000,657.14000,Aetna,First Health,,1853.59,,,,,,,1359.60,1853.59,percent of total billed charges,
RA Foot Steroid Injection,9005754,CDM,761,RC,,,,,facility,outpatient,,,2266.00000,657.14000,Aetna,First Health,,1853.59,,,,,,,100.00,1853.59,percent of total billed charges,
RA Foot Steroid Injection,9005777,CDM,761,RC,,,,,facility,inpatient,,,2266.00000,657.14000,Aetna,First Health,,1853.59,,,,,,,1359.60,1853.59,percent of total billed charges,
RA Foot Steroid Injection,9005777,CDM,761,RC,,,,,facility,outpatient,,,2266.00000,657.14000,Aetna,First Health,,1853.59,,,,,,,100.00,1853.59,percent of total billed charges,
RA Foot Steroid Injection Add,9005776,CDM,761,RC,,,,,facility,inpatient,,,2266.00000,657.14000,Aetna,First Health,,1853.59,,,,,,,1359.60,1853.59,percent of total billed charges,
RA Foot Steroid Injection Add,9005776,CDM,761,RC,,,,,facility,outpatient,,,2266.00000,657.14000,Aetna,First Health,,1853.59,,,,,,,100.00,1853.59,percent of total billed charges,
RA Foot Steroid Injection,9005745,CDM,761,RC,,,,,facility,inpatient,,,2266.00000,657.14000,Aetna,First Health,,1853.59,,,,,,,1359.60,1853.59,percent of total billed charges,
RA Foot Steroid Injection,9005745,CDM,761,RC,,,,,facility,outpatient,,,2266.00000,657.14000,Aetna,First Health,,1853.59,,,,,,,100.00,1853.59,percent of total billed charges,
RA OR Pain Management Fluoro Imaging,8160760,CDM,761,RC,,,,,facility,inpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,720.00,981.60,percent of total billed charges,
RA OR Pain Management Fluoro Imaging,8160760,CDM,761,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,First Health,,981.60,,,,,,,100.00,981.60,percent of total billed charges,
ELASTOGRAPHY LIVER,7935095,CDM,761,RC,91200,HCPCS,,,facility,inpatient,,,679.00000,196.91000,Aetna,First Health,,555.42,,,,,,,407.40,555.42,percent of total billed charges,
ELASTOGRAPHY LIVER,7935095,CDM,761,RC,91200,HCPCS,,,facility,outpatient,,,679.00000,196.91000,Aetna,First Health,,555.42,,,,,,,100.00,555.42,percent of total billed charges,
Fibroscan/Vibration Controlled Transient Elastography,9188431,CDM,761,RC,91200,HCPCS,,,facility,inpatient,,,679.00000,196.91000,Aetna,First Health,,555.42,,,,,,,407.40,555.42,percent of total billed charges,
Fibroscan/Vibration Controlled Transient Elastography,9188431,CDM,761,RC,91200,HCPCS,,,facility,outpatient,,,679.00000,196.91000,Aetna,First Health,,555.42,,,,,,,100.00,555.42,percent of total billed charges,
Direct Admit to Observation,8137552,CDM,762,RC,G0379,HCPCS,,,facility,inpatient,,,690.00000,200.10000,Aetna,First Health,,564.42,,,,,,,414.00,564.42,percent of total billed charges,
Direct Admit to Observation,8137552,CDM,762,RC,G0379,HCPCS,,,facility,outpatient,,,690.00000,200.10000,Aetna,First Health,,564.42,,,,,,,276.00,7424.10,percent of total billed charges,
Observation,1327815,CDM,762,RC,G0378,HCPCS,,,facility,inpatient,,,199.00000,57.71000,Aetna,First Health,,162.78,,,,,,,119.40,162.78,percent of total billed charges,
Observation,1327815,CDM,762,RC,G0378,HCPCS,,,facility,outpatient,,,199.00000,57.71000,Aetna,First Health,,162.78,,,,,,,58.12,7424.10,percent of total billed charges,
Administration of Vaccine Addl,8150967,CDM,771,RC,90472,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration of Vaccine Addl,8150967,CDM,771,RC,90472,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Flu Vaccine,7950051,CDM,771,RC,G0008,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Flu Vaccine,7950051,CDM,771,RC,G0008,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,20.50,265.85,percent of total billed charges,
Administration Of Pneumo Vaccine,7950052,CDM,771,RC,G0009,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Pneumo Vaccine,7950052,CDM,771,RC,G0009,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,46.90,265.85,percent of total billed charges,
Administration Of Vaccine,7950049,CDM,771,RC,90471,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Vaccine,7950049,CDM,771,RC,90471,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,62.50,265.85,percent of total billed charges,
Administration Of Hep B Vaccine,7950050,CDM,771,RC,G0010,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Hep B Vaccine,7950050,CDM,771,RC,G0010,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,46.90,265.85,percent of total billed charges,
Administration Regeneron,8426818,CDM,771,RC,M0243,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Administration Regeneron,8426818,CDM,771,RC,M0243,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,288.40,654.40,percent of total billed charges,
Administration Of Pfizer Covid Vaccine 5y thru11y Dose 1,8478329,CDM,771,RC,0001A,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine 5y thru11y Dose 1,8478329,CDM,771,RC,0001A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,117.16,265.85,percent of total billed charges,
Admin Of Pfizer Covid Vaccine 6m thru 4y Dose 1,8924187,CDM,771,RC,0001A,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Admin Of Pfizer Covid Vaccine 6m thru 4y Dose 1,8924187,CDM,771,RC,0001A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine 5y thru 11y Dose 2,8478330,CDM,771,RC,0001A,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine 5y thru 11y Dose 2,8478330,CDM,771,RC,0001A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,117.16,265.85,percent of total billed charges,
Administration of Sotrovimab,8547937,CDM,771,RC,M0247,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Administration of Sotrovimab,8547937,CDM,771,RC,M0247,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,288.40,654.40,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Bivalent Booster,8975065,CDM,771,RC,0124A,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Bivalent Booster,8975065,CDM,771,RC,0124A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 1,8982651,CDM,771,RC,0001A,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 1,8982651,CDM,771,RC,0001A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 2,8982652,CDM,771,RC,0002A,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 2,8982652,CDM,771,RC,0002A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Bivalent Booster,8982653,CDM,771,RC,0124A,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Bivalent Booster,8982653,CDM,771,RC,0124A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,117.16,265.85,percent of total billed charges,
Admin Tocilizumab 1st Dose,8440193,CDM,771,RC,M0249,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Admin Tocilizumab 1st Dose,8440193,CDM,771,RC,M0249,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,296.96,654.40,percent of total billed charges,
Admin Tocilizumab 2nd Dose,8440194,CDM,771,RC,M0250,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Admin Tocilizumab 2nd Dose,8440194,CDM,771,RC,M0250,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,296.96,654.40,percent of total billed charges,
Administration Charge Bebtelovimab,8918346,CDM,771,RC,M0222,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Administration Charge Bebtelovimab,8918346,CDM,771,RC,M0222,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,288.40,654.40,percent of total billed charges,
Administration Charge Cilgavimab Tixagevimab,8920380,CDM,771,RC,M0220,HCPCS,,,facility,inpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,480.00,654.40,percent of total billed charges,
Administration Charge Cilgavimab Tixagevimab,8920380,CDM,771,RC,M0220,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,First Health,,654.40,,,,,,,288.40,654.40,percent of total billed charges,
Administration Of Flu Vaccine,8975011,CDM,771,RC,G0008,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Administration Of Flu Vaccine,8975011,CDM,771,RC,G0008,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.71,123.14,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 1,8433884,CDM,771,RC,0001A,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 1,8433884,CDM,771,RC,0001A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 2,8433885,CDM,771,RC,0002A,HCPCS,,,facility,inpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,195.00,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 2,8433885,CDM,771,RC,0002A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,First Health,,265.85,,,,,,,117.16,265.85,percent of total billed charges,
NUR CRRT,7911611,CDM,801,RC,,,,,facility,inpatient,,,2472.00000,716.88000,Aetna,First Health,,2022.10,,,,,,,1483.20,2022.10,percent of total billed charges,
NUR CRRT,7911611,CDM,801,RC,,,,,facility,outpatient,,,2472.00000,716.88000,Aetna,First Health,,2022.10,,,,,,,891.16,2022.10,percent of total billed charges,
NUR CRRT,7911615,CDM,801,RC,,,,,facility,inpatient,,,2472.00000,716.88000,Aetna,First Health,,2022.10,,,,,,,1483.20,2022.10,percent of total billed charges,
NUR CRRT,7911615,CDM,801,RC,,,,,facility,outpatient,,,2472.00000,716.88000,Aetna,First Health,,2022.10,,,,,,,891.16,2022.10,percent of total billed charges,
NUR CRRT Cartridge Change,7887355,CDM,801,RC,,,,,facility,inpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,906.60,1236.00,percent of total billed charges,
NUR CRRT Cartridge Change,7887355,CDM,801,RC,,,,,facility,outpatient,,,1511.00000,438.19000,Aetna,First Health,,1236.00,,,,,,,544.72,1236.00,percent of total billed charges,
Continuous Cycling Peritoneal Dialysis,8297104,CDM,801,RC,,,,,facility,inpatient,,,3066.00000,889.14000,Aetna,First Health,,2507.99,,,,,,,1839.60,2507.99,percent of total billed charges,
Continuous Cycling Peritoneal Dialysis,8297104,CDM,801,RC,,,,,facility,outpatient,,,3066.00000,889.14000,Aetna,First Health,,2507.99,,,,,,,1105.29,2507.99,percent of total billed charges,
Continuous Cycling Peritoned Dialysis CCPD,8360510,CDM,801,RC,,,,,facility,inpatient,,,3066.00000,889.14000,Aetna,First Health,,2507.99,,,,,,,1839.60,2507.99,percent of total billed charges,
Continuous Cycling Peritoned Dialysis CCPD,8360510,CDM,801,RC,,,,,facility,outpatient,,,3066.00000,889.14000,Aetna,First Health,,2507.99,,,,,,,1105.29,2507.99,percent of total billed charges,
Hemodialysis,599436,CDM,801,RC,,,,,facility,inpatient,,,1401.00000,406.29000,Aetna,First Health,,1146.02,,,,,,,840.60,1146.02,percent of total billed charges,
Hemodialysis,599436,CDM,801,RC,,,,,facility,outpatient,,,1401.00000,406.29000,Aetna,First Health,,1146.02,,,,,,,505.06,1146.02,percent of total billed charges,
Hemodialysis,7902271,CDM,801,RC,,,,,facility,inpatient,,,1401.00000,406.29000,Aetna,First Health,,1146.02,,,,,,,840.60,1146.02,percent of total billed charges,
Hemodialysis,7902271,CDM,801,RC,,,,,facility,outpatient,,,1401.00000,406.29000,Aetna,First Health,,1146.02,,,,,,,505.06,1146.02,percent of total billed charges,
Peritoneal CAPD,7939048,CDM,803,RC,,,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Peritoneal CAPD,7939048,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939049,CDM,803,RC,,,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Peritoneal CAPD,7939049,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939050,CDM,803,RC,,,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Peritoneal CAPD,7939050,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939051,CDM,803,RC,,,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Peritoneal CAPD,7939051,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939052,CDM,803,RC,,,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Peritoneal CAPD,7939052,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939053,CDM,803,RC,,,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Peritoneal CAPD,7939053,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939054,CDM,803,RC,,,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Peritoneal CAPD,7939054,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939055,CDM,803,RC,,,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Peritoneal CAPD,7939055,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,1327818,CDM,880,RC,,,,,facility,inpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,198.00,269.94,percent of total billed charges,
Peritoneal CAPD,1327818,CDM,880,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,First Health,,269.94,,,,,,,118.97,754.78,percent of total billed charges,
Navigator PIN Services 60 min,9192582,CDM,900,RC,G0023,HCPCS,,,facility,inpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,130.80,178.32,percent of total billed charges,
Navigator PIN Services 60 min,9192582,CDM,900,RC,G0023,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,First Health,,178.32,,,,,,,80.92,246.90,percent of total billed charges,
Navigator PIN Services Addl 30 min,9196429,CDM,900,RC,G0024,HCPCS,,,facility,inpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,65.40,89.16,percent of total billed charges,
Navigator PIN Services Addl 30 min,9196429,CDM,900,RC,G0024,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,First Health,,89.16,,,,,,,39.29,89.16,percent of total billed charges,
Bladder Scan,1327798,CDM,920,RC,51798,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
Bladder Scan,1327798,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,7310963,CDM,920,RC,51798,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
Bladder Scan,7310963,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,7310964,CDM,920,RC,51798,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
Bladder Scan,7310964,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,7311846,CDM,920,RC,51798,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
Bladder Scan,7311846,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,7311847,CDM,920,RC,51798,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
Bladder Scan,7311847,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,7957581,CDM,920,RC,51798,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
Bladder Scan,7957581,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,8997124,CDM,920,RC,51798,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,156.00,212.68,percent of total billed charges,
Bladder Scan,8997124,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,52.15,2860.00,percent of total billed charges,
Electronic Uterine Monitoring,5975845,CDM,920,RC,59025,HCPCS,,,facility,inpatient,,,1543.00000,447.47000,Aetna,First Health,,1262.17,,,,,,,925.80,1262.17,percent of total billed charges,
Electronic Uterine Monitoring,5975845,CDM,920,RC,59025,HCPCS,,,facility,outpatient,,,1543.00000,447.47000,Aetna,First Health,,1262.17,,,,,,,176.65,2860.00,percent of total billed charges,
Mat Fetal Non Stress Test,7932403,CDM,920,RC,59025,HCPCS,,,facility,inpatient,,,1543.00000,447.47000,Aetna,First Health,,1262.17,,,,,,,925.80,1262.17,percent of total billed charges,
Mat Fetal Non Stress Test,7932403,CDM,920,RC,59025,HCPCS,,,facility,outpatient,,,1543.00000,447.47000,Aetna,First Health,,1262.17,,,,,,,176.65,2860.00,percent of total billed charges,
Fetal Non Stress Test,9020167,CDM,920,RC,59025,HCPCS,,,facility,inpatient,,,1543.00000,447.47000,Aetna,First Health,,1262.17,,,,,,,925.80,1262.17,percent of total billed charges,
Fetal Non Stress Test,9020167,CDM,920,RC,59025,HCPCS,,,facility,outpatient,,,1543.00000,447.47000,Aetna,First Health,,1262.17,,,,,,,176.65,2860.00,percent of total billed charges,
Fetal Non Stress Test,9020168,CDM,920,RC,59025,HCPCS,,,facility,inpatient,,,1543.00000,447.47000,Aetna,First Health,,1262.17,,,,,,,925.80,1262.17,percent of total billed charges,
Fetal Non Stress Test,9020168,CDM,920,RC,59025,HCPCS,,,facility,outpatient,,,1543.00000,447.47000,Aetna,First Health,,1262.17,,,,,,,176.65,2860.00,percent of total billed charges,
Mat Version,7932258,CDM,920,RC,,,,,facility,inpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,1035.60,1411.87,percent of total billed charges,
Mat Version,7932258,CDM,920,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,622.22,1411.87,percent of total billed charges,
Mat Version,8156195,CDM,920,RC,,,,,facility,inpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,1035.60,1411.87,percent of total billed charges,
Mat Version,8156195,CDM,920,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,First Health,,1411.87,,,,,,,622.22,1411.87,percent of total billed charges,
Short Latency Somatosens EP Std Upr Low Limb bce,9110074,CDM,920,RC,95938,HCPCS,,,facility,inpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,1708.20,2328.85,percent of total billed charges,
Short Latency Somatosens EP Std Upr Low Limb bce,9110074,CDM,920,RC,95938,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,465.90,2328.85,percent of total billed charges,
Ctr Motr EP Std Transcrnl Motr Stim Upr and Low Limb bce,9110075,CDM,920,RC,95939,HCPCS,,,facility,inpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,1708.20,2328.85,percent of total billed charges,
Ctr Motr EP Std Transcrnl Motr Stim Upr and Low Limb bce,9110075,CDM,920,RC,95939,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,First Health,,2328.85,,,,,,,860.13,2715.51,percent of total billed charges,
Neuromuscular Junct Tstg EA Nrv Any one Meth bce,9114654,CDM,920,RC,95937,HCPCS,,,facility,inpatient,,,776.00000,225.04000,Aetna,First Health,,634.77,,,,,,,465.60,634.77,percent of total billed charges,
Neuromuscular Junct Tstg EA Nrv Any one Meth bce,9114654,CDM,920,RC,95937,HCPCS,,,facility,outpatient,,,776.00000,225.04000,Aetna,First Health,,634.77,,,,,,,128.88,634.77,percent of total billed charges,
Sl Home Sleep Test Type 3,6047847,CDM,920,RC,G0399,HCPCS,,,facility,inpatient,,,1806.00000,523.74000,Aetna,First Health,,1477.31,,,,,,,1083.60,1477.31,percent of total billed charges,
Sl Home Sleep Test Type 3,6047847,CDM,920,RC,G0399,HCPCS,,,facility,outpatient,,,1806.00000,523.74000,Aetna,First Health,,1477.31,,,,,,,216.27,1477.31,percent of total billed charges,
Home Sleep Test Type 3,8410286,CDM,920,RC,G0399,HCPCS,,,facility,inpatient,,,1806.00000,523.74000,Aetna,First Health,,1477.31,,,,,,,1083.60,1477.31,percent of total billed charges,
Home Sleep Test Type 3,8410286,CDM,920,RC,G0399,HCPCS,,,facility,outpatient,,,1806.00000,523.74000,Aetna,First Health,,1477.31,,,,,,,216.27,1477.31,percent of total billed charges,
Sl Cpap Titration Study,7719223,CDM,920,RC,95811,HCPCS,,,facility,inpatient,,,5190.00000,1505.10000,Aetna,First Health,,4245.42,,,,,,,3114.00,4245.42,percent of total billed charges,
Sl Cpap Titration Study,7719223,CDM,920,RC,95811,HCPCS,,,facility,outpatient,,,5190.00000,1505.10000,Aetna,First Health,,4245.42,,,,,,,860.13,4245.42,percent of total billed charges,
CPAP Titration Study,8410260,CDM,920,RC,95811,HCPCS,,,facility,inpatient,,,5190.00000,1505.10000,Aetna,First Health,,4245.42,,,,,,,3114.00,4245.42,percent of total billed charges,
CPAP Titration Study,8410260,CDM,920,RC,95811,HCPCS,,,facility,outpatient,,,5190.00000,1505.10000,Aetna,First Health,,4245.42,,,,,,,860.13,4245.42,percent of total billed charges,
SL Device Analysis and Simple Programming,8441868,CDM,920,RC,95976,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,80.40,109.61,percent of total billed charges,
SL Device Analysis and Simple Programming,8441868,CDM,920,RC,95976,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,32.74,109.61,percent of total billed charges,
Device Analysis Simple Program 3 or fewer adj,8994606,CDM,920,RC,95976,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,80.40,109.61,percent of total billed charges,
Device Analysis Simple Program 3 or fewer adj,8994606,CDM,920,RC,95976,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,32.74,109.61,percent of total billed charges,
SL Device Analysis and Complex Programming,8441869,CDM,920,RC,95977,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,202.80,276.48,percent of total billed charges,
SL Device Analysis and Complex Programming,8441869,CDM,920,RC,95977,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,80.60,276.48,percent of total billed charges,
Device Interrogation Complex Program,8994612,CDM,920,RC,95977,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,202.80,276.48,percent of total billed charges,
Device Interrogation Complex Program,8994612,CDM,920,RC,95977,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,80.60,276.48,percent of total billed charges,
Short Home Sleep Test Type 3,8798123,CDM,920,RC,G0399,HCPCS,,,facility,inpatient,,,1024.00000,296.96000,Aetna,First Health,,837.63,,,,,,,614.40,837.63,percent of total billed charges,
Short Home Sleep Test Type 3,8798123,CDM,920,RC,G0399,HCPCS,,,facility,outpatient,,,1024.00000,296.96000,Aetna,First Health,,837.63,,,,,,,216.27,837.63,percent of total billed charges,
Sl Polysomnography Attended,612743,CDM,920,RC,95810,HCPCS,,,facility,inpatient,,,8897.00000,2580.13000,Aetna,First Health,,7277.75,,,,,,,5338.20,7277.75,percent of total billed charges,
Sl Polysomnography Attended,612743,CDM,920,RC,95810,HCPCS,,,facility,outpatient,,,8897.00000,2580.13000,Aetna,First Health,,7277.75,,,,,,,860.13,7277.75,percent of total billed charges,
Multi Channel Poly PSG,8410231,CDM,920,RC,95810,HCPCS,,,facility,inpatient,,,8897.00000,2580.13000,Aetna,First Health,,7277.75,,,,,,,5338.20,7277.75,percent of total billed charges,
Multi Channel Poly PSG,8410231,CDM,920,RC,95810,HCPCS,,,facility,outpatient,,,8897.00000,2580.13000,Aetna,First Health,,7277.75,,,,,,,860.13,7277.75,percent of total billed charges,
Sl Sleep Latency,612749,CDM,920,RC,95805,HCPCS,,,facility,inpatient,,,5808.00000,1684.32000,Aetna,First Health,,4750.94,,,,,,,3484.80,4750.94,percent of total billed charges,
Sl Sleep Latency,612749,CDM,920,RC,95805,HCPCS,,,facility,outpatient,,,5808.00000,1684.32000,Aetna,First Health,,4750.94,,,,,,,465.90,4750.94,percent of total billed charges,
Sleep Latency MSLT,8410253,CDM,920,RC,95805,HCPCS,,,facility,inpatient,,,5808.00000,1684.32000,Aetna,First Health,,4750.94,,,,,,,3484.80,4750.94,percent of total billed charges,
Sleep Latency MSLT,8410253,CDM,920,RC,95805,HCPCS,,,facility,outpatient,,,5808.00000,1684.32000,Aetna,First Health,,4750.94,,,,,,,465.90,4750.94,percent of total billed charges,
Sl Polysom With Cpap Bipap,612751,CDM,920,RC,95811,HCPCS,,,facility,inpatient,,,10257.00000,2974.53000,Aetna,First Health,,8390.23,,,,,,,6154.20,8390.23,percent of total billed charges,
Sl Polysom With Cpap Bipap,612751,CDM,920,RC,95811,HCPCS,,,facility,outpatient,,,10257.00000,2974.53000,Aetna,First Health,,8390.23,,,,,,,860.13,8390.23,percent of total billed charges,
Polysom with PAP Titration or Split Night,8410239,CDM,920,RC,95811,HCPCS,,,facility,inpatient,,,10257.00000,2974.53000,Aetna,First Health,,8390.23,,,,,,,6154.20,8390.23,percent of total billed charges,
Polysom with PAP Titration or Split Night,8410239,CDM,920,RC,95811,HCPCS,,,facility,outpatient,,,10257.00000,2974.53000,Aetna,First Health,,8390.23,,,,,,,860.13,8390.23,percent of total billed charges,
Sl Ventilatory Monitor Sleep Stdy,644560,CDM,920,RC,95807,HCPCS,,,facility,inpatient,,,4326.00000,1254.54000,Aetna,First Health,,3538.67,,,,,,,2595.60,3538.67,percent of total billed charges,
Sl Ventilatory Monitor Sleep Stdy,644560,CDM,920,RC,95807,HCPCS,,,facility,outpatient,,,4326.00000,1254.54000,Aetna,First Health,,3538.67,,,,,,,373.76,3538.67,percent of total billed charges,
Vent Monitor Sleep Study,8410275,CDM,920,RC,95807,HCPCS,,,facility,inpatient,,,4326.00000,1254.54000,Aetna,First Health,,3538.67,,,,,,,2595.60,3538.67,percent of total billed charges,
Vent Monitor Sleep Study,8410275,CDM,920,RC,95807,HCPCS,,,facility,outpatient,,,4326.00000,1254.54000,Aetna,First Health,,3538.67,,,,,,,373.76,3538.67,percent of total billed charges,
Multi CH Poly Short Study less than 6 hrs,8410246,CDM,920,RC,95810,HCPCS,,,facility,inpatient,,,4201.00000,1218.29000,Aetna,First Health,,3436.42,,,,,,,2520.60,3436.42,percent of total billed charges,
Multi CH Poly Short Study less than 6 hrs,8410246,CDM,920,RC,95810,HCPCS,,,facility,outpatient,,,4201.00000,1218.29000,Aetna,First Health,,3436.42,,,,,,,860.13,3436.42,percent of total billed charges,
Sl Mwt Wakefulness Test,644559,CDM,920,RC,95805,HCPCS,,,facility,inpatient,,,5808.00000,1684.32000,Aetna,First Health,,4750.94,,,,,,,3484.80,4750.94,percent of total billed charges,
Sl Mwt Wakefulness Test,644559,CDM,920,RC,95805,HCPCS,,,facility,outpatient,,,5808.00000,1684.32000,Aetna,First Health,,4750.94,,,,,,,465.90,4750.94,percent of total billed charges,
Wakefulness Test MWT,8410268,CDM,920,RC,95805,HCPCS,,,facility,inpatient,,,5808.00000,1684.32000,Aetna,First Health,,4750.94,,,,,,,3484.80,4750.94,percent of total billed charges,
Wakefulness Test MWT,8410268,CDM,920,RC,95805,HCPCS,,,facility,outpatient,,,5808.00000,1684.32000,Aetna,First Health,,4750.94,,,,,,,465.90,4750.94,percent of total billed charges,
NAS Multi Level,1792832,CDM,921,RC,93923,HCPCS,,,facility,inpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,1337.40,1823.32,percent of total billed charges,
NAS Multi Level,1792832,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,137.38,1823.32,percent of total billed charges,
NAS Multi Level,7959543,CDM,921,RC,93923,HCPCS,,,facility,inpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,1337.40,1823.32,percent of total billed charges,
NAS Multi Level,7959543,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,137.38,1823.32,percent of total billed charges,
NAS Multi Levels,602682,CDM,921,RC,93922,HCPCS,,,facility,inpatient,,,1622.00000,470.38000,Aetna,First Health,,1326.80,,,,,,,973.20,1326.80,percent of total billed charges,
NAS Multi Levels,602682,CDM,921,RC,93922,HCPCS,,,facility,outpatient,,,1622.00000,470.38000,Aetna,First Health,,1326.80,,,,,,,113.19,1326.80,percent of total billed charges,
TcPO ABI unilat 1 to 2 levels,7959545,CDM,921,RC,93922,HCPCS,,,facility,inpatient,,,1622.00000,470.38000,Aetna,First Health,,1326.80,,,,,,,973.20,1326.80,percent of total billed charges,
TcPO ABI unilat 1 to 2 levels,7959545,CDM,921,RC,93922,HCPCS,,,facility,outpatient,,,1622.00000,470.38000,Aetna,First Health,,1326.80,,,,,,,113.19,1326.80,percent of total billed charges,
NAS Multi Levels,7959560,CDM,921,RC,93922,HCPCS,,,facility,inpatient,,,1622.00000,470.38000,Aetna,First Health,,1326.80,,,,,,,973.20,1326.80,percent of total billed charges,
NAS Multi Levels,7959560,CDM,921,RC,93922,HCPCS,,,facility,outpatient,,,1622.00000,470.38000,Aetna,First Health,,1326.80,,,,,,,113.19,1326.80,percent of total billed charges,
Miscellaneous Noninvasive Proced,7943837,CDM,921,RC,93998,HCPCS,,,facility,inpatient,,,622.00000,180.38000,Aetna,First Health,,508.80,,,,,,,373.20,508.80,percent of total billed charges,
Miscellaneous Noninvasive Proced,7943837,CDM,921,RC,93998,HCPCS,,,facility,outpatient,,,622.00000,180.38000,Aetna,First Health,,508.80,,,,,,,21.51,525.00,percent of total billed charges,
Art Pvr Lowers W Exercise,599274,CDM,921,RC,93924,HCPCS,,,facility,inpatient,,,2452.00000,711.08000,Aetna,First Health,,2005.74,,,,,,,1471.20,2005.74,percent of total billed charges,
Art Pvr Lowers W Exercise,599274,CDM,921,RC,93924,HCPCS,,,facility,outpatient,,,2452.00000,711.08000,Aetna,First Health,,2005.74,,,,,,,137.38,2005.74,percent of total billed charges,
Art Pvr Lowers W Exercise,7957284,CDM,921,RC,93924,HCPCS,,,facility,inpatient,,,2452.00000,711.08000,Aetna,First Health,,2005.74,,,,,,,1471.20,2005.74,percent of total billed charges,
Art Pvr Lowers W Exercise,7957284,CDM,921,RC,93924,HCPCS,,,facility,outpatient,,,2452.00000,711.08000,Aetna,First Health,,2005.74,,,,,,,137.38,2005.74,percent of total billed charges,
Art Pvr Uppers,599272,CDM,921,RC,93923,HCPCS,,,facility,inpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,1337.40,1823.32,percent of total billed charges,
Art Pvr Uppers,599272,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,137.38,1823.32,percent of total billed charges,
Art Pvr Uppers,599280,CDM,921,RC,93923,HCPCS,,,facility,inpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,1337.40,1823.32,percent of total billed charges,
Art Pvr Uppers,599280,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,137.38,1823.32,percent of total billed charges,
Art Pvr Uppers,7957283,CDM,921,RC,93923,HCPCS,,,facility,inpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,1337.40,1823.32,percent of total billed charges,
Art Pvr Uppers,7957283,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,137.38,1823.32,percent of total billed charges,
Art Unilateral Study,599298,CDM,921,RC,93922,HCPCS,,,facility,inpatient,,,1622.00000,470.38000,Aetna,First Health,,1326.80,,,,,,,973.20,1326.80,percent of total billed charges,
Art Unilateral Study,599298,CDM,921,RC,93922,HCPCS,,,facility,outpatient,,,1622.00000,470.38000,Aetna,First Health,,1326.80,,,,,,,113.19,1326.80,percent of total billed charges,
Art Unilateral Study,7963886,CDM,921,RC,93922,HCPCS,,,facility,inpatient,,,1622.00000,470.38000,Aetna,First Health,,1326.80,,,,,,,973.20,1326.80,percent of total billed charges,
Art Unilateral Study,7963886,CDM,921,RC,93922,HCPCS,,,facility,outpatient,,,1622.00000,470.38000,Aetna,First Health,,1326.80,,,,,,,113.19,1326.80,percent of total billed charges,
Art Pvr Lowers Rest,599302,CDM,921,RC,93923,HCPCS,,,facility,inpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,1337.40,1823.32,percent of total billed charges,
Art Pvr Lowers Rest,599302,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,137.38,1823.32,percent of total billed charges,
Art Pvr Lowers Rest,7957285,CDM,921,RC,93923,HCPCS,,,facility,inpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,1337.40,1823.32,percent of total billed charges,
Art Pvr Lowers Rest,7957285,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,First Health,,1823.32,,,,,,,137.38,1823.32,percent of total billed charges,
Sono Arterial Duplex Upper Extremity Limited,7949906,CDM,921,RC,93931,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Arterial Duplex Upper Extremity Limited,7949906,CDM,921,RC,93931,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Arterial Duplex Upper Extremity Limited,7949910,CDM,921,RC,93931,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Arterial Duplex Upper Extremity Limited,7949910,CDM,921,RC,93931,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Venous Duplex Right,7235927,CDM,921,RC,93971,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,RT,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Venous Duplex Right,7235927,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,RT,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Venous Duplex Right,7273891,CDM,921,RC,93971,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,RT,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Venous Duplex Right,7273891,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,RT,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Venous Duplex Right,7949935,CDM,921,RC,93971,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,RT,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Venous Duplex Right,7949935,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,RT,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Venous Duplex Right,7949943,CDM,921,RC,93971,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,RT,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Venous Duplex Right,7949943,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,RT,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Venous Duplex Left,7235931,CDM,921,RC,93971,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,LT,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Venous Duplex Left,7235931,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,LT,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Venous Duplex Left,7235935,CDM,921,RC,93971,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,LT,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Venous Duplex Left,7235935,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,LT,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Venous Duplex Left,7949931,CDM,921,RC,93971,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,LT,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Venous Duplex Left,7949931,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,LT,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Venous Duplex Left,7949939,CDM,921,RC,93971,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,LT,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Venous Duplex Left,7949939,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,LT,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Venous Duplex Bilateral,7235939,CDM,921,RC,93970,HCPCS,,,facility,inpatient,,,4257.00000,1234.53000,Aetna,First Health,,3482.23,,,,,,,2554.20,3482.23,percent of total billed charges,
Sono Venous Duplex Bilateral,7235939,CDM,921,RC,93970,HCPCS,,,facility,outpatient,,,4257.00000,1234.53000,Aetna,First Health,,3482.23,,,,,,,212.24,3482.23,percent of total billed charges,
Sono Venous Duplex Bilateral,7273892,CDM,921,RC,93970,HCPCS,,,facility,inpatient,,,4257.00000,1234.53000,Aetna,First Health,,3482.23,,,,,,,2554.20,3482.23,percent of total billed charges,
Sono Venous Duplex Bilateral,7273892,CDM,921,RC,93970,HCPCS,,,facility,outpatient,,,4257.00000,1234.53000,Aetna,First Health,,3482.23,,,,,,,212.24,3482.23,percent of total billed charges,
Sono Venous Duplex Bilateral,7812050,CDM,921,RC,93970,HCPCS,,,facility,inpatient,,,4257.00000,1234.53000,Aetna,First Health,,3482.23,,,,,,,2554.20,3482.23,percent of total billed charges,
Sono Venous Duplex Bilateral,7812050,CDM,921,RC,93970,HCPCS,,,facility,outpatient,,,4257.00000,1234.53000,Aetna,First Health,,3482.23,,,,,,,212.24,3482.23,percent of total billed charges,
Sono Venous Duplex Bilateral,7812054,CDM,921,RC,93970,HCPCS,,,facility,inpatient,,,4257.00000,1234.53000,Aetna,First Health,,3482.23,,,,,,,2554.20,3482.23,percent of total billed charges,
Sono Venous Duplex Bilateral,7812054,CDM,921,RC,93970,HCPCS,,,facility,outpatient,,,4257.00000,1234.53000,Aetna,First Health,,3482.23,,,,,,,212.24,3482.23,percent of total billed charges,
Sono Arterial Duplex Upper Extremity Complete,7949902,CDM,921,RC,93930,HCPCS,,,facility,inpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,1405.20,1915.76,percent of total billed charges,
Sono Arterial Duplex Upper Extremity Complete,7949902,CDM,921,RC,93930,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,212.24,1915.76,percent of total billed charges,
Sono Abdomen Duplex Scan Limited,7938489,CDM,921,RC,93976,HCPCS,,,facility,inpatient,,,1229.00000,356.41000,Aetna,First Health,,1005.32,,,,,,,737.40,1005.32,percent of total billed charges,
Sono Abdomen Duplex Scan Limited,7938489,CDM,921,RC,93976,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,First Health,,1005.32,,,,,,,93.38,1005.32,percent of total billed charges,
Sono Duplex Scan,8001071,CDM,921,RC,93975,HCPCS,,,facility,inpatient,,,1229.00000,356.41000,Aetna,First Health,,1005.32,,,,,,,737.40,1005.32,percent of total billed charges,
Sono Duplex Scan,8001071,CDM,921,RC,93975,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,First Health,,1005.32,,,,,,,212.24,1005.32,percent of total billed charges,
Ultrasound Duplex,8436725,CDM,921,RC,93975,HCPCS,,,facility,inpatient,,,1229.00000,356.41000,Aetna,First Health,,1005.32,,,,,,,737.40,1005.32,percent of total billed charges,
Ultrasound Duplex,8436725,CDM,921,RC,93975,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,First Health,,1005.32,,,,,,,212.24,1005.32,percent of total billed charges,
Sono Arterial Duplex Leg Bilateral Limited,9162411,CDM,921,RC,93926,HCPCS,,,facility,inpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,2554.80,3483.04,percent of total billed charges,
Sono Arterial Duplex Leg Bilateral Limited,9162411,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,93.38,3483.04,percent of total billed charges,
Sono Arterial Duplex Leg Right Limited,9164403,CDM,921,RC,93926,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Arterial Duplex Leg Right Limited,9164403,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Arterial Duplex Leg Left Limited,9164401,CDM,921,RC,93926,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Arterial Duplex Leg Left Limited,9164401,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Arterial Duplex Arm Bilateral Limited,9162407,CDM,921,RC,93931,HCPCS,,,facility,inpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,2554.80,3483.04,percent of total billed charges,
Sono Arterial Duplex Arm Bilateral Limited,9162407,CDM,921,RC,93931,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,First Health,,3483.04,,,,,,,93.38,3483.04,percent of total billed charges,
Sono Arterial Duplex Arm Right Limited,9164399,CDM,921,RC,93931,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Arterial Duplex Arm Right Limited,9164399,CDM,921,RC,93931,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Arterial Duplex Arm Left Limited,9186638,CDM,921,RC,93931,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Arterial Duplex Arm Left Limited,9186638,CDM,921,RC,93931,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Abdomen Duplex Complete,7520004,CDM,921,RC,93975,HCPCS,,,facility,inpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,1405.20,1915.76,percent of total billed charges,
Sono Abdomen Duplex Complete,7520004,CDM,921,RC,93975,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,212.24,1915.76,percent of total billed charges,
Sono Abdomen Duplex Complete,7520008,CDM,921,RC,93975,HCPCS,,,facility,inpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,1405.20,1915.76,percent of total billed charges,
Sono Abdomen Duplex Complete,7520008,CDM,921,RC,93975,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,212.24,1915.76,percent of total billed charges,
Sono Abdomen Duplex Complete,7520012,CDM,921,RC,93975,HCPCS,,,facility,inpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,1405.20,1915.76,percent of total billed charges,
Sono Abdomen Duplex Complete,7520012,CDM,921,RC,93975,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,212.24,1915.76,percent of total billed charges,
Sono Saphenous Vein Mapping,614149,CDM,921,RC,93971,HCPCS,,,facility,inpatient,,,2027.00000,587.83000,Aetna,First Health,,1658.09,,,,,,,1216.20,1658.09,percent of total billed charges,
Sono Saphenous Vein Mapping,614149,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2027.00000,587.83000,Aetna,First Health,,1658.09,,,,,,,93.38,1658.09,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Complete,7856094,CDM,921,RC,93925,HCPCS,,,facility,inpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,1405.20,1915.76,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Complete,7856094,CDM,921,RC,93925,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,212.24,1915.76,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Complete,7949891,CDM,921,RC,93925,HCPCS,,,facility,inpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,1405.20,1915.76,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Complete,7949891,CDM,921,RC,93925,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,First Health,,1915.76,,,,,,,212.24,1915.76,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Limited,7949894,CDM,921,RC,93926,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Limited,7949894,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Limited,7949898,CDM,921,RC,93926,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Limited,7949898,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Limited,7949923,CDM,921,RC,93926,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Limited,7949923,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Limited,7949927,CDM,921,RC,93926,HCPCS,,,facility,inpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,1277.40,1741.52,percent of total billed charges,
Sono Arterial Duplex Lower Extremity Limited,7949927,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,First Health,,1741.52,,,,,,,93.38,1741.52,percent of total billed charges,
Auditory Potentials,599358,CDM,922,RC,92653,HCPCS,,,facility,inpatient,,,1465.00000,424.85000,Aetna,First Health,,1198.37,,,,,,,879.00,1198.37,percent of total billed charges,
Auditory Potentials,599358,CDM,922,RC,92653,HCPCS,,,facility,outpatient,,,1465.00000,424.85000,Aetna,First Health,,1198.37,,,,,,,216.27,1198.37,percent of total billed charges,
Auditory Evoked Potentials,8426907,CDM,922,RC,92653,HCPCS,,,facility,inpatient,,,1465.00000,424.85000,Aetna,First Health,,1198.37,,,,,,,879.00,1198.37,percent of total billed charges,
Auditory Evoked Potentials,8426907,CDM,922,RC,92653,HCPCS,,,facility,outpatient,,,1465.00000,424.85000,Aetna,First Health,,1198.37,,,,,,,216.27,1198.37,percent of total billed charges,
Needle EMG One Extremity,599316,CDM,922,RC,95860,HCPCS,,,facility,inpatient,,,830.00000,240.70000,Aetna,First Health,,678.94,,,,,,,498.00,678.94,percent of total billed charges,
Needle EMG One Extremity,599316,CDM,922,RC,95860,HCPCS,,,facility,outpatient,,,830.00000,240.70000,Aetna,First Health,,678.94,,,,,,,113.19,678.94,percent of total billed charges,
Needle EMG One Extremity,7957145,CDM,922,RC,95860,HCPCS,,,facility,inpatient,,,830.00000,240.70000,Aetna,First Health,,678.94,,,,,,,498.00,678.94,percent of total billed charges,
Needle EMG One Extremity,7957145,CDM,922,RC,95860,HCPCS,,,facility,outpatient,,,830.00000,240.70000,Aetna,First Health,,678.94,,,,,,,113.19,678.94,percent of total billed charges,
Needle EMG One Extremity,7957530,CDM,922,RC,95860,HCPCS,,,facility,inpatient,,,830.00000,240.70000,Aetna,First Health,,678.94,,,,,,,498.00,678.94,percent of total billed charges,
Needle EMG One Extremity,7957530,CDM,922,RC,95860,HCPCS,,,facility,outpatient,,,830.00000,240.70000,Aetna,First Health,,678.94,,,,,,,113.19,678.94,percent of total billed charges,
Needle EMG Two Extremities,599318,CDM,922,RC,95861,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,996.00,1357.88,percent of total billed charges,
Needle EMG Two Extremities,599318,CDM,922,RC,95861,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,113.19,1357.88,percent of total billed charges,
Needle EMG Two Extremities,7957531,CDM,922,RC,95861,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,996.00,1357.88,percent of total billed charges,
Needle EMG Two Extremities,7957531,CDM,922,RC,95861,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,First Health,,1357.88,,,,,,,113.19,1357.88,percent of total billed charges,
Repetetive Stimulation Each Nerve,7957144,CDM,922,RC,95937,HCPCS,,,facility,inpatient,,,892.00000,258.68000,Aetna,First Health,,729.66,,,,,,,535.20,729.66,percent of total billed charges,
Repetetive Stimulation Each Nerve,7957144,CDM,922,RC,95937,HCPCS,,,facility,outpatient,,,892.00000,258.68000,Aetna,First Health,,729.66,,,,,,,128.88,729.66,percent of total billed charges,
Repetetive Stimulation Each Nerve,971814,CDM,922,RC,95937,HCPCS,,,facility,inpatient,,,892.00000,258.68000,Aetna,First Health,,729.66,,,,,,,535.20,729.66,percent of total billed charges,
Repetetive Stimulation Each Nerve,971814,CDM,922,RC,95937,HCPCS,,,facility,outpatient,,,892.00000,258.68000,Aetna,First Health,,729.66,,,,,,,128.88,729.66,percent of total billed charges,
Motor F Wave Study,931800,CDM,922,RC,95905,HCPCS,,,facility,inpatient,,,460.00000,133.40000,Aetna,First Health,,376.28,,,,,,,276.00,376.28,percent of total billed charges,
Motor F Wave Study,931800,CDM,922,RC,95905,HCPCS,,,facility,outpatient,,,460.00000,133.40000,Aetna,First Health,,376.28,,,,,,,170.75,1065.07,percent of total billed charges,
EMG Thoracic Paraspinal,2490836,CDM,922,RC,95869,HCPCS,,,facility,inpatient,,,743.00000,215.47000,Aetna,First Health,,607.77,,,,,,,445.80,607.77,percent of total billed charges,
EMG Thoracic Paraspinal,2490836,CDM,922,RC,95869,HCPCS,,,facility,outpatient,,,743.00000,215.47000,Aetna,First Health,,607.77,,,,,,,216.27,831.14,percent of total billed charges,
EMG Thoracic Paraspinal,7957147,CDM,922,RC,95869,HCPCS,,,facility,inpatient,,,743.00000,215.47000,Aetna,First Health,,607.77,,,,,,,445.80,607.77,percent of total billed charges,
EMG Thoracic Paraspinal,7957147,CDM,922,RC,95869,HCPCS,,,facility,outpatient,,,743.00000,215.47000,Aetna,First Health,,607.77,,,,,,,216.27,831.14,percent of total billed charges,
EMG With Nerve Comp Each Ext,5517839,CDM,922,RC,95886,HCPCS,,,facility,inpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,709.20,966.88,percent of total billed charges,
EMG With Nerve Comp Each Ext,5517839,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,426.11,966.88,percent of total billed charges,
EMG With Nerve Comp Each Ext,7957148,CDM,922,RC,95886,HCPCS,,,facility,inpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,709.20,966.88,percent of total billed charges,
EMG With Nerve Comp Each Ext,7957148,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,426.11,966.88,percent of total billed charges,
Right,9016283,CDM,922,RC,95886,HCPCS,,,facility,inpatient,,,1182.00000,342.78000,Aetna,First Health,RT,966.88,,,,,,,709.20,966.88,percent of total billed charges,
Right,9016283,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,First Health,RT,966.88,,,,,,,426.11,966.88,percent of total billed charges,
Left,9016284,CDM,922,RC,95886,HCPCS,,,facility,inpatient,,,1182.00000,342.78000,Aetna,First Health,LT,966.88,,,,,,,709.20,966.88,percent of total billed charges,
Left,9016284,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,First Health,LT,966.88,,,,,,,426.11,966.88,percent of total billed charges,
Bilateral,9016285,CDM,922,RC,95886,HCPCS,,,facility,inpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,709.20,966.88,percent of total billed charges,
Bilateral,9016285,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,426.11,966.88,percent of total billed charges,
EMG With Nerve Limited Each Ext,7957149,CDM,922,RC,95885,HCPCS,,,facility,inpatient,,,591.00000,171.39000,Aetna,First Health,,483.44,,,,,,,354.60,483.44,percent of total billed charges,
EMG With Nerve Limited Each Ext,7957149,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,First Health,,483.44,,,,,,,213.06,483.44,percent of total billed charges,
Right,9014663,CDM,922,RC,95885,HCPCS,,,facility,inpatient,,,591.00000,171.39000,Aetna,First Health,RT,483.44,,,,,,,354.60,483.44,percent of total billed charges,
Right,9014663,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,First Health,RT,483.44,,,,,,,213.06,483.44,percent of total billed charges,
Bilateral,9014664,CDM,922,RC,95885,HCPCS,,,facility,inpatient,,,591.00000,171.39000,Aetna,First Health,,483.44,,,,,,,354.60,483.44,percent of total billed charges,
Bilateral,9014664,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,First Health,,483.44,,,,,,,213.06,483.44,percent of total billed charges,
Left,9016292,CDM,922,RC,95885,HCPCS,,,facility,inpatient,,,591.00000,171.39000,Aetna,First Health,LT,483.44,,,,,,,354.60,483.44,percent of total billed charges,
Left,9016292,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,First Health,LT,483.44,,,,,,,213.06,483.44,percent of total billed charges,
EMG Cranial Nerve,5517841,CDM,922,RC,95887,HCPCS,,,facility,inpatient,,,591.00000,171.39000,Aetna,First Health,,483.44,,,,,,,354.60,483.44,percent of total billed charges,
EMG Cranial Nerve,5517841,CDM,922,RC,95887,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,First Health,,483.44,,,,,,,213.06,483.44,percent of total billed charges,
EMG Cranial Nerve,7957146,CDM,922,RC,95887,HCPCS,,,facility,inpatient,,,591.00000,171.39000,Aetna,First Health,,483.44,,,,,,,354.60,483.44,percent of total billed charges,
EMG Cranial Nerve,7957146,CDM,922,RC,95887,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,First Health,,483.44,,,,,,,213.06,483.44,percent of total billed charges,
Nerve Conduction 1 To 2,7957543,CDM,922,RC,95907,HCPCS,,,facility,inpatient,,,1013.00000,293.77000,Aetna,First Health,,828.63,,,,,,,607.80,828.63,percent of total billed charges,
Nerve Conduction 1 To 2,7957543,CDM,922,RC,95907,HCPCS,,,facility,outpatient,,,1013.00000,293.77000,Aetna,First Health,,828.63,,,,,,,137.38,828.63,percent of total billed charges,
Nerve Conduction 3 To 4,7957544,CDM,922,RC,95908,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,852.00,1161.56,percent of total billed charges,
Nerve Conduction 3 To 4,7957544,CDM,922,RC,95908,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,First Health,,1161.56,,,,,,,216.27,1161.56,percent of total billed charges,
Nerve Conduction 5 To 6,7957545,CDM,922,RC,95909,HCPCS,,,facility,inpatient,,,1762.00000,510.98000,Aetna,First Health,,1441.32,,,,,,,1057.20,1441.32,percent of total billed charges,
Nerve Conduction 5 To 6,7957545,CDM,922,RC,95909,HCPCS,,,facility,outpatient,,,1762.00000,510.98000,Aetna,First Health,,1441.32,,,,,,,216.27,1441.32,percent of total billed charges,
Nerve Conduction 7 To 8,7957546,CDM,922,RC,95910,HCPCS,,,facility,inpatient,,,2635.00000,764.15000,Aetna,First Health,,2155.43,,,,,,,1581.00,2155.43,percent of total billed charges,
Nerve Conduction 7 To 8,7957546,CDM,922,RC,95910,HCPCS,,,facility,outpatient,,,2635.00000,764.15000,Aetna,First Health,,2155.43,,,,,,,273.42,2155.43,percent of total billed charges,
Nerve Conduction 9 To 10,7957547,CDM,922,RC,95911,HCPCS,,,facility,inpatient,,,3243.00000,940.47000,Aetna,First Health,,2652.77,,,,,,,1945.80,2652.77,percent of total billed charges,
Nerve Conduction 9 To 10,7957547,CDM,922,RC,95911,HCPCS,,,facility,outpatient,,,3243.00000,940.47000,Aetna,First Health,,2652.77,,,,,,,373.76,2652.77,percent of total billed charges,
Nerve Conduction 11 To 12,7957548,CDM,922,RC,95912,HCPCS,,,facility,inpatient,,,3852.00000,1117.08000,Aetna,First Health,,3150.94,,,,,,,2311.20,3150.94,percent of total billed charges,
Nerve Conduction 11 To 12,7957548,CDM,922,RC,95912,HCPCS,,,facility,outpatient,,,3852.00000,1117.08000,Aetna,First Health,,3150.94,,,,,,,373.76,3150.94,percent of total billed charges,
Nerve Conduction 13 Or More,7957549,CDM,922,RC,95913,HCPCS,,,facility,inpatient,,,4461.00000,1293.69000,Aetna,First Health,,3649.10,,,,,,,2676.60,3649.10,percent of total billed charges,
Nerve Conduction 13 Or More,7957549,CDM,922,RC,95913,HCPCS,,,facility,outpatient,,,4461.00000,1293.69000,Aetna,First Health,,3649.10,,,,,,,373.76,3649.10,percent of total billed charges,
Blink Reflex Nerve Conduction,7963892,CDM,922,RC,95933,HCPCS,,,facility,inpatient,,,520.00000,150.80000,Aetna,First Health,,425.36,,,,,,,312.00,425.36,percent of total billed charges,
Blink Reflex Nerve Conduction,7963892,CDM,922,RC,95933,HCPCS,,,facility,outpatient,,,520.00000,150.80000,Aetna,First Health,,425.36,,,,,,,59.09,425.36,percent of total billed charges,
EMG With Nerve Limited Each Right Ext,9016681,CDM,922,RC,95885,HCPCS,,,facility,inpatient,,,591.00000,171.39000,Aetna,First Health,RT,483.44,,,,,,,354.60,483.44,percent of total billed charges,
EMG With Nerve Limited Each Right Ext,9016681,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,First Health,RT,483.44,,,,,,,213.06,483.44,percent of total billed charges,
EMG With Nerve Limited Each Left Ext,9014980,CDM,922,RC,95885,HCPCS,,,facility,inpatient,,,591.00000,171.39000,Aetna,First Health,LT,483.44,,,,,,,354.60,483.44,percent of total billed charges,
EMG With Nerve Limited Each Left Ext,9014980,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,First Health,LT,483.44,,,,,,,213.06,483.44,percent of total billed charges,
EMG With Nerve Limited Each Bilateral,9016683,CDM,922,RC,95885,HCPCS,,,facility,inpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,709.20,966.88,percent of total billed charges,
EMG With Nerve Limited Each Bilateral,9016683,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,426.11,966.88,percent of total billed charges,
EMG With Nerve Comp Each Right Ext,9016677,CDM,922,RC,95886,HCPCS,,,facility,inpatient,,,591.00000,171.39000,Aetna,First Health,RT,483.44,,,,,,,354.60,483.44,percent of total billed charges,
EMG With Nerve Comp Each Right Ext,9016677,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,First Health,RT,483.44,,,,,,,213.06,483.44,percent of total billed charges,
EMG With Nerve Comp Each Left Ext,9014978,CDM,922,RC,95886,HCPCS,,,facility,inpatient,,,591.00000,171.39000,Aetna,First Health,LT,483.44,,,,,,,354.60,483.44,percent of total billed charges,
EMG With Nerve Comp Each Left Ext,9014978,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,First Health,LT,483.44,,,,,,,213.06,483.44,percent of total billed charges,
EMG With Nerve Comp Each Bilateral,9016679,CDM,922,RC,95886,HCPCS,,,facility,inpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,709.20,966.88,percent of total billed charges,
EMG With Nerve Comp Each Bilateral,9016679,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,426.11,966.88,percent of total billed charges,
EMG w Nerve Comp Ea Bilteral,9041348,CDM,922,RC,95886,HCPCS,,,facility,inpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,709.20,966.88,percent of total billed charges,
EMG w Nerve Comp Ea Bilteral,9041348,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,First Health,,966.88,,,,,,,426.11,966.88,percent of total billed charges,
Injection SubQ IM,9094184,CDM,940,RC,96372,HCPCS,,,facility,inpatient,,,375.00000,108.75000,Aetna,First Health,,306.75,,,,,,,225.00,306.75,percent of total billed charges,
Injection SubQ IM,9094184,CDM,940,RC,96372,HCPCS,,,facility,outpatient,,,375.00000,108.75000,Aetna,First Health,,306.75,,,,,,,62.50,306.75,percent of total billed charges,
OP Initial Injection SubQ IM,9106494,CDM,940,RC,96372,HCPCS,,,facility,inpatient,,,375.00000,108.75000,Aetna,First Health,,306.75,,,,,,,225.00,306.75,percent of total billed charges,
OP Initial Injection SubQ IM,9106494,CDM,940,RC,96372,HCPCS,,,facility,outpatient,,,375.00000,108.75000,Aetna,First Health,,306.75,,,,,,,62.50,306.75,percent of total billed charges,
Phlebotomy,7457902,CDM,940,RC,99195,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,383.40,522.70,percent of total billed charges,
Phlebotomy,7457902,CDM,940,RC,99195,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,113.19,522.70,percent of total billed charges,
Phlebotomy,7957593,CDM,940,RC,99195,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,383.40,522.70,percent of total billed charges,
Phlebotomy,7957593,CDM,940,RC,99195,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,113.19,522.70,percent of total billed charges,
Phlebotomy Therapeutic,8997121,CDM,940,RC,99195,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,383.40,522.70,percent of total billed charges,
Phlebotomy Therapeutic,8997121,CDM,940,RC,99195,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,First Health,,522.70,,,,,,,113.19,522.70,percent of total billed charges,
CR Periph Art Dx Rehab,7982780,CDM,940,RC,93668,HCPCS,,,facility,inpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,153.00,208.59,percent of total billed charges,
CR Periph Art Dx Rehab,7982780,CDM,940,RC,93668,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,First Health,,208.59,,,,,,,52.15,208.59,percent of total billed charges,
OP Injection SubQ IM of Patients Own Med,9092744,CDM,940,RC,96372,HCPCS,,,facility,inpatient,,,375.00000,108.75000,Aetna,First Health,FB,306.75,,,,,,,225.00,306.75,percent of total billed charges,
OP Injection SubQ IM of Patients Own Med,9092744,CDM,940,RC,96372,HCPCS,,,facility,outpatient,,,375.00000,108.75000,Aetna,First Health,FB,306.75,,,,,,,62.50,306.75,percent of total billed charges,
OP Initial Injection SubQ IM of Patients Own Med,9106495,CDM,940,RC,96372,HCPCS,,,facility,inpatient,,,375.00000,108.75000,Aetna,First Health,FB,306.75,,,,,,,225.00,306.75,percent of total billed charges,
OP Initial Injection SubQ IM of Patients Own Med,9106495,CDM,940,RC,96372,HCPCS,,,facility,outpatient,,,375.00000,108.75000,Aetna,First Health,FB,306.75,,,,,,,62.50,306.75,percent of total billed charges,
DSME RD Individual,8437087,CDM,942,RC,G0108,HCPCS,,,facility,inpatient,,,183.00000,53.07000,Aetna,First Health,,149.69,,,,,,,109.80,149.69,percent of total billed charges,
DSME RD Individual,8437087,CDM,942,RC,G0108,HCPCS,,,facility,outpatient,,,183.00000,53.07000,Aetna,First Health,,149.69,,,,,,,48.16,149.69,percent of total billed charges,
DSME RD Group,8437099,CDM,942,RC,G0109,HCPCS,,,facility,inpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,36.60,49.90,percent of total billed charges,
DSME RD Group,8437099,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Individual,7786274,CDM,942,RC,G0108,HCPCS,,,facility,inpatient,,,183.00000,53.07000,Aetna,First Health,,149.69,,,,,,,109.80,149.69,percent of total billed charges,
DSME CDCES Individual,7786274,CDM,942,RC,G0108,HCPCS,,,facility,outpatient,,,183.00000,53.07000,Aetna,First Health,,149.69,,,,,,,48.16,149.69,percent of total billed charges,
DSME CDCES Follow Up,8437123,CDM,942,RC,G0108,HCPCS,,,facility,inpatient,,,183.00000,53.07000,Aetna,First Health,,149.69,,,,,,,109.80,149.69,percent of total billed charges,
DSME CDCES Follow Up,8437123,CDM,942,RC,G0108,HCPCS,,,facility,outpatient,,,183.00000,53.07000,Aetna,First Health,,149.69,,,,,,,48.16,149.69,percent of total billed charges,
DSME CDCES Group,8123144,CDM,942,RC,G0109,HCPCS,,,facility,inpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,36.60,49.90,percent of total billed charges,
DSME CDCES Group,8123144,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8123145,CDM,942,RC,G0109,HCPCS,,,facility,inpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,36.60,49.90,percent of total billed charges,
DSME CDCES Group,8123145,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8123146,CDM,942,RC,G0109,HCPCS,,,facility,inpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,36.60,49.90,percent of total billed charges,
DSME CDCES Group,8123146,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8123147,CDM,942,RC,G0109,HCPCS,,,facility,inpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,36.60,49.90,percent of total billed charges,
DSME CDCES Group,8123147,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8123148,CDM,942,RC,G0109,HCPCS,,,facility,inpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,36.60,49.90,percent of total billed charges,
DSME CDCES Group,8123148,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8123149,CDM,942,RC,G0109,HCPCS,,,facility,inpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,36.60,49.90,percent of total billed charges,
DSME CDCES Group,8123149,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8437127,CDM,942,RC,G0109,HCPCS,,,facility,inpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,36.60,49.90,percent of total billed charges,
DSME CDCES Group,8437127,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,First Health,,49.90,,,,,,,13.78,49.90,percent of total billed charges,
MNT Initial,8437103,CDM,942,RC,97802,HCPCS,,,facility,inpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,52.20,71.17,percent of total billed charges,
MNT Initial,8437103,CDM,942,RC,97802,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,17.07,71.17,percent of total billed charges,
MNT Follow Up,8437107,CDM,942,RC,97803,HCPCS,,,facility,inpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,52.20,71.17,percent of total billed charges,
MNT Follow Up,8437107,CDM,942,RC,97803,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,First Health,,71.17,,,,,,,17.07,71.17,percent of total billed charges,
MNT Group,8437119,CDM,942,RC,97804,HCPCS,,,facility,inpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,34.20,46.63,percent of total billed charges,
MNT Group,8437119,CDM,942,RC,97804,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,6.75,46.63,percent of total billed charges,
CR Exercise Without Monitor,6717839,CDM,943,RC,93797,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,202.80,276.48,percent of total billed charges,
CR Exercise Without Monitor,6717839,CDM,943,RC,93797,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,110.55,336.06,percent of total billed charges,
CR Exercise And Monitor,1327802,CDM,943,RC,93798,HCPCS,,,facility,inpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,202.80,276.48,percent of total billed charges,
CR Exercise And Monitor,1327802,CDM,943,RC,93798,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,First Health,,276.48,,,,,,,110.55,336.06,percent of total billed charges,
PR Pulmonary Rehab,5263839,CDM,948,RC,94625,HCPCS,,,facility,inpatient,,,335.00000,97.15000,Aetna,First Health,,274.03,,,,,,,201.00,274.03,percent of total billed charges,
PR Pulmonary Rehab,5263839,CDM,948,RC,94625,HCPCS,,,facility,outpatient,,,335.00000,97.15000,Aetna,First Health,,274.03,,,,,,,52.15,274.03,percent of total billed charges,
PR Pulmon Rehab Procedure 15Min,5757841,CDM,948,RC,G0239,HCPCS,,,facility,inpatient,,,453.00000,131.37000,Aetna,First Health,,370.55,,,,,,,271.80,370.55,percent of total billed charges,
PR Pulmon Rehab Procedure 15Min,5757841,CDM,948,RC,G0239,HCPCS,,,facility,outpatient,,,453.00000,131.37000,Aetna,First Health,,370.55,,,,,,,37.41,370.55,percent of total billed charges,
PR Resp Therapy Group,5757840,CDM,948,RC,G0239,HCPCS,,,facility,inpatient,,,439.00000,127.31000,Aetna,First Health,,359.10,,,,,,,263.40,359.10,percent of total billed charges,
PR Resp Therapy Group,5757840,CDM,948,RC,G0239,HCPCS,,,facility,outpatient,,,439.00000,127.31000,Aetna,First Health,,359.10,,,,,,,37.41,359.10,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,23155048901,NDC,,,facility,inpatient,1,EA,37.40000,10.85000,Aetna,First Health,,30.59,,,,,,,22.44,30.59,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,23155048901,NDC,,,facility,outpatient,1,EA,37.40000,10.85000,Aetna,First Health,,30.59,,,,,,,13.48,30.59,percent of total billed charges,
Hip/Knee Periarticular Syringe,800025544,CDM,250,RC,J2795,HCPCS,,,facility,inpatient,1,EA,533.80000,154.80000,Aetna,First Health,,436.65,,,,,,,197.51,436.65,percent of total billed charges,
Hip/Knee Periarticular Syringe,800025544,CDM,250,RC,J2795,HCPCS,,,facility,outpatient,1,EA,533.80000,154.80000,Aetna,First Health,,436.65,,,,,,,0.04815,436.65,percent of total billed charges,
NUTR- Peptamen AF (1L),800040931,CDM,637,RC,98716066380,NDC,,,facility,inpatient,1,EA,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,189.39,258.20,percent of total billed charges,
NUTR- Peptamen AF (1L),800040931,CDM,637,RC,98716066380,NDC,,,facility,outpatient,1,EA,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,113.79,258.20,percent of total billed charges,
NUTR- Nutren 2.0 (1L),800040927,CDM,637,RC,98716033147,NDC,,,facility,inpatient,1,EA,54.90000,15.92000,Aetna,First Health,,44.91,,,,,,,32.94,44.91,percent of total billed charges,
NUTR- Nutren 2.0 (1L),800040927,CDM,637,RC,98716033147,NDC,,,facility,outpatient,1,EA,54.90000,15.92000,Aetna,First Health,,44.91,,,,,,,19.79,44.91,percent of total billed charges,
NUTR- Peptamen 1.5 (1L),800040930,CDM,637,RC,98716018194,NDC,,,facility,inpatient,1,EA,321.70000,93.29000,Aetna,First Health,,263.15,,,,,,,193.02,263.15,percent of total billed charges,
NUTR- Peptamen 1.5 (1L),800040930,CDM,637,RC,98716018194,NDC,,,facility,outpatient,1,EA,321.70000,93.29000,Aetna,First Health,,263.15,,,,,,,115.97,263.15,percent of total billed charges,
NUTR- Nutren 2.0 (250mL),800040926,CDM,637,RC,98716006230,NDC,,,facility,inpatient,1,EA,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,9.75,13.29,percent of total billed charges,
NUTR- Nutren 2.0 (250mL),800040926,CDM,637,RC,98716006230,NDC,,,facility,outpatient,1,EA,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,5.86,13.29,percent of total billed charges,
NUTR- PROSource TF20 60mL,800046575,CDM,637,RC,94688014406,NDC,,,facility,inpatient,1,EA,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,13.50,18.41,percent of total billed charges,
NUTR- PROSource TF20 60mL,800046575,CDM,637,RC,94688014406,NDC,,,facility,outpatient,1,EA,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,8.11,18.41,percent of total billed charges,
HYDROmorphone 0.2mg/mL /NS PCA,800019908,CDM,636,RC,J1171,HCPCS,88888772031,NDC,facility,inpatient,20,ME,204.70000,59.36000,Aetna,First Health,,167.44,,,,,,,73.79,167.44,percent of total billed charges,
HYDROmorphone 0.2mg/mL /NS PCA,800019908,CDM,636,RC,J1171,HCPCS,88888772031,NDC,facility,outpatient,20,ME,204.70000,59.36000,Aetna,First Health,,167.44,,,,,,,0.13482,167.44,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,87701040072,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.53,7.81,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,87701040072,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,83634050082,NDC,facility,inpatient,4,GM,57.40000,16.65000,Aetna,First Health,,46.95,,,,,,,20.69,46.95,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,83634050082,NDC,facility,outpatient,4,GM,57.40000,16.65000,Aetna,First Health,,46.95,,,,,,,0.39483,46.95,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,83634050081,NDC,facility,inpatient,2,GM,53.15000,15.41000,Aetna,First Health,,43.48,,,,,,,19.16,43.48,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,83634050081,NDC,facility,outpatient,2,GM,53.15000,15.41000,Aetna,First Health,,43.48,,,,,,,0.39483,43.48,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,83634045101,NDC,facility,inpatient,0.004,ME,388.10000,112.55000,Aetna,First Health,,317.47,,,,,,,139.91,317.47,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,83634045101,NDC,facility,outpatient,0.004,ME,388.10000,112.55000,Aetna,First Health,,317.47,,,,,,,3.28,317.47,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,83634040010,NDC,facility,inpatient,250,ME,846.00000,245.34000,Aetna,First Health,,692.03,,,,,,,304.98,692.03,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,83634040010,NDC,facility,outpatient,250,ME,846.00000,245.34000,Aetna,First Health,,692.03,,,,,,,0.15408,692.03,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,83634030204,NDC,facility,inpatient,40,ME,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,4.15,9.41,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,83634030204,NDC,facility,outpatient,40,ME,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,0.01926,9.41,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,800046518,CDM,250,RC,83490020760,NDC,,,facility,inpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.31,5.11,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,800046518,CDM,250,RC,83490020760,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,800046526,CDM,636,RC,Q5108,HCPCS,83257000541,NDC,facility,inpatient,6,ME,8506.60000,2466.91000,Aetna,First Health,,6958.40,,,,,,,3066.63,6958.40,percent of total billed charges,
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,800046526,CDM,636,RC,Q5108,HCPCS,83257000541,NDC,facility,outpatient,6,ME,8506.60000,2466.91000,Aetna,First Health,,6958.40,,,,,,,95.21,6958.40,percent of total billed charges,
Trastuzumab- dkst 420mg Inj,800051055,CDM,636,RC,Q5114,HCPCS,83257000412,NDC,facility,inpatient,420,ME,14362.25000,4165.05000,Aetna,First Health,,11748.32,,,,,,,5177.59,11748.32,percent of total billed charges,
Trastuzumab- dkst 420mg Inj,800051055,CDM,636,RC,Q5114,HCPCS,83257000412,NDC,facility,outpatient,420,ME,14362.25000,4165.05000,Aetna,First Health,,11748.32,,,,,,,36.31,11748.32,percent of total billed charges,
Trastuzumab- dkst 150mg Inj,800051054,CDM,636,RC,Q5114,HCPCS,83257000111,NDC,facility,inpatient,150,ME,5265.75000,1527.07000,Aetna,First Health,,4307.38,,,,,,,1898.30,4307.38,percent of total billed charges,
Trastuzumab- dkst 150mg Inj,800051054,CDM,636,RC,Q5114,HCPCS,83257000111,NDC,facility,outpatient,150,ME,5265.75000,1527.07000,Aetna,First Health,,4307.38,,,,,,,36.31,4307.38,percent of total billed charges,
naloxegol 25mg Tab UD,800046420,CDM,637,RC,82625880201,NDC,,,facility,inpatient,1,EA,123.60000,35.84000,Aetna,First Health,,101.10,,,,,,,74.16,101.10,percent of total billed charges,
naloxegol 25mg Tab UD,800046420,CDM,637,RC,82625880201,NDC,,,facility,outpatient,1,EA,123.60000,35.84000,Aetna,First Health,,101.10,,,,,,,44.56,101.10,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,82036427401,NDC,,,facility,inpatient,1,EA,477.75000,138.55000,Aetna,First Health,,390.80,,,,,,,286.65,390.80,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,82036427401,NDC,,,facility,outpatient,1,EA,477.75000,138.55000,Aetna,First Health,,390.80,,,,,,,172.23,390.80,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,81952011210,NDC,facility,inpatient,30000,UN,119.30000,34.60000,Aetna,First Health,,97.59,,,,,,,43.01,97.59,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,81952011210,NDC,facility,outpatient,30000,UN,119.30000,34.60000,Aetna,First Health,,97.59,,,,,,,0.17334,97.59,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,81952011106,NDC,facility,inpatient,5000,UN,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,7.80,13.58,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,81952011106,NDC,facility,outpatient,5000,UN,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,0.17334,13.58,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,81665020025,NDC,,,facility,inpatient,1,EA,155.55000,45.11000,Aetna,First Health,,127.24,,,,,,,57.55,127.24,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,81665020025,NDC,,,facility,outpatient,1,EA,155.55000,45.11000,Aetna,First Health,,127.24,,,,,,,56.08,127.24,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,81298965903,NDC,,,facility,inpatient,1,EA,274.20000,79.52000,Aetna,First Health,,224.30,,,,,,,101.45,224.30,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,81298965903,NDC,,,facility,outpatient,1,EA,274.20000,79.52000,Aetna,First Health,,224.30,,,,,,,98.85,224.30,percent of total billed charges,
Norepinephrine 8mg/NS 250mL-Dbl Conc,800051974,CDM,250,RC,81298965503,NDC,,,facility,inpatient,1,EA,379.80000,110.14000,Aetna,First Health,,310.68,,,,,,,140.53,310.68,percent of total billed charges,
Norepinephrine 8mg/NS 250mL-Dbl Conc,800051974,CDM,250,RC,81298965503,NDC,,,facility,outpatient,1,EA,379.80000,110.14000,Aetna,First Health,,310.68,,,,,,,136.92,310.68,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,81298811001,NDC,facility,inpatient,500,ME,1007.40000,292.15000,Aetna,First Health,,824.05,,,,,,,363.17,824.05,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,81298811001,NDC,facility,outpatient,500,ME,1007.40000,292.15000,Aetna,First Health,,824.05,,,,,,,0.56817,824.05,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,81298578105,NDC,facility,inpatient,40,ME,33.50000,9.72000,Aetna,First Health,,27.40,,,,,,,12.08,27.40,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,81298578105,NDC,facility,outpatient,40,ME,33.50000,9.72000,Aetna,First Health,,27.40,,,,,,,0.71262,27.40,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,81298501003,NDC,,,facility,inpatient,1,EA,352.05000,102.09000,Aetna,First Health,,287.98,,,,,,,126.91,287.98,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,81298501003,NDC,,,facility,outpatient,1,EA,352.05000,102.09000,Aetna,First Health,,287.98,,,,,,,126.91,287.98,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,81284061210,NDC,,,facility,inpatient,1,EA,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,13.51,29.86,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,81284061210,NDC,,,facility,outpatient,1,EA,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,13.16,29.86,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,81284061110,NDC,,,facility,inpatient,1,EA,52.80000,15.31000,Aetna,First Health,,43.19,,,,,,,19.54,43.19,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,81284061110,NDC,,,facility,outpatient,1,EA,52.80000,15.31000,Aetna,First Health,,43.19,,,,,,,19.03,43.19,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,81284041110,NDC,facility,inpatient,1,ME,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,143.84,326.38,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,81284041110,NDC,facility,outpatient,1,ME,399.00000,115.71000,Aetna,First Health,,326.38,,,,,,,54.97,326.38,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,81033051250,NDC,,,facility,inpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,5.61,7.65,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,81033051250,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,3.37,7.65,percent of total billed charges,
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,800046390,CDM,636,RC,J0612,HCPCS,80830236202,NDC,facility,inpatient,1,GM,201.45000,58.42000,Aetna,First Health,,164.79,,,,,,,72.62,164.79,percent of total billed charges,
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,800046390,CDM,636,RC,J0612,HCPCS,80830236202,NDC,facility,outpatient,1,GM,201.45000,58.42000,Aetna,First Health,,164.79,,,,,,,0.02889,164.79,percent of total billed charges,
Tranexamic Acid 1g/100mL Bolus,800062092,CDM,250,RC,80830232903,NDC,,,facility,inpatient,1,EA,208.90000,60.58000,Aetna,First Health,,170.88,,,,,,,77.29,170.88,percent of total billed charges,
Tranexamic Acid 1g/100mL Bolus,800062092,CDM,250,RC,80830232903,NDC,,,facility,outpatient,1,EA,208.90000,60.58000,Aetna,First Health,,170.88,,,,,,,75.31,170.88,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,80830169102,NDC,,,facility,inpatient,1,EA,445.00000,129.05000,Aetna,First Health,,364.01,,,,,,,164.65,364.01,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,80830169102,NDC,,,facility,outpatient,1,EA,445.00000,129.05000,Aetna,First Health,,364.01,,,,,,,160.42,364.01,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,79854051281,NDC,,,facility,inpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.18000,0.24540,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,79854051281,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.10815,0.24540,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,78670013002,NDC,facility,inpatient,0.3,ME,663.00000,192.27000,Aetna,First Health,,542.33,,,,,,,239.01,542.33,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,78670013002,NDC,facility,outpatient,0.3,ME,663.00000,192.27000,Aetna,First Health,,542.33,,,,,,,0.41409,542.33,percent of total billed charges,
inFLIXimab - abda 100mg Inj,800046544,CDM,636,RC,Q5104,HCPCS,78206016201,NDC,facility,inpatient,100,ME,5611.40000,1627.31000,Aetna,First Health,,4590.13,,,,,,,2022.91,4590.13,percent of total billed charges,
inFLIXimab - abda 100mg Inj,800046544,CDM,636,RC,Q5104,HCPCS,78206016201,NDC,facility,outpatient,100,ME,5611.40000,1627.31000,Aetna,First Health,,4590.13,,,,,,,26.72,4590.13,percent of total billed charges,
Etonogestrel 68 mg Implant,800062083,CDM,636,RC,J7307,HCPCS,78206014501,NDC,facility,inpatient,68,ME,7689.40000,2229.93000,Aetna,First Health,,6289.93,,,,,,,2772.03,6289.93,percent of total billed charges,
Etonogestrel 68 mg Implant,800062083,CDM,636,RC,J7307,HCPCS,78206014501,NDC,facility,outpatient,68,ME,7689.40000,2229.93000,Aetna,First Health,,6289.93,,,,,,,1336.20,6289.93,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,78206012302,NDC,,,facility,inpatient,1,EA,51.90000,15.05000,Aetna,First Health,,42.45,,,,,,,31.14,42.45,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,78206012302,NDC,,,facility,outpatient,1,EA,51.90000,15.05000,Aetna,First Health,,42.45,,,,,,,18.71,42.45,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,78206012202,NDC,,,facility,inpatient,1,EA,38.05000,11.03000,Aetna,First Health,,31.12,,,,,,,22.83,31.12,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,78206012202,NDC,,,facility,outpatient,1,EA,38.05000,11.03000,Aetna,First Health,,31.12,,,,,,,13.72,31.12,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,78206012201,NDC,,,facility,inpatient,1,EA,38.05000,11.03000,Aetna,First Health,,31.12,,,,,,,22.83,31.12,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,78206012201,NDC,,,facility,outpatient,1,EA,38.05000,11.03000,Aetna,First Health,,31.12,,,,,,,13.72,31.12,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,78206012101,NDC,,,facility,inpatient,1,EA,28.40000,8.24000,Aetna,First Health,,23.23,,,,,,,17.04,23.23,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,78206012101,NDC,,,facility,outpatient,1,EA,28.40000,8.24000,Aetna,First Health,,23.23,,,,,,,10.24,23.23,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,78206011801,NDC,facility,inpatient,30,ME,267.35000,77.53000,Aetna,First Health,,218.69,,,,,,,96.38,218.69,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,78206011801,NDC,facility,outpatient,30,ME,267.35000,77.53000,Aetna,First Health,,218.69,,,,,,,6.65,218.69,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,78112073623,NDC,,,facility,inpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,18.24,40.33,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,78112073623,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,17.77,40.33,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,78112073621,NDC,,,facility,inpatient,1,EA,56.80000,16.47000,Aetna,First Health,,46.46,,,,,,,21.02,46.46,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,78112073621,NDC,,,facility,outpatient,1,EA,56.80000,16.47000,Aetna,First Health,,46.46,,,,,,,20.48,46.46,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,76439030910,NDC,,,facility,inpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,4.65,6.34,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,76439030910,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,2.79,6.34,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,76439030210,NDC,,,facility,inpatient,1,EA,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,21.84,29.78,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,76439030210,NDC,,,facility,outpatient,1,EA,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,13.12,29.78,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,76385013401,NDC,,,facility,inpatient,1,EA,28.05000,8.13000,Aetna,First Health,,22.94,,,,,,,16.83,22.94,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,76385013401,NDC,,,facility,outpatient,1,EA,28.05000,8.13000,Aetna,First Health,,22.94,,,,,,,10.11,22.94,percent of total billed charges,
Lidocaine 4% Topical Trach Kit,800025652,CDM,250,RC,76329630005,NDC,,,facility,inpatient,1,EA,253.45000,73.50000,Aetna,First Health,,207.32,,,,,,,93.78,207.32,percent of total billed charges,
Lidocaine 4% Topical Trach Kit,800025652,CDM,250,RC,76329630005,NDC,,,facility,outpatient,1,EA,253.45000,73.50000,Aetna,First Health,,207.32,,,,,,,91.37,207.32,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,76329339001,NDC,,,facility,inpatient,1,EA,57.20000,16.59000,Aetna,First Health,,46.79,,,,,,,20.62,46.79,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,76329339001,NDC,,,facility,outpatient,1,EA,57.20000,16.59000,Aetna,First Health,,46.79,,,,,,,20.62,46.79,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,inpatient,2,ME,204.85000,59.41000,Aetna,First Health,,167.57,,,,,,,73.85,167.57,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,outpatient,2,ME,204.85000,59.41000,Aetna,First Health,,167.57,,,,,,,0.06741,167.57,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,800018007,CDM,250,RC,76329335201,NDC,,,facility,inpatient,1,EA,125.70000,36.45000,Aetna,First Health,,102.82,,,,,,,46.51,102.82,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,800018007,CDM,250,RC,76329335201,NDC,,,facility,outpatient,1,EA,125.70000,36.45000,Aetna,First Health,,102.82,,,,,,,45.31,102.82,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,76329334001,NDC,facility,inpatient,1,ME,73.10000,21.20000,Aetna,First Health,,59.80,,,,,,,26.35,59.80,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,76329334001,NDC,facility,outpatient,1,ME,73.10000,21.20000,Aetna,First Health,,59.80,,,,,,,0.09630,59.80,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,76329333901,NDC,facility,inpatient,1,ME,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,20.71,46.99,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,76329333901,NDC,facility,outpatient,1,ME,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,0.09630,46.99,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,76329331801,NDC,facility,inpatient,1,ME,87.70000,25.43000,Aetna,First Health,,71.74,,,,,,,31.62,71.74,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,76329331801,NDC,facility,outpatient,1,ME,87.70000,25.43000,Aetna,First Health,,71.74,,,,,,,2.89,71.74,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,76329331601,NDC,facility,inpatient,1,ME,62.90000,18.24000,Aetna,First Health,,51.45,,,,,,,22.68,51.45,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,76329331601,NDC,facility,outpatient,1,ME,62.90000,18.24000,Aetna,First Health,,51.45,,,,,,,2.89,51.45,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,76329330401,NDC,,,facility,inpatient,1,EA,67.05000,19.44000,Aetna,First Health,,54.85,,,,,,,24.81,54.85,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,76329330401,NDC,,,facility,outpatient,1,EA,67.05000,19.44000,Aetna,First Health,,54.85,,,,,,,24.17,54.85,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,76329146901,NDC,facility,inpatient,2,ME,108.20000,31.38000,Aetna,First Health,,88.51,,,,,,,39.01,88.51,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,76329146901,NDC,facility,outpatient,2,ME,108.20000,31.38000,Aetna,First Health,,88.51,,,,,,,0.06741,88.51,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,76329124005,NDC,facility,inpatient,1,ME,27.15000,7.87000,Aetna,First Health,,22.21,,,,,,,9.79,22.21,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,76329124005,NDC,facility,outpatient,1,ME,27.15000,7.87000,Aetna,First Health,,22.21,,,,,,,2.71,22.21,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,1,ME,144.15000,41.80000,Aetna,First Health,,117.91,,,,,,,51.97,117.91,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,1,ME,144.15000,41.80000,Aetna,First Health,,117.91,,,,,,,2.71,117.91,percent of total billed charges,
Phytonadione 1mg/0.5mL Inj - Alum Free,800051071,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,1,ME,144.15000,41.80000,Aetna,First Health,,117.91,,,,,,,51.97,117.91,percent of total billed charges,
Phytonadione 1mg/0.5mL Inj - Alum Free,800051071,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,outpatient,1,ME,144.15000,41.80000,Aetna,First Health,,117.91,,,,,,,2.71,117.91,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,76297000141,NDC,facility,inpatient,1,EA,93.95000,27.25000,Aetna,First Health,,76.85,,,,,,,33.87,76.85,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,76297000141,NDC,facility,outpatient,1,EA,93.95000,27.25000,Aetna,First Health,,76.85,,,,,,,1.92,76.85,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,76297000131,NDC,facility,inpatient,1,EA,51.85000,15.04000,Aetna,First Health,,42.41,,,,,,,18.69,42.41,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,76297000131,NDC,facility,outpatient,1,EA,51.85000,15.04000,Aetna,First Health,,42.41,,,,,,,0.63558,42.41,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,76297000121,NDC,facility,inpatient,1,EA,46.30000,13.43000,Aetna,First Health,,37.87,,,,,,,16.69,37.87,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,76297000121,NDC,facility,outpatient,1,EA,46.30000,13.43000,Aetna,First Health,,37.87,,,,,,,0.63558,37.87,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,76154047415,NDC,,,facility,inpatient,1,EA,178.50000,51.76000,Aetna,First Health,,146.01,,,,,,,66.05,146.01,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,76154047415,NDC,,,facility,outpatient,1,EA,178.50000,51.76000,Aetna,First Health,,146.01,,,,,,,64.35,146.01,percent of total billed charges,
EPINEPHrine 4 mg/NS 250mL IVPB,800020060,CDM,636,RC,J0165,HCPCS,76154046615,NDC,facility,inpatient,4,ME,212.50000,61.62000,Aetna,First Health,,173.82,,,,,,,76.61,173.82,percent of total billed charges,
EPINEPHrine 4 mg/NS 250mL IVPB,800020060,CDM,636,RC,J0165,HCPCS,76154046615,NDC,facility,outpatient,4,ME,212.50000,61.62000,Aetna,First Health,,173.82,,,,,,,0.41409,173.82,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,76125079025,NDC,facility,inpatient,12.5,GM,642.80000,186.41000,Aetna,First Health,,525.81,,,,,,,231.73,525.81,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,76125079025,NDC,facility,outpatient,12.5,GM,642.80000,186.41000,Aetna,First Health,,525.81,,,,,,,51.12,525.81,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,76045020420,NDC,facility,inpatient,10,ME,234.40000,67.98000,Aetna,First Health,,191.74,,,,,,,84.50,191.74,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,76045020420,NDC,facility,outpatient,10,ME,234.40000,67.98000,Aetna,First Health,,191.74,,,,,,,6.44,191.74,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,76045010810,NDC,facility,inpatient,5000,UN,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,9.00,15.66,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,76045010810,NDC,facility,outpatient,5000,UN,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,0.17334,15.66,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,76045001010,NDC,facility,inpatient,2,ME,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,12.46,28.26,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,76045001010,NDC,facility,outpatient,2,ME,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,0.13482,28.26,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,76045000910,NDC,facility,inpatient,1,ME,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,12.46,28.26,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,76045000910,NDC,facility,outpatient,1,ME,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,0.13482,28.26,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,76045000120,NDC,facility,inpatient,2,ME,30.15000,8.74000,Aetna,First Health,,24.66,,,,,,,10.87,24.66,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,76045000120,NDC,facility,outpatient,2,ME,30.15000,8.74000,Aetna,First Health,,24.66,,,,,,,0.13482,24.66,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,76014090310,NDC,facility,inpatient,10,ME,106.55000,30.90000,Aetna,First Health,,87.16,,,,,,,38.41,87.16,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,76014090310,NDC,facility,outpatient,10,ME,106.55000,30.90000,Aetna,First Health,,87.16,,,,,,,0.92448,87.16,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,76014000525,NDC,,,facility,inpatient,1,EA,263.10000,76.30000,Aetna,First Health,,215.22,,,,,,,97.35,215.22,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,76014000525,NDC,,,facility,outpatient,1,EA,263.10000,76.30000,Aetna,First Health,,215.22,,,,,,,94.85,215.22,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,76014000410,NDC,facility,inpatient,50,ME,226.85000,65.79000,Aetna,First Health,,185.56,,,,,,,81.78,185.56,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,76014000410,NDC,facility,outpatient,50,ME,226.85000,65.79000,Aetna,First Health,,185.56,,,,,,,83.93,185.56,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,76014000310,NDC,facility,inpatient,10,ME,117.20000,33.99000,Aetna,First Health,,95.87,,,,,,,42.25,95.87,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,76014000310,NDC,facility,outpatient,10,ME,117.20000,33.99000,Aetna,First Health,,95.87,,,,,,,0.92448,95.87,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,75907004601,NDC,,,facility,inpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,21.87,29.82,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,75907004601,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,13.14,29.82,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,75907004301,NDC,,,facility,inpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,9.90,13.50,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,75907004301,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,75907002548,NDC,,,facility,inpatient,1,EA,510.90000,148.16000,Aetna,First Health,,417.92,,,,,,,306.54,417.92,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,75907002548,NDC,,,facility,outpatient,1,EA,510.90000,148.16000,Aetna,First Health,,417.92,,,,,,,184.18,417.92,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,75907002448,NDC,,,facility,inpatient,1,EA,379.45000,110.04000,Aetna,First Health,,310.39,,,,,,,227.67,310.39,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,75907002448,NDC,,,facility,outpatient,1,EA,379.45000,110.04000,Aetna,First Health,,310.39,,,,,,,136.79,310.39,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,75907002348,NDC,,,facility,inpatient,1,EA,233.20000,67.63000,Aetna,First Health,,190.76,,,,,,,139.92,190.76,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,75907002348,NDC,,,facility,outpatient,1,EA,233.20000,67.63000,Aetna,First Health,,190.76,,,,,,,84.07,190.76,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,75907000530,NDC,,,facility,inpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,31.56,43.03,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,75907000530,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,18.96,43.03,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,75834031101,NDC,,,facility,inpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,4.44,6.05,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,75834031101,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,2.67,6.05,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,800055060,CDM,637,RC,75834028030,NDC,,,facility,inpatient,1,EA,28.45000,8.25000,Aetna,First Health,,23.27,,,,,,,17.07,23.27,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,800055060,CDM,637,RC,75834028030,NDC,,,facility,outpatient,1,EA,28.45000,8.25000,Aetna,First Health,,23.27,,,,,,,10.26,23.27,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,75834015801,NDC,,,facility,inpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,75834015801,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Balsam Peru-Castor Oil Topical Oint,800025588,CDM,637,RC,75834013960,NDC,,,facility,inpatient,1,EA,261.75000,75.91000,Aetna,First Health,,214.11,,,,,,,157.05,214.11,percent of total billed charges,
Balsam Peru-Castor Oil Topical Oint,800025588,CDM,637,RC,75834013960,NDC,,,facility,outpatient,1,EA,261.75000,75.91000,Aetna,First Health,,214.11,,,,,,,94.36,214.11,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,75834012401,NDC,,,facility,inpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,75834012401,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
PHENobarbital 97.2 mg Tab,800051981,CDM,637,RC,75826014210,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
PHENobarbital 97.2 mg Tab,800051981,CDM,637,RC,75826014210,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
PHENobarbital 64.8mg Tab,800051980,CDM,637,RC,75826014110,NDC,,,facility,inpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.90000,1.23,percent of total billed charges,
PHENobarbital 64.8mg Tab,800051980,CDM,637,RC,75826014110,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.54075,1.23,percent of total billed charges,
PHENobarbital 32.4 mg Tab,800051123,CDM,637,RC,75826013910,NDC,,,facility,inpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.84000,1.15,percent of total billed charges,
PHENobarbital 32.4 mg Tab,800051123,CDM,637,RC,75826013910,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.50470,1.15,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,75826011410,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,75826011410,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,74300008186,NDC,,,facility,inpatient,1,EA,45.05000,13.06000,Aetna,First Health,,36.85,,,,,,,16.67,36.85,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,74300008186,NDC,,,facility,outpatient,1,EA,45.05000,13.06000,Aetna,First Health,,36.85,,,,,,,16.24,36.85,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,74300000530,NDC,,,facility,inpatient,1,EA,44.25000,12.83000,Aetna,First Health,,36.20,,,,,,,16.37,36.20,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,74300000530,NDC,,,facility,outpatient,1,EA,44.25000,12.83000,Aetna,First Health,,36.20,,,,,,,15.95,36.20,percent of total billed charges,
Indomethacin 100mg Rectal Supp,800046501,CDM,637,RC,73702014071,NDC,,,facility,inpatient,1,EA,1809.00000,524.61000,Aetna,First Health,,1479.76,,,,,,,1085.40,1479.76,percent of total billed charges,
Indomethacin 100mg Rectal Supp,800046501,CDM,637,RC,73702014071,NDC,,,facility,outpatient,1,EA,1809.00000,524.61000,Aetna,First Health,,1479.76,,,,,,,652.14,1479.76,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,73702013410,NDC,facility,inpatient,200,ME,141.05000,40.90000,Aetna,First Health,,115.38,,,,,,,50.85,115.38,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,73702013410,NDC,facility,outpatient,200,ME,141.05000,40.90000,Aetna,First Health,,115.38,,,,,,,0.93411,115.38,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,73702012915,NDC,,,facility,inpatient,1,EA,61.25000,17.76000,Aetna,First Health,,50.10,,,,,,,22.66,50.10,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,73702012915,NDC,,,facility,outpatient,1,EA,61.25000,17.76000,Aetna,First Health,,50.10,,,,,,,22.08,50.10,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,73702012510,NDC,facility,inpatient,1,ME,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,8.58,19.47,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,73702012510,NDC,facility,outpatient,1,ME,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,8.81,19.47,percent of total billed charges,
efgartigimod alfa-hyaluronidase qvfc Inj - Pt Own Supply,800051962,CDM,636,RC,J9334,HCPCS,73475310203,NDC,facility,inpatient,1,EA,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
efgartigimod alfa-hyaluronidase qvfc Inj - Pt Own Supply,800051962,CDM,636,RC,J9334,HCPCS,73475310203,NDC,facility,outpatient,1,EA,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,105.23,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,73293000101,NDC,,,facility,inpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,5.66,12.84,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,73293000101,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,5.66,12.84,percent of total billed charges,
Ublituximab - xiiy 150mg- Pt Own Supply,800051074,CDM,636,RC,J2329,HCPCS,73150015006,NDC,facility,inpatient,150,ME,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.18025,0.40900,percent of total billed charges,
Ublituximab - xiiy 150mg- Pt Own Supply,800051074,CDM,636,RC,J2329,HCPCS,73150015006,NDC,facility,outpatient,150,ME,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.18500,216.44,percent of total billed charges,
Insulin Aspart Dispensing Pen,800051065,CDM,637,RC,J1815,HCPCS,73070010315,NDC,facility,inpatient,1,EA,175.60000,50.92000,Aetna,First Health,,143.64,,,,,,,105.36,143.64,percent of total billed charges,
Insulin Aspart Dispensing Pen,800051065,CDM,637,RC,J1815,HCPCS,73070010315,NDC,facility,outpatient,1,EA,175.60000,50.92000,Aetna,First Health,,143.64,,,,,,,0.26001,143.64,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,72888014938,NDC,,,facility,inpatient,1,EA,713.10000,206.80000,Aetna,First Health,,583.32,,,,,,,427.86,583.32,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,72888014938,NDC,,,facility,outpatient,1,EA,713.10000,206.80000,Aetna,First Health,,583.32,,,,,,,257.07,583.32,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,72888009401,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,72888009401,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,72888008001,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,72888008001,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,72888001201,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,72888001201,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,72819018509,NDC,,,facility,inpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,6.24,8.51,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,72819018509,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,72611076510,NDC,facility,inpatient,1,GM,57.50000,16.67000,Aetna,First Health,,47.03,,,,,,,20.73,47.03,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,72611076510,NDC,facility,outpatient,1,GM,57.50000,16.67000,Aetna,First Health,,47.03,,,,,,,0.02889,47.03,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,72611076110,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,72611076110,NDC,facility,outpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,0.02889,23.56,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,72611074010,NDC,,,facility,inpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.31,5.11,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,72611074010,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,72611072225,NDC,facility,inpatient,30,ME,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,72611072225,NDC,facility,outpatient,30,ME,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,0.31779,5.85,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,72611071925,NDC,facility,inpatient,15,ME,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,72611071925,NDC,facility,outpatient,15,ME,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,0.31779,5.48,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,72611071601,NDC,facility,inpatient,500,ME,3059.80000,887.34000,Aetna,First Health,,2502.92,,,,,,,1103.06,2502.92,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,72611071601,NDC,facility,outpatient,500,ME,3059.80000,887.34000,Aetna,First Health,,2502.92,,,,,,,55.86,2502.92,percent of total billed charges,
Bevacizumab - adcd 400mg Inj,800051963,CDM,636,RC,Q5129,HCPCS,72606001201,NDC,facility,inpatient,400,ME,14818.85000,4297.47000,Aetna,First Health,,12121.82,,,,,,,5342.20,12121.82,percent of total billed charges,
Bevacizumab - adcd 400mg Inj,800051963,CDM,636,RC,Q5129,HCPCS,72606001201,NDC,facility,outpatient,400,ME,14818.85000,4297.47000,Aetna,First Health,,12121.82,,,,,,,36.75,12121.82,percent of total billed charges,
Bevacizumab - adcd 100mg Inj,800051964,CDM,636,RC,Q5129,HCPCS,72606001101,NDC,facility,inpatient,100,ME,3844.95000,1115.04000,Aetna,First Health,,3145.17,,,,,,,1386.10,3145.17,percent of total billed charges,
Bevacizumab - adcd 100mg Inj,800051964,CDM,636,RC,Q5129,HCPCS,72606001101,NDC,facility,outpatient,100,ME,3844.95000,1115.04000,Aetna,First Health,,3145.17,,,,,,,36.75,3145.17,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,72578009301,NDC,,,facility,inpatient,1,EA,413.15000,119.81000,Aetna,First Health,,337.96,,,,,,,247.89,337.96,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,72578009301,NDC,,,facility,outpatient,1,EA,413.15000,119.81000,Aetna,First Health,,337.96,,,,,,,148.94,337.96,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,72578004001,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,72578004001,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,72578000201,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,72578000201,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Papaverine HCl 60mg/2mL I,800025540,CDM,637,RC,J2440,HCPCS,72516002425,NDC,facility,inpatient,60,ME,362.80000,105.21000,Aetna,First Health,,296.77,,,,,,,217.68,296.77,percent of total billed charges,
Papaverine HCl 60mg/2mL I,800025540,CDM,637,RC,J2440,HCPCS,72516002425,NDC,facility,outpatient,60,ME,362.80000,105.21000,Aetna,First Health,,296.77,,,,,,,43.34,296.77,percent of total billed charges,
Papaverine HCl 60mg/2mL I,800025540,CDM,637,RC,J2440,HCPCS,72516002410,NDC,facility,inpatient,60,ME,350.50000,101.64000,Aetna,First Health,,286.71,,,,,,,210.30,286.71,percent of total billed charges,
Papaverine HCl 60mg/2mL I,800025540,CDM,637,RC,J2440,HCPCS,72516002410,NDC,facility,outpatient,60,ME,350.50000,101.64000,Aetna,First Health,,286.71,,,,,,,43.34,286.71,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,72516001601,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,72516001601,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,72508020410,NDC,,,facility,inpatient,1,EA,51.40000,14.91000,Aetna,First Health,,42.05,,,,,,,30.84,42.05,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,72508020410,NDC,,,facility,outpatient,1,EA,51.40000,14.91000,Aetna,First Health,,42.05,,,,,,,18.53,42.05,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,72508020407,NDC,,,facility,inpatient,1,EA,51.30000,14.88000,Aetna,First Health,,41.96,,,,,,,30.78,41.96,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,72508020407,NDC,,,facility,outpatient,1,EA,51.30000,14.88000,Aetna,First Health,,41.96,,,,,,,18.49,41.96,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,72485067031,NDC,,,facility,inpatient,1,EA,141.85000,41.14000,Aetna,First Health,,116.03,,,,,,,85.11,116.03,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,72485067031,NDC,,,facility,outpatient,1,EA,141.85000,41.14000,Aetna,First Health,,116.03,,,,,,,51.14,116.03,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,72485062513,NDC,,,facility,inpatient,1,EA,948.35000,275.02000,Aetna,First Health,,775.75,,,,,,,569.01,775.75,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,72485062513,NDC,,,facility,outpatient,1,EA,948.35000,275.02000,Aetna,First Health,,775.75,,,,,,,341.88,775.75,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,72485050810,NDC,,,facility,inpatient,1,EA,28.90000,8.38000,Aetna,First Health,,23.64,,,,,,,10.69,23.64,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,72485050810,NDC,,,facility,outpatient,1,EA,28.90000,8.38000,Aetna,First Health,,23.64,,,,,,,10.42,23.64,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,72485050725,NDC,facility,inpatient,200,ME,39.60000,11.48000,Aetna,First Health,,32.39,,,,,,,14.28,32.39,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,72485050725,NDC,facility,outpatient,200,ME,39.60000,11.48000,Aetna,First Health,,32.39,,,,,,,1.74,32.39,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,72485050510,NDC,facility,inpatient,50,ME,101.50000,29.44000,Aetna,First Health,,83.03,,,,,,,36.59,83.03,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,72485050510,NDC,facility,outpatient,50,ME,101.50000,29.44000,Aetna,First Health,,83.03,,,,,,,37.55,83.03,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,72485042210,NDC,facility,inpatient,2,GM,68.25000,19.79000,Aetna,First Health,,55.83,,,,,,,24.60,55.83,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,72485042210,NDC,facility,outpatient,2,GM,68.25000,19.79000,Aetna,First Health,,55.83,,,,,,,0.56817,55.83,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,72485042110,NDC,facility,inpatient,1,GM,46.45000,13.47000,Aetna,First Health,,38.00,,,,,,,16.75,38.00,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,72485042110,NDC,facility,outpatient,1,GM,46.45000,13.47000,Aetna,First Health,,38.00,,,,,,,0.56817,38.00,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,72485041710,NDC,facility,inpatient,3,GM,50.90000,14.76000,Aetna,First Health,,41.64,,,,,,,18.35,41.64,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,72485041710,NDC,facility,outpatient,3,GM,50.90000,14.76000,Aetna,First Health,,41.64,,,,,,,1.28,41.64,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,72485041610,NDC,facility,inpatient,1.5,GM,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,10.91,24.74,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,72485041610,NDC,facility,outpatient,1.5,GM,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,1.28,24.74,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,72485040610,NDC,facility,inpatient,2,GM,98.70000,28.62000,Aetna,First Health,,80.74,,,,,,,35.58,80.74,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,72485040610,NDC,facility,outpatient,2,GM,98.70000,28.62000,Aetna,First Health,,80.74,,,,,,,0.05778,80.74,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,72485040410,NDC,facility,inpatient,4.5,GM,173.60000,50.34000,Aetna,First Health,,142.00,,,,,,,62.58,142.00,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,72485040410,NDC,facility,outpatient,4.5,GM,173.60000,50.34000,Aetna,First Health,,142.00,,,,,,,1.05,142.00,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,72485040310,NDC,facility,inpatient,3.375,GM,137.10000,39.76000,Aetna,First Health,,112.15,,,,,,,49.42,112.15,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,72485040310,NDC,facility,outpatient,3.375,GM,137.10000,39.76000,Aetna,First Health,,112.15,,,,,,,1.05,112.15,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,72485030501,NDC,,,facility,inpatient,1,EA,103.75000,30.09000,Aetna,First Health,,84.87,,,,,,,38.39,84.87,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,72485030501,NDC,,,facility,outpatient,1,EA,103.75000,30.09000,Aetna,First Health,,84.87,,,,,,,37.40,84.87,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,72485011610,NDC,facility,inpatient,25,ME,239.00000,69.31000,Aetna,First Health,,195.50,,,,,,,86.16,195.50,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,72485011610,NDC,facility,outpatient,25,ME,239.00000,69.31000,Aetna,First Health,,195.50,,,,,,,0.06741,195.50,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,72485011010,NDC,,,facility,inpatient,1,EA,169.05000,49.02000,Aetna,First Health,,138.28,,,,,,,101.43,138.28,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,72485011010,NDC,,,facility,outpatient,1,EA,169.05000,49.02000,Aetna,First Health,,138.28,,,,,,,60.94,138.28,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,72485010825,NDC,,,facility,inpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,12.30,27.20,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,72485010825,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,11.99,27.20,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,72485010625,NDC,facility,inpatient,500,ME,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,8.65,19.63,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,72485010625,NDC,facility,outpatient,500,ME,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,0.03852,19.63,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,72485010501,NDC,,,facility,inpatient,1,EA,210.10000,60.93000,Aetna,First Health,,171.86,,,,,,,77.74,171.86,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,72485010501,NDC,,,facility,outpatient,1,EA,210.10000,60.93000,Aetna,First Health,,171.86,,,,,,,75.74,171.86,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,72485010401,NDC,facility,inpatient,60,ME,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,34.61,78.53,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,72485010401,NDC,facility,outpatient,60,ME,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,1.40,78.53,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,72485010125,NDC,facility,inpatient,50,ME,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,72485010125,NDC,facility,outpatient,50,ME,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,0.68373,8.34,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,72485010105,NDC,facility,inpatient,50,ME,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,72485010105,NDC,facility,outpatient,50,ME,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,0.68373,15.66,percent of total billed charges,
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,72266025301,NDC,facility,inpatient,10,ME,38.40000,11.14000,Aetna,First Health,,31.41,,,,,,,13.84,31.41,percent of total billed charges,
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,72266025301,NDC,facility,outpatient,10,ME,38.40000,11.14000,Aetna,First Health,,31.41,,,,,,,2.03,31.41,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,72266023425,NDC,facility,inpatient,15,ME,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,2.33,5.28,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,72266023425,NDC,facility,outpatient,15,ME,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,0.31779,5.28,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,72266020410,NDC,facility,inpatient,10,ME,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,10.56,23.97,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,72266020410,NDC,facility,outpatient,10,ME,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,2.43,23.97,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,72266019701,NDC,,,facility,inpatient,1,EA,127.45000,36.96000,Aetna,First Health,,104.25,,,,,,,76.47,104.25,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,72266019701,NDC,,,facility,outpatient,1,EA,127.45000,36.96000,Aetna,First Health,,104.25,,,,,,,45.95,104.25,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,72266016306,NDC,,,facility,inpatient,1,EA,601.80000,174.52000,Aetna,First Health,,492.27,,,,,,,222.67,492.27,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,72266016306,NDC,,,facility,outpatient,1,EA,601.80000,174.52000,Aetna,First Health,,492.27,,,,,,,216.95,492.27,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,72266016201,NDC,facility,inpatient,100,ME,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,85.80,194.68,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,72266016201,NDC,facility,outpatient,100,ME,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,0.04815,194.68,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,72266016042,NDC,facility,inpatient,20,ME,203.65000,59.06000,Aetna,First Health,,166.59,,,,,,,73.42,166.59,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,72266016042,NDC,facility,outpatient,20,ME,203.65000,59.06000,Aetna,First Health,,166.59,,,,,,,8.81,166.59,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,72266016010,NDC,facility,inpatient,20,ME,203.65000,59.06000,Aetna,First Health,,166.59,,,,,,,73.42,166.59,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,72266016010,NDC,facility,outpatient,20,ME,203.65000,59.06000,Aetna,First Health,,166.59,,,,,,,8.81,166.59,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,72266015910,NDC,facility,inpatient,1,GM,710.00000,205.90000,Aetna,First Health,,580.78,,,,,,,255.96,580.78,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,72266015910,NDC,facility,outpatient,1,GM,710.00000,205.90000,Aetna,First Health,,580.78,,,,,,,8.82,580.78,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,72266015905,NDC,facility,inpatient,1,GM,710.00000,205.90000,Aetna,First Health,,580.78,,,,,,,255.96,580.78,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,72266015905,NDC,facility,outpatient,1,GM,710.00000,205.90000,Aetna,First Health,,580.78,,,,,,,8.82,580.78,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,72266015201,NDC,facility,inpatient,5,ME,1019.40000,295.63000,Aetna,First Health,,833.87,,,,,,,367.49,833.87,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,72266015201,NDC,facility,outpatient,5,ME,1019.40000,295.63000,Aetna,First Health,,833.87,,,,,,,4.89,833.87,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,72266014610,NDC,,,facility,inpatient,1,EA,28.35000,8.22000,Aetna,First Health,,23.19,,,,,,,10.49,23.19,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,72266014610,NDC,,,facility,outpatient,1,EA,28.35000,8.22000,Aetna,First Health,,23.19,,,,,,,10.22,23.19,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,72266012705,NDC,facility,inpatient,20,ME,156.30000,45.33000,Aetna,First Health,,127.85,,,,,,,56.35,127.85,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,72266012705,NDC,facility,outpatient,20,ME,156.30000,45.33000,Aetna,First Health,,127.85,,,,,,,10.91,127.85,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,72266012325,NDC,facility,inpatient,4,ME,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,72266012325,NDC,facility,outpatient,4,ME,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,0.08667,4.50,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,72266012225,NDC,,,facility,inpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,3.07,6.79,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,72266012225,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.99,6.79,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,72266012205,NDC,,,facility,inpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,2.24,4.95,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,72266012205,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,2.18,4.95,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,72266011825,NDC,facility,inpatient,30,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,4.02,9.12,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,72266011825,NDC,facility,outpatient,30,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,0.31779,9.12,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,72266010201,NDC,facility,inpatient,100,ME,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,18.89,41.76,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,72266010201,NDC,facility,outpatient,100,ME,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,0.33705,41.76,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,72266010101,NDC,facility,inpatient,500,ME,3488.25000,1011.59000,Aetna,First Health,,2853.39,,,,,,,1257.51,2853.39,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,72266010101,NDC,facility,outpatient,500,ME,3488.25000,1011.59000,Aetna,First Health,,2853.39,,,,,,,55.86,2853.39,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,72205026507,NDC,facility,inpatient,50,ME,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,18.39,41.72,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,72205026507,NDC,facility,outpatient,50,ME,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,18.87,41.72,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,72205022007,NDC,facility,inpatient,200,ME,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,134.47,305.11,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,72205022007,NDC,facility,outpatient,200,ME,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,0.37557,305.11,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,72205020830,NDC,,,facility,inpatient,1,EA,347.05000,100.64000,Aetna,First Health,,283.89,,,,,,,208.23,283.89,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,72205020830,NDC,,,facility,outpatient,1,EA,347.05000,100.64000,Aetna,First Health,,283.89,,,,,,,125.11,283.89,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),800015427,CDM,637,RC,72205020030,NDC,,,facility,inpatient,1,EA,87.65000,25.42000,Aetna,First Health,,71.70,,,,,,,52.59,71.70,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),800015427,CDM,637,RC,72205020030,NDC,,,facility,outpatient,1,EA,87.65000,25.42000,Aetna,First Health,,71.70,,,,,,,31.60,71.70,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,72205017072,NDC,,,facility,inpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,19.98,27.24,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,72205017072,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,12.00,27.24,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,72205010107,NDC,facility,inpatient,1,ME,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,5.98,13.58,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,72205010107,NDC,facility,outpatient,1,ME,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,0.34668,13.58,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,72205005401,NDC,facility,inpatient,150,ME,2114.50000,613.20000,Aetna,First Health,,1729.66,,,,,,,762.28,1729.66,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,72205005401,NDC,facility,outpatient,150,ME,2114.50000,613.20000,Aetna,First Health,,1729.66,,,,,,,0.10593,1729.66,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,72205004411,NDC,,,facility,inpatient,1,EA,109.45000,31.74000,Aetna,First Health,,89.53,,,,,,,65.67,89.53,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,72205004411,NDC,,,facility,outpatient,1,EA,109.45000,31.74000,Aetna,First Health,,89.53,,,,,,,39.46,89.53,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,72205004160,NDC,,,facility,inpatient,1,EA,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,41.40,56.44,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,72205004160,NDC,,,facility,outpatient,1,EA,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,24.87,56.44,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,72205004060,NDC,,,facility,inpatient,1,EA,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,41.40,56.44,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,72205004060,NDC,,,facility,outpatient,1,EA,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,24.87,56.44,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,72205003960,NDC,,,facility,inpatient,1,EA,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,41.40,56.44,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,72205003960,NDC,,,facility,outpatient,1,EA,69.00000,20.01000,Aetna,First Health,,56.44,,,,,,,24.87,56.44,percent of total billed charges,
NEOnatal TPN Starter Bag,800062119,CDM,258,RC,72196041601,NDC,,,facility,inpatient,1,EA,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,100.11,174.23,percent of total billed charges,
NEOnatal TPN Starter Bag,800062119,CDM,258,RC,72196041601,NDC,,,facility,outpatient,1,EA,213.00000,61.77000,Aetna,First Health,,174.23,,,,,,,76.79,174.23,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,72078003802,NDC,facility,inpatient,400,UN,12668.30000,3673.81000,Aetna,First Health,,10362.67,,,,,,,7600.98,10362.67,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,72078003802,NDC,facility,outpatient,400,UN,12668.30000,3673.81000,Aetna,First Health,,10362.67,,,,,,,4566.92,10362.67,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,72078003401,NDC,,,facility,inpatient,1,EA,603.80000,175.10000,Aetna,First Health,,493.91,,,,,,,223.41,493.91,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,72078003401,NDC,,,facility,outpatient,1,EA,603.80000,175.10000,Aetna,First Health,,493.91,,,,,,,217.67,493.91,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,72078003302,NDC,facility,inpatient,6,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,72078003302,NDC,facility,outpatient,6,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,0.51039,31.33,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,72078002510,NDC,facility,inpatient,20,ME,187.50000,54.37000,Aetna,First Health,,153.38,,,,,,,67.59,153.38,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,72078002510,NDC,facility,outpatient,20,ME,187.50000,54.37000,Aetna,First Health,,153.38,,,,,,,3.52,153.38,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,72078000204,NDC,,,facility,inpatient,1,EA,111.45000,32.32000,Aetna,First Health,,91.17,,,,,,,41.24,91.17,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,72078000204,NDC,,,facility,outpatient,1,EA,111.45000,32.32000,Aetna,First Health,,91.17,,,,,,,40.18,91.17,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,71930005712,NDC,,,facility,inpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,71930005712,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,71839012325,NDC,facility,inpatient,0.2,ME,55.05000,15.96000,Aetna,First Health,,45.03,,,,,,,19.85,45.03,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,71839012325,NDC,facility,outpatient,0.2,ME,55.05000,15.96000,Aetna,First Health,,45.03,,,,,,,0.36594,45.03,percent of total billed charges,
Eravacycline 100mg REC Inj,800046541,CDM,636,RC,J0122,HCPCS,71773010012,NDC,facility,inpatient,100,ME,997.00000,289.13000,Aetna,First Health,,815.55,,,,,,,359.42,815.55,percent of total billed charges,
Eravacycline 100mg REC Inj,800046541,CDM,636,RC,J0122,HCPCS,71773010012,NDC,facility,outpatient,100,ME,997.00000,289.13000,Aetna,First Health,,815.55,,,,,,,1.24,815.55,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,800055060,CDM,637,RC,71740011230,NDC,,,facility,inpatient,1,EA,40.45000,11.73000,Aetna,First Health,,33.09,,,,,,,24.27,33.09,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,800055060,CDM,637,RC,71740011230,NDC,,,facility,outpatient,1,EA,40.45000,11.73000,Aetna,First Health,,33.09,,,,,,,14.58,33.09,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,71656002150,NDC,,,facility,inpatient,1,EA,53.40000,15.49000,Aetna,First Health,,43.68,,,,,,,32.04,43.68,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,71656002150,NDC,,,facility,outpatient,1,EA,53.40000,15.49000,Aetna,First Health,,43.68,,,,,,,19.25,43.68,percent of total billed charges,
aminolevulinic acid 50mL REC Pwd Oral Soln,800046391,CDM,250,RC,71469023101,NDC,,,facility,inpatient,1,EA,17287.75000,5013.45000,Aetna,First Health,,14141.38,,,,,,,6396.47,14141.38,percent of total billed charges,
aminolevulinic acid 50mL REC Pwd Oral Soln,800046391,CDM,250,RC,71469023101,NDC,,,facility,outpatient,1,EA,17287.75000,5013.45000,Aetna,First Health,,14141.38,,,,,,,6232.23,14141.38,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,800019997,CDM,636,RC,J2795,HCPCS,71449012483,NDC,facility,inpatient,1,EA,742.00000,215.18000,Aetna,First Health,,606.96,,,,,,,267.49,606.96,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,800019997,CDM,636,RC,J2795,HCPCS,71449012483,NDC,facility,outpatient,1,EA,742.00000,215.18000,Aetna,First Health,,606.96,,,,,,,0.04815,606.96,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,71449000411,NDC,,,facility,inpatient,1,EA,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,25.97,57.42,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,71449000411,NDC,,,facility,outpatient,1,EA,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,25.31,57.42,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,71399748005,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,71399748005,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,71351002325,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,71351002325,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
Balsam Peru-Castor Oil Topical Oint,800025588,CDM,637,RC,71351001460,NDC,,,facility,inpatient,1,EA,236.80000,68.67000,Aetna,First Health,,193.70,,,,,,,142.08,193.70,percent of total billed charges,
Balsam Peru-Castor Oil Topical Oint,800025588,CDM,637,RC,71351001460,NDC,,,facility,outpatient,1,EA,236.80000,68.67000,Aetna,First Health,,193.70,,,,,,,85.37,193.70,percent of total billed charges,
Doxercalciferol 4mcg/2mL Inj,800062124,CDM,636,RC,J1270,HCPCS,71288080203,NDC,facility,inpatient,0.004,ME,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
Doxercalciferol 4mcg/2mL Inj,800062124,CDM,636,RC,J1270,HCPCS,71288080203,NDC,facility,outpatient,0.004,ME,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,0.29853,15.66,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,71288072096,NDC,,,facility,inpatient,1,EA,33.15000,9.61000,Aetna,First Health,,27.12,,,,,,,12.27,27.12,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,71288072096,NDC,,,facility,outpatient,1,EA,33.15000,9.61000,Aetna,First Health,,27.12,,,,,,,11.95,27.12,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,71288071610,NDC,facility,inpatient,1,GM,86.40000,25.06000,Aetna,First Health,,70.68,,,,,,,31.15,70.68,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,71288071610,NDC,facility,outpatient,1,GM,86.40000,25.06000,Aetna,First Health,,70.68,,,,,,,4.37,70.68,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,71288071206,NDC,,,facility,inpatient,1,EA,122.40000,35.50000,Aetna,First Health,,100.12,,,,,,,45.29,100.12,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,71288071206,NDC,,,facility,outpatient,1,EA,122.40000,35.50000,Aetna,First Health,,100.12,,,,,,,44.13,100.12,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,71288060011,NDC,facility,inpatient,40,ME,18.95000,5.50000,Aetna,First Health,,15.50,,,,,,,6.83,15.50,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,71288060011,NDC,facility,outpatient,40,ME,18.95000,5.50000,Aetna,First Health,,15.50,,,,,,,5.86,18.78,percent of total billed charges,
Haloperidol Decanoate 100mg/1mL Inj,800040916,CDM,636,RC,J1631,HCPCS,71288050302,NDC,facility,inpatient,100,ME,187.50000,54.37000,Aetna,First Health,,153.38,,,,,,,67.59,153.38,percent of total billed charges,
Haloperidol Decanoate 100mg/1mL Inj,800040916,CDM,636,RC,J1631,HCPCS,71288050302,NDC,facility,outpatient,100,ME,187.50000,54.37000,Aetna,First Health,,153.38,,,,,,,3.79,153.38,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,71288043392,NDC,facility,inpatient,40,ME,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,6.47,14.68,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,71288043392,NDC,facility,outpatient,40,ME,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,0.51039,14.68,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,71288042711,NDC,facility,inpatient,250,ME,670.00000,194.30000,Aetna,First Health,,548.06,,,,,,,241.53,548.06,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,71288042711,NDC,facility,outpatient,250,ME,670.00000,194.30000,Aetna,First Health,,548.06,,,,,,,0.15408,548.06,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,71288041403,NDC,facility,inpatient,0.2,ME,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,71288041403,NDC,facility,outpatient,0.2,ME,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,0.36594,13.05,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,71288041403,NDC,facility,inpatient,1,ME,79.80000,23.14000,Aetna,First Health,,65.28,,,,,,,28.77,65.28,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,71288041403,NDC,facility,outpatient,1,ME,79.80000,23.14000,Aetna,First Health,,65.28,,,,,,,0.36594,65.28,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,71288040905,NDC,facility,inpatient,0.25,ME,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,20.71,46.99,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,71288040905,NDC,facility,outpatient,0.25,ME,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,0.33705,46.99,percent of total billed charges,
"Heparin 5,000 unit/0.5mL Inj Syr",800051113,CDM,258,RC,J1644,HCPCS,71288040581,NDC,facility,inpatient,5000,UN,27.15000,7.87000,Aetna,First Health,,22.21,,,,,,,12.76,22.21,percent of total billed charges,
"Heparin 5,000 unit/0.5mL Inj Syr",800051113,CDM,258,RC,J1644,HCPCS,71288040581,NDC,facility,outpatient,5000,UN,27.15000,7.87000,Aetna,First Health,,22.21,,,,,,,0.17334,22.21,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,71288040302,NDC,facility,inpatient,5000,UN,12.15000,3.52000,Aetna,First Health,,9.94,,,,,,,5.71,9.94,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,71288040302,NDC,facility,outpatient,5000,UN,12.15000,3.52000,Aetna,First Health,,9.94,,,,,,,0.17334,9.94,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,71288040231,NDC,facility,inpatient,30000,UN,71.40000,20.71000,Aetna,First Health,,58.41,,,,,,,25.74,58.41,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,71288040231,NDC,facility,outpatient,30000,UN,71.40000,20.71000,Aetna,First Health,,58.41,,,,,,,0.17334,58.41,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,71288040211,NDC,facility,inpatient,10000,UN,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,9.12,20.70,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,71288040211,NDC,facility,outpatient,10000,UN,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,0.17334,20.70,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,71288030302,NDC,facility,inpatient,1,ME,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,71288030302,NDC,facility,outpatient,1,ME,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,0.61632,9.28,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,71288020311,NDC,facility,inpatient,100,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,71288020311,NDC,facility,outpatient,100,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,71288020305,NDC,facility,inpatient,40,ME,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,3.10,7.03,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,71288020305,NDC,facility,outpatient,40,ME,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,0.01926,7.03,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,71288020303,NDC,facility,inpatient,20,ME,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,71288020303,NDC,facility,outpatient,20,ME,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,0.01926,5.24,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,71288020202,NDC,,,facility,inpatient,1,EA,187.50000,54.37000,Aetna,First Health,,153.38,,,,,,,69.38,153.38,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,71288020202,NDC,,,facility,outpatient,1,EA,187.50000,54.37000,Aetna,First Health,,153.38,,,,,,,67.59,153.38,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,71288020185,NDC,facility,inpatient,0.4,ME,127.70000,37.03000,Aetna,First Health,,104.46,,,,,,,46.04,104.46,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,71288020185,NDC,facility,outpatient,0.4,ME,127.70000,37.03000,Aetna,First Health,,104.46,,,,,,,2.58,104.46,percent of total billed charges,
PEMEtrexed 500mg Rec Inj,800022535,CDM,636,RC,J9305,HCPCS,71288016795,NDC,facility,inpatient,500,ME,391.05000,113.40000,Aetna,First Health,,319.88,,,,,,,140.97,319.88,percent of total billed charges,
PEMEtrexed 500mg Rec Inj,800022535,CDM,636,RC,J9305,HCPCS,71288016795,NDC,facility,outpatient,500,ME,391.05000,113.40000,Aetna,First Health,,319.88,,,,,,,3.46,319.88,percent of total billed charges,
PEMEtrexed 500mg Rec Inj,800022535,CDM,636,RC,J9305,HCPCS,71288016750,NDC,facility,inpatient,500,ME,987.00000,286.23000,Aetna,First Health,,807.37,,,,,,,355.81,807.37,percent of total billed charges,
PEMEtrexed 500mg Rec Inj,800022535,CDM,636,RC,J9305,HCPCS,71288016750,NDC,facility,outpatient,500,ME,987.00000,286.23000,Aetna,First Health,,807.37,,,,,,,3.46,807.37,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,71288016330,NDC,facility,inpatient,350,ME,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,89.04,202.05,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,71288016330,NDC,facility,outpatient,350,ME,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,3.70,202.05,percent of total billed charges,
Gemcitabine 2000mg Inj,800016348,CDM,636,RC,J9201,HCPCS,71288011754,NDC,facility,inpatient,2000,ME,331.70000,96.19000,Aetna,First Health,,271.33,,,,,,,119.58,271.33,percent of total billed charges,
Gemcitabine 2000mg Inj,800016348,CDM,636,RC,J9201,HCPCS,71288011754,NDC,facility,outpatient,2000,ME,331.70000,96.19000,Aetna,First Health,,271.33,,,,,,,3.46,271.33,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,71288011530,NDC,facility,inpatient,100,ME,335.00000,97.15000,Aetna,First Health,,274.03,,,,,,,120.77,274.03,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,71288011530,NDC,facility,outpatient,100,ME,335.00000,97.15000,Aetna,First Health,,274.03,,,,,,,0.44298,274.03,percent of total billed charges,
Bendamustine 100mg I(Treanda),800012530,CDM,636,RC,J9033,HCPCS,71288010320,NDC,facility,inpatient,100,ME,2077.00000,602.33000,Aetna,First Health,,1698.99,,,,,,,748.76,1698.99,percent of total billed charges,
Bendamustine 100mg I(Treanda),800012530,CDM,636,RC,J9033,HCPCS,71288010320,NDC,facility,outpatient,100,ME,2077.00000,602.33000,Aetna,First Health,,1698.99,,,,,,,1.97,1698.99,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,71288003221,NDC,facility,inpatient,3,GM,78.45000,22.75000,Aetna,First Health,,64.17,,,,,,,28.28,64.17,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,71288003221,NDC,facility,outpatient,3,GM,78.45000,22.75000,Aetna,First Health,,64.17,,,,,,,1.28,64.17,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,71288003121,NDC,facility,inpatient,1.5,GM,49.25000,14.28000,Aetna,First Health,,40.29,,,,,,,17.75,40.29,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,71288003121,NDC,facility,outpatient,1.5,GM,49.25000,14.28000,Aetna,First Health,,40.29,,,,,,,1.28,40.29,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,71288003021,NDC,facility,inpatient,100,ME,153.60000,44.54000,Aetna,First Health,,125.64,,,,,,,56.83,125.64,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,71288003021,NDC,facility,outpatient,100,ME,153.60000,44.54000,Aetna,First Health,,125.64,,,,,,,0.09630,125.64,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,71288002321,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,71288002321,NDC,facility,outpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,0.02889,47.12,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,71288001695,NDC,facility,inpatient,500,ME,143.05000,41.48000,Aetna,First Health,,117.01,,,,,,,51.57,117.01,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,71288001695,NDC,facility,outpatient,500,ME,143.05000,41.48000,Aetna,First Health,,117.01,,,,,,,0.02889,117.01,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,71288001615,NDC,facility,inpatient,500,ME,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,102.02,231.49,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,71288001615,NDC,facility,outpatient,500,ME,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,0.02889,231.49,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,71288000630,NDC,facility,inpatient,3,GM,78.45000,22.75000,Aetna,First Health,,64.17,,,,,,,28.28,64.17,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,71288000630,NDC,facility,outpatient,3,GM,78.45000,22.75000,Aetna,First Health,,64.17,,,,,,,1.28,64.17,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,71288000520,NDC,facility,inpatient,1.5,GM,49.25000,14.28000,Aetna,First Health,,40.29,,,,,,,17.75,40.29,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,71288000520,NDC,facility,outpatient,1.5,GM,49.25000,14.28000,Aetna,First Health,,40.29,,,,,,,1.28,40.29,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,71225012606,NDC,,,facility,inpatient,1,EA,580.00000,168.20000,Aetna,First Health,,474.44,,,,,,,214.60,474.44,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,71225012606,NDC,,,facility,outpatient,1,EA,580.00000,168.20000,Aetna,First Health,,474.44,,,,,,,209.09,474.44,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,71093012204,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,71093012204,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,71093011104,NDC,,,facility,inpatient,1,EA,17.85000,5.18000,Aetna,First Health,,14.60,,,,,,,10.71,14.60,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,71093011104,NDC,,,facility,outpatient,1,EA,17.85000,5.18000,Aetna,First Health,,14.60,,,,,,,6.43,14.60,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,70954056510,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,70954056510,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
lacosamide 50mg/5mL Oral Soln,800051955,CDM,637,RC,70954048810,NDC,,,facility,inpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,47.37,64.58,percent of total billed charges,
lacosamide 50mg/5mL Oral Soln,800051955,CDM,637,RC,70954048810,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,28.46,64.58,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,70954048430,NDC,,,facility,inpatient,1,EA,43.60000,12.64000,Aetna,First Health,,35.66,,,,,,,26.16,35.66,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,70954048430,NDC,,,facility,outpatient,1,EA,43.60000,12.64000,Aetna,First Health,,35.66,,,,,,,15.72,35.66,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,70954048420,NDC,,,facility,inpatient,1,EA,44.45000,12.89000,Aetna,First Health,,36.36,,,,,,,26.67,36.36,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,70954048420,NDC,,,facility,outpatient,1,EA,44.45000,12.89000,Aetna,First Health,,36.36,,,,,,,16.02,36.36,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,70954045510,NDC,,,facility,inpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,9.57,13.05,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,70954045510,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,70954044420,NDC,,,facility,inpatient,1,EA,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,70954044420,NDC,,,facility,outpatient,1,EA,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,70954044320,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,70954044320,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,70954044310,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,70954044310,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
PARoxetine 20mg/10mL Oral Liq.,800021981,CDM,637,RC,70954031910,NDC,,,facility,inpatient,1,EA,111.70000,32.39000,Aetna,First Health,,91.37,,,,,,,67.02,91.37,percent of total billed charges,
PARoxetine 20mg/10mL Oral Liq.,800021981,CDM,637,RC,70954031910,NDC,,,facility,outpatient,1,EA,111.70000,32.39000,Aetna,First Health,,91.37,,,,,,,40.27,91.37,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),800065135,CDM,637,RC,70954026110,NDC,,,facility,inpatient,1,EA,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,6.39,8.71,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),800065135,CDM,637,RC,70954026110,NDC,,,facility,outpatient,1,EA,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,3.84,8.71,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,70954021210,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,70954021210,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,70954018810,NDC,,,facility,inpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,19.98,27.24,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,70954018810,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,12.00,27.24,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,70954013610,NDC,,,facility,inpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,12.84,17.51,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,70954013610,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,7.71,17.51,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,70954006010,NDC,facility,inpatient,20,ME,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,70954006010,NDC,facility,outpatient,20,ME,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.00963,1.51,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,70954005910,NDC,facility,inpatient,10,ME,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,1.05,1.43,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,70954005910,NDC,facility,outpatient,10,ME,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.00963,1.43,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,70860080282,NDC,facility,inpatient,5,ME,1000.50000,290.14000,Aetna,First Health,,818.41,,,,,,,360.68,818.41,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,70860080282,NDC,facility,outpatient,5,ME,1000.50000,290.14000,Aetna,First Health,,818.41,,,,,,,4.89,818.41,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,70860078405,NDC,,,facility,inpatient,1,EA,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,17.76,39.26,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,70860078405,NDC,,,facility,outpatient,1,EA,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,17.30,39.26,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,70860077802,NDC,facility,inpatient,10,ME,40.55000,11.76000,Aetna,First Health,,33.17,,,,,,,14.62,33.17,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,70860077802,NDC,facility,outpatient,10,ME,40.55000,11.76000,Aetna,First Health,,33.17,,,,,,,2.43,33.17,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,70860077720,NDC,facility,inpatient,4,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,70860077720,NDC,facility,outpatient,4,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,0.08667,7.85,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,70860077602,NDC,facility,inpatient,4,ME,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,70860077602,NDC,facility,outpatient,4,ME,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,0.08667,2.62,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,70860075102,NDC,facility,inpatient,20,ME,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,70860075102,NDC,facility,outpatient,20,ME,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,0.00963,4.50,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,70860070101,NDC,facility,inpatient,30,ME,12.15000,3.52000,Aetna,First Health,,9.94,,,,,,,4.38,9.94,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,70860070101,NDC,facility,outpatient,30,ME,12.15000,3.52000,Aetna,First Health,,9.94,,,,,,,0.31779,9.94,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,70860070002,NDC,facility,inpatient,15,ME,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,4.15,9.41,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,70860070002,NDC,facility,outpatient,15,ME,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,0.31779,9.41,percent of total billed charges,
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,70860060482,NDC,facility,inpatient,1500,ME,749.00000,217.21000,Aetna,First Health,,612.68,,,,,,,270.01,612.68,percent of total billed charges,
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,70860060482,NDC,facility,outpatient,1500,ME,749.00000,217.21000,Aetna,First Health,,612.68,,,,,,,0.03852,612.68,percent of total billed charges,
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,70860060382,NDC,facility,inpatient,1000,ME,542.00000,157.18000,Aetna,First Health,,443.36,,,,,,,195.39,443.36,percent of total billed charges,
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,70860060382,NDC,facility,outpatient,1000,ME,542.00000,157.18000,Aetna,First Health,,443.36,,,,,,,0.03852,443.36,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,70860060282,NDC,facility,inpatient,500,ME,319.00000,92.51000,Aetna,First Health,,260.94,,,,,,,115.00,260.94,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,70860060282,NDC,facility,outpatient,500,ME,319.00000,92.51000,Aetna,First Health,,260.94,,,,,,,0.03852,260.94,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,70860045410,NDC,facility,inpatient,0.04,ME,3967.00000,1150.43000,Aetna,First Health,,3245.01,,,,,,,1430.10,3245.01,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,70860045410,NDC,facility,outpatient,0.04,ME,3967.00000,1150.43000,Aetna,First Health,,3245.01,,,,,,,3.28,3245.01,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,70860045401,NDC,facility,inpatient,0.004,ME,313.15000,90.81000,Aetna,First Health,,256.16,,,,,,,112.89,256.16,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,70860045401,NDC,facility,outpatient,0.004,ME,313.15000,90.81000,Aetna,First Health,,256.16,,,,,,,3.28,256.16,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,70860040610,NDC,facility,inpatient,0.25,ME,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,70860040610,NDC,facility,outpatient,0.25,ME,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.34668,1.92,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,70860040504,NDC,facility,inpatient,1,ME,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,5.23,11.86,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,70860040504,NDC,facility,outpatient,1,ME,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,0.34668,11.86,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,70860040210,NDC,facility,inpatient,250,ME,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,70860040210,NDC,facility,outpatient,250,ME,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,0.15408,1069.94,percent of total billed charges,
Furosemide 100mg I,800013344,CDM,636,RC,J1938,HCPCS,70860030210,NDC,facility,inpatient,100,ME,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,8.31,18.85,percent of total billed charges,
Furosemide 100mg I,800013344,CDM,636,RC,J1938,HCPCS,70860030210,NDC,facility,outpatient,100,ME,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,0.01926,18.85,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,70860030202,NDC,facility,inpatient,20,ME,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,70860030202,NDC,facility,outpatient,20,ME,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,0.01926,5.24,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,70860030105,NDC,,,facility,inpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,6.64,14.68,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,70860030105,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,6.47,14.68,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,70860030005,NDC,,,facility,inpatient,1,EA,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,4.25,9.41,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,70860030005,NDC,,,facility,outpatient,1,EA,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,4.15,9.41,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,70860020050,NDC,facility,inpatient,6,ME,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,6.63,15.05,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,70860020050,NDC,facility,outpatient,6,ME,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,0.09630,15.05,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,70860020017,NDC,facility,inpatient,6,ME,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,6.65,15.09,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,70860020017,NDC,facility,outpatient,6,ME,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,0.09630,15.09,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,70860012620,NDC,facility,inpatient,1,EA,124.30000,36.05000,Aetna,First Health,,101.68,,,,,,,44.81,101.68,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,70860012620,NDC,facility,outpatient,1,EA,124.30000,36.05000,Aetna,First Health,,101.68,,,,,,,0.75114,101.68,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,70860011726,NDC,facility,inpatient,2,GM,208.30000,60.41000,Aetna,First Health,,170.39,,,,,,,75.09,170.39,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,70860011726,NDC,facility,outpatient,2,GM,208.30000,60.41000,Aetna,First Health,,170.39,,,,,,,0.05778,170.39,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,70860010520,NDC,facility,inpatient,1,GM,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,25.96,58.90,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,70860010520,NDC,facility,outpatient,1,GM,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,0.02889,58.90,percent of total billed charges,
Minocycline HCl 100mg Inj,800062068,CDM,636,RC,J2265,HCPCS,70842016010,NDC,facility,inpatient,100,ME,2048.20000,593.98000,Aetna,First Health,,1675.43,,,,,,,738.38,1675.43,percent of total billed charges,
Minocycline HCl 100mg Inj,800062068,CDM,636,RC,J2265,HCPCS,70842016010,NDC,facility,outpatient,100,ME,2048.20000,593.98000,Aetna,First Health,,1675.43,,,,,,,2.67,1675.43,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,70839015030,NDC,,,facility,inpatient,1,EA,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,53.82,73.37,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,70839015030,NDC,,,facility,outpatient,1,EA,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,32.34,73.37,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,70756070360,NDC,,,facility,inpatient,1,EA,45.50000,13.19000,Aetna,First Health,,37.22,,,,,,,27.30,37.22,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,70756070360,NDC,,,facility,outpatient,1,EA,45.50000,13.19000,Aetna,First Health,,37.22,,,,,,,16.40,37.22,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,800046518,CDM,250,RC,70756066460,NDC,,,facility,inpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.20,4.87,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,800046518,CDM,250,RC,70756066460,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,70756064825,NDC,,,facility,inpatient,1,EA,49.80000,14.44000,Aetna,First Health,,40.74,,,,,,,17.95,40.74,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,70756064825,NDC,,,facility,outpatient,1,EA,49.80000,14.44000,Aetna,First Health,,40.74,,,,,,,17.95,40.74,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,70756064625,NDC,,,facility,inpatient,1,EA,39.80000,11.54000,Aetna,First Health,,32.56,,,,,,,14.35,32.56,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,70756064625,NDC,,,facility,outpatient,1,EA,39.80000,11.54000,Aetna,First Health,,32.56,,,,,,,14.35,32.56,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,70756064025,NDC,,,facility,inpatient,1,EA,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,5.43,12.31,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,70756064025,NDC,,,facility,outpatient,1,EA,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,5.43,12.31,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,70756062210,NDC,facility,inpatient,50,ME,226.20000,65.60000,Aetna,First Health,,185.03,,,,,,,81.55,185.03,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,70756062210,NDC,facility,outpatient,50,ME,226.20000,65.60000,Aetna,First Health,,185.03,,,,,,,83.69,185.03,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,70756061125,NDC,,,facility,inpatient,1,EA,238.10000,69.05000,Aetna,First Health,,194.77,,,,,,,88.10,194.77,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,70756061125,NDC,,,facility,outpatient,1,EA,238.10000,69.05000,Aetna,First Health,,194.77,,,,,,,85.84,194.77,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,70756060730,NDC,,,facility,inpatient,1,EA,467.75000,135.65000,Aetna,First Health,,382.62,,,,,,,280.65,382.62,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,70756060730,NDC,,,facility,outpatient,1,EA,467.75000,135.65000,Aetna,First Health,,382.62,,,,,,,168.62,382.62,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,70756060525,NDC,,,facility,inpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,12.30,27.20,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,70756060525,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,11.99,27.20,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,70756021590,NDC,,,facility,inpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,10.11,13.78,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,70756021590,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.07,13.78,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,70756021490,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,70756021490,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,70756020511,NDC,,,facility,inpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,70756020511,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,6.49,14.72,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,70756020111,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,70756020111,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,70756001402,NDC,,,facility,inpatient,1,EA,183.95000,53.35000,Aetna,First Health,,150.47,,,,,,,110.37,150.47,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,70756001402,NDC,,,facility,outpatient,1,EA,183.95000,53.35000,Aetna,First Health,,150.47,,,,,,,66.31,150.47,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,70752013812,NDC,,,facility,inpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,4.32,5.89,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,70752013812,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,70752011303,NDC,,,facility,inpatient,1,EA,1893.75000,549.19000,Aetna,First Health,,1549.09,,,,,,,1136.25,1549.09,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,70752011303,NDC,,,facility,outpatient,1,EA,1893.75000,549.19000,Aetna,First Health,,1549.09,,,,,,,682.70,1549.09,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),800081264,CDM,637,RC,J0603,HCPCS,70748017326,NDC,facility,inpatient,800,ME,56.95000,16.52000,Aetna,First Health,,46.59,,,,,,,34.17,46.59,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),800081264,CDM,637,RC,J0603,HCPCS,70748017326,NDC,facility,outpatient,800,ME,56.95000,16.52000,Aetna,First Health,,46.59,,,,,,,0.19260,46.59,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,70710188606,NDC,facility,inpatient,200,ME,196.60000,57.01000,Aetna,First Health,,160.82,,,,,,,70.87,160.82,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,70710188606,NDC,facility,outpatient,200,ME,196.60000,57.01000,Aetna,First Health,,160.82,,,,,,,0.37557,160.82,percent of total billed charges,
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,70710183805,NDC,facility,inpatient,50,ME,1123.80000,325.90000,Aetna,First Health,,919.27,,,,,,,405.13,919.27,percent of total billed charges,
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,70710183805,NDC,facility,outpatient,50,ME,1123.80000,325.90000,Aetna,First Health,,919.27,,,,,,,5.42,919.27,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,70710171001,NDC,,,facility,inpatient,1,EA,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,9.15,12.47,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,70710171001,NDC,,,facility,outpatient,1,EA,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,5.50,12.47,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,70710166801,NDC,facility,inpatient,10,ME,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,3.78,5.15,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,70710166801,NDC,facility,outpatient,10,ME,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,0.57780,5.15,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70710166307,NDC,facility,inpatient,1,ME,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,6.31,14.31,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70710166307,NDC,facility,outpatient,1,ME,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,0.61632,14.31,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,70710164307,NDC,,,facility,inpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,12.30,27.20,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,70710164307,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,11.99,27.20,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,70710137702,NDC,facility,inpatient,200,ME,127.55000,36.99000,Aetna,First Health,,104.34,,,,,,,45.98,104.34,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,70710137702,NDC,facility,outpatient,200,ME,127.55000,36.99000,Aetna,First Health,,104.34,,,,,,,0.93411,104.34,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,70710135906,NDC,facility,inpatient,200,ME,588.30000,170.61000,Aetna,First Health,,481.23,,,,,,,212.08,481.23,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,70710135906,NDC,facility,outpatient,200,ME,588.30000,170.61000,Aetna,First Health,,481.23,,,,,,,0.37557,481.23,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,70710128901,NDC,,,facility,inpatient,1,EA,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,17.61,24.01,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,70710128901,NDC,,,facility,outpatient,1,EA,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,10.58,24.01,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,70710123301,NDC,,,facility,inpatient,1,EA,304.50000,88.30000,Aetna,First Health,,249.08,,,,,,,182.70,249.08,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,70710123301,NDC,,,facility,outpatient,1,EA,304.50000,88.30000,Aetna,First Health,,249.08,,,,,,,109.77,249.08,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,70710122901,NDC,,,facility,inpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,70710122901,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,6.49,14.72,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,70710122601,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,70710122601,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,70710121001,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,70710121001,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,70710120901,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,70710120901,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
mirabegron 50mg ER T,800051952,CDM,637,RC,70710116003,NDC,,,facility,inpatient,1,EA,117.30000,34.02000,Aetna,First Health,,95.95,,,,,,,70.38,95.95,percent of total billed charges,
mirabegron 50mg ER T,800051952,CDM,637,RC,70710116003,NDC,,,facility,outpatient,1,EA,117.30000,34.02000,Aetna,First Health,,95.95,,,,,,,42.29,95.95,percent of total billed charges,
Mirabegron 25mg ER T,800025525,CDM,637,RC,70710115903,NDC,,,facility,inpatient,1,EA,117.30000,34.02000,Aetna,First Health,,95.95,,,,,,,70.38,95.95,percent of total billed charges,
Mirabegron 25mg ER T,800025525,CDM,637,RC,70710115903,NDC,,,facility,outpatient,1,EA,117.30000,34.02000,Aetna,First Health,,95.95,,,,,,,42.29,95.95,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,70710101002,NDC,,,facility,inpatient,1,EA,109.45000,31.74000,Aetna,First Health,,89.53,,,,,,,65.67,89.53,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,70710101002,NDC,,,facility,outpatient,1,EA,109.45000,31.74000,Aetna,First Health,,89.53,,,,,,,39.46,89.53,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,70710100802,NDC,,,facility,inpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,60.24,82.13,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,70710100802,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,36.19,82.13,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,70700090225,NDC,facility,inpatient,1,ME,229.80000,66.64000,Aetna,First Health,,187.98,,,,,,,82.84,187.98,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,70700090225,NDC,facility,outpatient,1,ME,229.80000,66.64000,Aetna,First Health,,187.98,,,,,,,0.36594,187.98,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,70700026894,NDC,,,facility,inpatient,1,EA,650.25000,188.57000,Aetna,First Health,,531.90,,,,,,,390.15,531.90,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,70700026894,NDC,,,facility,outpatient,1,EA,650.25000,188.57000,Aetna,First Health,,531.90,,,,,,,234.42,531.90,percent of total billed charges,
Fluorouracil 2.5g/50mL Inj,800046552,CDM,636,RC,J9190,HCPCS,70700018822,NDC,facility,inpatient,2500,ME,270.85000,78.55000,Aetna,First Health,,221.56,,,,,,,97.64,221.56,percent of total billed charges,
Fluorouracil 2.5g/50mL Inj,800046552,CDM,636,RC,J9190,HCPCS,70700018822,NDC,facility,outpatient,2500,ME,270.85000,78.55000,Aetna,First Health,,221.56,,,,,,,1.87,221.56,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,70700018623,NDC,facility,inpatient,500,ME,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,45.96,104.30,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,70700018623,NDC,facility,outpatient,500,ME,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,1.87,104.30,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,70700017223,NDC,facility,inpatient,10,ME,119.70000,34.71000,Aetna,First Health,,97.91,,,,,,,43.15,97.91,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,70700017223,NDC,facility,outpatient,10,ME,119.70000,34.71000,Aetna,First Health,,97.91,,,,,,,0.92448,97.91,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,70700016725,NDC,facility,inpatient,1,ME,229.80000,66.64000,Aetna,First Health,,187.98,,,,,,,82.84,187.98,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,70700016725,NDC,facility,outpatient,1,ME,229.80000,66.64000,Aetna,First Health,,187.98,,,,,,,0.36594,187.98,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,70700016201,NDC,,,facility,inpatient,1,EA,36.60000,10.61000,Aetna,First Health,,29.94,,,,,,,21.96,29.94,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,70700016201,NDC,,,facility,outpatient,1,EA,36.60000,10.61000,Aetna,First Health,,29.94,,,,,,,13.19,29.94,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,70700010616,NDC,,,facility,inpatient,1,EA,1604.55000,465.32000,Aetna,First Health,,1312.52,,,,,,,962.73,1312.52,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,70700010616,NDC,,,facility,outpatient,1,EA,1604.55000,465.32000,Aetna,First Health,,1312.52,,,,,,,578.44,1312.52,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,70655000206,NDC,facility,inpatient,200,ME,61.20000,17.75000,Aetna,First Health,,50.06,,,,,,,22.06,50.06,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,70655000206,NDC,facility,outpatient,200,ME,61.20000,17.75000,Aetna,First Health,,50.06,,,,,,,4.31,50.06,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,70594012302,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,70594012302,NDC,facility,outpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,0.02889,47.12,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,70594011202,NDC,,,facility,inpatient,1,EA,245.35000,71.15000,Aetna,First Health,,200.70,,,,,,,88.45,200.70,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,70594011202,NDC,,,facility,outpatient,1,EA,245.35000,71.15000,Aetna,First Health,,200.70,,,,,,,88.45,200.70,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,70594011102,NDC,facility,inpatient,6000,ME,580.00000,168.20000,Aetna,First Health,,474.44,,,,,,,209.09,474.44,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,70594011102,NDC,facility,outpatient,6000,ME,580.00000,168.20000,Aetna,First Health,,474.44,,,,,,,0.35631,474.44,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,70594008902,NDC,facility,inpatient,1,GM,55.20000,16.01000,Aetna,First Health,,45.15,,,,,,,19.90,45.15,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,70594008902,NDC,facility,outpatient,1,GM,55.20000,16.01000,Aetna,First Health,,45.15,,,,,,,0.83781,45.15,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,70594007902,NDC,facility,inpatient,3.375,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,38.07,86.38,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,70594007902,NDC,facility,outpatient,3.375,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,1.05,86.38,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,70594007602,NDC,facility,inpatient,1,GM,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,69.22,157.06,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,70594007602,NDC,facility,outpatient,1,GM,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,0.36594,157.06,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,70594004801,NDC,facility,inpatient,1,GM,205.60000,59.62000,Aetna,First Health,,168.18,,,,,,,74.12,168.18,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,70594004801,NDC,facility,outpatient,1,GM,205.60000,59.62000,Aetna,First Health,,168.18,,,,,,,0.02889,168.18,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,70594003401,NDC,facility,inpatient,500,ME,542.00000,157.18000,Aetna,First Health,,443.36,,,,,,,195.39,443.36,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,70594003401,NDC,facility,outpatient,500,ME,542.00000,157.18000,Aetna,First Health,,443.36,,,,,,,0.02889,443.36,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,70515026010,NDC,facility,inpatient,0.5,ME,721.35000,209.19000,Aetna,First Health,,590.06,,,,,,,260.05,590.06,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,70515026010,NDC,facility,outpatient,0.5,ME,721.35000,209.19000,Aetna,First Health,,590.06,,,,,,,9.22,590.06,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,70512084325,NDC,facility,inpatient,30,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,70512084325,NDC,facility,outpatient,30,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,0.31779,8.26,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70512084025,NDC,facility,inpatient,1,ME,23.65000,6.86000,Aetna,First Health,,19.35,,,,,,,8.53,19.35,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70512084025,NDC,facility,outpatient,1,ME,23.65000,6.86000,Aetna,First Health,,19.35,,,,,,,0.61632,19.35,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,70436020201,NDC,,,facility,inpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,5.37,7.32,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,70436020201,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,3.23,7.32,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,70436018301,NDC,,,facility,inpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,5.37,7.32,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,70436018301,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,3.23,7.32,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,70436014781,NDC,facility,inpatient,20,ME,239.60000,69.48000,Aetna,First Health,,195.99,,,,,,,86.38,195.99,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,70436014781,NDC,facility,outpatient,20,ME,239.60000,69.48000,Aetna,First Health,,195.99,,,,,,,10.91,195.99,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,70436011056,NDC,,,facility,inpatient,1,EA,565.30000,163.94000,Aetna,First Health,,462.42,,,,,,,209.16,462.42,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,70436011056,NDC,,,facility,outpatient,1,EA,565.30000,163.94000,Aetna,First Health,,462.42,,,,,,,203.79,462.42,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,70436009205,NDC,,,facility,inpatient,1,EA,59.60000,17.28000,Aetna,First Health,,48.75,,,,,,,35.76,48.75,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,70436009205,NDC,,,facility,outpatient,1,EA,59.60000,17.28000,Aetna,First Health,,48.75,,,,,,,21.49,48.75,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,70436005901,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,70436005901,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,70436005801,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,70436005801,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,70436005106,NDC,,,facility,inpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,7.74,10.55,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,70436005106,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,4.65,10.55,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,70436003282,NDC,facility,inpatient,100,ME,239.50000,69.46000,Aetna,First Health,,195.91,,,,,,,88.61,195.91,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,70436003282,NDC,facility,outpatient,100,ME,239.50000,69.46000,Aetna,First Health,,195.91,,,,,,,0.09630,195.91,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,70436002880,NDC,,,facility,inpatient,1,EA,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,49.21,108.79,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,70436002880,NDC,,,facility,outpatient,1,EA,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,47.95,108.79,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,70436002680,NDC,facility,inpatient,20,ME,671.55000,194.75000,Aetna,First Health,,549.33,,,,,,,242.09,549.33,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,70436002680,NDC,facility,outpatient,20,ME,671.55000,194.75000,Aetna,First Health,,549.33,,,,,,,3.52,549.33,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,70436002582,NDC,facility,inpatient,250,ME,7582.25000,2198.85000,Aetna,First Health,,6202.28,,,,,,,2733.40,6202.28,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,70436002582,NDC,facility,outpatient,250,ME,7582.25000,2198.85000,Aetna,First Health,,6202.28,,,,,,,0.15408,6202.28,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,70436002382,NDC,facility,inpatient,1,GM,208.80000,60.55000,Aetna,First Health,,170.80,,,,,,,75.27,170.80,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,70436002382,NDC,facility,outpatient,1,GM,208.80000,60.55000,Aetna,First Health,,170.80,,,,,,,0.02889,170.80,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,70436002182,NDC,facility,inpatient,1,GM,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,70436002182,NDC,facility,outpatient,1,GM,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,0.02889,23.56,percent of total billed charges,
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,70436001304,NDC,,,facility,inpatient,1,EA,77.95000,22.61000,Aetna,First Health,,63.76,,,,,,,46.77,63.76,percent of total billed charges,
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,70436001304,NDC,,,facility,outpatient,1,EA,77.95000,22.61000,Aetna,First Health,,63.76,,,,,,,28.10,63.76,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,70436001204,NDC,,,facility,inpatient,1,EA,77.95000,22.61000,Aetna,First Health,,63.76,,,,,,,46.77,63.76,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,70436001204,NDC,,,facility,outpatient,1,EA,77.95000,22.61000,Aetna,First Health,,63.76,,,,,,,28.10,63.76,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,70436000704,NDC,,,facility,inpatient,1,EA,218.50000,63.36000,Aetna,First Health,,178.73,,,,,,,131.10,178.73,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,70436000704,NDC,,,facility,outpatient,1,EA,218.50000,63.36000,Aetna,First Health,,178.73,,,,,,,78.77,178.73,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,70377011512,NDC,,,facility,inpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,4.41,6.01,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,70377011512,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,2.65,6.01,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,70377011412,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,70377011412,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,70377006112,NDC,,,facility,inpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,4.83,6.58,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,70377006112,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,2.90,6.58,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,70377001511,NDC,facility,inpatient,1,ME,31.55000,9.15000,Aetna,First Health,,25.81,,,,,,,18.93,25.81,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,70377001511,NDC,facility,outpatient,1,ME,31.55000,9.15000,Aetna,First Health,,25.81,,,,,,,0.19260,25.81,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,70377000712,NDC,,,facility,inpatient,1,EA,63.25000,18.34000,Aetna,First Health,,51.74,,,,,,,37.95,51.74,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,70377000712,NDC,,,facility,outpatient,1,EA,63.25000,18.34000,Aetna,First Health,,51.74,,,,,,,22.80,51.74,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,70347002502,NDC,,,facility,inpatient,1,EA,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,6.69,9.12,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,70347002502,NDC,,,facility,outpatient,1,EA,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,4.02,9.12,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,70257056302,NDC,facility,inpatient,40,ME,3955.45000,1147.08000,Aetna,First Health,,3235.56,,,,,,,1425.94,3235.56,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,70257056302,NDC,facility,outpatient,40,ME,3955.45000,1147.08000,Aetna,First Health,,3235.56,,,,,,,174.76,3235.56,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,70121172009,NDC,facility,inpatient,4,GM,63.75000,18.49000,Aetna,First Health,,52.15,,,,,,,22.98,52.15,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,70121172009,NDC,facility,outpatient,4,GM,63.75000,18.49000,Aetna,First Health,,52.15,,,,,,,0.39483,52.15,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,70121171909,NDC,facility,inpatient,2,GM,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,45.96,104.30,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,70121171909,NDC,facility,outpatient,2,GM,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,0.39483,104.30,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,70121168007,NDC,,,facility,inpatient,1,EA,1460.85000,423.65000,Aetna,First Health,,1194.98,,,,,,,526.64,1194.98,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,70121168007,NDC,,,facility,outpatient,1,EA,1460.85000,423.65000,Aetna,First Health,,1194.98,,,,,,,526.64,1194.98,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121165105,NDC,facility,inpatient,40,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,19.56,44.38,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121165105,NDC,facility,outpatient,40,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,0.71262,44.38,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121165101,NDC,facility,inpatient,40,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,19.56,44.38,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121165101,NDC,facility,outpatient,40,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,0.71262,44.38,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,70121158007,NDC,facility,inpatient,10,ME,47.90000,13.89000,Aetna,First Health,,39.18,,,,,,,17.27,39.18,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,70121158007,NDC,facility,outpatient,10,ME,47.90000,13.89000,Aetna,First Health,,39.18,,,,,,,2.43,39.18,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,70121157807,NDC,facility,inpatient,50,ME,206.45000,59.87000,Aetna,First Health,,168.88,,,,,,,74.43,168.88,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,70121157807,NDC,facility,outpatient,50,ME,206.45000,59.87000,Aetna,First Health,,168.88,,,,,,,76.39,168.88,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,70121157607,NDC,,,facility,inpatient,1,EA,115.05000,33.36000,Aetna,First Health,,94.11,,,,,,,42.57,94.11,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,70121157607,NDC,,,facility,outpatient,1,EA,115.05000,33.36000,Aetna,First Health,,94.11,,,,,,,41.48,94.11,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,70121157405,NDC,facility,inpatient,80,ME,104.20000,30.22000,Aetna,First Health,,85.24,,,,,,,37.56,85.24,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,70121157405,NDC,facility,outpatient,80,ME,104.20000,30.22000,Aetna,First Health,,85.24,,,,,,,0.11556,85.24,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,70121157305,NDC,facility,inpatient,40,ME,61.50000,17.83000,Aetna,First Health,,50.31,,,,,,,22.17,50.31,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,70121157305,NDC,facility,outpatient,40,ME,61.50000,17.83000,Aetna,First Health,,50.31,,,,,,,0.11556,50.31,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,70121155205,NDC,facility,inpatient,80,ME,104.20000,30.22000,Aetna,First Health,,85.24,,,,,,,37.56,85.24,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,70121155205,NDC,facility,outpatient,80,ME,104.20000,30.22000,Aetna,First Health,,85.24,,,,,,,0.11556,85.24,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,70121155201,NDC,facility,inpatient,80,ME,104.15000,30.20000,Aetna,First Health,,85.19,,,,,,,37.55,85.19,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,70121155201,NDC,facility,outpatient,80,ME,104.15000,30.20000,Aetna,First Health,,85.19,,,,,,,0.11556,85.19,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,70121148001,NDC,facility,inpatient,150,ME,530.05000,153.71000,Aetna,First Health,,433.58,,,,,,,191.08,433.58,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,70121148001,NDC,facility,outpatient,150,ME,530.05000,153.71000,Aetna,First Health,,433.58,,,,,,,0.40446,433.58,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,70121147907,NDC,facility,inpatient,10,ME,164.40000,47.68000,Aetna,First Health,,134.48,,,,,,,59.27,134.48,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,70121147907,NDC,facility,outpatient,10,ME,164.40000,47.68000,Aetna,First Health,,134.48,,,,,,,0.92448,134.48,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,70121146302,NDC,facility,inpatient,250,ME,1684.00000,488.36000,Aetna,First Health,,1377.51,,,,,,,607.08,1377.51,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,70121146302,NDC,facility,outpatient,250,ME,1684.00000,488.36000,Aetna,First Health,,1377.51,,,,,,,5.51,1377.51,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,70121145407,NDC,facility,inpatient,500,ME,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,70121145407,NDC,facility,outpatient,500,ME,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,0.36594,47.12,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,70121145307,NDC,facility,inpatient,1,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,38.07,86.38,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,70121145307,NDC,facility,outpatient,1,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,0.36594,86.38,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,70121122101,NDC,facility,inpatient,20,ME,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,85.80,194.68,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,70121122101,NDC,facility,outpatient,20,ME,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,0.62595,194.68,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,70121118901,NDC,,,facility,inpatient,1,EA,155.70000,45.15000,Aetna,First Health,,127.36,,,,,,,57.61,127.36,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,70121118901,NDC,,,facility,outpatient,1,EA,155.70000,45.15000,Aetna,First Health,,127.36,,,,,,,56.13,127.36,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121104905,NDC,facility,inpatient,40,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,19.56,44.38,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121104905,NDC,facility,outpatient,40,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,0.71262,44.38,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121104902,NDC,facility,inpatient,40,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,19.56,44.38,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121104902,NDC,facility,outpatient,40,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,0.71262,44.38,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,70121100201,NDC,facility,inpatient,20,ME,548.40000,159.04000,Aetna,First Health,,448.59,,,,,,,197.70,448.59,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,70121100201,NDC,facility,outpatient,20,ME,548.40000,159.04000,Aetna,First Health,,448.59,,,,,,,3.52,448.59,percent of total billed charges,
Pegfilgrastim-cbqv 6mg/0.6mL Inj Syr,800040939,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,inpatient,6,ME,16823.20000,4878.73000,Aetna,First Health,,13761.38,,,,,,,6064.76,13761.38,percent of total billed charges,
Pegfilgrastim-cbqv 6mg/0.6mL Inj Syr,800040939,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,6,ME,16823.20000,4878.73000,Aetna,First Health,,13761.38,,,,,,,156.00,13761.38,percent of total billed charges,
Indocyanine Green 25 mg I,800080225,CDM,250,RC,70100042402,NDC,,,facility,inpatient,1,EA,1035.55000,300.31000,Aetna,First Health,,847.08,,,,,,,383.15,847.08,percent of total billed charges,
Indocyanine Green 25 mg I,800080225,CDM,250,RC,70100042402,NDC,,,facility,outpatient,1,EA,1035.55000,300.31000,Aetna,First Health,,847.08,,,,,,,373.32,847.08,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,800019997,CDM,636,RC,J2795,HCPCS,70092958838,NDC,facility,inpatient,1,EA,1419.95000,411.79000,Aetna,First Health,,1161.52,,,,,,,511.89,1161.52,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,800019997,CDM,636,RC,J2795,HCPCS,70092958838,NDC,facility,outpatient,1,EA,1419.95000,411.79000,Aetna,First Health,,1161.52,,,,,,,0.04815,1161.52,percent of total billed charges,
HYDROmorphone 0.2mg/mL /NS PCA,800019908,CDM,636,RC,J1171,HCPCS,70092911536,NDC,facility,inpatient,20,ME,408.00000,118.32000,Aetna,First Health,,333.74,,,,,,,147.08,333.74,percent of total billed charges,
HYDROmorphone 0.2mg/mL /NS PCA,800019908,CDM,636,RC,J1171,HCPCS,70092911536,NDC,facility,outpatient,20,ME,408.00000,118.32000,Aetna,First Health,,333.74,,,,,,,0.13482,333.74,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70092208746,NDC,facility,inpatient,200,ME,214.55000,62.22000,Aetna,First Health,,175.50,,,,,,,77.35,175.50,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70092208746,NDC,facility,outpatient,200,ME,214.55000,62.22000,Aetna,First Health,,175.50,,,,,,,0.93411,175.50,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,70092165005,NDC,,,facility,inpatient,1,EA,231.50000,67.13000,Aetna,First Health,,189.37,,,,,,,85.66,189.37,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,70092165005,NDC,,,facility,outpatient,1,EA,231.50000,67.13000,Aetna,First Health,,189.37,,,,,,,83.46,189.37,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,800019997,CDM,636,RC,J2795,HCPCS,70092158838,NDC,facility,inpatient,1,EA,969.75000,281.23000,Aetna,First Health,,793.26,,,,,,,349.59,793.26,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,800019997,CDM,636,RC,J2795,HCPCS,70092158838,NDC,facility,outpatient,1,EA,969.75000,281.23000,Aetna,First Health,,793.26,,,,,,,0.04815,793.26,percent of total billed charges,
dilTIAZem 125mg /125mL Premix IVPB,800081302,CDM,250,RC,70092157536,NDC,,,facility,inpatient,1,EA,240.35000,69.70000,Aetna,First Health,,196.61,,,,,,,88.93,196.61,percent of total billed charges,
dilTIAZem 125mg /125mL Premix IVPB,800081302,CDM,250,RC,70092157536,NDC,,,facility,outpatient,1,EA,240.35000,69.70000,Aetna,First Health,,196.61,,,,,,,86.65,196.61,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,70092145244,NDC,,,facility,inpatient,1,EA,94.10000,27.29000,Aetna,First Health,,76.97,,,,,,,34.82,76.97,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,70092145244,NDC,,,facility,outpatient,1,EA,94.10000,27.29000,Aetna,First Health,,76.97,,,,,,,33.92,76.97,percent of total billed charges,
Midazolam 100mg/NS 100mL IV,800046429,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,inpatient,100,ME,277.95000,80.61000,Aetna,First Health,,227.36,,,,,,,100.20,227.36,percent of total billed charges,
Midazolam 100mg/NS 100mL IV,800046429,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,outpatient,100,ME,277.95000,80.61000,Aetna,First Health,,227.36,,,,,,,0.13482,227.36,percent of total billed charges,
Morphine 1mg/mL / NS PCA,800019960,CDM,636,RC,J2274,HCPCS,70092138036,NDC,facility,inpatient,100,ME,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,55.16,125.15,percent of total billed charges,
Morphine 1mg/mL / NS PCA,800019960,CDM,636,RC,J2274,HCPCS,70092138036,NDC,facility,outpatient,100,ME,153.00000,44.37000,Aetna,First Health,,125.15,,,,,,,13.00,125.15,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,70092119146,NDC,facility,inpatient,1,ME,27.45000,7.96000,Aetna,First Health,,22.45,,,,,,,9.90,22.45,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,70092119146,NDC,facility,outpatient,1,ME,27.45000,7.96000,Aetna,First Health,,22.45,,,,,,,10.16,22.45,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70092118446,NDC,facility,inpatient,200,ME,129.30000,37.50000,Aetna,First Health,,105.77,,,,,,,46.61,105.77,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70092118446,NDC,facility,outpatient,200,ME,129.30000,37.50000,Aetna,First Health,,105.77,,,,,,,0.93411,105.77,percent of total billed charges,
Lidocaine-NaHCO1%-8.4% IS 10mL,800062126,CDM,250,RC,70092117546,NDC,,,facility,inpatient,1,EA,51.60000,14.96000,Aetna,First Health,,42.21,,,,,,,19.09,42.21,percent of total billed charges,
Lidocaine-NaHCO1%-8.4% IS 10mL,800062126,CDM,250,RC,70092117546,NDC,,,facility,outpatient,1,EA,51.60000,14.96000,Aetna,First Health,,42.21,,,,,,,18.60,42.21,percent of total billed charges,
Lidocaine HCl 1% 10mL IS PF - Anesthesia,800015334,CDM,636,RC,70092116946,NDC,,,facility,inpatient,1,EA,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,24.23,54.97,percent of total billed charges,
Lidocaine HCl 1% 10mL IS PF - Anesthesia,800015334,CDM,636,RC,70092116946,NDC,,,facility,outpatient,1,EA,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,24.23,54.97,percent of total billed charges,
sodium citrate 4%(120mg/3mL) IS,800046529,CDM,250,RC,70092114843,NDC,,,facility,inpatient,1,EA,81.45000,23.62000,Aetna,First Health,,66.63,,,,,,,30.14,66.63,percent of total billed charges,
sodium citrate 4%(120mg/3mL) IS,800046529,CDM,250,RC,70092114843,NDC,,,facility,outpatient,1,EA,81.45000,23.62000,Aetna,First Health,,66.63,,,,,,,29.36,66.63,percent of total billed charges,
Lido 40mg/Epi 0.5mg/Tetr 5mg Top Gel 3mL,800082551,CDM,250,RC,70092113544,NDC,,,facility,inpatient,1,EA,84.70000,24.56000,Aetna,First Health,,69.28,,,,,,,31.34,69.28,percent of total billed charges,
Lido 40mg/Epi 0.5mg/Tetr 5mg Top Gel 3mL,800082551,CDM,250,RC,70092113544,NDC,,,facility,outpatient,1,EA,84.70000,24.56000,Aetna,First Health,,69.28,,,,,,,30.53,69.28,percent of total billed charges,
HYDROmorphone 0.2mg/mL /NS PCA,800019908,CDM,636,RC,J1171,HCPCS,70092111536,NDC,facility,inpatient,20,ME,207.65000,60.22000,Aetna,First Health,,169.86,,,,,,,74.86,169.86,percent of total billed charges,
HYDROmorphone 0.2mg/mL /NS PCA,800019908,CDM,636,RC,J1171,HCPCS,70092111536,NDC,facility,outpatient,20,ME,207.65000,60.22000,Aetna,First Health,,169.86,,,,,,,0.13482,169.86,percent of total billed charges,
Labor Room Epidural 100mL,800022091,CDM,636,RC,J3010,HCPCS,70092110436,NDC,facility,inpatient,1,EA,260.30000,75.49000,Aetna,First Health,,212.93,,,,,,,93.84,212.93,percent of total billed charges,
Labor Room Epidural 100mL,800022091,CDM,636,RC,J3010,HCPCS,70092110436,NDC,facility,outpatient,1,EA,260.30000,75.49000,Aetna,First Health,,212.93,,,,,,,1.15,212.93,percent of total billed charges,
fentaNYL 10mcg/mL /NS PCA 100mL,800019907,CDM,636,RC,J3010,HCPCS,70092109236,NDC,facility,inpatient,1,ME,221.60000,64.26000,Aetna,First Health,,181.27,,,,,,,79.89,181.27,percent of total billed charges,
fentaNYL 10mcg/mL /NS PCA 100mL,800019907,CDM,636,RC,J3010,HCPCS,70092109236,NDC,facility,outpatient,1,ME,221.60000,64.26000,Aetna,First Health,,181.27,,,,,,,1.15,181.27,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70092108746,NDC,facility,inpatient,200,ME,210.60000,61.07000,Aetna,First Health,,172.27,,,,,,,75.92,172.27,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70092108746,NDC,facility,outpatient,200,ME,210.60000,61.07000,Aetna,First Health,,172.27,,,,,,,0.93411,172.27,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,70092107344,NDC,,,facility,inpatient,1,EA,62.45000,18.11000,Aetna,First Health,,51.08,,,,,,,23.11,51.08,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,70092107344,NDC,,,facility,outpatient,1,EA,62.45000,18.11000,Aetna,First Health,,51.08,,,,,,,22.51,51.08,percent of total billed charges,
Oxytocin 30 unit/500 mL-NaCl 0.9%,800046507,CDM,636,RC,J2590,HCPCS,70092106807,NDC,facility,inpatient,30,UN,279.40000,81.03000,Aetna,First Health,,228.55,,,,,,,100.72,228.55,percent of total billed charges,
Oxytocin 30 unit/500 mL-NaCl 0.9%,800046507,CDM,636,RC,J2590,HCPCS,70092106807,NDC,facility,outpatient,30,UN,279.40000,81.03000,Aetna,First Health,,228.55,,,,,,,1.00,228.55,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,inpatient,1,ME,57.70000,16.73000,Aetna,First Health,,47.20,,,,,,,20.80,47.20,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,outpatient,1,ME,57.70000,16.73000,Aetna,First Health,,47.20,,,,,,,21.35,47.20,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,70092103305,NDC,,,facility,inpatient,1,EA,169.40000,49.13000,Aetna,First Health,,138.57,,,,,,,62.68,138.57,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,70092103305,NDC,,,facility,outpatient,1,EA,169.40000,49.13000,Aetna,First Health,,138.57,,,,,,,61.07,138.57,percent of total billed charges,
dilTIAZem 125mg /125mL Premix IVPB,800081302,CDM,250,RC,70092100736,NDC,,,facility,inpatient,1,EA,361.10000,104.72000,Aetna,First Health,,295.38,,,,,,,133.61,295.38,percent of total billed charges,
dilTIAZem 125mg /125mL Premix IVPB,800081302,CDM,250,RC,70092100736,NDC,,,facility,outpatient,1,EA,361.10000,104.72000,Aetna,First Health,,295.38,,,,,,,130.18,295.38,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,70069080610,NDC,facility,inpatient,10,ME,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,17.99,40.82,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,70069080610,NDC,facility,outpatient,10,ME,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,0.92448,40.82,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,70069078804,NDC,facility,inpatient,6000,ME,539.20000,156.37000,Aetna,First Health,,441.07,,,,,,,194.38,441.07,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,70069078804,NDC,facility,outpatient,6000,ME,539.20000,156.37000,Aetna,First Health,,441.07,,,,,,,0.35631,441.07,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,70069074725,NDC,,,facility,inpatient,1,EA,451.95000,131.07000,Aetna,First Health,,369.70,,,,,,,167.22,369.70,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,70069074725,NDC,,,facility,outpatient,1,EA,451.95000,131.07000,Aetna,First Health,,369.70,,,,,,,162.93,369.70,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,70069050101,NDC,,,facility,inpatient,1,EA,593.05000,171.98000,Aetna,First Health,,485.11,,,,,,,355.83,485.11,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,70069050101,NDC,,,facility,outpatient,1,EA,593.05000,171.98000,Aetna,First Health,,485.11,,,,,,,213.79,485.11,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,70069049101,NDC,,,facility,inpatient,1,EA,126.15000,36.58000,Aetna,First Health,,103.19,,,,,,,75.69,103.19,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,70069049101,NDC,,,facility,outpatient,1,EA,126.15000,36.58000,Aetna,First Health,,103.19,,,,,,,45.48,103.19,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,70069042101,NDC,,,facility,inpatient,1,EA,617.60000,179.10000,Aetna,First Health,,505.20,,,,,,,370.56,505.20,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,70069042101,NDC,,,facility,outpatient,1,EA,617.60000,179.10000,Aetna,First Health,,505.20,,,,,,,222.64,505.20,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,70069036210,NDC,facility,inpatient,160,ME,121.65000,35.28000,Aetna,First Health,,99.51,,,,,,,45.01,99.51,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,70069036210,NDC,facility,outpatient,160,ME,121.65000,35.28000,Aetna,First Health,,99.51,,,,,,,0.03852,99.51,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,70069027125,NDC,,,facility,inpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,12.30,27.20,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,70069027125,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,11.99,27.20,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,70069026101,NDC,,,facility,inpatient,1,EA,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,49.21,108.79,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,70069026101,NDC,,,facility,outpatient,1,EA,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,47.95,108.79,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,70069023101,NDC,,,facility,inpatient,1,EA,88.50000,25.66000,Aetna,First Health,,72.39,,,,,,,53.10,72.39,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,70069023101,NDC,,,facility,outpatient,1,EA,88.50000,25.66000,Aetna,First Health,,72.39,,,,,,,31.90,72.39,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,70069014110,NDC,,,facility,inpatient,1,EA,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,52.84,116.81,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,70069014110,NDC,,,facility,outpatient,1,EA,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,51.48,116.81,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,70069013101,NDC,,,facility,inpatient,1,EA,44.25000,12.83000,Aetna,First Health,,36.20,,,,,,,26.55,36.20,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,70069013101,NDC,,,facility,outpatient,1,EA,44.25000,12.83000,Aetna,First Health,,36.20,,,,,,,15.95,36.20,percent of total billed charges,
Tropicamide 1% Ophth Soln(Mydriacyl),800061415,CDM,637,RC,70069012101,NDC,,,facility,inpatient,1,EA,249.45000,72.34000,Aetna,First Health,,204.05,,,,,,,149.67,204.05,percent of total billed charges,
Tropicamide 1% Ophth Soln(Mydriacyl),800061415,CDM,637,RC,70069012101,NDC,,,facility,outpatient,1,EA,249.45000,72.34000,Aetna,First Health,,204.05,,,,,,,89.93,204.05,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,70069010125,NDC,facility,inpatient,1,GM,59.60000,17.28000,Aetna,First Health,,48.75,,,,,,,21.49,48.75,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,70069010125,NDC,facility,outpatient,1,GM,59.60000,17.28000,Aetna,First Health,,48.75,,,,,,,4.37,48.75,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,70069007110,NDC,facility,inpatient,0.4,ME,99.60000,28.88000,Aetna,First Health,,81.47,,,,,,,35.91,81.47,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,70069007110,NDC,facility,outpatient,0.4,ME,99.60000,28.88000,Aetna,First Health,,81.47,,,,,,,0.06741,81.47,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,70069006425,NDC,facility,inpatient,150,ME,56.55000,16.40000,Aetna,First Health,,46.26,,,,,,,20.39,46.26,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,70069006425,NDC,facility,outpatient,150,ME,56.55000,16.40000,Aetna,First Health,,46.26,,,,,,,0.04815,46.26,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,70069006401,NDC,facility,inpatient,150,ME,56.55000,16.40000,Aetna,First Health,,46.26,,,,,,,20.39,46.26,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,70069006401,NDC,facility,outpatient,150,ME,56.55000,16.40000,Aetna,First Health,,46.26,,,,,,,0.04815,46.26,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,70069006225,NDC,facility,inpatient,40,ME,57.20000,16.59000,Aetna,First Health,,46.79,,,,,,,20.62,46.79,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,70069006225,NDC,facility,outpatient,40,ME,57.20000,16.59000,Aetna,First Health,,46.79,,,,,,,0.04815,46.79,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,70069006210,NDC,facility,inpatient,40,ME,57.55000,16.69000,Aetna,First Health,,47.08,,,,,,,20.75,47.08,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,70069006210,NDC,facility,outpatient,40,ME,57.55000,16.69000,Aetna,First Health,,47.08,,,,,,,0.04815,47.08,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,70069001325,NDC,facility,inpatient,1,ME,72.90000,21.14000,Aetna,First Health,,59.63,,,,,,,26.28,59.63,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,70069001325,NDC,facility,outpatient,1,ME,72.90000,21.14000,Aetna,First Health,,59.63,,,,,,,0.36594,59.63,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,70069001125,NDC,facility,inpatient,0.2,ME,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,6.42,14.56,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,70069001125,NDC,facility,outpatient,0.2,ME,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,0.36594,14.56,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70069000510,NDC,facility,inpatient,1,ME,23.65000,6.86000,Aetna,First Health,,19.35,,,,,,,8.53,19.35,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70069000510,NDC,facility,outpatient,1,ME,23.65000,6.86000,Aetna,First Health,,19.35,,,,,,,0.61632,19.35,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70069000501,NDC,facility,inpatient,1,ME,23.65000,6.86000,Aetna,First Health,,19.35,,,,,,,8.53,19.35,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70069000501,NDC,facility,outpatient,1,ME,23.65000,6.86000,Aetna,First Health,,19.35,,,,,,,0.61632,19.35,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,70010078201,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,70010078201,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,70010078101,NDC,,,facility,inpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,5.37,7.32,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,70010078101,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,3.23,7.32,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,70010078001,NDC,,,facility,inpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,5.37,7.32,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,70010078001,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,3.23,7.32,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,70010077001,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,70010077001,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,70010075401,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,70010075401,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,70010049109,NDC,,,facility,inpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,3.63,4.95,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,70010049109,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,2.18,4.95,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,70010014901,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,70010014901,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,70010013701,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,70010013701,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,70010006309,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,70010006309,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,70010006301,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,70010006301,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,70010000201,NDC,,,facility,inpatient,1,EA,55.95000,16.23000,Aetna,First Health,,45.77,,,,,,,33.57,45.77,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,70010000201,NDC,,,facility,outpatient,1,EA,55.95000,16.23000,Aetna,First Health,,45.77,,,,,,,20.17,45.77,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70004091029,NDC,facility,inpatient,200,ME,63.55000,18.43000,Aetna,First Health,,51.98,,,,,,,22.91,51.98,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70004091029,NDC,facility,outpatient,200,ME,63.55000,18.43000,Aetna,First Health,,51.98,,,,,,,0.93411,51.98,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70004090812,NDC,facility,inpatient,200,ME,182.45000,52.91000,Aetna,First Health,,149.24,,,,,,,65.77,149.24,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70004090812,NDC,facility,outpatient,200,ME,182.45000,52.91000,Aetna,First Health,,149.24,,,,,,,0.93411,149.24,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,70004085009,NDC,,,facility,inpatient,1,EA,48.15000,13.96000,Aetna,First Health,,39.39,,,,,,,17.82,39.39,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,70004085009,NDC,,,facility,outpatient,1,EA,48.15000,13.96000,Aetna,First Health,,39.39,,,,,,,17.36,39.39,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,70004081012,NDC,facility,inpatient,1,ME,40.20000,11.66000,Aetna,First Health,,32.88,,,,,,,14.49,32.88,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,70004081012,NDC,facility,outpatient,1,ME,40.20000,11.66000,Aetna,First Health,,32.88,,,,,,,14.87,32.88,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,70004077140,NDC,,,facility,inpatient,1,EA,202.30000,58.67000,Aetna,First Health,,165.48,,,,,,,74.85,165.48,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,70004077140,NDC,,,facility,outpatient,1,EA,202.30000,58.67000,Aetna,First Health,,165.48,,,,,,,72.93,165.48,percent of total billed charges,
Lidocaine HCl 1% 10mL IS PF - Anesthesia,800015334,CDM,636,RC,70004072012,NDC,,,facility,inpatient,1,EA,23.40000,6.79000,Aetna,First Health,,19.14,,,,,,,8.44,19.14,percent of total billed charges,
Lidocaine HCl 1% 10mL IS PF - Anesthesia,800015334,CDM,636,RC,70004072012,NDC,,,facility,outpatient,1,EA,23.40000,6.79000,Aetna,First Health,,19.14,,,,,,,8.44,19.14,percent of total billed charges,
Ketamine 10mg/mL Inj 10mL,800051999,CDM,250,RC,70004043512,NDC,,,facility,inpatient,1,EA,88.00000,25.52000,Aetna,First Health,,71.98,,,,,,,32.56,71.98,percent of total billed charges,
Ketamine 10mg/mL Inj 10mL,800051999,CDM,250,RC,70004043512,NDC,,,facility,outpatient,1,EA,88.00000,25.52000,Aetna,First Health,,71.98,,,,,,,31.72,71.98,percent of total billed charges,
Labor Room Epidural 100mL,800022091,CDM,636,RC,J3010,HCPCS,70004023132,NDC,facility,inpatient,1,EA,149.60000,43.38000,Aetna,First Health,,122.37,,,,,,,53.93,122.37,percent of total billed charges,
Labor Room Epidural 100mL,800022091,CDM,636,RC,J3010,HCPCS,70004023132,NDC,facility,outpatient,1,EA,149.60000,43.38000,Aetna,First Health,,122.37,,,,,,,1.15,122.37,percent of total billed charges,
NICU- Morphine 0.4mg/mLOral Liq,800025701,CDM,637,RC,70004013282,NDC,,,facility,inpatient,1,EA,39.60000,11.48000,Aetna,First Health,,32.39,,,,,,,23.76,32.39,percent of total billed charges,
NICU- Morphine 0.4mg/mLOral Liq,800025701,CDM,637,RC,70004013282,NDC,,,facility,outpatient,1,EA,39.60000,11.48000,Aetna,First Health,,32.39,,,,,,,14.28,32.39,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,70003030065,NDC,,,facility,inpatient,1,EA,1425.30000,413.34000,Aetna,First Health,,1165.90,,,,,,,855.18,1165.90,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,70003030065,NDC,,,facility,outpatient,1,EA,1425.30000,413.34000,Aetna,First Health,,1165.90,,,,,,,513.82,1165.90,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,70000055502,NDC,,,facility,inpatient,1,EA,116.75000,33.86000,Aetna,First Health,,95.50,,,,,,,70.05,95.50,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,70000055502,NDC,,,facility,outpatient,1,EA,116.75000,33.86000,Aetna,First Health,,95.50,,,,,,,42.09,95.50,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,70000034001,NDC,,,facility,inpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.98050,2.17,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,70000034001,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
Mineral Oil 100% Enema,800018020,CDM,637,RC,70000010901,NDC,,,facility,inpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,10.59,14.44,percent of total billed charges,
Mineral Oil 100% Enema,800018020,CDM,637,RC,70000010901,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,6.36,14.44,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,70000007001,NDC,,,facility,inpatient,1,EA,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,26.64,58.90,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,70000007001,NDC,,,facility,outpatient,1,EA,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,25.96,58.90,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,69918090111,NDC,facility,inpatient,0.04,ME,2501.15000,725.33000,Aetna,First Health,,2045.94,,,,,,,901.66,2045.94,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,69918090111,NDC,facility,outpatient,0.04,ME,2501.15000,725.33000,Aetna,First Health,,2045.94,,,,,,,3.28,2045.94,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,inpatient,0.04,ME,3031.00000,878.99000,Aetna,First Health,,2479.36,,,,,,,1092.68,2479.36,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,outpatient,0.04,ME,3031.00000,878.99000,Aetna,First Health,,2479.36,,,,,,,3.28,2479.36,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,69918089911,NDC,facility,inpatient,0.004,ME,197.65000,57.32000,Aetna,First Health,,161.68,,,,,,,71.25,161.68,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,69918089911,NDC,facility,outpatient,0.004,ME,197.65000,57.32000,Aetna,First Health,,161.68,,,,,,,3.28,161.68,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,inpatient,0.004,ME,233.80000,67.80000,Aetna,First Health,,191.25,,,,,,,84.28,191.25,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,outpatient,0.004,ME,233.80000,67.80000,Aetna,First Health,,191.25,,,,,,,3.28,191.25,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,69918073510,NDC,,,facility,inpatient,1,EA,1266.00000,367.14000,Aetna,First Health,,1035.59,,,,,,,468.42,1035.59,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,69918073510,NDC,,,facility,outpatient,1,EA,1266.00000,367.14000,Aetna,First Health,,1035.59,,,,,,,456.39,1035.59,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,69918050105,NDC,,,facility,inpatient,1,EA,1485.90000,430.91000,Aetna,First Health,,1215.47,,,,,,,891.54,1215.47,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,69918050105,NDC,,,facility,outpatient,1,EA,1485.90000,430.91000,Aetna,First Health,,1215.47,,,,,,,535.67,1215.47,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,69918030130,NDC,,,facility,inpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,22.14,30.18,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,69918030130,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,13.30,30.18,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,69918010101,NDC,,,facility,inpatient,1,EA,37.40000,10.85000,Aetna,First Health,,30.59,,,,,,,22.44,30.59,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,69918010101,NDC,,,facility,outpatient,1,EA,37.40000,10.85000,Aetna,First Health,,30.59,,,,,,,13.48,30.59,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,69865021002,NDC,,,facility,inpatient,1,EA,73.75000,21.39000,Aetna,First Health,,60.33,,,,,,,44.25,60.33,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,69865021002,NDC,,,facility,outpatient,1,EA,73.75000,21.39000,Aetna,First Health,,60.33,,,,,,,26.59,60.33,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,69680014412,NDC,,,facility,inpatient,1,EA,26.70000,7.74000,Aetna,First Health,,21.84,,,,,,,16.02,21.84,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,69680014412,NDC,,,facility,outpatient,1,EA,26.70000,7.74000,Aetna,First Health,,21.84,,,,,,,9.63,21.84,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,69680011225,NDC,facility,inpatient,1,ME,20.55000,5.96000,Aetna,First Health,,16.81,,,,,,,7.41,16.81,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,69680011225,NDC,facility,outpatient,1,ME,20.55000,5.96000,Aetna,First Health,,16.81,,,,,,,0.61632,16.81,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,69680011210,NDC,facility,inpatient,1,ME,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,10.36,23.52,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,69680011210,NDC,facility,outpatient,1,ME,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,0.61632,23.52,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,69584011110,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,69584011110,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,69543045510,NDC,facility,inpatient,200,ME,697.55000,202.29000,Aetna,First Health,,570.60,,,,,,,251.47,570.60,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,69543045510,NDC,facility,outpatient,200,ME,697.55000,202.29000,Aetna,First Health,,570.60,,,,,,,0.37557,570.60,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,69543038810,NDC,,,facility,inpatient,1,EA,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,9.15,12.47,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,69543038810,NDC,,,facility,outpatient,1,EA,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,5.50,12.47,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,69543038625,NDC,facility,inpatient,30,ME,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.50,26.09,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,69543038625,NDC,facility,outpatient,30,ME,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,0.31779,26.09,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,69543026010,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,69543026010,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,69452023320,NDC,,,facility,inpatient,1,EA,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,8.70,11.86,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,69452023320,NDC,,,facility,outpatient,1,EA,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,5.23,11.86,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,69452015825,NDC,,,facility,inpatient,1,EA,26.50000,7.68000,Aetna,First Health,,21.68,,,,,,,15.90,21.68,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,69452015825,NDC,,,facility,outpatient,1,EA,26.50000,7.68000,Aetna,First Health,,21.68,,,,,,,9.55,21.68,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,69452015020,NDC,,,facility,inpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,3.57,4.87,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,69452015020,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,69387010701,NDC,,,facility,inpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,69387010701,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,69367033801,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,69367033801,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,69367032709,NDC,,,facility,inpatient,1,EA,67.40000,19.55000,Aetna,First Health,,55.13,,,,,,,40.44,55.13,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,69367032709,NDC,,,facility,outpatient,1,EA,67.40000,19.55000,Aetna,First Health,,55.13,,,,,,,24.30,55.13,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,69367031401,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,69367031401,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,69367013304,NDC,,,facility,inpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,69367013304,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,69339020919,NDC,,,facility,inpatient,1,EA,76.45000,22.17000,Aetna,First Health,,62.54,,,,,,,45.87,62.54,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,69339020919,NDC,,,facility,outpatient,1,EA,76.45000,22.17000,Aetna,First Health,,62.54,,,,,,,27.56,62.54,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,69339017703,NDC,,,facility,inpatient,1,EA,58.20000,16.88000,Aetna,First Health,,47.61,,,,,,,34.92,47.61,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,69339017703,NDC,,,facility,outpatient,1,EA,58.20000,16.88000,Aetna,First Health,,47.61,,,,,,,20.98,47.61,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,69339016019,NDC,,,facility,inpatient,1,EA,35.50000,10.30000,Aetna,First Health,,29.04,,,,,,,21.30,29.04,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,69339016019,NDC,,,facility,outpatient,1,EA,35.50000,10.30000,Aetna,First Health,,29.04,,,,,,,12.80,29.04,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,800021977,CDM,637,RC,69339015917,NDC,,,facility,inpatient,1,EA,208.30000,60.41000,Aetna,First Health,,170.39,,,,,,,124.98,170.39,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,800021977,CDM,637,RC,69339015917,NDC,,,facility,outpatient,1,EA,208.30000,60.41000,Aetna,First Health,,170.39,,,,,,,75.09,170.39,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,69339015717,NDC,,,facility,inpatient,1,EA,48.85000,14.17000,Aetna,First Health,,39.96,,,,,,,29.31,39.96,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,69339015717,NDC,,,facility,outpatient,1,EA,48.85000,14.17000,Aetna,First Health,,39.96,,,,,,,17.61,39.96,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,69339014819,NDC,,,facility,inpatient,1,EA,76.45000,22.17000,Aetna,First Health,,62.54,,,,,,,45.87,62.54,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,69339014819,NDC,,,facility,outpatient,1,EA,76.45000,22.17000,Aetna,First Health,,62.54,,,,,,,27.56,62.54,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,69339013819,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,69339013819,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,69339013634,NDC,facility,inpatient,10,ME,234.55000,68.02000,Aetna,First Health,,191.86,,,,,,,84.56,191.86,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,69339013634,NDC,facility,outpatient,10,ME,234.55000,68.02000,Aetna,First Health,,191.86,,,,,,,6.44,191.86,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,69315091001,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,69315091001,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,69315090505,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,69315090505,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,69315090501,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,4.02,5.48,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,69315090501,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,69315090405,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,69315090405,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,69315090401,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,69315090401,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,69315030615,NDC,,,facility,inpatient,1,EA,164.80000,47.79000,Aetna,First Health,,134.81,,,,,,,98.88,134.81,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,69315030615,NDC,,,facility,outpatient,1,EA,164.80000,47.79000,Aetna,First Health,,134.81,,,,,,,59.41,134.81,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,69315015501,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,69315015501,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,69315013601,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,69315013601,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,69315012701,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,69315012701,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,69315011701,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,69315011701,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,69315011610,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,69315011610,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,69315011601,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,69315011601,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,69238207801,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,69238207801,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,69238207701,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,69238207701,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,69238160502,NDC,,,facility,inpatient,1,EA,448.75000,130.14000,Aetna,First Health,,367.08,,,,,,,269.25,367.08,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,69238160502,NDC,,,facility,outpatient,1,EA,448.75000,130.14000,Aetna,First Health,,367.08,,,,,,,161.77,367.08,percent of total billed charges,
Mycophenolate Mofetil 500mg/2.5mL Susp,800021979,CDM,637,RC,J7517,HCPCS,69238159502,NDC,facility,inpatient,500,ME,160.35000,46.50000,Aetna,First Health,,131.17,,,,,,,96.21,131.17,percent of total billed charges,
Mycophenolate Mofetil 500mg/2.5mL Susp,800021979,CDM,637,RC,J7517,HCPCS,69238159502,NDC,facility,outpatient,500,ME,160.35000,46.50000,Aetna,First Health,,131.17,,,,,,,0.14445,131.17,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,69238154001,NDC,,,facility,inpatient,1,EA,52.05000,15.09000,Aetna,First Health,,42.58,,,,,,,31.23,42.58,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,69238154001,NDC,,,facility,outpatient,1,EA,52.05000,15.09000,Aetna,First Health,,42.58,,,,,,,18.76,42.58,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,69238153405,NDC,,,facility,inpatient,1,EA,314.70000,91.26000,Aetna,First Health,,257.42,,,,,,,188.82,257.42,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,69238153405,NDC,,,facility,outpatient,1,EA,314.70000,91.26000,Aetna,First Health,,257.42,,,,,,,113.45,257.42,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,69238153203,NDC,,,facility,inpatient,1,EA,1587.75000,460.45000,Aetna,First Health,,1298.78,,,,,,,952.65,1298.78,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,69238153203,NDC,,,facility,outpatient,1,EA,1587.75000,460.45000,Aetna,First Health,,1298.78,,,,,,,572.38,1298.78,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,69238149001,NDC,,,facility,inpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,11.46,15.62,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,69238149001,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,6.89,15.62,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,69238148901,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,10.32,14.07,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,69238148901,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,69238147103,NDC,,,facility,inpatient,1,EA,59.40000,17.23000,Aetna,First Health,,48.59,,,,,,,35.64,48.59,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,69238147103,NDC,,,facility,outpatient,1,EA,59.40000,17.23000,Aetna,First Health,,48.59,,,,,,,21.41,48.59,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,69238142103,NDC,,,facility,inpatient,1,EA,63.55000,18.43000,Aetna,First Health,,51.98,,,,,,,38.13,51.98,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,69238142103,NDC,,,facility,outpatient,1,EA,63.55000,18.43000,Aetna,First Health,,51.98,,,,,,,22.91,51.98,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,69238131309,NDC,,,facility,inpatient,1,EA,67.40000,19.55000,Aetna,First Health,,55.13,,,,,,,40.44,55.13,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,69238131309,NDC,,,facility,outpatient,1,EA,67.40000,19.55000,Aetna,First Health,,55.13,,,,,,,24.30,55.13,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,69238131209,NDC,,,facility,inpatient,1,EA,67.40000,19.55000,Aetna,First Health,,55.13,,,,,,,40.44,55.13,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,69238131209,NDC,,,facility,outpatient,1,EA,67.40000,19.55000,Aetna,First Health,,55.13,,,,,,,24.30,55.13,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,69238131109,NDC,,,facility,inpatient,1,EA,67.40000,19.55000,Aetna,First Health,,55.13,,,,,,,40.44,55.13,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,69238131109,NDC,,,facility,outpatient,1,EA,67.40000,19.55000,Aetna,First Health,,55.13,,,,,,,24.30,55.13,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,69238131009,NDC,,,facility,inpatient,1,EA,67.40000,19.55000,Aetna,First Health,,55.13,,,,,,,40.44,55.13,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,69238131009,NDC,,,facility,outpatient,1,EA,67.40000,19.55000,Aetna,First Health,,55.13,,,,,,,24.30,55.13,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,69238110002,NDC,,,facility,inpatient,1,EA,68.10000,19.75000,Aetna,First Health,,55.71,,,,,,,40.86,55.71,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,69238110002,NDC,,,facility,outpatient,1,EA,68.10000,19.75000,Aetna,First Health,,55.71,,,,,,,24.55,55.71,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,69102031901,NDC,,,facility,inpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,20.19,27.53,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,69102031901,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,12.13,27.53,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,69102030101,NDC,,,facility,inpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,17.67,24.09,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,69102030101,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,10.62,24.09,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,69097096507,NDC,,,facility,inpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,5.67,7.73,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,69097096507,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,3.41,7.73,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,69097094605,NDC,,,facility,inpatient,1,EA,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,23.94,32.64,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,69097094605,NDC,,,facility,outpatient,1,EA,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,14.38,32.64,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,69097094505,NDC,,,facility,inpatient,1,EA,38.45000,11.15000,Aetna,First Health,,31.45,,,,,,,23.07,31.45,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,69097094505,NDC,,,facility,outpatient,1,EA,38.45000,11.15000,Aetna,First Health,,31.45,,,,,,,13.86,31.45,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,69097094405,NDC,,,facility,inpatient,1,EA,27.95000,8.11000,Aetna,First Health,,22.86,,,,,,,16.77,22.86,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,69097094405,NDC,,,facility,outpatient,1,EA,27.95000,8.11000,Aetna,First Health,,22.86,,,,,,,10.08,22.86,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,69097092735,NDC,facility,inpatient,0.25,ME,685.90000,198.91000,Aetna,First Health,,561.07,,,,,,,247.27,561.07,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,69097092735,NDC,facility,outpatient,0.25,ME,685.90000,198.91000,Aetna,First Health,,561.07,,,,,,,0.33705,561.07,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,69097089905,NDC,,,facility,inpatient,1,EA,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,23.94,32.64,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,69097089905,NDC,,,facility,outpatient,1,EA,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,14.38,32.64,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,69097086283,NDC,facility,inpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,69097086283,NDC,facility,outpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,0.03852,5.93,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,69097086107,NDC,,,facility,inpatient,1,EA,15.50000,4.50000,Aetna,First Health,,12.68,,,,,,,9.30,12.68,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,69097086107,NDC,,,facility,outpatient,1,EA,15.50000,4.50000,Aetna,First Health,,12.68,,,,,,,5.59,12.68,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,69097085907,NDC,,,facility,inpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,55.53,75.71,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,69097085907,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,33.36,75.71,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,69097085902,NDC,,,facility,inpatient,1,EA,92.20000,26.74000,Aetna,First Health,,75.42,,,,,,,55.32,75.42,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,69097085902,NDC,,,facility,outpatient,1,EA,92.20000,26.74000,Aetna,First Health,,75.42,,,,,,,33.24,75.42,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,69097084805,NDC,,,facility,inpatient,1,EA,37.10000,10.76000,Aetna,First Health,,30.35,,,,,,,22.26,30.35,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,69097084805,NDC,,,facility,outpatient,1,EA,37.10000,10.76000,Aetna,First Health,,30.35,,,,,,,13.37,30.35,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,69097084705,NDC,,,facility,inpatient,1,EA,30.95000,8.98000,Aetna,First Health,,25.32,,,,,,,18.57,25.32,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,69097084705,NDC,,,facility,outpatient,1,EA,30.95000,8.98000,Aetna,First Health,,25.32,,,,,,,11.16,25.32,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,69097084607,NDC,,,facility,inpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,4.92,6.71,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,69097084607,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,2.96,6.71,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,69097084407,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,69097084407,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,69097083805,NDC,,,facility,inpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,10.14,13.82,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,69097083805,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,6.09,13.82,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,69097083715,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,69097083715,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,69097083705,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,69097083705,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,69097083605,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,69097083605,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,69097082502,NDC,,,facility,inpatient,1,EA,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,30.27,41.27,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,69097082502,NDC,,,facility,outpatient,1,EA,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,18.19,41.27,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,69097082103,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,10.32,14.07,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,69097082103,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,69097081207,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,69097081207,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,69097073102,NDC,,,facility,inpatient,1,EA,92.20000,26.74000,Aetna,First Health,,75.42,,,,,,,55.32,75.42,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,69097073102,NDC,,,facility,outpatient,1,EA,92.20000,26.74000,Aetna,First Health,,75.42,,,,,,,33.24,75.42,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,69097070996,NDC,facility,inpatient,1,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,69097070996,NDC,facility,outpatient,1,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,2.71,31.33,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,69097057967,NDC,,,facility,inpatient,1,EA,650.25000,188.57000,Aetna,First Health,,531.90,,,,,,,390.15,531.90,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,69097057967,NDC,,,facility,outpatient,1,EA,650.25000,188.57000,Aetna,First Health,,531.90,,,,,,,234.42,531.90,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,69097053596,NDC,facility,inpatient,50,ME,227.00000,65.83000,Aetna,First Health,,185.69,,,,,,,81.83,185.69,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,69097053596,NDC,facility,outpatient,50,ME,227.00000,65.83000,Aetna,First Health,,185.69,,,,,,,83.99,185.69,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,69097052444,NDC,,,facility,inpatient,1,EA,359.95000,104.39000,Aetna,First Health,,294.44,,,,,,,215.97,294.44,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,69097052444,NDC,,,facility,outpatient,1,EA,359.95000,104.39000,Aetna,First Health,,294.44,,,,,,,129.76,294.44,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,69097052235,NDC,,,facility,inpatient,1,EA,4012.00000,1163.48000,Aetna,First Health,,3281.82,,,,,,,1484.44,3281.82,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,69097052235,NDC,,,facility,outpatient,1,EA,4012.00000,1163.48000,Aetna,First Health,,3281.82,,,,,,,1446.33,3281.82,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,69097042207,NDC,,,facility,inpatient,1,EA,32.70000,9.48000,Aetna,First Health,,26.75,,,,,,,19.62,26.75,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,69097042207,NDC,,,facility,outpatient,1,EA,32.70000,9.48000,Aetna,First Health,,26.75,,,,,,,11.79,26.75,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,69097042107,NDC,,,facility,inpatient,1,EA,53.65000,15.56000,Aetna,First Health,,43.89,,,,,,,32.19,43.89,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,69097042107,NDC,,,facility,outpatient,1,EA,53.65000,15.56000,Aetna,First Health,,43.89,,,,,,,19.34,43.89,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,69097028270,NDC,,,facility,inpatient,1,EA,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,71.40,97.34,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,69097028270,NDC,,,facility,outpatient,1,EA,119.00000,34.51000,Aetna,First Health,,97.34,,,,,,,42.90,97.34,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,69097015812,NDC,,,facility,inpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,13.44,18.32,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,69097015812,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,8.08,18.32,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,69097015807,NDC,,,facility,inpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,13.47,18.36,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,69097015807,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,8.09,18.36,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,69097014260,NDC,,,facility,inpatient,1,EA,490.05000,142.11000,Aetna,First Health,,400.86,,,,,,,294.03,400.86,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,69097014260,NDC,,,facility,outpatient,1,EA,490.05000,142.11000,Aetna,First Health,,400.86,,,,,,,176.66,400.86,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,69097012805,NDC,,,facility,inpatient,1,EA,16.80000,4.87000,Aetna,First Health,,13.74,,,,,,,10.08,13.74,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,69097012805,NDC,,,facility,outpatient,1,EA,16.80000,4.87000,Aetna,First Health,,13.74,,,,,,,6.06,13.74,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,69097012705,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,69097012705,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,69097012605,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,69097012605,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,69097012203,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,69097012203,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,69076047501,NDC,,,facility,inpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,5.58,7.61,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,69076047501,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,69076014601,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,69076014601,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Tacrolimus 1mg ER T(Envarsus XR),800046461,CDM,637,RC,J7503,HCPCS,68992301003,NDC,facility,inpatient,1,ME,60.10000,17.43000,Aetna,First Health,,49.16,,,,,,,36.06,49.16,percent of total billed charges,
Tacrolimus 1mg ER T(Envarsus XR),800046461,CDM,637,RC,J7503,HCPCS,68992301003,NDC,facility,outpatient,1,ME,60.10000,17.43000,Aetna,First Health,,49.16,,,,,,,1.80,49.16,percent of total billed charges,
Tacrolimus 1mg ER T(Envarsus XR),800046461,CDM,637,RC,J7503,HCPCS,68992301001,NDC,facility,inpatient,1,ME,60.10000,17.43000,Aetna,First Health,,49.16,,,,,,,36.06,49.16,percent of total billed charges,
Tacrolimus 1mg ER T(Envarsus XR),800046461,CDM,637,RC,J7503,HCPCS,68992301001,NDC,facility,outpatient,1,ME,60.10000,17.43000,Aetna,First Health,,49.16,,,,,,,1.80,49.16,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,68982062302,NDC,facility,inpatient,12.5,GM,563.00000,163.27000,Aetna,First Health,,460.53,,,,,,,202.96,460.53,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,68982062302,NDC,facility,outpatient,12.5,GM,563.00000,163.27000,Aetna,First Health,,460.53,,,,,,,51.12,460.53,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,68968449201,NDC,,,facility,inpatient,1,EA,25.60000,7.42000,Aetna,First Health,,20.94,,,,,,,15.36,20.94,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,68968449201,NDC,,,facility,outpatient,1,EA,25.60000,7.42000,Aetna,First Health,,20.94,,,,,,,9.23,20.94,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68850001202,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68850001202,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68850001201,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68850001201,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,inpatient,100,ME,8719.30000,2528.60000,Aetna,First Health,,7132.39,,,,,,,3143.31,7132.39,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,outpatient,100,ME,8719.30000,2528.60000,Aetna,First Health,,7132.39,,,,,,,7.88,7132.39,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,68774012260,NDC,,,facility,inpatient,1,EA,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,18.00,24.54,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,68774012260,NDC,,,facility,outpatient,1,EA,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,10.81,24.54,percent of total billed charges,
Lurbinectedin 4mg Inj (Zepzelca),800046519,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,inpatient,4,ME,58579.00000,16987.91000,Aetna,First Health,,47917.62,,,,,,,21117.73,47917.62,percent of total billed charges,
Lurbinectedin 4mg Inj (Zepzelca),800046519,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,outpatient,4,ME,58579.00000,16987.91000,Aetna,First Health,,47917.62,,,,,,,202.98,47917.62,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,68682099398,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,3.96,5.40,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,68682099398,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,68682081305,NDC,,,facility,inpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,56.07,76.44,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,68682081305,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,33.69,76.44,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,68682040910,NDC,,,facility,inpatient,1,EA,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,21.84,29.78,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,68682040910,NDC,,,facility,outpatient,1,EA,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,13.12,29.78,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,68682037090,NDC,,,facility,inpatient,1,EA,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,7.02,9.57,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,68682037090,NDC,,,facility,outpatient,1,EA,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,4.22,9.57,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,68682036890,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,68682036890,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,68682030210,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,68682030210,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,68682017030,NDC,,,facility,inpatient,1,EA,447.30000,129.72000,Aetna,First Health,,365.89,,,,,,,268.38,365.89,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,68682017030,NDC,,,facility,outpatient,1,EA,447.30000,129.72000,Aetna,First Health,,365.89,,,,,,,161.25,365.89,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,68682010810,NDC,,,facility,inpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,5.46,7.44,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,68682010810,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,3.28,7.44,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,68546014256,NDC,,,facility,inpatient,1,EA,290.10000,84.13000,Aetna,First Health,,237.30,,,,,,,174.06,237.30,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,68546014256,NDC,,,facility,outpatient,1,EA,290.10000,84.13000,Aetna,First Health,,237.30,,,,,,,104.58,237.30,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,68516521607,NDC,facility,inpatient,12.5,GM,424.40000,123.08000,Aetna,First Health,,347.16,,,,,,,153.00,347.16,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,68516521607,NDC,facility,outpatient,12.5,GM,424.40000,123.08000,Aetna,First Health,,347.16,,,,,,,51.12,347.16,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,68516521601,NDC,facility,inpatient,12.5,GM,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,240.81,546.42,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,68516521601,NDC,facility,outpatient,12.5,GM,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,51.12,546.42,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,68516521401,NDC,facility,inpatient,12.5,GM,497.05000,144.14000,Aetna,First Health,,406.59,,,,,,,179.19,406.59,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,68516521401,NDC,facility,outpatient,12.5,GM,497.05000,144.14000,Aetna,First Health,,406.59,,,,,,,51.12,406.59,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,68516521302,NDC,facility,inpatient,12.5,GM,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,240.81,546.42,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,68516521302,NDC,facility,outpatient,12.5,GM,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,51.12,546.42,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,68516521101,NDC,facility,inpatient,12.5,GM,563.00000,163.27000,Aetna,First Health,,460.53,,,,,,,202.96,460.53,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,68516521101,NDC,facility,outpatient,12.5,GM,563.00000,163.27000,Aetna,First Health,,460.53,,,,,,,51.12,460.53,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,68462085001,NDC,,,facility,inpatient,1,EA,24.50000,7.10000,Aetna,First Health,,20.04,,,,,,,14.70,20.04,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,68462085001,NDC,,,facility,outpatient,1,EA,24.50000,7.10000,Aetna,First Health,,20.04,,,,,,,8.83,20.04,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,68462062264,NDC,facility,inpatient,500,ME,437.00000,126.73000,Aetna,First Health,,357.47,,,,,,,157.54,357.47,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,68462062264,NDC,facility,outpatient,500,ME,437.00000,126.73000,Aetna,First Health,,357.47,,,,,,,1.34,357.47,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,68462062154,NDC,facility,inpatient,100,ME,94.50000,27.40000,Aetna,First Health,,77.30,,,,,,,34.07,77.30,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,68462062154,NDC,facility,outpatient,100,ME,94.50000,27.40000,Aetna,First Health,,77.30,,,,,,,1.34,77.30,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,68462058385,NDC,facility,inpatient,40,ME,703.45000,204.00000,Aetna,First Health,,575.42,,,,,,,422.07,575.42,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,68462058385,NDC,facility,outpatient,40,ME,703.45000,204.00000,Aetna,First Health,,575.42,,,,,,,2.67,575.42,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,68462058340,NDC,facility,inpatient,40,ME,703.45000,204.00000,Aetna,First Health,,575.42,,,,,,,422.07,575.42,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,68462058340,NDC,facility,outpatient,40,ME,703.45000,204.00000,Aetna,First Health,,575.42,,,,,,,2.67,575.42,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,68462056201,NDC,,,facility,inpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,21.87,29.82,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,68462056201,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,13.14,29.82,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,68462050201,NDC,facility,inpatient,50,ME,48.20000,13.98000,Aetna,First Health,,39.43,,,,,,,28.92,39.43,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,68462050201,NDC,facility,outpatient,50,ME,48.20000,13.98000,Aetna,First Health,,39.43,,,,,,,0.05778,39.43,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,68462046954,NDC,facility,inpatient,1,ME,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,5.23,11.86,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,68462046954,NDC,facility,outpatient,1,ME,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,0.34668,11.86,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,68462043318,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,68462043318,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,68462041820,NDC,,,facility,inpatient,1,EA,1893.65000,549.16000,Aetna,First Health,,1549.01,,,,,,,1136.19,1549.01,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,68462041820,NDC,,,facility,outpatient,1,EA,1893.65000,549.16000,Aetna,First Health,,1549.01,,,,,,,682.66,1549.01,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,68462040860,NDC,,,facility,inpatient,1,EA,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,33.54,45.73,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,68462040860,NDC,,,facility,outpatient,1,EA,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,20.15,45.73,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,68462040601,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,68462040601,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,68462040560,NDC,,,facility,inpatient,1,EA,59.15000,17.15000,Aetna,First Health,,48.38,,,,,,,35.49,48.38,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,68462040560,NDC,,,facility,outpatient,1,EA,59.15000,17.15000,Aetna,First Health,,48.38,,,,,,,21.32,48.38,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,68462038160,NDC,,,facility,inpatient,1,EA,230.15000,66.74000,Aetna,First Health,,188.26,,,,,,,138.09,188.26,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,68462038160,NDC,,,facility,outpatient,1,EA,230.15000,66.74000,Aetna,First Health,,188.26,,,,,,,82.97,188.26,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,68462036101,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,68462036101,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,68462035801,NDC,,,facility,inpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,5.85,7.98,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,68462035801,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,3.51,7.98,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,68462033290,NDC,,,facility,inpatient,1,EA,23.65000,6.86000,Aetna,First Health,,19.35,,,,,,,14.19,19.35,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,68462033290,NDC,,,facility,outpatient,1,EA,23.65000,6.86000,Aetna,First Health,,19.35,,,,,,,8.53,19.35,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,68462033090,NDC,,,facility,inpatient,1,EA,23.65000,6.86000,Aetna,First Health,,19.35,,,,,,,14.19,19.35,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,68462033090,NDC,,,facility,outpatient,1,EA,23.65000,6.86000,Aetna,First Health,,19.35,,,,,,,8.53,19.35,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,68462031435,NDC,,,facility,inpatient,1,EA,980.10000,284.23000,Aetna,First Health,,801.72,,,,,,,588.06,801.72,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,68462031435,NDC,,,facility,outpatient,1,EA,980.10000,284.23000,Aetna,First Health,,801.72,,,,,,,353.33,801.72,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,68462030450,NDC,,,facility,inpatient,1,EA,18.75000,5.44000,Aetna,First Health,,15.34,,,,,,,11.25,15.34,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,68462030450,NDC,,,facility,outpatient,1,EA,18.75000,5.44000,Aetna,First Health,,15.34,,,,,,,6.76,15.34,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,68462029817,NDC,,,facility,inpatient,1,EA,381.70000,110.69000,Aetna,First Health,,312.23,,,,,,,229.02,312.23,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,68462029817,NDC,,,facility,outpatient,1,EA,381.70000,110.69000,Aetna,First Health,,312.23,,,,,,,137.60,312.23,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,68462029735,NDC,,,facility,inpatient,1,EA,574.30000,166.55000,Aetna,First Health,,469.78,,,,,,,344.58,469.78,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,68462029735,NDC,,,facility,outpatient,1,EA,574.30000,166.55000,Aetna,First Health,,469.78,,,,,,,207.04,469.78,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,68462029301,NDC,,,facility,inpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,68462029301,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,68462029201,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,68462029201,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,68462029112,NDC,,,facility,inpatient,1,EA,1114.90000,323.32000,Aetna,First Health,,911.99,,,,,,,668.94,911.99,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,68462029112,NDC,,,facility,outpatient,1,EA,1114.90000,323.32000,Aetna,First Health,,911.99,,,,,,,401.92,911.99,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,68462027501,NDC,,,facility,inpatient,1,EA,52.10000,15.11000,Aetna,First Health,,42.62,,,,,,,31.26,42.62,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,68462027501,NDC,,,facility,outpatient,1,EA,52.10000,15.11000,Aetna,First Health,,42.62,,,,,,,18.78,42.62,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,68462026430,NDC,,,facility,inpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,38.01,51.82,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,68462026430,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,22.84,51.82,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,68462026290,NDC,,,facility,inpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,38.01,51.82,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,68462026290,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,22.84,51.82,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,68462025501,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,10.65,14.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,68462025501,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,68462023401,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,68462023401,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,68462022301,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,68462022301,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,68462022001,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,68462022001,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68462019690,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,13.89,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68462019690,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68462019605,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,13.89,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68462019605,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68462019590,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68462019590,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68462019505,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68462019505,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,68462018801,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,68462018801,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,68462018022,NDC,,,facility,inpatient,1,EA,296.30000,85.93000,Aetna,First Health,,242.37,,,,,,,177.78,242.37,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,68462018022,NDC,,,facility,outpatient,1,EA,296.30000,85.93000,Aetna,First Health,,242.37,,,,,,,106.82,242.37,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68462016505,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68462016505,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68462016501,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68462016501,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68462016405,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68462016405,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68462016401,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68462016401,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,68462016305,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,68462016305,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,68462016301,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,68462016301,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,68462016205,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,68462016205,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,68462016201,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,68462016201,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68462015901,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68462015901,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,68462015713,NDC,facility,inpatient,4,ME,163.65000,47.46000,Aetna,First Health,,133.87,,,,,,,98.19,133.87,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,68462015713,NDC,facility,outpatient,4,ME,163.65000,47.46000,Aetna,First Health,,133.87,,,,,,,0.00963,133.87,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,68462014645,NDC,,,facility,inpatient,1,EA,53.65000,15.56000,Aetna,First Health,,43.89,,,,,,,32.19,43.89,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,68462014645,NDC,,,facility,outpatient,1,EA,53.65000,15.56000,Aetna,First Health,,43.89,,,,,,,19.34,43.89,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,68462014625,NDC,,,facility,inpatient,1,EA,31.60000,9.16000,Aetna,First Health,,25.85,,,,,,,18.96,25.85,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,68462014625,NDC,,,facility,outpatient,1,EA,31.60000,9.16000,Aetna,First Health,,25.85,,,,,,,11.39,25.85,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,68462012801,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,68462012801,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,68462012605,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,68462012605,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,68462012601,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,68462012601,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68462010860,NDC,,,facility,inpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,9.42,12.84,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68462010860,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,5.66,12.84,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,68462010530,NDC,facility,inpatient,4,ME,173.45000,50.30000,Aetna,First Health,,141.88,,,,,,,62.53,141.88,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,68462010530,NDC,facility,outpatient,4,ME,173.45000,50.30000,Aetna,First Health,,141.88,,,,,,,0.00963,141.88,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,68462010230,NDC,,,facility,inpatient,1,EA,62.35000,18.08000,Aetna,First Health,,51.00,,,,,,,37.41,51.00,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,68462010230,NDC,,,facility,outpatient,1,EA,62.35000,18.08000,Aetna,First Health,,51.00,,,,,,,22.48,51.00,percent of total billed charges,
methylPREDNISolone 16 mg T(Medrol),800013327,CDM,637,RC,J7509,HCPCS,68382091818,NDC,facility,inpatient,16,ME,25.05000,7.26000,Aetna,First Health,,20.49,,,,,,,15.03,20.49,percent of total billed charges,
methylPREDNISolone 16 mg T(Medrol),800013327,CDM,637,RC,J7509,HCPCS,68382091818,NDC,facility,outpatient,16,ME,25.05000,7.26000,Aetna,First Health,,20.49,,,,,,,0.13482,20.49,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,68382091010,NDC,facility,inpatient,100,ME,239.50000,69.46000,Aetna,First Health,,195.91,,,,,,,88.61,195.91,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,68382091010,NDC,facility,outpatient,100,ME,239.50000,69.46000,Aetna,First Health,,195.91,,,,,,,0.09630,195.91,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,68382079901,NDC,,,facility,inpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,4.83,6.58,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,68382079901,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,2.90,6.58,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,68382079805,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,68382079805,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,68382079801,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,68382079801,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,68382077501,NDC,facility,inpatient,2.5,ME,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,15.15,20.65,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,68382077501,NDC,facility,outpatient,2.5,ME,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,0.14445,20.65,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,800046545,CDM,637,RC,68382077277,NDC,,,facility,inpatient,1,EA,111.70000,32.39000,Aetna,First Health,,91.37,,,,,,,67.02,91.37,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,800046545,CDM,637,RC,68382077277,NDC,,,facility,outpatient,1,EA,111.70000,32.39000,Aetna,First Health,,91.37,,,,,,,40.27,91.37,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,68382076214,NDC,,,facility,inpatient,1,EA,42.60000,12.35000,Aetna,First Health,,34.85,,,,,,,25.56,34.85,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,68382076214,NDC,,,facility,outpatient,1,EA,42.60000,12.35000,Aetna,First Health,,34.85,,,,,,,15.36,34.85,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,68382066001,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,68382066001,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,68382065001,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,68382065001,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,68382064928,NDC,,,facility,inpatient,1,EA,54.95000,15.94000,Aetna,First Health,,44.95,,,,,,,32.97,44.95,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,68382064928,NDC,,,facility,outpatient,1,EA,54.95000,15.94000,Aetna,First Health,,44.95,,,,,,,19.81,44.95,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,68382059816,NDC,,,facility,inpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,11.28,15.38,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,68382059816,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,68382059616,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,68382059616,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,68382059516,NDC,,,facility,inpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,5.10,6.95,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,68382059516,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,3.06,6.95,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,68382054507,NDC,,,facility,inpatient,1,EA,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,15.52,34.32,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,68382054507,NDC,,,facility,outpatient,1,EA,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,15.12,34.32,percent of total billed charges,
Cholestyramine 4g Lt Pkt,800018217,CDM,637,RC,68382052960,NDC,,,facility,inpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,14.25,19.43,percent of total billed charges,
Cholestyramine 4g Lt Pkt,800018217,CDM,637,RC,68382052960,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.56,19.43,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,68382043528,NDC,,,facility,inpatient,1,EA,65.65000,19.04000,Aetna,First Health,,53.70,,,,,,,39.39,53.70,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,68382043528,NDC,,,facility,outpatient,1,EA,65.65000,19.04000,Aetna,First Health,,53.70,,,,,,,23.67,53.70,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68382037001,NDC,,,facility,inpatient,1,EA,199.25000,57.78000,Aetna,First Health,,162.99,,,,,,,119.55,162.99,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68382037001,NDC,,,facility,outpatient,1,EA,199.25000,57.78000,Aetna,First Health,,162.99,,,,,,,71.83,162.99,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,68382031601,NDC,,,facility,inpatient,1,EA,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,7.23,9.86,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,68382031601,NDC,,,facility,outpatient,1,EA,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,4.34,9.86,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,68382025501,NDC,,,facility,inpatient,1,EA,23.30000,6.76000,Aetna,First Health,,19.06,,,,,,,13.98,19.06,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,68382025501,NDC,,,facility,outpatient,1,EA,23.30000,6.76000,Aetna,First Health,,19.06,,,,,,,8.40,19.06,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,68382024701,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,68382024701,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,68382022714,NDC,,,facility,inpatient,1,EA,23.50000,6.82000,Aetna,First Health,,19.22,,,,,,,14.10,19.22,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,68382022714,NDC,,,facility,outpatient,1,EA,23.50000,6.82000,Aetna,First Health,,19.22,,,,,,,8.47,19.22,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,68382022705,NDC,,,facility,inpatient,1,EA,22.85000,6.63000,Aetna,First Health,,18.69,,,,,,,13.71,18.69,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,68382022705,NDC,,,facility,outpatient,1,EA,22.85000,6.63000,Aetna,First Health,,18.69,,,,,,,8.24,18.69,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,68382019816,NDC,,,facility,inpatient,1,EA,22.95000,6.66000,Aetna,First Health,,18.77,,,,,,,13.77,18.77,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,68382019816,NDC,,,facility,outpatient,1,EA,22.95000,6.66000,Aetna,First Health,,18.77,,,,,,,8.27,18.77,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,68382019616,NDC,,,facility,inpatient,1,EA,22.95000,6.66000,Aetna,First Health,,18.77,,,,,,,13.77,18.77,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,68382019616,NDC,,,facility,outpatient,1,EA,22.95000,6.66000,Aetna,First Health,,18.77,,,,,,,8.27,18.77,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,68382018701,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,68382018701,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,68382018101,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,68382018101,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,68382018001,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,68382018001,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,68382014014,NDC,,,facility,inpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,29.58,40.33,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,68382014014,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,17.77,40.33,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,68382014005,NDC,,,facility,inpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,29.58,40.33,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,68382014005,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,17.77,40.33,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68382013814,NDC,,,facility,inpatient,1,EA,18.10000,5.25000,Aetna,First Health,,14.81,,,,,,,10.86,14.81,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68382013814,NDC,,,facility,outpatient,1,EA,18.10000,5.25000,Aetna,First Health,,14.81,,,,,,,6.53,14.81,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68382013805,NDC,,,facility,inpatient,1,EA,18.10000,5.25000,Aetna,First Health,,14.81,,,,,,,10.86,14.81,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68382013805,NDC,,,facility,outpatient,1,EA,18.10000,5.25000,Aetna,First Health,,14.81,,,,,,,6.53,14.81,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,68382013716,NDC,,,facility,inpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,13.08,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,68382013716,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,68382013616,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,68382013616,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,68382013210,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,68382013210,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,68382013201,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,68382013201,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,68382011414,NDC,,,facility,inpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,19.32,26.34,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,68382011414,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,68382011214,NDC,,,facility,inpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,16.56,22.58,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,68382011214,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,68382010601,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,68382010601,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,68382009801,NDC,,,facility,inpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,11.61,15.83,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,68382009801,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,6.98,15.83,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68382009505,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68382009505,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68382009501,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68382009501,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68382009405,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68382009405,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68382009401,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68382009401,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,68382009301,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,68382009301,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,68382009201,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,68382009201,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,68382007901,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,68382007901,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68382007116,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,13.89,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68382007116,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68382007016,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68382007016,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,68382005201,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,68382005201,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,68382005001,NDC,,,facility,inpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,13.47,18.36,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,68382005001,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,8.09,18.36,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,68382003606,NDC,,,facility,inpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,68382003606,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,12.98,29.45,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68382002810,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68382002810,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68382002805,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68382002805,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68382002801,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68382002801,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,68382002301,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,68382002301,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,68382002201,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,68382002201,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,68382001901,NDC,,,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,8.49,11.57,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,68382001901,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,68382001801,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,68382001801,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,68382000801,NDC,,,facility,inpatient,1,EA,36.75000,10.66000,Aetna,First Health,,30.06,,,,,,,22.05,30.06,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,68382000801,NDC,,,facility,outpatient,1,EA,36.75000,10.66000,Aetna,First Health,,30.06,,,,,,,13.25,30.06,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,68382000601,NDC,,,facility,inpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,19.32,26.34,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,68382000601,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,68382000514,NDC,,,facility,inpatient,1,EA,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,12.42,16.93,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,68382000514,NDC,,,facility,outpatient,1,EA,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,7.46,16.93,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,68382000301,NDC,facility,inpatient,50,ME,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,8.97,12.23,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,68382000301,NDC,facility,outpatient,50,ME,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,0.05778,12.23,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,68308050547,NDC,,,facility,inpatient,1,EA,4.10000,1.19000,Aetna,First Health,,3.35,,,,,,,2.46,3.35,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,68308050547,NDC,,,facility,outpatient,1,EA,4.10000,1.19000,Aetna,First Health,,3.35,,,,,,,1.48,3.35,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68308015260,NDC,,,facility,inpatient,1,EA,115.70000,33.55000,Aetna,First Health,,94.64,,,,,,,69.42,94.64,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68308015260,NDC,,,facility,outpatient,1,EA,115.70000,33.55000,Aetna,First Health,,94.64,,,,,,,41.71,94.64,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68308015230,NDC,,,facility,inpatient,1,EA,143.95000,41.75000,Aetna,First Health,,117.75,,,,,,,86.37,117.75,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68308015230,NDC,,,facility,outpatient,1,EA,143.95000,41.75000,Aetna,First Health,,117.75,,,,,,,51.89,117.75,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68308015215,NDC,,,facility,inpatient,1,EA,155.40000,45.07000,Aetna,First Health,,127.12,,,,,,,93.24,127.12,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68308015215,NDC,,,facility,outpatient,1,EA,155.40000,45.07000,Aetna,First Health,,127.12,,,,,,,56.02,127.12,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,68220011510,NDC,,,facility,inpatient,1,EA,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,20.82,28.38,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,68220011510,NDC,,,facility,outpatient,1,EA,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,12.51,28.38,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,68220011310,NDC,,,facility,inpatient,1,EA,20.30000,5.89000,Aetna,First Health,,16.61,,,,,,,12.18,16.61,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,68220011310,NDC,,,facility,outpatient,1,EA,20.30000,5.89000,Aetna,First Health,,16.61,,,,,,,7.32,16.61,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,68180098101,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,68180098101,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,68180098001,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,68180098001,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,68180097901,NDC,,,facility,inpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,6.60,9.00,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,68180097901,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,3.97,9.00,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,68180097401,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,68180097401,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,68180097201,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,68180097201,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,68180096901,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,68180096901,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,68180096801,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,68180096801,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,68180096709,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,68180096709,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,68180096701,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,68180096701,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,68180096601,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,68180096601,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,68180096301,NDC,,,facility,inpatient,1,EA,394.75000,114.48000,Aetna,First Health,,322.91,,,,,,,236.85,322.91,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,68180096301,NDC,,,facility,outpatient,1,EA,394.75000,114.48000,Aetna,First Health,,322.91,,,,,,,142.31,322.91,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,68180085211,NDC,,,facility,inpatient,1,EA,255.55000,74.11000,Aetna,First Health,,209.04,,,,,,,153.33,209.04,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,68180085211,NDC,,,facility,outpatient,1,EA,255.55000,74.11000,Aetna,First Health,,209.04,,,,,,,92.13,209.04,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,68180074006,NDC,,,facility,inpatient,1,EA,63.55000,18.43000,Aetna,First Health,,51.98,,,,,,,38.13,51.98,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,68180074006,NDC,,,facility,outpatient,1,EA,63.55000,18.43000,Aetna,First Health,,51.98,,,,,,,22.91,51.98,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,68180071160,NDC,,,facility,inpatient,1,EA,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,21.72,29.61,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,68180071160,NDC,,,facility,outpatient,1,EA,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,13.05,29.61,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,68180067711,NDC,,,facility,inpatient,1,EA,109.45000,31.74000,Aetna,First Health,,89.53,,,,,,,65.67,89.53,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,68180067711,NDC,,,facility,outpatient,1,EA,109.45000,31.74000,Aetna,First Health,,89.53,,,,,,,39.46,89.53,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,68180067511,NDC,,,facility,inpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,60.24,82.13,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,68180067511,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,36.19,82.13,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,68180067106,NDC,,,facility,inpatient,1,EA,350.50000,101.64000,Aetna,First Health,,286.71,,,,,,,210.30,286.71,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,68180067106,NDC,,,facility,outpatient,1,EA,350.50000,101.64000,Aetna,First Health,,286.71,,,,,,,126.36,286.71,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,68180065907,NDC,,,facility,inpatient,1,EA,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,19.50,26.59,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,68180065907,NDC,,,facility,outpatient,1,EA,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,11.72,26.59,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,68180064410,NDC,facility,inpatient,2,GM,435.90000,126.41000,Aetna,First Health,,356.57,,,,,,,157.14,356.57,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,68180064410,NDC,facility,outpatient,2,GM,435.90000,126.41000,Aetna,First Health,,356.57,,,,,,,0.44298,356.57,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,68180063310,NDC,facility,inpatient,1,GM,358.00000,103.82000,Aetna,First Health,,292.84,,,,,,,129.06,292.84,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,68180063310,NDC,facility,outpatient,1,GM,358.00000,103.82000,Aetna,First Health,,292.84,,,,,,,0.44298,292.84,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,68180060207,NDC,,,facility,inpatient,1,EA,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,30.42,41.47,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,68180060207,NDC,,,facility,outpatient,1,EA,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,18.28,41.47,percent of total billed charges,
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,68180059306,NDC,,,facility,inpatient,1,EA,81.25000,23.56000,Aetna,First Health,,66.46,,,,,,,48.75,66.46,percent of total billed charges,
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,68180059306,NDC,,,facility,outpatient,1,EA,81.25000,23.56000,Aetna,First Health,,66.46,,,,,,,29.29,66.46,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,68180059206,NDC,,,facility,inpatient,1,EA,81.25000,23.56000,Aetna,First Health,,66.46,,,,,,,48.75,66.46,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,68180059206,NDC,,,facility,outpatient,1,EA,81.25000,23.56000,Aetna,First Health,,66.46,,,,,,,29.29,66.46,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,68180059002,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,68180059002,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,68180059001,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,68180059001,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,68180058801,NDC,,,facility,inpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,6.51,8.88,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,68180058801,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,68180052406,NDC,,,facility,inpatient,1,EA,103.85000,30.12000,Aetna,First Health,,84.95,,,,,,,62.31,84.95,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,68180052406,NDC,,,facility,outpatient,1,EA,103.85000,30.12000,Aetna,First Health,,84.95,,,,,,,37.44,84.95,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,68180051701,NDC,,,facility,inpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,6.60,9.00,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,68180051701,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,3.97,9.00,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,68180051501,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,68180051501,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,68180051401,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,68180051401,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,68180051201,NDC,,,facility,inpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,2.76,3.76,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,68180051201,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,1.66,3.76,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,68180050101,NDC,,,facility,inpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,13.47,18.36,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,68180050101,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,8.09,18.36,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68180048609,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,13.89,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68180048609,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68180048509,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68180048509,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68180048502,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68180048502,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,68180044101,NDC,,,facility,inpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,68180044101,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,68180044101,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,68180044101,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Cefixime 400mg C (Suprax),800063049,CDM,637,RC,68180042311,NDC,,,facility,inpatient,1,EA,101.95000,29.57000,Aetna,First Health,,83.40,,,,,,,61.17,83.40,percent of total billed charges,
Cefixime 400mg C (Suprax),800063049,CDM,637,RC,68180042311,NDC,,,facility,outpatient,1,EA,101.95000,29.57000,Aetna,First Health,,83.40,,,,,,,36.75,83.40,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,68180036309,NDC,,,facility,inpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,10.11,13.78,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,68180036309,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.07,13.78,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,68180036209,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,68180036209,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,68180035407,NDC,,,facility,inpatient,1,EA,45.50000,13.19000,Aetna,First Health,,37.22,,,,,,,27.30,37.22,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,68180035407,NDC,,,facility,outpatient,1,EA,45.50000,13.19000,Aetna,First Health,,37.22,,,,,,,16.40,37.22,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,68180035309,NDC,,,facility,inpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,12.12,16.52,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,68180035309,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,68180035306,NDC,,,facility,inpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,12.12,16.52,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,68180035306,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,68180035302,NDC,,,facility,inpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,12.12,16.52,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,68180035302,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,68180035209,NDC,,,facility,inpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,12.12,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,68180035209,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,68180035206,NDC,,,facility,inpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,12.12,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,68180035206,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,68180035202,NDC,,,facility,inpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,12.12,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,68180035202,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline HCl 25mg T,800015414,CDM,637,RC,68180035109,NDC,,,facility,inpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,12.12,16.52,percent of total billed charges,
Sertraline HCl 25mg T,800015414,CDM,637,RC,68180035109,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,7.28,16.52,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,68180033607,NDC,,,facility,inpatient,1,EA,122.10000,35.41000,Aetna,First Health,,99.88,,,,,,,73.26,99.88,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,68180033607,NDC,,,facility,outpatient,1,EA,122.10000,35.41000,Aetna,First Health,,99.88,,,,,,,44.02,99.88,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,68180031909,NDC,,,facility,inpatient,1,EA,33.80000,9.80000,Aetna,First Health,,27.65,,,,,,,20.28,27.65,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,68180031909,NDC,,,facility,outpatient,1,EA,33.80000,9.80000,Aetna,First Health,,27.65,,,,,,,12.18,27.65,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,68180031906,NDC,,,facility,inpatient,1,EA,33.80000,9.80000,Aetna,First Health,,27.65,,,,,,,20.28,27.65,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,68180031906,NDC,,,facility,outpatient,1,EA,33.80000,9.80000,Aetna,First Health,,27.65,,,,,,,12.18,27.65,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,68180030260,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,68180030260,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,68180030220,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,68180030220,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,68180029609,NDC,,,facility,inpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,33.36,45.48,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,68180029609,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,68180029606,NDC,,,facility,inpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,33.36,45.48,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,68180029606,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,68180029509,NDC,,,facility,inpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,33.36,45.48,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,68180029509,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,68180029407,NDC,,,facility,inpatient,1,EA,49.55000,14.37000,Aetna,First Health,,40.53,,,,,,,29.73,40.53,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,68180029407,NDC,,,facility,outpatient,1,EA,49.55000,14.37000,Aetna,First Health,,40.53,,,,,,,17.86,40.53,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68180028101,NDC,,,facility,inpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,7.59,10.35,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68180028101,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,4.56,10.35,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,68180026701,NDC,,,facility,inpatient,1,EA,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,68180026701,NDC,,,facility,outpatient,1,EA,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,8.29,18.81,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,68180026601,NDC,,,facility,inpatient,1,EA,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,7.50,10.22,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,68180026601,NDC,,,facility,outpatient,1,EA,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,4.51,10.22,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,68180023007,NDC,,,facility,inpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,25.92,35.34,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,68180023007,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,15.57,35.34,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,68180022907,NDC,,,facility,inpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,25.92,35.34,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,68180022907,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,15.57,35.34,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,68180013415,NDC,facility,inpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,68180013415,NDC,facility,outpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,0.03852,5.93,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,68180012401,NDC,,,facility,inpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,68180012401,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,68180012301,NDC,,,facility,inpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,2.52,3.44,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,68180012301,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,1.51,3.44,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,68180012202,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,5.22,7.12,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,68180012202,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,68180012101,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,68180012101,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,68180011316,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,68180011316,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,68180011216,NDC,,,facility,inpatient,1,EA,20.35000,5.90000,Aetna,First Health,,16.65,,,,,,,12.21,16.65,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,68180011216,NDC,,,facility,outpatient,1,EA,20.35000,5.90000,Aetna,First Health,,16.65,,,,,,,7.34,16.65,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,68135045503,NDC,facility,inpatient,3,ME,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,68135045503,NDC,facility,outpatient,3,ME,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,0.88596,4.25,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,68094085362,NDC,,,facility,inpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,11.61,15.83,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,68094085362,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,6.98,15.83,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,68094085261,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,68094085261,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,68094081662,NDC,,,facility,inpatient,1,EA,48.70000,14.12000,Aetna,First Health,,39.84,,,,,,,29.22,39.84,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,68094081662,NDC,,,facility,outpatient,1,EA,48.70000,14.12000,Aetna,First Health,,39.84,,,,,,,17.56,39.84,percent of total billed charges,
Ondansetron 2mg/2.5 mL Oral Soln,800025699,CDM,636,RC,Q0162,HCPCS,68094076362,NDC,facility,inpatient,4,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,19.56,44.38,percent of total billed charges,
Ondansetron 2mg/2.5 mL Oral Soln,800025699,CDM,636,RC,Q0162,HCPCS,68094076362,NDC,facility,outpatient,4,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,0.00963,44.38,percent of total billed charges,
Furosemide 40mg/4mL (Lasix),800037134,CDM,637,RC,68094075662,NDC,,,facility,inpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,13.08,17.83,percent of total billed charges,
Furosemide 40mg/4mL (Lasix),800037134,CDM,637,RC,68094075662,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,7.86,17.83,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,800022076,CDM,637,RC,68094075062,NDC,,,facility,inpatient,1,EA,36.80000,10.67000,Aetna,First Health,,30.10,,,,,,,22.08,30.10,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,800022076,CDM,637,RC,68094075062,NDC,,,facility,outpatient,1,EA,36.80000,10.67000,Aetna,First Health,,30.10,,,,,,,13.27,30.10,percent of total billed charges,
Cetirizine 5mg/5mL L UD,800015481,CDM,637,RC,68094072062,NDC,,,facility,inpatient,1,EA,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,8.85,12.07,percent of total billed charges,
Cetirizine 5mg/5mL L UD,800015481,CDM,637,RC,68094072062,NDC,,,facility,outpatient,1,EA,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,5.32,12.07,percent of total billed charges,
Cetirizine 5mg/5mL L UD,800015481,CDM,637,RC,68094072059,NDC,,,facility,inpatient,1,EA,10.95000,3.18000,Aetna,First Health,,8.96,,,,,,,6.57,8.96,percent of total billed charges,
Cetirizine 5mg/5mL L UD,800015481,CDM,637,RC,68094072059,NDC,,,facility,outpatient,1,EA,10.95000,3.18000,Aetna,First Health,,8.96,,,,,,,3.95,8.96,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,68094070162,NDC,,,facility,inpatient,1,EA,10.55000,3.06000,Aetna,First Health,,8.63,,,,,,,6.33,8.63,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,68094070162,NDC,,,facility,outpatient,1,EA,10.55000,3.06000,Aetna,First Health,,8.63,,,,,,,3.80,8.63,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,68094070159,NDC,,,facility,inpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,6.30,8.59,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,68094070159,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,3.79,8.59,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094060061,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.46,5.44,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094060061,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,68094059962,NDC,,,facility,inpatient,1,EA,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,7.20,9.82,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,68094059962,NDC,,,facility,outpatient,1,EA,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,4.33,9.82,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,68094059961,NDC,,,facility,inpatient,1,EA,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,7.02,9.57,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,68094059961,NDC,,,facility,outpatient,1,EA,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,4.22,9.57,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094052862,NDC,,,facility,inpatient,1,EA,29.75000,8.63000,Aetna,First Health,,24.34,,,,,,,17.85,24.34,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094052862,NDC,,,facility,outpatient,1,EA,29.75000,8.63000,Aetna,First Health,,24.34,,,,,,,10.72,24.34,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094052861,NDC,,,facility,inpatient,1,EA,29.90000,8.67000,Aetna,First Health,,24.46,,,,,,,17.94,24.46,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094052861,NDC,,,facility,outpatient,1,EA,29.90000,8.67000,Aetna,First Health,,24.46,,,,,,,10.78,24.46,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,68094050362,NDC,,,facility,inpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,6.21,8.47,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,68094050362,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,3.73,8.47,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,68094050361,NDC,,,facility,inpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,6.18,8.43,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,68094050361,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094049461,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.28,5.03,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094049461,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094049458,NDC,,,facility,inpatient,1,EA,19.70000,5.71000,Aetna,First Health,,16.11,,,,,,,7.29,16.11,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094049458,NDC,,,facility,outpatient,1,EA,19.70000,5.71000,Aetna,First Health,,16.11,,,,,,,7.10,16.11,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,68094030162,NDC,,,facility,inpatient,1,EA,25.70000,7.45000,Aetna,First Health,,21.02,,,,,,,15.42,21.02,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,68094030162,NDC,,,facility,outpatient,1,EA,25.70000,7.45000,Aetna,First Health,,21.02,,,,,,,9.26,21.02,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094025061,NDC,,,facility,inpatient,1,EA,29.90000,8.67000,Aetna,First Health,,24.46,,,,,,,17.94,24.46,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094025061,NDC,,,facility,outpatient,1,EA,29.90000,8.67000,Aetna,First Health,,24.46,,,,,,,10.78,24.46,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,68094021462,NDC,,,facility,inpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,19.32,26.34,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,68094021462,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,68094021459,NDC,,,facility,inpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,19.32,26.34,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,68094021459,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094017162,NDC,,,facility,inpatient,1,EA,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094017162,NDC,,,facility,outpatient,1,EA,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,28.84,65.44,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094017161,NDC,,,facility,inpatient,1,EA,79.70000,23.11000,Aetna,First Health,,65.19,,,,,,,47.82,65.19,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094017161,NDC,,,facility,outpatient,1,EA,79.70000,23.11000,Aetna,First Health,,65.19,,,,,,,28.73,65.19,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094017159,NDC,,,facility,inpatient,1,EA,79.70000,23.11000,Aetna,First Health,,65.19,,,,,,,47.82,65.19,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094017159,NDC,,,facility,outpatient,1,EA,79.70000,23.11000,Aetna,First Health,,65.19,,,,,,,28.73,65.19,percent of total billed charges,
Phentolamine Mesylate 5mg I(Regitine),800013144,CDM,637,RC,J2760,HCPCS,68094010110,NDC,facility,inpatient,5,ME,1855.30000,538.04000,Aetna,First Health,,1517.64,,,,,,,1113.18,1517.64,percent of total billed charges,
Phentolamine Mesylate 5mg I(Regitine),800013144,CDM,637,RC,J2760,HCPCS,68094010110,NDC,facility,outpatient,5,ME,1855.30000,538.04000,Aetna,First Health,,1517.64,,,,,,,405.00,1517.64,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094006362,NDC,,,facility,inpatient,1,EA,40.50000,11.74000,Aetna,First Health,,33.13,,,,,,,24.30,33.13,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094006362,NDC,,,facility,outpatient,1,EA,40.50000,11.74000,Aetna,First Health,,33.13,,,,,,,14.60,33.13,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,68094004861,NDC,,,facility,inpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,4.50,6.13,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,68094004861,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,2.70,6.13,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094004362,NDC,,,facility,inpatient,1,EA,77.25000,22.40000,Aetna,First Health,,63.19,,,,,,,46.35,63.19,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094004362,NDC,,,facility,outpatient,1,EA,77.25000,22.40000,Aetna,First Health,,63.19,,,,,,,27.85,63.19,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094003758,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.96,10.96,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094003758,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,68094002862,NDC,,,facility,inpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,11.31,15.42,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,68094002862,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,6.80,15.42,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,68094002861,NDC,,,facility,inpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,10.14,13.82,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,68094002861,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,6.09,13.82,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,68094000862,NDC,,,facility,inpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,19.32,26.34,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,68094000862,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,68094000762,NDC,,,facility,inpatient,1,EA,25.70000,7.45000,Aetna,First Health,,21.02,,,,,,,15.42,21.02,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,68094000762,NDC,,,facility,outpatient,1,EA,25.70000,7.45000,Aetna,First Health,,21.02,,,,,,,9.26,21.02,percent of total billed charges,
Cetirizine 5mg/5mL L UD,800015481,CDM,637,RC,68094000462,NDC,,,facility,inpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,11.19,15.26,percent of total billed charges,
Cetirizine 5mg/5mL L UD,800015481,CDM,637,RC,68094000462,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,6.72,15.26,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,68094000261,NDC,facility,inpatient,667,ME,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,4.59,6.26,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,68094000261,NDC,facility,outpatient,667,ME,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,0.03852,6.26,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,68084099601,NDC,,,facility,inpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,7.59,10.35,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,68084099601,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,4.56,10.35,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,68084096425,NDC,,,facility,inpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,14.28,19.47,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,68084096425,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,8.58,19.47,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,68084092932,NDC,,,facility,inpatient,1,EA,52.45000,15.21000,Aetna,First Health,,42.90,,,,,,,31.47,42.90,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,68084092932,NDC,,,facility,outpatient,1,EA,52.45000,15.21000,Aetna,First Health,,42.90,,,,,,,18.91,42.90,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,68084092825,NDC,,,facility,inpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,12.75,17.38,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,68084092825,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,7.66,17.38,percent of total billed charges,
cycloSPORINE 100mg C(SandIMMUNE),800017381,CDM,637,RC,J7502,HCPCS,68084092125,NDC,facility,inpatient,100,ME,140.60000,40.77000,Aetna,First Health,,115.01,,,,,,,84.36,115.01,percent of total billed charges,
cycloSPORINE 100mg C(SandIMMUNE),800017381,CDM,637,RC,J7502,HCPCS,68084092125,NDC,facility,outpatient,100,ME,140.60000,40.77000,Aetna,First Health,,115.01,,,,,,,1.74,115.01,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,68084089625,NDC,,,facility,inpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,8.79,11.98,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,68084089625,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,5.28,11.98,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,68084089509,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,68084089509,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,68084089501,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,68084089501,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,68084088409,NDC,,,facility,inpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,5.28,7.20,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,68084088409,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,3.17,7.20,percent of total billed charges,
cycloSPORINE 25mg C(SandIMMUNE),800017380,CDM,637,RC,J7515,HCPCS,68084087925,NDC,facility,inpatient,25,ME,40.70000,11.80000,Aetna,First Health,,33.29,,,,,,,24.42,33.29,percent of total billed charges,
cycloSPORINE 25mg C(SandIMMUNE),800017380,CDM,637,RC,J7515,HCPCS,68084087925,NDC,facility,outpatient,25,ME,40.70000,11.80000,Aetna,First Health,,33.29,,,,,,,0.51039,33.29,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,68084087501,NDC,,,facility,inpatient,1,EA,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,68084087501,NDC,,,facility,outpatient,1,EA,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,14.06,31.90,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,68084086921,NDC,,,facility,inpatient,1,EA,143.20000,41.53000,Aetna,First Health,,117.14,,,,,,,85.92,117.14,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,68084086921,NDC,,,facility,outpatient,1,EA,143.20000,41.53000,Aetna,First Health,,117.14,,,,,,,51.62,117.14,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,68084085301,NDC,,,facility,inpatient,1,EA,19.50000,5.65000,Aetna,First Health,,15.95,,,,,,,11.70,15.95,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,68084085301,NDC,,,facility,outpatient,1,EA,19.50000,5.65000,Aetna,First Health,,15.95,,,,,,,7.03,15.95,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,68084085101,NDC,,,facility,inpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,4.65,6.34,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,68084085101,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,2.79,6.34,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,68084084701,NDC,facility,inpatient,25,ME,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,68084084701,NDC,facility,outpatient,25,ME,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,0.21186,3.48,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,68084084501,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,68084084501,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,68084084401,NDC,,,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,8.49,11.57,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,68084084401,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,68084082725,NDC,,,facility,inpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,5.52,7.53,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,68084082725,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,3.32,7.53,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,68084082321,NDC,,,facility,inpatient,1,EA,15.90000,4.61000,Aetna,First Health,,13.01,,,,,,,9.54,13.01,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,68084082321,NDC,,,facility,outpatient,1,EA,15.90000,4.61000,Aetna,First Health,,13.01,,,,,,,5.73,13.01,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,68084081309,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,68084081309,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,68084080801,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,68084080801,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,68084078825,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,68084078825,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,68084078301,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,68084078301,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,68084078261,NDC,,,facility,inpatient,1,EA,22.85000,6.63000,Aetna,First Health,,18.69,,,,,,,13.71,18.69,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,68084078261,NDC,,,facility,outpatient,1,EA,22.85000,6.63000,Aetna,First Health,,18.69,,,,,,,8.24,18.69,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,68084077601,NDC,,,facility,inpatient,1,EA,12.45000,3.61000,Aetna,First Health,,10.18,,,,,,,7.47,10.18,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,68084077601,NDC,,,facility,outpatient,1,EA,12.45000,3.61000,Aetna,First Health,,10.18,,,,,,,4.49,10.18,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,68084077201,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,68084077201,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,68084076521,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,68084076521,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,68084076201,NDC,,,facility,inpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,5.85,7.98,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,68084076201,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,3.51,7.98,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,68084075365,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,68084075365,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,68084075325,NDC,,,facility,inpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,5.31,7.24,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,68084075325,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,3.19,7.24,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,68084075025,NDC,,,facility,inpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,4.20,5.73,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,68084075025,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,2.52,5.73,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,68084074201,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,68084074201,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,68084073801,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,68084073801,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,68084073601,NDC,,,facility,inpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.80,2.45,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,68084073601,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.08,2.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,68084071301,NDC,,,facility,inpatient,1,EA,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,19.41,26.46,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,68084071301,NDC,,,facility,outpatient,1,EA,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,11.66,26.46,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,68084070901,NDC,,,facility,inpatient,1,EA,29.70000,8.61000,Aetna,First Health,,24.29,,,,,,,17.82,24.29,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,68084070901,NDC,,,facility,outpatient,1,EA,29.70000,8.61000,Aetna,First Health,,24.29,,,,,,,10.71,24.29,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,68084070301,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,68084070301,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,68084069801,NDC,,,facility,inpatient,1,EA,26.50000,7.68000,Aetna,First Health,,21.68,,,,,,,15.90,21.68,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,68084069801,NDC,,,facility,outpatient,1,EA,26.50000,7.68000,Aetna,First Health,,21.68,,,,,,,9.55,21.68,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,68084069701,NDC,,,facility,inpatient,1,EA,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,7.08,9.65,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,68084069701,NDC,,,facility,outpatient,1,EA,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,4.25,9.65,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,68084069201,NDC,,,facility,inpatient,1,EA,54.50000,15.80000,Aetna,First Health,,44.58,,,,,,,32.70,44.58,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,68084069201,NDC,,,facility,outpatient,1,EA,54.50000,15.80000,Aetna,First Health,,44.58,,,,,,,19.65,44.58,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,68084068301,NDC,,,facility,inpatient,1,EA,54.50000,15.80000,Aetna,First Health,,44.58,,,,,,,32.70,44.58,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,68084068301,NDC,,,facility,outpatient,1,EA,54.50000,15.80000,Aetna,First Health,,44.58,,,,,,,19.65,44.58,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,68084067201,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,68084067201,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,68084065801,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,68084065801,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,68084065501,NDC,,,facility,inpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,3.21,4.38,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,68084065501,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,1.93,4.38,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,68084065401,NDC,,,facility,inpatient,1,EA,16.45000,4.77000,Aetna,First Health,,13.46,,,,,,,9.87,13.46,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,68084065401,NDC,,,facility,outpatient,1,EA,16.45000,4.77000,Aetna,First Health,,13.46,,,,,,,5.93,13.46,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,68084064701,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,68084064701,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,68084064501,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,68084064501,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,68084064001,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,68084064001,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,68084062221,NDC,,,facility,inpatient,1,EA,143.20000,41.53000,Aetna,First Health,,117.14,,,,,,,85.92,117.14,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,68084062221,NDC,,,facility,outpatient,1,EA,143.20000,41.53000,Aetna,First Health,,117.14,,,,,,,51.62,117.14,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,68084062121,NDC,,,facility,inpatient,1,EA,210.85000,61.15000,Aetna,First Health,,172.48,,,,,,,126.51,172.48,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,68084062121,NDC,,,facility,outpatient,1,EA,210.85000,61.15000,Aetna,First Health,,172.48,,,,,,,76.01,172.48,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,68084061801,NDC,,,facility,inpatient,1,EA,32.55000,9.44000,Aetna,First Health,,26.63,,,,,,,19.53,26.63,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,68084061801,NDC,,,facility,outpatient,1,EA,32.55000,9.44000,Aetna,First Health,,26.63,,,,,,,11.73,26.63,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,68084060621,NDC,,,facility,inpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,12.84,17.51,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,68084060621,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,7.71,17.51,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,68084060501,NDC,,,facility,inpatient,1,EA,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,10.68,14.56,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,68084060501,NDC,,,facility,outpatient,1,EA,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,6.42,14.56,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,68084059701,NDC,,,facility,inpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,7.59,10.35,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,68084059701,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,4.56,10.35,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,68084057201,NDC,,,facility,inpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,4.26,5.81,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,68084057201,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,2.56,5.81,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,68084054921,NDC,,,facility,inpatient,1,EA,66.80000,19.37000,Aetna,First Health,,54.64,,,,,,,40.08,54.64,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,68084054921,NDC,,,facility,outpatient,1,EA,66.80000,19.37000,Aetna,First Health,,54.64,,,,,,,24.08,54.64,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,68084054101,NDC,,,facility,inpatient,1,EA,29.65000,8.60000,Aetna,First Health,,24.25,,,,,,,17.79,24.25,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,68084054101,NDC,,,facility,outpatient,1,EA,29.65000,8.60000,Aetna,First Health,,24.25,,,,,,,10.69,24.25,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,68084053901,NDC,,,facility,inpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,3.57,4.87,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,68084053901,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,68084053825,NDC,,,facility,inpatient,1,EA,323.65000,93.86000,Aetna,First Health,,264.75,,,,,,,194.19,264.75,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,68084053825,NDC,,,facility,outpatient,1,EA,323.65000,93.86000,Aetna,First Health,,264.75,,,,,,,116.68,264.75,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,68084053725,NDC,,,facility,inpatient,1,EA,190.25000,55.17000,Aetna,First Health,,155.62,,,,,,,114.15,155.62,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,68084053725,NDC,,,facility,outpatient,1,EA,190.25000,55.17000,Aetna,First Health,,155.62,,,,,,,68.59,155.62,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,68084053601,NDC,,,facility,inpatient,1,EA,48.25000,13.99000,Aetna,First Health,,39.47,,,,,,,28.95,39.47,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,68084053601,NDC,,,facility,outpatient,1,EA,48.25000,13.99000,Aetna,First Health,,39.47,,,,,,,17.39,39.47,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,68084048721,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,68084048721,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,68084048001,NDC,,,facility,inpatient,1,EA,21.30000,6.18000,Aetna,First Health,,17.42,,,,,,,12.78,17.42,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,68084048001,NDC,,,facility,outpatient,1,EA,21.30000,6.18000,Aetna,First Health,,17.42,,,,,,,7.68,17.42,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,68084047901,NDC,facility,inpatient,667,ME,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,7.14,9.73,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,68084047901,NDC,facility,outpatient,667,ME,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,0.03852,9.73,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,68084047201,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,68084047201,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,68084044821,NDC,,,facility,inpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,8.79,11.98,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,68084044821,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,5.28,11.98,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,68084044701,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,68084044701,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,68084044601,NDC,,,facility,inpatient,1,EA,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,68084044601,NDC,,,facility,outpatient,1,EA,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,68084042301,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,68084042301,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,68084040401,NDC,,,facility,inpatient,1,EA,26.65000,7.73000,Aetna,First Health,,21.80,,,,,,,15.99,21.80,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,68084040401,NDC,,,facility,outpatient,1,EA,26.65000,7.73000,Aetna,First Health,,21.80,,,,,,,9.61,21.80,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,68084040301,NDC,,,facility,inpatient,1,EA,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,8.85,12.07,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,68084040301,NDC,,,facility,outpatient,1,EA,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,5.32,12.07,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,68084040001,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,68084040001,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,68084039901,NDC,,,facility,inpatient,1,EA,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,14.16,19.30,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,68084039901,NDC,,,facility,outpatient,1,EA,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,8.51,19.30,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,68084039665,NDC,,,facility,inpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,8.28,11.29,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,68084039665,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,4.97,11.29,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,68084038101,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,68084038101,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,68084038001,NDC,,,facility,inpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.90000,1.23,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,68084038001,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.54075,1.23,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,68084037201,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,68084037201,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,68084036801,NDC,,,facility,inpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.92,2.62,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,68084036801,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,68084036009,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,68084036009,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,68084035901,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,68084035901,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,68084035401,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,68084035401,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,68084034801,NDC,,,facility,inpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,13.08,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,68084034801,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,68084034701,NDC,,,facility,inpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,9.57,13.05,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,68084034701,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,68084034601,NDC,,,facility,inpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,7.14,9.73,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,68084034601,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,4.29,9.73,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,68084034401,NDC,,,facility,inpatient,1,EA,43.90000,12.73000,Aetna,First Health,,35.91,,,,,,,26.34,35.91,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,68084034401,NDC,,,facility,outpatient,1,EA,43.90000,12.73000,Aetna,First Health,,35.91,,,,,,,15.83,35.91,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68084034201,NDC,,,facility,inpatient,1,EA,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,8.91,12.15,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68084034201,NDC,,,facility,outpatient,1,EA,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,5.35,12.15,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,68084034197,NDC,,,facility,inpatient,1,EA,18.05000,5.23000,Aetna,First Health,,14.76,,,,,,,10.83,14.76,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,68084034197,NDC,,,facility,outpatient,1,EA,18.05000,5.23000,Aetna,First Health,,14.76,,,,,,,6.51,14.76,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,68084033997,NDC,,,facility,inpatient,1,EA,18.05000,5.23000,Aetna,First Health,,14.76,,,,,,,10.83,14.76,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,68084033997,NDC,,,facility,outpatient,1,EA,18.05000,5.23000,Aetna,First Health,,14.76,,,,,,,6.51,14.76,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,68084032821,NDC,,,facility,inpatient,1,EA,50.50000,14.64000,Aetna,First Health,,41.31,,,,,,,30.30,41.31,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,68084032821,NDC,,,facility,outpatient,1,EA,50.50000,14.64000,Aetna,First Health,,41.31,,,,,,,18.21,41.31,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,68084031901,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,68084031901,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,68084031801,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,68084031801,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,68084031301,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,68084031301,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,68084029901,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,68084029901,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,68084029521,NDC,,,facility,inpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,5.79,7.89,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,68084029521,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,3.48,7.89,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,68084029121,NDC,,,facility,inpatient,1,EA,30.55000,8.86000,Aetna,First Health,,24.99,,,,,,,18.33,24.99,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,68084029121,NDC,,,facility,outpatient,1,EA,30.55000,8.86000,Aetna,First Health,,24.99,,,,,,,11.01,24.99,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,68084028801,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,68084028801,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,68084028401,NDC,,,facility,inpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,4.68,6.38,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,68084028401,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,2.81,6.38,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,68084028301,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,68084028301,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,68084028201,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,68084028201,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,68084028101,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,68084028101,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68084028001,NDC,,,facility,inpatient,1,EA,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,6.90,9.41,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68084028001,NDC,,,facility,outpatient,1,EA,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,4.15,9.41,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,68084027501,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,68084027501,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,68084027201,NDC,,,facility,inpatient,1,EA,32.15000,9.32000,Aetna,First Health,,26.30,,,,,,,19.29,26.30,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,68084027201,NDC,,,facility,outpatient,1,EA,32.15000,9.32000,Aetna,First Health,,26.30,,,,,,,11.59,26.30,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,68084027001,NDC,,,facility,inpatient,1,EA,27.55000,7.99000,Aetna,First Health,,22.54,,,,,,,16.53,22.54,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,68084027001,NDC,,,facility,outpatient,1,EA,27.55000,7.99000,Aetna,First Health,,22.54,,,,,,,9.93,22.54,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,68084026901,NDC,,,facility,inpatient,1,EA,31.10000,9.02000,Aetna,First Health,,25.44,,,,,,,18.66,25.44,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,68084026901,NDC,,,facility,outpatient,1,EA,31.10000,9.02000,Aetna,First Health,,25.44,,,,,,,11.21,25.44,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,68084024701,NDC,,,facility,inpatient,1,EA,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,14.16,19.30,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,68084024701,NDC,,,facility,outpatient,1,EA,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,8.51,19.30,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,68084024301,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,68084024301,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,68084022901,NDC,facility,inpatient,50,ME,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,68084022901,NDC,facility,outpatient,50,ME,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,0.05778,4.91,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,68084022601,NDC,,,facility,inpatient,1,EA,26.50000,7.68000,Aetna,First Health,,21.68,,,,,,,15.90,21.68,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,68084022601,NDC,,,facility,outpatient,1,EA,26.50000,7.68000,Aetna,First Health,,21.68,,,,,,,9.55,21.68,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,68084022501,NDC,,,facility,inpatient,1,EA,26.50000,7.68000,Aetna,First Health,,21.68,,,,,,,15.90,21.68,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,68084022501,NDC,,,facility,outpatient,1,EA,26.50000,7.68000,Aetna,First Health,,21.68,,,,,,,9.55,21.68,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,68084022001,NDC,facility,inpatient,4,ME,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,68084022001,NDC,facility,outpatient,4,ME,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,0.00963,5.19,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,68084021501,NDC,,,facility,inpatient,1,EA,28.15000,8.16000,Aetna,First Health,,23.03,,,,,,,16.89,23.03,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,68084021501,NDC,,,facility,outpatient,1,EA,28.15000,8.16000,Aetna,First Health,,23.03,,,,,,,10.15,23.03,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,68084021401,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,68084021401,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,68084020401,NDC,,,facility,inpatient,1,EA,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,7.20,9.82,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,68084020401,NDC,,,facility,outpatient,1,EA,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,4.33,9.82,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,68084020301,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,68084020301,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,68084020201,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,68084020201,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,68084019901,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,68084019901,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,68084018901,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,68084018901,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),800015411,CDM,637,RC,Q0169,HCPCS,68084015401,NDC,facility,inpatient,12.5,ME,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),800015411,CDM,637,RC,Q0169,HCPCS,68084015401,NDC,facility,outpatient,12.5,ME,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,0.24075,3.27,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,68084010309,NDC,,,facility,inpatient,1,EA,59.95000,17.39000,Aetna,First Health,,49.04,,,,,,,35.97,49.04,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,68084010309,NDC,,,facility,outpatient,1,EA,59.95000,17.39000,Aetna,First Health,,49.04,,,,,,,21.61,49.04,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,68084010001,NDC,,,facility,inpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,2.76,3.76,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,68084010001,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,1.66,3.76,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,68084009901,NDC,,,facility,inpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,3.63,4.95,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,68084009901,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,2.18,4.95,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,68084009801,NDC,,,facility,inpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,3.63,4.95,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,68084009801,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,2.18,4.95,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,68084009701,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,68084009701,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,68084009401,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,4.02,5.48,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,68084009401,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,68084009301,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,68084009301,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,68084008801,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,68084008801,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,68084008201,NDC,,,facility,inpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,5.31,7.24,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,68084008201,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,3.19,7.24,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,68084006501,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,68084006501,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,68084004590,NDC,,,facility,inpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,11.61,15.83,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,68084004590,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,6.98,15.83,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,68084004101,NDC,,,facility,inpatient,1,EA,19.30000,5.60000,Aetna,First Health,,15.79,,,,,,,11.58,15.79,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,68084004101,NDC,,,facility,outpatient,1,EA,19.30000,5.60000,Aetna,First Health,,15.79,,,,,,,6.96,15.79,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,68084004001,NDC,,,facility,inpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,10.53,14.36,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,68084004001,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,6.33,14.36,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,68084003101,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,68084003101,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,68084002801,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,68084002801,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,68084002701,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,68084002701,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,68084001901,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,68084001901,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,68084001801,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,68084001801,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,68047025501,NDC,,,facility,inpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,3.75,5.11,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,68047025501,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,68047025301,NDC,,,facility,inpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,2.01,2.74,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,68047025301,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,1.21,2.74,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,68013001801,NDC,,,facility,inpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,4.65,6.34,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,68013001801,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,2.79,6.34,percent of total billed charges,
Ceftolozane-Tazobactam 1.5g Inj,800021332,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,inpatient,1.5,GM,1442.40000,418.30000,Aetna,First Health,,1179.88,,,,,,,519.99,1179.88,percent of total billed charges,
Ceftolozane-Tazobactam 1.5g Inj,800021332,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,outpatient,1.5,GM,1442.40000,418.30000,Aetna,First Health,,1179.88,,,,,,,8.62,1179.88,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,67919001201,NDC,facility,inpatient,500,ME,3394.55000,984.42000,Aetna,First Health,,2776.74,,,,,,,1223.74,2776.74,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,67919001201,NDC,facility,outpatient,500,ME,3394.55000,984.42000,Aetna,First Health,,2776.74,,,,,,,0.02889,2776.74,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,67919001101,NDC,facility,inpatient,500,ME,3394.50000,984.40000,Aetna,First Health,,2776.70,,,,,,,1223.72,2776.70,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,67919001101,NDC,facility,outpatient,500,ME,3394.50000,984.40000,Aetna,First Health,,2776.70,,,,,,,0.02889,2776.70,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,67877084201,NDC,,,facility,inpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,10.29,14.03,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,67877084201,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,6.18,14.03,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,67877075158,NDC,,,facility,inpatient,1,EA,30.80000,8.93000,Aetna,First Health,,25.19,,,,,,,18.48,25.19,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,67877075158,NDC,,,facility,outpatient,1,EA,30.80000,8.93000,Aetna,First Health,,25.19,,,,,,,11.10,25.19,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,67877074957,NDC,,,facility,inpatient,1,EA,638.90000,185.28000,Aetna,First Health,,522.62,,,,,,,383.34,522.62,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,67877074957,NDC,,,facility,outpatient,1,EA,638.90000,185.28000,Aetna,First Health,,522.62,,,,,,,230.32,522.62,percent of total billed charges,
sirolimus 0.5 mg Tab,800051072,CDM,637,RC,J7520,HCPCS,67877074601,NDC,facility,inpatient,0.5,ME,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,36.00,49.08,percent of total billed charges,
sirolimus 0.5 mg Tab,800051072,CDM,637,RC,J7520,HCPCS,67877074601,NDC,facility,outpatient,0.5,ME,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,0.93411,49.08,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,67877073101,NDC,,,facility,inpatient,1,EA,276.55000,80.20000,Aetna,First Health,,226.22,,,,,,,165.93,226.22,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,67877073101,NDC,,,facility,outpatient,1,EA,276.55000,80.20000,Aetna,First Health,,226.22,,,,,,,99.70,226.22,percent of total billed charges,
Droxidopa 100mg Cap,800051058,CDM,637,RC,67877070490,NDC,,,facility,inpatient,1,EA,251.65000,72.98000,Aetna,First Health,,205.85,,,,,,,150.99,205.85,percent of total billed charges,
Droxidopa 100mg Cap,800051058,CDM,637,RC,67877070490,NDC,,,facility,outpatient,1,EA,251.65000,72.98000,Aetna,First Health,,205.85,,,,,,,90.72,205.85,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,67877063930,NDC,,,facility,inpatient,1,EA,350.25000,101.57000,Aetna,First Health,,286.50,,,,,,,210.15,286.50,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,67877063930,NDC,,,facility,outpatient,1,EA,350.25000,101.57000,Aetna,First Health,,286.50,,,,,,,126.27,286.50,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,67877063830,NDC,,,facility,inpatient,1,EA,350.25000,101.57000,Aetna,First Health,,286.50,,,,,,,210.15,286.50,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,67877063830,NDC,,,facility,outpatient,1,EA,350.25000,101.57000,Aetna,First Health,,286.50,,,,,,,126.27,286.50,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,67877063533,NDC,,,facility,inpatient,1,EA,2957.85000,857.78000,Aetna,First Health,,2419.52,,,,,,,1774.71,2419.52,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,67877063533,NDC,,,facility,outpatient,1,EA,2957.85000,857.78000,Aetna,First Health,,2419.52,,,,,,,1066.30,2419.52,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,67877063502,NDC,,,facility,inpatient,1,EA,2957.85000,857.78000,Aetna,First Health,,2419.52,,,,,,,1774.71,2419.52,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,67877063502,NDC,,,facility,outpatient,1,EA,2957.85000,857.78000,Aetna,First Health,,2419.52,,,,,,,1066.30,2419.52,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,67877061701,NDC,,,facility,inpatient,1,EA,8.25000,2.39000,Aetna,First Health,,6.75,,,,,,,4.95,6.75,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,67877061701,NDC,,,facility,outpatient,1,EA,8.25000,2.39000,Aetna,First Health,,6.75,,,,,,,2.97,6.75,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,67877058901,NDC,,,facility,inpatient,1,EA,47.70000,13.83000,Aetna,First Health,,39.02,,,,,,,28.62,39.02,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,67877058901,NDC,,,facility,outpatient,1,EA,47.70000,13.83000,Aetna,First Health,,39.02,,,,,,,17.20,39.02,percent of total billed charges,
Cefixime 400mg C (Suprax),800063049,CDM,637,RC,67877058450,NDC,,,facility,inpatient,1,EA,166.55000,48.30000,Aetna,First Health,,136.24,,,,,,,99.93,136.24,percent of total billed charges,
Cefixime 400mg C (Suprax),800063049,CDM,637,RC,67877058450,NDC,,,facility,outpatient,1,EA,166.55000,48.30000,Aetna,First Health,,136.24,,,,,,,60.04,136.24,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,67877057301,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,67877057301,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,67877054588,NDC,,,facility,inpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,4.86,6.63,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,67877054588,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,2.92,6.63,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,67877050651,NDC,,,facility,inpatient,1,EA,27.95000,8.11000,Aetna,First Health,,22.86,,,,,,,16.77,22.86,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,67877050651,NDC,,,facility,outpatient,1,EA,27.95000,8.11000,Aetna,First Health,,22.86,,,,,,,10.08,22.86,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,67877049301,NDC,facility,inpatient,50,ME,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,8.91,12.15,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,67877049301,NDC,facility,outpatient,50,ME,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,0.05778,12.15,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,67877049090,NDC,,,facility,inpatient,1,EA,73.10000,21.20000,Aetna,First Health,,59.80,,,,,,,43.86,59.80,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,67877049090,NDC,,,facility,outpatient,1,EA,73.10000,21.20000,Aetna,First Health,,59.80,,,,,,,26.35,59.80,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,67877049030,NDC,,,facility,inpatient,1,EA,72.80000,21.11000,Aetna,First Health,,59.55,,,,,,,43.68,59.55,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,67877049030,NDC,,,facility,outpatient,1,EA,72.80000,21.11000,Aetna,First Health,,59.55,,,,,,,26.24,59.55,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,67877049005,NDC,,,facility,inpatient,1,EA,72.80000,21.11000,Aetna,First Health,,59.55,,,,,,,43.68,59.55,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,67877049005,NDC,,,facility,outpatient,1,EA,72.80000,21.11000,Aetna,First Health,,59.55,,,,,,,26.24,59.55,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,67877047750,NDC,,,facility,inpatient,1,EA,676.80000,196.27000,Aetna,First Health,,553.62,,,,,,,406.08,553.62,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,67877047750,NDC,,,facility,outpatient,1,EA,676.80000,196.27000,Aetna,First Health,,553.62,,,,,,,243.99,553.62,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,67877047379,NDC,,,facility,inpatient,1,EA,1816.10000,526.67000,Aetna,First Health,,1485.57,,,,,,,1089.66,1485.57,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,67877047379,NDC,,,facility,outpatient,1,EA,1816.10000,526.67000,Aetna,First Health,,1485.57,,,,,,,654.70,1485.57,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,67877046290,NDC,,,facility,inpatient,1,EA,63.65000,18.46000,Aetna,First Health,,52.07,,,,,,,38.19,52.07,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,67877046290,NDC,,,facility,outpatient,1,EA,63.65000,18.46000,Aetna,First Health,,52.07,,,,,,,22.95,52.07,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,67877042612,NDC,facility,inpatient,180,ME,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,19.41,26.46,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,67877042612,NDC,facility,outpatient,180,ME,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,0.30816,26.46,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,67877041984,NDC,,,facility,inpatient,1,EA,1114.85000,323.31000,Aetna,First Health,,911.95,,,,,,,668.91,911.95,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,67877041984,NDC,,,facility,outpatient,1,EA,1114.85000,323.31000,Aetna,First Health,,911.95,,,,,,,401.90,911.95,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,67877041920,NDC,,,facility,inpatient,1,EA,1114.85000,323.31000,Aetna,First Health,,911.95,,,,,,,668.91,911.95,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,67877041920,NDC,,,facility,outpatient,1,EA,1114.85000,323.31000,Aetna,First Health,,911.95,,,,,,,401.90,911.95,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,67877041790,NDC,,,facility,inpatient,1,EA,33.45000,9.70000,Aetna,First Health,,27.36,,,,,,,20.07,27.36,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,67877041790,NDC,,,facility,outpatient,1,EA,33.45000,9.70000,Aetna,First Health,,27.36,,,,,,,12.06,27.36,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,67877041390,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,67877041390,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,67877032105,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,67877032105,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,67877032101,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,67877032101,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,67877032001,NDC,,,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,2.19,2.99,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,67877032001,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.32,2.99,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,67877031901,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,67877031901,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,67877031212,NDC,,,facility,inpatient,1,EA,50.55000,14.66000,Aetna,First Health,,41.35,,,,,,,30.33,41.35,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,67877031212,NDC,,,facility,outpatient,1,EA,50.55000,14.66000,Aetna,First Health,,41.35,,,,,,,18.22,41.35,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,67877029605,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,67877029605,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,67877029505,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,67877029505,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,67877028660,NDC,,,facility,inpatient,1,EA,258.05000,74.83000,Aetna,First Health,,211.08,,,,,,,154.83,211.08,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,67877028660,NDC,,,facility,outpatient,1,EA,258.05000,74.83000,Aetna,First Health,,211.08,,,,,,,93.03,211.08,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,67877025930,NDC,,,facility,inpatient,1,EA,176.90000,51.30000,Aetna,First Health,,144.70,,,,,,,106.14,144.70,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,67877025930,NDC,,,facility,outpatient,1,EA,176.90000,51.30000,Aetna,First Health,,144.70,,,,,,,63.77,144.70,percent of total billed charges,
Triamcinolone 0.1% TC 80g,800017794,CDM,637,RC,67877025180,NDC,,,facility,inpatient,1,EA,103.00000,29.87000,Aetna,First Health,,84.25,,,,,,,61.80,84.25,percent of total billed charges,
Triamcinolone 0.1% TC 80g,800017794,CDM,637,RC,67877025180,NDC,,,facility,outpatient,1,EA,103.00000,29.87000,Aetna,First Health,,84.25,,,,,,,37.13,84.25,percent of total billed charges,
Triamcinolone 0.1% TC 454g,800077205,CDM,637,RC,67877025145,NDC,,,facility,inpatient,1,EA,219.65000,63.70000,Aetna,First Health,,179.67,,,,,,,131.79,179.67,percent of total billed charges,
Triamcinolone 0.1% TC 454g,800077205,CDM,637,RC,67877025145,NDC,,,facility,outpatient,1,EA,219.65000,63.70000,Aetna,First Health,,179.67,,,,,,,79.18,179.67,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,67877025115,NDC,,,facility,inpatient,1,EA,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,24.78,33.78,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,67877025115,NDC,,,facility,outpatient,1,EA,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,14.89,33.78,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,67877025001,NDC,,,facility,inpatient,1,EA,48.55000,14.08000,Aetna,First Health,,39.71,,,,,,,29.13,39.71,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,67877025001,NDC,,,facility,outpatient,1,EA,48.55000,14.08000,Aetna,First Health,,39.71,,,,,,,17.50,39.71,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,67877024201,NDC,,,facility,inpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,16.98,23.15,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,67877024201,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,10.20,23.15,percent of total billed charges,
Mycophenolate Mofetil 250mg Oral Liq,800025494,CDM,637,RC,J7517,HCPCS,67877023022,NDC,facility,inpatient,250,ME,80.20000,23.26000,Aetna,First Health,,65.60,,,,,,,48.12,65.60,percent of total billed charges,
Mycophenolate Mofetil 250mg Oral Liq,800025494,CDM,637,RC,J7517,HCPCS,67877023022,NDC,facility,outpatient,250,ME,80.20000,23.26000,Aetna,First Health,,65.60,,,,,,,0.14445,65.60,percent of total billed charges,
Mycophenolate Mofetil 500mg/2.5mL Susp,800021979,CDM,637,RC,J7517,HCPCS,67877023022,NDC,facility,inpatient,500,ME,160.35000,46.50000,Aetna,First Health,,131.17,,,,,,,96.21,131.17,percent of total billed charges,
Mycophenolate Mofetil 500mg/2.5mL Susp,800021979,CDM,637,RC,J7517,HCPCS,67877023022,NDC,facility,outpatient,500,ME,160.35000,46.50000,Aetna,First Health,,131.17,,,,,,,0.14445,131.17,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,67877022401,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,67877022401,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,67877022305,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,67877022305,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,67877022301,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,67877022301,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,67877022210,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,67877022210,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,67877022205,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,67877022205,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,67877022201,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,67877022201,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,67877022001,NDC,,,facility,inpatient,1,EA,6.20000,1.80000,Aetna,First Health,,5.07,,,,,,,3.72,5.07,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,67877022001,NDC,,,facility,outpatient,1,EA,6.20000,1.80000,Aetna,First Health,,5.07,,,,,,,2.24,5.07,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,67877021905,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,67877021905,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,67877021901,NDC,,,facility,inpatient,1,EA,13.95000,4.05000,Aetna,First Health,,11.41,,,,,,,8.37,11.41,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,67877021901,NDC,,,facility,outpatient,1,EA,13.95000,4.05000,Aetna,First Health,,11.41,,,,,,,5.03,11.41,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,67877019990,NDC,,,facility,inpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,10.11,13.78,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,67877019990,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.07,13.78,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,67877019905,NDC,,,facility,inpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,10.11,13.78,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,67877019905,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.07,13.78,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,67877019890,NDC,,,facility,inpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,7.59,10.35,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,67877019890,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,4.56,10.35,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,67877019805,NDC,,,facility,inpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,7.59,10.35,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,67877019805,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,4.56,10.35,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,67877016930,NDC,facility,inpatient,4,ME,175.15000,50.79000,Aetna,First Health,,143.27,,,,,,,63.14,143.27,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,67877016930,NDC,facility,outpatient,4,ME,175.15000,50.79000,Aetna,First Health,,143.27,,,,,,,0.00963,143.27,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,67877015901,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,67877015901,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,67877012485,NDC,,,facility,inpatient,1,EA,231.15000,67.03000,Aetna,First Health,,189.08,,,,,,,138.69,189.08,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,67877012485,NDC,,,facility,outpatient,1,EA,231.15000,67.03000,Aetna,First Health,,189.08,,,,,,,83.33,189.08,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,67877010505,NDC,,,facility,inpatient,1,EA,16.05000,4.65000,Aetna,First Health,,13.13,,,,,,,9.63,13.13,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,67877010505,NDC,,,facility,outpatient,1,EA,16.05000,4.65000,Aetna,First Health,,13.13,,,,,,,5.79,13.13,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,67877010501,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,67877010501,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,67850015025,NDC,facility,inpatient,40,ME,26.60000,7.71000,Aetna,First Health,,21.76,,,,,,,9.59,21.76,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,67850015025,NDC,facility,outpatient,40,ME,26.60000,7.71000,Aetna,First Health,,21.76,,,,,,,5.86,21.76,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,67850004110,NDC,,,facility,inpatient,1,EA,275.50000,79.90000,Aetna,First Health,,225.36,,,,,,,101.94,225.36,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,67850004110,NDC,,,facility,outpatient,1,EA,275.50000,79.90000,Aetna,First Health,,225.36,,,,,,,99.32,225.36,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,67850003210,NDC,facility,inpatient,2,GM,207.25000,60.10000,Aetna,First Health,,169.53,,,,,,,74.71,169.53,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,67850003210,NDC,facility,outpatient,2,GM,207.25000,60.10000,Aetna,First Health,,169.53,,,,,,,0.05778,169.53,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,67850002210,NDC,facility,inpatient,2,GM,126.40000,36.66000,Aetna,First Health,,103.40,,,,,,,45.57,103.40,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,67850002210,NDC,facility,outpatient,2,GM,126.40000,36.66000,Aetna,First Health,,103.40,,,,,,,0.56817,103.40,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,67767015301,NDC,,,facility,inpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,5.91,8.06,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,67767015301,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,3.55,8.06,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,67767014190,NDC,,,facility,inpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,22.17,30.23,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,67767014190,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,13.32,30.23,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,67767014130,NDC,,,facility,inpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,22.17,30.23,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,67767014130,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,13.32,30.23,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,67767013360,NDC,,,facility,inpatient,1,EA,20.60000,5.97000,Aetna,First Health,,16.85,,,,,,,12.36,16.85,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,67767013360,NDC,,,facility,outpatient,1,EA,20.60000,5.97000,Aetna,First Health,,16.85,,,,,,,7.43,16.85,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,67767012318,NDC,,,facility,inpatient,1,EA,469.95000,136.29000,Aetna,First Health,,384.42,,,,,,,281.97,384.42,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,67767012318,NDC,,,facility,outpatient,1,EA,469.95000,136.29000,Aetna,First Health,,384.42,,,,,,,169.42,384.42,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,67767012218,NDC,,,facility,inpatient,1,EA,361.70000,104.89000,Aetna,First Health,,295.87,,,,,,,217.02,295.87,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,67767012218,NDC,,,facility,outpatient,1,EA,361.70000,104.89000,Aetna,First Health,,295.87,,,,,,,130.39,295.87,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,67767012118,NDC,,,facility,inpatient,1,EA,241.60000,70.06000,Aetna,First Health,,197.63,,,,,,,144.96,197.63,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,67767012118,NDC,,,facility,outpatient,1,EA,241.60000,70.06000,Aetna,First Health,,197.63,,,,,,,87.10,197.63,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,67767012018,NDC,,,facility,inpatient,1,EA,133.20000,38.63000,Aetna,First Health,,108.96,,,,,,,79.92,108.96,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,67767012018,NDC,,,facility,outpatient,1,EA,133.20000,38.63000,Aetna,First Health,,108.96,,,,,,,48.02,108.96,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,67767011215,NDC,,,facility,inpatient,1,EA,195.70000,56.75000,Aetna,First Health,,160.08,,,,,,,117.42,160.08,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,67767011215,NDC,,,facility,outpatient,1,EA,195.70000,56.75000,Aetna,First Health,,160.08,,,,,,,70.55,160.08,percent of total billed charges,
Ethiodized Oil 480 mg/mL Inj Soln 10mL,800046530,CDM,250,RC,67684190102,NDC,,,facility,inpatient,1,EA,4628.20000,1342.18000,Aetna,First Health,,3785.87,,,,,,,1712.43,3785.87,percent of total billed charges,
Ethiodized Oil 480 mg/mL Inj Soln 10mL,800046530,CDM,250,RC,67684190102,NDC,,,facility,outpatient,1,EA,4628.20000,1342.18000,Aetna,First Health,,3785.87,,,,,,,1668.47,3785.87,percent of total billed charges,
Nitazoxanide 500mg Tab,800017652,CDM,637,RC,67546011132,NDC,,,facility,inpatient,1,EA,133.10000,38.60000,Aetna,First Health,,108.88,,,,,,,79.86,108.88,percent of total billed charges,
Nitazoxanide 500mg Tab,800017652,CDM,637,RC,67546011132,NDC,,,facility,outpatient,1,EA,133.10000,38.60000,Aetna,First Health,,108.88,,,,,,,47.98,108.88,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,67467064301,NDC,facility,inpatient,12.5,GM,489.50000,141.95000,Aetna,First Health,,400.41,,,,,,,176.46,400.41,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,67467064301,NDC,facility,outpatient,12.5,GM,489.50000,141.95000,Aetna,First Health,,400.41,,,,,,,51.12,400.41,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,67467062302,NDC,facility,inpatient,12.5,GM,563.00000,163.27000,Aetna,First Health,,460.53,,,,,,,202.96,460.53,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,67467062302,NDC,facility,outpatient,12.5,GM,563.00000,163.27000,Aetna,First Health,,460.53,,,,,,,51.12,460.53,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,67457094010,NDC,facility,inpatient,1000,ME,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,134.47,305.11,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,67457094010,NDC,facility,outpatient,1000,ME,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,0.05778,305.11,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,67457092005,NDC,facility,inpatient,4,ME,407.60000,118.20000,Aetna,First Health,,333.42,,,,,,,146.94,333.42,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,67457092005,NDC,facility,outpatient,4,ME,407.60000,118.20000,Aetna,First Health,,333.42,,,,,,,4.89,333.42,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,67457088799,NDC,facility,inpatient,150,ME,212.90000,61.74000,Aetna,First Health,,174.15,,,,,,,76.75,174.15,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,67457088799,NDC,facility,outpatient,150,ME,212.90000,61.74000,Aetna,First Health,,174.15,,,,,,,0.40446,174.15,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,67457085930,NDC,facility,inpatient,6,ME,83.40000,24.19000,Aetna,First Health,,68.22,,,,,,,30.07,68.22,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,67457085930,NDC,facility,outpatient,6,ME,83.40000,24.19000,Aetna,First Health,,68.22,,,,,,,0.51039,68.22,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,67457085502,NDC,facility,inpatient,6,ME,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,14.38,32.64,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,67457085502,NDC,facility,outpatient,6,ME,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,0.51039,32.64,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,67457085350,NDC,facility,inpatient,500,ME,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,134.47,305.11,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,67457085350,NDC,facility,outpatient,500,ME,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,24.64,305.11,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,67457085204,NDC,,,facility,inpatient,1,EA,116.10000,33.67000,Aetna,First Health,,94.97,,,,,,,42.96,94.97,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,67457085204,NDC,,,facility,outpatient,1,EA,116.10000,33.67000,Aetna,First Health,,94.97,,,,,,,41.85,94.97,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,67457083902,NDC,,,facility,inpatient,1,EA,1264.50000,366.70000,Aetna,First Health,,1034.36,,,,,,,467.87,1034.36,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,67457083902,NDC,,,facility,outpatient,1,EA,1264.50000,366.70000,Aetna,First Health,,1034.36,,,,,,,455.85,1034.36,percent of total billed charges,
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,800046526,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,inpatient,6,ME,16823.20000,4878.73000,Aetna,First Health,,13761.38,,,,,,,6064.76,13761.38,percent of total billed charges,
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,800046526,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,6,ME,16823.20000,4878.73000,Aetna,First Health,,13761.38,,,,,,,95.21,13761.38,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,67457079410,NDC,facility,inpatient,5,ME,1049.50000,304.35000,Aetna,First Health,,858.49,,,,,,,378.34,858.49,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,67457079410,NDC,facility,outpatient,5,ME,1049.50000,304.35000,Aetna,First Health,,858.49,,,,,,,4.89,858.49,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,67457079005,NDC,facility,inpatient,500,ME,100.80000,29.23000,Aetna,First Health,,82.45,,,,,,,36.34,82.45,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,67457079005,NDC,facility,outpatient,500,ME,100.80000,29.23000,Aetna,First Health,,82.45,,,,,,,0.03852,82.45,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,67457067502,NDC,facility,inpatient,400,UN,4174.00000,1210.46000,Aetna,First Health,,3414.33,,,,,,,2504.40,3414.33,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,67457067502,NDC,facility,outpatient,400,UN,4174.00000,1210.46000,Aetna,First Health,,3414.33,,,,,,,1504.73,3414.33,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,67457065725,NDC,facility,inpatient,2.5,GM,3469.50000,1006.16000,Aetna,First Health,,2838.05,,,,,,,1250.75,2838.05,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,67457065725,NDC,facility,outpatient,2.5,GM,3469.50000,1006.16000,Aetna,First Health,,2838.05,,,,,,,0.20223,2838.05,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,67457064502,NDC,facility,inpatient,0.4,ME,126.20000,36.60000,Aetna,First Health,,103.23,,,,,,,45.50,103.23,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,67457064502,NDC,facility,outpatient,0.4,ME,126.20000,36.60000,Aetna,First Health,,103.23,,,,,,,0.06741,103.23,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,67457064099,NDC,facility,inpatient,10,ME,118.10000,34.25000,Aetna,First Health,,96.61,,,,,,,42.58,96.61,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,67457064099,NDC,facility,outpatient,10,ME,118.10000,34.25000,Aetna,First Health,,96.61,,,,,,,2.43,96.61,percent of total billed charges,
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,67457063110,NDC,facility,inpatient,75,ME,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,335.26,760.74,percent of total billed charges,
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,67457063110,NDC,facility,outpatient,75,ME,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,3.52,760.74,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,67457062910,NDC,facility,inpatient,20,ME,187.50000,54.37000,Aetna,First Health,,153.38,,,,,,,67.59,153.38,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,67457062910,NDC,facility,outpatient,20,ME,187.50000,54.37000,Aetna,First Health,,153.38,,,,,,,3.52,153.38,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,67457062199,NDC,facility,inpatient,40,ME,56.75000,16.46000,Aetna,First Health,,46.42,,,,,,,20.46,46.42,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,67457062199,NDC,facility,outpatient,40,ME,56.75000,16.46000,Aetna,First Health,,46.42,,,,,,,0.71262,46.42,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,67457061910,NDC,facility,inpatient,5,ME,2020.00000,585.80000,Aetna,First Health,,1652.36,,,,,,,728.21,1652.36,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,67457061910,NDC,facility,outpatient,5,ME,2020.00000,585.80000,Aetna,First Health,,1652.36,,,,,,,4.89,1652.36,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,67457058406,NDC,facility,inpatient,7.5,ME,581.30000,168.58000,Aetna,First Health,,475.50,,,,,,,209.56,475.50,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,67457058406,NDC,facility,outpatient,7.5,ME,581.30000,168.58000,Aetna,First Health,,475.50,,,,,,,0.84744,475.50,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,67457057110,NDC,,,facility,inpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.80,26.09,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,67457057110,NDC,,,facility,outpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.50,26.09,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,67457055400,NDC,facility,inpatient,4,GM,66.35000,19.24000,Aetna,First Health,,54.27,,,,,,,23.92,54.27,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,67457055400,NDC,facility,outpatient,4,GM,66.35000,19.24000,Aetna,First Health,,54.27,,,,,,,0.39483,54.27,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,67457055300,NDC,facility,inpatient,2,GM,133.75000,38.79000,Aetna,First Health,,109.41,,,,,,,48.22,109.41,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,67457055300,NDC,facility,outpatient,2,GM,133.75000,38.79000,Aetna,First Health,,109.41,,,,,,,0.39483,109.41,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,67457053035,NDC,facility,inpatient,350,ME,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,89.04,202.05,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,67457053035,NDC,facility,outpatient,350,ME,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,3.70,202.05,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,67457052433,NDC,facility,inpatient,3,ME,1867.25000,541.50000,Aetna,First Health,,1527.41,,,,,,,673.14,1527.41,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,67457052433,NDC,facility,outpatient,3,ME,1867.25000,541.50000,Aetna,First Health,,1527.41,,,,,,,12.65,1527.41,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,67457052237,NDC,facility,inpatient,3.375,GM,133.15000,38.61000,Aetna,First Health,,108.92,,,,,,,48.00,108.92,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,67457052237,NDC,facility,outpatient,3.375,GM,133.15000,38.61000,Aetna,First Health,,108.92,,,,,,,1.05,108.92,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,67457051701,NDC,facility,inpatient,500,ME,441.20000,127.95000,Aetna,First Health,,360.90,,,,,,,159.05,360.90,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,67457051701,NDC,facility,outpatient,500,ME,441.20000,127.95000,Aetna,First Health,,360.90,,,,,,,1.34,360.90,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,67457051625,NDC,facility,inpatient,100,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,34.52,78.32,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,67457051625,NDC,facility,outpatient,100,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,1.34,78.32,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,67457047710,NDC,,,facility,inpatient,1,EA,62.65000,18.17000,Aetna,First Health,,51.25,,,,,,,23.18,51.25,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,67457047710,NDC,,,facility,outpatient,1,EA,62.65000,18.17000,Aetna,First Health,,51.25,,,,,,,22.59,51.25,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,67457046799,NDC,facility,inpatient,50,ME,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,12.37,28.06,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,67457046799,NDC,facility,outpatient,50,ME,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,2.48,28.06,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,67457046201,NDC,facility,inpatient,1000,ME,533.00000,154.57000,Aetna,First Health,,435.99,,,,,,,192.15,435.99,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,67457046201,NDC,facility,outpatient,1000,ME,533.00000,154.57000,Aetna,First Health,,435.99,,,,,,,3.46,435.99,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,67457044753,NDC,,,facility,inpatient,1,EA,43.40000,12.59000,Aetna,First Health,,35.50,,,,,,,16.06,35.50,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,67457044753,NDC,,,facility,outpatient,1,EA,43.40000,12.59000,Aetna,First Health,,35.50,,,,,,,15.65,35.50,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,67457044022,NDC,facility,inpatient,4,ME,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,67457044022,NDC,facility,outpatient,4,ME,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,0.08667,3.15,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,67457043810,NDC,,,facility,inpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.80,26.09,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,67457043810,NDC,,,facility,outpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.50,26.09,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,67457043710,NDC,facility,inpatient,100,ME,156.40000,45.36000,Aetna,First Health,,127.94,,,,,,,57.87,127.94,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,67457043710,NDC,facility,outpatient,100,ME,156.40000,45.36000,Aetna,First Health,,127.94,,,,,,,0.09630,127.94,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,67457043322,NDC,facility,inpatient,20,ME,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,67457043322,NDC,facility,outpatient,20,ME,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,0.00963,4.66,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,67457042612,NDC,facility,inpatient,5,ME,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,67457042612,NDC,facility,outpatient,5,ME,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,0.70299,6.26,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,67457042312,NDC,facility,inpatient,4,ME,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,67457042312,NDC,facility,outpatient,4,ME,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,0.10593,4.29,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,67457042254,NDC,facility,inpatient,1,ME,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,67457042254,NDC,facility,outpatient,1,ME,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.10593,0.77710,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,67457042254,NDC,facility,inpatient,4,ME,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,67457042254,NDC,facility,outpatient,4,ME,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,0.00963,2.70,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,67457041901,NDC,facility,inpatient,4,ME,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,67457041901,NDC,facility,outpatient,4,ME,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,0.10593,4.05,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,67457041805,NDC,facility,inpatient,1,ME,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,67457041805,NDC,facility,outpatient,1,ME,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.10593,0.77710,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,67457041805,NDC,facility,inpatient,4,ME,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,67457041805,NDC,facility,outpatient,4,ME,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,0.00963,2.70,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,67457039054,NDC,facility,inpatient,4,ME,423.00000,122.67000,Aetna,First Health,,346.01,,,,,,,152.49,346.01,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,67457039054,NDC,facility,outpatient,4,ME,423.00000,122.67000,Aetna,First Health,,346.01,,,,,,,4.89,346.01,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,67457038599,NDC,facility,inpatient,10000,UN,26.45000,7.67000,Aetna,First Health,,21.64,,,,,,,9.54,21.64,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,67457038599,NDC,facility,outpatient,10000,UN,26.45000,7.67000,Aetna,First Health,,21.64,,,,,,,0.17334,21.64,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,67457038499,NDC,facility,inpatient,30000,UN,79.75000,23.13000,Aetna,First Health,,65.24,,,,,,,28.75,65.24,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,67457038499,NDC,facility,outpatient,30000,UN,79.75000,23.13000,Aetna,First Health,,65.24,,,,,,,0.17334,65.24,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,67457037499,NDC,facility,inpatient,5000,UN,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,8.98,15.62,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,67457037499,NDC,facility,outpatient,5000,UN,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,0.17334,15.62,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,67457035210,NDC,facility,inpatient,2,GM,127.35000,36.93000,Aetna,First Health,,104.17,,,,,,,45.91,104.17,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,67457035210,NDC,facility,outpatient,2,GM,127.35000,36.93000,Aetna,First Health,,104.17,,,,,,,0.56817,104.17,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,67457035110,NDC,facility,inpatient,1,GM,78.90000,22.88000,Aetna,First Health,,64.54,,,,,,,28.44,64.54,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,67457035110,NDC,facility,outpatient,1,GM,78.90000,22.88000,Aetna,First Health,,64.54,,,,,,,0.56817,64.54,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,inpatient,3,GM,122.95000,35.66000,Aetna,First Health,,100.57,,,,,,,44.32,100.57,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,outpatient,3,GM,122.95000,35.66000,Aetna,First Health,,100.57,,,,,,,1.28,100.57,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,67457034903,NDC,facility,inpatient,3,GM,122.95000,35.66000,Aetna,First Health,,100.57,,,,,,,44.32,100.57,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,67457034903,NDC,facility,outpatient,3,GM,122.95000,35.66000,Aetna,First Health,,100.57,,,,,,,1.28,100.57,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,67457034815,NDC,facility,inpatient,1.5,GM,65.10000,18.88000,Aetna,First Health,,53.25,,,,,,,23.47,53.25,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,67457034815,NDC,facility,outpatient,1.5,GM,65.10000,18.88000,Aetna,First Health,,53.25,,,,,,,1.28,53.25,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,67457034810,NDC,facility,inpatient,1.5,GM,65.10000,18.88000,Aetna,First Health,,53.25,,,,,,,23.47,53.25,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,67457034810,NDC,facility,outpatient,1.5,GM,65.10000,18.88000,Aetna,First Health,,53.25,,,,,,,1.28,53.25,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,inpatient,1,GM,205.60000,59.62000,Aetna,First Health,,168.18,,,,,,,74.12,168.18,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,outpatient,1,GM,205.60000,59.62000,Aetna,First Health,,168.18,,,,,,,0.02889,168.18,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,67457034001,NDC,facility,inpatient,1,GM,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,55.52,125.97,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,67457034001,NDC,facility,outpatient,1,GM,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,0.02889,125.97,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,67457033950,NDC,facility,inpatient,500,ME,77.20000,22.39000,Aetna,First Health,,63.15,,,,,,,27.83,63.15,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,67457033950,NDC,facility,outpatient,500,ME,77.20000,22.39000,Aetna,First Health,,63.15,,,,,,,0.02889,63.15,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,67457031105,NDC,facility,inpatient,250,ME,3811.20000,1105.25000,Aetna,First Health,,3117.56,,,,,,,1373.94,3117.56,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,67457031105,NDC,facility,outpatient,250,ME,3811.20000,1105.25000,Aetna,First Health,,3117.56,,,,,,,5.51,3117.56,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,67457029202,NDC,facility,inpatient,0.4,ME,126.20000,36.60000,Aetna,First Health,,103.23,,,,,,,45.50,103.23,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,67457029202,NDC,facility,outpatient,0.4,ME,126.20000,36.60000,Aetna,First Health,,103.23,,,,,,,0.06741,103.23,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,67457029101,NDC,facility,inpatient,20,ME,577.90000,167.59000,Aetna,First Health,,472.72,,,,,,,208.33,472.72,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,67457029101,NDC,facility,outpatient,20,ME,577.90000,167.59000,Aetna,First Health,,472.72,,,,,,,4.23,472.72,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,67457026330,NDC,facility,inpatient,500,ME,1376.05000,399.05000,Aetna,First Health,,1125.61,,,,,,,496.07,1125.61,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,67457026330,NDC,facility,outpatient,500,ME,1376.05000,399.05000,Aetna,First Health,,1125.61,,,,,,,55.98,1125.61,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,67457025610,NDC,facility,inpatient,250,ME,7582.25000,2198.85000,Aetna,First Health,,6202.28,,,,,,,2733.40,6202.28,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,67457025610,NDC,facility,outpatient,250,ME,7582.25000,2198.85000,Aetna,First Health,,6202.28,,,,,,,0.15408,6202.28,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,67457025510,NDC,facility,inpatient,500,ME,134.40000,38.98000,Aetna,First Health,,109.94,,,,,,,48.45,109.94,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,67457025510,NDC,facility,outpatient,500,ME,134.40000,38.98000,Aetna,First Health,,109.94,,,,,,,0.03852,109.94,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,67457024601,NDC,facility,inpatient,0.5,ME,243.60000,70.64000,Aetna,First Health,,199.26,,,,,,,146.16,199.26,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,67457024601,NDC,facility,outpatient,0.5,ME,243.60000,70.64000,Aetna,First Health,,199.26,,,,,,,0.63558,199.26,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,67457024501,NDC,facility,inpatient,0.1,ME,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,30.27,41.27,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,67457024501,NDC,facility,outpatient,0.1,ME,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,0.63558,41.27,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,67457023901,NDC,facility,inpatient,0.05,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,15.33,20.90,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,67457023901,NDC,facility,outpatient,0.05,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,0.63558,20.90,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,67457022805,NDC,,,facility,inpatient,1,EA,32.25000,9.35000,Aetna,First Health,,26.38,,,,,,,11.93,26.38,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,67457022805,NDC,,,facility,outpatient,1,EA,32.25000,9.35000,Aetna,First Health,,26.38,,,,,,,11.63,26.38,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,inpatient,0.25,ME,494.20000,143.32000,Aetna,First Health,,404.26,,,,,,,178.16,404.26,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,outpatient,0.25,ME,494.20000,143.32000,Aetna,First Health,,404.26,,,,,,,19.89,404.26,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,67457022615,NDC,facility,inpatient,3,GM,50.90000,14.76000,Aetna,First Health,,41.64,,,,,,,18.35,41.64,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,67457022615,NDC,facility,outpatient,3,GM,50.90000,14.76000,Aetna,First Health,,41.64,,,,,,,1.28,41.64,percent of total billed charges,
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,inpatient,50,ME,5027.35000,1457.93000,Aetna,First Health,,4112.37,,,,,,,1812.36,4112.37,percent of total billed charges,
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,50,ME,5027.35000,1457.93000,Aetna,First Health,,4112.37,,,,,,,5.42,4112.37,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,67457019803,NDC,,,facility,inpatient,1,EA,552.85000,160.33000,Aetna,First Health,,452.23,,,,,,,204.55,452.23,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,67457019803,NDC,,,facility,outpatient,1,EA,552.85000,160.33000,Aetna,First Health,,452.23,,,,,,,199.30,452.23,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,67457019710,NDC,,,facility,inpatient,1,EA,645.50000,187.20000,Aetna,First Health,,528.02,,,,,,,238.84,528.02,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,67457019710,NDC,,,facility,outpatient,1,EA,645.50000,187.20000,Aetna,First Health,,528.02,,,,,,,232.70,528.02,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,67457019602,NDC,facility,inpatient,200,ME,56.75000,16.46000,Aetna,First Health,,46.42,,,,,,,20.46,46.42,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,67457019602,NDC,facility,outpatient,200,ME,56.75000,16.46000,Aetna,First Health,,46.42,,,,,,,1.74,46.42,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,inpatient,100,ME,46.55000,13.50000,Aetna,First Health,,38.08,,,,,,,16.78,38.08,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,outpatient,100,ME,46.55000,13.50000,Aetna,First Health,,38.08,,,,,,,0.20223,38.08,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,67457015303,NDC,facility,inpatient,150,ME,42.25000,12.25000,Aetna,First Health,,34.56,,,,,,,15.23,34.56,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,67457015303,NDC,facility,outpatient,150,ME,42.25000,12.25000,Aetna,First Health,,34.56,,,,,,,0.39483,34.56,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,67457000110,NDC,,,facility,inpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,2.59,5.73,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,67457000110,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,2.52,5.73,percent of total billed charges,
Ketamine 500mg/NS 250mL IV,800052000,CDM,250,RC,67457000100,NDC,,,facility,inpatient,1,EA,81.70000,23.69000,Aetna,First Health,,66.83,,,,,,,30.23,66.83,percent of total billed charges,
Ketamine 500mg/NS 250mL IV,800052000,CDM,250,RC,67457000100,NDC,,,facility,outpatient,1,EA,81.70000,23.69000,Aetna,First Health,,66.83,,,,,,,29.45,66.83,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,67405060203,NDC,,,facility,inpatient,1,EA,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,67405060203,NDC,,,facility,outpatient,1,EA,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,22.35,50.72,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,67386071155,NDC,facility,inpatient,500,ME,1915.15000,555.39000,Aetna,First Health,,1566.59,,,,,,,690.41,1566.59,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,67386071155,NDC,facility,outpatient,500,ME,1915.15000,555.39000,Aetna,First Health,,1566.59,,,,,,,55.98,1566.59,percent of total billed charges,
eptinezumab - jjmr 100mg Inj,800062069,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,inpatient,100,ME,10951.00000,3175.79000,Aetna,First Health,,8957.92,,,,,,,3947.84,8957.92,percent of total billed charges,
eptinezumab - jjmr 100mg Inj,800062069,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,outpatient,100,ME,10951.00000,3175.79000,Aetna,First Health,,8957.92,,,,,,,19.74,8957.92,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,67286081203,NDC,facility,inpatient,25,ME,1536.15000,445.48000,Aetna,First Health,,1256.57,,,,,,,553.78,1256.57,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,67286081203,NDC,facility,outpatient,25,ME,1536.15000,445.48000,Aetna,First Health,,1256.57,,,,,,,0.06741,1256.57,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,67253090010,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,67253090010,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,67253066010,NDC,,,facility,inpatient,1,EA,20.25000,5.87000,Aetna,First Health,,16.56,,,,,,,12.15,16.56,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,67253066010,NDC,,,facility,outpatient,1,EA,20.25000,5.87000,Aetna,First Health,,16.56,,,,,,,7.30,16.56,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,67253065110,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,67253065110,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,67253062010,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,67253062010,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,67253042010,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,67253042010,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,67253038110,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,67253038110,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,67253038010,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,67253038010,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,67253020110,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,67253020110,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,67253014846,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,67253014846,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,67253014310,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,67253014310,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,67253000760,NDC,,,facility,inpatient,1,EA,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,21.72,29.61,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,67253000760,NDC,,,facility,outpatient,1,EA,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,13.05,29.61,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,67211010201,NDC,facility,inpatient,100,ME,2625.10000,761.28000,Aetna,First Health,,2147.33,,,,,,,946.35,2147.33,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,67211010201,NDC,facility,outpatient,100,ME,2625.10000,761.28000,Aetna,First Health,,2147.33,,,,,,,0.44298,2147.33,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,67159011203,NDC,,,facility,inpatient,1,EA,28.55000,8.28000,Aetna,First Health,,23.35,,,,,,,17.13,23.35,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,67159011203,NDC,,,facility,outpatient,1,EA,28.55000,8.28000,Aetna,First Health,,23.35,,,,,,,10.29,23.35,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,66993095077,NDC,,,facility,inpatient,1,EA,121.20000,35.15000,Aetna,First Health,,99.14,,,,,,,72.72,99.14,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,66993095077,NDC,,,facility,outpatient,1,EA,121.20000,35.15000,Aetna,First Health,,99.14,,,,,,,43.69,99.14,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,66993089815,NDC,,,facility,inpatient,1,EA,240.05000,69.61000,Aetna,First Health,,196.36,,,,,,,144.03,196.36,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,66993089815,NDC,,,facility,outpatient,1,EA,240.05000,69.61000,Aetna,First Health,,196.36,,,,,,,86.54,196.36,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,800015438,CDM,637,RC,66993079197,NDC,,,facility,inpatient,1,EA,1469.55000,426.17000,Aetna,First Health,,1202.09,,,,,,,881.73,1202.09,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,800015438,CDM,637,RC,66993079197,NDC,,,facility,outpatient,1,EA,1469.55000,426.17000,Aetna,First Health,,1202.09,,,,,,,529.77,1202.09,percent of total billed charges,
Fluticasone Prop 50mcg/INH Diskus,800017934,CDM,637,RC,66993079097,NDC,,,facility,inpatient,1,EA,1408.15000,408.36000,Aetna,First Health,,1151.87,,,,,,,844.89,1151.87,percent of total billed charges,
Fluticasone Prop 50mcg/INH Diskus,800017934,CDM,637,RC,66993079097,NDC,,,facility,outpatient,1,EA,1408.15000,408.36000,Aetna,First Health,,1151.87,,,,,,,507.64,1151.87,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,66993066430,NDC,,,facility,inpatient,1,EA,55.55000,16.11000,Aetna,First Health,,45.44,,,,,,,33.33,45.44,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,66993066430,NDC,,,facility,outpatient,1,EA,55.55000,16.11000,Aetna,First Health,,45.44,,,,,,,20.03,45.44,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,66993066330,NDC,,,facility,inpatient,1,EA,55.55000,16.11000,Aetna,First Health,,45.44,,,,,,,33.33,45.44,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,66993066330,NDC,,,facility,outpatient,1,EA,55.55000,16.11000,Aetna,First Health,,45.44,,,,,,,20.03,45.44,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,66993066130,NDC,,,facility,inpatient,1,EA,50.40000,14.62000,Aetna,First Health,,41.23,,,,,,,30.24,41.23,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,66993066130,NDC,,,facility,outpatient,1,EA,50.40000,14.62000,Aetna,First Health,,41.23,,,,,,,18.17,41.23,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,66993058697,NDC,,,facility,inpatient,1,EA,3253.85000,943.62000,Aetna,First Health,,2661.65,,,,,,,1952.31,2661.65,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,66993058697,NDC,,,facility,outpatient,1,EA,3253.85000,943.62000,Aetna,First Health,,2661.65,,,,,,,1173.01,2661.65,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,66993058597,NDC,,,facility,inpatient,1,EA,2542.35000,737.28000,Aetna,First Health,,2079.64,,,,,,,1525.41,2079.64,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,66993058597,NDC,,,facility,outpatient,1,EA,2542.35000,737.28000,Aetna,First Health,,2079.64,,,,,,,916.52,2079.64,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,66993041730,NDC,,,facility,inpatient,1,EA,50.40000,14.62000,Aetna,First Health,,41.23,,,,,,,30.24,41.23,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,66993041730,NDC,,,facility,outpatient,1,EA,50.40000,14.62000,Aetna,First Health,,41.23,,,,,,,18.17,41.23,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,66993040732,NDC,,,facility,inpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,8.34,11.37,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,66993040732,NDC,,,facility,outpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,5.01,11.37,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,66993037179,NDC,facility,inpatient,150,ME,530.05000,153.71000,Aetna,First Health,,433.58,,,,,,,191.08,433.58,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,66993037179,NDC,facility,outpatient,150,ME,530.05000,153.71000,Aetna,First Health,,433.58,,,,,,,0.40446,433.58,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,66993024150,NDC,,,facility,inpatient,1,EA,1425.30000,413.34000,Aetna,First Health,,1165.90,,,,,,,855.18,1165.90,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,66993024150,NDC,,,facility,outpatient,1,EA,1425.30000,413.34000,Aetna,First Health,,1165.90,,,,,,,513.82,1165.90,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,66993016502,NDC,,,facility,inpatient,1,EA,47.70000,13.83000,Aetna,First Health,,39.02,,,,,,,28.62,39.02,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,66993016502,NDC,,,facility,outpatient,1,EA,47.70000,13.83000,Aetna,First Health,,39.02,,,,,,,17.20,39.02,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,66993016030,NDC,,,facility,inpatient,1,EA,116.15000,33.68000,Aetna,First Health,,95.01,,,,,,,69.69,95.01,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,66993016030,NDC,,,facility,outpatient,1,EA,116.15000,33.68000,Aetna,First Health,,95.01,,,,,,,41.87,95.01,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,66993012130,NDC,,,facility,inpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,22.14,30.18,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,66993012130,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,13.30,30.18,percent of total billed charges,
SUMAtriptan 20mg/spray NS,800081034,CDM,637,RC,66993008269,NDC,,,facility,inpatient,1,EA,413.95000,120.05000,Aetna,First Health,,338.61,,,,,,,248.37,338.61,percent of total billed charges,
SUMAtriptan 20mg/spray NS,800081034,CDM,637,RC,66993008269,NDC,,,facility,outpatient,1,EA,413.95000,120.05000,Aetna,First Health,,338.61,,,,,,,149.23,338.61,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,66993006880,NDC,,,facility,inpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.92,2.62,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,66993006880,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,66993005702,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,66993005702,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,66993002501,NDC,,,facility,inpatient,1,EA,1539.45000,446.44000,Aetna,First Health,,1259.27,,,,,,,923.67,1259.27,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,66993002501,NDC,,,facility,outpatient,1,EA,1539.45000,446.44000,Aetna,First Health,,1259.27,,,,,,,554.97,1259.27,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,66993001968,NDC,,,facility,inpatient,1,EA,164.55000,47.72000,Aetna,First Health,,134.60,,,,,,,98.73,134.60,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,66993001968,NDC,,,facility,outpatient,1,EA,164.55000,47.72000,Aetna,First Health,,134.60,,,,,,,59.32,134.60,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,66993000960,NDC,,,facility,inpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,7.74,10.55,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,66993000960,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,4.65,10.55,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,66993000210,NDC,,,facility,inpatient,1,EA,1860.85000,539.65000,Aetna,First Health,,1522.18,,,,,,,1116.51,1522.18,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,66993000210,NDC,,,facility,outpatient,1,EA,1860.85000,539.65000,Aetna,First Health,,1522.18,,,,,,,670.84,1522.18,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,66870040215,NDC,,,facility,inpatient,1,EA,117.25000,34.00000,Aetna,First Health,,95.91,,,,,,,70.35,95.91,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,66870040215,NDC,,,facility,outpatient,1,EA,117.25000,34.00000,Aetna,First Health,,95.91,,,,,,,42.27,95.91,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,66860007302,NDC,facility,inpatient,1,GM,346.50000,100.48000,Aetna,First Health,,283.44,,,,,,,124.91,283.44,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,66860007302,NDC,facility,outpatient,1,GM,346.50000,100.48000,Aetna,First Health,,283.44,,,,,,,0.44298,283.44,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,66860002001,NDC,facility,inpatient,1,ME,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,66860002001,NDC,facility,outpatient,1,ME,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.41409,1.33,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,66860000203,NDC,facility,inpatient,1000,ME,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,8.08,18.32,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,66860000203,NDC,facility,outpatient,1000,ME,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,0.79929,18.32,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,66794021943,NDC,facility,inpatient,600,ME,182.40000,52.90000,Aetna,First Health,,149.20,,,,,,,65.76,149.20,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,66794021943,NDC,facility,outpatient,600,ME,182.40000,52.90000,Aetna,First Health,,149.20,,,,,,,2.64,149.20,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,66794021342,NDC,facility,inpatient,1,GM,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,5.23,11.86,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,66794021342,NDC,facility,outpatient,1,GM,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,0.44298,11.86,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,66794020741,NDC,facility,inpatient,3,GM,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,21.63,49.08,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,66794020741,NDC,facility,outpatient,3,GM,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,1.28,49.08,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,66794020641,NDC,facility,inpatient,1.5,GM,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,14.89,33.78,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,66794020641,NDC,facility,outpatient,1.5,GM,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,1.28,33.78,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,66794020442,NDC,facility,inpatient,1,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,66794020442,NDC,facility,outpatient,1,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,0.36594,20.90,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,66794015701,NDC,facility,inpatient,40,ME,4604.55000,1335.32000,Aetna,First Health,,3766.52,,,,,,,1659.94,3766.52,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,66794015701,NDC,facility,outpatient,40,ME,4604.55000,1335.32000,Aetna,First Health,,3766.52,,,,,,,174.76,3766.52,percent of total billed charges,
Isoflurane Inhl Sol 100mL,800081217,CDM,250,RC,66794001710,NDC,,,facility,inpatient,1,EA,169.90000,49.27000,Aetna,First Health,,138.98,,,,,,,62.86,138.98,percent of total billed charges,
Isoflurane Inhl Sol 100mL,800081217,CDM,250,RC,66794001710,NDC,,,facility,outpatient,1,EA,169.90000,49.27000,Aetna,First Health,,138.98,,,,,,,61.25,138.98,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,66758020854,NDC,,,facility,inpatient,1,EA,151.50000,43.93000,Aetna,First Health,,123.93,,,,,,,90.90,123.93,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,66758020854,NDC,,,facility,outpatient,1,EA,151.50000,43.93000,Aetna,First Health,,123.93,,,,,,,54.62,123.93,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,66758019013,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,66758019013,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,66689079050,NDC,,,facility,inpatient,1,EA,99.15000,28.75000,Aetna,First Health,,81.10,,,,,,,59.49,81.10,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,66689079050,NDC,,,facility,outpatient,1,EA,99.15000,28.75000,Aetna,First Health,,81.10,,,,,,,35.74,81.10,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,66689079001,NDC,,,facility,inpatient,1,EA,99.15000,28.75000,Aetna,First Health,,81.10,,,,,,,59.49,81.10,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,66689079001,NDC,,,facility,outpatient,1,EA,99.15000,28.75000,Aetna,First Health,,81.10,,,,,,,35.74,81.10,percent of total billed charges,
Methadone 50mg/5mL Oral Conc,800025566,CDM,637,RC,66689069430,NDC,,,facility,inpatient,1,EA,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,79.80,108.79,percent of total billed charges,
Methadone 50mg/5mL Oral Conc,800025566,CDM,637,RC,66689069430,NDC,,,facility,outpatient,1,EA,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,47.95,108.79,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,66689033950,NDC,,,facility,inpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,3.26,7.20,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,66689033950,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,3.17,7.20,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,66689006242,NDC,,,facility,inpatient,1,EA,286.75000,83.16000,Aetna,First Health,,234.56,,,,,,,172.05,234.56,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,66689006242,NDC,,,facility,outpatient,1,EA,286.75000,83.16000,Aetna,First Health,,234.56,,,,,,,103.37,234.56,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,66689004850,NDC,,,facility,inpatient,1,EA,203.15000,58.91000,Aetna,First Health,,166.18,,,,,,,121.89,166.18,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,66689004850,NDC,,,facility,outpatient,1,EA,203.15000,58.91000,Aetna,First Health,,166.18,,,,,,,73.24,166.18,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,66689004750,NDC,,,facility,inpatient,1,EA,131.70000,38.19000,Aetna,First Health,,107.73,,,,,,,79.02,107.73,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,66689004750,NDC,,,facility,outpatient,1,EA,131.70000,38.19000,Aetna,First Health,,107.73,,,,,,,47.48,107.73,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,66689003850,NDC,,,facility,inpatient,1,EA,11.85000,3.44000,Aetna,First Health,,9.69,,,,,,,7.11,9.69,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,66689003850,NDC,,,facility,outpatient,1,EA,11.85000,3.44000,Aetna,First Health,,9.69,,,,,,,4.27,9.69,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,66689003799,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,66689003799,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,66689003750,NDC,,,facility,inpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,6.54,8.92,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,66689003750,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,66689003650,NDC,,,facility,inpatient,1,EA,61.15000,17.73000,Aetna,First Health,,50.02,,,,,,,36.69,50.02,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,66689003650,NDC,,,facility,outpatient,1,EA,61.15000,17.73000,Aetna,First Health,,50.02,,,,,,,22.04,50.02,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,66689002050,NDC,,,facility,inpatient,1,EA,49.80000,14.44000,Aetna,First Health,,40.74,,,,,,,29.88,40.74,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,66689002050,NDC,,,facility,outpatient,1,EA,49.80000,14.44000,Aetna,First Health,,40.74,,,,,,,17.95,40.74,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,66689002001,NDC,,,facility,inpatient,1,EA,30.10000,8.73000,Aetna,First Health,,24.62,,,,,,,18.06,24.62,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,66689002001,NDC,,,facility,outpatient,1,EA,30.10000,8.73000,Aetna,First Health,,24.62,,,,,,,10.85,24.62,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,66689000950,NDC,,,facility,inpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,3.26,7.20,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,66689000950,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,3.17,7.20,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,66689000816,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,66689000816,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,800018013,CDM,637,RC,66689000550,NDC,,,facility,inpatient,1,EA,37.90000,10.99000,Aetna,First Health,,31.00,,,,,,,22.74,31.00,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,800018013,CDM,637,RC,66689000550,NDC,,,facility,outpatient,1,EA,37.90000,10.99000,Aetna,First Health,,31.00,,,,,,,13.66,31.00,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,66685101200,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,66685101200,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,66685100202,NDC,,,facility,inpatient,1,EA,26.00000,7.54000,Aetna,First Health,,21.27,,,,,,,15.60,21.27,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,66685100202,NDC,,,facility,outpatient,1,EA,26.00000,7.54000,Aetna,First Health,,21.27,,,,,,,9.37,21.27,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,66685100200,NDC,,,facility,inpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,16.08,21.92,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,66685100200,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,9.66,21.92,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,66685100101,NDC,,,facility,inpatient,1,EA,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,20.82,28.38,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,66685100101,NDC,,,facility,outpatient,1,EA,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,12.51,28.38,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,66685100100,NDC,,,facility,inpatient,1,EA,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,21.45,29.24,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,66685100100,NDC,,,facility,outpatient,1,EA,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,12.89,29.24,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,66591084142,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,66591084142,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,66591022141,NDC,facility,inpatient,50,ME,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,5.34,7.28,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,66591022141,NDC,facility,outpatient,50,ME,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,0.05778,7.28,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,66591019941,NDC,,,facility,inpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,30.45,67.32,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,66591019941,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,29.67,67.32,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,66591018442,NDC,,,facility,inpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,30.45,67.32,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,66591018442,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,29.67,67.32,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,66582041454,NDC,,,facility,inpatient,1,EA,97.70000,28.33000,Aetna,First Health,,79.92,,,,,,,58.62,79.92,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,66582041454,NDC,,,facility,outpatient,1,EA,97.70000,28.33000,Aetna,First Health,,79.92,,,,,,,35.22,79.92,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,66582041431,NDC,,,facility,inpatient,1,EA,97.70000,28.33000,Aetna,First Health,,79.92,,,,,,,58.62,79.92,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,66582041431,NDC,,,facility,outpatient,1,EA,97.70000,28.33000,Aetna,First Health,,79.92,,,,,,,35.22,79.92,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,66490004101,NDC,facility,inpatient,1,ME,4878.20000,1414.68000,Aetna,First Health,,3990.37,,,,,,,1758.59,3990.37,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,66490004101,NDC,facility,outpatient,1,ME,4878.20000,1414.68000,Aetna,First Health,,3990.37,,,,,,,54.97,3990.37,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,66479054325,NDC,,,facility,inpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,24.99,34.07,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,66479054325,NDC,,,facility,outpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,15.01,34.07,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,66479054310,NDC,,,facility,inpatient,1,EA,59.45000,17.24000,Aetna,First Health,,48.63,,,,,,,35.67,48.63,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,66479054310,NDC,,,facility,outpatient,1,EA,59.45000,17.24000,Aetna,First Health,,48.63,,,,,,,21.43,48.63,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,66479054125,NDC,,,facility,inpatient,1,EA,19.65000,5.70000,Aetna,First Health,,16.07,,,,,,,11.79,16.07,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,66479054125,NDC,,,facility,outpatient,1,EA,19.65000,5.70000,Aetna,First Health,,16.07,,,,,,,7.08,16.07,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,66479054025,NDC,,,facility,inpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,5.91,8.06,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,66479054025,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,3.55,8.06,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,66479054010,NDC,,,facility,inpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,6.51,8.88,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,66479054010,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,66479024725,NDC,facility,inpatient,350,ME,1593.75000,462.19000,Aetna,First Health,,1303.69,,,,,,,574.55,1303.69,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,66479024725,NDC,facility,outpatient,350,ME,1593.75000,462.19000,Aetna,First Health,,1303.69,,,,,,,3.70,1303.69,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,66220020730,NDC,facility,inpatient,6000,ME,263.75000,76.49000,Aetna,First Health,,215.75,,,,,,,95.08,215.75,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,66220020730,NDC,facility,outpatient,6000,ME,263.75000,76.49000,Aetna,First Health,,215.75,,,,,,,0.35631,215.75,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,66220010730,NDC,facility,inpatient,6000,ME,1485.75000,430.87000,Aetna,First Health,,1215.34,,,,,,,535.61,1215.34,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,66220010730,NDC,facility,outpatient,6000,ME,1485.75000,430.87000,Aetna,First Health,,1215.34,,,,,,,0.35631,1215.34,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65939038742,NDC,,,facility,inpatient,1,EA,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,19.50,26.59,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65939038742,NDC,,,facility,outpatient,1,EA,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,11.72,26.59,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,800046545,CDM,637,RC,65862089678,NDC,,,facility,inpatient,1,EA,111.70000,32.39000,Aetna,First Health,,91.37,,,,,,,67.02,91.37,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,800046545,CDM,637,RC,65862089678,NDC,,,facility,outpatient,1,EA,111.70000,32.39000,Aetna,First Health,,91.37,,,,,,,40.27,91.37,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,65862084401,NDC,,,facility,inpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,5.61,7.65,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,65862084401,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,3.37,7.65,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,65862083030,NDC,,,facility,inpatient,1,EA,116.85000,33.89000,Aetna,First Health,,95.58,,,,,,,70.11,95.58,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,65862083030,NDC,,,facility,outpatient,1,EA,116.85000,33.89000,Aetna,First Health,,95.58,,,,,,,42.12,95.58,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,65862082930,NDC,,,facility,inpatient,1,EA,116.85000,33.89000,Aetna,First Health,,95.58,,,,,,,70.11,95.58,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,65862082930,NDC,,,facility,outpatient,1,EA,116.85000,33.89000,Aetna,First Health,,95.58,,,,,,,42.12,95.58,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,65862080530,NDC,,,facility,inpatient,1,EA,58.10000,16.85000,Aetna,First Health,,47.53,,,,,,,34.86,47.53,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,65862080530,NDC,,,facility,outpatient,1,EA,58.10000,16.85000,Aetna,First Health,,47.53,,,,,,,20.95,47.53,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,65862078201,NDC,,,facility,inpatient,1,EA,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,8.88,12.11,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,65862078201,NDC,,,facility,outpatient,1,EA,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,5.34,12.11,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,65862073205,NDC,,,facility,inpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,14.37,19.59,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,65862073205,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.63,19.59,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862069960,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862069960,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862069920,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862069920,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,65862069790,NDC,,,facility,inpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,65862069790,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,12.98,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,65862069730,NDC,,,facility,inpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,65862069730,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,12.98,29.45,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,65862069201,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,65862069201,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,65862067701,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,65862067701,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,65862067601,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,65862067601,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,65862065401,NDC,,,facility,inpatient,1,EA,32.15000,9.32000,Aetna,First Health,,26.30,,,,,,,19.29,26.30,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,65862065401,NDC,,,facility,outpatient,1,EA,32.15000,9.32000,Aetna,First Health,,26.30,,,,,,,11.59,26.30,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,65862064860,NDC,,,facility,inpatient,1,EA,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,19.80,26.99,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,65862064860,NDC,,,facility,outpatient,1,EA,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,11.90,26.99,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,65862059801,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,65862059801,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,65862059501,NDC,,,facility,inpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,17.31,23.60,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,65862059501,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,10.40,23.60,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,65862057290,NDC,,,facility,inpatient,1,EA,35.40000,10.27000,Aetna,First Health,,28.96,,,,,,,21.24,28.96,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,65862057290,NDC,,,facility,outpatient,1,EA,35.40000,10.27000,Aetna,First Health,,28.96,,,,,,,12.76,28.96,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,65862057190,NDC,,,facility,inpatient,1,EA,32.90000,9.54000,Aetna,First Health,,26.91,,,,,,,19.74,26.91,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,65862057190,NDC,,,facility,outpatient,1,EA,32.90000,9.54000,Aetna,First Health,,26.91,,,,,,,11.86,26.91,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,65862056099,NDC,,,facility,inpatient,1,EA,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,22.38,30.51,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,65862056099,NDC,,,facility,outpatient,1,EA,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,13.45,30.51,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,65862056090,NDC,,,facility,inpatient,1,EA,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,22.38,30.51,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,65862056090,NDC,,,facility,outpatient,1,EA,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,13.45,30.51,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,65862055260,NDC,,,facility,inpatient,1,EA,50.65000,14.69000,Aetna,First Health,,41.43,,,,,,,30.39,41.43,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,65862055260,NDC,,,facility,outpatient,1,EA,50.65000,14.69000,Aetna,First Health,,41.43,,,,,,,18.26,41.43,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),800015332,CDM,637,RC,65862053820,NDC,,,facility,inpatient,1,EA,252.40000,73.20000,Aetna,First Health,,206.46,,,,,,,151.44,206.46,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),800015332,CDM,637,RC,65862053820,NDC,,,facility,outpatient,1,EA,252.40000,73.20000,Aetna,First Health,,206.46,,,,,,,90.99,206.46,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,65862053475,NDC,,,facility,inpatient,1,EA,22.10000,6.41000,Aetna,First Health,,18.08,,,,,,,13.26,18.08,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,65862053475,NDC,,,facility,outpatient,1,EA,22.10000,6.41000,Aetna,First Health,,18.08,,,,,,,7.97,18.08,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,65862053450,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,65862053450,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,65862052890,NDC,,,facility,inpatient,1,EA,33.05000,9.58000,Aetna,First Health,,27.03,,,,,,,19.83,27.03,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,65862052890,NDC,,,facility,outpatient,1,EA,33.05000,9.58000,Aetna,First Health,,27.03,,,,,,,11.91,27.03,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,65862052790,NDC,,,facility,inpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,17.70,24.13,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,65862052790,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,10.63,24.13,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,65862052730,NDC,,,facility,inpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,17.70,24.13,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,65862052730,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,10.63,24.13,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,65862052301,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,65862052301,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,65862050320,NDC,,,facility,inpatient,1,EA,35.90000,10.41000,Aetna,First Health,,29.37,,,,,,,21.54,29.37,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,65862050320,NDC,,,facility,outpatient,1,EA,35.90000,10.41000,Aetna,First Health,,29.37,,,,,,,12.94,29.37,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,65862050220,NDC,,,facility,inpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,16.08,21.92,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,65862050220,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,9.66,21.92,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,800072524,CDM,637,RC,65862049647,NDC,,,facility,inpatient,1,EA,64.50000,18.70000,Aetna,First Health,,52.76,,,,,,,38.70,52.76,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,800072524,CDM,637,RC,65862049647,NDC,,,facility,outpatient,1,EA,64.50000,18.70000,Aetna,First Health,,52.76,,,,,,,23.25,52.76,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,65862047601,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,65862047601,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,65862047501,NDC,,,facility,inpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,7.68,10.47,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,65862047501,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,4.61,10.47,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,65862047401,NDC,,,facility,inpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,6.51,8.88,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,65862047401,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,65862041901,NDC,,,facility,inpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,2.82,3.84,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,65862041901,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,65862039010,NDC,facility,inpatient,4,ME,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,94.71,129.12,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,65862039010,NDC,facility,outpatient,4,ME,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,0.00963,129.12,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,65862037501,NDC,,,facility,inpatient,1,EA,34.85000,10.11000,Aetna,First Health,,28.51,,,,,,,20.91,28.51,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,65862037501,NDC,,,facility,outpatient,1,EA,34.85000,10.11000,Aetna,First Health,,28.51,,,,,,,12.56,28.51,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,65862037401,NDC,,,facility,inpatient,1,EA,33.40000,9.69000,Aetna,First Health,,27.32,,,,,,,20.04,27.32,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,65862037401,NDC,,,facility,outpatient,1,EA,33.40000,9.69000,Aetna,First Health,,27.32,,,,,,,12.04,27.32,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,65862037301,NDC,,,facility,inpatient,1,EA,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,19.17,26.14,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,65862037301,NDC,,,facility,outpatient,1,EA,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,11.52,26.14,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,65862029630,NDC,,,facility,inpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,38.01,51.82,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,65862029630,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,22.84,51.82,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,65862029490,NDC,,,facility,inpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,38.01,51.82,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,65862029490,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,22.84,51.82,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,65862025047,NDC,,,facility,inpatient,1,EA,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,13.83,18.85,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,65862025047,NDC,,,facility,outpatient,1,EA,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,8.31,18.85,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,65862022801,NDC,,,facility,inpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,20.19,27.53,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,65862022801,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,12.13,27.53,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,65862022701,NDC,,,facility,inpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,17.67,24.09,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,65862022701,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,10.62,24.09,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,65862020390,NDC,,,facility,inpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,13.08,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,65862020390,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,65862020330,NDC,,,facility,inpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,13.08,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,65862020330,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,65862020299,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,65862020299,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,65862020290,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,65862020290,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,65862020230,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,65862020230,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,65862020190,NDC,,,facility,inpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,7.14,9.73,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,65862020190,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,4.29,9.73,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,65862019301,NDC,,,facility,inpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,11.34,15.46,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,65862019301,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,6.81,15.46,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,65862019201,NDC,,,facility,inpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,11.04,15.05,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,65862019201,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,6.63,15.05,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65862019105,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65862019105,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65862019101,NDC,,,facility,inpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,4.77,6.50,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65862019101,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,2.87,6.50,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,65862019001,NDC,,,facility,inpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,7.32,9.98,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,65862019001,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,4.40,9.98,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,65862018730,NDC,facility,inpatient,4,ME,171.35000,49.69000,Aetna,First Health,,140.16,,,,,,,61.77,140.16,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,65862018730,NDC,facility,outpatient,4,ME,171.35000,49.69000,Aetna,First Health,,140.16,,,,,,,0.00963,140.16,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,65862017760,NDC,,,facility,inpatient,1,EA,36.15000,10.48000,Aetna,First Health,,29.57,,,,,,,21.69,29.57,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,65862017760,NDC,,,facility,outpatient,1,EA,36.15000,10.48000,Aetna,First Health,,29.57,,,,,,,13.03,29.57,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,65862017601,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,65862017601,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,65862016901,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,65862016901,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,65862014990,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,13.29,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,65862014990,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,65862014836,NDC,,,facility,inpatient,1,EA,180.40000,52.32000,Aetna,First Health,,147.57,,,,,,,108.24,147.57,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,65862014836,NDC,,,facility,outpatient,1,EA,180.40000,52.32000,Aetna,First Health,,147.57,,,,,,,65.03,147.57,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,65862014636,NDC,,,facility,inpatient,1,EA,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,115.80,157.87,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,65862014636,NDC,,,facility,outpatient,1,EA,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,69.58,157.87,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,65862014501,NDC,,,facility,inpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,8.28,11.29,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,65862014501,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,4.97,11.29,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,65862014201,NDC,,,facility,inpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,8.28,11.29,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,65862014201,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,4.97,11.29,percent of total billed charges,
Cefpodoxime 200mg Tab,800051990,CDM,637,RC,51990,HCPCS,65862009620,NDC,facility,inpatient,200,ME,59.90000,17.37000,Aetna,First Health,,49.00,,,,,,,35.94,49.00,percent of total billed charges,
Cefpodoxime 200mg Tab,800051990,CDM,637,RC,51990,HCPCS,65862009620,NDC,facility,outpatient,200,ME,59.90000,17.37000,Aetna,First Health,,49.00,,,,,,,23.96,15572.44,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,65862007930,NDC,,,facility,inpatient,1,EA,90.50000,26.24000,Aetna,First Health,,74.03,,,,,,,54.30,74.03,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,65862007930,NDC,,,facility,outpatient,1,EA,90.50000,26.24000,Aetna,First Health,,74.03,,,,,,,32.63,74.03,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,65862006201,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,65862006201,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
LamiVUDine 10mg/1mL Oral L(Epivir),800081138,CDM,637,RC,65862005524,NDC,,,facility,inpatient,1,EA,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,5.01,6.83,percent of total billed charges,
LamiVUDine 10mg/1mL Oral L(Epivir),800081138,CDM,637,RC,65862005524,NDC,,,facility,outpatient,1,EA,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,3.01,6.83,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,65862004201,NDC,,,facility,inpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,6.54,8.92,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,65862004201,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,65862003901,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,65862003901,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862003460,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862003460,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862003420,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862003420,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,65862003130,NDC,,,facility,inpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,11.46,15.62,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,65862003130,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,6.89,15.62,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,65862002901,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,65862002901,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,800015404,CDM,637,RC,65862002801,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,800015404,CDM,637,RC,65862002801,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,65862001901,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,65862001901,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,65862001701,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,65862001701,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,65862001205,NDC,,,facility,inpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,12.09,16.48,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,65862001205,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,7.26,16.48,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,65862000801,NDC,,,facility,inpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,3.03,4.13,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,65862000801,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,1.82,4.13,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),800017683,CDM,637,RC,65726026315,NDC,,,facility,inpatient,1,EA,57.70000,16.73000,Aetna,First Health,,47.20,,,,,,,34.62,47.20,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),800017683,CDM,637,RC,65726026315,NDC,,,facility,outpatient,1,EA,57.70000,16.73000,Aetna,First Health,,47.20,,,,,,,20.80,47.20,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,65726026225,NDC,,,facility,inpatient,1,EA,47.15000,13.67000,Aetna,First Health,,38.57,,,,,,,28.29,38.57,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,65726026225,NDC,,,facility,outpatient,1,EA,47.15000,13.67000,Aetna,First Health,,38.57,,,,,,,17.00,38.57,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,65726026215,NDC,,,facility,inpatient,1,EA,57.25000,16.60000,Aetna,First Health,,46.83,,,,,,,34.35,46.83,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,65726026215,NDC,,,facility,outpatient,1,EA,57.25000,16.60000,Aetna,First Health,,46.83,,,,,,,20.64,46.83,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,65726026125,NDC,,,facility,inpatient,1,EA,35.80000,10.38000,Aetna,First Health,,29.28,,,,,,,21.48,29.28,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,65726026125,NDC,,,facility,outpatient,1,EA,35.80000,10.38000,Aetna,First Health,,29.28,,,,,,,12.91,29.28,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,65726026115,NDC,,,facility,inpatient,1,EA,45.20000,13.11000,Aetna,First Health,,36.97,,,,,,,27.12,36.97,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,65726026115,NDC,,,facility,outpatient,1,EA,45.20000,13.11000,Aetna,First Health,,36.97,,,,,,,16.29,36.97,percent of total billed charges,
Methylnaltrexone 12mg/0.6mL I,800020067,CDM,637,RC,J2212,HCPCS,65649055107,NDC,facility,inpatient,12,ME,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,520.20,709.21,percent of total billed charges,
Methylnaltrexone 12mg/0.6mL I,800020067,CDM,637,RC,J2212,HCPCS,65649055107,NDC,facility,outpatient,12,ME,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,1.54,709.21,percent of total billed charges,
Methylnaltrexone 12mg/0.6mL I,800020067,CDM,637,RC,J2212,HCPCS,65649055103,NDC,facility,inpatient,12,ME,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,520.20,709.21,percent of total billed charges,
Methylnaltrexone 12mg/0.6mL I,800020067,CDM,637,RC,J2212,HCPCS,65649055103,NDC,facility,outpatient,12,ME,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,1.54,709.21,percent of total billed charges,
Methylnaltrexone 12mg/0.6mL I,800020067,CDM,637,RC,J2212,HCPCS,65649055102,NDC,facility,inpatient,12,ME,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,520.20,709.21,percent of total billed charges,
Methylnaltrexone 12mg/0.6mL I,800020067,CDM,637,RC,J2212,HCPCS,65649055102,NDC,facility,outpatient,12,ME,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,1.54,709.21,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,65649041124,NDC,,,facility,inpatient,1,EA,521.00000,151.09000,Aetna,First Health,,426.18,,,,,,,312.60,426.18,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,65649041124,NDC,,,facility,outpatient,1,EA,521.00000,151.09000,Aetna,First Health,,426.18,,,,,,,187.82,426.18,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,65649041112,NDC,,,facility,inpatient,1,EA,521.00000,151.09000,Aetna,First Health,,426.18,,,,,,,312.60,426.18,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,65649041112,NDC,,,facility,outpatient,1,EA,521.00000,151.09000,Aetna,First Health,,426.18,,,,,,,187.82,426.18,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,65649040130,NDC,,,facility,inpatient,1,EA,1368.15000,396.76000,Aetna,First Health,,1119.15,,,,,,,820.89,1119.15,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,65649040130,NDC,,,facility,outpatient,1,EA,1368.15000,396.76000,Aetna,First Health,,1119.15,,,,,,,493.22,1119.15,percent of total billed charges,
NICU- Chlorothiazide 50mg/mL L,800081184,CDM,637,RC,65649031112,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
NICU- Chlorothiazide 50mg/mL L,800081184,CDM,637,RC,65649031112,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
rifAXIMin 200 mg T(Xifaxan),800070021,CDM,637,RC,65649030141,NDC,,,facility,inpatient,1,EA,113.55000,32.93000,Aetna,First Health,,92.88,,,,,,,68.13,92.88,percent of total billed charges,
rifAXIMin 200 mg T(Xifaxan),800070021,CDM,637,RC,65649030141,NDC,,,facility,outpatient,1,EA,113.55000,32.93000,Aetna,First Health,,92.88,,,,,,,40.93,92.88,percent of total billed charges,
rifAXIMin 200 mg T(Xifaxan),800070021,CDM,637,RC,65649030103,NDC,,,facility,inpatient,1,EA,95.40000,27.67000,Aetna,First Health,,78.04,,,,,,,57.24,78.04,percent of total billed charges,
rifAXIMin 200 mg T(Xifaxan),800070021,CDM,637,RC,65649030103,NDC,,,facility,outpatient,1,EA,95.40000,27.67000,Aetna,First Health,,78.04,,,,,,,34.39,78.04,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,65628020810,NDC,,,facility,inpatient,1,EA,40.15000,11.64000,Aetna,First Health,,32.84,,,,,,,24.09,32.84,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,65628020810,NDC,,,facility,outpatient,1,EA,40.15000,11.64000,Aetna,First Health,,32.84,,,,,,,14.47,32.84,percent of total billed charges,
Vancomycin 125mg/2.5mL Oral Soln,800072448,CDM,637,RC,65628020110,NDC,,,facility,inpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Vancomycin 125mg/2.5mL Oral Soln,800072448,CDM,637,RC,65628020110,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,65628020110,NDC,,,facility,inpatient,1,EA,19.95000,5.79000,Aetna,First Health,,16.32,,,,,,,11.97,16.32,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,65628020110,NDC,,,facility,outpatient,1,EA,19.95000,5.79000,Aetna,First Health,,16.32,,,,,,,7.19,16.32,percent of total billed charges,
Magic Mouthwash 10mL L UD,800081240,CDM,637,RC,65628005001,NDC,,,facility,inpatient,1,EA,44.80000,12.99000,Aetna,First Health,,36.65,,,,,,,26.88,36.65,percent of total billed charges,
Magic Mouthwash 10mL L UD,800081240,CDM,637,RC,65628005001,NDC,,,facility,outpatient,1,EA,44.80000,12.99000,Aetna,First Health,,36.65,,,,,,,16.15,36.65,percent of total billed charges,
Magic Mouthwash 5mL  L UD,800015325,CDM,637,RC,65628005001,NDC,,,facility,inpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,13.44,18.32,percent of total billed charges,
Magic Mouthwash 5mL  L UD,800015325,CDM,637,RC,65628005001,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,8.08,18.32,percent of total billed charges,
Magic Mouthwash 15mL L UD,800015326,CDM,637,RC,65628005001,NDC,,,facility,inpatient,1,EA,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,40.32,54.97,percent of total billed charges,
Magic Mouthwash 15mL L UD,800015326,CDM,637,RC,65628005001,NDC,,,facility,outpatient,1,EA,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,24.23,54.97,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,65628001610,NDC,,,facility,inpatient,1,EA,30.70000,8.90000,Aetna,First Health,,25.11,,,,,,,18.42,25.11,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,65628001610,NDC,,,facility,outpatient,1,EA,30.70000,8.90000,Aetna,First Health,,25.11,,,,,,,11.07,25.11,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,65597070118,NDC,,,facility,inpatient,1,EA,31.60000,9.16000,Aetna,First Health,,25.85,,,,,,,18.96,25.85,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,65597070118,NDC,,,facility,outpatient,1,EA,31.60000,9.16000,Aetna,First Health,,25.85,,,,,,,11.39,25.85,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,65580064371,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,65580064371,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,65483070210,NDC,,,facility,inpatient,1,EA,148.25000,42.99000,Aetna,First Health,,121.27,,,,,,,88.95,121.27,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,65483070210,NDC,,,facility,outpatient,1,EA,148.25000,42.99000,Aetna,First Health,,121.27,,,,,,,53.44,121.27,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,65473070301,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,65473070301,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,65293000101,NDC,facility,inpatient,250,ME,7795.00000,2260.55000,Aetna,First Health,,6376.31,,,,,,,2810.10,6376.31,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,65293000101,NDC,facility,outpatient,250,ME,7795.00000,2260.55000,Aetna,First Health,,6376.31,,,,,,,0.15408,6376.31,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,65219047910,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,65219047910,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,2.29,43.80,percent of total billed charges,
etomidate 2mg/mL 20mL Inj,800046520,CDM,250,RC,65219044720,NDC,,,facility,inpatient,1,EA,40.55000,11.76000,Aetna,First Health,,33.17,,,,,,,15.00,33.17,percent of total billed charges,
etomidate 2mg/mL 20mL Inj,800046520,CDM,250,RC,65219044720,NDC,,,facility,outpatient,1,EA,40.55000,11.76000,Aetna,First Health,,33.17,,,,,,,14.62,33.17,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,65219044510,NDC,,,facility,inpatient,1,EA,35.10000,10.18000,Aetna,First Health,,28.71,,,,,,,12.99,28.71,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,65219044510,NDC,,,facility,outpatient,1,EA,35.10000,10.18000,Aetna,First Health,,28.71,,,,,,,12.65,28.71,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,65219043315,NDC,facility,inpatient,40,ME,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,65219043315,NDC,facility,outpatient,40,ME,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,5.86,25.48,percent of total billed charges,
RAD- iodixanol 320mg/mL Inj 100mL,800022113,CDM,636,RC,Q9967,HCPCS,65219038310,NDC,facility,inpatient,1,EA,506.20000,146.80000,Aetna,First Health,,414.07,,,,,,,182.49,414.07,percent of total billed charges,
RAD- iodixanol 320mg/mL Inj 100mL,800022113,CDM,636,RC,Q9967,HCPCS,65219038310,NDC,facility,outpatient,1,EA,506.20000,146.80000,Aetna,First Health,,414.07,,,,,,,0.14445,414.07,percent of total billed charges,
RAD- iodixanol 270mg/mL I 100mL,800021696,CDM,636,RC,Q9966,HCPCS,65219038110,NDC,facility,inpatient,1,EA,464.55000,134.72000,Aetna,First Health,,380.00,,,,,,,167.47,380.00,percent of total billed charges,
RAD- iodixanol 270mg/mL I 100mL,800021696,CDM,636,RC,Q9966,HCPCS,65219038110,NDC,facility,outpatient,1,EA,464.55000,134.72000,Aetna,First Health,,380.00,,,,,,,0.38520,380.00,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,65219036802,NDC,facility,inpatient,2,ME,13.55000,3.93000,Aetna,First Health,,11.08,,,,,,,4.88,11.08,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,65219036802,NDC,facility,outpatient,2,ME,13.55000,3.93000,Aetna,First Health,,11.08,,,,,,,1.36,11.08,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,65219029510,NDC,facility,inpatient,0.04,ME,1257.00000,364.53000,Aetna,First Health,,1028.23,,,,,,,453.15,1028.23,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,65219029510,NDC,facility,outpatient,0.04,ME,1257.00000,364.53000,Aetna,First Health,,1028.23,,,,,,,3.28,1028.23,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,65219029301,NDC,facility,inpatient,0.004,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,34.52,78.32,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,65219029301,NDC,facility,outpatient,0.004,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,3.28,78.32,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,65219028965,NDC,facility,inpatient,1,EA,37.10000,10.76000,Aetna,First Health,,30.35,,,,,,,13.37,30.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,65219028965,NDC,facility,outpatient,1,EA,37.10000,10.76000,Aetna,First Health,,30.35,,,,,,,0.26964,30.35,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,65219025945,NDC,facility,inpatient,4.5,GM,101.55000,29.45000,Aetna,First Health,,83.07,,,,,,,36.61,83.07,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,65219025945,NDC,facility,outpatient,4.5,GM,101.55000,29.45000,Aetna,First Health,,83.07,,,,,,,1.05,83.07,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,65219025701,NDC,,,facility,inpatient,1,EA,74.80000,21.69000,Aetna,First Health,,61.19,,,,,,,27.68,61.19,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,65219025701,NDC,,,facility,outpatient,1,EA,74.80000,21.69000,Aetna,First Health,,61.19,,,,,,,26.97,61.19,percent of total billed charges,
NS 500mL PVC Free,800012833,CDM,258,RC,J7040,HCPCS,65219022450,NDC,facility,inpatient,1,EA,42.05000,12.19000,Aetna,First Health,,34.40,,,,,,,19.76,34.40,percent of total billed charges,
NS 500mL PVC Free,800012833,CDM,258,RC,J7040,HCPCS,65219022450,NDC,facility,outpatient,1,EA,42.05000,12.19000,Aetna,First Health,,34.40,,,,,,,1.24,34.40,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,65219022225,NDC,facility,inpatient,1,EA,35.70000,10.35000,Aetna,First Health,,29.20,,,,,,,12.87,29.20,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,65219022225,NDC,facility,outpatient,1,EA,35.70000,10.35000,Aetna,First Health,,29.20,,,,,,,0.63558,29.20,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,65219020420,NDC,facility,inpatient,200,ME,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,134.47,305.11,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,65219020420,NDC,facility,outpatient,200,ME,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,0.37557,305.11,percent of total billed charges,
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,800046390,CDM,636,RC,J0612,HCPCS,65219016210,NDC,facility,inpatient,1,GM,201.45000,58.42000,Aetna,First Health,,164.79,,,,,,,72.62,164.79,percent of total billed charges,
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,800046390,CDM,636,RC,J0612,HCPCS,65219016210,NDC,facility,outpatient,1,GM,201.45000,58.42000,Aetna,First Health,,164.79,,,,,,,0.02889,164.79,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,65219014410,NDC,,,facility,inpatient,1,EA,59.05000,17.12000,Aetna,First Health,,48.30,,,,,,,27.75,48.30,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,65219014410,NDC,,,facility,outpatient,1,EA,59.05000,17.12000,Aetna,First Health,,48.30,,,,,,,21.29,48.30,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,65219013520,NDC,facility,inpatient,500,ME,1483.00000,430.07000,Aetna,First Health,,1213.09,,,,,,,534.62,1213.09,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,65219013520,NDC,facility,outpatient,500,ME,1483.00000,430.07000,Aetna,First Health,,1213.09,,,,,,,0.56817,1213.09,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,65219005429,NDC,,,facility,inpatient,1,EA,471.65000,136.78000,Aetna,First Health,,385.81,,,,,,,174.51,385.81,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,65219005429,NDC,,,facility,outpatient,1,EA,471.65000,136.78000,Aetna,First Health,,385.81,,,,,,,170.03,385.81,percent of total billed charges,
Potassium Phosphate Inj 5mL,800022009,CDM,250,RC,65219005229,NDC,,,facility,inpatient,1,EA,152.70000,44.28000,Aetna,First Health,,124.91,,,,,,,56.50,124.91,percent of total billed charges,
Potassium Phosphate Inj 5mL,800022009,CDM,250,RC,65219005229,NDC,,,facility,outpatient,1,EA,152.70000,44.28000,Aetna,First Health,,124.91,,,,,,,55.05,124.91,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,65219001810,NDC,facility,inpatient,1,GM,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,20.42,46.34,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,65219001810,NDC,facility,outpatient,1,GM,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,0.56817,46.34,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,65219001610,NDC,facility,inpatient,500,ME,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,8.51,19.30,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,65219001610,NDC,facility,outpatient,500,ME,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,0.56817,19.30,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,65162089803,NDC,,,facility,inpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,135.63,184.91,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,65162089803,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,81.49,184.91,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,65162089709,NDC,,,facility,inpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,135.63,184.91,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,65162089709,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,81.49,184.91,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,65162089703,NDC,,,facility,inpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,135.63,184.91,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,65162089703,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,81.49,184.91,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,65162089609,NDC,,,facility,inpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,135.63,184.91,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,65162089609,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,81.49,184.91,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,65162089603,NDC,,,facility,inpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,135.63,184.91,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,65162089603,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,81.49,184.91,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,65162083366,NDC,,,facility,inpatient,1,EA,373.30000,108.26000,Aetna,First Health,,305.36,,,,,,,223.98,305.36,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,65162083366,NDC,,,facility,outpatient,1,EA,373.30000,108.26000,Aetna,First Health,,305.36,,,,,,,134.57,305.36,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,65162082634,NDC,,,facility,inpatient,1,EA,119.65000,34.70000,Aetna,First Health,,97.87,,,,,,,71.79,97.87,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,65162082634,NDC,,,facility,outpatient,1,EA,119.65000,34.70000,Aetna,First Health,,97.87,,,,,,,43.13,97.87,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,65162082534,NDC,,,facility,inpatient,1,EA,119.65000,34.70000,Aetna,First Health,,97.87,,,,,,,71.79,97.87,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,65162082534,NDC,,,facility,outpatient,1,EA,119.65000,34.70000,Aetna,First Health,,97.87,,,,,,,43.13,97.87,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,65162080710,NDC,,,facility,inpatient,1,EA,36.60000,10.61000,Aetna,First Health,,29.94,,,,,,,21.96,29.94,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,65162080710,NDC,,,facility,outpatient,1,EA,36.60000,10.61000,Aetna,First Health,,29.94,,,,,,,13.19,29.94,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,65162077810,NDC,,,facility,inpatient,1,EA,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,105.60,143.97,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,65162077810,NDC,,,facility,outpatient,1,EA,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,63.45,143.97,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,65162075710,NDC,,,facility,inpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,17.31,23.60,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,65162075710,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,10.40,23.60,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,65162075510,NDC,,,facility,inpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,10.44,14.23,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,65162075510,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,6.27,14.23,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,65162075003,NDC,,,facility,inpatient,1,EA,42.80000,12.41000,Aetna,First Health,,35.01,,,,,,,25.68,35.01,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,65162075003,NDC,,,facility,outpatient,1,EA,42.80000,12.41000,Aetna,First Health,,35.01,,,,,,,15.43,35.01,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),800015411,CDM,637,RC,Q0169,HCPCS,65162074510,NDC,facility,inpatient,12.5,ME,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),800015411,CDM,637,RC,Q0169,HCPCS,65162074510,NDC,facility,outpatient,12.5,ME,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,0.24075,2.82,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,65162071110,NDC,,,facility,inpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,4.32,5.89,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,65162071110,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
Gabapentin 200mg/4mL Oral Liq UD,800025503,CDM,637,RC,65162069890,NDC,,,facility,inpatient,1,EA,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,5.34,7.28,percent of total billed charges,
Gabapentin 200mg/4mL Oral Liq UD,800025503,CDM,637,RC,65162069890,NDC,,,facility,outpatient,1,EA,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,3.21,7.28,percent of total billed charges,
Ondansetron 2mg/2.5 mL Oral Soln,800025699,CDM,636,RC,Q0162,HCPCS,65162069179,NDC,facility,inpatient,4,ME,84.90000,24.62000,Aetna,First Health,,69.45,,,,,,,30.61,69.45,percent of total billed charges,
Ondansetron 2mg/2.5 mL Oral Soln,800025699,CDM,636,RC,Q0162,HCPCS,65162069179,NDC,facility,outpatient,4,ME,84.90000,24.62000,Aetna,First Health,,69.45,,,,,,,0.00963,69.45,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,65162068110,NDC,,,facility,inpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,11.46,15.62,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,65162068110,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,6.89,15.62,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,65162067684,NDC,,,facility,inpatient,1,EA,902.30000,261.67000,Aetna,First Health,,738.08,,,,,,,541.38,738.08,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,65162067684,NDC,,,facility,outpatient,1,EA,902.30000,261.67000,Aetna,First Health,,738.08,,,,,,,325.28,738.08,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,65162067384,NDC,,,facility,inpatient,1,EA,35.95000,10.43000,Aetna,First Health,,29.41,,,,,,,21.57,29.41,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,65162067384,NDC,,,facility,outpatient,1,EA,35.95000,10.43000,Aetna,First Health,,29.41,,,,,,,12.96,29.41,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,65162066910,NDC,,,facility,inpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,4.98,6.79,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,65162066910,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.99,6.79,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,65162064210,NDC,,,facility,inpatient,1,EA,28.40000,8.24000,Aetna,First Health,,23.23,,,,,,,17.04,23.23,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,65162064210,NDC,,,facility,outpatient,1,EA,28.40000,8.24000,Aetna,First Health,,23.23,,,,,,,10.24,23.23,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,65162062750,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,65162062750,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,65162062710,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,65162062710,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,65162059606,NDC,,,facility,inpatient,1,EA,59.15000,17.15000,Aetna,First Health,,48.38,,,,,,,35.49,48.38,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,65162059606,NDC,,,facility,outpatient,1,EA,59.15000,17.15000,Aetna,First Health,,48.38,,,,,,,21.32,48.38,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,65162055410,NDC,,,facility,inpatient,1,EA,66.55000,19.30000,Aetna,First Health,,54.44,,,,,,,39.93,54.44,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,65162055410,NDC,,,facility,outpatient,1,EA,66.55000,19.30000,Aetna,First Health,,54.44,,,,,,,23.99,54.44,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,65162055310,NDC,,,facility,inpatient,1,EA,42.40000,12.30000,Aetna,First Health,,34.68,,,,,,,25.44,34.68,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,65162055310,NDC,,,facility,outpatient,1,EA,42.40000,12.30000,Aetna,First Health,,34.68,,,,,,,15.29,34.68,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,65162054510,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,65162054510,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,65162054410,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,65162054410,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65162054150,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65162054150,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65162054110,NDC,,,facility,inpatient,1,EA,8.00000,2.32000,Aetna,First Health,,6.54,,,,,,,4.80,6.54,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65162054110,NDC,,,facility,outpatient,1,EA,8.00000,2.32000,Aetna,First Health,,6.54,,,,,,,2.88,6.54,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,65162053610,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,65162053610,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,65162051710,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,65162051710,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,65162051110,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,65162051110,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,65162047505,NDC,,,facility,inpatient,1,EA,18.75000,5.44000,Aetna,First Health,,15.34,,,,,,,11.25,15.34,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,65162047505,NDC,,,facility,outpatient,1,EA,18.75000,5.44000,Aetna,First Health,,15.34,,,,,,,6.76,15.34,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,65162046410,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,65162046410,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Buprenorphine-Naloxone 2-0.5mg SLTab,800072441,CDM,637,RC,J0572,HCPCS,65162041603,NDC,facility,inpatient,1,EA,46.60000,13.51000,Aetna,First Health,,38.12,,,,,,,27.96,38.12,percent of total billed charges,
Buprenorphine-Naloxone 2-0.5mg SLTab,800072441,CDM,637,RC,J0572,HCPCS,65162041603,NDC,facility,outpatient,1,EA,46.60000,13.51000,Aetna,First Health,,38.12,,,,,,,5.48,38.12,percent of total billed charges,
Buprenorphine-Naloxone 8-2mg SLT,800072440,CDM,637,RC,J0574,HCPCS,65162041503,NDC,facility,inpatient,1,EA,83.35000,24.17000,Aetna,First Health,,68.18,,,,,,,50.01,68.18,percent of total billed charges,
Buprenorphine-Naloxone 8-2mg SLT,800072440,CDM,637,RC,J0574,HCPCS,65162041503,NDC,facility,outpatient,1,EA,83.35000,24.17000,Aetna,First Health,,68.18,,,,,,,9.80,68.18,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,65162036110,NDC,,,facility,inpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,1.41,1.92,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,65162036110,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,65162035109,NDC,,,facility,inpatient,1,EA,141.60000,41.06000,Aetna,First Health,,115.83,,,,,,,84.96,115.83,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,65162035109,NDC,,,facility,outpatient,1,EA,141.60000,41.06000,Aetna,First Health,,115.83,,,,,,,51.05,115.83,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,65162030209,NDC,,,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,8.49,11.57,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,65162030209,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,65162030009,NDC,,,facility,inpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,1.50,2.04,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,65162030009,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,0.90125,2.04,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,65162028103,NDC,,,facility,inpatient,1,EA,216.30000,62.73000,Aetna,First Health,,176.93,,,,,,,129.78,176.93,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,65162028103,NDC,,,facility,outpatient,1,EA,216.30000,62.73000,Aetna,First Health,,176.93,,,,,,,77.98,176.93,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,65162027110,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,65162027110,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,65162022710,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,65162022710,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,65162018810,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,65162018810,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,65162017510,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,65162017510,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,65162005703,NDC,,,facility,inpatient,1,EA,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,30.27,41.27,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,65162005703,NDC,,,facility,outpatient,1,EA,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,18.19,41.27,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,65162000750,NDC,,,facility,inpatient,1,EA,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,8.07,11.00,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,65162000750,NDC,,,facility,outpatient,1,EA,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,4.85,11.00,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,65145012925,NDC,facility,inpatient,200,ME,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,14.06,31.90,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,65145012925,NDC,facility,outpatient,200,ME,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,1.74,31.90,percent of total billed charges,
Nitazoxanide 500mg Tab,800017652,CDM,637,RC,64980052660,NDC,,,facility,inpatient,1,EA,1011.85000,293.44000,Aetna,First Health,,827.69,,,,,,,607.11,827.69,percent of total billed charges,
Nitazoxanide 500mg Tab,800017652,CDM,637,RC,64980052660,NDC,,,facility,outpatient,1,EA,1011.85000,293.44000,Aetna,First Health,,827.69,,,,,,,364.77,827.69,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,64980051505,NDC,,,facility,inpatient,1,EA,467.75000,135.65000,Aetna,First Health,,382.62,,,,,,,280.65,382.62,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,64980051505,NDC,,,facility,outpatient,1,EA,467.75000,135.65000,Aetna,First Health,,382.62,,,,,,,168.62,382.62,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,64980051501,NDC,,,facility,inpatient,1,EA,452.40000,131.20000,Aetna,First Health,,370.06,,,,,,,271.44,370.06,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,64980051501,NDC,,,facility,outpatient,1,EA,452.40000,131.20000,Aetna,First Health,,370.06,,,,,,,163.09,370.06,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,64980051405,NDC,,,facility,inpatient,1,EA,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,72.21,98.45,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,64980051405,NDC,,,facility,outpatient,1,EA,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,43.39,98.45,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,64980051305,NDC,,,facility,inpatient,1,EA,106.20000,30.80000,Aetna,First Health,,86.87,,,,,,,63.72,86.87,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,64980051305,NDC,,,facility,outpatient,1,EA,106.20000,30.80000,Aetna,First Health,,86.87,,,,,,,38.29,86.87,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,64980051301,NDC,,,facility,inpatient,1,EA,98.25000,28.49000,Aetna,First Health,,80.37,,,,,,,58.95,80.37,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,64980051301,NDC,,,facility,outpatient,1,EA,98.25000,28.49000,Aetna,First Health,,80.37,,,,,,,35.42,80.37,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,64980032005,NDC,,,facility,inpatient,1,EA,530.00000,153.70000,Aetna,First Health,,433.54,,,,,,,318.00,433.54,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,64980032005,NDC,,,facility,outpatient,1,EA,530.00000,153.70000,Aetna,First Health,,433.54,,,,,,,191.06,433.54,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,64980019106,NDC,,,facility,inpatient,1,EA,258.15000,74.86000,Aetna,First Health,,211.17,,,,,,,154.89,211.17,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,64980019106,NDC,,,facility,outpatient,1,EA,258.15000,74.86000,Aetna,First Health,,211.17,,,,,,,93.06,211.17,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,64980017903,NDC,,,facility,inpatient,1,EA,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,323.40,440.90,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,64980017903,NDC,,,facility,outpatient,1,EA,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,194.31,440.90,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,64980017901,NDC,,,facility,inpatient,1,EA,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,323.40,440.90,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,64980017901,NDC,,,facility,outpatient,1,EA,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,194.31,440.90,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,64980015701,NDC,,,facility,inpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,6.18,8.43,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,64980015701,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,64980013901,NDC,,,facility,inpatient,1,EA,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,12.00,16.36,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,64980013901,NDC,,,facility,outpatient,1,EA,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,7.21,16.36,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,64980013801,NDC,,,facility,inpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,3.21,4.38,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,64980013801,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,1.93,4.38,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,64980013301,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,64980013301,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,64980013101,NDC,,,facility,inpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,5.58,7.61,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,64980013101,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,64980011901,NDC,,,facility,inpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,7.59,10.35,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,64980011901,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,4.56,10.35,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,64980011101,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,64980011101,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
K-Phos-Na Phos Neutral 250mg T,800081073,CDM,637,RC,64980010401,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
K-Phos-Na Phos Neutral 250mg T,800081073,CDM,637,RC,64980010401,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,64950021710,NDC,,,facility,inpatient,1,EA,24.80000,7.19000,Aetna,First Health,,20.29,,,,,,,14.88,20.29,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,64950021710,NDC,,,facility,outpatient,1,EA,24.80000,7.19000,Aetna,First Health,,20.29,,,,,,,8.94,20.29,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,64860010407,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,64860010407,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,64850050501,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,64850050501,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,64850050401,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,64850050401,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,64850050001,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,64850050001,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Vortioxetine 10mg Tab,800022073,CDM,637,RC,64764073030,NDC,,,facility,inpatient,1,EA,145.60000,42.22000,Aetna,First Health,,119.10,,,,,,,87.36,119.10,percent of total billed charges,
Vortioxetine 10mg Tab,800022073,CDM,637,RC,64764073030,NDC,,,facility,outpatient,1,EA,145.60000,42.22000,Aetna,First Health,,119.10,,,,,,,52.49,119.10,percent of total billed charges,
Vedolizumab 300mg I(Entyvio),800022032,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,inpatient,300,ME,67578.35000,19597.72000,Aetna,First Health,,55279.09,,,,,,,24362.00,55279.09,percent of total billed charges,
Vedolizumab 300mg I(Entyvio),800022032,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,outpatient,300,ME,67578.35000,19597.72000,Aetna,First Health,,55279.09,,,,,,,20.58,55279.09,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,64764024060,NDC,,,facility,inpatient,1,EA,52.55000,15.24000,Aetna,First Health,,42.99,,,,,,,31.53,42.99,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,64764024060,NDC,,,facility,outpatient,1,EA,52.55000,15.24000,Aetna,First Health,,42.99,,,,,,,18.94,42.99,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,64764024010,NDC,,,facility,inpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,13.95,19.02,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,64764024010,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,8.38,19.02,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,64764011907,NDC,,,facility,inpatient,1,EA,61.10000,17.72000,Aetna,First Health,,49.98,,,,,,,36.66,49.98,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,64764011907,NDC,,,facility,outpatient,1,EA,61.10000,17.72000,Aetna,First Health,,49.98,,,,,,,22.03,49.98,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,64764011901,NDC,,,facility,inpatient,1,EA,61.10000,17.72000,Aetna,First Health,,49.98,,,,,,,36.66,49.98,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,64764011901,NDC,,,facility,outpatient,1,EA,61.10000,17.72000,Aetna,First Health,,49.98,,,,,,,22.03,49.98,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,64727329901,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,64727329901,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,64720033210,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,64720033210,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,64720033105,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,64720033105,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,64720032110,NDC,,,facility,inpatient,1,EA,34.65000,10.05000,Aetna,First Health,,28.34,,,,,,,20.79,28.34,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,64720032110,NDC,,,facility,outpatient,1,EA,34.65000,10.05000,Aetna,First Health,,28.34,,,,,,,12.49,28.34,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,64720020410,NDC,,,facility,inpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,10.53,14.36,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,64720020410,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,6.33,14.36,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,64720020310,NDC,,,facility,inpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,10.53,14.36,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,64720020310,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,6.33,14.36,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,64720020110,NDC,,,facility,inpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,10.53,14.36,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,64720020110,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,6.33,14.36,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,64720015906,NDC,,,facility,inpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,7.74,10.55,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,64720015906,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,4.65,10.55,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,64720013910,NDC,,,facility,inpatient,1,EA,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,8.88,12.11,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,64720013910,NDC,,,facility,outpatient,1,EA,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,5.34,12.11,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,64720013510,NDC,,,facility,inpatient,1,EA,16.45000,4.77000,Aetna,First Health,,13.46,,,,,,,9.87,13.46,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,64720013510,NDC,,,facility,outpatient,1,EA,16.45000,4.77000,Aetna,First Health,,13.46,,,,,,,5.93,13.46,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,64720013010,NDC,,,facility,inpatient,1,EA,16.45000,4.77000,Aetna,First Health,,13.46,,,,,,,9.87,13.46,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,64720013010,NDC,,,facility,outpatient,1,EA,16.45000,4.77000,Aetna,First Health,,13.46,,,,,,,5.93,13.46,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,64720012810,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,64720012810,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,64720012410,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,64720012410,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,64720010350,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,64720010350,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,64720010310,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,64720010310,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,64679099001,NDC,,,facility,inpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,8.79,11.98,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,64679099001,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,5.28,11.98,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,64679098302,NDC,facility,inpatient,1,GM,346.50000,100.48000,Aetna,First Health,,283.44,,,,,,,124.91,283.44,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,64679098302,NDC,facility,outpatient,1,GM,346.50000,100.48000,Aetna,First Health,,283.44,,,,,,,0.44298,283.44,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,64679096601,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,64679096601,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,64679096101,NDC,,,facility,inpatient,1,EA,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,33.00,44.99,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,64679096101,NDC,,,facility,outpatient,1,EA,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,19.83,44.99,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,64679094201,NDC,,,facility,inpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,6.54,8.92,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,64679094201,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,64679093603,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,64679093603,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,64679093602,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,64679093602,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,64679093601,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,64679093601,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,64679092901,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,4.02,5.48,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,64679092901,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,64679092701,NDC,,,facility,inpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,2.76,3.76,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,64679092701,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,1.66,3.76,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,64679092602,NDC,,,facility,inpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,11.76,16.03,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,64679092602,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,7.07,16.03,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,64679092502,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,64679092502,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,64679092402,NDC,,,facility,inpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,7.86,10.72,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,64679092402,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,4.72,10.72,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,64679092302,NDC,,,facility,inpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,6.18,8.43,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,64679092302,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,64679092102,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,64679092102,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,64679075903,NDC,facility,inpatient,100,ME,21.60000,6.26000,Aetna,First Health,,17.67,,,,,,,7.79,17.67,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,64679075903,NDC,facility,outpatient,100,ME,21.60000,6.26000,Aetna,First Health,,17.67,,,,,,,7.79,17.67,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,64679075702,NDC,facility,inpatient,15,ME,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,64679075702,NDC,facility,outpatient,15,ME,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,0.31779,7.61,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,64679075701,NDC,facility,inpatient,15,ME,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,64679075701,NDC,facility,outpatient,15,ME,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,0.31779,7.61,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,64679072901,NDC,facility,inpatient,100,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,34.52,78.32,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,64679072901,NDC,facility,outpatient,100,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,1.34,78.32,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,64679072801,NDC,facility,inpatient,6,ME,408.20000,118.38000,Aetna,First Health,,333.91,,,,,,,244.92,333.91,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,64679072801,NDC,facility,outpatient,6,ME,408.20000,118.38000,Aetna,First Health,,333.91,,,,,,,85.32,333.91,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,64679072701,NDC,facility,inpatient,4,ME,185.90000,53.91000,Aetna,First Health,,152.07,,,,,,,67.02,152.07,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,64679072701,NDC,facility,outpatient,4,ME,185.90000,53.91000,Aetna,First Health,,152.07,,,,,,,0.08667,152.07,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,64679072601,NDC,facility,inpatient,4,ME,123.65000,35.86000,Aetna,First Health,,101.15,,,,,,,44.58,101.15,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,64679072601,NDC,facility,outpatient,4,ME,123.65000,35.86000,Aetna,First Health,,101.15,,,,,,,0.08667,101.15,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,64679072502,NDC,,,facility,inpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,12.54,17.10,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,64679072502,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,64679071804,NDC,,,facility,inpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,64679071804,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,12.98,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,64679071801,NDC,,,facility,inpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,64679071801,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,12.98,29.45,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,64679071704,NDC,,,facility,inpatient,1,EA,33.05000,9.58000,Aetna,First Health,,27.03,,,,,,,19.83,27.03,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,64679071704,NDC,,,facility,outpatient,1,EA,33.05000,9.58000,Aetna,First Health,,27.03,,,,,,,11.91,27.03,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,64679071604,NDC,,,facility,inpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,17.70,24.13,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,64679071604,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,10.63,24.13,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,64679071601,NDC,,,facility,inpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,17.70,24.13,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,64679071601,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,10.63,24.13,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,64679070302,NDC,facility,inpatient,2,GM,443.70000,128.67000,Aetna,First Health,,362.95,,,,,,,159.95,362.95,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,64679070302,NDC,facility,outpatient,2,GM,443.70000,128.67000,Aetna,First Health,,362.95,,,,,,,0.44298,362.95,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,64679070301,NDC,facility,inpatient,2,GM,431.50000,125.14000,Aetna,First Health,,352.97,,,,,,,155.56,352.97,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,64679070301,NDC,facility,outpatient,2,GM,431.50000,125.14000,Aetna,First Health,,352.97,,,,,,,0.44298,352.97,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,64679063502,NDC,facility,inpatient,0.5,ME,489.20000,141.87000,Aetna,First Health,,400.17,,,,,,,293.52,400.17,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,64679063502,NDC,facility,outpatient,0.5,ME,489.20000,141.87000,Aetna,First Health,,400.17,,,,,,,0.63558,400.17,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,64679063302,NDC,facility,inpatient,0.1,ME,115.25000,33.42000,Aetna,First Health,,94.27,,,,,,,69.15,94.27,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,64679063302,NDC,facility,outpatient,0.1,ME,115.25000,33.42000,Aetna,First Health,,94.27,,,,,,,0.63558,94.27,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,64679063102,NDC,facility,inpatient,25,ME,200.95000,58.28000,Aetna,First Health,,164.38,,,,,,,72.44,164.38,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,64679063102,NDC,facility,outpatient,25,ME,200.95000,58.28000,Aetna,First Health,,164.38,,,,,,,0.06741,164.38,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,64679043402,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,64679043402,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,64679042301,NDC,,,facility,inpatient,1,EA,16.80000,4.87000,Aetna,First Health,,13.74,,,,,,,10.08,13.74,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,64679042301,NDC,,,facility,outpatient,1,EA,16.80000,4.87000,Aetna,First Health,,13.74,,,,,,,6.06,13.74,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,64679042201,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,64679042201,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,64679042101,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,64679042101,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,64679020902,NDC,,,facility,inpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,55.53,75.71,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,64679020902,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,33.36,75.71,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,64679020901,NDC,,,facility,inpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,55.53,75.71,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,64679020901,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,33.36,75.71,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,64679005601,NDC,facility,inpatient,3.375,GM,174.05000,50.47000,Aetna,First Health,,142.37,,,,,,,62.75,142.37,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,64679005601,NDC,facility,outpatient,3.375,GM,174.05000,50.47000,Aetna,First Health,,142.37,,,,,,,1.05,142.37,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,64679003401,NDC,facility,inpatient,2.25,GM,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,41.82,94.89,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,64679003401,NDC,facility,outpatient,2.25,GM,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,1.05,94.89,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,64679001201,NDC,facility,inpatient,4.5,GM,219.65000,63.70000,Aetna,First Health,,179.67,,,,,,,79.18,179.67,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,64679001201,NDC,facility,outpatient,4.5,GM,219.65000,63.70000,Aetna,First Health,,179.67,,,,,,,1.05,179.67,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,64455073030,NDC,,,facility,inpatient,1,EA,59.20000,17.17000,Aetna,First Health,,48.43,,,,,,,35.52,48.43,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,64455073030,NDC,,,facility,outpatient,1,EA,59.20000,17.17000,Aetna,First Health,,48.43,,,,,,,21.34,48.43,percent of total billed charges,
Natalizumab - Pt Own Supply,800040903,CDM,636,RC,J2323,HCPCS,64406000801,NDC,facility,inpatient,300,ME,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05407,0.12270,percent of total billed charges,
Natalizumab - Pt Own Supply,800040903,CDM,636,RC,J2323,HCPCS,64406000801,NDC,facility,outpatient,300,ME,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05550,75.59,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,64380097025,NDC,,,facility,inpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,4.32,5.89,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,64380097025,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
predniSONE 50mg T,800020630,CDM,637,RC,J7512,HCPCS,64380094906,NDC,facility,inpatient,50,ME,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
predniSONE 50mg T,800020630,CDM,637,RC,J7512,HCPCS,64380094906,NDC,facility,outpatient,50,ME,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,0.00963,2.37,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,64380088304,NDC,,,facility,inpatient,1,EA,216.70000,62.84000,Aetna,First Health,,177.26,,,,,,,130.02,177.26,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,64380088304,NDC,,,facility,outpatient,1,EA,216.70000,62.84000,Aetna,First Health,,177.26,,,,,,,78.12,177.26,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,64380079901,NDC,,,facility,inpatient,1,EA,109.45000,31.74000,Aetna,First Health,,89.53,,,,,,,65.67,89.53,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,64380079901,NDC,,,facility,outpatient,1,EA,109.45000,31.74000,Aetna,First Health,,89.53,,,,,,,39.46,89.53,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,64380079701,NDC,,,facility,inpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,60.24,82.13,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,64380079701,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,36.19,82.13,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,64380078206,NDC,facility,inpatient,1,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,64380078206,NDC,facility,outpatient,1,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.00963,1.47,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,64380076921,NDC,,,facility,inpatient,1,EA,469.75000,136.23000,Aetna,First Health,,384.26,,,,,,,281.85,384.26,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,64380076921,NDC,,,facility,outpatient,1,EA,469.75000,136.23000,Aetna,First Health,,384.26,,,,,,,169.34,384.26,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,64380074207,NDC,,,facility,inpatient,1,EA,9.25000,2.68000,Aetna,First Health,,7.57,,,,,,,5.55,7.57,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,64380074207,NDC,,,facility,outpatient,1,EA,9.25000,2.68000,Aetna,First Health,,7.57,,,,,,,3.33,7.57,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,64380074107,NDC,,,facility,inpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,3.18,4.34,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,64380074107,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,1.91,4.34,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,64380074106,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,64380074106,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,64380073706,NDC,,,facility,inpatient,1,EA,13.95000,4.05000,Aetna,First Health,,11.41,,,,,,,8.37,11.41,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,64380073706,NDC,,,facility,outpatient,1,EA,13.95000,4.05000,Aetna,First Health,,11.41,,,,,,,5.03,11.41,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,64380073506,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,64380073506,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,64380073406,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,64380073406,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,64380072506,NDC,facility,inpatient,500,ME,56.10000,16.27000,Aetna,First Health,,45.89,,,,,,,20.22,45.89,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,64380072506,NDC,facility,outpatient,500,ME,56.10000,16.27000,Aetna,First Health,,45.89,,,,,,,0.14445,45.89,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,64380071206,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,64380071206,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,64380015102,NDC,,,facility,inpatient,1,EA,116.65000,33.83000,Aetna,First Health,,95.42,,,,,,,69.99,95.42,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,64380015102,NDC,,,facility,outpatient,1,EA,116.65000,33.83000,Aetna,First Health,,95.42,,,,,,,42.05,95.42,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,64376013790,NDC,,,facility,inpatient,1,EA,25.40000,7.37000,Aetna,First Health,,20.78,,,,,,,15.24,20.78,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,64376013790,NDC,,,facility,outpatient,1,EA,25.40000,7.37000,Aetna,First Health,,20.78,,,,,,,9.16,20.78,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,64376013712,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,64376013712,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,64376013612,NDC,,,facility,inpatient,1,EA,20.35000,5.90000,Aetna,First Health,,16.65,,,,,,,12.21,16.65,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,64376013612,NDC,,,facility,outpatient,1,EA,20.35000,5.90000,Aetna,First Health,,16.65,,,,,,,7.34,16.65,percent of total billed charges,
Methacholine Challenge Kit,800010977,CDM,636,RC,J7674,HCPCS,64281010006,NDC,facility,inpatient,1,EA,3613.40000,1047.89000,Aetna,First Health,,2955.76,,,,,,,1302.63,2955.76,percent of total billed charges,
Methacholine Challenge Kit,800010977,CDM,636,RC,J7674,HCPCS,64281010006,NDC,facility,outpatient,1,EA,3613.40000,1047.89000,Aetna,First Health,,2955.76,,,,,,,1.83,2955.76,percent of total billed charges,
Methacholine Challenge Kit,800010977,CDM,636,RC,J7674,HCPCS,64281010000,NDC,facility,inpatient,1,EA,426.70000,123.74000,Aetna,First Health,,349.04,,,,,,,153.83,349.04,percent of total billed charges,
Methacholine Challenge Kit,800010977,CDM,636,RC,J7674,HCPCS,64281010000,NDC,facility,outpatient,1,EA,426.70000,123.74000,Aetna,First Health,,349.04,,,,,,,1.83,349.04,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,64253090091,NDC,,,facility,inpatient,1,EA,63.85000,18.52000,Aetna,First Health,,52.23,,,,,,,23.62,52.23,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,64253090091,NDC,,,facility,outpatient,1,EA,63.85000,18.52000,Aetna,First Health,,52.23,,,,,,,23.02,52.23,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,64253090036,NDC,,,facility,inpatient,1,EA,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,21.26,46.99,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,64253090036,NDC,,,facility,outpatient,1,EA,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,20.71,46.99,percent of total billed charges,
NICU- Heparin 1unit/mL IS 2mL(Neonatal),800081088,CDM,258,RC,J1642,HCPCS,64253044422,NDC,facility,inpatient,2,UN,17.30000,5.02000,Aetna,First Health,,14.15,,,,,,,8.13,14.15,percent of total billed charges,
NICU- Heparin 1unit/mL IS 2mL(Neonatal),800081088,CDM,258,RC,J1642,HCPCS,64253044422,NDC,facility,outpatient,2,UN,17.30000,5.02000,Aetna,First Health,,14.15,,,,,,,0.01926,14.15,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,64253033335,NDC,facility,inpatient,500,UN,19.75000,5.73000,Aetna,First Health,,16.16,,,,,,,7.12,16.16,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,64253033335,NDC,facility,outpatient,500,UN,19.75000,5.73000,Aetna,First Health,,16.16,,,,,,,0.01926,16.16,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,64253022235,NDC,facility,inpatient,30,UN,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.89300,1.55,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,64253022235,NDC,facility,outpatient,30,UN,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.01926,1.55,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,64253022233,NDC,facility,inpatient,30,UN,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,8.22,14.31,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,64253022233,NDC,facility,outpatient,30,UN,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,0.01926,14.31,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,64253022223,NDC,facility,inpatient,30,UN,15.90000,4.61000,Aetna,First Health,,13.01,,,,,,,7.47,13.01,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,64253022223,NDC,facility,outpatient,30,UN,15.90000,4.61000,Aetna,First Health,,13.01,,,,,,,0.01926,13.01,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,64253020230,NDC,facility,inpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,3.60,6.26,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,64253020230,NDC,facility,outpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,0.63000,6.26,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,64253011130,NDC,facility,inpatient,1,EA,19.40000,5.63000,Aetna,First Health,,15.87,,,,,,,9.12,15.87,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,64253011130,NDC,facility,outpatient,1,EA,19.40000,5.63000,Aetna,First Health,,15.87,,,,,,,0.63000,15.87,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,64125090301,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,64125090301,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,64125090101,NDC,,,facility,inpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.18000,0.24540,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,64125090101,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.10815,0.24540,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,64125013201,NDC,,,facility,inpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,6.66,9.08,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,64125013201,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,4.00,9.08,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,64125010401,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,64125010401,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,63851050102,NDC,facility,inpatient,1,EA,1287.70000,373.43000,Aetna,First Health,,1053.34,,,,,,,464.22,1053.34,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,63851050102,NDC,facility,outpatient,1,EA,1287.70000,373.43000,Aetna,First Health,,1053.34,,,,,,,307.92,1053.34,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,63851050101,NDC,facility,inpatient,1,EA,1204.95000,349.44000,Aetna,First Health,,985.65,,,,,,,434.38,985.65,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,63851050101,NDC,facility,outpatient,1,EA,1204.95000,349.44000,Aetna,First Health,,985.65,,,,,,,307.92,986.11,percent of total billed charges,
Prothrombin Complex-Human I(Kcentra),800025539,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,inpatient,1,UN,28.55000,8.28000,Aetna,First Health,,23.35,,,,,,,10.29,23.35,percent of total billed charges,
Prothrombin Complex-Human I(Kcentra),800025539,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,outpatient,1,UN,28.55000,8.28000,Aetna,First Health,,23.35,,,,,,,2.09,23.35,percent of total billed charges,
Prothrombin Complex-Human I(Kcentra),800025539,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,28.55000,8.28000,Aetna,First Health,,23.35,,,,,,,10.29,23.35,percent of total billed charges,
Prothrombin Complex-Human I(Kcentra),800025539,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,outpatient,1,UN,28.55000,8.28000,Aetna,First Health,,23.35,,,,,,,2.09,23.35,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,63824005736,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,63824005736,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,63824005718,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,63824005718,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,63824005640,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.28,2.82,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,63824005640,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,63824005634,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.76,6.09,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,63824005634,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000850,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000850,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000840,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000840,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000820,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000820,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000813,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000813,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000810,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000810,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,63807060055,NDC,facility,inpatient,500,UN,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,63807060055,NDC,facility,outpatient,500,UN,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.01926,2.17,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,63807060005,NDC,facility,inpatient,500,UN,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,2.45,5.56,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,63807060005,NDC,facility,outpatient,500,UN,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,0.01926,5.56,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,63807050055,NDC,facility,inpatient,30,UN,8.75000,2.54000,Aetna,First Health,,7.16,,,,,,,4.11,7.16,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,63807050055,NDC,facility,outpatient,30,UN,8.75000,2.54000,Aetna,First Health,,7.16,,,,,,,0.01926,7.16,percent of total billed charges,
NICU- Heparin 1unit/mL IS 2mL(Neonatal),800081088,CDM,258,RC,J1642,HCPCS,63807030035,NDC,facility,inpatient,2,UN,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.15,2.00,percent of total billed charges,
NICU- Heparin 1unit/mL IS 2mL(Neonatal),800081088,CDM,258,RC,J1642,HCPCS,63807030035,NDC,facility,outpatient,2,UN,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.01926,2.00,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,63807010001,NDC,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.72,2.99,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,63807010001,NDC,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,0.63000,4.78,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,63739099510,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,63739099510,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,63739099210,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,63739099210,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,63739099110,NDC,,,facility,inpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,1.20,1.64,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,63739099110,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,63739098410,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,63739098410,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,63739097310,NDC,,,facility,inpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,3.66,4.99,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,63739097310,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,2.20,4.99,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,63739095325,NDC,facility,inpatient,5000,UN,21.50000,6.24000,Aetna,First Health,,17.59,,,,,,,10.11,17.59,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,63739095325,NDC,facility,outpatient,5000,UN,21.50000,6.24000,Aetna,First Health,,17.59,,,,,,,0.17334,17.59,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,63739094310,NDC,,,facility,inpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,1.41,1.92,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,63739094310,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63739093128,NDC,facility,inpatient,10000,UN,23.85000,6.92000,Aetna,First Health,,19.51,,,,,,,8.60,19.51,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63739093128,NDC,facility,outpatient,10000,UN,23.85000,6.92000,Aetna,First Health,,19.51,,,,,,,0.17334,19.51,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,63739090310,NDC,,,facility,inpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.84000,1.15,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,63739090310,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.50470,1.15,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,63739087710,NDC,,,facility,inpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.75000,1.02,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,63739087710,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.45062,1.02,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,63739079510,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,63739079510,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,63739079110,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,63739079110,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,63739072450,NDC,,,facility,inpatient,1,EA,70.50000,20.44000,Aetna,First Health,,57.67,,,,,,,42.30,57.67,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,63739072450,NDC,,,facility,outpatient,1,EA,70.50000,20.44000,Aetna,First Health,,57.67,,,,,,,25.42,57.67,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,63739069810,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,63739069810,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739069110,NDC,,,facility,inpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.51000,0.69530,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739069110,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.30643,0.69530,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739069101,NDC,,,facility,inpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.51000,0.69530,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739069101,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.30643,0.69530,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739068410,NDC,,,facility,inpatient,1,EA,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.48000,0.65440,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739068410,NDC,,,facility,outpatient,1,EA,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.28840,0.65440,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739068401,NDC,,,facility,inpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.39000,0.53170,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739068401,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.23433,0.53170,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,63739067310,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,63739067310,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739067210,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739067210,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739067201,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739067201,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,63739067110,NDC,,,facility,inpatient,1,EA,0.70000,0.20000,Aetna,First Health,,0.57260,,,,,,,0.42000,0.57260,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,63739067110,NDC,,,facility,outpatient,1,EA,0.70000,0.20000,Aetna,First Health,,0.57260,,,,,,,0.25235,0.57260,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,63739067010,NDC,,,facility,inpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,1.05,1.43,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,63739067010,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.63087,1.43,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,63739066910,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,63739066910,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,63739064510,NDC,,,facility,inpatient,1,EA,0.75000,0.22000,Aetna,First Health,,0.61350,,,,,,,0.45000,0.61350,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,63739064510,NDC,,,facility,outpatient,1,EA,0.75000,0.22000,Aetna,First Health,,0.61350,,,,,,,0.27037,0.61350,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,63739064410,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,63739064410,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,63739063456,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,3.96,5.40,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,63739063456,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,63739059110,NDC,,,facility,inpatient,1,EA,0.75000,0.22000,Aetna,First Health,,0.61350,,,,,,,0.45000,0.61350,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,63739059110,NDC,,,facility,outpatient,1,EA,0.75000,0.22000,Aetna,First Health,,0.61350,,,,,,,0.27037,0.61350,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,63739056910,NDC,,,facility,inpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,3.75,5.11,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,63739056910,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,63739056410,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,63739056410,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,63739054973,NDC,,,facility,inpatient,1,EA,47.60000,13.80000,Aetna,First Health,,38.94,,,,,,,28.56,38.94,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,63739054973,NDC,,,facility,outpatient,1,EA,47.60000,13.80000,Aetna,First Health,,38.94,,,,,,,17.16,38.94,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,63739054410,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,63739054410,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,63739053950,NDC,,,facility,inpatient,1,EA,19.50000,5.65000,Aetna,First Health,,15.95,,,,,,,11.70,15.95,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,63739053950,NDC,,,facility,outpatient,1,EA,19.50000,5.65000,Aetna,First Health,,15.95,,,,,,,7.03,15.95,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,63739053710,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,63739053710,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,63739053210,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,63739053210,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,63739053110,NDC,,,facility,inpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.39000,0.53170,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,63739053110,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.23433,0.53170,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,63739052610,NDC,,,facility,inpatient,1,EA,37.15000,10.77000,Aetna,First Health,,30.39,,,,,,,22.29,30.39,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,63739052610,NDC,,,facility,outpatient,1,EA,37.15000,10.77000,Aetna,First Health,,30.39,,,,,,,13.39,30.39,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,63739050832,NDC,,,facility,inpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,16.56,22.58,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,63739050832,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,63739050010,NDC,,,facility,inpatient,1,EA,0.90000,0.26000,Aetna,First Health,,0.73620,,,,,,,0.54000,0.73620,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,63739050010,NDC,,,facility,outpatient,1,EA,0.90000,0.26000,Aetna,First Health,,0.73620,,,,,,,0.32445,0.73620,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,63739049910,NDC,,,facility,inpatient,1,EA,0.75000,0.22000,Aetna,First Health,,0.61350,,,,,,,0.45000,0.61350,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,63739049910,NDC,,,facility,outpatient,1,EA,0.75000,0.22000,Aetna,First Health,,0.61350,,,,,,,0.27037,0.61350,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,63739048610,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,63739048610,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,63739047910,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,63739047910,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,63739044710,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,3.96,5.40,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,63739044710,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739044410,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739044410,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739044310,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739044310,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739044210,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739044210,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,63739041110,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,63739041110,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,63739041010,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,63739041010,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,63739038710,NDC,,,facility,inpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,14.37,19.59,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,63739038710,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.63,19.59,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,63739038410,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,63739038410,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,63739036510,NDC,,,facility,inpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,63739036510,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,63739032810,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,63739032810,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,63739032710,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,63739032710,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,63739032610,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,63739032610,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,63739027510,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,63739027510,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,63739026910,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,63739026910,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,63739026310,NDC,,,facility,inpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,3.87,5.28,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,63739026310,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,2.33,5.28,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,63739023610,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,63739023610,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,63739023110,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,63739023110,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,63739017830,NDC,,,facility,inpatient,1,EA,112.90000,32.74000,Aetna,First Health,,92.35,,,,,,,67.74,92.35,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,63739017830,NDC,,,facility,outpatient,1,EA,112.90000,32.74000,Aetna,First Health,,92.35,,,,,,,40.70,92.35,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,63739015510,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,4.05,5.52,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,63739015510,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,63739015410,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,63739015410,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,63739014310,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,63739014310,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739013710,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739013710,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739013701,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739013701,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739013610,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739013610,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739013601,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739013601,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739013510,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739013510,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739013501,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739013501,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,63739012710,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,63739012710,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,63739010810,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,63739010810,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,63739010310,NDC,,,facility,inpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,63739010310,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,63739009810,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,63739009810,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,63739008610,NDC,,,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,2.19,2.99,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,63739008610,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.32,2.99,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,63739008010,NDC,,,facility,inpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,1.20,1.64,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,63739008010,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,63739007910,NDC,,,facility,inpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.75000,1.02,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,63739007910,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.45062,1.02,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,63739007310,NDC,,,facility,inpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,1.05,1.43,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,63739007310,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.63087,1.43,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63739006702,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63739006702,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,63739006610,NDC,,,facility,inpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,5.79,7.89,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,63739006610,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,3.48,7.89,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,63739006010,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,63739006010,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,63739005910,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,63739005910,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,63739005269,NDC,,,facility,inpatient,1,EA,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,8.64,11.78,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,63739005269,NDC,,,facility,outpatient,1,EA,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,5.19,11.78,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,63739005110,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,63739005110,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,63739004910,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,63739004910,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,63739001971,NDC,,,facility,inpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,13.95,19.02,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,63739001971,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,8.38,19.02,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,63739001510,NDC,,,facility,inpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,63739001510,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,63739001110,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,63739001110,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,63739000410,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,63739000410,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,63653133203,NDC,,,facility,inpatient,1,EA,157.15000,45.57000,Aetna,First Health,,128.55,,,,,,,94.29,128.55,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,63653133203,NDC,,,facility,outpatient,1,EA,157.15000,45.57000,Aetna,First Health,,128.55,,,,,,,56.65,128.55,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,63653133202,NDC,,,facility,inpatient,1,EA,218.55000,63.38000,Aetna,First Health,,178.77,,,,,,,131.13,178.77,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,63653133202,NDC,,,facility,outpatient,1,EA,218.55000,63.38000,Aetna,First Health,,178.77,,,,,,,78.79,178.77,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117106,NDC,,,facility,inpatient,1,EA,54.75000,15.88000,Aetna,First Health,,44.79,,,,,,,32.85,44.79,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117106,NDC,,,facility,outpatient,1,EA,54.75000,15.88000,Aetna,First Health,,44.79,,,,,,,19.74,44.79,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117104,NDC,,,facility,inpatient,1,EA,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,19.92,27.16,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117104,NDC,,,facility,outpatient,1,EA,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,11.97,27.16,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117103,NDC,,,facility,inpatient,1,EA,54.75000,15.88000,Aetna,First Health,,44.79,,,,,,,32.85,44.79,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117103,NDC,,,facility,outpatient,1,EA,54.75000,15.88000,Aetna,First Health,,44.79,,,,,,,19.74,44.79,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117101,NDC,,,facility,inpatient,1,EA,54.75000,15.88000,Aetna,First Health,,44.79,,,,,,,32.85,44.79,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117101,NDC,,,facility,outpatient,1,EA,54.75000,15.88000,Aetna,First Health,,44.79,,,,,,,19.74,44.79,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,63481068447,NDC,,,facility,inpatient,1,EA,434.10000,125.89000,Aetna,First Health,,355.09,,,,,,,260.46,355.09,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,63481068447,NDC,,,facility,outpatient,1,EA,434.10000,125.89000,Aetna,First Health,,355.09,,,,,,,156.49,355.09,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,63481020516,NDC,,,facility,inpatient,1,EA,21.50000,6.24000,Aetna,First Health,,17.59,,,,,,,12.90,17.59,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,63481020516,NDC,,,facility,outpatient,1,EA,21.50000,6.24000,Aetna,First Health,,17.59,,,,,,,7.75,17.59,percent of total billed charges,
Bendamustine 100mg I(Treanda),800012530,CDM,636,RC,J9033,HCPCS,63459039120,NDC,facility,inpatient,100,ME,16234.70000,4708.06000,Aetna,First Health,,13279.98,,,,,,,5852.61,13279.98,percent of total billed charges,
Bendamustine 100mg I(Treanda),800012530,CDM,636,RC,J9033,HCPCS,63459039120,NDC,facility,outpatient,100,ME,16234.70000,4708.06000,Aetna,First Health,,13279.98,,,,,,,1.97,13279.98,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,63459020530,NDC,,,facility,inpatient,1,EA,107.80000,31.26000,Aetna,First Health,,88.18,,,,,,,64.68,88.18,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,63459020530,NDC,,,facility,outpatient,1,EA,107.80000,31.26000,Aetna,First Health,,88.18,,,,,,,38.86,88.18,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,63459010130,NDC,,,facility,inpatient,1,EA,506.75000,146.96000,Aetna,First Health,,414.52,,,,,,,304.05,414.52,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,63459010130,NDC,,,facility,outpatient,1,EA,506.75000,146.96000,Aetna,First Health,,414.52,,,,,,,182.68,414.52,percent of total billed charges,
Levalbuterol HFA 45 mcg/inh,800017835,CDM,637,RC,63402051001,NDC,,,facility,inpatient,1,EA,562.75000,163.20000,Aetna,First Health,,460.33,,,,,,,337.65,460.33,percent of total billed charges,
Levalbuterol HFA 45 mcg/inh,800017835,CDM,637,RC,63402051001,NDC,,,facility,outpatient,1,EA,562.75000,163.20000,Aetna,First Health,,460.33,,,,,,,202.87,460.33,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,63402030430,NDC,,,facility,inpatient,1,EA,385.05000,111.66000,Aetna,First Health,,314.97,,,,,,,231.03,314.97,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,63402030430,NDC,,,facility,outpatient,1,EA,385.05000,111.66000,Aetna,First Health,,314.97,,,,,,,138.81,314.97,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,63402030410,NDC,,,facility,inpatient,1,EA,367.45000,106.56000,Aetna,First Health,,300.57,,,,,,,220.47,300.57,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,63402030410,NDC,,,facility,outpatient,1,EA,367.45000,106.56000,Aetna,First Health,,300.57,,,,,,,132.47,300.57,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,63402030230,NDC,,,facility,inpatient,1,EA,385.05000,111.66000,Aetna,First Health,,314.97,,,,,,,231.03,314.97,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,63402030230,NDC,,,facility,outpatient,1,EA,385.05000,111.66000,Aetna,First Health,,314.97,,,,,,,138.81,314.97,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,63323098321,NDC,facility,inpatient,3.375,GM,133.15000,38.61000,Aetna,First Health,,108.92,,,,,,,48.00,108.92,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,63323098321,NDC,facility,outpatient,3.375,GM,133.15000,38.61000,Aetna,First Health,,108.92,,,,,,,1.05,108.92,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,63323098121,NDC,facility,inpatient,2.25,GM,88.80000,25.75000,Aetna,First Health,,72.64,,,,,,,32.01,72.64,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,63323098121,NDC,facility,outpatient,2.25,GM,88.80000,25.75000,Aetna,First Health,,72.64,,,,,,,1.05,72.64,percent of total billed charges,
Potassium Cl 2mEq/mL I,800013427,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,inpatient,1,EA,26.70000,7.74000,Aetna,First Health,,21.84,,,,,,,9.63,21.84,percent of total billed charges,
Potassium Cl 2mEq/mL I,800013427,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,outpatient,1,EA,26.70000,7.74000,Aetna,First Health,,21.84,,,,,,,0.11556,21.84,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,63323096330,NDC,facility,inpatient,6000,ME,1014.00000,294.06000,Aetna,First Health,,829.45,,,,,,,365.55,829.45,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,63323096330,NDC,facility,outpatient,6000,ME,1014.00000,294.06000,Aetna,First Health,,829.45,,,,,,,0.35631,829.45,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,63323093001,NDC,facility,inpatient,20,UN,147.05000,42.64000,Aetna,First Health,,120.29,,,,,,,53.01,120.29,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,63323093001,NDC,facility,outpatient,20,UN,147.05000,42.64000,Aetna,First Health,,120.29,,,,,,,0.51039,120.29,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,63323092430,NDC,,,facility,inpatient,1,EA,28.15000,8.16000,Aetna,First Health,,23.03,,,,,,,10.42,23.03,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,63323092430,NDC,,,facility,outpatient,1,EA,28.15000,8.16000,Aetna,First Health,,23.03,,,,,,,10.15,23.03,percent of total billed charges,
NS Bacteriostatic 0.9% 10mL I,800046448,CDM,250,RC,63323092410,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.20,9.28,percent of total billed charges,
NS Bacteriostatic 0.9% 10mL I,800046448,CDM,250,RC,63323092410,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Levothyroxine 100 mcg Inj (20mcg/mL),800046383,CDM,636,RC,J0651,HCPCS,63323088514,NDC,facility,inpatient,0.1,ME,667.45000,193.56000,Aetna,First Health,,545.97,,,,,,,240.62,545.97,percent of total billed charges,
Levothyroxine 100 mcg Inj (20mcg/mL),800046383,CDM,636,RC,J0651,HCPCS,63323088514,NDC,facility,outpatient,0.1,ME,667.45000,193.56000,Aetna,First Health,,545.97,,,,,,,6.68,545.97,percent of total billed charges,
Levothyroxine 100 mcg Inj (20mcg/mL),800046383,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,inpatient,0.1,ME,778.80000,225.85000,Aetna,First Health,,637.06,,,,,,,280.76,637.06,percent of total billed charges,
Levothyroxine 100 mcg Inj (20mcg/mL),800046383,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,outpatient,0.1,ME,778.80000,225.85000,Aetna,First Health,,637.06,,,,,,,6.68,637.06,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,63323088406,NDC,,,facility,inpatient,1,EA,564.05000,163.57000,Aetna,First Health,,461.39,,,,,,,208.70,461.39,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,63323088406,NDC,,,facility,outpatient,1,EA,564.05000,163.57000,Aetna,First Health,,461.39,,,,,,,203.34,461.39,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,63323088330,NDC,facility,inpatient,50,ME,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,91.21,206.95,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,63323088330,NDC,facility,outpatient,50,ME,253.00000,73.37000,Aetna,First Health,,206.95,,,,,,,2.68,206.95,percent of total billed charges,
Pentamidine 300mg Inh,800081348,CDM,637,RC,J2545,HCPCS,63323087715,NDC,facility,inpatient,300,ME,1302.35000,377.68000,Aetna,First Health,,1065.32,,,,,,,781.41,1065.32,percent of total billed charges,
Pentamidine 300mg Inh,800081348,CDM,637,RC,J2545,HCPCS,63323087715,NDC,facility,outpatient,300,ME,1302.35000,377.68000,Aetna,First Health,,1065.32,,,,,,,469.50,1065.32,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,63323087074,NDC,facility,inpatient,1,EA,44.90000,13.02000,Aetna,First Health,,36.73,,,,,,,21.10,36.73,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,63323087074,NDC,facility,outpatient,1,EA,44.90000,13.02000,Aetna,First Health,,36.73,,,,,,,1.26,36.73,percent of total billed charges,
D5.45NS 1000mL,800012347,CDM,258,RC,J7030,HCPCS,63323086910,NDC,facility,inpatient,1,EA,44.90000,13.02000,Aetna,First Health,,36.73,,,,,,,21.10,36.73,percent of total billed charges,
D5.45NS 1000mL,800012347,CDM,258,RC,J7030,HCPCS,63323086910,NDC,facility,outpatient,1,EA,44.90000,13.02000,Aetna,First Health,,36.73,,,,,,,1.92,36.73,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,63323085225,NDC,facility,inpatient,1,ME,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,12.46,28.26,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,63323085225,NDC,facility,outpatient,1,ME,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,0.13482,28.26,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,63323082476,NDC,,,facility,inpatient,1,EA,66.15000,19.18000,Aetna,First Health,,54.11,,,,,,,31.09,54.11,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,63323082476,NDC,,,facility,outpatient,1,EA,66.15000,19.18000,Aetna,First Health,,54.11,,,,,,,23.85,54.11,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,63323082474,NDC,,,facility,inpatient,1,EA,48.25000,13.99000,Aetna,First Health,,39.47,,,,,,,22.68,39.47,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,63323082474,NDC,,,facility,outpatient,1,EA,48.25000,13.99000,Aetna,First Health,,39.47,,,,,,,17.39,39.47,percent of total billed charges,
Bortezomib 3.5mg Inj- Pt Own Supply,800052008,CDM,636,RC,J9041,HCPCS,63323082110,NDC,facility,inpatient,3.5,ME,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Bortezomib 3.5mg Inj- Pt Own Supply,800052008,CDM,636,RC,J9041,HCPCS,63323082110,NDC,facility,outpatient,3.5,ME,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,8.27,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,63323082110,NDC,facility,inpatient,3.5,ME,1807.00000,524.03000,Aetna,First Health,,1478.13,,,,,,,651.42,1478.13,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,63323082110,NDC,facility,outpatient,3.5,ME,1807.00000,524.03000,Aetna,First Health,,1478.13,,,,,,,2.58,1478.13,percent of total billed charges,
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,63323081320,NDC,facility,inpatient,1000,ME,112.15000,32.52000,Aetna,First Health,,91.74,,,,,,,40.43,91.74,percent of total billed charges,
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,63323081320,NDC,facility,outpatient,1000,ME,112.15000,32.52000,Aetna,First Health,,91.74,,,,,,,0.54891,91.74,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,63323080602,NDC,facility,inpatient,0.1,ME,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,7.93,18.00,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,63323080602,NDC,facility,outpatient,0.1,ME,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,1.15,18.00,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 1mL I,800051051,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,inpatient,0.05,ME,21.20000,6.15000,Aetna,First Health,,17.34,,,,,,,7.64,17.34,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 1mL I,800051051,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,outpatient,0.05,ME,21.20000,6.15000,Aetna,First Health,,17.34,,,,,,,1.15,17.34,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,63323078110,NDC,,,facility,inpatient,1,EA,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,12.28,27.16,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,63323078110,NDC,,,facility,outpatient,1,EA,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,11.97,27.16,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,63323075105,NDC,facility,inpatient,50,ME,226.70000,65.74000,Aetna,First Health,,185.44,,,,,,,81.73,185.44,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,63323075105,NDC,facility,outpatient,50,ME,226.70000,65.74000,Aetna,First Health,,185.44,,,,,,,83.88,185.44,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,63323073916,NDC,facility,inpatient,20,ME,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,63323073916,NDC,facility,outpatient,20,ME,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,0.00963,3.80,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,inpatient,20,ME,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,outpatient,20,ME,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,0.00963,4.70,percent of total billed charges,
Mesna 200mg/2mL I (Mesnex),800025637,CDM,636,RC,J9209,HCPCS,63323073311,NDC,facility,inpatient,200,ME,135.25000,39.22000,Aetna,First Health,,110.63,,,,,,,48.76,110.63,percent of total billed charges,
Mesna 200mg/2mL I (Mesnex),800025637,CDM,636,RC,J9209,HCPCS,63323073311,NDC,facility,outpatient,200,ME,135.25000,39.22000,Aetna,First Health,,110.63,,,,,,,1.64,110.63,percent of total billed charges,
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,63323072910,NDC,facility,inpatient,100,ME,441.20000,127.95000,Aetna,First Health,,360.90,,,,,,,159.05,360.90,percent of total billed charges,
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,63323072910,NDC,facility,outpatient,100,ME,441.20000,127.95000,Aetna,First Health,,360.90,,,,,,,0.24075,360.90,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,63323072303,NDC,,,facility,inpatient,1,EA,653.80000,189.60000,Aetna,First Health,,534.81,,,,,,,241.91,534.81,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,63323072303,NDC,,,facility,outpatient,1,EA,653.80000,189.60000,Aetna,First Health,,534.81,,,,,,,235.69,534.81,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,63323068610,NDC,,,facility,inpatient,1,EA,48.45000,14.05000,Aetna,First Health,,39.63,,,,,,,22.77,39.63,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,63323068610,NDC,,,facility,outpatient,1,EA,48.45000,14.05000,Aetna,First Health,,39.63,,,,,,,17.47,39.63,percent of total billed charges,
0.45NS + 20mEq/L KCl 1000mL,800021700,CDM,258,RC,J3480,HCPCS,63323068310,NDC,facility,inpatient,1,EA,48.45000,14.05000,Aetna,First Health,,39.63,,,,,,,22.77,39.63,percent of total billed charges,
0.45NS + 20mEq/L KCl 1000mL,800021700,CDM,258,RC,J3480,HCPCS,63323068310,NDC,facility,outpatient,1,EA,48.45000,14.05000,Aetna,First Health,,39.63,,,,,,,0.11556,39.63,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,63323066501,NDC,facility,inpatient,1,ME,125.75000,36.47000,Aetna,First Health,,102.86,,,,,,,45.33,102.86,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,63323066501,NDC,facility,outpatient,1,ME,125.75000,36.47000,Aetna,First Health,,102.86,,,,,,,2.38,102.86,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,inpatient,50,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,outpatient,50,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,0.68373,15.71,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,63323066005,NDC,,,facility,inpatient,1,EA,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,5.22,11.53,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,63323066005,NDC,,,facility,outpatient,1,EA,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,5.08,11.53,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,63323065827,NDC,facility,inpatient,500,ME,1376.05000,399.05000,Aetna,First Health,,1125.61,,,,,,,496.07,1125.61,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,63323065827,NDC,facility,outpatient,500,ME,1376.05000,399.05000,Aetna,First Health,,1125.61,,,,,,,55.98,1125.61,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,63323065820,NDC,facility,inpatient,500,ME,1376.05000,399.05000,Aetna,First Health,,1125.61,,,,,,,496.07,1125.61,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,63323065820,NDC,facility,outpatient,500,ME,1376.05000,399.05000,Aetna,First Health,,1125.61,,,,,,,55.98,1125.61,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323065599,NDC,facility,inpatient,120,ME,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323065599,NDC,facility,outpatient,120,ME,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,0.51039,57.91,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,63323065210,NDC,facility,inpatient,100,ME,114.65000,33.25000,Aetna,First Health,,93.78,,,,,,,41.33,93.78,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,63323065210,NDC,facility,outpatient,100,ME,114.65000,33.25000,Aetna,First Health,,93.78,,,,,,,0.20223,93.78,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,63323065130,NDC,facility,inpatient,6,ME,82.60000,23.95000,Aetna,First Health,,67.57,,,,,,,29.78,67.57,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,63323065130,NDC,facility,outpatient,6,ME,82.60000,23.95000,Aetna,First Health,,67.57,,,,,,,0.51039,67.57,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,inpatient,6,ME,69.90000,20.27000,Aetna,First Health,,57.18,,,,,,,25.20,57.18,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,outpatient,6,ME,69.90000,20.27000,Aetna,First Health,,57.18,,,,,,,0.51039,57.18,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,inpatient,10,GM,92.30000,26.77000,Aetna,First Health,,75.50,,,,,,,33.27,75.50,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,outpatient,10,GM,92.30000,26.77000,Aetna,First Health,,75.50,,,,,,,0.39483,75.50,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,63323062655,NDC,,,facility,inpatient,1,EA,40.80000,11.83000,Aetna,First Health,,33.37,,,,,,,19.18,33.37,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,63323062655,NDC,,,facility,outpatient,1,EA,40.80000,11.83000,Aetna,First Health,,33.37,,,,,,,14.71,33.37,percent of total billed charges,
0.45% Sodium Cl 250mL,800081202,CDM,258,RC,63323062625,NDC,,,facility,inpatient,1,EA,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,16.31,28.38,percent of total billed charges,
0.45% Sodium Cl 250mL,800081202,CDM,258,RC,63323062625,NDC,,,facility,outpatient,1,EA,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,12.51,28.38,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,63323062610,NDC,,,facility,inpatient,1,EA,46.50000,13.48000,Aetna,First Health,,38.04,,,,,,,21.86,38.04,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,63323062610,NDC,,,facility,outpatient,1,EA,46.50000,13.48000,Aetna,First Health,,38.04,,,,,,,16.76,38.04,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,63323062374,NDC,facility,inpatient,1,EA,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,12.51,28.38,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,63323062374,NDC,facility,outpatient,1,EA,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,0.63558,28.38,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,inpatient,150,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,outpatient,150,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,0.39483,15.71,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,63323061455,NDC,facility,inpatient,20,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,27.61,62.66,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,63323061455,NDC,facility,outpatient,20,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,4.23,62.66,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,63323061401,NDC,facility,inpatient,20,ME,91.40000,26.51000,Aetna,First Health,,74.77,,,,,,,32.95,74.77,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,63323061401,NDC,facility,outpatient,20,ME,91.40000,26.51000,Aetna,First Health,,74.77,,,,,,,4.23,74.77,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323060990,NDC,facility,inpatient,120,ME,151.95000,44.07000,Aetna,First Health,,124.30,,,,,,,54.78,124.30,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323060990,NDC,facility,outpatient,120,ME,151.95000,44.07000,Aetna,First Health,,124.30,,,,,,,0.51039,124.30,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323060798,NDC,facility,inpatient,60,ME,38.45000,11.15000,Aetna,First Health,,31.45,,,,,,,13.86,31.45,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323060798,NDC,facility,outpatient,60,ME,38.45000,11.15000,Aetna,First Health,,31.45,,,,,,,0.51039,31.45,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323060788,NDC,facility,inpatient,60,ME,76.15000,22.08000,Aetna,First Health,,62.29,,,,,,,27.45,62.29,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323060788,NDC,facility,outpatient,60,ME,76.15000,22.08000,Aetna,First Health,,62.29,,,,,,,0.51039,62.29,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323060594,NDC,facility,inpatient,100,ME,126.90000,36.80000,Aetna,First Health,,103.80,,,,,,,45.75,103.80,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323060594,NDC,facility,outpatient,100,ME,126.90000,36.80000,Aetna,First Health,,103.80,,,,,,,0.51039,103.80,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323060584,NDC,facility,inpatient,100,ME,126.90000,36.80000,Aetna,First Health,,103.80,,,,,,,45.75,103.80,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323060584,NDC,facility,outpatient,100,ME,126.90000,36.80000,Aetna,First Health,,103.80,,,,,,,0.51039,103.80,percent of total billed charges,
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059616,NDC,facility,inpatient,1,ME,683.80000,198.30000,Aetna,First Health,,559.35,,,,,,,246.51,559.35,percent of total billed charges,
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059616,NDC,facility,outpatient,1,ME,683.80000,198.30000,Aetna,First Health,,559.35,,,,,,,158.76,559.35,percent of total billed charges,
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059613,NDC,facility,inpatient,1,ME,1196.70000,347.04000,Aetna,First Health,,978.90,,,,,,,431.41,978.90,percent of total billed charges,
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059613,NDC,facility,outpatient,1,ME,1196.70000,347.04000,Aetna,First Health,,978.90,,,,,,,158.76,978.90,percent of total billed charges,
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059403,NDC,facility,inpatient,1,ME,683.80000,198.30000,Aetna,First Health,,559.35,,,,,,,246.51,559.35,percent of total billed charges,
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059403,NDC,facility,outpatient,1,ME,683.80000,198.30000,Aetna,First Health,,559.35,,,,,,,158.76,559.35,percent of total billed charges,
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059303,NDC,facility,inpatient,1,ME,1196.70000,347.04000,Aetna,First Health,,978.90,,,,,,,431.41,978.90,percent of total billed charges,
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059303,NDC,facility,outpatient,1,ME,1196.70000,347.04000,Aetna,First Health,,978.90,,,,,,,158.76,978.90,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323058994,NDC,facility,inpatient,150,ME,89.10000,25.84000,Aetna,First Health,,72.88,,,,,,,32.12,72.88,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323058994,NDC,facility,outpatient,150,ME,89.10000,25.84000,Aetna,First Health,,72.88,,,,,,,0.51039,72.88,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323058696,NDC,facility,inpatient,100,ME,59.50000,17.26000,Aetna,First Health,,48.67,,,,,,,21.45,48.67,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323058696,NDC,facility,outpatient,100,ME,59.50000,17.26000,Aetna,First Health,,48.67,,,,,,,0.51039,48.67,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323058665,NDC,facility,inpatient,100,ME,59.50000,17.26000,Aetna,First Health,,48.67,,,,,,,21.45,48.67,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323058665,NDC,facility,outpatient,100,ME,59.50000,17.26000,Aetna,First Health,,48.67,,,,,,,0.51039,48.67,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323058499,NDC,facility,inpatient,80,ME,47.25000,13.70000,Aetna,First Health,,38.65,,,,,,,17.03,38.65,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323058499,NDC,facility,outpatient,80,ME,47.25000,13.70000,Aetna,First Health,,38.65,,,,,,,0.51039,38.65,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323058465,NDC,facility,inpatient,80,ME,47.25000,13.70000,Aetna,First Health,,38.65,,,,,,,17.03,38.65,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323058465,NDC,facility,outpatient,80,ME,47.25000,13.70000,Aetna,First Health,,38.65,,,,,,,0.51039,38.65,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,inpatient,120,ME,151.95000,44.07000,Aetna,First Health,,124.30,,,,,,,54.78,124.30,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,outpatient,120,ME,151.95000,44.07000,Aetna,First Health,,124.30,,,,,,,0.51039,124.30,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,inpatient,150,ME,186.40000,54.06000,Aetna,First Health,,152.48,,,,,,,67.20,152.48,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,outpatient,150,ME,186.40000,54.06000,Aetna,First Health,,152.48,,,,,,,0.51039,152.48,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323056990,NDC,facility,inpatient,120,ME,151.95000,44.07000,Aetna,First Health,,124.30,,,,,,,54.78,124.30,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323056990,NDC,facility,outpatient,120,ME,151.95000,44.07000,Aetna,First Health,,124.30,,,,,,,0.51039,124.30,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323056984,NDC,facility,inpatient,150,ME,186.40000,54.06000,Aetna,First Health,,152.48,,,,,,,67.20,152.48,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323056984,NDC,facility,outpatient,150,ME,186.40000,54.06000,Aetna,First Health,,152.48,,,,,,,0.51039,152.48,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323056899,NDC,facility,inpatient,80,ME,101.50000,29.44000,Aetna,First Health,,83.03,,,,,,,36.59,83.03,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323056899,NDC,facility,outpatient,80,ME,101.50000,29.44000,Aetna,First Health,,83.03,,,,,,,0.51039,83.03,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323056898,NDC,facility,inpatient,60,ME,76.15000,22.08000,Aetna,First Health,,62.29,,,,,,,27.45,62.29,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323056898,NDC,facility,outpatient,60,ME,76.15000,22.08000,Aetna,First Health,,62.29,,,,,,,0.51039,62.29,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056896,NDC,facility,inpatient,40,ME,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,18.28,41.47,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056896,NDC,facility,outpatient,40,ME,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,0.51039,41.47,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323056895,NDC,facility,inpatient,100,ME,126.90000,36.80000,Aetna,First Health,,103.80,,,,,,,45.75,103.80,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323056895,NDC,facility,outpatient,100,ME,126.90000,36.80000,Aetna,First Health,,103.80,,,,,,,0.51039,103.80,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323056894,NDC,facility,inpatient,30,ME,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,13.74,31.17,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323056894,NDC,facility,outpatient,30,ME,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,0.51039,31.17,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056887,NDC,facility,inpatient,40,ME,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,18.28,41.47,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056887,NDC,facility,outpatient,40,ME,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,0.51039,41.47,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323056883,NDC,facility,inpatient,30,ME,39.70000,11.51000,Aetna,First Health,,32.47,,,,,,,14.31,32.47,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323056883,NDC,facility,outpatient,30,ME,39.70000,11.51000,Aetna,First Health,,32.47,,,,,,,0.51039,32.47,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323056698,NDC,facility,inpatient,60,ME,36.85000,10.69000,Aetna,First Health,,30.14,,,,,,,13.28,30.14,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323056698,NDC,facility,outpatient,60,ME,36.85000,10.69000,Aetna,First Health,,30.14,,,,,,,0.51039,30.14,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056497,NDC,facility,inpatient,40,ME,23.50000,6.82000,Aetna,First Health,,19.22,,,,,,,8.47,19.22,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056497,NDC,facility,outpatient,40,ME,23.50000,6.82000,Aetna,First Health,,19.22,,,,,,,0.51039,19.22,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056465,NDC,facility,inpatient,40,ME,23.50000,6.82000,Aetna,First Health,,19.22,,,,,,,8.47,19.22,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056465,NDC,facility,outpatient,40,ME,23.50000,6.82000,Aetna,First Health,,19.22,,,,,,,0.51039,19.22,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,63323056310,NDC,,,facility,inpatient,1,EA,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,71.04,157.06,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,63323056310,NDC,,,facility,outpatient,1,EA,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,69.22,157.06,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,63323056210,NDC,facility,inpatient,250,ME,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,471.53,1069.94,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,63323056210,NDC,facility,outpatient,250,ME,1308.00000,379.32000,Aetna,First Health,,1069.94,,,,,,,0.15408,1069.94,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323055993,NDC,facility,inpatient,30,ME,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323055993,NDC,facility,outpatient,30,ME,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,0.51039,14.48,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323055965,NDC,facility,inpatient,30,ME,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323055965,NDC,facility,outpatient,30,ME,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,0.51039,13.50,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054067,NDC,facility,inpatient,10000,UN,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,4.92,11.17,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054067,NDC,facility,outpatient,10000,UN,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,0.17334,11.17,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054057,NDC,facility,inpatient,10000,UN,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,17.43,39.55,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054057,NDC,facility,outpatient,10000,UN,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,0.17334,39.55,percent of total billed charges,
"Heparin I(10,000/10mL)",800013343,CDM,636,RC,J1644,HCPCS,63323054057,NDC,facility,inpatient,10000,UN,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,17.43,39.55,percent of total billed charges,
"Heparin I(10,000/10mL)",800013343,CDM,636,RC,J1644,HCPCS,63323054057,NDC,facility,outpatient,10000,UN,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,0.17334,39.55,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,63323054036,NDC,facility,inpatient,30000,UN,72.75000,21.10000,Aetna,First Health,,59.51,,,,,,,26.23,59.51,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,63323054036,NDC,facility,outpatient,30000,UN,72.75000,21.10000,Aetna,First Health,,59.51,,,,,,,0.17334,59.51,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,63323054031,NDC,facility,inpatient,30000,UN,72.75000,21.10000,Aetna,First Health,,59.51,,,,,,,26.23,59.51,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,63323054031,NDC,facility,outpatient,30000,UN,72.75000,21.10000,Aetna,First Health,,59.51,,,,,,,0.17334,59.51,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054015,NDC,facility,inpatient,10000,UN,46.40000,13.46000,Aetna,First Health,,37.96,,,,,,,16.73,37.96,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054015,NDC,facility,outpatient,10000,UN,46.40000,13.46000,Aetna,First Health,,37.96,,,,,,,0.17334,37.96,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054011,NDC,facility,inpatient,10000,UN,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,17.43,39.55,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054011,NDC,facility,outpatient,10000,UN,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,0.17334,39.55,percent of total billed charges,
"Heparin I(10,000/10mL)",800013343,CDM,636,RC,J1644,HCPCS,63323054011,NDC,facility,inpatient,10000,UN,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,17.43,39.55,percent of total billed charges,
"Heparin I(10,000/10mL)",800013343,CDM,636,RC,J1644,HCPCS,63323054011,NDC,facility,outpatient,10000,UN,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,0.17334,39.55,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323053784,NDC,facility,inpatient,150,ME,186.40000,54.06000,Aetna,First Health,,152.48,,,,,,,67.20,152.48,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323053784,NDC,facility,outpatient,150,ME,186.40000,54.06000,Aetna,First Health,,152.48,,,,,,,0.51039,152.48,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323053598,NDC,facility,inpatient,40,ME,25.60000,7.42000,Aetna,First Health,,20.94,,,,,,,9.23,20.94,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323053598,NDC,facility,outpatient,40,ME,25.60000,7.42000,Aetna,First Health,,20.94,,,,,,,0.51039,20.94,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323053587,NDC,facility,inpatient,40,ME,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,18.28,41.47,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323053587,NDC,facility,outpatient,40,ME,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,0.51039,41.47,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323053393,NDC,facility,inpatient,30,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323053393,NDC,facility,outpatient,30,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,0.51039,15.71,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323053198,NDC,facility,inpatient,80,ME,51.25000,14.86000,Aetna,First Health,,41.92,,,,,,,18.48,41.92,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323053198,NDC,facility,outpatient,80,ME,51.25000,14.86000,Aetna,First Health,,41.92,,,,,,,0.51039,41.92,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323053190,NDC,facility,inpatient,80,ME,101.50000,29.44000,Aetna,First Health,,83.03,,,,,,,36.59,83.03,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323053190,NDC,facility,outpatient,80,ME,101.50000,29.44000,Aetna,First Health,,83.03,,,,,,,0.51039,83.03,percent of total billed charges,
Sodium Chloride 3% IV 500mL,800040915,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,inpatient,1,EA,40.80000,11.83000,Aetna,First Health,,33.37,,,,,,,14.71,33.37,percent of total billed charges,
Sodium Chloride 3% IV 500mL,800040915,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,outpatient,1,EA,40.80000,11.83000,Aetna,First Health,,33.37,,,,,,,0.14445,33.37,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,63323052374,NDC,facility,inpatient,25000,UN,109.25000,31.68000,Aetna,First Health,,89.37,,,,,,,39.38,89.37,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,63323052374,NDC,facility,outpatient,25000,UN,109.25000,31.68000,Aetna,First Health,,89.37,,,,,,,0.17334,89.37,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,63323050831,NDC,facility,inpatient,1,GM,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,20.42,46.34,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,63323050831,NDC,facility,outpatient,1,GM,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,0.36594,46.34,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,GM,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,20.42,46.34,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,outpatient,1,GM,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,0.36594,46.34,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,63323050725,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,63323050725,NDC,facility,outpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,0.36594,23.56,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,outpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,0.36594,23.56,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,outpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,0.36594,23.56,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323049697,NDC,,,facility,inpatient,1,EA,44.25000,12.83000,Aetna,First Health,,36.20,,,,,,,15.95,36.20,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323049697,NDC,,,facility,outpatient,1,EA,44.25000,12.83000,Aetna,First Health,,36.20,,,,,,,15.95,36.20,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,63323049507,NDC,,,facility,inpatient,1,EA,22.90000,6.64000,Aetna,First Health,,18.73,,,,,,,8.26,18.73,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,63323049507,NDC,,,facility,outpatient,1,EA,22.90000,6.64000,Aetna,First Health,,18.73,,,,,,,8.26,18.73,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,63323049416,NDC,,,facility,inpatient,1,EA,19.80000,5.74000,Aetna,First Health,,16.20,,,,,,,7.33,16.20,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,63323049416,NDC,,,facility,outpatient,1,EA,19.80000,5.74000,Aetna,First Health,,16.20,,,,,,,7.14,16.20,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,63323049405,NDC,,,facility,inpatient,1,EA,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,24.79,54.81,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,63323049405,NDC,,,facility,outpatient,1,EA,67.00000,19.43000,Aetna,First Health,,54.81,,,,,,,24.15,54.81,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,63323049289,NDC,,,facility,inpatient,1,EA,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,5.57,12.64,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,63323049289,NDC,,,facility,outpatient,1,EA,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,5.57,12.64,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049280,NDC,,,facility,inpatient,1,EA,11.45000,3.32000,Aetna,First Health,,9.37,,,,,,,4.13,9.37,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049280,NDC,,,facility,outpatient,1,EA,11.45000,3.32000,Aetna,First Health,,9.37,,,,,,,4.13,9.37,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,63323049257,NDC,,,facility,inpatient,1,EA,25.10000,7.28000,Aetna,First Health,,20.53,,,,,,,9.05,20.53,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,63323049257,NDC,,,facility,outpatient,1,EA,25.10000,7.28000,Aetna,First Health,,20.53,,,,,,,9.05,20.53,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049237,NDC,,,facility,inpatient,1,EA,75.25000,21.82000,Aetna,First Health,,61.55,,,,,,,27.13,61.55,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049237,NDC,,,facility,outpatient,1,EA,75.25000,21.82000,Aetna,First Health,,61.55,,,,,,,27.13,61.55,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049231,NDC,,,facility,inpatient,1,EA,60.45000,17.53000,Aetna,First Health,,49.45,,,,,,,21.79,49.45,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049231,NDC,,,facility,outpatient,1,EA,60.45000,17.53000,Aetna,First Health,,49.45,,,,,,,21.79,49.45,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049230,NDC,,,facility,inpatient,1,EA,54.55000,15.82000,Aetna,First Health,,44.62,,,,,,,19.67,44.62,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049230,NDC,,,facility,outpatient,1,EA,54.55000,15.82000,Aetna,First Health,,44.62,,,,,,,19.67,44.62,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049227,NDC,,,facility,inpatient,1,EA,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,5.43,12.31,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049227,NDC,,,facility,outpatient,1,EA,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,5.43,12.31,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049202,NDC,,,facility,inpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049202,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
Lidocaine 0.5% 50mL PF I,800044361,CDM,636,RC,63323049157,NDC,,,facility,inpatient,1,EA,92.45000,26.81000,Aetna,First Health,,75.62,,,,,,,33.33,75.62,percent of total billed charges,
Lidocaine 0.5% 50mL PF I,800044361,CDM,636,RC,63323049157,NDC,,,facility,outpatient,1,EA,92.45000,26.81000,Aetna,First Health,,75.62,,,,,,,33.33,75.62,percent of total billed charges,
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,63323049089,NDC,,,facility,inpatient,1,EA,40.15000,11.64000,Aetna,First Health,,32.84,,,,,,,14.47,32.84,percent of total billed charges,
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,63323049089,NDC,,,facility,outpatient,1,EA,40.15000,11.64000,Aetna,First Health,,32.84,,,,,,,14.47,32.84,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048927,NDC,,,facility,inpatient,1,EA,131.55000,38.15000,Aetna,First Health,,107.61,,,,,,,47.42,107.61,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048927,NDC,,,facility,outpatient,1,EA,131.55000,38.15000,Aetna,First Health,,107.61,,,,,,,47.42,107.61,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048921,NDC,,,facility,inpatient,1,EA,81.85000,23.74000,Aetna,First Health,,66.95,,,,,,,29.51,66.95,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048921,NDC,,,facility,outpatient,1,EA,81.85000,23.74000,Aetna,First Health,,66.95,,,,,,,29.51,66.95,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048920,NDC,,,facility,inpatient,1,EA,83.65000,24.26000,Aetna,First Health,,68.43,,,,,,,30.16,68.43,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048920,NDC,,,facility,outpatient,1,EA,83.65000,24.26000,Aetna,First Health,,68.43,,,,,,,30.16,68.43,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048737,NDC,,,facility,inpatient,1,EA,98.20000,28.48000,Aetna,First Health,,80.33,,,,,,,35.40,80.33,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048737,NDC,,,facility,outpatient,1,EA,98.20000,28.48000,Aetna,First Health,,80.33,,,,,,,35.40,80.33,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048731,NDC,,,facility,inpatient,1,EA,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,23.43,53.17,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048731,NDC,,,facility,outpatient,1,EA,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,23.43,53.17,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048730,NDC,,,facility,inpatient,1,EA,65.70000,19.05000,Aetna,First Health,,53.74,,,,,,,23.68,53.74,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048730,NDC,,,facility,outpatient,1,EA,65.70000,19.05000,Aetna,First Health,,53.74,,,,,,,23.68,53.74,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,63323048657,NDC,,,facility,inpatient,1,EA,45.50000,13.19000,Aetna,First Health,,37.22,,,,,,,16.40,37.22,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,63323048657,NDC,,,facility,outpatient,1,EA,45.50000,13.19000,Aetna,First Health,,37.22,,,,,,,16.40,37.22,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048627,NDC,,,facility,inpatient,1,EA,24.50000,7.10000,Aetna,First Health,,20.04,,,,,,,8.83,20.04,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048627,NDC,,,facility,outpatient,1,EA,24.50000,7.10000,Aetna,First Health,,20.04,,,,,,,8.83,20.04,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048620,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048620,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323048617,NDC,,,facility,inpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323048617,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048617,NDC,,,facility,inpatient,1,EA,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048617,NDC,,,facility,outpatient,1,EA,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323048610,NDC,,,facility,inpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323048610,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,63323048557,NDC,,,facility,inpatient,1,EA,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,13.16,29.86,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,63323048557,NDC,,,facility,outpatient,1,EA,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,13.16,29.86,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,63323048527,NDC,,,facility,inpatient,1,EA,21.65000,6.28000,Aetna,First Health,,17.71,,,,,,,7.80,17.71,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,63323048527,NDC,,,facility,outpatient,1,EA,21.65000,6.28000,Aetna,First Health,,17.71,,,,,,,7.80,17.71,percent of total billed charges,
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,63323048327,NDC,,,facility,inpatient,1,EA,36.25000,10.51000,Aetna,First Health,,29.65,,,,,,,13.07,29.65,percent of total billed charges,
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,63323048327,NDC,,,facility,outpatient,1,EA,36.25000,10.51000,Aetna,First Health,,29.65,,,,,,,13.07,29.65,percent of total billed charges,
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,63323048257,NDC,,,facility,inpatient,1,EA,83.10000,24.10000,Aetna,First Health,,67.98,,,,,,,29.96,67.98,percent of total billed charges,
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,63323048257,NDC,,,facility,outpatient,1,EA,83.10000,24.10000,Aetna,First Health,,67.98,,,,,,,29.96,67.98,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,63323048227,NDC,,,facility,inpatient,1,EA,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,12.89,29.24,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,63323048227,NDC,,,facility,outpatient,1,EA,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,12.89,29.24,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 10mL",800022038,CDM,636,RC,63323048217,NDC,,,facility,inpatient,1,EA,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,9.12,20.70,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 10mL",800022038,CDM,636,RC,63323048217,NDC,,,facility,outpatient,1,EA,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,9.12,20.70,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,inpatient,600,ME,143.45000,41.60000,Aetna,First Health,,117.34,,,,,,,51.71,117.34,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,outpatient,600,ME,143.45000,41.60000,Aetna,First Health,,117.34,,,,,,,0.03852,117.34,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,63323047410,NDC,facility,inpatient,5,ME,36.70000,10.64000,Aetna,First Health,,30.02,,,,,,,13.23,30.02,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,63323047410,NDC,facility,outpatient,5,ME,36.70000,10.64000,Aetna,First Health,,30.02,,,,,,,0.70299,30.02,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,63323047401,NDC,facility,inpatient,5,ME,38.25000,11.09000,Aetna,First Health,,31.29,,,,,,,13.79,31.29,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,63323047401,NDC,facility,outpatient,5,ME,38.25000,11.09000,Aetna,First Health,,31.29,,,,,,,0.70299,31.29,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,63323047302,NDC,,,facility,inpatient,1,EA,25.10000,7.28000,Aetna,First Health,,20.53,,,,,,,9.29,20.53,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,63323047302,NDC,,,facility,outpatient,1,EA,25.10000,7.28000,Aetna,First Health,,20.53,,,,,,,9.05,20.53,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,63323046837,NDC,,,facility,inpatient,1,EA,77.25000,22.40000,Aetna,First Health,,63.19,,,,,,,28.58,63.19,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,63323046837,NDC,,,facility,outpatient,1,EA,77.25000,22.40000,Aetna,First Health,,63.19,,,,,,,27.85,63.19,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,63323046830,NDC,,,facility,inpatient,1,EA,40.95000,11.88000,Aetna,First Health,,33.50,,,,,,,15.15,33.50,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,63323046830,NDC,,,facility,outpatient,1,EA,40.95000,11.88000,Aetna,First Health,,33.50,,,,,,,14.76,33.50,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,63323046637,NDC,,,facility,inpatient,1,EA,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,18.67,41.27,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,63323046637,NDC,,,facility,outpatient,1,EA,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,18.19,41.27,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,63323046630,NDC,,,facility,inpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,12.32,27.24,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,63323046630,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,12.00,27.24,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,63323046617,NDC,,,facility,inpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,13.49,29.82,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,63323046617,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,13.14,29.82,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,63323046610,NDC,,,facility,inpatient,1,EA,24.25000,7.03000,Aetna,First Health,,19.84,,,,,,,8.97,19.84,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,63323046610,NDC,,,facility,outpatient,1,EA,24.25000,7.03000,Aetna,First Health,,19.84,,,,,,,8.74,19.84,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,63323046437,NDC,,,facility,inpatient,1,EA,52.35000,15.18000,Aetna,First Health,,42.82,,,,,,,19.37,42.82,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,63323046437,NDC,,,facility,outpatient,1,EA,52.35000,15.18000,Aetna,First Health,,42.82,,,,,,,18.87,42.82,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,63323046431,NDC,,,facility,inpatient,1,EA,44.10000,12.79000,Aetna,First Health,,36.07,,,,,,,16.32,36.07,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,63323046431,NDC,,,facility,outpatient,1,EA,44.10000,12.79000,Aetna,First Health,,36.07,,,,,,,15.90,36.07,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,63323046237,NDC,,,facility,inpatient,1,EA,83.20000,24.13000,Aetna,First Health,,68.06,,,,,,,30.78,68.06,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,63323046237,NDC,,,facility,outpatient,1,EA,83.20000,24.13000,Aetna,First Health,,68.06,,,,,,,29.99,68.06,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,63323046231,NDC,,,facility,inpatient,1,EA,52.75000,15.30000,Aetna,First Health,,43.15,,,,,,,19.52,43.15,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,63323046231,NDC,,,facility,outpatient,1,EA,52.75000,15.30000,Aetna,First Health,,43.15,,,,,,,19.02,43.15,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,63323046230,NDC,,,facility,inpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.44,12.02,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,63323046230,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.30,12.02,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,63323046230,NDC,,,facility,inpatient,1,EA,44.10000,12.79000,Aetna,First Health,,36.07,,,,,,,16.32,36.07,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,63323046230,NDC,,,facility,outpatient,1,EA,44.10000,12.79000,Aetna,First Health,,36.07,,,,,,,15.90,36.07,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,63323046217,NDC,,,facility,inpatient,1,EA,50.05000,14.51000,Aetna,First Health,,40.94,,,,,,,18.52,40.94,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,63323046217,NDC,,,facility,outpatient,1,EA,50.05000,14.51000,Aetna,First Health,,40.94,,,,,,,18.04,40.94,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,63323046210,NDC,,,facility,inpatient,1,EA,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,9.82,21.72,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,63323046210,NDC,,,facility,outpatient,1,EA,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,9.57,21.72,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,63323043400,NDC,facility,inpatient,1000,ME,97.90000,28.39000,Aetna,First Health,,80.08,,,,,,,35.29,80.08,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,63323043400,NDC,facility,outpatient,1000,ME,97.90000,28.39000,Aetna,First Health,,80.08,,,,,,,0.05778,80.08,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,63323042610,NDC,,,facility,inpatient,1,EA,41.50000,12.03000,Aetna,First Health,,33.95,,,,,,,15.36,33.95,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,63323042610,NDC,,,facility,outpatient,1,EA,41.50000,12.03000,Aetna,First Health,,33.95,,,,,,,14.96,33.95,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,63323042605,NDC,,,facility,inpatient,1,EA,43.25000,12.54000,Aetna,First Health,,35.38,,,,,,,16.00,35.38,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,63323042605,NDC,,,facility,outpatient,1,EA,43.25000,12.54000,Aetna,First Health,,35.38,,,,,,,15.59,35.38,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,63323042405,NDC,,,facility,inpatient,1,EA,47.35000,13.73000,Aetna,First Health,,38.73,,,,,,,17.52,38.73,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,63323042405,NDC,,,facility,outpatient,1,EA,47.35000,13.73000,Aetna,First Health,,38.73,,,,,,,17.07,38.73,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,63323041820,NDC,,,facility,inpatient,1,EA,2299.90000,666.97000,Aetna,First Health,,1881.32,,,,,,,850.96,1881.32,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,63323041820,NDC,,,facility,outpatient,1,EA,2299.90000,666.97000,Aetna,First Health,,1881.32,,,,,,,829.11,1881.32,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,63323041510,NDC,facility,inpatient,10,ME,175.95000,51.03000,Aetna,First Health,,143.93,,,,,,,63.43,143.93,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,63323041510,NDC,facility,outpatient,10,ME,175.95000,51.03000,Aetna,First Health,,143.93,,,,,,,0.92448,143.93,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,inpatient,5,ME,31.10000,9.02000,Aetna,First Health,,25.44,,,,,,,11.21,25.44,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,outpatient,5,ME,31.10000,9.02000,Aetna,First Health,,25.44,,,,,,,0.13482,25.44,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,inpatient,2,ME,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,4.51,10.22,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,outpatient,2,ME,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,0.13482,10.22,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,inpatient,60,ME,293.20000,85.03000,Aetna,First Health,,239.84,,,,,,,105.70,239.84,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,outpatient,60,ME,293.20000,85.03000,Aetna,First Health,,239.84,,,,,,,1.40,239.84,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,63323040603,NDC,,,facility,inpatient,1,EA,362.35000,105.08000,Aetna,First Health,,296.40,,,,,,,217.41,296.40,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,63323040603,NDC,,,facility,outpatient,1,EA,362.35000,105.08000,Aetna,First Health,,296.40,,,,,,,130.63,296.40,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,63323040310,NDC,facility,inpatient,500,ME,243.85000,70.72000,Aetna,First Health,,199.47,,,,,,,87.91,199.47,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,63323040310,NDC,facility,outpatient,500,ME,243.85000,70.72000,Aetna,First Health,,199.47,,,,,,,1.34,199.47,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,inpatient,100,ME,34.90000,10.12000,Aetna,First Health,,28.55,,,,,,,12.58,28.55,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,outpatient,100,ME,34.90000,10.12000,Aetna,First Health,,28.55,,,,,,,1.34,28.55,percent of total billed charges,
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,63323040230,NDC,facility,inpatient,2,GM,435.60000,126.32000,Aetna,First Health,,356.32,,,,,,,157.03,356.32,percent of total billed charges,
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,63323040230,NDC,facility,outpatient,2,GM,435.60000,126.32000,Aetna,First Health,,356.32,,,,,,,2.15,356.32,percent of total billed charges,
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,inpatient,2,GM,653.80000,189.60000,Aetna,First Health,,534.81,,,,,,,235.69,534.81,percent of total billed charges,
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,outpatient,2,GM,653.80000,189.60000,Aetna,First Health,,534.81,,,,,,,2.15,534.81,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,63323040126,NDC,facility,inpatient,1,GM,221.65000,64.28000,Aetna,First Health,,181.31,,,,,,,79.90,181.31,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,63323040126,NDC,facility,outpatient,1,GM,221.65000,64.28000,Aetna,First Health,,181.31,,,,,,,2.15,181.31,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,63323040120,NDC,facility,inpatient,1,GM,337.70000,97.93000,Aetna,First Health,,276.24,,,,,,,121.74,276.24,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,63323040120,NDC,facility,outpatient,1,GM,337.70000,97.93000,Aetna,First Health,,276.24,,,,,,,2.15,276.24,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,63323040009,NDC,facility,inpatient,500,ME,172.80000,50.11000,Aetna,First Health,,141.35,,,,,,,62.29,141.35,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,63323040009,NDC,facility,outpatient,500,ME,172.80000,50.11000,Aetna,First Health,,141.35,,,,,,,0.03852,141.35,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,63323040005,NDC,facility,inpatient,500,ME,75.75000,21.97000,Aetna,First Health,,61.96,,,,,,,27.31,61.96,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,63323040005,NDC,facility,outpatient,500,ME,75.75000,21.97000,Aetna,First Health,,61.96,,,,,,,0.03852,61.96,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,63323039923,NDC,facility,inpatient,2,GM,76.25000,22.11000,Aetna,First Health,,62.37,,,,,,,27.49,62.37,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,63323039923,NDC,facility,outpatient,2,GM,76.25000,22.11000,Aetna,First Health,,62.37,,,,,,,0.56817,62.37,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,63323038910,NDC,facility,inpatient,1,GM,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,20.42,46.34,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,63323038910,NDC,facility,outpatient,1,GM,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,0.56817,46.34,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,63323038810,NDC,facility,inpatient,500,ME,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,8.51,19.30,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,63323038810,NDC,facility,outpatient,500,ME,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,0.56817,19.30,percent of total billed charges,
cefoTEtan 1g I(Cefotan),800070042,CDM,637,RC,63323038510,NDC,,,facility,inpatient,1,EA,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,138.60,188.96,percent of total billed charges,
cefoTEtan 1g I(Cefotan),800070042,CDM,637,RC,63323038510,NDC,,,facility,outpatient,1,EA,231.00000,66.99000,Aetna,First Health,,188.96,,,,,,,83.28,188.96,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,63323037704,NDC,facility,inpatient,0.5,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,45.96,62.66,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,63323037704,NDC,facility,outpatient,0.5,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,0.63558,62.66,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,63323037701,NDC,facility,inpatient,0.5,ME,298.60000,86.59000,Aetna,First Health,,244.25,,,,,,,179.16,244.25,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,63323037701,NDC,facility,outpatient,0.5,ME,298.60000,86.59000,Aetna,First Health,,244.25,,,,,,,0.63558,244.25,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,63323037601,NDC,facility,inpatient,0.1,ME,63.45000,18.40000,Aetna,First Health,,51.90,,,,,,,38.07,51.90,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,63323037601,NDC,facility,outpatient,0.1,ME,63.45000,18.40000,Aetna,First Health,,51.90,,,,,,,0.63558,51.90,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,63323037420,NDC,facility,inpatient,4,ME,19.45000,5.64000,Aetna,First Health,,15.91,,,,,,,7.01,15.91,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,63323037420,NDC,facility,outpatient,4,ME,19.45000,5.64000,Aetna,First Health,,15.91,,,,,,,0.08667,15.91,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,63323037302,NDC,facility,inpatient,4,ME,14.35000,4.16000,Aetna,First Health,,11.74,,,,,,,5.17,11.74,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,63323037302,NDC,facility,outpatient,4,ME,14.35000,4.16000,Aetna,First Health,,11.74,,,,,,,0.08667,11.74,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,63323037119,NDC,facility,inpatient,500,ME,3394.50000,984.40000,Aetna,First Health,,2776.70,,,,,,,1223.72,2776.70,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,63323037119,NDC,facility,outpatient,500,ME,3394.50000,984.40000,Aetna,First Health,,2776.70,,,,,,,0.02889,2776.70,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,63323036920,NDC,facility,inpatient,3,GM,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,26.68,60.53,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,63323036920,NDC,facility,outpatient,3,GM,74.00000,21.46000,Aetna,First Health,,60.53,,,,,,,1.28,60.53,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,63323036820,NDC,facility,inpatient,1.5,GM,37.35000,10.83000,Aetna,First Health,,30.55,,,,,,,13.46,30.55,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,63323036820,NDC,facility,outpatient,1.5,GM,37.35000,10.83000,Aetna,First Health,,30.55,,,,,,,1.28,30.55,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,63323036501,NDC,facility,inpatient,0.05,ME,32.30000,9.37000,Aetna,First Health,,26.42,,,,,,,19.38,26.42,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,63323036501,NDC,facility,outpatient,0.05,ME,32.30000,9.37000,Aetna,First Health,,26.42,,,,,,,0.63558,26.42,percent of total billed charges,
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,inpatient,1,GM,102.20000,29.64000,Aetna,First Health,,83.60,,,,,,,36.84,83.60,percent of total billed charges,
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,outpatient,1,GM,102.20000,29.64000,Aetna,First Health,,83.60,,,,,,,0.02889,83.60,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,63323035565,NDC,facility,inpatient,500,ME,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,43.26,98.16,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,63323035565,NDC,facility,outpatient,500,ME,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,2.08,98.16,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,63323035560,NDC,facility,inpatient,750,ME,124.80000,36.19000,Aetna,First Health,,102.09,,,,,,,44.99,102.09,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,63323035560,NDC,facility,outpatient,750,ME,124.80000,36.19000,Aetna,First Health,,102.09,,,,,,,2.08,102.09,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,63323034720,NDC,facility,inpatient,2,GM,49.80000,14.44000,Aetna,First Health,,40.74,,,,,,,17.95,40.74,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,63323034720,NDC,facility,outpatient,2,GM,49.80000,14.44000,Aetna,First Health,,40.74,,,,,,,0.44298,40.74,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,63323034610,NDC,facility,inpatient,1,GM,37.45000,10.86000,Aetna,First Health,,30.63,,,,,,,13.50,30.63,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,63323034610,NDC,facility,outpatient,1,GM,37.45000,10.86000,Aetna,First Health,,30.63,,,,,,,0.44298,30.63,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,63323034225,NDC,facility,inpatient,2,GM,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,48.31,109.61,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,63323034225,NDC,facility,outpatient,2,GM,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,4.56,109.61,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,63323034220,NDC,facility,inpatient,2,GM,122.40000,35.50000,Aetna,First Health,,100.12,,,,,,,44.13,100.12,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,63323034220,NDC,facility,outpatient,2,GM,122.40000,35.50000,Aetna,First Health,,100.12,,,,,,,4.56,100.12,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,63323034125,NDC,facility,inpatient,1,GM,67.10000,19.46000,Aetna,First Health,,54.89,,,,,,,24.19,54.89,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,63323034125,NDC,facility,outpatient,1,GM,67.10000,19.46000,Aetna,First Health,,54.89,,,,,,,4.56,54.89,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,63323034120,NDC,facility,inpatient,1,GM,89.80000,26.04000,Aetna,First Health,,73.46,,,,,,,32.37,73.46,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,63323034120,NDC,facility,outpatient,1,GM,89.80000,26.04000,Aetna,First Health,,73.46,,,,,,,4.56,73.46,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,63323034050,NDC,facility,inpatient,2,GM,303.55000,88.03000,Aetna,First Health,,248.30,,,,,,,109.43,248.30,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,63323034050,NDC,facility,outpatient,2,GM,303.55000,88.03000,Aetna,First Health,,248.30,,,,,,,0.83781,248.30,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,2,GM,104.05000,30.17000,Aetna,First Health,,85.11,,,,,,,37.51,85.11,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,outpatient,2,GM,104.05000,30.17000,Aetna,First Health,,85.11,,,,,,,0.83781,85.11,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,63323032820,NDC,facility,inpatient,2,GM,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,98.42,223.31,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,63323032820,NDC,facility,outpatient,2,GM,273.00000,79.17000,Aetna,First Health,,223.31,,,,,,,0.05778,223.31,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,63323032620,NDC,facility,inpatient,1,GM,55.70000,16.15000,Aetna,First Health,,45.56,,,,,,,20.08,45.56,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,63323032620,NDC,facility,outpatient,1,GM,55.70000,16.15000,Aetna,First Health,,45.56,,,,,,,0.83781,45.56,percent of total billed charges,
Acyclovir 50mg/mL Inj 20mL,800013250,CDM,636,RC,J0133,HCPCS,63323032520,NDC,facility,inpatient,1000,ME,328.00000,95.12000,Aetna,First Health,,268.30,,,,,,,118.24,268.30,percent of total billed charges,
Acyclovir 50mg/mL Inj 20mL,800013250,CDM,636,RC,J0133,HCPCS,63323032520,NDC,facility,outpatient,1000,ME,328.00000,95.12000,Aetna,First Health,,268.30,,,,,,,0.11556,268.30,percent of total billed charges,
Acyclovir 50mg/mL Inj 10mL,800020914,CDM,636,RC,J0133,HCPCS,63323032510,NDC,facility,inpatient,500,ME,180.50000,52.34000,Aetna,First Health,,147.65,,,,,,,65.07,147.65,percent of total billed charges,
Acyclovir 50mg/mL Inj 10mL,800020914,CDM,636,RC,J0133,HCPCS,63323032510,NDC,facility,outpatient,500,ME,180.50000,52.34000,Aetna,First Health,,147.65,,,,,,,0.11556,147.65,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,63323032050,NDC,facility,inpatient,4.5,GM,168.60000,48.89000,Aetna,First Health,,137.91,,,,,,,60.78,137.91,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,63323032050,NDC,facility,outpatient,4.5,GM,168.60000,48.89000,Aetna,First Health,,137.91,,,,,,,1.05,137.91,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,63323031468,NDC,facility,inpatient,1,GM,204.25000,59.23000,Aetna,First Health,,167.08,,,,,,,73.63,167.08,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,63323031468,NDC,facility,outpatient,1,GM,204.25000,59.23000,Aetna,First Health,,167.08,,,,,,,0.02889,167.08,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,63323031461,NDC,facility,inpatient,1,GM,204.25000,59.23000,Aetna,First Health,,167.08,,,,,,,73.63,167.08,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,63323031461,NDC,facility,outpatient,1,GM,204.25000,59.23000,Aetna,First Health,,167.08,,,,,,,0.02889,167.08,percent of total billed charges,
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,63323031119,NDC,facility,inpatient,1,GM,71.60000,20.76000,Aetna,First Health,,58.57,,,,,,,25.81,58.57,percent of total billed charges,
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,63323031119,NDC,facility,outpatient,1,GM,71.60000,20.76000,Aetna,First Health,,58.57,,,,,,,0.02889,58.57,percent of total billed charges,
NICU- Calcium Gluconate 0.465mEq/mL Inj,800017966,CDM,636,RC,J0612,HCPCS,63323031119,NDC,facility,inpatient,1,EA,71.60000,20.76000,Aetna,First Health,,58.57,,,,,,,25.81,58.57,percent of total billed charges,
NICU- Calcium Gluconate 0.465mEq/mL Inj,800017966,CDM,636,RC,J0612,HCPCS,63323031119,NDC,facility,outpatient,1,EA,71.60000,20.76000,Aetna,First Health,,58.57,,,,,,,0.02889,58.57,percent of total billed charges,
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,63323031110,NDC,facility,inpatient,1,GM,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,19.86,45.07,percent of total billed charges,
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,63323031110,NDC,facility,outpatient,1,GM,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,0.02889,45.07,percent of total billed charges,
NICU- Calcium Gluconate 0.465mEq/mL Inj,800017966,CDM,636,RC,J0612,HCPCS,63323031110,NDC,facility,inpatient,1,EA,26.10000,7.57000,Aetna,First Health,,21.35,,,,,,,9.41,21.35,percent of total billed charges,
NICU- Calcium Gluconate 0.465mEq/mL Inj,800017966,CDM,636,RC,J0612,HCPCS,63323031110,NDC,facility,outpatient,1,EA,26.10000,7.57000,Aetna,First Health,,21.35,,,,,,,0.02889,21.35,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,63323030920,NDC,facility,inpatient,2.25,GM,88.80000,25.75000,Aetna,First Health,,72.64,,,,,,,32.01,72.64,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,63323030920,NDC,facility,outpatient,2.25,GM,88.80000,25.75000,Aetna,First Health,,72.64,,,,,,,1.05,72.64,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,63323030602,NDC,facility,inpatient,80,ME,32.55000,9.44000,Aetna,First Health,,26.63,,,,,,,11.73,26.63,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,63323030602,NDC,facility,outpatient,80,ME,32.55000,9.44000,Aetna,First Health,,26.63,,,,,,,1.99,26.63,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,63323030351,NDC,,,facility,inpatient,1,EA,649.10000,188.24000,Aetna,First Health,,530.96,,,,,,,240.17,530.96,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,63323030351,NDC,,,facility,outpatient,1,EA,649.10000,188.24000,Aetna,First Health,,530.96,,,,,,,234.00,530.96,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,63323030201,NDC,facility,inpatient,20,UN,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,82.19,186.50,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,63323030201,NDC,facility,outpatient,20,UN,228.00000,66.12000,Aetna,First Health,,186.50,,,,,,,0.51039,186.50,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,63323030030,NDC,facility,inpatient,3.375,GM,133.15000,38.61000,Aetna,First Health,,108.92,,,,,,,48.00,108.92,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,63323030030,NDC,facility,outpatient,3.375,GM,133.15000,38.61000,Aetna,First Health,,108.92,,,,,,,1.05,108.92,percent of total billed charges,
Mepivacaine 2% PF I 20mL,800016887,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,inpatient,1,EA,78.90000,22.88000,Aetna,First Health,,64.54,,,,,,,28.44,64.54,percent of total billed charges,
Mepivacaine 2% PF I 20mL,800016887,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,outpatient,1,EA,78.90000,22.88000,Aetna,First Health,,64.54,,,,,,,3.61,64.54,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,63323029210,NDC,facility,inpatient,10,ME,103.10000,29.90000,Aetna,First Health,,84.34,,,,,,,37.17,84.34,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,63323029210,NDC,facility,outpatient,10,ME,103.10000,29.90000,Aetna,First Health,,84.34,,,,,,,13.00,84.34,percent of total billed charges,
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,63323029110,NDC,facility,inpatient,5,ME,101.55000,29.45000,Aetna,First Health,,83.07,,,,,,,36.61,83.07,percent of total billed charges,
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,63323029110,NDC,facility,outpatient,5,ME,101.55000,29.45000,Aetna,First Health,,83.07,,,,,,,13.00,83.07,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028695,NDC,facility,inpatient,150,ME,32.30000,9.37000,Aetna,First Health,,26.42,,,,,,,11.64,26.42,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028695,NDC,facility,outpatient,150,ME,32.30000,9.37000,Aetna,First Health,,26.42,,,,,,,0.04815,26.42,percent of total billed charges,
ROPivacaine 0.5% (5mg/1mL) I,800025669,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,inpatient,1,ME,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.28840,0.65440,percent of total billed charges,
ROPivacaine 0.5% (5mg/1mL) I,800025669,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,outpatient,1,ME,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.04815,0.65440,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028635,NDC,facility,inpatient,150,ME,144.60000,41.93000,Aetna,First Health,,118.28,,,,,,,52.13,118.28,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028635,NDC,facility,outpatient,150,ME,144.60000,41.93000,Aetna,First Health,,118.28,,,,,,,0.04815,118.28,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028631,NDC,facility,inpatient,150,ME,139.55000,40.47000,Aetna,First Health,,114.15,,,,,,,50.31,114.15,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028631,NDC,facility,outpatient,150,ME,139.55000,40.47000,Aetna,First Health,,114.15,,,,,,,0.04815,114.15,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028630,NDC,facility,inpatient,150,ME,139.55000,40.47000,Aetna,First Health,,114.15,,,,,,,50.31,114.15,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028630,NDC,facility,outpatient,150,ME,139.55000,40.47000,Aetna,First Health,,114.15,,,,,,,0.04815,114.15,percent of total billed charges,
ROPivacaine 0.5% 20mL I,800021331,CDM,636,RC,J2795,HCPCS,63323028623,NDC,facility,inpatient,100,ME,105.40000,30.57000,Aetna,First Health,,86.22,,,,,,,38.00,86.22,percent of total billed charges,
ROPivacaine 0.5% 20mL I,800021331,CDM,636,RC,J2795,HCPCS,63323028623,NDC,facility,outpatient,100,ME,105.40000,30.57000,Aetna,First Health,,86.22,,,,,,,0.04815,86.22,percent of total billed charges,
ROPivacaine 0.5% 20mL I,800021331,CDM,636,RC,J2795,HCPCS,63323028620,NDC,facility,inpatient,100,ME,92.45000,26.81000,Aetna,First Health,,75.62,,,,,,,33.33,75.62,percent of total billed charges,
ROPivacaine 0.5% 20mL I,800021331,CDM,636,RC,J2795,HCPCS,63323028620,NDC,facility,outpatient,100,ME,92.45000,26.81000,Aetna,First Health,,75.62,,,,,,,0.04815,75.62,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,63323028565,NDC,facility,inpatient,200,ME,405.35000,117.55000,Aetna,First Health,,331.58,,,,,,,146.13,331.58,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,63323028565,NDC,facility,outpatient,200,ME,405.35000,117.55000,Aetna,First Health,,331.58,,,,,,,0.04815,331.58,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,inpatient,200,ME,385.85000,111.90000,Aetna,First Health,,315.63,,,,,,,139.10,315.63,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,outpatient,200,ME,385.85000,111.90000,Aetna,First Health,,315.63,,,,,,,0.04815,315.63,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,63323028523,NDC,facility,inpatient,40,ME,70.50000,20.44000,Aetna,First Health,,57.67,,,,,,,25.42,57.67,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,63323028523,NDC,facility,outpatient,40,ME,70.50000,20.44000,Aetna,First Health,,57.67,,,,,,,0.04815,57.67,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,63323028520,NDC,facility,inpatient,40,ME,61.80000,17.92000,Aetna,First Health,,50.55,,,,,,,22.28,50.55,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,63323028520,NDC,facility,outpatient,40,ME,61.80000,17.92000,Aetna,First Health,,50.55,,,,,,,0.04815,50.55,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,63323028420,NDC,facility,inpatient,1,GM,152.65000,44.27000,Aetna,First Health,,124.87,,,,,,,55.03,124.87,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,63323028420,NDC,facility,outpatient,1,GM,152.65000,44.27000,Aetna,First Health,,124.87,,,,,,,0.02889,124.87,percent of total billed charges,
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,63323028204,NDC,facility,inpatient,600,ME,35.40000,10.27000,Aetna,First Health,,28.96,,,,,,,12.76,28.96,percent of total billed charges,
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,63323028204,NDC,facility,outpatient,600,ME,35.40000,10.27000,Aetna,First Health,,28.96,,,,,,,1.84,28.96,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,63323028010,NDC,facility,inpatient,100,ME,20.45000,5.93000,Aetna,First Health,,16.73,,,,,,,7.37,16.73,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,63323028010,NDC,facility,outpatient,100,ME,20.45000,5.93000,Aetna,First Health,,16.73,,,,,,,7.37,16.73,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,63323028004,NDC,facility,inpatient,40,ME,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,63323028004,NDC,facility,outpatient,40,ME,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,0.01926,14.64,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,63323028002,NDC,facility,inpatient,20,ME,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,63323028002,NDC,facility,outpatient,20,ME,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,0.01926,10.96,percent of total billed charges,
vinBLAStine 1mg/mL Inj,800025626,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,inpatient,1,ME,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,15.12,34.32,percent of total billed charges,
vinBLAStine 1mg/mL Inj,800025626,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,outpatient,1,ME,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,4.99,34.32,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,63323027301,NDC,facility,inpatient,6,ME,305.60000,88.62000,Aetna,First Health,,249.98,,,,,,,183.36,249.98,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,63323027301,NDC,facility,outpatient,6,ME,305.60000,88.62000,Aetna,First Health,,249.98,,,,,,,85.32,273.24,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323027065,NDC,facility,inpatient,1,GM,283.80000,82.30000,Aetna,First Health,,232.15,,,,,,,102.31,232.15,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323027065,NDC,facility,outpatient,1,GM,283.80000,82.30000,Aetna,First Health,,232.15,,,,,,,0.08667,232.15,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,63323027050,NDC,facility,inpatient,0.5,GM,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,51.48,116.81,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,63323027050,NDC,facility,outpatient,0.5,GM,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,0.08667,116.81,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323027025,NDC,facility,inpatient,200,ME,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,12.89,29.24,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323027025,NDC,facility,outpatient,200,ME,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,0.08667,29.24,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323027020,NDC,facility,inpatient,200,ME,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,12.89,29.24,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323027020,NDC,facility,outpatient,200,ME,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,0.08667,29.24,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323026969,NDC,facility,inpatient,1,GM,122.40000,35.50000,Aetna,First Health,,100.12,,,,,,,44.13,100.12,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323026969,NDC,facility,outpatient,1,GM,122.40000,35.50000,Aetna,First Health,,100.12,,,,,,,0.08667,100.12,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,inpatient,1,GM,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,113.56,257.67,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,outpatient,1,GM,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,0.08667,257.67,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323026965,NDC,facility,inpatient,1,GM,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,113.56,257.67,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323026965,NDC,facility,outpatient,1,GM,315.00000,91.35000,Aetna,First Health,,257.67,,,,,,,0.08667,257.67,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,63323026957,NDC,facility,inpatient,0.5,GM,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,51.48,116.81,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,63323026957,NDC,facility,outpatient,0.5,GM,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,0.08667,116.81,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,63323026950,NDC,facility,inpatient,0.5,GM,159.40000,46.23000,Aetna,First Health,,130.39,,,,,,,57.46,130.39,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,63323026950,NDC,facility,outpatient,0.5,GM,159.40000,46.23000,Aetna,First Health,,130.39,,,,,,,0.08667,130.39,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,inpatient,200,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,outpatient,200,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,0.08667,31.33,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323026929,NDC,facility,inpatient,200,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323026929,NDC,facility,outpatient,200,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,0.08667,31.33,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323026920,NDC,facility,inpatient,200,ME,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,14.38,32.64,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323026920,NDC,facility,outpatient,200,ME,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,0.08667,32.64,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,63323026530,NDC,facility,inpatient,1,GM,321.00000,93.09000,Aetna,First Health,,262.58,,,,,,,115.72,262.58,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,63323026530,NDC,facility,outpatient,1,GM,321.00000,93.09000,Aetna,First Health,,262.58,,,,,,,0.25038,262.58,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,63323026255,NDC,facility,inpatient,5000,UN,27.65000,8.02000,Aetna,First Health,,22.62,,,,,,,13.00,22.62,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,63323026255,NDC,facility,outpatient,5000,UN,27.65000,8.02000,Aetna,First Health,,22.62,,,,,,,0.17334,22.62,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,63323026226,NDC,facility,inpatient,5000,UN,6.20000,1.80000,Aetna,First Health,,5.07,,,,,,,2.91,5.07,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,63323026226,NDC,facility,outpatient,5000,UN,6.20000,1.80000,Aetna,First Health,,5.07,,,,,,,0.17334,5.07,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,63323026206,NDC,facility,inpatient,5000,UN,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,12.48,21.72,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,63323026206,NDC,facility,outpatient,5000,UN,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,0.17334,21.72,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,63323026201,NDC,facility,inpatient,5000,UN,27.65000,8.02000,Aetna,First Health,,22.62,,,,,,,13.00,22.62,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,63323026201,NDC,facility,outpatient,5000,UN,27.65000,8.02000,Aetna,First Health,,22.62,,,,,,,0.17334,22.62,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,63323025930,NDC,,,facility,inpatient,1,EA,16.45000,4.77000,Aetna,First Health,,13.46,,,,,,,6.09,13.46,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,63323025930,NDC,,,facility,outpatient,1,EA,16.45000,4.77000,Aetna,First Health,,13.46,,,,,,,5.93,13.46,percent of total billed charges,
Mineral Oil Light 10mL(Muri-Lube),800035815,CDM,250,RC,63323025410,NDC,,,facility,inpatient,1,EA,194.85000,56.51000,Aetna,First Health,,159.39,,,,,,,72.09,159.39,percent of total billed charges,
Mineral Oil Light 10mL(Muri-Lube),800035815,CDM,250,RC,63323025410,NDC,,,facility,outpatient,1,EA,194.85000,56.51000,Aetna,First Health,,159.39,,,,,,,70.24,159.39,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,63323023861,NDC,facility,inpatient,2,GM,346.30000,100.43000,Aetna,First Health,,283.27,,,,,,,124.84,283.27,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,63323023861,NDC,facility,outpatient,2,GM,346.30000,100.43000,Aetna,First Health,,283.27,,,,,,,0.79929,283.27,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,inpatient,1000,ME,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,5.50,12.47,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,outpatient,1000,ME,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,0.79929,12.47,percent of total billed charges,
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,63323022994,NDC,facility,inpatient,50,ME,86.40000,25.06000,Aetna,First Health,,70.68,,,,,,,31.15,70.68,percent of total billed charges,
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,63323022994,NDC,facility,outpatient,50,ME,86.40000,25.06000,Aetna,First Health,,70.68,,,,,,,1.51,70.68,percent of total billed charges,
Protamine Sulfate 250mg/25mL Inj,800013349,CDM,636,RC,J2720,HCPCS,63323022935,NDC,facility,inpatient,250,ME,309.80000,89.84000,Aetna,First Health,,253.42,,,,,,,111.68,253.42,percent of total billed charges,
Protamine Sulfate 250mg/25mL Inj,800013349,CDM,636,RC,J2720,HCPCS,63323022935,NDC,facility,outpatient,250,ME,309.80000,89.84000,Aetna,First Health,,253.42,,,,,,,1.51,253.42,percent of total billed charges,
Protamine Sulfate 250mg/25mL Inj,800013349,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,inpatient,250,ME,482.45000,139.91000,Aetna,First Health,,394.64,,,,,,,173.92,394.64,percent of total billed charges,
Protamine Sulfate 250mg/25mL Inj,800013349,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,outpatient,250,ME,482.45000,139.91000,Aetna,First Health,,394.64,,,,,,,1.51,394.64,percent of total billed charges,
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,63323022915,NDC,facility,inpatient,50,ME,86.40000,25.06000,Aetna,First Health,,70.68,,,,,,,31.15,70.68,percent of total billed charges,
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,63323022915,NDC,facility,outpatient,50,ME,86.40000,25.06000,Aetna,First Health,,70.68,,,,,,,1.51,70.68,percent of total billed charges,
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,inpatient,50,ME,148.60000,43.09000,Aetna,First Health,,121.55,,,,,,,53.57,121.55,percent of total billed charges,
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,outpatient,50,ME,148.60000,43.09000,Aetna,First Health,,121.55,,,,,,,1.51,121.55,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,63323022110,NDC,facility,inpatient,500,ME,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,24.23,54.97,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,63323022110,NDC,facility,outpatient,500,ME,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,0.02889,54.97,percent of total billed charges,
Lidocaine HCl 1% 10mL Inj,800040882,CDM,636,RC,63323020110,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
Lidocaine HCl 1% 10mL Inj,800040882,CDM,636,RC,63323020110,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
Sodium Chloride 23.4% Inj 30mL,800017960,CDM,250,RC,63323018730,NDC,,,facility,inpatient,1,EA,45.80000,13.28000,Aetna,First Health,,37.46,,,,,,,16.95,37.46,percent of total billed charges,
Sodium Chloride 23.4% Inj 30mL,800017960,CDM,250,RC,63323018730,NDC,,,facility,outpatient,1,EA,45.80000,13.28000,Aetna,First Health,,37.46,,,,,,,16.51,37.46,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,63323018610,NDC,,,facility,inpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,3.48,6.05,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,63323018610,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,2.67,6.05,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,63323018550,NDC,facility,inpatient,1,EA,54.05000,15.67000,Aetna,First Health,,44.21,,,,,,,25.40,44.21,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,63323018550,NDC,facility,outpatient,1,EA,54.05000,15.67000,Aetna,First Health,,44.21,,,,,,,0.63000,44.21,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,63323018510,NDC,facility,inpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,14.99,26.09,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,63323018510,NDC,facility,outpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,0.63000,26.09,percent of total billed charges,
Folic Acid 5mg/mL I,800061852,CDM,250,RC,J1808,HCPCS,63323018411,NDC,facility,inpatient,50,ME,271.30000,78.68000,Aetna,First Health,,221.92,,,,,,,100.38,221.92,percent of total billed charges,
Folic Acid 5mg/mL I,800061852,CDM,250,RC,J1808,HCPCS,63323018411,NDC,facility,outpatient,50,ME,271.30000,78.68000,Aetna,First Health,,221.92,,,,,,,0.04815,221.92,percent of total billed charges,
Folic Acid 5mg/mL I,800061852,CDM,250,RC,J1808,HCPCS,63323018410,NDC,facility,inpatient,50,ME,615.30000,178.44000,Aetna,First Health,,503.32,,,,,,,227.66,503.32,percent of total billed charges,
Folic Acid 5mg/mL I,800061852,CDM,250,RC,J1808,HCPCS,63323018410,NDC,facility,outpatient,50,ME,615.30000,178.44000,Aetna,First Health,,503.32,,,,,,,0.04815,503.32,percent of total billed charges,
Pyridoxine HCl 100mg/mL 1mL I(Vit B6),800056795,CDM,636,RC,J3415,HCPCS,63323018001,NDC,facility,inpatient,100,ME,139.70000,40.51000,Aetna,First Health,,114.27,,,,,,,50.36,114.27,percent of total billed charges,
Pyridoxine HCl 100mg/mL 1mL I(Vit B6),800056795,CDM,636,RC,J3415,HCPCS,63323018001,NDC,facility,outpatient,100,ME,139.70000,40.51000,Aetna,First Health,,114.27,,,,,,,14.98,114.27,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,63323017215,NDC,facility,inpatient,50,ME,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,25.31,57.42,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,63323017215,NDC,facility,outpatient,50,ME,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,2.82,57.42,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,63323017015,NDC,,,facility,inpatient,1,EA,331.90000,96.25000,Aetna,First Health,,271.49,,,,,,,122.80,271.49,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,63323017015,NDC,,,facility,outpatient,1,EA,331.90000,96.25000,Aetna,First Health,,271.49,,,,,,,119.65,271.49,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,63323016530,NDC,facility,inpatient,1,ME,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,63323016530,NDC,facility,outpatient,1,ME,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.10593,0.94070,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,63323016505,NDC,facility,inpatient,4,ME,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,63323016505,NDC,facility,outpatient,4,ME,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,0.10593,2.70,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,63323016505,NDC,facility,inpatient,1,ME,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,63323016505,NDC,facility,outpatient,1,ME,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,0.10593,2.70,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,63323016505,NDC,facility,inpatient,4,ME,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,5.37,7.32,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,63323016505,NDC,facility,outpatient,4,ME,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,0.00963,7.32,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,inpatient,4,ME,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,6.63,15.05,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,outpatient,4,ME,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,0.10593,15.05,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,63323016212,NDC,facility,inpatient,30,ME,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,63323016212,NDC,facility,outpatient,30,ME,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,0.31779,3.64,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,63323016201,NDC,facility,inpatient,30,ME,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,13.12,29.78,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,63323016201,NDC,facility,outpatient,30,ME,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,0.31779,29.78,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,inpatient,15,ME,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,outpatient,15,ME,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,0.31779,3.68,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,63323016101,NDC,facility,inpatient,15,ME,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.63,19.59,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,63323016101,NDC,facility,outpatient,15,ME,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,0.31779,19.59,percent of total billed charges,
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,63323014212,NDC,facility,inpatient,1000,ME,525.60000,152.42000,Aetna,First Health,,429.94,,,,,,,189.48,429.94,percent of total billed charges,
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,63323014212,NDC,facility,outpatient,1000,ME,525.60000,152.42000,Aetna,First Health,,429.94,,,,,,,23.92,429.94,percent of total billed charges,
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,63323014210,NDC,facility,inpatient,1000,ME,525.60000,152.42000,Aetna,First Health,,429.94,,,,,,,189.48,429.94,percent of total billed charges,
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,63323014210,NDC,facility,outpatient,1000,ME,525.60000,152.42000,Aetna,First Health,,429.94,,,,,,,23.92,429.94,percent of total billed charges,
Cladribine 10mg/10mL I(Leustatin),800022003,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,inpatient,10,ME,3319.00000,962.51000,Aetna,First Health,,2714.94,,,,,,,1196.50,2714.94,percent of total billed charges,
Cladribine 10mg/10mL I(Leustatin),800022003,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,outpatient,10,ME,3319.00000,962.51000,Aetna,First Health,,2714.94,,,,,,,7.15,2714.94,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,63323013017,NDC,facility,inpatient,100,ME,166.35000,48.24000,Aetna,First Health,,136.07,,,,,,,61.55,136.07,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,63323013017,NDC,facility,outpatient,100,ME,166.35000,48.24000,Aetna,First Health,,136.07,,,,,,,0.09630,136.07,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,63323013013,NDC,facility,inpatient,100,ME,166.30000,48.23000,Aetna,First Health,,136.03,,,,,,,61.53,136.03,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,63323013013,NDC,facility,outpatient,100,ME,166.30000,48.23000,Aetna,First Health,,136.03,,,,,,,0.09630,136.03,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,63323013011,NDC,facility,inpatient,100,ME,230.45000,66.83000,Aetna,First Health,,188.51,,,,,,,85.27,188.51,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,63323013011,NDC,facility,outpatient,100,ME,230.45000,66.83000,Aetna,First Health,,188.51,,,,,,,0.09630,188.51,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,63323013010,NDC,facility,inpatient,100,ME,118.00000,34.22000,Aetna,First Health,,96.52,,,,,,,43.66,96.52,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,63323013010,NDC,facility,outpatient,100,ME,118.00000,34.22000,Aetna,First Health,,96.52,,,,,,,0.09630,96.52,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,63323012550,NDC,facility,inpatient,1000,ME,987.00000,286.23000,Aetna,First Health,,807.37,,,,,,,355.81,807.37,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,63323012550,NDC,facility,outpatient,1000,ME,987.00000,286.23000,Aetna,First Health,,807.37,,,,,,,3.46,807.37,percent of total billed charges,
"Heparin 5,000 unit/0.5mL Inj Syr",800051113,CDM,258,RC,J1644,HCPCS,63323011805,NDC,facility,inpatient,5000,UN,19.80000,5.74000,Aetna,First Health,,16.20,,,,,,,9.31,16.20,percent of total billed charges,
"Heparin 5,000 unit/0.5mL Inj Syr",800051113,CDM,258,RC,J1644,HCPCS,63323011805,NDC,facility,outpatient,5000,UN,19.80000,5.74000,Aetna,First Health,,16.20,,,,,,,0.17334,16.20,percent of total billed charges,
Fluorouracil 2.5g/50mL Inj,800046552,CDM,636,RC,J9190,HCPCS,63323011759,NDC,facility,inpatient,2500,ME,89.40000,25.93000,Aetna,First Health,,73.13,,,,,,,32.23,73.13,percent of total billed charges,
Fluorouracil 2.5g/50mL Inj,800046552,CDM,636,RC,J9190,HCPCS,63323011759,NDC,facility,outpatient,2500,ME,89.40000,25.93000,Aetna,First Health,,73.13,,,,,,,1.87,73.13,percent of total billed charges,
Fluorouracil 2.5g/50mL Inj,800046552,CDM,636,RC,J9190,HCPCS,63323011751,NDC,facility,inpatient,2500,ME,140.65000,40.79000,Aetna,First Health,,115.05,,,,,,,50.70,115.05,percent of total billed charges,
Fluorouracil 2.5g/50mL Inj,800046552,CDM,636,RC,J9190,HCPCS,63323011751,NDC,facility,outpatient,2500,ME,140.65000,40.79000,Aetna,First Health,,115.05,,,,,,,1.87,115.05,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,63323011719,NDC,facility,inpatient,500,ME,26.40000,7.66000,Aetna,First Health,,21.60,,,,,,,9.52,21.60,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,63323011719,NDC,facility,outpatient,500,ME,26.40000,7.66000,Aetna,First Health,,21.60,,,,,,,1.87,21.60,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,500,ME,32.85000,9.53000,Aetna,First Health,,26.87,,,,,,,11.84,26.87,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,outpatient,500,ME,32.85000,9.53000,Aetna,First Health,,26.87,,,,,,,1.87,26.87,percent of total billed charges,
Mag Sulfate 40g/Water 1000mL,800040853,CDM,636,RC,J3475,HCPCS,63323010610,NDC,facility,inpatient,40,GM,1010.30000,292.99000,Aetna,First Health,,826.43,,,,,,,364.21,826.43,percent of total billed charges,
Mag Sulfate 40g/Water 1000mL,800040853,CDM,636,RC,J3475,HCPCS,63323010610,NDC,facility,outpatient,40,GM,1010.30000,292.99000,Aetna,First Health,,826.43,,,,,,,0.39483,826.43,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,inpatient,2,GM,130.85000,37.95000,Aetna,First Health,,107.04,,,,,,,47.17,107.04,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,outpatient,2,GM,130.85000,37.95000,Aetna,First Health,,107.04,,,,,,,0.39483,107.04,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,63323010601,NDC,facility,inpatient,4,GM,81.10000,23.52000,Aetna,First Health,,66.34,,,,,,,29.24,66.34,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,63323010601,NDC,facility,outpatient,4,GM,81.10000,23.52000,Aetna,First Health,,66.34,,,,,,,0.39483,66.34,percent of total billed charges,
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,63323010364,NDC,facility,inpatient,10,ME,39.50000,11.46000,Aetna,First Health,,32.31,,,,,,,14.24,32.31,percent of total billed charges,
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,63323010364,NDC,facility,outpatient,10,ME,39.50000,11.46000,Aetna,First Health,,32.31,,,,,,,2.03,32.31,percent of total billed charges,
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,63323010351,NDC,facility,inpatient,10,ME,39.50000,11.46000,Aetna,First Health,,32.31,,,,,,,14.24,32.31,percent of total billed charges,
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,63323010351,NDC,facility,outpatient,10,ME,39.50000,11.46000,Aetna,First Health,,32.31,,,,,,,2.03,32.31,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,63323010210,NDC,facility,inpatient,200,ME,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,82.55,187.32,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,63323010210,NDC,facility,outpatient,200,ME,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,3.46,187.32,percent of total billed charges,
Sodium Chloride 23.4% Inj 30mL,800017960,CDM,250,RC,63323009330,NDC,,,facility,inpatient,1,EA,78.05000,22.63000,Aetna,First Health,,63.84,,,,,,,28.88,63.84,percent of total billed charges,
Sodium Chloride 23.4% Inj 30mL,800017960,CDM,250,RC,63323009330,NDC,,,facility,outpatient,1,EA,78.05000,22.63000,Aetna,First Health,,63.84,,,,,,,28.14,63.84,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,63323008950,NDC,,,facility,inpatient,1,EA,253.45000,73.50000,Aetna,First Health,,207.32,,,,,,,93.78,207.32,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,63323008950,NDC,,,facility,outpatient,1,EA,253.45000,73.50000,Aetna,First Health,,207.32,,,,,,,91.37,207.32,percent of total billed charges,
Potassium Phosphate Inj 5mL,800022009,CDM,250,RC,63323008605,NDC,,,facility,inpatient,1,EA,94.55000,27.42000,Aetna,First Health,,77.34,,,,,,,34.98,77.34,percent of total billed charges,
Potassium Phosphate Inj 5mL,800022009,CDM,250,RC,63323008605,NDC,,,facility,outpatient,1,EA,94.55000,27.42000,Aetna,First Health,,77.34,,,,,,,34.09,77.34,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,63323008305,NDC,,,facility,inpatient,1,EA,224.75000,65.18000,Aetna,First Health,,183.85,,,,,,,83.16,183.85,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,63323008305,NDC,,,facility,outpatient,1,EA,224.75000,65.18000,Aetna,First Health,,183.85,,,,,,,81.02,183.85,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,63323006420,NDC,facility,inpatient,10,GM,73.35000,21.27000,Aetna,First Health,,60.00,,,,,,,26.44,60.00,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,63323006420,NDC,facility,outpatient,10,GM,73.35000,21.27000,Aetna,First Health,,60.00,,,,,,,0.39483,60.00,percent of total billed charges,
Magnesium Sulf 50% I 10mL,800020916,CDM,636,RC,J3475,HCPCS,63323006411,NDC,facility,inpatient,5,GM,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,10.36,23.52,percent of total billed charges,
Magnesium Sulf 50% I 10mL,800020916,CDM,636,RC,J3475,HCPCS,63323006411,NDC,facility,outpatient,5,GM,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,0.39483,23.52,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,63323006410,NDC,facility,inpatient,10,GM,35.30000,10.24000,Aetna,First Health,,28.88,,,,,,,12.73,28.88,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,63323006410,NDC,facility,outpatient,10,GM,35.30000,10.24000,Aetna,First Health,,28.88,,,,,,,0.39483,28.88,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,63323004401,NDC,facility,inpatient,1,ME,44.10000,12.79000,Aetna,First Health,,36.07,,,,,,,15.90,36.07,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,63323004401,NDC,facility,outpatient,1,ME,44.10000,12.79000,Aetna,First Health,,36.07,,,,,,,0.61632,36.07,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,63323002605,NDC,,,facility,inpatient,1,EA,24.50000,7.10000,Aetna,First Health,,20.04,,,,,,,9.06,20.04,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,63323002605,NDC,,,facility,outpatient,1,EA,24.50000,7.10000,Aetna,First Health,,20.04,,,,,,,8.83,20.04,percent of total billed charges,
Mannitol 25% I 50mL,800050889,CDM,636,RC,J2150,HCPCS,63323002425,NDC,facility,inpatient,12.5,GM,38.70000,11.22000,Aetna,First Health,,31.66,,,,,,,13.95,31.66,percent of total billed charges,
Mannitol 25% I 50mL,800050889,CDM,636,RC,J2150,HCPCS,63323002425,NDC,facility,outpatient,12.5,GM,38.70000,11.22000,Aetna,First Health,,31.66,,,,,,,13.95,31.66,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,63323001710,NDC,facility,inpatient,30,UN,15.20000,4.41000,Aetna,First Health,,12.43,,,,,,,7.14,12.43,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,63323001710,NDC,facility,outpatient,30,UN,15.20000,4.41000,Aetna,First Health,,12.43,,,,,,,0.01926,12.43,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,63323001309,NDC,facility,inpatient,200,ME,27.55000,7.99000,Aetna,First Health,,22.54,,,,,,,9.93,22.54,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,63323001309,NDC,facility,outpatient,200,ME,27.55000,7.99000,Aetna,First Health,,22.54,,,,,,,1.74,22.54,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,63323001302,NDC,facility,inpatient,200,ME,63.50000,18.42000,Aetna,First Health,,51.94,,,,,,,22.89,51.94,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,63323001302,NDC,facility,outpatient,200,ME,63.50000,18.42000,Aetna,First Health,,51.94,,,,,,,1.74,51.94,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001212,NDC,facility,inpatient,10,UN,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001212,NDC,facility,outpatient,10,UN,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,1.00,7.77,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001211,NDC,facility,inpatient,10,UN,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,7.93,18.00,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001211,NDC,facility,outpatient,10,UN,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,1.00,18.00,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001207,NDC,facility,inpatient,10,UN,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001207,NDC,facility,outpatient,10,UN,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,1.00,7.85,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001201,NDC,facility,inpatient,10,UN,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001201,NDC,facility,outpatient,10,UN,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,1.00,7.77,percent of total billed charges,
Gentamicin Sulf Mdv I,800015120,CDM,636,RC,J1580,HCPCS,63323001096,NDC,facility,inpatient,800,ME,155.50000,45.10000,Aetna,First Health,,127.20,,,,,,,56.06,127.20,percent of total billed charges,
Gentamicin Sulf Mdv I,800015120,CDM,636,RC,J1580,HCPCS,63323001096,NDC,facility,outpatient,800,ME,155.50000,45.10000,Aetna,First Health,,127.20,,,,,,,2.09,127.20,percent of total billed charges,
Gentamicin Sulf Mdv I,800015120,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,800,ME,312.80000,90.71000,Aetna,First Health,,255.87,,,,,,,112.76,255.87,percent of total billed charges,
Gentamicin Sulf Mdv I,800015120,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,outpatient,800,ME,312.80000,90.71000,Aetna,First Health,,255.87,,,,,,,2.09,255.87,percent of total billed charges,
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,inpatient,80,ME,44.55000,12.92000,Aetna,First Health,,36.44,,,,,,,16.06,36.44,percent of total billed charges,
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,outpatient,80,ME,44.55000,12.92000,Aetna,First Health,,36.44,,,,,,,2.09,36.44,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,63304097904,NDC,,,facility,inpatient,1,EA,24.40000,7.08000,Aetna,First Health,,19.96,,,,,,,14.64,19.96,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,63304097904,NDC,,,facility,outpatient,1,EA,24.40000,7.08000,Aetna,First Health,,19.96,,,,,,,8.80,19.96,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,63304095901,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,4.02,5.48,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,63304095901,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,63304094110,NDC,facility,inpatient,2,GM,287.05000,83.24000,Aetna,First Health,,234.81,,,,,,,103.48,234.81,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,63304094110,NDC,facility,outpatient,2,GM,287.05000,83.24000,Aetna,First Health,,234.81,,,,,,,0.79929,234.81,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,63304090430,NDC,,,facility,inpatient,1,EA,51.15000,14.83000,Aetna,First Health,,41.84,,,,,,,30.69,41.84,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,63304090430,NDC,,,facility,outpatient,1,EA,51.15000,14.83000,Aetna,First Health,,41.84,,,,,,,18.44,41.84,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,63304083701,NDC,,,facility,inpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,6.48,8.83,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,63304083701,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,3.89,8.83,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,63304083501,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,63304083501,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,63304082990,NDC,,,facility,inpatient,1,EA,40.90000,11.86000,Aetna,First Health,,33.46,,,,,,,24.54,33.46,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,63304082990,NDC,,,facility,outpatient,1,EA,40.90000,11.86000,Aetna,First Health,,33.46,,,,,,,14.74,33.46,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,63304082890,NDC,,,facility,inpatient,1,EA,40.90000,11.86000,Aetna,First Health,,33.46,,,,,,,24.54,33.46,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,63304082890,NDC,,,facility,outpatient,1,EA,40.90000,11.86000,Aetna,First Health,,33.46,,,,,,,14.74,33.46,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,63304082790,NDC,,,facility,inpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,17.19,23.44,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,63304082790,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,10.33,23.44,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,63304075160,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,63304075160,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,63304072660,NDC,,,facility,inpatient,1,EA,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,19.20,26.18,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,63304072660,NDC,,,facility,outpatient,1,EA,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,11.54,26.18,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,63304071320,NDC,,,facility,inpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,16.08,21.92,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,63304071320,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,9.66,21.92,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,63304069401,NDC,,,facility,inpatient,1,EA,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,7.23,9.86,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,63304069401,NDC,,,facility,outpatient,1,EA,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,4.34,9.86,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,63304069201,NDC,,,facility,inpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,5.07,6.91,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,63304069201,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,3.05,6.91,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,63304065601,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,63304065601,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,63304062501,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,63304062501,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,63304062401,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,63304062401,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,63304062201,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,63304062201,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,63304062101,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,63304062101,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,63304059690,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,13.89,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,63304059690,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,63304057901,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,63304057901,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,63304054001,NDC,,,facility,inpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,2.58,3.52,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,63304054001,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,1.55,3.52,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,63304053901,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,63304053901,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,63304050920,NDC,,,facility,inpatient,1,EA,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,21.45,29.24,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,63304050920,NDC,,,facility,outpatient,1,EA,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,12.89,29.24,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,63304050901,NDC,,,facility,inpatient,1,EA,35.45000,10.28000,Aetna,First Health,,29.00,,,,,,,21.27,29.00,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,63304050901,NDC,,,facility,outpatient,1,EA,35.45000,10.28000,Aetna,First Health,,29.00,,,,,,,12.78,29.00,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,63304048901,NDC,,,facility,inpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,63304048901,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,63304045830,NDC,facility,inpatient,4,ME,175.45000,50.88000,Aetna,First Health,,143.52,,,,,,,63.25,143.52,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,63304045830,NDC,facility,outpatient,4,ME,175.45000,50.88000,Aetna,First Health,,143.52,,,,,,,0.00963,143.52,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,63304043601,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,63304043601,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,63304029601,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,63304029601,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),800075274,CDM,637,RC,63304020518,NDC,,,facility,inpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,5.28,7.20,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),800075274,CDM,637,RC,63304020518,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,3.17,7.20,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,63304020302,NDC,,,facility,inpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,4.32,5.89,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,63304020302,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,63304020301,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,63304020301,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,63304016601,NDC,,,facility,inpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,12.12,16.52,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,63304016601,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,63304016501,NDC,,,facility,inpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,12.12,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,63304016501,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,7.28,16.52,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,63304009919,NDC,,,facility,inpatient,1,EA,180.40000,52.32000,Aetna,First Health,,147.57,,,,,,,108.24,147.57,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,63304009919,NDC,,,facility,outpatient,1,EA,180.40000,52.32000,Aetna,First Health,,147.57,,,,,,,65.03,147.57,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,63304009719,NDC,,,facility,inpatient,1,EA,200.90000,58.26000,Aetna,First Health,,164.34,,,,,,,120.54,164.34,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,63304009719,NDC,,,facility,outpatient,1,EA,200.90000,58.26000,Aetna,First Health,,164.34,,,,,,,72.42,164.34,percent of total billed charges,
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,63261025021,NDC,facility,inpatient,50,ME,2717.20000,787.99000,Aetna,First Health,,2222.67,,,,,,,979.55,2222.67,percent of total billed charges,
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,63261025021,NDC,facility,outpatient,50,ME,2717.20000,787.99000,Aetna,First Health,,2222.67,,,,,,,5.42,2222.67,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,63044062201,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,63044062201,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
fentaNYL 10mcg/mL /NS PCA 100mL,800019907,CDM,636,RC,J3010,HCPCS,63037010005,NDC,facility,inpatient,1,ME,328.00000,95.12000,Aetna,First Health,,268.30,,,,,,,118.24,268.30,percent of total billed charges,
fentaNYL 10mcg/mL /NS PCA 100mL,800019907,CDM,636,RC,J3010,HCPCS,63037010005,NDC,facility,outpatient,1,ME,328.00000,95.12000,Aetna,First Health,,268.30,,,,,,,1.15,268.30,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,3.5,ME,8843.20000,2564.53000,Aetna,First Health,,7233.74,,,,,,,3187.97,7233.74,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,outpatient,3.5,ME,8843.20000,2564.53000,Aetna,First Health,,7233.74,,,,,,,2.58,7233.74,percent of total billed charges,
leuprolide 22.5mg/3 month(Eligard),800046491,CDM,636,RC,J9217,HCPCS,62935022710,NDC,facility,inpatient,22.5,ME,5588.60000,1620.69000,Aetna,First Health,,4571.47,,,,,,,2014.69,4571.47,percent of total billed charges,
leuprolide 22.5mg/3 month(Eligard),800046491,CDM,636,RC,J9217,HCPCS,62935022710,NDC,facility,outpatient,22.5,ME,5588.60000,1620.69000,Aetna,First Health,,4571.47,,,,,,,164.46,4571.47,percent of total billed charges,
leuprolide 22.5mg/3 month(Eligard),800046491,CDM,636,RC,J9217,HCPCS,62935022305,NDC,facility,inpatient,22.5,ME,5588.60000,1620.69000,Aetna,First Health,,4571.47,,,,,,,2014.69,4571.47,percent of total billed charges,
leuprolide 22.5mg/3 month(Eligard),800046491,CDM,636,RC,J9217,HCPCS,62935022305,NDC,facility,outpatient,22.5,ME,5588.60000,1620.69000,Aetna,First Health,,4571.47,,,,,,,164.46,4571.47,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,62856079701,NDC,facility,inpatient,0.25,ME,986.80000,286.17000,Aetna,First Health,,807.20,,,,,,,355.74,807.20,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,62856079701,NDC,facility,outpatient,0.25,ME,986.80000,286.17000,Aetna,First Health,,807.20,,,,,,,0.33705,807.20,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,62856068010,NDC,,,facility,inpatient,1,EA,63.60000,18.44000,Aetna,First Health,,52.02,,,,,,,38.16,52.02,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,62856068010,NDC,,,facility,outpatient,1,EA,63.60000,18.44000,Aetna,First Health,,52.02,,,,,,,22.93,52.02,percent of total billed charges,
Donepezil 23mg T (Aricept),800072470,CDM,637,RC,62856024730,NDC,,,facility,inpatient,1,EA,116.45000,33.77000,Aetna,First Health,,95.26,,,,,,,69.87,95.26,percent of total billed charges,
Donepezil 23mg T (Aricept),800072470,CDM,637,RC,62856024730,NDC,,,facility,outpatient,1,EA,116.45000,33.77000,Aetna,First Health,,95.26,,,,,,,41.98,95.26,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,62856024590,NDC,,,facility,inpatient,1,EA,143.35000,41.57000,Aetna,First Health,,117.26,,,,,,,86.01,117.26,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,62856024590,NDC,,,facility,outpatient,1,EA,143.35000,41.57000,Aetna,First Health,,117.26,,,,,,,51.68,117.26,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,62856024541,NDC,,,facility,inpatient,1,EA,130.40000,37.82000,Aetna,First Health,,106.67,,,,,,,78.24,106.67,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,62856024541,NDC,,,facility,outpatient,1,EA,130.40000,37.82000,Aetna,First Health,,106.67,,,,,,,47.01,106.67,percent of total billed charges,
Lecanemab-irmb 500mg- Pt Own Supply,800051061,CDM,636,RC,J0174,HCPCS,62856021501,NDC,facility,inpatient,500,ME,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Lecanemab-irmb 500mg- Pt Own Supply,800051061,CDM,636,RC,J0174,HCPCS,62856021501,NDC,facility,outpatient,500,ME,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,4.10,percent of total billed charges,
Lecanemab - irmb 500mg Inj,800046571,CDM,636,RC,J0174,HCPCS,62856021501,NDC,facility,inpatient,500,ME,4842.60000,1404.35000,Aetna,First Health,,3961.25,,,,,,,1745.76,3961.25,percent of total billed charges,
Lecanemab - irmb 500mg Inj,800046571,CDM,636,RC,J0174,HCPCS,62856021501,NDC,facility,outpatient,500,ME,4842.60000,1404.35000,Aetna,First Health,,3961.25,,,,,,,1.28,3961.25,percent of total billed charges,
Lecanemab - irmb 200mg Inj,800046572,CDM,636,RC,J0174,HCPCS,62856021201,NDC,facility,inpatient,200,ME,2049.20000,594.27000,Aetna,First Health,,1676.25,,,,,,,738.74,1676.25,percent of total billed charges,
Lecanemab - irmb 200mg Inj,800046572,CDM,636,RC,J0174,HCPCS,62856021201,NDC,facility,outpatient,200,ME,2049.20000,594.27000,Aetna,First Health,,1676.25,,,,,,,1.28,1676.25,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,62794014510,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,62794014510,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,62756095501,NDC,,,facility,inpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,10.77,14.68,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,62756095501,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,6.47,14.68,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,62756082640,NDC,facility,inpatient,50,ME,254.20000,73.72000,Aetna,First Health,,207.94,,,,,,,91.64,207.94,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,62756082640,NDC,facility,outpatient,50,ME,254.20000,73.72000,Aetna,First Health,,207.94,,,,,,,2.68,207.94,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,62756079888,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,62756079888,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,62756079788,NDC,,,facility,inpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,7.41,10.10,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,62756079788,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,4.45,10.10,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,62756079713,NDC,,,facility,inpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,7.41,10.10,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,62756079713,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,4.45,10.10,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,62756075164,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,62756075164,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,62756071860,NDC,,,facility,inpatient,1,EA,169.90000,49.27000,Aetna,First Health,,138.98,,,,,,,101.94,138.98,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,62756071860,NDC,,,facility,outpatient,1,EA,169.90000,49.27000,Aetna,First Health,,138.98,,,,,,,61.25,138.98,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,62756070786,NDC,,,facility,inpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,10.77,14.68,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,62756070786,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,6.47,14.68,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,62756059088,NDC,,,facility,inpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,4.41,6.01,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,62756059088,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,2.65,6.01,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,62756058988,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,62756058988,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,62756055483,NDC,,,facility,inpatient,1,EA,140.85000,40.85000,Aetna,First Health,,115.22,,,,,,,84.51,115.22,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,62756055483,NDC,,,facility,outpatient,1,EA,140.85000,40.85000,Aetna,First Health,,115.22,,,,,,,50.78,115.22,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,62756052940,NDC,facility,inpatient,0.04,ME,4466.45000,1295.27000,Aetna,First Health,,3653.56,,,,,,,1610.16,3653.56,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,62756052940,NDC,facility,outpatient,0.04,ME,4466.45000,1295.27000,Aetna,First Health,,3653.56,,,,,,,3.28,3653.56,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,62756052288,NDC,,,facility,inpatient,1,EA,180.45000,52.33000,Aetna,First Health,,147.61,,,,,,,108.27,147.61,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,62756052288,NDC,,,facility,outpatient,1,EA,180.45000,52.33000,Aetna,First Health,,147.61,,,,,,,65.05,147.61,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,62756052269,NDC,,,facility,inpatient,1,EA,180.45000,52.33000,Aetna,First Health,,147.61,,,,,,,108.27,147.61,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,62756052269,NDC,,,facility,outpatient,1,EA,180.45000,52.33000,Aetna,First Health,,147.61,,,,,,,65.05,147.61,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,62756052069,NDC,,,facility,inpatient,1,EA,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,115.80,157.87,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,62756052069,NDC,,,facility,outpatient,1,EA,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,69.58,157.87,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,62756051988,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,4.02,5.48,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,62756051988,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,62756051888,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,62756051888,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,62756051788,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,62756051788,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,62756051344,NDC,facility,inpatient,500,ME,322.05000,93.39000,Aetna,First Health,,263.44,,,,,,,116.10,263.44,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,62756051344,NDC,facility,outpatient,500,ME,322.05000,93.39000,Aetna,First Health,,263.44,,,,,,,0.03852,263.44,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,62756051340,NDC,facility,inpatient,500,ME,343.00000,99.47000,Aetna,First Health,,280.57,,,,,,,123.65,280.57,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,62756051340,NDC,facility,outpatient,500,ME,343.00000,99.47000,Aetna,First Health,,280.57,,,,,,,0.03852,280.57,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,62756046188,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,62756046188,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,62756045788,NDC,,,facility,inpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,7.68,10.47,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,62756045788,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,4.61,10.47,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,62756044602,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,62756044602,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,62756040201,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,62756040201,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,62756035144,NDC,facility,inpatient,0.5,ME,484.80000,140.59000,Aetna,First Health,,396.57,,,,,,,290.88,396.57,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,62756035144,NDC,facility,outpatient,0.5,ME,484.80000,140.59000,Aetna,First Health,,396.57,,,,,,,0.63558,396.57,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,62756034944,NDC,facility,inpatient,0.1,ME,114.00000,33.06000,Aetna,First Health,,93.25,,,,,,,68.40,93.25,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,62756034944,NDC,facility,outpatient,0.1,ME,114.00000,33.06000,Aetna,First Health,,93.25,,,,,,,0.63558,93.25,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,62756034844,NDC,facility,inpatient,0.05,ME,58.80000,17.05000,Aetna,First Health,,48.10,,,,,,,35.28,48.10,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,62756034844,NDC,facility,outpatient,0.05,ME,58.80000,17.05000,Aetna,First Health,,48.10,,,,,,,0.63558,48.10,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,62756026002,NDC,,,facility,inpatient,1,EA,15.50000,4.50000,Aetna,First Health,,12.68,,,,,,,9.30,12.68,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,62756026002,NDC,,,facility,outpatient,1,EA,15.50000,4.50000,Aetna,First Health,,12.68,,,,,,,5.59,12.68,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,62756025802,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,62756025802,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,62756024064,NDC,facility,inpatient,4,ME,157.55000,45.69000,Aetna,First Health,,128.88,,,,,,,94.53,128.88,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,62756024064,NDC,facility,outpatient,4,ME,157.55000,45.69000,Aetna,First Health,,128.88,,,,,,,0.00963,128.88,percent of total billed charges,
Amphotericin B LIPO 50mg I,800010922,CDM,636,RC,J0289,HCPCS,62756023301,NDC,facility,inpatient,50,ME,2021.15000,586.13000,Aetna,First Health,,1653.30,,,,,,,728.62,1653.30,percent of total billed charges,
Amphotericin B LIPO 50mg I,800010922,CDM,636,RC,J0289,HCPCS,62756023301,NDC,facility,outpatient,50,ME,2021.15000,586.13000,Aetna,First Health,,1653.30,,,,,,,19.95,1653.30,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,62756020201,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,62756020201,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,62756018488,NDC,,,facility,inpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,11.22,15.30,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,62756018488,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,6.74,15.30,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,62756018388,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,62756018388,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,62756016088,NDC,,,facility,inpatient,1,EA,29.80000,8.64000,Aetna,First Health,,24.38,,,,,,,17.88,24.38,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,62756016088,NDC,,,facility,outpatient,1,EA,29.80000,8.64000,Aetna,First Health,,24.38,,,,,,,10.74,24.38,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,62756014586,NDC,,,facility,inpatient,1,EA,29.90000,8.67000,Aetna,First Health,,24.46,,,,,,,17.94,24.46,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,62756014586,NDC,,,facility,outpatient,1,EA,29.90000,8.67000,Aetna,First Health,,24.46,,,,,,,10.78,24.46,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,62756014201,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,62756014201,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,62756013902,NDC,,,facility,inpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,62756013902,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,62756013805,NDC,,,facility,inpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,5.67,7.73,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,62756013805,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,3.41,7.73,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,62756013705,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,62756013705,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,62756013702,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,62756013702,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,62756012944,NDC,facility,inpatient,40,ME,45.20000,13.11000,Aetna,First Health,,36.97,,,,,,,16.29,36.97,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,62756012944,NDC,facility,outpatient,40,ME,45.20000,13.11000,Aetna,First Health,,36.97,,,,,,,5.86,36.97,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,62584099401,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,62584099401,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,62584098801,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,62584098801,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,62584098401,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,62584098401,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,62584097790,NDC,,,facility,inpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,11.28,15.38,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,62584097790,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,62584097730,NDC,,,facility,inpatient,1,EA,19.05000,5.52000,Aetna,First Health,,15.58,,,,,,,11.43,15.58,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,62584097730,NDC,,,facility,outpatient,1,EA,19.05000,5.52000,Aetna,First Health,,15.58,,,,,,,6.87,15.58,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,62584097590,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,62584097590,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,62584097501,NDC,,,facility,inpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,62584097501,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,62584097401,NDC,,,facility,inpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,5.07,6.91,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,62584097401,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,3.05,6.91,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,62584089701,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,62584089701,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,62584088601,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,62584088601,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,62584074701,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,62584074701,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,62584055901,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,62584055901,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,62584026601,NDC,,,facility,inpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,62584026601,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,62584026501,NDC,,,facility,inpatient,1,EA,0.75000,0.22000,Aetna,First Health,,0.61350,,,,,,,0.45000,0.61350,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,62584026501,NDC,,,facility,outpatient,1,EA,0.75000,0.22000,Aetna,First Health,,0.61350,,,,,,,0.27037,0.61350,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,62584015901,NDC,,,facility,inpatient,1,EA,75.30000,21.84000,Aetna,First Health,,61.60,,,,,,,45.18,61.60,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,62584015901,NDC,,,facility,outpatient,1,EA,75.30000,21.84000,Aetna,First Health,,61.60,,,,,,,27.15,61.60,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,62559083003,NDC,,,facility,inpatient,1,EA,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,57.60,78.53,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,62559083003,NDC,,,facility,outpatient,1,EA,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,34.61,78.53,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,62559074401,NDC,,,facility,inpatient,1,EA,14.35000,4.16000,Aetna,First Health,,11.74,,,,,,,8.61,11.74,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,62559074401,NDC,,,facility,outpatient,1,EA,14.35000,4.16000,Aetna,First Health,,11.74,,,,,,,5.17,11.74,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,62559052001,NDC,,,facility,inpatient,1,EA,508.25000,147.39000,Aetna,First Health,,415.75,,,,,,,304.95,415.75,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,62559052001,NDC,,,facility,outpatient,1,EA,508.25000,147.39000,Aetna,First Health,,415.75,,,,,,,183.22,415.75,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),800017619,CDM,637,RC,62559051001,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),800017619,CDM,637,RC,62559051001,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,62559042401,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,62559042401,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,62559042007,NDC,,,facility,inpatient,1,EA,172.90000,50.14000,Aetna,First Health,,141.43,,,,,,,103.74,141.43,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,62559042007,NDC,,,facility,outpatient,1,EA,172.90000,50.14000,Aetna,First Health,,141.43,,,,,,,62.33,141.43,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,62559027630,NDC,,,facility,inpatient,1,EA,40.20000,11.66000,Aetna,First Health,,32.88,,,,,,,24.12,32.88,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,62559027630,NDC,,,facility,outpatient,1,EA,40.20000,11.66000,Aetna,First Health,,32.88,,,,,,,14.49,32.88,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,62559023001,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,62559023001,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,62559016001,NDC,,,facility,inpatient,1,EA,18.60000,5.39000,Aetna,First Health,,15.21,,,,,,,11.16,15.21,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,62559016001,NDC,,,facility,outpatient,1,EA,18.60000,5.39000,Aetna,First Health,,15.21,,,,,,,6.71,15.21,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,62559015304,NDC,,,facility,inpatient,1,EA,50.15000,14.54000,Aetna,First Health,,41.02,,,,,,,30.09,41.02,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,62559015304,NDC,,,facility,outpatient,1,EA,50.15000,14.54000,Aetna,First Health,,41.02,,,,,,,18.08,41.02,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,62559015116,NDC,,,facility,inpatient,1,EA,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,6.84,9.33,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,62559015116,NDC,,,facility,outpatient,1,EA,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,4.11,9.33,percent of total billed charges,
Urea 15g Oral Rec Powder,800062042,CDM,250,RC,62530000011,NDC,,,facility,inpatient,1,EA,30.80000,8.93000,Aetna,First Health,,25.19,,,,,,,11.40,25.19,percent of total billed charges,
Urea 15g Oral Rec Powder,800062042,CDM,250,RC,62530000011,NDC,,,facility,outpatient,1,EA,30.80000,8.93000,Aetna,First Health,,25.19,,,,,,,11.10,25.19,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,62332051805,NDC,,,facility,inpatient,1,EA,238.60000,69.19000,Aetna,First Health,,195.17,,,,,,,143.16,195.17,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,62332051805,NDC,,,facility,outpatient,1,EA,238.60000,69.19000,Aetna,First Health,,195.17,,,,,,,86.02,195.17,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,62332046431,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,62332046431,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,62332042631,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,62332042631,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,62332041310,NDC,,,facility,inpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,60.24,82.13,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,62332041310,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,36.19,82.13,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,62332038590,NDC,,,facility,inpatient,1,EA,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,105.60,143.97,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,62332038590,NDC,,,facility,outpatient,1,EA,176.00000,51.04000,Aetna,First Health,,143.97,,,,,,,63.45,143.97,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,62332038530,NDC,,,facility,inpatient,1,EA,176.55000,51.20000,Aetna,First Health,,144.42,,,,,,,105.93,144.42,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,62332038530,NDC,,,facility,outpatient,1,EA,176.55000,51.20000,Aetna,First Health,,144.42,,,,,,,63.65,144.42,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,62332037931,NDC,,,facility,inpatient,1,EA,79.50000,23.06000,Aetna,First Health,,65.03,,,,,,,47.70,65.03,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,62332037931,NDC,,,facility,outpatient,1,EA,79.50000,23.06000,Aetna,First Health,,65.03,,,,,,,28.66,65.03,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),800015397,CDM,637,RC,62332036506,NDC,,,facility,inpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,6.24,8.51,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),800015397,CDM,637,RC,62332036506,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,62332023330,NDC,,,facility,inpatient,1,EA,59.50000,17.26000,Aetna,First Health,,48.67,,,,,,,35.70,48.67,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,62332023330,NDC,,,facility,outpatient,1,EA,59.50000,17.26000,Aetna,First Health,,48.67,,,,,,,21.45,48.67,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,62332017160,NDC,,,facility,inpatient,1,EA,86.00000,24.94000,Aetna,First Health,,70.35,,,,,,,51.60,70.35,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,62332017160,NDC,,,facility,outpatient,1,EA,86.00000,24.94000,Aetna,First Health,,70.35,,,,,,,31.00,70.35,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,62332011431,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,62332011431,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,62332011231,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,62332011231,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,62332004590,NDC,,,facility,inpatient,1,EA,32.60000,9.45000,Aetna,First Health,,26.67,,,,,,,19.56,26.67,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,62332004590,NDC,,,facility,outpatient,1,EA,32.60000,9.45000,Aetna,First Health,,26.67,,,,,,,11.75,26.67,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,62332003331,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,62332003331,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,62332000191,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,62332000191,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,62332000131,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,62332000131,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,62269035124,NDC,facility,inpatient,4,ME,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,62269035124,NDC,facility,outpatient,4,ME,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,0.13482,4.01,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,62175061743,NDC,,,facility,inpatient,1,EA,28.70000,8.32000,Aetna,First Health,,23.48,,,,,,,17.22,23.48,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,62175061743,NDC,,,facility,outpatient,1,EA,28.70000,8.32000,Aetna,First Health,,23.48,,,,,,,10.35,23.48,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,62175049064,NDC,,,facility,inpatient,1,EA,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,16.05,21.88,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,62175049064,NDC,,,facility,outpatient,1,EA,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,9.64,21.88,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,62175044601,NDC,,,facility,inpatient,1,EA,88.65000,25.71000,Aetna,First Health,,72.52,,,,,,,53.19,72.52,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,62175044601,NDC,,,facility,outpatient,1,EA,88.65000,25.71000,Aetna,First Health,,72.52,,,,,,,31.96,72.52,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,62175027037,NDC,,,facility,inpatient,1,EA,21.75000,6.31000,Aetna,First Health,,17.79,,,,,,,13.05,17.79,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,62175027037,NDC,,,facility,outpatient,1,EA,21.75000,6.31000,Aetna,First Health,,17.79,,,,,,,7.84,17.79,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,62175026037,NDC,,,facility,inpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,5.67,7.73,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,62175026037,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,3.41,7.73,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,62175018146,NDC,,,facility,inpatient,1,EA,28.70000,8.32000,Aetna,First Health,,23.48,,,,,,,17.22,23.48,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,62175018146,NDC,,,facility,outpatient,1,EA,28.70000,8.32000,Aetna,First Health,,23.48,,,,,,,10.35,23.48,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,62175018143,NDC,,,facility,inpatient,1,EA,28.70000,8.32000,Aetna,First Health,,23.48,,,,,,,17.22,23.48,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,62175018143,NDC,,,facility,outpatient,1,EA,28.70000,8.32000,Aetna,First Health,,23.48,,,,,,,10.35,23.48,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,62175012837,NDC,,,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,2.19,2.99,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,62175012837,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.32,2.99,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,62175010201,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,62175010201,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,62135096001,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,62135096001,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,62135075047,NDC,,,facility,inpatient,1,EA,9.00000,2.61000,Aetna,First Health,,7.36,,,,,,,5.40,7.36,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,62135075047,NDC,,,facility,outpatient,1,EA,9.00000,2.61000,Aetna,First Health,,7.36,,,,,,,3.24,7.36,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,62135048142,NDC,,,facility,inpatient,1,EA,127.45000,36.96000,Aetna,First Health,,104.25,,,,,,,76.47,104.25,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,62135048142,NDC,,,facility,outpatient,1,EA,127.45000,36.96000,Aetna,First Health,,104.25,,,,,,,45.95,104.25,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,62135043690,NDC,,,facility,inpatient,1,EA,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,20.40,27.81,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,62135043690,NDC,,,facility,outpatient,1,EA,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,12.26,27.81,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,62135019122,NDC,facility,inpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,62135019122,NDC,facility,outpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,0.03852,5.93,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,62037084601,NDC,,,facility,inpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,11.61,15.83,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,62037084601,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,6.98,15.83,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,62037084530,NDC,,,facility,inpatient,1,EA,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,11.13,15.17,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,62037084530,NDC,,,facility,outpatient,1,EA,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,6.69,15.17,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,62037083201,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,62037083201,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,62037083101,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,62037083101,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,62037083001,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,62037083001,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,62037059890,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,62037059890,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,62037059790,NDC,,,facility,inpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,5.10,6.95,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,62037059790,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,3.06,6.95,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,62037057101,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,62037057101,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,61990061102,NDC,,,facility,inpatient,1,EA,199.60000,57.88000,Aetna,First Health,,163.27,,,,,,,73.85,163.27,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,61990061102,NDC,,,facility,outpatient,1,EA,199.60000,57.88000,Aetna,First Health,,163.27,,,,,,,71.96,163.27,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,61990041102,NDC,facility,inpatient,1,ME,775.30000,224.84000,Aetna,First Health,,634.20,,,,,,,279.50,634.20,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,61990041102,NDC,facility,outpatient,1,ME,775.30000,224.84000,Aetna,First Health,,634.20,,,,,,,54.97,634.20,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,61990012002,NDC,facility,inpatient,3.375,GM,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,20.55,46.63,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,61990012002,NDC,facility,outpatient,3.375,GM,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,1.05,46.63,percent of total billed charges,
Remdesivir 100mg Inj,800062067,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,100,ME,4757.90000,1379.79000,Aetna,First Health,,3891.96,,,,,,,1715.22,3891.96,percent of total billed charges,
Remdesivir 100mg Inj,800062067,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,outpatient,100,ME,4757.90000,1379.79000,Aetna,First Health,,3891.96,,,,,,,6.64,3891.96,percent of total billed charges,
Remdesivir 100mg Inj,800062067,CDM,636,RC,J0248,HCPCS,61958290101,NDC,facility,inpatient,100,ME,3931.00000,1139.99000,Aetna,First Health,,3215.56,,,,,,,1417.13,3215.56,percent of total billed charges,
Remdesivir 100mg Inj,800062067,CDM,636,RC,J0248,HCPCS,61958290101,NDC,facility,outpatient,100,ME,3931.00000,1139.99000,Aetna,First Health,,3215.56,,,,,,,6.64,3215.56,percent of total billed charges,
bictegr/emtric/tenofov 50-200-25 mg Tab,800046451,CDM,637,RC,61958250101,NDC,,,facility,inpatient,1,EA,1031.05000,299.00000,Aetna,First Health,,843.40,,,,,,,618.63,843.40,percent of total billed charges,
bictegr/emtric/tenofov 50-200-25 mg Tab,800046451,CDM,637,RC,61958250101,NDC,,,facility,outpatient,1,EA,1031.05000,299.00000,Aetna,First Health,,843.40,,,,,,,371.69,843.40,percent of total billed charges,
Tenofovir 25mg T(Vemlidy),800046464,CDM,637,RC,61958230101,NDC,,,facility,inpatient,1,EA,411.30000,119.28000,Aetna,First Health,,336.44,,,,,,,246.78,336.44,percent of total billed charges,
Tenofovir 25mg T(Vemlidy),800046464,CDM,637,RC,61958230101,NDC,,,facility,outpatient,1,EA,411.30000,119.28000,Aetna,First Health,,336.44,,,,,,,148.27,336.44,percent of total billed charges,
Emtricitabine-Tenofovir 200-25mg Tab,800040867,CDM,637,RC,61958200201,NDC,,,facility,inpatient,1,EA,575.60000,166.92000,Aetna,First Health,,470.84,,,,,,,345.36,470.84,percent of total billed charges,
Emtricitabine-Tenofovir 200-25mg Tab,800040867,CDM,637,RC,61958200201,NDC,,,facility,outpatient,1,EA,575.60000,166.92000,Aetna,First Health,,470.84,,,,,,,207.50,470.84,percent of total billed charges,
elviteg/cobic/emtrici/teno 150-150-200-10mg T,800040866,CDM,637,RC,61958190101,NDC,,,facility,inpatient,1,EA,1031.05000,299.00000,Aetna,First Health,,843.40,,,,,,,618.63,843.40,percent of total billed charges,
elviteg/cobic/emtrici/teno 150-150-200-10mg T,800040866,CDM,637,RC,61958190101,NDC,,,facility,outpatient,1,EA,1031.05000,299.00000,Aetna,First Health,,843.40,,,,,,,371.69,843.40,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,61958100301,NDC,,,facility,inpatient,1,EA,58.20000,16.88000,Aetna,First Health,,47.61,,,,,,,34.92,47.61,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,61958100301,NDC,,,facility,outpatient,1,EA,58.20000,16.88000,Aetna,First Health,,47.61,,,,,,,20.98,47.61,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,61958100101,NDC,,,facility,inpatient,1,EA,32.05000,9.29000,Aetna,First Health,,26.22,,,,,,,19.23,26.22,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,61958100101,NDC,,,facility,outpatient,1,EA,32.05000,9.29000,Aetna,First Health,,26.22,,,,,,,11.55,26.22,percent of total billed charges,
Emtricitabine-Tenofovir 200-300mg T(Truvada),800017719,CDM,637,RC,61958070101,NDC,,,facility,inpatient,1,EA,488.05000,141.53000,Aetna,First Health,,399.22,,,,,,,292.83,399.22,percent of total billed charges,
Emtricitabine-Tenofovir 200-300mg T(Truvada),800017719,CDM,637,RC,61958070101,NDC,,,facility,outpatient,1,EA,488.05000,141.53000,Aetna,First Health,,399.22,,,,,,,175.94,399.22,percent of total billed charges,
Tenofovir 300mg T(Viread),800017725,CDM,637,RC,61958040101,NDC,,,facility,inpatient,1,EA,344.85000,100.01000,Aetna,First Health,,282.09,,,,,,,206.91,282.09,percent of total billed charges,
Tenofovir 300mg T(Viread),800017725,CDM,637,RC,61958040101,NDC,,,facility,outpatient,1,EA,344.85000,100.01000,Aetna,First Health,,282.09,,,,,,,124.32,282.09,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,61953000201,NDC,facility,inpatient,12.5,GM,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,240.81,546.42,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,61953000201,NDC,facility,outpatient,12.5,GM,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,51.12,546.42,percent of total billed charges,
Cariprazine 1.5mg C(Vraylar),800046466,CDM,637,RC,61874011530,NDC,,,facility,inpatient,1,EA,409.40000,118.73000,Aetna,First Health,,334.89,,,,,,,245.64,334.89,percent of total billed charges,
Cariprazine 1.5mg C(Vraylar),800046466,CDM,637,RC,61874011530,NDC,,,facility,outpatient,1,EA,409.40000,118.73000,Aetna,First Health,,334.89,,,,,,,147.59,334.89,percent of total billed charges,
Cariprazine 1.5mg C(Vraylar),800046466,CDM,637,RC,61874011520,NDC,,,facility,inpatient,1,EA,409.40000,118.73000,Aetna,First Health,,334.89,,,,,,,245.64,334.89,percent of total billed charges,
Cariprazine 1.5mg C(Vraylar),800046466,CDM,637,RC,61874011520,NDC,,,facility,outpatient,1,EA,409.40000,118.73000,Aetna,First Health,,334.89,,,,,,,147.59,334.89,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,61787044202,NDC,,,facility,inpatient,1,EA,90.05000,26.11000,Aetna,First Health,,73.66,,,,,,,33.32,73.66,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,61787044202,NDC,,,facility,outpatient,1,EA,90.05000,26.11000,Aetna,First Health,,73.66,,,,,,,32.46,73.66,percent of total billed charges,
cemiplimab - rwlc 350 mg/7 mL Soln,800051954,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,inpatient,350,ME,59181.80000,17162.72000,Aetna,First Health,,48410.71,,,,,,,21335.04,48410.71,percent of total billed charges,
cemiplimab - rwlc 350 mg/7 mL Soln,800051954,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,outpatient,350,ME,59181.80000,17162.72000,Aetna,First Health,,48410.71,,,,,,,27.63,48410.71,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,61748001860,NDC,,,facility,inpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,8.55,11.66,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,61748001860,NDC,,,facility,outpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,5.14,11.66,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,61748001830,NDC,,,facility,inpatient,1,EA,14.30000,4.15000,Aetna,First Health,,11.70,,,,,,,8.58,11.70,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,61748001830,NDC,,,facility,outpatient,1,EA,14.30000,4.15000,Aetna,First Health,,11.70,,,,,,,5.16,11.70,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,61748001801,NDC,,,facility,inpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,8.55,11.66,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,61748001801,NDC,,,facility,outpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,5.14,11.66,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,61748001406,NDC,,,facility,inpatient,1,EA,12.60000,3.65000,Aetna,First Health,,10.31,,,,,,,7.56,10.31,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,61748001406,NDC,,,facility,outpatient,1,EA,12.60000,3.65000,Aetna,First Health,,10.31,,,,,,,4.54,10.31,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,61748001401,NDC,,,facility,inpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,6.30,8.59,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,61748001401,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,3.79,8.59,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,61748001211,NDC,,,facility,inpatient,1,EA,46.00000,13.34000,Aetna,First Health,,37.63,,,,,,,27.60,37.63,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,61748001211,NDC,,,facility,outpatient,1,EA,46.00000,13.34000,Aetna,First Health,,37.63,,,,,,,16.58,37.63,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,61748001201,NDC,,,facility,inpatient,1,EA,43.60000,12.64000,Aetna,First Health,,35.66,,,,,,,26.16,35.66,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,61748001201,NDC,,,facility,outpatient,1,EA,43.60000,12.64000,Aetna,First Health,,35.66,,,,,,,15.72,35.66,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,61703042381,NDC,,,facility,inpatient,1,EA,74.80000,21.69000,Aetna,First Health,,61.19,,,,,,,27.68,61.19,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,61703042381,NDC,,,facility,outpatient,1,EA,74.80000,21.69000,Aetna,First Health,,61.19,,,,,,,26.97,61.19,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,61703042282,NDC,,,facility,inpatient,1,EA,125.95000,36.53000,Aetna,First Health,,103.03,,,,,,,46.60,103.03,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,61703042282,NDC,,,facility,outpatient,1,EA,125.95000,36.53000,Aetna,First Health,,103.03,,,,,,,45.40,103.03,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,61703042281,NDC,,,facility,inpatient,1,EA,93.75000,27.19000,Aetna,First Health,,76.69,,,,,,,34.69,76.69,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,61703042281,NDC,,,facility,outpatient,1,EA,93.75000,27.19000,Aetna,First Health,,76.69,,,,,,,33.80,76.69,percent of total billed charges,
Methotrexate 1g/40mL I PF,800022022,CDM,636,RC,J9260,HCPCS,61703040841,NDC,facility,inpatient,1000,ME,343.55000,99.63000,Aetna,First Health,,281.02,,,,,,,123.85,281.02,percent of total billed charges,
Methotrexate 1g/40mL I PF,800022022,CDM,636,RC,J9260,HCPCS,61703040841,NDC,facility,outpatient,1000,ME,343.55000,99.63000,Aetna,First Health,,281.02,,,,,,,2.48,281.02,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,61703036322,NDC,facility,inpatient,100,ME,835.80000,242.38000,Aetna,First Health,,683.68,,,,,,,301.31,683.68,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,61703036322,NDC,facility,outpatient,100,ME,835.80000,242.38000,Aetna,First Health,,683.68,,,,,,,0.04815,683.68,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,61703036050,NDC,facility,inpatient,50,ME,39.40000,11.43000,Aetna,First Health,,32.23,,,,,,,14.20,32.23,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,61703036050,NDC,facility,outpatient,50,ME,39.40000,11.43000,Aetna,First Health,,32.23,,,,,,,2.82,32.23,percent of total billed charges,
Methotrexate 50mg/2mL Inj,800046553,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,inpatient,50,ME,56.70000,16.44000,Aetna,First Health,,46.38,,,,,,,20.44,46.38,percent of total billed charges,
Methotrexate 50mg/2mL Inj,800046553,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,outpatient,50,ME,56.70000,16.44000,Aetna,First Health,,46.38,,,,,,,2.48,46.38,percent of total billed charges,
Methotrexate 50mg/2mL Inj,800046553,CDM,636,RC,J9260,HCPCS,61703035010,NDC,facility,inpatient,50,ME,56.70000,16.44000,Aetna,First Health,,46.38,,,,,,,20.44,46.38,percent of total billed charges,
Methotrexate 50mg/2mL Inj,800046553,CDM,636,RC,J9260,HCPCS,61703035010,NDC,facility,outpatient,50,ME,56.70000,16.44000,Aetna,First Health,,46.38,,,,,,,2.48,46.38,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,inpatient,100,ME,210.75000,61.12000,Aetna,First Health,,172.39,,,,,,,75.98,172.39,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,outpatient,100,ME,210.75000,61.12000,Aetna,First Health,,172.39,,,,,,,1.72,172.39,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,61703034222,NDC,facility,inpatient,6,ME,13.15000,3.81000,Aetna,First Health,,10.76,,,,,,,4.74,10.76,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,61703034222,NDC,facility,outpatient,6,ME,13.15000,3.81000,Aetna,First Health,,10.76,,,,,,,0.09630,10.76,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,inpatient,50,ME,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,outpatient,50,ME,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,2.82,33.42,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,inpatient,50,ME,60.40000,17.52000,Aetna,First Health,,49.41,,,,,,,21.77,49.41,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,outpatient,50,ME,60.40000,17.52000,Aetna,First Health,,49.41,,,,,,,2.82,49.41,percent of total billed charges,
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,61703030925,NDC,facility,inpatient,2,ME,132.60000,38.45000,Aetna,First Health,,108.47,,,,,,,47.80,108.47,percent of total billed charges,
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,61703030925,NDC,facility,outpatient,2,ME,132.60000,38.45000,Aetna,First Health,,108.47,,,,,,,7.85,108.47,percent of total billed charges,
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ME,120.10000,34.83000,Aetna,First Health,,98.24,,,,,,,43.30,98.24,percent of total billed charges,
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,outpatient,2,ME,120.10000,34.83000,Aetna,First Health,,98.24,,,,,,,7.85,98.24,percent of total billed charges,
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,inpatient,2,ME,268.60000,77.89000,Aetna,First Health,,219.71,,,,,,,96.83,219.71,percent of total billed charges,
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,outpatient,2,ME,268.60000,77.89000,Aetna,First Health,,219.71,,,,,,,7.85,219.71,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,61703026205,NDC,facility,inpatient,50,ME,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,61703026205,NDC,facility,outpatient,50,ME,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,2.82,33.42,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,61570041605,NDC,facility,inpatient,10,UN,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,3.19,7.24,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,61570041605,NDC,facility,outpatient,10,UN,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,1.00,7.24,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,61570030361,NDC,,,facility,inpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,16.98,23.15,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,61570030361,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,10.20,23.15,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,61570019001,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,61570019001,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,61570017262,NDC,,,facility,inpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,11.46,15.62,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,61570017262,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,6.89,15.62,percent of total billed charges,
Pen G Benzathine 1.2 (Bicillin LA)2mL,800014282,CDM,636,RC,J0561,HCPCS,61570014710,NDC,facility,inpatient,1,EA,239.00000,69.31000,Aetna,First Health,,195.50,,,,,,,86.16,195.50,percent of total billed charges,
Pen G Benzathine 1.2 (Bicillin LA)2mL,800014282,CDM,636,RC,J0561,HCPCS,61570014710,NDC,facility,outpatient,1,EA,239.00000,69.31000,Aetna,First Health,,195.50,,,,,,,30.79,195.50,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,61570013185,NDC,,,facility,inpatient,1,EA,217.30000,63.02000,Aetna,First Health,,177.75,,,,,,,130.38,177.75,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,61570013185,NDC,,,facility,outpatient,1,EA,217.30000,63.02000,Aetna,First Health,,177.75,,,,,,,78.34,177.75,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,61570011256,NDC,,,facility,inpatient,1,EA,17.45000,5.06000,Aetna,First Health,,14.27,,,,,,,10.47,14.27,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,61570011256,NDC,,,facility,outpatient,1,EA,17.45000,5.06000,Aetna,First Health,,14.27,,,,,,,6.29,14.27,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,61570011201,NDC,,,facility,inpatient,1,EA,56.70000,16.44000,Aetna,First Health,,46.38,,,,,,,34.02,46.38,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,61570011201,NDC,,,facility,outpatient,1,EA,56.70000,16.44000,Aetna,First Health,,46.38,,,,,,,20.44,46.38,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,61570011101,NDC,,,facility,inpatient,1,EA,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,32.40,44.17,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,61570011101,NDC,,,facility,outpatient,1,EA,54.00000,15.66000,Aetna,First Health,,44.17,,,,,,,19.47,44.17,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,61570011001,NDC,,,facility,inpatient,1,EA,45.75000,13.27000,Aetna,First Health,,37.42,,,,,,,27.45,37.42,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,61570011001,NDC,,,facility,outpatient,1,EA,45.75000,13.27000,Aetna,First Health,,37.42,,,,,,,16.49,37.42,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,61570004935,NDC,,,facility,inpatient,1,EA,289.75000,84.03000,Aetna,First Health,,237.02,,,,,,,107.21,237.02,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,61570004935,NDC,,,facility,outpatient,1,EA,289.75000,84.03000,Aetna,First Health,,237.02,,,,,,,104.45,237.02,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,800018689,CDM,637,RC,61570003410,NDC,,,facility,inpatient,1,EA,740.30000,214.69000,Aetna,First Health,,605.57,,,,,,,444.18,605.57,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,800018689,CDM,637,RC,61570003410,NDC,,,facility,outpatient,1,EA,740.30000,214.69000,Aetna,First Health,,605.57,,,,,,,266.88,605.57,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,61553036472,NDC,facility,inpatient,200,ME,99.75000,28.93000,Aetna,First Health,,81.60,,,,,,,35.96,81.60,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,61553036472,NDC,facility,outpatient,200,ME,99.75000,28.93000,Aetna,First Health,,81.60,,,,,,,0.93411,81.60,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,61553032170,NDC,,,facility,inpatient,1,EA,212.85000,61.73000,Aetna,First Health,,174.11,,,,,,,78.75,174.11,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,61553032170,NDC,,,facility,outpatient,1,EA,212.85000,61.73000,Aetna,First Health,,174.11,,,,,,,76.73,174.11,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,61553030772,NDC,facility,inpatient,1,ME,53.20000,15.43000,Aetna,First Health,,43.52,,,,,,,19.18,43.52,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,61553030772,NDC,facility,outpatient,1,ME,53.20000,15.43000,Aetna,First Health,,43.52,,,,,,,19.68,43.52,percent of total billed charges,
Phenylephrine 25mg/NS 250mL PF PB,800019789,CDM,636,RC,J2371,HCPCS,61553015961,NDC,facility,inpatient,25,ME,99.20000,28.77000,Aetna,First Health,,81.15,,,,,,,35.76,81.15,percent of total billed charges,
Phenylephrine 25mg/NS 250mL PF PB,800019789,CDM,636,RC,J2371,HCPCS,61553015961,NDC,facility,outpatient,25,ME,99.20000,28.77000,Aetna,First Health,,81.15,,,,,,,36.70,81.15,percent of total billed charges,
ceFAZolin 2g/ Water  Syr (Ancef),800013628,CDM,636,RC,J0690,HCPCS,61553001473,NDC,facility,inpatient,2,GM,94.95000,27.54000,Aetna,First Health,,77.67,,,,,,,34.23,77.67,percent of total billed charges,
ceFAZolin 2g/ Water  Syr (Ancef),800013628,CDM,636,RC,J0690,HCPCS,61553001473,NDC,facility,outpatient,2,GM,94.95000,27.54000,Aetna,First Health,,77.67,,,,,,,0.79929,77.67,percent of total billed charges,
ceFAZolin 1g/ Water Syr (Ancef),800013627,CDM,636,RC,J0690,HCPCS,61553001272,NDC,facility,inpatient,1,GM,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,22.35,50.72,percent of total billed charges,
ceFAZolin 1g/ Water Syr (Ancef),800013627,CDM,636,RC,J0690,HCPCS,61553001272,NDC,facility,outpatient,1,GM,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,0.79929,50.72,percent of total billed charges,
Belladonna-Opium Supp(60mg Of Opium),800017087,CDM,637,RC,61451501607,NDC,,,facility,inpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,17.19,23.44,percent of total billed charges,
Belladonna-Opium Supp(60mg Of Opium),800017087,CDM,637,RC,61451501607,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,10.33,23.44,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,61442032110,NDC,,,facility,inpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.84000,1.15,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,61442032110,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.50470,1.15,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,61442032105,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,61442032105,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,61442032101,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,61442032101,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,61442012110,NDC,,,facility,inpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,8.82,12.02,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,61442012110,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.30,12.02,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,61442012101,NDC,,,facility,inpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,8.82,12.02,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,61442012101,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.30,12.02,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,61442011101,NDC,,,facility,inpatient,1,EA,20.65000,5.99000,Aetna,First Health,,16.89,,,,,,,12.39,16.89,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,61442011101,NDC,,,facility,outpatient,1,EA,20.65000,5.99000,Aetna,First Health,,16.89,,,,,,,7.44,16.89,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,61314064305,NDC,,,facility,inpatient,1,EA,238.70000,69.22000,Aetna,First Health,,195.26,,,,,,,143.22,195.26,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,61314064305,NDC,,,facility,outpatient,1,EA,238.70000,69.22000,Aetna,First Health,,195.26,,,,,,,86.05,195.26,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,61314063710,NDC,,,facility,inpatient,1,EA,376.05000,109.05000,Aetna,First Health,,307.61,,,,,,,225.63,307.61,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,61314063710,NDC,,,facility,outpatient,1,EA,376.05000,109.05000,Aetna,First Health,,307.61,,,,,,,135.57,307.61,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,61314063705,NDC,,,facility,inpatient,1,EA,376.35000,109.14000,Aetna,First Health,,307.85,,,,,,,225.81,307.85,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,61314063705,NDC,,,facility,outpatient,1,EA,376.35000,109.14000,Aetna,First Health,,307.85,,,,,,,135.67,307.85,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,61314063136,NDC,,,facility,inpatient,1,EA,304.50000,88.30000,Aetna,First Health,,249.08,,,,,,,182.70,249.08,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,61314063136,NDC,,,facility,outpatient,1,EA,304.50000,88.30000,Aetna,First Health,,249.08,,,,,,,109.77,249.08,percent of total billed charges,
Neo-Poly-Dex 5mL Ophth Susp(Maxitrol),800019117,CDM,637,RC,61314063006,NDC,,,facility,inpatient,1,EA,304.50000,88.30000,Aetna,First Health,,249.08,,,,,,,182.70,249.08,percent of total billed charges,
Neo-Poly-Dex 5mL Ophth Susp(Maxitrol),800019117,CDM,637,RC,61314063006,NDC,,,facility,outpatient,1,EA,304.50000,88.30000,Aetna,First Health,,249.08,,,,,,,109.77,249.08,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,61314062810,NDC,,,facility,inpatient,1,EA,123.35000,35.77000,Aetna,First Health,,100.90,,,,,,,74.01,100.90,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,61314062810,NDC,,,facility,outpatient,1,EA,123.35000,35.77000,Aetna,First Health,,100.90,,,,,,,44.47,100.90,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,61314054703,NDC,,,facility,inpatient,1,EA,617.60000,179.10000,Aetna,First Health,,505.20,,,,,,,370.56,505.20,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,61314054703,NDC,,,facility,outpatient,1,EA,617.60000,179.10000,Aetna,First Health,,505.20,,,,,,,222.64,505.20,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,61314054701,NDC,,,facility,inpatient,1,EA,617.60000,179.10000,Aetna,First Health,,505.20,,,,,,,370.56,505.20,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,61314054701,NDC,,,facility,outpatient,1,EA,617.60000,179.10000,Aetna,First Health,,505.20,,,,,,,222.64,505.20,percent of total billed charges,
Tropicamide 1% Ophth Soln(Mydriacyl),800061415,CDM,637,RC,61314035501,NDC,,,facility,inpatient,1,EA,465.60000,135.02000,Aetna,First Health,,380.86,,,,,,,279.36,380.86,percent of total billed charges,
Tropicamide 1% Ophth Soln(Mydriacyl),800061415,CDM,637,RC,61314035501,NDC,,,facility,outpatient,1,EA,465.60000,135.02000,Aetna,First Health,,380.86,,,,,,,167.85,380.86,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,61314030302,NDC,,,facility,inpatient,1,EA,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,45.60,62.17,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,61314030302,NDC,,,facility,outpatient,1,EA,76.00000,22.04000,Aetna,First Health,,62.17,,,,,,,27.40,62.17,percent of total billed charges,
dexaMETHasone 0.1% 5mL Ophth Soln,800036904,CDM,637,RC,61314029405,NDC,,,facility,inpatient,1,EA,149.40000,43.33000,Aetna,First Health,,122.21,,,,,,,89.64,122.21,percent of total billed charges,
dexaMETHasone 0.1% 5mL Ophth Soln,800036904,CDM,637,RC,61314029405,NDC,,,facility,outpatient,1,EA,149.40000,43.33000,Aetna,First Health,,122.21,,,,,,,53.86,122.21,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,61314022715,NDC,,,facility,inpatient,1,EA,115.05000,33.36000,Aetna,First Health,,94.11,,,,,,,69.03,94.11,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,61314022715,NDC,,,facility,outpatient,1,EA,115.05000,33.36000,Aetna,First Health,,94.11,,,,,,,41.48,94.11,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,61314022710,NDC,,,facility,inpatient,1,EA,114.50000,33.20000,Aetna,First Health,,93.66,,,,,,,68.70,93.66,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,61314022710,NDC,,,facility,outpatient,1,EA,114.50000,33.20000,Aetna,First Health,,93.66,,,,,,,41.28,93.66,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,61314022705,NDC,,,facility,inpatient,1,EA,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,72.21,98.45,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,61314022705,NDC,,,facility,outpatient,1,EA,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,43.39,98.45,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,61314022605,NDC,,,facility,inpatient,1,EA,106.20000,30.80000,Aetna,First Health,,86.87,,,,,,,63.72,86.87,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,61314022605,NDC,,,facility,outpatient,1,EA,106.20000,30.80000,Aetna,First Health,,86.87,,,,,,,38.29,86.87,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,61314020315,NDC,,,facility,inpatient,1,EA,639.25000,185.38000,Aetna,First Health,,522.91,,,,,,,383.55,522.91,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,61314020315,NDC,,,facility,outpatient,1,EA,639.25000,185.38000,Aetna,First Health,,522.91,,,,,,,230.45,522.91,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,61314014315,NDC,,,facility,inpatient,1,EA,43.30000,12.56000,Aetna,First Health,,35.42,,,,,,,25.98,35.42,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,61314014315,NDC,,,facility,outpatient,1,EA,43.30000,12.56000,Aetna,First Health,,35.42,,,,,,,15.61,35.42,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,61314014305,NDC,,,facility,inpatient,1,EA,84.95000,24.64000,Aetna,First Health,,69.49,,,,,,,50.97,69.49,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,61314014305,NDC,,,facility,outpatient,1,EA,84.95000,24.64000,Aetna,First Health,,69.49,,,,,,,30.62,69.49,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,61314012610,NDC,,,facility,inpatient,1,EA,675.90000,196.01000,Aetna,First Health,,552.89,,,,,,,405.54,552.89,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,61314012610,NDC,,,facility,outpatient,1,EA,675.90000,196.01000,Aetna,First Health,,552.89,,,,,,,243.66,552.89,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,61314012605,NDC,,,facility,inpatient,1,EA,678.70000,196.82000,Aetna,First Health,,555.18,,,,,,,407.22,555.18,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,61314012605,NDC,,,facility,outpatient,1,EA,678.70000,196.82000,Aetna,First Health,,555.18,,,,,,,244.67,555.18,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,61314001910,NDC,,,facility,inpatient,1,EA,445.85000,129.30000,Aetna,First Health,,364.71,,,,,,,267.51,364.71,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,61314001910,NDC,,,facility,outpatient,1,EA,445.85000,129.30000,Aetna,First Health,,364.71,,,,,,,160.73,364.71,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,61314001601,NDC,,,facility,inpatient,1,EA,303.75000,88.09000,Aetna,First Health,,248.47,,,,,,,182.25,248.47,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,61314001601,NDC,,,facility,outpatient,1,EA,303.75000,88.09000,Aetna,First Health,,248.47,,,,,,,109.50,248.47,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,61269098937,NDC,,,facility,inpatient,1,EA,113.50000,32.92000,Aetna,First Health,,92.84,,,,,,,41.99,92.84,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,61269098937,NDC,,,facility,outpatient,1,EA,113.50000,32.92000,Aetna,First Health,,92.84,,,,,,,40.92,92.84,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,61269073556,NDC,,,facility,inpatient,1,EA,21.70000,6.29000,Aetna,First Health,,17.75,,,,,,,8.03,17.75,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,61269073556,NDC,,,facility,outpatient,1,EA,21.70000,6.29000,Aetna,First Health,,17.75,,,,,,,7.82,17.75,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,61269073041,NDC,,,facility,inpatient,1,EA,50.55000,14.66000,Aetna,First Health,,41.35,,,,,,,30.33,41.35,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,61269073041,NDC,,,facility,outpatient,1,EA,50.55000,14.66000,Aetna,First Health,,41.35,,,,,,,18.22,41.35,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,61269033956,NDC,,,facility,inpatient,1,EA,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,4.44,9.82,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,61269033956,NDC,,,facility,outpatient,1,EA,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,4.33,9.82,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,61269022041,NDC,,,facility,inpatient,1,EA,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,12.58,27.81,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,61269022041,NDC,,,facility,outpatient,1,EA,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,12.26,27.81,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,61269017934,NDC,,,facility,inpatient,1,EA,58.75000,17.04000,Aetna,First Health,,48.06,,,,,,,21.74,48.06,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,61269017934,NDC,,,facility,outpatient,1,EA,58.75000,17.04000,Aetna,First Health,,48.06,,,,,,,21.18,48.06,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,60977015501,NDC,facility,inpatient,0.2,ME,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,2.94,6.67,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,60977015501,NDC,facility,outpatient,0.2,ME,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,0.36594,6.67,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,60977015071,NDC,facility,inpatient,1,GM,134.25000,38.93000,Aetna,First Health,,109.82,,,,,,,48.40,109.82,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,60977015071,NDC,facility,outpatient,1,GM,134.25000,38.93000,Aetna,First Health,,109.82,,,,,,,4.37,109.82,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,60977015001,NDC,facility,inpatient,1,GM,328.00000,95.12000,Aetna,First Health,,268.30,,,,,,,118.24,268.30,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,60977015001,NDC,facility,outpatient,1,GM,328.00000,95.12000,Aetna,First Health,,268.30,,,,,,,4.37,268.30,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,60977011201,NDC,facility,inpatient,2,ME,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,6.00,13.62,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,60977011201,NDC,facility,outpatient,2,ME,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,1.36,13.62,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,60977001701,NDC,facility,inpatient,10,ME,72.95000,21.16000,Aetna,First Health,,59.67,,,,,,,26.30,59.67,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,60977001701,NDC,facility,outpatient,10,ME,72.95000,21.16000,Aetna,First Health,,59.67,,,,,,,13.00,59.67,percent of total billed charges,
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,60977001673,NDC,facility,inpatient,5,ME,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,6.69,15.17,percent of total billed charges,
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,60977001673,NDC,facility,outpatient,5,ME,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,6.86,41.63,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,60976059755,NDC,facility,inpatient,50,ME,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,10.59,14.44,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,60976059755,NDC,facility,outpatient,50,ME,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,0.05778,14.44,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,60976034747,NDC,,,facility,inpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,4.44,6.05,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,60976034747,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,2.67,6.05,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,60951060768,NDC,,,facility,inpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,4.32,5.89,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,60951060768,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,60951060568,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,60951060568,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,60951060368,NDC,,,facility,inpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,3.03,4.13,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,60951060368,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,1.82,4.13,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,60793085601,NDC,,,facility,inpatient,1,EA,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,5.76,7.85,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,60793085601,NDC,,,facility,outpatient,1,EA,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,60793085501,NDC,,,facility,inpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,5.67,7.73,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,60793085501,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,3.41,7.73,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,60793085301,NDC,,,facility,inpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,4.89,6.67,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,60793085301,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,2.94,6.67,percent of total billed charges,
Pen G Benzathine 1.2 (Bicillin LA)2mL,800014282,CDM,636,RC,J0561,HCPCS,60793070110,NDC,facility,inpatient,1,EA,1660.25000,481.47000,Aetna,First Health,,1358.08,,,,,,,598.52,1358.08,percent of total billed charges,
Pen G Benzathine 1.2 (Bicillin LA)2mL,800014282,CDM,636,RC,J0561,HCPCS,60793070110,NDC,facility,outpatient,1,EA,1660.25000,481.47000,Aetna,First Health,,1358.08,,,,,,,30.79,1358.08,percent of total billed charges,
"Thrombin Bovine 20,000IUTp Kit",800050970,CDM,250,RC,60793021722,NDC,,,facility,inpatient,1,EA,2370.15000,687.34000,Aetna,First Health,,1938.78,,,,,,,876.96,1938.78,percent of total billed charges,
"Thrombin Bovine 20,000IUTp Kit",800050970,CDM,250,RC,60793021722,NDC,,,facility,outpatient,1,EA,2370.15000,687.34000,Aetna,First Health,,1938.78,,,,,,,854.44,1938.78,percent of total billed charges,
"Thrombin Bovine 20,000IUTp Kit",800050970,CDM,250,RC,60793021721,NDC,,,facility,inpatient,1,EA,2370.15000,687.34000,Aetna,First Health,,1938.78,,,,,,,876.96,1938.78,percent of total billed charges,
"Thrombin Bovine 20,000IUTp Kit",800050970,CDM,250,RC,60793021721,NDC,,,facility,outpatient,1,EA,2370.15000,687.34000,Aetna,First Health,,1938.78,,,,,,,854.44,1938.78,percent of total billed charges,
Thrombin Bovine 5000 IU,800016857,CDM,250,RC,60793021505,NDC,,,facility,inpatient,1,EA,592.90000,171.94000,Aetna,First Health,,484.99,,,,,,,219.37,484.99,percent of total billed charges,
Thrombin Bovine 5000 IU,800016857,CDM,250,RC,60793021505,NDC,,,facility,outpatient,1,EA,592.90000,171.94000,Aetna,First Health,,484.99,,,,,,,213.74,484.99,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,60793013605,NDC,,,facility,inpatient,1,EA,90.30000,26.19000,Aetna,First Health,,73.87,,,,,,,54.18,73.87,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,60793013605,NDC,,,facility,outpatient,1,EA,90.30000,26.19000,Aetna,First Health,,73.87,,,,,,,32.55,73.87,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,60793013601,NDC,,,facility,inpatient,1,EA,90.30000,26.19000,Aetna,First Health,,73.87,,,,,,,54.18,73.87,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,60793013601,NDC,,,facility,outpatient,1,EA,90.30000,26.19000,Aetna,First Health,,73.87,,,,,,,32.55,73.87,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,60793011601,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,60793011601,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,60793011501,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,60793011501,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,60758090810,NDC,,,facility,inpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,55.53,75.71,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,60758090810,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,33.36,75.71,percent of total billed charges,
Fluorometholone 0.1% 5mL Ophth Susp,800018804,CDM,637,RC,60758088005,NDC,,,facility,inpatient,1,EA,605.00000,175.45000,Aetna,First Health,,494.89,,,,,,,363.00,494.89,percent of total billed charges,
Fluorometholone 0.1% 5mL Ophth Susp,800018804,CDM,637,RC,60758088005,NDC,,,facility,outpatient,1,EA,605.00000,175.45000,Aetna,First Health,,494.89,,,,,,,218.10,494.89,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60758080210,NDC,,,facility,inpatient,1,EA,26.35000,7.64000,Aetna,First Health,,21.55,,,,,,,15.81,21.55,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60758080210,NDC,,,facility,outpatient,1,EA,26.35000,7.64000,Aetna,First Health,,21.55,,,,,,,9.50,21.55,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60758080205,NDC,,,facility,inpatient,1,EA,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,15.21,20.74,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60758080205,NDC,,,facility,outpatient,1,EA,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,9.14,20.74,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,60758080105,NDC,,,facility,inpatient,1,EA,46.45000,13.47000,Aetna,First Health,,38.00,,,,,,,27.87,38.00,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,60758080105,NDC,,,facility,outpatient,1,EA,46.45000,13.47000,Aetna,First Health,,38.00,,,,,,,16.75,38.00,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,60758011910,NDC,,,facility,inpatient,1,EA,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,216.60,295.30,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,60758011910,NDC,,,facility,outpatient,1,EA,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,130.14,295.30,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,60758011905,NDC,,,facility,inpatient,1,EA,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,216.60,295.30,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,60758011905,NDC,,,facility,outpatient,1,EA,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,130.14,295.30,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,60687086801,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,60687086801,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,60687083801,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,60687083801,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,60687083601,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,60687083601,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,60687083301,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,60687083301,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,60687082601,NDC,,,facility,inpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,3.75,5.11,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,60687082601,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,60687082201,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,60687082201,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,60687081501,NDC,,,facility,inpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,2.64,3.60,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,60687081501,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,60687081201,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,60687081201,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,60687080701,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,60687080701,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,60687080017,NDC,,,facility,inpatient,1,EA,16.15000,4.68000,Aetna,First Health,,13.21,,,,,,,9.69,13.21,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,60687080017,NDC,,,facility,outpatient,1,EA,16.15000,4.68000,Aetna,First Health,,13.21,,,,,,,5.82,13.21,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,60687079501,NDC,,,facility,inpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.84000,1.15,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,60687079501,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.50470,1.15,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,60687079201,NDC,,,facility,inpatient,1,EA,47.85000,13.88000,Aetna,First Health,,39.14,,,,,,,28.71,39.14,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,60687079201,NDC,,,facility,outpatient,1,EA,47.85000,13.88000,Aetna,First Health,,39.14,,,,,,,17.25,39.14,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,60687078201,NDC,,,facility,inpatient,1,EA,15.75000,4.57000,Aetna,First Health,,12.88,,,,,,,9.45,12.88,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,60687078201,NDC,,,facility,outpatient,1,EA,15.75000,4.57000,Aetna,First Health,,12.88,,,,,,,5.68,12.88,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,60687077701,NDC,,,facility,inpatient,1,EA,28.20000,8.18000,Aetna,First Health,,23.07,,,,,,,16.92,23.07,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,60687077701,NDC,,,facility,outpatient,1,EA,28.20000,8.18000,Aetna,First Health,,23.07,,,,,,,10.17,23.07,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,60687076821,NDC,,,facility,inpatient,1,EA,13.55000,3.93000,Aetna,First Health,,11.08,,,,,,,8.13,11.08,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,60687076821,NDC,,,facility,outpatient,1,EA,13.55000,3.93000,Aetna,First Health,,11.08,,,,,,,4.88,11.08,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,60687075821,NDC,,,facility,inpatient,1,EA,36.35000,10.54000,Aetna,First Health,,29.73,,,,,,,21.81,29.73,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,60687075821,NDC,,,facility,outpatient,1,EA,36.35000,10.54000,Aetna,First Health,,29.73,,,,,,,13.10,29.73,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,60687075609,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,60687075609,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,60687075021,NDC,,,facility,inpatient,1,EA,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,21.90,29.86,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,60687075021,NDC,,,facility,outpatient,1,EA,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,13.16,29.86,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,60687074721,NDC,,,facility,inpatient,1,EA,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,21.72,29.61,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,60687074721,NDC,,,facility,outpatient,1,EA,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,13.05,29.61,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,60687074601,NDC,,,facility,inpatient,1,EA,19.30000,5.60000,Aetna,First Health,,15.79,,,,,,,11.58,15.79,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,60687074601,NDC,,,facility,outpatient,1,EA,19.30000,5.60000,Aetna,First Health,,15.79,,,,,,,6.96,15.79,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,60687074501,NDC,,,facility,inpatient,1,EA,54.50000,15.80000,Aetna,First Health,,44.58,,,,,,,32.70,44.58,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,60687074501,NDC,,,facility,outpatient,1,EA,54.50000,15.80000,Aetna,First Health,,44.58,,,,,,,19.65,44.58,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,60687074421,NDC,,,facility,inpatient,1,EA,101.75000,29.51000,Aetna,First Health,,83.23,,,,,,,61.05,83.23,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,60687074421,NDC,,,facility,outpatient,1,EA,101.75000,29.51000,Aetna,First Health,,83.23,,,,,,,36.68,83.23,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,60687074265,NDC,,,facility,inpatient,1,EA,13.25000,3.84000,Aetna,First Health,,10.84,,,,,,,7.95,10.84,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,60687074265,NDC,,,facility,outpatient,1,EA,13.25000,3.84000,Aetna,First Health,,10.84,,,,,,,4.78,10.84,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,60687073856,NDC,,,facility,inpatient,1,EA,77.20000,22.39000,Aetna,First Health,,63.15,,,,,,,46.32,63.15,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,60687073856,NDC,,,facility,outpatient,1,EA,77.20000,22.39000,Aetna,First Health,,63.15,,,,,,,27.83,63.15,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,60687073665,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,60687073665,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,60687073501,NDC,,,facility,inpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,10.53,14.36,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,60687073501,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,6.33,14.36,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,60687073401,NDC,,,facility,inpatient,1,EA,54.50000,15.80000,Aetna,First Health,,44.58,,,,,,,32.70,44.58,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,60687073401,NDC,,,facility,outpatient,1,EA,54.50000,15.80000,Aetna,First Health,,44.58,,,,,,,19.65,44.58,percent of total billed charges,
dexaMETHasone 6mg Tab UD,800062110,CDM,637,RC,J8540,HCPCS,60687072901,NDC,facility,inpatient,6,ME,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,8.07,11.00,percent of total billed charges,
dexaMETHasone 6mg Tab UD,800062110,CDM,637,RC,J8540,HCPCS,60687072901,NDC,facility,outpatient,6,ME,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,0.00963,11.00,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,60687072721,NDC,,,facility,inpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,47.37,64.58,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,60687072721,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,28.46,64.58,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,60687072321,NDC,,,facility,inpatient,1,EA,57.80000,16.76000,Aetna,First Health,,47.28,,,,,,,34.68,47.28,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,60687072321,NDC,,,facility,outpatient,1,EA,57.80000,16.76000,Aetna,First Health,,47.28,,,,,,,20.84,47.28,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,60687071801,NDC,facility,inpatient,4,ME,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,60687071801,NDC,facility,outpatient,4,ME,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,0.00963,6.99,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,60687071701,NDC,,,facility,inpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,2.22,3.03,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,60687071701,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,60687071521,NDC,,,facility,inpatient,1,EA,35.45000,10.28000,Aetna,First Health,,29.00,,,,,,,21.27,29.00,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,60687071521,NDC,,,facility,outpatient,1,EA,35.45000,10.28000,Aetna,First Health,,29.00,,,,,,,12.78,29.00,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,60687070765,NDC,facility,inpatient,50,ME,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,60687070765,NDC,facility,outpatient,50,ME,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,0.21186,2.78,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,60687069501,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,60687069501,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,60687068101,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,60687068101,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,60687067801,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,60687067801,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,60687067701,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,60687067701,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,60687067657,NDC,,,facility,inpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,11.31,15.42,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,60687067657,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,6.80,15.42,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,60687067501,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,60687067501,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,60687067265,NDC,,,facility,inpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,8.28,11.29,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,60687067265,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,4.97,11.29,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,60687066621,NDC,,,facility,inpatient,1,EA,50.50000,14.64000,Aetna,First Health,,41.31,,,,,,,30.30,41.31,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,60687066621,NDC,,,facility,outpatient,1,EA,50.50000,14.64000,Aetna,First Health,,41.31,,,,,,,18.21,41.31,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,60687066101,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,60687066101,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),800015411,CDM,637,RC,Q0169,HCPCS,60687066001,NDC,facility,inpatient,12.5,ME,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),800015411,CDM,637,RC,Q0169,HCPCS,60687066001,NDC,facility,outpatient,12.5,ME,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,0.24075,3.27,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,60687065701,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,60687065701,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,60687065621,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,60687065621,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,60687065521,NDC,,,facility,inpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,5.52,7.53,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,60687065521,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,3.32,7.53,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,60687065121,NDC,,,facility,inpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,4.07,9.00,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,60687065121,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,3.97,9.00,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,60687064121,NDC,,,facility,inpatient,1,EA,24.85000,7.21000,Aetna,First Health,,20.33,,,,,,,14.91,20.33,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,60687064121,NDC,,,facility,outpatient,1,EA,24.85000,7.21000,Aetna,First Health,,20.33,,,,,,,8.96,20.33,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,60687064001,NDC,,,facility,inpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,2.64,3.60,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,60687064001,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,60687063994,NDC,,,facility,inpatient,1,EA,45.70000,13.25000,Aetna,First Health,,37.38,,,,,,,27.42,37.38,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,60687063994,NDC,,,facility,outpatient,1,EA,45.70000,13.25000,Aetna,First Health,,37.38,,,,,,,16.47,37.38,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,60687063801,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,60687063801,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,60687063601,NDC,facility,inpatient,4,ME,169.50000,49.15000,Aetna,First Health,,138.65,,,,,,,61.10,138.65,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,60687063601,NDC,facility,outpatient,4,ME,169.50000,49.15000,Aetna,First Health,,138.65,,,,,,,0.00963,138.65,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,60687063401,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,60687063401,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,60687063365,NDC,,,facility,inpatient,1,EA,30.35000,8.80000,Aetna,First Health,,24.83,,,,,,,18.21,24.83,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,60687063365,NDC,,,facility,outpatient,1,EA,30.35000,8.80000,Aetna,First Health,,24.83,,,,,,,10.94,24.83,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,60687063021,NDC,,,facility,inpatient,1,EA,11.75000,3.41000,Aetna,First Health,,9.61,,,,,,,7.05,9.61,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,60687063021,NDC,,,facility,outpatient,1,EA,11.75000,3.41000,Aetna,First Health,,9.61,,,,,,,4.24,9.61,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,60687062872,NDC,,,facility,inpatient,1,EA,183.90000,53.33000,Aetna,First Health,,150.43,,,,,,,110.34,150.43,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,60687062872,NDC,,,facility,outpatient,1,EA,183.90000,53.33000,Aetna,First Health,,150.43,,,,,,,66.30,150.43,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,60687062871,NDC,,,facility,inpatient,1,EA,118.25000,34.29000,Aetna,First Health,,96.73,,,,,,,70.95,96.73,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,60687062871,NDC,,,facility,outpatient,1,EA,118.25000,34.29000,Aetna,First Health,,96.73,,,,,,,42.63,96.73,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,60687062701,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,60687062701,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,60687062401,NDC,,,facility,inpatient,1,EA,23.35000,6.77000,Aetna,First Health,,19.10,,,,,,,14.01,19.10,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,60687062401,NDC,,,facility,outpatient,1,EA,23.35000,6.77000,Aetna,First Health,,19.10,,,,,,,8.42,19.10,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,60687062301,NDC,,,facility,inpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,5.49,7.48,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,60687062301,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.30,7.48,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,60687062001,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,60687062001,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,60687061701,NDC,,,facility,inpatient,1,EA,9.90000,2.87000,Aetna,First Health,,8.10,,,,,,,5.94,8.10,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,60687061701,NDC,,,facility,outpatient,1,EA,9.90000,2.87000,Aetna,First Health,,8.10,,,,,,,3.57,8.10,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,60687060721,NDC,,,facility,inpatient,1,EA,18.20000,5.28000,Aetna,First Health,,14.89,,,,,,,10.92,14.89,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,60687060721,NDC,,,facility,outpatient,1,EA,18.20000,5.28000,Aetna,First Health,,14.89,,,,,,,6.56,14.89,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,60687060501,NDC,,,facility,inpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,60687060501,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.79310,1.80,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,60687060201,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,60687060201,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,60687059801,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,60687059801,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,60687059632,NDC,,,facility,inpatient,1,EA,114.70000,33.26000,Aetna,First Health,,93.82,,,,,,,68.82,93.82,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,60687059632,NDC,,,facility,outpatient,1,EA,114.70000,33.26000,Aetna,First Health,,93.82,,,,,,,41.35,93.82,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,60687059501,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,60687059501,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,60687059301,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,60687059301,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,60687059101,NDC,,,facility,inpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,5.85,7.98,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,60687059101,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,3.51,7.98,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,60687059001,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,60687059001,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,60687058701,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,60687058701,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,60687058601,NDC,,,facility,inpatient,1,EA,15.80000,4.58000,Aetna,First Health,,12.92,,,,,,,9.48,12.92,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,60687058601,NDC,,,facility,outpatient,1,EA,15.80000,4.58000,Aetna,First Health,,12.92,,,,,,,5.70,12.92,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,60687058421,NDC,,,facility,inpatient,1,EA,24.20000,7.02000,Aetna,First Health,,19.80,,,,,,,14.52,19.80,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,60687058421,NDC,,,facility,outpatient,1,EA,24.20000,7.02000,Aetna,First Health,,19.80,,,,,,,8.72,19.80,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,60687058201,NDC,,,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,8.49,11.57,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,60687058201,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,60687058121,NDC,,,facility,inpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,4.26,5.81,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,60687058121,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,2.56,5.81,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,60687058001,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,60687058001,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,60687057901,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,60687057901,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,60687057701,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,60687057701,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Midazolam HCl 5mg/2.5mL L UD,800078849,CDM,637,RC,60687057610,NDC,,,facility,inpatient,1,EA,51.20000,14.85000,Aetna,First Health,,41.88,,,,,,,30.72,41.88,percent of total billed charges,
Midazolam HCl 5mg/2.5mL L UD,800078849,CDM,637,RC,60687057610,NDC,,,facility,outpatient,1,EA,51.20000,14.85000,Aetna,First Health,,41.88,,,,,,,18.46,41.88,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,60687056801,NDC,,,facility,inpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,1.59,2.17,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,60687056801,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,60687056301,NDC,,,facility,inpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,3.66,4.99,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,60687056301,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,2.20,4.99,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,60687056201,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,60687056201,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,60687055901,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,60687055901,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,60687055801,NDC,,,facility,inpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.90000,1.23,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,60687055801,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.54075,1.23,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,60687055301,NDC,,,facility,inpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,5.61,7.65,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,60687055301,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,3.37,7.65,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,60687055001,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,60687055001,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,60687054921,NDC,,,facility,inpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,7.14,9.73,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,60687054921,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,4.29,9.73,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,60687054401,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,60687054401,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,60687053478,NDC,,,facility,inpatient,1,EA,249.05000,72.22000,Aetna,First Health,,203.72,,,,,,,149.43,203.72,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,60687053478,NDC,,,facility,outpatient,1,EA,249.05000,72.22000,Aetna,First Health,,203.72,,,,,,,89.78,203.72,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,60687052521,NDC,,,facility,inpatient,1,EA,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,131.40,179.14,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,60687052521,NDC,,,facility,outpatient,1,EA,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,78.95,179.14,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,60687051365,NDC,,,facility,inpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,8.55,11.66,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,60687051365,NDC,,,facility,outpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,5.14,11.66,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,60687051101,NDC,,,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,8.49,11.57,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,60687051101,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,60687050701,NDC,,,facility,inpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,10.29,14.03,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,60687050701,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,6.18,14.03,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,60687050601,NDC,,,facility,inpatient,1,EA,12.95000,3.76000,Aetna,First Health,,10.59,,,,,,,7.77,10.59,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,60687050601,NDC,,,facility,outpatient,1,EA,12.95000,3.76000,Aetna,First Health,,10.59,,,,,,,4.67,10.59,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,60687050401,NDC,,,facility,inpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,7.68,10.47,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,60687050401,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,4.61,10.47,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,60687050301,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,60687050301,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,60687049701,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,60687049701,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,60687049501,NDC,,,facility,inpatient,1,EA,12.95000,3.76000,Aetna,First Health,,10.59,,,,,,,7.77,10.59,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,60687049501,NDC,,,facility,outpatient,1,EA,12.95000,3.76000,Aetna,First Health,,10.59,,,,,,,4.67,10.59,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,60687049301,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,60687049301,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,60687048601,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,60687048601,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,60687048401,NDC,,,facility,inpatient,1,EA,12.95000,3.76000,Aetna,First Health,,10.59,,,,,,,7.77,10.59,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,60687048401,NDC,,,facility,outpatient,1,EA,12.95000,3.76000,Aetna,First Health,,10.59,,,,,,,4.67,10.59,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,60687048021,NDC,,,facility,inpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,5.79,7.89,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,60687048021,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,3.48,7.89,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,60687047901,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,60687047901,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,60687047501,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,60687047501,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,60687047301,NDC,,,facility,inpatient,1,EA,12.95000,3.76000,Aetna,First Health,,10.59,,,,,,,7.77,10.59,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,60687047301,NDC,,,facility,outpatient,1,EA,12.95000,3.76000,Aetna,First Health,,10.59,,,,,,,4.67,10.59,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,60687046801,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,60687046801,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,60687046501,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,60687046501,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,60687046401,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,60687046401,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,60687045701,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,60687045701,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,60687045401,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,60687045401,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,60687045301,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,60687045301,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,60687045201,NDC,,,facility,inpatient,1,EA,110.35000,32.00000,Aetna,First Health,,90.27,,,,,,,66.21,90.27,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,60687045201,NDC,,,facility,outpatient,1,EA,110.35000,32.00000,Aetna,First Health,,90.27,,,,,,,39.78,90.27,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,60687045121,NDC,,,facility,inpatient,1,EA,35.40000,10.27000,Aetna,First Health,,28.96,,,,,,,21.24,28.96,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,60687045121,NDC,,,facility,outpatient,1,EA,35.40000,10.27000,Aetna,First Health,,28.96,,,,,,,12.76,28.96,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,60687045001,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,60687045001,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),800081264,CDM,637,RC,J0603,HCPCS,60687044901,NDC,facility,inpatient,800,ME,63.20000,18.33000,Aetna,First Health,,51.70,,,,,,,37.92,51.70,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),800081264,CDM,637,RC,J0603,HCPCS,60687044901,NDC,facility,outpatient,800,ME,63.20000,18.33000,Aetna,First Health,,51.70,,,,,,,0.19260,51.70,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,60687044701,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,10.32,14.07,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,60687044701,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,60687044601,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,60687044601,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,60687044301,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,60687044301,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,60687043901,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,60687043901,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,60687043701,NDC,,,facility,inpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,2.58,3.52,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,60687043701,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,1.55,3.52,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,60687043301,NDC,,,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,2.19,2.99,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,60687043301,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.32,2.99,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,60687042865,NDC,,,facility,inpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,4.08,5.56,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,60687042865,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,2.45,5.56,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,60687042501,NDC,,,facility,inpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,5.31,7.24,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,60687042501,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,3.19,7.24,percent of total billed charges,
cloBAZam 10mg Tab UD,800051956,CDM,637,RC,60687042321,NDC,,,facility,inpatient,1,EA,24.95000,7.24000,Aetna,First Health,,20.41,,,,,,,14.97,20.41,percent of total billed charges,
cloBAZam 10mg Tab UD,800051956,CDM,637,RC,60687042321,NDC,,,facility,outpatient,1,EA,24.95000,7.24000,Aetna,First Health,,20.41,,,,,,,8.99,20.41,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,60687041801,NDC,,,facility,inpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,5.28,7.20,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,60687041801,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,3.17,7.20,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,60687041501,NDC,,,facility,inpatient,1,EA,24.50000,7.10000,Aetna,First Health,,20.04,,,,,,,14.70,20.04,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,60687041501,NDC,,,facility,outpatient,1,EA,24.50000,7.10000,Aetna,First Health,,20.04,,,,,,,8.83,20.04,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,60687041301,NDC,,,facility,inpatient,1,EA,11.85000,3.44000,Aetna,First Health,,9.69,,,,,,,7.11,9.69,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,60687041301,NDC,,,facility,outpatient,1,EA,11.85000,3.44000,Aetna,First Health,,9.69,,,,,,,4.27,9.69,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,60687040825,NDC,,,facility,inpatient,1,EA,116.10000,33.67000,Aetna,First Health,,94.97,,,,,,,69.66,94.97,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,60687040825,NDC,,,facility,outpatient,1,EA,116.10000,33.67000,Aetna,First Health,,94.97,,,,,,,41.85,94.97,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,60687040677,NDC,,,facility,inpatient,1,EA,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,33.99,46.34,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,60687040677,NDC,,,facility,outpatient,1,EA,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,20.42,46.34,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,60687040401,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,60687040401,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,60687040265,NDC,,,facility,inpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,3.63,4.95,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,60687040265,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,2.18,4.95,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,60687040101,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,60687040101,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,60687039801,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,60687039801,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,60687039601,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,60687039601,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,60687039001,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,60687039001,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,60687038921,NDC,,,facility,inpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,47.37,64.58,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,60687038921,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,28.46,64.58,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,60687038801,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,60687038801,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,60687038525,NDC,,,facility,inpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,16.98,23.15,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,60687038525,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,10.20,23.15,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,60687038401,NDC,,,facility,inpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,5.52,7.53,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,60687038401,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,3.32,7.53,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,60687038194,NDC,,,facility,inpatient,1,EA,531.55000,154.15000,Aetna,First Health,,434.81,,,,,,,318.93,434.81,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,60687038194,NDC,,,facility,outpatient,1,EA,531.55000,154.15000,Aetna,First Health,,434.81,,,,,,,191.62,434.81,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,60687037701,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,60687037701,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,60687037001,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,60687037001,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,60687036901,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,60687036901,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,60687036221,NDC,,,facility,inpatient,1,EA,58.55000,16.98000,Aetna,First Health,,47.89,,,,,,,35.13,47.89,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,60687036221,NDC,,,facility,outpatient,1,EA,58.55000,16.98000,Aetna,First Health,,47.89,,,,,,,21.11,47.89,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,60687035601,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,60687035601,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,60687035501,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,60687035501,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,60687034601,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,60687034601,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,60687034501,NDC,,,facility,inpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,3.75,5.11,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,60687034501,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,60687034172,NDC,,,facility,inpatient,1,EA,183.90000,53.33000,Aetna,First Health,,150.43,,,,,,,110.34,150.43,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,60687034172,NDC,,,facility,outpatient,1,EA,183.90000,53.33000,Aetna,First Health,,150.43,,,,,,,66.30,150.43,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,60687034171,NDC,,,facility,inpatient,1,EA,118.25000,34.29000,Aetna,First Health,,96.73,,,,,,,70.95,96.73,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,60687034171,NDC,,,facility,outpatient,1,EA,118.25000,34.29000,Aetna,First Health,,96.73,,,,,,,42.63,96.73,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,60687033301,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,60687033301,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,60687032501,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,60687032501,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,60687031921,NDC,,,facility,inpatient,1,EA,85.30000,24.74000,Aetna,First Health,,69.78,,,,,,,51.18,69.78,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,60687031921,NDC,,,facility,outpatient,1,EA,85.30000,24.74000,Aetna,First Health,,69.78,,,,,,,30.75,69.78,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,60687031201,NDC,,,facility,inpatient,1,EA,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,19.80,26.99,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,60687031201,NDC,,,facility,outpatient,1,EA,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,11.90,26.99,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,60687029301,NDC,,,facility,inpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,3.75,5.11,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,60687029301,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,60687029201,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,60687029201,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,60687028621,NDC,,,facility,inpatient,1,EA,58.60000,16.99000,Aetna,First Health,,47.93,,,,,,,35.16,47.93,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,60687028621,NDC,,,facility,outpatient,1,EA,58.60000,16.99000,Aetna,First Health,,47.93,,,,,,,21.13,47.93,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,60687028265,NDC,,,facility,inpatient,1,EA,13.25000,3.84000,Aetna,First Health,,10.84,,,,,,,7.95,10.84,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,60687028265,NDC,,,facility,outpatient,1,EA,13.25000,3.84000,Aetna,First Health,,10.84,,,,,,,4.78,10.84,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,60687027566,NDC,,,facility,inpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,34.14,46.54,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,60687027566,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,20.51,46.54,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,60687027294,NDC,,,facility,inpatient,1,EA,29.20000,8.47000,Aetna,First Health,,23.89,,,,,,,17.52,23.89,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,60687027294,NDC,,,facility,outpatient,1,EA,29.20000,8.47000,Aetna,First Health,,23.89,,,,,,,10.53,23.89,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,60687026256,NDC,,,facility,inpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,4.26,5.81,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,60687026256,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,2.56,5.81,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,60687025301,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,60687025301,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,60687024977,NDC,,,facility,inpatient,1,EA,50.30000,14.59000,Aetna,First Health,,41.15,,,,,,,30.18,41.15,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,60687024977,NDC,,,facility,outpatient,1,EA,50.30000,14.59000,Aetna,First Health,,41.15,,,,,,,18.13,41.15,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,60687024565,NDC,,,facility,inpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,5.85,7.98,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,60687024565,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,3.51,7.98,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,60687024501,NDC,,,facility,inpatient,1,EA,50.60000,14.67000,Aetna,First Health,,41.39,,,,,,,30.36,41.39,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,60687024501,NDC,,,facility,outpatient,1,EA,50.60000,14.67000,Aetna,First Health,,41.39,,,,,,,18.24,41.39,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,800015336,CDM,637,RC,60687024477,NDC,,,facility,inpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,29.94,40.82,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,800015336,CDM,637,RC,60687024477,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,17.99,40.82,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,800015336,CDM,637,RC,60687024467,NDC,,,facility,inpatient,1,EA,47.25000,13.70000,Aetna,First Health,,38.65,,,,,,,28.35,38.65,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,800015336,CDM,637,RC,60687024467,NDC,,,facility,outpatient,1,EA,47.25000,13.70000,Aetna,First Health,,38.65,,,,,,,17.03,38.65,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,60687024201,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,60687024201,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Sertraline HCl 25mg T,800015414,CDM,637,RC,60687023101,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Sertraline HCl 25mg T,800015414,CDM,637,RC,60687023101,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,60687023001,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,60687023001,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,60687022801,NDC,,,facility,inpatient,1,EA,18.95000,5.50000,Aetna,First Health,,15.50,,,,,,,11.37,15.50,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,60687022801,NDC,,,facility,outpatient,1,EA,18.95000,5.50000,Aetna,First Health,,15.50,,,,,,,6.83,15.50,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,60687022601,NDC,,,facility,inpatient,1,EA,17.35000,5.03000,Aetna,First Health,,14.19,,,,,,,10.41,14.19,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,60687022601,NDC,,,facility,outpatient,1,EA,17.35000,5.03000,Aetna,First Health,,14.19,,,,,,,6.25,14.19,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,60687022401,NDC,,,facility,inpatient,1,EA,16.40000,4.76000,Aetna,First Health,,13.42,,,,,,,9.84,13.42,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,60687022401,NDC,,,facility,outpatient,1,EA,16.40000,4.76000,Aetna,First Health,,13.42,,,,,,,5.91,13.42,percent of total billed charges,
Entecavir 0.5mg Tab,800046457,CDM,637,RC,60687021625,NDC,,,facility,inpatient,1,EA,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,94.71,129.12,percent of total billed charges,
Entecavir 0.5mg Tab,800046457,CDM,637,RC,60687021625,NDC,,,facility,outpatient,1,EA,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,56.90,129.12,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,60687021501,NDC,,,facility,inpatient,1,EA,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,9.27,12.64,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,60687021501,NDC,,,facility,outpatient,1,EA,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,5.57,12.64,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,60687021401,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,60687021401,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,60687020601,NDC,,,facility,inpatient,1,EA,6.85000,1.99000,Aetna,First Health,,5.60,,,,,,,4.11,5.60,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,60687020601,NDC,,,facility,outpatient,1,EA,6.85000,1.99000,Aetna,First Health,,5.60,,,,,,,2.47,5.60,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,60687019501,NDC,,,facility,inpatient,1,EA,6.85000,1.99000,Aetna,First Health,,5.60,,,,,,,4.11,5.60,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,60687019501,NDC,,,facility,outpatient,1,EA,6.85000,1.99000,Aetna,First Health,,5.60,,,,,,,2.47,5.60,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,60687019221,NDC,,,facility,inpatient,1,EA,31.65000,9.18000,Aetna,First Health,,25.89,,,,,,,18.99,25.89,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,60687019221,NDC,,,facility,outpatient,1,EA,31.65000,9.18000,Aetna,First Health,,25.89,,,,,,,11.41,25.89,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,60687018821,NDC,,,facility,inpatient,1,EA,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,21.00,28.63,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,60687018821,NDC,,,facility,outpatient,1,EA,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,12.62,28.63,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,60687017357,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,60687017357,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,60687016301,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,60687016301,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,60687015501,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,60687015501,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,60687015201,NDC,,,facility,inpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,3.03,4.13,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,60687015201,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,1.82,4.13,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,60687014501,NDC,facility,inpatient,20,ME,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,60687014501,NDC,facility,outpatient,20,ME,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.00963,1.39,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,60687013801,NDC,,,facility,inpatient,1,EA,36.10000,10.47000,Aetna,First Health,,29.53,,,,,,,21.66,29.53,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,60687013801,NDC,,,facility,outpatient,1,EA,36.10000,10.47000,Aetna,First Health,,29.53,,,,,,,13.01,29.53,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,60687013401,NDC,facility,inpatient,10,ME,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.90000,1.23,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,60687013401,NDC,facility,outpatient,10,ME,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.00963,1.23,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,60687011301,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,60687011301,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,60687011221,NDC,,,facility,inpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,8.79,11.98,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,60687011221,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,5.28,11.98,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,60687010421,NDC,,,facility,inpatient,1,EA,51.80000,15.02000,Aetna,First Health,,42.37,,,,,,,31.08,42.37,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,60687010421,NDC,,,facility,outpatient,1,EA,51.80000,15.02000,Aetna,First Health,,42.37,,,,,,,18.67,42.37,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,60505708402,NDC,,,facility,inpatient,1,EA,589.00000,170.81000,Aetna,First Health,,481.80,,,,,,,353.40,481.80,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,60505708402,NDC,,,facility,outpatient,1,EA,589.00000,170.81000,Aetna,First Health,,481.80,,,,,,,212.33,481.80,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,60505708302,NDC,,,facility,inpatient,1,EA,453.15000,131.41000,Aetna,First Health,,370.68,,,,,,,271.89,370.68,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,60505708302,NDC,,,facility,outpatient,1,EA,453.15000,131.41000,Aetna,First Health,,370.68,,,,,,,163.36,370.68,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,60505708202,NDC,,,facility,inpatient,1,EA,304.60000,88.33000,Aetna,First Health,,249.16,,,,,,,182.76,249.16,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,60505708202,NDC,,,facility,outpatient,1,EA,304.60000,88.33000,Aetna,First Health,,249.16,,,,,,,109.81,249.16,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505708102,NDC,,,facility,inpatient,1,EA,170.15000,49.34000,Aetna,First Health,,139.18,,,,,,,102.09,139.18,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505708102,NDC,,,facility,outpatient,1,EA,170.15000,49.34000,Aetna,First Health,,139.18,,,,,,,61.34,139.18,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,60505700902,NDC,,,facility,inpatient,1,EA,589.00000,170.81000,Aetna,First Health,,481.80,,,,,,,353.40,481.80,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,60505700902,NDC,,,facility,outpatient,1,EA,589.00000,170.81000,Aetna,First Health,,481.80,,,,,,,212.33,481.80,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,60505700802,NDC,,,facility,inpatient,1,EA,453.15000,131.41000,Aetna,First Health,,370.68,,,,,,,271.89,370.68,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,60505700802,NDC,,,facility,outpatient,1,EA,453.15000,131.41000,Aetna,First Health,,370.68,,,,,,,163.36,370.68,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,60505700800,NDC,,,facility,inpatient,1,EA,453.15000,131.41000,Aetna,First Health,,370.68,,,,,,,271.89,370.68,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,60505700800,NDC,,,facility,outpatient,1,EA,453.15000,131.41000,Aetna,First Health,,370.68,,,,,,,163.36,370.68,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,60505700702,NDC,,,facility,inpatient,1,EA,304.60000,88.33000,Aetna,First Health,,249.16,,,,,,,182.76,249.16,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,60505700702,NDC,,,facility,outpatient,1,EA,304.60000,88.33000,Aetna,First Health,,249.16,,,,,,,109.81,249.16,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505700602,NDC,,,facility,inpatient,1,EA,170.15000,49.34000,Aetna,First Health,,139.18,,,,,,,102.09,139.18,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505700602,NDC,,,facility,outpatient,1,EA,170.15000,49.34000,Aetna,First Health,,139.18,,,,,,,61.34,139.18,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505700600,NDC,,,facility,inpatient,1,EA,170.15000,49.34000,Aetna,First Health,,139.18,,,,,,,102.09,139.18,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505700600,NDC,,,facility,outpatient,1,EA,170.15000,49.34000,Aetna,First Health,,139.18,,,,,,,61.34,139.18,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505700102,NDC,,,facility,inpatient,1,EA,170.15000,49.34000,Aetna,First Health,,139.18,,,,,,,102.09,139.18,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505700102,NDC,,,facility,outpatient,1,EA,170.15000,49.34000,Aetna,First Health,,139.18,,,,,,,61.34,139.18,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,60505628704,NDC,facility,inpatient,100,ME,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,312.55,709.21,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,60505628704,NDC,facility,outpatient,100,ME,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,0.04815,709.21,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,60505628203,NDC,facility,inpatient,50,ME,79.95000,23.19000,Aetna,First Health,,65.40,,,,,,,28.82,65.40,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,60505628203,NDC,facility,outpatient,50,ME,79.95000,23.19000,Aetna,First Health,,65.40,,,,,,,2.82,65.40,percent of total billed charges,
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,60505627700,NDC,facility,inpatient,10,ME,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,60505627700,NDC,facility,outpatient,10,ME,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,2.03,47.12,percent of total billed charges,
ceFAZolin 2g Inj (Ancef),800046483,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,inpatient,2,GM,58.50000,16.96000,Aetna,First Health,,47.85,,,,,,,21.09,47.85,percent of total billed charges,
ceFAZolin 2g Inj (Ancef),800046483,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,outpatient,2,GM,58.50000,16.96000,Aetna,First Health,,47.85,,,,,,,0.79929,47.85,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,60505622601,NDC,,,facility,inpatient,1,EA,377.20000,109.39000,Aetna,First Health,,308.55,,,,,,,226.32,308.55,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,60505622601,NDC,,,facility,outpatient,1,EA,377.20000,109.39000,Aetna,First Health,,308.55,,,,,,,135.98,308.55,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,60505619604,NDC,facility,inpatient,1,GM,1000.15000,290.04000,Aetna,First Health,,818.12,,,,,,,360.55,818.12,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,60505619604,NDC,facility,outpatient,1,GM,1000.15000,290.04000,Aetna,First Health,,818.12,,,,,,,8.82,818.12,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,60505619301,NDC,facility,inpatient,0.25,ME,731.75000,212.21000,Aetna,First Health,,598.57,,,,,,,263.80,598.57,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,60505619301,NDC,facility,outpatient,0.25,ME,731.75000,212.21000,Aetna,First Health,,598.57,,,,,,,0.33705,598.57,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,60505616901,NDC,,,facility,inpatient,1,EA,202.00000,58.58000,Aetna,First Health,,165.24,,,,,,,74.74,165.24,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,60505616901,NDC,,,facility,outpatient,1,EA,202.00000,58.58000,Aetna,First Health,,165.24,,,,,,,72.82,165.24,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,60505615904,NDC,facility,inpatient,4.5,GM,174.00000,50.46000,Aetna,First Health,,142.33,,,,,,,62.73,142.33,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,60505615904,NDC,facility,outpatient,4.5,GM,174.00000,50.46000,Aetna,First Health,,142.33,,,,,,,1.05,142.33,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,60505615704,NDC,facility,inpatient,3.375,GM,137.40000,39.85000,Aetna,First Health,,112.39,,,,,,,49.53,112.39,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,60505615704,NDC,facility,outpatient,3.375,GM,137.40000,39.85000,Aetna,First Health,,112.39,,,,,,,1.05,112.39,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505615604,NDC,facility,inpatient,2.25,GM,91.60000,26.56000,Aetna,First Health,,74.93,,,,,,,33.02,74.93,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505615604,NDC,facility,outpatient,2.25,GM,91.60000,26.56000,Aetna,First Health,,74.93,,,,,,,1.05,74.93,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505615600,NDC,facility,inpatient,2.25,GM,94.70000,27.46000,Aetna,First Health,,77.46,,,,,,,34.14,77.46,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505615600,NDC,facility,outpatient,2.25,GM,94.70000,27.46000,Aetna,First Health,,77.46,,,,,,,1.05,77.46,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,60505614904,NDC,facility,inpatient,2,GM,435.45000,126.28000,Aetna,First Health,,356.20,,,,,,,156.98,356.20,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,60505614904,NDC,facility,outpatient,2,GM,435.45000,126.28000,Aetna,First Health,,356.20,,,,,,,0.44298,356.20,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505614704,NDC,facility,inpatient,2,GM,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,113.79,258.20,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505614704,NDC,facility,outpatient,2,GM,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,0.83781,258.20,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,58.64,133.05,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,outpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,0.83781,133.05,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505614600,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,58.64,133.05,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505614600,NDC,facility,outpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,0.83781,133.05,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505614504,NDC,facility,inpatient,2,GM,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,113.79,258.20,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505614504,NDC,facility,outpatient,2,GM,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,0.83781,258.20,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505614400,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,58.64,133.05,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505614400,NDC,facility,outpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,0.83781,133.05,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505614205,NDC,facility,inpatient,1000,ME,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505614205,NDC,facility,outpatient,1000,ME,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,0.79929,17.10,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,60505613207,NDC,facility,inpatient,100,ME,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,312.55,709.21,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,60505613207,NDC,facility,outpatient,100,ME,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,0.04815,709.21,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,60505613005,NDC,facility,inpatient,4,ME,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,60505613005,NDC,facility,outpatient,4,ME,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,0.08667,3.15,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,60505611600,NDC,facility,inpatient,0.4,ME,1187.00000,344.23000,Aetna,First Health,,970.97,,,,,,,427.91,970.97,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,60505611600,NDC,facility,outpatient,0.4,ME,1187.00000,344.23000,Aetna,First Health,,970.97,,,,,,,2.58,970.97,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,60505611000,NDC,facility,inpatient,4,ME,5990.50000,1737.24000,Aetna,First Health,,4900.23,,,,,,,2159.58,4900.23,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,60505611000,NDC,facility,outpatient,4,ME,5990.50000,1737.24000,Aetna,First Health,,4900.23,,,,,,,4.89,4900.23,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,60505610204,NDC,facility,inpatient,2,GM,435.45000,126.28000,Aetna,First Health,,356.20,,,,,,,156.98,356.20,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,60505610204,NDC,facility,outpatient,2,GM,435.45000,126.28000,Aetna,First Health,,356.20,,,,,,,0.44298,356.20,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,60505609700,NDC,facility,inpatient,3,ME,1867.25000,541.50000,Aetna,First Health,,1527.41,,,,,,,673.14,1527.41,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,60505609700,NDC,facility,outpatient,3,ME,1867.25000,541.50000,Aetna,First Health,,1527.41,,,,,,,12.65,1527.41,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,60505609401,NDC,facility,inpatient,2,GM,209.50000,60.76000,Aetna,First Health,,171.37,,,,,,,75.52,171.37,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,60505609401,NDC,facility,outpatient,2,GM,209.50000,60.76000,Aetna,First Health,,171.37,,,,,,,0.79929,171.37,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505609305,NDC,facility,inpatient,1000,ME,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505609305,NDC,facility,outpatient,1000,ME,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,0.79929,17.10,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,60505608004,NDC,facility,inpatient,7.5,ME,581.30000,168.58000,Aetna,First Health,,475.50,,,,,,,209.56,475.50,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,60505608004,NDC,facility,outpatient,7.5,ME,581.30000,168.58000,Aetna,First Health,,475.50,,,,,,,0.84744,475.50,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,60505607804,NDC,facility,inpatient,2.5,ME,277.10000,80.36000,Aetna,First Health,,226.67,,,,,,,99.89,226.67,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,60505607804,NDC,facility,outpatient,2.5,ME,277.10000,80.36000,Aetna,First Health,,226.67,,,,,,,0.84744,226.67,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505603104,NDC,facility,inpatient,2,GM,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,113.79,258.20,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505603104,NDC,facility,outpatient,2,GM,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,0.83781,258.20,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,60505477303,NDC,,,facility,inpatient,1,EA,80.30000,23.29000,Aetna,First Health,,65.69,,,,,,,48.18,65.69,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,60505477303,NDC,,,facility,outpatient,1,EA,80.30000,23.29000,Aetna,First Health,,65.69,,,,,,,28.95,65.69,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,60505470400,NDC,,,facility,inpatient,1,EA,3154.10000,914.69000,Aetna,First Health,,2580.05,,,,,,,1892.46,2580.05,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,60505470400,NDC,,,facility,outpatient,1,EA,3154.10000,914.69000,Aetna,First Health,,2580.05,,,,,,,1137.05,2580.05,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,60505464303,NDC,,,facility,inpatient,1,EA,116.85000,33.89000,Aetna,First Health,,95.58,,,,,,,70.11,95.58,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,60505464303,NDC,,,facility,outpatient,1,EA,116.85000,33.89000,Aetna,First Health,,95.58,,,,,,,42.12,95.58,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,60505464203,NDC,,,facility,inpatient,1,EA,116.85000,33.89000,Aetna,First Health,,95.58,,,,,,,70.11,95.58,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,60505464203,NDC,,,facility,outpatient,1,EA,116.85000,33.89000,Aetna,First Health,,95.58,,,,,,,42.12,95.58,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,60505437303,NDC,,,facility,inpatient,1,EA,80.30000,23.29000,Aetna,First Health,,65.69,,,,,,,48.18,65.69,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,60505437303,NDC,,,facility,outpatient,1,EA,80.30000,23.29000,Aetna,First Health,,65.69,,,,,,,28.95,65.69,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,60505434706,NDC,,,facility,inpatient,1,EA,26.70000,7.74000,Aetna,First Health,,21.84,,,,,,,16.02,21.84,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,60505434706,NDC,,,facility,outpatient,1,EA,26.70000,7.74000,Aetna,First Health,,21.84,,,,,,,9.63,21.84,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,60505387703,NDC,,,facility,inpatient,1,EA,42.85000,12.43000,Aetna,First Health,,35.05,,,,,,,25.71,35.05,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,60505387703,NDC,,,facility,outpatient,1,EA,42.85000,12.43000,Aetna,First Health,,35.05,,,,,,,15.45,35.05,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,60505378009,NDC,,,facility,inpatient,1,EA,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,22.86,31.17,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,60505378009,NDC,,,facility,outpatient,1,EA,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,13.74,31.17,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,60505377909,NDC,,,facility,inpatient,1,EA,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,21.00,28.63,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,60505377909,NDC,,,facility,outpatient,1,EA,35.00000,10.15000,Aetna,First Health,,28.63,,,,,,,12.62,28.63,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,60505377903,NDC,,,facility,inpatient,1,EA,34.95000,10.14000,Aetna,First Health,,28.59,,,,,,,20.97,28.59,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,60505377903,NDC,,,facility,outpatient,1,EA,34.95000,10.14000,Aetna,First Health,,28.59,,,,,,,12.60,28.59,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,60505366303,NDC,,,facility,inpatient,1,EA,52.35000,15.18000,Aetna,First Health,,42.82,,,,,,,31.41,42.82,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,60505366303,NDC,,,facility,outpatient,1,EA,52.35000,15.18000,Aetna,First Health,,42.82,,,,,,,18.87,42.82,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,60505327500,NDC,,,facility,inpatient,1,EA,101.05000,29.30000,Aetna,First Health,,82.66,,,,,,,60.63,82.66,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,60505327500,NDC,,,facility,outpatient,1,EA,101.05000,29.30000,Aetna,First Health,,82.66,,,,,,,36.43,82.66,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,60505324703,NDC,,,facility,inpatient,1,EA,98.75000,28.64000,Aetna,First Health,,80.78,,,,,,,59.25,80.78,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,60505324703,NDC,,,facility,outpatient,1,EA,98.75000,28.64000,Aetna,First Health,,80.78,,,,,,,35.60,80.78,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,60505324603,NDC,,,facility,inpatient,1,EA,49.20000,14.27000,Aetna,First Health,,40.25,,,,,,,29.52,40.25,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,60505324603,NDC,,,facility,outpatient,1,EA,49.20000,14.27000,Aetna,First Health,,40.25,,,,,,,17.74,40.25,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,60505313301,NDC,,,facility,inpatient,1,EA,48.55000,14.08000,Aetna,First Health,,39.71,,,,,,,29.13,39.71,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,60505313301,NDC,,,facility,outpatient,1,EA,48.55000,14.08000,Aetna,First Health,,39.71,,,,,,,17.50,39.71,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,60505313001,NDC,,,facility,inpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,16.98,23.15,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,60505313001,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,10.20,23.15,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,60505311003,NDC,,,facility,inpatient,1,EA,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,47.58,64.87,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,60505311003,NDC,,,facility,outpatient,1,EA,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,28.59,64.87,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,60505311000,NDC,,,facility,inpatient,1,EA,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,47.58,64.87,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,60505311000,NDC,,,facility,outpatient,1,EA,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,28.59,64.87,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,60505307503,NDC,,,facility,inpatient,1,EA,226.30000,65.63000,Aetna,First Health,,185.11,,,,,,,135.78,185.11,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,60505307503,NDC,,,facility,outpatient,1,EA,226.30000,65.63000,Aetna,First Health,,185.11,,,,,,,81.58,185.11,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,60505296507,NDC,facility,inpatient,180,ME,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,19.41,26.46,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,60505296507,NDC,facility,outpatient,180,ME,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,0.30816,26.46,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,60505285001,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,60505285001,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,60505280507,NDC,,,facility,inpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,8.34,11.37,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,60505280507,NDC,,,facility,outpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,5.01,11.37,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,60505268106,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,60505268106,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,60505268102,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,60505268102,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,60505267403,NDC,,,facility,inpatient,1,EA,226.30000,65.63000,Aetna,First Health,,185.11,,,,,,,135.78,185.11,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,60505267403,NDC,,,facility,outpatient,1,EA,226.30000,65.63000,Aetna,First Health,,185.11,,,,,,,81.58,185.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,60505267303,NDC,,,facility,inpatient,1,EA,226.30000,65.63000,Aetna,First Health,,185.11,,,,,,,135.78,185.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,60505267303,NDC,,,facility,outpatient,1,EA,226.30000,65.63000,Aetna,First Health,,185.11,,,,,,,81.58,185.11,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,60505266401,NDC,,,facility,inpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,20.19,27.53,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,60505266401,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,12.13,27.53,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,60505266301,NDC,,,facility,inpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,17.67,24.09,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,60505266301,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,10.62,24.09,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,60505265605,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,60505265605,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,60505265601,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,60505265601,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,60505265401,NDC,,,facility,inpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,5.91,8.06,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,60505265401,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,3.55,8.06,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,60505265301,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,60505265301,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,60505260801,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,60505260801,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,60505260601,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,60505260601,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,60505260500,NDC,,,facility,inpatient,1,EA,37.15000,10.77000,Aetna,First Health,,30.39,,,,,,,22.29,30.39,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,60505260500,NDC,,,facility,outpatient,1,EA,37.15000,10.77000,Aetna,First Health,,30.39,,,,,,,13.39,30.39,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,60505260400,NDC,,,facility,inpatient,1,EA,37.15000,10.77000,Aetna,First Health,,30.39,,,,,,,22.29,30.39,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,60505260400,NDC,,,facility,outpatient,1,EA,37.15000,10.77000,Aetna,First Health,,30.39,,,,,,,13.39,30.39,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,60505258605,NDC,,,facility,inpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,19.32,26.34,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,60505258605,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,60505258406,NDC,,,facility,inpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,16.56,22.58,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,60505258406,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,60505258009,NDC,,,facility,inpatient,1,EA,40.90000,11.86000,Aetna,First Health,,33.46,,,,,,,24.54,33.46,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,60505258009,NDC,,,facility,outpatient,1,EA,40.90000,11.86000,Aetna,First Health,,33.46,,,,,,,14.74,33.46,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,60505255105,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,60505255105,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,60505255101,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,60505255101,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,60505254701,NDC,,,facility,inpatient,1,EA,15.55000,4.51000,Aetna,First Health,,12.72,,,,,,,9.33,12.72,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,60505254701,NDC,,,facility,outpatient,1,EA,15.55000,4.51000,Aetna,First Health,,12.72,,,,,,,5.61,12.72,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,60505252201,NDC,,,facility,inpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,7.74,10.55,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,60505252201,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,4.65,10.55,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,60505251602,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,60505251602,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,60505250201,NDC,,,facility,inpatient,1,EA,116.15000,33.68000,Aetna,First Health,,95.01,,,,,,,69.69,95.01,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,60505250201,NDC,,,facility,outpatient,1,EA,116.15000,33.68000,Aetna,First Health,,95.01,,,,,,,41.87,95.01,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,60505132101,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,10.32,14.07,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,60505132101,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,60505100302,NDC,,,facility,inpatient,1,EA,686.30000,199.03000,Aetna,First Health,,561.39,,,,,,,411.78,561.39,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,60505100302,NDC,,,facility,outpatient,1,EA,686.30000,199.03000,Aetna,First Health,,561.39,,,,,,,247.41,561.39,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,60505084703,NDC,,,facility,inpatient,1,EA,558.40000,161.94000,Aetna,First Health,,456.77,,,,,,,335.04,456.77,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,60505084703,NDC,,,facility,outpatient,1,EA,558.40000,161.94000,Aetna,First Health,,456.77,,,,,,,201.30,456.77,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505083404,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,58.64,133.05,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505083404,NDC,facility,outpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,0.83781,133.05,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505083400,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,58.64,133.05,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505083400,NDC,facility,outpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,0.83781,133.05,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,60505083305,NDC,,,facility,inpatient,1,EA,677.25000,196.40000,Aetna,First Health,,553.99,,,,,,,406.35,553.99,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,60505083305,NDC,,,facility,outpatient,1,EA,677.25000,196.40000,Aetna,First Health,,553.99,,,,,,,244.15,553.99,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,60505082901,NDC,,,facility,inpatient,1,EA,558.40000,161.94000,Aetna,First Health,,456.77,,,,,,,335.04,456.77,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,60505082901,NDC,,,facility,outpatient,1,EA,558.40000,161.94000,Aetna,First Health,,456.77,,,,,,,201.30,456.77,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,60505082601,NDC,,,facility,inpatient,1,EA,713.10000,206.80000,Aetna,First Health,,583.32,,,,,,,427.86,583.32,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,60505082601,NDC,,,facility,outpatient,1,EA,713.10000,206.80000,Aetna,First Health,,583.32,,,,,,,257.07,583.32,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,60505082306,NDC,,,facility,inpatient,1,EA,751.45000,217.92000,Aetna,First Health,,614.69,,,,,,,450.87,614.69,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,60505082306,NDC,,,facility,outpatient,1,EA,751.45000,217.92000,Aetna,First Health,,614.69,,,,,,,270.90,614.69,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,60505081500,NDC,,,facility,inpatient,1,EA,1535.95000,445.43000,Aetna,First Health,,1256.41,,,,,,,921.57,1256.41,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,60505081500,NDC,,,facility,outpatient,1,EA,1535.95000,445.43000,Aetna,First Health,,1256.41,,,,,,,553.71,1256.41,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,60505079604,NDC,facility,inpatient,120,ME,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,41.42,93.99,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,60505079604,NDC,facility,outpatient,120,ME,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,0.51039,93.99,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,60505079504,NDC,facility,inpatient,100,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,34.52,78.32,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,60505079504,NDC,facility,outpatient,100,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,0.51039,78.32,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,60505079404,NDC,facility,inpatient,80,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,27.61,62.66,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,60505079404,NDC,facility,outpatient,80,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,0.51039,62.66,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,60505079304,NDC,facility,inpatient,60,ME,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,20.71,46.99,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,60505079304,NDC,facility,outpatient,60,ME,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,0.51039,46.99,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,60505079204,NDC,facility,inpatient,40,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,60505079204,NDC,facility,outpatient,40,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,0.51039,31.33,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,60505079200,NDC,facility,inpatient,40,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,60505079200,NDC,facility,outpatient,40,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,0.51039,31.33,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,60505076900,NDC,facility,inpatient,2,GM,209.50000,60.76000,Aetna,First Health,,171.37,,,,,,,75.52,171.37,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,60505076900,NDC,facility,outpatient,2,GM,209.50000,60.76000,Aetna,First Health,,171.37,,,,,,,0.79929,171.37,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,60505076005,NDC,facility,inpatient,2,GM,180.00000,52.20000,Aetna,First Health,,147.24,,,,,,,64.89,147.24,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,60505076005,NDC,facility,outpatient,2,GM,180.00000,52.20000,Aetna,First Health,,147.24,,,,,,,4.56,147.24,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,60505075905,NDC,facility,inpatient,1,GM,89.80000,26.04000,Aetna,First Health,,73.46,,,,,,,32.37,73.46,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,60505075905,NDC,facility,outpatient,1,GM,89.80000,26.04000,Aetna,First Health,,73.46,,,,,,,4.56,73.46,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,60505075304,NDC,facility,inpatient,2,GM,435.45000,126.28000,Aetna,First Health,,356.20,,,,,,,156.98,356.20,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,60505075304,NDC,facility,outpatient,2,GM,435.45000,126.28000,Aetna,First Health,,356.20,,,,,,,0.44298,356.20,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,60505075204,NDC,facility,inpatient,1,GM,357.65000,103.72000,Aetna,First Health,,292.56,,,,,,,128.93,292.56,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,60505075204,NDC,facility,outpatient,1,GM,357.65000,103.72000,Aetna,First Health,,292.56,,,,,,,0.44298,292.56,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505074905,NDC,facility,inpatient,1000,ME,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505074905,NDC,facility,outpatient,1000,ME,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,0.79929,17.10,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505074904,NDC,facility,inpatient,1000,ME,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505074904,NDC,facility,outpatient,1000,ME,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,0.79929,17.10,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,60505074406,NDC,facility,inpatient,4,ME,192.30000,55.77000,Aetna,First Health,,157.30,,,,,,,69.32,157.30,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,60505074406,NDC,facility,outpatient,4,ME,192.30000,55.77000,Aetna,First Health,,157.30,,,,,,,0.08667,157.30,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,60505068804,NDC,facility,inpatient,4.5,GM,174.00000,50.46000,Aetna,First Health,,142.33,,,,,,,62.73,142.33,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,60505068804,NDC,facility,outpatient,4.5,GM,174.00000,50.46000,Aetna,First Health,,142.33,,,,,,,1.05,142.33,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,60505068704,NDC,facility,inpatient,3.375,GM,137.40000,39.85000,Aetna,First Health,,112.39,,,,,,,49.53,112.39,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,60505068704,NDC,facility,outpatient,3.375,GM,137.40000,39.85000,Aetna,First Health,,112.39,,,,,,,1.05,112.39,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505068604,NDC,facility,inpatient,2.25,GM,91.60000,26.56000,Aetna,First Health,,74.93,,,,,,,33.02,74.93,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505068604,NDC,facility,outpatient,2.25,GM,91.60000,26.56000,Aetna,First Health,,74.93,,,,,,,1.05,74.93,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505068601,NDC,facility,inpatient,2.25,GM,91.60000,26.56000,Aetna,First Health,,74.93,,,,,,,33.02,74.93,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505068601,NDC,facility,outpatient,2.25,GM,91.60000,26.56000,Aetna,First Health,,74.93,,,,,,,1.05,74.93,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505068104,NDC,facility,inpatient,2,GM,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,113.79,258.20,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505068104,NDC,facility,outpatient,2,GM,315.65000,91.54000,Aetna,First Health,,258.20,,,,,,,0.83781,258.20,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505068100,NDC,facility,inpatient,2,GM,315.70000,91.55000,Aetna,First Health,,258.24,,,,,,,113.81,258.24,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505068100,NDC,facility,outpatient,2,GM,315.70000,91.55000,Aetna,First Health,,258.24,,,,,,,0.83781,258.24,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,60505066701,NDC,,,facility,inpatient,1,EA,424.15000,123.00000,Aetna,First Health,,346.95,,,,,,,156.94,346.95,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,60505066701,NDC,,,facility,outpatient,1,EA,424.15000,123.00000,Aetna,First Health,,346.95,,,,,,,152.91,346.95,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,60505059801,NDC,,,facility,inpatient,1,EA,127.45000,36.96000,Aetna,First Health,,104.25,,,,,,,76.47,104.25,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,60505059801,NDC,,,facility,outpatient,1,EA,127.45000,36.96000,Aetna,First Health,,104.25,,,,,,,45.95,104.25,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60505059701,NDC,,,facility,inpatient,1,EA,123.70000,35.87000,Aetna,First Health,,101.19,,,,,,,74.22,101.19,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60505059701,NDC,,,facility,outpatient,1,EA,123.70000,35.87000,Aetna,First Health,,101.19,,,,,,,44.59,101.19,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,60505058604,NDC,,,facility,inpatient,1,EA,1091.05000,316.40000,Aetna,First Health,,892.48,,,,,,,654.63,892.48,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,60505058604,NDC,,,facility,outpatient,1,EA,1091.05000,316.40000,Aetna,First Health,,892.48,,,,,,,393.32,892.48,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,60505056701,NDC,,,facility,inpatient,1,EA,446.25000,129.41000,Aetna,First Health,,365.03,,,,,,,267.75,365.03,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,60505056701,NDC,,,facility,outpatient,1,EA,446.25000,129.41000,Aetna,First Health,,365.03,,,,,,,160.87,365.03,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,60505056000,NDC,,,facility,inpatient,1,EA,148.25000,42.99000,Aetna,First Health,,121.27,,,,,,,88.95,121.27,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,60505056000,NDC,,,facility,outpatient,1,EA,148.25000,42.99000,Aetna,First Health,,121.27,,,,,,,53.44,121.27,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60505055202,NDC,,,facility,inpatient,1,EA,106.20000,30.80000,Aetna,First Health,,86.87,,,,,,,63.72,86.87,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60505055202,NDC,,,facility,outpatient,1,EA,106.20000,30.80000,Aetna,First Health,,86.87,,,,,,,38.29,86.87,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,60505055102,NDC,,,facility,inpatient,1,EA,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,72.21,98.45,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,60505055102,NDC,,,facility,outpatient,1,EA,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,43.39,98.45,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,60505026001,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,60505026001,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,60505025701,NDC,,,facility,inpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,12.84,17.51,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,60505025701,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,7.71,17.51,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,60505025302,NDC,,,facility,inpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,29.58,40.33,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,60505025302,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,17.77,40.33,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,60505025203,NDC,,,facility,inpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,6.21,8.47,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,60505025203,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,3.73,8.47,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,60505025103,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,60505025103,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,60505023401,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,60505023401,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,60505019402,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,60505019402,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,60505019000,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,60505019000,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,60505018103,NDC,,,facility,inpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.92,2.62,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,60505018103,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,60505017101,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,60505017101,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,60505016909,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,13.89,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,60505016909,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,60505016809,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,60505016809,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,60505016601,NDC,,,facility,inpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,11.22,15.30,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,60505016601,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,6.74,15.30,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,60505015900,NDC,,,facility,inpatient,1,EA,24.20000,7.02000,Aetna,First Health,,19.80,,,,,,,14.52,19.80,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,60505015900,NDC,,,facility,outpatient,1,EA,24.20000,7.02000,Aetna,First Health,,19.80,,,,,,,8.72,19.80,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,60505015801,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,60505015801,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,60505015701,NDC,,,facility,inpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,4.50,6.13,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,60505015701,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,2.70,6.13,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,60505014100,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,60505014100,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
cycloSPORINE 100mg C(SandIMMUNE),800017381,CDM,637,RC,J7502,HCPCS,60505013400,NDC,facility,inpatient,100,ME,125.00000,36.25000,Aetna,First Health,,102.25,,,,,,,75.00,102.25,percent of total billed charges,
cycloSPORINE 100mg C(SandIMMUNE),800017381,CDM,637,RC,J7502,HCPCS,60505013400,NDC,facility,outpatient,100,ME,125.00000,36.25000,Aetna,First Health,,102.25,,,,,,,1.74,102.25,percent of total billed charges,
cycloSPORINE 25mg C(SandIMMUNE),800017380,CDM,637,RC,J7515,HCPCS,60505013300,NDC,facility,inpatient,25,ME,31.30000,9.08000,Aetna,First Health,,25.60,,,,,,,18.78,25.60,percent of total billed charges,
cycloSPORINE 25mg C(SandIMMUNE),800017380,CDM,637,RC,J7515,HCPCS,60505013300,NDC,facility,outpatient,25,ME,31.30000,9.08000,Aetna,First Health,,25.60,,,,,,,0.51039,25.60,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,60505013201,NDC,,,facility,inpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,7.68,10.47,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,60505013201,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,4.61,10.47,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,60505013101,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,60505013101,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,60505011700,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,60505011700,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,60505011500,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,60505011500,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,60505011405,NDC,,,facility,inpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,60505011405,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,60505011401,NDC,,,facility,inpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,60505011401,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,60505011301,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,60505011301,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,60505011201,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,60505011201,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,60505009702,NDC,,,facility,inpatient,1,EA,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,11.13,15.17,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,60505009702,NDC,,,facility,outpatient,1,EA,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,6.69,15.17,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,60505009701,NDC,,,facility,inpatient,1,EA,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,11.13,15.17,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,60505009701,NDC,,,facility,outpatient,1,EA,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,6.69,15.17,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,60505009400,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,60505009400,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,60505009300,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,60505009300,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,60505008302,NDC,,,facility,inpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,11.61,15.83,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,60505008302,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,6.98,15.83,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,60505008000,NDC,,,facility,inpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,10.89,14.85,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,60505008000,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,6.54,14.85,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,60505005207,NDC,,,facility,inpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,6.48,8.83,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,60505005207,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,3.89,8.83,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,60505005107,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,60505005107,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,60505005007,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,60505005007,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,60505004907,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,60505004907,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,60505004206,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,60505004206,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Etodolac 200 mg C (Lodine),800080985,CDM,637,RC,60505003901,NDC,,,facility,inpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,6.09,8.30,percent of total billed charges,
Etodolac 200 mg C (Lodine),800080985,CDM,637,RC,60505003901,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.66,8.30,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,60505003408,NDC,,,facility,inpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,5.04,6.87,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,60505003408,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,3.03,6.87,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,60505003404,NDC,,,facility,inpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,5.28,7.20,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,60505003404,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,3.17,7.20,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,60505001506,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,60505001506,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,60505001406,NDC,,,facility,inpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,4.83,6.58,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,60505001406,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,2.90,6.58,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,60432060804,NDC,,,facility,inpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,2.64,3.60,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,60432060804,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,60432060616,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,60432060616,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,60432053760,NDC,,,facility,inpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,60432053760,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Selenium 2.5% 120mL Lotion,800065887,CDM,250,RC,60432052804,NDC,,,facility,inpatient,1,EA,142.55000,41.34000,Aetna,First Health,,116.61,,,,,,,52.74,116.61,percent of total billed charges,
Selenium 2.5% 120mL Lotion,800065887,CDM,250,RC,60432052804,NDC,,,facility,outpatient,1,EA,142.55000,41.34000,Aetna,First Health,,116.61,,,,,,,51.39,116.61,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,60432046551,NDC,,,facility,inpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,2.52,5.56,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,60432046551,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,2.45,5.56,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,60432021208,NDC,facility,inpatient,3,ME,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,60432021208,NDC,facility,outpatient,3,ME,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.88596,2.84,percent of total billed charges,
prednisoLONE Sod Phos 15mg/5mL L UD,800015349,CDM,637,RC,J7510,HCPCS,60432021208,NDC,facility,inpatient,15,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,6.69,9.12,percent of total billed charges,
prednisoLONE Sod Phos 15mg/5mL L UD,800015349,CDM,637,RC,J7510,HCPCS,60432021208,NDC,facility,outpatient,15,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,0.88596,9.12,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,60432015004,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,60432015004,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,800023340,CDM,637,RC,60432013108,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,800023340,CDM,637,RC,60432013108,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,60432012916,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,60432012916,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,60432012608,NDC,,,facility,inpatient,1,EA,42.45000,12.31000,Aetna,First Health,,34.72,,,,,,,25.47,34.72,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,60432012608,NDC,,,facility,outpatient,1,EA,42.45000,12.31000,Aetna,First Health,,34.72,,,,,,,15.30,34.72,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,60432006575,NDC,,,facility,inpatient,1,EA,30.55000,8.86000,Aetna,First Health,,24.99,,,,,,,18.33,24.99,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,60432006575,NDC,,,facility,outpatient,1,EA,30.55000,8.86000,Aetna,First Health,,24.99,,,,,,,11.01,24.99,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,800053917,CDM,637,RC,60432006575,NDC,,,facility,inpatient,1,EA,15.30000,4.44000,Aetna,First Health,,12.52,,,,,,,9.18,12.52,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,800053917,CDM,637,RC,60432006575,NDC,,,facility,outpatient,1,EA,15.30000,4.44000,Aetna,First Health,,12.52,,,,,,,5.52,12.52,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,800053917,CDM,637,RC,60432006547,NDC,,,facility,inpatient,1,EA,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,9.00,12.27,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,800053917,CDM,637,RC,60432006547,NDC,,,facility,outpatient,1,EA,15.00000,4.35000,Aetna,First Health,,12.27,,,,,,,5.41,12.27,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,60432006500,NDC,,,facility,inpatient,1,EA,30.60000,8.87000,Aetna,First Health,,25.03,,,,,,,18.36,25.03,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,60432006500,NDC,,,facility,outpatient,1,EA,30.60000,8.87000,Aetna,First Health,,25.03,,,,,,,11.03,25.03,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,60432003816,NDC,,,facility,inpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.24000,0.32720,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,60432003816,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.14420,0.32720,percent of total billed charges,
Sodium Thiosulfate 12.5g/50mL Inj,800017828,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,inpatient,12.5,GM,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,179.80,407.98,percent of total billed charges,
Sodium Thiosulfate 12.5g/50mL Inj,800017828,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,outpatient,12.5,GM,498.75000,144.64000,Aetna,First Health,,407.98,,,,,,,0.88000,407.98,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,60258085001,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,60258085001,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,60258080215,NDC,,,facility,inpatient,1,ML,19.80000,5.74000,Aetna,First Health,,16.20,,,,,,,11.88,16.20,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,60258080215,NDC,,,facility,outpatient,1,ML,19.80000,5.74000,Aetna,First Health,,16.20,,,,,,,7.14,16.20,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,60258016201,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,60258016201,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,60219126401,NDC,,,facility,inpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,60.24,82.13,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,60219126401,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,36.19,82.13,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,60219107601,NDC,facility,inpatient,50,ME,48.20000,13.98000,Aetna,First Health,,39.43,,,,,,,28.92,39.43,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,60219107601,NDC,facility,outpatient,50,ME,48.20000,13.98000,Aetna,First Health,,39.43,,,,,,,0.05778,39.43,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,59930153202,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,59930153202,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,59930150201,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,59930150201,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,59923070205,NDC,facility,inpatient,100,ME,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,89.04,202.05,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,59923070205,NDC,facility,outpatient,100,ME,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,1.72,202.05,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,59911589801,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,59911589801,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,59911586901,NDC,,,facility,inpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,5.31,7.24,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,59911586901,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,3.19,7.24,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,59911547101,NDC,,,facility,inpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,5.37,7.32,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,59911547101,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,3.23,7.32,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,59911547001,NDC,,,facility,inpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,4.59,6.26,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,59911547001,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
NUTR- Juven 23g/1 packet,800051052,CDM,637,RC,59781066695,NDC,,,facility,inpatient,1,EA,15.20000,4.41000,Aetna,First Health,,12.43,,,,,,,9.12,12.43,percent of total billed charges,
NUTR- Juven 23g/1 packet,800051052,CDM,637,RC,59781066695,NDC,,,facility,outpatient,1,EA,15.20000,4.41000,Aetna,First Health,,12.43,,,,,,,5.48,12.43,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,59772246201,NDC,,,facility,inpatient,1,EA,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,4.38,5.97,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,59772246201,NDC,,,facility,outpatient,1,EA,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,2.63,5.97,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,59772002603,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,59772002603,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59762503101,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59762503101,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,59762502701,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,59762502701,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,800015357,CDM,637,RC,59762502501,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,800015357,CDM,637,RC,59762502501,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,59762502301,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,59762502301,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,59762501101,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,59762501101,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,59762500802,NDC,,,facility,inpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,5.10,6.95,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,59762500802,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,3.06,6.95,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,59762500801,NDC,,,facility,inpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,5.10,6.95,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,59762500801,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,3.06,6.95,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,59762500701,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,59762500701,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,59762500006,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,59762500006,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,59762500005,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,59762500005,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,59762500001,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,59762500001,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,59762491004,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,59762491004,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,59762490004,NDC,,,facility,inpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,1.20,1.64,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,59762490004,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,59762453701,NDC,facility,inpatient,150,ME,463.70000,134.47000,Aetna,First Health,,379.31,,,,,,,167.16,379.31,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,59762453701,NDC,facility,outpatient,150,ME,463.70000,134.47000,Aetna,First Health,,379.31,,,,,,,0.40446,379.31,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,59762374001,NDC,,,facility,inpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,59762374001,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.79310,1.80,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,59762372603,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,59762372603,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,59762372001,NDC,,,facility,inpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,3.57,4.87,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,59762372001,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,59762371901,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,59762371901,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,59762371809,NDC,,,facility,inpatient,1,EA,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,17.61,24.01,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,59762371809,NDC,,,facility,outpatient,1,EA,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,10.58,24.01,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,59762371804,NDC,,,facility,inpatient,1,EA,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,17.61,24.01,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,59762371804,NDC,,,facility,outpatient,1,EA,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,10.58,24.01,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,59762332801,NDC,,,facility,inpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,5.07,6.91,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,59762332801,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,3.05,6.91,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,59762330403,NDC,,,facility,inpatient,1,EA,183.95000,53.35000,Aetna,First Health,,150.47,,,,,,,110.37,150.47,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,59762330403,NDC,,,facility,outpatient,1,EA,183.95000,53.35000,Aetna,First Health,,150.47,,,,,,,66.31,150.47,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,59762330401,NDC,,,facility,inpatient,1,EA,83.30000,24.16000,Aetna,First Health,,68.14,,,,,,,49.98,68.14,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,59762330401,NDC,,,facility,outpatient,1,EA,83.30000,24.16000,Aetna,First Health,,68.14,,,,,,,30.03,68.14,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,59762311001,NDC,,,facility,inpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,49.38,67.32,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,59762311001,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,29.67,67.32,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,59762306002,NDC,,,facility,inpatient,1,EA,18.05000,5.23000,Aetna,First Health,,14.76,,,,,,,10.83,14.76,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,59762306002,NDC,,,facility,outpatient,1,EA,18.05000,5.23000,Aetna,First Health,,14.76,,,,,,,6.51,14.76,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,59762200401,NDC,,,facility,inpatient,1,EA,76.15000,22.08000,Aetna,First Health,,62.29,,,,,,,45.69,62.29,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,59762200401,NDC,,,facility,outpatient,1,EA,76.15000,22.08000,Aetna,First Health,,62.29,,,,,,,27.45,62.29,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,59762200101,NDC,,,facility,inpatient,1,EA,62.75000,18.20000,Aetna,First Health,,51.33,,,,,,,37.65,51.33,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,59762200101,NDC,,,facility,outpatient,1,EA,62.75000,18.20000,Aetna,First Health,,51.33,,,,,,,22.62,51.33,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,59762181002,NDC,,,facility,inpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,11.22,15.30,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,59762181002,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,6.74,15.30,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,59762171003,NDC,,,facility,inpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,17.70,24.13,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,59762171003,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,10.63,24.13,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,59762171002,NDC,,,facility,inpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,17.70,24.13,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,59762171002,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,10.63,24.13,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,59762171001,NDC,,,facility,inpatient,1,EA,29.00000,8.41000,Aetna,First Health,,23.72,,,,,,,17.40,23.72,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,59762171001,NDC,,,facility,outpatient,1,EA,29.00000,8.41000,Aetna,First Health,,23.72,,,,,,,10.45,23.72,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,59762153701,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,59762153701,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,59762153002,NDC,,,facility,inpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,1.05,1.43,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,59762153002,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.63087,1.43,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,59762151701,NDC,,,facility,inpatient,1,EA,53.65000,15.56000,Aetna,First Health,,43.89,,,,,,,32.19,43.89,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,59762151701,NDC,,,facility,outpatient,1,EA,53.65000,15.56000,Aetna,First Health,,43.89,,,,,,,19.34,43.89,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,59762151601,NDC,,,facility,inpatient,1,EA,32.70000,9.48000,Aetna,First Health,,26.75,,,,,,,19.62,26.75,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,59762151601,NDC,,,facility,outpatient,1,EA,32.70000,9.48000,Aetna,First Health,,26.75,,,,,,,11.79,26.75,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,59762141503,NDC,,,facility,inpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,11.19,15.26,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,59762141503,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,6.72,15.26,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,59762130701,NDC,,,facility,inpatient,1,EA,1114.90000,323.32000,Aetna,First Health,,911.99,,,,,,,668.94,911.99,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,59762130701,NDC,,,facility,outpatient,1,EA,1114.90000,323.32000,Aetna,First Health,,911.99,,,,,,,401.92,911.99,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,59762108102,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,59762108102,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,59762106101,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,59762106101,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Cabergoline 0.5 mg Tab,800017393,CDM,637,RC,J8515,HCPCS,59762100501,NDC,facility,inpatient,0.5,ME,256.20000,74.30000,Aetna,First Health,,209.57,,,,,,,153.72,209.57,percent of total billed charges,
Cabergoline 0.5 mg Tab,800017393,CDM,637,RC,J8515,HCPCS,59762100501,NDC,facility,outpatient,0.5,ME,256.20000,74.30000,Aetna,First Health,,209.57,,,,,,,17.65,209.57,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59762054001,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59762054001,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,59762045001,NDC,,,facility,inpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,5.37,7.32,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,59762045001,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,3.23,7.32,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,59762033302,NDC,,,facility,inpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,12.75,17.38,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,59762033302,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,7.66,17.38,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,59762033301,NDC,,,facility,inpatient,1,EA,619.30000,179.60000,Aetna,First Health,,506.59,,,,,,,371.58,506.59,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,59762033301,NDC,,,facility,outpatient,1,EA,619.30000,179.60000,Aetna,First Health,,506.59,,,,,,,223.26,506.59,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,59762026002,NDC,,,facility,inpatient,1,EA,27.80000,8.06000,Aetna,First Health,,22.74,,,,,,,16.68,22.74,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,59762026002,NDC,,,facility,outpatient,1,EA,27.80000,8.06000,Aetna,First Health,,22.74,,,,,,,10.02,22.74,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,59762026001,NDC,,,facility,inpatient,1,EA,27.85000,8.08000,Aetna,First Health,,22.78,,,,,,,16.71,22.78,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,59762026001,NDC,,,facility,outpatient,1,EA,27.85000,8.08000,Aetna,First Health,,22.78,,,,,,,10.04,22.78,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,59762024504,NDC,,,facility,inpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,2.22,3.03,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,59762024504,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,59762024502,NDC,,,facility,inpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,2.22,3.03,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,59762024502,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,59762018202,NDC,,,facility,inpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,59762018202,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,12.98,29.45,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,59762015701,NDC,,,facility,inpatient,1,EA,38.95000,11.30000,Aetna,First Health,,31.86,,,,,,,23.37,31.86,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,59762015701,NDC,,,facility,outpatient,1,EA,38.95000,11.30000,Aetna,First Health,,31.86,,,,,,,14.04,31.86,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,59762015601,NDC,,,facility,inpatient,1,EA,38.90000,11.28000,Aetna,First Health,,31.82,,,,,,,23.34,31.82,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,59762015601,NDC,,,facility,outpatient,1,EA,38.90000,11.28000,Aetna,First Health,,31.82,,,,,,,14.02,31.82,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,59762011901,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,59762011901,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,59762011701,NDC,,,facility,inpatient,1,EA,29.65000,8.60000,Aetna,First Health,,24.25,,,,,,,17.79,24.25,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,59762011701,NDC,,,facility,outpatient,1,EA,29.65000,8.60000,Aetna,First Health,,24.25,,,,,,,10.69,24.25,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,59762007401,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,59762007401,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,59762007301,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,59762007301,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
methylPREDNISolone 16 mg T(Medrol),800013327,CDM,637,RC,J7509,HCPCS,59762005001,NDC,facility,inpatient,16,ME,25.05000,7.26000,Aetna,First Health,,20.49,,,,,,,15.03,20.49,percent of total billed charges,
methylPREDNISolone 16 mg T(Medrol),800013327,CDM,637,RC,J7509,HCPCS,59762005001,NDC,facility,outpatient,16,ME,25.05000,7.26000,Aetna,First Health,,20.49,,,,,,,0.13482,20.49,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,59746038506,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,59746038506,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,59746038306,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,59746038306,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,59746032430,NDC,,,facility,inpatient,1,EA,51.15000,14.83000,Aetna,First Health,,41.84,,,,,,,30.69,41.84,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,59746032430,NDC,,,facility,outpatient,1,EA,51.15000,14.83000,Aetna,First Health,,41.84,,,,,,,18.44,41.84,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,59746024601,NDC,,,facility,inpatient,1,EA,33.55000,9.73000,Aetna,First Health,,27.44,,,,,,,20.13,27.44,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,59746024601,NDC,,,facility,outpatient,1,EA,33.55000,9.73000,Aetna,First Health,,27.44,,,,,,,12.09,27.44,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,59746024501,NDC,,,facility,inpatient,1,EA,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,17.61,24.01,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,59746024501,NDC,,,facility,outpatient,1,EA,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,10.58,24.01,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,59746017706,NDC,,,facility,inpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,4.92,6.71,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,59746017706,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,2.96,6.71,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,59746017509,NDC,facility,inpatient,20,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,59746017509,NDC,facility,outpatient,20,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,0.00963,8.26,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,59746017506,NDC,facility,inpatient,20,ME,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,6.39,8.71,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,59746017506,NDC,facility,outpatient,20,ME,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,0.00963,8.71,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,59746017306,NDC,facility,inpatient,10,ME,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,3.87,5.28,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,59746017306,NDC,facility,outpatient,10,ME,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,0.00963,5.28,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,59746017106,NDC,facility,inpatient,1,ME,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,59746017106,NDC,facility,outpatient,1,ME,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,0.00963,3.68,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,59746011506,NDC,facility,inpatient,10,ME,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,3.78,5.15,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,59746011506,NDC,facility,outpatient,10,ME,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,0.57780,5.15,percent of total billed charges,
methylPREDNISolone 16 mg T(Medrol),800013327,CDM,637,RC,J7509,HCPCS,59746000314,NDC,facility,inpatient,16,ME,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,13.20,18.00,percent of total billed charges,
methylPREDNISolone 16 mg T(Medrol),800013327,CDM,637,RC,J7509,HCPCS,59746000314,NDC,facility,outpatient,16,ME,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,0.13482,18.00,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,59746000106,NDC,facility,inpatient,4,ME,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,7.02,9.57,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,59746000106,NDC,facility,outpatient,4,ME,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,0.13482,9.57,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,59746000103,NDC,facility,inpatient,4,ME,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,4.22,9.57,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,59746000103,NDC,facility,outpatient,4,ME,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,0.13482,9.57,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,59730640201,NDC,facility,inpatient,667,ME,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,2.01,2.74,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,59730640201,NDC,facility,outpatient,667,ME,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,0.03852,2.74,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,59730640101,NDC,facility,inpatient,667,ME,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,59730640101,NDC,facility,outpatient,667,ME,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.03852,1.39,percent of total billed charges,
darun/cobic/emtric/tenof 800-150-200-10mg T,800046459,CDM,637,RC,59676080030,NDC,,,facility,inpatient,1,EA,1142.80000,331.41000,Aetna,First Health,,934.81,,,,,,,685.68,934.81,percent of total billed charges,
darun/cobic/emtric/tenof 800-150-200-10mg T,800046459,CDM,637,RC,59676080030,NDC,,,facility,outpatient,1,EA,1142.80000,331.41000,Aetna,First Health,,934.81,,,,,,,411.98,934.81,percent of total billed charges,
"Epoetin 40,000 unit/mL I",800010965,CDM,636,RC,J0885,HCPCS,59676034001,NDC,facility,inpatient,40000,UN,4448.90000,1290.18000,Aetna,First Health,,3639.20,,,,,,,1603.83,3639.20,percent of total billed charges,
"Epoetin 40,000 unit/mL I",800010965,CDM,636,RC,J0885,HCPCS,59676034001,NDC,facility,outpatient,40000,UN,4448.90000,1290.18000,Aetna,First Health,,3639.20,,,,,,,7.45,3639.20,percent of total billed charges,
"Epoetin 10,000 unit Inj",800010933,CDM,636,RC,J0885,HCPCS,59676031002,NDC,facility,inpatient,10000,UN,1254.70000,363.86000,Aetna,First Health,,1026.34,,,,,,,452.32,1026.34,percent of total billed charges,
"Epoetin 10,000 unit Inj",800010933,CDM,636,RC,J0885,HCPCS,59676031002,NDC,facility,outpatient,10000,UN,1254.70000,363.86000,Aetna,First Health,,1026.34,,,,,,,7.45,1026.34,percent of total billed charges,
"Epoetin 10,000 unit Inj",800010933,CDM,636,RC,J0885,HCPCS,59676031001,NDC,facility,inpatient,10000,UN,1254.70000,363.86000,Aetna,First Health,,1026.34,,,,,,,452.32,1026.34,percent of total billed charges,
"Epoetin 10,000 unit Inj",800010933,CDM,636,RC,J0885,HCPCS,59676031001,NDC,facility,outpatient,10000,UN,1254.70000,363.86000,Aetna,First Health,,1026.34,,,,,,,7.45,1026.34,percent of total billed charges,
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,59676030402,NDC,facility,inpatient,4000,UN,388.40000,112.64000,Aetna,First Health,,317.71,,,,,,,140.02,317.71,percent of total billed charges,
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,59676030402,NDC,facility,outpatient,4000,UN,388.40000,112.64000,Aetna,First Health,,317.71,,,,,,,7.45,317.71,percent of total billed charges,
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,59676030401,NDC,facility,inpatient,4000,UN,580.05000,168.21000,Aetna,First Health,,474.48,,,,,,,209.11,474.48,percent of total billed charges,
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,59676030401,NDC,facility,outpatient,4000,UN,580.05000,168.21000,Aetna,First Health,,474.48,,,,,,,7.45,474.48,percent of total billed charges,
"Epoetin 3,000 unit/mL Inj",800013635,CDM,636,RC,J0885,HCPCS,59676030301,NDC,facility,inpatient,3000,UN,456.65000,132.43000,Aetna,First Health,,373.54,,,,,,,164.62,373.54,percent of total billed charges,
"Epoetin 3,000 unit/mL Inj",800013635,CDM,636,RC,J0885,HCPCS,59676030301,NDC,facility,outpatient,3000,UN,456.65000,132.43000,Aetna,First Health,,373.54,,,,,,,7.45,373.54,percent of total billed charges,
Cladribine 10mg/10mL I(Leustatin),800022003,CDM,636,RC,J9065,HCPCS,59676020101,NDC,facility,inpatient,10,ME,6474.30000,1877.55000,Aetna,First Health,,5295.98,,,,,,,2333.99,5295.98,percent of total billed charges,
Cladribine 10mg/10mL I(Leustatin),800022003,CDM,636,RC,J9065,HCPCS,59676020101,NDC,facility,outpatient,10,ME,6474.30000,1877.55000,Aetna,First Health,,5295.98,,,,,,,7.15,5295.98,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59651078030,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59651078030,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
clonazePAM 2mg T(KlonoPIN),800051122,CDM,637,RC,59651072401,NDC,,,facility,inpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,5.67,7.73,percent of total billed charges,
clonazePAM 2mg T(KlonoPIN),800051122,CDM,637,RC,59651072401,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,3.41,7.73,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,59651072201,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,59651072201,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,59651053901,NDC,,,facility,inpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,14.25,19.43,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,59651053901,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.56,19.43,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,59651048801,NDC,facility,inpatient,20,ME,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,59651048801,NDC,facility,outpatient,20,ME,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.00963,1.51,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,59651048701,NDC,facility,inpatient,10,ME,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,59651048701,NDC,facility,outpatient,10,ME,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.00963,1.39,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,59651048401,NDC,facility,inpatient,1,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,59651048401,NDC,facility,outpatient,1,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.00963,1.47,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,59651045360,NDC,,,facility,inpatient,1,EA,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,12.42,16.93,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,59651045360,NDC,,,facility,outpatient,1,EA,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,7.46,16.93,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,59651037801,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,59651037801,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,59651033101,NDC,,,facility,inpatient,1,EA,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,323.40,440.90,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,59651033101,NDC,,,facility,outpatient,1,EA,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,194.31,440.90,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,59651030601,NDC,,,facility,inpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,4.59,6.26,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,59651030601,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59651026830,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59651026830,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,59651025701,NDC,,,facility,inpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,9.90,13.50,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,59651025701,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,59651025601,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,59651025601,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,59651021430,NDC,,,facility,inpatient,1,EA,677.25000,196.40000,Aetna,First Health,,553.99,,,,,,,406.35,553.99,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,59651021430,NDC,,,facility,outpatient,1,EA,677.25000,196.40000,Aetna,First Health,,553.99,,,,,,,244.15,553.99,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,59651015201,NDC,,,facility,inpatient,1,EA,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,8.91,12.15,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,59651015201,NDC,,,facility,outpatient,1,EA,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,5.35,12.15,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,59651012060,NDC,,,facility,inpatient,1,EA,60.65000,17.59000,Aetna,First Health,,49.61,,,,,,,36.39,49.61,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,59651012060,NDC,,,facility,outpatient,1,EA,60.65000,17.59000,Aetna,First Health,,49.61,,,,,,,21.86,49.61,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,59651002601,NDC,,,facility,inpatient,1,EA,30.60000,8.87000,Aetna,First Health,,25.03,,,,,,,18.36,25.03,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,59651002601,NDC,,,facility,outpatient,1,EA,30.60000,8.87000,Aetna,First Health,,25.03,,,,,,,11.03,25.03,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,59630071008,NDC,facility,inpatient,3,ME,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,10.11,13.78,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,59630071008,NDC,facility,outpatient,3,ME,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,0.88596,13.78,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,59630030065,NDC,,,facility,inpatient,1,EA,1442.40000,418.30000,Aetna,First Health,,1179.88,,,,,,,865.44,1179.88,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,59630030065,NDC,,,facility,outpatient,1,EA,1442.40000,418.30000,Aetna,First Health,,1179.88,,,,,,,519.99,1179.88,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,59630020010,NDC,,,facility,inpatient,1,EA,50.15000,14.54000,Aetna,First Health,,41.02,,,,,,,30.09,41.02,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,59630020010,NDC,,,facility,outpatient,1,EA,50.15000,14.54000,Aetna,First Health,,41.02,,,,,,,18.08,41.02,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,inpatient,100,ME,3085.05000,894.66000,Aetna,First Health,,2523.57,,,,,,,1112.16,2523.57,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,outpatient,100,ME,3085.05000,894.66000,Aetna,First Health,,2523.57,,,,,,,0.44298,2523.57,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,59439045502,NDC,facility,inpatient,3,ME,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,59439045502,NDC,facility,outpatient,3,ME,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,0.88596,2.84,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,59390002317,NDC,,,facility,inpatient,1,EA,19.55000,5.67000,Aetna,First Health,,15.99,,,,,,,7.23,15.99,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,59390002317,NDC,,,facility,outpatient,1,EA,19.55000,5.67000,Aetna,First Health,,15.99,,,,,,,7.05,15.99,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,59366281703,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,59366281703,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,59366280702,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,59366280702,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,59366269206,NDC,,,facility,inpatient,1,EA,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,17.89,39.55,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,59366269206,NDC,,,facility,outpatient,1,EA,48.35000,14.02000,Aetna,First Health,,39.55,,,,,,,17.43,39.55,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,59310057922,NDC,,,facility,inpatient,1,EA,461.55000,133.85000,Aetna,First Health,,377.55,,,,,,,276.93,377.55,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,59310057922,NDC,,,facility,outpatient,1,EA,461.55000,133.85000,Aetna,First Health,,377.55,,,,,,,166.39,377.55,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,59310057920,NDC,,,facility,inpatient,1,EA,205.45000,59.58000,Aetna,First Health,,168.06,,,,,,,123.27,168.06,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,59310057920,NDC,,,facility,outpatient,1,EA,205.45000,59.58000,Aetna,First Health,,168.06,,,,,,,74.06,168.06,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,59148002050,NDC,,,facility,inpatient,1,EA,3456.10000,1002.27000,Aetna,First Health,,2827.09,,,,,,,2073.66,2827.09,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,59148002050,NDC,,,facility,outpatient,1,EA,3456.10000,1002.27000,Aetna,First Health,,2827.09,,,,,,,1245.92,2827.09,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,59148000813,NDC,,,facility,inpatient,1,EA,165.35000,47.95000,Aetna,First Health,,135.26,,,,,,,99.21,135.26,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,59148000813,NDC,,,facility,outpatient,1,EA,165.35000,47.95000,Aetna,First Health,,135.26,,,,,,,59.61,135.26,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,59148000735,NDC,,,facility,inpatient,1,EA,249.75000,72.43000,Aetna,First Health,,204.30,,,,,,,149.85,204.30,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,59148000735,NDC,,,facility,outpatient,1,EA,249.75000,72.43000,Aetna,First Health,,204.30,,,,,,,90.03,204.30,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,59148000713,NDC,,,facility,inpatient,1,EA,165.35000,47.95000,Aetna,First Health,,135.26,,,,,,,99.21,135.26,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,59148000713,NDC,,,facility,outpatient,1,EA,165.35000,47.95000,Aetna,First Health,,135.26,,,,,,,59.61,135.26,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,59148000613,NDC,,,facility,inpatient,1,EA,165.35000,47.95000,Aetna,First Health,,135.26,,,,,,,99.21,135.26,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,59148000613,NDC,,,facility,outpatient,1,EA,165.35000,47.95000,Aetna,First Health,,135.26,,,,,,,59.61,135.26,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,59148000216,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,59148000216,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
aminolevulinic acid 50mL REC Pwd Oral Soln,800046391,CDM,250,RC,59137023101,NDC,,,facility,inpatient,1,EA,19767.80000,5732.66000,Aetna,First Health,,16170.06,,,,,,,7314.09,16170.06,percent of total billed charges,
aminolevulinic acid 50mL REC Pwd Oral Soln,800046391,CDM,250,RC,59137023101,NDC,,,facility,outpatient,1,EA,19767.80000,5732.66000,Aetna,First Health,,16170.06,,,,,,,7126.29,16170.06,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,59075069010,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,59075069010,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,59075068010,NDC,,,facility,inpatient,1,EA,17.25000,5.00000,Aetna,First Health,,14.11,,,,,,,10.35,14.11,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,59075068010,NDC,,,facility,outpatient,1,EA,17.25000,5.00000,Aetna,First Health,,14.11,,,,,,,6.22,14.11,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,59075059415,NDC,,,facility,inpatient,1,EA,11.55000,3.35000,Aetna,First Health,,9.45,,,,,,,6.93,9.45,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,59075059415,NDC,,,facility,outpatient,1,EA,11.55000,3.35000,Aetna,First Health,,9.45,,,,,,,4.16,9.45,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,59075059215,NDC,,,facility,inpatient,1,EA,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,5.76,7.85,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,59075059215,NDC,,,facility,outpatient,1,EA,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),800081290,CDM,637,RC,59011081510,NDC,,,facility,inpatient,1,EA,25.75000,7.47000,Aetna,First Health,,21.06,,,,,,,15.45,21.06,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),800081290,CDM,637,RC,59011081510,NDC,,,facility,outpatient,1,EA,25.75000,7.47000,Aetna,First Health,,21.06,,,,,,,9.28,21.06,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,59011045401,NDC,,,facility,inpatient,1,EA,25.85000,7.50000,Aetna,First Health,,21.15,,,,,,,15.51,21.15,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,59011045401,NDC,,,facility,outpatient,1,EA,25.85000,7.50000,Aetna,First Health,,21.15,,,,,,,9.32,21.15,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,59011045210,NDC,,,facility,inpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,10.44,14.23,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,59011045210,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,6.27,14.23,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,59011045201,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,59011045201,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,59011044225,NDC,facility,inpatient,2,ME,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,59011044225,NDC,facility,outpatient,2,ME,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,0.13482,11.25,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,59011044210,NDC,facility,inpatient,2,ME,14.45000,4.19000,Aetna,First Health,,11.82,,,,,,,5.21,11.82,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,59011044210,NDC,facility,outpatient,2,ME,14.45000,4.19000,Aetna,First Health,,11.82,,,,,,,0.13482,11.82,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011042020,NDC,,,facility,inpatient,1,EA,104.05000,30.17000,Aetna,First Health,,85.11,,,,,,,62.43,85.11,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011042020,NDC,,,facility,outpatient,1,EA,104.05000,30.17000,Aetna,First Health,,85.11,,,,,,,37.51,85.11,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011042010,NDC,,,facility,inpatient,1,EA,101.45000,29.42000,Aetna,First Health,,82.99,,,,,,,60.87,82.99,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011042010,NDC,,,facility,outpatient,1,EA,101.45000,29.42000,Aetna,First Health,,82.99,,,,,,,36.57,82.99,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),800081290,CDM,637,RC,59011041520,NDC,,,facility,inpatient,1,EA,82.15000,23.82000,Aetna,First Health,,67.20,,,,,,,49.29,67.20,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),800081290,CDM,637,RC,59011041520,NDC,,,facility,outpatient,1,EA,82.15000,23.82000,Aetna,First Health,,67.20,,,,,,,29.62,67.20,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),800081290,CDM,637,RC,59011041510,NDC,,,facility,inpatient,1,EA,80.05000,23.21000,Aetna,First Health,,65.48,,,,,,,48.03,65.48,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),800081290,CDM,637,RC,59011041510,NDC,,,facility,outpatient,1,EA,80.05000,23.21000,Aetna,First Health,,65.48,,,,,,,28.86,65.48,percent of total billed charges,
oxyCODONE 10mg/12hr ER T(OxyCONTIN),800073865,CDM,637,RC,59011041020,NDC,,,facility,inpatient,1,EA,55.85000,16.20000,Aetna,First Health,,45.69,,,,,,,33.51,45.69,percent of total billed charges,
oxyCODONE 10mg/12hr ER T(OxyCONTIN),800073865,CDM,637,RC,59011041020,NDC,,,facility,outpatient,1,EA,55.85000,16.20000,Aetna,First Health,,45.69,,,,,,,20.13,45.69,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011010325,NDC,,,facility,inpatient,1,EA,27.15000,7.87000,Aetna,First Health,,22.21,,,,,,,16.29,22.21,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011010325,NDC,,,facility,outpatient,1,EA,27.15000,7.87000,Aetna,First Health,,22.21,,,,,,,9.79,22.21,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011010320,NDC,,,facility,inpatient,1,EA,33.75000,9.79000,Aetna,First Health,,27.61,,,,,,,20.25,27.61,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011010320,NDC,,,facility,outpatient,1,EA,33.75000,9.79000,Aetna,First Health,,27.61,,,,,,,12.17,27.61,percent of total billed charges,
oxyCODONE 10mg/12hr ER T(OxyCONTIN),800073865,CDM,637,RC,59011010025,NDC,,,facility,inpatient,1,EA,14.20000,4.12000,Aetna,First Health,,11.62,,,,,,,8.52,11.62,percent of total billed charges,
oxyCODONE 10mg/12hr ER T(OxyCONTIN),800073865,CDM,637,RC,59011010025,NDC,,,facility,outpatient,1,EA,14.20000,4.12000,Aetna,First Health,,11.62,,,,,,,5.12,11.62,percent of total billed charges,
oxyCODONE 10mg/12hr ER T(OxyCONTIN),800073865,CDM,637,RC,59011010020,NDC,,,facility,inpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,10.59,14.44,percent of total billed charges,
oxyCODONE 10mg/12hr ER T(OxyCONTIN),800073865,CDM,637,RC,59011010020,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,6.36,14.44,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,58980082405,NDC,,,facility,inpatient,1,EA,116.90000,33.90000,Aetna,First Health,,95.62,,,,,,,70.14,95.62,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,58980082405,NDC,,,facility,outpatient,1,EA,116.90000,33.90000,Aetna,First Health,,95.62,,,,,,,42.14,95.62,percent of total billed charges,
Mesalamine 1000mg Supp (Canasa),800017778,CDM,637,RC,58914050156,NDC,,,facility,inpatient,1,EA,320.80000,93.03000,Aetna,First Health,,262.41,,,,,,,192.48,262.41,percent of total billed charges,
Mesalamine 1000mg Supp (Canasa),800017778,CDM,637,RC,58914050156,NDC,,,facility,outpatient,1,EA,320.80000,93.03000,Aetna,First Health,,262.41,,,,,,,115.65,262.41,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,58914017110,NDC,,,facility,inpatient,1,EA,42.15000,12.22000,Aetna,First Health,,34.48,,,,,,,25.29,34.48,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,58914017110,NDC,,,facility,outpatient,1,EA,42.15000,12.22000,Aetna,First Health,,34.48,,,,,,,15.20,34.48,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,58914008052,NDC,facility,inpatient,20,ME,475.30000,137.84000,Aetna,First Health,,388.80,,,,,,,171.35,388.80,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,58914008052,NDC,facility,outpatient,20,ME,475.30000,137.84000,Aetna,First Health,,388.80,,,,,,,10.91,388.80,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,58887001976,NDC,,,facility,inpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,1.14,1.55,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,58887001976,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.68495,1.55,percent of total billed charges,
prednisoLONE 0.12% 5mL Ophth Susp(Pred Mild),800043967,CDM,637,RC,58768087505,NDC,,,facility,inpatient,1,EA,1050.05000,304.51000,Aetna,First Health,,858.94,,,,,,,630.03,858.94,percent of total billed charges,
prednisoLONE 0.12% 5mL Ophth Susp(Pred Mild),800043967,CDM,637,RC,58768087505,NDC,,,facility,outpatient,1,EA,1050.05000,304.51000,Aetna,First Health,,858.94,,,,,,,378.54,858.94,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,58657070101,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,58657070101,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,58657070001,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,58657070001,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,58657062301,NDC,,,facility,inpatient,1,EA,17.85000,5.18000,Aetna,First Health,,14.60,,,,,,,10.71,14.60,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,58657062301,NDC,,,facility,outpatient,1,EA,17.85000,5.18000,Aetna,First Health,,14.60,,,,,,,6.43,14.60,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,58657061230,NDC,,,facility,inpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,13.08,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,58657061230,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,7.86,17.83,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,58602000739,NDC,,,facility,inpatient,1,EA,74.75000,21.68000,Aetna,First Health,,61.15,,,,,,,44.85,61.15,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,58602000739,NDC,,,facility,outpatient,1,EA,74.75000,21.68000,Aetna,First Health,,61.15,,,,,,,26.95,61.15,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),800081264,CDM,637,RC,J0603,HCPCS,58468002101,NDC,facility,inpatient,800,ME,63.20000,18.33000,Aetna,First Health,,51.70,,,,,,,37.92,51.70,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),800081264,CDM,637,RC,J0603,HCPCS,58468002101,NDC,facility,outpatient,800,ME,63.20000,18.33000,Aetna,First Health,,51.70,,,,,,,0.19260,51.70,percent of total billed charges,
Methotrexate Na 250mg/10mL I PF,800022021,CDM,636,RC,J9260,HCPCS,58406068316,NDC,facility,inpatient,250,ME,133.10000,38.60000,Aetna,First Health,,108.88,,,,,,,47.98,108.88,percent of total billed charges,
Methotrexate Na 250mg/10mL I PF,800022021,CDM,636,RC,J9260,HCPCS,58406068316,NDC,facility,outpatient,250,ME,133.10000,38.60000,Aetna,First Health,,108.88,,,,,,,2.48,108.88,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,58406068315,NDC,facility,inpatient,50,ME,30.90000,8.96000,Aetna,First Health,,25.28,,,,,,,11.14,25.28,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,58406068315,NDC,facility,outpatient,50,ME,30.90000,8.96000,Aetna,First Health,,25.28,,,,,,,2.48,25.28,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),800010165,CDM,250,RC,J0281,HCPCS,58406061012,NDC,facility,inpatient,5000,ME,533.60000,154.74000,Aetna,First Health,,436.48,,,,,,,197.43,436.48,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),800010165,CDM,250,RC,J0281,HCPCS,58406061012,NDC,facility,outpatient,5000,ME,533.60000,154.74000,Aetna,First Health,,436.48,,,,,,,1.53,436.48,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,58281056301,NDC,facility,inpatient,40,ME,3955.45000,1147.08000,Aetna,First Health,,3235.56,,,,,,,1425.94,3235.56,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,58281056301,NDC,facility,outpatient,40,ME,3955.45000,1147.08000,Aetna,First Health,,3235.56,,,,,,,174.76,3235.56,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,58281056104,NDC,facility,inpatient,40,ME,3357.30000,973.62000,Aetna,First Health,,2746.27,,,,,,,1210.31,2746.27,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,58281056104,NDC,facility,outpatient,40,ME,3357.30000,973.62000,Aetna,First Health,,2746.27,,,,,,,174.76,2746.27,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,58177093205,NDC,facility,inpatient,3,ME,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,58177093205,NDC,facility,outpatient,3,ME,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,0.88596,2.84,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,58177062511,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,58177062511,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,58177062111,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,58177062111,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,58177062011,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,58177062011,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,58177036904,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,58177036904,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,58177036804,NDC,,,facility,inpatient,1,EA,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,5.76,7.85,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,58177036804,NDC,,,facility,outpatient,1,EA,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,58177033104,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,58177033104,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,58177032418,NDC,,,facility,inpatient,1,EA,32.30000,9.37000,Aetna,First Health,,26.42,,,,,,,19.38,26.42,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,58177032418,NDC,,,facility,outpatient,1,EA,32.30000,9.37000,Aetna,First Health,,26.42,,,,,,,11.64,26.42,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,58177031304,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,58177031304,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,58177030104,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,3.96,5.40,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,58177030104,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,58177029304,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,3.69,5.03,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,58177029304,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,58177026704,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,4.05,5.52,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,58177026704,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,58177026404,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,58177026404,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,58177025504,NDC,,,facility,inpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,1.23,1.68,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,58177025504,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,0.73903,1.68,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,58177023704,NDC,,,facility,inpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.92,2.62,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,58177023704,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,58177022204,NDC,,,facility,inpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,5.49,7.48,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,58177022204,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.30,7.48,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,58177020508,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,58177020508,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,58177009104,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,58177009104,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,58177003106,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,58177003106,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,58177003104,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,58177003104,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,58160096412,NDC,facility,inpatient,1,EA,1700.10000,493.03000,Aetna,First Health,,1390.68,,,,,,,612.89,1390.68,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,58160096412,NDC,facility,outpatient,1,EA,1700.10000,493.03000,Aetna,First Health,,1390.68,,,,,,,307.92,1390.68,percent of total billed charges,
"Influenza Virus Vaccine, Inact Trivalent Inj",800051083,CDM,636,RC,90656,HCPCS,58160088452,NDC,facility,inpatient,1,EA,125.15000,36.29000,Aetna,First Health,,102.37,,,,,,,45.12,102.37,percent of total billed charges,
"Influenza Virus Vaccine, Inact Trivalent Inj",800051083,CDM,636,RC,90656,HCPCS,58160088452,NDC,facility,outpatient,1,EA,125.15000,36.29000,Aetna,First Health,,102.37,,,,,,,14.13,102.37,percent of total billed charges,
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160085901,NDC,facility,inpatient,0.01,ME,139.70000,40.51000,Aetna,First Health,,114.27,,,,,,,50.36,114.27,percent of total billed charges,
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160085901,NDC,facility,outpatient,0.01,ME,139.70000,40.51000,Aetna,First Health,,114.27,,,,,,,21.65,114.27,percent of total billed charges,
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,800082171,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,inpatient,1,EA,293.70000,85.17000,Aetna,First Health,,240.25,,,,,,,105.88,240.25,percent of total billed charges,
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,800082171,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,1,EA,293.70000,85.17000,Aetna,First Health,,240.25,,,,,,,38.22,240.25,percent of total billed charges,
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,800082171,CDM,636,RC,90715,HCPCS,58160084211,NDC,facility,inpatient,1,EA,293.70000,85.17000,Aetna,First Health,,240.25,,,,,,,105.88,240.25,percent of total billed charges,
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,800082171,CDM,636,RC,90715,HCPCS,58160084211,NDC,facility,outpatient,1,EA,293.70000,85.17000,Aetna,First Health,,240.25,,,,,,,38.22,240.25,percent of total billed charges,
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160084046,NDC,facility,inpatient,1,EA,140.50000,40.74000,Aetna,First Health,,114.93,,,,,,,50.65,114.93,percent of total billed charges,
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160084046,NDC,facility,outpatient,1,EA,140.50000,40.74000,Aetna,First Health,,114.93,,,,,,,32.84,114.93,percent of total billed charges,
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160084011,NDC,facility,inpatient,1,EA,124.45000,36.09000,Aetna,First Health,,101.80,,,,,,,44.86,101.80,percent of total billed charges,
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160084011,NDC,facility,outpatient,1,EA,124.45000,36.09000,Aetna,First Health,,101.80,,,,,,,32.84,105.16,percent of total billed charges,
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160082052,NDC,facility,inpatient,0.01,ME,183.20000,53.13000,Aetna,First Health,,149.86,,,,,,,66.04,149.86,percent of total billed charges,
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160082052,NDC,facility,outpatient,0.01,ME,183.20000,53.13000,Aetna,First Health,,149.86,,,,,,,21.65,149.86,percent of total billed charges,
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160082011,NDC,facility,inpatient,0.01,ME,129.25000,37.48000,Aetna,First Health,,105.73,,,,,,,46.59,105.73,percent of total billed charges,
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160082011,NDC,facility,outpatient,0.01,ME,129.25000,37.48000,Aetna,First Health,,105.73,,,,,,,21.65,105.73,percent of total billed charges,
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,58160081811,NDC,facility,inpatient,1,EA,84.05000,24.37000,Aetna,First Health,,68.75,,,,,,,30.30,68.75,percent of total billed charges,
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,58160081811,NDC,facility,outpatient,1,EA,84.05000,24.37000,Aetna,First Health,,68.75,,,,,,,14.65,68.75,percent of total billed charges,
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160081052,NDC,facility,inpatient,1,EA,185.15000,53.69000,Aetna,First Health,,151.45,,,,,,,66.75,151.45,percent of total billed charges,
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160081052,NDC,facility,outpatient,1,EA,185.15000,53.69000,Aetna,First Health,,151.45,,,,,,,32.84,151.45,percent of total billed charges,
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160081046,NDC,facility,inpatient,1,EA,144.70000,41.96000,Aetna,First Health,,118.36,,,,,,,52.16,118.36,percent of total billed charges,
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160081046,NDC,facility,outpatient,1,EA,144.70000,41.96000,Aetna,First Health,,118.36,,,,,,,32.84,118.36,percent of total billed charges,
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,58160072615,NDC,facility,inpatient,1,EA,84.05000,24.37000,Aetna,First Health,,68.75,,,,,,,30.30,68.75,percent of total billed charges,
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,58160072615,NDC,facility,outpatient,1,EA,84.05000,24.37000,Aetna,First Health,,68.75,,,,,,,14.65,68.75,percent of total billed charges,
Phenytoin Na 30mg Sr C(Dilantin),800071703,CDM,637,RC,58151011801,NDC,,,facility,inpatient,1,EA,12.70000,3.68000,Aetna,First Health,,10.39,,,,,,,7.62,10.39,percent of total billed charges,
Phenytoin Na 30mg Sr C(Dilantin),800071703,CDM,637,RC,58151011801,NDC,,,facility,outpatient,1,EA,12.70000,3.68000,Aetna,First Health,,10.39,,,,,,,4.58,10.39,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,58063079725,NDC,facility,inpatient,0.25,ME,1552.55000,450.24000,Aetna,First Health,,1269.99,,,,,,,559.69,1269.99,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,58063079725,NDC,facility,outpatient,0.25,ME,1552.55000,450.24000,Aetna,First Health,,1269.99,,,,,,,0.33705,1269.99,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,58063070510,NDC,,,facility,inpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,8.55,11.66,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,58063070510,NDC,,,facility,outpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,5.14,11.66,percent of total billed charges,
Dalbavancin 500mg I (Dalvance),800022094,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,inpatient,500,ME,12996.75000,3769.06000,Aetna,First Health,,10631.34,,,,,,,4685.33,10631.34,percent of total billed charges,
Dalbavancin 500mg I (Dalvance),800022094,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,outpatient,500,ME,12996.75000,3769.06000,Aetna,First Health,,10631.34,,,,,,,15.01,10631.34,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,57896048914,NDC,,,facility,inpatient,1,EA,50.55000,14.66000,Aetna,First Health,,41.35,,,,,,,18.70,41.35,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,57896048914,NDC,,,facility,outpatient,1,EA,50.55000,14.66000,Aetna,First Health,,41.35,,,,,,,18.22,41.35,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,57896014001,NDC,,,facility,inpatient,1,EA,84.80000,24.59000,Aetna,First Health,,69.37,,,,,,,50.88,69.37,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,57896014001,NDC,,,facility,outpatient,1,EA,84.80000,24.59000,Aetna,First Health,,69.37,,,,,,,30.57,69.37,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,57896011603,NDC,,,facility,inpatient,1,EA,35.90000,10.41000,Aetna,First Health,,29.37,,,,,,,13.28,29.37,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,57896011603,NDC,,,facility,outpatient,1,EA,35.90000,10.41000,Aetna,First Health,,29.37,,,,,,,12.94,29.37,percent of total billed charges,
guselkumab 200mg I - Pt Own Supply,800051995,CDM,636,RC,J1628,HCPCS,57894065002,NDC,facility,inpatient,200,ME,0.20000,0.06000,Aetna,First Health,,0.16360,,,,,,,0.07210,0.16360,percent of total billed charges,
guselkumab 200mg I - Pt Own Supply,800051995,CDM,636,RC,J1628,HCPCS,57894065002,NDC,facility,outpatient,200,ME,0.20000,0.06000,Aetna,First Health,,0.16360,,,,,,,0.07400,224.95,percent of total billed charges,
daratumumab-hyaluronidase fihj Inj - Pt Own Supply,800051023,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,inpatient,1800,ME,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05407,0.12270,percent of total billed charges,
daratumumab-hyaluronidase fihj Inj - Pt Own Supply,800051023,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,1800,ME,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05550,169.81,percent of total billed charges,
"daratumumab-hyaluronidase fihj 1800 mg-30,000 units/15 mL I",800051124,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,inpatient,1800,ME,54309.20000,15749.67000,Aetna,First Health,,44424.93,,,,,,,19578.47,44424.93,percent of total billed charges,
"daratumumab-hyaluronidase fihj 1800 mg-30,000 units/15 mL I",800051124,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,outpatient,1800,ME,54309.20000,15749.67000,Aetna,First Health,,44424.93,,,,,,,53.02,44424.93,percent of total billed charges,
golimumab 50mg/4mL Inj,800046557,CDM,636,RC,J1602,HCPCS,57894035001,NDC,facility,inpatient,50,ME,14581.20000,4228.55000,Aetna,First Health,,11927.42,,,,,,,5256.52,11927.42,percent of total billed charges,
golimumab 50mg/4mL Inj,800046557,CDM,636,RC,J1602,HCPCS,57894035001,NDC,facility,outpatient,50,ME,14581.20000,4228.55000,Aetna,First Health,,11927.42,,,,,,,11.20,11927.42,percent of total billed charges,
inFLIXimab 100mg/10mL I,800010935,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,inpatient,100,ME,3607.00000,1046.03000,Aetna,First Health,,2950.53,,,,,,,1300.32,2950.53,percent of total billed charges,
inFLIXimab 100mg/10mL I,800010935,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,outpatient,100,ME,3607.00000,1046.03000,Aetna,First Health,,2950.53,,,,,,,31.22,2950.53,percent of total billed charges,
inFLIXimab 100mg/10mL I,800010935,CDM,636,RC,J1745,HCPCS,57894003001,NDC,facility,inpatient,100,ME,8595.30000,2492.64000,Aetna,First Health,,7030.96,,,,,,,3098.61,7030.96,percent of total billed charges,
inFLIXimab 100mg/10mL I,800010935,CDM,636,RC,J1745,HCPCS,57894003001,NDC,facility,outpatient,100,ME,8595.30000,2492.64000,Aetna,First Health,,7030.96,,,,,,,31.22,7030.96,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,57844069298,NDC,,,facility,inpatient,1,EA,35.45000,10.28000,Aetna,First Health,,29.00,,,,,,,21.27,29.00,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,57844069298,NDC,,,facility,outpatient,1,EA,35.45000,10.28000,Aetna,First Health,,29.00,,,,,,,12.78,29.00,percent of total billed charges,
naloxegol 25mg Tab UD,800046420,CDM,637,RC,57841130103,NDC,,,facility,inpatient,1,EA,112.10000,32.51000,Aetna,First Health,,91.70,,,,,,,67.26,91.70,percent of total billed charges,
naloxegol 25mg Tab UD,800046420,CDM,637,RC,57841130103,NDC,,,facility,outpatient,1,EA,112.10000,32.51000,Aetna,First Health,,91.70,,,,,,,40.41,91.70,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,57782039726,NDC,,,facility,inpatient,1,EA,91.35000,26.49000,Aetna,First Health,,74.72,,,,,,,54.81,74.72,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,57782039726,NDC,,,facility,outpatient,1,EA,91.35000,26.49000,Aetna,First Health,,74.72,,,,,,,32.93,74.72,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,57664068788,NDC,,,facility,inpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,57664068788,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.46865,1.06,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,57664068357,NDC,facility,inpatient,600,ME,584.90000,169.62000,Aetna,First Health,,478.45,,,,,,,210.86,478.45,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,57664068357,NDC,facility,outpatient,600,ME,584.90000,169.62000,Aetna,First Health,,478.45,,,,,,,2.64,478.45,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,57664064888,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,57664064888,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,57664056999,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,57664056999,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,57664051288,NDC,,,facility,inpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,13.44,18.32,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,57664051288,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,8.08,18.32,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,57664051083,NDC,,,facility,inpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,11.19,15.26,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,57664051083,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,6.72,15.26,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,57664050658,NDC,,,facility,inpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,1.14,1.55,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,57664050658,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.68495,1.55,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,57664050652,NDC,,,facility,inpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,1.14,1.55,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,57664050652,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.68495,1.55,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,57664050608,NDC,,,facility,inpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,1.14,1.55,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,57664050608,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.68495,1.55,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,57664050389,NDC,,,facility,inpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,6.21,8.47,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,57664050389,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,3.73,8.47,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,57664050289,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,57664050289,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,57664049983,NDC,,,facility,inpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,11.52,15.71,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,57664049983,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,57664047752,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,57664047752,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,57664043788,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,57664043788,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,57664039751,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,57664039751,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,57664039388,NDC,,,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,8.49,11.57,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,57664039388,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,57664039288,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,57664039288,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,57664037713,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,57664037713,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,57664037708,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,4.02,5.48,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,57664037708,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,57664034288,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,57664034288,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,57664029288,NDC,,,facility,inpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,4.65,6.34,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,57664029288,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,2.79,6.34,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,57664024788,NDC,,,facility,inpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,8.97,12.23,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,57664024788,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,5.39,12.23,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,57664024588,NDC,,,facility,inpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,8.97,12.23,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,57664024588,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,5.39,12.23,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,57664024488,NDC,,,facility,inpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,8.97,12.23,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,57664024488,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,5.39,12.23,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,57664017688,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,57664017688,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,57664016708,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,57664016708,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,57664016618,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,57664016618,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,57664015213,NDC,,,facility,inpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.18000,0.24540,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,57664015213,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.10815,0.24540,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,57664012688,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,57664012688,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,57664001472,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,57664001472,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,57317023210,NDC,facility,inpatient,6,ME,394.70000,114.46000,Aetna,First Health,,322.86,,,,,,,142.29,322.86,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,57317023210,NDC,facility,outpatient,6,ME,394.70000,114.46000,Aetna,First Health,,322.86,,,,,,,0.51039,322.86,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,57237023201,NDC,,,facility,inpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,2.82,3.84,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,57237023201,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,57237018290,NDC,,,facility,inpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,12.54,17.10,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,57237018290,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,57237018090,NDC,,,facility,inpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,12.54,17.10,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,57237018090,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,57237017301,NDC,,,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,8.49,11.57,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,57237017301,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,57237017201,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,57237017201,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,57237017130,NDC,,,facility,inpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,38.01,51.82,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,57237017130,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,22.84,51.82,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,57237011490,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,57237011490,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,57237009960,NDC,,,facility,inpatient,1,EA,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,21.72,29.61,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,57237009960,NDC,,,facility,outpatient,1,EA,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,13.05,29.61,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,57237007710,NDC,facility,inpatient,4,ME,157.75000,45.75000,Aetna,First Health,,129.04,,,,,,,94.65,129.04,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,57237007710,NDC,facility,outpatient,4,ME,157.75000,45.75000,Aetna,First Health,,129.04,,,,,,,0.00963,129.04,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,57237004801,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,57237004801,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,57237004701,NDC,,,facility,inpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,7.41,10.10,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,57237004701,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,4.45,10.10,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,57237001930,NDC,,,facility,inpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,33.36,45.48,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,57237001930,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,57237001890,NDC,,,facility,inpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,33.36,45.48,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,57237001890,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,57237001830,NDC,,,facility,inpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,33.36,45.48,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,57237001830,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,57237001760,NDC,,,facility,inpatient,1,EA,49.55000,14.37000,Aetna,First Health,,40.53,,,,,,,29.73,40.53,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,57237001760,NDC,,,facility,outpatient,1,EA,49.55000,14.37000,Aetna,First Health,,40.53,,,,,,,17.86,40.53,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,57237001405,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,57237001405,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,57237001401,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,57237001401,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,57237000830,NDC,,,facility,inpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,11.46,15.62,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,57237000830,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,6.89,15.62,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,57237000430,NDC,,,facility,inpatient,1,EA,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,57237000430,NDC,,,facility,outpatient,1,EA,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,22.35,50.72,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,55953073440,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,55953073440,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,55953071670,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,55953071670,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,55953071640,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,55953071640,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,55953034340,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,55953034340,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,55953021470,NDC,,,facility,inpatient,1,EA,19.45000,5.64000,Aetna,First Health,,15.91,,,,,,,11.67,15.91,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,55953021470,NDC,,,facility,outpatient,1,EA,19.45000,5.64000,Aetna,First Health,,15.91,,,,,,,7.01,15.91,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,55953021440,NDC,,,facility,inpatient,1,EA,19.65000,5.70000,Aetna,First Health,,16.07,,,,,,,11.79,16.07,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,55953021440,NDC,,,facility,outpatient,1,EA,19.65000,5.70000,Aetna,First Health,,16.07,,,,,,,7.08,16.07,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,55953011470,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,55953011470,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,55953011440,NDC,,,facility,inpatient,1,EA,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,5.34,7.28,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,55953011440,NDC,,,facility,outpatient,1,EA,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,3.21,7.28,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,55953008440,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,55953008440,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Citric Acid/MgOx/Na pico Oral Soln,800040895,CDM,250,RC,55566680001,NDC,,,facility,inpatient,1,EA,1395.45000,404.68000,Aetna,First Health,,1141.48,,,,,,,516.32,1141.48,percent of total billed charges,
Citric Acid/MgOx/Na pico Oral Soln,800040895,CDM,250,RC,55566680001,NDC,,,facility,outpatient,1,EA,1395.45000,404.68000,Aetna,First Health,,1141.48,,,,,,,503.06,1141.48,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,55566504001,NDC,facility,inpatient,0.04,ME,3557.55000,1031.69000,Aetna,First Health,,2910.08,,,,,,,1282.50,2910.08,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,55566504001,NDC,facility,outpatient,0.04,ME,3557.55000,1031.69000,Aetna,First Health,,2910.08,,,,,,,3.28,2910.08,percent of total billed charges,
Dinoprostone 10mg VS(Cervidil),800073303,CDM,252,RC,55566280001,NDC,,,facility,inpatient,1,EA,3638.90000,1055.28000,Aetna,First Health,,2976.62,,,,,,,1346.39,2976.62,percent of total billed charges,
Dinoprostone 10mg VS(Cervidil),800073303,CDM,252,RC,55566280001,NDC,,,facility,outpatient,1,EA,3638.90000,1055.28000,Aetna,First Health,,2976.62,,,,,,,1311.82,2976.62,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,55566250000,NDC,,,facility,inpatient,1,EA,3185.80000,923.88000,Aetna,First Health,,2605.98,,,,,,,1911.48,2605.98,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,55566250000,NDC,,,facility,outpatient,1,EA,3185.80000,923.88000,Aetna,First Health,,2605.98,,,,,,,1148.48,2605.98,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,55566210002,NDC,,,facility,inpatient,1,EA,41.05000,11.90000,Aetna,First Health,,33.58,,,,,,,24.63,33.58,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,55566210002,NDC,,,facility,outpatient,1,EA,41.05000,11.90000,Aetna,First Health,,33.58,,,,,,,14.80,33.58,percent of total billed charges,
Romosozumab-aqqg 105mg Inj Syr (Evenity),800062094,CDM,636,RC,J3111,HCPCS,55513099802,NDC,facility,inpatient,105,ME,5426.80000,1573.77000,Aetna,First Health,,4439.12,,,,,,,1956.36,4439.12,percent of total billed charges,
Romosozumab-aqqg 105mg Inj Syr (Evenity),800062094,CDM,636,RC,J3111,HCPCS,55513099802,NDC,facility,outpatient,105,ME,5426.80000,1573.77000,Aetna,First Health,,4439.12,,,,,,,11.66,4439.12,percent of total billed charges,
Panitumumab 400mg/20mL I(Vectibix),800051978,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,inpatient,400,ME,39318.65000,11402.41000,Aetna,First Health,,32162.66,,,,,,,14174.37,32162.66,percent of total billed charges,
Panitumumab 400mg/20mL I(Vectibix),800051978,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,outpatient,400,ME,39318.65000,11402.41000,Aetna,First Health,,32162.66,,,,,,,167.24,32162.66,percent of total billed charges,
Panitumumab 100mg/5mL I(Vectibix),800022004,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,inpatient,100,ME,9969.90000,2891.27000,Aetna,First Health,,8155.38,,,,,,,3594.15,8155.38,percent of total billed charges,
Panitumumab 100mg/5mL I(Vectibix),800022004,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,outpatient,100,ME,9969.90000,2891.27000,Aetna,First Health,,8155.38,,,,,,,167.24,8155.38,percent of total billed charges,
Romosozumab-aqqg 105mg Inj Syr (Evenity),800062094,CDM,636,RC,J3111,HCPCS,55513088002,NDC,facility,inpatient,105,ME,5426.80000,1573.77000,Aetna,First Health,,4439.12,,,,,,,1956.36,4439.12,percent of total billed charges,
Romosozumab-aqqg 105mg Inj Syr (Evenity),800062094,CDM,636,RC,J3111,HCPCS,55513088002,NDC,facility,outpatient,105,ME,5426.80000,1573.77000,Aetna,First Health,,4439.12,,,,,,,11.66,4439.12,percent of total billed charges,
Ivabradine 5mg Tab,800025653,CDM,637,RC,55513080060,NDC,,,facility,inpatient,1,EA,88.65000,25.71000,Aetna,First Health,,72.52,,,,,,,53.19,72.52,percent of total billed charges,
Ivabradine 5mg Tab,800025653,CDM,637,RC,55513080060,NDC,,,facility,outpatient,1,EA,88.65000,25.71000,Aetna,First Health,,72.52,,,,,,,31.96,72.52,percent of total billed charges,
Denosumab 120mg/1.7mL I (Xgeva),800022092,CDM,636,RC,J0897,HCPCS,55513073001,NDC,facility,inpatient,120,ME,13933.75000,4040.79000,Aetna,First Health,,11397.81,,,,,,,5023.12,11397.81,percent of total billed charges,
Denosumab 120mg/1.7mL I (Xgeva),800022092,CDM,636,RC,J0897,HCPCS,55513073001,NDC,facility,outpatient,120,ME,13933.75000,4040.79000,Aetna,First Health,,11397.81,,,,,,,28.37,11397.81,percent of total billed charges,
Denosumab 60mg/1mL IS(Prolia),800020909,CDM,636,RC,J0897,HCPCS,55513071001,NDC,facility,inpatient,60,ME,7661.70000,2221.89000,Aetna,First Health,,6267.27,,,,,,,2762.04,6267.27,percent of total billed charges,
Denosumab 60mg/1mL IS(Prolia),800020909,CDM,636,RC,J0897,HCPCS,55513071001,NDC,facility,outpatient,60,ME,7661.70000,2221.89000,Aetna,First Health,,6267.27,,,,,,,28.37,6267.27,percent of total billed charges,
inFLIXimab - axxq 100mg Inj,800046538,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,inpatient,100,ME,3787.00000,1098.23000,Aetna,First Health,,3097.77,,,,,,,1365.21,3097.77,percent of total billed charges,
inFLIXimab - axxq 100mg Inj,800046538,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,100,ME,3787.00000,1098.23000,Aetna,First Health,,3097.77,,,,,,,22.93,3097.77,percent of total billed charges,
"Epoetin 3,000 unit/mL Inj",800013635,CDM,636,RC,J0885,HCPCS,55513026710,NDC,facility,inpatient,3000,UN,298.85000,86.67000,Aetna,First Health,,244.46,,,,,,,107.74,244.46,percent of total billed charges,
"Epoetin 3,000 unit/mL Inj",800013635,CDM,636,RC,J0885,HCPCS,55513026710,NDC,facility,outpatient,3000,UN,298.85000,86.67000,Aetna,First Health,,244.46,,,,,,,7.45,244.46,percent of total billed charges,
"Epoetin 3,000 unit/mL Inj",800013635,CDM,636,RC,J0885,HCPCS,55513026701,NDC,facility,inpatient,3000,UN,220.25000,63.87000,Aetna,First Health,,180.16,,,,,,,79.40,180.16,percent of total billed charges,
"Epoetin 3,000 unit/mL Inj",800013635,CDM,636,RC,J0885,HCPCS,55513026701,NDC,facility,outpatient,3000,UN,220.25000,63.87000,Aetna,First Health,,180.16,,,,,,,7.45,180.16,percent of total billed charges,
romiPLOStim 125mcg Inj,800046482,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,inpatient,0.125,ME,5674.10000,1645.49000,Aetna,First Health,,4641.41,,,,,,,2045.51,4641.41,percent of total billed charges,
romiPLOStim 125mcg Inj,800046482,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,outpatient,0.125,ME,5674.10000,1645.49000,Aetna,First Health,,4641.41,,,,,,,10.64,4641.41,percent of total billed charges,
romiPLOStim 250mcg Inj,800012181,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,inpatient,0.25,ME,11158.05000,3235.83000,Aetna,First Health,,9127.28,,,,,,,4022.48,9127.28,percent of total billed charges,
romiPLOStim 250mcg Inj,800012181,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,outpatient,0.25,ME,11158.05000,3235.83000,Aetna,First Health,,9127.28,,,,,,,10.64,9127.28,percent of total billed charges,
Pegfilgrastim 6mg/0.6mL Inj,800079110,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,inpatient,6,ME,42805.45000,12413.58000,Aetna,First Health,,35014.86,,,,,,,15431.36,35014.86,percent of total billed charges,
Pegfilgrastim 6mg/0.6mL Inj,800079110,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,outpatient,6,ME,42805.45000,12413.58000,Aetna,First Health,,35014.86,,,,,,,118.29,35014.86,percent of total billed charges,
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,55513014810,NDC,facility,inpatient,4000,UN,384.80000,111.59000,Aetna,First Health,,314.77,,,,,,,138.72,314.77,percent of total billed charges,
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,55513014810,NDC,facility,outpatient,4000,UN,384.80000,111.59000,Aetna,First Health,,314.77,,,,,,,7.45,314.77,percent of total billed charges,
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,55513014801,NDC,facility,inpatient,4000,UN,289.90000,84.07000,Aetna,First Health,,237.14,,,,,,,104.51,237.14,percent of total billed charges,
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,55513014801,NDC,facility,outpatient,4000,UN,289.90000,84.07000,Aetna,First Health,,237.14,,,,,,,7.45,237.14,percent of total billed charges,
"Epoetin 10,000 unit Inj",800010933,CDM,636,RC,J0885,HCPCS,55513014410,NDC,facility,inpatient,10000,UN,850.05000,246.51000,Aetna,First Health,,695.34,,,,,,,306.44,695.34,percent of total billed charges,
"Epoetin 10,000 unit Inj",800010933,CDM,636,RC,J0885,HCPCS,55513014410,NDC,facility,outpatient,10000,UN,850.05000,246.51000,Aetna,First Health,,695.34,,,,,,,7.45,695.34,percent of total billed charges,
Tezepelumab-ekko 210mg Inj (Tezspire),800046454,CDM,636,RC,J2356,HCPCS,55513011201,NDC,facility,inpatient,210,ME,17595.95000,5102.83000,Aetna,First Health,,14393.49,,,,,,,6343.34,14393.49,percent of total billed charges,
Tezepelumab-ekko 210mg Inj (Tezspire),800046454,CDM,636,RC,J2356,HCPCS,55513011201,NDC,facility,outpatient,210,ME,17595.95000,5102.83000,Aetna,First Health,,14393.49,,,,,,,17.16,14393.49,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,55513007330,NDC,,,facility,inpatient,1,EA,227.30000,65.92000,Aetna,First Health,,185.93,,,,,,,136.38,185.93,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,55513007330,NDC,,,facility,outpatient,1,EA,227.30000,65.92000,Aetna,First Health,,185.93,,,,,,,81.94,185.93,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,55390076210,NDC,,,facility,inpatient,1,EA,70.55000,20.46000,Aetna,First Health,,57.71,,,,,,,26.10,57.71,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,55390076210,NDC,,,facility,outpatient,1,EA,70.55000,20.46000,Aetna,First Health,,57.71,,,,,,,25.43,57.71,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,55390050010,NDC,facility,inpatient,0.25,ME,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,55390050010,NDC,facility,outpatient,0.25,ME,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,0.34668,3.93,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,55390050005,NDC,facility,inpatient,1,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,4.02,9.12,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,55390050005,NDC,facility,outpatient,1,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,0.34668,9.12,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,55390048101,NDC,facility,inpatient,30,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,55390048101,NDC,facility,outpatient,30,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,0.31779,7.85,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,55390047510,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.35,5.19,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,55390047510,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,55390046001,NDC,facility,inpatient,500,ME,341.50000,99.04000,Aetna,First Health,,279.35,,,,,,,123.11,279.35,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,55390046001,NDC,facility,outpatient,500,ME,341.50000,99.04000,Aetna,First Health,,279.35,,,,,,,24.64,279.35,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,55390040420,NDC,facility,inpatient,600,ME,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,33.36,75.71,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,55390040420,NDC,facility,outpatient,600,ME,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,0.03852,75.71,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,55390035803,NDC,,,facility,inpatient,1,EA,169.90000,49.27000,Aetna,First Health,,138.98,,,,,,,101.94,138.98,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,55390035803,NDC,,,facility,outpatient,1,EA,169.90000,49.27000,Aetna,First Health,,138.98,,,,,,,61.25,138.98,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,55390031510,NDC,facility,inpatient,6,ME,357.20000,103.59000,Aetna,First Health,,292.19,,,,,,,214.32,292.19,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,55390031510,NDC,facility,outpatient,6,ME,357.20000,103.59000,Aetna,First Health,,292.19,,,,,,,85.32,292.19,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,55390031110,NDC,facility,inpatient,1,GM,21.10000,6.12000,Aetna,First Health,,17.26,,,,,,,7.61,17.26,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,55390031110,NDC,facility,outpatient,1,GM,21.10000,6.12000,Aetna,First Health,,17.26,,,,,,,0.44298,17.26,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,55390025901,NDC,facility,inpatient,1,GM,256.75000,74.46000,Aetna,First Health,,210.02,,,,,,,92.56,210.02,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,55390025901,NDC,facility,outpatient,1,GM,256.75000,74.46000,Aetna,First Health,,210.02,,,,,,,0.25038,210.02,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,55390025801,NDC,facility,inpatient,500,ME,932.00000,270.28000,Aetna,First Health,,762.38,,,,,,,335.99,762.38,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,55390025801,NDC,facility,outpatient,500,ME,932.00000,270.28000,Aetna,First Health,,762.38,,,,,,,0.25038,762.38,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,55390025201,NDC,facility,inpatient,20,ME,933.00000,270.57000,Aetna,First Health,,763.19,,,,,,,336.35,763.19,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,55390025201,NDC,facility,outpatient,20,ME,933.00000,270.57000,Aetna,First Health,,763.19,,,,,,,25.13,763.19,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,55390023701,NDC,facility,inpatient,50,ME,404.30000,117.25000,Aetna,First Health,,330.72,,,,,,,145.75,330.72,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,55390023701,NDC,facility,outpatient,50,ME,404.30000,117.25000,Aetna,First Health,,330.72,,,,,,,2.68,330.72,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,55390023510,NDC,facility,inpatient,10,ME,85.80000,24.88000,Aetna,First Health,,70.18,,,,,,,30.93,70.18,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,55390023510,NDC,facility,outpatient,10,ME,85.80000,24.88000,Aetna,First Health,,70.18,,,,,,,2.68,70.18,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,55390022801,NDC,facility,inpatient,400,ME,117.30000,34.02000,Aetna,First Health,,95.95,,,,,,,42.29,95.95,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,55390022801,NDC,facility,outpatient,400,ME,117.30000,34.02000,Aetna,First Health,,95.95,,,,,,,4.31,95.95,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,55390022701,NDC,facility,inpatient,200,ME,102.00000,29.58000,Aetna,First Health,,83.44,,,,,,,36.77,83.44,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,55390022701,NDC,facility,outpatient,200,ME,102.00000,29.58000,Aetna,First Health,,83.44,,,,,,,4.31,83.44,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,55390021901,NDC,facility,inpatient,1,GM,256.75000,74.46000,Aetna,First Health,,210.02,,,,,,,92.56,210.02,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,55390021901,NDC,facility,outpatient,1,GM,256.75000,74.46000,Aetna,First Health,,210.02,,,,,,,0.25038,210.02,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,55390021801,NDC,facility,inpatient,500,ME,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,46.87,106.34,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,55390021801,NDC,facility,outpatient,500,ME,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,0.25038,106.34,percent of total billed charges,
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,55390018401,NDC,facility,inpatient,2,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,55390018401,NDC,facility,outpatient,2,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,5.34,23.56,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,55390017610,NDC,facility,inpatient,500,ME,177.60000,51.50000,Aetna,First Health,,145.28,,,,,,,64.02,145.28,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,55390017610,NDC,facility,outpatient,500,ME,177.60000,51.50000,Aetna,First Health,,145.28,,,,,,,1.34,145.28,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,55390017510,NDC,facility,inpatient,100,ME,29.95000,8.69000,Aetna,First Health,,24.50,,,,,,,10.80,24.50,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,55390017510,NDC,facility,outpatient,100,ME,29.95000,8.69000,Aetna,First Health,,24.50,,,,,,,1.34,24.50,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,55390016810,NDC,facility,inpatient,2,ME,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,55390016810,NDC,facility,outpatient,2,ME,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,1.36,8.38,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,55390016210,NDC,facility,inpatient,0.5,ME,130.25000,37.77000,Aetna,First Health,,106.54,,,,,,,78.15,106.54,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,55390016210,NDC,facility,outpatient,0.5,ME,130.25000,37.77000,Aetna,First Health,,106.54,,,,,,,0.63558,106.54,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,55390016110,NDC,facility,inpatient,0.1,ME,63.85000,18.52000,Aetna,First Health,,52.23,,,,,,,38.31,52.23,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,55390016110,NDC,facility,outpatient,0.1,ME,63.85000,18.52000,Aetna,First Health,,52.23,,,,,,,0.63558,52.23,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,55390016010,NDC,facility,inpatient,0.05,ME,63.40000,18.39000,Aetna,First Health,,51.86,,,,,,,38.04,51.86,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,55390016010,NDC,facility,outpatient,0.05,ME,63.40000,18.39000,Aetna,First Health,,51.86,,,,,,,0.63558,51.86,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,55390014710,NDC,facility,inpatient,5,ME,14.35000,4.16000,Aetna,First Health,,11.74,,,,,,,5.17,11.74,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,55390014710,NDC,facility,outpatient,5,ME,14.35000,4.16000,Aetna,First Health,,11.74,,,,,,,0.70299,11.74,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,55390013801,NDC,facility,inpatient,5,ME,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,5.19,11.78,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,55390013801,NDC,facility,outpatient,5,ME,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,0.13482,11.78,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,55390013705,NDC,facility,inpatient,5,ME,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,5.19,11.78,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,55390013705,NDC,facility,outpatient,5,ME,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,0.13482,11.78,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,55390013702,NDC,facility,inpatient,2,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,55390013702,NDC,facility,outpatient,2,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,0.13482,7.85,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,55390013020,NDC,facility,inpatient,100,ME,26.60000,7.71000,Aetna,First Health,,21.76,,,,,,,9.84,21.76,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,55390013020,NDC,facility,outpatient,100,ME,26.60000,7.71000,Aetna,First Health,,21.76,,,,,,,0.33705,21.76,percent of total billed charges,
Labetalol 100mg/20mL - for IV Set,800025515,CDM,250,RC,J1920,HCPCS,55390013020,NDC,facility,inpatient,100,ME,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,18.87,41.72,percent of total billed charges,
Labetalol 100mg/20mL - for IV Set,800025515,CDM,250,RC,J1920,HCPCS,55390013020,NDC,facility,outpatient,100,ME,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,0.33705,41.72,percent of total billed charges,
Cladribine 10mg/10mL I(Leustatin),800022003,CDM,636,RC,J9065,HCPCS,55390012401,NDC,facility,inpatient,10,ME,3074.20000,891.52000,Aetna,First Health,,2514.70,,,,,,,1108.25,2514.70,percent of total billed charges,
Cladribine 10mg/10mL I(Leustatin),800022003,CDM,636,RC,J9065,HCPCS,55390012401,NDC,facility,outpatient,10,ME,3074.20000,891.52000,Aetna,First Health,,2514.70,,,,,,,7.15,2514.70,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,55390012110,NDC,facility,inpatient,4,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,55390012110,NDC,facility,outpatient,4,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,0.08667,7.85,percent of total billed charges,
Phentolamine Mesylate 5mg I(Regitine),800013144,CDM,637,RC,J2760,HCPCS,55390011301,NDC,facility,inpatient,5,ME,777.60000,225.50000,Aetna,First Health,,636.08,,,,,,,466.56,636.08,percent of total billed charges,
Phentolamine Mesylate 5mg I(Regitine),800013144,CDM,637,RC,J2760,HCPCS,55390011301,NDC,facility,outpatient,5,ME,777.60000,225.50000,Aetna,First Health,,636.08,,,,,,,311.04,1297.01,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,55390011010,NDC,facility,inpatient,100,ME,116.15000,33.68000,Aetna,First Health,,95.01,,,,,,,42.98,95.01,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,55390011010,NDC,facility,outpatient,100,ME,116.15000,33.68000,Aetna,First Health,,95.01,,,,,,,0.09630,95.01,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,55390010499,NDC,facility,inpatient,1,GM,106.25000,30.81000,Aetna,First Health,,86.91,,,,,,,38.30,86.91,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,55390010499,NDC,facility,outpatient,1,GM,106.25000,30.81000,Aetna,First Health,,86.91,,,,,,,0.08667,86.91,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,55390010450,NDC,facility,inpatient,0.5,GM,280.70000,81.40000,Aetna,First Health,,229.61,,,,,,,101.19,229.61,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,55390010450,NDC,facility,outpatient,0.5,GM,280.70000,81.40000,Aetna,First Health,,229.61,,,,,,,0.08667,229.61,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,55390010420,NDC,facility,inpatient,200,ME,70.70000,20.50000,Aetna,First Health,,57.83,,,,,,,25.49,57.83,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,55390010420,NDC,facility,outpatient,200,ME,70.70000,20.50000,Aetna,First Health,,57.83,,,,,,,0.08667,57.83,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,55390010110,NDC,facility,inpatient,1,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,55390010110,NDC,facility,outpatient,1,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,2.38,20.90,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,55390009210,NDC,,,facility,inpatient,1,EA,47.90000,13.89000,Aetna,First Health,,39.18,,,,,,,17.72,39.18,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,55390009210,NDC,,,facility,outpatient,1,EA,47.90000,13.89000,Aetna,First Health,,39.18,,,,,,,17.27,39.18,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,55390007710,NDC,facility,inpatient,10,ME,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,10.58,24.01,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,55390007710,NDC,facility,outpatient,10,ME,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,2.43,24.01,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,55390007310,NDC,,,facility,inpatient,1,EA,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.72,10.43,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,55390007310,NDC,,,facility,outpatient,1,EA,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,55390006710,NDC,facility,inpatient,6,ME,58.10000,16.85000,Aetna,First Health,,47.53,,,,,,,20.95,47.53,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,55390006710,NDC,facility,outpatient,6,ME,58.10000,16.85000,Aetna,First Health,,47.53,,,,,,,0.51039,47.53,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,55390006610,NDC,facility,inpatient,20,ME,91.30000,26.48000,Aetna,First Health,,74.68,,,,,,,32.91,74.68,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,55390006610,NDC,facility,outpatient,20,ME,91.30000,26.48000,Aetna,First Health,,74.68,,,,,,,10.91,74.68,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,55390006210,NDC,facility,inpatient,100,ME,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,11.97,27.16,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,55390006210,NDC,facility,outpatient,100,ME,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,0.20223,27.16,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,55390006002,NDC,facility,inpatient,500,ME,3142.30000,911.27000,Aetna,First Health,,2570.40,,,,,,,1132.80,2570.40,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,55390006002,NDC,facility,outpatient,500,ME,3142.30000,911.27000,Aetna,First Health,,2570.40,,,,,,,55.86,2570.40,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,55390005910,NDC,facility,inpatient,60,ME,109.05000,31.62000,Aetna,First Health,,89.20,,,,,,,39.31,89.20,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,55390005910,NDC,facility,outpatient,60,ME,109.05000,31.62000,Aetna,First Health,,89.20,,,,,,,6.15,89.20,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,55390005710,NDC,facility,inpatient,150,ME,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,7.21,16.36,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,55390005710,NDC,facility,outpatient,150,ME,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,0.39483,16.36,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,55390005401,NDC,facility,inpatient,350,ME,292.00000,84.68000,Aetna,First Health,,238.86,,,,,,,105.27,238.86,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,55390005401,NDC,facility,outpatient,350,ME,292.00000,84.68000,Aetna,First Health,,238.86,,,,,,,3.70,238.86,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,55390003710,NDC,,,facility,inpatient,1,EA,41.25000,11.96000,Aetna,First Health,,33.74,,,,,,,15.26,33.74,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,55390003710,NDC,,,facility,outpatient,1,EA,41.25000,11.96000,Aetna,First Health,,33.74,,,,,,,14.87,33.74,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,55390003110,NDC,facility,inpatient,50,ME,31.20000,9.05000,Aetna,First Health,,25.52,,,,,,,11.25,25.52,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,55390003110,NDC,facility,outpatient,50,ME,31.20000,9.05000,Aetna,First Health,,25.52,,,,,,,2.48,25.52,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,55390002910,NDC,facility,inpatient,20,ME,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,55390002910,NDC,facility,outpatient,20,ME,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,0.00963,6.22,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,55390001310,NDC,facility,inpatient,1,ME,182.70000,52.98000,Aetna,First Health,,149.45,,,,,,,65.86,149.45,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,55390001310,NDC,facility,outpatient,1,ME,182.70000,52.98000,Aetna,First Health,,149.45,,,,,,,54.97,176.03,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,55390001110,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.62,14.64,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,55390001110,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,55390001010,NDC,,,facility,inpatient,1,EA,42.75000,12.40000,Aetna,First Health,,34.97,,,,,,,15.82,34.97,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,55390001010,NDC,,,facility,outpatient,1,EA,42.75000,12.40000,Aetna,First Health,,34.97,,,,,,,15.41,34.97,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,55390000710,NDC,,,facility,inpatient,1,EA,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,12.78,28.26,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,55390000710,NDC,,,facility,outpatient,1,EA,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,12.46,28.26,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,55390000210,NDC,,,facility,inpatient,1,EA,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,10.86,24.01,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,55390000210,NDC,,,facility,outpatient,1,EA,29.35000,8.51000,Aetna,First Health,,24.01,,,,,,,10.58,24.01,percent of total billed charges,
hemin 350mg Inj,800051985,CDM,636,RC,J1640,HCPCS,55292070255,NDC,facility,inpatient,350,ME,80770.35000,23423.40000,Aetna,First Health,,66070.15,,,,,,,29117.71,66070.15,percent of total billed charges,
hemin 350mg Inj,800051985,CDM,636,RC,J1640,HCPCS,55292070255,NDC,facility,outpatient,350,ME,80770.35000,23423.40000,Aetna,First Health,,66070.15,,,,,,,34.00,66070.15,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,55150047006,NDC,,,facility,inpatient,1,EA,565.30000,163.94000,Aetna,First Health,,462.42,,,,,,,209.16,462.42,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,55150047006,NDC,,,facility,outpatient,1,EA,565.30000,163.94000,Aetna,First Health,,462.42,,,,,,,203.79,462.42,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,55150044301,NDC,facility,inpatient,0.4,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,57.18,129.73,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,55150044301,NDC,facility,outpatient,0.4,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,2.58,129.73,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,55150043701,NDC,facility,inpatient,500,ME,4136.25000,1199.51000,Aetna,First Health,,3383.45,,,,,,,1491.12,3383.45,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,55150043701,NDC,facility,outpatient,500,ME,4136.25000,1199.51000,Aetna,First Health,,3383.45,,,,,,,55.86,3383.45,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,55150042510,NDC,,,facility,inpatient,1,EA,24.25000,7.03000,Aetna,First Health,,19.84,,,,,,,8.97,19.84,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,55150042510,NDC,,,facility,outpatient,1,EA,24.25000,7.03000,Aetna,First Health,,19.84,,,,,,,8.74,19.84,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,55150042010,NDC,facility,inpatient,2.5,GM,1264.30000,366.65000,Aetna,First Health,,1034.20,,,,,,,455.78,1034.20,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,55150042010,NDC,facility,outpatient,2.5,GM,1264.30000,366.65000,Aetna,First Health,,1034.20,,,,,,,0.20223,1034.20,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,55150040025,NDC,facility,inpatient,20,ME,43.40000,12.59000,Aetna,First Health,,35.50,,,,,,,15.65,35.50,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,55150040025,NDC,facility,outpatient,20,ME,43.40000,12.59000,Aetna,First Health,,35.50,,,,,,,4.23,35.50,percent of total billed charges,
Bendamustine 100mg I(Treanda),800012530,CDM,636,RC,J9033,HCPCS,55150039201,NDC,facility,inpatient,100,ME,3157.00000,915.53000,Aetna,First Health,,2582.43,,,,,,,1138.10,2582.43,percent of total billed charges,
Bendamustine 100mg I(Treanda),800012530,CDM,636,RC,J9033,HCPCS,55150039201,NDC,facility,outpatient,100,ME,3157.00000,915.53000,Aetna,First Health,,2582.43,,,,,,,1.97,2582.43,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,55150037125,NDC,facility,inpatient,20,UN,778.25000,225.69000,Aetna,First Health,,636.61,,,,,,,280.56,636.61,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,55150037125,NDC,facility,outpatient,20,UN,778.25000,225.69000,Aetna,First Health,,636.61,,,,,,,0.51039,636.61,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,55150037025,NDC,facility,inpatient,20,UN,175.95000,51.03000,Aetna,First Health,,143.93,,,,,,,63.43,143.93,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,55150037025,NDC,facility,outpatient,20,UN,175.95000,51.03000,Aetna,First Health,,143.93,,,,,,,0.51039,143.93,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,55150037024,NDC,facility,inpatient,20,UN,429.80000,124.64000,Aetna,First Health,,351.58,,,,,,,154.94,351.58,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,55150037024,NDC,facility,outpatient,20,UN,429.80000,124.64000,Aetna,First Health,,351.58,,,,,,,0.51039,351.58,percent of total billed charges,
Amphotericin B LIPO 50mg I,800010922,CDM,636,RC,J0289,HCPCS,55150036501,NDC,facility,inpatient,50,ME,2021.20000,586.15000,Aetna,First Health,,1653.34,,,,,,,728.64,1653.34,percent of total billed charges,
Amphotericin B LIPO 50mg I,800010922,CDM,636,RC,J0289,HCPCS,55150036501,NDC,facility,outpatient,50,ME,2021.20000,586.15000,Aetna,First Health,,1653.34,,,,,,,19.95,1653.34,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,55150036425,NDC,facility,inpatient,1,ME,21.70000,6.29000,Aetna,First Health,,17.75,,,,,,,7.82,17.75,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,55150036425,NDC,facility,outpatient,1,ME,21.70000,6.29000,Aetna,First Health,,17.75,,,,,,,0.61632,17.75,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,55150034510,NDC,facility,inpatient,2,ME,196.20000,56.90000,Aetna,First Health,,160.49,,,,,,,70.73,160.49,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,55150034510,NDC,facility,outpatient,2,ME,196.20000,56.90000,Aetna,First Health,,160.49,,,,,,,0.06741,160.49,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,55150034401,NDC,facility,inpatient,500,ME,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,102.02,231.49,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,55150034401,NDC,facility,outpatient,500,ME,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,0.02889,231.49,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,55150033701,NDC,facility,inpatient,3.5,ME,315.20000,91.41000,Aetna,First Health,,257.83,,,,,,,113.63,257.83,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,55150033701,NDC,facility,outpatient,3.5,ME,315.20000,91.41000,Aetna,First Health,,257.83,,,,,,,2.58,257.83,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,55150033001,NDC,facility,inpatient,150,ME,403.90000,117.13000,Aetna,First Health,,330.39,,,,,,,145.61,330.39,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,55150033001,NDC,facility,outpatient,150,ME,403.90000,117.13000,Aetna,First Health,,330.39,,,,,,,0.40446,330.39,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,55150032710,NDC,facility,inpatient,0.4,ME,79.55000,23.07000,Aetna,First Health,,65.07,,,,,,,28.68,65.07,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,55150032710,NDC,facility,outpatient,0.4,ME,79.55000,23.07000,Aetna,First Health,,65.07,,,,,,,0.06741,65.07,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,55150032425,NDC,facility,inpatient,100,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,55150032425,NDC,facility,outpatient,100,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,55150032225,NDC,facility,inpatient,20,ME,16.75000,4.86000,Aetna,First Health,,13.70,,,,,,,6.04,13.70,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,55150032225,NDC,facility,outpatient,20,ME,16.75000,4.86000,Aetna,First Health,,13.70,,,,,,,0.01926,13.70,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,55150030801,NDC,facility,inpatient,10,ME,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,78.95,179.14,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,55150030801,NDC,facility,outpatient,10,ME,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,0.78003,179.14,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,inpatient,50,ME,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,73.54,166.87,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,outpatient,50,ME,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,75.48,166.87,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,55150029901,NDC,facility,inpatient,150,ME,584.00000,169.36000,Aetna,First Health,,477.71,,,,,,,210.53,477.71,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,55150029901,NDC,facility,outpatient,150,ME,584.00000,169.36000,Aetna,First Health,,477.71,,,,,,,0.10593,477.71,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,55150029710,NDC,,,facility,inpatient,1,EA,512.50000,148.62000,Aetna,First Health,,419.23,,,,,,,189.62,419.23,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,55150029710,NDC,,,facility,outpatient,1,EA,512.50000,148.62000,Aetna,First Health,,419.23,,,,,,,184.76,419.23,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,55150028710,NDC,facility,inpatient,20,ME,155.05000,44.96000,Aetna,First Health,,126.83,,,,,,,55.90,126.83,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,55150028710,NDC,facility,outpatient,20,ME,155.05000,44.96000,Aetna,First Health,,126.83,,,,,,,1.30,126.83,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,55150028220,NDC,facility,inpatient,1,GM,542.00000,157.18000,Aetna,First Health,,443.36,,,,,,,195.39,443.36,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,55150028220,NDC,facility,outpatient,1,GM,542.00000,157.18000,Aetna,First Health,,443.36,,,,,,,8.82,443.36,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,55150028209,NDC,facility,inpatient,1,GM,710.00000,205.90000,Aetna,First Health,,580.78,,,,,,,255.96,580.78,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,55150028209,NDC,facility,outpatient,1,GM,710.00000,205.90000,Aetna,First Health,,580.78,,,,,,,8.82,580.78,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,55150025930,NDC,facility,inpatient,6000,ME,519.25000,150.58000,Aetna,First Health,,424.75,,,,,,,187.19,424.75,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,55150025930,NDC,facility,outpatient,6000,ME,519.25000,150.58000,Aetna,First Health,,424.75,,,,,,,0.35631,424.75,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,55150025650,NDC,,,facility,inpatient,1,EA,49.80000,14.44000,Aetna,First Health,,40.74,,,,,,,17.95,40.74,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,55150025650,NDC,,,facility,outpatient,1,EA,49.80000,14.44000,Aetna,First Health,,40.74,,,,,,,17.95,40.74,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,55150025520,NDC,,,facility,inpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,9.66,21.92,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,55150025520,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,9.66,21.92,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,55150025350,NDC,,,facility,inpatient,1,EA,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,14.38,32.64,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,55150025350,NDC,,,facility,outpatient,1,EA,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,14.38,32.64,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,55150025220,NDC,,,facility,inpatient,1,EA,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,8.51,19.30,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,55150025220,NDC,,,facility,outpatient,1,EA,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,8.51,19.30,percent of total billed charges,
Lidocaine HCl 1% 10mL Inj,800040882,CDM,636,RC,55150025110,NDC,,,facility,inpatient,1,EA,17.25000,5.00000,Aetna,First Health,,14.11,,,,,,,6.22,14.11,percent of total billed charges,
Lidocaine HCl 1% 10mL Inj,800040882,CDM,636,RC,55150025110,NDC,,,facility,outpatient,1,EA,17.25000,5.00000,Aetna,First Health,,14.11,,,,,,,6.22,14.11,percent of total billed charges,
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,55150024747,NDC,facility,inpatient,1000,ME,443.00000,128.47000,Aetna,First Health,,362.37,,,,,,,159.70,362.37,percent of total billed charges,
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,55150024747,NDC,facility,outpatient,1000,ME,443.00000,128.47000,Aetna,First Health,,362.37,,,,,,,0.03852,362.37,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,55150024647,NDC,facility,inpatient,500,ME,262.75000,76.20000,Aetna,First Health,,214.93,,,,,,,94.72,214.93,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,55150024647,NDC,facility,outpatient,500,ME,262.75000,76.20000,Aetna,First Health,,214.93,,,,,,,0.03852,214.93,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,55150024251,NDC,facility,inpatient,600,ME,134.40000,38.98000,Aetna,First Health,,109.94,,,,,,,48.45,109.94,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,55150024251,NDC,facility,outpatient,600,ME,134.40000,38.98000,Aetna,First Health,,109.94,,,,,,,2.64,109.94,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,55150024110,NDC,facility,inpatient,50,ME,2091.25000,606.46000,Aetna,First Health,,1710.64,,,,,,,753.90,1710.64,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,55150024110,NDC,facility,outpatient,50,ME,2091.25000,606.46000,Aetna,First Health,,1710.64,,,,,,,0.58743,1710.64,percent of total billed charges,
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,55150024005,NDC,facility,inpatient,50,ME,4257.00000,1234.53000,Aetna,First Health,,3482.23,,,,,,,1534.65,3482.23,percent of total billed charges,
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,55150024005,NDC,facility,outpatient,50,ME,4257.00000,1234.53000,Aetna,First Health,,3482.23,,,,,,,5.42,3482.23,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,55150023805,NDC,facility,inpatient,1,ME,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.28840,0.65440,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,55150023805,NDC,facility,outpatient,1,ME,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.10593,0.65440,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,55150023511,NDC,,,facility,inpatient,1,EA,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,9.36,20.70,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,55150023511,NDC,,,facility,outpatient,1,EA,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,9.12,20.70,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,55150023510,NDC,,,facility,inpatient,1,EA,35.10000,10.18000,Aetna,First Health,,28.71,,,,,,,12.99,28.71,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,55150023510,NDC,,,facility,outpatient,1,EA,35.10000,10.18000,Aetna,First Health,,28.71,,,,,,,12.65,28.71,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,55150022505,NDC,,,facility,inpatient,1,EA,55.85000,16.20000,Aetna,First Health,,45.69,,,,,,,20.66,45.69,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,55150022505,NDC,,,facility,outpatient,1,EA,55.85000,16.20000,Aetna,First Health,,45.69,,,,,,,20.13,45.69,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,55150022310,NDC,facility,inpatient,1,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,34.61,78.53,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,55150022310,NDC,facility,outpatient,1,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,4.37,78.53,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,55150022110,NDC,,,facility,inpatient,1,EA,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,18.89,41.76,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,55150022110,NDC,,,facility,outpatient,1,EA,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,18.40,41.76,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,55150021910,NDC,facility,inpatient,20,ME,274.30000,79.55000,Aetna,First Health,,224.38,,,,,,,98.89,224.38,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,55150021910,NDC,facility,outpatient,20,ME,274.30000,79.55000,Aetna,First Health,,224.38,,,,,,,3.52,224.38,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,55150021010,NDC,facility,inpatient,250,ME,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,335.26,760.74,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,55150021010,NDC,facility,outpatient,250,ME,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,0.15408,760.74,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,55150020830,NDC,facility,inpatient,1,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,38.07,86.38,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,55150020830,NDC,facility,outpatient,1,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,0.36594,86.38,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,55150020720,NDC,facility,inpatient,500,ME,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,55150020720,NDC,facility,outpatient,500,ME,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,0.36594,47.12,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,55150020210,NDC,facility,inpatient,40,ME,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,55150020210,NDC,facility,outpatient,40,ME,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,5.86,18.78,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,55150019830,NDC,facility,inpatient,150,ME,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,18.40,41.76,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,55150019830,NDC,facility,outpatient,150,ME,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,0.04815,41.76,percent of total billed charges,
ROPivacaine 0.5% 20mL I,800021331,CDM,636,RC,J2795,HCPCS,55150019720,NDC,facility,inpatient,100,ME,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,12.89,29.24,percent of total billed charges,
ROPivacaine 0.5% 20mL I,800021331,CDM,636,RC,J2795,HCPCS,55150019720,NDC,facility,outpatient,100,ME,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,0.04815,29.24,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,55150019699,NDC,facility,inpatient,200,ME,580.00000,168.20000,Aetna,First Health,,474.44,,,,,,,209.09,474.44,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,55150019699,NDC,facility,outpatient,200,ME,580.00000,168.20000,Aetna,First Health,,474.44,,,,,,,0.04815,474.44,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,55150019520,NDC,facility,inpatient,40,ME,86.20000,25.00000,Aetna,First Health,,70.51,,,,,,,31.08,70.51,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,55150019520,NDC,facility,outpatient,40,ME,86.20000,25.00000,Aetna,First Health,,70.51,,,,,,,0.04815,70.51,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,55150019410,NDC,facility,inpatient,100,ME,46.80000,13.57000,Aetna,First Health,,38.28,,,,,,,16.87,38.28,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,55150019410,NDC,facility,outpatient,100,ME,46.80000,13.57000,Aetna,First Health,,38.28,,,,,,,0.20223,38.28,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,55150019183,NDC,facility,inpatient,3,ME,1850.00000,536.50000,Aetna,First Health,,1513.30,,,,,,,666.92,1513.30,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,55150019183,NDC,facility,outpatient,3,ME,1850.00000,536.50000,Aetna,First Health,,1513.30,,,,,,,12.65,1513.30,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,55150018810,NDC,,,facility,inpatient,1,EA,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,21.31,47.12,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,55150018810,NDC,,,facility,outpatient,1,EA,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,55150018703,NDC,facility,inpatient,60,ME,313.00000,90.77000,Aetna,First Health,,256.03,,,,,,,112.84,256.03,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,55150018703,NDC,facility,outpatient,60,ME,313.00000,90.77000,Aetna,First Health,,256.03,,,,,,,1.40,256.03,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,55150018605,NDC,facility,inpatient,0.25,ME,127.70000,37.03000,Aetna,First Health,,104.46,,,,,,,46.04,104.46,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,55150018605,NDC,facility,outpatient,0.25,ME,127.70000,37.03000,Aetna,First Health,,104.46,,,,,,,0.33705,104.46,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,55150018311,NDC,facility,inpatient,25,ME,194.95000,56.54000,Aetna,First Health,,159.47,,,,,,,70.28,159.47,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,55150018311,NDC,facility,outpatient,25,ME,194.95000,56.54000,Aetna,First Health,,159.47,,,,,,,0.06741,159.47,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,55150018310,NDC,facility,inpatient,25,ME,218.85000,63.47000,Aetna,First Health,,179.02,,,,,,,78.90,179.02,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,55150018310,NDC,facility,outpatient,25,ME,218.85000,63.47000,Aetna,First Health,,179.02,,,,,,,0.06741,179.02,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,55150018003,NDC,facility,inpatient,150,ME,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,8.65,19.63,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,55150018003,NDC,facility,outpatient,150,ME,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,0.39483,19.63,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,55150017705,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,55150017705,NDC,facility,outpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,0.03852,23.56,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,55150017305,NDC,facility,inpatient,6,ME,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,42.12,57.42,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,55150017305,NDC,facility,outpatient,6,ME,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,25.31,273.24,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,55150017301,NDC,facility,inpatient,6,ME,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,42.12,57.42,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,55150017301,NDC,facility,outpatient,6,ME,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,25.31,273.24,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,55150017030,NDC,,,facility,inpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,6.97,15.42,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,55150017030,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,6.80,15.42,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,55150016910,NDC,,,facility,inpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,7.09,15.66,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,55150016910,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,55150016830,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.29,13.91,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,55150016830,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,55150016710,NDC,,,facility,inpatient,1,EA,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,6.14,13.58,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,55150016710,NDC,,,facility,outpatient,1,EA,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,5.98,13.58,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,55150016330,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,55150016330,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,55150016205,NDC,,,facility,inpatient,1,EA,21.55000,6.25000,Aetna,First Health,,17.63,,,,,,,7.77,17.63,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,55150016205,NDC,,,facility,outpatient,1,EA,21.55000,6.25000,Aetna,First Health,,17.63,,,,,,,7.77,17.63,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,55150016102,NDC,,,facility,inpatient,1,EA,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,5.89,13.37,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,55150016102,NDC,,,facility,outpatient,1,EA,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,5.89,13.37,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,55150015974,NDC,,,facility,inpatient,1,EA,14.20000,4.12000,Aetna,First Health,,11.62,,,,,,,5.12,11.62,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,55150015974,NDC,,,facility,outpatient,1,EA,14.20000,4.12000,Aetna,First Health,,11.62,,,,,,,5.12,11.62,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,55150015872,NDC,,,facility,inpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,3.79,8.59,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,55150015872,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,3.79,8.59,percent of total billed charges,
Acyclovir 50mg/mL Inj 20mL,800013250,CDM,636,RC,J0133,HCPCS,55150015520,NDC,facility,inpatient,1000,ME,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,85.80,194.68,percent of total billed charges,
Acyclovir 50mg/mL Inj 20mL,800013250,CDM,636,RC,J0133,HCPCS,55150015520,NDC,facility,outpatient,1000,ME,238.00000,69.02000,Aetna,First Health,,194.68,,,,,,,0.11556,194.68,percent of total billed charges,
Acyclovir 50mg/mL Inj 10mL,800020914,CDM,636,RC,J0133,HCPCS,55150015411,NDC,facility,inpatient,500,ME,128.00000,37.12000,Aetna,First Health,,104.70,,,,,,,46.14,104.70,percent of total billed charges,
Acyclovir 50mg/mL Inj 10mL,800020914,CDM,636,RC,J0133,HCPCS,55150015411,NDC,facility,outpatient,500,ME,128.00000,37.12000,Aetna,First Health,,104.70,,,,,,,0.11556,104.70,percent of total billed charges,
Acyclovir 50mg/mL Inj 10mL,800020914,CDM,636,RC,J0133,HCPCS,55150015410,NDC,facility,inpatient,500,ME,128.00000,37.12000,Aetna,First Health,,104.70,,,,,,,46.14,104.70,percent of total billed charges,
Acyclovir 50mg/mL Inj 10mL,800020914,CDM,636,RC,J0133,HCPCS,55150015410,NDC,facility,outpatient,500,ME,128.00000,37.12000,Aetna,First Health,,104.70,,,,,,,0.11556,104.70,percent of total billed charges,
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,55150012715,NDC,facility,inpatient,1000,ME,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,41.82,94.89,percent of total billed charges,
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,55150012715,NDC,facility,outpatient,1000,ME,116.00000,33.64000,Aetna,First Health,,94.89,,,,,,,0.54891,94.89,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,55150012620,NDC,facility,inpatient,4,ME,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,7.21,16.36,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,55150012620,NDC,facility,outpatient,4,ME,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,0.08667,16.36,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,55150012502,NDC,facility,inpatient,4,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,55150012502,NDC,facility,outpatient,4,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,0.08667,10.43,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,inpatient,2,GM,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,43.26,98.16,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,outpatient,2,GM,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,0.05778,98.16,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,55150012315,NDC,facility,inpatient,2,GM,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,43.26,98.16,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,55150012315,NDC,facility,outpatient,2,GM,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,0.05778,98.16,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,4.5,GM,62.40000,18.10000,Aetna,First Health,,51.04,,,,,,,22.50,51.04,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,outpatient,4.5,GM,62.40000,18.10000,Aetna,First Health,,51.04,,,,,,,1.05,51.04,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,55150012030,NDC,facility,inpatient,3.375,GM,52.80000,15.31000,Aetna,First Health,,43.19,,,,,,,19.03,43.19,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,55150012030,NDC,facility,outpatient,3.375,GM,52.80000,15.31000,Aetna,First Health,,43.19,,,,,,,1.05,43.19,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,55150011930,NDC,facility,inpatient,2.25,GM,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,55150011930,NDC,facility,outpatient,2.25,GM,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,1.05,23.56,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,55150011720,NDC,facility,inpatient,3,GM,116.80000,33.87000,Aetna,First Health,,95.54,,,,,,,42.11,95.54,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,55150011720,NDC,facility,outpatient,3,GM,116.80000,33.87000,Aetna,First Health,,95.54,,,,,,,1.28,95.54,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,55150011620,NDC,facility,inpatient,1.5,GM,61.90000,17.95000,Aetna,First Health,,50.63,,,,,,,22.31,50.63,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,55150011620,NDC,facility,outpatient,1.5,GM,61.90000,17.95000,Aetna,First Health,,50.63,,,,,,,1.28,50.63,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,inpatient,2,GM,127.30000,36.92000,Aetna,First Health,,104.13,,,,,,,45.89,104.13,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,outpatient,2,GM,127.30000,36.92000,Aetna,First Health,,104.13,,,,,,,0.56817,104.13,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,55150011310,NDC,facility,inpatient,1,GM,65.65000,19.04000,Aetna,First Health,,53.70,,,,,,,23.67,53.70,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,55150011310,NDC,facility,outpatient,1,GM,65.65000,19.04000,Aetna,First Health,,53.70,,,,,,,0.56817,53.70,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,55150011210,NDC,facility,inpatient,500,ME,33.50000,9.72000,Aetna,First Health,,27.40,,,,,,,12.08,27.40,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,55150011210,NDC,facility,outpatient,500,ME,33.50000,9.72000,Aetna,First Health,,27.40,,,,,,,0.56817,27.40,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,55111079835,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,55111079835,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,55111073809,NDC,,,facility,inpatient,1,EA,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,115.80,157.87,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,55111073809,NDC,,,facility,outpatient,1,EA,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,69.58,157.87,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,55111073709,NDC,,,facility,inpatient,1,EA,180.40000,52.32000,Aetna,First Health,,147.57,,,,,,,108.24,147.57,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,55111073709,NDC,,,facility,outpatient,1,EA,180.40000,52.32000,Aetna,First Health,,147.57,,,,,,,65.03,147.57,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,55111073390,NDC,,,facility,inpatient,1,EA,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,8.85,12.07,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,55111073390,NDC,,,facility,outpatient,1,EA,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,5.32,12.07,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,55111073001,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,55111073001,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,55111072901,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,55111072901,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,55111069407,NDC,facility,inpatient,0.25,ME,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,41.42,93.99,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,55111069407,NDC,facility,outpatient,0.25,ME,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,0.33705,93.99,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,55111068852,NDC,facility,inpatient,5,ME,2527.00000,732.83000,Aetna,First Health,,2067.09,,,,,,,910.98,2067.09,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,55111068852,NDC,facility,outpatient,5,ME,2527.00000,732.83000,Aetna,First Health,,2067.09,,,,,,,4.89,2067.09,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,55111068507,NDC,facility,inpatient,4,ME,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,240.81,546.42,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,55111068507,NDC,facility,outpatient,4,ME,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,4.89,546.42,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,55111068301,NDC,,,facility,inpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,1.23,1.68,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,55111068301,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,0.73903,1.68,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,55111068002,NDC,facility,inpatient,7.5,ME,608.75000,176.54000,Aetna,First Health,,497.96,,,,,,,219.45,497.96,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,55111068002,NDC,facility,outpatient,7.5,ME,608.75000,176.54000,Aetna,First Health,,497.96,,,,,,,0.84744,497.96,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,55111067802,NDC,facility,inpatient,2.5,ME,290.25000,84.17000,Aetna,First Health,,237.42,,,,,,,104.64,237.42,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,55111067802,NDC,facility,outpatient,2.5,ME,290.25000,84.17000,Aetna,First Health,,237.42,,,,,,,0.84744,237.42,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,55111067131,NDC,,,facility,inpatient,1,EA,198.20000,57.48000,Aetna,First Health,,162.13,,,,,,,118.92,162.13,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,55111067131,NDC,,,facility,outpatient,1,EA,198.20000,57.48000,Aetna,First Health,,162.13,,,,,,,71.45,162.13,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,55111065237,NDC,facility,inpatient,250,ME,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,335.26,760.74,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,55111065237,NDC,facility,outpatient,250,ME,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,0.15408,760.74,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,55111065001,NDC,,,facility,inpatient,1,EA,34.65000,10.05000,Aetna,First Health,,28.34,,,,,,,20.79,28.34,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,55111065001,NDC,,,facility,outpatient,1,EA,34.65000,10.05000,Aetna,First Health,,28.34,,,,,,,12.49,28.34,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,55111064801,NDC,,,facility,inpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,5.58,7.61,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,55111064801,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,55111053401,NDC,,,facility,inpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,17.31,23.60,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,55111053401,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,10.40,23.60,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,55111053301,NDC,,,facility,inpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,10.44,14.23,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,55111053301,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,6.27,14.23,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,55111053201,NDC,,,facility,inpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,4.77,6.50,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,55111053201,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,2.87,6.50,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,55111046801,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,55111046801,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,55111046705,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,55111046705,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,55111046701,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,55111046701,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,55111046601,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,55111046601,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,55111035260,NDC,,,facility,inpatient,1,EA,30.05000,8.71000,Aetna,First Health,,24.58,,,,,,,18.03,24.58,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,55111035260,NDC,,,facility,outpatient,1,EA,30.05000,8.71000,Aetna,First Health,,24.58,,,,,,,10.83,24.58,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,55111033390,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,55111033390,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Donepezil 23mg T (Aricept),800072470,CDM,637,RC,55111030230,NDC,,,facility,inpatient,1,EA,80.40000,23.32000,Aetna,First Health,,65.77,,,,,,,48.24,65.77,percent of total billed charges,
Donepezil 23mg T (Aricept),800072470,CDM,637,RC,55111030230,NDC,,,facility,outpatient,1,EA,80.40000,23.32000,Aetna,First Health,,65.77,,,,,,,28.98,65.77,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,55111029198,NDC,,,facility,inpatient,1,EA,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,115.80,157.87,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,55111029198,NDC,,,facility,outpatient,1,EA,193.00000,55.97000,Aetna,First Health,,157.87,,,,,,,69.58,157.87,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),800015332,CDM,637,RC,55111028130,NDC,,,facility,inpatient,1,EA,180.00000,52.20000,Aetna,First Health,,147.24,,,,,,,108.00,147.24,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),800015332,CDM,637,RC,55111028130,NDC,,,facility,outpatient,1,EA,180.00000,52.20000,Aetna,First Health,,147.24,,,,,,,64.89,147.24,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,55111028050,NDC,,,facility,inpatient,1,EA,142.25000,41.25000,Aetna,First Health,,116.36,,,,,,,85.35,116.36,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,55111028050,NDC,,,facility,outpatient,1,EA,142.25000,41.25000,Aetna,First Health,,116.36,,,,,,,51.28,116.36,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,55111027950,NDC,,,facility,inpatient,1,EA,124.10000,35.99000,Aetna,First Health,,101.51,,,,,,,74.46,101.51,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,55111027950,NDC,,,facility,outpatient,1,EA,124.10000,35.99000,Aetna,First Health,,101.51,,,,,,,44.74,101.51,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,55111026281,NDC,,,facility,inpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,8.82,12.02,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,55111026281,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.30,12.02,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,55111025960,NDC,,,facility,inpatient,1,EA,76.15000,22.08000,Aetna,First Health,,62.29,,,,,,,45.69,62.29,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,55111025960,NDC,,,facility,outpatient,1,EA,76.15000,22.08000,Aetna,First Health,,62.29,,,,,,,27.45,62.29,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,55111025660,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,55111025660,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,55111022101,NDC,,,facility,inpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,20.19,27.53,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,55111022101,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,12.13,27.53,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,55111022001,NDC,,,facility,inpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,17.67,24.09,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,55111022001,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,10.62,24.09,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,55111019690,NDC,,,facility,inpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,29.58,40.33,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,55111019690,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,17.77,40.33,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,55111018015,NDC,,,facility,inpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,6.21,8.47,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,55111018015,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,3.73,8.47,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,55111017915,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,55111017915,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,55111016630,NDC,,,facility,inpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,5.07,6.91,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,55111016630,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,3.05,6.91,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,55111016330,NDC,,,facility,inpatient,1,EA,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,47.58,64.87,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,55111016330,NDC,,,facility,outpatient,1,EA,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,28.59,64.87,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,55111015330,NDC,facility,inpatient,4,ME,175.40000,50.87000,Aetna,First Health,,143.48,,,,,,,63.23,143.48,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,55111015330,NDC,facility,outpatient,4,ME,175.40000,50.87000,Aetna,First Health,,143.48,,,,,,,0.00963,143.48,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,55111012205,NDC,,,facility,inpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,24.51,33.42,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,55111012205,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,55111011901,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,55111011901,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,54879000201,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,54879000201,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,54879000200,NDC,,,facility,inpatient,1,EA,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,6.90,9.41,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,54879000200,NDC,,,facility,outpatient,1,EA,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,4.15,9.41,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,54838050615,NDC,,,facility,inpatient,1,ML,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,11.34,15.46,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,54838050615,NDC,,,facility,outpatient,1,ML,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,6.81,15.46,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,54838050280,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,54838050280,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,54838001150,NDC,,,facility,inpatient,1,EA,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.48000,0.65440,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,54838001150,NDC,,,facility,outpatient,1,EA,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.28840,0.65440,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,54766079904,NDC,,,facility,inpatient,1,EA,2165.20000,627.91000,Aetna,First Health,,1771.13,,,,,,,1299.12,1771.13,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,54766079904,NDC,,,facility,outpatient,1,EA,2165.20000,627.91000,Aetna,First Health,,1771.13,,,,,,,780.55,1771.13,percent of total billed charges,
Hydrocortisone 2.5%-Pramox 1% Top Oint,800025581,CDM,637,RC,54766077704,NDC,,,facility,inpatient,1,EA,1808.55000,524.48000,Aetna,First Health,,1479.39,,,,,,,1085.13,1479.39,percent of total billed charges,
Hydrocortisone 2.5%-Pramox 1% Top Oint,800025581,CDM,637,RC,54766077704,NDC,,,facility,outpatient,1,EA,1808.55000,524.48000,Aetna,First Health,,1479.39,,,,,,,651.98,1479.39,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,54766014923,NDC,facility,inpatient,400,UN,9287.40000,2693.35000,Aetna,First Health,,7597.09,,,,,,,5572.44,7597.09,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,54766014923,NDC,facility,outpatient,400,UN,9287.40000,2693.35000,Aetna,First Health,,7597.09,,,,,,,3348.11,7597.09,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,54643900701,NDC,,,facility,inpatient,1,EA,103.15000,29.91000,Aetna,First Health,,84.38,,,,,,,38.17,84.38,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,54643900701,NDC,,,facility,outpatient,1,EA,103.15000,29.91000,Aetna,First Health,,84.38,,,,,,,37.19,84.38,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,54643564901,NDC,,,facility,inpatient,1,EA,156.90000,45.50000,Aetna,First Health,,128.34,,,,,,,58.05,128.34,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,54643564901,NDC,,,facility,outpatient,1,EA,156.90000,45.50000,Aetna,First Health,,128.34,,,,,,,56.56,128.34,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,54629012810,NDC,,,facility,inpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.24000,0.32720,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,54629012810,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.14420,0.32720,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,54629012800,NDC,,,facility,inpatient,1,EA,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.06000,0.08180,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,54629012800,NDC,,,facility,outpatient,1,EA,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,54505033210,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,54505033210,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,54505033105,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,54505033105,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,54505010202,NDC,facility,inpatient,0.3,ME,1010.05000,292.91000,Aetna,First Health,,826.22,,,,,,,364.12,826.22,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,54505010202,NDC,facility,outpatient,0.3,ME,1010.05000,292.91000,Aetna,First Health,,826.22,,,,,,,0.41409,826.22,percent of total billed charges,
levOCARNitine 200mg/1mL I 5mL Vial,800017796,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,inpatient,1000,ME,238.85000,69.27000,Aetna,First Health,,195.38,,,,,,,86.11,195.38,percent of total billed charges,
levOCARNitine 200mg/1mL I 5mL Vial,800017796,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,outpatient,1000,ME,238.85000,69.27000,Aetna,First Health,,195.38,,,,,,,22.41,195.38,percent of total billed charges,
Papaverine HCl 60mg/2mL I,800025540,CDM,637,RC,J2440,HCPCS,54288014210,NDC,facility,inpatient,60,ME,305.50000,88.60000,Aetna,First Health,,249.90,,,,,,,183.30,249.90,percent of total billed charges,
Papaverine HCl 60mg/2mL I,800025540,CDM,637,RC,J2440,HCPCS,54288014210,NDC,facility,outpatient,60,ME,305.50000,88.60000,Aetna,First Health,,249.90,,,,,,,43.34,249.90,percent of total billed charges,
Alcohol (Dehydrated) - 5g/5mL Inj,800061613,CDM,250,RC,54288010515,NDC,,,facility,inpatient,1,EA,4154.10000,1204.69000,Aetna,First Health,,3398.05,,,,,,,1537.02,3398.05,percent of total billed charges,
Alcohol (Dehydrated) - 5g/5mL Inj,800061613,CDM,250,RC,54288010515,NDC,,,facility,outpatient,1,EA,4154.10000,1204.69000,Aetna,First Health,,3398.05,,,,,,,1497.55,3398.05,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,54288010310,NDC,facility,inpatient,1,ME,93.10000,27.00000,Aetna,First Health,,76.16,,,,,,,33.56,76.16,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,54288010310,NDC,facility,outpatient,1,ME,93.10000,27.00000,Aetna,First Health,,76.16,,,,,,,0.41409,76.16,percent of total billed charges,
Mineral Oil 100% Enema,800018020,CDM,637,RC,54162017505,NDC,,,facility,inpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,11.19,15.26,percent of total billed charges,
Mineral Oil 100% Enema,800018020,CDM,637,RC,54162017505,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,6.72,15.26,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,54092041912,NDC,,,facility,inpatient,1,EA,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,6.69,9.12,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,54092041912,NDC,,,facility,outpatient,1,EA,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,4.02,9.12,percent of total billed charges,
Mesalamine 250mg CR C(Pentasa),800077536,CDM,637,RC,54092018981,NDC,,,facility,inpatient,1,EA,25.80000,7.48000,Aetna,First Health,,21.10,,,,,,,15.48,21.10,percent of total billed charges,
Mesalamine 250mg CR C(Pentasa),800077536,CDM,637,RC,54092018981,NDC,,,facility,outpatient,1,EA,25.80000,7.48000,Aetna,First Health,,21.10,,,,,,,9.30,21.10,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,54092017112,NDC,,,facility,inpatient,1,EA,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,9.03,12.31,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,54092017112,NDC,,,facility,outpatient,1,EA,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,5.43,12.31,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),800080654,CDM,637,RC,54092006301,NDC,,,facility,inpatient,1,EA,70.25000,20.37000,Aetna,First Health,,57.46,,,,,,,42.15,57.46,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),800080654,CDM,637,RC,54092006301,NDC,,,facility,outpatient,1,EA,70.25000,20.37000,Aetna,First Health,,57.46,,,,,,,25.33,57.46,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,54092000401,NDC,,,facility,inpatient,1,EA,20.95000,6.08000,Aetna,First Health,,17.14,,,,,,,12.57,17.14,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,54092000401,NDC,,,facility,outpatient,1,EA,20.95000,6.08000,Aetna,First Health,,17.14,,,,,,,7.55,17.14,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),800015411,CDM,637,RC,Q0169,HCPCS,53746074501,NDC,facility,inpatient,12.5,ME,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),800015411,CDM,637,RC,Q0169,HCPCS,53746074501,NDC,facility,outpatient,12.5,ME,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,0.24075,2.82,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,53746071101,NDC,,,facility,inpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,4.32,5.89,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,53746071101,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,53746066901,NDC,,,facility,inpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,4.98,6.79,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,53746066901,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.99,6.79,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,53746064201,NDC,,,facility,inpatient,1,EA,28.40000,8.24000,Aetna,First Health,,23.23,,,,,,,17.04,23.23,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,53746064201,NDC,,,facility,outpatient,1,EA,28.40000,8.24000,Aetna,First Health,,23.23,,,,,,,10.24,23.23,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,53746054501,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,53746054501,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,53746054401,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,53746054401,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,53746051101,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,53746051101,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,53746046605,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,53746046605,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,53746046505,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,53746046505,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,53746046401,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,53746046401,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Sulfamethoxazole-Trimethoprim DS 800-160mg T,800021992,CDM,637,RC,53746027201,NDC,,,facility,inpatient,1,EA,9.95000,2.89000,Aetna,First Health,,8.14,,,,,,,5.97,8.14,percent of total billed charges,
Sulfamethoxazole-Trimethoprim DS 800-160mg T,800021992,CDM,637,RC,53746027201,NDC,,,facility,outpatient,1,EA,9.95000,2.89000,Aetna,First Health,,8.14,,,,,,,3.59,8.14,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,53746027101,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,53746027101,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,53746018801,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,53746018801,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,53746017801,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,53746017801,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,53746010301,NDC,,,facility,inpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,53746010301,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,53746010205,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,53746010205,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,53746010201,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,53746010201,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,53746010101,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,53746010101,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,53489064801,NDC,,,facility,inpatient,1,EA,79.50000,23.06000,Aetna,First Health,,65.03,,,,,,,47.70,65.03,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,53489064801,NDC,,,facility,outpatient,1,EA,79.50000,23.06000,Aetna,First Health,,65.03,,,,,,,28.66,65.03,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,53489055201,NDC,,,facility,inpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,9.90,13.50,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,53489055201,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,53489055101,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,53489055101,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,53489051101,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,53489051101,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,53489038701,NDC,,,facility,inpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,5.49,7.48,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,53489038701,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.30,7.48,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,53489038601,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,53489038601,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,53489036901,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,53489036901,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,53489036801,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,53489036801,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,53489036601,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,53489036601,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,53489021501,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,53489021501,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,53489015601,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,53489015601,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,53489014901,NDC,,,facility,inpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,1.50,2.04,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,53489014901,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,0.90125,2.04,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,53489014501,NDC,,,facility,inpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,2.82,3.84,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,53489014501,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,53489014301,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,53489014301,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,53489013601,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,53489013601,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,53489012701,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,53489012701,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,53489011905,NDC,,,facility,inpatient,1,EA,43.50000,12.61000,Aetna,First Health,,35.58,,,,,,,26.10,35.58,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,53489011905,NDC,,,facility,outpatient,1,EA,43.50000,12.61000,Aetna,First Health,,35.58,,,,,,,15.68,35.58,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,53489011902,NDC,,,facility,inpatient,1,EA,43.50000,12.61000,Aetna,First Health,,35.58,,,,,,,26.10,35.58,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,53489011902,NDC,,,facility,outpatient,1,EA,43.50000,12.61000,Aetna,First Health,,35.58,,,,,,,15.68,35.58,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,53489010401,NDC,,,facility,inpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,53489010401,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.46865,1.06,percent of total billed charges,
Patiromer 8.4g REC Packet (Veltassa),800022030,CDM,637,RC,53436008404,NDC,,,facility,inpatient,1,EA,386.10000,111.97000,Aetna,First Health,,315.83,,,,,,,231.66,315.83,percent of total billed charges,
Patiromer 8.4g REC Packet (Veltassa),800022030,CDM,637,RC,53436008404,NDC,,,facility,outpatient,1,EA,386.10000,111.97000,Aetna,First Health,,315.83,,,,,,,139.19,315.83,percent of total billed charges,
Microfibrillar 1g TP(Avitene),800034537,CDM,637,RC,53276101002,NDC,,,facility,inpatient,1,EA,1758.20000,509.88000,Aetna,First Health,,1438.21,,,,,,,1054.92,1438.21,percent of total billed charges,
Microfibrillar 1g TP(Avitene),800034537,CDM,637,RC,53276101002,NDC,,,facility,outpatient,1,EA,1758.20000,509.88000,Aetna,First Health,,1438.21,,,,,,,633.83,1438.21,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,53265028310,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,53265028310,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,53265026610,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,53265026610,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,53014097571,NDC,,,facility,inpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,11.19,15.26,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,53014097571,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,6.72,15.26,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,53014054867,NDC,,,facility,inpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,19.95,27.20,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,53014054867,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,11.99,27.20,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,53014054801,NDC,,,facility,inpatient,1,EA,60.30000,17.49000,Aetna,First Health,,49.33,,,,,,,36.18,49.33,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,53014054801,NDC,,,facility,outpatient,1,EA,60.30000,17.49000,Aetna,First Health,,49.33,,,,,,,21.74,49.33,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,53014053007,NDC,,,facility,inpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,4.26,5.81,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,53014053007,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,2.56,5.81,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,53014003010,NDC,,,facility,inpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,1.98,4.38,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,53014003010,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,1.93,4.38,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,53014001210,NDC,,,facility,inpatient,1,EA,4.10000,1.19000,Aetna,First Health,,3.35,,,,,,,2.46,3.35,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,53014001210,NDC,,,facility,outpatient,1,EA,4.10000,1.19000,Aetna,First Health,,3.35,,,,,,,1.48,3.35,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,52817081701,NDC,,,facility,inpatient,1,EA,967.20000,280.49000,Aetna,First Health,,791.17,,,,,,,580.32,791.17,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,52817081701,NDC,,,facility,outpatient,1,EA,967.20000,280.49000,Aetna,First Health,,791.17,,,,,,,348.68,791.17,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,52817033010,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,52817033010,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,52817032410,NDC,,,facility,inpatient,1,EA,26.45000,7.67000,Aetna,First Health,,21.64,,,,,,,15.87,21.64,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,52817032410,NDC,,,facility,outpatient,1,EA,26.45000,7.67000,Aetna,First Health,,21.64,,,,,,,9.54,21.64,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,52817032110,NDC,,,facility,inpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,21.78,29.69,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,52817032110,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,13.09,29.69,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,52817027030,NDC,,,facility,inpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,9.57,13.05,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,52817027030,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,52817027010,NDC,,,facility,inpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,9.57,13.05,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,52817027010,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,52817021010,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,52817021010,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,52817012110,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,52817012110,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,52769025105,NDC,facility,inpatient,12.5,GM,727.50000,210.98000,Aetna,First Health,,595.10,,,,,,,262.26,595.10,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,52769025105,NDC,facility,outpatient,12.5,GM,727.50000,210.98000,Aetna,First Health,,595.10,,,,,,,51.12,595.10,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,52761055245,NDC,,,facility,inpatient,1,EA,34.40000,9.98000,Aetna,First Health,,28.14,,,,,,,12.73,28.14,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,52761055245,NDC,,,facility,outpatient,1,EA,34.40000,9.98000,Aetna,First Health,,28.14,,,,,,,12.40,28.14,percent of total billed charges,
Zonisamide 100 mg/5 mL Oral Susp,800046548,CDM,637,RC,52652800101,NDC,,,facility,inpatient,1,EA,118.80000,34.45000,Aetna,First Health,,97.18,,,,,,,71.28,97.18,percent of total billed charges,
Zonisamide 100 mg/5 mL Oral Susp,800046548,CDM,637,RC,52652800101,NDC,,,facility,outpatient,1,EA,118.80000,34.45000,Aetna,First Health,,97.18,,,,,,,42.83,97.18,percent of total billed charges,
"Thrombin Bovine 20,000IUTp Kit",800050970,CDM,250,RC,52604710502,NDC,,,facility,inpatient,1,EA,2172.20000,629.94000,Aetna,First Health,,1776.86,,,,,,,803.71,1776.86,percent of total billed charges,
"Thrombin Bovine 20,000IUTp Kit",800050970,CDM,250,RC,52604710502,NDC,,,facility,outpatient,1,EA,2172.20000,629.94000,Aetna,First Health,,1776.86,,,,,,,783.08,1776.86,percent of total billed charges,
Thrombin Bovine 5000 IU,800016857,CDM,250,RC,52604710201,NDC,,,facility,inpatient,1,EA,585.45000,169.78000,Aetna,First Health,,478.90,,,,,,,216.62,478.90,percent of total billed charges,
Thrombin Bovine 5000 IU,800016857,CDM,250,RC,52604710201,NDC,,,facility,outpatient,1,EA,585.45000,169.78000,Aetna,First Health,,478.90,,,,,,,211.05,478.90,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,52604512501,NDC,,,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,2.19,2.99,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,52604512501,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.32,2.99,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,52604341601,NDC,,,facility,inpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,4.08,5.56,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,52604341601,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,2.45,5.56,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,52604341401,NDC,,,facility,inpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,2.58,3.52,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,52604341401,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,1.55,3.52,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,52604109501,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,52604109501,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,52604109401,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,52604109401,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
Triamcinolone 0.1% TC 80g,800017794,CDM,637,RC,52565005680,NDC,,,facility,inpatient,1,EA,103.00000,29.87000,Aetna,First Health,,84.25,,,,,,,61.80,84.25,percent of total billed charges,
Triamcinolone 0.1% TC 80g,800017794,CDM,637,RC,52565005680,NDC,,,facility,outpatient,1,EA,103.00000,29.87000,Aetna,First Health,,84.25,,,,,,,37.13,84.25,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,52565005615,NDC,,,facility,inpatient,1,EA,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,24.78,33.78,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,52565005615,NDC,,,facility,outpatient,1,EA,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,14.89,33.78,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,52565000950,NDC,,,facility,inpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.39,7.48,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,52565000950,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.30,7.48,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,52565000814,NDC,,,facility,inpatient,1,EA,1893.65000,549.16000,Aetna,First Health,,1549.01,,,,,,,1136.19,1549.01,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,52565000814,NDC,,,facility,outpatient,1,EA,1893.65000,549.16000,Aetna,First Health,,1549.01,,,,,,,682.66,1549.01,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,52544095701,NDC,,,facility,inpatient,1,EA,18.50000,5.36000,Aetna,First Health,,15.13,,,,,,,11.10,15.13,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,52544095701,NDC,,,facility,outpatient,1,EA,18.50000,5.36000,Aetna,First Health,,15.13,,,,,,,6.67,15.13,percent of total billed charges,
Iron Dextran 100mg/2mL I(Infed),800012496,CDM,636,RC,J1750,HCPCS,52544093102,NDC,facility,inpatient,100,ME,275.90000,80.01000,Aetna,First Health,,225.69,,,,,,,99.46,225.69,percent of total billed charges,
Iron Dextran 100mg/2mL I(Infed),800012496,CDM,636,RC,J1750,HCPCS,52544093102,NDC,facility,outpatient,100,ME,275.90000,80.01000,Aetna,First Health,,225.69,,,,,,,17.41,225.69,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,52544090401,NDC,,,facility,inpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,1.41,1.92,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,52544090401,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,52544080101,NDC,facility,inpatient,50,ME,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,52544080101,NDC,facility,outpatient,50,ME,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.21186,1.88,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,52544080001,NDC,facility,inpatient,25,ME,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,52544080001,NDC,facility,outpatient,25,ME,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.21186,1.72,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,52544079601,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,52544079601,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,52544079401,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,52544079401,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,52544078001,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,52544078001,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,52544077601,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,52544077601,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,52544077501,NDC,,,facility,inpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,2.01,2.74,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,52544077501,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,1.21,2.74,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,52544069301,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,52544069301,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,52544065801,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,52544065801,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,52544058301,NDC,,,facility,inpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,9.90,13.50,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,52544058301,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,52544049850,NDC,,,facility,inpatient,1,EA,9.70000,2.81000,Aetna,First Health,,7.93,,,,,,,5.82,7.93,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,52544049850,NDC,,,facility,outpatient,1,EA,9.70000,2.81000,Aetna,First Health,,7.93,,,,,,,3.50,7.93,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,52544046301,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,52544046301,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,52544044401,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,52544044401,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,52544043701,NDC,,,facility,inpatient,1,EA,8.00000,2.32000,Aetna,First Health,,6.54,,,,,,,4.80,6.54,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,52544043701,NDC,,,facility,outpatient,1,EA,8.00000,2.32000,Aetna,First Health,,6.54,,,,,,,2.88,6.54,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,52544040401,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,52544040401,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,52544034501,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,52544034501,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,52544015130,NDC,,,facility,inpatient,1,EA,70.60000,20.47000,Aetna,First Health,,57.75,,,,,,,42.36,57.75,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,52544015130,NDC,,,facility,outpatient,1,EA,70.60000,20.47000,Aetna,First Health,,57.75,,,,,,,25.45,57.75,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,52536030065,NDC,,,facility,inpatient,1,EA,1319.30000,382.60000,Aetna,First Health,,1079.19,,,,,,,791.58,1079.19,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,52536030065,NDC,,,facility,outpatient,1,EA,1319.30000,382.60000,Aetna,First Health,,1079.19,,,,,,,475.61,1079.19,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,52536018003,NDC,,,facility,inpatient,1,EA,59.40000,17.23000,Aetna,First Health,,48.59,,,,,,,35.64,48.59,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,52536018003,NDC,,,facility,outpatient,1,EA,59.40000,17.23000,Aetna,First Health,,48.59,,,,,,,21.41,48.59,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,52536016201,NDC,facility,inpatient,2,ME,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,7.41,10.10,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,52536016201,NDC,facility,outpatient,2,ME,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,2.30,10.10,percent of total billed charges,
Vancomycin 125mg/2.5mL Oral Soln,800072448,CDM,637,RC,52536010810,NDC,,,facility,inpatient,1,EA,16.75000,4.86000,Aetna,First Health,,13.70,,,,,,,10.05,13.70,percent of total billed charges,
Vancomycin 125mg/2.5mL Oral Soln,800072448,CDM,637,RC,52536010810,NDC,,,facility,outpatient,1,EA,16.75000,4.86000,Aetna,First Health,,13.70,,,,,,,6.04,13.70,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,800025528,CDM,637,RC,52376002102,NDC,,,facility,inpatient,1,EA,40.60000,11.77000,Aetna,First Health,,33.21,,,,,,,24.36,33.21,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,800025528,CDM,637,RC,52376002102,NDC,,,facility,outpatient,1,EA,40.60000,11.77000,Aetna,First Health,,33.21,,,,,,,14.64,33.21,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,52268030201,NDC,,,facility,inpatient,1,EA,167.35000,48.53000,Aetna,First Health,,136.89,,,,,,,100.41,136.89,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,52268030201,NDC,,,facility,outpatient,1,EA,167.35000,48.53000,Aetna,First Health,,136.89,,,,,,,60.33,136.89,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,52268020001,NDC,facility,inpatient,667,ME,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,52268020001,NDC,facility,outpatient,667,ME,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.03852,1.10,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,52268010001,NDC,,,facility,inpatient,1,EA,211.60000,61.36000,Aetna,First Health,,173.09,,,,,,,126.96,173.09,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,52268010001,NDC,,,facility,outpatient,1,EA,211.60000,61.36000,Aetna,First Health,,173.09,,,,,,,76.28,173.09,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,52183019914,NDC,,,facility,inpatient,1,EA,125.20000,36.31000,Aetna,First Health,,102.41,,,,,,,75.12,102.41,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,52183019914,NDC,,,facility,outpatient,1,EA,125.20000,36.31000,Aetna,First Health,,102.41,,,,,,,45.13,102.41,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,52152053830,NDC,facility,inpatient,4,ME,176.20000,51.10000,Aetna,First Health,,144.13,,,,,,,63.52,144.13,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,52152053830,NDC,facility,outpatient,4,ME,176.20000,51.10000,Aetna,First Health,,144.13,,,,,,,0.00963,144.13,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,52152034002,NDC,,,facility,inpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,8.82,12.02,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,52152034002,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.30,12.02,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,52152013902,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.13,2.49,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,52152013902,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,52152006002,NDC,,,facility,inpatient,1,EA,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,12.00,16.36,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,52152006002,NDC,,,facility,outpatient,1,EA,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,7.21,16.36,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,52152001802,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,52152001802,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
Fidaxomicin 200mg T(Dificid),800025643,CDM,637,RC,52015008001,NDC,,,facility,inpatient,1,EA,1871.50000,542.74000,Aetna,First Health,,1530.89,,,,,,,1122.90,1530.89,percent of total billed charges,
Fidaxomicin 200mg T(Dificid),800025643,CDM,637,RC,52015008001,NDC,,,facility,outpatient,1,EA,1871.50000,542.74000,Aetna,First Health,,1530.89,,,,,,,674.68,1530.89,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,51991098317,NDC,,,facility,inpatient,1,EA,55.80000,16.18000,Aetna,First Health,,45.64,,,,,,,20.65,45.64,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,51991098317,NDC,,,facility,outpatient,1,EA,55.80000,16.18000,Aetna,First Health,,45.64,,,,,,,20.12,45.64,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,51991096158,NDC,,,facility,inpatient,1,EA,33.55000,9.73000,Aetna,First Health,,27.44,,,,,,,12.41,27.44,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,51991096158,NDC,,,facility,outpatient,1,EA,33.55000,9.73000,Aetna,First Health,,27.44,,,,,,,12.09,27.44,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,51991094117,NDC,facility,inpatient,1,GM,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,21.63,49.08,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,51991094117,NDC,facility,outpatient,1,GM,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,0.02889,49.08,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,51991093498,NDC,facility,inpatient,100,ME,83.15000,24.11000,Aetna,First Health,,68.02,,,,,,,30.77,68.02,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,51991093498,NDC,facility,outpatient,100,ME,83.15000,24.11000,Aetna,First Health,,68.02,,,,,,,0.33705,68.02,percent of total billed charges,
Entecavir 0.5mg Tab,800046457,CDM,637,RC,51991089533,NDC,,,facility,inpatient,1,EA,307.40000,89.15000,Aetna,First Health,,251.45,,,,,,,184.44,251.45,percent of total billed charges,
Entecavir 0.5mg Tab,800046457,CDM,637,RC,51991089533,NDC,,,facility,outpatient,1,EA,307.40000,89.15000,Aetna,First Health,,251.45,,,,,,,110.82,251.45,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,51991083801,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,51991083801,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,51991081801,NDC,,,facility,inpatient,1,EA,17.05000,4.94000,Aetna,First Health,,13.95,,,,,,,10.23,13.95,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,51991081801,NDC,,,facility,outpatient,1,EA,17.05000,4.94000,Aetna,First Health,,13.95,,,,,,,6.15,13.95,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,51991081701,NDC,,,facility,inpatient,1,EA,14.55000,4.22000,Aetna,First Health,,11.90,,,,,,,8.73,11.90,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,51991081701,NDC,,,facility,outpatient,1,EA,14.55000,4.22000,Aetna,First Health,,11.90,,,,,,,5.25,11.90,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,51991081403,NDC,,,facility,inpatient,1,EA,677.00000,196.33000,Aetna,First Health,,553.79,,,,,,,406.20,553.79,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,51991081403,NDC,,,facility,outpatient,1,EA,677.00000,196.33000,Aetna,First Health,,553.79,,,,,,,244.06,553.79,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,51991079306,NDC,,,facility,inpatient,1,EA,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,19.80,26.99,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,51991079306,NDC,,,facility,outpatient,1,EA,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,11.90,26.99,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,51991075933,NDC,,,facility,inpatient,1,EA,128.25000,37.19000,Aetna,First Health,,104.91,,,,,,,76.95,104.91,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,51991075933,NDC,,,facility,outpatient,1,EA,128.25000,37.19000,Aetna,First Health,,104.91,,,,,,,46.23,104.91,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,51991074890,NDC,,,facility,inpatient,1,EA,53.40000,15.49000,Aetna,First Health,,43.68,,,,,,,32.04,43.68,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,51991074890,NDC,,,facility,outpatient,1,EA,53.40000,15.49000,Aetna,First Health,,43.68,,,,,,,19.25,43.68,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,51991062033,NDC,,,facility,inpatient,1,EA,94.50000,27.40000,Aetna,First Health,,77.30,,,,,,,56.70,77.30,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,51991062033,NDC,,,facility,outpatient,1,EA,94.50000,27.40000,Aetna,First Health,,77.30,,,,,,,34.07,77.30,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,51991052601,NDC,,,facility,inpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,55.53,75.71,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,51991052601,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,33.36,75.71,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,51991046801,NDC,,,facility,inpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,4.92,6.71,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,51991046801,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,2.96,6.71,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,51991045801,NDC,facility,inpatient,1,ME,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,51991045801,NDC,facility,outpatient,1,ME,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.00963,1.10,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,51991045758,NDC,,,facility,inpatient,1,EA,144.80000,41.99000,Aetna,First Health,,118.45,,,,,,,53.58,118.45,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,51991045758,NDC,,,facility,outpatient,1,EA,144.80000,41.99000,Aetna,First Health,,118.45,,,,,,,52.20,118.45,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,51991040601,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,51991040601,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,51991031233,NDC,,,facility,inpatient,1,EA,81.20000,23.55000,Aetna,First Health,,66.42,,,,,,,48.72,66.42,percent of total billed charges,
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,51991031233,NDC,,,facility,outpatient,1,EA,81.20000,23.55000,Aetna,First Health,,66.42,,,,,,,29.27,66.42,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,51991031190,NDC,,,facility,inpatient,1,EA,81.20000,23.55000,Aetna,First Health,,66.42,,,,,,,48.72,66.42,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,51991031190,NDC,,,facility,outpatient,1,EA,81.20000,23.55000,Aetna,First Health,,66.42,,,,,,,29.27,66.42,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,51991031133,NDC,,,facility,inpatient,1,EA,81.20000,23.55000,Aetna,First Health,,66.42,,,,,,,48.72,66.42,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,51991031133,NDC,,,facility,outpatient,1,EA,81.20000,23.55000,Aetna,First Health,,66.42,,,,,,,29.27,66.42,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,51991029301,NDC,,,facility,inpatient,1,EA,18.60000,5.39000,Aetna,First Health,,15.21,,,,,,,11.16,15.21,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,51991029301,NDC,,,facility,outpatient,1,EA,18.60000,5.39000,Aetna,First Health,,15.21,,,,,,,6.71,15.21,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,51991029201,NDC,,,facility,inpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,51991029201,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,51991018831,NDC,facility,inpatient,4,ME,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,51991018831,NDC,facility,outpatient,4,ME,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,0.13482,3.03,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,51991014417,NDC,facility,inpatient,0.2,ME,126.15000,36.58000,Aetna,First Health,,103.19,,,,,,,45.48,103.19,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,51991014417,NDC,facility,outpatient,0.2,ME,126.15000,36.58000,Aetna,First Health,,103.19,,,,,,,20.57,103.19,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,51862048601,NDC,,,facility,inpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,9.90,13.50,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,51862048601,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,51862046047,NDC,facility,inpatient,100,ME,38.90000,11.28000,Aetna,First Health,,31.82,,,,,,,23.34,31.82,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,51862046047,NDC,facility,outpatient,100,ME,38.90000,11.28000,Aetna,First Health,,31.82,,,,,,,1.74,31.82,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,800080621,CDM,637,RC,J7515,HCPCS,51862045847,NDC,facility,inpatient,25,ME,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,5.85,7.98,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,800080621,CDM,637,RC,J7515,HCPCS,51862045847,NDC,facility,outpatient,25,ME,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,0.51039,7.98,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,51862044960,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,51862044960,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,51862033001,NDC,,,facility,inpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,21.87,29.82,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,51862033001,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,13.14,29.82,percent of total billed charges,
dilTIAZem 90mg SR C(CardiZEM),800057751,CDM,637,RC,51862032901,NDC,,,facility,inpatient,1,EA,27.95000,8.11000,Aetna,First Health,,22.86,,,,,,,16.77,22.86,percent of total billed charges,
dilTIAZem 90mg SR C(CardiZEM),800057751,CDM,637,RC,51862032901,NDC,,,facility,outpatient,1,EA,27.95000,8.11000,Aetna,First Health,,22.86,,,,,,,10.08,22.86,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,51862032101,NDC,,,facility,inpatient,1,EA,17.60000,5.10000,Aetna,First Health,,14.40,,,,,,,10.56,14.40,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,51862032101,NDC,,,facility,outpatient,1,EA,17.60000,5.10000,Aetna,First Health,,14.40,,,,,,,6.34,14.40,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,51862032001,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,51862032001,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,51862031578,NDC,,,facility,inpatient,1,EA,241.60000,70.06000,Aetna,First Health,,197.63,,,,,,,144.96,197.63,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,51862031578,NDC,,,facility,outpatient,1,EA,241.60000,70.06000,Aetna,First Health,,197.63,,,,,,,87.10,197.63,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,51862024030,NDC,,,facility,inpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,31.56,43.03,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,51862024030,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,18.96,43.03,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,51862015430,NDC,,,facility,inpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,31.56,43.03,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,51862015430,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,18.96,43.03,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,51862007901,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,3.69,5.03,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,51862007901,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,800015247,CDM,637,RC,51801000130,NDC,,,facility,inpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,2.01,2.74,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,800015247,CDM,637,RC,51801000130,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,1.21,2.74,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,51754506001,NDC,facility,inpatient,30,ME,245.35000,71.15000,Aetna,First Health,,200.70,,,,,,,88.45,200.70,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,51754506001,NDC,facility,outpatient,30,ME,245.35000,71.15000,Aetna,First Health,,200.70,,,,,,,6.65,200.70,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,51754500105,NDC,,,facility,inpatient,1,EA,89.25000,25.88000,Aetna,First Health,,73.01,,,,,,,33.02,73.01,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,51754500105,NDC,,,facility,outpatient,1,EA,89.25000,25.88000,Aetna,First Health,,73.01,,,,,,,32.17,73.01,percent of total billed charges,
ePHEDrine sulfate 25mg/5mL IS,800051986,CDM,250,RC,51754425003,NDC,,,facility,inpatient,1,EA,78.85000,22.87000,Aetna,First Health,,64.50,,,,,,,29.17,64.50,percent of total billed charges,
ePHEDrine sulfate 25mg/5mL IS,800051986,CDM,250,RC,51754425003,NDC,,,facility,outpatient,1,EA,78.85000,22.87000,Aetna,First Health,,64.50,,,,,,,28.43,64.50,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,51754400003,NDC,facility,inpatient,50,ME,226.85000,65.79000,Aetna,First Health,,185.56,,,,,,,81.78,185.56,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,51754400003,NDC,facility,outpatient,50,ME,226.85000,65.79000,Aetna,First Health,,185.56,,,,,,,83.93,185.56,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,51754122003,NDC,facility,inpatient,10,ME,117.20000,33.99000,Aetna,First Health,,95.87,,,,,,,42.25,95.87,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,51754122003,NDC,facility,outpatient,10,ME,117.20000,33.99000,Aetna,First Health,,95.87,,,,,,,0.92448,95.87,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,51754050303,NDC,,,facility,inpatient,1,EA,20.40000,5.92000,Aetna,First Health,,16.69,,,,,,,12.24,16.69,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,51754050303,NDC,,,facility,outpatient,1,EA,20.40000,5.92000,Aetna,First Health,,16.69,,,,,,,7.35,16.69,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,51754050201,NDC,facility,inpatient,60,ME,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,82.55,187.32,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,51754050201,NDC,facility,outpatient,60,ME,229.00000,66.41000,Aetna,First Health,,187.32,,,,,,,1.40,187.32,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,51754050103,NDC,,,facility,inpatient,1,EA,101.95000,29.57000,Aetna,First Health,,83.40,,,,,,,61.17,83.40,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,51754050103,NDC,,,facility,outpatient,1,EA,101.95000,29.57000,Aetna,First Health,,83.40,,,,,,,36.75,83.40,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,51754050001,NDC,facility,inpatient,60,ME,115.20000,33.41000,Aetna,First Health,,94.23,,,,,,,41.53,94.23,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,51754050001,NDC,facility,outpatient,60,ME,115.20000,33.41000,Aetna,First Health,,94.23,,,,,,,1.40,94.23,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,51754020304,NDC,,,facility,inpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.80,26.09,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,51754020304,NDC,,,facility,outpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.50,26.09,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,51754020302,NDC,,,facility,inpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.80,26.09,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,51754020302,NDC,,,facility,outpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.50,26.09,percent of total billed charges,
Tranexamic Acid 1g/100mL Bolus,800062092,CDM,250,RC,51754010803,NDC,,,facility,inpatient,1,EA,214.60000,62.23000,Aetna,First Health,,175.54,,,,,,,79.40,175.54,percent of total billed charges,
Tranexamic Acid 1g/100mL Bolus,800062092,CDM,250,RC,51754010803,NDC,,,facility,outpatient,1,EA,214.60000,62.23000,Aetna,First Health,,175.54,,,,,,,77.36,175.54,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,51672413101,NDC,,,facility,inpatient,1,EA,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,21.84,29.78,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,51672413101,NDC,,,facility,outpatient,1,EA,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,13.12,29.78,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,51672413001,NDC,,,facility,inpatient,1,EA,31.85000,9.24000,Aetna,First Health,,26.05,,,,,,,19.11,26.05,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,51672413001,NDC,,,facility,outpatient,1,EA,31.85000,9.24000,Aetna,First Health,,26.05,,,,,,,11.48,26.05,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,51672411704,NDC,,,facility,inpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,51672411704,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,51672411101,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,51672411101,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,51672410601,NDC,,,facility,inpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,11.22,15.30,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,51672410601,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,6.74,15.30,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,800023340,CDM,637,RC,51672406901,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,800023340,CDM,637,RC,51672406901,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,51672405506,NDC,,,facility,inpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,31.56,43.03,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,51672405506,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,18.96,43.03,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,51672404801,NDC,,,facility,inpatient,1,EA,217.15000,62.97000,Aetna,First Health,,177.63,,,,,,,130.29,177.63,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,51672404801,NDC,,,facility,outpatient,1,EA,217.15000,62.97000,Aetna,First Health,,177.63,,,,,,,78.28,177.63,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,51672404709,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,51672404709,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,51672404101,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,51672404101,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,51672404001,NDC,,,facility,inpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,11.76,16.03,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,51672404001,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,7.07,16.03,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,51672403901,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,51672403901,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,51672402504,NDC,,,facility,inpatient,1,EA,23.40000,6.79000,Aetna,First Health,,19.14,,,,,,,14.04,19.14,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,51672402504,NDC,,,facility,outpatient,1,EA,23.40000,6.79000,Aetna,First Health,,19.14,,,,,,,8.44,19.14,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,51672402301,NDC,,,facility,inpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,51672402301,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
Etodolac 200 mg C (Lodine),800080985,CDM,637,RC,51672401601,NDC,,,facility,inpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,6.09,8.30,percent of total billed charges,
Etodolac 200 mg C (Lodine),800080985,CDM,637,RC,51672401601,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.66,8.30,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,51672400205,NDC,,,facility,inpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.75000,1.02,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,51672400205,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.45062,1.02,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,51672400201,NDC,,,facility,inpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,6.24,8.51,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,51672400201,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,51672400101,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,51672400101,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,51672302009,NDC,,,facility,inpatient,1,EA,1893.65000,549.16000,Aetna,First Health,,1549.01,,,,,,,1136.19,1549.01,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,51672302009,NDC,,,facility,outpatient,1,EA,1893.65000,549.16000,Aetna,First Health,,1549.01,,,,,,,682.66,1549.01,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,51672300302,NDC,,,facility,inpatient,1,EA,72.45000,21.01000,Aetna,First Health,,59.26,,,,,,,43.47,59.26,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,51672300302,NDC,,,facility,outpatient,1,EA,72.45000,21.01000,Aetna,First Health,,59.26,,,,,,,26.12,59.26,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,51672204402,NDC,,,facility,inpatient,1,EA,48.55000,14.08000,Aetna,First Health,,39.71,,,,,,,17.96,39.71,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,51672204402,NDC,,,facility,outpatient,1,EA,48.55000,14.08000,Aetna,First Health,,39.71,,,,,,,17.50,39.71,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,51672203506,NDC,,,facility,inpatient,1,EA,81.05000,23.50000,Aetna,First Health,,66.30,,,,,,,48.63,66.30,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,51672203506,NDC,,,facility,outpatient,1,EA,81.05000,23.50000,Aetna,First Health,,66.30,,,,,,,29.22,66.30,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,51672201302,NDC,,,facility,inpatient,1,EA,41.15000,11.93000,Aetna,First Health,,33.66,,,,,,,15.23,33.66,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,51672201302,NDC,,,facility,outpatient,1,EA,41.15000,11.93000,Aetna,First Health,,33.66,,,,,,,14.83,33.66,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,51672200306,NDC,,,facility,inpatient,1,EA,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,20.96,46.34,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,51672200306,NDC,,,facility,outpatient,1,EA,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,20.42,46.34,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,51672200201,NDC,,,facility,inpatient,1,EA,60.20000,17.46000,Aetna,First Health,,49.24,,,,,,,22.27,49.24,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,51672200201,NDC,,,facility,outpatient,1,EA,60.20000,17.46000,Aetna,First Health,,49.24,,,,,,,21.70,49.24,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,51672200102,NDC,,,facility,inpatient,1,EA,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,18.87,41.72,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,51672200102,NDC,,,facility,outpatient,1,EA,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,18.39,41.72,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,51672131802,NDC,,,facility,inpatient,1,EA,350.70000,101.70000,Aetna,First Health,,286.87,,,,,,,210.42,286.87,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,51672131802,NDC,,,facility,outpatient,1,EA,350.70000,101.70000,Aetna,First Health,,286.87,,,,,,,126.43,286.87,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,51672131201,NDC,,,facility,inpatient,1,EA,179.55000,52.07000,Aetna,First Health,,146.87,,,,,,,107.73,146.87,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,51672131201,NDC,,,facility,outpatient,1,EA,179.55000,52.07000,Aetna,First Health,,146.87,,,,,,,64.73,146.87,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,51672131200,NDC,,,facility,inpatient,1,EA,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,51672131200,NDC,,,facility,outpatient,1,EA,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,63.81,144.79,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,51672129802,NDC,,,facility,inpatient,1,EA,671.55000,194.75000,Aetna,First Health,,549.33,,,,,,,402.93,549.33,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,51672129802,NDC,,,facility,outpatient,1,EA,671.55000,194.75000,Aetna,First Health,,549.33,,,,,,,242.09,549.33,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,51672129801,NDC,,,facility,inpatient,1,EA,822.80000,238.61000,Aetna,First Health,,673.05,,,,,,,493.68,673.05,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,51672129801,NDC,,,facility,outpatient,1,EA,822.80000,238.61000,Aetna,First Health,,673.05,,,,,,,296.62,673.05,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,51672129702,NDC,,,facility,inpatient,1,EA,404.80000,117.39000,Aetna,First Health,,331.13,,,,,,,242.88,331.13,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,51672129702,NDC,,,facility,outpatient,1,EA,404.80000,117.39000,Aetna,First Health,,331.13,,,,,,,145.93,331.13,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,51672128901,NDC,,,facility,inpatient,1,EA,124.25000,36.03000,Aetna,First Health,,101.64,,,,,,,74.55,101.64,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,51672128901,NDC,,,facility,outpatient,1,EA,124.25000,36.03000,Aetna,First Health,,101.64,,,,,,,44.79,101.64,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,51672128408,NDC,,,facility,inpatient,1,EA,93.60000,27.14000,Aetna,First Health,,76.56,,,,,,,56.16,76.56,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,51672128408,NDC,,,facility,outpatient,1,EA,93.60000,27.14000,Aetna,First Health,,76.56,,,,,,,33.74,76.56,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,51672128401,NDC,,,facility,inpatient,1,EA,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,8.85,12.07,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,51672128401,NDC,,,facility,outpatient,1,EA,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,5.32,12.07,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,51672128202,NDC,,,facility,inpatient,1,EA,29.75000,8.63000,Aetna,First Health,,24.34,,,,,,,17.85,24.34,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,51672128202,NDC,,,facility,outpatient,1,EA,29.75000,8.63000,Aetna,First Health,,24.34,,,,,,,10.72,24.34,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,51672127501,NDC,,,facility,inpatient,1,EA,141.15000,40.93000,Aetna,First Health,,115.46,,,,,,,52.23,115.46,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,51672127501,NDC,,,facility,outpatient,1,EA,141.15000,40.93000,Aetna,First Health,,115.46,,,,,,,50.88,115.46,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,51672126705,NDC,,,facility,inpatient,1,EA,530.00000,153.70000,Aetna,First Health,,433.54,,,,,,,318.00,433.54,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,51672126705,NDC,,,facility,outpatient,1,EA,530.00000,153.70000,Aetna,First Health,,433.54,,,,,,,191.06,433.54,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,51672126302,NDC,,,facility,inpatient,1,EA,980.10000,284.23000,Aetna,First Health,,801.72,,,,,,,588.06,801.72,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,51672126302,NDC,,,facility,outpatient,1,EA,980.10000,284.23000,Aetna,First Health,,801.72,,,,,,,353.33,801.72,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,51672125902,NDC,,,facility,inpatient,1,EA,1604.55000,465.32000,Aetna,First Health,,1312.52,,,,,,,962.73,1312.52,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,51672125902,NDC,,,facility,outpatient,1,EA,1604.55000,465.32000,Aetna,First Health,,1312.52,,,,,,,578.44,1312.52,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,51672125802,NDC,,,facility,inpatient,1,EA,1587.85000,460.48000,Aetna,First Health,,1298.86,,,,,,,952.71,1298.86,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,51672125802,NDC,,,facility,outpatient,1,EA,1587.85000,460.48000,Aetna,First Health,,1298.86,,,,,,,572.42,1298.86,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,51672125401,NDC,,,facility,inpatient,1,EA,331.90000,96.25000,Aetna,First Health,,271.49,,,,,,,199.14,271.49,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,51672125401,NDC,,,facility,outpatient,1,EA,331.90000,96.25000,Aetna,First Health,,271.49,,,,,,,119.65,271.49,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,51672125301,NDC,,,facility,inpatient,1,EA,314.70000,91.26000,Aetna,First Health,,257.42,,,,,,,188.82,257.42,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,51672125301,NDC,,,facility,outpatient,1,EA,314.70000,91.26000,Aetna,First Health,,257.42,,,,,,,113.45,257.42,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,51660099628,NDC,,,facility,inpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,4.68,6.38,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,51660099628,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,2.81,6.38,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,51660078701,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,51660078701,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,51660078501,NDC,,,facility,inpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.18000,0.24540,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,51660078501,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.10815,0.24540,percent of total billed charges,
Acetic Acid 3% TS 30mL,800022043,CDM,250,RC,51552005106,NDC,,,facility,inpatient,1,EA,30.15000,8.74000,Aetna,First Health,,24.66,,,,,,,11.16,24.66,percent of total billed charges,
Acetic Acid 3% TS 30mL,800022043,CDM,250,RC,51552005106,NDC,,,facility,outpatient,1,EA,30.15000,8.74000,Aetna,First Health,,24.66,,,,,,,10.87,24.66,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,51525029403,NDC,,,facility,inpatient,1,EA,677.00000,196.33000,Aetna,First Health,,553.79,,,,,,,406.20,553.79,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,51525029403,NDC,,,facility,outpatient,1,EA,677.00000,196.33000,Aetna,First Health,,553.79,,,,,,,244.06,553.79,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,51525011501,NDC,,,facility,inpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,4.20,5.73,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,51525011501,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,2.52,5.73,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,51479005530,NDC,facility,inpatient,2,GM,335.80000,97.38000,Aetna,First Health,,274.68,,,,,,,121.06,274.68,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,51479005530,NDC,facility,outpatient,2,GM,335.80000,97.38000,Aetna,First Health,,274.68,,,,,,,0.83781,274.68,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,51479005430,NDC,facility,inpatient,1,GM,173.60000,50.34000,Aetna,First Health,,142.00,,,,,,,62.58,142.00,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,51479005430,NDC,facility,outpatient,1,GM,173.60000,50.34000,Aetna,First Health,,142.00,,,,,,,0.83781,142.00,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,51479004701,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,51479004701,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,51479004115,NDC,facility,inpatient,1,GM,318.85000,92.47000,Aetna,First Health,,260.82,,,,,,,114.95,260.82,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,51479004115,NDC,facility,outpatient,1,GM,318.85000,92.47000,Aetna,First Health,,260.82,,,,,,,2.15,260.82,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,51293080101,NDC,,,facility,inpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,11.46,15.62,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,51293080101,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,6.89,15.62,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,51293061101,NDC,,,facility,inpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,11.46,15.62,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,51293061101,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,6.89,15.62,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,51293060701,NDC,,,facility,inpatient,1,EA,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,21.84,29.78,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,51293060701,NDC,,,facility,outpatient,1,EA,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,13.12,29.78,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,51285091602,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,51285091602,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,51285054002,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,51285054002,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,51285042410,NDC,,,facility,inpatient,1,EA,51.55000,14.95000,Aetna,First Health,,42.17,,,,,,,30.93,42.17,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,51285042410,NDC,,,facility,outpatient,1,EA,51.55000,14.95000,Aetna,First Health,,42.17,,,,,,,18.58,42.17,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,51285016288,NDC,,,facility,inpatient,1,EA,268.35000,77.82000,Aetna,First Health,,219.51,,,,,,,161.01,219.51,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,51285016288,NDC,,,facility,outpatient,1,EA,268.35000,77.82000,Aetna,First Health,,219.51,,,,,,,96.74,219.51,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,51224020650,NDC,,,facility,inpatient,1,EA,24.30000,7.05000,Aetna,First Health,,19.88,,,,,,,14.58,19.88,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,51224020650,NDC,,,facility,outpatient,1,EA,24.30000,7.05000,Aetna,First Health,,19.88,,,,,,,8.76,19.88,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,51224001325,NDC,facility,inpatient,500,ME,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,19.83,44.99,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,51224001325,NDC,facility,outpatient,500,ME,55.00000,15.95000,Aetna,First Health,,44.99,,,,,,,0.03852,44.99,percent of total billed charges,
Phentolamine Mesylate 5mg I(Regitine),800013144,CDM,637,RC,J2760,HCPCS,51224001220,NDC,facility,inpatient,5,ME,1862.50000,540.12000,Aetna,First Health,,1523.53,,,,,,,1117.50,1523.53,percent of total billed charges,
Phentolamine Mesylate 5mg I(Regitine),800013144,CDM,637,RC,J2760,HCPCS,51224001220,NDC,facility,outpatient,5,ME,1862.50000,540.12000,Aetna,First Health,,1523.53,,,,,,,405.00,1523.53,percent of total billed charges,
enfortumab vedotin-ejfv 30mg I(Padcev),800051970,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,30,ME,22939.90000,6652.57000,Aetna,First Health,,18764.84,,,,,,,8269.83,18764.84,percent of total billed charges,
enfortumab vedotin-ejfv 30mg I(Padcev),800051970,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,outpatient,30,ME,22939.90000,6652.57000,Aetna,First Health,,18764.84,,,,,,,35.36,18764.84,percent of total billed charges,
enfortumab vedotin-ejfv 20mg I(Padcev),800051972,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,inpatient,20,ME,15355.60000,4453.12000,Aetna,First Health,,12560.88,,,,,,,5535.69,12560.88,percent of total billed charges,
enfortumab vedotin-ejfv 20mg I(Padcev),800051972,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,outpatient,20,ME,15355.60000,4453.12000,Aetna,First Health,,12560.88,,,,,,,35.36,12560.88,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,51079099320,NDC,,,facility,inpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,11.22,15.30,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,51079099320,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,6.74,15.30,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,51079099120,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,51079099120,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,51079098620,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,51079098620,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,51079098520,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,51079098520,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,51079097820,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,3.96,5.40,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,51079097820,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,51079097220,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,51079097220,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,51079095820,NDC,,,facility,inpatient,1,EA,26.60000,7.71000,Aetna,First Health,,21.76,,,,,,,15.96,21.76,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,51079095820,NDC,,,facility,outpatient,1,EA,26.60000,7.71000,Aetna,First Health,,21.76,,,,,,,9.59,21.76,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,51079094420,NDC,,,facility,inpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,8.34,11.37,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,51079094420,NDC,,,facility,outpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,5.01,11.37,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,51079093220,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,51079093220,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,51079093120,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,51079093120,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,51079092920,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,51079092920,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,51079092420,NDC,,,facility,inpatient,1,EA,28.15000,8.16000,Aetna,First Health,,23.03,,,,,,,16.89,23.03,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,51079092420,NDC,,,facility,outpatient,1,EA,28.15000,8.16000,Aetna,First Health,,23.03,,,,,,,10.15,23.03,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,51079092320,NDC,,,facility,inpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,7.41,10.10,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,51079092320,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,4.45,10.10,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,51079092120,NDC,,,facility,inpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,5.61,7.65,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,51079092120,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,3.37,7.65,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,51079089120,NDC,,,facility,inpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,1.23,1.68,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,51079089120,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,0.73903,1.68,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,51079088620,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,51079088620,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,51079088121,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,51079088121,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,51079088120,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,51079088120,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,51079084610,NDC,,,facility,inpatient,1,EA,15.60000,4.52000,Aetna,First Health,,12.76,,,,,,,9.36,12.76,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,51079084610,NDC,,,facility,outpatient,1,EA,15.60000,4.52000,Aetna,First Health,,12.76,,,,,,,5.62,12.76,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,51079082120,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,51079082120,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,51079081920,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,51079081920,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,51079081320,NDC,,,facility,inpatient,1,EA,51.15000,14.83000,Aetna,First Health,,41.84,,,,,,,30.69,41.84,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,51079081320,NDC,,,facility,outpatient,1,EA,51.15000,14.83000,Aetna,First Health,,41.84,,,,,,,18.44,41.84,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,51079080120,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,51079080120,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,51079078920,NDC,,,facility,inpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,3.66,4.99,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,51079078920,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,2.20,4.99,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,51079078820,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,51079078820,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,51079078720,NDC,,,facility,inpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,4.41,6.01,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,51079078720,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,2.65,6.01,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,51079077721,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,51079077721,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,51079077120,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,51079077120,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,51079076820,NDC,,,facility,inpatient,1,EA,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,51079076820,NDC,,,facility,outpatient,1,EA,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,5.05,11.45,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,51079076708,NDC,,,facility,inpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,17.31,23.60,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,51079076708,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,10.40,23.60,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,51079075920,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,51079075920,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,51079075320,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,51079075320,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,51079073620,NDC,,,facility,inpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,4.65,6.34,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,51079073620,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,2.79,6.34,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,51079073420,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,51079073420,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,51079073320,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,51079073320,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,51079072520,NDC,,,facility,inpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,22.17,30.23,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,51079072520,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,13.32,30.23,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,51079072420,NDC,,,facility,inpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,22.17,30.23,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,51079072420,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,13.32,30.23,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,51079072220,NDC,,,facility,inpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,13.95,19.02,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,51079072220,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,8.38,19.02,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,51079068420,NDC,,,facility,inpatient,1,EA,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,3.78,5.15,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,51079068420,NDC,,,facility,outpatient,1,EA,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,2.27,5.15,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,51079067005,NDC,facility,inpatient,2.5,ME,44.15000,12.80000,Aetna,First Health,,36.11,,,,,,,26.49,36.11,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,51079067005,NDC,facility,outpatient,2.5,ME,44.15000,12.80000,Aetna,First Health,,36.11,,,,,,,0.14445,36.11,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,51079064420,NDC,,,facility,inpatient,1,EA,6.85000,1.99000,Aetna,First Health,,5.60,,,,,,,4.11,5.60,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,51079064420,NDC,,,facility,outpatient,1,EA,6.85000,1.99000,Aetna,First Health,,5.60,,,,,,,2.47,5.60,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,51079063020,NDC,,,facility,inpatient,1,EA,12.85000,3.73000,Aetna,First Health,,10.51,,,,,,,7.71,10.51,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,51079063020,NDC,,,facility,outpatient,1,EA,12.85000,3.73000,Aetna,First Health,,10.51,,,,,,,4.63,10.51,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,51079062820,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,51079062820,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,51079062006,NDC,facility,inpatient,50,ME,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,9.96,13.58,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,51079062006,NDC,facility,outpatient,50,ME,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,0.05778,13.58,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,51079060520,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,51079060520,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,51079060420,NDC,,,facility,inpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,3.57,4.87,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,51079060420,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,51079059820,NDC,,,facility,inpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,4.89,6.67,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,51079059820,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,2.94,6.67,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,51079058420,NDC,,,facility,inpatient,1,EA,19.55000,5.67000,Aetna,First Health,,15.99,,,,,,,11.73,15.99,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,51079058420,NDC,,,facility,outpatient,1,EA,19.55000,5.67000,Aetna,First Health,,15.99,,,,,,,7.05,15.99,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,51079056620,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,51079056620,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,51079056103,NDC,,,facility,inpatient,1,EA,210.85000,61.15000,Aetna,First Health,,172.48,,,,,,,126.51,172.48,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,51079056103,NDC,,,facility,outpatient,1,EA,210.85000,61.15000,Aetna,First Health,,172.48,,,,,,,76.01,172.48,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,51079055803,NDC,,,facility,inpatient,1,EA,182.30000,52.87000,Aetna,First Health,,149.12,,,,,,,109.38,149.12,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,51079055803,NDC,,,facility,outpatient,1,EA,182.30000,52.87000,Aetna,First Health,,149.12,,,,,,,65.72,149.12,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,51079055720,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,51079055720,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,51079054220,NDC,facility,inpatient,10,ME,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,51079054220,NDC,facility,outpatient,10,ME,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,0.57780,5.64,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,51079052056,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,13.29,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,51079052056,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,51079052020,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,13.29,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,51079052020,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,51079051920,NDC,facility,inpatient,25,ME,67.70000,19.63000,Aetna,First Health,,55.38,,,,,,,40.62,55.38,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,51079051920,NDC,facility,outpatient,25,ME,67.70000,19.63000,Aetna,First Health,,55.38,,,,,,,2.07,55.38,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,51079051820,NDC,facility,inpatient,10,ME,46.95000,13.62000,Aetna,First Health,,38.41,,,,,,,28.17,38.41,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,51079051820,NDC,facility,outpatient,10,ME,46.95000,13.62000,Aetna,First Health,,38.41,,,,,,,2.07,38.41,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,51079051620,NDC,,,facility,inpatient,1,EA,157.45000,45.66000,Aetna,First Health,,128.79,,,,,,,94.47,128.79,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,51079051620,NDC,,,facility,outpatient,1,EA,157.45000,45.66000,Aetna,First Health,,128.79,,,,,,,56.76,128.79,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,51079045320,NDC,,,facility,inpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,11.52,15.71,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,51079045320,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,51079044420,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,51079044420,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,51079044320,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,51079044320,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,51079044220,NDC,,,facility,inpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,2.82,3.84,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,51079044220,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,51079044120,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,51079044120,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,51079044020,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,51079044020,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,51079042820,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,51079042820,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,51079041820,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,51079041820,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,51079041720,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,51079041720,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,51079039220,NDC,,,facility,inpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,7.68,10.47,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,51079039220,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,4.61,10.47,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,51079038621,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,51079038621,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,51079038620,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,51079038620,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,51079037520,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,51079037520,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,51079030710,NDC,,,facility,inpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,4.77,6.50,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,51079030710,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,2.87,6.50,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,51079029920,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,51079029920,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,51079029808,NDC,,,facility,inpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.92,2.62,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,51079029808,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,51079028520,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,51079028520,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
diazePAM 2mg T(Valium),800050533,CDM,637,RC,51079028420,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
diazePAM 2mg T(Valium),800050533,CDM,637,RC,51079028420,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,51079028220,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,51079028220,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,51079028120,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,51079028120,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
Metoprolol 12.5mg T(Lopressor),800046484,CDM,637,RC,51079025520,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Metoprolol 12.5mg T(Lopressor),800046484,CDM,637,RC,51079025520,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,51079025520,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,51079025520,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,51079022020,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,51079022020,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,51079021320,NDC,,,facility,inpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,7.74,10.55,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,51079021320,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,4.65,10.55,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,51079021020,NDC,,,facility,inpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,2.22,3.03,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,51079021020,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,51079020820,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,51079020820,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,51079020620,NDC,,,facility,inpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,3.21,4.38,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,51079020620,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,1.93,4.38,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,51079020520,NDC,,,facility,inpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,1.59,2.17,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,51079020520,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,51079020519,NDC,,,facility,inpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,1.59,2.17,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,51079020519,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,51079019020,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,51079019020,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,51079019019,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,51079019019,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,51079017103,NDC,,,facility,inpatient,1,EA,12.45000,3.61000,Aetna,First Health,,10.18,,,,,,,7.47,10.18,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,51079017103,NDC,,,facility,outpatient,1,EA,12.45000,3.61000,Aetna,First Health,,10.18,,,,,,,4.49,10.18,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,51079017020,NDC,,,facility,inpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,4.98,6.79,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,51079017020,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.99,6.79,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,51079016920,NDC,,,facility,inpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,4.98,6.79,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,51079016920,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.99,6.79,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,51079016520,NDC,,,facility,inpatient,1,EA,323.65000,93.86000,Aetna,First Health,,264.75,,,,,,,194.19,264.75,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,51079016520,NDC,,,facility,outpatient,1,EA,323.65000,93.86000,Aetna,First Health,,264.75,,,,,,,116.68,264.75,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,51079016503,NDC,,,facility,inpatient,1,EA,357.25000,103.60000,Aetna,First Health,,292.23,,,,,,,214.35,292.23,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,51079016503,NDC,,,facility,outpatient,1,EA,357.25000,103.60000,Aetna,First Health,,292.23,,,,,,,128.79,292.23,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,51079016120,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,51079016120,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,51079014220,NDC,,,facility,inpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,3.21,4.38,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,51079014220,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,1.93,4.38,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,51079014120,NDC,,,facility,inpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,3.21,4.38,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,51079014120,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,1.93,4.38,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,51079013120,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,51079013120,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,51079011820,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,51079011820,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,51079010720,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,51079010720,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,51079010320,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,51079010320,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,51079009520,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,51079009520,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,51079008620,NDC,,,facility,inpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,11.52,15.71,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,51079008620,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,51079008320,NDC,,,facility,inpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,5.46,7.44,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,51079008320,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,3.28,7.44,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,51079007820,NDC,facility,inpatient,50,ME,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,51079007820,NDC,facility,outpatient,50,ME,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.21186,1.88,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,51079007620,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,51079007620,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,51079007520,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,51079007520,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,51079007420,NDC,,,facility,inpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,51079007420,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,51079007320,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,51079007320,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,51079007220,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,51079007220,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,51079007219,NDC,,,facility,inpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.90000,1.23,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,51079007219,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.54075,1.23,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,51079006720,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,51079006720,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,51079005820,NDC,,,facility,inpatient,1,EA,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,9.75,13.29,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,51079005820,NDC,,,facility,outpatient,1,EA,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,5.86,13.29,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,51079005520,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,51079005520,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,51079005120,NDC,,,facility,inpatient,1,EA,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,22.38,30.51,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,51079005120,NDC,,,facility,outpatient,1,EA,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,13.45,30.51,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,51079004120,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,51079004120,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,51079002320,NDC,,,facility,inpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,13.95,19.02,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,51079002320,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,8.38,19.02,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,51079002003,NDC,,,facility,inpatient,1,EA,161.45000,46.82000,Aetna,First Health,,132.07,,,,,,,96.87,132.07,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,51079002003,NDC,,,facility,outpatient,1,EA,161.45000,46.82000,Aetna,First Health,,132.07,,,,,,,58.20,132.07,percent of total billed charges,
Neomycin 500mg T,800016609,CDM,637,RC,51079001520,NDC,,,facility,inpatient,1,EA,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,8.40,11.45,percent of total billed charges,
Neomycin 500mg T,800016609,CDM,637,RC,51079001520,NDC,,,facility,outpatient,1,EA,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,5.05,11.45,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,50962047560,NDC,,,facility,inpatient,1,EA,67.95000,19.71000,Aetna,First Health,,55.58,,,,,,,25.14,55.58,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,50962047560,NDC,,,facility,outpatient,1,EA,67.95000,19.71000,Aetna,First Health,,55.58,,,,,,,24.50,55.58,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,50962022560,NDC,,,facility,inpatient,1,EA,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,7.08,9.65,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,50962022560,NDC,,,facility,outpatient,1,EA,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,4.25,9.65,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,50742063360,NDC,,,facility,inpatient,1,EA,122.10000,35.41000,Aetna,First Health,,99.88,,,,,,,73.26,99.88,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,50742063360,NDC,,,facility,outpatient,1,EA,122.10000,35.41000,Aetna,First Health,,99.88,,,,,,,44.02,99.88,percent of total billed charges,
Nitroglycerin 0.3mg/hr TD(Nitro-Dur),800074251,CDM,637,RC,50742051530,NDC,,,facility,inpatient,1,EA,426.60000,123.71000,Aetna,First Health,,348.96,,,,,,,255.96,348.96,percent of total billed charges,
Nitroglycerin 0.3mg/hr TD(Nitro-Dur),800074251,CDM,637,RC,50742051530,NDC,,,facility,outpatient,1,EA,426.60000,123.71000,Aetna,First Health,,348.96,,,,,,,153.79,348.96,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,50742050524,NDC,,,facility,inpatient,1,EA,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,97.59,133.05,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,50742050524,NDC,,,facility,outpatient,1,EA,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,58.64,133.05,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,50742050510,NDC,,,facility,inpatient,1,EA,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,97.59,133.05,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,50742050510,NDC,,,facility,outpatient,1,EA,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,58.64,133.05,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,50742048401,NDC,facility,inpatient,3.5,ME,1807.00000,524.03000,Aetna,First Health,,1478.13,,,,,,,651.42,1478.13,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,50742048401,NDC,facility,outpatient,3.5,ME,1807.00000,524.03000,Aetna,First Health,,1478.13,,,,,,,2.58,1478.13,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,50742044745,NDC,facility,inpatient,50,ME,174.75000,50.68000,Aetna,First Health,,142.95,,,,,,,63.00,142.95,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,50742044745,NDC,facility,outpatient,50,ME,174.75000,50.68000,Aetna,First Health,,142.95,,,,,,,2.82,142.95,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,50742026001,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,50742026001,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,50742024990,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,50742024990,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,50742024930,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,50742024930,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,50742024001,NDC,,,facility,inpatient,1,EA,21.45000,6.22000,Aetna,First Health,,17.55,,,,,,,12.87,17.55,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,50742024001,NDC,,,facility,outpatient,1,EA,21.45000,6.22000,Aetna,First Health,,17.55,,,,,,,7.73,17.55,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,50742023901,NDC,,,facility,inpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,10.77,14.68,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,50742023901,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,6.47,14.68,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,50742017901,NDC,,,facility,inpatient,1,EA,28.40000,8.24000,Aetna,First Health,,23.23,,,,,,,17.04,23.23,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,50742017901,NDC,,,facility,outpatient,1,EA,28.40000,8.24000,Aetna,First Health,,23.23,,,,,,,10.24,23.23,percent of total billed charges,
Cabergoline 0.5 mg Tab,800017393,CDM,637,RC,J8515,HCPCS,50742011808,NDC,facility,inpatient,0.5,ME,256.20000,74.30000,Aetna,First Health,,209.57,,,,,,,153.72,209.57,percent of total billed charges,
Cabergoline 0.5 mg Tab,800017393,CDM,637,RC,J8515,HCPCS,50742011808,NDC,facility,outpatient,0.5,ME,256.20000,74.30000,Aetna,First Health,,209.57,,,,,,,17.65,209.57,percent of total billed charges,
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,50673025021,NDC,facility,inpatient,50,ME,825.35000,239.35000,Aetna,First Health,,675.14,,,,,,,297.54,675.14,percent of total billed charges,
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,50673025021,NDC,facility,outpatient,50,ME,825.35000,239.35000,Aetna,First Health,,675.14,,,,,,,5.42,675.14,percent of total billed charges,
Hydroxocobalamin 5g Kit,800081127,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,inpatient,5,GM,7372.60000,2138.05000,Aetna,First Health,,6030.79,,,,,,,2657.82,6030.79,percent of total billed charges,
Hydroxocobalamin 5g Kit,800081127,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,outpatient,5,GM,7372.60000,2138.05000,Aetna,First Health,,6030.79,,,,,,,5.44,6030.79,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,50632001001,NDC,facility,inpatient,1,EA,1921.50000,557.24000,Aetna,First Health,,1571.79,,,,,,,692.70,1571.79,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,50632001001,NDC,facility,outpatient,1,EA,1921.50000,557.24000,Aetna,First Health,,1571.79,,,,,,,307.92,1571.79,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,50532011510,NDC,,,facility,inpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,4.20,5.73,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,50532011510,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,2.52,5.73,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,50532011310,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,50532011310,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,50484001030,NDC,,,facility,inpatient,1,EA,2128.15000,617.16000,Aetna,First Health,,1740.83,,,,,,,1276.89,1740.83,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,50484001030,NDC,,,facility,outpatient,1,EA,2128.15000,617.16000,Aetna,First Health,,1740.83,,,,,,,767.20,1740.83,percent of total billed charges,
Brivaracetam 10mg/mL Inj 5mL,800040910,CDM,636,RC,50474097075,NDC,,,facility,inpatient,1,EA,568.30000,164.81000,Aetna,First Health,,464.87,,,,,,,204.87,464.87,percent of total billed charges,
Brivaracetam 10mg/mL Inj 5mL,800040910,CDM,636,RC,50474097075,NDC,,,facility,outpatient,1,EA,568.30000,164.81000,Aetna,First Health,,464.87,,,,,,,204.87,464.87,percent of total billed charges,
Certolizumab Pegol Lypholized Kit,800046570,CDM,636,RC,J0717,HCPCS,50474070062,NDC,facility,inpatient,200,ME,19375.20000,5618.81000,Aetna,First Health,,15848.91,,,,,,,6984.76,15848.91,percent of total billed charges,
Certolizumab Pegol Lypholized Kit,800046570,CDM,636,RC,J0717,HCPCS,50474070062,NDC,facility,outpatient,200,ME,19375.20000,5618.81000,Aetna,First Health,,15848.91,,,,,,,3.73,15848.91,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,50474059540,NDC,,,facility,inpatient,1,EA,86.00000,24.94000,Aetna,First Health,,70.35,,,,,,,51.60,70.35,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,50474059540,NDC,,,facility,outpatient,1,EA,86.00000,24.94000,Aetna,First Health,,70.35,,,,,,,31.00,70.35,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,50474059440,NDC,,,facility,inpatient,1,EA,70.35000,20.40000,Aetna,First Health,,57.55,,,,,,,42.21,57.55,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,50474059440,NDC,,,facility,outpatient,1,EA,70.35000,20.40000,Aetna,First Health,,57.55,,,,,,,25.36,57.55,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,50474059240,NDC,,,facility,inpatient,1,EA,20.65000,5.99000,Aetna,First Health,,16.89,,,,,,,12.39,16.89,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,50474059240,NDC,,,facility,outpatient,1,EA,20.65000,5.99000,Aetna,First Health,,16.89,,,,,,,7.44,16.89,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,50474059140,NDC,,,facility,inpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,10.14,13.82,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,50474059140,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,6.09,13.82,percent of total billed charges,
Brivaracetam 25 mg Tab,800046422,CDM,637,RC,50474047066,NDC,,,facility,inpatient,1,EA,233.95000,67.85000,Aetna,First Health,,191.37,,,,,,,140.37,191.37,percent of total billed charges,
Brivaracetam 25 mg Tab,800046422,CDM,637,RC,50474047066,NDC,,,facility,outpatient,1,EA,233.95000,67.85000,Aetna,First Health,,191.37,,,,,,,84.34,191.37,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,50474000263,NDC,facility,inpatient,500,ME,611.10000,177.22000,Aetna,First Health,,499.88,,,,,,,220.30,499.88,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,50474000263,NDC,facility,outpatient,500,ME,611.10000,177.22000,Aetna,First Health,,499.88,,,,,,,0.03852,499.88,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,50458092550,NDC,,,facility,inpatient,1,EA,252.15000,73.12000,Aetna,First Health,,206.26,,,,,,,151.29,206.26,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,50458092550,NDC,,,facility,outpatient,1,EA,252.15000,73.12000,Aetna,First Health,,206.26,,,,,,,90.90,206.26,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,50458092050,NDC,,,facility,inpatient,1,EA,203.10000,58.90000,Aetna,First Health,,166.14,,,,,,,121.86,166.14,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,50458092050,NDC,,,facility,outpatient,1,EA,203.10000,58.90000,Aetna,First Health,,166.14,,,,,,,73.22,166.14,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,50458082004,NDC,,,facility,inpatient,1,EA,50.55000,14.66000,Aetna,First Health,,41.35,,,,,,,30.33,41.35,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,50458082004,NDC,,,facility,outpatient,1,EA,50.55000,14.66000,Aetna,First Health,,41.35,,,,,,,18.22,41.35,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,50458082002,NDC,,,facility,inpatient,1,EA,73.75000,21.39000,Aetna,First Health,,60.33,,,,,,,44.25,60.33,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,50458082002,NDC,,,facility,outpatient,1,EA,73.75000,21.39000,Aetna,First Health,,60.33,,,,,,,26.59,60.33,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,50458064565,NDC,,,facility,inpatient,1,EA,64.95000,18.84000,Aetna,First Health,,53.13,,,,,,,38.97,53.13,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,50458064565,NDC,,,facility,outpatient,1,EA,64.95000,18.84000,Aetna,First Health,,53.13,,,,,,,23.41,53.13,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,50458064165,NDC,,,facility,inpatient,1,EA,154.80000,44.89000,Aetna,First Health,,126.63,,,,,,,92.88,126.63,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,50458064165,NDC,,,facility,outpatient,1,EA,154.80000,44.89000,Aetna,First Health,,126.63,,,,,,,55.81,126.63,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,50458063965,NDC,,,facility,inpatient,1,EA,56.80000,16.47000,Aetna,First Health,,46.46,,,,,,,34.08,46.46,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,50458063965,NDC,,,facility,outpatient,1,EA,56.80000,16.47000,Aetna,First Health,,46.46,,,,,,,20.48,46.46,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,50458059601,NDC,,,facility,inpatient,1,EA,34.50000,10.00000,Aetna,First Health,,28.22,,,,,,,20.70,28.22,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,50458059601,NDC,,,facility,outpatient,1,EA,34.50000,10.00000,Aetna,First Health,,28.22,,,,,,,12.44,28.22,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458059260,NDC,,,facility,inpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,6.48,8.83,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458059260,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,3.89,8.83,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458059210,NDC,,,facility,inpatient,1,EA,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,9.99,13.62,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458059210,NDC,,,facility,outpatient,1,EA,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,6.00,13.62,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,50458059060,NDC,,,facility,inpatient,1,EA,9.25000,2.68000,Aetna,First Health,,7.57,,,,,,,5.55,7.57,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,50458059060,NDC,,,facility,outpatient,1,EA,9.25000,2.68000,Aetna,First Health,,7.57,,,,,,,3.33,7.57,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),800015373,CDM,637,RC,50458058090,NDC,,,facility,inpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,96.78,131.94,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),800015373,CDM,637,RC,50458058090,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),800015373,CDM,637,RC,50458058030,NDC,,,facility,inpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,96.78,131.94,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),800015373,CDM,637,RC,50458058030,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),800015373,CDM,637,RC,50458058010,NDC,,,facility,inpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,96.78,131.94,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),800015373,CDM,637,RC,50458058010,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),800017952,CDM,637,RC,50458057990,NDC,,,facility,inpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,96.78,131.94,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),800017952,CDM,637,RC,50458057990,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),800017952,CDM,637,RC,50458057930,NDC,,,facility,inpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,96.78,131.94,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),800017952,CDM,637,RC,50458057930,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),800017952,CDM,637,RC,50458057910,NDC,,,facility,inpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,96.78,131.94,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),800017952,CDM,637,RC,50458057910,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),800015432,CDM,637,RC,50458057890,NDC,,,facility,inpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,96.78,131.94,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),800015432,CDM,637,RC,50458057890,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),800015432,CDM,637,RC,50458057830,NDC,,,facility,inpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,96.78,131.94,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),800015432,CDM,637,RC,50458057830,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),800015432,CDM,637,RC,50458057810,NDC,,,facility,inpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,96.78,131.94,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),800015432,CDM,637,RC,50458057810,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,First Health,,131.94,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 2.5mg T(Xarelto),800046453,CDM,637,RC,50458057710,NDC,,,facility,inpatient,1,EA,80.65000,23.39000,Aetna,First Health,,65.97,,,,,,,48.39,65.97,percent of total billed charges,
Rivaroxaban 2.5mg T(Xarelto),800046453,CDM,637,RC,50458057710,NDC,,,facility,outpatient,1,EA,80.65000,23.39000,Aetna,First Health,,65.97,,,,,,,29.07,65.97,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,50458055010,NDC,,,facility,inpatient,1,EA,331.40000,96.11000,Aetna,First Health,,271.09,,,,,,,198.84,271.09,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,50458055010,NDC,,,facility,outpatient,1,EA,331.40000,96.11000,Aetna,First Health,,271.09,,,,,,,119.47,271.09,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,50458055001,NDC,,,facility,inpatient,1,EA,106.25000,30.81000,Aetna,First Health,,86.91,,,,,,,63.75,86.91,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,50458055001,NDC,,,facility,outpatient,1,EA,106.25000,30.81000,Aetna,First Health,,86.91,,,,,,,38.30,86.91,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,50458051360,NDC,,,facility,inpatient,1,EA,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,7.08,9.65,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,50458051360,NDC,,,facility,outpatient,1,EA,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,4.25,9.65,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,50458030503,NDC,,,facility,inpatient,1,EA,46.50000,13.48000,Aetna,First Health,,38.04,,,,,,,27.90,38.04,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,50458030503,NDC,,,facility,outpatient,1,EA,46.50000,13.48000,Aetna,First Health,,38.04,,,,,,,16.76,38.04,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,50458030150,NDC,,,facility,inpatient,1,EA,75.45000,21.88000,Aetna,First Health,,61.72,,,,,,,45.27,61.72,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,50458030150,NDC,,,facility,outpatient,1,EA,75.45000,21.88000,Aetna,First Health,,61.72,,,,,,,27.20,61.72,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,50458030104,NDC,,,facility,inpatient,1,EA,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,49.80,67.89,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,50458030104,NDC,,,facility,outpatient,1,EA,83.00000,24.07000,Aetna,First Health,,67.89,,,,,,,29.92,67.89,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458030006,NDC,,,facility,inpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,24.99,34.07,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458030006,NDC,,,facility,outpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,15.01,34.07,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458030001,NDC,,,facility,inpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,24.99,34.07,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458030001,NDC,,,facility,outpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,15.01,34.07,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,800021977,CDM,637,RC,50458029515,NDC,,,facility,inpatient,1,EA,195.40000,56.67000,Aetna,First Health,,159.84,,,,,,,117.24,159.84,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,800021977,CDM,637,RC,50458029515,NDC,,,facility,outpatient,1,EA,195.40000,56.67000,Aetna,First Health,,159.84,,,,,,,70.44,159.84,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,50458025501,NDC,facility,inpatient,5,ME,131.75000,38.21000,Aetna,First Health,,107.77,,,,,,,47.50,107.77,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,50458025501,NDC,facility,outpatient,5,ME,131.75000,38.21000,Aetna,First Health,,107.77,,,,,,,0.70299,107.77,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,50458022115,NDC,,,facility,inpatient,1,EA,1678.70000,486.82000,Aetna,First Health,,1373.18,,,,,,,1007.22,1373.18,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,50458022115,NDC,,,facility,outpatient,1,EA,1678.70000,486.82000,Aetna,First Health,,1373.18,,,,,,,605.17,1373.18,percent of total billed charges,
levoFLOXacin  25mg/mL L,800081070,CDM,637,RC,50458017001,NDC,,,facility,inpatient,1,ML,13.20000,3.83000,Aetna,First Health,,10.80,,,,,,,7.92,10.80,percent of total billed charges,
levoFLOXacin  25mg/mL L,800081070,CDM,637,RC,50458017001,NDC,,,facility,outpatient,1,ML,13.20000,3.83000,Aetna,First Health,,10.80,,,,,,,4.76,10.80,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,50458016801,NDC,facility,inpatient,500,ME,202.25000,58.65000,Aetna,First Health,,165.44,,,,,,,72.91,165.44,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,50458016801,NDC,facility,outpatient,500,ME,202.25000,58.65000,Aetna,First Health,,165.44,,,,,,,2.08,165.44,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,50458016701,NDC,facility,inpatient,250,ME,102.35000,29.68000,Aetna,First Health,,83.72,,,,,,,36.90,83.72,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,50458016701,NDC,facility,outpatient,250,ME,102.35000,29.68000,Aetna,First Health,,83.72,,,,,,,2.08,83.72,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,50458016601,NDC,facility,inpatient,750,ME,264.65000,76.75000,Aetna,First Health,,216.48,,,,,,,95.41,216.48,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,50458016601,NDC,facility,outpatient,750,ME,264.65000,76.75000,Aetna,First Health,,216.48,,,,,,,2.08,216.48,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,50458009005,NDC,,,facility,inpatient,1,EA,355.30000,103.04000,Aetna,First Health,,290.64,,,,,,,213.18,290.64,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,50458009005,NDC,,,facility,outpatient,1,EA,355.30000,103.04000,Aetna,First Health,,290.64,,,,,,,128.09,290.64,percent of total billed charges,
SUFentanil 50mcg/mL 1mL I,800049758,CDM,250,RC,50458005001,NDC,,,facility,inpatient,1,EA,117.20000,33.99000,Aetna,First Health,,95.87,,,,,,,43.36,95.87,percent of total billed charges,
SUFentanil 50mcg/mL 1mL I,800049758,CDM,250,RC,50458005001,NDC,,,facility,outpatient,1,EA,117.20000,33.99000,Aetna,First Health,,95.87,,,,,,,42.25,95.87,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,50458003705,NDC,,,facility,inpatient,1,EA,151.75000,44.01000,Aetna,First Health,,124.13,,,,,,,91.05,124.13,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,50458003705,NDC,,,facility,outpatient,1,EA,151.75000,44.01000,Aetna,First Health,,124.13,,,,,,,54.71,124.13,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,50458003605,NDC,,,facility,inpatient,1,EA,631.25000,183.06000,Aetna,First Health,,516.36,,,,,,,378.75,516.36,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,50458003605,NDC,,,facility,outpatient,1,EA,631.25000,183.06000,Aetna,First Health,,516.36,,,,,,,227.57,516.36,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,50458003505,NDC,,,facility,inpatient,1,EA,484.95000,140.64000,Aetna,First Health,,396.69,,,,,,,290.97,396.69,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,50458003505,NDC,,,facility,outpatient,1,EA,484.95000,140.64000,Aetna,First Health,,396.69,,,,,,,174.82,396.69,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,50458003405,NDC,,,facility,inpatient,1,EA,224.05000,64.97000,Aetna,First Health,,183.27,,,,,,,134.43,183.27,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,50458003405,NDC,,,facility,outpatient,1,EA,224.05000,64.97000,Aetna,First Health,,183.27,,,,,,,80.77,183.27,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,50458003305,NDC,,,facility,inpatient,1,EA,123.05000,35.68000,Aetna,First Health,,100.65,,,,,,,73.83,100.65,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,50458003305,NDC,,,facility,outpatient,1,EA,123.05000,35.68000,Aetna,First Health,,100.65,,,,,,,44.36,100.65,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,50419045204,NDC,,,facility,inpatient,1,EA,162.05000,46.99000,Aetna,First Health,,132.56,,,,,,,97.23,132.56,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,50419045204,NDC,,,facility,outpatient,1,EA,162.05000,46.99000,Aetna,First Health,,132.56,,,,,,,58.42,132.56,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,50419045104,NDC,,,facility,inpatient,1,EA,162.05000,46.99000,Aetna,First Health,,132.56,,,,,,,97.23,132.56,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,50419045104,NDC,,,facility,outpatient,1,EA,162.05000,46.99000,Aetna,First Health,,132.56,,,,,,,58.42,132.56,percent of total billed charges,
Levonorgestrel 52mg IUD(Mirena),800062031,CDM,636,RC,J7298,HCPCS,50419042301,NDC,facility,inpatient,52,ME,7689.40000,2229.93000,Aetna,First Health,,6289.93,,,,,,,2772.03,6289.93,percent of total billed charges,
Levonorgestrel 52mg IUD(Mirena),800062031,CDM,636,RC,J7298,HCPCS,50419042301,NDC,facility,outpatient,52,ME,7689.40000,2229.93000,Aetna,First Health,,6289.93,,,,,,,1336.79,6289.93,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032537,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,19.11,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032537,NDC,facility,outpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,0.26964,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032519,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,19.11,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032519,NDC,facility,outpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,0.26964,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032518,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,19.11,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032518,NDC,facility,outpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,0.26964,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032513,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,19.11,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032513,NDC,facility,outpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,0.26964,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032512,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,19.11,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032512,NDC,facility,outpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,0.26964,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032511,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,19.11,43.35,percent of total billed charges,
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032511,NDC,facility,outpatient,1,EA,53.00000,15.37000,Aetna,First Health,,43.35,,,,,,,0.26964,43.35,percent of total billed charges,
RAD- Gadoxetate 181.43mg/mL I 10mL,800022111,CDM,636,RC,A9581,HCPCS,50419032005,NDC,facility,inpatient,1,EA,740.75000,214.82000,Aetna,First Health,,605.93,,,,,,,267.04,605.93,percent of total billed charges,
RAD- Gadoxetate 181.43mg/mL I 10mL,800022111,CDM,636,RC,A9581,HCPCS,50419032005,NDC,facility,outpatient,1,EA,740.75000,214.82000,Aetna,First Health,,605.93,,,,,,,14.20,605.93,percent of total billed charges,
RAD- Gadoxetate 181.43mg/mL I 10mL,800022111,CDM,636,RC,A9581,HCPCS,50419032001,NDC,facility,inpatient,1,EA,710.75000,206.12000,Aetna,First Health,,581.39,,,,,,,256.23,581.39,percent of total billed charges,
RAD- Gadoxetate 181.43mg/mL I 10mL,800022111,CDM,636,RC,A9581,HCPCS,50419032001,NDC,facility,outpatient,1,EA,710.75000,206.12000,Aetna,First Health,,581.39,,,,,,,14.20,581.39,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,50419010511,NDC,,,facility,inpatient,1,EA,22.20000,6.44000,Aetna,First Health,,18.16,,,,,,,13.32,18.16,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,50419010511,NDC,,,facility,outpatient,1,EA,22.20000,6.44000,Aetna,First Health,,18.16,,,,,,,8.00,18.16,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,50419010510,NDC,,,facility,inpatient,1,EA,33.70000,9.77000,Aetna,First Health,,27.57,,,,,,,20.22,27.57,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,50419010510,NDC,,,facility,outpatient,1,EA,33.70000,9.77000,Aetna,First Health,,27.57,,,,,,,12.15,27.57,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,50383093335,NDC,,,facility,inpatient,1,EA,1809.00000,524.61000,Aetna,First Health,,1479.76,,,,,,,1085.40,1479.76,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,50383093335,NDC,,,facility,outpatient,1,EA,1809.00000,524.61000,Aetna,First Health,,1479.76,,,,,,,652.14,1479.76,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,50383081016,NDC,,,facility,inpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,19.98,27.24,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,50383081016,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,12.00,27.24,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,50383080716,NDC,,,facility,inpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,6.54,8.92,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,50383080716,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,50383080116,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,50383080116,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,50383079616,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,50383079616,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,50383079516,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,50383079516,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,50383077931,NDC,,,facility,inpatient,1,EA,21.10000,6.12000,Aetna,First Health,,17.26,,,,,,,12.66,17.26,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,50383077931,NDC,,,facility,outpatient,1,EA,21.10000,6.12000,Aetna,First Health,,17.26,,,,,,,7.61,17.26,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,800062055,CDM,637,RC,50383077917,NDC,,,facility,inpatient,1,EA,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,10.68,14.56,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,800062055,CDM,637,RC,50383077917,NDC,,,facility,outpatient,1,EA,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,6.42,14.56,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,50383077517,NDC,,,facility,inpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,4.59,6.26,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,50383077517,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
GI Cocktail 50mL UD - ED Use,800025577,CDM,637,RC,50383077515,NDC,,,facility,inpatient,1,EA,48.15000,13.96000,Aetna,First Health,,39.39,,,,,,,28.89,39.39,percent of total billed charges,
GI Cocktail 50mL UD - ED Use,800025577,CDM,637,RC,50383077515,NDC,,,facility,outpatient,1,EA,48.15000,13.96000,Aetna,First Health,,39.39,,,,,,,17.36,39.39,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,50383072017,NDC,,,facility,inpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,4.86,6.63,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,50383072017,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,2.92,6.63,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,50383072016,NDC,,,facility,inpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,1.41,1.92,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,50383072016,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,50383070016,NDC,,,facility,inpatient,1,EA,552.65000,160.27000,Aetna,First Health,,452.07,,,,,,,331.59,452.07,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,50383070016,NDC,,,facility,outpatient,1,EA,552.65000,160.27000,Aetna,First Health,,452.07,,,,,,,199.23,452.07,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,50383062750,NDC,,,facility,inpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.75000,1.02,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,50383062750,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.45062,1.02,percent of total billed charges,
NICU- Ferrous Sulfate 2.25mg/0.15mL L UD,800015385,CDM,637,RC,50383062750,NDC,,,facility,inpatient,1,EA,0.20000,0.06000,Aetna,First Health,,0.16360,,,,,,,0.12000,0.16360,percent of total billed charges,
NICU- Ferrous Sulfate 2.25mg/0.15mL L UD,800015385,CDM,637,RC,50383062750,NDC,,,facility,outpatient,1,EA,0.20000,0.06000,Aetna,First Health,,0.16360,,,,,,,0.07210,0.16360,percent of total billed charges,
NICU- Ferrous Sulfate 3.75mg/0.25mL L UD,800015387,CDM,637,RC,50383062750,NDC,,,facility,inpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.18000,0.24540,percent of total billed charges,
NICU- Ferrous Sulfate 3.75mg/0.25mL L UD,800015387,CDM,637,RC,50383062750,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.10815,0.24540,percent of total billed charges,
Gabapentin 300mg/6mL Oral Liq UD,800017998,CDM,637,RC,50383031109,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
Gabapentin 300mg/6mL Oral Liq UD,800017998,CDM,637,RC,50383031109,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,800015357,CDM,637,RC,50383031107,NDC,,,facility,inpatient,1,EA,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,8.85,12.07,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,800015357,CDM,637,RC,50383031107,NDC,,,facility,outpatient,1,EA,14.75000,4.28000,Aetna,First Health,,12.07,,,,,,,5.32,12.07,percent of total billed charges,
levoFLOXacin  25mg/mL L,800081070,CDM,637,RC,50383028616,NDC,,,facility,inpatient,1,ML,9.80000,2.84000,Aetna,First Health,,8.02,,,,,,,5.88,8.02,percent of total billed charges,
levoFLOXacin  25mg/mL L,800081070,CDM,637,RC,50383028616,NDC,,,facility,outpatient,1,ML,9.80000,2.84000,Aetna,First Health,,8.02,,,,,,,3.53,8.02,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,50383026730,NDC,,,facility,inpatient,1,EA,1587.75000,460.45000,Aetna,First Health,,1298.78,,,,,,,952.65,1298.78,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,50383026730,NDC,,,facility,outpatient,1,EA,1587.75000,460.45000,Aetna,First Health,,1298.78,,,,,,,572.38,1298.78,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,50383024116,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,50383024116,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,50383024106,NDC,,,facility,inpatient,1,EA,48.65000,14.11000,Aetna,First Health,,39.80,,,,,,,29.19,39.80,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,50383024106,NDC,,,facility,outpatient,1,EA,48.65000,14.11000,Aetna,First Health,,39.80,,,,,,,17.54,39.80,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,50383023210,NDC,,,facility,inpatient,1,EA,446.15000,129.38000,Aetna,First Health,,364.95,,,,,,,267.69,364.95,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,50383023210,NDC,,,facility,outpatient,1,EA,446.15000,129.38000,Aetna,First Health,,364.95,,,,,,,160.84,364.95,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,800072518,CDM,637,RC,50383008712,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,800072518,CDM,637,RC,50383008712,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,50268081915,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,50268081915,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,50268081615,NDC,,,facility,inpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,7.32,9.98,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,50268081615,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,4.40,9.98,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,50268079815,NDC,,,facility,inpatient,1,EA,14.60000,4.23000,Aetna,First Health,,11.94,,,,,,,8.76,11.94,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,50268079815,NDC,,,facility,outpatient,1,EA,14.60000,4.23000,Aetna,First Health,,11.94,,,,,,,5.26,11.94,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,50268079715,NDC,,,facility,inpatient,1,EA,54.10000,15.69000,Aetna,First Health,,44.25,,,,,,,32.46,44.25,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,50268079715,NDC,,,facility,outpatient,1,EA,54.10000,15.69000,Aetna,First Health,,44.25,,,,,,,19.50,44.25,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,50268077915,NDC,,,facility,inpatient,1,EA,7.85000,2.28000,Aetna,First Health,,6.42,,,,,,,4.71,6.42,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,50268077915,NDC,,,facility,outpatient,1,EA,7.85000,2.28000,Aetna,First Health,,6.42,,,,,,,2.83,6.42,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,50268077515,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,50268077515,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,50268077213,NDC,,,facility,inpatient,1,EA,37.25000,10.80000,Aetna,First Health,,30.47,,,,,,,22.35,30.47,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,50268077213,NDC,,,facility,outpatient,1,EA,37.25000,10.80000,Aetna,First Health,,30.47,,,,,,,13.43,30.47,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,50268077015,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,50268077015,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,50268076615,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,50268076615,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,50268076415,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,50268076415,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,50268076015,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,50268076015,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,50268075915,NDC,,,facility,inpatient,1,EA,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,7.44,10.14,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,50268075915,NDC,,,facility,outpatient,1,EA,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,4.47,10.14,percent of total billed charges,
Tenofovir 300mg T(Viread),800017725,CDM,637,RC,50268075812,NDC,,,facility,inpatient,1,EA,40.05000,11.61000,Aetna,First Health,,32.76,,,,,,,24.03,32.76,percent of total billed charges,
Tenofovir 300mg T(Viread),800017725,CDM,637,RC,50268075812,NDC,,,facility,outpatient,1,EA,40.05000,11.61000,Aetna,First Health,,32.76,,,,,,,14.44,32.76,percent of total billed charges,
Torsemide 100mg T,800046505,CDM,637,RC,50268075715,NDC,,,facility,inpatient,1,EA,20.50000,5.94000,Aetna,First Health,,16.77,,,,,,,12.30,16.77,percent of total billed charges,
Torsemide 100mg T,800046505,CDM,637,RC,50268075715,NDC,,,facility,outpatient,1,EA,20.50000,5.94000,Aetna,First Health,,16.77,,,,,,,7.39,16.77,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,50268075615,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,50268075615,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,50268075415,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,50268075415,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,50268074514,NDC,,,facility,inpatient,1,EA,60.90000,17.66000,Aetna,First Health,,49.82,,,,,,,36.54,49.82,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,50268074514,NDC,,,facility,outpatient,1,EA,60.90000,17.66000,Aetna,First Health,,49.82,,,,,,,21.95,49.82,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,50268074415,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,50268074415,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,50268074315,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,50268074315,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,50268074115,NDC,,,facility,inpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,2.52,3.44,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,50268074115,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,1.51,3.44,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,50268074015,NDC,,,facility,inpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,2.01,2.74,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,50268074015,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,1.21,2.74,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,50268073212,NDC,,,facility,inpatient,1,EA,86.25000,25.01000,Aetna,First Health,,70.55,,,,,,,51.75,70.55,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,50268073212,NDC,,,facility,outpatient,1,EA,86.25000,25.01000,Aetna,First Health,,70.55,,,,,,,31.09,70.55,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,50268072515,NDC,,,facility,inpatient,1,EA,24.50000,7.10000,Aetna,First Health,,20.04,,,,,,,14.70,20.04,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,50268072515,NDC,,,facility,outpatient,1,EA,24.50000,7.10000,Aetna,First Health,,20.04,,,,,,,8.83,20.04,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,50268072215,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,50268072215,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,50268071115,NDC,,,facility,inpatient,1,EA,11.25000,3.26000,Aetna,First Health,,9.20,,,,,,,6.75,9.20,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,50268071115,NDC,,,facility,outpatient,1,EA,11.25000,3.26000,Aetna,First Health,,9.20,,,,,,,4.06,9.20,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,50268070915,NDC,,,facility,inpatient,1,EA,9.70000,2.81000,Aetna,First Health,,7.93,,,,,,,5.82,7.93,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,50268070915,NDC,,,facility,outpatient,1,EA,9.70000,2.81000,Aetna,First Health,,7.93,,,,,,,3.50,7.93,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,50268069415,NDC,,,facility,inpatient,1,EA,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,30.27,41.27,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,50268069415,NDC,,,facility,outpatient,1,EA,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,18.19,41.27,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,50268068715,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,50268068715,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,50268068615,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,4.05,5.52,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,50268068615,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,50268068515,NDC,facility,inpatient,10,ME,12.55000,3.64000,Aetna,First Health,,10.27,,,,,,,7.53,10.27,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,50268068515,NDC,facility,outpatient,10,ME,12.55000,3.64000,Aetna,First Health,,10.27,,,,,,,0.57780,10.27,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,50268067415,NDC,,,facility,inpatient,1,EA,105.05000,30.46000,Aetna,First Health,,85.93,,,,,,,63.03,85.93,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,50268067415,NDC,,,facility,outpatient,1,EA,105.05000,30.46000,Aetna,First Health,,85.93,,,,,,,37.87,85.93,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,50268066615,NDC,,,facility,inpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,10.59,14.44,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,50268066615,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,6.36,14.44,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,50268066315,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,50268066315,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,50268065415,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,5.22,7.12,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,50268065415,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,50268065212,NDC,,,facility,inpatient,1,EA,23.90000,6.93000,Aetna,First Health,,19.55,,,,,,,14.34,19.55,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,50268065212,NDC,,,facility,outpatient,1,EA,23.90000,6.93000,Aetna,First Health,,19.55,,,,,,,8.62,19.55,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,50268064015,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,50268064015,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,50268063915,NDC,,,facility,inpatient,1,EA,28.50000,8.26000,Aetna,First Health,,23.31,,,,,,,17.10,23.31,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,50268063915,NDC,,,facility,outpatient,1,EA,28.50000,8.26000,Aetna,First Health,,23.31,,,,,,,10.27,23.31,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,50268063215,NDC,,,facility,inpatient,1,EA,45.75000,13.27000,Aetna,First Health,,37.42,,,,,,,27.45,37.42,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,50268063215,NDC,,,facility,outpatient,1,EA,45.75000,13.27000,Aetna,First Health,,37.42,,,,,,,16.49,37.42,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,50268063015,NDC,,,facility,inpatient,1,EA,26.30000,7.63000,Aetna,First Health,,21.51,,,,,,,15.78,21.51,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,50268063015,NDC,,,facility,outpatient,1,EA,26.30000,7.63000,Aetna,First Health,,21.51,,,,,,,9.48,21.51,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,50268062715,NDC,,,facility,inpatient,1,EA,21.75000,6.31000,Aetna,First Health,,17.79,,,,,,,13.05,17.79,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,50268062715,NDC,,,facility,outpatient,1,EA,21.75000,6.31000,Aetna,First Health,,17.79,,,,,,,7.84,17.79,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,50268062515,NDC,,,facility,inpatient,1,EA,30.35000,8.80000,Aetna,First Health,,24.83,,,,,,,18.21,24.83,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,50268062515,NDC,,,facility,outpatient,1,EA,30.35000,8.80000,Aetna,First Health,,24.83,,,,,,,10.94,24.83,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,50268062315,NDC,,,facility,inpatient,1,EA,31.30000,9.08000,Aetna,First Health,,25.60,,,,,,,18.78,25.60,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,50268062315,NDC,,,facility,outpatient,1,EA,31.30000,9.08000,Aetna,First Health,,25.60,,,,,,,11.28,25.60,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,50268061513,NDC,,,facility,inpatient,1,EA,98.95000,28.70000,Aetna,First Health,,80.94,,,,,,,59.37,80.94,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,50268061513,NDC,,,facility,outpatient,1,EA,98.95000,28.70000,Aetna,First Health,,80.94,,,,,,,35.67,80.94,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,50268060415,NDC,,,facility,inpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,2.52,3.44,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,50268060415,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,1.51,3.44,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,50268060315,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,50268060315,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,50268059715,NDC,,,facility,inpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,5.58,7.61,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,50268059715,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,50268059415,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,50268059415,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,50268058813,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,50268058813,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,50268057515,NDC,,,facility,inpatient,1,EA,35.25000,10.22000,Aetna,First Health,,28.83,,,,,,,21.15,28.83,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,50268057515,NDC,,,facility,outpatient,1,EA,35.25000,10.22000,Aetna,First Health,,28.83,,,,,,,12.71,28.83,percent of total billed charges,
Mupirocin 2% Top Oint 1g UD,800022088,CDM,637,RC,50268057260,NDC,,,facility,inpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,21.78,29.69,percent of total billed charges,
Mupirocin 2% Top Oint 1g UD,800022088,CDM,637,RC,50268057260,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,13.09,29.69,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,50268056215,NDC,,,facility,inpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,4.41,6.01,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,50268056215,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,2.65,6.01,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,50268055313,NDC,,,facility,inpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,8.28,11.29,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,50268055313,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,4.97,11.29,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,50268055015,NDC,,,facility,inpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,2.64,3.60,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,50268055015,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,50268054215,NDC,,,facility,inpatient,1,EA,11.85000,3.44000,Aetna,First Health,,9.69,,,,,,,7.11,9.69,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,50268054215,NDC,,,facility,outpatient,1,EA,11.85000,3.44000,Aetna,First Health,,9.69,,,,,,,4.27,9.69,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,50268054115,NDC,,,facility,inpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,4.68,6.38,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,50268054115,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,2.81,6.38,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,50268054015,NDC,,,facility,inpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,4.68,6.38,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,50268054015,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,2.81,6.38,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,50268053115,NDC,,,facility,inpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,5.67,7.73,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,50268053115,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,3.41,7.73,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,50268052715,NDC,facility,inpatient,2.5,ME,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,15.15,20.65,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,50268052715,NDC,facility,outpatient,2.5,ME,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,0.14445,20.65,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,50268052515,NDC,,,facility,inpatient,1,EA,21.95000,6.37000,Aetna,First Health,,17.96,,,,,,,13.17,17.96,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,50268052515,NDC,,,facility,outpatient,1,EA,21.95000,6.37000,Aetna,First Health,,17.96,,,,,,,7.91,17.96,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,50268052115,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,50268052115,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,50268052015,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,50268052015,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,50268050615,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,50268050615,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,50268050515,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,50268050515,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,50268050415,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,50268050415,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,50268047715,NDC,,,facility,inpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,25.50,34.77,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,50268047715,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,15.32,34.77,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,50268047013,NDC,,,facility,inpatient,1,EA,48.65000,14.11000,Aetna,First Health,,39.80,,,,,,,29.19,39.80,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,50268047013,NDC,,,facility,outpatient,1,EA,48.65000,14.11000,Aetna,First Health,,39.80,,,,,,,17.54,39.80,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,50268045115,NDC,,,facility,inpatient,1,EA,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,6.99,9.53,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,50268045115,NDC,,,facility,outpatient,1,EA,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,4.20,9.53,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,50268043015,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,50268043015,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,50268041112,NDC,,,facility,inpatient,1,EA,102.10000,29.61000,Aetna,First Health,,83.52,,,,,,,61.26,83.52,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,50268041112,NDC,,,facility,outpatient,1,EA,102.10000,29.61000,Aetna,First Health,,83.52,,,,,,,36.81,83.52,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,50268040815,NDC,,,facility,inpatient,1,EA,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,7.50,10.22,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,50268040815,NDC,,,facility,outpatient,1,EA,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,4.51,10.22,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,50268040515,NDC,,,facility,inpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,8.28,11.29,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,50268040515,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,4.97,11.29,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,50268040315,NDC,,,facility,inpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,4.77,6.50,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,50268040315,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,2.87,6.50,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,50268040115,NDC,,,facility,inpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,4.77,6.50,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,50268040115,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,2.87,6.50,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,50268039950,NDC,facility,inpatient,50,ME,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,50268039950,NDC,facility,outpatient,50,ME,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,0.21186,3.31,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,50268039850,NDC,facility,inpatient,25,ME,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,50268039850,NDC,facility,outpatient,25,ME,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,0.21186,3.31,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,50268035815,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,50268035815,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,50268035115,NDC,,,facility,inpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,10.11,13.78,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,50268035115,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.07,13.78,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,50268035015,NDC,,,facility,inpatient,1,EA,8.25000,2.39000,Aetna,First Health,,6.75,,,,,,,4.95,6.75,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,50268035015,NDC,,,facility,outpatient,1,EA,8.25000,2.39000,Aetna,First Health,,6.75,,,,,,,2.97,6.75,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,50268033715,NDC,,,facility,inpatient,1,EA,67.50000,19.58000,Aetna,First Health,,55.22,,,,,,,40.50,55.22,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,50268033715,NDC,,,facility,outpatient,1,EA,67.50000,19.58000,Aetna,First Health,,55.22,,,,,,,24.33,55.22,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,50268033015,NDC,,,facility,inpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,50268033015,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,50268032315,NDC,,,facility,inpatient,1,EA,22.30000,6.47000,Aetna,First Health,,18.24,,,,,,,13.38,18.24,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,50268032315,NDC,,,facility,outpatient,1,EA,22.30000,6.47000,Aetna,First Health,,18.24,,,,,,,8.04,18.24,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,50268032115,NDC,,,facility,inpatient,1,EA,42.30000,12.27000,Aetna,First Health,,34.60,,,,,,,25.38,34.60,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,50268032115,NDC,,,facility,outpatient,1,EA,42.30000,12.27000,Aetna,First Health,,34.60,,,,,,,15.25,34.60,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,50268031415,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,13.29,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,50268031415,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,50268031315,NDC,,,facility,inpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,21.78,29.69,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,50268031315,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,13.09,29.69,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,50268031215,NDC,,,facility,inpatient,1,EA,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,7.23,9.86,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,50268031215,NDC,,,facility,outpatient,1,EA,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,4.34,9.86,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,50268030613,NDC,,,facility,inpatient,1,EA,45.85000,13.30000,Aetna,First Health,,37.51,,,,,,,27.51,37.51,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,50268030613,NDC,,,facility,outpatient,1,EA,45.85000,13.30000,Aetna,First Health,,37.51,,,,,,,16.53,37.51,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,50268029915,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,50268029915,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,50268029812,NDC,,,facility,inpatient,1,EA,87.75000,25.45000,Aetna,First Health,,71.78,,,,,,,52.65,71.78,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,50268029812,NDC,,,facility,outpatient,1,EA,87.75000,25.45000,Aetna,First Health,,71.78,,,,,,,31.63,71.78,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,50268029515,NDC,,,facility,inpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,25.50,34.77,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,50268029515,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,15.32,34.77,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,50268028813,NDC,,,facility,inpatient,1,EA,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,25.17,34.32,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,50268028813,NDC,,,facility,outpatient,1,EA,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,15.12,34.32,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,50268028213,NDC,,,facility,inpatient,1,EA,42.80000,12.41000,Aetna,First Health,,35.01,,,,,,,25.68,35.01,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,50268028213,NDC,,,facility,outpatient,1,EA,42.80000,12.41000,Aetna,First Health,,35.01,,,,,,,15.43,35.01,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,50268027815,NDC,,,facility,inpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,16.98,23.15,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,50268027815,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,10.20,23.15,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,50268027013,NDC,,,facility,inpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,7.32,9.98,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,50268027013,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,4.40,9.98,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,50268026013,NDC,,,facility,inpatient,1,EA,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,6.99,9.53,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,50268026013,NDC,,,facility,outpatient,1,EA,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,4.20,9.53,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,50268025915,NDC,,,facility,inpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,2.64,3.60,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,50268025915,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,50268022015,NDC,,,facility,inpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,12.75,17.38,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,50268022015,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,7.66,17.38,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,50268019560,NDC,,,facility,inpatient,1,EA,70.45000,20.43000,Aetna,First Health,,57.63,,,,,,,26.07,57.63,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,50268019560,NDC,,,facility,outpatient,1,EA,70.45000,20.43000,Aetna,First Health,,57.63,,,,,,,25.40,57.63,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,50268019115,NDC,,,facility,inpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.90000,1.23,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,50268019115,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.54075,1.23,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,50268019015,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,5.22,7.12,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,50268019015,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,50268018915,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,50268018915,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,50268018715,NDC,,,facility,inpatient,1,EA,50.95000,14.78000,Aetna,First Health,,41.68,,,,,,,30.57,41.68,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,50268018715,NDC,,,facility,outpatient,1,EA,50.95000,14.78000,Aetna,First Health,,41.68,,,,,,,18.37,41.68,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,50268018412,NDC,,,facility,inpatient,1,EA,136.40000,39.56000,Aetna,First Health,,111.58,,,,,,,81.84,111.58,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,50268018412,NDC,,,facility,outpatient,1,EA,136.40000,39.56000,Aetna,First Health,,111.58,,,,,,,49.17,111.58,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,50268017715,NDC,,,facility,inpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,9.57,13.05,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,50268017715,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
clonazePAM 2mg T(KlonoPIN),800051122,CDM,637,RC,50268017515,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
clonazePAM 2mg T(KlonoPIN),800051122,CDM,637,RC,50268017515,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,50268017315,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,50268017315,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,50268016915,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,10.32,14.07,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,50268016915,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,50268016215,NDC,facility,inpatient,10,ME,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,21.84,29.78,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,50268016215,NDC,facility,outpatient,10,ME,36.40000,10.56000,Aetna,First Health,,29.78,,,,,,,2.07,29.78,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,50268015215,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,50268015215,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,50268014815,NDC,facility,inpatient,667,ME,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,7.44,10.14,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,50268014815,NDC,facility,outpatient,667,ME,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,0.03852,10.14,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,50268013015,NDC,,,facility,inpatient,1,EA,10.75000,3.12000,Aetna,First Health,,8.79,,,,,,,6.45,8.79,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,50268013015,NDC,,,facility,outpatient,1,EA,10.75000,3.12000,Aetna,First Health,,8.79,,,,,,,3.88,8.79,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,50268010615,NDC,,,facility,inpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,2.64,3.60,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,50268010615,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,50268009715,NDC,,,facility,inpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,31.56,43.03,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,50268009715,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,18.96,43.03,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,50268009315,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,50268009315,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,50268008415,NDC,,,facility,inpatient,1,EA,24.65000,7.15000,Aetna,First Health,,20.16,,,,,,,14.79,20.16,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,50268008415,NDC,,,facility,outpatient,1,EA,24.65000,7.15000,Aetna,First Health,,20.16,,,,,,,8.89,20.16,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,50268007515,NDC,,,facility,inpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,8.79,11.98,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,50268007515,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,5.28,11.98,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,50268007413,NDC,,,facility,inpatient,1,EA,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,5.34,7.28,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,50268007413,NDC,,,facility,outpatient,1,EA,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,3.21,7.28,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,50268005015,NDC,,,facility,inpatient,1,EA,12.60000,3.65000,Aetna,First Health,,10.31,,,,,,,7.56,10.31,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,50268005015,NDC,,,facility,outpatient,1,EA,12.60000,3.65000,Aetna,First Health,,10.31,,,,,,,4.54,10.31,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,50268003715,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,50268003715,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Atezolizumab 840mg- Pt Own Supply,800052010,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,840,ME,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05407,0.12270,percent of total billed charges,
Atezolizumab 840mg- Pt Own Supply,800052010,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,outpatient,840,ME,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05550,289.62,percent of total billed charges,
atezolizumab 1200 mg/20 mL Inj (Tecentriq),800062075,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,1200,ME,60946.75000,17674.56000,Aetna,First Health,,49854.44,,,,,,,21971.30,49854.44,percent of total billed charges,
atezolizumab 1200 mg/20 mL Inj (Tecentriq),800062075,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,outpatient,1200,ME,60946.75000,17674.56000,Aetna,First Health,,49854.44,,,,,,,90.44,49854.44,percent of total billed charges,
pertuz/trastuz/hyal 10mL I-Maint. Dose,800051992,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,inpatient,1,EA,66983.70000,19425.27000,Aetna,First Health,,54792.67,,,,,,,24147.62,54792.67,percent of total billed charges,
pertuz/trastuz/hyal 10mL I-Maint. Dose,800051992,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,outpatient,1,EA,66983.70000,19425.27000,Aetna,First Health,,54792.67,,,,,,,58.70,54792.67,percent of total billed charges,
omalizumab 300mg/2mL IS(Xolair),800051050,CDM,636,RC,J2357,HCPCS,50242022701,NDC,facility,inpatient,300,ME,11473.65000,3327.36000,Aetna,First Health,,9385.45,,,,,,,4136.25,9385.45,percent of total billed charges,
omalizumab 300mg/2mL IS(Xolair),800051050,CDM,636,RC,J2357,HCPCS,50242022701,NDC,facility,outpatient,300,ME,11473.65000,3327.36000,Aetna,First Health,,9385.45,,,,,,,43.82,9385.45,percent of total billed charges,
Omalizumab 150mg/mL IS(Xolair),800040913,CDM,636,RC,J2357,HCPCS,50242021503,NDC,facility,inpatient,150,ME,5831.80000,1691.22000,Aetna,First Health,,4770.41,,,,,,,2102.36,4770.41,percent of total billed charges,
Omalizumab 150mg/mL IS(Xolair),800040913,CDM,636,RC,J2357,HCPCS,50242021503,NDC,facility,outpatient,150,ME,5831.80000,1691.22000,Aetna,First Health,,4770.41,,,,,,,43.82,4770.41,percent of total billed charges,
Omalizumab 150mg/mL IS(Xolair),800040913,CDM,636,RC,J2357,HCPCS,50242021501,NDC,facility,inpatient,150,ME,5831.80000,1691.22000,Aetna,First Health,,4770.41,,,,,,,2102.36,4770.41,percent of total billed charges,
Omalizumab 150mg/mL IS(Xolair),800040913,CDM,636,RC,J2357,HCPCS,50242021501,NDC,facility,outpatient,150,ME,5831.80000,1691.22000,Aetna,First Health,,4770.41,,,,,,,43.82,4770.41,percent of total billed charges,
Omalizumab 75mg/0.5mL IS(Xolair),800040914,CDM,636,RC,J2357,HCPCS,50242021403,NDC,facility,inpatient,75,ME,3010.90000,873.16000,Aetna,First Health,,2462.92,,,,,,,1085.43,2462.92,percent of total billed charges,
Omalizumab 75mg/0.5mL IS(Xolair),800040914,CDM,636,RC,J2357,HCPCS,50242021403,NDC,facility,outpatient,75,ME,3010.90000,873.16000,Aetna,First Health,,2462.92,,,,,,,43.82,2462.92,percent of total billed charges,
Omalizumab 75mg/0.5mL IS(Xolair),800040914,CDM,636,RC,J2357,HCPCS,50242021401,NDC,facility,inpatient,75,ME,3010.90000,873.16000,Aetna,First Health,,2462.92,,,,,,,1085.43,2462.92,percent of total billed charges,
Omalizumab 75mg/0.5mL IS(Xolair),800040914,CDM,636,RC,J2357,HCPCS,50242021401,NDC,facility,outpatient,75,ME,3010.90000,873.16000,Aetna,First Health,,2462.92,,,,,,,43.82,2462.92,percent of total billed charges,
Ocrelizumab 300mg/10mL I(Ocrevus),800040862,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,inpatient,300,ME,148801.90000,43152.55000,Aetna,First Health,,121719.95,,,,,,,53643.08,121719.95,percent of total billed charges,
Ocrelizumab 300mg/10mL I(Ocrevus),800040862,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,300,ME,148801.90000,43152.55000,Aetna,First Health,,121719.95,,,,,,,57.13,121719.95,percent of total billed charges,
Ocrelizumab- Pt Own Supply,800040901,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,inpatient,300,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
Ocrelizumab- Pt Own Supply,800040901,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,outpatient,300,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,182.94,percent of total billed charges,
Pertuzumab 420 mg Inj- Pt Own Supply,800051015,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,inpatient,420,ME,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05407,0.12270,percent of total billed charges,
Pertuzumab 420 mg Inj- Pt Own Supply,800051015,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,420,ME,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05550,52.46,percent of total billed charges,
Pertuzumab 420 mg/14 mL I(Perjeta),800022005,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,inpatient,420,ME,37017.65000,10735.12000,Aetna,First Health,,30280.44,,,,,,,13344.86,30280.44,percent of total billed charges,
Pertuzumab 420 mg/14 mL I(Perjeta),800022005,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,outpatient,420,ME,37017.65000,10735.12000,Aetna,First Health,,30280.44,,,,,,,16.38,30280.44,percent of total billed charges,
tocilizumab- Pt Own Supply,800051984,CDM,636,RC,J3262,HCPCS,50242013501,NDC,facility,inpatient,80,ME,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
tocilizumab- Pt Own Supply,800051984,CDM,636,RC,J3262,HCPCS,50242013501,NDC,facility,outpatient,80,ME,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,17.30,percent of total billed charges,
Trastuzumab 150mg I(Herceptin),800022087,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,inpatient,150,ME,8602.45000,2494.71000,Aetna,First Health,,7036.80,,,,,,,3101.18,7036.80,percent of total billed charges,
Trastuzumab 150mg I(Herceptin),800022087,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,outpatient,150,ME,8602.45000,2494.71000,Aetna,First Health,,7036.80,,,,,,,70.76,7036.80,percent of total billed charges,
Tenecteplase 50mg Inj,800079383,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,inpatient,50,ME,33246.30000,9641.43000,Aetna,First Health,,27195.47,,,,,,,11985.29,27195.47,percent of total billed charges,
Tenecteplase 50mg Inj,800079383,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,outpatient,50,ME,33246.30000,9641.43000,Aetna,First Health,,27195.47,,,,,,,180.05,27195.47,percent of total billed charges,
polatuzumab vedotin - piiq 140mg I(Polivy),800051076,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,inpatient,140,ME,134189.15000,38914.85000,Aetna,First Health,,109766.72,,,,,,,48375.19,109766.72,percent of total billed charges,
polatuzumab vedotin - piiq 140mg I(Polivy),800051076,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,outpatient,140,ME,134189.15000,38914.85000,Aetna,First Health,,109766.72,,,,,,,131.71,109766.72,percent of total billed charges,
polatuzumab vedotin - piiq 30mg I(Polivy),800051075,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,inpatient,30,ME,28901.80000,8381.52000,Aetna,First Health,,23641.67,,,,,,,10419.10,23641.67,percent of total billed charges,
polatuzumab vedotin - piiq 30mg I(Polivy),800051075,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,outpatient,30,ME,28901.80000,8381.52000,Aetna,First Health,,23641.67,,,,,,,131.71,23641.67,percent of total billed charges,
Dornase Alfa 2.5mg/2.5mL Inhl UD,800012141,CDM,250,RC,J7639,HCPCS,50242010040,NDC,facility,inpatient,2.5,ME,703.20000,203.93000,Aetna,First Health,,575.22,,,,,,,260.18,575.22,percent of total billed charges,
Dornase Alfa 2.5mg/2.5mL Inhl UD,800012141,CDM,250,RC,J7639,HCPCS,50242010040,NDC,facility,outpatient,2.5,ME,703.20000,203.93000,Aetna,First Health,,575.22,,,,,,,53.12,575.22,percent of total billed charges,
Dornase Alfa 2.5mg/2.5mL Inhl UD,800012141,CDM,250,RC,J7639,HCPCS,50242010039,NDC,facility,inpatient,2.5,ME,502.60000,145.75000,Aetna,First Health,,411.13,,,,,,,185.96,411.13,percent of total billed charges,
Dornase Alfa 2.5mg/2.5mL Inhl UD,800012141,CDM,250,RC,J7639,HCPCS,50242010039,NDC,facility,outpatient,2.5,ME,502.60000,145.75000,Aetna,First Health,,411.13,,,,,,,53.12,411.13,percent of total billed charges,
riTUXimab 100mg/10mL I,800074699,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,inpatient,100,ME,6951.55000,2015.95000,Aetna,First Health,,5686.37,,,,,,,2506.03,5686.37,percent of total billed charges,
riTUXimab 100mg/10mL I,800074699,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,100,ME,6951.55000,2015.95000,Aetna,First Health,,5686.37,,,,,,,72.00,5686.37,percent of total billed charges,
RiTUXimab 500mg/50mL I,800074707,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,inpatient,500,ME,34009.70000,9862.81000,Aetna,First Health,,27819.93,,,,,,,12260.50,27819.93,percent of total billed charges,
RiTUXimab 500mg/50mL I,800074707,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,outpatient,500,ME,34009.70000,9862.81000,Aetna,First Health,,27819.93,,,,,,,72.00,27819.93,percent of total billed charges,
riTUXimab 100mg/10mL I,800074699,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,inpatient,100,ME,6951.55000,2015.95000,Aetna,First Health,,5686.37,,,,,,,2506.03,5686.37,percent of total billed charges,
riTUXimab 100mg/10mL I,800074699,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,outpatient,100,ME,6951.55000,2015.95000,Aetna,First Health,,5686.37,,,,,,,72.00,5686.37,percent of total billed charges,
Alteplase 2mg/2mL I(Cathflo),800010875,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,inpatient,2,ME,1520.20000,440.86000,Aetna,First Health,,1243.52,,,,,,,548.03,1243.52,percent of total billed charges,
Alteplase 2mg/2mL I(Cathflo),800010875,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,outpatient,2,ME,1520.20000,440.86000,Aetna,First Health,,1243.52,,,,,,,90.36,1243.52,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,50228048201,NDC,,,facility,inpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,6.66,9.08,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,50228048201,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,4.00,9.08,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,50228048101,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,50228048101,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,50228046101,NDC,,,facility,inpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,7.68,10.47,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,50228046101,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,4.61,10.47,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,50228046001,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,50228046001,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,50228045701,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,50228045701,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,50228037930,NDC,,,facility,inpatient,1,EA,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,50228037930,NDC,,,facility,outpatient,1,EA,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,28.84,65.44,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,50228017501,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,50228017501,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,50228010901,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,50228010901,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,50111099001,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,50111099001,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,50111091701,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,50111091701,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,50111091501,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,50111091501,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,50111085201,NDC,,,facility,inpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,3.75,5.11,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,50111085201,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,50111085101,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,50111085101,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,50111079320,NDC,,,facility,inpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,49.38,67.32,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,50111079320,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,29.67,67.32,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,50111078710,NDC,,,facility,inpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,33.06,45.07,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,50111078710,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,19.86,45.07,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,50111065201,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,4.05,5.52,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,50111065201,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,50111064801,NDC,,,facility,inpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,11.34,15.46,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,50111064801,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,6.81,15.46,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,50111064701,NDC,,,facility,inpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,11.04,15.05,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,50111064701,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,6.63,15.05,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,50111060801,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,50111060801,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,50111056301,NDC,,,facility,inpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,4.86,6.63,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,50111056301,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,2.92,6.63,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,50111056101,NDC,,,facility,inpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,5.91,8.06,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,50111056101,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,3.55,8.06,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,50111056001,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,50111056001,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,50111053402,NDC,,,facility,inpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,1.50,2.04,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,50111053402,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,0.90125,2.04,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,50111053401,NDC,,,facility,inpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,1.50,2.04,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,50111053401,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,0.90125,2.04,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,50111051702,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,50111051702,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,50111051701,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,50111051701,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,50111046801,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,50111046801,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,50111046701,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,50111046701,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,50111045602,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,50111045602,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,50111045601,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,50111045601,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,50111043402,NDC,,,facility,inpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,5.61,7.65,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,50111043402,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,3.37,7.65,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,50111043401,NDC,,,facility,inpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,5.91,8.06,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,50111043401,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,3.55,8.06,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,50111043301,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,50111043301,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,50111039801,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,50111039801,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,50111039301,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,50111039301,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,50111033402,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,50111033402,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,50111033401,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,50111033401,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,50111032801,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,50111032801,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,50111032701,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,50111032701,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,50111032401,NDC,,,facility,inpatient,1,EA,14.20000,4.12000,Aetna,First Health,,11.62,,,,,,,8.52,11.62,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,50111032401,NDC,,,facility,outpatient,1,EA,14.20000,4.12000,Aetna,First Health,,11.62,,,,,,,5.12,11.62,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,50111031401,NDC,,,facility,inpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.80,2.45,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,50111031401,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.08,2.45,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,50111030801,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,50111030801,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,50102059140,NDC,facility,inpatient,150,ME,496.75000,144.06000,Aetna,First Health,,406.34,,,,,,,179.08,406.34,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,50102059140,NDC,facility,outpatient,150,ME,496.75000,144.06000,Aetna,First Health,,406.34,,,,,,,0.40446,406.34,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,49938010130,NDC,,,facility,inpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,14.28,19.47,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,49938010130,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,8.58,19.47,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,49938010101,NDC,,,facility,inpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,12.75,17.38,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,49938010101,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,7.66,17.38,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,49884092101,NDC,,,facility,inpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,3.18,4.34,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,49884092101,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,1.91,4.34,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,49884090738,NDC,,,facility,inpatient,1,EA,42.45000,12.31000,Aetna,First Health,,34.72,,,,,,,25.47,34.72,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,49884090738,NDC,,,facility,outpatient,1,EA,42.45000,12.31000,Aetna,First Health,,34.72,,,,,,,15.30,34.72,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,49884083209,NDC,,,facility,inpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,11.28,15.38,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,49884083209,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,49884083011,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,49884083011,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,49884083009,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,49884083009,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,49884082911,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,49884082911,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,49884082909,NDC,,,facility,inpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,5.10,6.95,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,49884082909,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,3.06,6.95,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,49884078353,NDC,,,facility,inpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,6.21,8.47,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,49884078353,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,3.73,8.47,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,49884078253,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,49884078253,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,49884077901,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,49884077901,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,49884077805,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,49884077805,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,49884077686,NDC,,,facility,inpatient,1,EA,449.10000,130.24000,Aetna,First Health,,367.36,,,,,,,269.46,367.36,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,49884077686,NDC,,,facility,outpatient,1,EA,449.10000,130.24000,Aetna,First Health,,367.36,,,,,,,161.90,367.36,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,49884077586,NDC,,,facility,inpatient,1,EA,334.10000,96.89000,Aetna,First Health,,273.29,,,,,,,200.46,273.29,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,49884077586,NDC,,,facility,outpatient,1,EA,334.10000,96.89000,Aetna,First Health,,273.29,,,,,,,120.44,273.29,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,49884077101,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,49884077101,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,49884076854,NDC,,,facility,inpatient,1,EA,3138.85000,910.27000,Aetna,First Health,,2567.58,,,,,,,1883.31,2567.58,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,49884076854,NDC,,,facility,outpatient,1,EA,3138.85000,910.27000,Aetna,First Health,,2567.58,,,,,,,1131.56,2567.58,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,49884076478,NDC,,,facility,inpatient,1,EA,469.95000,136.29000,Aetna,First Health,,384.42,,,,,,,281.97,384.42,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,49884076478,NDC,,,facility,outpatient,1,EA,469.95000,136.29000,Aetna,First Health,,384.42,,,,,,,169.42,384.42,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,49884076378,NDC,,,facility,inpatient,1,EA,361.70000,104.89000,Aetna,First Health,,295.87,,,,,,,217.02,295.87,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,49884076378,NDC,,,facility,outpatient,1,EA,361.70000,104.89000,Aetna,First Health,,295.87,,,,,,,130.39,295.87,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,49884076278,NDC,,,facility,inpatient,1,EA,241.60000,70.06000,Aetna,First Health,,197.63,,,,,,,144.96,197.63,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,49884076278,NDC,,,facility,outpatient,1,EA,241.60000,70.06000,Aetna,First Health,,197.63,,,,,,,87.10,197.63,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,49884076178,NDC,,,facility,inpatient,1,EA,133.20000,38.63000,Aetna,First Health,,108.96,,,,,,,79.92,108.96,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,49884076178,NDC,,,facility,outpatient,1,EA,133.20000,38.63000,Aetna,First Health,,108.96,,,,,,,48.02,108.96,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,49884075101,NDC,,,facility,inpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,11.34,15.46,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,49884075101,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,6.81,15.46,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,49884072703,NDC,,,facility,inpatient,1,EA,16.75000,4.86000,Aetna,First Health,,13.70,,,,,,,10.05,13.70,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,49884072703,NDC,,,facility,outpatient,1,EA,16.75000,4.86000,Aetna,First Health,,13.70,,,,,,,6.04,13.70,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,49884072401,NDC,,,facility,inpatient,1,EA,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,5.43,7.40,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,49884072401,NDC,,,facility,outpatient,1,EA,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,3.26,7.40,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,49884070801,NDC,,,facility,inpatient,1,EA,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,49884070801,NDC,,,facility,outpatient,1,EA,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,49884070701,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,49884070701,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,49884069501,NDC,,,facility,inpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,11.61,15.83,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,49884069501,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,6.98,15.83,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,49884067701,NDC,,,facility,inpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,5.91,8.06,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,49884067701,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,3.55,8.06,percent of total billed charges,
Cabergoline 0.5 mg Tab,800017393,CDM,637,RC,J8515,HCPCS,49884067314,NDC,facility,inpatient,0.5,ME,242.75000,70.40000,Aetna,First Health,,198.57,,,,,,,145.65,198.57,percent of total billed charges,
Cabergoline 0.5 mg Tab,800017393,CDM,637,RC,J8515,HCPCS,49884067314,NDC,facility,outpatient,0.5,ME,242.75000,70.40000,Aetna,First Health,,198.57,,,,,,,17.65,198.57,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,49884065301,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,49884065301,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,49884065101,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,49884065101,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,49884064901,NDC,,,facility,inpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,5.52,7.53,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,49884064901,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,3.32,7.53,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,49884064101,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,49884064101,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,49884064001,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,49884064001,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,49884060810,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,49884060810,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,49884060801,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,49884060801,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,49884060301,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,49884060301,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,49884060085,NDC,,,facility,inpatient,1,EA,5056.40000,1466.36000,Aetna,First Health,,4136.14,,,,,,,3033.84,4136.14,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,49884060085,NDC,,,facility,outpatient,1,EA,5056.40000,1466.36000,Aetna,First Health,,4136.14,,,,,,,1822.83,4136.14,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,49884058701,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,5.22,7.12,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,49884058701,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,49884057201,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,3.69,5.03,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,49884057201,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,49884056001,NDC,,,facility,inpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,6.60,9.00,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,49884056001,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,3.97,9.00,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,49884055801,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,49884055801,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,49884051401,NDC,,,facility,inpatient,1,EA,16.30000,4.73000,Aetna,First Health,,13.33,,,,,,,9.78,13.33,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,49884051401,NDC,,,facility,outpatient,1,EA,16.30000,4.73000,Aetna,First Health,,13.33,,,,,,,5.88,13.33,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,49884050101,NDC,,,facility,inpatient,1,EA,133.40000,38.69000,Aetna,First Health,,109.12,,,,,,,80.04,109.12,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,49884050101,NDC,,,facility,outpatient,1,EA,133.40000,38.69000,Aetna,First Health,,109.12,,,,,,,48.09,109.12,percent of total billed charges,
LamoTRIgine 25mg ODT,800046462,CDM,637,RC,49884048411,NDC,,,facility,inpatient,1,EA,62.85000,18.23000,Aetna,First Health,,51.41,,,,,,,37.71,51.41,percent of total billed charges,
LamoTRIgine 25mg ODT,800046462,CDM,637,RC,49884048411,NDC,,,facility,outpatient,1,EA,62.85000,18.23000,Aetna,First Health,,51.41,,,,,,,22.66,51.41,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,49884042411,NDC,,,facility,inpatient,1,EA,52.95000,15.36000,Aetna,First Health,,43.31,,,,,,,31.77,43.31,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,49884042411,NDC,,,facility,outpatient,1,EA,52.95000,15.36000,Aetna,First Health,,43.31,,,,,,,19.09,43.31,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,49884040601,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,49884040601,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,49884040501,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,49884040501,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,49884040401,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,49884040401,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,49884032801,NDC,,,facility,inpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,6.60,9.00,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,49884032801,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,3.97,9.00,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,49884032055,NDC,,,facility,inpatient,1,EA,101.05000,29.30000,Aetna,First Health,,82.66,,,,,,,60.63,82.66,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,49884032055,NDC,,,facility,outpatient,1,EA,101.05000,29.30000,Aetna,First Health,,82.66,,,,,,,36.43,82.66,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),800015397,CDM,637,RC,49884030702,NDC,,,facility,inpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,6.24,8.51,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),800015397,CDM,637,RC,49884030702,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,49884028201,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,49884028201,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,49884027101,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,49884027101,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,49884025701,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,49884025701,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,49884025601,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,49884025601,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,49884023537,NDC,,,facility,inpatient,1,EA,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,16.05,21.88,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,49884023537,NDC,,,facility,outpatient,1,EA,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,9.64,21.88,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,49884023533,NDC,,,facility,inpatient,1,EA,26.05000,7.55000,Aetna,First Health,,21.31,,,,,,,15.63,21.31,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,49884023533,NDC,,,facility,outpatient,1,EA,26.05000,7.55000,Aetna,First Health,,21.31,,,,,,,9.39,21.31,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),800017683,CDM,637,RC,49884021102,NDC,,,facility,inpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,42.48,57.91,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),800017683,CDM,637,RC,49884021102,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,49884021002,NDC,,,facility,inpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,42.48,57.91,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,49884021002,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,49884016401,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,49884016401,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,49884016111,NDC,,,facility,inpatient,1,EA,751.45000,217.92000,Aetna,First Health,,614.69,,,,,,,450.87,614.69,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,49884016111,NDC,,,facility,outpatient,1,EA,751.45000,217.92000,Aetna,First Health,,614.69,,,,,,,270.90,614.69,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,49884012201,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,49884012201,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,49884011302,NDC,,,facility,inpatient,1,EA,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,33.54,45.73,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,49884011302,NDC,,,facility,outpatient,1,EA,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,20.15,45.73,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,49884010601,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,49884010601,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,49884009902,NDC,,,facility,inpatient,1,EA,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,33.54,45.73,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,49884009902,NDC,,,facility,outpatient,1,EA,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,20.15,45.73,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,49884008701,NDC,facility,inpatient,4,ME,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,49884008701,NDC,facility,outpatient,4,ME,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.00963,0.77710,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,49884006501,NDC,,,facility,inpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,5.58,7.61,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,49884006501,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,49884002801,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,49884002801,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,49884002701,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,49884002701,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,49884002101,NDC,,,facility,inpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,4.59,6.26,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,49884002101,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
Abacavir/Dolut/Lamiv 600-50-300mg T,800040898,CDM,637,RC,49702023113,NDC,,,facility,inpatient,1,EA,959.90000,278.37000,Aetna,First Health,,785.20,,,,,,,575.94,785.20,percent of total billed charges,
Abacavir/Dolut/Lamiv 600-50-300mg T,800040898,CDM,637,RC,49702023113,NDC,,,facility,outpatient,1,EA,959.90000,278.37000,Aetna,First Health,,785.20,,,,,,,346.04,785.20,percent of total billed charges,
Dolutegravir 50mg Tab,800040863,CDM,637,RC,49702022813,NDC,,,facility,inpatient,1,EA,605.50000,175.60000,Aetna,First Health,,495.30,,,,,,,363.30,495.30,percent of total billed charges,
Dolutegravir 50mg Tab,800040863,CDM,637,RC,49702022813,NDC,,,facility,outpatient,1,EA,605.50000,175.60000,Aetna,First Health,,495.30,,,,,,,218.28,495.30,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,49669521302,NDC,facility,inpatient,12.5,GM,18337.00000,5317.73000,Aetna,First Health,,14999.67,,,,,,,6610.49,14999.67,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,49669521302,NDC,facility,outpatient,12.5,GM,18337.00000,5317.73000,Aetna,First Health,,14999.67,,,,,,,51.12,14999.67,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,49669521101,NDC,facility,inpatient,12.5,GM,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,240.81,546.42,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,49669521101,NDC,facility,outpatient,12.5,GM,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,51.12,546.42,percent of total billed charges,
EPINEPHrine 0.15mg Syringe,800019822,CDM,636,RC,J0165,HCPCS,49502050102,NDC,facility,inpatient,0.15,ME,1402.35000,406.68000,Aetna,First Health,,1147.12,,,,,,,505.55,1147.12,percent of total billed charges,
EPINEPHrine 0.15mg Syringe,800019822,CDM,636,RC,J0165,HCPCS,49502050102,NDC,facility,outpatient,0.15,ME,1402.35000,406.68000,Aetna,First Health,,1147.12,,,,,,,0.41409,1147.12,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,49502050002,NDC,facility,inpatient,0.3,ME,1402.35000,406.68000,Aetna,First Health,,1147.12,,,,,,,505.55,1147.12,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,49502050002,NDC,facility,outpatient,0.3,ME,1402.35000,406.68000,Aetna,First Health,,1147.12,,,,,,,0.41409,1147.12,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,49502050001,NDC,facility,inpatient,0.3,ME,468.65000,135.91000,Aetna,First Health,,383.36,,,,,,,168.95,383.36,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,49502050001,NDC,facility,outpatient,0.3,ME,468.65000,135.91000,Aetna,First Health,,383.36,,,,,,,0.41409,383.36,percent of total billed charges,
Poractant 240mg/3mL Intratrach Inj,800017811,CDM,252,RC,49502018003,NDC,,,facility,inpatient,1,EA,2802.55000,812.74000,Aetna,First Health,,2292.49,,,,,,,1036.94,2292.49,percent of total billed charges,
Poractant 240mg/3mL Intratrach Inj,800017811,CDM,252,RC,49502018003,NDC,,,facility,outpatient,1,EA,2802.55000,812.74000,Aetna,First Health,,2292.49,,,,,,,1010.32,2292.49,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,49502010202,NDC,facility,inpatient,0.3,ME,806.25000,233.81000,Aetna,First Health,,659.51,,,,,,,290.65,659.51,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,49502010202,NDC,facility,outpatient,0.3,ME,806.25000,233.81000,Aetna,First Health,,659.51,,,,,,,0.41409,659.51,percent of total billed charges,
EPINEPHrine 0.15mg Syringe,800019822,CDM,636,RC,J0165,HCPCS,49502010102,NDC,facility,inpatient,0.15,ME,806.25000,233.81000,Aetna,First Health,,659.51,,,,,,,290.65,659.51,percent of total billed charges,
EPINEPHrine 0.15mg Syringe,800019822,CDM,636,RC,J0165,HCPCS,49502010102,NDC,facility,outpatient,0.15,ME,806.25000,233.81000,Aetna,First Health,,659.51,,,,,,,0.41409,659.51,percent of total billed charges,
Bismuth Subgallate Pwd,800068840,CDM,250,RC,49452115501,NDC,,,facility,inpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,7.09,15.66,percent of total billed charges,
Bismuth Subgallate Pwd,800068840,CDM,250,RC,49452115501,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
belimumab 400mg REC Inj (Benlysta),800051111,CDM,636,RC,J0490,HCPCS,49401010201,NDC,facility,inpatient,400,ME,11840.25000,3433.67000,Aetna,First Health,,9685.32,,,,,,,4268.41,9685.32,percent of total billed charges,
belimumab 400mg REC Inj (Benlysta),800051111,CDM,636,RC,J0490,HCPCS,49401010201,NDC,facility,outpatient,400,ME,11840.25000,3433.67000,Aetna,First Health,,9685.32,,,,,,,55.05,9685.32,percent of total billed charges,
belimumab 120mg REC Inj(Benlysta),800051110,CDM,636,RC,J0490,HCPCS,49401010101,NDC,facility,inpatient,120,ME,3683.25000,1068.14000,Aetna,First Health,,3012.90,,,,,,,1327.81,3012.90,percent of total billed charges,
belimumab 120mg REC Inj(Benlysta),800051110,CDM,636,RC,J0490,HCPCS,49401010101,NDC,facility,outpatient,120,ME,3683.25000,1068.14000,Aetna,First Health,,3012.90,,,,,,,55.05,3012.90,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,49281075222,NDC,facility,inpatient,5,UN,54.85000,15.91000,Aetna,First Health,,44.87,,,,,,,19.77,44.87,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,49281075222,NDC,facility,outpatient,5,UN,54.85000,15.91000,Aetna,First Health,,44.87,,,,,,,9.58,65.38,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,49281075221,NDC,facility,inpatient,5,UN,70.35000,20.40000,Aetna,First Health,,57.55,,,,,,,25.36,57.55,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,49281075221,NDC,facility,outpatient,5,UN,70.35000,20.40000,Aetna,First Health,,57.55,,,,,,,9.58,65.38,percent of total billed charges,
nirsevimab - alip 50mg/0.5mL PF IS,800051021,CDM,636,RC,90380,HCPCS,49281057515,NDC,facility,inpatient,50,ME,2405.65000,697.64000,Aetna,First Health,,1967.82,,,,,,,867.24,1967.82,percent of total billed charges,
nirsevimab - alip 50mg/0.5mL PF IS,800051021,CDM,636,RC,90380,HCPCS,49281057515,NDC,facility,outpatient,50,ME,2405.65000,697.64000,Aetna,First Health,,1967.82,,,,,,,600.62,1967.82,percent of total billed charges,
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,49281054505,NDC,facility,inpatient,1,EA,180.00000,52.20000,Aetna,First Health,,147.24,,,,,,,64.89,147.24,percent of total billed charges,
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,49281054505,NDC,facility,outpatient,1,EA,180.00000,52.20000,Aetna,First Health,,147.24,,,,,,,14.65,147.24,percent of total billed charges,
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281029110,NDC,facility,inpatient,1,EA,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,55.88,126.79,percent of total billed charges,
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281029110,NDC,facility,outpatient,1,EA,155.00000,44.95000,Aetna,First Health,,126.79,,,,,,,37.53,126.79,percent of total billed charges,
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281021515,NDC,facility,inpatient,1,EA,245.70000,71.25000,Aetna,First Health,,200.98,,,,,,,88.57,200.98,percent of total billed charges,
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281021515,NDC,facility,outpatient,1,EA,245.70000,71.25000,Aetna,First Health,,200.98,,,,,,,37.53,200.98,percent of total billed charges,
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281021510,NDC,facility,inpatient,1,EA,245.70000,71.25000,Aetna,First Health,,200.98,,,,,,,88.57,200.98,percent of total billed charges,
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281021510,NDC,facility,outpatient,1,EA,245.70000,71.25000,Aetna,First Health,,200.98,,,,,,,37.53,200.98,percent of total billed charges,
"Influenza Virus Vaccine, Inact High-Dose-Trivalent PF Inj",800051127,CDM,636,RC,90662,HCPCS,49281012465,NDC,facility,inpatient,1,EA,420.65000,121.99000,Aetna,First Health,,344.09,,,,,,,151.64,344.09,percent of total billed charges,
"Influenza Virus Vaccine, Inact High-Dose-Trivalent PF Inj",800051127,CDM,636,RC,90662,HCPCS,49281012465,NDC,facility,outpatient,1,EA,420.65000,121.99000,Aetna,First Health,,344.09,,,,,,,94.53,344.09,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,49230064021,NDC,facility,inpatient,667,ME,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,3.57,4.87,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,49230064021,NDC,facility,outpatient,667,ME,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,0.03852,4.87,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,800025528,CDM,637,RC,48878062001,NDC,,,facility,inpatient,1,EA,45.05000,13.06000,Aetna,First Health,,36.85,,,,,,,27.03,36.85,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,800025528,CDM,637,RC,48878062001,NDC,,,facility,outpatient,1,EA,45.05000,13.06000,Aetna,First Health,,36.85,,,,,,,16.24,36.85,percent of total billed charges,
Ferric Subsulfate 8mL TS(Monsel's),800021997,CDM,637,RC,48783011208,NDC,,,facility,inpatient,1,EA,99.90000,28.97000,Aetna,First Health,,81.72,,,,,,,59.94,81.72,percent of total billed charges,
Ferric Subsulfate 8mL TS(Monsel's),800021997,CDM,637,RC,48783011208,NDC,,,facility,outpatient,1,EA,99.90000,28.97000,Aetna,First Health,,81.72,,,,,,,36.01,81.72,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,48582051201,NDC,,,facility,inpatient,1,EA,74.60000,21.63000,Aetna,First Health,,61.02,,,,,,,27.60,61.02,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,48582051201,NDC,,,facility,outpatient,1,EA,74.60000,21.63000,Aetna,First Health,,61.02,,,,,,,26.89,61.02,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,800066885,CDM,250,RC,48433023015,NDC,,,facility,inpatient,1,EA,319.40000,92.63000,Aetna,First Health,,261.27,,,,,,,118.18,261.27,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,800066885,CDM,250,RC,48433023015,NDC,,,facility,outpatient,1,EA,319.40000,92.63000,Aetna,First Health,,261.27,,,,,,,115.14,261.27,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,48433021740,NDC,,,facility,inpatient,1,EA,67.95000,19.71000,Aetna,First Health,,55.58,,,,,,,40.77,55.58,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,48433021740,NDC,,,facility,outpatient,1,EA,67.95000,19.71000,Aetna,First Health,,55.58,,,,,,,24.50,55.58,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,48102005711,NDC,,,facility,inpatient,1,EA,83.25000,24.14000,Aetna,First Health,,68.10,,,,,,,49.95,68.10,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,48102005711,NDC,,,facility,outpatient,1,EA,83.25000,24.14000,Aetna,First Health,,68.10,,,,,,,30.01,68.10,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,48102004720,NDC,facility,inpatient,4,ME,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,48102004720,NDC,facility,outpatient,4,ME,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,0.00963,6.99,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,48102000811,NDC,,,facility,inpatient,1,EA,61.55000,17.85000,Aetna,First Health,,50.35,,,,,,,36.93,50.35,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,48102000811,NDC,,,facility,outpatient,1,EA,61.55000,17.85000,Aetna,First Health,,50.35,,,,,,,22.19,50.35,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,48102000335,NDC,,,facility,inpatient,1,EA,141.45000,41.02000,Aetna,First Health,,115.71,,,,,,,84.87,115.71,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,48102000335,NDC,,,facility,outpatient,1,EA,141.45000,41.02000,Aetna,First Health,,115.71,,,,,,,50.99,115.71,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,47781091451,NDC,facility,inpatient,4,ME,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,47781091451,NDC,facility,outpatient,4,ME,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,0.00963,6.99,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,47781060191,NDC,,,facility,inpatient,1,EA,186.25000,54.01000,Aetna,First Health,,152.35,,,,,,,68.91,152.35,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,47781060191,NDC,,,facility,outpatient,1,EA,186.25000,54.01000,Aetna,First Health,,152.35,,,,,,,67.14,152.35,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,47781059791,NDC,facility,inpatient,1,GM,57.50000,16.67000,Aetna,First Health,,47.03,,,,,,,20.73,47.03,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,47781059791,NDC,facility,outpatient,1,GM,57.50000,16.67000,Aetna,First Health,,47.03,,,,,,,0.02889,47.03,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,47781059507,NDC,facility,inpatient,6,ME,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,3.10,7.03,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,47781059507,NDC,facility,outpatient,6,ME,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,0.09630,7.03,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,47781059307,NDC,facility,inpatient,6,ME,16.40000,4.76000,Aetna,First Health,,13.42,,,,,,,5.91,13.42,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,47781059307,NDC,facility,outpatient,6,ME,16.40000,4.76000,Aetna,First Health,,13.42,,,,,,,0.09630,13.42,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,47781058717,NDC,,,facility,inpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.31,5.11,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,47781058717,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,47781058629,NDC,facility,inpatient,100,ME,73.15000,21.21000,Aetna,First Health,,59.84,,,,,,,27.07,59.84,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,47781058629,NDC,facility,outpatient,100,ME,73.15000,21.21000,Aetna,First Health,,59.84,,,,,,,0.33705,59.84,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,47781058468,NDC,facility,inpatient,30,ME,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,47781058468,NDC,facility,outpatient,30,ME,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,0.31779,5.85,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,47781058368,NDC,facility,inpatient,15,ME,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,47781058368,NDC,facility,outpatient,15,ME,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,0.31779,5.48,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,47781057807,NDC,facility,inpatient,500,ME,3059.80000,887.34000,Aetna,First Health,,2502.92,,,,,,,1103.06,2502.92,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,47781057807,NDC,facility,outpatient,500,ME,3059.80000,887.34000,Aetna,First Health,,2502.92,,,,,,,55.86,2502.92,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,47781042847,NDC,,,facility,inpatient,1,EA,589.00000,170.81000,Aetna,First Health,,481.80,,,,,,,353.40,481.80,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,47781042847,NDC,,,facility,outpatient,1,EA,589.00000,170.81000,Aetna,First Health,,481.80,,,,,,,212.33,481.80,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,47781042747,NDC,,,facility,inpatient,1,EA,453.15000,131.41000,Aetna,First Health,,370.68,,,,,,,271.89,370.68,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,47781042747,NDC,,,facility,outpatient,1,EA,453.15000,131.41000,Aetna,First Health,,370.68,,,,,,,163.36,370.68,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,47781042647,NDC,,,facility,inpatient,1,EA,304.60000,88.33000,Aetna,First Health,,249.16,,,,,,,182.76,249.16,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,47781042647,NDC,,,facility,outpatient,1,EA,304.60000,88.33000,Aetna,First Health,,249.16,,,,,,,109.81,249.16,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,47781042447,NDC,,,facility,inpatient,1,EA,170.15000,49.34000,Aetna,First Health,,139.18,,,,,,,102.09,139.18,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,47781042447,NDC,,,facility,outpatient,1,EA,170.15000,49.34000,Aetna,First Health,,139.18,,,,,,,61.34,139.18,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,47781042347,NDC,,,facility,inpatient,1,EA,162.40000,47.10000,Aetna,First Health,,132.84,,,,,,,97.44,132.84,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,47781042347,NDC,,,facility,outpatient,1,EA,162.40000,47.10000,Aetna,First Health,,132.84,,,,,,,58.55,132.84,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,47781033431,NDC,,,facility,inpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,12.84,17.51,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,47781033431,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,7.71,17.51,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,47781030701,NDC,,,facility,inpatient,1,EA,16.10000,4.67000,Aetna,First Health,,13.17,,,,,,,9.66,13.17,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,47781030701,NDC,,,facility,outpatient,1,EA,16.10000,4.67000,Aetna,First Health,,13.17,,,,,,,5.80,13.17,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,47781030503,NDC,,,facility,inpatient,1,EA,114.70000,33.26000,Aetna,First Health,,93.82,,,,,,,68.82,93.82,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,47781030503,NDC,,,facility,outpatient,1,EA,114.70000,33.26000,Aetna,First Health,,93.82,,,,,,,41.35,93.82,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,47781030403,NDC,,,facility,inpatient,1,EA,114.70000,33.26000,Aetna,First Health,,93.82,,,,,,,68.82,93.82,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,47781030403,NDC,,,facility,outpatient,1,EA,114.70000,33.26000,Aetna,First Health,,93.82,,,,,,,41.35,93.82,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,47781030301,NDC,,,facility,inpatient,1,EA,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,16.20,22.09,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,47781030301,NDC,,,facility,outpatient,1,EA,27.00000,7.83000,Aetna,First Health,,22.09,,,,,,,9.73,22.09,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,47781020904,NDC,,,facility,inpatient,1,EA,156.45000,45.37000,Aetna,First Health,,127.98,,,,,,,93.87,127.98,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,47781020904,NDC,,,facility,outpatient,1,EA,156.45000,45.37000,Aetna,First Health,,127.98,,,,,,,56.40,127.98,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,47781020604,NDC,,,facility,inpatient,1,EA,156.45000,45.37000,Aetna,First Health,,127.98,,,,,,,93.87,127.98,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,47781020604,NDC,,,facility,outpatient,1,EA,156.45000,45.37000,Aetna,First Health,,127.98,,,,,,,56.40,127.98,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,47781017901,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,47781017901,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,47781017801,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,47781017801,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,47781017401,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,47781017401,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,47781010444,NDC,,,facility,inpatient,1,EA,2010.55000,583.06000,Aetna,First Health,,1644.63,,,,,,,1206.33,1644.63,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,47781010444,NDC,,,facility,outpatient,1,EA,2010.55000,583.06000,Aetna,First Health,,1644.63,,,,,,,724.80,1644.63,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,47781001101,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,47781001101,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,47335099301,NDC,facility,inpatient,500,ME,27.40000,7.95000,Aetna,First Health,,22.41,,,,,,,9.88,22.41,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,47335099301,NDC,facility,outpatient,500,ME,27.40000,7.95000,Aetna,First Health,,22.41,,,,,,,0.02889,22.41,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,47335099201,NDC,facility,inpatient,2,GM,133.70000,38.77000,Aetna,First Health,,109.37,,,,,,,48.20,109.37,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,47335099201,NDC,facility,outpatient,2,GM,133.70000,38.77000,Aetna,First Health,,109.37,,,,,,,0.39483,109.37,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,47335093144,NDC,,,facility,inpatient,1,EA,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,20.07,44.38,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,47335093144,NDC,,,facility,outpatient,1,EA,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,19.56,44.38,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,47335090288,NDC,,,facility,inpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,16.98,23.15,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,47335090288,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,10.20,23.15,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,47335089413,NDC,,,facility,inpatient,1,EA,49.20000,14.27000,Aetna,First Health,,40.25,,,,,,,29.52,40.25,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,47335089413,NDC,,,facility,outpatient,1,EA,49.20000,14.27000,Aetna,First Health,,40.25,,,,,,,17.74,40.25,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,47335078891,NDC,,,facility,inpatient,1,EA,1535.95000,445.43000,Aetna,First Health,,1256.41,,,,,,,921.57,1256.41,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,47335078891,NDC,,,facility,outpatient,1,EA,1535.95000,445.43000,Aetna,First Health,,1256.41,,,,,,,553.71,1256.41,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,47335077991,NDC,,,facility,inpatient,1,EA,677.00000,196.33000,Aetna,First Health,,553.79,,,,,,,406.20,553.79,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,47335077991,NDC,,,facility,outpatient,1,EA,677.00000,196.33000,Aetna,First Health,,553.79,,,,,,,244.06,553.79,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,47335076583,NDC,,,facility,inpatient,1,EA,216.10000,62.67000,Aetna,First Health,,176.77,,,,,,,129.66,176.77,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,47335076583,NDC,,,facility,outpatient,1,EA,216.10000,62.67000,Aetna,First Health,,176.77,,,,,,,77.90,176.77,percent of total billed charges,
Paliperidone 1.5mg ER T(Invega),800046569,CDM,637,RC,47335074483,NDC,,,facility,inpatient,1,EA,216.10000,62.67000,Aetna,First Health,,176.77,,,,,,,129.66,176.77,percent of total billed charges,
Paliperidone 1.5mg ER T(Invega),800046569,CDM,637,RC,47335074483,NDC,,,facility,outpatient,1,EA,216.10000,62.67000,Aetna,First Health,,176.77,,,,,,,77.90,176.77,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,47335073713,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,47335073713,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,47335067881,NDC,,,facility,inpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,11.28,15.38,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,47335067881,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,47335067681,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,47335067681,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,47335067581,NDC,,,facility,inpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,5.10,6.95,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,47335067581,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,3.06,6.95,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,47335061544,NDC,,,facility,inpatient,1,EA,55.80000,16.18000,Aetna,First Health,,45.64,,,,,,,20.65,45.64,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,47335061544,NDC,,,facility,outpatient,1,EA,55.80000,16.18000,Aetna,First Health,,45.64,,,,,,,20.12,45.64,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,47335060488,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,47335060488,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,47335060388,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,47335060388,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,47335058583,NDC,,,facility,inpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,38.01,51.82,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,47335058583,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,22.84,51.82,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,47335048583,NDC,,,facility,inpatient,1,EA,131.20000,38.05000,Aetna,First Health,,107.32,,,,,,,78.72,107.32,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,47335048583,NDC,,,facility,outpatient,1,EA,131.20000,38.05000,Aetna,First Health,,107.32,,,,,,,47.30,107.32,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,47335047281,NDC,,,facility,inpatient,1,EA,685.65000,198.84000,Aetna,First Health,,560.86,,,,,,,411.39,560.86,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,47335047281,NDC,,,facility,outpatient,1,EA,685.65000,198.84000,Aetna,First Health,,560.86,,,,,,,247.18,560.86,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,47335038383,NDC,,,facility,inpatient,1,EA,55.50000,16.10000,Aetna,First Health,,45.40,,,,,,,33.30,45.40,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,47335038383,NDC,,,facility,outpatient,1,EA,55.50000,16.10000,Aetna,First Health,,45.40,,,,,,,20.01,45.40,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,47335033040,NDC,facility,inpatient,500,ME,566.55000,164.30000,Aetna,First Health,,463.44,,,,,,,204.24,463.44,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,47335033040,NDC,facility,outpatient,500,ME,566.55000,164.30000,Aetna,First Health,,463.44,,,,,,,55.98,463.44,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,47335032683,NDC,,,facility,inpatient,1,EA,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,18.15,24.74,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,47335032683,NDC,,,facility,outpatient,1,EA,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,10.91,24.74,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,47335032286,NDC,,,facility,inpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,25.89,35.30,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,47335032286,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,15.56,35.30,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,47335032186,NDC,,,facility,inpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,25.89,35.30,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,47335032186,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,15.56,35.30,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,47335029044,NDC,,,facility,inpatient,1,EA,169.05000,49.02000,Aetna,First Health,,138.28,,,,,,,101.43,138.28,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,47335029044,NDC,,,facility,outpatient,1,EA,169.05000,49.02000,Aetna,First Health,,138.28,,,,,,,60.94,138.28,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,47335029040,NDC,,,facility,inpatient,1,EA,169.05000,49.02000,Aetna,First Health,,138.28,,,,,,,101.43,138.28,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,47335029040,NDC,,,facility,outpatient,1,EA,169.05000,49.02000,Aetna,First Health,,138.28,,,,,,,60.94,138.28,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,47335028940,NDC,facility,inpatient,60,ME,313.00000,90.77000,Aetna,First Health,,256.03,,,,,,,112.84,256.03,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,47335028940,NDC,facility,outpatient,60,ME,313.00000,90.77000,Aetna,First Health,,256.03,,,,,,,1.40,256.03,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,47335015340,NDC,facility,inpatient,200,ME,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,262.80,596.32,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,47335015340,NDC,facility,outpatient,200,ME,729.00000,211.41000,Aetna,First Health,,596.32,,,,,,,3.46,596.32,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,47335006386,NDC,,,facility,inpatient,1,EA,60.65000,17.59000,Aetna,First Health,,49.61,,,,,,,36.39,49.61,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,47335006386,NDC,,,facility,outpatient,1,EA,60.65000,17.59000,Aetna,First Health,,49.61,,,,,,,21.86,49.61,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,47335006286,NDC,,,facility,inpatient,1,EA,60.65000,17.59000,Aetna,First Health,,49.61,,,,,,,36.39,49.61,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,47335006286,NDC,,,facility,outpatient,1,EA,60.65000,17.59000,Aetna,First Health,,49.61,,,,,,,21.86,49.61,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,47335006186,NDC,,,facility,inpatient,1,EA,60.65000,17.59000,Aetna,First Health,,49.61,,,,,,,36.39,49.61,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,47335006186,NDC,,,facility,outpatient,1,EA,60.65000,17.59000,Aetna,First Health,,49.61,,,,,,,21.86,49.61,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,47335000788,NDC,,,facility,inpatient,1,EA,32.15000,9.32000,Aetna,First Health,,26.30,,,,,,,19.29,26.30,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,47335000788,NDC,,,facility,outpatient,1,EA,32.15000,9.32000,Aetna,First Health,,26.30,,,,,,,11.59,26.30,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,46581083001,NDC,,,facility,inpatient,1,EA,18.60000,5.39000,Aetna,First Health,,15.21,,,,,,,11.16,15.21,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,46581083001,NDC,,,facility,outpatient,1,EA,18.60000,5.39000,Aetna,First Health,,15.21,,,,,,,6.71,15.21,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,46122055705,NDC,,,facility,inpatient,1,EA,53.75000,15.59000,Aetna,First Health,,43.97,,,,,,,19.89,43.97,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,46122055705,NDC,,,facility,outpatient,1,EA,53.75000,15.59000,Aetna,First Health,,43.97,,,,,,,19.38,43.97,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,45963076552,NDC,facility,inpatient,80,ME,5947.00000,1724.63000,Aetna,First Health,,4864.65,,,,,,,2143.89,4864.65,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,45963076552,NDC,facility,outpatient,80,ME,5947.00000,1724.63000,Aetna,First Health,,4864.65,,,,,,,0.62595,4864.65,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,45963073355,NDC,facility,inpatient,10,ME,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,28.12,63.80,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,45963073355,NDC,facility,outpatient,10,ME,78.00000,22.62000,Aetna,First Health,,63.80,,,,,,,2.68,63.80,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,45963070911,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,45963070911,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,45963067711,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,45963067711,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,45963067611,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,45963067611,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,45963061959,NDC,facility,inpatient,1000,ME,927.00000,268.83000,Aetna,First Health,,758.29,,,,,,,334.18,758.29,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,45963061959,NDC,facility,outpatient,1000,ME,927.00000,268.83000,Aetna,First Health,,758.29,,,,,,,3.46,758.29,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,45963057008,NDC,,,facility,inpatient,1,EA,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,22.38,30.51,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,45963057008,NDC,,,facility,outpatient,1,EA,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,13.45,30.51,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,45963053830,NDC,facility,inpatient,4,ME,176.20000,51.10000,Aetna,First Health,,144.13,,,,,,,63.52,144.13,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,45963053830,NDC,facility,outpatient,4,ME,176.20000,51.10000,Aetna,First Health,,144.13,,,,,,,0.00963,144.13,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,45963043963,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,45963043963,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,45963043864,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,45963043864,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,45963041806,NDC,,,facility,inpatient,1,EA,50.35000,14.60000,Aetna,First Health,,41.19,,,,,,,30.21,41.19,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,45963041806,NDC,,,facility,outpatient,1,EA,50.35000,14.60000,Aetna,First Health,,41.19,,,,,,,18.15,41.19,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,45945015702,NDC,facility,inpatient,40,ME,3616.25000,1048.71000,Aetna,First Health,,2958.09,,,,,,,1303.66,2958.09,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,45945015702,NDC,facility,outpatient,40,ME,3616.25000,1048.71000,Aetna,First Health,,2958.09,,,,,,,174.76,2958.09,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,45945015701,NDC,facility,inpatient,40,ME,3875.20000,1123.81000,Aetna,First Health,,3169.91,,,,,,,1397.01,3169.91,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,45945015701,NDC,facility,outpatient,40,ME,3875.20000,1123.81000,Aetna,First Health,,3169.91,,,,,,,174.76,3169.91,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,45802095301,NDC,,,facility,inpatient,1,EA,104.10000,30.19000,Aetna,First Health,,85.15,,,,,,,62.46,85.15,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,45802095301,NDC,,,facility,outpatient,1,EA,104.10000,30.19000,Aetna,First Health,,85.15,,,,,,,37.53,85.15,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,45802088094,NDC,,,facility,inpatient,1,EA,247.25000,71.70000,Aetna,First Health,,202.25,,,,,,,148.35,202.25,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,45802088094,NDC,,,facility,outpatient,1,EA,247.25000,71.70000,Aetna,First Health,,202.25,,,,,,,89.13,202.25,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,45802086802,NDC,,,facility,inpatient,1,EA,64.20000,18.62000,Aetna,First Health,,52.52,,,,,,,23.75,52.52,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,45802086802,NDC,,,facility,outpatient,1,EA,64.20000,18.62000,Aetna,First Health,,52.52,,,,,,,23.14,52.52,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,45802077078,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,45802077078,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,45802075830,NDC,,,facility,inpatient,1,EA,125.35000,36.35000,Aetna,First Health,,102.54,,,,,,,75.21,102.54,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,45802075830,NDC,,,facility,outpatient,1,EA,125.35000,36.35000,Aetna,First Health,,102.54,,,,,,,45.19,102.54,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,45802072530,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,45802072530,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,45802058062,NDC,,,facility,inpatient,1,EA,162.85000,47.23000,Aetna,First Health,,133.21,,,,,,,97.71,133.21,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,45802058062,NDC,,,facility,outpatient,1,EA,162.85000,47.23000,Aetna,First Health,,133.21,,,,,,,58.71,133.21,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,45802058046,NDC,,,facility,inpatient,1,EA,162.85000,47.23000,Aetna,First Health,,133.21,,,,,,,97.71,133.21,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,45802058046,NDC,,,facility,outpatient,1,EA,162.85000,47.23000,Aetna,First Health,,133.21,,,,,,,58.71,133.21,percent of total billed charges,
Ammonium Lactate 12% Lotion,800025491,CDM,637,RC,45802052555,NDC,,,facility,inpatient,1,EA,129.15000,37.45000,Aetna,First Health,,105.64,,,,,,,77.49,105.64,percent of total billed charges,
Ammonium Lactate 12% Lotion,800025491,CDM,637,RC,45802052555,NDC,,,facility,outpatient,1,EA,129.15000,37.45000,Aetna,First Health,,105.64,,,,,,,46.56,105.64,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,45802047264,NDC,,,facility,inpatient,1,EA,967.25000,280.50000,Aetna,First Health,,791.21,,,,,,,580.35,791.21,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,45802047264,NDC,,,facility,outpatient,1,EA,967.25000,280.50000,Aetna,First Health,,791.21,,,,,,,348.69,791.21,percent of total billed charges,
Ketoconazole 2% Top Shampoo 120mL,800017775,CDM,637,RC,45802046564,NDC,,,facility,inpatient,1,EA,214.05000,62.07000,Aetna,First Health,,175.09,,,,,,,128.43,175.09,percent of total billed charges,
Ketoconazole 2% Top Shampoo 120mL,800017775,CDM,637,RC,45802046564,NDC,,,facility,outpatient,1,EA,214.05000,62.07000,Aetna,First Health,,175.09,,,,,,,77.17,175.09,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,45802043870,NDC,,,facility,inpatient,1,EA,25.45000,7.38000,Aetna,First Health,,20.82,,,,,,,9.42,20.82,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,45802043870,NDC,,,facility,outpatient,1,EA,25.45000,7.38000,Aetna,First Health,,20.82,,,,,,,9.17,20.82,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,45802043803,NDC,,,facility,inpatient,1,EA,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,11.19,24.74,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,45802043803,NDC,,,facility,outpatient,1,EA,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,10.91,24.74,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,45802043401,NDC,,,facility,inpatient,1,EA,42.40000,12.30000,Aetna,First Health,,34.68,,,,,,,15.69,34.68,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,45802043401,NDC,,,facility,outpatient,1,EA,42.40000,12.30000,Aetna,First Health,,34.68,,,,,,,15.29,34.68,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,45802037635,NDC,,,facility,inpatient,1,EA,32.80000,9.51000,Aetna,First Health,,26.83,,,,,,,19.68,26.83,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,45802037635,NDC,,,facility,outpatient,1,EA,32.80000,9.51000,Aetna,First Health,,26.83,,,,,,,11.82,26.83,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,45802026937,NDC,,,facility,inpatient,1,EA,752.90000,218.34000,Aetna,First Health,,615.87,,,,,,,451.74,615.87,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,45802026937,NDC,,,facility,outpatient,1,EA,752.90000,218.34000,Aetna,First Health,,615.87,,,,,,,271.42,615.87,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,45802021002,NDC,,,facility,inpatient,1,EA,853.65000,247.56000,Aetna,First Health,,698.29,,,,,,,512.19,698.29,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,45802021002,NDC,,,facility,outpatient,1,EA,853.65000,247.56000,Aetna,First Health,,698.29,,,,,,,307.74,698.29,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,45802021001,NDC,,,facility,inpatient,1,EA,1425.30000,413.34000,Aetna,First Health,,1165.90,,,,,,,855.18,1165.90,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,45802021001,NDC,,,facility,outpatient,1,EA,1425.30000,413.34000,Aetna,First Health,,1165.90,,,,,,,513.82,1165.90,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,45802017453,NDC,,,facility,inpatient,1,EA,27.30000,7.92000,Aetna,First Health,,22.33,,,,,,,10.10,22.33,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,45802017453,NDC,,,facility,outpatient,1,EA,27.30000,7.92000,Aetna,First Health,,22.33,,,,,,,9.84,22.33,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,45802014303,NDC,,,facility,inpatient,1,EA,44.15000,12.80000,Aetna,First Health,,36.11,,,,,,,16.34,36.11,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,45802014303,NDC,,,facility,outpatient,1,EA,44.15000,12.80000,Aetna,First Health,,36.11,,,,,,,15.92,36.11,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,45802013811,NDC,,,facility,inpatient,1,EA,383.50000,111.21000,Aetna,First Health,,313.70,,,,,,,230.10,313.70,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,45802013811,NDC,,,facility,outpatient,1,EA,383.50000,111.21000,Aetna,First Health,,313.70,,,,,,,138.25,313.70,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,45802011665,NDC,,,facility,inpatient,1,EA,82.65000,23.97000,Aetna,First Health,,67.61,,,,,,,49.59,67.61,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,45802011665,NDC,,,facility,outpatient,1,EA,82.65000,23.97000,Aetna,First Health,,67.61,,,,,,,29.80,67.61,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,45802011222,NDC,,,facility,inpatient,1,EA,81.05000,23.50000,Aetna,First Health,,66.30,,,,,,,48.63,66.30,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,45802011222,NDC,,,facility,outpatient,1,EA,81.05000,23.50000,Aetna,First Health,,66.30,,,,,,,29.22,66.30,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,45802009851,NDC,,,facility,inpatient,1,EA,171.95000,49.87000,Aetna,First Health,,140.66,,,,,,,103.17,140.66,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,45802009851,NDC,,,facility,outpatient,1,EA,171.95000,49.87000,Aetna,First Health,,140.66,,,,,,,61.99,140.66,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,45802009735,NDC,,,facility,inpatient,1,EA,565.30000,163.94000,Aetna,First Health,,462.42,,,,,,,339.18,462.42,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,45802009735,NDC,,,facility,outpatient,1,EA,565.30000,163.94000,Aetna,First Health,,462.42,,,,,,,203.79,462.42,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,45802006435,NDC,,,facility,inpatient,1,EA,27.55000,7.99000,Aetna,First Health,,22.54,,,,,,,16.53,22.54,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,45802006435,NDC,,,facility,outpatient,1,EA,27.55000,7.99000,Aetna,First Health,,22.54,,,,,,,9.93,22.54,percent of total billed charges,
Triamcinolone 0.1% TC 454g,800077205,CDM,637,RC,45802006405,NDC,,,facility,inpatient,1,EA,165.20000,47.91000,Aetna,First Health,,135.13,,,,,,,99.12,135.13,percent of total billed charges,
Triamcinolone 0.1% TC 454g,800077205,CDM,637,RC,45802006405,NDC,,,facility,outpatient,1,EA,165.20000,47.91000,Aetna,First Health,,135.13,,,,,,,59.55,135.13,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,45802006103,NDC,,,facility,inpatient,1,EA,44.15000,12.80000,Aetna,First Health,,36.11,,,,,,,16.34,36.11,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,45802006103,NDC,,,facility,outpatient,1,EA,44.15000,12.80000,Aetna,First Health,,36.11,,,,,,,15.92,36.11,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,45802006003,NDC,,,facility,inpatient,1,EA,37.15000,10.77000,Aetna,First Health,,30.39,,,,,,,13.75,30.39,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,45802006003,NDC,,,facility,outpatient,1,EA,37.15000,10.77000,Aetna,First Health,,30.39,,,,,,,13.39,30.39,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,45802005935,NDC,,,facility,inpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,74.34,101.35,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,45802005935,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,44.67,101.35,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,45802005536,NDC,,,facility,inpatient,1,EA,90.90000,26.36000,Aetna,First Health,,74.36,,,,,,,54.54,74.36,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,45802005536,NDC,,,facility,outpatient,1,EA,90.90000,26.36000,Aetna,First Health,,74.36,,,,,,,32.77,74.36,percent of total billed charges,
Triamcinolone 0.025% TO 80g,800017793,CDM,637,RC,45802005436,NDC,,,facility,inpatient,1,EA,71.60000,20.76000,Aetna,First Health,,58.57,,,,,,,42.96,58.57,percent of total billed charges,
Triamcinolone 0.025% TO 80g,800017793,CDM,637,RC,45802005436,NDC,,,facility,outpatient,1,EA,71.60000,20.76000,Aetna,First Health,,58.57,,,,,,,25.81,58.57,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,45802004835,NDC,,,facility,inpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,74.34,101.35,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,45802004835,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,44.67,101.35,percent of total billed charges,
Selenium 2.5% 120mL Lotion,800065887,CDM,250,RC,45802004064,NDC,,,facility,inpatient,1,EA,140.20000,40.66000,Aetna,First Health,,114.68,,,,,,,51.87,114.68,percent of total billed charges,
Selenium 2.5% 120mL Lotion,800065887,CDM,250,RC,45802004064,NDC,,,facility,outpatient,1,EA,140.20000,40.66000,Aetna,First Health,,114.68,,,,,,,50.54,114.68,percent of total billed charges,
Betamethasone Dipr 0.05% 60mL TL,800058635,CDM,637,RC,45802002146,NDC,,,facility,inpatient,1,EA,311.10000,90.22000,Aetna,First Health,,254.48,,,,,,,186.66,254.48,percent of total billed charges,
Betamethasone Dipr 0.05% 60mL TL,800058635,CDM,637,RC,45802002146,NDC,,,facility,outpatient,1,EA,311.10000,90.22000,Aetna,First Health,,254.48,,,,,,,112.15,254.48,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,45802000403,NDC,,,facility,inpatient,1,EA,81.90000,23.75000,Aetna,First Health,,66.99,,,,,,,49.14,66.99,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,45802000403,NDC,,,facility,outpatient,1,EA,81.90000,23.75000,Aetna,First Health,,66.99,,,,,,,29.52,66.99,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,44567082010,NDC,facility,inpatient,1,GM,1169.65000,339.20000,Aetna,First Health,,956.77,,,,,,,421.66,956.77,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,44567082010,NDC,facility,outpatient,1,GM,1169.65000,339.20000,Aetna,First Health,,956.77,,,,,,,8.82,956.77,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,44567081110,NDC,facility,inpatient,2.5,GM,1093.80000,317.20000,Aetna,First Health,,894.73,,,,,,,394.31,894.73,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,44567081110,NDC,facility,outpatient,2.5,GM,1093.80000,317.20000,Aetna,First Health,,894.73,,,,,,,0.20223,894.73,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,44567080310,NDC,facility,inpatient,4.5,GM,65.30000,18.94000,Aetna,First Health,,53.42,,,,,,,23.54,53.42,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,44567080310,NDC,facility,outpatient,4.5,GM,65.30000,18.94000,Aetna,First Health,,53.42,,,,,,,1.05,53.42,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,44567080210,NDC,facility,inpatient,3.375,GM,49.35000,14.31000,Aetna,First Health,,40.37,,,,,,,17.79,40.37,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,44567080210,NDC,facility,outpatient,3.375,GM,49.35000,14.31000,Aetna,First Health,,40.37,,,,,,,1.05,40.37,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,44567080110,NDC,facility,inpatient,2.25,GM,28.70000,8.32000,Aetna,First Health,,23.48,,,,,,,10.35,23.48,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,44567080110,NDC,facility,outpatient,2.25,GM,28.70000,8.32000,Aetna,First Health,,23.48,,,,,,,1.05,23.48,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,44567070810,NDC,facility,inpatient,2,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,38.07,86.38,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,44567070810,NDC,facility,outpatient,2,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,0.79929,86.38,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,44567070725,NDC,facility,inpatient,1000,ME,15.85000,4.60000,Aetna,First Health,,12.97,,,,,,,5.71,12.97,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,44567070725,NDC,facility,outpatient,1000,ME,15.85000,4.60000,Aetna,First Health,,12.97,,,,,,,0.79929,12.97,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,44567070225,NDC,facility,inpatient,2,GM,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,44567070225,NDC,facility,outpatient,2,GM,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,0.44298,31.33,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,44567070125,NDC,facility,inpatient,1,GM,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,44567070125,NDC,facility,outpatient,1,GM,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,0.44298,23.56,percent of total billed charges,
Norepinephrine 8mg/NS 250mL-Dbl Conc,800051974,CDM,250,RC,44567064110,NDC,,,facility,inpatient,1,EA,481.00000,139.49000,Aetna,First Health,,393.46,,,,,,,177.97,393.46,percent of total billed charges,
Norepinephrine 8mg/NS 250mL-Dbl Conc,800051974,CDM,250,RC,44567064110,NDC,,,facility,outpatient,1,EA,481.00000,139.49000,Aetna,First Health,,393.46,,,,,,,173.40,393.46,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,44567064010,NDC,,,facility,inpatient,1,EA,370.20000,107.36000,Aetna,First Health,,302.82,,,,,,,136.97,302.82,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,44567064010,NDC,,,facility,outpatient,1,EA,370.20000,107.36000,Aetna,First Health,,302.82,,,,,,,133.46,302.82,percent of total billed charges,
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,800046390,CDM,636,RC,J0612,HCPCS,44567062024,NDC,facility,inpatient,1,GM,201.45000,58.42000,Aetna,First Health,,164.79,,,,,,,72.62,164.79,percent of total billed charges,
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,800046390,CDM,636,RC,J0612,HCPCS,44567062024,NDC,facility,outpatient,1,GM,201.45000,58.42000,Aetna,First Health,,164.79,,,,,,,0.02889,164.79,percent of total billed charges,
Midazolam 100mg/NS 100mL IV,800046429,CDM,636,RC,J2250,HCPCS,44567061110,NDC,facility,inpatient,100,ME,220.95000,64.08000,Aetna,First Health,,180.74,,,,,,,79.65,180.74,percent of total billed charges,
Midazolam 100mg/NS 100mL IV,800046429,CDM,636,RC,J2250,HCPCS,44567061110,NDC,facility,outpatient,100,ME,220.95000,64.08000,Aetna,First Health,,180.74,,,,,,,0.13482,180.74,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,44567050501,NDC,facility,inpatient,6,ME,15.40000,4.47000,Aetna,First Health,,12.60,,,,,,,5.55,12.60,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,44567050501,NDC,facility,outpatient,6,ME,15.40000,4.47000,Aetna,First Health,,12.60,,,,,,,0.09630,12.60,percent of total billed charges,
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,44567050310,NDC,facility,inpatient,1500,ME,154.65000,44.85000,Aetna,First Health,,126.50,,,,,,,55.75,126.50,percent of total billed charges,
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,44567050310,NDC,facility,outpatient,1500,ME,154.65000,44.85000,Aetna,First Health,,126.50,,,,,,,0.03852,126.50,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,44567050110,NDC,facility,inpatient,500,ME,78.55000,22.78000,Aetna,First Health,,64.25,,,,,,,28.32,64.25,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,44567050110,NDC,facility,outpatient,500,ME,78.55000,22.78000,Aetna,First Health,,64.25,,,,,,,0.03852,64.25,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,44567045010,NDC,facility,inpatient,2.5,GM,870.60000,252.47000,Aetna,First Health,,712.15,,,,,,,313.85,712.15,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,44567045010,NDC,facility,outpatient,2.5,GM,870.60000,252.47000,Aetna,First Health,,712.15,,,,,,,0.20223,712.15,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,44567043724,NDC,facility,inpatient,750,ME,54.45000,15.79000,Aetna,First Health,,44.54,,,,,,,19.63,44.54,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,44567043724,NDC,facility,outpatient,750,ME,54.45000,15.79000,Aetna,First Health,,44.54,,,,,,,2.08,44.54,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,44567043624,NDC,facility,inpatient,500,ME,47.40000,13.75000,Aetna,First Health,,38.77,,,,,,,17.09,38.77,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,44567043624,NDC,facility,outpatient,500,ME,47.40000,13.75000,Aetna,First Health,,38.77,,,,,,,2.08,38.77,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,44567043524,NDC,facility,inpatient,250,ME,32.25000,9.35000,Aetna,First Health,,26.38,,,,,,,11.63,26.38,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,44567043524,NDC,facility,outpatient,250,ME,32.25000,9.35000,Aetna,First Health,,26.38,,,,,,,2.08,26.38,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,44567042124,NDC,facility,inpatient,4,GM,91.30000,26.48000,Aetna,First Health,,74.68,,,,,,,32.91,74.68,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,44567042124,NDC,facility,outpatient,4,GM,91.30000,26.48000,Aetna,First Health,,74.68,,,,,,,0.39483,74.68,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,44567042024,NDC,facility,inpatient,2,GM,170.85000,49.55000,Aetna,First Health,,139.76,,,,,,,61.59,139.76,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,44567042024,NDC,facility,outpatient,2,GM,170.85000,49.55000,Aetna,First Health,,139.76,,,,,,,0.39483,139.76,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,44567040110,NDC,facility,inpatient,1,GM,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,102.02,231.49,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,44567040110,NDC,facility,outpatient,1,GM,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,0.36594,231.49,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,44567031110,NDC,facility,inpatient,1,EA,43.60000,12.64000,Aetna,First Health,,35.66,,,,,,,15.72,35.66,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,44567031110,NDC,facility,outpatient,1,EA,43.60000,12.64000,Aetna,First Health,,35.66,,,,,,,0.75114,35.66,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,44567024625,NDC,facility,inpatient,2,GM,191.50000,55.54000,Aetna,First Health,,156.65,,,,,,,69.04,156.65,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,44567024625,NDC,facility,outpatient,2,GM,191.50000,55.54000,Aetna,First Health,,156.65,,,,,,,4.56,156.65,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,44567024525,NDC,facility,inpatient,1,GM,95.50000,27.69000,Aetna,First Health,,78.12,,,,,,,34.43,78.12,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,44567024525,NDC,facility,outpatient,1,GM,95.50000,27.69000,Aetna,First Health,,78.12,,,,,,,4.56,78.12,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,44567024110,NDC,facility,inpatient,2,GM,94.10000,27.29000,Aetna,First Health,,76.97,,,,,,,33.92,76.97,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,44567024110,NDC,facility,outpatient,2,GM,94.10000,27.29000,Aetna,First Health,,76.97,,,,,,,0.83781,76.97,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,44567024010,NDC,facility,inpatient,1,GM,54.70000,15.86000,Aetna,First Health,,44.74,,,,,,,19.72,44.74,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,44567024010,NDC,facility,outpatient,1,GM,54.70000,15.86000,Aetna,First Health,,44.74,,,,,,,0.83781,44.74,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,inpatient,1,GM,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,15.57,35.34,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,outpatient,1,GM,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,1.42,35.34,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,44567022210,NDC,facility,inpatient,2,GM,211.00000,61.19000,Aetna,First Health,,172.60,,,,,,,76.07,172.60,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,44567022210,NDC,facility,outpatient,2,GM,211.00000,61.19000,Aetna,First Health,,172.60,,,,,,,0.05778,172.60,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,44567021110,NDC,facility,inpatient,3,GM,153.10000,44.40000,Aetna,First Health,,125.24,,,,,,,55.19,125.24,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,44567021110,NDC,facility,outpatient,3,GM,153.10000,44.40000,Aetna,First Health,,125.24,,,,,,,1.28,125.24,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,44567021010,NDC,facility,inpatient,1.5,GM,76.30000,22.13000,Aetna,First Health,,62.41,,,,,,,27.51,62.41,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,44567021010,NDC,facility,outpatient,1.5,GM,76.30000,22.13000,Aetna,First Health,,62.41,,,,,,,1.28,62.41,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,inpatient,2,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,38.07,86.38,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,outpatient,2,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,0.56817,86.38,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,44567010110,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,44567010110,NDC,facility,outpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,0.56817,23.56,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,44206031025,NDC,facility,inpatient,12.5,GM,444.00000,128.76000,Aetna,First Health,,363.19,,,,,,,160.06,363.19,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,44206031025,NDC,facility,outpatient,12.5,GM,444.00000,128.76000,Aetna,First Health,,363.19,,,,,,,51.12,363.19,percent of total billed charges,
RHo (D) Immune Globulin 300mcg/2mL Inj,800021963,CDM,636,RC,J2791,HCPCS,44206030010,NDC,facility,inpatient,0.3,ME,799.05000,231.72000,Aetna,First Health,,653.62,,,,,,,288.06,653.62,percent of total billed charges,
RHo (D) Immune Globulin 300mcg/2mL Inj,800021963,CDM,636,RC,J2791,HCPCS,44206030010,NDC,facility,outpatient,0.3,ME,799.05000,231.72000,Aetna,First Health,,653.62,,,,,,,4.65,653.62,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,44206025105,NDC,facility,inpatient,12.5,GM,444.00000,128.76000,Aetna,First Health,,363.19,,,,,,,160.06,363.19,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,44206025105,NDC,facility,outpatient,12.5,GM,444.00000,128.76000,Aetna,First Health,,363.19,,,,,,,51.12,363.19,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,43975035003,NDC,,,facility,inpatient,1,EA,103.85000,30.12000,Aetna,First Health,,84.95,,,,,,,62.31,84.95,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,43975035003,NDC,,,facility,outpatient,1,EA,103.85000,30.12000,Aetna,First Health,,84.95,,,,,,,37.44,84.95,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,43975032209,NDC,,,facility,inpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,34.14,46.54,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,43975032209,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,20.51,46.54,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,43975032203,NDC,,,facility,inpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,34.14,46.54,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,43975032203,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,20.51,46.54,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),800017619,CDM,637,RC,43975021710,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),800017619,CDM,637,RC,43975021710,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
NUTR- Peptamen Intense VHP(1L),800040932,CDM,637,RC,43900072395,NDC,,,facility,inpatient,1,EA,345.90000,100.31000,Aetna,First Health,,282.95,,,,,,,207.54,282.95,percent of total billed charges,
NUTR- Peptamen Intense VHP(1L),800040932,CDM,637,RC,43900072395,NDC,,,facility,outpatient,1,EA,345.90000,100.31000,Aetna,First Health,,282.95,,,,,,,124.70,282.95,percent of total billed charges,
NUTR- Novasource Renal(1L),800040925,CDM,637,RC,43900035180,NDC,,,facility,inpatient,1,EA,161.75000,46.91000,Aetna,First Health,,132.31,,,,,,,97.05,132.31,percent of total billed charges,
NUTR- Novasource Renal(1L),800040925,CDM,637,RC,43900035180,NDC,,,facility,outpatient,1,EA,161.75000,46.91000,Aetna,First Health,,132.31,,,,,,,58.31,132.31,percent of total billed charges,
NUTR- Novasource Renal (237mL),800040924,CDM,637,RC,43900035110,NDC,,,facility,inpatient,1,EA,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,19.92,27.16,percent of total billed charges,
NUTR- Novasource Renal (237mL),800040924,CDM,637,RC,43900035110,NDC,,,facility,outpatient,1,EA,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,11.97,27.16,percent of total billed charges,
NUTR- Isosource HN (1L),800040879,CDM,636,RC,43900018480,NDC,,,facility,inpatient,1,EA,656.50000,190.38000,Aetna,First Health,,537.02,,,,,,,236.67,537.02,percent of total billed charges,
NUTR- Isosource HN (1L),800040879,CDM,636,RC,43900018480,NDC,,,facility,outpatient,1,EA,656.50000,190.38000,Aetna,First Health,,537.02,,,,,,,236.67,537.02,percent of total billed charges,
NUTR- Isosource HN (250mL),800040892,CDM,250,RC,43900018457,NDC,,,facility,inpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.85,8.51,percent of total billed charges,
NUTR- Isosource HN (250mL),800040892,CDM,250,RC,43900018457,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
NUTR- Isosource 1.5 (1L),800040891,CDM,637,RC,43900018181,NDC,,,facility,inpatient,1,EA,65.10000,18.88000,Aetna,First Health,,53.25,,,,,,,39.06,53.25,percent of total billed charges,
NUTR- Isosource 1.5 (1L),800040891,CDM,637,RC,43900018181,NDC,,,facility,outpatient,1,EA,65.10000,18.88000,Aetna,First Health,,53.25,,,,,,,23.47,53.25,percent of total billed charges,
NUTR- Isosource 1.5 (250mL),800040890,CDM,637,RC,43900018150,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
NUTR- Isosource 1.5 (250mL),800040890,CDM,637,RC,43900018150,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,43825010201,NDC,facility,inpatient,1000,ME,464.30000,134.65000,Aetna,First Health,,379.80,,,,,,,167.38,379.80,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,43825010201,NDC,facility,outpatient,1000,ME,464.30000,134.65000,Aetna,First Health,,379.80,,,,,,,0.05778,379.80,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,43598097710,NDC,,,facility,inpatient,1,EA,101.80000,29.52000,Aetna,First Health,,83.27,,,,,,,61.08,83.27,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,43598097710,NDC,,,facility,outpatient,1,EA,101.80000,29.52000,Aetna,First Health,,83.27,,,,,,,36.70,83.27,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,43598091758,NDC,,,facility,inpatient,1,EA,1460.85000,423.65000,Aetna,First Health,,1194.98,,,,,,,526.64,1194.98,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,43598091758,NDC,,,facility,outpatient,1,EA,1460.85000,423.65000,Aetna,First Health,,1194.98,,,,,,,526.64,1194.98,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,43598090111,NDC,facility,inpatient,1,GM,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,312.55,709.21,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,43598090111,NDC,facility,outpatient,1,GM,867.00000,251.43000,Aetna,First Health,,709.21,,,,,,,8.82,709.21,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,43598084858,NDC,facility,inpatient,20,ME,284.65000,82.55000,Aetna,First Health,,232.84,,,,,,,102.62,232.84,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,43598084858,NDC,facility,outpatient,20,ME,284.65000,82.55000,Aetna,First Health,,232.84,,,,,,,8.81,232.84,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,43598083936,NDC,facility,inpatient,1,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,34.61,78.53,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,43598083936,NDC,facility,outpatient,1,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,4.37,78.53,percent of total billed charges,
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,43598075910,NDC,facility,inpatient,1500,ME,397.00000,115.13000,Aetna,First Health,,324.75,,,,,,,143.12,324.75,percent of total billed charges,
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,43598075910,NDC,facility,outpatient,1500,ME,397.00000,115.13000,Aetna,First Health,,324.75,,,,,,,0.03852,324.75,percent of total billed charges,
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,43598075710,NDC,facility,inpatient,1000,ME,301.00000,87.29000,Aetna,First Health,,246.22,,,,,,,108.51,246.22,percent of total billed charges,
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,43598075710,NDC,facility,outpatient,1000,ME,301.00000,87.29000,Aetna,First Health,,246.22,,,,,,,0.03852,246.22,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,43598075510,NDC,facility,inpatient,500,ME,177.60000,51.50000,Aetna,First Health,,145.28,,,,,,,64.02,145.28,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,43598075510,NDC,facility,outpatient,500,ME,177.60000,51.50000,Aetna,First Health,,145.28,,,,,,,0.03852,145.28,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43598075160,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43598075160,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43598075101,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43598075101,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,43598072525,NDC,,,facility,inpatient,1,EA,147.85000,42.88000,Aetna,First Health,,120.94,,,,,,,54.70,120.94,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,43598072525,NDC,,,facility,outpatient,1,EA,147.85000,42.88000,Aetna,First Health,,120.94,,,,,,,53.30,120.94,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,43598072101,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,43598072101,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,43598071901,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,43598071901,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,43598069858,NDC,,,facility,inpatient,1,EA,1460.85000,423.65000,Aetna,First Health,,1194.98,,,,,,,526.64,1194.98,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,43598069858,NDC,,,facility,outpatient,1,EA,1460.85000,423.65000,Aetna,First Health,,1194.98,,,,,,,526.64,1194.98,percent of total billed charges,
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,43598063752,NDC,facility,inpatient,1500,ME,397.00000,115.13000,Aetna,First Health,,324.75,,,,,,,143.12,324.75,percent of total billed charges,
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,43598063752,NDC,facility,outpatient,1500,ME,397.00000,115.13000,Aetna,First Health,,324.75,,,,,,,0.03852,324.75,percent of total billed charges,
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,43598063610,NDC,facility,inpatient,1000,ME,301.00000,87.29000,Aetna,First Health,,246.22,,,,,,,108.51,246.22,percent of total billed charges,
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,43598063610,NDC,facility,outpatient,1000,ME,301.00000,87.29000,Aetna,First Health,,246.22,,,,,,,0.03852,246.22,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,43598063510,NDC,facility,inpatient,500,ME,177.60000,51.50000,Aetna,First Health,,145.28,,,,,,,64.02,145.28,percent of total billed charges,
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,43598063510,NDC,facility,outpatient,500,ME,177.60000,51.50000,Aetna,First Health,,145.28,,,,,,,0.03852,145.28,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,43598061611,NDC,facility,inpatient,0.4,ME,479.65000,139.10000,Aetna,First Health,,392.35,,,,,,,172.91,392.35,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,43598061611,NDC,facility,outpatient,0.4,ME,479.65000,139.10000,Aetna,First Health,,392.35,,,,,,,2.58,392.35,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,43598061111,NDC,facility,inpatient,20,ME,458.00000,132.82000,Aetna,First Health,,374.64,,,,,,,165.11,374.64,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,43598061111,NDC,facility,outpatient,20,ME,458.00000,132.82000,Aetna,First Health,,374.64,,,,,,,0.62595,374.64,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,43598061040,NDC,facility,inpatient,80,ME,1627.00000,471.83000,Aetna,First Health,,1330.89,,,,,,,586.53,1330.89,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,43598061040,NDC,facility,outpatient,80,ME,1627.00000,471.83000,Aetna,First Health,,1330.89,,,,,,,0.62595,1330.89,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,43598060902,NDC,facility,inpatient,7.5,ME,344.25000,99.83000,Aetna,First Health,,281.60,,,,,,,124.10,281.60,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,43598060902,NDC,facility,outpatient,7.5,ME,344.25000,99.83000,Aetna,First Health,,281.60,,,,,,,0.84744,281.60,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,43598060702,NDC,facility,inpatient,2.5,ME,149.80000,43.44000,Aetna,First Health,,122.54,,,,,,,54.00,122.54,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,43598060702,NDC,facility,outpatient,2.5,ME,149.80000,43.44000,Aetna,First Health,,122.54,,,,,,,0.84744,122.54,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,43598058723,NDC,,,facility,inpatient,1,EA,127.70000,37.03000,Aetna,First Health,,104.46,,,,,,,47.25,104.46,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,43598058723,NDC,,,facility,outpatient,1,EA,127.70000,37.03000,Aetna,First Health,,104.46,,,,,,,46.04,104.46,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,43598054910,NDC,facility,inpatient,1,GM,283.80000,82.30000,Aetna,First Health,,232.15,,,,,,,102.31,232.15,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,43598054910,NDC,facility,outpatient,1,GM,283.80000,82.30000,Aetna,First Health,,232.15,,,,,,,0.08667,232.15,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,43598054821,NDC,facility,inpatient,0.5,GM,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,51.48,116.81,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,43598054821,NDC,facility,outpatient,0.5,GM,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,0.08667,116.81,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43598053660,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43598053660,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,43598043611,NDC,,,facility,inpatient,1,EA,182.05000,52.79000,Aetna,First Health,,148.92,,,,,,,109.23,148.92,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,43598043611,NDC,,,facility,outpatient,1,EA,182.05000,52.79000,Aetna,First Health,,148.92,,,,,,,65.63,148.92,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,43598040516,NDC,facility,inpatient,10,ME,262.70000,76.18000,Aetna,First Health,,214.89,,,,,,,94.70,214.89,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,43598040516,NDC,facility,outpatient,10,ME,262.70000,76.18000,Aetna,First Health,,214.89,,,,,,,2.71,214.89,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,43598033111,NDC,facility,inpatient,5,ME,1878.85000,544.87000,Aetna,First Health,,1536.90,,,,,,,677.33,1536.90,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,43598033111,NDC,facility,outpatient,5,ME,1878.85000,544.87000,Aetna,First Health,,1536.90,,,,,,,4.89,1536.90,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,inpatient,4,ME,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,240.81,546.42,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,outpatient,4,ME,668.00000,193.72000,Aetna,First Health,,546.42,,,,,,,4.89,546.42,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,43598032675,NDC,,,facility,inpatient,1,EA,1651.60000,478.96000,Aetna,First Health,,1351.01,,,,,,,990.96,1351.01,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,43598032675,NDC,,,facility,outpatient,1,EA,1651.60000,478.96000,Aetna,First Health,,1351.01,,,,,,,595.40,1351.01,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,43598030562,NDC,facility,inpatient,100,ME,1267.00000,367.43000,Aetna,First Health,,1036.41,,,,,,,456.75,1036.41,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,43598030562,NDC,facility,outpatient,100,ME,1267.00000,367.43000,Aetna,First Health,,1036.41,,,,,,,0.44298,1036.41,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,43598021085,NDC,,,facility,inpatient,1,EA,189.15000,54.85000,Aetna,First Health,,154.72,,,,,,,113.49,154.72,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,43598021085,NDC,,,facility,outpatient,1,EA,189.15000,54.85000,Aetna,First Health,,154.72,,,,,,,68.19,154.72,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,43598020452,NDC,,,facility,inpatient,1,EA,51.40000,14.91000,Aetna,First Health,,42.05,,,,,,,30.84,42.05,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,43598020452,NDC,,,facility,outpatient,1,EA,51.40000,14.91000,Aetna,First Health,,42.05,,,,,,,18.53,42.05,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,43598020451,NDC,,,facility,inpatient,1,EA,51.30000,14.88000,Aetna,First Health,,41.96,,,,,,,30.78,41.96,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,43598020451,NDC,,,facility,outpatient,1,EA,51.30000,14.88000,Aetna,First Health,,41.96,,,,,,,18.49,41.96,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,43598016630,NDC,,,facility,inpatient,1,EA,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,84.60,115.34,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,43598016630,NDC,,,facility,outpatient,1,EA,141.00000,40.89000,Aetna,First Health,,115.34,,,,,,,50.83,115.34,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,43598016430,NDC,,,facility,inpatient,1,EA,93.55000,27.13000,Aetna,First Health,,76.52,,,,,,,56.13,76.52,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,43598016430,NDC,,,facility,outpatient,1,EA,93.55000,27.13000,Aetna,First Health,,76.52,,,,,,,33.72,76.52,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,43598016053,NDC,,,facility,inpatient,1,EA,107.05000,31.04000,Aetna,First Health,,87.57,,,,,,,64.23,87.57,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,43598016053,NDC,,,facility,outpatient,1,EA,107.05000,31.04000,Aetna,First Health,,87.57,,,,,,,38.59,87.57,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,43598013074,NDC,facility,inpatient,1,GM,305.50000,88.60000,Aetna,First Health,,249.90,,,,,,,110.13,249.90,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,43598013074,NDC,facility,outpatient,1,GM,305.50000,88.60000,Aetna,First Health,,249.90,,,,,,,0.25038,249.90,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,43598012811,NDC,facility,inpatient,500,ME,1454.20000,421.72000,Aetna,First Health,,1189.54,,,,,,,524.24,1189.54,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,43598012811,NDC,facility,outpatient,500,ME,1454.20000,421.72000,Aetna,First Health,,1189.54,,,,,,,0.25038,1189.54,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,43598010610,NDC,facility,inpatient,10,ME,234.50000,68.00000,Aetna,First Health,,191.82,,,,,,,84.54,191.82,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,43598010610,NDC,facility,outpatient,10,ME,234.50000,68.00000,Aetna,First Health,,191.82,,,,,,,6.44,191.82,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,43598008525,NDC,facility,inpatient,20,UN,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,293.63,666.26,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,43598008525,NDC,facility,outpatient,20,UN,814.50000,236.20000,Aetna,First Health,,666.26,,,,,,,0.51039,666.26,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,43598005311,NDC,facility,inpatient,0.04,ME,3967.00000,1150.43000,Aetna,First Health,,3245.01,,,,,,,1430.10,3245.01,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,43598005311,NDC,facility,outpatient,0.04,ME,3967.00000,1150.43000,Aetna,First Health,,3245.01,,,,,,,3.28,3245.01,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,43598005025,NDC,facility,inpatient,200,ME,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,43598005025,NDC,facility,outpatient,200,ME,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,1.74,33.42,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,43598002114,NDC,,,facility,inpatient,1,EA,509.65000,147.80000,Aetna,First Health,,416.89,,,,,,,305.79,416.89,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,43598002114,NDC,,,facility,outpatient,1,EA,509.65000,147.80000,Aetna,First Health,,416.89,,,,,,,183.73,416.89,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,43547063925,NDC,facility,inpatient,0.2,ME,17.35000,5.03000,Aetna,First Health,,14.19,,,,,,,6.25,14.19,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,43547063925,NDC,facility,outpatient,0.2,ME,17.35000,5.03000,Aetna,First Health,,14.19,,,,,,,0.36594,14.19,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,43547054325,NDC,facility,inpatient,0.2,ME,17.35000,5.03000,Aetna,First Health,,14.19,,,,,,,6.25,14.19,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,43547054325,NDC,facility,outpatient,0.2,ME,17.35000,5.03000,Aetna,First Health,,14.19,,,,,,,0.36594,14.19,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,43547052509,NDC,,,facility,inpatient,1,EA,33.55000,9.73000,Aetna,First Health,,27.44,,,,,,,20.13,27.44,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,43547052509,NDC,,,facility,outpatient,1,EA,33.55000,9.73000,Aetna,First Health,,27.44,,,,,,,12.09,27.44,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,43547040610,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,43547040610,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,43547040510,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,43547040510,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,43547040210,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,43547040210,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,43547040110,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,43547040110,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,43547036909,NDC,,,facility,inpatient,1,EA,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,21.90,29.86,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,43547036909,NDC,,,facility,outpatient,1,EA,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,13.16,29.86,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,43547036809,NDC,,,facility,inpatient,1,EA,34.20000,9.92000,Aetna,First Health,,27.98,,,,,,,20.52,27.98,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,43547036809,NDC,,,facility,outpatient,1,EA,34.20000,9.92000,Aetna,First Health,,27.98,,,,,,,12.33,27.98,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,43547035410,NDC,,,facility,inpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,4.50,6.13,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,43547035410,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,2.70,6.13,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,43547034703,NDC,,,facility,inpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,11.34,15.46,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,43547034703,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,6.81,15.46,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43547028810,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43547028810,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,43547028210,NDC,,,facility,inpatient,1,EA,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,19.20,26.18,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,43547028210,NDC,,,facility,outpatient,1,EA,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,11.54,26.18,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,43547028110,NDC,,,facility,inpatient,1,EA,30.65000,8.89000,Aetna,First Health,,25.07,,,,,,,18.39,25.07,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,43547028110,NDC,,,facility,outpatient,1,EA,30.65000,8.89000,Aetna,First Health,,25.07,,,,,,,11.05,25.07,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,43547028010,NDC,,,facility,inpatient,1,EA,29.40000,8.53000,Aetna,First Health,,24.05,,,,,,,17.64,24.05,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,43547028010,NDC,,,facility,outpatient,1,EA,29.40000,8.53000,Aetna,First Health,,24.05,,,,,,,10.60,24.05,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,43547027509,NDC,,,facility,inpatient,1,EA,61.30000,17.78000,Aetna,First Health,,50.14,,,,,,,36.78,50.14,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,43547027509,NDC,,,facility,outpatient,1,EA,61.30000,17.78000,Aetna,First Health,,50.14,,,,,,,22.10,50.14,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,43547027503,NDC,,,facility,inpatient,1,EA,61.30000,17.78000,Aetna,First Health,,50.14,,,,,,,36.78,50.14,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,43547027503,NDC,,,facility,outpatient,1,EA,61.30000,17.78000,Aetna,First Health,,50.14,,,,,,,22.10,50.14,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,43547027110,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,43547027110,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,43547027010,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,43547027010,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,43547026810,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,43547026810,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,43547025750,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,43547025750,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,43547025710,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,43547025710,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,43547025610,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,43547025610,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,43547025550,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,43547025550,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,43547025510,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,43547025510,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,43547025410,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,43547025410,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,43547022215,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,43547022215,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,43538060030,NDC,,,facility,inpatient,1,EA,167.20000,48.49000,Aetna,First Health,,136.77,,,,,,,100.32,136.77,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,43538060030,NDC,,,facility,outpatient,1,EA,167.20000,48.49000,Aetna,First Health,,136.77,,,,,,,60.28,136.77,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,43478090188,NDC,,,facility,inpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,10.14,13.82,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,43478090188,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,6.09,13.82,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,43478090088,NDC,,,facility,inpatient,1,EA,14.45000,4.19000,Aetna,First Health,,11.82,,,,,,,8.67,11.82,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,43478090088,NDC,,,facility,outpatient,1,EA,14.45000,4.19000,Aetna,First Health,,11.82,,,,,,,5.21,11.82,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,43386077101,NDC,,,facility,inpatient,1,EA,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,323.40,440.90,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,43386077101,NDC,,,facility,outpatient,1,EA,539.00000,156.31000,Aetna,First Health,,440.90,,,,,,,194.31,440.90,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,43386062230,NDC,,,facility,inpatient,1,EA,255.55000,74.11000,Aetna,First Health,,209.04,,,,,,,153.33,209.04,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,43386062230,NDC,,,facility,outpatient,1,EA,255.55000,74.11000,Aetna,First Health,,209.04,,,,,,,92.13,209.04,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,43386053001,NDC,,,facility,inpatient,1,EA,264.70000,76.76000,Aetna,First Health,,216.52,,,,,,,158.82,216.52,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,43386053001,NDC,,,facility,outpatient,1,EA,264.70000,76.76000,Aetna,First Health,,216.52,,,,,,,95.42,216.52,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,43386051087,NDC,,,facility,inpatient,1,EA,172.90000,50.14000,Aetna,First Health,,141.43,,,,,,,103.74,141.43,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,43386051087,NDC,,,facility,outpatient,1,EA,172.90000,50.14000,Aetna,First Health,,141.43,,,,,,,62.33,141.43,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,43386048026,NDC,,,facility,inpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,9.42,12.84,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,43386048026,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,5.66,12.84,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,43386048024,NDC,,,facility,inpatient,1,EA,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,9.81,13.37,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,43386048024,NDC,,,facility,outpatient,1,EA,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,5.89,13.37,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,43386044024,NDC,,,facility,inpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,5.46,7.44,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,43386044024,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,3.28,7.44,percent of total billed charges,
Nitazoxanide 500mg Tab,800017652,CDM,637,RC,43386040512,NDC,,,facility,inpatient,1,EA,1011.85000,293.44000,Aetna,First Health,,827.69,,,,,,,607.11,827.69,percent of total billed charges,
Nitazoxanide 500mg Tab,800017652,CDM,637,RC,43386040512,NDC,,,facility,outpatient,1,EA,1011.85000,293.44000,Aetna,First Health,,827.69,,,,,,,364.77,827.69,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,43386036021,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,43386036021,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,43386033001,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,43386033001,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,43386031208,NDC,,,facility,inpatient,1,EA,99.35000,28.81000,Aetna,First Health,,81.27,,,,,,,36.76,81.27,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,43386031208,NDC,,,facility,outpatient,1,EA,99.35000,28.81000,Aetna,First Health,,81.27,,,,,,,35.82,81.27,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,43386016106,NDC,,,facility,inpatient,1,EA,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,43386016106,NDC,,,facility,outpatient,1,EA,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,43386016101,NDC,,,facility,inpatient,1,EA,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,43386016101,NDC,,,facility,outpatient,1,EA,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,43386016012,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,43386016012,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,43386016006,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,43386016006,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
miSOPROStol 25mcg/0.25 Tab,800025693,CDM,637,RC,43386016006,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
miSOPROStol 25mcg/0.25 Tab,800025693,CDM,637,RC,43386016006,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,43386014028,NDC,,,facility,inpatient,1,EA,448.50000,130.06000,Aetna,First Health,,366.87,,,,,,,269.10,366.87,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,43386014028,NDC,,,facility,outpatient,1,EA,448.50000,130.06000,Aetna,First Health,,366.87,,,,,,,161.68,366.87,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,43386014001,NDC,,,facility,inpatient,1,EA,51.85000,15.04000,Aetna,First Health,,42.41,,,,,,,31.11,42.41,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,43386014001,NDC,,,facility,outpatient,1,EA,51.85000,15.04000,Aetna,First Health,,42.41,,,,,,,18.69,42.41,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,43386009661,NDC,,,facility,inpatient,1,EA,1604.55000,465.32000,Aetna,First Health,,1312.52,,,,,,,962.73,1312.52,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,43386009661,NDC,,,facility,outpatient,1,EA,1604.55000,465.32000,Aetna,First Health,,1312.52,,,,,,,578.44,1312.52,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,43386009019,NDC,,,facility,inpatient,1,EA,149.55000,43.37000,Aetna,First Health,,122.33,,,,,,,89.73,122.33,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,43386009019,NDC,,,facility,outpatient,1,EA,149.55000,43.37000,Aetna,First Health,,122.33,,,,,,,53.91,122.33,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,43386006019,NDC,,,facility,inpatient,1,EA,208.70000,60.52000,Aetna,First Health,,170.72,,,,,,,125.22,170.72,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,43386006019,NDC,,,facility,outpatient,1,EA,208.70000,60.52000,Aetna,First Health,,170.72,,,,,,,75.24,170.72,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,43199002124,NDC,,,facility,inpatient,1,EA,13.95000,4.05000,Aetna,First Health,,11.41,,,,,,,8.37,11.41,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,43199002124,NDC,,,facility,outpatient,1,EA,13.95000,4.05000,Aetna,First Health,,11.41,,,,,,,5.03,11.41,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,43199002112,NDC,,,facility,inpatient,1,EA,16.15000,4.68000,Aetna,First Health,,13.21,,,,,,,9.69,13.21,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,43199002112,NDC,,,facility,outpatient,1,EA,16.15000,4.68000,Aetna,First Health,,13.21,,,,,,,5.82,13.21,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,43199002001,NDC,,,facility,inpatient,1,EA,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,8.88,12.11,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,43199002001,NDC,,,facility,outpatient,1,EA,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,5.34,12.11,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,43199001101,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,43199001101,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,43066099710,NDC,,,facility,inpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.80,26.09,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,43066099710,NDC,,,facility,outpatient,1,EA,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.50,26.09,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,43066099524,NDC,facility,inpatient,900,ME,133.10000,38.60000,Aetna,First Health,,108.88,,,,,,,47.98,108.88,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,43066099524,NDC,facility,outpatient,900,ME,133.10000,38.60000,Aetna,First Health,,108.88,,,,,,,2.26,108.88,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,43066055712,NDC,,,facility,inpatient,1,EA,760.00000,220.40000,Aetna,First Health,,621.68,,,,,,,281.20,621.68,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,43066055712,NDC,,,facility,outpatient,1,EA,760.00000,220.40000,Aetna,First Health,,621.68,,,,,,,273.98,621.68,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,43066015210,NDC,facility,inpatient,200,ME,223.10000,64.70000,Aetna,First Health,,182.50,,,,,,,80.43,182.50,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,43066015210,NDC,facility,outpatient,200,ME,223.10000,64.70000,Aetna,First Health,,182.50,,,,,,,0.04815,182.50,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,43066009025,NDC,facility,inpatient,10,ME,33.85000,9.82000,Aetna,First Health,,27.69,,,,,,,12.20,27.69,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,43066009025,NDC,facility,outpatient,10,ME,33.85000,9.82000,Aetna,First Health,,27.69,,,,,,,2.43,27.69,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,inpatient,150,ME,51.10000,14.82000,Aetna,First Health,,41.80,,,,,,,18.42,41.80,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,outpatient,150,ME,51.10000,14.82000,Aetna,First Health,,41.80,,,,,,,0.04815,41.80,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,43066001510,NDC,facility,inpatient,40,ME,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,11.52,26.14,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,43066001510,NDC,facility,outpatient,40,ME,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,0.04815,26.14,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,43066000710,NDC,,,facility,inpatient,1,EA,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,8.73,19.30,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,43066000710,NDC,,,facility,outpatient,1,EA,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,8.51,19.30,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,42998040205,NDC,,,facility,inpatient,1,EA,12883.50000,3736.21000,Aetna,First Health,,10538.70,,,,,,,4766.90,10538.70,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,42998040205,NDC,,,facility,outpatient,1,EA,12883.50000,3736.21000,Aetna,First Health,,10538.70,,,,,,,4644.50,10538.70,percent of total billed charges,
Isoproterenol HCl 1mg/5mL Inj - for IV Set,800025518,CDM,250,RC,42998040205,NDC,,,facility,inpatient,1,EA,12883.50000,3736.21000,Aetna,First Health,,10538.70,,,,,,,4766.90,10538.70,percent of total billed charges,
Isoproterenol HCl 1mg/5mL Inj - for IV Set,800025518,CDM,250,RC,42998040205,NDC,,,facility,outpatient,1,EA,12883.50000,3736.21000,Aetna,First Health,,10538.70,,,,,,,4644.50,10538.70,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,42998030202,NDC,,,facility,inpatient,1,EA,3380.45000,980.33000,Aetna,First Health,,2765.21,,,,,,,1250.77,2765.21,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,42998030202,NDC,,,facility,outpatient,1,EA,3380.45000,980.33000,Aetna,First Health,,2765.21,,,,,,,1218.65,2765.21,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,42865030002,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,42865030002,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,42858080201,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,42858080201,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,42858080101,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,42858080101,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
HYDROmorphone 1mg/1mL Oral Soln,800025664,CDM,250,RC,42858030416,NDC,,,facility,inpatient,1,ML,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.18,2.62,percent of total billed charges,
HYDROmorphone 1mg/1mL Oral Soln,800025664,CDM,250,RC,42858030416,NDC,,,facility,outpatient,1,ML,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,42858030301,NDC,,,facility,inpatient,1,EA,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,4.38,5.97,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,42858030301,NDC,,,facility,outpatient,1,EA,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,2.63,5.97,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,42858030225,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,42858030225,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,42858030201,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,42858030201,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,42858030125,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,42858030125,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,42858030101,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,42858030101,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,42858000110,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,42858000110,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,42806071401,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,42806071401,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,42806050301,NDC,,,facility,inpatient,1,EA,52.05000,15.09000,Aetna,First Health,,42.58,,,,,,,31.23,42.58,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,42806050301,NDC,,,facility,outpatient,1,EA,52.05000,15.09000,Aetna,First Health,,42.58,,,,,,,18.76,42.58,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,42806014731,NDC,,,facility,inpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,49.38,67.32,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,42806014731,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,29.67,67.32,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,42806014301,NDC,,,facility,inpatient,1,EA,133.10000,38.60000,Aetna,First Health,,108.88,,,,,,,79.86,108.88,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,42806014301,NDC,,,facility,outpatient,1,EA,133.10000,38.60000,Aetna,First Health,,108.88,,,,,,,47.98,108.88,percent of total billed charges,
Ivermectin 3 mg T(Stomectol),800017621,CDM,637,RC,42799080601,NDC,,,facility,inpatient,1,EA,35.20000,10.21000,Aetna,First Health,,28.79,,,,,,,21.12,28.79,percent of total billed charges,
Ivermectin 3 mg T(Stomectol),800017621,CDM,637,RC,42799080601,NDC,,,facility,outpatient,1,EA,35.20000,10.21000,Aetna,First Health,,28.79,,,,,,,12.69,28.79,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,42799021701,NDC,,,facility,inpatient,1,EA,50.25000,14.57000,Aetna,First Health,,41.10,,,,,,,30.15,41.10,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,42799021701,NDC,,,facility,outpatient,1,EA,50.25000,14.57000,Aetna,First Health,,41.10,,,,,,,18.12,41.10,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,42794001902,NDC,,,facility,inpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,4.41,6.01,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,42794001902,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,2.65,6.01,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,42794001802,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,42794001802,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,42582030010,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,42582030010,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,42571016242,NDC,,,facility,inpatient,1,EA,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,21.45,29.24,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,42571016242,NDC,,,facility,outpatient,1,EA,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,12.89,29.24,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,42571014126,NDC,,,facility,inpatient,1,EA,446.15000,129.38000,Aetna,First Health,,364.95,,,,,,,267.69,364.95,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,42571014126,NDC,,,facility,outpatient,1,EA,446.15000,129.38000,Aetna,First Health,,364.95,,,,,,,160.84,364.95,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,42571013726,NDC,,,facility,inpatient,1,EA,681.50000,197.64000,Aetna,First Health,,557.47,,,,,,,408.90,557.47,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,42571013726,NDC,,,facility,outpatient,1,EA,681.50000,197.64000,Aetna,First Health,,557.47,,,,,,,245.68,557.47,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,42571013725,NDC,,,facility,inpatient,1,EA,681.50000,197.64000,Aetna,First Health,,557.47,,,,,,,408.90,557.47,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,42571013725,NDC,,,facility,outpatient,1,EA,681.50000,197.64000,Aetna,First Health,,557.47,,,,,,,245.68,557.47,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,42543040701,NDC,,,facility,inpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,10.44,14.23,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,42543040701,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,6.27,14.23,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,42543005261,NDC,,,facility,inpatient,1,EA,195.70000,56.75000,Aetna,First Health,,160.08,,,,,,,117.42,160.08,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,42543005261,NDC,,,facility,outpatient,1,EA,195.70000,56.75000,Aetna,First Health,,160.08,,,,,,,70.55,160.08,percent of total billed charges,
PHENobarbital 130mg/1mL  Inj,800051979,CDM,636,RC,J2560,HCPCS,42494044225,NDC,facility,inpatient,130,ME,513.70000,148.97000,Aetna,First Health,,420.21,,,,,,,185.19,420.21,percent of total billed charges,
PHENobarbital 130mg/1mL  Inj,800051979,CDM,636,RC,J2560,HCPCS,42494044225,NDC,facility,outpatient,130,ME,513.70000,148.97000,Aetna,First Health,,420.21,,,,,,,28.00,420.21,percent of total billed charges,
PHENobarbital 65mg/1mL Inj,800077015,CDM,636,RC,J2560,HCPCS,42494044125,NDC,facility,inpatient,65,ME,132.75000,38.50000,Aetna,First Health,,108.59,,,,,,,47.86,108.59,percent of total billed charges,
PHENobarbital 65mg/1mL Inj,800077015,CDM,636,RC,J2560,HCPCS,42494044125,NDC,facility,outpatient,65,ME,132.75000,38.50000,Aetna,First Health,,108.59,,,,,,,28.00,108.59,percent of total billed charges,
PHENobarbital 130mg/1mL  Inj,800051979,CDM,636,RC,J2560,HCPCS,42494041625,NDC,facility,inpatient,130,ME,513.70000,148.97000,Aetna,First Health,,420.21,,,,,,,185.19,420.21,percent of total billed charges,
PHENobarbital 130mg/1mL  Inj,800051979,CDM,636,RC,J2560,HCPCS,42494041625,NDC,facility,outpatient,130,ME,513.70000,148.97000,Aetna,First Health,,420.21,,,,,,,28.00,420.21,percent of total billed charges,
PHENobarbital 65mg/1mL Inj,800077015,CDM,636,RC,J2560,HCPCS,42494041525,NDC,facility,inpatient,65,ME,209.40000,60.73000,Aetna,First Health,,171.29,,,,,,,75.49,171.29,percent of total billed charges,
PHENobarbital 65mg/1mL Inj,800077015,CDM,636,RC,J2560,HCPCS,42494041525,NDC,facility,outpatient,65,ME,209.40000,60.73000,Aetna,First Health,,171.29,,,,,,,28.00,171.29,percent of total billed charges,
Emtricitabine-Tenofovir 200-300mg T(Truvada),800017719,CDM,637,RC,42385095330,NDC,,,facility,inpatient,1,EA,465.65000,135.04000,Aetna,First Health,,380.90,,,,,,,279.39,380.90,percent of total billed charges,
Emtricitabine-Tenofovir 200-300mg T(Truvada),800017719,CDM,637,RC,42385095330,NDC,,,facility,outpatient,1,EA,465.65000,135.04000,Aetna,First Health,,380.90,,,,,,,167.87,380.90,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,42292004120,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,42292004120,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,42292004020,NDC,,,facility,inpatient,1,EA,6.20000,1.80000,Aetna,First Health,,5.07,,,,,,,3.72,5.07,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,42292004020,NDC,,,facility,outpatient,1,EA,6.20000,1.80000,Aetna,First Health,,5.07,,,,,,,2.24,5.07,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,42292003820,NDC,,,facility,inpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,2.58,3.52,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,42292003820,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,1.55,3.52,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,42291080815,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,42291080815,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,42291036601,NDC,,,facility,inpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,17.67,24.09,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,42291036601,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,10.62,24.09,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,42291035190,NDC,,,facility,inpatient,1,EA,654.30000,189.75000,Aetna,First Health,,535.22,,,,,,,392.58,535.22,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,42291035190,NDC,,,facility,outpatient,1,EA,654.30000,189.75000,Aetna,First Health,,535.22,,,,,,,235.88,535.22,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,42192080101,NDC,,,facility,inpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,11.46,15.62,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,42192080101,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,6.89,15.62,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,42192061701,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,42192061701,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Gabapentin 100mg/2mL Oral Liq UD,800025502,CDM,637,RC,42192060816,NDC,,,facility,inpatient,1,EA,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,7.08,9.65,percent of total billed charges,
Gabapentin 100mg/2mL Oral Liq UD,800025502,CDM,637,RC,42192060816,NDC,,,facility,outpatient,1,EA,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,4.25,9.65,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,42192060510,NDC,,,facility,inpatient,1,EA,294.25000,85.33000,Aetna,First Health,,240.70,,,,,,,108.87,240.70,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,42192060510,NDC,,,facility,outpatient,1,EA,294.25000,85.33000,Aetna,First Health,,240.70,,,,,,,106.08,240.70,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,42192032901,NDC,,,facility,inpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,4.44,6.05,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,42192032901,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,2.67,6.05,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,42192032801,NDC,,,facility,inpatient,1,EA,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,9.03,12.31,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,42192032801,NDC,,,facility,outpatient,1,EA,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,5.43,12.31,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,42043014105,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,5.22,7.12,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,42043014105,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,42037010479,NDC,,,facility,inpatient,1,EA,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,26.27,58.08,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,42037010479,NDC,,,facility,outpatient,1,EA,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,25.60,58.08,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,42037010478,NDC,,,facility,inpatient,1,EA,62.30000,18.07000,Aetna,First Health,,50.96,,,,,,,23.05,50.96,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,42037010478,NDC,,,facility,outpatient,1,EA,62.30000,18.07000,Aetna,First Health,,50.96,,,,,,,22.46,50.96,percent of total billed charges,
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,42023023010,NDC,facility,inpatient,100,ME,1253.90000,363.63000,Aetna,First Health,,1025.69,,,,,,,452.03,1025.69,percent of total billed charges,
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,42023023010,NDC,facility,outpatient,100,ME,1253.90000,363.63000,Aetna,First Health,,1025.69,,,,,,,0.24075,1025.69,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,42023022110,NDC,facility,inpatient,1,GM,1000.15000,290.04000,Aetna,First Health,,818.12,,,,,,,360.55,818.12,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,42023022110,NDC,facility,outpatient,1,GM,1000.15000,290.04000,Aetna,First Health,,818.12,,,,,,,8.82,818.12,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,42023021410,NDC,facility,inpatient,50,ME,226.20000,65.60000,Aetna,First Health,,185.03,,,,,,,81.55,185.03,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,42023021410,NDC,facility,outpatient,50,ME,226.20000,65.60000,Aetna,First Health,,185.03,,,,,,,83.69,185.03,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,42023020501,NDC,facility,inpatient,400,UN,3377.20000,979.39000,Aetna,First Health,,2762.55,,,,,,,2026.32,2762.55,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,42023020501,NDC,facility,outpatient,400,UN,3377.20000,979.39000,Aetna,First Health,,2762.55,,,,,,,1217.48,2762.55,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,42023018910,NDC,facility,inpatient,10,ME,265.10000,76.88000,Aetna,First Health,,216.85,,,,,,,95.57,216.85,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,42023018910,NDC,facility,outpatient,10,ME,265.10000,76.88000,Aetna,First Health,,216.85,,,,,,,0.92448,216.85,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,1,ME,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.68495,1.55,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,outpatient,1,ME,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.41409,1.55,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,inpatient,20,UN,127.70000,37.03000,Aetna,First Health,,104.46,,,,,,,46.04,104.46,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,outpatient,20,UN,127.70000,37.03000,Aetna,First Health,,104.46,,,,,,,0.51039,104.46,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,42023016301,NDC,facility,inpatient,5,ME,1611.05000,467.20000,Aetna,First Health,,1317.84,,,,,,,580.78,1317.84,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,42023016301,NDC,facility,outpatient,5,ME,1611.05000,467.20000,Aetna,First Health,,1317.84,,,,,,,4.89,1317.84,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,1,ME,95.50000,27.69000,Aetna,First Health,,78.12,,,,,,,34.43,78.12,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,outpatient,1,ME,95.50000,27.69000,Aetna,First Health,,78.12,,,,,,,0.41409,78.12,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,42023015101,NDC,facility,inpatient,4,ME,577.45000,167.46000,Aetna,First Health,,472.35,,,,,,,208.17,472.35,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,42023015101,NDC,facility,outpatient,4,ME,577.45000,167.46000,Aetna,First Health,,472.35,,,,,,,4.89,472.35,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,42023014025,NDC,facility,inpatient,10,UN,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,42023014025,NDC,facility,outpatient,10,UN,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,1.00,4.87,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,42023013810,NDC,,,facility,inpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,1.55,3.44,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,42023013810,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,1.51,3.44,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023012225,NDC,facility,inpatient,1,ME,12.15000,3.52000,Aetna,First Health,,9.94,,,,,,,4.38,9.94,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023012225,NDC,facility,outpatient,1,ME,12.15000,3.52000,Aetna,First Health,,9.94,,,,,,,0.41409,9.94,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,42023011725,NDC,facility,inpatient,20,UN,27.25000,7.90000,Aetna,First Health,,22.29,,,,,,,9.82,22.29,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,42023011725,NDC,facility,outpatient,20,UN,27.25000,7.90000,Aetna,First Health,,22.29,,,,,,,0.51039,22.29,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,inpatient,10,UN,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,8.29,18.81,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,outpatient,10,UN,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,1.00,18.81,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,42023011410,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.50,5.52,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,42023011410,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,42023010405,NDC,facility,inpatient,5,UN,54.85000,15.91000,Aetna,First Health,,44.87,,,,,,,19.77,44.87,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,42023010405,NDC,facility,outpatient,5,UN,54.85000,15.91000,Aetna,First Health,,44.87,,,,,,,9.58,65.38,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,42023010401,NDC,facility,inpatient,5,UN,70.35000,20.40000,Aetna,First Health,,57.55,,,,,,,25.36,57.55,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,42023010401,NDC,facility,outpatient,5,UN,70.35000,20.40000,Aetna,First Health,,57.55,,,,,,,9.58,65.38,percent of total billed charges,
EPINEPHrine 1:1000 Topical Soln 30mL,800081136,CDM,250,RC,42023010301,NDC,,,facility,inpatient,1,EA,1812.45000,525.61000,Aetna,First Health,,1482.58,,,,,,,670.61,1482.58,percent of total billed charges,
EPINEPHrine 1:1000 Topical Soln 30mL,800081136,CDM,250,RC,42023010301,NDC,,,facility,outpatient,1,EA,1812.45000,525.61000,Aetna,First Health,,1482.58,,,,,,,653.39,1482.58,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023010110,NDC,facility,inpatient,1,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023010110,NDC,facility,outpatient,1,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.41409,1.33,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,41616093144,NDC,,,facility,inpatient,1,EA,56.55000,16.40000,Aetna,First Health,,46.26,,,,,,,20.92,46.26,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,41616093144,NDC,,,facility,outpatient,1,EA,56.55000,16.40000,Aetna,First Health,,46.26,,,,,,,20.39,46.26,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,41616088244,NDC,facility,inpatient,25,ME,1815.85000,526.60000,Aetna,First Health,,1485.37,,,,,,,654.61,1485.37,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,41616088244,NDC,facility,outpatient,25,ME,1815.85000,526.60000,Aetna,First Health,,1485.37,,,,,,,0.06741,1485.37,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,41616022090,NDC,,,facility,inpatient,1,EA,683.05000,198.08000,Aetna,First Health,,558.73,,,,,,,409.83,558.73,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,41616022090,NDC,,,facility,outpatient,1,EA,683.05000,198.08000,Aetna,First Health,,558.73,,,,,,,246.24,558.73,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,41167057303,NDC,,,facility,inpatient,1,EA,151.45000,43.92000,Aetna,First Health,,123.89,,,,,,,90.87,123.89,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,41167057303,NDC,,,facility,outpatient,1,EA,151.45000,43.92000,Aetna,First Health,,123.89,,,,,,,54.60,123.89,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,41100082073,NDC,,,facility,inpatient,1,EA,59.55000,17.27000,Aetna,First Health,,48.71,,,,,,,22.03,48.71,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,41100082073,NDC,,,facility,outpatient,1,EA,59.55000,17.27000,Aetna,First Health,,48.71,,,,,,,21.47,48.71,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,40085021560,NDC,,,facility,inpatient,1,EA,752.90000,218.34000,Aetna,First Health,,615.87,,,,,,,451.74,615.87,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,40085021560,NDC,,,facility,outpatient,1,EA,752.90000,218.34000,Aetna,First Health,,615.87,,,,,,,271.42,615.87,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,40042005101,NDC,facility,inpatient,0.2,ME,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,10.13,22.99,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,40042005101,NDC,facility,outpatient,0.2,ME,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,10.40,65.87,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,39822904501,NDC,,,facility,inpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,2.76,3.76,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,39822904501,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,1.66,3.76,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,39822620002,NDC,facility,inpatient,0.004,ME,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,47.95,108.79,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,39822620002,NDC,facility,outpatient,0.004,ME,133.00000,38.57000,Aetna,First Health,,108.79,,,,,,,3.28,108.79,percent of total billed charges,
Magnesium Sulf 50% I 10mL,800020916,CDM,636,RC,J3475,HCPCS,39822402502,NDC,facility,inpatient,5,GM,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,8.09,18.36,percent of total billed charges,
Magnesium Sulf 50% I 10mL,800020916,CDM,636,RC,J3475,HCPCS,39822402502,NDC,facility,outpatient,5,GM,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,0.39483,18.36,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,39822400001,NDC,facility,inpatient,500,ME,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,10.81,24.54,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,39822400001,NDC,facility,outpatient,500,ME,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,0.03852,24.54,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,39822301501,NDC,,,facility,inpatient,1,EA,132.75000,38.50000,Aetna,First Health,,108.59,,,,,,,79.65,108.59,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,39822301501,NDC,,,facility,outpatient,1,EA,132.75000,38.50000,Aetna,First Health,,108.59,,,,,,,47.86,108.59,percent of total billed charges,
Folic Acid 5mg/mL I,800061852,CDM,250,RC,J1808,HCPCS,39822110001,NDC,facility,inpatient,50,ME,365.00000,105.85000,Aetna,First Health,,298.57,,,,,,,135.05,298.57,percent of total billed charges,
Folic Acid 5mg/mL I,800061852,CDM,250,RC,J1808,HCPCS,39822110001,NDC,facility,outpatient,50,ME,365.00000,105.85000,Aetna,First Health,,298.57,,,,,,,0.04815,298.57,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,39822100107,NDC,,,facility,inpatient,1,EA,289.30000,83.90000,Aetna,First Health,,236.65,,,,,,,107.04,236.65,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,39822100107,NDC,,,facility,outpatient,1,EA,289.30000,83.90000,Aetna,First Health,,236.65,,,,,,,104.29,236.65,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,39822100001,NDC,,,facility,inpatient,1,EA,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,22.20,49.08,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,39822100001,NDC,,,facility,outpatient,1,EA,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,21.63,49.08,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,39822041206,NDC,,,facility,inpatient,1,EA,1206.00000,349.74000,Aetna,First Health,,986.51,,,,,,,446.22,986.51,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,39822041206,NDC,,,facility,outpatient,1,EA,1206.00000,349.74000,Aetna,First Health,,986.51,,,,,,,434.76,986.51,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,39822041201,NDC,,,facility,inpatient,1,EA,648.00000,187.92000,Aetna,First Health,,530.06,,,,,,,239.76,530.06,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,39822041201,NDC,,,facility,outpatient,1,EA,648.00000,187.92000,Aetna,First Health,,530.06,,,,,,,233.60,530.06,percent of total billed charges,
Neomycin 500mg T,800016609,CDM,637,RC,39822031005,NDC,,,facility,inpatient,1,EA,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,7.20,9.82,percent of total billed charges,
Neomycin 500mg T,800016609,CDM,637,RC,39822031005,NDC,,,facility,outpatient,1,EA,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,4.33,9.82,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,39822020501,NDC,,,facility,inpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,3.66,4.99,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,39822020501,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,2.20,4.99,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,39822019007,NDC,facility,inpatient,500,ME,386.50000,112.08000,Aetna,First Health,,316.16,,,,,,,139.33,316.16,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,39822019007,NDC,facility,outpatient,500,ME,386.50000,112.08000,Aetna,First Health,,316.16,,,,,,,24.64,316.16,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,inpatient,500,ME,308.35000,89.42000,Aetna,First Health,,252.23,,,,,,,111.16,252.23,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,outpatient,500,ME,308.35000,89.42000,Aetna,First Health,,252.23,,,,,,,24.64,252.23,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,39822012706,NDC,facility,inpatient,4.5,GM,124.80000,36.19000,Aetna,First Health,,102.09,,,,,,,44.99,102.09,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,39822012706,NDC,facility,outpatient,4.5,GM,124.80000,36.19000,Aetna,First Health,,102.09,,,,,,,1.05,102.09,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,39822012504,NDC,facility,inpatient,3.375,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,34.61,78.53,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,39822012504,NDC,facility,outpatient,3.375,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,1.05,78.53,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,39822012302,NDC,facility,inpatient,2.25,GM,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,24.23,54.97,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,39822012302,NDC,facility,outpatient,2.25,GM,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,1.05,54.97,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,39328053099,NDC,,,facility,inpatient,1,EA,30.10000,8.73000,Aetna,First Health,,24.62,,,,,,,18.06,24.62,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,39328053099,NDC,,,facility,outpatient,1,EA,30.10000,8.73000,Aetna,First Health,,24.62,,,,,,,10.85,24.62,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,39328053016,NDC,,,facility,inpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,3.18,4.34,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,39328053016,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,1.91,4.34,percent of total billed charges,
Sodium Hypochlor 0.125% TS 473mL,800022086,CDM,637,RC,39328006412,NDC,,,facility,inpatient,1,EA,130.95000,37.98000,Aetna,First Health,,107.12,,,,,,,78.57,107.12,percent of total billed charges,
Sodium Hypochlor 0.125% TS 473mL,800022086,CDM,637,RC,39328006412,NDC,,,facility,outpatient,1,EA,130.95000,37.98000,Aetna,First Health,,107.12,,,,,,,47.21,107.12,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,39328005750,NDC,,,facility,inpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.75000,1.02,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,39328005750,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.45062,1.02,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,39328004715,NDC,,,facility,inpatient,1,ML,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,11.28,15.38,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,39328004715,NDC,,,facility,outpatient,1,ML,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,6.78,15.38,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,39328002415,NDC,,,facility,inpatient,1,EA,212.40000,61.60000,Aetna,First Health,,173.74,,,,,,,127.44,173.74,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,39328002415,NDC,,,facility,outpatient,1,EA,212.40000,61.60000,Aetna,First Health,,173.74,,,,,,,76.57,173.74,percent of total billed charges,
Bismuth Subgallate Pwd,800068840,CDM,250,RC,38779104605,NDC,,,facility,inpatient,1,EA,16.80000,4.87000,Aetna,First Health,,13.74,,,,,,,6.22,13.74,percent of total billed charges,
Bismuth Subgallate Pwd,800068840,CDM,250,RC,38779104605,NDC,,,facility,outpatient,1,EA,16.80000,4.87000,Aetna,First Health,,13.74,,,,,,,6.06,13.74,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,800066885,CDM,250,RC,38779059808,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.76,6.09,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,800066885,CDM,250,RC,38779059808,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,38245077410,NDC,,,facility,inpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,4.98,6.79,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,38245077410,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.99,6.79,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,37205045705,NDC,,,facility,inpatient,1,EA,28.25000,8.19000,Aetna,First Health,,23.11,,,,,,,10.45,23.11,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,37205045705,NDC,,,facility,outpatient,1,EA,28.25000,8.19000,Aetna,First Health,,23.11,,,,,,,10.18,23.11,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,37205027510,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.42,18.61,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,37205027510,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,37000000701,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,37000000701,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,36000036401,NDC,facility,inpatient,0.4,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,57.18,129.73,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,36000036401,NDC,facility,outpatient,0.4,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,2.58,129.73,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,36000032202,NDC,facility,inpatient,100,ME,13.50000,3.91000,Aetna,First Health,,11.04,,,,,,,5.00,11.04,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,36000032202,NDC,facility,outpatient,100,ME,13.50000,3.91000,Aetna,First Health,,11.04,,,,,,,0.33705,11.04,percent of total billed charges,
Labetalol 5mg/mL 4mL I(Normodyne),800046377,CDM,250,RC,J1920,HCPCS,36000032010,NDC,facility,inpatient,20,ME,26.95000,7.82000,Aetna,First Health,,22.05,,,,,,,9.97,22.05,percent of total billed charges,
Labetalol 5mg/mL 4mL I(Normodyne),800046377,CDM,250,RC,J1920,HCPCS,36000032010,NDC,facility,outpatient,20,ME,26.95000,7.82000,Aetna,First Health,,22.05,,,,,,,0.33705,22.05,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,36000030810,NDC,facility,inpatient,0.4,ME,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.50,26.09,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,36000030810,NDC,facility,outpatient,0.4,ME,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,0.06741,26.09,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,36000028806,NDC,facility,inpatient,400,ME,101.30000,29.38000,Aetna,First Health,,82.86,,,,,,,36.52,82.86,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,36000028806,NDC,facility,outpatient,400,ME,101.30000,29.38000,Aetna,First Health,,82.86,,,,,,,4.31,82.86,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,36000028706,NDC,facility,inpatient,200,ME,66.30000,19.23000,Aetna,First Health,,54.23,,,,,,,23.90,54.23,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,36000028706,NDC,facility,outpatient,200,ME,66.30000,19.23000,Aetna,First Health,,54.23,,,,,,,4.31,54.23,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,36000028425,NDC,facility,inpatient,100,ME,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,36000028425,NDC,facility,outpatient,100,ME,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,36000028325,NDC,facility,inpatient,40,ME,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,2.65,6.01,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,36000028325,NDC,facility,outpatient,40,ME,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,0.01926,6.01,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,36000028225,NDC,facility,inpatient,20,ME,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,36000028225,NDC,facility,outpatient,20,ME,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,0.01926,3.56,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,36000016210,NDC,,,facility,inpatient,1,EA,53.10000,15.40000,Aetna,First Health,,43.44,,,,,,,19.65,43.44,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,36000016210,NDC,,,facility,outpatient,1,EA,53.10000,15.40000,Aetna,First Health,,43.44,,,,,,,19.14,43.44,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,36000014810,NDC,,,facility,inpatient,1,EA,45.25000,13.12000,Aetna,First Health,,37.01,,,,,,,16.74,37.01,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,36000014810,NDC,,,facility,outpatient,1,EA,45.25000,13.12000,Aetna,First Health,,37.01,,,,,,,16.31,37.01,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,36000007210,NDC,facility,inpatient,1,GM,46.00000,13.34000,Aetna,First Health,,37.63,,,,,,,16.58,37.63,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,36000007210,NDC,facility,outpatient,1,GM,46.00000,13.34000,Aetna,First Health,,37.63,,,,,,,0.56817,37.63,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,36000007110,NDC,facility,inpatient,500,ME,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,8.11,18.41,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,36000007110,NDC,facility,outpatient,500,ME,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,0.56817,18.41,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,36000006505,NDC,facility,inpatient,100,ME,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,8.11,18.41,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,36000006505,NDC,facility,outpatient,100,ME,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,8.11,18.41,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,36000006405,NDC,facility,inpatient,40,ME,20.05000,5.81000,Aetna,First Health,,16.40,,,,,,,7.23,16.40,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,36000006405,NDC,facility,outpatient,40,ME,20.05000,5.81000,Aetna,First Health,,16.40,,,,,,,0.01926,16.40,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,36000006301,NDC,facility,inpatient,20,ME,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,4.65,10.55,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,36000006301,NDC,facility,outpatient,20,ME,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,0.01926,10.55,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,36000004824,NDC,facility,inpatient,750,ME,62.40000,18.10000,Aetna,First Health,,51.04,,,,,,,22.50,51.04,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,36000004824,NDC,facility,outpatient,750,ME,62.40000,18.10000,Aetna,First Health,,51.04,,,,,,,2.08,51.04,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,36000004724,NDC,facility,inpatient,500,ME,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,17.30,39.26,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,36000004724,NDC,facility,outpatient,500,ME,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,2.08,39.26,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,36000004624,NDC,facility,inpatient,250,ME,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,14.42,32.72,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,36000004624,NDC,facility,outpatient,250,ME,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,2.08,32.72,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,36000003310,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.46,5.44,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,36000003310,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,36000001301,NDC,facility,inpatient,4,ME,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,36000001301,NDC,facility,outpatient,4,ME,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.08667,2.13,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,36000001225,NDC,facility,inpatient,4,ME,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,36000001225,NDC,facility,outpatient,4,ME,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,0.08667,4.79,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,36000000306,NDC,facility,inpatient,400,ME,77.35000,22.43000,Aetna,First Health,,63.27,,,,,,,27.88,63.27,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,36000000306,NDC,facility,outpatient,400,ME,77.35000,22.43000,Aetna,First Health,,63.27,,,,,,,4.31,63.27,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,36000000210,NDC,facility,inpatient,200,ME,49.75000,14.43000,Aetna,First Health,,40.70,,,,,,,17.93,40.70,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,36000000210,NDC,facility,outpatient,200,ME,49.75000,14.43000,Aetna,First Health,,40.70,,,,,,,4.31,40.70,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,36000000206,NDC,facility,inpatient,200,ME,66.30000,19.23000,Aetna,First Health,,54.23,,,,,,,23.90,54.23,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,36000000206,NDC,facility,outpatient,200,ME,66.30000,19.23000,Aetna,First Health,,54.23,,,,,,,4.31,54.23,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,36000000124,NDC,facility,inpatient,500,ME,38.65000,11.21000,Aetna,First Health,,31.62,,,,,,,13.93,31.62,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,36000000124,NDC,facility,outpatient,500,ME,38.65000,11.21000,Aetna,First Health,,31.62,,,,,,,0.02889,31.62,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,35573042880,NDC,,,facility,inpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.92,2.62,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,35573042880,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
Enteral Feeding Tube Declogging Kit,800051053,CDM,272,RC,35077045609,NDC,,,facility,inpatient,1,EA,112.00000,32.48000,Aetna,First Health,,91.62,,,,,,,67.20,91.62,percent of total billed charges,
Enteral Feeding Tube Declogging Kit,800051053,CDM,272,RC,35077045609,NDC,,,facility,outpatient,1,EA,112.00000,32.48000,Aetna,First Health,,91.62,,,,,,,40.38,91.62,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,33406991501,NDC,,,facility,inpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,4.89,6.67,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,33406991501,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,2.94,6.67,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,33342033380,NDC,,,facility,inpatient,1,EA,89.75000,26.03000,Aetna,First Health,,73.42,,,,,,,53.85,73.42,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,33342033380,NDC,,,facility,outpatient,1,EA,89.75000,26.03000,Aetna,First Health,,73.42,,,,,,,32.35,73.42,percent of total billed charges,
Triamcinolone 0.025% TO 80g,800017793,CDM,637,RC,33342033180,NDC,,,facility,inpatient,1,EA,71.60000,20.76000,Aetna,First Health,,58.57,,,,,,,42.96,58.57,percent of total billed charges,
Triamcinolone 0.025% TO 80g,800017793,CDM,637,RC,33342033180,NDC,,,facility,outpatient,1,EA,71.60000,20.76000,Aetna,First Health,,58.57,,,,,,,25.81,58.57,percent of total billed charges,
Triamcinolone 0.025% TC 80g,800017792,CDM,637,RC,33342032780,NDC,,,facility,inpatient,1,EA,71.60000,20.76000,Aetna,First Health,,58.57,,,,,,,42.96,58.57,percent of total billed charges,
Triamcinolone 0.025% TC 80g,800017792,CDM,637,RC,33342032780,NDC,,,facility,outpatient,1,EA,71.60000,20.76000,Aetna,First Health,,58.57,,,,,,,25.81,58.57,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,33342025666,NDC,,,facility,inpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,60.24,82.13,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,33342025666,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,36.19,82.13,percent of total billed charges,
Tenofovir 300mg T(Viread),800017725,CDM,637,RC,33342009607,NDC,,,facility,inpatient,1,EA,281.70000,81.69000,Aetna,First Health,,230.43,,,,,,,169.02,230.43,percent of total billed charges,
Tenofovir 300mg T(Viread),800017725,CDM,637,RC,33342009607,NDC,,,facility,outpatient,1,EA,281.70000,81.69000,Aetna,First Health,,230.43,,,,,,,101.55,230.43,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,33342008307,NDC,,,facility,inpatient,1,EA,99.10000,28.74000,Aetna,First Health,,81.06,,,,,,,59.46,81.06,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,33342008307,NDC,,,facility,outpatient,1,EA,99.10000,28.74000,Aetna,First Health,,81.06,,,,,,,35.73,81.06,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,33342002607,NDC,,,facility,inpatient,1,EA,89.85000,26.06000,Aetna,First Health,,73.50,,,,,,,53.91,73.50,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,33342002607,NDC,,,facility,outpatient,1,EA,89.85000,26.06000,Aetna,First Health,,73.50,,,,,,,32.39,73.50,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,33342002507,NDC,,,facility,inpatient,1,EA,44.75000,12.98000,Aetna,First Health,,36.61,,,,,,,26.85,36.61,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,33342002507,NDC,,,facility,outpatient,1,EA,44.75000,12.98000,Aetna,First Health,,36.61,,,,,,,16.13,36.61,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,31722083710,NDC,,,facility,inpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,42.48,57.91,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,31722083710,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
Entecavir 0.5mg Tab,800046457,CDM,637,RC,31722083330,NDC,,,facility,inpatient,1,EA,307.35000,89.13000,Aetna,First Health,,251.41,,,,,,,184.41,251.41,percent of total billed charges,
Entecavir 0.5mg Tab,800046457,CDM,637,RC,31722083330,NDC,,,facility,outpatient,1,EA,307.35000,89.13000,Aetna,First Health,,251.41,,,,,,,110.80,251.41,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),800017736,CDM,637,RC,31722083260,NDC,,,facility,inpatient,1,EA,431.55000,125.15000,Aetna,First Health,,353.01,,,,,,,258.93,353.01,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),800017736,CDM,637,RC,31722083260,NDC,,,facility,outpatient,1,EA,431.55000,125.15000,Aetna,First Health,,353.01,,,,,,,155.57,353.01,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,31722075360,NDC,,,facility,inpatient,1,EA,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,30.42,41.47,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,31722075360,NDC,,,facility,outpatient,1,EA,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,18.28,41.47,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,31722074920,NDC,,,facility,inpatient,1,EA,1114.90000,323.32000,Aetna,First Health,,911.99,,,,,,,668.94,911.99,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,31722074920,NDC,,,facility,outpatient,1,EA,1114.90000,323.32000,Aetna,First Health,,911.99,,,,,,,401.92,911.99,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,31722066860,NDC,,,facility,inpatient,1,EA,52.40000,15.20000,Aetna,First Health,,42.86,,,,,,,31.44,42.86,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,31722066860,NDC,,,facility,outpatient,1,EA,52.40000,15.20000,Aetna,First Health,,42.86,,,,,,,18.89,42.86,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,31722063530,NDC,,,facility,inpatient,1,EA,66.65000,19.33000,Aetna,First Health,,54.52,,,,,,,39.99,54.52,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,31722063530,NDC,,,facility,outpatient,1,EA,66.65000,19.33000,Aetna,First Health,,54.52,,,,,,,24.03,54.52,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,31722063031,NDC,,,facility,inpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,60.24,82.13,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,31722063031,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,36.19,82.13,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,31722062921,NDC,,,facility,inpatient,1,EA,262.05000,75.99000,Aetna,First Health,,214.36,,,,,,,157.23,214.36,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,31722062921,NDC,,,facility,outpatient,1,EA,262.05000,75.99000,Aetna,First Health,,214.36,,,,,,,94.47,214.36,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,31722062830,NDC,,,facility,inpatient,1,EA,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,31722062830,NDC,,,facility,outpatient,1,EA,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,28.84,65.44,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,31722054401,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,31722054401,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,31722054201,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,31722054201,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,31722053712,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,31722053712,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,31722053612,NDC,,,facility,inpatient,1,EA,20.35000,5.90000,Aetna,First Health,,16.65,,,,,,,12.21,16.65,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,31722053612,NDC,,,facility,outpatient,1,EA,20.35000,5.90000,Aetna,First Health,,16.65,,,,,,,7.34,16.65,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,31722053401,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,31722053401,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,31722053101,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,31722053101,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,31722052901,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,31722052901,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,31722052101,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,31722052101,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,31722052001,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,31722052001,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,31722051901,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,31722051901,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,31722040505,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,31722040505,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,31722037702,NDC,facility,inpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,31722037702,NDC,facility,outpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,0.03852,5.93,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,31722030801,NDC,facility,inpatient,10,ME,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,78.95,179.14,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,31722030801,NDC,facility,outpatient,10,ME,219.00000,63.51000,Aetna,First Health,,179.14,,,,,,,0.78003,179.14,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,31722030201,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,31722030201,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,31722028301,NDC,,,facility,inpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,4.92,6.71,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,31722028301,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,2.96,6.71,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,31722028201,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,31722028201,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,31722028060,NDC,,,facility,inpatient,1,EA,48.75000,14.14000,Aetna,First Health,,39.88,,,,,,,29.25,39.88,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,31722028060,NDC,,,facility,outpatient,1,EA,48.75000,14.14000,Aetna,First Health,,39.88,,,,,,,17.57,39.88,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,31722027860,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,31722027860,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,31722025301,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,31722025301,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,31722023990,NDC,,,facility,inpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,10.14,13.82,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,31722023990,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,6.09,13.82,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,31722023890,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,31722023890,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,31722023810,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,31722023810,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,31722023790,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,31722023790,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,31722022801,NDC,,,facility,inpatient,1,EA,15.50000,4.50000,Aetna,First Health,,12.68,,,,,,,9.30,12.68,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,31722022801,NDC,,,facility,outpatient,1,EA,15.50000,4.50000,Aetna,First Health,,12.68,,,,,,,5.59,12.68,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,31722022560,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,10.32,14.07,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,31722022560,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,31722022505,NDC,,,facility,inpatient,1,EA,16.40000,4.76000,Aetna,First Health,,13.42,,,,,,,9.84,13.42,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,31722022505,NDC,,,facility,outpatient,1,EA,16.40000,4.76000,Aetna,First Health,,13.42,,,,,,,5.91,13.42,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,31722022105,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,31722022105,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,31722021601,NDC,facility,inpatient,500,ME,3394.25000,984.33000,Aetna,First Health,,2776.50,,,,,,,1223.63,2776.50,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,31722021601,NDC,facility,outpatient,500,ME,3394.25000,984.33000,Aetna,First Health,,2776.50,,,,,,,0.02889,2776.50,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,31722020930,NDC,,,facility,inpatient,1,EA,92.20000,26.74000,Aetna,First Health,,75.42,,,,,,,55.32,75.42,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,31722020930,NDC,,,facility,outpatient,1,EA,92.20000,26.74000,Aetna,First Health,,75.42,,,,,,,33.24,75.42,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,31722020901,NDC,,,facility,inpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,55.53,75.71,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,31722020901,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,First Health,,75.71,,,,,,,33.36,75.71,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,31722020410,NDC,facility,inpatient,40,ME,29.15000,8.45000,Aetna,First Health,,23.84,,,,,,,10.51,23.84,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,31722020410,NDC,facility,outpatient,40,ME,29.15000,8.45000,Aetna,First Health,,23.84,,,,,,,5.86,23.84,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,31722020320,NDC,facility,inpatient,200,ME,75.45000,21.88000,Aetna,First Health,,61.72,,,,,,,27.20,61.72,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,31722020320,NDC,facility,outpatient,200,ME,75.45000,21.88000,Aetna,First Health,,61.72,,,,,,,0.37557,61.72,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,31722013190,NDC,,,facility,inpatient,1,EA,42.85000,12.43000,Aetna,First Health,,35.05,,,,,,,25.71,35.05,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,31722013190,NDC,,,facility,outpatient,1,EA,42.85000,12.43000,Aetna,First Health,,35.05,,,,,,,15.45,35.05,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,31722013130,NDC,,,facility,inpatient,1,EA,42.85000,12.43000,Aetna,First Health,,35.05,,,,,,,25.71,35.05,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,31722013130,NDC,,,facility,outpatient,1,EA,42.85000,12.43000,Aetna,First Health,,35.05,,,,,,,15.45,35.05,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,31722013001,NDC,,,facility,inpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,10.44,14.23,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,31722013001,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,6.27,14.23,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,800021977,CDM,637,RC,31722000631,NDC,,,facility,inpatient,1,EA,174.70000,50.66000,Aetna,First Health,,142.90,,,,,,,104.82,142.90,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,800021977,CDM,637,RC,31722000631,NDC,,,facility,outpatient,1,EA,174.70000,50.66000,Aetna,First Health,,142.90,,,,,,,62.98,142.90,percent of total billed charges,
Mesalamine 1000mg Supp (Canasa),800017778,CDM,637,RC,31722000530,NDC,,,facility,inpatient,1,EA,290.15000,84.14000,Aetna,First Health,,237.34,,,,,,,174.09,237.34,percent of total billed charges,
Mesalamine 1000mg Supp (Canasa),800017778,CDM,637,RC,31722000530,NDC,,,facility,outpatient,1,EA,290.15000,84.14000,Aetna,First Health,,237.34,,,,,,,104.60,237.34,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,30698041912,NDC,,,facility,inpatient,1,EA,14.45000,4.19000,Aetna,First Health,,11.82,,,,,,,8.67,11.82,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,30698041912,NDC,,,facility,outpatient,1,EA,14.45000,4.19000,Aetna,First Health,,11.82,,,,,,,5.21,11.82,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,30698006001,NDC,,,facility,inpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,5.58,7.61,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,30698006001,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,29336054006,NDC,facility,inpatient,60,ME,151.95000,44.07000,Aetna,First Health,,124.30,,,,,,,54.78,124.30,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,29336054006,NDC,facility,outpatient,60,ME,151.95000,44.07000,Aetna,First Health,,124.30,,,,,,,6.15,124.30,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,29300042301,NDC,,,facility,inpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,29300042301,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,6.49,14.72,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,29300035916,NDC,,,facility,inpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,14.37,19.59,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,29300035916,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.63,19.59,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,29300022705,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,29300022705,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,29300022019,NDC,,,facility,inpatient,1,EA,40.05000,11.61000,Aetna,First Health,,32.76,,,,,,,24.03,32.76,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,29300022019,NDC,,,facility,outpatient,1,EA,40.05000,11.61000,Aetna,First Health,,32.76,,,,,,,14.44,32.76,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,29300017216,NDC,,,facility,inpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,25.89,35.30,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,29300017216,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,15.56,35.30,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,29300017116,NDC,,,facility,inpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,25.89,35.30,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,29300017116,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,15.56,35.30,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,29300016815,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,29300016815,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,29300014901,NDC,,,facility,inpatient,1,EA,48.55000,14.08000,Aetna,First Health,,39.71,,,,,,,29.13,39.71,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,29300014901,NDC,,,facility,outpatient,1,EA,48.55000,14.08000,Aetna,First Health,,39.71,,,,,,,17.50,39.71,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,29300013505,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,29300013505,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,29300013501,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,29300013501,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,29300012601,NDC,,,facility,inpatient,1,EA,9.95000,2.89000,Aetna,First Health,,8.14,,,,,,,5.97,8.14,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,29300012601,NDC,,,facility,outpatient,1,EA,9.95000,2.89000,Aetna,First Health,,8.14,,,,,,,3.59,8.14,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,29300011516,NDC,,,facility,inpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,10.77,14.68,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,29300011516,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,6.47,14.68,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,29033002602,NDC,facility,inpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,29033002602,NDC,facility,outpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,0.03852,5.93,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,29033000305,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,29033000305,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,29033000301,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,29033000301,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,28595012049,NDC,,,facility,inpatient,1,EA,1425.30000,413.34000,Aetna,First Health,,1165.90,,,,,,,855.18,1165.90,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,28595012049,NDC,,,facility,outpatient,1,EA,1425.30000,413.34000,Aetna,First Health,,1165.90,,,,,,,513.82,1165.90,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,27808015801,NDC,,,facility,inpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,38.01,51.82,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,27808015801,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,22.84,51.82,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,27808008602,NDC,,,facility,inpatient,1,EA,26.05000,7.55000,Aetna,First Health,,21.31,,,,,,,15.63,21.31,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,27808008602,NDC,,,facility,outpatient,1,EA,26.05000,7.55000,Aetna,First Health,,21.31,,,,,,,9.39,21.31,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,27808008601,NDC,,,facility,inpatient,1,EA,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,16.05,21.88,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,27808008601,NDC,,,facility,outpatient,1,EA,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,9.64,21.88,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,27808006502,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,27808006502,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,27808000201,NDC,,,facility,inpatient,1,EA,39.55000,11.47000,Aetna,First Health,,32.35,,,,,,,23.73,32.35,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,27808000201,NDC,,,facility,outpatient,1,EA,39.55000,11.47000,Aetna,First Health,,32.35,,,,,,,14.26,32.35,percent of total billed charges,
Cefixime 400mg C (Suprax),800063049,CDM,637,RC,27437020811,NDC,,,facility,inpatient,1,EA,197.10000,57.16000,Aetna,First Health,,161.23,,,,,,,118.26,161.23,percent of total billed charges,
Cefixime 400mg C (Suprax),800063049,CDM,637,RC,27437020811,NDC,,,facility,outpatient,1,EA,197.10000,57.16000,Aetna,First Health,,161.23,,,,,,,71.05,161.23,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,27437005057,NDC,,,facility,inpatient,1,EA,494.20000,143.32000,Aetna,First Health,,404.26,,,,,,,296.52,404.26,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,27437005057,NDC,,,facility,outpatient,1,EA,494.20000,143.32000,Aetna,First Health,,404.26,,,,,,,178.16,404.26,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,27437005056,NDC,,,facility,inpatient,1,EA,493.90000,143.23000,Aetna,First Health,,404.01,,,,,,,296.34,404.01,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,27437005056,NDC,,,facility,outpatient,1,EA,493.90000,143.23000,Aetna,First Health,,404.01,,,,,,,178.05,404.01,percent of total billed charges,
LamoTRIgine 25mg ODT,800046462,CDM,637,RC,27241018330,NDC,,,facility,inpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,38.01,51.82,percent of total billed charges,
LamoTRIgine 25mg ODT,800046462,CDM,637,RC,27241018330,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,22.84,51.82,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,27241015919,NDC,,,facility,inpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,42.48,57.91,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,27241015919,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,27241015504,NDC,,,facility,inpatient,1,EA,23.30000,6.76000,Aetna,First Health,,19.06,,,,,,,13.98,19.06,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,27241015504,NDC,,,facility,outpatient,1,EA,23.30000,6.76000,Aetna,First Health,,19.06,,,,,,,8.40,19.06,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,27241014401,NDC,,,facility,inpatient,1,EA,63.55000,18.43000,Aetna,First Health,,51.98,,,,,,,38.13,51.98,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,27241014401,NDC,,,facility,outpatient,1,EA,63.55000,18.43000,Aetna,First Health,,51.98,,,,,,,22.91,51.98,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,27241006303,NDC,,,facility,inpatient,1,EA,523.45000,151.80000,Aetna,First Health,,428.18,,,,,,,314.07,428.18,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,27241006303,NDC,,,facility,outpatient,1,EA,523.45000,151.80000,Aetna,First Health,,428.18,,,,,,,188.70,428.18,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,27241000206,NDC,,,facility,inpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,16.56,22.58,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,27241000206,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
ravulizumab-cwvz- Pt Own Supply,800046500,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,inpatient,1100,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
ravulizumab-cwvz- Pt Own Supply,800046500,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,outpatient,1100,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,693.28,percent of total billed charges,
Eculizumab- Pt Own Supply,800040879,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,inpatient,300,ME,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Eculizumab- Pt Own Supply,800040879,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,outpatient,300,ME,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,138.87,percent of total billed charges,
Indocyanine Green 25 mg I,800080225,CDM,250,RC,25431042402,NDC,,,facility,inpatient,1,EA,494.90000,143.52000,Aetna,First Health,,404.83,,,,,,,183.11,404.83,percent of total billed charges,
Indocyanine Green 25 mg I,800080225,CDM,250,RC,25431042402,NDC,,,facility,outpatient,1,EA,494.90000,143.52000,Aetna,First Health,,404.83,,,,,,,178.41,404.83,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,25208000305,NDC,,,facility,inpatient,1,EA,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,111.07,245.56,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,25208000305,NDC,,,facility,outpatient,1,EA,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,25021083082,NDC,facility,inpatient,5,ME,2917.00000,845.93000,Aetna,First Health,,2386.11,,,,,,,1051.58,2386.11,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,25021083082,NDC,facility,outpatient,5,ME,2917.00000,845.93000,Aetna,First Health,,2386.11,,,,,,,4.89,2386.11,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,25021082761,NDC,facility,inpatient,3,ME,1186.00000,343.94000,Aetna,First Health,,970.15,,,,,,,427.55,970.15,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,25021082761,NDC,facility,outpatient,3,ME,1186.00000,343.94000,Aetna,First Health,,970.15,,,,,,,12.65,970.15,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,25021082583,NDC,facility,inpatient,750,ME,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,38.07,86.38,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,25021082583,NDC,facility,outpatient,750,ME,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,2.08,86.38,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,25021082582,NDC,facility,inpatient,500,ME,111.60000,32.36000,Aetna,First Health,,91.29,,,,,,,40.23,91.29,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,25021082582,NDC,facility,outpatient,500,ME,111.60000,32.36000,Aetna,First Health,,91.29,,,,,,,2.08,91.29,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,25021082581,NDC,facility,inpatient,250,ME,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,25.60,58.08,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,25021082581,NDC,facility,outpatient,250,ME,71.00000,20.59000,Aetna,First Health,,58.08,,,,,,,2.08,58.08,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,25021081710,NDC,facility,inpatient,500,ME,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,134.47,305.11,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,25021081710,NDC,facility,outpatient,500,ME,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,24.64,305.11,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,inpatient,350,ME,626.00000,181.54000,Aetna,First Health,,512.07,,,,,,,225.67,512.07,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,outpatient,350,ME,626.00000,181.54000,Aetna,First Health,,512.07,,,,,,,3.70,512.07,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,25021081230,NDC,facility,inpatient,6000,ME,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,335.26,760.74,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,25021081230,NDC,facility,outpatient,6000,ME,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,0.35631,760.74,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,25021080601,NDC,facility,inpatient,5,ME,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,8.06,18.28,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,25021080601,NDC,facility,outpatient,5,ME,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,0.70299,18.28,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,25021080166,NDC,facility,inpatient,4,ME,1483.00000,430.07000,Aetna,First Health,,1213.09,,,,,,,534.62,1213.09,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,25021080166,NDC,facility,outpatient,4,ME,1483.00000,430.07000,Aetna,First Health,,1213.09,,,,,,,4.89,1213.09,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,25021079120,NDC,facility,inpatient,200,ME,587.60000,170.40000,Aetna,First Health,,480.66,,,,,,,211.83,480.66,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,25021079120,NDC,facility,outpatient,200,ME,587.60000,170.40000,Aetna,First Health,,480.66,,,,,,,0.37557,480.66,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,25021079002,NDC,facility,inpatient,10,ME,33.85000,9.82000,Aetna,First Health,,27.69,,,,,,,12.20,27.69,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,25021079002,NDC,facility,outpatient,10,ME,33.85000,9.82000,Aetna,First Health,,27.69,,,,,,,2.43,27.69,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,25021078220,NDC,facility,inpatient,4,ME,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,5.19,11.78,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,25021078220,NDC,facility,outpatient,4,ME,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,0.08667,11.78,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,25021078005,NDC,facility,inpatient,500,ME,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,8.65,19.63,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,25021078005,NDC,facility,outpatient,500,ME,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,0.03852,19.63,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,inpatient,4,ME,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,outpatient,4,ME,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,0.08667,6.26,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,25021075110,NDC,facility,inpatient,40,ME,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,8.06,18.28,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,25021075110,NDC,facility,outpatient,40,ME,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,5.86,18.78,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,25021070360,NDC,facility,inpatient,6,ME,164.40000,47.68000,Aetna,First Health,,134.48,,,,,,,98.64,134.48,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,25021070360,NDC,facility,outpatient,6,ME,164.40000,47.68000,Aetna,First Health,,134.48,,,,,,,59.27,273.24,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,25021070101,NDC,facility,inpatient,30,ME,31.85000,9.24000,Aetna,First Health,,26.05,,,,,,,11.48,26.05,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,25021070101,NDC,facility,outpatient,30,ME,31.85000,9.24000,Aetna,First Health,,26.05,,,,,,,0.31779,26.05,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,25021070001,NDC,facility,inpatient,15,ME,23.90000,6.93000,Aetna,First Health,,19.55,,,,,,,8.62,19.55,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,25021070001,NDC,facility,outpatient,15,ME,23.90000,6.93000,Aetna,First Health,,19.55,,,,,,,0.31779,19.55,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,25021068510,NDC,,,facility,inpatient,1,EA,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,10.40,22.99,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,25021068510,NDC,,,facility,outpatient,1,EA,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,10.13,22.99,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,25021068310,NDC,,,facility,inpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,3.37,7.44,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,25021068310,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,3.28,7.44,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,25021067410,NDC,,,facility,inpatient,1,EA,92.75000,26.90000,Aetna,First Health,,75.87,,,,,,,34.32,75.87,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,25021067410,NDC,,,facility,outpatient,1,EA,92.75000,26.90000,Aetna,First Health,,75.87,,,,,,,33.44,75.87,percent of total billed charges,
Lidocaine 2% Topical Jelly w/ Appl,800046502,CDM,250,RC,25021067376,NDC,,,facility,inpatient,1,EA,50.55000,14.66000,Aetna,First Health,,41.35,,,,,,,18.70,41.35,percent of total billed charges,
Lidocaine 2% Topical Jelly w/ Appl,800046502,CDM,250,RC,25021067376,NDC,,,facility,outpatient,1,EA,50.55000,14.66000,Aetna,First Health,,41.35,,,,,,,18.22,41.35,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,25021067182,NDC,facility,inpatient,200,ME,385.85000,111.90000,Aetna,First Health,,315.63,,,,,,,139.10,315.63,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,25021067182,NDC,facility,outpatient,200,ME,385.85000,111.90000,Aetna,First Health,,315.63,,,,,,,0.04815,315.63,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,25021067166,NDC,facility,inpatient,200,ME,253.15000,73.41000,Aetna,First Health,,207.08,,,,,,,91.26,207.08,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,25021067166,NDC,facility,outpatient,200,ME,253.15000,73.41000,Aetna,First Health,,207.08,,,,,,,0.04815,207.08,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,25021066205,NDC,,,facility,inpatient,1,EA,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,14.17,31.33,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,25021066205,NDC,,,facility,outpatient,1,EA,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,25021066205,NDC,,,facility,inpatient,1,EA,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,18.89,41.76,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,25021066205,NDC,,,facility,outpatient,1,EA,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,18.40,41.76,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,25021065710,NDC,,,facility,inpatient,1,EA,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,18.89,41.76,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,25021065710,NDC,,,facility,outpatient,1,EA,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,18.40,41.76,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,25021065601,NDC,facility,inpatient,5,ME,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,4.33,9.82,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,25021065601,NDC,facility,outpatient,5,ME,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,0.13482,9.82,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,25021065505,NDC,facility,inpatient,5,ME,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,4.33,9.82,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,25021065505,NDC,facility,outpatient,5,ME,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,0.13482,9.82,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,25021065502,NDC,facility,inpatient,2,ME,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,25021065502,NDC,facility,outpatient,2,ME,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,0.13482,5.19,percent of total billed charges,
ROPivacaine 0.5% (5mg/1mL) I,800025669,CDM,636,RC,J2795,HCPCS,25021065287,NDC,facility,inpatient,1,ME,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.28840,0.65440,percent of total billed charges,
ROPivacaine 0.5% (5mg/1mL) I,800025669,CDM,636,RC,J2795,HCPCS,25021065287,NDC,facility,outpatient,1,ME,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.04815,0.65440,percent of total billed charges,
ROPivacaine 0.5% (5mg/1mL) I,800025669,CDM,636,RC,J2795,HCPCS,25021065282,NDC,facility,inpatient,1,ME,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.28840,0.65440,percent of total billed charges,
ROPivacaine 0.5% (5mg/1mL) I,800025669,CDM,636,RC,J2795,HCPCS,25021065282,NDC,facility,outpatient,1,ME,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.04815,0.65440,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,25021065231,NDC,facility,inpatient,150,ME,164.40000,47.68000,Aetna,First Health,,134.48,,,,,,,59.27,134.48,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,25021065231,NDC,facility,outpatient,150,ME,164.40000,47.68000,Aetna,First Health,,134.48,,,,,,,0.04815,134.48,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,25021065230,NDC,facility,inpatient,150,ME,164.40000,47.68000,Aetna,First Health,,134.48,,,,,,,59.27,134.48,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,25021065230,NDC,facility,outpatient,150,ME,164.40000,47.68000,Aetna,First Health,,134.48,,,,,,,0.04815,134.48,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,25021065102,NDC,facility,inpatient,60,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,27.61,62.66,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,25021065102,NDC,facility,outpatient,60,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,6.15,62.66,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,25021061281,NDC,facility,inpatient,2,GM,130.85000,37.95000,Aetna,First Health,,107.04,,,,,,,47.17,107.04,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,25021061281,NDC,facility,outpatient,2,GM,130.85000,37.95000,Aetna,First Health,,107.04,,,,,,,0.39483,107.04,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,25021060851,NDC,facility,inpatient,1,GM,283.80000,82.30000,Aetna,First Health,,232.15,,,,,,,102.31,232.15,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,25021060851,NDC,facility,outpatient,1,GM,283.80000,82.30000,Aetna,First Health,,232.15,,,,,,,0.08667,232.15,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,25021060850,NDC,facility,inpatient,0.5,GM,148.95000,43.20000,Aetna,First Health,,121.84,,,,,,,53.70,121.84,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,25021060850,NDC,facility,outpatient,0.5,GM,148.95000,43.20000,Aetna,First Health,,121.84,,,,,,,0.08667,121.84,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,25021060820,NDC,facility,inpatient,200,ME,37.10000,10.76000,Aetna,First Health,,30.35,,,,,,,13.37,30.35,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,25021060820,NDC,facility,outpatient,200,ME,37.10000,10.76000,Aetna,First Health,,30.35,,,,,,,0.08667,30.35,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,25021060203,NDC,,,facility,inpatient,1,EA,169.90000,49.27000,Aetna,First Health,,138.98,,,,,,,101.94,138.98,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,25021060203,NDC,,,facility,outpatient,1,EA,169.90000,49.27000,Aetna,First Health,,138.98,,,,,,,61.25,138.98,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,25021060103,NDC,facility,inpatient,60,ME,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,69.22,157.06,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,25021060103,NDC,facility,outpatient,60,ME,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,1.40,157.06,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,25021060005,NDC,,,facility,inpatient,1,EA,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,14.17,31.33,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,25021060005,NDC,,,facility,outpatient,1,EA,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,25021050002,NDC,facility,inpatient,200,ME,63.50000,18.42000,Aetna,First Health,,51.94,,,,,,,22.89,51.94,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,25021050002,NDC,facility,outpatient,200,ME,63.50000,18.42000,Aetna,First Health,,51.94,,,,,,,1.74,51.94,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,25021048101,NDC,facility,inpatient,50,ME,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,2.70,6.13,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,25021048101,NDC,facility,outpatient,50,ME,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,0.68373,6.13,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,25021046301,NDC,facility,inpatient,0.05,ME,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,17.25,23.52,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,25021046301,NDC,facility,outpatient,0.05,ME,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,0.63558,23.52,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,25021046110,NDC,facility,inpatient,0.04,ME,2498.20000,724.48000,Aetna,First Health,,2043.53,,,,,,,900.60,2043.53,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,25021046110,NDC,facility,outpatient,0.04,ME,2498.20000,724.48000,Aetna,First Health,,2043.53,,,,,,,3.28,2043.53,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,inpatient,0.004,ME,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,71.14,161.43,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,outpatient,0.004,ME,197.35000,57.23000,Aetna,First Health,,161.43,,,,,,,3.28,161.43,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,25021045301,NDC,facility,inpatient,0.5,ME,216.45000,62.77000,Aetna,First Health,,177.06,,,,,,,129.87,177.06,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,25021045301,NDC,facility,outpatient,0.5,ME,216.45000,62.77000,Aetna,First Health,,177.06,,,,,,,0.63558,177.06,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,25021045201,NDC,facility,inpatient,0.1,ME,41.50000,12.03000,Aetna,First Health,,33.95,,,,,,,24.90,33.95,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,25021045201,NDC,facility,outpatient,0.1,ME,41.50000,12.03000,Aetna,First Health,,33.95,,,,,,,0.63558,33.95,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,25021045101,NDC,facility,inpatient,0.05,ME,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,17.25,23.52,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,25021045101,NDC,facility,outpatient,0.05,ME,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,0.63558,23.52,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,25021041450,NDC,facility,inpatient,50,ME,1555.00000,450.95000,Aetna,First Health,,1271.99,,,,,,,560.58,1271.99,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,25021041450,NDC,facility,outpatient,50,ME,1555.00000,450.95000,Aetna,First Health,,1271.99,,,,,,,0.58743,1271.99,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,25021041170,NDC,facility,inpatient,120,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,27.61,62.66,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,25021041170,NDC,facility,outpatient,120,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,0.51039,62.66,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,25021041077,NDC,facility,inpatient,60,ME,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,12.37,28.06,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,25021041077,NDC,facility,outpatient,60,ME,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,0.51039,28.06,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,25021041076,NDC,facility,inpatient,40,ME,23.50000,6.82000,Aetna,First Health,,19.22,,,,,,,8.47,19.22,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,25021041076,NDC,facility,outpatient,40,ME,23.50000,6.82000,Aetna,First Health,,19.22,,,,,,,0.51039,19.22,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,25021040910,NDC,facility,inpatient,20,ME,498.00000,144.42000,Aetna,First Health,,407.36,,,,,,,179.53,407.36,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,25021040910,NDC,facility,outpatient,20,ME,498.00000,144.42000,Aetna,First Health,,407.36,,,,,,,3.52,407.36,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,25021040201,NDC,facility,inpatient,5000,UN,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,4.51,7.85,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,25021040201,NDC,facility,outpatient,5000,UN,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,0.17334,7.85,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,25021040067,NDC,facility,inpatient,10000,UN,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.66,8.30,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,25021040067,NDC,facility,outpatient,10000,UN,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,0.17334,8.30,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,inpatient,30000,UN,69.35000,20.11000,Aetna,First Health,,56.73,,,,,,,25.00,56.73,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,outpatient,30000,UN,69.35000,20.11000,Aetna,First Health,,56.73,,,,,,,0.17334,56.73,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,25021040010,NDC,facility,inpatient,10000,UN,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,8.29,18.81,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,25021040010,NDC,facility,outpatient,10000,UN,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,0.17334,18.81,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,25021031905,NDC,,,facility,inpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,6.64,14.68,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,25021031905,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,6.47,14.68,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,25021031382,NDC,facility,inpatient,20,ME,96.90000,28.10000,Aetna,First Health,,79.26,,,,,,,34.93,79.26,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,25021031382,NDC,facility,outpatient,20,ME,96.90000,28.10000,Aetna,First Health,,79.26,,,,,,,1.30,79.26,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,25021031110,NDC,facility,inpatient,100,ME,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,25021031110,NDC,facility,outpatient,100,ME,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,25021031104,NDC,facility,inpatient,40,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,25021031104,NDC,facility,outpatient,40,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,0.01926,10.43,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,25021031102,NDC,facility,inpatient,20,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,25021031102,NDC,facility,outpatient,20,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,0.01926,7.85,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,25021031066,NDC,,,facility,inpatient,1,EA,471.95000,136.87000,Aetna,First Health,,386.06,,,,,,,174.62,386.06,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,25021031066,NDC,,,facility,outpatient,1,EA,471.95000,136.87000,Aetna,First Health,,386.06,,,,,,,170.14,386.06,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,25021031002,NDC,,,facility,inpatient,1,EA,685.90000,198.91000,Aetna,First Health,,561.07,,,,,,,253.78,561.07,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,25021031002,NDC,,,facility,outpatient,1,EA,685.90000,198.91000,Aetna,First Health,,561.07,,,,,,,247.27,561.07,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,25021030884,NDC,facility,inpatient,2.5,GM,1476.00000,428.04000,Aetna,First Health,,1207.37,,,,,,,532.10,1207.37,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,25021030884,NDC,facility,outpatient,2.5,GM,1476.00000,428.04000,Aetna,First Health,,1207.37,,,,,,,0.20223,1207.37,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,25021030566,NDC,facility,inpatient,500,ME,197.25000,57.20000,Aetna,First Health,,161.35,,,,,,,71.11,161.35,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,25021030566,NDC,facility,outpatient,500,ME,197.25000,57.20000,Aetna,First Health,,161.35,,,,,,,55.98,179.27,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,inpatient,500,ME,352.05000,102.09000,Aetna,First Health,,287.98,,,,,,,126.91,287.98,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,outpatient,500,ME,352.05000,102.09000,Aetna,First Health,,287.98,,,,,,,55.98,287.98,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,25021030305,NDC,,,facility,inpatient,1,EA,18.20000,5.28000,Aetna,First Health,,14.89,,,,,,,6.73,14.89,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,25021030305,NDC,,,facility,outpatient,1,EA,18.20000,5.28000,Aetna,First Health,,14.89,,,,,,,6.56,14.89,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,25021030172,NDC,facility,inpatient,6,ME,102.15000,29.62000,Aetna,First Health,,83.56,,,,,,,36.83,83.56,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,25021030172,NDC,facility,outpatient,6,ME,102.15000,29.62000,Aetna,First Health,,83.56,,,,,,,0.51039,83.56,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,25021030102,NDC,facility,inpatient,6,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,25021030102,NDC,facility,outpatient,6,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,0.51039,31.33,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,25021030020,NDC,facility,inpatient,100,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.72,10.43,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,25021030020,NDC,facility,outpatient,100,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,0.33705,10.43,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,25021025517,NDC,facility,inpatient,6,ME,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,5.05,11.45,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,25021025517,NDC,facility,outpatient,6,ME,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,0.09630,11.45,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,25021024504,NDC,facility,inpatient,80,ME,750.00000,217.50000,Aetna,First Health,,613.50,,,,,,,270.38,613.50,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,25021024504,NDC,facility,outpatient,80,ME,750.00000,217.50000,Aetna,First Health,,613.50,,,,,,,0.62595,613.50,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,25021023410,NDC,facility,inpatient,200,ME,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,33.89,76.89,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,25021023410,NDC,facility,outpatient,200,ME,94.00000,27.26000,Aetna,First Health,,76.89,,,,,,,3.46,76.89,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,25021022204,NDC,facility,inpatient,80,ME,5947.00000,1724.63000,Aetna,First Health,,4864.65,,,,,,,2143.89,4864.65,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,25021022204,NDC,facility,outpatient,80,ME,5947.00000,1724.63000,Aetna,First Health,,4864.65,,,,,,,0.62595,4864.65,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,25021021350,NDC,facility,inpatient,6,ME,20.30000,5.89000,Aetna,First Health,,16.61,,,,,,,7.32,16.61,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,25021021350,NDC,facility,outpatient,6,ME,20.30000,5.89000,Aetna,First Health,,16.61,,,,,,,0.09630,16.61,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,25021020725,NDC,facility,inpatient,50,ME,189.40000,54.93000,Aetna,First Health,,154.93,,,,,,,68.28,154.93,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,25021020725,NDC,facility,outpatient,50,ME,189.40000,54.93000,Aetna,First Health,,154.93,,,,,,,2.68,154.93,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,25021020245,NDC,facility,inpatient,50,ME,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,23.43,53.17,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,25021020245,NDC,facility,outpatient,50,ME,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,2.82,53.17,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,25021020215,NDC,facility,inpatient,50,ME,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,23.43,53.17,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,25021020215,NDC,facility,outpatient,50,ME,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,2.82,53.17,percent of total billed charges,
Mesna 200mg/2mL I (Mesnex),800025637,CDM,636,RC,J9209,HCPCS,25021020110,NDC,facility,inpatient,200,ME,40.80000,11.83000,Aetna,First Health,,33.37,,,,,,,14.71,33.37,percent of total billed charges,
Mesna 200mg/2mL I (Mesnex),800025637,CDM,636,RC,J9209,HCPCS,25021020110,NDC,facility,outpatient,200,ME,40.80000,11.83000,Aetna,First Health,,33.37,,,,,,,1.64,33.37,percent of total billed charges,
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,25021019111,NDC,facility,inpatient,100,ME,1533.40000,444.69000,Aetna,First Health,,1254.32,,,,,,,552.79,1254.32,percent of total billed charges,
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,25021019111,NDC,facility,outpatient,100,ME,1533.40000,444.69000,Aetna,First Health,,1254.32,,,,,,,0.24075,1254.32,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,25021018487,NDC,facility,inpatient,400,ME,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,51.48,116.81,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,25021018487,NDC,facility,outpatient,400,ME,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,4.31,116.81,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,25021018482,NDC,facility,inpatient,200,ME,91.80000,26.62000,Aetna,First Health,,75.09,,,,,,,33.09,75.09,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,25021018482,NDC,facility,outpatient,200,ME,91.80000,26.62000,Aetna,First Health,,75.09,,,,,,,4.31,75.09,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,25021018467,NDC,facility,inpatient,400,ME,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,51.48,116.81,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,25021018467,NDC,facility,outpatient,400,ME,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,4.31,116.81,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,25021018466,NDC,facility,inpatient,200,ME,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,25021018466,NDC,facility,outpatient,200,ME,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,4.31,33.42,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,25021017750,NDC,facility,inpatient,4.5,GM,149.75000,43.43000,Aetna,First Health,,122.50,,,,,,,53.98,122.50,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,25021017750,NDC,facility,outpatient,4.5,GM,149.75000,43.43000,Aetna,First Health,,122.50,,,,,,,1.05,122.50,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,25021017620,NDC,facility,inpatient,3.375,GM,84.50000,24.50000,Aetna,First Health,,69.12,,,,,,,30.46,69.12,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,25021017620,NDC,facility,outpatient,3.375,GM,84.50000,24.50000,Aetna,First Health,,69.12,,,,,,,1.05,69.12,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,25021017520,NDC,facility,inpatient,2.25,GM,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,25021017520,NDC,facility,outpatient,2.25,GM,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,1.05,23.56,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,25021016648,NDC,facility,inpatient,4.5,GM,139.20000,40.37000,Aetna,First Health,,113.87,,,,,,,50.18,113.87,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,25021016648,NDC,facility,outpatient,4.5,GM,139.20000,40.37000,Aetna,First Health,,113.87,,,,,,,1.05,113.87,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,25021016530,NDC,facility,inpatient,3.375,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,38.07,86.38,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,25021016530,NDC,facility,outpatient,3.375,GM,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,1.05,86.38,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,25021016430,NDC,facility,inpatient,2.25,GM,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,24.23,54.97,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,25021016430,NDC,facility,outpatient,2.25,GM,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,1.05,54.97,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,25021015899,NDC,facility,inpatient,1,GM,95.05000,27.56000,Aetna,First Health,,77.75,,,,,,,34.27,77.75,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,25021015899,NDC,facility,outpatient,1,GM,95.05000,27.56000,Aetna,First Health,,77.75,,,,,,,0.02889,77.75,percent of total billed charges,
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,25021014610,NDC,facility,inpatient,1000,ME,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,38.93,88.34,percent of total billed charges,
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,25021014610,NDC,facility,outpatient,1000,ME,108.00000,31.32000,Aetna,First Health,,88.34,,,,,,,0.54891,88.34,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,25021014330,NDC,facility,inpatient,3,GM,86.40000,25.06000,Aetna,First Health,,70.68,,,,,,,31.15,70.68,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,25021014330,NDC,facility,outpatient,3,GM,86.40000,25.06000,Aetna,First Health,,70.68,,,,,,,1.28,70.68,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,25021014220,NDC,facility,inpatient,1.5,GM,52.80000,15.31000,Aetna,First Health,,43.19,,,,,,,19.03,43.19,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,25021014220,NDC,facility,outpatient,1.5,GM,52.80000,15.31000,Aetna,First Health,,43.19,,,,,,,1.28,43.19,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,25021014010,NDC,facility,inpatient,2,GM,215.50000,62.50000,Aetna,First Health,,176.28,,,,,,,77.69,176.28,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,25021014010,NDC,facility,outpatient,2,GM,215.50000,62.50000,Aetna,First Health,,176.28,,,,,,,0.05778,176.28,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,25021013720,NDC,facility,inpatient,2,GM,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,25.96,58.90,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,25021013720,NDC,facility,outpatient,2,GM,72.00000,20.88000,Aetna,First Health,,58.90,,,,,,,0.56817,58.90,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,25021013610,NDC,facility,inpatient,1,GM,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,17.30,39.26,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,25021013610,NDC,facility,outpatient,1,GM,48.00000,13.92000,Aetna,First Health,,39.26,,,,,,,0.56817,39.26,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,outpatient,500,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,0.56817,23.56,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,inpatient,750,ME,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,38.07,86.38,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,outpatient,750,ME,105.60000,30.62000,Aetna,First Health,,86.38,,,,,,,2.08,86.38,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,inpatient,500,ME,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,20.19,45.81,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,outpatient,500,ME,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,2.08,45.81,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,25021013281,NDC,facility,inpatient,250,ME,40.40000,11.72000,Aetna,First Health,,33.05,,,,,,,14.56,33.05,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,25021013281,NDC,facility,outpatient,250,ME,40.40000,11.72000,Aetna,First Health,,33.05,,,,,,,2.08,33.05,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,25021013182,NDC,facility,inpatient,500,ME,26.95000,7.82000,Aetna,First Health,,22.05,,,,,,,9.72,22.05,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,25021013182,NDC,facility,outpatient,500,ME,26.95000,7.82000,Aetna,First Health,,22.05,,,,,,,0.02889,22.05,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,inpatient,1,GM,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,17.99,40.82,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,outpatient,1,GM,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,1.42,40.82,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,25021012267,NDC,facility,inpatient,2,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,34.61,78.53,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,25021012267,NDC,facility,outpatient,2,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,0.83781,78.53,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,inpatient,2,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,34.61,78.53,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,outpatient,2,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,0.83781,78.53,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,25021012166,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,25021012166,NDC,facility,outpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,0.83781,47.12,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,outpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,0.83781,47.12,percent of total billed charges,
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,25021011504,NDC,facility,inpatient,600,ME,38.75000,11.24000,Aetna,First Health,,31.70,,,,,,,13.97,31.70,percent of total billed charges,
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,25021011504,NDC,facility,outpatient,600,ME,38.75000,11.24000,Aetna,First Health,,31.70,,,,,,,1.84,31.70,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,25021011387,NDC,facility,inpatient,400,ME,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,51.48,116.81,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,25021011387,NDC,facility,outpatient,400,ME,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,4.31,116.81,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,25021011382,NDC,facility,inpatient,200,ME,91.80000,26.62000,Aetna,First Health,,75.09,,,,,,,33.09,75.09,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,25021011382,NDC,facility,outpatient,200,ME,91.80000,26.62000,Aetna,First Health,,75.09,,,,,,,4.31,75.09,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,inpatient,2,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,34.61,78.53,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,outpatient,2,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,4.56,78.53,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,25021010910,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,25021010910,NDC,facility,outpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,4.56,47.12,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,25021010610,NDC,facility,inpatient,1,GM,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,8.31,18.85,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,25021010610,NDC,facility,outpatient,1,GM,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,0.44298,18.85,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,25021010299,NDC,facility,inpatient,2,GM,48.60000,14.09000,Aetna,First Health,,39.75,,,,,,,17.52,39.75,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,25021010299,NDC,facility,outpatient,2,GM,48.60000,14.09000,Aetna,First Health,,39.75,,,,,,,0.79929,39.75,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,25021010110,NDC,facility,inpatient,1000,ME,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,2.70,6.13,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,25021010110,NDC,facility,outpatient,1000,ME,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,0.79929,6.13,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,25010081356,NDC,,,facility,inpatient,1,EA,1368.15000,396.76000,Aetna,First Health,,1119.15,,,,,,,820.89,1119.15,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,25010081356,NDC,,,facility,outpatient,1,EA,1368.15000,396.76000,Aetna,First Health,,1119.15,,,,,,,493.22,1119.15,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,25010040515,NDC,,,facility,inpatient,1,EA,71.15000,20.63000,Aetna,First Health,,58.20,,,,,,,42.69,58.20,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,25010040515,NDC,,,facility,outpatient,1,EA,71.15000,20.63000,Aetna,First Health,,58.20,,,,,,,25.65,58.20,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,24987037810,NDC,facility,inpatient,1,GM,113.85000,33.02000,Aetna,First Health,,93.13,,,,,,,41.04,93.13,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,24987037810,NDC,facility,outpatient,1,GM,113.85000,33.02000,Aetna,First Health,,93.13,,,,,,,1.42,93.13,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,24987026010,NDC,facility,inpatient,0.5,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,24987026010,NDC,facility,outpatient,0.5,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,9.22,31.33,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,24987024255,NDC,,,facility,inpatient,1,EA,20.40000,5.92000,Aetna,First Health,,16.69,,,,,,,12.24,16.69,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,24987024255,NDC,,,facility,outpatient,1,EA,20.40000,5.92000,Aetna,First Health,,16.69,,,,,,,7.35,16.69,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,24979021104,NDC,,,facility,inpatient,1,EA,20.65000,5.99000,Aetna,First Health,,16.89,,,,,,,12.39,16.89,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,24979021104,NDC,,,facility,outpatient,1,EA,20.65000,5.99000,Aetna,First Health,,16.89,,,,,,,7.44,16.89,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,24979002907,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,24979002907,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,24979002707,NDC,,,facility,inpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,4.32,5.89,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,24979002707,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,24979002607,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,24979002607,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
Donepezil 23mg T (Aricept),800072470,CDM,637,RC,24979000406,NDC,,,facility,inpatient,1,EA,73.70000,21.37000,Aetna,First Health,,60.29,,,,,,,44.22,60.29,percent of total billed charges,
Donepezil 23mg T (Aricept),800072470,CDM,637,RC,24979000406,NDC,,,facility,outpatient,1,EA,73.70000,21.37000,Aetna,First Health,,60.29,,,,,,,26.57,60.29,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,24658026060,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,10.32,14.07,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,24658026060,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,24658026018,NDC,,,facility,inpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,24658026018,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
PrismaSol BGK 4/2.5 - 5L,800017935,CDM,250,RC,24571010505,NDC,,,facility,inpatient,1,EA,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,181.30,400.82,percent of total billed charges,
PrismaSol BGK 4/2.5 - 5L,800017935,CDM,250,RC,24571010505,NDC,,,facility,outpatient,1,EA,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,176.65,400.82,percent of total billed charges,
PrismaSol BGK 2/3.5 - 5L,800025462,CDM,250,RC,24571010305,NDC,,,facility,inpatient,1,EA,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,181.30,400.82,percent of total billed charges,
PrismaSol BGK 2/3.5 - 5L,800025462,CDM,250,RC,24571010305,NDC,,,facility,outpatient,1,EA,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,176.65,400.82,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,24510005010,NDC,,,facility,inpatient,1,EA,116.85000,33.89000,Aetna,First Health,,95.58,,,,,,,70.11,95.58,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,24510005010,NDC,,,facility,outpatient,1,EA,116.85000,33.89000,Aetna,First Health,,95.58,,,,,,,42.12,95.58,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,24486060210,NDC,,,facility,inpatient,1,EA,11.45000,3.32000,Aetna,First Health,,9.37,,,,,,,6.87,9.37,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,24486060210,NDC,,,facility,outpatient,1,EA,11.45000,3.32000,Aetna,First Health,,9.37,,,,,,,4.13,9.37,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,24486060110,NDC,,,facility,inpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,3.66,4.99,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,24486060110,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,2.20,4.99,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,24477003025,NDC,facility,inpatient,25,ME,1844.65000,534.95000,Aetna,First Health,,1508.92,,,,,,,665.00,1508.92,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,24477003025,NDC,facility,outpatient,25,ME,1844.65000,534.95000,Aetna,First Health,,1508.92,,,,,,,0.06741,1508.92,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,24385014126,NDC,,,facility,inpatient,1,EA,1464.60000,424.73000,Aetna,First Health,,1198.04,,,,,,,541.90,1198.04,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,24385014126,NDC,,,facility,outpatient,1,EA,1464.60000,424.73000,Aetna,First Health,,1198.04,,,,,,,527.99,1198.04,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,24357070130,NDC,,,facility,inpatient,1,EA,106.20000,30.80000,Aetna,First Health,,86.87,,,,,,,63.72,86.87,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,24357070130,NDC,,,facility,outpatient,1,EA,106.20000,30.80000,Aetna,First Health,,86.87,,,,,,,38.29,86.87,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,24357070115,NDC,,,facility,inpatient,1,EA,135.95000,39.43000,Aetna,First Health,,111.21,,,,,,,81.57,111.21,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,24357070115,NDC,,,facility,outpatient,1,EA,135.95000,39.43000,Aetna,First Health,,111.21,,,,,,,49.01,111.21,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,24338012213,NDC,,,facility,inpatient,1,EA,62.50000,18.12000,Aetna,First Health,,51.12,,,,,,,37.50,51.12,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,24338012213,NDC,,,facility,outpatient,1,EA,62.50000,18.12000,Aetna,First Health,,51.12,,,,,,,22.53,51.12,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,24338012203,NDC,,,facility,inpatient,1,EA,72.50000,21.02000,Aetna,First Health,,59.30,,,,,,,43.50,59.30,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,24338012203,NDC,,,facility,outpatient,1,EA,72.50000,21.02000,Aetna,First Health,,59.30,,,,,,,26.14,59.30,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,24208091019,NDC,,,facility,inpatient,1,EA,87.90000,25.49000,Aetna,First Health,,71.90,,,,,,,52.74,71.90,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,24208091019,NDC,,,facility,outpatient,1,EA,87.90000,25.49000,Aetna,First Health,,71.90,,,,,,,31.69,71.90,percent of total billed charges,
Neo-Poly-Dex 5mL Ophth Susp(Maxitrol),800019117,CDM,637,RC,24208083060,NDC,,,facility,inpatient,1,EA,140.60000,40.77000,Aetna,First Health,,115.01,,,,,,,84.36,115.01,percent of total billed charges,
Neo-Poly-Dex 5mL Ophth Susp(Maxitrol),800019117,CDM,637,RC,24208083060,NDC,,,facility,outpatient,1,EA,140.60000,40.77000,Aetna,First Health,,115.01,,,,,,,50.69,115.01,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,24208079535,NDC,,,facility,inpatient,1,EA,140.60000,40.77000,Aetna,First Health,,115.01,,,,,,,84.36,115.01,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,24208079535,NDC,,,facility,outpatient,1,EA,140.60000,40.77000,Aetna,First Health,,115.01,,,,,,,50.69,115.01,percent of total billed charges,
Neo-Poly-Bac-Hc 3.5g Ophth Oint(Cortispor,800019588,CDM,637,RC,24208078555,NDC,,,facility,inpatient,1,EA,435.50000,126.29000,Aetna,First Health,,356.24,,,,,,,261.30,356.24,percent of total billed charges,
Neo-Poly-Bac-Hc 3.5g Ophth Oint(Cortispor,800019588,CDM,637,RC,24208078555,NDC,,,facility,outpatient,1,EA,435.50000,126.29000,Aetna,First Health,,356.24,,,,,,,157.00,356.24,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,24208078055,NDC,,,facility,inpatient,1,EA,386.25000,112.01000,Aetna,First Health,,315.95,,,,,,,142.91,315.95,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,24208078055,NDC,,,facility,outpatient,1,EA,386.25000,112.01000,Aetna,First Health,,315.95,,,,,,,139.24,315.95,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,24208075006,NDC,,,facility,inpatient,1,EA,89.35000,25.91000,Aetna,First Health,,73.09,,,,,,,53.61,73.09,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,24208075006,NDC,,,facility,outpatient,1,EA,89.35000,25.91000,Aetna,First Health,,73.09,,,,,,,32.21,73.09,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,24208073006,NDC,,,facility,inpatient,1,EA,292.10000,84.71000,Aetna,First Health,,238.94,,,,,,,175.26,238.94,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,24208073006,NDC,,,facility,outpatient,1,EA,292.10000,84.71000,Aetna,First Health,,238.94,,,,,,,105.30,238.94,percent of total billed charges,
dexaMETHasone 0.1% 5mL Ophth Soln,800036904,CDM,637,RC,24208072002,NDC,,,facility,inpatient,1,EA,433.25000,125.64000,Aetna,First Health,,354.40,,,,,,,259.95,354.40,percent of total billed charges,
dexaMETHasone 0.1% 5mL Ophth Soln,800036904,CDM,637,RC,24208072002,NDC,,,facility,outpatient,1,EA,433.25000,125.64000,Aetna,First Health,,354.40,,,,,,,156.19,354.40,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,24208067615,NDC,,,facility,inpatient,1,EA,168.55000,48.88000,Aetna,First Health,,137.87,,,,,,,101.13,137.87,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,24208067615,NDC,,,facility,outpatient,1,EA,168.55000,48.88000,Aetna,First Health,,137.87,,,,,,,60.76,137.87,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sus(Cortispor,800062843,CDM,637,RC,24208063562,NDC,,,facility,inpatient,1,EA,1042.25000,302.25000,Aetna,First Health,,852.56,,,,,,,625.35,852.56,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sus(Cortispor,800062843,CDM,637,RC,24208063562,NDC,,,facility,outpatient,1,EA,1042.25000,302.25000,Aetna,First Health,,852.56,,,,,,,375.73,852.56,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,800018689,CDM,637,RC,24208063110,NDC,,,facility,inpatient,1,EA,1042.25000,302.25000,Aetna,First Health,,852.56,,,,,,,625.35,852.56,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,800018689,CDM,637,RC,24208063110,NDC,,,facility,outpatient,1,EA,1042.25000,302.25000,Aetna,First Health,,852.56,,,,,,,375.73,852.56,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),800018655,CDM,637,RC,24208060564,NDC,,,facility,inpatient,1,EA,581.75000,168.71000,Aetna,First Health,,475.87,,,,,,,349.05,475.87,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),800018655,CDM,637,RC,24208060564,NDC,,,facility,outpatient,1,EA,581.75000,168.71000,Aetna,First Health,,475.87,,,,,,,209.72,475.87,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,24208055555,NDC,,,facility,inpatient,1,EA,203.50000,59.01000,Aetna,First Health,,166.46,,,,,,,75.30,166.46,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,24208055555,NDC,,,facility,outpatient,1,EA,203.50000,59.01000,Aetna,First Health,,166.46,,,,,,,73.36,166.46,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,24208048510,NDC,,,facility,inpatient,1,EA,316.95000,91.92000,Aetna,First Health,,259.27,,,,,,,190.17,259.27,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,24208048510,NDC,,,facility,outpatient,1,EA,316.95000,91.92000,Aetna,First Health,,259.27,,,,,,,114.26,259.27,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,24208046325,NDC,,,facility,inpatient,1,EA,172.60000,50.05000,Aetna,First Health,,141.19,,,,,,,103.56,141.19,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,24208046325,NDC,,,facility,outpatient,1,EA,172.60000,50.05000,Aetna,First Health,,141.19,,,,,,,62.22,141.19,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,24208043405,NDC,,,facility,inpatient,1,EA,173.65000,50.36000,Aetna,First Health,,142.05,,,,,,,104.19,142.05,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,24208043405,NDC,,,facility,outpatient,1,EA,173.65000,50.36000,Aetna,First Health,,142.05,,,,,,,62.60,142.05,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,24208041105,NDC,,,facility,inpatient,1,EA,130.65000,37.89000,Aetna,First Health,,106.87,,,,,,,78.39,106.87,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,24208041105,NDC,,,facility,outpatient,1,EA,130.65000,37.89000,Aetna,First Health,,106.87,,,,,,,47.10,106.87,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,24208039830,NDC,,,facility,inpatient,1,EA,315.25000,91.42000,Aetna,First Health,,257.87,,,,,,,189.15,257.87,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,24208039830,NDC,,,facility,outpatient,1,EA,315.25000,91.42000,Aetna,First Health,,257.87,,,,,,,113.65,257.87,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,24208034205,NDC,,,facility,inpatient,1,EA,1536.00000,445.44000,Aetna,First Health,,1256.45,,,,,,,921.60,1256.45,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,24208034205,NDC,,,facility,outpatient,1,EA,1536.00000,445.44000,Aetna,First Health,,1256.45,,,,,,,553.73,1256.45,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,24208032405,NDC,,,facility,inpatient,1,EA,44.15000,12.80000,Aetna,First Health,,36.11,,,,,,,26.49,36.11,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,24208032405,NDC,,,facility,outpatient,1,EA,44.15000,12.80000,Aetna,First Health,,36.11,,,,,,,15.92,36.11,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,24208031510,NDC,,,facility,inpatient,1,EA,95.15000,27.59000,Aetna,First Health,,77.83,,,,,,,57.09,77.83,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,24208031510,NDC,,,facility,outpatient,1,EA,95.15000,27.59000,Aetna,First Health,,77.83,,,,,,,34.30,77.83,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,24208029525,NDC,,,facility,inpatient,1,EA,767.20000,222.49000,Aetna,First Health,,627.57,,,,,,,460.32,627.57,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,24208029525,NDC,,,facility,outpatient,1,EA,767.20000,222.49000,Aetna,First Health,,627.57,,,,,,,276.58,627.57,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,24208029505,NDC,,,facility,inpatient,1,EA,768.95000,223.00000,Aetna,First Health,,629.00,,,,,,,461.37,629.00,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,24208029505,NDC,,,facility,outpatient,1,EA,768.95000,223.00000,Aetna,First Health,,629.00,,,,,,,277.21,629.00,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,24208029005,NDC,,,facility,inpatient,1,EA,169.20000,49.07000,Aetna,First Health,,138.41,,,,,,,101.52,138.41,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,24208029005,NDC,,,facility,outpatient,1,EA,169.20000,49.07000,Aetna,First Health,,138.41,,,,,,,61.00,138.41,percent of total billed charges,
Fluorometholone 0.1% 5mL Ophth Susp,800018804,CDM,637,RC,24208028805,NDC,,,facility,inpatient,1,EA,111.85000,32.44000,Aetna,First Health,,91.49,,,,,,,67.11,91.49,percent of total billed charges,
Fluorometholone 0.1% 5mL Ophth Susp,800018804,CDM,637,RC,24208028805,NDC,,,facility,outpatient,1,EA,111.85000,32.44000,Aetna,First Health,,91.49,,,,,,,40.32,91.49,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,24201040002,NDC,facility,inpatient,400,UN,3377.20000,979.39000,Aetna,First Health,,2762.55,,,,,,,2026.32,2762.55,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,24201040002,NDC,facility,outpatient,400,UN,3377.20000,979.39000,Aetna,First Health,,2762.55,,,,,,,1217.48,2762.55,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,24201011024,NDC,facility,inpatient,1000,ME,84.15000,24.40000,Aetna,First Health,,68.83,,,,,,,30.34,68.83,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,24201011024,NDC,facility,outpatient,1000,ME,84.15000,24.40000,Aetna,First Health,,68.83,,,,,,,0.05778,68.83,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,24201010024,NDC,facility,inpatient,1000,ME,110.65000,32.09000,Aetna,First Health,,90.51,,,,,,,39.89,90.51,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,24201010024,NDC,facility,outpatient,1000,ME,110.65000,32.09000,Aetna,First Health,,90.51,,,,,,,0.05778,90.51,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,24200111610,NDC,,,facility,inpatient,1,EA,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,104.71,231.49,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,24200111610,NDC,,,facility,outpatient,1,EA,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,102.02,231.49,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,24090047188,NDC,,,facility,inpatient,1,EA,175.50000,50.90000,Aetna,First Health,,143.56,,,,,,,105.30,143.56,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,24090047188,NDC,,,facility,outpatient,1,EA,175.50000,50.90000,Aetna,First Health,,143.56,,,,,,,63.27,143.56,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,23635052460,NDC,,,facility,inpatient,1,EA,57.30000,16.62000,Aetna,First Health,,46.87,,,,,,,34.38,46.87,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,23635052460,NDC,,,facility,outpatient,1,EA,57.30000,16.62000,Aetna,First Health,,46.87,,,,,,,20.66,46.87,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,23360015250,NDC,facility,inpatient,1,GM,62.25000,18.05000,Aetna,First Health,,50.92,,,,,,,22.44,50.92,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,23360015250,NDC,facility,outpatient,1,GM,62.25000,18.05000,Aetna,First Health,,50.92,,,,,,,0.02889,50.92,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,23360001402,NDC,facility,inpatient,80,ME,19.85000,5.76000,Aetna,First Health,,16.24,,,,,,,7.16,16.24,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,23360001402,NDC,facility,outpatient,80,ME,19.85000,5.76000,Aetna,First Health,,16.24,,,,,,,1.99,16.24,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,23317032128,NDC,,,facility,inpatient,1,EA,188.70000,54.72000,Aetna,First Health,,154.36,,,,,,,69.82,154.36,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,23317032128,NDC,,,facility,outpatient,1,EA,188.70000,54.72000,Aetna,First Health,,154.36,,,,,,,68.03,154.36,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,23317016515,NDC,,,facility,inpatient,1,EA,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,7.65,10.43,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,23317016515,NDC,,,facility,outpatient,1,EA,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,23317016015,NDC,,,facility,inpatient,1,EA,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,92.40,125.97,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,23317016015,NDC,,,facility,outpatient,1,EA,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,55.52,125.97,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,23155088331,NDC,facility,inpatient,6,ME,15.40000,4.47000,Aetna,First Health,,12.60,,,,,,,5.55,12.60,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,23155088331,NDC,facility,outpatient,6,ME,15.40000,4.47000,Aetna,First Health,,12.60,,,,,,,0.09630,12.60,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,23155088231,NDC,facility,inpatient,6,ME,15.60000,4.52000,Aetna,First Health,,12.76,,,,,,,5.62,12.76,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,23155088231,NDC,facility,outpatient,6,ME,15.60000,4.52000,Aetna,First Health,,12.76,,,,,,,0.09630,12.76,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,23155087101,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,23155087101,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155083410,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155083410,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155083401,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155083401,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,23155083301,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,23155083301,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Cabergoline 0.5 mg Tab,800017393,CDM,637,RC,J8515,HCPCS,23155082373,NDC,facility,inpatient,0.5,ME,256.20000,74.30000,Aetna,First Health,,209.57,,,,,,,153.72,209.57,percent of total billed charges,
Cabergoline 0.5 mg Tab,800017393,CDM,637,RC,J8515,HCPCS,23155082373,NDC,facility,outpatient,0.5,ME,256.20000,74.30000,Aetna,First Health,,209.57,,,,,,,17.65,209.57,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,23155077301,NDC,,,facility,inpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,11.76,16.03,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,23155077301,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,7.07,16.03,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,23155077201,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,23155077201,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,23155076401,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,23155076401,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,23155073501,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,23155073501,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,23155070501,NDC,,,facility,inpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,7.86,10.72,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,23155070501,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,4.72,10.72,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,23155070401,NDC,,,facility,inpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,6.18,8.43,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,23155070401,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,23155068941,NDC,facility,inpatient,0.5,ME,124.50000,36.10000,Aetna,First Health,,101.84,,,,,,,74.70,101.84,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,23155068941,NDC,facility,outpatient,0.5,ME,124.50000,36.10000,Aetna,First Health,,101.84,,,,,,,0.63558,101.84,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,23155068741,NDC,facility,inpatient,0.05,ME,18.50000,5.36000,Aetna,First Health,,15.13,,,,,,,11.10,15.13,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,23155068741,NDC,facility,outpatient,0.05,ME,18.50000,5.36000,Aetna,First Health,,15.13,,,,,,,0.63558,15.13,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,23155066201,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,23155066201,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,23155066142,NDC,,,facility,inpatient,1,EA,1266.00000,367.14000,Aetna,First Health,,1035.59,,,,,,,468.42,1035.59,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,23155066142,NDC,,,facility,outpatient,1,EA,1266.00000,367.14000,Aetna,First Health,,1035.59,,,,,,,456.39,1035.59,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,23155060601,NDC,,,facility,inpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,5.58,7.61,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,23155060601,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,23155054931,NDC,facility,inpatient,4,ME,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,3.03,6.87,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,23155054931,NDC,facility,outpatient,4,ME,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,0.08667,6.87,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,23155054742,NDC,facility,inpatient,4,ME,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,23155054742,NDC,facility,outpatient,4,ME,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,0.08667,2.41,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,23155054741,NDC,facility,inpatient,4,ME,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,23155054741,NDC,facility,outpatient,4,ME,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,0.08667,2.49,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,23155053102,NDC,facility,inpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,23155053102,NDC,facility,outpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,0.03852,5.93,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,23155051901,NDC,,,facility,inpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,14.25,19.43,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,23155051901,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.56,19.43,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,23155050101,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,23155050101,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,23155049742,NDC,facility,inpatient,10,ME,118.10000,34.25000,Aetna,First Health,,96.61,,,,,,,42.58,96.61,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,23155049742,NDC,facility,outpatient,10,ME,118.10000,34.25000,Aetna,First Health,,96.61,,,,,,,2.43,96.61,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,23155048901,NDC,,,facility,inpatient,1,EA,37.40000,10.85000,Aetna,First Health,,30.59,,,,,,,22.44,30.59,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,23155048901,NDC,,,facility,outpatient,1,EA,37.40000,10.85000,Aetna,First Health,,30.59,,,,,,,13.48,30.59,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,23155048601,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,23155048601,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,23155048551,NDC,,,facility,inpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,19.98,27.24,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,23155048551,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,12.00,27.24,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,23155047342,NDC,facility,inpatient,40,ME,22.55000,6.54000,Aetna,First Health,,18.45,,,,,,,8.13,18.45,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,23155047342,NDC,facility,outpatient,40,ME,22.55000,6.54000,Aetna,First Health,,18.45,,,,,,,0.01926,18.45,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,23155047341,NDC,facility,inpatient,20,ME,17.45000,5.06000,Aetna,First Health,,14.27,,,,,,,6.29,14.27,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,23155047341,NDC,facility,outpatient,20,ME,17.45000,5.06000,Aetna,First Health,,14.27,,,,,,,0.01926,14.27,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,23155034543,NDC,facility,inpatient,1,GM,282.85000,82.03000,Aetna,First Health,,231.37,,,,,,,101.97,231.37,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,23155034543,NDC,facility,outpatient,1,GM,282.85000,82.03000,Aetna,First Health,,231.37,,,,,,,0.08667,231.37,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,23155031331,NDC,facility,inpatient,500,ME,370.30000,107.39000,Aetna,First Health,,302.91,,,,,,,133.49,302.91,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,23155031331,NDC,facility,outpatient,500,ME,370.30000,107.39000,Aetna,First Health,,302.91,,,,,,,24.64,302.91,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,23155029442,NDC,facility,inpatient,10,ME,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,12.89,29.24,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,23155029442,NDC,facility,outpatient,10,ME,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,2.43,29.24,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,23155028801,NDC,,,facility,inpatient,1,EA,20.40000,5.92000,Aetna,First Health,,16.69,,,,,,,12.24,16.69,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,23155028801,NDC,,,facility,outpatient,1,EA,20.40000,5.92000,Aetna,First Health,,16.69,,,,,,,7.35,16.69,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,23155025832,NDC,facility,inpatient,6,ME,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,23155025832,NDC,facility,outpatient,6,ME,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,0.51039,57.91,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,23155024701,NDC,,,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,8.49,11.57,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,23155024701,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,23155024609,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,23155024609,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,23155024601,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,23155024601,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,23155024041,NDC,facility,inpatient,10,ME,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,23155024041,NDC,facility,outpatient,10,ME,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,1.04,11.49,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,23155022901,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,23155022901,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,23155019642,NDC,facility,inpatient,4,ME,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,23155019642,NDC,facility,outpatient,4,ME,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,0.08667,4.83,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,23155019401,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,23155019401,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,23155018631,NDC,facility,inpatient,5,ME,6648.50000,1928.06000,Aetna,First Health,,5438.47,,,,,,,2396.78,5438.47,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,23155018631,NDC,facility,outpatient,5,ME,6648.50000,1928.06000,Aetna,First Health,,5438.47,,,,,,,4.89,5438.47,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,23155017031,NDC,facility,inpatient,4,ME,211.00000,61.19000,Aetna,First Health,,172.60,,,,,,,76.07,172.60,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,23155017031,NDC,facility,outpatient,4,ME,211.00000,61.19000,Aetna,First Health,,172.60,,,,,,,4.89,172.60,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,23155016831,NDC,facility,inpatient,4,ME,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,23155016831,NDC,facility,outpatient,4,ME,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,0.08667,3.93,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,23155016641,NDC,,,facility,inpatient,1,EA,39.35000,11.41000,Aetna,First Health,,32.19,,,,,,,14.56,32.19,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,23155016641,NDC,,,facility,outpatient,1,EA,39.35000,11.41000,Aetna,First Health,,32.19,,,,,,,14.19,32.19,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,23155014601,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,23155014601,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,23155013701,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,23155013701,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,23155012401,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,10.65,14.52,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,23155012401,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,23155012301,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,10.65,14.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,23155012301,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,23155012101,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,10.65,14.52,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,23155012101,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,23155011803,NDC,,,facility,inpatient,1,EA,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,5.43,7.40,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,23155011803,NDC,,,facility,outpatient,1,EA,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,3.26,7.40,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,23155011801,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,23155011801,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,23155011101,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,23155011101,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,23155011001,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,23155011001,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,23155010601,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,23155010601,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,23155010205,NDC,,,facility,inpatient,1,EA,0.25000,0.07000,Aetna,First Health,,0.20450,,,,,,,0.15000,0.20450,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,23155010205,NDC,,,facility,outpatient,1,EA,0.25000,0.07000,Aetna,First Health,,0.20450,,,,,,,0.09012,0.20450,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,23155007101,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,23155007101,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,23155007001,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,23155007001,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,23155006505,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,23155006505,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,23155006501,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,23155006501,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,23155005901,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,23155005901,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,23155005701,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,23155005701,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,800015404,CDM,637,RC,23155005601,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,800015404,CDM,637,RC,23155005601,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,23155004901,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,23155004901,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,23155004801,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,23155004801,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,23155004303,NDC,,,facility,inpatient,1,EA,116.30000,33.73000,Aetna,First Health,,95.13,,,,,,,69.78,95.13,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,23155004303,NDC,,,facility,outpatient,1,EA,116.30000,33.73000,Aetna,First Health,,95.13,,,,,,,41.93,95.13,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,23155002701,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,23155002701,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,23155002401,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,23155002401,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,23155002301,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,23155002301,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,23155000801,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,23155000801,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155000310,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155000310,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155000301,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155000301,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,23155000201,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,23155000201,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,23155000101,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,23155000101,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,21922006204,NDC,,,facility,inpatient,1,EA,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,24.78,33.78,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,21922006204,NDC,,,facility,outpatient,1,EA,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,14.89,33.78,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,21922002107,NDC,,,facility,inpatient,1,EA,748.45000,217.05000,Aetna,First Health,,612.23,,,,,,,449.07,612.23,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,21922002107,NDC,,,facility,outpatient,1,EA,748.45000,217.05000,Aetna,First Health,,612.23,,,,,,,269.82,612.23,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,21922001952,NDC,,,facility,inpatient,1,EA,116.65000,33.83000,Aetna,First Health,,95.42,,,,,,,69.99,95.42,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,21922001952,NDC,,,facility,outpatient,1,EA,116.65000,33.83000,Aetna,First Health,,95.42,,,,,,,42.05,95.42,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,21922001705,NDC,,,facility,inpatient,1,EA,1551.75000,450.01000,Aetna,First Health,,1269.33,,,,,,,931.05,1269.33,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,21922001705,NDC,,,facility,outpatient,1,EA,1551.75000,450.01000,Aetna,First Health,,1269.33,,,,,,,559.41,1269.33,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,21922001605,NDC,,,facility,inpatient,1,EA,1587.80000,460.46000,Aetna,First Health,,1298.82,,,,,,,952.68,1298.82,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,21922001605,NDC,,,facility,outpatient,1,EA,1587.80000,460.46000,Aetna,First Health,,1298.82,,,,,,,572.40,1298.82,percent of total billed charges,
"Influenza Virus Vaccine, Inact Trivalent Inj",800051083,CDM,636,RC,90656,HCPCS,19515081052,NDC,facility,inpatient,1,EA,125.15000,36.29000,Aetna,First Health,,102.37,,,,,,,45.12,102.37,percent of total billed charges,
"Influenza Virus Vaccine, Inact Trivalent Inj",800051083,CDM,636,RC,90656,HCPCS,19515081052,NDC,facility,outpatient,1,EA,125.15000,36.29000,Aetna,First Health,,102.37,,,,,,,14.13,102.37,percent of total billed charges,
Hyaluronidase 150units/1mL Inj.,800025673,CDM,636,RC,J3470,HCPCS,18657011704,NDC,facility,inpatient,150,UN,330.25000,95.77000,Aetna,First Health,,270.14,,,,,,,119.06,270.14,percent of total billed charges,
Hyaluronidase 150units/1mL Inj.,800025673,CDM,636,RC,J3470,HCPCS,18657011704,NDC,facility,outpatient,150,UN,330.25000,95.77000,Aetna,First Health,,270.14,,,,,,,30.63,270.14,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,18393027253,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,18393027253,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,17478095302,NDC,facility,inpatient,6,ME,39.60000,11.48000,Aetna,First Health,,32.39,,,,,,,14.28,32.39,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,17478095302,NDC,facility,outpatient,6,ME,39.60000,11.48000,Aetna,First Health,,32.39,,,,,,,0.51039,32.39,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,17478093705,NDC,,,facility,inpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,6.90,15.26,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,17478093705,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,6.72,15.26,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,17478093415,NDC,facility,inpatient,20,ME,59.85000,17.36000,Aetna,First Health,,48.96,,,,,,,21.58,48.96,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,17478093415,NDC,facility,outpatient,20,ME,59.85000,17.36000,Aetna,First Health,,48.96,,,,,,,4.23,48.96,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,17478093401,NDC,facility,inpatient,20,ME,270.25000,78.37000,Aetna,First Health,,221.06,,,,,,,97.43,221.06,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,17478093401,NDC,facility,outpatient,20,ME,270.25000,78.37000,Aetna,First Health,,221.06,,,,,,,4.23,221.06,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),800018655,CDM,637,RC,17478092019,NDC,,,facility,inpatient,1,EA,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,22.86,31.17,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),800018655,CDM,637,RC,17478092019,NDC,,,facility,outpatient,1,EA,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,13.74,31.17,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,17478076610,NDC,,,facility,inpatient,1,EA,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,8.91,12.15,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,17478076610,NDC,,,facility,outpatient,1,EA,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,5.35,12.15,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,17478071510,NDC,,,facility,inpatient,1,EA,229.85000,66.66000,Aetna,First Health,,188.02,,,,,,,137.91,188.02,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,17478071510,NDC,,,facility,outpatient,1,EA,229.85000,66.66000,Aetna,First Health,,188.02,,,,,,,82.86,188.02,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,17478071310,NDC,,,facility,inpatient,1,EA,148.25000,42.99000,Aetna,First Health,,121.27,,,,,,,88.95,121.27,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,17478071310,NDC,,,facility,outpatient,1,EA,148.25000,42.99000,Aetna,First Health,,121.27,,,,,,,53.44,121.27,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,17478070311,NDC,,,facility,inpatient,1,EA,91.10000,26.42000,Aetna,First Health,,74.52,,,,,,,54.66,74.52,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,17478070311,NDC,,,facility,outpatient,1,EA,91.10000,26.42000,Aetna,First Health,,74.52,,,,,,,32.84,74.52,percent of total billed charges,
Indocyanine Green 25 mg I,800080225,CDM,250,RC,17478070102,NDC,,,facility,inpatient,1,EA,643.80000,186.70000,Aetna,First Health,,526.63,,,,,,,238.21,526.63,percent of total billed charges,
Indocyanine Green 25 mg I,800080225,CDM,250,RC,17478070102,NDC,,,facility,outpatient,1,EA,643.80000,186.70000,Aetna,First Health,,526.63,,,,,,,232.09,526.63,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,17478062512,NDC,,,facility,inpatient,1,EA,137.65000,39.92000,Aetna,First Health,,112.60,,,,,,,82.59,112.60,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,17478062512,NDC,,,facility,outpatient,1,EA,137.65000,39.92000,Aetna,First Health,,112.60,,,,,,,49.62,112.60,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,17478054225,NDC,facility,inpatient,6,ME,35.90000,10.41000,Aetna,First Health,,29.37,,,,,,,12.94,29.37,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,17478054225,NDC,facility,outpatient,6,ME,35.90000,10.41000,Aetna,First Health,,29.37,,,,,,,0.51039,29.37,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,17478054202,NDC,facility,inpatient,6,ME,39.55000,11.47000,Aetna,First Health,,32.35,,,,,,,14.26,32.35,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,17478054202,NDC,facility,outpatient,6,ME,39.55000,11.47000,Aetna,First Health,,32.35,,,,,,,0.51039,32.35,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,17478053802,NDC,facility,inpatient,60,ME,118.15000,34.26000,Aetna,First Health,,96.65,,,,,,,42.59,96.65,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,17478053802,NDC,facility,outpatient,60,ME,118.15000,34.26000,Aetna,First Health,,96.65,,,,,,,6.15,96.65,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,17478050101,NDC,facility,inpatient,0.2,ME,45.65000,13.24000,Aetna,First Health,,37.34,,,,,,,16.46,37.34,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,17478050101,NDC,facility,outpatient,0.2,ME,45.65000,13.24000,Aetna,First Health,,37.34,,,,,,,16.89,65.87,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,17478042020,NDC,facility,inpatient,100,ME,164.65000,47.75000,Aetna,First Health,,134.68,,,,,,,60.92,134.68,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,17478042020,NDC,facility,outpatient,100,ME,164.65000,47.75000,Aetna,First Health,,134.68,,,,,,,0.33705,134.68,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,17478041940,NDC,facility,inpatient,500,ME,566.55000,164.30000,Aetna,First Health,,463.44,,,,,,,204.24,463.44,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,17478041940,NDC,facility,outpatient,500,ME,566.55000,164.30000,Aetna,First Health,,463.44,,,,,,,55.98,463.44,percent of total billed charges,
Fluorescein Ophth Test Strip,800081069,CDM,250,RC,17478040401,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.49950,1.10,percent of total billed charges,
Fluorescein Ophth Test Strip,800081069,CDM,250,RC,17478040401,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,17478029010,NDC,,,facility,inpatient,1,EA,103.10000,29.90000,Aetna,First Health,,84.34,,,,,,,61.86,84.34,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,17478029010,NDC,,,facility,outpatient,1,EA,103.10000,29.90000,Aetna,First Health,,84.34,,,,,,,37.17,84.34,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,17478028810,NDC,,,facility,inpatient,1,EA,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,72.21,98.45,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,17478028810,NDC,,,facility,outpatient,1,EA,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,43.39,98.45,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,17478026312,NDC,,,facility,inpatient,1,EA,303.65000,88.06000,Aetna,First Health,,248.39,,,,,,,182.19,248.39,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,17478026312,NDC,,,facility,outpatient,1,EA,303.65000,88.06000,Aetna,First Health,,248.39,,,,,,,109.47,248.39,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,17478023835,NDC,,,facility,inpatient,1,EA,184.10000,53.39000,Aetna,First Health,,150.59,,,,,,,68.12,150.59,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,17478023835,NDC,,,facility,outpatient,1,EA,184.10000,53.39000,Aetna,First Health,,150.59,,,,,,,66.37,150.59,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,17478023535,NDC,,,facility,inpatient,1,EA,375.90000,109.01000,Aetna,First Health,,307.49,,,,,,,139.08,307.49,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,17478023535,NDC,,,facility,outpatient,1,EA,375.90000,109.01000,Aetna,First Health,,307.49,,,,,,,135.51,307.49,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,17478022312,NDC,,,facility,inpatient,1,EA,616.45000,178.77000,Aetna,First Health,,504.26,,,,,,,369.87,504.26,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,17478022312,NDC,,,facility,outpatient,1,EA,616.45000,178.77000,Aetna,First Health,,504.26,,,,,,,222.23,504.26,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,17478021515,NDC,,,facility,inpatient,1,EA,374.50000,108.60000,Aetna,First Health,,306.34,,,,,,,224.70,306.34,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,17478021515,NDC,,,facility,outpatient,1,EA,374.50000,108.60000,Aetna,First Health,,306.34,,,,,,,135.01,306.34,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,17478020919,NDC,,,facility,inpatient,1,EA,533.80000,154.80000,Aetna,First Health,,436.65,,,,,,,320.28,436.65,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,17478020919,NDC,,,facility,outpatient,1,EA,533.80000,154.80000,Aetna,First Health,,436.65,,,,,,,192.43,436.65,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,17478020911,NDC,,,facility,inpatient,1,EA,686.30000,199.03000,Aetna,First Health,,561.39,,,,,,,411.78,561.39,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,17478020911,NDC,,,facility,outpatient,1,EA,686.30000,199.03000,Aetna,First Health,,561.39,,,,,,,247.41,561.39,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,17478020910,NDC,,,facility,inpatient,1,EA,686.35000,199.04000,Aetna,First Health,,561.43,,,,,,,411.81,561.43,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,17478020910,NDC,,,facility,outpatient,1,EA,686.35000,199.04000,Aetna,First Health,,561.43,,,,,,,247.43,561.43,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,17478012150,NDC,facility,inpatient,600,ME,70.15000,20.34000,Aetna,First Health,,57.38,,,,,,,25.29,57.38,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,17478012150,NDC,facility,outpatient,600,ME,70.15000,20.34000,Aetna,First Health,,57.38,,,,,,,1.84,57.38,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,17478008130,NDC,facility,inpatient,150,ME,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,14.38,32.64,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,17478008130,NDC,facility,outpatient,150,ME,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,0.04815,32.64,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,17478007031,NDC,,,facility,inpatient,1,EA,72.35000,20.98000,Aetna,First Health,,59.18,,,,,,,43.41,59.18,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,17478007031,NDC,,,facility,outpatient,1,EA,72.35000,20.98000,Aetna,First Health,,59.18,,,,,,,26.08,59.18,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,17478006914,NDC,facility,inpatient,40,ME,19.25000,5.58000,Aetna,First Health,,15.75,,,,,,,6.94,15.75,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,17478006914,NDC,facility,outpatient,40,ME,19.25000,5.58000,Aetna,First Health,,15.75,,,,,,,5.86,18.78,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,17478004001,NDC,facility,inpatient,2,ME,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,11.72,26.59,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,17478004001,NDC,facility,outpatient,2,ME,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,1.36,26.59,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,17478003002,NDC,facility,inpatient,0.1,ME,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,7.07,16.03,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,17478003002,NDC,facility,outpatient,0.1,ME,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,1.15,16.03,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,17478001502,NDC,facility,inpatient,20,ME,433.20000,125.63000,Aetna,First Health,,354.36,,,,,,,156.17,354.36,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,17478001502,NDC,facility,outpatient,20,ME,433.20000,125.63000,Aetna,First Health,,354.36,,,,,,,10.91,354.36,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,17474300201,NDC,facility,inpatient,1,EA,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,8.67,15.09,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,17474300201,NDC,facility,outpatient,1,EA,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,0.63000,15.09,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,17474012505,NDC,facility,inpatient,500,UN,18.10000,5.25000,Aetna,First Health,,14.81,,,,,,,6.53,14.81,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,17474012505,NDC,facility,outpatient,500,UN,18.10000,5.25000,Aetna,First Health,,14.81,,,,,,,0.01926,14.81,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,17314940003,NDC,,,facility,inpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,7.32,9.98,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,17314940003,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,4.40,9.98,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,17314940002,NDC,,,facility,inpatient,1,EA,14.30000,4.15000,Aetna,First Health,,11.70,,,,,,,8.58,11.70,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,17314940002,NDC,,,facility,outpatient,1,EA,14.30000,4.15000,Aetna,First Health,,11.70,,,,,,,5.16,11.70,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,17314940001,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,17314940001,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,17314920001,NDC,,,facility,inpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,4.92,6.71,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,17314920001,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,2.96,6.71,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,17314850001,NDC,,,facility,inpatient,1,EA,29.20000,8.47000,Aetna,First Health,,23.89,,,,,,,17.52,23.89,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,17314850001,NDC,,,facility,outpatient,1,EA,29.20000,8.47000,Aetna,First Health,,23.89,,,,,,,10.53,23.89,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,17271071007,NDC,facility,inpatient,1,EA,96.55000,28.00000,Aetna,First Health,,78.98,,,,,,,45.38,78.98,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,17271071007,NDC,facility,outpatient,1,EA,96.55000,28.00000,Aetna,First Health,,78.98,,,,,,,2.29,78.98,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,17271070107,NDC,facility,inpatient,1,EA,93.50000,27.12000,Aetna,First Health,,76.48,,,,,,,33.71,76.48,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,17271070107,NDC,facility,outpatient,1,EA,93.50000,27.12000,Aetna,First Health,,76.48,,,,,,,1.92,76.48,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,17271070102,NDC,facility,inpatient,1,EA,62.20000,18.04000,Aetna,First Health,,50.88,,,,,,,22.42,50.88,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,17271070102,NDC,facility,outpatient,1,EA,62.20000,18.04000,Aetna,First Health,,50.88,,,,,,,0.63558,50.88,percent of total billed charges,
Fluorescein Ophth Test Strip,800081069,CDM,250,RC,17238090030,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.53650,1.19,percent of total billed charges,
Fluorescein Ophth Test Strip,800081069,CDM,250,RC,17238090030,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
Fluorescein Ophth Test Strip,800081069,CDM,250,RC,17238090011,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.68450,1.51,percent of total billed charges,
Fluorescein Ophth Test Strip,800081069,CDM,250,RC,17238090011,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Indocyanine Green 25 mg I,800080225,CDM,250,RC,17238042406,NDC,,,facility,inpatient,1,EA,468.50000,135.86000,Aetna,First Health,,383.23,,,,,,,173.34,383.23,percent of total billed charges,
Indocyanine Green 25 mg I,800080225,CDM,250,RC,17238042406,NDC,,,facility,outpatient,1,EA,468.50000,135.86000,Aetna,First Health,,383.23,,,,,,,168.89,383.23,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,17236061001,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,17236061001,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,17236026701,NDC,,,facility,inpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.18000,0.24540,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,17236026701,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.10815,0.24540,percent of total billed charges,
benzocaine-menthol Topical Spray,800046392,CDM,637,RC,16864068003,NDC,,,facility,inpatient,1,EA,45.10000,13.08000,Aetna,First Health,,36.89,,,,,,,27.06,36.89,percent of total billed charges,
benzocaine-menthol Topical Spray,800046392,CDM,637,RC,16864068003,NDC,,,facility,outpatient,1,EA,45.10000,13.08000,Aetna,First Health,,36.89,,,,,,,16.26,36.89,percent of total billed charges,
benzocaine-menthol Topical Spray,800046392,CDM,637,RC,16864068001,NDC,,,facility,inpatient,1,EA,45.55000,13.21000,Aetna,First Health,,37.26,,,,,,,27.33,37.26,percent of total billed charges,
benzocaine-menthol Topical Spray,800046392,CDM,637,RC,16864068001,NDC,,,facility,outpatient,1,EA,45.55000,13.21000,Aetna,First Health,,37.26,,,,,,,16.42,37.26,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,16837085514,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,16837085514,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,16837085508,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,16837085508,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,16729053308,NDC,facility,inpatient,1,ME,45.35000,13.15000,Aetna,First Health,,37.10,,,,,,,16.35,37.10,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,16729053308,NDC,facility,outpatient,1,ME,45.35000,13.15000,Aetna,First Health,,37.10,,,,,,,0.61632,37.10,percent of total billed charges,
Atropine SO4 0.4mg/mL 1mL I,800019204,CDM,636,RC,J0461,HCPCS,16729052508,NDC,facility,inpatient,0.4,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,27.61,62.66,percent of total billed charges,
Atropine SO4 0.4mg/mL 1mL I,800019204,CDM,636,RC,J0461,HCPCS,16729052508,NDC,facility,outpatient,0.4,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,0.09630,62.66,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,16729050243,NDC,facility,inpatient,100,ME,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,8.11,18.41,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,16729050243,NDC,facility,outpatient,100,ME,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,8.11,18.41,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,16729050008,NDC,facility,inpatient,20,ME,15.20000,4.41000,Aetna,First Health,,12.43,,,,,,,5.48,12.43,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,16729050008,NDC,facility,outpatient,20,ME,15.20000,4.41000,Aetna,First Health,,12.43,,,,,,,0.01926,12.43,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,16729048501,NDC,,,facility,inpatient,1,EA,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,17.28,23.56,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,16729048501,NDC,,,facility,outpatient,1,EA,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,16729047901,NDC,,,facility,inpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,4.86,6.63,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,16729047901,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,2.92,6.63,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,16729047731,NDC,facility,inpatient,0.4,ME,1187.00000,344.23000,Aetna,First Health,,970.97,,,,,,,427.91,970.97,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,16729047731,NDC,facility,outpatient,0.4,ME,1187.00000,344.23000,Aetna,First Health,,970.97,,,,,,,2.58,970.97,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,16729047108,NDC,facility,inpatient,0.2,ME,38.90000,11.28000,Aetna,First Health,,31.82,,,,,,,14.02,31.82,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,16729047108,NDC,facility,outpatient,0.2,ME,38.90000,11.28000,Aetna,First Health,,31.82,,,,,,,0.36594,31.82,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,16729046503,NDC,facility,inpatient,50,ME,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,73.54,166.87,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,16729046503,NDC,facility,outpatient,50,ME,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,75.48,166.87,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,16729044315,NDC,,,facility,inpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,22.17,30.23,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,16729044315,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,13.32,30.23,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,16729044310,NDC,,,facility,inpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,22.17,30.23,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,16729044310,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,13.32,30.23,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,16729043011,NDC,facility,inpatient,50,ME,1734.40000,502.98000,Aetna,First Health,,1418.74,,,,,,,625.25,1418.74,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,16729043011,NDC,facility,outpatient,50,ME,1734.40000,502.98000,Aetna,First Health,,1418.74,,,,,,,0.58743,1418.74,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,16729041401,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,16729041401,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,16729036566,NDC,facility,inpatient,0.25,ME,1814.10000,526.09000,Aetna,First Health,,1483.93,,,,,,,653.98,1483.93,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,16729036566,NDC,facility,outpatient,0.25,ME,1814.10000,526.09000,Aetna,First Health,,1483.93,,,,,,,0.33705,1483.93,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,16729029805,NDC,facility,inpatient,4,ME,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,16729029805,NDC,facility,outpatient,4,ME,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,0.08667,6.18,percent of total billed charges,
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,16729028811,NDC,facility,inpatient,10,ME,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,12.98,29.45,percent of total billed charges,
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,16729028811,NDC,facility,outpatient,10,ME,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,2.03,29.45,percent of total billed charges,
Methotrexate 1g/40mL I PF,800022022,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,inpatient,1000,ME,321.70000,93.29000,Aetna,First Health,,263.15,,,,,,,115.97,263.15,percent of total billed charges,
Methotrexate 1g/40mL I PF,800022022,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,outpatient,1000,ME,321.70000,93.29000,Aetna,First Health,,263.15,,,,,,,2.48,263.15,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,16729027730,NDC,facility,inpatient,50,ME,31.85000,9.24000,Aetna,First Health,,26.05,,,,,,,11.48,26.05,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,16729027730,NDC,facility,outpatient,50,ME,31.85000,9.24000,Aetna,First Health,,26.05,,,,,,,2.48,26.05,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,16729027668,NDC,facility,inpatient,500,ME,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,45.96,104.30,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,16729027668,NDC,facility,outpatient,500,ME,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,1.87,104.30,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,16729027567,NDC,facility,inpatient,250,ME,7582.25000,2198.85000,Aetna,First Health,,6202.28,,,,,,,2733.40,6202.28,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,16729027567,NDC,facility,outpatient,250,ME,7582.25000,2198.85000,Aetna,First Health,,6202.28,,,,,,,0.15408,6202.28,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,16729026764,NDC,facility,inpatient,80,ME,8950.60000,2595.67000,Aetna,First Health,,7321.59,,,,,,,3226.69,7321.59,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,16729026764,NDC,facility,outpatient,80,ME,8950.60000,2595.67000,Aetna,First Health,,7321.59,,,,,,,0.62595,7321.59,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,16729026763,NDC,facility,inpatient,20,ME,2377.90000,689.59000,Aetna,First Health,,1945.12,,,,,,,857.23,1945.12,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,16729026763,NDC,facility,outpatient,20,ME,2377.90000,689.59000,Aetna,First Health,,1945.12,,,,,,,0.62595,1945.12,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,16729026231,NDC,facility,inpatient,10,ME,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,16729026231,NDC,facility,outpatient,10,ME,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.00,3.64,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,16729024711,NDC,facility,inpatient,20,ME,840.10000,243.63000,Aetna,First Health,,687.20,,,,,,,302.86,687.20,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,16729024711,NDC,facility,outpatient,20,ME,840.10000,243.63000,Aetna,First Health,,687.20,,,,,,,25.13,687.20,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,16729021815,NDC,,,facility,inpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,29.58,40.33,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,16729021815,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,17.77,40.33,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,16729021715,NDC,,,facility,inpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,12.09,16.48,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,16729021715,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,7.26,16.48,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,16729021201,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,16729021201,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,16729021101,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,16729021101,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,16729020201,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,16729020201,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,16729020001,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,16729020001,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,16729018301,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,16729018301,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,16729018217,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,16729018217,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,16729018201,NDC,,,facility,inpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.80,2.45,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,16729018201,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.08,2.45,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,16729017501,NDC,,,facility,inpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,16729017501,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,6.49,14.72,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,16729017201,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,16729017201,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,16729017101,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,16729017101,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,16729017001,NDC,,,facility,inpatient,1,EA,34.85000,10.11000,Aetna,First Health,,28.51,,,,,,,20.91,28.51,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,16729017001,NDC,,,facility,outpatient,1,EA,34.85000,10.11000,Aetna,First Health,,28.51,,,,,,,12.56,28.51,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,16729016801,NDC,,,facility,inpatient,1,EA,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,19.17,26.14,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,16729016801,NDC,,,facility,outpatient,1,EA,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,11.52,26.14,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,16729013616,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,16729013616,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,16729013501,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,16729013501,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,16729013401,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,16729013401,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,16729011711,NDC,facility,inpatient,1000,ME,434.00000,125.86000,Aetna,First Health,,355.01,,,,,,,156.46,355.01,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,16729011711,NDC,facility,outpatient,1000,ME,434.00000,125.86000,Aetna,First Health,,355.01,,,,,,,3.46,355.01,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,16729011431,NDC,facility,inpatient,10,ME,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,2.67,6.05,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,16729011431,NDC,facility,outpatient,10,ME,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,1.00,6.05,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,inpatient,20,ME,3372.20000,977.94000,Aetna,First Health,,2758.46,,,,,,,1215.68,2758.46,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,outpatient,20,ME,3372.20000,977.94000,Aetna,First Health,,2758.46,,,,,,,25.13,2758.46,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,16729009203,NDC,facility,inpatient,200,ME,301.00000,87.29000,Aetna,First Health,,246.22,,,,,,,108.51,246.22,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,16729009203,NDC,facility,outpatient,200,ME,301.00000,87.29000,Aetna,First Health,,246.22,,,,,,,3.46,246.22,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,16729009010,NDC,,,facility,inpatient,1,EA,22.05000,6.39000,Aetna,First Health,,18.04,,,,,,,13.23,18.04,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,16729009010,NDC,,,facility,outpatient,1,EA,22.05000,6.39000,Aetna,First Health,,18.04,,,,,,,7.95,18.04,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,16729009001,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,13.29,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,16729009001,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,16729006529,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,16729006529,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,16729004201,NDC,facility,inpatient,1,ME,31.55000,9.15000,Aetna,First Health,,25.81,,,,,,,18.93,25.81,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,16729004201,NDC,facility,outpatient,1,ME,31.55000,9.15000,Aetna,First Health,,25.81,,,,,,,0.19260,25.81,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),800081868,CDM,637,RC,J7507,HCPCS,16729004101,NDC,facility,inpatient,0.5,ME,15.80000,4.58000,Aetna,First Health,,12.92,,,,,,,9.48,12.92,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),800081868,CDM,637,RC,J7507,HCPCS,16729004101,NDC,facility,outpatient,0.5,ME,15.80000,4.58000,Aetna,First Health,,12.92,,,,,,,0.19260,12.92,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,16729003510,NDC,,,facility,inpatient,1,EA,94.20000,27.32000,Aetna,First Health,,77.06,,,,,,,56.52,77.06,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,16729003510,NDC,,,facility,outpatient,1,EA,94.20000,27.32000,Aetna,First Health,,77.06,,,,,,,33.96,77.06,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,16729003410,NDC,,,facility,inpatient,1,EA,127.80000,37.06000,Aetna,First Health,,104.54,,,,,,,76.68,104.54,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,16729003410,NDC,,,facility,outpatient,1,EA,127.80000,37.06000,Aetna,First Health,,104.54,,,,,,,46.07,104.54,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,16729002310,NDC,,,facility,inpatient,1,EA,129.95000,37.69000,Aetna,First Health,,106.30,,,,,,,77.97,106.30,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,16729002310,NDC,,,facility,outpatient,1,EA,129.95000,37.69000,Aetna,First Health,,106.30,,,,,,,46.85,106.30,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,16729002301,NDC,,,facility,inpatient,1,EA,129.95000,37.69000,Aetna,First Health,,106.30,,,,,,,77.97,106.30,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,16729002301,NDC,,,facility,outpatient,1,EA,129.95000,37.69000,Aetna,First Health,,106.30,,,,,,,46.85,106.30,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,16729001901,NDC,facility,inpatient,500,ME,55.55000,16.11000,Aetna,First Health,,45.44,,,,,,,20.03,45.44,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,16729001901,NDC,facility,outpatient,500,ME,55.55000,16.11000,Aetna,First Health,,45.44,,,,,,,0.14445,45.44,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,16729000101,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,16729000101,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,16714075301,NDC,,,facility,inpatient,1,EA,29.65000,8.60000,Aetna,First Health,,24.25,,,,,,,17.79,24.25,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,16714075301,NDC,,,facility,outpatient,1,EA,29.65000,8.60000,Aetna,First Health,,24.25,,,,,,,10.69,24.25,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,16714013025,NDC,facility,inpatient,40,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,19.56,44.38,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,16714013025,NDC,facility,outpatient,40,ME,54.25000,15.73000,Aetna,First Health,,44.38,,,,,,,0.71262,44.38,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,16571083101,NDC,,,facility,inpatient,1,EA,26.40000,7.66000,Aetna,First Health,,21.60,,,,,,,15.84,21.60,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,16571083101,NDC,,,facility,outpatient,1,EA,26.40000,7.66000,Aetna,First Health,,21.60,,,,,,,9.52,21.60,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,16571077810,NDC,,,facility,inpatient,1,EA,61.25000,17.76000,Aetna,First Health,,50.10,,,,,,,36.75,50.10,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,16571077810,NDC,,,facility,outpatient,1,EA,61.25000,17.76000,Aetna,First Health,,50.10,,,,,,,22.08,50.10,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,16571077809,NDC,,,facility,inpatient,1,EA,61.25000,17.76000,Aetna,First Health,,50.10,,,,,,,36.75,50.10,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,16571077809,NDC,,,facility,outpatient,1,EA,61.25000,17.76000,Aetna,First Health,,50.10,,,,,,,22.08,50.10,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,16571075453,NDC,,,facility,inpatient,1,EA,386.25000,112.01000,Aetna,First Health,,315.95,,,,,,,142.91,315.95,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,16571075453,NDC,,,facility,outpatient,1,EA,386.25000,112.01000,Aetna,First Health,,315.95,,,,,,,139.24,315.95,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,16571073528,NDC,,,facility,inpatient,1,EA,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,282.72,385.44,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,16571073528,NDC,,,facility,outpatient,1,EA,471.20000,136.65000,Aetna,First Health,,385.44,,,,,,,169.87,385.44,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,16571073521,NDC,,,facility,inpatient,1,EA,471.45000,136.72000,Aetna,First Health,,385.65,,,,,,,282.87,385.65,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,16571073521,NDC,,,facility,outpatient,1,EA,471.45000,136.72000,Aetna,First Health,,385.65,,,,,,,169.96,385.65,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,16571067621,NDC,,,facility,inpatient,1,EA,160.35000,46.50000,Aetna,First Health,,131.17,,,,,,,96.21,131.17,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,16571067621,NDC,,,facility,outpatient,1,EA,160.35000,46.50000,Aetna,First Health,,131.17,,,,,,,57.81,131.17,percent of total billed charges,
PHENobarbital 32.4 mg Tab,800051123,CDM,637,RC,16571067301,NDC,,,facility,inpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,3.21,4.38,percent of total billed charges,
PHENobarbital 32.4 mg Tab,800051123,CDM,637,RC,16571067301,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,1.93,4.38,percent of total billed charges,
PHENobarbital 97.2 mg Tab,800051981,CDM,637,RC,16571066801,NDC,,,facility,inpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,5.67,7.73,percent of total billed charges,
PHENobarbital 97.2 mg Tab,800051981,CDM,637,RC,16571066801,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,First Health,,7.73,,,,,,,3.41,7.73,percent of total billed charges,
PHENobarbital 64.8mg Tab,800051980,CDM,637,RC,16571066701,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,4.02,5.48,percent of total billed charges,
PHENobarbital 64.8mg Tab,800051980,CDM,637,RC,16571066701,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Cetirizine 5 mg Tab,800015396,CDM,637,RC,16571040110,NDC,,,facility,inpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,10.59,14.44,percent of total billed charges,
Cetirizine 5 mg Tab,800015396,CDM,637,RC,16571040110,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,6.36,14.44,percent of total billed charges,
Diclofenac Na 25mg EC T,800058437,CDM,637,RC,16571020310,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Diclofenac Na 25mg EC T,800058437,CDM,637,RC,16571020310,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,16571016010,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,16571016010,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,16571014150,NDC,,,facility,inpatient,1,EA,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,72.21,98.45,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,16571014150,NDC,,,facility,outpatient,1,EA,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,43.39,98.45,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,16571014050,NDC,,,facility,inpatient,1,EA,106.20000,30.80000,Aetna,First Health,,86.87,,,,,,,63.72,86.87,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,16571014050,NDC,,,facility,outpatient,1,EA,106.20000,30.80000,Aetna,First Health,,86.87,,,,,,,38.29,86.87,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,16252059299,NDC,,,facility,inpatient,1,EA,186.75000,54.16000,Aetna,First Health,,152.76,,,,,,,112.05,152.76,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,16252059299,NDC,,,facility,outpatient,1,EA,186.75000,54.16000,Aetna,First Health,,152.76,,,,,,,67.32,152.76,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,16252059099,NDC,,,facility,inpatient,1,EA,199.80000,57.94000,Aetna,First Health,,163.44,,,,,,,119.88,163.44,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,16252059099,NDC,,,facility,outpatient,1,EA,199.80000,57.94000,Aetna,First Health,,163.44,,,,,,,72.03,163.44,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,16252057201,NDC,,,facility,inpatient,1,EA,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,7.65,10.43,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,16252057201,NDC,,,facility,outpatient,1,EA,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,16252057101,NDC,,,facility,inpatient,1,EA,12.15000,3.52000,Aetna,First Health,,9.94,,,,,,,7.29,9.94,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,16252057101,NDC,,,facility,outpatient,1,EA,12.15000,3.52000,Aetna,First Health,,9.94,,,,,,,4.38,9.94,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,16252057030,NDC,,,facility,inpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,6.18,8.43,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,16252057030,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,16252052790,NDC,,,facility,inpatient,1,EA,22.90000,6.64000,Aetna,First Health,,18.73,,,,,,,13.74,18.73,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,16252052790,NDC,,,facility,outpatient,1,EA,22.90000,6.64000,Aetna,First Health,,18.73,,,,,,,8.26,18.73,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,15330002801,NDC,,,facility,inpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,3.57,4.87,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,15330002801,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,15330002501,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,15330002501,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,14832001103,NDC,,,facility,inpatient,1,EA,118.65000,34.41000,Aetna,First Health,,97.06,,,,,,,71.19,97.06,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,14832001103,NDC,,,facility,outpatient,1,EA,118.65000,34.41000,Aetna,First Health,,97.06,,,,,,,42.77,97.06,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,14832001101,NDC,,,facility,inpatient,1,EA,172.35000,49.98000,Aetna,First Health,,140.98,,,,,,,103.41,140.98,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,14832001101,NDC,,,facility,outpatient,1,EA,172.35000,49.98000,Aetna,First Health,,140.98,,,,,,,62.13,140.98,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,14789070002,NDC,facility,inpatient,10,ME,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,41.42,93.99,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,14789070002,NDC,facility,outpatient,10,ME,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,2.43,93.99,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,14789040005,NDC,facility,inpatient,500,ME,172.80000,50.11000,Aetna,First Health,,141.35,,,,,,,62.29,141.35,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,14789040005,NDC,facility,outpatient,500,ME,172.80000,50.11000,Aetna,First Health,,141.35,,,,,,,0.03852,141.35,percent of total billed charges,
Erythromycin Lact.500mg I,800081135,CDM,636,RC,J1364,HCPCS,14789011605,NDC,facility,inpatient,500,ME,1627.00000,471.83000,Aetna,First Health,,1330.89,,,,,,,586.53,1330.89,percent of total billed charges,
Erythromycin Lact.500mg I,800081135,CDM,636,RC,J1364,HCPCS,14789011605,NDC,facility,outpatient,500,ME,1627.00000,471.83000,Aetna,First Health,,1330.89,,,,,,,19.41,1330.89,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,14789010910,NDC,facility,inpatient,1,EA,397.00000,115.13000,Aetna,First Health,,324.75,,,,,,,143.12,324.75,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,14789010910,NDC,facility,outpatient,1,EA,397.00000,115.13000,Aetna,First Health,,324.75,,,,,,,0.11556,324.75,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,14789010810,NDC,facility,inpatient,1,EA,397.00000,115.13000,Aetna,First Health,,324.75,,,,,,,143.12,324.75,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,14789010810,NDC,facility,outpatient,1,EA,397.00000,115.13000,Aetna,First Health,,324.75,,,,,,,0.11556,324.75,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,14789001505,NDC,,,facility,inpatient,1,EA,4870.00000,1412.30000,Aetna,First Health,,3983.66,,,,,,,1801.90,3983.66,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,14789001505,NDC,,,facility,outpatient,1,EA,4870.00000,1412.30000,Aetna,First Health,,3983.66,,,,,,,1755.63,3983.66,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,14789001202,NDC,,,facility,inpatient,1,EA,455.70000,132.15000,Aetna,First Health,,372.76,,,,,,,168.61,372.76,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,14789001202,NDC,,,facility,outpatient,1,EA,455.70000,132.15000,Aetna,First Health,,372.76,,,,,,,164.28,372.76,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,14550051302,NDC,,,facility,inpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,14550051302,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,14550051204,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,14550051204,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,14550051202,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,14550051202,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,14550051104,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,14550051104,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,14539067501,NDC,facility,inpatient,50,ME,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,14539067501,NDC,facility,outpatient,50,ME,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,0.21186,3.56,percent of total billed charges,
Pentamidine 300mg Inh,800081348,CDM,637,RC,J2545,HCPCS,13925052201,NDC,facility,inpatient,300,ME,1097.20000,318.19000,Aetna,First Health,,897.51,,,,,,,658.32,897.51,percent of total billed charges,
Pentamidine 300mg Inh,800081348,CDM,637,RC,J2545,HCPCS,13925052201,NDC,facility,outpatient,300,ME,1097.20000,318.19000,Aetna,First Health,,897.51,,,,,,,395.54,897.51,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,13811068130,NDC,,,facility,inpatient,1,EA,226.30000,65.63000,Aetna,First Health,,185.11,,,,,,,135.78,185.11,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,13811068130,NDC,,,facility,outpatient,1,EA,226.30000,65.63000,Aetna,First Health,,185.11,,,,,,,81.58,185.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,13811068030,NDC,,,facility,inpatient,1,EA,226.30000,65.63000,Aetna,First Health,,185.11,,,,,,,135.78,185.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,13811068030,NDC,,,facility,outpatient,1,EA,226.30000,65.63000,Aetna,First Health,,185.11,,,,,,,81.58,185.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,13811068010,NDC,,,facility,inpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,135.63,184.91,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,13811068010,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,First Health,,184.91,,,,,,,81.49,184.91,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,13811067930,NDC,,,facility,inpatient,1,EA,223.90000,64.93000,Aetna,First Health,,183.15,,,,,,,134.34,183.15,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,13811067930,NDC,,,facility,outpatient,1,EA,223.90000,64.93000,Aetna,First Health,,183.15,,,,,,,80.72,183.15,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,13811052501,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,13811052501,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,13668059501,NDC,,,facility,inpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,74.34,101.35,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,13668059501,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,44.67,101.35,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,13668059182,NDC,facility,inpatient,40,ME,703.45000,204.00000,Aetna,First Health,,575.42,,,,,,,422.07,575.42,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,13668059182,NDC,facility,outpatient,40,ME,703.45000,204.00000,Aetna,First Health,,575.42,,,,,,,2.67,575.42,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,13668059181,NDC,facility,inpatient,40,ME,703.45000,204.00000,Aetna,First Health,,575.42,,,,,,,422.07,575.42,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,13668059181,NDC,facility,outpatient,40,ME,703.45000,204.00000,Aetna,First Health,,575.42,,,,,,,2.67,575.42,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),800080654,CDM,637,RC,13668045301,NDC,,,facility,inpatient,1,EA,79.05000,22.92000,Aetna,First Health,,64.66,,,,,,,47.43,64.66,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),800080654,CDM,637,RC,13668045301,NDC,,,facility,outpatient,1,EA,79.05000,22.92000,Aetna,First Health,,64.66,,,,,,,28.50,64.66,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,13668027101,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,13668027101,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,13668018930,NDC,,,facility,inpatient,1,EA,67.60000,19.60000,Aetna,First Health,,55.30,,,,,,,40.56,55.30,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,13668018930,NDC,,,facility,outpatient,1,EA,67.60000,19.60000,Aetna,First Health,,55.30,,,,,,,24.37,55.30,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,13668013501,NDC,,,facility,inpatient,1,EA,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,17.58,23.97,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,13668013501,NDC,,,facility,outpatient,1,EA,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,10.56,23.97,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,13668013301,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,13668013301,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,13668011390,NDC,,,facility,inpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,7.14,9.73,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,13668011390,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,4.29,9.73,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,13668010401,NDC,,,facility,inpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,14.25,19.43,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,13668010401,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.56,19.43,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,13668009390,NDC,,,facility,inpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,12.54,17.10,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,13668009390,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,13668009190,NDC,,,facility,inpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,12.54,17.10,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,13668009190,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,13668008190,NDC,,,facility,inpatient,1,EA,35.60000,10.32000,Aetna,First Health,,29.12,,,,,,,21.36,29.12,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,13668008190,NDC,,,facility,outpatient,1,EA,35.60000,10.32000,Aetna,First Health,,29.12,,,,,,,12.83,29.12,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,13668004701,NDC,,,facility,inpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,20.19,27.53,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,13668004701,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,12.13,27.53,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,13668004501,NDC,,,facility,inpatient,1,EA,29.40000,8.53000,Aetna,First Health,,24.05,,,,,,,17.64,24.05,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,13668004501,NDC,,,facility,outpatient,1,EA,29.40000,8.53000,Aetna,First Health,,24.05,,,,,,,10.60,24.05,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,13668003560,NDC,,,facility,inpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,16.56,22.58,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,13668003560,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,13668001990,NDC,,,facility,inpatient,1,EA,33.05000,9.58000,Aetna,First Health,,27.03,,,,,,,19.83,27.03,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,13668001990,NDC,,,facility,outpatient,1,EA,33.05000,9.58000,Aetna,First Health,,27.03,,,,,,,11.91,27.03,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,13668001512,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,13668001512,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,13668001412,NDC,,,facility,inpatient,1,EA,20.35000,5.90000,Aetna,First Health,,16.65,,,,,,,12.21,16.65,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,13668001412,NDC,,,facility,outpatient,1,EA,20.35000,5.90000,Aetna,First Health,,16.65,,,,,,,7.34,16.65,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,13668000801,NDC,,,facility,inpatient,1,EA,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,22.20,30.27,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,13668000801,NDC,,,facility,outpatient,1,EA,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,13.34,30.27,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,13668000774,NDC,,,facility,inpatient,1,EA,37.15000,10.77000,Aetna,First Health,,30.39,,,,,,,22.29,30.39,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,13668000774,NDC,,,facility,outpatient,1,EA,37.15000,10.77000,Aetna,First Health,,30.39,,,,,,,13.39,30.39,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,13668000701,NDC,,,facility,inpatient,1,EA,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,22.20,30.27,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,13668000701,NDC,,,facility,outpatient,1,EA,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,13.34,30.27,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,13551020101,NDC,,,facility,inpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,8.82,12.02,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,13551020101,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.30,12.02,percent of total billed charges,
Alpha 1-Proteinase Inhbitor Human 10mg I(Prolastin),800040897,CDM,636,RC,J0256,HCPCS,13533070501,NDC,facility,inpatient,10,ME,36.80000,10.67000,Aetna,First Health,,30.10,,,,,,,13.27,30.10,percent of total billed charges,
Alpha 1-Proteinase Inhbitor Human 10mg I(Prolastin),800040897,CDM,636,RC,J0256,HCPCS,13533070501,NDC,facility,outpatient,10,ME,36.80000,10.67000,Aetna,First Health,,30.10,,,,,,,5.17,30.10,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,13533069220,NDC,facility,inpatient,12.5,GM,426.55000,123.70000,Aetna,First Health,,348.92,,,,,,,153.77,348.92,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,13533069220,NDC,facility,outpatient,12.5,GM,426.55000,123.70000,Aetna,First Health,,348.92,,,,,,,51.12,348.92,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,13533068525,NDC,facility,inpatient,12.5,GM,453.05000,131.38000,Aetna,First Health,,370.59,,,,,,,163.32,370.59,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,13533068525,NDC,facility,outpatient,12.5,GM,453.05000,131.38000,Aetna,First Health,,370.59,,,,,,,51.12,370.59,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,13533068420,NDC,facility,inpatient,12.5,GM,426.55000,123.70000,Aetna,First Health,,348.92,,,,,,,153.77,348.92,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,13533068420,NDC,facility,outpatient,12.5,GM,426.55000,123.70000,Aetna,First Health,,348.92,,,,,,,51.12,348.92,percent of total billed charges,
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,13533063603,NDC,facility,inpatient,1,EA,419.10000,121.54000,Aetna,First Health,,342.82,,,,,,,151.09,342.82,percent of total billed charges,
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,13533063603,NDC,facility,outpatient,1,EA,419.10000,121.54000,Aetna,First Health,,342.82,,,,,,,67.02,342.82,percent of total billed charges,
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,13533063602,NDC,facility,inpatient,1,EA,377.80000,109.56000,Aetna,First Health,,309.04,,,,,,,136.20,309.04,percent of total billed charges,
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,13533063602,NDC,facility,outpatient,1,EA,377.80000,109.56000,Aetna,First Health,,309.04,,,,,,,67.02,309.04,percent of total billed charges,
Tetanus IG 250U I(Bay-Tet),800011759,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,inpatient,250,UN,2406.70000,697.94000,Aetna,First Health,,1968.68,,,,,,,867.62,1968.68,percent of total billed charges,
Tetanus IG 250U I(Bay-Tet),800011759,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,outpatient,250,UN,2406.70000,697.94000,Aetna,First Health,,1968.68,,,,,,,566.76,1968.68,percent of total billed charges,
Rabies Immune Glob 300IU/1mL Inj,800040856,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,inpatient,300,F2,3019.10000,875.54000,Aetna,First Health,,2469.62,,,,,,,1088.39,2469.62,percent of total billed charges,
Rabies Immune Glob 300IU/1mL Inj,800040856,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,300,F2,3019.10000,875.54000,Aetna,First Health,,2469.62,,,,,,,269.59,2469.62,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,13310011907,NDC,,,facility,inpatient,1,EA,41.20000,11.95000,Aetna,First Health,,33.70,,,,,,,24.72,33.70,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,13310011907,NDC,,,facility,outpatient,1,EA,41.20000,11.95000,Aetna,First Health,,33.70,,,,,,,14.85,33.70,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,13310011901,NDC,,,facility,inpatient,1,EA,41.20000,11.95000,Aetna,First Health,,33.70,,,,,,,24.72,33.70,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,13310011901,NDC,,,facility,outpatient,1,EA,41.20000,11.95000,Aetna,First Health,,33.70,,,,,,,14.85,33.70,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,13143030136,NDC,facility,inpatient,12.5,GM,458.00000,132.82000,Aetna,First Health,,374.64,,,,,,,165.11,374.64,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,13143030136,NDC,facility,outpatient,12.5,GM,458.00000,132.82000,Aetna,First Health,,374.64,,,,,,,51.12,374.64,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,13107015530,NDC,,,facility,inpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,11.22,15.30,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,13107015530,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,6.74,15.30,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,13107015430,NDC,,,facility,inpatient,1,EA,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,11.13,15.17,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,13107015430,NDC,,,facility,outpatient,1,EA,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,6.69,15.17,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,13107014401,NDC,,,facility,inpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,8.28,11.29,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,13107014401,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,4.97,11.29,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,13107008405,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,4.05,5.52,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,13107008405,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,13107008401,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,13107008401,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,13107007301,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,13107007301,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,13107007201,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,13107007201,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,13107003134,NDC,,,facility,inpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,11.46,15.62,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,13107003134,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,6.89,15.62,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,13107000130,NDC,,,facility,inpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,11.19,15.26,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,13107000130,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,6.72,15.26,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,13107000105,NDC,,,facility,inpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,11.19,15.26,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,13107000105,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,6.72,15.26,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12870000102,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12870000102,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12870000101,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12870000101,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Buprenorphine 8mg SL Tab,800019980,CDM,637,RC,J0571,HCPCS,12496131002,NDC,facility,inpatient,8,ME,99.20000,28.77000,Aetna,First Health,,81.15,,,,,,,59.52,81.15,percent of total billed charges,
Buprenorphine 8mg SL Tab,800019980,CDM,637,RC,J0571,HCPCS,12496131002,NDC,facility,outpatient,8,ME,99.20000,28.77000,Aetna,First Health,,81.15,,,,,,,2.08,81.15,percent of total billed charges,
Buprenorphine-Naloxone 8-2mg SLT,800072440,CDM,637,RC,J0574,HCPCS,12496130602,NDC,facility,inpatient,1,EA,92.75000,26.90000,Aetna,First Health,,75.87,,,,,,,55.65,75.87,percent of total billed charges,
Buprenorphine-Naloxone 8-2mg SLT,800072440,CDM,637,RC,J0574,HCPCS,12496130602,NDC,facility,outpatient,1,EA,92.75000,26.90000,Aetna,First Health,,75.87,,,,,,,9.80,75.87,percent of total billed charges,
Buprenorphine-Naloxone 2-0.5mg SLTab,800072441,CDM,637,RC,J0572,HCPCS,12496128302,NDC,facility,inpatient,1,EA,51.75000,15.01000,Aetna,First Health,,42.33,,,,,,,31.05,42.33,percent of total billed charges,
Buprenorphine-Naloxone 2-0.5mg SLTab,800072441,CDM,637,RC,J0572,HCPCS,12496128302,NDC,facility,outpatient,1,EA,51.75000,15.01000,Aetna,First Health,,42.33,,,,,,,5.48,42.33,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12165010003,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12165010003,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12165010001,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12165010001,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,11980077905,NDC,,,facility,inpatient,1,EA,920.70000,267.00000,Aetna,First Health,,753.13,,,,,,,552.42,753.13,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,11980077905,NDC,,,facility,outpatient,1,EA,920.70000,267.00000,Aetna,First Health,,753.13,,,,,,,331.91,753.13,percent of total billed charges,
Fluorometholone 0.1% 5mL Ophth Susp,800018804,CDM,637,RC,11980021105,NDC,,,facility,inpatient,1,EA,1311.65000,380.38000,Aetna,First Health,,1072.93,,,,,,,786.99,1072.93,percent of total billed charges,
Fluorometholone 0.1% 5mL Ophth Susp,800018804,CDM,637,RC,11980021105,NDC,,,facility,outpatient,1,EA,1311.65000,380.38000,Aetna,First Health,,1072.93,,,,,,,472.85,1072.93,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,11980018010,NDC,,,facility,inpatient,1,EA,938.10000,272.05000,Aetna,First Health,,767.37,,,,,,,562.86,767.37,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,11980018010,NDC,,,facility,outpatient,1,EA,938.10000,272.05000,Aetna,First Health,,767.37,,,,,,,338.19,767.37,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,11980018005,NDC,,,facility,inpatient,1,EA,1164.05000,337.57000,Aetna,First Health,,952.19,,,,,,,698.43,952.19,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,11980018005,NDC,,,facility,outpatient,1,EA,1164.05000,337.57000,Aetna,First Health,,952.19,,,,,,,419.64,952.19,percent of total billed charges,
prednisoLONE 0.12% 5mL Ophth Susp(Pred Mild),800043967,CDM,637,RC,11980017405,NDC,,,facility,inpatient,1,EA,1164.05000,337.57000,Aetna,First Health,,952.19,,,,,,,698.43,952.19,percent of total billed charges,
prednisoLONE 0.12% 5mL Ophth Susp(Pred Mild),800043967,CDM,637,RC,11980017405,NDC,,,facility,outpatient,1,EA,1164.05000,337.57000,Aetna,First Health,,952.19,,,,,,,419.64,952.19,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,11793752202,NDC,facility,inpatient,5,UN,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,3.19,7.24,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,11793752202,NDC,facility,outpatient,5,UN,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,3.27,65.38,percent of total billed charges,
Hydroxocobalamin 5g Kit,800081127,CDM,636,RC,J3424,HCPCS,11704037001,NDC,facility,inpatient,5,GM,4863.10000,1410.30000,Aetna,First Health,,3978.02,,,,,,,1753.15,3978.02,percent of total billed charges,
Hydroxocobalamin 5g Kit,800081127,CDM,636,RC,J3424,HCPCS,11704037001,NDC,facility,outpatient,5,GM,4863.10000,1410.30000,Aetna,First Health,,3978.02,,,,,,,5.44,3978.02,percent of total billed charges,
Zinc Oxide 20% Topical Paste,800046419,CDM,637,RC,11701005033,NDC,,,facility,inpatient,1,EA,680.60000,197.37000,Aetna,First Health,,556.73,,,,,,,408.36,556.73,percent of total billed charges,
Zinc Oxide 20% Topical Paste,800046419,CDM,637,RC,11701005033,NDC,,,facility,outpatient,1,EA,680.60000,197.37000,Aetna,First Health,,556.73,,,,,,,245.36,556.73,percent of total billed charges,
Zinc Oxide 20% Topical Paste,800046419,CDM,637,RC,11701005032,NDC,,,facility,inpatient,1,EA,32.10000,9.31000,Aetna,First Health,,26.26,,,,,,,19.26,26.26,percent of total billed charges,
Zinc Oxide 20% Topical Paste,800046419,CDM,637,RC,11701005032,NDC,,,facility,outpatient,1,EA,32.10000,9.31000,Aetna,First Health,,26.26,,,,,,,11.57,26.26,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,11534019701,NDC,,,facility,inpatient,1,EA,276.55000,80.20000,Aetna,First Health,,226.22,,,,,,,165.93,226.22,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,11534019701,NDC,,,facility,outpatient,1,EA,276.55000,80.20000,Aetna,First Health,,226.22,,,,,,,99.70,226.22,percent of total billed charges,
sodium polystyrene sulfonate 15g Oral Rec Pwd,800046514,CDM,637,RC,11534016616,NDC,,,facility,inpatient,1,EA,111.95000,32.47000,Aetna,First Health,,91.58,,,,,,,67.17,91.58,percent of total billed charges,
sodium polystyrene sulfonate 15g Oral Rec Pwd,800046514,CDM,637,RC,11534016616,NDC,,,facility,outpatient,1,EA,111.95000,32.47000,Aetna,First Health,,91.58,,,,,,,40.36,91.58,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,11534016501,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,11534016501,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
droPERidol 2.5mg/mL 2mL I,800011791,CDM,636,RC,J1790,HCPCS,11098001002,NDC,facility,inpatient,5,ME,30.50000,8.84000,Aetna,First Health,,24.95,,,,,,,11.00,24.95,percent of total billed charges,
droPERidol 2.5mg/mL 2mL I,800011791,CDM,636,RC,J1790,HCPCS,11098001002,NDC,facility,outpatient,5,ME,30.50000,8.84000,Aetna,First Health,,24.95,,,,,,,6.91,24.95,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,10702010001,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,10702010001,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Dextroamphetamine 5mg T,800081078,CDM,637,RC,S0160,HCPCS,10702006501,NDC,facility,inpatient,5,ME,23.20000,6.73000,Aetna,First Health,,18.98,,,,,,,13.92,18.98,percent of total billed charges,
Dextroamphetamine 5mg T,800081078,CDM,637,RC,S0160,HCPCS,10702006501,NDC,facility,outpatient,5,ME,23.20000,6.73000,Aetna,First Health,,18.98,,,,,,,2.79,18.98,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,10702001801,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,10702001801,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,10702001101,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,10702001101,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,10702000601,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,10702000601,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,10572010101,NDC,,,facility,inpatient,1,EA,116.70000,33.84000,Aetna,First Health,,95.46,,,,,,,70.02,95.46,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,10572010101,NDC,,,facility,outpatient,1,EA,116.70000,33.84000,Aetna,First Health,,95.46,,,,,,,42.07,95.46,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,10572010001,NDC,,,facility,inpatient,1,EA,195.05000,56.56000,Aetna,First Health,,159.55,,,,,,,117.03,159.55,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,10572010001,NDC,,,facility,outpatient,1,EA,195.05000,56.56000,Aetna,First Health,,159.55,,,,,,,70.32,159.55,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,10370083011,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,10370083011,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,10370083009,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,10370083009,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,10370082909,NDC,,,facility,inpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,5.10,6.95,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,10370082909,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,3.06,6.95,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,10370051110,NDC,,,facility,inpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,17.31,23.60,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,10370051110,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,10.40,23.60,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,10370051010,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,10370051010,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,10370010103,NDC,,,facility,inpatient,1,EA,33.80000,9.80000,Aetna,First Health,,27.65,,,,,,,20.28,27.65,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,10370010103,NDC,,,facility,outpatient,1,EA,33.80000,9.80000,Aetna,First Health,,27.65,,,,,,,12.18,27.65,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,10310032280,NDC,,,facility,inpatient,1,EA,29.60000,8.58000,Aetna,First Health,,24.21,,,,,,,10.95,24.21,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,10310032280,NDC,,,facility,outpatient,1,EA,29.60000,8.58000,Aetna,First Health,,24.21,,,,,,,10.67,24.21,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,10147095203,NDC,,,facility,inpatient,1,EA,93.55000,27.13000,Aetna,First Health,,76.52,,,,,,,56.13,76.52,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,10147095203,NDC,,,facility,outpatient,1,EA,93.55000,27.13000,Aetna,First Health,,76.52,,,,,,,33.72,76.52,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,10147095201,NDC,,,facility,inpatient,1,EA,215.85000,62.60000,Aetna,First Health,,176.57,,,,,,,129.51,176.57,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,10147095201,NDC,,,facility,outpatient,1,EA,215.85000,62.60000,Aetna,First Health,,176.57,,,,,,,77.81,176.57,percent of total billed charges,
Haloperidol Decanoate 100mg/1mL Inj,800040916,CDM,636,RC,J1631,HCPCS,10147092205,NDC,facility,inpatient,100,ME,296.85000,86.09000,Aetna,First Health,,242.82,,,,,,,107.01,242.82,percent of total billed charges,
Haloperidol Decanoate 100mg/1mL Inj,800040916,CDM,636,RC,J1631,HCPCS,10147092205,NDC,facility,outpatient,100,ME,296.85000,86.09000,Aetna,First Health,,242.82,,,,,,,3.79,242.82,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,10147076100,NDC,,,facility,inpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,12.54,17.10,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,10147076100,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
Ketoconazole 2% Top Shampoo 120mL,800017775,CDM,637,RC,10147075004,NDC,,,facility,inpatient,1,EA,197.80000,57.36000,Aetna,First Health,,161.80,,,,,,,118.68,161.80,percent of total billed charges,
Ketoconazole 2% Top Shampoo 120mL,800017775,CDM,637,RC,10147075004,NDC,,,facility,outpatient,1,EA,197.80000,57.36000,Aetna,First Health,,161.80,,,,,,,71.31,161.80,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,10139090510,NDC,facility,inpatient,0.25,ME,472.95000,137.16000,Aetna,First Health,,386.87,,,,,,,170.50,386.87,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,10139090510,NDC,facility,outpatient,0.25,ME,472.95000,137.16000,Aetna,First Health,,386.87,,,,,,,19.89,386.87,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,10139050120,NDC,facility,inpatient,1,GM,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,43.26,98.16,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,10139050120,NDC,facility,outpatient,1,GM,120.00000,34.80000,Aetna,First Health,,98.16,,,,,,,0.02889,98.16,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,10139023511,NDC,,,facility,inpatient,1,EA,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,8.27,18.28,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,10139023511,NDC,,,facility,outpatient,1,EA,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,8.06,18.28,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,10139023510,NDC,,,facility,inpatient,1,EA,59.05000,17.12000,Aetna,First Health,,48.30,,,,,,,21.85,48.30,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,10139023510,NDC,,,facility,outpatient,1,EA,59.05000,17.12000,Aetna,First Health,,48.30,,,,,,,21.29,48.30,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,10139023010,NDC,facility,inpatient,60,ME,106.40000,30.86000,Aetna,First Health,,87.04,,,,,,,38.36,87.04,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,10139023010,NDC,facility,outpatient,60,ME,106.40000,30.86000,Aetna,First Health,,87.04,,,,,,,6.15,87.04,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,10139023002,NDC,facility,inpatient,60,ME,106.40000,30.86000,Aetna,First Health,,87.04,,,,,,,38.36,87.04,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,10139023002,NDC,facility,outpatient,60,ME,106.40000,30.86000,Aetna,First Health,,87.04,,,,,,,6.15,87.04,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,10139007011,NDC,facility,inpatient,1.5,GM,62.50000,18.12000,Aetna,First Health,,51.12,,,,,,,22.53,51.12,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,10139007011,NDC,facility,outpatient,1.5,GM,62.50000,18.12000,Aetna,First Health,,51.12,,,,,,,1.28,51.12,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,10139006311,NDC,facility,inpatient,500,ME,27.50000,7.98000,Aetna,First Health,,22.50,,,,,,,9.91,22.50,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,10139006311,NDC,facility,outpatient,500,ME,27.50000,7.98000,Aetna,First Health,,22.50,,,,,,,1.87,22.50,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,10139006202,NDC,facility,inpatient,50,ME,30.55000,8.86000,Aetna,First Health,,24.99,,,,,,,11.01,24.99,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,10139006202,NDC,facility,outpatient,50,ME,30.55000,8.86000,Aetna,First Health,,24.99,,,,,,,2.48,24.99,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,10139006045,NDC,facility,inpatient,50,ME,81.25000,23.56000,Aetna,First Health,,66.46,,,,,,,29.29,66.46,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,10139006045,NDC,facility,outpatient,50,ME,81.25000,23.56000,Aetna,First Health,,66.46,,,,,,,2.82,66.46,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,10139006015,NDC,facility,inpatient,50,ME,86.60000,25.11000,Aetna,First Health,,70.84,,,,,,,31.22,70.84,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,10139006015,NDC,facility,outpatient,50,ME,86.60000,25.11000,Aetna,First Health,,70.84,,,,,,,2.82,70.84,percent of total billed charges,
cangrelor 50mg Inj,800046560,CDM,636,RC,C9460,HCPCS,10122062010,NDC,facility,inpatient,50,ME,7395.65000,2144.74000,Aetna,First Health,,6049.64,,,,,,,2666.13,6049.64,percent of total billed charges,
cangrelor 50mg Inj,800046560,CDM,636,RC,C9460,HCPCS,10122062010,NDC,facility,outpatient,50,ME,7395.65000,2144.74000,Aetna,First Health,,6049.64,,,,,,,19.94,6049.64,percent of total billed charges,
Poractant 240mg/3mL Intratrach Inj,800017811,CDM,252,RC,10122051003,NDC,,,facility,inpatient,1,EA,4895.45000,1419.68000,Aetna,First Health,,4004.48,,,,,,,1811.32,4004.48,percent of total billed charges,
Poractant 240mg/3mL Intratrach Inj,800017811,CDM,252,RC,10122051003,NDC,,,facility,outpatient,1,EA,4895.45000,1419.68000,Aetna,First Health,,4004.48,,,,,,,1764.81,4004.48,percent of total billed charges,
Poractant 120mg/1.5mL Intratrach I(Curosurf),800022090,CDM,250,RC,10122051001,NDC,,,facility,inpatient,1,EA,2576.25000,747.11000,Aetna,First Health,,2107.37,,,,,,,953.21,2107.37,percent of total billed charges,
Poractant 120mg/1.5mL Intratrach I(Curosurf),800022090,CDM,250,RC,10122051001,NDC,,,facility,outpatient,1,EA,2576.25000,747.11000,Aetna,First Health,,2107.37,,,,,,,928.74,2107.37,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,10019099959,NDC,,,facility,inpatient,1,EA,159.40000,46.23000,Aetna,First Health,,130.39,,,,,,,58.98,130.39,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,10019099959,NDC,,,facility,outpatient,1,EA,159.40000,46.23000,Aetna,First Health,,130.39,,,,,,,57.46,130.39,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,10019099101,NDC,facility,inpatient,3.5,ME,454.40000,131.78000,Aetna,First Health,,371.70,,,,,,,163.81,371.70,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,10019099101,NDC,facility,outpatient,3.5,ME,454.40000,131.78000,Aetna,First Health,,371.70,,,,,,,2.58,371.70,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,10019095501,NDC,facility,inpatient,500,ME,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,10019095501,NDC,facility,outpatient,500,ME,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,0.56817,2310.03,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,10019093801,NDC,facility,inpatient,500,ME,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,1018.05,2310.03,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,10019093801,NDC,facility,outpatient,500,ME,2824.00000,818.96000,Aetna,First Health,,2310.03,,,,,,,0.56817,2310.03,percent of total billed charges,
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,10019092582,NDC,facility,inpatient,1000,ME,275.50000,79.90000,Aetna,First Health,,225.36,,,,,,,99.32,225.36,percent of total billed charges,
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,10019092582,NDC,facility,outpatient,1000,ME,275.50000,79.90000,Aetna,First Health,,225.36,,,,,,,23.92,225.36,percent of total billed charges,
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,inpatient,1000,ME,349.80000,101.44000,Aetna,First Health,,286.14,,,,,,,126.10,286.14,percent of total billed charges,
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,outpatient,1000,ME,349.80000,101.44000,Aetna,First Health,,286.14,,,,,,,23.92,286.14,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,inpatient,2.5,GM,3837.85000,1112.98000,Aetna,First Health,,3139.36,,,,,,,1383.54,3139.36,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,outpatient,2.5,GM,3837.85000,1112.98000,Aetna,First Health,,3139.36,,,,,,,0.20223,3139.36,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,10019063002,NDC,facility,inpatient,3,GM,118.00000,34.22000,Aetna,First Health,,96.52,,,,,,,42.54,96.52,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,10019063002,NDC,facility,outpatient,3,GM,118.00000,34.22000,Aetna,First Health,,96.52,,,,,,,1.28,96.52,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,10019063001,NDC,facility,inpatient,1.5,GM,62.50000,18.12000,Aetna,First Health,,51.12,,,,,,,22.53,51.12,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,10019063001,NDC,facility,outpatient,1.5,GM,62.50000,18.12000,Aetna,First Health,,51.12,,,,,,,1.28,51.12,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,10019061110,NDC,facility,inpatient,1000,ME,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,2.78,6.30,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,10019061110,NDC,facility,outpatient,1000,ME,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,0.79929,6.30,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,10019061103,NDC,facility,inpatient,1000,ME,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,5.23,11.86,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,10019061103,NDC,facility,outpatient,1000,ME,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,0.79929,11.86,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055388,NDC,,,facility,inpatient,1,EA,84.25000,24.43000,Aetna,First Health,,68.92,,,,,,,50.55,68.92,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055388,NDC,,,facility,outpatient,1,EA,84.25000,24.43000,Aetna,First Health,,68.92,,,,,,,30.37,68.92,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055304,NDC,,,facility,inpatient,1,EA,183.15000,53.11000,Aetna,First Health,,149.82,,,,,,,109.89,149.82,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055304,NDC,,,facility,outpatient,1,EA,183.15000,53.11000,Aetna,First Health,,149.82,,,,,,,66.03,149.82,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055303,NDC,,,facility,inpatient,1,EA,183.15000,53.11000,Aetna,First Health,,149.82,,,,,,,109.89,149.82,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055303,NDC,,,facility,outpatient,1,EA,183.15000,53.11000,Aetna,First Health,,149.82,,,,,,,66.03,149.82,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055302,NDC,,,facility,inpatient,1,EA,183.15000,53.11000,Aetna,First Health,,149.82,,,,,,,109.89,149.82,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055302,NDC,,,facility,outpatient,1,EA,183.15000,53.11000,Aetna,First Health,,149.82,,,,,,,66.03,149.82,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055301,NDC,,,facility,inpatient,1,EA,183.15000,53.11000,Aetna,First Health,,149.82,,,,,,,109.89,149.82,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055301,NDC,,,facility,outpatient,1,EA,183.15000,53.11000,Aetna,First Health,,149.82,,,,,,,66.03,149.82,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,10019050645,NDC,facility,inpatient,1,ME,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,5.23,11.86,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,10019050645,NDC,facility,outpatient,1,ME,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,0.34668,11.86,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,10019050610,NDC,facility,inpatient,0.25,ME,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,10019050610,NDC,facility,outpatient,0.25,ME,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.34668,1.92,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,10019045002,NDC,facility,inpatient,10,ME,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,10019045002,NDC,facility,outpatient,10,ME,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.04,3.33,percent of total billed charges,
Isoflurane Inhl Sol 100mL,800081217,CDM,250,RC,10019036040,NDC,,,facility,inpatient,1,EA,204.35000,59.26000,Aetna,First Health,,167.16,,,,,,,75.61,167.16,percent of total billed charges,
Isoflurane Inhl Sol 100mL,800081217,CDM,250,RC,10019036040,NDC,,,facility,outpatient,1,EA,204.35000,59.26000,Aetna,First Health,,167.16,,,,,,,73.67,167.16,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,10019032101,NDC,,,facility,inpatient,1,EA,75.75000,21.97000,Aetna,First Health,,61.96,,,,,,,28.03,61.96,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,10019032101,NDC,,,facility,outpatient,1,EA,75.75000,21.97000,Aetna,First Health,,61.96,,,,,,,27.31,61.96,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,10019029102,NDC,facility,inpatient,10,UN,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,10019029102,NDC,facility,outpatient,10,UN,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,1.00,5.48,percent of total billed charges,
Atropine SO4 1mg/mL 1mL I,800013438,CDM,636,RC,J0461,HCPCS,10019025112,NDC,facility,inpatient,1,ME,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
Atropine SO4 1mg/mL 1mL I,800013438,CDM,636,RC,J0461,HCPCS,10019025112,NDC,facility,outpatient,1,ME,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,0.09630,8.38,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,10019015901,NDC,facility,inpatient,25,ME,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,10019015901,NDC,facility,outpatient,25,ME,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.70,25.13,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,10019013301,NDC,facility,inpatient,150,ME,19.45000,5.64000,Aetna,First Health,,15.91,,,,,,,7.01,15.91,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,10019013301,NDC,facility,outpatient,150,ME,19.45000,5.64000,Aetna,First Health,,15.91,,,,,,,0.39483,15.91,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,10019012001,NDC,facility,inpatient,100,ME,77.65000,22.52000,Aetna,First Health,,63.52,,,,,,,27.99,63.52,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,10019012001,NDC,facility,outpatient,100,ME,77.65000,22.52000,Aetna,First Health,,63.52,,,,,,,0.20223,63.52,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,10019011501,NDC,facility,inpatient,100,ME,137.35000,39.83000,Aetna,First Health,,112.35,,,,,,,49.51,112.35,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,10019011501,NDC,facility,outpatient,100,ME,137.35000,39.83000,Aetna,First Health,,112.35,,,,,,,0.20223,112.35,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,10019010201,NDC,facility,inpatient,2,ME,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,10019010201,NDC,facility,outpatient,2,ME,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,1.36,5.89,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,10019006303,NDC,facility,inpatient,6,ME,84.80000,24.59000,Aetna,First Health,,69.37,,,,,,,30.57,69.37,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,10019006303,NDC,facility,outpatient,6,ME,84.80000,24.59000,Aetna,First Health,,69.37,,,,,,,0.51039,69.37,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,10019006302,NDC,facility,inpatient,6,ME,81.40000,23.61000,Aetna,First Health,,66.59,,,,,,,29.34,66.59,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,10019006302,NDC,facility,outpatient,6,ME,81.40000,23.61000,Aetna,First Health,,66.59,,,,,,,0.51039,66.59,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,10019005561,NDC,facility,inpatient,2.5,GM,1178.65000,341.81000,Aetna,First Health,,964.14,,,,,,,424.90,964.14,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,10019005561,NDC,facility,outpatient,2.5,GM,1178.65000,341.81000,Aetna,First Health,,964.14,,,,,,,0.20223,964.14,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,10019004502,NDC,facility,inpatient,20,ME,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,10019004502,NDC,facility,outpatient,20,ME,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,0.00963,3.84,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,10019004501,NDC,facility,inpatient,20,ME,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,10019004501,NDC,facility,outpatient,20,ME,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,0.00963,4.83,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,10019003867,NDC,facility,inpatient,0.1,ME,15.35000,4.45000,Aetna,First Health,,12.56,,,,,,,5.53,12.56,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,10019003867,NDC,facility,outpatient,0.1,ME,15.35000,4.45000,Aetna,First Health,,12.56,,,,,,,1.15,12.56,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,10019003727,NDC,facility,inpatient,0.1,ME,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,5.28,11.98,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,10019003727,NDC,facility,outpatient,0.1,ME,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,1.15,11.98,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,10019002902,NDC,facility,inpatient,15,ME,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,2.56,5.81,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,10019002902,NDC,facility,outpatient,15,ME,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,0.31779,5.81,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,10019002805,NDC,facility,inpatient,5,ME,13.35000,3.87000,Aetna,First Health,,10.92,,,,,,,4.81,10.92,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,10019002805,NDC,facility,outpatient,5,ME,13.35000,3.87000,Aetna,First Health,,10.92,,,,,,,0.13482,10.92,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,10019002804,NDC,facility,inpatient,2,ME,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,10019002804,NDC,facility,outpatient,2,ME,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,0.13482,5.11,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,10019002803,NDC,facility,inpatient,2,ME,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,10019002803,NDC,facility,outpatient,2,ME,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,0.13482,4.70,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,10019002801,NDC,facility,inpatient,2,ME,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,10019002801,NDC,facility,outpatient,2,ME,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,0.13482,5.11,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,10019001681,NDC,facility,inpatient,0.2,ME,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.66,8.30,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,10019001681,NDC,facility,outpatient,0.2,ME,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,0.36594,8.30,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,10019001571,NDC,facility,inpatient,100,ME,860.65000,249.59000,Aetna,First Health,,704.01,,,,,,,310.26,704.01,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,10019001571,NDC,facility,outpatient,100,ME,860.65000,249.59000,Aetna,First Health,,704.01,,,,,,,0.20223,704.01,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,10019001303,NDC,facility,inpatient,1,GM,447.85000,129.88000,Aetna,First Health,,366.34,,,,,,,161.45,366.34,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,10019001303,NDC,facility,outpatient,1,GM,447.85000,129.88000,Aetna,First Health,,366.34,,,,,,,0.08667,366.34,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,10019001302,NDC,facility,inpatient,0.5,GM,232.50000,67.42000,Aetna,First Health,,190.19,,,,,,,83.82,190.19,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,10019001302,NDC,facility,outpatient,0.5,GM,232.50000,67.42000,Aetna,First Health,,190.19,,,,,,,0.08667,190.19,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,10019001301,NDC,facility,inpatient,200,ME,57.90000,16.79000,Aetna,First Health,,47.36,,,,,,,20.87,47.36,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,10019001301,NDC,facility,outpatient,200,ME,57.90000,16.79000,Aetna,First Health,,47.36,,,,,,,0.08667,47.36,percent of total billed charges,
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,10019000673,NDC,facility,inpatient,5,ME,19.30000,5.60000,Aetna,First Health,,15.79,,,,,,,6.96,15.79,percent of total billed charges,
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,10019000673,NDC,facility,outpatient,5,ME,19.30000,5.60000,Aetna,First Health,,15.79,,,,,,,7.14,41.63,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,08881590125,NDC,facility,inpatient,500,UN,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,08881590125,NDC,facility,outpatient,500,UN,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,0.01926,2.94,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08881579121,NDC,facility,inpatient,1,EA,24.95000,7.24000,Aetna,First Health,,20.41,,,,,,,11.73,20.41,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08881579121,NDC,facility,outpatient,1,EA,24.95000,7.24000,Aetna,First Health,,20.41,,,,,,,0.63000,20.41,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08881570121,NDC,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.67,2.90,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08881570121,NDC,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,0.63000,4.78,percent of total billed charges,
Spacer for Inhaler,800040918,CDM,637,RC,A4627,HCPCS,08373747800,NDC,facility,inpatient,1,EA,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
Spacer for Inhaler,800040918,CDM,637,RC,A4627,HCPCS,08373747800,NDC,facility,outpatient,1,EA,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,51.55,116.97,percent of total billed charges,
NS (Sterile Field) IS 10mL,800022041,CDM,250,RC,08290306553,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.44,5.40,percent of total billed charges,
NS (Sterile Field) IS 10mL,800022041,CDM,250,RC,08290306553,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08290306551,NDC,facility,inpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,2.02,3.52,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08290306551,NDC,facility,outpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,0.63000,4.78,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08290306547,NDC,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.55,2.70,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08290306547,NDC,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,0.63000,4.78,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08290306546,NDC,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.34,2.33,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08290306546,NDC,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,0.63000,4.78,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,08290306513,NDC,facility,inpatient,500,UN,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,08290306513,NDC,facility,outpatient,500,UN,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,0.01926,3.11,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,08290306510,NDC,facility,inpatient,30,UN,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.06,1.84,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,08290306510,NDC,facility,outpatient,30,UN,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.01926,1.84,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,inpatient,500,UN,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,outpatient,500,UN,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,0.01926,3.60,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,08290306414,NDC,facility,inpatient,30,UN,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.86950,1.51,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,08290306414,NDC,facility,outpatient,30,UN,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.01926,1.51,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,08290306413,NDC,facility,inpatient,30,UN,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.43,2.49,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,08290306413,NDC,facility,outpatient,30,UN,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,0.01926,2.49,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,08290034003,NDC,facility,inpatient,30,UN,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,7.68,13.37,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,08290034003,NDC,facility,outpatient,30,UN,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,0.01926,13.37,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,800041391,CDM,250,RC,08065183085,NDC,,,facility,inpatient,1,EA,1167.50000,338.58000,Aetna,First Health,,955.01,,,,,,,431.98,955.01,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,800041391,CDM,250,RC,08065183085,NDC,,,facility,outpatient,1,EA,1167.50000,338.58000,Aetna,First Health,,955.01,,,,,,,420.88,955.01,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,800041391,CDM,250,RC,05047450842,NDC,,,facility,inpatient,1,EA,751.80000,218.02000,Aetna,First Health,,614.97,,,,,,,278.17,614.97,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,800041391,CDM,250,RC,05047450842,NDC,,,facility,outpatient,1,EA,751.80000,218.02000,Aetna,First Health,,614.97,,,,,,,271.02,614.97,percent of total billed charges,
Belladonna-Opium Supp(60mg Of Opium),800017087,CDM,637,RC,00998501675,NDC,,,facility,inpatient,1,EA,24.15000,7.00000,Aetna,First Health,,19.75,,,,,,,14.49,19.75,percent of total billed charges,
Belladonna-Opium Supp(60mg Of Opium),800017087,CDM,637,RC,00998501675,NDC,,,facility,outpatient,1,EA,24.15000,7.00000,Aetna,First Health,,19.75,,,,,,,8.71,19.75,percent of total billed charges,
Microfibrillar 1g TP(Avitene),800034537,CDM,637,RC,00998101002,NDC,,,facility,inpatient,1,EA,1354.85000,392.91000,Aetna,First Health,,1108.27,,,,,,,812.91,1108.27,percent of total billed charges,
Microfibrillar 1g TP(Avitene),800034537,CDM,637,RC,00998101002,NDC,,,facility,outpatient,1,EA,1354.85000,392.91000,Aetna,First Health,,1108.27,,,,,,,488.42,1108.27,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,00998064305,NDC,,,facility,inpatient,1,EA,417.75000,121.15000,Aetna,First Health,,341.72,,,,,,,250.65,341.72,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,00998064305,NDC,,,facility,outpatient,1,EA,417.75000,121.15000,Aetna,First Health,,341.72,,,,,,,150.60,341.72,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,00998063710,NDC,,,facility,inpatient,1,EA,215.70000,62.55000,Aetna,First Health,,176.44,,,,,,,129.42,176.44,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,00998063710,NDC,,,facility,outpatient,1,EA,215.70000,62.55000,Aetna,First Health,,176.44,,,,,,,77.76,176.44,percent of total billed charges,
Neo-Poly-Dex 5mL Ophth Susp(Maxitrol),800019117,CDM,637,RC,00998063006,NDC,,,facility,inpatient,1,EA,846.85000,245.59000,Aetna,First Health,,692.72,,,,,,,508.11,692.72,percent of total billed charges,
Neo-Poly-Dex 5mL Ophth Susp(Maxitrol),800019117,CDM,637,RC,00998063006,NDC,,,facility,outpatient,1,EA,846.85000,245.59000,Aetna,First Health,,692.72,,,,,,,305.29,692.72,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,00998020315,NDC,,,facility,inpatient,1,EA,677.80000,196.56000,Aetna,First Health,,554.44,,,,,,,406.68,554.44,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,00998020315,NDC,,,facility,outpatient,1,EA,677.80000,196.56000,Aetna,First Health,,554.44,,,,,,,244.35,554.44,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,00998001615,NDC,,,facility,inpatient,1,EA,341.50000,99.04000,Aetna,First Health,,279.35,,,,,,,204.90,279.35,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,00998001615,NDC,,,facility,outpatient,1,EA,341.50000,99.04000,Aetna,First Health,,279.35,,,,,,,123.11,279.35,percent of total billed charges,
0.45NS + 20mEq/L KCl 1000mL,800021700,CDM,258,RC,J3480,HCPCS,00990925739,NDC,facility,inpatient,1,EA,69.95000,20.29000,Aetna,First Health,,57.22,,,,,,,32.88,57.22,percent of total billed charges,
0.45NS + 20mEq/L KCl 1000mL,800021700,CDM,258,RC,J3480,HCPCS,00990925739,NDC,facility,outpatient,1,EA,69.95000,20.29000,Aetna,First Health,,57.22,,,,,,,0.11556,57.22,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00990798509,NDC,,,facility,inpatient,1,EA,61.80000,17.92000,Aetna,First Health,,50.55,,,,,,,29.05,50.55,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00990798509,NDC,,,facility,outpatient,1,EA,61.80000,17.92000,Aetna,First Health,,50.55,,,,,,,22.28,50.55,percent of total billed charges,
0.45% Sodium Cl 250mL,800081202,CDM,258,RC,00990798502,NDC,,,facility,inpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,25.90,45.07,percent of total billed charges,
0.45% Sodium Cl 250mL,800081202,CDM,258,RC,00990798502,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,19.86,45.07,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00990798436,NDC,facility,inpatient,1,EA,28.50000,8.26000,Aetna,First Health,,23.31,,,,,,,10.27,23.31,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00990798436,NDC,facility,outpatient,1,EA,28.50000,8.26000,Aetna,First Health,,23.31,,,,,,,0.63558,23.31,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00990798413,NDC,facility,inpatient,1,EA,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,13.16,29.86,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00990798413,NDC,facility,outpatient,1,EA,36.50000,10.58000,Aetna,First Health,,29.86,,,,,,,0.63558,29.86,percent of total billed charges,
NS 500mL,800012693,CDM,258,RC,J7040,HCPCS,00990798355,NDC,facility,inpatient,1,EA,75.90000,22.01000,Aetna,First Health,,62.09,,,,,,,35.67,62.09,percent of total billed charges,
NS 500mL,800012693,CDM,258,RC,J7040,HCPCS,00990798355,NDC,facility,outpatient,1,EA,75.90000,22.01000,Aetna,First Health,,62.09,,,,,,,1.24,62.09,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00990798309,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00990798309,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,1.92,43.80,percent of total billed charges,
NS 500mL,800012693,CDM,258,RC,J7040,HCPCS,00990798303,NDC,facility,inpatient,1,EA,55.25000,16.02000,Aetna,First Health,,45.19,,,,,,,25.97,45.19,percent of total billed charges,
NS 500mL,800012693,CDM,258,RC,J7040,HCPCS,00990798303,NDC,facility,outpatient,1,EA,55.25000,16.02000,Aetna,First Health,,45.19,,,,,,,1.24,45.19,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00990798302,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00990798302,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,0.63558,43.80,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,00990795309,NDC,facility,inpatient,1,EA,59.15000,17.15000,Aetna,First Health,,48.38,,,,,,,27.80,48.38,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,00990795309,NDC,facility,outpatient,1,EA,59.15000,17.15000,Aetna,First Health,,48.38,,,,,,,2.29,48.38,percent of total billed charges,
LR 500 mL,800012635,CDM,258,RC,J7120,HCPCS,00990795303,NDC,facility,inpatient,1,EA,59.45000,17.24000,Aetna,First Health,,48.63,,,,,,,27.94,48.63,percent of total billed charges,
LR 500 mL,800012635,CDM,258,RC,J7120,HCPCS,00990795303,NDC,facility,outpatient,1,EA,59.45000,17.24000,Aetna,First Health,,48.63,,,,,,,2.29,48.63,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,00990794109,NDC,facility,inpatient,1,EA,55.25000,16.02000,Aetna,First Health,,45.19,,,,,,,25.97,45.19,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,00990794109,NDC,facility,outpatient,1,EA,55.25000,16.02000,Aetna,First Health,,45.19,,,,,,,1.26,45.19,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00990793009,NDC,,,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00990793009,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00990793002,NDC,,,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00990793002,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
D5LR 1000 mL,800012214,CDM,258,RC,J7121,HCPCS,00990792909,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D5LR 1000 mL,800012214,CDM,258,RC,J7121,HCPCS,00990792909,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,8.94,43.80,percent of total billed charges,
D5.45NS 1000mL,800012347,CDM,258,RC,J7030,HCPCS,00990792609,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D5.45NS 1000mL,800012347,CDM,258,RC,J7030,HCPCS,00990792609,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,1.92,43.80,percent of total billed charges,
Dextrose 5% in Water 1L,800012172,CDM,258,RC,J7070,HCPCS,00990792209,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
Dextrose 5% in Water 1L,800012172,CDM,258,RC,J7070,HCPCS,00990792209,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,2.83,43.80,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00990790209,NDC,,,facility,inpatient,1,EA,74.40000,21.58000,Aetna,First Health,,60.86,,,,,,,34.97,60.86,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00990790209,NDC,,,facility,outpatient,1,EA,74.40000,21.58000,Aetna,First Health,,60.86,,,,,,,26.82,60.86,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00990767009,NDC,,,facility,inpatient,1,EA,55.25000,16.02000,Aetna,First Health,,45.19,,,,,,,25.97,45.19,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00990767009,NDC,,,facility,outpatient,1,EA,55.25000,16.02000,Aetna,First Health,,45.19,,,,,,,19.92,45.19,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00990711509,NDC,,,facility,inpatient,1,EA,69.95000,20.29000,Aetna,First Health,,57.22,,,,,,,32.88,57.22,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00990711509,NDC,,,facility,outpatient,1,EA,69.95000,20.29000,Aetna,First Health,,57.22,,,,,,,25.22,57.22,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00990710709,NDC,,,facility,inpatient,1,EA,72.50000,21.02000,Aetna,First Health,,59.30,,,,,,,34.08,59.30,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00990710709,NDC,,,facility,outpatient,1,EA,72.50000,21.02000,Aetna,First Health,,59.30,,,,,,,26.14,59.30,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00990707526,NDC,facility,inpatient,1,EA,52.50000,15.22000,Aetna,First Health,,42.95,,,,,,,18.93,42.95,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00990707526,NDC,facility,outpatient,1,EA,52.50000,15.22000,Aetna,First Health,,42.95,,,,,,,0.11556,42.95,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00990707426,NDC,facility,inpatient,1,EA,50.60000,14.67000,Aetna,First Health,,41.39,,,,,,,18.24,41.39,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00990707426,NDC,facility,outpatient,1,EA,50.60000,14.67000,Aetna,First Health,,41.39,,,,,,,0.11556,41.39,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00955173530,NDC,,,facility,inpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,25.50,34.77,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00955173530,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,15.32,34.77,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),800081264,CDM,637,RC,J0603,HCPCS,00955104818,NDC,facility,inpatient,800,ME,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,30.60,41.72,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),800081264,CDM,637,RC,J0603,HCPCS,00955104818,NDC,facility,outpatient,800,ME,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,0.19260,41.72,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00955102104,NDC,facility,inpatient,80,ME,3319.00000,962.51000,Aetna,First Health,,2714.94,,,,,,,1196.50,2714.94,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00955102104,NDC,facility,outpatient,80,ME,3319.00000,962.51000,Aetna,First Health,,2714.94,,,,,,,0.62595,2714.94,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00955102001,NDC,facility,inpatient,20,ME,937.20000,271.79000,Aetna,First Health,,766.63,,,,,,,337.86,766.63,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00955102001,NDC,facility,outpatient,20,ME,937.20000,271.79000,Aetna,First Health,,766.63,,,,,,,0.62595,766.63,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00955101510,NDC,facility,inpatient,150,ME,199.40000,57.83000,Aetna,First Health,,163.11,,,,,,,71.88,163.11,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00955101510,NDC,facility,outpatient,150,ME,199.40000,57.83000,Aetna,First Health,,163.11,,,,,,,0.51039,163.11,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00955101210,NDC,facility,inpatient,120,ME,162.30000,47.07000,Aetna,First Health,,132.76,,,,,,,58.51,132.76,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00955101210,NDC,facility,outpatient,120,ME,162.30000,47.07000,Aetna,First Health,,132.76,,,,,,,0.51039,132.76,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00955101010,NDC,facility,inpatient,100,ME,137.60000,39.90000,Aetna,First Health,,112.56,,,,,,,49.60,112.56,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00955101010,NDC,facility,outpatient,100,ME,137.60000,39.90000,Aetna,First Health,,112.56,,,,,,,0.51039,112.56,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00955100810,NDC,facility,inpatient,80,ME,109.10000,31.64000,Aetna,First Health,,89.24,,,,,,,39.33,89.24,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00955100810,NDC,facility,outpatient,80,ME,109.10000,31.64000,Aetna,First Health,,89.24,,,,,,,0.51039,89.24,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00955100410,NDC,facility,inpatient,40,ME,54.50000,15.80000,Aetna,First Health,,44.58,,,,,,,19.65,44.58,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00955100410,NDC,facility,outpatient,40,ME,54.50000,15.80000,Aetna,First Health,,44.58,,,,,,,0.51039,44.58,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,00955025050,NDC,,,facility,inpatient,1,EA,13.55000,3.93000,Aetna,First Health,,11.08,,,,,,,8.13,11.08,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,00955025050,NDC,,,facility,outpatient,1,EA,13.55000,3.93000,Aetna,First Health,,11.08,,,,,,,4.88,11.08,percent of total billed charges,
Immune Globulin 30g/300mL I,800062123,CDM,636,RC,J1569,HCPCS,00944270007,NDC,facility,inpatient,30,GM,37902.75000,10991.80000,Aetna,First Health,,31004.45,,,,,,,13663.94,31004.45,percent of total billed charges,
Immune Globulin 30g/300mL I,800062123,CDM,636,RC,J1569,HCPCS,00944270007,NDC,facility,outpatient,30,GM,37902.75000,10991.80000,Aetna,First Health,,31004.45,,,,,,,45.54,31004.45,percent of total billed charges,
Immune Globulin 20g/200mL I,800017442,CDM,636,RC,J1569,HCPCS,00944270006,NDC,facility,inpatient,20,GM,25330.85000,7345.95000,Aetna,First Health,,20720.64,,,,,,,9131.77,20720.64,percent of total billed charges,
Immune Globulin 20g/200mL I,800017442,CDM,636,RC,J1569,HCPCS,00944270006,NDC,facility,outpatient,20,GM,25330.85000,7345.95000,Aetna,First Health,,20720.64,,,,,,,45.54,20720.64,percent of total billed charges,
Immune Globulin 10g/100mL I,800062122,CDM,636,RC,J1569,HCPCS,00944270005,NDC,facility,inpatient,10,GM,12758.90000,3700.08000,Aetna,First Health,,10436.78,,,,,,,4599.58,10436.78,percent of total billed charges,
Immune Globulin 10g/100mL I,800062122,CDM,636,RC,J1569,HCPCS,00944270005,NDC,facility,outpatient,10,GM,12758.90000,3700.08000,Aetna,First Health,,10436.78,,,,,,,45.54,10436.78,percent of total billed charges,
Immune Globulin 5g/50mL I,800062121,CDM,636,RC,J1569,HCPCS,00944270004,NDC,facility,inpatient,5,GM,6472.95000,1877.16000,Aetna,First Health,,5294.87,,,,,,,2333.50,5294.87,percent of total billed charges,
Immune Globulin 5g/50mL I,800062121,CDM,636,RC,J1569,HCPCS,00944270004,NDC,facility,outpatient,5,GM,6472.95000,1877.16000,Aetna,First Health,,5294.87,,,,,,,45.54,5294.87,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,00944049505,NDC,facility,inpatient,12.5,GM,1192.40000,345.80000,Aetna,First Health,,975.38,,,,,,,429.86,975.38,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,00944049505,NDC,facility,outpatient,12.5,GM,1192.40000,345.80000,Aetna,First Health,,975.38,,,,,,,51.12,975.38,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,00944049303,NDC,facility,inpatient,12.5,GM,504.60000,146.33000,Aetna,First Health,,412.76,,,,,,,181.91,412.76,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,00944049303,NDC,facility,outpatient,12.5,GM,504.60000,146.33000,Aetna,First Health,,412.76,,,,,,,51.12,412.76,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,12.5,GM,524.00000,151.96000,Aetna,First Health,,428.63,,,,,,,188.90,428.63,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,outpatient,12.5,GM,524.00000,151.96000,Aetna,First Health,,428.63,,,,,,,51.12,428.63,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,00944049101,NDC,facility,inpatient,12.5,GM,809.15000,234.65000,Aetna,First Health,,661.88,,,,,,,291.70,661.88,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,00944049101,NDC,facility,outpatient,12.5,GM,809.15000,234.65000,Aetna,First Health,,661.88,,,,,,,51.12,661.88,percent of total billed charges,
Na Citrate 4% 500mL Inj,800076314,CDM,250,RC,00942950410,NDC,,,facility,inpatient,1,EA,97.40000,28.25000,Aetna,First Health,,79.67,,,,,,,36.04,79.67,percent of total billed charges,
Na Citrate 4% 500mL Inj,800076314,CDM,250,RC,00942950410,NDC,,,facility,outpatient,1,EA,97.40000,28.25000,Aetna,First Health,,79.67,,,,,,,35.11,79.67,percent of total billed charges,
Anticoag Citr Dextr-A 1L (ACDA),800072509,CDM,250,RC,00942064104,NDC,,,facility,inpatient,1,EA,118.90000,34.48000,Aetna,First Health,,97.26,,,,,,,43.99,97.26,percent of total billed charges,
Anticoag Citr Dextr-A 1L (ACDA),800072509,CDM,250,RC,00942064104,NDC,,,facility,outpatient,1,EA,118.90000,34.48000,Aetna,First Health,,97.26,,,,,,,42.86,97.26,percent of total billed charges,
Dianeal LCA Soln 4.25% 6000mL,800062049,CDM,636,RC,A4726,HCPCS,00941045901,NDC,facility,inpatient,1,EA,434.65000,126.05000,Aetna,First Health,,355.54,,,,,,,156.69,355.54,percent of total billed charges,
Dianeal LCA Soln 4.25% 6000mL,800062049,CDM,636,RC,A4726,HCPCS,00941045901,NDC,facility,outpatient,1,EA,434.65000,126.05000,Aetna,First Health,,355.54,,,,,,,156.69,355.54,percent of total billed charges,
Dianeal LCA Soln 2.5% 6000mL,800062048,CDM,636,RC,A4726,HCPCS,00941045701,NDC,facility,inpatient,1,EA,423.85000,122.92000,Aetna,First Health,,346.71,,,,,,,152.80,346.71,percent of total billed charges,
Dianeal LCA Soln 2.5% 6000mL,800062048,CDM,636,RC,A4726,HCPCS,00941045701,NDC,facility,outpatient,1,EA,423.85000,122.92000,Aetna,First Health,,346.71,,,,,,,152.80,346.71,percent of total billed charges,
Dianeal LCA Soln 2.5% 2000mL,800018439,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,inpatient,1,EA,255.30000,74.04000,Aetna,First Health,,208.84,,,,,,,92.04,208.84,percent of total billed charges,
Dianeal LCA Soln 2.5% 2000mL,800018439,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,1,EA,255.30000,74.04000,Aetna,First Health,,208.84,,,,,,,92.04,208.84,percent of total billed charges,
Dianeal LCA Soln 1.5% 2000mL,800018421,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,inpatient,1,EA,230.50000,66.84000,Aetna,First Health,,188.55,,,,,,,83.10,188.55,percent of total billed charges,
Dianeal LCA Soln 1.5% 2000mL,800018421,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,1,EA,230.50000,66.84000,Aetna,First Health,,188.55,,,,,,,83.10,188.55,percent of total billed charges,
Dianeal LCA Soln 1.5% 6000mL,800062047,CDM,636,RC,A4726,HCPCS,00941040901,NDC,facility,inpatient,1,EA,415.75000,120.57000,Aetna,First Health,,340.08,,,,,,,149.88,340.08,percent of total billed charges,
Dianeal LCA Soln 1.5% 6000mL,800062047,CDM,636,RC,A4726,HCPCS,00941040901,NDC,facility,outpatient,1,EA,415.75000,120.57000,Aetna,First Health,,340.08,,,,,,,149.88,340.08,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00904880531,NDC,,,facility,inpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,7.86,17.38,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00904880531,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,7.66,17.38,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00904794660,NDC,,,facility,inpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.24000,0.32720,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00904794660,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.14420,0.32720,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,00904792260,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,00904792260,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,00904786560,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,00904786560,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00904782236,NDC,,,facility,inpatient,1,EA,37.45000,10.86000,Aetna,First Health,,30.63,,,,,,,13.86,30.63,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00904782236,NDC,,,facility,outpatient,1,EA,37.45000,10.86000,Aetna,First Health,,30.63,,,,,,,13.50,30.63,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00904780961,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00904780961,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00904775960,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00904775960,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904773760,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904773760,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00904773445,NDC,,,facility,inpatient,1,EA,83.45000,24.20000,Aetna,First Health,,68.26,,,,,,,50.07,68.26,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00904773445,NDC,,,facility,outpatient,1,EA,83.45000,24.20000,Aetna,First Health,,68.26,,,,,,,30.08,68.26,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00904762331,NDC,,,facility,inpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,8.29,18.32,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00904762331,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,8.08,18.32,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00904750504,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00904750504,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00904750161,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00904750161,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00904749804,NDC,,,facility,inpatient,1,EA,26.65000,7.73000,Aetna,First Health,,21.80,,,,,,,15.99,21.80,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00904749804,NDC,,,facility,outpatient,1,EA,26.65000,7.73000,Aetna,First Health,,21.80,,,,,,,9.61,21.80,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00904747095,NDC,,,facility,inpatient,1,EA,76.40000,22.16000,Aetna,First Health,,62.50,,,,,,,45.84,62.50,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00904747095,NDC,,,facility,outpatient,1,EA,76.40000,22.16000,Aetna,First Health,,62.50,,,,,,,27.54,62.50,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00904746806,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00904746806,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00904746273,NDC,,,facility,inpatient,1,EA,61.60000,17.86000,Aetna,First Health,,50.39,,,,,,,36.96,50.39,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00904746273,NDC,,,facility,outpatient,1,EA,61.60000,17.86000,Aetna,First Health,,50.39,,,,,,,22.21,50.39,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00904746187,NDC,,,facility,inpatient,1,EA,68.45000,19.85000,Aetna,First Health,,55.99,,,,,,,41.07,55.99,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00904746187,NDC,,,facility,outpatient,1,EA,68.45000,19.85000,Aetna,First Health,,55.99,,,,,,,24.68,55.99,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,00904744861,NDC,,,facility,inpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,1.20,1.64,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,00904744861,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,00904744761,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,00904744761,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00904741761,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00904741761,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00904740161,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00904740161,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,00904738961,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,00904738961,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,00904738206,NDC,facility,inpatient,10,ME,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,00904738206,NDC,facility,outpatient,10,ME,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,0.57780,9.49,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,00904736761,NDC,,,facility,inpatient,1,EA,152.95000,44.36000,Aetna,First Health,,125.11,,,,,,,91.77,125.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,00904736761,NDC,,,facility,outpatient,1,EA,152.95000,44.36000,Aetna,First Health,,125.11,,,,,,,55.14,125.11,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,00904736261,NDC,,,facility,inpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.80,2.45,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,00904736261,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.08,2.45,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,00904736061,NDC,,,facility,inpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,1.23,1.68,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,00904736061,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,0.73903,1.68,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,00904735661,NDC,,,facility,inpatient,1,EA,7.85000,2.28000,Aetna,First Health,,6.42,,,,,,,4.71,6.42,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,00904735661,NDC,,,facility,outpatient,1,EA,7.85000,2.28000,Aetna,First Health,,6.42,,,,,,,2.83,6.42,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,00904735504,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,00904735504,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904735061,NDC,,,facility,inpatient,1,EA,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,10.68,14.56,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904735061,NDC,,,facility,outpatient,1,EA,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,6.42,14.56,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904735006,NDC,,,facility,inpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,6.30,8.59,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904735006,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,3.79,8.59,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00904733761,NDC,,,facility,inpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.92,2.62,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00904733761,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00904733706,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00904733706,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00904733661,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00904733661,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00904732861,NDC,,,facility,inpatient,1,EA,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,15.93,21.72,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00904732861,NDC,,,facility,outpatient,1,EA,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,9.57,21.72,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00904731706,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00904731706,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00904730761,NDC,,,facility,inpatient,1,EA,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.48000,0.65440,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00904730761,NDC,,,facility,outpatient,1,EA,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.28840,0.65440,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00904730661,NDC,,,facility,inpatient,1,EA,0.90000,0.26000,Aetna,First Health,,0.73620,,,,,,,0.54000,0.73620,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00904730661,NDC,,,facility,outpatient,1,EA,0.90000,0.26000,Aetna,First Health,,0.73620,,,,,,,0.32445,0.73620,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00904729361,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00904729361,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00904728861,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00904728861,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,00904728306,NDC,,,facility,inpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.80,2.45,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,00904728306,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.08,2.45,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00904727692,NDC,,,facility,inpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,6.24,8.51,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00904727692,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00904727061,NDC,,,facility,inpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,4.44,6.05,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00904727061,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,2.67,6.05,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00904726918,NDC,,,facility,inpatient,1,EA,60.90000,17.66000,Aetna,First Health,,49.82,,,,,,,36.54,49.82,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00904726918,NDC,,,facility,outpatient,1,EA,60.90000,17.66000,Aetna,First Health,,49.82,,,,,,,21.95,49.82,percent of total billed charges,
dexaMETHasone 6mg Tab UD,800062110,CDM,637,RC,J8540,HCPCS,00904726761,NDC,facility,inpatient,6,ME,15.20000,4.41000,Aetna,First Health,,12.43,,,,,,,9.12,12.43,percent of total billed charges,
dexaMETHasone 6mg Tab UD,800062110,CDM,637,RC,J8540,HCPCS,00904726761,NDC,facility,outpatient,6,ME,15.20000,4.41000,Aetna,First Health,,12.43,,,,,,,0.00963,12.43,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00904726261,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00904726261,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00904725761,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00904725761,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,00904724468,NDC,,,facility,inpatient,1,EA,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,7.08,9.65,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,00904724468,NDC,,,facility,outpatient,1,EA,11.80000,3.42000,Aetna,First Health,,9.65,,,,,,,4.25,9.65,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00904724161,NDC,,,facility,inpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,2.82,3.84,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00904724161,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904722761,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904722761,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00904722461,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00904722461,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00904722061,NDC,,,facility,inpatient,1,EA,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,9.27,12.64,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00904722061,NDC,,,facility,outpatient,1,EA,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,5.57,12.64,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00904721461,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00904721461,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),800081264,CDM,637,RC,J0603,HCPCS,00904720906,NDC,facility,inpatient,800,ME,75.20000,21.81000,Aetna,First Health,,61.51,,,,,,,45.12,61.51,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),800081264,CDM,637,RC,J0603,HCPCS,00904720906,NDC,facility,outpatient,800,ME,75.20000,21.81000,Aetna,First Health,,61.51,,,,,,,0.19260,61.51,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00904720061,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00904720061,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00904719361,NDC,,,facility,inpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.39000,0.53170,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00904719361,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.23433,0.53170,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00904718904,NDC,,,facility,inpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,14.28,19.47,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00904718904,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,8.58,19.47,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00904718761,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00904718761,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00904718461,NDC,,,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,2.19,2.99,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00904718461,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.32,2.99,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00904718261,NDC,,,facility,inpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,10.50,14.31,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00904718261,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,6.31,14.31,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00904718245,NDC,,,facility,inpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,12.84,17.51,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00904718245,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,7.71,17.51,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904717961,NDC,,,facility,inpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.84000,1.15,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904717961,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.50470,1.15,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00904717861,NDC,,,facility,inpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.39000,0.53170,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00904717861,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.23433,0.53170,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00904717761,NDC,,,facility,inpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.39000,0.53170,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00904717761,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.23433,0.53170,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00904716806,NDC,,,facility,inpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,24.99,34.07,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00904716806,NDC,,,facility,outpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,15.01,34.07,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00904716261,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00904716261,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Buprenorphine 8mg SL Tab,800019980,CDM,637,RC,J0571,HCPCS,00904715504,NDC,facility,inpatient,8,ME,38.50000,11.16000,Aetna,First Health,,31.49,,,,,,,23.10,31.49,percent of total billed charges,
Buprenorphine 8mg SL Tab,800019980,CDM,637,RC,J0571,HCPCS,00904715504,NDC,facility,outpatient,8,ME,38.50000,11.16000,Aetna,First Health,,31.49,,,,,,,2.08,31.49,percent of total billed charges,
Buprenorphine 2mg SL Tab,800021993,CDM,637,RC,J0571,HCPCS,00904715404,NDC,facility,inpatient,2,ME,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,13.47,18.36,percent of total billed charges,
Buprenorphine 2mg SL Tab,800021993,CDM,637,RC,J0571,HCPCS,00904715404,NDC,facility,outpatient,2,ME,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,2.08,18.36,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904715361,NDC,,,facility,inpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,2.52,3.44,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904715361,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,1.51,3.44,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00904714110,NDC,facility,inpatient,2.5,ME,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,15.21,20.74,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00904714110,NDC,facility,outpatient,2.5,ME,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,0.14445,20.74,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00904714004,NDC,,,facility,inpatient,1,EA,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,8.19,11.17,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00904714004,NDC,,,facility,outpatient,1,EA,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,4.92,11.17,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00904713861,NDC,,,facility,inpatient,1,EA,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,15.93,21.72,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00904713861,NDC,,,facility,outpatient,1,EA,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,9.57,21.72,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00904713761,NDC,,,facility,inpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,11.76,16.03,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00904713761,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,7.07,16.03,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00904713261,NDC,,,facility,inpatient,1,EA,106.10000,30.77000,Aetna,First Health,,86.79,,,,,,,63.66,86.79,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00904713261,NDC,,,facility,outpatient,1,EA,106.10000,30.77000,Aetna,First Health,,86.79,,,,,,,38.25,86.79,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,00904713061,NDC,facility,inpatient,25,ME,44.25000,12.83000,Aetna,First Health,,36.20,,,,,,,26.55,36.20,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,00904713061,NDC,facility,outpatient,25,ME,44.25000,12.83000,Aetna,First Health,,36.20,,,,,,,2.07,36.20,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00904712804,NDC,,,facility,inpatient,1,EA,22.85000,6.63000,Aetna,First Health,,18.69,,,,,,,13.71,18.69,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00904712804,NDC,,,facility,outpatient,1,EA,22.85000,6.63000,Aetna,First Health,,18.69,,,,,,,8.24,18.69,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00904712761,NDC,facility,inpatient,20,ME,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00904712761,NDC,facility,outpatient,20,ME,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.00963,1.19,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00904712661,NDC,,,facility,inpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,3.57,4.87,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00904712661,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00904712361,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00904712361,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00904712261,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00904712261,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00904712161,NDC,,,facility,inpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.90000,1.23,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00904712161,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.54075,1.23,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00904712004,NDC,,,facility,inpatient,1,EA,40.75000,11.82000,Aetna,First Health,,33.33,,,,,,,24.45,33.33,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00904712004,NDC,,,facility,outpatient,1,EA,40.75000,11.82000,Aetna,First Health,,33.33,,,,,,,14.69,33.33,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,00904711961,NDC,facility,inpatient,667,ME,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,7.32,9.98,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,00904711961,NDC,facility,outpatient,667,ME,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,0.03852,9.98,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,800022076,CDM,637,RC,00904711793,NDC,,,facility,inpatient,1,EA,35.25000,10.22000,Aetna,First Health,,28.83,,,,,,,21.15,28.83,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,800022076,CDM,637,RC,00904711793,NDC,,,facility,outpatient,1,EA,35.25000,10.22000,Aetna,First Health,,28.83,,,,,,,12.71,28.83,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00904711061,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00904711061,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00904710961,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00904710961,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00904710761,NDC,,,facility,inpatient,1,EA,27.90000,8.09000,Aetna,First Health,,22.82,,,,,,,16.74,22.82,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00904710761,NDC,,,facility,outpatient,1,EA,27.90000,8.09000,Aetna,First Health,,22.82,,,,,,,10.06,22.82,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00904710310,NDC,,,facility,inpatient,1,EA,45.25000,13.12000,Aetna,First Health,,37.01,,,,,,,27.15,37.01,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00904710310,NDC,,,facility,outpatient,1,EA,45.25000,13.12000,Aetna,First Health,,37.01,,,,,,,16.31,37.01,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00904710304,NDC,,,facility,inpatient,1,EA,77.90000,22.59000,Aetna,First Health,,63.72,,,,,,,46.74,63.72,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00904710304,NDC,,,facility,outpatient,1,EA,77.90000,22.59000,Aetna,First Health,,63.72,,,,,,,28.08,63.72,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,00904709761,NDC,facility,inpatient,1,ME,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,00904709761,NDC,facility,outpatient,1,ME,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,0.19260,9.49,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00904708961,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00904708961,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00904708761,NDC,,,facility,inpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,4.77,6.50,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00904708761,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,2.87,6.50,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00904708661,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00904708661,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00904708645,NDC,,,facility,inpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,4.26,5.81,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00904708645,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,2.56,5.81,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00904708461,NDC,,,facility,inpatient,1,EA,15.75000,4.57000,Aetna,First Health,,12.88,,,,,,,9.45,12.88,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00904708461,NDC,,,facility,outpatient,1,EA,15.75000,4.57000,Aetna,First Health,,12.88,,,,,,,5.68,12.88,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00904708404,NDC,,,facility,inpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,6.72,9.16,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00904708404,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,First Health,,9.16,,,,,,,4.04,9.16,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,00904707957,NDC,,,facility,inpatient,1,EA,41.60000,12.06000,Aetna,First Health,,34.03,,,,,,,24.96,34.03,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,00904707957,NDC,,,facility,outpatient,1,EA,41.60000,12.06000,Aetna,First Health,,34.03,,,,,,,15.00,34.03,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00904707861,NDC,facility,inpatient,500,ME,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,2.90,6.58,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00904707861,NDC,facility,outpatient,500,ME,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,0.14445,6.58,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00904707761,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00904707761,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00904707661,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00904707661,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00904707561,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00904707561,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00904707161,NDC,,,facility,inpatient,1,EA,35.20000,10.21000,Aetna,First Health,,28.79,,,,,,,21.12,28.79,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00904707161,NDC,,,facility,outpatient,1,EA,35.20000,10.21000,Aetna,First Health,,28.79,,,,,,,12.69,28.79,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00904707107,NDC,,,facility,inpatient,1,EA,30.70000,8.90000,Aetna,First Health,,25.11,,,,,,,18.42,25.11,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00904707107,NDC,,,facility,outpatient,1,EA,30.70000,8.90000,Aetna,First Health,,25.11,,,,,,,11.07,25.11,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,00904706704,NDC,,,facility,inpatient,1,EA,242.65000,70.37000,Aetna,First Health,,198.49,,,,,,,145.59,198.49,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,00904706704,NDC,,,facility,outpatient,1,EA,242.65000,70.37000,Aetna,First Health,,198.49,,,,,,,87.48,198.49,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00904706561,NDC,facility,inpatient,25,ME,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00904706561,NDC,facility,outpatient,25,ME,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,0.21186,3.31,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00904706453,NDC,,,facility,inpatient,1,EA,137.15000,39.77000,Aetna,First Health,,112.19,,,,,,,82.29,112.19,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00904706453,NDC,,,facility,outpatient,1,EA,137.15000,39.77000,Aetna,First Health,,112.19,,,,,,,49.44,112.19,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00904706296,NDC,,,facility,inpatient,1,EA,195.85000,56.80000,Aetna,First Health,,160.21,,,,,,,117.51,160.21,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00904706296,NDC,,,facility,outpatient,1,EA,195.85000,56.80000,Aetna,First Health,,160.21,,,,,,,70.60,160.21,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00904706260,NDC,,,facility,inpatient,1,EA,125.05000,36.26000,Aetna,First Health,,102.29,,,,,,,75.03,102.29,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00904706260,NDC,,,facility,outpatient,1,EA,125.05000,36.26000,Aetna,First Health,,102.29,,,,,,,45.08,102.29,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00904706187,NDC,,,facility,inpatient,1,EA,68.45000,19.85000,Aetna,First Health,,55.99,,,,,,,41.07,55.99,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00904706187,NDC,,,facility,outpatient,1,EA,68.45000,19.85000,Aetna,First Health,,55.99,,,,,,,24.68,55.99,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,00904706094,NDC,,,facility,inpatient,1,EA,30.55000,8.86000,Aetna,First Health,,24.99,,,,,,,18.33,24.99,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,00904706094,NDC,,,facility,outpatient,1,EA,30.55000,8.86000,Aetna,First Health,,24.99,,,,,,,11.01,24.99,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00904705861,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00904705861,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00904705761,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00904705761,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,00904705699,NDC,,,facility,inpatient,1,EA,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,53.82,73.37,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,00904705699,NDC,,,facility,outpatient,1,EA,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,32.34,73.37,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00904704961,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00904704961,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00904704861,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00904704861,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00904704761,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00904704761,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00904704561,NDC,,,facility,inpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,7.32,9.98,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00904704561,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,4.40,9.98,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,00904704361,NDC,,,facility,inpatient,1,EA,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,8.19,11.17,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,00904704361,NDC,,,facility,outpatient,1,EA,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,4.92,11.17,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,00904704304,NDC,,,facility,inpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,7.41,10.10,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,00904704304,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,4.45,10.10,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00904704161,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00904704161,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,00904703604,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,00904703604,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00904703587,NDC,,,facility,inpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,8.79,11.98,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00904703587,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,First Health,,11.98,,,,,,,5.28,11.98,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00904703580,NDC,,,facility,inpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,8.28,11.29,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00904703580,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,4.97,11.29,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00904702661,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,10.32,14.07,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00904702661,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00904702061,NDC,,,facility,inpatient,1,EA,11.45000,3.32000,Aetna,First Health,,9.37,,,,,,,6.87,9.37,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00904702061,NDC,,,facility,outpatient,1,EA,11.45000,3.32000,Aetna,First Health,,9.37,,,,,,,4.13,9.37,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00904701661,NDC,,,facility,inpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,6.24,8.51,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00904701661,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
Buprenorphine-Naloxone 8-2mg SLT,800072440,CDM,637,RC,J0574,HCPCS,00904701006,NDC,facility,inpatient,1,EA,38.25000,11.09000,Aetna,First Health,,31.29,,,,,,,22.95,31.29,percent of total billed charges,
Buprenorphine-Naloxone 8-2mg SLT,800072440,CDM,637,RC,J0574,HCPCS,00904701006,NDC,facility,outpatient,1,EA,38.25000,11.09000,Aetna,First Health,,31.29,,,,,,,9.80,31.40,percent of total billed charges,
Buprenorphine-Naloxone 2-0.5mg SLTab,800072441,CDM,637,RC,J0572,HCPCS,00904700906,NDC,facility,inpatient,1,EA,29.70000,8.61000,Aetna,First Health,,24.29,,,,,,,17.82,24.29,percent of total billed charges,
Buprenorphine-Naloxone 2-0.5mg SLTab,800072441,CDM,637,RC,J0572,HCPCS,00904700906,NDC,facility,outpatient,1,EA,29.70000,8.61000,Aetna,First Health,,24.29,,,,,,,5.48,24.29,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,00904700861,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,00904700861,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,00904700761,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,00904700761,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,00904700161,NDC,,,facility,inpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,4.83,6.58,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,00904700161,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,2.90,6.58,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,00904700061,NDC,,,facility,inpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,4.41,6.01,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,00904700061,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,2.65,6.01,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00904699361,NDC,,,facility,inpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,1.50,2.04,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00904699361,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,0.90125,2.04,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,00904699261,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,00904699261,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,00904699161,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,00904699161,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,00904699104,NDC,,,facility,inpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,7.59,10.35,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,00904699104,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,4.56,10.35,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00904698761,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00904698761,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00904696661,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00904696661,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00904695761,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00904695761,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00904695561,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00904695561,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00904695461,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00904695461,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00904695361,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00904695361,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00904695261,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00904695261,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00904695161,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00904695161,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00904695061,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00904695061,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00904694961,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00904694961,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,00904693961,NDC,,,facility,inpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,4.92,6.71,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,00904693961,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,2.96,6.71,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00904693806,NDC,,,facility,inpatient,1,EA,15.35000,4.45000,Aetna,First Health,,12.56,,,,,,,9.21,12.56,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00904693806,NDC,,,facility,outpatient,1,EA,15.35000,4.45000,Aetna,First Health,,12.56,,,,,,,5.53,12.56,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,00904693561,NDC,,,facility,inpatient,1,EA,115.95000,33.63000,Aetna,First Health,,94.85,,,,,,,69.57,94.85,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,00904693561,NDC,,,facility,outpatient,1,EA,115.95000,33.63000,Aetna,First Health,,94.85,,,,,,,41.80,94.85,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00904692761,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00904692761,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00904692661,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00904692661,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00904692561,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00904692561,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Sertraline HCl 25mg T,800015414,CDM,637,RC,00904692461,NDC,,,facility,inpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
Sertraline HCl 25mg T,800015414,CDM,637,RC,00904692461,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00904692361,NDC,facility,inpatient,10,ME,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00904692361,NDC,facility,outpatient,10,ME,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.00963,1.06,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00904691661,NDC,,,facility,inpatient,1,EA,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,15.93,21.72,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00904691661,NDC,,,facility,outpatient,1,EA,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,9.57,21.72,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00904691461,NDC,facility,inpatient,4,ME,15.75000,4.57000,Aetna,First Health,,12.88,,,,,,,9.45,12.88,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00904691461,NDC,facility,outpatient,4,ME,15.75000,4.57000,Aetna,First Health,,12.88,,,,,,,0.13482,12.88,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904690706,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904690706,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00904690204,NDC,,,facility,inpatient,1,EA,56.70000,16.44000,Aetna,First Health,,46.38,,,,,,,34.02,46.38,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00904690204,NDC,,,facility,outpatient,1,EA,56.70000,16.44000,Aetna,First Health,,46.38,,,,,,,20.44,46.38,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,00904690004,NDC,,,facility,inpatient,1,EA,16.80000,4.87000,Aetna,First Health,,13.74,,,,,,,10.08,13.74,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,00904690004,NDC,,,facility,outpatient,1,EA,16.80000,4.87000,Aetna,First Health,,13.74,,,,,,,6.06,13.74,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,00904688210,NDC,,,facility,inpatient,1,EA,663.10000,192.30000,Aetna,First Health,,542.42,,,,,,,397.86,542.42,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,00904688210,NDC,,,facility,outpatient,1,EA,663.10000,192.30000,Aetna,First Health,,542.42,,,,,,,239.05,542.42,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00904687204,NDC,,,facility,inpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,16.56,22.58,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00904687204,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00904686961,NDC,,,facility,inpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.90000,1.23,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00904686961,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.54075,1.23,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00904686861,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00904686861,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00904686190,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00904686190,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00904686161,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00904686161,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00904686061,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00904686061,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,00904683104,NDC,,,facility,inpatient,1,EA,46.75000,13.56000,Aetna,First Health,,38.24,,,,,,,28.05,38.24,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,00904683104,NDC,,,facility,outpatient,1,EA,46.75000,13.56000,Aetna,First Health,,38.24,,,,,,,16.85,38.24,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00904683061,NDC,,,facility,inpatient,1,EA,8.75000,2.54000,Aetna,First Health,,7.16,,,,,,,5.25,7.16,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00904683061,NDC,,,facility,outpatient,1,EA,8.75000,2.54000,Aetna,First Health,,7.16,,,,,,,3.15,7.16,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00904683006,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00904683006,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00904682894,NDC,,,facility,inpatient,1,EA,42.10000,12.21000,Aetna,First Health,,34.44,,,,,,,25.26,34.44,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00904682894,NDC,,,facility,outpatient,1,EA,42.10000,12.21000,Aetna,First Health,,34.44,,,,,,,15.18,34.44,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00904682561,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00904682561,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00904682461,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00904682461,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00904682361,NDC,,,facility,inpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00904682361,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00904681861,NDC,,,facility,inpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,4.41,6.01,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00904681861,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,2.65,6.01,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00904681806,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00904681806,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00904681004,NDC,,,facility,inpatient,1,EA,22.85000,6.63000,Aetna,First Health,,18.69,,,,,,,13.71,18.69,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00904681004,NDC,,,facility,outpatient,1,EA,22.85000,6.63000,Aetna,First Health,,18.69,,,,,,,8.24,18.69,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00904680861,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00904680861,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00904680806,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00904680806,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00904680061,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00904680061,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00904679961,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00904679961,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00904679861,NDC,,,facility,inpatient,1,EA,0.45000,0.13000,Aetna,First Health,,0.36810,,,,,,,0.27000,0.36810,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00904679861,NDC,,,facility,outpatient,1,EA,0.45000,0.13000,Aetna,First Health,,0.36810,,,,,,,0.16223,0.36810,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),800017736,CDM,637,RC,00904679610,NDC,,,facility,inpatient,1,EA,192.65000,55.87000,Aetna,First Health,,157.59,,,,,,,115.59,157.59,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),800017736,CDM,637,RC,00904679610,NDC,,,facility,outpatient,1,EA,192.65000,55.87000,Aetna,First Health,,157.59,,,,,,,69.45,157.59,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,00904679104,NDC,,,facility,inpatient,1,EA,89.50000,25.96000,Aetna,First Health,,73.21,,,,,,,53.70,73.21,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,00904679104,NDC,,,facility,outpatient,1,EA,89.50000,25.96000,Aetna,First Health,,73.21,,,,,,,32.26,73.21,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00904678861,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00904678861,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,00904678561,NDC,facility,inpatient,180,ME,41.75000,12.11000,Aetna,First Health,,34.15,,,,,,,25.05,34.15,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,00904678561,NDC,facility,outpatient,180,ME,41.75000,12.11000,Aetna,First Health,,34.15,,,,,,,0.30816,34.15,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,00904678504,NDC,facility,inpatient,180,ME,35.30000,10.24000,Aetna,First Health,,28.88,,,,,,,21.18,28.88,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,00904678504,NDC,facility,outpatient,180,ME,35.30000,10.24000,Aetna,First Health,,28.88,,,,,,,0.30816,28.88,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00904678261,NDC,,,facility,inpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,3.87,5.28,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00904678261,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,2.33,5.28,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,00904678161,NDC,,,facility,inpatient,1,EA,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,6.90,9.41,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,00904678161,NDC,,,facility,outpatient,1,EA,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,4.15,9.41,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,00904677961,NDC,,,facility,inpatient,1,EA,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,6.99,9.53,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,00904677961,NDC,,,facility,outpatient,1,EA,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,4.20,9.53,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904672852,NDC,,,facility,inpatient,1,EA,0.45000,0.13000,Aetna,First Health,,0.36810,,,,,,,0.27000,0.36810,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904672852,NDC,,,facility,outpatient,1,EA,0.45000,0.13000,Aetna,First Health,,0.36810,,,,,,,0.16223,0.36810,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904672846,NDC,,,facility,inpatient,1,EA,0.70000,0.20000,Aetna,First Health,,0.57260,,,,,,,0.42000,0.57260,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904672846,NDC,,,facility,outpatient,1,EA,0.70000,0.20000,Aetna,First Health,,0.57260,,,,,,,0.25235,0.57260,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00904671839,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00904671839,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904670861,NDC,,,facility,inpatient,1,EA,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,10.68,14.56,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904670861,NDC,,,facility,outpatient,1,EA,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,6.42,14.56,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904670806,NDC,,,facility,inpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,6.30,8.59,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904670806,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,3.79,8.59,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00904670561,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00904670561,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00904670506,NDC,,,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,2.19,2.99,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00904670506,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.32,2.99,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00904668961,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00904668961,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,00904668308,NDC,,,facility,inpatient,1,EA,44.75000,12.98000,Aetna,First Health,,36.61,,,,,,,26.85,36.61,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,00904668308,NDC,,,facility,outpatient,1,EA,44.75000,12.98000,Aetna,First Health,,36.61,,,,,,,16.13,36.61,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,00904668208,NDC,,,facility,inpatient,1,EA,44.30000,12.85000,Aetna,First Health,,36.24,,,,,,,26.58,36.24,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,00904668208,NDC,,,facility,outpatient,1,EA,44.30000,12.85000,Aetna,First Health,,36.24,,,,,,,15.97,36.24,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00904668108,NDC,,,facility,inpatient,1,EA,43.85000,12.72000,Aetna,First Health,,35.87,,,,,,,26.31,35.87,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00904668108,NDC,,,facility,outpatient,1,EA,43.85000,12.72000,Aetna,First Health,,35.87,,,,,,,15.81,35.87,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,00904667106,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,00904667106,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,00904667104,NDC,,,facility,inpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,5.91,8.06,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,00904667104,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,First Health,,8.06,,,,,,,3.55,8.06,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00904666761,NDC,,,facility,inpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,1.05,1.43,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00904666761,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.63087,1.43,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00904666661,NDC,,,facility,inpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.84000,1.15,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00904666661,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.50470,1.15,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00904666561,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00904666561,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00904666404,NDC,,,facility,inpatient,1,EA,93.55000,27.13000,Aetna,First Health,,76.52,,,,,,,56.13,76.52,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00904666404,NDC,,,facility,outpatient,1,EA,93.55000,27.13000,Aetna,First Health,,76.52,,,,,,,33.72,76.52,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,00904666361,NDC,,,facility,inpatient,1,EA,30.70000,8.90000,Aetna,First Health,,25.11,,,,,,,18.42,25.11,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,00904666361,NDC,,,facility,outpatient,1,EA,30.70000,8.90000,Aetna,First Health,,25.11,,,,,,,11.07,25.11,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,00904664061,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,00904664061,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,00904663861,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,00904663861,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00904663761,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00904663761,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00904663661,NDC,,,facility,inpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,8.34,11.37,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00904663661,NDC,,,facility,outpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,5.01,11.37,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00904663561,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00904663561,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00904662735,NDC,,,facility,inpatient,1,EA,16.05000,4.65000,Aetna,First Health,,13.13,,,,,,,5.94,13.13,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00904662735,NDC,,,facility,outpatient,1,EA,16.05000,4.65000,Aetna,First Health,,13.13,,,,,,,5.79,13.13,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),800081868,CDM,637,RC,J7507,HCPCS,00904662361,NDC,facility,inpatient,0.5,ME,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,5.34,7.28,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),800081868,CDM,637,RC,J7507,HCPCS,00904662361,NDC,facility,outpatient,0.5,ME,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,0.19260,7.28,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00904662261,NDC,,,facility,inpatient,1,EA,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,6.84,9.33,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00904662261,NDC,,,facility,outpatient,1,EA,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,4.11,9.33,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00904661961,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00904661961,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00904661761,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00904661761,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,00904661561,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,00904661561,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,00904659961,NDC,facility,inpatient,2,ME,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,5.04,6.87,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,00904659961,NDC,facility,outpatient,2,ME,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,2.30,7.37,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00904659204,NDC,,,facility,inpatient,1,EA,77.05000,22.34000,Aetna,First Health,,63.03,,,,,,,46.23,63.03,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00904659204,NDC,,,facility,outpatient,1,EA,77.05000,22.34000,Aetna,First Health,,63.03,,,,,,,27.78,63.03,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00904658561,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00904658561,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,00904658304,NDC,,,facility,inpatient,1,EA,65.40000,18.97000,Aetna,First Health,,53.50,,,,,,,39.24,53.50,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,00904658304,NDC,,,facility,outpatient,1,EA,65.40000,18.97000,Aetna,First Health,,53.50,,,,,,,23.58,53.50,percent of total billed charges,
PHENobarbital 32.4 mg Tab,800051123,CDM,637,RC,00904657561,NDC,,,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,2.19,2.99,percent of total billed charges,
PHENobarbital 32.4 mg Tab,800051123,CDM,637,RC,00904657561,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.32,2.99,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00904657261,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00904657261,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00904657161,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00904657161,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00904657061,NDC,,,facility,inpatient,1,EA,19.45000,5.64000,Aetna,First Health,,15.91,,,,,,,11.67,15.91,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00904657061,NDC,,,facility,outpatient,1,EA,19.45000,5.64000,Aetna,First Health,,15.91,,,,,,,7.01,15.91,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00904657006,NDC,,,facility,inpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,14.28,19.47,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00904657006,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,8.58,19.47,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00904657004,NDC,,,facility,inpatient,1,EA,29.15000,8.45000,Aetna,First Health,,23.84,,,,,,,17.49,23.84,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00904657004,NDC,,,facility,outpatient,1,EA,29.15000,8.45000,Aetna,First Health,,23.84,,,,,,,10.51,23.84,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00904656761,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00904656761,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00904656561,NDC,,,facility,inpatient,1,EA,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,12.42,16.93,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00904656561,NDC,,,facility,outpatient,1,EA,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,7.46,16.93,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904656461,NDC,,,facility,inpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,2.52,3.44,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904656461,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,1.51,3.44,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904656460,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904656460,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00904656061,NDC,,,facility,inpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,20.19,27.53,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00904656061,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,First Health,,27.53,,,,,,,12.13,27.53,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00904655861,NDC,,,facility,inpatient,1,EA,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,7.20,9.82,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00904655861,NDC,,,facility,outpatient,1,EA,12.00000,3.48000,Aetna,First Health,,9.82,,,,,,,4.33,9.82,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,00904655761,NDC,,,facility,inpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,6.60,9.00,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,00904655761,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,3.97,9.00,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00904655661,NDC,,,facility,inpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,2.52,3.44,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00904655661,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,1.51,3.44,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00904655304,NDC,,,facility,inpatient,1,EA,1111.15000,322.23000,Aetna,First Health,,908.92,,,,,,,666.69,908.92,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00904655304,NDC,,,facility,outpatient,1,EA,1111.15000,322.23000,Aetna,First Health,,908.92,,,,,,,400.57,908.92,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,00904655161,NDC,facility,inpatient,4,ME,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,00904655161,NDC,facility,outpatient,4,ME,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,0.00963,4.29,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00904655061,NDC,,,facility,inpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,1.50,2.04,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00904655061,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,0.90125,2.04,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00904653806,NDC,,,facility,inpatient,1,EA,15.35000,4.45000,Aetna,First Health,,12.56,,,,,,,9.21,12.56,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00904653806,NDC,,,facility,outpatient,1,EA,15.35000,4.45000,Aetna,First Health,,12.56,,,,,,,5.53,12.56,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00904653061,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00904653061,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00904651961,NDC,,,facility,inpatient,1,EA,20.25000,5.87000,Aetna,First Health,,16.56,,,,,,,12.15,16.56,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00904651961,NDC,,,facility,outpatient,1,EA,20.25000,5.87000,Aetna,First Health,,16.56,,,,,,,7.30,16.56,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,00904651106,NDC,,,facility,inpatient,1,EA,71.10000,20.62000,Aetna,First Health,,58.16,,,,,,,42.66,58.16,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,00904651106,NDC,,,facility,outpatient,1,EA,71.10000,20.62000,Aetna,First Health,,58.16,,,,,,,25.63,58.16,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,00904651061,NDC,,,facility,inpatient,1,EA,163.95000,47.55000,Aetna,First Health,,134.11,,,,,,,98.37,134.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,00904651061,NDC,,,facility,outpatient,1,EA,163.95000,47.55000,Aetna,First Health,,134.11,,,,,,,59.10,134.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,00904651006,NDC,,,facility,inpatient,1,EA,71.10000,20.62000,Aetna,First Health,,58.16,,,,,,,42.66,58.16,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,00904651006,NDC,,,facility,outpatient,1,EA,71.10000,20.62000,Aetna,First Health,,58.16,,,,,,,25.63,58.16,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00904650661,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,4.05,5.52,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00904650661,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00904650606,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00904650606,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00904650561,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,4.05,5.52,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00904650561,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00904650361,NDC,,,facility,inpatient,1,EA,53.65000,15.56000,Aetna,First Health,,43.89,,,,,,,32.19,43.89,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00904650361,NDC,,,facility,outpatient,1,EA,53.65000,15.56000,Aetna,First Health,,43.89,,,,,,,19.34,43.89,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00904650261,NDC,,,facility,inpatient,1,EA,30.90000,8.96000,Aetna,First Health,,25.28,,,,,,,18.54,25.28,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00904650261,NDC,,,facility,outpatient,1,EA,30.90000,8.96000,Aetna,First Health,,25.28,,,,,,,11.14,25.28,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00904650061,NDC,,,facility,inpatient,1,EA,68.75000,19.94000,Aetna,First Health,,56.24,,,,,,,41.25,56.24,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00904650061,NDC,,,facility,outpatient,1,EA,68.75000,19.94000,Aetna,First Health,,56.24,,,,,,,24.78,56.24,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00904650006,NDC,,,facility,inpatient,1,EA,11.25000,3.26000,Aetna,First Health,,9.20,,,,,,,6.75,9.20,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00904650006,NDC,,,facility,outpatient,1,EA,11.25000,3.26000,Aetna,First Health,,9.20,,,,,,,4.06,9.20,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00904647761,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00904647761,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00904647661,NDC,,,facility,inpatient,1,EA,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,4.62,6.30,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00904647661,NDC,,,facility,outpatient,1,EA,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,2.78,6.30,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00904647561,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00904647561,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00904647461,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00904647461,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,00904647104,NDC,,,facility,inpatient,1,EA,220.75000,64.02000,Aetna,First Health,,180.57,,,,,,,132.45,180.57,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,00904647104,NDC,,,facility,outpatient,1,EA,220.75000,64.02000,Aetna,First Health,,180.57,,,,,,,79.58,180.57,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00904647061,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00904647061,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00904646961,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00904646961,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00904646861,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00904646861,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,00904646710,NDC,,,facility,inpatient,1,EA,69.50000,20.15000,Aetna,First Health,,56.85,,,,,,,41.70,56.85,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,00904646710,NDC,,,facility,outpatient,1,EA,69.50000,20.15000,Aetna,First Health,,56.85,,,,,,,25.05,56.85,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,00904646707,NDC,,,facility,inpatient,1,EA,136.40000,39.56000,Aetna,First Health,,111.58,,,,,,,81.84,111.58,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,00904646707,NDC,,,facility,outpatient,1,EA,136.40000,39.56000,Aetna,First Health,,111.58,,,,,,,49.17,111.58,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00904645461,NDC,,,facility,inpatient,1,EA,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,25.17,34.32,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00904645461,NDC,,,facility,outpatient,1,EA,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,15.12,34.32,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,00904645361,NDC,,,facility,inpatient,1,EA,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,25.17,34.32,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,00904645361,NDC,,,facility,outpatient,1,EA,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,15.12,34.32,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00904644961,NDC,,,facility,inpatient,1,EA,11.75000,3.41000,Aetna,First Health,,9.61,,,,,,,7.05,9.61,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00904644961,NDC,,,facility,outpatient,1,EA,11.75000,3.41000,Aetna,First Health,,9.61,,,,,,,4.24,9.61,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00904644461,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00904644461,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,00904644261,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,00904644261,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,00904644161,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,00904644161,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,00904644061,NDC,,,facility,inpatient,1,EA,0.90000,0.26000,Aetna,First Health,,0.73620,,,,,,,0.54000,0.73620,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,00904644061,NDC,,,facility,outpatient,1,EA,0.90000,0.26000,Aetna,First Health,,0.73620,,,,,,,0.32445,0.73620,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00904643604,NDC,,,facility,inpatient,1,EA,37.85000,10.98000,Aetna,First Health,,30.96,,,,,,,22.71,30.96,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00904643604,NDC,,,facility,outpatient,1,EA,37.85000,10.98000,Aetna,First Health,,30.96,,,,,,,13.64,30.96,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00904642761,NDC,,,facility,inpatient,1,EA,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,19.41,26.46,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00904642761,NDC,,,facility,outpatient,1,EA,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,11.66,26.46,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00904642661,NDC,,,facility,inpatient,1,EA,31.00000,8.99000,Aetna,First Health,,25.36,,,,,,,18.60,25.36,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00904642661,NDC,,,facility,outpatient,1,EA,31.00000,8.99000,Aetna,First Health,,25.36,,,,,,,11.18,25.36,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,00904642304,NDC,,,facility,inpatient,1,EA,196.20000,56.90000,Aetna,First Health,,160.49,,,,,,,117.72,160.49,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,00904642304,NDC,,,facility,outpatient,1,EA,196.20000,56.90000,Aetna,First Health,,160.49,,,,,,,70.73,160.49,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00904642161,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,5.22,7.12,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00904642161,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00904641961,NDC,,,facility,inpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,2.82,3.84,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00904641961,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,00904641861,NDC,,,facility,inpatient,1,EA,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,7.50,10.22,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,00904641861,NDC,,,facility,outpatient,1,EA,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,4.51,10.22,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00904640161,NDC,,,facility,inpatient,1,EA,29.80000,8.64000,Aetna,First Health,,24.38,,,,,,,17.88,24.38,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00904640161,NDC,,,facility,outpatient,1,EA,29.80000,8.64000,Aetna,First Health,,24.38,,,,,,,10.74,24.38,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00904637761,NDC,,,facility,inpatient,1,EA,93.55000,27.13000,Aetna,First Health,,76.52,,,,,,,56.13,76.52,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00904637761,NDC,,,facility,outpatient,1,EA,93.55000,27.13000,Aetna,First Health,,76.52,,,,,,,33.72,76.52,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00904637661,NDC,,,facility,inpatient,1,EA,93.55000,27.13000,Aetna,First Health,,76.52,,,,,,,56.13,76.52,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00904637661,NDC,,,facility,outpatient,1,EA,93.55000,27.13000,Aetna,First Health,,76.52,,,,,,,33.72,76.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00904637461,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00904637461,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,00904637361,NDC,,,facility,inpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,2.52,3.44,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,00904637361,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,First Health,,3.44,,,,,,,1.51,3.44,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,00904637161,NDC,,,facility,inpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,9.57,13.05,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,00904637161,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00904637061,NDC,,,facility,inpatient,1,EA,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,6.99,9.53,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00904637061,NDC,,,facility,outpatient,1,EA,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,4.20,9.53,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,00904636961,NDC,,,facility,inpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,00904636961,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00904636861,NDC,,,facility,inpatient,1,EA,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,25.17,34.32,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00904636861,NDC,,,facility,outpatient,1,EA,41.95000,12.17000,Aetna,First Health,,34.32,,,,,,,15.12,34.32,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904636561,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904636561,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00904636461,NDC,,,facility,inpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,10.50,14.31,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00904636461,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,6.31,14.31,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00904636361,NDC,,,facility,inpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,6.60,9.00,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00904636361,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,3.97,9.00,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00904636345,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00904636345,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,00904635961,NDC,,,facility,inpatient,1,EA,32.30000,9.37000,Aetna,First Health,,26.42,,,,,,,19.38,26.42,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,00904635961,NDC,,,facility,outpatient,1,EA,32.30000,9.37000,Aetna,First Health,,26.42,,,,,,,11.64,26.42,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,00904635761,NDC,,,facility,inpatient,1,EA,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,15.21,20.74,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,00904635761,NDC,,,facility,outpatient,1,EA,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,9.14,20.74,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),800015332,CDM,637,RC,00904635361,NDC,,,facility,inpatient,1,EA,174.25000,50.53000,Aetna,First Health,,142.54,,,,,,,104.55,142.54,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),800015332,CDM,637,RC,00904635361,NDC,,,facility,outpatient,1,EA,174.25000,50.53000,Aetna,First Health,,142.54,,,,,,,62.82,142.54,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,00904635261,NDC,,,facility,inpatient,1,EA,119.10000,34.54000,Aetna,First Health,,97.42,,,,,,,71.46,97.42,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,00904635261,NDC,,,facility,outpatient,1,EA,119.10000,34.54000,Aetna,First Health,,97.42,,,,,,,42.94,97.42,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,00904635161,NDC,,,facility,inpatient,1,EA,104.25000,30.23000,Aetna,First Health,,85.28,,,,,,,62.55,85.28,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,00904635161,NDC,,,facility,outpatient,1,EA,104.25000,30.23000,Aetna,First Health,,85.28,,,,,,,37.58,85.28,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00904634261,NDC,,,facility,inpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,3.87,5.28,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00904634261,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,2.33,5.28,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00904634161,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00904634161,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,00904634061,NDC,,,facility,inpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,1.20,1.64,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,00904634061,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,00904632461,NDC,,,facility,inpatient,1,EA,13.20000,3.83000,Aetna,First Health,,10.80,,,,,,,7.92,10.80,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,00904632461,NDC,,,facility,outpatient,1,EA,13.20000,3.83000,Aetna,First Health,,10.80,,,,,,,4.76,10.80,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00904632361,NDC,,,facility,inpatient,1,EA,8.75000,2.54000,Aetna,First Health,,7.16,,,,,,,5.25,7.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00904632361,NDC,,,facility,outpatient,1,EA,8.75000,2.54000,Aetna,First Health,,7.16,,,,,,,3.15,7.16,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00904632261,NDC,,,facility,inpatient,1,EA,8.75000,2.54000,Aetna,First Health,,7.16,,,,,,,5.25,7.16,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00904632261,NDC,,,facility,outpatient,1,EA,8.75000,2.54000,Aetna,First Health,,7.16,,,,,,,3.15,7.16,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00904632206,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00904632206,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00904630361,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00904630361,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00904630261,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00904630261,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00904630161,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00904630161,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00904630061,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,8.94,12.19,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00904630061,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,00904629461,NDC,,,facility,inpatient,1,EA,30.90000,8.96000,Aetna,First Health,,25.28,,,,,,,18.54,25.28,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,00904629461,NDC,,,facility,outpatient,1,EA,30.90000,8.96000,Aetna,First Health,,25.28,,,,,,,11.14,25.28,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00904629261,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00904629261,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00904629206,NDC,,,facility,inpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,1.23,1.68,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00904629206,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,0.73903,1.68,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00904629161,NDC,,,facility,inpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,2.22,3.03,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00904629161,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00904629061,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00904629061,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00904629006,NDC,,,facility,inpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,1.14,1.55,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00904629006,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.68495,1.55,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00904628361,NDC,,,facility,inpatient,1,EA,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,47.58,64.87,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00904628361,NDC,,,facility,outpatient,1,EA,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,28.59,64.87,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00904627245,NDC,,,facility,inpatient,1,EA,23.45000,6.80000,Aetna,First Health,,19.18,,,,,,,14.07,19.18,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00904627245,NDC,,,facility,outpatient,1,EA,23.45000,6.80000,Aetna,First Health,,19.18,,,,,,,8.45,19.18,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00904627208,NDC,,,facility,inpatient,1,EA,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,46.20,62.99,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00904627208,NDC,,,facility,outpatient,1,EA,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,27.76,62.99,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,00904626945,NDC,,,facility,inpatient,1,EA,23.45000,6.80000,Aetna,First Health,,19.18,,,,,,,14.07,19.18,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,00904626945,NDC,,,facility,outpatient,1,EA,23.45000,6.80000,Aetna,First Health,,19.18,,,,,,,8.45,19.18,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00904623861,NDC,,,facility,inpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,3.63,4.95,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00904623861,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,2.18,4.95,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00904623761,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00904623761,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00904623561,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00904623561,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00904622160,NDC,,,facility,inpatient,1,EA,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,6.90,9.41,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00904622160,NDC,,,facility,outpatient,1,EA,11.50000,3.34000,Aetna,First Health,,9.41,,,,,,,4.15,9.41,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00904622106,NDC,,,facility,inpatient,1,EA,20.65000,5.99000,Aetna,First Health,,16.89,,,,,,,12.39,16.89,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00904622106,NDC,,,facility,outpatient,1,EA,20.65000,5.99000,Aetna,First Health,,16.89,,,,,,,7.44,16.89,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00904618761,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00904618761,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904611961,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904611961,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904610161,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904610161,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00904608361,NDC,,,facility,inpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.51000,0.69530,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00904608361,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.30643,0.69530,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00904608261,NDC,,,facility,inpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.51000,0.69530,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00904608261,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.30643,0.69530,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,00904606050,NDC,,,facility,inpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.51000,0.69530,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,00904606050,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.30643,0.69530,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,00904605261,NDC,,,facility,inpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,13.44,18.32,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,00904605261,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,8.08,18.32,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00904605161,NDC,,,facility,inpatient,1,EA,18.30000,5.31000,Aetna,First Health,,14.97,,,,,,,10.98,14.97,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00904605161,NDC,,,facility,outpatient,1,EA,18.30000,5.31000,Aetna,First Health,,14.97,,,,,,,6.60,14.97,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00904601960,NDC,,,facility,inpatient,1,EA,131.40000,38.11000,Aetna,First Health,,107.49,,,,,,,78.84,107.49,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00904601960,NDC,,,facility,outpatient,1,EA,131.40000,38.11000,Aetna,First Health,,107.49,,,,,,,47.37,107.49,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00904601946,NDC,,,facility,inpatient,1,EA,116.55000,33.80000,Aetna,First Health,,95.34,,,,,,,69.93,95.34,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00904601946,NDC,,,facility,outpatient,1,EA,116.55000,33.80000,Aetna,First Health,,95.34,,,,,,,42.02,95.34,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00904601260,NDC,facility,inpatient,2.5,ME,25.85000,7.50000,Aetna,First Health,,21.15,,,,,,,15.51,21.15,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00904601260,NDC,facility,outpatient,2.5,ME,25.85000,7.50000,Aetna,First Health,,21.15,,,,,,,0.14445,21.15,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,00904600860,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,00904600860,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00904600760,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00904600760,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Ammonium Lactate 12% Lotion,800025491,CDM,637,RC,00904598426,NDC,,,facility,inpatient,1,EA,264.70000,76.76000,Aetna,First Health,,216.52,,,,,,,158.82,216.52,percent of total billed charges,
Ammonium Lactate 12% Lotion,800025491,CDM,637,RC,00904598426,NDC,,,facility,outpatient,1,EA,264.70000,76.76000,Aetna,First Health,,216.52,,,,,,,95.42,216.52,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,00904598161,NDC,,,facility,inpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,4.41,6.01,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,00904598161,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,2.65,6.01,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00904598061,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00904598061,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00904595961,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00904595961,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00904592961,NDC,,,facility,inpatient,1,EA,24.70000,7.16000,Aetna,First Health,,20.20,,,,,,,14.82,20.20,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00904592961,NDC,,,facility,outpatient,1,EA,24.70000,7.16000,Aetna,First Health,,20.20,,,,,,,8.90,20.20,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00904592861,NDC,,,facility,inpatient,1,EA,16.15000,4.68000,Aetna,First Health,,13.21,,,,,,,9.69,13.21,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00904592861,NDC,,,facility,outpatient,1,EA,16.15000,4.68000,Aetna,First Health,,13.21,,,,,,,5.82,13.21,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00904592561,NDC,,,facility,inpatient,1,EA,12.55000,3.64000,Aetna,First Health,,10.27,,,,,,,7.53,10.27,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00904592561,NDC,,,facility,outpatient,1,EA,12.55000,3.64000,Aetna,First Health,,10.27,,,,,,,4.52,10.27,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00904592161,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00904592161,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00904589261,NDC,,,facility,inpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,10.59,14.44,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00904589261,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,6.36,14.44,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00904589161,NDC,,,facility,inpatient,1,EA,20.50000,5.94000,Aetna,First Health,,16.77,,,,,,,12.30,16.77,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00904589161,NDC,,,facility,outpatient,1,EA,20.50000,5.94000,Aetna,First Health,,16.77,,,,,,,7.39,16.77,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,00904588061,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,00904588061,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00904586861,NDC,,,facility,inpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,14.25,19.43,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00904586861,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.56,19.43,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00904585961,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00904585961,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00904585861,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00904585861,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904585561,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904585561,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00904585461,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00904585461,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904585361,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904585361,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00904579761,NDC,,,facility,inpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00904579761,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00904578961,NDC,,,facility,inpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,6.51,8.88,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00904578961,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00904578561,NDC,,,facility,inpatient,1,EA,17.60000,5.10000,Aetna,First Health,,14.40,,,,,,,10.56,14.40,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00904578561,NDC,,,facility,outpatient,1,EA,17.60000,5.10000,Aetna,First Health,,14.40,,,,,,,6.34,14.40,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00904578461,NDC,,,facility,inpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,10.29,14.03,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00904578461,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,6.18,14.03,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00904578017,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00904578017,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00904567761,NDC,,,facility,inpatient,1,EA,20.80000,6.03000,Aetna,First Health,,17.01,,,,,,,12.48,17.01,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00904567761,NDC,,,facility,outpatient,1,EA,20.80000,6.03000,Aetna,First Health,,17.01,,,,,,,7.50,17.01,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00904567661,NDC,,,facility,inpatient,1,EA,19.95000,5.79000,Aetna,First Health,,16.32,,,,,,,11.97,16.32,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00904567661,NDC,,,facility,outpatient,1,EA,19.95000,5.79000,Aetna,First Health,,16.32,,,,,,,7.19,16.32,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00904565661,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00904565661,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00904561161,NDC,,,facility,inpatient,1,EA,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,9.75,13.29,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00904561161,NDC,,,facility,outpatient,1,EA,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,5.86,13.29,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00904561061,NDC,,,facility,inpatient,1,EA,11.45000,3.32000,Aetna,First Health,,9.37,,,,,,,6.87,9.37,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00904561061,NDC,,,facility,outpatient,1,EA,11.45000,3.32000,Aetna,First Health,,9.37,,,,,,,4.13,9.37,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00904561060,NDC,,,facility,inpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,4.44,6.05,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00904561060,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,2.67,6.05,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,00904560961,NDC,,,facility,inpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,6.18,8.43,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,00904560961,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00904555960,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00904555960,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904555661,NDC,,,facility,inpatient,1,EA,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,4.38,5.97,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904555661,NDC,,,facility,outpatient,1,EA,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,2.63,5.97,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00904555380,NDC,,,facility,inpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,7.32,9.98,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00904555380,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,4.40,9.98,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00904552361,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00904552361,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00904552261,NDC,,,facility,inpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,4.32,5.89,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00904552261,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00904550261,NDC,,,facility,inpatient,1,EA,10.95000,3.18000,Aetna,First Health,,8.96,,,,,,,6.57,8.96,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00904550261,NDC,,,facility,outpatient,1,EA,10.95000,3.18000,Aetna,First Health,,8.96,,,,,,,3.95,8.96,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00904550260,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00904550260,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00904539260,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00904539260,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904534261,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904534261,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904534240,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904534240,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00904530920,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.59200,1.31,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00904530920,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00904528261,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00904528261,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,00904522760,NDC,,,facility,inpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,00904522760,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.79310,1.80,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00904522060,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00904522060,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904518761,NDC,,,facility,inpatient,1,EA,0.70000,0.20000,Aetna,First Health,,0.57260,,,,,,,0.42000,0.57260,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904518761,NDC,,,facility,outpatient,1,EA,0.70000,0.20000,Aetna,First Health,,0.57260,,,,,,,0.25235,0.57260,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904518760,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904518760,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904518740,NDC,,,facility,inpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,1.23,1.68,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904518740,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,0.73903,1.68,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00904518661,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00904518661,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00904518640,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00904518640,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,00904517060,NDC,,,facility,inpatient,1,EA,0.35000,0.10000,Aetna,First Health,,0.28630,,,,,,,0.21000,0.28630,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,00904517060,NDC,,,facility,outpatient,1,EA,0.35000,0.10000,Aetna,First Health,,0.28630,,,,,,,0.12618,0.28630,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904512559,NDC,,,facility,inpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.24000,0.32720,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904512559,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.14420,0.32720,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904512546,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904512546,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00904399061,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00904399061,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,00904385461,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,00904385461,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00904322035,NDC,,,facility,inpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,6.49,14.36,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00904322035,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,6.33,14.36,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00904292461,NDC,,,facility,inpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,3.18,4.34,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00904292461,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,1.91,4.34,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00904282161,NDC,,,facility,inpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,2.82,3.84,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00904282161,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
Sulfamethoxazole-Trimethoprim DS 800-160mg T,800021992,CDM,637,RC,00904272561,NDC,,,facility,inpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,1.59,2.17,percent of total billed charges,
Sulfamethoxazole-Trimethoprim DS 800-160mg T,800021992,CDM,637,RC,00904272561,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,800015247,CDM,637,RC,00904272046,NDC,,,facility,inpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,1.41,1.92,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,800015247,CDM,637,RC,00904272046,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
Calamine-Zinc Oxide 8% Topical Lotion,800018168,CDM,250,RC,00904253321,NDC,,,facility,inpatient,1,EA,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,6.16,13.62,percent of total billed charges,
Calamine-Zinc Oxide 8% Topical Lotion,800018168,CDM,250,RC,00904253321,NDC,,,facility,outpatient,1,EA,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,6.00,13.62,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00904236560,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00904236560,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00904236460,NDC,,,facility,inpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,1.50,2.04,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00904236460,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,0.90125,2.04,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00904215160,NDC,,,facility,inpatient,1,EA,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.09000,0.12270,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00904215160,NDC,,,facility,outpatient,1,EA,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05407,0.12270,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00904209660,NDC,,,facility,inpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00904209660,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904174861,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904174861,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904174860,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904174860,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904174840,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904174840,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,00904098950,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,00904098950,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00904073431,NDC,,,facility,inpatient,1,EA,23.35000,6.77000,Aetna,First Health,,19.10,,,,,,,8.64,19.10,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00904073431,NDC,,,facility,outpatient,1,EA,23.35000,6.77000,Aetna,First Health,,19.10,,,,,,,8.42,19.10,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00904056060,NDC,,,facility,inpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,4.20,5.73,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00904056060,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,2.52,5.73,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042861,NDC,,,facility,inpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042861,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042851,NDC,,,facility,inpatient,1,EA,39.15000,11.35000,Aetna,First Health,,32.02,,,,,,,23.49,32.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042851,NDC,,,facility,outpatient,1,EA,39.15000,11.35000,Aetna,First Health,,32.02,,,,,,,14.11,32.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042806,NDC,,,facility,inpatient,1,EA,17.35000,5.03000,Aetna,First Health,,14.19,,,,,,,10.41,14.19,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042806,NDC,,,facility,outpatient,1,EA,17.35000,5.03000,Aetna,First Health,,14.19,,,,,,,6.25,14.19,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042804,NDC,,,facility,inpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,10.89,14.85,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042804,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,6.54,14.85,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,00904029160,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,00904029160,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00904020161,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00904020161,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00904009160,NDC,,,facility,inpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,1.50,2.04,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00904009160,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,0.90125,2.04,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00832712401,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00832712401,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00832602000,NDC,,,facility,inpatient,1,EA,105.40000,30.57000,Aetna,First Health,,86.22,,,,,,,63.24,86.22,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00832602000,NDC,,,facility,outpatient,1,EA,105.40000,30.57000,Aetna,First Health,,86.22,,,,,,,38.00,86.22,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,00832601700,NDC,facility,inpatient,10,ME,29.75000,8.63000,Aetna,First Health,,24.34,,,,,,,17.85,24.34,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,00832601700,NDC,facility,outpatient,10,ME,29.75000,8.63000,Aetna,First Health,,24.34,,,,,,,2.07,24.34,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00832532515,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00832532515,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00832532511,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00832532511,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00832532510,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00832532510,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00832152001,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00832152001,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00832121801,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00832121801,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00832121800,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00832121800,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,00832121601,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,00832121601,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00832121301,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00832121301,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,00832121201,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,00832121201,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00832121189,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00832121189,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00832121101,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00832121101,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00832108000,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00832108000,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00832102500,NDC,,,facility,inpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,21.78,29.69,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00832102500,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,13.09,29.69,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00832102400,NDC,,,facility,inpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,10.50,14.31,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00832102400,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,6.31,14.31,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,00832100800,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,00832100800,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),800017683,CDM,637,RC,00832074260,NDC,,,facility,inpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,42.48,57.91,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),800017683,CDM,637,RC,00832074260,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,00832074160,NDC,,,facility,inpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,42.48,57.91,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,00832074160,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00832074060,NDC,,,facility,inpatient,1,EA,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,33.54,45.73,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00832074060,NDC,,,facility,outpatient,1,EA,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,20.15,45.73,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,00832051101,NDC,,,facility,inpatient,1,EA,14.20000,4.12000,Aetna,First Health,,11.62,,,,,,,8.52,11.62,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,00832051101,NDC,,,facility,outpatient,1,EA,14.20000,4.12000,Aetna,First Health,,11.62,,,,,,,5.12,11.62,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,00832051100,NDC,,,facility,inpatient,1,EA,14.20000,4.12000,Aetna,First Health,,11.62,,,,,,,8.52,11.62,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,00832051100,NDC,,,facility,outpatient,1,EA,14.20000,4.12000,Aetna,First Health,,11.62,,,,,,,5.12,11.62,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00832046560,NDC,,,facility,inpatient,1,EA,230.05000,66.71000,Aetna,First Health,,188.18,,,,,,,138.03,188.18,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00832046560,NDC,,,facility,outpatient,1,EA,230.05000,66.71000,Aetna,First Health,,188.18,,,,,,,82.93,188.18,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00832046515,NDC,,,facility,inpatient,1,EA,261.50000,75.83000,Aetna,First Health,,213.91,,,,,,,156.90,213.91,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00832046515,NDC,,,facility,outpatient,1,EA,261.50000,75.83000,Aetna,First Health,,213.91,,,,,,,94.27,213.91,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00832035711,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00832035711,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00832030300,NDC,,,facility,inpatient,1,EA,105.40000,30.57000,Aetna,First Health,,86.22,,,,,,,63.24,86.22,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00832030300,NDC,,,facility,outpatient,1,EA,105.40000,30.57000,Aetna,First Health,,86.22,,,,,,,38.00,86.22,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,00832030100,NDC,facility,inpatient,25,ME,54.10000,15.69000,Aetna,First Health,,44.25,,,,,,,32.46,44.25,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,00832030100,NDC,facility,outpatient,25,ME,54.10000,15.69000,Aetna,First Health,,44.25,,,,,,,2.07,44.25,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,00832030000,NDC,facility,inpatient,10,ME,29.75000,8.63000,Aetna,First Health,,24.34,,,,,,,17.85,24.34,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,00832030000,NDC,facility,outpatient,10,ME,29.75000,8.63000,Aetna,First Health,,24.34,,,,,,,2.07,24.34,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00832004309,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00832004309,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00832003801,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00832003801,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00832003800,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00832003800,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,00781940895,NDC,facility,inpatient,2,GM,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,48.31,109.61,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,00781940895,NDC,facility,outpatient,2,GM,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,0.56817,109.61,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00781940795,NDC,facility,inpatient,500,ME,35.30000,10.24000,Aetna,First Health,,28.88,,,,,,,12.73,28.88,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00781940795,NDC,facility,outpatient,500,ME,35.30000,10.24000,Aetna,First Health,,28.88,,,,,,,0.56817,28.88,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,inpatient,1,GM,69.10000,20.04000,Aetna,First Health,,56.52,,,,,,,24.91,56.52,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,outpatient,1,GM,69.10000,20.04000,Aetna,First Health,,56.52,,,,,,,0.56817,56.52,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781936795,NDC,facility,inpatient,4.5,GM,187.10000,54.26000,Aetna,First Health,,153.05,,,,,,,67.45,153.05,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781936795,NDC,facility,outpatient,4.5,GM,187.10000,54.26000,Aetna,First Health,,153.05,,,,,,,1.05,153.05,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781935095,NDC,facility,inpatient,3.375,GM,147.70000,42.83000,Aetna,First Health,,120.82,,,,,,,53.25,120.82,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781935095,NDC,facility,outpatient,3.375,GM,147.70000,42.83000,Aetna,First Health,,120.82,,,,,,,1.05,120.82,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781934495,NDC,facility,inpatient,2.25,GM,98.45000,28.55000,Aetna,First Health,,80.53,,,,,,,35.49,80.53,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781934495,NDC,facility,outpatient,2.25,GM,98.45000,28.55000,Aetna,First Health,,80.53,,,,,,,1.05,80.53,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,00781931780,NDC,facility,inpatient,100,ME,2733.30000,792.66000,Aetna,First Health,,2235.84,,,,,,,985.35,2235.84,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,00781931780,NDC,facility,outpatient,100,ME,2733.30000,792.66000,Aetna,First Health,,2235.84,,,,,,,0.04815,2235.84,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,00781930301,NDC,facility,inpatient,1,ME,31.55000,9.15000,Aetna,First Health,,25.81,,,,,,,18.93,25.81,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,00781930301,NDC,facility,outpatient,1,ME,31.55000,9.15000,Aetna,First Health,,25.81,,,,,,,0.19260,25.81,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),800081868,CDM,637,RC,J7507,HCPCS,00781930201,NDC,facility,inpatient,0.5,ME,15.80000,4.58000,Aetna,First Health,,12.92,,,,,,,9.48,12.92,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),800081868,CDM,637,RC,J7507,HCPCS,00781930201,NDC,facility,outpatient,0.5,ME,15.80000,4.58000,Aetna,First Health,,12.92,,,,,,,0.19260,12.92,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,00781925394,NDC,facility,inpatient,100,ME,2966.30000,860.23000,Aetna,First Health,,2426.43,,,,,,,1069.35,2426.43,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,00781925394,NDC,facility,outpatient,100,ME,2966.30000,860.23000,Aetna,First Health,,2426.43,,,,,,,0.44298,2426.43,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00781922209,NDC,facility,inpatient,900,ME,154.05000,44.67000,Aetna,First Health,,126.01,,,,,,,55.54,126.01,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00781922209,NDC,facility,outpatient,900,ME,154.05000,44.67000,Aetna,First Health,,126.01,,,,,,,2.26,126.01,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00781922109,NDC,facility,inpatient,600,ME,126.15000,36.58000,Aetna,First Health,,103.19,,,,,,,45.48,103.19,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00781922109,NDC,facility,outpatient,600,ME,126.15000,36.58000,Aetna,First Health,,103.19,,,,,,,1.84,103.19,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781921495,NDC,facility,inpatient,4.5,GM,187.10000,54.26000,Aetna,First Health,,153.05,,,,,,,67.45,153.05,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781921495,NDC,facility,outpatient,4.5,GM,187.10000,54.26000,Aetna,First Health,,153.05,,,,,,,1.05,153.05,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781921395,NDC,facility,inpatient,3.375,GM,147.70000,42.83000,Aetna,First Health,,120.82,,,,,,,53.25,120.82,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781921395,NDC,facility,outpatient,3.375,GM,147.70000,42.83000,Aetna,First Health,,120.82,,,,,,,1.05,120.82,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781921095,NDC,facility,inpatient,2.25,GM,98.45000,28.55000,Aetna,First Health,,80.53,,,,,,,35.49,80.53,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781921095,NDC,facility,outpatient,2.25,GM,98.45000,28.55000,Aetna,First Health,,80.53,,,,,,,1.05,80.53,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,00781915895,NDC,facility,inpatient,250,ME,7582.25000,2198.85000,Aetna,First Health,,6202.28,,,,,,,2733.40,6202.28,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,00781915895,NDC,facility,outpatient,250,ME,7582.25000,2198.85000,Aetna,First Health,,6202.28,,,,,,,0.15408,6202.28,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00781905395,NDC,facility,inpatient,200,ME,127.55000,36.99000,Aetna,First Health,,104.34,,,,,,,45.98,104.34,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00781905395,NDC,facility,outpatient,200,ME,127.55000,36.99000,Aetna,First Health,,104.34,,,,,,,0.93411,104.34,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00781903795,NDC,,,facility,inpatient,1,EA,142.30000,41.27000,Aetna,First Health,,116.40,,,,,,,52.65,116.40,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00781903795,NDC,,,facility,outpatient,1,EA,142.30000,41.27000,Aetna,First Health,,116.40,,,,,,,51.30,116.40,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00781808931,NDC,,,facility,inpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,33.06,45.07,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00781808931,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,19.86,45.07,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,00781802931,NDC,,,facility,inpatient,1,EA,58.10000,16.85000,Aetna,First Health,,47.53,,,,,,,34.86,47.53,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,00781802931,NDC,,,facility,outpatient,1,EA,58.10000,16.85000,Aetna,First Health,,47.53,,,,,,,20.95,47.53,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,00781730931,NDC,,,facility,inpatient,1,EA,119.65000,34.70000,Aetna,First Health,,97.87,,,,,,,71.79,97.87,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,00781730931,NDC,,,facility,outpatient,1,EA,119.65000,34.70000,Aetna,First Health,,97.87,,,,,,,43.13,97.87,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00781729685,NDC,,,facility,inpatient,1,EA,310.95000,90.18000,Aetna,First Health,,254.36,,,,,,,186.57,254.36,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00781729685,NDC,,,facility,outpatient,1,EA,310.95000,90.18000,Aetna,First Health,,254.36,,,,,,,112.10,254.36,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00781724255,NDC,,,facility,inpatient,1,EA,210.90000,61.16000,Aetna,First Health,,172.52,,,,,,,126.54,172.52,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00781724255,NDC,,,facility,outpatient,1,EA,210.90000,61.16000,Aetna,First Health,,172.52,,,,,,,76.03,172.52,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00781724055,NDC,,,facility,inpatient,1,EA,162.40000,47.10000,Aetna,First Health,,132.84,,,,,,,97.44,132.84,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00781724055,NDC,,,facility,outpatient,1,EA,162.40000,47.10000,Aetna,First Health,,132.84,,,,,,,58.55,132.84,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,00781713354,NDC,,,facility,inpatient,1,EA,164.30000,47.65000,Aetna,First Health,,134.40,,,,,,,98.58,134.40,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,00781713354,NDC,,,facility,outpatient,1,EA,164.30000,47.65000,Aetna,First Health,,134.40,,,,,,,59.23,134.40,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00781711455,NDC,,,facility,inpatient,1,EA,411.90000,119.45000,Aetna,First Health,,336.93,,,,,,,247.14,336.93,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00781711455,NDC,,,facility,outpatient,1,EA,411.90000,119.45000,Aetna,First Health,,336.93,,,,,,,148.49,336.93,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00781711355,NDC,,,facility,inpatient,1,EA,314.85000,91.31000,Aetna,First Health,,257.55,,,,,,,188.91,257.55,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00781711355,NDC,,,facility,outpatient,1,EA,314.85000,91.31000,Aetna,First Health,,257.55,,,,,,,113.50,257.55,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00781711255,NDC,,,facility,inpatient,1,EA,210.90000,61.16000,Aetna,First Health,,172.52,,,,,,,126.54,172.52,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00781711255,NDC,,,facility,outpatient,1,EA,210.90000,61.16000,Aetna,First Health,,172.52,,,,,,,76.03,172.52,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,00781710454,NDC,,,facility,inpatient,1,EA,164.30000,47.65000,Aetna,First Health,,134.40,,,,,,,98.58,134.40,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,00781710454,NDC,,,facility,outpatient,1,EA,164.30000,47.65000,Aetna,First Health,,134.40,,,,,,,59.23,134.40,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00781705839,NDC,,,facility,inpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,21.05,46.54,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00781705839,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,20.51,46.54,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00781705805,NDC,,,facility,inpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,21.05,46.54,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00781705805,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,20.51,46.54,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00781632079,NDC,,,facility,inpatient,1,EA,751.45000,217.92000,Aetna,First Health,,614.69,,,,,,,450.87,614.69,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00781632079,NDC,,,facility,outpatient,1,EA,751.45000,217.92000,Aetna,First Health,,614.69,,,,,,,270.90,614.69,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,00781618667,NDC,,,facility,inpatient,1,EA,1708.55000,495.48000,Aetna,First Health,,1397.59,,,,,,,1025.13,1397.59,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,00781618667,NDC,,,facility,outpatient,1,EA,1708.55000,495.48000,Aetna,First Health,,1397.59,,,,,,,615.93,1397.59,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00781613595,NDC,facility,inpatient,1,EA,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,45.78,103.89,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00781613595,NDC,facility,outpatient,1,EA,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,0.75114,103.89,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,00781604146,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,00781604146,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781599401,NDC,,,facility,inpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,4.32,5.89,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781599401,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,00781591401,NDC,facility,inpatient,25,ME,43.50000,12.61000,Aetna,First Health,,35.58,,,,,,,26.10,35.58,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,00781591401,NDC,facility,outpatient,25,ME,43.50000,12.61000,Aetna,First Health,,35.58,,,,,,,2.07,35.58,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,00781591301,NDC,facility,inpatient,10,ME,30.45000,8.83000,Aetna,First Health,,24.91,,,,,,,18.27,24.91,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,00781591301,NDC,facility,outpatient,10,ME,30.45000,8.83000,Aetna,First Health,,24.91,,,,,,,2.07,24.91,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00781580710,NDC,,,facility,inpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,13.08,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00781580710,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781580692,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781580692,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781580631,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781580631,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00781580592,NDC,,,facility,inpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,7.14,9.73,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00781580592,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,4.29,9.73,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00781577631,NDC,,,facility,inpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,33.06,45.07,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00781577631,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,19.86,45.07,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00781572005,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00781572005,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00781570292,NDC,,,facility,inpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,13.08,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00781570292,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00781570210,NDC,,,facility,inpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,13.08,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00781570210,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,First Health,,17.83,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781570192,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781570192,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781570131,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781570131,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781570110,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781570110,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00781570092,NDC,,,facility,inpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,7.14,9.73,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00781570092,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,4.29,9.73,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00781569092,NDC,,,facility,inpatient,1,EA,18.50000,5.36000,Aetna,First Health,,15.13,,,,,,,11.10,15.13,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00781569092,NDC,,,facility,outpatient,1,EA,18.50000,5.36000,Aetna,First Health,,15.13,,,,,,,6.67,15.13,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00781561892,NDC,,,facility,inpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,22.14,30.18,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00781561892,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,13.30,30.18,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,00781550301,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,00781550301,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00781540931,NDC,,,facility,inpatient,1,EA,131.40000,38.11000,Aetna,First Health,,107.49,,,,,,,78.84,107.49,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00781540931,NDC,,,facility,outpatient,1,EA,131.40000,38.11000,Aetna,First Health,,107.49,,,,,,,47.37,107.49,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00781540901,NDC,,,facility,inpatient,1,EA,131.40000,38.11000,Aetna,First Health,,107.49,,,,,,,78.84,107.49,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00781540901,NDC,,,facility,outpatient,1,EA,131.40000,38.11000,Aetna,First Health,,107.49,,,,,,,47.37,107.49,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,00781540331,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,00781540331,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,00781540192,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,00781540192,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,00781537701,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,00781537701,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,00781532531,NDC,,,facility,inpatient,1,EA,44.40000,12.88000,Aetna,First Health,,36.32,,,,,,,26.64,36.32,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,00781532531,NDC,,,facility,outpatient,1,EA,44.40000,12.88000,Aetna,First Health,,36.32,,,,,,,16.01,36.32,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,00781532501,NDC,,,facility,inpatient,1,EA,44.25000,12.83000,Aetna,First Health,,36.20,,,,,,,26.55,36.20,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,00781532501,NDC,,,facility,outpatient,1,EA,44.25000,12.83000,Aetna,First Health,,36.20,,,,,,,15.95,36.20,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,00781526564,NDC,facility,inpatient,4,ME,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,94.71,129.12,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,00781526564,NDC,facility,outpatient,4,ME,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,0.00963,129.12,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,00781525092,NDC,,,facility,inpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,12.54,17.10,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,00781525092,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,00781523864,NDC,facility,inpatient,4,ME,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,94.71,129.12,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,00781523864,NDC,facility,outpatient,4,ME,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,0.00963,129.12,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00781523292,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,13.89,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00781523292,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00781519192,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00781519192,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00781518892,NDC,,,facility,inpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,3.57,4.87,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00781518892,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00781518692,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00781518692,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00781518592,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00781518592,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00781518492,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00781518492,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00781518401,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00781518401,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00781518392,NDC,,,facility,inpatient,1,EA,4.10000,1.19000,Aetna,First Health,,3.35,,,,,,,2.46,3.35,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00781518392,NDC,,,facility,outpatient,1,EA,4.10000,1.19000,Aetna,First Health,,3.35,,,,,,,1.48,3.35,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00781518292,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00781518292,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00781518201,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00781518201,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00781518192,NDC,,,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,2.19,2.99,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00781518192,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.32,2.99,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00781518101,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00781518101,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00781518092,NDC,,,facility,inpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.92,2.62,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00781518092,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00781517501,NDC,facility,inpatient,500,ME,56.20000,16.30000,Aetna,First Health,,45.97,,,,,,,20.26,45.97,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00781517501,NDC,facility,outpatient,500,ME,56.20000,16.30000,Aetna,First Health,,45.97,,,,,,,0.14445,45.97,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00781505631,NDC,,,facility,inpatient,1,EA,116.30000,33.73000,Aetna,First Health,,95.13,,,,,,,69.78,95.13,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00781505631,NDC,,,facility,outpatient,1,EA,116.30000,33.73000,Aetna,First Health,,95.13,,,,,,,41.93,95.13,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00781505001,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00781505001,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,00781504501,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,00781504501,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,00781503201,NDC,,,facility,inpatient,1,EA,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,6.99,9.53,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,00781503201,NDC,,,facility,outpatient,1,EA,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,4.20,9.53,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00781502207,NDC,facility,inpatient,4,ME,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00781502207,NDC,facility,outpatient,4,ME,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,0.13482,3.89,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00781502201,NDC,facility,inpatient,4,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00781502201,NDC,facility,outpatient,4,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,0.13482,8.26,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,00781502101,NDC,facility,inpatient,10,ME,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,3.78,5.15,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,00781502101,NDC,facility,outpatient,10,ME,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,0.57780,5.15,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00781501501,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00781501501,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00781375595,NDC,,,facility,inpatient,1,EA,81.35000,23.59000,Aetna,First Health,,66.54,,,,,,,30.10,66.54,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00781375595,NDC,,,facility,outpatient,1,EA,81.35000,23.59000,Aetna,First Health,,66.54,,,,,,,29.33,66.54,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00781365569,NDC,facility,inpatient,150,ME,555.90000,161.21000,Aetna,First Health,,454.73,,,,,,,200.40,454.73,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00781365569,NDC,facility,outpatient,150,ME,555.90000,161.21000,Aetna,First Health,,454.73,,,,,,,0.51039,454.73,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00781354325,NDC,facility,inpatient,30000,UN,72.25000,20.95000,Aetna,First Health,,59.10,,,,,,,26.05,59.10,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00781354325,NDC,facility,outpatient,30000,UN,72.25000,20.95000,Aetna,First Health,,59.10,,,,,,,0.17334,59.10,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,00781353191,NDC,facility,inpatient,100,ME,7866.05000,2281.15000,Aetna,First Health,,6434.43,,,,,,,2835.71,6434.43,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,00781353191,NDC,facility,outpatient,100,ME,7866.05000,2281.15000,Aetna,First Health,,6434.43,,,,,,,7.88,6434.43,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00781350069,NDC,facility,inpatient,100,ME,392.15000,113.72000,Aetna,First Health,,320.78,,,,,,,141.37,320.78,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00781350069,NDC,facility,outpatient,100,ME,392.15000,113.72000,Aetna,First Health,,320.78,,,,,,,0.51039,320.78,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00781345895,NDC,facility,inpatient,50,ME,235.00000,68.15000,Aetna,First Health,,192.23,,,,,,,84.72,192.23,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00781345895,NDC,facility,outpatient,50,ME,235.00000,68.15000,Aetna,First Health,,192.23,,,,,,,86.95,192.23,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00781345295,NDC,facility,inpatient,2,GM,458.00000,132.82000,Aetna,First Health,,374.64,,,,,,,165.11,374.64,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00781345295,NDC,facility,outpatient,2,GM,458.00000,132.82000,Aetna,First Health,,374.64,,,,,,,0.79929,374.64,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00781345196,NDC,facility,inpatient,1000,ME,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,21.63,49.08,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00781345196,NDC,facility,outpatient,1000,ME,60.00000,17.40000,Aetna,First Health,,49.08,,,,,,,0.79929,49.08,percent of total billed charges,
ceFAZolin 500mg I (Ancef),800062014,CDM,636,RC,J0690,HCPCS,00781345095,NDC,facility,inpatient,500,ME,77.90000,22.59000,Aetna,First Health,,63.72,,,,,,,28.08,63.72,percent of total billed charges,
ceFAZolin 500mg I (Ancef),800062014,CDM,636,RC,J0690,HCPCS,00781345095,NDC,facility,outpatient,500,ME,77.90000,22.59000,Aetna,First Health,,63.72,,,,,,,0.79929,63.72,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,00781344095,NDC,facility,inpatient,0.25,ME,456.75000,132.46000,Aetna,First Health,,373.62,,,,,,,164.66,373.62,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,00781344095,NDC,facility,outpatient,0.25,ME,456.75000,132.46000,Aetna,First Health,,373.62,,,,,,,19.89,373.62,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00781343395,NDC,facility,inpatient,600,ME,182.40000,52.90000,Aetna,First Health,,149.20,,,,,,,65.76,149.20,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00781343395,NDC,facility,outpatient,600,ME,182.40000,52.90000,Aetna,First Health,,149.20,,,,,,,2.64,149.20,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00781342868,NDC,facility,inpatient,80,ME,321.90000,93.35000,Aetna,First Health,,263.31,,,,,,,116.04,263.31,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00781342868,NDC,facility,outpatient,80,ME,321.90000,93.35000,Aetna,First Health,,263.31,,,,,,,0.51039,263.31,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,00781341575,NDC,facility,inpatient,0.25,ME,1317.95000,382.21000,Aetna,First Health,,1078.08,,,,,,,475.12,1078.08,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,00781341575,NDC,facility,outpatient,0.25,ME,1317.95000,382.21000,Aetna,First Health,,1078.08,,,,,,,0.33705,1078.08,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00781341195,NDC,facility,inpatient,200,ME,127.55000,36.99000,Aetna,First Health,,104.34,,,,,,,45.98,104.34,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00781341195,NDC,facility,outpatient,200,ME,127.55000,36.99000,Aetna,First Health,,104.34,,,,,,,0.93411,104.34,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,00781340895,NDC,facility,inpatient,2,GM,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,48.31,109.61,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,00781340895,NDC,facility,outpatient,2,GM,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,0.56817,109.61,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00781340795,NDC,facility,inpatient,500,ME,35.25000,10.22000,Aetna,First Health,,28.83,,,,,,,12.71,28.83,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00781340795,NDC,facility,outpatient,500,ME,35.25000,10.22000,Aetna,First Health,,28.83,,,,,,,0.56817,28.83,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,00781340495,NDC,facility,inpatient,1,GM,69.10000,20.04000,Aetna,First Health,,56.52,,,,,,,24.91,56.52,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,00781340495,NDC,facility,outpatient,1,GM,69.10000,20.04000,Aetna,First Health,,56.52,,,,,,,0.56817,56.52,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781336795,NDC,facility,inpatient,4.5,GM,187.10000,54.26000,Aetna,First Health,,153.05,,,,,,,67.45,153.05,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781336795,NDC,facility,outpatient,4.5,GM,187.10000,54.26000,Aetna,First Health,,153.05,,,,,,,1.05,153.05,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00781335666,NDC,facility,inpatient,60,ME,249.10000,72.24000,Aetna,First Health,,203.76,,,,,,,89.80,203.76,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00781335666,NDC,facility,outpatient,60,ME,249.10000,72.24000,Aetna,First Health,,203.76,,,,,,,0.51039,203.76,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781335095,NDC,facility,inpatient,3.375,GM,147.70000,42.83000,Aetna,First Health,,120.82,,,,,,,53.25,120.82,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781335095,NDC,facility,outpatient,3.375,GM,147.70000,42.83000,Aetna,First Health,,120.82,,,,,,,1.05,120.82,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00781334695,NDC,facility,inpatient,2,GM,287.00000,83.23000,Aetna,First Health,,234.77,,,,,,,103.46,234.77,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00781334695,NDC,facility,outpatient,2,GM,287.00000,83.23000,Aetna,First Health,,234.77,,,,,,,0.79929,234.77,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781334495,NDC,facility,inpatient,2.25,GM,98.45000,28.55000,Aetna,First Health,,80.53,,,,,,,35.49,80.53,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781334495,NDC,facility,outpatient,2.25,GM,98.45000,28.55000,Aetna,First Health,,80.53,,,,,,,1.05,80.53,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00781334209,NDC,facility,inpatient,500,ME,132.30000,38.37000,Aetna,First Health,,108.22,,,,,,,47.69,108.22,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00781334209,NDC,facility,outpatient,500,ME,132.30000,38.37000,Aetna,First Health,,108.22,,,,,,,2.08,108.22,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00781334109,NDC,facility,inpatient,250,ME,69.30000,20.10000,Aetna,First Health,,56.69,,,,,,,24.98,56.69,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00781334109,NDC,facility,outpatient,250,ME,69.30000,20.10000,Aetna,First Health,,56.69,,,,,,,2.08,56.69,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,00781331275,NDC,facility,inpatient,0.25,ME,1317.95000,382.21000,Aetna,First Health,,1078.08,,,,,,,475.12,1078.08,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,00781331275,NDC,facility,outpatient,0.25,ME,1317.95000,382.21000,Aetna,First Health,,1078.08,,,,,,,0.33705,1078.08,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00781329969,NDC,facility,inpatient,150,ME,216.10000,62.67000,Aetna,First Health,,176.77,,,,,,,77.90,176.77,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00781329969,NDC,facility,outpatient,150,ME,216.10000,62.67000,Aetna,First Health,,176.77,,,,,,,0.51039,176.77,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00781329868,NDC,facility,inpatient,120,ME,175.65000,50.94000,Aetna,First Health,,143.68,,,,,,,63.32,143.68,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00781329868,NDC,facility,outpatient,120,ME,175.65000,50.94000,Aetna,First Health,,143.68,,,,,,,0.51039,143.68,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00781329009,NDC,facility,inpatient,900,ME,154.05000,44.67000,Aetna,First Health,,126.01,,,,,,,55.54,126.01,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00781329009,NDC,facility,outpatient,900,ME,154.05000,44.67000,Aetna,First Health,,126.01,,,,,,,2.26,126.01,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,inpatient,600,ME,126.15000,36.58000,Aetna,First Health,,103.19,,,,,,,45.48,103.19,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,outpatient,600,ME,126.15000,36.58000,Aetna,First Health,,103.19,,,,,,,1.84,103.19,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,00781328379,NDC,facility,inpatient,1000,ME,3788.05000,1098.53000,Aetna,First Health,,3098.62,,,,,,,1365.59,3098.62,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,00781328379,NDC,facility,outpatient,1000,ME,3788.05000,1098.53000,Aetna,First Health,,3098.62,,,,,,,3.46,3098.62,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,00781328275,NDC,facility,inpatient,200,ME,887.25000,257.30000,Aetna,First Health,,725.77,,,,,,,319.85,725.77,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,00781328275,NDC,facility,outpatient,200,ME,887.25000,257.30000,Aetna,First Health,,725.77,,,,,,,3.46,725.77,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00781326869,NDC,facility,inpatient,100,ME,148.70000,43.12000,Aetna,First Health,,121.64,,,,,,,53.61,121.64,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00781326869,NDC,facility,outpatient,100,ME,148.70000,43.12000,Aetna,First Health,,121.64,,,,,,,0.51039,121.64,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00781326795,NDC,facility,inpatient,1,GM,537.65000,155.92000,Aetna,First Health,,439.80,,,,,,,193.82,439.80,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00781326795,NDC,facility,outpatient,1,GM,537.65000,155.92000,Aetna,First Health,,439.80,,,,,,,0.36594,439.80,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00781326268,NDC,facility,inpatient,80,ME,118.90000,34.48000,Aetna,First Health,,97.26,,,,,,,42.86,97.26,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00781326268,NDC,facility,outpatient,80,ME,118.90000,34.48000,Aetna,First Health,,97.26,,,,,,,0.51039,97.26,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00781325666,NDC,facility,inpatient,60,ME,89.20000,25.87000,Aetna,First Health,,72.97,,,,,,,32.16,72.97,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00781325666,NDC,facility,outpatient,60,ME,89.20000,25.87000,Aetna,First Health,,72.97,,,,,,,0.51039,72.97,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,00781325394,NDC,facility,inpatient,100,ME,2966.30000,860.23000,Aetna,First Health,,2426.43,,,,,,,1069.35,2426.43,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,00781325394,NDC,facility,outpatient,100,ME,2966.30000,860.23000,Aetna,First Health,,2426.43,,,,,,,0.44298,2426.43,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00781324664,NDC,facility,inpatient,40,ME,59.40000,17.23000,Aetna,First Health,,48.59,,,,,,,21.41,48.59,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00781324664,NDC,facility,outpatient,40,ME,59.40000,17.23000,Aetna,First Health,,48.59,,,,,,,0.51039,48.59,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,00781323863,NDC,facility,inpatient,30,ME,44.55000,12.92000,Aetna,First Health,,36.44,,,,,,,16.06,36.44,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,00781323863,NDC,facility,outpatient,30,ME,44.55000,12.92000,Aetna,First Health,,36.44,,,,,,,0.51039,36.44,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,inpatient,500,ME,2659.20000,771.17000,Aetna,First Health,,2175.23,,,,,,,958.64,2175.23,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,outpatient,500,ME,2659.20000,771.17000,Aetna,First Health,,2175.23,,,,,,,0.56817,2175.23,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00781323295,NDC,facility,inpatient,40,ME,32.60000,9.45000,Aetna,First Health,,26.67,,,,,,,11.75,26.67,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00781323295,NDC,facility,outpatient,40,ME,32.60000,9.45000,Aetna,First Health,,26.67,,,,,,,5.86,26.67,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00781322464,NDC,facility,inpatient,40,ME,170.50000,49.44000,Aetna,First Health,,139.47,,,,,,,61.47,139.47,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00781322464,NDC,facility,outpatient,40,ME,170.50000,49.44000,Aetna,First Health,,139.47,,,,,,,0.51039,139.47,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00781322295,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,58.64,133.05,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00781322295,NDC,facility,outpatient,1,GM,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,0.83781,133.05,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00781322095,NDC,,,facility,inpatient,1,EA,104.60000,30.33000,Aetna,First Health,,85.56,,,,,,,38.70,85.56,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00781322095,NDC,,,facility,outpatient,1,EA,104.60000,30.33000,Aetna,First Health,,85.56,,,,,,,37.71,85.56,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00781322092,NDC,,,facility,inpatient,1,EA,100.45000,29.13000,Aetna,First Health,,82.17,,,,,,,37.17,82.17,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00781322092,NDC,,,facility,outpatient,1,EA,100.45000,29.13000,Aetna,First Health,,82.17,,,,,,,36.21,82.17,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,00781322075,NDC,,,facility,inpatient,1,EA,104.60000,30.33000,Aetna,First Health,,85.56,,,,,,,38.70,85.56,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,00781322075,NDC,,,facility,outpatient,1,EA,104.60000,30.33000,Aetna,First Health,,85.56,,,,,,,37.71,85.56,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00781322070,NDC,,,facility,inpatient,1,EA,100.45000,29.13000,Aetna,First Health,,82.17,,,,,,,37.17,82.17,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00781322070,NDC,,,facility,outpatient,1,EA,100.45000,29.13000,Aetna,First Health,,82.17,,,,,,,36.21,82.17,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00781320995,NDC,facility,inpatient,2,GM,435.90000,126.41000,Aetna,First Health,,356.57,,,,,,,157.14,356.57,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00781320995,NDC,facility,outpatient,2,GM,435.90000,126.41000,Aetna,First Health,,356.57,,,,,,,0.44298,356.57,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00781320895,NDC,facility,inpatient,1,GM,358.00000,103.82000,Aetna,First Health,,292.84,,,,,,,129.06,292.84,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00781320895,NDC,facility,outpatient,1,GM,358.00000,103.82000,Aetna,First Health,,292.84,,,,,,,0.44298,292.84,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00781320795,NDC,facility,inpatient,500,ME,143.60000,41.64000,Aetna,First Health,,117.46,,,,,,,51.77,117.46,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00781320795,NDC,facility,outpatient,500,ME,143.60000,41.64000,Aetna,First Health,,117.46,,,,,,,0.44298,117.46,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00781320495,NDC,facility,inpatient,25,ME,1834.10000,531.89000,Aetna,First Health,,1500.29,,,,,,,661.19,1500.29,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00781320495,NDC,facility,outpatient,25,ME,1834.10000,531.89000,Aetna,First Health,,1500.29,,,,,,,0.06741,1500.29,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00781318895,NDC,facility,inpatient,1,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,34.61,78.53,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00781318895,NDC,facility,outpatient,1,GM,96.00000,27.84000,Aetna,First Health,,78.53,,,,,,,0.02889,78.53,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00781317796,NDC,facility,inpatient,1,GM,83.95000,24.35000,Aetna,First Health,,68.67,,,,,,,30.26,68.67,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00781317796,NDC,facility,outpatient,1,GM,83.95000,24.35000,Aetna,First Health,,68.67,,,,,,,1.42,68.67,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,00781317414,NDC,facility,inpatient,6,ME,433.45000,125.70000,Aetna,First Health,,354.56,,,,,,,260.07,354.56,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,00781317414,NDC,facility,outpatient,6,ME,433.45000,125.70000,Aetna,First Health,,354.56,,,,,,,85.32,354.56,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,inpatient,10,ME,214.05000,62.07000,Aetna,First Health,,175.09,,,,,,,77.17,175.09,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,outpatient,10,ME,214.05000,62.07000,Aetna,First Health,,175.09,,,,,,,0.78003,175.09,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,inpatient,250,ME,7582.25000,2198.85000,Aetna,First Health,,6202.28,,,,,,,2733.40,6202.28,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,outpatient,250,ME,7582.25000,2198.85000,Aetna,First Health,,6202.28,,,,,,,0.15408,6202.28,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,00781315695,NDC,facility,inpatient,1000,ME,368.25000,106.79000,Aetna,First Health,,301.23,,,,,,,132.75,301.23,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,00781315695,NDC,facility,outpatient,1000,ME,368.25000,106.79000,Aetna,First Health,,301.23,,,,,,,0.05778,301.23,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00781315395,NDC,,,facility,inpatient,1,EA,2410.10000,698.93000,Aetna,First Health,,1971.46,,,,,,,891.74,1971.46,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00781315395,NDC,,,facility,outpatient,1,EA,2410.10000,698.93000,Aetna,First Health,,1971.46,,,,,,,868.84,1971.46,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00781315095,NDC,,,facility,inpatient,1,EA,153.20000,44.43000,Aetna,First Health,,125.32,,,,,,,56.68,125.32,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00781315095,NDC,,,facility,outpatient,1,EA,153.20000,44.43000,Aetna,First Health,,125.32,,,,,,,55.23,125.32,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,00781313363,NDC,facility,inpatient,30,ME,129.55000,37.57000,Aetna,First Health,,105.97,,,,,,,46.70,105.97,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,00781313363,NDC,facility,outpatient,30,ME,129.55000,37.57000,Aetna,First Health,,105.97,,,,,,,0.51039,105.97,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00781312595,NDC,facility,inpatient,2,GM,225.40000,65.37000,Aetna,First Health,,184.38,,,,,,,81.26,184.38,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00781312595,NDC,facility,outpatient,2,GM,225.40000,65.37000,Aetna,First Health,,184.38,,,,,,,0.05778,184.38,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00781312585,NDC,facility,inpatient,2,GM,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,48.31,109.61,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00781312585,NDC,facility,outpatient,2,GM,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,0.05778,109.61,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781311495,NDC,facility,inpatient,4.5,GM,65.90000,19.11000,Aetna,First Health,,53.91,,,,,,,23.76,53.91,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781311495,NDC,facility,outpatient,4.5,GM,65.90000,19.11000,Aetna,First Health,,53.91,,,,,,,1.05,53.91,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781311395,NDC,facility,inpatient,3.375,GM,49.45000,14.34000,Aetna,First Health,,40.45,,,,,,,17.83,40.45,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781311395,NDC,facility,outpatient,3.375,GM,49.45000,14.34000,Aetna,First Health,,40.45,,,,,,,1.05,40.45,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781311095,NDC,facility,inpatient,2.25,GM,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,11.90,26.99,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781311095,NDC,facility,outpatient,2.25,GM,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,1.05,26.99,percent of total billed charges,
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,00781309995,NDC,facility,inpatient,1000,ME,116.80000,33.87000,Aetna,First Health,,95.54,,,,,,,42.11,95.54,percent of total billed charges,
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,00781309995,NDC,facility,outpatient,1000,ME,116.80000,33.87000,Aetna,First Health,,95.54,,,,,,,0.54891,95.54,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00781309896,NDC,facility,inpatient,1,GM,286.20000,83.00000,Aetna,First Health,,234.11,,,,,,,103.18,234.11,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00781309896,NDC,facility,outpatient,1,GM,286.20000,83.00000,Aetna,First Health,,234.11,,,,,,,0.36594,234.11,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00781309895,NDC,facility,inpatient,1,GM,286.20000,83.00000,Aetna,First Health,,234.11,,,,,,,103.18,234.11,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00781309895,NDC,facility,outpatient,1,GM,286.20000,83.00000,Aetna,First Health,,234.11,,,,,,,0.36594,234.11,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00781307195,NDC,,,facility,inpatient,1,EA,24.35000,7.06000,Aetna,First Health,,19.92,,,,,,,9.01,19.92,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00781307195,NDC,,,facility,outpatient,1,EA,24.35000,7.06000,Aetna,First Health,,19.92,,,,,,,8.78,19.92,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,00781306675,NDC,facility,inpatient,100,ME,4329.10000,1255.44000,Aetna,First Health,,3541.20,,,,,,,1560.64,3541.20,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,00781306675,NDC,facility,outpatient,100,ME,4329.10000,1255.44000,Aetna,First Health,,3541.20,,,,,,,1.72,3541.20,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00781305995,NDC,facility,inpatient,0.5,ME,39.75000,11.53000,Aetna,First Health,,32.52,,,,,,,14.33,32.52,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00781305995,NDC,facility,outpatient,0.5,ME,39.75000,11.53000,Aetna,First Health,,32.52,,,,,,,9.22,32.52,percent of total billed charges,
pyRIDostigmine 10mg/2mL I,800081421,CDM,250,RC,00781304095,NDC,,,facility,inpatient,1,EA,102.15000,29.62000,Aetna,First Health,,83.56,,,,,,,37.80,83.56,percent of total billed charges,
pyRIDostigmine 10mg/2mL I,800081421,CDM,250,RC,00781304095,NDC,,,facility,outpatient,1,EA,102.15000,29.62000,Aetna,First Health,,83.56,,,,,,,36.83,83.56,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00781303395,NDC,facility,inpatient,3,GM,122.95000,35.66000,Aetna,First Health,,100.57,,,,,,,44.32,100.57,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00781303395,NDC,facility,outpatient,3,GM,122.95000,35.66000,Aetna,First Health,,100.57,,,,,,,1.28,100.57,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00781303295,NDC,facility,inpatient,1.5,GM,65.15000,18.89000,Aetna,First Health,,53.29,,,,,,,23.49,53.29,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00781303295,NDC,facility,outpatient,1.5,GM,65.15000,18.89000,Aetna,First Health,,53.29,,,,,,,1.28,53.29,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00781301095,NDC,facility,inpatient,4,ME,127.95000,37.11000,Aetna,First Health,,104.66,,,,,,,46.13,104.66,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00781301095,NDC,facility,outpatient,4,ME,127.95000,37.11000,Aetna,First Health,,104.66,,,,,,,0.08667,104.66,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00781300995,NDC,facility,inpatient,200,ME,20.05000,5.81000,Aetna,First Health,,16.40,,,,,,,7.23,16.40,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00781300995,NDC,facility,outpatient,200,ME,20.05000,5.81000,Aetna,First Health,,16.40,,,,,,,0.93411,16.40,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00781300392,NDC,,,facility,inpatient,1,EA,443.70000,128.67000,Aetna,First Health,,362.95,,,,,,,164.17,362.95,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00781300392,NDC,,,facility,outpatient,1,EA,443.70000,128.67000,Aetna,First Health,,362.95,,,,,,,159.95,362.95,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00781300095,NDC,facility,inpatient,500,ME,145.70000,42.25000,Aetna,First Health,,119.18,,,,,,,52.52,119.18,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00781300095,NDC,facility,outpatient,500,ME,145.70000,42.25000,Aetna,First Health,,119.18,,,,,,,0.36594,119.18,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00781282201,NDC,,,facility,inpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,11.31,15.42,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00781282201,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,6.80,15.42,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,00781267202,NDC,facility,inpatient,667,ME,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,00781267202,NDC,facility,outpatient,667,ME,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,0.03852,4.58,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00781263113,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00781263113,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00781261460,NDC,,,facility,inpatient,1,EA,30.05000,8.71000,Aetna,First Health,,24.58,,,,,,,18.03,24.58,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00781261460,NDC,,,facility,outpatient,1,EA,30.05000,8.71000,Aetna,First Health,,24.58,,,,,,,10.83,24.58,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00781261305,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00781261305,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00781261301,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00781261301,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00781250201,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00781250201,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,00781217660,NDC,,,facility,inpatient,1,EA,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,21.72,29.61,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,00781217660,NDC,,,facility,outpatient,1,EA,36.20000,10.50000,Aetna,First Health,,29.61,,,,,,,13.05,29.61,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,00781216460,NDC,,,facility,inpatient,1,EA,62.75000,18.20000,Aetna,First Health,,51.33,,,,,,,37.65,51.33,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,00781216460,NDC,,,facility,outpatient,1,EA,62.75000,18.20000,Aetna,First Health,,51.33,,,,,,,22.62,51.33,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00781211201,NDC,,,facility,inpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,5.07,6.91,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00781211201,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,3.05,6.91,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,00781210301,NDC,facility,inpatient,1,ME,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,4.68,6.38,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,00781210301,NDC,facility,outpatient,1,ME,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,0.19260,6.38,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),800081868,CDM,637,RC,J7507,HCPCS,00781210201,NDC,facility,inpatient,0.5,ME,15.80000,4.58000,Aetna,First Health,,12.92,,,,,,,9.48,12.92,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),800081868,CDM,637,RC,J7507,HCPCS,00781210201,NDC,facility,outpatient,0.5,ME,15.80000,4.58000,Aetna,First Health,,12.92,,,,,,,0.19260,12.92,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,00781208102,NDC,facility,inpatient,667,ME,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,00781208102,NDC,facility,outpatient,667,ME,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,0.03852,4.58,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00781207601,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00781207601,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,00781205301,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,00781205301,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,00781205101,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,00781205101,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00781196610,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00781196610,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00781196260,NDC,,,facility,inpatient,1,EA,42.60000,12.35000,Aetna,First Health,,34.85,,,,,,,25.56,34.85,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00781196260,NDC,,,facility,outpatient,1,EA,42.60000,12.35000,Aetna,First Health,,34.85,,,,,,,15.36,34.85,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00781183120,NDC,,,facility,inpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,16.08,21.92,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00781183120,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,9.66,21.92,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00781181801,NDC,,,facility,inpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00781181801,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
Diclofenac Na 25mg EC T,800058437,CDM,637,RC,00781178501,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Diclofenac Na 25mg EC T,800058437,CDM,637,RC,00781178501,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00781175001,NDC,,,facility,inpatient,1,EA,56.20000,16.30000,Aetna,First Health,,45.97,,,,,,,33.72,45.97,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00781175001,NDC,,,facility,outpatient,1,EA,56.20000,16.30000,Aetna,First Health,,45.97,,,,,,,20.26,45.97,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00781171813,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,3.96,5.40,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00781171813,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00781171801,NDC,,,facility,inpatient,1,EA,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,8.64,11.78,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00781171801,NDC,,,facility,outpatient,1,EA,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,5.19,11.78,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,00781171613,NDC,facility,inpatient,25,ME,0.70000,0.20000,Aetna,First Health,,0.57260,,,,,,,0.42000,0.57260,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,00781171613,NDC,facility,outpatient,25,ME,0.70000,0.20000,Aetna,First Health,,0.57260,,,,,,,0.25235,6.63,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,00781171601,NDC,facility,inpatient,25,ME,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
chlorproMAZINE 25mg T(Thorazine),800019817,CDM,637,RC,Q0161,HCPCS,00781171601,NDC,facility,outpatient,25,ME,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,6.63,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,00781171513,NDC,facility,inpatient,10,ME,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,00781171513,NDC,facility,outpatient,10,ME,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,6.63,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,00781171501,NDC,facility,inpatient,10,ME,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
chlorproMAZINE 10mg T(Thorazine),800019815,CDM,637,RC,Q0161,HCPCS,00781171501,NDC,facility,outpatient,10,ME,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,6.63,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,00781165501,NDC,,,facility,inpatient,1,EA,8.25000,2.39000,Aetna,First Health,,6.75,,,,,,,4.95,6.75,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,00781165501,NDC,,,facility,outpatient,1,EA,8.25000,2.39000,Aetna,First Health,,6.75,,,,,,,2.97,6.75,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,00781162401,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,00781162401,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00781159910,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00781159910,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00781159901,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00781159901,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00781155601,NDC,,,facility,inpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,4.59,6.26,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00781155601,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00781150610,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00781150610,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00781150601,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00781150601,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00781149631,NDC,,,facility,inpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,33.06,45.07,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00781149631,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,19.86,45.07,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,00781149001,NDC,,,facility,inpatient,1,EA,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,00781149001,NDC,,,facility,outpatient,1,EA,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00781148710,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00781148710,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00781148701,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00781148701,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,00781148601,NDC,,,facility,inpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,00781148601,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.46865,1.06,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00781145601,NDC,,,facility,inpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00781145601,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.79310,1.80,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00781145210,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00781145210,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00781145201,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00781145201,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781140797,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781140797,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781140705,NDC,,,facility,inpatient,1,EA,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,4.38,5.97,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781140705,NDC,,,facility,outpatient,1,EA,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,2.63,5.97,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781140701,NDC,,,facility,inpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,4.65,6.34,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781140701,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,2.79,6.34,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00781139613,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00781139613,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00781139601,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00781139601,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00781139201,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00781139201,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,00781139101,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,00781139101,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00781135413,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00781135413,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00781126201,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00781126201,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00781122801,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00781122801,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00781122301,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00781122301,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00781118201,NDC,,,facility,inpatient,1,EA,28.40000,8.24000,Aetna,First Health,,23.23,,,,,,,17.04,23.23,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00781118201,NDC,,,facility,outpatient,1,EA,28.40000,8.24000,Aetna,First Health,,23.23,,,,,,,10.24,23.23,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,00781116301,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,00781116301,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00781114601,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00781114601,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,800015404,CDM,637,RC,00781113801,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,800015404,CDM,637,RC,00781113801,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00781112301,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00781112301,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00781107801,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00781107801,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00781107705,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,4.05,5.52,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00781107705,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00781107701,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00781107701,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00781106401,NDC,,,facility,inpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,4.08,5.56,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00781106401,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,2.45,5.56,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00781106101,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00781106101,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00781105301,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00781105301,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00781105001,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00781105001,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,00781104613,NDC,facility,inpatient,2,ME,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,8.34,11.37,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,00781104613,NDC,facility,outpatient,2,ME,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,2.30,11.37,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,00781104601,NDC,facility,inpatient,2,ME,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,7.41,10.10,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,00781104601,NDC,facility,outpatient,2,ME,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,2.30,10.10,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,00781101401,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,00781101401,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00777310533,NDC,,,facility,inpatient,1,EA,34.75000,10.08000,Aetna,First Health,,28.43,,,,,,,20.85,28.43,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00777310533,NDC,,,facility,outpatient,1,EA,34.75000,10.08000,Aetna,First Health,,28.43,,,,,,,12.53,28.43,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00777310502,NDC,,,facility,inpatient,1,EA,123.95000,35.95000,Aetna,First Health,,101.39,,,,,,,74.37,101.39,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00777310502,NDC,,,facility,outpatient,1,EA,123.95000,35.95000,Aetna,First Health,,101.39,,,,,,,44.68,101.39,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00777310402,NDC,,,facility,inpatient,1,EA,120.55000,34.96000,Aetna,First Health,,98.61,,,,,,,72.33,98.61,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00777310402,NDC,,,facility,outpatient,1,EA,120.55000,34.96000,Aetna,First Health,,98.61,,,,,,,43.46,98.61,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00766080155,NDC,,,facility,inpatient,1,EA,109.75000,31.83000,Aetna,First Health,,89.78,,,,,,,40.61,89.78,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00766080155,NDC,,,facility,outpatient,1,EA,109.75000,31.83000,Aetna,First Health,,89.78,,,,,,,39.56,89.78,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00766080135,NDC,,,facility,inpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.23,13.78,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00766080135,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.07,13.78,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00766080100,NDC,,,facility,inpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,34.58,76.44,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00766080100,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,33.69,76.44,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,00713093681,NDC,,,facility,inpatient,1,EA,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,16.80,22.90,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,00713093681,NDC,,,facility,outpatient,1,EA,28.00000,8.12000,Aetna,First Health,,22.90,,,,,,,10.09,22.90,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,00713068615,NDC,,,facility,inpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,74.34,101.35,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,00713068615,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,44.67,101.35,percent of total billed charges,
Gentamicin 0.1% TC,800046445,CDM,637,RC,00713068315,NDC,,,facility,inpatient,1,EA,339.90000,98.57000,Aetna,First Health,,278.04,,,,,,,203.94,278.04,percent of total billed charges,
Gentamicin 0.1% TC,800046445,CDM,637,RC,00713068315,NDC,,,facility,outpatient,1,EA,339.90000,98.57000,Aetna,First Health,,278.04,,,,,,,122.53,278.04,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,00713065540,NDC,,,facility,inpatient,1,EA,544.80000,157.99000,Aetna,First Health,,445.65,,,,,,,326.88,445.65,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,00713065540,NDC,,,facility,outpatient,1,EA,544.80000,157.99000,Aetna,First Health,,445.65,,,,,,,196.40,445.65,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00713053612,NDC,,,facility,inpatient,1,EA,125.35000,36.35000,Aetna,First Health,,102.54,,,,,,,75.21,102.54,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00713053612,NDC,,,facility,outpatient,1,EA,125.35000,36.35000,Aetna,First Health,,102.54,,,,,,,45.19,102.54,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00713050324,NDC,,,facility,inpatient,1,EA,152.30000,44.17000,Aetna,First Health,,124.58,,,,,,,91.38,124.58,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00713050324,NDC,,,facility,outpatient,1,EA,152.30000,44.17000,Aetna,First Health,,124.58,,,,,,,54.90,124.58,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00713050312,NDC,,,facility,inpatient,1,EA,160.35000,46.50000,Aetna,First Health,,131.17,,,,,,,96.21,131.17,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00713050312,NDC,,,facility,outpatient,1,EA,160.35000,46.50000,Aetna,First Health,,131.17,,,,,,,57.81,131.17,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00713035125,NDC,facility,inpatient,10,ME,29.55000,8.57000,Aetna,First Health,,24.17,,,,,,,10.65,24.17,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00713035125,NDC,facility,outpatient,10,ME,29.55000,8.57000,Aetna,First Health,,24.17,,,,,,,2.43,24.17,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,00713028304,NDC,,,facility,inpatient,1,EA,24.70000,7.16000,Aetna,First Health,,20.20,,,,,,,9.14,20.20,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,00713028304,NDC,,,facility,outpatient,1,EA,24.70000,7.16000,Aetna,First Health,,20.20,,,,,,,8.90,20.20,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00713028031,NDC,,,facility,inpatient,1,EA,24.20000,7.02000,Aetna,First Health,,19.80,,,,,,,8.95,19.80,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00713028031,NDC,,,facility,outpatient,1,EA,24.20000,7.02000,Aetna,First Health,,19.80,,,,,,,8.72,19.80,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00713026831,NDC,,,facility,inpatient,1,EA,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.25,20.45,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00713026831,NDC,,,facility,outpatient,1,EA,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00713025237,NDC,,,facility,inpatient,1,EA,60.90000,17.66000,Aetna,First Health,,49.82,,,,,,,36.54,49.82,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00713025237,NDC,,,facility,outpatient,1,EA,60.90000,17.66000,Aetna,First Health,,49.82,,,,,,,21.95,49.82,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,00713022880,NDC,,,facility,inpatient,1,EA,89.75000,26.03000,Aetna,First Health,,73.42,,,,,,,53.85,73.42,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,00713022880,NDC,,,facility,outpatient,1,EA,89.75000,26.03000,Aetna,First Health,,73.42,,,,,,,32.35,73.42,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,00713022515,NDC,,,facility,inpatient,1,EA,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,00713022515,NDC,,,facility,outpatient,1,EA,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,14.06,31.90,percent of total billed charges,
Prochlorperazine 25mg Supp(Compazine,800017137,CDM,637,RC,00713013512,NDC,,,facility,inpatient,1,EA,86.80000,25.17000,Aetna,First Health,,71.00,,,,,,,52.08,71.00,percent of total billed charges,
Prochlorperazine 25mg Supp(Compazine,800017137,CDM,637,RC,00713013512,NDC,,,facility,outpatient,1,EA,86.80000,25.17000,Aetna,First Health,,71.00,,,,,,,31.29,71.00,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,00703952601,NDC,facility,inpatient,160,ME,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,44.53,98.45,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,00703952601,NDC,facility,outpatient,160,ME,120.35000,34.90000,Aetna,First Health,,98.45,,,,,,,0.03852,98.45,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,00703951493,NDC,facility,inpatient,160,ME,120.40000,34.92000,Aetna,First Health,,98.49,,,,,,,44.55,98.49,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,00703951493,NDC,facility,outpatient,160,ME,120.40000,34.92000,Aetna,First Health,,98.49,,,,,,,0.03852,98.49,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,00703951403,NDC,facility,inpatient,160,ME,120.40000,34.92000,Aetna,First Health,,98.49,,,,,,,44.55,98.49,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,00703951403,NDC,facility,outpatient,160,ME,120.40000,34.92000,Aetna,First Health,,98.49,,,,,,,0.03852,98.49,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,00703950303,NDC,facility,inpatient,160,ME,89.20000,25.87000,Aetna,First Health,,72.97,,,,,,,33.00,72.97,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,00703950303,NDC,facility,outpatient,160,ME,89.20000,25.87000,Aetna,First Health,,72.97,,,,,,,0.03852,72.97,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00703940204,NDC,facility,inpatient,80,ME,19.00000,5.51000,Aetna,First Health,,15.54,,,,,,,6.85,15.54,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00703940204,NDC,facility,outpatient,80,ME,19.00000,5.51000,Aetna,First Health,,15.54,,,,,,,1.99,15.54,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00703910503,NDC,facility,inpatient,2,GM,216.40000,62.76000,Aetna,First Health,,177.02,,,,,,,78.01,177.02,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00703910503,NDC,facility,outpatient,2,GM,216.40000,62.76000,Aetna,First Health,,177.02,,,,,,,0.05778,177.02,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00703906033,NDC,facility,inpatient,600,ME,519.65000,150.70000,Aetna,First Health,,425.07,,,,,,,187.33,425.07,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00703906033,NDC,facility,outpatient,600,ME,519.65000,150.70000,Aetna,First Health,,425.07,,,,,,,2.64,425.07,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,00703877103,NDC,facility,inpatient,6,ME,86.20000,25.00000,Aetna,First Health,,70.51,,,,,,,31.08,70.51,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,00703877103,NDC,facility,outpatient,6,ME,86.20000,25.00000,Aetna,First Health,,70.51,,,,,,,0.51039,70.51,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00703868023,NDC,facility,inpatient,80,ME,101.50000,29.44000,Aetna,First Health,,83.03,,,,,,,36.59,83.03,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00703868023,NDC,facility,outpatient,80,ME,101.50000,29.44000,Aetna,First Health,,83.03,,,,,,,0.51039,83.03,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00703861023,NDC,facility,inpatient,120,ME,151.95000,44.07000,Aetna,First Health,,124.30,,,,,,,54.78,124.30,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00703861023,NDC,facility,outpatient,120,ME,151.95000,44.07000,Aetna,First Health,,124.30,,,,,,,0.51039,124.30,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00703858023,NDC,facility,inpatient,100,ME,126.90000,36.80000,Aetna,First Health,,103.80,,,,,,,45.75,103.80,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00703858023,NDC,facility,outpatient,100,ME,126.90000,36.80000,Aetna,First Health,,103.80,,,,,,,0.51039,103.80,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00703856023,NDC,facility,inpatient,60,ME,76.15000,22.08000,Aetna,First Health,,62.29,,,,,,,27.45,62.29,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00703856023,NDC,facility,outpatient,60,ME,76.15000,22.08000,Aetna,First Health,,62.29,,,,,,,0.51039,62.29,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00703854023,NDC,facility,inpatient,40,ME,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,18.28,41.47,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00703854023,NDC,facility,outpatient,40,ME,50.70000,14.70000,Aetna,First Health,,41.47,,,,,,,0.51039,41.47,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00703854021,NDC,facility,inpatient,40,ME,45.95000,13.33000,Aetna,First Health,,37.59,,,,,,,16.56,37.59,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00703854021,NDC,facility,outpatient,40,ME,45.95000,13.33000,Aetna,First Health,,37.59,,,,,,,0.51039,37.59,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00703851023,NDC,facility,inpatient,150,ME,186.40000,54.06000,Aetna,First Health,,152.48,,,,,,,67.20,152.48,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00703851023,NDC,facility,outpatient,150,ME,186.40000,54.06000,Aetna,First Health,,152.48,,,,,,,0.51039,152.48,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00703851021,NDC,facility,inpatient,150,ME,170.40000,49.42000,Aetna,First Health,,139.39,,,,,,,61.43,139.39,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00703851021,NDC,facility,outpatient,150,ME,170.40000,49.42000,Aetna,First Health,,139.39,,,,,,,0.51039,139.39,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00703841101,NDC,,,facility,inpatient,1,EA,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,8.27,18.28,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00703841101,NDC,,,facility,outpatient,1,EA,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,8.06,18.28,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00703722104,NDC,facility,inpatient,4,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00703722104,NDC,facility,outpatient,4,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,0.08667,10.43,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00703722102,NDC,facility,inpatient,4,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00703722102,NDC,facility,outpatient,4,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,0.08667,10.43,percent of total billed charges,
Haloperidol Decanoate 100mg/1mL Inj,800040916,CDM,636,RC,J1631,HCPCS,00703713103,NDC,facility,inpatient,100,ME,267.55000,77.59000,Aetna,First Health,,218.86,,,,,,,96.45,218.86,percent of total billed charges,
Haloperidol Decanoate 100mg/1mL Inj,800040916,CDM,636,RC,J1631,HCPCS,00703713103,NDC,facility,outpatient,100,ME,267.55000,77.59000,Aetna,First Health,,218.86,,,,,,,3.79,218.86,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00703710104,NDC,facility,inpatient,100,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00703710104,NDC,facility,outpatient,100,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,1.34,17.67,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,00703704103,NDC,facility,inpatient,5,ME,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,6.80,15.42,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,00703704103,NDC,facility,outpatient,5,ME,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,0.70299,15.42,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00703681121,NDC,facility,inpatient,150,ME,239.60000,69.48000,Aetna,First Health,,195.99,,,,,,,86.38,195.99,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00703681121,NDC,facility,outpatient,150,ME,239.60000,69.48000,Aetna,First Health,,195.99,,,,,,,0.40446,195.99,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00703680101,NDC,facility,inpatient,150,ME,274.30000,79.55000,Aetna,First Health,,224.38,,,,,,,98.89,224.38,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00703680101,NDC,facility,outpatient,150,ME,274.30000,79.55000,Aetna,First Health,,224.38,,,,,,,0.40446,224.38,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,00703627104,NDC,facility,inpatient,10,UN,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,00703627104,NDC,facility,outpatient,10,UN,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,1.00,6.26,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,00703565301,NDC,facility,inpatient,10,ME,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,2.63,5.97,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,00703565301,NDC,facility,outpatient,10,ME,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,1.00,5.97,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,00703514591,NDC,facility,inpatient,350,ME,166.95000,48.42000,Aetna,First Health,,136.57,,,,,,,60.19,136.57,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,00703514591,NDC,facility,outpatient,350,ME,166.95000,48.42000,Aetna,First Health,,136.57,,,,,,,3.70,136.57,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,00703514501,NDC,facility,inpatient,350,ME,189.50000,54.96000,Aetna,First Health,,155.01,,,,,,,68.31,155.01,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,00703514501,NDC,facility,outpatient,350,ME,189.50000,54.96000,Aetna,First Health,,155.01,,,,,,,3.70,155.01,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,00703507937,NDC,,,facility,inpatient,1,EA,179.95000,52.19000,Aetna,First Health,,147.20,,,,,,,66.58,147.20,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,00703507937,NDC,,,facility,outpatient,1,EA,179.95000,52.19000,Aetna,First Health,,147.20,,,,,,,64.87,147.20,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00703505401,NDC,facility,inpatient,0.004,ME,39.25000,11.38000,Aetna,First Health,,32.11,,,,,,,14.15,32.11,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00703505401,NDC,facility,outpatient,0.004,ME,39.25000,11.38000,Aetna,First Health,,32.11,,,,,,,3.28,32.11,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,00703505401,NDC,facility,inpatient,0.04,ME,4472.45000,1297.01000,Aetna,First Health,,3658.46,,,,,,,1612.32,3658.46,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,00703505401,NDC,facility,outpatient,0.04,ME,4472.45000,1297.01000,Aetna,First Health,,3658.46,,,,,,,3.28,3658.46,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00703505103,NDC,facility,inpatient,0.004,ME,349.55000,101.37000,Aetna,First Health,,285.93,,,,,,,126.01,285.93,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00703505103,NDC,facility,outpatient,0.004,ME,349.55000,101.37000,Aetna,First Health,,285.93,,,,,,,3.28,285.93,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00703504601,NDC,facility,inpatient,50,ME,348.20000,100.98000,Aetna,First Health,,284.83,,,,,,,125.53,284.83,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00703504601,NDC,facility,outpatient,50,ME,348.20000,100.98000,Aetna,First Health,,284.83,,,,,,,2.68,284.83,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,00703476601,NDC,facility,inpatient,6,ME,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,7.28,16.52,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,00703476601,NDC,facility,outpatient,6,ME,20.20000,5.86000,Aetna,First Health,,16.52,,,,,,,0.09630,16.52,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,00703476401,NDC,facility,inpatient,6,ME,18.30000,5.31000,Aetna,First Health,,14.97,,,,,,,6.60,14.97,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,00703476401,NDC,facility,outpatient,6,ME,18.30000,5.31000,Aetna,First Health,,14.97,,,,,,,0.09630,14.97,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00703450294,NDC,facility,inpatient,10,ME,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00703450294,NDC,facility,outpatient,10,ME,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,1.04,4.70,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00703450204,NDC,facility,inpatient,10,ME,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,7.71,17.51,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00703450204,NDC,facility,outpatient,10,ME,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,1.04,17.51,percent of total billed charges,
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,00703440211,NDC,facility,inpatient,2,ME,229.70000,66.61000,Aetna,First Health,,187.89,,,,,,,82.81,187.89,percent of total billed charges,
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,00703440211,NDC,facility,outpatient,2,ME,229.70000,66.61000,Aetna,First Health,,187.89,,,,,,,7.85,187.89,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,00703424891,NDC,facility,inpatient,50,ME,56.35000,16.34000,Aetna,First Health,,46.09,,,,,,,20.31,46.09,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,00703424891,NDC,facility,outpatient,50,ME,56.35000,16.34000,Aetna,First Health,,46.09,,,,,,,2.82,46.09,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,inpatient,50,ME,54.60000,15.83000,Aetna,First Health,,44.66,,,,,,,19.68,44.66,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,outpatient,50,ME,54.60000,15.83000,Aetna,First Health,,44.66,,,,,,,2.82,44.66,percent of total billed charges,
Methotrexate 1g/40mL I PF,800022022,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,1000,ME,312.25000,90.55000,Aetna,First Health,,255.42,,,,,,,112.57,255.42,percent of total billed charges,
Methotrexate 1g/40mL I PF,800022022,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,outpatient,1000,ME,312.25000,90.55000,Aetna,First Health,,255.42,,,,,,,2.48,255.42,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,00703367103,NDC,facility,inpatient,50,ME,80.75000,23.42000,Aetna,First Health,,66.05,,,,,,,29.11,66.05,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,00703367103,NDC,facility,outpatient,50,ME,80.75000,23.42000,Aetna,First Health,,66.05,,,,,,,2.48,66.05,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,00703332104,NDC,facility,inpatient,0.5,ME,216.45000,62.77000,Aetna,First Health,,177.06,,,,,,,129.87,177.06,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,00703332104,NDC,facility,outpatient,0.5,ME,216.45000,62.77000,Aetna,First Health,,177.06,,,,,,,0.63558,177.06,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,00703331104,NDC,facility,inpatient,0.1,ME,41.50000,12.03000,Aetna,First Health,,33.95,,,,,,,24.90,33.95,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,00703331104,NDC,facility,outpatient,0.1,ME,41.50000,12.03000,Aetna,First Health,,33.95,,,,,,,0.63558,33.95,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,00703330104,NDC,facility,inpatient,0.05,ME,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,17.25,23.52,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,00703330104,NDC,facility,outpatient,0.05,ME,28.75000,8.34000,Aetna,First Health,,23.52,,,,,,,0.63558,23.52,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,00703324811,NDC,facility,inpatient,50,ME,128.20000,37.18000,Aetna,First Health,,104.87,,,,,,,46.22,104.87,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,00703324811,NDC,facility,outpatient,50,ME,128.20000,37.18000,Aetna,First Health,,104.87,,,,,,,2.82,104.87,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,00703321301,NDC,facility,inpatient,6,ME,15.60000,4.52000,Aetna,First Health,,12.76,,,,,,,5.62,12.76,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,00703321301,NDC,facility,outpatient,6,ME,15.60000,4.52000,Aetna,First Health,,12.76,,,,,,,0.09630,12.76,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,00703301513,NDC,facility,inpatient,500,ME,53.30000,15.46000,Aetna,First Health,,43.60,,,,,,,19.21,43.60,percent of total billed charges,
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,00703301513,NDC,facility,outpatient,500,ME,53.30000,15.46000,Aetna,First Health,,43.60,,,,,,,1.87,43.60,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00703291403,NDC,,,facility,inpatient,1,EA,40.20000,11.66000,Aetna,First Health,,32.88,,,,,,,14.87,32.88,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00703291403,NDC,,,facility,outpatient,1,EA,40.20000,11.66000,Aetna,First Health,,32.88,,,,,,,14.49,32.88,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00703285903,NDC,facility,inpatient,1,GM,112.20000,32.54000,Aetna,First Health,,91.78,,,,,,,40.45,91.78,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00703285903,NDC,facility,outpatient,1,GM,112.20000,32.54000,Aetna,First Health,,91.78,,,,,,,0.08667,91.78,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00703285809,NDC,facility,inpatient,0.5,GM,135.30000,39.24000,Aetna,First Health,,110.68,,,,,,,48.78,110.68,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00703285809,NDC,facility,outpatient,0.5,GM,135.30000,39.24000,Aetna,First Health,,110.68,,,,,,,0.08667,110.68,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00703285604,NDC,facility,inpatient,200,ME,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,13.45,30.51,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00703285604,NDC,facility,outpatient,200,ME,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,0.08667,30.51,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00703208503,NDC,,,facility,inpatient,1,EA,346.10000,100.37000,Aetna,First Health,,283.11,,,,,,,128.06,283.11,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00703208503,NDC,,,facility,outpatient,1,EA,346.10000,100.37000,Aetna,First Health,,283.11,,,,,,,124.77,283.11,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00703204503,NDC,,,facility,inpatient,1,EA,2299.90000,666.97000,Aetna,First Health,,1881.32,,,,,,,850.96,1881.32,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00703204503,NDC,,,facility,outpatient,1,EA,2299.90000,666.97000,Aetna,First Health,,1881.32,,,,,,,829.11,1881.32,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00703203303,NDC,,,facility,inpatient,1,EA,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,52.84,116.81,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00703203303,NDC,,,facility,outpatient,1,EA,142.80000,41.41000,Aetna,First Health,,116.81,,,,,,,51.48,116.81,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00703133203,NDC,facility,inpatient,150,ME,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,8.31,18.85,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00703133203,NDC,facility,outpatient,150,ME,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,0.39483,18.85,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00703127104,NDC,facility,inpatient,1,ME,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00703127104,NDC,facility,outpatient,1,ME,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,2.38,15.66,percent of total billed charges,
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00703117901,NDC,facility,inpatient,75,ME,3856.45000,1118.37000,Aetna,First Health,,3154.58,,,,,,,1390.25,3154.58,percent of total billed charges,
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00703117901,NDC,facility,outpatient,75,ME,3856.45000,1118.37000,Aetna,First Health,,3154.58,,,,,,,3.52,3154.58,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,00703116501,NDC,facility,inpatient,20,ME,761.55000,220.85000,Aetna,First Health,,622.95,,,,,,,274.54,622.95,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,00703116501,NDC,facility,outpatient,20,ME,761.55000,220.85000,Aetna,First Health,,622.95,,,,,,,3.52,622.95,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00703115303,NDC,,,facility,inpatient,1,EA,115.05000,33.36000,Aetna,First Health,,94.11,,,,,,,42.57,94.11,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00703115303,NDC,,,facility,outpatient,1,EA,115.05000,33.36000,Aetna,First Health,,94.11,,,,,,,41.48,94.11,percent of total billed charges,
Norepinephrine 8mg/8mL Inj - IV Set Use,800025520,CDM,250,RC,00703115303,NDC,,,facility,inpatient,1,EA,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,133.57,295.30,percent of total billed charges,
Norepinephrine 8mg/8mL Inj - IV Set Use,800025520,CDM,250,RC,00703115303,NDC,,,facility,outpatient,1,EA,361.00000,104.69000,Aetna,First Health,,295.30,,,,,,,130.14,295.30,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00703102930,NDC,facility,inpatient,200,ME,178.50000,51.76000,Aetna,First Health,,146.01,,,,,,,64.35,146.01,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00703102930,NDC,facility,outpatient,200,ME,178.50000,51.76000,Aetna,First Health,,146.01,,,,,,,4.31,146.01,percent of total billed charges,
levOCARNitine 200mg/1mL I 5mL Vial,800017796,CDM,636,RC,J1955,HCPCS,00703040402,NDC,facility,inpatient,1000,ME,67.65000,19.62000,Aetna,First Health,,55.34,,,,,,,24.39,55.34,percent of total billed charges,
levOCARNitine 200mg/1mL I 5mL Vial,800017796,CDM,636,RC,J1955,HCPCS,00703040402,NDC,facility,outpatient,1000,ME,67.65000,19.62000,Aetna,First Health,,55.34,,,,,,,22.41,71.76,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00703033504,NDC,facility,inpatient,1,GM,52.50000,15.22000,Aetna,First Health,,42.95,,,,,,,18.93,42.95,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00703033504,NDC,facility,outpatient,1,GM,52.50000,15.22000,Aetna,First Health,,42.95,,,,,,,0.44298,42.95,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00703024101,NDC,facility,inpatient,40,ME,51.65000,14.98000,Aetna,First Health,,42.25,,,,,,,18.62,42.25,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00703024101,NDC,facility,outpatient,40,ME,51.65000,14.98000,Aetna,First Health,,42.25,,,,,,,0.71262,42.25,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,00703012501,NDC,facility,inpatient,500,ME,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,326.61,741.11,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,00703012501,NDC,facility,outpatient,500,ME,906.00000,262.74000,Aetna,First Health,,741.11,,,,,,,0.02889,741.11,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00703006301,NDC,facility,inpatient,80,ME,91.30000,26.48000,Aetna,First Health,,74.68,,,,,,,32.91,74.68,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00703006301,NDC,facility,outpatient,80,ME,91.30000,26.48000,Aetna,First Health,,74.68,,,,,,,0.11556,74.68,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00703005104,NDC,facility,inpatient,80,ME,91.30000,26.48000,Aetna,First Health,,74.68,,,,,,,32.91,74.68,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00703005104,NDC,facility,outpatient,80,ME,91.30000,26.48000,Aetna,First Health,,74.68,,,,,,,0.11556,74.68,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00703005101,NDC,facility,inpatient,80,ME,91.30000,26.48000,Aetna,First Health,,74.68,,,,,,,32.91,74.68,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00703005101,NDC,facility,outpatient,80,ME,91.30000,26.48000,Aetna,First Health,,74.68,,,,,,,0.11556,74.68,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00703003104,NDC,facility,inpatient,40,ME,55.55000,16.11000,Aetna,First Health,,45.44,,,,,,,20.03,45.44,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00703003104,NDC,facility,outpatient,40,ME,55.55000,16.11000,Aetna,First Health,,45.44,,,,,,,0.11556,45.44,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00703003101,NDC,facility,inpatient,40,ME,55.55000,16.11000,Aetna,First Health,,45.44,,,,,,,20.03,45.44,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00703003101,NDC,facility,outpatient,40,ME,55.55000,16.11000,Aetna,First Health,,45.44,,,,,,,0.11556,45.44,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00689112001,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00689112001,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00677181501,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00677181501,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00677176901,NDC,,,facility,inpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,5.49,7.48,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00677176901,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.30,7.48,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00677176801,NDC,,,facility,inpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,5.49,7.48,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00677176801,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.30,7.48,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00677170906,NDC,,,facility,inpatient,1,EA,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,9.96,13.58,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00677170906,NDC,,,facility,outpatient,1,EA,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,5.98,13.58,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00677170201,NDC,,,facility,inpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,3.03,4.13,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00677170201,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,1.82,4.13,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,00677165303,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,00677165303,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00677148301,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00677148301,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00677148210,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00677148210,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00677147201,NDC,,,facility,inpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,4.08,5.56,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00677147201,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,2.45,5.56,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00677132301,NDC,,,facility,inpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,1.41,1.92,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00677132301,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00677124701,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00677124701,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,00677120036,NDC,,,facility,inpatient,1,EA,101.25000,29.36000,Aetna,First Health,,82.82,,,,,,,60.75,82.82,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,00677120036,NDC,,,facility,outpatient,1,EA,101.25000,29.36000,Aetna,First Health,,82.82,,,,,,,36.50,82.82,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,00677082401,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,00677082401,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00677081601,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00677081601,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00677062506,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00677062506,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00677062501,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00677062501,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00677058901,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00677058901,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00677056202,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00677056202,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,00641921710,NDC,,,facility,inpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,5.14,11.37,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,00641921710,NDC,,,facility,outpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,5.01,11.37,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00641628225,NDC,facility,inpatient,50,ME,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00641628225,NDC,facility,outpatient,50,ME,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,0.68373,2.90,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,00641626510,NDC,facility,inpatient,10,ME,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,00641626510,NDC,facility,outpatient,10,ME,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,0.92448,11.49,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 1mL I,800051051,CDM,636,RC,J3010,HCPCS,00641624725,NDC,facility,inpatient,0.05,ME,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,6.74,15.30,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 1mL I,800051051,CDM,636,RC,J3010,HCPCS,00641624725,NDC,facility,outpatient,0.05,ME,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,1.15,15.30,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00641624410,NDC,facility,inpatient,10,ME,234.50000,68.00000,Aetna,First Health,,191.82,,,,,,,84.54,191.82,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00641624410,NDC,facility,outpatient,10,ME,234.50000,68.00000,Aetna,First Health,,191.82,,,,,,,6.44,191.82,percent of total billed charges,
ePHEDrine sulfate 25mg/5mL IS,800051986,CDM,250,RC,00641623610,NDC,,,facility,inpatient,1,EA,78.85000,22.87000,Aetna,First Health,,64.50,,,,,,,29.17,64.50,percent of total billed charges,
ePHEDrine sulfate 25mg/5mL IS,800051986,CDM,250,RC,00641623610,NDC,,,facility,outpatient,1,EA,78.85000,22.87000,Aetna,First Health,,64.50,,,,,,,28.43,64.50,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,00641623125,NDC,facility,inpatient,20,ME,89.40000,25.93000,Aetna,First Health,,73.13,,,,,,,32.23,73.13,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,00641623125,NDC,facility,outpatient,20,ME,89.40000,25.93000,Aetna,First Health,,73.13,,,,,,,4.23,73.13,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,inpatient,200,ME,63.50000,18.42000,Aetna,First Health,,51.94,,,,,,,22.89,51.94,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,outpatient,200,ME,63.50000,18.42000,Aetna,First Health,,51.94,,,,,,,1.74,51.94,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641621725,NDC,facility,inpatient,1,GM,76.80000,22.27000,Aetna,First Health,,62.82,,,,,,,27.69,62.82,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641621725,NDC,facility,outpatient,1,GM,76.80000,22.27000,Aetna,First Health,,62.82,,,,,,,4.37,62.82,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641621710,NDC,facility,inpatient,1,GM,76.80000,22.27000,Aetna,First Health,,62.82,,,,,,,27.69,62.82,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641621710,NDC,facility,outpatient,1,GM,76.80000,22.27000,Aetna,First Health,,62.82,,,,,,,4.37,62.82,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,00641620510,NDC,facility,inpatient,2,ME,196.20000,56.90000,Aetna,First Health,,160.49,,,,,,,70.73,160.49,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,00641620510,NDC,facility,outpatient,2,ME,196.20000,56.90000,Aetna,First Health,,160.49,,,,,,,0.06741,160.49,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00641619610,NDC,facility,inpatient,1,GM,303.00000,87.87000,Aetna,First Health,,247.85,,,,,,,109.23,247.85,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00641619610,NDC,facility,outpatient,1,GM,303.00000,87.87000,Aetna,First Health,,247.85,,,,,,,0.08667,247.85,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00641619410,NDC,facility,inpatient,200,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00641619410,NDC,facility,outpatient,200,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,0.08667,31.33,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00641619110,NDC,facility,inpatient,2,ME,24.75000,7.18000,Aetna,First Health,,20.25,,,,,,,8.92,20.25,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00641619110,NDC,facility,outpatient,2,ME,24.75000,7.18000,Aetna,First Health,,20.25,,,,,,,2.93,20.25,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00641618810,NDC,facility,inpatient,50,ME,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,73.54,166.87,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00641618810,NDC,facility,outpatient,50,ME,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,75.48,166.87,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641618425,NDC,facility,inpatient,0.5,ME,35.10000,10.18000,Aetna,First Health,,28.71,,,,,,,12.65,28.71,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641618425,NDC,facility,outpatient,0.5,ME,35.10000,10.18000,Aetna,First Health,,28.71,,,,,,,9.22,29.51,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00641618225,NDC,facility,inpatient,60,ME,99.60000,28.88000,Aetna,First Health,,81.47,,,,,,,35.91,81.47,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00641618225,NDC,facility,outpatient,60,ME,99.60000,28.88000,Aetna,First Health,,81.47,,,,,,,6.15,81.47,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00641618210,NDC,facility,inpatient,60,ME,99.60000,28.88000,Aetna,First Health,,81.47,,,,,,,35.91,81.47,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00641618210,NDC,facility,outpatient,60,ME,99.60000,28.88000,Aetna,First Health,,81.47,,,,,,,6.15,81.47,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,00641617610,NDC,facility,inpatient,0.5,ME,216.45000,62.77000,Aetna,First Health,,177.06,,,,,,,129.87,177.06,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,00641617610,NDC,facility,outpatient,0.5,ME,216.45000,62.77000,Aetna,First Health,,177.06,,,,,,,0.63558,177.06,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,00641617410,NDC,facility,inpatient,0.05,ME,29.25000,8.48000,Aetna,First Health,,23.93,,,,,,,17.55,23.93,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,00641617410,NDC,facility,outpatient,0.05,ME,29.25000,8.48000,Aetna,First Health,,23.93,,,,,,,0.63558,23.93,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00641616210,NDC,facility,inpatient,1,ME,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,2.27,5.15,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00641616210,NDC,facility,outpatient,1,ME,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,0.34668,5.15,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00641616201,NDC,facility,inpatient,0.25,ME,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00641616201,NDC,facility,outpatient,0.25,ME,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.34668,1.92,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00641616110,NDC,facility,inpatient,1,ME,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,5.23,11.86,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00641616110,NDC,facility,outpatient,1,ME,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,0.34668,11.86,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00641615125,NDC,facility,inpatient,2,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,10.38,23.56,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00641615125,NDC,facility,outpatient,2,ME,28.80000,8.35000,Aetna,First Health,,23.56,,,,,,,0.13482,23.56,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,00641614910,NDC,facility,inpatient,10,ME,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,20.71,46.99,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,00641614910,NDC,facility,outpatient,10,ME,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,0.92448,46.99,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,00641614710,NDC,facility,inpatient,1,EA,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,9.35,16.28,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,00641614710,NDC,facility,outpatient,1,EA,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,0.63000,16.28,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,00641614625,NDC,facility,inpatient,4,ME,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,00641614625,NDC,facility,outpatient,4,ME,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.00963,1.51,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,00641614525,NDC,facility,inpatient,4,ME,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,2.27,5.15,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,00641614525,NDC,facility,outpatient,4,ME,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,0.10593,5.15,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,00641614525,NDC,facility,inpatient,4,ME,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,5.01,6.83,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,00641614525,NDC,facility,outpatient,4,ME,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,0.00963,6.83,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00641613710,NDC,facility,inpatient,500,ME,437.00000,126.73000,Aetna,First Health,,357.47,,,,,,,157.54,357.47,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00641613710,NDC,facility,outpatient,500,ME,437.00000,126.73000,Aetna,First Health,,357.47,,,,,,,1.34,357.47,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00641613625,NDC,facility,inpatient,100,ME,94.50000,27.40000,Aetna,First Health,,77.30,,,,,,,34.07,77.30,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00641613625,NDC,facility,outpatient,100,ME,94.50000,27.40000,Aetna,First Health,,77.30,,,,,,,1.34,77.30,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00641613525,NDC,facility,inpatient,10,ME,46.30000,13.43000,Aetna,First Health,,37.87,,,,,,,16.69,37.87,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00641613525,NDC,facility,outpatient,10,ME,46.30000,13.43000,Aetna,First Health,,37.87,,,,,,,2.43,37.87,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00641613225,NDC,facility,inpatient,0.4,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00641613225,NDC,facility,outpatient,0.4,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,0.06741,31.33,percent of total billed charges,
Morphine 10mg/1mL PF Inj,800059971,CDM,636,RC,J2274,HCPCS,00641612725,NDC,facility,inpatient,10,ME,24.45000,7.09000,Aetna,First Health,,20.00,,,,,,,8.81,20.00,percent of total billed charges,
Morphine 10mg/1mL PF Inj,800059971,CDM,636,RC,J2274,HCPCS,00641612725,NDC,facility,outpatient,10,ME,24.45000,7.09000,Aetna,First Health,,20.00,,,,,,,9.05,41.63,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00641612525,NDC,facility,inpatient,4,ME,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.63,19.59,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00641612525,NDC,facility,outpatient,4,ME,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,2.93,19.59,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00641611710,NDC,facility,inpatient,3,GM,73.15000,21.21000,Aetna,First Health,,59.84,,,,,,,26.37,59.84,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00641611710,NDC,facility,outpatient,3,GM,73.15000,21.21000,Aetna,First Health,,59.84,,,,,,,1.28,59.84,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00641611610,NDC,facility,inpatient,1.5,GM,40.30000,11.69000,Aetna,First Health,,32.97,,,,,,,14.53,32.97,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00641611610,NDC,facility,outpatient,1.5,GM,40.30000,11.69000,Aetna,First Health,,32.97,,,,,,,1.28,32.97,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641610325,NDC,facility,inpatient,1,GM,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,95.53,216.77,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641610325,NDC,facility,outpatient,1,GM,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,4.37,216.77,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641610310,NDC,facility,inpatient,1,GM,110.40000,32.02000,Aetna,First Health,,90.31,,,,,,,39.80,90.31,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641610310,NDC,facility,outpatient,1,GM,110.40000,32.02000,Aetna,First Health,,90.31,,,,,,,4.37,90.31,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00641608025,NDC,facility,inpatient,4,ME,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,2.18,4.95,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00641608025,NDC,facility,outpatient,4,ME,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,0.08667,4.95,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,inpatient,4,ME,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,outpatient,4,ME,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,0.08667,6.18,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00641607825,NDC,facility,inpatient,4,ME,6.20000,1.80000,Aetna,First Health,,5.07,,,,,,,2.24,5.07,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00641607825,NDC,facility,outpatient,4,ME,6.20000,1.80000,Aetna,First Health,,5.07,,,,,,,0.08667,5.07,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00641605225,NDC,facility,inpatient,25,ME,24.35000,7.06000,Aetna,First Health,,19.92,,,,,,,8.78,19.92,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00641605225,NDC,facility,outpatient,25,ME,24.35000,7.06000,Aetna,First Health,,19.92,,,,,,,7.85,25.13,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00641604825,NDC,facility,inpatient,2,ME,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,4.47,10.14,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00641604825,NDC,facility,outpatient,2,ME,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,1.36,10.14,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00641604425,NDC,facility,inpatient,2,ME,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,4.92,11.17,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00641604425,NDC,facility,outpatient,2,ME,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,1.36,11.17,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00641604225,NDC,facility,inpatient,30,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00641604225,NDC,facility,outpatient,30,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,0.31779,8.26,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00641603325,NDC,facility,inpatient,0.2,ME,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.66,8.30,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00641603325,NDC,facility,outpatient,0.2,ME,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,0.36594,8.30,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,inpatient,0.1,ME,20.95000,6.08000,Aetna,First Health,,17.14,,,,,,,7.55,17.14,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,outpatient,0.1,ME,20.95000,6.08000,Aetna,First Health,,17.14,,,,,,,1.15,17.14,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00641602410,NDC,facility,inpatient,0.1,ME,15.35000,4.45000,Aetna,First Health,,12.56,,,,,,,5.53,12.56,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00641602410,NDC,facility,outpatient,0.1,ME,15.35000,4.45000,Aetna,First Health,,12.56,,,,,,,1.15,12.56,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,00641602225,NDC,facility,inpatient,20,ME,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,2.20,4.99,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,00641602225,NDC,facility,outpatient,20,ME,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,0.00963,4.99,percent of total billed charges,
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,00641602010,NDC,facility,inpatient,5,ME,273.65000,79.36000,Aetna,First Health,,223.85,,,,,,,98.65,223.85,percent of total billed charges,
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,00641602010,NDC,facility,outpatient,5,ME,273.65000,79.36000,Aetna,First Health,,223.85,,,,,,,13.00,223.85,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00641601910,NDC,facility,inpatient,10,ME,273.65000,79.36000,Aetna,First Health,,223.85,,,,,,,98.65,223.85,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00641601910,NDC,facility,outpatient,10,ME,273.65000,79.36000,Aetna,First Health,,223.85,,,,,,,13.00,223.85,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,00641601310,NDC,,,facility,inpatient,1,EA,21.85000,6.34000,Aetna,First Health,,17.87,,,,,,,8.08,17.87,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,00641601310,NDC,,,facility,outpatient,1,EA,21.85000,6.34000,Aetna,First Health,,17.87,,,,,,,7.88,17.87,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00641600810,NDC,facility,inpatient,1,ME,19.30000,5.60000,Aetna,First Health,,15.79,,,,,,,6.96,15.79,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00641600810,NDC,facility,outpatient,1,ME,19.30000,5.60000,Aetna,First Health,,15.79,,,,,,,0.34668,15.79,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00641600710,NDC,facility,inpatient,0.25,ME,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00641600710,NDC,facility,outpatient,0.25,ME,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,0.34668,2.58,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00641600125,NDC,facility,inpatient,2,ME,18.25000,5.29000,Aetna,First Health,,14.93,,,,,,,6.58,14.93,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00641600125,NDC,facility,outpatient,2,ME,18.25000,5.29000,Aetna,First Health,,14.93,,,,,,,1.36,14.93,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,00641296545,NDC,facility,inpatient,100,ME,67.05000,19.44000,Aetna,First Health,,54.85,,,,,,,24.17,54.85,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,00641296545,NDC,facility,outpatient,100,ME,67.05000,19.44000,Aetna,First Health,,54.85,,,,,,,0.20223,54.85,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,00641296541,NDC,facility,inpatient,100,ME,117.40000,34.05000,Aetna,First Health,,96.03,,,,,,,42.32,96.03,percent of total billed charges,
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,00641296541,NDC,facility,outpatient,100,ME,117.40000,34.05000,Aetna,First Health,,96.03,,,,,,,0.20223,96.03,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,00641276543,NDC,facility,inpatient,160,ME,55.20000,16.01000,Aetna,First Health,,45.15,,,,,,,20.42,45.15,percent of total billed charges,
Sulfamethoxazole-Trimethoprim 80-16mg/mL Inj,800040153,CDM,250,RC,J2865,HCPCS,00641276543,NDC,facility,outpatient,160,ME,55.20000,16.01000,Aetna,First Health,,45.15,,,,,,,0.03852,45.15,percent of total billed charges,
Protamine Sulfate 250mg/25mL Inj,800013349,CDM,636,RC,J2720,HCPCS,00641255441,NDC,facility,inpatient,250,ME,2060.50000,597.54000,Aetna,First Health,,1685.49,,,,,,,742.81,1685.49,percent of total billed charges,
Protamine Sulfate 250mg/25mL Inj,800013349,CDM,636,RC,J2720,HCPCS,00641255441,NDC,facility,outpatient,250,ME,2060.50000,597.54000,Aetna,First Health,,1685.49,,,,,,,1.51,1685.49,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00641245045,NDC,facility,inpatient,30000,UN,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00641245045,NDC,facility,outpatient,30000,UN,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,0.17334,15.66,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,00641244345,NDC,facility,inpatient,500,UN,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.63087,1.43,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,00641244345,NDC,facility,outpatient,500,UN,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.01926,1.43,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,00641244045,NDC,facility,inpatient,10000,UN,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,1.91,4.34,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,00641244045,NDC,facility,outpatient,10000,UN,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,0.17334,4.34,percent of total billed charges,
"Heparin I(10,000/10mL)",800013343,CDM,636,RC,J1644,HCPCS,00641244045,NDC,facility,inpatient,10000,UN,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,1.91,4.34,percent of total billed charges,
"Heparin I(10,000/10mL)",800013343,CDM,636,RC,J1644,HCPCS,00641244045,NDC,facility,outpatient,10000,UN,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,0.17334,4.34,percent of total billed charges,
Gentamicin Sulf Mdv I,800015120,CDM,636,RC,J1580,HCPCS,00641233143,NDC,facility,inpatient,800,ME,127.60000,37.00000,Aetna,First Health,,104.38,,,,,,,46.00,104.38,percent of total billed charges,
Gentamicin Sulf Mdv I,800015120,CDM,636,RC,J1580,HCPCS,00641233143,NDC,facility,outpatient,800,ME,127.60000,37.00000,Aetna,First Health,,104.38,,,,,,,2.09,104.38,percent of total billed charges,
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,00641149435,NDC,facility,inpatient,50,ME,32.40000,9.40000,Aetna,First Health,,26.50,,,,,,,11.68,26.50,percent of total billed charges,
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,00641149435,NDC,facility,outpatient,50,ME,32.40000,9.40000,Aetna,First Health,,26.50,,,,,,,1.51,26.50,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,00641143835,NDC,,,facility,inpatient,1,EA,631.75000,183.21000,Aetna,First Health,,516.77,,,,,,,233.75,516.77,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,00641143835,NDC,,,facility,outpatient,1,EA,631.75000,183.21000,Aetna,First Health,,516.77,,,,,,,227.75,516.77,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641141036,NDC,facility,inpatient,0.5,ME,23.20000,6.73000,Aetna,First Health,,18.98,,,,,,,8.36,18.98,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641141036,NDC,facility,outpatient,0.5,ME,23.20000,6.73000,Aetna,First Health,,18.98,,,,,,,8.58,29.51,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,inpatient,0.5,ME,35.10000,10.18000,Aetna,First Health,,28.71,,,,,,,12.65,28.71,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,outpatient,0.5,ME,35.10000,10.18000,Aetna,First Health,,28.71,,,,,,,9.22,29.51,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641141031,NDC,facility,inpatient,0.5,ME,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641141031,NDC,facility,outpatient,0.5,ME,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.40,29.51,percent of total billed charges,
chlorproMAZINE 25mg/mL 2mL I(Thoraz,800013680,CDM,636,RC,J3230,HCPCS,00641139835,NDC,facility,inpatient,50,ME,205.45000,59.58000,Aetna,First Health,,168.06,,,,,,,74.06,168.06,percent of total billed charges,
chlorproMAZINE 25mg/mL 2mL I(Thoraz,800013680,CDM,636,RC,J3230,HCPCS,00641139835,NDC,facility,outpatient,50,ME,205.45000,59.58000,Aetna,First Health,,168.06,,,,,,,22.89,168.06,percent of total billed charges,
chlorproMAZINE 25mg/mL 2mL I(Thoraz,800013680,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,inpatient,50,ME,300.80000,87.23000,Aetna,First Health,,246.05,,,,,,,108.44,246.05,percent of total billed charges,
chlorproMAZINE 25mg/mL 2mL I(Thoraz,800013680,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,outpatient,50,ME,300.80000,87.23000,Aetna,First Health,,246.05,,,,,,,22.89,246.05,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00641111633,NDC,facility,inpatient,0.1,ME,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00641111633,NDC,facility,outpatient,0.1,ME,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,1.15,13.50,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00641111433,NDC,facility,inpatient,10,ME,73.85000,21.42000,Aetna,First Health,,60.41,,,,,,,26.62,60.41,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00641111433,NDC,facility,outpatient,10,ME,73.85000,21.42000,Aetna,First Health,,60.41,,,,,,,13.00,60.41,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,00641061025,NDC,facility,inpatient,200,ME,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,3.84,8.71,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,00641061025,NDC,facility,outpatient,200,ME,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,1.74,8.71,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00641049125,NDC,facility,inpatient,10,ME,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,6.00,13.62,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00641049125,NDC,facility,outpatient,10,ME,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,2.43,13.62,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00641049121,NDC,facility,inpatient,10,ME,48.85000,14.17000,Aetna,First Health,,39.96,,,,,,,17.61,39.96,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00641049121,NDC,facility,outpatient,10,ME,48.85000,14.17000,Aetna,First Health,,39.96,,,,,,,2.43,39.96,percent of total billed charges,
PHENobarbital 130mg/1mL  Inj,800051979,CDM,636,RC,J2560,HCPCS,00641047725,NDC,facility,inpatient,130,ME,513.70000,148.97000,Aetna,First Health,,420.21,,,,,,,185.19,420.21,percent of total billed charges,
PHENobarbital 130mg/1mL  Inj,800051979,CDM,636,RC,J2560,HCPCS,00641047725,NDC,facility,outpatient,130,ME,513.70000,148.97000,Aetna,First Health,,420.21,,,,,,,28.00,420.21,percent of total billed charges,
PHENobarbital 65mg/1mL Inj,800077015,CDM,636,RC,J2560,HCPCS,00641047625,NDC,facility,inpatient,65,ME,228.80000,66.35000,Aetna,First Health,,187.16,,,,,,,82.48,187.16,percent of total billed charges,
PHENobarbital 65mg/1mL Inj,800077015,CDM,636,RC,J2560,HCPCS,00641047625,NDC,facility,outpatient,65,ME,228.80000,66.35000,Aetna,First Health,,187.16,,,,,,,28.00,187.16,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,00641041425,NDC,facility,inpatient,30,UN,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,3.15,5.48,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,00641041425,NDC,facility,outpatient,30,UN,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,0.01926,5.48,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00641040025,NDC,facility,inpatient,5000,UN,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,2.40,4.17,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00641040025,NDC,facility,outpatient,5000,UN,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,0.17334,4.17,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00641040012,NDC,facility,inpatient,5000,UN,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,7.68,13.37,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00641040012,NDC,facility,outpatient,5000,UN,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,0.17334,13.37,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00641040002,NDC,facility,inpatient,5000,UN,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,2.84,4.95,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00641040002,NDC,facility,outpatient,5000,UN,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,0.17334,4.95,percent of total billed charges,
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00641039525,NDC,facility,inpatient,80,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00641039525,NDC,facility,outpatient,80,ME,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,2.09,10.43,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,00641039225,NDC,facility,inpatient,30,UN,12.45000,3.61000,Aetna,First Health,,10.18,,,,,,,5.85,10.18,percent of total billed charges,
NICU- Heparin 10unit/1mL PF IS,800019555,CDM,258,RC,J1642,HCPCS,00641039225,NDC,facility,outpatient,30,UN,12.45000,3.61000,Aetna,First Health,,10.18,,,,,,,0.01926,10.18,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00641037625,NDC,facility,inpatient,50,ME,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,2.70,6.13,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00641037625,NDC,facility,outpatient,50,ME,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,0.68373,6.13,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,inpatient,50,ME,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,outpatient,50,ME,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,0.68373,5.03,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00641037125,NDC,facility,inpatient,10,ME,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,8.11,18.41,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00641037125,NDC,facility,outpatient,10,ME,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,6.44,20.63,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00641012521,NDC,,,facility,inpatient,1,EA,66.50000,19.28000,Aetna,First Health,,54.40,,,,,,,24.61,54.40,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00641012521,NDC,,,facility,outpatient,1,EA,66.50000,19.28000,Aetna,First Health,,54.40,,,,,,,23.97,54.40,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00641012125,NDC,facility,inpatient,2,ME,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,4.97,11.29,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00641012125,NDC,facility,outpatient,2,ME,13.80000,4.00000,Aetna,First Health,,11.29,,,,,,,0.13482,11.29,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00615257913,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00615257913,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00603812718,NDC,,,facility,inpatient,1,EA,4.10000,1.19000,Aetna,First Health,,3.35,,,,,,,2.46,3.35,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00603812718,NDC,,,facility,outpatient,1,EA,4.10000,1.19000,Aetna,First Health,,3.35,,,,,,,1.48,3.35,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00603812711,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00603812711,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Triamcinolone 0.025% TC 80g,800017792,CDM,637,RC,00603786190,NDC,,,facility,inpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,47.37,64.58,percent of total billed charges,
Triamcinolone 0.025% TC 80g,800017792,CDM,637,RC,00603786190,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,28.46,64.58,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00603781874,NDC,,,facility,inpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,74.34,101.35,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00603781874,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,44.67,101.35,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00603780550,NDC,,,facility,inpatient,1,EA,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,19.24,42.54,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00603780550,NDC,,,facility,outpatient,1,EA,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,18.75,42.54,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00603616121,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00603616121,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,00603605421,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,00603605421,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,00603580121,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,00603580121,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,00603577021,NDC,,,facility,inpatient,1,EA,24.20000,7.02000,Aetna,First Health,,19.80,,,,,,,14.52,19.80,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,00603577021,NDC,,,facility,outpatient,1,EA,24.20000,7.02000,Aetna,First Health,,19.80,,,,,,,8.72,19.80,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00603576921,NDC,,,facility,inpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,10.89,14.85,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00603576921,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,6.54,14.85,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00603554328,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00603554328,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,00603544921,NDC,,,facility,inpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,9.90,13.50,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,00603544921,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00603544825,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00603544825,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),800015411,CDM,637,RC,Q0169,HCPCS,00603543721,NDC,facility,inpatient,12.5,ME,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Promethazine HCl 12.5mg T(Phenergan),800015411,CDM,637,RC,Q0169,HCPCS,00603543721,NDC,facility,outpatient,12.5,ME,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,0.24075,2.82,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00603537221,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00603537221,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00603537121,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00603537121,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00603536921,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00603536921,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00603533932,NDC,facility,inpatient,20,ME,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,1.05,1.43,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00603533932,NDC,facility,outpatient,20,ME,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.00963,1.43,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00603533928,NDC,facility,inpatient,20,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00603533928,NDC,facility,outpatient,20,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.00963,1.47,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00603533921,NDC,facility,inpatient,20,ME,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00603533921,NDC,facility,outpatient,20,ME,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.00963,1.10,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00603533832,NDC,facility,inpatient,10,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00603533832,NDC,facility,outpatient,10,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.00963,1.27,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00603533821,NDC,facility,inpatient,10,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00603533821,NDC,facility,outpatient,10,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.00963,1.27,percent of total billed charges,
predniSONE 2.5mg T,800020638,CDM,637,RC,J7512,HCPCS,00603533621,NDC,facility,inpatient,2.5,ME,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
predniSONE 2.5mg T,800020638,CDM,637,RC,J7512,HCPCS,00603533621,NDC,facility,outpatient,2.5,ME,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.00963,0.94070,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,00603533521,NDC,facility,inpatient,1,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,00603533521,NDC,facility,outpatient,1,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.00963,1.47,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,00603514121,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,00603514121,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,00603509021,NDC,facility,inpatient,2,ME,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,00603509021,NDC,facility,outpatient,2,ME,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,7.37,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00603499021,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00603499021,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00603497528,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00603497528,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00603497521,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00603497521,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00603465502,NDC,,,facility,inpatient,1,EA,40.05000,11.61000,Aetna,First Health,,32.76,,,,,,,24.03,32.76,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00603465502,NDC,,,facility,outpatient,1,EA,40.05000,11.61000,Aetna,First Health,,32.76,,,,,,,14.44,32.76,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00603459321,NDC,facility,inpatient,4,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,6.06,8.26,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00603459321,NDC,facility,outpatient,4,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,0.13482,8.26,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00603459315,NDC,facility,inpatient,4,ME,112.50000,32.62000,Aetna,First Health,,92.03,,,,,,,40.56,92.03,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00603459315,NDC,facility,outpatient,4,ME,112.50000,32.62000,Aetna,First Health,,92.03,,,,,,,0.13482,92.03,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00603448621,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00603448621,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00603448521,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00603448521,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00603421221,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00603421221,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00603421202,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00603421202,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00603421128,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00603421128,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00603411021,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00603411021,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00603396821,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00603396821,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00603390021,NDC,,,facility,inpatient,1,EA,4.10000,1.19000,Aetna,First Health,,3.35,,,,,,,2.46,3.35,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00603390021,NDC,,,facility,outpatient,1,EA,4.10000,1.19000,Aetna,First Health,,3.35,,,,,,,1.48,3.35,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,00603389919,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,00603389919,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00603385621,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00603385621,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00603373921,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00603373921,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00603348119,NDC,,,facility,inpatient,1,EA,9.95000,2.89000,Aetna,First Health,,8.14,,,,,,,5.97,8.14,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00603348119,NDC,,,facility,outpatient,1,EA,9.95000,2.89000,Aetna,First Health,,8.14,,,,,,,3.59,8.14,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00603344328,NDC,,,facility,inpatient,1,EA,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00603344328,NDC,,,facility,outpatient,1,EA,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,8.29,18.81,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,00603318021,NDC,,,facility,inpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,5.58,7.61,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,00603318021,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00603316221,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00603316221,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00603307928,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00603307928,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00603307921,NDC,,,facility,inpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,4.92,6.71,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00603307921,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,2.96,6.71,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,00603307821,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,00603307821,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00603305221,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00603305221,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00603294821,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00603294821,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00603271421,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00603271421,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00603258221,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00603258221,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00603254721,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00603254721,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00603254421,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00603254421,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00603243321,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00603243321,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00603240721,NDC,,,facility,inpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,21.78,29.69,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00603240721,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,13.09,29.69,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00603240628,NDC,,,facility,inpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,9.60,13.09,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00603240628,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,First Health,,13.09,,,,,,,5.77,13.09,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00603240621,NDC,,,facility,inpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,10.50,14.31,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00603240621,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,6.31,14.31,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,00603221621,NDC,,,facility,inpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,00603221621,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,6.49,14.72,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00603221321,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00603221321,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,00603221221,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,00603221221,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00603211621,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00603211621,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00603211521,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00603211521,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,00603211002,NDC,,,facility,inpatient,1,EA,18.95000,5.50000,Aetna,First Health,,15.50,,,,,,,11.37,15.50,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,00603211002,NDC,,,facility,outpatient,1,EA,18.95000,5.50000,Aetna,First Health,,15.50,,,,,,,6.83,15.50,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,00603158558,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,00603158558,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,00603158458,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,00603158458,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Potassium Cl 10mEq/7.5 mL L UD,800015331,CDM,637,RC,00603153458,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Potassium Cl 10mEq/7.5 mL L UD,800015331,CDM,637,RC,00603153458,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00603148149,NDC,,,facility,inpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00603148149,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00603139447,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.83250,1.84,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00603139447,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00603137858,NDC,,,facility,inpatient,1,EA,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.30000,0.40900,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00603137858,NDC,,,facility,outpatient,1,EA,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.18025,0.40900,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,00603131473,NDC,,,facility,inpatient,1,ML,19.80000,5.74000,Aetna,First Health,,16.20,,,,,,,11.88,16.20,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,00603131473,NDC,,,facility,outpatient,1,ML,19.80000,5.74000,Aetna,First Health,,16.20,,,,,,,7.14,16.20,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),800065135,CDM,637,RC,00603116158,NDC,,,facility,inpatient,1,EA,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,6.39,8.71,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),800065135,CDM,637,RC,00603116158,NDC,,,facility,outpatient,1,EA,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,3.84,8.71,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,00603076247,NDC,,,facility,inpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.39000,0.53170,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,00603076247,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.23433,0.53170,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,00603064888,NDC,,,facility,inpatient,1,EA,116.80000,33.87000,Aetna,First Health,,95.54,,,,,,,43.22,95.54,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,00603064888,NDC,,,facility,outpatient,1,EA,116.80000,33.87000,Aetna,First Health,,95.54,,,,,,,42.11,95.54,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00603064450,NDC,,,facility,inpatient,1,EA,46.60000,13.51000,Aetna,First Health,,38.12,,,,,,,17.24,38.12,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00603064450,NDC,,,facility,outpatient,1,EA,46.60000,13.51000,Aetna,First Health,,38.12,,,,,,,16.80,38.12,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00603053550,NDC,,,facility,inpatient,1,EA,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,7.36,16.28,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00603053550,NDC,,,facility,outpatient,1,EA,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,7.17,16.28,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00603053450,NDC,,,facility,inpatient,1,EA,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,6.05,13.37,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00603053450,NDC,,,facility,outpatient,1,EA,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,5.89,13.37,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597035556,NDC,,,facility,inpatient,1,EA,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,16.86,22.99,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597035556,NDC,,,facility,outpatient,1,EA,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,10.13,22.99,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597035509,NDC,,,facility,inpatient,1,EA,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,16.86,22.99,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597035509,NDC,,,facility,outpatient,1,EA,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,10.13,22.99,percent of total billed charges,
idaruCIZUmab  2.5g/50mL I(Praxbind),800025665,CDM,636,RC,C9399,HCPCS,00597019705,NDC,facility,inpatient,2.5,GM,18555.70000,5381.15000,Aetna,First Health,,15178.56,,,,,,,6689.33,15178.56,percent of total billed charges,
idaruCIZUmab  2.5g/50mL I(Praxbind),800025665,CDM,636,RC,C9399,HCPCS,00597019705,NDC,facility,outpatient,2.5,GM,18555.70000,5381.15000,Aetna,First Health,,15178.56,,,,,,,6689.33,15178.56,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,00597018590,NDC,,,facility,inpatient,1,EA,58.60000,16.99000,Aetna,First Health,,47.93,,,,,,,35.16,47.93,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,00597018590,NDC,,,facility,outpatient,1,EA,58.60000,16.99000,Aetna,First Health,,47.93,,,,,,,21.13,47.93,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00597018390,NDC,,,facility,inpatient,1,EA,58.60000,16.99000,Aetna,First Health,,47.93,,,,,,,35.16,47.93,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00597018390,NDC,,,facility,outpatient,1,EA,58.60000,16.99000,Aetna,First Health,,47.93,,,,,,,21.13,47.93,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00597016601,NDC,,,facility,inpatient,1,EA,53.30000,15.46000,Aetna,First Health,,43.60,,,,,,,31.98,43.60,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00597016601,NDC,,,facility,outpatient,1,EA,53.30000,15.46000,Aetna,First Health,,43.60,,,,,,,19.21,43.60,percent of total billed charges,
Empagliflozin 25mg Tab,800046460,CDM,637,RC,00597015390,NDC,,,facility,inpatient,1,EA,180.65000,52.39000,Aetna,First Health,,147.77,,,,,,,108.39,147.77,percent of total billed charges,
Empagliflozin 25mg Tab,800046460,CDM,637,RC,00597015390,NDC,,,facility,outpatient,1,EA,180.65000,52.39000,Aetna,First Health,,147.77,,,,,,,65.12,147.77,percent of total billed charges,
Empagliflozin 25mg Tab,800046460,CDM,637,RC,00597015337,NDC,,,facility,inpatient,1,EA,180.65000,52.39000,Aetna,First Health,,147.77,,,,,,,108.39,147.77,percent of total billed charges,
Empagliflozin 25mg Tab,800046460,CDM,637,RC,00597015337,NDC,,,facility,outpatient,1,EA,180.65000,52.39000,Aetna,First Health,,147.77,,,,,,,65.12,147.77,percent of total billed charges,
Empagliflozin 10mg Tab,800046380,CDM,637,RC,00597015290,NDC,,,facility,inpatient,1,EA,180.65000,52.39000,Aetna,First Health,,147.77,,,,,,,108.39,147.77,percent of total billed charges,
Empagliflozin 10mg Tab,800046380,CDM,637,RC,00597015290,NDC,,,facility,outpatient,1,EA,180.65000,52.39000,Aetna,First Health,,147.77,,,,,,,65.12,147.77,percent of total billed charges,
Empagliflozin 10mg Tab,800046380,CDM,637,RC,00597015237,NDC,,,facility,inpatient,1,EA,180.65000,52.39000,Aetna,First Health,,147.77,,,,,,,108.39,147.77,percent of total billed charges,
Empagliflozin 10mg Tab,800046380,CDM,637,RC,00597015237,NDC,,,facility,outpatient,1,EA,180.65000,52.39000,Aetna,First Health,,147.77,,,,,,,65.12,147.77,percent of total billed charges,
Empagliflozin 10mg Tab,800046380,CDM,637,RC,00597015230,NDC,,,facility,inpatient,1,EA,180.65000,52.39000,Aetna,First Health,,147.77,,,,,,,108.39,147.77,percent of total billed charges,
Empagliflozin 10mg Tab,800046380,CDM,637,RC,00597015230,NDC,,,facility,outpatient,1,EA,180.65000,52.39000,Aetna,First Health,,147.77,,,,,,,65.12,147.77,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597014960,NDC,,,facility,inpatient,1,EA,55.70000,16.15000,Aetna,First Health,,45.56,,,,,,,33.42,45.56,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597014960,NDC,,,facility,outpatient,1,EA,55.70000,16.15000,Aetna,First Health,,45.56,,,,,,,20.08,45.56,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597010760,NDC,,,facility,inpatient,1,EA,30.95000,8.98000,Aetna,First Health,,25.32,,,,,,,18.57,25.32,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597010760,NDC,,,facility,outpatient,1,EA,30.95000,8.98000,Aetna,First Health,,25.32,,,,,,,11.16,25.32,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597010754,NDC,,,facility,inpatient,1,EA,30.95000,8.98000,Aetna,First Health,,25.32,,,,,,,18.57,25.32,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597010754,NDC,,,facility,outpatient,1,EA,30.95000,8.98000,Aetna,First Health,,25.32,,,,,,,11.16,25.32,percent of total billed charges,
Tiotropium 2.5mcg/1INH Aerosol,800062012,CDM,637,RC,00597010061,NDC,,,facility,inpatient,1,EA,3499.95000,1014.99000,Aetna,First Health,,2862.96,,,,,,,2099.97,2862.96,percent of total billed charges,
Tiotropium 2.5mcg/1INH Aerosol,800062012,CDM,637,RC,00597010061,NDC,,,facility,outpatient,1,EA,3499.95000,1014.99000,Aetna,First Health,,2862.96,,,,,,,1261.73,2862.96,percent of total billed charges,
Tiotropium 2.5mcg/1INH Aerosol,800062012,CDM,637,RC,00597010051,NDC,,,facility,inpatient,1,EA,587.20000,170.29000,Aetna,First Health,,480.33,,,,,,,352.32,480.33,percent of total billed charges,
Tiotropium 2.5mcg/1INH Aerosol,800062012,CDM,637,RC,00597010051,NDC,,,facility,outpatient,1,EA,587.20000,170.29000,Aetna,First Health,,480.33,,,,,,,211.69,480.33,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00597008353,NDC,,,facility,inpatient,1,EA,13.20000,3.83000,Aetna,First Health,,10.80,,,,,,,7.92,10.80,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00597008353,NDC,,,facility,outpatient,1,EA,13.20000,3.83000,Aetna,First Health,,10.80,,,,,,,4.76,10.80,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,00597008130,NDC,,,facility,inpatient,1,EA,992.85000,287.93000,Aetna,First Health,,812.15,,,,,,,595.71,812.15,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,00597008130,NDC,,,facility,outpatient,1,EA,992.85000,287.93000,Aetna,First Health,,812.15,,,,,,,357.92,812.15,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,00597006761,NDC,,,facility,inpatient,1,EA,9.00000,2.61000,Aetna,First Health,,7.36,,,,,,,5.40,7.36,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,00597006761,NDC,,,facility,outpatient,1,EA,9.00000,2.61000,Aetna,First Health,,7.36,,,,,,,3.24,7.36,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00597005801,NDC,,,facility,inpatient,1,EA,82.65000,23.97000,Aetna,First Health,,67.61,,,,,,,49.59,67.61,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00597005801,NDC,,,facility,outpatient,1,EA,82.65000,23.97000,Aetna,First Health,,67.61,,,,,,,29.80,67.61,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,00597003334,NDC,,,facility,inpatient,1,EA,1181.20000,342.55000,Aetna,First Health,,966.22,,,,,,,708.72,966.22,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,00597003334,NDC,,,facility,outpatient,1,EA,1181.20000,342.55000,Aetna,First Health,,966.22,,,,,,,425.82,966.22,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00597003234,NDC,,,facility,inpatient,1,EA,908.10000,263.35000,Aetna,First Health,,742.83,,,,,,,544.86,742.83,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00597003234,NDC,,,facility,outpatient,1,EA,908.10000,263.35000,Aetna,First Health,,742.83,,,,,,,327.37,742.83,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00597003212,NDC,,,facility,inpatient,1,EA,300.25000,87.07000,Aetna,First Health,,245.60,,,,,,,180.15,245.60,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00597003212,NDC,,,facility,outpatient,1,EA,300.25000,87.07000,Aetna,First Health,,245.60,,,,,,,108.24,245.60,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00597003134,NDC,,,facility,inpatient,1,EA,549.05000,159.22000,Aetna,First Health,,449.12,,,,,,,329.43,449.12,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00597003134,NDC,,,facility,outpatient,1,EA,549.05000,159.22000,Aetna,First Health,,449.12,,,,,,,197.93,449.12,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00597003112,NDC,,,facility,inpatient,1,EA,184.90000,53.62000,Aetna,First Health,,151.25,,,,,,,110.94,151.25,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00597003112,NDC,,,facility,outpatient,1,EA,184.90000,53.62000,Aetna,First Health,,151.25,,,,,,,66.66,151.25,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00597002901,NDC,,,facility,inpatient,1,EA,82.20000,23.84000,Aetna,First Health,,67.24,,,,,,,49.32,67.24,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00597002901,NDC,,,facility,outpatient,1,EA,82.20000,23.84000,Aetna,First Health,,67.24,,,,,,,29.63,67.24,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00597000601,NDC,,,facility,inpatient,1,EA,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,13.83,18.85,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00597000601,NDC,,,facility,outpatient,1,EA,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,8.31,18.85,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,00597000160,NDC,,,facility,inpatient,1,EA,79.85000,23.16000,Aetna,First Health,,65.32,,,,,,,47.91,65.32,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,00597000160,NDC,,,facility,outpatient,1,EA,79.85000,23.16000,Aetna,First Health,,65.32,,,,,,,28.79,65.32,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00591588301,NDC,,,facility,inpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,5.07,6.91,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00591588301,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,3.05,6.91,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00591588201,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00591588201,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00591578701,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00591578701,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00591578601,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00591578601,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00591573101,NDC,,,facility,inpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,4.68,6.38,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00591573101,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,2.81,6.38,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00591573001,NDC,,,facility,inpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,2.58,3.52,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00591573001,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,1.55,3.52,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00591570801,NDC,,,facility,inpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,5.07,6.91,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00591570801,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,3.05,6.91,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,00591569401,NDC,,,facility,inpatient,1,EA,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,7.23,9.86,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,00591569401,NDC,,,facility,outpatient,1,EA,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,4.34,9.86,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00591565805,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00591565805,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00591565801,NDC,,,facility,inpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,4.89,6.67,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00591565801,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,2.94,6.67,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,00591564301,NDC,,,facility,inpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,5.49,7.48,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,00591564301,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.30,7.48,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,00591564201,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,00591564201,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
diazePAM 2mg T(Valium),800050533,CDM,637,RC,00591562101,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
diazePAM 2mg T(Valium),800050533,CDM,637,RC,00591562101,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00591560001,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00591560001,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00591559901,NDC,,,facility,inpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.39000,0.53170,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00591559901,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,First Health,,0.53170,,,,,,,0.23433,0.53170,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,00591557101,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,00591557101,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00591555501,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00591555501,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00591555401,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00591555401,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00591555250,NDC,,,facility,inpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,3.03,4.13,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00591555250,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,1.82,4.13,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00591554401,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00591554401,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00591554301,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00591554301,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00591552301,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00591552301,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00591551301,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00591551301,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00591544301,NDC,facility,inpatient,20,ME,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00591544301,NDC,facility,outpatient,20,ME,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.00963,1.51,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00591544050,NDC,,,facility,inpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,13.95,19.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00591544050,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,8.38,19.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00591544005,NDC,,,facility,inpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,13.95,19.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00591544005,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,8.38,19.02,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,00591543001,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,00591543001,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00591538201,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00591538201,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00591534701,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00591534701,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,00591533501,NDC,,,facility,inpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,00591533501,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.46865,1.06,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00591532101,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00591532101,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00591521601,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00591521601,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,00591401201,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,00591401201,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00591401105,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00591401105,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00591396801,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00591396801,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00591387560,NDC,,,facility,inpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,25.92,35.34,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00591387560,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,15.57,35.34,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00591387544,NDC,,,facility,inpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,25.92,35.34,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00591387544,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,15.57,35.34,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00591387060,NDC,,,facility,inpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,25.92,35.34,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00591387060,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,15.57,35.34,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00591387044,NDC,,,facility,inpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,25.92,35.34,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00591387044,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,First Health,,35.34,,,,,,,15.57,35.34,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,00591372030,NDC,,,facility,inpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,22.17,30.23,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,00591372030,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,13.32,30.23,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00591371330,NDC,,,facility,inpatient,1,EA,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,48.00,65.44,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00591371330,NDC,,,facility,outpatient,1,EA,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,28.84,65.44,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00591368501,NDC,,,facility,inpatient,1,EA,16.10000,4.67000,Aetna,First Health,,13.17,,,,,,,9.66,13.17,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00591368501,NDC,,,facility,outpatient,1,EA,16.10000,4.67000,Aetna,First Health,,13.17,,,,,,,5.80,13.17,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00591354160,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00591354160,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00591354060,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00591354060,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00591343710,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00591343710,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00591343701,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00591343701,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00591333130,NDC,,,facility,inpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,22.17,30.23,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00591333130,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,13.32,30.23,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00591323001,NDC,,,facility,inpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,13.44,18.32,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00591323001,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,8.08,18.32,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00591322247,NDC,facility,inpatient,60,ME,119.70000,34.71000,Aetna,First Health,,97.91,,,,,,,43.15,97.91,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00591322247,NDC,facility,outpatient,60,ME,119.70000,34.71000,Aetna,First Health,,97.91,,,,,,,6.15,97.91,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,00591321630,NDC,,,facility,inpatient,1,EA,116.65000,33.83000,Aetna,First Health,,95.42,,,,,,,69.99,95.42,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,00591321630,NDC,,,facility,outpatient,1,EA,116.65000,33.83000,Aetna,First Health,,95.42,,,,,,,42.05,95.42,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00591321472,NDC,,,facility,inpatient,1,EA,411.90000,119.45000,Aetna,First Health,,336.93,,,,,,,247.14,336.93,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00591321472,NDC,,,facility,outpatient,1,EA,411.90000,119.45000,Aetna,First Health,,336.93,,,,,,,148.49,336.93,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00591321372,NDC,,,facility,inpatient,1,EA,314.85000,91.31000,Aetna,First Health,,257.55,,,,,,,188.91,257.55,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00591321372,NDC,,,facility,outpatient,1,EA,314.85000,91.31000,Aetna,First Health,,257.55,,,,,,,113.50,257.55,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00591321272,NDC,,,facility,inpatient,1,EA,210.90000,61.16000,Aetna,First Health,,172.52,,,,,,,126.54,172.52,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00591321272,NDC,,,facility,outpatient,1,EA,210.90000,61.16000,Aetna,First Health,,172.52,,,,,,,76.03,172.52,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00591319872,NDC,,,facility,inpatient,1,EA,115.45000,33.48000,Aetna,First Health,,94.44,,,,,,,69.27,94.44,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00591319872,NDC,,,facility,outpatient,1,EA,115.45000,33.48000,Aetna,First Health,,94.44,,,,,,,41.62,94.44,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00591319101,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00591319101,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00591315901,NDC,,,facility,inpatient,1,EA,52.05000,15.09000,Aetna,First Health,,42.58,,,,,,,31.23,42.58,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00591315901,NDC,,,facility,outpatient,1,EA,52.05000,15.09000,Aetna,First Health,,42.58,,,,,,,18.76,42.58,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00591304105,NDC,,,facility,inpatient,1,EA,27.50000,7.98000,Aetna,First Health,,22.50,,,,,,,16.50,22.50,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00591304105,NDC,,,facility,outpatient,1,EA,27.50000,7.98000,Aetna,First Health,,22.50,,,,,,,9.91,22.50,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00591298539,NDC,,,facility,inpatient,1,EA,125.35000,36.35000,Aetna,First Health,,102.54,,,,,,,75.21,102.54,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00591298539,NDC,,,facility,outpatient,1,EA,125.35000,36.35000,Aetna,First Health,,102.54,,,,,,,45.19,102.54,percent of total billed charges,
Levalbuterol HFA 45 mcg/inh,800017835,CDM,637,RC,00591292754,NDC,,,facility,inpatient,1,EA,488.10000,141.55000,Aetna,First Health,,399.27,,,,,,,292.86,399.27,percent of total billed charges,
Levalbuterol HFA 45 mcg/inh,800017835,CDM,637,RC,00591292754,NDC,,,facility,outpatient,1,EA,488.10000,141.55000,Aetna,First Health,,399.27,,,,,,,175.96,399.27,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00591283001,NDC,,,facility,inpatient,1,EA,15.40000,4.47000,Aetna,First Health,,12.60,,,,,,,9.24,12.60,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00591283001,NDC,,,facility,outpatient,1,EA,15.40000,4.47000,Aetna,First Health,,12.60,,,,,,,5.55,12.60,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00591271301,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00591271301,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00591269201,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00591269201,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00591261205,NDC,,,facility,inpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,3.75,5.11,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00591261205,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,First Health,,5.11,,,,,,,2.25,5.11,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,00591257920,NDC,,,facility,inpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,42.48,57.91,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,00591257920,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,First Health,,57.91,,,,,,,25.52,57.91,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00591252001,NDC,,,facility,inpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,4.59,6.26,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00591252001,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00591247260,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00591247260,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,00591246401,NDC,,,facility,inpatient,1,EA,37.40000,10.85000,Aetna,First Health,,30.59,,,,,,,22.44,30.59,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,00591246401,NDC,,,facility,outpatient,1,EA,37.40000,10.85000,Aetna,First Health,,30.59,,,,,,,13.48,30.59,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,00591241630,NDC,,,facility,inpatient,1,EA,216.70000,62.84000,Aetna,First Health,,177.26,,,,,,,130.02,177.26,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,00591241630,NDC,,,facility,outpatient,1,EA,216.70000,62.84000,Aetna,First Health,,177.26,,,,,,,78.12,177.26,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00591222805,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00591222805,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00591222801,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00591222801,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,800080621,CDM,637,RC,J7515,HCPCS,00591222215,NDC,facility,inpatient,25,ME,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,5.85,7.98,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,800080621,CDM,637,RC,J7515,HCPCS,00591222215,NDC,facility,outpatient,25,ME,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,0.51039,7.98,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00591213668,NDC,facility,inpatient,1,GM,288.60000,83.69000,Aetna,First Health,,236.07,,,,,,,104.04,236.07,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00591213668,NDC,facility,outpatient,1,GM,288.60000,83.69000,Aetna,First Health,,236.07,,,,,,,0.08667,236.07,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00591213651,NDC,facility,inpatient,0.5,GM,145.35000,42.15000,Aetna,First Health,,118.90,,,,,,,52.40,118.90,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00591213651,NDC,facility,outpatient,0.5,GM,145.35000,42.15000,Aetna,First Health,,118.90,,,,,,,0.08667,118.90,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00591111730,NDC,,,facility,inpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,11.52,15.71,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00591111730,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00591094401,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00591094401,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,00591090030,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,00591090030,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00591085860,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00591085860,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00591083960,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00591083960,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00591083925,NDC,,,facility,inpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,6.66,9.08,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00591083925,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,4.00,9.08,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,00591081085,NDC,,,facility,inpatient,1,EA,189.15000,54.85000,Aetna,First Health,,154.72,,,,,,,113.49,154.72,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,00591081085,NDC,,,facility,outpatient,1,EA,189.15000,54.85000,Aetna,First Health,,154.72,,,,,,,68.19,154.72,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00591080105,NDC,facility,inpatient,50,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00591080105,NDC,facility,outpatient,50,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.21186,1.27,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00591080101,NDC,facility,inpatient,50,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00591080101,NDC,facility,outpatient,50,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.21186,1.27,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00591080001,NDC,facility,inpatient,25,ME,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00591080001,NDC,facility,outpatient,25,ME,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.21186,1.19,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,00591079601,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,00591079601,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00591079401,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00591079401,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00591078701,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00591078701,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00591078601,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00591078601,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00591078005,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00591078005,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00591078001,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00591078001,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00591069801,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,5.22,7.12,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00591069801,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00591067101,NDC,,,facility,inpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,6.48,8.83,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00591067101,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,3.89,8.83,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00591067001,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00591067001,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00591065801,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00591065801,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00591065701,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00591065701,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00591060605,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00591060605,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00591060601,NDC,,,facility,inpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,3.03,4.13,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00591060601,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,1.82,4.13,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00591060501,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00591060501,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,00591058301,NDC,,,facility,inpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,9.90,13.50,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,00591058301,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00591058201,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00591058201,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00591048701,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00591048701,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00591046301,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00591046301,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00591046001,NDC,,,facility,inpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,1.59,2.17,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00591046001,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00591044401,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,3.69,5.03,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00591044401,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00591042405,NDC,,,facility,inpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,1.50,2.04,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00591042405,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,First Health,,2.04,,,,,,,0.90125,2.04,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00591042401,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00591042401,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00591040901,NDC,,,facility,inpatient,1,EA,10.95000,3.18000,Aetna,First Health,,8.96,,,,,,,6.57,8.96,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00591040901,NDC,,,facility,outpatient,1,EA,10.95000,3.18000,Aetna,First Health,,8.96,,,,,,,3.95,8.96,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00591040701,NDC,,,facility,inpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,4.20,5.73,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00591040701,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,2.52,5.73,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,00591040401,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,00591040401,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00591034501,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00591034501,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00591030101,NDC,,,facility,inpatient,1,EA,0.35000,0.10000,Aetna,First Health,,0.28630,,,,,,,0.21000,0.28630,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00591030101,NDC,,,facility,outpatient,1,EA,0.35000,0.10000,Aetna,First Health,,0.28630,,,,,,,0.12618,0.28630,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00591030001,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00591030001,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00591024001,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00591024001,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00591001419,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,13.89,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00591001419,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00591001319,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00591001319,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,00590036805,NDC,facility,inpatient,2,ME,80.65000,23.39000,Aetna,First Health,,65.97,,,,,,,29.07,65.97,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,00590036805,NDC,facility,outpatient,2,ME,80.65000,23.39000,Aetna,First Health,,65.97,,,,,,,0.06741,65.97,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00590035810,NDC,facility,inpatient,0.4,ME,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00590035810,NDC,facility,outpatient,0.4,ME,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,0.06741,5.77,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00585097572,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00585097572,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,00585067103,NDC,,,facility,inpatient,1,EA,325.85000,94.50000,Aetna,First Health,,266.55,,,,,,,195.51,266.55,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,00585067103,NDC,,,facility,outpatient,1,EA,325.85000,94.50000,Aetna,First Health,,266.55,,,,,,,117.47,266.55,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,00585054867,NDC,,,facility,inpatient,1,EA,17.10000,4.96000,Aetna,First Health,,13.99,,,,,,,10.26,13.99,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,00585054867,NDC,,,facility,outpatient,1,EA,17.10000,4.96000,Aetna,First Health,,13.99,,,,,,,6.16,13.99,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00574723612,NDC,,,facility,inpatient,1,EA,27.55000,7.99000,Aetna,First Health,,22.54,,,,,,,16.53,22.54,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00574723612,NDC,,,facility,outpatient,1,EA,27.55000,7.99000,Aetna,First Health,,22.54,,,,,,,9.93,22.54,percent of total billed charges,
Prochlorperazine 25mg Supp(Compazine,800017137,CDM,637,RC,00574722612,NDC,,,facility,inpatient,1,EA,89.10000,25.84000,Aetna,First Health,,72.88,,,,,,,53.46,72.88,percent of total billed charges,
Prochlorperazine 25mg Supp(Compazine,800017137,CDM,637,RC,00574722612,NDC,,,facility,outpatient,1,EA,89.10000,25.84000,Aetna,First Health,,72.88,,,,,,,32.12,72.88,percent of total billed charges,
Belladonna-Opium Supp(60mg Of Opium),800017087,CDM,637,RC,00574704012,NDC,,,facility,inpatient,1,EA,263.90000,76.53000,Aetna,First Health,,215.87,,,,,,,158.34,215.87,percent of total billed charges,
Belladonna-Opium Supp(60mg Of Opium),800017087,CDM,637,RC,00574704012,NDC,,,facility,outpatient,1,EA,263.90000,76.53000,Aetna,First Health,,215.87,,,,,,,95.14,215.87,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,00574416035,NDC,,,facility,inpatient,1,EA,107.25000,31.10000,Aetna,First Health,,87.73,,,,,,,64.35,87.73,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,00574416035,NDC,,,facility,outpatient,1,EA,107.25000,31.10000,Aetna,First Health,,87.73,,,,,,,38.66,87.73,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,800018689,CDM,637,RC,00574410010,NDC,,,facility,inpatient,1,EA,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,78.60,107.16,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,800018689,CDM,637,RC,00574410010,NDC,,,facility,outpatient,1,EA,131.00000,37.99000,Aetna,First Health,,107.16,,,,,,,47.23,107.16,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,00574403105,NDC,,,facility,inpatient,1,EA,594.85000,172.51000,Aetna,First Health,,486.59,,,,,,,356.91,486.59,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,00574403105,NDC,,,facility,outpatient,1,EA,594.85000,172.51000,Aetna,First Health,,486.59,,,,,,,214.44,486.59,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,00574402450,NDC,,,facility,inpatient,1,EA,61.55000,17.85000,Aetna,First Health,,50.35,,,,,,,36.93,50.35,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,00574402450,NDC,,,facility,outpatient,1,EA,61.55000,17.85000,Aetna,First Health,,50.35,,,,,,,22.19,50.35,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,00574402135,NDC,,,facility,inpatient,1,EA,186.85000,54.19000,Aetna,First Health,,152.84,,,,,,,69.13,152.84,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,00574402135,NDC,,,facility,outpatient,1,EA,186.85000,54.19000,Aetna,First Health,,152.84,,,,,,,67.36,152.84,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00574200815,NDC,,,facility,inpatient,1,EA,164.80000,47.79000,Aetna,First Health,,134.81,,,,,,,98.88,134.81,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00574200815,NDC,,,facility,outpatient,1,EA,164.80000,47.79000,Aetna,First Health,,134.81,,,,,,,59.41,134.81,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,00574085010,NDC,facility,inpatient,1,ME,662.00000,191.98000,Aetna,First Health,,541.52,,,,,,,238.65,541.52,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,00574085010,NDC,facility,outpatient,1,ME,662.00000,191.98000,Aetna,First Health,,541.52,,,,,,,54.97,541.52,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,00574085005,NDC,facility,inpatient,1,ME,692.10000,200.71000,Aetna,First Health,,566.14,,,,,,,249.50,566.14,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,00574085005,NDC,facility,outpatient,1,ME,692.10000,200.71000,Aetna,First Health,,566.14,,,,,,,54.97,566.14,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,00574082301,NDC,facility,inpatient,60,ME,355.25000,103.02000,Aetna,First Health,,290.59,,,,,,,128.07,290.59,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,00574082301,NDC,facility,outpatient,60,ME,355.25000,103.02000,Aetna,First Health,,290.59,,,,,,,1.40,290.59,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,00574081530,NDC,facility,inpatient,6000,ME,1656.40000,480.36000,Aetna,First Health,,1354.94,,,,,,,597.13,1354.94,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,00574081530,NDC,facility,outpatient,6000,ME,1656.40000,480.36000,Aetna,First Health,,1354.94,,,,,,,0.35631,1354.94,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,inpatient,6000,ME,1014.00000,294.06000,Aetna,First Health,,829.45,,,,,,,365.55,829.45,percent of total billed charges,
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,outpatient,6000,ME,1014.00000,294.06000,Aetna,First Health,,829.45,,,,,,,0.35631,829.45,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00574079201,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00574079201,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,00574041202,NDC,,,facility,inpatient,1,EA,144.40000,41.88000,Aetna,First Health,,118.12,,,,,,,53.43,118.12,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,00574041202,NDC,,,facility,outpatient,1,EA,144.40000,41.88000,Aetna,First Health,,118.12,,,,,,,52.06,118.12,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,00574025101,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,00574025101,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,00574022201,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,00574022201,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,00574022001,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,00574022001,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,00574019401,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,00574019401,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,00574015210,NDC,,,facility,inpatient,1,EA,316.05000,91.65000,Aetna,First Health,,258.53,,,,,,,189.63,258.53,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,00574015210,NDC,,,facility,outpatient,1,EA,316.05000,91.65000,Aetna,First Health,,258.53,,,,,,,113.94,258.53,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00574010770,NDC,,,facility,inpatient,1,EA,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,6.84,9.33,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00574010770,NDC,,,facility,outpatient,1,EA,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,4.11,9.33,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,00574010603,NDC,,,facility,inpatient,1,EA,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,17.58,23.97,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,00574010603,NDC,,,facility,outpatient,1,EA,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,10.56,23.97,percent of total billed charges,
Glucose 15g Gel(Glutose 15),800053933,CDM,250,RC,00574007030,NDC,,,facility,inpatient,1,EA,27.95000,8.11000,Aetna,First Health,,22.86,,,,,,,10.34,22.86,percent of total billed charges,
Glucose 15g Gel(Glutose 15),800053933,CDM,250,RC,00574007030,NDC,,,facility,outpatient,1,EA,27.95000,8.11000,Aetna,First Health,,22.86,,,,,,,10.08,22.86,percent of total billed charges,
Glucose 15g Gel(Glutose 15),800053933,CDM,250,RC,00574006930,NDC,,,facility,inpatient,1,EA,43.55000,12.63000,Aetna,First Health,,35.62,,,,,,,16.11,35.62,percent of total billed charges,
Glucose 15g Gel(Glutose 15),800053933,CDM,250,RC,00574006930,NDC,,,facility,outpatient,1,EA,43.55000,12.63000,Aetna,First Health,,35.62,,,,,,,15.70,35.62,percent of total billed charges,
Norgestimate-ethinyl estradiol,800062117,CDM,637,RC,00555901658,NDC,,,facility,inpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,4.89,6.67,percent of total billed charges,
Norgestimate-ethinyl estradiol,800062117,CDM,637,RC,00555901658,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,2.94,6.67,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00555112810,NDC,facility,inpatient,10,ME,120.40000,34.92000,Aetna,First Health,,98.49,,,,,,,43.40,98.49,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00555112810,NDC,facility,outpatient,10,ME,120.40000,34.92000,Aetna,First Health,,98.49,,,,,,,13.00,98.49,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,00555101116,NDC,,,facility,inpatient,1,EA,510.90000,148.16000,Aetna,First Health,,417.92,,,,,,,306.54,417.92,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,00555101116,NDC,,,facility,outpatient,1,EA,510.90000,148.16000,Aetna,First Health,,417.92,,,,,,,184.18,417.92,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00555101016,NDC,,,facility,inpatient,1,EA,379.45000,110.04000,Aetna,First Health,,310.39,,,,,,,227.67,310.39,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00555101016,NDC,,,facility,outpatient,1,EA,379.45000,110.04000,Aetna,First Health,,310.39,,,,,,,136.79,310.39,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00555100916,NDC,,,facility,inpatient,1,EA,233.20000,67.63000,Aetna,First Health,,190.76,,,,,,,139.92,190.76,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00555100916,NDC,,,facility,outpatient,1,EA,233.20000,67.63000,Aetna,First Health,,190.76,,,,,,,84.07,190.76,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00555099702,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00555099702,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,00555097302,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,00555097302,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,00555097102,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,00555097102,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine 5mg T,800081078,CDM,637,RC,S0160,HCPCS,00555095202,NDC,facility,inpatient,5,ME,23.20000,6.73000,Aetna,First Health,,18.98,,,,,,,13.92,18.98,percent of total billed charges,
Dextroamphetamine 5mg T,800081078,CDM,637,RC,S0160,HCPCS,00555095202,NDC,facility,outpatient,5,ME,23.20000,6.73000,Aetna,First Health,,18.98,,,,,,,2.79,18.98,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,00555092302,NDC,,,facility,inpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,7.59,10.35,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,00555092302,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,4.56,10.35,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00555091709,NDC,,,facility,inpatient,1,EA,23.70000,6.87000,Aetna,First Health,,19.39,,,,,,,14.22,19.39,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00555091709,NDC,,,facility,outpatient,1,EA,23.70000,6.87000,Aetna,First Health,,19.39,,,,,,,8.54,19.39,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00555088604,NDC,,,facility,inpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,2.82,3.84,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00555088604,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00555088602,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00555088602,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,00555088202,NDC,,,facility,inpatient,1,EA,10.45000,3.03000,Aetna,First Health,,8.55,,,,,,,6.27,8.55,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,00555088202,NDC,,,facility,outpatient,1,EA,10.45000,3.03000,Aetna,First Health,,8.55,,,,,,,3.77,8.55,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00555087702,NDC,,,facility,inpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,11.34,15.46,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00555087702,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,6.81,15.46,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,00555087202,NDC,,,facility,inpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,00555087202,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.79310,1.80,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,00555077702,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,00555077702,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,00555076702,NDC,,,facility,inpatient,1,EA,42.30000,12.27000,Aetna,First Health,,34.60,,,,,,,25.38,34.60,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,00555076702,NDC,,,facility,outpatient,1,EA,42.30000,12.27000,Aetna,First Health,,34.60,,,,,,,15.25,34.60,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,00555076602,NDC,,,facility,inpatient,1,EA,42.30000,12.27000,Aetna,First Health,,34.60,,,,,,,25.38,34.60,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,00555076602,NDC,,,facility,outpatient,1,EA,42.30000,12.27000,Aetna,First Health,,34.60,,,,,,,15.25,34.60,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,00555070102,NDC,,,facility,inpatient,1,EA,74.90000,21.72000,Aetna,First Health,,61.27,,,,,,,44.94,61.27,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,00555070102,NDC,,,facility,outpatient,1,EA,74.90000,21.72000,Aetna,First Health,,61.27,,,,,,,27.00,61.27,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00555061762,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00555061762,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,00555061314,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,00555061314,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00555058504,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00555058504,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00555058502,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00555058502,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00555057202,NDC,facility,inpatient,2.5,ME,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,15.15,20.65,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00555057202,NDC,facility,outpatient,2.5,ME,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,0.14445,20.65,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00555044609,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00555044609,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00555032304,NDC,facility,inpatient,25,ME,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00555032304,NDC,facility,outpatient,25,ME,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,0.21186,3.23,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00555032302,NDC,facility,inpatient,25,ME,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00555032302,NDC,facility,outpatient,25,ME,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,0.21186,3.31,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00555030202,NDC,facility,inpatient,50,ME,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00555030202,NDC,facility,outpatient,50,ME,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.21186,1.88,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00555030138,NDC,facility,inpatient,4,ME,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00555030138,NDC,facility,outpatient,4,ME,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,0.13482,3.03,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00555030102,NDC,facility,inpatient,4,ME,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00555030102,NDC,facility,outpatient,4,ME,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,0.13482,3.11,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,00555025202,NDC,,,facility,inpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,4.50,6.13,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,00555025202,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,2.70,6.13,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,00555021110,NDC,,,facility,inpatient,1,EA,18.75000,5.44000,Aetna,First Health,,15.34,,,,,,,11.25,15.34,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,00555021110,NDC,,,facility,outpatient,1,EA,18.75000,5.44000,Aetna,First Health,,15.34,,,,,,,6.76,15.34,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00555015904,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00555015904,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00555015902,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00555015902,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),800015397,CDM,637,RC,00555009596,NDC,,,facility,inpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,6.24,8.51,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),800015397,CDM,637,RC,00555009596,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00555007102,NDC,,,facility,inpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00555007102,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.79310,1.80,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00555007101,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00555007101,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00555003302,NDC,,,facility,inpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.92,2.62,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00555003302,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,inpatient,10,ME,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,41.42,93.99,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,outpatient,10,ME,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,0.92448,93.99,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00548906100,NDC,facility,inpatient,1,ME,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00548906100,NDC,facility,outpatient,1,ME,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.37000,1.33,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,00548590000,NDC,facility,inpatient,0.25,ME,578.60000,167.79000,Aetna,First Health,,473.29,,,,,,,208.59,473.29,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,00548590000,NDC,facility,outpatient,0.25,ME,578.60000,167.79000,Aetna,First Health,,473.29,,,,,,,19.89,473.29,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00548571100,NDC,facility,inpatient,150,ME,326.10000,94.57000,Aetna,First Health,,266.75,,,,,,,117.56,266.75,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00548571100,NDC,facility,outpatient,150,ME,326.10000,94.57000,Aetna,First Health,,266.75,,,,,,,0.40446,266.75,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00548570100,NDC,facility,inpatient,150,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,57.18,129.73,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00548570100,NDC,facility,outpatient,150,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,0.40446,129.73,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00548560700,NDC,facility,inpatient,150,ME,144.15000,41.80000,Aetna,First Health,,117.91,,,,,,,51.97,117.91,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00548560700,NDC,facility,outpatient,150,ME,144.15000,41.80000,Aetna,First Health,,117.91,,,,,,,0.51039,117.91,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00548560600,NDC,facility,inpatient,120,ME,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,41.42,93.99,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00548560600,NDC,facility,outpatient,120,ME,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,0.51039,93.99,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00548560500,NDC,facility,inpatient,100,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,34.52,78.32,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00548560500,NDC,facility,outpatient,100,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,0.51039,78.32,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00548560300,NDC,facility,inpatient,60,ME,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,20.71,46.99,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00548560300,NDC,facility,outpatient,60,ME,57.45000,16.66000,Aetna,First Health,,46.99,,,,,,,0.51039,46.99,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00548560200,NDC,facility,inpatient,40,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00548560200,NDC,facility,outpatient,40,ME,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,0.51039,31.33,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00548540000,NDC,facility,inpatient,150,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,57.18,129.73,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00548540000,NDC,facility,outpatient,150,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,0.40446,129.73,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00548339000,NDC,,,facility,inpatient,1,EA,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00548339000,NDC,,,facility,outpatient,1,EA,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,00548336900,NDC,facility,inpatient,2,ME,108.20000,31.38000,Aetna,First Health,,88.51,,,,,,,39.01,88.51,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,00548336900,NDC,facility,outpatient,2,ME,108.20000,31.38000,Aetna,First Health,,88.51,,,,,,,0.06741,88.51,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00548333900,NDC,facility,inpatient,1,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00548333900,NDC,facility,outpatient,1,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,0.09630,20.90,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00548331600,NDC,facility,inpatient,1,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00548331600,NDC,facility,outpatient,1,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,2.89,20.90,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00548330400,NDC,,,facility,inpatient,1,EA,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.45,20.90,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00548330400,NDC,,,facility,outpatient,1,EA,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
D50W 50mL Inj Syr,800011221,CDM,258,RC,00548330100,NDC,,,facility,inpatient,1,EA,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,18.00,31.33,percent of total billed charges,
D50W 50mL Inj Syr,800011221,CDM,258,RC,00548330100,NDC,,,facility,outpatient,1,EA,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00548124000,NDC,facility,inpatient,1,ME,27.15000,7.87000,Aetna,First Health,,22.21,,,,,,,9.79,22.21,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00548124000,NDC,facility,outpatient,1,ME,27.15000,7.87000,Aetna,First Health,,22.21,,,,,,,2.71,22.21,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00548114000,NDC,facility,inpatient,1,ME,28.35000,8.22000,Aetna,First Health,,23.19,,,,,,,10.22,23.19,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00548114000,NDC,facility,outpatient,1,ME,28.35000,8.22000,Aetna,First Health,,23.19,,,,,,,2.71,23.19,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00536567201,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00536567201,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,00536461701,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,00536461701,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,00536351501,NDC,,,facility,inpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.18000,0.24540,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,00536351501,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.10815,0.24540,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00536300094,NDC,,,facility,inpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,6.66,14.72,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00536300094,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,6.49,14.72,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,00536252525,NDC,,,facility,inpatient,1,EA,70.45000,20.43000,Aetna,First Health,,57.63,,,,,,,26.07,57.63,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,00536252525,NDC,,,facility,outpatient,1,EA,70.45000,20.43000,Aetna,First Health,,57.63,,,,,,,25.40,57.63,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00536140795,NDC,,,facility,inpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,4.85,10.72,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00536140795,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,4.72,10.72,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00536137904,NDC,,,facility,inpatient,1,EA,152.85000,44.33000,Aetna,First Health,,125.03,,,,,,,56.55,125.03,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00536137904,NDC,,,facility,outpatient,1,EA,152.85000,44.33000,Aetna,First Health,,125.03,,,,,,,55.10,125.03,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00536137575,NDC,,,facility,inpatient,1,EA,39.55000,11.47000,Aetna,First Health,,32.35,,,,,,,14.63,32.35,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00536137575,NDC,,,facility,outpatient,1,EA,39.55000,11.47000,Aetna,First Health,,32.35,,,,,,,14.26,32.35,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,00536134957,NDC,,,facility,inpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,10.60,23.44,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,00536134957,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,10.33,23.44,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,00536133321,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,00536133321,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00536130723,NDC,,,facility,inpatient,1,EA,118.85000,34.47000,Aetna,First Health,,97.22,,,,,,,71.31,97.22,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00536130723,NDC,,,facility,outpatient,1,EA,118.85000,34.47000,Aetna,First Health,,97.22,,,,,,,42.85,97.22,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00536129801,NDC,,,facility,inpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.51000,0.69530,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00536129801,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.30643,0.69530,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,00536129497,NDC,,,facility,inpatient,1,EA,108.40000,31.44000,Aetna,First Health,,88.67,,,,,,,65.04,88.67,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,00536129497,NDC,,,facility,outpatient,1,EA,108.40000,31.44000,Aetna,First Health,,88.67,,,,,,,39.08,88.67,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00536127803,NDC,,,facility,inpatient,1,EA,102.65000,29.77000,Aetna,First Health,,83.97,,,,,,,61.59,83.97,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00536127803,NDC,,,facility,outpatient,1,EA,102.65000,29.77000,Aetna,First Health,,83.97,,,,,,,37.01,83.97,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00536127780,NDC,,,facility,inpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,4.85,10.72,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00536127780,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,4.72,10.72,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00536126720,NDC,,,facility,inpatient,1,EA,78.85000,22.87000,Aetna,First Health,,64.50,,,,,,,47.31,64.50,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00536126720,NDC,,,facility,outpatient,1,EA,78.85000,22.87000,Aetna,First Health,,64.50,,,,,,,28.43,64.50,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00536126526,NDC,,,facility,inpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,2.39,5.28,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00536126526,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,2.33,5.28,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00536126511,NDC,,,facility,inpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,4.11,9.08,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00536126511,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,4.00,9.08,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00536125628,NDC,,,facility,inpatient,1,EA,16.10000,4.67000,Aetna,First Health,,13.17,,,,,,,5.96,13.17,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00536125628,NDC,,,facility,outpatient,1,EA,16.10000,4.67000,Aetna,First Health,,13.17,,,,,,,5.80,13.17,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,00536120215,NDC,,,facility,inpatient,1,EA,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,6.39,8.71,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,00536120215,NDC,,,facility,outpatient,1,EA,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,3.84,8.71,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,00536120207,NDC,,,facility,inpatient,1,EA,9.25000,2.68000,Aetna,First Health,,7.57,,,,,,,5.55,7.57,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,00536120207,NDC,,,facility,outpatient,1,EA,9.25000,2.68000,Aetna,First Health,,7.57,,,,,,,3.33,7.57,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,00536116137,NDC,,,facility,inpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,1.59,3.52,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,00536116137,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,1.55,3.52,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,00536105224,NDC,,,facility,inpatient,1,EA,77.80000,22.56000,Aetna,First Health,,63.64,,,,,,,28.79,63.64,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,00536105224,NDC,,,facility,outpatient,1,EA,77.80000,22.56000,Aetna,First Health,,63.64,,,,,,,28.05,63.64,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00536101294,NDC,,,facility,inpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,15.11,33.42,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00536101294,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00527600480,NDC,,,facility,inpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.39,7.48,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00527600480,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.30,7.48,percent of total billed charges,
Mycophenolate Mofetil 500mg/2.5mL Susp,800021979,CDM,637,RC,J7517,HCPCS,00527516082,NDC,facility,inpatient,500,ME,160.35000,46.50000,Aetna,First Health,,131.17,,,,,,,96.21,131.17,percent of total billed charges,
Mycophenolate Mofetil 500mg/2.5mL Susp,800021979,CDM,637,RC,J7517,HCPCS,00527516082,NDC,facility,outpatient,500,ME,160.35000,46.50000,Aetna,First Health,,131.17,,,,,,,0.14445,131.17,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,00527459313,NDC,,,facility,inpatient,1,EA,109.45000,31.74000,Aetna,First Health,,89.53,,,,,,,65.67,89.53,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,00527459313,NDC,,,facility,outpatient,1,EA,109.45000,31.74000,Aetna,First Health,,89.53,,,,,,,39.46,89.53,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,00527459113,NDC,,,facility,inpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,60.24,82.13,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,00527459113,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,36.19,82.13,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00527260137,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00527260137,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00527221537,NDC,,,facility,inpatient,1,EA,17.35000,5.03000,Aetna,First Health,,14.19,,,,,,,10.41,14.19,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00527221537,NDC,,,facility,outpatient,1,EA,17.35000,5.03000,Aetna,First Health,,14.19,,,,,,,6.25,14.19,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00527169501,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00527169501,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00527163810,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00527163810,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00527163801,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00527163801,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,00527144201,NDC,,,facility,inpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,2.82,3.84,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,00527144201,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
Loxapine Succinate 10mg,800062072,CDM,637,RC,00527139501,NDC,,,facility,inpatient,1,EA,9.00000,2.61000,Aetna,First Health,,7.36,,,,,,,5.40,7.36,percent of total billed charges,
Loxapine Succinate 10mg,800062072,CDM,637,RC,00527139501,NDC,,,facility,outpatient,1,EA,9.00000,2.61000,Aetna,First Health,,7.36,,,,,,,3.24,7.36,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00527136701,NDC,,,facility,inpatient,1,EA,26.40000,7.66000,Aetna,First Health,,21.60,,,,,,,15.84,21.60,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00527136701,NDC,,,facility,outpatient,1,EA,26.40000,7.66000,Aetna,First Health,,21.60,,,,,,,9.52,21.60,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00527135001,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00527135001,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00527134710,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00527134710,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00527134701,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00527134701,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00527134601,NDC,,,facility,inpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,2.76,3.76,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00527134601,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,1.66,3.76,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00527134501,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00527134501,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00527134401,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00527134401,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00527134301,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00527134301,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00527134201,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00527134201,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00527134110,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00527134110,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00527134101,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00527134101,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00527132601,NDC,,,facility,inpatient,1,EA,52.05000,15.09000,Aetna,First Health,,42.58,,,,,,,31.23,42.58,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00527132601,NDC,,,facility,outpatient,1,EA,52.05000,15.09000,Aetna,First Health,,42.58,,,,,,,18.76,42.58,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00527132410,NDC,,,facility,inpatient,1,EA,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,8.07,11.00,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00527132410,NDC,,,facility,outpatient,1,EA,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,4.85,11.00,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00527132401,NDC,,,facility,inpatient,1,EA,16.30000,4.73000,Aetna,First Health,,13.33,,,,,,,9.78,13.33,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00527132401,NDC,,,facility,outpatient,1,EA,16.30000,4.73000,Aetna,First Health,,13.33,,,,,,,5.88,13.33,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00527131530,NDC,,,facility,inpatient,1,EA,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,19.50,26.59,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00527131530,NDC,,,facility,outpatient,1,EA,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,11.72,26.59,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00527131301,NDC,,,facility,inpatient,1,EA,12.85000,3.73000,Aetna,First Health,,10.51,,,,,,,7.71,10.51,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00527131301,NDC,,,facility,outpatient,1,EA,12.85000,3.73000,Aetna,First Health,,10.51,,,,,,,4.63,10.51,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00527130105,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00527130105,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00527130101,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00527130101,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00527123101,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00527123101,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00527058610,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00527058610,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00527058601,NDC,,,facility,inpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.92,2.62,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00527058601,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
droPERidol 2.5mg/mL 2mL I,800011791,CDM,636,RC,J1790,HCPCS,00517970225,NDC,facility,inpatient,5,ME,67.85000,19.68000,Aetna,First Health,,55.50,,,,,,,24.46,55.50,percent of total billed charges,
droPERidol 2.5mg/mL 2mL I,800011791,CDM,636,RC,J1790,HCPCS,00517970225,NDC,facility,outpatient,5,ME,67.85000,19.68000,Aetna,First Health,,55.50,,,,,,,6.91,55.50,percent of total billed charges,
trace elements (Cu/Mn/Se/Zn) 0.3mg-55mcg-60mcg-3mg/mL I,800046540,CDM,250,RC,00517930525,NDC,,,facility,inpatient,1,EA,170.05000,49.31000,Aetna,First Health,,139.10,,,,,,,62.92,139.10,percent of total billed charges,
trace elements (Cu/Mn/Se/Zn) 0.3mg-55mcg-60mcg-3mg/mL I,800046540,CDM,250,RC,00517930525,NDC,,,facility,outpatient,1,EA,170.05000,49.31000,Aetna,First Health,,139.10,,,,,,,61.30,139.10,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),800010165,CDM,250,RC,J0281,HCPCS,00517919125,NDC,facility,inpatient,5000,ME,86.40000,25.06000,Aetna,First Health,,70.68,,,,,,,31.97,70.68,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),800010165,CDM,250,RC,J0281,HCPCS,00517919125,NDC,facility,outpatient,5000,ME,86.40000,25.06000,Aetna,First Health,,70.68,,,,,,,1.53,70.68,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),800010165,CDM,250,RC,J0281,HCPCS,00517912025,NDC,facility,inpatient,5000,ME,98.60000,28.59000,Aetna,First Health,,80.65,,,,,,,36.48,80.65,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),800010165,CDM,250,RC,J0281,HCPCS,00517912025,NDC,facility,outpatient,5000,ME,98.60000,28.59000,Aetna,First Health,,80.65,,,,,,,1.53,80.65,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,800042530,CDM,250,RC,00517671010,NDC,,,facility,inpatient,1,EA,206.25000,59.81000,Aetna,First Health,,168.71,,,,,,,76.31,168.71,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,800042530,CDM,250,RC,00517671010,NDC,,,facility,outpatient,1,EA,206.25000,59.81000,Aetna,First Health,,168.71,,,,,,,74.35,168.71,percent of total billed charges,
Furosemide 100mg I,800013344,CDM,636,RC,J1938,HCPCS,00517571025,NDC,facility,inpatient,100,ME,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,8.11,18.41,percent of total billed charges,
Furosemide 100mg I,800013344,CDM,636,RC,J1938,HCPCS,00517571025,NDC,facility,outpatient,100,ME,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,0.01926,18.41,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,00517571025,NDC,facility,inpatient,100,ME,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,5.39,12.23,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,00517571025,NDC,facility,outpatient,100,ME,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,5.39,12.23,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00517570425,NDC,facility,inpatient,40,ME,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,4.20,9.53,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00517570425,NDC,facility,outpatient,40,ME,11.65000,3.38000,Aetna,First Health,,9.53,,,,,,,0.01926,9.53,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,00517570225,NDC,facility,inpatient,20,ME,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,00517570225,NDC,facility,outpatient,20,ME,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,0.01926,8.18,percent of total billed charges,
hydrOXYzine HCl 50mg/1mL Inj,800021995,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,inpatient,50,ME,200.80000,58.23000,Aetna,First Health,,164.25,,,,,,,72.39,164.25,percent of total billed charges,
hydrOXYzine HCl 50mg/1mL Inj,800021995,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,outpatient,50,ME,200.80000,58.23000,Aetna,First Health,,164.25,,,,,,,12.52,164.25,percent of total billed charges,
Sodium Thiosulfate 12.5g/50mL Inj,800017828,CDM,636,RC,J0209,HCPCS,00517501901,NDC,facility,inpatient,12.5,GM,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,41.42,93.99,percent of total billed charges,
Sodium Thiosulfate 12.5g/50mL Inj,800017828,CDM,636,RC,J0209,HCPCS,00517501901,NDC,facility,outpatient,12.5,GM,114.90000,33.32000,Aetna,First Health,,93.99,,,,,,,0.88000,93.99,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,00517490525,NDC,facility,inpatient,1,ME,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.30643,0.69530,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,00517490525,NDC,facility,outpatient,1,ME,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.10593,0.69530,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,00517490525,NDC,facility,inpatient,4,ME,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
dexaMETHasone 4mg/mL I- For Oral Use,800025574,CDM,637,RC,J8540,HCPCS,00517490525,NDC,facility,outpatient,4,ME,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,0.00963,2.41,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,00517490125,NDC,facility,inpatient,4,ME,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,00517490125,NDC,facility,outpatient,4,ME,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,0.10593,4.54,percent of total billed charges,
Nitroglycerin 50mg/10mL I,800040484,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,inpatient,50,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,57.18,129.73,percent of total billed charges,
Nitroglycerin 50mg/10mL I,800040484,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,outpatient,50,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,1.46,129.73,percent of total billed charges,
Nitroglycerin 50mg/10mL I,800040484,CDM,636,RC,J2305,HCPCS,00517481010,NDC,facility,inpatient,50,ME,119.85000,34.76000,Aetna,First Health,,98.04,,,,,,,43.21,98.04,percent of total billed charges,
Nitroglycerin 50mg/10mL I,800040484,CDM,636,RC,J2305,HCPCS,00517481010,NDC,facility,outpatient,50,ME,119.85000,34.76000,Aetna,First Health,,98.04,,,,,,,1.46,98.04,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,00517460525,NDC,facility,inpatient,1,ME,278.60000,80.79000,Aetna,First Health,,227.89,,,,,,,100.44,227.89,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,00517460525,NDC,facility,outpatient,1,ME,278.60000,80.79000,Aetna,First Health,,227.89,,,,,,,0.36594,227.89,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00517460125,NDC,facility,inpatient,0.2,ME,86.45000,25.07000,Aetna,First Health,,70.72,,,,,,,31.17,70.72,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00517460125,NDC,facility,outpatient,0.2,ME,86.45000,25.07000,Aetna,First Health,,70.72,,,,,,,0.36594,70.72,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,00517430001,NDC,facility,inpatient,100,ME,9037.40000,2620.85000,Aetna,First Health,,7392.59,,,,,,,3257.98,7392.59,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,00517430001,NDC,facility,outpatient,100,ME,9037.40000,2620.85000,Aetna,First Health,,7392.59,,,,,,,7.88,7392.59,percent of total billed charges,
Mannitol 25% I 50mL,800050889,CDM,636,RC,J2150,HCPCS,00517405025,NDC,facility,inpatient,12.5,GM,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,6.33,14.36,percent of total billed charges,
Mannitol 25% I 50mL,800050889,CDM,636,RC,J2150,HCPCS,00517405025,NDC,facility,outpatient,12.5,GM,17.55000,5.09000,Aetna,First Health,,14.36,,,,,,,6.33,14.36,percent of total billed charges,
Papaverine HCl 60mg/2mL I,800025540,CDM,637,RC,J2440,HCPCS,00517400225,NDC,facility,inpatient,60,ME,385.70000,111.85000,Aetna,First Health,,315.50,,,,,,,231.42,315.50,percent of total billed charges,
Papaverine HCl 60mg/2mL I,800025540,CDM,637,RC,J2440,HCPCS,00517400225,NDC,facility,outpatient,60,ME,385.70000,111.85000,Aetna,First Health,,315.50,,,,,,,43.34,315.50,percent of total billed charges,
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,00517391025,NDC,facility,inpatient,1,GM,115.60000,33.52000,Aetna,First Health,,94.56,,,,,,,41.67,94.56,percent of total billed charges,
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,00517391025,NDC,facility,outpatient,1,GM,115.60000,33.52000,Aetna,First Health,,94.56,,,,,,,0.02889,94.56,percent of total billed charges,
NICU- Calcium Gluconate 0.465mEq/mL Inj,800017966,CDM,636,RC,J0612,HCPCS,00517391025,NDC,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
NICU- Calcium Gluconate 0.465mEq/mL Inj,800017966,CDM,636,RC,J0612,HCPCS,00517391025,NDC,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,0.02889,6.18,percent of total billed charges,
Aminophylline 500mg/20mL I,800013441,CDM,636,RC,J0280,HCPCS,00517382025,NDC,facility,inpatient,500,ME,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,2.56,5.81,percent of total billed charges,
Aminophylline 500mg/20mL I,800013441,CDM,636,RC,J0280,HCPCS,00517382025,NDC,facility,outpatient,500,ME,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,2.63,32.10,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00517360525,NDC,facility,inpatient,500,ME,134.80000,39.09000,Aetna,First Health,,110.27,,,,,,,48.60,110.27,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00517360525,NDC,facility,outpatient,500,ME,134.80000,39.09000,Aetna,First Health,,110.27,,,,,,,0.03852,110.27,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,00517341525,NDC,,,facility,inpatient,1,EA,249.00000,72.21000,Aetna,First Health,,203.68,,,,,,,92.13,203.68,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,00517341525,NDC,,,facility,outpatient,1,EA,249.00000,72.21000,Aetna,First Health,,203.68,,,,,,,89.76,203.68,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,00517340525,NDC,,,facility,inpatient,1,EA,87.65000,25.42000,Aetna,First Health,,71.70,,,,,,,32.43,71.70,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,00517340525,NDC,,,facility,outpatient,1,EA,87.65000,25.42000,Aetna,First Health,,71.70,,,,,,,31.60,71.70,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,00517305025,NDC,facility,inpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,4.37,7.61,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,00517305025,NDC,facility,outpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,0.63000,7.61,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,800042530,CDM,250,RC,00517271025,NDC,,,facility,inpatient,1,EA,197.10000,57.16000,Aetna,First Health,,161.23,,,,,,,72.93,161.23,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,800042530,CDM,250,RC,00517271025,NDC,,,facility,outpatient,1,EA,197.10000,57.16000,Aetna,First Health,,161.23,,,,,,,71.05,161.23,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,00517261025,NDC,facility,inpatient,10,GM,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,9.57,21.72,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,00517261025,NDC,facility,outpatient,10,GM,26.55000,7.70000,Aetna,First Health,,21.72,,,,,,,0.39483,21.72,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517234025,NDC,facility,inpatient,100,ME,567.70000,164.63000,Aetna,First Health,,464.38,,,,,,,204.66,464.38,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517234025,NDC,facility,outpatient,100,ME,567.70000,164.63000,Aetna,First Health,,464.38,,,,,,,0.23112,464.38,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,inpatient,100,ME,567.70000,164.63000,Aetna,First Health,,464.38,,,,,,,204.66,464.38,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,outpatient,100,ME,567.70000,164.63000,Aetna,First Health,,464.38,,,,,,,0.23112,464.38,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517234001,NDC,facility,inpatient,100,ME,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,180.25,409.00,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517234001,NDC,facility,outpatient,100,ME,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,0.23112,409.00,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00517231525,NDC,,,facility,inpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,15.72,34.77,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00517231525,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,15.32,34.77,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517231001,NDC,facility,inpatient,100,ME,519.60000,150.68000,Aetna,First Health,,425.03,,,,,,,187.32,425.03,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517231001,NDC,facility,outpatient,100,ME,519.60000,150.68000,Aetna,First Health,,425.03,,,,,,,0.23112,425.03,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00517210225,NDC,,,facility,inpatient,1,EA,471.55000,136.75000,Aetna,First Health,,385.73,,,,,,,174.47,385.73,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00517210225,NDC,,,facility,outpatient,1,EA,471.55000,136.75000,Aetna,First Health,,385.73,,,,,,,169.99,385.73,percent of total billed charges,
NICU- Sodium Acetate 2mEq/mL Inj,800072480,CDM,250,RC,00517209625,NDC,,,facility,inpatient,1,EA,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,12.78,28.26,percent of total billed charges,
NICU- Sodium Acetate 2mEq/mL Inj,800072480,CDM,250,RC,00517209625,NDC,,,facility,outpatient,1,EA,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,12.46,28.26,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,inpatient,500,ME,854.00000,247.66000,Aetna,First Health,,698.57,,,,,,,307.87,698.57,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,outpatient,500,ME,854.00000,247.66000,Aetna,First Health,,698.57,,,,,,,55.98,698.57,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00517135525,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.46,5.44,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00517135525,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00517107125,NDC,facility,inpatient,1,ME,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,8.06,18.28,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00517107125,NDC,facility,outpatient,1,ME,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,0.41409,18.28,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,00517102025,NDC,facility,inpatient,20,UN,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,00517102025,NDC,facility,outpatient,20,UN,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,0.51039,245.56,percent of total billed charges,
Vasopressin 20units/1mL- For IV Set,800025670,CDM,636,RC,J2599,HCPCS,00517102025,NDC,facility,inpatient,20,UN,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,176.65,400.82,percent of total billed charges,
Vasopressin 20units/1mL- For IV Set,800025670,CDM,636,RC,J2599,HCPCS,00517102025,NDC,facility,outpatient,20,UN,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,0.82818,400.82,percent of total billed charges,
Atropine SO4 1mg/mL 1mL I,800013438,CDM,636,RC,J0461,HCPCS,00517101025,NDC,facility,inpatient,1,ME,80.20000,23.26000,Aetna,First Health,,65.60,,,,,,,28.91,65.60,percent of total billed charges,
Atropine SO4 1mg/mL 1mL I,800013438,CDM,636,RC,J0461,HCPCS,00517101025,NDC,facility,outpatient,1,ME,80.20000,23.26000,Aetna,First Health,,65.60,,,,,,,0.09630,65.60,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,00517096010,NDC,,,facility,inpatient,1,EA,199.85000,57.96000,Aetna,First Health,,163.48,,,,,,,73.94,163.48,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,00517096010,NDC,,,facility,outpatient,1,EA,199.85000,57.96000,Aetna,First Health,,163.48,,,,,,,72.05,163.48,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,00517095501,NDC,facility,inpatient,10,ME,242.40000,70.30000,Aetna,First Health,,198.28,,,,,,,87.39,198.28,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,00517095501,NDC,facility,outpatient,10,ME,242.40000,70.30000,Aetna,First Health,,198.28,,,,,,,0.78003,198.28,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,00517090125,NDC,facility,inpatient,20,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,34.52,78.32,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,00517090125,NDC,facility,outpatient,20,ME,95.75000,27.77000,Aetna,First Health,,78.32,,,,,,,4.23,78.32,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00517079101,NDC,facility,inpatient,30,ME,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,111.03,251.94,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00517079101,NDC,facility,outpatient,30,ME,308.00000,89.32000,Aetna,First Health,,251.94,,,,,,,6.65,251.94,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00517078110,NDC,,,facility,inpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,12.30,27.20,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00517078110,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,11.99,27.20,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00517078010,NDC,,,facility,inpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,18.46,40.82,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00517078010,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,17.99,40.82,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,inpatient,0.2,ME,194.90000,56.52000,Aetna,First Health,,159.43,,,,,,,70.26,159.43,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,outpatient,0.2,ME,194.90000,56.52000,Aetna,First Health,,159.43,,,,,,,20.57,159.43,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00517073510,NDC,facility,inpatient,25,ME,310.10000,89.93000,Aetna,First Health,,253.66,,,,,,,111.79,253.66,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00517073510,NDC,facility,outpatient,25,ME,310.10000,89.93000,Aetna,First Health,,253.66,,,,,,,0.06741,253.66,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,inpatient,30,ME,334.00000,96.86000,Aetna,First Health,,273.21,,,,,,,120.41,273.21,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,outpatient,30,ME,334.00000,96.86000,Aetna,First Health,,273.21,,,,,,,6.65,273.21,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00517062625,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00517062625,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00517062525,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00517062525,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00517040525,NDC,facility,inpatient,50,ME,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,45.96,104.30,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00517040525,NDC,facility,outpatient,50,ME,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,47.17,104.30,percent of total billed charges,
Atropine SO4 0.4mg/mL 1mL I,800019204,CDM,636,RC,J0461,HCPCS,00517040125,NDC,facility,inpatient,0.4,ME,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,18.40,41.76,percent of total billed charges,
Atropine SO4 0.4mg/mL 1mL I,800019204,CDM,636,RC,J0461,HCPCS,00517040125,NDC,facility,outpatient,0.4,ME,51.05000,14.80000,Aetna,First Health,,41.76,,,,,,,0.09630,41.76,percent of total billed charges,
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,00517038105,NDC,facility,inpatient,50,ME,1123.80000,325.90000,Aetna,First Health,,919.27,,,,,,,405.13,919.27,percent of total billed charges,
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,00517038105,NDC,facility,outpatient,50,ME,1123.80000,325.90000,Aetna,First Health,,919.27,,,,,,,5.42,919.27,percent of total billed charges,
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,00517037405,NDC,facility,inpatient,50,ME,1123.80000,325.90000,Aetna,First Health,,919.27,,,,,,,405.13,919.27,percent of total billed charges,
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,00517037405,NDC,facility,outpatient,50,ME,1123.80000,325.90000,Aetna,First Health,,919.27,,,,,,,5.42,919.27,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00517029925,NDC,facility,inpatient,50,ME,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,45.96,104.30,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00517029925,NDC,facility,outpatient,50,ME,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,47.17,104.30,percent of total billed charges,
Iron Dextran 100mg/2mL I(Infed),800012496,CDM,636,RC,J1750,HCPCS,00517023410,NDC,facility,inpatient,100,ME,350.50000,101.64000,Aetna,First Health,,286.71,,,,,,,126.36,286.71,percent of total billed charges,
Iron Dextran 100mg/2mL I(Infed),800012496,CDM,636,RC,J1750,HCPCS,00517023410,NDC,facility,outpatient,100,ME,350.50000,101.64000,Aetna,First Health,,286.71,,,,,,,17.41,286.71,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,00517013005,NDC,facility,inpatient,1,ME,23.70000,6.87000,Aetna,First Health,,19.39,,,,,,,8.54,19.39,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,00517013005,NDC,facility,outpatient,1,ME,23.70000,6.87000,Aetna,First Health,,19.39,,,,,,,0.61632,19.39,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,00517003125,NDC,facility,inpatient,1,ME,46.50000,13.48000,Aetna,First Health,,38.04,,,,,,,16.76,38.04,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,00517003125,NDC,facility,outpatient,1,ME,46.50000,13.48000,Aetna,First Health,,38.04,,,,,,,0.61632,38.04,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,00517002010,NDC,facility,inpatient,60,ME,180.00000,52.20000,Aetna,First Health,,147.24,,,,,,,64.89,147.24,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,00517002010,NDC,facility,outpatient,60,ME,180.00000,52.20000,Aetna,First Health,,147.24,,,,,,,1.40,147.24,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,00501379801,NDC,,,facility,inpatient,1,EA,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,29.60,65.44,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,00501379801,NDC,,,facility,outpatient,1,EA,80.00000,23.20000,Aetna,First Health,,65.44,,,,,,,28.84,65.44,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,00496095305,NDC,,,facility,inpatient,1,EA,336.45000,97.57000,Aetna,First Health,,275.22,,,,,,,201.87,275.22,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,00496095305,NDC,,,facility,outpatient,1,EA,336.45000,97.57000,Aetna,First Health,,275.22,,,,,,,121.29,275.22,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00496088230,NDC,,,facility,inpatient,1,EA,192.75000,55.90000,Aetna,First Health,,157.67,,,,,,,115.65,157.67,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00496088230,NDC,,,facility,outpatient,1,EA,192.75000,55.90000,Aetna,First Health,,157.67,,,,,,,69.49,157.67,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00496088215,NDC,,,facility,inpatient,1,EA,207.20000,60.09000,Aetna,First Health,,169.49,,,,,,,124.32,169.49,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00496088215,NDC,,,facility,outpatient,1,EA,207.20000,60.09000,Aetna,First Health,,169.49,,,,,,,74.70,169.49,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,00496080004,NDC,,,facility,inpatient,1,EA,603.60000,175.04000,Aetna,First Health,,493.74,,,,,,,362.16,493.74,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,00496080004,NDC,,,facility,outpatient,1,EA,603.60000,175.04000,Aetna,First Health,,493.74,,,,,,,217.60,493.74,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,00496079904,NDC,,,facility,inpatient,1,EA,1421.30000,412.18000,Aetna,First Health,,1162.62,,,,,,,852.78,1162.62,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,00496079904,NDC,,,facility,outpatient,1,EA,1421.30000,412.18000,Aetna,First Health,,1162.62,,,,,,,512.38,1162.62,percent of total billed charges,
Hydrocortisone 2.5%-Pramox 1% Top Oint,800025581,CDM,637,RC,00496077704,NDC,,,facility,inpatient,1,EA,1115.90000,323.61000,Aetna,First Health,,912.81,,,,,,,669.54,912.81,percent of total billed charges,
Hydrocortisone 2.5%-Pramox 1% Top Oint,800025581,CDM,637,RC,00496077704,NDC,,,facility,outpatient,1,EA,1115.90000,323.61000,Aetna,First Health,,912.81,,,,,,,402.28,912.81,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,800046518,CDM,250,RC,00487900760,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.05,2.33,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,800046518,CDM,250,RC,00487900760,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
K-Phos-Na Phos Neutral 250mg T,800081073,CDM,637,RC,00486112501,NDC,,,facility,inpatient,1,EA,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,3.78,5.15,percent of total billed charges,
K-Phos-Na Phos Neutral 250mg T,800081073,CDM,637,RC,00486112501,NDC,,,facility,outpatient,1,EA,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,2.27,5.15,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,00480924201,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,00480924201,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,00480775080,NDC,,,facility,inpatient,1,EA,75.90000,22.01000,Aetna,First Health,,62.09,,,,,,,45.54,62.09,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,00480775080,NDC,,,facility,outpatient,1,EA,75.90000,22.01000,Aetna,First Health,,62.09,,,,,,,27.36,62.09,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,00480413806,NDC,,,facility,inpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,29.94,40.82,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,00480413806,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,17.99,40.82,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,00480329001,NDC,facility,inpatient,100,ME,8827.00000,2559.83000,Aetna,First Health,,7220.49,,,,,,,3182.13,7220.49,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,00480329001,NDC,facility,outpatient,100,ME,8827.00000,2559.83000,Aetna,First Health,,7220.49,,,,,,,7.88,7220.49,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,00472500260,NDC,,,facility,inpatient,1,EA,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,8.19,11.17,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,00472500260,NDC,,,facility,outpatient,1,EA,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,4.92,11.17,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,00472162716,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,00472162716,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00472136016,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00472136016,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00472132016,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,5.22,7.12,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00472132016,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00472127094,NDC,,,facility,inpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,1.24,2.74,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00472127094,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,1.21,2.74,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,00472077116,NDC,,,facility,inpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.24000,0.32720,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,00472077116,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.14420,0.32720,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00472073556,NDC,,,facility,inpatient,1,EA,24.70000,7.16000,Aetna,First Health,,20.20,,,,,,,9.14,20.20,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00472073556,NDC,,,facility,outpatient,1,EA,24.70000,7.16000,Aetna,First Health,,20.20,,,,,,,8.90,20.20,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00472073542,NDC,,,facility,inpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.86,19.59,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00472073542,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.63,19.59,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00472073063,NDC,,,facility,inpatient,1,EA,77.75000,22.55000,Aetna,First Health,,63.60,,,,,,,46.65,63.60,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00472073063,NDC,,,facility,outpatient,1,EA,77.75000,22.55000,Aetna,First Health,,63.60,,,,,,,28.03,63.60,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00472073041,NDC,,,facility,inpatient,1,EA,81.30000,23.58000,Aetna,First Health,,66.50,,,,,,,48.78,66.50,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00472073041,NDC,,,facility,outpatient,1,EA,81.30000,23.58000,Aetna,First Health,,66.50,,,,,,,29.31,66.50,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00472051124,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00472051124,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,00472046730,NDC,,,facility,inpatient,1,EA,574.30000,166.55000,Aetna,First Health,,469.78,,,,,,,344.58,469.78,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,00472046730,NDC,,,facility,outpatient,1,EA,574.30000,166.55000,Aetna,First Health,,469.78,,,,,,,207.04,469.78,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,00472040130,NDC,,,facility,inpatient,1,EA,4299.20000,1246.77000,Aetna,First Health,,3516.75,,,,,,,2579.52,3516.75,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,00472040130,NDC,,,facility,outpatient,1,EA,4299.20000,1246.77000,Aetna,First Health,,3516.75,,,,,,,1549.86,3516.75,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,00472038115,NDC,,,facility,inpatient,1,EA,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,208.05,283.64,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,00472038115,NDC,,,facility,outpatient,1,EA,346.75000,100.56000,Aetna,First Health,,283.64,,,,,,,125.00,283.64,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,00472038015,NDC,,,facility,inpatient,1,EA,288.75000,83.74000,Aetna,First Health,,236.20,,,,,,,173.25,236.20,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,00472038015,NDC,,,facility,outpatient,1,EA,288.75000,83.74000,Aetna,First Health,,236.20,,,,,,,104.09,236.20,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,00472037915,NDC,,,facility,inpatient,1,EA,269.95000,78.29000,Aetna,First Health,,220.82,,,,,,,161.97,220.82,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,00472037915,NDC,,,facility,outpatient,1,EA,269.95000,78.29000,Aetna,First Health,,220.82,,,,,,,97.32,220.82,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00472033956,NDC,,,facility,inpatient,1,EA,26.40000,7.66000,Aetna,First Health,,21.60,,,,,,,9.77,21.60,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00472033956,NDC,,,facility,outpatient,1,EA,26.40000,7.66000,Aetna,First Health,,21.60,,,,,,,9.52,21.60,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,00472033730,NDC,,,facility,inpatient,1,EA,77.90000,22.59000,Aetna,First Health,,63.72,,,,,,,46.74,63.72,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,00472033730,NDC,,,facility,outpatient,1,EA,77.90000,22.59000,Aetna,First Health,,63.72,,,,,,,28.08,63.72,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,00472030115,NDC,,,facility,inpatient,1,EA,30.10000,8.73000,Aetna,First Health,,24.62,,,,,,,18.06,24.62,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,00472030115,NDC,,,facility,outpatient,1,EA,30.10000,8.73000,Aetna,First Health,,24.62,,,,,,,10.85,24.62,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,00472024260,NDC,,,facility,inpatient,1,EA,780.50000,226.34000,Aetna,First Health,,638.45,,,,,,,468.30,638.45,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,00472024260,NDC,,,facility,outpatient,1,EA,780.50000,226.34000,Aetna,First Health,,638.45,,,,,,,281.37,638.45,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,00472022063,NDC,,,facility,inpatient,1,EA,84.95000,24.64000,Aetna,First Health,,69.49,,,,,,,31.43,69.49,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,00472022063,NDC,,,facility,outpatient,1,EA,84.95000,24.64000,Aetna,First Health,,69.49,,,,,,,30.62,69.49,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,00472022041,NDC,,,facility,inpatient,1,EA,84.95000,24.64000,Aetna,First Health,,69.49,,,,,,,31.43,69.49,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,00472022041,NDC,,,facility,outpatient,1,EA,84.95000,24.64000,Aetna,First Health,,69.49,,,,,,,30.62,69.49,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00472016315,NDC,,,facility,inpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,74.34,101.35,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00472016315,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,First Health,,101.35,,,,,,,44.67,101.35,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,00472008216,NDC,,,facility,inpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,19.98,27.24,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,00472008216,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,12.00,27.24,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00472003616,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00472003616,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,00469823412,NDC,facility,inpatient,6,ME,222.40000,64.50000,Aetna,First Health,,181.92,,,,,,,80.18,181.92,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,00469823412,NDC,facility,outpatient,6,ME,222.40000,64.50000,Aetna,First Health,,181.92,,,,,,,0.51039,181.92,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,00469650189,NDC,facility,inpatient,0.4,ME,1216.90000,352.90000,Aetna,First Health,,995.42,,,,,,,438.69,995.42,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,00469650189,NDC,facility,outpatient,0.4,ME,1216.90000,352.90000,Aetna,First Health,,995.42,,,,,,,2.58,995.42,percent of total billed charges,
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,inpatient,100,ME,1533.40000,444.69000,Aetna,First Health,,1254.32,,,,,,,552.79,1254.32,percent of total billed charges,
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,outpatient,100,ME,1533.40000,444.69000,Aetna,First Health,,1254.32,,,,,,,0.24075,1254.32,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00469314061,NDC,facility,inpatient,1,GM,362.50000,105.12000,Aetna,First Health,,296.52,,,,,,,130.68,296.52,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00469314061,NDC,facility,outpatient,1,GM,362.50000,105.12000,Aetna,First Health,,296.52,,,,,,,0.02889,296.52,percent of total billed charges,
Amphotericin B LIPO 50mg I,800010922,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,inpatient,50,ME,2478.80000,718.85000,Aetna,First Health,,2027.66,,,,,,,893.61,2027.66,percent of total billed charges,
Amphotericin B LIPO 50mg I,800010922,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,outpatient,50,ME,2478.80000,718.85000,Aetna,First Health,,2027.66,,,,,,,19.95,2027.66,percent of total billed charges,
Tacrolimus 5mg/mL Inj,800017829,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,inpatient,5,ME,2179.20000,631.97000,Aetna,First Health,,1782.59,,,,,,,785.60,1782.59,percent of total billed charges,
Tacrolimus 5mg/mL Inj,800017829,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,outpatient,5,ME,2179.20000,631.97000,Aetna,First Health,,1782.59,,,,,,,252.74,1782.59,percent of total billed charges,
Mirabegron 25mg ER T,800025525,CDM,637,RC,00469260130,NDC,,,facility,inpatient,1,EA,130.35000,37.80000,Aetna,First Health,,106.63,,,,,,,78.21,106.63,percent of total billed charges,
Mirabegron 25mg ER T,800025525,CDM,637,RC,00469260130,NDC,,,facility,outpatient,1,EA,130.35000,37.80000,Aetna,First Health,,106.63,,,,,,,46.99,106.63,percent of total billed charges,
Mineral Oil Light 10mL(Muri-Lube),800035815,CDM,250,RC,00469225425,NDC,,,facility,inpatient,1,EA,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,5.49,12.15,percent of total billed charges,
Mineral Oil Light 10mL(Muri-Lube),800035815,CDM,250,RC,00469225425,NDC,,,facility,outpatient,1,EA,14.85000,4.31000,Aetna,First Health,,12.15,,,,,,,5.35,12.15,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,00469221030,NDC,facility,inpatient,500,ME,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,25.23,57.26,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,00469221030,NDC,facility,outpatient,500,ME,70.00000,20.30000,Aetna,First Health,,57.26,,,,,,,0.02889,57.26,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,00469101325,NDC,facility,inpatient,200,ME,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,00469101325,NDC,facility,outpatient,200,ME,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,1.74,5.58,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,00469101215,NDC,facility,inpatient,10,UN,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,2.20,4.99,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,00469101215,NDC,facility,outpatient,10,UN,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,1.00,4.99,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,00469061773,NDC,facility,inpatient,1,ME,62.85000,18.23000,Aetna,First Health,,51.41,,,,,,,37.71,51.41,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,00469061773,NDC,facility,outpatient,1,ME,62.85000,18.23000,Aetna,First Health,,51.41,,,,,,,0.19260,51.41,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,00469061771,NDC,facility,inpatient,1,ME,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
Tacrolimus 1 mg C(Prograf),800081876,CDM,637,RC,J7507,HCPCS,00469061771,NDC,facility,outpatient,1,ME,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,0.19260,18.81,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),800081868,CDM,637,RC,J7507,HCPCS,00469060773,NDC,facility,inpatient,0.5,ME,31.45000,9.12000,Aetna,First Health,,25.73,,,,,,,18.87,25.73,percent of total billed charges,
Tacrolimus 0.5 mg C(Prograf),800081868,CDM,637,RC,J7507,HCPCS,00469060773,NDC,facility,outpatient,0.5,ME,31.45000,9.12000,Aetna,First Health,,25.73,,,,,,,0.19260,25.73,percent of total billed charges,
Pyridoxine HCl 100mg/mL 1mL I(Vit B6),800056795,CDM,636,RC,J3415,HCPCS,00469001825,NDC,facility,inpatient,100,ME,240.55000,69.76000,Aetna,First Health,,196.77,,,,,,,86.72,196.77,percent of total billed charges,
Pyridoxine HCl 100mg/mL 1mL I(Vit B6),800056795,CDM,636,RC,J3415,HCPCS,00469001825,NDC,facility,outpatient,100,ME,240.55000,69.76000,Aetna,First Health,,196.77,,,,,,,14.98,196.77,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,00456430008,NDC,,,facility,inpatient,1,EA,481.45000,139.62000,Aetna,First Health,,393.83,,,,,,,288.87,393.83,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,00456430008,NDC,,,facility,outpatient,1,EA,481.45000,139.62000,Aetna,First Health,,393.83,,,,,,,173.56,393.83,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,00456430001,NDC,,,facility,inpatient,1,EA,701.15000,203.33000,Aetna,First Health,,573.54,,,,,,,420.69,573.54,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,00456430001,NDC,,,facility,outpatient,1,EA,701.15000,203.33000,Aetna,First Health,,573.54,,,,,,,252.76,573.54,percent of total billed charges,
Dinoprostone 10mg VS(Cervidil),800073303,CDM,252,RC,00456412363,NDC,,,facility,inpatient,1,EA,2152.00000,624.08000,Aetna,First Health,,1760.34,,,,,,,796.24,1760.34,percent of total billed charges,
Dinoprostone 10mg VS(Cervidil),800073303,CDM,252,RC,00456412363,NDC,,,facility,outpatient,1,EA,2152.00000,624.08000,Aetna,First Health,,1760.34,,,,,,,775.80,1760.34,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00456321060,NDC,,,facility,inpatient,1,EA,63.00000,18.27000,Aetna,First Health,,51.53,,,,,,,37.80,51.53,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00456321060,NDC,,,facility,outpatient,1,EA,63.00000,18.27000,Aetna,First Health,,51.53,,,,,,,22.71,51.53,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00456320560,NDC,,,facility,inpatient,1,EA,63.00000,18.27000,Aetna,First Health,,51.53,,,,,,,37.80,51.53,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00456320560,NDC,,,facility,outpatient,1,EA,63.00000,18.27000,Aetna,First Health,,51.53,,,,,,,22.71,51.53,percent of total billed charges,
Ceftazidime-Avibactam2-0.5g Inj,800040874,CDM,636,RC,J0714,HCPCS,00456270010,NDC,facility,inpatient,2.5,GM,3177.65000,921.52000,Aetna,First Health,,2599.32,,,,,,,1145.54,2599.32,percent of total billed charges,
Ceftazidime-Avibactam2-0.5g Inj,800040874,CDM,636,RC,J0714,HCPCS,00456270010,NDC,facility,outpatient,2.5,GM,3177.65000,921.52000,Aetna,First Health,,2599.32,,,,,,,100.84,2599.32,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00456202001,NDC,,,facility,inpatient,1,EA,136.30000,39.53000,Aetna,First Health,,111.49,,,,,,,81.78,111.49,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00456202001,NDC,,,facility,outpatient,1,EA,136.30000,39.53000,Aetna,First Health,,111.49,,,,,,,49.14,111.49,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00456201001,NDC,,,facility,inpatient,1,EA,130.65000,37.89000,Aetna,First Health,,106.87,,,,,,,78.39,106.87,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00456201001,NDC,,,facility,outpatient,1,EA,130.65000,37.89000,Aetna,First Health,,106.87,,,,,,,47.10,106.87,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,00456200501,NDC,,,facility,inpatient,1,EA,124.95000,36.24000,Aetna,First Health,,102.21,,,,,,,74.97,102.21,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,00456200501,NDC,,,facility,outpatient,1,EA,124.95000,36.24000,Aetna,First Health,,102.21,,,,,,,45.04,102.21,percent of total billed charges,
Milnacipran 50mg T(Savella),800025654,CDM,637,RC,00456155060,NDC,,,facility,inpatient,1,EA,72.45000,21.01000,Aetna,First Health,,59.26,,,,,,,43.47,59.26,percent of total billed charges,
Milnacipran 50mg T(Savella),800025654,CDM,637,RC,00456155060,NDC,,,facility,outpatient,1,EA,72.45000,21.01000,Aetna,First Health,,59.26,,,,,,,26.12,59.26,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140590,NDC,,,facility,inpatient,1,EA,54.35000,15.76000,Aetna,First Health,,44.46,,,,,,,32.61,44.46,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140590,NDC,,,facility,outpatient,1,EA,54.35000,15.76000,Aetna,First Health,,44.46,,,,,,,19.59,44.46,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140563,NDC,,,facility,inpatient,1,EA,50.25000,14.57000,Aetna,First Health,,41.10,,,,,,,30.15,41.10,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140563,NDC,,,facility,outpatient,1,EA,50.25000,14.57000,Aetna,First Health,,41.10,,,,,,,18.12,41.10,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140530,NDC,,,facility,inpatient,1,EA,51.75000,15.01000,Aetna,First Health,,42.33,,,,,,,31.05,42.33,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140530,NDC,,,facility,outpatient,1,EA,51.75000,15.01000,Aetna,First Health,,42.33,,,,,,,18.66,42.33,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140501,NDC,,,facility,inpatient,1,EA,24.05000,6.97000,Aetna,First Health,,19.67,,,,,,,14.43,19.67,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140501,NDC,,,facility,outpatient,1,EA,24.05000,6.97000,Aetna,First Health,,19.67,,,,,,,8.67,19.67,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00456133001,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00456133001,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00456132901,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00456132901,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00456132601,NDC,,,facility,inpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,1.59,2.17,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00456132601,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00456132401,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00456132401,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00456132301,NDC,,,facility,inpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00456132301,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.70298,1.60,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00456132201,NDC,,,facility,inpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,1.14,1.55,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00456132201,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.68495,1.55,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00456132101,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00456132101,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00456132001,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00456132001,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
LinaCLOtide 72mcg C (Linzess),800040869,CDM,637,RC,00456120330,NDC,,,facility,inpatient,1,EA,160.85000,46.65000,Aetna,First Health,,131.58,,,,,,,96.51,131.58,percent of total billed charges,
LinaCLOtide 72mcg C (Linzess),800040869,CDM,637,RC,00456120330,NDC,,,facility,outpatient,1,EA,160.85000,46.65000,Aetna,First Health,,131.58,,,,,,,57.99,131.58,percent of total billed charges,
Linaclotide 145mcg C(Linzess),800025526,CDM,637,RC,00456120130,NDC,,,facility,inpatient,1,EA,160.85000,46.65000,Aetna,First Health,,131.58,,,,,,,96.51,131.58,percent of total billed charges,
Linaclotide 145mcg C(Linzess),800025526,CDM,637,RC,00456120130,NDC,,,facility,outpatient,1,EA,160.85000,46.65000,Aetna,First Health,,131.58,,,,,,,57.99,131.58,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,00456112030,NDC,,,facility,inpatient,1,EA,103.30000,29.96000,Aetna,First Health,,84.50,,,,,,,61.98,84.50,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,00456112030,NDC,,,facility,outpatient,1,EA,103.30000,29.96000,Aetna,First Health,,84.50,,,,,,,37.24,84.50,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,00456046101,NDC,,,facility,inpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,10.50,14.31,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,00456046101,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,6.31,14.31,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,00456045801,NDC,,,facility,inpatient,1,EA,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,5.16,7.03,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,00456045801,NDC,,,facility,outpatient,1,EA,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,3.10,7.03,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00456033001,NDC,,,facility,inpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.75000,1.02,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00456033001,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.45062,1.02,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00456032901,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00456032901,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00456032601,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00456032601,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00456032401,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00456032401,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00456032301,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00456032301,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00456032201,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00456032201,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00456032101,NDC,,,facility,inpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00456032101,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.79310,1.80,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00456032001,NDC,,,facility,inpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00456032001,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),800015427,CDM,637,RC,00456009530,NDC,,,facility,inpatient,1,EA,73.05000,21.18000,Aetna,First Health,,59.75,,,,,,,43.83,59.75,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),800015427,CDM,637,RC,00456009530,NDC,,,facility,outpatient,1,EA,73.05000,21.18000,Aetna,First Health,,59.75,,,,,,,26.33,59.75,percent of total billed charges,
Sodium Hypochlor 0.125% TS 473mL,800022086,CDM,637,RC,00436067216,NDC,,,facility,inpatient,1,EA,121.05000,35.10000,Aetna,First Health,,99.02,,,,,,,72.63,99.02,percent of total billed charges,
Sodium Hypochlor 0.125% TS 473mL,800022086,CDM,637,RC,00436067216,NDC,,,facility,outpatient,1,EA,121.05000,35.10000,Aetna,First Health,,99.02,,,,,,,43.64,99.02,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,00430375414,NDC,,,facility,inpatient,1,EA,2386.80000,692.17000,Aetna,First Health,,1952.40,,,,,,,1432.08,1952.40,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,00430375414,NDC,,,facility,outpatient,1,EA,2386.80000,692.17000,Aetna,First Health,,1952.40,,,,,,,860.44,1952.40,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,00430075327,NDC,,,facility,inpatient,1,EA,22.95000,6.66000,Aetna,First Health,,18.77,,,,,,,13.77,18.77,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,00430075327,NDC,,,facility,outpatient,1,EA,22.95000,6.66000,Aetna,First Health,,18.77,,,,,,,8.27,18.77,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00430072124,NDC,,,facility,inpatient,1,EA,46.30000,13.43000,Aetna,First Health,,37.87,,,,,,,27.78,37.87,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00430072124,NDC,,,facility,outpatient,1,EA,46.30000,13.43000,Aetna,First Health,,37.87,,,,,,,16.69,37.87,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,00409973510,NDC,facility,inpatient,2,GM,96.50000,27.98000,Aetna,First Health,,78.94,,,,,,,34.79,78.94,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,00409973510,NDC,facility,outpatient,2,GM,96.50000,27.98000,Aetna,First Health,,78.94,,,,,,,0.83781,78.94,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00409963104,NDC,facility,inpatient,40,ME,85.90000,24.91000,Aetna,First Health,,70.27,,,,,,,30.97,70.27,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00409963104,NDC,facility,outpatient,40,ME,85.90000,24.91000,Aetna,First Health,,70.27,,,,,,,0.01926,70.27,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00409956610,NDC,facility,inpatient,1,GM,58.45000,16.95000,Aetna,First Health,,47.81,,,,,,,21.07,47.81,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00409956610,NDC,facility,outpatient,1,GM,58.45000,16.95000,Aetna,First Health,,47.81,,,,,,,0.83781,47.81,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409955849,NDC,,,facility,inpatient,1,EA,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,8.71,19.26,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409955849,NDC,,,facility,outpatient,1,EA,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,8.49,19.26,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,00409955849,NDC,,,facility,inpatient,1,EA,28.35000,8.22000,Aetna,First Health,,23.19,,,,,,,10.49,23.19,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,00409955849,NDC,,,facility,outpatient,1,EA,28.35000,8.22000,Aetna,First Health,,23.19,,,,,,,10.22,23.19,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409955810,NDC,,,facility,inpatient,1,EA,22.85000,6.63000,Aetna,First Health,,18.69,,,,,,,8.45,18.69,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409955810,NDC,,,facility,outpatient,1,EA,22.85000,6.63000,Aetna,First Health,,18.69,,,,,,,8.24,18.69,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409955805,NDC,,,facility,inpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.79,19.43,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409955805,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.56,19.43,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00409930130,NDC,facility,inpatient,150,ME,44.50000,12.90000,Aetna,First Health,,36.40,,,,,,,16.04,36.40,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00409930130,NDC,facility,outpatient,150,ME,44.50000,12.90000,Aetna,First Health,,36.40,,,,,,,0.04815,36.40,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00409930020,NDC,facility,inpatient,40,ME,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,8.49,19.26,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00409930020,NDC,facility,outpatient,40,ME,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,0.04815,19.26,percent of total billed charges,
0.45NS + 20mEq/L KCl 1000mL,800021700,CDM,258,RC,J3480,HCPCS,00409925739,NDC,facility,inpatient,1,EA,73.80000,21.40000,Aetna,First Health,,60.37,,,,,,,34.69,60.37,percent of total billed charges,
0.45NS + 20mEq/L KCl 1000mL,800021700,CDM,258,RC,J3480,HCPCS,00409925739,NDC,facility,outpatient,1,EA,73.80000,21.40000,Aetna,First Health,,60.37,,,,,,,0.11556,60.37,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00409915825,NDC,facility,inpatient,10,ME,289.80000,84.04000,Aetna,First Health,,237.06,,,,,,,104.47,237.06,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00409915825,NDC,facility,outpatient,10,ME,289.80000,84.04000,Aetna,First Health,,237.06,,,,,,,2.71,237.06,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00409915801,NDC,facility,inpatient,10,ME,294.85000,85.51000,Aetna,First Health,,241.19,,,,,,,106.29,241.19,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00409915801,NDC,facility,outpatient,10,ME,294.85000,85.51000,Aetna,First Health,,241.19,,,,,,,2.71,241.19,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00409915725,NDC,facility,inpatient,1,ME,26.95000,7.82000,Aetna,First Health,,22.05,,,,,,,9.72,22.05,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00409915725,NDC,facility,outpatient,1,ME,26.95000,7.82000,Aetna,First Health,,22.05,,,,,,,2.71,22.05,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00409915701,NDC,facility,inpatient,1,ME,30.30000,8.79000,Aetna,First Health,,24.79,,,,,,,10.92,24.79,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00409915701,NDC,facility,outpatient,1,ME,30.30000,8.79000,Aetna,First Health,,24.79,,,,,,,2.71,24.79,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909422,NDC,facility,inpatient,0.1,ME,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,5.34,12.11,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909422,NDC,facility,outpatient,0.1,ME,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,1.15,12.11,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909411,NDC,facility,inpatient,0.1,ME,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,2.78,6.30,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909411,NDC,facility,outpatient,0.1,ME,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,1.15,6.30,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909332,NDC,facility,inpatient,0.1,ME,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.08,2.45,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909332,NDC,facility,outpatient,0.1,ME,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.11,3.67,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909311,NDC,facility,inpatient,0.1,ME,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909311,NDC,facility,outpatient,0.1,ME,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,1.15,5.44,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409904601,NDC,,,facility,inpatient,1,EA,24.75000,7.18000,Aetna,First Health,,20.25,,,,,,,9.16,20.25,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409904601,NDC,,,facility,outpatient,1,EA,24.75000,7.18000,Aetna,First Health,,20.25,,,,,,,8.92,20.25,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409904502,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.61,12.39,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409904502,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,00409904501,NDC,,,facility,inpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,6.25,13.82,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,00409904501,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,6.09,13.82,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409904217,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,8.20,18.12,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409904217,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409904210,NDC,,,facility,inpatient,1,EA,27.40000,7.95000,Aetna,First Health,,22.41,,,,,,,10.14,22.41,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409904210,NDC,,,facility,outpatient,1,EA,27.40000,7.95000,Aetna,First Health,,22.41,,,,,,,9.88,22.41,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409904202,NDC,,,facility,inpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,6.72,14.85,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409904202,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,6.54,14.85,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409806201,NDC,,,facility,inpatient,1,EA,109.25000,31.68000,Aetna,First Health,,89.37,,,,,,,40.42,89.37,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409806201,NDC,,,facility,outpatient,1,EA,109.25000,31.68000,Aetna,First Health,,89.37,,,,,,,39.38,89.37,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00409799009,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00409799009,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,3.80,43.80,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00409798509,NDC,,,facility,inpatient,1,EA,46.85000,13.59000,Aetna,First Health,,38.32,,,,,,,22.02,38.32,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00409798509,NDC,,,facility,outpatient,1,EA,46.85000,13.59000,Aetna,First Health,,38.32,,,,,,,16.89,38.32,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,00409798503,NDC,,,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,00409798503,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
0.45% Sodium Cl 250mL,800081202,CDM,258,RC,00409798502,NDC,,,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
0.45% Sodium Cl 250mL,800081202,CDM,258,RC,00409798502,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00409798437,NDC,facility,inpatient,1,EA,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,6.65,15.09,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00409798437,NDC,facility,outpatient,1,EA,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,0.63558,15.09,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00409798436,NDC,facility,inpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,5.01,11.37,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00409798436,NDC,facility,outpatient,1,EA,13.90000,4.03000,Aetna,First Health,,11.37,,,,,,,0.63558,11.37,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00409798423,NDC,facility,inpatient,1,EA,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,8.06,18.28,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00409798423,NDC,facility,outpatient,1,EA,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,0.63558,18.28,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00409798413,NDC,facility,inpatient,1,EA,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,8.51,19.30,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00409798413,NDC,facility,outpatient,1,EA,23.60000,6.84000,Aetna,First Health,,19.30,,,,,,,0.63558,19.30,percent of total billed charges,
NS 1000mL PVC Free,800070037,CDM,258,RC,J7030,HCPCS,00409798348,NDC,facility,inpatient,1,EA,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,11.87,20.65,percent of total billed charges,
NS 1000mL PVC Free,800070037,CDM,258,RC,J7030,HCPCS,00409798348,NDC,facility,outpatient,1,EA,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,1.92,20.65,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00409798325,NDC,facility,inpatient,1,EA,46.85000,13.59000,Aetna,First Health,,38.32,,,,,,,16.89,38.32,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00409798325,NDC,facility,outpatient,1,EA,46.85000,13.59000,Aetna,First Health,,38.32,,,,,,,0.63558,38.32,percent of total billed charges,
NS Inj,800012007,CDM,258,RC,J7030,HCPCS,00409798309,NDC,facility,inpatient,1,EA,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.02350,0.04090,percent of total billed charges,
NS Inj,800012007,CDM,258,RC,J7030,HCPCS,00409798309,NDC,facility,outpatient,1,EA,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.02000,6.14,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00409798309,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00409798309,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,1.92,43.80,percent of total billed charges,
NS 500mL,800012693,CDM,258,RC,J7040,HCPCS,00409798303,NDC,facility,inpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,26.13,45.48,percent of total billed charges,
NS 500mL,800012693,CDM,258,RC,J7040,HCPCS,00409798303,NDC,facility,outpatient,1,EA,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,1.24,45.48,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00409798302,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00409798302,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,0.63558,43.80,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00409796709,NDC,,,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00409796709,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,00409795309,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,00409795309,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,2.29,43.80,percent of total billed charges,
LR 500 mL,800012635,CDM,258,RC,J7120,HCPCS,00409795303,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
LR 500 mL,800012635,CDM,258,RC,J7120,HCPCS,00409795303,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,2.29,43.80,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,00409794109,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,00409794109,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,1.26,43.80,percent of total billed charges,
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00409793932,NDC,facility,inpatient,2,GM,77.40000,22.45000,Aetna,First Health,,63.31,,,,,,,27.90,63.31,percent of total billed charges,
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00409793932,NDC,facility,outpatient,2,GM,77.40000,22.45000,Aetna,First Health,,63.31,,,,,,,28.64,63.31,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00409793009,NDC,,,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00409793009,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00409793002,NDC,,,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00409793002,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
D5LR 1000 mL,800012214,CDM,258,RC,J7121,HCPCS,00409792909,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D5LR 1000 mL,800012214,CDM,258,RC,J7121,HCPCS,00409792909,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,8.94,43.80,percent of total billed charges,
D5.45NS 1000mL,800012347,CDM,258,RC,J7030,HCPCS,00409792609,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D5.45NS 1000mL,800012347,CDM,258,RC,J7030,HCPCS,00409792609,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,1.92,43.80,percent of total billed charges,
D5.45NS 500mL,800011306,CDM,258,RC,J7030,HCPCS,00409792603,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D5.45NS 500mL,800011306,CDM,258,RC,J7030,HCPCS,00409792603,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,1.92,43.80,percent of total billed charges,
Dextose 5% in Water 50mL,800013014,CDM,258,RC,J7060,HCPCS,00409792336,NDC,facility,inpatient,1,EA,20.45000,5.93000,Aetna,First Health,,16.73,,,,,,,9.61,16.73,percent of total billed charges,
Dextose 5% in Water 50mL,800013014,CDM,258,RC,J7060,HCPCS,00409792336,NDC,facility,outpatient,1,EA,20.45000,5.93000,Aetna,First Health,,16.73,,,,,,,1.69,16.73,percent of total billed charges,
Dextrose 5% / Water PVC Free,800012817,CDM,258,RC,J7060,HCPCS,00409792230,NDC,facility,inpatient,1,EA,21.95000,6.37000,Aetna,First Health,,17.96,,,,,,,10.32,17.96,percent of total billed charges,
Dextrose 5% / Water PVC Free,800012817,CDM,258,RC,J7060,HCPCS,00409792230,NDC,facility,outpatient,1,EA,21.95000,6.37000,Aetna,First Health,,17.96,,,,,,,1.69,17.96,percent of total billed charges,
Dextrose 5% in Water 1L,800012172,CDM,258,RC,J7070,HCPCS,00409792209,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
Dextrose 5% in Water 1L,800012172,CDM,258,RC,J7070,HCPCS,00409792209,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,2.83,43.80,percent of total billed charges,
D5W  250mL,800012123,CDM,258,RC,J7060,HCPCS,00409792202,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
D5W  250mL,800012123,CDM,258,RC,J7060,HCPCS,00409792202,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,1.69,43.80,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00409790209,NDC,,,facility,inpatient,1,EA,66.30000,19.23000,Aetna,First Health,,54.23,,,,,,,31.16,54.23,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00409790209,NDC,,,facility,outpatient,1,EA,66.30000,19.23000,Aetna,First Health,,54.23,,,,,,,23.90,54.23,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409781137,NDC,facility,inpatient,500,ME,15.80000,4.58000,Aetna,First Health,,12.92,,,,,,,5.70,12.92,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409781137,NDC,facility,outpatient,500,ME,15.80000,4.58000,Aetna,First Health,,12.92,,,,,,,0.02889,12.92,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409781124,NDC,facility,inpatient,500,ME,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,7.07,16.03,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409781124,NDC,facility,outpatient,500,ME,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,0.02889,16.03,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409781110,NDC,facility,inpatient,500,ME,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,6.69,15.17,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409781110,NDC,facility,outpatient,500,ME,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,0.02889,15.17,percent of total billed charges,
DOPamine 400mg/D5W 250mL,800012469,CDM,636,RC,J1265,HCPCS,00409780922,NDC,facility,inpatient,400,ME,161.90000,46.95000,Aetna,First Health,,132.43,,,,,,,58.36,132.43,percent of total billed charges,
DOPamine 400mg/D5W 250mL,800012469,CDM,636,RC,J1265,HCPCS,00409780922,NDC,facility,outpatient,400,ME,161.90000,46.95000,Aetna,First Health,,132.43,,,,,,,0.77040,132.43,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00409779362,NDC,facility,inpatient,25000,UN,98.15000,28.46000,Aetna,First Health,,80.29,,,,,,,35.38,80.29,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00409779362,NDC,facility,outpatient,25000,UN,98.15000,28.46000,Aetna,First Health,,80.29,,,,,,,0.17334,80.29,percent of total billed charges,
Mannitol 20% 500mL,800022060,CDM,250,RC,00409771503,NDC,,,facility,inpatient,1,EA,194.30000,56.35000,Aetna,First Health,,158.94,,,,,,,71.89,158.94,percent of total billed charges,
Mannitol 20% 500mL,800022060,CDM,250,RC,00409771503,NDC,,,facility,outpatient,1,EA,194.30000,56.35000,Aetna,First Health,,158.94,,,,,,,70.05,158.94,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00409767009,NDC,,,facility,inpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,25.17,43.80,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00409767009,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,First Health,,43.80,,,,,,,19.30,43.80,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00409762003,NDC,facility,inpatient,1000,UN,56.05000,16.25000,Aetna,First Health,,45.85,,,,,,,20.21,45.85,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00409762003,NDC,facility,outpatient,1000,UN,56.05000,16.25000,Aetna,First Health,,45.85,,,,,,,0.17334,45.85,percent of total billed charges,
D50W 50mL Inj Syr,800011221,CDM,258,RC,00409751716,NDC,,,facility,inpatient,1,EA,125.90000,36.51000,Aetna,First Health,,102.99,,,,,,,59.17,102.99,percent of total billed charges,
D50W 50mL Inj Syr,800011221,CDM,258,RC,00409751716,NDC,,,facility,outpatient,1,EA,125.90000,36.51000,Aetna,First Health,,102.99,,,,,,,45.39,102.99,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,00409739172,NDC,,,facility,inpatient,1,EA,401.00000,116.29000,Aetna,First Health,,328.02,,,,,,,148.37,328.02,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,00409739172,NDC,,,facility,outpatient,1,EA,401.00000,116.29000,Aetna,First Health,,328.02,,,,,,,144.56,328.02,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00409733820,NDC,facility,inpatient,500,ME,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00409733820,NDC,facility,outpatient,500,ME,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,0.44298,5.03,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,inpatient,500,ME,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,outpatient,500,ME,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,0.44298,5.03,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00409733604,NDC,facility,inpatient,2,GM,50.90000,14.76000,Aetna,First Health,,41.64,,,,,,,18.35,41.64,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00409733604,NDC,facility,outpatient,2,GM,50.90000,14.76000,Aetna,First Health,,41.64,,,,,,,0.44298,41.64,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00409733520,NDC,facility,inpatient,2,GM,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,6.65,15.09,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00409733520,NDC,facility,outpatient,2,GM,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,0.44298,15.09,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,2,GM,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,6.65,15.09,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,outpatient,2,GM,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,0.44298,15.09,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00409733220,NDC,facility,inpatient,1,GM,14.60000,4.23000,Aetna,First Health,,11.94,,,,,,,5.26,11.94,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00409733220,NDC,facility,outpatient,1,GM,14.60000,4.23000,Aetna,First Health,,11.94,,,,,,,0.44298,11.94,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00409733201,NDC,facility,inpatient,1,GM,14.60000,4.23000,Aetna,First Health,,11.94,,,,,,,5.26,11.94,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00409733201,NDC,facility,outpatient,1,GM,14.60000,4.23000,Aetna,First Health,,11.94,,,,,,,0.44298,11.94,percent of total billed charges,
NICU- Sodium Acetate 2mEq/mL Inj,800072480,CDM,250,RC,00409729973,NDC,,,facility,inpatient,1,EA,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,2.33,5.15,percent of total billed charges,
NICU- Sodium Acetate 2mEq/mL Inj,800072480,CDM,250,RC,00409729973,NDC,,,facility,outpatient,1,EA,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,2.27,5.15,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00409729501,NDC,,,facility,inpatient,1,EA,150.85000,43.75000,Aetna,First Health,,123.40,,,,,,,55.81,123.40,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00409729501,NDC,,,facility,outpatient,1,EA,150.85000,43.75000,Aetna,First Health,,123.40,,,,,,,54.38,123.40,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,00409724803,NDC,,,facility,inpatient,1,EA,420.60000,121.97000,Aetna,First Health,,344.05,,,,,,,155.62,344.05,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,00409724803,NDC,,,facility,outpatient,1,EA,420.60000,121.97000,Aetna,First Health,,344.05,,,,,,,151.63,344.05,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00409724125,NDC,facility,inpatient,1,ME,13.30000,3.86000,Aetna,First Health,,10.88,,,,,,,4.79,10.88,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00409724125,NDC,facility,outpatient,1,ME,13.30000,3.86000,Aetna,First Health,,10.88,,,,,,,0.41409,10.88,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00409724101,NDC,facility,inpatient,1,ME,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00409724101,NDC,facility,outpatient,1,ME,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,0.41409,10.96,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00409711509,NDC,,,facility,inpatient,1,EA,69.95000,20.29000,Aetna,First Health,,57.22,,,,,,,32.88,57.22,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00409711509,NDC,,,facility,outpatient,1,EA,69.95000,20.29000,Aetna,First Health,,57.22,,,,,,,25.22,57.22,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00409710709,NDC,,,facility,inpatient,1,EA,66.65000,19.33000,Aetna,First Health,,54.52,,,,,,,31.33,54.52,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00409710709,NDC,,,facility,outpatient,1,EA,66.65000,19.33000,Aetna,First Health,,54.52,,,,,,,24.03,54.52,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00409707526,NDC,facility,inpatient,1,EA,51.40000,14.91000,Aetna,First Health,,42.05,,,,,,,18.53,42.05,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00409707526,NDC,facility,outpatient,1,EA,51.40000,14.91000,Aetna,First Health,,42.05,,,,,,,0.11556,42.05,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00409707426,NDC,facility,inpatient,1,EA,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00409707426,NDC,facility,outpatient,1,EA,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,0.11556,40.90,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00409677802,NDC,facility,inpatient,2,ME,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,5.89,13.37,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00409677802,NDC,facility,outpatient,2,ME,16.35000,4.74000,Aetna,First Health,,13.37,,,,,,,1.36,13.37,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,00409672924,NDC,facility,inpatient,2,GM,165.20000,47.91000,Aetna,First Health,,135.13,,,,,,,59.55,135.13,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,00409672924,NDC,facility,outpatient,2,GM,165.20000,47.91000,Aetna,First Health,,135.13,,,,,,,0.39483,135.13,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,inpatient,4,GM,81.90000,23.75000,Aetna,First Health,,66.99,,,,,,,29.52,66.99,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,outpatient,4,GM,81.90000,23.75000,Aetna,First Health,,66.99,,,,,,,0.39483,66.99,percent of total billed charges,
Mag Sulfate 40g/Water 1000mL,800040853,CDM,636,RC,J3475,HCPCS,00409672909,NDC,facility,inpatient,40,GM,85.95000,24.93000,Aetna,First Health,,70.31,,,,,,,30.98,70.31,percent of total billed charges,
Mag Sulfate 40g/Water 1000mL,800040853,CDM,636,RC,J3475,HCPCS,00409672909,NDC,facility,outpatient,40,GM,85.95000,24.93000,Aetna,First Health,,70.31,,,,,,,0.39483,70.31,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409669510,NDC,,,facility,inpatient,1,EA,34.90000,10.12000,Aetna,First Health,,28.55,,,,,,,12.91,28.55,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409669510,NDC,,,facility,outpatient,1,EA,34.90000,10.12000,Aetna,First Health,,28.55,,,,,,,12.58,28.55,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409669502,NDC,,,facility,inpatient,1,EA,33.10000,9.60000,Aetna,First Health,,27.08,,,,,,,12.25,27.08,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409669502,NDC,,,facility,outpatient,1,EA,33.10000,9.60000,Aetna,First Health,,27.08,,,,,,,11.93,27.08,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409669501,NDC,,,facility,inpatient,1,EA,36.05000,10.45000,Aetna,First Health,,29.49,,,,,,,13.34,29.49,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409669501,NDC,,,facility,outpatient,1,EA,36.05000,10.45000,Aetna,First Health,,29.49,,,,,,,13.00,29.49,percent of total billed charges,
Potassium Cl 2mEq/mL I,800013427,CDM,636,RC,J3480,HCPCS,00409665305,NDC,facility,inpatient,1,EA,51.55000,14.95000,Aetna,First Health,,42.17,,,,,,,18.58,42.17,percent of total billed charges,
Potassium Cl 2mEq/mL I,800013427,CDM,636,RC,J3480,HCPCS,00409665305,NDC,facility,outpatient,1,EA,51.55000,14.95000,Aetna,First Health,,42.17,,,,,,,0.11556,42.17,percent of total billed charges,
D50W 50mL,800067479,CDM,258,RC,00409664802,NDC,,,facility,inpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,11.19,19.47,percent of total billed charges,
D50W 50mL,800067479,CDM,258,RC,00409664802,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,8.58,19.47,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409663734,NDC,,,facility,inpatient,1,EA,52.20000,15.14000,Aetna,First Health,,42.70,,,,,,,19.31,42.70,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409663734,NDC,,,facility,outpatient,1,EA,52.20000,15.14000,Aetna,First Health,,42.70,,,,,,,18.82,42.70,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,800018007,CDM,250,RC,00409663734,NDC,,,facility,inpatient,1,EA,69.15000,20.05000,Aetna,First Health,,56.56,,,,,,,25.59,56.56,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,800018007,CDM,250,RC,00409663734,NDC,,,facility,outpatient,1,EA,69.15000,20.05000,Aetna,First Health,,56.56,,,,,,,24.93,56.56,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,800018007,CDM,250,RC,00409663714,NDC,,,facility,inpatient,1,EA,136.05000,39.45000,Aetna,First Health,,111.29,,,,,,,50.34,111.29,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,800018007,CDM,250,RC,00409663714,NDC,,,facility,outpatient,1,EA,136.05000,39.45000,Aetna,First Health,,111.29,,,,,,,49.05,111.29,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00409662902,NDC,facility,inpatient,200,ME,123.65000,35.86000,Aetna,First Health,,101.15,,,,,,,44.58,101.15,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00409662902,NDC,facility,outpatient,200,ME,123.65000,35.86000,Aetna,First Health,,101.15,,,,,,,0.93411,101.15,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662535,NDC,,,facility,inpatient,1,EA,93.40000,27.09000,Aetna,First Health,,76.40,,,,,,,34.56,76.40,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662535,NDC,,,facility,outpatient,1,EA,93.40000,27.09000,Aetna,First Health,,76.40,,,,,,,33.67,76.40,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662525,NDC,,,facility,inpatient,1,EA,92.45000,26.81000,Aetna,First Health,,75.62,,,,,,,34.21,75.62,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662525,NDC,,,facility,outpatient,1,EA,92.45000,26.81000,Aetna,First Health,,75.62,,,,,,,33.33,75.62,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662514,NDC,,,facility,inpatient,1,EA,100.35000,29.10000,Aetna,First Health,,82.09,,,,,,,37.13,82.09,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662514,NDC,,,facility,outpatient,1,EA,100.35000,29.10000,Aetna,First Health,,82.09,,,,,,,36.18,82.09,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662502,NDC,,,facility,inpatient,1,EA,99.35000,28.81000,Aetna,First Health,,81.27,,,,,,,36.76,81.27,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662502,NDC,,,facility,outpatient,1,EA,99.35000,28.81000,Aetna,First Health,,81.27,,,,,,,35.82,81.27,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00409660902,NDC,,,facility,inpatient,1,EA,73.25000,21.24000,Aetna,First Health,,59.92,,,,,,,27.10,59.92,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00409660902,NDC,,,facility,outpatient,1,EA,73.25000,21.24000,Aetna,First Health,,59.92,,,,,,,26.41,59.92,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,00409653401,NDC,facility,inpatient,500,ME,52.10000,15.11000,Aetna,First Health,,42.62,,,,,,,18.78,42.62,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,00409653401,NDC,facility,outpatient,500,ME,52.10000,15.11000,Aetna,First Health,,42.62,,,,,,,0.02889,42.62,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653349,NDC,facility,inpatient,1,GM,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,55.52,125.97,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653349,NDC,facility,outpatient,1,GM,154.00000,44.66000,Aetna,First Health,,125.97,,,,,,,0.02889,125.97,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653331,NDC,facility,inpatient,1,GM,35.85000,10.40000,Aetna,First Health,,29.33,,,,,,,12.92,29.33,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653331,NDC,facility,outpatient,1,GM,35.85000,10.40000,Aetna,First Health,,29.33,,,,,,,0.02889,29.33,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653321,NDC,facility,inpatient,1,GM,156.30000,45.33000,Aetna,First Health,,127.85,,,,,,,56.35,127.85,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653321,NDC,facility,outpatient,1,GM,156.30000,45.33000,Aetna,First Health,,127.85,,,,,,,0.02889,127.85,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653301,NDC,facility,inpatient,1,GM,154.75000,44.88000,Aetna,First Health,,126.59,,,,,,,55.79,126.59,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653301,NDC,facility,outpatient,1,GM,154.75000,44.88000,Aetna,First Health,,126.59,,,,,,,0.02889,126.59,percent of total billed charges,
Vancomycin HCl 750mg Inj,800019998,CDM,636,RC,J3373,HCPCS,00409653102,NDC,facility,inpatient,750,ME,94.40000,27.38000,Aetna,First Health,,77.22,,,,,,,34.03,77.22,percent of total billed charges,
Vancomycin HCl 750mg Inj,800019998,CDM,636,RC,J3373,HCPCS,00409653102,NDC,facility,outpatient,750,ME,94.40000,27.38000,Aetna,First Health,,77.22,,,,,,,0.02889,77.22,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00409651001,NDC,facility,inpatient,1,GM,208.50000,60.46000,Aetna,First Health,,170.55,,,,,,,75.16,170.55,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00409651001,NDC,facility,outpatient,1,GM,208.50000,60.46000,Aetna,First Health,,170.55,,,,,,,0.02889,170.55,percent of total billed charges,
Erythromycin Lact.500mg I,800081135,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,inpatient,500,ME,943.00000,273.47000,Aetna,First Health,,771.37,,,,,,,339.95,771.37,percent of total billed charges,
Erythromycin Lact.500mg I,800081135,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,outpatient,500,ME,943.00000,273.47000,Aetna,First Health,,771.37,,,,,,,19.41,771.37,percent of total billed charges,
Erythromycin Lact.500mg I,800081135,CDM,636,RC,J1364,HCPCS,00409647644,NDC,facility,inpatient,500,ME,746.35000,216.44000,Aetna,First Health,,610.51,,,,,,,269.06,610.51,percent of total billed charges,
Erythromycin Lact.500mg I,800081135,CDM,636,RC,J1364,HCPCS,00409647644,NDC,facility,outpatient,500,ME,746.35000,216.44000,Aetna,First Health,,610.51,,,,,,,19.41,610.51,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,00409610227,NDC,facility,inpatient,100,ME,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,11.52,26.14,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,00409610227,NDC,facility,outpatient,100,ME,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,11.52,26.14,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,inpatient,40,ME,18.75000,5.44000,Aetna,First Health,,15.34,,,,,,,6.76,15.34,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,outpatient,40,ME,18.75000,5.44000,Aetna,First Health,,15.34,,,,,,,0.01926,15.34,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,00409610225,NDC,facility,inpatient,20,ME,21.85000,6.34000,Aetna,First Health,,17.87,,,,,,,7.88,17.87,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,00409610225,NDC,facility,outpatient,20,ME,21.85000,6.34000,Aetna,First Health,,17.87,,,,,,,0.01926,17.87,percent of total billed charges,
Furosemide 100mg I,800013344,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,inpatient,100,ME,56.05000,16.25000,Aetna,First Health,,45.85,,,,,,,20.21,45.85,percent of total billed charges,
Furosemide 100mg I,800013344,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,outpatient,100,ME,56.05000,16.25000,Aetna,First Health,,45.85,,,,,,,0.01926,45.85,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,00409610210,NDC,facility,inpatient,100,ME,37.25000,10.80000,Aetna,First Health,,30.47,,,,,,,13.43,30.47,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,00409610210,NDC,facility,outpatient,100,ME,37.25000,10.80000,Aetna,First Health,,30.47,,,,,,,13.43,30.47,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00409610204,NDC,facility,inpatient,40,ME,18.75000,5.44000,Aetna,First Health,,15.34,,,,,,,6.76,15.34,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00409610204,NDC,facility,outpatient,40,ME,18.75000,5.44000,Aetna,First Health,,15.34,,,,,,,0.01926,15.34,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,inpatient,20,ME,26.70000,7.74000,Aetna,First Health,,21.84,,,,,,,9.63,21.84,percent of total billed charges,
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,outpatient,20,ME,26.70000,7.74000,Aetna,First Health,,21.84,,,,,,,0.01926,21.84,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00409601025,NDC,facility,inpatient,200,ME,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00409601025,NDC,facility,outpatient,200,ME,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,0.08667,22.58,percent of total billed charges,
Aminophylline 500mg/20mL I,800013441,CDM,636,RC,J0280,HCPCS,00409592201,NDC,facility,inpatient,500,ME,123.55000,35.83000,Aetna,First Health,,101.06,,,,,,,44.54,101.06,percent of total billed charges,
Aminophylline 500mg/20mL I,800013441,CDM,636,RC,J0280,HCPCS,00409592201,NDC,facility,outpatient,500,ME,123.55000,35.83000,Aetna,First Health,,101.06,,,,,,,10.02,101.06,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00409568523,NDC,facility,inpatient,125,ME,21.60000,6.26000,Aetna,First Health,,17.67,,,,,,,7.79,17.67,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00409568523,NDC,facility,outpatient,125,ME,21.60000,6.26000,Aetna,First Health,,17.67,,,,,,,0.25038,17.67,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00409555502,NDC,,,facility,inpatient,1,EA,74.35000,21.56000,Aetna,First Health,,60.82,,,,,,,27.51,60.82,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00409555502,NDC,,,facility,outpatient,1,EA,74.35000,21.56000,Aetna,First Health,,60.82,,,,,,,26.80,60.82,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00409555501,NDC,,,facility,inpatient,1,EA,74.35000,21.56000,Aetna,First Health,,60.82,,,,,,,27.51,60.82,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00409555501,NDC,,,facility,outpatient,1,EA,74.35000,21.56000,Aetna,First Health,,60.82,,,,,,,26.80,60.82,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00409508216,NDC,facility,inpatient,1,GM,40.95000,11.88000,Aetna,First Health,,33.50,,,,,,,14.76,33.50,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00409508216,NDC,facility,outpatient,1,GM,40.95000,11.88000,Aetna,First Health,,33.50,,,,,,,1.42,33.50,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00409501701,NDC,facility,inpatient,1,GM,208.50000,60.46000,Aetna,First Health,,170.55,,,,,,,75.16,170.55,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00409501701,NDC,facility,outpatient,1,GM,208.50000,60.46000,Aetna,First Health,,170.55,,,,,,,0.02889,170.55,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00409493301,NDC,facility,inpatient,1,ME,65.15000,18.89000,Aetna,First Health,,53.29,,,,,,,23.49,53.29,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00409493301,NDC,facility,outpatient,1,ME,65.15000,18.89000,Aetna,First Health,,53.29,,,,,,,2.89,53.29,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00409492834,NDC,,,facility,inpatient,1,EA,109.15000,31.65000,Aetna,First Health,,89.28,,,,,,,40.39,89.28,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00409492834,NDC,,,facility,outpatient,1,EA,109.15000,31.65000,Aetna,First Health,,89.28,,,,,,,39.35,89.28,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00409492134,NDC,facility,inpatient,1,ME,34.05000,9.87000,Aetna,First Health,,27.85,,,,,,,12.28,27.85,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00409492134,NDC,facility,outpatient,1,ME,34.05000,9.87000,Aetna,First Health,,27.85,,,,,,,2.89,27.85,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,inpatient,1,ME,117.85000,34.18000,Aetna,First Health,,96.40,,,,,,,42.48,96.40,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,outpatient,1,ME,117.85000,34.18000,Aetna,First Health,,96.40,,,,,,,0.09630,96.40,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00409490434,NDC,,,facility,inpatient,1,EA,139.90000,40.57000,Aetna,First Health,,114.44,,,,,,,50.43,114.44,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00409490434,NDC,,,facility,outpatient,1,EA,139.90000,40.57000,Aetna,First Health,,114.44,,,,,,,50.43,114.44,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00409490334,NDC,,,facility,inpatient,1,EA,48.45000,14.05000,Aetna,First Health,,39.63,,,,,,,17.47,39.63,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00409490334,NDC,,,facility,outpatient,1,EA,48.45000,14.05000,Aetna,First Health,,39.63,,,,,,,17.47,39.63,percent of total billed charges,
D50W 50mL Inj Syr,800011221,CDM,258,RC,00409490234,NDC,,,facility,inpatient,1,EA,117.05000,33.94000,Aetna,First Health,,95.75,,,,,,,55.01,95.75,percent of total billed charges,
D50W 50mL Inj Syr,800011221,CDM,258,RC,00409490234,NDC,,,facility,outpatient,1,EA,117.05000,33.94000,Aetna,First Health,,95.75,,,,,,,42.20,95.75,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,800049618,CDM,250,RC,00409490034,NDC,,,facility,inpatient,1,EA,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,33.19,73.37,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,800049618,CDM,250,RC,00409490034,NDC,,,facility,outpatient,1,EA,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,32.34,73.37,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,800049618,CDM,250,RC,00409490014,NDC,,,facility,inpatient,1,EA,195.75000,56.77000,Aetna,First Health,,160.12,,,,,,,72.43,160.12,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,800049618,CDM,250,RC,00409490014,NDC,,,facility,outpatient,1,EA,195.75000,56.77000,Aetna,First Health,,160.12,,,,,,,70.57,160.12,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00409488850,NDC,facility,inpatient,1,EA,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,12.26,27.81,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00409488850,NDC,facility,outpatient,1,EA,34.00000,9.86000,Aetna,First Health,,27.81,,,,,,,0.63558,27.81,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,00409488812,NDC,,,facility,inpatient,1,EA,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,6.32,11.00,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,00409488812,NDC,,,facility,outpatient,1,EA,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,4.85,11.00,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,00409488810,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.82,4.91,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,00409488810,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,00409488750,NDC,facility,inpatient,1,EA,45.05000,13.06000,Aetna,First Health,,36.85,,,,,,,21.17,36.85,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,00409488750,NDC,facility,outpatient,1,EA,45.05000,13.06000,Aetna,First Health,,36.85,,,,,,,0.63000,36.85,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,00409488710,NDC,facility,inpatient,1,EA,21.85000,6.34000,Aetna,First Health,,17.87,,,,,,,10.27,17.87,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,00409488710,NDC,facility,outpatient,1,EA,21.85000,6.34000,Aetna,First Health,,17.87,,,,,,,0.63000,17.87,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00409485710,NDC,facility,inpatient,500,ME,39.95000,11.59000,Aetna,First Health,,32.68,,,,,,,14.40,32.68,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00409485710,NDC,facility,outpatient,500,ME,39.95000,11.59000,Aetna,First Health,,32.68,,,,,,,1.34,32.68,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00409485702,NDC,facility,inpatient,100,ME,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,3.06,6.95,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00409485702,NDC,facility,outpatient,100,ME,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,1.34,17.67,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00409485605,NDC,facility,inpatient,100,ME,15.35000,4.45000,Aetna,First Health,,12.56,,,,,,,5.53,12.56,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00409485605,NDC,facility,outpatient,100,ME,15.35000,4.45000,Aetna,First Health,,12.56,,,,,,,5.68,68.03,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,inpatient,4,ME,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,outpatient,4,ME,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,0.08667,5.64,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,inpatient,4,ME,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,2.96,6.71,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,outpatient,4,ME,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,0.08667,6.71,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409475502,NDC,facility,inpatient,4,ME,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409475502,NDC,facility,outpatient,4,ME,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,0.08667,5.03,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409475501,NDC,facility,inpatient,4,ME,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409475501,NDC,facility,outpatient,4,ME,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,0.08667,2.41,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,00409471332,NDC,,,facility,inpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,2.96,6.71,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,00409471332,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,First Health,,6.71,,,,,,,2.96,6.71,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00409471302,NDC,,,facility,inpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00409471302,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00409469933,NDC,facility,inpatient,0.5,GM,110.15000,31.94000,Aetna,First Health,,90.10,,,,,,,39.71,90.10,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00409469933,NDC,facility,outpatient,0.5,GM,110.15000,31.94000,Aetna,First Health,,90.10,,,,,,,0.08667,90.10,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00409469930,NDC,facility,inpatient,200,ME,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00409469930,NDC,facility,outpatient,200,ME,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,0.08667,22.58,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,inpatient,1,GM,222.30000,64.47000,Aetna,First Health,,181.84,,,,,,,80.14,181.84,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,outpatient,1,GM,222.30000,64.47000,Aetna,First Health,,181.84,,,,,,,0.08667,181.84,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00409468823,NDC,facility,inpatient,200,ME,119.90000,34.77000,Aetna,First Health,,98.08,,,,,,,43.22,98.08,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00409468823,NDC,facility,outpatient,200,ME,119.90000,34.77000,Aetna,First Health,,98.08,,,,,,,4.31,98.08,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00409468818,NDC,facility,inpatient,200,ME,76.10000,22.07000,Aetna,First Health,,62.25,,,,,,,27.43,62.25,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00409468818,NDC,facility,outpatient,200,ME,76.10000,22.07000,Aetna,First Health,,62.25,,,,,,,4.31,62.25,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00409468802,NDC,facility,inpatient,400,ME,91.85000,26.64000,Aetna,First Health,,75.13,,,,,,,33.11,75.13,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00409468802,NDC,facility,outpatient,400,ME,91.85000,26.64000,Aetna,First Health,,75.13,,,,,,,4.31,75.13,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00409452030,NDC,facility,inpatient,25000,UN,113.40000,32.89000,Aetna,First Health,,92.76,,,,,,,40.88,92.76,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00409452030,NDC,facility,outpatient,25000,UN,113.40000,32.89000,Aetna,First Health,,92.76,,,,,,,0.17334,92.76,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00409434835,NDC,facility,inpatient,150,ME,16.45000,4.77000,Aetna,First Health,,13.46,,,,,,,5.93,13.46,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00409434835,NDC,facility,outpatient,150,ME,16.45000,4.77000,Aetna,First Health,,13.46,,,,,,,0.39483,13.46,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),800010165,CDM,250,RC,J0281,HCPCS,00409434673,NDC,facility,inpatient,5000,ME,69.90000,20.27000,Aetna,First Health,,57.18,,,,,,,25.86,57.18,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),800010165,CDM,250,RC,J0281,HCPCS,00409434673,NDC,facility,outpatient,5000,ME,69.90000,20.27000,Aetna,First Health,,57.18,,,,,,,1.53,57.18,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),800010165,CDM,250,RC,J0281,HCPCS,00409434610,NDC,facility,inpatient,5000,ME,60.15000,17.44000,Aetna,First Health,,49.20,,,,,,,22.26,49.20,percent of total billed charges,
Aminocaproic 5g/20mL I(AMicAR),800010165,CDM,250,RC,J0281,HCPCS,00409434610,NDC,facility,outpatient,5000,ME,60.15000,17.44000,Aetna,First Health,,49.20,,,,,,,1.53,49.20,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,00409433201,NDC,facility,inpatient,500,ME,78.35000,22.72000,Aetna,First Health,,64.09,,,,,,,28.25,64.09,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,00409433201,NDC,facility,outpatient,500,ME,78.35000,22.72000,Aetna,First Health,,64.09,,,,,,,0.02889,64.09,percent of total billed charges,
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,00409428301,NDC,,,facility,inpatient,1,EA,30.85000,8.95000,Aetna,First Health,,25.24,,,,,,,11.12,25.24,percent of total billed charges,
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,00409428301,NDC,,,facility,outpatient,1,EA,30.85000,8.95000,Aetna,First Health,,25.24,,,,,,,11.12,25.24,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00409428202,NDC,,,facility,inpatient,1,EA,46.15000,13.38000,Aetna,First Health,,37.75,,,,,,,16.64,37.75,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00409428202,NDC,,,facility,outpatient,1,EA,46.15000,13.38000,Aetna,First Health,,37.75,,,,,,,16.64,37.75,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,00409427902,NDC,,,facility,inpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,00409427902,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,First Health,,17.10,,,,,,,7.53,17.10,percent of total billed charges,
Lidocaine 0.5% 50mL PF I,800044361,CDM,636,RC,00409427801,NDC,,,facility,inpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
Lidocaine 0.5% 50mL PF I,800044361,CDM,636,RC,00409427801,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00409427702,NDC,,,facility,inpatient,1,EA,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,9.64,21.88,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00409427702,NDC,,,facility,outpatient,1,EA,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,9.64,21.88,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00409427701,NDC,,,facility,inpatient,1,EA,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,9.14,20.74,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00409427701,NDC,,,facility,outpatient,1,EA,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,9.14,20.74,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00409427602,NDC,,,facility,inpatient,1,EA,20.30000,5.89000,Aetna,First Health,,16.61,,,,,,,7.32,16.61,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00409427602,NDC,,,facility,outpatient,1,EA,20.30000,5.89000,Aetna,First Health,,16.61,,,,,,,7.32,16.61,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00409427601,NDC,,,facility,inpatient,1,EA,20.25000,5.87000,Aetna,First Health,,16.56,,,,,,,7.30,16.56,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00409427601,NDC,,,facility,outpatient,1,EA,20.25000,5.87000,Aetna,First Health,,16.56,,,,,,,7.30,16.56,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409420810,NDC,,,facility,inpatient,1,EA,37.75000,10.95000,Aetna,First Health,,30.88,,,,,,,13.97,30.88,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409420810,NDC,,,facility,outpatient,1,EA,37.75000,10.95000,Aetna,First Health,,30.88,,,,,,,13.61,30.88,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00409412150,NDC,facility,inpatient,4,GM,81.95000,23.77000,Aetna,First Health,,67.04,,,,,,,29.54,67.04,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00409412150,NDC,facility,outpatient,4,GM,81.95000,23.77000,Aetna,First Health,,67.04,,,,,,,0.39483,67.04,percent of total billed charges,
Cupric Cl (Copper) I 10mL,800017803,CDM,250,RC,00409409201,NDC,,,facility,inpatient,1,EA,197.40000,57.25000,Aetna,First Health,,161.47,,,,,,,73.04,161.47,percent of total billed charges,
Cupric Cl (Copper) I 10mL,800017803,CDM,250,RC,00409409201,NDC,,,facility,outpatient,1,EA,197.40000,57.25000,Aetna,First Health,,161.47,,,,,,,71.16,161.47,percent of total billed charges,
Zinc Chloride 1mg/mL I 10mL,800081010,CDM,250,RC,00409409001,NDC,,,facility,inpatient,1,EA,151.05000,43.80000,Aetna,First Health,,123.56,,,,,,,55.89,123.56,percent of total billed charges,
Zinc Chloride 1mg/mL I 10mL,800081010,CDM,250,RC,00409409001,NDC,,,facility,outpatient,1,EA,151.05000,43.80000,Aetna,First Health,,123.56,,,,,,,54.45,123.56,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00409405812,NDC,facility,inpatient,10,ME,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,8.31,18.85,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00409405812,NDC,facility,outpatient,10,ME,23.05000,6.68000,Aetna,First Health,,18.85,,,,,,,8.53,41.63,percent of total billed charges,
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,00409405101,NDC,facility,inpatient,600,ME,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,11.52,26.14,percent of total billed charges,
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,00409405101,NDC,facility,outpatient,600,ME,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,1.84,26.14,percent of total billed charges,
Mannitol 25% I 50mL,800050889,CDM,636,RC,J2150,HCPCS,00409403101,NDC,facility,inpatient,12.5,GM,38.80000,11.25000,Aetna,First Health,,31.74,,,,,,,13.99,31.74,percent of total billed charges,
Mannitol 25% I 50mL,800050889,CDM,636,RC,J2150,HCPCS,00409403101,NDC,facility,outpatient,12.5,GM,38.80000,11.25000,Aetna,First Health,,31.74,,,,,,,13.99,31.74,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409401101,NDC,,,facility,inpatient,1,EA,58.40000,16.94000,Aetna,First Health,,47.77,,,,,,,21.61,47.77,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409401101,NDC,,,facility,outpatient,1,EA,58.40000,16.94000,Aetna,First Health,,47.77,,,,,,,21.05,47.77,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,inpatient,10,ME,201.80000,58.52000,Aetna,First Health,,165.07,,,,,,,72.75,165.07,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,outpatient,10,ME,201.80000,58.52000,Aetna,First Health,,165.07,,,,,,,13.00,165.07,percent of total billed charges,
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,00409381412,NDC,facility,inpatient,5,ME,203.45000,59.00000,Aetna,First Health,,166.42,,,,,,,73.34,166.42,percent of total billed charges,
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,00409381412,NDC,facility,outpatient,5,ME,203.45000,59.00000,Aetna,First Health,,166.42,,,,,,,13.00,166.42,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,30,ME,41.70000,12.09000,Aetna,First Health,,34.11,,,,,,,15.03,34.11,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,outpatient,30,ME,41.70000,12.09000,Aetna,First Health,,34.11,,,,,,,0.31779,34.11,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,00409379301,NDC,facility,inpatient,15,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,00409379301,NDC,facility,outpatient,15,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,0.31779,15.71,percent of total billed charges,
DOBUTamine 1g/D5W 250mL,800013360,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,inpatient,1,GM,293.40000,85.09000,Aetna,First Health,,240.00,,,,,,,105.77,240.00,percent of total billed charges,
DOBUTamine 1g/D5W 250mL,800013360,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,outpatient,1,GM,293.40000,85.09000,Aetna,First Health,,240.00,,,,,,,7.72,240.00,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00409371801,NDC,facility,inpatient,500,ME,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,8.08,18.32,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00409371801,NDC,facility,outpatient,500,ME,22.40000,6.50000,Aetna,First Health,,18.32,,,,,,,0.56817,18.32,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00409361301,NDC,,,facility,inpatient,1,EA,18.20000,5.28000,Aetna,First Health,,14.89,,,,,,,6.73,14.89,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00409361301,NDC,,,facility,outpatient,1,EA,18.20000,5.28000,Aetna,First Health,,14.89,,,,,,,6.56,14.89,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00409357801,NDC,facility,inpatient,80,ME,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,10.33,23.44,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00409357801,NDC,facility,outpatient,80,ME,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,1.99,23.44,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00409350601,NDC,facility,inpatient,1,GM,111.95000,32.47000,Aetna,First Health,,91.58,,,,,,,40.36,91.58,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00409350601,NDC,facility,outpatient,1,GM,111.95000,32.47000,Aetna,First Health,,91.58,,,,,,,0.36594,91.58,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00409350501,NDC,facility,inpatient,500,ME,55.70000,16.15000,Aetna,First Health,,45.56,,,,,,,20.08,45.56,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00409350501,NDC,facility,outpatient,500,ME,55.70000,16.15000,Aetna,First Health,,45.56,,,,,,,0.36594,45.56,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00409341401,NDC,facility,inpatient,10,ME,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,2.87,6.50,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00409341401,NDC,facility,outpatient,10,ME,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,1.04,6.50,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00409339004,NDC,facility,inpatient,4.5,GM,133.85000,38.82000,Aetna,First Health,,109.49,,,,,,,48.25,109.49,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00409339004,NDC,facility,outpatient,4.5,GM,133.85000,38.82000,Aetna,First Health,,109.49,,,,,,,1.05,109.49,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00409338513,NDC,facility,inpatient,3.375,GM,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,36.19,82.13,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00409338513,NDC,facility,outpatient,3.375,GM,100.40000,29.12000,Aetna,First Health,,82.13,,,,,,,1.05,82.13,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00409338302,NDC,facility,inpatient,2.25,GM,66.90000,19.40000,Aetna,First Health,,54.72,,,,,,,24.12,54.72,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00409338302,NDC,facility,outpatient,2.25,GM,66.90000,19.40000,Aetna,First Health,,54.72,,,,,,,1.05,54.72,percent of total billed charges,
SUFentanil 50mcg/mL 1mL I,800049758,CDM,250,RC,00409338221,NDC,,,facility,inpatient,1,EA,125.90000,36.51000,Aetna,First Health,,102.99,,,,,,,46.58,102.99,percent of total billed charges,
SUFentanil 50mcg/mL 1mL I,800049758,CDM,250,RC,00409338221,NDC,,,facility,outpatient,1,EA,125.90000,36.51000,Aetna,First Health,,102.99,,,,,,,45.39,102.99,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00409337504,NDC,,,facility,inpatient,1,EA,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,53.28,117.79,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00409337504,NDC,,,facility,outpatient,1,EA,144.00000,41.76000,Aetna,First Health,,117.79,,,,,,,51.91,117.79,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409336501,NDC,facility,inpatient,2,ME,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,5.43,12.31,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409336501,NDC,facility,outpatient,2,ME,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,0.13482,12.31,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409335601,NDC,facility,inpatient,2,ME,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,5.19,11.78,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409335601,NDC,facility,outpatient,2,ME,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,0.13482,11.78,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00409333024,NDC,facility,inpatient,500,ME,56.50000,16.38000,Aetna,First Health,,46.22,,,,,,,20.37,46.22,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00409333024,NDC,facility,outpatient,500,ME,56.50000,16.38000,Aetna,First Health,,46.22,,,,,,,2.08,46.22,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00409321805,NDC,facility,inpatient,125,ME,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00409321805,NDC,facility,outpatient,125,ME,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,0.25038,18.12,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409318910,NDC,,,facility,inpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.79,19.43,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409318910,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.56,19.43,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,00409318301,NDC,,,facility,inpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,00409318301,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00409318201,NDC,,,facility,inpatient,1,EA,21.30000,6.18000,Aetna,First Health,,17.42,,,,,,,7.68,17.42,percent of total billed charges,
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00409318201,NDC,,,facility,outpatient,1,EA,21.30000,6.18000,Aetna,First Health,,17.42,,,,,,,7.68,17.42,percent of total billed charges,
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,00409317803,NDC,,,facility,inpatient,1,EA,50.85000,14.75000,Aetna,First Health,,41.60,,,,,,,18.33,41.60,percent of total billed charges,
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,00409317803,NDC,,,facility,outpatient,1,EA,50.85000,14.75000,Aetna,First Health,,41.60,,,,,,,18.33,41.60,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00409317801,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00409317801,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
Mag Sulfate 40g/Water 1000mL,800040853,CDM,636,RC,J3475,HCPCS,00409316412,NDC,facility,inpatient,40,GM,85.95000,24.93000,Aetna,First Health,,70.31,,,,,,,30.98,70.31,percent of total billed charges,
Mag Sulfate 40g/Water 1000mL,800040853,CDM,636,RC,J3475,HCPCS,00409316412,NDC,facility,outpatient,40,GM,85.95000,24.93000,Aetna,First Health,,70.31,,,,,,,0.39483,70.31,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00409302401,NDC,,,facility,inpatient,1,EA,339.85000,98.56000,Aetna,First Health,,278.00,,,,,,,125.74,278.00,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00409302401,NDC,,,facility,outpatient,1,EA,339.85000,98.56000,Aetna,First Health,,278.00,,,,,,,122.52,278.00,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00409299803,NDC,facility,inpatient,3,GM,35.15000,10.19000,Aetna,First Health,,28.75,,,,,,,12.67,28.75,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00409299803,NDC,facility,outpatient,3,GM,35.15000,10.19000,Aetna,First Health,,28.75,,,,,,,1.28,28.75,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00409298801,NDC,facility,inpatient,1.5,GM,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,7.17,16.28,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00409298801,NDC,facility,outpatient,1.5,GM,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,1.28,16.28,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00409272301,NDC,facility,inpatient,5000,UN,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,6.06,10.55,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00409272301,NDC,facility,outpatient,5000,UN,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,0.17334,10.55,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00409272003,NDC,facility,inpatient,30000,UN,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,28.59,64.87,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00409272003,NDC,facility,outpatient,30000,UN,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,0.17334,64.87,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,00409272002,NDC,facility,inpatient,10000,UN,21.55000,6.25000,Aetna,First Health,,17.63,,,,,,,7.77,17.63,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,00409272002,NDC,facility,outpatient,10000,UN,21.55000,6.25000,Aetna,First Health,,17.63,,,,,,,0.17334,17.63,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00409258501,NDC,facility,inpatient,1000,ME,26.25000,7.61000,Aetna,First Health,,21.47,,,,,,,9.46,21.47,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00409258501,NDC,facility,outpatient,1000,ME,26.25000,7.61000,Aetna,First Health,,21.47,,,,,,,0.79929,21.47,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,00409255201,NDC,facility,inpatient,1,ME,26.00000,7.54000,Aetna,First Health,,21.27,,,,,,,9.37,21.27,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,00409255201,NDC,facility,outpatient,1,ME,26.00000,7.54000,Aetna,First Health,,21.27,,,,,,,0.13482,21.27,percent of total billed charges,
DOBUTamine 250mg/D5W 250mL,800012791,CDM,636,RC,J1250,HCPCS,00409234632,NDC,facility,inpatient,250,ME,226.15000,65.58000,Aetna,First Health,,184.99,,,,,,,81.53,184.99,percent of total billed charges,
DOBUTamine 250mg/D5W 250mL,800012791,CDM,636,RC,J1250,HCPCS,00409234632,NDC,facility,outpatient,250,ME,226.15000,65.58000,Aetna,First Health,,184.99,,,,,,,7.72,184.99,percent of total billed charges,
Labetalol 5mg/mL 4mL I(Normodyne),800046377,CDM,250,RC,J1920,HCPCS,00409233934,NDC,facility,inpatient,20,ME,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,21.46,47.44,percent of total billed charges,
Labetalol 5mg/mL 4mL I(Normodyne),800046377,CDM,250,RC,J1920,HCPCS,00409233934,NDC,facility,outpatient,20,ME,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,0.33705,47.44,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,00409230849,NDC,facility,inpatient,5,ME,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,3.97,9.00,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,00409230849,NDC,facility,outpatient,5,ME,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,0.13482,9.00,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,00409230801,NDC,facility,inpatient,5,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,4.02,9.12,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,00409230801,NDC,facility,outpatient,5,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,0.13482,9.12,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230662,NDC,facility,inpatient,2,ME,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,5.08,11.53,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230662,NDC,facility,outpatient,2,ME,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,0.13482,11.53,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230612,NDC,facility,inpatient,2,ME,18.30000,5.31000,Aetna,First Health,,14.97,,,,,,,6.60,14.97,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230612,NDC,facility,outpatient,2,ME,18.30000,5.31000,Aetna,First Health,,14.97,,,,,,,0.13482,14.97,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,00409230550,NDC,facility,inpatient,5,ME,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,3.73,8.47,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,00409230550,NDC,facility,outpatient,5,ME,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,0.13482,8.47,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230521,NDC,facility,inpatient,2,ME,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230521,NDC,facility,outpatient,2,ME,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,0.13482,4.29,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230517,NDC,facility,inpatient,2,ME,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230517,NDC,facility,outpatient,2,ME,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,0.13482,8.43,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,inpatient,5,ME,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,outpatient,5,ME,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,0.13482,8.92,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230502,NDC,facility,inpatient,2,ME,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230502,NDC,facility,outpatient,2,ME,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,0.13482,3.97,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00409229031,NDC,facility,inpatient,50,ME,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,4.00,9.08,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00409229031,NDC,facility,outpatient,50,ME,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,0.68373,9.08,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00409229011,NDC,facility,inpatient,50,ME,6.85000,1.99000,Aetna,First Health,,5.60,,,,,,,2.47,5.60,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00409229011,NDC,facility,outpatient,50,ME,6.85000,1.99000,Aetna,First Health,,5.60,,,,,,,0.68373,5.60,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228731,NDC,facility,inpatient,30,ME,23.35000,6.77000,Aetna,First Health,,19.10,,,,,,,8.42,19.10,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228731,NDC,facility,outpatient,30,ME,23.35000,6.77000,Aetna,First Health,,19.10,,,,,,,0.31779,19.10,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228723,NDC,facility,inpatient,30,ME,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,9.66,21.92,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228723,NDC,facility,outpatient,30,ME,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,0.31779,21.92,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228722,NDC,facility,inpatient,30,ME,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,3.89,8.83,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228722,NDC,facility,outpatient,30,ME,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,0.31779,8.83,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228721,NDC,facility,inpatient,30,ME,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,3.37,7.65,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228721,NDC,facility,outpatient,30,ME,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,0.31779,7.65,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00409228505,NDC,,,facility,inpatient,1,EA,13.85000,4.02000,Aetna,First Health,,11.33,,,,,,,5.12,11.33,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00409228505,NDC,,,facility,outpatient,1,EA,13.85000,4.02000,Aetna,First Health,,11.33,,,,,,,4.99,11.33,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,00409226725,NDC,facility,inpatient,100,ME,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,7.92,17.51,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,00409226725,NDC,facility,outpatient,100,ME,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,0.33705,17.51,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,00409226720,NDC,facility,inpatient,100,ME,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,9.36,20.70,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,00409226720,NDC,facility,outpatient,100,ME,25.30000,7.34000,Aetna,First Health,,20.70,,,,,,,0.33705,20.70,percent of total billed charges,
Labetalol 100mg/20mL - for IV Set,800025515,CDM,250,RC,J1920,HCPCS,00409226720,NDC,facility,inpatient,100,ME,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,6.01,13.29,percent of total billed charges,
Labetalol 100mg/20mL - for IV Set,800025515,CDM,250,RC,J1920,HCPCS,00409226720,NDC,facility,outpatient,100,ME,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,0.33705,13.29,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00409226501,NDC,facility,inpatient,0.004,ME,65.65000,19.04000,Aetna,First Health,,53.70,,,,,,,23.67,53.70,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00409226501,NDC,facility,outpatient,0.004,ME,65.65000,19.04000,Aetna,First Health,,53.70,,,,,,,3.28,53.70,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00409222024,NDC,facility,inpatient,250,ME,40.90000,11.86000,Aetna,First Health,,33.46,,,,,,,14.74,33.46,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00409222024,NDC,facility,outpatient,250,ME,40.90000,11.86000,Aetna,First Health,,33.46,,,,,,,2.08,33.46,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00409217332,NDC,facility,inpatient,10,ME,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00409217332,NDC,facility,outpatient,10,ME,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.04,4.09,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,00409216877,NDC,facility,inpatient,10,GM,93.00000,26.97000,Aetna,First Health,,76.07,,,,,,,33.53,76.07,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,00409216877,NDC,facility,outpatient,10,GM,93.00000,26.97000,Aetna,First Health,,76.07,,,,,,,0.39483,76.07,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,00409216802,NDC,facility,inpatient,10,GM,38.65000,11.21000,Aetna,First Health,,31.62,,,,,,,13.93,31.62,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,00409216802,NDC,facility,outpatient,10,GM,38.65000,11.21000,Aetna,First Health,,31.62,,,,,,,0.39483,31.62,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00409212202,NDC,,,facility,inpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,7.16,15.83,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00409212202,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,6.98,15.83,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,00409206605,NDC,,,facility,inpatient,1,EA,17.45000,5.06000,Aetna,First Health,,14.27,,,,,,,6.29,14.27,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,00409206605,NDC,,,facility,outpatient,1,EA,17.45000,5.06000,Aetna,First Health,,14.27,,,,,,,6.29,14.27,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,00409205310,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.29,2.86,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,00409205310,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,00409204510,NDC,facility,inpatient,20,ME,163.50000,47.42000,Aetna,First Health,,133.74,,,,,,,58.94,133.74,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,00409204510,NDC,facility,outpatient,20,ME,163.50000,47.42000,Aetna,First Health,,133.74,,,,,,,1.30,133.74,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00409201125,NDC,facility,inpatient,500,ME,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,13.45,30.51,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00409201125,NDC,facility,outpatient,500,ME,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,0.03852,30.51,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00409198530,NDC,facility,inpatient,2,ME,34.45000,9.99000,Aetna,First Health,,28.18,,,,,,,12.42,28.18,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00409198530,NDC,facility,outpatient,2,ME,34.45000,9.99000,Aetna,First Health,,28.18,,,,,,,1.36,28.18,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00409198505,NDC,facility,inpatient,2,ME,19.30000,5.60000,Aetna,First Health,,15.79,,,,,,,6.96,15.79,percent of total billed charges,
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00409198505,NDC,facility,outpatient,2,ME,19.30000,5.60000,Aetna,First Health,,15.79,,,,,,,1.36,15.79,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,00409196607,NDC,,,facility,inpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.44,12.02,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,00409196607,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.30,12.02,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,00409196605,NDC,,,facility,inpatient,1,EA,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,5.18,11.45,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,00409196605,NDC,,,facility,outpatient,1,EA,14.00000,4.06000,Aetna,First Health,,11.45,,,,,,,5.05,11.45,percent of total billed charges,
Morphine 10mg/1mL PF Inj,800059971,CDM,636,RC,J2274,HCPCS,00409189301,NDC,facility,inpatient,10,ME,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
Morphine 10mg/1mL PF Inj,800059971,CDM,636,RC,J2274,HCPCS,00409189301,NDC,facility,outpatient,10,ME,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,8.20,41.63,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,inpatient,4,ME,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,6.74,15.30,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,outpatient,4,ME,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,2.93,15.30,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00409189023,NDC,facility,inpatient,2,ME,41.15000,11.93000,Aetna,First Health,,33.66,,,,,,,14.83,33.66,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00409189023,NDC,facility,outpatient,2,ME,41.15000,11.93000,Aetna,First Health,,33.66,,,,,,,2.93,33.66,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,inpatient,2,ME,20.45000,5.93000,Aetna,First Health,,16.73,,,,,,,7.37,16.73,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,outpatient,2,ME,20.45000,5.93000,Aetna,First Health,,16.73,,,,,,,2.93,16.73,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00409188602,NDC,facility,inpatient,500,ME,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,13.45,30.51,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00409188602,NDC,facility,outpatient,500,ME,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,0.03852,30.51,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409178269,NDC,facility,inpatient,0.4,ME,98.55000,28.58000,Aetna,First Health,,80.61,,,,,,,35.53,80.61,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409178269,NDC,facility,outpatient,0.4,ME,98.55000,28.58000,Aetna,First Health,,80.61,,,,,,,0.06741,80.61,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00409177835,NDC,,,facility,inpatient,1,EA,33.50000,9.72000,Aetna,First Health,,27.40,,,,,,,12.39,27.40,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00409177835,NDC,,,facility,outpatient,1,EA,33.50000,9.72000,Aetna,First Health,,27.40,,,,,,,12.08,27.40,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00409177805,NDC,,,facility,inpatient,1,EA,8.25000,2.39000,Aetna,First Health,,6.75,,,,,,,3.05,6.75,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00409177805,NDC,,,facility,outpatient,1,EA,8.25000,2.39000,Aetna,First Health,,6.75,,,,,,,2.97,6.75,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00409176230,NDC,facility,inpatient,2,ME,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,5.19,11.78,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00409176230,NDC,facility,outpatient,2,ME,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,2.93,11.78,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00409176162,NDC,,,facility,inpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.44,7.61,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00409176162,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,3.35,7.61,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00409176102,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.71,23.68,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00409176102,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409174929,NDC,,,facility,inpatient,1,EA,62.65000,18.17000,Aetna,First Health,,51.25,,,,,,,23.18,51.25,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409174929,NDC,,,facility,outpatient,1,EA,62.65000,18.17000,Aetna,First Health,,51.25,,,,,,,22.59,51.25,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,00409174910,NDC,,,facility,inpatient,1,EA,43.55000,12.63000,Aetna,First Health,,35.62,,,,,,,16.11,35.62,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,00409174910,NDC,,,facility,outpatient,1,EA,43.55000,12.63000,Aetna,First Health,,35.62,,,,,,,15.70,35.62,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409174630,NDC,,,facility,inpatient,1,EA,74.05000,21.47000,Aetna,First Health,,60.57,,,,,,,27.40,60.57,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409174630,NDC,,,facility,outpatient,1,EA,74.05000,21.47000,Aetna,First Health,,60.57,,,,,,,26.70,60.57,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,00409166010,NDC,,,facility,inpatient,1,EA,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,181.30,400.82,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,00409166010,NDC,,,facility,outpatient,1,EA,490.00000,142.10000,Aetna,First Health,,400.82,,,,,,,176.65,400.82,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00409163201,NDC,,,facility,inpatient,1,EA,46.85000,13.59000,Aetna,First Health,,38.32,,,,,,,17.33,38.32,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00409163201,NDC,,,facility,outpatient,1,EA,46.85000,13.59000,Aetna,First Health,,38.32,,,,,,,16.89,38.32,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00409163110,NDC,,,facility,inpatient,1,EA,80.55000,23.36000,Aetna,First Health,,65.89,,,,,,,29.80,65.89,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00409163110,NDC,,,facility,outpatient,1,EA,80.55000,23.36000,Aetna,First Health,,65.89,,,,,,,29.04,65.89,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,800042530,CDM,250,RC,00409163110,NDC,,,facility,inpatient,1,EA,69.20000,20.07000,Aetna,First Health,,56.61,,,,,,,25.60,56.61,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,800042530,CDM,250,RC,00409163110,NDC,,,facility,outpatient,1,EA,69.20000,20.07000,Aetna,First Health,,56.61,,,,,,,24.95,56.61,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00409163010,NDC,facility,inpatient,1,ME,65.55000,19.01000,Aetna,First Health,,53.62,,,,,,,23.63,53.62,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00409163010,NDC,facility,outpatient,1,ME,65.55000,19.01000,Aetna,First Health,,53.62,,,,,,,0.09630,53.62,percent of total billed charges,
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,00409162610,NDC,facility,inpatient,2,ME,46.25000,13.41000,Aetna,First Health,,37.83,,,,,,,16.67,37.83,percent of total billed charges,
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,00409162610,NDC,facility,outpatient,2,ME,46.25000,13.41000,Aetna,First Health,,37.83,,,,,,,5.34,37.83,percent of total billed charges,
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,00409162601,NDC,facility,inpatient,2,ME,133.20000,38.63000,Aetna,First Health,,108.96,,,,,,,48.02,108.96,percent of total billed charges,
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,00409162601,NDC,facility,outpatient,2,ME,133.20000,38.63000,Aetna,First Health,,108.96,,,,,,,5.34,108.96,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00409156029,NDC,,,facility,inpatient,1,EA,34.35000,9.96000,Aetna,First Health,,28.10,,,,,,,12.71,28.10,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00409156029,NDC,,,facility,outpatient,1,EA,34.35000,9.96000,Aetna,First Health,,28.10,,,,,,,12.38,28.10,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00409156010,NDC,,,facility,inpatient,1,EA,33.15000,9.61000,Aetna,First Health,,27.12,,,,,,,12.27,27.12,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00409156010,NDC,,,facility,outpatient,1,EA,33.15000,9.61000,Aetna,First Health,,27.12,,,,,,,11.95,27.12,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00409155930,NDC,,,facility,inpatient,1,EA,32.60000,9.45000,Aetna,First Health,,26.67,,,,,,,12.06,26.67,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00409155930,NDC,,,facility,outpatient,1,EA,32.60000,9.45000,Aetna,First Health,,26.67,,,,,,,11.75,26.67,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00409155910,NDC,,,facility,inpatient,1,EA,28.15000,8.16000,Aetna,First Health,,23.03,,,,,,,10.42,23.03,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00409155910,NDC,,,facility,outpatient,1,EA,28.15000,8.16000,Aetna,First Health,,23.03,,,,,,,10.15,23.03,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409154110,NDC,,,facility,inpatient,1,EA,74.05000,21.47000,Aetna,First Health,,60.57,,,,,,,27.40,60.57,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409154110,NDC,,,facility,outpatient,1,EA,74.05000,21.47000,Aetna,First Health,,60.57,,,,,,,26.70,60.57,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00409148303,NDC,facility,inpatient,25,ME,47.75000,13.85000,Aetna,First Health,,39.06,,,,,,,17.21,39.06,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00409148303,NDC,facility,outpatient,25,ME,47.75000,13.85000,Aetna,First Health,,39.06,,,,,,,1.46,39.06,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00409148302,NDC,facility,inpatient,25,ME,83.75000,24.29000,Aetna,First Health,,68.51,,,,,,,30.19,68.51,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00409148302,NDC,facility,outpatient,25,ME,83.75000,24.29000,Aetna,First Health,,68.51,,,,,,,1.46,68.51,percent of total billed charges,
Nalbuphine 10mg/mL I (Nubain),800046443,CDM,636,RC,J2300,HCPCS,00409146349,NDC,facility,inpatient,10,ME,28.20000,8.18000,Aetna,First Health,,23.07,,,,,,,10.17,23.07,percent of total billed charges,
Nalbuphine 10mg/mL I (Nubain),800046443,CDM,636,RC,J2300,HCPCS,00409146349,NDC,facility,outpatient,10,ME,28.20000,8.18000,Aetna,First Health,,23.07,,,,,,,3.32,23.07,percent of total billed charges,
Nalbuphine 10mg/mL I (Nubain),800046443,CDM,636,RC,J2300,HCPCS,00409146301,NDC,facility,inpatient,10,ME,28.45000,8.25000,Aetna,First Health,,23.27,,,,,,,10.26,23.27,percent of total billed charges,
Nalbuphine 10mg/mL I (Nubain),800046443,CDM,636,RC,J2300,HCPCS,00409146301,NDC,facility,outpatient,10,ME,28.45000,8.25000,Aetna,First Health,,23.27,,,,,,,3.32,23.27,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00409144304,NDC,,,facility,inpatient,1,EA,129.15000,37.45000,Aetna,First Health,,105.64,,,,,,,47.79,105.64,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00409144304,NDC,,,facility,outpatient,1,EA,129.15000,37.45000,Aetna,First Health,,105.64,,,,,,,46.56,105.64,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00409141249,NDC,facility,inpatient,1,ME,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,5.86,13.29,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00409141249,NDC,facility,outpatient,1,ME,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,0.34668,13.29,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00409141210,NDC,facility,inpatient,0.25,ME,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,1.15,2.62,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00409141210,NDC,facility,outpatient,0.25,ME,3.20000,0.93000,Aetna,First Health,,2.62,,,,,,,0.34668,2.62,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00409141204,NDC,facility,inpatient,1,ME,13.60000,3.94000,Aetna,First Health,,11.12,,,,,,,4.90,11.12,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00409141204,NDC,facility,outpatient,1,ME,13.60000,3.94000,Aetna,First Health,,11.12,,,,,,,0.34668,11.12,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,00409141005,NDC,,,facility,inpatient,1,EA,567.25000,164.50000,Aetna,First Health,,464.01,,,,,,,209.88,464.01,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,00409141005,NDC,,,facility,outpatient,1,EA,567.25000,164.50000,Aetna,First Health,,464.01,,,,,,,204.49,464.01,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00409140231,NDC,facility,inpatient,5000,UN,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,8.77,15.26,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00409140231,NDC,facility,outpatient,5000,UN,18.65000,5.41000,Aetna,First Health,,15.26,,,,,,,0.17334,15.26,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00409140212,NDC,facility,inpatient,5000,UN,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,10.50,18.28,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00409140212,NDC,facility,outpatient,5000,UN,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,0.17334,18.28,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00409139122,NDC,facility,inpatient,1,GM,198.75000,57.64000,Aetna,First Health,,162.58,,,,,,,71.65,162.58,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00409139122,NDC,facility,outpatient,1,GM,198.75000,57.64000,Aetna,First Health,,162.58,,,,,,,0.36594,162.58,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00409136201,NDC,facility,inpatient,25,ME,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,33.69,76.44,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00409136201,NDC,facility,outpatient,25,ME,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,7.85,76.44,percent of total billed charges,
Doxercalciferol 4mcg/2mL Inj,800062124,CDM,636,RC,J1270,HCPCS,00409133001,NDC,facility,inpatient,0.004,ME,25.90000,7.51000,Aetna,First Health,,21.19,,,,,,,9.34,21.19,percent of total billed charges,
Doxercalciferol 4mcg/2mL Inj,800062124,CDM,636,RC,J1270,HCPCS,00409133001,NDC,facility,outpatient,0.004,ME,25.90000,7.51000,Aetna,First Health,,21.19,,,,,,,0.29853,21.19,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00409132305,NDC,,,facility,inpatient,1,EA,46.40000,13.46000,Aetna,First Health,,37.96,,,,,,,16.73,37.96,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00409132305,NDC,,,facility,outpatient,1,EA,46.40000,13.46000,Aetna,First Health,,37.96,,,,,,,16.73,37.96,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00409131901,NDC,facility,inpatient,1,GM,208.50000,60.46000,Aetna,First Health,,170.55,,,,,,,75.16,170.55,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00409131901,NDC,facility,outpatient,1,GM,208.50000,60.46000,Aetna,First Health,,170.55,,,,,,,0.02889,170.55,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,inpatient,2,ME,32.30000,9.37000,Aetna,First Health,,26.42,,,,,,,11.64,26.42,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,outpatient,2,ME,32.30000,9.37000,Aetna,First Health,,26.42,,,,,,,0.13482,26.42,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409131210,NDC,facility,inpatient,2,ME,26.30000,7.63000,Aetna,First Health,,21.51,,,,,,,9.48,21.51,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409131210,NDC,facility,outpatient,2,ME,26.30000,7.63000,Aetna,First Health,,21.51,,,,,,,0.13482,21.51,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,00409128331,NDC,facility,inpatient,1,ME,24.95000,7.24000,Aetna,First Health,,20.41,,,,,,,8.99,20.41,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,00409128331,NDC,facility,outpatient,1,ME,24.95000,7.24000,Aetna,First Health,,20.41,,,,,,,0.13482,20.41,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,00409128310,NDC,facility,inpatient,1,ME,24.60000,7.13000,Aetna,First Health,,20.12,,,,,,,8.87,20.12,percent of total billed charges,
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,00409128310,NDC,facility,outpatient,1,ME,24.60000,7.13000,Aetna,First Health,,20.12,,,,,,,0.13482,20.12,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409127632,NDC,facility,inpatient,0.1,ME,22.20000,6.44000,Aetna,First Health,,18.16,,,,,,,8.00,18.16,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409127632,NDC,facility,outpatient,0.1,ME,22.20000,6.44000,Aetna,First Health,,18.16,,,,,,,1.15,18.16,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,inpatient,10,ME,315.95000,91.63000,Aetna,First Health,,258.45,,,,,,,113.90,258.45,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,outpatient,10,ME,315.95000,91.63000,Aetna,First Health,,258.45,,,,,,,6.44,258.45,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00409127305,NDC,facility,inpatient,10,ME,20.40000,5.92000,Aetna,First Health,,16.69,,,,,,,7.35,16.69,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00409127305,NDC,facility,outpatient,10,ME,20.40000,5.92000,Aetna,First Health,,16.69,,,,,,,6.44,20.63,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00409125830,NDC,facility,inpatient,4,ME,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,6.81,15.46,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00409125830,NDC,facility,outpatient,4,ME,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,2.93,15.46,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409121525,NDC,facility,inpatient,0.4,ME,99.55000,28.87000,Aetna,First Health,,81.43,,,,,,,35.89,81.43,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409121525,NDC,facility,outpatient,0.4,ME,99.55000,28.87000,Aetna,First Health,,81.43,,,,,,,0.06741,81.43,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,0.4,ME,101.05000,29.30000,Aetna,First Health,,82.66,,,,,,,36.43,82.66,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,outpatient,0.4,ME,101.05000,29.30000,Aetna,First Health,,82.66,,,,,,,0.06741,82.66,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409121201,NDC,facility,inpatient,0.4,ME,26.45000,7.67000,Aetna,First Health,,21.64,,,,,,,9.54,21.64,percent of total billed charges,
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409121201,NDC,facility,outpatient,0.4,ME,26.45000,7.67000,Aetna,First Health,,21.64,,,,,,,0.06741,21.64,percent of total billed charges,
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00409120725,NDC,facility,inpatient,80,ME,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,3.10,7.03,percent of total billed charges,
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00409120725,NDC,facility,outpatient,80,ME,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,2.09,7.03,percent of total billed charges,
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00409120703,NDC,facility,inpatient,80,ME,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,12.51,28.38,percent of total billed charges,
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00409120703,NDC,facility,outpatient,80,ME,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,2.09,28.38,percent of total billed charges,
droPERidol 2.5mg/mL 2mL I,800011791,CDM,636,RC,J1790,HCPCS,00409118701,NDC,facility,inpatient,5,ME,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,5.57,12.64,percent of total billed charges,
droPERidol 2.5mg/mL 2mL I,800011791,CDM,636,RC,J1790,HCPCS,00409118701,NDC,facility,outpatient,5,ME,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,5.72,22.14,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,inpatient,25,ME,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,20.91,47.44,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,outpatient,25,ME,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,7.85,47.44,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00409116210,NDC,,,facility,inpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,5.27,11.66,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00409116210,NDC,,,facility,outpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,5.14,11.66,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00409116202,NDC,,,facility,inpatient,1,EA,17.10000,4.96000,Aetna,First Health,,13.99,,,,,,,6.33,13.99,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00409116202,NDC,,,facility,outpatient,1,EA,17.10000,4.96000,Aetna,First Health,,13.99,,,,,,,6.16,13.99,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00409116201,NDC,,,facility,inpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,6.53,14.44,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00409116201,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,6.36,14.44,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00409115910,NDC,,,facility,inpatient,1,EA,11.05000,3.20000,Aetna,First Health,,9.04,,,,,,,4.09,9.04,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00409115910,NDC,,,facility,outpatient,1,EA,11.05000,3.20000,Aetna,First Health,,9.04,,,,,,,3.98,9.04,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00409115902,NDC,,,facility,inpatient,1,EA,15.50000,4.50000,Aetna,First Health,,12.68,,,,,,,5.74,12.68,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00409115902,NDC,,,facility,outpatient,1,EA,15.50000,4.50000,Aetna,First Health,,12.68,,,,,,,5.59,12.68,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00409115901,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.59,12.35,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00409115901,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,00409115278,NDC,facility,inpatient,500,UN,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.28840,0.65440,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,00409115278,NDC,facility,outpatient,500,UN,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.01926,0.65440,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409114410,NDC,,,facility,inpatient,1,EA,93.75000,27.19000,Aetna,First Health,,76.69,,,,,,,34.69,76.69,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409114410,NDC,,,facility,outpatient,1,EA,93.75000,27.19000,Aetna,First Health,,76.69,,,,,,,33.80,76.69,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409114405,NDC,,,facility,inpatient,1,EA,93.75000,27.19000,Aetna,First Health,,76.69,,,,,,,34.69,76.69,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409114405,NDC,,,facility,outpatient,1,EA,93.75000,27.19000,Aetna,First Health,,76.69,,,,,,,33.80,76.69,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409114401,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,2.02,4.46,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409114401,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409112062,NDC,facility,inpatient,4,ME,8.25000,2.39000,Aetna,First Health,,6.75,,,,,,,2.97,6.75,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409112062,NDC,facility,outpatient,4,ME,8.25000,2.39000,Aetna,First Health,,6.75,,,,,,,0.08667,6.75,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00409110301,NDC,,,facility,inpatient,1,EA,2321.00000,673.09000,Aetna,First Health,,1898.58,,,,,,,858.77,1898.58,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00409110301,NDC,,,facility,outpatient,1,EA,2321.00000,673.09000,Aetna,First Health,,1898.58,,,,,,,836.72,1898.58,percent of total billed charges,
Mepivacaine 2% PF I 20mL,800016887,CDM,636,RC,J0670,HCPCS,00409106720,NDC,facility,inpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,12.00,27.24,percent of total billed charges,
Mepivacaine 2% PF I 20mL,800016887,CDM,636,RC,J0670,HCPCS,00409106720,NDC,facility,outpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,3.61,27.24,percent of total billed charges,
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,00409083001,NDC,facility,inpatient,2,GM,600.40000,174.12000,Aetna,First Health,,491.13,,,,,,,216.44,491.13,percent of total billed charges,
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,00409083001,NDC,facility,outpatient,2,GM,600.40000,174.12000,Aetna,First Health,,491.13,,,,,,,2.15,491.13,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,00409082901,NDC,facility,inpatient,1,GM,318.90000,92.48000,Aetna,First Health,,260.86,,,,,,,114.96,260.86,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,00409082901,NDC,facility,outpatient,1,GM,318.90000,92.48000,Aetna,First Health,,260.86,,,,,,,2.15,260.86,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00409080601,NDC,facility,inpatient,2,GM,80.85000,23.45000,Aetna,First Health,,66.14,,,,,,,29.15,66.14,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00409080601,NDC,facility,outpatient,2,GM,80.85000,23.45000,Aetna,First Health,,66.14,,,,,,,0.79929,66.14,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00409080501,NDC,facility,inpatient,1000,ME,10.55000,3.06000,Aetna,First Health,,8.63,,,,,,,3.80,8.63,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00409080501,NDC,facility,outpatient,1000,ME,10.55000,3.06000,Aetna,First Health,,8.63,,,,,,,0.79929,8.63,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00409036701,NDC,facility,inpatient,80,ME,2196.80000,637.07000,Aetna,First Health,,1796.98,,,,,,,791.95,1796.98,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00409036701,NDC,facility,outpatient,80,ME,2196.80000,637.07000,Aetna,First Health,,1796.98,,,,,,,0.62595,1796.98,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00409036601,NDC,facility,inpatient,20,ME,624.15000,181.00000,Aetna,First Health,,510.55,,,,,,,225.01,510.55,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00409036601,NDC,facility,outpatient,20,ME,624.15000,181.00000,Aetna,First Health,,510.55,,,,,,,0.62595,510.55,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,00409022001,NDC,facility,inpatient,2,GM,87.65000,25.42000,Aetna,First Health,,71.70,,,,,,,31.60,71.70,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,00409022001,NDC,facility,outpatient,2,GM,87.65000,25.42000,Aetna,First Health,,71.70,,,,,,,0.83781,71.70,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00409021901,NDC,facility,inpatient,1,GM,49.55000,14.37000,Aetna,First Health,,40.53,,,,,,,17.86,40.53,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00409021901,NDC,facility,outpatient,1,GM,49.55000,14.37000,Aetna,First Health,,40.53,,,,,,,0.83781,40.53,percent of total billed charges,
Gemcitabine 2000mg Inj,800016348,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,inpatient,2000,ME,632.10000,183.31000,Aetna,First Health,,517.06,,,,,,,227.87,517.06,percent of total billed charges,
Gemcitabine 2000mg Inj,800016348,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,outpatient,2000,ME,632.10000,183.31000,Aetna,First Health,,517.06,,,,,,,3.46,517.06,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409015224,NDC,facility,inpatient,500,ME,21.55000,6.25000,Aetna,First Health,,17.63,,,,,,,7.77,17.63,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409015224,NDC,facility,outpatient,500,ME,21.55000,6.25000,Aetna,First Health,,17.63,,,,,,,0.02889,17.63,percent of total billed charges,
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00409014710,NDC,,,facility,inpatient,1,EA,21.30000,6.18000,Aetna,First Health,,17.42,,,,,,,7.68,17.42,percent of total billed charges,
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00409014710,NDC,,,facility,outpatient,1,EA,21.30000,6.18000,Aetna,First Health,,17.42,,,,,,,7.68,17.42,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00409006410,NDC,,,facility,inpatient,1,EA,574.05000,166.47000,Aetna,First Health,,469.57,,,,,,,206.95,469.57,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00409006410,NDC,,,facility,outpatient,1,EA,574.05000,166.47000,Aetna,First Health,,469.57,,,,,,,206.95,469.57,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00409000710,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00409000710,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
RAD- iodixanol 320mg/mL Inj 100mL,800022113,CDM,636,RC,Q9967,HCPCS,00407222364,NDC,facility,inpatient,1,EA,615.50000,178.49000,Aetna,First Health,,503.48,,,,,,,221.89,503.48,percent of total billed charges,
RAD- iodixanol 320mg/mL Inj 100mL,800022113,CDM,636,RC,Q9967,HCPCS,00407222364,NDC,facility,outpatient,1,EA,615.50000,178.49000,Aetna,First Health,,503.48,,,,,,,0.14445,503.48,percent of total billed charges,
RAD- iodixanol 320mg/mL Inj 100mL,800022113,CDM,636,RC,Q9967,HCPCS,00407222317,NDC,facility,inpatient,1,EA,575.60000,166.92000,Aetna,First Health,,470.84,,,,,,,207.50,470.84,percent of total billed charges,
RAD- iodixanol 320mg/mL Inj 100mL,800022113,CDM,636,RC,Q9967,HCPCS,00407222317,NDC,facility,outpatient,1,EA,575.60000,166.92000,Aetna,First Health,,470.84,,,,,,,0.14445,470.84,percent of total billed charges,
RAD- iodixanol 270mg/mL I 100mL,800021696,CDM,636,RC,Q9966,HCPCS,00407222217,NDC,facility,inpatient,1,EA,526.80000,152.77000,Aetna,First Health,,430.92,,,,,,,189.91,430.92,percent of total billed charges,
RAD- iodixanol 270mg/mL I 100mL,800021696,CDM,636,RC,Q9966,HCPCS,00407222217,NDC,facility,outpatient,1,EA,526.80000,152.77000,Aetna,First Health,,430.92,,,,,,,0.38520,430.92,percent of total billed charges,
RAD- iodixanol 270mg/mL I 50mL,800015112,CDM,636,RC,Q9966,HCPCS,00407222216,NDC,facility,inpatient,1,EA,293.20000,85.03000,Aetna,First Health,,239.84,,,,,,,105.70,239.84,percent of total billed charges,
RAD- iodixanol 270mg/mL I 50mL,800015112,CDM,636,RC,Q9966,HCPCS,00407222216,NDC,facility,outpatient,1,EA,293.20000,85.03000,Aetna,First Health,,239.84,,,,,,,0.38520,239.84,percent of total billed charges,
RAD- Iohexol 9mg/mL Oral  500mL,800062060,CDM,250,RC,A9698,HCPCS,00407141509,NDC,facility,inpatient,4500,ME,85.80000,24.88000,Aetna,First Health,,70.18,,,,,,,31.75,70.18,percent of total billed charges,
RAD- Iohexol 9mg/mL Oral  500mL,800062060,CDM,250,RC,A9698,HCPCS,00407141509,NDC,facility,outpatient,4500,ME,85.80000,24.88000,Aetna,First Health,,70.18,,,,,,,30.93,70.18,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 500mL MDV,800014519,CDM,636,RC,Q9967,HCPCS,00407141498,NDC,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 500mL MDV,800014519,CDM,636,RC,Q9967,HCPCS,00407141498,NDC,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,0.14445,4.25,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 100mL,800022120,CDM,636,RC,Q9967,HCPCS,00407141491,NDC,facility,inpatient,1,EA,552.50000,160.22000,Aetna,First Health,,451.94,,,,,,,199.18,451.94,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 100mL,800022120,CDM,636,RC,Q9967,HCPCS,00407141491,NDC,facility,outpatient,1,EA,552.50000,160.22000,Aetna,First Health,,451.94,,,,,,,0.14445,451.94,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 50mL,800022121,CDM,636,RC,Q9967,HCPCS,00407141489,NDC,facility,inpatient,1,EA,408.30000,118.41000,Aetna,First Health,,333.99,,,,,,,147.19,333.99,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 50mL,800022121,CDM,636,RC,Q9967,HCPCS,00407141489,NDC,facility,outpatient,1,EA,408.30000,118.41000,Aetna,First Health,,333.99,,,,,,,0.14445,333.99,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 100mL,800022120,CDM,636,RC,Q9967,HCPCS,00407141484,NDC,facility,inpatient,1,EA,539.15000,156.35000,Aetna,First Health,,441.02,,,,,,,194.36,441.02,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 100mL,800022120,CDM,636,RC,Q9967,HCPCS,00407141484,NDC,facility,outpatient,1,EA,539.15000,156.35000,Aetna,First Health,,441.02,,,,,,,0.14445,441.02,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 50mL,800022121,CDM,636,RC,Q9967,HCPCS,00407141482,NDC,facility,inpatient,1,EA,398.65000,115.61000,Aetna,First Health,,326.10,,,,,,,143.71,326.10,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 50mL,800022121,CDM,636,RC,Q9967,HCPCS,00407141482,NDC,facility,outpatient,1,EA,398.65000,115.61000,Aetna,First Health,,326.10,,,,,,,0.14445,326.10,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 50mL,800022121,CDM,636,RC,Q9967,HCPCS,00407141450,NDC,facility,inpatient,1,EA,397.55000,115.29000,Aetna,First Health,,325.20,,,,,,,143.32,325.20,percent of total billed charges,
RAD- Iohexol 350mg/mL Inj 50mL,800022121,CDM,636,RC,Q9967,HCPCS,00407141450,NDC,facility,outpatient,1,EA,397.55000,115.29000,Aetna,First Health,,325.20,,,,,,,0.14445,325.20,percent of total billed charges,
RAD- Iohexol 300mg/mL Inj 50mL,800015111,CDM,636,RC,Q9967,HCPCS,00407141386,NDC,facility,inpatient,1,EA,274.30000,79.55000,Aetna,First Health,,224.38,,,,,,,98.89,224.38,percent of total billed charges,
RAD- Iohexol 300mg/mL Inj 50mL,800015111,CDM,636,RC,Q9967,HCPCS,00407141386,NDC,facility,outpatient,1,EA,274.30000,79.55000,Aetna,First Health,,224.38,,,,,,,0.14445,224.38,percent of total billed charges,
RAD- Iohexol 300mg/mL Inj 50mL,800015111,CDM,636,RC,Q9967,HCPCS,00407141361,NDC,facility,inpatient,1,EA,280.65000,81.39000,Aetna,First Health,,229.57,,,,,,,101.17,229.57,percent of total billed charges,
RAD- Iohexol 300mg/mL Inj 50mL,800015111,CDM,636,RC,Q9967,HCPCS,00407141361,NDC,facility,outpatient,1,EA,280.65000,81.39000,Aetna,First Health,,229.57,,,,,,,0.14445,229.57,percent of total billed charges,
RAD- Iohexol 300mg/mL Inj 50mL,800015111,CDM,636,RC,Q9967,HCPCS,00407141350,NDC,facility,inpatient,1,EA,274.30000,79.55000,Aetna,First Health,,224.38,,,,,,,98.89,224.38,percent of total billed charges,
RAD- Iohexol 300mg/mL Inj 50mL,800015111,CDM,636,RC,Q9967,HCPCS,00407141350,NDC,facility,outpatient,1,EA,274.30000,79.55000,Aetna,First Health,,224.38,,,,,,,0.14445,224.38,percent of total billed charges,
RAD- Iohexol 240mg/mL Inj 20mL,800081454,CDM,636,RC,Q9966,HCPCS,00407141220,NDC,facility,inpatient,1,EA,279.55000,81.07000,Aetna,First Health,,228.67,,,,,,,100.78,228.67,percent of total billed charges,
RAD- Iohexol 240mg/mL Inj 20mL,800081454,CDM,636,RC,Q9966,HCPCS,00407141220,NDC,facility,outpatient,1,EA,279.55000,81.07000,Aetna,First Health,,228.67,,,,,,,0.38520,228.67,percent of total billed charges,
RAD- Iohexol 240mg/mL Inj 20mL,800081454,CDM,636,RC,Q9966,HCPCS,00407141210,NDC,facility,inpatient,1,EA,505.85000,146.70000,Aetna,First Health,,413.79,,,,,,,182.36,413.79,percent of total billed charges,
RAD- Iohexol 240mg/mL Inj 20mL,800081454,CDM,636,RC,Q9966,HCPCS,00407141210,NDC,facility,outpatient,1,EA,505.85000,146.70000,Aetna,First Health,,413.79,,,,,,,0.38520,413.79,percent of total billed charges,
RAD- Iohexol 240mg/mL Inj 10mL,800014718,CDM,636,RC,Q9966,HCPCS,00407141210,NDC,facility,inpatient,1,EA,266.70000,77.34000,Aetna,First Health,,218.16,,,,,,,96.15,218.16,percent of total billed charges,
RAD- Iohexol 240mg/mL Inj 10mL,800014718,CDM,636,RC,Q9966,HCPCS,00407141210,NDC,facility,outpatient,1,EA,266.70000,77.34000,Aetna,First Health,,218.16,,,,,,,0.38520,218.16,percent of total billed charges,
RAD- Iohexol 180mg/mL Inj 20mL,800022118,CDM,636,RC,Q9965,HCPCS,00407141120,NDC,facility,inpatient,1,EA,311.35000,90.29000,Aetna,First Health,,254.68,,,,,,,112.24,254.68,percent of total billed charges,
RAD- Iohexol 180mg/mL Inj 20mL,800022118,CDM,636,RC,Q9965,HCPCS,00407141120,NDC,facility,outpatient,1,EA,311.35000,90.29000,Aetna,First Health,,254.68,,,,,,,1.00,254.68,percent of total billed charges,
RAD- Iohexol 180mg/mL Inj 10mL,800022115,CDM,636,RC,Q9965,HCPCS,00407141110,NDC,facility,inpatient,1,EA,245.60000,71.22000,Aetna,First Health,,200.90,,,,,,,88.54,200.90,percent of total billed charges,
RAD- Iohexol 180mg/mL Inj 10mL,800022115,CDM,636,RC,Q9965,HCPCS,00407141110,NDC,facility,outpatient,1,EA,245.60000,71.22000,Aetna,First Health,,200.90,,,,,,,1.00,200.90,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00406996001,NDC,,,facility,inpatient,1,EA,79.50000,23.06000,Aetna,First Health,,65.03,,,,,,,47.70,65.03,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00406996001,NDC,,,facility,outpatient,1,EA,79.50000,23.06000,Aetna,First Health,,65.03,,,,,,,28.66,65.03,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00406991501,NDC,,,facility,inpatient,1,EA,278.55000,80.78000,Aetna,First Health,,227.85,,,,,,,167.13,227.85,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00406991501,NDC,,,facility,outpatient,1,EA,278.55000,80.78000,Aetna,First Health,,227.85,,,,,,,100.42,227.85,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00406917576,NDC,,,facility,inpatient,1,EA,314.55000,91.22000,Aetna,First Health,,257.30,,,,,,,188.73,257.30,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00406917576,NDC,,,facility,outpatient,1,EA,314.55000,91.22000,Aetna,First Health,,257.30,,,,,,,113.40,257.30,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00406915076,NDC,,,facility,inpatient,1,EA,210.70000,61.10000,Aetna,First Health,,172.35,,,,,,,126.42,172.35,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00406915076,NDC,,,facility,outpatient,1,EA,210.70000,61.10000,Aetna,First Health,,172.35,,,,,,,75.96,172.35,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00406912576,NDC,,,facility,inpatient,1,EA,115.35000,33.45000,Aetna,First Health,,94.36,,,,,,,69.21,94.36,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00406912576,NDC,,,facility,outpatient,1,EA,115.35000,33.45000,Aetna,First Health,,94.36,,,,,,,41.58,94.36,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00406911276,NDC,,,facility,inpatient,1,EA,162.40000,47.10000,Aetna,First Health,,132.84,,,,,,,97.44,132.84,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00406911276,NDC,,,facility,outpatient,1,EA,162.40000,47.10000,Aetna,First Health,,132.84,,,,,,,58.55,132.84,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00406907576,NDC,,,facility,inpatient,1,EA,314.55000,91.22000,Aetna,First Health,,257.30,,,,,,,188.73,257.30,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00406907576,NDC,,,facility,outpatient,1,EA,314.55000,91.22000,Aetna,First Health,,257.30,,,,,,,113.40,257.30,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00406905076,NDC,,,facility,inpatient,1,EA,210.70000,61.10000,Aetna,First Health,,172.35,,,,,,,126.42,172.35,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00406905076,NDC,,,facility,outpatient,1,EA,210.70000,61.10000,Aetna,First Health,,172.35,,,,,,,75.96,172.35,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00406902576,NDC,,,facility,inpatient,1,EA,115.35000,33.45000,Aetna,First Health,,94.36,,,,,,,69.21,94.36,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00406902576,NDC,,,facility,outpatient,1,EA,115.35000,33.45000,Aetna,First Health,,94.36,,,,,,,41.58,94.36,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00406901276,NDC,,,facility,inpatient,1,EA,162.40000,47.10000,Aetna,First Health,,132.84,,,,,,,97.44,132.84,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00406901276,NDC,,,facility,outpatient,1,EA,162.40000,47.10000,Aetna,First Health,,132.84,,,,,,,58.55,132.84,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00406900076,NDC,,,facility,inpatient,1,EA,411.50000,119.34000,Aetna,First Health,,336.61,,,,,,,246.90,336.61,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00406900076,NDC,,,facility,outpatient,1,EA,411.50000,119.34000,Aetna,First Health,,336.61,,,,,,,148.35,336.61,percent of total billed charges,
Dextroamphetamine 5mg T,800081078,CDM,637,RC,S0160,HCPCS,00406895801,NDC,facility,inpatient,5,ME,23.20000,6.73000,Aetna,First Health,,18.98,,,,,,,13.92,18.98,percent of total billed charges,
Dextroamphetamine 5mg T,800081078,CDM,637,RC,S0160,HCPCS,00406895801,NDC,facility,outpatient,5,ME,23.20000,6.73000,Aetna,First Health,,18.98,,,,,,,2.79,18.98,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00406839062,NDC,,,facility,inpatient,1,EA,72.70000,21.08000,Aetna,First Health,,59.47,,,,,,,43.62,59.47,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00406839062,NDC,,,facility,outpatient,1,EA,72.70000,21.08000,Aetna,First Health,,59.47,,,,,,,26.21,59.47,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00406839001,NDC,,,facility,inpatient,1,EA,73.60000,21.34000,Aetna,First Health,,60.20,,,,,,,44.16,60.20,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00406839001,NDC,,,facility,outpatient,1,EA,73.60000,21.34000,Aetna,First Health,,60.20,,,,,,,26.53,60.20,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00406833062,NDC,,,facility,inpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,17.67,24.09,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00406833062,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,10.62,24.09,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00406833001,NDC,,,facility,inpatient,1,EA,25.40000,7.37000,Aetna,First Health,,20.78,,,,,,,15.24,20.78,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00406833001,NDC,,,facility,outpatient,1,EA,25.40000,7.37000,Aetna,First Health,,20.78,,,,,,,9.16,20.78,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,00406831562,NDC,,,facility,inpatient,1,EA,16.30000,4.73000,Aetna,First Health,,13.33,,,,,,,9.78,13.33,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,00406831562,NDC,,,facility,outpatient,1,EA,16.30000,4.73000,Aetna,First Health,,13.33,,,,,,,5.88,13.33,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00406717162,NDC,,,facility,inpatient,1,EA,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,3.78,5.15,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00406717162,NDC,,,facility,outpatient,1,EA,6.30000,1.83000,Aetna,First Health,,5.15,,,,,,,2.27,5.15,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00406577162,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00406577162,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,00406575562,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,00406575562,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00406345434,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00406345434,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,00406324901,NDC,,,facility,inpatient,1,EA,14.30000,4.15000,Aetna,First Health,,11.70,,,,,,,8.58,11.70,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,00406324901,NDC,,,facility,outpatient,1,EA,14.30000,4.15000,Aetna,First Health,,11.70,,,,,,,5.16,11.70,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00406324401,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00406324401,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,00406324301,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,00406324301,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00406202301,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00406202301,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00406202201,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00406202201,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00406114401,NDC,,,facility,inpatient,1,EA,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,5.01,6.83,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00406114401,NDC,,,facility,outpatient,1,EA,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,3.01,6.83,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00406114210,NDC,,,facility,inpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,1.59,2.17,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00406114210,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00406114201,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00406114201,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00406112201,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00406112201,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00406112101,NDC,,,facility,inpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,1.59,2.17,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00406112101,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00406066303,NDC,,,facility,inpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,11.31,15.42,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00406066303,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,6.80,15.42,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00406066301,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00406066301,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00406066101,NDC,,,facility,inpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,11.04,15.05,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00406066101,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,6.63,15.05,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00406055262,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00406055262,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00406055201,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00406055201,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00406048462,NDC,,,facility,inpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,6.09,8.30,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00406048462,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.66,8.30,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00406048401,NDC,,,facility,inpatient,1,EA,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,6.84,9.33,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00406048401,NDC,,,facility,outpatient,1,EA,11.40000,3.31000,Aetna,First Health,,9.33,,,,,,,4.11,9.33,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00406036762,NDC,,,facility,inpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,5.28,7.20,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00406036762,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,First Health,,7.20,,,,,,,3.17,7.20,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00406036562,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00406036562,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Bismuth Subgallate Pwd,800068840,CDM,250,RC,00406030401,NDC,,,facility,inpatient,1,EA,62.85000,18.23000,Aetna,First Health,,51.41,,,,,,,23.25,51.41,percent of total billed charges,
Bismuth Subgallate Pwd,800068840,CDM,250,RC,00406030401,NDC,,,facility,outpatient,1,EA,62.85000,18.23000,Aetna,First Health,,51.41,,,,,,,22.66,51.41,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00406012562,NDC,,,facility,inpatient,1,EA,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,8.07,11.00,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00406012562,NDC,,,facility,outpatient,1,EA,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,4.85,11.00,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00406012362,NDC,,,facility,inpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,5.31,7.24,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00406012362,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,3.19,7.24,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00406012301,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00406012301,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,800066885,CDM,250,RC,00395277516,NDC,,,facility,inpatient,1,EA,17.60000,5.10000,Aetna,First Health,,14.40,,,,,,,6.51,14.40,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,800066885,CDM,250,RC,00395277516,NDC,,,facility,outpatient,1,EA,17.60000,5.10000,Aetna,First Health,,14.40,,,,,,,6.34,14.40,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,00395103196,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.81,6.22,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,00395103196,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Calamine-Zinc Oxide 8% Topical Lotion,800018168,CDM,250,RC,00395041396,NDC,,,facility,inpatient,1,EA,35.35000,10.25000,Aetna,First Health,,28.92,,,,,,,13.08,28.92,percent of total billed charges,
Calamine-Zinc Oxide 8% Topical Lotion,800018168,CDM,250,RC,00395041396,NDC,,,facility,outpatient,1,EA,35.35000,10.25000,Aetna,First Health,,28.92,,,,,,,12.74,28.92,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000111,NDC,,,facility,inpatient,1,EA,225.60000,65.42000,Aetna,First Health,,184.54,,,,,,,135.36,184.54,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000111,NDC,,,facility,outpatient,1,EA,225.60000,65.42000,Aetna,First Health,,184.54,,,,,,,81.33,184.54,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000106,NDC,,,facility,inpatient,1,EA,209.95000,60.89000,Aetna,First Health,,171.74,,,,,,,125.97,171.74,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000106,NDC,,,facility,outpatient,1,EA,209.95000,60.89000,Aetna,First Health,,171.74,,,,,,,75.69,171.74,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000104,NDC,,,facility,inpatient,1,EA,278.75000,80.84000,Aetna,First Health,,228.02,,,,,,,167.25,228.02,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000104,NDC,,,facility,outpatient,1,EA,278.75000,80.84000,Aetna,First Health,,228.02,,,,,,,100.49,228.02,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000102,NDC,,,facility,inpatient,1,EA,228.60000,66.29000,Aetna,First Health,,186.99,,,,,,,137.16,186.99,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000102,NDC,,,facility,outpatient,1,EA,228.60000,66.29000,Aetna,First Health,,186.99,,,,,,,82.41,186.99,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,00378964532,NDC,,,facility,inpatient,1,EA,576.85000,167.29000,Aetna,First Health,,471.86,,,,,,,346.11,471.86,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,00378964532,NDC,,,facility,outpatient,1,EA,576.85000,167.29000,Aetna,First Health,,471.86,,,,,,,207.95,471.86,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00378932232,NDC,,,facility,inpatient,1,EA,3285.40000,952.77000,Aetna,First Health,,2687.46,,,,,,,1971.24,2687.46,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00378932232,NDC,,,facility,outpatient,1,EA,3285.40000,952.77000,Aetna,First Health,,2687.46,,,,,,,1184.39,2687.46,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00378932132,NDC,,,facility,inpatient,1,EA,2566.35000,744.24000,Aetna,First Health,,2099.27,,,,,,,1539.81,2099.27,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00378932132,NDC,,,facility,outpatient,1,EA,2566.35000,744.24000,Aetna,First Health,,2099.27,,,,,,,925.17,2099.27,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00378932032,NDC,,,facility,inpatient,1,EA,2121.10000,615.12000,Aetna,First Health,,1735.06,,,,,,,1272.66,1735.06,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00378932032,NDC,,,facility,outpatient,1,EA,2121.10000,615.12000,Aetna,First Health,,1735.06,,,,,,,764.66,1735.06,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00378912498,NDC,,,facility,inpatient,1,EA,411.50000,119.34000,Aetna,First Health,,336.61,,,,,,,246.90,336.61,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00378912498,NDC,,,facility,outpatient,1,EA,411.50000,119.34000,Aetna,First Health,,336.61,,,,,,,148.35,336.61,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00378912398,NDC,,,facility,inpatient,1,EA,314.55000,91.22000,Aetna,First Health,,257.30,,,,,,,188.73,257.30,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00378912398,NDC,,,facility,outpatient,1,EA,314.55000,91.22000,Aetna,First Health,,257.30,,,,,,,113.40,257.30,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00378912298,NDC,,,facility,inpatient,1,EA,210.70000,61.10000,Aetna,First Health,,172.35,,,,,,,126.42,172.35,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00378912298,NDC,,,facility,outpatient,1,EA,210.70000,61.10000,Aetna,First Health,,172.35,,,,,,,75.96,172.35,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00378912198,NDC,,,facility,inpatient,1,EA,115.35000,33.45000,Aetna,First Health,,94.36,,,,,,,69.21,94.36,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00378912198,NDC,,,facility,outpatient,1,EA,115.35000,33.45000,Aetna,First Health,,94.36,,,,,,,41.58,94.36,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00378911998,NDC,,,facility,inpatient,1,EA,162.40000,47.10000,Aetna,First Health,,132.84,,,,,,,97.44,132.84,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00378911998,NDC,,,facility,outpatient,1,EA,162.40000,47.10000,Aetna,First Health,,132.84,,,,,,,58.55,132.84,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00378911916,NDC,,,facility,inpatient,1,EA,110.40000,32.02000,Aetna,First Health,,90.31,,,,,,,66.24,90.31,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00378911916,NDC,,,facility,outpatient,1,EA,110.40000,32.02000,Aetna,First Health,,90.31,,,,,,,39.80,90.31,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,00378800801,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,00378800801,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,00378773293,NDC,facility,inpatient,4,ME,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,94.71,129.12,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,00378773293,NDC,facility,outpatient,4,ME,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,0.00963,129.12,percent of total billed charges,
Etodolac 200 mg C (Lodine),800080985,CDM,637,RC,00378720001,NDC,,,facility,inpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,4.86,6.63,percent of total billed charges,
Etodolac 200 mg C (Lodine),800080985,CDM,637,RC,00378720001,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,2.92,6.63,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,00378715501,NDC,,,facility,inpatient,1,EA,133.40000,38.69000,Aetna,First Health,,109.12,,,,,,,80.04,109.12,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,00378715501,NDC,,,facility,outpatient,1,EA,133.40000,38.69000,Aetna,First Health,,109.12,,,,,,,48.09,109.12,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00378710177,NDC,,,facility,inpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,10.11,13.78,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00378710177,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.07,13.78,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,00378710077,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,00378710077,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00378700293,NDC,,,facility,inpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,11.61,15.83,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00378700293,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,First Health,,15.83,,,,,,,6.98,15.83,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00378700193,NDC,,,facility,inpatient,1,EA,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,11.13,15.17,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00378700193,NDC,,,facility,outpatient,1,EA,18.55000,5.38000,Aetna,First Health,,15.17,,,,,,,6.69,15.17,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00378700110,NDC,,,facility,inpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00378700110,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,800046545,CDM,637,RC,00378698288,NDC,,,facility,inpatient,1,EA,111.70000,32.39000,Aetna,First Health,,91.37,,,,,,,67.02,91.37,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,800046545,CDM,637,RC,00378698288,NDC,,,facility,outpatient,1,EA,111.70000,32.39000,Aetna,First Health,,91.37,,,,,,,40.27,91.37,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,00378672701,NDC,,,facility,inpatient,1,EA,15.50000,4.50000,Aetna,First Health,,12.68,,,,,,,9.30,12.68,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,00378672701,NDC,,,facility,outpatient,1,EA,15.50000,4.50000,Aetna,First Health,,12.68,,,,,,,5.59,12.68,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00378668910,NDC,,,facility,inpatient,1,EA,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,22.38,30.51,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00378668910,NDC,,,facility,outpatient,1,EA,37.30000,10.82000,Aetna,First Health,,30.51,,,,,,,13.45,30.51,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00378660501,NDC,,,facility,inpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,13.95,19.02,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00378660501,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,8.38,19.02,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,00378647099,NDC,,,facility,inpatient,1,EA,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,85.80,116.97,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,00378647099,NDC,,,facility,outpatient,1,EA,143.00000,41.47000,Aetna,First Health,,116.97,,,,,,,51.55,116.97,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,00378647044,NDC,,,facility,inpatient,1,EA,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,97.59,133.05,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,00378647044,NDC,,,facility,outpatient,1,EA,162.65000,47.17000,Aetna,First Health,,133.05,,,,,,,58.64,133.05,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,00378618001,NDC,,,facility,inpatient,1,EA,10.95000,3.18000,Aetna,First Health,,8.96,,,,,,,6.57,8.96,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,00378618001,NDC,,,facility,outpatient,1,EA,10.95000,3.18000,Aetna,First Health,,8.96,,,,,,,3.95,8.96,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00378617201,NDC,,,facility,inpatient,1,EA,18.25000,5.29000,Aetna,First Health,,14.93,,,,,,,10.95,14.93,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00378617201,NDC,,,facility,outpatient,1,EA,18.25000,5.29000,Aetna,First Health,,14.93,,,,,,,6.58,14.93,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,00378616001,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,00378616001,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,00378612001,NDC,,,facility,inpatient,1,EA,33.45000,9.70000,Aetna,First Health,,27.36,,,,,,,20.07,27.36,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,00378612001,NDC,,,facility,outpatient,1,EA,33.45000,9.70000,Aetna,First Health,,27.36,,,,,,,12.06,27.36,percent of total billed charges,
dilTIAZem 90mg SR C(CardiZEM),800057751,CDM,637,RC,00378609001,NDC,,,facility,inpatient,1,EA,25.65000,7.44000,Aetna,First Health,,20.98,,,,,,,15.39,20.98,percent of total billed charges,
dilTIAZem 90mg SR C(CardiZEM),800057751,CDM,637,RC,00378609001,NDC,,,facility,outpatient,1,EA,25.65000,7.44000,Aetna,First Health,,20.98,,,,,,,9.25,20.98,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,00378606001,NDC,,,facility,inpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,13.47,18.36,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,00378606001,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,8.09,18.36,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00378581477,NDC,,,facility,inpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,22.14,30.18,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00378581477,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,13.30,30.18,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00378581377,NDC,,,facility,inpatient,1,EA,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,20.58,28.06,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00378581377,NDC,,,facility,outpatient,1,EA,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,12.37,28.06,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,00378571093,NDC,,,facility,inpatient,1,EA,92.45000,26.81000,Aetna,First Health,,75.62,,,,,,,55.47,75.62,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,00378571093,NDC,,,facility,outpatient,1,EA,92.45000,26.81000,Aetna,First Health,,75.62,,,,,,,33.33,75.62,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00378563059,NDC,,,facility,inpatient,1,EA,193.05000,55.98000,Aetna,First Health,,157.91,,,,,,,115.83,157.91,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00378563059,NDC,,,facility,outpatient,1,EA,193.05000,55.98000,Aetna,First Health,,157.91,,,,,,,69.59,157.91,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,00378561578,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,00378561578,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00378561378,NDC,,,facility,inpatient,1,EA,20.35000,5.90000,Aetna,First Health,,16.65,,,,,,,12.21,16.65,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00378561378,NDC,,,facility,outpatient,1,EA,20.35000,5.90000,Aetna,First Health,,16.65,,,,,,,7.34,16.65,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,00378551093,NDC,,,facility,inpatient,1,EA,99.95000,28.99000,Aetna,First Health,,81.76,,,,,,,59.97,81.76,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,00378551093,NDC,,,facility,outpatient,1,EA,99.95000,28.99000,Aetna,First Health,,81.76,,,,,,,36.03,81.76,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00378550201,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00378550201,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00378550101,NDC,,,facility,inpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,10.62,14.48,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00378550101,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,First Health,,14.48,,,,,,,6.38,14.48,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00378531001,NDC,,,facility,inpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,22.17,30.23,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00378531001,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,First Health,,30.23,,,,,,,13.32,30.23,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00378528001,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00378528001,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00378522001,NDC,,,facility,inpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,4.83,6.58,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00378522001,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,2.90,6.58,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,00378521077,NDC,,,facility,inpatient,1,EA,16.80000,4.87000,Aetna,First Health,,13.74,,,,,,,10.08,13.74,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,00378521077,NDC,,,facility,outpatient,1,EA,16.80000,4.87000,Aetna,First Health,,13.74,,,,,,,6.06,13.74,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00378520977,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00378520977,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,00378520877,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,00378520877,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,00378511001,NDC,facility,inpatient,10,ME,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,00378511001,NDC,facility,outpatient,10,ME,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,0.57780,5.19,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00378501201,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00378501201,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00378501101,NDC,,,facility,inpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,6.42,8.75,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00378501101,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,First Health,,8.75,,,,,,,3.86,8.75,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00378488201,NDC,,,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,8.49,11.57,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00378488201,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00378488101,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00378488101,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,00378459777,NDC,,,facility,inpatient,1,EA,12.45000,3.61000,Aetna,First Health,,10.18,,,,,,,7.47,10.18,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,00378459777,NDC,,,facility,outpatient,1,EA,12.45000,3.61000,Aetna,First Health,,10.18,,,,,,,4.49,10.18,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00378459677,NDC,,,facility,inpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,4.98,6.79,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00378459677,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.99,6.79,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00378459577,NDC,,,facility,inpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,4.98,6.79,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00378459577,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.99,6.79,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00378427593,NDC,,,facility,inpatient,1,EA,51.15000,14.83000,Aetna,First Health,,41.84,,,,,,,30.69,41.84,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00378427593,NDC,,,facility,outpatient,1,EA,51.15000,14.83000,Aetna,First Health,,41.84,,,,,,,18.44,41.84,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00378427577,NDC,,,facility,inpatient,1,EA,51.15000,14.83000,Aetna,First Health,,41.84,,,,,,,30.69,41.84,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00378427577,NDC,,,facility,outpatient,1,EA,51.15000,14.83000,Aetna,First Health,,41.84,,,,,,,18.44,41.84,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00378422001,NDC,,,facility,inpatient,1,EA,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,8.64,11.78,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00378422001,NDC,,,facility,outpatient,1,EA,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,5.19,11.78,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,00378420178,NDC,facility,inpatient,180,ME,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,19.41,26.46,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,00378420178,NDC,facility,outpatient,180,ME,32.35000,9.38000,Aetna,First Health,,26.46,,,,,,,0.30816,26.46,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00378418893,NDC,,,facility,inpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,12.09,16.48,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00378418893,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,7.26,16.48,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00378418801,NDC,,,facility,inpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,12.09,16.48,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00378418801,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,7.26,16.48,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00378418793,NDC,,,facility,inpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,12.09,16.48,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00378418793,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,7.26,16.48,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00378418701,NDC,,,facility,inpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,12.09,16.48,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00378418701,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,First Health,,16.48,,,,,,,7.26,16.48,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00378415101,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,4.02,5.48,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00378415101,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00378402201,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00378402201,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00378402101,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00378402101,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,00378401001,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,00378401001,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00378395277,NDC,,,facility,inpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,24.51,33.42,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00378395277,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00378395205,NDC,,,facility,inpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,24.51,33.42,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00378395205,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00378395105,NDC,,,facility,inpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,24.51,33.42,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00378395105,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00378395077,NDC,,,facility,inpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,17.19,23.44,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00378395077,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,10.33,23.44,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00378395005,NDC,,,facility,inpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,17.19,23.44,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00378395005,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,10.33,23.44,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00378385777,NDC,,,facility,inpatient,1,EA,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,19.17,26.14,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00378385777,NDC,,,facility,outpatient,1,EA,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,11.52,26.14,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00378385677,NDC,,,facility,inpatient,1,EA,30.60000,8.87000,Aetna,First Health,,25.03,,,,,,,18.36,25.03,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00378385677,NDC,,,facility,outpatient,1,EA,30.60000,8.87000,Aetna,First Health,,25.03,,,,,,,11.03,25.03,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00378385610,NDC,,,facility,inpatient,1,EA,30.60000,8.87000,Aetna,First Health,,25.03,,,,,,,18.36,25.03,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00378385610,NDC,,,facility,outpatient,1,EA,30.60000,8.87000,Aetna,First Health,,25.03,,,,,,,11.03,25.03,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,00378385577,NDC,,,facility,inpatient,1,EA,29.25000,8.48000,Aetna,First Health,,23.93,,,,,,,17.55,23.93,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,00378385577,NDC,,,facility,outpatient,1,EA,29.25000,8.48000,Aetna,First Health,,23.93,,,,,,,10.54,23.93,percent of total billed charges,
Cetirizine 5 mg Tab,800015396,CDM,637,RC,00378363501,NDC,,,facility,inpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,10.59,14.44,percent of total billed charges,
Cetirizine 5 mg Tab,800015396,CDM,637,RC,00378363501,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,6.36,14.44,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00378363405,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00378363405,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00378363401,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00378363401,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00378363301,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00378363301,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00378363201,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00378363201,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00378363105,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00378363105,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00378363101,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00378363101,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,00378362793,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,00378362793,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,00378362777,NDC,,,facility,inpatient,1,EA,49.20000,14.27000,Aetna,First Health,,40.25,,,,,,,29.52,40.25,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,00378362777,NDC,,,facility,outpatient,1,EA,49.20000,14.27000,Aetna,First Health,,40.25,,,,,,,17.74,40.25,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00378351593,NDC,,,facility,inpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,11.52,15.71,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00378351593,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00378347501,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00378347501,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00378342201,NDC,,,facility,inpatient,1,EA,22.70000,6.58000,Aetna,First Health,,18.57,,,,,,,13.62,18.57,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00378342201,NDC,,,facility,outpatient,1,EA,22.70000,6.58000,Aetna,First Health,,18.57,,,,,,,8.18,18.57,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00378340293,NDC,,,facility,inpatient,1,EA,56.85000,16.49000,Aetna,First Health,,46.50,,,,,,,34.11,46.50,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00378340293,NDC,,,facility,outpatient,1,EA,56.85000,16.49000,Aetna,First Health,,46.50,,,,,,,20.49,46.50,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00378335801,NDC,,,facility,inpatient,1,EA,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,5.01,6.83,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00378335801,NDC,,,facility,outpatient,1,EA,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,3.01,6.83,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,00378335299,NDC,,,facility,inpatient,1,EA,164.30000,47.65000,Aetna,First Health,,134.40,,,,,,,98.58,134.40,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,00378335299,NDC,,,facility,outpatient,1,EA,164.30000,47.65000,Aetna,First Health,,134.40,,,,,,,59.23,134.40,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,00378335099,NDC,,,facility,inpatient,1,EA,164.30000,47.65000,Aetna,First Health,,134.40,,,,,,,98.58,134.40,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,00378335099,NDC,,,facility,outpatient,1,EA,164.30000,47.65000,Aetna,First Health,,134.40,,,,,,,59.23,134.40,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00378315193,NDC,,,facility,inpatient,1,EA,22.05000,6.39000,Aetna,First Health,,18.04,,,,,,,13.23,18.04,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00378315193,NDC,,,facility,outpatient,1,EA,22.05000,6.39000,Aetna,First Health,,18.04,,,,,,,7.95,18.04,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00378315177,NDC,,,facility,inpatient,1,EA,22.05000,6.39000,Aetna,First Health,,18.04,,,,,,,13.23,18.04,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00378315177,NDC,,,facility,outpatient,1,EA,22.05000,6.39000,Aetna,First Health,,18.04,,,,,,,7.95,18.04,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00378311001,NDC,,,facility,inpatient,1,EA,79.50000,23.06000,Aetna,First Health,,65.03,,,,,,,47.70,65.03,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00378311001,NDC,,,facility,outpatient,1,EA,79.50000,23.06000,Aetna,First Health,,65.03,,,,,,,28.66,65.03,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00378302401,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00378302401,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00378302005,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00378302005,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00378302001,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00378302001,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,00378268501,NDC,,,facility,inpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,10.80,14.72,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,00378268501,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,First Health,,14.72,,,,,,,6.49,14.72,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00378262501,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00378262501,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,00378261001,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,00378261001,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00378258701,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00378258701,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,00378226801,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,00378226801,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00378220001,NDC,,,facility,inpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,3.87,5.28,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00378220001,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,2.33,5.28,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,00378218001,NDC,,,facility,inpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,11.49,15.66,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,00378218001,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00378214605,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00378214605,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00378214601,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00378214601,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00378212177,NDC,,,facility,inpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,24.51,33.42,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00378212177,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00378207601,NDC,,,facility,inpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,6.60,9.00,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00378207601,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,First Health,,9.00,,,,,,,3.97,9.00,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00378207510,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00378207510,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00378207501,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00378207501,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00378207401,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00378207401,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,00378207201,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,00378207201,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00378201777,NDC,,,facility,inpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,24.51,33.42,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00378201777,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00378201577,NDC,,,facility,inpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,17.19,23.44,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00378201577,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,10.33,23.44,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00378190201,NDC,,,facility,inpatient,1,EA,17.10000,4.96000,Aetna,First Health,,13.99,,,,,,,10.26,13.99,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00378190201,NDC,,,facility,outpatient,1,EA,17.10000,4.96000,Aetna,First Health,,13.99,,,,,,,6.16,13.99,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00378182377,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00378182377,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00378182310,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00378182310,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00378182301,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00378182301,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00378181777,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00378181777,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00378181701,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00378181701,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00378181377,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00378181377,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00378181301,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00378181301,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00378181177,NDC,,,facility,inpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,2.76,3.76,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00378181177,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,1.66,3.76,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00378181105,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00378181105,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00378181101,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00378181101,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00378180977,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00378180977,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00378180910,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00378180910,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00378180901,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00378180901,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00378180777,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00378180777,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00378180701,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00378180701,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00378180577,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00378180577,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00378180501,NDC,,,facility,inpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,2.34,3.19,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00378180501,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00378180377,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00378180377,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00378180301,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00378180301,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00378180077,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00378180077,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00378180010,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00378180010,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00378180001,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00378180001,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00378165001,NDC,,,facility,inpatient,1,EA,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,8.46,11.53,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00378165001,NDC,,,facility,outpatient,1,EA,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,5.08,11.53,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,00378164093,NDC,,,facility,inpatient,1,EA,323.65000,93.86000,Aetna,First Health,,264.75,,,,,,,194.19,264.75,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,00378164093,NDC,,,facility,outpatient,1,EA,323.65000,93.86000,Aetna,First Health,,264.75,,,,,,,116.68,264.75,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00378161005,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00378161005,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00378161001,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00378161001,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00378156001,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00378156001,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00378145401,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00378145401,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00378145001,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00378145001,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00378135201,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00378135201,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,00378130001,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,00378130001,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,00378127093,NDC,,,facility,inpatient,1,EA,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,00378127093,NDC,,,facility,outpatient,1,EA,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,63.81,144.79,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00378125891,NDC,,,facility,inpatient,1,EA,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,33.54,45.73,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00378125891,NDC,,,facility,outpatient,1,EA,55.90000,16.21000,Aetna,First Health,,45.73,,,,,,,20.15,45.73,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,00378120001,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,00378120001,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00378117101,NDC,,,facility,inpatient,1,EA,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,16.86,22.99,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00378117101,NDC,,,facility,outpatient,1,EA,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,10.13,22.99,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00378116001,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,3.69,5.03,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00378116001,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00378115001,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00378115001,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00378114001,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00378114001,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,00378112001,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,00378112001,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00378110101,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00378110101,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00378105401,NDC,,,facility,inpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,11.76,16.03,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00378105401,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,7.07,16.03,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00378105301,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00378105301,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00378105201,NDC,,,facility,inpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,7.86,10.72,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00378105201,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,4.72,10.72,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,00378105101,NDC,,,facility,inpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,6.18,8.43,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,00378105101,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00378104501,NDC,,,facility,inpatient,1,EA,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00378104501,NDC,,,facility,outpatient,1,EA,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,8.29,18.81,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00378104401,NDC,,,facility,inpatient,1,EA,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,7.50,10.22,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00378104401,NDC,,,facility,outpatient,1,EA,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,4.51,10.22,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,00378103077,NDC,,,facility,inpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,17.70,24.13,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,00378103077,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,10.63,24.13,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,00378100501,NDC,facility,inpatient,50,ME,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,8.97,12.23,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,00378100501,NDC,facility,outpatient,50,ME,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,0.05778,12.23,percent of total billed charges,
Buprenorphine 2mg SL Tab,800021993,CDM,637,RC,J0571,HCPCS,00378092393,NDC,facility,inpatient,2,ME,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
Buprenorphine 2mg SL Tab,800021993,CDM,637,RC,J0571,HCPCS,00378092393,NDC,facility,outpatient,2,ME,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,6.66,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,00378087399,NDC,,,facility,inpatient,1,EA,510.35000,148.00000,Aetna,First Health,,417.47,,,,,,,306.21,417.47,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,00378087399,NDC,,,facility,outpatient,1,EA,510.35000,148.00000,Aetna,First Health,,417.47,,,,,,,183.98,417.47,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00378087299,NDC,,,facility,inpatient,1,EA,379.05000,109.92000,Aetna,First Health,,310.06,,,,,,,227.43,310.06,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00378087299,NDC,,,facility,outpatient,1,EA,379.05000,109.92000,Aetna,First Health,,310.06,,,,,,,136.65,310.06,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00378087199,NDC,,,facility,inpatient,1,EA,232.95000,67.56000,Aetna,First Health,,190.55,,,,,,,139.77,190.55,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00378087199,NDC,,,facility,outpatient,1,EA,232.95000,67.56000,Aetna,First Health,,190.55,,,,,,,83.98,190.55,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00378077201,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00378077201,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00378075101,NDC,,,facility,inpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,4.65,6.34,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00378075101,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,2.79,6.34,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,00378072419,NDC,,,facility,inpatient,1,EA,18.05000,5.23000,Aetna,First Health,,14.76,,,,,,,10.83,14.76,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,00378072419,NDC,,,facility,outpatient,1,EA,18.05000,5.23000,Aetna,First Health,,14.76,,,,,,,6.51,14.76,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,00378072219,NDC,,,facility,inpatient,1,EA,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,9.03,12.31,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,00378072219,NDC,,,facility,outpatient,1,EA,15.05000,4.36000,Aetna,First Health,,12.31,,,,,,,5.43,12.31,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,00378061401,NDC,,,facility,inpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,3.57,4.87,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,00378061401,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00378052393,NDC,,,facility,inpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,9.57,13.05,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00378052393,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00378048001,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00378048001,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00378047301,NDC,,,facility,inpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,17.31,23.60,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00378047301,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,10.40,23.60,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00378047201,NDC,,,facility,inpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,10.44,14.23,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00378047201,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,6.27,14.23,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00378046401,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00378046401,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00378043501,NDC,,,facility,inpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,4.50,6.13,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00378043501,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,2.70,6.13,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00378043301,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00378043301,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00378041501,NDC,,,facility,inpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,4.20,5.73,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00378041501,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,2.52,5.73,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,00378041401,NDC,,,facility,inpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,11.22,15.30,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,00378041401,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,First Health,,15.30,,,,,,,6.74,15.30,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00378037301,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00378037301,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00378037001,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00378037001,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,00378035101,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,00378035101,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00378032701,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00378032701,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00378032101,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00378032101,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,00378031001,NDC,,,facility,inpatient,1,EA,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,8.46,11.53,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,00378031001,NDC,,,facility,outpatient,1,EA,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,5.08,11.53,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00378025701,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00378025701,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00378024501,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00378024501,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00378023101,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00378023101,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,00378022201,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,00378022201,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00378021801,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00378021801,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00378021610,NDC,,,facility,inpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.75000,1.02,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00378021610,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.45062,1.02,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00378021601,NDC,,,facility,inpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.75000,1.02,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00378021601,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.45062,1.02,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00378020810,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00378020810,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00378020801,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00378020801,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00378018301,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00378018301,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00378018201,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00378018201,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00378018101,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00378018101,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00378015601,NDC,,,facility,inpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,4.86,6.63,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00378015601,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,2.92,6.63,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00378015201,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00378015201,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00378014491,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00378014491,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,00378014301,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,00378014301,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00378013701,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00378013701,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00378009401,NDC,,,facility,inpatient,1,EA,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,8.07,11.00,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00378009401,NDC,,,facility,outpatient,1,EA,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,4.85,11.00,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,00378008801,NDC,,,facility,inpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,4.20,5.73,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,00378008801,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,First Health,,5.73,,,,,,,2.52,5.73,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,00378007801,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,00378007801,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),800017619,CDM,637,RC,00378006901,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),800017619,CDM,637,RC,00378006901,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00378004701,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00378004701,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,00378004501,NDC,,,facility,inpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,6.66,9.08,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,00378004501,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,4.00,9.08,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00378003210,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00378003210,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00378003201,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00378003201,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,00378002301,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,00378002301,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,00378001805,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,00378001805,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,00378001801,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,00378001801,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sus(Cortispor,800062843,CDM,637,RC,00364737454,NDC,,,facility,inpatient,1,EA,440.60000,127.77000,Aetna,First Health,,360.41,,,,,,,264.36,360.41,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sus(Cortispor,800062843,CDM,637,RC,00364737454,NDC,,,facility,outpatient,1,EA,440.60000,127.77000,Aetna,First Health,,360.41,,,,,,,158.84,360.41,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00364672846,NDC,facility,inpatient,40,ME,271.00000,78.59000,Aetna,First Health,,221.68,,,,,,,97.70,221.68,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00364672846,NDC,facility,outpatient,40,ME,271.00000,78.59000,Aetna,First Health,,221.68,,,,,,,0.71262,221.68,percent of total billed charges,
hydrOXYzine HCl 50mg/1mL Inj,800021995,CDM,636,RC,J3410,HCPCS,00364671954,NDC,facility,inpatient,50,ME,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,3.32,7.53,percent of total billed charges,
hydrOXYzine HCl 50mg/1mL Inj,800021995,CDM,636,RC,J3410,HCPCS,00364671954,NDC,facility,outpatient,50,ME,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,3.40,40.09,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00364283001,NDC,,,facility,inpatient,1,EA,15.40000,4.47000,Aetna,First Health,,12.60,,,,,,,9.24,12.60,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00364283001,NDC,,,facility,outpatient,1,EA,15.40000,4.47000,Aetna,First Health,,12.60,,,,,,,5.55,12.60,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00364273401,NDC,,,facility,inpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,6.48,8.83,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00364273401,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,3.89,8.83,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00364250901,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00364250901,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00364250801,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00364250801,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00364238990,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00364238990,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00364233701,NDC,,,facility,inpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,5.07,6.91,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00364233701,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,3.05,6.91,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,00364217301,NDC,,,facility,inpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,5.49,7.48,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,00364217301,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.30,7.48,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,00364217201,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,00364217201,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00364211001,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00364211001,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00364210901,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00364210901,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,00364206801,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,00364206801,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00364076605,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00364076605,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00364076505,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00364076505,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00364075701,NDC,,,facility,inpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,1.14,1.55,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00364075701,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.68495,1.55,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00364075601,NDC,,,facility,inpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,1.05,1.43,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00364075601,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.63087,1.43,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00364063301,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00364063301,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00364063201,NDC,,,facility,inpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00364063201,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.46865,1.06,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00364049501,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00364049501,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00364047501,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00364047501,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00364046101,NDC,facility,inpatient,10,ME,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.30000,0.40900,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00364046101,NDC,facility,outpatient,10,ME,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.00963,0.40900,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00364044201,NDC,facility,inpatient,20,ME,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00364044201,NDC,facility,outpatient,20,ME,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.00963,0.81800,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,00364040801,NDC,,,facility,inpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,00364040801,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.46865,1.06,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,00364040001,NDC,,,facility,inpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,1.20,1.64,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,00364040001,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00364036601,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00364036601,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00364034701,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00364034701,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00364034601,NDC,,,facility,inpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,1.59,2.17,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00364034601,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00364031401,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00364031401,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00364013701,NDC,,,facility,inpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.51000,0.69530,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00364013701,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.30643,0.69530,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00364007401,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00364007401,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00338979140,NDC,facility,inpatient,1,EA,43.70000,12.67000,Aetna,First Health,,35.75,,,,,,,15.75,35.75,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00338979140,NDC,facility,outpatient,1,EA,43.70000,12.67000,Aetna,First Health,,35.75,,,,,,,0.63558,35.75,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00338979140,NDC,facility,inpatient,1,EA,43.70000,12.67000,Aetna,First Health,,35.75,,,,,,,15.75,35.75,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00338979140,NDC,facility,outpatient,1,EA,43.70000,12.67000,Aetna,First Health,,35.75,,,,,,,0.63558,35.75,percent of total billed charges,
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00338955810,NDC,facility,inpatient,75,ME,846.00000,245.34000,Aetna,First Health,,692.03,,,,,,,304.98,692.03,percent of total billed charges,
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00338955810,NDC,facility,outpatient,75,ME,846.00000,245.34000,Aetna,First Health,,692.03,,,,,,,3.52,692.03,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,00338955712,NDC,,,facility,inpatient,1,EA,201.95000,58.57000,Aetna,First Health,,165.20,,,,,,,74.72,165.20,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,00338955712,NDC,,,facility,outpatient,1,EA,201.95000,58.57000,Aetna,First Health,,165.20,,,,,,,72.80,165.20,percent of total billed charges,
NS 1000mL PVC Free,800070037,CDM,258,RC,J7030,HCPCS,00338954306,NDC,facility,inpatient,1,EA,38.95000,11.30000,Aetna,First Health,,31.86,,,,,,,18.31,31.86,percent of total billed charges,
NS 1000mL PVC Free,800070037,CDM,258,RC,J7030,HCPCS,00338954306,NDC,facility,outpatient,1,EA,38.95000,11.30000,Aetna,First Health,,31.86,,,,,,,1.92,31.86,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00338954305,NDC,facility,inpatient,1,EA,50.50000,14.64000,Aetna,First Health,,41.31,,,,,,,18.21,41.31,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00338954305,NDC,facility,outpatient,1,EA,50.50000,14.64000,Aetna,First Health,,41.31,,,,,,,1.92,41.31,percent of total billed charges,
NS 500mL PVC Free,800012833,CDM,258,RC,J7040,HCPCS,00338954304,NDC,facility,inpatient,1,EA,58.10000,16.85000,Aetna,First Health,,47.53,,,,,,,27.31,47.53,percent of total billed charges,
NS 500mL PVC Free,800012833,CDM,258,RC,J7040,HCPCS,00338954304,NDC,facility,outpatient,1,EA,58.10000,16.85000,Aetna,First Health,,47.53,,,,,,,1.24,47.53,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00338954302,NDC,facility,inpatient,1,EA,52.45000,15.21000,Aetna,First Health,,42.90,,,,,,,18.91,42.90,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00338954302,NDC,facility,outpatient,1,EA,52.45000,15.21000,Aetna,First Health,,42.90,,,,,,,0.63558,42.90,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00338954006,NDC,,,facility,inpatient,1,EA,196.30000,56.93000,Aetna,First Health,,160.57,,,,,,,72.63,160.57,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00338954006,NDC,,,facility,outpatient,1,EA,196.30000,56.93000,Aetna,First Health,,160.57,,,,,,,70.77,160.57,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338915930,NDC,facility,inpatient,1,EA,69.15000,20.05000,Aetna,First Health,,56.56,,,,,,,24.93,56.56,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338915930,NDC,facility,outpatient,1,EA,69.15000,20.05000,Aetna,First Health,,56.56,,,,,,,0.63558,56.56,percent of total billed charges,
Dextrose 5% / Water PVC Free,800012817,CDM,258,RC,J7060,HCPCS,00338634603,NDC,facility,inpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,15.63,27.20,percent of total billed charges,
Dextrose 5% / Water PVC Free,800012817,CDM,258,RC,J7060,HCPCS,00338634603,NDC,facility,outpatient,1,EA,33.25000,9.64000,Aetna,First Health,,27.20,,,,,,,1.69,27.20,percent of total billed charges,
Dextrose 5%/Water PVC Free 250mL,800012809,CDM,258,RC,J7060,HCPCS,00338634602,NDC,facility,inpatient,1,EA,38.40000,11.14000,Aetna,First Health,,31.41,,,,,,,18.05,31.41,percent of total billed charges,
Dextrose 5%/Water PVC Free 250mL,800012809,CDM,258,RC,J7060,HCPCS,00338634602,NDC,facility,outpatient,1,EA,38.40000,11.14000,Aetna,First Health,,31.41,,,,,,,1.69,31.41,percent of total billed charges,
NS 500mL PVC Free,800012833,CDM,258,RC,J7040,HCPCS,00338630403,NDC,facility,inpatient,1,EA,46.30000,13.43000,Aetna,First Health,,37.87,,,,,,,21.76,37.87,percent of total billed charges,
NS 500mL PVC Free,800012833,CDM,258,RC,J7040,HCPCS,00338630403,NDC,facility,outpatient,1,EA,46.30000,13.43000,Aetna,First Health,,37.87,,,,,,,1.24,37.87,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00338630402,NDC,facility,inpatient,1,EA,38.15000,11.06000,Aetna,First Health,,31.21,,,,,,,13.75,31.21,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00338630402,NDC,facility,outpatient,1,EA,38.15000,11.06000,Aetna,First Health,,31.21,,,,,,,0.63558,31.21,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00338630402,NDC,facility,inpatient,1,EA,38.15000,11.06000,Aetna,First Health,,31.21,,,,,,,13.75,31.21,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00338630402,NDC,facility,outpatient,1,EA,38.15000,11.06000,Aetna,First Health,,31.21,,,,,,,0.63558,31.21,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,inpatient,200,ME,190.35000,55.20000,Aetna,First Health,,155.71,,,,,,,68.62,155.71,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,outpatient,200,ME,190.35000,55.20000,Aetna,First Health,,155.71,,,,,,,4.31,155.71,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00338604537,NDC,facility,inpatient,400,ME,212.30000,61.57000,Aetna,First Health,,173.66,,,,,,,76.53,173.66,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00338604537,NDC,facility,outpatient,400,ME,212.30000,61.57000,Aetna,First Health,,173.66,,,,,,,4.31,173.66,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00338381424,NDC,facility,inpatient,900,ME,133.10000,38.60000,Aetna,First Health,,108.88,,,,,,,47.98,108.88,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00338381424,NDC,facility,outpatient,900,ME,133.10000,38.60000,Aetna,First Health,,108.88,,,,,,,2.26,108.88,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00338361224,NDC,facility,inpatient,600,ME,108.95000,31.60000,Aetna,First Health,,89.12,,,,,,,39.28,89.12,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00338361224,NDC,facility,outpatient,600,ME,108.95000,31.60000,Aetna,First Health,,89.12,,,,,,,1.84,89.12,percent of total billed charges,
Vancomycin HCl 1g /200mL  IVPB,800013370,CDM,636,RC,J3373,HCPCS,00338355248,NDC,facility,inpatient,1,GM,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,102.02,231.49,percent of total billed charges,
Vancomycin HCl 1g /200mL  IVPB,800013370,CDM,636,RC,J3373,HCPCS,00338355248,NDC,facility,outpatient,1,GM,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,0.02889,231.49,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00338171540,NDC,facility,inpatient,4,GM,63.65000,18.46000,Aetna,First Health,,52.07,,,,,,,22.95,52.07,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00338171540,NDC,facility,outpatient,4,GM,63.65000,18.46000,Aetna,First Health,,52.07,,,,,,,0.39483,52.07,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,00338170840,NDC,facility,inpatient,2,GM,128.40000,37.24000,Aetna,First Health,,105.03,,,,,,,46.29,105.03,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,00338170840,NDC,facility,outpatient,2,GM,128.40000,37.24000,Aetna,First Health,,105.03,,,,,,,0.39483,105.03,percent of total billed charges,
Mesna 200mg/2mL I (Mesnex),800025637,CDM,636,RC,J9209,HCPCS,00338130501,NDC,facility,inpatient,200,ME,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,18.39,41.72,percent of total billed charges,
Mesna 200mg/2mL I (Mesnex),800025637,CDM,636,RC,J9209,HCPCS,00338130501,NDC,facility,outpatient,200,ME,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,1.64,41.72,percent of total billed charges,
DOBUTamine 1g/D5W 250mL,800013360,CDM,636,RC,J1250,HCPCS,00338107702,NDC,facility,inpatient,1,GM,295.55000,85.71000,Aetna,First Health,,241.76,,,,,,,106.55,241.76,percent of total billed charges,
DOBUTamine 1g/D5W 250mL,800013360,CDM,636,RC,J1250,HCPCS,00338107702,NDC,facility,outpatient,1,GM,295.55000,85.71000,Aetna,First Health,,241.76,,,,,,,7.72,241.76,percent of total billed charges,
DOBUTamine 250mg/D5W 250mL,800012791,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,inpatient,250,ME,230.50000,66.84000,Aetna,First Health,,188.55,,,,,,,83.10,188.55,percent of total billed charges,
DOBUTamine 250mg/D5W 250mL,800012791,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,outpatient,250,ME,230.50000,66.84000,Aetna,First Health,,188.55,,,,,,,7.72,188.55,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00338105548,NDC,facility,inpatient,500,ME,23.40000,6.79000,Aetna,First Health,,19.14,,,,,,,8.44,19.14,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00338105548,NDC,facility,outpatient,500,ME,23.40000,6.79000,Aetna,First Health,,19.14,,,,,,,0.02889,19.14,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,inpatient,25,ME,208.95000,60.60000,Aetna,First Health,,170.92,,,,,,,75.33,170.92,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,outpatient,25,ME,208.95000,60.60000,Aetna,First Health,,170.92,,,,,,,1.46,170.92,percent of total billed charges,
Penicillin GK 3MU/50mL P,800019217,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,inpatient,1,EA,121.25000,35.16000,Aetna,First Health,,99.18,,,,,,,43.71,99.18,percent of total billed charges,
Penicillin GK 3MU/50mL P,800019217,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,outpatient,1,EA,121.25000,35.16000,Aetna,First Health,,99.18,,,,,,,0.75114,99.18,percent of total billed charges,
DOPamine 400mg/D5W 250mL,800012469,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,inpatient,400,ME,144.90000,42.02000,Aetna,First Health,,118.53,,,,,,,52.24,118.53,percent of total billed charges,
DOPamine 400mg/D5W 250mL,800012469,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,outpatient,400,ME,144.90000,42.02000,Aetna,First Health,,118.53,,,,,,,0.77040,118.53,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00338080304,NDC,,,facility,inpatient,1,EA,108.45000,31.45000,Aetna,First Health,,88.71,,,,,,,50.97,88.71,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00338080304,NDC,,,facility,outpatient,1,EA,108.45000,31.45000,Aetna,First Health,,88.71,,,,,,,39.10,88.71,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00338070948,NDC,facility,inpatient,1,EA,40.25000,11.67000,Aetna,First Health,,32.92,,,,,,,14.51,32.92,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00338070948,NDC,facility,outpatient,1,EA,40.25000,11.67000,Aetna,First Health,,32.92,,,,,,,0.11556,32.92,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,inpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,15.01,34.07,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,outpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,0.11556,34.07,percent of total billed charges,
0.45NS + 20mEq/L KCl 1000mL,800021700,CDM,258,RC,J3480,HCPCS,00338070434,NDC,facility,inpatient,1,EA,73.80000,21.40000,Aetna,First Health,,60.37,,,,,,,34.69,60.37,percent of total billed charges,
0.45NS + 20mEq/L KCl 1000mL,800021700,CDM,258,RC,J3480,HCPCS,00338070434,NDC,facility,outpatient,1,EA,73.80000,21.40000,Aetna,First Health,,60.37,,,,,,,0.11556,60.37,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00338069104,NDC,,,facility,inpatient,1,EA,108.45000,31.45000,Aetna,First Health,,88.71,,,,,,,50.97,88.71,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00338069104,NDC,,,facility,outpatient,1,EA,108.45000,31.45000,Aetna,First Health,,88.71,,,,,,,39.10,88.71,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00338067104,NDC,,,facility,inpatient,1,EA,60.25000,17.47000,Aetna,First Health,,49.28,,,,,,,28.32,49.28,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00338067104,NDC,,,facility,outpatient,1,EA,60.25000,17.47000,Aetna,First Health,,49.28,,,,,,,21.72,49.28,percent of total billed charges,
NS 100mL(Mini-Bag+),800012288,CDM,636,RC,J7050,HCPCS,00338055318,NDC,facility,inpatient,1,EA,69.75000,20.23000,Aetna,First Health,,57.06,,,,,,,25.14,57.06,percent of total billed charges,
NS 100mL(Mini-Bag+),800012288,CDM,636,RC,J7050,HCPCS,00338055318,NDC,facility,outpatient,1,EA,69.75000,20.23000,Aetna,First Health,,57.06,,,,,,,0.63558,57.06,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00338051909,NDC,,,facility,inpatient,1,EA,196.30000,56.93000,Aetna,First Health,,160.57,,,,,,,72.63,160.57,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00338051909,NDC,,,facility,outpatient,1,EA,196.30000,56.93000,Aetna,First Health,,160.57,,,,,,,70.77,160.57,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00338051902,NDC,,,facility,inpatient,1,EA,150.20000,43.56000,Aetna,First Health,,122.86,,,,,,,55.57,122.86,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00338051902,NDC,,,facility,outpatient,1,EA,150.20000,43.56000,Aetna,First Health,,122.86,,,,,,,54.15,122.86,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,800064963,CDM,636,RC,J1580,HCPCS,00338050348,NDC,facility,inpatient,80,ME,40.70000,11.80000,Aetna,First Health,,33.29,,,,,,,14.67,33.29,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,800064963,CDM,636,RC,J1580,HCPCS,00338050348,NDC,facility,outpatient,80,ME,40.70000,11.80000,Aetna,First Health,,33.29,,,,,,,2.09,33.29,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00338043103,NDC,facility,inpatient,1000,UN,51.75000,15.01000,Aetna,First Health,,42.33,,,,,,,18.66,42.33,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00338043103,NDC,facility,outpatient,1000,UN,51.75000,15.01000,Aetna,First Health,,42.33,,,,,,,0.17334,42.33,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00338042418,NDC,facility,inpatient,1000,UN,51.75000,15.01000,Aetna,First Health,,42.33,,,,,,,18.66,42.33,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00338042418,NDC,facility,outpatient,1000,UN,51.75000,15.01000,Aetna,First Health,,42.33,,,,,,,0.17334,42.33,percent of total billed charges,
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,inpatient,2,GM,88.20000,25.58000,Aetna,First Health,,72.15,,,,,,,31.80,72.15,percent of total billed charges,
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,outpatient,2,GM,88.20000,25.58000,Aetna,First Health,,72.15,,,,,,,32.63,72.15,percent of total billed charges,
Mannitol 20% 500mL,800022060,CDM,250,RC,00338035703,NDC,,,facility,inpatient,1,EA,607.55000,176.19000,Aetna,First Health,,496.98,,,,,,,224.79,496.98,percent of total billed charges,
Mannitol 20% 500mL,800022060,CDM,250,RC,00338035703,NDC,,,facility,outpatient,1,EA,607.55000,176.19000,Aetna,First Health,,496.98,,,,,,,219.02,496.98,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00338022104,NDC,,,facility,inpatient,1,EA,173.75000,50.39000,Aetna,First Health,,142.13,,,,,,,81.66,142.13,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00338022104,NDC,,,facility,outpatient,1,EA,173.75000,50.39000,Aetna,First Health,,142.13,,,,,,,62.64,142.13,percent of total billed charges,
Insulin(R) 100unit/100mL NS,800062046,CDM,636,RC,J1815,HCPCS,00338012612,NDC,facility,inpatient,100,UN,351.00000,101.79000,Aetna,First Health,,287.12,,,,,,,126.54,287.12,percent of total billed charges,
Insulin(R) 100unit/100mL NS,800062046,CDM,636,RC,J1815,HCPCS,00338012612,NDC,facility,outpatient,100,UN,351.00000,101.79000,Aetna,First Health,,287.12,,,,,,,0.26001,287.12,percent of total billed charges,
D5LR 1000 mL,800012214,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,inpatient,1,EA,60.80000,17.63000,Aetna,First Health,,49.73,,,,,,,28.58,49.73,percent of total billed charges,
D5LR 1000 mL,800012214,CDM,258,RC,J7121,HCPCS,00338012504,NDC,facility,outpatient,1,EA,60.80000,17.63000,Aetna,First Health,,49.73,,,,,,,8.94,49.73,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,inpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,24.72,43.03,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,00338011704,NDC,facility,outpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,2.29,43.03,percent of total billed charges,
LR 500 mL,800012635,CDM,258,RC,J7120,HCPCS,00338011703,NDC,facility,inpatient,1,EA,47.05000,13.64000,Aetna,First Health,,38.49,,,,,,,22.11,38.49,percent of total billed charges,
LR 500 mL,800012635,CDM,258,RC,J7120,HCPCS,00338011703,NDC,facility,outpatient,1,EA,47.05000,13.64000,Aetna,First Health,,38.49,,,,,,,2.29,38.49,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,inpatient,1,EA,60.25000,17.47000,Aetna,First Health,,49.28,,,,,,,28.32,49.28,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,00338008904,NDC,facility,outpatient,1,EA,60.25000,17.47000,Aetna,First Health,,49.28,,,,,,,1.26,49.28,percent of total billed charges,
D5.45NS 1000mL,800012347,CDM,258,RC,J7030,HCPCS,00338008504,NDC,facility,inpatient,1,EA,63.40000,18.39000,Aetna,First Health,,51.86,,,,,,,29.80,51.86,percent of total billed charges,
D5.45NS 1000mL,800012347,CDM,258,RC,J7030,HCPCS,00338008504,NDC,facility,outpatient,1,EA,63.40000,18.39000,Aetna,First Health,,51.86,,,,,,,1.92,51.86,percent of total billed charges,
D5.45NS 500mL,800011306,CDM,258,RC,J7030,HCPCS,00338008503,NDC,facility,inpatient,1,EA,48.05000,13.93000,Aetna,First Health,,39.30,,,,,,,22.58,39.30,percent of total billed charges,
D5.45NS 500mL,800011306,CDM,258,RC,J7030,HCPCS,00338008503,NDC,facility,outpatient,1,EA,48.05000,13.93000,Aetna,First Health,,39.30,,,,,,,1.92,39.30,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00338007225,NDC,facility,inpatient,30,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,4.02,9.12,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00338007225,NDC,facility,outpatient,30,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,0.31779,9.12,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,00338006910,NDC,facility,inpatient,15,ME,8.00000,2.32000,Aetna,First Health,,6.54,,,,,,,2.88,6.54,percent of total billed charges,
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,00338006910,NDC,facility,outpatient,15,ME,8.00000,2.32000,Aetna,First Health,,6.54,,,,,,,0.31779,6.54,percent of total billed charges,
Dextrose 5% / Water PVC Free,800012817,CDM,258,RC,J7060,HCPCS,00338006620,NDC,facility,inpatient,1,EA,60.85000,17.65000,Aetna,First Health,,49.78,,,,,,,28.60,49.78,percent of total billed charges,
Dextrose 5% / Water PVC Free,800012817,CDM,258,RC,J7060,HCPCS,00338006620,NDC,facility,outpatient,1,EA,60.85000,17.65000,Aetna,First Health,,49.78,,,,,,,1.69,49.78,percent of total billed charges,
Sodium Chloride 3% IVPB 250mL,800012312,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,inpatient,1,EA,28.70000,8.32000,Aetna,First Health,,23.48,,,,,,,10.35,23.48,percent of total billed charges,
Sodium Chloride 3% IVPB 250mL,800012312,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,1,EA,28.70000,8.32000,Aetna,First Health,,23.48,,,,,,,0.14445,23.48,percent of total billed charges,
Sodium Chloride 3% IV 500mL,800040915,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,inpatient,1,EA,58.90000,17.08000,Aetna,First Health,,48.18,,,,,,,21.23,48.18,percent of total billed charges,
Sodium Chloride 3% IV 500mL,800040915,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,outpatient,1,EA,58.90000,17.08000,Aetna,First Health,,48.18,,,,,,,0.14445,48.18,percent of total billed charges,
NS 1000mL Irrigation Bag-Sterile,800012254,CDM,258,RC,00338005144,NDC,,,facility,inpatient,1,EA,1037.65000,300.92000,Aetna,First Health,,848.80,,,,,,,487.70,848.80,percent of total billed charges,
NS 1000mL Irrigation Bag-Sterile,800012254,CDM,258,RC,00338005144,NDC,,,facility,outpatient,1,EA,1037.65000,300.92000,Aetna,First Health,,848.80,,,,,,,374.07,848.80,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338004948,NDC,facility,inpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,10.33,23.44,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338004948,NDC,facility,outpatient,1,EA,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,0.63558,23.44,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00338004941,NDC,facility,inpatient,1,EA,24.45000,7.09000,Aetna,First Health,,20.00,,,,,,,8.81,20.00,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00338004941,NDC,facility,outpatient,1,EA,24.45000,7.09000,Aetna,First Health,,20.00,,,,,,,0.63558,20.00,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338004938,NDC,facility,inpatient,1,EA,26.85000,7.79000,Aetna,First Health,,21.96,,,,,,,9.68,21.96,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338004938,NDC,facility,outpatient,1,EA,26.85000,7.79000,Aetna,First Health,,21.96,,,,,,,0.63558,21.96,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00338004931,NDC,facility,inpatient,1,EA,24.65000,7.15000,Aetna,First Health,,20.16,,,,,,,8.89,20.16,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00338004931,NDC,facility,outpatient,1,EA,24.65000,7.15000,Aetna,First Health,,20.16,,,,,,,0.63558,20.16,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338004918,NDC,facility,inpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338004918,NDC,facility,outpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,0.63558,22.58,percent of total billed charges,
NS 100mL Inj,800025641,CDM,636,RC,J7050,HCPCS,00338004918,NDC,facility,inpatient,1,EA,21.30000,6.18000,Aetna,First Health,,17.42,,,,,,,7.68,17.42,percent of total billed charges,
NS 100mL Inj,800025641,CDM,636,RC,J7050,HCPCS,00338004918,NDC,facility,outpatient,1,EA,21.30000,6.18000,Aetna,First Health,,17.42,,,,,,,0.63558,17.42,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00338004911,NDC,facility,inpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00338004911,NDC,facility,outpatient,1,EA,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,0.63558,22.58,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00338004904,NDC,facility,inpatient,1,EA,50.25000,14.57000,Aetna,First Health,,41.10,,,,,,,18.12,41.10,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00338004904,NDC,facility,outpatient,1,EA,50.25000,14.57000,Aetna,First Health,,41.10,,,,,,,1.92,41.10,percent of total billed charges,
NS 500mL,800012693,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,inpatient,1,EA,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,20.21,35.17,percent of total billed charges,
NS 500mL,800012693,CDM,258,RC,J7040,HCPCS,00338004903,NDC,facility,outpatient,1,EA,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,1.24,35.17,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00338004902,NDC,facility,inpatient,1,EA,43.70000,12.67000,Aetna,First Health,,35.75,,,,,,,15.75,35.75,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00338004902,NDC,facility,outpatient,1,EA,43.70000,12.67000,Aetna,First Health,,35.75,,,,,,,0.63558,35.75,percent of total billed charges,
NS 1000mL Irrigation Bag-Sterile,800012254,CDM,258,RC,00338004804,NDC,,,facility,inpatient,1,EA,46.75000,13.56000,Aetna,First Health,,38.24,,,,,,,21.97,38.24,percent of total billed charges,
NS 1000mL Irrigation Bag-Sterile,800012254,CDM,258,RC,00338004804,NDC,,,facility,outpatient,1,EA,46.75000,13.56000,Aetna,First Health,,38.24,,,,,,,16.85,38.24,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00338004304,NDC,,,facility,inpatient,1,EA,63.85000,18.52000,Aetna,First Health,,52.23,,,,,,,30.01,52.23,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00338004304,NDC,,,facility,outpatient,1,EA,63.85000,18.52000,Aetna,First Health,,52.23,,,,,,,23.02,52.23,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,00338004303,NDC,,,facility,inpatient,1,EA,48.05000,13.93000,Aetna,First Health,,39.30,,,,,,,22.58,39.30,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,00338004303,NDC,,,facility,outpatient,1,EA,48.05000,13.93000,Aetna,First Health,,39.30,,,,,,,17.32,39.30,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00338002304,NDC,,,facility,inpatient,1,EA,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,36.19,62.99,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00338002304,NDC,,,facility,outpatient,1,EA,77.00000,22.33000,Aetna,First Health,,62.99,,,,,,,27.76,62.99,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00338002302,NDC,,,facility,inpatient,1,EA,64.75000,18.78000,Aetna,First Health,,52.97,,,,,,,30.43,52.97,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00338002302,NDC,,,facility,outpatient,1,EA,64.75000,18.78000,Aetna,First Health,,52.97,,,,,,,23.34,52.97,percent of total billed charges,
Dextose 5% in Water 50mL,800013014,CDM,258,RC,J7060,HCPCS,00338001741,NDC,facility,inpatient,1,EA,26.20000,7.60000,Aetna,First Health,,21.43,,,,,,,12.31,21.43,percent of total billed charges,
Dextose 5% in Water 50mL,800013014,CDM,258,RC,J7060,HCPCS,00338001741,NDC,facility,outpatient,1,EA,26.20000,7.60000,Aetna,First Health,,21.43,,,,,,,1.69,21.43,percent of total billed charges,
Dextose 5% in Water 50mL,800013014,CDM,258,RC,J7060,HCPCS,00338001718,NDC,facility,inpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,4.89,8.51,percent of total billed charges,
Dextose 5% in Water 50mL,800013014,CDM,258,RC,J7060,HCPCS,00338001718,NDC,facility,outpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,1.69,8.51,percent of total billed charges,
Dextrose 5% / Water/mL IV Room,800046428,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,inpatient,1,EA,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.02350,0.04090,percent of total billed charges,
Dextrose 5% / Water/mL IV Room,800046428,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1,EA,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.02000,9.07,percent of total billed charges,
Dextrose 5% in Water 1L,800012172,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,inpatient,1,EA,56.45000,16.37000,Aetna,First Health,,46.18,,,,,,,26.53,46.18,percent of total billed charges,
Dextrose 5% in Water 1L,800012172,CDM,258,RC,J7070,HCPCS,00338001704,NDC,facility,outpatient,1,EA,56.45000,16.37000,Aetna,First Health,,46.18,,,,,,,2.83,46.18,percent of total billed charges,
D5W  250mL,800012123,CDM,258,RC,J7060,HCPCS,00338001702,NDC,facility,inpatient,1,EA,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,16.24,28.26,percent of total billed charges,
D5W  250mL,800012123,CDM,258,RC,J7060,HCPCS,00338001702,NDC,facility,outpatient,1,EA,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,1.69,28.26,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00338001304,NDC,facility,inpatient,1,EA,98.45000,28.55000,Aetna,First Health,,80.53,,,,,,,46.27,80.53,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00338001304,NDC,facility,outpatient,1,EA,98.45000,28.55000,Aetna,First Health,,80.53,,,,,,,3.80,80.53,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,00332417732,NDC,,,facility,inpatient,1,EA,614.55000,178.22000,Aetna,First Health,,502.70,,,,,,,368.73,502.70,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,00332417732,NDC,,,facility,outpatient,1,EA,614.55000,178.22000,Aetna,First Health,,502.70,,,,,,,221.55,502.70,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,00332417532,NDC,,,facility,inpatient,1,EA,135.40000,39.27000,Aetna,First Health,,110.76,,,,,,,81.24,110.76,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,00332417532,NDC,,,facility,outpatient,1,EA,135.40000,39.27000,Aetna,First Health,,110.76,,,,,,,48.81,110.76,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00316022115,NDC,,,facility,inpatient,1,EA,124.25000,36.03000,Aetna,First Health,,101.64,,,,,,,74.55,101.64,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00316022115,NDC,,,facility,outpatient,1,EA,124.25000,36.03000,Aetna,First Health,,101.64,,,,,,,44.79,101.64,percent of total billed charges,
dapagliflozin 10mg Tab UD,800051047,CDM,637,RC,00310621039,NDC,,,facility,inpatient,1,EA,169.85000,49.26000,Aetna,First Health,,138.94,,,,,,,101.91,138.94,percent of total billed charges,
dapagliflozin 10mg Tab UD,800051047,CDM,637,RC,00310621039,NDC,,,facility,outpatient,1,EA,169.85000,49.26000,Aetna,First Health,,138.94,,,,,,,61.23,138.94,percent of total billed charges,
durvalumab 500mg/10mL Inj - Pt Own Supply,800051068,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,inpatient,500,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
durvalumab 500mg/10mL Inj - Pt Own Supply,800051068,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,500,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,266.06,percent of total billed charges,
durvalumab 500mg/10mL (Imfinzi),800051084,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,inpatient,500,ME,31108.55000,9021.48000,Aetna,First Health,,25446.79,,,,,,,11214.63,25446.79,percent of total billed charges,
durvalumab 500mg/10mL (Imfinzi),800051084,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,outpatient,500,ME,31108.55000,9021.48000,Aetna,First Health,,25446.79,,,,,,,83.08,25446.79,percent of total billed charges,
Tremelimumab- actl- Pt Own Supply,800052003,CDM,636,RC,J9347,HCPCS,00310453530,NDC,facility,inpatient,300,ME,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05407,0.12270,percent of total billed charges,
Tremelimumab- actl- Pt Own Supply,800052003,CDM,636,RC,J9347,HCPCS,00310453530,NDC,facility,outpatient,300,ME,0.15000,0.04000,Aetna,First Health,,0.12270,,,,,,,0.05550,441.07,percent of total billed charges,
Benralizumab 30mg IS (Fasenra),800051069,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,inpatient,30,ME,22806.15000,6613.78000,Aetna,First Health,,18655.43,,,,,,,8221.62,18655.43,percent of total billed charges,
Benralizumab 30mg IS (Fasenra),800051069,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,outpatient,30,ME,22806.15000,6613.78000,Aetna,First Health,,18655.43,,,,,,,157.90,18655.43,percent of total billed charges,
Goserelin 10.8 mg Impl,800012528,CDM,636,RC,J9202,HCPCS,00310095130,NDC,facility,inpatient,10.8,ME,8294.30000,2405.35000,Aetna,First Health,,6784.74,,,,,,,2990.10,6784.74,percent of total billed charges,
Goserelin 10.8 mg Impl,800012528,CDM,636,RC,J9202,HCPCS,00310095130,NDC,facility,outpatient,10.8,ME,8294.30000,2405.35000,Aetna,First Health,,6784.74,,,,,,,748.73,6784.74,percent of total billed charges,
Goserelin 3.6mg Impl,800081180,CDM,636,RC,J9202,HCPCS,00310095036,NDC,facility,inpatient,3.6,ME,2889.45000,837.94000,Aetna,First Health,,2363.57,,,,,,,1041.65,2363.57,percent of total billed charges,
Goserelin 3.6mg Impl,800081180,CDM,636,RC,J9202,HCPCS,00310095036,NDC,facility,outpatient,3.6,ME,2889.45000,837.94000,Aetna,First Health,,2363.57,,,,,,,748.73,2397.81,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,00310075430,NDC,,,facility,inpatient,1,EA,78.30000,22.71000,Aetna,First Health,,64.05,,,,,,,46.98,64.05,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,00310075430,NDC,,,facility,outpatient,1,EA,78.30000,22.71000,Aetna,First Health,,64.05,,,,,,,28.23,64.05,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,00310075190,NDC,,,facility,inpatient,1,EA,78.30000,22.71000,Aetna,First Health,,64.05,,,,,,,46.98,64.05,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,00310075190,NDC,,,facility,outpatient,1,EA,78.30000,22.71000,Aetna,First Health,,64.05,,,,,,,28.23,64.05,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,00310072050,NDC,facility,inpatient,250,ME,3420.15000,991.84000,Aetna,First Health,,2797.68,,,,,,,1232.96,2797.68,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,00310072050,NDC,facility,outpatient,250,ME,3420.15000,991.84000,Aetna,First Health,,2797.68,,,,,,,5.51,2797.68,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,inpatient,250,ME,4052.60000,1175.25000,Aetna,First Health,,3315.03,,,,,,,1460.96,3315.03,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,outpatient,250,ME,4052.60000,1175.25000,Aetna,First Health,,3315.03,,,,,,,5.51,3315.03,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00310070530,NDC,,,facility,inpatient,1,EA,163.40000,47.39000,Aetna,First Health,,133.66,,,,,,,98.04,133.66,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00310070530,NDC,,,facility,outpatient,1,EA,163.40000,47.39000,Aetna,First Health,,133.66,,,,,,,58.91,133.66,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00310070510,NDC,,,facility,inpatient,1,EA,140.15000,40.64000,Aetna,First Health,,114.64,,,,,,,84.09,114.64,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00310070510,NDC,,,facility,outpatient,1,EA,140.15000,40.64000,Aetna,First Health,,114.64,,,,,,,50.52,114.64,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00310060060,NDC,,,facility,inpatient,1,EA,15.20000,4.41000,Aetna,First Health,,12.43,,,,,,,9.12,12.43,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00310060060,NDC,,,facility,outpatient,1,EA,15.20000,4.41000,Aetna,First Health,,12.43,,,,,,,5.48,12.43,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00310032520,NDC,facility,inpatient,500,ME,315.05000,91.36000,Aetna,First Health,,257.71,,,,,,,113.58,257.71,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00310032520,NDC,facility,outpatient,500,ME,315.05000,91.36000,Aetna,First Health,,257.71,,,,,,,0.36594,257.71,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00310032130,NDC,facility,inpatient,1,GM,601.70000,174.49000,Aetna,First Health,,492.19,,,,,,,216.91,492.19,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00310032130,NDC,facility,outpatient,1,GM,601.70000,174.49000,Aetna,First Health,,492.19,,,,,,,0.36594,492.19,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00310030050,NDC,facility,inpatient,0.5,GM,404.20000,117.22000,Aetna,First Health,,330.64,,,,,,,145.71,330.64,percent of total billed charges,
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00310030050,NDC,facility,outpatient,0.5,GM,404.20000,117.22000,Aetna,First Health,,330.64,,,,,,,0.08667,330.64,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00310030022,NDC,facility,inpatient,200,ME,103.40000,29.99000,Aetna,First Health,,84.58,,,,,,,37.28,84.58,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00310030022,NDC,facility,outpatient,200,ME,103.40000,29.99000,Aetna,First Health,,84.58,,,,,,,0.08667,84.58,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00310030011,NDC,facility,inpatient,1,GM,43369.50000,12577.16000,Aetna,First Health,,35476.25,,,,,,,15634.70,35476.25,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00310030011,NDC,facility,outpatient,1,GM,43369.50000,12577.16000,Aetna,First Health,,35476.25,,,,,,,0.08667,35476.25,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,00310027510,NDC,,,facility,inpatient,1,EA,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,19.80,26.99,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,00310027510,NDC,,,facility,outpatient,1,EA,33.00000,9.57000,Aetna,First Health,,26.99,,,,,,,11.90,26.99,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,00310027110,NDC,,,facility,inpatient,1,EA,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,33.99,46.34,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,00310027110,NDC,,,facility,outpatient,1,EA,56.65000,16.43000,Aetna,First Health,,46.34,,,,,,,20.42,46.34,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,00310020137,NDC,,,facility,inpatient,1,EA,91.80000,26.62000,Aetna,First Health,,75.09,,,,,,,55.08,75.09,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,00310020137,NDC,,,facility,outpatient,1,EA,91.80000,26.62000,Aetna,First Health,,75.09,,,,,,,33.09,75.09,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,00310020130,NDC,,,facility,inpatient,1,EA,122.90000,35.64000,Aetna,First Health,,100.53,,,,,,,73.74,100.53,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,00310020130,NDC,,,facility,outpatient,1,EA,122.90000,35.64000,Aetna,First Health,,100.53,,,,,,,44.31,100.53,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00310013139,NDC,,,facility,inpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,5.04,6.87,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00310013139,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,3.03,6.87,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),800015427,CDM,637,RC,00310009530,NDC,,,facility,inpatient,1,EA,129.45000,37.54000,Aetna,First Health,,105.89,,,,,,,77.67,105.89,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),800015427,CDM,637,RC,00310009530,NDC,,,facility,outpatient,1,EA,129.45000,37.54000,Aetna,First Health,,105.89,,,,,,,46.67,105.89,percent of total billed charges,
Benzocaine 20% Top Spray 0.5mL UD,800015359,CDM,637,RC,00283061026,NDC,,,facility,inpatient,1,EA,37.65000,10.92000,Aetna,First Health,,30.80,,,,,,,22.59,30.80,percent of total billed charges,
Benzocaine 20% Top Spray 0.5mL UD,800015359,CDM,637,RC,00283061026,NDC,,,facility,outpatient,1,EA,37.65000,10.92000,Aetna,First Health,,30.80,,,,,,,13.57,30.80,percent of total billed charges,
Nitroglycerin 2% TO 1g,800081827,CDM,637,RC,00281032608,NDC,,,facility,inpatient,1,GM,21.45000,6.22000,Aetna,First Health,,17.55,,,,,,,12.87,17.55,percent of total billed charges,
Nitroglycerin 2% TO 1g,800081827,CDM,637,RC,00281032608,NDC,,,facility,outpatient,1,GM,21.45000,6.22000,Aetna,First Health,,17.55,,,,,,,7.73,17.55,percent of total billed charges,
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),800022035,CDM,636,RC,Q9950,HCPCS,00270709973,NDC,facility,inpatient,1,EA,754.70000,218.86000,Aetna,First Health,,617.34,,,,,,,272.07,617.34,percent of total billed charges,
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),800022035,CDM,636,RC,Q9950,HCPCS,00270709973,NDC,facility,outpatient,1,EA,754.70000,218.86000,Aetna,First Health,,617.34,,,,,,,17.50,617.34,percent of total billed charges,
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),800022035,CDM,636,RC,Q9950,HCPCS,00270709916,NDC,facility,inpatient,1,EA,741.40000,215.01000,Aetna,First Health,,606.47,,,,,,,267.27,606.47,percent of total billed charges,
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),800022035,CDM,636,RC,Q9950,HCPCS,00270709916,NDC,facility,outpatient,1,EA,741.40000,215.01000,Aetna,First Health,,606.47,,,,,,,17.50,606.47,percent of total billed charges,
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),800022035,CDM,636,RC,Q9950,HCPCS,00270709707,NDC,facility,inpatient,1,EA,755.85000,219.20000,Aetna,First Health,,618.29,,,,,,,272.48,618.29,percent of total billed charges,
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),800022035,CDM,636,RC,Q9950,HCPCS,00270709707,NDC,facility,outpatient,1,EA,755.85000,219.20000,Aetna,First Health,,618.29,,,,,,,17.50,618.29,percent of total billed charges,
Diatrizoate Meglumine 30% I 100mL,800046535,CDM,636,RC,Q9958,HCPCS,00270014960,NDC,facility,inpatient,1,EA,308.95000,89.60000,Aetna,First Health,,252.72,,,,,,,111.38,252.72,percent of total billed charges,
Diatrizoate Meglumine 30% I 100mL,800046535,CDM,636,RC,Q9958,HCPCS,00270014960,NDC,facility,outpatient,1,EA,308.95000,89.60000,Aetna,First Health,,252.72,,,,,,,0.06741,252.72,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00264987210,NDC,facility,inpatient,1000,UN,45.40000,13.17000,Aetna,First Health,,37.14,,,,,,,16.37,37.14,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00264987210,NDC,facility,outpatient,1000,UN,45.40000,13.17000,Aetna,First Health,,37.14,,,,,,,0.17334,37.14,percent of total billed charges,
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00264959820,NDC,facility,inpatient,2,GM,86.90000,25.20000,Aetna,First Health,,71.08,,,,,,,31.33,71.08,percent of total billed charges,
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00264959820,NDC,facility,outpatient,2,GM,86.90000,25.20000,Aetna,First Health,,71.08,,,,,,,32.15,71.08,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00264958720,NDC,facility,inpatient,25000,UN,159.65000,46.30000,Aetna,First Health,,130.59,,,,,,,57.55,130.59,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00264958720,NDC,facility,outpatient,25000,UN,159.65000,46.30000,Aetna,First Health,,130.59,,,,,,,0.17334,130.59,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00264937988,NDC,,,facility,inpatient,1,EA,15.60000,4.52000,Aetna,First Health,,12.76,,,,,,,5.77,12.76,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00264937988,NDC,,,facility,outpatient,1,EA,15.60000,4.52000,Aetna,First Health,,12.76,,,,,,,5.62,12.76,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00264786500,NDC,,,facility,inpatient,1,EA,55.50000,16.10000,Aetna,First Health,,45.40,,,,,,,26.09,45.40,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00264786500,NDC,,,facility,outpatient,1,EA,55.50000,16.10000,Aetna,First Health,,45.40,,,,,,,20.01,45.40,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00264785000,NDC,facility,inpatient,1,EA,47.75000,13.85000,Aetna,First Health,,39.06,,,,,,,22.44,39.06,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00264785000,NDC,facility,outpatient,1,EA,47.75000,13.85000,Aetna,First Health,,39.06,,,,,,,3.80,39.06,percent of total billed charges,
Sodium Chloride 3% IVPB 250mL,800012312,CDM,636,RC,J7131,HCPCS,00264780510,NDC,facility,inpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,10.40,23.60,percent of total billed charges,
Sodium Chloride 3% IVPB 250mL,800012312,CDM,636,RC,J7131,HCPCS,00264780510,NDC,facility,outpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,0.14445,23.60,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00264780020,NDC,facility,inpatient,1,EA,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,7.17,16.28,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00264780020,NDC,facility,outpatient,1,EA,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,0.63558,16.28,percent of total billed charges,
NS 500mL PVC Free,800012833,CDM,258,RC,J7040,HCPCS,00264780010,NDC,facility,inpatient,1,EA,34.45000,9.99000,Aetna,First Health,,28.18,,,,,,,16.19,28.18,percent of total billed charges,
NS 500mL PVC Free,800012833,CDM,258,RC,J7040,HCPCS,00264780010,NDC,facility,outpatient,1,EA,34.45000,9.99000,Aetna,First Health,,28.18,,,,,,,1.24,28.18,percent of total billed charges,
NS 1000mL PVC Free,800070037,CDM,258,RC,J7030,HCPCS,00264780009,NDC,facility,inpatient,1,EA,38.95000,11.30000,Aetna,First Health,,31.86,,,,,,,18.31,31.86,percent of total billed charges,
NS 1000mL PVC Free,800070037,CDM,258,RC,J7030,HCPCS,00264780009,NDC,facility,outpatient,1,EA,38.95000,11.30000,Aetna,First Health,,31.86,,,,,,,1.92,31.86,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00264780000,NDC,facility,inpatient,1,EA,27.90000,8.09000,Aetna,First Health,,22.82,,,,,,,10.06,22.82,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00264780000,NDC,facility,outpatient,1,EA,27.90000,8.09000,Aetna,First Health,,22.82,,,,,,,1.92,22.82,percent of total billed charges,
LR 500 mL,800012635,CDM,258,RC,J7120,HCPCS,00264775010,NDC,facility,inpatient,1,EA,37.65000,10.92000,Aetna,First Health,,30.80,,,,,,,17.70,30.80,percent of total billed charges,
LR 500 mL,800012635,CDM,258,RC,J7120,HCPCS,00264775010,NDC,facility,outpatient,1,EA,37.65000,10.92000,Aetna,First Health,,30.80,,,,,,,2.29,30.80,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,00264775000,NDC,facility,inpatient,1,EA,31.00000,8.99000,Aetna,First Health,,25.36,,,,,,,14.57,25.36,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,00264775000,NDC,facility,outpatient,1,EA,31.00000,8.99000,Aetna,First Health,,25.36,,,,,,,2.29,25.36,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00264763500,NDC,,,facility,inpatient,1,EA,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,23.50,40.90,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00264763500,NDC,,,facility,outpatient,1,EA,50.00000,14.50000,Aetna,First Health,,40.90,,,,,,,18.02,40.90,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,00264761000,NDC,facility,inpatient,1,EA,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,9.35,16.28,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,00264761000,NDC,facility,outpatient,1,EA,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,1.26,16.28,percent of total billed charges,
Mannitol 20% 500mL,800022060,CDM,250,RC,00264757810,NDC,,,facility,inpatient,1,EA,443.75000,128.69000,Aetna,First Health,,362.99,,,,,,,164.19,362.99,percent of total billed charges,
Mannitol 20% 500mL,800022060,CDM,250,RC,00264757810,NDC,,,facility,outpatient,1,EA,443.75000,128.69000,Aetna,First Health,,362.99,,,,,,,159.97,362.99,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00264752020,NDC,,,facility,inpatient,1,EA,44.45000,12.89000,Aetna,First Health,,36.36,,,,,,,20.89,36.36,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00264752020,NDC,,,facility,outpatient,1,EA,44.45000,12.89000,Aetna,First Health,,36.36,,,,,,,16.02,36.36,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00264752000,NDC,,,facility,inpatient,1,EA,17.85000,5.18000,Aetna,First Health,,14.60,,,,,,,8.39,14.60,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00264752000,NDC,,,facility,outpatient,1,EA,17.85000,5.18000,Aetna,First Health,,14.60,,,,,,,6.43,14.60,percent of total billed charges,
Dextrose 5%/Water PVC Free 250mL,800012809,CDM,258,RC,J7060,HCPCS,00264751020,NDC,facility,inpatient,1,EA,37.70000,10.93000,Aetna,First Health,,30.84,,,,,,,17.72,30.84,percent of total billed charges,
Dextrose 5%/Water PVC Free 250mL,800012809,CDM,258,RC,J7060,HCPCS,00264751020,NDC,facility,outpatient,1,EA,37.70000,10.93000,Aetna,First Health,,30.84,,,,,,,1.69,30.84,percent of total billed charges,
Dextrose 5% / Water PVC Free,800012817,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,inpatient,1,EA,41.15000,11.93000,Aetna,First Health,,33.66,,,,,,,19.34,33.66,percent of total billed charges,
Dextrose 5% / Water PVC Free,800012817,CDM,258,RC,J7060,HCPCS,00264751010,NDC,facility,outpatient,1,EA,41.15000,11.93000,Aetna,First Health,,33.66,,,,,,,1.69,33.66,percent of total billed charges,
Dextrose 5% in Water 1L,800012172,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,inpatient,1,EA,37.65000,10.92000,Aetna,First Health,,30.80,,,,,,,17.70,30.80,percent of total billed charges,
Dextrose 5% in Water 1L,800012172,CDM,258,RC,J7070,HCPCS,00264751000,NDC,facility,outpatient,1,EA,37.65000,10.92000,Aetna,First Health,,30.80,,,,,,,2.83,30.80,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,800064963,CDM,636,RC,J1580,HCPCS,00264580832,NDC,facility,inpatient,80,ME,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,12.46,28.26,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,800064963,CDM,636,RC,J1580,HCPCS,00264580832,NDC,facility,outpatient,80,ME,34.55000,10.02000,Aetna,First Health,,28.26,,,,,,,2.09,28.26,percent of total billed charges,
"Heparin 5,000 unit/0.5mL Inj Syr",800051113,CDM,258,RC,J1644,HCPCS,00264570510,NDC,facility,inpatient,5000,UN,493.40000,143.09000,Aetna,First Health,,403.60,,,,,,,231.90,403.60,percent of total billed charges,
"Heparin 5,000 unit/0.5mL Inj Syr",800051113,CDM,258,RC,J1644,HCPCS,00264570510,NDC,facility,outpatient,5000,UN,493.40000,143.09000,Aetna,First Health,,403.60,,,,,,,0.17334,403.60,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,inpatient,500,ME,32.65000,9.47000,Aetna,First Health,,26.71,,,,,,,11.77,26.71,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,outpatient,500,ME,32.65000,9.47000,Aetna,First Health,,26.71,,,,,,,0.02889,26.71,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00264446030,NDC,,,facility,inpatient,1,EA,119.70000,34.71000,Aetna,First Health,,97.91,,,,,,,44.29,97.91,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00264446030,NDC,,,facility,outpatient,1,EA,119.70000,34.71000,Aetna,First Health,,97.91,,,,,,,43.15,97.91,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00264420654,NDC,facility,inpatient,4,GM,35.90000,10.41000,Aetna,First Health,,29.37,,,,,,,12.94,29.37,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00264420654,NDC,facility,outpatient,4,GM,35.90000,10.41000,Aetna,First Health,,29.37,,,,,,,0.39483,29.37,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,00264420452,NDC,facility,inpatient,2,GM,45.10000,13.08000,Aetna,First Health,,36.89,,,,,,,16.26,36.89,percent of total billed charges,
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,00264420452,NDC,facility,outpatient,2,GM,45.10000,13.08000,Aetna,First Health,,36.89,,,,,,,0.39483,36.89,percent of total billed charges,
NS 1000mL Irrigation Bag-Sterile,800012254,CDM,258,RC,00264220100,NDC,,,facility,inpatient,1,EA,44.20000,12.82000,Aetna,First Health,,36.16,,,,,,,20.77,36.16,percent of total billed charges,
NS 1000mL Irrigation Bag-Sterile,800012254,CDM,258,RC,00264220100,NDC,,,facility,outpatient,1,EA,44.20000,12.82000,Aetna,First Health,,36.16,,,,,,,15.93,36.16,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,00264196510,NDC,,,facility,inpatient,1,EA,265.90000,77.11000,Aetna,First Health,,217.51,,,,,,,98.38,217.51,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,00264196510,NDC,,,facility,outpatient,1,EA,265.90000,77.11000,Aetna,First Health,,217.51,,,,,,,95.86,217.51,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00264180032,NDC,facility,inpatient,1,EA,26.10000,7.57000,Aetna,First Health,,21.35,,,,,,,9.41,21.35,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00264180032,NDC,facility,outpatient,1,EA,26.10000,7.57000,Aetna,First Health,,21.35,,,,,,,0.63558,21.35,percent of total billed charges,
NS 100mL Inj,800025641,CDM,636,RC,J7050,HCPCS,00264180032,NDC,facility,inpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,8.58,19.47,percent of total billed charges,
NS 100mL Inj,800025641,CDM,636,RC,J7050,HCPCS,00264180032,NDC,facility,outpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,0.63558,19.47,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00264180031,NDC,facility,inpatient,1,EA,25.90000,7.51000,Aetna,First Health,,21.19,,,,,,,9.34,21.19,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00264180031,NDC,facility,outpatient,1,EA,25.90000,7.51000,Aetna,First Health,,21.19,,,,,,,0.63558,21.19,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00258369090,NDC,,,facility,inpatient,1,EA,16.30000,4.73000,Aetna,First Health,,13.33,,,,,,,9.78,13.33,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00258369090,NDC,,,facility,outpatient,1,EA,16.30000,4.73000,Aetna,First Health,,13.33,,,,,,,5.88,13.33,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00258365401,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,4.05,5.52,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00258365401,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,00256018505,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,00256018505,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,00256018504,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,00256018504,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,00256018501,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,00256018501,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00254531235,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00254531235,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00254391928,NDC,,,facility,inpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,1.23,1.68,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00254391928,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,0.73903,1.68,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,00254302902,NDC,,,facility,inpatient,1,EA,47.30000,13.72000,Aetna,First Health,,38.69,,,,,,,28.38,38.69,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,00254302902,NDC,,,facility,outpatient,1,EA,47.30000,13.72000,Aetna,First Health,,38.69,,,,,,,17.05,38.69,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00254273228,NDC,,,facility,inpatient,1,EA,0.25000,0.07000,Aetna,First Health,,0.20450,,,,,,,0.15000,0.20450,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00254273228,NDC,,,facility,outpatient,1,EA,0.25000,0.07000,Aetna,First Health,,0.20450,,,,,,,0.09012,0.20450,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00254200801,NDC,,,facility,inpatient,1,EA,47.70000,13.83000,Aetna,First Health,,39.02,,,,,,,28.62,39.02,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00254200801,NDC,,,facility,outpatient,1,EA,47.70000,13.83000,Aetna,First Health,,39.02,,,,,,,17.20,39.02,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00254100752,NDC,,,facility,inpatient,1,EA,490.05000,142.11000,Aetna,First Health,,400.86,,,,,,,294.03,400.86,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00254100752,NDC,,,facility,outpatient,1,EA,490.05000,142.11000,Aetna,First Health,,400.86,,,,,,,176.66,400.86,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,800015247,CDM,637,RC,00245532630,NDC,,,facility,inpatient,1,EA,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,6.69,9.12,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,800015247,CDM,637,RC,00245532630,NDC,,,facility,outpatient,1,EA,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,4.02,9.12,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00245531901,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00245531901,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00245021211,NDC,,,facility,inpatient,1,EA,29.40000,8.53000,Aetna,First Health,,24.05,,,,,,,17.64,24.05,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00245021211,NDC,,,facility,outpatient,1,EA,29.40000,8.53000,Aetna,First Health,,24.05,,,,,,,10.60,24.05,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00245021201,NDC,,,facility,inpatient,1,EA,31.75000,9.21000,Aetna,First Health,,25.97,,,,,,,19.05,25.97,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00245021201,NDC,,,facility,outpatient,1,EA,31.75000,9.21000,Aetna,First Health,,25.97,,,,,,,11.45,25.97,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00245018111,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00245018111,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00245014715,NDC,,,facility,inpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,29.94,40.82,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00245014715,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,17.99,40.82,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00245014701,NDC,,,facility,inpatient,1,EA,56.25000,16.31000,Aetna,First Health,,46.01,,,,,,,33.75,46.01,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00245014701,NDC,,,facility,outpatient,1,EA,56.25000,16.31000,Aetna,First Health,,46.01,,,,,,,20.28,46.01,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,00245014430,NDC,,,facility,inpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,31.56,43.03,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,00245014430,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,First Health,,43.03,,,,,,,18.96,43.03,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,00245007111,NDC,,,facility,inpatient,1,EA,19.55000,5.67000,Aetna,First Health,,15.99,,,,,,,11.73,15.99,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,00245007111,NDC,,,facility,outpatient,1,EA,19.55000,5.67000,Aetna,First Health,,15.99,,,,,,,7.05,15.99,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00245001201,NDC,,,facility,inpatient,1,EA,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,11.07,15.09,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00245001201,NDC,,,facility,outpatient,1,EA,18.45000,5.35000,Aetna,First Health,,15.09,,,,,,,6.65,15.09,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00245000835,NDC,,,facility,inpatient,1,EA,664.15000,192.60000,Aetna,First Health,,543.27,,,,,,,398.49,543.27,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00245000835,NDC,,,facility,outpatient,1,EA,664.15000,192.60000,Aetna,First Health,,543.27,,,,,,,239.43,543.27,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,800055060,CDM,637,RC,00245000331,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,800055060,CDM,637,RC,00245000331,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00228300350,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00228300350,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00228300311,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00228300311,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00228299611,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00228299611,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,00228289803,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,00228289803,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,00228282011,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,00228282011,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00228280311,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00228280311,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00228280111,NDC,,,facility,inpatient,1,EA,10.75000,3.12000,Aetna,First Health,,8.79,,,,,,,6.45,8.79,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00228280111,NDC,,,facility,outpatient,1,EA,10.75000,3.12000,Aetna,First Health,,8.79,,,,,,,3.88,8.79,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,00228277811,NDC,,,facility,inpatient,1,EA,14.55000,4.22000,Aetna,First Health,,11.90,,,,,,,8.73,11.90,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,00228277811,NDC,,,facility,outpatient,1,EA,14.55000,4.22000,Aetna,First Health,,11.90,,,,,,,5.25,11.90,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00228271311,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00228271311,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00228266750,NDC,,,facility,inpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00228266750,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00228266711,NDC,,,facility,inpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,6.78,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00228266711,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,First Health,,9.24,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00228266650,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00228266650,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00228266611,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00228266611,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00228266550,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00228266550,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00228266511,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00228266511,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00228263650,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00228263650,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00228263611,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00228263611,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00228258809,NDC,,,facility,inpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,5.10,6.95,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00228258809,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,3.06,6.95,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00228258803,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00228258803,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00228257909,NDC,,,facility,inpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,11.28,15.38,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00228257909,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00228257709,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00228257709,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00228254010,NDC,,,facility,inpatient,1,EA,7.85000,2.28000,Aetna,First Health,,6.42,,,,,,,4.71,6.42,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00228254010,NDC,,,facility,outpatient,1,EA,7.85000,2.28000,Aetna,First Health,,6.42,,,,,,,2.83,6.42,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00228253910,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,3.69,5.03,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00228253910,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,00228253810,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,00228253810,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,00228249710,NDC,,,facility,inpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,4.53,6.18,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,00228249710,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,00228234810,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,00228234810,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00228212750,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00228212750,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00228212710,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00228212710,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,00228207610,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,00228207610,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00228205710,NDC,,,facility,inpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,3.24,4.42,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00228205710,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,First Health,,4.42,,,,,,,1.95,4.42,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00228202910,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00228202910,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00206885516,NDC,facility,inpatient,4.5,GM,119.85000,34.76000,Aetna,First Health,,98.04,,,,,,,43.21,98.04,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00206885516,NDC,facility,outpatient,4.5,GM,119.85000,34.76000,Aetna,First Health,,98.04,,,,,,,1.05,98.04,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00206885416,NDC,facility,inpatient,3.375,GM,98.90000,28.68000,Aetna,First Health,,80.90,,,,,,,35.65,80.90,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00206885416,NDC,facility,outpatient,3.375,GM,98.90000,28.68000,Aetna,First Health,,80.90,,,,,,,1.05,80.90,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00206885216,NDC,facility,inpatient,2.25,GM,59.90000,17.37000,Aetna,First Health,,49.00,,,,,,,21.59,49.00,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00206885216,NDC,facility,outpatient,2.25,GM,59.90000,17.37000,Aetna,First Health,,49.00,,,,,,,1.05,49.00,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00206845525,NDC,facility,inpatient,4.5,GM,219.65000,63.70000,Aetna,First Health,,179.67,,,,,,,79.18,179.67,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00206845525,NDC,facility,outpatient,4.5,GM,219.65000,63.70000,Aetna,First Health,,179.67,,,,,,,1.05,179.67,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00206845455,NDC,facility,inpatient,3.375,GM,149.10000,43.24000,Aetna,First Health,,121.96,,,,,,,53.75,121.96,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00206845455,NDC,facility,outpatient,3.375,GM,149.10000,43.24000,Aetna,First Health,,121.96,,,,,,,1.05,121.96,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00206410002,NDC,facility,inpatient,4.5,GM,193.35000,56.07000,Aetna,First Health,,158.16,,,,,,,69.70,158.16,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00206410002,NDC,facility,outpatient,4.5,GM,193.35000,56.07000,Aetna,First Health,,158.16,,,,,,,1.05,158.16,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00206240402,NDC,facility,inpatient,2.25,GM,101.75000,29.51000,Aetna,First Health,,83.23,,,,,,,36.68,83.23,percent of total billed charges,
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00206240402,NDC,facility,outpatient,2.25,GM,101.75000,29.51000,Aetna,First Health,,83.23,,,,,,,1.05,83.23,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00187442030,NDC,,,facility,inpatient,1,EA,112.35000,32.58000,Aetna,First Health,,91.90,,,,,,,67.41,91.90,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00187442030,NDC,,,facility,outpatient,1,EA,112.35000,32.58000,Aetna,First Health,,91.90,,,,,,,40.50,91.90,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00187442010,NDC,,,facility,inpatient,1,EA,112.35000,32.58000,Aetna,First Health,,91.90,,,,,,,67.41,91.90,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00187442010,NDC,,,facility,outpatient,1,EA,112.35000,32.58000,Aetna,First Health,,91.90,,,,,,,40.50,91.90,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,00187433005,NDC,,,facility,inpatient,1,EA,14152.85000,4104.33000,Aetna,First Health,,11577.03,,,,,,,5236.55,11577.03,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,00187433005,NDC,,,facility,outpatient,1,EA,14152.85000,4104.33000,Aetna,First Health,,11577.03,,,,,,,5102.10,11577.03,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00187430202,NDC,,,facility,inpatient,1,EA,1385.20000,401.71000,Aetna,First Health,,1133.09,,,,,,,512.52,1133.09,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00187430202,NDC,,,facility,outpatient,1,EA,1385.20000,401.71000,Aetna,First Health,,1133.09,,,,,,,499.36,1133.09,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00187410010,NDC,,,facility,inpatient,1,EA,400.75000,116.22000,Aetna,First Health,,327.81,,,,,,,240.45,327.81,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00187410010,NDC,,,facility,outpatient,1,EA,400.75000,116.22000,Aetna,First Health,,327.81,,,,,,,144.47,327.81,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,00187355410,NDC,,,facility,inpatient,1,EA,515.10000,149.38000,Aetna,First Health,,421.35,,,,,,,309.06,421.35,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,00187355410,NDC,,,facility,outpatient,1,EA,515.10000,149.38000,Aetna,First Health,,421.35,,,,,,,185.69,421.35,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00187301030,NDC,,,facility,inpatient,1,EA,185.75000,53.87000,Aetna,First Health,,151.94,,,,,,,111.45,151.94,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00187301030,NDC,,,facility,outpatient,1,EA,185.75000,53.87000,Aetna,First Health,,151.94,,,,,,,66.96,151.94,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,00187170405,NDC,,,facility,inpatient,1,EA,468.70000,135.92000,Aetna,First Health,,383.40,,,,,,,281.22,383.40,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,00187170405,NDC,,,facility,outpatient,1,EA,468.70000,135.92000,Aetna,First Health,,383.40,,,,,,,168.97,383.40,percent of total billed charges,
Glucose 15g Gel(Glutose 15),800053933,CDM,250,RC,00187074633,NDC,,,facility,inpatient,1,EA,58.50000,16.96000,Aetna,First Health,,47.85,,,,,,,21.64,47.85,percent of total billed charges,
Glucose 15g Gel(Glutose 15),800053933,CDM,250,RC,00187074633,NDC,,,facility,outpatient,1,EA,58.50000,16.96000,Aetna,First Health,,47.85,,,,,,,21.09,47.85,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00187014390,NDC,,,facility,inpatient,1,EA,273.45000,79.30000,Aetna,First Health,,223.68,,,,,,,164.07,223.68,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00187014390,NDC,,,facility,outpatient,1,EA,273.45000,79.30000,Aetna,First Health,,223.68,,,,,,,98.58,223.68,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00186730005,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,3.69,5.03,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00186730005,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00186115102,NDC,facility,inpatient,10,ME,92.25000,26.75000,Aetna,First Health,,75.46,,,,,,,33.26,75.46,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00186115102,NDC,facility,outpatient,10,ME,92.25000,26.75000,Aetna,First Health,,75.46,,,,,,,13.00,75.46,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,00186109205,NDC,,,facility,inpatient,1,EA,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,9.15,12.47,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,00186109205,NDC,,,facility,outpatient,1,EA,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,5.50,12.47,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00186109005,NDC,,,facility,inpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,6.09,8.30,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00186109005,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.66,8.30,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00186108805,NDC,,,facility,inpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,6.09,8.30,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00186108805,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.66,8.30,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,00186103412,NDC,,,facility,inpatient,1,EA,223.65000,64.86000,Aetna,First Health,,182.95,,,,,,,82.75,182.95,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,00186103412,NDC,,,facility,outpatient,1,EA,223.65000,64.86000,Aetna,First Health,,182.95,,,,,,,80.63,182.95,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00186103312,NDC,,,facility,inpatient,1,EA,24.25000,7.03000,Aetna,First Health,,19.84,,,,,,,8.97,19.84,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00186103312,NDC,,,facility,outpatient,1,EA,24.25000,7.03000,Aetna,First Health,,19.84,,,,,,,8.74,19.84,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00186103201,NDC,,,facility,inpatient,1,EA,42.70000,12.38000,Aetna,First Health,,34.93,,,,,,,15.80,34.93,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00186103201,NDC,,,facility,outpatient,1,EA,42.70000,12.38000,Aetna,First Health,,34.93,,,,,,,15.39,34.93,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00186103012,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.57,18.94,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00186103012,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00186103001,NDC,,,facility,inpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.81,8.43,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00186103001,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00186102603,NDC,,,facility,inpatient,1,EA,25.10000,7.28000,Aetna,First Health,,20.53,,,,,,,9.29,20.53,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00186102603,NDC,,,facility,outpatient,1,EA,25.10000,7.28000,Aetna,First Health,,20.53,,,,,,,9.05,20.53,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,00186099466,NDC,facility,inpatient,600,ME,69.60000,20.18000,Aetna,First Health,,56.93,,,,,,,25.09,56.93,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,00186099466,NDC,facility,outpatient,600,ME,69.60000,20.18000,Aetna,First Health,,56.93,,,,,,,0.03852,56.93,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,00186099266,NDC,facility,inpatient,600,ME,148.85000,43.17000,Aetna,First Health,,121.76,,,,,,,53.66,121.76,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,00186099266,NDC,facility,outpatient,600,ME,148.85000,43.17000,Aetna,First Health,,121.76,,,,,,,0.03852,121.76,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00186086369,NDC,facility,inpatient,150,ME,99.00000,28.71000,Aetna,First Health,,80.98,,,,,,,35.69,80.98,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00186086369,NDC,facility,outpatient,150,ME,99.00000,28.71000,Aetna,First Health,,80.98,,,,,,,0.04815,80.98,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00186086361,NDC,facility,inpatient,150,ME,97.05000,28.14000,Aetna,First Health,,79.39,,,,,,,34.99,79.39,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00186086361,NDC,facility,outpatient,150,ME,97.05000,28.14000,Aetna,First Health,,79.39,,,,,,,0.04815,79.39,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00186086354,NDC,facility,inpatient,150,ME,79.95000,23.19000,Aetna,First Health,,65.40,,,,,,,28.82,65.40,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00186086354,NDC,facility,outpatient,150,ME,79.95000,23.19000,Aetna,First Health,,65.40,,,,,,,0.04815,65.40,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,00186085981,NDC,facility,inpatient,200,ME,232.30000,67.37000,Aetna,First Health,,190.02,,,,,,,83.74,190.02,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,00186085981,NDC,facility,outpatient,200,ME,232.30000,67.37000,Aetna,First Health,,190.02,,,,,,,0.04815,190.02,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00186085954,NDC,facility,inpatient,40,ME,49.00000,14.21000,Aetna,First Health,,40.08,,,,,,,17.66,40.08,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00186085954,NDC,facility,outpatient,40,ME,49.00000,14.21000,Aetna,First Health,,40.08,,,,,,,0.04815,40.08,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00186085951,NDC,facility,inpatient,40,ME,48.95000,14.20000,Aetna,First Health,,40.04,,,,,,,17.65,40.04,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00186085951,NDC,facility,outpatient,40,ME,48.95000,14.20000,Aetna,First Health,,40.04,,,,,,,0.04815,40.04,percent of total billed charges,
Ticagrelor 90mg T,800015340,CDM,637,RC,00186077760,NDC,,,facility,inpatient,1,EA,65.80000,19.08000,Aetna,First Health,,53.82,,,,,,,39.48,53.82,percent of total billed charges,
Ticagrelor 90mg T,800015340,CDM,637,RC,00186077760,NDC,,,facility,outpatient,1,EA,65.80000,19.08000,Aetna,First Health,,53.82,,,,,,,23.72,53.82,percent of total billed charges,
Ticagrelor 90mg T,800015340,CDM,637,RC,00186077739,NDC,,,facility,inpatient,1,EA,65.80000,19.08000,Aetna,First Health,,53.82,,,,,,,39.48,53.82,percent of total billed charges,
Ticagrelor 90mg T,800015340,CDM,637,RC,00186077739,NDC,,,facility,outpatient,1,EA,65.80000,19.08000,Aetna,First Health,,53.82,,,,,,,23.72,53.82,percent of total billed charges,
Ticagrelor 60mg Tab,800022075,CDM,637,RC,00186077660,NDC,,,facility,inpatient,1,EA,65.80000,19.08000,Aetna,First Health,,53.82,,,,,,,39.48,53.82,percent of total billed charges,
Ticagrelor 60mg Tab,800022075,CDM,637,RC,00186077660,NDC,,,facility,outpatient,1,EA,65.80000,19.08000,Aetna,First Health,,53.82,,,,,,,23.72,53.82,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,00186070210,NDC,,,facility,inpatient,1,EA,196.75000,57.06000,Aetna,First Health,,160.94,,,,,,,118.05,160.94,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,00186070210,NDC,,,facility,outpatient,1,EA,196.75000,57.06000,Aetna,First Health,,160.94,,,,,,,70.93,160.94,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00186061101,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00186061101,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00186045158,NDC,,,facility,inpatient,1,EA,9.90000,2.87000,Aetna,First Health,,8.10,,,,,,,5.94,8.10,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00186045158,NDC,,,facility,outpatient,1,EA,9.90000,2.87000,Aetna,First Health,,8.10,,,,,,,3.57,8.10,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00186045058,NDC,,,facility,inpatient,1,EA,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,7.50,10.22,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00186045058,NDC,,,facility,outpatient,1,EA,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,4.51,10.22,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00186045031,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00186045031,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00186032001,NDC,,,facility,inpatient,1,EA,64.80000,18.79000,Aetna,First Health,,53.01,,,,,,,23.98,53.01,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00186032001,NDC,,,facility,outpatient,1,EA,64.80000,18.79000,Aetna,First Health,,53.01,,,,,,,23.36,53.01,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,00186031521,NDC,,,facility,inpatient,1,EA,1865.70000,541.05000,Aetna,First Health,,1526.14,,,,,,,1119.42,1526.14,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,00186031521,NDC,,,facility,outpatient,1,EA,1865.70000,541.05000,Aetna,First Health,,1526.14,,,,,,,672.58,1526.14,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186026002,NDC,,,facility,inpatient,1,EA,70.60000,20.47000,Aetna,First Health,,57.75,,,,,,,25.45,57.75,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186026002,NDC,,,facility,outpatient,1,EA,70.60000,20.47000,Aetna,First Health,,57.75,,,,,,,25.45,57.75,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,00186025502,NDC,,,facility,inpatient,1,EA,61.55000,17.85000,Aetna,First Health,,50.35,,,,,,,22.19,50.35,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,00186025502,NDC,,,facility,outpatient,1,EA,61.55000,17.85000,Aetna,First Health,,50.35,,,,,,,22.19,50.35,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00186024002,NDC,,,facility,inpatient,1,EA,35.40000,10.27000,Aetna,First Health,,28.96,,,,,,,12.76,28.96,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00186024002,NDC,,,facility,outpatient,1,EA,35.40000,10.27000,Aetna,First Health,,28.96,,,,,,,12.76,28.96,percent of total billed charges,
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,00186023503,NDC,,,facility,inpatient,1,EA,40.15000,11.64000,Aetna,First Health,,32.84,,,,,,,14.47,32.84,percent of total billed charges,
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,00186023503,NDC,,,facility,outpatient,1,EA,40.15000,11.64000,Aetna,First Health,,32.84,,,,,,,14.47,32.84,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00186023003,NDC,,,facility,inpatient,1,EA,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,5.57,12.64,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00186023003,NDC,,,facility,outpatient,1,EA,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,5.57,12.64,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,00186021003,NDC,,,facility,inpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,4.29,9.73,percent of total billed charges,
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,00186021003,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,4.29,9.73,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00186015501,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00186015501,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,First Health,,5.40,,,,,,,2.38,5.40,percent of total billed charges,
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,00186015001,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,00186015001,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00186014501,NDC,,,facility,inpatient,1,EA,26.45000,7.67000,Aetna,First Health,,21.64,,,,,,,9.54,21.64,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00186014501,NDC,,,facility,outpatient,1,EA,26.45000,7.67000,Aetna,First Health,,21.64,,,,,,,9.54,21.64,percent of total billed charges,
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00186012501,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00186012501,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,00186012201,NDC,,,facility,inpatient,1,EA,16.75000,4.86000,Aetna,First Health,,13.70,,,,,,,6.04,13.70,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,00186012201,NDC,,,facility,outpatient,1,EA,16.75000,4.86000,Aetna,First Health,,13.70,,,,,,,6.04,13.70,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00186012001,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00186012001,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00186011501,NDC,,,facility,inpatient,1,EA,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,7.17,16.28,percent of total billed charges,
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00186011501,NDC,,,facility,outpatient,1,EA,19.90000,5.77000,Aetna,First Health,,16.28,,,,,,,7.17,16.28,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186011491,NDC,,,facility,inpatient,1,EA,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,23.43,53.17,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186011491,NDC,,,facility,outpatient,1,EA,65.00000,18.85000,Aetna,First Health,,53.17,,,,,,,23.43,53.17,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186011401,NDC,,,facility,inpatient,1,EA,1340.40000,388.72000,Aetna,First Health,,1096.45,,,,,,,483.21,1096.45,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186011401,NDC,,,facility,outpatient,1,EA,1340.40000,388.72000,Aetna,First Health,,1096.45,,,,,,,483.21,1096.45,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00186011001,NDC,,,facility,inpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,5.66,12.84,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00186011001,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,5.66,12.84,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00185505001,NDC,,,facility,inpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,8.82,12.02,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00185505001,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.30,12.02,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,00185441601,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,00185441601,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,00185440051,NDC,,,facility,inpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,6.21,8.47,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,00185440051,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,3.73,8.47,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00185435030,NDC,,,facility,inpatient,1,EA,15.75000,4.57000,Aetna,First Health,,12.88,,,,,,,9.45,12.88,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00185435030,NDC,,,facility,outpatient,1,EA,15.75000,4.57000,Aetna,First Health,,12.88,,,,,,,5.68,12.88,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00185435001,NDC,,,facility,inpatient,1,EA,15.75000,4.57000,Aetna,First Health,,12.88,,,,,,,9.45,12.88,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00185435001,NDC,,,facility,outpatient,1,EA,15.75000,4.57000,Aetna,First Health,,12.88,,,,,,,5.68,12.88,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00185079930,NDC,,,facility,inpatient,1,EA,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,19.50,26.59,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00185079930,NDC,,,facility,outpatient,1,EA,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,11.72,26.59,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00185079901,NDC,,,facility,inpatient,1,EA,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,19.50,26.59,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00185079901,NDC,,,facility,outpatient,1,EA,32.50000,9.42000,Aetna,First Health,,26.59,,,,,,,11.72,26.59,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00185077130,NDC,,,facility,inpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,5.19,7.08,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00185077130,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,First Health,,7.08,,,,,,,3.12,7.08,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00185067601,NDC,facility,inpatient,50,ME,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00185067601,NDC,facility,outpatient,50,ME,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.21186,1.88,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00185067401,NDC,facility,inpatient,25,ME,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00185067401,NDC,facility,outpatient,25,ME,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.21186,1.72,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00185061501,NDC,facility,inpatient,50,ME,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00185061501,NDC,facility,outpatient,50,ME,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.21186,1.88,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00185061301,NDC,facility,inpatient,25,ME,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00185061301,NDC,facility,outpatient,25,ME,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.21186,1.72,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00185041560,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00185041560,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00185041501,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00185041501,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00185041060,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00185041060,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00185041001,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00185041001,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,00185040101,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,00185040101,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00185031101,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,4.02,5.48,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00185031101,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00185028201,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00185028201,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00185028110,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,3.69,5.03,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00185028110,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00185028101,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,3.69,5.03,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00185028101,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,00185022360,NDC,,,facility,inpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,7.74,10.55,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,00185022360,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,4.65,10.55,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00185021401,NDC,,,facility,inpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,6.48,8.83,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00185021401,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,3.89,8.83,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00185021301,NDC,,,facility,inpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,3.00,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00185021301,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,First Health,,4.09,,,,,,,1.80,4.09,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,00185021001,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,00185021001,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,00185020501,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,00185020501,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00185017101,NDC,,,facility,inpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,10.89,14.85,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00185017101,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,6.54,14.85,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00185014701,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00185014701,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00185014505,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,5.22,7.12,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00185014505,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00185014501,NDC,,,facility,inpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,5.52,7.53,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00185014501,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,3.32,7.53,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00185014460,NDC,,,facility,inpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,14.37,19.59,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00185014460,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.63,19.59,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00185014409,NDC,,,facility,inpatient,1,EA,22.90000,6.64000,Aetna,First Health,,18.73,,,,,,,13.74,18.73,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00185014409,NDC,,,facility,outpatient,1,EA,22.90000,6.64000,Aetna,First Health,,18.73,,,,,,,8.26,18.73,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00185014405,NDC,,,facility,inpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,14.37,19.59,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00185014405,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.63,19.59,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00185012901,NDC,,,facility,inpatient,1,EA,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,4.62,6.30,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00185012901,NDC,,,facility,outpatient,1,EA,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,2.78,6.30,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00185012801,NDC,,,facility,inpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,4.59,6.26,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00185012801,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00185012201,NDC,,,facility,inpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,2.64,3.60,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00185012201,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00185011701,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00185011701,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00185010401,NDC,,,facility,inpatient,1,EA,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,6.69,9.12,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00185010401,NDC,,,facility,outpatient,1,EA,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,4.02,9.12,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00185010101,NDC,,,facility,inpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,4.26,5.81,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00185010101,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,2.56,5.81,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00185009105,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00185009105,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,00185008401,NDC,,,facility,inpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,8.22,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,00185008401,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,First Health,,11.21,,,,,,,4.94,11.21,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00185006301,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00185006301,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00185004301,NDC,,,facility,inpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,10.29,14.03,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00185004301,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,6.18,14.03,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00185002401,NDC,,,facility,inpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,2.22,3.03,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00185002401,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00185002201,NDC,,,facility,inpatient,1,EA,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,9.27,12.64,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00185002201,NDC,,,facility,outpatient,1,EA,15.45000,4.48000,Aetna,First Health,,12.64,,,,,,,5.57,12.64,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00185001001,NDC,,,facility,inpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,2.19,2.99,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00185001001,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,First Health,,2.99,,,,,,,1.32,2.99,percent of total billed charges,
Selenium 2.5% 120mL Lotion,800065887,CDM,250,RC,00182608837,NDC,,,facility,inpatient,1,EA,82.10000,23.81000,Aetna,First Health,,67.16,,,,,,,30.38,67.16,percent of total billed charges,
Selenium 2.5% 120mL Lotion,800065887,CDM,250,RC,00182608837,NDC,,,facility,outpatient,1,EA,82.10000,23.81000,Aetna,First Health,,67.16,,,,,,,29.60,67.16,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00182607240,NDC,,,facility,inpatient,1,EA,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.30000,0.40900,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00182607240,NDC,,,facility,outpatient,1,EA,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.18025,0.40900,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00182602464,NDC,,,facility,inpatient,1,EA,21.15000,6.13000,Aetna,First Health,,17.30,,,,,,,7.83,17.30,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00182602464,NDC,,,facility,outpatient,1,EA,21.15000,6.13000,Aetna,First Health,,17.30,,,,,,,7.62,17.30,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,00182512852,NDC,,,facility,inpatient,1,EA,49.20000,14.27000,Aetna,First Health,,40.25,,,,,,,18.20,40.25,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,00182512852,NDC,,,facility,outpatient,1,EA,49.20000,14.27000,Aetna,First Health,,40.25,,,,,,,17.74,40.25,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00182268926,NDC,,,facility,inpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,18.69,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00182268926,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,First Health,,25.48,,,,,,,11.23,25.48,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00182194989,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00182194989,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00182194489,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00182194489,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00182189801,NDC,,,facility,inpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,1.41,1.92,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00182189801,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00182181089,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00182181089,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,00182173151,NDC,,,facility,inpatient,1,EA,62.65000,18.17000,Aetna,First Health,,51.25,,,,,,,37.59,51.25,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,00182173151,NDC,,,facility,outpatient,1,EA,62.65000,18.17000,Aetna,First Health,,51.25,,,,,,,22.59,51.25,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,00182137640,NDC,,,facility,inpatient,1,EA,0.35000,0.10000,Aetna,First Health,,0.28630,,,,,,,0.21000,0.28630,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,00182137640,NDC,,,facility,outpatient,1,EA,0.35000,0.10000,Aetna,First Health,,0.28630,,,,,,,0.12618,0.28630,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00182129901,NDC,,,facility,inpatient,1,EA,0.70000,0.20000,Aetna,First Health,,0.57260,,,,,,,0.42000,0.57260,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00182129901,NDC,,,facility,outpatient,1,EA,0.70000,0.20000,Aetna,First Health,,0.57260,,,,,,,0.25235,0.57260,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00182118801,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00182118801,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00182109889,NDC,facility,inpatient,25,ME,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00182109889,NDC,facility,outpatient,25,ME,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,0.21186,2.66,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00182097989,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00182097989,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00182097889,NDC,,,facility,inpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,1.05,1.43,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00182097889,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.63087,1.43,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00182055689,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00182055689,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00182050789,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00182050789,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,00182045489,NDC,,,facility,inpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,00182045489,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.46865,1.06,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,00178061001,NDC,,,facility,inpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,10.89,14.85,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,00178061001,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,6.54,14.85,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,00173300101,NDC,,,facility,inpatient,1,EA,168.65000,48.91000,Aetna,First Health,,137.96,,,,,,,101.19,137.96,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,00173300101,NDC,,,facility,outpatient,1,EA,168.65000,48.91000,Aetna,First Health,,137.96,,,,,,,60.80,137.96,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00173099156,NDC,,,facility,inpatient,1,EA,17.45000,5.06000,Aetna,First Health,,14.27,,,,,,,10.47,14.27,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00173099156,NDC,,,facility,outpatient,1,EA,17.45000,5.06000,Aetna,First Health,,14.27,,,,,,,6.29,14.27,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00173099155,NDC,,,facility,inpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,14.94,20.37,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00173099155,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,First Health,,20.37,,,,,,,8.98,20.37,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,00173095396,NDC,,,facility,inpatient,1,EA,21.85000,6.34000,Aetna,First Health,,17.87,,,,,,,13.11,17.87,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,00173095396,NDC,,,facility,outpatient,1,EA,21.85000,6.34000,Aetna,First Health,,17.87,,,,,,,7.88,17.87,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00173094755,NDC,,,facility,inpatient,1,EA,62.40000,18.10000,Aetna,First Health,,51.04,,,,,,,37.44,51.04,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00173094755,NDC,,,facility,outpatient,1,EA,62.40000,18.10000,Aetna,First Health,,51.04,,,,,,,22.50,51.04,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093356,NDC,,,facility,inpatient,1,EA,113.20000,32.83000,Aetna,First Health,,92.60,,,,,,,67.92,92.60,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093356,NDC,,,facility,outpatient,1,EA,113.20000,32.83000,Aetna,First Health,,92.60,,,,,,,40.81,92.60,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093310,NDC,,,facility,inpatient,1,EA,114.05000,33.07000,Aetna,First Health,,93.29,,,,,,,68.43,93.29,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093310,NDC,,,facility,outpatient,1,EA,114.05000,33.07000,Aetna,First Health,,93.29,,,,,,,41.12,93.29,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093308,NDC,,,facility,inpatient,1,EA,114.05000,33.07000,Aetna,First Health,,93.29,,,,,,,68.43,93.29,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093308,NDC,,,facility,outpatient,1,EA,114.05000,33.07000,Aetna,First Health,,93.29,,,,,,,41.12,93.29,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093303,NDC,,,facility,inpatient,1,EA,28.55000,8.28000,Aetna,First Health,,23.35,,,,,,,17.13,23.35,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093303,NDC,,,facility,outpatient,1,EA,28.55000,8.28000,Aetna,First Health,,23.35,,,,,,,10.29,23.35,percent of total billed charges,
Mepolizumab 100mg/1mL IS (Nucala),800062011,CDM,636,RC,J2182,HCPCS,00173089242,NDC,facility,inpatient,100,ME,15478.50000,4488.76000,Aetna,First Health,,12661.41,,,,,,,5580.00,12661.41,percent of total billed charges,
Mepolizumab 100mg/1mL IS (Nucala),800062011,CDM,636,RC,J2182,HCPCS,00173089242,NDC,facility,outpatient,100,ME,15478.50000,4488.76000,Aetna,First Health,,12661.41,,,,,,,30.71,12661.41,percent of total billed charges,
Mepolizumab 100mg Inj,800022031,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,inpatient,100,ME,14543.65000,4217.66000,Aetna,First Health,,11896.71,,,,,,,5242.99,11896.71,percent of total billed charges,
Mepolizumab 100mg Inj,800022031,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,outpatient,100,ME,14543.65000,4217.66000,Aetna,First Health,,11896.71,,,,,,,30.71,11896.71,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00173082318,NDC,,,facility,inpatient,1,EA,103.40000,29.99000,Aetna,First Health,,84.58,,,,,,,62.04,84.58,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00173082318,NDC,,,facility,outpatient,1,EA,103.40000,29.99000,Aetna,First Health,,84.58,,,,,,,37.28,84.58,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,00173078801,NDC,,,facility,inpatient,1,EA,60.60000,17.57000,Aetna,First Health,,49.57,,,,,,,36.36,49.57,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,00173078801,NDC,,,facility,outpatient,1,EA,60.60000,17.57000,Aetna,First Health,,49.57,,,,,,,21.85,49.57,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00173078601,NDC,,,facility,inpatient,1,EA,47.80000,13.86000,Aetna,First Health,,39.10,,,,,,,28.68,39.10,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00173078601,NDC,,,facility,outpatient,1,EA,47.80000,13.86000,Aetna,First Health,,39.10,,,,,,,17.23,39.10,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,00173073701,NDC,,,facility,inpatient,1,EA,592.45000,171.81000,Aetna,First Health,,484.62,,,,,,,355.47,484.62,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,00173073701,NDC,,,facility,outpatient,1,EA,592.45000,171.81000,Aetna,First Health,,484.62,,,,,,,213.58,484.62,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00173073500,NDC,,,facility,inpatient,1,EA,289.30000,83.90000,Aetna,First Health,,236.65,,,,,,,173.58,236.65,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00173073500,NDC,,,facility,outpatient,1,EA,289.30000,83.90000,Aetna,First Health,,236.65,,,,,,,104.29,236.65,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00173073002,NDC,,,facility,inpatient,1,EA,46.55000,13.50000,Aetna,First Health,,38.08,,,,,,,27.93,38.08,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00173073002,NDC,,,facility,outpatient,1,EA,46.55000,13.50000,Aetna,First Health,,38.08,,,,,,,16.78,38.08,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00173073001,NDC,,,facility,inpatient,1,EA,36.80000,10.67000,Aetna,First Health,,30.10,,,,,,,22.08,30.10,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00173073001,NDC,,,facility,outpatient,1,EA,36.80000,10.67000,Aetna,First Health,,30.10,,,,,,,13.27,30.10,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,00173071215,NDC,,,facility,inpatient,1,EA,81.15000,23.53000,Aetna,First Health,,66.38,,,,,,,48.69,66.38,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,00173071215,NDC,,,facility,outpatient,1,EA,81.15000,23.53000,Aetna,First Health,,66.38,,,,,,,29.25,66.38,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,00173071204,NDC,,,facility,inpatient,1,EA,81.15000,23.53000,Aetna,First Health,,66.38,,,,,,,48.69,66.38,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,00173071204,NDC,,,facility,outpatient,1,EA,81.15000,23.53000,Aetna,First Health,,66.38,,,,,,,29.25,66.38,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00173069704,NDC,,,facility,inpatient,1,EA,6745.90000,1956.31000,Aetna,First Health,,5518.15,,,,,,,4047.54,5518.15,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00173069704,NDC,,,facility,outpatient,1,EA,6745.90000,1956.31000,Aetna,First Health,,5518.15,,,,,,,2431.90,5518.15,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00173069702,NDC,,,facility,inpatient,1,EA,1939.30000,562.40000,Aetna,First Health,,1586.35,,,,,,,1163.58,1586.35,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00173069702,NDC,,,facility,outpatient,1,EA,1939.30000,562.40000,Aetna,First Health,,1586.35,,,,,,,699.12,1586.35,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00173069700,NDC,,,facility,inpatient,1,EA,1902.10000,551.61000,Aetna,First Health,,1555.92,,,,,,,1141.26,1555.92,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00173069700,NDC,,,facility,outpatient,1,EA,1902.10000,551.61000,Aetna,First Health,,1555.92,,,,,,,685.71,1555.92,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00173069604,NDC,,,facility,inpatient,1,EA,4249.15000,1232.25000,Aetna,First Health,,3475.80,,,,,,,2549.49,3475.80,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00173069604,NDC,,,facility,outpatient,1,EA,4249.15000,1232.25000,Aetna,First Health,,3475.80,,,,,,,1531.82,3475.80,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00173069602,NDC,,,facility,inpatient,1,EA,1509.65000,437.80000,Aetna,First Health,,1234.89,,,,,,,905.79,1234.89,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00173069602,NDC,,,facility,outpatient,1,EA,1509.65000,437.80000,Aetna,First Health,,1234.89,,,,,,,544.23,1234.89,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00173069504,NDC,,,facility,inpatient,1,EA,4249.15000,1232.25000,Aetna,First Health,,3475.80,,,,,,,2549.49,3475.80,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00173069504,NDC,,,facility,outpatient,1,EA,4249.15000,1232.25000,Aetna,First Health,,3475.80,,,,,,,1531.82,3475.80,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00173069502,NDC,,,facility,inpatient,1,EA,1488.95000,431.80000,Aetna,First Health,,1217.96,,,,,,,893.37,1217.96,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00173069502,NDC,,,facility,outpatient,1,EA,1488.95000,431.80000,Aetna,First Health,,1217.96,,,,,,,536.77,1217.96,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00173069500,NDC,,,facility,inpatient,1,EA,1134.50000,329.00000,Aetna,First Health,,928.02,,,,,,,680.70,928.02,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00173069500,NDC,,,facility,outpatient,1,EA,1134.50000,329.00000,Aetna,First Health,,928.02,,,,,,,408.99,928.02,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00173068224,NDC,,,facility,inpatient,1,EA,161.65000,46.88000,Aetna,First Health,,132.23,,,,,,,96.99,132.23,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00173068224,NDC,,,facility,outpatient,1,EA,161.65000,46.88000,Aetna,First Health,,132.23,,,,,,,58.27,132.23,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00173068221,NDC,,,facility,inpatient,1,EA,138.60000,40.19000,Aetna,First Health,,113.37,,,,,,,83.16,113.37,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00173068221,NDC,,,facility,outpatient,1,EA,138.60000,40.19000,Aetna,First Health,,113.37,,,,,,,49.97,113.37,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00173068220,NDC,,,facility,inpatient,1,EA,182.60000,52.95000,Aetna,First Health,,149.37,,,,,,,109.56,149.37,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00173068220,NDC,,,facility,outpatient,1,EA,182.60000,52.95000,Aetna,First Health,,149.37,,,,,,,65.83,149.37,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,00173064255,NDC,,,facility,inpatient,1,EA,97.05000,28.14000,Aetna,First Health,,79.39,,,,,,,58.23,79.39,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,00173064255,NDC,,,facility,outpatient,1,EA,97.05000,28.14000,Aetna,First Health,,79.39,,,,,,,34.99,79.39,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,00173063302,NDC,,,facility,inpatient,1,EA,91.25000,26.46000,Aetna,First Health,,74.64,,,,,,,54.75,74.64,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,00173063302,NDC,,,facility,outpatient,1,EA,91.25000,26.46000,Aetna,First Health,,74.64,,,,,,,32.90,74.64,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,800015438,CDM,637,RC,00173060202,NDC,,,facility,inpatient,1,EA,1531.90000,444.25000,Aetna,First Health,,1253.09,,,,,,,919.14,1253.09,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,800015438,CDM,637,RC,00173060202,NDC,,,facility,outpatient,1,EA,1531.90000,444.25000,Aetna,First Health,,1253.09,,,,,,,552.25,1253.09,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,800015438,CDM,637,RC,00173060200,NDC,,,facility,inpatient,1,EA,1795.15000,520.59000,Aetna,First Health,,1468.43,,,,,,,1077.09,1468.43,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,800015438,CDM,637,RC,00173060200,NDC,,,facility,outpatient,1,EA,1795.15000,520.59000,Aetna,First Health,,1468.43,,,,,,,647.15,1468.43,percent of total billed charges,
Fluticasone Prop 250mcg/INH Diskus,800015439,CDM,637,RC,00173060102,NDC,,,facility,inpatient,1,EA,1858.45000,538.95000,Aetna,First Health,,1520.21,,,,,,,1115.07,1520.21,percent of total billed charges,
Fluticasone Prop 250mcg/INH Diskus,800015439,CDM,637,RC,00173060102,NDC,,,facility,outpatient,1,EA,1858.45000,538.95000,Aetna,First Health,,1520.21,,,,,,,669.97,1520.21,percent of total billed charges,
Fluticasone Prop 250mcg/INH Diskus,800015439,CDM,637,RC,00173060100,NDC,,,facility,inpatient,1,EA,2307.35000,669.13000,Aetna,First Health,,1887.41,,,,,,,1384.41,1887.41,percent of total billed charges,
Fluticasone Prop 250mcg/INH Diskus,800015439,CDM,637,RC,00173060100,NDC,,,facility,outpatient,1,EA,2307.35000,669.13000,Aetna,First Health,,1887.41,,,,,,,831.80,1887.41,percent of total billed charges,
Fluticasone Prop 50mcg/INH Diskus,800017934,CDM,637,RC,00173060002,NDC,,,facility,inpatient,1,EA,1467.25000,425.50000,Aetna,First Health,,1200.21,,,,,,,880.35,1200.21,percent of total billed charges,
Fluticasone Prop 50mcg/INH Diskus,800017934,CDM,637,RC,00173060002,NDC,,,facility,outpatient,1,EA,1467.25000,425.50000,Aetna,First Health,,1200.21,,,,,,,528.94,1200.21,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,00173059755,NDC,facility,inpatient,50,ME,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,00173059755,NDC,facility,outpatient,50,ME,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,0.05778,8.34,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,00173056900,NDC,facility,inpatient,4,ME,169.45000,49.14000,Aetna,First Health,,138.61,,,,,,,101.67,138.61,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,00173056900,NDC,facility,outpatient,4,ME,169.45000,49.14000,Aetna,First Health,,138.61,,,,,,,0.00963,138.61,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00173054700,NDC,,,facility,inpatient,1,EA,276.80000,80.27000,Aetna,First Health,,226.42,,,,,,,166.08,226.42,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00173054700,NDC,,,facility,outpatient,1,EA,276.80000,80.27000,Aetna,First Health,,226.42,,,,,,,99.79,226.42,percent of total billed charges,
SUMAtriptan 20mg/spray NS,800081034,CDM,637,RC,00173052300,NDC,,,facility,inpatient,1,EA,716.30000,207.73000,Aetna,First Health,,585.93,,,,,,,429.78,585.93,percent of total billed charges,
SUMAtriptan 20mg/spray NS,800081034,CDM,637,RC,00173052300,NDC,,,facility,outpatient,1,EA,716.30000,207.73000,Aetna,First Health,,585.93,,,,,,,258.23,585.93,percent of total billed charges,
Salmeterol 50 mcg Pwd/Inh,800080076,CDM,637,RC,00173052100,NDC,,,facility,inpatient,1,EA,2866.40000,831.26000,Aetna,First Health,,2344.72,,,,,,,1719.84,2344.72,percent of total billed charges,
Salmeterol 50 mcg Pwd/Inh,800080076,CDM,637,RC,00173052100,NDC,,,facility,outpatient,1,EA,2866.40000,831.26000,Aetna,First Health,,2344.72,,,,,,,1033.34,2344.72,percent of total billed charges,
Salmeterol 50 mcg Pwd/Inh,800080076,CDM,637,RC,00173052000,NDC,,,facility,inpatient,1,EA,3455.45000,1002.08000,Aetna,First Health,,2826.56,,,,,,,2073.27,2826.56,percent of total billed charges,
Salmeterol 50 mcg Pwd/Inh,800080076,CDM,637,RC,00173052000,NDC,,,facility,outpatient,1,EA,3455.45000,1002.08000,Aetna,First Health,,2826.56,,,,,,,1245.69,2826.56,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,00173048300,NDC,,,facility,inpatient,1,EA,99.65000,28.90000,Aetna,First Health,,81.51,,,,,,,36.87,81.51,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,00173048300,NDC,,,facility,outpatient,1,EA,99.65000,28.90000,Aetna,First Health,,81.51,,,,,,,35.92,81.51,percent of total billed charges,
LamiVUDine 10mg/1mL Oral L(Epivir),800081138,CDM,637,RC,00173047100,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
LamiVUDine 10mg/1mL Oral L(Epivir),800081138,CDM,637,RC,00173047100,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,00173047001,NDC,,,facility,inpatient,1,EA,54.05000,15.67000,Aetna,First Health,,44.21,,,,,,,32.43,44.21,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,00173047001,NDC,,,facility,outpatient,1,EA,54.05000,15.67000,Aetna,First Health,,44.21,,,,,,,19.49,44.21,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00173046002,NDC,,,facility,inpatient,1,EA,149.25000,43.28000,Aetna,First Health,,122.09,,,,,,,89.55,122.09,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00173046002,NDC,,,facility,outpatient,1,EA,149.25000,43.28000,Aetna,First Health,,122.09,,,,,,,53.80,122.09,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,00173045301,NDC,,,facility,inpatient,1,EA,661.55000,191.85000,Aetna,First Health,,541.15,,,,,,,396.93,541.15,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,00173045301,NDC,,,facility,outpatient,1,EA,661.55000,191.85000,Aetna,First Health,,541.15,,,,,,,238.49,541.15,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,00173044902,NDC,facility,inpatient,6,ME,971.50000,281.73000,Aetna,First Health,,794.69,,,,,,,582.90,794.69,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,00173044902,NDC,facility,outpatient,6,ME,971.50000,281.73000,Aetna,First Health,,794.69,,,,,,,85.32,794.69,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,00173044600,NDC,facility,inpatient,4,ME,198.65000,57.61000,Aetna,First Health,,162.50,,,,,,,71.61,162.50,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,00173044600,NDC,facility,outpatient,4,ME,198.65000,57.61000,Aetna,First Health,,162.50,,,,,,,0.00963,162.50,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00173044202,NDC,facility,inpatient,4,ME,137.65000,39.92000,Aetna,First Health,,112.60,,,,,,,49.62,112.60,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00173044202,NDC,facility,outpatient,4,ME,137.65000,39.92000,Aetna,First Health,,112.60,,,,,,,0.08667,112.60,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00173044200,NDC,facility,inpatient,4,ME,195.80000,56.78000,Aetna,First Health,,160.16,,,,,,,70.59,160.16,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00173044200,NDC,facility,outpatient,4,ME,195.80000,56.78000,Aetna,First Health,,160.16,,,,,,,0.08667,160.16,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00173038742,NDC,,,facility,inpatient,1,EA,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,25.20,34.36,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00173038742,NDC,,,facility,outpatient,1,EA,42.00000,12.18000,Aetna,First Health,,34.36,,,,,,,15.14,34.36,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00173038701,NDC,,,facility,inpatient,1,EA,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,22.86,31.17,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00173038701,NDC,,,facility,outpatient,1,EA,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,13.74,31.17,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00173038700,NDC,,,facility,inpatient,1,EA,133.20000,38.63000,Aetna,First Health,,108.96,,,,,,,79.92,108.96,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00173038700,NDC,,,facility,outpatient,1,EA,133.20000,38.63000,Aetna,First Health,,108.96,,,,,,,48.02,108.96,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00173037835,NDC,facility,inpatient,1,GM,113.80000,33.00000,Aetna,First Health,,93.09,,,,,,,41.02,93.09,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00173037835,NDC,facility,outpatient,1,GM,113.80000,33.00000,Aetna,First Health,,93.09,,,,,,,1.42,93.09,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00173037810,NDC,facility,inpatient,1,GM,113.85000,33.02000,Aetna,First Health,,93.13,,,,,,,41.04,93.13,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00173037810,NDC,facility,outpatient,1,GM,113.85000,33.02000,Aetna,First Health,,93.13,,,,,,,1.42,93.13,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00173034643,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00173034643,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00173024255,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00173024255,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Neo-Poly-Bac-Hc 3.5g Ophth Oint(Cortispor,800019588,CDM,637,RC,00173019786,NDC,,,facility,inpatient,1,EA,88.45000,25.65000,Aetna,First Health,,72.35,,,,,,,53.07,72.35,percent of total billed charges,
Neo-Poly-Bac-Hc 3.5g Ophth Oint(Cortispor,800019588,CDM,637,RC,00173019786,NDC,,,facility,outpatient,1,EA,88.45000,25.65000,Aetna,First Health,,72.35,,,,,,,31.89,72.35,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00173013555,NDC,,,facility,inpatient,1,EA,66.90000,19.40000,Aetna,First Health,,54.72,,,,,,,40.14,54.72,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00173013555,NDC,,,facility,outpatient,1,EA,66.90000,19.40000,Aetna,First Health,,54.72,,,,,,,24.12,54.72,percent of total billed charges,
cycloSPORINE Microemul 100mg/1mL L,800081097,CDM,637,RC,J7502,HCPCS,00172731320,NDC,facility,inpatient,100,ME,42.40000,12.30000,Aetna,First Health,,34.68,,,,,,,25.44,34.68,percent of total billed charges,
cycloSPORINE Microemul 100mg/1mL L,800081097,CDM,637,RC,J7502,HCPCS,00172731320,NDC,facility,outpatient,100,ME,42.40000,12.30000,Aetna,First Health,,34.68,,,,,,,1.74,34.68,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00172731246,NDC,facility,inpatient,100,ME,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,23.40,31.90,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00172731246,NDC,facility,outpatient,100,ME,39.00000,11.31000,Aetna,First Health,,31.90,,,,,,,1.74,31.90,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,800080621,CDM,637,RC,J7515,HCPCS,00172731046,NDC,facility,inpatient,25,ME,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,5.85,7.98,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,800080621,CDM,637,RC,J7515,HCPCS,00172731046,NDC,facility,outpatient,25,ME,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,0.51039,7.98,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00172572880,NDC,,,facility,inpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,10.29,14.03,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00172572880,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,6.18,14.03,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00172572870,NDC,,,facility,inpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,10.29,14.03,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00172572870,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,6.18,14.03,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00172572860,NDC,,,facility,inpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,10.29,14.03,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00172572860,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,First Health,,14.03,,,,,,,6.18,14.03,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00172566460,NDC,,,facility,inpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00172566460,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00172566360,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00172566360,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00172566310,NDC,,,facility,inpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,3.33,4.54,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00172566310,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,First Health,,4.54,,,,,,,2.00,4.54,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00172541160,NDC,,,facility,inpatient,1,EA,58.90000,17.08000,Aetna,First Health,,48.18,,,,,,,35.34,48.18,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00172541160,NDC,,,facility,outpatient,1,EA,58.90000,17.08000,Aetna,First Health,,48.18,,,,,,,21.23,48.18,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00172541146,NDC,,,facility,inpatient,1,EA,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,37.20,50.72,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00172541146,NDC,,,facility,outpatient,1,EA,62.00000,17.98000,Aetna,First Health,,50.72,,,,,,,22.35,50.72,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),800080654,CDM,637,RC,00172524160,NDC,,,facility,inpatient,1,EA,79.05000,22.92000,Aetna,First Health,,64.66,,,,,,,47.43,64.66,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),800080654,CDM,637,RC,00172524160,NDC,,,facility,outpatient,1,EA,79.05000,22.92000,Aetna,First Health,,64.66,,,,,,,28.50,64.66,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00172443160,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00172443160,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00172443149,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00172443149,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00172443059,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00172443059,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00172443049,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,3.51,4.79,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00172443049,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00172436560,NDC,,,facility,inpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,4.83,6.58,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00172436560,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,2.90,6.58,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00172436460,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00172436460,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00172436060,NDC,,,facility,inpatient,1,EA,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,14.13,19.26,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00172436060,NDC,,,facility,outpatient,1,EA,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,8.49,19.26,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00172435960,NDC,,,facility,inpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,5.46,7.44,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00172435960,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,3.28,7.44,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,00172433660,NDC,,,facility,inpatient,1,EA,12.10000,3.51000,Aetna,First Health,,9.90,,,,,,,7.26,9.90,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,00172433660,NDC,,,facility,outpatient,1,EA,12.10000,3.51000,Aetna,First Health,,9.90,,,,,,,4.36,9.90,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00172433160,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00172433160,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,00172428660,NDC,,,facility,inpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,00172428660,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,00172428560,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,00172428560,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00172426660,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00172426660,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00172423660,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00172423660,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00172423360,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00172423360,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00172423260,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00172423260,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00172419860,NDC,,,facility,inpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,6.51,8.88,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00172419860,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00172419760,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00172419760,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00172419660,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00172419660,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00172409760,NDC,,,facility,inpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,21.78,29.69,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00172409760,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,First Health,,29.69,,,,,,,13.09,29.69,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00172409660,NDC,,,facility,inpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,10.50,14.31,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00172409660,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,6.31,14.31,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00172407470,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00172407470,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00172407460,NDC,,,facility,inpatient,1,EA,10.60000,3.07000,Aetna,First Health,,8.67,,,,,,,6.36,8.67,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00172407460,NDC,,,facility,outpatient,1,EA,10.60000,3.07000,Aetna,First Health,,8.67,,,,,,,3.82,8.67,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00172407370,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00172407370,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00172407360,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00172407360,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,00172402960,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,00172402960,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00172396660,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00172396660,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,00172392660,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,00172392660,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
diazePAM 2mg T(Valium),800050533,CDM,637,RC,00172392560,NDC,,,facility,inpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.60000,0.81800,percent of total billed charges,
diazePAM 2mg T(Valium),800050533,CDM,637,RC,00172392560,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,First Health,,0.81800,,,,,,,0.36050,0.81800,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00172376160,NDC,,,facility,inpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,6.54,8.92,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00172376160,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00172375960,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00172375960,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00172368660,NDC,,,facility,inpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00172368660,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,00172366760,NDC,facility,inpatient,2,ME,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Perphenazine 2mg T(Trilafon),800017416,CDM,637,RC,Q0175,HCPCS,00172366760,NDC,facility,outpatient,2,ME,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,7.37,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00172364960,NDC,,,facility,inpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.24000,0.32720,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00172364960,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.14420,0.32720,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00172300760,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00172300760,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00172298548,NDC,,,facility,inpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00172298548,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.41458,0.94070,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,00172292960,NDC,,,facility,inpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.80,2.45,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,00172292960,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.08,2.45,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00172291170,NDC,facility,inpatient,25,ME,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.84000,1.15,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00172291170,NDC,facility,outpatient,25,ME,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.21186,1.15,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00172291160,NDC,facility,inpatient,25,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
hydrOXYzine PAM 25mg C(Vistaril),800020874,CDM,637,RC,Q0177,HCPCS,00172291160,NDC,facility,outpatient,25,ME,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.21186,1.27,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00172290960,NDC,facility,inpatient,50,ME,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
hydrOXYzine PAM 50mg C(Vistaril),800019820,CDM,637,RC,Q0177,HCPCS,00172290960,NDC,facility,outpatient,50,ME,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.21186,1.35,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00172290860,NDC,,,facility,inpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.66000,0.89980,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00172290860,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,First Health,,0.89980,,,,,,,0.39655,0.89980,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00172290760,NDC,,,facility,inpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.75000,1.02,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00172290760,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.45062,1.02,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00172213070,NDC,,,facility,inpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,2.88,3.93,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00172213070,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,First Health,,3.93,,,,,,,1.73,3.93,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00172213060,NDC,,,facility,inpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,4.65,6.34,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00172213060,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,2.79,6.34,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00172208380,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00172208380,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00172208360,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00172208360,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
Factor VIIa I (NovoSeven RT),800013451,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,ME,19483.00000,5650.07000,Aetna,First Health,,15937.09,,,,,,,7023.62,15937.09,percent of total billed charges,
Factor VIIa I (NovoSeven RT),800013451,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,outpatient,1,ME,19483.00000,5650.07000,Aetna,First Health,,15937.09,,,,,,,2.52,15937.09,percent of total billed charges,
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,00169706515,NDC,facility,inpatient,1,ME,1415.90000,410.61000,Aetna,First Health,,1158.21,,,,,,,510.43,1158.21,percent of total billed charges,
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,00169706515,NDC,facility,outpatient,1,ME,1415.90000,410.61000,Aetna,First Health,,1158.21,,,,,,,158.76,1158.21,percent of total billed charges,
Factor VIIa I (NovoSeven RT),800013451,CDM,636,RC,J7189,HCPCS,00169701001,NDC,facility,inpatient,1,ME,19483.00000,5650.07000,Aetna,First Health,,15937.09,,,,,,,7023.62,15937.09,percent of total billed charges,
Factor VIIa I (NovoSeven RT),800013451,CDM,636,RC,J7189,HCPCS,00169701001,NDC,facility,outpatient,1,ME,19483.00000,5650.07000,Aetna,First Health,,15937.09,,,,,,,2.52,15937.09,percent of total billed charges,
Insulin Regular human recomb. Inj Pen,800051063,CDM,637,RC,J1815,HCPCS,00169300315,NDC,facility,inpatient,100,UN,116.30000,33.73000,Aetna,First Health,,95.13,,,,,,,69.78,95.13,percent of total billed charges,
Insulin Regular human recomb. Inj Pen,800051063,CDM,637,RC,J1815,HCPCS,00169300315,NDC,facility,outpatient,100,UN,116.30000,33.73000,Aetna,First Health,,95.13,,,,,,,0.26001,95.13,percent of total billed charges,
Insulin Isophane (NPH) Inj,800062036,CDM,637,RC,J1815,HCPCS,00169183411,NDC,facility,inpatient,5,UN,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Insulin Isophane (NPH) Inj,800062036,CDM,637,RC,J1815,HCPCS,00169183411,NDC,facility,outpatient,5,UN,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.26001,1.27,percent of total billed charges,
Insulin Regular - 5 unit/ 0.05 mL,800046534,CDM,637,RC,J1815,HCPCS,00169183311,NDC,facility,inpatient,5,UN,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Insulin Regular - 5 unit/ 0.05 mL,800046534,CDM,637,RC,J1815,HCPCS,00169183311,NDC,facility,outpatient,5,UN,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.26001,1.27,percent of total billed charges,
Insulin Reg - TPN/PPN Use,800013471,CDM,637,RC,J1815,HCPCS,00169183311,NDC,facility,inpatient,100,UN,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,13.20,18.00,percent of total billed charges,
Insulin Reg - TPN/PPN Use,800013471,CDM,637,RC,J1815,HCPCS,00169183311,NDC,facility,outpatient,100,UN,22.00000,6.38000,Aetna,First Health,,18.00,,,,,,,0.26001,18.00,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00168035756,NDC,,,facility,inpatient,1,EA,341.10000,98.92000,Aetna,First Health,,279.02,,,,,,,126.21,279.02,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00168035756,NDC,,,facility,outpatient,1,EA,341.10000,98.92000,Aetna,First Health,,279.02,,,,,,,122.97,279.02,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00168035755,NDC,,,facility,inpatient,1,EA,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,25.97,57.42,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00168035755,NDC,,,facility,outpatient,1,EA,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,25.31,57.42,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,00168035222,NDC,,,facility,inpatient,1,EA,269.65000,78.20000,Aetna,First Health,,220.57,,,,,,,161.79,220.57,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,00168035222,NDC,,,facility,outpatient,1,EA,269.65000,78.20000,Aetna,First Health,,220.57,,,,,,,97.21,220.57,percent of total billed charges,
Nitroglycerin 2% TO 1g,800081827,CDM,637,RC,00168032608,NDC,,,facility,inpatient,1,GM,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Nitroglycerin 2% TO 1g,800081827,CDM,637,RC,00168032608,NDC,,,facility,outpatient,1,GM,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,00168031330,NDC,,,facility,inpatient,1,EA,351.25000,101.86000,Aetna,First Health,,287.32,,,,,,,210.75,287.32,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,00168031330,NDC,,,facility,outpatient,1,EA,351.25000,101.86000,Aetna,First Health,,287.32,,,,,,,126.63,287.32,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,00168030130,NDC,,,facility,inpatient,1,EA,850.35000,246.60000,Aetna,First Health,,695.59,,,,,,,510.21,695.59,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,00168030130,NDC,,,facility,outpatient,1,EA,850.35000,246.60000,Aetna,First Health,,695.59,,,,,,,306.55,695.59,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,00168025815,NDC,,,facility,inpatient,1,EA,143.25000,41.54000,Aetna,First Health,,117.18,,,,,,,85.95,117.18,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,00168025815,NDC,,,facility,outpatient,1,EA,143.25000,41.54000,Aetna,First Health,,117.18,,,,,,,51.64,117.18,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,00168024615,NDC,,,facility,inpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,25.50,34.77,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,00168024615,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,15.32,34.77,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,00168020437,NDC,,,facility,inpatient,1,EA,1809.00000,524.61000,Aetna,First Health,,1479.76,,,,,,,1085.40,1479.76,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,00168020437,NDC,,,facility,outpatient,1,EA,1809.00000,524.61000,Aetna,First Health,,1479.76,,,,,,,652.14,1479.76,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,00168017215,NDC,,,facility,inpatient,1,EA,10.55000,3.06000,Aetna,First Health,,8.63,,,,,,,6.33,8.63,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,00168017215,NDC,,,facility,outpatient,1,EA,10.55000,3.06000,Aetna,First Health,,8.63,,,,,,,3.80,8.63,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,00168016330,NDC,,,facility,inpatient,1,EA,1587.75000,460.45000,Aetna,First Health,,1298.78,,,,,,,952.65,1298.78,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,00168016330,NDC,,,facility,outpatient,1,EA,1587.75000,460.45000,Aetna,First Health,,1298.78,,,,,,,572.38,1298.78,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,00168016230,NDC,,,facility,inpatient,1,EA,1604.55000,465.32000,Aetna,First Health,,1312.52,,,,,,,962.73,1312.52,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,00168016230,NDC,,,facility,outpatient,1,EA,1604.55000,465.32000,Aetna,First Health,,1312.52,,,,,,,578.44,1312.52,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00168015431,NDC,,,facility,inpatient,1,EA,35.95000,10.43000,Aetna,First Health,,29.41,,,,,,,13.30,29.41,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00168015431,NDC,,,facility,outpatient,1,EA,35.95000,10.43000,Aetna,First Health,,29.41,,,,,,,12.96,29.41,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,00168013915,NDC,,,facility,inpatient,1,EA,75.10000,21.78000,Aetna,First Health,,61.43,,,,,,,45.06,61.43,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,00168013915,NDC,,,facility,outpatient,1,EA,75.10000,21.78000,Aetna,First Health,,61.43,,,,,,,27.07,61.43,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00168013315,NDC,,,facility,inpatient,1,EA,140.90000,40.86000,Aetna,First Health,,115.26,,,,,,,52.13,115.26,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00168013315,NDC,,,facility,outpatient,1,EA,140.90000,40.86000,Aetna,First Health,,115.26,,,,,,,50.79,115.26,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,00168009915,NDC,,,facility,inpatient,1,EA,218.30000,63.31000,Aetna,First Health,,178.57,,,,,,,130.98,178.57,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,00168009915,NDC,,,facility,outpatient,1,EA,218.30000,63.31000,Aetna,First Health,,178.57,,,,,,,78.70,178.57,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,00168008130,NDC,,,facility,inpatient,1,EA,980.05000,284.21000,Aetna,First Health,,801.68,,,,,,,588.03,801.68,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,00168008130,NDC,,,facility,outpatient,1,EA,980.05000,284.21000,Aetna,First Health,,801.68,,,,,,,353.31,801.68,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,00168008031,NDC,,,facility,inpatient,1,EA,77.90000,22.59000,Aetna,First Health,,63.72,,,,,,,46.74,63.72,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,00168008031,NDC,,,facility,outpatient,1,EA,77.90000,22.59000,Aetna,First Health,,63.72,,,,,,,28.08,63.72,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,00168007011,NDC,,,facility,inpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,17.70,24.13,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,00168007011,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,10.63,24.13,percent of total billed charges,
Betamethasone Dipr 0.05% 60mL TL,800058635,CDM,637,RC,00168005760,NDC,,,facility,inpatient,1,EA,330.75000,95.92000,Aetna,First Health,,270.55,,,,,,,198.45,270.55,percent of total billed charges,
Betamethasone Dipr 0.05% 60mL TL,800058635,CDM,637,RC,00168005760,NDC,,,facility,outpatient,1,EA,330.75000,95.92000,Aetna,First Health,,270.55,,,,,,,119.24,270.55,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,00168005646,NDC,,,facility,inpatient,1,EA,284.70000,82.56000,Aetna,First Health,,232.88,,,,,,,170.82,232.88,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,00168005646,NDC,,,facility,outpatient,1,EA,284.70000,82.56000,Aetna,First Health,,232.88,,,,,,,102.63,232.88,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,00168005615,NDC,,,facility,inpatient,1,EA,413.85000,120.02000,Aetna,First Health,,338.53,,,,,,,248.31,338.53,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,00168005615,NDC,,,facility,outpatient,1,EA,413.85000,120.02000,Aetna,First Health,,338.53,,,,,,,149.19,338.53,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,00168005515,NDC,,,facility,inpatient,1,EA,361.20000,104.75000,Aetna,First Health,,295.46,,,,,,,216.72,295.46,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,00168005515,NDC,,,facility,outpatient,1,EA,361.20000,104.75000,Aetna,First Health,,295.46,,,,,,,130.21,295.46,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00168005430,NDC,,,facility,inpatient,1,EA,92.90000,26.94000,Aetna,First Health,,75.99,,,,,,,55.74,75.99,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00168005430,NDC,,,facility,outpatient,1,EA,92.90000,26.94000,Aetna,First Health,,75.99,,,,,,,33.49,75.99,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00168005415,NDC,,,facility,inpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,12.75,17.38,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00168005415,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,First Health,,17.38,,,,,,,7.66,17.38,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00168003760,NDC,,,facility,inpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00168003760,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
"NICU- Nystatin 100,000unit/1mL L",800017943,CDM,637,RC,00168003760,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
"NICU- Nystatin 100,000unit/1mL L",800017943,CDM,637,RC,00168003760,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Neo-Poly-Bac-Hc 3.5g Ophth Oint(Cortispor,800019588,CDM,637,RC,00168002938,NDC,,,facility,inpatient,1,EA,115.60000,33.52000,Aetna,First Health,,94.56,,,,,,,69.36,94.56,percent of total billed charges,
Neo-Poly-Bac-Hc 3.5g Ophth Oint(Cortispor,800019588,CDM,637,RC,00168002938,NDC,,,facility,outpatient,1,EA,115.60000,33.52000,Aetna,First Health,,94.56,,,,,,,41.67,94.56,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,00168002738,NDC,,,facility,inpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.76,8.30,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,00168002738,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.66,8.30,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,00168002131,NDC,,,facility,inpatient,1,EA,84.30000,24.45000,Aetna,First Health,,68.96,,,,,,,31.19,68.96,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,00168002131,NDC,,,facility,outpatient,1,EA,84.30000,24.45000,Aetna,First Health,,68.96,,,,,,,30.39,68.96,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00168001531,NDC,,,facility,inpatient,1,EA,53.95000,15.65000,Aetna,First Health,,44.13,,,,,,,19.96,44.13,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00168001531,NDC,,,facility,outpatient,1,EA,53.95000,15.65000,Aetna,First Health,,44.13,,,,,,,19.45,44.13,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00168001231,NDC,,,facility,inpatient,1,EA,50.05000,14.51000,Aetna,First Health,,40.94,,,,,,,18.52,40.94,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00168001231,NDC,,,facility,outpatient,1,EA,50.05000,14.51000,Aetna,First Health,,40.94,,,,,,,18.04,40.94,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00168001135,NDC,,,facility,inpatient,1,EA,51.75000,15.01000,Aetna,First Health,,42.33,,,,,,,19.15,42.33,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00168001135,NDC,,,facility,outpatient,1,EA,51.75000,15.01000,Aetna,First Health,,42.33,,,,,,,18.66,42.33,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00168001131,NDC,,,facility,inpatient,1,EA,38.65000,11.21000,Aetna,First Health,,31.62,,,,,,,14.30,31.62,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00168001131,NDC,,,facility,outpatient,1,EA,38.65000,11.21000,Aetna,First Health,,31.62,,,,,,,13.93,31.62,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,00168000715,NDC,,,facility,inpatient,1,EA,118.95000,34.50000,Aetna,First Health,,97.30,,,,,,,71.37,97.30,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,00168000715,NDC,,,facility,outpatient,1,EA,118.95000,34.50000,Aetna,First Health,,97.30,,,,,,,42.88,97.30,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,00168000680,NDC,,,facility,inpatient,1,EA,98.70000,28.62000,Aetna,First Health,,80.74,,,,,,,59.22,80.74,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,00168000680,NDC,,,facility,outpatient,1,EA,98.70000,28.62000,Aetna,First Health,,80.74,,,,,,,35.58,80.74,percent of total billed charges,
Triamcinolone 0.025% TO 80g,800017793,CDM,637,RC,00168000580,NDC,,,facility,inpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,47.37,64.58,percent of total billed charges,
Triamcinolone 0.025% TO 80g,800017793,CDM,637,RC,00168000580,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,28.46,64.58,percent of total billed charges,
Triamcinolone 0.1% TC 80g,800017794,CDM,637,RC,00168000480,NDC,,,facility,inpatient,1,EA,59.45000,17.24000,Aetna,First Health,,48.63,,,,,,,35.67,48.63,percent of total billed charges,
Triamcinolone 0.1% TC 80g,800017794,CDM,637,RC,00168000480,NDC,,,facility,outpatient,1,EA,59.45000,17.24000,Aetna,First Health,,48.63,,,,,,,21.43,48.63,percent of total billed charges,
Triamcinolone 0.1% TC 454g,800077205,CDM,637,RC,00168000416,NDC,,,facility,inpatient,1,EA,179.65000,52.10000,Aetna,First Health,,146.95,,,,,,,107.79,146.95,percent of total billed charges,
Triamcinolone 0.1% TC 454g,800077205,CDM,637,RC,00168000416,NDC,,,facility,outpatient,1,EA,179.65000,52.10000,Aetna,First Health,,146.95,,,,,,,64.76,146.95,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,00168000415,NDC,,,facility,inpatient,1,EA,25.50000,7.40000,Aetna,First Health,,20.86,,,,,,,15.30,20.86,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,00168000415,NDC,,,facility,outpatient,1,EA,25.50000,7.40000,Aetna,First Health,,20.86,,,,,,,9.19,20.86,percent of total billed charges,
Triamcinolone 0.025% TC 80g,800017792,CDM,637,RC,00168000380,NDC,,,facility,inpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,47.37,64.58,percent of total billed charges,
Triamcinolone 0.025% TC 80g,800017792,CDM,637,RC,00168000380,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,First Health,,64.58,,,,,,,28.46,64.58,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00149071001,NDC,,,facility,inpatient,1,EA,30.30000,8.79000,Aetna,First Health,,24.79,,,,,,,18.18,24.79,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00149071001,NDC,,,facility,outpatient,1,EA,30.30000,8.79000,Aetna,First Health,,24.79,,,,,,,10.92,24.79,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00149000805,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00149000805,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00143999301,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00143999301,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,inpatient,2,GM,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,69.22,157.06,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,outpatient,2,GM,192.00000,55.68000,Aetna,First Health,,157.06,,,,,,,0.79929,157.06,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00143998303,NDC,facility,inpatient,2,GM,106.10000,30.77000,Aetna,First Health,,86.79,,,,,,,38.25,86.79,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00143998303,NDC,facility,outpatient,2,GM,106.10000,30.77000,Aetna,First Health,,86.79,,,,,,,0.79929,86.79,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,00143998250,NDC,,,facility,inpatient,1,EA,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,16.05,21.88,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,00143998250,NDC,,,facility,outpatient,1,EA,26.75000,7.76000,Aetna,First Health,,21.88,,,,,,,9.64,21.88,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00143992490,NDC,facility,inpatient,1000,ME,13.15000,3.81000,Aetna,First Health,,10.76,,,,,,,4.74,10.76,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00143992490,NDC,facility,outpatient,1000,ME,13.15000,3.81000,Aetna,First Health,,10.76,,,,,,,0.79929,10.76,percent of total billed charges,
ceFAZolin 500mg I (Ancef),800062014,CDM,636,RC,J0690,HCPCS,00143992390,NDC,facility,inpatient,500,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
ceFAZolin 500mg I (Ancef),800062014,CDM,636,RC,J0690,HCPCS,00143992390,NDC,facility,outpatient,500,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,0.79929,15.71,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00143989906,NDC,facility,inpatient,200,ME,158.80000,46.05000,Aetna,First Health,,129.90,,,,,,,57.25,129.90,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00143989906,NDC,facility,outpatient,200,ME,158.80000,46.05000,Aetna,First Health,,129.90,,,,,,,4.31,129.90,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00143989705,NDC,,,facility,inpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,5.10,6.95,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00143989705,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,First Health,,6.95,,,,,,,3.06,6.95,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00143989105,NDC,facility,inpatient,4,ME,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00143989105,NDC,facility,outpatient,4,ME,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,0.08667,6.22,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00143989001,NDC,facility,inpatient,4,ME,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,2.72,6.18,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00143989001,NDC,facility,outpatient,4,ME,7.55000,2.19000,Aetna,First Health,,6.18,,,,,,,0.08667,6.18,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,00143988901,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,00143988901,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,00143987725,NDC,facility,inpatient,2,GM,76.80000,22.27000,Aetna,First Health,,62.82,,,,,,,27.69,62.82,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,00143987725,NDC,facility,outpatient,2,GM,76.80000,22.27000,Aetna,First Health,,62.82,,,,,,,4.56,62.82,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00143987525,NDC,facility,inpatient,150,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00143987525,NDC,facility,outpatient,150,ME,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,0.39483,15.71,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00143987510,NDC,facility,inpatient,150,ME,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,7.21,16.36,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00143987510,NDC,facility,outpatient,150,ME,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,0.39483,16.36,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00143987325,NDC,,,facility,inpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,0.75850,1.68,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00143987325,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,0.73903,1.68,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00143987310,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.36,14.07,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00143987310,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00143985825,NDC,facility,inpatient,500,ME,8.00000,2.32000,Aetna,First Health,,6.54,,,,,,,2.88,6.54,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00143985825,NDC,facility,outpatient,500,ME,8.00000,2.32000,Aetna,First Health,,6.54,,,,,,,0.44298,6.54,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,inpatient,1,GM,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,outpatient,1,GM,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,0.44298,15.71,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,2,GM,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,outpatient,2,GM,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,0.44298,15.66,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,00143985101,NDC,facility,inpatient,1,GM,389.90000,113.07000,Aetna,First Health,,318.94,,,,,,,140.56,318.94,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,00143985101,NDC,facility,outpatient,1,GM,389.90000,113.07000,Aetna,First Health,,318.94,,,,,,,0.25038,318.94,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,00143985001,NDC,facility,inpatient,500,ME,1518.50000,440.36000,Aetna,First Health,,1242.13,,,,,,,547.42,1242.13,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,00143985001,NDC,facility,outpatient,500,ME,1518.50000,440.36000,Aetna,First Health,,1242.13,,,,,,,0.25038,1242.13,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00143980350,NDC,,,facility,inpatient,1,EA,39.15000,11.35000,Aetna,First Health,,32.02,,,,,,,23.49,32.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00143980350,NDC,,,facility,outpatient,1,EA,39.15000,11.35000,Aetna,First Health,,32.02,,,,,,,14.11,32.02,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00143978825,NDC,facility,inpatient,100,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00143978825,NDC,facility,outpatient,100,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,1.34,17.67,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00143978710,NDC,,,facility,inpatient,1,EA,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,14.17,31.33,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00143978710,NDC,,,facility,outpatient,1,EA,38.30000,11.11000,Aetna,First Health,,31.33,,,,,,,13.81,31.33,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00143978610,NDC,,,facility,inpatient,1,EA,60.55000,17.56000,Aetna,First Health,,49.53,,,,,,,22.40,49.53,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00143978610,NDC,,,facility,outpatient,1,EA,60.55000,17.56000,Aetna,First Health,,49.53,,,,,,,21.83,49.53,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,00143978510,NDC,,,facility,inpatient,1,EA,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,24.86,54.97,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,00143978510,NDC,,,facility,outpatient,1,EA,67.20000,19.49000,Aetna,First Health,,54.97,,,,,,,24.23,54.97,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00143978410,NDC,,,facility,inpatient,1,EA,43.25000,12.54000,Aetna,First Health,,35.38,,,,,,,16.00,35.38,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00143978410,NDC,,,facility,outpatient,1,EA,43.25000,12.54000,Aetna,First Health,,35.38,,,,,,,15.59,35.38,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00143978210,NDC,facility,inpatient,500,ME,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,23.79,53.99,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00143978210,NDC,facility,outpatient,500,ME,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,1.34,53.99,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00143974610,NDC,facility,inpatient,1,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00143974610,NDC,facility,outpatient,1,ME,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,2.38,20.90,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00143972224,NDC,facility,inpatient,250,ME,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00143972224,NDC,facility,outpatient,250,ME,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,2.08,47.12,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00143972201,NDC,facility,inpatient,250,ME,69.30000,20.10000,Aetna,First Health,,56.69,,,,,,,24.98,56.69,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00143972201,NDC,facility,outpatient,250,ME,69.30000,20.10000,Aetna,First Health,,56.69,,,,,,,2.08,56.69,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00143972101,NDC,facility,inpatient,500,ME,262.30000,76.07000,Aetna,First Health,,214.56,,,,,,,94.56,214.56,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00143972101,NDC,facility,outpatient,500,ME,262.30000,76.07000,Aetna,First Health,,214.56,,,,,,,2.08,214.56,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00143972024,NDC,facility,inpatient,750,ME,59.90000,17.37000,Aetna,First Health,,49.00,,,,,,,21.59,49.00,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00143972024,NDC,facility,outpatient,750,ME,59.90000,17.37000,Aetna,First Health,,49.00,,,,,,,2.08,49.00,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00143972001,NDC,facility,inpatient,750,ME,59.85000,17.36000,Aetna,First Health,,48.96,,,,,,,21.58,48.96,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00143972001,NDC,facility,outpatient,750,ME,59.85000,17.36000,Aetna,First Health,,48.96,,,,,,,2.08,48.96,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,00143971910,NDC,facility,inpatient,20,ME,155.05000,44.96000,Aetna,First Health,,126.83,,,,,,,55.90,126.83,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,00143971910,NDC,facility,outpatient,20,ME,155.05000,44.96000,Aetna,First Health,,126.83,,,,,,,1.30,126.83,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,inpatient,25,ME,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,93.73,212.68,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,outpatient,25,ME,260.00000,75.40000,Aetna,First Health,,212.68,,,,,,,0.06741,212.68,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00143968410,NDC,,,facility,inpatient,1,EA,41.50000,12.03000,Aetna,First Health,,33.95,,,,,,,15.36,33.95,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00143968410,NDC,,,facility,outpatient,1,EA,41.50000,12.03000,Aetna,First Health,,33.95,,,,,,,14.96,33.95,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00143968225,NDC,facility,inpatient,0.2,ME,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,5.98,13.58,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00143968225,NDC,facility,outpatient,0.2,ME,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,0.36594,13.58,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,00143968025,NDC,facility,inpatient,1,ME,63.85000,18.52000,Aetna,First Health,,52.23,,,,,,,23.02,52.23,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,00143968025,NDC,facility,outpatient,1,ME,63.85000,18.52000,Aetna,First Health,,52.23,,,,,,,0.36594,52.23,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143967325,NDC,facility,inpatient,500,ME,38.40000,11.14000,Aetna,First Health,,31.41,,,,,,,13.84,31.41,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143967325,NDC,facility,outpatient,500,ME,38.40000,11.14000,Aetna,First Health,,31.41,,,,,,,0.03852,31.41,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143967310,NDC,facility,inpatient,500,ME,100.80000,29.23000,Aetna,First Health,,82.45,,,,,,,36.34,82.45,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143967310,NDC,facility,outpatient,500,ME,100.80000,29.23000,Aetna,First Health,,82.45,,,,,,,0.03852,82.45,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00143966806,NDC,facility,inpatient,400,ME,140.70000,40.80000,Aetna,First Health,,115.09,,,,,,,50.72,115.09,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00143966806,NDC,facility,outpatient,400,ME,140.70000,40.80000,Aetna,First Health,,115.09,,,,,,,4.31,115.09,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00143966010,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.36,14.07,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00143966010,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,00143963805,NDC,facility,inpatient,6,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,45.96,62.66,percent of total billed charges,
SUMAtriptan 6mg/0.5mL I(Imitrex),800069939,CDM,637,RC,J3030,HCPCS,00143963805,NDC,facility,outpatient,6,ME,76.60000,22.21000,Aetna,First Health,,62.66,,,,,,,27.61,273.24,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,00143963710,NDC,,,facility,inpatient,1,EA,165.95000,48.13000,Aetna,First Health,,135.75,,,,,,,61.40,135.75,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,00143963710,NDC,,,facility,outpatient,1,EA,165.95000,48.13000,Aetna,First Health,,135.75,,,,,,,59.82,135.75,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,00143962201,NDC,facility,inpatient,100,ME,46.55000,13.50000,Aetna,First Health,,38.08,,,,,,,17.22,38.08,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,00143962201,NDC,facility,outpatient,100,ME,46.55000,13.50000,Aetna,First Health,,38.08,,,,,,,0.33705,38.08,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,00143962125,NDC,facility,inpatient,1,ME,44.20000,12.82000,Aetna,First Health,,36.16,,,,,,,15.93,36.16,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,00143962125,NDC,facility,outpatient,1,ME,44.20000,12.82000,Aetna,First Health,,36.16,,,,,,,0.61632,36.16,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00143959525,NDC,,,facility,inpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,5.66,12.84,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00143959525,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,5.66,12.84,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,00143959425,NDC,,,facility,inpatient,1,EA,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,5.08,11.53,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,00143959425,NDC,,,facility,outpatient,1,EA,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,5.08,11.53,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00143959310,NDC,facility,inpatient,25,ME,205.45000,59.58000,Aetna,First Health,,168.06,,,,,,,74.06,168.06,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00143959310,NDC,facility,outpatient,25,ME,205.45000,59.58000,Aetna,First Health,,168.06,,,,,,,0.06741,168.06,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00143958725,NDC,facility,inpatient,0.2,ME,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00143958725,NDC,facility,outpatient,0.2,ME,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,0.36594,14.64,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,00143958525,NDC,facility,inpatient,1,ME,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,25.31,57.42,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,00143958525,NDC,facility,outpatient,1,ME,70.20000,20.36000,Aetna,First Health,,57.42,,,,,,,0.36594,57.42,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00143958009,NDC,,,facility,inpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,11.04,15.05,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00143958009,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,6.63,15.05,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00143957710,NDC,,,facility,inpatient,1,EA,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,6.42,14.56,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00143957710,NDC,,,facility,outpatient,1,EA,17.80000,5.16000,Aetna,First Health,,14.56,,,,,,,6.42,14.56,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00143957510,NDC,,,facility,inpatient,1,EA,23.50000,6.82000,Aetna,First Health,,19.22,,,,,,,8.47,19.22,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00143957510,NDC,,,facility,outpatient,1,EA,23.50000,6.82000,Aetna,First Health,,19.22,,,,,,,8.47,19.22,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143957425,NDC,facility,inpatient,500,ME,17.30000,5.02000,Aetna,First Health,,14.15,,,,,,,6.24,14.15,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143957425,NDC,facility,outpatient,500,ME,17.30000,5.02000,Aetna,First Health,,14.15,,,,,,,0.03852,14.15,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143957410,NDC,facility,inpatient,500,ME,100.80000,29.23000,Aetna,First Health,,82.45,,,,,,,36.34,82.45,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143957410,NDC,facility,outpatient,500,ME,100.80000,29.23000,Aetna,First Health,,82.45,,,,,,,0.03852,82.45,percent of total billed charges,
Phentolamine Mesylate 5mg I(Regitine),800013144,CDM,637,RC,J2760,HCPCS,00143956410,NDC,facility,inpatient,5,ME,2142.00000,621.18000,Aetna,First Health,,1752.16,,,,,,,1285.20,1752.16,percent of total billed charges,
Phentolamine Mesylate 5mg I(Regitine),800013144,CDM,637,RC,J2760,HCPCS,00143956410,NDC,facility,outpatient,5,ME,2142.00000,621.18000,Aetna,First Health,,1752.16,,,,,,,405.00,1752.16,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,00143955901,NDC,facility,inpatient,50,ME,1734.40000,502.98000,Aetna,First Health,,1418.74,,,,,,,625.25,1418.74,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,00143955901,NDC,facility,outpatient,50,ME,1734.40000,502.98000,Aetna,First Health,,1418.74,,,,,,,0.58743,1418.74,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,00143955201,NDC,facility,inpatient,350,ME,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,89.04,202.05,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,00143955201,NDC,facility,outpatient,350,ME,247.00000,71.63000,Aetna,First Health,,202.05,,,,,,,3.70,202.05,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00143954901,NDC,facility,inpatient,10,ME,62.40000,18.10000,Aetna,First Health,,51.04,,,,,,,22.50,51.04,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00143954901,NDC,facility,outpatient,10,ME,62.40000,18.10000,Aetna,First Health,,51.04,,,,,,,2.68,51.04,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00143954701,NDC,facility,inpatient,50,ME,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,95.53,216.77,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00143954701,NDC,facility,outpatient,50,ME,265.00000,76.85000,Aetna,First Health,,216.77,,,,,,,2.68,216.77,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00143953410,NDC,facility,inpatient,600,ME,134.40000,38.98000,Aetna,First Health,,109.94,,,,,,,48.45,109.94,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00143953410,NDC,facility,outpatient,600,ME,134.40000,38.98000,Aetna,First Health,,109.94,,,,,,,2.64,109.94,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,00143952510,NDC,,,facility,inpatient,1,EA,322.20000,93.44000,Aetna,First Health,,263.56,,,,,,,119.21,263.56,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,00143952510,NDC,,,facility,outpatient,1,EA,322.20000,93.44000,Aetna,First Health,,263.56,,,,,,,116.15,263.56,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,00143951910,NDC,facility,inpatient,50,ME,27.30000,7.92000,Aetna,First Health,,22.33,,,,,,,9.84,22.33,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,00143951910,NDC,facility,outpatient,50,ME,27.30000,7.92000,Aetna,First Health,,22.33,,,,,,,2.48,22.33,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,00143951001,NDC,facility,inpatient,10,ME,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,2.63,5.97,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,00143951001,NDC,facility,outpatient,10,ME,7.30000,2.12000,Aetna,First Health,,5.97,,,,,,,1.00,5.97,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,00143950810,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.28,5.03,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,00143950810,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00143950610,NDC,,,facility,inpatient,1,EA,39.70000,11.51000,Aetna,First Health,,32.47,,,,,,,14.69,32.47,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00143950610,NDC,,,facility,outpatient,1,EA,39.70000,11.51000,Aetna,First Health,,32.47,,,,,,,14.31,32.47,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,00143950301,NDC,facility,inpatient,500,ME,407.25000,118.10000,Aetna,First Health,,333.13,,,,,,,146.81,333.13,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,00143950301,NDC,facility,outpatient,500,ME,407.25000,118.10000,Aetna,First Health,,333.13,,,,,,,24.64,333.13,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,00143950125,NDC,facility,inpatient,5,ME,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,00143950125,NDC,facility,outpatient,5,ME,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,0.70299,8.34,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00143943110,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00143943110,NDC,facility,outpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,0.36594,47.12,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,00143939810,NDC,facility,inpatient,1,GM,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,134.47,305.11,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,00143939810,NDC,facility,outpatient,1,GM,373.00000,108.17000,Aetna,First Health,,305.11,,,,,,,8.82,305.11,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00143939601,NDC,,,facility,inpatient,1,EA,60.70000,17.60000,Aetna,First Health,,49.65,,,,,,,22.46,49.65,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00143939601,NDC,,,facility,outpatient,1,EA,60.70000,17.60000,Aetna,First Health,,49.65,,,,,,,21.88,49.65,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,00143939110,NDC,,,facility,inpatient,1,EA,552.50000,160.22000,Aetna,First Health,,451.94,,,,,,,204.43,451.94,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,00143939110,NDC,,,facility,outpatient,1,EA,552.50000,160.22000,Aetna,First Health,,451.94,,,,,,,199.18,451.94,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00143938725,NDC,facility,inpatient,40,ME,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,11.97,27.16,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00143938725,NDC,facility,outpatient,40,ME,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,0.71262,27.16,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,00143938610,NDC,facility,inpatient,1000,ME,122.40000,35.50000,Aetna,First Health,,100.12,,,,,,,44.13,100.12,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,00143938610,NDC,facility,outpatient,1000,ME,122.40000,35.50000,Aetna,First Health,,100.12,,,,,,,0.05778,100.12,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00143938401,NDC,facility,inpatient,150,ME,390.80000,113.33000,Aetna,First Health,,319.67,,,,,,,140.88,319.67,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00143938401,NDC,facility,outpatient,150,ME,390.80000,113.33000,Aetna,First Health,,319.67,,,,,,,0.10593,319.67,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ME,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,335.26,760.74,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,outpatient,50,ME,930.00000,269.70000,Aetna,First Health,,760.74,,,,,,,0.58743,760.74,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,00143937601,NDC,facility,inpatient,10,ME,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.41,3.19,percent of total billed charges,
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,00143937601,NDC,facility,outpatient,10,ME,3.90000,1.13000,Aetna,First Health,,3.19,,,,,,,1.00,3.21,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00143937510,NDC,facility,inpatient,1,ME,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.99,6.79,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00143937510,NDC,facility,outpatient,1,ME,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.38,7.62,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00143935901,NDC,facility,inpatient,1,GM,205.60000,59.62000,Aetna,First Health,,168.18,,,,,,,74.12,168.18,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00143935901,NDC,facility,outpatient,1,GM,205.60000,59.62000,Aetna,First Health,,168.18,,,,,,,0.02889,168.18,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00143935710,NDC,facility,inpatient,1,GM,152.65000,44.27000,Aetna,First Health,,124.87,,,,,,,55.03,124.87,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00143935710,NDC,facility,outpatient,1,GM,152.65000,44.27000,Aetna,First Health,,124.87,,,,,,,0.02889,124.87,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00143933410,NDC,,,facility,inpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,7.09,15.66,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00143933410,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00143933310,NDC,,,facility,inpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,7.09,15.66,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00143933310,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,First Health,,15.66,,,,,,,6.90,15.66,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00143933110,NDC,,,facility,inpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.90,13.05,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00143933110,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,First Health,,13.05,,,,,,,5.75,13.05,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00143933010,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.96,10.96,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00143933010,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00143931810,NDC,,,facility,inpatient,1,EA,92.05000,26.69000,Aetna,First Health,,75.30,,,,,,,34.06,75.30,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00143931810,NDC,,,facility,outpatient,1,EA,92.05000,26.69000,Aetna,First Health,,75.30,,,,,,,33.18,75.30,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00143931724,NDC,facility,inpatient,750,ME,21.20000,6.15000,Aetna,First Health,,17.34,,,,,,,7.64,17.34,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00143931724,NDC,facility,outpatient,750,ME,21.20000,6.15000,Aetna,First Health,,17.34,,,,,,,2.08,17.34,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00143931624,NDC,facility,inpatient,500,ME,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,7.21,16.36,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00143931624,NDC,facility,outpatient,500,ME,20.00000,5.80000,Aetna,First Health,,16.36,,,,,,,2.08,16.36,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00143931524,NDC,facility,inpatient,250,ME,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,5.34,12.11,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00143931524,NDC,facility,outpatient,250,ME,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,2.08,12.11,percent of total billed charges,
etomidate 2mg/mL 20mL Inj,800046520,CDM,250,RC,00143931110,NDC,,,facility,inpatient,1,EA,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.45,20.90,percent of total billed charges,
etomidate 2mg/mL 20mL Inj,800046520,CDM,250,RC,00143931110,NDC,,,facility,outpatient,1,EA,25.55000,7.41000,Aetna,First Health,,20.90,,,,,,,9.21,20.90,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00143931010,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.62,14.64,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00143931010,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00143930010,NDC,facility,inpatient,40,ME,21.70000,6.29000,Aetna,First Health,,17.75,,,,,,,7.82,17.75,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00143930010,NDC,facility,outpatient,40,ME,21.70000,6.29000,Aetna,First Health,,17.75,,,,,,,5.86,18.78,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00143928410,NDC,facility,inpatient,40,ME,41.50000,12.03000,Aetna,First Health,,33.95,,,,,,,14.96,33.95,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00143928410,NDC,facility,outpatient,40,ME,41.50000,12.03000,Aetna,First Health,,33.95,,,,,,,5.86,33.95,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,00143927901,NDC,facility,inpatient,20,ME,2941.00000,852.89000,Aetna,First Health,,2405.74,,,,,,,1060.23,2405.74,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,00143927901,NDC,facility,outpatient,20,ME,2941.00000,852.89000,Aetna,First Health,,2405.74,,,,,,,25.13,2405.74,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,00143927310,NDC,facility,inpatient,1,ME,571.30000,165.68000,Aetna,First Health,,467.32,,,,,,,205.95,467.32,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,00143927310,NDC,facility,outpatient,1,ME,571.30000,165.68000,Aetna,First Health,,467.32,,,,,,,54.97,467.32,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00143926310,NDC,facility,inpatient,40,ME,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,20.04,45.48,percent of total billed charges,
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00143926310,NDC,facility,outpatient,40,ME,55.60000,16.12000,Aetna,First Health,,45.48,,,,,,,0.04815,45.48,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,inpatient,1000,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,3.64,8.26,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,outpatient,1000,ME,10.10000,2.93000,Aetna,First Health,,8.26,,,,,,,0.79929,8.26,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00143926110,NDC,facility,inpatient,2,GM,81.60000,23.66000,Aetna,First Health,,66.75,,,,,,,29.42,66.75,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00143926110,NDC,facility,outpatient,2,GM,81.60000,23.66000,Aetna,First Health,,66.75,,,,,,,0.79929,66.75,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00143925010,NDC,,,facility,inpatient,1,EA,32.80000,9.51000,Aetna,First Health,,26.83,,,,,,,12.14,26.83,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00143925010,NDC,,,facility,outpatient,1,EA,32.80000,9.51000,Aetna,First Health,,26.83,,,,,,,11.82,26.83,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00143923410,NDC,,,facility,inpatient,1,EA,32.85000,9.53000,Aetna,First Health,,26.87,,,,,,,12.15,26.87,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00143923410,NDC,,,facility,outpatient,1,EA,32.85000,9.53000,Aetna,First Health,,26.87,,,,,,,11.84,26.87,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,00143921010,NDC,facility,inpatient,600,ME,143.45000,41.60000,Aetna,First Health,,117.34,,,,,,,51.71,117.34,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,00143921010,NDC,facility,outpatient,600,ME,143.45000,41.60000,Aetna,First Health,,117.34,,,,,,,0.03852,117.34,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00143916401,NDC,facility,inpatient,1,GM,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,180.25,409.00,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00143916401,NDC,facility,outpatient,1,GM,500.00000,145.00000,Aetna,First Health,,409.00,,,,,,,0.02889,409.00,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00143916210,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,20.76,47.12,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00143916210,NDC,facility,outpatient,1,GM,57.60000,16.70000,Aetna,First Health,,47.12,,,,,,,0.02889,47.12,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,00143913501,NDC,facility,inpatient,20,ME,747.00000,216.63000,Aetna,First Health,,611.05,,,,,,,269.29,611.05,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,00143913501,NDC,facility,outpatient,20,ME,747.00000,216.63000,Aetna,First Health,,611.05,,,,,,,25.13,611.05,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,00143902202,NDC,facility,inpatient,250,ME,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,108.22,245.56,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,00143902202,NDC,facility,outpatient,250,ME,300.20000,87.06000,Aetna,First Health,,245.56,,,,,,,5.51,245.56,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,00143900601,NDC,facility,inpatient,500,ME,310.00000,89.90000,Aetna,First Health,,253.58,,,,,,,111.75,253.58,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,00143900601,NDC,facility,outpatient,500,ME,310.00000,89.90000,Aetna,First Health,,253.58,,,,,,,24.64,253.58,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,00143318801,NDC,,,facility,inpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,00143318801,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.34247,0.77710,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00143314250,NDC,,,facility,inpatient,1,EA,39.15000,11.35000,Aetna,First Health,,32.02,,,,,,,23.49,32.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00143314250,NDC,,,facility,outpatient,1,EA,39.15000,11.35000,Aetna,First Health,,32.02,,,,,,,14.11,32.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00143314205,NDC,,,facility,inpatient,1,EA,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,7.23,9.86,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00143314205,NDC,,,facility,outpatient,1,EA,12.05000,3.49000,Aetna,First Health,,9.86,,,,,,,4.34,9.86,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00143312601,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00143312601,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00143223001,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00143223001,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00143212801,NDC,,,facility,inpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,4.68,6.38,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00143212801,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,2.81,6.38,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00143178701,NDC,,,facility,inpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,7.17,9.78,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00143178701,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,First Health,,9.78,,,,,,,4.31,9.78,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00143177101,NDC,,,facility,inpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,4.59,6.26,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00143177101,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,00143176401,NDC,,,facility,inpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,00143176401,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.46865,1.06,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,00143150001,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,00143150001,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00143148401,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00143148401,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00143148205,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00143148205,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00143148201,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00143148201,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,00143148001,NDC,,,facility,inpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,3.18,4.34,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,00143148001,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,1.91,4.34,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00143147310,NDC,facility,inpatient,10,ME,0.45000,0.13000,Aetna,First Health,,0.36810,,,,,,,0.27000,0.36810,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00143147310,NDC,facility,outpatient,10,ME,0.45000,0.13000,Aetna,First Health,,0.36810,,,,,,,0.00963,0.36810,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,00143145805,NDC,,,facility,inpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.80,2.45,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,00143145805,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,First Health,,2.45,,,,,,,1.08,2.45,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,00143145801,NDC,,,facility,inpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,3.57,4.87,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,00143145801,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,First Health,,4.87,,,,,,,2.14,4.87,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,00143145005,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,00143145005,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,00143145001,NDC,,,facility,inpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,2.04,2.78,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,00143145001,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,00143134601,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,00143134601,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00143129205,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00143129205,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00143129201,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00143129201,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00143129005,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00143129005,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00143129001,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00143129001,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00143127701,NDC,,,facility,inpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,2.22,3.03,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00143127701,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,00143126501,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,00143126501,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00143125601,NDC,,,facility,inpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.36000,0.49080,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00143125601,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,First Health,,0.49080,,,,,,,0.21630,0.49080,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00143124810,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00143124810,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00143124801,NDC,,,facility,inpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,1.47,2.00,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00143124801,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,First Health,,2.00,,,,,,,0.88323,2.00,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00143124001,NDC,,,facility,inpatient,1,EA,16.30000,4.73000,Aetna,First Health,,13.33,,,,,,,9.78,13.33,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00143124001,NDC,,,facility,outpatient,1,EA,16.30000,4.73000,Aetna,First Health,,13.33,,,,,,,5.88,13.33,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00143120125,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00143120125,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00143120101,NDC,,,facility,inpatient,1,EA,0.75000,0.22000,Aetna,First Health,,0.61350,,,,,,,0.45000,0.61350,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00143120101,NDC,,,facility,outpatient,1,EA,0.75000,0.22000,Aetna,First Health,,0.61350,,,,,,,0.27037,0.61350,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00135020003,NDC,,,facility,inpatient,1,EA,218.80000,63.45000,Aetna,First Health,,178.98,,,,,,,80.96,178.98,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00135020003,NDC,,,facility,outpatient,1,EA,218.80000,63.45000,Aetna,First Health,,178.98,,,,,,,78.88,178.98,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00135020001,NDC,,,facility,inpatient,1,EA,218.85000,63.47000,Aetna,First Health,,179.02,,,,,,,80.97,179.02,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00135020001,NDC,,,facility,outpatient,1,EA,218.85000,63.47000,Aetna,First Health,,179.02,,,,,,,78.90,179.02,percent of total billed charges,
Mineral Oil 100% Enema,800018020,CDM,637,RC,00132030140,NDC,,,facility,inpatient,1,EA,18.50000,5.36000,Aetna,First Health,,15.13,,,,,,,11.10,15.13,percent of total billed charges,
Mineral Oil 100% Enema,800018020,CDM,637,RC,00132030140,NDC,,,facility,outpatient,1,EA,18.50000,5.36000,Aetna,First Health,,15.13,,,,,,,6.67,15.13,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,00131247760,NDC,,,facility,inpatient,1,EA,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,76.50,104.30,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,00131247760,NDC,,,facility,outpatient,1,EA,127.50000,36.97000,Aetna,First Health,,104.30,,,,,,,45.96,104.30,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,00131247735,NDC,,,facility,inpatient,1,EA,115.90000,33.61000,Aetna,First Health,,94.81,,,,,,,69.54,94.81,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,00131247735,NDC,,,facility,outpatient,1,EA,115.90000,33.61000,Aetna,First Health,,94.81,,,,,,,41.78,94.81,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,inpatient,200,ME,859.85000,249.36000,Aetna,First Health,,703.36,,,,,,,309.98,703.36,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,200,ME,859.85000,249.36000,Aetna,First Health,,703.36,,,,,,,0.37557,703.36,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00126027116,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00126027116,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,00121495040,NDC,,,facility,inpatient,1,EA,54.55000,15.82000,Aetna,First Health,,44.62,,,,,,,32.73,44.62,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,00121495040,NDC,,,facility,outpatient,1,EA,54.55000,15.82000,Aetna,First Health,,44.62,,,,,,,19.67,44.62,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00121483940,NDC,,,facility,inpatient,1,EA,59.05000,17.12000,Aetna,First Health,,48.30,,,,,,,35.43,48.30,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00121483940,NDC,,,facility,outpatient,1,EA,59.05000,17.12000,Aetna,First Health,,48.30,,,,,,,21.29,48.30,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00121482740,NDC,,,facility,inpatient,1,EA,59.45000,17.24000,Aetna,First Health,,48.63,,,,,,,35.67,48.63,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00121482740,NDC,,,facility,outpatient,1,EA,59.45000,17.24000,Aetna,First Health,,48.63,,,,,,,21.43,48.63,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121481040,NDC,,,facility,inpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,7.14,9.73,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121481040,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,4.29,9.73,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121481000,NDC,,,facility,inpatient,1,EA,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,7.02,9.57,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121481000,NDC,,,facility,outpatient,1,EA,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,4.22,9.57,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,00121480205,NDC,,,facility,inpatient,1,EA,66.20000,19.20000,Aetna,First Health,,54.15,,,,,,,39.72,54.15,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,00121480205,NDC,,,facility,outpatient,1,EA,66.20000,19.20000,Aetna,First Health,,54.15,,,,,,,23.87,54.15,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,00121479905,NDC,,,facility,inpatient,1,EA,53.25000,15.44000,Aetna,First Health,,43.56,,,,,,,31.95,43.56,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,00121479905,NDC,,,facility,outpatient,1,EA,53.25000,15.44000,Aetna,First Health,,43.56,,,,,,,19.20,43.56,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,800072524,CDM,637,RC,00121479320,NDC,,,facility,inpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,16.98,23.15,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,800072524,CDM,637,RC,00121479320,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,10.20,23.15,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121478505,NDC,,,facility,inpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,5.37,7.32,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121478505,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,First Health,,7.32,,,,,,,3.23,7.32,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00121477610,NDC,,,facility,inpatient,1,EA,32.05000,9.29000,Aetna,First Health,,26.22,,,,,,,19.23,26.22,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00121477610,NDC,,,facility,outpatient,1,EA,32.05000,9.29000,Aetna,First Health,,26.22,,,,,,,11.55,26.22,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,00121477410,NDC,,,facility,inpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,4.89,6.67,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,00121477410,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,2.94,6.67,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00121477405,NDC,,,facility,inpatient,1,EA,13.30000,3.86000,Aetna,First Health,,10.88,,,,,,,4.92,10.88,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00121477405,NDC,,,facility,outpatient,1,EA,13.30000,3.86000,Aetna,First Health,,10.88,,,,,,,4.79,10.88,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,800018013,CDM,637,RC,00121477210,NDC,,,facility,inpatient,1,EA,64.15000,18.60000,Aetna,First Health,,52.47,,,,,,,38.49,52.47,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,800018013,CDM,637,RC,00121477210,NDC,,,facility,outpatient,1,EA,64.15000,18.60000,Aetna,First Health,,52.47,,,,,,,23.13,52.47,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,800015336,CDM,637,RC,00121472105,NDC,,,facility,inpatient,1,EA,48.30000,14.01000,Aetna,First Health,,39.51,,,,,,,28.98,39.51,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,800015336,CDM,637,RC,00121472105,NDC,,,facility,outpatient,1,EA,48.30000,14.01000,Aetna,First Health,,39.51,,,,,,,17.41,39.51,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,00121467510,NDC,,,facility,inpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,10.74,14.64,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,00121467510,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,First Health,,14.64,,,,,,,6.45,14.64,percent of total billed charges,
Valproic Acid 250 mg/5 mL Liq UD,800015339,CDM,637,RC,00121467505,NDC,,,facility,inpatient,1,EA,229.05000,66.42000,Aetna,First Health,,187.36,,,,,,,137.43,187.36,percent of total billed charges,
Valproic Acid 250 mg/5 mL Liq UD,800015339,CDM,637,RC,00121467505,NDC,,,facility,outpatient,1,EA,229.05000,66.42000,Aetna,First Health,,187.36,,,,,,,82.57,187.36,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,800062055,CDM,637,RC,00121457715,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,800062055,CDM,637,RC,00121457715,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121252040,NDC,,,facility,inpatient,1,EA,165.60000,48.02000,Aetna,First Health,,135.46,,,,,,,99.36,135.46,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121252040,NDC,,,facility,outpatient,1,EA,165.60000,48.02000,Aetna,First Health,,135.46,,,,,,,59.70,135.46,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121189600,NDC,,,facility,inpatient,1,EA,157.10000,45.56000,Aetna,First Health,,128.51,,,,,,,94.26,128.51,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121189600,NDC,,,facility,outpatient,1,EA,157.10000,45.56000,Aetna,First Health,,128.51,,,,,,,56.63,128.51,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,00121189494,NDC,,,facility,inpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,19.32,26.34,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,00121189494,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00121183605,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.28,5.03,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00121183605,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,00121182800,NDC,,,facility,inpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,6.21,8.47,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,00121182800,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,First Health,,8.47,,,,,,,3.73,8.47,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,800072518,CDM,637,RC,00121177510,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,800072518,CDM,637,RC,00121177510,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,00121172430,NDC,,,facility,inpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,19.32,26.34,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,00121172430,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,First Health,,26.34,,,,,,,11.61,26.34,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00121168040,NDC,,,facility,inpatient,1,EA,107.75000,31.25000,Aetna,First Health,,88.14,,,,,,,64.65,88.14,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00121168040,NDC,,,facility,outpatient,1,EA,107.75000,31.25000,Aetna,First Health,,88.14,,,,,,,38.84,88.14,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,800072518,CDM,637,RC,00121155000,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,800072518,CDM,637,RC,00121155000,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,800018013,CDM,637,RC,00121154440,NDC,,,facility,inpatient,1,EA,90.30000,26.19000,Aetna,First Health,,73.87,,,,,,,54.18,73.87,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,800018013,CDM,637,RC,00121154440,NDC,,,facility,outpatient,1,EA,90.30000,26.19000,Aetna,First Health,,73.87,,,,,,,32.55,73.87,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121146530,NDC,,,facility,inpatient,1,EA,43.65000,12.66000,Aetna,First Health,,35.71,,,,,,,26.19,35.71,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121146530,NDC,,,facility,outpatient,1,EA,43.65000,12.66000,Aetna,First Health,,35.71,,,,,,,15.74,35.71,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00121146515,NDC,,,facility,inpatient,1,EA,38.35000,11.12000,Aetna,First Health,,31.37,,,,,,,23.01,31.37,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00121146515,NDC,,,facility,outpatient,1,EA,38.35000,11.12000,Aetna,First Health,,31.37,,,,,,,13.83,31.37,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,00121135000,NDC,,,facility,inpatient,1,EA,21.85000,6.34000,Aetna,First Health,,17.87,,,,,,,13.11,17.87,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,00121135000,NDC,,,facility,outpatient,1,EA,21.85000,6.34000,Aetna,First Health,,17.87,,,,,,,7.88,17.87,percent of total billed charges,
Na Citrate-Citric Acid 30mL L(Bicit,800072313,CDM,637,RC,00121119000,NDC,,,facility,inpatient,1,EA,44.90000,13.02000,Aetna,First Health,,36.73,,,,,,,26.94,36.73,percent of total billed charges,
Na Citrate-Citric Acid 30mL L(Bicit,800072313,CDM,637,RC,00121119000,NDC,,,facility,outpatient,1,EA,44.90000,13.02000,Aetna,First Health,,36.73,,,,,,,16.19,36.73,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,00121115440,NDC,,,facility,inpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,10.44,14.23,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,00121115440,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,First Health,,14.23,,,,,,,6.27,14.23,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00121097494,NDC,,,facility,inpatient,1,EA,76.90000,22.30000,Aetna,First Health,,62.90,,,,,,,46.14,62.90,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00121097494,NDC,,,facility,outpatient,1,EA,76.90000,22.30000,Aetna,First Health,,62.90,,,,,,,27.72,62.90,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00121097251,NDC,,,facility,inpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.39,7.48,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00121097251,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,First Health,,7.48,,,,,,,3.30,7.48,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,00121097030,NDC,,,facility,inpatient,1,EA,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,9.96,13.58,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,00121097030,NDC,,,facility,outpatient,1,EA,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,5.98,13.58,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,00121094794,NDC,,,facility,inpatient,1,EA,25.70000,7.45000,Aetna,First Health,,21.02,,,,,,,15.42,21.02,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,00121094794,NDC,,,facility,outpatient,1,EA,25.70000,7.45000,Aetna,First Health,,21.02,,,,,,,9.26,21.02,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00121094540,NDC,,,facility,inpatient,1,EA,47.60000,13.80000,Aetna,First Health,,38.94,,,,,,,28.56,38.94,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00121094540,NDC,,,facility,outpatient,1,EA,47.60000,13.80000,Aetna,First Health,,38.94,,,,,,,17.16,38.94,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00121094500,NDC,,,facility,inpatient,1,EA,35.50000,10.30000,Aetna,First Health,,29.04,,,,,,,21.30,29.04,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00121094500,NDC,,,facility,outpatient,1,EA,35.50000,10.30000,Aetna,First Health,,29.04,,,,,,,12.80,29.04,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,00121092716,NDC,,,facility,inpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,4.32,5.89,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,00121092716,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,First Health,,5.89,,,,,,,2.60,5.89,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00121091700,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.46,5.44,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00121091700,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,800022076,CDM,637,RC,00121090594,NDC,,,facility,inpatient,1,EA,36.80000,10.67000,Aetna,First Health,,30.10,,,,,,,22.08,30.10,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,800022076,CDM,637,RC,00121090594,NDC,,,facility,outpatient,1,EA,36.80000,10.67000,Aetna,First Health,,30.10,,,,,,,13.27,30.10,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,00121090340,NDC,,,facility,inpatient,1,EA,33.10000,9.60000,Aetna,First Health,,27.08,,,,,,,19.86,27.08,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,00121090340,NDC,,,facility,outpatient,1,EA,33.10000,9.60000,Aetna,First Health,,27.08,,,,,,,11.93,27.08,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00121089842,NDC,,,facility,inpatient,1,EA,286.75000,83.16000,Aetna,First Health,,234.56,,,,,,,172.05,234.56,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00121089842,NDC,,,facility,outpatient,1,EA,286.75000,83.16000,Aetna,First Health,,234.56,,,,,,,103.37,234.56,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00121089340,NDC,,,facility,inpatient,1,EA,16.15000,4.68000,Aetna,First Health,,13.21,,,,,,,9.69,13.21,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00121089340,NDC,,,facility,outpatient,1,EA,16.15000,4.68000,Aetna,First Health,,13.21,,,,,,,5.82,13.21,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,00121089250,NDC,,,facility,inpatient,1,EA,61.15000,17.73000,Aetna,First Health,,50.02,,,,,,,36.69,50.02,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,00121089250,NDC,,,facility,outpatient,1,EA,61.15000,17.73000,Aetna,First Health,,50.02,,,,,,,22.04,50.02,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00121088842,NDC,,,facility,inpatient,1,EA,286.75000,83.16000,Aetna,First Health,,234.56,,,,,,,172.05,234.56,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00121088842,NDC,,,facility,outpatient,1,EA,286.75000,83.16000,Aetna,First Health,,234.56,,,,,,,103.37,234.56,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121086850,NDC,,,facility,inpatient,1,EA,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,9.99,13.62,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121086850,NDC,,,facility,outpatient,1,EA,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,6.00,13.62,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121086800,NDC,,,facility,inpatient,1,EA,16.05000,4.65000,Aetna,First Health,,13.13,,,,,,,9.63,13.13,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121086800,NDC,,,facility,outpatient,1,EA,16.05000,4.65000,Aetna,First Health,,13.13,,,,,,,5.79,13.13,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,800072524,CDM,637,RC,00121085340,NDC,,,facility,inpatient,1,EA,145.05000,42.06000,Aetna,First Health,,118.65,,,,,,,87.03,118.65,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,800072524,CDM,637,RC,00121085340,NDC,,,facility,outpatient,1,EA,145.05000,42.06000,Aetna,First Health,,118.65,,,,,,,52.29,118.65,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121081016,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,5.22,7.12,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121081016,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
LORazepam 1mg/0.5mL Oral Conc,800025501,CDM,637,RC,00121077001,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
LORazepam 1mg/0.5mL Oral Conc,800025501,CDM,637,RC,00121077001,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,00121075908,NDC,facility,inpatient,3,ME,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
prednisoLONE Sod Phos 3mg/mL L,800080282,CDM,637,RC,J7510,HCPCS,00121075908,NDC,facility,outpatient,3,ME,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.88000,2.84,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00121074740,NDC,,,facility,inpatient,1,EA,86.25000,25.01000,Aetna,First Health,,70.55,,,,,,,51.75,70.55,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00121074740,NDC,,,facility,outpatient,1,EA,86.25000,25.01000,Aetna,First Health,,70.55,,,,,,,31.09,70.55,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00121074710,NDC,,,facility,inpatient,1,EA,71.20000,20.65000,Aetna,First Health,,58.24,,,,,,,42.72,58.24,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00121074710,NDC,,,facility,outpatient,1,EA,71.20000,20.65000,Aetna,First Health,,58.24,,,,,,,25.67,58.24,percent of total billed charges,
oxyBUTYnin 5mg/5mL L UD,800015338,CDM,637,RC,00121067105,NDC,,,facility,inpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,11.04,15.05,percent of total billed charges,
oxyBUTYnin 5mg/5mL L UD,800015338,CDM,637,RC,00121067105,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,6.63,15.05,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,00121064616,NDC,,,facility,inpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,6.54,8.92,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,00121064616,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,00121064610,NDC,,,facility,inpatient,1,EA,34.95000,10.14000,Aetna,First Health,,28.59,,,,,,,20.97,28.59,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,00121064610,NDC,,,facility,outpatient,1,EA,34.95000,10.14000,Aetna,First Health,,28.59,,,,,,,12.60,28.59,percent of total billed charges,
Na Citrate-Citric Acid 30mL L(Bicit,800072313,CDM,637,RC,00121059530,NDC,,,facility,inpatient,1,EA,21.10000,6.12000,Aetna,First Health,,17.26,,,,,,,12.66,17.26,percent of total billed charges,
Na Citrate-Citric Acid 30mL L(Bicit,800072313,CDM,637,RC,00121059530,NDC,,,facility,outpatient,1,EA,21.10000,6.12000,Aetna,First Health,,17.26,,,,,,,7.61,17.26,percent of total billed charges,
Haloperidol 1mg/0.5mL LC UD,800015323,CDM,637,RC,00121058104,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Haloperidol 1mg/0.5mL LC UD,800015323,CDM,637,RC,00121058104,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Haloperidol 0.5mg/0.25mL LC UD,800015324,CDM,637,RC,00121058104,NDC,,,facility,inpatient,1,EA,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.48000,0.65440,percent of total billed charges,
Haloperidol 0.5mg/0.25mL LC UD,800015324,CDM,637,RC,00121058104,NDC,,,facility,outpatient,1,EA,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.28840,0.65440,percent of total billed charges,
Haloperidol 5mg/2.5mL LC UD,800021986,CDM,637,RC,00121058104,NDC,,,facility,inpatient,1,EA,8.00000,2.32000,Aetna,First Health,,6.54,,,,,,,4.80,6.54,percent of total billed charges,
Haloperidol 5mg/2.5mL LC UD,800021986,CDM,637,RC,00121058104,NDC,,,facility,outpatient,1,EA,8.00000,2.32000,Aetna,First Health,,6.54,,,,,,,2.88,6.54,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00121057716,NDC,,,facility,inpatient,1,EA,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.30000,0.40900,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00121057716,NDC,,,facility,outpatient,1,EA,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.18025,0.40900,percent of total billed charges,
PHENobarbital 40mg/10mL Soln,800025499,CDM,637,RC,00121053116,NDC,,,facility,inpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,2.40,3.27,percent of total billed charges,
PHENobarbital 40mg/10mL Soln,800025499,CDM,637,RC,00121053116,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,First Health,,3.27,,,,,,,1.44,3.27,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121046530,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121046530,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,800062055,CDM,637,RC,00116400540,NDC,,,facility,inpatient,1,EA,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,7.44,10.14,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,800062055,CDM,637,RC,00116400540,NDC,,,facility,outpatient,1,EA,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,4.47,10.14,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,00116400530,NDC,,,facility,inpatient,1,EA,13.95000,4.05000,Aetna,First Health,,11.41,,,,,,,8.37,11.41,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,00116400530,NDC,,,facility,outpatient,1,EA,13.95000,4.05000,Aetna,First Health,,11.41,,,,,,,5.03,11.41,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,800025528,CDM,637,RC,00116200116,NDC,,,facility,inpatient,1,EA,86.20000,25.00000,Aetna,First Health,,70.51,,,,,,,51.72,70.51,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,800025528,CDM,637,RC,00116200116,NDC,,,facility,outpatient,1,EA,86.20000,25.00000,Aetna,First Health,,70.51,,,,,,,31.08,70.51,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00116200116,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00116200116,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00116200115,NDC,,,facility,inpatient,1,EA,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,13.80,18.81,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00116200115,NDC,,,facility,outpatient,1,EA,23.00000,6.67000,Aetna,First Health,,18.81,,,,,,,8.29,18.81,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00116200107,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00116200107,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00115981101,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00115981101,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00115821101,NDC,,,facility,inpatient,1,EA,29.80000,8.64000,Aetna,First Health,,24.38,,,,,,,17.88,24.38,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00115821101,NDC,,,facility,outpatient,1,EA,29.80000,8.64000,Aetna,First Health,,24.38,,,,,,,10.74,24.38,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,00115703501,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,00115703501,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00115703302,NDC,,,facility,inpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,3.18,4.34,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00115703302,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,1.91,4.34,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00115703301,NDC,,,facility,inpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,3.18,4.34,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00115703301,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,1.91,4.34,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00115681110,NDC,,,facility,inpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,22.14,30.18,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00115681110,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,13.30,30.18,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00115592201,NDC,,,facility,inpatient,1,EA,11.45000,3.32000,Aetna,First Health,,9.37,,,,,,,6.87,9.37,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00115592201,NDC,,,facility,outpatient,1,EA,11.45000,3.32000,Aetna,First Health,,9.37,,,,,,,4.13,9.37,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00115552210,NDC,,,facility,inpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,10.11,13.78,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00115552210,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.07,13.78,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,00115551110,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,00115551110,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,00115521218,NDC,,,facility,inpatient,1,EA,27.85000,8.08000,Aetna,First Health,,22.78,,,,,,,16.71,22.78,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,00115521218,NDC,,,facility,outpatient,1,EA,27.85000,8.08000,Aetna,First Health,,22.78,,,,,,,10.04,22.78,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,00115521116,NDC,,,facility,inpatient,1,EA,8.75000,2.54000,Aetna,First Health,,7.16,,,,,,,5.25,7.16,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,00115521116,NDC,,,facility,outpatient,1,EA,8.75000,2.54000,Aetna,First Health,,7.16,,,,,,,3.15,7.16,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00115422201,NDC,,,facility,inpatient,1,EA,17.10000,4.96000,Aetna,First Health,,13.99,,,,,,,10.26,13.99,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00115422201,NDC,,,facility,outpatient,1,EA,17.10000,4.96000,Aetna,First Health,,13.99,,,,,,,6.16,13.99,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00115391101,NDC,,,facility,inpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,7.68,10.47,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00115391101,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,4.61,10.47,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00115351101,NDC,,,facility,inpatient,1,EA,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,5.43,7.40,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00115351101,NDC,,,facility,outpatient,1,EA,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,3.26,7.40,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,00115211101,NDC,,,facility,inpatient,1,EA,65.45000,18.98000,Aetna,First Health,,53.54,,,,,,,39.27,53.54,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,00115211101,NDC,,,facility,outpatient,1,EA,65.45000,18.98000,Aetna,First Health,,53.54,,,,,,,23.59,53.54,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00115201101,NDC,,,facility,inpatient,1,EA,15.40000,4.47000,Aetna,First Health,,12.60,,,,,,,9.24,12.60,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00115201101,NDC,,,facility,outpatient,1,EA,15.40000,4.47000,Aetna,First Health,,12.60,,,,,,,5.55,12.60,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00115169701,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,2.43,3.31,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00115169701,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,First Health,,3.31,,,,,,,1.46,3.31,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,00115169606,NDC,,,facility,inpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,00115169606,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.86520,1.96,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,00115169449,NDC,facility,inpatient,0.3,ME,1010.05000,292.91000,Aetna,First Health,,826.22,,,,,,,364.12,826.22,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,00115169449,NDC,facility,outpatient,0.3,ME,1010.05000,292.91000,Aetna,First Health,,826.22,,,,,,,0.41409,826.22,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00115166001,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00115166001,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00115165901,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00115165901,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,00115107001,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,00115107001,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,00113030602,NDC,,,facility,inpatient,1,EA,52.30000,15.17000,Aetna,First Health,,42.78,,,,,,,19.35,42.78,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,00113030602,NDC,,,facility,outpatient,1,EA,52.30000,15.17000,Aetna,First Health,,42.78,,,,,,,18.85,42.78,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00093977401,NDC,,,facility,inpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,4.98,6.79,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00093977401,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,First Health,,6.79,,,,,,,2.99,6.79,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00093970201,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,3.69,5.03,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00093970201,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,00093965201,NDC,facility,inpatient,10,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,6.69,9.12,percent of total billed charges,
Prochlorperazine Maleate 10mg T(Compazine),800019799,CDM,637,RC,Q0164,HCPCS,00093965201,NDC,facility,outpatient,10,ME,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,0.57780,9.12,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00093943301,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00093943301,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00093938001,NDC,,,facility,inpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,3.93,5.36,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00093938001,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,First Health,,5.36,,,,,,,2.36,5.36,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00093913352,NDC,,,facility,inpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00093913352,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.79310,1.80,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00093913306,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00093913306,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00093902065,NDC,facility,inpatient,100,ME,38.90000,11.28000,Aetna,First Health,,31.82,,,,,,,23.34,31.82,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00093902065,NDC,facility,outpatient,100,ME,38.90000,11.28000,Aetna,First Health,,31.82,,,,,,,1.74,31.82,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00093894093,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00093894093,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00093894001,NDC,,,facility,inpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,4.14,5.64,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00093894001,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,First Health,,5.64,,,,,,,2.49,5.64,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,00093874001,NDC,,,facility,inpatient,1,EA,21.45000,6.22000,Aetna,First Health,,17.55,,,,,,,12.87,17.55,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,00093874001,NDC,,,facility,outpatient,1,EA,21.45000,6.22000,Aetna,First Health,,17.55,,,,,,,7.73,17.55,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,00093873901,NDC,,,facility,inpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,10.77,14.68,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,00093873901,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,First Health,,14.68,,,,,,,6.47,14.68,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00093834301,NDC,,,facility,inpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.95,2.66,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00093834301,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,First Health,,2.66,,,,,,,1.17,2.66,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00093824434,NDC,,,facility,inpatient,1,EA,1114.90000,323.32000,Aetna,First Health,,911.99,,,,,,,668.94,911.99,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00093824434,NDC,,,facility,outpatient,1,EA,1114.90000,323.32000,Aetna,First Health,,911.99,,,,,,,401.92,911.99,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,00093817101,NDC,,,facility,inpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,00093817101,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,1.71,3.89,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00093812101,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00093812101,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00093812001,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00093812001,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00093811956,NDC,,,facility,inpatient,1,EA,89.85000,26.06000,Aetna,First Health,,73.50,,,,,,,53.91,73.50,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00093811956,NDC,,,facility,outpatient,1,EA,89.85000,26.06000,Aetna,First Health,,73.50,,,,,,,32.39,73.50,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,00093811856,NDC,,,facility,inpatient,1,EA,44.75000,12.98000,Aetna,First Health,,36.61,,,,,,,26.85,36.61,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,00093811856,NDC,,,facility,outpatient,1,EA,44.75000,12.98000,Aetna,First Health,,36.61,,,,,,,16.13,36.61,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00093777293,NDC,,,facility,inpatient,1,EA,24.25000,7.03000,Aetna,First Health,,19.84,,,,,,,14.55,19.84,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00093777293,NDC,,,facility,outpatient,1,EA,24.25000,7.03000,Aetna,First Health,,19.84,,,,,,,8.74,19.84,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00093777201,NDC,,,facility,inpatient,1,EA,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,14.13,19.26,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00093777201,NDC,,,facility,outpatient,1,EA,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,8.49,19.26,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00093768432,NDC,,,facility,inpatient,1,EA,1146.65000,332.53000,Aetna,First Health,,937.96,,,,,,,687.99,937.96,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00093768432,NDC,,,facility,outpatient,1,EA,1146.65000,332.53000,Aetna,First Health,,937.96,,,,,,,413.37,937.96,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,00093762998,NDC,,,facility,inpatient,1,EA,654.30000,189.75000,Aetna,First Health,,535.22,,,,,,,392.58,535.22,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,00093762998,NDC,,,facility,outpatient,1,EA,654.30000,189.75000,Aetna,First Health,,535.22,,,,,,,235.88,535.22,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,00093762056,NDC,,,facility,inpatient,1,EA,128.40000,37.24000,Aetna,First Health,,105.03,,,,,,,77.04,105.03,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,00093762056,NDC,,,facility,outpatient,1,EA,128.40000,37.24000,Aetna,First Health,,105.03,,,,,,,46.29,105.03,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00093754456,NDC,,,facility,inpatient,1,EA,11.55000,3.35000,Aetna,First Health,,9.45,,,,,,,6.93,9.45,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00093754456,NDC,,,facility,outpatient,1,EA,11.55000,3.35000,Aetna,First Health,,9.45,,,,,,,4.16,9.45,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00093747701,NDC,facility,inpatient,500,ME,56.20000,16.30000,Aetna,First Health,,45.97,,,,,,,20.26,45.97,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00093747701,NDC,facility,outpatient,500,ME,56.20000,16.30000,Aetna,First Health,,45.97,,,,,,,0.14445,45.97,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,00093743701,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,00093743701,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,00093743601,NDC,,,facility,inpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,7.68,10.47,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,00093743601,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,4.61,10.47,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00093743398,NDC,,,facility,inpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,22.14,30.18,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00093743398,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,First Health,,30.18,,,,,,,13.30,30.18,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00093743298,NDC,,,facility,inpatient,1,EA,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,20.58,28.06,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00093743298,NDC,,,facility,outpatient,1,EA,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,12.37,28.06,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00093738698,NDC,,,facility,inpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,21.60,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00093738698,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,First Health,,29.45,,,,,,,12.98,29.45,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00093738598,NDC,,,facility,inpatient,1,EA,33.05000,9.58000,Aetna,First Health,,27.03,,,,,,,19.83,27.03,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00093738598,NDC,,,facility,outpatient,1,EA,33.05000,9.58000,Aetna,First Health,,27.03,,,,,,,11.91,27.03,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00093738556,NDC,,,facility,inpatient,1,EA,33.05000,9.58000,Aetna,First Health,,27.03,,,,,,,19.83,27.03,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00093738556,NDC,,,facility,outpatient,1,EA,33.05000,9.58000,Aetna,First Health,,27.03,,,,,,,11.91,27.03,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00093738498,NDC,,,facility,inpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,17.70,24.13,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00093738498,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,First Health,,24.13,,,,,,,10.63,24.13,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00093738001,NDC,,,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,8.49,11.57,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00093738001,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00093736698,NDC,,,facility,inpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.87000,1.19,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00093736698,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,First Health,,1.19,,,,,,,0.52272,1.19,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00093736598,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00093736598,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00093736556,NDC,,,facility,inpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.63000,0.85890,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00093736556,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,First Health,,0.85890,,,,,,,0.37853,0.85890,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00093736498,NDC,,,facility,inpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,7.14,9.73,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00093736498,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,First Health,,9.73,,,,,,,4.29,9.73,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735598,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735598,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735556,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,13.29,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735556,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735505,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,13.29,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735505,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735501,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735501,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00093733801,NDC,,,facility,inpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,17.91,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00093733801,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,First Health,,24.42,,,,,,,10.76,24.42,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,00093733606,NDC,,,facility,inpatient,1,EA,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,12.42,16.93,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,00093733606,NDC,,,facility,outpatient,1,EA,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,7.46,16.93,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,00093731601,NDC,,,facility,inpatient,1,EA,37.40000,10.85000,Aetna,First Health,,30.59,,,,,,,22.44,30.59,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,00093731601,NDC,,,facility,outpatient,1,EA,37.40000,10.85000,Aetna,First Health,,30.59,,,,,,,13.48,30.59,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,00093730165,NDC,facility,inpatient,4,ME,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,94.71,129.12,percent of total billed charges,
Ondansetron 4mg ODT(Zofran ODT),800016712,CDM,637,RC,Q0162,HCPCS,00093730165,NDC,facility,outpatient,4,ME,157.85000,45.78000,Aetna,First Health,,129.12,,,,,,,0.00963,129.12,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00093729056,NDC,,,facility,inpatient,1,EA,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,30.27,41.27,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00093729056,NDC,,,facility,outpatient,1,EA,50.45000,14.63000,Aetna,First Health,,41.27,,,,,,,18.19,41.27,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00093728589,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00093728589,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,00093726701,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,00093726701,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,00093725401,NDC,,,facility,inpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,4.59,6.26,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,00093725401,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,00093723106,NDC,,,facility,inpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,7.74,10.55,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,00093723106,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,First Health,,10.55,,,,,,,4.65,10.55,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,00093721906,NDC,,,facility,inpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.84000,1.15,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,00093721906,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.50470,1.15,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00093720656,NDC,,,facility,inpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,11.52,15.71,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00093720656,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00093720356,NDC,,,facility,inpatient,1,EA,62.35000,18.08000,Aetna,First Health,,51.00,,,,,,,37.41,51.00,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00093720356,NDC,,,facility,outpatient,1,EA,62.35000,18.08000,Aetna,First Health,,51.00,,,,,,,22.48,51.00,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00093720198,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,13.89,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00093720198,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,First Health,,18.94,,,,,,,8.35,18.94,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00093717756,NDC,,,facility,inpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,11.52,15.71,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00093717756,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00093717656,NDC,,,facility,inpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,11.52,15.71,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00093717656,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00093716755,NDC,,,facility,inpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,7.35,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00093716755,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,First Health,,10.02,,,,,,,4.42,10.02,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00093716356,NDC,,,facility,inpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,34.14,46.54,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00093716356,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,20.51,46.54,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00093715806,NDC,,,facility,inpatient,1,EA,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,19.20,26.18,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00093715806,NDC,,,facility,outpatient,1,EA,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,11.54,26.18,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,00093714823,NDC,,,facility,inpatient,1,EA,82.65000,23.97000,Aetna,First Health,,67.61,,,,,,,49.59,67.61,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,00093714823,NDC,,,facility,outpatient,1,EA,82.65000,23.97000,Aetna,First Health,,67.61,,,,,,,29.80,67.61,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00093714656,NDC,,,facility,inpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,33.06,45.07,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00093714656,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,First Health,,45.07,,,,,,,19.86,45.07,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,00093712901,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,00093712901,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,00093712701,NDC,,,facility,inpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,2.70,3.68,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,00093712701,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,First Health,,3.68,,,,,,,1.62,3.68,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00093711498,NDC,,,facility,inpatient,1,EA,17.85000,5.18000,Aetna,First Health,,14.60,,,,,,,10.71,14.60,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00093711498,NDC,,,facility,outpatient,1,EA,17.85000,5.18000,Aetna,First Health,,14.60,,,,,,,6.43,14.60,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,00093688871,NDC,,,facility,inpatient,1,EA,180.60000,52.37000,Aetna,First Health,,147.73,,,,,,,108.36,147.73,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,00093688871,NDC,,,facility,outpatient,1,EA,180.60000,52.37000,Aetna,First Health,,147.73,,,,,,,65.11,147.73,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,00093590786,NDC,,,facility,inpatient,1,EA,31.30000,9.08000,Aetna,First Health,,25.60,,,,,,,18.78,25.60,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,00093590786,NDC,,,facility,outpatient,1,EA,31.30000,9.08000,Aetna,First Health,,25.60,,,,,,,11.28,25.60,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00093585201,NDC,,,facility,inpatient,1,EA,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,19.17,26.14,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00093585201,NDC,,,facility,outpatient,1,EA,31.95000,9.27000,Aetna,First Health,,26.14,,,,,,,11.52,26.14,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00093585101,NDC,,,facility,inpatient,1,EA,30.65000,8.89000,Aetna,First Health,,25.07,,,,,,,18.39,25.07,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00093585101,NDC,,,facility,outpatient,1,EA,30.65000,8.89000,Aetna,First Health,,25.07,,,,,,,11.05,25.07,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,00093585001,NDC,,,facility,inpatient,1,EA,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,17.58,23.97,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,00093585001,NDC,,,facility,outpatient,1,EA,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,10.56,23.97,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093582556,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,13.29,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093582556,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093582501,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,13.29,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093582501,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00093576756,NDC,,,facility,inpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.99000,1.35,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00093576756,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,First Health,,1.35,,,,,,,0.59483,1.35,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00093574265,NDC,facility,inpatient,100,ME,38.90000,11.28000,Aetna,First Health,,31.82,,,,,,,23.34,31.82,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00093574265,NDC,facility,outpatient,100,ME,38.90000,11.28000,Aetna,First Health,,31.82,,,,,,,1.74,31.82,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,00093573201,NDC,,,facility,inpatient,1,EA,45.10000,13.08000,Aetna,First Health,,36.89,,,,,,,27.06,36.89,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,00093573201,NDC,,,facility,outpatient,1,EA,45.10000,13.08000,Aetna,First Health,,36.89,,,,,,,16.26,36.89,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00093550201,NDC,,,facility,inpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,7.68,10.47,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00093550201,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,First Health,,10.47,,,,,,,4.61,10.47,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00093550101,NDC,,,facility,inpatient,1,EA,19.95000,5.79000,Aetna,First Health,,16.32,,,,,,,11.97,16.32,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00093550101,NDC,,,facility,outpatient,1,EA,19.95000,5.79000,Aetna,First Health,,16.32,,,,,,,7.19,16.32,percent of total billed charges,
Cabergoline 0.5 mg Tab,800017393,CDM,637,RC,J8515,HCPCS,00093542088,NDC,facility,inpatient,0.5,ME,256.20000,74.30000,Aetna,First Health,,209.57,,,,,,,153.72,209.57,percent of total billed charges,
Cabergoline 0.5 mg Tab,800017393,CDM,637,RC,J8515,HCPCS,00093542088,NDC,facility,outpatient,0.5,ME,256.20000,74.30000,Aetna,First Health,,209.57,,,,,,,17.65,209.57,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00093535056,NDC,,,facility,inpatient,1,EA,33.80000,9.80000,Aetna,First Health,,27.65,,,,,,,20.28,27.65,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00093535056,NDC,,,facility,outpatient,1,EA,33.80000,9.80000,Aetna,First Health,,27.65,,,,,,,12.18,27.65,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00093528501,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,10.65,14.52,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00093528501,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00093528401,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,10.65,14.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00093528401,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00093527056,NDC,,,facility,inpatient,1,EA,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,5.16,7.03,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00093527056,NDC,,,facility,outpatient,1,EA,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,3.10,7.03,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,00093524565,NDC,,,facility,inpatient,1,EA,101.05000,29.30000,Aetna,First Health,,82.66,,,,,,,60.63,82.66,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,00093524565,NDC,,,facility,outpatient,1,EA,101.05000,29.30000,Aetna,First Health,,82.66,,,,,,,36.43,82.66,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00093520601,NDC,,,facility,inpatient,1,EA,23.30000,6.76000,Aetna,First Health,,19.06,,,,,,,13.98,19.06,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00093520601,NDC,,,facility,outpatient,1,EA,23.30000,6.76000,Aetna,First Health,,19.06,,,,,,,8.40,19.06,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,00093519501,NDC,,,facility,inpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.68,2.29,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,00093519501,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,First Health,,2.29,,,,,,,1.01,2.29,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00093511998,NDC,,,facility,inpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,11.28,15.38,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00093511998,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00093511798,NDC,,,facility,inpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,6.15,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00093511798,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,First Health,,8.38,,,,,,,3.70,8.38,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00093505998,NDC,,,facility,inpatient,1,EA,75.75000,21.97000,Aetna,First Health,,61.96,,,,,,,45.45,61.96,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00093505998,NDC,,,facility,outpatient,1,EA,75.75000,21.97000,Aetna,First Health,,61.96,,,,,,,27.31,61.96,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00093505898,NDC,,,facility,inpatient,1,EA,75.75000,21.97000,Aetna,First Health,,61.96,,,,,,,45.45,61.96,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00093505898,NDC,,,facility,outpatient,1,EA,75.75000,21.97000,Aetna,First Health,,61.96,,,,,,,27.31,61.96,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00093505698,NDC,,,facility,inpatient,1,EA,53.10000,15.40000,Aetna,First Health,,43.44,,,,,,,31.86,43.44,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00093505698,NDC,,,facility,outpatient,1,EA,53.10000,15.40000,Aetna,First Health,,43.44,,,,,,,19.14,43.44,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00093444305,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00093444305,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00093436001,NDC,,,facility,inpatient,1,EA,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,14.13,19.26,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00093436001,NDC,,,facility,outpatient,1,EA,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,8.49,19.26,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00093435993,NDC,,,facility,inpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,5.61,7.65,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00093435993,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,First Health,,7.65,,,,,,,3.37,7.65,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00093435901,NDC,,,facility,inpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,5.46,7.44,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00093435901,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,3.28,7.44,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00093435601,NDC,,,facility,inpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,11.34,15.46,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00093435601,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,6.81,15.46,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,00093433801,NDC,,,facility,inpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,6.81,9.28,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,00093433801,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,First Health,,9.28,,,,,,,4.09,9.28,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00093423601,NDC,,,facility,inpatient,1,EA,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,16.86,22.99,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00093423601,NDC,,,facility,outpatient,1,EA,28.10000,8.15000,Aetna,First Health,,22.99,,,,,,,10.13,22.99,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00093423301,NDC,,,facility,inpatient,1,EA,9.70000,2.81000,Aetna,First Health,,7.93,,,,,,,5.82,7.93,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00093423301,NDC,,,facility,outpatient,1,EA,9.70000,2.81000,Aetna,First Health,,7.93,,,,,,,3.50,7.93,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00093423201,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00093423201,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,00093417773,NDC,,,facility,inpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,6.12,8.34,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,00093417773,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,First Health,,8.34,,,,,,,3.68,8.34,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,00093417773,NDC,,,facility,inpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,2.01,2.74,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,00093417773,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,1.21,2.74,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,00093417573,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,00093417573,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,00093415573,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,00093415573,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00093406701,NDC,,,facility,inpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,4.05,5.52,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00093406701,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,First Health,,5.52,,,,,,,2.43,5.52,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,00093402901,NDC,,,facility,inpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,1.62,2.21,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,00093402901,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,First Health,,2.21,,,,,,,0.97335,2.21,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,00093365522,NDC,,,facility,inpatient,1,EA,471.45000,136.72000,Aetna,First Health,,385.65,,,,,,,282.87,385.65,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,00093365522,NDC,,,facility,outpatient,1,EA,471.45000,136.72000,Aetna,First Health,,385.65,,,,,,,169.96,385.65,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00093317431,NDC,,,facility,inpatient,1,EA,394.75000,114.48000,Aetna,First Health,,322.91,,,,,,,236.85,322.91,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00093317431,NDC,,,facility,outpatient,1,EA,394.75000,114.48000,Aetna,First Health,,322.91,,,,,,,142.31,322.91,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00093317101,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00093317101,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,00093316501,NDC,,,facility,inpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,1.35,1.84,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,00093316501,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,First Health,,1.84,,,,,,,0.81112,1.84,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00093314705,NDC,,,facility,inpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,5.73,7.81,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00093314705,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,First Health,,7.81,,,,,,,3.44,7.81,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00093314701,NDC,,,facility,inpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,5.85,7.98,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00093314701,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,3.51,7.98,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00093314501,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00093314501,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00093310953,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00093310953,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00093310905,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00093310905,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,00093306056,NDC,,,facility,inpatient,1,EA,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,106.20,144.79,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,00093306056,NDC,,,facility,outpatient,1,EA,177.00000,51.33000,Aetna,First Health,,144.79,,,,,,,63.81,144.79,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,00093304006,NDC,,,facility,inpatient,1,EA,49.05000,14.22000,Aetna,First Health,,40.12,,,,,,,29.43,40.12,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,00093304006,NDC,,,facility,outpatient,1,EA,49.05000,14.22000,Aetna,First Health,,40.12,,,,,,,17.68,40.12,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,00093227973,NDC,,,facility,inpatient,1,EA,24.40000,7.08000,Aetna,First Health,,19.96,,,,,,,14.64,19.96,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,00093227973,NDC,,,facility,outpatient,1,EA,24.40000,7.08000,Aetna,First Health,,19.96,,,,,,,8.80,19.96,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,00093227534,NDC,,,facility,inpatient,1,EA,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,21.45,29.24,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,00093227534,NDC,,,facility,outpatient,1,EA,35.75000,10.37000,Aetna,First Health,,29.24,,,,,,,12.89,29.24,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00093227434,NDC,,,facility,inpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,16.08,21.92,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00093227434,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,First Health,,21.92,,,,,,,9.66,21.92,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00093221005,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00093221005,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00093221001,NDC,,,facility,inpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,3.42,4.66,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00093221001,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00093220405,NDC,,,facility,inpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,1.41,1.92,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00093220405,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00093220401,NDC,,,facility,inpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,1.41,1.92,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00093220401,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,00093217801,NDC,,,facility,inpatient,1,EA,20.45000,5.93000,Aetna,First Health,,16.73,,,,,,,12.27,16.73,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,00093217801,NDC,,,facility,outpatient,1,EA,20.45000,5.93000,Aetna,First Health,,16.73,,,,,,,7.37,16.73,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,00093215801,NDC,,,facility,inpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,2.91,3.97,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,00093215801,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,First Health,,3.97,,,,,,,1.75,3.97,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00093213001,NDC,,,facility,inpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,9.06,12.35,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00093213001,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,First Health,,12.35,,,,,,,5.44,12.35,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00093205098,NDC,,,facility,inpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,34.14,46.54,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00093205098,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,20.51,46.54,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00093205056,NDC,,,facility,inpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,34.14,46.54,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00093205056,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,First Health,,46.54,,,,,,,20.51,46.54,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,00093202723,NDC,,,facility,inpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,49.38,67.32,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,00093202723,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,First Health,,67.32,,,,,,,29.67,67.32,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00093172301,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00093172301,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00093171401,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00093171401,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,00093171301,NDC,,,facility,inpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,2.73,3.72,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,00093171301,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,First Health,,3.72,,,,,,,1.64,3.72,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00093171201,NDC,,,facility,inpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,2.61,3.56,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00093171201,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,First Health,,3.56,,,,,,,1.57,3.56,percent of total billed charges,
Neomycin 500mg T,800016609,CDM,637,RC,00093117701,NDC,,,facility,inpatient,1,EA,10.55000,3.06000,Aetna,First Health,,8.63,,,,,,,6.33,8.63,percent of total billed charges,
Neomycin 500mg T,800016609,CDM,637,RC,00093117701,NDC,,,facility,outpatient,1,EA,10.55000,3.06000,Aetna,First Health,,8.63,,,,,,,3.80,8.63,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,00093117401,NDC,,,facility,inpatient,1,EA,14.30000,4.15000,Aetna,First Health,,11.70,,,,,,,8.58,11.70,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,00093117401,NDC,,,facility,outpatient,1,EA,14.30000,4.15000,Aetna,First Health,,11.70,,,,,,,5.16,11.70,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00093111301,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00093111301,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00093106101,NDC,,,facility,inpatient,1,EA,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,9.96,13.58,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00093106101,NDC,,,facility,outpatient,1,EA,16.60000,4.81000,Aetna,First Health,,13.58,,,,,,,5.98,13.58,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,00093106001,NDC,,,facility,inpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,13.29,18.12,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,00093106001,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,First Health,,18.12,,,,,,,7.99,18.12,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00093104201,NDC,,,facility,inpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,11.04,15.05,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00093104201,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,First Health,,15.05,,,,,,,6.63,15.05,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00093103905,NDC,,,facility,inpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,5.64,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00093103905,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,First Health,,7.69,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00093103805,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00093103805,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00093102101,NDC,,,facility,inpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,4.89,6.67,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00093102101,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,2.94,6.67,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00093101501,NDC,,,facility,inpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,5.52,7.53,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00093101501,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,3.32,7.53,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,00093101042,NDC,,,facility,inpatient,1,EA,559.85000,162.36000,Aetna,First Health,,457.96,,,,,,,335.91,457.96,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,00093101042,NDC,,,facility,outpatient,1,EA,559.85000,162.36000,Aetna,First Health,,457.96,,,,,,,201.83,457.96,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00093089601,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00093089601,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00093085253,NDC,,,facility,inpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,3.03,4.13,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00093085253,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,1.82,4.13,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00093085205,NDC,,,facility,inpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,4.47,6.09,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00093085205,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,First Health,,6.09,,,,,,,2.69,6.09,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,00093084015,NDC,,,facility,inpatient,1,EA,218.30000,63.31000,Aetna,First Health,,178.57,,,,,,,130.98,178.57,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,00093084015,NDC,,,facility,outpatient,1,EA,218.30000,63.31000,Aetna,First Health,,178.57,,,,,,,78.70,178.57,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00093083205,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00093083205,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00093083201,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00093083201,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00093081901,NDC,,,facility,inpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,5.79,7.89,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00093081901,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,3.48,7.89,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00093081101,NDC,,,facility,inpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,6.24,8.51,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00093081101,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,First Health,,8.51,,,,,,,3.75,8.51,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00093081001,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00093081001,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00093078710,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00093078710,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00093078701,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00093078701,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00093078406,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00093078406,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,00093077801,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,00093077801,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00093077198,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00093077198,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00093075201,NDC,,,facility,inpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,3.54,4.83,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00093075201,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,First Health,,4.83,,,,,,,2.13,4.83,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00093073898,NDC,,,facility,inpatient,1,EA,61.35000,17.79000,Aetna,First Health,,50.18,,,,,,,36.81,50.18,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00093073898,NDC,,,facility,outpatient,1,EA,61.35000,17.79000,Aetna,First Health,,50.18,,,,,,,22.12,50.18,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00093073856,NDC,,,facility,inpatient,1,EA,61.30000,17.78000,Aetna,First Health,,50.14,,,,,,,36.78,50.14,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00093073856,NDC,,,facility,outpatient,1,EA,61.30000,17.78000,Aetna,First Health,,50.14,,,,,,,22.10,50.14,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00093073805,NDC,,,facility,inpatient,1,EA,61.35000,17.79000,Aetna,First Health,,50.18,,,,,,,36.81,50.18,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00093073805,NDC,,,facility,outpatient,1,EA,61.35000,17.79000,Aetna,First Health,,50.18,,,,,,,22.12,50.18,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00093073401,NDC,,,facility,inpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,3.39,4.62,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00093073401,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,First Health,,4.62,,,,,,,2.04,4.62,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00093073310,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00093073310,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00093073301,NDC,,,facility,inpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,2.37,3.23,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00093073301,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,First Health,,3.23,,,,,,,1.42,3.23,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,00093067006,NDC,,,facility,inpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,10.32,14.07,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,00093067006,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,First Health,,14.07,,,,,,,6.20,14.07,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,00093067005,NDC,,,facility,inpatient,1,EA,16.40000,4.76000,Aetna,First Health,,13.42,,,,,,,9.84,13.42,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,00093067005,NDC,,,facility,outpatient,1,EA,16.40000,4.76000,Aetna,First Health,,13.42,,,,,,,5.91,13.42,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00093065701,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00093065701,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00093054201,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00093054201,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,00093031901,NDC,,,facility,inpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,6.66,9.08,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,00093031901,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,4.00,9.08,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,00093031801,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,00093031801,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,00093031401,NDC,,,facility,inpatient,1,EA,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,9.15,12.47,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,00093031401,NDC,,,facility,outpatient,1,EA,15.25000,4.42000,Aetna,First Health,,12.47,,,,,,,5.50,12.47,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00093029401,NDC,,,facility,inpatient,1,EA,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,6.39,8.71,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00093029401,NDC,,,facility,outpatient,1,EA,10.65000,3.09000,Aetna,First Health,,8.71,,,,,,,3.84,8.71,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00093029301,NDC,,,facility,inpatient,1,EA,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,5.01,6.83,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00093029301,NDC,,,facility,outpatient,1,EA,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,3.01,6.83,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,00093029201,NDC,,,facility,inpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,4.44,6.05,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,00093029201,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,First Health,,6.05,,,,,,,2.67,6.05,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00093029001,NDC,,,facility,inpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,4.08,5.56,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00093029001,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,2.45,5.56,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00093028001,NDC,,,facility,inpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,3.06,4.17,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00093028001,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,First Health,,4.17,,,,,,,1.84,4.17,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,00093023356,NDC,facility,inpatient,4,ME,172.50000,50.02000,Aetna,First Health,,141.10,,,,,,,62.19,141.10,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,00093023356,NDC,facility,outpatient,4,ME,172.50000,50.02000,Aetna,First Health,,141.10,,,,,,,0.00963,141.10,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,00093022490,NDC,,,facility,inpatient,1,EA,180.45000,52.33000,Aetna,First Health,,147.61,,,,,,,108.27,147.61,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,00093022490,NDC,,,facility,outpatient,1,EA,180.45000,52.33000,Aetna,First Health,,147.61,,,,,,,65.05,147.61,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00093022290,NDC,,,facility,inpatient,1,EA,193.05000,55.98000,Aetna,First Health,,157.91,,,,,,,115.83,157.91,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00093022290,NDC,,,facility,outpatient,1,EA,193.05000,55.98000,Aetna,First Health,,157.91,,,,,,,69.59,157.91,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,00093022106,NDC,,,facility,inpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,2.01,2.74,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,00093022106,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,1.21,2.74,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00093022056,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00093022056,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00093022001,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00093022001,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00093019901,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00093019901,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00093017356,NDC,,,facility,inpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,4.26,5.81,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00093017356,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,First Health,,5.81,,,,,,,2.56,5.81,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,00093015506,NDC,,,facility,inpatient,1,EA,18.10000,5.25000,Aetna,First Health,,14.81,,,,,,,10.86,14.81,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,00093015506,NDC,,,facility,outpatient,1,EA,18.10000,5.25000,Aetna,First Health,,14.81,,,,,,,6.53,14.81,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00093015001,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00093015001,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,00093014701,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,00093014701,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,00093008801,NDC,,,facility,inpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,2.82,3.84,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,00093008801,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,First Health,,3.84,,,,,,,1.69,3.84,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00093005801,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,3.99,5.44,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00093005801,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,First Health,,5.44,,,,,,,2.40,5.44,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00093005401,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00093005401,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00093005305,NDC,,,facility,inpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,3.18,4.34,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00093005305,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,First Health,,4.34,,,,,,,1.91,4.34,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00093005301,NDC,,,facility,inpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,3.27,4.46,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00093005301,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00093005101,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00093005101,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,00093003901,NDC,,,facility,inpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,17.67,24.09,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,00093003901,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,First Health,,24.09,,,,,,,10.62,24.09,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00093002901,NDC,,,facility,inpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,11.76,16.03,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00093002901,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,7.07,16.03,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00093002801,NDC,,,facility,inpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,8.25,11.25,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00093002801,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,First Health,,11.25,,,,,,,4.96,11.25,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00093002701,NDC,,,facility,inpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,7.86,10.72,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00093002701,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,First Health,,10.72,,,,,,,4.72,10.72,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,00093002601,NDC,,,facility,inpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,6.18,8.43,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,00093002601,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00093001298,NDC,,,facility,inpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,17.37,23.68,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00093001298,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,First Health,,23.68,,,,,,,10.44,23.68,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00091744963,NDC,,,facility,inpatient,1,EA,19.80000,5.74000,Aetna,First Health,,16.20,,,,,,,11.88,16.20,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00091744963,NDC,,,facility,outpatient,1,EA,19.80000,5.74000,Aetna,First Health,,16.20,,,,,,,7.14,16.20,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,00091703623,NDC,,,facility,inpatient,1,EA,245.85000,71.30000,Aetna,First Health,,201.11,,,,,,,147.51,201.11,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,00091703623,NDC,,,facility,outpatient,1,EA,245.85000,71.30000,Aetna,First Health,,201.11,,,,,,,88.63,201.11,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00089054006,NDC,facility,inpatient,60,ME,157.70000,45.73000,Aetna,First Health,,129.00,,,,,,,56.85,129.00,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00089054006,NDC,facility,outpatient,60,ME,157.70000,45.73000,Aetna,First Health,,129.00,,,,,,,6.15,129.00,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,00089030710,NDC,,,facility,inpatient,1,EA,30.20000,8.76000,Aetna,First Health,,24.70,,,,,,,18.12,24.70,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,00089030710,NDC,,,facility,outpatient,1,EA,30.20000,8.76000,Aetna,First Health,,24.70,,,,,,,10.89,24.70,percent of total billed charges,
Insulin Glargine (LanTUS),800077668,CDM,637,RC,J1815,HCPCS,00088502101,NDC,facility,inpatient,5,UN,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,5.43,7.40,percent of total billed charges,
Insulin Glargine (LanTUS),800077668,CDM,637,RC,J1815,HCPCS,00088502101,NDC,facility,outpatient,5,UN,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,0.26001,7.40,percent of total billed charges,
Insulin Glargine (LanTUS),800077668,CDM,637,RC,J1815,HCPCS,00088222033,NDC,facility,inpatient,5,UN,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,1.23,1.68,percent of total billed charges,
Insulin Glargine (LanTUS),800077668,CDM,637,RC,J1815,HCPCS,00088222033,NDC,facility,outpatient,5,UN,2.05000,0.59000,Aetna,First Health,,1.68,,,,,,,0.26001,1.68,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00088216030,NDC,,,facility,inpatient,1,EA,403.45000,117.00000,Aetna,First Health,,330.02,,,,,,,242.07,330.02,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00088216030,NDC,,,facility,outpatient,1,EA,403.45000,117.00000,Aetna,First Health,,330.02,,,,,,,145.44,330.02,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00088179849,NDC,,,facility,inpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,13.47,18.36,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00088179849,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,8.09,18.36,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00088179842,NDC,,,facility,inpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,14.28,19.47,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00088179842,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,First Health,,19.47,,,,,,,8.58,19.47,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00088179642,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00088179642,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00088179530,NDC,,,facility,inpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,3.87,5.28,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00088179530,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,First Health,,5.28,,,,,,,2.33,5.28,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,00088177949,NDC,,,facility,inpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,4.77,6.50,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,00088177949,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,First Health,,6.50,,,,,,,2.87,6.50,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,00088177947,NDC,,,facility,inpatient,1,EA,11.55000,3.35000,Aetna,First Health,,9.45,,,,,,,6.93,9.45,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,00088177947,NDC,,,facility,outpatient,1,EA,11.55000,3.35000,Aetna,First Health,,9.45,,,,,,,4.16,9.45,percent of total billed charges,
dilTIAZem 90mg SR C(CardiZEM),800057751,CDM,637,RC,00088177849,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
dilTIAZem 90mg SR C(CardiZEM),800057751,CDM,637,RC,00088177849,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,00088177749,NDC,,,facility,inpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,3.21,4.38,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,00088177749,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,1.93,4.38,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,00088177249,NDC,,,facility,inpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,2.64,3.60,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,00088177249,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,00088177149,NDC,,,facility,inpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.71,2.33,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,00088177149,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,First Health,,2.33,,,,,,,1.03,2.33,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00088171249,NDC,,,facility,inpatient,1,EA,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,4.62,6.30,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00088171249,NDC,,,facility,outpatient,1,EA,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,2.78,6.30,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00088171247,NDC,,,facility,inpatient,1,EA,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,5.01,6.83,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00088171247,NDC,,,facility,outpatient,1,EA,8.35000,2.42000,Aetna,First Health,,6.83,,,,,,,3.01,6.83,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00088102105,NDC,,,facility,inpatient,1,EA,232.15000,67.32000,Aetna,First Health,,189.90,,,,,,,85.90,189.90,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00088102105,NDC,,,facility,outpatient,1,EA,232.15000,67.32000,Aetna,First Health,,189.90,,,,,,,83.69,189.90,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00087606010,NDC,,,facility,inpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,5.04,6.87,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00087606010,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,3.03,6.87,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00087606005,NDC,,,facility,inpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,5.04,6.87,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00087606005,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,3.03,6.87,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,00087601142,NDC,facility,inpatient,60,ME,379.25000,109.98000,Aetna,First Health,,310.23,,,,,,,136.72,310.23,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,00087601142,NDC,facility,outpatient,60,ME,379.25000,109.98000,Aetna,First Health,,310.23,,,,,,,1.40,310.23,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00087081941,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,9.09,12.39,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00087081941,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,First Health,,12.39,,,,,,,5.46,12.39,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00087081843,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00087081843,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00087081841,NDC,,,facility,inpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,4.86,6.63,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00087081841,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,First Health,,6.63,,,,,,,2.92,6.63,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00087075501,NDC,,,facility,inpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00087075501,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.79310,1.80,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00085432001,NDC,facility,inpatient,30,ME,230.30000,66.79000,Aetna,First Health,,188.39,,,,,,,83.02,188.39,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00085432001,NDC,facility,outpatient,30,ME,230.30000,66.79000,Aetna,First Health,,188.39,,,,,,,6.65,188.39,percent of total billed charges,
Nitroglycerin 0.3mg/hr TD(Nitro-Dur),800074251,CDM,637,RC,00085331535,NDC,,,facility,inpatient,1,EA,44.60000,12.93000,Aetna,First Health,,36.48,,,,,,,26.76,36.48,percent of total billed charges,
Nitroglycerin 0.3mg/hr TD(Nitro-Dur),800074251,CDM,637,RC,00085331535,NDC,,,facility,outpatient,1,EA,44.60000,12.93000,Aetna,First Health,,36.48,,,,,,,16.08,36.48,percent of total billed charges,
Nitroglycerin 0.3mg/hr TD(Nitro-Dur),800074251,CDM,637,RC,00085331530,NDC,,,facility,inpatient,1,EA,44.60000,12.93000,Aetna,First Health,,36.48,,,,,,,26.76,36.48,percent of total billed charges,
Nitroglycerin 0.3mg/hr TD(Nitro-Dur),800074251,CDM,637,RC,00085331530,NDC,,,facility,outpatient,1,EA,44.60000,12.93000,Aetna,First Health,,36.48,,,,,,,16.08,36.48,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00085137401,NDC,,,facility,inpatient,1,EA,25.85000,7.50000,Aetna,First Health,,21.15,,,,,,,15.51,21.15,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00085137401,NDC,,,facility,outpatient,1,EA,25.85000,7.50000,Aetna,First Health,,21.15,,,,,,,9.32,21.15,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,00085117705,NDC,facility,inpatient,20,ME,776.80000,225.27000,Aetna,First Health,,635.42,,,,,,,280.04,635.42,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,00085117705,NDC,facility,outpatient,20,ME,776.80000,225.27000,Aetna,First Health,,635.42,,,,,,,3.52,635.42,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,00085117701,NDC,facility,inpatient,20,ME,882.60000,255.95000,Aetna,First Health,,721.97,,,,,,,318.18,721.97,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,00085117701,NDC,facility,outpatient,20,ME,882.60000,255.95000,Aetna,First Health,,721.97,,,,,,,3.52,721.97,percent of total billed charges,
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00085113602,NDC,facility,inpatient,75,ME,4051.30000,1174.88000,Aetna,First Health,,3313.96,,,,,,,1460.49,3313.96,percent of total billed charges,
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00085113602,NDC,facility,outpatient,75,ME,4051.30000,1174.88000,Aetna,First Health,,3313.96,,,,,,,3.52,3313.96,percent of total billed charges,
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00085113601,NDC,facility,inpatient,75,ME,4433.60000,1285.74000,Aetna,First Health,,3626.68,,,,,,,1598.31,3626.68,percent of total billed charges,
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00085113601,NDC,facility,outpatient,75,ME,4433.60000,1285.74000,Aetna,First Health,,3626.68,,,,,,,3.52,3626.68,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00085113204,NDC,,,facility,inpatient,1,EA,621.75000,180.31000,Aetna,First Health,,508.59,,,,,,,373.05,508.59,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00085113204,NDC,,,facility,outpatient,1,EA,621.75000,180.31000,Aetna,First Health,,508.59,,,,,,,224.14,508.59,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00085113201,NDC,,,facility,inpatient,1,EA,621.70000,180.29000,Aetna,First Health,,508.55,,,,,,,373.02,508.55,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00085113201,NDC,,,facility,outpatient,1,EA,621.70000,180.29000,Aetna,First Health,,508.55,,,,,,,224.12,508.55,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,00085092401,NDC,,,facility,inpatient,1,EA,466.80000,135.37000,Aetna,First Health,,381.84,,,,,,,280.08,381.84,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,00085092401,NDC,,,facility,outpatient,1,EA,466.80000,135.37000,Aetna,First Health,,381.84,,,,,,,168.28,381.84,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,00085088709,NDC,,,facility,inpatient,1,EA,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,18.87,41.72,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,00085088709,NDC,,,facility,outpatient,1,EA,51.00000,14.79000,Aetna,First Health,,41.72,,,,,,,18.39,41.72,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00085056605,NDC,facility,inpatient,30,ME,230.30000,66.79000,Aetna,First Health,,188.39,,,,,,,83.02,188.39,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00085056605,NDC,facility,outpatient,30,ME,230.30000,66.79000,Aetna,First Health,,188.39,,,,,,,6.65,188.39,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,00085036207,NDC,facility,inpatient,100,ME,232.60000,67.45000,Aetna,First Health,,190.27,,,,,,,86.06,190.27,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),800052711,CDM,250,RC,J1920,HCPCS,00085036207,NDC,facility,outpatient,100,ME,232.60000,67.45000,Aetna,First Health,,190.27,,,,,,,0.33705,190.27,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00083000730,NDC,,,facility,inpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,3.12,4.25,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00083000730,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00083000330,NDC,,,facility,inpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00083000330,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.05,2.37,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,00081095396,NDC,,,facility,inpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,5.85,7.98,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,00081095396,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,First Health,,7.98,,,,,,,3.51,7.98,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,00081079887,NDC,,,facility,inpatient,1,EA,47.20000,13.69000,Aetna,First Health,,38.61,,,,,,,17.46,38.61,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,00081079887,NDC,,,facility,outpatient,1,EA,47.20000,13.69000,Aetna,First Health,,38.61,,,,,,,17.02,38.61,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00081054047,NDC,,,facility,inpatient,1,EA,690.65000,200.29000,Aetna,First Health,,564.95,,,,,,,255.54,564.95,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00081054047,NDC,,,facility,outpatient,1,EA,690.65000,200.29000,Aetna,First Health,,564.95,,,,,,,248.98,564.95,percent of total billed charges,
Inclisiran 284mg/1.5 mL IS (Leqvio),800046537,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,inpatient,284,ME,13629.65000,3952.60000,Aetna,First Health,,11149.05,,,,,,,4913.49,11149.05,percent of total billed charges,
Inclisiran 284mg/1.5 mL IS (Leqvio),800046537,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,outpatient,284,ME,13629.65000,3952.60000,Aetna,First Health,,11149.05,,,,,,,12.22,11149.05,percent of total billed charges,
Octreotide 20mg I Kit (SandoSTATIN LAR),800081045,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,inpatient,20,ME,18581.35000,5388.59000,Aetna,First Health,,15199.54,,,,,,,6698.58,15199.54,percent of total billed charges,
Octreotide 20mg I Kit (SandoSTATIN LAR),800081045,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,outpatient,20,ME,18581.35000,5388.59000,Aetna,First Health,,15199.54,,,,,,,191.80,15199.54,percent of total billed charges,
Tobramycin 0.3% 3.5g Ophth Oint(Tobrex),800041185,CDM,637,RC,00078081301,NDC,,,facility,inpatient,1,EA,1991.90000,577.65000,Aetna,First Health,,1629.37,,,,,,,1195.14,1629.37,percent of total billed charges,
Tobramycin 0.3% 3.5g Ophth Oint(Tobrex),800041185,CDM,637,RC,00078081301,NDC,,,facility,outpatient,1,EA,1991.90000,577.65000,Aetna,First Health,,1629.37,,,,,,,718.08,1629.37,percent of total billed charges,
Sacubitril-Valsartan 49-51mg Tab,800025659,CDM,637,RC,00078077735,NDC,,,facility,inpatient,1,EA,59.65000,17.30000,Aetna,First Health,,48.79,,,,,,,35.79,48.79,percent of total billed charges,
Sacubitril-Valsartan 49-51mg Tab,800025659,CDM,637,RC,00078077735,NDC,,,facility,outpatient,1,EA,59.65000,17.30000,Aetna,First Health,,48.79,,,,,,,21.50,48.79,percent of total billed charges,
Sacubitril-Valsartan 49-51mg Tab,800025659,CDM,637,RC,00078077720,NDC,,,facility,inpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,59.91,81.68,percent of total billed charges,
Sacubitril-Valsartan 49-51mg Tab,800025659,CDM,637,RC,00078077720,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,36.00,81.68,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,800025660,CDM,637,RC,00078069667,NDC,,,facility,inpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,59.91,81.68,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,800025660,CDM,637,RC,00078069667,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,36.00,81.68,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,800025660,CDM,637,RC,00078069635,NDC,,,facility,inpatient,1,EA,59.65000,17.30000,Aetna,First Health,,48.79,,,,,,,35.79,48.79,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,800025660,CDM,637,RC,00078069635,NDC,,,facility,outpatient,1,EA,59.65000,17.30000,Aetna,First Health,,48.79,,,,,,,21.50,48.79,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,800025660,CDM,637,RC,00078069620,NDC,,,facility,inpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,59.91,81.68,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,800025660,CDM,637,RC,00078069620,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,36.00,81.68,percent of total billed charges,
Sacubitril-Valsartan 24-26mg Tab,800025658,CDM,637,RC,00078065935,NDC,,,facility,inpatient,1,EA,59.65000,17.30000,Aetna,First Health,,48.79,,,,,,,35.79,48.79,percent of total billed charges,
Sacubitril-Valsartan 24-26mg Tab,800025658,CDM,637,RC,00078065935,NDC,,,facility,outpatient,1,EA,59.65000,17.30000,Aetna,First Health,,48.79,,,,,,,21.50,48.79,percent of total billed charges,
Sacubitril-Valsartan 24-26mg Tab,800025658,CDM,637,RC,00078065920,NDC,,,facility,inpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,59.91,81.68,percent of total billed charges,
Sacubitril-Valsartan 24-26mg Tab,800025658,CDM,637,RC,00078065920,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,36.00,81.68,percent of total billed charges,
artemether-lumefantrine 20mg-120mg Tab,800046516,CDM,637,RC,00078056845,NDC,,,facility,inpatient,1,EA,47.70000,13.83000,Aetna,First Health,,39.02,,,,,,,28.62,39.02,percent of total billed charges,
artemether-lumefantrine 20mg-120mg Tab,800046516,CDM,637,RC,00078056845,NDC,,,facility,outpatient,1,EA,47.70000,13.83000,Aetna,First Health,,39.02,,,,,,,17.20,39.02,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,00078050261,NDC,,,facility,inpatient,1,EA,195.50000,56.69000,Aetna,First Health,,159.92,,,,,,,117.30,159.92,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,00078050261,NDC,,,facility,outpatient,1,EA,195.50000,56.69000,Aetna,First Health,,159.92,,,,,,,70.48,159.92,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,00078050215,NDC,,,facility,inpatient,1,EA,195.55000,56.71000,Aetna,First Health,,159.96,,,,,,,117.33,159.96,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,00078050215,NDC,,,facility,outpatient,1,EA,195.55000,56.71000,Aetna,First Health,,159.96,,,,,,,70.50,159.96,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,00078050161,NDC,,,facility,inpatient,1,EA,195.50000,56.69000,Aetna,First Health,,159.92,,,,,,,117.30,159.92,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,00078050161,NDC,,,facility,outpatient,1,EA,195.50000,56.69000,Aetna,First Health,,159.92,,,,,,,70.48,159.92,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,00078050115,NDC,,,facility,inpatient,1,EA,195.55000,56.71000,Aetna,First Health,,159.96,,,,,,,117.33,159.96,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,00078050115,NDC,,,facility,outpatient,1,EA,195.55000,56.71000,Aetna,First Health,,159.96,,,,,,,70.50,159.96,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,00078048535,NDC,,,facility,inpatient,1,EA,29.40000,8.53000,Aetna,First Health,,24.05,,,,,,,17.64,24.05,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,00078048535,NDC,,,facility,outpatient,1,EA,29.40000,8.53000,Aetna,First Health,,24.05,,,,,,,10.60,24.05,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,00078048515,NDC,,,facility,inpatient,1,EA,38.65000,11.21000,Aetna,First Health,,31.62,,,,,,,23.19,31.62,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,00078048515,NDC,,,facility,outpatient,1,EA,38.65000,11.21000,Aetna,First Health,,31.62,,,,,,,13.93,31.62,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00078045605,NDC,,,facility,inpatient,1,EA,49.45000,14.34000,Aetna,First Health,,40.45,,,,,,,29.67,40.45,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00078045605,NDC,,,facility,outpatient,1,EA,49.45000,14.34000,Aetna,First Health,,40.45,,,,,,,17.83,40.45,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,00078043561,NDC,facility,inpatient,5,ME,8640.90000,2505.86000,Aetna,First Health,,7068.26,,,,,,,3115.04,7068.26,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,00078043561,NDC,facility,outpatient,5,ME,8640.90000,2505.86000,Aetna,First Health,,7068.26,,,,,,,4.89,7068.26,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,00078040134,NDC,,,facility,inpatient,1,EA,717.00000,207.93000,Aetna,First Health,,586.51,,,,,,,430.20,586.51,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,00078040134,NDC,,,facility,outpatient,1,EA,717.00000,207.93000,Aetna,First Health,,586.51,,,,,,,258.48,586.51,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,00078040105,NDC,,,facility,inpatient,1,EA,240.35000,69.70000,Aetna,First Health,,196.61,,,,,,,144.21,196.61,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,00078040105,NDC,,,facility,outpatient,1,EA,240.35000,69.70000,Aetna,First Health,,196.61,,,,,,,86.65,196.61,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00078040001,NDC,,,facility,inpatient,1,EA,112.60000,32.65000,Aetna,First Health,,92.11,,,,,,,41.66,92.11,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00078040001,NDC,,,facility,outpatient,1,EA,112.60000,32.65000,Aetna,First Health,,92.11,,,,,,,40.59,92.11,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,00078038725,NDC,facility,inpatient,4,ME,6828.90000,1980.38000,Aetna,First Health,,5586.04,,,,,,,2461.82,5586.04,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,00078038725,NDC,facility,outpatient,4,ME,6828.90000,1980.38000,Aetna,First Health,,5586.04,,,,,,,4.89,5586.04,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,00078038566,NDC,facility,inpatient,180,ME,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,38.01,51.82,percent of total billed charges,
Mycophenolic Acid 180 mg EC T (Myfortic),800017647,CDM,637,RC,J7518,HCPCS,00078038566,NDC,facility,outpatient,180,ME,63.35000,18.37000,Aetna,First Health,,51.82,,,,,,,0.30816,51.82,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00078036815,NDC,,,facility,inpatient,1,EA,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,108.60,148.06,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00078036815,NDC,,,facility,outpatient,1,EA,181.00000,52.49000,Aetna,First Health,,148.06,,,,,,,65.25,148.06,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,00078036715,NDC,,,facility,inpatient,1,EA,91.45000,26.52000,Aetna,First Health,,74.81,,,,,,,54.87,74.81,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,00078036715,NDC,,,facility,outpatient,1,EA,91.45000,26.52000,Aetna,First Health,,74.81,,,,,,,32.97,74.81,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00078035934,NDC,,,facility,inpatient,1,EA,86.55000,25.10000,Aetna,First Health,,70.80,,,,,,,51.93,70.80,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00078035934,NDC,,,facility,outpatient,1,EA,86.55000,25.10000,Aetna,First Health,,70.80,,,,,,,31.20,70.80,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00078035906,NDC,,,facility,inpatient,1,EA,25.70000,7.45000,Aetna,First Health,,21.02,,,,,,,15.42,21.02,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00078035906,NDC,,,facility,outpatient,1,EA,25.70000,7.45000,Aetna,First Health,,21.02,,,,,,,9.26,21.02,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00078035905,NDC,,,facility,inpatient,1,EA,13.35000,3.87000,Aetna,First Health,,10.92,,,,,,,8.01,10.92,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00078035905,NDC,,,facility,outpatient,1,EA,13.35000,3.87000,Aetna,First Health,,10.92,,,,,,,4.81,10.92,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00078035834,NDC,,,facility,inpatient,1,EA,80.50000,23.34000,Aetna,First Health,,65.85,,,,,,,48.30,65.85,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00078035834,NDC,,,facility,outpatient,1,EA,80.50000,23.34000,Aetna,First Health,,65.85,,,,,,,29.02,65.85,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00078035805,NDC,,,facility,inpatient,1,EA,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,7.44,10.14,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00078035805,NDC,,,facility,outpatient,1,EA,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,4.47,10.14,percent of total billed charges,
Octreotide 20mg I Kit (SandoSTATIN LAR),800081045,CDM,636,RC,J2353,HCPCS,00078034161,NDC,facility,inpatient,20,ME,17520.55000,5080.96000,Aetna,First Health,,14331.81,,,,,,,6316.16,14331.81,percent of total billed charges,
Octreotide 20mg I Kit (SandoSTATIN LAR),800081045,CDM,636,RC,J2353,HCPCS,00078034161,NDC,facility,outpatient,20,ME,17520.55000,5080.96000,Aetna,First Health,,14331.81,,,,,,,191.80,14331.81,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,00078033705,NDC,,,facility,inpatient,1,EA,90.35000,26.20000,Aetna,First Health,,73.91,,,,,,,54.21,73.91,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,00078033705,NDC,,,facility,outpatient,1,EA,90.35000,26.20000,Aetna,First Health,,73.91,,,,,,,32.57,73.91,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00078033605,NDC,,,facility,inpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,6.09,8.30,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00078033605,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,First Health,,8.30,,,,,,,3.66,8.30,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,00078032705,NDC,,,facility,inpatient,1,EA,65.50000,18.99000,Aetna,First Health,,53.58,,,,,,,39.30,53.58,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,00078032705,NDC,,,facility,outpatient,1,EA,65.50000,18.99000,Aetna,First Health,,53.58,,,,,,,23.61,53.58,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00078032344,NDC,,,facility,inpatient,1,EA,44.20000,12.82000,Aetna,First Health,,36.16,,,,,,,26.52,36.16,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00078032344,NDC,,,facility,outpatient,1,EA,44.20000,12.82000,Aetna,First Health,,36.16,,,,,,,15.93,36.16,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00078032315,NDC,,,facility,inpatient,1,EA,24.15000,7.00000,Aetna,First Health,,19.75,,,,,,,14.49,19.75,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00078032315,NDC,,,facility,outpatient,1,EA,24.15000,7.00000,Aetna,First Health,,19.75,,,,,,,8.71,19.75,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00078032306,NDC,,,facility,inpatient,1,EA,36.60000,10.61000,Aetna,First Health,,29.94,,,,,,,21.96,29.94,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00078032306,NDC,,,facility,outpatient,1,EA,36.60000,10.61000,Aetna,First Health,,29.94,,,,,,,13.19,29.94,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00078031905,NDC,,,facility,inpatient,1,EA,27.50000,7.98000,Aetna,First Health,,22.50,,,,,,,16.50,22.50,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00078031905,NDC,,,facility,outpatient,1,EA,27.50000,7.98000,Aetna,First Health,,22.50,,,,,,,9.91,22.50,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00078031190,NDC,,,facility,inpatient,1,EA,1038.05000,301.03000,Aetna,First Health,,849.12,,,,,,,622.83,849.12,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00078031190,NDC,,,facility,outpatient,1,EA,1038.05000,301.03000,Aetna,First Health,,849.12,,,,,,,374.22,849.12,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00078031154,NDC,,,facility,inpatient,1,EA,1950.15000,565.54000,Aetna,First Health,,1595.22,,,,,,,1170.09,1595.22,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00078031154,NDC,,,facility,outpatient,1,EA,1950.15000,565.54000,Aetna,First Health,,1595.22,,,,,,,703.03,1595.22,percent of total billed charges,
cycloSPORINE Microemul 100mg/1mL L,800081097,CDM,637,RC,J7502,HCPCS,00078027422,NDC,facility,inpatient,100,ME,108.90000,31.58000,Aetna,First Health,,89.08,,,,,,,65.34,89.08,percent of total billed charges,
cycloSPORINE Microemul 100mg/1mL L,800081097,CDM,637,RC,J7502,HCPCS,00078027422,NDC,facility,outpatient,100,ME,108.90000,31.58000,Aetna,First Health,,89.08,,,,,,,1.74,89.08,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,00078024915,NDC,,,facility,inpatient,1,EA,229.40000,66.53000,Aetna,First Health,,187.65,,,,,,,137.64,187.65,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,00078024915,NDC,,,facility,outpatient,1,EA,229.40000,66.53000,Aetna,First Health,,187.65,,,,,,,82.70,187.65,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00078024815,NDC,facility,inpatient,100,ME,99.90000,28.97000,Aetna,First Health,,81.72,,,,,,,59.94,81.72,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00078024815,NDC,facility,outpatient,100,ME,99.90000,28.97000,Aetna,First Health,,81.72,,,,,,,1.74,81.72,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,800080621,CDM,637,RC,J7515,HCPCS,00078024615,NDC,facility,inpatient,25,ME,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,800080621,CDM,637,RC,J7515,HCPCS,00078024615,NDC,facility,outpatient,25,ME,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,0.51039,20.45,percent of total billed charges,
cycloSPORINE 100mg C(SandIMMUNE),800017381,CDM,637,RC,J7502,HCPCS,00078024115,NDC,facility,inpatient,100,ME,152.10000,44.11000,Aetna,First Health,,124.42,,,,,,,91.26,124.42,percent of total billed charges,
cycloSPORINE 100mg C(SandIMMUNE),800017381,CDM,637,RC,J7502,HCPCS,00078024115,NDC,facility,outpatient,100,ME,152.10000,44.11000,Aetna,First Health,,124.42,,,,,,,1.74,124.42,percent of total billed charges,
cycloSPORINE 25mg C(SandIMMUNE),800017380,CDM,637,RC,J7515,HCPCS,00078024015,NDC,facility,inpatient,25,ME,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,22.86,31.17,percent of total billed charges,
cycloSPORINE 25mg C(SandIMMUNE),800017380,CDM,637,RC,J7515,HCPCS,00078024015,NDC,facility,outpatient,25,ME,38.10000,11.05000,Aetna,First Health,,31.17,,,,,,,0.51039,31.17,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,00078018201,NDC,facility,inpatient,0.5,ME,695.40000,201.67000,Aetna,First Health,,568.84,,,,,,,417.24,568.84,percent of total billed charges,
Octreotide Acet 500 mcg/mL I,800012523,CDM,637,RC,J2354,HCPCS,00078018201,NDC,facility,outpatient,0.5,ME,695.40000,201.67000,Aetna,First Health,,568.84,,,,,,,0.63558,568.84,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,00078018103,NDC,facility,inpatient,0.1,ME,128.10000,37.15000,Aetna,First Health,,104.79,,,,,,,76.86,104.79,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,00078018103,NDC,facility,outpatient,0.1,ME,128.10000,37.15000,Aetna,First Health,,104.79,,,,,,,0.63558,104.79,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,00078018101,NDC,facility,inpatient,0.1,ME,172.40000,50.00000,Aetna,First Health,,141.02,,,,,,,103.44,141.02,percent of total billed charges,
Octreotide Acet 100mcg/mL I(SandoSTATIN),800012498,CDM,637,RC,J2354,HCPCS,00078018101,NDC,facility,outpatient,0.1,ME,172.40000,50.00000,Aetna,First Health,,141.02,,,,,,,0.63558,141.02,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,00078018003,NDC,facility,inpatient,0.05,ME,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,39.60,53.99,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,00078018003,NDC,facility,outpatient,0.05,ME,66.00000,19.14000,Aetna,First Health,,53.99,,,,,,,0.63558,53.99,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,00078018001,NDC,facility,inpatient,0.05,ME,90.10000,26.13000,Aetna,First Health,,73.70,,,,,,,54.06,73.70,percent of total billed charges,
Octreotide Acet 50mcg/mL I(SandoSTATIN),800012487,CDM,637,RC,J2354,HCPCS,00078018001,NDC,facility,outpatient,0.05,ME,90.10000,26.13000,Aetna,First Health,,73.70,,,,,,,0.63558,73.70,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,00078017915,NDC,,,facility,inpatient,1,EA,210.10000,60.93000,Aetna,First Health,,171.86,,,,,,,126.06,171.86,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,00078017915,NDC,,,facility,outpatient,1,EA,210.10000,60.93000,Aetna,First Health,,171.86,,,,,,,75.74,171.86,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,00078014923,NDC,facility,inpatient,400,UN,7388.65000,2142.71000,Aetna,First Health,,6043.92,,,,,,,4433.19,6043.92,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,00078014923,NDC,facility,outpatient,400,UN,7388.65000,2142.71000,Aetna,First Health,,6043.92,,,,,,,2663.61,6043.92,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00078014006,NDC,,,facility,inpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,4.41,6.01,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00078014006,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,First Health,,6.01,,,,,,,2.65,6.01,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00078014005,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00078014005,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00078012706,NDC,,,facility,inpatient,1,EA,23.70000,6.87000,Aetna,First Health,,19.39,,,,,,,14.22,19.39,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00078012706,NDC,,,facility,outpatient,1,EA,23.70000,6.87000,Aetna,First Health,,19.39,,,,,,,8.54,19.39,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00078012606,NDC,,,facility,inpatient,1,EA,39.05000,11.32000,Aetna,First Health,,31.94,,,,,,,23.43,31.94,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00078012606,NDC,,,facility,outpatient,1,EA,39.05000,11.32000,Aetna,First Health,,31.94,,,,,,,14.08,31.94,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,00078009813,NDC,,,facility,inpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,2.64,3.60,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,00078009813,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00078008706,NDC,,,facility,inpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,5.46,7.44,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00078008706,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,First Health,,7.44,,,,,,,3.28,7.44,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00078008606,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00078008606,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00078008405,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00078008405,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,00078005406,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,00078005406,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,00078005405,NDC,,,facility,inpatient,1,EA,12.10000,3.51000,Aetna,First Health,,9.90,,,,,,,7.26,9.90,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,00078005405,NDC,,,facility,outpatient,1,EA,12.10000,3.51000,Aetna,First Health,,9.90,,,,,,,4.36,9.90,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,00078005303,NDC,facility,inpatient,0.2,ME,50.25000,14.57000,Aetna,First Health,,41.10,,,,,,,18.12,41.10,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,00078005303,NDC,facility,outpatient,0.2,ME,50.25000,14.57000,Aetna,First Health,,41.10,,,,,,,18.59,65.87,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00075800404,NDC,facility,inpatient,80,ME,16763.85000,4861.52000,Aetna,First Health,,13712.83,,,,,,,6043.37,13712.83,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00075800404,NDC,facility,outpatient,80,ME,16763.85000,4861.52000,Aetna,First Health,,13712.83,,,,,,,0.62595,13712.83,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00075800301,NDC,facility,inpatient,20,ME,3954.55000,1146.82000,Aetna,First Health,,3234.82,,,,,,,1425.62,3234.82,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00075800301,NDC,facility,outpatient,20,ME,3954.55000,1146.82000,Aetna,First Health,,3234.82,,,,,,,0.62595,3234.82,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00075800180,NDC,facility,inpatient,80,ME,21753.15000,6308.41000,Aetna,First Health,,17794.08,,,,,,,7842.01,17794.08,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00075800180,NDC,facility,outpatient,80,ME,21753.15000,6308.41000,Aetna,First Health,,17794.08,,,,,,,0.62595,17794.08,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00075800120,NDC,facility,inpatient,20,ME,2855.55000,828.11000,Aetna,First Health,,2335.84,,,,,,,1029.43,2335.84,percent of total billed charges,
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00075800120,NDC,facility,outpatient,20,ME,2855.55000,828.11000,Aetna,First Health,,2335.84,,,,,,,0.62595,2335.84,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,00075770060,NDC,,,facility,inpatient,1,EA,122.50000,35.52000,Aetna,First Health,,100.20,,,,,,,73.50,100.20,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,00075770060,NDC,,,facility,outpatient,1,EA,122.50000,35.52000,Aetna,First Health,,100.20,,,,,,,44.16,100.20,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00075291501,NDC,facility,inpatient,150,ME,659.45000,191.24000,Aetna,First Health,,539.43,,,,,,,237.73,539.43,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00075291501,NDC,facility,outpatient,150,ME,659.45000,191.24000,Aetna,First Health,,539.43,,,,,,,0.51039,539.43,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00075291201,NDC,facility,inpatient,120,ME,545.55000,158.21000,Aetna,First Health,,446.26,,,,,,,196.67,446.26,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00075291201,NDC,facility,outpatient,120,ME,545.55000,158.21000,Aetna,First Health,,446.26,,,,,,,0.51039,446.26,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,00075245201,NDC,,,facility,inpatient,1,EA,2441.60000,708.06000,Aetna,First Health,,1997.23,,,,,,,1464.96,1997.23,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,00075245201,NDC,,,facility,outpatient,1,EA,2441.60000,708.06000,Aetna,First Health,,1997.23,,,,,,,880.20,1997.23,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,00075245153,NDC,facility,inpatient,0.04,ME,4584.35000,1329.46000,Aetna,First Health,,3750.00,,,,,,,1652.66,3750.00,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,00075245153,NDC,facility,outpatient,0.04,ME,4584.35000,1329.46000,Aetna,First Health,,3750.00,,,,,,,3.28,3750.00,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00075245101,NDC,facility,inpatient,0.004,ME,353.70000,102.57000,Aetna,First Health,,289.33,,,,,,,127.51,289.33,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00075245101,NDC,facility,outpatient,0.004,ME,353.70000,102.57000,Aetna,First Health,,289.33,,,,,,,3.28,289.33,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,00075130601,NDC,facility,inpatient,400,UN,180.50000,52.34000,Aetna,First Health,,147.65,,,,,,,108.30,147.65,percent of total billed charges,
Calcitonin 400 IU/2mL Inj,800010595,CDM,637,RC,J0630,HCPCS,00075130601,NDC,facility,outpatient,400,UN,180.50000,52.34000,Aetna,First Health,,147.65,,,,,,,65.07,147.65,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,00075085084,NDC,,,facility,inpatient,1,EA,986.55000,286.10000,Aetna,First Health,,807.00,,,,,,,591.93,807.00,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,00075085084,NDC,,,facility,outpatient,1,EA,986.55000,286.10000,Aetna,First Health,,807.00,,,,,,,355.65,807.00,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,inpatient,30,ME,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,56.78,128.84,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,outpatient,30,ME,157.50000,45.68000,Aetna,First Health,,128.84,,,,,,,0.51039,128.84,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,inpatient,100,ME,470.15000,136.34000,Aetna,First Health,,384.58,,,,,,,169.49,384.58,percent of total billed charges,
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,outpatient,100,ME,470.15000,136.34000,Aetna,First Health,,384.58,,,,,,,0.51039,384.58,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,inpatient,80,ME,384.35000,111.46000,Aetna,First Health,,314.40,,,,,,,138.56,314.40,percent of total billed charges,
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,outpatient,80,ME,384.35000,111.46000,Aetna,First Health,,314.40,,,,,,,0.51039,314.40,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,inpatient,60,ME,298.50000,86.56000,Aetna,First Health,,244.17,,,,,,,107.61,244.17,percent of total billed charges,
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,outpatient,60,ME,298.50000,86.56000,Aetna,First Health,,244.17,,,,,,,0.51039,244.17,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,inpatient,40,ME,205.30000,59.54000,Aetna,First Health,,167.94,,,,,,,74.01,167.94,percent of total billed charges,
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,outpatient,40,ME,205.30000,59.54000,Aetna,First Health,,167.94,,,,,,,0.51039,167.94,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00075025162,NDC,,,facility,inpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,6.54,8.92,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00075025162,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,First Health,,8.92,,,,,,,3.93,8.92,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00074929690,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00074929690,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00074915801,NDC,facility,inpatient,10,ME,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,10.91,24.74,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00074915801,NDC,facility,outpatient,10,ME,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,2.71,24.74,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00074909332,NDC,facility,inpatient,0.1,ME,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.87,4.25,percent of total billed charges,
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00074909332,NDC,facility,outpatient,0.1,ME,5.20000,1.51000,Aetna,First Health,,4.25,,,,,,,1.15,4.25,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00074806201,NDC,,,facility,inpatient,1,EA,123.05000,35.68000,Aetna,First Health,,100.65,,,,,,,45.53,100.65,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00074806201,NDC,,,facility,outpatient,1,EA,123.05000,35.68000,Aetna,First Health,,100.65,,,,,,,44.36,100.65,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00074799009,NDC,facility,inpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,9.02,15.71,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00074799009,NDC,facility,outpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,3.80,15.71,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00074798509,NDC,,,facility,inpatient,1,EA,13.20000,3.83000,Aetna,First Health,,10.80,,,,,,,6.20,10.80,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00074798509,NDC,,,facility,outpatient,1,EA,13.20000,3.83000,Aetna,First Health,,10.80,,,,,,,4.76,10.80,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,00074798503,NDC,,,facility,inpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.89,5.03,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,00074798503,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,First Health,,5.03,,,,,,,2.22,5.03,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00074798423,NDC,facility,inpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,6.09,13.82,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00074798423,NDC,facility,outpatient,1,EA,16.90000,4.90000,Aetna,First Health,,13.82,,,,,,,0.63558,13.82,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00074798413,NDC,facility,inpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,5.10,11.57,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00074798413,NDC,facility,outpatient,1,EA,14.15000,4.10000,Aetna,First Health,,11.57,,,,,,,0.63558,11.57,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00074798309,NDC,facility,inpatient,1,EA,13.00000,3.77000,Aetna,First Health,,10.63,,,,,,,4.69,10.63,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00074798309,NDC,facility,outpatient,1,EA,13.00000,3.77000,Aetna,First Health,,10.63,,,,,,,1.92,10.63,percent of total billed charges,
NS 500mL,800012693,CDM,258,RC,J7040,HCPCS,00074798303,NDC,facility,inpatient,1,EA,2270.00000,658.30000,Aetna,First Health,,1856.86,,,,,,,1066.90,1856.86,percent of total billed charges,
NS 500mL,800012693,CDM,258,RC,J7040,HCPCS,00074798303,NDC,facility,outpatient,1,EA,2270.00000,658.30000,Aetna,First Health,,1856.86,,,,,,,1.24,1856.86,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00074798302,NDC,facility,inpatient,1,EA,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,436.20,989.78,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00074798302,NDC,facility,outpatient,1,EA,1210.00000,350.90000,Aetna,First Health,,989.78,,,,,,,0.63558,989.78,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00074796709,NDC,,,facility,inpatient,1,EA,33.85000,9.82000,Aetna,First Health,,27.69,,,,,,,15.91,27.69,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00074796709,NDC,,,facility,outpatient,1,EA,33.85000,9.82000,Aetna,First Health,,27.69,,,,,,,12.20,27.69,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,00074795309,NDC,facility,inpatient,1,EA,13.25000,3.84000,Aetna,First Health,,10.84,,,,,,,6.23,10.84,percent of total billed charges,
LR 1000mL,800049587,CDM,258,RC,J7120,HCPCS,00074795309,NDC,facility,outpatient,1,EA,13.25000,3.84000,Aetna,First Health,,10.84,,,,,,,2.29,10.84,percent of total billed charges,
LR 500 mL,800012635,CDM,258,RC,J7120,HCPCS,00074795303,NDC,facility,inpatient,1,EA,15.30000,4.44000,Aetna,First Health,,12.52,,,,,,,7.19,12.52,percent of total billed charges,
LR 500 mL,800012635,CDM,258,RC,J7120,HCPCS,00074795303,NDC,facility,outpatient,1,EA,15.30000,4.44000,Aetna,First Health,,12.52,,,,,,,2.29,12.52,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,00074794109,NDC,facility,inpatient,1,EA,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,6.96,12.11,percent of total billed charges,
D5.9NS 1000mL,800020051,CDM,258,RC,J7042,HCPCS,00074794109,NDC,facility,outpatient,1,EA,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,1.26,12.11,percent of total billed charges,
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00074793932,NDC,facility,inpatient,2,GM,61.95000,17.97000,Aetna,First Health,,50.68,,,,,,,22.33,50.68,percent of total billed charges,
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00074793932,NDC,facility,outpatient,2,GM,61.95000,17.97000,Aetna,First Health,,50.68,,,,,,,22.92,50.68,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00074793009,NDC,,,facility,inpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,7.75,13.50,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00074793009,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,13.50,percent of total billed charges,
D5LR 1000 mL,800012214,CDM,258,RC,J7121,HCPCS,00074792909,NDC,facility,inpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,7.75,13.50,percent of total billed charges,
D5LR 1000 mL,800012214,CDM,258,RC,J7121,HCPCS,00074792909,NDC,facility,outpatient,1,EA,16.50000,4.78000,Aetna,First Health,,13.50,,,,,,,5.95,28.62,percent of total billed charges,
D5.45NS 1000mL,800012347,CDM,258,RC,J7030,HCPCS,00074792609,NDC,facility,inpatient,1,EA,16.40000,4.76000,Aetna,First Health,,13.42,,,,,,,7.71,13.42,percent of total billed charges,
D5.45NS 1000mL,800012347,CDM,258,RC,J7030,HCPCS,00074792609,NDC,facility,outpatient,1,EA,16.40000,4.76000,Aetna,First Health,,13.42,,,,,,,1.92,13.42,percent of total billed charges,
D5.45NS 500mL,800011306,CDM,258,RC,J7030,HCPCS,00074792603,NDC,facility,inpatient,1,EA,13.00000,3.77000,Aetna,First Health,,10.63,,,,,,,6.11,10.63,percent of total billed charges,
D5.45NS 500mL,800011306,CDM,258,RC,J7030,HCPCS,00074792603,NDC,facility,outpatient,1,EA,13.00000,3.77000,Aetna,First Health,,10.63,,,,,,,1.92,10.63,percent of total billed charges,
Dextose 5% in Water 50mL,800013014,CDM,258,RC,J7060,HCPCS,00074792313,NDC,facility,inpatient,1,EA,412.50000,119.62000,Aetna,First Health,,337.43,,,,,,,193.88,337.43,percent of total billed charges,
Dextose 5% in Water 50mL,800013014,CDM,258,RC,J7060,HCPCS,00074792313,NDC,facility,outpatient,1,EA,412.50000,119.62000,Aetna,First Health,,337.43,,,,,,,1.69,337.43,percent of total billed charges,
Dextrose 5% in Water 1L,800012172,CDM,258,RC,J7070,HCPCS,00074792209,NDC,facility,inpatient,1,EA,19.70000,5.71000,Aetna,First Health,,16.11,,,,,,,9.26,16.11,percent of total billed charges,
Dextrose 5% in Water 1L,800012172,CDM,258,RC,J7070,HCPCS,00074792209,NDC,facility,outpatient,1,EA,19.70000,5.71000,Aetna,First Health,,16.11,,,,,,,2.83,16.11,percent of total billed charges,
D5W  250mL,800012123,CDM,258,RC,J7060,HCPCS,00074792202,NDC,facility,inpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,6.70,11.66,percent of total billed charges,
D5W  250mL,800012123,CDM,258,RC,J7060,HCPCS,00074792202,NDC,facility,outpatient,1,EA,14.25000,4.13000,Aetna,First Health,,11.66,,,,,,,1.69,11.66,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00074790209,NDC,,,facility,inpatient,1,EA,18.35000,5.32000,Aetna,First Health,,15.01,,,,,,,8.62,15.01,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00074790209,NDC,,,facility,outpatient,1,EA,18.35000,5.32000,Aetna,First Health,,15.01,,,,,,,6.62,15.01,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,800064963,CDM,636,RC,J1580,HCPCS,00074788423,NDC,facility,inpatient,80,ME,1452.00000,421.08000,Aetna,First Health,,1187.74,,,,,,,523.45,1187.74,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,800064963,CDM,636,RC,J1580,HCPCS,00074788423,NDC,facility,outpatient,80,ME,1452.00000,421.08000,Aetna,First Health,,1187.74,,,,,,,2.09,1187.74,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00074781137,NDC,facility,inpatient,500,ME,23047.50000,6683.78000,Aetna,First Health,,18852.85,,,,,,,8308.62,18852.85,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00074781137,NDC,facility,outpatient,500,ME,23047.50000,6683.78000,Aetna,First Health,,18852.85,,,,,,,0.02889,18852.85,percent of total billed charges,
DOPamine 400mg/D5W 250mL,800012469,CDM,636,RC,J1265,HCPCS,00074780922,NDC,facility,inpatient,400,ME,159.80000,46.34000,Aetna,First Health,,130.72,,,,,,,57.61,130.72,percent of total billed charges,
DOPamine 400mg/D5W 250mL,800012469,CDM,636,RC,J1265,HCPCS,00074780922,NDC,facility,outpatient,400,ME,159.80000,46.34000,Aetna,First Health,,130.72,,,,,,,0.77040,130.72,percent of total billed charges,
Mannitol 20% 500mL,800022060,CDM,250,RC,00074771503,NDC,,,facility,inpatient,1,EA,170.75000,49.52000,Aetna,First Health,,139.67,,,,,,,63.18,139.67,percent of total billed charges,
Mannitol 20% 500mL,800022060,CDM,250,RC,00074771503,NDC,,,facility,outpatient,1,EA,170.75000,49.52000,Aetna,First Health,,139.67,,,,,,,61.56,139.67,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00074762003,NDC,facility,inpatient,1000,UN,7372.50000,2138.02000,Aetna,First Health,,6030.70,,,,,,,2657.79,6030.70,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00074762003,NDC,facility,outpatient,1000,UN,7372.50000,2138.02000,Aetna,First Health,,6030.70,,,,,,,0.17334,6030.70,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00074729501,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.07,4.58,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00074729501,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00074724101,NDC,facility,inpatient,1,ME,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00074724101,NDC,facility,outpatient,1,ME,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,0.41409,2.78,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00074712613,NDC,,,facility,inpatient,1,EA,52.25000,15.15000,Aetna,First Health,,42.74,,,,,,,31.35,42.74,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00074712613,NDC,,,facility,outpatient,1,EA,52.25000,15.15000,Aetna,First Health,,42.74,,,,,,,18.84,42.74,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00074711509,NDC,,,facility,inpatient,1,EA,73.20000,21.23000,Aetna,First Health,,59.88,,,,,,,34.40,59.88,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00074711509,NDC,,,facility,outpatient,1,EA,73.20000,21.23000,Aetna,First Health,,59.88,,,,,,,26.39,59.88,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00074710709,NDC,,,facility,inpatient,1,EA,35.35000,10.25000,Aetna,First Health,,28.92,,,,,,,16.61,28.92,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00074710709,NDC,,,facility,outpatient,1,EA,35.35000,10.25000,Aetna,First Health,,28.92,,,,,,,12.74,28.92,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00074707526,NDC,facility,inpatient,1,EA,1403.00000,406.87000,Aetna,First Health,,1147.65,,,,,,,505.78,1147.65,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00074707526,NDC,facility,outpatient,1,EA,1403.00000,406.87000,Aetna,First Health,,1147.65,,,,,,,0.11556,1147.65,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00074707426,NDC,facility,inpatient,1,EA,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,8.06,18.28,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00074707426,NDC,facility,outpatient,1,EA,22.35000,6.48000,Aetna,First Health,,18.28,,,,,,,0.11556,18.28,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00074707090,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00074707090,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00074706890,NDC,,,facility,inpatient,1,EA,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,8.46,11.53,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00074706890,NDC,,,facility,outpatient,1,EA,14.10000,4.09000,Aetna,First Health,,11.53,,,,,,,5.08,11.53,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00074706813,NDC,,,facility,inpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,3.03,4.13,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00074706813,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,1.82,4.13,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00074697801,NDC,,,facility,inpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.24000,0.32720,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00074697801,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.14420,0.32720,percent of total billed charges,
Potassium Cl 2mEq/mL I,800013427,CDM,636,RC,J3480,HCPCS,00074665305,NDC,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Potassium Cl 2mEq/mL I,800013427,CDM,636,RC,J3480,HCPCS,00074665305,NDC,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,0.11556,3.11,percent of total billed charges,
D50W 50mL,800067479,CDM,258,RC,00074664802,NDC,,,facility,inpatient,1,EA,650.50000,188.64000,Aetna,First Health,,532.11,,,,,,,305.74,532.11,percent of total billed charges,
D50W 50mL,800067479,CDM,258,RC,00074664802,NDC,,,facility,outpatient,1,EA,650.50000,188.64000,Aetna,First Health,,532.11,,,,,,,234.51,532.11,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00074663722,NDC,,,facility,inpatient,1,EA,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,8.32,18.41,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00074663722,NDC,,,facility,outpatient,1,EA,22.50000,6.52000,Aetna,First Health,,18.41,,,,,,,8.11,18.41,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00074662902,NDC,facility,inpatient,200,ME,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,5.34,12.11,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00074662902,NDC,facility,outpatient,200,ME,14.80000,4.29000,Aetna,First Health,,12.11,,,,,,,0.93411,12.11,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00074662502,NDC,,,facility,inpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.16,4.79,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00074662502,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,First Health,,4.79,,,,,,,2.11,4.79,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00074662490,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00074662490,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00074662411,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00074662411,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00074660902,NDC,,,facility,inpatient,1,EA,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,11.19,24.74,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00074660902,NDC,,,facility,outpatient,1,EA,30.25000,8.77000,Aetna,First Health,,24.74,,,,,,,10.91,24.74,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00074659490,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00074659490,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00074653301,NDC,facility,inpatient,1,GM,56.10000,16.27000,Aetna,First Health,,45.89,,,,,,,20.22,45.89,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00074653301,NDC,facility,outpatient,1,GM,56.10000,16.27000,Aetna,First Health,,45.89,,,,,,,0.02889,45.89,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00074647932,NDC,facility,inpatient,100,ME,52.15000,15.12000,Aetna,First Health,,42.66,,,,,,,31.29,42.66,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00074647932,NDC,facility,outpatient,100,ME,52.15000,15.12000,Aetna,First Health,,42.66,,,,,,,1.74,42.66,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,00074630413,NDC,,,facility,inpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,4.65,6.34,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,00074630413,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,First Health,,6.34,,,,,,,2.79,6.34,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00074621513,NDC,,,facility,inpatient,1,EA,60.25000,17.47000,Aetna,First Health,,49.28,,,,,,,36.15,49.28,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00074621513,NDC,,,facility,outpatient,1,EA,60.25000,17.47000,Aetna,First Health,,49.28,,,,,,,21.72,49.28,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00074621511,NDC,,,facility,inpatient,1,EA,18.05000,5.23000,Aetna,First Health,,14.76,,,,,,,10.83,14.76,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00074621511,NDC,,,facility,outpatient,1,EA,18.05000,5.23000,Aetna,First Health,,14.76,,,,,,,6.51,14.76,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00074621453,NDC,,,facility,inpatient,1,EA,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,20.58,28.06,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00074621453,NDC,,,facility,outpatient,1,EA,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,12.37,28.06,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00074621413,NDC,,,facility,inpatient,1,EA,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,20.58,28.06,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00074621413,NDC,,,facility,outpatient,1,EA,34.30000,9.95000,Aetna,First Health,,28.06,,,,,,,12.37,28.06,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00074621411,NDC,,,facility,inpatient,1,EA,9.25000,2.68000,Aetna,First Health,,7.57,,,,,,,5.55,7.57,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00074621411,NDC,,,facility,outpatient,1,EA,9.25000,2.68000,Aetna,First Health,,7.57,,,,,,,3.33,7.57,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,00074611413,NDC,,,facility,inpatient,1,EA,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,9.99,13.62,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,00074611413,NDC,,,facility,outpatient,1,EA,16.65000,4.83000,Aetna,First Health,,13.62,,,,,,,6.00,13.62,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00074610204,NDC,facility,inpatient,40,ME,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,1.55,3.52,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00074610204,NDC,facility,outpatient,40,ME,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,0.01926,3.52,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,00074568113,NDC,,,facility,inpatient,1,EA,42.30000,12.27000,Aetna,First Health,,34.60,,,,,,,25.38,34.60,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,00074568113,NDC,,,facility,outpatient,1,EA,42.30000,12.27000,Aetna,First Health,,34.60,,,,,,,15.25,34.60,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00074518290,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00074518290,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00074518211,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00074518211,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00074508216,NDC,facility,inpatient,1,GM,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,33.69,76.44,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00074508216,NDC,facility,outpatient,1,GM,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,1.42,76.44,percent of total billed charges,
risankizumab-rzaa- Pt Own Supply,800051987,CDM,636,RC,J2327,HCPCS,00074501501,NDC,facility,inpatient,600,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
risankizumab-rzaa- Pt Own Supply,800051987,CDM,636,RC,J2327,HCPCS,00074501501,NDC,facility,outpatient,600,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,46.04,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00074492834,NDC,,,facility,inpatient,1,EA,19.40000,5.63000,Aetna,First Health,,15.87,,,,,,,7.18,15.87,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00074492834,NDC,,,facility,outpatient,1,EA,19.40000,5.63000,Aetna,First Health,,15.87,,,,,,,6.99,15.87,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00074492801,NDC,,,facility,inpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.51,12.19,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00074492801,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,First Health,,12.19,,,,,,,5.37,12.19,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00074492134,NDC,facility,inpatient,1,ME,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,4.85,11.00,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00074492134,NDC,facility,outpatient,1,ME,13.45000,3.90000,Aetna,First Health,,11.00,,,,,,,2.89,11.00,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00074492101,NDC,facility,inpatient,1,ME,129.30000,37.50000,Aetna,First Health,,105.77,,,,,,,46.61,105.77,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00074492101,NDC,facility,outpatient,1,ME,129.30000,37.50000,Aetna,First Health,,105.77,,,,,,,2.89,105.77,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00074491134,NDC,facility,inpatient,1,ME,19.05000,5.52000,Aetna,First Health,,15.58,,,,,,,6.87,15.58,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00074491134,NDC,facility,outpatient,1,ME,19.05000,5.52000,Aetna,First Health,,15.58,,,,,,,0.09630,15.58,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00074491101,NDC,facility,inpatient,1,ME,737.85000,213.98000,Aetna,First Health,,603.56,,,,,,,265.99,603.56,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00074491101,NDC,facility,outpatient,1,ME,737.85000,213.98000,Aetna,First Health,,603.56,,,,,,,0.09630,603.56,percent of total billed charges,
D50W 50mL Inj Syr,800011221,CDM,258,RC,00074490222,NDC,,,facility,inpatient,1,EA,713.25000,206.84000,Aetna,First Health,,583.44,,,,,,,335.23,583.44,percent of total billed charges,
D50W 50mL Inj Syr,800011221,CDM,258,RC,00074490222,NDC,,,facility,outpatient,1,EA,713.25000,206.84000,Aetna,First Health,,583.44,,,,,,,257.13,583.44,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,800049618,CDM,250,RC,00074490001,NDC,,,facility,inpatient,1,EA,68.75000,19.94000,Aetna,First Health,,56.24,,,,,,,25.44,56.24,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,800049618,CDM,250,RC,00074490001,NDC,,,facility,outpatient,1,EA,68.75000,19.94000,Aetna,First Health,,56.24,,,,,,,24.78,56.24,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,00074488810,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.84600,1.47,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,00074488810,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,00074488750,NDC,facility,inpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,2.84,4.95,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,00074488750,NDC,facility,outpatient,1,EA,6.05000,1.75000,Aetna,First Health,,4.95,,,,,,,0.63000,4.95,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,00074488710,NDC,facility,inpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.03,1.80,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,00074488710,NDC,facility,outpatient,1,EA,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.63000,4.78,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00074471302,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00074471302,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00074468823,NDC,facility,inpatient,200,ME,202.15000,58.62000,Aetna,First Health,,165.36,,,,,,,72.88,165.36,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00074468823,NDC,facility,outpatient,200,ME,202.15000,58.62000,Aetna,First Health,,165.36,,,,,,,4.31,165.36,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00074468802,NDC,facility,inpatient,400,ME,301.00000,87.29000,Aetna,First Health,,246.22,,,,,,,108.51,246.22,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00074468802,NDC,facility,outpatient,400,ME,301.00000,87.29000,Aetna,First Health,,246.22,,,,,,,4.31,246.22,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00074455290,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00074455290,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00074455213,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00074455213,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00074455211,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00074455211,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,00074449803,NDC,,,facility,inpatient,1,EA,248.90000,72.18000,Aetna,First Health,,203.60,,,,,,,92.09,203.60,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,00074449803,NDC,,,facility,outpatient,1,EA,248.90000,72.18000,Aetna,First Health,,203.60,,,,,,,89.73,203.60,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00074438220,NDC,,,facility,inpatient,1,EA,2506.55000,726.90000,Aetna,First Health,,2050.36,,,,,,,927.42,2050.36,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00074438220,NDC,,,facility,outpatient,1,EA,2506.55000,726.90000,Aetna,First Health,,2050.36,,,,,,,903.61,2050.36,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00074438010,NDC,,,facility,inpatient,1,EA,140.25000,40.67000,Aetna,First Health,,114.72,,,,,,,51.89,114.72,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00074438010,NDC,,,facility,outpatient,1,EA,140.25000,40.67000,Aetna,First Health,,114.72,,,,,,,50.56,114.72,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00074437836,NDC,,,facility,inpatient,1,EA,1407.00000,408.03000,Aetna,First Health,,1150.93,,,,,,,520.59,1150.93,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00074437836,NDC,,,facility,outpatient,1,EA,1407.00000,408.03000,Aetna,First Health,,1150.93,,,,,,,507.22,1150.93,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00074437805,NDC,,,facility,inpatient,1,EA,159.90000,46.37000,Aetna,First Health,,130.80,,,,,,,59.16,130.80,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00074437805,NDC,,,facility,outpatient,1,EA,159.90000,46.37000,Aetna,First Health,,130.80,,,,,,,57.64,130.80,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00074434190,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00074434190,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00074434113,NDC,,,facility,inpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,2.01,2.74,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00074434113,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,1.21,2.74,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00074428202,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00074428202,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00074427702,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00074427702,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00074427701,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00074427701,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00074427602,NDC,,,facility,inpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,1.82,4.13,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00074427602,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,First Health,,4.13,,,,,,,1.82,4.13,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00074427601,NDC,,,facility,inpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00074427601,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
Cupric Cl (Copper) I 10mL,800017803,CDM,250,RC,00074409201,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.37,5.24,percent of total billed charges,
Cupric Cl (Copper) I 10mL,800017803,CDM,250,RC,00074409201,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,00074400990,NDC,,,facility,inpatient,1,EA,6.20000,1.80000,Aetna,First Health,,5.07,,,,,,,3.72,5.07,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,00074400990,NDC,,,facility,outpatient,1,EA,6.20000,1.80000,Aetna,First Health,,5.07,,,,,,,2.24,5.07,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00074382613,NDC,,,facility,inpatient,1,EA,29.70000,8.61000,Aetna,First Health,,24.29,,,,,,,17.82,24.29,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00074382613,NDC,,,facility,outpatient,1,EA,29.70000,8.61000,Aetna,First Health,,24.29,,,,,,,10.71,24.29,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,00074380513,NDC,,,facility,inpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,10.11,13.78,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,00074380513,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,First Health,,13.78,,,,,,,6.07,13.78,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,00074376960,NDC,,,facility,inpatient,1,EA,43.80000,12.70000,Aetna,First Health,,35.83,,,,,,,26.28,35.83,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,00074376960,NDC,,,facility,outpatient,1,EA,43.80000,12.70000,Aetna,First Health,,35.83,,,,,,,15.79,35.83,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00074372790,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00074372790,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
DOBUTamine 1g/D5W 250mL,800013360,CDM,636,RC,J1250,HCPCS,00074372432,NDC,facility,inpatient,1,GM,171.35000,49.69000,Aetna,First Health,,140.16,,,,,,,61.77,140.16,percent of total billed charges,
DOBUTamine 1g/D5W 250mL,800013360,CDM,636,RC,J1250,HCPCS,00074372432,NDC,facility,outpatient,1,GM,171.35000,49.69000,Aetna,First Health,,140.16,,,,,,,7.72,140.16,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00074357801,NDC,facility,inpatient,80,ME,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,7.07,16.03,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00074357801,NDC,facility,outpatient,80,ME,19.60000,5.68000,Aetna,First Health,,16.03,,,,,,,1.99,16.03,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00074310932,NDC,facility,inpatient,100,ME,62.40000,18.10000,Aetna,First Health,,51.04,,,,,,,37.44,51.04,percent of total billed charges,
cycloSPORINE microemulsion 100mg C,800080639,CDM,637,RC,J7502,HCPCS,00074310932,NDC,facility,outpatient,100,ME,62.40000,18.10000,Aetna,First Health,,51.04,,,,,,,1.74,51.04,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,800080621,CDM,637,RC,J7515,HCPCS,00074310832,NDC,facility,inpatient,25,ME,15.60000,4.52000,Aetna,First Health,,12.76,,,,,,,9.36,12.76,percent of total billed charges,
cycloSPORINE microemulsion 25mg C,800080621,CDM,637,RC,J7515,HCPCS,00074310832,NDC,facility,outpatient,25,ME,15.60000,4.52000,Aetna,First Health,,12.76,,,,,,,0.51039,12.76,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00074302401,NDC,,,facility,inpatient,1,EA,79.25000,22.98000,Aetna,First Health,,64.83,,,,,,,29.32,64.83,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00074302401,NDC,,,facility,outpatient,1,EA,79.25000,22.98000,Aetna,First Health,,64.83,,,,,,,28.57,64.83,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00074258660,NDC,,,facility,inpatient,1,EA,72.60000,21.05000,Aetna,First Health,,59.39,,,,,,,43.56,59.39,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00074258660,NDC,,,facility,outpatient,1,EA,72.60000,21.05000,Aetna,First Health,,59.39,,,,,,,26.17,59.39,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00074258611,NDC,,,facility,inpatient,1,EA,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,34.80,47.44,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00074258611,NDC,,,facility,outpatient,1,EA,58.00000,16.82000,Aetna,First Health,,47.44,,,,,,,20.91,47.44,percent of total billed charges,
DOBUTamine 250mg/D5W 250mL,800012791,CDM,636,RC,J1250,HCPCS,00074234632,NDC,facility,inpatient,250,ME,85.75000,24.87000,Aetna,First Health,,70.14,,,,,,,30.91,70.14,percent of total billed charges,
DOBUTamine 250mg/D5W 250mL,800012791,CDM,636,RC,J1250,HCPCS,00074234632,NDC,facility,outpatient,250,ME,85.75000,24.87000,Aetna,First Health,,70.14,,,,,,,7.72,70.14,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00074231660,NDC,,,facility,inpatient,1,EA,392.80000,113.91000,Aetna,First Health,,321.31,,,,,,,235.68,321.31,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00074231660,NDC,,,facility,outpatient,1,EA,392.80000,113.91000,Aetna,First Health,,321.31,,,,,,,141.60,321.31,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00074212202,NDC,,,facility,inpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,15.11,33.42,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00074212202,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,First Health,,33.42,,,,,,,14.73,33.42,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,00074196607,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.85100,1.88,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,00074196607,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00074176230,NDC,facility,inpatient,2,ME,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,3.14,7.12,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00074176230,NDC,facility,outpatient,2,ME,8.70000,2.52000,Aetna,First Health,,7.12,,,,,,,2.93,9.38,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00074174929,NDC,,,facility,inpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.86,19.59,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00074174929,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.63,19.59,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00074174630,NDC,,,facility,inpatient,1,EA,813.15000,235.81000,Aetna,First Health,,665.16,,,,,,,300.87,665.16,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00074174630,NDC,,,facility,outpatient,1,EA,813.15000,235.81000,Aetna,First Health,,665.16,,,,,,,293.14,665.16,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,00074156410,NDC,,,facility,inpatient,1,EA,298.45000,86.55000,Aetna,First Health,,244.13,,,,,,,110.43,244.13,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,00074156410,NDC,,,facility,outpatient,1,EA,298.45000,86.55000,Aetna,First Health,,244.13,,,,,,,107.59,244.13,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00074153002,NDC,,,facility,inpatient,1,EA,1571.25000,455.66000,Aetna,First Health,,1285.28,,,,,,,738.49,1285.28,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00074153002,NDC,,,facility,outpatient,1,EA,1571.25000,455.66000,Aetna,First Health,,1285.28,,,,,,,566.44,1285.28,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00074148303,NDC,facility,inpatient,25,ME,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,12.51,28.38,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00074148303,NDC,facility,outpatient,25,ME,34.70000,10.06000,Aetna,First Health,,28.38,,,,,,,1.46,28.38,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00074144304,NDC,,,facility,inpatient,1,EA,449.35000,130.31000,Aetna,First Health,,367.57,,,,,,,166.26,367.57,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00074144304,NDC,,,facility,outpatient,1,EA,449.35000,130.31000,Aetna,First Health,,367.57,,,,,,,161.99,367.57,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00074132305,NDC,,,facility,inpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,4.00,9.08,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00074132305,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,First Health,,9.08,,,,,,,4.00,9.08,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00074127332,NDC,facility,inpatient,10,ME,20.30000,5.89000,Aetna,First Health,,16.61,,,,,,,7.32,16.61,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00074127332,NDC,facility,outpatient,10,ME,20.30000,5.89000,Aetna,First Health,,16.61,,,,,,,6.44,20.63,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00074125830,NDC,facility,inpatient,4,ME,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,3.26,7.40,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00074125830,NDC,facility,outpatient,4,ME,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,2.93,9.38,percent of total billed charges,
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00074120703,NDC,facility,inpatient,80,ME,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00074120703,NDC,facility,outpatient,80,ME,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.09,6.69,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00074117630,NDC,facility,inpatient,25,ME,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,3.03,6.87,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00074117630,NDC,facility,outpatient,25,ME,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,3.11,25.13,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00074116202,NDC,,,facility,inpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,3.88,8.59,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00074116202,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,First Health,,8.59,,,,,,,3.79,8.59,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00074116201,NDC,,,facility,inpatient,1,EA,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,4.59,10.14,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00074116201,NDC,,,facility,outpatient,1,EA,12.40000,3.60000,Aetna,First Health,,10.14,,,,,,,4.47,10.14,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00074115902,NDC,,,facility,inpatient,1,EA,966.90000,280.40000,Aetna,First Health,,790.92,,,,,,,357.75,790.92,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00074115902,NDC,,,facility,outpatient,1,EA,966.90000,280.40000,Aetna,First Health,,790.92,,,,,,,348.57,790.92,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00074114401,NDC,,,facility,inpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,2.26,4.99,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00074114401,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,2.20,4.99,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,00071458210,NDC,,,facility,inpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,6.72,14.85,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,00071458210,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,6.54,14.85,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00071400810,NDC,facility,inpatient,500,ME,642.30000,186.27000,Aetna,First Health,,525.40,,,,,,,231.55,525.40,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00071400810,NDC,facility,outpatient,500,ME,642.30000,186.27000,Aetna,First Health,,525.40,,,,,,,1.34,525.40,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00071400705,NDC,facility,inpatient,100,ME,130.35000,37.80000,Aetna,First Health,,106.63,,,,,,,46.99,106.63,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00071400705,NDC,facility,outpatient,100,ME,130.35000,37.80000,Aetna,First Health,,106.63,,,,,,,1.34,106.63,percent of total billed charges,
Phenytoin Na 30mg Sr C(Dilantin),800071703,CDM,637,RC,00071374066,NDC,,,facility,inpatient,1,EA,12.70000,3.68000,Aetna,First Health,,10.39,,,,,,,7.62,10.39,percent of total billed charges,
Phenytoin Na 30mg Sr C(Dilantin),800071703,CDM,637,RC,00071374066,NDC,,,facility,outpatient,1,EA,12.70000,3.68000,Aetna,First Health,,10.39,,,,,,,4.58,10.39,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,800023340,CDM,637,RC,00071221420,NDC,,,facility,inpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,3.66,4.99,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,800023340,CDM,637,RC,00071221420,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,2.20,4.99,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,800015357,CDM,637,RC,00071201223,NDC,,,facility,inpatient,1,EA,37.60000,10.90000,Aetna,First Health,,30.76,,,,,,,22.56,30.76,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,800015357,CDM,637,RC,00071201223,NDC,,,facility,outpatient,1,EA,37.60000,10.90000,Aetna,First Health,,30.76,,,,,,,13.55,30.76,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,00071101568,NDC,,,facility,inpatient,1,EA,92.50000,26.82000,Aetna,First Health,,75.67,,,,,,,55.50,75.67,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,00071101568,NDC,,,facility,outpatient,1,EA,92.50000,26.82000,Aetna,First Health,,75.67,,,,,,,33.35,75.67,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,00071101541,NDC,,,facility,inpatient,1,EA,106.85000,30.99000,Aetna,First Health,,87.40,,,,,,,64.11,87.40,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,00071101541,NDC,,,facility,outpatient,1,EA,106.85000,30.99000,Aetna,First Health,,87.40,,,,,,,38.52,87.40,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,00071101468,NDC,,,facility,inpatient,1,EA,92.50000,26.82000,Aetna,First Health,,75.67,,,,,,,55.50,75.67,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,00071101468,NDC,,,facility,outpatient,1,EA,92.50000,26.82000,Aetna,First Health,,75.67,,,,,,,33.35,75.67,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,00071101441,NDC,,,facility,inpatient,1,EA,106.85000,30.99000,Aetna,First Health,,87.40,,,,,,,64.11,87.40,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,00071101441,NDC,,,facility,outpatient,1,EA,106.85000,30.99000,Aetna,First Health,,87.40,,,,,,,38.52,87.40,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,00071101368,NDC,,,facility,inpatient,1,EA,92.50000,26.82000,Aetna,First Health,,75.67,,,,,,,55.50,75.67,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,00071101368,NDC,,,facility,outpatient,1,EA,92.50000,26.82000,Aetna,First Health,,75.67,,,,,,,33.35,75.67,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,00071101341,NDC,,,facility,inpatient,1,EA,106.85000,30.99000,Aetna,First Health,,87.40,,,,,,,64.11,87.40,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,00071101341,NDC,,,facility,outpatient,1,EA,106.85000,30.99000,Aetna,First Health,,87.40,,,,,,,38.52,87.40,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,00071101268,NDC,,,facility,inpatient,1,EA,92.50000,26.82000,Aetna,First Health,,75.67,,,,,,,55.50,75.67,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,00071101268,NDC,,,facility,outpatient,1,EA,92.50000,26.82000,Aetna,First Health,,75.67,,,,,,,33.35,75.67,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00071080624,NDC,,,facility,inpatient,1,EA,75.25000,21.82000,Aetna,First Health,,61.55,,,,,,,45.15,61.55,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00071080624,NDC,,,facility,outpatient,1,EA,75.25000,21.82000,Aetna,First Health,,61.55,,,,,,,27.13,61.55,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00071080540,NDC,,,facility,inpatient,1,EA,39.25000,11.38000,Aetna,First Health,,32.11,,,,,,,23.55,32.11,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00071080540,NDC,,,facility,outpatient,1,EA,39.25000,11.38000,Aetna,First Health,,32.11,,,,,,,14.15,32.11,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00071080524,NDC,,,facility,inpatient,1,EA,62.70000,18.18000,Aetna,First Health,,51.29,,,,,,,37.62,51.29,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00071080524,NDC,,,facility,outpatient,1,EA,62.70000,18.18000,Aetna,First Health,,51.29,,,,,,,22.60,51.29,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00071080340,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00071080340,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00071080324,NDC,,,facility,inpatient,1,EA,25.10000,7.28000,Aetna,First Health,,20.53,,,,,,,15.06,20.53,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00071080324,NDC,,,facility,outpatient,1,EA,25.10000,7.28000,Aetna,First Health,,20.53,,,,,,,9.05,20.53,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00071051324,NDC,,,facility,inpatient,1,EA,119.15000,34.55000,Aetna,First Health,,97.46,,,,,,,71.49,97.46,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00071051324,NDC,,,facility,outpatient,1,EA,119.15000,34.55000,Aetna,First Health,,97.46,,,,,,,42.95,97.46,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,00071041813,NDC,,,facility,inpatient,1,EA,334.10000,96.89000,Aetna,First Health,,273.29,,,,,,,200.46,273.29,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,00071041813,NDC,,,facility,outpatient,1,EA,334.10000,96.89000,Aetna,First Health,,273.29,,,,,,,120.44,273.29,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036940,NDC,,,facility,inpatient,1,EA,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,9.75,13.29,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036940,NDC,,,facility,outpatient,1,EA,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,5.86,13.29,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036924,NDC,,,facility,inpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,8.82,12.02,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036924,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.30,12.02,percent of total billed charges,
Phenytoin Na 30mg Sr C(Dilantin),800071703,CDM,637,RC,00071036524,NDC,,,facility,inpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,1.65,2.25,percent of total billed charges,
Phenytoin Na 30mg Sr C(Dilantin),800071703,CDM,637,RC,00071036524,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,First Health,,2.25,,,,,,,0.99138,2.25,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036240,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036240,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036224,NDC,,,facility,inpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,1.41,1.92,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036224,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,First Health,,1.92,,,,,,,0.84718,1.92,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,00071035060,NDC,,,facility,inpatient,1,EA,21.70000,6.29000,Aetna,First Health,,17.75,,,,,,,13.02,17.75,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,00071035060,NDC,,,facility,outpatient,1,EA,21.70000,6.29000,Aetna,First Health,,17.75,,,,,,,7.82,17.75,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,00071027024,NDC,,,facility,inpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,2.31,3.15,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,00071027024,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,First Health,,3.15,,,,,,,1.39,3.15,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00071015773,NDC,,,facility,inpatient,1,EA,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,76.20,103.89,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00071015773,NDC,,,facility,outpatient,1,EA,127.00000,36.83000,Aetna,First Health,,103.89,,,,,,,45.78,103.89,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00071015723,NDC,,,facility,inpatient,1,EA,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00071015723,NDC,,,facility,outpatient,1,EA,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,56.60,128.43,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00071015640,NDC,,,facility,inpatient,1,EA,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,94.20,128.43,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00071015640,NDC,,,facility,outpatient,1,EA,157.00000,45.53000,Aetna,First Health,,128.43,,,,,,,56.60,128.43,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00071015623,NDC,,,facility,inpatient,1,EA,149.55000,43.37000,Aetna,First Health,,122.33,,,,,,,89.73,122.33,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00071015623,NDC,,,facility,outpatient,1,EA,149.55000,43.37000,Aetna,First Health,,122.33,,,,,,,53.91,122.33,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00071015540,NDC,,,facility,inpatient,1,EA,102.85000,29.83000,Aetna,First Health,,84.13,,,,,,,61.71,84.13,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00071015540,NDC,,,facility,outpatient,1,EA,102.85000,29.83000,Aetna,First Health,,84.13,,,,,,,37.08,84.13,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00071015523,NDC,,,facility,inpatient,1,EA,113.40000,32.89000,Aetna,First Health,,92.76,,,,,,,68.04,92.76,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00071015523,NDC,,,facility,outpatient,1,EA,113.40000,32.89000,Aetna,First Health,,92.76,,,,,,,40.88,92.76,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00069600125,NDC,facility,inpatient,100,ME,247.85000,71.88000,Aetna,First Health,,202.74,,,,,,,89.35,202.74,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00069600125,NDC,facility,outpatient,100,ME,247.85000,71.88000,Aetna,First Health,,202.74,,,,,,,1.34,202.74,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,inpatient,500,ME,1033.10000,299.60000,Aetna,First Health,,845.08,,,,,,,372.43,845.08,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,outpatient,500,ME,1033.10000,299.60000,Aetna,First Health,,845.08,,,,,,,1.34,845.08,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,00069582061,NDC,,,facility,inpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,8.97,12.23,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,00069582061,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,5.39,12.23,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,00069582043,NDC,,,facility,inpatient,1,EA,94.15000,27.30000,Aetna,First Health,,77.01,,,,,,,56.49,77.01,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,00069582043,NDC,,,facility,outpatient,1,EA,94.15000,27.30000,Aetna,First Health,,77.01,,,,,,,33.94,77.01,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,00069581061,NDC,,,facility,inpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,8.97,12.23,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,00069581061,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,5.39,12.23,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,00069581043,NDC,,,facility,inpatient,1,EA,94.15000,27.30000,Aetna,First Health,,77.01,,,,,,,56.49,77.01,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,00069581043,NDC,,,facility,outpatient,1,EA,94.15000,27.30000,Aetna,First Health,,77.01,,,,,,,33.94,77.01,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00069580061,NDC,,,facility,inpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,8.97,12.23,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00069580061,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,5.39,12.23,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00069580060,NDC,,,facility,inpatient,1,EA,95.10000,27.58000,Aetna,First Health,,77.79,,,,,,,57.06,77.79,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00069580060,NDC,,,facility,outpatient,1,EA,95.10000,27.58000,Aetna,First Health,,77.79,,,,,,,34.28,77.79,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00069580043,NDC,,,facility,inpatient,1,EA,94.15000,27.30000,Aetna,First Health,,77.01,,,,,,,56.49,77.01,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00069580043,NDC,,,facility,outpatient,1,EA,94.15000,27.30000,Aetna,First Health,,77.01,,,,,,,33.94,77.01,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00069547402,NDC,facility,inpatient,500,ME,726.25000,210.61000,Aetna,First Health,,594.07,,,,,,,261.81,594.07,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00069547402,NDC,facility,outpatient,500,ME,726.25000,210.61000,Aetna,First Health,,594.07,,,,,,,1.34,594.07,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00069547102,NDC,facility,inpatient,100,ME,171.95000,49.87000,Aetna,First Health,,140.66,,,,,,,61.99,140.66,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00069547102,NDC,facility,outpatient,100,ME,171.95000,49.87000,Aetna,First Health,,140.66,,,,,,,1.34,140.66,percent of total billed charges,
nirmatrelvir-ritonavir 300mg-100mg Dose Tab,800046441,CDM,250,RC,00069532130,NDC,,,facility,inpatient,1,EA,1091.80000,316.62000,Aetna,First Health,,893.09,,,,,,,403.97,893.09,percent of total billed charges,
nirmatrelvir-ritonavir 300mg-100mg Dose Tab,800046441,CDM,250,RC,00069532130,NDC,,,facility,outpatient,1,EA,1091.80000,316.62000,Aetna,First Health,,893.09,,,,,,,393.59,893.09,percent of total billed charges,
nirmatrelvir-ritonavir 150 mg-100 mg (Renal Dose) Tab,800051949,CDM,250,RC,00069531720,NDC,,,facility,inpatient,1,EA,1091.80000,316.62000,Aetna,First Health,,893.09,,,,,,,403.97,893.09,percent of total billed charges,
nirmatrelvir-ritonavir 150 mg-100 mg (Renal Dose) Tab,800051949,CDM,250,RC,00069531720,NDC,,,facility,outpatient,1,EA,1091.80000,316.62000,Aetna,First Health,,893.09,,,,,,,393.59,893.09,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,00069454702,NDC,facility,inpatient,4,ME,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,00069454702,NDC,facility,outpatient,4,ME,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,0.10593,4.29,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00069431071,NDC,,,facility,inpatient,1,EA,19.65000,5.70000,Aetna,First Health,,16.07,,,,,,,11.79,16.07,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00069431071,NDC,,,facility,outpatient,1,EA,19.65000,5.70000,Aetna,First Health,,16.07,,,,,,,7.08,16.07,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,00069419068,NDC,,,facility,inpatient,1,EA,469.80000,136.24000,Aetna,First Health,,384.30,,,,,,,281.88,384.30,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,00069419068,NDC,,,facility,outpatient,1,EA,469.80000,136.24000,Aetna,First Health,,384.30,,,,,,,169.36,384.30,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00069406189,NDC,,,facility,inpatient,1,EA,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,17.58,23.97,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00069406189,NDC,,,facility,outpatient,1,EA,29.30000,8.50000,Aetna,First Health,,23.97,,,,,,,10.56,23.97,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00069403201,NDC,facility,inpatient,50,ME,266.30000,77.23000,Aetna,First Health,,217.83,,,,,,,96.00,217.83,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00069403201,NDC,facility,outpatient,50,ME,266.30000,77.23000,Aetna,First Health,,217.83,,,,,,,2.68,217.83,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00069403001,NDC,facility,inpatient,10,ME,78.40000,22.74000,Aetna,First Health,,64.13,,,,,,,28.26,64.13,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00069403001,NDC,facility,outpatient,10,ME,78.40000,22.74000,Aetna,First Health,,64.13,,,,,,,2.68,64.13,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,00069311019,NDC,,,facility,inpatient,1,EA,75.20000,21.81000,Aetna,First Health,,61.51,,,,,,,45.12,61.51,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,00069311019,NDC,,,facility,outpatient,1,EA,75.20000,21.81000,Aetna,First Health,,61.51,,,,,,,27.11,61.51,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00069306030,NDC,,,facility,inpatient,1,EA,18.35000,5.32000,Aetna,First Health,,15.01,,,,,,,11.01,15.01,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00069306030,NDC,,,facility,outpatient,1,EA,18.35000,5.32000,Aetna,First Health,,15.01,,,,,,,6.62,15.01,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,inpatient,10,ME,79.15000,22.95000,Aetna,First Health,,64.74,,,,,,,28.53,64.74,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,outpatient,10,ME,79.15000,22.95000,Aetna,First Health,,64.74,,,,,,,2.68,64.74,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00069265066,NDC,,,facility,inpatient,1,EA,56.15000,16.28000,Aetna,First Health,,45.93,,,,,,,33.69,45.93,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00069265066,NDC,,,facility,outpatient,1,EA,56.15000,16.28000,Aetna,First Health,,45.93,,,,,,,20.24,45.93,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00069265041,NDC,,,facility,inpatient,1,EA,18.10000,5.25000,Aetna,First Health,,14.81,,,,,,,10.86,14.81,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00069265041,NDC,,,facility,outpatient,1,EA,18.10000,5.25000,Aetna,First Health,,14.81,,,,,,,6.53,14.81,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00069260101,NDC,facility,inpatient,1,GM,543.70000,157.67000,Aetna,First Health,,444.75,,,,,,,196.00,444.75,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00069260101,NDC,facility,outpatient,1,GM,543.70000,157.67000,Aetna,First Health,,444.75,,,,,,,0.02889,444.75,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00069259999,NDC,facility,inpatient,1,GM,496.65000,144.03000,Aetna,First Health,,406.26,,,,,,,179.04,406.26,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00069259999,NDC,facility,outpatient,1,GM,496.65000,144.03000,Aetna,First Health,,406.26,,,,,,,0.02889,406.26,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00069153072,NDC,,,facility,inpatient,1,EA,61.05000,17.70000,Aetna,First Health,,49.94,,,,,,,36.63,49.94,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00069153072,NDC,,,facility,outpatient,1,EA,61.05000,17.70000,Aetna,First Health,,49.94,,,,,,,22.01,49.94,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00069153068,NDC,,,facility,inpatient,1,EA,73.40000,21.29000,Aetna,First Health,,60.04,,,,,,,44.04,60.04,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00069153068,NDC,,,facility,outpatient,1,EA,73.40000,21.29000,Aetna,First Health,,60.04,,,,,,,26.46,60.04,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00069153066,NDC,,,facility,inpatient,1,EA,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,7.02,9.57,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00069153066,NDC,,,facility,outpatient,1,EA,11.70000,3.39000,Aetna,First Health,,9.57,,,,,,,4.22,9.57,percent of total billed charges,
"Epoetin alfa - epbx 20,000 units/mL Inj",800062118,CDM,636,RC,Q5106,HCPCS,00069131110,NDC,facility,inpatient,20000,UN,1068.85000,309.97000,Aetna,First Health,,874.32,,,,,,,385.32,874.32,percent of total billed charges,
"Epoetin alfa - epbx 20,000 units/mL Inj",800062118,CDM,636,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,20000,UN,1068.85000,309.97000,Aetna,First Health,,874.32,,,,,,,7.29,874.32,percent of total billed charges,
"Epoetin alfa - epbx 40,000units/mL PF Inj",800062006,CDM,636,RC,Q5106,HCPCS,00069130904,NDC,facility,inpatient,40000,UN,1947.75000,564.85000,Aetna,First Health,,1593.26,,,,,,,702.16,1593.26,percent of total billed charges,
"Epoetin alfa - epbx 40,000units/mL PF Inj",800062006,CDM,636,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,40000,UN,1947.75000,564.85000,Aetna,First Health,,1593.26,,,,,,,7.29,1593.26,percent of total billed charges,
"Epoetin alfa - epbx 10,000units/mL PF Inj",800062004,CDM,636,RC,Q5106,HCPCS,00069130810,NDC,facility,inpatient,10000,UN,595.60000,172.72000,Aetna,First Health,,487.20,,,,,,,214.71,487.20,percent of total billed charges,
"Epoetin alfa - epbx 10,000units/mL PF Inj",800062004,CDM,636,RC,Q5106,HCPCS,00069130810,NDC,facility,outpatient,10000,UN,595.60000,172.72000,Aetna,First Health,,487.20,,,,,,,7.29,487.20,percent of total billed charges,
"Epoetin alfa - epbx 4,000units/mL PF Inj",800062003,CDM,636,RC,Q5106,HCPCS,00069130710,NDC,facility,inpatient,4000,UN,269.70000,78.21000,Aetna,First Health,,220.61,,,,,,,97.23,220.61,percent of total billed charges,
"Epoetin alfa - epbx 4,000units/mL PF Inj",800062003,CDM,636,RC,Q5106,HCPCS,00069130710,NDC,facility,outpatient,4000,UN,269.70000,78.21000,Aetna,First Health,,220.61,,,,,,,7.29,220.61,percent of total billed charges,
"Epoetin alfa - epbx 3,000units/mL PF Inj",800062001,CDM,636,RC,Q5106,HCPCS,00069130610,NDC,facility,inpatient,3000,UN,205.40000,59.57000,Aetna,First Health,,168.02,,,,,,,74.05,168.02,percent of total billed charges,
"Epoetin alfa - epbx 3,000units/mL PF Inj",800062001,CDM,636,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,3000,UN,205.40000,59.57000,Aetna,First Health,,168.02,,,,,,,7.29,168.02,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00069035820,NDC,facility,inpatient,10,ME,79.15000,22.95000,Aetna,First Health,,64.74,,,,,,,28.53,64.74,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00069035820,NDC,facility,outpatient,10,ME,79.15000,22.95000,Aetna,First Health,,64.74,,,,,,,2.68,64.74,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00069034302,NDC,facility,inpatient,50,ME,189.90000,55.07000,Aetna,First Health,,155.34,,,,,,,68.46,155.34,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00069034302,NDC,facility,outpatient,50,ME,189.90000,55.07000,Aetna,First Health,,155.34,,,,,,,2.68,155.34,percent of total billed charges,
Pegfilgrastim-apgf 6 mg/0.6 mL Inj Syr,800046522,CDM,636,RC,Q5122,HCPCS,00069032401,NDC,facility,inpatient,6,ME,30805.00000,8933.45000,Aetna,First Health,,25198.49,,,,,,,11105.20,25198.49,percent of total billed charges,
Pegfilgrastim-apgf 6 mg/0.6 mL Inj Syr,800046522,CDM,636,RC,Q5122,HCPCS,00069032401,NDC,facility,outpatient,6,ME,30805.00000,8933.45000,Aetna,First Health,,25198.49,,,,,,,128.13,25198.49,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00069031410,NDC,facility,inpatient,1,GM,275.25000,79.82000,Aetna,First Health,,225.15,,,,,,,99.23,225.15,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00069031410,NDC,facility,outpatient,1,GM,275.25000,79.82000,Aetna,First Health,,225.15,,,,,,,0.36594,225.15,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00069031310,NDC,facility,inpatient,500,ME,139.20000,40.37000,Aetna,First Health,,113.87,,,,,,,50.18,113.87,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00069031310,NDC,facility,outpatient,500,ME,139.20000,40.37000,Aetna,First Health,,113.87,,,,,,,0.36594,113.87,percent of total billed charges,
Trastuzumab- qyyp 150mg Inj,800046524,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,inpatient,150,ME,6726.95000,1950.82000,Aetna,First Health,,5502.65,,,,,,,2425.07,5502.65,percent of total billed charges,
Trastuzumab- qyyp 150mg Inj,800046524,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,150,ME,6726.95000,1950.82000,Aetna,First Health,,5502.65,,,,,,,7.91,5502.65,percent of total billed charges,
Trastuzumab- qyyp 420mg Inj,800046523,CDM,636,RC,Q5116,HCPCS,00069030501,NDC,facility,inpatient,420,ME,18498.85000,5364.67000,Aetna,First Health,,15132.06,,,,,,,6668.84,15132.06,percent of total billed charges,
Trastuzumab- qyyp 420mg Inj,800046523,CDM,636,RC,Q5116,HCPCS,00069030501,NDC,facility,outpatient,420,ME,18498.85000,5364.67000,Aetna,First Health,,15132.06,,,,,,,7.91,15132.06,percent of total billed charges,
Filgrastim- aafi 480mcg Inj Syr,800046528,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,inpatient,0.48,ME,1586.00000,459.94000,Aetna,First Health,,1297.35,,,,,,,571.75,1297.35,percent of total billed charges,
Filgrastim- aafi 480mcg Inj Syr,800046528,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.48,ME,1586.00000,459.94000,Aetna,First Health,,1297.35,,,,,,,0.26964,1297.35,percent of total billed charges,
riTUXimab-pvvr 500mg- Pt Own Supply,800051027,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,inpatient,500,ME,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.18025,0.40900,percent of total billed charges,
riTUXimab-pvvr 500mg- Pt Own Supply,800051027,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,500,ME,0.50000,0.14000,Aetna,First Health,,0.40900,,,,,,,0.18500,40.92,percent of total billed charges,
riTUXimab - pvvr 500mg/50mL Inj,800062099,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,inpatient,500,ME,25991.80000,7537.62000,Aetna,First Health,,21261.29,,,,,,,9370.04,21261.29,percent of total billed charges,
riTUXimab - pvvr 500mg/50mL Inj,800062099,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,500,ME,25991.80000,7537.62000,Aetna,First Health,,21261.29,,,,,,,12.78,21261.29,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00069024810,NDC,facility,inpatient,1,GM,222.30000,64.47000,Aetna,First Health,,181.84,,,,,,,80.14,181.84,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00069024810,NDC,facility,outpatient,1,GM,222.30000,64.47000,Aetna,First Health,,181.84,,,,,,,0.08667,181.84,percent of total billed charges,
riTUXimab-pvvr 100mg- Pt Own Supply,800051017,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,inpatient,100,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
riTUXimab-pvvr 100mg- Pt Own Supply,800051017,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,100,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,40.92,percent of total billed charges,
riTUXimab - pvvr 100mg/10mL Inj,800062100,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,inpatient,100,ME,5347.95000,1550.91000,Aetna,First Health,,4374.62,,,,,,,1927.94,4374.62,percent of total billed charges,
riTUXimab - pvvr 100mg/10mL Inj,800062100,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,100,ME,5347.95000,1550.91000,Aetna,First Health,,4374.62,,,,,,,12.78,4374.62,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00069020910,NDC,facility,inpatient,200,ME,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,9.95,22.58,percent of total billed charges,
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00069020910,NDC,facility,outpatient,200,ME,27.60000,8.00000,Aetna,First Health,,22.58,,,,,,,0.08667,22.58,percent of total billed charges,
Methotrexate Na 250mg/10mL I PF,800022021,CDM,636,RC,J9260,HCPCS,00069014801,NDC,facility,inpatient,250,ME,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,32.34,73.37,percent of total billed charges,
Methotrexate Na 250mg/10mL I PF,800022021,CDM,636,RC,J9260,HCPCS,00069014801,NDC,facility,outpatient,250,ME,89.70000,26.01000,Aetna,First Health,,73.37,,,,,,,2.48,73.37,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00069013703,NDC,facility,inpatient,30000,UN,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,28.59,64.87,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00069013703,NDC,facility,outpatient,30000,UN,79.30000,23.00000,Aetna,First Health,,64.87,,,,,,,0.17334,64.87,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,00069012102,NDC,facility,inpatient,20,ME,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,00069012102,NDC,facility,outpatient,20,ME,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,0.00963,4.66,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00069010503,NDC,,,facility,inpatient,1,EA,43.40000,12.59000,Aetna,First Health,,35.50,,,,,,,16.06,35.50,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00069010503,NDC,,,facility,outpatient,1,EA,43.40000,12.59000,Aetna,First Health,,35.50,,,,,,,15.65,35.50,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,00069010404,NDC,facility,inpatient,100,ME,145.65000,42.24000,Aetna,First Health,,119.14,,,,,,,53.89,119.14,percent of total billed charges,
Doxycycline 100mg I,800013896,CDM,250,RC,J1271,HCPCS,00069010404,NDC,facility,outpatient,100,ME,145.65000,42.24000,Aetna,First Health,,119.14,,,,,,,0.09630,119.14,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00069008802,NDC,facility,inpatient,80,ME,19.00000,5.51000,Aetna,First Health,,15.54,,,,,,,6.85,15.54,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00069008802,NDC,facility,outpatient,80,ME,19.00000,5.51000,Aetna,First Health,,15.54,,,,,,,1.99,15.54,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00069005903,NDC,facility,inpatient,5000,UN,26.85000,7.79000,Aetna,First Health,,21.96,,,,,,,12.62,21.96,percent of total billed charges,
"Heparin 5,000 unit/1mL Inj",800013384,CDM,258,RC,J1644,HCPCS,00069005903,NDC,facility,outpatient,5000,UN,26.85000,7.79000,Aetna,First Health,,21.96,,,,,,,0.17334,21.96,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,00069005801,NDC,facility,inpatient,10000,UN,21.55000,6.25000,Aetna,First Health,,17.63,,,,,,,7.77,17.63,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,00069005801,NDC,facility,outpatient,10000,UN,21.55000,6.25000,Aetna,First Health,,17.63,,,,,,,0.17334,17.63,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00069004503,NDC,facility,inpatient,400,ME,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,46.87,106.34,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00069004503,NDC,facility,outpatient,400,ME,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,4.31,106.34,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00069003803,NDC,facility,inpatient,200,ME,85.70000,24.85000,Aetna,First Health,,70.10,,,,,,,30.89,70.10,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00069003803,NDC,facility,outpatient,200,ME,85.70000,24.85000,Aetna,First Health,,70.10,,,,,,,4.31,70.10,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00069000601,NDC,,,facility,inpatient,1,EA,62.65000,18.17000,Aetna,First Health,,51.25,,,,,,,23.18,51.25,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00069000601,NDC,,,facility,outpatient,1,EA,62.65000,18.17000,Aetna,First Health,,51.25,,,,,,,22.59,51.25,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,00068080923,NDC,facility,inpatient,20,ME,136.45000,39.57000,Aetna,First Health,,111.62,,,,,,,49.19,111.62,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,00068080923,NDC,facility,outpatient,20,ME,136.45000,39.57000,Aetna,First Health,,111.62,,,,,,,10.91,111.62,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00068050861,NDC,,,facility,inpatient,1,EA,37.10000,10.76000,Aetna,First Health,,30.35,,,,,,,22.26,30.35,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00068050861,NDC,,,facility,outpatient,1,EA,37.10000,10.76000,Aetna,First Health,,30.35,,,,,,,13.37,30.35,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00068050830,NDC,,,facility,inpatient,1,EA,22.80000,6.61000,Aetna,First Health,,18.65,,,,,,,13.68,18.65,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00068050830,NDC,,,facility,outpatient,1,EA,22.80000,6.61000,Aetna,First Health,,18.65,,,,,,,8.22,18.65,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),800065135,CDM,637,RC,00068012516,NDC,,,facility,inpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.89,2.58,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),800065135,CDM,637,RC,00068012516,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,First Health,,2.58,,,,,,,1.14,2.58,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,00067815203,NDC,,,facility,inpatient,1,EA,176.80000,51.27000,Aetna,First Health,,144.62,,,,,,,106.08,144.62,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,00067815203,NDC,,,facility,outpatient,1,EA,176.80000,51.27000,Aetna,First Health,,144.62,,,,,,,63.74,144.62,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,00067621597,NDC,,,facility,inpatient,1,EA,204.90000,59.42000,Aetna,First Health,,167.61,,,,,,,122.94,167.61,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,00067621597,NDC,,,facility,outpatient,1,EA,204.90000,59.42000,Aetna,First Health,,167.61,,,,,,,73.87,167.61,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,00065853302,NDC,,,facility,inpatient,1,EA,1803.45000,523.00000,Aetna,First Health,,1475.22,,,,,,,1082.07,1475.22,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,00065853302,NDC,,,facility,outpatient,1,EA,1803.45000,523.00000,Aetna,First Health,,1475.22,,,,,,,650.14,1475.22,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00065815001,NDC,,,facility,inpatient,1,EA,126.15000,36.58000,Aetna,First Health,,103.19,,,,,,,75.69,103.19,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00065815001,NDC,,,facility,outpatient,1,EA,126.15000,36.58000,Aetna,First Health,,103.19,,,,,,,45.48,103.19,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),800018655,CDM,637,RC,00065079515,NDC,,,facility,inpatient,1,EA,107.45000,31.16000,Aetna,First Health,,87.89,,,,,,,64.47,87.89,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),800018655,CDM,637,RC,00065079515,NDC,,,facility,outpatient,1,EA,107.45000,31.16000,Aetna,First Health,,87.89,,,,,,,38.74,87.89,percent of total billed charges,
Tetracaine HCl 0.5% 4mL Ophth Soln,800021991,CDM,637,RC,00065074114,NDC,,,facility,inpatient,1,EA,117.90000,34.19000,Aetna,First Health,,96.44,,,,,,,70.74,96.44,percent of total billed charges,
Tetracaine HCl 0.5% 4mL Ophth Soln,800021991,CDM,637,RC,00065074114,NDC,,,facility,outpatient,1,EA,117.90000,34.19000,Aetna,First Health,,96.44,,,,,,,42.50,96.44,percent of total billed charges,
Tobra-Dex 3.5g Ophth Oint(Tobradex),800053479,CDM,637,RC,00065064835,NDC,,,facility,inpatient,1,EA,1676.15000,486.08000,Aetna,First Health,,1371.09,,,,,,,1005.69,1371.09,percent of total billed charges,
Tobra-Dex 3.5g Ophth Oint(Tobradex),800053479,CDM,637,RC,00065064835,NDC,,,facility,outpatient,1,EA,1676.15000,486.08000,Aetna,First Health,,1371.09,,,,,,,604.25,1371.09,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,00065064705,NDC,,,facility,inpatient,1,EA,1205.30000,349.54000,Aetna,First Health,,985.94,,,,,,,723.18,985.94,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,00065064705,NDC,,,facility,outpatient,1,EA,1205.30000,349.54000,Aetna,First Health,,985.94,,,,,,,434.51,985.94,percent of total billed charges,
Tobramycin 0.3% 3.5g Ophth Oint(Tobrex),800041185,CDM,637,RC,00065064435,NDC,,,facility,inpatient,1,EA,1591.75000,461.61000,Aetna,First Health,,1302.05,,,,,,,955.05,1302.05,percent of total billed charges,
Tobramycin 0.3% 3.5g Ophth Oint(Tobrex),800041185,CDM,637,RC,00065064435,NDC,,,facility,outpatient,1,EA,1591.75000,461.61000,Aetna,First Health,,1302.05,,,,,,,573.83,1302.05,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,00065063136,NDC,,,facility,inpatient,1,EA,1473.05000,427.18000,Aetna,First Health,,1204.95,,,,,,,883.83,1204.95,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,00065063136,NDC,,,facility,outpatient,1,EA,1473.05000,427.18000,Aetna,First Health,,1204.95,,,,,,,531.03,1204.95,percent of total billed charges,
Tropicamide 1% Ophth Soln(Mydriacyl),800061415,CDM,637,RC,00065035503,NDC,,,facility,inpatient,1,EA,65.70000,19.05000,Aetna,First Health,,53.74,,,,,,,39.42,53.74,percent of total billed charges,
Tropicamide 1% Ophth Soln(Mydriacyl),800061415,CDM,637,RC,00065035503,NDC,,,facility,outpatient,1,EA,65.70000,19.05000,Aetna,First Health,,53.74,,,,,,,23.68,53.74,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,00065030355,NDC,,,facility,inpatient,1,EA,460.05000,133.41000,Aetna,First Health,,376.32,,,,,,,276.03,376.32,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,00065030355,NDC,,,facility,outpatient,1,EA,460.05000,133.41000,Aetna,First Health,,376.32,,,,,,,165.85,376.32,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00065027225,NDC,,,facility,inpatient,1,EA,1422.75000,412.60000,Aetna,First Health,,1163.81,,,,,,,853.65,1163.81,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00065027225,NDC,,,facility,outpatient,1,EA,1422.75000,412.60000,Aetna,First Health,,1163.81,,,,,,,512.90,1163.81,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00064501030,NDC,,,facility,inpatient,1,EA,1533.45000,444.70000,Aetna,First Health,,1254.36,,,,,,,920.07,1254.36,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00064501030,NDC,,,facility,outpatient,1,EA,1533.45000,444.70000,Aetna,First Health,,1254.36,,,,,,,552.81,1254.36,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00064501015,NDC,,,facility,inpatient,1,EA,816.05000,236.65000,Aetna,First Health,,667.53,,,,,,,489.63,667.53,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00064501015,NDC,,,facility,outpatient,1,EA,816.05000,236.65000,Aetna,First Health,,667.53,,,,,,,294.19,667.53,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00062542601,NDC,,,facility,inpatient,1,EA,1985.80000,575.88000,Aetna,First Health,,1624.38,,,,,,,1191.48,1624.38,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00062542601,NDC,,,facility,outpatient,1,EA,1985.80000,575.88000,Aetna,First Health,,1624.38,,,,,,,715.88,1624.38,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00056065068,NDC,,,facility,inpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,4.83,6.58,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00056065068,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,First Health,,6.58,,,,,,,2.90,6.58,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,00056060128,NDC,,,facility,inpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,4.68,6.38,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,00056060128,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,First Health,,6.38,,,,,,,2.81,6.38,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00056052168,NDC,,,facility,inpatient,1,EA,12.10000,3.51000,Aetna,First Health,,9.90,,,,,,,7.26,9.90,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00056052168,NDC,,,facility,outpatient,1,EA,12.10000,3.51000,Aetna,First Health,,9.90,,,,,,,4.36,9.90,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00056052128,NDC,,,facility,inpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,9.42,12.84,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00056052128,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,First Health,,12.84,,,,,,,5.66,12.84,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00056017675,NDC,,,facility,inpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,11.31,15.42,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00056017675,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,6.80,15.42,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00056017670,NDC,,,facility,inpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,11.31,15.42,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00056017670,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,First Health,,15.42,,,,,,,6.80,15.42,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00056017375,NDC,,,facility,inpatient,1,EA,26.20000,7.60000,Aetna,First Health,,21.43,,,,,,,15.72,21.43,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00056017375,NDC,,,facility,outpatient,1,EA,26.20000,7.60000,Aetna,First Health,,21.43,,,,,,,9.45,21.43,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00056017370,NDC,,,facility,inpatient,1,EA,26.20000,7.60000,Aetna,First Health,,21.43,,,,,,,15.72,21.43,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00056017370,NDC,,,facility,outpatient,1,EA,26.20000,7.60000,Aetna,First Health,,21.43,,,,,,,9.45,21.43,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,00056017275,NDC,,,facility,inpatient,1,EA,19.65000,5.70000,Aetna,First Health,,16.07,,,,,,,11.79,16.07,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,00056017275,NDC,,,facility,outpatient,1,EA,19.65000,5.70000,Aetna,First Health,,16.07,,,,,,,7.08,16.07,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,00056017270,NDC,,,facility,inpatient,1,EA,19.65000,5.70000,Aetna,First Health,,16.07,,,,,,,11.79,16.07,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,00056017270,NDC,,,facility,outpatient,1,EA,19.65000,5.70000,Aetna,First Health,,16.07,,,,,,,7.08,16.07,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,00056017075,NDC,,,facility,inpatient,1,EA,18.30000,5.31000,Aetna,First Health,,14.97,,,,,,,10.98,14.97,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,00056017075,NDC,,,facility,outpatient,1,EA,18.30000,5.31000,Aetna,First Health,,14.97,,,,,,,6.60,14.97,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00056016975,NDC,,,facility,inpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,10.50,14.31,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00056016975,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,6.31,14.31,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,00054885925,NDC,,,facility,inpatient,1,EA,21.95000,6.37000,Aetna,First Health,,17.96,,,,,,,13.17,17.96,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,00054885925,NDC,,,facility,outpatient,1,EA,21.95000,6.37000,Aetna,First Health,,17.96,,,,,,,7.91,17.96,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00054880524,NDC,,,facility,inpatient,1,EA,13.60000,3.94000,Aetna,First Health,,11.12,,,,,,,8.16,11.12,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00054880524,NDC,,,facility,outpatient,1,EA,13.60000,3.94000,Aetna,First Health,,11.12,,,,,,,4.90,11.12,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00054879311,NDC,,,facility,inpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,24.99,34.07,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00054879311,NDC,,,facility,outpatient,1,EA,41.65000,12.08000,Aetna,First Health,,34.07,,,,,,,15.01,34.07,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,00054879024,NDC,,,facility,inpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,4.29,5.85,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,00054879024,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,First Health,,5.85,,,,,,,2.58,5.85,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00054874425,NDC,,,facility,inpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.33000,0.44990,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00054874425,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,First Health,,0.44990,,,,,,,0.19828,0.44990,percent of total billed charges,
predniSONE 2.5mg T,800020638,CDM,637,RC,J7512,HCPCS,00054874025,NDC,facility,inpatient,2.5,ME,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
predniSONE 2.5mg T,800020638,CDM,637,RC,J7512,HCPCS,00054874025,NDC,facility,outpatient,2.5,ME,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.00963,1.06,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,00054873925,NDC,facility,inpatient,1,ME,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,1.17,1.60,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,00054873925,NDC,facility,outpatient,1,ME,1.95000,0.57000,Aetna,First Health,,1.60,,,,,,,0.00963,1.60,percent of total billed charges,
predniSONE 50mg T,800020630,CDM,637,RC,J7512,HCPCS,00054872925,NDC,facility,inpatient,50,ME,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,1.44,1.96,percent of total billed charges,
predniSONE 50mg T,800020630,CDM,637,RC,J7512,HCPCS,00054872925,NDC,facility,outpatient,50,ME,2.40000,0.70000,Aetna,First Health,,1.96,,,,,,,0.00963,1.96,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054872625,NDC,facility,inpatient,20,ME,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.75000,1.02,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054872625,NDC,facility,outpatient,20,ME,1.25000,0.36000,Aetna,First Health,,1.02,,,,,,,0.00963,1.02,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054872525,NDC,facility,inpatient,10,ME,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.57000,0.77710,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054872525,NDC,facility,outpatient,10,ME,0.95000,0.28000,Aetna,First Health,,0.77710,,,,,,,0.00963,0.77710,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00054871404,NDC,,,facility,inpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00054871404,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00054871304,NDC,,,facility,inpatient,1,EA,30.10000,8.73000,Aetna,First Health,,24.62,,,,,,,18.06,24.62,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00054871304,NDC,,,facility,outpatient,1,EA,30.10000,8.73000,Aetna,First Health,,24.62,,,,,,,10.85,24.62,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,00054858224,NDC,,,facility,inpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,00054858224,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.93730,2.13,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00054855424,NDC,,,facility,inpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,2.10,2.86,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00054855424,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,First Health,,2.86,,,,,,,1.26,2.86,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,00054855324,NDC,,,facility,inpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.86,2.54,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,00054855324,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,First Health,,2.54,,,,,,,1.12,2.54,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00054855025,NDC,facility,inpatient,2.5,ME,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,15.15,20.65,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00054855025,NDC,facility,outpatient,2.5,ME,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,0.14445,20.65,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,00054852625,NDC,,,facility,inpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.81000,1.10,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,00054852625,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,First Health,,1.10,,,,,,,0.48668,1.10,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,00054850016,NDC,,,facility,inpatient,1,EA,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,5.34,7.28,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,00054850016,NDC,,,facility,outpatient,1,EA,8.90000,2.58000,Aetna,First Health,,7.28,,,,,,,3.21,7.28,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00054839424,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00054839424,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,00054839224,NDC,,,facility,inpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,2.25,3.07,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,00054839224,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,First Health,,3.07,,,,,,,1.35,3.07,percent of total billed charges,
Digoxin 125mcg/2.5mL (0.125mg/2.5mL) L UD,800048289,CDM,637,RC,00054819216,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
Digoxin 125mcg/2.5mL (0.125mg/2.5mL) L UD,800048289,CDM,637,RC,00054819216,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
dexaMETHasone 6mg Tab UD,800062110,CDM,637,RC,J8540,HCPCS,00054818325,NDC,facility,inpatient,6,ME,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
dexaMETHasone 6mg Tab UD,800062110,CDM,637,RC,J8540,HCPCS,00054818325,NDC,facility,outpatient,6,ME,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,0.00963,10.96,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,00054817525,NDC,facility,inpatient,4,ME,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,00054817525,NDC,facility,outpatient,4,ME,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,0.00963,6.99,percent of total billed charges,
dexaMETHasone 1mg Tab UD,800062045,CDM,636,RC,J8540,HCPCS,00054817425,NDC,facility,inpatient,1,ME,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.95532,2.17,percent of total billed charges,
dexaMETHasone 1mg Tab UD,800062045,CDM,636,RC,J8540,HCPCS,00054817425,NDC,facility,outpatient,1,ME,2.65000,0.77000,Aetna,First Health,,2.17,,,,,,,0.00963,2.17,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00054814622,NDC,,,facility,inpatient,1,EA,24.30000,7.05000,Aetna,First Health,,19.88,,,,,,,14.58,19.88,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00054814622,NDC,,,facility,outpatient,1,EA,24.30000,7.05000,Aetna,First Health,,19.88,,,,,,,8.76,19.88,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,00054485906,NDC,,,facility,inpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,3.21,4.38,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,00054485906,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,First Health,,4.38,,,,,,,1.93,4.38,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00054483121,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,8.04,10.96,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00054483121,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,First Health,,10.96,,,,,,,4.83,10.96,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00054474425,NDC,,,facility,inpatient,1,EA,0.45000,0.13000,Aetna,First Health,,0.36810,,,,,,,0.27000,0.36810,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00054474425,NDC,,,facility,outpatient,1,EA,0.45000,0.13000,Aetna,First Health,,0.36810,,,,,,,0.16223,0.36810,percent of total billed charges,
predniSONE 2.5mg T,800020638,CDM,637,RC,J7512,HCPCS,00054474225,NDC,facility,inpatient,2.5,ME,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.69000,0.94070,percent of total billed charges,
predniSONE 2.5mg T,800020638,CDM,637,RC,J7512,HCPCS,00054474225,NDC,facility,outpatient,2.5,ME,1.15000,0.33000,Aetna,First Health,,0.94070,,,,,,,0.00963,0.94070,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,00054474125,NDC,facility,inpatient,1,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
predniSONE 1mg T,800072743,CDM,637,RC,J7512,HCPCS,00054474125,NDC,facility,outpatient,1,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.00963,1.47,percent of total billed charges,
predniSONE 50mg T,800020630,CDM,637,RC,J7512,HCPCS,00054473325,NDC,facility,inpatient,50,ME,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,1.32,1.80,percent of total billed charges,
predniSONE 50mg T,800020630,CDM,637,RC,J7512,HCPCS,00054473325,NDC,facility,outpatient,50,ME,2.20000,0.64000,Aetna,First Health,,1.80,,,,,,,0.00963,1.80,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054473029,NDC,facility,inpatient,10,ME,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.18000,0.24540,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054473029,NDC,facility,outpatient,10,ME,0.30000,0.09000,Aetna,First Health,,0.24540,,,,,,,0.00963,0.24540,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054473025,NDC,facility,inpatient,10,ME,0.45000,0.13000,Aetna,First Health,,0.36810,,,,,,,0.27000,0.36810,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054473025,NDC,facility,outpatient,10,ME,0.45000,0.13000,Aetna,First Health,,0.36810,,,,,,,0.00963,0.36810,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054472929,NDC,facility,inpatient,20,ME,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.48000,0.65440,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054472929,NDC,facility,outpatient,20,ME,0.80000,0.23000,Aetna,First Health,,0.65440,,,,,,,0.00963,0.65440,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054472925,NDC,facility,inpatient,20,ME,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.51000,0.69530,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054472925,NDC,facility,outpatient,20,ME,0.85000,0.25000,Aetna,First Health,,0.69530,,,,,,,0.00963,0.69530,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00054467613,NDC,,,facility,inpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,11.52,15.71,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00054467613,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,First Health,,15.71,,,,,,,6.92,15.71,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00054465725,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00054465725,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00054457125,NDC,,,facility,inpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,2.13,2.90,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00054457125,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,First Health,,2.90,,,,,,,1.28,2.90,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,00054457025,NDC,,,facility,inpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,1.29,1.76,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,00054457025,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,First Health,,1.76,,,,,,,0.77507,1.76,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00054455025,NDC,facility,inpatient,2.5,ME,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,15.15,20.65,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00054455025,NDC,facility,outpatient,2.5,ME,25.25000,7.32000,Aetna,First Health,,20.65,,,,,,,0.14445,20.65,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00054455015,NDC,facility,inpatient,2.5,ME,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,17.19,23.44,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00054455015,NDC,facility,outpatient,2.5,ME,28.65000,8.31000,Aetna,First Health,,23.44,,,,,,,0.14445,23.44,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00054439425,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00054439425,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,00054437025,NDC,,,facility,inpatient,1,EA,10.55000,3.06000,Aetna,First Health,,8.63,,,,,,,6.33,8.63,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,00054437025,NDC,,,facility,outpatient,1,EA,10.55000,3.06000,Aetna,First Health,,8.63,,,,,,,3.80,8.63,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00054429925,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00054429925,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00054429725,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00054429725,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00054428813,NDC,,,facility,inpatient,1,EA,62.35000,18.08000,Aetna,First Health,,51.00,,,,,,,37.41,51.00,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00054428813,NDC,,,facility,outpatient,1,EA,62.35000,18.08000,Aetna,First Health,,51.00,,,,,,,22.48,51.00,percent of total billed charges,
dexaMETHasone 6mg Tab UD,800062110,CDM,637,RC,J8540,HCPCS,00054418625,NDC,facility,inpatient,6,ME,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,7.59,10.35,percent of total billed charges,
dexaMETHasone 6mg Tab UD,800062110,CDM,637,RC,J8540,HCPCS,00054418625,NDC,facility,outpatient,6,ME,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,0.00963,10.35,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,00054418425,NDC,facility,inpatient,4,ME,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,5.04,6.87,percent of total billed charges,
dexaMETHasone 4mg T(Decadron),800013428,CDM,637,RC,J8540,HCPCS,00054418425,NDC,facility,outpatient,4,ME,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,0.00963,6.87,percent of total billed charges,
dexaMETHasone 1mg Tab UD,800062045,CDM,636,RC,J8540,HCPCS,00054418125,NDC,facility,inpatient,1,ME,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
dexaMETHasone 1mg Tab UD,800062045,CDM,636,RC,J8540,HCPCS,00054418125,NDC,facility,outpatient,1,ME,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.00963,1.72,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00054414623,NDC,,,facility,inpatient,1,EA,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,12.42,16.93,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00054414623,NDC,,,facility,outpatient,1,EA,20.70000,6.00000,Aetna,First Health,,16.93,,,,,,,7.46,16.93,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00054414622,NDC,,,facility,inpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,13.65,18.61,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00054414622,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,First Health,,18.61,,,,,,,8.20,18.61,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,00054408425,NDC,facility,inpatient,50,ME,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,5.58,7.61,percent of total billed charges,
azaTHIOprine 50mg T(Imuran),800014869,CDM,637,RC,J7500,HCPCS,00054408425,NDC,facility,outpatient,50,ME,9.30000,2.70000,Aetna,First Health,,7.61,,,,,,,0.05778,7.61,percent of total billed charges,
predniSONE 5mg/mL L(Pred Intensol),800020633,CDM,637,RC,J7512,HCPCS,00054372144,NDC,facility,inpatient,5,ME,36.80000,10.67000,Aetna,First Health,,30.10,,,,,,,22.08,30.10,percent of total billed charges,
predniSONE 5mg/mL L(Pred Intensol),800020633,CDM,637,RC,J7512,HCPCS,00054372144,NDC,facility,outpatient,5,ME,36.80000,10.67000,Aetna,First Health,,30.10,,,,,,,0.00963,30.10,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00054368263,NDC,,,facility,inpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,2.22,3.03,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00054368263,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),800075274,CDM,637,RC,00054356699,NDC,,,facility,inpatient,1,EA,17.25000,5.00000,Aetna,First Health,,14.11,,,,,,,10.35,14.11,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),800075274,CDM,637,RC,00054356699,NDC,,,facility,outpatient,1,EA,17.25000,5.00000,Aetna,First Health,,14.11,,,,,,,6.22,14.11,percent of total billed charges,
Methadone 100mg/10mL Oral Conc,800025565,CDM,637,RC,00054355344,NDC,,,facility,inpatient,1,EA,67.60000,19.60000,Aetna,First Health,,55.30,,,,,,,40.56,55.30,percent of total billed charges,
Methadone 100mg/10mL Oral Conc,800025565,CDM,637,RC,00054355344,NDC,,,facility,outpatient,1,EA,67.60000,19.60000,Aetna,First Health,,55.30,,,,,,,24.37,55.30,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00054354258,NDC,,,facility,inpatient,1,EA,42.45000,12.31000,Aetna,First Health,,34.72,,,,,,,25.47,34.72,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00054354258,NDC,,,facility,outpatient,1,EA,42.45000,12.31000,Aetna,First Health,,34.72,,,,,,,15.30,34.72,percent of total billed charges,
LORazepam 1mg/0.5mL Oral Conc,800025501,CDM,637,RC,00054353244,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
LORazepam 1mg/0.5mL Oral Conc,800025501,CDM,637,RC,00054353244,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00054350547,NDC,,,facility,inpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,2.52,5.56,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00054350547,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,First Health,,5.56,,,,,,,2.45,5.56,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,00054327099,NDC,,,facility,inpatient,1,EA,607.45000,176.16000,Aetna,First Health,,496.89,,,,,,,364.47,496.89,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,00054327099,NDC,,,facility,outpatient,1,EA,607.45000,176.16000,Aetna,First Health,,496.89,,,,,,,218.99,496.89,percent of total billed charges,
Diphenoxylate - Atrop 5mL UD Oral Liq,800015356,CDM,637,RC,00054319446,NDC,,,facility,inpatient,1,EA,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,33.60,45.81,percent of total billed charges,
Diphenoxylate - Atrop 5mL UD Oral Liq,800015356,CDM,637,RC,00054319446,NDC,,,facility,outpatient,1,EA,56.00000,16.24000,Aetna,First Health,,45.81,,,,,,,20.19,45.81,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,00054261725,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,3.48,4.74,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,00054261725,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,First Health,,4.74,,,,,,,2.09,4.74,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,00054261625,NDC,,,facility,inpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,2.94,4.01,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,00054261625,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,First Health,,4.01,,,,,,,1.77,4.01,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,00054252625,NDC,,,facility,inpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.72000,0.98160,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,00054252625,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,First Health,,0.98160,,,,,,,0.43260,0.98160,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00054074287,NDC,,,facility,inpatient,1,EA,592.65000,171.87000,Aetna,First Health,,484.79,,,,,,,355.59,484.79,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00054074287,NDC,,,facility,outpatient,1,EA,592.65000,171.87000,Aetna,First Health,,484.79,,,,,,,213.65,484.79,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,00054043425,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,4.02,5.48,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,00054043425,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,First Health,,5.48,,,,,,,2.42,5.48,percent of total billed charges,
HYDROmorphone 5mg/5mL Oral Soln,800025677,CDM,637,RC,00054038663,NDC,,,facility,inpatient,1,EA,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,14.40,19.63,percent of total billed charges,
HYDROmorphone 5mg/5mL Oral Soln,800025677,CDM,637,RC,00054038663,NDC,,,facility,outpatient,1,EA,24.00000,6.96000,Aetna,First Health,,19.63,,,,,,,8.65,19.63,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00054032856,NDC,,,facility,inpatient,1,EA,3285.40000,952.77000,Aetna,First Health,,2687.46,,,,,,,1971.24,2687.46,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00054032856,NDC,,,facility,outpatient,1,EA,3285.40000,952.77000,Aetna,First Health,,2687.46,,,,,,,1184.39,2687.46,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00054032756,NDC,,,facility,inpatient,1,EA,2566.35000,744.24000,Aetna,First Health,,2099.27,,,,,,,1539.81,2099.27,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00054032756,NDC,,,facility,outpatient,1,EA,2566.35000,744.24000,Aetna,First Health,,2099.27,,,,,,,925.17,2099.27,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00054032656,NDC,,,facility,inpatient,1,EA,2121.10000,615.12000,Aetna,First Health,,1735.06,,,,,,,1272.66,1735.06,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00054032656,NDC,,,facility,outpatient,1,EA,2121.10000,615.12000,Aetna,First Health,,1735.06,,,,,,,764.66,1735.06,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,00054029399,NDC,,,facility,inpatient,1,EA,677.00000,196.33000,Aetna,First Health,,553.79,,,,,,,406.20,553.79,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,00054029399,NDC,,,facility,outpatient,1,EA,677.00000,196.33000,Aetna,First Health,,553.79,,,,,,,244.06,553.79,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,00054026913,NDC,,,facility,inpatient,1,EA,128.40000,37.24000,Aetna,First Health,,105.03,,,,,,,77.04,105.03,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,00054026913,NDC,,,facility,outpatient,1,EA,128.40000,37.24000,Aetna,First Health,,105.03,,,,,,,46.29,105.03,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00054026424,NDC,,,facility,inpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,3.45,4.70,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00054026424,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,First Health,,4.70,,,,,,,2.07,4.70,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00054025922,NDC,,,facility,inpatient,1,EA,40.05000,11.61000,Aetna,First Health,,32.76,,,,,,,24.03,32.76,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00054025922,NDC,,,facility,outpatient,1,EA,40.05000,11.61000,Aetna,First Health,,32.76,,,,,,,14.44,32.76,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00054025913,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,2.16,2.94,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00054025913,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,First Health,,2.94,,,,,,,1.30,2.94,percent of total billed charges,
Morphine 5mg/1.25 mL Oral Liq,800015448,CDM,637,RC,00054023849,NDC,,,facility,inpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,1.05,1.43,percent of total billed charges,
Morphine 5mg/1.25 mL Oral Liq,800015448,CDM,637,RC,00054023849,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,First Health,,1.43,,,,,,,0.63087,1.43,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,00054023525,NDC,,,facility,inpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,2.49,3.39,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,00054023525,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,First Health,,3.39,,,,,,,1.50,3.39,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,00054023524,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,00054023524,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00054022625,NDC,,,facility,inpatient,1,EA,22.65000,6.57000,Aetna,First Health,,18.53,,,,,,,13.59,18.53,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00054022625,NDC,,,facility,outpatient,1,EA,22.65000,6.57000,Aetna,First Health,,18.53,,,,,,,8.17,18.53,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00054022613,NDC,,,facility,inpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,13.47,18.36,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00054022613,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,8.09,18.36,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,00054022125,NDC,,,facility,inpatient,1,EA,48.55000,14.08000,Aetna,First Health,,39.71,,,,,,,29.13,39.71,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,00054022125,NDC,,,facility,outpatient,1,EA,48.55000,14.08000,Aetna,First Health,,39.71,,,,,,,17.50,39.71,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,00054022025,NDC,,,facility,inpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,16.98,23.15,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,00054022025,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,First Health,,23.15,,,,,,,10.20,23.15,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,00054019713,NDC,,,facility,inpatient,1,EA,49.20000,14.27000,Aetna,First Health,,40.25,,,,,,,29.52,40.25,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,00054019713,NDC,,,facility,outpatient,1,EA,49.20000,14.27000,Aetna,First Health,,40.25,,,,,,,17.74,40.25,percent of total billed charges,
Buprenorphine-Naloxone 8-2mg SLT,800072440,CDM,637,RC,J0574,HCPCS,00054018913,NDC,facility,inpatient,1,EA,83.35000,24.17000,Aetna,First Health,,68.18,,,,,,,50.01,68.18,percent of total billed charges,
Buprenorphine-Naloxone 8-2mg SLT,800072440,CDM,637,RC,J0574,HCPCS,00054018913,NDC,facility,outpatient,1,EA,83.35000,24.17000,Aetna,First Health,,68.18,,,,,,,9.80,68.18,percent of total billed charges,
Buprenorphine-Naloxone 2-0.5mg SLTab,800072441,CDM,637,RC,J0572,HCPCS,00054018813,NDC,facility,inpatient,1,EA,46.60000,13.51000,Aetna,First Health,,38.12,,,,,,,27.96,38.12,percent of total billed charges,
Buprenorphine-Naloxone 2-0.5mg SLTab,800072441,CDM,637,RC,J0572,HCPCS,00054018813,NDC,facility,outpatient,1,EA,46.60000,13.51000,Aetna,First Health,,38.12,,,,,,,5.48,38.12,percent of total billed charges,
Buprenorphine 8mg SL Tab,800019980,CDM,637,RC,J0571,HCPCS,00054017713,NDC,facility,inpatient,8,ME,61.90000,17.95000,Aetna,First Health,,50.63,,,,,,,37.14,50.63,percent of total billed charges,
Buprenorphine 8mg SL Tab,800019980,CDM,637,RC,J0571,HCPCS,00054017713,NDC,facility,outpatient,8,ME,61.90000,17.95000,Aetna,First Health,,50.63,,,,,,,2.08,50.63,percent of total billed charges,
Buprenorphine 2mg SL Tab,800021993,CDM,637,RC,J0571,HCPCS,00054017613,NDC,facility,inpatient,2,ME,33.10000,9.60000,Aetna,First Health,,27.08,,,,,,,19.86,27.08,percent of total billed charges,
Buprenorphine 2mg SL Tab,800021993,CDM,637,RC,J0571,HCPCS,00054017613,NDC,facility,outpatient,2,ME,33.10000,9.60000,Aetna,First Health,,27.08,,,,,,,2.08,27.08,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00054012322,NDC,,,facility,inpatient,1,EA,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,7.65,10.43,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00054012322,NDC,,,facility,outpatient,1,EA,12.75000,3.70000,Aetna,First Health,,10.43,,,,,,,4.60,10.43,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00054011925,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,10.65,14.52,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00054011925,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00054011825,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,10.65,14.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00054011825,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,First Health,,14.52,,,,,,,6.40,14.52,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,00054011625,NDC,,,facility,inpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,1.53,2.09,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,00054011625,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,00054010825,NDC,,,facility,inpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,00054010825,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.61285,1.39,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,00054010725,NDC,,,facility,inpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.96000,1.31,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,00054010725,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,00054010625,NDC,,,facility,inpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,6.51,8.88,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,00054010625,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,00054009825,NDC,,,facility,inpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,11.28,15.38,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,00054009825,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,First Health,,15.38,,,,,,,6.78,15.38,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00054009725,NDC,,,facility,inpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,6.18,8.43,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00054009725,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,First Health,,8.43,,,,,,,3.71,8.43,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,00054008826,NDC,facility,inpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,00054008826,NDC,facility,outpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,0.03852,5.93,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,00054008813,NDC,facility,inpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Calcium Acetate 667 mg C(PhosLo Gelcap),800069715,CDM,637,RC,J0615,HCPCS,00054008813,NDC,facility,outpatient,667,ME,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,0.03852,5.93,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00054008720,NDC,,,facility,inpatient,1,EA,38.85000,11.27000,Aetna,First Health,,31.78,,,,,,,23.31,31.78,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00054008720,NDC,,,facility,outpatient,1,EA,38.85000,11.27000,Aetna,First Health,,31.78,,,,,,,14.01,31.78,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00054008625,NDC,,,facility,inpatient,1,EA,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,22.20,30.27,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00054008625,NDC,,,facility,outpatient,1,EA,37.00000,10.73000,Aetna,First Health,,30.27,,,,,,,13.34,30.27,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00054008620,NDC,,,facility,inpatient,1,EA,38.85000,11.27000,Aetna,First Health,,31.78,,,,,,,23.31,31.78,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00054008620,NDC,,,facility,outpatient,1,EA,38.85000,11.27000,Aetna,First Health,,31.78,,,,,,,14.01,31.78,percent of total billed charges,
Digoxin 125mcg/2.5mL (0.125mg/2.5mL) L UD,800048289,CDM,637,RC,00054005716,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Digoxin 125mcg/2.5mL (0.125mg/2.5mL) L UD,800048289,CDM,637,RC,00054005716,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00054005625,NDC,,,facility,inpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,6.48,8.83,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00054005625,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,First Health,,8.83,,,,,,,3.89,8.83,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,00054004544,NDC,,,facility,inpatient,1,EA,713.10000,206.80000,Aetna,First Health,,583.32,,,,,,,427.86,583.32,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,00054004544,NDC,,,facility,outpatient,1,EA,713.10000,206.80000,Aetna,First Health,,583.32,,,,,,,257.07,583.32,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00054003721,NDC,,,facility,inpatient,1,EA,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,19.20,26.18,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00054003721,NDC,,,facility,outpatient,1,EA,32.00000,9.28000,Aetna,First Health,,26.18,,,,,,,11.54,26.18,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,00054002125,NDC,,,facility,inpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.98,2.70,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,00054002125,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,First Health,,2.70,,,,,,,1.19,2.70,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00054002025,NDC,,,facility,inpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,2.28,3.11,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00054002025,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,First Health,,3.11,,,,,,,1.37,3.11,percent of total billed charges,
predniSONE 50mg T,800020630,CDM,637,RC,J7512,HCPCS,00054001925,NDC,facility,inpatient,50,ME,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,1.74,2.37,percent of total billed charges,
predniSONE 50mg T,800020630,CDM,637,RC,J7512,HCPCS,00054001925,NDC,facility,outpatient,50,ME,2.90000,0.84000,Aetna,First Health,,2.37,,,,,,,0.00963,2.37,percent of total billed charges,
predniSONE 50mg T,800020630,CDM,637,RC,J7512,HCPCS,00054001920,NDC,facility,inpatient,50,ME,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
predniSONE 50mg T,800020630,CDM,637,RC,J7512,HCPCS,00054001920,NDC,facility,outpatient,50,ME,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,0.00963,2.41,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054001829,NDC,facility,inpatient,20,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054001829,NDC,facility,outpatient,20,ME,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.00963,1.47,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054001825,NDC,facility,inpatient,20,ME,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054001825,NDC,facility,outpatient,20,ME,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.00963,1.51,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054001820,NDC,facility,inpatient,20,ME,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,1.20,1.64,percent of total billed charges,
predniSONE 20mg T,800020636,CDM,637,RC,J7512,HCPCS,00054001820,NDC,facility,outpatient,20,ME,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.00963,1.64,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054001729,NDC,facility,inpatient,10,ME,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054001729,NDC,facility,outpatient,10,ME,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.00963,1.39,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054001725,NDC,facility,inpatient,10,ME,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,1.02,1.39,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054001725,NDC,facility,outpatient,10,ME,1.70000,0.49000,Aetna,First Health,,1.39,,,,,,,0.00963,1.39,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054001720,NDC,facility,inpatient,10,ME,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,1.14,1.55,percent of total billed charges,
predniSONE 10mg T,800020628,CDM,637,RC,J7512,HCPCS,00054001720,NDC,facility,outpatient,10,ME,1.90000,0.55000,Aetna,First Health,,1.55,,,,,,,0.00963,1.55,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,00054001125,NDC,,,facility,inpatient,1,EA,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,15.21,20.74,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,00054001125,NDC,,,facility,outpatient,1,EA,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,9.14,20.74,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,00054001120,NDC,,,facility,inpatient,1,EA,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,15.21,20.74,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,00054001120,NDC,,,facility,outpatient,1,EA,25.35000,7.35000,Aetna,First Health,,20.74,,,,,,,9.14,20.74,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00054000725,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00054000725,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00054000713,NDC,,,facility,inpatient,1,EA,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,5.43,7.40,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00054000713,NDC,,,facility,outpatient,1,EA,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,3.26,7.40,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,00053768032,NDC,facility,inpatient,12.5,GM,733.50000,212.71000,Aetna,First Health,,600.00,,,,,,,264.43,600.00,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,00053768032,NDC,facility,outpatient,12.5,GM,733.50000,212.71000,Aetna,First Health,,600.00,,,,,,,51.12,600.00,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,00053767031,NDC,facility,inpatient,12.5,GM,818.25000,237.29000,Aetna,First Health,,669.33,,,,,,,294.98,669.33,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,00053767031,NDC,facility,outpatient,12.5,GM,818.25000,237.29000,Aetna,First Health,,669.33,,,,,,,51.12,669.33,percent of total billed charges,
Alpha 1-Proteinase inhibitor human 10mg I(Zemaira),800051045,CDM,636,RC,J0256,HCPCS,00053720202,NDC,facility,inpatient,10,ME,58.55000,16.98000,Aetna,First Health,,47.89,,,,,,,21.11,47.89,percent of total billed charges,
Alpha 1-Proteinase inhibitor human 10mg I(Zemaira),800051045,CDM,636,RC,J0256,HCPCS,00053720202,NDC,facility,outpatient,10,ME,58.55000,16.98000,Aetna,First Health,,47.89,,,,,,,5.17,47.89,percent of total billed charges,
Alpha 1-Proteinase inhibitor human 10mg I(Zemaira),800051045,CDM,636,RC,J0256,HCPCS,00053720102,NDC,facility,inpatient,10,ME,58.55000,16.98000,Aetna,First Health,,47.89,,,,,,,21.11,47.89,percent of total billed charges,
Alpha 1-Proteinase inhibitor human 10mg I(Zemaira),800051045,CDM,636,RC,J0256,HCPCS,00053720102,NDC,facility,outpatient,10,ME,58.55000,16.98000,Aetna,First Health,,47.89,,,,,,,5.17,47.89,percent of total billed charges,
Thrombin Bovine 5000 IU,800016857,CDM,250,RC,00053710201,NDC,,,facility,inpatient,1,EA,506.70000,146.94000,Aetna,First Health,,414.48,,,,,,,187.48,414.48,percent of total billed charges,
Thrombin Bovine 5000 IU,800016857,CDM,250,RC,00053710201,NDC,,,facility,outpatient,1,EA,506.70000,146.94000,Aetna,First Health,,414.48,,,,,,,182.67,414.48,percent of total billed charges,
Etonogestrel 68 mg Implant,800062083,CDM,636,RC,J7307,HCPCS,00052433001,NDC,facility,inpatient,68,ME,6567.80000,1904.66000,Aetna,First Health,,5372.46,,,,,,,2367.69,5372.46,percent of total billed charges,
Etonogestrel 68 mg Implant,800062083,CDM,636,RC,J7307,HCPCS,00052433001,NDC,facility,outpatient,68,ME,6567.80000,1904.66000,Aetna,First Health,,5372.46,,,,,,,1336.20,5372.46,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,00052073110,NDC,facility,inpatient,0.25,ME,85.90000,24.91000,Aetna,First Health,,70.27,,,,,,,30.97,70.27,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,00052073110,NDC,facility,outpatient,0.25,ME,85.90000,24.91000,Aetna,First Health,,70.27,,,,,,,19.89,70.27,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00052045016,NDC,,,facility,inpatient,1,EA,129.80000,37.64000,Aetna,First Health,,106.18,,,,,,,48.03,106.18,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00052045016,NDC,,,facility,outpatient,1,EA,129.80000,37.64000,Aetna,First Health,,106.18,,,,,,,46.79,106.18,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00052045015,NDC,,,facility,inpatient,1,EA,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,50.51,111.66,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00052045015,NDC,,,facility,outpatient,1,EA,136.50000,39.58000,Aetna,First Health,,111.66,,,,,,,49.21,111.66,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00052044115,NDC,,,facility,inpatient,1,EA,86.45000,25.07000,Aetna,First Health,,70.72,,,,,,,31.99,70.72,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00052044115,NDC,,,facility,outpatient,1,EA,86.45000,25.07000,Aetna,First Health,,70.72,,,,,,,31.17,70.72,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00052010590,NDC,,,facility,inpatient,1,EA,22.30000,6.47000,Aetna,First Health,,18.24,,,,,,,13.38,18.24,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00052010590,NDC,,,facility,outpatient,1,EA,22.30000,6.47000,Aetna,First Health,,18.24,,,,,,,8.04,18.24,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00052010530,NDC,,,facility,inpatient,1,EA,45.35000,13.15000,Aetna,First Health,,37.10,,,,,,,27.21,37.10,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00052010530,NDC,,,facility,outpatient,1,EA,45.35000,13.15000,Aetna,First Health,,37.10,,,,,,,16.35,37.10,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,00051842530,NDC,,,facility,inpatient,1,EA,199.40000,57.83000,Aetna,First Health,,163.11,,,,,,,119.64,163.11,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,00051842530,NDC,,,facility,outpatient,1,EA,199.40000,57.83000,Aetna,First Health,,163.11,,,,,,,71.88,163.11,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00049561066,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00049561066,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490073,NDC,,,facility,inpatient,1,EA,20.50000,5.94000,Aetna,First Health,,16.77,,,,,,,12.30,16.77,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490073,NDC,,,facility,outpatient,1,EA,20.50000,5.94000,Aetna,First Health,,16.77,,,,,,,7.39,16.77,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490066,NDC,,,facility,inpatient,1,EA,20.50000,5.94000,Aetna,First Health,,16.77,,,,,,,12.30,16.77,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490066,NDC,,,facility,outpatient,1,EA,20.50000,5.94000,Aetna,First Health,,16.77,,,,,,,7.39,16.77,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490041,NDC,,,facility,inpatient,1,EA,126.55000,36.70000,Aetna,First Health,,103.52,,,,,,,75.93,103.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490041,NDC,,,facility,outpatient,1,EA,126.55000,36.70000,Aetna,First Health,,103.52,,,,,,,45.62,103.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490030,NDC,,,facility,inpatient,1,EA,126.55000,36.70000,Aetna,First Health,,103.52,,,,,,,75.93,103.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490030,NDC,,,facility,outpatient,1,EA,126.55000,36.70000,Aetna,First Health,,103.52,,,,,,,45.62,103.52,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00049399060,NDC,,,facility,inpatient,1,EA,199.30000,57.80000,Aetna,First Health,,163.03,,,,,,,119.58,163.03,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00049399060,NDC,,,facility,outpatient,1,EA,199.30000,57.80000,Aetna,First Health,,163.03,,,,,,,71.85,163.03,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00049399041,NDC,,,facility,inpatient,1,EA,131.65000,38.18000,Aetna,First Health,,107.69,,,,,,,78.99,107.69,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00049399041,NDC,,,facility,outpatient,1,EA,131.65000,38.18000,Aetna,First Health,,107.69,,,,,,,47.46,107.69,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,00049396060,NDC,,,facility,inpatient,1,EA,163.40000,47.39000,Aetna,First Health,,133.66,,,,,,,98.04,133.66,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,00049396060,NDC,,,facility,outpatient,1,EA,163.40000,47.39000,Aetna,First Health,,133.66,,,,,,,58.91,133.66,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,00049392083,NDC,facility,inpatient,20,ME,375.00000,108.75000,Aetna,First Health,,306.75,,,,,,,135.19,306.75,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,00049392083,NDC,facility,outpatient,20,ME,375.00000,108.75000,Aetna,First Health,,306.75,,,,,,,8.81,306.75,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00049343526,NDC,facility,inpatient,200,ME,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,73.54,166.87,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00049343526,NDC,facility,outpatient,200,ME,204.00000,59.16000,Aetna,First Health,,166.87,,,,,,,4.31,166.87,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00049342041,NDC,,,facility,inpatient,1,EA,317.00000,91.93000,Aetna,First Health,,259.31,,,,,,,190.20,259.31,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00049342041,NDC,,,facility,outpatient,1,EA,317.00000,91.93000,Aetna,First Health,,259.31,,,,,,,114.28,259.31,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00049342030,NDC,,,facility,inpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,5.79,7.89,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00049342030,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,3.48,7.89,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00049337226,NDC,facility,inpatient,400,ME,1470.20000,426.36000,Aetna,First Health,,1202.62,,,,,,,530.01,1202.62,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00049337226,NDC,facility,outpatient,400,ME,1470.20000,426.36000,Aetna,First Health,,1202.62,,,,,,,4.31,1202.62,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00049337126,NDC,facility,inpatient,200,ME,1057.90000,306.79000,Aetna,First Health,,865.36,,,,,,,381.37,865.36,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00049337126,NDC,facility,outpatient,200,ME,1057.90000,306.79000,Aetna,First Health,,865.36,,,,,,,4.31,865.36,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,00049318030,NDC,,,facility,inpatient,1,EA,31.65000,9.18000,Aetna,First Health,,25.89,,,,,,,18.99,25.89,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,00049318030,NDC,,,facility,outpatient,1,EA,31.65000,9.18000,Aetna,First Health,,25.89,,,,,,,11.41,25.89,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00049276066,NDC,,,facility,inpatient,1,EA,43.55000,12.63000,Aetna,First Health,,35.62,,,,,,,26.13,35.62,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00049276066,NDC,,,facility,outpatient,1,EA,43.55000,12.63000,Aetna,First Health,,35.62,,,,,,,15.70,35.62,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00049276041,NDC,,,facility,inpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,4.50,6.13,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00049276041,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,First Health,,6.13,,,,,,,2.70,6.13,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00049275066,NDC,,,facility,inpatient,1,EA,43.55000,12.63000,Aetna,First Health,,35.62,,,,,,,26.13,35.62,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00049275066,NDC,,,facility,outpatient,1,EA,43.55000,12.63000,Aetna,First Health,,35.62,,,,,,,15.70,35.62,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00049275041,NDC,,,facility,inpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,5.04,6.87,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00049275041,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,3.03,6.87,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,00049162030,NDC,,,facility,inpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,3.81,5.19,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,00049162030,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,First Health,,5.19,,,,,,,2.29,5.19,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,inpatient,1,EA,122.10000,35.41000,Aetna,First Health,,99.88,,,,,,,44.02,99.88,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,outpatient,1,EA,122.10000,35.41000,Aetna,First Health,,99.88,,,,,,,0.75114,99.88,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00049052022,NDC,facility,inpatient,1,EA,122.10000,35.41000,Aetna,First Health,,99.88,,,,,,,44.02,99.88,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00049052022,NDC,facility,outpatient,1,EA,122.10000,35.41000,Aetna,First Health,,99.88,,,,,,,0.75114,99.88,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,inpatient,3,GM,139.80000,40.54000,Aetna,First Health,,114.36,,,,,,,50.40,114.36,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,outpatient,3,GM,139.80000,40.54000,Aetna,First Health,,114.36,,,,,,,1.28,114.36,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1.5,GM,74.05000,21.47000,Aetna,First Health,,60.57,,,,,,,26.70,60.57,percent of total billed charges,
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,outpatient,1.5,GM,74.05000,21.47000,Aetna,First Health,,60.57,,,,,,,1.28,60.57,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00048110003,NDC,,,facility,inpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,2.76,3.76,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00048110003,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,First Health,,3.76,,,,,,,1.66,3.76,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00048108003,NDC,,,facility,inpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,2.22,3.03,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00048108003,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,First Health,,3.03,,,,,,,1.33,3.03,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00048106003,NDC,,,facility,inpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.93000,1.27,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00048106003,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,First Health,,1.27,,,,,,,0.55878,1.27,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00048105013,NDC,,,facility,inpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.90000,1.23,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00048105013,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.54075,1.23,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00048102005,NDC,,,facility,inpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,1.20,1.64,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00048102005,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,00047008420,NDC,,,facility,inpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,4.23,5.77,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,00047008420,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,First Health,,5.77,,,,,,,2.54,5.77,percent of total billed charges,
Conj Estrogen 0.3mg T(Premarin),800017821,CDM,637,RC,00046110081,NDC,,,facility,inpatient,1,EA,60.10000,17.43000,Aetna,First Health,,49.16,,,,,,,36.06,49.16,percent of total billed charges,
Conj Estrogen 0.3mg T(Premarin),800017821,CDM,637,RC,00046110081,NDC,,,facility,outpatient,1,EA,60.10000,17.43000,Aetna,First Health,,49.16,,,,,,,21.67,49.16,percent of total billed charges,
Conjugated Estrogen 30g Vag Cr,800034412,CDM,637,RC,00046087293,NDC,,,facility,inpatient,1,EA,744.55000,215.92000,Aetna,First Health,,609.04,,,,,,,446.73,609.04,percent of total billed charges,
Conjugated Estrogen 30g Vag Cr,800034412,CDM,637,RC,00046087293,NDC,,,facility,outpatient,1,EA,744.55000,215.92000,Aetna,First Health,,609.04,,,,,,,268.41,609.04,percent of total billed charges,
Conjugated Estrogen 30g Vag Cr,800034412,CDM,637,RC,00046087221,NDC,,,facility,inpatient,1,EA,3094.35000,897.36000,Aetna,First Health,,2531.18,,,,,,,1856.61,2531.18,percent of total billed charges,
Conjugated Estrogen 30g Vag Cr,800034412,CDM,637,RC,00046087221,NDC,,,facility,outpatient,1,EA,3094.35000,897.36000,Aetna,First Health,,2531.18,,,,,,,1115.51,2531.18,percent of total billed charges,
Conjugated Estrogen 30g Vag Cr,800034412,CDM,637,RC,00046087201,NDC,,,facility,inpatient,1,EA,317.20000,91.99000,Aetna,First Health,,259.47,,,,,,,190.32,259.47,percent of total billed charges,
Conjugated Estrogen 30g Vag Cr,800034412,CDM,637,RC,00046087201,NDC,,,facility,outpatient,1,EA,317.20000,91.99000,Aetna,First Health,,259.47,,,,,,,114.35,259.47,percent of total billed charges,
Conj Estrogen 0.3mg T(Premarin),800017821,CDM,637,RC,00046086881,NDC,,,facility,inpatient,1,EA,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,5.43,7.40,percent of total billed charges,
Conj Estrogen 0.3mg T(Premarin),800017821,CDM,637,RC,00046086881,NDC,,,facility,outpatient,1,EA,9.05000,2.62000,Aetna,First Health,,7.40,,,,,,,3.26,7.40,percent of total billed charges,
Conj Estrogen 25mg I (Premarin),800012898,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,inpatient,25,ME,2900.55000,841.16000,Aetna,First Health,,2372.65,,,,,,,1045.65,2372.65,percent of total billed charges,
Conj Estrogen 25mg I (Premarin),800012898,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,outpatient,25,ME,2900.55000,841.16000,Aetna,First Health,,2372.65,,,,,,,377.26,2372.65,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,00046047181,NDC,,,facility,inpatient,1,EA,31.85000,9.24000,Aetna,First Health,,26.05,,,,,,,19.11,26.05,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,00046047181,NDC,,,facility,outpatient,1,EA,31.85000,9.24000,Aetna,First Health,,26.05,,,,,,,11.48,26.05,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,00046047081,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,00046047081,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,00045152550,NDC,,,facility,inpatient,1,EA,108.35000,31.42000,Aetna,First Health,,88.63,,,,,,,65.01,88.63,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,00045152550,NDC,,,facility,outpatient,1,EA,108.35000,31.42000,Aetna,First Health,,88.63,,,,,,,39.06,88.63,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,00045152510,NDC,,,facility,inpatient,1,EA,78.50000,22.76000,Aetna,First Health,,64.21,,,,,,,47.10,64.21,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,00045152510,NDC,,,facility,outpatient,1,EA,78.50000,22.76000,Aetna,First Health,,64.21,,,,,,,28.30,64.21,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,00045152050,NDC,,,facility,inpatient,1,EA,109.60000,31.78000,Aetna,First Health,,89.65,,,,,,,65.76,89.65,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,00045152050,NDC,,,facility,outpatient,1,EA,109.60000,31.78000,Aetna,First Health,,89.65,,,,,,,39.51,89.65,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,00045152010,NDC,,,facility,inpatient,1,EA,68.50000,19.86000,Aetna,First Health,,56.03,,,,,,,41.10,56.03,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,00045152010,NDC,,,facility,outpatient,1,EA,68.50000,19.86000,Aetna,First Health,,56.03,,,,,,,24.69,56.03,percent of total billed charges,
levoFLOXacin  25mg/mL L,800081070,CDM,637,RC,00045151501,NDC,,,facility,inpatient,1,ML,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,3.90,5.32,percent of total billed charges,
levoFLOXacin  25mg/mL L,800081070,CDM,637,RC,00045151501,NDC,,,facility,outpatient,1,ML,6.50000,1.88000,Aetna,First Health,,5.32,,,,,,,2.34,5.32,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00045065960,NDC,,,facility,inpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,8.43,11.49,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00045065960,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,First Health,,11.49,,,,,,,5.07,11.49,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00045065910,NDC,,,facility,inpatient,1,EA,10.60000,3.07000,Aetna,First Health,,8.67,,,,,,,6.36,8.67,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00045065910,NDC,,,facility,outpatient,1,EA,10.60000,3.07000,Aetna,First Health,,8.67,,,,,,,3.82,8.67,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,00045064565,NDC,,,facility,inpatient,1,EA,22.10000,6.41000,Aetna,First Health,,18.08,,,,,,,13.26,18.08,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,00045064565,NDC,,,facility,outpatient,1,EA,22.10000,6.41000,Aetna,First Health,,18.08,,,,,,,7.97,18.08,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,00045064165,NDC,,,facility,inpatient,1,EA,54.85000,15.91000,Aetna,First Health,,44.87,,,,,,,32.91,44.87,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,00045064165,NDC,,,facility,outpatient,1,EA,54.85000,15.91000,Aetna,First Health,,44.87,,,,,,,19.77,44.87,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,00045063965,NDC,,,facility,inpatient,1,EA,20.10000,5.83000,Aetna,First Health,,16.44,,,,,,,12.06,16.44,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,00045063965,NDC,,,facility,outpatient,1,EA,20.10000,5.83000,Aetna,First Health,,16.44,,,,,,,7.25,16.44,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00045051372,NDC,,,facility,inpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,1.11,1.51,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00045051372,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,First Health,,1.51,,,,,,,0.66692,1.51,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00045032510,NDC,,,facility,inpatient,1,EA,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,5.16,7.03,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00045032510,NDC,,,facility,outpatient,1,EA,8.60000,2.49000,Aetna,First Health,,7.03,,,,,,,3.10,7.03,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,00045025501,NDC,facility,inpatient,5,ME,64.60000,18.73000,Aetna,First Health,,52.84,,,,,,,23.29,52.84,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,00045025501,NDC,facility,outpatient,5,ME,64.60000,18.73000,Aetna,First Health,,52.84,,,,,,,0.70299,52.84,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,00045009560,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,00045009560,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00045006801,NDC,facility,inpatient,500,ME,341.65000,99.08000,Aetna,First Health,,279.47,,,,,,,123.16,279.47,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00045006801,NDC,facility,outpatient,500,ME,341.65000,99.08000,Aetna,First Health,,279.47,,,,,,,2.08,279.47,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00045006701,NDC,facility,inpatient,250,ME,59.90000,17.37000,Aetna,First Health,,49.00,,,,,,,21.59,49.00,percent of total billed charges,
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00045006701,NDC,facility,outpatient,250,ME,59.90000,17.37000,Aetna,First Health,,49.00,,,,,,,2.08,49.00,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00045006601,NDC,facility,inpatient,750,ME,462.15000,134.02000,Aetna,First Health,,378.04,,,,,,,166.61,378.04,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00045006601,NDC,facility,outpatient,750,ME,462.15000,134.02000,Aetna,First Health,,378.04,,,,,,,2.08,378.04,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00044527003,NDC,,,facility,inpatient,1,EA,8962.65000,2599.17000,Aetna,First Health,,7331.45,,,,,,,5377.59,7331.45,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00044527003,NDC,,,facility,outpatient,1,EA,8962.65000,2599.17000,Aetna,First Health,,7331.45,,,,,,,3231.04,7331.45,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,00044502402,NDC,,,facility,inpatient,1,EA,19.85000,5.76000,Aetna,First Health,,16.24,,,,,,,11.91,16.24,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,00044502402,NDC,,,facility,outpatient,1,EA,19.85000,5.76000,Aetna,First Health,,16.24,,,,,,,7.16,16.24,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00044502202,NDC,,,facility,inpatient,1,EA,11.25000,3.26000,Aetna,First Health,,9.20,,,,,,,6.75,9.20,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00044502202,NDC,,,facility,outpatient,1,EA,11.25000,3.26000,Aetna,First Health,,9.20,,,,,,,4.06,9.20,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,00044182702,NDC,,,facility,inpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,2.58,3.52,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,00044182702,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,First Health,,3.52,,,,,,,1.55,3.52,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,00044182512,NDC,,,facility,inpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,4.17,5.69,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,00044182512,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,First Health,,5.69,,,,,,,2.51,5.69,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00044182310,NDC,,,facility,inpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,2.64,3.60,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00044182310,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,First Health,,3.60,,,,,,,1.59,3.60,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,00044182110,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,00044182110,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,00044102245,NDC,,,facility,inpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.77,2.41,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,00044102245,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,First Health,,2.41,,,,,,,1.06,2.41,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,00039010511,NDC,,,facility,inpatient,1,EA,10.95000,3.18000,Aetna,First Health,,8.96,,,,,,,6.57,8.96,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,00039010511,NDC,,,facility,outpatient,1,EA,10.95000,3.18000,Aetna,First Health,,8.96,,,,,,,3.95,8.96,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,00039010411,NDC,,,facility,inpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,6.03,8.22,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,00039010411,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,First Health,,8.22,,,,,,,3.62,8.22,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00039006710,NDC,,,facility,inpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,2.97,4.05,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00039006710,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,First Health,,4.05,,,,,,,1.78,4.05,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00039005111,NDC,,,facility,inpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,1.26,1.72,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00039005111,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,First Health,,1.72,,,,,,,0.75705,1.72,percent of total billed charges,
cefoTEtan 1g I(Cefotan),800070042,CDM,637,RC,00038037610,NDC,,,facility,inpatient,1,EA,92.95000,26.96000,Aetna,First Health,,76.03,,,,,,,55.77,76.03,percent of total billed charges,
cefoTEtan 1g I(Cefotan),800070042,CDM,637,RC,00038037610,NDC,,,facility,outpatient,1,EA,92.95000,26.96000,Aetna,First Health,,76.03,,,,,,,33.51,76.03,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00037200101,NDC,,,facility,inpatient,1,EA,107.95000,31.31000,Aetna,First Health,,88.30,,,,,,,64.77,88.30,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00037200101,NDC,,,facility,outpatient,1,EA,107.95000,31.31000,Aetna,First Health,,88.30,,,,,,,38.92,88.30,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,00037024130,NDC,,,facility,inpatient,1,EA,840.15000,243.64000,Aetna,First Health,,687.24,,,,,,,504.09,687.24,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,00037024130,NDC,,,facility,outpatient,1,EA,840.15000,243.64000,Aetna,First Health,,687.24,,,,,,,302.87,687.24,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,00037024110,NDC,,,facility,inpatient,1,EA,418.50000,121.36000,Aetna,First Health,,342.33,,,,,,,251.10,342.33,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,00037024110,NDC,,,facility,outpatient,1,EA,418.50000,121.36000,Aetna,First Health,,342.33,,,,,,,150.87,342.33,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,00033243553,NDC,,,facility,inpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,4.56,6.22,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,00033243553,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,First Health,,6.22,,,,,,,2.74,6.22,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,00032449201,NDC,,,facility,inpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,2.67,3.64,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,00032449201,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,First Health,,3.64,,,,,,,1.60,3.64,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,00032192482,NDC,,,facility,inpatient,1,EA,185.15000,53.69000,Aetna,First Health,,151.45,,,,,,,111.09,151.45,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,00032192482,NDC,,,facility,outpatient,1,EA,185.15000,53.69000,Aetna,First Health,,151.45,,,,,,,66.75,151.45,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,00032170801,NDC,,,facility,inpatient,1,EA,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,15.00,20.45,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,00032170801,NDC,,,facility,outpatient,1,EA,25.00000,7.25000,Aetna,First Health,,20.45,,,,,,,9.01,20.45,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00032160278,NDC,,,facility,inpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.24000,0.32720,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00032160278,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,First Health,,0.32720,,,,,,,0.14420,0.32720,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",800062051,CDM,637,RC,00032121207,NDC,,,facility,inpatient,1,EA,35.30000,10.24000,Aetna,First Health,,28.88,,,,,,,21.18,28.88,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",800062051,CDM,637,RC,00032121207,NDC,,,facility,outpatient,1,EA,35.30000,10.24000,Aetna,First Health,,28.88,,,,,,,12.73,28.88,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",800062051,CDM,637,RC,00032121201,NDC,,,facility,inpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,21.87,29.82,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",800062051,CDM,637,RC,00032121201,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,13.14,29.82,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",800062051,CDM,637,RC,00032004770,NDC,,,facility,inpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,21.87,29.82,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",800062051,CDM,637,RC,00032004770,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,First Health,,29.82,,,,,,,13.14,29.82,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00031890163,NDC,,,facility,inpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,10.59,14.44,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00031890163,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,First Health,,14.44,,,,,,,6.36,14.44,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,00031782463,NDC,,,facility,inpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,2.79,3.80,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,00031782463,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,First Health,,3.80,,,,,,,1.68,3.80,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00031744963,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00031744963,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00031740994,NDC,facility,inpatient,1,GM,124.40000,36.08000,Aetna,First Health,,101.76,,,,,,,44.85,101.76,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00031740994,NDC,facility,outpatient,1,GM,124.40000,36.08000,Aetna,First Health,,101.76,,,,,,,4.37,101.76,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00031670972,NDC,facility,inpatient,10,ME,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,4.51,10.22,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00031670972,NDC,facility,outpatient,10,ME,12.50000,3.62000,Aetna,First Health,,10.22,,,,,,,1.04,10.22,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,00029609039,NDC,,,facility,inpatient,1,EA,35.65000,10.34000,Aetna,First Health,,29.16,,,,,,,21.39,29.16,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,00029609039,NDC,,,facility,outpatient,1,EA,35.65000,10.34000,Aetna,First Health,,29.16,,,,,,,12.85,29.16,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,800053917,CDM,637,RC,00029609022,NDC,,,facility,inpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,10.50,14.31,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,800053917,CDM,637,RC,00029609022,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,6.31,14.31,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,00029608621,NDC,,,facility,inpatient,1,EA,45.20000,13.11000,Aetna,First Health,,36.97,,,,,,,27.12,36.97,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,00029608621,NDC,,,facility,outpatient,1,EA,45.20000,13.11000,Aetna,First Health,,36.97,,,,,,,16.29,36.97,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,00029608612,NDC,,,facility,inpatient,1,EA,56.30000,16.33000,Aetna,First Health,,46.05,,,,,,,33.78,46.05,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,00029608612,NDC,,,facility,outpatient,1,EA,56.30000,16.33000,Aetna,First Health,,46.05,,,,,,,20.30,46.05,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00029608031,NDC,,,facility,inpatient,1,EA,27.10000,7.86000,Aetna,First Health,,22.17,,,,,,,16.26,22.17,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00029608031,NDC,,,facility,outpatient,1,EA,27.10000,7.86000,Aetna,First Health,,22.17,,,,,,,9.77,22.17,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00029608012,NDC,,,facility,inpatient,1,EA,42.15000,12.22000,Aetna,First Health,,34.48,,,,,,,25.29,34.48,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00029608012,NDC,,,facility,outpatient,1,EA,42.15000,12.22000,Aetna,First Health,,34.48,,,,,,,15.20,34.48,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00029485121,NDC,,,facility,inpatient,1,EA,15.55000,4.51000,Aetna,First Health,,12.72,,,,,,,9.33,12.72,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00029485121,NDC,,,facility,outpatient,1,EA,15.55000,4.51000,Aetna,First Health,,12.72,,,,,,,5.61,12.72,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00029485120,NDC,,,facility,inpatient,1,EA,15.55000,4.51000,Aetna,First Health,,12.72,,,,,,,9.33,12.72,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00029485120,NDC,,,facility,outpatient,1,EA,15.55000,4.51000,Aetna,First Health,,12.72,,,,,,,5.61,12.72,percent of total billed charges,
PARoxetine 20mg/10mL Oral Liq.,800021981,CDM,637,RC,00029321548,NDC,,,facility,inpatient,1,EA,60.80000,17.63000,Aetna,First Health,,49.73,,,,,,,36.48,49.73,percent of total billed charges,
PARoxetine 20mg/10mL Oral Liq.,800021981,CDM,637,RC,00029321548,NDC,,,facility,outpatient,1,EA,60.80000,17.63000,Aetna,First Health,,49.73,,,,,,,21.92,49.73,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00029321159,NDC,,,facility,inpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,17.31,23.60,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00029321159,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,First Health,,23.60,,,,,,,10.40,23.60,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00029321121,NDC,,,facility,inpatient,1,EA,27.85000,8.08000,Aetna,First Health,,22.78,,,,,,,16.71,22.78,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00029321121,NDC,,,facility,outpatient,1,EA,27.85000,8.08000,Aetna,First Health,,22.78,,,,,,,10.04,22.78,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00029321120,NDC,,,facility,inpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,14.25,19.43,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00029321120,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,First Health,,19.43,,,,,,,8.56,19.43,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00029321013,NDC,,,facility,inpatient,1,EA,29.15000,8.45000,Aetna,First Health,,23.84,,,,,,,17.49,23.84,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00029321013,NDC,,,facility,outpatient,1,EA,29.15000,8.45000,Aetna,First Health,,23.84,,,,,,,10.51,23.84,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,00029152544,NDC,,,facility,inpatient,1,EA,871.50000,252.74000,Aetna,First Health,,712.89,,,,,,,522.90,712.89,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,00029152544,NDC,,,facility,outpatient,1,EA,871.50000,252.74000,Aetna,First Health,,712.89,,,,,,,314.18,712.89,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00028750723,NDC,facility,inpatient,1,ME,119.65000,34.70000,Aetna,First Health,,97.87,,,,,,,43.13,97.87,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00028750723,NDC,facility,outpatient,1,ME,119.65000,34.70000,Aetna,First Health,,97.87,,,,,,,2.38,97.87,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00028420133,NDC,,,facility,inpatient,1,EA,161.95000,46.97000,Aetna,First Health,,132.48,,,,,,,59.92,132.48,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00028420133,NDC,,,facility,outpatient,1,EA,161.95000,46.97000,Aetna,First Health,,132.48,,,,,,,58.38,132.48,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00028002301,NDC,,,facility,inpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,3.09,4.21,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00028002301,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,First Health,,4.21,,,,,,,1.86,4.21,percent of total billed charges,
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,00026063603,NDC,facility,inpatient,1,EA,367.60000,106.60000,Aetna,First Health,,300.70,,,,,,,132.52,300.70,percent of total billed charges,
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,00026063603,NDC,facility,outpatient,1,EA,367.60000,106.60000,Aetna,First Health,,300.70,,,,,,,67.02,300.70,percent of total billed charges,
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,00026063600,NDC,facility,inpatient,1,EA,367.60000,106.60000,Aetna,First Health,,300.70,,,,,,,132.52,300.70,percent of total billed charges,
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,00026063600,NDC,facility,outpatient,1,EA,367.60000,106.60000,Aetna,First Health,,300.70,,,,,,,67.02,300.70,percent of total billed charges,
Tetanus IG 250U I(Bay-Tet),800011759,CDM,636,RC,J1670,HCPCS,00026063402,NDC,facility,inpatient,250,UN,591.40000,171.51000,Aetna,First Health,,483.77,,,,,,,213.20,483.77,percent of total billed charges,
Tetanus IG 250U I(Bay-Tet),800011759,CDM,636,RC,J1670,HCPCS,00026063402,NDC,facility,outpatient,250,UN,591.40000,171.51000,Aetna,First Health,,483.77,,,,,,,218.82,1815.06,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00025542134,NDC,,,facility,inpatient,1,EA,29.70000,8.61000,Aetna,First Health,,24.29,,,,,,,17.82,24.29,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00025542134,NDC,,,facility,outpatient,1,EA,29.70000,8.61000,Aetna,First Health,,24.29,,,,,,,10.71,24.29,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00025540134,NDC,,,facility,inpatient,1,EA,24.15000,7.00000,Aetna,First Health,,19.75,,,,,,,14.49,19.75,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00025540134,NDC,,,facility,outpatient,1,EA,24.15000,7.00000,Aetna,First Health,,19.75,,,,,,,8.71,19.75,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00025182150,NDC,,,facility,inpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,3.84,5.24,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00025182150,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,First Health,,5.24,,,,,,,2.31,5.24,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,00025171002,NDC,,,facility,inpatient,1,EA,106.60000,30.91000,Aetna,First Health,,87.20,,,,,,,63.96,87.20,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,00025171002,NDC,,,facility,outpatient,1,EA,106.60000,30.91000,Aetna,First Health,,87.20,,,,,,,38.43,87.20,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,00025171001,NDC,,,facility,inpatient,1,EA,125.60000,36.42000,Aetna,First Health,,102.74,,,,,,,75.36,102.74,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,00025171001,NDC,,,facility,outpatient,1,EA,125.60000,36.42000,Aetna,First Health,,102.74,,,,,,,45.28,102.74,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00025152551,NDC,,,facility,inpatient,1,EA,139.50000,40.46000,Aetna,First Health,,114.11,,,,,,,83.70,114.11,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00025152551,NDC,,,facility,outpatient,1,EA,139.50000,40.46000,Aetna,First Health,,114.11,,,,,,,50.29,114.11,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00025152534,NDC,,,facility,inpatient,1,EA,132.85000,38.53000,Aetna,First Health,,108.67,,,,,,,79.71,108.67,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00025152534,NDC,,,facility,outpatient,1,EA,132.85000,38.53000,Aetna,First Health,,108.67,,,,,,,47.89,108.67,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00025152531,NDC,,,facility,inpatient,1,EA,139.50000,40.46000,Aetna,First Health,,114.11,,,,,,,83.70,114.11,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00025152531,NDC,,,facility,outpatient,1,EA,139.50000,40.46000,Aetna,First Health,,114.11,,,,,,,50.29,114.11,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00025152051,NDC,,,facility,inpatient,1,EA,85.05000,24.66000,Aetna,First Health,,69.57,,,,,,,51.03,69.57,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00025152051,NDC,,,facility,outpatient,1,EA,85.05000,24.66000,Aetna,First Health,,69.57,,,,,,,30.66,69.57,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00025152034,NDC,,,facility,inpatient,1,EA,81.00000,23.49000,Aetna,First Health,,66.26,,,,,,,48.60,66.26,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00025152034,NDC,,,facility,outpatient,1,EA,81.00000,23.49000,Aetna,First Health,,66.26,,,,,,,29.20,66.26,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00025152031,NDC,,,facility,inpatient,1,EA,85.05000,24.66000,Aetna,First Health,,69.57,,,,,,,51.03,69.57,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00025152031,NDC,,,facility,outpatient,1,EA,85.05000,24.66000,Aetna,First Health,,69.57,,,,,,,30.66,69.57,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00025146160,NDC,,,facility,inpatient,1,EA,49.95000,14.49000,Aetna,First Health,,40.86,,,,,,,29.97,40.86,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00025146160,NDC,,,facility,outpatient,1,EA,49.95000,14.49000,Aetna,First Health,,40.86,,,,,,,18.01,40.86,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00025146134,NDC,,,facility,inpatient,1,EA,49.15000,14.25000,Aetna,First Health,,40.20,,,,,,,29.49,40.20,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00025146134,NDC,,,facility,outpatient,1,EA,49.15000,14.25000,Aetna,First Health,,40.20,,,,,,,17.72,40.20,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00025146131,NDC,,,facility,inpatient,1,EA,49.95000,14.49000,Aetna,First Health,,40.86,,,,,,,29.97,40.86,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00025146131,NDC,,,facility,outpatient,1,EA,49.95000,14.49000,Aetna,First Health,,40.86,,,,,,,18.01,40.86,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00025145160,NDC,,,facility,inpatient,1,EA,33.95000,9.85000,Aetna,First Health,,27.77,,,,,,,20.37,27.77,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00025145160,NDC,,,facility,outpatient,1,EA,33.95000,9.85000,Aetna,First Health,,27.77,,,,,,,12.24,27.77,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00025145134,NDC,,,facility,inpatient,1,EA,35.60000,10.32000,Aetna,First Health,,29.12,,,,,,,21.36,29.12,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00025145134,NDC,,,facility,outpatient,1,EA,35.60000,10.32000,Aetna,First Health,,29.12,,,,,,,12.83,29.12,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00025100131,NDC,,,facility,inpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,13.95,19.02,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00025100131,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,First Health,,19.02,,,,,,,8.38,19.02,percent of total billed charges,
Dupilumab 200mg/1.14mL Inj,800052004,CDM,636,RC,C9399,HCPCS,00024591902,NDC,facility,inpatient,200,ME,8144.75000,2361.98000,Aetna,First Health,,6662.41,,,,,,,2936.18,6662.41,percent of total billed charges,
Dupilumab 200mg/1.14mL Inj,800052004,CDM,636,RC,C9399,HCPCS,00024591902,NDC,facility,outpatient,200,ME,8144.75000,2361.98000,Aetna,First Health,,6662.41,,,,,,,2936.18,6662.41,percent of total billed charges,
Dupilumab 200mg/1.14mL Inj,800052004,CDM,636,RC,C9399,HCPCS,00024591801,NDC,facility,inpatient,200,ME,8144.75000,2361.98000,Aetna,First Health,,6662.41,,,,,,,2936.18,6662.41,percent of total billed charges,
Dupilumab 200mg/1.14mL Inj,800052004,CDM,636,RC,C9399,HCPCS,00024591801,NDC,facility,outpatient,200,ME,8144.75000,2361.98000,Aetna,First Health,,6662.41,,,,,,,2936.18,6662.41,percent of total billed charges,
Dupilumab 300mg/2mL Inj,800046554,CDM,636,RC,C9399,HCPCS,00024591502,NDC,facility,inpatient,300,ME,8144.75000,2361.98000,Aetna,First Health,,6662.41,,,,,,,2936.18,6662.41,percent of total billed charges,
Dupilumab 300mg/2mL Inj,800046554,CDM,636,RC,C9399,HCPCS,00024591502,NDC,facility,outpatient,300,ME,8144.75000,2361.98000,Aetna,First Health,,6662.41,,,,,,,2936.18,6662.41,percent of total billed charges,
Dupilumab 300mg/2mL Inj,800046554,CDM,636,RC,C9399,HCPCS,00024591401,NDC,facility,inpatient,300,ME,8144.75000,2361.98000,Aetna,First Health,,6662.41,,,,,,,2936.18,6662.41,percent of total billed charges,
Dupilumab 300mg/2mL Inj,800046554,CDM,636,RC,C9399,HCPCS,00024591401,NDC,facility,outpatient,300,ME,8144.75000,2361.98000,Aetna,First Health,,6662.41,,,,,,,2936.18,6662.41,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00024542134,NDC,,,facility,inpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,25.89,35.30,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00024542134,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,15.56,35.30,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00024542131,NDC,,,facility,inpatient,1,EA,206.40000,59.86000,Aetna,First Health,,168.84,,,,,,,123.84,168.84,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00024542131,NDC,,,facility,outpatient,1,EA,206.40000,59.86000,Aetna,First Health,,168.84,,,,,,,74.41,168.84,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00024540134,NDC,,,facility,inpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,25.89,35.30,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00024540134,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,First Health,,35.30,,,,,,,15.56,35.30,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,00024420010,NDC,,,facility,inpatient,1,EA,104.65000,30.35000,Aetna,First Health,,85.60,,,,,,,62.79,85.60,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,00024420010,NDC,,,facility,outpatient,1,EA,104.65000,30.35000,Aetna,First Health,,85.60,,,,,,,37.73,85.60,percent of total billed charges,
Dronedarone 400mg T,800081234,CDM,637,RC,00024414260,NDC,,,facility,inpatient,1,EA,114.70000,33.26000,Aetna,First Health,,93.82,,,,,,,68.82,93.82,percent of total billed charges,
Dronedarone 400mg T,800081234,CDM,637,RC,00024414260,NDC,,,facility,outpatient,1,EA,114.70000,33.26000,Aetna,First Health,,93.82,,,,,,,41.35,93.82,percent of total billed charges,
Dronedarone 400mg T,800081234,CDM,637,RC,00024414210,NDC,,,facility,inpatient,1,EA,93.25000,27.04000,Aetna,First Health,,76.28,,,,,,,55.95,76.28,percent of total billed charges,
Dronedarone 400mg T,800081234,CDM,637,RC,00024414210,NDC,,,facility,outpatient,1,EA,93.25000,27.04000,Aetna,First Health,,76.28,,,,,,,33.62,76.28,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00024156210,NDC,,,facility,inpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,19.98,27.24,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00024156210,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,First Health,,27.24,,,,,,,12.00,27.24,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00024125802,NDC,facility,inpatient,4,ME,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.05,4.66,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00024125802,NDC,facility,outpatient,4,ME,5.70000,1.65000,Aetna,First Health,,4.66,,,,,,,2.11,9.38,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00024125702,NDC,facility,inpatient,2,ME,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,1.96,4.46,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00024125702,NDC,facility,outpatient,2,ME,5.45000,1.58000,Aetna,First Health,,4.46,,,,,,,2.02,9.38,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00024121310,NDC,,,facility,inpatient,1,EA,444.05000,128.77000,Aetna,First Health,,363.23,,,,,,,164.30,363.23,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00024121310,NDC,,,facility,outpatient,1,EA,444.05000,128.77000,Aetna,First Health,,363.23,,,,,,,160.08,363.23,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00024072802,NDC,facility,inpatient,2,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,3.46,7.85,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00024072802,NDC,facility,outpatient,2,ME,9.60000,2.78000,Aetna,First Health,,7.85,,,,,,,0.13482,7.85,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,00024059120,NDC,facility,inpatient,100,ME,18360.25000,5324.47000,Aetna,First Health,,15018.68,,,,,,,6618.87,15018.68,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,00024059120,NDC,facility,outpatient,100,ME,18360.25000,5324.47000,Aetna,First Health,,15018.68,,,,,,,0.04815,15018.68,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00024032402,NDC,facility,inpatient,25,ME,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.76,6.26,percent of total billed charges,
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00024032402,NDC,facility,outpatient,25,ME,7.65000,2.22000,Aetna,First Health,,6.26,,,,,,,2.83,25.13,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,00023791560,NDC,,,facility,inpatient,1,EA,480.50000,139.34000,Aetna,First Health,,393.05,,,,,,,288.30,393.05,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,00023791560,NDC,,,facility,outpatient,1,EA,480.50000,139.34000,Aetna,First Health,,393.05,,,,,,,173.22,393.05,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,00023782410,NDC,,,facility,inpatient,1,EA,622.70000,180.58000,Aetna,First Health,,509.37,,,,,,,373.62,509.37,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,00023782410,NDC,,,facility,outpatient,1,EA,622.70000,180.58000,Aetna,First Health,,509.37,,,,,,,224.48,509.37,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,00023614730,NDC,,,facility,inpatient,1,EA,74.05000,21.47000,Aetna,First Health,,60.57,,,,,,,44.43,60.57,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,00023614730,NDC,,,facility,outpatient,1,EA,74.05000,21.47000,Aetna,First Health,,60.57,,,,,,,26.70,60.57,percent of total billed charges,
Iron Dextran 100mg/2mL I(Infed),800012496,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,inpatient,100,ME,348.55000,101.08000,Aetna,First Health,,285.11,,,,,,,125.65,285.11,percent of total billed charges,
Iron Dextran 100mg/2mL I(Infed),800012496,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,outpatient,100,ME,348.55000,101.08000,Aetna,First Health,,285.11,,,,,,,17.41,285.11,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,00023585318,NDC,,,facility,inpatient,1,EA,32.95000,9.56000,Aetna,First Health,,26.95,,,,,,,19.77,26.95,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,00023585318,NDC,,,facility,outpatient,1,EA,32.95000,9.56000,Aetna,First Health,,26.95,,,,,,,11.88,26.95,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,00023218105,NDC,,,facility,inpatient,1,EA,1964.05000,569.57000,Aetna,First Health,,1606.59,,,,,,,1178.43,1606.59,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,00023218105,NDC,,,facility,outpatient,1,EA,1964.05000,569.57000,Aetna,First Health,,1606.59,,,,,,,708.04,1606.59,percent of total billed charges,
Onabotulinumtoxin A 100unit I(Botox),800010975,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,inpatient,100,UN,2783.60000,807.24000,Aetna,First Health,,2276.98,,,,,,,1003.49,2276.98,percent of total billed charges,
Onabotulinumtoxin A 100unit I(Botox),800010975,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,outpatient,100,UN,2783.60000,807.24000,Aetna,First Health,,2276.98,,,,,,,6.27,2276.98,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,800041391,CDM,250,RC,00016031085,NDC,,,facility,inpatient,1,EA,686.90000,199.20000,Aetna,First Health,,561.88,,,,,,,254.15,561.88,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,800041391,CDM,250,RC,00016031085,NDC,,,facility,outpatient,1,EA,686.90000,199.20000,Aetna,First Health,,561.88,,,,,,,247.63,561.88,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,00015740599,NDC,facility,inpatient,2,GM,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,48.31,109.61,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,00015740599,NDC,facility,outpatient,2,GM,134.00000,38.86000,Aetna,First Health,,109.61,,,,,,,0.56817,109.61,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00015740320,NDC,facility,inpatient,500,ME,32.80000,9.51000,Aetna,First Health,,26.83,,,,,,,11.82,26.83,percent of total billed charges,
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00015740320,NDC,facility,outpatient,500,ME,32.80000,9.51000,Aetna,First Health,,26.83,,,,,,,0.56817,26.83,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00015722699,NDC,facility,inpatient,2,GM,121.85000,35.34000,Aetna,First Health,,99.67,,,,,,,43.93,99.67,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00015722699,NDC,facility,outpatient,2,GM,121.85000,35.34000,Aetna,First Health,,99.67,,,,,,,0.05778,99.67,percent of total billed charges,
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,00015564633,NDC,facility,inpatient,2,ME,70.25000,20.37000,Aetna,First Health,,57.46,,,,,,,25.33,57.46,percent of total billed charges,
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,00015564633,NDC,facility,outpatient,2,ME,70.25000,20.37000,Aetna,First Health,,57.46,,,,,,,5.34,57.46,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,00015321230,NDC,facility,inpatient,50,ME,906.15000,262.78000,Aetna,First Health,,741.23,,,,,,,326.67,741.23,percent of total billed charges,
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,00015321230,NDC,facility,outpatient,50,ME,906.15000,262.78000,Aetna,First Health,,741.23,,,,,,,2.82,741.23,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,00015321130,NDC,facility,inpatient,50,ME,906.15000,262.78000,Aetna,First Health,,741.23,,,,,,,326.67,741.23,percent of total billed charges,
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,00015321130,NDC,facility,outpatient,50,ME,906.15000,262.78000,Aetna,First Health,,741.23,,,,,,,2.82,741.23,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,00015300220,NDC,facility,inpatient,20,ME,2225.10000,645.28000,Aetna,First Health,,1820.13,,,,,,,802.15,1820.13,percent of total billed charges,
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,00015300220,NDC,facility,outpatient,20,ME,2225.10000,645.28000,Aetna,First Health,,1820.13,,,,,,,25.13,1820.13,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00015050842,NDC,,,facility,inpatient,1,EA,53.25000,15.44000,Aetna,First Health,,43.56,,,,,,,31.95,43.56,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00015050842,NDC,,,facility,outpatient,1,EA,53.25000,15.44000,Aetna,First Health,,43.56,,,,,,,19.20,43.56,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,00015050241,NDC,facility,inpatient,500,ME,127.10000,36.86000,Aetna,First Health,,103.97,,,,,,,45.82,103.97,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,00015050241,NDC,facility,outpatient,500,ME,127.10000,36.86000,Aetna,First Health,,103.97,,,,,,,0.56817,103.97,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,00013872789,NDC,facility,inpatient,500,ME,3569.30000,1035.10000,Aetna,First Health,,2919.69,,,,,,,1286.73,2919.69,percent of total billed charges,
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,00013872789,NDC,facility,outpatient,500,ME,3569.30000,1035.10000,Aetna,First Health,,2919.69,,,,,,,55.86,2919.69,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,00013830304,NDC,,,facility,inpatient,1,EA,1896.10000,549.87000,Aetna,First Health,,1551.01,,,,,,,1137.66,1551.01,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,00013830304,NDC,,,facility,outpatient,1,EA,1896.10000,549.87000,Aetna,First Health,,1551.01,,,,,,,683.54,1551.01,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,00013830301,NDC,,,facility,inpatient,1,EA,995.90000,288.81000,Aetna,First Health,,814.65,,,,,,,597.54,814.65,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,00013830301,NDC,,,facility,outpatient,1,EA,995.90000,288.81000,Aetna,First Health,,814.65,,,,,,,359.02,814.65,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,00013111410,NDC,,,facility,inpatient,1,EA,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,104.71,231.49,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,00013111410,NDC,,,facility,outpatient,1,EA,283.00000,82.07000,Aetna,First Health,,231.49,,,,,,,102.02,231.49,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00009771802,NDC,,,facility,inpatient,1,EA,67.95000,19.71000,Aetna,First Health,,55.58,,,,,,,25.14,55.58,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00009771802,NDC,,,facility,outpatient,1,EA,67.95000,19.71000,Aetna,First Health,,55.58,,,,,,,24.50,55.58,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,00009770902,NDC,,,facility,inpatient,1,EA,104.70000,30.36000,Aetna,First Health,,85.64,,,,,,,62.82,85.64,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,00009770902,NDC,,,facility,outpatient,1,EA,104.70000,30.36000,Aetna,First Health,,85.64,,,,,,,37.74,85.64,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,00009752901,NDC,facility,inpatient,100,ME,1257.00000,364.53000,Aetna,First Health,,1028.23,,,,,,,453.15,1028.23,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,00009752901,NDC,facility,outpatient,100,ME,1257.00000,364.53000,Aetna,First Health,,1028.23,,,,,,,1.72,1028.23,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00009737611,NDC,facility,inpatient,150,ME,325.85000,94.50000,Aetna,First Health,,266.55,,,,,,,117.47,266.55,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00009737611,NDC,facility,outpatient,150,ME,325.85000,94.50000,Aetna,First Health,,266.55,,,,,,,0.40446,266.55,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00009737604,NDC,facility,inpatient,150,ME,429.85000,124.66000,Aetna,First Health,,351.62,,,,,,,154.96,351.62,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00009737604,NDC,facility,outpatient,150,ME,429.85000,124.66000,Aetna,First Health,,351.62,,,,,,,0.40446,351.62,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00009519002,NDC,,,facility,inpatient,1,EA,111.15000,32.23000,Aetna,First Health,,90.92,,,,,,,66.69,90.92,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00009519002,NDC,,,facility,outpatient,1,EA,111.15000,32.23000,Aetna,First Health,,90.92,,,,,,,40.07,90.92,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00009519001,NDC,,,facility,inpatient,1,EA,111.15000,32.23000,Aetna,First Health,,90.92,,,,,,,66.69,90.92,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00009519001,NDC,,,facility,outpatient,1,EA,111.15000,32.23000,Aetna,First Health,,90.92,,,,,,,40.07,90.92,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,inpatient,600,ME,648.90000,188.18000,Aetna,First Health,,530.80,,,,,,,233.93,530.80,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,outpatient,600,ME,648.90000,188.18000,Aetna,First Health,,530.80,,,,,,,2.64,530.80,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00009513803,NDC,,,facility,inpatient,1,EA,53.40000,15.49000,Aetna,First Health,,43.68,,,,,,,32.04,43.68,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00009513803,NDC,,,facility,outpatient,1,EA,53.40000,15.49000,Aetna,First Health,,43.68,,,,,,,19.25,43.68,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00009513502,NDC,,,facility,inpatient,1,EA,1134.75000,329.08000,Aetna,First Health,,928.23,,,,,,,680.85,928.23,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00009513502,NDC,,,facility,outpatient,1,EA,1134.75000,329.08000,Aetna,First Health,,928.23,,,,,,,409.08,928.23,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00009499202,NDC,facility,inpatient,600,ME,441.90000,128.15000,Aetna,First Health,,361.47,,,,,,,159.30,361.47,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00009499202,NDC,facility,outpatient,600,ME,441.90000,128.15000,Aetna,First Health,,361.47,,,,,,,2.64,361.47,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009347523,NDC,facility,inpatient,80,ME,117.70000,34.13000,Aetna,First Health,,96.28,,,,,,,42.43,96.28,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009347523,NDC,facility,outpatient,80,ME,117.70000,34.13000,Aetna,First Health,,96.28,,,,,,,0.11556,96.28,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,inpatient,80,ME,125.90000,36.51000,Aetna,First Health,,102.99,,,,,,,45.39,102.99,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,outpatient,80,ME,125.90000,36.51000,Aetna,First Health,,102.99,,,,,,,0.11556,102.99,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009347501,NDC,facility,inpatient,80,ME,125.90000,36.51000,Aetna,First Health,,102.99,,,,,,,45.39,102.99,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009347501,NDC,facility,outpatient,80,ME,125.90000,36.51000,Aetna,First Health,,102.99,,,,,,,0.11556,102.99,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,00009338901,NDC,facility,inpatient,1,GM,177.70000,51.53000,Aetna,First Health,,145.36,,,,,,,64.06,145.36,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,00009338901,NDC,facility,outpatient,1,GM,177.70000,51.53000,Aetna,First Health,,145.36,,,,,,,0.25038,145.36,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00009338202,NDC,facility,inpatient,900,ME,217.60000,63.10000,Aetna,First Health,,178.00,,,,,,,78.44,178.00,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00009338202,NDC,facility,outpatient,900,ME,217.60000,63.10000,Aetna,First Health,,178.00,,,,,,,2.26,178.00,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00009338201,NDC,facility,inpatient,900,ME,51.55000,14.95000,Aetna,First Health,,42.17,,,,,,,18.58,42.17,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00009338201,NDC,facility,outpatient,900,ME,51.55000,14.95000,Aetna,First Health,,42.17,,,,,,,2.26,42.17,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00009337502,NDC,facility,inpatient,600,ME,177.90000,51.59000,Aetna,First Health,,145.52,,,,,,,64.13,145.52,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00009337502,NDC,facility,outpatient,600,ME,177.90000,51.59000,Aetna,First Health,,145.52,,,,,,,1.84,145.52,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00009337501,NDC,facility,inpatient,600,ME,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,17.77,40.33,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00009337501,NDC,facility,outpatient,600,ME,49.30000,14.30000,Aetna,First Health,,40.33,,,,,,,1.84,40.33,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00009307323,NDC,facility,inpatient,40,ME,67.85000,19.68000,Aetna,First Health,,55.50,,,,,,,24.46,55.50,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00009307323,NDC,facility,outpatient,40,ME,67.85000,19.68000,Aetna,First Health,,55.50,,,,,,,0.11556,55.50,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,inpatient,40,ME,72.60000,21.05000,Aetna,First Health,,59.39,,,,,,,26.17,59.39,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,outpatient,40,ME,72.60000,21.05000,Aetna,First Health,,59.39,,,,,,,0.11556,59.39,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00009307301,NDC,facility,inpatient,40,ME,72.50000,21.02000,Aetna,First Health,,59.30,,,,,,,26.14,59.30,percent of total billed charges,
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00009307301,NDC,facility,outpatient,40,ME,72.50000,21.02000,Aetna,First Health,,59.30,,,,,,,0.11556,59.30,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009090020,NDC,facility,inpatient,100,ME,25.80000,7.48000,Aetna,First Health,,21.10,,,,,,,9.30,21.10,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009090020,NDC,facility,outpatient,100,ME,25.80000,7.48000,Aetna,First Health,,21.10,,,,,,,9.55,68.03,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009090013,NDC,facility,inpatient,100,ME,20.55000,5.96000,Aetna,First Health,,16.81,,,,,,,7.41,16.81,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009090013,NDC,facility,outpatient,100,ME,20.55000,5.96000,Aetna,First Health,,16.81,,,,,,,7.60,68.03,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00009085608,NDC,,,facility,inpatient,1,EA,731.75000,212.21000,Aetna,First Health,,598.57,,,,,,,263.80,598.57,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00009085608,NDC,,,facility,outpatient,1,EA,731.75000,212.21000,Aetna,First Health,,598.57,,,,,,,263.80,598.57,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00009085605,NDC,,,facility,inpatient,1,EA,436.00000,126.44000,Aetna,First Health,,356.65,,,,,,,157.18,356.65,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00009085605,NDC,,,facility,outpatient,1,EA,436.00000,126.44000,Aetna,First Health,,356.65,,,,,,,157.18,356.65,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,inpatient,100,ME,122.25000,35.45000,Aetna,First Health,,100.00,,,,,,,44.07,100.00,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,outpatient,100,ME,122.25000,35.45000,Aetna,First Health,,100.00,,,,,,,21.24,100.00,percent of total billed charges,
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,00009077526,NDC,facility,inpatient,600,ME,28.25000,8.19000,Aetna,First Health,,23.11,,,,,,,10.18,23.11,percent of total billed charges,
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,00009077526,NDC,facility,outpatient,600,ME,28.25000,8.19000,Aetna,First Health,,23.11,,,,,,,1.84,23.11,percent of total billed charges,
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,00009077520,NDC,facility,inpatient,600,ME,110.90000,32.16000,Aetna,First Health,,90.72,,,,,,,39.98,90.72,percent of total billed charges,
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,00009077520,NDC,facility,outpatient,600,ME,110.90000,32.16000,Aetna,First Health,,90.72,,,,,,,1.84,90.72,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,00009075801,NDC,facility,inpatient,500,ME,1585.55000,459.81000,Aetna,First Health,,1296.98,,,,,,,571.59,1296.98,percent of total billed charges,
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,00009075801,NDC,facility,outpatient,500,ME,1585.55000,459.81000,Aetna,First Health,,1296.98,,,,,,,0.25038,1296.98,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00009074630,NDC,facility,inpatient,150,ME,313.85000,91.02000,Aetna,First Health,,256.73,,,,,,,113.14,256.73,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00009074630,NDC,facility,outpatient,150,ME,313.85000,91.02000,Aetna,First Health,,256.73,,,,,,,0.40446,256.73,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,inpatient,1,GM,26.40000,7.66000,Aetna,First Health,,21.60,,,,,,,9.52,21.60,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,outpatient,1,GM,26.40000,7.66000,Aetna,First Health,,21.60,,,,,,,0.25038,21.60,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,00009045003,NDC,,,facility,inpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,11.46,15.62,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,00009045003,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,First Health,,15.62,,,,,,,6.89,15.62,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009030602,NDC,facility,inpatient,80,ME,117.15000,33.97000,Aetna,First Health,,95.83,,,,,,,42.23,95.83,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009030602,NDC,facility,outpatient,80,ME,117.15000,33.97000,Aetna,First Health,,95.83,,,,,,,0.11556,95.83,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,00009026001,NDC,,,facility,inpatient,1,EA,60.25000,17.47000,Aetna,First Health,,49.28,,,,,,,36.15,49.28,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,00009026001,NDC,,,facility,outpatient,1,EA,60.25000,17.47000,Aetna,First Health,,49.28,,,,,,,21.72,49.28,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009019016,NDC,facility,inpatient,125,ME,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,5.86,13.29,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009019016,NDC,facility,outpatient,125,ME,16.25000,4.71000,Aetna,First Health,,13.29,,,,,,,0.25038,13.29,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009019009,NDC,facility,inpatient,125,ME,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,6.54,14.85,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009019009,NDC,facility,outpatient,125,ME,18.15000,5.26000,Aetna,First Health,,14.85,,,,,,,0.25038,14.85,percent of total billed charges,
methylPREDNISolone 16 mg T(Medrol),800013327,CDM,637,RC,J7509,HCPCS,00009007301,NDC,facility,inpatient,16,ME,24.45000,7.09000,Aetna,First Health,,20.00,,,,,,,14.67,20.00,percent of total billed charges,
methylPREDNISolone 16 mg T(Medrol),800013327,CDM,637,RC,J7509,HCPCS,00009007301,NDC,facility,outpatient,16,ME,24.45000,7.09000,Aetna,First Health,,20.00,,,,,,,0.13482,20.00,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00009005605,NDC,facility,inpatient,4,ME,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,3.66,4.99,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00009005605,NDC,facility,outpatient,4,ME,6.10000,1.77000,Aetna,First Health,,4.99,,,,,,,0.13482,4.99,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00009005604,NDC,facility,inpatient,4,ME,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.91927,2.09,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00009005604,NDC,facility,outpatient,4,ME,2.55000,0.74000,Aetna,First Health,,2.09,,,,,,,0.13482,2.09,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00009005602,NDC,facility,inpatient,4,ME,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,1.56,2.13,percent of total billed charges,
methylPREDNISolone 4mg T(Medrol),800015841,CDM,637,RC,J7509,HCPCS,00009005602,NDC,facility,outpatient,4,ME,2.60000,0.75000,Aetna,First Health,,2.13,,,,,,,0.13482,2.13,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00009005501,NDC,,,facility,inpatient,1,EA,67.10000,19.46000,Aetna,First Health,,54.89,,,,,,,40.26,54.89,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00009005501,NDC,,,facility,outpatient,1,EA,67.10000,19.46000,Aetna,First Health,,54.89,,,,,,,24.19,54.89,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009004726,NDC,facility,inpatient,125,ME,66.50000,19.28000,Aetna,First Health,,54.40,,,,,,,23.97,54.40,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009004726,NDC,facility,outpatient,125,ME,66.50000,19.28000,Aetna,First Health,,54.40,,,,,,,0.25038,54.40,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,125,ME,66.50000,19.28000,Aetna,First Health,,54.40,,,,,,,23.97,54.40,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,outpatient,125,ME,66.50000,19.28000,Aetna,First Health,,54.40,,,,,,,0.25038,54.40,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009004704,NDC,facility,inpatient,125,ME,69.50000,20.15000,Aetna,First Health,,56.85,,,,,,,25.05,56.85,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009004704,NDC,facility,outpatient,125,ME,69.50000,20.15000,Aetna,First Health,,56.85,,,,,,,0.25038,56.85,percent of total billed charges,
methylPREDNISolone NaSucc 40mg PF Inj,800013326,CDM,636,RC,J2919,HCPCS,00009003932,NDC,facility,inpatient,40,ME,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,14.89,33.78,percent of total billed charges,
methylPREDNISolone NaSucc 40mg PF Inj,800013326,CDM,636,RC,J2919,HCPCS,00009003932,NDC,facility,outpatient,40,ME,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,0.25038,33.78,percent of total billed charges,
methylPREDNISolone NaSucc 40mg PF Inj,800013326,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,40,ME,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,14.89,33.78,percent of total billed charges,
methylPREDNISolone NaSucc 40mg PF Inj,800013326,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,outpatient,40,ME,41.30000,11.98000,Aetna,First Health,,33.78,,,,,,,0.25038,33.78,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00009003101,NDC,,,facility,inpatient,1,EA,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,8.64,11.78,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00009003101,NDC,,,facility,outpatient,1,EA,14.40000,4.18000,Aetna,First Health,,11.78,,,,,,,5.19,11.78,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00009002946,NDC,,,facility,inpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,2.55,3.48,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00009002946,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,First Health,,3.48,,,,,,,1.53,3.48,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00009002901,NDC,,,facility,inpatient,1,EA,53.85000,15.62000,Aetna,First Health,,44.05,,,,,,,32.31,44.05,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00009002901,NDC,,,facility,outpatient,1,EA,53.85000,15.62000,Aetna,First Health,,44.05,,,,,,,19.41,44.05,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,00009001759,NDC,,,facility,inpatient,1,EA,26.10000,7.57000,Aetna,First Health,,21.35,,,,,,,15.66,21.35,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,00009001759,NDC,,,facility,outpatient,1,EA,26.10000,7.57000,Aetna,First Health,,21.35,,,,,,,9.41,21.35,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,00009001201,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,00009001201,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009001104,NDC,facility,inpatient,100,ME,150.65000,43.69000,Aetna,First Health,,123.23,,,,,,,54.31,123.23,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009001104,NDC,facility,outpatient,100,ME,150.65000,43.69000,Aetna,First Health,,123.23,,,,,,,21.24,123.23,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,inpatient,100,ME,153.20000,44.43000,Aetna,First Health,,125.32,,,,,,,55.23,125.32,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,outpatient,100,ME,153.20000,44.43000,Aetna,First Health,,125.32,,,,,,,21.24,125.32,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00009000202,NDC,,,facility,inpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,3.15,4.29,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00009000202,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,First Health,,4.29,,,,,,,1.89,4.29,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00008418806,NDC,,,facility,inpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,3.60,4.91,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00008418806,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,First Health,,4.91,,,,,,,2.16,4.91,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00008415305,NDC,,,facility,inpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,1.38,1.88,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00008415305,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,First Health,,1.88,,,,,,,0.82915,1.88,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008400125,NDC,facility,inpatient,40,ME,32.40000,9.40000,Aetna,First Health,,26.50,,,,,,,11.68,26.50,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008400125,NDC,facility,outpatient,40,ME,32.40000,9.40000,Aetna,First Health,,26.50,,,,,,,5.86,26.50,percent of total billed charges,
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,00008122214,NDC,,,facility,inpatient,1,EA,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,74.40,101.43,percent of total billed charges,
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,00008122214,NDC,,,facility,outpatient,1,EA,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,44.70,101.43,percent of total billed charges,
Methylnaltrexone 12mg/0.6mL I,800020067,CDM,637,RC,J2212,HCPCS,00008121801,NDC,facility,inpatient,12,ME,224.35000,65.06000,Aetna,First Health,,183.52,,,,,,,134.61,183.52,percent of total billed charges,
Methylnaltrexone 12mg/0.6mL I,800020067,CDM,637,RC,J2212,HCPCS,00008121801,NDC,facility,outpatient,12,ME,224.35000,65.06000,Aetna,First Health,,183.52,,,,,,,1.54,183.52,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121150,NDC,,,facility,inpatient,1,EA,98.75000,28.64000,Aetna,First Health,,80.78,,,,,,,59.25,80.78,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121150,NDC,,,facility,outpatient,1,EA,98.75000,28.64000,Aetna,First Health,,80.78,,,,,,,35.60,80.78,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121130,NDC,,,facility,inpatient,1,EA,124.05000,35.97000,Aetna,First Health,,101.47,,,,,,,74.43,101.47,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121130,NDC,,,facility,outpatient,1,EA,124.05000,35.97000,Aetna,First Health,,101.47,,,,,,,44.72,101.47,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121114,NDC,,,facility,inpatient,1,EA,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,74.40,101.43,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121114,NDC,,,facility,outpatient,1,EA,124.00000,35.96000,Aetna,First Health,,101.43,,,,,,,44.70,101.43,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121101,NDC,,,facility,inpatient,1,EA,124.05000,35.97000,Aetna,First Health,,101.47,,,,,,,74.43,101.47,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121101,NDC,,,facility,outpatient,1,EA,124.05000,35.97000,Aetna,First Health,,101.47,,,,,,,44.72,101.47,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008094103,NDC,facility,inpatient,40,ME,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.50,26.09,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008094103,NDC,facility,outpatient,40,ME,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,5.86,26.09,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008094102,NDC,facility,inpatient,40,ME,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.50,26.09,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008094102,NDC,facility,outpatient,40,ME,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,5.86,26.09,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092360,NDC,facility,inpatient,40,ME,32.40000,9.40000,Aetna,First Health,,26.50,,,,,,,11.68,26.50,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092360,NDC,facility,outpatient,40,ME,32.40000,9.40000,Aetna,First Health,,26.50,,,,,,,5.86,26.50,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092355,NDC,facility,inpatient,40,ME,32.40000,9.40000,Aetna,First Health,,26.50,,,,,,,11.68,26.50,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092355,NDC,facility,outpatient,40,ME,32.40000,9.40000,Aetna,First Health,,26.50,,,,,,,5.86,26.50,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,inpatient,40,ME,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,11.50,26.09,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,outpatient,40,ME,31.90000,9.25000,Aetna,First Health,,26.09,,,,,,,5.86,26.09,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092303,NDC,facility,inpatient,40,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,57.18,129.73,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092303,NDC,facility,outpatient,40,ME,158.60000,45.99000,Aetna,First Health,,129.73,,,,,,,5.86,129.73,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008084199,NDC,,,facility,inpatient,1,EA,68.30000,19.81000,Aetna,First Health,,55.87,,,,,,,40.98,55.87,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008084199,NDC,,,facility,outpatient,1,EA,68.30000,19.81000,Aetna,First Health,,55.87,,,,,,,24.62,55.87,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008084181,NDC,,,facility,inpatient,1,EA,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,73.80,100.61,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008084181,NDC,,,facility,outpatient,1,EA,123.00000,35.67000,Aetna,First Health,,100.61,,,,,,,44.34,100.61,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00008083722,NDC,,,facility,inpatient,1,EA,145.30000,42.14000,Aetna,First Health,,118.86,,,,,,,87.18,118.86,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00008083722,NDC,,,facility,outpatient,1,EA,145.30000,42.14000,Aetna,First Health,,118.86,,,,,,,52.38,118.86,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00008083721,NDC,,,facility,inpatient,1,EA,145.30000,42.14000,Aetna,First Health,,118.86,,,,,,,87.18,118.86,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00008083721,NDC,,,facility,outpatient,1,EA,145.30000,42.14000,Aetna,First Health,,118.86,,,,,,,52.38,118.86,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00008083701,NDC,,,facility,inpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,13.47,18.36,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00008083701,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,First Health,,18.36,,,,,,,8.09,18.36,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00008083622,NDC,,,facility,inpatient,1,EA,179.80000,52.14000,Aetna,First Health,,147.08,,,,,,,107.88,147.08,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00008083622,NDC,,,facility,outpatient,1,EA,179.80000,52.14000,Aetna,First Health,,147.08,,,,,,,64.82,147.08,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00008083621,NDC,,,facility,inpatient,1,EA,184.75000,53.58000,Aetna,First Health,,151.13,,,,,,,110.85,151.13,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00008083621,NDC,,,facility,outpatient,1,EA,184.75000,53.58000,Aetna,First Health,,151.13,,,,,,,66.60,151.13,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00008083601,NDC,,,facility,inpatient,1,EA,26.25000,7.61000,Aetna,First Health,,21.47,,,,,,,15.75,21.47,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00008083601,NDC,,,facility,outpatient,1,EA,26.25000,7.61000,Aetna,First Health,,21.47,,,,,,,9.46,21.47,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083322,NDC,,,facility,inpatient,1,EA,167.70000,48.63000,Aetna,First Health,,137.18,,,,,,,100.62,137.18,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083322,NDC,,,facility,outpatient,1,EA,167.70000,48.63000,Aetna,First Health,,137.18,,,,,,,60.46,137.18,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083321,NDC,,,facility,inpatient,1,EA,162.80000,47.21000,Aetna,First Health,,133.17,,,,,,,97.68,133.17,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083321,NDC,,,facility,outpatient,1,EA,162.80000,47.21000,Aetna,First Health,,133.17,,,,,,,58.69,133.17,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083320,NDC,,,facility,inpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,59.91,81.68,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083320,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,36.00,81.68,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083303,NDC,,,facility,inpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,59.91,81.68,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083303,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,First Health,,81.68,,,,,,,36.00,81.68,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083301,NDC,,,facility,inpatient,1,EA,25.15000,7.29000,Aetna,First Health,,20.57,,,,,,,15.09,20.57,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083301,NDC,,,facility,outpatient,1,EA,25.15000,7.29000,Aetna,First Health,,20.57,,,,,,,9.07,20.57,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00008081401,NDC,facility,inpatient,150,ME,1966.65000,570.33000,Aetna,First Health,,1608.72,,,,,,,708.98,1608.72,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00008081401,NDC,facility,outpatient,150,ME,1966.65000,570.33000,Aetna,First Health,,1608.72,,,,,,,0.39483,1608.72,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00008078108,NDC,,,facility,inpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,10.50,14.31,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00008078108,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,First Health,,14.31,,,,,,,6.31,14.31,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00008078102,NDC,,,facility,inpatient,1,EA,13.35000,3.87000,Aetna,First Health,,10.92,,,,,,,8.01,10.92,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00008078102,NDC,,,facility,outpatient,1,EA,13.35000,3.87000,Aetna,First Health,,10.92,,,,,,,4.81,10.92,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00008078101,NDC,,,facility,inpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,8.97,12.23,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00008078101,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,First Health,,12.23,,,,,,,5.39,12.23,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070108,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070108,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070107,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,10.20,13.91,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070107,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,First Health,,13.91,,,,,,,6.13,13.91,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070102,NDC,,,facility,inpatient,1,EA,12.95000,3.76000,Aetna,First Health,,10.59,,,,,,,7.77,10.59,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070102,NDC,,,facility,outpatient,1,EA,12.95000,3.76000,Aetna,First Health,,10.59,,,,,,,4.67,10.59,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070101,NDC,,,facility,inpatient,1,EA,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,8.70,11.86,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070101,NDC,,,facility,outpatient,1,EA,14.50000,4.20000,Aetna,First Health,,11.86,,,,,,,5.23,11.86,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008060701,NDC,,,facility,inpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.83,2.49,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008060701,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,First Health,,2.49,,,,,,,1.10,2.49,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00008049801,NDC,,,facility,inpatient,1,EA,25.20000,7.31000,Aetna,First Health,,20.61,,,,,,,15.12,20.61,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00008049801,NDC,,,facility,outpatient,1,EA,25.20000,7.31000,Aetna,First Health,,20.61,,,,,,,9.08,20.61,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008024199,NDC,,,facility,inpatient,1,EA,12.60000,3.65000,Aetna,First Health,,10.31,,,,,,,7.56,10.31,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008024199,NDC,,,facility,outpatient,1,EA,12.60000,3.65000,Aetna,First Health,,10.31,,,,,,,4.54,10.31,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00007489320,NDC,,,facility,inpatient,1,EA,47.75000,13.85000,Aetna,First Health,,39.06,,,,,,,28.65,39.06,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00007489320,NDC,,,facility,outpatient,1,EA,47.75000,13.85000,Aetna,First Health,,39.06,,,,,,,17.21,39.06,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00007489220,NDC,,,facility,inpatient,1,EA,46.00000,13.34000,Aetna,First Health,,37.63,,,,,,,27.60,37.63,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00007489220,NDC,,,facility,outpatient,1,EA,46.00000,13.34000,Aetna,First Health,,37.63,,,,,,,16.58,37.63,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,00007489020,NDC,,,facility,inpatient,1,EA,47.75000,13.85000,Aetna,First Health,,39.06,,,,,,,28.65,39.06,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,00007489020,NDC,,,facility,outpatient,1,EA,47.75000,13.85000,Aetna,First Health,,39.06,,,,,,,17.21,39.06,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00007414220,NDC,,,facility,inpatient,1,EA,60.60000,17.57000,Aetna,First Health,,49.57,,,,,,,36.36,49.57,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00007414220,NDC,,,facility,outpatient,1,EA,60.60000,17.57000,Aetna,First Health,,49.57,,,,,,,21.85,49.57,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00007414120,NDC,,,facility,inpatient,1,EA,60.60000,17.57000,Aetna,First Health,,49.57,,,,,,,36.36,49.57,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00007414120,NDC,,,facility,outpatient,1,EA,60.60000,17.57000,Aetna,First Health,,49.57,,,,,,,21.85,49.57,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00007414020,NDC,,,facility,inpatient,1,EA,60.60000,17.57000,Aetna,First Health,,49.57,,,,,,,36.36,49.57,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00007414020,NDC,,,facility,outpatient,1,EA,60.60000,17.57000,Aetna,First Health,,49.57,,,,,,,21.85,49.57,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00007413955,NDC,,,facility,inpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,7.32,9.98,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00007413955,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,First Health,,9.98,,,,,,,4.40,9.98,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00007413920,NDC,,,facility,inpatient,1,EA,60.60000,17.57000,Aetna,First Health,,49.57,,,,,,,36.36,49.57,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00007413920,NDC,,,facility,outpatient,1,EA,60.60000,17.57000,Aetna,First Health,,49.57,,,,,,,21.85,49.57,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00007411719,NDC,,,facility,inpatient,1,EA,62.50000,18.12000,Aetna,First Health,,51.12,,,,,,,37.50,51.12,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00007411719,NDC,,,facility,outpatient,1,EA,62.50000,18.12000,Aetna,First Health,,51.12,,,,,,,22.53,51.12,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00007411713,NDC,,,facility,inpatient,1,EA,52.25000,15.15000,Aetna,First Health,,42.74,,,,,,,31.35,42.74,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00007411713,NDC,,,facility,outpatient,1,EA,52.25000,15.15000,Aetna,First Health,,42.74,,,,,,,18.84,42.74,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00007401020,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,3.36,4.58,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00007401020,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,First Health,,4.58,,,,,,,2.02,4.58,percent of total billed charges,
Prochlorperazine 25mg Supp(Compazine,800017137,CDM,637,RC,00007336203,NDC,,,facility,inpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,14.37,19.59,percent of total billed charges,
Prochlorperazine 25mg Supp(Compazine,800017137,CDM,637,RC,00007336203,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,First Health,,19.59,,,,,,,8.63,19.59,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00007335216,NDC,facility,inpatient,10,ME,48.70000,14.12000,Aetna,First Health,,39.84,,,,,,,17.56,39.84,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00007335216,NDC,facility,outpatient,10,ME,48.70000,14.12000,Aetna,First Health,,39.84,,,,,,,2.43,39.84,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,00007323411,NDC,facility,inpatient,7.5,ME,689.95000,200.09000,Aetna,First Health,,564.38,,,,,,,248.73,564.38,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,00007323411,NDC,facility,outpatient,7.5,ME,689.95000,200.09000,Aetna,First Health,,564.38,,,,,,,0.84744,564.38,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,00007323402,NDC,facility,inpatient,7.5,ME,663.20000,192.33000,Aetna,First Health,,542.50,,,,,,,239.08,542.50,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,00007323402,NDC,facility,outpatient,7.5,ME,663.20000,192.33000,Aetna,First Health,,542.50,,,,,,,0.84744,542.50,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,00007323011,NDC,facility,inpatient,2.5,ME,329.30000,95.50000,Aetna,First Health,,269.37,,,,,,,118.71,269.37,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,00007323011,NDC,facility,outpatient,2.5,ME,329.30000,95.50000,Aetna,First Health,,269.37,,,,,,,0.84744,269.37,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,00007323002,NDC,facility,inpatient,2.5,ME,316.45000,91.77000,Aetna,First Health,,258.86,,,,,,,114.08,258.86,percent of total billed charges,
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,00007323002,NDC,facility,outpatient,2.5,ME,316.45000,91.77000,Aetna,First Health,,258.86,,,,,,,0.84744,258.86,percent of total billed charges,
ceFAZolin 500mg I (Ancef),800062014,CDM,636,RC,J0690,HCPCS,00007313116,NDC,facility,inpatient,500,ME,16.55000,4.80000,Aetna,First Health,,13.54,,,,,,,5.97,13.54,percent of total billed charges,
ceFAZolin 500mg I (Ancef),800062014,CDM,636,RC,J0690,HCPCS,00007313116,NDC,facility,outpatient,500,ME,16.55000,4.80000,Aetna,First Health,,13.54,,,,,,,0.79929,13.54,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00007313016,NDC,facility,inpatient,1000,ME,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,11.97,27.16,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00007313016,NDC,facility,outpatient,1000,ME,33.20000,9.63000,Aetna,First Health,,27.16,,,,,,,0.79929,27.16,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00006778433,NDC,facility,inpatient,1,ME,10.75000,3.12000,Aetna,First Health,,8.79,,,,,,,3.88,8.79,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00006778433,NDC,facility,outpatient,1,ME,10.75000,3.12000,Aetna,First Health,,8.79,,,,,,,2.71,8.79,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00006778066,NDC,facility,inpatient,10,ME,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.23,2.78,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00006778066,NDC,facility,outpatient,10,ME,3.40000,0.99000,Aetna,First Health,,2.78,,,,,,,1.26,8.67,percent of total billed charges,
dexaMETHasone 0.1% 5mL Ophth Soln,800036904,CDM,637,RC,00006764303,NDC,,,facility,inpatient,1,EA,137.70000,39.93000,Aetna,First Health,,112.64,,,,,,,82.62,112.64,percent of total billed charges,
dexaMETHasone 0.1% 5mL Ophth Soln,800036904,CDM,637,RC,00006764303,NDC,,,facility,outpatient,1,EA,137.70000,39.93000,Aetna,First Health,,112.64,,,,,,,49.64,112.64,percent of total billed charges,
Sugammadex 100mg/mL Inj 5mL(Bridion SD),800040851,CDM,250,RC,00006542515,NDC,,,facility,inpatient,1,EA,1183.40000,343.19000,Aetna,First Health,,968.02,,,,,,,437.86,968.02,percent of total billed charges,
Sugammadex 100mg/mL Inj 5mL(Bridion SD),800040851,CDM,250,RC,00006542515,NDC,,,facility,outpatient,1,EA,1183.40000,343.19000,Aetna,First Health,,968.02,,,,,,,426.62,968.02,percent of total billed charges,
Sugammadex 100mg/mL Inj 2mL(Bridion SD),800025674,CDM,250,RC,00006542312,NDC,,,facility,inpatient,1,EA,714.05000,207.07000,Aetna,First Health,,584.09,,,,,,,264.20,584.09,percent of total billed charges,
Sugammadex 100mg/mL Inj 2mL(Bridion SD),800025674,CDM,250,RC,00006542312,NDC,,,facility,outpatient,1,EA,714.05000,207.07000,Aetna,First Health,,584.09,,,,,,,257.42,584.09,percent of total billed charges,
Measles-Mumps-Rubella Inj (MMR),800070770,CDM,636,RC,90707,HCPCS,00006468100,NDC,facility,inpatient,1,EA,526.40000,152.66000,Aetna,First Health,,430.60,,,,,,,189.77,430.60,percent of total billed charges,
Measles-Mumps-Rubella Inj (MMR),800070770,CDM,636,RC,90707,HCPCS,00006468100,NDC,facility,outpatient,1,EA,526.40000,152.66000,Aetna,First Health,,430.60,,,,,,,106.45,430.60,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006394132,NDC,facility,inpatient,150,ME,2483.95000,720.35000,Aetna,First Health,,2031.87,,,,,,,895.46,2031.87,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006394132,NDC,facility,outpatient,150,ME,2483.95000,720.35000,Aetna,First Health,,2031.87,,,,,,,0.10593,2031.87,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00006391968,NDC,,,facility,inpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,12.84,17.51,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00006391968,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,First Health,,17.51,,,,,,,7.71,17.51,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,00006391868,NDC,,,facility,inpatient,1,EA,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,6.69,9.12,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,00006391868,NDC,,,facility,outpatient,1,EA,11.15000,3.23000,Aetna,First Health,,9.12,,,,,,,4.02,9.12,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00006391768,NDC,,,facility,inpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,7.59,10.35,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00006391768,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,First Health,,10.35,,,,,,,4.56,10.35,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006388432,NDC,facility,inpatient,150,ME,1468.00000,425.72000,Aetna,First Health,,1200.82,,,,,,,529.21,1200.82,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006388432,NDC,facility,outpatient,150,ME,1468.00000,425.72000,Aetna,First Health,,1200.82,,,,,,,0.10593,1200.82,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,00006384371,NDC,facility,inpatient,1,GM,1090.55000,316.26000,Aetna,First Health,,892.07,,,,,,,393.14,892.07,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,00006384371,NDC,facility,outpatient,1,GM,1090.55000,316.26000,Aetna,First Health,,892.07,,,,,,,8.82,892.07,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00006382404,NDC,,,facility,inpatient,1,EA,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,14.76,32.64,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00006382404,NDC,,,facility,outpatient,1,EA,39.90000,11.57000,Aetna,First Health,,32.64,,,,,,,14.38,32.64,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,00006353904,NDC,facility,inpatient,20,ME,25.20000,7.31000,Aetna,First Health,,20.61,,,,,,,9.08,20.61,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,00006353904,NDC,facility,outpatient,20,ME,25.20000,7.31000,Aetna,First Health,,20.61,,,,,,,0.00963,20.61,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,00006351936,NDC,,,facility,inpatient,1,EA,593.05000,171.98000,Aetna,First Health,,485.11,,,,,,,355.83,485.11,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,00006351936,NDC,,,facility,outpatient,1,EA,593.05000,171.98000,Aetna,First Health,,485.11,,,,,,,213.79,485.11,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,00006351935,NDC,,,facility,inpatient,1,EA,431.05000,125.00000,Aetna,First Health,,352.60,,,,,,,258.63,352.60,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,00006351935,NDC,,,facility,outpatient,1,EA,431.05000,125.00000,Aetna,First Health,,352.60,,,,,,,155.39,352.60,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,00006351903,NDC,,,facility,inpatient,1,EA,352.40000,102.20000,Aetna,First Health,,288.26,,,,,,,211.44,288.26,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,00006351903,NDC,,,facility,outpatient,1,EA,352.40000,102.20000,Aetna,First Health,,288.26,,,,,,,127.04,288.26,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00006350804,NDC,,,facility,inpatient,1,EA,175.15000,50.79000,Aetna,First Health,,143.27,,,,,,,64.81,143.27,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00006350804,NDC,,,facility,outpatient,1,EA,175.15000,50.79000,Aetna,First Health,,143.27,,,,,,,63.14,143.27,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,00006336703,NDC,,,facility,inpatient,1,EA,156.45000,45.37000,Aetna,First Health,,127.98,,,,,,,93.87,127.98,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,00006336703,NDC,,,facility,outpatient,1,EA,156.45000,45.37000,Aetna,First Health,,127.98,,,,,,,56.40,127.98,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,00006335645,NDC,facility,inpatient,1,GM,89.80000,26.04000,Aetna,First Health,,73.46,,,,,,,32.37,73.46,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,00006335645,NDC,facility,outpatient,1,GM,89.80000,26.04000,Aetna,First Health,,73.46,,,,,,,4.56,73.46,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006306104,NDC,facility,inpatient,150,ME,2596.35000,752.94000,Aetna,First Health,,2123.81,,,,,,,935.98,2123.81,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006306104,NDC,facility,outpatient,150,ME,2596.35000,752.94000,Aetna,First Health,,2123.81,,,,,,,0.10593,2123.81,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006306100,NDC,facility,inpatient,150,ME,2596.35000,752.94000,Aetna,First Health,,2123.81,,,,,,,935.98,2123.81,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006306100,NDC,facility,outpatient,150,ME,2596.35000,752.94000,Aetna,First Health,,2123.81,,,,,,,0.10593,2123.81,percent of total billed charges,
Pembrolizumab 25mg/mL Inj 4mL,800046436,CDM,636,RC,J9271,HCPCS,00006302604,NDC,facility,inpatient,100,ME,31410.25000,9108.97000,Aetna,First Health,,25693.58,,,,,,,11323.40,25693.58,percent of total billed charges,
Pembrolizumab 25mg/mL Inj 4mL,800046436,CDM,636,RC,J9271,HCPCS,00006302604,NDC,facility,outpatient,100,ME,31410.25000,9108.97000,Aetna,First Health,,25693.58,,,,,,,57.52,25693.58,percent of total billed charges,
Pembrolizumab 100mg/4mL Inj - Pt Own Supply,800051013,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,inpatient,100,ME,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01802,0.04090,percent of total billed charges,
Pembrolizumab 100mg/4mL Inj - Pt Own Supply,800051013,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,100,ME,0.05000,0.01000,Aetna,First Health,,0.04090,,,,,,,0.01850,184.21,percent of total billed charges,
Pembrolizumab 25mg/mL Inj 4mL,800046436,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,inpatient,100,ME,31410.25000,9108.97000,Aetna,First Health,,25693.58,,,,,,,11323.40,25693.58,percent of total billed charges,
Pembrolizumab 25mg/mL Inj 4mL,800046436,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,outpatient,100,ME,31410.25000,9108.97000,Aetna,First Health,,25693.58,,,,,,,57.52,25693.58,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096382,NDC,,,facility,inpatient,1,EA,14.35000,4.16000,Aetna,First Health,,11.74,,,,,,,8.61,11.74,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096382,NDC,,,facility,outpatient,1,EA,14.35000,4.16000,Aetna,First Health,,11.74,,,,,,,5.17,11.74,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096358,NDC,,,facility,inpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,11.34,15.46,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096358,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,6.81,15.46,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096331,NDC,,,facility,inpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,11.34,15.46,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096331,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,First Health,,15.46,,,,,,,6.81,15.46,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096328,NDC,,,facility,inpatient,1,EA,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,8.19,11.17,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096328,NDC,,,facility,outpatient,1,EA,13.65000,3.96000,Aetna,First Health,,11.17,,,,,,,4.92,11.17,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00006096031,NDC,,,facility,inpatient,1,EA,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,25.80,35.17,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00006096031,NDC,,,facility,outpatient,1,EA,43.00000,12.47000,Aetna,First Health,,35.17,,,,,,,15.50,35.17,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00006095254,NDC,,,facility,inpatient,1,EA,31.50000,9.14000,Aetna,First Health,,25.77,,,,,,,18.90,25.77,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00006095254,NDC,,,facility,outpatient,1,EA,31.50000,9.14000,Aetna,First Health,,25.77,,,,,,,11.36,25.77,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00006095231,NDC,,,facility,inpatient,1,EA,31.50000,9.14000,Aetna,First Health,,25.77,,,,,,,18.90,25.77,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00006095231,NDC,,,facility,outpatient,1,EA,31.50000,9.14000,Aetna,First Health,,25.77,,,,,,,11.36,25.77,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00006095228,NDC,,,facility,inpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,7.38,10.06,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00006095228,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,First Health,,10.06,,,,,,,4.43,10.06,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00006095158,NDC,,,facility,inpatient,1,EA,11.75000,3.41000,Aetna,First Health,,9.61,,,,,,,7.05,9.61,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00006095158,NDC,,,facility,outpatient,1,EA,11.75000,3.41000,Aetna,First Health,,9.61,,,,,,,4.24,9.61,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00006095154,NDC,,,facility,inpatient,1,EA,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,14.13,19.26,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00006095154,NDC,,,facility,outpatient,1,EA,23.55000,6.83000,Aetna,First Health,,19.26,,,,,,,8.49,19.26,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00006095128,NDC,,,facility,inpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,5.52,7.53,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00006095128,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,First Health,,7.53,,,,,,,3.32,7.53,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00006071468,NDC,,,facility,inpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,6.51,8.88,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00006071468,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00006071428,NDC,,,facility,inpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,7.41,10.10,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00006071428,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,First Health,,10.10,,,,,,,4.45,10.10,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00006071368,NDC,,,facility,inpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,5.31,7.24,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00006071368,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,First Health,,7.24,,,,,,,3.19,7.24,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00006071328,NDC,,,facility,inpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,4.89,6.67,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00006071328,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,2.94,6.67,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00006071268,NDC,,,facility,inpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,5.07,6.91,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00006071268,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,First Health,,6.91,,,,,,,3.05,6.91,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00006071228,NDC,,,facility,inpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,4.35,5.93,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00006071228,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,First Health,,5.93,,,,,,,2.61,5.93,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00006061968,NDC,,,facility,inpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,1.08,1.47,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00006061968,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,First Health,,1.47,,,,,,,0.64890,1.47,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,00006046410,NDC,facility,inpatient,40,ME,880.30000,255.29000,Aetna,First Health,,720.09,,,,,,,528.18,720.09,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,00006046410,NDC,facility,outpatient,40,ME,880.30000,255.29000,Aetna,First Health,,720.09,,,,,,,2.67,720.09,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,00006046405,NDC,facility,inpatient,40,ME,854.35000,247.76000,Aetna,First Health,,698.86,,,,,,,512.61,698.86,percent of total billed charges,
Aprepitant 40mg C (Emend),800018376,CDM,637,RC,J8501,HCPCS,00006046405,NDC,facility,outpatient,40,ME,854.35000,247.76000,Aetna,First Health,,698.86,,,,,,,2.67,698.86,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00006045158,NDC,,,facility,inpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,5.70,7.77,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00006045158,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,First Health,,7.77,,,,,,,3.42,7.77,percent of total billed charges,
Raltegravir 400mg T (Isentress),800081144,CDM,637,RC,00006022761,NDC,,,facility,inpatient,1,EA,289.15000,83.85000,Aetna,First Health,,236.52,,,,,,,173.49,236.52,percent of total billed charges,
Raltegravir 400mg T (Isentress),800081144,CDM,637,RC,00006022761,NDC,,,facility,outpatient,1,EA,289.15000,83.85000,Aetna,First Health,,236.52,,,,,,,104.24,236.52,percent of total billed charges,
SITagliptin 25 mg T (Januvia),800025461,CDM,637,RC,00006022131,NDC,,,facility,inpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,56.07,76.44,percent of total billed charges,
SITagliptin 25 mg T (Januvia),800025461,CDM,637,RC,00006022131,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,33.69,76.44,percent of total billed charges,
SITagliptin 25 mg T (Januvia),800025461,CDM,637,RC,00006022128,NDC,,,facility,inpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,56.07,76.44,percent of total billed charges,
SITagliptin 25 mg T (Januvia),800025461,CDM,637,RC,00006022128,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,33.69,76.44,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00006011754,NDC,,,facility,inpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,29.94,40.82,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00006011754,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,17.99,40.82,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00006011731,NDC,,,facility,inpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,29.94,40.82,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00006011731,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,First Health,,40.82,,,,,,,17.99,40.82,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00006011728,NDC,,,facility,inpatient,1,EA,23.20000,6.73000,Aetna,First Health,,18.98,,,,,,,13.92,18.98,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00006011728,NDC,,,facility,outpatient,1,EA,23.20000,6.73000,Aetna,First Health,,18.98,,,,,,,8.36,18.98,percent of total billed charges,
SITagliptin 50 mg T(Januvia),800017359,CDM,637,RC,00006011254,NDC,,,facility,inpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,56.07,76.44,percent of total billed charges,
SITagliptin 50 mg T(Januvia),800017359,CDM,637,RC,00006011254,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,33.69,76.44,percent of total billed charges,
SITagliptin 50 mg T(Januvia),800017359,CDM,637,RC,00006011231,NDC,,,facility,inpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,56.07,76.44,percent of total billed charges,
SITagliptin 50 mg T(Januvia),800017359,CDM,637,RC,00006011231,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,33.69,76.44,percent of total billed charges,
SITagliptin 50 mg T(Januvia),800017359,CDM,637,RC,00006011228,NDC,,,facility,inpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,56.07,76.44,percent of total billed charges,
SITagliptin 50 mg T(Januvia),800017359,CDM,637,RC,00006011228,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,First Health,,76.44,,,,,,,33.69,76.44,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00006010682,NDC,,,facility,inpatient,1,EA,7.85000,2.28000,Aetna,First Health,,6.42,,,,,,,4.71,6.42,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00006010682,NDC,,,facility,outpatient,1,EA,7.85000,2.28000,Aetna,First Health,,6.42,,,,,,,2.83,6.42,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00006010658,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00006010658,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00006010628,NDC,,,facility,inpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,4.74,6.46,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00006010628,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,First Health,,6.46,,,,,,,2.85,6.46,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00006007258,NDC,,,facility,inpatient,1,EA,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,24.00,32.72,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00006007258,NDC,,,facility,outpatient,1,EA,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,14.42,32.72,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00006007231,NDC,,,facility,inpatient,1,EA,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,24.00,32.72,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00006007231,NDC,,,facility,outpatient,1,EA,40.00000,11.60000,Aetna,First Health,,32.72,,,,,,,14.42,32.72,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,00006004368,NDC,,,facility,inpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,2.01,2.74,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,00006004368,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,First Health,,2.74,,,,,,,1.21,2.74,percent of total billed charges,
Ivermectin 3 mg T(Stomectol),800017621,CDM,637,RC,00006003220,NDC,,,facility,inpatient,1,EA,39.55000,11.47000,Aetna,First Health,,32.35,,,,,,,23.73,32.35,percent of total billed charges,
Ivermectin 3 mg T(Stomectol),800017621,CDM,637,RC,00006003220,NDC,,,facility,outpatient,1,EA,39.55000,11.47000,Aetna,First Health,,32.35,,,,,,,14.26,32.35,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,00005921823,NDC,,,facility,inpatient,1,EA,29.90000,8.67000,Aetna,First Health,,24.46,,,,,,,17.94,24.46,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,00005921823,NDC,,,facility,outpatient,1,EA,29.90000,8.67000,Aetna,First Health,,24.46,,,,,,,10.78,24.46,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00005542965,NDC,,,facility,inpatient,1,EA,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,4.62,6.30,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00005542965,NDC,,,facility,outpatient,1,EA,7.70000,2.23000,Aetna,First Health,,6.30,,,,,,,2.78,6.30,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00005542918,NDC,,,facility,inpatient,1,EA,287.10000,83.26000,Aetna,First Health,,234.85,,,,,,,172.26,234.85,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00005542918,NDC,,,facility,outpatient,1,EA,287.10000,83.26000,Aetna,First Health,,234.85,,,,,,,103.50,234.85,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,00005509323,NDC,,,facility,inpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,5.13,6.99,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,00005509323,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,First Health,,6.99,,,,,,,3.08,6.99,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00005450723,NDC,facility,inpatient,2.5,ME,37.20000,10.79000,Aetna,First Health,,30.43,,,,,,,22.32,30.43,percent of total billed charges,
Methotrexate Na 2.5mg T,800016062,CDM,637,RC,J8610,HCPCS,00005450723,NDC,facility,outpatient,2.5,ME,37.20000,10.79000,Aetna,First Health,,30.43,,,,,,,0.14445,30.43,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00005381638,NDC,,,facility,inpatient,1,EA,10.60000,3.07000,Aetna,First Health,,8.67,,,,,,,6.36,8.67,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00005381638,NDC,,,facility,outpatient,1,EA,10.60000,3.07000,Aetna,First Health,,8.67,,,,,,,3.82,8.67,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00005318023,NDC,,,facility,inpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.78000,1.06,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00005318023,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,First Health,,1.06,,,,,,,0.46865,1.06,percent of total billed charges,
Pneumococcal 20-Valent Conjugate Vaccine,800046481,CDM,636,RC,90677,HCPCS,00005200010,NDC,facility,inpatient,1,ML,1281.00000,371.49000,Aetna,First Health,,1047.86,,,,,,,461.80,1047.86,percent of total billed charges,
Pneumococcal 20-Valent Conjugate Vaccine,800046481,CDM,636,RC,90677,HCPCS,00005200010,NDC,facility,outpatient,1,ML,1281.00000,371.49000,Aetna,First Health,,1047.86,,,,,,,301.32,1047.86,percent of total billed charges,
Pneumococcal 20-Valent Conjugate Vaccine,800046481,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,inpatient,1,ML,1315.30000,381.44000,Aetna,First Health,,1075.92,,,,,,,474.17,1075.92,percent of total billed charges,
Pneumococcal 20-Valent Conjugate Vaccine,800046481,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,1,ML,1315.30000,381.44000,Aetna,First Health,,1075.92,,,,,,,301.32,1075.92,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00004691106,NDC,,,facility,inpatient,1,EA,660.35000,191.50000,Aetna,First Health,,540.17,,,,,,,244.33,540.17,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00004691106,NDC,,,facility,outpatient,1,EA,660.35000,191.50000,Aetna,First Health,,540.17,,,,,,,238.06,540.17,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00004690414,NDC,,,facility,inpatient,1,EA,1143.85000,331.72000,Aetna,First Health,,935.67,,,,,,,423.22,935.67,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00004690414,NDC,,,facility,outpatient,1,EA,1143.85000,331.72000,Aetna,First Health,,935.67,,,,,,,412.36,935.67,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,00004199901,NDC,facility,inpatient,5,ME,134.40000,38.98000,Aetna,First Health,,109.94,,,,,,,48.45,109.94,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,00004199901,NDC,facility,outpatient,5,ME,134.40000,38.98000,Aetna,First Health,,109.94,,,,,,,0.13482,109.94,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00004197001,NDC,facility,inpatient,0.25,ME,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,2.94,6.67,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00004197001,NDC,facility,outpatient,0.25,ME,8.15000,2.36000,Aetna,First Health,,6.67,,,,,,,0.34668,6.67,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00004196404,NDC,facility,inpatient,1,GM,538.10000,156.05000,Aetna,First Health,,440.17,,,,,,,193.99,440.17,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00004196404,NDC,facility,outpatient,1,GM,538.10000,156.05000,Aetna,First Health,,440.17,,,,,,,0.44298,440.17,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,00004080285,NDC,,,facility,inpatient,1,EA,118.40000,34.34000,Aetna,First Health,,96.85,,,,,,,71.04,96.85,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,00004080285,NDC,,,facility,outpatient,1,EA,118.40000,34.34000,Aetna,First Health,,96.85,,,,,,,42.68,96.85,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,00004080085,NDC,,,facility,inpatient,1,EA,129.05000,37.42000,Aetna,First Health,,105.56,,,,,,,77.43,105.56,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,00004080085,NDC,,,facility,outpatient,1,EA,129.05000,37.42000,Aetna,First Health,,105.56,,,,,,,46.52,105.56,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,00004026401,NDC,,,facility,inpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,6.51,8.88,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,00004026401,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,First Health,,8.88,,,,,,,3.91,8.88,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,00004026201,NDC,,,facility,inpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,5.04,6.87,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,00004026201,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,First Health,,6.87,,,,,,,3.03,6.87,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00004026001,NDC,facility,inpatient,500,ME,152.85000,44.33000,Aetna,First Health,,125.03,,,,,,,55.10,125.03,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00004026001,NDC,facility,outpatient,500,ME,152.85000,44.33000,Aetna,First Health,,125.03,,,,,,,0.14445,125.03,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,00004019109,NDC,facility,inpatient,3,ME,2291.15000,664.43000,Aetna,First Health,,1874.16,,,,,,,825.96,1874.16,percent of total billed charges,
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,00004019109,NDC,facility,outpatient,3,ME,2291.15000,664.43000,Aetna,First Health,,1874.16,,,,,,,12.65,1874.16,percent of total billed charges,
Midazolam HCl 5mg/2.5mL L UD,800078849,CDM,637,RC,00004016851,NDC,,,facility,inpatient,1,EA,24.95000,7.24000,Aetna,First Health,,20.41,,,,,,,14.97,20.41,percent of total billed charges,
Midazolam HCl 5mg/2.5mL L UD,800078849,CDM,637,RC,00004016851,NDC,,,facility,outpatient,1,EA,24.95000,7.24000,Aetna,First Health,,20.41,,,,,,,8.99,20.41,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),800075274,CDM,637,RC,00004016851,NDC,,,facility,inpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,6.00,8.18,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),800075274,CDM,637,RC,00004016851,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,First Health,,8.18,,,,,,,3.60,8.18,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00004014323,NDC,,,facility,inpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,5.79,7.89,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00004014323,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,First Health,,7.89,,,,,,,3.48,7.89,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00004014301,NDC,,,facility,inpatient,1,EA,9.90000,2.87000,Aetna,First Health,,8.10,,,,,,,5.94,8.10,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00004014301,NDC,,,facility,outpatient,1,EA,9.90000,2.87000,Aetna,First Health,,8.10,,,,,,,3.57,8.10,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00004012501,NDC,,,facility,inpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.90000,1.23,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00004012501,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,First Health,,1.23,,,,,,,0.54075,1.23,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,00004007701,NDC,,,facility,inpatient,1,EA,24.85000,7.21000,Aetna,First Health,,20.33,,,,,,,14.91,20.33,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,00004007701,NDC,,,facility,outpatient,1,EA,24.85000,7.21000,Aetna,First Health,,20.33,,,,,,,8.96,20.33,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,00004003909,NDC,,,facility,inpatient,1,EA,103.30000,29.96000,Aetna,First Health,,84.50,,,,,,,61.98,84.50,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,00004003909,NDC,,,facility,outpatient,1,EA,103.30000,29.96000,Aetna,First Health,,84.50,,,,,,,37.24,84.50,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),800017736,CDM,637,RC,00004003822,NDC,,,facility,inpatient,1,EA,681.95000,197.77000,Aetna,First Health,,557.84,,,,,,,409.17,557.84,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),800017736,CDM,637,RC,00004003822,NDC,,,facility,outpatient,1,EA,681.95000,197.77000,Aetna,First Health,,557.84,,,,,,,245.84,557.84,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,00003773395,NDC,facility,inpatient,2,GM,258.65000,75.01000,Aetna,First Health,,211.58,,,,,,,93.24,211.58,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,00003773395,NDC,facility,outpatient,2,GM,258.65000,75.01000,Aetna,First Health,,211.58,,,,,,,0.83781,211.58,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00003773299,NDC,facility,inpatient,1,GM,151.80000,44.02000,Aetna,First Health,,124.17,,,,,,,54.72,124.17,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00003773299,NDC,facility,outpatient,1,GM,151.80000,44.02000,Aetna,First Health,,124.17,,,,,,,0.83781,124.17,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00003517805,NDC,,,facility,inpatient,1,EA,32.75000,9.50000,Aetna,First Health,,26.79,,,,,,,19.65,26.79,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00003517805,NDC,,,facility,outpatient,1,EA,32.75000,9.50000,Aetna,First Health,,26.79,,,,,,,11.81,26.79,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00003515405,NDC,,,facility,inpatient,1,EA,30.40000,8.82000,Aetna,First Health,,24.87,,,,,,,18.24,24.87,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00003515405,NDC,,,facility,outpatient,1,EA,30.40000,8.82000,Aetna,First Health,,24.87,,,,,,,10.96,24.87,percent of total billed charges,
Nivolumab 40mg/4mL I(Opdivo),800062007,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,inpatient,40,ME,7335.80000,2127.38000,Aetna,First Health,,6000.68,,,,,,,2644.56,6000.68,percent of total billed charges,
Nivolumab 40mg/4mL I(Opdivo),800062007,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,outpatient,40,ME,7335.80000,2127.38000,Aetna,First Health,,6000.68,,,,,,,32.33,6000.68,percent of total billed charges,
Nivolumab 120mg Inj - Pt Own Supply,800051025,CDM,636,RC,J9299,HCPCS,00003375614,NDC,facility,inpatient,120,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03605,0.08180,percent of total billed charges,
Nivolumab 120mg Inj - Pt Own Supply,800051025,CDM,636,RC,J9299,HCPCS,00003375614,NDC,facility,outpatient,120,ME,0.10000,0.03000,Aetna,First Health,,0.08180,,,,,,,0.03700,103.53,percent of total billed charges,
Nivolumab 120mg/12mL I(Opdivo),800051959,CDM,636,RC,J9299,HCPCS,00003375614,NDC,facility,inpatient,120,ME,21633.25000,6273.64000,Aetna,First Health,,17696.00,,,,,,,7798.79,17696.00,percent of total billed charges,
Nivolumab 120mg/12mL I(Opdivo),800051959,CDM,636,RC,J9299,HCPCS,00003375614,NDC,facility,outpatient,120,ME,21633.25000,6273.64000,Aetna,First Health,,17696.00,,,,,,,32.33,17696.00,percent of total billed charges,
Nivolumab 240mg Inj - Pt Own Supply,800051026,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,inpatient,240,ME,0.25000,0.07000,Aetna,First Health,,0.20450,,,,,,,0.09012,0.20450,percent of total billed charges,
Nivolumab 240mg Inj - Pt Own Supply,800051026,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,outpatient,240,ME,0.25000,0.07000,Aetna,First Health,,0.20450,,,,,,,0.09250,103.53,percent of total billed charges,
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,2,GM,537.40000,155.85000,Aetna,First Health,,439.59,,,,,,,193.73,439.59,percent of total billed charges,
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,outpatient,2,GM,537.40000,155.85000,Aetna,First Health,,439.59,,,,,,,2.15,439.59,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,GM,280.55000,81.36000,Aetna,First Health,,229.49,,,,,,,101.14,229.49,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,outpatient,1,GM,280.55000,81.36000,Aetna,First Health,,229.49,,,,,,,2.15,229.49,percent of total billed charges,
ipilimumab 50mg/10mL I(Yervoy),800051077,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,50,ME,65381.15000,18960.53000,Aetna,First Health,,53481.78,,,,,,,23569.90,53481.78,percent of total billed charges,
ipilimumab 50mg/10mL I(Yervoy),800051077,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,outpatient,50,ME,65381.15000,18960.53000,Aetna,First Health,,53481.78,,,,,,,179.99,53481.78,percent of total billed charges,
Abatacept 250mg I(Orencia),800011587,CDM,636,RC,J0129,HCPCS,00003218713,NDC,facility,inpatient,250,ME,11347.00000,3290.63000,Aetna,First Health,,9281.85,,,,,,,4090.59,9281.85,percent of total billed charges,
Abatacept 250mg I(Orencia),800011587,CDM,636,RC,J0129,HCPCS,00003218713,NDC,facility,outpatient,250,ME,11347.00000,3290.63000,Aetna,First Health,,9281.85,,,,,,,43.11,9281.85,percent of total billed charges,
Abatacept 250mg I(Orencia),800011587,CDM,636,RC,J0129,HCPCS,00003218710,NDC,facility,inpatient,250,ME,8651.10000,2508.82000,Aetna,First Health,,7076.60,,,,,,,3118.72,7076.60,percent of total billed charges,
Abatacept 250mg I(Orencia),800011587,CDM,636,RC,J0129,HCPCS,00003218710,NDC,facility,outpatient,250,ME,8651.10000,2508.82000,Aetna,First Health,,7076.60,,,,,,,43.11,7076.60,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),800017949,CDM,637,RC,00003089470,NDC,,,facility,inpatient,1,EA,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,51.51,70.23,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),800017949,CDM,637,RC,00003089470,NDC,,,facility,outpatient,1,EA,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,30.95,70.23,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),800017949,CDM,637,RC,00003089431,NDC,,,facility,inpatient,1,EA,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,51.51,70.23,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),800017949,CDM,637,RC,00003089431,NDC,,,facility,outpatient,1,EA,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,30.95,70.23,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),800017949,CDM,637,RC,00003089421,NDC,,,facility,inpatient,1,EA,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,51.51,70.23,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),800017949,CDM,637,RC,00003089421,NDC,,,facility,outpatient,1,EA,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,30.95,70.23,percent of total billed charges,
Apixaban 2.5mg Tab (Eliquis),800017948,CDM,637,RC,00003089331,NDC,,,facility,inpatient,1,EA,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,51.51,70.23,percent of total billed charges,
Apixaban 2.5mg Tab (Eliquis),800017948,CDM,637,RC,00003089331,NDC,,,facility,outpatient,1,EA,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,30.95,70.23,percent of total billed charges,
Apixaban 2.5mg Tab (Eliquis),800017948,CDM,637,RC,00003089321,NDC,,,facility,inpatient,1,EA,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,51.51,70.23,percent of total billed charges,
Apixaban 2.5mg Tab (Eliquis),800017948,CDM,637,RC,00003089321,NDC,,,facility,outpatient,1,EA,85.85000,24.90000,Aetna,First Health,,70.23,,,,,,,30.95,70.23,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,00003083050,NDC,,,facility,inpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,6.96,9.49,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,00003083050,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,First Health,,9.49,,,,,,,4.18,9.49,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00003067371,NDC,facility,inpatient,1,EA,329.35000,95.51000,Aetna,First Health,,269.41,,,,,,,118.73,269.41,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00003067371,NDC,facility,outpatient,1,EA,329.35000,95.51000,Aetna,First Health,,269.41,,,,,,,0.75114,269.41,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00003059320,NDC,,,facility,inpatient,1,EA,223.85000,64.92000,Aetna,First Health,,183.11,,,,,,,134.31,183.11,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00003059320,NDC,,,facility,outpatient,1,EA,223.85000,64.92000,Aetna,First Health,,183.11,,,,,,,80.70,183.11,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00003042950,NDC,,,facility,inpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,3.30,4.50,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00003042950,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,First Health,,4.50,,,,,,,1.98,4.50,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,40,ME,59.75000,17.33000,Aetna,First Health,,48.88,,,,,,,21.54,48.88,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,outpatient,40,ME,59.75000,17.33000,Aetna,First Health,,48.88,,,,,,,0.71262,48.88,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00003017850,NDC,,,facility,inpatient,1,EA,12.85000,3.73000,Aetna,First Health,,10.51,,,,,,,7.71,10.51,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00003017850,NDC,,,facility,outpatient,1,EA,12.85000,3.73000,Aetna,First Health,,10.51,,,,,,,4.63,10.51,percent of total billed charges,
donanemab - azbt 350mg I,800051993,CDM,636,RC,J0175,HCPCS,00002940101,NDC,facility,inpatient,350,ME,5258.30000,1524.91000,Aetna,First Health,,4301.29,,,,,,,1895.62,4301.29,percent of total billed charges,
donanemab - azbt 350mg I,800051993,CDM,636,RC,J0175,HCPCS,00002940101,NDC,facility,outpatient,350,ME,5258.30000,1524.91000,Aetna,First Health,,4301.29,,,,,,,4.02,4301.29,percent of total billed charges,
Insulin Regular (Concentrated) U-500 Pen/Needle,800022074,CDM,637,RC,J1815,HCPCS,00002882427,NDC,facility,inpatient,500,UN,1333.80000,386.80000,Aetna,First Health,,1091.05,,,,,,,800.28,1091.05,percent of total billed charges,
Insulin Regular (Concentrated) U-500 Pen/Needle,800022074,CDM,637,RC,J1815,HCPCS,00002882427,NDC,facility,outpatient,500,UN,1333.80000,386.80000,Aetna,First Health,,1091.05,,,,,,,0.26001,1091.05,percent of total billed charges,
Insulin Isophane (NPH) Inj,800062036,CDM,637,RC,J1815,HCPCS,00002831517,NDC,facility,inpatient,5,UN,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,2.85,3.89,percent of total billed charges,
Insulin Isophane (NPH) Inj,800062036,CDM,637,RC,J1815,HCPCS,00002831517,NDC,facility,outpatient,5,UN,4.75000,1.38000,Aetna,First Health,,3.89,,,,,,,0.26001,3.89,percent of total billed charges,
Insulin Isophane (NPH) Inj,800062036,CDM,637,RC,J1815,HCPCS,00002831501,NDC,facility,inpatient,5,UN,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.84000,1.15,percent of total billed charges,
Insulin Isophane (NPH) Inj,800062036,CDM,637,RC,J1815,HCPCS,00002831501,NDC,facility,outpatient,5,UN,1.40000,0.41000,Aetna,First Health,,1.15,,,,,,,0.26001,1.15,percent of total billed charges,
PEMEtrexed 500mg Rec Inj,800022535,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,inpatient,500,ME,22019.20000,6385.57000,Aetna,First Health,,18011.71,,,,,,,7937.92,18011.71,percent of total billed charges,
PEMEtrexed 500mg Rec Inj,800022535,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,outpatient,500,ME,22019.20000,6385.57000,Aetna,First Health,,18011.71,,,,,,,3.46,18011.71,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,00002759701,NDC,facility,inpatient,10,ME,301.55000,87.45000,Aetna,First Health,,246.67,,,,,,,108.71,246.67,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,00002759701,NDC,facility,outpatient,10,ME,301.55000,87.45000,Aetna,First Health,,246.67,,,,,,,0.78003,246.67,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,00002750201,NDC,facility,inpatient,1000,ME,4188.15000,1214.56000,Aetna,First Health,,3425.91,,,,,,,1509.83,3425.91,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,00002750201,NDC,facility,outpatient,1000,ME,4188.15000,1214.56000,Aetna,First Health,,3425.91,,,,,,,3.46,3425.91,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,00002750101,NDC,facility,inpatient,200,ME,894.30000,259.35000,Aetna,First Health,,731.54,,,,,,,322.40,731.54,percent of total billed charges,
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,00002750101,NDC,facility,outpatient,200,ME,894.30000,259.35000,Aetna,First Health,,731.54,,,,,,,3.46,731.54,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,00002512377,NDC,,,facility,inpatient,1,EA,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,78.00,106.34,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,00002512377,NDC,,,facility,outpatient,1,EA,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,46.87,106.34,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,00002512152,NDC,,,facility,inpatient,1,EA,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,78.00,106.34,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,00002512152,NDC,,,facility,outpatient,1,EA,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,46.87,106.34,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,00002512130,NDC,,,facility,inpatient,1,EA,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,78.00,106.34,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,00002512130,NDC,,,facility,outpatient,1,EA,130.00000,37.70000,Aetna,First Health,,106.34,,,,,,,46.87,106.34,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,00002476030,NDC,,,facility,inpatient,1,EA,49.70000,14.41000,Aetna,First Health,,40.65,,,,,,,29.82,40.65,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,00002476030,NDC,,,facility,outpatient,1,EA,49.70000,14.41000,Aetna,First Health,,40.65,,,,,,,17.92,40.65,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,00002475977,NDC,,,facility,inpatient,1,EA,49.70000,14.41000,Aetna,First Health,,40.65,,,,,,,29.82,40.65,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,00002475977,NDC,,,facility,outpatient,1,EA,49.70000,14.41000,Aetna,First Health,,40.65,,,,,,,17.92,40.65,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,00002475930,NDC,,,facility,inpatient,1,EA,49.70000,14.41000,Aetna,First Health,,40.65,,,,,,,29.82,40.65,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,00002475930,NDC,,,facility,outpatient,1,EA,49.70000,14.41000,Aetna,First Health,,40.65,,,,,,,17.92,40.65,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,00002445385,NDC,,,facility,inpatient,1,EA,142.15000,41.22000,Aetna,First Health,,116.28,,,,,,,85.29,116.28,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,00002445385,NDC,,,facility,outpatient,1,EA,142.15000,41.22000,Aetna,First Health,,116.28,,,,,,,51.25,116.28,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00002416530,NDC,,,facility,inpatient,1,EA,56.05000,16.25000,Aetna,First Health,,45.85,,,,,,,33.63,45.85,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00002416530,NDC,,,facility,outpatient,1,EA,56.05000,16.25000,Aetna,First Health,,45.85,,,,,,,20.21,45.85,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00002416502,NDC,,,facility,inpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,25.50,34.77,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00002416502,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,First Health,,34.77,,,,,,,15.32,34.77,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00002411760,NDC,,,facility,inpatient,1,EA,81.40000,23.61000,Aetna,First Health,,66.59,,,,,,,48.84,66.59,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00002411760,NDC,,,facility,outpatient,1,EA,81.40000,23.61000,Aetna,First Health,,66.59,,,,,,,29.34,66.59,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00002411733,NDC,,,facility,inpatient,1,EA,156.65000,45.43000,Aetna,First Health,,128.14,,,,,,,93.99,128.14,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00002411733,NDC,,,facility,outpatient,1,EA,156.65000,45.43000,Aetna,First Health,,128.14,,,,,,,56.47,128.14,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00002411730,NDC,,,facility,inpatient,1,EA,202.35000,58.68000,Aetna,First Health,,165.52,,,,,,,121.41,165.52,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00002411730,NDC,,,facility,outpatient,1,EA,202.35000,58.68000,Aetna,First Health,,165.52,,,,,,,72.95,165.52,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00002411560,NDC,,,facility,inpatient,1,EA,54.05000,15.67000,Aetna,First Health,,44.21,,,,,,,32.43,44.21,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00002411560,NDC,,,facility,outpatient,1,EA,54.05000,15.67000,Aetna,First Health,,44.21,,,,,,,19.49,44.21,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00002411533,NDC,,,facility,inpatient,1,EA,51.90000,15.05000,Aetna,First Health,,42.45,,,,,,,31.14,42.45,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00002411533,NDC,,,facility,outpatient,1,EA,51.90000,15.05000,Aetna,First Health,,42.45,,,,,,,18.71,42.45,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00002411530,NDC,,,facility,inpatient,1,EA,133.80000,38.80000,Aetna,First Health,,109.45,,,,,,,80.28,109.45,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00002411530,NDC,,,facility,outpatient,1,EA,133.80000,38.80000,Aetna,First Health,,109.45,,,,,,,48.23,109.45,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00002411260,NDC,,,facility,inpatient,1,EA,35.40000,10.27000,Aetna,First Health,,28.96,,,,,,,21.24,28.96,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00002411260,NDC,,,facility,outpatient,1,EA,35.40000,10.27000,Aetna,First Health,,28.96,,,,,,,12.76,28.96,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00002411230,NDC,,,facility,inpatient,1,EA,113.40000,32.89000,Aetna,First Health,,92.76,,,,,,,68.04,92.76,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00002411230,NDC,,,facility,outpatient,1,EA,113.40000,32.89000,Aetna,First Health,,92.76,,,,,,,40.88,92.76,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00002327033,NDC,,,facility,inpatient,1,EA,51.45000,14.92000,Aetna,First Health,,42.09,,,,,,,30.87,42.09,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00002327033,NDC,,,facility,outpatient,1,EA,51.45000,14.92000,Aetna,First Health,,42.09,,,,,,,18.55,42.09,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00002327030,NDC,,,facility,inpatient,1,EA,79.45000,23.04000,Aetna,First Health,,64.99,,,,,,,47.67,64.99,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00002327030,NDC,,,facility,outpatient,1,EA,79.45000,23.04000,Aetna,First Health,,64.99,,,,,,,28.64,64.99,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,00002324090,NDC,,,facility,inpatient,1,EA,79.45000,23.04000,Aetna,First Health,,64.99,,,,,,,47.67,64.99,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,00002324090,NDC,,,facility,outpatient,1,EA,79.45000,23.04000,Aetna,First Health,,64.99,,,,,,,28.64,64.99,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,00002324030,NDC,,,facility,inpatient,1,EA,79.45000,23.04000,Aetna,First Health,,64.99,,,,,,,47.67,64.99,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,00002324030,NDC,,,facility,outpatient,1,EA,79.45000,23.04000,Aetna,First Health,,64.99,,,,,,,28.64,64.99,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00002323730,NDC,,,facility,inpatient,1,EA,36.65000,10.63000,Aetna,First Health,,29.98,,,,,,,21.99,29.98,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00002323730,NDC,,,facility,outpatient,1,EA,36.65000,10.63000,Aetna,First Health,,29.98,,,,,,,13.21,29.98,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,00002323560,NDC,,,facility,inpatient,1,EA,70.85000,20.55000,Aetna,First Health,,57.96,,,,,,,42.51,57.96,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,00002323560,NDC,,,facility,outpatient,1,EA,70.85000,20.55000,Aetna,First Health,,57.96,,,,,,,25.54,57.96,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,00002260658,NDC,,,facility,inpatient,1,EA,40.25000,11.67000,Aetna,First Health,,32.92,,,,,,,24.15,32.92,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,00002260658,NDC,,,facility,outpatient,1,EA,40.25000,11.67000,Aetna,First Health,,32.92,,,,,,,14.51,32.92,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,00002109402,NDC,,,facility,inpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,2.07,2.82,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,00002109402,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,First Health,,2.82,,,,,,,1.24,2.82,percent of total billed charges,
NICU- DexAMETHasone 0.1mg/mL IV in D5W,800051126,CDM,636,RC,J1100,HCPCS,00000000300,NDC,facility,inpatient,5,ME,98.20000,28.48000,Aetna,First Health,,80.33,,,,,,,35.40,80.33,percent of total billed charges,
NICU- DexAMETHasone 0.1mg/mL IV in D5W,800051126,CDM,636,RC,J1100,HCPCS,00000000300,NDC,facility,outpatient,5,ME,98.20000,28.48000,Aetna,First Health,,80.33,,,,,,,0.10593,80.33,percent of total billed charges,
Remdesivir 100mg Inj,800062067,CDM,636,RC,J0248,HCPCS,00000000290,NDC,facility,inpatient,100,ME,3307.00000,959.03000,Aetna,First Health,,2705.13,,,,,,,1192.17,2705.13,percent of total billed charges,
Remdesivir 100mg Inj,800062067,CDM,636,RC,J0248,HCPCS,00000000290,NDC,facility,outpatient,100,ME,3307.00000,959.03000,Aetna,First Health,,2705.13,,,,,,,6.64,2705.13,percent of total billed charges,
"NICU- Penicillin GK 100,000 unit/mL IM",800040896,CDM,636,RC,J2540,HCPCS,00000000284,NDC,facility,inpatient,100000,UN,19.95000,5.79000,Aetna,First Health,,16.32,,,,,,,7.19,16.32,percent of total billed charges,
"NICU- Penicillin GK 100,000 unit/mL IM",800040896,CDM,636,RC,J2540,HCPCS,00000000284,NDC,facility,outpatient,100000,UN,19.95000,5.79000,Aetna,First Health,,16.32,,,,,,,0.75114,16.32,percent of total billed charges,
Alteplase 0.5mg/1mL Inj Syr,800022089,CDM,636,RC,J2997,HCPCS,00000000272,NDC,facility,inpatient,0.5,ME,385.60000,111.82000,Aetna,First Health,,315.42,,,,,,,139.01,315.42,percent of total billed charges,
Alteplase 0.5mg/1mL Inj Syr,800022089,CDM,636,RC,J2997,HCPCS,00000000272,NDC,facility,outpatient,0.5,ME,385.60000,111.82000,Aetna,First Health,,315.42,,,,,,,90.36,315.42,percent of total billed charges,
Mupirocin/Nystatin/Betameth/Antifungal Oint.,800022042,CDM,637,RC,00000000264,NDC,,,facility,inpatient,1,EA,603.90000,175.13000,Aetna,First Health,,493.99,,,,,,,362.34,493.99,percent of total billed charges,
Mupirocin/Nystatin/Betameth/Antifungal Oint.,800022042,CDM,637,RC,00000000264,NDC,,,facility,outpatient,1,EA,603.90000,175.13000,Aetna,First Health,,493.99,,,,,,,217.71,493.99,percent of total billed charges,
Alteplase 10mg/10mL Bolus Syringe,800022033,CDM,636,RC,J2997,HCPCS,00000000255,NDC,facility,inpatient,10,ME,4529.40000,1313.53000,Aetna,First Health,,3705.05,,,,,,,1632.85,3705.05,percent of total billed charges,
Alteplase 10mg/10mL Bolus Syringe,800022033,CDM,636,RC,J2997,HCPCS,00000000255,NDC,facility,outpatient,10,ME,4529.40000,1313.53000,Aetna,First Health,,3705.05,,,,,,,90.36,3705.05,percent of total billed charges,
NICU- Indomethacin 0.1mg/1mL IS,800025705,CDM,252,RC,00000000253,NDC,,,facility,inpatient,1,EA,3504.40000,1016.28000,Aetna,First Health,,2866.60,,,,,,,1296.63,2866.60,percent of total billed charges,
NICU- Indomethacin 0.1mg/1mL IS,800025705,CDM,252,RC,00000000253,NDC,,,facility,outpatient,1,EA,3504.40000,1016.28000,Aetna,First Health,,2866.60,,,,,,,1263.34,2866.60,percent of total billed charges,
Cholestyramine 5g/ZincOxide 20% TP,800025703,CDM,637,RC,00000000250,NDC,,,facility,inpatient,1,EA,77.30000,22.42000,Aetna,First Health,,63.23,,,,,,,46.38,63.23,percent of total billed charges,
Cholestyramine 5g/ZincOxide 20% TP,800025703,CDM,637,RC,00000000250,NDC,,,facility,outpatient,1,EA,77.30000,22.42000,Aetna,First Health,,63.23,,,,,,,27.87,63.23,percent of total billed charges,
Dextrose (For TPN/PPN),800025672,CDM,250,RC,00000000239,NDC,,,facility,inpatient,1,EA,28.50000,8.26000,Aetna,First Health,,23.31,,,,,,,10.54,23.31,percent of total billed charges,
Dextrose (For TPN/PPN),800025672,CDM,250,RC,00000000239,NDC,,,facility,outpatient,1,EA,28.50000,8.26000,Aetna,First Health,,23.31,,,,,,,10.27,23.31,percent of total billed charges,
Amino Acids (for TPN/PPN),800025671,CDM,250,RC,00000000238,NDC,,,facility,inpatient,1,EA,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,21.09,46.63,percent of total billed charges,
Amino Acids (for TPN/PPN),800025671,CDM,250,RC,00000000238,NDC,,,facility,outpatient,1,EA,57.00000,16.53000,Aetna,First Health,,46.63,,,,,,,20.55,46.63,percent of total billed charges,
NICU- cefTAZidime 50mg/mL IS,800025650,CDM,636,RC,J0713,HCPCS,00000000234,NDC,facility,inpatient,50,ME,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,18.75,42.54,percent of total billed charges,
NICU- cefTAZidime 50mg/mL IS,800025650,CDM,636,RC,J0713,HCPCS,00000000234,NDC,facility,outpatient,50,ME,52.00000,15.08000,Aetna,First Health,,42.54,,,,,,,1.42,42.54,percent of total billed charges,
NS 100mL Inj,800025641,CDM,636,RC,J7050,HCPCS,00000000233,NDC,facility,inpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,5.30,12.02,percent of total billed charges,
NS 100mL Inj,800025641,CDM,636,RC,J7050,HCPCS,00000000233,NDC,facility,outpatient,1,EA,14.70000,4.26000,Aetna,First Health,,12.02,,,,,,,0.63558,12.02,percent of total billed charges,
NS 250mL Inj IVR,800025640,CDM,636,RC,J7050,HCPCS,00000000232,NDC,facility,inpatient,1,EA,12.55000,3.64000,Aetna,First Health,,10.27,,,,,,,4.52,10.27,percent of total billed charges,
NS 250mL Inj IVR,800025640,CDM,636,RC,J7050,HCPCS,00000000232,NDC,facility,outpatient,1,EA,12.55000,3.64000,Aetna,First Health,,10.27,,,,,,,0.63558,10.27,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,00000000225,NDC,facility,inpatient,1,GM,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,47.59,107.98,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,00000000225,NDC,facility,outpatient,1,GM,132.00000,38.28000,Aetna,First Health,,107.98,,,,,,,0.56817,107.98,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL - for IV Set,800025512,CDM,250,RC,00000000221,NDC,,,facility,inpatient,1,EA,3313.20000,960.83000,Aetna,First Health,,2710.20,,,,,,,1225.88,2710.20,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL - for IV Set,800025512,CDM,250,RC,00000000221,NDC,,,facility,outpatient,1,EA,3313.20000,960.83000,Aetna,First Health,,2710.20,,,,,,,1194.41,2710.20,percent of total billed charges,
ceFAZolin 3g/ NS 115mL P (Ancef),800020015,CDM,636,RC,J0690,HCPCS,00000000184,NDC,facility,inpatient,3,GM,87.40000,25.35000,Aetna,First Health,,71.49,,,,,,,31.51,71.49,percent of total billed charges,
ceFAZolin 3g/ NS 115mL P (Ancef),800020015,CDM,636,RC,J0690,HCPCS,00000000184,NDC,facility,outpatient,3,GM,87.40000,25.35000,Aetna,First Health,,71.49,,,,,,,0.79929,71.49,percent of total billed charges,
Nitroglycerin 40mcg/mL D5W Vial - OR Use ONLY,800025569,CDM,250,RC,00000000183,NDC,,,facility,inpatient,1,EA,79.65000,23.10000,Aetna,First Health,,65.15,,,,,,,29.47,65.15,percent of total billed charges,
Nitroglycerin 40mcg/mL D5W Vial - OR Use ONLY,800025569,CDM,250,RC,00000000183,NDC,,,facility,outpatient,1,EA,79.65000,23.10000,Aetna,First Health,,65.15,,,,,,,28.71,65.15,percent of total billed charges,
NICU- Ampicillin 100mg/mL IV Syr,800025529,CDM,636,RC,J0290,HCPCS,00000000171,NDC,facility,inpatient,100,ME,33.50000,9.72000,Aetna,First Health,,27.40,,,,,,,12.08,27.40,percent of total billed charges,
NICU- Ampicillin 100mg/mL IV Syr,800025529,CDM,636,RC,J0290,HCPCS,00000000171,NDC,facility,outpatient,100,ME,33.50000,9.72000,Aetna,First Health,,27.40,,,,,,,0.56817,27.40,percent of total billed charges,
fentaNYL 10mcg/mL Cont Inf.,800018033,CDM,636,RC,J3010,HCPCS,00000000167,NDC,facility,inpatient,1,ME,212.50000,61.62000,Aetna,First Health,,173.82,,,,,,,76.61,173.82,percent of total billed charges,
fentaNYL 10mcg/mL Cont Inf.,800018033,CDM,636,RC,J3010,HCPCS,00000000167,NDC,facility,outpatient,1,ME,212.50000,61.62000,Aetna,First Health,,173.82,,,,,,,1.15,173.82,percent of total billed charges,
Metoclopramide 5mg/5mL L UD,800072514,CDM,637,RC,00000000155,NDC,,,facility,inpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,1.20,1.64,percent of total billed charges,
Metoclopramide 5mg/5mL L UD,800072514,CDM,637,RC,00000000155,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,First Health,,1.64,,,,,,,0.72100,1.64,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,00000000144,NDC,facility,inpatient,1,ME,230.90000,66.96000,Aetna,First Health,,188.88,,,,,,,83.24,188.88,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,00000000144,NDC,facility,outpatient,1,ME,230.90000,66.96000,Aetna,First Health,,188.88,,,,,,,85.43,188.88,percent of total billed charges,
Azithromycin 500mg/NS 250mL P,800081292,CDM,636,RC,J0456,HCPCS,00000000140,NDC,facility,inpatient,500,ME,177.50000,51.47000,Aetna,First Health,,145.19,,,,,,,63.99,145.19,percent of total billed charges,
Azithromycin 500mg/NS 250mL P,800081292,CDM,636,RC,J0456,HCPCS,00000000140,NDC,facility,outpatient,500,ME,177.50000,51.47000,Aetna,First Health,,145.19,,,,,,,1.96,145.19,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00000000137,NDC,facility,inpatient,25000,UN,95.65000,27.74000,Aetna,First Health,,78.24,,,,,,,34.48,78.24,percent of total billed charges,
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00000000137,NDC,facility,outpatient,25000,UN,95.65000,27.74000,Aetna,First Health,,78.24,,,,,,,0.17334,78.24,percent of total billed charges,
NICU- Acyclovir 7mg/mL IV,800019213,CDM,636,RC,J0133,HCPCS,00000000115,NDC,facility,inpatient,7,ME,376.00000,109.04000,Aetna,First Health,,307.57,,,,,,,135.55,307.57,percent of total billed charges,
NICU- Acyclovir 7mg/mL IV,800019213,CDM,636,RC,J0133,HCPCS,00000000115,NDC,facility,outpatient,7,ME,376.00000,109.04000,Aetna,First Health,,307.57,,,,,,,0.11556,307.57,percent of total billed charges,
"NICU- Penicillin GK 50,000 unit/mL IV",800081197,CDM,636,RC,J2540,HCPCS,00000000114,NDC,facility,inpatient,50000,UN,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,10.81,24.54,percent of total billed charges,
"NICU- Penicillin GK 50,000 unit/mL IV",800081197,CDM,636,RC,J2540,HCPCS,00000000114,NDC,facility,outpatient,50000,UN,30.00000,8.70000,Aetna,First Health,,24.54,,,,,,,0.75114,24.54,percent of total billed charges,
NICU- Ampicillin 500mg/2mL IM,800081194,CDM,636,RC,J0290,HCPCS,00000000110,NDC,facility,inpatient,500,ME,53.20000,15.43000,Aetna,First Health,,43.52,,,,,,,19.18,43.52,percent of total billed charges,
NICU- Ampicillin 500mg/2mL IM,800081194,CDM,636,RC,J0290,HCPCS,00000000110,NDC,facility,outpatient,500,ME,53.20000,15.43000,Aetna,First Health,,43.52,,,,,,,0.56817,43.52,percent of total billed charges,
NICU- Vancomycin 5mg/mL IV,800081192,CDM,636,RC,J3373,HCPCS,00000000109,NDC,facility,inpatient,5,ME,172.80000,50.11000,Aetna,First Health,,141.35,,,,,,,62.29,141.35,percent of total billed charges,
NICU- Vancomycin 5mg/mL IV,800081192,CDM,636,RC,J3373,HCPCS,00000000109,NDC,facility,outpatient,5,ME,172.80000,50.11000,Aetna,First Health,,141.35,,,,,,,0.02889,141.35,percent of total billed charges,
NICU- Gentamicin Sulf 5mg/mL IV,800081191,CDM,636,RC,J1580,HCPCS,00000000108,NDC,facility,inpatient,20,ME,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.57680,1.31,percent of total billed charges,
NICU- Gentamicin Sulf 5mg/mL IV,800081191,CDM,636,RC,J1580,HCPCS,00000000108,NDC,facility,outpatient,20,ME,1.60000,0.46000,Aetna,First Health,,1.31,,,,,,,0.59200,6.69,percent of total billed charges,
NEOnatal Lipid 20% Inf,800081154,CDM,252,RC,00000000102,NDC,,,facility,inpatient,1,EA,128.50000,37.26000,Aetna,First Health,,105.11,,,,,,,47.55,105.11,percent of total billed charges,
NEOnatal Lipid 20% Inf,800081154,CDM,252,RC,00000000102,NDC,,,facility,outpatient,1,EA,128.50000,37.26000,Aetna,First Health,,105.11,,,,,,,46.32,105.11,percent of total billed charges,
NICU- NEOnatal TPN Infusion,800081155,CDM,258,RC,00000000101,NDC,,,facility,inpatient,1,EA,836.80000,242.67000,Aetna,First Health,,684.50,,,,,,,393.30,684.50,percent of total billed charges,
NICU- NEOnatal TPN Infusion,800081155,CDM,258,RC,00000000101,NDC,,,facility,outpatient,1,EA,836.80000,242.67000,Aetna,First Health,,684.50,,,,,,,301.67,684.50,percent of total billed charges,
Parenteral Nutrition Chg,800012668,CDM,251,RC,00000000079,NDC,,,facility,inpatient,1,EA,970.00000,281.30000,Aetna,First Health,,793.46,,,,,,,358.90,793.46,percent of total billed charges,
Parenteral Nutrition Chg,800012668,CDM,251,RC,00000000079,NDC,,,facility,outpatient,1,EA,970.00000,281.30000,Aetna,First Health,,793.46,,,,,,,349.69,793.46,percent of total billed charges,
Open Heart Kit,800071505,CDM,251,RC,00000000050,NDC,,,facility,inpatient,1,EA,4044.10000,1172.79000,Aetna,First Health,,3308.07,,,,,,,1496.32,3308.07,percent of total billed charges,
Open Heart Kit,800071505,CDM,251,RC,00000000050,NDC,,,facility,outpatient,1,EA,4044.10000,1172.79000,Aetna,First Health,,3308.07,,,,,,,1457.90,3308.07,percent of total billed charges,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,493.02,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB",360,RC,74420,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,173.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION;",481,RC,93454,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22853,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",361,RC,10005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC); WITH IMAGING GUIDANCE,361,RC,49083,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,363.66,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED",481,RC,93458,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",361,RC,36561,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1898.00,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,257.40,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",361,RC,19083,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20936,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4015.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; BIOPSY(IES) AND ASPIRATION(S),361,RC,38222,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,4265.00,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64473,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,4509.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,434.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,548.46,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NEEDLE ENTRY, WITH PERMANENT RECORDING AND REPORTING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,76937,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,16.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20930,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ADDITIONAL LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION OF THE LEFT OR RIGHT ATRIUM FOR TREATMENT OF ATRIAL FIBRILLATION REMAINING AFTER COMPLETION OF PULMONARY VEIN ISOLATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93657,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC GUIDANCE FOR VASCULAR ACCESS AND CATHETER MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHY RADIOLOGIC SUPERVISION AND INTERPRETATION, AND RADIOGRAPHIC DOCUMENTATION OF FINAL CATHETER POSITION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,77001,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,111.41,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",360,RC,31645,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",361,RC,38505,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,538.56,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63048,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,315.00,4125.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PROGRAMMED STIMULATION AND PACING AFTER INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93623,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,9357.00,,,,,,,849.52,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",360,RC,31629,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRACARDIAC CATHETER ABLATION OF A DISCRETE MECHANISM OF ARRHYTHMIA WHICH IS DISTINCT FROM THE PRIMARY ABLATED MECHANISM, INCLUDING REPEAT DIAGNOSTIC MANEUVERS, TO TREAT A SPONTANEOUS OR INDUCED ARRHYTHMIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93655,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,77002,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,86.34,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,548.46,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH COMPUTER-ASSISTED, IMAGE-GUIDED NAVIGATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",360,RC,31627,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION",360,RC,76942,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,103.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC,361,RC,29125,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22845,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",361,RC,62323,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF INTRAUTERINE DEVICE (IUD),360,RC,58300,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,171.75,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,81336.71,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORE NEEDLE BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",361,RC,32408,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSENDOSCOPIC ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) FOR PERIPHERAL LESION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",360,RC,31654,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; LUMBOSACRAL",361,RC,62304,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT/MRI SHOULDER ARTHROGRAPHY,361,RC,23350,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",361,RC,36590,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",361,RC,47000,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH CORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,29826,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITH IMAGING GUIDANCE",361,RC,32555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,542.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",361,RC,50590,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,6882.00,,,,,,,2721.18,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,57236.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1114.08,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,210.63,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NEEDLE ENTRY, WITH PERMANENT RECORDING AND REPORTING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,76937,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,16.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,4265.00,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING STEREOTACTIC GUIDANCE",361,RC,19081,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1154.34,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",361,RC,20611,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,259.20,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS) INCLUDING INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT ANGIOGRAPHY",481,RC,93455,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITH IMAGING GUIDANCE",490,RC,32555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,542.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,63867.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64488,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",361,RC,62328,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR,481,RC,33208,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2860.00,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,19084,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",361,RC,20610,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,481,RC,33228,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)",361,RC,74177,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,313.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,913.44,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL",361,RC,64483,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,10006,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12001,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCHANGE NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,50435,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")",361,RC,20550,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS 1 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22840,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC,360,RC,29125,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",361,RC,19285,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,92928,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,1510.07,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING",360,RC,99285,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,304.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASOUND, TRANSRECTAL;",360,RC,76872,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,91.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,57236.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",361,RC,62321,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,6882.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR LEFT VENTRICULAR PACING, AT TIME OF INSERTION OF IMPLANTABLE DEFIBRILLATOR OR PACEMAKER PULSE GENERATOR (EG, FOR UPGRADE TO DUAL CHAMBER SYSTEM) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,33225,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY,361,RC,58340,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,96375,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,33.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF MULTI-LAYER COMPRESSION SYSTEM; LEG (BELOW KNEE), INCLUDING ANKLE AND FOOT",360,RC,29581,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,4265.00,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER",360,RC,99152,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING",360,RC,99284,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,206.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA,361,RC,27093,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,481,RC,33264,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,85575.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",490,RC,47562,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",361,RC,50200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, INCLUDING ALL IMAGING GUIDANCE, IMAGE DOCUMENTATION, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE INSERTION; AGE 5 YEARS OR OLDER",361,RC,36573,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1364.01,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; BIOPSY(IES),361,RC,38221,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,235.62,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, SUBCUTANEOUS CARDIAC RHYTHM MONITOR",481,RC,33286,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,617.79,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION",361,RC,76942,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,103.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,446.82,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS NEEDLE",361,RC,49180,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF PERMANENT IMPLANTABLE DEFIBRILLATOR SYSTEM, WITH TRANSVENOUS LEAD(S), SINGLE OR DUAL CHAMBER",481,RC,33249,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2860.00,85575.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS",360,RC,97597,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12002,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; SINGLE VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63052,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64484,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",490,RC,58661,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),360,RC,29515,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",361,RC,97605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC,490,RC,29125,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF MULTI-LAYER COMPRESSION SYSTEM; LEG (BELOW KNEE), INCLUDING ANKLE AND FOOT",490,RC,29581,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1154.34,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,147.18,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; CERVICAL",361,RC,62302,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS) WITH BYPASS GRAFT ANGIOGRAPHY",481,RC,93459,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75625,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)",360,RC,99153,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER",490,RC,99152,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64494,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",361,RC,22514,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,2860.00,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64636,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG",360,RC,96374,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,33.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1154.34,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,361,RC,38792,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,151.14,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,61783,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1154.34,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,128.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC); WITH IMAGING GUIDANCE,490,RC,49083,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,363.66,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75710,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY; SINGLE MAJOR CORONARY ARTERY OR BRANCH,481,RC,92920,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1359.24,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19737.41,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,92921,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",361,RC,22513,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,2860.00,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING",360,RC,99283,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,128.04,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",490,RC,43239,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST), SOFT TISSUE (EG, EXTREMITY, ABDOMINAL WALL, NECK), PERCUTANEOUS",361,RC,10030,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",361,RC,20206,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,538.56,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY LITHOTRIPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,92972,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1630.20,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",490,RC,59812,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR",360,RC,96365,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,119.46,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62321,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",490,RC,69436,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1114.08,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY, CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36907,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, WITHOUT IMAGING GUIDANCE; AGE 5 YEARS OR OLDER",361,RC,36569,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",361,RC,20225,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64491,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; EACH ADDITIONAL PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,52442,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)",490,RC,99153,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR TUMORS, ORGAN ISCHEMIA, OR INFARCTION",361,RC,37243,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; MULTIPLE LEAD SYSTEM,481,RC,33229,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,50902.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,866.58,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)",360,RC,43644,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,7492.10,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),490,RC,29515,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",490,RC,52356,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",490,RC,17250,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY",361,RC,G0260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2360.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED",481,RC,93460,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",361,RC,36247,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL",361,RC,64493,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-GUIDANCE BASED ON CT/MRI IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,0055T,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG-ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,C9601,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,22515,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,4509.00,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS",361,RC,97597,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19737.41,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL",360,RC,59320,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49616,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,11548.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",490,RC,11042,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22842,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",361,RC,64635,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,851.40,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC GUIDANCE FOR VASCULAR ACCESS AND CATHETER MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHY RADIOLOGIC SUPERVISION AND INTERPRETATION, AND RADIOGRAPHIC DOCUMENTATION OF FINAL CATHETER POSITION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,77001,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,111.41,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR VISUALIZATION OF ILEAL CONDUIT AND/OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE",361,RC,50690,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,210.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STRAPPING; UNNA BOOT,360,RC,29580,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",361,RC,19281,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22614,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,3918.53,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,46437.75,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64421,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",361,RC,10160,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,50432,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1798.70,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; 2 OR MORE REGIONS (EG, LUMBAR/THORACIC, CERVICAL/THORACIC, LUMBAR/CERVICAL, LUMBAR/THORACIC/CERVICAL)",361,RC,62305,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),360,RC,29105,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER CLOSURE OF CONGENITAL INTERATRIAL COMMUNICATION (IE, FONTAN FENESTRATION, ATRIAL SEPTAL DEFECT) WITH IMPLANT",481,RC,93580,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,4509.00,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,4065.07,20253.32,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22846,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,7331.50,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP",360,RC,36589,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1035.30,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63053,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12013,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, SPERMATIC CORD",360,RC,55559,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP",361,RC,36589,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",490,RC,52332,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,4509.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION;",360,RC,93454,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10853.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",361,RC,43762,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,213.55,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),490,RC,29105,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENIPUNCTURE, AGE 3 YEARS OR OLDER, NECESSITATING THE SKILL OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (SEPARATE PROCEDURE), FOR DIAGNOSTIC OR THERAPEUTIC PURPOSES (NOT TO BE USED FOR ROUTINE VENIPUNCTURE)",361,RC,36410,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,4610.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH",360,RC,62273,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",490,RC,44970,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTING GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO-JEJUNOSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, FROM A PERCUTANEOUS APPROACH INCLUDING IMAGE DOCUMENTATION AND REPORT",361,RC,49465,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,133.98,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL",361,RC,64490,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63035,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,315.00,4125.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,63867.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",361,RC,36558,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1663.00,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED",360,RC,93458,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10853.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,96376,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",361,RC,20606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,490,RC,42820,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",490,RC,59820,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,4265.00,20253.32,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION, RENAL TUMOR(S), UNILATERAL, PERCUTANEOUS, CRYOTHERAPY",361,RC,50593,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,6882.00,,,,,,,2860.00,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER INSERTION OR REPLACEMENT OF PERMANENT LEADLESS PACEMAKER, RIGHT VENTRICULAR, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, VENTRICULOGRAPHY, FEMORAL VENOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED",481,RC,33274,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,50902.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIVER ELASTOGRAPHY, MECHANICALLY INDUCED SHEAR WAVE (EG, VIBRATION), WITHOUT IMAGING, WITH INTERPRETATION AND REPORT",361,RC,91200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,128.88,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC); WITH IMAGING GUIDANCE,360,RC,49083,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,363.66,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED;",360,RC,50436,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64634,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",361,RC,49450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAOPERATIVE IDENTIFICATION (EG, MAPPING) OF SENTINEL LYMPH NODE(S) INCLUDES INJECTION OF NON-RADIOACTIVE DYE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,38900,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11045,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER IMPLANTATION OF WIRELESS PULMONARY ARTERY PRESSURE SENSOR FOR LONG-TERM HEMODYNAMIC MONITORING, INCLUDING DEPLOYMENT AND CALIBRATION OF THE SENSOR, RIGHT HEART CATHETERIZATION, SELECTIVE PULMONARY CATHETERIZATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION, AND PULMONARY ARTERY ANGIOGRAPHY, WHEN PERFORMED",481,RC,33289,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2860.00,75877.73,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,335.94,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1665.66,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION;",490,RC,93454,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10853.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,10030.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8341.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE FOR INITIAL SECOND OR THIRD ORDER VESSEL AS APPROPRIATE)",361,RC,36248,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36247,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",490,RC,10005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR MORE SELECTIVE, BRANCH (EG, LEFT ADRENAL VEIN, PETROSAL SINUS)",361,RC,36012,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13122,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11046,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",490,RC,43235,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93621,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,877.76,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT/MRI SHOULDER ARTHROGRAPHY,360,RC,23350,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, PELVIC, SELECTIVE OR SUPRASELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75736,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1968.78,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR",360,RC,22558,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,63867.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22634,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),361,RC,29105,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MANIPULATION OF TEMPOROMANDIBULAR JOINT(S) (TMJ), THERAPEUTIC, REQUIRING AN ANESTHESIA SERVICE (IE, GENERAL OR MONITORED ANESTHESIA CARE)",360,RC,21073,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,492.36,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,361,RC,32550,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2032.80,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,291.72,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36245,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS",490,RC,97606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING CENTRAL VENOUS ACCESS DEVICE, INCLUDING FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT",361,RC,36598,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,152.46,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64415,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,574.59,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1665.66,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LEFT HEART CATHETERIZATION BY TRANSSEPTAL PUNCTURE THROUGH INTACT SEPTUM OR BY TRANSAPICAL PUNCTURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93462,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,481,RC,33233,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASONIC GUIDANCE, INTRAOPERATIVE",360,RC,76998,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CONTRAST INJECTION FOR ASSESSMENT OF ABSCESS OR CYST VIA PREVIOUSLY PLACED DRAINAGE CATHETER OR TUBE (SEPARATE PROCEDURE),361,RC,49424,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,215.16,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL VESSEL STUDIED AFTER BASIC EXAMINATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,75774,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,472.21,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); MORSELIZED (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,20937,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4015.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; INTRAOPERATIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,74300,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,18.09,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; RADICAL NEPHRECTOMY (INCLUDES REMOVAL OF GEROTA'S FASCIA AND SURROUNDING FATTY TISSUE, REMOVAL OF REGIONAL LYMPH NODES, AND ADRENALECTOMY)",360,RC,50545,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; SINGLE LEAD SYSTEM,481,RC,33262,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,59910.88,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",490,RC,57522,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,31633,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",490,RC,58662,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1630.20,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY,360,RC,51600,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,315.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, FEMUR OR KNEE",360,RC,27599,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED",481,RC,C9764,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,3456.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); BICONDYLAR, WITH OR WITHOUT INTERNAL FIXATION",360,RC,27536,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS",360,RC,36581,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",490,RC,36561,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER EXTREMITY, CATHETER, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75630,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",490,RC,58558,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); VENTRICULAR,481,RC,33207,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2860.00,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",490,RC,31500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,147.18,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITH ANESTHESIA,360,RC,27095,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF ACUTE TOTAL/SUBTOTAL OCCLUSION DURING ACUTE MYOCARDIAL INFARCTION, CORONARY ARTERY OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING ASPIRATION THROMBECTOMY WHEN PERFORMED, SINGLE VESSEL",481,RC,92941,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,9329.00,,,,,,,1692.15,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,6882.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",361,RC,49451,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CHANGE OF CYSTOSTOMY TUBE; COMPLICATED,360,RC,51710,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS",360,RC,97606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADIOLOGIC EXAMINATION, ABSCESS, FISTULA OR SINUS TRACT STUDY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,76080,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,223.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13102,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA",360,RC,23650,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",481,RC,37224,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY (INCLUDING INTRODUCTION OF NEEDLE OR INTRACATHETER),361,RC,36005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22585,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),360,RC,29505,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION",361,RC,97602,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",360,RC,49596,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,11548.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",490,RC,58571,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19286,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",361,RC,64633,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",490,RC,22902,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/OR GASTROESOPHAGEAL JUNCTION) STUDY WITH INTERPRETATION AND REPORT;,490,RC,91010,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,269.28,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF CEREBROSPINAL FLUID (BY NEEDLE OR CATHETER); WITH FLUOROSCOPIC OR CT GUIDANCE",361,RC,62329,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION, 1 OR MORE RENAL TUMOR(S), PERCUTANEOUS, UNILATERAL, RADIOFREQUENCY",361,RC,50592,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64448,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,493.02,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PROGRAMMED STIMULATION AND PACING AFTER INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93623,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,315.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",490,RC,47000,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")",360,RC,20550,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,8.58,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",361,RC,49418,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2032.80,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCHANGE OF BILIARY DRAINAGE CATHETER (EG, EXTERNAL, INTERNAL-EXTERNAL, OR CONVERSION OF INTERNAL-EXTERNAL TO EXTERNAL ONLY), PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,47536,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1035.30,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,9179.02,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",361,RC,20600,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,64634,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75716,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE (WITH OR WITHOUT FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75726,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",361,RC,37187,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,6882.00,,,,,,,2709.30,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",490,RC,10160,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43229,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",360,RC,49618,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,11548.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",490,RC,38505,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,538.56,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S);",360,RC,58150,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,7412.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75625,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1968.78,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTING GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO-JEJUNOSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, FROM A PERCUTANEOUS APPROACH INCLUDING IMAGE DOCUMENTATION AND REPORT",360,RC,49465,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,133.98,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,31632,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",490,RC,45378,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75820,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF GASTROSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",361,RC,49440,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITH IMAGING GUIDANCE",360,RC,32555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,542.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,213.55,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DIALYSIS CIRCUIT PERMANENT VASCULAR EMBOLIZATION OR OCCLUSION (INCLUDING MAIN CIRCUIT OR ANY ACCESSORY VEINS), ENDOVASCULAR, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO COMPLETE THE INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36909,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF CATHETER, AORTA",481,RC,36200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PARATHYROID AUTOTRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,60512,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, EXTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,61782,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",490,RC,49650,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2850.00,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,97598,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",490,RC,50081,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED",490,RC,93458,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10853.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)",360,RC,16020,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,10030.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",490,RC,52260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1154.34,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",490,RC,52352,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, SOFT TISSUE OF NECK OR THORAX",361,RC,21550,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,481,RC,33263,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,59910.88,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ALVEOLOPLASTY, EACH QUADRANT (SPECIFY)",360,RC,41874,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,92937,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,1508.45,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",361,RC,12002,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; SINGLE IMPLANT",360,RC,52441,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; INITIAL VEIN",361,RC,37248,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,22853,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,27829,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",360,RC,31500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,147.18,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,618.42,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,490,RC,59151,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,335.94,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; THORACIC",361,RC,62303,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF MULTI-LAYER COMPRESSION SYSTEM; LEG (BELOW KNEE), INCLUDING ANKLE AND FOOT",361,RC,29581,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF INTRAUTERINE DEVICE (IUD),490,RC,58300,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,171.75,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64495,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,53724.93,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STRAPPING; UNNA BOOT,490,RC,29580,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THERMAL DESTRUCTION OF INTRAOSSEOUS BASIVERTEBRAL NERVE, INCLUDING ALL IMAGING GUIDANCE; FIRST 2 VERTEBRAL BODIES, LUMBAR OR SACRAL",361,RC,64628,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,2860.00,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH",361,RC,62273,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC;",361,RC,62270,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION INCLUDING IMAGING SUPERVISION, INTERPRETATION, AND REPORT; FOR SUPRAVALVULAR AORTOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93567,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,9355.00,,,,,,,9200.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. Secondary and subsequent procedures are not eligible for payment."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLAVICULECTOMY; PARTIAL,360,RC,23120,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH LOCAL ADVANCEMENT FLAPS (V-Y, HOOD)",360,RC,26952,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, PATELLA; WITH PROSTHESIS",360,RC,27438,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",490,RC,33285,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL",490,RC,59320,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",490,RC,19301,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; BIOPSY(IES) AND ASPIRATION(S),360,RC,38222,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, SINGLE SEGMENT",360,RC,63081,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8263.20,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27535,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,682.44,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF TRANSVENOUS PACEMAKER ELECTRODE(S); DUAL LEAD SYSTEM,481,RC,33235,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF ACUTE TOTAL/SUBTOTAL OCCLUSION DURING ACUTE MYOCARDIAL INFARCTION, CORONARY ARTERY OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING ASPIRATION THROMBECTOMY WHEN PERFORMED, SINGLE VESSEL",481,RC,C9606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,9329.00,,,,,,,9200.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; INTRAOPERATIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,74300,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,18.09,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37229,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMPLANTATION OF BIOLOGIC IMPLANT (EG, ACELLULAR DERMAL MATRIX) FOR SOFT TISSUE REINFORCEMENT (IE, BREAST, TRUNK) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15777,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12004,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,481,RC,33241,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE OR INTRACATHETER, UPPER OR LOWER EXTREMITY ARTERY",481,RC,36140,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT/MRI SHOULDER ARTHROGRAPHY,490,RC,23350,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY,490,RC,58340,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64468,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITH ANESTHESIA,361,RC,27095,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,64491,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,28043,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2850.00,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",490,RC,49320,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,9179.02,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY (INCLUDING INTRODUCTION OF NEEDLE OR INTRACATHETER),360,RC,36005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",481,RC,37226,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,361,RC,32552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.06,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27134,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",360,RC,20606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",361,RC,20553,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,64636,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SECOND LEVEL, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22858,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL",361,RC,64420,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTRAVENTRICULAR AND/OR INTRA-ATRIAL MAPPING OF TACHYCARDIA SITE(S) WITH CATHETER MANIPULATION TO RECORD FROM MULTIPLE SITES TO IDENTIFY ORIGIN OF TACHYCARDIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93609,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2984.17,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",490,RC,93620,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,20253.32,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93621,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,315.00,4540.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",490,RC,93653,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ADDITIONAL LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION OF THE LEFT OR RIGHT ATRIUM FOR TREATMENT OF ATRIAL FIBRILLATION REMAINING AFTER COMPLETION OF PULMONARY VEIN ISOLATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93657,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION",490,RC,97602,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,682.44,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",490,RC,19083,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST), SOFT TISSUE (EG, EXTREMITY, ABDOMINAL WALL, NECK), PERCUTANEOUS",360,RC,10030,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REALIGNMENT OF EXTENSOR TENDON, HAND, EACH TENDON",360,RC,26437,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM, OR LEADLESS PACEMAKER SYSTEM",481,RC,93288,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,528.00,,,,,,,32.74,10865.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT",360,RC,27487,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION",360,RC,27810,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM",360,RC,12014,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE,360,RC,10080,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36246,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, NONCORONARY, NON-INTRACRANIAL, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); INITIAL VESSEL",360,RC,37184,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,6882.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37252,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,538.56,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC CANNULATION OF PAPILLA WITH DIRECT VISUALIZATION OF PANCREATIC/COMMON BILE DUCT(S) (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE),750,RC,43273,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,366.96,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR CHOLANGIOGRAPHY, PERCUTANEOUS, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,47531,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19084,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TOTAL OR NEAR TOTAL NON-INFECTED MESH OR OTHER PROSTHESIS AT THE TIME OF INITIAL OR RECURRENT ANTERIOR ABDOMINAL HERNIA REPAIR OR PARASTOMAL HERNIA REPAIR, ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49623,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROPLASTY; FIRST STAGE, FOR FISTULA, DIVERTICULUM, OR STRICTURE (EG, JOHANNSEN TYPE)",360,RC,53400,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL",360,RC,60650,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING; WITH CONNECTION TO 2 OR MORE ELECTRODE ARRAYS",360,RC,61886,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,81336.71,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND REFILL",360,RC,62369,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,157.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,33284.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1665.66,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75820,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,77002,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,86.34,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,96368,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS, INCLUDING ALL IMAGING GUIDANCE, IMAGE DOCUMENTATION, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE REPLACEMENT",361,RC,36584,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",361,RC,37193,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2003.76,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BIOPSY OF SALIVARY GLAND; NEEDLE,361,RC,42400,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,538.56,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); PERITONEAL OR RETROPERITONEAL, PERCUTANEOUS",361,RC,49406,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",361,RC,50431,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,586.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; PRE-EXISTING NEPHROSTOMY TRACT",361,RC,50693,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY,361,RC,51600,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,315.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",361,RC,63650,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1663.00,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE",361,RC,64405,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADIOLOGICAL GUIDANCE (IE, FLUOROSCOPY, ULTRASOUND, OR COMPUTED TOMOGRAPHY), FOR PERCUTANEOUS DRAINAGE (EG, ABSCESS, SPECIMEN COLLECTION), WITH PLACEMENT OF CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75989,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,118.31,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),361,RC,77003,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,78.69,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF PERMANENT SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR SYSTEM, WITH SUBCUTANEOUS ELECTRODE, INCLUDING DEFIBRILLATION THRESHOLD EVALUATION, INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING FOR ARRHYTHMIA TERMINATION, AND PROGRAMMING OR REPROGRAMMING OF SENSING OR THERAPEUTIC PARAMETERS, WHEN PERFORMED",481,RC,33270,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,85575.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURES (EG, THROMBIN) FOR PERCUTANEOUS TREATMENT OF EXTREMITY PSEUDOANEURYSM",481,RC,36002,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,542.87,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",481,RC,36215,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,4509.00,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64447,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,257.40,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO VERTEBRAL CORPECTOMY(IES) (VERTEBRAL BODY RESECTION, PARTIAL OR COMPLETE) DEFECT, IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH CONTIGUOUS DEFECT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22854,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",490,RC,20553,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",490,RC,20611,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,259.20,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR,490,RC,33208,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ACROMIOPLASTY OR ACROMIONECTOMY, PARTIAL, WITH OR WITHOUT CORACOACROMIAL LIGAMENT RELEASE",360,RC,23130,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",490,RC,45385,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",490,RC,57288,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",490,RC,62323,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL",490,RC,64483,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DRAINAGE OF FINGER ABSCESS; SIMPLE,360,RC,26010,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,93.72,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",490,RC,26055,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",490,RC,26440,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",490,RC,26520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,92943,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,1692.15,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,122.76,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",361,RC,37241,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL",360,RC,69209,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,52.15,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,10065.14,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS) WITH BYPASS GRAFT ANGIOGRAPHY",481,RC,93461,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT SITE PREPARATION OF PERFORATION FOR CLOSURE, WITH OR WITHOUT PATCH",360,RC,69610,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1021.02,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",360,RC,43762,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,213.55,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",360,RC,43450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,434.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9771.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",490,RC,63030,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9771.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",490,RC,50200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS); WITH MANIPULATION,360,RC,27788,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,215.16,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64416,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF MANDIBULAR FRACTURE; WITH INTERDENTAL FIXATION,360,RC,21462,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",490,RC,41899,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,490,RC,42821,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2850.00,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,230.34,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1630.20,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR CHOLANGIOGRAPHY, PERCUTANEOUS, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",361,RC,47531,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",490,RC,43247,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",490,RC,10060,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,10030.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",361,RC,36571,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1668.48,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",490,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,6882.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE STENTING, AND ALL ANGIOPLASTY IN THE CENTRAL DIALYSIS SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36908,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY,360,RC,51610,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,315.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, THROUGH SAME VENOUS ACCESS",360,RC,36582,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",490,RC,49591,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT",360,RC,23474,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",490,RC,49594,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)",490,RC,64400,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RIGHT HEART CATHETERIZATION INCLUDING MEASUREMENT(S) OF OXYGEN SATURATION AND CARDIAC OUTPUT, WHEN PERFORMED",481,RC,93451,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING BILIARY STENTS), INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,47537,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,823.23,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,490,RC,64721,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,64634,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA CAVA",360,RC,36010,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, COLON",361,RC,45399,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,800.53,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR ELBOW ARTHROGRAPHY,361,RC,24220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",360,RC,20611,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,259.20,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ALVEOLOPLASTY, EACH QUADRANT (SPECIFY)",490,RC,41874,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",490,RC,93656,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",490,RC,20610,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",361,RC,20552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",490,RC,20680,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,20930,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,20936,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4015.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING STEREOTACTIC GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,19082,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); PERITONEAL OR RETROPERITONEAL, PERCUTANEOUS",360,RC,49406,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING; WITH CONNECTION TO A SINGLE ELECTRODE ARRAY",360,RC,61885,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,72632.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORE NEEDLE BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,32408,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,210.63,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,37252,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22632,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",490,RC,22551,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITH IMAGING GUIDANCE",361,RC,32557,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1364.01,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, EACH BONE",360,RC,26608,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH SEPARATE ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,56606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER BRANCH (EG, RENAL VEIN, JUGULAR VEIN)",361,RC,36011,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION",360,RC,97602,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); VISCERAL (EG, KIDNEY, LIVER, SPLEEN, LUNG/MEDIASTINUM), PERCUTANEOUS",361,RC,49405,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",490,RC,58120,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, METACARPOPHALANGEAL JOINT; WITH PROSTHETIC IMPLANT, EACH JOINT",360,RC,26531,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; EACH ADDITIONAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37253,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH INTERPRETATION AND REPORT",360,RC,91110,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,682.44,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",490,RC,26615,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",490,RC,27327,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,27792,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL",490,RC,64490,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS AND ULNA",360,RC,25575,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23044,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",490,RC,29881,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",490,RC,63047,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOLUMINAL IMAGING OF CORONARY VESSEL OR GRAFT USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,92978,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,315.00,5111.18,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",490,RC,42830,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,176.65,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",490,RC,43248,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",490,RC,49329,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,490,RC,69205,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF SCAPULAR FRACTURE (BODY, GLENOID OR ACROMION) INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23585,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",490,RC,52351,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1042.14,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",490,RC,57250,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY)",360,RC,43775,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8635.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR WRIST ARTHROGRAPHY,361,RC,25246,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",361,RC,22999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,210.63,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",361,RC,22511,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2848.95,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",361,RC,20982,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,537.48,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF FINGER SPLINT; STATIC,361,RC,29130,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",361,RC,19125,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1683.66,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",361,RC,12011,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",361,RC,11981,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20985,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF SOFT TISSUE LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS, INCLUDING IMAGING GUIDANCE; FIRST LESION",361,RC,10035,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY",360,RC,G0260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2360.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED",360,RC,C9764,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING",360,RC,99282,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,81.84,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURES (EG, THROMBIN) FOR PERCUTANEOUS TREATMENT OF EXTREMITY PSEUDOANEURYSM",361,RC,36002,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,143.22,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA CAVA",361,RC,36010,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR",360,RC,96372,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,33.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,96367,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,33.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,80.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS) INCLUDING INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT ANGIOGRAPHY",360,RC,93455,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10853.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,361,RC,36556,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,731.94,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOLUMINAL IMAGING OF CORONARY VESSEL OR GRAFT USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,92978,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,315.00,5111.18,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIVER ELASTOGRAPHY, MECHANICALLY INDUCED SHEAR WAVE (EG, VIBRATION), WITHOUT IMAGING, WITH INTERPRETATION AND REPORT",360,RC,91200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,128.88,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/OR GASTROESOPHAGEAL JUNCTION) STUDY WITH INTERPRETATION AND REPORT;,360,RC,91010,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,269.28,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75825,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, THROUGH SAME VENOUS ACCESS",361,RC,36582,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1898.00,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MICROSURGICAL TECHNIQUES, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,69990,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",361,RC,37191,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NERVE REPAIR; WITH SYNTHETIC CONDUIT OR VEIN ALLOGRAFT (EG, NERVE TUBE), EACH NERVE",360,RC,64910,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,20656.55,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,851.40,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY CONTINUOUS INFUSIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64489,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37223,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL",360,RC,64420,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, MATERNITY CARE AND DELIVERY",360,RC,59899,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,8.58,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY,360,RC,58340,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED;",361,RC,50436,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BONE, OPEN; SUPERFICIAL (EG, STERNUM, SPINOUS PROCESS, RIB, PATELLA, OLECRANON PROCESS, CALCANEUS, TARSAL, METATARSAL, CARPAL, METACARPAL, PHALANX)",360,RC,20240,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PLASTIC REPAIR OF URETHROCELE,360,RC,57230,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, WITHOUT IMAGING GUIDANCE; AGE 5 YEARS OR OLDER",360,RC,36569,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,230.34,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,866.58,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REDUCTION OF TORSION OF TESTIS, SURGICAL, WITH OR WITHOUT FIXATION OF CONTRALATERAL TESTIS",360,RC,54600,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA",360,RC,23655,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,54057,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,25540.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC, SINGLE LEVEL",361,RC,64479,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROMEATOPLASTY, WITH MUCOSAL ADVANCEMENT",360,RC,53450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,42.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",361,RC,64520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION",360,RC,51700,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,128.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",360,RC,49452,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",360,RC,49450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UMBILECTOMY, OMPHALECTOMY, EXCISION OF UMBILICUS (SEPARATE PROCEDURE)",360,RC,49250,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, RENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75831,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1968.78,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,42.90,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1035.30,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,366.96,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",490,RC,43249,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE)",360,RC,45400,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4015.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",361,RC,20604,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,259.20,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,481,RC,33215,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2763.68,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,40.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; INITIAL VEIN",360,RC,37248,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37237,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37222,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENIPUNCTURE, AGE 3 YEARS OR OLDER, NECESSITATING THE SKILL OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (SEPARATE PROCEDURE), FOR DIAGNOSTIC OR THERAPEUTIC PURPOSES (NOT TO BE USED FOR ROUTINE VENIPUNCTURE)",360,RC,36410,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",481,RC,37221,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",481,RC,37236,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),361,RC,49423,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1072.50,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,92929,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,0.02447,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,411.18,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE, WITH MANIPULATION, EACH",360,RC,28476,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, TARSAL BONES, OTHER THAN CALCANEUS OR TALUS;",360,RC,28304,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH LEFT VENTRICULAR PACING AND RECORDING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93622,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,3097.15,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA;",360,RC,27880,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",490,RC,58999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,8.58,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); SUPERFICIAL (EG, ANTERIOR TIBIAL EXTENSORS INTO MIDFOOT)",360,RC,27690,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA,360,RC,27560,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY, AND TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED",481,RC,C9765,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,3456.00,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST), SOFT TISSUE (EG, EXTREMITY, ABDOMINAL WALL, NECK), PERCUTANEOUS",490,RC,10030,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",490,RC,10061,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; 1 COMPONENT",360,RC,27486,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; WITH FIXATION",360,RC,27450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",490,RC,11043,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; MULTIPLE TENDONS (THROUGH SAME INCISION), EACH",360,RC,27686,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS",490,RC,97597,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,490,RC,11770,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITH INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27245,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,786.83,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27132,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA,360,RC,27093,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRACARDIAC ECHOCARDIOGRAPHY DURING THERAPEUTIC/DIAGNOSTIC INTERVENTION, INCLUDING IMAGING SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,93662,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,315.00,5111.18,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",490,RC,19120,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",490,RC,19285,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",490,RC,21235,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",490,RC,21552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER",360,RC,11719,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,25.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH",490,RC,62273,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIECTOMY, PALM ONLY, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT)",360,RC,26121,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH LEFT VENTRICULAR PACING AND RECORDING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93622,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,315.00,4900.35,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), PLATELET RICH PLASMA, ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION WHEN PERFORMED",360,RC,0232T,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,42.90,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11107,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EVACUATION OF SUBUNGUAL HEMATOMA,360,RC,11740,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,25.74,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM",360,RC,13120,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13133,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM",360,RC,13152,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,215.16,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT EYELIDS, NOSE, EARS, OR LIPS",360,RC,15630,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FOREHEAD FLAP WITH PRESERVATION OF VASCULAR PEDICLE (EG, AXIAL PATTERN FLAP, PARAMEDIAN FOREHEAD FLAP)",360,RC,15731,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9771.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BONE, TROCAR, OR NEEDLE; SUPERFICIAL (EG, ILIUM, STERNUM, SPINOUS PROCESS, RIBS)",360,RC,20220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF IMPLANT; SUPERFICIAL (EG, BURIED WIRE, PIN OR ROD) (SEPARATE PROCEDURE)",360,RC,20670,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ALLOGRAFT, STRUCTURAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20931,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITHOUT STABILIZATION,360,RC,21315,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1114.08,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION FIRST AND/OR CERVICAL RIB;,360,RC,21615,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,63867.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION,360,RC,22852,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; HUMERAL AND GLENOID COMPONENTS (EG, TOTAL SHOULDER)",360,RC,23335,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH CORACOID PROCESS TRANSFER",360,RC,23462,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING APPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED)",360,RC,23700,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; HUMERAL AND ULNAR COMPONENTS",360,RC,24160,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, LESION OF TENDON SHEATH, FOREARM AND/OR WRIST",360,RC,25110,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS (EG, TENOSYNOVITIS, FUNGUS, TBC, OR OTHER GRANULOMAS, RHEUMATOID ARTHRITIS); EXTENSORS, WITH OR WITHOUT TRANSPOSITION OF DORSAL RETINACULUM",360,RC,25116,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES;,360,RC,25130,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIOTOMY, PALMAR (EG, DUPUYTREN'S CONTRACTURE); OPEN, PARTIAL",360,RC,26045,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,26111,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); DISTAL PHALANX OF FINGER",360,RC,26236,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, EXTENSOR TENDON, HAND, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26410,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, HANDS OR FINGERS",360,RC,26989,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27047,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, WITH OR WITHOUT ALLOGRAFT",360,RC,27138,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27328,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27540,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF KNEE DISLOCATION; REQUIRING ANESTHESIA,360,RC,27552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; MULTIPLE AREAS",360,RC,28003,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE)",360,RC,28060,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF FINGER SPLINT; STATIC,360,RC,29130,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ARTHROSCOPICALLY AIDED POSTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29889,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, FLEXIBLE; DIAGNOSTIC",360,RC,31575,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,122.76,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITHOUT PLASTIC REPAIR,360,RC,31820,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER IMPLANTATION OF WIRELESS PULMONARY ARTERY PRESSURE SENSOR FOR LONG-TERM HEMODYNAMIC MONITORING, INCLUDING DEPLOYMENT AND CALIBRATION OF THE SENSOR, RIGHT HEART CATHETERIZATION, SELECTIVE PULMONARY CATHETERIZATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION, AND PULMONARY ARTERY ANGIOGRAPHY, WHEN PERFORMED",360,RC,33289,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,75877.73,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR BLOOD VESSEL, DIRECT; UPPER EXTREMITY",360,RC,35206,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE OR INTRACATHETER, UPPER OR LOWER EXTREMITY ARTERY",360,RC,36140,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,731.94,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, INCLUDING ALL IMAGING GUIDANCE, IMAGE DOCUMENTATION, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE INSERTION; AGE 5 YEARS OR OLDER",360,RC,36573,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS CIRCUIT",360,RC,36906,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37191,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37231,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37247,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; EACH ADDITIONAL VEIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37249,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,235.62,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAOPERATIVE IDENTIFICATION (EG, MAPPING) OF SENTINEL LYMPH NODE(S) INCLUDES INJECTION OF NON-RADIOACTIVE DYE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,38900,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE ABSCESS; PERITONSILLAR,360,RC,42700,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,203.91,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",360,RC,43255,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",360,RC,43277,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45381,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING BILIARY STENTS), INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,47537,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,823.23,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, EXCLUSIVE OF APPENDICEAL ABSCESS, OPEN",360,RC,49020,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS NEEDLE",360,RC,49180,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION OF AIR OR CONTRAST INTO PERITONEAL CAVITY (SEPARATE PROCEDURE),360,RC,49400,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",360,RC,49451,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,446.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCHANGE NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50435,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; NEPHRECTOMY WITH TOTAL URETERECTOMY",360,RC,50548,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, ANY TECHNIQUE",360,RC,51785,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,128.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,73.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,866.58,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,73.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPACTED VAGINAL FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57415,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58550,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS);,360,RC,59409,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ENDOCRINE SYSTEM",360,RC,60699,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; CERVICAL",360,RC,62302,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST,360,RC,64719,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL",360,RC,65205,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,69.96,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN, WITH FREE MUCOUS MEMBRANE GRAFT",360,RC,67835,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,73040,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,264.66,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)",360,RC,74177,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,313.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROCYSTOGRAPHY, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,74450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,173.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, PELVIC, SELECTIVE OR SUPRASELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75736,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75827,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY, AND TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED",360,RC,C9765,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",361,RC,11424,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",361,RC,12004,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PUNCTURE ASPIRATION OF CYST OF BREAST;,361,RC,19000,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,301.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION OF SINUS TRACT; DIAGNOSTIC (SINOGRAM),361,RC,20501,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",361,RC,25605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,335.94,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT; WITH MANIPULATION, EACH",361,RC,26742,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,99.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",361,RC,27040,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION",361,RC,27810,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),361,RC,29505,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, PLEURA, PERCUTANEOUS NEEDLE",361,RC,32400,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VENOUS CATHETERIZATION FOR SELECTIVE ORGAN BLOOD SAMPLING,361,RC,36500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS",361,RC,36581,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1663.00,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR FOREIGN BODY (EG, FRACTURED VENOUS OR ARTERIAL CATHETER), INCLUDES RADIOLOGICAL SUPERVISION AND INTERPRETATION, AND IMAGING GUIDANCE (ULTRASOUND OR FLUOROSCOPY), WHEN PERFORMED",361,RC,37197,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2763.68,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",361,RC,37242,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; EACH ADDITIONAL VEIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,37249,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",361,RC,38525,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1663.00,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",361,RC,38999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,226.38,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION, 1 OR MORE LIVER TUMOR(S), PERCUTANEOUS, RADIOFREQUENCY",361,RC,47382,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF CALCULI/DEBRIS FROM BILIARY DUCT(S) AND/OR GALLBLADDER, PERCUTANEOUS, INCLUDING DESTRUCTION OF CALCULI BY ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY) WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,47544,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION OF AIR OR CONTRAST INTO PERITONEAL CAVITY (SEPARATE PROCEDURE),361,RC,49400,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ASPIRATION AND/OR INJECTION OF RENAL CYST OR PELVIS BY NEEDLE, PERCUTANEOUS",361,RC,50390,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONVERT NEPHROSTOMY CATHETER TO NEPHROURETERAL CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, VIA PRE-EXISTING NEPHROSTOMY TRACT",361,RC,50434,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BALLOON DILATION, URETERAL STRICTURE, INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,50706,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,446.82,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, URINARY SYSTEM",361,RC,53899,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,73.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",361,RC,60100,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,301.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",361,RC,64450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64480,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64492,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75822,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75827,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, VENOUS SINUS (EG, PETROSAL AND INFERIOR SAGITTAL) OR JUGULAR, CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75860,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,622.38,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,97598,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED",361,RC,C1889,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,4610.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER INSERTION OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED; COMPLETE SYSTEM (IE, RIGHT ATRIAL AND RIGHT VENTRICULAR PACEMAKER COMPONENTS)",481,RC,0795T,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,3976.00,50902.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RELOCATION OF SKIN POCKET FOR PACEMAKER,481,RC,33222,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1606.16,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,481,RC,33227,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,481,RC,33244,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,92924,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1616.05,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; SINGLE, DUAL, OR MULTIPLE LEAD TRANSVENOUS IMPLANTABLE DEFIBRILLATOR SYSTEM, INCLUDING ANALYSIS OF HEART RHYTHM DERIVED DATA ELEMENTS",481,RC,93289,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,528.00,,,,,,,32.74,10865.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT HEART CATHETERIZATION",481,RC,93456,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",490,RC,11104,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",490,RC,11403,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS",490,RC,12001,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",490,RC,12002,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",490,RC,12032,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",490,RC,13132,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",490,RC,14040,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",490,RC,21555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,22552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,22845,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",490,RC,24075,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",490,RC,26605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, EACH BONE",490,RC,26608,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",490,RC,26735,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",490,RC,26951,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA,490,RC,27093,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),490,RC,29505,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",490,RC,29880,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, PLEURA, PERCUTANEOUS NEEDLE",490,RC,32400,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORE NEEDLE BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,32408,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,490,RC,32550,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPOSITIONING OF PREVIOUSLY IMPLANTED CARDIAC VENOUS SYSTEM (LEFT VENTRICULAR) ELECTRODE (INCLUDING REMOVAL, INSERTION AND/OR REPLACEMENT OF EXISTING GENERATOR)",490,RC,33226,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF PERMANENT IMPLANTABLE DEFIBRILLATOR SYSTEM, WITH TRANSVENOUS LEAD(S), SINGLE OR DUAL CHAMBER",490,RC,33249,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,85575.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, SUBCUTANEOUS CARDIAC RHYTHM MONITOR",490,RC,33286,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",490,RC,36590,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",490,RC,37187,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,6882.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",490,RC,45330,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,490,RC,45915,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1021.02,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),490,RC,46040,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1035.30,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",490,RC,47563,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); VISCERAL (EG, KIDNEY, LIVER, SPLEEN, LUNG/MEDIASTINUM), PERCUTANEOUS",490,RC,49405,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); PERITONEAL OR RETROPERITONEAL, PERCUTANEOUS",490,RC,49406,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",490,RC,49521,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",490,RC,49592,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",490,RC,49593,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",490,RC,50432,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED;",490,RC,50436,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",490,RC,51798,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,42.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",490,RC,52287,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, SPERMATIC CORD",490,RC,55559,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,490,RC,57460,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF INTRAUTERINE DEVICE (IUD),490,RC,58301,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",490,RC,58555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",490,RC,58562,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",490,RC,58570,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CURETTAGE, POSTPARTUM",490,RC,59160,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS);,490,RC,59409,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",490,RC,62321,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",490,RC,63685,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,81336.71,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",490,RC,64430,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64445,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,64484,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL",490,RC,64493,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,64494,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",490,RC,64633,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)",490,RC,74177,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,313.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEPATOBILIARY SYSTEM IMAGING, INCLUDING GALLBLADDER WHEN PRESENT;",490,RC,78226,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,276.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",490,RC,92928,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY LITHOTRIPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,92972,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTRAVENTRICULAR AND/OR INTRA-ATRIAL MAPPING OF TACHYCARDIA SITE(S) WITH CATHETER MANIPULATION TO RECORD FROM MULTIPLE SITES TO IDENTIFY ORIGIN OF TACHYCARDIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93609,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,315.00,4721.94,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93613,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,315.00,6014.79,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1665.66,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1630.20,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1630.20,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF ESOPHAGUS, OVER GUIDE WIRE",750,RC,43453,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,434.28,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",750,RC,43659,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2566.74,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,411.18,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,750,RC,G0104,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,357.06,2433.43,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; LUMBOSACRAL",360,RC,62304,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, COMMON CAROTID OR INNOMINATE ARTERY, UNILATERAL, ANY APPROACH, WITH ANGIOGRAPHY OF THE IPSILATERAL INTRACRANIAL CAROTID CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID AND CERVICOCEREBRAL ARCH, WHEN PERFORMED",481,RC,36223,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; IMPLANTABLE SUBCUTANEOUS LEAD DEFIBRILLATOR SYSTEM",481,RC,93260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,528.00,,,,,,,32.74,10865.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",490,RC,20605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",490,RC,20694,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC DEFECT CLOSURE WITHIN THE ENTIRE GASTROINTESTINAL TRACT, INCLUDING UPPER ENDOSCOPY (INCLUDING DIAGNOSTIC, IF PERFORMED) OR COLONOSCOPY (INCLUDING DIAGNOSTIC, IF PERFORMED), WITH ALL SYSTEM AND TISSUE ANCHORING COMPONENTS",750,RC,C9901,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,3307.00,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR CONTRAST KNEE ARTHROGRAPHY OR CONTRAST ENHANCED CT/MRI KNEE ARTHROGRAPHY,361,RC,27369,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; THORACIC (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22610,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TENODESIS AT WRIST; EXTENSORS OF FINGERS,360,RC,25301,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, SUBCUTANEOUS CARDIAC RHYTHM MONITOR",360,RC,33286,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; FEMOROPOPLITEAL, AORTOILIAC ARTERY, BY LEG INCISION",360,RC,34201,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1114.08,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,492.36,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",360,RC,43238,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,45390,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,230.34,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOMY (SALPINGONEOSTOMY)",360,RC,58673,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64466,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,19126,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,361,RC,20551,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION",361,RC,26645,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",361,RC,49452,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,361,RC,51102,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1349.70,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS",361,RC,97606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",481,RC,33216,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,975.53,20253.32,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,11045,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",490,RC,12013,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,490,RC,25608,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",490,RC,43238,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",490,RC,43245,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",490,RC,43259,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",490,RC,57265,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",490,RC,58670,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64466,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",490,RC,93654,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRACARDIAC CATHETER ABLATION OF A DISCRETE MECHANISM OF ARRHYTHMIA WHICH IS DISTINCT FROM THE PRIMARY ABLATED MECHANISM, INCLUDING REPEAT DIAGNOSTIC MANEUVERS, TO TREAT A SPONTANEOUS OR INDUCED ARRHYTHMIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,93655,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,43231,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45398,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1035.30,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",750,RC,47000,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, SIMPLE, COMPLETE",490,RC,19303,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")",490,RC,20550,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11105,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,106.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY,361,RC,51610,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,315.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,361,RC,51705,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,128.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",750,RC,57288,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,2670.00,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",750,RC,52356,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,490,RC,21299,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,70.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,731.28,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,490,RC,21453,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF MANDIBULAR FRACTURE; WITH INTERDENTAL FIXATION,490,RC,21462,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC MUCOSAL RESECTION,750,RC,44403,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1035.30,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,682.44,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",490,RC,22511,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,22515,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",490,RC,22633,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,63867.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,557.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS 1 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,22840,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INJECTION SCLEROSIS OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43243,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43217,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43201,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",750,RC,31645,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",490,RC,97605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,97598,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
UNLISTED CARDIOVASCULAR SERVICE OR PROCEDURE,490,RC,93799,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,61.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",490,RC,93619,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,20253.32,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOLUMINAL IMAGING OF CORONARY VESSEL OR GRAFT USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,92979,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,160.88,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF ACUTE TOTAL/SUBTOTAL OCCLUSION DURING ACUTE MYOCARDIAL INFARCTION, CORONARY ARTERY OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING ASPIRATION THROMBECTOMY WHEN PERFORMED, SINGLE VESSEL",490,RC,92941,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY; SINGLE MAJOR CORONARY ARTERY OR BRANCH,490,RC,92920,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,25628,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,490,RC,25652,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,490,RC,64718,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",490,RC,64488,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64473,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64468,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64417,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",490,RC,63655,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,57236.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",490,RC,63650,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,63048,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,315.00,4125.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; 2 OR MORE REGIONS (EG, LUMBAR/THORACIC, CERVICAL/THORACIC, LUMBAR/CERVICAL, LUMBAR/THORACIC/CERVICAL)",490,RC,62305,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT; WITHOUT ANESTHESIA",490,RC,26670,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC;",490,RC,62270,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",490,RC,11044,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",490,RC,27130,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,61783,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",490,RC,27447,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",490,RC,23472,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS AND ULNA",490,RC,25575,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB; WITH MANIPULATION, EACH",490,RC,26755,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",490,RC,27412,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",490,RC,27427,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,27535,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,27814,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",490,RC,27524,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, EXTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,61782,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THYROIDECTOMY, TOTAL OR COMPLETE",490,RC,60240,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",490,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH COMPUTER-ASSISTED, IMAGE-GUIDED NAVIGATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",490,RC,31627,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",490,RC,31628,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",490,RC,31629,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",490,RC,31645,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",490,RC,31653,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSENDOSCOPIC ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) FOR PERIPHERAL LESION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",490,RC,31654,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",490,RC,60220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",490,RC,42826,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",490,RC,58573,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",490,RC,43242,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",490,RC,43244,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,490,RC,27726,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",490,RC,27822,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",490,RC,43266,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",490,RC,28297,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",490,RC,58563,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS NEEDLE",490,RC,49180,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",490,RC,49418,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",490,RC,50389,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,446.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",490,RC,50590,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,6882.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",490,RC,58561,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,328.02,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",490,RC,58552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF VAGINAL SEPTUM,490,RC,57130,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH (EG, KELLY URETHRAL PLICATION)",490,RC,57220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",490,RC,57425,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",490,RC,57520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; CERVICAL",490,RC,62302,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH INTERPRETATION AND REPORT",490,RC,91110,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,682.44,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIVER ELASTOGRAPHY, MECHANICALLY INDUCED SHEAR WAVE (EG, VIBRATION), WITHOUT IMAGING, WITH INTERPRETATION AND REPORT",490,RC,91200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,128.88,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",490,RC,58260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S);",490,RC,58150,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,7412.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CAUTERY OF CERVIX; LASER ABLATION,490,RC,57513,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,490,RC,57461,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,490,RC,57454,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,230.34,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",490,RC,57283,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19737.41,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PLASTIC REPAIR OF URETHROCELE,490,RC,57230,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF VAGINAL CYST OR TUMOR,490,RC,57135,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VULVECTOMY SIMPLE; PARTIAL,490,RC,56620,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,682.44,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,490,RC,56440,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF HYDROCELE; UNILATERAL,490,RC,55040,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",490,RC,54001,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",490,RC,52601,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),490,RC,52500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",490,RC,52353,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",490,RC,52214,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",490,RC,52005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,490,RC,51715,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",490,RC,50695,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",490,RC,50551,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,446.82,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED; INCLUDING NEW ACCESS INTO THE RENAL COLLECTING SYSTEM",490,RC,50437,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCHANGE NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",490,RC,50435,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",490,RC,49596,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,11548.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",490,RC,49520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",490,RC,49507,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",490,RC,49450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,490,RC,49422,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",490,RC,49321,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BALLOON DILATION OF BILIARY DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), PERCUTANEOUS, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, EACH DUCT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,47542,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF STENT(S) INTO A BILE DUCT, PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY, IMAGING GUIDANCE (EG, FLUOROSCOPY AND/OR ULTRASOUND), BALLOON DILATION, CATHETER EXCHANGE(S) AND CATHETER REMOVAL(S) WHEN PERFORMED, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",490,RC,47538,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING BILIARY STENTS), INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",490,RC,47537,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,823.23,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",490,RC,47379,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ANUS",490,RC,46999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,366.96,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",490,RC,46260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",490,RC,44238,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",490,RC,29828,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",490,RC,43762,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,213.55,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",490,RC,30140,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE",360,RC,11005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",490,RC,43281,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",490,RC,43237,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,174.47,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",490,RC,43236,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",490,RC,41800,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",490,RC,38570,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; BIOPSY(IES) AND ASPIRATION(S),490,RC,38222,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); EXTREMITY",490,RC,37618,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",490,RC,37193,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",490,RC,36832,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",490,RC,36830,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",490,RC,30520,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS",490,RC,36581,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",490,RC,36558,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,490,RC,33228,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",490,RC,31238,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",490,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, FLEXIBLE; DIAGNOSTIC",490,RC,31575,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,122.76,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",490,RC,31276,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",490,RC,31257,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",490,RC,31256,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ARTHROSCOPY",490,RC,29999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,210.63,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",490,RC,29914,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,24505,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG",360,RC,15833,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)",360,RC,16025,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",490,RC,36246,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR ULNAR COMPONENT",360,RC,24370,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING MAGNETIC RESONANCE GUIDANCE",360,RC,19085,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",490,RC,29883,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",490,RC,29882,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",490,RC,29877,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAGNETIC RESONANCE GUIDANCE",360,RC,19287,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,617.79,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",490,RC,29824,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",490,RC,29823,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF FINGER SPLINT; STATIC,490,RC,29130,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION",490,RC,27762,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",490,RC,27752,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OSTEOTOMY; TIBIA,490,RC,27705,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF DRUG-DELIVERY DEVICE(S), DEEP (EG, SUBFASCIAL) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20701,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENDON GRAFT, FROM A DISTANCE (EG, PALMARIS, TOE EXTENSOR, PLANTARIS)",360,RC,20924,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",490,RC,27632,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",490,RC,27422,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21046,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,70.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",490,RC,27299,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF MANDIBULAR FRACTURE; WITHOUT INTERDENTAL FIXATION,360,RC,21461,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH LOCAL ADVANCEMENT FLAPS (V-Y, HOOD)",490,RC,26952,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA",490,RC,26770,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",490,RC,26746,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION",490,RC,26645,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, FLEXOR, FINGER, OPEN, EACH TENDON",490,RC,26455,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRAINAGE OF TENDON SHEATH, DIGIT AND/OR PALM, EACH",490,RC,26020,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,490,RC,25609,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",490,RC,37241,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",490,RC,25607,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",490,RC,25605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,335.94,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",490,RC,25075,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; INITIAL VEIN",490,RC,37248,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,23515,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TENODESIS OF LONG TENDON OF BICEPS,490,RC,23430,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION,490,RC,22852,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); SINGLE INTERSPACE, LUMBAR",360,RC,22857,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); SECOND INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22860,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, RADIAL HEAD;",360,RC,24365,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",490,RC,22514,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",490,RC,40812,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1114.08,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF STERNOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC; WITH FASCIAL GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,23532,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC; WITH FASCIAL GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,23552,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF MANDIBULAR FRACTURE; WITHOUT INTERDENTAL FIXATION,490,RC,21461,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DEPRESSED FRONTAL SINUS FRACTURE,490,RC,21343,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13934.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",490,RC,42104,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24345,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF NASOETHMOID FRACTURE; WITHOUT EXTERNAL FIXATION,490,RC,21338,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,490,RC,21320,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 3 CM",360,RC,25076,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",490,RC,42825,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",490,RC,20606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",490,RC,20600,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BONE, TROCAR, OR NEEDLE; SUPERFICIAL (EG, ILIUM, STERNUM, SPINOUS PROCESS, RIBS)",490,RC,20220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",490,RC,19125,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,19084,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT; WITHOUT ANESTHESIA",360,RC,26670,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING STEREOTACTIC GUIDANCE",490,RC,19081,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",490,RC,15260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK, INTERNAL FIXATION OR PROSTHETIC REPLACEMENT",360,RC,27236,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",490,RC,14060,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",490,RC,13160,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8341.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",490,RC,13121,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,215.16,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR AND POSTERIOR INCLUDING POPLITEAL AREA",360,RC,27335,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",490,RC,12051,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF FOREIGN BODY, DEEP, THIGH REGION OR KNEE AREA",360,RC,27372,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",490,RC,12041,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",490,RC,12031,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM",360,RC,13100,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE WITH INTERCONDYLAR EXTENSION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27513,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM",490,RC,12014,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",490,RC,11982,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",490,RC,11462,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, ANKLE, WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,27620,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",490,RC,11441,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",490,RC,11422,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, RADIAL HEAD",360,RC,24130,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",490,RC,11420,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",490,RC,11402,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",490,RC,10180,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",490,RC,10120,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS;",360,RC,28104,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS;",360,RC,24110,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RIGHT AND LEFT HEART CATHETERIZATION FOR CONGENITAL HEART DEFECT(S) INCLUDING IMAGING GUIDANCE BY THE PROCEDURALIST TO ADVANCE THE CATHETER TO THE TARGET ZONE(S); NORMAL NATIVE CONNECTIONS,481,RC,93596,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12051,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY",481,RC,93308,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,528.00,,,,,,,212.24,10865.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",490,RC,43270,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTERROGATION DEVICE EVALUATION(S) (REMOTE), UP TO 90 DAYS; SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM, OR LEADLESS PACEMAKER SYSTEM WITH INTERIM ANALYSIS, REVIEW(S) AND REPORT(S) BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",481,RC,93294,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,528.00,,,,,,,528.00,10865.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,37247,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",481,RC,37246,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",490,RC,43274,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,37222,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",481,RC,37220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SECONDARY PERCUTANEOUS TRANSLUMINAL THROMBECTOMY (EG, NONPRIMARY MECHANICAL, SNARE BASKET, SUCTION TECHNIQUE), NONCORONARY, NON-INTRACRANIAL, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS, PROVIDED IN CONJUNCTION WITH ANOTHER PERCUTANEOUS INTERVENTION OTHER THAN PRIMARY MECHANICAL THROMBECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,37186,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOMY, COMPLETE",360,RC,29845,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",481,RC,36247,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",481,RC,36246,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPOSITIONING OF PREVIOUSLY IMPLANTED SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,481,RC,33273,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPOSITIONING OF PREVIOUSLY IMPLANTED CARDIAC VENOUS SYSTEM (LEFT VENTRICULAR) ELECTRODE (INCLUDING REMOVAL, INSERTION AND/OR REPLACEMENT OF EXISTING GENERATOR)",481,RC,33226,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2763.68,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",490,RC,43450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,434.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,481,RC,33221,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,50902.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",481,RC,33218,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),481,RC,33210,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER INSERTION OF PERMANENT SINGLE-CHAMBER LEADLESS PACEMAKER, RIGHT ATRIAL, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY AND/OR RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY, CAVOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED",481,RC,0823T,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,3976.00,50902.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR SACROILIAC JOINT; ARTHROGRAPHY,361,RC,G0259,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30901,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,24076,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL)",361,RC,76999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,59.40,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASONIC GUIDANCE, INTRAOPERATIVE",361,RC,76998,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,4610.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)",361,RC,76857,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,59.40,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED FLUOROSCOPIC PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL)",361,RC,76496,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,77.31,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FLUOROSCOPY (SEPARATE PROCEDURE), UP TO 1 HOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL TIME",361,RC,76000,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,83.16,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL;",360,RC,31530,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; BURSA",360,RC,23931,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHANGE OF PERCUTANEOUS TUBE OR DRAINAGE CATHETER WITH CONTRAST MONITORING (EG, GENITOURINARY SYSTEM, ABSCESS), RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75984,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,73.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75842,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1968.78,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, RENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75833,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1968.78,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE (WITH OR WITHOUT FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75726,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1968.78,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UROGRAPHY, ANTEGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,74425,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,173.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERITONEOGRAM (EG, AFTER INJECTION OF AIR OR CONTRAST), RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,74190,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,223.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; PERIPHERAL NERVE (EXCLUDES SACRAL NERVE),361,RC,64555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1610.00,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",361,RC,64454,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND REFILL",361,RC,62369,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,157.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE",361,RC,62320,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR MYELOGRAPHY AND/OR COMPUTED TOMOGRAPHY, LUMBAR",361,RC,62284,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",361,RC,59300,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1362.90,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",361,RC,55876,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,899.58,3652.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,363.66,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, SHOULDER",360,RC,23929,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",490,RC,45390,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT (OTHER THAN HEMODIALYSIS GRAFT OR FISTULA);,360,RC,35875,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",490,RC,46250,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36216,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",490,RC,46255,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT (FIRST-ORDER), MAIN RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE AND CATHETER PLACEMENT(S), FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POSTPROCESSING, PERMANENT RECORDING OF IMAGES, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS WHEN PERFORMED, AND FLUSH AORTOGRAM WHEN PERFORMED; BILATERAL",360,RC,36252,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1734.48,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",361,RC,52005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1663.00,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",361,RC,50947,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,2860.00,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",361,RC,50695,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING CENTRAL VENOUS ACCESS DEVICE, INCLUDING FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT",360,RC,36598,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,152.46,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS",360,RC,36620,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",361,RC,50389,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,446.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,361,RC,49422,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1241.00,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",361,RC,48102,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BALLOON DILATION OF BILIARY DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), PERCUTANEOUS, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, EACH DUCT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,47542,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; INTERNAL-EXTERNAL",361,RC,47534,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXTERNAL",361,RC,47533,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,2076.00,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF STERNOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23530,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHOLECYSTOSTOMY, PERCUTANEOUS, COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CHOLECYSTOGRAM WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,47490,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1925.22,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER THERAPY, ARTERIAL INFUSION FOR THROMBOLYSIS OTHER THAN CORONARY OR INTRACRANIAL, ANY METHOD, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION, INITIAL TREATMENT DAY",360,RC,37211,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",361,RC,45381,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",361,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULORRHAPHY, ANTERIOR; WITH LABRAL REPAIR (EG, BANKART PROCEDURE)",360,RC,23455,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPOSITIONING OF A NASO- OR ORO-GASTRIC FEEDING TUBE, THROUGH THE DUODENUM FOR ENTERIC NUTRITION",361,RC,43761,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,213.55,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, VASCULAR SURGERY",361,RC,37799,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,40.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTING GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO-JEJUNOSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, FROM A PERCUTANEOUS APPROACH INCLUDING IMAGE DOCUMENTATION AND REPORT",490,RC,49465,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,133.98,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",361,RC,37228,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY, UNILATERAL, EACH ADDITIONAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37232,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY, UNILATERAL, EACH ADDITIONAL VESSEL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37233,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8903.51,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",361,RC,37224,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY, CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,36907,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",361,RC,36902,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITH SUBCUTANEOUS PORT(S)",361,RC,36566,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1898.00,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23334,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),490,RC,52318,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",361,RC,36246,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,492.36,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, SOFT TISSUE OF SHOULDER AREA; SUPERFICIAL",360,RC,23065,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",361,RC,36245,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,542.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",361,RC,32551,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,363.66,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,361,RC,31502,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,93.06,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF BARTHOLIN'S GLAND OR CYST,490,RC,56740,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",360,RC,43231,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STRAPPING; UNNA BOOT,361,RC,29580,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",360,RC,43242,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",360,RC,43244,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12006,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",490,RC,57282,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19737.41,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,43251,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),360,RC,43275,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF ANKLE IMPLANT,361,RC,27704,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1457.28,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED",361,RC,27096,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA",361,RC,26770,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA",361,RC,26700,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,361,RC,25608,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,2670.00,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RESECTION, HUMERAL HEAD",361,RC,23195,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,2139.06,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED MUSCULOSKELETAL PROCEDURE, HEAD",361,RC,21499,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,70.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, TEMPOROMANDIBULAR JOINT",361,RC,21010,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1644.06,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,45379,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",361,RC,19301,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1683.66,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,366.96,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING STEREOTACTIC GUIDANCE",361,RC,19283,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF LIVER, NEEDLE; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,47001,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS",361,RC,17260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",361,RC,15839,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM",361,RC,12014,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS",361,RC,12001,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",490,RC,58263,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",361,RC,11404,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",361,RC,11402,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM",361,RC,11307,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",361,RC,11011,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION, FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM)",360,RC,G0413,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,548.46,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,548.46,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,96366,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,33.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,823.23,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RIGHT AND LEFT HEART CATHETERIZATION FOR CONGENITAL HEART DEFECT(S) INCLUDING IMAGING GUIDANCE BY THE PROCEDURALIST TO ADVANCE THE CATHETER TO THE TARGET ZONE(S); NORMAL NATIVE CONNECTIONS,360,RC,93596,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,8584.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT",360,RC,93312,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,481.44,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF ACUTE TOTAL/SUBTOTAL OCCLUSION DURING ACUTE MYOCARDIAL INFARCTION, CORONARY ARTERY OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING ASPIRATION THROMBECTOMY WHEN PERFORMED, SINGLE VESSEL",360,RC,92941,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,73.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",360,RC,92928,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEPATOBILIARY SYSTEM IMAGING, INCLUDING GALLBLADDER WHEN PRESENT;",360,RC,78226,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,276.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULAR CONTRACTURE RELEASE (EG, SEVER TYPE PROCEDURE)",360,RC,23020,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED FLUOROSCOPIC PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL)",360,RC,76496,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,77.31,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, VENOUS SINUS (EG, PETROSAL AND INFERIOR SAGITTAL) OR JUGULAR, CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75860,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,622.38,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75822,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,74740,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,212.24,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,73525,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,264.66,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW",360,RC,71045,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,77.31,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA,360,RC,69200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,42.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,506.22,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH DRAINAGE ONLY,360,RC,67405,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP",360,RC,65220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,69.96,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,20656.55,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,490,RC,59150,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",360,RC,64680,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,781.73,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY WITH INCISION, FULGURATION, OR RESECTION OF CONGENITAL POSTERIOR URETHRAL VALVES, OR CONGENITAL OBSTRUCTIVE HYPERTROPHIC MUCOSAL FOLDS",360,RC,52400,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TRANSURETHRAL INCISION OF PROSTATE,360,RC,52450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND THIRD DIVISION BRANCHES AT FORAMEN OVALE UNDER RADIOLOGIC MONITORING",360,RC,64610,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; PERIPHERAL NERVE (EXCLUDES SACRAL NERVE),360,RC,64555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROTOMY OR URETHROSTOMY, EXTERNAL (SEPARATE PROCEDURE); PERINEAL URETHRA, EXTERNAL",360,RC,53010,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY INJECTION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64486,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,210.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,210.63,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SUTURE OR REPAIR OF TESTICULAR INJURY,360,RC,54670,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH, METHYLMETHACRYLATE) TO INTERVERTEBRAL DISC SPACE OR VERTEBRAL BODY DEFECT WITHOUT INTERBODY ARTHRODESIS, EACH CONTIGUOUS DEFECT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22859,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,446.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,47173.79,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; 2 OR MORE REGIONS (EG, LUMBAR/THORACIC, CERVICAL/THORACIC, LUMBAR/CERVICAL, LUMBAR/THORACIC/CERVICAL)",360,RC,62305,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; THORACIC",360,RC,62303,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC;",360,RC,62270,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CRANIECTOMY; WITH EXCISION OF TUMOR OR OTHER BONE LESION OF SKULL,360,RC,61500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4509.00,,,,,,,1232.85,7088.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF CERCLAGE SUTURE UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,59871,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; SINGLE VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,63052,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF ANTERIOR INSTRUMENTATION,360,RC,22855,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),360,RC,59414,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS)",360,RC,58740,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,4125.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,58720,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE (EG, BAND, CLIP, OR FALOPE RING)",360,RC,58671,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G, ABDOMINAL APPROACH",360,RC,58146,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF CERVICAL CANAL, INSTRUMENTAL (SEPARATE PROCEDURE)",360,RC,57800,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,446.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PELVIC FIXATION (ATTACHMENT OF CAUDAL END OF INSTRUMENTATION TO PELVIC BONY STRUCTURES) OTHER THAN SACRUM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22848,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF PERFORMED); VAGINAL APPROACH",360,RC,57285,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19737.41,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPOPEXY, ABDOMINAL APPROACH",360,RC,57280,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,4125.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH (EG, KELLY URETHRAL PLICATION)",360,RC,57220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,104.28,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",490,RC,64517,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,913.44,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,490,RC,69424,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
1-STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH URETHROPLASTY BY LOCAL SKIN FLAPS AND MOBILIZATION OF URETHRA,360,RC,54326,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; CERVICAL BELOW C2 SEGMENT",360,RC,22600,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,54065,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF URETHRAL STRICTURE OR VESICAL NECK BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53605,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1154.34,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,34677.93,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROPLASTY, 2-STAGE RECONSTRUCTION OR REPAIR OF PROSTATIC OR MEMBRANOUS URETHRA; FIRST STAGE",360,RC,53420,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",490,RC,69706,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY; WITH URETERAL MEATOTOMY, UNILATERAL OR BILATERAL",360,RC,52290,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH STEROID INJECTION INTO STRICTURE",360,RC,52283,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY OF STERNUM, PARTIAL",360,RC,21620,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,786.83,7701.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)",360,RC,51701,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE",360,RC,51040,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
URETERONEOCYSTOSTOMY; WITH VESICO-PSOAS HITCH OR BLADDER FLAP,360,RC,50785,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BALLOON DILATION, URETERAL STRICTURE, INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,50706,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; PRE-EXISTING NEPHROSTOMY TRACT",360,RC,50693,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE",360,RC,11730,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE OF RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS, AND/OR PALPEBRAL CONJUNCTIVA DIRECT CLOSURE; FULL THICKNESS",360,RC,67935,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,204.60,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,133.98,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION, 1 OR MORE RENAL TUMOR(S), PERCUTANEOUS, UNILATERAL, RADIOFREQUENCY",360,RC,50592,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS",360,RC,50561,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,50551,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,446.82,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED; INCLUDING NEW ACCESS INTO THE RENAL COLLECTING SYSTEM",360,RC,50437,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,586.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,586.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,446.82,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11644,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE, SECONDARY, OF ABDOMINAL WALL FOR EVISCERATION OR DEHISCENCE",360,RC,49900,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,92921,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), BONE-SUBSTITUTE MATERIAL (EG, CALCIUM PHOSPHATE) INTO SUBCHONDRAL BONE DEFECT (IE, BONE MARROW LESION, BONE BRUISE, STRESS INJURY, MICROTRABECULAR FRACTURE), INCLUDING IMAGING GUIDANCE AND ARTHROSCOPIC ASSISTANCE FOR JOINT VISUALIZATION",360,RC,0707T,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DELAYED CREATION OF EXIT SITE FROM EMBEDDED SUBCUTANEOUS SEGMENT OF INTRAPERITONEAL CANNULA OR CATHETER,360,RC,49436,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1072.50,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
UNLISTED CARDIOVASCULAR SERVICE OR PROCEDURE,360,RC,93799,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,61.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); VISCERAL (EG, KIDNEY, LIVER, SPLEEN, LUNG/MEDIASTINUM), PERCUTANEOUS",360,RC,49405,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL (IE, PERITONEAL, MESENTERIC, RETROPERITONEAL), PRIMARY OR SECONDARY TUMOR(S) OR CYST(S), SUM OF THE MAXIMUM LENGTH OF TUMOR(S) OR CYST(S); 5 CM OR LESS",360,RC,49186,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BALLOON DILATION OF BILIARY DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), PERCUTANEOUS, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, EACH DUCT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,47542,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF STENT(S) INTO A BILE DUCT, PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY, IMAGING GUIDANCE (EG, FLUOROSCOPY AND/OR ULTRASOUND), BALLOON DILATION, CATHETER EXCHANGE(S) AND CATHETER REMOVAL(S) WHEN PERFORMED, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,47538,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION, 1 OR MORE LIVER TUMOR(S), PERCUTANEOUS, RADIOFREQUENCY",360,RC,47382,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ANOSCOPY; WITH REMOVAL OF FOREIGN BODY,360,RC,46608,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,411.18,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1021.02,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,366.96,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE,360,RC,21465,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",360,RC,45382,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPENDECTOMY;,360,RC,44950,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",361,RC,12005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",361,RC,12034,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",361,RC,13132,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE (SINGLE OR MULTIPLE PERFORATIONS); WITHOUT COLOSTOMY",360,RC,44604,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE; SINGLE PERFORATION",360,RC,44602,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,9075.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH PLACEMENT OF PERCUTANEOUS JEJUNOSTOMY TUBE",360,RC,44372,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1042.14,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESECTION OF SMALL INTESTINE, SINGLE RESECTION AND ANASTOMOSIS",360,RC,44202,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLECTOMY, PARTIAL; WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE)",360,RC,44143,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL",360,RC,44020,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,557.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL LENGTHENING PROCEDURE (EG, COLLIS GASTROPLASTY OR WEDGE GASTROPLASTY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,43283,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC CANNULATION OF PAPILLA WITH DIRECT VISUALIZATION OF PANCREATIC/COMMON BILE DUCT(S) (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE),360,RC,43273,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1630.20,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",360,RC,43237,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,43236,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",361,RC,21555,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF LACERATION OF TONGUE, FLOOR OF MOUTH, OVER 2.6 CM OR COMPLEX",360,RC,41252,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,203.91,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TENODESIS OF LONG TENDON OF BICEPS,361,RC,23430,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,2347.00,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DEPRESSED FRONTAL SINUS FRACTURE,360,RC,21343,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,13934.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF LESION OF TONGUE WITH CLOSURE; POSTERIOR ONE-THIRD,360,RC,41113,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION OF LINGUAL FRENUM (FRENOTOMY),360,RC,41010,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,492.36,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF NASOETHMOID FRACTURE; WITHOUT EXTERNAL FIXATION,360,RC,21338,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VESTIBULOPLASTY; ANTERIOR,360,RC,40840,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT, OR COMPLEX",360,RC,40654,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,492.36,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,151.14,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION),360,RC,38724,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,4200.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; BIOPSY(IES),360,RC,38221,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,235.62,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); EXTREMITY",360,RC,37618,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR WITHOUT STABILIZATION",360,RC,21337,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); NECK",360,RC,37615,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION, INTERNAL JUGULAR VEIN",360,RC,37565,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, NONCORONARY, NON-INTRACRANIAL, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); SECOND AND ALL SUBSEQUENT VESSEL(S) WITHIN THE SAME VASCULAR FAMILY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY MECHANICAL THROMBECTOMY PROCEDURE)",360,RC,37185,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,3160.85,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS",360,RC,36580,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36215,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR MORE SELECTIVE, BRANCH (EG, LEFT ADRENAL VEIN, PETROSAL SINUS)",360,RC,36012,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER BRANCH (EG, RENAL VEIN, JUGULAR VEIN)",360,RC,36011,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; COMMON FEMORAL",360,RC,35371,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT",360,RC,21242,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER CLOSURE OF THE LEFT ATRIAL APPENDAGE WITH ENDOCARDIAL IMPLANT, INCLUDING FLUOROSCOPY, TRANSSEPTAL PUNCTURE, CATHETER PLACEMENT(S), LEFT ATRIAL ANGIOGRAPHY, LEFT ATRIAL APPENDAGE ANGIOGRAPHY, WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,33340,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",360,RC,33285,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,59910.88,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERICARDIOCENTESIS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,33016,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, LARYNX",360,RC,31599,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4265.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); MAXILLARY SINUS OSTIUM, TRANSNASAL OR VIA CANINE FOSSA",360,RC,31295,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILATERAL ALVEOLAR CLEFT OR MULTIPLE OSTEOTOMIES)",360,RC,21147,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,13934.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION MIDFACE, LEFORT I; 2 PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT",360,RC,21142,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, NOSE",360,RC,30999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPAIR FISTULA; OROMAXILLARY (COMBINE WITH 31030 IF ANTROTOMY IS INCLUDED),360,RC,30580,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,205.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITHOUT SEPARATE NEPHROSTOMY CATHETER",361,RC,50694,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,2860.00,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, WITH OR WITHOUT MANIPULATION; WITH INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY)",360,RC,29851,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29819,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF RIGID TOTAL CONTACT LEG CAST,360,RC,29445,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,169.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, WITH TENDON LENGTHENING AND ADVANCEMENT, MIDTARSAL, TARSAL NAVICULAR-CUNEIFORM (EG, MILLER TYPE PROCEDURE)",360,RC,28737,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",361,RC,64468,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MANUAL PREPARATION AND INSERTION OF DRUG-DELIVERY DEVICE(S), INTRA-ARTICULAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20704,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (CERVICAL SYMPATHETIC)",361,RC,64510,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED TRANSMURAL INJECTION OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, NEUROLYTIC AGENT) OR FIDUCIAL MARKER(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43253,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1665.66,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; OTHER PHALANGES, ANY TOE",360,RC,28312,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRALUMINAL DILATION OF STRICTURES AND/OR OBSTRUCTIONS (EG, ESOPHAGUS), RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,74360,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,118.31,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASOUND, CHEST (INCLUDES MEDIASTINUM), REAL TIME WITH IMAGE DOCUMENTATION",361,RC,76604,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,59.40,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS",360,RC,28190,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,77012,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,463.06,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT",360,RC,28024,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL TUNNEL",360,RC,20526,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT,361,RC,G0463,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,113.16,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION OF SINUS TRACT; DIAGNOSTIC (SINOGRAM),360,RC,20501,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27784,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION",360,RC,27762,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, ANKLE; REVISION, TOTAL ANKLE",360,RC,27703,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3976.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, OR SUPRACONDYLAR OR TRANSCONDYLAR, WITH OR WITHOUT INTERCONDYLAR EXTENSION, OR DISTAL FEMORAL EPIPHYSEAL SEPARATION",360,RC,27509,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION OF DISLOCATING PATELLA; (EG, HAUSER TYPE PROCEDURE)",360,RC,27420,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING MAMMOGRAPHIC GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19282,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; EACH ADDITIONAL BRANCH SUBTENDED BY THE BYPASS GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,92938,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,0.02447,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, WITH EXCISION OF SEMILUNAR CARTILAGE (MENISCECTOMY) KNEE; MEDIAL OR LATERAL",360,RC,27332,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), BY ABDUCTION, SPLINT OR TRACTION; WITH MANIPULATION, REQUIRING ANESTHESIA",360,RC,27257,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE;",360,RC,27146,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA",360,RC,26770,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, EACH",360,RC,26756,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION",360,RC,26650,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR TUMORS, ORGAN ISCHEMIA, OR INFARCTION",360,RC,37243,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION",360,RC,26645,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, LESION OF PALATE, UVULA; WITH SIMPLE PRIMARY CLOSURE",360,RC,42106,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, CATHETER ONLY, OF CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION SITE",360,RC,36578,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",360,RC,43274,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, EXTENSOR, HAND OR FINGER, OPEN, EACH TENDON",360,RC,26460,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44361,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,682.44,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,44366,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1042.14,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING STEREOTACTIC GUIDANCE",360,RC,19081,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",360,RC,45392,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,618.42,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, PANCREAS",360,RC,48999,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,301.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY;",360,RC,31287,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, FLEXOR, FINGER, OPEN, EACH TENDON",360,RC,26455,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, NOT IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY OR SECONDARY WITHOUT FREE GRAFT, EACH TENDON",360,RC,26350,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MANIPULATION, FINGER JOINT, UNDER ANESTHESIA, EACH JOINT",360,RC,26340,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); 1.5 CM OR GREATER",360,RC,26113,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STRAPPING; TOES,360,RC,29550,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,52.15,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRAINAGE OF TENDON SHEATH, DIGIT AND/OR PALM, EACH",360,RC,26020,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, WRIST; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,25825,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR EPIPHYSEAL SEPARATION,360,RC,25606,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL;",360,RC,57110,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-GUIDANCE BASED ON CT/MRI IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,0055T,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH FEMORAL OSTEOTOMY AND WITH OPEN REDUCTION OF HIP",360,RC,27156,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3875.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB; WITH MANIPULATION, EACH",360,RC,26755,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OR REVISION OF CEREBROSPINAL FLUID SHUNT, OBSTRUCTED VALVE, OR DISTAL CATHETER IN SHUNT SYSTEM",360,RC,62230,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,20656.55,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE",490,RC,11005,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,25405,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15241,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,215.16,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION",360,RC,24640,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN IMPLANTATION OF CRANIAL NERVE (EG, VAGUS NERVE) NEUROSTIMULATOR ELECTRODE ARRAY AND PULSE GENERATOR",360,RC,64568,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,2076.00,,,,,,,1232.85,103676.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DECOMPRESSION; PLANTAR DIGITAL NERVE,360,RC,64726,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS",490,RC,11056,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH SIMPLE CRANIAL NERVE NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95976,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,4610.00,,,,,,,32.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",490,RC,13101,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,13122,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG",490,RC,15833,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3307.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RADIAL STYLOIDECTOMY (SEPARATE PROCEDURE),360,RC,25230,CPT,,,,,facility,outpatient,,,,,Aetna,Local,,3456.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,370363.86,,,,,,,176830.81,445482.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,149761.07,,,,,,,71503.66,181739.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,280512.24,,,,,,,133931.01,338059.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,183060.10,,,,,,,87402.33,221550.36,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,136263.57,,,,,,,76650.52,165602.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,61282.59,,,,,,,35158.05,75958.55,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,171149.84,,,,,,,81715.76,207310.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,74070.39,,,,,,,42234.47,91247.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,40571.80,,,,,,,25756.46,116071.18,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,72081.39,,,,,,,34415.37,88869.13,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,55718.66,,,,,,,26602.96,69306.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,38085.87,,,,,,,18184.16,48225.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,158828.57,,,,,,,86963.29,192580.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,78366.92,,,,,,,43523.96,96383.81,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,63942.97,,,,,,,39975.02,88524.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,570703.88,,,,,,,272483.47,685000.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,87585.08,,,,,,,41817.63,115421.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,103994.06,,,,,,,49652.13,127022.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,69962.86,,,,,,,33403.88,86336.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,40640.52,,,,,,,19403.88,52896.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,75731.64,,,,,,,36158.19,93233.20,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,51699.67,,,,,,,24684.09,64501.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,60089.19,,,,,,,28689.68,74531.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,41091.19,,,,,,,19619.05,51818.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,33342.65,,,,,,,15919.50,42554.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,79405.69,,,,,,,37912.37,97625.75,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,45087.71,,,,,,,21527.20,56596.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,29011.76,,,,,,,13851.71,37376.97,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,59214.29,,,,,,,28271.96,73485.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28163.30,,,,,,,13446.61,36362.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21976.89,,,,,,,10492.90,28966.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,51155.17,,,,,,,24424.12,63850.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,31592.85,,,,,,,15084.06,40462.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25676.04,,,,,,,12259.07,33388.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,43508.39,,,,,,,20773.15,54708.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21444.28,,,,,,,10238.61,28329.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15535.41,,,,,,,7417.40,21265.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,51029.62,,,,,,,24364.17,63700.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,29058.02,,,,,,,13873.80,37432.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22833.28,,,,,,,10901.79,29990.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23535.05,,,,,,,11236.85,31311.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12941.11,,,,,,,6178.75,18163.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20179.51,,,,,,,9634.74,26817.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13475.03,,,,,,,6433.68,18801.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30702.09,,,,,,,14658.76,39397.84,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17122.65,,,,,,,8175.24,23162.89,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22592.75,,,,,,,10786.94,29702.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16399.73,,,,,,,7830.08,22298.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12156.08,,,,,,,5803.94,17225.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,36437.83,,,,,,,17397.30,46255.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23223.16,,,,,,,11087.93,30456.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18552.62,,,,,,,8857.98,24872.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26577.38,,,,,,,12689.41,34466.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13352.12,,,,,,,6374.99,18655.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9045.03,,,,,,,4318.56,13505.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19410.34,,,,,,,9267.50,25897.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11423.91,,,,,,,5454.36,16349.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10556.94,,,,,,,5040.43,15313.20,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22002.00,,,,,,,10504.89,28996.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13559.62,,,,,,,6474.06,18903.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9993.94,,,,,,,4771.62,14640.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21202.43,,,,,,,10123.13,28040.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13623.05,,,,,,,6504.35,18978.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25341.68,,,,,,,12099.42,32989.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9896.14,,,,,,,4724.93,15730.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23920.96,,,,,,,11421.10,31290.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11836.25,,,,,,,5651.24,16842.71,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30206.49,,,,,,,14422.14,38805.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18446.89,,,,,,,8807.50,24746.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12631.85,,,,,,,6031.10,17793.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30025.43,,,,,,,14335.69,38588.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17216.48,,,,,,,8220.04,23275.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12088.68,,,,,,,5771.76,17144.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17865.39,,,,,,,8529.86,24050.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14519.10,,,,,,,6932.17,20050.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10879.41,,,,,,,5194.39,15698.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23209.94,,,,,,,11081.62,30440.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13519.97,,,,,,,6455.13,18855.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10523.90,,,,,,,5024.65,15273.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,46512.39,,,,,,,22207.41,58299.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,34086.71,,,,,,,16274.75,43444.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,34086.71,,,,,,,16274.75,43444.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47733.55,,,,,,,22790.46,59759.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30329.40,,,,,,,14480.82,38952.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18005.48,,,,,,,8596.74,24218.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25596.75,,,,,,,12221.21,33294.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11928.76,,,,,,,5695.41,16953.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14813.81,,,,,,,7072.88,20402.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11052.54,,,,,,,5277.05,15905.73,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,31072.14,,,,,,,14835.44,39840.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17881.25,,,,,,,8537.43,24069.80,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20285.24,,,,,,,9685.22,26943.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23895.85,,,,,,,11409.11,31260.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14338.04,,,,,,,6845.72,19833.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15374.17,,,,,,,7340.42,21072.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10385.13,,,,,,,4958.40,15107.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10554.30,,,,,,,5039.17,15310.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17486.09,,,,,,,8348.76,23597.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10147.24,,,,,,,4844.82,14823.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27954.48,,,,,,,13346.91,36978.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13418.20,,,,,,,6406.54,18734.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19734.13,,,,,,,9422.09,26285.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11712.02,,,,,,,5591.92,16694.16,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15972.86,,,,,,,10032.25,22216.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,56370.20,,,,,,,26914.04,70085.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28825.42,,,,,,,13762.74,37154.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21098.02,,,,,,,10073.28,27915.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,49515.07,,,,,,,23641.05,61889.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22902.01,,,,,,,10934.60,30072.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15889.60,,,,,,,7586.51,21688.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27983.56,,,,,,,13360.79,36147.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16804.14,,,,,,,8023.16,22782.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10534.47,,,,,,,5029.70,15286.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9933.15,,,,,,,4742.60,14567.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17597.10,,,,,,,8401.76,23730.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9700.54,,,,,,,4631.54,14289.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15623.96,,,,,,,7459.68,21371.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9756.05,,,,,,,4658.04,14355.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20663.22,,,,,,,9865.68,27395.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12112.46,,,,,,,5783.11,17172.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9133.58,,,,,,,4360.84,13611.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22689.23,,,,,,,10833.01,29818.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12023.92,,,,,,,5740.84,17067.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9363.54,,,,,,,4470.64,13886.44,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,59231.47,,,,,,,28280.16,73506.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,33357.18,,,,,,,15926.44,42572.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25298.07,,,,,,,12078.60,32937.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,49397.44,,,,,,,23584.89,61749.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23833.73,,,,,,,11379.45,31186.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18058.34,,,,,,,8621.98,24281.55,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,39336.10,,,,,,,18781.08,49720.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18153.50,,,,,,,8667.42,24395.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10638.88,,,,,,,5079.55,15411.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20652.64,,,,,,,9860.64,27383.20,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12898.82,,,,,,,6158.56,18113.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9978.08,,,,,,,4764.05,14621.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23339.46,,,,,,,11143.46,30595.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14154.34,,,,,,,6758.01,19614.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9832.70,,,,,,,4694.64,14602.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20219.16,,,,,,,9653.67,26864.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14063.15,,,,,,,6714.47,19505.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10394.38,,,,,,,4962.81,15118.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20597.14,,,,,,,9834.14,27316.81,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13071.95,,,,,,,6241.22,18320.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9478.52,,,,,,,4525.53,14023.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16327.05,,,,,,,7795.37,22211.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14639.36,,,,,,,6989.59,20193.98,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11141.09,,,,,,,5319.33,16011.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8484.67,,,,,,,4051.02,12835.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17371.11,,,,,,,8293.86,23459.97,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10650.77,,,,,,,5085.23,15425.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8306.26,,,,,,,3965.84,12622.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24941.24,,,,,,,11908.23,32510.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12543.31,,,,,,,7962.95,17687.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9465.30,,,,,,,6008.92,14008.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23314.35,,,,,,,11131.47,30565.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14528.35,,,,,,,6936.58,20061.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9450.76,,,,,,,4512.28,13990.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12835.38,,,,,,,6128.27,18037.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8854.72,,,,,,,4227.70,13278.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10670.60,,,,,,,5094.69,15449.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24198.50,,,,,,,11553.61,31622.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12437.58,,,,,,,5938.34,17561.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,85041.00,,,,,,,40602.96,104363.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,36326.82,,,,,,,17344.30,46122.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,149589.26,,,,,,,71421.63,181534.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,143712.11,,,,,,,68615.57,174507.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,75422.39,,,,,,,36010.54,92863.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,131591.71,,,,,,,62828.67,160017.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,129289.48,,,,,,,61729.47,157264.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,86899.16,,,,,,,41490.14,106584.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,86899.16,,,,,,,41490.14,106584.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,101476.41,,,,,,,48450.07,124012.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,70478.28,,,,,,,33649.97,86952.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,66611.28,,,,,,,31803.66,82329.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,65384.84,,,,,,,31218.09,80863.02,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,41623.79,,,,,,,19873.35,52455.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,111409.56,,,,,,,53192.67,135888.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,80123.32,,,,,,,38255.01,98483.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,101038.96,,,,,,,48241.21,123489.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,72195.04,,,,,,,34469.64,89005.03,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,77559.42,,,,,,,37030.87,95418.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,55359.18,,,,,,,26431.33,68876.80,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,65045.19,,,,,,,31055.93,80456.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,37672.21,,,,,,,17986.65,47731.00,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18296.23,,,,,,,8735.56,24566.00,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42196.04,,,,,,,20146.57,53139.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28161.97,,,,,,,13445.98,36361.03,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23887.92,,,,,,,11405.33,31251.13,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,60296.68,,,,,,,28788.74,74779.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28843.92,,,,,,,13771.58,37176.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19751.31,,,,,,,9430.30,26305.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,46101.37,,,,,,,22011.17,57808.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,34303.45,,,,,,,16378.24,43703.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23546.95,,,,,,,11242.53,30843.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,35648.84,,,,,,,17020.59,45311.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22439.45,,,,,,,10713.75,29519.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14434.52,,,,,,,6891.78,19949.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,41525.99,,,,,,,19826.65,52338.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26724.07,,,,,,,12759.45,34641.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42989.00,,,,,,,20525.17,54087.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24984.85,,,,,,,11929.06,32562.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21540.76,,,,,,,10284.67,28444.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,40406.60,,,,,,,19292.19,51000.13,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,44149.37,,,,,,,21079.19,55474.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47818.13,,,,,,,22830.84,59861.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,80992.93,,,,,,,38670.20,99523.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,62918.73,,,,,,,30040.65,77914.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,90898.33,,,,,,,43399.55,111365.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,55813.81,,,,,,,26648.39,69420.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,69731.58,,,,,,,33293.45,86059.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47000.06,,,,,,,22440.25,58883.00,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,33740.45,,,,,,,16109.43,43030.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,54522.61,,,,,,,26031.90,67876.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,43503.11,,,,,,,20770.63,54702.18,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,94235.37,,,,,,,44992.82,115355.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,79383.23,,,,,,,37901.65,97598.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,61038.10,,,,,,,29142.74,75666.25,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,73562.90,,,,,,,35122.72,90640.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47662.18,,,,,,,22756.38,59674.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21199.79,,,,,,,10121.87,28037.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12146.83,,,,,,,5799.52,17213.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9556.49,,,,,,,4562.76,14117.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26178.25,,,,,,,12498.85,33989.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9148.12,,,,,,,4367.78,13628.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,7915.06,,,,,,,3779.06,12154.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,29244.36,,,,,,,13962.77,37655.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14142.44,,,,,,,6752.33,19599.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,35765.14,,,,,,,17076.12,45451.02,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22558.39,,,,,,,10770.54,29661.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12286.92,,,,,,,5866.41,17381.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16966.70,,,,,,,8100.78,22976.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11220.38,,,,,,,5357.19,16106.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,7480.26,,,,,,,3571.46,11634.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20642.07,,,,,,,9855.59,27370.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8240.18,,,,,,,3934.28,12709.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,6014.60,,,,,,,2871.68,9882.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21577.76,,,,,,,10302.34,28489.23,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14108.08,,,,,,,6735.93,19558.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9511.56,,,,,,,4541.31,14063.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15814.27,,,,,,,7550.55,21598.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8897.01,,,,,,,4247.89,13328.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15727.04,,,,,,,7508.90,21494.36,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9979.40,,,,,,,4764.68,14622.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20825.77,,,,,,,12458.87,27590.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12068.85,,,,,,,7661.75,17120.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15912.06,,,,,,,7597.24,21715.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9723.01,,,,,,,4642.27,14316.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,7481.58,,,,,,,3572.09,11636.44,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9276.31,,,,,,,4428.99,13782.18,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11519.07,,,,,,,5499.80,16463.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9515.52,,,,,,,4543.20,14068.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27558.00,,,,,,,13157.61,35638.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12730.97,,,,,,,6078.42,17912.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9014.63,,,,,,,4304.05,13469.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,88368.78,,,,,,,42191.82,108341.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,32011.80,,,,,,,15284.08,40963.71,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,58981.69,,,,,,,28160.90,73207.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,31788.44,,,,,,,15177.44,40696.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,35958.09,,,,,,,17168.25,45681.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23299.81,,,,,,,11124.53,30548.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,57190.92,,,,,,,27305.89,71066.74,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,41643.62,,,,,,,19882.81,52479.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42428.65,,,,,,,20257.62,53417.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,65913.48,,,,,,,31470.49,81495.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,32302.55,,,,,,,15422.90,41311.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21176.00,,,,,,,10110.51,28008.89,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,60747.34,,,,,,,29003.92,75318.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,31681.40,,,,,,,15126.33,40568.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22241.21,,,,,,,10619.10,29282.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47851.17,,,,,,,27049.25,59900.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30954.52,,,,,,,14779.28,39699.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21646.49,,,,,,,10335.15,28571.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47193.01,,,,,,,22532.38,59113.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27868.58,,,,,,,13305.90,36010.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20286.56,,,,,,,9685.85,26945.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,34134.28,,,,,,,16297.47,43501.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19886.12,,,,,,,9494.66,26466.80,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15676.82,,,,,,,7484.92,21434.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30338.65,,,,,,,14485.24,38963.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17297.10,,,,,,,8258.53,23371.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11505.85,,,,,,,5493.49,16447.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,32932.95,,,,,,,15723.89,42064.98,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20147.79,,,,,,,9619.59,26779.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15433.64,,,,,,,7368.82,21143.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,38352.83,,,,,,,18311.62,48544.74,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22234.60,,,,,,,10615.94,29274.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17775.52,,,,,,,8486.95,23943.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,58055.24,,,,,,,27718.57,72100.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30733.81,,,,,,,14673.91,39435.77,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18474.65,,,,,,,8820.75,24779.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,45444.54,,,,,,,21697.57,57023.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,31907.39,,,,,,,15234.23,40838.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21038.55,,,,,,,10044.89,27844.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13218.64,,,,,,,6311.26,18495.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9261.77,,,,,,,4422.05,13764.73,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23433.29,,,,,,,11188.26,30707.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13493.54,,,,,,,6442.51,18824.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9613.32,,,,,,,4589.89,14185.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28265.06,,,,,,,13495.20,36484.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15986.07,,,,,,,7632.58,21804.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12215.55,,,,,,,5832.33,17296.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24158.85,,,,,,,11534.68,31575.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12960.93,,,,,,,6188.22,18187.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8331.37,,,,,,,3977.82,12652.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25932.44,,,,,,,12381.48,33695.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14319.54,,,,,,,6836.89,19811.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10580.73,,,,,,,5051.79,15341.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18247.33,,,,,,,8712.22,24507.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11297.04,,,,,,,5393.79,16198.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20911.68,,,,,,,9984.31,27692.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12902.78,,,,,,,6160.45,18117.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9004.06,,,,,,,4299.00,13456.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19517.39,,,,,,,9318.61,26025.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10438.00,,,,,,,4983.64,15171.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,7189.50,,,,,,,3432.64,11287.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16761.85,,,,,,,8002.97,22731.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10303.19,,,,,,,4919.28,15009.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21136.35,,,,,,,10091.58,27961.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12366.21,,,,,,,5904.27,17476.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8577.18,,,,,,,4095.19,12946.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,31651.00,,,,,,,15111.82,40532.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20003.74,,,,,,,9550.82,26607.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15128.36,,,,,,,7223.06,20778.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,53134.93,,,,,,,25369.35,66217.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,72298.13,,,,,,,34518.86,89128.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,38329.04,,,,,,,18300.26,48516.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,29334.23,,,,,,,14005.68,37762.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47122.97,,,,,,,22498.94,59029.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28775.20,,,,,,,13738.76,37094.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20983.04,,,,,,,10018.39,27778.20,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,43656.41,,,,,,,20843.82,54885.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27786.64,,,,,,,13266.77,35912.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21945.17,,,,,,,10477.75,28928.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47083.32,,,,,,,22480.01,58982.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27313.51,,,,,,,13040.88,35346.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18017.37,,,,,,,8602.42,24232.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,31538.66,,,,,,,15058.18,40398.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22356.19,,,,,,,10674.00,29419.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18050.41,,,,,,,8618.20,24272.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,45028.23,,,,,,,21498.80,56525.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22962.80,,,,,,,10963.62,30145.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18495.79,,,,,,,8830.84,24804.57,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,54886.05,,,,,,,30847.19,68311.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28915.29,,,,,,,16826.20,37261.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19827.96,,,,,,,9466.89,26397.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,145656.18,,,,,,,69543.77,176831.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,95401.02,,,,,,,45549.37,116749.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,74300.35,,,,,,,35474.82,91522.03,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,119070.87,,,,,,,56850.58,145047.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,76217.99,,,,,,,36390.40,93814.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26011.73,,,,,,,12419.34,33790.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13958.74,,,,,,,6664.62,19380.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9416.40,,,,,,,4495.88,13949.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24273.83,,,,,,,11589.58,31712.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14948.62,,,,,,,7137.24,20563.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11277.21,,,,,,,5384.32,16174.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21544.72,,,,,,,10286.56,28449.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11117.30,,,,,,,5307.97,15983.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8212.42,,,,,,,3921.03,12510.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23718.76,,,,,,,11324.56,31048.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12757.40,,,,,,,6091.04,17943.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9247.24,,,,,,,4415.11,13747.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22082.61,,,,,,,10543.38,29092.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14463.59,,,,,,,6905.66,19983.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10933.60,,,,,,,5220.26,15763.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,88304.03,,,,,,,42160.90,108264.18,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,56046.41,,,,,,,26759.45,69698.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,70435.99,,,,,,,33629.78,86901.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42692.97,,,,,,,20383.82,53733.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,111059.33,,,,,,,53025.45,135469.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,78808.33,,,,,,,37627.16,96911.55,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,55145.08,,,,,,,26329.11,68620.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,70845.69,,,,,,,33825.39,89957.77,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,35154.56,,,,,,,16784.60,44721.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,75324.59,,,,,,,35963.85,92746.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,41163.88,,,,,,,19653.76,51905.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24102.02,,,,,,,11507.55,31507.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,68794.57,,,,,,,32846.07,84939.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,46607.55,,,,,,,22252.85,58413.73,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,36317.57,,,,,,,17339.88,46111.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,40086.77,,,,,,,19139.49,50617.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25492.34,,,,,,,12171.36,33169.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,63816.10,,,,,,,30469.10,78987.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,38935.66,,,,,,,18589.89,49241.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,32264.22,,,,,,,15404.60,41265.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,56734.97,,,,,,,27088.20,70521.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30075.65,,,,,,,14359.67,38648.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15597.52,,,,,,,7447.06,21339.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,45655.99,,,,,,,21798.53,57276.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,32500.79,,,,,,,15517.55,41548.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24567.22,,,,,,,11729.66,32063.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,38488.96,,,,,,,18376.61,48707.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27680.91,,,,,,,13216.30,35785.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21555.30,,,,,,,10291.61,28462.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,36633.43,,,,,,,17490.69,46489.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42649.35,,,,,,,20363.00,53681.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27635.98,,,,,,,13194.84,35732.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20698.90,,,,,,,9882.72,27438.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20135.90,,,,,,,9613.92,30641.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14759.63,,,,,,,7047.01,20337.75,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,48523.87,,,,,,,23167.80,60704.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,33517.10,,,,,,,16002.79,42763.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26517.90,,,,,,,12661.01,34395.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47917.25,,,,,,,22878.17,59979.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23840.34,,,,,,,11382.61,31194.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15220.87,,,,,,,7267.23,21783.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,39870.03,,,,,,,22740.43,50358.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26627.60,,,,,,,12713.39,34526.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,41826.00,,,,,,,19969.89,52697.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23102.89,,,,,,,11030.51,30312.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17787.41,,,,,,,8492.63,23957.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,36887.18,,,,,,,17611.84,46792.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24703.35,,,,,,,11794.65,32226.02,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23693.64,,,,,,,11312.57,31018.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15853.91,,,,,,,7569.48,24009.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23873.38,,,,,,,11398.38,31233.73,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20014.31,,,,,,,9555.86,26620.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,39918.93,,,,,,,19059.35,50417.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27481.35,,,,,,,13121.01,35547.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21877.77,,,,,,,10445.57,28847.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20805.95,,,,,,,12448.17,27566.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13510.72,,,,,,,8509.66,18844.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42118.07,,,,,,,20109.34,53046.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27464.17,,,,,,,13112.81,35526.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20309.03,,,,,,,9696.58,26972.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,49392.16,,,,,,,23582.36,61742.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26434.64,,,,,,,12621.26,34295.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19743.38,,,,,,,9426.51,26296.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,37932.56,,,,,,,18110.96,48042.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27987.52,,,,,,,13362.69,36152.44,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20718.72,,,,,,,9892.19,27462.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10653.42,,,,,,,5086.49,15428.55,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16942.91,,,,,,,8089.42,22948.02,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10673.24,,,,,,,5095.96,15452.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12612.03,,,,,,,6021.63,17770.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9519.48,,,,,,,4545.09,14072.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26031.56,,,,,,,12428.81,33813.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17131.90,,,,,,,8179.65,23173.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10196.14,,,,,,,4868.16,15133.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23346.06,,,,,,,11146.61,30603.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13586.05,,,,,,,6486.68,18934.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9972.79,,,,,,,4761.53,14614.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,32798.15,,,,,,,15659.53,41903.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15243.33,,,,,,,7277.95,20916.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11051.22,,,,,,,5276.42,15904.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25518.77,,,,,,,12183.98,33200.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15954.36,,,,,,,7617.43,21766.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11552.11,,,,,,,5515.57,16502.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22151.34,,,,,,,10576.19,29174.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12704.54,,,,,,,6065.80,17880.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17131.90,,,,,,,8179.65,23173.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10970.60,,,,,,,5237.93,15807.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17468.91,,,,,,,10646.58,23576.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10977.21,,,,,,,5241.09,15815.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19650.87,,,,,,,9382.34,26185.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11804.53,,,,,,,5636.09,16804.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24646.52,,,,,,,11767.52,32158.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14882.54,,,,,,,7105.69,20484.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10624.34,,,,,,,5072.61,15393.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18830.16,,,,,,,8990.49,25204.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11834.93,,,,,,,5650.60,16841.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20400.22,,,,,,,9740.12,27081.36,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12877.67,,,,,,,6148.46,18087.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9902.75,,,,,,,4728.08,14531.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,38869.58,,,,,,,18558.34,49162.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22328.43,,,,,,,10660.75,29386.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15149.50,,,,,,,7233.15,20803.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,86583.30,,,,,,,41339.33,106207.00,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,45878.02,,,,,,,21904.53,57541.57,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21589.66,,,,,,,10308.02,31085.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,64774.26,,,,,,,30926.57,80133.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,35031.65,,,,,,,16725.92,44574.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21230.18,,,,,,,10136.38,28073.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42800.02,,,,,,,20434.94,53861.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22837.25,,,,,,,10903.68,29994.98,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19072.01,,,,,,,9105.96,25493.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25461.95,,,,,,,12156.85,33132.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22789.67,,,,,,,10880.96,29938.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28291.49,,,,,,,13507.82,36515.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25494.99,,,,,,,12172.62,33172.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25576.92,,,,,,,12211.74,33270.40,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15678.14,,,,,,,7485.55,21435.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11455.63,,,,,,,5469.51,16387.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28027.17,,,,,,,13381.62,36199.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14306.32,,,,,,,6830.57,19795.81,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22032.39,,,,,,,10519.40,29032.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14951.26,,,,,,,7138.50,20566.84,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9689.97,,,,,,,4626.49,14848.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13765.79,,,,,,,6572.50,19149.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,7995.68,,,,,,,3817.55,12251.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18783.90,,,,,,,8968.40,25149.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11509.81,,,,,,,5495.38,16452.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19455.27,,,,,,,9288.95,25951.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12105.86,,,,,,,5779.96,17165.03,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19998.45,,,,,,,9548.29,26601.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11978.98,,,,,,,5719.38,17013.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28966.83,,,,,,,13830.26,37323.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18493.15,,,,,,,8829.58,24801.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,46089.48,,,,,,,22005.49,57794.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24717.88,,,,,,,11801.59,32243.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18744.25,,,,,,,8949.47,25101.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,38159.88,,,,,,,18219.49,48314.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21149.56,,,,,,,10097.89,27977.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19935.01,,,,,,,9518.00,26525.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47038.39,,,,,,,26610.44,58928.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23708.18,,,,,,,11319.51,31036.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16545.11,,,,,,,7899.49,22472.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,39913.64,,,,,,,22763.96,50410.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19816.07,,,,,,,11913.76,26383.02,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17554.81,,,,,,,8381.57,23679.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,49253.39,,,,,,,23516.11,61576.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28795.02,,,,,,,13748.23,37117.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19288.75,,,,,,,9209.44,25752.55,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18987.43,,,,,,,9065.58,25392.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11844.18,,,,,,,5655.02,16852.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8209.78,,,,,,,3919.77,12507.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17651.29,,,,,,,8427.64,23794.89,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10284.69,,,,,,,4910.44,14987.71,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18794.47,,,,,,,8973.45,25161.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21754.86,,,,,,,10386.89,28700.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13546.40,,,,,,,6467.75,18887.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10153.85,,,,,,,4847.97,14831.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,62133.70,,,,,,,29665.83,76976.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,48975.85,,,,,,,23383.60,61245.16,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42681.07,,,,,,,24864.48,53719.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,68675.62,,,,,,,38291.86,84797.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,36995.55,,,,,,,21188.55,46922.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27972.99,,,,,,,13355.75,36135.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42077.10,,,,,,,20089.78,52997.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24185.28,,,,,,,11547.30,31606.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20508.59,,,,,,,9791.86,27210.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,33580.53,,,,,,,16033.08,42839.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17467.59,,,,,,,8339.93,23575.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13683.85,,,,,,,6533.37,19051.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,40460.78,,,,,,,19318.06,51064.93,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20090.96,,,,,,,9592.46,26711.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13835.83,,,,,,,6605.94,19233.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,41249.78,,,,,,,19694.77,52008.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23118.75,,,,,,,11038.08,30331.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14619.54,,,,,,,6980.12,20170.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,38590.72,,,,,,,22049.75,48829.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20511.23,,,,,,,9793.12,27214.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12916.00,,,,,,,6166.76,18133.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23722.72,,,,,,,14022.86,31053.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14266.67,,,,,,,8917.77,19748.40,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,55528.35,,,,,,,31193.97,69079.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30906.94,,,,,,,14756.57,39642.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21692.74,,,,,,,10357.23,28626.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19572.90,,,,,,,9345.11,26092.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11574.57,,,,,,,5526.30,16529.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,7933.56,,,,,,,3787.89,12176.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23837.70,,,,,,,11381.35,31191.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13847.72,,,,,,,6611.62,19247.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10444.60,,,,,,,4986.79,15178.89,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15334.52,,,,,,,7321.49,21025.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10698.35,,,,,,,5107.94,15482.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17768.91,,,,,,,8483.80,23935.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10330.95,,,,,,,4932.53,15043.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15116.46,,,,,,,7217.38,20764.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9105.82,,,,,,,4347.59,13578.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14244.20,,,,,,,6800.92,19721.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21864.55,,,,,,,10439.26,28832.13,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13414.24,,,,,,,6404.65,18729.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9117.72,,,,,,,4353.27,13592.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26435.96,,,,,,,12621.89,34297.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20275.99,,,,,,,9680.80,26932.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30754.95,,,,,,,14684.00,39461.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18518.26,,,,,,,8841.57,24831.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27539.50,,,,,,,16083.46,35616.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14533.64,,,,,,,6939.11,20067.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19868.93,,,,,,,9486.45,26446.18,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13974.60,,,,,,,6672.19,19399.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,29568.16,,,,,,,17178.68,38042.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19440.74,,,,,,,9282.01,25934.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24984.85,,,,,,,14704.27,32562.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17750.41,,,,,,,8474.96,23913.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23917.00,,,,,,,14127.76,31285.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15101.92,,,,,,,9368.70,20746.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8084.23,,,,,,,3859.83,13052.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15465.36,,,,,,,7383.96,21181.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9541.95,,,,,,,4555.82,14099.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19598.01,,,,,,,9357.10,26122.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10720.82,,,,,,,5118.67,15509.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13991.78,,,,,,,6680.40,19419.77,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8881.15,,,,,,,4240.32,13309.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28150.08,,,,,,,16413.10,36346.81,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17782.13,,,,,,,8490.10,23951.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47240.59,,,,,,,22555.10,59170.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27232.89,,,,,,,13002.39,35250.23,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19407.70,,,,,,,9266.24,25894.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,46603.58,,,,,,,22250.95,59301.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23915.67,,,,,,,11418.58,31284.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18847.34,,,,,,,8998.69,25224.84,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24248.72,,,,,,,11577.59,31682.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16397.09,,,,,,,7828.82,22295.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27080.91,,,,,,,12929.82,35068.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15033.20,,,,,,,7177.62,20664.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22957.51,,,,,,,10961.10,30138.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11094.83,,,,,,,5297.24,16275.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18334.56,,,,,,,8753.86,24611.80,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,33933.40,,,,,,,16201.56,43261.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19504.17,,,,,,,9312.30,26010.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24339.91,,,,,,,14356.07,31791.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14376.36,,,,,,,8977.00,19879.57,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12693.97,,,,,,,6060.76,17868.16,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18923.99,,,,,,,9035.29,25316.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12938.46,,,,,,,6177.49,18160.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8770.14,,,,,,,4187.32,13176.98,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13315.12,,,,,,,6357.32,18610.75,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,7527.83,,,,,,,3594.18,11705.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14162.27,,,,,,,2575.00,15077.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22332.40,,,,,,,10662.64,29391.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13251.68,,,,,,,6327.04,18534.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8652.52,,,,,,,4131.16,13036.36,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9424.33,,,,,,,4499.66,15984.73,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,32446.60,,,,,,,4570.00,34543.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14010.28,,,,,,,4570.00,14915.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12658.28,,,,,,,4570.00,13476.25,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21799.79,,,,,,,4570.00,23208.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14759.63,,,,,,,4570.00,15713.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12671.50,,,,,,,4570.00,13490.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23817.88,,,,,,,11371.88,31167.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,78549.30,,,,,,,37503.49,96601.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,53643.74,,,,,,,25612.29,66825.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,32368.63,,,,,,,15454.45,41390.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,55105.43,,,,,,,26310.18,68573.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19505.49,,,,,,,9312.93,26011.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,2640.56,,,,,,,909.00,5848.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15423.07,,,,,,,2575.00,17901.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13221.29,,,,,,,2575.00,15346.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12649.03,,,,,,,2575.00,14681.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,59853.94,,,,,,,28577.36,74250.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,37129.03,,,,,,,17727.31,47081.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25228.02,,,,,,,12045.16,32853.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,52653.87,,,,,,,25139.67,65642.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24567.22,,,,,,,11729.66,32063.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17920.90,,,,,,,8556.36,24117.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14262.71,,,,,,,2575.00,15184.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9964.86,,,,,,,2575.00,10608.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8910.23,,,,,,,2575.00,9485.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,29179.61,,,,,,,13931.85,37577.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16730.13,,,,,,,7987.83,22693.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13831.87,,,,,,,6604.05,19228.57,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18559.23,,,,,,,8861.13,24880.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12134.93,,,,,,,5793.84,17199.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20158.36,,,,,,,9624.64,26792.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28106.47,,,,,,,13419.48,36294.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13401.02,,,,,,,6398.34,18713.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8352.51,,,,,,,3987.92,12677.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22308.61,,,,,,,10651.28,38742.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13932.31,,,,,,,6652.00,21007.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11364.44,,,,,,,5425.97,16278.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,77509.20,,,,,,,43060.90,95358.36,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,29585.34,,,,,,,17187.95,38062.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15912.06,,,,,,,7597.24,21715.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,60592.72,,,,,,,33928.09,75133.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,29942.17,,,,,,,14295.94,38489.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17833.67,,,,,,,8514.71,24012.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,61821.80,,,,,,,29516.92,76603.23,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30544.82,,,,,,,14583.67,39209.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22517.42,,,,,,,10750.98,29612.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,41762.56,,,,,,,19939.60,52621.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19890.08,,,,,,,9496.55,26471.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15892.24,,,,,,,7587.77,21691.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9536.67,,,,,,,4553.30,14093.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,6910.65,,,,,,,3299.50,10953.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,72554.52,,,,,,,34641.27,89434.80,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27565.93,,,,,,,13161.40,35648.40,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16116.91,,,,,,,7695.05,21960.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,63493.63,,,,,,,35494.22,78601.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27587.08,,,,,,,16109.15,35673.71,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19082.58,,,,,,,11517.77,25506.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42752.44,,,,,,,20412.22,53804.71,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21560.58,,,,,,,10294.13,28468.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13353.45,,,,,,,6375.62,18656.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26363.28,,,,,,,12587.19,34210.57,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16089.16,,,,,,,7681.79,21927.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11254.75,,,,,,,5373.60,16147.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,34262.48,,,,,,,16358.67,43654.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17289.17,,,,,,,8254.74,23361.98,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11225.67,,,,,,,5359.71,16112.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,35808.75,,,,,,,17096.94,45503.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,114443.95,,,,,,,54641.44,139515.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,65268.54,,,,,,,31162.57,80723.97,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26406.89,,,,,,,12608.01,34262.74,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19787.00,,,,,,,9447.33,26348.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,60115.62,,,,,,,28702.30,74563.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,28302.06,,,,,,,13512.86,36528.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18408.57,,,,,,,8789.20,24700.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24102.02,,,,,,,11507.55,31507.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13188.25,,,,,,,6296.75,18459.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11731.84,,,,,,,5601.39,16717.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,19801.53,,,,,,,9454.27,26365.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11492.63,,,,,,,5487.18,16431.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27663.73,,,,,,,13208.09,35765.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13627.02,,,,,,,6506.24,18983.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9643.72,,,,,,,4604.41,14221.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,91346.35,,,,,,,43613.46,111901.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25672.08,,,,,,,12257.17,33384.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13523.93,,,,,,,6457.02,18860.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,51078.52,,,,,,,24387.52,63759.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12690.00,,,,,,,720.00,17863.40,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12434.93,,,,,,,720.00,17558.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14191.34,,,,,,,720.00,19658.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25986.62,,,,,,,720.00,33760.25,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21263.22,,,,,,,720.00,28113.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18460.11,,,,,,,720.00,24761.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27427.16,,,,,,,720.00,35482.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,14153.01,,,,,,,720.00,19612.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8152.95,,,,,,,720.00,12439.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18708.57,,,,,,,720.00,25058.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23063.24,,,,,,,720.00,30265.20,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11667.08,,,,,,,720.00,16640.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,55462.27,,,,,,,26480.55,69000.03,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,25302.03,,,,,,,12080.50,32941.77,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15457.43,,,,,,,7380.18,21172.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,48543.69,,,,,,,27423.13,60728.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,18922.67,,,,,,,11799.58,26130.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23291.88,,,,,,,11120.74,33728.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,50740.19,,,,,,,24225.98,63354.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26368.56,,,,,,,12589.71,34216.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17348.64,,,,,,,8283.14,23433.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21602.87,,,,,,,10314.33,28519.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11702.77,,,,,,,5587.51,16683.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22224.03,,,,,,,10610.90,29261.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8805.82,,,,,,,4204.35,13219.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20727.97,,,,,,,9896.60,27473.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11327.43,,,,,,,5408.30,16234.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,24195.85,,,,,,,11552.35,31619.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13246.40,,,,,,,6324.51,18528.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,9097.89,,,,,,,4343.80,13568.84,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,23120.07,,,,,,,11038.71,30333.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,13449.92,,,,,,,6421.69,18771.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,243573.52,,,,,,,153551.43,340039.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,94794.40,,,,,,,52392.77,116023.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,42566.09,,,,,,,24195.95,53581.93,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,50441.51,,,,,,,29000.66,64221.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,29215.29,,,,,,,16988.17,37620.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,27224.96,,,,,,,15913.64,35240.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,47954.26,,,,,,,22895.83,60023.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,30884.47,,,,,,,14745.84,39615.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,26798.08,,,,,,,12794.79,34730.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20466.30,,,,,,,9771.67,27160.40,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15156.11,,,,,,,7236.31,20811.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16776.39,,,,,,,8009.91,22748.89,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,10579.41,,,,,,,5051.15,15340.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15723.08,,,,,,,7507.01,21489.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,8295.68,,,,,,,3960.79,12609.74,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,7348.10,,,,,,,3508.36,11476.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,88958.22,,,,,,,42473.24,109046.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,49731.81,,,,,,,23744.53,62148.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,100704.60,,,,,,,48081.57,123089.77,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,55690.90,,,,,,,26589.71,69273.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,38909.23,,,,,,,18577.27,49209.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,36129.90,,,,,,,17250.28,45887.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,20254.84,,,,,,,9670.71,26907.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,12429.65,,,,,,,5934.56,17552.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,80899.10,,,,,,,38625.40,99411.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,34855.88,,,,,,,16641.99,44363.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,38141.38,,,,,,,18210.66,48291.93,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,17114.72,,,,,,,8171.45,23153.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,11821.71,,,,,,,5644.30,16954.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,16752.60,,,,,,,7998.56,23196.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,62006.83,,,,,,,29605.26,76824.44,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,32491.54,,,,,,,15513.14,41537.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,22652.22,,,,,,,10815.34,29773.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,45309.73,,,,,,,21633.20,56862.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,21721.82,,,,,,,10371.12,28661.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,Local,,15848.63,,,,,,,7566.95,21639.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.79% of charges."
Hetastarch 6% -NS 500mL,8724320,CDM,250,RC,,,,,facility,outpatient,,,356.81000,103.47000,Aetna,Local,,181.15,,,,,,,128.63,291.87,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,8726055,CDM,250,RC,,,,,facility,outpatient,,,263.15000,76.31000,Aetna,Local,,133.60,,,,,,,94.87,215.26,percent of total billed charges,
Dornase Alfa 2.5mg/2.5mL Inhl UD,8724890,CDM,250,RC,,,,,facility,outpatient,,,703.25000,203.94000,Aetna,Local,,357.04,,,,,,,253.52,575.26,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,8725160,CDM,250,RC,,,,,facility,outpatient,,,48.33000,14.02000,Aetna,Local,,24.54,,,,,,,17.42,39.53,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,8724697,CDM,250,RC,,,,,facility,outpatient,,,341.10000,98.92000,Aetna,Local,,173.18,,,,,,,122.97,279.02,percent of total billed charges,
Cupric Cl (Copper) I 10mL,8723455,CDM,250,RC,,,,,facility,outpatient,,,197.42000,57.25000,Aetna,Local,,100.23,,,,,,,71.17,161.49,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,8724717,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
PrismaSol BGK 4/2.5 - 5L,8725288,CDM,250,RC,,,,,facility,outpatient,,,490.00000,142.10000,Aetna,Local,,248.77,,,,,,,176.65,400.82,percent of total billed charges,
Sodium Chloride 23.4% Inj 30mL,8725323,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,8725332,CDM,250,RC,,,,,facility,outpatient,,,238.49000,69.16000,Aetna,Local,,121.08,,,,,,,85.98,195.08,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,8725361,CDM,250,RC,,,,,facility,outpatient,,,114.23000,33.13000,Aetna,Local,,57.99,,,,,,,41.18,93.44,percent of total billed charges,
Calamine-Zinc Oxide 8% Topical Lotion,8725867,CDM,250,RC,,,,,facility,outpatient,,,16.65000,4.83000,Aetna,Local,,8.45,,,,,,,6.00,13.62,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),8723468,CDM,250,RC,,,,,facility,outpatient,,,16.10000,4.67000,Aetna,Local,,8.17,,,,,,,5.80,13.17,percent of total billed charges,
Potassium Phosphate Inj 5mL,8725748,CDM,250,RC,,,,,facility,outpatient,,,94.55000,27.42000,Aetna,Local,,48.00,,,,,,,34.09,77.34,percent of total billed charges,
NS (Sterile Field) IS 10mL,8725796,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Acetic Acid 3% TS 30mL,8725773,CDM,250,RC,,,,,facility,outpatient,,,30.20000,8.76000,Aetna,Local,,15.33,,,,,,,10.89,24.70,percent of total billed charges,
Mannitol 20% 500mL,8723714,CDM,250,RC,,,,,facility,outpatient,,,194.35000,56.36000,Aetna,Local,,98.67,,,,,,,70.06,158.98,percent of total billed charges,
Poractant 120mg/1.5mL Intratrach I(Curosurf),8725823,CDM,250,RC,,,,,facility,outpatient,,,2576.30000,747.13000,Aetna,Local,,1307.99,,,,,,,928.76,2107.41,percent of total billed charges,
PrismaSol BGK 2/3.5 - 5L,8725381,CDM,250,RC,,,,,facility,outpatient,,,490.00000,142.10000,Aetna,Local,,248.77,,,,,,,176.65,400.82,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,8725393,CDM,250,RC,,,,,facility,outpatient,,,330.83000,95.94000,Aetna,Local,,167.96,,,,,,,119.26,270.62,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL - for IV Set,8725432,CDM,250,RC,,,,,facility,outpatient,,,3313.25000,960.84000,Aetna,Local,,1682.14,,,,,,,1194.43,2710.24,percent of total billed charges,
Labetalol 100mg/20mL - for IV Set,8725436,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
Isoproterenol HCl 1mg/5mL Inj - for IV Set,8725438,CDM,250,RC,,,,,facility,outpatient,,,12883.50000,3736.21000,Aetna,Local,,6540.95,,,,,,,4644.50,10538.70,percent of total billed charges,
Norepinephrine 8mg/8mL Inj - IV Set Use,8725440,CDM,250,RC,,,,,facility,outpatient,,,360.98000,104.68000,Aetna,Local,,183.27,,,,,,,130.13,295.28,percent of total billed charges,
Hip/Knee Periarticular Syringe,8725500,CDM,250,RC,,,,,facility,outpatient,,,533.80000,154.80000,Aetna,Local,,271.01,,,,,,,192.43,436.65,percent of total billed charges,
Nitroglycerin 40mcg/mL D5W Vial - OR Use ONLY,8725526,CDM,250,RC,,,,,facility,outpatient,,,79.70000,23.11000,Aetna,Local,,40.46,,,,,,,28.73,65.19,percent of total billed charges,
Lidocaine 4% Topical Trach Kit,8725574,CDM,250,RC,,,,,facility,outpatient,,,253.50000,73.52000,Aetna,Local,,128.70,,,,,,,91.39,207.36,percent of total billed charges,
HYDROmorphone 1mg/1mL Oral Soln,8725580,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Amino Acids (for TPN/PPN),8725685,CDM,250,RC,,,,,facility,outpatient,,,57.00000,16.53000,Aetna,Local,,28.94,,,,,,,20.55,46.63,percent of total billed charges,
Dextrose (For TPN/PPN),8725686,CDM,250,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,18.02,40.90,percent of total billed charges,
Sugammadex 100mg/mL Inj 2mL(Bridion SD),8725653,CDM,250,RC,,,,,facility,outpatient,,,714.10000,207.09000,Aetna,Local,,362.55,,,,,,,257.43,584.13,percent of total billed charges,
Mineral Oil Light 10mL(Muri-Lube),8723421,CDM,250,RC,,,,,facility,outpatient,,,194.90000,56.52000,Aetna,Local,,98.95,,,,,,,70.26,159.43,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,8724133,CDM,250,RC,,,,,facility,outpatient,,,56.65000,16.43000,Aetna,Local,,28.76,,,,,,,20.42,46.34,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,8723539,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,8723536,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,8723537,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Sugammadex 100mg/mL Inj 5mL(Bridion SD),8725829,CDM,250,RC,,,,,facility,outpatient,,,1183.45000,343.20000,Aetna,Local,,600.84,,,,,,,426.63,968.06,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,8725830,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
NUTR- Isosource HN (250mL),8725911,CDM,250,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,18.02,40.90,percent of total billed charges,
Citric Acid/MgOx/Na pico Oral Soln,9005005,CDM,250,RC,,,,,facility,outpatient,,,1395.45000,404.68000,Aetna,Local,,708.47,,,,,,,503.06,1141.48,percent of total billed charges,
NS 3000mL Irrigation - Bag,8725935,CDM,250,RC,,,,,facility,outpatient,,,87.80000,25.46000,Aetna,Local,,44.58,,,,,,,31.65,71.82,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,8723416,CDM,250,RC,,,,,facility,outpatient,,,50.10000,14.53000,Aetna,Local,,25.44,,,,,,,18.06,40.98,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,8723981,CDM,250,RC,,,,,facility,outpatient,,,751.85000,218.04000,Aetna,Local,,381.71,,,,,,,271.04,615.01,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,8723426,CDM,250,RC,,,,,facility,outpatient,,,197.15000,57.17000,Aetna,Local,,100.09,,,,,,,71.07,161.27,percent of total billed charges,
Potassium Phosphate Inj 15mL,8723469,CDM,250,RC,,,,,facility,outpatient,,,150.90000,43.76000,Aetna,Local,,76.61,,,,,,,54.40,123.44,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,8723541,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Labetalol 5mg/mL 4mL I(Normodyne),8726135,CDM,250,RC,,,,,facility,outpatient,,,28.43000,8.24000,Aetna,Local,,14.43,,,,,,,10.25,23.26,percent of total billed charges,
aminolevulinic acid 50mL REC Pwd Oral Soln,8726098,CDM,250,RC,,,,,facility,outpatient,,,17287.80000,5013.46000,Aetna,Local,,8777.02,,,,,,,6232.25,14141.42,percent of total billed charges,
nirmatrelvir-ritonavir 300mg-100mg Dose Tab,8726145,CDM,250,RC,,,,,facility,outpatient,,,1091.85000,316.64000,Aetna,Local,,554.33,,,,,,,393.61,893.13,percent of total billed charges,
NS Bacteriostatic 0.9% 10mL I,8726150,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Lidocaine 2% Topical Jelly w/ Appl,8974995,CDM,250,RC,,,,,facility,outpatient,,,50.60000,14.67000,Aetna,Local,,25.69,,,,,,,18.24,41.39,percent of total billed charges,
docusate/phosphate/water 250mL enema,8984010,CDM,250,RC,,,,,facility,outpatient,,,138.80000,40.25000,Aetna,Local,,70.47,,,,,,,50.04,113.54,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,8986201,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
etomidate 2mg/mL 20mL Inj,8986277,CDM,250,RC,,,,,facility,outpatient,,,25.55000,7.41000,Aetna,Local,,12.97,,,,,,,9.21,20.90,percent of total billed charges,
sodium citrate 4%(120mg/3mL) IS,8986968,CDM,250,RC,,,,,facility,outpatient,,,77.20000,22.39000,Aetna,Local,,39.19,,,,,,,27.83,63.15,percent of total billed charges,
Ethiodized Oil 480 mg/mL Inj Soln 10mL,8990224,CDM,250,RC,,,,,facility,outpatient,,,4628.20000,1342.18000,Aetna,Local,,2349.74,,,,,,,1668.47,3785.87,percent of total billed charges,
trace elements (Cu/Mn/Se/Zn) 0.3mg-55mcg-60mcg-3mg/mL I,9000947,CDM,250,RC,,,,,facility,outpatient,,,166.88000,48.40000,Aetna,Local,,84.72,,,,,,,60.16,136.51,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,8723404,CDM,250,RC,,,,,facility,outpatient,,,28.75000,8.34000,Aetna,Local,,14.60,,,,,,,10.36,23.52,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,8723394,CDM,250,RC,,,,,facility,outpatient,,,89.70000,26.01000,Aetna,Local,,45.54,,,,,,,32.34,73.37,percent of total billed charges,
nirmatrelvir-ritonavir 150 mg-100 mg (Renal Dose) Tab,9090588,CDM,250,RC,,,,,facility,outpatient,,,1091.85000,316.64000,Aetna,Local,,554.33,,,,,,,393.61,893.13,percent of total billed charges,
Norepinephrine 8mg/NS 250mL-Dbl Conc,9098880,CDM,250,RC,,,,,facility,outpatient,,,481.00000,139.49000,Aetna,Local,,244.20,,,,,,,173.40,393.46,percent of total billed charges,
ePHEDrine sulfate 25mg/5mL IS,9115161,CDM,250,RC,,,,,facility,outpatient,,,78.85000,22.87000,Aetna,Local,,40.03,,,,,,,28.43,64.50,percent of total billed charges,
Ketamine 10mg/mL Inj 10mL,9144896,CDM,250,RC,,,,,facility,outpatient,,,88.00000,25.52000,Aetna,Local,,44.68,,,,,,,31.72,71.98,percent of total billed charges,
Ketamine 500mg/NS 250mL IV,9160464,CDM,250,RC,,,,,facility,outpatient,,,81.70000,23.69000,Aetna,Local,,41.48,,,,,,,29.45,66.83,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),8723502,CDM,250,RC,,,,,facility,outpatient,,,25.30000,7.34000,Aetna,Local,,12.84,,,,,,,9.12,20.70,percent of total billed charges,
Sodium Phosphate Inj,8723470,CDM,250,RC,,,,,facility,outpatient,,,324.18000,94.01000,Aetna,Local,,164.59,,,,,,,116.87,265.18,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,8723583,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,8723400,CDM,250,RC,,,,,facility,outpatient,,,107.10000,31.06000,Aetna,Local,,54.37,,,,,,,38.61,87.61,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,8724145,CDM,250,RC,,,,,facility,outpatient,,,35.00000,10.15000,Aetna,Local,,17.77,,,,,,,12.62,28.63,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,8723538,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Alcohol (Dehydrated) - 5g/5mL Inj,8725953,CDM,250,RC,,,,,facility,outpatient,,,4154.10000,1204.69000,Aetna,Local,,2109.04,,,,,,,1497.55,3398.05,percent of total billed charges,
Urea 15g Oral Rec Powder,8725966,CDM,250,RC,,,,,facility,outpatient,,,30.80000,8.93000,Aetna,Local,,15.64,,,,,,,11.10,25.19,percent of total billed charges,
RAD- Iohexol 9mg/mL Oral  500mL,8726019,CDM,250,RC,,,,,facility,outpatient,,,85.85000,24.90000,Aetna,Local,,43.59,,,,,,,30.95,70.23,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,8726023,CDM,250,RC,,,,,facility,outpatient,,,2410.10000,698.93000,Aetna,Local,,1223.61,,,,,,,868.84,1971.46,percent of total billed charges,
Tranexamic Acid 1g/100mL Bolus,8726057,CDM,250,RC,,,,,facility,outpatient,,,214.37000,62.17000,Aetna,Local,,108.84,,,,,,,77.28,175.35,percent of total billed charges,
Lidocaine-NaHCO1%-8.4% IS 10mL,8726089,CDM,250,RC,,,,,facility,outpatient,,,50.10000,14.53000,Aetna,Local,,25.44,,,,,,,18.06,40.98,percent of total billed charges,
Multiple Vitamin Inj,8724124,CDM,250,RC,,,,,facility,outpatient,,,103.20000,29.93000,Aetna,Local,,52.39,,,,,,,37.20,84.42,percent of total billed charges,
Selenium 2.5% 120mL Lotion,8723661,CDM,250,RC,,,,,facility,outpatient,,,140.20000,40.66000,Aetna,Local,,71.18,,,,,,,50.54,114.68,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,8723696,CDM,250,RC,,,,,facility,outpatient,,,319.40000,92.63000,Aetna,Local,,162.16,,,,,,,115.14,261.27,percent of total billed charges,
Bismuth Subgallate Pwd,8723879,CDM,250,RC,,,,,facility,outpatient,,,16.85000,4.89000,Aetna,Local,,8.55,,,,,,,6.07,13.78,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),8723818,CDM,250,RC,,,,,facility,outpatient,,,42.44000,12.31000,Aetna,Local,,21.55,,,,,,,15.30,34.72,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,8724468,CDM,250,RC,,,,,facility,outpatient,,,196.35000,56.94000,Aetna,Local,,99.69,,,,,,,70.78,160.61,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,8723382,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,8723414,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
NICU- Sodium Acetate 2mEq/mL Inj,8725108,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,8725311,CDM,250,RC,,,,,facility,outpatient,,,53.65000,15.56000,Aetna,Local,,27.24,,,,,,,19.34,43.89,percent of total billed charges,
Anticoag Citr Dextr-A 1L (ACDA),8725309,CDM,250,RC,,,,,facility,outpatient,,,118.95000,34.50000,Aetna,Local,,60.39,,,,,,,42.88,97.30,percent of total billed charges,
Na Citrate 4% 500mL Inj,8724092,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
RX6308491,646493,CDM,250,RC,,,,,facility,outpatient,,,37.50000,10.88000,Aetna,Local,,19.04,,,,,,,13.52,30.68,percent of total billed charges,
Sodium Bica 50mEq/50mL I,8723572,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),8724175,CDM,250,RC,,,,,facility,outpatient,,,1206.00000,349.74000,Aetna,Local,,612.29,,,,,,,434.76,986.51,percent of total billed charges,
Indocyanine Green 25 mg I,8724169,CDM,250,RC,,,,,facility,outpatient,,,868.19000,251.78000,Aetna,Local,,440.78,,,,,,,312.98,710.18,percent of total billed charges,
Zinc Chloride 1mg/mL I 10mL,8724753,CDM,250,RC,,,,,facility,outpatient,,,151.03000,43.80000,Aetna,Local,,76.68,,,,,,,54.45,123.54,percent of total billed charges,
Fluorescein Ophth Test Strip,8724831,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,8724865,CDM,250,RC,,,,,facility,outpatient,,,77.85000,22.58000,Aetna,Local,,39.52,,,,,,,28.06,63.68,percent of total billed charges,
EPINEPHrine 1:1000 Topical Soln 30mL,8725964,CDM,250,RC,,,,,facility,outpatient,,,1812.50000,525.62000,Aetna,Local,,920.21,,,,,,,653.41,1482.62,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),8724288,CDM,250,RC,,,,,facility,outpatient,,,27.30000,7.92000,Aetna,Local,,13.86,,,,,,,9.84,22.33,percent of total billed charges,
Isoflurane Inhl Sol 100mL,8723623,CDM,250,RC,,,,,facility,outpatient,,,169.95000,49.29000,Aetna,Local,,86.28,,,,,,,61.27,139.02,percent of total billed charges,
dilTIAZem 125mg /125mL Premix IVPB,8726035,CDM,250,RC,,,,,facility,outpatient,,,237.15000,68.77000,Aetna,Local,,120.40,,,,,,,85.49,193.99,percent of total billed charges,
pyRIDostigmine 10mg/2mL I,8724313,CDM,250,RC,,,,,facility,outpatient,,,102.15000,29.62000,Aetna,Local,,51.86,,,,,,,36.83,83.56,percent of total billed charges,
Docosanol 10%  2g TC,8724343,CDM,250,RC,,,,,facility,outpatient,,,218.85000,63.47000,Aetna,Local,,111.11,,,,,,,78.90,179.02,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),8724361,CDM,250,RC,,,,,facility,outpatient,,,74.65000,21.65000,Aetna,Local,,37.90,,,,,,,26.91,61.06,percent of total billed charges,
Lido 40mg/Epi 0.5mg/Tetr 5mg Top Gel 3mL,8726034,CDM,250,RC,,,,,facility,outpatient,,,89.61000,25.99000,Aetna,Local,,45.49,,,,,,,32.30,73.30,percent of total billed charges,
Miscellaneous Medication - Pharmacy,8726061,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
Parenteral Nutrition Chg,8723895,CDM,251,RC,,,,,facility,outpatient,,,970.00000,281.30000,Aetna,Local,,492.47,,,,,,,349.69,793.46,percent of total billed charges,
Open Heart Kit,8723804,CDM,251,RC,,,,,facility,outpatient,,,4044.10000,1172.79000,Aetna,Local,,2053.19,,,,,,,1457.90,3308.07,percent of total billed charges,
Poractant 240mg/3mL Intratrach Inj,8724729,CDM,252,RC,,,,,facility,inpatient,,,4895.45000,1419.68000,Aetna,Local,,1958.18,,,,,,,1811.32,4004.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Poractant 240mg/3mL Intratrach Inj,8724729,CDM,252,RC,,,,,facility,outpatient,,,4895.45000,1419.68000,Aetna,Local,,2485.42,,,,,,,1764.81,4004.48,percent of total billed charges,
NICU- Indomethacin 0.1mg/1mL IS,8725711,CDM,252,RC,,,,,facility,inpatient,,,3504.40000,1016.28000,Aetna,Local,,1401.76,,,,,,,1296.63,2866.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Indomethacin 0.1mg/1mL IS,8725711,CDM,252,RC,,,,,facility,outpatient,,,3504.40000,1016.28000,Aetna,Local,,1779.18,,,,,,,1263.34,2866.60,percent of total billed charges,
NEOnatal Lipid 20% Inf,8724911,CDM,252,RC,,,,,facility,inpatient,,,128.50000,37.26000,Aetna,Local,,51.40,,,,,,,47.55,105.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEOnatal Lipid 20% Inf,8724911,CDM,252,RC,,,,,facility,outpatient,,,128.50000,37.26000,Aetna,Local,,65.24,,,,,,,46.32,105.11,percent of total billed charges,
D50W 50mL Inj Syr,8723571,CDM,258,RC,,,,,facility,outpatient,,,121.37000,35.20000,Aetna,Local,,61.62,,,,,,,43.75,99.28,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,8723735,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
0.45% Sodium Cl 500mL,8723722,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
0.45% Sodium Cl 1000mL,8723976,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,8723746,CDM,258,RC,,,,,facility,outpatient,,,173.75000,50.39000,Aetna,Local,,88.21,,,,,,,62.64,142.13,percent of total billed charges,
D5.45NS+ KCl 10mEq 1000mL,8723750,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
D10W 1000mL,8723741,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
D10W 250mL,8723683,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
NS + 20mEq KCl 1000mL,8723733,CDM,258,RC,,,,,facility,outpatient,,,106.17000,30.79000,Aetna,Local,,53.90,,,,,,,38.27,86.85,percent of total billed charges,
D5NS+20 mEq KCl/L,8723732,CDM,258,RC,,,,,facility,outpatient,,,108.50000,31.46000,Aetna,Local,,55.09,,,,,,,39.11,88.75,percent of total billed charges,
Water For Inj 50mL I,8723570,CDM,258,RC,A4216,HCPCS,,,facility,outpatient,,,32.16000,9.33000,Aetna,Local,,16.33,,,,,,,0.63000,26.31,percent of total billed charges,
Sterile Water 1000mL,8723748,CDM,258,RC,A4217,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,3.80,81.80,percent of total billed charges,
NS 10mL PF Inj,8724129,CDM,258,RC,,,,,facility,outpatient,,,40.52000,11.75000,Aetna,Local,,20.57,,,,,,,14.61,33.15,percent of total billed charges,
Water For Inj 10mL I,8723393,CDM,258,RC,A4216,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,0.63000,20.45,percent of total billed charges,
NEOnatal TPN Starter Bag,8726082,CDM,258,RC,,,,,facility,outpatient,,,213.00000,61.77000,Aetna,Local,,108.14,,,,,,,76.79,174.23,percent of total billed charges,
D50W 50mL,8723573,CDM,258,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,18.02,40.90,percent of total billed charges,
NICU- NEOnatal TPN Infusion,8724910,CDM,258,RC,,,,,facility,outpatient,,,836.80000,242.67000,Aetna,Local,,424.84,,,,,,,301.67,684.50,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),8724905,CDM,258,RC,A4216,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,0.63000,20.45,percent of total billed charges,
0.45% Sodium Cl 250mL,8724936,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,36.05,81.80,percent of total billed charges,
IV Infusion Sequential Drug,9094166,CDM,260,RC,96367,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,62.50,305.93,percent of total billed charges,
IV Infusion First Drug Each Hour,9092696,CDM,260,RC,96366,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,40.51,305.93,percent of total billed charges,
IV Infusion Concurrent Drug,9094167,CDM,260,RC,96368,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,134.83,305.93,percent of total billed charges,
IV Push Additional drug,9094168,CDM,260,RC,96375,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,Local,,189.37,,,,,,,40.51,305.11,percent of total billed charges,
Hydration IV Infusion Each Hour,9094170,CDM,260,RC,96361,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,40.51,305.93,percent of total billed charges,
IV Infusion Initial First Hour,9092745,CDM,260,RC,96365,HCPCS,,,facility,outpatient,,,662.00000,191.98000,Aetna,Local,,336.10,,,,,,,185.00,562.35,percent of total billed charges,
IV Push Sequential,9094169,CDM,260,RC,96376,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,Local,,189.37,,,,,,,134.47,305.11,percent of total billed charges,
Initial IV Hydration First Hour,9094312,CDM,260,RC,96360,HCPCS,,,facility,outpatient,,,575.00000,166.75000,Aetna,Local,,291.93,,,,,,,185.00,562.35,percent of total billed charges,
IV Push Initial,9092748,CDM,260,RC,96374,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,Local,,335.59,,,,,,,185.00,562.35,percent of total billed charges,
IV Infusion 8Hrs Or More,9092697,CDM,260,RC,C8957,HCPCS,,,facility,outpatient,,,2936.00000,851.44000,Aetna,Local,,1490.61,,,,,,,213.05,2401.65,percent of total billed charges,
IV Infusion Initial Of Pts Own,9094171,CDM,260,RC,96365,HCPCS,,,facility,outpatient,,,662.00000,191.98000,Aetna,Local,FB,336.10,,,,,,,185.00,562.35,percent of total billed charges,
IV Infusion Ea Hr Of Pts Own Med,9094314,CDM,260,RC,96366,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,FB,189.88,,,,,,,40.51,305.93,percent of total billed charges,
IV Infusion Sequent Of Pts Own,9092746,CDM,260,RC,96367,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,FB,189.88,,,,,,,62.50,305.93,percent of total billed charges,
IV Infusion Concurrent Of Pts Own,9092747,CDM,260,RC,96368,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,FB,189.88,,,,,,,134.83,305.93,percent of total billed charges,
IV Infusion 8Hrs Of Pts Own Med,9094320,CDM,260,RC,C8957,HCPCS,,,facility,outpatient,,,2295.00000,665.55000,Aetna,Local,,1165.17,,,,,,,213.05,1877.31,percent of total billed charges,
IV Push Initial Of Pts Own Med,9094172,CDM,260,RC,96374,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,Local,FB,335.59,,,,,,,185.00,562.35,percent of total billed charges,
IV Push Of Pts Own Med,9094315,CDM,260,RC,96375,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,Local,FB,189.37,,,,,,,40.51,305.11,percent of total billed charges,
IV Push Sequential of Pts Own Med,9092749,CDM,260,RC,96376,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,Local,FB,189.37,,,,,,,134.47,305.11,percent of total billed charges,
Irrigate Implanted Delivery Device Not pre or post injection,8997081,CDM,260,RC,96523,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,52.15,213.50,percent of total billed charges,
Irrigate Implanted Delivery Device,8999394,CDM,260,RC,96523,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,52.15,213.50,percent of total billed charges,
PROGRAMMER,7697116,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,2087.92,,,,,,,1482.56,3364.03,percent of total billed charges,
CHARGING SYSTEM,7695290,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,3731.59,,,,,,,2113.62,6012.30,percent of total billed charges,
CHARGING SYSTEM,7969749,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,5465.25000,1584.92000,Aetna,Local,,2774.71,,,,,,,1970.22,4470.57,percent of total billed charges,
PROGRAMMER,7736629,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,934.17,,,,,,,663.32,1505.12,percent of total billed charges,
PROGRAMMER,7924581,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,2176.76,,,,,,,1545.64,3507.18,percent of total billed charges,
INTERSTIM PROGRAMMER,7968188,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,4952.50000,1436.22000,Aetna,Local,,2514.38,,,,,,,1785.38,4051.14,percent of total billed charges,
CATHETER DILATOR,7965295,CDM,270,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,330.50,,,,,,,234.67,532.49,percent of total billed charges,
CHARGING SYSTEM IN KIT,8339348,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,56246.00000,16311.34000,Aetna,Local,,28556.09,,,,,,,2113.62,46009.23,percent of total billed charges,
ROD,8437301,CDM,270,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,629.55,,,,,,,447.02,1014.32,percent of total billed charges,
RECHARGER,9084224,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,5465.25000,1584.92000,Aetna,Local,,2774.71,,,,,,,1970.22,4470.57,percent of total billed charges,
SCREW TORX,9093619,CDM,270,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,331.27,,,,,,,235.23,533.75,percent of total billed charges,
Catheter 5fr,9082639,CDM,270,RC,C1887,HCPCS,,,facility,outpatient,,,88.52000,25.67000,Aetna,Local,,44.94,,,,,,,31.91,72.41,percent of total billed charges,
Catheter 12fr,9098580,CDM,270,RC,C1887,HCPCS,,,facility,outpatient,,,28732.50000,8332.42000,Aetna,Local,,14587.49,,,,,,,10358.07,23503.19,percent of total billed charges,
CAPSULE PILLCAM ENDOSCOPY SB 3,7694336,CDM,272,RC,,,,,facility,outpatient,,,2604.40000,755.28000,Aetna,Local,,1322.25,,,,,,,938.89,2130.40,percent of total billed charges,
MORCELLATOR,7696744,CDM,272,RC,C1782,HCPCS,,,facility,outpatient,,,2426.60000,703.71000,Aetna,Local,,1231.98,,,,,,,874.79,1984.96,percent of total billed charges,
MORCELLATOR,8328437,CDM,272,RC,C1782,HCPCS,,,facility,outpatient,,,1841.91000,534.15000,Aetna,Local,,935.14,,,,,,,664.01,1506.68,percent of total billed charges,
HEMOSPRAY,8170766,CDM,272,RC,C1052,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,4645.45,,,,,,,3298.57,7484.70,percent of total billed charges,
HEMOSPRAY,8170767,CDM,272,RC,C1052,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,4645.45,,,,,,,3298.57,7484.70,percent of total billed charges,
INCISION MANAGEMENT,7972134,CDM,272,RC,A6550,HCPCS,,,facility,outpatient,,,2676.00000,776.04000,Aetna,Local,,1358.61,,,,,,,31.78,2188.97,percent of total billed charges,
MORCELLATOR,8168049,CDM,272,RC,C1782,HCPCS,,,facility,outpatient,,,1220.00000,353.80000,Aetna,Local,,619.39,,,,,,,439.81,997.96,percent of total billed charges,
HANDPIECE,8950540,CDM,272,RC,C2596,HCPCS,,,facility,outpatient,,,12720.00000,3688.80000,Aetna,Local,,6457.94,,,,,,,4585.56,10404.96,percent of total billed charges,
KIT PROCEDURE MILD,7695188,CDM,272,RC,C1889,HCPCS,,,facility,outpatient,,,12579.00000,3647.91000,Aetna,Local,,6386.36,,,,,,,4534.73,10289.62,percent of total billed charges,
HEMOSTATIC NEXPOWDER,9012618,CDM,272,RC,C1052,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,Local,,1826.70,,,,,,,1297.08,2943.16,percent of total billed charges,
Catheter Mapping,9088702,CDM,272,RC,C1730,HCPCS,,,facility,outpatient,,,756.00000,219.24000,Aetna,Local,,9357.00,,,,,,,272.54,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Introducer,9091167,CDM,272,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,Local,,1828.48,,,,,,,1298.34,2946.03,percent of total billed charges,
Catheter,9088876,CDM,272,RC,C1733,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,9357.00,,,,,,,519.12,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9088875,CDM,272,RC,C1887,HCPCS,,,facility,outpatient,,,3220.00000,933.80000,Aetna,Local,,1634.79,,,,,,,1160.81,2633.96,percent of total billed charges,
KIT PROCEDURE MILD,9098522,CDM,272,RC,C1889,HCPCS,,,facility,outpatient,,,12579.00000,3647.91000,Aetna,Local,,6386.36,,,,,,,4534.73,10289.62,percent of total billed charges,
PROBE,9180595,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,2276.00000,660.04000,Aetna,Local,,1155.53,,,,,,,820.50,1861.77,percent of total billed charges,
Ablation Antenna,9184498,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,Local,,4028.60,,,,,,,2860.57,6490.83,percent of total billed charges,
Ablation Antenna,9182903,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,Local,,4028.60,,,,,,,2860.57,6490.83,percent of total billed charges,
Ablation Needle,9196884,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,Local,,4028.60,,,,,,,2860.57,6490.83,percent of total billed charges,
Enteral Feeding Tube Declogging Kit,9074404,CDM,272,RC,,,,,facility,outpatient,,,112.00000,32.48000,Aetna,Local,,56.86,,,,,,,40.38,91.62,percent of total billed charges,
OTS Orthotic Elbow Static Custom,4922320,CDM,274,RC,L3702,HCPCS,,,facility,outpatient,,,523.00000,151.67000,Aetna,Local,,209.20,,,,,,,168.41,427.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Elbow Dynamic Custom,4922323,CDM,274,RC,L3730,HCPCS,,,facility,outpatient,,,1171.00000,339.59000,Aetna,Local,,468.40,,,,,,,377.06,1207.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Elbow Wrist Hand Sta,4922326,CDM,274,RC,L3763,HCPCS,,,facility,outpatient,,,798.00000,231.42000,Aetna,Local,,319.20,,,,,,,256.96,790.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Splint Hand Wrist Elbow Dynamic Units,8185135,CDM,274,RC,L3763,HCPCS,,,facility,outpatient,,,798.00000,231.42000,Aetna,Local,,319.20,,,,,,,256.96,790.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Elbow Wrist Hand Dyn,4922329,CDM,274,RC,L3764,HCPCS,,,facility,outpatient,,,838.00000,243.02000,Aetna,Local,,335.20,,,,,,,269.84,830.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Splint Hand Wrist Elbow Static Units,8185127,CDM,274,RC,L3764,HCPCS,,,facility,outpatient,,,838.00000,243.02000,Aetna,Local,,335.20,,,,,,,269.84,830.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Finger Static Custom,4922332,CDM,274,RC,L3808,HCPCS,,,facility,outpatient,,,428.00000,124.12000,Aetna,Local,,171.20,,,,,,,137.82,382.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Finger Dynamic Custom,4922335,CDM,274,RC,L3806,HCPCS,,,facility,outpatient,,,728.00000,211.12000,Aetna,Local,,291.20,,,,,,,234.42,595.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Static Custom,4922338,CDM,274,RC,L3906,HCPCS,,,facility,outpatient,,,453.00000,131.37000,Aetna,Local,,181.20,,,,,,,145.87,449.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Dynam Custom,4922321,CDM,274,RC,L3905,HCPCS,,,facility,outpatient,,,1060.00000,307.40000,Aetna,Local,,424.00,,,,,,,341.32,1103.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Stat Cu,4922324,CDM,274,RC,L3913,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,Local,,148.00,,,,,,,119.14,302.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Dynamic,4922327,CDM,274,RC,L3921,HCPCS,,,facility,outpatient,,,596.00000,172.84000,Aetna,Local,,238.40,,,,,,,191.91,487.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Static Custom,4922330,CDM,274,RC,L3919,HCPCS,,,facility,outpatient,,,304.00000,88.16000,Aetna,Local,,121.60,,,,,,,97.89,301.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Static Custom,4922333,CDM,274,RC,L3933,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,Local,,96.00,,,,,,,77.28,237.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Dynamic Cust,4922336,CDM,274,RC,L3935,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,Local,,106.80,,,,,,,85.97,245.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Ankle Foot Stat Cus,4922339,CDM,274,RC,L1940,HCPCS,,,facility,outpatient,,,535.00000,155.15000,Aetna,Local,,214.00,,,,,,,172.27,622.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Shoulder Prefab,4922322,CDM,274,RC,L3670,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,62.00,,,,,,,49.91,169.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Finger Prefab,4922325,CDM,274,RC,L3807,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,Local,,112.40,,,,,,,90.48,278.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Prefab,4922328,CDM,274,RC,L3908,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,Local,,30.40,,,,,,,24.47,68.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Glove Pr,4922331,CDM,274,RC,L3912,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,Local,,53.60,,,,,,,43.15,131.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Prefab,4922334,CDM,274,RC,L3923,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,Local,,53.60,,,,,,,43.15,109.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Prefab Static,4922337,CDM,274,RC,L3927,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,Local,,30.40,,,,,,,24.47,62.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Prefab Dyn,4922340,CDM,274,RC,L3925,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,Local,,101.20,,,,,,,71.46,206.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Orthotic Thumb Spica,8235904,CDM,274,RC,L3809,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,104.00,,,,,,,83.72,278.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Orthotic Ulnar Drift,8235912,CDM,274,RC,L3917,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,48.80,,,,,,,39.28,117.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Orthotic Cool Comfort,8235908,CDM,274,RC,L3924,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,Local,,37.60,,,,,,,30.27,99.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Humerus,8282801,CDM,274,RC,L3671,HCPCS,,,facility,outpatient,,,1680.00000,487.20000,Aetna,Local,,672.00,,,,,,,540.96,1374.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9116839,CDM,275,RC,C1713,HCPCS,,,facility,outpatient,,,3810.21000,1104.96000,Aetna,Local,,1524.08,,,,,,,1226.89,3116.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER URETERAL,7694745,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1384.72000,401.57000,Aetna,Local,,553.89,,,,,,,499.19,1132.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER URETERAL,7694745,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1384.72000,401.57000,Aetna,Local,,553.89,,,,,,,445.88,1132.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lead Pacemaker,8063006,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lead Pacemaker,8063006,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8400632,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8400632,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE GRAFT DURAL,7694890,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,3527.83000,1023.07000,Aetna,Local,,1411.13,,,,,,,1271.78,2885.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE GRAFT DURAL,7694890,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,3527.83000,1023.07000,Aetna,Local,,1411.13,,,,,,,1135.96,2885.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STRAIT,7694566,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2347.00000,680.63000,Aetna,Local,,938.80,,,,,,,846.09,1919.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STRAIT,7694566,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2347.00000,680.63000,Aetna,Local,,938.80,,,,,,,755.73,1919.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,7694927,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,7694927,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695001,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695001,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702887,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,134.40000,38.98000,Aetna,Local,,53.76,,,,,,,48.45,109.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702887,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,134.40000,38.98000,Aetna,Local,,53.76,,,,,,,43.28,109.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 90,7695079,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,7539.00000,2186.31000,Aetna,Local,,3015.60,,,,,,,2717.81,6166.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 90,7695079,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,7539.00000,2186.31000,Aetna,Local,,3015.60,,,,,,,2427.56,6166.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695074,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2936.27,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695074,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2622.69,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696776,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1532.00000,444.28000,Aetna,Local,,612.80,,,,,,,552.29,1253.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696776,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1532.00000,444.28000,Aetna,Local,,612.80,,,,,,,493.30,1253.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,666.58,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,595.39,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135822,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135822,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135823,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,432.25000,125.35000,Aetna,Local,,172.90,,,,,,,155.83,353.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135823,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,432.25000,125.35000,Aetna,Local,,172.90,,,,,,,139.18,353.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135722,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135722,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135647,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135647,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696334,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696334,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696341,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696341,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8151668,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8151668,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696710,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2891.42000,838.51000,Aetna,Local,,1156.57,,,,,,,1042.36,2365.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696710,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2891.42000,838.51000,Aetna,Local,,1156.57,,,,,,,931.04,2365.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7702795,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7702795,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694998,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,792.00000,229.68000,Aetna,Local,,316.80,,,,,,,285.52,647.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694998,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,Local,,316.80,,,,,,,255.02,647.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7695317,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7695317,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7695970,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2705.91000,784.71000,Aetna,Local,,1082.36,,,,,,,975.48,2213.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7695970,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2705.91000,784.71000,Aetna,Local,,1082.36,,,,,,,871.30,2213.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSSPHENOIDAL SELLAR IMPLANT,7696666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2455.20000,712.01000,Aetna,Local,,982.08,,,,,,,885.10,2008.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSSPHENOIDAL SELLAR IMPLANT,7696666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2455.20000,712.01000,Aetna,Local,,982.08,,,,,,,790.57,2008.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693596,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,Local,,584.00,,,,,,,526.33,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693596,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,Local,,584.00,,,,,,,470.12,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SWAN,7695755,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2532.48000,734.42000,Aetna,Local,,1012.99,,,,,,,912.96,2071.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SWAN,7695755,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2532.48000,734.42000,Aetna,Local,,1012.99,,,,,,,815.46,2071.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695042,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695042,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7694368,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,368.13000,106.76000,Aetna,Local,,147.25,,,,,,,132.71,301.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7694368,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,368.13000,106.76000,Aetna,Local,,147.25,,,,,,,118.54,301.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7694367,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,Local,,134.90,,,,,,,121.58,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7694367,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,Local,,134.90,,,,,,,108.59,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7699403,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,789.08000,228.83000,Aetna,Local,,315.63,,,,,,,284.46,645.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7699403,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,789.08000,228.83000,Aetna,Local,,315.63,,,,,,,254.08,645.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694918,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4857.30000,1408.62000,Aetna,Local,,1942.92,,,,,,,1751.06,3973.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694918,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4857.30000,1408.62000,Aetna,Local,,1942.92,,,,,,,1564.05,3973.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695671,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,375.25000,108.82000,Aetna,Local,,150.10,,,,,,,135.28,306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695671,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,375.25000,108.82000,Aetna,Local,,150.10,,,,,,,120.83,306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694747,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,175.35000,50.85000,Aetna,Local,,70.14,,,,,,,63.21,143.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694747,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,175.35000,50.85000,Aetna,Local,,70.14,,,,,,,56.46,143.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695038,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,680.76000,197.42000,Aetna,Local,,272.30,,,,,,,245.41,556.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695038,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,680.76000,197.42000,Aetna,Local,,272.30,,,,,,,219.20,556.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696705,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,616.32000,178.73000,Aetna,Local,,246.53,,,,,,,222.18,504.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696705,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,616.32000,178.73000,Aetna,Local,,246.53,,,,,,,198.46,504.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694067,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,724.95000,210.24000,Aetna,Local,,289.98,,,,,,,261.34,593.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694067,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,724.95000,210.24000,Aetna,Local,,289.98,,,,,,,233.43,593.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694321,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2211.76000,641.41000,Aetna,Local,,884.70,,,,,,,797.34,1809.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694321,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2211.76000,641.41000,Aetna,Local,,884.70,,,,,,,712.19,1809.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696737,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4047.59000,1173.80000,Aetna,Local,,1619.04,,,,,,,1459.16,3310.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696737,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4047.59000,1173.80000,Aetna,Local,,1619.04,,,,,,,1303.32,3310.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696738,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1968.07000,570.74000,Aetna,Local,,787.23,,,,,,,709.49,1609.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696738,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1968.07000,570.74000,Aetna,Local,,787.23,,,,,,,633.72,1609.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702876,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2370.56000,687.46000,Aetna,Local,,948.22,,,,,,,854.59,1939.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702876,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2370.56000,687.46000,Aetna,Local,,948.22,,,,,,,763.32,1939.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7694438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,Local,,722.00,,,,,,,650.70,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7694438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,Local,,722.00,,,,,,,581.21,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1861.44000,539.82000,Aetna,Local,,744.58,,,,,,,671.05,1522.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1861.44000,539.82000,Aetna,Local,,744.58,,,,,,,599.38,1522.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7702856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,Local,,1673.00,,,,,,,1507.79,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7702856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,Local,,1673.00,,,,,,,1346.77,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,694.54,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,620.37,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON ACHILLES,7702911,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8651.37000,2508.90000,Aetna,Local,,3460.55,,,,,,,3118.82,7076.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON ACHILLES,7702911,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8651.37000,2508.90000,Aetna,Local,,3460.55,,,,,,,2785.74,7076.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7741660,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7741660,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7696453,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16502.08000,4785.60000,Aetna,Local,,6600.83,,,,,,,5949.00,13498.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7696453,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16502.08000,4785.60000,Aetna,Local,,6600.83,,,,,,,5313.67,13498.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7702855,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22795.38000,6610.66000,Aetna,Local,,9118.15,,,,,,,8217.73,18646.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7702855,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22795.38000,6610.66000,Aetna,Local,,9118.15,,,,,,,7340.11,18646.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT ROPE,7702857,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8965.17000,2599.90000,Aetna,Local,,3586.07,,,,,,,3231.94,7333.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT ROPE,7702857,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8965.17000,2599.90000,Aetna,Local,,3586.07,,,,,,,2886.78,7333.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696265,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,4634.42000,1343.98000,Aetna,Local,,1853.77,,,,,,,1670.71,3790.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696265,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,4634.42000,1343.98000,Aetna,Local,,1853.77,,,,,,,1492.28,3790.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7702702,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,2097.03,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7702702,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,1873.07,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695595,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,545.40000,158.17000,Aetna,Local,,218.16,,,,,,,196.62,446.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695595,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,545.40000,158.17000,Aetna,Local,,218.16,,,,,,,175.62,446.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702798,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,222.77,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702798,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,198.98,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7694049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,395.68000,114.75000,Aetna,Local,,158.27,,,,,,,142.64,323.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7694049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,395.68000,114.75000,Aetna,Local,,158.27,,,,,,,127.41,323.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694068,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,815.85000,236.60000,Aetna,Local,,326.34,,,,,,,294.11,667.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694068,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,815.85000,236.60000,Aetna,Local,,326.34,,,,,,,262.70,667.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RETRIEVAL DEVICE,7694844,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,Local,,587.60,,,,,,,529.57,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RETRIEVAL DEVICE,7694844,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,Local,,587.60,,,,,,,473.02,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7694647,CDM,278,RC,,,,,facility,inpatient,,,340.61000,98.78000,Aetna,Local,,136.24,,,,,,,122.79,278.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7694647,CDM,278,RC,,,,,facility,outpatient,,,340.61000,98.78000,Aetna,Local,,136.24,,,,,,,109.68,278.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7703364,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,1432.00000,415.28000,Aetna,Local,,572.80,,,,,,,516.24,1171.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7703364,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,1432.00000,415.28000,Aetna,Local,,572.80,,,,,,,461.10,1171.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695655,CDM,278,RC,C1877,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695655,CDM,278,RC,C1877,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,375.11000,108.78000,Aetna,Local,,150.04,,,,,,,135.23,306.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,375.11000,108.78000,Aetna,Local,,150.04,,,,,,,120.79,306.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING,7695670,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,7505.27000,2176.53000,Aetna,Local,,3002.11,,,,,,,2705.65,6139.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING,7695670,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,7505.27000,2176.53000,Aetna,Local,,3002.11,,,,,,,2416.70,6139.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1544.00000,447.76000,Aetna,Local,,617.60,,,,,,,556.61,1262.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1544.00000,447.76000,Aetna,Local,,617.60,,,,,,,497.17,1262.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,7696140,CDM,278,RC,,,,,facility,inpatient,,,2230.00000,646.70000,Aetna,Local,,892.00,,,,,,,803.91,1824.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,7696140,CDM,278,RC,,,,,facility,outpatient,,,2230.00000,646.70000,Aetna,Local,,892.00,,,,,,,718.06,1824.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RENAL DILATOR,7694500,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1423.24000,412.74000,Aetna,Local,,569.30,,,,,,,513.08,1164.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RENAL DILATOR,7694500,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1423.24000,412.74000,Aetna,Local,,569.30,,,,,,,458.28,1164.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694846,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1902.32000,551.67000,Aetna,Local,,760.93,,,,,,,685.79,1556.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694846,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1902.32000,551.67000,Aetna,Local,,760.93,,,,,,,612.55,1556.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEPRA FILM,7694879,CDM,278,RC,C1765,HCPCS,,,facility,inpatient,,,1904.50000,552.30000,Aetna,Local,,761.80,,,,,,,686.57,1557.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEPRA FILM,7694879,CDM,278,RC,C1765,HCPCS,,,facility,outpatient,,,1904.50000,552.30000,Aetna,Local,,761.80,,,,,,,613.25,1557.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7703356,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,Local,,2471.00,,,,,,,2226.99,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7703356,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,Local,,2471.00,,,,,,,1989.15,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE MYRINGOTOMY,7696094,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,148.74000,43.13000,Aetna,Local,,59.50,,,,,,,53.62,121.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE MYRINGOTOMY,7696094,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,148.74000,43.13000,Aetna,Local,,59.50,,,,,,,47.89,332.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697045,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697045,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696938,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,913.59000,264.94000,Aetna,Local,,365.44,,,,,,,329.35,747.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696938,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,913.59000,264.94000,Aetna,Local,,365.44,,,,,,,294.18,747.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696119,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1951.93,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696119,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1743.47,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7736634,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,336.30000,97.53000,Aetna,Local,,134.52,,,,,,,121.24,275.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7736634,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,336.30000,97.53000,Aetna,Local,,134.52,,,,,,,108.29,275.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696876,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696876,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7693894,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,311.13000,90.23000,Aetna,Local,,124.45,,,,,,,112.16,254.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7693894,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,311.13000,90.23000,Aetna,Local,,124.45,,,,,,,100.18,254.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694066,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,716.27000,207.72000,Aetna,Local,,286.51,,,,,,,258.22,585.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694066,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,716.27000,207.72000,Aetna,Local,,286.51,,,,,,,230.64,585.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7696284,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1592.60000,461.85000,Aetna,Local,,637.04,,,,,,,574.13,1302.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7696284,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1592.60000,461.85000,Aetna,Local,,637.04,,,,,,,512.82,1302.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP,7695396,CDM,278,RC,C1772,HCPCS,,,facility,inpatient,,,31810.50000,9225.04000,Aetna,Local,,12724.20,,,,,,,11467.69,26020.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP,7695396,CDM,278,RC,C1772,HCPCS,,,facility,outpatient,,,31810.50000,9225.04000,Aetna,Local,,12724.20,,,,,,,10242.98,26020.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697085,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15710.00000,4555.90000,Aetna,Local,,6284.00,,,,,,,5663.45,12850.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697085,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15710.00000,4555.90000,Aetna,Local,,6284.00,,,,,,,5058.62,12850.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697114,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697114,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697120,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697120,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7702853,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,39656.25000,11500.31000,Aetna,Local,,15862.50,,,,,,,14296.08,32438.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7702853,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,39656.25000,11500.31000,Aetna,Local,,15862.50,,,,,,,12769.31,32438.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696458,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,918.00000,266.22000,Aetna,Local,,367.20,,,,,,,330.94,750.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696458,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,918.00000,266.22000,Aetna,Local,,367.20,,,,,,,295.60,750.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7696613,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8787.00000,2548.23000,Aetna,Local,,3514.80,,,,,,,3167.71,7187.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7696613,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8787.00000,2548.23000,Aetna,Local,,3514.80,,,,,,,2829.41,7187.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7697058,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2800.00000,812.00000,Aetna,Local,,1120.00,,,,,,,1009.40,2290.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7697058,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2800.00000,812.00000,Aetna,Local,,1120.00,,,,,,,901.60,2290.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694669,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,418.19000,121.28000,Aetna,Local,,167.28,,,,,,,150.76,342.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694669,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,418.19000,121.28000,Aetna,Local,,167.28,,,,,,,134.66,342.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7707512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7707512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOBUTTON,7697179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1596.00000,462.84000,Aetna,Local,,638.40,,,,,,,575.36,1305.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOBUTTON,7697179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1596.00000,462.84000,Aetna,Local,,638.40,,,,,,,513.91,1305.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOBUTTON,7697181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1928.00000,559.12000,Aetna,Local,,771.20,,,,,,,695.04,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOBUTTON,7697181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1928.00000,559.12000,Aetna,Local,,771.20,,,,,,,620.82,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,Local,,782.40,,,,,,,705.14,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,Local,,782.40,,,,,,,629.83,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697235,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,6125.00000,1776.25000,Aetna,Local,,2450.00,,,,,,,2208.06,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697235,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,6125.00000,1776.25000,Aetna,Local,,2450.00,,,,,,,1972.25,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,Local,,965.60,,,,,,,870.25,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,Local,,965.60,,,,,,,777.31,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694751,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1667.28000,483.51000,Aetna,Local,,666.91,,,,,,,601.05,1363.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694751,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1667.28000,483.51000,Aetna,Local,,666.91,,,,,,,536.86,1363.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697270,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697270,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696363,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,6123.99,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696363,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,5469.98,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694310,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694310,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696449,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,577.47000,167.47000,Aetna,Local,,230.99,,,,,,,208.18,472.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696449,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,577.47000,167.47000,Aetna,Local,,230.99,,,,,,,185.95,472.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7697323,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1294.00000,375.26000,Aetna,Local,,517.60,,,,,,,466.49,1058.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7697323,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1294.00000,375.26000,Aetna,Local,,517.60,,,,,,,416.67,1058.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7697322,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7697322,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1406.00000,407.74000,Aetna,Local,,562.40,,,,,,,506.86,1150.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1406.00000,407.74000,Aetna,Local,,562.40,,,,,,,452.73,1150.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1272.00000,368.88000,Aetna,Local,,508.80,,,,,,,458.56,1040.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1272.00000,368.88000,Aetna,Local,,508.80,,,,,,,409.58,1040.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7695108,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7695108,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,563.54000,163.43000,Aetna,Local,,225.42,,,,,,,203.16,460.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,563.54000,163.43000,Aetna,Local,,225.42,,,,,,,181.46,460.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4752.34000,1378.18000,Aetna,Local,,1900.94,,,,,,,1713.22,3887.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4752.34000,1378.18000,Aetna,Local,,1900.94,,,,,,,1530.25,3887.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697384,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697384,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,764.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697388,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697388,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2714.36000,787.16000,Aetna,Local,,1085.74,,,,,,,978.53,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2714.36000,787.16000,Aetna,Local,,1085.74,,,,,,,874.02,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,171.36000,49.69000,Aetna,Local,,68.54,,,,,,,61.78,140.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,171.36000,49.69000,Aetna,Local,,68.54,,,,,,,55.18,140.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER GLENOSPHERE REVERSE,7697434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER GLENOSPHERE REVERSE,7697434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697406,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697406,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,688.50000,199.66000,Aetna,Local,,275.40,,,,,,,248.20,563.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,688.50000,199.66000,Aetna,Local,,275.40,,,,,,,221.70,563.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697410,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1708.00000,495.32000,Aetna,Local,,683.20,,,,,,,615.73,1397.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697410,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1708.00000,495.32000,Aetna,Local,,683.20,,,,,,,549.98,1397.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696567,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696567,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8346.00000,2420.34000,Aetna,Local,,3338.40,,,,,,,3008.73,6827.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8346.00000,2420.34000,Aetna,Local,,3338.40,,,,,,,2687.41,6827.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695221,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695221,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695222,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695222,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135809,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135809,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135810,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135810,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135811,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135811,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER VENA CAVA,8135664,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5718.83000,1658.46000,Aetna,Local,,2287.53,,,,,,,2061.64,4678.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER VENA CAVA,8135664,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5718.83000,1658.46000,Aetna,Local,,2287.53,,,,,,,1841.46,4678.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6552.84000,1900.32000,Aetna,Local,,2621.14,,,,,,,2362.30,5360.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6552.84000,1900.32000,Aetna,Local,,2621.14,,,,,,,2110.01,5360.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697440,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,329.79000,95.64000,Aetna,Local,,131.92,,,,,,,118.89,269.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697440,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,329.79000,95.64000,Aetna,Local,,131.92,,,,,,,106.19,269.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694448,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,128.31000,37.21000,Aetna,Local,,51.32,,,,,,,46.26,104.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694448,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,128.31000,37.21000,Aetna,Local,,51.32,,,,,,,41.32,104.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7945880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8271.00000,2398.59000,Aetna,Local,,3308.40,,,,,,,2981.70,6765.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7945880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8271.00000,2398.59000,Aetna,Local,,3308.40,,,,,,,2663.26,6765.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7696663,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7696663,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697529,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,964.71000,279.77000,Aetna,Local,,385.88,,,,,,,347.78,789.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697529,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,964.71000,279.77000,Aetna,Local,,385.88,,,,,,,310.64,789.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693595,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,981.00000,284.49000,Aetna,Local,,392.40,,,,,,,353.65,802.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693595,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,981.00000,284.49000,Aetna,Local,,392.40,,,,,,,315.88,802.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697567,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,Local,,199.12,,,,,,,179.46,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697567,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,Local,,199.12,,,,,,,160.29,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697612,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2670.40000,774.42000,Aetna,Local,,1068.16,,,,,,,962.68,2184.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697612,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2670.40000,774.42000,Aetna,Local,,1068.16,,,,,,,859.87,2184.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SUBSTITUTE,7697640,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9877.35000,2864.43000,Aetna,Local,,3950.94,,,,,,,3560.78,8079.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SUBSTITUTE,7697640,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9877.35000,2864.43000,Aetna,Local,,3950.94,,,,,,,3180.51,8079.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5577.88000,1617.59000,Aetna,Local,,2231.15,,,,,,,2010.83,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5577.88000,1617.59000,Aetna,Local,,2231.15,,,,,,,1796.08,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697658,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3684.23000,1068.43000,Aetna,Local,,1473.69,,,,,,,1328.16,3013.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697658,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3684.23000,1068.43000,Aetna,Local,,1473.69,,,,,,,1186.32,3013.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697659,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2200.50000,638.14000,Aetna,Local,,880.20,,,,,,,793.28,1800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697659,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2200.50000,638.14000,Aetna,Local,,880.20,,,,,,,708.56,1800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697660,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4434.85000,1286.11000,Aetna,Local,,1773.94,,,,,,,1598.76,3627.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697660,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4434.85000,1286.11000,Aetna,Local,,1773.94,,,,,,,1428.02,3627.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1510.76000,438.12000,Aetna,Local,,604.30,,,,,,,544.63,1235.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1510.76000,438.12000,Aetna,Local,,604.30,,,,,,,486.46,1235.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1665.92000,483.12000,Aetna,Local,,666.37,,,,,,,600.56,1362.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1665.92000,483.12000,Aetna,Local,,666.37,,,,,,,536.43,1362.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER CERV,7702771,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER CERV,7702771,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697865,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1554.21000,450.72000,Aetna,Local,,621.68,,,,,,,560.29,1271.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697865,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1554.21000,450.72000,Aetna,Local,,621.68,,,,,,,500.46,1271.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7774084,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7774084,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7695683,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,741.19,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7695683,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,662.03,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7916959,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,729.36000,211.51000,Aetna,Local,,291.74,,,,,,,262.93,596.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7916959,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,729.36000,211.51000,Aetna,Local,,291.74,,,,,,,234.85,596.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2948.00000,854.92000,Aetna,Local,,1179.20,,,,,,,1062.75,2411.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2948.00000,854.92000,Aetna,Local,,1179.20,,,,,,,949.26,2411.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7697897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1843.60000,534.64000,Aetna,Local,,737.44,,,,,,,664.62,1508.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7697897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1843.60000,534.64000,Aetna,Local,,737.44,,,,,,,593.64,1508.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7697914,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3790.66,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7697914,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3385.83,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXPLOR HEAD,7697918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXPLOR HEAD,7697918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM AND SCREW,7697917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM AND SCREW,7697917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7697561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1871.68,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7697561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1671.79,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7697553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,3290.36,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7697553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,2938.96,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CORE REVISION,7697947,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4428.38000,1284.23000,Aetna,Local,,1771.35,,,,,,,1596.43,3622.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CORE REVISION,7697947,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4428.38000,1284.23000,Aetna,Local,,1771.35,,,,,,,1425.94,3622.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACL TIGHTROPE,7697360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,839.97,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACL TIGHTROPE,7697360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,750.26,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697950,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697950,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1173.43,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1048.11,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7697964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.72000,560.20000,Aetna,Local,,772.69,,,,,,,696.39,1580.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7697964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.72000,560.20000,Aetna,Local,,772.69,,,,,,,622.01,1580.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER,7697969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER,7697969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2498.00000,724.42000,Aetna,Local,,999.20,,,,,,,900.53,2043.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2498.00000,724.42000,Aetna,Local,,999.20,,,,,,,804.36,2043.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRUCIATE TIBIAL,7698010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3027.20000,877.89000,Aetna,Local,,1210.88,,,,,,,1091.31,2476.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRUCIATE TIBIAL,7698010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3027.20000,877.89000,Aetna,Local,,1210.88,,,,,,,974.76,2476.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10658.40000,3090.94000,Aetna,Local,,4263.36,,,,,,,3842.35,8718.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10658.40000,3090.94000,Aetna,Local,,4263.36,,,,,,,3432.00,8718.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1485.60000,430.82000,Aetna,Local,,594.24,,,,,,,535.56,1215.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1485.60000,430.82000,Aetna,Local,,594.24,,,,,,,478.36,1215.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2649.80000,768.44000,Aetna,Local,,1059.92,,,,,,,955.25,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2649.80000,768.44000,Aetna,Local,,1059.92,,,,,,,853.24,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,631.90,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,564.41,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRALIZER,7698167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRALIZER,7698167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT NECK LENGTH ADAPTER,7698168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT NECK LENGTH ADAPTER,7698168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT UNIPOLAR,7698169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT UNIPOLAR,7698169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,850.50000,246.64000,Aetna,Local,,340.20,,,,,,,306.61,695.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,850.50000,246.64000,Aetna,Local,,340.20,,,,,,,273.86,695.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696660,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,77.60,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696660,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,69.31,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7698195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7698195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1873.70,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1673.60,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR PATCH,7698211,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2196.00000,636.84000,Aetna,Local,,878.40,,,,,,,791.66,1796.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR PATCH,7698211,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2196.00000,636.84000,Aetna,Local,,878.40,,,,,,,707.11,1796.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,Local,,8400.00,,,,,,,7570.50,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,Local,,8400.00,,,,,,,6762.00,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7695982,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7695982,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696120,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,11175.00000,3240.75000,Aetna,Local,,4470.00,,,,,,,4028.59,9141.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696120,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,11175.00000,3240.75000,Aetna,Local,,4470.00,,,,,,,3598.35,9141.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7698231,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3381.00000,980.49000,Aetna,Local,,1352.40,,,,,,,1218.85,2765.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7698231,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3381.00000,980.49000,Aetna,Local,,1352.40,,,,,,,1088.68,2765.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1995.20000,578.61000,Aetna,Local,,798.08,,,,,,,719.27,1632.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1995.20000,578.61000,Aetna,Local,,798.08,,,,,,,642.45,1632.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7698226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7698226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BEARING,7698228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BEARING,7698228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,7698229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,7698229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,7698243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,7698243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1534.16,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1370.32,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP NECK ADAPTER,7698249,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,Local,,639.68,,,,,,,576.51,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP NECK ADAPTER,7698249,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,Local,,639.68,,,,,,,514.94,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7697849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1949.08000,565.23000,Aetna,Local,,779.63,,,,,,,702.64,1594.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7697849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1949.08000,565.23000,Aetna,Local,,779.63,,,,,,,627.60,1594.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695880,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695880,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697269,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697269,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7696310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,293.63,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7696310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,262.27,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO PUSHLOCK,7696346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,703.70,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO PUSHLOCK,7696346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,628.54,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698604,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,51.10,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698604,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,45.64,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698654,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,174.09000,50.49000,Aetna,Local,,69.64,,,,,,,62.76,142.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698654,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,174.09000,50.49000,Aetna,Local,,69.64,,,,,,,56.06,142.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,7696653,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,504.70,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,7696653,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,450.80,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8380724,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8380724,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6188.91000,1794.78000,Aetna,Local,,2475.56,,,,,,,2231.10,5062.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6188.91000,1794.78000,Aetna,Local,,2475.56,,,,,,,1992.83,5062.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING CAP,7698278,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,746.78000,216.57000,Aetna,Local,,298.71,,,,,,,269.21,610.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING CAP,7698278,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,746.78000,216.57000,Aetna,Local,,298.71,,,,,,,240.46,610.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3285.91000,952.91000,Aetna,Local,,1314.36,,,,,,,1184.57,2687.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3285.91000,952.91000,Aetna,Local,,1314.36,,,,,,,1058.06,2687.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3356.50000,973.38000,Aetna,Local,,1342.60,,,,,,,1210.02,2745.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3356.50000,973.38000,Aetna,Local,,1342.60,,,,,,,1080.79,2745.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7698335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7698335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694428,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694428,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3863.48000,1120.41000,Aetna,Local,,1545.39,,,,,,,1392.78,3160.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3863.48000,1120.41000,Aetna,Local,,1545.39,,,,,,,1244.04,3160.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7698362,CDM,278,RC,L8631,HCPCS,,,facility,inpatient,,,7443.00000,2158.47000,Aetna,Local,,2977.20,,,,,,,2683.20,6088.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7698362,CDM,278,RC,L8631,HCPCS,,,facility,outpatient,,,7443.00000,2158.47000,Aetna,Local,,2977.20,,,,,,,2396.65,6088.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,Local,,543.95,,,,,,,490.24,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,Local,,543.95,,,,,,,437.88,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1256.00000,364.24000,Aetna,Local,,502.40,,,,,,,452.79,1027.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1256.00000,364.24000,Aetna,Local,,502.40,,,,,,,404.43,1027.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7702780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2125.60000,616.42000,Aetna,Local,,850.24,,,,,,,766.28,1738.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7702780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2125.60000,616.42000,Aetna,Local,,850.24,,,,,,,684.44,1738.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7695386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,Local,,534.40,,,,,,,481.63,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7695386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,Local,,534.40,,,,,,,430.19,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,Local,,746.05,,,,,,,672.38,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,Local,,746.05,,,,,,,600.57,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6433.32000,1865.66000,Aetna,Local,,2573.33,,,,,,,2319.21,5262.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6433.32000,1865.66000,Aetna,Local,,2573.33,,,,,,,2071.53,5262.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,121.96000,35.37000,Aetna,Local,,48.78,,,,,,,43.97,99.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,121.96000,35.37000,Aetna,Local,,48.78,,,,,,,39.27,99.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1648.40000,478.04000,Aetna,Local,,659.36,,,,,,,594.25,1348.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1648.40000,478.04000,Aetna,Local,,659.36,,,,,,,530.78,1348.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1634.88000,474.12000,Aetna,Local,,653.95,,,,,,,589.37,1337.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1634.88000,474.12000,Aetna,Local,,653.95,,,,,,,526.43,1337.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,878.67000,254.81000,Aetna,Local,,351.47,,,,,,,316.76,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,878.67000,254.81000,Aetna,Local,,351.47,,,,,,,282.93,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2348.72000,681.13000,Aetna,Local,,939.49,,,,,,,846.71,1921.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2348.72000,681.13000,Aetna,Local,,939.49,,,,,,,756.29,1921.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2680.56000,777.36000,Aetna,Local,,1072.22,,,,,,,966.34,2192.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2680.56000,777.36000,Aetna,Local,,1072.22,,,,,,,863.14,2192.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2714.36000,787.16000,Aetna,Local,,1085.74,,,,,,,978.53,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2714.36000,787.16000,Aetna,Local,,1085.74,,,,,,,874.02,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698508,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20837.50000,6042.88000,Aetna,Local,,8335.00,,,,,,,7511.92,17045.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698508,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20837.50000,6042.88000,Aetna,Local,,8335.00,,,,,,,6709.68,17045.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702867,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,9312.00000,2700.48000,Aetna,Local,,3724.80,,,,,,,3356.98,7617.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702867,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,9312.00000,2700.48000,Aetna,Local,,3724.80,,,,,,,2998.46,7617.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695332,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695332,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.22000,1054.50000,Aetna,Local,,1454.49,,,,,,,1310.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.22000,1054.50000,Aetna,Local,,1454.49,,,,,,,1170.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,777.47000,225.47000,Aetna,Local,,310.99,,,,,,,280.28,635.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,777.47000,225.47000,Aetna,Local,,310.99,,,,,,,250.35,635.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698589,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698589,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 60,7695237,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,7539.00000,2186.31000,Aetna,Local,,3015.60,,,,,,,2717.81,6166.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 60,7695237,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,7539.00000,2186.31000,Aetna,Local,,3015.60,,,,,,,2427.56,6166.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7699269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14010.75000,4063.12000,Aetna,Local,,5604.30,,,,,,,5050.88,11460.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7699269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14010.75000,4063.12000,Aetna,Local,,5604.30,,,,,,,4511.46,11460.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7699090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7699090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7699249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7699249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TROCHANTERIC CLAW,7699101,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3698.10000,1072.45000,Aetna,Local,,1479.24,,,,,,,1333.17,3025.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TROCHANTERIC CLAW,7699101,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3698.10000,1072.45000,Aetna,Local,,1479.24,,,,,,,1190.79,3025.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7700811,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,533.11,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7700811,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,476.17,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7699108,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,873.00000,253.17000,Aetna,Local,,349.20,,,,,,,314.72,714.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7699108,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,873.00000,253.17000,Aetna,Local,,349.20,,,,,,,281.11,714.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7614.00000,2208.06000,Aetna,Local,,3045.60,,,,,,,2744.85,6228.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7614.00000,2208.06000,Aetna,Local,,3045.60,,,,,,,2451.71,6228.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,Local,,245.02,,,,,,,220.82,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,Local,,245.02,,,,,,,197.24,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695193,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695193,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7699135,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,Local,,994.72,,,,,,,896.49,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7699135,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,Local,,994.72,,,,,,,800.75,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7696942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1871.68,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7696942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1671.79,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1613.16000,467.82000,Aetna,Local,,645.26,,,,,,,581.54,1319.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1613.16000,467.82000,Aetna,Local,,645.26,,,,,,,519.44,1319.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3410.82000,989.14000,Aetna,Local,,1364.33,,,,,,,1229.60,2790.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3410.82000,989.14000,Aetna,Local,,1364.33,,,,,,,1098.28,2790.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5048.37000,1464.03000,Aetna,Local,,2019.35,,,,,,,1819.94,4129.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5048.37000,1464.03000,Aetna,Local,,2019.35,,,,,,,1625.58,4129.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.32000,1538.83000,Aetna,Local,,2122.53,,,,,,,1912.93,4340.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.32000,1538.83000,Aetna,Local,,2122.53,,,,,,,1708.64,4340.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699725,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1971.60000,571.76000,Aetna,Local,,788.64,,,,,,,710.76,1612.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699725,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1971.60000,571.76000,Aetna,Local,,788.64,,,,,,,634.86,1612.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.22000,1054.50000,Aetna,Local,,1454.49,,,,,,,1310.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.22000,1054.50000,Aetna,Local,,1454.49,,,,,,,1170.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBULAR SHAFT,7695784,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3121.80000,905.32000,Aetna,Local,,1248.72,,,,,,,1125.41,2553.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBULAR SHAFT,7695784,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3121.80000,905.32000,Aetna,Local,,1248.72,,,,,,,1005.22,2553.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,2052.78,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,1833.55,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,Local,,3699.60,,,,,,,3334.26,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,Local,,3699.60,,,,,,,2978.18,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,1065.64,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,951.83,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,794.54,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,709.69,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694402,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1352.00000,392.08000,Aetna,Local,,540.80,,,,,,,487.40,1105.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694402,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1352.00000,392.08000,Aetna,Local,,540.80,,,,,,,435.34,1105.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740529,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21567.50000,6254.58000,Aetna,Local,,8627.00,,,,,,,7775.08,17642.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740529,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21567.50000,6254.58000,Aetna,Local,,8627.00,,,,,,,6944.73,17642.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7699599,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,8306.10000,2408.77000,Aetna,Local,,3322.44,,,,,,,2994.35,6794.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7699599,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,8306.10000,2408.77000,Aetna,Local,,3322.44,,,,,,,2364.47,6794.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698235,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698235,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7699524,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,892.60,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7699524,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,797.27,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7697986,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7697986,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135831,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,1652.00000,479.08000,Aetna,Local,,660.80,,,,,,,595.55,1351.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135831,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,1652.00000,479.08000,Aetna,Local,,9357.00,,,,,,,531.94,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PLATE,7699218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,829.85000,240.66000,Aetna,Local,,331.94,,,,,,,299.16,678.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,829.85000,240.66000,Aetna,Local,,331.94,,,,,,,267.21,678.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7697463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5105.63000,1480.63000,Aetna,Local,,2042.25,,,,,,,1840.58,4176.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7697463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5105.63000,1480.63000,Aetna,Local,,2042.25,,,,,,,1644.01,4176.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694850,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1652.76000,479.30000,Aetna,Local,,661.10,,,,,,,595.82,1351.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694850,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1652.76000,479.30000,Aetna,Local,,661.10,,,,,,,532.19,1351.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS,7693559,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,414.92000,120.33000,Aetna,Local,,165.97,,,,,,,149.58,339.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS,7693559,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,414.92000,120.33000,Aetna,Local,,165.97,,,,,,,133.60,339.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7694362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,427.83000,124.07000,Aetna,Local,,171.13,,,,,,,154.23,349.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7694362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,427.83000,124.07000,Aetna,Local,,171.13,,,,,,,137.76,349.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,130.14,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,116.24,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694442,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694442,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BARRIER ADHESION,7694666,CDM,278,RC,C1765,HCPCS,,,facility,inpatient,,,2308.40000,669.44000,Aetna,Local,,923.36,,,,,,,832.18,1888.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BARRIER ADHESION,7694666,CDM,278,RC,C1765,HCPCS,,,facility,outpatient,,,2308.40000,669.44000,Aetna,Local,,923.36,,,,,,,743.30,1888.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7694853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1466.40000,425.26000,Aetna,Local,,586.56,,,,,,,528.64,1199.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7694853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1466.40000,425.26000,Aetna,Local,,586.56,,,,,,,472.18,1199.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7694896,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17859.38000,5179.22000,Aetna,Local,,7143.75,,,,,,,6438.31,14608.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7694896,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17859.38000,5179.22000,Aetna,Local,,7143.75,,,,,,,5750.72,14608.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7695394,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,29632.50000,8593.42000,Aetna,Local,,11853.00,,,,,,,10682.52,24239.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7695394,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,29632.50000,8593.42000,Aetna,Local,,11853.00,,,,,,,9541.67,24239.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,868.50000,251.86000,Aetna,Local,,347.40,,,,,,,313.09,710.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,868.50000,251.86000,Aetna,Local,,347.40,,,,,,,279.66,710.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696123,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8055.00000,2335.95000,Aetna,Local,,3222.00,,,,,,,2903.83,6588.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696123,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8055.00000,2335.95000,Aetna,Local,,3222.00,,,,,,,2593.71,6588.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696128,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,940.69000,272.80000,Aetna,Local,,376.28,,,,,,,339.12,769.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696128,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,940.69000,272.80000,Aetna,Local,,376.28,,,,,,,302.90,769.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696129,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,932.73000,270.49000,Aetna,Local,,373.09,,,,,,,336.25,762.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696129,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,932.73000,270.49000,Aetna,Local,,373.09,,,,,,,300.34,762.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135599,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135599,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135847,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135847,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135846,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135846,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135844,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135844,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135843,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135843,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135842,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135842,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135840,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135840,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE SYSTEM,8135849,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2806.72000,813.95000,Aetna,Local,,1122.69,,,,,,,1011.82,2295.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE SYSTEM,8135849,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2806.72000,813.95000,Aetna,Local,,1122.69,,,,,,,903.76,2295.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE GOOSENECK,8135850,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE GOOSENECK,8135850,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135469,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135469,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,Local,,9357.00,,,,,,,1110.10,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
GUIDE CATHETER,8135523,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135523,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135853,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135853,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135852,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135852,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135851,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135851,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP SET AIC IMPELLA,8135854,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,52000.00000,15080.00000,Aetna,Local,,20800.00,,,,,,,18746.00,42536.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP SET AIC IMPELLA,8135854,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,52000.00000,15080.00000,Aetna,Local,,20800.00,,,,,,,16744.00,42536.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135496,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135496,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2389.04000,692.82000,Aetna,Local,,955.62,,,,,,,861.25,1954.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2389.04000,692.82000,Aetna,Local,,955.62,,,,,,,769.27,1954.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1845.92000,535.32000,Aetna,Local,,738.37,,,,,,,665.45,1509.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1845.92000,535.32000,Aetna,Local,,738.37,,,,,,,594.39,1509.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7695520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1658.08000,480.84000,Aetna,Local,,663.23,,,,,,,597.74,1356.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7695520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1658.08000,480.84000,Aetna,Local,,663.23,,,,,,,533.90,1356.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699171,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699171,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7698172,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7698172,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694311,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694311,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7695606,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,6218.62,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7695606,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,5554.50,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.48000,143.40000,Aetna,Local,,197.79,,,,,,,178.26,404.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.48000,143.40000,Aetna,Local,,197.79,,,,,,,159.22,404.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7699315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17887.00000,5187.23000,Aetna,Local,,7154.80,,,,,,,6448.26,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7699315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17887.00000,5187.23000,Aetna,Local,,7154.80,,,,,,,5759.61,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7695587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7695587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7695590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7695590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,Local,,3099.36,,,,,,,2793.30,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,Local,,3099.36,,,,,,,2494.98,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7694881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,870.20,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7694881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,777.27,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15425.00000,4473.25000,Aetna,Local,,6170.00,,,,,,,5560.71,12617.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15425.00000,4473.25000,Aetna,Local,,6170.00,,,,,,,4966.85,12617.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2752.42,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2458.47,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1932.00000,560.28000,Aetna,Local,,772.80,,,,,,,696.49,1580.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1932.00000,560.28000,Aetna,Local,,772.80,,,,,,,622.10,1580.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7696939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3759.70000,1090.31000,Aetna,Local,,1503.88,,,,,,,1355.37,3075.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7696939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3759.70000,1090.31000,Aetna,Local,,1503.88,,,,,,,1210.62,3075.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5471.97000,1586.87000,Aetna,Local,,2188.79,,,,,,,1972.65,4476.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5471.97000,1586.87000,Aetna,Local,,2188.79,,,,,,,1761.97,4476.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2426.28000,703.62000,Aetna,Local,,970.51,,,,,,,874.67,1984.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2426.28000,703.62000,Aetna,Local,,970.51,,,,,,,781.26,1984.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7698918,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7698918,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1361.95,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1216.50,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2009.40000,582.73000,Aetna,Local,,803.76,,,,,,,724.39,1643.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2009.40000,582.73000,Aetna,Local,,803.76,,,,,,,647.03,1643.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7699428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7699428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8611.20000,2497.25000,Aetna,Local,,3444.48,,,,,,,3104.34,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8611.20000,2497.25000,Aetna,Local,,3444.48,,,,,,,2772.81,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3737.30000,1083.82000,Aetna,Local,,1494.92,,,,,,,1347.30,3057.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3737.30000,1083.82000,Aetna,Local,,1494.92,,,,,,,1203.41,3057.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7698527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17887.00000,5187.23000,Aetna,Local,,7154.80,,,,,,,6448.26,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7698527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17887.00000,5187.23000,Aetna,Local,,7154.80,,,,,,,5759.61,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6077.86000,1762.58000,Aetna,Local,,2431.14,,,,,,,2191.07,4971.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6077.86000,1762.58000,Aetna,Local,,2431.14,,,,,,,1957.07,4971.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699461,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699461,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7694389,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7694389,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.80000,359.83000,Aetna,Local,,496.32,,,,,,,447.31,1014.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.80000,359.83000,Aetna,Local,,496.32,,,,,,,399.54,1014.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5693.10000,1651.00000,Aetna,Local,,2277.24,,,,,,,2052.36,4656.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5693.10000,1651.00000,Aetna,Local,,2277.24,,,,,,,1833.18,4656.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7696190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,347.16,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7696190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,310.09,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2993.56000,868.13000,Aetna,Local,,1197.42,,,,,,,1079.18,2448.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2993.56000,868.13000,Aetna,Local,,1197.42,,,,,,,963.93,2448.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7695589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7695589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,Local,,1396.85,,,,,,,1258.91,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,Local,,1396.85,,,,,,,1124.47,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,7689.47,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,6868.26,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7699497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7699497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7699498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2812.98,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7699498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2512.57,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1549.73,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1384.23,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT DUODENAL,7695159,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT DUODENAL,7695159,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO ULTRA,7695245,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8142.00000,2361.18000,Aetna,Local,,3256.80,,,,,,,2935.19,6660.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO ULTRA,7695245,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8142.00000,2361.18000,Aetna,Local,,3256.80,,,,,,,2621.72,6660.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRASPING DEVICE TALON,7695186,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,720.00000,208.80000,Aetna,Local,,288.00,,,,,,,259.56,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRASPING DEVICE TALON,7695186,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,720.00000,208.80000,Aetna,Local,,288.00,,,,,,,231.84,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,7694306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.16000,352.69000,Aetna,Local,,486.46,,,,,,,438.43,994.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,7694306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.16000,352.69000,Aetna,Local,,486.46,,,,,,,391.60,994.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697453,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697453,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695081,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695081,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7768032,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7768032,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOCONVEX PATELLA,7768031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7665.00000,2222.85000,Aetna,Local,,3066.00,,,,,,,2763.23,6269.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOCONVEX PATELLA,7768031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7665.00000,2222.85000,Aetna,Local,,3066.00,,,,,,,2468.13,6269.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697309,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697309,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7694970,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7694970,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694386,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,774.00000,224.46000,Aetna,Local,,309.60,,,,,,,279.03,633.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694386,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,774.00000,224.46000,Aetna,Local,,309.60,,,,,,,249.23,633.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT INTRO,7695006,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT INTRO,7695006,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695192,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695192,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8148864,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8148864,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699512,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,Local,,1123.20,,,,,,,1012.28,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699512,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,Local,,1123.20,,,,,,,904.18,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699513,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,Local,,1501.50,,,,,,,1353.23,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699513,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,Local,,1501.50,,,,,,,1208.71,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699528,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,5515.65,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699528,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,4926.60,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7698027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,Local,,7344.00,,,,,,,6618.78,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7698027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,Local,,7344.00,,,,,,,5911.92,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7698618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7698618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699544,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,18652.27,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699544,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,16660.28,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699545,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,16524.24,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699545,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,14759.51,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1802.48000,522.72000,Aetna,Local,,720.99,,,,,,,649.79,1474.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1802.48000,522.72000,Aetna,Local,,720.99,,,,,,,580.40,1474.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1920.40000,556.92000,Aetna,Local,,768.16,,,,,,,692.30,1570.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1920.40000,556.92000,Aetna,Local,,768.16,,,,,,,618.37,1570.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699553,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2816.00000,816.64000,Aetna,Local,,1126.40,,,,,,,1015.17,2303.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699553,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2816.00000,816.64000,Aetna,Local,,1126.40,,,,,,,906.75,2303.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702688,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,3671.50000,1064.73000,Aetna,Local,,1468.60,,,,,,,1323.58,3003.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702688,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,3671.50000,1064.73000,Aetna,Local,,1468.60,,,,,,,1182.22,3003.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,958.50000,277.96000,Aetna,Local,,383.40,,,,,,,345.54,784.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,958.50000,277.96000,Aetna,Local,,383.40,,,,,,,308.64,784.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8144.13000,2361.80000,Aetna,Local,,3257.65,,,,,,,2935.96,6661.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8144.13000,2361.80000,Aetna,Local,,3257.65,,,,,,,2622.41,6661.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1580.00000,458.20000,Aetna,Local,,632.00,,,,,,,569.59,1292.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1580.00000,458.20000,Aetna,Local,,632.00,,,,,,,508.76,1292.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1566.60000,454.31000,Aetna,Local,,626.64,,,,,,,564.76,1281.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1566.60000,454.31000,Aetna,Local,,626.64,,,,,,,504.45,1281.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,302.94,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,270.59,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698144,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698144,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6862.61,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6129.71,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1894.12000,549.29000,Aetna,Local,,757.65,,,,,,,682.83,1549.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1894.12000,549.29000,Aetna,Local,,757.65,,,,,,,609.91,1549.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699644,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699644,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7698401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,5416.16,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7698401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,4837.74,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7699107,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7699107,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,742.63,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,663.32,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699703,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,118.15,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699703,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,105.54,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7407.00000,2148.03000,Aetna,Local,,2962.80,,,,,,,2670.22,6058.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7407.00000,2148.03000,Aetna,Local,,2962.80,,,,,,,2385.05,6058.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7697285,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7697285,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7697960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,Local,,1208.00,,,,,,,1088.71,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7697960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,Local,,1208.00,,,,,,,972.44,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1173.43,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1048.11,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697096,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697096,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7699764,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7699764,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.68000,235.10000,Aetna,Local,,324.27,,,,,,,292.25,663.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.68000,235.10000,Aetna,Local,,324.27,,,,,,,261.04,663.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,802.11,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,716.45,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7699792,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7699792,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699799,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699799,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7699809,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,1957.20000,567.59000,Aetna,Local,,782.88,,,,,,,705.57,1600.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7699809,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,1957.20000,567.59000,Aetna,Local,,782.88,,,,,,,630.22,1600.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699841,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699841,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7699822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8932.50000,2590.42000,Aetna,Local,,3573.00,,,,,,,3220.17,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7699822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8932.50000,2590.42000,Aetna,Local,,3573.00,,,,,,,2876.26,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893608,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893608,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7893610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4673.59000,1355.34000,Aetna,Local,,1869.44,,,,,,,1684.83,3823.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7893610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4673.59000,1355.34000,Aetna,Local,,1869.44,,,,,,,1504.90,3823.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695623,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695623,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7893958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1820.00000,527.80000,Aetna,Local,,728.00,,,,,,,656.11,1488.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7893958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1820.00000,527.80000,Aetna,Local,,728.00,,,,,,,586.04,1488.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE CRYOABLATION,7852029,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3460.80,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE CRYOABLATION,7852029,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3091.20,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE CRYOABLATION,7694870,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,11280.00000,3271.20000,Aetna,Local,,4512.00,,,,,,,4066.44,9227.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE CRYOABLATION,7694870,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,11280.00000,3271.20000,Aetna,Local,,4512.00,,,,,,,3632.16,9227.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,582.57,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,520.35,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7894125,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,906.12000,262.77000,Aetna,Local,,362.45,,,,,,,326.66,741.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7894125,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,906.12000,262.77000,Aetna,Local,,362.45,,,,,,,291.77,741.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,7894202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,7894202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,7894203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14700.00000,4263.00000,Aetna,Local,,5880.00,,,,,,,5299.35,12024.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,7894203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14700.00000,4263.00000,Aetna,Local,,5880.00,,,,,,,4733.40,12024.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699120,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,230.78000,66.93000,Aetna,Local,,92.31,,,,,,,83.20,188.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699120,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,230.78000,66.93000,Aetna,Local,,92.31,,,,,,,74.31,188.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2078.68000,602.82000,Aetna,Local,,831.47,,,,,,,749.36,1700.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2078.68000,602.82000,Aetna,Local,,831.47,,,,,,,669.33,1700.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,Local,,740.85,,,,,,,667.69,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,Local,,740.85,,,,,,,596.38,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9978.00000,2893.62000,Aetna,Local,,3991.20,,,,,,,3597.07,8162.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9978.00000,2893.62000,Aetna,Local,,3991.20,,,,,,,3212.92,8162.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7894315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5675.25000,1645.82000,Aetna,Local,,2270.10,,,,,,,2045.93,4642.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7894315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5675.25000,1645.82000,Aetna,Local,,2270.10,,,,,,,1827.43,4642.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7895648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2920.05,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7895648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2608.20,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7895649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7895649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7895465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1854.68000,537.86000,Aetna,Local,,741.87,,,,,,,668.61,1517.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7895465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1854.68000,537.86000,Aetna,Local,,741.87,,,,,,,597.21,1517.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA,7895673,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA,7895673,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7698839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,Local,,1929.06,,,,,,,1738.57,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7698839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,Local,,1929.06,,,,,,,1552.89,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5600.00000,1624.00000,Aetna,Local,,2240.00,,,,,,,2018.80,4580.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5600.00000,1624.00000,Aetna,Local,,2240.00,,,,,,,1803.20,4580.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7896749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1847.20,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7896749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1649.93,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896843,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896843,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7896881,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,Local,,199.12,,,,,,,179.46,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7896881,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,Local,,199.12,,,,,,,160.29,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7896875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,166.10,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7896875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,148.36,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BRONCHIAL THERMOPLASTY,7896969,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BRONCHIAL THERMOPLASTY,7896969,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7897116,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7897116,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7897118,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,58000.00000,16820.00000,Aetna,Local,,23200.00,,,,,,,20909.00,47444.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7897118,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,58000.00000,16820.00000,Aetna,Local,,23200.00,,,,,,,18676.00,47444.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7897119,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7897119,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,7897120,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4494.00000,1303.26000,Aetna,Local,,1797.60,,,,,,,1620.09,3676.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,7897120,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4494.00000,1303.26000,Aetna,Local,,1797.60,,,,,,,1447.07,3676.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CHARGING SYSTEM,7897121,CDM,278,RC,C1822,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CHARGING SYSTEM,7897121,CDM,278,RC,C1822,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7897352,CDM,278,RC,,,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,Local,,1396.85,,,,,,,1258.91,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7897352,CDM,278,RC,,,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,Local,,1396.85,,,,,,,1124.47,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7897359,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9144.09000,2651.79000,Aetna,Local,,3657.64,,,,,,,3296.44,7479.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7897359,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9144.09000,2651.79000,Aetna,Local,,3657.64,,,,,,,2944.40,7479.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7897361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1421.99,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7897361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1270.13,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7695586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7695586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7900150,CDM,278,RC,C1755,HCPCS,,,facility,inpatient,,,4980.50000,1444.34000,Aetna,Local,,1992.20,,,,,,,1795.47,4074.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7900150,CDM,278,RC,C1755,HCPCS,,,facility,outpatient,,,4980.50000,1444.34000,Aetna,Local,,1992.20,,,,,,,1603.72,4074.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7900141,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7900141,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1596.11,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1425.65,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7900297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7900297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,Local,,1779.28,,,,,,,1603.57,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,Local,,1779.28,,,,,,,1432.32,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1771.97,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1582.73,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7741812,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7741812,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7699527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,Local,,8825.00,,,,,,,7953.53,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7699527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,Local,,8825.00,,,,,,,7104.12,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7901616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7901616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7901621,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7901621,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7901700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7901700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7901703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1299.40,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7901703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1160.63,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PASTE BEADS,7698897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9810.03000,2844.91000,Aetna,Local,,3924.01,,,,,,,3536.52,8024.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PASTE BEADS,7698897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9810.03000,2844.91000,Aetna,Local,,3924.01,,,,,,,3158.83,8024.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,507.78000,147.26000,Aetna,Local,,203.11,,,,,,,183.05,415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,507.78000,147.26000,Aetna,Local,,203.11,,,,,,,163.51,415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5936.39000,1721.55000,Aetna,Local,,2374.56,,,,,,,2140.07,4855.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5936.39000,1721.55000,Aetna,Local,,2374.56,,,,,,,1911.52,4855.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7901859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7901859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7902103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7902103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STERNA BAND,7702706,CDM,278,RC,,,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STERNA BAND,7702706,CDM,278,RC,,,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7902345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7902345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7902350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7902350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRIP CABLE,7902352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3493.00000,1012.97000,Aetna,Local,,1397.20,,,,,,,1259.23,2857.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRIP CABLE,7902352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3493.00000,1012.97000,Aetna,Local,,1397.20,,,,,,,1124.75,2857.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7902637,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,646.47000,187.48000,Aetna,Local,,258.59,,,,,,,233.05,528.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7902637,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,646.47000,187.48000,Aetna,Local,,258.59,,,,,,,208.16,528.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,324.90000,94.22000,Aetna,Local,,129.96,,,,,,,117.13,265.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,324.90000,94.22000,Aetna,Local,,129.96,,,,,,,104.62,265.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1803.80,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1611.16,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7901701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7901701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7902776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6268.50000,1817.86000,Aetna,Local,,2507.40,,,,,,,2259.79,5127.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7902776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6268.50000,1817.86000,Aetna,Local,,2507.40,,,,,,,2018.46,5127.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7880447,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,1220.00000,353.80000,Aetna,Local,,488.00,,,,,,,439.81,997.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7880447,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,1220.00000,353.80000,Aetna,Local,,488.00,,,,,,,392.84,997.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7902978,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4163.25000,1207.34000,Aetna,Local,,1665.30,,,,,,,1500.85,3405.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7902978,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4163.25000,1207.34000,Aetna,Local,,1665.30,,,,,,,1340.57,3405.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,330.96,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,295.61,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7903145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1622.36,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7903145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1449.10,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7903148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7903148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7903504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11521.50000,3341.23000,Aetna,Local,,4608.60,,,,,,,4153.50,9424.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7903504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11521.50000,3341.23000,Aetna,Local,,4608.60,,,,,,,3709.92,9424.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7903581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8952.00000,2596.08000,Aetna,Local,,3580.80,,,,,,,3227.20,7322.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7903581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8952.00000,2596.08000,Aetna,Local,,3580.80,,,,,,,2882.54,7322.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT HV FOR AUTOPLEX SYST,7903761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3806.69000,1103.94000,Aetna,Local,,1522.68,,,,,,,1372.31,3113.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT HV FOR AUTOPLEX SYST,7903761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3806.69000,1103.94000,Aetna,Local,,1522.68,,,,,,,1225.75,3113.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7903659,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1124.76,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7903659,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1004.64,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911814,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,Local,,59.01,,,,,,,53.18,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911814,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,Local,,59.01,,,,,,,47.50,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911815,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,191.63000,55.57000,Aetna,Local,,76.65,,,,,,,69.08,156.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911815,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,191.63000,55.57000,Aetna,Local,,76.65,,,,,,,61.70,156.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911816,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,169.58000,49.18000,Aetna,Local,,67.83,,,,,,,61.13,138.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911816,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,169.58000,49.18000,Aetna,Local,,67.83,,,,,,,54.60,138.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7912133,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1828.28000,530.20000,Aetna,Local,,731.31,,,,,,,659.09,1495.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7912133,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1828.28000,530.20000,Aetna,Local,,731.31,,,,,,,588.71,1495.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7912134,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2592.76000,751.90000,Aetna,Local,,1037.10,,,,,,,934.69,2120.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7912134,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2592.76000,751.90000,Aetna,Local,,1037.10,,,,,,,834.87,2120.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7776325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,3136.35,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7776325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,2801.40,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7912168,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,34537.50000,10015.88000,Aetna,Local,,13815.00,,,,,,,12450.77,28251.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7912168,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,34537.50000,10015.88000,Aetna,Local,,13815.00,,,,,,,11121.08,28251.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7912141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7912141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7912137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4554.38000,1320.77000,Aetna,Local,,1821.75,,,,,,,1641.85,3725.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7912137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4554.38000,1320.77000,Aetna,Local,,1821.75,,,,,,,1466.51,3725.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9633.75000,2793.79000,Aetna,Local,,3853.50,,,,,,,3472.97,7880.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9633.75000,2793.79000,Aetna,Local,,3853.50,,,,,,,3102.07,7880.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7912276,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7912276,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,261.39,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,233.48,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2634.24000,763.93000,Aetna,Local,,1053.70,,,,,,,949.64,2154.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2634.24000,763.93000,Aetna,Local,,1053.70,,,,,,,848.23,2154.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7912610,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7912610,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7912607,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,11025.00000,3197.25000,Aetna,Local,,4410.00,,,,,,,3974.51,9018.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7912607,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,11025.00000,3197.25000,Aetna,Local,,4410.00,,,,,,,3550.05,9018.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7912611,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7912611,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912753,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912753,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912755,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,Local,,936.00,,,,,,,843.57,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912755,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,Local,,936.00,,,,,,,753.48,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7912756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,806.18000,233.79000,Aetna,Local,,322.47,,,,,,,290.63,659.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7912756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,806.18000,233.79000,Aetna,Local,,322.47,,,,,,,259.59,659.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,2061.39,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,1841.24,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3706.50000,1074.88000,Aetna,Local,,1482.60,,,,,,,1336.19,3031.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3706.50000,1074.88000,Aetna,Local,,1482.60,,,,,,,1193.49,3031.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7913629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7913629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATES IN A KIT,7913653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5198.20000,1507.48000,Aetna,Local,,2079.28,,,,,,,1873.95,4252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATES IN A KIT,7913653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5198.20000,1507.48000,Aetna,Local,,2079.28,,,,,,,1673.82,4252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3465.42000,1004.97000,Aetna,Local,,1386.17,,,,,,,1249.28,2834.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3465.42000,1004.97000,Aetna,Local,,1386.17,,,,,,,1115.87,2834.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7913883,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1225.68000,355.45000,Aetna,Local,,490.27,,,,,,,441.86,1002.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7913883,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1225.68000,355.45000,Aetna,Local,,490.27,,,,,,,394.67,1002.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7913914,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7913914,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7914034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5257.46000,1524.66000,Aetna,Local,,2102.98,,,,,,,1895.31,4300.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7914034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5257.46000,1524.66000,Aetna,Local,,2102.98,,,,,,,1692.90,4300.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7914403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,179.80,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7914403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,160.60,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7914556,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7914556,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8559.00000,2482.11000,Aetna,Local,,3423.60,,,,,,,3085.52,7001.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8559.00000,2482.11000,Aetna,Local,,3423.60,,,,,,,2756.00,7001.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2893.01,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2584.05,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7736.40000,2243.56000,Aetna,Local,,3094.56,,,,,,,2788.97,6328.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7736.40000,2243.56000,Aetna,Local,,3094.56,,,,,,,2491.12,6328.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7916494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7916494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7916709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2057.00000,596.53000,Aetna,Local,,822.80,,,,,,,741.55,1682.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7916709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2057.00000,596.53000,Aetna,Local,,822.80,,,,,,,662.35,1682.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7916710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7916710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2934.80000,851.09000,Aetna,Local,,1173.92,,,,,,,1058.00,2400.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2934.80000,851.09000,Aetna,Local,,1173.92,,,,,,,945.01,2400.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7916929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6300.00000,1827.00000,Aetna,Local,,2520.00,,,,,,,2271.15,5153.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7916929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6300.00000,1827.00000,Aetna,Local,,2520.00,,,,,,,2028.60,5153.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13275.00000,3849.75000,Aetna,Local,,5310.00,,,,,,,4785.64,10858.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13275.00000,3849.75000,Aetna,Local,,5310.00,,,,,,,4274.55,10858.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5088.30000,1475.61000,Aetna,Local,,2035.32,,,,,,,1834.33,4162.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5088.30000,1475.61000,Aetna,Local,,2035.32,,,,,,,1638.43,4162.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING,7916982,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,5603.50000,1625.02000,Aetna,Local,,2241.40,,,,,,,2020.06,4583.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING,7916982,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,5603.50000,1625.02000,Aetna,Local,,2241.40,,,,,,,1804.33,4583.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7916997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7916997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2053.88000,595.63000,Aetna,Local,,821.55,,,,,,,740.42,1680.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2053.88000,595.63000,Aetna,Local,,821.55,,,,,,,661.35,1680.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7917356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7917356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7917667,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,17399.73000,5045.92000,Aetna,Local,,6959.89,,,,,,,6272.60,14232.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7917667,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,17399.73000,5045.92000,Aetna,Local,,6959.89,,,,,,,5602.71,14232.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7917697,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7917697,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7910312,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7910312,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7909290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7909290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7917854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7917854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7917894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7917894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6270.39000,1818.41000,Aetna,Local,,2508.16,,,,,,,2260.48,5129.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6270.39000,1818.41000,Aetna,Local,,2508.16,,,,,,,2019.07,5129.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7918133,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1648.40000,478.04000,Aetna,Local,,659.36,,,,,,,594.25,1348.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7918133,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1648.40000,478.04000,Aetna,Local,,659.36,,,,,,,530.78,1348.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7816132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,2211.03,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7816132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,1974.90,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7918404,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,Local,,13473.00,,,,,,,12142.54,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7918404,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,Local,,13473.00,,,,,,,10845.76,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7918862,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7868.40000,2281.84000,Aetna,Local,,3147.36,,,,,,,2836.56,6436.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7918862,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7868.40000,2281.84000,Aetna,Local,,3147.36,,,,,,,2533.62,6436.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7698317,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,11145.00000,3232.05000,Aetna,Local,,4458.00,,,,,,,4017.77,9116.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7698317,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,11145.00000,3232.05000,Aetna,Local,,4458.00,,,,,,,3588.69,9116.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1544.88000,448.02000,Aetna,Local,,617.95,,,,,,,556.93,1263.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1544.88000,448.02000,Aetna,Local,,617.95,,,,,,,497.45,1263.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1613.16000,467.82000,Aetna,Local,,645.26,,,,,,,581.54,1319.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1613.16000,467.82000,Aetna,Local,,645.26,,,,,,,519.44,1319.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7918560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,906.12000,262.77000,Aetna,Local,,362.45,,,,,,,326.66,741.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7918560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,906.12000,262.77000,Aetna,Local,,362.45,,,,,,,291.77,741.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7932.00000,2300.28000,Aetna,Local,,3172.80,,,,,,,2859.49,6488.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7932.00000,2300.28000,Aetna,Local,,3172.80,,,,,,,2554.10,6488.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7918628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,703.70,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7918628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,628.54,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7918629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1928.00000,559.12000,Aetna,Local,,771.20,,,,,,,695.04,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7918629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1928.00000,559.12000,Aetna,Local,,771.20,,,,,,,620.82,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7918811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7918811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7918816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7918816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4540.73000,1316.81000,Aetna,Local,,1816.29,,,,,,,1636.93,3714.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4540.73000,1316.81000,Aetna,Local,,1816.29,,,,,,,1462.12,3714.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,895.16,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1963.88000,569.53000,Aetna,Local,,785.55,,,,,,,707.98,1606.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1963.88000,569.53000,Aetna,Local,,785.55,,,,,,,632.37,1606.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7900102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7900102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903505,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903505,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858116,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858116,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858113,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858113,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858110,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858110,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750487,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750487,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE MYRINGOTOMY,7694026,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,96.78000,28.07000,Aetna,Local,,38.71,,,,,,,34.89,79.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE MYRINGOTOMY,7694026,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,96.78000,28.07000,Aetna,Local,,38.71,,,,,,,31.16,332.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918877,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13587.00000,3940.23000,Aetna,Local,,5434.80,,,,,,,4898.11,11114.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918877,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13587.00000,3940.23000,Aetna,Local,,5434.80,,,,,,,4375.01,11114.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8611.20000,2497.25000,Aetna,Local,,3444.48,,,,,,,3104.34,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8611.20000,2497.25000,Aetna,Local,,3444.48,,,,,,,2772.81,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7918945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9102.00000,2639.58000,Aetna,Local,,3640.80,,,,,,,3281.27,7445.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7918945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9102.00000,2639.58000,Aetna,Local,,3640.80,,,,,,,2930.84,7445.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918977,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6114.33000,1773.16000,Aetna,Local,,2445.73,,,,,,,2204.22,5001.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918977,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6114.33000,1773.16000,Aetna,Local,,2445.73,,,,,,,1968.81,5001.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7918989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7918989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7910999,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2811.90,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7910999,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2511.60,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7919019,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2657.48000,770.67000,Aetna,Local,,1062.99,,,,,,,958.02,2173.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7919019,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2657.48000,770.67000,Aetna,Local,,1062.99,,,,,,,855.71,2173.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
THYROPLASTY IMPLANT IN KIT,7916655,CDM,278,RC,C1878,HCPCS,,,facility,inpatient,,,1912.00000,554.48000,Aetna,Local,,764.80,,,,,,,689.28,1564.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
THYROPLASTY IMPLANT IN KIT,7916655,CDM,278,RC,C1878,HCPCS,,,facility,outpatient,,,1912.00000,554.48000,Aetna,Local,,764.80,,,,,,,615.66,1564.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1645.01,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1469.33,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7700111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,3057.18,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7700111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,2730.69,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7920398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10194.00000,2956.26000,Aetna,Local,,4077.60,,,,,,,3674.94,8338.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7920398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10194.00000,2956.26000,Aetna,Local,,4077.60,,,,,,,3282.47,8338.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1771.48000,513.73000,Aetna,Local,,708.59,,,,,,,638.62,1449.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1771.48000,513.73000,Aetna,Local,,708.59,,,,,,,570.42,1449.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2072.52000,601.03000,Aetna,Local,,829.01,,,,,,,747.14,1695.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2072.52000,601.03000,Aetna,Local,,829.01,,,,,,,667.35,1695.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7920462,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7920462,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7920488,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7920488,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7912365,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7912365,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7920509,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1552.00000,450.08000,Aetna,Local,,620.80,,,,,,,559.50,1269.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7920509,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1552.00000,450.08000,Aetna,Local,,620.80,,,,,,,499.74,1269.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,703.70,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,628.54,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3783.50000,1097.21000,Aetna,Local,,1513.40,,,,,,,1363.95,3094.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3783.50000,1097.21000,Aetna,Local,,1513.40,,,,,,,1218.29,3094.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5845.00000,1695.05000,Aetna,Local,,2338.00,,,,,,,2107.12,4781.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5845.00000,1695.05000,Aetna,Local,,2338.00,,,,,,,1882.09,4781.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT EXTENDER,7920563,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11775.00000,3414.75000,Aetna,Local,,4710.00,,,,,,,4244.89,9631.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT EXTENDER,7920563,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11775.00000,3414.75000,Aetna,Local,,4710.00,,,,,,,3791.55,9631.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,179.55000,52.07000,Aetna,Local,,71.82,,,,,,,64.73,146.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,179.55000,52.07000,Aetna,Local,,71.82,,,,,,,57.82,146.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7921011,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4656.75000,1350.46000,Aetna,Local,,1862.70,,,,,,,1678.76,3809.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7921011,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4656.75000,1350.46000,Aetna,Local,,1862.70,,,,,,,1499.47,3809.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7921145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7921145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7921147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7921147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5729.99000,1661.70000,Aetna,Local,,2292.00,,,,,,,2065.66,4687.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5729.99000,1661.70000,Aetna,Local,,2292.00,,,,,,,1845.06,4687.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7786150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7786150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2351.80000,682.02000,Aetna,Local,,940.72,,,,,,,847.82,1923.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2351.80000,682.02000,Aetna,Local,,940.72,,,,,,,757.28,1923.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO TRANSFIX,7702903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1653.80000,479.60000,Aetna,Local,,661.52,,,,,,,596.19,1352.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO TRANSFIX,7702903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1653.80000,479.60000,Aetna,Local,,661.52,,,,,,,532.52,1352.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2438.72000,707.23000,Aetna,Local,,975.49,,,,,,,879.16,1994.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2438.72000,707.23000,Aetna,Local,,975.49,,,,,,,785.27,1994.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2947.72000,854.84000,Aetna,Local,,1179.09,,,,,,,1062.65,2411.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2947.72000,854.84000,Aetna,Local,,1179.09,,,,,,,949.17,2411.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7922475,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7922475,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7695239,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7695239,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7786155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7786155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7922574,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1976.48000,573.18000,Aetna,Local,,790.59,,,,,,,712.52,1616.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7922574,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1976.48000,573.18000,Aetna,Local,,790.59,,,,,,,636.43,1616.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE EXTENDER,7922871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1385.00000,401.65000,Aetna,Local,,554.00,,,,,,,499.29,1132.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE EXTENDER,7922871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1385.00000,401.65000,Aetna,Local,,554.00,,,,,,,445.97,1132.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP,7698319,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,32951.25000,9555.86000,Aetna,Local,,13180.50,,,,,,,11878.93,26954.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP,7698319,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,32951.25000,9555.86000,Aetna,Local,,13180.50,,,,,,,10610.30,26954.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7923285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.70000,1465.86000,Aetna,Local,,2021.88,,,,,,,1822.22,4134.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7923285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.70000,1465.86000,Aetna,Local,,2021.88,,,,,,,1627.61,4134.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7923287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7923287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,793.10,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,708.40,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,7699612,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,7699612,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7924638,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,422.85000,122.63000,Aetna,Local,,169.14,,,,,,,152.44,345.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7924638,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,422.85000,122.63000,Aetna,Local,,169.14,,,,,,,136.16,345.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7924634,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,10128.00000,2937.12000,Aetna,Local,,4051.20,,,,,,,3651.14,8284.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7924634,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,10128.00000,2937.12000,Aetna,Local,,4051.20,,,,,,,3261.22,8284.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3930.50000,1139.84000,Aetna,Local,,1572.20,,,,,,,1416.95,3215.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3930.50000,1139.84000,Aetna,Local,,1572.20,,,,,,,1265.62,3215.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7911781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7911781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7924873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7924873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2520.00000,730.80000,Aetna,Local,,1008.00,,,,,,,908.46,2061.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2520.00000,730.80000,Aetna,Local,,1008.00,,,,,,,811.44,2061.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,549.00000,159.21000,Aetna,Local,,219.60,,,,,,,197.91,449.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,549.00000,159.21000,Aetna,Local,,219.60,,,,,,,176.78,449.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5456.50000,1582.38000,Aetna,Local,,2182.60,,,,,,,1967.07,4463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5456.50000,1582.38000,Aetna,Local,,2182.60,,,,,,,1756.99,4463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,7924904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,7924904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7924903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,2191.66,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7924903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,1957.60,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,7924913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,940.19000,272.66000,Aetna,Local,,376.08,,,,,,,338.94,769.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,7924913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,940.19000,272.66000,Aetna,Local,,376.08,,,,,,,302.74,769.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7925233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7925233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,Local,,3434.40,,,,,,,3095.25,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,Local,,3434.40,,,,,,,2764.69,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7924900,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,Local,,1929.06,,,,,,,1738.57,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7924900,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,Local,,1929.06,,,,,,,1552.89,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2525.64000,732.44000,Aetna,Local,,1010.26,,,,,,,910.49,2065.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2525.64000,732.44000,Aetna,Local,,1010.26,,,,,,,813.26,2065.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7912606,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,172.99000,50.17000,Aetna,Local,,69.20,,,,,,,62.36,141.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7912606,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,172.99000,50.17000,Aetna,Local,,69.20,,,,,,,55.70,141.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7925455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,129.50000,37.56000,Aetna,Local,,51.80,,,,,,,46.68,105.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7925455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,129.50000,37.56000,Aetna,Local,,51.80,,,,,,,41.70,105.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7925627,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7925627,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7954585,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7954585,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7894318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7894318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7925633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7925633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7925800,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,23000.00000,6670.00000,Aetna,Local,,9200.00,,,,,,,8291.50,18814.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7925800,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,Local,,9200.00,,,,,,,7406.00,18814.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7908759,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7908759,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,873.04,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,779.81,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7925917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,Local,,4521.24,,,,,,,4074.77,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7925917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,Local,,4521.24,,,,,,,3639.60,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7926526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9222.90000,2674.64000,Aetna,Local,,3689.16,,,,,,,3324.86,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7926526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9222.90000,2674.64000,Aetna,Local,,3689.16,,,,,,,2969.77,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926548,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926548,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926549,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5634.61,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926549,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5032.86,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4515.97,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4033.68,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7926564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4812.68,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7926564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4298.70,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926577,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21272.50000,6169.02000,Aetna,Local,,8509.00,,,,,,,7668.74,17400.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926577,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21272.50000,6169.02000,Aetna,Local,,8509.00,,,,,,,6849.74,17400.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7926579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9083.55000,2634.23000,Aetna,Local,,3633.42,,,,,,,3274.62,7430.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7926579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9083.55000,2634.23000,Aetna,Local,,3633.42,,,,,,,2924.90,7430.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926672,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926672,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7926711,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,7480.38,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7926711,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,6681.50,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3447.33000,999.73000,Aetna,Local,,1378.93,,,,,,,1242.76,2819.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3447.33000,999.73000,Aetna,Local,,1378.93,,,,,,,1110.04,2819.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIMULATOR,7926956,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,54586.00000,15829.94000,Aetna,Local,,21834.40,,,,,,,19678.25,44651.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIMULATOR,7926956,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,54586.00000,15829.94000,Aetna,Local,,21834.40,,,,,,,17576.69,44651.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7926984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2903.18,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7926984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2593.13,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,Local,,1100.00,,,,,,,991.38,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,Local,,1100.00,,,,,,,885.50,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7927051,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7927051,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7927136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3249.75000,942.43000,Aetna,Local,,1299.90,,,,,,,1171.53,2658.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7927136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3249.75000,942.43000,Aetna,Local,,1299.90,,,,,,,1046.42,2658.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,37091.48000,10756.53000,Aetna,Local,,14836.59,,,,,,,13371.48,30340.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,37091.48000,10756.53000,Aetna,Local,,14836.59,,,,,,,11943.46,30340.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS SHORT TERM,7736620,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,428.23000,124.19000,Aetna,Local,,171.29,,,,,,,154.38,350.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS SHORT TERM,7736620,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,428.23000,124.19000,Aetna,Local,,171.29,,,,,,,137.89,350.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4053.00000,1175.37000,Aetna,Local,,1621.20,,,,,,,1461.11,3315.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4053.00000,1175.37000,Aetna,Local,,1621.20,,,,,,,1305.07,3315.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7736435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3420.78,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7736435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3055.46,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3783.50000,1097.21000,Aetna,Local,,1513.40,,,,,,,1363.95,3094.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3783.50000,1097.21000,Aetna,Local,,1513.40,,,,,,,1218.29,3094.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7927186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7927186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7927258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7927258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7927270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7927270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7707520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,7151.42,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7707520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,6387.68,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7927340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7927340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7927342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3458.00000,1002.82000,Aetna,Local,,1383.20,,,,,,,1246.61,2828.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7927342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3458.00000,1002.82000,Aetna,Local,,1383.20,,,,,,,1113.48,2828.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7927344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7927344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.80000,391.73000,Aetna,Local,,540.32,,,,,,,486.96,1104.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.80000,391.73000,Aetna,Local,,540.32,,,,,,,434.96,1104.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7927506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.99000,167.33000,Aetna,Local,,230.80,,,,,,,208.00,471.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7927506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.99000,167.33000,Aetna,Local,,230.80,,,,,,,185.79,471.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7927548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3170.00000,919.30000,Aetna,Local,,1268.00,,,,,,,1142.79,2593.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7927548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3170.00000,919.30000,Aetna,Local,,1268.00,,,,,,,1020.74,2593.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7929702,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5439.00000,1577.31000,Aetna,Local,,2175.60,,,,,,,1960.76,4449.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7929702,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5439.00000,1577.31000,Aetna,Local,,2175.60,,,,,,,1751.36,4449.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7929705,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7929705,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7929723,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12426.00000,3603.54000,Aetna,Local,,4970.40,,,,,,,4479.57,10164.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7929723,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12426.00000,3603.54000,Aetna,Local,,4970.40,,,,,,,4001.17,10164.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7929725,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,4284.00000,1242.36000,Aetna,Local,,1713.60,,,,,,,1544.38,3504.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7929725,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,4284.00000,1242.36000,Aetna,Local,,1713.60,,,,,,,1379.45,3504.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7929741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1211.28,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7929741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1081.92,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929752,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929752,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7930116,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3896.38000,1129.95000,Aetna,Local,,1558.55,,,,,,,1404.64,3187.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7930116,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3896.38000,1129.95000,Aetna,Local,,1558.55,,,,,,,1254.63,3187.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7895932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,2104.22,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7895932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,1879.50,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7930146,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7930146,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7930181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7930181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700832,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13117.38000,3804.04000,Aetna,Local,,5246.95,,,,,,,4728.82,10730.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700832,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13117.38000,3804.04000,Aetna,Local,,5246.95,,,,,,,4223.80,10730.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7930203,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,484.88000,140.62000,Aetna,Local,,193.95,,,,,,,174.80,396.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7930203,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,484.88000,140.62000,Aetna,Local,,193.95,,,,,,,156.13,396.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7930206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9222.90000,2674.64000,Aetna,Local,,3689.16,,,,,,,3324.86,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7930206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9222.90000,2674.64000,Aetna,Local,,3689.16,,,,,,,2969.77,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FINGER IMPLANT,7930262,CDM,278,RC,L8630,HCPCS,,,facility,inpatient,,,4560.50000,1322.54000,Aetna,Local,,1824.20,,,,,,,1644.06,3730.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FINGER IMPLANT,7930262,CDM,278,RC,L8630,HCPCS,,,facility,outpatient,,,4560.50000,1322.54000,Aetna,Local,,1824.20,,,,,,,412.46,3730.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2592.00000,751.68000,Aetna,Local,,1036.80,,,,,,,934.42,2120.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2592.00000,751.68000,Aetna,Local,,1036.80,,,,,,,834.62,2120.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7930308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,444.13000,128.80000,Aetna,Local,,177.65,,,,,,,160.11,363.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7930308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,444.13000,128.80000,Aetna,Local,,177.65,,,,,,,143.01,363.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7926648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,Local,,936.00,,,,,,,843.57,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7926648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,Local,,936.00,,,,,,,753.48,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR TEST,7922458,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,670.53,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR TEST,7922458,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,598.92,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696542,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696542,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7702698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7702698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7550.10000,2189.53000,Aetna,Local,,3020.04,,,,,,,2721.81,6175.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7550.10000,2189.53000,Aetna,Local,,3020.04,,,,,,,2431.13,6175.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7933915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,620.33000,179.90000,Aetna,Local,,248.13,,,,,,,223.63,507.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7933915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,620.33000,179.90000,Aetna,Local,,248.13,,,,,,,199.75,507.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7933955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13059.00000,3787.11000,Aetna,Local,,5223.60,,,,,,,4707.77,10682.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7933955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13059.00000,3787.11000,Aetna,Local,,5223.60,,,,,,,4205.00,10682.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7934011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3358.53000,973.97000,Aetna,Local,,1343.41,,,,,,,1210.75,2747.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7934011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3358.53000,973.97000,Aetna,Local,,1343.41,,,,,,,1081.45,2747.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7934019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,Local,,3864.00,,,,,,,3482.43,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7934019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,Local,,3864.00,,,,,,,3110.52,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7934020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3281.25000,951.56000,Aetna,Local,,1312.50,,,,,,,1182.89,2684.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7934020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3281.25000,951.56000,Aetna,Local,,1312.50,,,,,,,1056.56,2684.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7934021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,Local,,3864.00,,,,,,,3482.43,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7934021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,Local,,3864.00,,,,,,,3110.52,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7934063,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,737.60000,213.90000,Aetna,Local,,295.04,,,,,,,265.90,603.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7934063,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,737.60000,213.90000,Aetna,Local,,295.04,,,,,,,237.51,603.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSCONNECTOR SPINAL,7695522,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7657.02000,2220.54000,Aetna,Local,,3062.81,,,,,,,2760.36,6263.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSCONNECTOR SPINAL,7695522,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7657.02000,2220.54000,Aetna,Local,,3062.81,,,,,,,2465.56,6263.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7935071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7935071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7935114,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,19710.00000,5715.90000,Aetna,Local,,7884.00,,,,,,,7105.45,16122.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7935114,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,19710.00000,5715.90000,Aetna,Local,,7884.00,,,,,,,6346.62,16122.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7935107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,Local,,1818.04,,,,,,,1638.51,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7935107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,Local,,1818.04,,,,,,,1463.52,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7695327,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8079.00000,2342.91000,Aetna,Local,,3231.60,,,,,,,2912.48,6608.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7695327,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8079.00000,2342.91000,Aetna,Local,,3231.60,,,,,,,2601.44,6608.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7696921,CDM,278,RC,,,,,facility,inpatient,,,2288.00000,663.52000,Aetna,Local,,915.20,,,,,,,824.82,1871.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7696921,CDM,278,RC,,,,,facility,outpatient,,,2288.00000,663.52000,Aetna,Local,,915.20,,,,,,,736.74,1871.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694978,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,153.30000,44.46000,Aetna,Local,,61.32,,,,,,,55.26,125.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694978,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,153.30000,44.46000,Aetna,Local,,61.32,,,,,,,49.36,125.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BULKING AGENT,7696685,CDM,278,RC,L8606,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BULKING AGENT,7696685,CDM,278,RC,L8606,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,268.67,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2750.40000,797.62000,Aetna,Local,,1100.16,,,,,,,991.52,2249.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2750.40000,797.62000,Aetna,Local,,1100.16,,,,,,,885.63,2249.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694587,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1476.00000,428.04000,Aetna,Local,,590.40,,,,,,,532.10,1207.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694587,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1476.00000,428.04000,Aetna,Local,,590.40,,,,,,,475.27,1207.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7700511,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1490.84000,432.34000,Aetna,Local,,596.34,,,,,,,537.45,1219.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7700511,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1490.84000,432.34000,Aetna,Local,,596.34,,,,,,,480.05,1219.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7696455,CDM,278,RC,C1727,HCPCS,,,facility,inpatient,,,2163.68000,627.47000,Aetna,Local,,865.47,,,,,,,780.01,1769.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7696455,CDM,278,RC,C1727,HCPCS,,,facility,outpatient,,,2163.68000,627.47000,Aetna,Local,,865.47,,,,,,,696.70,1769.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696019,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,11078.35,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696019,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,9895.22,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING GRAFT,7696357,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,8728.27000,2531.20000,Aetna,Local,,3491.31,,,,,,,3146.54,7139.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING GRAFT,7696357,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,8728.27000,2531.20000,Aetna,Local,,3491.31,,,,,,,2810.50,7139.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7944264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,2197.43,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7944264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,1962.75,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696248,CDM,278,RC,C1877,HCPCS,,,facility,inpatient,,,5321.54000,1543.25000,Aetna,Local,,2128.62,,,,,,,1918.42,4353.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696248,CDM,278,RC,C1877,HCPCS,,,facility,outpatient,,,5321.54000,1543.25000,Aetna,Local,,2128.62,,,,,,,1713.54,4353.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696767,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,5398.72000,1565.63000,Aetna,Local,,2159.49,,,,,,,1946.24,4416.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696767,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,5398.72000,1565.63000,Aetna,Local,,2159.49,,,,,,,1738.39,4416.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7696809,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1518.80000,440.45000,Aetna,Local,,607.52,,,,,,,547.53,1242.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7696809,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1518.80000,440.45000,Aetna,Local,,607.52,,,,,,,489.05,1242.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR PATCH,7694425,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR PATCH,7694425,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7696940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3220.70000,934.00000,Aetna,Local,,1288.28,,,,,,,1161.06,2634.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7696940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3220.70000,934.00000,Aetna,Local,,1288.28,,,,,,,1037.07,2634.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7694371,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7694371,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935389,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4625.25000,1341.32000,Aetna,Local,,1850.10,,,,,,,1667.40,3783.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935389,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4625.25000,1341.32000,Aetna,Local,,1850.10,,,,,,,1489.33,3783.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935390,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,Local,,2337.30,,,,,,,2106.49,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935390,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,Local,,2337.30,,,,,,,1881.53,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935395,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4345.25000,1260.12000,Aetna,Local,,1738.10,,,,,,,1566.46,3554.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935395,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4345.25000,1260.12000,Aetna,Local,,1738.10,,,,,,,1399.17,3554.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935396,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5514.25000,1599.13000,Aetna,Local,,2205.70,,,,,,,1987.89,4510.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935396,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5514.25000,1599.13000,Aetna,Local,,2205.70,,,,,,,1775.59,4510.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697082,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697082,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699837,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4345.25000,1260.12000,Aetna,Local,,1738.10,,,,,,,1566.46,3554.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699837,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4345.25000,1260.12000,Aetna,Local,,1738.10,,,,,,,1399.17,3554.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,507.58,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,453.38,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MENISCAL DART,7935473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.73000,204.95000,Aetna,Local,,282.69,,,,,,,254.78,578.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MENISCAL DART,7935473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.73000,204.95000,Aetna,Local,,282.69,,,,,,,227.57,578.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697291,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,16562.50000,4803.12000,Aetna,Local,,6625.00,,,,,,,5970.78,13548.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697291,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,16562.50000,4803.12000,Aetna,Local,,6625.00,,,,,,,5333.12,13548.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8736.57000,2533.61000,Aetna,Local,,3494.63,,,,,,,3149.53,7146.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8736.57000,2533.61000,Aetna,Local,,3494.63,,,,,,,2813.18,7146.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1299.40,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1160.63,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7935560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8524.20000,2472.02000,Aetna,Local,,3409.68,,,,,,,3072.97,6972.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7935560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8524.20000,2472.02000,Aetna,Local,,3409.68,,,,,,,2744.79,6972.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,7935590,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16057.50000,4656.67000,Aetna,Local,,6423.00,,,,,,,5788.73,13135.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,7935590,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16057.50000,4656.67000,Aetna,Local,,6423.00,,,,,,,5170.52,13135.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,7935591,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,7935591,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION LEAD,7935588,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,2678.39000,776.73000,Aetna,Local,,1071.36,,,,,,,965.56,2190.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION LEAD,7935588,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,2678.39000,776.73000,Aetna,Local,,1071.36,,,,,,,862.44,2190.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3957.21,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3534.59,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIC PROTECTOR,7697570,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIC PROTECTOR,7697570,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935723,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19620.00000,5689.80000,Aetna,Local,,7848.00,,,,,,,7073.01,16049.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935723,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19620.00000,5689.80000,Aetna,Local,,7848.00,,,,,,,6317.64,16049.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7927397,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7927397,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7962570,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7962570,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7945882,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,23750.00000,6887.50000,Aetna,Local,,9500.00,,,,,,,8561.88,19427.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7945882,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,23750.00000,6887.50000,Aetna,Local,,9500.00,,,,,,,7647.50,19427.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918349,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918349,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702261,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702261,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7766038,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,Local,,4858.80,,,,,,,4378.99,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7766038,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,Local,,4858.80,,,,,,,3911.33,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2592.00000,751.68000,Aetna,Local,,1036.80,,,,,,,934.42,2120.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2592.00000,751.68000,Aetna,Local,,1036.80,,,,,,,834.62,2120.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7700076,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15217.50000,4413.08000,Aetna,Local,,6087.00,,,,,,,5485.91,12447.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7700076,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15217.50000,4413.08000,Aetna,Local,,6087.00,,,,,,,4900.03,12447.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7744661,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7744661,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700124,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700124,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7700126,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,Local,,4858.80,,,,,,,4378.99,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7700126,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,Local,,4858.80,,,,,,,3911.33,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7707536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10473.00000,3037.17000,Aetna,Local,,4189.20,,,,,,,3775.52,8566.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7707536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10473.00000,3037.17000,Aetna,Local,,4189.20,,,,,,,3372.31,8566.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7935027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10473.00000,3037.17000,Aetna,Local,,4189.20,,,,,,,3775.52,8566.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7935027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10473.00000,3037.17000,Aetna,Local,,4189.20,,,,,,,3372.31,8566.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8869.20000,2572.07000,Aetna,Local,,3547.68,,,,,,,3197.35,7255.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8869.20000,2572.07000,Aetna,Local,,3547.68,,,,,,,2855.88,7255.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935848,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935848,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,Local,,936.00,,,,,,,843.57,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,Local,,936.00,,,,,,,753.48,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THROMBECTOMY,7698210,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,15800.00000,4582.00000,Aetna,Local,,6320.00,,,,,,,5695.90,12924.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THROMBECTOMY,7698210,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,15800.00000,4582.00000,Aetna,Local,,6320.00,,,,,,,5087.60,12924.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7917307,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1431.96000,415.27000,Aetna,Local,,572.78,,,,,,,516.22,1171.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7917307,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1431.96000,415.27000,Aetna,Local,,572.78,,,,,,,461.09,1171.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1421.99,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1270.13,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DILATION URETRAL BALLOON,7696485,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1574.88000,456.72000,Aetna,Local,,629.95,,,,,,,567.74,1288.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DILATION URETRAL BALLOON,7696485,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1574.88000,456.72000,Aetna,Local,,629.95,,,,,,,507.11,1288.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694335,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,32.41,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694335,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,28.94,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9950.01000,2885.50000,Aetna,Local,,3980.00,,,,,,,3586.98,8139.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9950.01000,2885.50000,Aetna,Local,,3980.00,,,,,,,3203.90,8139.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19864.05000,5760.57000,Aetna,Local,,7945.62,,,,,,,7160.99,16248.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19864.05000,5760.57000,Aetna,Local,,7945.62,,,,,,,6396.22,16248.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10667.67000,3093.62000,Aetna,Local,,4267.07,,,,,,,3845.70,8726.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10667.67000,3093.62000,Aetna,Local,,4267.07,,,,,,,3434.99,8726.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7936060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16741.50000,4855.04000,Aetna,Local,,6696.60,,,,,,,6035.31,13694.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7936060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16741.50000,4855.04000,Aetna,Local,,6696.60,,,,,,,5390.76,13694.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ROTATION,7936061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6613.88000,1918.03000,Aetna,Local,,2645.55,,,,,,,2384.30,5410.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ROTATION,7936061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6613.88000,1918.03000,Aetna,Local,,2645.55,,,,,,,2129.67,5410.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7936062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25606.63000,7425.92000,Aetna,Local,,10242.65,,,,,,,9231.19,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7936062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25606.63000,7425.92000,Aetna,Local,,10242.65,,,,,,,8245.33,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1608.00000,466.32000,Aetna,Local,,643.20,,,,,,,579.68,1315.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1608.00000,466.32000,Aetna,Local,,643.20,,,,,,,517.78,1315.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7904345,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7904345,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7936111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7936111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7936117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10929.00000,3169.41000,Aetna,Local,,4371.60,,,,,,,3939.90,8939.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7936117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10929.00000,3169.41000,Aetna,Local,,4371.60,,,,,,,3519.14,8939.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7808031,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,7886.67000,2287.13000,Aetna,Local,,3154.67,,,,,,,2843.14,6451.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7808031,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,7886.67000,2287.13000,Aetna,Local,,3154.67,,,,,,,2364.47,6451.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7936395,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11472.00000,3326.88000,Aetna,Local,,4588.80,,,,,,,4135.66,9384.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7936395,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11472.00000,3326.88000,Aetna,Local,,4588.80,,,,,,,3693.98,9384.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698909,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,895.50000,259.70000,Aetna,Local,,358.20,,,,,,,322.83,732.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698909,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,895.50000,259.70000,Aetna,Local,,358.20,,,,,,,288.35,732.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7937667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7937667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937697,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937697,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7937699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7937699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7937700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7937700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7937737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4920.30000,1426.89000,Aetna,Local,,1968.12,,,,,,,1773.77,4024.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7937737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4920.30000,1426.89000,Aetna,Local,,1968.12,,,,,,,1584.34,4024.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7937748,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16050.00000,4654.50000,Aetna,Local,,6420.00,,,,,,,5786.02,13128.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7937748,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16050.00000,4654.50000,Aetna,Local,,6420.00,,,,,,,5168.10,13128.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880522,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880522,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7918609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7918609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7937956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,Local,,4589.28,,,,,,,4136.09,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7937956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,Local,,4589.28,,,,,,,3694.37,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7762384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1299.40,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7762384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1160.63,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7938337,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7938337,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938778,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938778,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7938909,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,15637.50000,4534.88000,Aetna,Local,,6255.00,,,,,,,5637.32,12791.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7938909,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,15637.50000,4534.88000,Aetna,Local,,6255.00,,,,,,,5035.27,12791.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,Local,,7344.00,,,,,,,6618.78,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,Local,,7344.00,,,,,,,5911.92,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7938928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12638.40000,3665.14000,Aetna,Local,,5055.36,,,,,,,4556.14,10338.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7938928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12638.40000,3665.14000,Aetna,Local,,5055.36,,,,,,,4069.56,10338.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938965,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8362.50000,2425.12000,Aetna,Local,,3345.00,,,,,,,3014.68,6840.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938965,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8362.50000,2425.12000,Aetna,Local,,3345.00,,,,,,,2692.72,6840.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938994,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938994,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7939263,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7939263,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7697859,CDM,278,RC,,,,,facility,inpatient,,,14132.91000,4098.54000,Aetna,Local,,5653.16,,,,,,,5094.91,11560.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7697859,CDM,278,RC,,,,,facility,outpatient,,,14132.91000,4098.54000,Aetna,Local,,5653.16,,,,,,,4550.80,11560.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7939277,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7939277,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7939319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7939319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,Local,,2225.88,,,,,,,2006.07,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,Local,,2225.88,,,,,,,1791.83,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13275.00000,3849.75000,Aetna,Local,,5310.00,,,,,,,4785.64,10858.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13275.00000,3849.75000,Aetna,Local,,5310.00,,,,,,,4274.55,10858.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7939311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,6518.74,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7939311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,5822.56,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7939312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18910.00000,5483.90000,Aetna,Local,,7564.00,,,,,,,6817.06,15468.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7939312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18910.00000,5483.90000,Aetna,Local,,7564.00,,,,,,,6089.02,15468.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7939327,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,Local,,1244.80,,,,,,,1121.88,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7939327,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,Local,,1244.80,,,,,,,1002.06,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1211.28,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1081.92,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3819.38000,1107.62000,Aetna,Local,,1527.75,,,,,,,1376.89,3124.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3819.38000,1107.62000,Aetna,Local,,1527.75,,,,,,,1229.84,3124.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,174.10,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,155.50,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7939860,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,32256.00000,9354.24000,Aetna,Local,,12902.40,,,,,,,11628.29,26385.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7939860,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,32256.00000,9354.24000,Aetna,Local,,12902.40,,,,,,,10386.43,26385.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7939861,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,558.23000,161.89000,Aetna,Local,,223.29,,,,,,,201.24,456.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7939861,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,558.23000,161.89000,Aetna,Local,,223.29,,,,,,,179.75,456.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7939433,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7939433,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4667.92000,1353.70000,Aetna,Local,,1867.17,,,,,,,1682.79,3818.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4667.92000,1353.70000,Aetna,Local,,1867.17,,,,,,,1503.07,3818.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7940060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7940060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5648.51000,1638.07000,Aetna,Local,,2259.40,,,,,,,2036.29,4620.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5648.51000,1638.07000,Aetna,Local,,2259.40,,,,,,,1818.82,4620.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7940794,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7940794,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8979.00000,2603.91000,Aetna,Local,,3591.60,,,,,,,3236.93,7344.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8979.00000,2603.91000,Aetna,Local,,3591.60,,,,,,,2891.24,7344.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7940826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7940826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941863,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941863,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE IN A KIT,7699083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE IN A KIT,7699083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3420.78,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3055.46,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7943248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7943248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3192.92000,925.95000,Aetna,Local,,1277.17,,,,,,,1151.05,2611.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3192.92000,925.95000,Aetna,Local,,1277.17,,,,,,,1028.12,2611.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3342.96000,969.46000,Aetna,Local,,1337.18,,,,,,,1205.14,2734.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3342.96000,969.46000,Aetna,Local,,1337.18,,,,,,,1076.43,2734.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,Local,,2667.35,,,,,,,2403.95,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,Local,,2667.35,,,,,,,2147.22,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7943627,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,Local,,13473.00,,,,,,,12142.54,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7943627,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,Local,,13473.00,,,,,,,10845.76,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7943679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,Local,,4521.24,,,,,,,4074.77,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7943679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,Local,,4521.24,,,,,,,3639.60,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943725,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943725,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7943806,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16425.00000,4763.25000,Aetna,Local,,6570.00,,,,,,,5921.21,13435.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7943806,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16425.00000,4763.25000,Aetna,Local,,6570.00,,,,,,,5288.85,13435.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943807,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,533.11,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943807,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,476.17,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943912,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943912,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7943918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7943918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943930,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943930,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,7943971,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,7943971,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1753.28000,508.45000,Aetna,Local,,701.31,,,,,,,632.06,1434.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1753.28000,508.45000,Aetna,Local,,701.31,,,,,,,564.56,1434.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7944036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25225.20000,7315.31000,Aetna,Local,,10090.08,,,,,,,9093.68,20634.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7944036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25225.20000,7315.31000,Aetna,Local,,10090.08,,,,,,,8122.51,20634.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7944037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7944037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7944075,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7944075,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7944204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3872.44000,1123.01000,Aetna,Local,,1548.98,,,,,,,1396.01,3167.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7944204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3872.44000,1123.01000,Aetna,Local,,1548.98,,,,,,,1246.93,3167.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7944206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10701.00000,3103.29000,Aetna,Local,,4280.40,,,,,,,3857.71,8753.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7944206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10701.00000,3103.29000,Aetna,Local,,4280.40,,,,,,,3445.72,8753.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7944207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7944207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7944226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7944226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,Local,,5242.24,,,,,,,4724.57,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,Local,,5242.24,,,,,,,4220.00,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOMONITOR 2 AF,8136109,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOMONITOR 2 AF,8136109,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7953969,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,8782.32000,2546.87000,Aetna,Local,,3512.93,,,,,,,3166.03,7183.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7953969,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,8782.32000,2546.87000,Aetna,Local,,3512.93,,,,,,,2827.91,7183.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136108,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,113.66000,32.96000,Aetna,Local,,45.46,,,,,,,40.97,92.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136108,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,113.66000,32.96000,Aetna,Local,,45.46,,,,,,,36.60,92.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911544,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911544,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882791,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882791,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750492,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750492,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750483,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750483,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136120,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136120,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136121,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136121,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136119,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136119,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8136221,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8136221,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LASER ARTHRECTOMY CATHETER,8136224,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LASER ARTHRECTOMY CATHETER,8136224,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8136225,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8136225,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701403,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4805.10,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701403,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4291.94,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697528,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,790.20000,229.16000,Aetna,Local,,316.08,,,,,,,284.87,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697528,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,790.20000,229.16000,Aetna,Local,,316.08,,,,,,,254.44,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136227,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136227,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7944414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7944414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7944417,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11472.00000,3326.88000,Aetna,Local,,4588.80,,,,,,,4135.66,9384.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7944417,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11472.00000,3326.88000,Aetna,Local,,4588.80,,,,,,,3693.98,9384.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7944553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5463.50000,1584.42000,Aetna,Local,,2185.40,,,,,,,1969.59,4469.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7944553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5463.50000,1584.42000,Aetna,Local,,2185.40,,,,,,,1759.25,4469.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7944566,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7944566,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7944573,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,790.20000,229.16000,Aetna,Local,,316.08,,,,,,,284.87,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7944573,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,790.20000,229.16000,Aetna,Local,,316.08,,,,,,,254.44,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7945881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,728.50,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7945881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,650.70,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7945949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7945949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7945951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7945951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7844.40000,2274.88000,Aetna,Local,,3137.76,,,,,,,2827.91,6416.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7844.40000,2274.88000,Aetna,Local,,3137.76,,,,,,,2525.90,6416.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3907.58000,1133.20000,Aetna,Local,,1563.03,,,,,,,1408.68,3196.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3907.58000,1133.20000,Aetna,Local,,1563.03,,,,,,,1258.24,3196.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697936,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697936,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7946021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7946021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7946023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7946023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7946040,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,647.19000,187.69000,Aetna,Local,,258.88,,,,,,,233.31,529.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7946040,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,647.19000,187.69000,Aetna,Local,,258.88,,,,,,,208.40,529.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7946119,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,69264.00000,20086.56000,Aetna,Local,,27705.60,,,,,,,24969.67,56657.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7946119,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,69264.00000,20086.56000,Aetna,Local,,27705.60,,,,,,,22303.01,56657.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7946120,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,22607.50000,6556.17000,Aetna,Local,,9043.00,,,,,,,8150.00,18492.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7946120,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,22607.50000,6556.17000,Aetna,Local,,9043.00,,,,,,,7279.61,18492.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7947887,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5634.61,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7947887,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5032.86,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7947893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7947893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7947896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7947896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7947914,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,32951.25000,9555.86000,Aetna,Local,,13180.50,,,,,,,11878.93,26954.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7947914,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,32951.25000,9555.86000,Aetna,Local,,13180.50,,,,,,,10610.30,26954.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7947922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7947922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7947952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3942.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7947952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3521.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1433.16000,415.62000,Aetna,Local,,573.26,,,,,,,516.65,1172.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1433.16000,415.62000,Aetna,Local,,573.26,,,,,,,461.48,1172.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7948096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7948096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7948097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7948097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948124,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12426.00000,3603.54000,Aetna,Local,,4970.40,,,,,,,4479.57,10164.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948124,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12426.00000,3603.54000,Aetna,Local,,4970.40,,,,,,,4001.17,10164.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7948152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7948152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7948170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1906.06,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7948170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1702.50,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7948206,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3804.50000,1103.30000,Aetna,Local,,1521.80,,,,,,,1371.52,3112.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7948206,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3804.50000,1103.30000,Aetna,Local,,1521.80,,,,,,,1225.05,3112.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS,7948209,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9888.00000,2867.52000,Aetna,Local,,3955.20,,,,,,,3564.62,8088.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS,7948209,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9888.00000,2867.52000,Aetna,Local,,3955.20,,,,,,,3183.94,8088.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948225,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,289.57,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948225,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,258.65,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948214,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948214,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,1072.65,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,958.09,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,7948230,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,7948230,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6214.74000,1802.27000,Aetna,Local,,2485.90,,,,,,,2240.41,5083.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6214.74000,1802.27000,Aetna,Local,,2485.90,,,,,,,2001.15,5083.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7948358,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1748.32000,507.01000,Aetna,Local,,699.33,,,,,,,630.27,1430.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7948358,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1748.32000,507.01000,Aetna,Local,,699.33,,,,,,,562.96,1430.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948359,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17212.25000,4991.55000,Aetna,Local,,6884.90,,,,,,,6205.02,14079.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948359,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17212.25000,4991.55000,Aetna,Local,,6884.90,,,,,,,5542.34,14079.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948360,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15369.90000,4457.27000,Aetna,Local,,6147.96,,,,,,,5540.85,12572.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948360,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15369.90000,4457.27000,Aetna,Local,,6147.96,,,,,,,4949.11,12572.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948411,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33862.50000,9820.12000,Aetna,Local,,13545.00,,,,,,,12207.43,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948411,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33862.50000,9820.12000,Aetna,Local,,13545.00,,,,,,,10903.73,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7948412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7948412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,7948519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,7948519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TESTICULAR IMPLANT,7948610,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8499.00000,2464.71000,Aetna,Local,,3399.60,,,,,,,3063.89,6952.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TESTICULAR IMPLANT,7948610,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8499.00000,2464.71000,Aetna,Local,,3399.60,,,,,,,2736.68,6952.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7948232,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7948232,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948596,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948596,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948606,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948606,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948525,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948525,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7948683,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10871.25000,3152.66000,Aetna,Local,,4348.50,,,,,,,3919.09,8892.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7948683,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10871.25000,3152.66000,Aetna,Local,,4348.50,,,,,,,3500.54,8892.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7948614,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7948614,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7948749,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4403.00000,1276.87000,Aetna,Local,,1761.20,,,,,,,1587.28,3601.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7948749,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4403.00000,1276.87000,Aetna,Local,,1761.20,,,,,,,1417.77,3601.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948778,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948778,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6107.50000,1771.18000,Aetna,Local,,2443.00,,,,,,,2201.75,4995.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6107.50000,1771.18000,Aetna,Local,,2443.00,,,,,,,1966.62,4995.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10914.00000,3165.06000,Aetna,Local,,4365.60,,,,,,,3934.50,8927.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10914.00000,3165.06000,Aetna,Local,,4365.60,,,,,,,3514.31,8927.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948864,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948864,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER IN A KIT,7948866,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER IN A KIT,7948866,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950093,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950093,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7950154,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7950154,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7950207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3486.76,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7950207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3114.38,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950343,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950343,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,461.65000,133.88000,Aetna,Local,,184.66,,,,,,,166.42,377.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,461.65000,133.88000,Aetna,Local,,184.66,,,,,,,148.65,377.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7950458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7950458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950498,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950498,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7945854,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,5264.00000,1526.56000,Aetna,Local,,2105.60,,,,,,,1897.67,4305.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7945854,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,5264.00000,1526.56000,Aetna,Local,,2105.60,,,,,,,1695.01,4305.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7950558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7950558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7951863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8464.05000,2454.57000,Aetna,Local,,3385.62,,,,,,,3051.29,6923.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7951863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8464.05000,2454.57000,Aetna,Local,,3385.62,,,,,,,2725.42,6923.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7699723,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22591.50000,6551.54000,Aetna,Local,,9036.60,,,,,,,8144.24,18479.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7699723,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22591.50000,6551.54000,Aetna,Local,,9036.60,,,,,,,7274.46,18479.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7951935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19208.75000,5570.54000,Aetna,Local,,7683.50,,,,,,,6924.75,15712.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7951935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19208.75000,5570.54000,Aetna,Local,,7683.50,,,,,,,6185.22,15712.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT IMPLANTS IN KIT,7953868,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9126.00000,2646.54000,Aetna,Local,,3650.40,,,,,,,3289.92,7465.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT IMPLANTS IN KIT,7953868,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9126.00000,2646.54000,Aetna,Local,,3650.40,,,,,,,2938.57,7465.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7953912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.00000,578.26000,Aetna,Local,,797.60,,,,,,,718.84,1631.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7953912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.00000,578.26000,Aetna,Local,,797.60,,,,,,,642.07,1631.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7953972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7953972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7954116,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7954116,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7954474,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,Local,,1244.80,,,,,,,1121.88,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7954474,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,Local,,1244.80,,,,,,,1002.06,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7954587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7954587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954612,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954612,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7954747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7954747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7954749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7954749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7954750,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,6475.00000,1877.75000,Aetna,Local,,2590.00,,,,,,,2334.24,5296.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7954750,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,6475.00000,1877.75000,Aetna,Local,,2590.00,,,,,,,2084.95,5296.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7954791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7954791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7954792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7954792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7955062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7955062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7955808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1681.44000,487.62000,Aetna,Local,,672.58,,,,,,,606.16,1375.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7955808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1681.44000,487.62000,Aetna,Local,,672.58,,,,,,,541.42,1375.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7956547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7956547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7956662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7956662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7956683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7956683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7956955,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3249.05000,942.22000,Aetna,Local,,1299.62,,,,,,,1171.28,2657.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7956955,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3249.05000,942.22000,Aetna,Local,,1299.62,,,,,,,1046.19,2657.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABSORBABLE SECURESTRAP,7697287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2503.71000,726.08000,Aetna,Local,,1001.48,,,,,,,902.59,2048.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABSORBABLE SECURESTRAP,7697287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2503.71000,726.08000,Aetna,Local,,1001.48,,,,,,,806.19,2048.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7957694,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7957694,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7957716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3524.61,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7957716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3148.19,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7716.45000,2237.77000,Aetna,Local,,3086.58,,,,,,,2781.78,6312.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7716.45000,2237.77000,Aetna,Local,,3086.58,,,,,,,2484.70,6312.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7957790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7957790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,7957816,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,7957816,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,Local,,590.72,,,,,,,532.39,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,Local,,590.72,,,,,,,475.53,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,Local,,590.72,,,,,,,532.39,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,Local,,590.72,,,,,,,475.53,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7957909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7957909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7957910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7957910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7957913,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7957913,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,Local,,4589.28,,,,,,,4136.09,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,Local,,4589.28,,,,,,,3694.37,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7958052,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1304.00000,378.16000,Aetna,Local,,521.60,,,,,,,470.09,1066.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7958052,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1304.00000,378.16000,Aetna,Local,,521.60,,,,,,,419.89,1066.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7958095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7958095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,731.09,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,653.02,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,210.00000,60.90000,Aetna,Local,,84.00,,,,,,,75.70,171.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,Local,,84.00,,,,,,,67.62,171.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7958109,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7958109,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7959591,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,33862.50000,9820.12000,Aetna,Local,,13545.00,,,,,,,12207.43,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7959591,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,33862.50000,9820.12000,Aetna,Local,,13545.00,,,,,,,10903.73,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7959958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,843.86,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7959958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,753.74,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7744546,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,Local,,3615.58,,,,,,,3258.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7744546,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,Local,,3615.58,,,,,,,2910.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7960019,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6125.00000,1776.25000,Aetna,Local,,2450.00,,,,,,,2208.06,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7960019,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6125.00000,1776.25000,Aetna,Local,,2450.00,,,,,,,1972.25,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7960041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7960041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7960155,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7960155,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7962229,CDM,278,RC,,,,,facility,inpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,504.70,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7962229,CDM,278,RC,,,,,facility,outpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,450.80,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7962243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7962243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7962643,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7962643,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7963012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8077.50000,2342.48000,Aetna,Local,,3231.00,,,,,,,2911.94,6607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7963012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8077.50000,2342.48000,Aetna,Local,,3231.00,,,,,,,2600.95,6607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7963934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7963934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,7963957,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,325.85000,94.50000,Aetna,Local,,130.34,,,,,,,117.47,266.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,7963957,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,325.85000,94.50000,Aetna,Local,,130.34,,,,,,,104.92,266.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,7963958,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,360.48000,104.54000,Aetna,Local,,144.19,,,,,,,129.95,294.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,7963958,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,360.48000,104.54000,Aetna,Local,,144.19,,,,,,,116.07,294.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7963961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4365.90000,1266.11000,Aetna,Local,,1746.36,,,,,,,1573.91,3571.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7963961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4365.90000,1266.11000,Aetna,Local,,1746.36,,,,,,,1405.82,3571.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,7964335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,Local,,2225.88,,,,,,,2006.07,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,7964335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,Local,,2225.88,,,,,,,1791.83,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7964476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,Local,,4036.80,,,,,,,3638.17,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7964476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,Local,,4036.80,,,,,,,3249.62,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7964997,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3983.00000,1155.07000,Aetna,Local,,1593.20,,,,,,,1435.87,3258.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7964997,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3983.00000,1155.07000,Aetna,Local,,1593.20,,,,,,,1282.53,3258.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965057,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965057,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965061,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965061,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7965235,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7965235,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7965448,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7965448,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7965452,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7965452,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7965480,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,10224.57000,2965.13000,Aetna,Local,,4089.83,,,,,,,3685.96,8363.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7965480,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,10224.57000,2965.13000,Aetna,Local,,4089.83,,,,,,,3292.31,8363.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7965485,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,Local,,13473.00,,,,,,,12142.54,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7965485,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,Local,,13473.00,,,,,,,10845.76,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7965924,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7965924,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,Local,,1066.40,,,,,,,961.09,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,Local,,1066.40,,,,,,,858.45,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7966067,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7966067,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,3076.87,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,2748.27,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7966070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1266.60000,367.31000,Aetna,Local,,506.64,,,,,,,456.61,1036.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7966070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1266.60000,367.31000,Aetna,Local,,506.64,,,,,,,407.85,1036.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7966074,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1652.00000,479.08000,Aetna,Local,,660.80,,,,,,,595.55,1351.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7966074,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1652.00000,479.08000,Aetna,Local,,660.80,,,,,,,531.94,1351.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7966077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,876.74,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7966077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,783.10,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7966086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7966086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7966087,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2428.28000,704.20000,Aetna,Local,,971.31,,,,,,,875.39,1986.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7966087,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2428.28000,704.20000,Aetna,Local,,971.31,,,,,,,781.91,1986.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7975017,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4544.46,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7975017,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4059.13,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIM,7966235,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,54586.00000,15829.94000,Aetna,Local,,21834.40,,,,,,,19678.25,44651.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIM,7966235,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,54586.00000,15829.94000,Aetna,Local,,21834.40,,,,,,,17576.69,44651.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7967968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7967968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7967971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5404.11000,1567.19000,Aetna,Local,,2161.64,,,,,,,1948.18,4420.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7967971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5404.11000,1567.19000,Aetna,Local,,2161.64,,,,,,,1740.12,4420.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7967960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11374.50000,3298.60000,Aetna,Local,,4549.80,,,,,,,4100.51,9304.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7967960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11374.50000,3298.60000,Aetna,Local,,4549.80,,,,,,,3662.59,9304.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7967962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5771.50000,1673.74000,Aetna,Local,,2308.60,,,,,,,2080.63,4721.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7967962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5771.50000,1673.74000,Aetna,Local,,2308.60,,,,,,,1858.42,4721.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7967974,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,21158.90000,6136.08000,Aetna,Local,,8463.56,,,,,,,7627.78,17307.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7967974,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,21158.90000,6136.08000,Aetna,Local,,8463.56,,,,,,,6813.17,17307.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26350.50000,7641.64000,Aetna,Local,,10540.20,,,,,,,9499.36,21554.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26350.50000,7641.64000,Aetna,Local,,10540.20,,,,,,,8484.86,21554.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUTOGRAFT,7968114,CDM,278,RC,C9399,HCPCS,,,facility,inpatient,,,3286.50000,953.08000,Aetna,Local,,1314.60,,,,,,,1184.78,2688.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUTOGRAFT,7968114,CDM,278,RC,C9399,HCPCS,,,facility,outpatient,,,3286.50000,953.08000,Aetna,Local,,1314.60,,,,,,,1058.25,2688.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,7968118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,7968118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7969242,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7969242,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,Local,,2225.88,,,,,,,2006.07,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,Local,,2225.88,,,,,,,1791.83,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7968187,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,43616.25000,12648.71000,Aetna,Local,,17446.50,,,,,,,15723.66,35678.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7968187,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,43616.25000,12648.71000,Aetna,Local,,17446.50,,,,,,,14044.43,35678.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7968189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7968189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1869.80000,542.24000,Aetna,Local,,747.92,,,,,,,674.06,1529.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1869.80000,542.24000,Aetna,Local,,747.92,,,,,,,602.08,1529.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968225,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1445.72000,419.26000,Aetna,Local,,578.29,,,,,,,521.18,1182.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968225,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1445.72000,419.26000,Aetna,Local,,578.29,,,,,,,465.52,1182.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968230,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1254.66,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968230,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1120.67,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7974720,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7974720,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7968236,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7968236,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968237,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968237,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,Local,,1409.80,,,,,,,1270.58,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,Local,,1409.80,,,,,,,1134.89,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7903716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,8029.01,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7903716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,7171.55,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7903720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7447.50000,2159.77000,Aetna,Local,,2979.00,,,,,,,2684.82,6092.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7903720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7447.50000,2159.77000,Aetna,Local,,2979.00,,,,,,,2398.09,6092.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1527.56000,442.99000,Aetna,Local,,611.02,,,,,,,550.69,1249.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1527.56000,442.99000,Aetna,Local,,611.02,,,,,,,491.87,1249.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903784,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903784,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7736565,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15675.00000,4545.75000,Aetna,Local,,6270.00,,,,,,,5650.84,12822.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7736565,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15675.00000,4545.75000,Aetna,Local,,6270.00,,,,,,,5047.35,12822.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903791,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,21347.50000,6190.78000,Aetna,Local,,8539.00,,,,,,,7695.77,17462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903791,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,21347.50000,6190.78000,Aetna,Local,,8539.00,,,,,,,6873.90,17462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903793,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,22570.00000,6545.30000,Aetna,Local,,9028.00,,,,,,,8136.48,18462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903793,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,22570.00000,6545.30000,Aetna,Local,,9028.00,,,,,,,7267.54,18462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903778,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,25885.00000,7506.65000,Aetna,Local,,10354.00,,,,,,,9331.54,21173.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903778,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,25885.00000,7506.65000,Aetna,Local,,10354.00,,,,,,,8334.97,21173.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903780,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,27960.75000,8108.62000,Aetna,Local,,11184.30,,,,,,,10079.85,22871.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903780,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,27960.75000,8108.62000,Aetna,Local,,11184.30,,,,,,,9003.36,22871.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7866113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7866113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7904053,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7904053,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,338.17,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,302.06,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7904148,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,122.87000,35.63000,Aetna,Local,,49.15,,,,,,,44.29,100.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7904148,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,122.87000,35.63000,Aetna,Local,,49.15,,,,,,,39.56,100.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694140,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1938.32000,562.11000,Aetna,Local,,775.33,,,,,,,698.76,1585.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694140,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1938.32000,562.11000,Aetna,Local,,775.33,,,,,,,624.14,1585.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7904740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7904740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7904977,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7904977,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7905308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7905308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7694586,CDM,278,RC,,,,,facility,inpatient,,,2171.64000,629.78000,Aetna,Local,,868.66,,,,,,,782.88,1776.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7694586,CDM,278,RC,,,,,facility,outpatient,,,2171.64000,629.78000,Aetna,Local,,868.66,,,,,,,699.27,1776.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7760137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7760137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2659.08000,771.13000,Aetna,Local,,1063.63,,,,,,,958.60,2175.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2659.08000,771.13000,Aetna,Local,,1063.63,,,,,,,856.22,2175.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1979.40000,574.03000,Aetna,Local,,791.76,,,,,,,713.57,1619.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1979.40000,574.03000,Aetna,Local,,791.76,,,,,,,637.37,1619.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905403,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3228.96000,936.40000,Aetna,Local,,1291.58,,,,,,,1164.04,2641.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905403,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3228.96000,936.40000,Aetna,Local,,1291.58,,,,,,,1039.73,2641.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905404,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2974.12000,862.49000,Aetna,Local,,1189.65,,,,,,,1072.17,2432.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905404,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2974.12000,862.49000,Aetna,Local,,1189.65,,,,,,,957.67,2432.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905410,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2293.12000,665.00000,Aetna,Local,,917.25,,,,,,,826.67,1875.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905410,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2293.12000,665.00000,Aetna,Local,,917.25,,,,,,,738.38,1875.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7804053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7804053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7905548,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,741.19,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7905548,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,662.03,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7905550,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1991.36000,577.49000,Aetna,Local,,796.54,,,,,,,717.89,1628.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7905550,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1991.36000,577.49000,Aetna,Local,,796.54,,,,,,,641.22,1628.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7905567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7905567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7802049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7802049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7893762,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1693.52,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7893762,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1512.66,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.48000,574.92000,Aetna,Local,,792.99,,,,,,,714.68,1621.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.48000,574.92000,Aetna,Local,,792.99,,,,,,,638.36,1621.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1871.68,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1671.79,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7698227,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7698227,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7908365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5781.58000,1676.66000,Aetna,Local,,2312.63,,,,,,,2084.26,4729.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7908365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5781.58000,1676.66000,Aetna,Local,,2312.63,,,,,,,1861.67,4729.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3328.50000,965.26000,Aetna,Local,,1331.40,,,,,,,1199.92,2722.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3328.50000,965.26000,Aetna,Local,,1331.40,,,,,,,1071.78,2722.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7908507,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,6286.00000,1822.94000,Aetna,Local,,2514.40,,,,,,,2266.10,5141.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7908507,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,6286.00000,1822.94000,Aetna,Local,,2514.40,,,,,,,2024.09,5141.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908597,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908597,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7908714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7908714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7878470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8445.00000,2449.05000,Aetna,Local,,3378.00,,,,,,,3044.42,6908.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7878470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8445.00000,2449.05000,Aetna,Local,,3378.00,,,,,,,2719.29,6908.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7908749,CDM,278,RC,,,,,facility,inpatient,,,1936.00000,561.44000,Aetna,Local,,774.40,,,,,,,697.93,1583.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7908749,CDM,278,RC,,,,,facility,outpatient,,,1936.00000,561.44000,Aetna,Local,,774.40,,,,,,,623.39,1583.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7909029,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7909029,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5152.00000,1494.08000,Aetna,Local,,2060.80,,,,,,,1857.30,4214.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5152.00000,1494.08000,Aetna,Local,,2060.80,,,,,,,1658.94,4214.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6102.04000,1769.59000,Aetna,Local,,2440.82,,,,,,,2199.79,4991.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6102.04000,1769.59000,Aetna,Local,,2440.82,,,,,,,1964.86,4991.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7698399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7698399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7909407,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7909407,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PLUG,7909414,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PLUG,7909414,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7909483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7909483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7909485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7909485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910136,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910136,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5950.35000,1725.60000,Aetna,Local,,2380.14,,,,,,,2145.10,4867.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5950.35000,1725.60000,Aetna,Local,,2380.14,,,,,,,1916.01,4867.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7910164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9409.02000,2728.62000,Aetna,Local,,3763.61,,,,,,,3391.95,7696.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7910164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9409.02000,2728.62000,Aetna,Local,,3763.61,,,,,,,3029.70,7696.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910198,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,16350.00000,4741.50000,Aetna,Local,,6540.00,,,,,,,5894.18,13374.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910198,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,16350.00000,4741.50000,Aetna,Local,,6540.00,,,,,,,5264.70,13374.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910199,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,28192.50000,8175.82000,Aetna,Local,,11277.00,,,,,,,10163.40,23061.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910199,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,28192.50000,8175.82000,Aetna,Local,,11277.00,,,,,,,9077.99,23061.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910200,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,43357.50000,12573.68000,Aetna,Local,,17343.00,,,,,,,15630.38,35466.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910200,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,43357.50000,12573.68000,Aetna,Local,,17343.00,,,,,,,13961.11,35466.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910201,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,52520.00000,15230.80000,Aetna,Local,,21008.00,,,,,,,18933.46,42961.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910201,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,52520.00000,15230.80000,Aetna,Local,,21008.00,,,,,,,16911.44,42961.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910202,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,35797.50000,10381.28000,Aetna,Local,,14319.00,,,,,,,12905.00,29282.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910202,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,35797.50000,10381.28000,Aetna,Local,,14319.00,,,,,,,11526.80,29282.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910203,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,42232.50000,12247.42000,Aetna,Local,,16893.00,,,,,,,15224.82,34546.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910203,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,42232.50000,12247.42000,Aetna,Local,,16893.00,,,,,,,13598.86,34546.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910204,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,13629.00000,3952.41000,Aetna,Local,,5451.60,,,,,,,4913.25,11148.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910204,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,13629.00000,3952.41000,Aetna,Local,,5451.60,,,,,,,4388.54,11148.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910205,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,20345.00000,5900.05000,Aetna,Local,,8138.00,,,,,,,7334.37,16642.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910205,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,20345.00000,5900.05000,Aetna,Local,,8138.00,,,,,,,6551.09,16642.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910206,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,28273.50000,8199.31000,Aetna,Local,,11309.40,,,,,,,10192.60,23127.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910206,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,28273.50000,8199.31000,Aetna,Local,,11309.40,,,,,,,9104.07,23127.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PROXIMAL,7698363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10362.00000,3004.98000,Aetna,Local,,4144.80,,,,,,,3735.50,8476.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PROXIMAL,7698363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10362.00000,3004.98000,Aetna,Local,,4144.80,,,,,,,3336.56,8476.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PROXIMAL,7910253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,Local,,3463.20,,,,,,,3121.21,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PROXIMAL,7910253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,Local,,3463.20,,,,,,,2787.88,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7910310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,Local,,2241.68,,,,,,,2020.31,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7910310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,Local,,2241.68,,,,,,,1804.55,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7910275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5791.42000,1679.51000,Aetna,Local,,2316.57,,,,,,,2087.81,4737.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7910275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5791.42000,1679.51000,Aetna,Local,,2316.57,,,,,,,1864.84,4737.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7910504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7910504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7910512,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7910512,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7910540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2322.80000,673.61000,Aetna,Local,,929.12,,,,,,,837.37,1900.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7910540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2322.80000,673.61000,Aetna,Local,,929.12,,,,,,,747.94,1900.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE HELMET,7910541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1764.64000,511.75000,Aetna,Local,,705.86,,,,,,,636.15,1443.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE HELMET,7910541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1764.64000,511.75000,Aetna,Local,,705.86,,,,,,,568.21,1443.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910692,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910692,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910976,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,792.32000,229.77000,Aetna,Local,,316.93,,,,,,,285.63,648.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910976,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,792.32000,229.77000,Aetna,Local,,316.93,,,,,,,255.13,648.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910978,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1244.80000,360.99000,Aetna,Local,,497.92,,,,,,,448.75,1018.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910978,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1244.80000,360.99000,Aetna,Local,,497.92,,,,,,,400.83,1018.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7911003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7911003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7911005,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1491.35,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7911005,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1332.08,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7911035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7911035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION DEVICE IMPLANT IN KIT,7911304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4494.00000,1303.26000,Aetna,Local,,1797.60,,,,,,,1620.09,3676.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION DEVICE IMPLANT IN KIT,7911304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4494.00000,1303.26000,Aetna,Local,,1797.60,,,,,,,1447.07,3676.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911312,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,Local,,2461.20,,,,,,,2218.16,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911312,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,Local,,2461.20,,,,,,,1981.27,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7794037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,4133.49,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7794037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,3692.05,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,116.29,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,103.87,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOTAL KNEE,7911437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,5497.62,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOTAL KNEE,7911437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,4910.50,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7911440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7911440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP BIPOLAR M,7911441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP BIPOLAR M,7911441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DRILL GUIDE,7911589,CDM,278,RC,,,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DRILL GUIDE,7911589,CDM,278,RC,,,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911720,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911720,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,497.63,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,444.49,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7968227,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2028.40000,588.24000,Aetna,Local,,811.36,,,,,,,731.24,1659.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7968227,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2028.40000,588.24000,Aetna,Local,,811.36,,,,,,,653.14,1659.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7968234,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,7596.00000,2202.84000,Aetna,Local,,3038.40,,,,,,,2738.36,6213.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7968234,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,7596.00000,2202.84000,Aetna,Local,,3038.40,,,,,,,2445.91,6213.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7968246,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9321.42000,2703.21000,Aetna,Local,,3728.57,,,,,,,3360.37,7624.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7968246,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9321.42000,2703.21000,Aetna,Local,,3728.57,,,,,,,3001.50,7624.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968354,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4544.46,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968354,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4059.13,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7968409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7968409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968431,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968431,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968434,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968434,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7968435,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7968435,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2091.92000,606.66000,Aetna,Local,,836.77,,,,,,,754.14,1711.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2091.92000,606.66000,Aetna,Local,,836.77,,,,,,,673.60,1711.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7968506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,432.25000,125.35000,Aetna,Local,,172.90,,,,,,,155.83,353.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7968506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,432.25000,125.35000,Aetna,Local,,172.90,,,,,,,139.18,353.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7968510,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26000.00000,7540.00000,Aetna,Local,,10400.00,,,,,,,9373.00,21268.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7968510,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26000.00000,7540.00000,Aetna,Local,,10400.00,,,,,,,8372.00,21268.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975099,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975099,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7967963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3070.00000,890.30000,Aetna,Local,,1228.00,,,,,,,1106.73,2511.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7967963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3070.00000,890.30000,Aetna,Local,,1228.00,,,,,,,988.54,2511.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7967964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,Local,,832.00,,,,,,,749.84,1701.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7967964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,Local,,832.00,,,,,,,669.76,1701.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7968693,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7968693,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8913.30000,2584.86000,Aetna,Local,,3565.32,,,,,,,3213.24,7291.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8913.30000,2584.86000,Aetna,Local,,3565.32,,,,,,,2870.08,7291.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,728.50,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,650.70,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2142.40000,621.30000,Aetna,Local,,856.96,,,,,,,772.34,1752.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2142.40000,621.30000,Aetna,Local,,856.96,,,,,,,689.85,1752.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7968723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7968723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7968825,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7968825,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7968954,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4028.15000,1168.16000,Aetna,Local,,1611.26,,,,,,,1452.15,3295.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7968954,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4028.15000,1168.16000,Aetna,Local,,1611.26,,,,,,,1297.06,3295.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1395.50,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1246.46,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7968967,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,25750.00000,7467.50000,Aetna,Local,,10300.00,,,,,,,9282.88,21063.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7968967,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,25750.00000,7467.50000,Aetna,Local,,10300.00,,,,,,,8291.50,21063.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7968969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7968969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,Local,,1409.80,,,,,,,1270.58,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,Local,,1409.80,,,,,,,1134.89,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969028,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969028,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7969024,CDM,278,RC,C1714,HCPCS,,,facility,inpatient,,,13185.00000,3823.65000,Aetna,Local,,5274.00,,,,,,,4753.19,10785.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7969024,CDM,278,RC,C1714,HCPCS,,,facility,outpatient,,,13185.00000,3823.65000,Aetna,Local,,5274.00,,,,,,,4245.57,10785.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5618.62000,1629.40000,Aetna,Local,,2247.45,,,,,,,2025.51,4596.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5618.62000,1629.40000,Aetna,Local,,2247.45,,,,,,,1809.20,4596.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7969316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7969316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.76000,961.57000,Aetna,Local,,1326.30,,,,,,,1195.33,2712.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.76000,961.57000,Aetna,Local,,1326.30,,,,,,,1067.67,2712.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974079,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974079,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7969473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7969473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7969476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,801.38,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7969476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,715.79,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7969540,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1958.96000,568.10000,Aetna,Local,,783.58,,,,,,,706.21,1602.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7969540,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1958.96000,568.10000,Aetna,Local,,783.58,,,,,,,630.79,1602.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2283.52000,662.22000,Aetna,Local,,913.41,,,,,,,823.21,1867.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2283.52000,662.22000,Aetna,Local,,913.41,,,,,,,735.29,1867.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2137.68000,619.93000,Aetna,Local,,855.07,,,,,,,770.63,1748.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2137.68000,619.93000,Aetna,Local,,855.07,,,,,,,688.33,1748.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1939.04000,562.32000,Aetna,Local,,775.62,,,,,,,699.02,1586.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1939.04000,562.32000,Aetna,Local,,775.62,,,,,,,624.37,1586.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1631.80000,473.22000,Aetna,Local,,652.72,,,,,,,588.26,1334.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1631.80000,473.22000,Aetna,Local,,652.72,,,,,,,525.44,1334.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969544,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969544,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7969566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1469.63,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7969566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1312.67,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969634,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969634,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6637.02000,1924.74000,Aetna,Local,,2654.81,,,,,,,2392.65,5429.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6637.02000,1924.74000,Aetna,Local,,2654.81,,,,,,,2137.12,5429.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7969679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7969679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969714,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969714,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7976331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7976331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7969724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1855.02,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7969724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1656.92,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7969747,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,39829.50000,11550.55000,Aetna,Local,,15931.80,,,,,,,14358.53,32580.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7969747,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,39829.50000,11550.55000,Aetna,Local,,15931.80,,,,,,,12825.10,32580.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7969748,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3578.56000,1037.78000,Aetna,Local,,1431.42,,,,,,,1290.07,2927.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7969748,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3578.56000,1037.78000,Aetna,Local,,1431.42,,,,,,,1152.30,2927.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969742,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969742,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,731.09,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,653.02,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5941.78000,1723.12000,Aetna,Local,,2376.71,,,,,,,2142.01,4860.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5941.78000,1723.12000,Aetna,Local,,2376.71,,,,,,,1913.25,4860.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7969784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1244.00000,360.76000,Aetna,Local,,497.60,,,,,,,448.46,1017.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7969784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1244.00000,360.76000,Aetna,Local,,497.60,,,,,,,400.57,1017.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7969826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6210.33000,1801.00000,Aetna,Local,,2484.13,,,,,,,2238.82,5080.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7969826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6210.33000,1801.00000,Aetna,Local,,2484.13,,,,,,,1999.73,5080.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969827,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9564.00000,2773.56000,Aetna,Local,,3825.60,,,,,,,3447.82,7823.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969827,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9564.00000,2773.56000,Aetna,Local,,3825.60,,,,,,,3079.61,7823.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969828,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969828,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,7969833,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,7969833,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7969832,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,114.19000,33.12000,Aetna,Local,,45.68,,,,,,,41.17,93.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7969832,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,114.19000,33.12000,Aetna,Local,,45.68,,,,,,,36.77,93.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7971855,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1547.56000,448.79000,Aetna,Local,,619.02,,,,,,,557.90,1265.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7971855,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1547.56000,448.79000,Aetna,Local,,619.02,,,,,,,498.31,1265.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7971861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7971861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7971854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2876.80000,834.27000,Aetna,Local,,1150.72,,,,,,,1037.09,2353.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7971854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2876.80000,834.27000,Aetna,Local,,1150.72,,,,,,,926.33,2353.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2168.72000,628.93000,Aetna,Local,,867.49,,,,,,,781.82,1774.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2168.72000,628.93000,Aetna,Local,,867.49,,,,,,,698.33,1774.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2365.78,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2113.12,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7972021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7972021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7973848,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7973848,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7972278,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7972278,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972238,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,Local,,1818.04,,,,,,,1638.51,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972238,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,Local,,1818.04,,,,,,,1463.52,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5527.55000,1602.99000,Aetna,Local,,2211.02,,,,,,,1992.68,4521.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5527.55000,1602.99000,Aetna,Local,,2211.02,,,,,,,1779.87,4521.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6180.65000,1792.39000,Aetna,Local,,2472.26,,,,,,,2228.12,5055.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6180.65000,1792.39000,Aetna,Local,,2472.26,,,,,,,1990.17,5055.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3892.18000,1128.73000,Aetna,Local,,1556.87,,,,,,,1403.13,3183.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3892.18000,1128.73000,Aetna,Local,,1556.87,,,,,,,1253.28,3183.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972263,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972263,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7972277,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7972277,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,Local,,873.60,,,,,,,787.33,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,Local,,873.60,,,,,,,703.25,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7972594,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4309.20000,1249.67000,Aetna,Local,,1723.68,,,,,,,1553.47,3524.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7972594,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4309.20000,1249.67000,Aetna,Local,,1723.68,,,,,,,1387.56,3524.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,7972583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5012.00000,1453.48000,Aetna,Local,,2004.80,,,,,,,1806.83,4099.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,7972583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5012.00000,1453.48000,Aetna,Local,,2004.80,,,,,,,1613.86,4099.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FUSION DEVICE,7972656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FUSION DEVICE,7972656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7973830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4945.50000,1434.20000,Aetna,Local,,1978.20,,,,,,,1782.85,4045.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7973830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4945.50000,1434.20000,Aetna,Local,,1978.20,,,,,,,1592.45,4045.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7973839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5153.40000,1494.49000,Aetna,Local,,2061.36,,,,,,,1857.80,4215.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7973839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5153.40000,1494.49000,Aetna,Local,,2061.36,,,,,,,1659.39,4215.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694901,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4541.88000,1317.15000,Aetna,Local,,1816.75,,,,,,,1637.35,3715.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694901,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4541.88000,1317.15000,Aetna,Local,,1816.75,,,,,,,1462.49,3715.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,7962808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,7962808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8160823,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8160823,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160911,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160911,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160917,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160917,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8160919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8160919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5793.90000,1680.23000,Aetna,Local,,2317.56,,,,,,,2088.70,4739.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5793.90000,1680.23000,Aetna,Local,,2317.56,,,,,,,1865.64,4739.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8160983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8160983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8160984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8160984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8160985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8160985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8160981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8160981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8161098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8161098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HUMAN TISS,8161100,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6083.00000,1764.07000,Aetna,Local,,2433.20,,,,,,,2192.92,4975.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HUMAN TISS,8161100,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6083.00000,1764.07000,Aetna,Local,,2433.20,,,,,,,1958.73,4975.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8161261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8161261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8161144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8161144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8161167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,6060.91,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8161167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,5413.62,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.00000,516.20000,Aetna,Local,,712.00,,,,,,,641.69,1456.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.00000,516.20000,Aetna,Local,,712.00,,,,,,,573.16,1456.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8161169,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8161169,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT CORE,8161173,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT CORE,8161173,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8161174,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8161174,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8161175,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8161175,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8161299,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,Local,,20156.16,,,,,,,18165.74,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8161299,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,Local,,20156.16,,,,,,,16225.71,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8161301,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8161301,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8161366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8161366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONET FEMORAL,8161367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONET FEMORAL,8161367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG MICROVASCULAR,8161369,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,2170.21,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG MICROVASCULAR,8161369,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,1938.44,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8161373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8161373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8161375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8161375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8161409,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8161409,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8161404,CDM,278,RC,C1785,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8161404,CDM,278,RC,C1785,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8161547,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8061.39000,2337.80000,Aetna,Local,,3224.56,,,,,,,2906.13,6594.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8161547,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8061.39000,2337.80000,Aetna,Local,,3224.56,,,,,,,2595.77,6594.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,258.04,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,230.48,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8161594,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,20820.00000,6037.80000,Aetna,Local,,8328.00,,,,,,,7505.61,17030.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8161594,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,20820.00000,6037.80000,Aetna,Local,,8328.00,,,,,,,6704.04,17030.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8161595,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8161595,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8161598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8161598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161724,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161724,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.39000,1486.07000,Aetna,Local,,2049.76,,,,,,,1847.34,4191.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.39000,1486.07000,Aetna,Local,,2049.76,,,,,,,1650.05,4191.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8161799,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8161799,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,8161803,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,8161803,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8163806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8163806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8163807,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,6060.91,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8163807,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,5413.62,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8163808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8163808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,Local,,1738.80,,,,,,,1567.09,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,Local,,1738.80,,,,,,,1399.73,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,Local,,1738.80,,,,,,,1567.09,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,Local,,1738.80,,,,,,,1399.73,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,Local,,1738.80,,,,,,,1567.09,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,Local,,1738.80,,,,,,,1399.73,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8163983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8163983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8166017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8166017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8166018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8166018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8166020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8166020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166126,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166126,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166128,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8082.00000,2343.78000,Aetna,Local,,3232.80,,,,,,,2913.56,6611.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166128,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8082.00000,2343.78000,Aetna,Local,,3232.80,,,,,,,2602.40,6611.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166224,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8082.00000,2343.78000,Aetna,Local,,3232.80,,,,,,,2913.56,6611.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166224,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8082.00000,2343.78000,Aetna,Local,,3232.80,,,,,,,2602.40,6611.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166130,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,11970.00000,3471.30000,Aetna,Local,,4788.00,,,,,,,4315.19,9791.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166130,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,11970.00000,3471.30000,Aetna,Local,,4788.00,,,,,,,3854.34,9791.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166132,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17460.00000,5063.40000,Aetna,Local,,6984.00,,,,,,,6294.33,14282.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166132,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17460.00000,5063.40000,Aetna,Local,,6984.00,,,,,,,5622.12,14282.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166134,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17460.00000,5063.40000,Aetna,Local,,6984.00,,,,,,,6294.33,14282.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166134,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17460.00000,5063.40000,Aetna,Local,,6984.00,,,,,,,5622.12,14282.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166136,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166136,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166138,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,28462.50000,8254.12000,Aetna,Local,,11385.00,,,,,,,10260.73,23282.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166138,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,28462.50000,8254.12000,Aetna,Local,,11385.00,,,,,,,9164.92,23282.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166143,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7734.60000,2243.03000,Aetna,Local,,3093.84,,,,,,,2788.32,6326.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166143,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7734.60000,2243.03000,Aetna,Local,,3093.84,,,,,,,2490.54,6326.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,525.09,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,469.01,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,525.09,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,469.01,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166146,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166146,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,843.86,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,753.74,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8166141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8166141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8166291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8166291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8167850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8167850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8166264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8166264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
insert,8166266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
insert,8166266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8166268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8166268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8167808,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1645.01,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8167808,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1469.33,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING LCKNG,8167809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,Local,,994.72,,,,,,,896.49,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING LCKNG,8167809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,Local,,994.72,,,,,,,800.75,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8167810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8167810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8167811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1645.01,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8167811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1469.33,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8167812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8167812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8167852,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21412.50000,6209.62000,Aetna,Local,,8565.00,,,,,,,7719.21,17515.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8167852,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21412.50000,6209.62000,Aetna,Local,,8565.00,,,,,,,6894.82,17515.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8167854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8167854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8167963,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6545.00000,1898.05000,Aetna,Local,,2618.00,,,,,,,2359.47,5353.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8167963,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6545.00000,1898.05000,Aetna,Local,,2618.00,,,,,,,2107.49,5353.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911543,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911543,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6620.25000,1919.87000,Aetna,Local,,2648.10,,,,,,,2386.60,5415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6620.25000,1919.87000,Aetna,Local,,2648.10,,,,,,,2131.72,5415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7701605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7701605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702144,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,17763.64,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702144,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,15866.55,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701576,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5520.87000,1601.05000,Aetna,Local,,2208.35,,,,,,,1990.27,4516.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701576,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5520.87000,1601.05000,Aetna,Local,,2208.35,,,,,,,1777.72,4516.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7702166,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7702166,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,277.40,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,247.78,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,7699669,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,594.00000,172.26000,Aetna,Local,,237.60,,,,,,,214.14,485.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,7699669,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,594.00000,172.26000,Aetna,Local,,237.60,,,,,,,191.27,485.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION LIMB,7702228,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,Local,,4858.80,,,,,,,4378.99,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION LIMB,7702228,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,Local,,4858.80,,,,,,,3911.33,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7702252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7702252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,7702255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3408.13000,988.36000,Aetna,Local,,1363.25,,,,,,,1228.63,2787.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,7702255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3408.13000,988.36000,Aetna,Local,,1363.25,,,,,,,1097.42,2787.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7702239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.80000,386.51000,Aetna,Local,,533.12,,,,,,,480.47,1090.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7702239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.80000,386.51000,Aetna,Local,,533.12,,,,,,,429.16,1090.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3745.00000,1086.05000,Aetna,Local,,1498.00,,,,,,,1350.07,3063.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3745.00000,1086.05000,Aetna,Local,,1498.00,,,,,,,1205.89,3063.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5376.95000,1559.32000,Aetna,Local,,2150.78,,,,,,,1938.39,4398.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5376.95000,1559.32000,Aetna,Local,,2150.78,,,,,,,1731.38,4398.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.00000,508.08000,Aetna,Local,,700.80,,,,,,,631.60,1433.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.00000,508.08000,Aetna,Local,,700.80,,,,,,,564.14,1433.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,Local,,535.04,,,,,,,482.20,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,Local,,535.04,,,,,,,430.71,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,62.32,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,55.67,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2345.64000,680.24000,Aetna,Local,,938.26,,,,,,,845.60,1918.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2345.64000,680.24000,Aetna,Local,,938.26,,,,,,,755.30,1918.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,605.93,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,541.22,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,739.17,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,660.23,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1548.80000,449.15000,Aetna,Local,,619.52,,,,,,,558.34,1266.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1548.80000,449.15000,Aetna,Local,,619.52,,,,,,,498.71,1266.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1601.60000,464.46000,Aetna,Local,,640.64,,,,,,,577.38,1310.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1601.60000,464.46000,Aetna,Local,,640.64,,,,,,,515.72,1310.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1414.56000,410.22000,Aetna,Local,,565.82,,,,,,,509.95,1157.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1414.56000,410.22000,Aetna,Local,,565.82,,,,,,,455.49,1157.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2499.20000,724.77000,Aetna,Local,,999.68,,,,,,,900.96,2044.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2499.20000,724.77000,Aetna,Local,,999.68,,,,,,,804.74,2044.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2811.20000,815.25000,Aetna,Local,,1124.48,,,,,,,1013.44,2299.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2811.20000,815.25000,Aetna,Local,,1124.48,,,,,,,905.21,2299.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,472.69,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,422.21,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,605.93,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,541.22,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,701.10,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,626.23,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4067.70000,1179.63000,Aetna,Local,,1627.08,,,,,,,1466.41,3327.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4067.70000,1179.63000,Aetna,Local,,1627.08,,,,,,,1309.80,3327.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1958.00000,567.82000,Aetna,Local,,783.20,,,,,,,705.86,1601.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1958.00000,567.82000,Aetna,Local,,783.20,,,,,,,630.48,1601.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4137.00000,1199.73000,Aetna,Local,,1654.80,,,,,,,1491.39,3384.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4137.00000,1199.73000,Aetna,Local,,1654.80,,,,,,,1332.11,3384.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2882.00000,835.78000,Aetna,Local,,1152.80,,,,,,,1038.96,2357.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2882.00000,835.78000,Aetna,Local,,1152.80,,,,,,,928.00,2357.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8932.50000,2590.42000,Aetna,Local,,3573.00,,,,,,,3220.17,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8932.50000,2590.42000,Aetna,Local,,3573.00,,,,,,,2876.26,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7694909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7694909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,3098.50,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,2767.59,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7702625,CDM,278,RC,L8641,HCPCS,,,facility,inpatient,,,3712.80000,1076.71000,Aetna,Local,,1485.12,,,,,,,1338.46,3037.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7702625,CDM,278,RC,L8641,HCPCS,,,facility,outpatient,,,3712.80000,1076.71000,Aetna,Local,,1485.12,,,,,,,428.55,3037.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7702621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7702621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,2173.83,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,1941.68,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7360.47000,2134.54000,Aetna,Local,,2944.19,,,,,,,2653.45,6020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7360.47000,2134.54000,Aetna,Local,,2944.19,,,,,,,2370.07,6020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7419.12000,2151.54000,Aetna,Local,,2967.65,,,,,,,2674.59,6068.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7419.12000,2151.54000,Aetna,Local,,2967.65,,,,,,,2388.96,6068.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7703022,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2360.00000,684.40000,Aetna,Local,,944.00,,,,,,,850.78,1930.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7703022,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2360.00000,684.40000,Aetna,Local,,944.00,,,,,,,759.92,1930.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7707439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2520.00000,730.80000,Aetna,Local,,1008.00,,,,,,,908.46,2061.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7707439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2520.00000,730.80000,Aetna,Local,,1008.00,,,,,,,811.44,2061.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,Local,,1619.80,,,,,,,1459.84,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,Local,,1619.80,,,,,,,1303.94,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.40000,730.63000,Aetna,Local,,1007.76,,,,,,,908.24,2060.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.40000,730.63000,Aetna,Local,,1007.76,,,,,,,811.25,2060.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,Local,,2290.68,,,,,,,2064.48,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,Local,,2290.68,,,,,,,1844.00,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7736079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7564.05000,2193.57000,Aetna,Local,,3025.62,,,,,,,2726.84,6187.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7736079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7564.05000,2193.57000,Aetna,Local,,3025.62,,,,,,,2435.62,6187.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7695235,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,872.55000,253.04000,Aetna,Local,,349.02,,,,,,,314.55,713.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7695235,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,872.55000,253.04000,Aetna,Local,,349.02,,,,,,,280.96,713.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7736085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7736085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7700188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15691.15000,4550.43000,Aetna,Local,,6276.46,,,,,,,5656.66,12835.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7700188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15691.15000,4550.43000,Aetna,Local,,6276.46,,,,,,,5052.55,12835.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,526.16,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,469.97,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7736107,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,10252.50000,2973.22000,Aetna,Local,,4101.00,,,,,,,3696.03,8386.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7736107,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,10252.50000,2973.22000,Aetna,Local,,4101.00,,,,,,,3301.30,8386.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699418,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699418,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7736131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7731.00000,2241.99000,Aetna,Local,,3092.40,,,,,,,2787.03,6323.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7736131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7731.00000,2241.99000,Aetna,Local,,3092.40,,,,,,,2489.38,6323.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3423.00000,992.67000,Aetna,Local,,1369.20,,,,,,,1233.99,2800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3423.00000,992.67000,Aetna,Local,,1369.20,,,,,,,1102.21,2800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7736170,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,20587.50000,5970.38000,Aetna,Local,,8235.00,,,,,,,7421.79,16840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7736170,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,20587.50000,5970.38000,Aetna,Local,,8235.00,,,,,,,6629.18,16840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3430.00000,994.70000,Aetna,Local,,1372.00,,,,,,,1236.52,2805.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3430.00000,994.70000,Aetna,Local,,1372.00,,,,,,,1104.46,2805.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7736197,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14382.00000,4170.78000,Aetna,Local,,5752.80,,,,,,,5184.71,11764.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7736197,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14382.00000,4170.78000,Aetna,Local,,5752.80,,,,,,,4631.00,11764.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695215,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3414.53,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695215,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3049.87,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736217,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,555.75000,161.17000,Aetna,Local,,222.30,,,,,,,200.35,454.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736217,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,555.75000,161.17000,Aetna,Local,,222.30,,,,,,,178.95,454.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700422,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700422,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7697458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7697458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7736354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7736354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7736448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6696.76000,1942.06000,Aetna,Local,,2678.70,,,,,,,2414.18,5477.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7736448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6696.76000,1942.06000,Aetna,Local,,2678.70,,,,,,,2156.36,5477.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1664.96000,482.84000,Aetna,Local,,665.98,,,,,,,600.22,1361.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1664.96000,482.84000,Aetna,Local,,665.98,,,,,,,536.12,1361.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5934.95000,1721.14000,Aetna,Local,,2373.98,,,,,,,2139.55,4854.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5934.95000,1721.14000,Aetna,Local,,2373.98,,,,,,,1911.05,4854.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,Local,,1619.80,,,,,,,1459.84,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,Local,,1619.80,,,,,,,1303.94,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7736506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,906.53000,262.89000,Aetna,Local,,362.61,,,,,,,326.80,741.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7736506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,906.53000,262.89000,Aetna,Local,,362.61,,,,,,,291.90,741.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7736512,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7736512,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.76000,516.42000,Aetna,Local,,712.30,,,,,,,641.96,1456.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.76000,516.42000,Aetna,Local,,712.30,,,,,,,573.40,1456.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7973840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7973840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7973841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,892.35000,258.78000,Aetna,Local,,356.94,,,,,,,321.69,729.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7973841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,892.35000,258.78000,Aetna,Local,,356.94,,,,,,,287.34,729.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2001.72000,580.50000,Aetna,Local,,800.69,,,,,,,721.62,1637.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2001.72000,580.50000,Aetna,Local,,800.69,,,,,,,644.55,1637.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3042.72000,882.39000,Aetna,Local,,1217.09,,,,,,,1096.90,2488.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3042.72000,882.39000,Aetna,Local,,1217.09,,,,,,,979.76,2488.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4361.25000,1264.76000,Aetna,Local,,1744.50,,,,,,,1572.23,3567.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4361.25000,1264.76000,Aetna,Local,,1744.50,,,,,,,1404.32,3567.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7973849,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7973849,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7973851,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,25250.00000,7322.50000,Aetna,Local,,10100.00,,,,,,,9102.62,20654.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7973851,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,25250.00000,7322.50000,Aetna,Local,,10100.00,,,,,,,8130.50,20654.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974141,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974141,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7974588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7974588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974595,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974595,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7974596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7974596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7974648,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7974648,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7974702,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1895.60000,549.72000,Aetna,Local,,758.24,,,,,,,683.36,1550.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7974702,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1895.60000,549.72000,Aetna,Local,,758.24,,,,,,,610.38,1550.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7974756,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,6218.62,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7974756,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,5554.50,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,666.58,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,595.39,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1803.80,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1611.16,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7974815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7974815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7974816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7974816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7974856,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7974856,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7976741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7976741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4822.93000,1398.65000,Aetna,Local,,1929.17,,,,,,,1738.67,3945.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4822.93000,1398.65000,Aetna,Local,,1929.17,,,,,,,1552.98,3945.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7975021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,444.13000,128.80000,Aetna,Local,,177.65,,,,,,,160.11,363.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7975021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,444.13000,128.80000,Aetna,Local,,177.65,,,,,,,143.01,363.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7975047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5995.50000,1738.70000,Aetna,Local,,2398.20,,,,,,,2161.38,4904.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7975047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5995.50000,1738.70000,Aetna,Local,,2398.20,,,,,,,1930.55,4904.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7975065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7975065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7975066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7975066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980714,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980714,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975078,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975078,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975087,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975087,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975094,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975094,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975119,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975119,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,7975185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,7975185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7975186,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7975186,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7976362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,3098.50,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7976362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,2767.59,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7976428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7976428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7976429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7976429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6167.00000,1788.43000,Aetna,Local,,2466.80,,,,,,,2223.20,5044.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6167.00000,1788.43000,Aetna,Local,,2466.80,,,,,,,1985.77,5044.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3753.65000,1088.56000,Aetna,Local,,1501.46,,,,,,,1353.19,3070.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3753.65000,1088.56000,Aetna,Local,,1501.46,,,,,,,1208.68,3070.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7976531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,701.28000,203.37000,Aetna,Local,,280.51,,,,,,,252.81,573.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7976531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,701.28000,203.37000,Aetna,Local,,280.51,,,,,,,225.81,573.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7976624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7976624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,Local,,1456.80,,,,,,,1312.94,2979.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,Local,,1456.80,,,,,,,1172.72,2979.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7976652,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7976652,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7982902,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7982902,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIC PROTECTOR,7976733,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,14217.00000,4122.93000,Aetna,Local,,5686.80,,,,,,,5125.23,11629.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIC PROTECTOR,7976733,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,14217.00000,4122.93000,Aetna,Local,,5686.80,,,,,,,4577.87,11629.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7978329,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7978329,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,577.91,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,516.19,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7978416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3544.10000,1027.79000,Aetna,Local,,1417.64,,,,,,,1277.65,2899.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7978416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3544.10000,1027.79000,Aetna,Local,,1417.64,,,,,,,1141.20,2899.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7980352,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,670.53,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7980352,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,598.92,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ELBOW,7980402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ELBOW,7980402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ELBOW,7980403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ELBOW,7980403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,4491.90,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,6038.38,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,5393.50,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5488.28000,1591.60000,Aetna,Local,,2195.31,,,,,,,1978.52,4489.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5488.28000,1591.60000,Aetna,Local,,2195.31,,,,,,,1767.23,4489.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7980407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7980407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2205.72000,639.66000,Aetna,Local,,882.29,,,,,,,795.16,1804.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2205.72000,639.66000,Aetna,Local,,882.29,,,,,,,710.24,1804.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,Local,,11651.76,,,,,,,10501.15,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,Local,,11651.76,,,,,,,9379.67,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARDIAC DEFIBRILLATOR,7980699,CDM,278,RC,C1882,HCPCS,,,facility,inpatient,,,44887.50000,13017.38000,Aetna,Local,,17955.00,,,,,,,16181.94,36717.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARDIAC DEFIBRILLATOR,7980699,CDM,278,RC,C1882,HCPCS,,,facility,outpatient,,,44887.50000,13017.38000,Aetna,Local,,17955.00,,,,,,,14453.77,36717.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7980698,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7980698,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6110.16000,1771.95000,Aetna,Local,,2444.06,,,,,,,2202.71,4998.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6110.16000,1771.95000,Aetna,Local,,2444.06,,,,,,,1967.47,4998.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7980712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7980712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7980713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7980713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5844.02000,1694.77000,Aetna,Local,,2337.61,,,,,,,2106.77,4780.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5844.02000,1694.77000,Aetna,Local,,2337.61,,,,,,,1881.77,4780.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2616.04000,758.65000,Aetna,Local,,1046.42,,,,,,,943.08,2139.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2616.04000,758.65000,Aetna,Local,,1046.42,,,,,,,842.36,2139.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2649.80000,768.44000,Aetna,Local,,1059.92,,,,,,,955.25,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2649.80000,768.44000,Aetna,Local,,1059.92,,,,,,,853.24,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2781.96000,806.77000,Aetna,Local,,1112.78,,,,,,,1002.90,2275.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2781.96000,806.77000,Aetna,Local,,1112.78,,,,,,,895.79,2275.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2815.80000,816.58000,Aetna,Local,,1126.32,,,,,,,1015.10,2303.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2815.80000,816.58000,Aetna,Local,,1126.32,,,,,,,906.69,2303.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2846.52000,825.49000,Aetna,Local,,1138.61,,,,,,,1026.17,2328.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2846.52000,825.49000,Aetna,Local,,1138.61,,,,,,,916.58,2328.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7981158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5724.57000,1660.13000,Aetna,Local,,2289.83,,,,,,,2063.71,4682.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7981158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5724.57000,1660.13000,Aetna,Local,,2289.83,,,,,,,1843.31,4682.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5987.98000,1736.51000,Aetna,Local,,2395.19,,,,,,,2158.67,4898.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5987.98000,1736.51000,Aetna,Local,,2395.19,,,,,,,1928.13,4898.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8271.03000,2398.60000,Aetna,Local,,3308.41,,,,,,,2981.71,6765.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8271.03000,2398.60000,Aetna,Local,,3308.41,,,,,,,2663.27,6765.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,62.32,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,55.67,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,338.17,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,302.06,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,302.94,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,270.59,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.35000,1115.15000,Aetna,Local,,1538.14,,,,,,,1386.25,3145.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.35000,1115.15000,Aetna,Local,,1538.14,,,,,,,1238.20,3145.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7981168,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7981168,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,155.72000,45.16000,Aetna,Local,,62.29,,,,,,,56.14,127.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,155.72000,45.16000,Aetna,Local,,62.29,,,,,,,50.14,127.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7982397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.59000,194.47000,Aetna,Local,,268.24,,,,,,,241.75,548.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7982397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.59000,194.47000,Aetna,Local,,268.24,,,,,,,215.93,548.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5868.45000,1701.85000,Aetna,Local,,2347.38,,,,,,,2115.58,4800.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5868.45000,1701.85000,Aetna,Local,,2347.38,,,,,,,1889.64,4800.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5974.36000,1732.56000,Aetna,Local,,2389.74,,,,,,,2153.76,4887.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5974.36000,1732.56000,Aetna,Local,,2389.74,,,,,,,1923.74,4887.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5230.30000,1516.79000,Aetna,Local,,2092.12,,,,,,,1885.52,4278.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5230.30000,1516.79000,Aetna,Local,,2092.12,,,,,,,1684.16,4278.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5284.58000,1532.53000,Aetna,Local,,2113.83,,,,,,,1905.09,4322.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5284.58000,1532.53000,Aetna,Local,,2113.83,,,,,,,1701.63,4322.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5436.69000,1576.64000,Aetna,Local,,2174.68,,,,,,,1959.93,4447.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5436.69000,1576.64000,Aetna,Local,,2174.68,,,,,,,1750.61,4447.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1855.24000,538.02000,Aetna,Local,,742.10,,,,,,,668.81,1517.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1855.24000,538.02000,Aetna,Local,,742.10,,,,,,,597.39,1517.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,878.67000,254.81000,Aetna,Local,,351.47,,,,,,,316.76,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,878.67000,254.81000,Aetna,Local,,351.47,,,,,,,282.93,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1802.48000,522.72000,Aetna,Local,,720.99,,,,,,,649.79,1474.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1802.48000,522.72000,Aetna,Local,,720.99,,,,,,,580.40,1474.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.14000,132.28000,Aetna,Local,,182.46,,,,,,,164.44,373.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.14000,132.28000,Aetna,Local,,182.46,,,,,,,146.88,373.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,474.62000,137.64000,Aetna,Local,,189.85,,,,,,,171.10,388.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,474.62000,137.64000,Aetna,Local,,189.85,,,,,,,152.83,388.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,Local,,133.08,,,,,,,119.93,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,Local,,133.08,,,,,,,107.13,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,358.53000,103.97000,Aetna,Local,,143.41,,,,,,,129.25,293.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,358.53000,103.97000,Aetna,Local,,143.41,,,,,,,115.45,293.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3215.28000,932.43000,Aetna,Local,,1286.11,,,,,,,1159.11,2630.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3215.28000,932.43000,Aetna,Local,,1286.11,,,,,,,1035.32,2630.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2078.68000,602.82000,Aetna,Local,,831.47,,,,,,,749.36,1700.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2078.68000,602.82000,Aetna,Local,,831.47,,,,,,,669.33,1700.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1383.48000,401.21000,Aetna,Local,,553.39,,,,,,,498.74,1131.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1383.48000,401.21000,Aetna,Local,,553.39,,,,,,,445.48,1131.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1445.56000,419.21000,Aetna,Local,,578.22,,,,,,,521.12,1182.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1445.56000,419.21000,Aetna,Local,,578.22,,,,,,,465.47,1182.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7982463,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7982463,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7982777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7982777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7982774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7982774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7982775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7982775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7982868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13680.00000,3967.20000,Aetna,Local,,5472.00,,,,,,,4931.64,11190.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7982868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13680.00000,3967.20000,Aetna,Local,,5472.00,,,,,,,4404.96,11190.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7982898,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7982898,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7982906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7982906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7982907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7982907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7983031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1876.22,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7983031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1675.85,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7983032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12166.50000,3528.28000,Aetna,Local,,4866.60,,,,,,,4386.02,9952.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7983032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12166.50000,3528.28000,Aetna,Local,,4866.60,,,,,,,3917.61,9952.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7983035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9298.80000,2696.65000,Aetna,Local,,3719.52,,,,,,,3352.22,7606.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7983035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9298.80000,2696.65000,Aetna,Local,,3719.52,,,,,,,2994.21,7606.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,7983036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3497.90000,1014.39000,Aetna,Local,,1399.16,,,,,,,1260.99,2861.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,7983036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3497.90000,1014.39000,Aetna,Local,,1399.16,,,,,,,1126.32,2861.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7983037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4213.65000,1221.96000,Aetna,Local,,1685.46,,,,,,,1519.02,3446.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7983037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4213.65000,1221.96000,Aetna,Local,,1685.46,,,,,,,1356.80,3446.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7983041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7983041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7983045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5952.66000,1726.27000,Aetna,Local,,2381.06,,,,,,,2145.93,4869.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7983045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5952.66000,1726.27000,Aetna,Local,,2381.06,,,,,,,1916.76,4869.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7985605,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,124381.00000,36070.49000,Aetna,Local,,49752.40,,,,,,,44839.35,101743.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7985605,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,124381.00000,36070.49000,Aetna,Local,,49752.40,,,,,,,40050.68,101743.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986469,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986469,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986566,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986566,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7986604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2968.00000,860.72000,Aetna,Local,,1187.20,,,,,,,1069.96,2427.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7986604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2968.00000,860.72000,Aetna,Local,,1187.20,,,,,,,955.70,2427.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986853,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2132.80000,618.51000,Aetna,Local,,853.12,,,,,,,768.87,1744.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986853,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2132.80000,618.51000,Aetna,Local,,853.12,,,,,,,686.76,1744.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986855,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2172.40000,630.00000,Aetna,Local,,868.96,,,,,,,783.15,1777.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986855,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2172.40000,630.00000,Aetna,Local,,868.96,,,,,,,699.51,1777.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986857,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2212.00000,641.48000,Aetna,Local,,884.80,,,,,,,797.43,1809.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986857,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2212.00000,641.48000,Aetna,Local,,884.80,,,,,,,712.26,1809.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7987151,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2251.60000,652.96000,Aetna,Local,,900.64,,,,,,,811.70,1841.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7987151,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2251.60000,652.96000,Aetna,Local,,900.64,,,,,,,725.02,1841.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7986865,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7986865,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URINARY CONTROL SYSTEM,7987206,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,24850.00000,7206.50000,Aetna,Local,,9940.00,,,,,,,8958.42,20327.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URINARY CONTROL SYSTEM,7987206,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,24850.00000,7206.50000,Aetna,Local,,9940.00,,,,,,,8001.70,20327.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS URETHRAL,7987208,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,13440.00000,3897.60000,Aetna,Local,,5376.00,,,,,,,4845.12,10993.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS URETHRAL,7987208,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,13440.00000,3897.60000,Aetna,Local,,5376.00,,,,,,,4327.68,10993.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URINARY CONTROL PUMP,7987210,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,24100.00000,6989.00000,Aetna,Local,,9640.00,,,,,,,8688.05,19713.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URINARY CONTROL PUMP,7987210,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,24100.00000,6989.00000,Aetna,Local,,9640.00,,,,,,,7760.20,19713.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7987238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7987238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987582,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,4004.53000,1161.31000,Aetna,Local,,1601.81,,,,,,,1443.63,3275.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987582,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,4004.53000,1161.31000,Aetna,Local,,1601.81,,,,,,,1289.46,3275.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3184.00000,923.36000,Aetna,Local,,1273.60,,,,,,,1147.83,2604.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3184.00000,923.36000,Aetna,Local,,1273.60,,,,,,,1025.25,2604.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11412.00000,3309.48000,Aetna,Local,,4564.80,,,,,,,4114.03,9335.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11412.00000,3309.48000,Aetna,Local,,4564.80,,,,,,,3674.66,9335.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987577,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,1529.60000,443.58000,Aetna,Local,,611.84,,,,,,,551.42,1251.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987577,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,1529.60000,443.58000,Aetna,Local,,611.84,,,,,,,492.53,1251.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987578,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2068.40000,599.84000,Aetna,Local,,827.36,,,,,,,745.66,1691.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987578,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2068.40000,599.84000,Aetna,Local,,827.36,,,,,,,666.02,1691.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987580,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,5720.58000,1658.97000,Aetna,Local,,2288.23,,,,,,,2062.27,4679.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987580,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,5720.58000,1658.97000,Aetna,Local,,2288.23,,,,,,,1842.03,4679.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987581,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2382.00000,690.78000,Aetna,Local,,952.80,,,,,,,858.71,1948.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987581,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2382.00000,690.78000,Aetna,Local,,952.80,,,,,,,767.00,1948.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987583,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,5720.58000,1658.97000,Aetna,Local,,2288.23,,,,,,,2062.27,4679.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987583,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,5720.58000,1658.97000,Aetna,Local,,2288.23,,,,,,,1842.03,4679.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7987619,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,34008.75000,9862.54000,Aetna,Local,,13603.50,,,,,,,12260.15,27819.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7987619,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,34008.75000,9862.54000,Aetna,Local,,13603.50,,,,,,,10950.82,27819.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,873.04,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,779.81,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7987677,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7987677,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7987733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7987733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION DEVICE IN KIT,7987803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9652.50000,2799.22000,Aetna,Local,,3861.00,,,,,,,3479.73,7895.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION DEVICE IN KIT,7987803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9652.50000,2799.22000,Aetna,Local,,3861.00,,,,,,,3108.11,7895.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,Local,,3099.36,,,,,,,2793.30,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,Local,,3099.36,,,,,,,2494.98,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7987908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7987908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7987910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16743.20000,4855.53000,Aetna,Local,,6697.28,,,,,,,6035.92,13695.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7987910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16743.20000,4855.53000,Aetna,Local,,6697.28,,,,,,,5391.31,13695.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4958.73000,1438.03000,Aetna,Local,,1983.49,,,,,,,1787.62,4056.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4958.73000,1438.03000,Aetna,Local,,1983.49,,,,,,,1596.71,4056.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7987914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25606.63000,7425.92000,Aetna,Local,,10242.65,,,,,,,9231.19,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7987914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25606.63000,7425.92000,Aetna,Local,,10242.65,,,,,,,8245.33,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8147624,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8147624,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136122,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136122,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136123,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136123,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136124,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136124,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136125,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136125,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136126,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136126,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136127,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136127,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136129,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136129,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136130,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136130,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136131,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136131,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136132,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136132,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136133,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136133,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136134,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136134,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136135,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136135,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136136,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136136,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136137,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136137,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136138,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136138,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136139,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136139,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136140,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136140,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136141,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136141,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136142,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136142,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136143,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136143,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136144,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136144,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136145,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136145,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136146,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136146,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136147,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136147,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136148,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136148,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136149,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136149,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136150,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136150,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136158,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136158,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136162,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136162,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136166,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136166,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136170,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136170,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136174,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136174,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136178,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136178,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136182,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136182,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136151,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136151,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136155,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136155,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136159,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136159,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136163,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136163,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136167,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136167,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136171,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136171,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136175,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136175,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136179,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136179,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136183,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136183,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136186,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136186,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136189,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136189,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136152,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136152,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136156,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136156,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136160,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136160,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136164,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136164,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136168,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136168,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136172,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136172,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136176,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136176,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136180,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136180,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136184,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136184,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136187,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136187,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136190,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136190,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136153,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136153,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136157,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136157,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136161,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136161,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136165,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136165,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136169,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136169,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136173,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136173,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136177,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136177,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136181,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136181,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136185,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136185,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136188,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136188,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136191,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136191,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136238,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,Local,,746.00,,,,,,,672.33,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136238,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,Local,,746.00,,,,,,,600.53,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136239,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,Local,,746.00,,,,,,,672.33,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136239,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,Local,,746.00,,,,,,,600.53,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8136236,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,26375.00000,7648.75000,Aetna,Local,,10550.00,,,,,,,9508.19,21574.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8136236,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,26375.00000,7648.75000,Aetna,Local,,10550.00,,,,,,,8492.75,21574.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8148644,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8148644,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATOR,8136237,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,138.92000,40.29000,Aetna,Local,,55.57,,,,,,,50.08,113.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATOR,8136237,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,138.92000,40.29000,Aetna,Local,,55.57,,,,,,,44.73,113.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136038,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136038,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136240,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,Local,,746.00,,,,,,,672.33,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136240,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,Local,,746.00,,,,,,,600.53,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136241,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,Local,,1376.20,,,,,,,1240.30,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136241,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,Local,,1376.20,,,,,,,1107.84,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8148865,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8148865,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sensor and Delivery System,8136242,CDM,278,RC,C2624,HCPCS,,,facility,inpatient,,,57000.00000,16530.00000,Aetna,Local,,22800.00,,,,,,,20548.50,46626.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sensor and Delivery System,8136242,CDM,278,RC,C2624,HCPCS,,,facility,outpatient,,,57000.00000,16530.00000,Aetna,Local,,22800.00,,,,,,,18354.00,46626.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOOP RECORDER,8143326,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOOP RECORDER,8143326,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7750486,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7750486,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136284,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136284,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136285,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136285,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136286,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136286,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136287,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136287,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8155957,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8155957,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8155958,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8155958,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159922,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159922,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159924,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159924,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159926,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159926,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159928,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159928,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159930,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159930,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159932,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159932,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159934,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159934,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159936,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159936,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159938,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159938,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159940,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159940,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159942,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159942,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159944,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159944,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159946,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159946,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159948,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159948,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159950,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159950,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159952,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159952,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159954,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159954,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159956,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159956,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159958,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159958,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159960,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159960,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159962,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159962,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159964,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159964,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159966,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159966,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159968,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159968,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159970,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159970,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159972,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159972,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159974,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159974,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159976,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159976,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159978,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159978,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159980,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159980,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159982,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159982,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159984,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159984,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159986,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159986,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159988,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159988,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159990,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159990,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159992,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159992,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159994,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159994,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159996,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159996,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159998,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159998,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160000,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160000,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160002,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160002,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160004,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160004,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160006,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160006,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160008,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160008,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160010,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160010,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160012,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160012,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160014,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160014,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160016,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160016,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160018,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160018,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160020,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160020,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160022,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160022,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160024,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160024,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160026,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160026,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160028,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160028,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8161163,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8161163,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8161164,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8161164,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8161165,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8161165,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8161166,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8161166,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8167879,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,364.17000,105.61000,Aetna,Local,,145.67,,,,,,,131.28,297.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8167879,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,364.17000,105.61000,Aetna,Local,,145.67,,,,,,,117.26,297.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167880,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167880,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167881,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167881,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167882,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167882,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8167893,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8167893,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8168647,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,277.40,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8168647,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,247.78,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8168648,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8168648,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170299,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170299,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170300,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170300,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170301,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170301,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170302,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170302,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170303,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170303,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170304,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170304,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,Local,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8214486,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,8625.00000,2501.25000,Aetna,Local,,3450.00,,,,,,,3109.31,7055.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8214486,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,8625.00000,2501.25000,Aetna,Local,,9357.00,,,,,,,2777.25,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ROD,8994477,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8994477,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7698633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7698633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR ASSEMBLY,7698635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR ASSEMBLY,7698635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7698637,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14649.00000,4248.21000,Aetna,Local,,5859.60,,,,,,,5280.96,11982.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7698637,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14649.00000,4248.21000,Aetna,Local,,5859.60,,,,,,,4716.98,11982.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1445.56000,419.21000,Aetna,Local,,578.22,,,,,,,521.12,1182.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1445.56000,419.21000,Aetna,Local,,578.22,,,,,,,465.47,1182.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7698625,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7698625,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,873.04,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,779.81,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1743.52000,505.62000,Aetna,Local,,697.41,,,,,,,628.54,1426.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1743.52000,505.62000,Aetna,Local,,697.41,,,,,,,561.41,1426.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7523.40000,2181.79000,Aetna,Local,,3009.36,,,,,,,2712.19,6154.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7523.40000,2181.79000,Aetna,Local,,3009.36,,,,,,,2422.53,6154.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7698717,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7698717,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5692.40000,1650.80000,Aetna,Local,,2276.96,,,,,,,2052.11,4656.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5692.40000,1650.80000,Aetna,Local,,2276.96,,,,,,,1832.95,4656.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2556.64000,741.43000,Aetna,Local,,1022.66,,,,,,,921.67,2091.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2556.64000,741.43000,Aetna,Local,,1022.66,,,,,,,823.24,2091.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2745.96000,796.33000,Aetna,Local,,1098.38,,,,,,,989.92,2246.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2745.96000,796.33000,Aetna,Local,,1098.38,,,,,,,884.20,2246.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,Local,,740.85,,,,,,,667.69,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,Local,,740.85,,,,,,,596.38,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3028.40000,878.24000,Aetna,Local,,1211.36,,,,,,,1091.74,2477.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3028.40000,878.24000,Aetna,Local,,1211.36,,,,,,,975.14,2477.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2159.40000,626.23000,Aetna,Local,,863.76,,,,,,,778.46,1766.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2159.40000,626.23000,Aetna,Local,,863.76,,,,,,,695.33,1766.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1314.51,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1174.12,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698803,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,7126.63,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698803,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,6365.54,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698813,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698813,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698827,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3457.48000,1002.67000,Aetna,Local,,1382.99,,,,,,,1246.42,2828.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698827,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3457.48000,1002.67000,Aetna,Local,,1382.99,,,,,,,1113.31,2828.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2999.00,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2678.72,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2748.16000,796.97000,Aetna,Local,,1099.26,,,,,,,990.71,2247.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2748.16000,796.97000,Aetna,Local,,1099.26,,,,,,,884.91,2247.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695809,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695809,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,461.81,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,412.49,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697657,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.86000,59.41000,Aetna,Local,,81.94,,,,,,,73.85,167.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697657,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.86000,59.41000,Aetna,Local,,81.94,,,,,,,65.96,167.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2463.52000,714.42000,Aetna,Local,,985.41,,,,,,,888.10,2015.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2463.52000,714.42000,Aetna,Local,,985.41,,,,,,,793.25,2015.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693562,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,383.71000,111.28000,Aetna,Local,,153.48,,,,,,,138.33,313.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693562,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,383.71000,111.28000,Aetna,Local,,153.48,,,,,,,123.55,313.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911607,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911607,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696883,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2810.64000,815.09000,Aetna,Local,,1124.26,,,,,,,1013.24,2299.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696883,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2810.64000,815.09000,Aetna,Local,,1124.26,,,,,,,905.03,2299.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7695666,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,Local,,1162.19,,,,,,,1047.43,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7695666,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,Local,,1162.19,,,,,,,935.56,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698713,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,168.95000,49.00000,Aetna,Local,,67.58,,,,,,,60.91,138.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698713,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,168.95000,49.00000,Aetna,Local,,67.58,,,,,,,54.40,138.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694874,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,345.36000,100.15000,Aetna,Local,,138.14,,,,,,,124.50,282.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694874,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,345.36000,100.15000,Aetna,Local,,138.14,,,,,,,111.21,282.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696456,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,133.61000,38.75000,Aetna,Local,,53.44,,,,,,,48.17,109.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696456,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,133.61000,38.75000,Aetna,Local,,53.44,,,,,,,43.02,109.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696127,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,948.64000,275.11000,Aetna,Local,,379.46,,,,,,,341.98,775.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696127,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,948.64000,275.11000,Aetna,Local,,379.46,,,,,,,305.46,775.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3603.64000,1045.06000,Aetna,Local,,1441.46,,,,,,,1299.11,2947.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3603.64000,1045.06000,Aetna,Local,,1441.46,,,,,,,1160.37,2947.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694694,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,403.42000,116.99000,Aetna,Local,,161.37,,,,,,,145.43,330.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694694,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,403.42000,116.99000,Aetna,Local,,161.37,,,,,,,129.90,330.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695665,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,770.99000,223.59000,Aetna,Local,,308.40,,,,,,,277.94,630.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695665,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,770.99000,223.59000,Aetna,Local,,308.40,,,,,,,248.26,630.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,Local,,2625.52,,,,,,,2366.25,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,Local,,2625.52,,,,,,,2113.54,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ROTATION,7987922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6613.88000,1918.03000,Aetna,Local,,2645.55,,,,,,,2384.30,5410.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ROTATION,7987922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6613.88000,1918.03000,Aetna,Local,,2645.55,,,,,,,2129.67,5410.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRANIAL IMPLANT,7987935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRANIAL IMPLANT,7987935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7987937,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1819.44,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7987937,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1625.13,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7987949,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7987949,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7987951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7987951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7987971,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,11850.00000,3436.50000,Aetna,Local,,4740.00,,,,,,,4271.93,9693.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7987971,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,11850.00000,3436.50000,Aetna,Local,,4740.00,,,,,,,3815.70,9693.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7988511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7988511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7988515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7988515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7988521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5131.18000,1488.04000,Aetna,Local,,2052.47,,,,,,,1849.79,4197.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7988521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5131.18000,1488.04000,Aetna,Local,,2052.47,,,,,,,1652.24,4197.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING SYSTEM,7696292,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,7766.97000,2252.42000,Aetna,Local,,3106.79,,,,,,,2799.99,6353.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING SYSTEM,7696292,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,7766.97000,2252.42000,Aetna,Local,,3106.79,,,,,,,2500.96,6353.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7989146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7989146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE WEDGE,7989185,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,Local,,3252.00,,,,,,,2930.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE WEDGE,7989185,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,Local,,3252.00,,,,,,,2617.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7989268,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1783.07,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7989268,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1592.64,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,3076.60,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,2748.03,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7989503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7989503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7989565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7395.00000,2144.55000,Aetna,Local,,2958.00,,,,,,,2665.90,6049.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7989565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7395.00000,2144.55000,Aetna,Local,,2958.00,,,,,,,2381.19,6049.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7989580,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,686.25000,199.01000,Aetna,Local,,274.50,,,,,,,247.39,561.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7989580,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,686.25000,199.01000,Aetna,Local,,274.50,,,,,,,220.97,561.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7989584,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7989584,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989586,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4902.21000,1421.64000,Aetna,Local,,1960.88,,,,,,,1767.25,4010.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989586,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4902.21000,1421.64000,Aetna,Local,,1960.88,,,,,,,1578.51,4010.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7989620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1151.87,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7989620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1028.85,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7989635,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7989635,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7989637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7989637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BODY,7989638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11571.00000,3355.59000,Aetna,Local,,4628.40,,,,,,,4171.35,9465.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BODY,7989638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11571.00000,3355.59000,Aetna,Local,,4628.40,,,,,,,3725.86,9465.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9531.00000,2763.99000,Aetna,Local,,3812.40,,,,,,,3435.93,7796.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9531.00000,2763.99000,Aetna,Local,,3812.40,,,,,,,3068.98,7796.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6569.50000,1905.16000,Aetna,Local,,2627.80,,,,,,,2368.30,5373.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6569.50000,1905.16000,Aetna,Local,,2627.80,,,,,,,2115.38,5373.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7989636,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7989636,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7989674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1951.93,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7989674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1743.47,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7989675,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,48037.50000,13930.87000,Aetna,Local,,19215.00,,,,,,,17317.52,39294.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7989675,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,48037.50000,13930.87000,Aetna,Local,,19215.00,,,,,,,15468.08,39294.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7989676,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7989676,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7989677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7989677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7989672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7989672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON SHEATH,7989698,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON SHEATH,7989698,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7989726,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7989726,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989830,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989830,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7989832,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,801.38,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7989832,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,715.79,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7989877,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7989877,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7989890,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7989890,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989891,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989891,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7989892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7989892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3136.40000,909.56000,Aetna,Local,,1254.56,,,,,,,1130.67,2565.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3136.40000,909.56000,Aetna,Local,,1254.56,,,,,,,1009.92,2565.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3136.40000,909.56000,Aetna,Local,,1254.56,,,,,,,1130.67,2565.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3136.40000,909.56000,Aetna,Local,,1254.56,,,,,,,1009.92,2565.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3064.40000,888.68000,Aetna,Local,,1225.76,,,,,,,1104.72,2506.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3064.40000,888.68000,Aetna,Local,,1225.76,,,,,,,986.74,2506.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,671.84,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,600.09,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7989952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7989952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7989956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7989956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989964,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989964,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7989966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7989966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7989969,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7989969,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7990086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9528.00000,2763.12000,Aetna,Local,,3811.20,,,,,,,3434.84,7793.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7990086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9528.00000,2763.12000,Aetna,Local,,3811.20,,,,,,,3068.02,7793.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7990089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7990089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7990090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7990090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7990091,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7990091,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7990103,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,47362.50000,13735.12000,Aetna,Local,,18945.00,,,,,,,17074.18,38742.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7990103,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,47362.50000,13735.12000,Aetna,Local,,18945.00,,,,,,,15250.73,38742.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7990104,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7990104,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7990113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7990113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7990115,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7990115,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7990126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7990126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7990129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7990129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7990135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7990135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7990137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7990137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7990139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7990139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7991223,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7991223,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991224,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,Local,,873.60,,,,,,,787.33,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991224,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,Local,,873.60,,,,,,,703.25,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7991281,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7991281,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7698927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7698927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,7991284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,7991284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7991285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7991285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7991497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7991497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7991499,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7991499,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7991623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7991623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7991625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8162.25000,2367.05000,Aetna,Local,,3264.90,,,,,,,2942.49,6676.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7991625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8162.25000,2367.05000,Aetna,Local,,3264.90,,,,,,,2628.24,6676.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,134.94,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,120.52,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7991631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7991631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7991708,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7991708,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7991714,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7991714,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1948.00000,564.92000,Aetna,Local,,779.20,,,,,,,702.25,1593.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1948.00000,564.92000,Aetna,Local,,779.20,,,,,,,627.26,1593.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1395.50,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1246.46,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7993519,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7993519,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7993521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7993521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7993523,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7993523,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7993525,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7993525,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5577.88000,1617.59000,Aetna,Local,,2231.15,,,,,,,2010.83,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5577.88000,1617.59000,Aetna,Local,,2231.15,,,,,,,1796.08,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,261.39,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,233.48,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2205.24000,639.52000,Aetna,Local,,882.10,,,,,,,794.99,1803.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2205.24000,639.52000,Aetna,Local,,882.10,,,,,,,710.09,1803.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7993593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7993593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9885.00000,2866.65000,Aetna,Local,,3954.00,,,,,,,3563.54,8085.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9885.00000,2866.65000,Aetna,Local,,3954.00,,,,,,,3182.97,8085.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7993606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7993606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135984,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,153.20000,44.43000,Aetna,Local,,61.28,,,,,,,55.23,125.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135984,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,153.20000,44.43000,Aetna,Local,,61.28,,,,,,,49.33,125.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135985,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,790.20000,229.16000,Aetna,Local,,316.08,,,,,,,284.87,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135985,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,790.20000,229.16000,Aetna,Local,,316.08,,,,,,,254.44,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8143404,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8143404,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135986,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,295.07000,85.57000,Aetna,Local,,118.03,,,,,,,106.37,241.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135986,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,295.07000,85.57000,Aetna,Local,,118.03,,,,,,,95.01,241.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROWN DIAMONDBACK,8135988,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,13635.00000,3954.15000,Aetna,Local,,5454.00,,,,,,,4915.42,11153.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROWN DIAMONDBACK,8135988,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,13635.00000,3954.15000,Aetna,Local,,5454.00,,,,,,,4390.47,11153.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135987,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1220.00000,353.80000,Aetna,Local,,488.00,,,,,,,439.81,997.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135987,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1220.00000,353.80000,Aetna,Local,,488.00,,,,,,,392.84,997.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER TRANSEPTAL,8135989,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER TRANSEPTAL,8135989,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700200,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700200,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7818076,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7818076,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7741655,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7741655,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696333,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696333,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696335,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696335,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696337,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696337,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696340,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696340,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696342,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696342,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696343,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696343,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696344,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696344,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858082,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858082,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858080,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858080,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858088,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858088,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858263,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858263,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7794048,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7794048,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858086,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858086,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858087,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858087,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858092,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858092,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858093,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858093,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858100,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858100,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858098,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858098,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858099,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858099,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858104,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858104,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858117,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858117,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858105,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858105,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858107,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858107,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858109,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858109,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858112,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858112,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858115,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858115,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135991,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135991,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135992,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135992,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135993,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135993,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135995,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135995,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135996,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135996,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135997,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135997,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135998,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135998,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135999,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135999,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136000,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136000,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136001,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136001,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136002,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136002,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136003,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136003,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136004,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136004,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136005,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136005,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136006,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136006,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136007,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136007,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136008,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136008,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136009,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136009,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136010,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136010,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136011,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136011,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136012,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136012,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136013,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136013,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136014,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136014,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136015,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136015,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136016,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136016,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136017,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136017,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136018,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136018,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136019,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136019,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136020,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136020,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136021,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136021,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136022,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136022,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136023,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136023,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136024,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136024,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136025,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136025,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136026,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136026,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136027,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136027,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136028,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136028,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136029,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136029,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136030,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136030,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136031,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136031,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136032,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136032,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136033,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136033,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136034,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136034,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136035,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136035,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136036,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136036,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136037,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136037,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136039,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136039,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136040,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136040,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136041,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136041,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136042,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136042,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7927605,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7927605,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136043,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136043,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136044,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136044,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7927606,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7927606,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136045,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136045,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136046,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136046,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136047,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136047,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136048,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136048,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136049,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136049,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7894328,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,720.00000,208.80000,Aetna,Local,,288.00,,,,,,,259.56,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7894328,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,720.00000,208.80000,Aetna,Local,,288.00,,,,,,,231.84,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136052,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,506.83000,146.98000,Aetna,Local,,202.73,,,,,,,182.71,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136052,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,506.83000,146.98000,Aetna,Local,,202.73,,,,,,,163.20,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136050,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136050,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136053,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,506.83000,146.98000,Aetna,Local,,202.73,,,,,,,182.71,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136053,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,506.83000,146.98000,Aetna,Local,,202.73,,,,,,,163.20,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136054,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,506.83000,146.98000,Aetna,Local,,202.73,,,,,,,182.71,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136054,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,506.83000,146.98000,Aetna,Local,,202.73,,,,,,,163.20,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136051,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,319.20000,92.57000,Aetna,Local,,127.68,,,,,,,115.07,261.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136051,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,319.20000,92.57000,Aetna,Local,,127.68,,,,,,,102.78,261.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696336,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696336,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP SET IMPELLA CP,8136105,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,62000.00000,17980.00000,Aetna,Local,,24800.00,,,,,,,22351.00,50716.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP SET IMPELLA CP,8136105,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,62000.00000,17980.00000,Aetna,Local,,24800.00,,,,,,,19964.00,50716.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136107,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,115.92000,33.62000,Aetna,Local,,46.37,,,,,,,41.79,94.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136107,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,115.92000,33.62000,Aetna,Local,,46.37,,,,,,,37.33,94.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8136106,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8136106,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136103,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3377.50000,979.47000,Aetna,Local,,1351.00,,,,,,,1217.59,2762.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136103,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3377.50000,979.47000,Aetna,Local,,1351.00,,,,,,,1087.56,2762.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135994,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135994,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7904978,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7904978,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7937702,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7937702,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7911244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7911244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7905310,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2171.64000,629.78000,Aetna,Local,,868.66,,,,,,,782.88,1776.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7905310,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2171.64000,629.78000,Aetna,Local,,868.66,,,,,,,699.27,1776.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7951856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1868.00000,541.72000,Aetna,Local,,747.20,,,,,,,673.41,1528.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7951856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1868.00000,541.72000,Aetna,Local,,747.20,,,,,,,601.50,1528.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7866104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7866104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920463,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920463,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7905551,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1991.36000,577.49000,Aetna,Local,,796.54,,,,,,,717.89,1628.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7905551,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1991.36000,577.49000,Aetna,Local,,796.54,,,,,,,641.22,1628.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7905578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7905578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7920464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7920464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7939309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7939309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7939854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7939854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7905616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1693.52,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7905616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1512.66,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7918961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1693.52,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7918961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1512.66,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916495,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916495,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7858549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7858549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7832097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7832097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7850174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7850174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7700295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7700295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7832098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7832098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7901683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7901683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7908337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6062.00000,1757.98000,Aetna,Local,,2424.80,,,,,,,2185.35,4958.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7908337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6062.00000,1757.98000,Aetna,Local,,2424.80,,,,,,,1951.96,4958.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7908467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7908467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7908468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7908468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7925635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6062.00000,1757.98000,Aetna,Local,,2424.80,,,,,,,2185.35,4958.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7925635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6062.00000,1757.98000,Aetna,Local,,2424.80,,,,,,,1951.96,4958.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3328.50000,965.26000,Aetna,Local,,1331.40,,,,,,,1199.92,2722.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3328.50000,965.26000,Aetna,Local,,1331.40,,,,,,,1071.78,2722.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7940364,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7940364,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7963015,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7963015,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7914404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8445.00000,2449.05000,Aetna,Local,,3378.00,,,,,,,3044.42,6908.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7914404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8445.00000,2449.05000,Aetna,Local,,3378.00,,,,,,,2719.29,6908.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7930001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,Local,,3463.20,,,,,,,3121.21,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7930001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,Local,,3463.20,,,,,,,2787.88,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8259.60000,2395.28000,Aetna,Local,,3303.84,,,,,,,2977.59,6756.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8259.60000,2395.28000,Aetna,Local,,3303.84,,,,,,,2659.59,6756.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7912363,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7912363,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7912364,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7912364,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7916469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7916469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918999,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918999,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920371,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920371,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920374,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920374,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920522,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920522,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920780,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920780,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921282,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921282,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7929759,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7929759,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7929760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7929760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7929761,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7929761,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7930204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7930204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7934016,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7934016,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935563,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935563,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935786,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935786,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7936193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7936193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938391,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938391,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939808,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939808,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7946095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7946095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7946096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7946096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7947861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7947861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7953854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7953854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7954584,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7954584,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7960034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7960034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7960313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7960313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7961943,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7961943,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7961944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7961944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913848,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913848,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943993,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943993,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7955809,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5887.49000,1707.37000,Aetna,Local,,2355.00,,,,,,,2122.44,4815.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7955809,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5887.49000,1707.37000,Aetna,Local,,2355.00,,,,,,,1895.77,4815.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7700015,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7700015,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7909382,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7909382,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7918190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7918190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7926533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7926533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7943286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7943286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7804042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7804042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7838116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7838116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7921149,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7921149,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935566,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935566,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7909462,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7909462,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7924907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7924907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7956573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7956573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7910143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3945.90000,1144.31000,Aetna,Local,,1578.36,,,,,,,1422.50,3227.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7910143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3945.90000,1144.31000,Aetna,Local,,1578.36,,,,,,,1270.58,3227.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PROXIMAL,7910251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10362.00000,3004.98000,Aetna,Local,,4144.80,,,,,,,3735.50,8476.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PROXIMAL,7910251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10362.00000,3004.98000,Aetna,Local,,4144.80,,,,,,,3336.56,8476.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7925631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,Local,,2241.68,,,,,,,2020.31,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7925631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,Local,,2241.68,,,,,,,1804.55,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7912214,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7912214,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1110.10,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7939806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7939806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912871,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912871,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3486.76,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3114.38,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7922572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7922572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2708.08,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2418.86,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910977,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,792.29000,229.76000,Aetna,Local,,316.92,,,,,,,285.62,648.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910977,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,792.29000,229.76000,Aetna,Local,,316.92,,,,,,,255.12,648.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910979,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1244.80000,360.99000,Aetna,Local,,497.92,,,,,,,448.75,1018.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910979,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1244.80000,360.99000,Aetna,Local,,497.92,,,,,,,400.83,1018.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7911004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7911004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7947963,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7947963,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7947964,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7947964,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7957908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7957908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7911319,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7911319,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,Local,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1360.00000,394.40000,Aetna,Local,,544.00,,,,,,,490.28,1112.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1360.00000,394.40000,Aetna,Local,,544.00,,,,,,,437.92,1112.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7917873,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7917873,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911313,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,Local,,2461.20,,,,,,,2218.16,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911313,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,Local,,2461.20,,,,,,,1981.27,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911314,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,Local,,2461.20,,,,,,,2218.16,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911314,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,Local,,2461.20,,,,,,,1981.27,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911315,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,Local,,2461.20,,,,,,,2218.16,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911315,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,Local,,2461.20,,,,,,,1981.27,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911316,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,Local,,2461.20,,,,,,,2218.16,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911316,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,Local,,2461.20,,,,,,,1981.27,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7911318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,4133.49,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7911318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,3692.05,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7911773,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,4133.49,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7911773,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,3692.05,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7927419,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,4133.49,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7927419,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,3692.05,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,497.63,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,444.49,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925632,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925632,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7702068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7702068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7784278,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7784278,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7882860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7882860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7954586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7954586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7702133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7702133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7736193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7736193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7812180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7812180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740551,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,47556.00000,13791.24000,Aetna,Local,,19022.40,,,,,,,17143.94,38900.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740551,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,47556.00000,13791.24000,Aetna,Local,,19022.40,,,,,,,15313.03,38900.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740552,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,47556.00000,13791.24000,Aetna,Local,,19022.40,,,,,,,17143.94,38900.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740552,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,47556.00000,13791.24000,Aetna,Local,,19022.40,,,,,,,15313.03,38900.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764087,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,17763.64,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764087,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,15866.55,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764088,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,17763.64,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764088,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,15866.55,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764089,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,17763.64,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764089,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,15866.55,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764094,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,17763.64,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764094,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,15866.55,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7905309,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,17763.64,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7905309,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,15866.55,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7943626,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,17763.64,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7943626,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,15866.55,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5420.38000,1571.91000,Aetna,Local,,2168.15,,,,,,,1954.05,4433.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5420.38000,1571.91000,Aetna,Local,,2168.15,,,,,,,1745.36,4433.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5420.38000,1571.91000,Aetna,Local,,2168.15,,,,,,,1954.05,4433.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5420.38000,1571.91000,Aetna,Local,,2168.15,,,,,,,1745.36,4433.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5420.38000,1571.91000,Aetna,Local,,2168.15,,,,,,,1954.05,4433.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5420.38000,1571.91000,Aetna,Local,,2168.15,,,,,,,1745.36,4433.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5420.38000,1571.91000,Aetna,Local,,2168.15,,,,,,,1954.05,4433.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5420.38000,1571.91000,Aetna,Local,,2168.15,,,,,,,1745.36,4433.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7741727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7741727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5520.87000,1601.05000,Aetna,Local,,2208.35,,,,,,,1990.27,4516.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5520.87000,1601.05000,Aetna,Local,,2208.35,,,,,,,1777.72,4516.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5520.87000,1601.05000,Aetna,Local,,2208.35,,,,,,,1990.27,4516.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5520.87000,1601.05000,Aetna,Local,,2208.35,,,,,,,1777.72,4516.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,Local,,3099.36,,,,,,,2793.30,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,Local,,3099.36,,,,,,,2494.98,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.26000,96.36000,Aetna,Local,,132.90,,,,,,,119.78,271.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.26000,96.36000,Aetna,Local,,132.90,,,,,,,106.99,271.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.26000,96.36000,Aetna,Local,,132.90,,,,,,,119.78,271.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.26000,96.36000,Aetna,Local,,132.90,,,,,,,106.99,271.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.26000,96.36000,Aetna,Local,,132.90,,,,,,,119.78,271.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.26000,96.36000,Aetna,Local,,132.90,,,,,,,106.99,271.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,439.09000,127.34000,Aetna,Local,,175.64,,,,,,,158.29,359.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,439.09000,127.34000,Aetna,Local,,175.64,,,,,,,141.39,359.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,439.09000,127.34000,Aetna,Local,,175.64,,,,,,,158.29,359.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,439.09000,127.34000,Aetna,Local,,175.64,,,,,,,141.39,359.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,439.09000,127.34000,Aetna,Local,,175.64,,,,,,,158.29,359.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,439.09000,127.34000,Aetna,Local,,175.64,,,,,,,141.39,359.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,439.09000,127.34000,Aetna,Local,,175.64,,,,,,,158.29,359.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,439.09000,127.34000,Aetna,Local,,175.64,,,,,,,141.39,359.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,439.09000,127.34000,Aetna,Local,,175.64,,,,,,,158.29,359.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,439.09000,127.34000,Aetna,Local,,175.64,,,,,,,141.39,359.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695648,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695648,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695652,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695652,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695653,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695653,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695002,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,711.00000,206.19000,Aetna,Local,,284.40,,,,,,,256.32,581.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695002,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,711.00000,206.19000,Aetna,Local,,284.40,,,,,,,228.94,581.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695003,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,711.00000,206.19000,Aetna,Local,,284.40,,,,,,,256.32,581.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695003,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,711.00000,206.19000,Aetna,Local,,284.40,,,,,,,228.94,581.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695004,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,711.00000,206.19000,Aetna,Local,,284.40,,,,,,,256.32,581.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695004,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,711.00000,206.19000,Aetna,Local,,284.40,,,,,,,228.94,581.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695211,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,776.12000,225.07000,Aetna,Local,,310.45,,,,,,,279.79,634.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695211,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,776.12000,225.07000,Aetna,Local,,310.45,,,,,,,249.91,634.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695212,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,776.12000,225.07000,Aetna,Local,,310.45,,,,,,,279.79,634.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695212,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,776.12000,225.07000,Aetna,Local,,310.45,,,,,,,249.91,634.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695213,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,776.12000,225.07000,Aetna,Local,,310.45,,,,,,,279.79,634.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695213,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,776.12000,225.07000,Aetna,Local,,310.45,,,,,,,249.91,634.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7703333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,144.43000,41.88000,Aetna,Local,,57.77,,,,,,,52.07,118.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7703333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,144.43000,41.88000,Aetna,Local,,57.77,,,,,,,46.51,118.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695075,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2936.27,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695075,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2622.69,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695076,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2936.27,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695076,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2622.69,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695077,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2936.27,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695077,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2622.69,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695080,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2936.27,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695080,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2622.69,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694683,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,421.80000,122.32000,Aetna,Local,,168.72,,,,,,,152.06,345.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694683,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,421.80000,122.32000,Aetna,Local,,168.72,,,,,,,135.82,345.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694685,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,421.80000,122.32000,Aetna,Local,,168.72,,,,,,,152.06,345.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694685,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,421.80000,122.32000,Aetna,Local,,168.72,,,,,,,135.82,345.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7696162,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7696162,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7696404,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,339.53000,98.46000,Aetna,Local,,135.81,,,,,,,122.40,277.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7696404,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,339.53000,98.46000,Aetna,Local,,135.81,,,,,,,109.33,277.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696443,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1992.24000,577.75000,Aetna,Local,,796.90,,,,,,,718.20,1629.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696443,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1992.24000,577.75000,Aetna,Local,,796.90,,,,,,,641.50,1629.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695526,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695526,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,338.17,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,302.06,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696713,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696713,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,619.79000,179.74000,Aetna,Local,,247.92,,,,,,,223.43,506.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,619.79000,179.74000,Aetna,Local,,247.92,,,,,,,199.57,506.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697632,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697632,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1430.60000,414.87000,Aetna,Local,,572.24,,,,,,,515.73,1170.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1430.60000,414.87000,Aetna,Local,,572.24,,,,,,,460.65,1170.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1262.80000,366.21000,Aetna,Local,,505.12,,,,,,,455.24,1032.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1262.80000,366.21000,Aetna,Local,,505.12,,,,,,,406.62,1032.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,451.25000,130.86000,Aetna,Local,,180.50,,,,,,,162.68,369.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,451.25000,130.86000,Aetna,Local,,180.50,,,,,,,145.30,369.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699918,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699918,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,759.92000,220.38000,Aetna,Local,,303.97,,,,,,,273.95,621.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,759.92000,220.38000,Aetna,Local,,303.97,,,,,,,244.69,621.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7768118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7768118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7814058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7814058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7872075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7872075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,284.93,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,790.38000,229.21000,Aetna,Local,,316.15,,,,,,,254.50,646.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,666.58,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,595.39,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7866083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,666.58,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7866083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,595.39,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7911722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2074.60000,601.63000,Aetna,Local,,829.84,,,,,,,747.89,1697.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7911722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2074.60000,601.63000,Aetna,Local,,829.84,,,,,,,668.02,1697.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7930348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,666.58,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7930348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,595.39,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7695143,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5100.20000,1479.06000,Aetna,Local,,2040.08,,,,,,,1838.62,4171.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7695143,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5100.20000,1479.06000,Aetna,Local,,2040.08,,,,,,,1642.26,4171.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5577.88000,1617.59000,Aetna,Local,,2231.15,,,,,,,2010.83,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5577.88000,1617.59000,Aetna,Local,,2231.15,,,,,,,1796.08,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5970.30000,1731.39000,Aetna,Local,,2388.12,,,,,,,2152.29,4883.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5970.30000,1731.39000,Aetna,Local,,2388.12,,,,,,,1922.44,4883.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5970.30000,1731.39000,Aetna,Local,,2388.12,,,,,,,2152.29,4883.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5970.30000,1731.39000,Aetna,Local,,2388.12,,,,,,,1922.44,4883.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5970.30000,1731.39000,Aetna,Local,,2388.12,,,,,,,2152.29,4883.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5970.30000,1731.39000,Aetna,Local,,2388.12,,,,,,,1922.44,4883.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5970.30000,1731.39000,Aetna,Local,,2388.12,,,,,,,2152.29,4883.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5970.30000,1731.39000,Aetna,Local,,2388.12,,,,,,,1922.44,4883.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5575.19000,1616.81000,Aetna,Local,,2230.08,,,,,,,2009.86,4560.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5575.19000,1616.81000,Aetna,Local,,2230.08,,,,,,,1795.21,4560.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7904045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5575.19000,1616.81000,Aetna,Local,,2230.08,,,,,,,2009.86,4560.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7904045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5575.19000,1616.81000,Aetna,Local,,2230.08,,,,,,,1795.21,4560.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS,7736553,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8329.50000,2415.55000,Aetna,Local,,3331.80,,,,,,,3002.78,6813.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS,7736553,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8329.50000,2415.55000,Aetna,Local,,3331.80,,,,,,,2682.10,6813.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15486.75000,4491.16000,Aetna,Local,,6194.70,,,,,,,5582.97,12668.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15486.75000,4491.16000,Aetna,Local,,6194.70,,,,,,,4986.73,12668.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4396.95000,1275.12000,Aetna,Local,,1758.78,,,,,,,1585.10,3596.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4396.95000,1275.12000,Aetna,Local,,1758.78,,,,,,,1415.82,3596.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5995.50000,1738.70000,Aetna,Local,,2398.20,,,,,,,2161.38,4904.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5995.50000,1738.70000,Aetna,Local,,2398.20,,,,,,,1930.55,4904.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.80000,818.03000,Aetna,Local,,1128.32,,,,,,,1016.90,2307.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.80000,818.03000,Aetna,Local,,1128.32,,,,,,,908.30,2307.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7736585,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7736585,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,7689.47,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,6868.26,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,Local,,2667.35,,,,,,,2403.95,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,Local,,2667.35,,,,,,,2147.22,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4137.00000,1199.73000,Aetna,Local,,1654.80,,,,,,,1491.39,3384.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4137.00000,1199.73000,Aetna,Local,,1654.80,,,,,,,1332.11,3384.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1543.44,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1378.60,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908263,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908263,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8475.00000,2457.75000,Aetna,Local,,3390.00,,,,,,,3055.24,6932.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8475.00000,2457.75000,Aetna,Local,,3390.00,,,,,,,2728.95,6932.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7736658,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7736658,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736664,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21412.50000,6209.62000,Aetna,Local,,8565.00,,,,,,,7719.21,17515.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736664,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21412.50000,6209.62000,Aetna,Local,,8565.00,,,,,,,6894.82,17515.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4701.90000,1363.55000,Aetna,Local,,1880.76,,,,,,,1695.03,3846.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4701.90000,1363.55000,Aetna,Local,,1880.76,,,,,,,1514.01,3846.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7740532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7740532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.73000,141.15000,Aetna,Local,,194.69,,,,,,,175.47,398.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.73000,141.15000,Aetna,Local,,194.69,,,,,,,156.73,398.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7740760,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,488.12,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7740760,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,435.99,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7740779,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7740779,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7740889,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2512.36000,728.58000,Aetna,Local,,1004.94,,,,,,,905.71,2055.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7740889,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2512.36000,728.58000,Aetna,Local,,1004.94,,,,,,,808.98,2055.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7740890,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,19300.00000,5597.00000,Aetna,Local,,7720.00,,,,,,,6957.65,15787.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7740890,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,19300.00000,5597.00000,Aetna,Local,,7720.00,,,,,,,6214.60,15787.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7740891,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,7953.00000,2306.37000,Aetna,Local,,3181.20,,,,,,,2867.06,6505.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7740891,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,7953.00000,2306.37000,Aetna,Local,,3181.20,,,,,,,2560.87,6505.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7697893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7838.67,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7697893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7001.53,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699732,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2556.80000,741.47000,Aetna,Local,,1022.72,,,,,,,921.73,2091.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699732,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2556.80000,741.47000,Aetna,Local,,1022.72,,,,,,,823.29,2091.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7741340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7741340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PORT,7741436,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,713.79,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PORT,7741436,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,637.56,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695008,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695008,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7894156,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7894156,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7741661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4903.50000,1422.02000,Aetna,Local,,1961.40,,,,,,,1767.71,4011.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7741661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4903.50000,1422.02000,Aetna,Local,,1961.40,,,,,,,1578.93,4011.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7741657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,665.84,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7741657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,594.73,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7741711,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7741711,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7741717,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7741717,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7741721,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7741721,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7741766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9083.55000,2634.23000,Aetna,Local,,3633.42,,,,,,,3274.62,7430.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7741766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9083.55000,2634.23000,Aetna,Local,,3633.42,,,,,,,2924.90,7430.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7741811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2844.00000,824.76000,Aetna,Local,,1137.60,,,,,,,1025.26,2326.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7741811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2844.00000,824.76000,Aetna,Local,,1137.60,,,,,,,915.77,2326.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694313,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,6421.10000,1862.12000,Aetna,Local,,2568.44,,,,,,,2314.81,5252.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694313,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,6421.10000,1862.12000,Aetna,Local,,2568.44,,,,,,,2067.59,5252.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7949854,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7949854,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7744659,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,849.81000,246.44000,Aetna,Local,,339.92,,,,,,,306.36,695.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7744659,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,849.81000,246.44000,Aetna,Local,,339.92,,,,,,,273.64,695.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700175,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700175,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7748108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7748108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748824,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748824,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7695939,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7695939,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7750114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7750114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7750116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7750116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7754164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5455.63000,1582.13000,Aetna,Local,,2182.25,,,,,,,1966.75,4462.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7754164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5455.63000,1582.13000,Aetna,Local,,2182.25,,,,,,,1756.71,4462.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7694866,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,352.89,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7694866,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,315.20,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7695082,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1340.04000,388.61000,Aetna,Local,,536.02,,,,,,,483.08,1096.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7695082,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1340.04000,388.61000,Aetna,Local,,536.02,,,,,,,431.49,1096.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7754281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7754281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE IMPLANT,7754286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,9270.49,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE IMPLANT,7754286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,8280.44,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695158,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,515.04000,149.36000,Aetna,Local,,206.02,,,,,,,185.67,421.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695158,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,515.04000,149.36000,Aetna,Local,,206.02,,,,,,,165.84,421.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694357,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,219.00,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694357,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,195.62,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756253,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756253,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756256,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756256,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756279,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756279,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8271.03000,2398.60000,Aetna,Local,,3308.41,,,,,,,2981.71,6765.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8271.03000,2398.60000,Aetna,Local,,3308.41,,,,,,,2663.27,6765.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1765.24000,511.92000,Aetna,Local,,706.10,,,,,,,636.37,1443.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1765.24000,511.92000,Aetna,Local,,706.10,,,,,,,568.41,1443.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,7695005,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,7695005,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE PIN,7703360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,Local,,587.60,,,,,,,529.57,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE PIN,7703360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,Local,,587.60,,,,,,,473.02,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7758256,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8587.38000,2490.34000,Aetna,Local,,3434.95,,,,,,,3095.75,7024.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7758256,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8587.38000,2490.34000,Aetna,Local,,3434.95,,,,,,,2765.14,7024.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695157,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8882.13000,2575.82000,Aetna,Local,,3552.85,,,,,,,3202.01,7265.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695157,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8882.13000,2575.82000,Aetna,Local,,3552.85,,,,,,,2860.05,7265.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695029,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695029,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695218,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9262.38000,2686.09000,Aetna,Local,,3704.95,,,,,,,3339.09,7576.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695218,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9262.38000,2686.09000,Aetna,Local,,3704.95,,,,,,,2982.49,7576.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7760042,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,876.74,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7760042,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,783.10,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7760078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,817.25,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7760078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,729.97,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7760073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7760073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7760126,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,3001.16,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7760126,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,2680.65,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7699221,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7699221,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7736447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6209.00000,1800.61000,Aetna,Local,,2483.60,,,,,,,2238.34,5078.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7736447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6209.00000,1800.61000,Aetna,Local,,2483.60,,,,,,,1999.30,5078.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARTILAGE,7762377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARTILAGE,7762377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10758.00000,3119.82000,Aetna,Local,,4303.20,,,,,,,3878.26,8800.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10758.00000,3119.82000,Aetna,Local,,4303.20,,,,,,,3464.08,8800.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7762382,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4812.68,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7762382,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4298.70,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7702169,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,10635.00000,3084.15000,Aetna,Local,,4254.00,,,,,,,3833.92,8699.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7702169,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,10635.00000,3084.15000,Aetna,Local,,4254.00,,,,,,,3424.47,8699.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7736624,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,31072.50000,9011.02000,Aetna,Local,,12429.00,,,,,,,11201.64,25417.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7736624,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,31072.50000,9011.02000,Aetna,Local,,12429.00,,,,,,,10005.34,25417.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRIP CABLE,7695958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2892.00000,838.68000,Aetna,Local,,1156.80,,,,,,,1042.57,2365.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRIP CABLE,7695958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2892.00000,838.68000,Aetna,Local,,1156.80,,,,,,,931.22,2365.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER REPLACE,7764046,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER REPLACE,7764046,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7764096,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7764096,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7695284,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1124.76,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7695284,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1004.64,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696401,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,3869.78000,1122.24000,Aetna,Local,,1547.91,,,,,,,1395.06,3165.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696401,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,3869.78000,1122.24000,Aetna,Local,,1547.91,,,,,,,1246.07,3165.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695019,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,308.23000,89.39000,Aetna,Local,,123.29,,,,,,,111.12,252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695019,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,308.23000,89.39000,Aetna,Local,,123.29,,,,,,,99.25,252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7768152,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,8844.00000,2564.76000,Aetna,Local,,3537.60,,,,,,,3188.26,7234.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7768152,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,8844.00000,2564.76000,Aetna,Local,,3537.60,,,,,,,2847.77,7234.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7768154,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,63790.00000,18499.10000,Aetna,Local,,25516.00,,,,,,,22996.29,52180.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7768154,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,63790.00000,18499.10000,Aetna,Local,,25516.00,,,,,,,20540.38,52180.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNAR,7770032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNAR,7770032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ARTICULATION KIT,7770033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ARTICULATION KIT,7770033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE GRAFT DURAL,7695897,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,1785.36000,517.75000,Aetna,Local,,714.14,,,,,,,643.62,1460.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE GRAFT DURAL,7695897,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,1785.36000,517.75000,Aetna,Local,,714.14,,,,,,,574.89,1460.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695680,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1583.20000,459.13000,Aetna,Local,,633.28,,,,,,,570.74,1295.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695680,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1583.20000,459.13000,Aetna,Local,,633.28,,,,,,,509.79,1295.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1482.80000,430.01000,Aetna,Local,,593.12,,,,,,,534.55,1212.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1482.80000,430.01000,Aetna,Local,,593.12,,,,,,,477.46,1212.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1469.60000,426.18000,Aetna,Local,,587.84,,,,,,,529.79,1202.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1469.60000,426.18000,Aetna,Local,,587.84,,,,,,,473.21,1202.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1839.20000,533.37000,Aetna,Local,,735.68,,,,,,,663.03,1504.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1839.20000,533.37000,Aetna,Local,,735.68,,,,,,,592.22,1504.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,300.28,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,268.21,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.40000,422.36000,Aetna,Local,,582.56,,,,,,,525.03,1191.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.40000,422.36000,Aetna,Local,,582.56,,,,,,,468.96,1191.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7695875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,708.48000,205.46000,Aetna,Local,,283.39,,,,,,,255.41,579.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7695875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,708.48000,205.46000,Aetna,Local,,283.39,,,,,,,228.13,579.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7774085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2741.60,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7774085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2448.81,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7774102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7774102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7774227,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,10853.10000,3147.40000,Aetna,Local,,4341.24,,,,,,,3912.54,8877.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7774227,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,10853.10000,3147.40000,Aetna,Local,,4341.24,,,,,,,3494.70,8877.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7774228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.70000,2383.71000,Aetna,Local,,3287.88,,,,,,,2963.20,6723.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7774228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.70000,2383.71000,Aetna,Local,,3287.88,,,,,,,2646.74,6723.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697051,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1484.00000,430.36000,Aetna,Local,,593.60,,,,,,,534.98,1213.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697051,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1484.00000,430.36000,Aetna,Local,,593.60,,,,,,,477.85,1213.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7774233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7774233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7930141,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,838.31000,243.11000,Aetna,Local,,335.32,,,,,,,302.21,685.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7930141,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,838.31000,243.11000,Aetna,Local,,335.32,,,,,,,269.94,685.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRIAL TIBIAL TRAY,7696303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,450.30000,130.59000,Aetna,Local,,180.12,,,,,,,162.33,368.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRIAL TIBIAL TRAY,7696303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,450.30000,130.59000,Aetna,Local,,180.12,,,,,,,145.00,368.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7696874,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,658.40000,190.94000,Aetna,Local,,263.36,,,,,,,237.35,538.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7696874,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,658.40000,190.94000,Aetna,Local,,263.36,,,,,,,212.00,538.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7776326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7776326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7742027,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7742027,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7760046,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1952.80000,566.31000,Aetna,Local,,781.12,,,,,,,703.98,1597.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7760046,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1952.80000,566.31000,Aetna,Local,,781.12,,,,,,,628.80,1597.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7760047,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1642.80000,476.41000,Aetna,Local,,657.12,,,,,,,592.23,1343.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7760047,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1642.80000,476.41000,Aetna,Local,,657.12,,,,,,,528.98,1343.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HAND WRIST,7698732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3670.38000,1064.41000,Aetna,Local,,1468.15,,,,,,,1323.17,3002.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HAND WRIST,7698732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3670.38000,1064.41000,Aetna,Local,,1468.15,,,,,,,1181.86,3002.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7694292,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,335.35000,97.25000,Aetna,Local,,134.14,,,,,,,120.89,274.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7694292,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,335.35000,97.25000,Aetna,Local,,134.14,,,,,,,107.98,274.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700227,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,957.20000,277.59000,Aetna,Local,,382.88,,,,,,,345.07,782.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700227,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,957.20000,277.59000,Aetna,Local,,382.88,,,,,,,308.22,782.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7780090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5987.98000,1736.51000,Aetna,Local,,2395.19,,,,,,,2158.67,4898.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7780090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5987.98000,1736.51000,Aetna,Local,,2395.19,,,,,,,1928.13,4898.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT EXTENSION,7782099,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT EXTENSION,7782099,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,714.57,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,638.26,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3746.12000,1086.37000,Aetna,Local,,1498.45,,,,,,,1350.48,3064.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3746.12000,1086.37000,Aetna,Local,,1498.45,,,,,,,1206.25,3064.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,700.74,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,625.90,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2056.68000,596.44000,Aetna,Local,,822.67,,,,,,,741.43,1682.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2056.68000,596.44000,Aetna,Local,,822.67,,,,,,,662.25,1682.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7784067,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,1755.16000,509.00000,Aetna,Local,,702.06,,,,,,,632.74,1435.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7784067,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,1755.16000,509.00000,Aetna,Local,,702.06,,,,,,,565.16,1435.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7697892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9226.20000,2675.60000,Aetna,Local,,3690.48,,,,,,,3326.05,7547.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7697892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9226.20000,2675.60000,Aetna,Local,,3690.48,,,,,,,2970.84,7547.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7784276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7784276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7784280,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7793.25000,2260.04000,Aetna,Local,,3117.30,,,,,,,2809.47,6374.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7784280,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7793.25000,2260.04000,Aetna,Local,,3117.30,,,,,,,2509.43,6374.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,757.22,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,676.35,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT EXTENSION,7786143,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,Local,,4858.80,,,,,,,4378.99,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT EXTENSION,7786143,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,Local,,4858.80,,,,,,,3911.33,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7786154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7786154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7695280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,793.10,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7695280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,708.40,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7947886,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7947886,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7790171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7790171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7790231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,Local,,5242.24,,,,,,,4724.57,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7790231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,Local,,5242.24,,,,,,,4220.00,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7790237,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7790237,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7790243,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,26475.00000,7677.75000,Aetna,Local,,10590.00,,,,,,,9544.24,21656.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7790243,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,26475.00000,7677.75000,Aetna,Local,,10590.00,,,,,,,8524.95,21656.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7794031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7794031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7794033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7794033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700077,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700077,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOTAL KNEE,7794300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOTAL KNEE,7794300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7794406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7794406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7794407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7794407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7794448,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7794448,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7794452,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7794452,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7794453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16192.50000,4695.82000,Aetna,Local,,6477.00,,,,,,,5837.40,13245.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7794453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16192.50000,4695.82000,Aetna,Local,,6477.00,,,,,,,5213.98,13245.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2956.98,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2641.19,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7800037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7800037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7802038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7802038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7802040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7802040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7802046,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9201.00000,2668.29000,Aetna,Local,,3680.40,,,,,,,3316.96,7526.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7802046,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9201.00000,2668.29000,Aetna,Local,,3680.40,,,,,,,2962.72,7526.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20923.00000,6067.67000,Aetna,Local,,8369.20,,,,,,,7542.74,17115.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20923.00000,6067.67000,Aetna,Local,,8369.20,,,,,,,6737.21,17115.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7802063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7802063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7736555,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7736555,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE RESERVOIR,7802100,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,12540.00000,3636.60000,Aetna,Local,,5016.00,,,,,,,4520.67,10257.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE RESERVOIR,7802100,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,12540.00000,3636.60000,Aetna,Local,,5016.00,,,,,,,4037.88,10257.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,755.10000,218.98000,Aetna,Local,,302.04,,,,,,,272.21,617.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,755.10000,218.98000,Aetna,Local,,302.04,,,,,,,243.14,617.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7802054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1672.00000,484.88000,Aetna,Local,,668.80,,,,,,,602.76,1367.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7802054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1672.00000,484.88000,Aetna,Local,,668.80,,,,,,,538.38,1367.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7802071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7802071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7802085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7802085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858076,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858076,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858077,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858077,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858078,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858078,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858079,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858079,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858081,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858081,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858083,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858083,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858084,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858084,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858085,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858085,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858089,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858089,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858090,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858090,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858091,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858091,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858094,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858094,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858095,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858095,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858096,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858096,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858097,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858097,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858101,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858101,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858102,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858102,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858103,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858103,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858106,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858106,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858108,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858108,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858111,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858111,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858114,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858114,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7939375,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7939375,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7948916,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7948916,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7964533,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7964533,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695840,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,398.86000,115.67000,Aetna,Local,,159.54,,,,,,,143.79,326.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695840,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,398.86000,115.67000,Aetna,Local,,159.54,,,,,,,128.43,326.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696565,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,887.94000,257.50000,Aetna,Local,,355.18,,,,,,,320.10,726.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696565,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,887.94000,257.50000,Aetna,Local,,355.18,,,,,,,285.92,726.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697400,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,887.94000,257.50000,Aetna,Local,,355.18,,,,,,,320.10,726.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697400,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,887.94000,257.50000,Aetna,Local,,355.18,,,,,,,285.92,726.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697591,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,382.57000,110.95000,Aetna,Local,,153.03,,,,,,,137.92,312.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697591,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,382.57000,110.95000,Aetna,Local,,153.03,,,,,,,123.19,312.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7956953,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7956953,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
X STOP,7696575,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,14461.20000,4193.75000,Aetna,Local,,5784.48,,,,,,,5213.26,11829.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
X STOP,7696575,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,14461.20000,4193.75000,Aetna,Local,,5784.48,,,,,,,4656.51,11829.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
X STOP,7696964,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,14461.20000,4193.75000,Aetna,Local,,5784.48,,,,,,,5213.26,11829.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
X STOP,7696964,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,14461.20000,4193.75000,Aetna,Local,,5784.48,,,,,,,4656.51,11829.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697594,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697594,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697595,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697595,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697596,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697596,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697597,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697597,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697598,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697598,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697599,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697599,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697600,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697600,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697601,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697601,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697602,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697602,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697603,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697603,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697604,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697604,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697605,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697605,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697606,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697606,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697607,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697607,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697608,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697608,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697609,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697609,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697610,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697610,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697611,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7697611,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7699181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7699181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7696669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1722.29,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7696669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1538.36,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7696670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1722.29,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7696670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1538.36,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7696671,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1722.29,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7696671,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1538.36,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7696672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1722.29,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7696672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1538.36,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7882520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1722.29,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7882520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1538.36,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACL TIGHTROPE,7697143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACL TIGHTROPE,7697143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,Local,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7696149,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1592.00000,461.68000,Aetna,Local,,636.80,,,,,,,573.92,1302.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7696149,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1592.00000,461.68000,Aetna,Local,,636.80,,,,,,,512.62,1302.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7696245,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1592.00000,461.68000,Aetna,Local,,636.80,,,,,,,573.92,1302.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7696245,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1592.00000,461.68000,Aetna,Local,,636.80,,,,,,,512.62,1302.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697513,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697513,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697516,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697516,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,821.48000,238.23000,Aetna,Local,,328.59,,,,,,,296.14,671.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,821.48000,238.23000,Aetna,Local,,328.59,,,,,,,264.52,671.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,821.48000,238.23000,Aetna,Local,,328.59,,,,,,,296.14,671.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,821.48000,238.23000,Aetna,Local,,328.59,,,,,,,264.52,671.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,637.79000,184.96000,Aetna,Local,,255.12,,,,,,,229.92,521.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,637.79000,184.96000,Aetna,Local,,255.12,,,,,,,205.37,521.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,47.83,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,42.72,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,47.83,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,42.72,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699716,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699716,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699724,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699724,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,300.28,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,268.21,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701497,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,77.60,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701497,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,69.31,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.09000,110.81000,Aetna,Local,,152.84,,,,,,,137.74,312.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.09000,110.81000,Aetna,Local,,152.84,,,,,,,123.03,312.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.09000,110.81000,Aetna,Local,,152.84,,,,,,,137.74,312.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.09000,110.81000,Aetna,Local,,152.84,,,,,,,123.03,312.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.09000,110.81000,Aetna,Local,,152.84,,,,,,,137.74,312.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.09000,110.81000,Aetna,Local,,152.84,,,,,,,123.03,312.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.09000,110.81000,Aetna,Local,,152.84,,,,,,,137.74,312.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.09000,110.81000,Aetna,Local,,152.84,,,,,,,123.03,312.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.09000,110.81000,Aetna,Local,,152.84,,,,,,,137.74,312.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.09000,110.81000,Aetna,Local,,152.84,,,,,,,123.03,312.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,108.03,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,96.50,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,108.03,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,96.50,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,108.03,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,96.50,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,108.03,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,96.50,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,108.03,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,96.50,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,108.03,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,96.50,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,108.03,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.68000,86.91000,Aetna,Local,,119.87,,,,,,,96.50,245.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,508.16000,147.37000,Aetna,Local,,203.26,,,,,,,183.19,415.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,508.16000,147.37000,Aetna,Local,,203.26,,,,,,,163.63,415.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702322,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,508.16000,147.37000,Aetna,Local,,203.26,,,,,,,183.19,415.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702322,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,508.16000,147.37000,Aetna,Local,,203.26,,,,,,,163.63,415.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.05000,167.05000,Aetna,Local,,230.42,,,,,,,207.67,471.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.05000,167.05000,Aetna,Local,,230.42,,,,,,,185.49,471.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.05000,167.05000,Aetna,Local,,230.42,,,,,,,207.67,471.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.05000,167.05000,Aetna,Local,,230.42,,,,,,,185.49,471.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.05000,167.05000,Aetna,Local,,230.42,,,,,,,207.67,471.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.05000,167.05000,Aetna,Local,,230.42,,,,,,,185.49,471.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,47.83,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,42.72,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,767.61000,222.61000,Aetna,Local,,307.04,,,,,,,276.72,627.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,767.61000,222.61000,Aetna,Local,,307.04,,,,,,,247.17,627.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,300.28,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,268.21,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,605.25000,175.52000,Aetna,Local,,242.10,,,,,,,218.19,495.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,605.25000,175.52000,Aetna,Local,,242.10,,,,,,,194.89,495.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7870036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7870036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882522,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882522,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,948.02000,274.93000,Aetna,Local,,379.21,,,,,,,341.76,775.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,948.02000,274.93000,Aetna,Local,,379.21,,,,,,,305.26,775.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703242,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703242,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2062.40000,598.10000,Aetna,Local,,824.96,,,,,,,743.50,1687.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2062.40000,598.10000,Aetna,Local,,824.96,,,,,,,664.09,1687.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2062.40000,598.10000,Aetna,Local,,824.96,,,,,,,743.50,1687.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2062.40000,598.10000,Aetna,Local,,824.96,,,,,,,664.09,1687.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10578.00000,3067.62000,Aetna,Local,,4231.20,,,,,,,3813.37,8652.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10578.00000,3067.62000,Aetna,Local,,4231.20,,,,,,,3406.12,8652.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2816.00000,816.64000,Aetna,Local,,1126.40,,,,,,,1015.17,2303.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2816.00000,816.64000,Aetna,Local,,1126.40,,,,,,,906.75,2303.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2488.40000,721.64000,Aetna,Local,,995.36,,,,,,,897.07,2035.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2488.40000,721.64000,Aetna,Local,,995.36,,,,,,,801.26,2035.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695043,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695043,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696304,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696304,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696480,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696480,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696692,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696692,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7700023,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7700023,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7700573,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7700573,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR PATCH,7694877,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,Local,,782.40,,,,,,,705.14,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR PATCH,7694877,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,Local,,782.40,,,,,,,629.83,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7802410,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7802410,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7804043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4144.70000,1201.96000,Aetna,Local,,1657.88,,,,,,,1494.16,3390.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7804043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4144.70000,1201.96000,Aetna,Local,,1657.88,,,,,,,1334.59,3390.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7804044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7804044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7804045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7804045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1639.29000,475.39000,Aetna,Local,,655.72,,,,,,,590.96,1340.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1639.29000,475.39000,Aetna,Local,,655.72,,,,,,,527.85,1340.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7770031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7770031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4599.00000,1333.71000,Aetna,Local,,1839.60,,,,,,,1657.94,3761.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4599.00000,1333.71000,Aetna,Local,,1839.60,,,,,,,1480.88,3761.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3213.00000,931.77000,Aetna,Local,,1285.20,,,,,,,1158.29,2628.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3213.00000,931.77000,Aetna,Local,,1285.20,,,,,,,1034.59,2628.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7699347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8265.00000,2396.85000,Aetna,Local,,3306.00,,,,,,,2979.53,6760.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7699347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8265.00000,2396.85000,Aetna,Local,,3306.00,,,,,,,2661.33,6760.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7697895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12638.40000,3665.14000,Aetna,Local,,5055.36,,,,,,,4556.14,10338.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7697895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12638.40000,3665.14000,Aetna,Local,,5055.36,,,,,,,4069.56,10338.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7760136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,8029.01,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7760136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,7171.55,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7760138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2893.01,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7760138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2584.05,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1684.00000,488.36000,Aetna,Local,,673.60,,,,,,,607.08,1377.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1684.00000,488.36000,Aetna,Local,,673.60,,,,,,,542.25,1377.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7697957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7872.75000,2283.10000,Aetna,Local,,3149.10,,,,,,,2838.13,6439.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7697957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7872.75000,2283.10000,Aetna,Local,,3149.10,,,,,,,2535.03,6439.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7516.80000,2179.87000,Aetna,Local,,3006.72,,,,,,,2709.81,6148.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7516.80000,2179.87000,Aetna,Local,,3006.72,,,,,,,2420.41,6148.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,684.00000,198.36000,Aetna,Local,,273.60,,,,,,,246.58,559.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,684.00000,198.36000,Aetna,Local,,273.60,,,,,,,220.25,559.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,596.48000,172.98000,Aetna,Local,,238.59,,,,,,,215.03,487.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,596.48000,172.98000,Aetna,Local,,238.59,,,,,,,192.07,487.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1433.16000,415.62000,Aetna,Local,,573.26,,,,,,,516.65,1172.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1433.16000,415.62000,Aetna,Local,,573.26,,,,,,,461.48,1172.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.36000,365.50000,Aetna,Local,,504.14,,,,,,,454.36,1030.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.36000,365.50000,Aetna,Local,,504.14,,,,,,,405.84,1030.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9100.20000,2639.06000,Aetna,Local,,3640.08,,,,,,,3280.62,7443.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9100.20000,2639.06000,Aetna,Local,,3640.08,,,,,,,2930.26,7443.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7694905,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13324.62000,3864.14000,Aetna,Local,,5329.85,,,,,,,4803.53,10899.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7694905,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13324.62000,3864.14000,Aetna,Local,,5329.85,,,,,,,4290.53,10899.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7694900,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9934.83000,2881.10000,Aetna,Local,,3973.93,,,,,,,3581.51,8126.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7694900,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9934.83000,2881.10000,Aetna,Local,,3973.93,,,,,,,3199.02,8126.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7694903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4041.94000,1172.16000,Aetna,Local,,1616.78,,,,,,,1457.12,3306.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7694903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4041.94000,1172.16000,Aetna,Local,,1616.78,,,,,,,1301.50,3306.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7694409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3414.11000,990.09000,Aetna,Local,,1365.64,,,,,,,1230.79,2792.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7694409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3414.11000,990.09000,Aetna,Local,,1365.64,,,,,,,1099.34,2792.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7740787,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2164.80000,627.79000,Aetna,Local,,865.92,,,,,,,780.41,1770.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7740787,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2164.80000,627.79000,Aetna,Local,,865.92,,,,,,,697.07,1770.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7806238,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3498.67000,1014.61000,Aetna,Local,,1399.47,,,,,,,1261.27,2861.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7806238,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3498.67000,1014.61000,Aetna,Local,,1399.47,,,,,,,1126.57,2861.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7806239,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4220.48000,1223.94000,Aetna,Local,,1688.19,,,,,,,1521.48,3452.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7806239,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4220.48000,1223.94000,Aetna,Local,,1688.19,,,,,,,1358.99,3452.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7806293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7806293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7806294,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7806294,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7806344,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,2887.72000,837.44000,Aetna,Local,,1155.09,,,,,,,1041.02,2362.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7806344,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,2887.72000,837.44000,Aetna,Local,,1155.09,,,,,,,929.85,2362.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698719,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698719,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7694753,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1356.68000,393.44000,Aetna,Local,,542.67,,,,,,,489.08,1109.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7694753,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1356.68000,393.44000,Aetna,Local,,542.67,,,,,,,436.85,1109.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695085,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2329.43,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695085,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2080.66,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694374,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,515.04000,149.36000,Aetna,Local,,206.02,,,,,,,185.67,421.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694374,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,515.04000,149.36000,Aetna,Local,,206.02,,,,,,,165.84,421.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7707510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7707510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIA ADAPTER,7697456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3266.90000,947.40000,Aetna,Local,,1306.76,,,,,,,1177.72,2672.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIA ADAPTER,7697456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3266.90000,947.40000,Aetna,Local,,1306.76,,,,,,,1051.94,2672.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7816131,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23750.00000,6887.50000,Aetna,Local,,9500.00,,,,,,,8561.88,19427.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7816131,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23750.00000,6887.50000,Aetna,Local,,9500.00,,,,,,,7647.50,19427.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7818167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,2052.78,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7818167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,1833.55,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7820087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2920.05,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7820087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2608.20,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7820088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2920.05,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7820088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2608.20,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7820143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.84000,487.15000,Aetna,Local,,671.94,,,,,,,605.58,1374.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7820143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.84000,487.15000,Aetna,Local,,671.94,,,,,,,540.91,1374.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7822088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1951.93,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7822088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1743.47,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7822096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,624.39,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7822096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,557.70,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE BUTTON,7822181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,884.70000,256.56000,Aetna,Local,,353.88,,,,,,,318.93,723.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE BUTTON,7822181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,884.70000,256.56000,Aetna,Local,,353.88,,,,,,,284.87,723.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE END PLATE,7822188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1498.40000,434.54000,Aetna,Local,,599.36,,,,,,,540.17,1225.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE END PLATE,7822188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1498.40000,434.54000,Aetna,Local,,599.36,,,,,,,482.48,1225.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7822260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7822260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMERAL,7824044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7831.80000,2271.22000,Aetna,Local,,3132.72,,,,,,,2823.36,6406.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMERAL,7824044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7831.80000,2271.22000,Aetna,Local,,3132.72,,,,,,,2521.84,6406.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL TENODESIS,7828029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3268.13000,947.76000,Aetna,Local,,1307.25,,,,,,,1178.16,2673.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL TENODESIS,7828029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3268.13000,947.76000,Aetna,Local,,1307.25,,,,,,,1052.34,2673.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOTAL ELBOW,7828152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOTAL ELBOW,7828152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7832043,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,676.61000,196.22000,Aetna,Local,,270.64,,,,,,,243.92,553.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7832043,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,676.61000,196.22000,Aetna,Local,,270.64,,,,,,,217.87,553.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7832044,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,707.17000,205.08000,Aetna,Local,,282.87,,,,,,,254.93,578.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7832044,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,707.17000,205.08000,Aetna,Local,,282.87,,,,,,,227.71,578.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7832104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1480.00000,429.20000,Aetna,Local,,592.00,,,,,,,533.54,1210.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7832104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1480.00000,429.20000,Aetna,Local,,592.00,,,,,,,476.56,1210.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7832060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7832060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,4346.82,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,3882.60,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7794032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7794032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,895.16,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7834106,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,752.40000,218.20000,Aetna,Local,,300.96,,,,,,,271.24,615.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7834106,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,752.40000,218.20000,Aetna,Local,,300.96,,,,,,,242.27,615.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7834108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7834108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7834118,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,7029.75,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7834118,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,6279.00,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1740.40000,504.72000,Aetna,Local,,696.16,,,,,,,627.41,1423.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1740.40000,504.72000,Aetna,Local,,696.16,,,,,,,560.41,1423.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7836140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7836140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7700062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,2191.66,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7700062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,1957.60,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7836189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7836189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7836196,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7836196,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7836198,CDM,278,RC,,,,,facility,inpatient,,,17389.45000,5042.94000,Aetna,Local,,6955.78,,,,,,,6268.90,14224.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7836198,CDM,278,RC,,,,,facility,outpatient,,,17389.45000,5042.94000,Aetna,Local,,6955.78,,,,,,,5599.40,14224.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRANIAL IMPLANT,7840037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,29176.11000,8461.07000,Aetna,Local,,11670.44,,,,,,,10517.99,23866.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRANIAL IMPLANT,7840037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,29176.11000,8461.07000,Aetna,Local,,11670.44,,,,,,,9394.71,23866.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9306.00000,2698.74000,Aetna,Local,,3722.40,,,,,,,3354.81,7612.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9306.00000,2698.74000,Aetna,Local,,3722.40,,,,,,,2996.53,7612.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7846131,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7846131,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7846132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7846132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7846155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7846155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7846251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6389.88000,1853.07000,Aetna,Local,,2555.95,,,,,,,2303.55,5226.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7846251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6389.88000,1853.07000,Aetna,Local,,2555.95,,,,,,,2057.54,5226.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7846252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,637.79000,184.96000,Aetna,Local,,255.12,,,,,,,229.92,521.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7846252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,637.79000,184.96000,Aetna,Local,,255.12,,,,,,,205.37,521.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7846253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,865.20,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7846253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,772.80,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7848091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12972.60000,3762.05000,Aetna,Local,,5189.04,,,,,,,4676.62,10611.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7848091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12972.60000,3762.05000,Aetna,Local,,5189.04,,,,,,,4177.18,10611.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7850086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7850086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7850087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7850087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7699777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,210.49,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7699777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,188.01,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7850192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7850192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7852069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7852069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7858075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,795.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7858075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,710.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7780213,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7780213,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7858548,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7858548,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858550,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,19825.00000,5749.25000,Aetna,Local,,7930.00,,,,,,,7146.91,16216.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858550,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,19825.00000,5749.25000,Aetna,Local,,7930.00,,,,,,,6383.65,16216.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7698090,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,24775.00000,7184.75000,Aetna,Local,,9910.00,,,,,,,8931.39,20265.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7698090,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,24775.00000,7184.75000,Aetna,Local,,9910.00,,,,,,,7977.55,20265.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858552,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,25737.50000,7463.87000,Aetna,Local,,10295.00,,,,,,,9278.37,21053.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858552,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,25737.50000,7463.87000,Aetna,Local,,10295.00,,,,,,,8287.48,21053.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858553,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,29103.75000,8440.09000,Aetna,Local,,11641.50,,,,,,,10491.90,23806.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858553,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,29103.75000,8440.09000,Aetna,Local,,11641.50,,,,,,,9371.41,23806.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858554,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,30501.00000,8845.29000,Aetna,Local,,12200.40,,,,,,,10995.61,24949.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858554,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,30501.00000,8845.29000,Aetna,Local,,12200.40,,,,,,,9821.32,24949.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858555,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,33750.00000,9787.50000,Aetna,Local,,13500.00,,,,,,,12166.88,27607.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858555,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,33750.00000,9787.50000,Aetna,Local,,13500.00,,,,,,,10867.50,27607.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4866.75000,1411.36000,Aetna,Local,,1946.70,,,,,,,1754.46,3981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4866.75000,1411.36000,Aetna,Local,,1946.70,,,,,,,1567.09,3981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7860077,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7860077,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7866032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1338.80000,388.25000,Aetna,Local,,535.52,,,,,,,482.64,1095.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7866032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1338.80000,388.25000,Aetna,Local,,535.52,,,,,,,431.09,1095.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7866080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7866080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3753.65000,1088.56000,Aetna,Local,,1501.46,,,,,,,1353.19,3070.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3753.65000,1088.56000,Aetna,Local,,1501.46,,,,,,,1208.68,3070.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7868038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,109.87,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7868038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,98.13,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7868039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7868039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7911038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,758.70000,220.02000,Aetna,Local,,303.48,,,,,,,273.51,620.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7911038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,758.70000,220.02000,Aetna,Local,,303.48,,,,,,,244.30,620.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1784.00000,517.36000,Aetna,Local,,713.60,,,,,,,643.13,1459.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1784.00000,517.36000,Aetna,Local,,713.60,,,,,,,574.45,1459.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7872039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6571.85000,1905.84000,Aetna,Local,,2628.74,,,,,,,2369.15,5375.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7872039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6571.85000,1905.84000,Aetna,Local,,2628.74,,,,,,,2116.14,5375.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS,7872045,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7364.25000,2135.63000,Aetna,Local,,2945.70,,,,,,,2654.81,6023.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS,7872045,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7364.25000,2135.63000,Aetna,Local,,2945.70,,,,,,,2371.29,6023.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7872097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7872097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BODY,7872099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11100.00000,3219.00000,Aetna,Local,,4440.00,,,,,,,4001.55,9079.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BODY,7872099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11100.00000,3219.00000,Aetna,Local,,4440.00,,,,,,,3574.20,9079.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7872100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7872100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7872102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7872102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL EXTENSION,7872103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL EXTENSION,7872103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7874121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7874121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7874123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7874123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7874125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,6524.15,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7874125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,5827.40,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874266,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874266,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7874326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7874326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7874337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,289.75000,84.03000,Aetna,Local,,115.90,,,,,,,104.45,237.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7874337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,289.75000,84.03000,Aetna,Local,,115.90,,,,,,,93.30,237.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7874341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1855.02,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7874341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1656.92,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7874394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7874394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7874422,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6125.00000,1776.25000,Aetna,Local,,2450.00,,,,,,,2208.06,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7874422,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6125.00000,1776.25000,Aetna,Local,,2450.00,,,,,,,1972.25,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7876345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8915.49000,2585.49000,Aetna,Local,,3566.20,,,,,,,3214.03,7292.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7876345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8915.49000,2585.49000,Aetna,Local,,3566.20,,,,,,,2870.79,7292.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7878485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7878485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2920.05,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2608.20,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7878537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2920.05,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7878537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2608.20,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STERNAL CLOSURE FLATWIRE,7878544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2320.00000,672.80000,Aetna,Local,,928.00,,,,,,,836.36,1897.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STERNAL CLOSURE FLATWIRE,7878544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2320.00000,672.80000,Aetna,Local,,928.00,,,,,,,747.04,1897.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7696694,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,4078.34,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7696694,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,3642.79,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7880516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7880516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880517,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880517,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7880534,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7880534,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7880535,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,588.34,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7880535,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,525.50,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7880752,CDM,278,RC,A4305,HCPCS,,,facility,inpatient,,,584.10000,169.39000,Aetna,Local,,233.64,,,,,,,210.57,477.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7880752,CDM,278,RC,A4305,HCPCS,,,facility,outpatient,,,584.10000,169.39000,Aetna,Local,,233.64,,,,,,,188.08,477.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880761,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1392.66,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880761,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1243.93,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON SEPTAL,7876343,CDM,278,RC,L8047,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,Local,,534.40,,,,,,,481.63,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON SEPTAL,7876343,CDM,278,RC,L8047,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,Local,,534.40,,,,,,,430.19,1561.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON SEPTAL,7880782,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1335.28000,387.23000,Aetna,Local,,534.11,,,,,,,481.37,1092.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON SEPTAL,7880782,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1335.28000,387.23000,Aetna,Local,,534.11,,,,,,,429.96,1092.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER ANATOMIC PROSTHESIS,7880788,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER ANATOMIC PROSTHESIS,7880788,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7880789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7880789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880787,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880787,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882256,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,38051.55000,11034.95000,Aetna,Local,,15220.62,,,,,,,13717.58,31126.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882256,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,38051.55000,11034.95000,Aetna,Local,,15220.62,,,,,,,12252.60,31126.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7882259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,174.66,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7882259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,156.01,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7882320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7882320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7882345,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7882345,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882382,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882382,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7882482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7882482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.60000,3007.76000,Aetna,Local,,4148.64,,,,,,,3738.96,8483.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.60000,3007.76000,Aetna,Local,,4148.64,,,,,,,3339.66,8483.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,920.57000,266.97000,Aetna,Local,,368.23,,,,,,,331.87,753.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,920.57000,266.97000,Aetna,Local,,368.23,,,,,,,296.42,753.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7882688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7882688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882691,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882691,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7882692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7882692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
JOINT TOE CERAMIC SPHERIC,7882766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8421.00000,2442.09000,Aetna,Local,,3368.40,,,,,,,3035.77,6888.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
JOINT TOE CERAMIC SPHERIC,7882766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8421.00000,2442.09000,Aetna,Local,,3368.40,,,,,,,2711.56,6888.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7882781,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10410.00000,3018.90000,Aetna,Local,,4164.00,,,,,,,3752.80,8515.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7882781,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10410.00000,3018.90000,Aetna,Local,,4164.00,,,,,,,3352.02,8515.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1445.92000,419.32000,Aetna,Local,,578.37,,,,,,,521.25,1182.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1445.92000,419.32000,Aetna,Local,,578.37,,,,,,,465.59,1182.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7882828,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,45787.50000,13278.37000,Aetna,Local,,18315.00,,,,,,,16506.39,37454.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7882828,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,45787.50000,13278.37000,Aetna,Local,,18315.00,,,,,,,14743.58,37454.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882789,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882789,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882792,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882792,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7882868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7882868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7870089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,449.02000,130.22000,Aetna,Local,,179.61,,,,,,,161.87,367.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7870089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,449.02000,130.22000,Aetna,Local,,179.61,,,,,,,144.58,367.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7893284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7893284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7893287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7893287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7893329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5724.57000,1660.13000,Aetna,Local,,2289.83,,,,,,,2063.71,4682.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7893329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5724.57000,1660.13000,Aetna,Local,,2289.83,,,,,,,1843.31,4682.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893348,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893348,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694071,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,824.94000,239.23000,Aetna,Local,,329.98,,,,,,,297.39,674.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694071,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,824.94000,239.23000,Aetna,Local,,329.98,,,,,,,265.63,674.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7893473,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5110.00000,1481.90000,Aetna,Local,,2044.00,,,,,,,1842.15,4179.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7893473,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5110.00000,1481.90000,Aetna,Local,,2044.00,,,,,,,1645.42,4179.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7834044,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7834044,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7902824,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7902824,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7905711,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7905711,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702805,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702805,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702806,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702806,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7703392,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7703392,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,7695678,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,985.50000,285.79000,Aetna,Local,,394.20,,,,,,,355.27,806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,7695678,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,985.50000,285.79000,Aetna,Local,,394.20,,,,,,,317.33,806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,7696513,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,220.03,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,7696513,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,196.53,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,7699124,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,220.03,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,7699124,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,196.53,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695883,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,368.13000,106.76000,Aetna,Local,,147.25,,,,,,,132.71,301.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695883,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,368.13000,106.76000,Aetna,Local,,147.25,,,,,,,118.54,301.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695936,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,351.50000,101.93000,Aetna,Local,,140.60,,,,,,,126.72,287.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695936,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,351.50000,101.93000,Aetna,Local,,140.60,,,,,,,113.18,287.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7698515,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,351.50000,101.93000,Aetna,Local,,140.60,,,,,,,126.72,287.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7698515,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,351.50000,101.93000,Aetna,Local,,140.60,,,,,,,113.18,287.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694913,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1120.28,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694913,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1000.63,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694914,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1120.28,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694914,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1000.63,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7954369,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1120.28,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7954369,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1000.63,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702868,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1120.28,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702868,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1000.63,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702869,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1120.28,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702869,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1000.63,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702880,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1120.28,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702880,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1000.63,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7703391,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7703391,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7695905,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3531.22000,1024.05000,Aetna,Local,,1412.49,,,,,,,1273.00,2888.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7695905,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3531.22000,1024.05000,Aetna,Local,,1412.49,,,,,,,1137.05,2888.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7695906,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3531.22000,1024.05000,Aetna,Local,,1412.49,,,,,,,1273.00,2888.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7695906,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3531.22000,1024.05000,Aetna,Local,,1412.49,,,,,,,1137.05,2888.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696289,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,375.25000,108.82000,Aetna,Local,,150.10,,,,,,,135.28,306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696289,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,375.25000,108.82000,Aetna,Local,,150.10,,,,,,,120.83,306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696271,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,222.55000,64.54000,Aetna,Local,,89.02,,,,,,,80.23,182.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696271,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,222.55000,64.54000,Aetna,Local,,89.02,,,,,,,71.66,182.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702892,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,184.70000,53.56000,Aetna,Local,,73.88,,,,,,,66.58,151.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702892,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,184.70000,53.56000,Aetna,Local,,73.88,,,,,,,59.47,151.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702893,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,222.55000,64.54000,Aetna,Local,,89.02,,,,,,,80.23,182.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702893,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,222.55000,64.54000,Aetna,Local,,89.02,,,,,,,71.66,182.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695037,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,487.78000,141.46000,Aetna,Local,,195.11,,,,,,,175.84,399.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695037,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,487.78000,141.46000,Aetna,Local,,195.11,,,,,,,157.07,399.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702894,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,336.30000,97.53000,Aetna,Local,,134.52,,,,,,,121.24,275.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702894,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,336.30000,97.53000,Aetna,Local,,134.52,,,,,,,108.29,275.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702899,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,720.90000,209.06000,Aetna,Local,,288.36,,,,,,,259.88,589.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702899,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,720.90000,209.06000,Aetna,Local,,288.36,,,,,,,232.13,589.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695955,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,680.76000,197.42000,Aetna,Local,,272.30,,,,,,,245.41,556.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695955,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,680.76000,197.42000,Aetna,Local,,272.30,,,,,,,219.20,556.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695688,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.55000,107.46000,Aetna,Local,,148.22,,,,,,,133.58,303.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695688,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.55000,107.46000,Aetna,Local,,148.22,,,,,,,119.32,303.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702237,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,354.73000,102.87000,Aetna,Local,,141.89,,,,,,,127.88,290.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702237,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,354.73000,102.87000,Aetna,Local,,141.89,,,,,,,114.22,290.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7696984,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,306.90000,89.00000,Aetna,Local,,122.76,,,,,,,110.64,251.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7696984,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,306.90000,89.00000,Aetna,Local,,122.76,,,,,,,98.82,251.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7702801,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7702801,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7903364,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2130.08000,617.72000,Aetna,Local,,852.03,,,,,,,767.89,1742.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7903364,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2130.08000,617.72000,Aetna,Local,,852.03,,,,,,,685.89,1742.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696974,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2833.67000,821.76000,Aetna,Local,,1133.47,,,,,,,1021.54,2317.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696974,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2833.67000,821.76000,Aetna,Local,,1133.47,,,,,,,912.44,2317.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697864,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1968.07000,570.74000,Aetna,Local,,787.23,,,,,,,709.49,1609.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697864,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1968.07000,570.74000,Aetna,Local,,787.23,,,,,,,633.72,1609.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702872,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2270.40000,658.42000,Aetna,Local,,908.16,,,,,,,818.48,1857.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702872,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2270.40000,658.42000,Aetna,Local,,908.16,,,,,,,731.07,1857.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702874,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2270.40000,658.42000,Aetna,Local,,908.16,,,,,,,818.48,1857.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702874,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2270.40000,658.42000,Aetna,Local,,908.16,,,,,,,731.07,1857.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702877,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2370.56000,687.46000,Aetna,Local,,948.22,,,,,,,854.59,1939.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702877,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2370.56000,687.46000,Aetna,Local,,948.22,,,,,,,763.32,1939.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3318.00000,962.22000,Aetna,Local,,1327.20,,,,,,,1196.14,2714.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3318.00000,962.22000,Aetna,Local,,1327.20,,,,,,,1068.40,2714.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,670.53,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,598.92,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7700237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1832.00000,531.28000,Aetna,Local,,732.80,,,,,,,660.44,1498.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7700237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1832.00000,531.28000,Aetna,Local,,732.80,,,,,,,589.90,1498.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7707499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7707499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7748125,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7748125,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7748126,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7748126,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7748127,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7748127,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7943790,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,799.79000,231.94000,Aetna,Local,,319.92,,,,,,,288.32,654.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7943790,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,799.79000,231.94000,Aetna,Local,,319.92,,,,,,,257.53,654.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7962120,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,799.79000,231.94000,Aetna,Local,,319.92,,,,,,,288.32,654.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7962120,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,799.79000,231.94000,Aetna,Local,,319.92,,,,,,,257.53,654.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7702697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,703.70,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7702697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,628.54,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSS CONNECTOR,7698587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSS CONNECTOR,7698587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.12000,90.51000,Aetna,Local,,124.85,,,,,,,112.52,255.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.12000,90.51000,Aetna,Local,,124.85,,,,,,,100.50,255.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.12000,90.51000,Aetna,Local,,124.85,,,,,,,112.52,255.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.12000,90.51000,Aetna,Local,,124.85,,,,,,,100.50,255.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701773,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701773,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701775,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701775,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,114.73,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,102.48,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7804057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7804057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7816123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7816123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822147,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.12000,90.51000,Aetna,Local,,124.85,,,,,,,112.52,255.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822147,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.12000,90.51000,Aetna,Local,,124.85,,,,,,,100.50,255.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.12000,90.51000,Aetna,Local,,124.85,,,,,,,112.52,255.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.12000,90.51000,Aetna,Local,,124.85,,,,,,,100.50,255.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.12000,90.51000,Aetna,Local,,124.85,,,,,,,112.52,255.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.12000,90.51000,Aetna,Local,,124.85,,,,,,,100.50,255.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7840032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7840032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7872041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7872041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7876321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7876321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,109.98,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.09000,88.48000,Aetna,Local,,122.04,,,,,,,98.24,249.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,109.95,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,98.21,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,109.95,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,98.21,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,109.95,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,98.21,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701924,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701924,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7698446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,648.90,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7698446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,579.60,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7698585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7698585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,Local,,740.85,,,,,,,667.69,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,Local,,740.85,,,,,,,596.38,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1796.28000,520.92000,Aetna,Local,,718.51,,,,,,,647.56,1469.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1796.28000,520.92000,Aetna,Local,,718.51,,,,,,,578.40,1469.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702163,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,892.60,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702163,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,797.27,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1880.08000,545.22000,Aetna,Local,,752.03,,,,,,,677.77,1537.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1880.08000,545.22000,Aetna,Local,,752.03,,,,,,,605.39,1537.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,739.17,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,660.23,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,739.17,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,660.23,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7802394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,892.60,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7802394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,797.27,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,554.00000,160.66000,Aetna,Local,,221.60,,,,,,,199.72,453.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,554.00000,160.66000,Aetna,Local,,221.60,,,,,,,178.39,453.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,223.23000,64.74000,Aetna,Local,,89.29,,,,,,,80.47,182.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,223.23000,64.74000,Aetna,Local,,89.29,,,,,,,71.88,182.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,714.15000,207.10000,Aetna,Local,,285.66,,,,,,,257.45,584.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,714.15000,207.10000,Aetna,Local,,285.66,,,,,,,229.96,584.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,694.54,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,620.37,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,694.54,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,620.37,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1864.52000,540.71000,Aetna,Local,,745.81,,,,,,,672.16,1525.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1864.52000,540.71000,Aetna,Local,,745.81,,,,,,,600.38,1525.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2494.40000,723.38000,Aetna,Local,,997.76,,,,,,,899.23,2040.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2494.40000,723.38000,Aetna,Local,,997.76,,,,,,,803.20,2040.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7836197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,694.54,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7836197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,620.37,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,694.54,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,620.37,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,694.54,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,Local,,770.64,,,,,,,620.37,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2128.00000,617.12000,Aetna,Local,,851.20,,,,,,,767.14,1740.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2128.00000,617.12000,Aetna,Local,,851.20,,,,,,,685.22,1740.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697669,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697669,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698669,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698669,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701593,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701593,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,129.10000,37.44000,Aetna,Local,,51.64,,,,,,,46.54,105.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,129.10000,37.44000,Aetna,Local,,51.64,,,,,,,41.57,105.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7768119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7768119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7921012,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7921012,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703147,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703147,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703154,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703154,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,128.05000,37.13000,Aetna,Local,,51.22,,,,,,,46.16,104.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,128.05000,37.13000,Aetna,Local,,51.22,,,,,,,41.23,104.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7954115,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7954115,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,467.40000,135.55000,Aetna,Local,,186.96,,,,,,,168.50,382.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,467.40000,135.55000,Aetna,Local,,186.96,,,,,,,150.50,382.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,147.26,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,131.54,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,467.40000,135.55000,Aetna,Local,,186.96,,,,,,,168.50,382.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,467.40000,135.55000,Aetna,Local,,186.96,,,,,,,150.50,382.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698755,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698755,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698756,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698756,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,169.87,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,151.73,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,169.87,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,151.73,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,169.87,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,151.73,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,169.87,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,151.73,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701793,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701793,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,111.13,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,99.27,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,309.18000,89.66000,Aetna,Local,,123.67,,,,,,,111.46,252.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,309.18000,89.66000,Aetna,Local,,123.67,,,,,,,99.56,252.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,309.18000,89.66000,Aetna,Local,,123.67,,,,,,,111.46,252.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,309.18000,89.66000,Aetna,Local,,123.67,,,,,,,99.56,252.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,111.13,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,99.27,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,111.13,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,99.27,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,111.13,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,99.27,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,111.13,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,99.27,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,111.13,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.28000,89.40000,Aetna,Local,,123.31,,,,,,,99.27,252.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7774106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7774106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882623,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882623,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,783.00000,227.07000,Aetna,Local,,313.20,,,,,,,282.27,640.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,783.00000,227.07000,Aetna,Local,,313.20,,,,,,,252.13,640.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,783.00000,227.07000,Aetna,Local,,313.20,,,,,,,282.27,640.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,783.00000,227.07000,Aetna,Local,,313.20,,,,,,,252.13,640.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.25000,86.78000,Aetna,Local,,119.70,,,,,,,107.88,244.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.25000,86.78000,Aetna,Local,,119.70,,,,,,,96.36,244.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,418.00000,121.22000,Aetna,Local,,167.20,,,,,,,150.69,341.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,418.00000,121.22000,Aetna,Local,,167.20,,,,,,,134.60,341.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,147.26,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,131.54,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7768156,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7768156,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703278,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703278,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7699916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,795.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7699916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,710.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7702912,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6662.25000,1932.05000,Aetna,Local,,2664.90,,,,,,,2401.74,5449.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7702912,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6662.25000,1932.05000,Aetna,Local,,2664.90,,,,,,,2145.24,5449.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER URETERAL,7696249,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,381.71000,110.70000,Aetna,Local,,152.68,,,,,,,137.61,312.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER URETERAL,7696249,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,381.71000,110.70000,Aetna,Local,,152.68,,,,,,,122.91,312.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7699112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7699112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7740751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7740751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7746049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7746049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7762379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7762379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7874432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7874432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7901860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7901860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7905300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7905300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7910833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7910833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7913430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7913430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7913881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7913881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7917332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7917332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7920822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7920822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7922465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7922465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7926457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7926457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7927552,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7927552,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7935609,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7935609,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7955060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7955060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7965171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7965171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7695435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.58000,214.48000,Aetna,Local,,295.83,,,,,,,266.62,604.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7695435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.58000,214.48000,Aetna,Local,,295.83,,,,,,,238.14,604.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7695445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.58000,214.48000,Aetna,Local,,295.83,,,,,,,266.62,604.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7695445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.58000,214.48000,Aetna,Local,,295.83,,,,,,,238.14,604.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7696821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.58000,214.48000,Aetna,Local,,295.83,,,,,,,266.62,604.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7696821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.58000,214.48000,Aetna,Local,,295.83,,,,,,,238.14,604.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7698293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.58000,214.48000,Aetna,Local,,295.83,,,,,,,266.62,604.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7698293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.58000,214.48000,Aetna,Local,,295.83,,,,,,,238.14,604.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7699807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,876.74000,254.25000,Aetna,Local,,350.70,,,,,,,316.06,717.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7699807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,876.74000,254.25000,Aetna,Local,,350.70,,,,,,,282.31,717.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7893926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,876.74000,254.25000,Aetna,Local,,350.70,,,,,,,316.06,717.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7893926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,876.74000,254.25000,Aetna,Local,,350.70,,,,,,,282.31,717.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7904024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,876.74000,254.25000,Aetna,Local,,350.70,,,,,,,316.06,717.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7904024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,876.74000,254.25000,Aetna,Local,,350.70,,,,,,,282.31,717.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696829,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,4634.42000,1343.98000,Aetna,Local,,1853.77,,,,,,,1670.71,3790.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696829,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,4634.42000,1343.98000,Aetna,Local,,1853.77,,,,,,,1492.28,3790.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7697009,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,4634.42000,1343.98000,Aetna,Local,,1853.77,,,,,,,1670.71,3790.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7697009,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,4634.42000,1343.98000,Aetna,Local,,1853.77,,,,,,,1492.28,3790.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7699142,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,4634.42000,1343.98000,Aetna,Local,,1853.77,,,,,,,1670.71,3790.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7699142,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,4634.42000,1343.98000,Aetna,Local,,1853.77,,,,,,,1492.28,3790.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1544.00000,447.76000,Aetna,Local,,617.60,,,,,,,556.61,1262.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1544.00000,447.76000,Aetna,Local,,617.60,,,,,,,497.17,1262.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696773,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696773,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8148643,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,431.59000,125.16000,Aetna,Local,,172.64,,,,,,,155.59,353.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8148643,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,431.59000,125.16000,Aetna,Local,,172.64,,,,,,,138.97,353.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDESHEATH,8135906,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDESHEATH,8135906,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135905,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135905,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135907,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135907,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135908,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1380.00000,400.20000,Aetna,Local,,552.00,,,,,,,497.49,1128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135908,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,552.00,,,,,,,444.36,1128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135909,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135909,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROWN STEALTH,7895438,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12435.00000,3606.15000,Aetna,Local,,4974.00,,,,,,,4482.82,10171.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROWN STEALTH,7895438,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12435.00000,3606.15000,Aetna,Local,,4974.00,,,,,,,4004.07,10171.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROWN STEALTH,7905197,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12435.00000,3606.15000,Aetna,Local,,4974.00,,,,,,,4482.82,10171.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROWN STEALTH,7905197,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12435.00000,3606.15000,Aetna,Local,,4974.00,,,,,,,4004.07,10171.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7913195,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12435.00000,3606.15000,Aetna,Local,,4974.00,,,,,,,4482.82,10171.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7913195,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12435.00000,3606.15000,Aetna,Local,,4974.00,,,,,,,4004.07,10171.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7921035,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,189.63000,54.99000,Aetna,Local,,75.85,,,,,,,68.36,155.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7921035,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,189.63000,54.99000,Aetna,Local,,75.85,,,,,,,61.06,155.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695243,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,15512.50000,4498.62000,Aetna,Local,,6205.00,,,,,,,5592.26,12689.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695243,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,15512.50000,4498.62000,Aetna,Local,,6205.00,,,,,,,4995.02,12689.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135965,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,148.68000,43.12000,Aetna,Local,,59.47,,,,,,,53.60,121.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135965,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,148.68000,43.12000,Aetna,Local,,59.47,,,,,,,47.87,121.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135966,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,489.25000,141.88000,Aetna,Local,,195.70,,,,,,,176.37,400.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135966,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,489.25000,141.88000,Aetna,Local,,195.70,,,,,,,157.54,400.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135969,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135969,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135970,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135970,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135972,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,947.88,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135972,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,846.65,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135973,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,947.88,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135973,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,846.65,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135974,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,947.88,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135974,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,846.65,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135975,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,947.88,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135975,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,846.65,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135976,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,947.88,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135976,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,846.65,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135977,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,214.62000,62.24000,Aetna,Local,,85.85,,,,,,,77.37,175.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135977,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,214.62000,62.24000,Aetna,Local,,85.85,,,,,,,69.11,175.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750490,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750490,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750493,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750493,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,8135981,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,113.30000,32.86000,Aetna,Local,,45.32,,,,,,,40.84,92.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,8135981,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,113.30000,32.86000,Aetna,Local,,45.32,,,,,,,36.48,92.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135971,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,728.10000,211.15000,Aetna,Local,,291.24,,,,,,,262.48,595.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135971,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,728.10000,211.15000,Aetna,Local,,291.24,,,,,,,234.45,595.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7950525,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7950525,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135968,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,173.67000,50.36000,Aetna,Local,,69.47,,,,,,,62.61,142.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135968,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,173.67000,50.36000,Aetna,Local,,69.47,,,,,,,55.92,142.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694369,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694369,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135565,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,207.38000,60.14000,Aetna,Local,,82.95,,,,,,,74.76,169.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135565,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,207.38000,60.14000,Aetna,Local,,82.95,,,,,,,66.78,169.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135983,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,133.35000,38.67000,Aetna,Local,,53.34,,,,,,,48.07,109.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135983,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,133.35000,38.67000,Aetna,Local,,53.34,,,,,,,42.94,109.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135982,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135982,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135463,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135463,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,964.35000,279.66000,Aetna,Local,,385.74,,,,,,,347.65,788.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,964.35000,279.66000,Aetna,Local,,385.74,,,,,,,310.52,788.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,Local,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7760139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7760139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1227.20000,355.89000,Aetna,Local,,490.88,,,,,,,442.41,1003.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1227.20000,355.89000,Aetna,Local,,490.88,,,,,,,395.16,1003.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,283.89,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,253.57,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,283.89,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,253.57,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1227.20000,355.89000,Aetna,Local,,490.88,,,,,,,442.41,1003.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1227.20000,355.89000,Aetna,Local,,490.88,,,,,,,395.16,1003.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7702703,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,2097.03,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7702703,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,1873.07,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7702704,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,2097.03,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7702704,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,1873.07,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7741715,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,2097.03,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7741715,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,1873.07,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7702705,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,2097.03,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7702705,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,1873.07,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7784068,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,2097.03,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7784068,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,Local,,2326.80,,,,,,,1873.07,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7694515,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7694515,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7695328,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,451.25000,130.86000,Aetna,Local,,180.50,,,,,,,162.68,369.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7695328,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,451.25000,130.86000,Aetna,Local,,180.50,,,,,,,145.30,369.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7696831,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,360.86000,104.65000,Aetna,Local,,144.34,,,,,,,130.09,295.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7696831,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,360.86000,104.65000,Aetna,Local,,144.34,,,,,,,116.20,295.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695596,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,545.40000,158.17000,Aetna,Local,,218.16,,,,,,,196.62,446.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695596,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,545.40000,158.17000,Aetna,Local,,218.16,,,,,,,175.62,446.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5541.90000,1607.15000,Aetna,Local,,2216.76,,,,,,,1997.85,4533.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5541.90000,1607.15000,Aetna,Local,,2216.76,,,,,,,1784.49,4533.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3559.50000,1032.25000,Aetna,Local,,1423.80,,,,,,,1283.20,2911.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3559.50000,1032.25000,Aetna,Local,,1423.80,,,,,,,1146.16,2911.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3444.00000,998.76000,Aetna,Local,,1377.60,,,,,,,1241.56,2817.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3444.00000,998.76000,Aetna,Local,,1377.60,,,,,,,1108.97,2817.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696884,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2489.64000,722.00000,Aetna,Local,,995.86,,,,,,,897.52,2036.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696884,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2489.64000,722.00000,Aetna,Local,,995.86,,,,,,,801.66,2036.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,180.50000,52.34000,Aetna,Local,,72.20,,,,,,,65.07,147.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,180.50000,52.34000,Aetna,Local,,72.20,,,,,,,58.12,147.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,114.73,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,102.48,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,114.73,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,102.48,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,116.29,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,103.87,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7834151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7834151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7836162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7836162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,180.50000,52.34000,Aetna,Local,,72.20,,,,,,,65.07,147.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,180.50000,52.34000,Aetna,Local,,72.20,,,,,,,58.12,147.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,467.40000,135.55000,Aetna,Local,,186.96,,,,,,,168.50,382.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,467.40000,135.55000,Aetna,Local,,186.96,,,,,,,150.50,382.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697497,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697497,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,114.73,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,102.48,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,114.73,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,102.48,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698753,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698753,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698754,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698754,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,Local,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,156.61000,45.42000,Aetna,Local,,62.64,,,,,,,56.46,128.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,156.61000,45.42000,Aetna,Local,,62.64,,,,,,,50.43,128.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702804,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,451.11000,130.82000,Aetna,Local,,180.44,,,,,,,162.63,369.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702804,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,451.11000,130.82000,Aetna,Local,,180.44,,,,,,,145.26,369.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702799,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,222.77,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702799,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,198.98,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694470,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,1744.00000,505.76000,Aetna,Local,,697.60,,,,,,,628.71,1426.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694470,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,1744.00000,505.76000,Aetna,Local,,697.60,,,,,,,561.57,1426.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RETRIEVAL DEVICE,7701195,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RETRIEVAL DEVICE,7701195,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,398.00000,115.42000,Aetna,Local,,159.20,,,,,,,143.48,325.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,398.00000,115.42000,Aetna,Local,,159.20,,,,,,,128.16,325.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,398.00000,115.42000,Aetna,Local,,159.20,,,,,,,143.48,325.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,398.00000,115.42000,Aetna,Local,,159.20,,,,,,,128.16,325.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,300.28,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,268.21,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,335.87000,97.40000,Aetna,Local,,134.35,,,,,,,121.08,274.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,335.87000,97.40000,Aetna,Local,,134.35,,,,,,,108.15,274.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,398.00000,115.42000,Aetna,Local,,159.20,,,,,,,143.48,325.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,398.00000,115.42000,Aetna,Local,,159.20,,,,,,,128.16,325.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,47.32,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,42.26,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,47.32,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,42.26,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,47.32,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,42.26,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,47.32,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,42.26,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,47.32,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,42.26,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,47.32,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,42.26,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,47.32,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,42.26,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,47.32,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.25000,38.06000,Aetna,Local,,52.50,,,,,,,42.26,107.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7702153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,670.53,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7702153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,598.92,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7776067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1820.00000,527.80000,Aetna,Local,,728.00,,,,,,,656.11,1488.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7776067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1820.00000,527.80000,Aetna,Local,,728.00,,,,,,,586.04,1488.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695658,CDM,278,RC,C1877,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695658,CDM,278,RC,C1877,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1328.00000,385.12000,Aetna,Local,,531.20,,,,,,,478.74,1086.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1328.00000,385.12000,Aetna,Local,,531.20,,,,,,,427.62,1086.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1328.00000,385.12000,Aetna,Local,,531.20,,,,,,,478.74,1086.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1328.00000,385.12000,Aetna,Local,,531.20,,,,,,,427.62,1086.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,166.10,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,148.36,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,166.10,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,148.36,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,378.77000,109.84000,Aetna,Local,,151.51,,,,,,,136.55,309.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,378.77000,109.84000,Aetna,Local,,151.51,,,,,,,121.96,309.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,389.83000,113.05000,Aetna,Local,,155.93,,,,,,,140.53,318.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,389.83000,113.05000,Aetna,Local,,155.93,,,,,,,125.53,318.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,389.83000,113.05000,Aetna,Local,,155.93,,,,,,,140.53,318.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,389.83000,113.05000,Aetna,Local,,155.93,,,,,,,125.53,318.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1544.00000,447.76000,Aetna,Local,,617.60,,,,,,,556.61,1262.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1544.00000,447.76000,Aetna,Local,,617.60,,,,,,,497.17,1262.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,436.93,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,390.26,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,400.90000,116.26000,Aetna,Local,,160.36,,,,,,,144.52,327.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,400.90000,116.26000,Aetna,Local,,160.36,,,,,,,129.09,327.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,174.66,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,156.01,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,241.72,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,215.90,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,118.68,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,106.01,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700793,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700793,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,578.03000,167.63000,Aetna,Local,,231.21,,,,,,,208.38,472.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,578.03000,167.63000,Aetna,Local,,231.21,,,,,,,186.13,472.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,578.03000,167.63000,Aetna,Local,,231.21,,,,,,,208.38,472.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,578.03000,167.63000,Aetna,Local,,231.21,,,,,,,186.13,472.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.35000,114.07000,Aetna,Local,,157.34,,,,,,,141.80,321.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.35000,114.07000,Aetna,Local,,157.34,,,,,,,126.66,321.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.35000,114.07000,Aetna,Local,,157.34,,,,,,,141.80,321.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.35000,114.07000,Aetna,Local,,157.34,,,,,,,126.66,321.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.35000,114.07000,Aetna,Local,,157.34,,,,,,,141.80,321.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.35000,114.07000,Aetna,Local,,157.34,,,,,,,126.66,321.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.35000,114.07000,Aetna,Local,,157.34,,,,,,,141.80,321.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.35000,114.07000,Aetna,Local,,157.34,,,,,,,126.66,321.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.87000,108.71000,Aetna,Local,,149.95,,,,,,,135.14,306.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.87000,108.71000,Aetna,Local,,149.95,,,,,,,120.71,306.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.87000,108.71000,Aetna,Local,,149.95,,,,,,,135.14,306.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.87000,108.71000,Aetna,Local,,149.95,,,,,,,120.71,306.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.87000,108.71000,Aetna,Local,,149.95,,,,,,,135.14,306.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.87000,108.71000,Aetna,Local,,149.95,,,,,,,120.71,306.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.87000,108.71000,Aetna,Local,,149.95,,,,,,,135.14,306.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.87000,108.71000,Aetna,Local,,149.95,,,,,,,120.71,306.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736609,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736609,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,770.85000,223.55000,Aetna,Local,,308.34,,,,,,,277.89,630.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,770.85000,223.55000,Aetna,Local,,308.34,,,,,,,248.21,630.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7810069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7810069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7816127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7816127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7834035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7834035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,454.29000,131.74000,Aetna,Local,,181.72,,,,,,,163.77,371.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,454.29000,131.74000,Aetna,Local,,181.72,,,,,,,146.28,371.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,7699770,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3732.75000,1082.50000,Aetna,Local,,1493.10,,,,,,,1345.66,3053.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,7699770,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3732.75000,1082.50000,Aetna,Local,,1493.10,,,,,,,1201.95,3053.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7698545,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7698545,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7893416,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7893416,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7894160,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7894160,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7935069,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,577.80000,167.56000,Aetna,Local,,231.12,,,,,,,208.30,472.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7935069,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,577.80000,167.56000,Aetna,Local,,231.12,,,,,,,186.05,472.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699734,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699734,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7832056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7832056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699721,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,166.53000,48.29000,Aetna,Local,,66.61,,,,,,,60.03,136.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699721,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,166.53000,48.29000,Aetna,Local,,66.61,,,,,,,53.62,136.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696121,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1951.93,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696121,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1743.47,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696122,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1951.93,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696122,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1743.47,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696306,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5498.50000,1594.56000,Aetna,Local,,2199.40,,,,,,,1982.21,4497.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696306,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5498.50000,1594.56000,Aetna,Local,,2199.40,,,,,,,1770.52,4497.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696307,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5498.50000,1594.56000,Aetna,Local,,2199.40,,,,,,,1982.21,4497.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696307,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5498.50000,1594.56000,Aetna,Local,,2199.40,,,,,,,1770.52,4497.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7905615,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5579.00000,1617.91000,Aetna,Local,,2231.60,,,,,,,2011.23,4563.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7905615,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5579.00000,1617.91000,Aetna,Local,,2231.60,,,,,,,1796.44,4563.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695597,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695597,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695598,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695598,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696502,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,10962.00000,3178.98000,Aetna,Local,,4384.80,,,,,,,3951.80,8966.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696502,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,10962.00000,3178.98000,Aetna,Local,,4384.80,,,,,,,3529.76,8966.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702871,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1120.28,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702871,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3107.56000,901.19000,Aetna,Local,,1243.02,,,,,,,1000.63,2541.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7902528,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7902528,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7902534,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7902534,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695881,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,311.13000,90.23000,Aetna,Local,,124.45,,,,,,,112.16,254.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695881,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,311.13000,90.23000,Aetna,Local,,124.45,,,,,,,100.18,254.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7703359,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7703359,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7760132,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7760132,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697121,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697121,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697122,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697122,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697123,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697123,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697124,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697124,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697125,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697125,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697939,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697939,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698092,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698092,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698346,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698346,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7701622,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7701622,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7702287,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7702287,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7702643,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7702643,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736051,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736051,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736248,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736248,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736306,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736306,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736308,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736308,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736310,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736310,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736311,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736311,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736312,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736312,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736314,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736314,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736366,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736366,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736317,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736317,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736319,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736319,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736320,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736320,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736321,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736321,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736322,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736322,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736323,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736323,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736324,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736324,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7697166,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7697166,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7697631,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8502.00000,2465.58000,Aetna,Local,,3400.80,,,,,,,3064.97,6954.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7697631,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8502.00000,2465.58000,Aetna,Local,,3400.80,,,,,,,2737.64,6954.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694670,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,418.19000,121.28000,Aetna,Local,,167.28,,,,,,,150.76,342.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694670,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,418.19000,121.28000,Aetna,Local,,167.28,,,,,,,134.66,342.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,665.84,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,594.73,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7784036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,Local,,722.00,,,,,,,650.70,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7784036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,Local,,722.00,,,,,,,581.21,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7903142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,Local,,722.00,,,,,,,650.70,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7903142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,Local,,722.00,,,,,,,581.21,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7935397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,Local,,722.00,,,,,,,650.70,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7935397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,Local,,722.00,,,,,,,581.21,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7965092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2384.00000,691.36000,Aetna,Local,,953.60,,,,,,,859.43,1950.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7965092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2384.00000,691.36000,Aetna,Local,,953.60,,,,,,,767.65,1950.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7700121,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2036.00000,590.44000,Aetna,Local,,814.40,,,,,,,733.98,1665.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7700121,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2036.00000,590.44000,Aetna,Local,,814.40,,,,,,,655.59,1665.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7945855,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3881.50000,1125.64000,Aetna,Local,,1552.60,,,,,,,1399.28,3175.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7945855,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3881.50000,1125.64000,Aetna,Local,,1552.60,,,,,,,1249.84,3175.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7948838,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3881.50000,1125.64000,Aetna,Local,,1552.60,,,,,,,1399.28,3175.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7948838,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3881.50000,1125.64000,Aetna,Local,,1552.60,,,,,,,1249.84,3175.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7954476,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3881.50000,1125.64000,Aetna,Local,,1552.60,,,,,,,1399.28,3175.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7954476,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3881.50000,1125.64000,Aetna,Local,,1552.60,,,,,,,1249.84,3175.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7954477,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3881.50000,1125.64000,Aetna,Local,,1552.60,,,,,,,1399.28,3175.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7954477,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3881.50000,1125.64000,Aetna,Local,,1552.60,,,,,,,1249.84,3175.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694752,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1560.80000,452.63000,Aetna,Local,,624.32,,,,,,,562.67,1276.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694752,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1560.80000,452.63000,Aetna,Local,,624.32,,,,,,,502.58,1276.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697259,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697259,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IAB CATHETER,8135556,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IAB CATHETER,8135556,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IAB CATHETER,8135557,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IAB CATHETER,8135557,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135590,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135590,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,9357.00,,,,,,,1775.03,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,8135623,CDM,278,RC,C2630,HCPCS,,,facility,inpatient,,,6618.50000,1919.36000,Aetna,Local,,2647.40,,,,,,,2385.97,5413.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135623,CDM,278,RC,C2630,HCPCS,,,facility,outpatient,,,6618.50000,1919.36000,Aetna,Local,,9357.00,,,,,,,2131.16,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER ABLATION,8135470,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135470,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,Local,,9357.00,,,,,,,1110.10,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER ABLATION,8135468,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135468,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,Local,,9357.00,,,,,,,1110.10,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ABLATION CATHETER,8135466,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8135466,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,Local,,9357.00,,,,,,,1110.10,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ABLATION CATHETER,8135467,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8135467,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,Local,,9357.00,,,,,,,1110.10,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER ABLATION,8135465,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135465,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,Local,,9357.00,,,,,,,1110.10,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER ABLATION,8135471,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135471,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,Local,,9357.00,,,,,,,1110.10,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
GUIDEWIRE,7694948,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,201.16,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694948,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,179.68,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7848087,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,201.16,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7848087,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,179.68,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135663,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135663,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8135618,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8135618,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135563,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135563,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8135619,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8135619,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135574,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135574,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANGIOJET,8135593,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2752.42,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANGIOJET,8135593,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2458.47,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THROMBECTOMY,8135575,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2752.42,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THROMBECTOMY,8135575,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2458.47,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY,8135585,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,804.83000,233.40000,Aetna,Local,,321.93,,,,,,,290.14,658.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY,8135585,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,804.83000,233.40000,Aetna,Local,,321.93,,,,,,,259.16,658.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135412,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135412,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8136299,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8136299,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8136302,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8136302,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8136303,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8136303,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8136304,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8136304,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135653,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135653,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135652,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135652,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135643,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135643,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135654,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135654,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135655,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135655,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135415,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135415,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135416,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135416,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135417,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135417,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135418,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135418,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135419,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135419,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135421,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135421,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135424,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135424,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135425,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8135425,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135427,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135427,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135428,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135428,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135429,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CORONARY,8135429,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135605,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135605,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7695041,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7695041,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7736134,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7736134,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7876183,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7876183,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER EMBOLIZATION,8135606,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,4735.50000,1373.29000,Aetna,Local,,1894.20,,,,,,,1707.15,3873.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER EMBOLIZATION,8135606,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,4735.50000,1373.29000,Aetna,Local,,1894.20,,,,,,,1524.83,3873.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135662,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1988.00000,576.52000,Aetna,Local,,795.20,,,,,,,716.67,1626.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135662,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1988.00000,576.52000,Aetna,Local,,795.20,,,,,,,640.14,1626.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE SYSTEM,8135646,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2688.36000,779.62000,Aetna,Local,,1075.34,,,,,,,969.15,2199.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE SYSTEM,8135646,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2688.36000,779.62000,Aetna,Local,,1075.34,,,,,,,865.65,2199.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135438,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,35.30,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135438,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,31.53,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135522,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135522,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135560,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135560,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135538,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135538,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135539,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135539,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135540,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135540,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135541,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135541,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135555,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135555,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135515,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135515,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135803,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,560.25000,162.47000,Aetna,Local,,224.10,,,,,,,201.97,458.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135803,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,560.25000,162.47000,Aetna,Local,,224.10,,,,,,,180.40,458.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135804,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,560.25000,162.47000,Aetna,Local,,224.10,,,,,,,201.97,458.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135804,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,560.25000,162.47000,Aetna,Local,,224.10,,,,,,,180.40,458.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702691,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702691,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135551,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135551,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135550,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135550,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135561,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135561,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135805,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,560.25000,162.47000,Aetna,Local,,224.10,,,,,,,201.97,458.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135805,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,560.25000,162.47000,Aetna,Local,,224.10,,,,,,,180.40,458.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135806,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,560.25000,162.47000,Aetna,Local,,224.10,,,,,,,201.97,458.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135806,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,560.25000,162.47000,Aetna,Local,,224.10,,,,,,,180.40,458.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135516,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135516,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135517,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135517,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135518,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135518,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136569,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136569,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135519,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135519,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135520,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135520,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135521,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135521,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135533,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135533,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135535,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135535,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135534,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135534,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135536,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135536,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135537,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135537,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135532,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135532,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135545,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135545,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135544,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135544,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135546,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135546,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135554,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135554,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135553,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135553,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135552,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135552,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135542,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135542,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135548,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135548,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135547,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135547,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135549,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135549,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135562,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135562,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135524,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135524,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135525,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135525,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135526,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135526,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135527,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135527,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135528,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135528,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135530,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135530,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135529,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135529,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135531,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135531,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135543,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135543,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135656,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135656,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135627,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135627,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135649,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135649,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135602,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135602,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135495,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135495,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135499,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135499,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135497,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135497,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135490,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135490,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135491,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135491,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIO,8135498,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIO,8135498,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135492,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135492,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135501,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135501,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135475,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135475,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135502,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135502,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135503,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135503,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135504,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135504,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135488,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135488,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135482,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135482,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135474,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135474,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135505,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135505,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135483,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135483,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135486,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135486,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135485,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135485,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135487,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135487,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135506,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135506,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135478,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135478,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135510,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135510,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135494,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135494,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135479,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135479,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135484,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135484,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135507,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135507,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135508,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135508,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135509,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135509,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135512,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135512,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135513,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135513,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135476,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135476,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135477,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135477,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135500,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135500,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135481,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135481,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135493,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135493,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON SIZING,8135641,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2320.00000,672.80000,Aetna,Local,,928.00,,,,,,,836.36,1897.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON SIZING,8135641,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2320.00000,672.80000,Aetna,Local,,928.00,,,,,,,747.04,1897.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135582,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135582,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135401,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135401,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135403,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135403,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE FLP HI-TORQUE STR,8135443,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE FLP HI-TORQUE STR,8135443,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135400,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135400,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135402,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135402,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135444,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135444,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDWIRE,8370413,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDWIRE,8370413,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695687,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,458.99000,133.11000,Aetna,Local,,183.60,,,,,,,165.47,375.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695687,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,458.99000,133.11000,Aetna,Local,,183.60,,,,,,,147.79,375.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8135617,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8135617,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136307,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136307,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8135620,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8135620,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135632,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135632,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135442,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135442,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135472,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.55000,107.46000,Aetna,Local,,148.22,,,,,,,133.58,303.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135472,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.55000,107.46000,Aetna,Local,,148.22,,,,,,,119.32,303.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135473,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.55000,107.46000,Aetna,Local,,148.22,,,,,,,133.58,303.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135473,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.55000,107.46000,Aetna,Local,,148.22,,,,,,,119.32,303.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8135591,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,386.51000,112.09000,Aetna,Local,,154.60,,,,,,,139.34,316.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8135591,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,386.51000,112.09000,Aetna,Local,,154.60,,,,,,,124.46,316.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEVICE LEAD LOCKING,8136291,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,3026.67000,877.73000,Aetna,Local,,1210.67,,,,,,,1091.11,2475.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEVICE LEAD LOCKING,8136291,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,3026.67000,877.73000,Aetna,Local,,1210.67,,,,,,,974.59,2475.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135452,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135452,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135455,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135455,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7950338,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,677.74,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7950338,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,605.36,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136293,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,670.53,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136293,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,598.92,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135568,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135568,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135453,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135453,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135625,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135625,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135630,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135630,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135570,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135570,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135461,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135461,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,9357.00,,,,,,,1746.85,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER ABLATION,8135462,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135462,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,9357.00,,,,,,,1746.85,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SHEATH,8136570,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8136570,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135464,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5740.00000,1664.60000,Aetna,Local,,2296.00,,,,,,,2069.27,4695.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135464,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5740.00000,1664.60000,Aetna,Local,,9357.00,,,,,,,1848.28,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTRODUCER,8135449,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,463.74000,134.48000,Aetna,Local,,185.50,,,,,,,167.18,379.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135449,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,463.74000,134.48000,Aetna,Local,,185.50,,,,,,,149.32,379.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135584,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,478.47000,138.76000,Aetna,Local,,191.39,,,,,,,172.49,391.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135584,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,478.47000,138.76000,Aetna,Local,,191.39,,,,,,,154.07,391.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,8135454,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,8135454,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694464,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694464,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135567,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,133.35000,38.67000,Aetna,Local,,53.34,,,,,,,48.07,109.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135567,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,133.35000,38.67000,Aetna,Local,,53.34,,,,,,,42.94,109.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135588,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,133.35000,38.67000,Aetna,Local,,53.34,,,,,,,48.07,109.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135588,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,133.35000,38.67000,Aetna,Local,,53.34,,,,,,,42.94,109.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135707,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,3465.00000,1004.85000,Aetna,Local,,1386.00,,,,,,,1249.13,2834.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135707,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,3465.00000,1004.85000,Aetna,Local,,9357.00,,,,,,,1115.73,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER DECAPOLAR,8135587,CDM,278,RC,C1731,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DECAPOLAR,8135587,CDM,278,RC,C1731,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,9357.00,,,,,,,1183.35,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ROTABLATOR ROTALINK,8135448,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,4681.08000,1357.51000,Aetna,Local,,1872.43,,,,,,,1687.53,3829.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROTABLATOR ROTALINK,8135448,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,4681.08000,1357.51000,Aetna,Local,,1872.43,,,,,,,1507.31,3829.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7693492,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7693492,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135650,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135650,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7694463,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7694463,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER TRANSEPTAL,8135457,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER TRANSEPTAL,8135457,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694465,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694465,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7960336,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,11535.00000,3345.15000,Aetna,Local,,4614.00,,,,,,,4158.37,9435.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7960336,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,11535.00000,3345.15000,Aetna,Local,,4614.00,,,,,,,3714.27,9435.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135594,CDM,278,RC,C1759,HCPCS,,,facility,inpatient,,,13023.00000,3776.67000,Aetna,Local,,5209.20,,,,,,,4694.79,10652.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135594,CDM,278,RC,C1759,HCPCS,,,facility,outpatient,,,13023.00000,3776.67000,Aetna,Local,,5209.20,,,,,,,4193.41,10652.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135644,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3601.50000,1044.44000,Aetna,Local,,1440.60,,,,,,,1298.34,2946.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135644,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,Local,,1440.60,,,,,,,1159.68,2946.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT INTRO AGILIS,8135645,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT INTRO AGILIS,8135645,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135633,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,5768.00000,1672.72000,Aetna,Local,,2307.20,,,,,,,2079.36,4718.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135633,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,5768.00000,1672.72000,Aetna,Local,,2307.20,,,,,,,1857.30,4718.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135634,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,5530.00000,1603.70000,Aetna,Local,,2212.00,,,,,,,1993.57,4523.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135634,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,5530.00000,1603.70000,Aetna,Local,,2212.00,,,,,,,1780.66,4523.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135635,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,211.89000,61.45000,Aetna,Local,,84.76,,,,,,,76.39,173.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135635,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,211.89000,61.45000,Aetna,Local,,84.76,,,,,,,68.23,173.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135451,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,190.05000,55.11000,Aetna,Local,,76.02,,,,,,,68.51,155.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135451,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,190.05000,55.11000,Aetna,Local,,76.02,,,,,,,61.20,155.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135636,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,Local,,75.60,,,,,,,68.13,154.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135636,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,,75.60,,,,,,,60.86,154.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694462,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694462,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7954681,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7954681,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135603,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135603,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATH WOVEN FLEXIE,8136295,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATH WOVEN FLEXIE,8136295,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,9357.00,,,,,,,268.06,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER IVUS,8135706,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER IVUS,8135706,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATH WOVEN FLEXIE,8136294,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATH WOVEN FLEXIE,8136294,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,9357.00,,,,,,,268.06,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STENT,7696339,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696339,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696332,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696332,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696338,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696338,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696345,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696345,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8135793,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8135793,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8135794,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8135794,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8135791,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8135791,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8135792,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8135792,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135604,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135604,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135458,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135458,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135600,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135600,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135708,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135708,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135710,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135710,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135711,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135711,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135709,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135709,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135786,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135786,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135713,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135713,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135714,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135714,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135788,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135788,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135712,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135712,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135747,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135747,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135716,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135716,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135748,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135748,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135717,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135717,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135718,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135718,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135715,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135715,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135761,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135761,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135719,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135719,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135720,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135720,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135721,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135721,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135750,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135750,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135723,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135723,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135751,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135751,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135724,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135724,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135749,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135749,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135726,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135726,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135753,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135753,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135727,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135727,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135754,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135754,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135732,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135732,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135733,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135733,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DIL OTW TREK 3.50X08MM,8135752,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DIL OTW TREK 3.50X08MM,8135752,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135730,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135730,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135735,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135735,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135736,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135736,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135737,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135737,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135734,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135734,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135739,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135739,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135740,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135740,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135741,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135741,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135775,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135775,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135738,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135738,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135742,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135742,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135744,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135744,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135745,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135745,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135581,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135581,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135755,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135755,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135514,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135514,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VICERAL,8135607,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,175.09000,50.78000,Aetna,Local,,70.04,,,,,,,63.12,143.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VICERAL,8135607,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,175.09000,50.78000,Aetna,Local,,70.04,,,,,,,56.38,143.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135631,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135631,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135586,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135586,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135460,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135460,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,8135459,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,8135459,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135440,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,Local,,832.00,,,,,,,749.84,1701.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135440,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,Local,,9357.00,,,,,,,669.76,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,8135441,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,648.90,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135441,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,9357.00,,,,,,,579.60,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STENT GRAFT,7695236,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4805.10,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7695236,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4291.94,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8151574,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11799.00000,3421.71000,Aetna,Local,,4719.60,,,,,,,4253.54,9651.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8151574,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11799.00000,3421.71000,Aetna,Local,,4719.60,,,,,,,3799.28,9651.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740746,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,4429.82,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740746,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,3956.74,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736631,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,4429.82,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736631,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,3956.74,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135660,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135660,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135661,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135661,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STYLET LOCKING LIBERATOR,8135814,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2602.00000,754.58000,Aetna,Local,,1040.80,,,,,,,938.02,2128.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STYLET LOCKING LIBERATOR,8135814,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2602.00000,754.58000,Aetna,Local,,1040.80,,,,,,,837.84,2128.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDECATH,8135598,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDECATH,8135598,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,8135589,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,8135589,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135583,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,478.47000,138.76000,Aetna,Local,,191.39,,,,,,,172.49,391.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135583,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,478.47000,138.76000,Aetna,Local,,191.39,,,,,,,154.07,391.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135569,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135569,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE ZIP,8135592,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE ZIP,8135592,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE ZIP,8135597,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,319.20000,92.57000,Aetna,Local,,127.68,,,,,,,115.07,261.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE ZIP,8135597,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,319.20000,92.57000,Aetna,Local,,127.68,,,,,,,102.78,261.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE ZIP,8135596,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,314.45000,91.19000,Aetna,Local,,125.78,,,,,,,113.36,257.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE ZIP,8135596,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,314.45000,91.19000,Aetna,Local,,125.78,,,,,,,101.25,257.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136292,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136292,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,9357.00,,,,,,,3767.40,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
GUIDEWIRE,8135638,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,549.00000,159.21000,Aetna,Local,,219.60,,,,,,,197.91,449.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135638,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,549.00000,159.21000,Aetna,Local,,219.60,,,,,,,176.78,449.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696384,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,323.33000,93.77000,Aetna,Local,,129.33,,,,,,,116.56,264.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696384,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,323.33000,93.77000,Aetna,Local,,129.33,,,,,,,104.11,264.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACING CATHETER,8135902,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACING CATHETER,8135902,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,9357.00,,,,,,,218.80,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSURE DEVICE VASCULAR,7695242,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,7695242,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,7693641,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1452.00000,421.08000,Aetna,Local,,580.80,,,,,,,523.45,1187.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,7693641,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1452.00000,421.08000,Aetna,Local,,580.80,,,,,,,467.54,1187.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1928.00000,559.12000,Aetna,Local,,771.20,,,,,,,695.04,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1928.00000,559.12000,Aetna,Local,,771.20,,,,,,,620.82,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9115188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26664.00000,7732.56000,Aetna,Local,,10665.60,,,,,,,9612.37,21811.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9115188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26664.00000,7732.56000,Aetna,Local,,10665.60,,,,,,,8585.81,21811.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698160,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1468.00000,425.72000,Aetna,Local,,587.20,,,,,,,529.21,1200.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698160,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1468.00000,425.72000,Aetna,Local,,587.20,,,,,,,472.70,1200.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702886,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702886,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697277,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697277,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697278,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697278,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697279,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697279,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697337,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697337,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697372,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697372,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7698170,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7698170,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7698171,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7698171,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699509,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699509,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7784279,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7784279,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7962228,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7962228,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5776.12000,1675.07000,Aetna,Local,,2310.45,,,,,,,2082.29,4724.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5776.12000,1675.07000,Aetna,Local,,2310.45,,,,,,,1859.91,4724.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6571.85000,1905.84000,Aetna,Local,,2628.74,,,,,,,2369.15,5375.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6571.85000,1905.84000,Aetna,Local,,2628.74,,,,,,,2116.14,5375.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT GEL,9114960,CDM,278,RC,C1878,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT GEL,9114960,CDM,278,RC,C1878,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7698014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7698014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7698693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7698693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7698694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7698694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7698769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7698769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7736482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7736482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7878227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7878227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7903495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7903495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7908505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7908505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696364,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,6123.99,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696364,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,5469.98,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696365,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,6123.99,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696365,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,5469.98,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696366,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,6123.99,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696366,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,5469.98,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694926,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694926,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694933,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694933,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694934,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694934,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694947,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694947,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878242,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878242,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878244,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878244,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878245,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878245,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878246,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878246,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878247,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878247,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878248,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878248,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878249,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878249,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878250,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878250,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878251,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7878251,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698945,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698945,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7880786,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7880786,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7909379,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7909379,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7953975,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7953975,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702889,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,322.34000,93.48000,Aetna,Local,,128.94,,,,,,,116.20,263.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702889,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,322.34000,93.48000,Aetna,Local,,128.94,,,,,,,103.79,263.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1322.00000,383.38000,Aetna,Local,,528.80,,,,,,,476.58,1081.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1322.00000,383.38000,Aetna,Local,,528.80,,,,,,,425.68,1081.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1832.00000,531.28000,Aetna,Local,,732.80,,,,,,,660.44,1498.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1832.00000,531.28000,Aetna,Local,,732.80,,,,,,,589.90,1498.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7927440,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,7151.42,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7927440,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,6387.68,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1432.00000,415.28000,Aetna,Local,,572.80,,,,,,,516.24,1171.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1432.00000,415.28000,Aetna,Local,,572.80,,,,,,,461.10,1171.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697359,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697359,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,174.66,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,156.01,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,303.91000,88.13000,Aetna,Local,,121.56,,,,,,,109.56,248.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,303.91000,88.13000,Aetna,Local,,121.56,,,,,,,97.86,248.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.64000,198.26000,Aetna,Local,,273.46,,,,,,,246.45,559.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.64000,198.26000,Aetna,Local,,273.46,,,,,,,220.13,559.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,169.87,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,151.73,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,283.89,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,253.57,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,283.89,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,253.57,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701552,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701552,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701553,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701553,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,358.86000,104.07000,Aetna,Local,,143.54,,,,,,,129.37,293.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,358.86000,104.07000,Aetna,Local,,143.54,,,,,,,115.55,293.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,376.68000,109.24000,Aetna,Local,,150.67,,,,,,,135.79,308.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,376.68000,109.24000,Aetna,Local,,150.67,,,,,,,121.29,308.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,376.68000,109.24000,Aetna,Local,,150.67,,,,,,,135.79,308.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,376.68000,109.24000,Aetna,Local,,150.67,,,,,,,121.29,308.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,376.68000,109.24000,Aetna,Local,,150.67,,,,,,,135.79,308.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,376.68000,109.24000,Aetna,Local,,150.67,,,,,,,121.29,308.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,174.66,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,156.01,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,300.28,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,268.21,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,300.28,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.95000,241.56000,Aetna,Local,,333.18,,,,,,,268.21,681.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880755,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.45000,169.78000,Aetna,Local,,234.18,,,,,,,211.05,478.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880755,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.45000,169.78000,Aetna,Local,,234.18,,,,,,,188.51,478.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1227.20000,355.89000,Aetna,Local,,490.88,,,,,,,442.41,1003.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1227.20000,355.89000,Aetna,Local,,490.88,,,,,,,395.16,1003.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7934062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4752.34000,1378.18000,Aetna,Local,,1900.94,,,,,,,1713.22,3887.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7934062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4752.34000,1378.18000,Aetna,Local,,1900.94,,,,,,,1530.25,3887.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7934956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12702.00000,3683.58000,Aetna,Local,,5080.80,,,,,,,4579.07,10390.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7934956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12702.00000,3683.58000,Aetna,Local,,5080.80,,,,,,,4090.04,10390.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1920.00000,556.80000,Aetna,Local,,768.00,,,,,,,692.16,1570.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1920.00000,556.80000,Aetna,Local,,768.00,,,,,,,618.24,1570.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1757.96000,509.81000,Aetna,Local,,703.18,,,,,,,633.74,1438.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1757.96000,509.81000,Aetna,Local,,703.18,,,,,,,566.06,1438.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697385,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697385,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,764.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697386,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697386,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,764.47,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697387,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697387,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,764.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7698209,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7698209,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,764.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7698950,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7698950,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,764.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7698951,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7698951,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,764.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7698952,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7698952,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,764.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697390,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697390,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697938,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697938,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2748.16000,796.97000,Aetna,Local,,1099.26,,,,,,,990.71,2247.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2748.16000,796.97000,Aetna,Local,,1099.26,,,,,,,884.91,2247.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,7700074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,7700074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736639,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,633.60000,183.74000,Aetna,Local,,253.44,,,,,,,228.41,518.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736639,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,633.60000,183.74000,Aetna,Local,,253.44,,,,,,,204.02,518.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7872101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7872101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908716,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908716,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918814,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918814,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,436.93,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,390.26,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7802033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3772.02000,1093.89000,Aetna,Local,,1508.81,,,,,,,1359.81,3085.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7802033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3772.02000,1093.89000,Aetna,Local,,1508.81,,,,,,,1214.59,3085.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2364.24000,685.63000,Aetna,Local,,945.70,,,,,,,852.31,1933.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2364.24000,685.63000,Aetna,Local,,945.70,,,,,,,761.29,1933.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701242,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701242,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701250,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701250,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER GLENOSPHERE REVERSE,7748826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER GLENOSPHERE REVERSE,7748826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698291,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698291,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698454,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698454,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698544,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698544,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948609,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948609,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698550,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698550,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696589,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696589,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696668,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696668,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696696,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696696,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696779,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696779,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696812,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696812,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696813,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696813,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696890,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696890,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697147,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697147,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697193,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697193,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697246,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,998.44,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697246,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2769.60000,803.18000,Aetna,Local,,1107.84,,,,,,,891.81,2265.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697375,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697375,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697413,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,703.70,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697413,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,628.54,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698246,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698246,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8346.00000,2420.34000,Aetna,Local,,3338.40,,,,,,,3008.73,6827.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8346.00000,2420.34000,Aetna,Local,,3338.40,,,,,,,2687.41,6827.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1647.85,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1471.86,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1647.85,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1471.86,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.85000,1223.18000,Aetna,Local,,1687.14,,,,,,,1520.53,3450.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.85000,1223.18000,Aetna,Local,,1687.14,,,,,,,1358.15,3450.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6552.84000,1900.32000,Aetna,Local,,2621.14,,,,,,,2362.30,5360.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6552.84000,1900.32000,Aetna,Local,,2621.14,,,,,,,2110.01,5360.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697462,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,154.88000,44.92000,Aetna,Local,,61.95,,,,,,,55.83,126.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697462,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,154.88000,44.92000,Aetna,Local,,61.95,,,,,,,49.87,126.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700398,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,127.47000,36.97000,Aetna,Local,,50.99,,,,,,,45.95,104.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700398,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,127.47000,36.97000,Aetna,Local,,50.99,,,,,,,41.05,104.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,202.23,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,180.63,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,202.23,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,180.63,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7740765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7740765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7802092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7802092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7904165,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7904165,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918998,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918998,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7943140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7943140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7948757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7948757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7964474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7964474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,Local,,133.08,,,,,,,119.93,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,Local,,133.08,,,,,,,107.13,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6179.39000,1792.02000,Aetna,Local,,2471.76,,,,,,,2227.67,5054.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6179.39000,1792.02000,Aetna,Local,,2471.76,,,,,,,1989.76,5054.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6179.39000,1792.02000,Aetna,Local,,2471.76,,,,,,,2227.67,5054.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6179.39000,1792.02000,Aetna,Local,,2471.76,,,,,,,1989.76,5054.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7696676,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7696676,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7696677,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7696677,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697091,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697091,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697092,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697092,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697093,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697093,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697095,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697095,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697508,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697508,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697509,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697509,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697940,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697940,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698263,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698263,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698264,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698264,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698265,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698265,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698266,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698266,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698267,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698267,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698268,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698268,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698586,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7698586,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736305,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736305,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736307,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736307,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736309,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736309,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736313,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736313,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736315,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736315,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736316,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736316,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736318,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736318,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7740568,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7740568,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7808033,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7808033,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697623,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697623,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.65000,171.87000,Aetna,Local,,237.06,,,,,,,213.65,484.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.65000,171.87000,Aetna,Local,,237.06,,,,,,,190.83,484.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700734,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700734,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.10000,93.70000,Aetna,Local,,129.24,,,,,,,116.48,264.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.10000,93.70000,Aetna,Local,,129.24,,,,,,,104.04,264.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,179.56,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,160.38,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,179.56,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,160.38,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,179.56,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,160.38,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,179.56,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,160.38,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,179.56,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,160.38,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,179.56,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,160.38,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,179.56,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,160.38,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,179.56,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,160.38,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,179.56,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.09000,144.45000,Aetna,Local,,199.24,,,,,,,160.38,407.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,761.40000,220.81000,Aetna,Local,,304.56,,,,,,,274.48,622.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,761.40000,220.81000,Aetna,Local,,304.56,,,,,,,245.17,622.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7844036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7844036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7740894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7740894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7911721,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7911721,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7940327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7940327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7943681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7943681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697565,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,882.00000,255.78000,Aetna,Local,,352.80,,,,,,,317.96,721.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697565,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,882.00000,255.78000,Aetna,Local,,352.80,,,,,,,284.00,721.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697571,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,973.85000,282.42000,Aetna,Local,,389.54,,,,,,,351.07,796.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697571,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,973.85000,282.42000,Aetna,Local,,389.54,,,,,,,313.58,796.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697568,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,564.30000,163.65000,Aetna,Local,,225.72,,,,,,,203.43,461.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697568,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,564.30000,163.65000,Aetna,Local,,225.72,,,,,,,181.70,461.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7963959,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,564.30000,163.65000,Aetna,Local,,225.72,,,,,,,203.43,461.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7963959,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,564.30000,163.65000,Aetna,Local,,225.72,,,,,,,181.70,461.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697569,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,Local,,199.12,,,,,,,179.46,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697569,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,Local,,199.12,,,,,,,160.29,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7900101,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7900101,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,728.50,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,650.70,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2096.00000,607.84000,Aetna,Local,,838.40,,,,,,,755.61,1714.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2096.00000,607.84000,Aetna,Local,,838.40,,,,,,,674.91,1714.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2096.00000,607.84000,Aetna,Local,,838.40,,,,,,,755.61,1714.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2096.00000,607.84000,Aetna,Local,,838.40,,,,,,,674.91,1714.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698745,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698745,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7921148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7921148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7921186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7921186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,596.03000,172.85000,Aetna,Local,,238.41,,,,,,,214.87,487.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,596.03000,172.85000,Aetna,Local,,238.41,,,,,,,191.92,487.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,169.53,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,151.42,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700012,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700012,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700013,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700013,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,169.53,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,151.42,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.65000,171.87000,Aetna,Local,,237.06,,,,,,,213.65,484.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.65000,171.87000,Aetna,Local,,237.06,,,,,,,190.83,484.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,358.86000,104.07000,Aetna,Local,,143.54,,,,,,,129.37,293.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,358.86000,104.07000,Aetna,Local,,143.54,,,,,,,115.55,293.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,169.53,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,151.42,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701986,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,169.53,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701986,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,151.42,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,169.53,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,151.42,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,169.53,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,151.42,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701997,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701997,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702250,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702250,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,266.21,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.45000,214.15000,Aetna,Local,,295.38,,,,,,,237.78,604.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,51.10,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,45.64,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,720.00000,208.80000,Aetna,Local,,288.00,,,,,,,259.56,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,720.00000,208.80000,Aetna,Local,,288.00,,,,,,,231.84,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5577.88000,1617.59000,Aetna,Local,,2231.15,,,,,,,2010.83,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5577.88000,1617.59000,Aetna,Local,,2231.15,,,,,,,1796.08,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7963863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5330.64000,1545.89000,Aetna,Local,,2132.26,,,,,,,1921.70,4360.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7963863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5330.64000,1545.89000,Aetna,Local,,2132.26,,,,,,,1716.47,4360.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7742074,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,602.80000,174.81000,Aetna,Local,,241.12,,,,,,,217.31,493.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7742074,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,602.80000,174.81000,Aetna,Local,,241.12,,,,,,,194.10,493.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2283.20000,662.13000,Aetna,Local,,913.28,,,,,,,823.09,1867.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2283.20000,662.13000,Aetna,Local,,913.28,,,,,,,735.19,1867.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1784.00000,517.36000,Aetna,Local,,713.60,,,,,,,643.13,1459.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1784.00000,517.36000,Aetna,Local,,713.60,,,,,,,574.45,1459.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696766,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696766,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698003,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698003,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698221,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698221,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698222,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698222,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698416,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698416,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698417,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698417,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698426,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7698426,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700840,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700840,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7702072,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7702072,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7702226,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7702226,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7800040,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7800040,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7834150,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7834150,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7836195,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7836195,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7913593,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7913593,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7896899,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7896899,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7836186,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7836186,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7696298,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,741.19,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7696298,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,662.03,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7927545,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,741.19,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7927545,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,662.03,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7916960,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,726.53000,210.69000,Aetna,Local,,290.61,,,,,,,261.91,594.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7916960,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,726.53000,210.69000,Aetna,Local,,290.61,,,,,,,233.94,594.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7703365,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,726.53000,210.69000,Aetna,Local,,290.61,,,,,,,261.91,594.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7703365,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,726.53000,210.69000,Aetna,Local,,290.61,,,,,,,233.94,594.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2908.00000,843.32000,Aetna,Local,,1163.20,,,,,,,1048.33,2378.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2908.00000,843.32000,Aetna,Local,,1163.20,,,,,,,936.38,2378.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7698422,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1843.60000,534.64000,Aetna,Local,,737.44,,,,,,,664.62,1508.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7698422,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1843.60000,534.64000,Aetna,Local,,737.44,,,,,,,593.64,1508.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7697996,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9255.00000,2683.95000,Aetna,Local,,3702.00,,,,,,,3336.43,7570.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7697996,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9255.00000,2683.95000,Aetna,Local,,3702.00,,,,,,,2980.11,7570.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7774236,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3790.66,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7774236,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3385.83,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7698259,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1963.32000,569.36000,Aetna,Local,,785.33,,,,,,,707.78,1606.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7698259,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1963.32000,569.36000,Aetna,Local,,785.33,,,,,,,632.19,1606.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7736622,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6545.00000,1898.05000,Aetna,Local,,2618.00,,,,,,,2359.47,5353.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7736622,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6545.00000,1898.05000,Aetna,Local,,2618.00,,,,,,,2107.49,5353.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7703007,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6545.00000,1898.05000,Aetna,Local,,2618.00,,,,,,,2359.47,5353.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7703007,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6545.00000,1898.05000,Aetna,Local,,2618.00,,,,,,,2107.49,5353.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM AND SCREW,7698207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM AND SCREW,7698207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3441.90000,998.15000,Aetna,Local,,1376.76,,,,,,,1240.80,2815.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3441.90000,998.15000,Aetna,Local,,1376.76,,,,,,,1108.29,2815.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7844123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5795.30000,1680.64000,Aetna,Local,,2318.12,,,,,,,2089.21,4740.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7844123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5795.30000,1680.64000,Aetna,Local,,2318.12,,,,,,,1866.09,4740.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7697925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7697925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7697931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7697931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1871.68,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1671.79,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698224,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698224,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7698996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7699526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7699526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7699654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7699654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7699656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7699656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7699951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7699951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7699957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7699957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7700846,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7700846,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7707545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7707545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7736465,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7736465,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7697562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,3290.36,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7697562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,2938.96,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7697926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,3290.36,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7697926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,2938.96,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7698009,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,3290.36,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7698009,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,2938.96,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7698997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,3290.36,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7698997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,2938.96,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7699960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,3290.36,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7699960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,2938.96,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7908617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,3290.36,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7908617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,2938.96,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7908618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,3290.36,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7908618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,2938.96,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7908619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,3290.36,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7908619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,Local,,3650.88,,,,,,,2938.96,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CRUCIATE,7697929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3027.20000,877.89000,Aetna,Local,,1210.88,,,,,,,1091.31,2476.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CRUCIATE,7697929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3027.20000,877.89000,Aetna,Local,,1210.88,,,,,,,974.76,2476.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3664.26000,1062.64000,Aetna,Local,,1465.70,,,,,,,1320.97,2997.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3664.26000,1062.64000,Aetna,Local,,1465.70,,,,,,,1179.89,2997.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CORE REVISION,7697948,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4428.38000,1284.23000,Aetna,Local,,1771.35,,,,,,,1596.43,3622.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CORE REVISION,7697948,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4428.38000,1284.23000,Aetna,Local,,1771.35,,,,,,,1425.94,3622.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACL TIGHTROPE,7697945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,839.97,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACL TIGHTROPE,7697945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,750.26,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1847.20,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1649.93,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4053.00000,1175.37000,Aetna,Local,,1621.20,,,,,,,1461.11,3315.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4053.00000,1175.37000,Aetna,Local,,1621.20,,,,,,,1305.07,3315.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1173.43,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1048.11,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1173.43,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1048.11,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736442,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736442,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697973,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697973,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697975,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697975,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,432.92,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,386.68,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,432.92,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,386.68,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,760.50000,220.54000,Aetna,Local,,304.20,,,,,,,274.16,622.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,760.50000,220.54000,Aetna,Local,,304.20,,,,,,,244.88,622.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700609,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700609,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700612,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700612,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700615,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700615,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700632,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700632,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700634,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700634,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700635,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700635,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700636,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700636,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700638,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700638,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700639,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700639,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700640,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700640,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,Local,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7895936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2498.00000,724.42000,Aetna,Local,,999.20,,,,,,,900.53,2043.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7895936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2498.00000,724.42000,Aetna,Local,,999.20,,,,,,,804.36,2043.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7702948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2498.00000,724.42000,Aetna,Local,,999.20,,,,,,,900.53,2043.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7702948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2498.00000,724.42000,Aetna,Local,,999.20,,,,,,,804.36,2043.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10658.40000,3090.94000,Aetna,Local,,4263.36,,,,,,,3842.35,8718.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10658.40000,3090.94000,Aetna,Local,,4263.36,,,,,,,3432.00,8718.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7870094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10830.00000,3140.70000,Aetna,Local,,4332.00,,,,,,,3904.22,8858.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7870094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10830.00000,3140.70000,Aetna,Local,,4332.00,,,,,,,3487.26,8858.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7943141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10830.00000,3140.70000,Aetna,Local,,4332.00,,,,,,,3904.22,8858.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7943141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10830.00000,3140.70000,Aetna,Local,,4332.00,,,,,,,3487.26,8858.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONDYLAR,7698077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2389.25,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONDYLAR,7698077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2134.09,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONDYLAR,7698406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2389.25,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONDYLAR,7698406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2134.09,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1485.60000,430.82000,Aetna,Local,,594.24,,,,,,,535.56,1215.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1485.60000,430.82000,Aetna,Local,,594.24,,,,,,,478.36,1215.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2649.80000,768.44000,Aetna,Local,,1059.92,,,,,,,955.25,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2649.80000,768.44000,Aetna,Local,,1059.92,,,,,,,853.24,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,631.90,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,564.41,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,631.90,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,564.41,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,631.90,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,564.41,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,631.90,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,564.41,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,631.90,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,564.41,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,843.86,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,753.74,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7946022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7946022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7953866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,843.86,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7953866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,753.74,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,843.86,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,753.74,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,843.86,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,753.74,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,631.90,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,564.41,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRALIZER,7698792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRALIZER,7698792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRALIZER,7844124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRALIZER,7844124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRALIZER,7912246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRALIZER,7912246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT NECK LENGTH ADAPTER,7882397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT NECK LENGTH ADAPTER,7882397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,850.50000,246.64000,Aetna,Local,,340.20,,,,,,,306.61,695.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,850.50000,246.64000,Aetna,Local,,340.20,,,,,,,273.86,695.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.50000,184.00000,Aetna,Local,,253.80,,,,,,,228.74,519.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.50000,184.00000,Aetna,Local,,253.80,,,,,,,204.31,519.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.50000,184.00000,Aetna,Local,,253.80,,,,,,,228.74,519.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.50000,184.00000,Aetna,Local,,253.80,,,,,,,204.31,519.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7858074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7858074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7870095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7870095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,843.86,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,753.74,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957756,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,577.91,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957756,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,516.19,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,577.91,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,516.19,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,577.91,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,516.19,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696662,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,77.60,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696662,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,69.31,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697126,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,77.60,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697126,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,69.31,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697316,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,77.60,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697316,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,69.31,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698190,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,77.60,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698190,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,69.31,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699084,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,39.27,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699084,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,35.08,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700576,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,39.27,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700576,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,35.08,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698022,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698022,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698023,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698023,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698025,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698025,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699813,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699813,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7736120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7736120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7736121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7736121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7910505,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7910505,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7910507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7910507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,Local,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7698723,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7698723,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7760074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7760074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7784189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7784189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7918195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7918195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1873.70,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1673.60,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1873.70,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1673.60,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7760072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1873.70,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7760072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1673.60,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7957715,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1873.70,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7957715,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1673.60,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,7698212,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,220.03,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,7698212,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,196.53,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696914,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,Local,,8400.00,,,,,,,7570.50,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696914,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,Local,,8400.00,,,,,,,6762.00,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696915,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,Local,,8400.00,,,,,,,7570.50,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696915,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,Local,,8400.00,,,,,,,6762.00,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7736187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,Local,,8400.00,,,,,,,7570.50,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7736187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,Local,,8400.00,,,,,,,6762.00,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7768117,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,Local,,8400.00,,,,,,,7570.50,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7768117,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,Local,,8400.00,,,,,,,6762.00,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696824,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,7620.00000,2209.80000,Aetna,Local,,3048.00,,,,,,,2747.01,6233.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696824,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,7620.00000,2209.80000,Aetna,Local,,3048.00,,,,,,,2453.64,6233.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696825,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8007.00000,2322.03000,Aetna,Local,,3202.80,,,,,,,2886.52,6549.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696825,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8007.00000,2322.03000,Aetna,Local,,3202.80,,,,,,,2578.25,6549.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696969,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8511.00000,2468.19000,Aetna,Local,,3404.40,,,,,,,3068.22,6962.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696969,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8511.00000,2468.19000,Aetna,Local,,3404.40,,,,,,,2740.54,6962.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696989,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8007.00000,2322.03000,Aetna,Local,,3202.80,,,,,,,2886.52,6549.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696989,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8007.00000,2322.03000,Aetna,Local,,3202.80,,,,,,,2578.25,6549.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7695999,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7695999,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1560.40000,452.52000,Aetna,Local,,624.16,,,,,,,562.52,1276.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1560.40000,452.52000,Aetna,Local,,624.16,,,,,,,502.45,1276.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BEARING,7700296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BEARING,7700296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BEARING,7794043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BEARING,7794043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,7700297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,7700297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,7698244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,7698244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,7700375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,7700375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,7702024,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,7702024,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1534.16,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1370.32,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1534.16,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1370.32,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1534.16,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1370.32,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1534.16,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1370.32,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699263,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1534.16,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699263,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1370.32,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699891,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699891,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700378,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700378,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1534.16,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1370.32,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7736358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7736358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7736684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7736684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7754284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7754284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7754285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7754285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7756048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7756048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP NECK ADAPTER,7698838,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,Local,,639.68,,,,,,,576.51,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP NECK ADAPTER,7698838,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,Local,,639.68,,,,,,,514.94,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3168.04000,918.73000,Aetna,Local,,1267.22,,,,,,,1142.08,2591.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3168.04000,918.73000,Aetna,Local,,1267.22,,,,,,,1020.11,2591.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3168.04000,918.73000,Aetna,Local,,1267.22,,,,,,,1142.08,2591.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3168.04000,918.73000,Aetna,Local,,1267.22,,,,,,,1020.11,2591.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3168.04000,918.73000,Aetna,Local,,1267.22,,,,,,,1142.08,2591.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3168.04000,918.73000,Aetna,Local,,1267.22,,,,,,,1020.11,2591.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3168.04000,918.73000,Aetna,Local,,1267.22,,,,,,,1142.08,2591.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3168.04000,918.73000,Aetna,Local,,1267.22,,,,,,,1020.11,2591.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3168.04000,918.73000,Aetna,Local,,1267.22,,,,,,,1142.08,2591.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3168.04000,918.73000,Aetna,Local,,1267.22,,,,,,,1020.11,2591.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3161.84000,916.93000,Aetna,Local,,1264.74,,,,,,,1139.84,2586.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3161.84000,916.93000,Aetna,Local,,1264.74,,,,,,,1018.11,2586.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695937,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695937,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695668,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,287.31000,83.32000,Aetna,Local,,114.92,,,,,,,103.58,235.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695668,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,287.31000,83.32000,Aetna,Local,,114.92,,,,,,,92.51,235.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697409,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,288.61000,83.70000,Aetna,Local,,115.44,,,,,,,104.04,236.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697409,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,288.61000,83.70000,Aetna,Local,,115.44,,,,,,,92.93,236.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7697036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20637.50000,5984.88000,Aetna,Local,,8255.00,,,,,,,7439.82,16881.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7697036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20637.50000,5984.88000,Aetna,Local,,8255.00,,,,,,,6645.27,16881.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697271,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697271,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697272,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697272,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697273,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697273,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697274,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697274,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697275,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697275,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697276,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697276,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697280,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697280,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697281,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697281,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697333,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697333,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697921,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697921,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697922,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697922,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699482,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699482,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7736450,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7736450,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698743,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,165.74000,48.06000,Aetna,Local,,66.30,,,,,,,59.75,135.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698743,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,165.74000,48.06000,Aetna,Local,,66.30,,,,,,,53.37,135.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700025,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700025,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7758163,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,164.17000,47.61000,Aetna,Local,,65.67,,,,,,,59.18,134.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7758163,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,164.17000,47.61000,Aetna,Local,,65.67,,,,,,,52.86,134.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702895,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,364.71000,105.77000,Aetna,Local,,145.88,,,,,,,131.48,298.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702895,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,364.71000,105.77000,Aetna,Local,,145.88,,,,,,,117.44,298.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702897,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,192.10000,55.71000,Aetna,Local,,76.84,,,,,,,69.25,157.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702897,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,192.10000,55.71000,Aetna,Local,,76.84,,,,,,,61.86,157.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,7697488,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,504.70,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,7697488,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,450.80,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7748743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7748743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7816133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7816133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7903717,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7903717,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7905145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7905145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7913506,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7913506,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7940867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7940867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7961899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7961899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6188.91000,1794.78000,Aetna,Local,,2475.56,,,,,,,2231.10,5062.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6188.91000,1794.78000,Aetna,Local,,2475.56,,,,,,,1992.83,5062.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7762383,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7762383,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6434.75000,1866.08000,Aetna,Local,,2573.90,,,,,,,2319.73,5263.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6434.75000,1866.08000,Aetna,Local,,2573.90,,,,,,,2071.99,5263.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7963936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7963936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699711,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699711,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7741710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7741710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7794304,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7794304,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912280,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912280,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7940865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7940865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3285.91000,952.91000,Aetna,Local,,1314.36,,,,,,,1184.57,2687.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3285.91000,952.91000,Aetna,Local,,1314.36,,,,,,,1058.06,2687.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3285.91000,952.91000,Aetna,Local,,1314.36,,,,,,,1184.57,2687.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3285.91000,952.91000,Aetna,Local,,1314.36,,,,,,,1058.06,2687.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3285.91000,952.91000,Aetna,Local,,1314.36,,,,,,,1184.57,2687.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3285.91000,952.91000,Aetna,Local,,1314.36,,,,,,,1058.06,2687.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4414.20000,1280.12000,Aetna,Local,,1765.68,,,,,,,1591.32,3610.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4414.20000,1280.12000,Aetna,Local,,1765.68,,,,,,,1421.37,3610.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3356.50000,973.38000,Aetna,Local,,1342.60,,,,,,,1210.02,2745.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3356.50000,973.38000,Aetna,Local,,1342.60,,,,,,,1080.79,2745.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3356.50000,973.38000,Aetna,Local,,1342.60,,,,,,,1210.02,2745.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3356.50000,973.38000,Aetna,Local,,1342.60,,,,,,,1080.79,2745.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3356.50000,973.38000,Aetna,Local,,1342.60,,,,,,,1210.02,2745.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3356.50000,973.38000,Aetna,Local,,1342.60,,,,,,,1080.79,2745.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7699103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7699103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7882869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7882869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7882870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2968.72,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7882870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2651.67,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7897507,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,213.26000,61.85000,Aetna,Local,,85.30,,,,,,,76.88,174.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7897507,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,213.26000,61.85000,Aetna,Local,,85.30,,,,,,,68.67,174.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694466,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694466,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7695684,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7695684,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7695685,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7695685,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3863.48000,1120.41000,Aetna,Local,,1545.39,,,,,,,1392.78,3160.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3863.48000,1120.41000,Aetna,Local,,1545.39,,,,,,,1244.04,3160.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3863.48000,1120.41000,Aetna,Local,,1545.39,,,,,,,1392.78,3160.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3863.48000,1120.41000,Aetna,Local,,1545.39,,,,,,,1244.04,3160.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3863.48000,1120.41000,Aetna,Local,,1545.39,,,,,,,1392.78,3160.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3863.48000,1120.41000,Aetna,Local,,1545.39,,,,,,,1244.04,3160.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7910250,CDM,278,RC,L8631,HCPCS,,,facility,inpatient,,,7443.00000,2158.47000,Aetna,Local,,2977.20,,,,,,,2683.20,6088.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7910250,CDM,278,RC,L8631,HCPCS,,,facility,outpatient,,,7443.00000,2158.47000,Aetna,Local,,2977.20,,,,,,,2396.65,6088.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699713,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699713,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702585,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702585,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7741016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7741016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7816126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7816126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7848090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7848090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7904025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7904025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7910311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7910311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7916934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7916934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7927010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7927010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7935881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7935881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7943318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7943318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7943629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7943629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7963963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7963963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,Local,,543.95,,,,,,,490.24,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,Local,,543.95,,,,,,,437.88,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,Local,,543.95,,,,,,,490.24,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,Local,,543.95,,,,,,,437.88,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,Local,,543.95,,,,,,,490.24,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,Local,,543.95,,,,,,,437.88,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,Local,,543.95,,,,,,,490.24,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,Local,,543.95,,,,,,,437.88,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7768125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7768125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,219.00,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,195.62,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,330.96,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,295.61,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,330.96,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,295.61,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,118.68,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,106.01,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,118.68,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,106.01,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,118.68,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,106.01,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,118.68,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,106.01,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,118.68,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,106.01,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,118.68,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,106.01,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,118.68,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.22000,95.47000,Aetna,Local,,131.69,,,,,,,106.01,269.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,378.20000,109.68000,Aetna,Local,,151.28,,,,,,,136.34,309.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,378.20000,109.68000,Aetna,Local,,151.28,,,,,,,121.78,309.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,378.20000,109.68000,Aetna,Local,,151.28,,,,,,,136.34,309.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,378.20000,109.68000,Aetna,Local,,151.28,,,,,,,121.78,309.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,378.20000,109.68000,Aetna,Local,,151.28,,,,,,,136.34,309.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,378.20000,109.68000,Aetna,Local,,151.28,,,,,,,121.78,309.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,Local,,360.00,,,,,,,324.45,736.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,,360.00,,,,,,,289.80,736.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700918,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700918,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,344.57,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,307.77,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1227.20000,355.89000,Aetna,Local,,490.88,,,,,,,442.41,1003.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1227.20000,355.89000,Aetna,Local,,490.88,,,,,,,395.16,1003.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7774103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7774103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7774104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7774104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,942.08000,273.20000,Aetna,Local,,376.83,,,,,,,339.62,770.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,942.08000,273.20000,Aetna,Local,,376.83,,,,,,,303.35,770.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,306.52000,88.89000,Aetna,Local,,122.61,,,,,,,110.50,250.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,306.52000,88.89000,Aetna,Local,,122.61,,,,,,,98.70,250.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.80000,391.73000,Aetna,Local,,540.32,,,,,,,486.96,1104.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.80000,391.73000,Aetna,Local,,540.32,,,,,,,434.96,1104.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,458.41,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,409.46,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1365.60000,396.02000,Aetna,Local,,546.24,,,,,,,492.30,1117.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1365.60000,396.02000,Aetna,Local,,546.24,,,,,,,439.72,1117.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1365.60000,396.02000,Aetna,Local,,546.24,,,,,,,492.30,1117.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1365.60000,396.02000,Aetna,Local,,546.24,,,,,,,439.72,1117.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1377.60000,399.50000,Aetna,Local,,551.04,,,,,,,496.62,1126.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1377.60000,399.50000,Aetna,Local,,551.04,,,,,,,443.59,1126.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1365.60000,396.02000,Aetna,Local,,546.24,,,,,,,492.30,1117.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1365.60000,396.02000,Aetna,Local,,546.24,,,,,,,439.72,1117.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,458.41,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,409.46,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.80000,391.73000,Aetna,Local,,540.32,,,,,,,486.96,1104.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.80000,391.73000,Aetna,Local,,540.32,,,,,,,434.96,1104.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,458.41,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,409.46,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.80000,391.73000,Aetna,Local,,540.32,,,,,,,486.96,1104.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.80000,391.73000,Aetna,Local,,540.32,,,,,,,434.96,1104.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO TRANSFIX,7699074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2115.80000,613.58000,Aetna,Local,,846.32,,,,,,,762.75,1730.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO TRANSFIX,7699074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2115.80000,613.58000,Aetna,Local,,846.32,,,,,,,681.29,1730.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7702782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2125.60000,616.42000,Aetna,Local,,850.24,,,,,,,766.28,1738.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7702782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2125.60000,616.42000,Aetna,Local,,850.24,,,,,,,684.44,1738.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,Local,,746.05,,,,,,,672.38,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,Local,,746.05,,,,,,,600.57,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,Local,,746.05,,,,,,,672.38,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,Local,,746.05,,,,,,,600.57,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,Local,,746.05,,,,,,,672.38,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,Local,,746.05,,,,,,,600.57,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,Local,,746.05,,,,,,,672.38,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,Local,,746.05,,,,,,,600.57,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1495.20000,433.61000,Aetna,Local,,598.08,,,,,,,539.02,1223.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1495.20000,433.61000,Aetna,Local,,598.08,,,,,,,481.45,1223.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1495.20000,433.61000,Aetna,Local,,598.08,,,,,,,539.02,1223.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1495.20000,433.61000,Aetna,Local,,598.08,,,,,,,481.45,1223.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1495.20000,433.61000,Aetna,Local,,598.08,,,,,,,539.02,1223.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1495.20000,433.61000,Aetna,Local,,598.08,,,,,,,481.45,1223.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700486,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700486,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7699328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26556.38000,7701.35000,Aetna,Local,,10622.55,,,,,,,9573.57,21723.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7699328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26556.38000,7701.35000,Aetna,Local,,10622.55,,,,,,,8551.15,21723.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135489,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8135489,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135743,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135743,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135725,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135725,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135746,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135746,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135601,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135601,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7750461,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7750461,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RETRIEVAL DEVICE,7694845,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,Local,,587.60,,,,,,,529.57,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RETRIEVAL DEVICE,7694845,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,Local,,587.60,,,,,,,473.02,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7698611,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5529.37000,1603.52000,Aetna,Local,,2211.75,,,,,,,1993.34,4523.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7698611,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5529.37000,1603.52000,Aetna,Local,,2211.75,,,,,,,1780.46,4523.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,9270.49,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,8280.44,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1487.44000,431.36000,Aetna,Local,,594.98,,,,,,,536.22,1216.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1487.44000,431.36000,Aetna,Local,,594.98,,,,,,,478.96,1216.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,912.60000,264.65000,Aetna,Local,,365.04,,,,,,,328.99,746.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,912.60000,264.65000,Aetna,Local,,365.04,,,,,,,293.86,746.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7836161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7836161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918593,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918593,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,582.57,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,520.35,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,582.57,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,520.35,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6433.32000,1865.66000,Aetna,Local,,2573.33,,,,,,,2319.21,5262.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6433.32000,1865.66000,Aetna,Local,,2573.33,,,,,,,2071.53,5262.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700484,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,210.71000,61.11000,Aetna,Local,,84.28,,,,,,,75.96,172.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700484,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,210.71000,61.11000,Aetna,Local,,84.28,,,,,,,67.85,172.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700485,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,210.71000,61.11000,Aetna,Local,,84.28,,,,,,,75.96,172.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700485,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,210.71000,61.11000,Aetna,Local,,84.28,,,,,,,67.85,172.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700516,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,210.71000,61.11000,Aetna,Local,,84.28,,,,,,,75.96,172.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700516,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,210.71000,61.11000,Aetna,Local,,84.28,,,,,,,67.85,172.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700875,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,210.71000,61.11000,Aetna,Local,,84.28,,,,,,,75.96,172.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700875,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,210.71000,61.11000,Aetna,Local,,84.28,,,,,,,67.85,172.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700876,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,210.71000,61.11000,Aetna,Local,,84.28,,,,,,,75.96,172.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700876,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,210.71000,61.11000,Aetna,Local,,84.28,,,,,,,67.85,172.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7746050,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,149.05000,43.22000,Aetna,Local,,59.62,,,,,,,53.73,121.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7746050,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,149.05000,43.22000,Aetna,Local,,59.62,,,,,,,47.99,121.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702885,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,304.00000,88.16000,Aetna,Local,,121.60,,,,,,,109.59,248.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702885,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,304.00000,88.16000,Aetna,Local,,121.60,,,,,,,97.89,248.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702896,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,134.72000,39.07000,Aetna,Local,,53.89,,,,,,,48.57,110.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702896,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,134.72000,39.07000,Aetna,Local,,53.89,,,,,,,43.38,110.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7784550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7784550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7784551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7784551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1644.00000,476.76000,Aetna,Local,,657.60,,,,,,,592.66,1344.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1644.00000,476.76000,Aetna,Local,,657.60,,,,,,,529.37,1344.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2261.60000,655.86000,Aetna,Local,,904.64,,,,,,,815.31,1849.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2261.60000,655.86000,Aetna,Local,,904.64,,,,,,,728.24,1849.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1681.44000,487.62000,Aetna,Local,,672.58,,,,,,,606.16,1375.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1681.44000,487.62000,Aetna,Local,,672.58,,,,,,,541.42,1375.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1690.76000,490.32000,Aetna,Local,,676.30,,,,,,,609.52,1383.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1690.76000,490.32000,Aetna,Local,,676.30,,,,,,,544.42,1383.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.80000,244.70000,Aetna,Local,,337.52,,,,,,,304.19,690.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.80000,244.70000,Aetna,Local,,337.52,,,,,,,271.70,690.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,878.67000,254.81000,Aetna,Local,,351.47,,,,,,,316.76,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,878.67000,254.81000,Aetna,Local,,351.47,,,,,,,282.93,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2348.72000,681.13000,Aetna,Local,,939.49,,,,,,,846.71,1921.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2348.72000,681.13000,Aetna,Local,,939.49,,,,,,,756.29,1921.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2271.12000,658.62000,Aetna,Local,,908.45,,,,,,,818.74,1857.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2271.12000,658.62000,Aetna,Local,,908.45,,,,,,,731.30,1857.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,355.06000,102.97000,Aetna,Local,,142.02,,,,,,,128.00,290.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,355.06000,102.97000,Aetna,Local,,142.02,,,,,,,114.33,290.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7961903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7961903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2680.56000,777.36000,Aetna,Local,,1072.22,,,,,,,966.34,2192.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2680.56000,777.36000,Aetna,Local,,1072.22,,,,,,,863.14,2192.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2680.56000,777.36000,Aetna,Local,,1072.22,,,,,,,966.34,2192.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2680.56000,777.36000,Aetna,Local,,1072.22,,,,,,,863.14,2192.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702986,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2699.40000,782.83000,Aetna,Local,,1079.76,,,,,,,973.13,2208.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702986,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2699.40000,782.83000,Aetna,Local,,1079.76,,,,,,,869.21,2208.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2714.36000,787.16000,Aetna,Local,,1085.74,,,,,,,978.53,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2714.36000,787.16000,Aetna,Local,,1085.74,,,,,,,874.02,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3825.15000,1109.29000,Aetna,Local,,1530.06,,,,,,,1378.97,3128.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3825.15000,1109.29000,Aetna,Local,,1530.06,,,,,,,1231.70,3128.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3596.78000,1043.07000,Aetna,Local,,1438.71,,,,,,,1296.64,2942.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3596.78000,1043.07000,Aetna,Local,,1438.71,,,,,,,1158.16,2942.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3596.78000,1043.07000,Aetna,Local,,1438.71,,,,,,,1296.64,2942.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3596.78000,1043.07000,Aetna,Local,,1438.71,,,,,,,1158.16,2942.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7816122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7816122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7830029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7830029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7897134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7897134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1728.89,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1544.25,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1728.89,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1544.25,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1728.89,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1544.25,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1728.89,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1544.25,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5067.37000,1469.54000,Aetna,Local,,2026.95,,,,,,,1826.79,4145.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5067.37000,1469.54000,Aetna,Local,,2026.95,,,,,,,1631.69,4145.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5067.37000,1469.54000,Aetna,Local,,2026.95,,,,,,,1826.79,4145.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5067.37000,1469.54000,Aetna,Local,,2026.95,,,,,,,1631.69,4145.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5067.37000,1469.54000,Aetna,Local,,2026.95,,,,,,,1826.79,4145.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5067.37000,1469.54000,Aetna,Local,,2026.95,,,,,,,1631.69,4145.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5067.37000,1469.54000,Aetna,Local,,2026.95,,,,,,,1826.79,4145.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5067.37000,1469.54000,Aetna,Local,,2026.95,,,,,,,1631.69,4145.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1675.04,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4646.43000,1347.46000,Aetna,Local,,1858.57,,,,,,,1496.15,3800.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1728.89,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1544.25,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1728.89,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1544.25,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1728.89,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1544.25,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901793,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1728.89,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901793,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1544.25,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698801,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20587.50000,5970.38000,Aetna,Local,,8235.00,,,,,,,7421.79,16840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698801,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20587.50000,5970.38000,Aetna,Local,,8235.00,,,,,,,6629.18,16840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698876,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20587.50000,5970.38000,Aetna,Local,,8235.00,,,,,,,7421.79,16840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698876,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20587.50000,5970.38000,Aetna,Local,,8235.00,,,,,,,6629.18,16840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7939858,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7939858,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7698517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7698517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699454,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699454,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7874343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7874343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7947859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7947859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7962616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7962616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.55000,1075.77000,Aetna,Local,,1483.82,,,,,,,1337.29,3034.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.55000,1075.77000,Aetna,Local,,1483.82,,,,,,,1194.48,3034.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.55000,1075.77000,Aetna,Local,,1483.82,,,,,,,1337.29,3034.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.55000,1075.77000,Aetna,Local,,1483.82,,,,,,,1194.48,3034.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.55000,1075.77000,Aetna,Local,,1483.82,,,,,,,1337.29,3034.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.55000,1075.77000,Aetna,Local,,1483.82,,,,,,,1194.48,3034.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1274.90,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1138.74,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2243.20000,650.53000,Aetna,Local,,897.28,,,,,,,808.67,1834.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2243.20000,650.53000,Aetna,Local,,897.28,,,,,,,722.31,1834.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1274.90,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1138.74,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1274.90,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1138.74,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1274.90,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1138.74,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3259.20000,945.17000,Aetna,Local,,1303.68,,,,,,,1174.94,2666.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3259.20000,945.17000,Aetna,Local,,1303.68,,,,,,,1049.46,2666.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.55000,1075.77000,Aetna,Local,,1483.82,,,,,,,1337.29,3034.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.55000,1075.77000,Aetna,Local,,1483.82,,,,,,,1194.48,3034.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4970.70000,1441.50000,Aetna,Local,,1988.28,,,,,,,1791.94,4066.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4970.70000,1441.50000,Aetna,Local,,1988.28,,,,,,,1600.57,4066.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7768037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7768037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7895962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7895962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7895963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7895963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7904979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1274.90,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7904979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1138.74,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7911285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1274.90,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7911285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1138.74,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7699486,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4163.92000,1207.54000,Aetna,Local,,1665.57,,,,,,,1501.09,3406.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7699486,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4163.92000,1207.54000,Aetna,Local,,1665.57,,,,,,,1340.78,3406.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7842039,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4163.92000,1207.54000,Aetna,Local,,1665.57,,,,,,,1501.09,3406.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7842039,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4163.92000,1207.54000,Aetna,Local,,1665.57,,,,,,,1340.78,3406.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7842040,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4163.92000,1207.54000,Aetna,Local,,1665.57,,,,,,,1501.09,3406.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7842040,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4163.92000,1207.54000,Aetna,Local,,1665.57,,,,,,,1340.78,3406.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7874184,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5128.59000,1487.29000,Aetna,Local,,2051.44,,,,,,,1848.86,4195.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7874184,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5128.59000,1487.29000,Aetna,Local,,2051.44,,,,,,,1651.41,4195.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7874185,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5128.59000,1487.29000,Aetna,Local,,2051.44,,,,,,,1848.86,4195.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7874185,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5128.59000,1487.29000,Aetna,Local,,2051.44,,,,,,,1651.41,4195.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5648.51000,1638.07000,Aetna,Local,,2259.40,,,,,,,2036.29,4620.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5648.51000,1638.07000,Aetna,Local,,2259.40,,,,,,,1818.82,4620.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5844.02000,1694.77000,Aetna,Local,,2337.61,,,,,,,2106.77,4780.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5844.02000,1694.77000,Aetna,Local,,2337.61,,,,,,,1881.77,4780.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7761.00000,2250.69000,Aetna,Local,,3104.40,,,,,,,2797.84,6348.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7761.00000,2250.69000,Aetna,Local,,3104.40,,,,,,,2499.04,6348.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4263.00000,1236.27000,Aetna,Local,,1705.20,,,,,,,1536.81,3487.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4263.00000,1236.27000,Aetna,Local,,1705.20,,,,,,,1372.69,3487.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4263.00000,1236.27000,Aetna,Local,,1705.20,,,,,,,1536.81,3487.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4263.00000,1236.27000,Aetna,Local,,1705.20,,,,,,,1372.69,3487.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702003,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4263.00000,1236.27000,Aetna,Local,,1705.20,,,,,,,1536.81,3487.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702003,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4263.00000,1236.27000,Aetna,Local,,1705.20,,,,,,,1372.69,3487.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4263.00000,1236.27000,Aetna,Local,,1705.20,,,,,,,1536.81,3487.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4263.00000,1236.27000,Aetna,Local,,1705.20,,,,,,,1372.69,3487.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4203.50000,1219.01000,Aetna,Local,,1681.40,,,,,,,1515.36,3438.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4203.50000,1219.01000,Aetna,Local,,1681.40,,,,,,,1353.53,3438.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702006,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4203.50000,1219.01000,Aetna,Local,,1681.40,,,,,,,1515.36,3438.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702006,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4203.50000,1219.01000,Aetna,Local,,1681.40,,,,,,,1353.53,3438.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4203.50000,1219.01000,Aetna,Local,,1681.40,,,,,,,1515.36,3438.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4203.50000,1219.01000,Aetna,Local,,1681.40,,,,,,,1353.53,3438.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4203.50000,1219.01000,Aetna,Local,,1681.40,,,,,,,1515.36,3438.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4203.50000,1219.01000,Aetna,Local,,1681.40,,,,,,,1353.53,3438.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699576,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699576,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,222.13000,64.42000,Aetna,Local,,88.85,,,,,,,80.08,181.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,222.13000,64.42000,Aetna,Local,,88.85,,,,,,,71.53,181.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7746043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7746043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7746044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7746044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,149.84000,43.45000,Aetna,Local,,59.94,,,,,,,54.02,122.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,149.84000,43.45000,Aetna,Local,,59.94,,,,,,,48.25,122.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,102.59000,29.75000,Aetna,Local,,41.04,,,,,,,36.98,83.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,102.59000,29.75000,Aetna,Local,,41.04,,,,,,,33.03,83.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,102.59000,29.75000,Aetna,Local,,41.04,,,,,,,36.98,83.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7828064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,102.59000,29.75000,Aetna,Local,,41.04,,,,,,,33.03,83.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7856119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7856119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,222.13000,64.42000,Aetna,Local,,88.85,,,,,,,80.08,181.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,222.13000,64.42000,Aetna,Local,,88.85,,,,,,,71.53,181.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,222.13000,64.42000,Aetna,Local,,88.85,,,,,,,80.08,181.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,222.13000,64.42000,Aetna,Local,,88.85,,,,,,,71.53,181.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,222.13000,64.42000,Aetna,Local,,88.85,,,,,,,80.08,181.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,222.13000,64.42000,Aetna,Local,,88.85,,,,,,,71.53,181.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7776481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,777.47000,225.47000,Aetna,Local,,310.99,,,,,,,280.28,635.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7776481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,777.47000,225.47000,Aetna,Local,,310.99,,,,,,,250.35,635.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7910457,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7910457,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7910458,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7910458,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7878345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7878345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7742072,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7742072,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TROCHANTERIC CLAW,7701635,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3698.10000,1072.45000,Aetna,Local,,1479.24,,,,,,,1333.17,3025.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TROCHANTERIC CLAW,7701635,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3698.10000,1072.45000,Aetna,Local,,1479.24,,,,,,,1190.79,3025.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7700864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,533.11,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7700864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,476.17,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7707459,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,533.11,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7707459,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,476.17,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935110,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,533.11,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935110,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,476.17,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948616,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948616,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948617,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948617,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964998,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964998,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964999,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964999,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,633.51000,183.72000,Aetna,Local,,253.40,,,,,,,228.38,518.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,633.51000,183.72000,Aetna,Local,,253.40,,,,,,,203.99,518.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701734,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701734,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695195,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695195,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695196,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695196,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695197,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695197,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695198,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695198,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695199,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695199,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695200,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695200,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695201,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695201,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695202,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695202,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695203,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695203,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695204,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695204,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695205,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695205,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,Local,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699673,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699673,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7699674,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,Local,,994.72,,,,,,,896.49,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7699674,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,Local,,994.72,,,,,,,800.75,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697459,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1871.68,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697459,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1671.79,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1871.68,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,Local,,2076.76,,,,,,,1671.79,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699627,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699627,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,Local,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882391,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882391,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7812179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7812179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7816118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7816118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909380,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909380,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701911,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701911,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5048.37000,1464.03000,Aetna,Local,,2019.35,,,,,,,1819.94,4129.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5048.37000,1464.03000,Aetna,Local,,2019.35,,,,,,,1625.58,4129.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5311.78000,1540.42000,Aetna,Local,,2124.71,,,,,,,1914.90,4345.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5311.78000,1540.42000,Aetna,Local,,2124.71,,,,,,,1710.39,4345.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5311.78000,1540.42000,Aetna,Local,,2124.71,,,,,,,1914.90,4345.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5311.78000,1540.42000,Aetna,Local,,2124.71,,,,,,,1710.39,4345.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1981.68000,574.69000,Aetna,Local,,792.67,,,,,,,714.40,1621.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1981.68000,574.69000,Aetna,Local,,792.67,,,,,,,638.10,1621.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1993.88000,578.23000,Aetna,Local,,797.55,,,,,,,718.79,1630.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1993.88000,578.23000,Aetna,Local,,797.55,,,,,,,642.03,1630.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.22000,1054.50000,Aetna,Local,,1454.49,,,,,,,1310.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.22000,1054.50000,Aetna,Local,,1454.49,,,,,,,1170.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2202.84000,638.82000,Aetna,Local,,881.14,,,,,,,794.12,1801.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2202.84000,638.82000,Aetna,Local,,881.14,,,,,,,709.31,1801.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3040.40000,881.72000,Aetna,Local,,1216.16,,,,,,,1096.06,2487.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3040.40000,881.72000,Aetna,Local,,1216.16,,,,,,,979.01,2487.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7744536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7744536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1996.00000,578.84000,Aetna,Local,,798.40,,,,,,,719.56,1632.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1996.00000,578.84000,Aetna,Local,,798.40,,,,,,,642.71,1632.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2789.60000,808.98000,Aetna,Local,,1115.84,,,,,,,1005.65,2281.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2789.60000,808.98000,Aetna,Local,,1115.84,,,,,,,898.25,2281.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2789.60000,808.98000,Aetna,Local,,1115.84,,,,,,,1005.65,2281.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2789.60000,808.98000,Aetna,Local,,1115.84,,,,,,,898.25,2281.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1914.20000,555.12000,Aetna,Local,,765.68,,,,,,,690.07,1565.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1914.20000,555.12000,Aetna,Local,,765.68,,,,,,,616.37,1565.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7702028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7702028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7741331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7741331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7806291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7806291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7806292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7806292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2680.00000,777.20000,Aetna,Local,,1072.00,,,,,,,966.14,2192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2680.00000,777.20000,Aetna,Local,,1072.00,,,,,,,862.96,2192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,2052.78,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,1833.55,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7736678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,2052.78,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7736678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,1833.55,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7748746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7748746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7790172,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7790172,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7806034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7806034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7874290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7874290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7882381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7882381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8813.70000,2555.97000,Aetna,Local,,3525.48,,,,,,,3177.34,7209.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8813.70000,2555.97000,Aetna,Local,,3525.48,,,,,,,2838.01,7209.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,1065.64,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,951.83,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702012,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,1065.64,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702012,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,951.83,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702013,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,1065.64,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702013,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,951.83,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,1065.64,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,951.83,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702015,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,1065.64,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702015,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,Local,,1182.40,,,,,,,951.83,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2939.00000,852.31000,Aetna,Local,,1175.60,,,,,,,1059.51,2404.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2939.00000,852.31000,Aetna,Local,,1175.60,,,,,,,946.36,2404.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,794.54,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,709.69,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,794.54,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,709.69,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,794.54,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,709.69,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,794.54,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,709.69,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740564,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21567.50000,6254.58000,Aetna,Local,,8627.00,,,,,,,7775.08,17642.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740564,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21567.50000,6254.58000,Aetna,Local,,8627.00,,,,,,,6944.73,17642.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740565,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21567.50000,6254.58000,Aetna,Local,,8627.00,,,,,,,7775.08,17642.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740565,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21567.50000,6254.58000,Aetna,Local,,8627.00,,,,,,,6944.73,17642.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7744629,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21567.50000,6254.58000,Aetna,Local,,8627.00,,,,,,,7775.08,17642.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7744629,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21567.50000,6254.58000,Aetna,Local,,8627.00,,,,,,,6944.73,17642.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7699600,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,7886.67000,2287.13000,Aetna,Local,,3154.67,,,,,,,2843.14,6451.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7699600,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,7886.67000,2287.13000,Aetna,Local,,3154.67,,,,,,,2364.47,6451.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7699601,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,8306.10000,2408.77000,Aetna,Local,,3322.44,,,,,,,2994.35,6794.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7699601,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,8306.10000,2408.77000,Aetna,Local,,3322.44,,,,,,,2364.47,6794.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7910290,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,Local,,3463.20,,,,,,,3121.21,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7910290,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,Local,,3463.20,,,,,,,2364.47,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698462,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698462,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698463,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698463,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699830,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699830,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699831,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699831,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700313,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16057.50000,4656.67000,Aetna,Local,,6423.00,,,,,,,5788.73,13135.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700313,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16057.50000,4656.67000,Aetna,Local,,6423.00,,,,,,,5170.52,13135.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7768034,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7768034,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7778036,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7778036,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7778037,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7778037,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7790539,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7790539,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7818078,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7818078,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7818079,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7818079,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7826031,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7826031,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7872043,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7872043,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7882321,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7882321,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7901622,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7901622,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7902730,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7902730,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904152,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904152,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698232,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698232,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698258,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698258,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699523,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699523,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700075,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700075,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700314,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700314,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701025,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701025,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702067,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702067,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736169,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736169,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736190,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736190,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7778035,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7778035,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7790538,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7790538,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7818077,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7818077,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7826033,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7826033,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7872042,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7872042,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7876434,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7876434,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7893772,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7893772,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7901623,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7901623,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904026,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904026,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904151,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904151,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7917662,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7917662,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926458,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926458,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926541,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926541,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7929722,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33862.50000,9820.12000,Aetna,Local,,13545.00,,,,,,,12207.43,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7929722,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33862.50000,9820.12000,Aetna,Local,,13545.00,,,,,,,10903.73,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7938913,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33862.50000,9820.12000,Aetna,Local,,13545.00,,,,,,,12207.43,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7938913,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33862.50000,9820.12000,Aetna,Local,,13545.00,,,,,,,10903.73,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7939278,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7939278,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954371,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954371,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954523,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954523,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,829.85000,240.66000,Aetna,Local,,331.94,,,,,,,299.16,678.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,829.85000,240.66000,Aetna,Local,,331.94,,,,,,,267.21,678.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,829.85000,240.66000,Aetna,Local,,331.94,,,,,,,299.16,678.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,829.85000,240.66000,Aetna,Local,,331.94,,,,,,,267.21,678.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7695046,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1588.00000,460.52000,Aetna,Local,,635.20,,,,,,,572.47,1298.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7695046,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1588.00000,460.52000,Aetna,Local,,635.20,,,,,,,511.34,1298.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7695329,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1652.76000,479.30000,Aetna,Local,,661.10,,,,,,,595.82,1351.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7695329,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1652.76000,479.30000,Aetna,Local,,661.10,,,,,,,532.19,1351.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7696247,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1652.76000,479.30000,Aetna,Local,,661.10,,,,,,,595.82,1351.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7696247,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1652.76000,479.30000,Aetna,Local,,661.10,,,,,,,532.19,1351.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7696514,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7696514,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7696702,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7696702,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7846239,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7846239,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7699042,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7699042,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7699417,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7699417,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7700117,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7700117,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7707507,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7707507,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7748128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7748128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7905712,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7905712,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7942055,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7942055,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7953855,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7953855,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7782038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,422.75000,122.60000,Aetna,Local,,169.10,,,,,,,152.40,345.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7782038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,422.75000,122.60000,Aetna,Local,,169.10,,,,,,,136.13,345.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694653,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694653,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694654,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694654,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7697874,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7697874,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4206.30000,1219.83000,Aetna,Local,,1682.52,,,,,,,1516.37,3440.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4206.30000,1219.83000,Aetna,Local,,1682.52,,,,,,,1354.43,3440.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7880276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7880276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1222.30,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1091.76,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1222.30,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1091.76,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7699768,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,7596.00000,2202.84000,Aetna,Local,,3038.40,,,,,,,2738.36,6213.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7699768,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,7596.00000,2202.84000,Aetna,Local,,3038.40,,,,,,,2445.91,6213.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7696146,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4705.02000,1364.46000,Aetna,Local,,1882.01,,,,,,,1696.16,3848.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7696146,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4705.02000,1364.46000,Aetna,Local,,1882.01,,,,,,,1515.02,3848.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7702908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4705.02000,1364.46000,Aetna,Local,,1882.01,,,,,,,1696.16,3848.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7702908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4705.02000,1364.46000,Aetna,Local,,1882.01,,,,,,,1515.02,3848.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,868.50000,251.86000,Aetna,Local,,347.40,,,,,,,313.09,710.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,868.50000,251.86000,Aetna,Local,,347.40,,,,,,,279.66,710.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,Local,,534.40,,,,,,,481.63,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,Local,,534.40,,,,,,,430.19,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,Local,,534.40,,,,,,,481.63,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,Local,,534.40,,,,,,,430.19,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,241.72,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,215.90,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,981.45000,284.62000,Aetna,Local,,392.58,,,,,,,353.81,802.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,981.45000,284.62000,Aetna,Local,,392.58,,,,,,,316.03,802.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7880757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,241.72,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7880757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,215.90,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7880758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,241.72,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7880758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,215.90,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696124,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8055.00000,2335.95000,Aetna,Local,,3222.00,,,,,,,2903.83,6588.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696124,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8055.00000,2335.95000,Aetna,Local,,3222.00,,,,,,,2593.71,6588.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7840053,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8055.00000,2335.95000,Aetna,Local,,3222.00,,,,,,,2903.83,6588.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7840053,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8055.00000,2335.95000,Aetna,Local,,3222.00,,,,,,,2593.71,6588.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7822179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5289.90000,1534.07000,Aetna,Local,,2115.96,,,,,,,1907.01,4327.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7822179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5289.90000,1534.07000,Aetna,Local,,2115.96,,,,,,,1703.35,4327.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7910161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5289.90000,1534.07000,Aetna,Local,,2115.96,,,,,,,1907.01,4327.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7910161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5289.90000,1534.07000,Aetna,Local,,2115.96,,,,,,,1703.35,4327.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5289.90000,1534.07000,Aetna,Local,,2115.96,,,,,,,1907.01,4327.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5289.90000,1534.07000,Aetna,Local,,2115.96,,,,,,,1703.35,4327.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7774235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2220.00000,643.80000,Aetna,Local,,888.00,,,,,,,800.31,1815.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7774235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2220.00000,643.80000,Aetna,Local,,888.00,,,,,,,714.84,1815.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7699182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1552.40000,450.20000,Aetna,Local,,620.96,,,,,,,559.64,1269.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7699182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1552.40000,450.20000,Aetna,Local,,620.96,,,,,,,499.87,1269.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699172,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699172,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699035,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699035,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699036,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699036,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699037,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699037,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699038,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699038,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699039,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699039,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699040,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699040,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699041,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699041,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699043,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699043,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699044,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699044,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699045,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699045,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699046,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699046,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699047,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699047,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699123,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7699123,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7850227,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7850227,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694324,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694324,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694325,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694325,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694326,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694326,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694407,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694407,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695654,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695654,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696724,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696724,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696757,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696757,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696777,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696777,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696891,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696891,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696908,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696908,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7756046,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7756046,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703267,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703267,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703268,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703268,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703269,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703269,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7701325,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,6218.62,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7701325,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,5554.50,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7784184,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,6218.62,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7784184,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,5554.50,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7850228,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,6218.62,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7850228,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,5554.50,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7878185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,6218.62,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7878185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,5554.50,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7703328,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,6218.62,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7703328,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,Local,,6900.00,,,,,,,5554.50,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7736126,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1380.00000,400.20000,Aetna,Local,,552.00,,,,,,,497.49,1128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7736126,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,552.00,,,,,,,444.36,1128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7699248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7701597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7701597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7954643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7954643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7954644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7954644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7954645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7954645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7707474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7707474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7707504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7707504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7748067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7748067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7810034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7810034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7820144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7820144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7852132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7852132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7858270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7858270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7910126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6585.18000,1909.70000,Aetna,Local,,2634.07,,,,,,,2373.96,5386.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7910126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6585.18000,1909.70000,Aetna,Local,,2634.07,,,,,,,2120.43,5386.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7940866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7940866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7950389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7950389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7963861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7963861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7964528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7964528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699823,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699823,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7699824,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1495.17,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7699824,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1335.49,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7702291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1495.17,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7702291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1335.49,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7699903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7699903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7701636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7701636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7736487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7736487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7699329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7699329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7874395,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7874395,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7880202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7880202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7828141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7828141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7964532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7964532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7830036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7830036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7903724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7903724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7957936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7957936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,Local,,3099.36,,,,,,,2793.30,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,Local,,3099.36,,,,,,,2494.98,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699754,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,Local,,3099.36,,,,,,,2793.30,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699754,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,Local,,3099.36,,,,,,,2494.98,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5887.49000,1707.37000,Aetna,Local,,2355.00,,,,,,,2122.44,4815.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5887.49000,1707.37000,Aetna,Local,,2355.00,,,,,,,1895.77,4815.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3780.14000,1096.24000,Aetna,Local,,1512.06,,,,,,,1362.74,3092.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3780.14000,1096.24000,Aetna,Local,,1512.06,,,,,,,1217.21,3092.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3557.47000,1031.67000,Aetna,Local,,1422.99,,,,,,,1282.47,2910.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3557.47000,1031.67000,Aetna,Local,,1422.99,,,,,,,1145.51,2910.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3557.47000,1031.67000,Aetna,Local,,1422.99,,,,,,,1282.47,2910.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3557.47000,1031.67000,Aetna,Local,,1422.99,,,,,,,1145.51,2910.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7749.00000,2247.21000,Aetna,Local,,3099.60,,,,,,,2793.51,6338.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7749.00000,2247.21000,Aetna,Local,,3099.60,,,,,,,2495.18,6338.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5887.49000,1707.37000,Aetna,Local,,2355.00,,,,,,,2122.44,4815.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5887.49000,1707.37000,Aetna,Local,,2355.00,,,,,,,1895.77,4815.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5887.49000,1707.37000,Aetna,Local,,2355.00,,,,,,,2122.44,4815.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5887.49000,1707.37000,Aetna,Local,,2355.00,,,,,,,1895.77,4815.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5441.56000,1578.05000,Aetna,Local,,2176.62,,,,,,,1961.68,4451.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5441.56000,1578.05000,Aetna,Local,,2176.62,,,,,,,1752.18,4451.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7960014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5683.83000,1648.31000,Aetna,Local,,2273.53,,,,,,,2049.02,4649.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7960014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5683.83000,1648.31000,Aetna,Local,,2273.53,,,,,,,1830.19,4649.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2398.36000,695.52000,Aetna,Local,,959.34,,,,,,,864.61,1961.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2398.36000,695.52000,Aetna,Local,,959.34,,,,,,,772.27,1961.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,870.20,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,777.27,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,870.20,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,777.27,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740753,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,870.20,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740753,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,777.27,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2475.20000,717.81000,Aetna,Local,,990.08,,,,,,,892.31,2024.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2475.20000,717.81000,Aetna,Local,,990.08,,,,,,,797.01,2024.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7901707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7901707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7750089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7750089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7750119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7750119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7786147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7786147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7804038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7804038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7836169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7836169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7850226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7850226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882255,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3940.65000,1142.79000,Aetna,Local,,1576.26,,,,,,,1420.60,3223.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882255,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3940.65000,1142.79000,Aetna,Local,,1576.26,,,,,,,1268.89,3223.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7896385,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7896385,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7896742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7896742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7903725,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7903725,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7905491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7905491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7695879,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7695879,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7740758,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7740758,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7740759,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7740759,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7697930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7697930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7699094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7699094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7736111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7736111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7904695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7904695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7908620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7908620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7908621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7908621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7908622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7908622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699814,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699814,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7786148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7786148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7936054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7936054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7701193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7701193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7876186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7876186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7896904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7896904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7902293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7902293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700828,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700828,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7701684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7701684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7778031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7778031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7816135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7816135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7897081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7897081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7700317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7700317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7736219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7736219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5471.97000,1586.87000,Aetna,Local,,2188.79,,,,,,,1972.65,4476.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5471.97000,1586.87000,Aetna,Local,,2188.79,,,,,,,1761.97,4476.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5471.97000,1586.87000,Aetna,Local,,2188.79,,,,,,,1972.65,4476.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5471.97000,1586.87000,Aetna,Local,,2188.79,,,,,,,1761.97,4476.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5835.87000,1692.40000,Aetna,Local,,2334.35,,,,,,,2103.83,4773.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5835.87000,1692.40000,Aetna,Local,,2334.35,,,,,,,1879.15,4773.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7699387,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7699387,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7736074,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7736074,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7736650,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7736650,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4185.72000,1213.86000,Aetna,Local,,1674.29,,,,,,,1508.95,3423.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4185.72000,1213.86000,Aetna,Local,,1674.29,,,,,,,1347.80,3423.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7736659,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7736659,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1403.60000,407.04000,Aetna,Local,,561.44,,,,,,,506.00,1148.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1403.60000,407.04000,Aetna,Local,,561.44,,,,,,,451.96,1148.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1403.60000,407.04000,Aetna,Local,,561.44,,,,,,,506.00,1148.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1403.60000,407.04000,Aetna,Local,,561.44,,,,,,,451.96,1148.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1403.60000,407.04000,Aetna,Local,,561.44,,,,,,,506.00,1148.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1403.60000,407.04000,Aetna,Local,,561.44,,,,,,,451.96,1148.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1390.40000,403.22000,Aetna,Local,,556.16,,,,,,,501.24,1137.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1390.40000,403.22000,Aetna,Local,,556.16,,,,,,,447.71,1137.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7960029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7960029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7790173,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7790173,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7810032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7810032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7958151,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7958151,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7830039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7830039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7893768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7893768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3745.00000,1086.05000,Aetna,Local,,1498.00,,,,,,,1350.07,3063.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3745.00000,1086.05000,Aetna,Local,,1498.00,,,,,,,1205.89,3063.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3776.50000,1095.18000,Aetna,Local,,1510.60,,,,,,,1361.43,3089.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3776.50000,1095.18000,Aetna,Local,,1510.60,,,,,,,1216.03,3089.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3745.00000,1086.05000,Aetna,Local,,1498.00,,,,,,,1350.07,3063.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3745.00000,1086.05000,Aetna,Local,,1498.00,,,,,,,1205.89,3063.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3801.00000,1102.29000,Aetna,Local,,1520.40,,,,,,,1370.26,3109.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3801.00000,1102.29000,Aetna,Local,,1520.40,,,,,,,1223.92,3109.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3801.00000,1102.29000,Aetna,Local,,1520.40,,,,,,,1370.26,3109.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3801.00000,1102.29000,Aetna,Local,,1520.40,,,,,,,1223.92,3109.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3801.00000,1102.29000,Aetna,Local,,1520.40,,,,,,,1370.26,3109.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3801.00000,1102.29000,Aetna,Local,,1520.40,,,,,,,1223.92,3109.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3801.00000,1102.29000,Aetna,Local,,1520.40,,,,,,,1370.26,3109.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3801.00000,1102.29000,Aetna,Local,,1520.40,,,,,,,1223.92,3109.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3745.00000,1086.05000,Aetna,Local,,1498.00,,,,,,,1350.07,3063.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3745.00000,1086.05000,Aetna,Local,,1498.00,,,,,,,1205.89,3063.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4130.70000,1197.90000,Aetna,Local,,1652.28,,,,,,,1489.12,3378.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4130.70000,1197.90000,Aetna,Local,,1652.28,,,,,,,1330.09,3378.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7910234,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1368.20000,396.78000,Aetna,Local,,547.28,,,,,,,493.24,1119.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7910234,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1368.20000,396.78000,Aetna,Local,,547.28,,,,,,,440.56,1119.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,62.32,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,55.67,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,62.32,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,55.67,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7830030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7830030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7830031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7830031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7830033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7830033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7832100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7832100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7748068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6556.45000,1901.37000,Aetna,Local,,2622.58,,,,,,,2363.60,5363.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7748068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6556.45000,1901.37000,Aetna,Local,,2622.58,,,,,,,2111.18,5363.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7794301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6556.45000,1901.37000,Aetna,Local,,2622.58,,,,,,,2363.60,5363.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7794301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6556.45000,1901.37000,Aetna,Local,,2622.58,,,,,,,2111.18,5363.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1654.40000,479.78000,Aetna,Local,,661.76,,,,,,,596.41,1353.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1654.40000,479.78000,Aetna,Local,,661.76,,,,,,,532.72,1353.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,605.93,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,541.22,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,605.93,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,541.22,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1469.60000,426.18000,Aetna,Local,,587.84,,,,,,,529.79,1202.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1469.60000,426.18000,Aetna,Local,,587.84,,,,,,,473.21,1202.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1905.20000,552.51000,Aetna,Local,,762.08,,,,,,,686.82,1558.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1905.20000,552.51000,Aetna,Local,,762.08,,,,,,,613.47,1558.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1905.20000,552.51000,Aetna,Local,,762.08,,,,,,,686.82,1558.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1905.20000,552.51000,Aetna,Local,,762.08,,,,,,,613.47,1558.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1548.80000,449.15000,Aetna,Local,,619.52,,,,,,,558.34,1266.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1548.80000,449.15000,Aetna,Local,,619.52,,,,,,,498.71,1266.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1498.40000,434.54000,Aetna,Local,,599.36,,,,,,,540.17,1225.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1498.40000,434.54000,Aetna,Local,,599.36,,,,,,,482.48,1225.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1601.60000,464.46000,Aetna,Local,,640.64,,,,,,,577.38,1310.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1601.60000,464.46000,Aetna,Local,,640.64,,,,,,,515.72,1310.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,605.93,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,541.22,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7903034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1361.95,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7903034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1216.50,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7934085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1361.95,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7934085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1216.50,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1361.95,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1216.50,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2446.40000,709.46000,Aetna,Local,,978.56,,,,,,,881.93,2001.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2446.40000,709.46000,Aetna,Local,,978.56,,,,,,,787.74,2001.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2446.40000,709.46000,Aetna,Local,,978.56,,,,,,,881.93,2001.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2446.40000,709.46000,Aetna,Local,,978.56,,,,,,,787.74,2001.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2811.20000,815.25000,Aetna,Local,,1124.48,,,,,,,1013.44,2299.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2811.20000,815.25000,Aetna,Local,,1124.48,,,,,,,905.21,2299.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699000,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699000,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7740768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7740768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748823,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748823,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7782039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7782039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7959957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7959957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7965297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7965297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740755,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1518.00000,440.22000,Aetna,Local,,607.20,,,,,,,547.24,1241.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740755,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1518.00000,440.22000,Aetna,Local,,607.20,,,,,,,488.80,1241.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7742071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1518.00000,440.22000,Aetna,Local,,607.20,,,,,,,547.24,1241.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7742071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1518.00000,440.22000,Aetna,Local,,607.20,,,,,,,488.80,1241.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1518.00000,440.22000,Aetna,Local,,607.20,,,,,,,547.24,1241.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1518.00000,440.22000,Aetna,Local,,607.20,,,,,,,488.80,1241.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2046.00000,593.34000,Aetna,Local,,818.40,,,,,,,737.58,1673.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2046.00000,593.34000,Aetna,Local,,818.40,,,,,,,658.81,1673.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1385.00000,401.65000,Aetna,Local,,554.00,,,,,,,499.29,1132.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1385.00000,401.65000,Aetna,Local,,554.00,,,,,,,445.97,1132.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,701.10,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,626.23,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,701.10,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,626.23,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,701.10,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,626.23,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1526.80000,442.77000,Aetna,Local,,610.72,,,,,,,550.41,1248.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1526.80000,442.77000,Aetna,Local,,610.72,,,,,,,491.63,1248.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7911780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7911780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,475.25,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,424.50,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2882.00000,835.78000,Aetna,Local,,1152.80,,,,,,,1038.96,2357.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2882.00000,835.78000,Aetna,Local,,1152.80,,,,,,,928.00,2357.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7804059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6161.75000,1786.91000,Aetna,Local,,2464.70,,,,,,,2221.31,5040.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7804059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6161.75000,1786.91000,Aetna,Local,,2464.70,,,,,,,1984.08,5040.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6620.25000,1919.87000,Aetna,Local,,2648.10,,,,,,,2386.60,5415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6620.25000,1919.87000,Aetna,Local,,2648.10,,,,,,,2131.72,5415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7880554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2714.36000,787.16000,Aetna,Local,,1085.74,,,,,,,978.53,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7880554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2714.36000,787.16000,Aetna,Local,,1085.74,,,,,,,874.02,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7696191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7696191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10686.00000,3098.94000,Aetna,Local,,4274.40,,,,,,,3852.30,8741.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10686.00000,3098.94000,Aetna,Local,,4274.40,,,,,,,3440.89,8741.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,2173.83,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,1941.68,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,2173.83,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,1941.68,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,2173.83,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,1941.68,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7360.47000,2134.54000,Aetna,Local,,2944.19,,,,,,,2653.45,6020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7360.47000,2134.54000,Aetna,Local,,2944.19,,,,,,,2370.07,6020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7360.47000,2134.54000,Aetna,Local,,2944.19,,,,,,,2653.45,6020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7360.47000,2134.54000,Aetna,Local,,2944.19,,,,,,,2370.07,6020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7806.00000,2263.74000,Aetna,Local,,3122.40,,,,,,,2814.06,6385.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7806.00000,2263.74000,Aetna,Local,,3122.40,,,,,,,2513.53,6385.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7419.12000,2151.54000,Aetna,Local,,2967.65,,,,,,,2674.59,6068.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7419.12000,2151.54000,Aetna,Local,,2967.65,,,,,,,2388.96,6068.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7419.12000,2151.54000,Aetna,Local,,2967.65,,,,,,,2674.59,6068.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7419.12000,2151.54000,Aetna,Local,,2967.65,,,,,,,2388.96,6068.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6354.60000,1842.83000,Aetna,Local,,2541.84,,,,,,,2290.83,5198.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6354.60000,1842.83000,Aetna,Local,,2541.84,,,,,,,2046.18,5198.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7419.12000,2151.54000,Aetna,Local,,2967.65,,,,,,,2674.59,6068.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7419.12000,2151.54000,Aetna,Local,,2967.65,,,,,,,2388.96,6068.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903623,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903623,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7703023,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2560.00000,742.40000,Aetna,Local,,1024.00,,,,,,,922.88,2094.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7703023,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2560.00000,742.40000,Aetna,Local,,1024.00,,,,,,,824.32,2094.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,Local,,1619.80,,,,,,,1459.84,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,Local,,1619.80,,,,,,,1303.94,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7707537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,Local,,1619.80,,,,,,,1459.84,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7707537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,Local,,1619.80,,,,,,,1303.94,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,Local,,2290.68,,,,,,,2064.48,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,Local,,2290.68,,,,,,,1844.00,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7959985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,Local,,2290.68,,,,,,,2064.48,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7959985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,Local,,2290.68,,,,,,,1844.00,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7962255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,Local,,2290.68,,,,,,,2064.48,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7962255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,Local,,2290.68,,,,,,,1844.00,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7736086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7736086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7736360,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7736360,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7802299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7802299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7895436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7895436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,526.16,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,469.97,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7740764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,526.16,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7740764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,469.97,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7820077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,526.16,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7820077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,469.97,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,526.16,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,469.97,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7916983,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,10252.50000,2973.22000,Aetna,Local,,4101.00,,,,,,,3696.03,8386.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7916983,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,10252.50000,2973.22000,Aetna,Local,,4101.00,,,,,,,3301.30,8386.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7858119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7858119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7874327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7874327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7876325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7876325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7878333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7878333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748830,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748830,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7750113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7750113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7784192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7784192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7784272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7784272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7790168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7790168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7800033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7800033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802101,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802101,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7810066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7810066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7810087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7810087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7812115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7812115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7812117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7812117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828052,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828052,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7850198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7850198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878567,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878567,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880442,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880442,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7913879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7913879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878332,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878332,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7921280,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7921280,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699487,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699487,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699488,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699488,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699651,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699651,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699652,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699652,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7707506,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7707506,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7736128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7736128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7736129,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7736129,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7748747,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7748747,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7768158,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7768158,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7836194,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7836194,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7842038,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7842038,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7902823,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7902823,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7930132,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7930132,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7938058,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7938058,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7956684,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7956684,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7956685,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7956685,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3423.00000,992.67000,Aetna,Local,,1369.20,,,,,,,1233.99,2800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3423.00000,992.67000,Aetna,Local,,1369.20,,,,,,,1102.21,2800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3423.00000,992.67000,Aetna,Local,,1369.20,,,,,,,1233.99,2800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3423.00000,992.67000,Aetna,Local,,1369.20,,,,,,,1102.21,2800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3423.00000,992.67000,Aetna,Local,,1369.20,,,,,,,1233.99,2800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3423.00000,992.67000,Aetna,Local,,1369.20,,,,,,,1102.21,2800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7828148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7828148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901745,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901745,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1361.95,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1216.50,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695216,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3414.53,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695216,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3049.87,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695217,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3414.53,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695217,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3049.87,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7740763,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7740763,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7820076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7820076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7894081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7894081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7896393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7896393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7904042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7904042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7905029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7905029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7926531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7926531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7930256,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7930256,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7935398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7935398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736277,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736277,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748751,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748751,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7820075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7820075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7836158,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7836158,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7836192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7836192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7850088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7850088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7850197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7850197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7858070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7858070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7896902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7896902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7897206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7897206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7804054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7804054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7804056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7804056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822256,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822256,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7832049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7832049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7846162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7846162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7754104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7754104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7768161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7768161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7736282,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7736282,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7927539,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7927539,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7930205,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7930205,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7946099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7946099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7954472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7954472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7790242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7790242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7820141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7820141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880762,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880762,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7894082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7894082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7748754,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7748754,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7912245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7912245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7820074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7820074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7874298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7874298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882829,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882829,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7910430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7910430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7750120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7750120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7784271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7784271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7786151,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7786151,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7790167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7790167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7902768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7902768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7697552,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7697552,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7697662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7697662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7697928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7697928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7698011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7698011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7698220,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7698220,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7702131,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7702131,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7736286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7736286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7748900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7748900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7784273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7784273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7830037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7830037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7702634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7702634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736348,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736348,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7808034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7808034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7812122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7812122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7848089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7848089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880673,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880673,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882584,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882584,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748739,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748739,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7750035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7750035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7754080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7754080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7766066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7766066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7794485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7794485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7808112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7808112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7822231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7822231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7838122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7838122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7846153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7846153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880577,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880577,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880674,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880674,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7750034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7750034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7808111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7808111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7834037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7834037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880576,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880576,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7900572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7900572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7904109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7904109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7939866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7939866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7939955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7939955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7944572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7944572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7964339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7964339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7965238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7965238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7750036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7750036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7754082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7754082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7766064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7766064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7766067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7766067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7766069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7766069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7790541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7790541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7808113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7808113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7822230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7822230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7834036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7834036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7846152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7846152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7858273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7858273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7866044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7866044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880578,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880578,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882378,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882378,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882386,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882386,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882597,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882597,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7897080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7897080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7900571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7900571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7906240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7906240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910998,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910998,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7914553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7914553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7914554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7914554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7929726,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7929726,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943782,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943782,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7925628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7925628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7748738,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7748738,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7754081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7754081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7802066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7802066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7902930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7902930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,4346.82,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,3882.60,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7848030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7848030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882830,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882830,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935804,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935804,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699157,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699157,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700173,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700173,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700829,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700829,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7698634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7698634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7698784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7698784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7904738,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7904738,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7965197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7965197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR ASSEMBLY,7698636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR ASSEMBLY,7698636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR ASSEMBLY,7698785,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR ASSEMBLY,7698785,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,677.74,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,605.36,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,677.74,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,605.36,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,677.74,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,605.36,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957717,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957717,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1743.52000,505.62000,Aetna,Local,,697.41,,,,,,,628.54,1426.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1743.52000,505.62000,Aetna,Local,,697.41,,,,,,,561.41,1426.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7523.40000,2181.79000,Aetna,Local,,3009.36,,,,,,,2712.19,6154.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7523.40000,2181.79000,Aetna,Local,,3009.36,,,,,,,2422.53,6154.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2815.80000,816.58000,Aetna,Local,,1126.32,,,,,,,1015.10,2303.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2815.80000,816.58000,Aetna,Local,,1126.32,,,,,,,906.69,2303.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3395.00000,984.55000,Aetna,Local,,1358.00,,,,,,,1223.90,2777.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1358.00,,,,,,,1093.19,2777.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2616.04000,758.65000,Aetna,Local,,1046.42,,,,,,,943.08,2139.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2616.04000,758.65000,Aetna,Local,,1046.42,,,,,,,842.36,2139.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2634.24000,763.93000,Aetna,Local,,1053.70,,,,,,,949.64,2154.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2634.24000,763.93000,Aetna,Local,,1053.70,,,,,,,848.23,2154.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7903161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2616.04000,758.65000,Aetna,Local,,1046.42,,,,,,,943.08,2139.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7903161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2616.04000,758.65000,Aetna,Local,,1046.42,,,,,,,842.36,2139.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3028.40000,878.24000,Aetna,Local,,1211.36,,,,,,,1091.74,2477.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3028.40000,878.24000,Aetna,Local,,1211.36,,,,,,,975.14,2477.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3028.40000,878.24000,Aetna,Local,,1211.36,,,,,,,1091.74,2477.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3028.40000,878.24000,Aetna,Local,,1211.36,,,,,,,975.14,2477.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3028.40000,878.24000,Aetna,Local,,1211.36,,,,,,,1091.74,2477.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3028.40000,878.24000,Aetna,Local,,1211.36,,,,,,,975.14,2477.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4609.35,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4117.09,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736283,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736283,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3040.40000,881.72000,Aetna,Local,,1216.16,,,,,,,1096.06,2487.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3040.40000,881.72000,Aetna,Local,,1216.16,,,,,,,979.01,2487.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1314.51,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1174.12,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1314.51,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1174.12,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1314.51,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1174.12,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1314.51,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1174.12,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3826.31000,1109.63000,Aetna,Local,,1530.52,,,,,,,1379.38,3129.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3826.31000,1109.63000,Aetna,Local,,1530.52,,,,,,,1232.07,3129.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1314.51,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1174.12,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,7126.63,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,6365.54,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701023,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,7126.63,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701023,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,6365.54,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,7126.63,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,6365.54,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,7126.63,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,6365.54,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,7126.63,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,6365.54,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,7126.63,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,6365.54,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7919080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,7126.63,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7919080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,Local,,7907.50,,,,,,,6365.54,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7736656,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7736656,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7742177,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7742177,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7880508,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1818.00000,527.22000,Aetna,Local,,727.20,,,,,,,655.39,1487.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7880508,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1818.00000,527.22000,Aetna,Local,,727.20,,,,,,,585.40,1487.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7702212,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7702212,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7804041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7804041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7806410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7806410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7836199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7836199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7878329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7878329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7939321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7939321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2999.00,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2678.72,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2999.00,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2678.72,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2999.00,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2678.72,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7919095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2999.00,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7919095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2678.72,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7927540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2999.00,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7927540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2678.72,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2748.16000,796.97000,Aetna,Local,,1099.26,,,,,,,990.71,2247.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2748.16000,796.97000,Aetna,Local,,1099.26,,,,,,,884.91,2247.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697634,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697634,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7740883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7752054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7752054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7758260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,461.81,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,412.49,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,461.81,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,412.49,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,461.81,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,412.49,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698885,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698885,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698886,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698886,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1511.00000,438.19000,Aetna,Local,,604.40,,,,,,,544.72,1236.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1511.00000,438.19000,Aetna,Local,,604.40,,,,,,,486.54,1236.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7704.00000,2234.16000,Aetna,Local,,3081.60,,,,,,,2777.29,6301.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7704.00000,2234.16000,Aetna,Local,,3081.60,,,,,,,2480.69,6301.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7704.00000,2234.16000,Aetna,Local,,3081.60,,,,,,,2777.29,6301.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7704.00000,2234.16000,Aetna,Local,,3081.60,,,,,,,2480.69,6301.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17051.00000,4944.79000,Aetna,Local,,6820.40,,,,,,,6146.89,13947.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17051.00000,4944.79000,Aetna,Local,,6820.40,,,,,,,5490.42,13947.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17051.00000,4944.79000,Aetna,Local,,6820.40,,,,,,,6146.89,13947.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17051.00000,4944.79000,Aetna,Local,,6820.40,,,,,,,5490.42,13947.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7701058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7701058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7702193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7702193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7702245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7702245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7702259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17051.00000,4944.79000,Aetna,Local,,6820.40,,,,,,,6146.89,13947.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7702259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17051.00000,4944.79000,Aetna,Local,,6820.40,,,,,,,5490.42,13947.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736578,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736578,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7776035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7776035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7776480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7776480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7896957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7896957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7897362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7897362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7905494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7905494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7964334,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7964334,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2451.12000,710.82000,Aetna,Local,,980.45,,,,,,,883.63,2005.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2451.12000,710.82000,Aetna,Local,,980.45,,,,,,,789.26,2005.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693563,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,411.11000,119.22000,Aetna,Local,,164.44,,,,,,,148.21,336.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693563,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,411.11000,119.22000,Aetna,Local,,164.44,,,,,,,132.38,336.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693564,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,411.11000,119.22000,Aetna,Local,,164.44,,,,,,,148.21,336.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693564,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,411.11000,119.22000,Aetna,Local,,164.44,,,,,,,132.38,336.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693565,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,411.11000,119.22000,Aetna,Local,,164.44,,,,,,,148.21,336.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693565,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,411.11000,119.22000,Aetna,Local,,164.44,,,,,,,132.38,336.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693566,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,411.11000,119.22000,Aetna,Local,,164.44,,,,,,,148.21,336.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693566,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,411.11000,119.22000,Aetna,Local,,164.44,,,,,,,132.38,336.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693567,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,411.11000,119.22000,Aetna,Local,,164.44,,,,,,,148.21,336.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693567,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,411.11000,119.22000,Aetna,Local,,164.44,,,,,,,132.38,336.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911403,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1768.00000,512.72000,Aetna,Local,,707.20,,,,,,,637.36,1446.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911403,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1768.00000,512.72000,Aetna,Local,,707.20,,,,,,,569.30,1446.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911404,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1768.00000,512.72000,Aetna,Local,,707.20,,,,,,,637.36,1446.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911404,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1768.00000,512.72000,Aetna,Local,,707.20,,,,,,,569.30,1446.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702681,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1768.00000,512.72000,Aetna,Local,,707.20,,,,,,,637.36,1446.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702681,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1768.00000,512.72000,Aetna,Local,,707.20,,,,,,,569.30,1446.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911405,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911405,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911406,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911406,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911407,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911407,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702881,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2959.40000,858.23000,Aetna,Local,,1183.76,,,,,,,1066.86,2420.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702881,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2959.40000,858.23000,Aetna,Local,,1183.76,,,,,,,952.93,2420.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7736642,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,Local,,1162.19,,,,,,,1047.43,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7736642,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,Local,,1162.19,,,,,,,935.56,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696029,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,Local,,1162.19,,,,,,,1047.43,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696029,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,Local,,1162.19,,,,,,,935.56,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696750,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,Local,,1162.19,,,,,,,1047.43,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696750,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,Local,,1162.19,,,,,,,935.56,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696918,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,Local,,1162.19,,,,,,,1047.43,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696918,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,Local,,1162.19,,,,,,,935.56,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702866,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3565.14000,1033.89000,Aetna,Local,,1426.06,,,,,,,1285.23,2916.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702866,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3565.14000,1033.89000,Aetna,Local,,1426.06,,,,,,,1147.98,2916.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702898,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,208.53000,60.47000,Aetna,Local,,83.41,,,,,,,75.18,170.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702898,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,208.53000,60.47000,Aetna,Local,,83.41,,,,,,,67.15,170.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694786,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,704.95000,204.44000,Aetna,Local,,281.98,,,,,,,254.13,576.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694786,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,704.95000,204.44000,Aetna,Local,,281.98,,,,,,,226.99,576.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3603.64000,1045.06000,Aetna,Local,,1441.46,,,,,,,1299.11,2947.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3603.64000,1045.06000,Aetna,Local,,1441.46,,,,,,,1160.37,2947.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2168.72000,628.93000,Aetna,Local,,867.49,,,,,,,781.82,1774.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2168.72000,628.93000,Aetna,Local,,867.49,,,,,,,698.33,1774.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,210.49,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,188.01,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929721,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,210.49,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929721,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,188.01,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954154,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,210.49,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954154,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,188.01,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,210.49,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,188.01,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698639,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,5546.29,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698639,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,4953.97,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698658,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,5546.29,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698658,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,4953.97,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698748,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,5546.29,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698748,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,4953.97,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698831,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,5546.29,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698831,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,4953.97,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698837,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14583.00000,4229.07000,Aetna,Local,,5833.20,,,,,,,5257.17,11928.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698837,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14583.00000,4229.07000,Aetna,Local,,5833.20,,,,,,,4695.73,11928.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700871,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,5546.29,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700871,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,4953.97,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700872,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14583.00000,4229.07000,Aetna,Local,,5833.20,,,,,,,5257.17,11928.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700872,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14583.00000,4229.07000,Aetna,Local,,5833.20,,,,,,,4695.73,11928.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7909032,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,5546.29,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7909032,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,4953.97,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7914401,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,5546.29,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7914401,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15385.00000,4461.65000,Aetna,Local,,6154.00,,,,,,,4953.97,12584.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698615,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698615,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698638,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698638,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698747,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698747,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698830,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698830,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698832,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698832,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698836,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698836,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700072,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700072,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700437,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700437,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700591,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700591,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700667,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700667,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700867,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700867,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700868,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700868,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700869,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700869,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701188,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701188,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702592,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,28857.38000,8368.64000,Aetna,Local,,11542.95,,,,,,,10403.09,23605.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702592,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,28857.38000,8368.64000,Aetna,Local,,11542.95,,,,,,,9292.08,23605.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740553,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740553,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7741765,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7741765,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7794044,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7794044,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7840050,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7840050,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7905577,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7905577,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7912131,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7912131,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698616,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15495.00000,4493.55000,Aetna,Local,,6198.00,,,,,,,5585.95,12674.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698616,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15495.00000,4493.55000,Aetna,Local,,6198.00,,,,,,,4989.39,12674.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699781,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15495.00000,4493.55000,Aetna,Local,,6198.00,,,,,,,5585.95,12674.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699781,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15495.00000,4493.55000,Aetna,Local,,6198.00,,,,,,,4989.39,12674.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700065,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14118.00000,4094.22000,Aetna,Local,,5647.20,,,,,,,5089.54,11548.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700065,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14118.00000,4094.22000,Aetna,Local,,5647.20,,,,,,,4546.00,11548.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700592,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15495.00000,4493.55000,Aetna,Local,,6198.00,,,,,,,5585.95,12674.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700592,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15495.00000,4493.55000,Aetna,Local,,6198.00,,,,,,,4989.39,12674.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701189,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15495.00000,4493.55000,Aetna,Local,,6198.00,,,,,,,5585.95,12674.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701189,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15495.00000,4493.55000,Aetna,Local,,6198.00,,,,,,,4989.39,12674.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7812157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7795.35000,2260.65000,Aetna,Local,,3118.14,,,,,,,2810.22,6376.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7812157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7795.35000,2260.65000,Aetna,Local,,3118.14,,,,,,,2510.10,6376.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,619.79000,179.74000,Aetna,Local,,247.92,,,,,,,223.43,506.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,619.79000,179.74000,Aetna,Local,,247.92,,,,,,,199.57,506.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1304.00000,378.16000,Aetna,Local,,521.60,,,,,,,470.09,1066.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1304.00000,378.16000,Aetna,Local,,521.60,,,,,,,419.89,1066.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1304.00000,378.16000,Aetna,Local,,521.60,,,,,,,470.09,1066.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1304.00000,378.16000,Aetna,Local,,521.60,,,,,,,419.89,1066.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701638,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701638,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.32000,177.57000,Aetna,Local,,244.93,,,,,,,220.74,500.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.32000,177.57000,Aetna,Local,,244.93,,,,,,,197.17,500.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1565.16000,453.90000,Aetna,Local,,626.06,,,,,,,564.24,1280.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1565.16000,453.90000,Aetna,Local,,626.06,,,,,,,503.98,1280.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7752052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7752052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7762378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7762378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7788030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7788030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,315.11,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,874.08000,253.48000,Aetna,Local,,349.63,,,,,,,281.45,715.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,619.79000,179.74000,Aetna,Local,,247.92,,,,,,,223.43,506.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,619.79000,179.74000,Aetna,Local,,247.92,,,,,,,199.57,506.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,302.94,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,270.59,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1565.16000,453.90000,Aetna,Local,,626.06,,,,,,,564.24,1280.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1565.16000,453.90000,Aetna,Local,,626.06,,,,,,,503.98,1280.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,51.10,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,45.64,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1204.00000,349.16000,Aetna,Local,,481.60,,,,,,,434.04,984.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1204.00000,349.16000,Aetna,Local,,481.60,,,,,,,387.69,984.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7699118,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,770.99000,223.59000,Aetna,Local,,308.40,,,,,,,277.94,630.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7699118,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,770.99000,223.59000,Aetna,Local,,308.40,,,,,,,248.26,630.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7699119,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,770.99000,223.59000,Aetna,Local,,308.40,,,,,,,277.94,630.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7699119,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,770.99000,223.59000,Aetna,Local,,308.40,,,,,,,248.26,630.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5995.50000,1738.70000,Aetna,Local,,2398.20,,,,,,,2161.38,4904.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5995.50000,1738.70000,Aetna,Local,,2398.20,,,,,,,1930.55,4904.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,Local,,2290.68,,,,,,,2064.48,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,Local,,2290.68,,,,,,,1844.00,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5995.50000,1738.70000,Aetna,Local,,2398.20,,,,,,,2161.38,4904.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5995.50000,1738.70000,Aetna,Local,,2398.20,,,,,,,1930.55,4904.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2009.40000,582.73000,Aetna,Local,,803.76,,,,,,,724.39,1643.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2009.40000,582.73000,Aetna,Local,,803.76,,,,,,,647.03,1643.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2051.20000,594.85000,Aetna,Local,,820.48,,,,,,,739.46,1677.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2051.20000,594.85000,Aetna,Local,,820.48,,,,,,,660.49,1677.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,179.55000,52.07000,Aetna,Local,,71.82,,,,,,,64.73,146.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,179.55000,52.07000,Aetna,Local,,71.82,,,,,,,57.82,146.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,179.55000,52.07000,Aetna,Local,,71.82,,,,,,,64.73,146.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,179.55000,52.07000,Aetna,Local,,71.82,,,,,,,57.82,146.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2051.20000,594.85000,Aetna,Local,,820.48,,,,,,,739.46,1677.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2051.20000,594.85000,Aetna,Local,,820.48,,,,,,,660.49,1677.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7919000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7919000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2051.20000,594.85000,Aetna,Local,,820.48,,,,,,,739.46,1677.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2051.20000,594.85000,Aetna,Local,,820.48,,,,,,,660.49,1677.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965918,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,588.34,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965918,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,525.50,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,588.34,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,525.50,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7914555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4396.95000,1275.12000,Aetna,Local,,1758.78,,,,,,,1585.10,3596.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7914555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4396.95000,1275.12000,Aetna,Local,,1758.78,,,,,,,1415.82,3596.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4396.95000,1275.12000,Aetna,Local,,1758.78,,,,,,,1585.10,3596.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4396.95000,1275.12000,Aetna,Local,,1758.78,,,,,,,1415.82,3596.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7954009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4396.95000,1275.12000,Aetna,Local,,1758.78,,,,,,,1585.10,3596.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7954009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4396.95000,1275.12000,Aetna,Local,,1758.78,,,,,,,1415.82,3596.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7958130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4396.95000,1275.12000,Aetna,Local,,1758.78,,,,,,,1585.10,3596.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7958130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4396.95000,1275.12000,Aetna,Local,,1758.78,,,,,,,1415.82,3596.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7812074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,Local,,2667.35,,,,,,,2403.95,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7812074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,Local,,2667.35,,,,,,,2147.22,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7824041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7824041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7924905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7924905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938800,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938800,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7736618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5675.25000,1645.82000,Aetna,Local,,2270.10,,,,,,,2045.93,4642.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7736618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5675.25000,1645.82000,Aetna,Local,,2270.10,,,,,,,1827.43,4642.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902673,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902673,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7904735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7904735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880659,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8475.00000,2457.75000,Aetna,Local,,3390.00,,,,,,,3055.24,6932.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880659,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8475.00000,2457.75000,Aetna,Local,,3390.00,,,,,,,2728.95,6932.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7740533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7740533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7740534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7740534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7740535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7740535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7740536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7740536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,Local,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7946100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7946100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,578.03000,167.63000,Aetna,Local,,231.21,,,,,,,208.38,472.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,578.03000,167.63000,Aetna,Local,,231.21,,,,,,,186.13,472.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893606,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893606,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.73000,141.15000,Aetna,Local,,194.69,,,,,,,175.47,398.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.73000,141.15000,Aetna,Local,,194.69,,,,,,,156.73,398.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,507.78000,147.26000,Aetna,Local,,203.11,,,,,,,183.05,415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,507.78000,147.26000,Aetna,Local,,203.11,,,,,,,163.51,415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7740780,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7740780,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7740781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7740781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7740782,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7740782,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7758263,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7758263,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7758264,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7758264,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7937656,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7937656,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7937657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7937657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7774229,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8932.50000,2590.42000,Aetna,Local,,3573.00,,,,,,,3220.17,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7774229,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8932.50000,2590.42000,Aetna,Local,,3573.00,,,,,,,2876.26,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7740893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7740893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7810089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7810089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7832048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7832048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880795,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880795,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7838.67,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7001.53,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7838.67,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7001.53,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698419,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7838.67,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698419,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7001.53,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7838.67,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7001.53,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7838.67,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7001.53,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7838.67,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7001.53,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7910506,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7838.67,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7910506,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21743.88000,6305.73000,Aetna,Local,,8697.55,,,,,,,7001.53,17786.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695009,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695009,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695010,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695010,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695011,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695011,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695012,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695012,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695013,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695013,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695014,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695014,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695093,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695093,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695094,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695094,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695095,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695095,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695128,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695128,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695153,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695153,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695163,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695163,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695164,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695164,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695166,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695166,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695172,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695172,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695223,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695223,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695244,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695244,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695255,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695255,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695256,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695256,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695257,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695257,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695258,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695258,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695259,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695259,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695278,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695278,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703271,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703271,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703272,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703272,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7741658,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7741658,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7699192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7699192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7893457,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7893457,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7750597,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9083.55000,2634.23000,Aetna,Local,,3633.42,,,,,,,3274.62,7430.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7750597,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9083.55000,2634.23000,Aetna,Local,,3633.42,,,,,,,2924.90,7430.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD EXT,7905611,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9083.55000,2634.23000,Aetna,Local,,3633.42,,,,,,,3274.62,7430.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD EXT,7905611,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9083.55000,2634.23000,Aetna,Local,,3633.42,,,,,,,2924.90,7430.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7744591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2844.00000,824.76000,Aetna,Local,,1137.60,,,,,,,1025.26,2326.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7744591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2844.00000,824.76000,Aetna,Local,,1137.60,,,,,,,915.77,2326.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7744662,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,849.81000,246.44000,Aetna,Local,,339.92,,,,,,,306.36,695.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7744662,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,849.81000,246.44000,Aetna,Local,,339.92,,,,,,,273.64,695.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7948208,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7948208,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748889,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748889,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7782096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7782096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7790239,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7790239,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7800041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7800041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7804030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7804030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7804049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7804049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7820140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7820140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822255,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822255,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7874398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7874398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880514,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880514,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893761,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893761,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7896745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7896745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7896900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7896900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7900162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7900162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7900328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7900328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7911546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7911546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7913928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7913928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7917824,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7917824,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7922503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7922503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7924906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7924906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7934017,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7934017,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935785,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935785,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7937741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7937741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7939807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7939807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7943992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7943992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7946097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7946097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948685,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948685,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7782097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7782097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7804050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7804050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7806411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7806411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7822254,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7822254,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7828068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7828068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7834148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7834148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7838069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7838069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7846160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7846160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7874397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7874397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7876337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7876337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748832,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748832,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7766059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7766059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7806370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7806370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7850200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7850200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882371,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882371,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7900095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7900095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7903123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7903123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908717,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908717,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3420.78,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3055.46,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1495.17,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1335.49,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7766060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1495.17,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7766060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1335.49,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7784203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1495.17,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7784203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1335.49,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1495.17,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4147.50000,1202.77000,Aetna,Local,,1659.00,,,,,,,1335.49,3392.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7748892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7748892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7790240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7790240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7806412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7806412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7893339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7893339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7794034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7794034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834083,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834083,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7858120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7858120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7858123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7858123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7874291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7874291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7903718,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7903718,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,Local,,3864.00,,,,,,,3482.43,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,Local,,3864.00,,,,,,,3110.52,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7882389,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7882389,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7858276,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7858276,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7750115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7750115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7834110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7834110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7834111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7834111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7882687,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7882687,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7896751,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7896751,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7935918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7935918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7943922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7943922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7944007,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7944007,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7834109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7834109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7927339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7927339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7935919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7935919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7943921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7943921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750474,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750474,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750475,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750475,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750478,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750478,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750482,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750482,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750484,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750484,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750485,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750485,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750489,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750489,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750491,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750491,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911541,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911541,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911542,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911542,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965172,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965172,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965173,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965173,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965174,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965174,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965175,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965175,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965176,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965176,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965177,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965177,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965178,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7965178,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7894317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5455.63000,1582.13000,Aetna,Local,,2182.25,,,,,,,1966.75,4462.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7894317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5455.63000,1582.13000,Aetna,Local,,2182.25,,,,,,,1756.71,4462.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7948114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5455.63000,1582.13000,Aetna,Local,,2182.25,,,,,,,1966.75,4462.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7948114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5455.63000,1582.13000,Aetna,Local,,2182.25,,,,,,,1756.71,4462.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7694867,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,352.89,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7694867,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,315.20,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695028,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,352.89,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695028,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,315.20,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695230,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,352.89,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695230,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,315.20,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695232,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,352.89,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695232,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,315.20,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7702689,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,352.89,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7702689,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,978.89000,283.88000,Aetna,Local,,391.56,,,,,,,315.20,800.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7962119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,669.60000,194.18000,Aetna,Local,,267.84,,,,,,,241.39,547.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7962119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,669.60000,194.18000,Aetna,Local,,267.84,,,,,,,215.61,547.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7918648,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7918648,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7927466,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,702.00000,203.58000,Aetna,Local,,280.80,,,,,,,253.07,574.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7927466,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,702.00000,203.58000,Aetna,Local,,280.80,,,,,,,226.04,574.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7930246,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,415.63000,120.53000,Aetna,Local,,166.25,,,,,,,149.83,339.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7930246,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,415.63000,120.53000,Aetna,Local,,166.25,,,,,,,133.83,339.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7933871,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7933871,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756254,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756254,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756257,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756257,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756258,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756258,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756259,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756259,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756261,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7756261,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756280,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756280,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756282,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756282,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756283,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756283,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756284,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756284,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756285,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756285,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756286,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756286,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756291,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756291,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756292,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756292,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756293,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756293,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756294,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756294,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756366,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7756366,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756322,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756322,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5920.08000,1716.82000,Aetna,Local,,2368.03,,,,,,,2134.19,4842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5920.08000,1716.82000,Aetna,Local,,2368.03,,,,,,,1906.27,4842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7758261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8271.03000,2398.60000,Aetna,Local,,3308.41,,,,,,,2981.71,6765.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7758261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8271.03000,2398.60000,Aetna,Local,,3308.41,,,,,,,2663.27,6765.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695160,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8882.13000,2575.82000,Aetna,Local,,3552.85,,,,,,,3202.01,7265.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695160,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8882.13000,2575.82000,Aetna,Local,,3552.85,,,,,,,2860.05,7265.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695161,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8882.13000,2575.82000,Aetna,Local,,3552.85,,,,,,,3202.01,7265.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695161,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8882.13000,2575.82000,Aetna,Local,,3552.85,,,,,,,2860.05,7265.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695208,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8882.13000,2575.82000,Aetna,Local,,3552.85,,,,,,,3202.01,7265.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695208,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8882.13000,2575.82000,Aetna,Local,,3552.85,,,,,,,2860.05,7265.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695210,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8882.13000,2575.82000,Aetna,Local,,3552.85,,,,,,,3202.01,7265.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695210,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8882.13000,2575.82000,Aetna,Local,,3552.85,,,,,,,2860.05,7265.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695251,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8587.38000,2490.34000,Aetna,Local,,3434.95,,,,,,,3095.75,7024.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695251,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8587.38000,2490.34000,Aetna,Local,,3434.95,,,,,,,2765.14,7024.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695030,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695030,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695031,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695031,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695254,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695254,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695219,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9262.38000,2686.09000,Aetna,Local,,3704.95,,,,,,,3339.09,7576.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695219,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9262.38000,2686.09000,Aetna,Local,,3704.95,,,,,,,2982.49,7576.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7760079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,817.25,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7760079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,729.97,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7903162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,817.25,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7903162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,729.97,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7903163,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,817.25,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7903163,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,729.97,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7903164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,817.25,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7903164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,729.97,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7957791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7957791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7850189,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6373.50000,1848.31000,Aetna,Local,,2549.40,,,,,,,2297.65,5213.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7850189,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6373.50000,1848.31000,Aetna,Local,,2549.40,,,,,,,2052.27,5213.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7902583,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6678.00000,1936.62000,Aetna,Local,,2671.20,,,,,,,2407.42,5462.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7902583,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6678.00000,1936.62000,Aetna,Local,,2671.20,,,,,,,2150.32,5462.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7902773,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4812.68,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7902773,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4298.70,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4812.68,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4298.70,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7910286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4812.68,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7910286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4298.70,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911000,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4812.68,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911000,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4298.70,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7937861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4812.68,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7937861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4298.70,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7950557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4812.68,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7950557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4298.70,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7736682,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5116.30000,1483.73000,Aetna,Local,,2046.52,,,,,,,1844.43,4185.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7736682,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5116.30000,1483.73000,Aetna,Local,,2046.52,,,,,,,1647.45,4185.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7736683,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5116.30000,1483.73000,Aetna,Local,,2046.52,,,,,,,1844.43,4185.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7736683,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5116.30000,1483.73000,Aetna,Local,,2046.52,,,,,,,1647.45,4185.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7699700,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5071.50000,1470.74000,Aetna,Local,,2028.60,,,,,,,1828.28,4148.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7699700,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5071.50000,1470.74000,Aetna,Local,,2028.60,,,,,,,1633.02,4148.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695020,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,308.23000,89.39000,Aetna,Local,,123.29,,,,,,,111.12,252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695020,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,308.23000,89.39000,Aetna,Local,,123.29,,,,,,,99.25,252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695021,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,308.23000,89.39000,Aetna,Local,,123.29,,,,,,,111.12,252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695021,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,308.23000,89.39000,Aetna,Local,,123.29,,,,,,,99.25,252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695022,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,308.23000,89.39000,Aetna,Local,,123.29,,,,,,,111.12,252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695022,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,308.23000,89.39000,Aetna,Local,,123.29,,,,,,,99.25,252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7895463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1303.60000,378.04000,Aetna,Local,,521.44,,,,,,,469.95,1066.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7895463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1303.60000,378.04000,Aetna,Local,,521.44,,,,,,,419.76,1066.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,347.16,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,310.09,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.27000,188.00000,Aetna,Local,,259.31,,,,,,,233.70,530.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.27000,188.00000,Aetna,Local,,259.31,,,,,,,208.74,530.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.27000,188.00000,Aetna,Local,,259.31,,,,,,,233.70,530.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.27000,188.00000,Aetna,Local,,259.31,,,,,,,208.74,530.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.27000,188.00000,Aetna,Local,,259.31,,,,,,,233.70,530.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.27000,188.00000,Aetna,Local,,259.31,,,,,,,208.74,530.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7836183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7836183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7840125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7840125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880653,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2741.60,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880653,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2448.81,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2741.60,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2448.81,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2741.60,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2448.81,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882387,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882387,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2741.60,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2448.81,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7900099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7900099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7900100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7900100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7922573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7922573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7926699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7926699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935847,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935847,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7964652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7964652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7806050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7806050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7895466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3511.31000,1018.28000,Aetna,Local,,1404.52,,,,,,,1265.83,2872.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7895466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3511.31000,1018.28000,Aetna,Local,,1404.52,,,,,,,1130.64,2872.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7776291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7776291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7776292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7776292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7930142,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,838.31000,243.11000,Aetna,Local,,335.32,,,,,,,302.21,685.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7930142,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,838.31000,243.11000,Aetna,Local,,335.32,,,,,,,269.94,685.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7832050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7832050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7937715,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7937715,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7939847,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7939847,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7944260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7944260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7742028,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7742028,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7742029,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7742029,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7742030,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,548.06000,158.94000,Aetna,Local,,219.22,,,,,,,197.58,448.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7742030,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,548.06000,158.94000,Aetna,Local,,219.22,,,,,,,176.48,448.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7927546,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,Local,,199.12,,,,,,,179.46,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7927546,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,Local,,199.12,,,,,,,160.29,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,957.20000,277.59000,Aetna,Local,,382.88,,,,,,,345.07,782.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,957.20000,277.59000,Aetna,Local,,382.88,,,,,,,308.22,782.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,352.03,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,314.43,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740548,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12918.00000,3746.22000,Aetna,Local,,5167.20,,,,,,,4656.94,10566.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740548,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12918.00000,3746.22000,Aetna,Local,,5167.20,,,,,,,4159.60,10566.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7788042,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11799.00000,3421.71000,Aetna,Local,,4719.60,,,,,,,4253.54,9651.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7788042,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11799.00000,3421.71000,Aetna,Local,,4719.60,,,,,,,3799.28,9651.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904230,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11799.00000,3421.71000,Aetna,Local,,4719.60,,,,,,,4253.54,9651.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904230,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11799.00000,3421.71000,Aetna,Local,,4719.60,,,,,,,3799.28,9651.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904231,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12918.00000,3746.22000,Aetna,Local,,5167.20,,,,,,,4656.94,10566.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904231,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12918.00000,3746.22000,Aetna,Local,,5167.20,,,,,,,4159.60,10566.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904232,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11799.00000,3421.71000,Aetna,Local,,4719.60,,,,,,,4253.54,9651.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7904232,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11799.00000,3421.71000,Aetna,Local,,4719.60,,,,,,,3799.28,9651.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950032,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950032,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,714.57,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,638.26,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,714.57,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,638.26,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,714.57,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,638.26,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7900567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,714.57,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7900567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,638.26,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7902712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,700.74,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7902712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,625.90,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7927492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,700.74,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7927492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,625.90,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7784199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9226.20000,2675.60000,Aetna,Local,,3690.48,,,,,,,3326.05,7547.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7784199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9226.20000,2675.60000,Aetna,Local,,3690.48,,,,,,,2970.84,7547.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7858261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7858261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7918863,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6544.13000,1897.80000,Aetna,Local,,2617.65,,,,,,,2359.16,5353.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7918863,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6544.13000,1897.80000,Aetna,Local,,2617.65,,,,,,,2107.21,5353.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696725,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,757.22,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696725,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,676.35,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7926456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,757.22,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7926456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,676.35,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,757.22,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,676.35,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,757.22,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,676.35,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,757.22,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,676.35,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,757.22,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,676.35,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,757.22,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,676.35,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,757.22,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7702752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2100.48000,609.14000,Aetna,Local,,840.19,,,,,,,676.35,1718.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748827,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748827,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7784257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7784257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7784270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7784270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7786152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7786152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5240.17000,1519.65000,Aetna,Local,,2096.07,,,,,,,1889.08,4286.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5240.17000,1519.65000,Aetna,Local,,2096.07,,,,,,,1687.33,4286.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7806049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7806049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7822236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7822236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7822245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7822245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880660,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880660,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902769,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902769,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902770,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902770,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912827,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912827,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7961945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7961945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964447,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964447,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7868042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7868042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882385,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882385,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893627,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893627,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7910169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7910169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7902915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,Local,,5242.24,,,,,,,4724.57,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7902915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,Local,,5242.24,,,,,,,4220.00,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,Local,,5242.24,,,,,,,4724.57,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,Local,,5242.24,,,,,,,4220.00,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7964337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,Local,,5242.24,,,,,,,4724.57,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7964337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,Local,,5242.24,,,,,,,4220.00,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7916931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,2197.43,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7916931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,1962.75,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7944339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,2197.43,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7944339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,1962.75,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7964336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,2197.43,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7964336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,1962.75,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7790235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7946025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7946025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7834038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7834038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893417,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893417,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7874289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7874289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7846154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7846154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7866042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7866042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7954473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7954473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7957712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7957712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7958150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7958150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7858118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7858118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7904797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7904797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7905248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7905248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7911317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1680.00000,487.20000,Aetna,Local,,672.00,,,,,,,605.64,1374.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7911317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1680.00000,487.20000,Aetna,Local,,672.00,,,,,,,540.96,1374.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7927418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1680.00000,487.20000,Aetna,Local,,672.00,,,,,,,605.64,1374.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7927418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1680.00000,487.20000,Aetna,Local,,672.00,,,,,,,540.96,1374.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702076,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702076,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736492,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736492,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7794045,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7794045,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7903410,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7903410,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIA ALL POLY M,7806414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIA ALL POLY M,7806414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7810035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7810035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7820084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7820084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7844034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7844034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7850085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7850085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7894209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7894209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7895650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7895650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7902301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7902301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7904798,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7904798,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7909378,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7909378,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7910248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7910248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7936399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7936399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7961900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7961900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7794409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7794409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7794413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7794413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7820082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7820082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7828065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7828065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7844033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7844033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7878327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7878327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7902128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7902128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7904741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7904741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7794411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7794411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7794415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7794415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7802074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7802074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7820083,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7820083,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7810036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7810036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7820085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7820085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7836178,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7836178,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7844035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7844035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880756,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880756,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7894208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7894208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7895928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7895928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902302,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902302,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7903122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7903122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904799,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904799,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912612,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912612,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918876,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918876,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918878,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918878,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920781,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920781,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7922870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7922870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7924909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7924909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7934072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7934072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7936400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7936400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7956549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7956549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7960043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7960043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7943705,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7943705,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7954779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7954779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2956.98,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2641.19,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7804051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7804051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7816128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7816128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7900161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7900161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7900294,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7900294,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7901614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7901614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920813,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2956.98,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920813,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2641.19,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926552,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2956.98,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926552,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2641.19,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926708,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2956.98,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926708,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2641.19,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2956.98,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2641.19,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2956.98,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2641.19,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7822234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7832047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7832047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882595,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882595,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748891,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748891,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7750030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7750030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7754078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7754078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7782098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7782098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7786051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7786051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7790241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7790241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7800042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7800042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7804031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7804031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7806372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7806372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7808074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7808074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7806413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7806413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7834164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7834164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7836106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7836106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7858277,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7858277,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7858278,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3850.00000,1116.50000,Aetna,Local,,1540.00,,,,,,,1387.92,3149.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7858278,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3850.00000,1116.50000,Aetna,Local,,1540.00,,,,,,,1239.70,3149.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7874393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7874393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7874399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7874399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882374,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882374,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882506,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882506,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882594,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882594,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893770,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893770,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7895652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7895652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7903124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7903124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904975,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904975,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905013,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905013,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917874,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917874,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7936194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7936194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7936195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7936195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7953913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7953913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7959515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7959515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7960314,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7960314,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7802081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7802081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7802084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7802084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7836180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7836180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7950462,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7950462,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7958153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7958153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7880531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9201.00000,2668.29000,Aetna,Local,,3680.40,,,,,,,3316.96,7526.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7880531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9201.00000,2668.29000,Aetna,Local,,3680.40,,,,,,,2962.72,7526.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7802110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7802110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7804055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7804055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7925893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7925893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7802096,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7802096,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7802097,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7802097,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1438.48000,417.16000,Aetna,Local,,575.39,,,,,,,518.57,1176.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1438.48000,417.16000,Aetna,Local,,575.39,,,,,,,463.19,1176.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1533.36000,444.67000,Aetna,Local,,613.34,,,,,,,552.78,1254.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1533.36000,444.67000,Aetna,Local,,613.34,,,,,,,493.74,1254.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,582.57,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,520.35,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1565.16000,453.90000,Aetna,Local,,626.06,,,,,,,564.24,1280.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1565.16000,453.90000,Aetna,Local,,626.06,,,,,,,503.98,1280.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1428.44000,414.25000,Aetna,Local,,571.38,,,,,,,514.95,1168.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1428.44000,414.25000,Aetna,Local,,571.38,,,,,,,459.96,1168.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,480.29,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.28000,386.36000,Aetna,Local,,532.91,,,,,,,428.99,1089.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1335.80000,387.38000,Aetna,Local,,534.32,,,,,,,481.56,1092.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1335.80000,387.38000,Aetna,Local,,534.32,,,,,,,430.13,1092.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7836033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1449.16000,420.26000,Aetna,Local,,579.66,,,,,,,522.42,1185.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7836033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1449.16000,420.26000,Aetna,Local,,579.66,,,,,,,466.63,1185.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911911,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911911,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,582.57,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,520.35,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7834080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7834080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7882695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7882695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7918851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7918851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7920119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7920119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7962242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7962242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802083,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802083,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7836179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7836179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7901857,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7901857,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7958154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7958154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948242,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948242,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7961894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7961894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7804047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7804047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7836188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7836188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7836191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7836191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7874294,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7874294,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882519,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882519,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7836187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7836187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7858124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7858124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7874293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7874293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7698026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12638.40000,3665.14000,Aetna,Local,,5055.36,,,,,,,4556.14,10338.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7698026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12638.40000,3665.14000,Aetna,Local,,5055.36,,,,,,,4069.56,10338.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7816134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2302.56000,667.74000,Aetna,Local,,921.02,,,,,,,830.07,1883.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7816134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2302.56000,667.74000,Aetna,Local,,921.02,,,,,,,741.42,1883.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,920.00,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,821.74,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,920.00,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,821.74,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1641.12000,475.92000,Aetna,Local,,656.45,,,,,,,591.62,1342.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1641.12000,475.92000,Aetna,Local,,656.45,,,,,,,528.44,1342.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7806235,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7806235,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7902105,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,451.25000,130.86000,Aetna,Local,,180.50,,,,,,,162.68,369.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7902105,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,451.25000,130.86000,Aetna,Local,,180.50,,,,,,,145.30,369.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7868037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7868037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7876322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7876322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7900570,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7900570,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7910649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7910649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7926455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7926455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7940365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7940365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7942054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7942054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7948863,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7948863,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7960040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7960040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7876323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882379,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882379,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7808075,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,2887.72000,837.44000,Aetna,Local,,1155.09,,,,,,,1041.02,2362.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7808075,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,2887.72000,837.44000,Aetna,Local,,1155.09,,,,,,,929.85,2362.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7880678,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,2887.72000,837.44000,Aetna,Local,,1155.09,,,,,,,1041.02,2362.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7880678,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,2887.72000,837.44000,Aetna,Local,,1155.09,,,,,,,929.85,2362.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698718,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698718,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7742073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7742073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748756,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748756,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7782032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7782032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7806375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7806375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7816120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7816120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7828135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7828135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7838065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7838065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7848065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7848065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7876329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7876329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7876438,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7876438,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880665,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880665,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7901617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7901617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7901856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7901856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7903726,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7903726,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7904734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7904734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908599,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908599,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7908882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7921281,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7921281,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7927347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7927347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699314,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699314,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7740523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7740523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7748114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7748114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7748755,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7748755,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7748833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7748833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7806377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7806377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7806405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7806405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7816119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7816119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7822237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7822237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7838064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7838064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7850199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7850199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7878460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7878460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7878477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7878477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7882221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7882221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7910509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7910509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7910640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7910640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7910641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7910641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7910834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7910834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911007,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911007,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7916925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7916925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7934070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7934070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7943250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7943250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7947858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7947858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7950204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7950204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7750090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7750090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7778029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7778029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7800032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7800032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7810088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7810088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7814060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7814060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7822246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7822246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7836105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7836105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7850175,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7850175,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878566,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878566,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880581,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880581,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880668,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880668,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7894126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7894126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7900129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7900129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7903362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7903362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919093,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919093,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695025,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1340.04000,388.61000,Aetna,Local,,536.02,,,,,,,483.08,1096.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695025,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1340.04000,388.61000,Aetna,Local,,536.02,,,,,,,431.49,1096.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695026,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1340.04000,388.61000,Aetna,Local,,536.02,,,,,,,483.08,1096.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695026,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1340.04000,388.61000,Aetna,Local,,536.02,,,,,,,431.49,1096.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695027,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1340.04000,388.61000,Aetna,Local,,536.02,,,,,,,483.08,1096.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7695027,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1340.04000,388.61000,Aetna,Local,,536.02,,,,,,,431.49,1096.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7893622,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1356.68000,393.44000,Aetna,Local,,542.67,,,,,,,489.08,1109.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7893622,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1356.68000,393.44000,Aetna,Local,,542.67,,,,,,,436.85,1109.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695104,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2329.43,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695104,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2080.66,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695105,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2329.43,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695105,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2080.66,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695106,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2329.43,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695106,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2080.66,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694375,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,515.04000,149.36000,Aetna,Local,,206.02,,,,,,,185.67,421.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694375,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,515.04000,149.36000,Aetna,Local,,206.02,,,,,,,165.84,421.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694376,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,515.04000,149.36000,Aetna,Local,,206.02,,,,,,,185.67,421.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694376,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,515.04000,149.36000,Aetna,Local,,206.02,,,,,,,165.84,421.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7695515,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7695515,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7695516,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7695516,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7695517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7695517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7695876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7695876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7695877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7695877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7702618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7702618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7740546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7740546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7702905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7702905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7957917,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7957917,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965042,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965042,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965055,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965055,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965056,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965056,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIA ADAPTER,7816101,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3266.90000,947.40000,Aetna,Local,,1306.76,,,,,,,1177.72,2672.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIA ADAPTER,7816101,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3266.90000,947.40000,Aetna,Local,,1306.76,,,,,,,1051.94,2672.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,2052.78,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,1833.55,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,2052.78,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,1833.55,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,2052.78,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,1833.55,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,2052.78,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,Local,,2277.70,,,,,,,1833.55,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7902123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7902123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,664.20000,192.62000,Aetna,Local,,265.68,,,,,,,239.44,543.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,664.20000,192.62000,Aetna,Local,,265.68,,,,,,,213.87,543.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,664.20000,192.62000,Aetna,Local,,265.68,,,,,,,239.44,543.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,664.20000,192.62000,Aetna,Local,,265.68,,,,,,,213.87,543.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,664.20000,192.62000,Aetna,Local,,265.68,,,,,,,239.44,543.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,664.20000,192.62000,Aetna,Local,,265.68,,,,,,,213.87,543.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,664.20000,192.62000,Aetna,Local,,265.68,,,,,,,239.44,543.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,664.20000,192.62000,Aetna,Local,,265.68,,,,,,,213.87,543.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7909472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7909472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13059.00000,3787.11000,Aetna,Local,,5223.60,,,,,,,4707.77,10682.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13059.00000,3787.11000,Aetna,Local,,5223.60,,,,,,,4205.00,10682.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699452,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699452,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7866111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7866111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7876332,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7876332,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7896743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7896743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7900096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7900096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7901618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7901618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7910508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7910508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7917876,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7917876,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7918630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7918630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7920411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7920411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7920820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7920820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7934071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7934071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7943251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7943251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7944261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7944261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7962118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7962118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882513,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882513,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7695145,CDM,278,RC,C1777,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7695145,CDM,278,RC,C1777,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,4491.90,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2592.00000,751.68000,Aetna,Local,,1036.80,,,,,,,934.42,2120.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2592.00000,751.68000,Aetna,Local,,1036.80,,,,,,,834.62,2120.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7927400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7927400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7944505,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7944505,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7909243,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7909243,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE IMPLANT,7908635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE IMPLANT,7908635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7846159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7846159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7874296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7874296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7905246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7905246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912752,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912752,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,Local,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,4346.82,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,3882.60,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7896958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,4346.82,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7896958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,3882.60,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7903498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8692.80000,2520.91000,Aetna,Local,,3477.12,,,,,,,3133.75,7110.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7903498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8692.80000,2520.91000,Aetna,Local,,3477.12,,,,,,,2799.08,7110.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7925894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,4346.82,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7925894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,3882.60,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7954745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,4346.82,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7954745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,3882.60,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7834081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7834081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,895.16,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7846163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7846163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,895.16,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7850194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7850194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,895.16,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7858121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7858121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,895.16,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7866039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7866039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,895.16,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7866041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7866041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,895.16,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7834107,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,752.40000,218.20000,Aetna,Local,,300.96,,,,,,,271.24,615.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7834107,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,752.40000,218.20000,Aetna,Local,,300.96,,,,,,,242.27,615.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882690,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882690,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7943927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7943927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7947954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7947954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7836181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7836181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7840126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7840126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7902538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7902538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7701645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,2191.66,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7701645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,1957.60,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7836143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7836143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7836144,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,2191.66,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7836144,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,1957.60,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7938963,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,2191.66,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7938963,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,1957.60,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7858247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7858247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7874323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7874323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7920117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7920117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7912354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,793.10,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7912354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,708.40,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7840048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9306.00000,2698.74000,Aetna,Local,,3722.40,,,,,,,3354.81,7612.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7840048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9306.00000,2698.74000,Aetna,Local,,3722.40,,,,,,,2996.53,7612.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882615,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2220.00000,643.80000,Aetna,Local,,888.00,,,,,,,800.31,1815.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882615,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2220.00000,643.80000,Aetna,Local,,888.00,,,,,,,714.84,1815.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2220.00000,643.80000,Aetna,Local,,888.00,,,,,,,800.31,1815.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2220.00000,643.80000,Aetna,Local,,888.00,,,,,,,714.84,1815.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7868041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7868041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7874292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7874292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7878330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7878330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7868040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7868040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7925197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7925197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7872038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6389.88000,1853.07000,Aetna,Local,,2555.95,,,,,,,2303.55,5226.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7872038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6389.88000,1853.07000,Aetna,Local,,2555.95,,,,,,,2057.54,5226.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,637.79000,184.96000,Aetna,Local,,255.12,,,,,,,229.92,521.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,637.79000,184.96000,Aetna,Local,,255.12,,,,,,,205.37,521.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7921022,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,865.20,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7921022,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,772.80,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7850190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7850190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7850191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7850191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7878296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7878296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7920115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.38000,1728.80000,Aetna,Local,,2384.55,,,,,,,2149.08,4876.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7920115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.38000,1728.80000,Aetna,Local,,2384.55,,,,,,,1919.56,4876.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,795.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,710.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7858547,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7858547,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7893957,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7893957,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7929706,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7929706,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7957916,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7957916,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7882344,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7882344,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7882346,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7882346,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858551,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,19825.00000,5749.25000,Aetna,Local,,7930.00,,,,,,,7146.91,16216.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7858551,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,19825.00000,5749.25000,Aetna,Local,,7930.00,,,,,,,6383.65,16216.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4866.75000,1411.36000,Aetna,Local,,1946.70,,,,,,,1754.46,3981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4866.75000,1411.36000,Aetna,Local,,1946.70,,,,,,,1567.09,3981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4866.75000,1411.36000,Aetna,Local,,1946.70,,,,,,,1754.46,3981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4866.75000,1411.36000,Aetna,Local,,1946.70,,,,,,,1567.09,3981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4866.75000,1411.36000,Aetna,Local,,1946.70,,,,,,,1754.46,3981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4866.75000,1411.36000,Aetna,Local,,1946.70,,,,,,,1567.09,3981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921013,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921013,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695048,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695048,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7920487,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7920487,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3753.65000,1088.56000,Aetna,Local,,1501.46,,,,,,,1353.19,3070.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3753.65000,1088.56000,Aetna,Local,,1501.46,,,,,,,1208.68,3070.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7880433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,109.87,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7880433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,98.13,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7910648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,109.87,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7910648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,98.13,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7942053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,109.87,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7942053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,98.13,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7935738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,1117.55,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7935738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,998.20,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7940362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7940362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7870085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7870085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7882871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7882871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7882872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7882872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7872040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6571.85000,1905.84000,Aetna,Local,,2628.74,,,,,,,2369.15,5375.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7872040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6571.85000,1905.84000,Aetna,Local,,2628.74,,,,,,,2116.14,5375.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7878571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,3352.65,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7878571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,2994.60,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878570,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878570,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7874122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7874122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7896370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7896370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7896372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7896372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7910691,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7910691,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7912531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7912531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7926453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7926453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7933689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7933689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7896384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7896384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7910690,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7910690,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7911746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7911746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912873,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912873,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7913646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7913646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7922623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7922623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7926454,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7926454,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896383,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896383,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7933690,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7933690,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7896755,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,6524.15,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7896755,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,5827.40,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7911744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,6524.15,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7911744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,5827.40,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,6524.15,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,5827.40,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19767.50000,5732.58000,Aetna,Local,,7907.00,,,,,,,7126.18,16169.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19767.50000,5732.58000,Aetna,Local,,7907.00,,,,,,,6365.14,16169.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7913654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19767.50000,5732.58000,Aetna,Local,,7907.00,,,,,,,7126.18,16169.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7913654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19767.50000,5732.58000,Aetna,Local,,7907.00,,,,,,,6365.14,16169.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7924504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,6524.15,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7924504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,5827.40,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,6524.15,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,5827.40,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1948.00000,564.92000,Aetna,Local,,779.20,,,,,,,702.25,1593.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1948.00000,564.92000,Aetna,Local,,779.20,,,,,,,627.26,1593.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,582.57,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,520.35,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874267,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874267,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874268,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874268,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874269,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874269,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874270,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874270,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874271,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7874271,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7902279,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7902279,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7902283,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7902283,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7902286,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7902286,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7902289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE SYSTEM S,7902289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7895651,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7895651,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7920544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7920544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7874330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12678.00000,3676.62000,Aetna,Local,,5071.20,,,,,,,4570.42,10370.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7874330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12678.00000,3676.62000,Aetna,Local,,5071.20,,,,,,,4082.32,10370.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7903042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12678.00000,3676.62000,Aetna,Local,,5071.20,,,,,,,4570.42,10370.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7903042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12678.00000,3676.62000,Aetna,Local,,5071.20,,,,,,,4082.32,10370.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7922504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7922504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7909471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7909471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7912140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7913429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7913429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7913911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7913911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7916712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7916712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7917663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7917663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7919169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7919169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920348,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920348,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7922452,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7922452,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7925272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7925272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7944016,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7944016,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7944305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7944305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7947961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7947961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7954794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7954794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7894010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7894010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3850.00000,1116.50000,Aetna,Local,,1540.00,,,,,,,1387.92,3149.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3850.00000,1116.50000,Aetna,Local,,1540.00,,,,,,,1239.70,3149.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882693,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882693,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905715,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905715,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7942051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7942051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7942052,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7942052,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957788,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957788,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7878539,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,4078.34,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7878539,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,3642.79,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7936397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1392.66,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7936397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1243.93,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7882736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7882736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7893340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7893340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7948125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7948125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7948171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7948171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7882744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7908230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7908230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7930208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7930208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939378,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939378,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7954358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7954358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7930207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7930207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7882261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,174.66,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7882261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,156.01,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7937957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7937957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7937958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7937958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7893769,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7893769,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7901684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7901684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7903564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7903564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7918192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7918192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7882689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7882689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT SPACER,7896752,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT SPACER,7896752,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7896753,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7896753,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7902684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7902684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7902685,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7902685,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7947955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7947955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7921295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,2191.66,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7921295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,Local,,2431.80,,,,,,,1957.60,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7943973,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,45787.50000,13278.37000,Aetna,Local,,18315.00,,,,,,,16506.39,37454.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7943973,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,45787.50000,13278.37000,Aetna,Local,,18315.00,,,,,,,14743.58,37454.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882790,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882790,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882793,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882793,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882794,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882794,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7926920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7926920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7953867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7953867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7956691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7956691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7957695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7957695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7959960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7959960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7960044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7960044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7963862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7963862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,Local,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7905301,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7905301,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7927019,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7927019,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3486.76,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3114.38,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3486.76,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3114.38,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7954650,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2562.68000,743.18000,Aetna,Local,,1025.07,,,,,,,923.85,2096.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7954650,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2562.68000,743.18000,Aetna,Local,,1025.07,,,,,,,825.18,2096.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700487,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700487,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700488,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700488,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700489,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700489,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700490,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700490,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700491,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700491,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700492,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700492,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700493,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700493,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700494,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700494,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700495,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700495,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700496,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700496,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700497,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700497,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700498,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700498,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700502,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700502,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700503,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700503,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7700319,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26556.38000,7701.35000,Aetna,Local,,10622.55,,,,,,,9573.57,21723.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7700319,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26556.38000,7701.35000,Aetna,Local,,10622.55,,,,,,,8551.15,21723.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7736122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26556.38000,7701.35000,Aetna,Local,,10622.55,,,,,,,9573.57,21723.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7736122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26556.38000,7701.35000,Aetna,Local,,10622.55,,,,,,,8551.15,21723.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7698612,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5219.17000,1513.56000,Aetna,Local,,2087.67,,,,,,,1881.51,4269.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7698612,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5219.17000,1513.56000,Aetna,Local,,2087.67,,,,,,,1680.57,4269.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7954651,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5529.37000,1603.52000,Aetna,Local,,2211.75,,,,,,,1993.34,4523.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7954651,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5529.37000,1603.52000,Aetna,Local,,2211.75,,,,,,,1780.46,4523.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,9270.49,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,8280.44,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,9270.49,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,8280.44,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893763,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,9270.49,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893763,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,8280.44,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7919058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,9270.49,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7919058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,8280.44,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7919078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,9270.49,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7919078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,8280.44,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7943811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,9270.49,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7943811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25715.65000,7457.54000,Aetna,Local,,10286.26,,,,,,,8280.44,21035.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2810.33,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2510.20,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2810.33,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2510.20,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2810.33,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2510.20,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700837,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700837,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2810.33,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2510.20,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7838120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7838120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7872046,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7872046,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882254,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2810.33,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882254,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2510.20,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882694,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882694,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2810.33,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2510.20,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7700106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7700106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7700172,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7700172,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7700415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7700415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7736191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7736191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTOR,7696822,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTOR,7696822,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7696953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7696953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7696956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7696956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7698716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7698716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700441,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700441,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17514.75000,5079.28000,Aetna,Local,,7005.90,,,,,,,6314.07,14327.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17514.75000,5079.28000,Aetna,Local,,7005.90,,,,,,,5639.75,14327.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7699481,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7699481,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7700127,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7700127,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7702216,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7702216,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7702217,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7702217,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7702628,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7702628,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7702629,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7702629,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7707538,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7707538,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736152,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736152,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736162,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736162,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736225,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736225,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736226,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736226,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736227,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736227,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736228,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736228,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736229,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736229,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736230,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736230,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736231,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736231,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736368,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736368,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736369,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736369,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736371,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736371,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736372,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736372,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736373,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736373,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736374,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736374,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736375,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736375,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736376,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736376,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736377,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736377,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736379,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736379,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736380,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736380,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736381,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736381,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736384,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736384,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736385,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736385,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736386,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736386,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736387,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736387,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736388,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736388,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894171,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894171,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894172,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894172,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894173,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894173,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894174,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894174,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894268,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894268,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894269,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894269,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894270,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7894270,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7895929,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7895929,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7895930,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7895930,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7904262,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7904262,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7904263,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7904263,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7905515,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7905515,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7905516,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7905516,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7908333,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7908333,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7908334,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7908334,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7908335,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7908335,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7908336,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7908336,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909273,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909273,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909274,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909274,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909275,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909275,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7918818,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7918818,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7918819,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7918819,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927141,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927141,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927142,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927142,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927143,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927143,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927144,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927144,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927145,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927145,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,764.47,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935860,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935860,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935983,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935983,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935984,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935984,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935985,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935985,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938152,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938152,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938153,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938153,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938154,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938154,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938155,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938155,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938156,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938156,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938157,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938157,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938334,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938334,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938335,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938335,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938336,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938336,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938651,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938651,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938652,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938652,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938653,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938653,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938654,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938654,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938655,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7938655,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941867,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941867,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941868,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941868,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941869,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941869,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941870,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941870,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941871,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941871,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941872,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941872,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941873,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941873,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941874,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941874,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965087,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965087,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699872,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5509.00000,1597.61000,Aetna,Local,,2203.60,,,,,,,1985.99,4506.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699872,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5509.00000,1597.61000,Aetna,Local,,2203.60,,,,,,,1773.90,4506.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7700002,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5509.00000,1597.61000,Aetna,Local,,2203.60,,,,,,,1985.99,4506.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7700002,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5509.00000,1597.61000,Aetna,Local,,2203.60,,,,,,,1773.90,4506.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7910254,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1819.44,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7910254,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1625.13,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7910255,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1819.44,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7910255,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1625.13,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7910256,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1819.44,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7910256,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1625.13,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7910289,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1819.44,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7910289,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1625.13,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7921034,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1819.44,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7921034,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,Local,,2018.80,,,,,,,1625.13,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2900.00000,841.00000,Aetna,Local,,1160.00,,,,,,,1045.45,2372.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2900.00000,841.00000,Aetna,Local,,1160.00,,,,,,,933.80,2372.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2900.00000,841.00000,Aetna,Local,,1160.00,,,,,,,1045.45,2372.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2900.00000,841.00000,Aetna,Local,,1160.00,,,,,,,933.80,2372.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2900.00000,841.00000,Aetna,Local,,1160.00,,,,,,,1045.45,2372.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2900.00000,841.00000,Aetna,Local,,1160.00,,,,,,,933.80,2372.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882388,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2900.00000,841.00000,Aetna,Local,,1160.00,,,,,,,1045.45,2372.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882388,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2900.00000,841.00000,Aetna,Local,,1160.00,,,,,,,933.80,2372.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7736106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4930.45000,1429.83000,Aetna,Local,,1972.18,,,,,,,1777.43,4033.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7736106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4930.45000,1429.83000,Aetna,Local,,1972.18,,,,,,,1587.60,4033.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7736441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7736441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7800034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7800034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7802089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7802089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7828054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7828054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7828056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7828056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7878194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7878194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7878321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7878321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7902295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7902295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7905492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7905492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7910167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7910167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7925242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7925242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25305.00000,7338.45000,Aetna,Local,,10122.00,,,,,,,9122.45,20699.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25305.00000,7338.45000,Aetna,Local,,10122.00,,,,,,,8148.21,20699.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920814,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25305.00000,7338.45000,Aetna,Local,,10122.00,,,,,,,9122.45,20699.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7920814,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25305.00000,7338.45000,Aetna,Local,,10122.00,,,,,,,8148.21,20699.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25305.00000,7338.45000,Aetna,Local,,10122.00,,,,,,,9122.45,20699.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25305.00000,7338.45000,Aetna,Local,,10122.00,,,,,,,8148.21,20699.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7756047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7756047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1762.40000,511.10000,Aetna,Local,,704.96,,,,,,,635.35,1441.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1762.40000,511.10000,Aetna,Local,,704.96,,,,,,,567.49,1441.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7699914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2143.88000,621.73000,Aetna,Local,,857.55,,,,,,,772.87,1753.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7699914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2143.88000,621.73000,Aetna,Local,,857.55,,,,,,,690.33,1753.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,124.63,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,111.32,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,124.63,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,111.32,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,124.63,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,111.32,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,124.63,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,111.32,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,124.63,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,111.32,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,124.63,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,111.32,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,124.63,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,111.32,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,124.63,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,111.32,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,124.63,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,111.32,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,124.63,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.71000,100.26000,Aetna,Local,,138.28,,,,,,,111.32,282.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,126.20,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,112.73,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,126.20,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,112.73,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,126.20,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,112.73,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,126.20,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,112.73,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,126.20,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,112.73,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,126.20,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,350.08000,101.52000,Aetna,Local,,140.03,,,,,,,112.73,286.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,351.17000,101.84000,Aetna,Local,,140.47,,,,,,,126.60,287.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,351.17000,101.84000,Aetna,Local,,140.47,,,,,,,113.08,287.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,353.64000,102.56000,Aetna,Local,,141.46,,,,,,,127.49,289.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,353.64000,102.56000,Aetna,Local,,141.46,,,,,,,113.87,289.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,353.64000,102.56000,Aetna,Local,,141.46,,,,,,,127.49,289.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,353.64000,102.56000,Aetna,Local,,141.46,,,,,,,113.87,289.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7784198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7784198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7914406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7914406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7701606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7701606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7701607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7701607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7742040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7742040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7788041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7788041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7824029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7824029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUPLER,7698619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3764.25000,1091.63000,Aetna,Local,,1505.70,,,,,,,1357.01,3079.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUPLER,7698619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3764.25000,1091.63000,Aetna,Local,,1505.70,,,,,,,1212.09,3079.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUPLER,7698620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3764.25000,1091.63000,Aetna,Local,,1505.70,,,,,,,1357.01,3079.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUPLER,7698620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3764.25000,1091.63000,Aetna,Local,,1505.70,,,,,,,1212.09,3079.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7736532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7736532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7736533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7736533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7740554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7740554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7740556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7740556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7740783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7740783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7768030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7768030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7778032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7778032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7778033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7778033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7788038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7788038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7788039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7788039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7816137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7816137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7854029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7854029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7904986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7904986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7825.50000,2269.40000,Aetna,Local,,3130.20,,,,,,,2821.09,6401.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7825.50000,2269.40000,Aetna,Local,,3130.20,,,,,,,2519.81,6401.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7697613,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7697613,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7697614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7697614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7698403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7698403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7882502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7882502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7696562,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,4078.34,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7696562,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,3642.79,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7696563,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,4078.34,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7696563,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,3642.79,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697151,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,4078.34,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697151,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,3642.79,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7700809,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,4078.34,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7700809,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,3642.79,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1554.48,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1388.46,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1554.48,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1388.46,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1554.48,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1388.46,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1554.48,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1388.46,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1554.48,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1388.46,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1554.48,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1388.46,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD 20,7700112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD 20,7700112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD 20,7700534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD 20,7700534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD 20,7740762,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD 20,7740762,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COLLAR,7700154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9409.02000,2728.62000,Aetna,Local,,3763.61,,,,,,,3391.95,7696.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COLLAR,7700154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9409.02000,2728.62000,Aetna,Local,,3763.61,,,,,,,3029.70,7696.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COLLAR,7736516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9409.02000,2728.62000,Aetna,Local,,3763.61,,,,,,,3391.95,7696.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COLLAR,7736516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9409.02000,2728.62000,Aetna,Local,,3763.61,,,,,,,3029.70,7696.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7699923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7699923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7702587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7702587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7740748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7740748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7918352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7918352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7697661,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7697661,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7697927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7697927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699963,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699963,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7707544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7707544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908627,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908627,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7908628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698225,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698225,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8137.20000,2359.79000,Aetna,Local,,3254.88,,,,,,,2933.46,6656.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8137.20000,2359.79000,Aetna,Local,,3254.88,,,,,,,2620.18,6656.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698993,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698993,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699093,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699093,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8137.20000,2359.79000,Aetna,Local,,3254.88,,,,,,,2933.46,6656.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8137.20000,2359.79000,Aetna,Local,,3254.88,,,,,,,2620.18,6656.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7816194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7816194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7832096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7832096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908486,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908486,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908495,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908495,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4515.97,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4033.68,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7858546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4515.97,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7858546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4033.68,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7865354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4515.97,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7865354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4033.68,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19850.33000,5756.60000,Aetna,Local,,7940.13,,,,,,,7156.04,16237.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19850.33000,5756.60000,Aetna,Local,,7940.13,,,,,,,6391.81,16237.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7698028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12922.20000,3747.44000,Aetna,Local,,5168.88,,,,,,,4658.45,10570.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7698028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12922.20000,3747.44000,Aetna,Local,,5168.88,,,,,,,4160.95,10570.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698465,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698465,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698644,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698644,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700016,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700016,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7788040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7788040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7790163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7790163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878302,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878302,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904694,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904694,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7701032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7701032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7702662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7702662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7782095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7782095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7818074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7818074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7937668,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7937668,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694997,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,293.63,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694997,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,262.27,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695036,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,442.69,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695036,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,395.42,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695090,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,705.00000,204.45000,Aetna,Local,,282.00,,,,,,,254.15,576.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695090,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,705.00000,204.45000,Aetna,Local,,282.00,,,,,,,227.01,576.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695096,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,293.63,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695096,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,262.27,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695098,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,796.01000,230.84000,Aetna,Local,,318.40,,,,,,,286.96,651.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695098,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,796.01000,230.84000,Aetna,Local,,318.40,,,,,,,256.32,651.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695136,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,796.01000,230.84000,Aetna,Local,,318.40,,,,,,,286.96,651.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695136,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,796.01000,230.84000,Aetna,Local,,318.40,,,,,,,256.32,651.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7878466,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,442.69,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7878466,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,395.42,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702891,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,796.01000,230.84000,Aetna,Local,,318.40,,,,,,,286.96,651.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702891,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,796.01000,230.84000,Aetna,Local,,318.40,,,,,,,256.32,651.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7702205,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5176.50000,1501.18000,Aetna,Local,,2070.60,,,,,,,1866.13,4234.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7702205,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5176.50000,1501.18000,Aetna,Local,,2070.60,,,,,,,1666.83,4234.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7957754,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1254.66,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7957754,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1120.67,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7957755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1254.66,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7957755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1120.67,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7957911,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1254.66,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7957911,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1120.67,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2628.04000,762.13000,Aetna,Local,,1051.22,,,,,,,947.41,2149.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2628.04000,762.13000,Aetna,Local,,1051.22,,,,,,,846.23,2149.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7701049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7701049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7701050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7701050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7702258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7702258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7741713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7741713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7806037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7806037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7850195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7850195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7858122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7858122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7918852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7918852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.00000,428.04000,Aetna,Local,,590.40,,,,,,,532.10,1207.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.00000,428.04000,Aetna,Local,,590.40,,,,,,,475.27,1207.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2584.00000,749.36000,Aetna,Local,,1033.60,,,,,,,931.53,2113.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2584.00000,749.36000,Aetna,Local,,1033.60,,,,,,,832.05,2113.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,472.69,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,422.21,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,472.69,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,422.21,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1654.40000,479.78000,Aetna,Local,,661.76,,,,,,,596.41,1353.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1654.40000,479.78000,Aetna,Local,,661.76,,,,,,,532.72,1353.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1654.40000,479.78000,Aetna,Local,,661.76,,,,,,,596.41,1353.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1654.40000,479.78000,Aetna,Local,,661.76,,,,,,,532.72,1353.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,472.69,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,422.21,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,472.69,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,422.21,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,472.69,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,422.21,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,472.69,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,Local,,524.48,,,,,,,422.21,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1692.00000,490.68000,Aetna,Local,,676.80,,,,,,,609.97,1384.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1692.00000,490.68000,Aetna,Local,,676.80,,,,,,,544.82,1384.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7625.13000,2211.29000,Aetna,Local,,3050.05,,,,,,,2748.86,6237.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7625.13000,2211.29000,Aetna,Local,,3050.05,,,,,,,2455.29,6237.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,661.01000,191.69000,Aetna,Local,,264.40,,,,,,,238.29,540.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,661.01000,191.69000,Aetna,Local,,264.40,,,,,,,212.85,540.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,717.08000,207.95000,Aetna,Local,,286.83,,,,,,,258.51,586.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,717.08000,207.95000,Aetna,Local,,286.83,,,,,,,230.90,586.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,727.97000,211.11000,Aetna,Local,,291.19,,,,,,,262.43,595.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,727.97000,211.11000,Aetna,Local,,291.19,,,,,,,234.41,595.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,649.67000,188.40000,Aetna,Local,,259.87,,,,,,,234.21,531.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,649.67000,188.40000,Aetna,Local,,259.87,,,,,,,209.19,531.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,783.00000,227.07000,Aetna,Local,,313.20,,,,,,,282.27,640.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,783.00000,227.07000,Aetna,Local,,313.20,,,,,,,252.13,640.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7822187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7836141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7836141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7922818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7922818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7702589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7702589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7740749,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7740749,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7822263,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7822263,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7882222,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7882222,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7902587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7902587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7904800,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7904800,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7904982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7904982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7908234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7908234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7917872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7917872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7927537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7927537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7701639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5109.30000,1481.70000,Aetna,Local,,2043.72,,,,,,,1841.90,4179.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7701639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5109.30000,1481.70000,Aetna,Local,,2043.72,,,,,,,1645.19,4179.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7893727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5109.30000,1481.70000,Aetna,Local,,2043.72,,,,,,,1841.90,4179.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7893727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5109.30000,1481.70000,Aetna,Local,,2043.72,,,,,,,1645.19,4179.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7701640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1906.06,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7701640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1702.50,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7836142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1906.06,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7836142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1702.50,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7910235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1906.06,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7910235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1702.50,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7911302,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1906.06,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7911302,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1702.50,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7922502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1906.06,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7922502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1702.50,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7924902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1906.06,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7924902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1702.50,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700870,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15217.50000,4413.08000,Aetna,Local,,6087.00,,,,,,,5485.91,12447.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700870,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15217.50000,4413.08000,Aetna,Local,,6087.00,,,,,,,4900.03,12447.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7741337,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15217.50000,4413.08000,Aetna,Local,,6087.00,,,,,,,5485.91,12447.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7741337,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15217.50000,4413.08000,Aetna,Local,,6087.00,,,,,,,4900.03,12447.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7920566,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15217.50000,4413.08000,Aetna,Local,,6087.00,,,,,,,5485.91,12447.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7920566,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15217.50000,4413.08000,Aetna,Local,,6087.00,,,,,,,4900.03,12447.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7914011,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7914011,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7702928,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7702928,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7922476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,475.25,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7922476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,424.50,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7882347,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7882347,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7882523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7882523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7834039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7834039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7838121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7846157,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7846157,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7866086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7866086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7876341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935725,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935725,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ADAPTER TRAY,7880649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2365.78,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ADAPTER TRAY,7880649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2113.12,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7740761,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7740761,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7762381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7762381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7826097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7826097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7901852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7901852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943374,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943374,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7962116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7962116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7914036,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7914036,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695952,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695952,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696244,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696244,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696279,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696279,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7697117,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7697117,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7697158,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7697158,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7697236,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7697236,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7702168,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3392.17000,983.73000,Aetna,Local,,1356.87,,,,,,,1222.88,2774.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7702168,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3392.17000,983.73000,Aetna,Local,,1356.87,,,,,,,1092.28,2774.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7736035,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3392.17000,983.73000,Aetna,Local,,1356.87,,,,,,,1222.88,2774.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7736035,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3392.17000,983.73000,Aetna,Local,,1356.87,,,,,,,1092.28,2774.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7874183,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7874183,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7910539,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7910539,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7938030,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7938030,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700425,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700425,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7750107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7750107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7822257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7822257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882585,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882585,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,441.75000,128.11000,Aetna,Local,,176.70,,,,,,,159.25,361.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,441.75000,128.11000,Aetna,Local,,176.70,,,,,,,142.24,361.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1246.96000,361.62000,Aetna,Local,,498.78,,,,,,,449.53,1020.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1246.96000,361.62000,Aetna,Local,,498.78,,,,,,,401.52,1020.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1630.40000,472.82000,Aetna,Local,,652.16,,,,,,,587.76,1333.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1630.40000,472.82000,Aetna,Local,,652.16,,,,,,,524.99,1333.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7874342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7874342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HEAD,7702663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1855.02,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HEAD,7702663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1656.92,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2389.25,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2134.09,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2389.25,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2134.09,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2389.25,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2134.09,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701613,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2389.25,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701613,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2134.09,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1337.71,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1194.85,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1337.71,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1194.85,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3798.90000,1101.68000,Aetna,Local,,1519.56,,,,,,,1369.50,3107.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3798.90000,1101.68000,Aetna,Local,,1519.56,,,,,,,1223.25,3107.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7701599,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3798.90000,1101.68000,Aetna,Local,,1519.56,,,,,,,1369.50,3107.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7701599,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3798.90000,1101.68000,Aetna,Local,,1519.56,,,,,,,1223.25,3107.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7701611,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3798.90000,1101.68000,Aetna,Local,,1519.56,,,,,,,1369.50,3107.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7701611,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3798.90000,1101.68000,Aetna,Local,,1519.56,,,,,,,1223.25,3107.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7701612,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1337.71,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7701612,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1194.85,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7701619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1337.71,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7701619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1194.85,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7736355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7736355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7736483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1337.71,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7736483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1194.85,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7736675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7736675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7736679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7736679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7741332,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7741332,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7741333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7741333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7754283,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7754283,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7756049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7756049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7818166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7818166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7893765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7893765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7903722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7903722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7699850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,4451.45,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7699850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,3976.06,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,4451.45,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,3976.06,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,4451.45,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,3976.06,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700838,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,4451.45,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700838,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,3976.06,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16277.50000,4720.47000,Aetna,Local,,6511.00,,,,,,,5868.04,13315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16277.50000,4720.47000,Aetna,Local,,6511.00,,,,,,,5241.35,13315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7897358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15688.63000,4549.70000,Aetna,Local,,6275.45,,,,,,,5655.75,12833.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7897358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15688.63000,4549.70000,Aetna,Local,,6275.45,,,,,,,5051.74,12833.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7948368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,4451.45,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7948368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,3976.06,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7956675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,4451.45,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7956675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,3976.06,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7962615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,4451.45,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7962615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,3976.06,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7822261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7822261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7880529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7880529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7700196,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7700196,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2406.80000,697.97000,Aetna,Local,,962.72,,,,,,,867.65,1968.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2406.80000,697.97000,Aetna,Local,,962.72,,,,,,,774.99,1968.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7786158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1776.60000,515.21000,Aetna,Local,,710.64,,,,,,,640.46,1453.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7786158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1776.60000,515.21000,Aetna,Local,,710.64,,,,,,,572.07,1453.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5669.30000,1644.10000,Aetna,Local,,2267.72,,,,,,,2043.78,4637.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5669.30000,1644.10000,Aetna,Local,,2267.72,,,,,,,1825.51,4637.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PLUG,7700252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PLUG,7700252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7702134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7702134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7794451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7794451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7812181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7812181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7882610,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7882610,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7902537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7902537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7926933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7926933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7936196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7936196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7701603,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7701603,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7812121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7812121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7830040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7830040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7846156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7846156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878552,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7878552,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882728,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882728,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964526,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964526,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7754291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7754291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7754293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7754293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7937745,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7937745,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701685,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701685,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7740555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7740555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7742042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7742042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7768029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7768029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7816139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7816139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7866102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7866102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7903719,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7903719,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7911006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7925925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7925925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7933646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7933646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7959512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7959512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7736549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1491.35,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7736549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1332.08,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7816138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1491.35,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7816138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1332.08,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7854030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1491.35,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7854030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1332.08,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7844037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1380.00000,400.20000,Aetna,Local,,552.00,,,,,,,497.49,1128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7844037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,552.00,,,,,,,444.36,1128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.80000,525.71000,Aetna,Local,,725.12,,,,,,,653.51,1482.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.80000,525.71000,Aetna,Local,,725.12,,,,,,,583.72,1482.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,906.62000,262.92000,Aetna,Local,,362.65,,,,,,,326.84,741.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,906.62000,262.92000,Aetna,Local,,362.65,,,,,,,291.93,741.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7784183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1439.60000,417.48000,Aetna,Local,,575.84,,,,,,,518.98,1177.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7784183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1439.60000,417.48000,Aetna,Local,,575.84,,,,,,,463.55,1177.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.50000,184.00000,Aetna,Local,,253.80,,,,,,,228.74,519.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.50000,184.00000,Aetna,Local,,253.80,,,,,,,204.31,519.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1298.00000,376.42000,Aetna,Local,,519.20,,,,,,,467.93,1061.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1298.00000,376.42000,Aetna,Local,,519.20,,,,,,,417.96,1061.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,477.45,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,426.46,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1298.00000,376.42000,Aetna,Local,,519.20,,,,,,,467.93,1061.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1298.00000,376.42000,Aetna,Local,,519.20,,,,,,,417.96,1061.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,477.45,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,426.46,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,477.45,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,426.46,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,477.45,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,426.46,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,477.45,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,426.46,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,477.45,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,426.46,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,477.45,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1324.40000,384.08000,Aetna,Local,,529.76,,,,,,,426.46,1083.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,Local,,535.04,,,,,,,482.20,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,Local,,535.04,,,,,,,430.71,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,Local,,535.04,,,,,,,482.20,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,Local,,535.04,,,,,,,430.71,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,Local,,535.04,,,,,,,482.20,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,Local,,535.04,,,,,,,430.71,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,Local,,535.04,,,,,,,482.20,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,Local,,535.04,,,,,,,430.71,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2781.96000,806.77000,Aetna,Local,,1112.78,,,,,,,1002.90,2275.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2781.96000,806.77000,Aetna,Local,,1112.78,,,,,,,895.79,2275.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7897103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2781.96000,806.77000,Aetna,Local,,1112.78,,,,,,,1002.90,2275.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7897103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2781.96000,806.77000,Aetna,Local,,1112.78,,,,,,,895.79,2275.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7840033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7840033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7838126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7838126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7976.13000,2313.08000,Aetna,Local,,3190.45,,,,,,,2875.39,6524.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7976.13000,2313.08000,Aetna,Local,,3190.45,,,,,,,2568.31,6524.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7790501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7790501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7828137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7838114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880438,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16243.88000,4710.73000,Aetna,Local,,6497.55,,,,,,,5855.92,13287.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7880438,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16243.88000,4710.73000,Aetna,Local,,6497.55,,,,,,,5230.53,13287.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882518,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7882518,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7902616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7902616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748759,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748759,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7790500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7790500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7810065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7810065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7828058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7828058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7828061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7828061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7701560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7788032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7788032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880201,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880201,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882517,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882517,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7902617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7940853,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7940853,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7806234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7806234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7828138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7828138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7840031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7840031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7880555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7880555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7882729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7882729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3324.30000,964.05000,Aetna,Local,,1329.72,,,,,,,1198.41,2719.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3324.30000,964.05000,Aetna,Local,,1329.72,,,,,,,1070.42,2719.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2488.40000,721.64000,Aetna,Local,,995.36,,,,,,,897.07,2035.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2488.40000,721.64000,Aetna,Local,,995.36,,,,,,,801.26,2035.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7806346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,870.20,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7806346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,777.27,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7874187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2475.20000,717.81000,Aetna,Local,,990.08,,,,,,,892.31,2024.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7874187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2475.20000,717.81000,Aetna,Local,,990.08,,,,,,,797.01,2024.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7896386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2488.40000,721.64000,Aetna,Local,,995.36,,,,,,,897.07,2035.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7896386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2488.40000,721.64000,Aetna,Local,,995.36,,,,,,,801.26,2035.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748831,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748831,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7748896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7766058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7766058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7766062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7766062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7794049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7794049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7800038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7800038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7802090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7806369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7806369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7808035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7808035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7810031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7810031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7812119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7812119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7878320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7878320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7878324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7878324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7880672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7900094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7900094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736220,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2691.85,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736220,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2404.37,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2691.85,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7748199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2404.37,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7750086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2691.85,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7750086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2404.37,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7754103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2691.85,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7754103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2404.37,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2691.85,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7766056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2404.37,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794294,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2691.85,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7794294,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2404.37,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2691.85,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2404.37,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7814062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2691.85,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7814062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2404.37,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7834074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2691.85,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7834074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2404.37,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7750088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7750088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7786157,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7786157,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7790170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7790170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7836185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7836185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7901764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7901764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,708.30000,205.41000,Aetna,Local,,283.32,,,,,,,255.34,579.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,708.30000,205.41000,Aetna,Local,,283.32,,,,,,,228.07,579.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7927063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,179.80,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7927063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,160.60,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7750118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7750118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7760130,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7760130,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7804046,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7804046,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7804048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7804048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7810067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7810067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7834112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7834112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7836190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7836190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7874295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7874295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7880647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882803,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882803,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.60000,2523.17000,Aetna,Local,,3480.24,,,,,,,3136.57,7117.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.60000,2523.17000,Aetna,Local,,3480.24,,,,,,,2801.59,7117.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939864,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939864,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701814,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,739.17,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701814,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,660.23,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,739.17,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,660.23,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,739.17,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,660.23,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,701.10,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,626.23,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,277.40,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,247.78,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,940.23000,272.67000,Aetna,Local,,376.09,,,,,,,338.95,769.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,940.23000,272.67000,Aetna,Local,,376.09,,,,,,,302.75,769.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7696414,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7696414,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7696416,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7696416,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7699808,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,1749.40000,507.33000,Aetna,Local,,699.76,,,,,,,630.66,1431.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7699808,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,1749.40000,507.33000,Aetna,Local,,699.76,,,,,,,563.31,1431.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2810.33,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7795.65000,2260.74000,Aetna,Local,,3118.26,,,,,,,2510.20,6376.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2984.00000,865.36000,Aetna,Local,,1193.60,,,,,,,1075.73,2440.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2984.00000,865.36000,Aetna,Local,,1193.60,,,,,,,960.85,2440.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7696726,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7696726,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14143.50000,4101.62000,Aetna,Local,,5657.40,,,,,,,5098.73,11569.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14143.50000,4101.62000,Aetna,Local,,5657.40,,,,,,,4554.21,11569.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699857,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,661.50000,191.83000,Aetna,Local,,264.60,,,,,,,238.47,541.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699857,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,661.50000,191.83000,Aetna,Local,,264.60,,,,,,,213.00,541.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17514.75000,5079.28000,Aetna,Local,,7005.90,,,,,,,6314.07,14327.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17514.75000,5079.28000,Aetna,Local,,7005.90,,,,,,,5639.75,14327.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEGMENT,7699865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10274.40000,2979.58000,Aetna,Local,,4109.76,,,,,,,3703.92,8404.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEGMENT,7699865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10274.40000,2979.58000,Aetna,Local,,4109.76,,,,,,,3308.36,8404.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7699357,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7699357,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699871,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5509.00000,1597.61000,Aetna,Local,,2203.60,,,,,,,1985.99,4506.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699871,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5509.00000,1597.61000,Aetna,Local,,2203.60,,,,,,,1773.90,4506.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7699901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7699901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25177.25000,7301.40000,Aetna,Local,,10070.90,,,,,,,9076.40,20594.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25177.25000,7301.40000,Aetna,Local,,10070.90,,,,,,,8107.07,20594.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1914.00000,555.06000,Aetna,Local,,765.60,,,,,,,690.00,1565.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1914.00000,555.06000,Aetna,Local,,765.60,,,,,,,616.31,1565.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COLLAR,7699910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7982.22000,2314.84000,Aetna,Local,,3192.89,,,,,,,2877.59,6529.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COLLAR,7699910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7982.22000,2314.84000,Aetna,Local,,3192.89,,,,,,,2570.27,6529.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699900,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,850.50000,246.64000,Aetna,Local,,340.20,,,,,,,306.61,695.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699900,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,850.50000,246.64000,Aetna,Local,,340.20,,,,,,,273.86,695.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7696285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2143.88000,621.73000,Aetna,Local,,857.55,,,,,,,772.87,1753.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7696285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2143.88000,621.73000,Aetna,Local,,857.55,,,,,,,690.33,1753.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698024,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,4392.57,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698024,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12184.65000,3533.55000,Aetna,Local,,4873.86,,,,,,,3923.46,9967.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUPLER,7698051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3764.25000,1091.63000,Aetna,Local,,1505.70,,,,,,,1357.01,3079.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUPLER,7698051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3764.25000,1091.63000,Aetna,Local,,1505.70,,,,,,,1212.09,3079.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698052,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698052,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7695604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7695604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7695293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7695293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7696532,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,4078.34,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7696532,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11313.00000,3280.77000,Aetna,Local,,4525.20,,,,,,,3642.79,9254.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1554.48,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4312.00000,1250.48000,Aetna,Local,,1724.80,,,,,,,1388.46,3527.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD 20,7699941,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD 20,7699941,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COLLAR,7699939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9409.02000,2728.62000,Aetna,Local,,3763.61,,,,,,,3391.95,7696.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COLLAR,7699939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9409.02000,2728.62000,Aetna,Local,,3763.61,,,,,,,3029.70,7696.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7697030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,864.00000,250.56000,Aetna,Local,,345.60,,,,,,,311.47,706.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7697030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,864.00000,250.56000,Aetna,Local,,345.60,,,,,,,278.21,706.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7699289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7699289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7697457,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6916.19,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7697457,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19185.00000,5563.65000,Aetna,Local,,7674.00,,,,,,,6177.57,15693.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7697924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2890.63,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7697924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8018.40000,2325.34000,Aetna,Local,,3207.36,,,,,,,2581.92,6559.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4515.97,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4033.68,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19850.33000,5756.60000,Aetna,Local,,7940.13,,,,,,,7156.04,16237.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19850.33000,5756.60000,Aetna,Local,,7940.13,,,,,,,6391.81,16237.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7699940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5198.20000,1507.48000,Aetna,Local,,2079.28,,,,,,,1873.95,4252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7699940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5198.20000,1507.48000,Aetna,Local,,2079.28,,,,,,,1673.82,4252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERAMIC HEAD,7699955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERAMIC HEAD,7699955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7697894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12922.20000,3747.44000,Aetna,Local,,5168.88,,,,,,,4658.45,10570.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7697894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12922.20000,3747.44000,Aetna,Local,,5168.88,,,,,,,4160.95,10570.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7697880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7697880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7699973,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7699973,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ASSEMBLY KIT,7699975,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,2560.00000,742.40000,Aetna,Local,,1024.00,,,,,,,922.88,2094.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ASSEMBLY KIT,7699975,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,2560.00000,742.40000,Aetna,Local,,1024.00,,,,,,,824.32,2094.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694358,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,293.63,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694358,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,262.27,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7700001,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1902.00000,551.58000,Aetna,Local,,760.80,,,,,,,685.67,1555.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7700001,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1902.00000,551.58000,Aetna,Local,,760.80,,,,,,,612.44,1555.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7700003,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,2114.00000,613.06000,Aetna,Local,,845.60,,,,,,,762.10,1729.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7700003,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,2114.00000,613.06000,Aetna,Local,,845.60,,,,,,,680.71,1729.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7700004,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,2366.00000,686.14000,Aetna,Local,,946.40,,,,,,,852.94,1935.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7700004,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,2366.00000,686.14000,Aetna,Local,,946.40,,,,,,,761.85,1935.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOSPHERE,7699998,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,485.06,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOSPHERE,7699998,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,433.26,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7699980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1511.00000,438.19000,Aetna,Local,,604.40,,,,,,,544.72,1236.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7699980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1511.00000,438.19000,Aetna,Local,,604.40,,,,,,,486.54,1236.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2631.12000,763.02000,Aetna,Local,,1052.45,,,,,,,948.52,2152.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2631.12000,763.02000,Aetna,Local,,1052.45,,,,,,,847.22,2152.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,448.35000,130.02000,Aetna,Local,,179.34,,,,,,,161.63,366.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,448.35000,130.02000,Aetna,Local,,179.34,,,,,,,144.37,366.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7625.13000,2211.29000,Aetna,Local,,3050.05,,,,,,,2748.86,6237.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7625.13000,2211.29000,Aetna,Local,,3050.05,,,,,,,2455.29,6237.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7700063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2365.78,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7700063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2113.12,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5109.30000,1481.70000,Aetna,Local,,2043.72,,,,,,,1841.90,4179.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5109.30000,1481.70000,Aetna,Local,,2043.72,,,,,,,1645.19,4179.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7700060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1906.06,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7700060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,Local,,2114.91,,,,,,,1702.50,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7700073,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7700073,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700085,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14583.00000,4229.07000,Aetna,Local,,5833.20,,,,,,,5257.17,11928.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700085,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14583.00000,4229.07000,Aetna,Local,,5833.20,,,,,,,4695.73,11928.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACUTE AC REPAIR SYSTEM,7700078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4921.88000,1427.35000,Aetna,Local,,1968.75,,,,,,,1774.34,4026.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACUTE AC REPAIR SYSTEM,7700078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4921.88000,1427.35000,Aetna,Local,,1968.75,,,,,,,1584.85,4026.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7784548,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7784548,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1358.68000,394.02000,Aetna,Local,,543.47,,,,,,,489.80,1111.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1358.68000,394.02000,Aetna,Local,,543.47,,,,,,,437.49,1111.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694996,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,293.63,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694996,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,262.27,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7700102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7700102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ADAPTER TRAY,7700105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2365.78,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ADAPTER TRAY,7700105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2113.12,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7948896,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7948896,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1246.96000,361.62000,Aetna,Local,,498.78,,,,,,,449.53,1020.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1246.96000,361.62000,Aetna,Local,,498.78,,,,,,,401.52,1020.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1899.20000,550.77000,Aetna,Local,,759.68,,,,,,,684.66,1553.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1899.20000,550.77000,Aetna,Local,,759.68,,,,,,,611.54,1553.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15410.25000,4468.97000,Aetna,Local,,6164.10,,,,,,,5555.40,12605.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7700155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15410.25000,4468.97000,Aetna,Local,,6164.10,,,,,,,4962.10,12605.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HEAD,7700147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1855.02,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HEAD,7700147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1656.92,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2022.84000,586.62000,Aetna,Local,,809.14,,,,,,,729.23,1654.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2022.84000,586.62000,Aetna,Local,,809.14,,,,,,,651.35,1654.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2389.25,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2134.09,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1337.71,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7699266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1194.85,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7700180,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2026.20000,587.60000,Aetna,Local,,810.48,,,,,,,730.45,1657.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7700180,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2026.20000,587.60000,Aetna,Local,,810.48,,,,,,,652.44,1657.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7699492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,4451.45,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7699492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12348.00000,3580.92000,Aetna,Local,,4939.20,,,,,,,3976.06,10100.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698424,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3158.92000,916.09000,Aetna,Local,,1263.57,,,,,,,1138.79,2584.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698424,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3158.92000,916.09000,Aetna,Local,,1263.57,,,,,,,1017.17,2584.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736638,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3483.90000,1010.33000,Aetna,Local,,1393.56,,,,,,,1255.95,2849.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736638,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3483.90000,1010.33000,Aetna,Local,,1393.56,,,,,,,1121.82,2849.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7700218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5447.68000,1579.83000,Aetna,Local,,2179.07,,,,,,,1963.89,4456.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7700218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5447.68000,1579.83000,Aetna,Local,,2179.07,,,,,,,1754.15,4456.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1269.48000,368.15000,Aetna,Local,,507.79,,,,,,,457.65,1038.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1269.48000,368.15000,Aetna,Local,,507.79,,,,,,,408.77,1038.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTING NUT,7700204,CDM,278,RC,,,,,facility,inpatient,,,153.83000,44.61000,Aetna,Local,,61.53,,,,,,,55.46,125.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTING NUT,7700204,CDM,278,RC,,,,,facility,outpatient,,,153.83000,44.61000,Aetna,Local,,61.53,,,,,,,49.53,125.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7700209,CDM,278,RC,,,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7700209,CDM,278,RC,,,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,7700211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,730.35000,211.80000,Aetna,Local,,292.14,,,,,,,263.29,597.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,7700211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,730.35000,211.80000,Aetna,Local,,292.14,,,,,,,235.17,597.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1529.36000,443.51000,Aetna,Local,,611.74,,,,,,,551.33,1251.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1529.36000,443.51000,Aetna,Local,,611.74,,,,,,,492.45,1251.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7700239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4945.50000,1434.20000,Aetna,Local,,1978.20,,,,,,,1782.85,4045.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7700239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4945.50000,1434.20000,Aetna,Local,,1978.20,,,,,,,1592.45,4045.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5669.30000,1644.10000,Aetna,Local,,2267.72,,,,,,,2043.78,4637.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5669.30000,1644.10000,Aetna,Local,,2267.72,,,,,,,1825.51,4637.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PLUG,7699287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PLUG,7699287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.76000,568.62000,Aetna,Local,,784.30,,,,,,,706.85,1603.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.76000,568.62000,Aetna,Local,,784.30,,,,,,,631.36,1603.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1606.00000,465.74000,Aetna,Local,,642.40,,,,,,,578.96,1313.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1606.00000,465.74000,Aetna,Local,,642.40,,,,,,,517.13,1313.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7700247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7700247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7700248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7700248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7700316,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7700316,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1491.35,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1332.08,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,7700326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5091.70000,1476.59000,Aetna,Local,,2036.68,,,,,,,1835.56,4165.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,7700326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5091.70000,1476.59000,Aetna,Local,,2036.68,,,,,,,1639.53,4165.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,Local,,92.40,,,,,,,83.28,188.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,Local,,92.40,,,,,,,74.38,188.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,828.00000,240.12000,Aetna,Local,,331.20,,,,,,,298.49,677.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,828.00000,240.12000,Aetna,Local,,331.20,,,,,,,266.62,677.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7700336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6142.50000,1781.32000,Aetna,Local,,2457.00,,,,,,,2214.37,5024.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7700336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6142.50000,1781.32000,Aetna,Local,,2457.00,,,,,,,1977.88,5024.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,507.58,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,453.38,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,Local,,534.40,,,,,,,481.63,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,Local,,534.40,,,,,,,430.19,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9966.00000,2890.14000,Aetna,Local,,3986.40,,,,,,,3592.74,8152.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9966.00000,2890.14000,Aetna,Local,,3986.40,,,,,,,3209.05,8152.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7694931,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3194.00000,926.26000,Aetna,Local,,1277.60,,,,,,,1151.44,2612.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIPS,7694931,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3194.00000,926.26000,Aetna,Local,,1277.60,,,,,,,1028.47,2612.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,791.42000,229.51000,Aetna,Local,,316.57,,,,,,,285.31,647.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,791.42000,229.51000,Aetna,Local,,316.57,,,,,,,254.84,647.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7976.13000,2313.08000,Aetna,Local,,3190.45,,,,,,,2875.39,6524.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7976.13000,2313.08000,Aetna,Local,,3190.45,,,,,,,2568.31,6524.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7700405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7700405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2691.85,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7467.00000,2165.43000,Aetna,Local,,2986.80,,,,,,,2404.37,6108.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7700421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7700421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700426,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700426,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,Local,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7694787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.20000,255.26000,Aetna,Local,,352.08,,,,,,,317.31,720.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7694787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.20000,255.26000,Aetna,Local,,352.08,,,,,,,283.42,720.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BAND FIXATE,7700447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BAND FIXATE,7700447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,739.17,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,Local,,820.16,,,,,,,660.23,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,348.37000,101.03000,Aetna,Local,,139.35,,,,,,,125.59,284.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,348.37000,101.03000,Aetna,Local,,139.35,,,,,,,112.18,284.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7696554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10755.00000,3118.95000,Aetna,Local,,4302.00,,,,,,,3877.18,8797.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7696554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10755.00000,3118.95000,Aetna,Local,,4302.00,,,,,,,3463.11,8797.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7700505,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,235.94,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7700505,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,210.74,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7700513,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7700513,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7700514,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8992.80000,2607.91000,Aetna,Local,,3597.12,,,,,,,3241.90,7356.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7700514,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8992.80000,2607.91000,Aetna,Local,,3597.12,,,,,,,2895.68,7356.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698642,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698642,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7700538,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21572.50000,6256.02000,Aetna,Local,,8629.00,,,,,,,7776.89,17646.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7700538,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21572.50000,6256.02000,Aetna,Local,,8629.00,,,,,,,6946.35,17646.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8017.29000,2325.01000,Aetna,Local,,3206.92,,,,,,,2890.23,6558.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8017.29000,2325.01000,Aetna,Local,,3206.92,,,,,,,2581.57,6558.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2680.56000,777.36000,Aetna,Local,,1072.22,,,,,,,966.34,2192.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2680.56000,777.36000,Aetna,Local,,1072.22,,,,,,,863.14,2192.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7700589,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,352.03,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7700589,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,314.43,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7699692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,344.38000,99.87000,Aetna,Local,,137.75,,,,,,,124.15,281.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7699692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,344.38000,99.87000,Aetna,Local,,137.75,,,,,,,110.89,281.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7700646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.45000,190.66000,Aetna,Local,,262.98,,,,,,,237.01,537.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7700646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.45000,190.66000,Aetna,Local,,262.98,,,,,,,211.70,537.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7695434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,703.98000,204.15000,Aetna,Local,,281.59,,,,,,,253.78,575.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7695434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,703.98000,204.15000,Aetna,Local,,281.59,,,,,,,226.68,575.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7736640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2262.12000,656.01000,Aetna,Local,,904.85,,,,,,,815.49,1850.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7736640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2262.12000,656.01000,Aetna,Local,,904.85,,,,,,,728.40,1850.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4179.35000,1212.01000,Aetna,Local,,1671.74,,,,,,,1506.66,3418.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4179.35000,1212.01000,Aetna,Local,,1671.74,,,,,,,1345.75,3418.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,305.07,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,272.49,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700717,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,70.03,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700717,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,62.55,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2936.27,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2622.69,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.00000,206.19000,Aetna,Local,,284.40,,,,,,,256.32,581.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.00000,206.19000,Aetna,Local,,284.40,,,,,,,228.94,581.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,475.25,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,424.50,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7693460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7693460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IVC RETRIEVAL,7695049,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,665.84,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IVC RETRIEVAL,7695049,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,594.73,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9500.94000,2755.27000,Aetna,Local,,3800.38,,,,,,,3425.09,7771.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9500.94000,2755.27000,Aetna,Local,,3800.38,,,,,,,3059.30,7771.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698793,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698793,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7700835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7700835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10671.60000,3094.76000,Aetna,Local,,4268.64,,,,,,,3847.11,8729.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10671.60000,3094.76000,Aetna,Local,,4268.64,,,,,,,3436.26,8729.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7700887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,178.50000,51.76000,Aetna,Local,,71.40,,,,,,,64.35,146.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7700887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,178.50000,51.76000,Aetna,Local,,71.40,,,,,,,57.48,146.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700889,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700889,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7700879,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1469.76000,426.23000,Aetna,Local,,587.90,,,,,,,529.85,1202.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7700879,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1469.76000,426.23000,Aetna,Local,,587.90,,,,,,,473.26,1202.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6485.50000,1880.79000,Aetna,Local,,2594.20,,,,,,,2338.02,5305.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6485.50000,1880.79000,Aetna,Local,,2594.20,,,,,,,2088.33,5305.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,430.40000,124.82000,Aetna,Local,,172.16,,,,,,,155.16,352.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,430.40000,124.82000,Aetna,Local,,172.16,,,,,,,138.59,352.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8568.00000,2484.72000,Aetna,Local,,3427.20,,,,,,,3088.76,7008.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8568.00000,2484.72000,Aetna,Local,,3427.20,,,,,,,2758.90,7008.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7700911,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,Local,,245.02,,,,,,,220.82,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7700911,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,Local,,245.02,,,,,,,197.24,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7699820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7699820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5327.42000,1544.95000,Aetna,Local,,2130.97,,,,,,,1920.53,4357.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5327.42000,1544.95000,Aetna,Local,,2130.97,,,,,,,1715.43,4357.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736632,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,4429.82,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7736632,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,3956.74,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695364,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,241.72,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695364,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,215.90,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7701069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,756.00000,219.24000,Aetna,Local,,302.40,,,,,,,272.54,618.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7701069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,756.00000,219.24000,Aetna,Local,,302.40,,,,,,,243.43,618.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3910.52000,1134.05000,Aetna,Local,,1564.21,,,,,,,1409.74,3198.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3910.52000,1134.05000,Aetna,Local,,1564.21,,,,,,,1259.19,3198.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,912.60000,264.65000,Aetna,Local,,365.04,,,,,,,328.99,746.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,912.60000,264.65000,Aetna,Local,,365.04,,,,,,,293.86,746.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1585.24000,459.72000,Aetna,Local,,634.10,,,,,,,571.48,1296.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1585.24000,459.72000,Aetna,Local,,634.10,,,,,,,510.45,1296.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7699710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7699710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,130.14,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,116.24,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3796.45000,1100.97000,Aetna,Local,,1518.58,,,,,,,1368.62,3105.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3796.45000,1100.97000,Aetna,Local,,1518.58,,,,,,,1222.46,3105.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.60000,3007.76000,Aetna,Local,,4148.64,,,,,,,3738.96,8483.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.60000,3007.76000,Aetna,Local,,4148.64,,,,,,,3339.66,8483.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8280.00000,2401.20000,Aetna,Local,,3312.00,,,,,,,2984.94,6773.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8280.00000,2401.20000,Aetna,Local,,3312.00,,,,,,,2666.16,6773.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7701037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10953.00000,3176.37000,Aetna,Local,,4381.20,,,,,,,3948.56,8959.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7701037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10953.00000,3176.37000,Aetna,Local,,4381.20,,,,,,,3526.87,8959.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7701056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7701056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7700873,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21020.00000,6095.80000,Aetna,Local,,8408.00,,,,,,,7577.71,17194.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7700873,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21020.00000,6095.80000,Aetna,Local,,8408.00,,,,,,,6768.44,17194.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7700874,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21240.00000,6159.60000,Aetna,Local,,8496.00,,,,,,,7657.02,17374.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7700874,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21240.00000,6159.60000,Aetna,Local,,8496.00,,,,,,,6839.28,17374.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7701521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7701521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7701522,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.75000,53.29000,Aetna,Local,,73.50,,,,,,,66.24,150.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7701522,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.75000,53.29000,Aetna,Local,,73.50,,,,,,,59.17,150.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1784.00000,517.36000,Aetna,Local,,713.60,,,,,,,643.13,1459.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1784.00000,517.36000,Aetna,Local,,713.60,,,,,,,574.45,1459.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2288.00000,663.52000,Aetna,Local,,915.20,,,,,,,824.82,1871.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2288.00000,663.52000,Aetna,Local,,915.20,,,,,,,736.74,1871.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BICEPS REPAIR,7696886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BICEPS REPAIR,7696886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698165,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5787.51,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698165,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5169.43,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ARTERIAL GRAFT,7701199,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,4672.50000,1355.02000,Aetna,Local,,1869.00,,,,,,,1684.44,3822.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ARTERIAL GRAFT,7701199,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,4672.50000,1355.02000,Aetna,Local,,1869.00,,,,,,,1504.55,3822.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697994,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697994,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7701293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7701293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.76000,349.96000,Aetna,Local,,482.70,,,,,,,435.04,987.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.76000,349.96000,Aetna,Local,,482.70,,,,,,,388.58,987.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1658.84000,481.06000,Aetna,Local,,663.54,,,,,,,598.01,1356.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1658.84000,481.06000,Aetna,Local,,663.54,,,,,,,534.15,1356.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1894.08000,549.28000,Aetna,Local,,757.63,,,,,,,682.82,1549.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1894.08000,549.28000,Aetna,Local,,757.63,,,,,,,609.89,1549.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1643.56000,476.63000,Aetna,Local,,657.42,,,,,,,592.50,1344.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1643.56000,476.63000,Aetna,Local,,657.42,,,,,,,529.23,1344.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1823.80000,528.90000,Aetna,Local,,729.52,,,,,,,657.48,1491.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1823.80000,528.90000,Aetna,Local,,729.52,,,,,,,587.26,1491.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2013.20000,583.83000,Aetna,Local,,805.28,,,,,,,725.76,1646.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2013.20000,583.83000,Aetna,Local,,805.28,,,,,,,648.25,1646.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,442.69,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,395.42,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1816.00000,526.64000,Aetna,Local,,726.40,,,,,,,654.67,1485.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1816.00000,526.64000,Aetna,Local,,726.40,,,,,,,584.75,1485.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7701323,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7701323,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7701197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7701197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE PLUG,7701729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE PLUG,7701729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5127.50000,1486.98000,Aetna,Local,,2051.00,,,,,,,1848.46,4194.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5127.50000,1486.98000,Aetna,Local,,2051.00,,,,,,,1651.06,4194.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1856.03,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1657.82,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7701559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1548.17,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7701559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1382.83,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7701562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7701562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7701573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1202.32000,348.67000,Aetna,Local,,480.93,,,,,,,433.44,983.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7701573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1202.32000,348.67000,Aetna,Local,,480.93,,,,,,,387.15,983.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701400,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4805.10,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701400,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4291.94,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701401,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14706.00000,4264.74000,Aetna,Local,,5882.40,,,,,,,5301.51,12029.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701401,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14706.00000,4264.74000,Aetna,Local,,5882.40,,,,,,,4735.33,12029.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7701589,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7701589,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7698053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7698053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7701608,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4135.95000,1199.43000,Aetna,Local,,1654.38,,,,,,,1491.01,3383.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7701608,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4135.95000,1199.43000,Aetna,Local,,1654.38,,,,,,,1331.78,3383.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7701610,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7577.10000,2197.36000,Aetna,Local,,3030.84,,,,,,,2731.54,6198.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7701610,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7577.10000,2197.36000,Aetna,Local,,3030.84,,,,,,,2439.83,6198.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701615,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,437.00000,126.73000,Aetna,Local,,174.80,,,,,,,157.54,357.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701615,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,437.00000,126.73000,Aetna,Local,,174.80,,,,,,,140.71,357.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PORT,7701621,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,2020.00000,585.80000,Aetna,Local,,808.00,,,,,,,728.21,1652.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PORT,7701621,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,2020.00000,585.80000,Aetna,Local,,808.00,,,,,,,650.44,1652.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7699835,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1682.00000,487.78000,Aetna,Local,,672.80,,,,,,,606.36,1375.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7699835,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1682.00000,487.78000,Aetna,Local,,672.80,,,,,,,541.60,1375.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699834,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3939.25000,1142.38000,Aetna,Local,,1575.70,,,,,,,1420.10,3222.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699834,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3939.25000,1142.38000,Aetna,Local,,1575.70,,,,,,,1268.44,3222.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7699102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,907.31,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7699102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,810.41,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMAN TISSUE,7701667,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5089.49000,1475.95000,Aetna,Local,,2035.80,,,,,,,1834.76,4163.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMAN TISSUE,7701667,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5089.49000,1475.95000,Aetna,Local,,2035.80,,,,,,,1638.82,4163.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2069.36000,600.11000,Aetna,Local,,827.74,,,,,,,746.00,1692.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2069.36000,600.11000,Aetna,Local,,827.74,,,,,,,666.33,1692.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5436.27000,1576.52000,Aetna,Local,,2174.51,,,,,,,1959.78,4446.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5436.27000,1576.52000,Aetna,Local,,2174.51,,,,,,,1750.48,4446.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7701498,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7701498,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANCHOR,7702020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANCHOR,7702020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7702025,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7702025,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7702027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11239.20000,3259.37000,Aetna,Local,,4495.68,,,,,,,4051.73,9193.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7702027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11239.20000,3259.37000,Aetna,Local,,4495.68,,,,,,,3619.02,9193.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,742.63,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,663.32,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1124.76,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1004.64,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7702102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7702102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT SINUS,7701623,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,5362.00000,1554.98000,Aetna,Local,,2144.80,,,,,,,1933.00,4386.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT SINUS,7701623,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,5362.00000,1554.98000,Aetna,Local,,2144.80,,,,,,,1726.56,4386.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3506.06000,1016.76000,Aetna,Local,,1402.42,,,,,,,1263.93,2867.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3506.06000,1016.76000,Aetna,Local,,1402.42,,,,,,,1128.95,2867.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,Local,,1456.80,,,,,,,1312.94,2979.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,Local,,1456.80,,,,,,,1172.72,2979.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,344.57,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,307.77,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697530,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,134.72000,39.07000,Aetna,Local,,53.89,,,,,,,48.57,110.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697530,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,134.72000,39.07000,Aetna,Local,,53.89,,,,,,,43.38,110.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7702066,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3381.00000,980.49000,Aetna,Local,,1352.40,,,,,,,1218.85,2765.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7702066,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3381.00000,980.49000,Aetna,Local,,1352.40,,,,,,,1088.68,2765.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975121,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975121,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7700500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10755.00000,3118.95000,Aetna,Local,,4302.00,,,,,,,3877.18,8797.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7700500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10755.00000,3118.95000,Aetna,Local,,4302.00,,,,,,,3463.11,8797.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7741021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10755.00000,3118.95000,Aetna,Local,,4302.00,,,,,,,3877.18,8797.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7741021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10755.00000,3118.95000,Aetna,Local,,4302.00,,,,,,,3463.11,8797.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7700506,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,235.94,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7700506,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,210.74,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7702236,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,235.94,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7702236,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,210.74,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7848092,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,235.94,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7848092,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,210.74,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7848093,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,235.94,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7848093,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,210.74,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7910689,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,235.94,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7910689,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,654.48000,189.80000,Aetna,Local,,261.79,,,,,,,210.74,535.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7903627,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7903627,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700830,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700830,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7802048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7802048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7874324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7874324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7904987,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7904987,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736361,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736361,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7790174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7790174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7812120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7812120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7818168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7818168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7828153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7874325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7874325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7922493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7922493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8017.29000,2325.01000,Aetna,Local,,3206.92,,,,,,,2890.23,6558.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8017.29000,2325.01000,Aetna,Local,,3206.92,,,,,,,2581.57,6558.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8017.29000,2325.01000,Aetna,Local,,3206.92,,,,,,,2890.23,6558.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8017.29000,2325.01000,Aetna,Local,,3206.92,,,,,,,2581.57,6558.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7700590,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,352.03,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7700590,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,314.43,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7790244,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,352.03,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7790244,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,314.43,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7700623,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,604.80000,175.39000,Aetna,Local,,241.92,,,,,,,218.03,494.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7700623,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,604.80000,175.39000,Aetna,Local,,241.92,,,,,,,194.75,494.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7699855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7699855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,305.07,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,272.49,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,305.07,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,272.49,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,305.07,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,272.49,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,507.58,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,453.38,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700689,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700689,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700713,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700713,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700716,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700716,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,305.07,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,272.49,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,305.07,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,272.49,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,305.07,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7750589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,272.49,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7770034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7770034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,305.07,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,846.23000,245.41000,Aetna,Local,,338.49,,,,,,,272.49,692.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7842037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7842037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,498.93,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,445.65,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,498.93,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,445.65,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,582.57,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,520.35,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700726,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700726,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7701609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7701609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7882390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7882390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4309.20000,1249.67000,Aetna,Local,,1723.68,,,,,,,1553.47,3524.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4309.20000,1249.67000,Aetna,Local,,1723.68,,,,,,,1387.56,3524.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7748109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,174.66,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,156.01,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7700902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,475.25,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,424.50,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,475.25,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,424.50,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,461.81,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,412.49,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701713,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701713,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701716,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701716,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701717,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701717,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701721,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701721,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701724,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701724,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7784149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7804058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7804058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7816125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7816125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,69.29,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,192.20000,55.74000,Aetna,Local,,76.88,,,,,,,61.89,157.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697006,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697006,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2108.20000,611.38000,Aetna,Local,,843.28,,,,,,,760.01,1724.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2108.20000,611.38000,Aetna,Local,,843.28,,,,,,,678.84,1724.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2196.00000,636.84000,Aetna,Local,,878.40,,,,,,,791.66,1796.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2196.00000,636.84000,Aetna,Local,,878.40,,,,,,,707.11,1796.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2196.00000,636.84000,Aetna,Local,,878.40,,,,,,,791.66,1796.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2196.00000,636.84000,Aetna,Local,,878.40,,,,,,,707.11,1796.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,701.10,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,626.23,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700773,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700773,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700775,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700775,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7752053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1362.04000,394.99000,Aetna,Local,,544.82,,,,,,,491.02,1114.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7752053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1362.04000,394.99000,Aetna,Local,,544.82,,,,,,,438.58,1114.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1362.04000,394.99000,Aetna,Local,,544.82,,,,,,,491.02,1114.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1362.04000,394.99000,Aetna,Local,,544.82,,,,,,,438.58,1114.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,701.10,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,626.23,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2196.00000,636.84000,Aetna,Local,,878.40,,,,,,,791.66,1796.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2196.00000,636.84000,Aetna,Local,,878.40,,,,,,,707.11,1796.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,701.10,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,Local,,777.92,,,,,,,626.23,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2000.00000,580.00000,Aetna,Local,,800.00,,,,,,,721.00,1636.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2000.00000,580.00000,Aetna,Local,,800.00,,,,,,,644.00,1636.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9500.94000,2755.27000,Aetna,Local,,3800.38,,,,,,,3425.09,7771.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9500.94000,2755.27000,Aetna,Local,,3800.38,,,,,,,3059.30,7771.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7700834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7834075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7834075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7840139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7840139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7866038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7866038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7893678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7893678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7896394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7896394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7736276,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7736276,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700845,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700845,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700847,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7700847,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7802117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7802117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7802118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7802118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7816099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7816099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7816100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7816100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7908634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10671.60000,3094.76000,Aetna,Local,,4268.64,,,,,,,3847.11,8729.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10671.60000,3094.76000,Aetna,Local,,4268.64,,,,,,,3436.26,8729.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7702636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10671.60000,3094.76000,Aetna,Local,,4268.64,,,,,,,3847.11,8729.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7702636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10671.60000,3094.76000,Aetna,Local,,4268.64,,,,,,,3436.26,8729.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7816130,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10671.60000,3094.76000,Aetna,Local,,4268.64,,,,,,,3847.11,8729.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7816130,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10671.60000,3094.76000,Aetna,Local,,4268.64,,,,,,,3436.26,8729.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7802070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7802070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7854032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7854032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7954087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7954087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7700880,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1469.76000,426.23000,Aetna,Local,,587.90,,,,,,,529.85,1202.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7700880,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1469.76000,426.23000,Aetna,Local,,587.90,,,,,,,473.26,1202.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7700881,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1469.76000,426.23000,Aetna,Local,,587.90,,,,,,,529.85,1202.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7700881,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1469.76000,426.23000,Aetna,Local,,587.90,,,,,,,473.26,1202.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7740745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7740745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7746042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7746042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7826098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7826098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7850196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7850196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7876185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7876185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902294,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902294,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7904167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7904167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7917698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7917698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7918959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7918959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7935821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7935821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7702638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6485.50000,1880.79000,Aetna,Local,,2594.20,,,,,,,2338.02,5305.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7702638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6485.50000,1880.79000,Aetna,Local,,2594.20,,,,,,,2088.33,5305.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7902821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7742176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7742176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7917896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,287.47000,83.37000,Aetna,Local,,114.99,,,,,,,103.63,235.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,287.47000,83.37000,Aetna,Local,,114.99,,,,,,,92.57,235.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8568.00000,2484.72000,Aetna,Local,,3427.20,,,,,,,3088.76,7008.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8568.00000,2484.72000,Aetna,Local,,3427.20,,,,,,,2758.90,7008.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748878,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748878,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7748880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7786153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7786153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7788034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7788034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7790536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7790536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7794486,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7794486,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7800031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7800031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7800036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7800036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7802088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7804039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7804039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7804040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7804040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806371,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806371,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7814061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7814061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7816121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7816121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7820081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7820081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7822247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7828053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7828053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7828055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7828055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7834041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7838066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7838066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7846134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7846134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7848066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7848066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7858125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7858125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7858274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7858274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7876333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7876333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7876334,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7876334,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878319,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878319,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878563,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878563,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7878565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880445,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880445,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880666,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880666,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880671,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7880671,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893771,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893771,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7897084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7897084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7900097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7900097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7900128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7900128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7903782,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7903782,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7910510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7910510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7912138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7912138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7914035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7914035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7926709,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7926709,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7926710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7926710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7934014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7934014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939804,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939804,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7961897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7961897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7961901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7961901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7700970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7700970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7702906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7702906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7703354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7703354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700986,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700986,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700997,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700997,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701006,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701006,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7703355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1496.44,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7703355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4151.00000,1203.79000,Aetna,Local,,1660.40,,,,,,,1336.62,3395.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701399,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,4429.82,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701399,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,3956.74,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7903584,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,4429.82,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7903584,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,3956.74,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7905468,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,4429.82,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7905468,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,3956.74,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7746048,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7746048,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7822089,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7822089,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7822091,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7822091,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3910.52000,1134.05000,Aetna,Local,,1564.21,,,,,,,1409.74,3198.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3910.52000,1134.05000,Aetna,Local,,1564.21,,,,,,,1259.19,3198.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3932.22000,1140.34000,Aetna,Local,,1572.89,,,,,,,1417.57,3216.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3932.22000,1140.34000,Aetna,Local,,1572.89,,,,,,,1266.17,3216.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7776293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2656.00000,770.24000,Aetna,Local,,1062.40,,,,,,,957.49,2172.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7776293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2656.00000,770.24000,Aetna,Local,,1062.40,,,,,,,855.23,2172.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7776294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2700.00000,783.00000,Aetna,Local,,1080.00,,,,,,,973.35,2208.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7776294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2700.00000,783.00000,Aetna,Local,,1080.00,,,,,,,869.40,2208.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7939432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,203.23000,58.94000,Aetna,Local,,81.29,,,,,,,73.26,166.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7939432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,203.23000,58.94000,Aetna,Local,,81.29,,,,,,,65.44,166.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,130.14,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,116.24,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,130.14,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,116.24,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,130.14,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,116.24,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699827,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699827,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7701028,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7701028,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7701029,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7701029,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7701030,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7701030,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8280.00000,2401.20000,Aetna,Local,,3312.00,,,,,,,2984.94,6773.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8280.00000,2401.20000,Aetna,Local,,3312.00,,,,,,,2666.16,6773.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7896376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,128.05000,37.13000,Aetna,Local,,51.22,,,,,,,46.16,104.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7896376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,128.05000,37.13000,Aetna,Local,,51.22,,,,,,,41.23,104.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,Local,,590.72,,,,,,,532.39,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,Local,,590.72,,,,,,,475.53,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,Local,,590.72,,,,,,,532.39,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,Local,,590.72,,,,,,,475.53,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.72000,657.64000,Aetna,Local,,907.09,,,,,,,817.51,1854.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.72000,657.64000,Aetna,Local,,907.09,,,,,,,730.21,1854.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7830034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,953.52,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7830034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,851.69,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7958152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2072.52000,601.03000,Aetna,Local,,829.01,,,,,,,747.14,1695.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7958152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2072.52000,601.03000,Aetna,Local,,829.01,,,,,,,667.35,1695.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5787.51,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5169.43,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7740766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5787.51,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7740766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5169.43,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957822,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5787.51,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957822,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5169.43,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7958126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5787.51,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7958126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5169.43,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1218.80000,353.45000,Aetna,Local,,487.52,,,,,,,439.38,996.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1218.80000,353.45000,Aetna,Local,,487.52,,,,,,,392.45,996.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4914.00000,1425.06000,Aetna,Local,,1965.60,,,,,,,1771.50,4019.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4914.00000,1425.06000,Aetna,Local,,1965.60,,,,,,,1582.31,4019.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4914.00000,1425.06000,Aetna,Local,,1965.60,,,,,,,1771.50,4019.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4914.00000,1425.06000,Aetna,Local,,1965.60,,,,,,,1582.31,4019.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4914.00000,1425.06000,Aetna,Local,,1965.60,,,,,,,1771.50,4019.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4914.00000,1425.06000,Aetna,Local,,1965.60,,,,,,,1582.31,4019.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7870096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7870096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7882685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698749,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698749,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935273,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935273,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7703017,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7703017,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.76000,349.96000,Aetna,Local,,482.70,,,,,,,435.04,987.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.76000,349.96000,Aetna,Local,,482.70,,,,,,,388.58,987.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.76000,349.96000,Aetna,Local,,482.70,,,,,,,435.04,987.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.76000,349.96000,Aetna,Local,,482.70,,,,,,,388.58,987.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1658.84000,481.06000,Aetna,Local,,663.54,,,,,,,598.01,1356.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1658.84000,481.06000,Aetna,Local,,663.54,,,,,,,534.15,1356.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1553.00000,450.37000,Aetna,Local,,621.20,,,,,,,559.86,1270.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1553.00000,450.37000,Aetna,Local,,621.20,,,,,,,500.07,1270.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.50000,259.70000,Aetna,Local,,358.20,,,,,,,322.83,732.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.50000,259.70000,Aetna,Local,,358.20,,,,,,,288.35,732.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1892.00000,548.68000,Aetna,Local,,756.80,,,,,,,682.07,1547.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1892.00000,548.68000,Aetna,Local,,756.80,,,,,,,609.22,1547.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7929695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1286.60000,373.11000,Aetna,Local,,514.64,,,,,,,463.82,1052.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7929695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1286.60000,373.11000,Aetna,Local,,514.64,,,,,,,414.29,1052.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1823.80000,528.90000,Aetna,Local,,729.52,,,,,,,657.48,1491.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1823.80000,528.90000,Aetna,Local,,729.52,,,,,,,587.26,1491.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1823.80000,528.90000,Aetna,Local,,729.52,,,,,,,657.48,1491.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1823.80000,528.90000,Aetna,Local,,729.52,,,,,,,587.26,1491.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1667.60000,483.60000,Aetna,Local,,667.04,,,,,,,601.17,1364.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1667.60000,483.60000,Aetna,Local,,667.04,,,,,,,536.97,1364.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1667.60000,483.60000,Aetna,Local,,667.04,,,,,,,601.17,1364.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1667.60000,483.60000,Aetna,Local,,667.04,,,,,,,536.97,1364.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7816124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.63000,103.42000,Aetna,Local,,142.65,,,,,,,128.57,291.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7816124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.63000,103.42000,Aetna,Local,,142.65,,,,,,,114.83,291.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1448.00000,419.92000,Aetna,Local,,579.20,,,,,,,522.00,1184.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1448.00000,419.92000,Aetna,Local,,579.20,,,,,,,466.26,1184.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2013.20000,583.83000,Aetna,Local,,805.28,,,,,,,725.76,1646.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2013.20000,583.83000,Aetna,Local,,805.28,,,,,,,648.25,1646.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2013.20000,583.83000,Aetna,Local,,805.28,,,,,,,725.76,1646.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2013.20000,583.83000,Aetna,Local,,805.28,,,,,,,648.25,1646.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1659.68000,481.31000,Aetna,Local,,663.87,,,,,,,598.31,1357.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1659.68000,481.31000,Aetna,Local,,663.87,,,,,,,534.42,1357.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,442.69,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,395.42,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1816.00000,526.64000,Aetna,Local,,726.40,,,,,,,654.67,1485.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1816.00000,526.64000,Aetna,Local,,726.40,,,,,,,584.75,1485.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7832046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2264.00000,656.56000,Aetna,Local,,905.60,,,,,,,816.17,1851.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7832046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2264.00000,656.56000,Aetna,Local,,905.60,,,,,,,729.01,1851.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7840045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7840045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7846035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,795.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7846035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,710.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1583.50,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4392.50000,1273.82000,Aetna,Local,,1757.00,,,,,,,1414.38,3593.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1598.64,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4434.50000,1286.00000,Aetna,Local,,1773.80,,,,,,,1427.91,3627.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7865351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2815.80000,816.58000,Aetna,Local,,1126.32,,,,,,,1015.10,2303.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7865351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2815.80000,816.58000,Aetna,Local,,1126.32,,,,,,,906.69,2303.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7920410,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7920410,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1647.85,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1471.86,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1647.85,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1471.86,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1647.85,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1471.86,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1647.85,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1471.86,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1647.85,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4571.00000,1325.59000,Aetna,Local,,1828.40,,,,,,,1471.86,3739.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3177.36000,921.43000,Aetna,Local,,1270.94,,,,,,,1145.44,2599.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3177.36000,921.43000,Aetna,Local,,1270.94,,,,,,,1023.11,2599.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.00000,1380.40000,Aetna,Local,,1904.00,,,,,,,1715.98,3893.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.00000,1380.40000,Aetna,Local,,1904.00,,,,,,,1532.72,3893.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.00000,1380.40000,Aetna,Local,,1904.00,,,,,,,1715.98,3893.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.00000,1380.40000,Aetna,Local,,1904.00,,,,,,,1532.72,3893.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.00000,1380.40000,Aetna,Local,,1904.00,,,,,,,1715.98,3893.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.00000,1380.40000,Aetna,Local,,1904.00,,,,,,,1532.72,3893.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.00000,1380.40000,Aetna,Local,,1904.00,,,,,,,1715.98,3893.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.00000,1380.40000,Aetna,Local,,1904.00,,,,,,,1532.72,3893.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.00000,1380.40000,Aetna,Local,,1904.00,,,,,,,1715.98,3893.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.00000,1380.40000,Aetna,Local,,1904.00,,,,,,,1532.72,3893.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3607.91000,1046.29000,Aetna,Local,,1443.16,,,,,,,1300.65,2951.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3607.91000,1046.29000,Aetna,Local,,1443.16,,,,,,,1161.75,2951.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3607.91000,1046.29000,Aetna,Local,,1443.16,,,,,,,1300.65,2951.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3607.91000,1046.29000,Aetna,Local,,1443.16,,,,,,,1161.75,2951.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7760080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2162.00000,626.98000,Aetna,Local,,864.80,,,,,,,779.40,1768.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7760080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2162.00000,626.98000,Aetna,Local,,864.80,,,,,,,696.16,1768.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5127.50000,1486.98000,Aetna,Local,,2051.00,,,,,,,1848.46,4194.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5127.50000,1486.98000,Aetna,Local,,2051.00,,,,,,,1651.06,4194.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1856.03,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1657.82,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1856.03,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1657.82,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1856.03,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1657.82,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1856.03,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1657.82,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5127.50000,1486.98000,Aetna,Local,,2051.00,,,,,,,1848.46,4194.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5127.50000,1486.98000,Aetna,Local,,2051.00,,,,,,,1651.06,4194.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1856.03,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1657.82,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1856.03,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1657.82,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1856.03,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1657.82,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1856.03,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5148.50000,1493.06000,Aetna,Local,,2059.40,,,,,,,1657.82,4211.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7768035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5567.03000,1614.44000,Aetna,Local,,2226.81,,,,,,,2006.91,4553.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7768035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5567.03000,1614.44000,Aetna,Local,,2226.81,,,,,,,1792.58,4553.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7768036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5567.03000,1614.44000,Aetna,Local,,2226.81,,,,,,,2006.91,4553.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7768036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5567.03000,1614.44000,Aetna,Local,,2226.81,,,,,,,1792.58,4553.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7956954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5376.95000,1559.32000,Aetna,Local,,2150.78,,,,,,,1938.39,4398.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7956954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5376.95000,1559.32000,Aetna,Local,,2150.78,,,,,,,1731.38,4398.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7750117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1548.17,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7750117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1382.83,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7760129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1548.17,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7760129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1382.83,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7893306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1548.17,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7893306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1382.83,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7940851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1548.17,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7940851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1382.83,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1548.17,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1382.83,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882686,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882686,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7940852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7940852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7701563,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7701563,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7947956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7947956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7947957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7947957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7744660,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4805.10,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7744660,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4291.94,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922551,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4805.10,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922551,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4291.94,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922552,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4805.10,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922552,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4291.94,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922553,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4805.10,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922553,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4291.94,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922554,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4805.10,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922554,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,Local,,5331.60,,,,,,,4291.94,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701402,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14706.00000,4264.74000,Aetna,Local,,5882.40,,,,,,,5301.51,12029.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701402,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14706.00000,4264.74000,Aetna,Local,,5882.40,,,,,,,4735.33,12029.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701404,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14706.00000,4264.74000,Aetna,Local,,5882.40,,,,,,,5301.51,12029.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701404,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14706.00000,4264.74000,Aetna,Local,,5882.40,,,,,,,4735.33,12029.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7910542,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14706.00000,4264.74000,Aetna,Local,,5882.40,,,,,,,5301.51,12029.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7910542,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14706.00000,4264.74000,Aetna,Local,,5882.40,,,,,,,4735.33,12029.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7698469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7698469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7698621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7698621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7698643,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7698643,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7699229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7699229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7699376,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7699376,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700528,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700528,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7700883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7701554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7701554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7701602,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7701602,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7701683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7701683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7742041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7742041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7774232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7774232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7814064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7814064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7871.40000,2282.71000,Aetna,Local,,3148.56,,,,,,,2837.64,6438.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7871.40000,2282.71000,Aetna,Local,,3148.56,,,,,,,2534.59,6438.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740756,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740756,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,Local,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7701630,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1608.00000,466.32000,Aetna,Local,,643.20,,,,,,,579.68,1315.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7701630,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1608.00000,466.32000,Aetna,Local,,643.20,,,,,,,517.78,1315.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699869,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1418.84,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699869,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1267.31,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7701628,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1418.84,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7701628,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1267.31,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7820145,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3939.25000,1142.38000,Aetna,Local,,1575.70,,,,,,,1420.10,3222.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7820145,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3939.25000,1142.38000,Aetna,Local,,1575.70,,,,,,,1268.44,3222.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7848031,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1418.84,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7848031,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1267.31,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7874450,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1418.84,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7874450,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1267.31,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7902979,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1418.84,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7902979,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1267.31,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935393,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1418.84,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935393,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3935.75000,1141.37000,Aetna,Local,,1574.30,,,,,,,1267.31,3219.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7701634,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,907.31,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7701634,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,810.41,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMAN TISSUE,7701668,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5089.49000,1475.95000,Aetna,Local,,2035.80,,,,,,,1834.76,4163.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMAN TISSUE,7701668,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5089.49000,1475.95000,Aetna,Local,,2035.80,,,,,,,1638.82,4163.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMAN TISSUE,7701669,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5089.49000,1475.95000,Aetna,Local,,2035.80,,,,,,,1834.76,4163.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMAN TISSUE,7701669,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5089.49000,1475.95000,Aetna,Local,,2035.80,,,,,,,1638.82,4163.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2066.28000,599.22000,Aetna,Local,,826.51,,,,,,,744.89,1690.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2066.28000,599.22000,Aetna,Local,,826.51,,,,,,,665.34,1690.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3945.90000,1144.31000,Aetna,Local,,1578.36,,,,,,,1422.50,3227.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3945.90000,1144.31000,Aetna,Local,,1578.36,,,,,,,1270.58,3227.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANCHOR,7736474,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANCHOR,7736474,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7702026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7702026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,742.63,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,663.32,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2216.00000,642.64000,Aetna,Local,,886.40,,,,,,,798.87,1812.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2216.00000,642.64000,Aetna,Local,,886.40,,,,,,,713.55,1812.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,742.63,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,663.32,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,742.63,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,663.32,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7774100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,742.63,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7774100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,Local,,824.00,,,,,,,663.32,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7786159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1776.60000,515.21000,Aetna,Local,,710.64,,,,,,,640.46,1453.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7786159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1776.60000,515.21000,Aetna,Local,,710.64,,,,,,,572.07,1453.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1124.76,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1004.64,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1124.76,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1004.64,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7965932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2314.80000,671.29000,Aetna,Local,,925.92,,,,,,,834.49,1893.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7965932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2314.80000,671.29000,Aetna,Local,,925.92,,,,,,,745.37,1893.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT SINUS,7701627,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT SINUS,7701627,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT SINUS,7955820,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT SINUS,7955820,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3370.12000,977.33000,Aetna,Local,,1348.05,,,,,,,1214.93,2756.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3370.12000,977.33000,Aetna,Local,,1348.05,,,,,,,1085.18,2756.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7964527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3638.95000,1055.30000,Aetna,Local,,1455.58,,,,,,,1311.84,2976.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7964527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3638.95000,1055.30000,Aetna,Local,,1455.58,,,,,,,1171.74,2976.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7896905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5816.83000,1686.88000,Aetna,Local,,2326.73,,,,,,,2096.97,4758.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7896905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5816.83000,1686.88000,Aetna,Local,,2326.73,,,,,,,1873.02,4758.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7866036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7866036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,344.57,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,307.77,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,344.57,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,307.77,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,344.57,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,307.77,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939513,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939513,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939515,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939515,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939516,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939516,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939522,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939522,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939526,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939526,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701643,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7701643,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893802,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893802,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7922501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7922501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7695947,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7695947,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7695948,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7695948,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7696058,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7696058,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7698519,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7698519,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7880283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,35.30,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7880283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,31.53,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7701186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,99.75000,28.93000,Aetna,Local,,39.90,,,,,,,35.96,81.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7701186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,99.75000,28.93000,Aetna,Local,,39.90,,,,,,,32.12,81.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7701184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,99.75000,28.93000,Aetna,Local,,39.90,,,,,,,35.96,81.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7701184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,99.75000,28.93000,Aetna,Local,,39.90,,,,,,,32.12,81.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7701185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,99.75000,28.93000,Aetna,Local,,39.90,,,,,,,35.96,81.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7701185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,99.75000,28.93000,Aetna,Local,,39.90,,,,,,,32.12,81.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7697871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,114.45000,33.19000,Aetna,Local,,45.78,,,,,,,41.26,93.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7697871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,114.45000,33.19000,Aetna,Local,,45.78,,,,,,,36.85,93.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7699397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,94.50000,27.40000,Aetna,Local,,37.80,,,,,,,34.07,77.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7699397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,94.50000,27.40000,Aetna,Local,,37.80,,,,,,,30.43,77.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7972584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,128.63000,37.30000,Aetna,Local,,51.45,,,,,,,46.37,105.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7972584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,128.63000,37.30000,Aetna,Local,,51.45,,,,,,,41.42,105.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7806380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,128.63000,37.30000,Aetna,Local,,51.45,,,,,,,46.37,105.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7806380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,128.63000,37.30000,Aetna,Local,,51.45,,,,,,,41.42,105.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7902073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7902073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7908713,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7908713,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7926976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7926976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7694962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,137.88000,39.99000,Aetna,Local,,55.15,,,,,,,49.71,112.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7694962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,137.88000,39.99000,Aetna,Local,,55.15,,,,,,,44.40,112.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7694963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,137.88000,39.99000,Aetna,Local,,55.15,,,,,,,49.71,112.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7694963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,137.88000,39.99000,Aetna,Local,,55.15,,,,,,,44.40,112.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,137.88000,39.99000,Aetna,Local,,55.15,,,,,,,49.71,112.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,137.88000,39.99000,Aetna,Local,,55.15,,,,,,,44.40,112.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7695480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,88.99000,25.81000,Aetna,Local,,35.60,,,,,,,32.08,72.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7695480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,88.99000,25.81000,Aetna,Local,,35.60,,,,,,,28.65,72.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7697873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,88.99000,25.81000,Aetna,Local,,35.60,,,,,,,32.08,72.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7697873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,88.99000,25.81000,Aetna,Local,,35.60,,,,,,,28.65,72.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7695345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7695345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7822191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,202.65000,58.77000,Aetna,Local,,81.06,,,,,,,73.06,165.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7822191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,202.65000,58.77000,Aetna,Local,,81.06,,,,,,,65.25,165.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,51.10,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,45.64,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,105.00000,30.45000,Aetna,Local,,42.00,,,,,,,37.85,85.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,Local,,42.00,,,,,,,33.81,85.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,51.10,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,45.64,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7758085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7758085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7911784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7911784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7924876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7924876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7740541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7740541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7968208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7968208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7968631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7968631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7882262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7882262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7925865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7925865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7876433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,51.10,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7876433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,45.64,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,235.73000,68.36000,Aetna,Local,,94.29,,,,,,,84.98,192.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,235.73000,68.36000,Aetna,Local,,94.29,,,,,,,75.91,192.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700028,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700028,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7699658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7699658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700924,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700924,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700917,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6218.80000,1803.45000,Aetna,Local,,2487.52,,,,,,,2241.88,5086.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700917,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6218.80000,1803.45000,Aetna,Local,,2487.52,,,,,,,2002.45,5086.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3438.09000,997.05000,Aetna,Local,,1375.24,,,,,,,1239.43,2812.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3438.09000,997.05000,Aetna,Local,,1375.24,,,,,,,1107.06,2812.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702154,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6218.80000,1803.45000,Aetna,Local,,2487.52,,,,,,,2241.88,5086.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702154,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6218.80000,1803.45000,Aetna,Local,,2487.52,,,,,,,2002.45,5086.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3511.31000,1018.28000,Aetna,Local,,1404.52,,,,,,,1265.83,2872.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3511.31000,1018.28000,Aetna,Local,,1404.52,,,,,,,1130.64,2872.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7742175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6161.75000,1786.91000,Aetna,Local,,2464.70,,,,,,,2221.31,5040.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7742175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6161.75000,1786.91000,Aetna,Local,,2464.70,,,,,,,1984.08,5040.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5549.92000,1609.48000,Aetna,Local,,2219.97,,,,,,,2000.75,4539.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5549.92000,1609.48000,Aetna,Local,,2219.97,,,,,,,1787.07,4539.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7756379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7786052,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7786052,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7790169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7790169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2424.00000,702.96000,Aetna,Local,,969.60,,,,,,,873.85,1982.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2424.00000,702.96000,Aetna,Local,,969.60,,,,,,,780.53,1982.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2009.40000,582.73000,Aetna,Local,,803.76,,,,,,,724.39,1643.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2009.40000,582.73000,Aetna,Local,,803.76,,,,,,,647.03,1643.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,795.42000,230.67000,Aetna,Local,,318.17,,,,,,,286.75,650.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,795.42000,230.67000,Aetna,Local,,318.17,,,,,,,256.13,650.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,795.42000,230.67000,Aetna,Local,,318.17,,,,,,,286.75,650.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,795.42000,230.67000,Aetna,Local,,318.17,,,,,,,256.13,650.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699438,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8611.20000,2497.25000,Aetna,Local,,3444.48,,,,,,,3104.34,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699438,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8611.20000,2497.25000,Aetna,Local,,3444.48,,,,,,,2772.81,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2816.00000,816.64000,Aetna,Local,,1126.40,,,,,,,1015.17,2303.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2816.00000,816.64000,Aetna,Local,,1126.40,,,,,,,906.75,2303.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,124.66,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,111.35,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,335.87000,97.40000,Aetna,Local,,134.35,,,,,,,121.08,274.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,335.87000,97.40000,Aetna,Local,,134.35,,,,,,,108.15,274.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,79.50000,23.06000,Aetna,Local,,31.80,,,,,,,28.66,65.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,79.50000,23.06000,Aetna,Local,,31.80,,,,,,,25.60,65.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,321.58000,93.26000,Aetna,Local,,128.63,,,,,,,115.93,263.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,321.58000,93.26000,Aetna,Local,,128.63,,,,,,,103.55,263.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,321.58000,93.26000,Aetna,Local,,128.63,,,,,,,115.93,263.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,321.58000,93.26000,Aetna,Local,,128.63,,,,,,,103.55,263.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,124.66,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,111.35,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,124.66,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,111.35,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,124.66,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,111.35,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7754160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7754160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7699453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17887.00000,5187.23000,Aetna,Local,,7154.80,,,,,,,6448.26,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7699453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17887.00000,5187.23000,Aetna,Local,,7154.80,,,,,,,5759.61,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698772,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698772,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7702246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7702246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736165,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736165,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7741709,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7741709,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7786156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7786156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7834040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7834040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7846133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7846133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7848088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7848088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7893914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7893914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7938992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7938992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6077.86000,1762.58000,Aetna,Local,,2431.14,,,,,,,2191.07,4971.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6077.86000,1762.58000,Aetna,Local,,2431.14,,,,,,,1957.07,4971.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4957.05000,1437.54000,Aetna,Local,,1982.82,,,,,,,1787.02,4054.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4957.05000,1437.54000,Aetna,Local,,1982.82,,,,,,,1596.17,4054.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5153.40000,1494.49000,Aetna,Local,,2061.36,,,,,,,1857.80,4215.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5153.40000,1494.49000,Aetna,Local,,2061.36,,,,,,,1659.39,4215.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699752,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699752,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699943,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699943,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7700293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7701057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7701057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7701625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7701625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7702192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7702192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7707511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7707511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7760133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7760133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7820079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7820079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7822252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7822252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7834078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7834078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7878315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7896903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7896903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7954744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7954744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699753,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699753,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7784547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7784547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7802064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7802064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7802108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7802108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7822251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7822251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7882505,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7882505,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7902683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7902683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699470,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699470,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699471,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699471,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699472,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699472,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7694928,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7694928,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699473,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699473,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699474,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699474,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699475,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699475,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699476,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699476,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699477,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7699477,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7922462,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7922462,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7922463,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7922463,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699798,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699798,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7700310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7700310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7700721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7700721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.80000,359.83000,Aetna,Local,,496.32,,,,,,,447.31,1014.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.80000,359.83000,Aetna,Local,,496.32,,,,,,,399.54,1014.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7698166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2000.00000,580.00000,Aetna,Local,,800.00,,,,,,,721.00,1636.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7698166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2000.00000,580.00000,Aetna,Local,,800.00,,,,,,,644.00,1636.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7702781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1890.40000,548.22000,Aetna,Local,,756.16,,,,,,,681.49,1546.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7702781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1890.40000,548.22000,Aetna,Local,,756.16,,,,,,,608.71,1546.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1262.80000,366.21000,Aetna,Local,,505.12,,,,,,,455.24,1032.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1262.80000,366.21000,Aetna,Local,,505.12,,,,,,,406.62,1032.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1262.80000,366.21000,Aetna,Local,,505.12,,,,,,,455.24,1032.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1262.80000,366.21000,Aetna,Local,,505.12,,,,,,,406.62,1032.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7746052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,330.96,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7746052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,295.61,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7746053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,330.96,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7746053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,295.61,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.32000,281.97000,Aetna,Local,,388.93,,,,,,,350.52,795.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.32000,281.97000,Aetna,Local,,388.93,,,,,,,313.09,795.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3086.32000,895.03000,Aetna,Local,,1234.53,,,,,,,1112.62,2524.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3086.32000,895.03000,Aetna,Local,,1234.53,,,,,,,993.80,2524.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699702,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,8029.01,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699702,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,7171.55,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,8029.01,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,7171.55,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,8029.01,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,7171.55,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,8029.01,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,7171.55,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7854033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,8029.01,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7854033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,7171.55,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893454,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,8029.01,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893454,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,7171.55,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,8029.01,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,Local,,8908.75,,,,,,,7171.55,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7695893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7695893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7697534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7697534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7698498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7698498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7707440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7707440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7736607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7736607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7802324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7802324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7816129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7816129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7822249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7822249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7828071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7828071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7828140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7828140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7874396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7874396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7880618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7880618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7882508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7882508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7918900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7918900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7962548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7962548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,Local,,1396.85,,,,,,,1258.91,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,Local,,1396.85,,,,,,,1124.47,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7700170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,Local,,1396.85,,,,,,,1258.91,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7700170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,Local,,1396.85,,,,,,,1124.47,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7812075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,Local,,1396.85,,,,,,,1258.91,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7812075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,Local,,1396.85,,,,,,,1124.47,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700395,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700395,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700836,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700836,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948518,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948518,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957711,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957711,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699603,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,7689.47,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699603,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,6868.26,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,7689.47,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,6868.26,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7740558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,7689.47,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7740558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,6868.26,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7897104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,7689.47,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7897104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,6868.26,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,7689.47,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,6868.26,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7699495,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1543.44,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7699495,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1378.60,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7699496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1543.44,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7699496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1378.60,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1543.44,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1378.60,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7754163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1543.44,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7754163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1378.60,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7894316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1543.44,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7894316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1378.60,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7905326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1543.44,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7905326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1378.60,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7700184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7740557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7740557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7760071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7760071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7895935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7895935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7905327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7905327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7948366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7948366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7948367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7948367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7948520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7948520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7956676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7956676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7957907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7957907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7700560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2812.98,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7700560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2512.57,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7736093,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2812.98,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7736093,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2512.57,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1549.73,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1384.23,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1549.73,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1384.23,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3478.65000,1008.81000,Aetna,Local,,1391.46,,,,,,,1254.05,2845.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3478.65000,1008.81000,Aetna,Local,,1391.46,,,,,,,1120.13,2845.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4265.10000,1236.88000,Aetna,Local,,1706.04,,,,,,,1537.57,3488.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4265.10000,1236.88000,Aetna,Local,,1706.04,,,,,,,1373.36,3488.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1549.73,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1384.23,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2448.04000,709.93000,Aetna,Local,,979.22,,,,,,,882.52,2002.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2448.04000,709.93000,Aetna,Local,,979.22,,,,,,,788.27,2002.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1549.73,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1384.23,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1549.73,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,Local,,1719.54,,,,,,,1384.23,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7768033,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7768033,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7790540,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7790540,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7818080,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7818080,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7826034,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7826034,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7700290,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,2321.00000,673.09000,Aetna,Local,,928.40,,,,,,,836.72,1898.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7700290,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,2321.00000,673.09000,Aetna,Local,,928.40,,,,,,,747.36,1898.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7700291,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,2321.00000,673.09000,Aetna,Local,,928.40,,,,,,,836.72,1898.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7700291,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,2321.00000,673.09000,Aetna,Local,,928.40,,,,,,,747.36,1898.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697447,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697447,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697898,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697898,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694937,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694937,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694951,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694951,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694992,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694992,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695007,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695007,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699833,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,Local,,1501.50,,,,,,,1353.23,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699833,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,Local,,1501.50,,,,,,,1208.71,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7701629,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7701629,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7878540,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,Local,,1501.50,,,,,,,1353.23,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7878540,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,Local,,1501.50,,,,,,,1208.71,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7944416,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,Local,,1501.50,,,,,,,1353.23,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7944416,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,Local,,1501.50,,,,,,,1208.71,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7700476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,Local,,8825.00,,,,,,,7953.53,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7700476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,Local,,8825.00,,,,,,,7104.12,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7707473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,Local,,8825.00,,,,,,,7953.53,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7707473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,Local,,8825.00,,,,,,,7104.12,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7736088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,Local,,8825.00,,,,,,,7953.53,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7736088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,Local,,8825.00,,,,,,,7104.12,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7921151,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,Local,,8825.00,,,,,,,7953.53,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7921151,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,Local,,8825.00,,,,,,,7104.12,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,5515.65,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,4926.60,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,5515.65,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,4926.60,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,5515.65,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,4926.60,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7921150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,5515.65,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7921150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,4926.60,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7698418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,Local,,7344.00,,,,,,,6618.78,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7698418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,Local,,7344.00,,,,,,,5911.92,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7699530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,Local,,7344.00,,,,,,,6618.78,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7699530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,Local,,7344.00,,,,,,,5911.92,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7699816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,Local,,7344.00,,,,,,,6618.78,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7699816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,Local,,7344.00,,,,,,,5911.92,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7740525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7740525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7776153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7776153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7782042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7782042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7840127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7840127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7935474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7935474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7944047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7944047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7954160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7954160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7961865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7961865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698922,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698922,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,202.23,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,180.63,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7741726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,619.79000,179.74000,Aetna,Local,,247.92,,,,,,,223.43,506.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7802413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,619.79000,179.74000,Aetna,Local,,247.92,,,,,,,199.57,506.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7806189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7812153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7848029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7848029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,912.60000,264.65000,Aetna,Local,,365.04,,,,,,,328.99,746.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7893283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,912.60000,264.65000,Aetna,Local,,365.04,,,,,,,293.86,746.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,Local,,360.00,,,,,,,324.45,736.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,,360.00,,,,,,,289.80,736.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7748735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7748735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7893453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7893453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7904985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7904985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740550,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,18652.27,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740550,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,16660.28,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764086,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,18652.27,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764086,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,16660.28,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764090,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,18652.27,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764090,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,16660.28,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764093,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,18652.27,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764093,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,16660.28,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764095,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,18652.27,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764095,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,16660.28,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764082,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,16524.24,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764082,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,14759.51,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764083,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,16524.24,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764083,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,14759.51,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764084,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,16524.24,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764084,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,14759.51,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764085,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,16524.24,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7764085,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,14759.51,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954010,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,16524.24,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954010,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,14759.51,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954430,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,16524.24,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954430,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,14759.51,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1737.32000,503.82000,Aetna,Local,,694.93,,,,,,,626.30,1421.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1737.32000,503.82000,Aetna,Local,,694.93,,,,,,,559.42,1421.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1746.60000,506.51000,Aetna,Local,,698.64,,,,,,,629.65,1428.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1746.60000,506.51000,Aetna,Local,,698.64,,,,,,,562.41,1428.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1970.08000,571.32000,Aetna,Local,,788.03,,,,,,,710.21,1611.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1970.08000,571.32000,Aetna,Local,,788.03,,,,,,,634.37,1611.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1917.32000,556.02000,Aetna,Local,,766.93,,,,,,,691.19,1568.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1917.32000,556.02000,Aetna,Local,,766.93,,,,,,,617.38,1568.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2812.00000,815.48000,Aetna,Local,,1124.80,,,,,,,1013.73,2300.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2812.00000,815.48000,Aetna,Local,,1124.80,,,,,,,905.46,2300.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7961993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2115.92000,613.62000,Aetna,Local,,846.37,,,,,,,762.79,1730.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7961993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2115.92000,613.62000,Aetna,Local,,846.37,,,,,,,681.33,1730.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7895467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7895467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7895468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7895468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7895469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7895469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7895961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7895961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,948.02000,274.93000,Aetna,Local,,379.21,,,,,,,341.76,775.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,948.02000,274.93000,Aetna,Local,,379.21,,,,,,,305.26,775.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,948.02000,274.93000,Aetna,Local,,379.21,,,,,,,341.76,775.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,948.02000,274.93000,Aetna,Local,,379.21,,,,,,,305.26,775.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,948.02000,274.93000,Aetna,Local,,379.21,,,,,,,341.76,775.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,948.02000,274.93000,Aetna,Local,,379.21,,,,,,,305.26,775.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,948.02000,274.93000,Aetna,Local,,379.21,,,,,,,341.76,775.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,948.02000,274.93000,Aetna,Local,,379.21,,,,,,,305.26,775.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701809,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701809,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,981.45000,284.62000,Aetna,Local,,392.58,,,,,,,353.81,802.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,981.45000,284.62000,Aetna,Local,,392.58,,,,,,,316.03,802.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,Local,,590.72,,,,,,,532.39,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7707529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,Local,,590.72,,,,,,,475.53,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7936053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,684.00000,198.36000,Aetna,Local,,273.60,,,,,,,246.58,559.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7936053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,684.00000,198.36000,Aetna,Local,,273.60,,,,,,,220.25,559.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4773.06000,1384.19000,Aetna,Local,,1909.22,,,,,,,1720.69,3904.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4773.06000,1384.19000,Aetna,Local,,1909.22,,,,,,,1536.93,3904.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4773.06000,1384.19000,Aetna,Local,,1909.22,,,,,,,1720.69,3904.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4773.06000,1384.19000,Aetna,Local,,1909.22,,,,,,,1536.93,3904.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4773.06000,1384.19000,Aetna,Local,,1909.22,,,,,,,1720.69,3904.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4773.06000,1384.19000,Aetna,Local,,1909.22,,,,,,,1536.93,3904.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4773.02000,1384.18000,Aetna,Local,,1909.21,,,,,,,1720.67,3904.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4773.02000,1384.18000,Aetna,Local,,1909.21,,,,,,,1536.91,3904.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7856030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2693.24000,781.04000,Aetna,Local,,1077.30,,,,,,,970.91,2203.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7856030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2693.24000,781.04000,Aetna,Local,,1077.30,,,,,,,867.22,2203.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7929709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1582.12000,458.81000,Aetna,Local,,632.85,,,,,,,570.35,1294.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7929709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1582.12000,458.81000,Aetna,Local,,632.85,,,,,,,509.44,1294.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1582.12000,458.81000,Aetna,Local,,632.85,,,,,,,570.35,1294.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1582.12000,458.81000,Aetna,Local,,632.85,,,,,,,509.44,1294.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1224.00000,354.96000,Aetna,Local,,489.60,,,,,,,441.25,1001.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1224.00000,354.96000,Aetna,Local,,489.60,,,,,,,394.13,1001.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698505,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698505,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7900336,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7900336,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7927167,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7927167,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935730,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935730,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7937744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7937744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7937746,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7937746,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964531,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964531,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,432.92,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,386.68,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736603,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736603,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7744548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7744548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7748744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7784194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7784194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7806295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7806295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882380,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882380,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,302.94,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,270.59,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7754282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7754282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,302.94,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7897353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,270.59,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,302.94,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,Local,,336.13,,,,,,,270.59,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,Local,,245.02,,,,,,,220.82,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,Local,,245.02,,,,,,,197.24,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700419,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700419,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700423,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700423,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700813,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700813,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7707441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7707441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736218,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736218,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736222,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736222,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736685,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736685,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7742038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7742038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7750087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7750087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7754102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7754102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7754105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7754105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7754159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7754159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7794295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7802113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7822259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7822259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7836247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7836247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7846158,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7846158,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7846161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7846161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7874297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7874297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878314,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7878314,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7882393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893452,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893452,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904846,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904846,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7905618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6862.61,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6129.71,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736359,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6862.61,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736359,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6129.71,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6862.61,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7802098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6129.71,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7909381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6862.61,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7909381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6129.71,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7910369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6862.61,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7910369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6129.71,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6862.61,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6129.71,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7736615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2002.36000,580.68000,Aetna,Local,,800.94,,,,,,,721.85,1637.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7736615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2002.36000,580.68000,Aetna,Local,,800.94,,,,,,,644.76,1637.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7852076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2002.80000,580.81000,Aetna,Local,,801.12,,,,,,,722.01,1638.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7852076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2002.80000,580.81000,Aetna,Local,,801.12,,,,,,,644.90,1638.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7854031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2851.37,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7854031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2546.86,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7874329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1935.44000,561.28000,Aetna,Local,,774.18,,,,,,,697.73,1583.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7874329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1935.44000,561.28000,Aetna,Local,,774.18,,,,,,,623.21,1583.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7913414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2002.36000,580.68000,Aetna,Local,,800.94,,,,,,,721.85,1637.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7913414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2002.36000,580.68000,Aetna,Local,,800.94,,,,,,,644.76,1637.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,47.83,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,42.72,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,47.83,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,42.72,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,47.83,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,42.72,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736606,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,47.83,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736606,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,42.72,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7778030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,47.83,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7778030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,42.72,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7874334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7893432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7893432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7919003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7919003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7926704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7926704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7935780,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7935780,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7948082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7948082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1739.65,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1553.86,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740526,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7740526,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7750595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,Local,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1739.65,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1553.86,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1739.65,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1553.86,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1739.65,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1553.86,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1739.65,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1553.86,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1739.65,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1553.86,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1739.65,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1553.86,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1739.65,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4825.66000,1399.44000,Aetna,Local,,1930.26,,,,,,,1553.86,3947.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699690,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699690,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700376,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7700376,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7741334,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7741334,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7893766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7925926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7925926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699691,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,5416.16,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699691,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,4837.74,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,5416.16,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7699893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,4837.74,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,5416.16,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,4837.74,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7700189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,5416.16,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7700189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,4837.74,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7754287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,5416.16,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7754287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,4837.74,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7699699,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7699699,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7736171,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7736171,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7756362,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7756362,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7756363,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7756363,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7756364,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7756364,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2446.40000,709.46000,Aetna,Local,,978.56,,,,,,,881.93,2001.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2446.40000,709.46000,Aetna,Local,,978.56,,,,,,,787.74,2001.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7698944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,124.66,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7698944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,111.35,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7707476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,124.66,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7707476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,111.35,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7703332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,156.61000,45.42000,Aetna,Local,,62.64,,,,,,,56.46,128.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7703332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,156.61000,45.42000,Aetna,Local,,62.64,,,,,,,50.43,128.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700891,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7700891,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7935737,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,299.49000,86.85000,Aetna,Local,,119.80,,,,,,,107.97,244.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7935737,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,299.49000,86.85000,Aetna,Local,,119.80,,,,,,,96.44,244.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8475.00000,2457.75000,Aetna,Local,,3390.00,,,,,,,3055.24,6932.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8475.00000,2457.75000,Aetna,Local,,3390.00,,,,,,,2728.95,6932.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3506.06000,1016.76000,Aetna,Local,,1402.42,,,,,,,1263.93,2867.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3506.06000,1016.76000,Aetna,Local,,1402.42,,,,,,,1128.95,2867.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7697286,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7697286,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7880654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699255,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,Local,,1208.00,,,,,,,1088.71,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699255,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,Local,,1208.00,,,,,,,972.44,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,Local,,1208.00,,,,,,,1088.71,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,Local,,1208.00,,,,,,,972.44,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7802041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7802041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,Local,,1208.00,,,,,,,1088.71,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,Local,,1208.00,,,,,,,972.44,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,Local,,1208.00,,,,,,,1088.71,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7880655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,Local,,1208.00,,,,,,,972.44,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882831,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6238.58000,1809.19000,Aetna,Local,,2495.43,,,,,,,2249.01,5103.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7882831,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6238.58000,1809.19000,Aetna,Local,,2495.43,,,,,,,2008.82,5103.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7939811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6238.58000,1809.19000,Aetna,Local,,2495.43,,,,,,,2249.01,5103.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7939811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6238.58000,1809.19000,Aetna,Local,,2495.43,,,,,,,2008.82,5103.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880651,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1173.43,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880651,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1048.11,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7882524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1173.43,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7882524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,Local,,1302.00,,,,,,,1048.11,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697097,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697097,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697098,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697098,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697099,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697099,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697100,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697100,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697101,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697101,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697106,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697106,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697130,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697130,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697131,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697131,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697132,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697132,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697133,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697133,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,764.47,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697134,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697134,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697135,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697135,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697136,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697136,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697137,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697137,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697138,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697138,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697139,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697139,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697209,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697209,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697211,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697211,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697215,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697215,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697216,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697216,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697217,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697217,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697218,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697218,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,764.47,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697220,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697220,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697221,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697221,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697222,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697222,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697223,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697223,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697224,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697224,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697225,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697225,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,764.47,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697226,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697226,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,764.47,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697227,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697227,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698309,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698309,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698310,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698310,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698946,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698946,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698947,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698947,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698948,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698948,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698967,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7698967,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7702060,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7702060,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736042,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736042,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736043,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736043,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736237,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736237,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736239,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736239,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736240,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736240,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736241,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736241,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736242,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736242,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736243,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736243,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736244,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736244,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736245,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736245,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736246,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736246,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736247,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736247,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736249,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736249,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736325,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736325,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736326,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736326,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736327,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736327,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736328,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736328,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736329,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736329,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736330,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736330,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736331,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736331,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736332,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736332,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736427,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736427,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736428,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736428,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736429,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736429,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736430,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736430,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736431,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736431,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736432,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736432,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736433,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736433,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736434,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7736434,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699772,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699772,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7702077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7702077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7784191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7784191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7852035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7852035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7699765,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7699765,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736362,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736362,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736363,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736363,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736364,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736364,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736365,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7736365,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7774110,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7774110,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698725,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698725,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7699920,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7699920,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7903656,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1838.00000,533.02000,Aetna,Local,,735.20,,,,,,,662.60,1503.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7903656,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1838.00000,533.02000,Aetna,Local,,735.20,,,,,,,591.84,1503.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7938338,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1838.00000,533.02000,Aetna,Local,,735.20,,,,,,,662.60,1503.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7938338,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1838.00000,533.02000,Aetna,Local,,735.20,,,,,,,591.84,1503.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695513,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695513,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,Local,,245.02,,,,,,,220.82,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,Local,,245.02,,,,,,,197.24,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,344.57,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,307.77,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,344.57,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,307.77,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,733.50000,212.71000,Aetna,Local,,293.40,,,,,,,264.43,600.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,733.50000,212.71000,Aetna,Local,,293.40,,,,,,,236.19,600.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7748733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7756051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7760134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7760134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7772056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7880450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7882187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,Local,,245.02,,,,,,,220.82,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,Local,,245.02,,,,,,,197.24,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693555,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,616.94000,178.91000,Aetna,Local,,246.78,,,,,,,222.41,504.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693555,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,616.94000,178.91000,Aetna,Local,,246.78,,,,,,,198.65,504.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7947959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7947959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7905006,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7905006,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1110.10,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2893.01,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2584.05,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1993.80000,578.20000,Aetna,Local,,797.52,,,,,,,718.76,1630.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1993.80000,578.20000,Aetna,Local,,797.52,,,,,,,642.00,1630.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,Local,,740.85,,,,,,,667.69,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,Local,,740.85,,,,,,,596.38,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,Local,,740.85,,,,,,,667.69,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,Local,,740.85,,,,,,,596.38,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9636.00000,2794.44000,Aetna,Local,,3854.40,,,,,,,3473.78,7882.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9636.00000,2794.44000,Aetna,Local,,3854.40,,,,,,,3102.79,7882.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7937665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9807.00000,2844.03000,Aetna,Local,,3922.80,,,,,,,3535.42,8022.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7937665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9807.00000,2844.03000,Aetna,Local,,3922.80,,,,,,,3157.85,8022.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10323.00000,2993.67000,Aetna,Local,,4129.20,,,,,,,3721.44,8444.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10323.00000,2993.67000,Aetna,Local,,4129.20,,,,,,,3324.01,8444.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,7896395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1968.80000,570.95000,Aetna,Local,,787.52,,,,,,,709.75,1610.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,7896395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1968.80000,570.95000,Aetna,Local,,787.52,,,,,,,633.95,1610.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7736612,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,Local,,1929.06,,,,,,,1738.57,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7736612,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,Local,,1929.06,,,,,,,1552.89,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7895933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,Local,,1929.06,,,,,,,1738.57,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7895933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,Local,,1929.06,,,,,,,1552.89,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7930143,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,Local,,1929.06,,,,,,,1738.57,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7930143,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,Local,,1929.06,,,,,,,1552.89,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8862.00000,2569.98000,Aetna,Local,,3544.80,,,,,,,3194.75,7249.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8862.00000,2569.98000,Aetna,Local,,3544.80,,,,,,,2853.56,7249.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903576,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903576,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7965483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5376.00000,1559.04000,Aetna,Local,,2150.40,,,,,,,1938.05,4397.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7965483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5376.00000,1559.04000,Aetna,Local,,2150.40,,,,,,,1731.07,4397.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7904736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7916958,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,490.20000,142.16000,Aetna,Local,,196.08,,,,,,,176.72,400.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7916958,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,490.20000,142.16000,Aetna,Local,,196.08,,,,,,,157.84,400.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7896876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,166.10,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7896876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,148.36,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7700070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7762380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7762380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.27000,188.00000,Aetna,Local,,259.31,,,,,,,233.70,530.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.27000,188.00000,Aetna,Local,,259.31,,,,,,,208.74,530.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.27000,188.00000,Aetna,Local,,259.31,,,,,,,233.70,530.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.27000,188.00000,Aetna,Local,,259.31,,,,,,,208.74,530.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7901702,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7901702,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7903059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7903059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904739,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7904739,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909386,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909386,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7954793,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7954793,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7897117,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7897117,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9144.09000,2651.79000,Aetna,Local,,3657.64,,,,,,,3296.44,7479.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9144.09000,2651.79000,Aetna,Local,,3657.64,,,,,,,2944.40,7479.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1421.99,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1270.13,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1421.99,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1270.13,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1421.99,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1270.13,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7959548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1421.99,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7959548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1270.13,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7900098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7900098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7948521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7948521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7926646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7926646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7926668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7926668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1596.11,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1425.65,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,Local,,1779.28,,,,,,,1603.57,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,Local,,1779.28,,,,,,,1432.32,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1771.97,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1582.73,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1771.97,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1582.73,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1771.97,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1582.73,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1771.97,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1582.73,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1771.97,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1582.73,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1771.97,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1582.73,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1771.97,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1582.73,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7742036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7742036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7742037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7742037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7900568,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7900568,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7900569,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7900569,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7902811,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7902811,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7903043,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1299.40,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7903043,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1160.63,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7911001,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1299.40,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7911001,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1160.63,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,507.78000,147.26000,Aetna,Local,,203.11,,,,,,,183.05,415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,507.78000,147.26000,Aetna,Local,,203.11,,,,,,,163.51,415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7934012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7934012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7944504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7944504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRIP CABLE,7902353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3493.00000,1012.97000,Aetna,Local,,1397.20,,,,,,,1259.23,2857.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRIP CABLE,7902353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3493.00000,1012.97000,Aetna,Local,,1397.20,,,,,,,1124.75,2857.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRIP CABLE,7902354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3493.00000,1012.97000,Aetna,Local,,1397.20,,,,,,,1259.23,2857.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRIP CABLE,7902354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3493.00000,1012.97000,Aetna,Local,,1397.20,,,,,,,1124.75,2857.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7963956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,118.15,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7963956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,105.54,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7934018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1392.66,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7934018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1243.93,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911423,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,556.74000,161.45000,Aetna,Local,,222.70,,,,,,,200.70,455.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911423,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,556.74000,161.45000,Aetna,Local,,222.70,,,,,,,179.27,455.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7964445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7964445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7902775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7902775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7902814,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7902814,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2811.90,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2511.60,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935392,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4163.25000,1207.34000,Aetna,Local,,1665.30,,,,,,,1500.85,3405.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935392,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4163.25000,1207.34000,Aetna,Local,,1665.30,,,,,,,1340.57,3405.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7910688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5344.50000,1549.90000,Aetna,Local,,2137.80,,,,,,,1926.69,4371.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7910688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5344.50000,1549.90000,Aetna,Local,,2137.80,,,,,,,1720.93,4371.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7919018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7919018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7939964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5179.13000,1501.95000,Aetna,Local,,2071.65,,,,,,,1867.08,4236.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7939964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5179.13000,1501.95000,Aetna,Local,,2071.65,,,,,,,1667.68,4236.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7930350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7930350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7930351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7930351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948615,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948615,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7951855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5436.69000,1576.64000,Aetna,Local,,2174.68,,,,,,,1959.93,4447.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7951855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5436.69000,1576.64000,Aetna,Local,,2174.68,,,,,,,1750.61,4447.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911817,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,Local,,59.01,,,,,,,53.18,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911817,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,Local,,59.01,,,,,,,47.50,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911818,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,191.63000,55.57000,Aetna,Local,,76.65,,,,,,,69.08,156.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911818,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,191.63000,55.57000,Aetna,Local,,76.65,,,,,,,61.70,156.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911819,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,169.58000,49.18000,Aetna,Local,,67.83,,,,,,,61.13,138.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911819,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,169.58000,49.18000,Aetna,Local,,67.83,,,,,,,54.60,138.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7935183,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,173.67000,50.36000,Aetna,Local,,69.47,,,,,,,62.61,142.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7935183,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,173.67000,50.36000,Aetna,Local,,69.47,,,,,,,55.92,142.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7912135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,3136.35,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7912135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,2801.40,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,3136.35,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,2801.40,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939848,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,3136.35,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939848,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,2801.40,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913422,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913422,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7916713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7916713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917665,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917665,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917666,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7917666,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919076,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7919076,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7920819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7922445,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7922445,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7924908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7924908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926705,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926705,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926787,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926787,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7933872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7933872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939863,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939863,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7940892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7940892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943518,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943518,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944017,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944017,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944304,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944304,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944552,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944552,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944575,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944575,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7947962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7947962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948016,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948016,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7951981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964446,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964446,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964568,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964568,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7913421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7913421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7916711,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7916711,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7917664,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7917664,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7920347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7920347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7926788,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7926788,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939862,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939862,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7944307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7944307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7948814,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7948814,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7918356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7918356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7944306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7944306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7912277,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7912277,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7918405,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7918405,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7927054,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7927054,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7927055,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7927055,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935708,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935708,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935709,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935709,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935710,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935710,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7947966,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7947966,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7954647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7954647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5241.15000,1519.93000,Aetna,Local,,2096.46,,,,,,,1889.43,4287.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5241.15000,1519.93000,Aetna,Local,,2096.46,,,,,,,1687.65,4287.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912823,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,Local,,936.00,,,,,,,843.57,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912823,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,Local,,936.00,,,,,,,753.48,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7912824,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,806.18000,233.79000,Aetna,Local,,322.47,,,,,,,290.63,659.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7912824,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,806.18000,233.79000,Aetna,Local,,322.47,,,,,,,259.59,659.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912876,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,2061.39,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912876,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,1841.24,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,2061.39,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,1841.24,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912878,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,2061.39,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912878,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,1841.24,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,2061.39,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,1841.24,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,2061.39,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,1841.24,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,2061.39,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,1841.24,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,2061.39,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,1841.24,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,2061.39,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,Local,,2287.25,,,,,,,1841.24,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912885,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912885,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912886,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912886,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912887,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912887,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912889,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912889,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912891,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912891,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,Local,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912920,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912920,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912922,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912922,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912924,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912924,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,Local,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3105.96000,900.73000,Aetna,Local,,1242.38,,,,,,,1119.70,2540.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3105.96000,900.73000,Aetna,Local,,1242.38,,,,,,,1000.12,2540.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959513,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959513,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,51.67,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,143.33000,41.57000,Aetna,Local,,57.33,,,,,,,46.15,117.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7938091,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7938091,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7963962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7963962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7920745,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7920745,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7944228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8559.00000,2482.11000,Aetna,Local,,3423.60,,,,,,,3085.52,7001.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7944228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8559.00000,2482.11000,Aetna,Local,,3423.60,,,,,,,2756.00,7001.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2893.01,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2584.05,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7951960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2893.01,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7951960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2584.05,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7916472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7736.40000,2243.56000,Aetna,Local,,3094.56,,,,,,,2788.97,6328.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7916472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7736.40000,2243.56000,Aetna,Local,,3094.56,,,,,,,2491.12,6328.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7919059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7919059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7917855,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7917855,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7919094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7919094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7920121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7960333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.00000,559.99000,Aetna,Local,,772.40,,,,,,,696.13,1579.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7960333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.00000,559.99000,Aetna,Local,,772.40,,,,,,,621.78,1579.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7926702,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7926702,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7929708,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7929708,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7935782,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7935782,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7965002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7965002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7916714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3506.06000,1016.76000,Aetna,Local,,1402.42,,,,,,,1263.93,2867.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3506.06000,1016.76000,Aetna,Local,,1402.42,,,,,,,1128.95,2867.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3370.12000,977.33000,Aetna,Local,,1348.05,,,,,,,1214.93,2756.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7938860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3370.12000,977.33000,Aetna,Local,,1348.05,,,,,,,1085.18,2756.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7917822,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7917822,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7918048,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7918048,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7918049,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7918049,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7919001,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7919001,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7919002,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7919002,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7921023,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7921023,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7910459,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7910459,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7917823,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7917823,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7930115,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7930115,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7939298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7939298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7935479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7935479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,801.38,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,715.79,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,2211.03,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,1974.90,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7925196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,2211.03,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7925196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,1974.90,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7939322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,2211.03,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7939322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,1974.90,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7940868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,2211.03,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7940868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,1974.90,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7948127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,2211.03,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7948127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,1974.90,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7950210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,2211.03,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7950210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,1974.90,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7925195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7925195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7940893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7940893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7918401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7918401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7926452,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7926452,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7927413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7927413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7927416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7927416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7927417,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7927417,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7935028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7935028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7935032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7935032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7935033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7935033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7944415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7944415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7957819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7957819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7934013,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,906.12000,262.77000,Aetna,Local,,362.45,,,,,,,326.66,741.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7934013,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,906.12000,262.77000,Aetna,Local,,362.45,,,,,,,291.77,741.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7934957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,703.70,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7934957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,Local,,780.80,,,,,,,628.54,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7920543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1900.00000,551.00000,Aetna,Local,,760.00,,,,,,,684.95,1554.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7920543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1900.00000,551.00000,Aetna,Local,,760.00,,,,,,,611.80,1554.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7945868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1928.00000,559.12000,Aetna,Local,,771.20,,,,,,,695.04,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7945868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1928.00000,559.12000,Aetna,Local,,771.20,,,,,,,620.82,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7701620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7701620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736464,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736464,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7740560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7740560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7790537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7790537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7808036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7808036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7836193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7836193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7878480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7878480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7922464,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7922464,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7959547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7959547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7930353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7930353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7930354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7930354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7959516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7959516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7930352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7930352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7919079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7919079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903506,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903506,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903508,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903508,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903509,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903509,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903510,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903510,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7905041,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7905041,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7905470,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7905470,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909330,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909330,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909417,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909417,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909418,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909418,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909419,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909419,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909420,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909420,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909421,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909421,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909422,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7909422,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7920350,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7920350,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7920351,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7920351,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7920352,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7920352,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7924893,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7924893,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7924894,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7924894,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7924895,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7924895,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926565,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926565,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926566,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926566,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926567,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926567,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926568,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926568,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926877,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926877,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926878,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926878,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926879,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926879,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926880,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926880,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926895,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926895,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926896,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926896,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926897,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926897,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926966,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926966,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926967,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926967,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926968,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926968,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926969,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926969,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926970,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7926970,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927012,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927012,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927013,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927013,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927014,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927014,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927015,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927015,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927241,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927241,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927476,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927476,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927477,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927477,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927478,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7927478,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7930268,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7930268,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7930269,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7930269,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7930270,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7930270,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7930271,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7930271,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7930272,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7930272,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935421,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935421,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935422,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7935422,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7948759,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7948759,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7956574,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7956574,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918988,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8611.20000,2497.25000,Aetna,Local,,3444.48,,,,,,,3104.34,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918988,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8611.20000,2497.25000,Aetna,Local,,3444.48,,,,,,,2772.81,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7920817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6114.33000,1773.16000,Aetna,Local,,2445.73,,,,,,,2204.22,5001.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7920817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6114.33000,1773.16000,Aetna,Local,,2445.73,,,,,,,1968.81,5001.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7926703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7926703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7940800,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7940800,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7940869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7940869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7964473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7964473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7918990,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7918990,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7925895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2811.90,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7925895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2511.60,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
THYROPLASTY IMPLANT IN KIT,7919070,CDM,278,RC,C1878,HCPCS,,,facility,inpatient,,,1984.00000,575.36000,Aetna,Local,,793.60,,,,,,,715.23,1622.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
THYROPLASTY IMPLANT IN KIT,7919070,CDM,278,RC,C1878,HCPCS,,,facility,outpatient,,,1984.00000,575.36000,Aetna,Local,,793.60,,,,,,,638.85,1622.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7923286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1645.01,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7923286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1469.33,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7701624,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,3057.18,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7701624,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,2730.69,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7702637,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,3057.18,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7702637,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,2730.69,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7736445,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,3057.18,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7736445,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,2730.69,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,7920354,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,3057.18,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,7920354,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,2730.69,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7934015,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,3057.18,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7934015,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,2730.69,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8037.00000,2330.73000,Aetna,Local,,3214.80,,,,,,,2897.34,6574.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8037.00000,2330.73000,Aetna,Local,,3214.80,,,,,,,2587.91,6574.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7920399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10194.00000,2956.26000,Aetna,Local,,4077.60,,,,,,,3674.94,8338.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7920399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10194.00000,2956.26000,Aetna,Local,,4077.60,,,,,,,3282.47,8338.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,839.97,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,750.26,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7920489,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7920489,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7920492,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7920492,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7920744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7920744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,116.29,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,103.87,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,116.29,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,103.87,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,116.29,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,103.87,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3986.50000,1156.08000,Aetna,Local,,1594.60,,,,,,,1437.13,3260.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3986.50000,1156.08000,Aetna,Local,,1594.60,,,,,,,1283.65,3260.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3986.50000,1156.08000,Aetna,Local,,1594.60,,,,,,,1437.13,3260.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3986.50000,1156.08000,Aetna,Local,,1594.60,,,,,,,1283.65,3260.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7878474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,149.84000,43.45000,Aetna,Local,,59.94,,,,,,,54.02,122.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,149.84000,43.45000,Aetna,Local,,59.94,,,,,,,48.25,122.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7944023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,146.42000,42.46000,Aetna,Local,,58.57,,,,,,,52.78,119.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,146.42000,42.46000,Aetna,Local,,58.57,,,,,,,47.15,119.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7925897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7925897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938659,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938659,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7940801,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7940801,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7925898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7925898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938773,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938773,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7921207,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,8040.00000,2331.60000,Aetna,Local,,3216.00,,,,,,,2898.42,6576.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7921207,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,8040.00000,2331.60000,Aetna,Local,,3216.00,,,,,,,2588.88,6576.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7794042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7794042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7810030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7810030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7812116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7812116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7830035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7830035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7832099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7832099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7866114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7876328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7876328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7903144,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7903144,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905612,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905612,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7921279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7921279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7937839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7937839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939803,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939803,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7942057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7942057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7950205,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7950205,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7954086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7954086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7925634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7925634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO TRANSFIX,7702904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1653.80000,479.60000,Aetna,Local,,661.52,,,,,,,596.19,1352.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO TRANSFIX,7702904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1653.80000,479.60000,Aetna,Local,,661.52,,,,,,,532.52,1352.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7951881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7951881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924775,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924775,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,Local,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3930.50000,1139.84000,Aetna,Local,,1572.20,,,,,,,1416.95,3215.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3930.50000,1139.84000,Aetna,Local,,1572.20,,,,,,,1265.62,3215.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924793,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924793,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924806,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924806,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924809,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924809,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924814,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924814,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7924843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,147.26,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,131.54,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,147.26,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7794450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,131.54,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935612,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935612,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,134.94,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,120.52,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,134.94,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,120.52,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7930309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7930309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938993,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7938993,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7946098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7946098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940793,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,Local,,3434.40,,,,,,,3095.25,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940793,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,Local,,3434.40,,,,,,,2764.69,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7925239,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7925239,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7925240,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7925240,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7939859,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7939859,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7960033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7925626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7925626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7925629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7925629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7925630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7925630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7965451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7965451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7925855,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7925855,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,873.04,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,779.81,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7927179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,Local,,4521.24,,,,,,,4074.77,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7927179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,Local,,4521.24,,,,,,,3639.60,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7935863,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,Local,,4521.24,,,,,,,4074.77,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7935863,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,Local,,4521.24,,,,,,,3639.60,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7943287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,Local,,4521.24,,,,,,,4074.77,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7943287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,Local,,4521.24,,,,,,,3639.60,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926578,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21272.50000,6169.02000,Aetna,Local,,8509.00,,,,,,,7668.74,17400.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926578,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21272.50000,6169.02000,Aetna,Local,,8509.00,,,,,,,6849.74,17400.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926673,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926673,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926674,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926674,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926675,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926675,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926676,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926676,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926677,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926677,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926678,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926678,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926679,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926679,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926680,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926680,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926681,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926681,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926682,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926682,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926683,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926683,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926684,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926684,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926685,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926685,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926686,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926686,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926687,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926687,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926688,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926688,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926689,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926689,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926690,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926690,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926691,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926691,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926692,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926692,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926693,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926693,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926694,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926694,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926695,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926695,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7948018,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7948018,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7948019,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7948019,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7948020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,7480.38,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7948020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,6681.50,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7948021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,7480.38,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7948021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,6681.50,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7948022,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,7480.38,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7948022,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,6681.50,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7954158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2903.18,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7954158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2593.13,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7957821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2903.18,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7957821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2593.13,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7959959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2903.18,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7959959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2593.13,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,Local,,1100.00,,,,,,,991.38,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,Local,,1100.00,,,,,,,885.50,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,Local,,1100.00,,,,,,,991.38,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,Local,,1100.00,,,,,,,885.50,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7935113,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,577.80000,167.56000,Aetna,Local,,231.12,,,,,,,208.30,472.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7935113,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,577.80000,167.56000,Aetna,Local,,231.12,,,,,,,186.05,472.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7955061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7955061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS SHORT TERM,7693557,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,428.23000,124.19000,Aetna,Local,,171.29,,,,,,,154.38,350.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS SHORT TERM,7693557,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,428.23000,124.19000,Aetna,Local,,171.29,,,,,,,137.89,350.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7927182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3420.78,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7927182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3055.46,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7736159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,7151.42,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7736159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,6387.68,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7736437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,7151.42,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7736437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,6387.68,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7929762,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7929762,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7947953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7947953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948017,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948017,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7927343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3458.00000,1002.82000,Aetna,Local,,1383.20,,,,,,,1246.61,2828.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7927343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3458.00000,1002.82000,Aetna,Local,,1383.20,,,,,,,1113.48,2828.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7947958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7947958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935781,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7935781,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948364,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948364,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7950208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7950208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7959535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7959535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7960337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7966084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7966084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7966085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7966085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7946094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7946094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7935152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937840,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937840,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7962254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7962254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3170.00000,919.30000,Aetna,Local,,1268.00,,,,,,,1142.79,2593.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3170.00000,919.30000,Aetna,Local,,1268.00,,,,,,,1020.74,2593.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7929724,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12426.00000,3603.54000,Aetna,Local,,4970.40,,,,,,,4479.57,10164.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7929724,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12426.00000,3603.54000,Aetna,Local,,4970.40,,,,,,,4001.17,10164.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7959514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1211.28,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7959514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1081.92,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929753,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929753,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929754,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929754,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929757,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929757,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929758,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929758,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,873.04,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,779.81,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,Local,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7924639,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,2104.22,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7924639,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,1879.50,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7927098,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,2104.22,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7927098,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,1879.50,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7930118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,2104.22,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7930118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,1879.50,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7930144,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,2104.22,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7930144,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,1879.50,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7930147,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7930147,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7930183,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7930183,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935790,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935790,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13117.38000,3804.04000,Aetna,Local,,5246.95,,,,,,,4728.82,10730.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7893923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13117.38000,3804.04000,Aetna,Local,,5246.95,,,,,,,4223.80,10730.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7930202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13117.38000,3804.04000,Aetna,Local,,5246.95,,,,,,,4728.82,10730.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7930202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13117.38000,3804.04000,Aetna,Local,,5246.95,,,,,,,4223.80,10730.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7937838,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1818.00000,527.22000,Aetna,Local,,727.20,,,,,,,655.39,1487.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7937838,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1818.00000,527.22000,Aetna,Local,,727.20,,,,,,,585.40,1487.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7954114,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1818.00000,527.22000,Aetna,Local,,727.20,,,,,,,655.39,1487.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7954114,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1818.00000,527.22000,Aetna,Local,,727.20,,,,,,,585.40,1487.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7960315,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7960315,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903147,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903147,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,900.00000,261.00000,Aetna,Local,,360.00,,,,,,,324.45,736.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,,360.00,,,,,,,289.80,736.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,202.23,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,180.63,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7950496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,202.23,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,180.63,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,Local,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7754165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7754165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7760070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7760070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7816136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7816136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7895934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7895934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7929763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7929763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7947965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7947965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7951955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7951955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7905493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3670.17000,1064.35000,Aetna,Local,,1468.07,,,,,,,1323.10,3002.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3670.17000,1064.35000,Aetna,Local,,1468.07,,,,,,,1181.79,3002.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3670.17000,1064.35000,Aetna,Local,,1468.07,,,,,,,1323.10,3002.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3670.17000,1064.35000,Aetna,Local,,1468.07,,,,,,,1181.79,3002.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7938959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,19710.00000,5715.90000,Aetna,Local,,7884.00,,,,,,,7105.45,16122.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7938959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,19710.00000,5715.90000,Aetna,Local,,7884.00,,,,,,,6346.62,16122.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.32000,177.57000,Aetna,Local,,244.93,,,,,,,220.74,500.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7938400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.32000,177.57000,Aetna,Local,,244.93,,,,,,,197.17,500.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696020,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,11078.35,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696020,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,9895.22,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696021,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,11078.35,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696021,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,9895.22,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696022,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,11078.35,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696022,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,9895.22,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696024,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,11078.35,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696024,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,9895.22,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696025,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,11078.35,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696025,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,9895.22,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696580,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,11078.35,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696580,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,9895.22,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696023,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,11078.35,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696023,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,Local,,12292.20,,,,,,,9895.22,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7939316,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7939316,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7944074,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7944074,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7935342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,2197.43,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7935342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,1962.75,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7939323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,2197.43,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7939323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,1962.75,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7699366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3266.90000,947.40000,Aetna,Local,,1306.76,,,,,,,1177.72,2672.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7699366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3266.90000,947.40000,Aetna,Local,,1306.76,,,,,,,1051.94,2672.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7695039,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7695039,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7700224,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7700224,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7702059,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7702059,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7914407,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7914407,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7912692,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,663.75000,192.49000,Aetna,Local,,265.50,,,,,,,239.28,542.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7912692,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,663.75000,192.49000,Aetna,Local,,265.50,,,,,,,213.73,542.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7695015,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,663.75000,192.49000,Aetna,Local,,265.50,,,,,,,239.28,542.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7695015,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,663.75000,192.49000,Aetna,Local,,265.50,,,,,,,213.73,542.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935394,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1902.00000,551.58000,Aetna,Local,,760.80,,,,,,,685.67,1555.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935394,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1902.00000,551.58000,Aetna,Local,,760.80,,,,,,,612.44,1555.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935391,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,Local,,2337.30,,,,,,,2106.49,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935391,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,Local,,2337.30,,,,,,,1881.53,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7937860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7937860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7960153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7960153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7935593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8524.20000,2472.02000,Aetna,Local,,3409.68,,,,,,,3072.97,6972.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7935593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8524.20000,2472.02000,Aetna,Local,,3409.68,,,,,,,2744.79,6972.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7935565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7935565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7950206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7950206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7956661,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7956661,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7965201,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7965201,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922446,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922446,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7925221,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7925221,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7925222,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7925222,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7935072,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7935072,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7935739,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7935739,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7937691,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7937691,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7947967,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7947967,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7956687,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7956687,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7965200,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7965200,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935776,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935776,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7937938,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,23750.00000,6887.50000,Aetna,Local,,9500.00,,,,,,,8561.88,19427.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7937938,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,23750.00000,6887.50000,Aetna,Local,,9500.00,,,,,,,7647.50,19427.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7945948,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7945948,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7946010,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7946010,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948523,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948523,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948524,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948524,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7957667,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7957667,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935775,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935775,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7937874,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,23750.00000,6887.50000,Aetna,Local,,9500.00,,,,,,,8561.88,19427.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7937874,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,23750.00000,6887.50000,Aetna,Local,,9500.00,,,,,,,7647.50,19427.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7944052,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7944052,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918350,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918350,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918408,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918408,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918946,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918946,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7920409,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7920409,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922453,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7922453,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7927614,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7927614,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7935740,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7935740,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7936087,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7936087,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7943307,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7943307,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948361,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948361,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948914,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948914,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950156,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950156,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7957958,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7957958,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7963960,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7963960,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7700125,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16392.50000,4753.82000,Aetna,Local,,6557.00,,,,,,,5909.50,13409.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7700125,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16392.50000,4753.82000,Aetna,Local,,6557.00,,,,,,,5278.39,13409.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7701587,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16392.50000,4753.82000,Aetna,Local,,6557.00,,,,,,,5909.50,13409.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7701587,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16392.50000,4753.82000,Aetna,Local,,6557.00,,,,,,,5278.39,13409.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7788036,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7788036,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701588,CDM,278,RC,,,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701588,CDM,278,RC,,,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702227,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702227,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702247,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702247,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7766037,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7766037,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7782034,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7782034,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7790164,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7790164,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7882341,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7882341,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7882343,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7882343,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7893455,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7893455,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7911779,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7911779,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,Local,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7736081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10473.00000,3037.17000,Aetna,Local,,4189.20,,,,,,,3775.52,8566.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7736081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10473.00000,3037.17000,Aetna,Local,,4189.20,,,,,,,3372.31,8566.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7942776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8869.20000,2572.07000,Aetna,Local,,3547.68,,,,,,,3197.35,7255.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7942776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8869.20000,2572.07000,Aetna,Local,,3547.68,,,,,,,2855.88,7255.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7935915,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1431.96000,415.27000,Aetna,Local,,572.78,,,,,,,516.22,1171.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7935915,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1431.96000,415.27000,Aetna,Local,,572.78,,,,,,,461.09,1171.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7935916,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1431.96000,415.27000,Aetna,Local,,572.78,,,,,,,516.22,1171.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7935916,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1431.96000,415.27000,Aetna,Local,,572.78,,,,,,,461.09,1171.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7840052,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13323.00000,3863.67000,Aetna,Local,,5329.20,,,,,,,4802.94,10898.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7840052,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13323.00000,3863.67000,Aetna,Local,,5329.20,,,,,,,4290.01,10898.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694643,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,32.41,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694643,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,28.94,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694690,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,32.41,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694690,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,28.94,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702800,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,32.41,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702800,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,28.94,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10667.67000,3093.62000,Aetna,Local,,4267.07,,,,,,,3845.70,8726.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10667.67000,3093.62000,Aetna,Local,,4267.07,,,,,,,3434.99,8726.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7936110,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7936110,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7936112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7936112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964478,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,Local,,873.60,,,,,,,787.33,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964478,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,Local,,873.60,,,,,,,703.25,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,Local,,873.60,,,,,,,787.33,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,Local,,873.60,,,,,,,703.25,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7936511,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,118.15,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7936511,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,105.54,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957708,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957708,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957709,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957709,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7961898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7961898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7961942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7961942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7964340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7965258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7950553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7950553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7950554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7950554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7957706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7957706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7964341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7964341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7965239,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7965239,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,Local,,134.90,,,,,,,121.58,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,Local,,134.90,,,,,,,108.59,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7937809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7937809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7943249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7943249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7954790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7954790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7943139,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7943139,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7950095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7950095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7938910,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,15637.50000,4534.88000,Aetna,Local,,6255.00,,,,,,,5637.32,12791.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7938910,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,15637.50000,4534.88000,Aetna,Local,,6255.00,,,,,,,5035.27,12791.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7938911,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,15637.50000,4534.88000,Aetna,Local,,6255.00,,,,,,,5637.32,12791.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7938911,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,15637.50000,4534.88000,Aetna,Local,,6255.00,,,,,,,5035.27,12791.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7938912,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,15637.50000,4534.88000,Aetna,Local,,6255.00,,,,,,,5637.32,12791.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7938912,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,15637.50000,4534.88000,Aetna,Local,,6255.00,,,,,,,5035.27,12791.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938995,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938995,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7943917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7943917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7956548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7956548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7956550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7956550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7945952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7945952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7947923,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7947923,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,Local,,2225.88,,,,,,,2006.07,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,Local,,2225.88,,,,,,,1791.83,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944263,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13275.00000,3849.75000,Aetna,Local,,5310.00,,,,,,,4785.64,10858.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944263,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13275.00000,3849.75000,Aetna,Local,,5310.00,,,,,,,4274.55,10858.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1211.28,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1081.92,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1211.28,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1081.92,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3451.88000,1001.05000,Aetna,Local,,1380.75,,,,,,,1244.40,2823.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3451.88000,1001.05000,Aetna,Local,,1380.75,,,,,,,1111.51,2823.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3819.38000,1107.62000,Aetna,Local,,1527.75,,,,,,,1376.89,3124.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3819.38000,1107.62000,Aetna,Local,,1527.75,,,,,,,1229.84,3124.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,487.87000,141.48000,Aetna,Local,,195.15,,,,,,,175.88,399.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,487.87000,141.48000,Aetna,Local,,195.15,,,,,,,157.09,399.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,174.10,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,155.50,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,174.10,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,155.50,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,174.10,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,155.50,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,174.10,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,155.50,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,174.10,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,155.50,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,174.10,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,Local,,193.17,,,,,,,155.50,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7744539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7933873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939497,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939497,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7940850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7961896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1595.00000,462.55000,Aetna,Local,,638.00,,,,,,,575.00,1304.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7961896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1595.00000,462.55000,Aetna,Local,,638.00,,,,,,,513.59,1304.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7964557,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7964557,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7965261,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7965261,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941913,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941913,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941914,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941914,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7943320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7953973,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,Local,,2667.35,,,,,,,2403.95,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7953973,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,Local,,2667.35,,,,,,,2147.22,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8374458,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8374458,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7956686,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,5321.54000,1543.25000,Aetna,Local,,2128.62,,,,,,,1918.42,4353.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7956686,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,5321.54000,1543.25000,Aetna,Local,,2128.62,,,,,,,1713.54,4353.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7959984,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7959984,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7958122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15485.00000,4490.65000,Aetna,Local,,6194.00,,,,,,,5582.34,12666.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7958122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15485.00000,4490.65000,Aetna,Local,,6194.00,,,,,,,4986.17,12666.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7956551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7956551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7950459,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7950459,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7953899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7953899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7945950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7945950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7947924,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7947924,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7844.40000,2274.88000,Aetna,Local,,3137.76,,,,,,,2827.91,6416.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7844.40000,2274.88000,Aetna,Local,,3137.76,,,,,,,2525.90,6416.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7820086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7844.40000,2274.88000,Aetna,Local,,3137.76,,,,,,,2827.91,6416.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7820086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7844.40000,2274.88000,Aetna,Local,,3137.76,,,,,,,2525.90,6416.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7896396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7844.40000,2274.88000,Aetna,Local,,3137.76,,,,,,,2827.91,6416.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7896396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7844.40000,2274.88000,Aetna,Local,,3137.76,,,,,,,2525.90,6416.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3907.58000,1133.20000,Aetna,Local,,1563.03,,,,,,,1408.68,3196.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3907.58000,1133.20000,Aetna,Local,,1563.03,,,,,,,1258.24,3196.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3907.58000,1133.20000,Aetna,Local,,1563.03,,,,,,,1408.68,3196.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3907.58000,1133.20000,Aetna,Local,,1563.03,,,,,,,1258.24,3196.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7699312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3907.58000,1133.20000,Aetna,Local,,1563.03,,,,,,,1408.68,3196.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7699312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3907.58000,1133.20000,Aetna,Local,,1563.03,,,,,,,1258.24,3196.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697937,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697937,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698094,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698094,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7953908,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7953908,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7950155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7950155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7953909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7953909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7964383,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5634.61,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7964383,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5032.86,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7956553,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7956553,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7964651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7964651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948522,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948522,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7950096,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7950096,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7950461,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7950461,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7953910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7953910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7957666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7948867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.58000,1439.73000,Aetna,Local,,1985.83,,,,,,,1789.73,4061.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7948867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.58000,1439.73000,Aetna,Local,,1985.83,,,,,,,1598.59,4061.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,1072.65,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,958.09,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7960152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1151.87,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7960152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1028.85,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,7950501,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,7950501,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,7957820,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,7957820,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7948414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7948414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7948693,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7948693,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7948696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7948696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7951956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7951956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7951957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7951957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7951958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7951958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7953974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7953974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7958094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7958094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7960042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7960042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7963932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7963932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TESTICULAR IMPLANT,7948611,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8499.00000,2464.71000,Aetna,Local,,3399.60,,,,,,,3063.89,6952.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TESTICULAR IMPLANT,7948611,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8499.00000,2464.71000,Aetna,Local,,3399.60,,,,,,,2736.68,6952.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7948595,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7948595,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7965009,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7965009,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948612,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948612,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7951862,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7951862,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7954524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7954524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957705,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7957705,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948865,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948865,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950030,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950030,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950031,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950031,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950341,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950341,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950342,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950342,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954161,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954161,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954162,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954162,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954163,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954163,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954164,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954164,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954614,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954614,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954682,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954682,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950094,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950094,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950463,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950463,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950497,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950497,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7958107,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7958107,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7962618,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7962618,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7964485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7955063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7955063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7957765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7957765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950552,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950552,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7954746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7954746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7954475,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,Local,,1244.80,,,,,,,1121.88,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7954475,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,Local,,1244.80,,,,,,,1002.06,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954613,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954613,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10420.80000,3022.03000,Aetna,Local,,4168.32,,,,,,,3756.70,8524.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10420.80000,3022.03000,Aetna,Local,,4168.32,,,,,,,3355.50,8524.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10420.80000,3022.03000,Aetna,Local,,4168.32,,,,,,,3756.70,8524.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10420.80000,3022.03000,Aetna,Local,,4168.32,,,,,,,3355.50,8524.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7964380,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7964380,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7964381,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7964381,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7964382,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7964382,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7957914,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7957914,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,731.09,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,653.02,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,731.09,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,653.02,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,731.09,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,653.02,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7948233,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,Local,,3615.58,,,,,,,3258.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7948233,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,Local,,3615.58,,,,,,,2910.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7948234,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,Local,,3615.58,,,,,,,3258.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7948234,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,Local,,3615.58,,,,,,,2910.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7948235,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,Local,,3615.58,,,,,,,3258.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7948235,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,Local,,3615.58,,,,,,,2910.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7948236,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,Local,,3615.58,,,,,,,3258.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7948236,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,Local,,3615.58,,,,,,,2910.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7960020,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6125.00000,1776.25000,Aetna,Local,,2450.00,,,,,,,2208.06,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7960020,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6125.00000,1776.25000,Aetna,Local,,2450.00,,,,,,,1972.25,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7963935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7963935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7964477,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,Local,,4036.80,,,,,,,3638.17,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7964477,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,Local,,4036.80,,,,,,,3249.62,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965058,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965058,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965059,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965059,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965060,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965060,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965062,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965062,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965063,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965063,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,876.74,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,783.10,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1527.56000,442.99000,Aetna,Local,,611.02,,,,,,,550.69,1249.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1527.56000,442.99000,Aetna,Local,,611.02,,,,,,,491.87,1249.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903785,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903785,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903786,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903786,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903787,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903787,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903788,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15675.00000,4545.75000,Aetna,Local,,6270.00,,,,,,,5650.84,12822.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903788,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15675.00000,4545.75000,Aetna,Local,,6270.00,,,,,,,5047.35,12822.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903789,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15675.00000,4545.75000,Aetna,Local,,6270.00,,,,,,,5650.84,12822.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903789,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15675.00000,4545.75000,Aetna,Local,,6270.00,,,,,,,5047.35,12822.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903790,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15675.00000,4545.75000,Aetna,Local,,6270.00,,,,,,,5650.84,12822.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903790,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15675.00000,4545.75000,Aetna,Local,,6270.00,,,,,,,5047.35,12822.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903792,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,21347.50000,6190.78000,Aetna,Local,,8539.00,,,,,,,7695.77,17462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903792,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,21347.50000,6190.78000,Aetna,Local,,8539.00,,,,,,,6873.90,17462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903794,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,22570.00000,6545.30000,Aetna,Local,,9028.00,,,,,,,8136.48,18462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903794,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,22570.00000,6545.30000,Aetna,Local,,9028.00,,,,,,,7267.54,18462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903779,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,25885.00000,7506.65000,Aetna,Local,,10354.00,,,,,,,9331.54,21173.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903779,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,25885.00000,7506.65000,Aetna,Local,,10354.00,,,,,,,8334.97,21173.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903781,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,27960.75000,8108.62000,Aetna,Local,,11184.30,,,,,,,10079.85,22871.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903781,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,27960.75000,8108.62000,Aetna,Local,,11184.30,,,,,,,9003.36,22871.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7955807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,239.14,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7955807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.35000,192.37000,Aetna,Local,,265.34,,,,,,,213.60,542.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,338.17,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,302.06,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,338.17,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7914399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,302.06,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7922550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7910503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7910503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7917699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7917699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7935822,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7935822,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7948758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7948758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7964475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7964475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7908183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7930311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7930311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7942775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7942775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948613,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948613,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7962257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7904845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3265.50000,946.99000,Aetna,Local,,1306.20,,,,,,,1177.21,2671.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7904845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3265.50000,946.99000,Aetna,Local,,1306.20,,,,,,,1051.49,2671.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7993619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7993619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7993626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7993626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7993638,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18855.00000,5467.95000,Aetna,Local,,7542.00,,,,,,,6797.23,15423.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7993638,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18855.00000,5467.95000,Aetna,Local,,7542.00,,,,,,,6071.31,15423.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7993667,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7993667,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7993669,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7993669,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,731.09,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,653.02,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7993671,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7993671,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7993672,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7993672,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7993748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7993748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7993773,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7993773,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7993777,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7993777,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7993779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7993779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7993811,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7993811,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7993813,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7993813,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1222.30,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1091.76,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7993990,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7993990,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7993992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7993992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7993994,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7993994,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7994180,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7994180,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7994182,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7994182,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7994184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7994184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7994255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1151.87,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7994255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1028.85,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7994294,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,48037.50000,13930.87000,Aetna,Local,,19215.00,,,,,,,17317.52,39294.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7994294,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,48037.50000,13930.87000,Aetna,Local,,19215.00,,,,,,,15468.08,39294.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8001083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8001083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8001085,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,799.79000,231.94000,Aetna,Local,,319.92,,,,,,,288.32,654.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8001085,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,799.79000,231.94000,Aetna,Local,,319.92,,,,,,,257.53,654.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8001414,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8001414,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8001437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8001437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8001439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8001439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,8001678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,7151.42,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,8001678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,6387.68,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8001679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2708.08,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8001679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2418.86,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8001680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,6518.74,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8001680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,5822.56,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8001681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4609.35,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8001681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4117.09,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8001682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8001682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8001980,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8001980,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8002094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8002094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8002202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8002202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8002204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1395.50,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8002204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1246.46,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8002206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,370.50000,107.44000,Aetna,Local,,148.20,,,,,,,133.57,303.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8002206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,370.50000,107.44000,Aetna,Local,,148.20,,,,,,,119.30,303.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8002387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8002387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8002389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8002389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8003089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1222.30,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8003089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1091.76,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8003093,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4544.46,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8003093,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4059.13,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8003095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8003095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8003091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8003091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8003183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1948.00000,564.92000,Aetna,Local,,779.20,,,,,,,702.25,1593.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8003183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1948.00000,564.92000,Aetna,Local,,779.20,,,,,,,627.26,1593.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8003185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8003185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8003188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3574.03000,1036.47000,Aetna,Local,,1429.61,,,,,,,1288.44,2923.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8003188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3574.03000,1036.47000,Aetna,Local,,1429.61,,,,,,,1150.84,2923.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,8003300,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,18870.25000,5472.37000,Aetna,Local,,7548.10,,,,,,,6802.73,15435.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,8003300,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,18870.25000,5472.37000,Aetna,Local,,7548.10,,,,,,,6076.22,15435.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8003302,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25875.00000,7503.75000,Aetna,Local,,10350.00,,,,,,,9327.94,21165.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8003302,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25875.00000,7503.75000,Aetna,Local,,10350.00,,,,,,,8331.75,21165.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8003303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26750.00000,7757.50000,Aetna,Local,,10700.00,,,,,,,9643.38,21881.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8003303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26750.00000,7757.50000,Aetna,Local,,10700.00,,,,,,,8613.50,21881.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8003304,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8003304,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FLEXIGRAFT,8005020,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8838.00000,2563.02000,Aetna,Local,,3535.20,,,,,,,3186.10,7229.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FLEXIGRAFT,8005020,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8838.00000,2563.02000,Aetna,Local,,3535.20,,,,,,,2845.84,7229.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8008786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4634.00000,1343.86000,Aetna,Local,,1853.60,,,,,,,1670.56,3790.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8008786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4634.00000,1343.86000,Aetna,Local,,1853.60,,,,,,,1492.15,3790.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8008784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,366.70000,106.34000,Aetna,Local,,146.68,,,,,,,132.20,299.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8008784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,366.70000,106.34000,Aetna,Local,,146.68,,,,,,,118.08,299.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8008804,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8008804,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8008806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8008806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8008812,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,801.38,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8008812,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,715.79,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8008814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2337.36000,677.83000,Aetna,Local,,934.94,,,,,,,842.62,1911.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8008814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2337.36000,677.83000,Aetna,Local,,934.94,,,,,,,752.63,1911.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8008808,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8008808,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8008810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8008810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8008816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8008816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8008818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8008818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8008841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,907.31,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8008841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,810.41,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8009529,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,Local,,4036.80,,,,,,,3638.17,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8009529,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,Local,,4036.80,,,,,,,3249.62,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8009531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8009531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8009533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8009533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8009723,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8009723,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8061877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8061877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8062076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8062076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8062083,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8062083,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8062084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8062084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8062085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8062085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8062086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8062086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8062087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8062087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8062088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8062088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8062089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2365.78,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8062089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2113.12,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8062079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8062079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABLUR AUGMENT,8062080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABLUR AUGMENT,8062080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8062081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8062081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8062082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8062082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8067256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5971.00000,1731.59000,Aetna,Local,,2388.40,,,,,,,2152.55,4884.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8067256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5971.00000,1731.59000,Aetna,Local,,2388.40,,,,,,,1922.66,4884.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.00000,206.19000,Aetna,Local,,284.40,,,,,,,256.32,581.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.00000,206.19000,Aetna,Local,,284.40,,,,,,,228.94,581.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8067260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,920.00,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8067260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,821.74,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8067264,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8067264,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8067265,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,Local,,832.00,,,,,,,749.84,1701.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8067265,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,Local,,832.00,,,,,,,669.76,1701.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8067384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8067384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8067494,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,24670.00000,7154.30000,Aetna,Local,,9868.00,,,,,,,8893.53,20180.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8067494,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,24670.00000,7154.30000,Aetna,Local,,9868.00,,,,,,,7943.74,20180.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8067497,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20775.00000,6024.75000,Aetna,Local,,8310.00,,,,,,,7489.39,16993.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8067497,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20775.00000,6024.75000,Aetna,Local,,8310.00,,,,,,,6689.55,16993.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8067502,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,24670.00000,7154.30000,Aetna,Local,,9868.00,,,,,,,8893.53,20180.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8067502,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,24670.00000,7154.30000,Aetna,Local,,9868.00,,,,,,,7943.74,20180.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8067496,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20775.00000,6024.75000,Aetna,Local,,8310.00,,,,,,,7489.39,16993.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8067496,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20775.00000,6024.75000,Aetna,Local,,8310.00,,,,,,,6689.55,16993.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8067498,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20775.00000,6024.75000,Aetna,Local,,8310.00,,,,,,,7489.39,16993.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8067498,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20775.00000,6024.75000,Aetna,Local,,8310.00,,,,,,,6689.55,16993.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8067499,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20775.00000,6024.75000,Aetna,Local,,8310.00,,,,,,,7489.39,16993.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8067499,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20775.00000,6024.75000,Aetna,Local,,8310.00,,,,,,,6689.55,16993.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8067500,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20775.00000,6024.75000,Aetna,Local,,8310.00,,,,,,,7489.39,16993.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8067500,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20775.00000,6024.75000,Aetna,Local,,8310.00,,,,,,,6689.55,16993.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8067505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,208.85000,60.57000,Aetna,Local,,83.54,,,,,,,75.29,170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8067505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,208.85000,60.57000,Aetna,Local,,83.54,,,,,,,67.25,170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,70.03,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8067506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,62.55,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8067508,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8067508,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8067958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8067958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8067960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8067960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8069196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8069196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8069205,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8069205,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8069543,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8069543,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,8069772,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,8069772,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8069546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8069546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8069547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8069547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,342.48000,99.32000,Aetna,Local,,136.99,,,,,,,123.46,280.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,342.48000,99.32000,Aetna,Local,,136.99,,,,,,,110.28,280.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,70.03,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,62.55,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,70.03,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8069800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,62.55,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8069802,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2893.01,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8069802,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2584.05,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8069805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8069805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8108662,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8108662,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8117183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8117183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8117184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8117184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8117212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8117212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8117214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8117214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8117216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8117216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT SM,8117294,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT SM,8117294,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT SM,8117296,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT SM,8117296,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8117298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8117298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8117324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8117324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE FEMORAL,8117326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE FEMORAL,8117326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE FEMORAL,8117363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE FEMORAL,8117363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8117461,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8117461,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPEEDBRIDGE IMPLANT SYS,8117463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8266.50000,2397.28000,Aetna,Local,,3306.60,,,,,,,2980.07,6762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPEEDBRIDGE IMPLANT SYS,8117463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8266.50000,2397.28000,Aetna,Local,,3306.60,,,,,,,2661.81,6762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,8117464,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,8117464,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CATH,8117481,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT CATH,8117481,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,8117483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8017.29000,2325.01000,Aetna,Local,,3206.92,,,,,,,2890.23,6558.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,8117483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8017.29000,2325.01000,Aetna,Local,,3206.92,,,,,,,2581.57,6558.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CONTRD,8117547,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CONTRD,8117547,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8117673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,Local,,1409.80,,,,,,,1270.58,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8117673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,Local,,1409.80,,,,,,,1134.89,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT INNER BODY,8117675,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT INNER BODY,8117675,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8117677,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8117677,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8117679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16087.50000,4665.38000,Aetna,Local,,6435.00,,,,,,,5799.54,13159.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8117679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16087.50000,4665.38000,Aetna,Local,,6435.00,,,,,,,5180.18,13159.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8117770,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4544.46,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8117770,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4059.13,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,8117884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6110.16000,1771.95000,Aetna,Local,,2444.06,,,,,,,2202.71,4998.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,8117884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6110.16000,1771.95000,Aetna,Local,,2444.06,,,,,,,1967.47,4998.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,8117886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,761.40000,220.81000,Aetna,Local,,304.56,,,,,,,274.48,622.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,8117886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,761.40000,220.81000,Aetna,Local,,304.56,,,,,,,245.17,622.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT RDL HEAD,8117888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8670.00000,2514.30000,Aetna,Local,,3468.00,,,,,,,3125.53,7092.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT RDL HEAD,8117888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8670.00000,2514.30000,Aetna,Local,,3468.00,,,,,,,2791.74,7092.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8117764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8117764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8117766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8117766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8117768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8117768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117911,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117911,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8117913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8117913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8117915,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8117915,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,219.00,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8117941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,195.62,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8118247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8118247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANC,8117943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANC,8117943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HUMERAL,8117945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HUMERAL,8117945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8118249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8118249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING SYS ADVANCE MALE,8119055,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,28080.00000,8143.20000,Aetna,Local,,11232.00,,,,,,,10122.84,22969.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING SYS ADVANCE MALE,8119055,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,28080.00000,8143.20000,Aetna,Local,,11232.00,,,,,,,9041.76,22969.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT SM,8119279,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT SM,8119279,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR CROSS,8119281,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR CROSS,8119281,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8119287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8119287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8119283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8119283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8119285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8119285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8119541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1222.30,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8119541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1091.76,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8119579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8119579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8119916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8119916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8119918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8119918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8119906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11490.00000,3332.10000,Aetna,Local,,4596.00,,,,,,,4142.15,9398.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8119906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11490.00000,3332.10000,Aetna,Local,,4596.00,,,,,,,3699.78,9398.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8119908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12276.00000,3560.04000,Aetna,Local,,4910.40,,,,,,,4425.50,10041.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8119908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12276.00000,3560.04000,Aetna,Local,,4910.40,,,,,,,3952.87,10041.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8119910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8119910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8119912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,2211.03,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8119912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,1974.90,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8119914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8119914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANC,8120041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANC,8120041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,557.87000,161.78000,Aetna,Local,,223.15,,,,,,,201.11,456.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,557.87000,161.78000,Aetna,Local,,223.15,,,,,,,179.63,456.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.35000,103.34000,Aetna,Local,,142.54,,,,,,,128.46,291.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.35000,103.34000,Aetna,Local,,142.54,,,,,,,114.74,291.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.72000,167.25000,Aetna,Local,,230.69,,,,,,,207.91,471.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.72000,167.25000,Aetna,Local,,230.69,,,,,,,185.70,471.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,353.26000,102.45000,Aetna,Local,,141.30,,,,,,,127.35,288.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,353.26000,102.45000,Aetna,Local,,141.30,,,,,,,113.75,288.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,931.59000,270.16000,Aetna,Local,,372.64,,,,,,,335.84,762.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,931.59000,270.16000,Aetna,Local,,372.64,,,,,,,299.97,762.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.65000,196.81000,Aetna,Local,,271.46,,,,,,,244.65,555.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.65000,196.81000,Aetna,Local,,271.46,,,,,,,218.53,555.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1228.64000,356.31000,Aetna,Local,,491.46,,,,,,,442.92,1005.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1228.64000,356.31000,Aetna,Local,,491.46,,,,,,,395.62,1005.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8121269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8121269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8121270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8121270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8121271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8121271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8121291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8121291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT JRNY,8121292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT JRNY,8121292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT IN TRAY,8121293,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16375.00000,4748.75000,Aetna,Local,,6550.00,,,,,,,5903.19,13394.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT IN TRAY,8121293,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16375.00000,4748.75000,Aetna,Local,,6550.00,,,,,,,5272.75,13394.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8121294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8121294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8121295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8121295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR AXIAL,8121296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR AXIAL,8121296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER REVISION,8121089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29812.50000,8645.62000,Aetna,Local,,11925.00,,,,,,,10747.41,24386.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER REVISION,8121089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29812.50000,8645.62000,Aetna,Local,,11925.00,,,,,,,9599.62,24386.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HEAD,8121347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HEAD,8121347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121348,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121348,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8121349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8121349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8121350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8121350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8121351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8121351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,8121352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5455.70000,1582.15000,Aetna,Local,,2182.28,,,,,,,1966.78,4462.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,8121352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5455.70000,1582.15000,Aetna,Local,,2182.28,,,,,,,1756.74,4462.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8121353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,261.39,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8121353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,233.48,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2705.64000,784.64000,Aetna,Local,,1082.26,,,,,,,975.38,2213.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2705.64000,784.64000,Aetna,Local,,1082.26,,,,,,,871.22,2213.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8121355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8121355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8121356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8121356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8121357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8121357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8121359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121360,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121360,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121361,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121361,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8121420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8121420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8121424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8121424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8121416,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8121416,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,8121418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,8121418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,8121422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9384.00000,2721.36000,Aetna,Local,,3753.60,,,,,,,3382.93,7676.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,8121422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9384.00000,2721.36000,Aetna,Local,,3753.60,,,,,,,3021.65,7676.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8121519,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,461.42000,133.81000,Aetna,Local,,184.57,,,,,,,166.34,377.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8121519,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,461.42000,133.81000,Aetna,Local,,184.57,,,,,,,148.58,377.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,8121521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,8121521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,8121523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,8121523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8121572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3248.00000,941.92000,Aetna,Local,,1299.20,,,,,,,1170.90,2656.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8121572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3248.00000,941.92000,Aetna,Local,,1299.20,,,,,,,1045.86,2656.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8121574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8121574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8121575,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8121575,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE BODY FEM,8121576,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE BODY FEM,8121576,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9357.00000,2713.53000,Aetna,Local,,3742.80,,,,,,,3373.20,7654.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9357.00000,2713.53000,Aetna,Local,,3742.80,,,,,,,3012.95,7654.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8121604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,843.86,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8121604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,Local,,936.32,,,,,,,753.74,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG SMOOTH,8121606,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG SMOOTH,8121606,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG SMOOTH,8121608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG SMOOTH,8121608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG SMOOTH,8121610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG SMOOTH,8121610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VANSCHIE,8121613,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,842.99000,244.47000,Aetna,Local,,337.20,,,,,,,303.90,689.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VANSCHIE,8121613,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,842.99000,244.47000,Aetna,Local,,337.20,,,,,,,271.44,689.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CODA BALLOON,8121614,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,876.74,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CODA BALLOON,8121614,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,783.10,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8121631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8121631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8121868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8121868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5793.90000,1680.23000,Aetna,Local,,2317.56,,,,,,,2088.70,4739.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8121870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5793.90000,1680.23000,Aetna,Local,,2317.56,,,,,,,1865.64,4739.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT SM,8121873,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT SM,8121873,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM DISTAL,8121875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15325.00000,4444.25000,Aetna,Local,,6130.00,,,,,,,5524.66,12535.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM DISTAL,8121875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15325.00000,4444.25000,Aetna,Local,,6130.00,,,,,,,4934.65,12535.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AXLE CONN IMPLANT FEM TIB,8121877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2924.00000,847.96000,Aetna,Local,,1169.60,,,,,,,1054.10,2391.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AXLE CONN IMPLANT FEM TIB,8121877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2924.00000,847.96000,Aetna,Local,,1169.60,,,,,,,941.53,2391.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE TIBIAL ROTATING HINGE NEUTRAL,8121879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE TIBIAL ROTATING HINGE NEUTRAL,8121879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8121881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8265.00000,2396.85000,Aetna,Local,,3306.00,,,,,,,2979.53,6760.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8121881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8265.00000,2396.85000,Aetna,Local,,3306.00,,,,,,,2661.33,6760.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8121883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8121885,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7326.00000,2124.54000,Aetna,Local,,2930.40,,,,,,,2641.02,5992.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8121885,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7326.00000,2124.54000,Aetna,Local,,2930.40,,,,,,,2358.97,5992.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE COROENT,8122087,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE COROENT,8122087,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8122089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8122089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CANC ASEPTIC FREEZE DRIED CHIPS,8122101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.40000,465.86000,Aetna,Local,,642.56,,,,,,,579.11,1314.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CANC ASEPTIC FREEZE DRIED CHIPS,8122101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.40000,465.86000,Aetna,Local,,642.56,,,,,,,517.26,1314.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CANC ASEPTIC FREEZE DRIED CRUSH,8122102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2319.20000,672.57000,Aetna,Local,,927.68,,,,,,,836.07,1897.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CANC ASEPTIC FREEZE DRIED CRUSH,8122102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2319.20000,672.57000,Aetna,Local,,927.68,,,,,,,746.78,1897.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT SM 1CC,8122103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,814.73,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT SM 1CC,8122103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,727.72,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8122165,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,35.30,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8122165,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,31.53,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CLAVICLE,8122279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CLAVICLE,8122279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8122281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8122281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8122283,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8122283,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8122285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8122285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8123490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8123490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8123494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8123494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,8123492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,8123492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8123508,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,442.69,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8123508,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,395.42,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7758257,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,3510.85000,1018.15000,Aetna,Local,,1404.34,,,,,,,1265.66,2871.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7758257,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,3510.85000,1018.15000,Aetna,Local,,1404.34,,,,,,,1130.49,2871.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8123539,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8123539,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8123542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8123542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,8123544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.32000,188.01000,Aetna,Local,,259.33,,,,,,,233.72,530.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,8123544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.32000,188.01000,Aetna,Local,,259.33,,,,,,,208.76,530.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8123546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,84.26000,24.44000,Aetna,Local,,33.70,,,,,,,30.38,68.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8123546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,84.26000,24.44000,Aetna,Local,,33.70,,,,,,,27.13,68.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8123548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8123548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8123550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,84.30000,24.45000,Aetna,Local,,33.72,,,,,,,30.39,68.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8123550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,84.30000,24.45000,Aetna,Local,,33.72,,,,,,,27.14,68.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8123554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8123554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8123532,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8123532,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8123736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8123732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,836.51000,242.59000,Aetna,Local,,334.60,,,,,,,301.56,684.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8123732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,836.51000,242.59000,Aetna,Local,,334.60,,,,,,,269.36,684.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8123738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.41000,95.53000,Aetna,Local,,131.76,,,,,,,118.75,269.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8123738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.41000,95.53000,Aetna,Local,,131.76,,,,,,,106.07,269.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8123795,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8123795,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8123797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8123797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8123896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8123896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8123897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8123897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEX,8123906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEX,8123906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEX,8123908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEX,8123908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8123953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8123953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8124275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8124275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8124277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8124277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8123955,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8123955,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY FUSION,8123956,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY FUSION,8123956,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8124273,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8124273,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8124272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8124272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT XL,8124294,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT XL,8124294,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT XL,8124296,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT XL,8124296,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8124298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8124298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT BONE,8124314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,351.50000,101.93000,Aetna,Local,,140.60,,,,,,,126.72,287.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT BONE,8124314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,351.50000,101.93000,Aetna,Local,,140.60,,,,,,,113.18,287.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT BONE,8124316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT BONE,8124316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8124318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8124318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8124327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8124327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL EMBOLIZATION,8124391,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,Local,,1501.50,,,,,,,1353.23,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL EMBOLIZATION,8124391,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,Local,,1501.50,,,,,,,1208.71,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANC,8124392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANC,8124392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FEMORAL,8124393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5541.90000,1607.15000,Aetna,Local,,2216.76,,,,,,,1997.85,4533.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FEMORAL,8124393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5541.90000,1607.15000,Aetna,Local,,2216.76,,,,,,,1784.49,4533.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8124395,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8124395,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8124396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8124396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8124394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8124394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,Local,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHINCTEROTOME,8124413,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1932.00000,560.28000,Aetna,Local,,772.80,,,,,,,696.49,1580.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHINCTEROTOME,8124413,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1932.00000,560.28000,Aetna,Local,,772.80,,,,,,,622.10,1580.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8124414,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1848.00000,535.92000,Aetna,Local,,739.20,,,,,,,666.20,1511.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8124414,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1848.00000,535.92000,Aetna,Local,,739.20,,,,,,,595.06,1511.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8124416,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,293.63,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8124416,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,262.27,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER STENT,8124417,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,Local,,255.60,,,,,,,230.36,522.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER STENT,8124417,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,255.60,,,,,,,205.76,522.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8124420,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1276.00000,370.04000,Aetna,Local,,510.40,,,,,,,460.00,1043.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8124420,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1276.00000,370.04000,Aetna,Local,,510.40,,,,,,,410.87,1043.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8124421,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1276.00000,370.04000,Aetna,Local,,510.40,,,,,,,460.00,1043.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8124421,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1276.00000,370.04000,Aetna,Local,,510.40,,,,,,,410.87,1043.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8124593,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8124593,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8124595,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8124595,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHERE GLENOID,8124815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHERE GLENOID,8124815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8124816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8124816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT TI,8124819,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,7734.60000,2243.03000,Aetna,Local,,3093.84,,,,,,,2788.32,6326.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COROENT TI,8124819,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,7734.60000,2243.03000,Aetna,Local,,3093.84,,,,,,,2490.54,6326.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8124833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8124833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHERE GLENOID,8124835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHERE GLENOID,8124835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8124842,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30026.25000,8707.61000,Aetna,Local,,12010.50,,,,,,,10824.46,24561.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8124842,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30026.25000,8707.61000,Aetna,Local,,12010.50,,,,,,,9668.45,24561.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HEAD,8124843,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1855.02,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HEAD,8124843,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1656.92,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8124844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,3000.08,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8124844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,2679.68,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8124845,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8124845,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8124846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8124846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE NON LCKNG,8124847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE NON LCKNG,8124847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE NON LCKNG,8124848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE NON LCKNG,8124848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8124849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8124849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8124850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8124850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8124851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8124851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8124852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8124852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8124856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16598.03000,4813.43000,Aetna,Local,,6639.21,,,,,,,5983.59,13577.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8124856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16598.03000,4813.43000,Aetna,Local,,6639.21,,,,,,,5344.57,13577.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8124857,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7460.70000,2163.60000,Aetna,Local,,2984.28,,,,,,,2689.58,6102.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8124857,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7460.70000,2163.60000,Aetna,Local,,2984.28,,,,,,,2402.35,6102.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8124921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2378.80000,689.85000,Aetna,Local,,951.52,,,,,,,857.56,1945.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8124921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2378.80000,689.85000,Aetna,Local,,951.52,,,,,,,765.97,1945.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8124858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2143.80000,621.70000,Aetna,Local,,857.52,,,,,,,772.84,1753.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8124858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2143.80000,621.70000,Aetna,Local,,857.52,,,,,,,690.30,1753.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8124859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2222.00000,644.38000,Aetna,Local,,888.80,,,,,,,801.03,1817.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8124859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2222.00000,644.38000,Aetna,Local,,888.80,,,,,,,715.48,1817.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,8124860,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5671.26000,1644.67000,Aetna,Local,,2268.50,,,,,,,2044.49,4639.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,8124860,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5671.26000,1644.67000,Aetna,Local,,2268.50,,,,,,,1826.15,4639.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8124861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12466.80000,3615.37000,Aetna,Local,,4986.72,,,,,,,4494.28,10197.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8124861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12466.80000,3615.37000,Aetna,Local,,4986.72,,,,,,,4014.31,10197.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8124862,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23879.25000,6924.98000,Aetna,Local,,9551.70,,,,,,,8608.47,19533.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8124862,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23879.25000,6924.98000,Aetna,Local,,9551.70,,,,,,,7689.12,19533.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER FEMORAL,8124863,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4271.75000,1238.81000,Aetna,Local,,1708.70,,,,,,,1539.97,3494.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER FEMORAL,8124863,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4271.75000,1238.81000,Aetna,Local,,1708.70,,,,,,,1375.50,3494.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8124864,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4599.00000,1333.71000,Aetna,Local,,1839.60,,,,,,,1657.94,3761.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8124864,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4599.00000,1333.71000,Aetna,Local,,1839.60,,,,,,,1480.88,3761.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AXLE CONN FEMORAL TIBIAL OSS,7698867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2398.00000,695.42000,Aetna,Local,,959.20,,,,,,,864.48,1961.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AXLE CONN FEMORAL TIBIAL OSS,7698867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2398.00000,695.42000,Aetna,Local,,959.20,,,,,,,772.16,1961.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2244.00000,650.76000,Aetna,Local,,897.60,,,,,,,808.96,1835.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2244.00000,650.76000,Aetna,Local,,897.60,,,,,,,722.57,1835.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1738.00000,504.02000,Aetna,Local,,695.20,,,,,,,626.55,1421.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1738.00000,504.02000,Aetna,Local,,695.20,,,,,,,559.64,1421.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698873,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4753.00000,1378.37000,Aetna,Local,,1901.20,,,,,,,1713.46,3887.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698873,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4753.00000,1378.37000,Aetna,Local,,1901.20,,,,,,,1530.47,3887.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8124865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8124865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE TIBIAL,8124866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE TIBIAL,8124866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8124923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8124923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1583.72000,459.28000,Aetna,Local,,633.49,,,,,,,570.93,1295.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1583.72000,459.28000,Aetna,Local,,633.49,,,,,,,509.96,1295.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8124959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5964.00000,1729.56000,Aetna,Local,,2385.60,,,,,,,2150.02,4878.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8124959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5964.00000,1729.56000,Aetna,Local,,2385.60,,,,,,,1920.41,4878.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ACCU FLO CSF,8124965,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1564.48000,453.70000,Aetna,Local,,625.79,,,,,,,564.00,1279.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ACCU FLO CSF,8124965,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1564.48000,453.70000,Aetna,Local,,625.79,,,,,,,503.76,1279.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,8124966,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2885.96000,836.93000,Aetna,Local,,1154.38,,,,,,,1040.39,2360.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,8124966,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2885.96000,836.93000,Aetna,Local,,1154.38,,,,,,,929.28,2360.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,8124967,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2885.96000,836.93000,Aetna,Local,,1154.38,,,,,,,1040.39,2360.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,8124967,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2885.96000,836.93000,Aetna,Local,,1154.38,,,,,,,929.28,2360.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8125159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8910.90000,2584.16000,Aetna,Local,,3564.36,,,,,,,3212.38,7289.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8125159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8910.90000,2584.16000,Aetna,Local,,3564.36,,,,,,,2869.31,7289.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8125161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2786.32000,808.03000,Aetna,Local,,1114.53,,,,,,,1004.47,2279.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8125161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2786.32000,808.03000,Aetna,Local,,1114.53,,,,,,,897.20,2279.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8125266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8125266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8125268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8125268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BIO AVS C PLUG,8125448,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1783.07,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BIO AVS C PLUG,8125448,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1592.64,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BIO AVS C PLUG,8125449,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1783.07,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BIO AVS C PLUG,8125449,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1592.64,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BIO AVS C PLUG,8125450,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1783.07,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BIO AVS C PLUG,8125450,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1592.64,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BIO AVS C PLUG,8125451,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1783.07,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BIO AVS C PLUG,8125451,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1592.64,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BIO AVS C PLUG,8125452,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1783.07,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE BIO AVS C PLUG,8125452,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,Local,,1978.44,,,,,,,1592.64,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7697887,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,133.35000,38.67000,Aetna,Local,,53.34,,,,,,,48.07,109.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7697887,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,133.35000,38.67000,Aetna,Local,,53.34,,,,,,,42.94,109.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8125538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8125538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8125540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8125540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8125542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8125542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8125544,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8125544,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8125546,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8125546,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY,8125548,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY,8125548,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE TENDON,7696686,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE TENDON,7696686,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE FEMORAL,8125555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE FEMORAL,8125555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8125584,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8125584,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER DISTAL,8125585,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER DISTAL,8125585,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8125586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8125586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8125587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8125587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8125750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8125750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8125588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2708.08,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8125588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2418.86,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8125589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,6518.74,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8125589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,5822.56,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8125580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4515.97,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8125580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4033.68,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,8125582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25225.20000,7315.31000,Aetna,Local,,10090.08,,,,,,,9093.68,20634.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,8125582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25225.20000,7315.31000,Aetna,Local,,10090.08,,,,,,,8122.51,20634.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,8126039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5012.00000,1453.48000,Aetna,Local,,2004.80,,,,,,,1806.83,4099.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,8126039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5012.00000,1453.48000,Aetna,Local,,2004.80,,,,,,,1613.86,4099.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMP AUGMENT INJ,8126042,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMP AUGMENT INJ,8126042,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8126046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8126046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8126047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8126047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8126048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8126048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8126049,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8126049,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANN,8126078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1608.00000,466.32000,Aetna,Local,,643.20,,,,,,,579.68,1315.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANN,8126078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1608.00000,466.32000,Aetna,Local,,643.20,,,,,,,517.78,1315.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,8126084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,8126084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8126086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8126086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8126088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8126088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8126090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8126090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8126187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8126187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8126189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3420.78,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8126189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3055.46,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUM,8126191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,2197.43,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUM,8126191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,1962.75,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8126193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8126193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8126197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8126197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8126199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8126199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8126298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3486.76,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8126298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3114.38,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8126300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8126300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8126384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8126384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8126536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8126536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8126538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8126538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY DIVERGENCE,8126911,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY DIVERGENCE,8126911,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW FEMORAL,8126912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW FEMORAL,8126912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,8126913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,3076.87,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,8126913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,2748.27,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8126914,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8126914,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8126915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8126915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8126916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8126916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8126917,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8126917,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,8126920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5455.70000,1582.15000,Aetna,Local,,2182.28,,,,,,,1966.78,4462.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,8126920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5455.70000,1582.15000,Aetna,Local,,2182.28,,,,,,,1756.74,4462.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8126921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8126921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8126922,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8126922,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEX,8126930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEX,8126930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8126924,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3896.80000,1130.07000,Aetna,Local,,1558.72,,,,,,,1404.80,3187.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8126924,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3896.80000,1130.07000,Aetna,Local,,1558.72,,,,,,,1254.77,3187.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8126926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8126926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8126927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8126927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8126928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8126928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8126970,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8126970,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE FEMORAL,8126985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE FEMORAL,8126985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8126987,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7460.70000,2163.60000,Aetna,Local,,2984.28,,,,,,,2689.58,6102.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8126987,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7460.70000,2163.60000,Aetna,Local,,2984.28,,,,,,,2402.35,6102.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8126989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6381.55000,1850.65000,Aetna,Local,,2552.62,,,,,,,2300.55,5220.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8126989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6381.55000,1850.65000,Aetna,Local,,2552.62,,,,,,,2054.86,5220.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8127003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20917.50000,6066.08000,Aetna,Local,,8367.00,,,,,,,7540.76,17110.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8127003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20917.50000,6066.08000,Aetna,Local,,8367.00,,,,,,,6735.44,17110.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8127004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8397.90000,2435.39000,Aetna,Local,,3359.16,,,,,,,3027.44,6869.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8127004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8397.90000,2435.39000,Aetna,Local,,3359.16,,,,,,,2704.12,6869.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER TIBIAL,8127005,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4564.35000,1323.66000,Aetna,Local,,1825.74,,,,,,,1645.45,3733.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER TIBIAL,8127005,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4564.35000,1323.66000,Aetna,Local,,1825.74,,,,,,,1469.72,3733.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8127006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12466.80000,3615.37000,Aetna,Local,,4986.72,,,,,,,4494.28,10197.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8127006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12466.80000,3615.37000,Aetna,Local,,4986.72,,,,,,,4014.31,10197.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8127007,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2398.00000,695.42000,Aetna,Local,,959.20,,,,,,,864.48,1961.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8127007,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2398.00000,695.42000,Aetna,Local,,959.20,,,,,,,772.16,1961.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT BRUSHING,8127008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2244.00000,650.76000,Aetna,Local,,897.60,,,,,,,808.96,1835.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT BRUSHING,8127008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2244.00000,650.76000,Aetna,Local,,897.60,,,,,,,722.57,1835.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8127009,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23136.75000,6709.66000,Aetna,Local,,9254.70,,,,,,,8340.80,18925.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8127009,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23136.75000,6709.66000,Aetna,Local,,9254.70,,,,,,,7450.03,18925.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8127010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4599.00000,1333.71000,Aetna,Local,,1839.60,,,,,,,1657.94,3761.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8127010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4599.00000,1333.71000,Aetna,Local,,1839.60,,,,,,,1480.88,3761.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER TIBIAL,8127011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4564.35000,1323.66000,Aetna,Local,,1825.74,,,,,,,1645.45,3733.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER TIBIAL,8127011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4564.35000,1323.66000,Aetna,Local,,1825.74,,,,,,,1469.72,3733.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FEMORAL,8127012,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10323.00000,2993.67000,Aetna,Local,,4129.20,,,,,,,3721.44,8444.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FEMORAL,8127012,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10323.00000,2993.67000,Aetna,Local,,4129.20,,,,,,,3324.01,8444.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8127013,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8127013,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8127014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,8127014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8127065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8397.90000,2435.39000,Aetna,Local,,3359.16,,,,,,,3027.44,6869.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8127065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8397.90000,2435.39000,Aetna,Local,,3359.16,,,,,,,2704.12,6869.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8126999,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24250.50000,7032.64000,Aetna,Local,,9700.20,,,,,,,8742.31,19836.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8126999,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24250.50000,7032.64000,Aetna,Local,,9700.20,,,,,,,7808.66,19836.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8127001,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12466.80000,3615.37000,Aetna,Local,,4986.72,,,,,,,4494.28,10197.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,8127001,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12466.80000,3615.37000,Aetna,Local,,4986.72,,,,,,,4014.31,10197.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8127646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1257.68000,364.73000,Aetna,Local,,503.07,,,,,,,453.39,1028.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8127646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1257.68000,364.73000,Aetna,Local,,503.07,,,,,,,404.97,1028.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,8127648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25606.63000,7425.92000,Aetna,Local,,10242.65,,,,,,,9231.19,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,8127648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25606.63000,7425.92000,Aetna,Local,,10242.65,,,,,,,8245.33,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CEMENTED,8127650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7609.95000,2206.89000,Aetna,Local,,3043.98,,,,,,,2743.39,6224.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CEMENTED,8127650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7609.95000,2206.89000,Aetna,Local,,3043.98,,,,,,,2450.40,6224.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ROTATION CONNECT NEUTRAL MED,8127652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6613.88000,1918.03000,Aetna,Local,,2645.55,,,,,,,2384.30,5410.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ROTATION CONNECT NEUTRAL MED,8127652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6613.88000,1918.03000,Aetna,Local,,2645.55,,,,,,,2129.67,5410.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8127654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16743.20000,4855.53000,Aetna,Local,,6697.28,,,,,,,6035.92,13695.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8127654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16743.20000,4855.53000,Aetna,Local,,6697.28,,,,,,,5391.31,13695.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE TERMINAL,8127656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5240.17000,1519.65000,Aetna,Local,,2096.07,,,,,,,1889.08,4286.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE TERMINAL,8127656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5240.17000,1519.65000,Aetna,Local,,2096.07,,,,,,,1687.33,4286.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE TIBIAL,8127658,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4958.73000,1438.03000,Aetna,Local,,1983.49,,,,,,,1787.62,4056.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE TIBIAL,8127658,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4958.73000,1438.03000,Aetna,Local,,1983.49,,,,,,,1596.71,4056.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CEMENTED,8127660,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,Local,,2625.52,,,,,,,2366.25,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CEMENTED,8127660,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,Local,,2625.52,,,,,,,2113.54,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8127662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8127662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8127898,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8127898,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8127900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,109.95,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8127900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,98.21,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8127902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,109.95,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TAP,8127902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,98.21,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR CROSS,8127904,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR CROSS,8127904,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8132016,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8132016,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8132109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8132109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8132104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8132104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8132107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1941.96000,563.17000,Aetna,Local,,776.78,,,,,,,700.08,1588.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8132107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1941.96000,563.17000,Aetna,Local,,776.78,,,,,,,625.31,1588.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8134096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8134096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7920397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7920397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7943370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7943370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,325.38000,94.36000,Aetna,Local,,130.15,,,,,,,117.30,266.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,325.38000,94.36000,Aetna,Local,,130.15,,,,,,,104.77,266.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7702211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7702211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7918351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,Local,,75.60,,,,,,,68.13,154.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7918351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,,75.60,,,,,,,60.86,154.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7934086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,164.17000,47.61000,Aetna,Local,,65.67,,,,,,,59.18,134.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7934086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,164.17000,47.61000,Aetna,Local,,65.67,,,,,,,52.86,134.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,235.73000,68.36000,Aetna,Local,,94.29,,,,,,,84.98,192.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,235.73000,68.36000,Aetna,Local,,94.29,,,,,,,75.91,192.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,316.11000,91.67000,Aetna,Local,,126.44,,,,,,,113.96,258.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,316.11000,91.67000,Aetna,Local,,126.44,,,,,,,101.79,258.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7880575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7880575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7903038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7903038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,174.66,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,156.01,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7698107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7974862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7974862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7699425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,307.09000,89.06000,Aetna,Local,,122.84,,,,,,,110.71,251.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7699425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,307.09000,89.06000,Aetna,Local,,122.84,,,,,,,98.88,251.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7882190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7882190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7895455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.25000,86.78000,Aetna,Local,,119.70,,,,,,,107.88,244.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7895455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.25000,86.78000,Aetna,Local,,119.70,,,,,,,96.36,244.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7699426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.51000,133.55000,Aetna,Local,,184.20,,,,,,,166.01,376.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7699426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.51000,133.55000,Aetna,Local,,184.20,,,,,,,148.28,376.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7968707,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.54000,136.17000,Aetna,Local,,187.82,,,,,,,169.27,384.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7968707,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.54000,136.17000,Aetna,Local,,187.82,,,,,,,151.19,384.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7896373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.54000,103.40000,Aetna,Local,,142.62,,,,,,,128.53,291.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7896373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.54000,103.40000,Aetna,Local,,142.62,,,,,,,114.81,291.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7740538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7740538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7694940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7694940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7933691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7933691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7701068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,166.10,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7701068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,148.36,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7840049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7840049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7703341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7959352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,429.73000,124.62000,Aetna,Local,,171.89,,,,,,,154.92,351.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7959352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,429.73000,124.62000,Aetna,Local,,171.89,,,,,,,138.37,351.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7897360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,448.69000,130.12000,Aetna,Local,,179.48,,,,,,,161.75,367.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7897360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,448.69000,130.12000,Aetna,Local,,179.48,,,,,,,144.48,367.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7957823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,448.69000,130.12000,Aetna,Local,,179.48,,,,,,,161.75,367.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7957823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,448.69000,130.12000,Aetna,Local,,179.48,,,,,,,144.48,367.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7695380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,777.60000,225.50000,Aetna,Local,,311.04,,,,,,,280.32,636.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7695380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,777.60000,225.50000,Aetna,Local,,311.04,,,,,,,250.39,636.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7983039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7983039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7944227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7944227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7882260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7882260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,Local,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7896374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,726.35000,210.64000,Aetna,Local,,290.54,,,,,,,261.85,594.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7896374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,726.35000,210.64000,Aetna,Local,,290.54,,,,,,,233.88,594.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7802055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1512.00000,438.48000,Aetna,Local,,604.80,,,,,,,545.08,1236.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7802055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1512.00000,438.48000,Aetna,Local,,604.80,,,,,,,486.86,1236.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7802057,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1512.00000,438.48000,Aetna,Local,,604.80,,,,,,,545.08,1236.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7802057,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1512.00000,438.48000,Aetna,Local,,604.80,,,,,,,486.86,1236.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7736082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1766.56000,512.30000,Aetna,Local,,706.62,,,,,,,636.84,1445.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7736082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1766.56000,512.30000,Aetna,Local,,706.62,,,,,,,568.83,1445.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7736083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1766.56000,512.30000,Aetna,Local,,706.62,,,,,,,636.84,1445.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7736083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1766.56000,512.30000,Aetna,Local,,706.62,,,,,,,568.83,1445.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136154,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136154,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7989240,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2721.60000,789.26000,Aetna,Local,,1088.64,,,,,,,981.14,2226.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7989240,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2721.60000,789.26000,Aetna,Local,,1088.64,,,,,,,876.36,2226.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1796.28000,520.92000,Aetna,Local,,718.51,,,,,,,647.56,1469.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1796.28000,520.92000,Aetna,Local,,718.51,,,,,,,578.40,1469.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7968201,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7968201,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7969560,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7969560,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7976610,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7976610,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7969161,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7969161,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,564.48000,163.70000,Aetna,Local,,225.79,,,,,,,203.50,461.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,564.48000,163.70000,Aetna,Local,,225.79,,,,,,,181.76,461.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975081,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975081,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975082,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975082,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975084,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975084,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5541.90000,1607.15000,Aetna,Local,,2216.76,,,,,,,1997.85,4533.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5541.90000,1607.15000,Aetna,Local,,2216.76,,,,,,,1784.49,4533.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975085,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975085,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975086,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1535.87,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975086,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4260.38000,1235.51000,Aetna,Local,,1704.15,,,,,,,1371.84,3484.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969636,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969636,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7987671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7987671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.28000,468.72000,Aetna,Local,,646.51,,,,,,,582.67,1322.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.28000,468.72000,Aetna,Local,,646.51,,,,,,,520.44,1322.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5043.50000,1462.62000,Aetna,Local,,2017.40,,,,,,,1818.18,4125.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5043.50000,1462.62000,Aetna,Local,,2017.40,,,,,,,1624.01,4125.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7982852,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8280.00000,2401.20000,Aetna,Local,,3312.00,,,,,,,2984.94,6773.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7982852,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8280.00000,2401.20000,Aetna,Local,,3312.00,,,,,,,2666.16,6773.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER,7969571,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,147.26,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER,7969571,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,131.54,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2649.80000,768.44000,Aetna,Local,,1059.92,,,,,,,955.25,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2649.80000,768.44000,Aetna,Local,,1059.92,,,,,,,853.24,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7982904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1873.70,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7982904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1673.60,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,7969546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,7969546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7972128,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,288.61000,83.70000,Aetna,Local,,115.44,,,,,,,104.04,236.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7972128,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,288.61000,83.70000,Aetna,Local,,115.44,,,,,,,92.93,236.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7968729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7968729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7978437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7978437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7969312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7969312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7969311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7969311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7971940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7971940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7972661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7972661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,Local,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7971932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7971932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7982764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7982764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7968820,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4163.92000,1207.54000,Aetna,Local,,1665.57,,,,,,,1501.09,3406.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7968820,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4163.92000,1207.54000,Aetna,Local,,1665.57,,,,,,,1340.78,3406.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1929.72000,559.62000,Aetna,Local,,771.89,,,,,,,695.66,1578.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1929.72000,559.62000,Aetna,Local,,771.89,,,,,,,621.37,1578.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1526.28000,442.62000,Aetna,Local,,610.51,,,,,,,550.22,1248.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1526.28000,442.62000,Aetna,Local,,610.51,,,,,,,491.46,1248.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7972676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7972676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7972001,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7972001,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,Local,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5689.25000,1649.88000,Aetna,Local,,2275.70,,,,,,,2050.97,4653.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5689.25000,1649.88000,Aetna,Local,,2275.70,,,,,,,1831.94,4653.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7989394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7989394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7983033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7983033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7989423,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7989423,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7975011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,7689.47,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7975011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,Local,,8532.00,,,,,,,6868.26,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7968556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7968556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7968555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7968555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7974764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2812.98,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7974764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2512.57,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7969158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7969158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7987813,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3939.25000,1142.38000,Aetna,Local,,1575.70,,,,,,,1420.10,3222.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7987813,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3939.25000,1142.38000,Aetna,Local,,1575.70,,,,,,,1268.44,3222.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7968883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7968883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986559,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,16524.24,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986559,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,14759.51,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969570,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969570,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7976607,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7976607,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7974088,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7974088,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7974795,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7974795,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969569,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969569,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7974797,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7974797,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7974796,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7974796,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7978414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7978414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7974182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6862.61,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7974182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,Local,,7614.55,,,,,,,6129.71,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7967966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2851.37,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7967966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2546.86,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7976758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2851.37,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7976758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2546.86,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7988513,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1935.44000,561.28000,Aetna,Local,,774.18,,,,,,,697.73,1583.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7988513,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1935.44000,561.28000,Aetna,Local,,774.18,,,,,,,623.21,1583.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7989199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,146.84000,42.58000,Aetna,Local,,58.74,,,,,,,52.94,120.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7989199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,146.84000,42.58000,Aetna,Local,,58.74,,,,,,,47.28,120.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7969324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7969324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7972313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,Local,,2241.68,,,,,,,2020.31,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7972313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,Local,,2241.68,,,,,,,1804.55,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7973831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8932.50000,2590.42000,Aetna,Local,,3573.00,,,,,,,3220.17,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7973831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8932.50000,2590.42000,Aetna,Local,,3573.00,,,,,,,2876.26,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7982766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7982766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7972678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1534.16,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7972678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,Local,,1702.26,,,,,,,1370.32,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7986565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7986565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7969310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7969310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE CRYOABLATION,7982862,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3460.80,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE CRYOABLATION,7982862,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3091.20,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,942.98000,273.46000,Aetna,Local,,377.19,,,,,,,339.94,771.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,942.98000,273.46000,Aetna,Local,,377.19,,,,,,,303.64,771.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7968202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5675.25000,1645.82000,Aetna,Local,,2270.10,,,,,,,2045.93,4642.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7968202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5675.25000,1645.82000,Aetna,Local,,2270.10,,,,,,,1827.43,4642.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2475.20000,717.81000,Aetna,Local,,990.08,,,,,,,892.31,2024.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2475.20000,717.81000,Aetna,Local,,990.08,,,,,,,797.01,2024.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9144.09000,2651.79000,Aetna,Local,,3657.64,,,,,,,3296.44,7479.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9144.09000,2651.79000,Aetna,Local,,3657.64,,,,,,,2944.40,7479.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,124.66,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,345.80000,100.28000,Aetna,Local,,138.32,,,,,,,111.35,282.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7973842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7973842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,Local,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7967961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7967961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7980558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7980558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,Local,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,414.20000,120.12000,Aetna,Local,,165.68,,,,,,,149.32,338.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,414.20000,120.12000,Aetna,Local,,165.68,,,,,,,133.37,338.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7972276,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,44115.75000,12793.57000,Aetna,Local,,17646.30,,,,,,,15903.73,36086.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7972276,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,44115.75000,12793.57000,Aetna,Local,,17646.30,,,,,,,14205.27,36086.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7986556,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,44115.75000,12793.57000,Aetna,Local,,17646.30,,,,,,,15903.73,36086.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7986556,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,44115.75000,12793.57000,Aetna,Local,,17646.30,,,,,,,14205.27,36086.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7986557,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,44115.75000,12793.57000,Aetna,Local,,17646.30,,,,,,,15903.73,36086.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7986557,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,44115.75000,12793.57000,Aetna,Local,,17646.30,,,,,,,14205.27,36086.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7975019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,3136.35,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7975019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,2801.40,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,3136.35,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,2801.40,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7982763,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7982763,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7976427,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7976427,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7972133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7972133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7974589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7974589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7974078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7974078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,151.25000,43.86000,Aetna,Local,,60.50,,,,,,,54.53,123.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,151.25000,43.86000,Aetna,Local,,60.50,,,,,,,48.70,123.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7981159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7981159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,Local,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7988517,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7988517,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,Local,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,147.26,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,131.54,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976719,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976719,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976666,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976666,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2893.01,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2584.05,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2137.68000,619.93000,Aetna,Local,,855.07,,,,,,,770.63,1748.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2137.68000,619.93000,Aetna,Local,,855.07,,,,,,,688.33,1748.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2202.84000,638.82000,Aetna,Local,,881.14,,,,,,,794.12,1801.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2202.84000,638.82000,Aetna,Local,,881.14,,,,,,,709.31,1801.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7988519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1988.72000,576.73000,Aetna,Local,,795.49,,,,,,,716.93,1626.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7988519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1988.72000,576.73000,Aetna,Local,,795.49,,,,,,,640.37,1626.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7983043,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7983043,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7989425,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7989425,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7972074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7972074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,895.16,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2010.44000,583.03000,Aetna,Local,,804.18,,,,,,,724.76,1644.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2010.44000,583.03000,Aetna,Local,,804.18,,,,,,,647.36,1644.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.60000,706.32000,Aetna,Local,,974.24,,,,,,,878.03,1992.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.60000,706.32000,Aetna,Local,,974.24,,,,,,,784.26,1992.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7976433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7976433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7974089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7974089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7974594,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7974594,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5398.65000,1565.61000,Aetna,Local,,2159.46,,,,,,,1946.21,4416.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5398.65000,1565.61000,Aetna,Local,,2159.46,,,,,,,1738.37,4416.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5398.65000,1565.61000,Aetna,Local,,2159.46,,,,,,,1946.21,4416.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5398.65000,1565.61000,Aetna,Local,,2159.46,,,,,,,1738.37,4416.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987735,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8436.00000,2446.44000,Aetna,Local,,3374.40,,,,,,,3041.18,6900.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987735,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8436.00000,2446.44000,Aetna,Local,,3374.40,,,,,,,2716.39,6900.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7972681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9222.90000,2674.64000,Aetna,Local,,3689.16,,,,,,,3324.86,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7972681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9222.90000,2674.64000,Aetna,Local,,3689.16,,,,,,,2969.77,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7972680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9222.90000,2674.64000,Aetna,Local,,3689.16,,,,,,,3324.86,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7972680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9222.90000,2674.64000,Aetna,Local,,3689.16,,,,,,,2969.77,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7967972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,261.39,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7967972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,233.48,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7987523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7987523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7967967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7967967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7972275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7972275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7982870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7982870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7971859,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5193.13000,1506.01000,Aetna,Local,,2077.25,,,,,,,1872.12,4247.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7971859,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5193.13000,1506.01000,Aetna,Local,,2077.25,,,,,,,1672.19,4247.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975083,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975083,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,Local,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.88000,578.52000,Aetna,Local,,797.95,,,,,,,719.15,1631.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.88000,578.52000,Aetna,Local,,797.95,,,,,,,642.35,1631.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969635,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969635,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,Local,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987522,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987522,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7975068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7975068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7976605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1299.40,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7976605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1160.63,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7974631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7974631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7980691,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7980691,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7968634,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7968634,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969874,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969874,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969873,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969873,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969872,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969872,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7972673,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7972673,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969875,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969875,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7978444,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7978444,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969876,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969876,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969563,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969563,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974755,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974755,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969871,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969871,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7989436,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7989436,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7968806,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7968806,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7968830,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7968830,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7987856,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7987856,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7968353,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,Local,,873.60,,,,,,,787.33,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7968353,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,Local,,873.60,,,,,,,703.25,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7974905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7974905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,Local,,134.90,,,,,,,121.58,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,Local,,134.90,,,,,,,108.59,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7980370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7980370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7974599,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7974599,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976426,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976426,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974799,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974799,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974085,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974085,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974086,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974086,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974087,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974087,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974798,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974798,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7975020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7975020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7987303,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7987303,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7987801,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7987801,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7976627,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,Local,,13473.00,,,,,,,12142.54,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7976627,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,Local,,13473.00,,,,,,,10845.76,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7988822,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7988822,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1753.28000,508.45000,Aetna,Local,,701.31,,,,,,,632.06,1434.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1753.28000,508.45000,Aetna,Local,,701.31,,,,,,,564.56,1434.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7974081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25225.20000,7315.31000,Aetna,Local,,10090.08,,,,,,,9093.68,20634.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7974081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25225.20000,7315.31000,Aetna,Local,,10090.08,,,,,,,8122.51,20634.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968824,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968824,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7982819,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7982819,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7969568,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7969568,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7969567,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7969567,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7968610,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7968610,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1151.87,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1028.85,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1151.87,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1028.85,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1151.87,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1028.85,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,7968560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,7968560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7973836,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7973836,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7988470,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7988470,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7988468,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7988468,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969034,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969034,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7973838,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7973838,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969475,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969475,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7968591,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7968591,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975104,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975104,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975105,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975105,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975108,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975108,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975092,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1511.00000,438.19000,Aetna,Local,,604.40,,,,,,,544.72,1236.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975092,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1511.00000,438.19000,Aetna,Local,,604.40,,,,,,,486.54,1236.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975097,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975097,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975098,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975098,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975100,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975100,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975101,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975101,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975107,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975107,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7968710,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7968710,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7968186,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7968186,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7972272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7972272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7968694,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7968694,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2528.72000,733.33000,Aetna,Local,,1011.49,,,,,,,911.60,2068.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2528.72000,733.33000,Aetna,Local,,1011.49,,,,,,,814.25,2068.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7978455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7978455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7987626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7987626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7987681,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7987681,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7973850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7973850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7978417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7978417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1631.80000,473.22000,Aetna,Local,,652.72,,,,,,,588.26,1334.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1631.80000,473.22000,Aetna,Local,,652.72,,,,,,,525.44,1334.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969777,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969777,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7969474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7969474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7972273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7972273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7972274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7972274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975093,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975093,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975096,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975096,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,731.09,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,653.02,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,731.09,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,Local,,811.20,,,,,,,653.02,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7968481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7968481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7976470,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7976470,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7987258,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7987258,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7987211,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7987211,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7976759,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,Local,,4036.80,,,,,,,3638.17,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7976759,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,Local,,4036.80,,,,,,,3249.62,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7975064,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,Local,,4036.80,,,,,,,3638.17,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7975064,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,Local,,4036.80,,,,,,,3249.62,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7973837,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,Local,,13473.00,,,,,,,12142.54,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7973837,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,Local,,13473.00,,,,,,,10845.76,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7972070,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7972070,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,3076.87,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,2748.27,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,3076.87,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,2748.27,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,3076.87,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,2748.27,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7974852,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,876.74,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7974852,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,783.10,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7974853,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,876.74,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7974853,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,783.10,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7974854,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,876.74,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7974854,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,783.10,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7971857,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1958.96000,568.10000,Aetna,Local,,783.58,,,,,,,706.21,1602.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7971857,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1958.96000,568.10000,Aetna,Local,,783.58,,,,,,,630.79,1602.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,Local,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7968609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7968609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1976.28000,573.12000,Aetna,Local,,790.51,,,,,,,712.45,1616.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1976.28000,573.12000,Aetna,Local,,790.51,,,,,,,636.36,1616.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7974183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1693.52,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7974183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1512.66,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7974137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,5416.16,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7974137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,4837.74,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7974138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1693.52,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7974138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1512.66,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7974139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1693.52,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7974139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1512.66,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7972312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7972312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968827,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968827,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7971904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7971904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7972008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7972008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7975048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7975048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7968497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7968497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7972672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7972672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,Local,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968728,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968728,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7976678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7976678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7978374,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7978374,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7980408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7980408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1491.35,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1332.08,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7978372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7978372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7974933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,4133.49,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7974933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,3692.05,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,79.94,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.76000,64.31000,Aetna,Local,,88.70,,,,,,,71.41,181.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,66.00,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.07000,53.09000,Aetna,Local,,73.23,,,,,,,58.95,149.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2920.05,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2608.20,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986558,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,17763.64,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986558,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,15866.55,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5336.21000,1547.50000,Aetna,Local,,2134.48,,,,,,,1923.70,4365.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5336.21000,1547.50000,Aetna,Local,,2134.48,,,,,,,1718.26,4365.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5336.21000,1547.50000,Aetna,Local,,2134.48,,,,,,,1923.70,4365.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5336.21000,1547.50000,Aetna,Local,,2134.48,,,,,,,1718.26,4365.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,Local,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7988466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7988466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,194.62000,56.44000,Aetna,Local,,77.85,,,,,,,70.16,159.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,194.62000,56.44000,Aetna,Local,,77.85,,,,,,,62.67,159.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,475.25,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,424.50,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,475.25,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1318.32000,382.31000,Aetna,Local,,527.33,,,,,,,424.50,1078.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7969322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,526.16,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7969322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,469.97,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7983028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7983028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7969775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7969775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7969323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7969323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7974902,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7974902,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7978443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7978443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7978456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7978456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR ASSEMBLY,7972586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR ASSEMBLY,7972586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3739.44000,1084.44000,Aetna,Local,,1495.78,,,,,,,1348.07,3058.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3739.44000,1084.44000,Aetna,Local,,1495.78,,,,,,,1204.10,3058.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3739.44000,1084.44000,Aetna,Local,,1495.78,,,,,,,1348.07,3058.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3739.44000,1084.44000,Aetna,Local,,1495.78,,,,,,,1204.10,3058.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7969650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2999.00,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7969650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2678.72,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7989381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2999.00,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7989381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2678.72,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7982903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2999.00,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7982903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,Local,,3327.60,,,,,,,2678.72,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1246.96000,361.62000,Aetna,Local,,498.78,,,,,,,449.53,1020.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1246.96000,361.62000,Aetna,Local,,498.78,,,,,,,401.52,1020.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1246.96000,361.62000,Aetna,Local,,498.78,,,,,,,449.53,1020.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1246.96000,361.62000,Aetna,Local,,498.78,,,,,,,401.52,1020.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,461.81,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,412.49,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5488.28000,1591.60000,Aetna,Local,,2195.31,,,,,,,1978.52,4489.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5488.28000,1591.60000,Aetna,Local,,2195.31,,,,,,,1767.23,4489.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3794.70000,1100.46000,Aetna,Local,,1517.88,,,,,,,1367.99,3104.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3794.70000,1100.46000,Aetna,Local,,1517.88,,,,,,,1221.89,3104.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1543.44,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1378.60,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7968243,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7968243,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7968245,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7968245,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7968242,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7968242,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7968244,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7968244,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7968419,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7968419,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7969565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7969565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7976528,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7976528,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7969314,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7969314,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7986564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7986564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7988820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7988820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7987665,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7987665,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7988818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7988818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7982765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7982765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7969313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7969313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7974186,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,7974186,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969863,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969863,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7974187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7974187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7972177,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7972177,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7982905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7982905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4812.68,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,Local,,5340.00,,,,,,,4298.70,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,700.74,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,625.90,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969720,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969720,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7968124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,2197.43,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7968124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,Local,,2438.20,,,,,,,1962.75,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980583,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980583,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7972677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7972677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7983034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2956.98,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7983034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2641.19,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7972675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7972675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7973832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14724.00000,4269.96000,Aetna,Local,,5889.60,,,,,,,5308.00,12044.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7973832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14724.00000,4269.96000,Aetna,Local,,5889.60,,,,,,,4741.13,12044.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1495.20000,433.61000,Aetna,Local,,598.08,,,,,,,539.02,1223.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1495.20000,433.61000,Aetna,Local,,598.08,,,,,,,481.45,1223.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,588.34,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,525.50,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,588.34,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,525.50,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7969030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7969030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7969031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,7969031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7967970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1951.93,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7967970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,Local,,2165.80,,,,,,,1743.47,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7981170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7981170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7976527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7976527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7982855,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7982855,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7968122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7968122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7969365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7969365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7987663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7987663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7968498,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7968498,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7968119,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7968119,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7968121,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7968121,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7969783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7969783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7968692,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7968692,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7968695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7968695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,795.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,710.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975113,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975113,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7971972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7971972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7989319,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7989319,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7980585,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7980585,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7976432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7976432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7976757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7976757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7987234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7987234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7978418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7978418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7976680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7976680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7972657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7972657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7989190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7989190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7987236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7987236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7989148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7989148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7989192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7989192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7978457,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7978457,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7972075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7972075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7978442,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7978442,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7978441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7978441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7975049,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7975049,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,920.57000,266.97000,Aetna,Local,,368.23,,,,,,,331.87,753.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,920.57000,266.97000,Aetna,Local,,368.23,,,,,,,296.42,753.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7987659,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7987659,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7987661,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7987661,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7986563,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7986563,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7987669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7987669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,588.34,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,525.50,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,588.34,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1632.00000,473.28000,Aetna,Local,,652.80,,,,,,,525.50,1334.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7975050,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,45787.50000,13278.37000,Aetna,Local,,18315.00,,,,,,,16506.39,37454.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7975050,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,45787.50000,13278.37000,Aetna,Local,,18315.00,,,,,,,14743.58,37454.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7974863,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,45787.50000,13278.37000,Aetna,Local,,18315.00,,,,,,,16506.39,37454.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7974863,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,45787.50000,13278.37000,Aetna,Local,,18315.00,,,,,,,14743.58,37454.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7980763,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5529.37000,1603.52000,Aetna,Local,,2211.75,,,,,,,1993.34,4523.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7980763,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5529.37000,1603.52000,Aetna,Local,,2211.75,,,,,,,1780.46,4523.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7968828,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7968828,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7968829,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7968829,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7969718,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7969718,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7980557,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7980557,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7973828,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7973828,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7976720,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7976720,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7989323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7989323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7976363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7976363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7978373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7978373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7987862,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2852.56,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7987862,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7912.80000,2294.71000,Aetna,Local,,3165.12,,,,,,,2547.92,6472.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7968559,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1254.66,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7968559,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1120.67,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7968727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7968727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7976726,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1722.29,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7976726,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1538.36,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974721,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974721,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7969441,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7969441,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975073,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975073,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975074,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975074,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975075,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975075,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975076,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975076,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975077,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975077,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7969722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,3000.08,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7969722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,2679.68,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7978412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,3000.08,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7978412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,2679.68,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7969723,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,3000.08,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7969723,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,2679.68,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7972679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1337.71,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7972679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3710.70000,1076.10000,Aetna,Local,,1484.28,,,,,,,1194.85,3035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7978375,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7978375,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7989427,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7989427,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,Local,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7973829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3207.75000,930.25000,Aetna,Local,,1283.10,,,,,,,1156.39,2623.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7973829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3207.75000,930.25000,Aetna,Local,,1283.10,,,,,,,1032.90,2623.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7972019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7972019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7969237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7987624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7987624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7989321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1491.35,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7989321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,Local,,1654.76,,,,,,,1332.08,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8201.94000,2378.56000,Aetna,Local,,3280.78,,,,,,,2956.80,6709.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8201.94000,2378.56000,Aetna,Local,,3280.78,,,,,,,2641.02,6709.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7974907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7974907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1358.68000,394.02000,Aetna,Local,,543.47,,,,,,,489.80,1111.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1358.68000,394.02000,Aetna,Local,,543.47,,,,,,,437.49,1111.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1358.68000,394.02000,Aetna,Local,,543.47,,,,,,,489.80,1111.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1358.68000,394.02000,Aetna,Local,,543.47,,,,,,,437.49,1111.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7975018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7975018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7971860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7971860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7973847,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7973847,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7988523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7988523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,461.81,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,Local,,512.42,,,,,,,412.49,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7973852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7973852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7969683,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7969683,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7969684,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1736.00000,503.44000,Aetna,Local,,694.40,,,,,,,625.83,1420.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7969684,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1736.00000,503.44000,Aetna,Local,,694.40,,,,,,,558.99,1420.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7968605,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7968605,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7969036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7976664,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7976664,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7974900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1548.17,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7974900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1382.83,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7986560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1548.17,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7986560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4294.50000,1245.40000,Aetna,Local,,1717.80,,,,,,,1382.83,3512.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7969315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7969315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7983029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7983029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7986561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7986561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7986562,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7986562,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7987575,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7987575,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7972593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4135.95000,1199.43000,Aetna,Local,,1654.38,,,,,,,1491.01,3383.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7972593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4135.95000,1199.43000,Aetna,Local,,1654.38,,,,,,,1331.78,3383.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7972592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7577.10000,2197.36000,Aetna,Local,,3030.84,,,,,,,2731.54,6198.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7972592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7577.10000,2197.36000,Aetna,Local,,3030.84,,,,,,,2439.83,6198.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7971933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,907.31,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7971933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,810.41,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7978415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,907.31,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7978415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,810.41,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE KNEE,7987525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE KNEE,7987525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1541.76000,447.11000,Aetna,Local,,616.70,,,,,,,555.80,1261.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1541.76000,447.11000,Aetna,Local,,616.70,,,,,,,496.45,1261.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1541.76000,447.11000,Aetna,Local,,616.70,,,,,,,555.80,1261.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1541.76000,447.11000,Aetna,Local,,616.70,,,,,,,496.45,1261.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7974140,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7974140,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7974939,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7974939,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7974938,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7974938,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694370,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,364.17000,105.61000,Aetna,Local,,145.67,,,,,,,131.28,297.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694370,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,364.17000,105.61000,Aetna,Local,,145.67,,,,,,,117.26,297.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135731,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135731,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM,8141200,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2741.60,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM,8141200,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,124.65,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7987809,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4902.21000,1421.64000,Aetna,Local,,1960.88,,,,,,,1767.25,4010.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7987809,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4902.21000,1421.64000,Aetna,Local,,1960.88,,,,,,,1578.51,4010.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8143405,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,1117.55,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8143405,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,998.20,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT ALLODERM,8125550,CDM,278,RC,C9359,HCPCS,,,facility,inpatient,,,4190.06000,1215.12000,Aetna,Local,,1676.02,,,,,,,1510.52,3427.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT ALLODERM,8125550,CDM,278,RC,C9359,HCPCS,,,facility,outpatient,,,4190.06000,1215.12000,Aetna,Local,,1676.02,,,,,,,1349.20,3427.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8143406,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,1117.55,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8143406,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,998.20,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8143407,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,1117.55,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8143407,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,998.20,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8143408,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,1117.55,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8143408,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,998.20,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8167962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8167962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8167966,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8167966,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8167967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8167967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8167968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8167968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8167969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8167969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8167970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8167970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8167971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8167971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8167972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8167972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8167973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8167973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168046,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8061.39000,2337.80000,Aetna,Local,,3224.56,,,,,,,2906.13,6594.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168046,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8061.39000,2337.80000,Aetna,Local,,3224.56,,,,,,,2595.77,6594.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,258.04,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,230.48,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8168109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1297.08,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8168109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1158.56,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8168111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5946.50000,1724.48000,Aetna,Local,,2378.60,,,,,,,2143.71,4864.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8168111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5946.50000,1724.48000,Aetna,Local,,2378.60,,,,,,,1914.77,4864.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8168113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8168113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8168117,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8168117,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8168119,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8168119,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168121,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22000.00000,6380.00000,Aetna,Local,,8800.00,,,,,,,7931.00,17996.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168121,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22000.00000,6380.00000,Aetna,Local,,8800.00,,,,,,,7084.00,17996.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168123,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22000.00000,6380.00000,Aetna,Local,,8800.00,,,,,,,7931.00,17996.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168123,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22000.00000,6380.00000,Aetna,Local,,8800.00,,,,,,,7084.00,17996.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VNS THERAPY,7946117,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,3552.50000,1030.22000,Aetna,Local,,1421.00,,,,,,,1280.68,2905.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VNS THERAPY,7946117,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,3552.50000,1030.22000,Aetna,Local,,1421.00,,,,,,,1143.90,2905.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,258.04,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,230.48,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8168192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8061.39000,2337.80000,Aetna,Local,,3224.56,,,,,,,2906.13,6594.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8168192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8061.39000,2337.80000,Aetna,Local,,3224.56,,,,,,,2595.77,6594.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,258.04,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,230.48,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP SYSTEM,8168196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP SYSTEM,8168196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168197,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,6060.91,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168197,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,5413.62,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,6060.91,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,5413.62,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168200,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,6060.91,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168200,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,5413.62,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8168241,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8168241,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8168239,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8168239,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7950029,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9242.61000,2680.36000,Aetna,Local,,3697.04,,,,,,,3331.96,7560.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7950029,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9242.61000,2680.36000,Aetna,Local,,3697.04,,,,,,,2976.12,7560.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7695288,CDM,278,RC,,,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7695288,CDM,278,RC,,,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1293.60000,375.14000,Aetna,Local,,517.44,,,,,,,466.34,1058.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1293.60000,375.14000,Aetna,Local,,517.44,,,,,,,416.54,1058.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7912526,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7912526,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7934007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DILATOR,7965294,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DILATOR,7965294,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7935557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7935557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7935558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7935558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,Local,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7938980,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7938980,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7965928,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,533.11,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7965928,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,476.17,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESOLUTION CLIP,7936052,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1329.20000,385.47000,Aetna,Local,,531.68,,,,,,,479.18,1087.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESOLUTION CLIP,7936052,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1329.20000,385.47000,Aetna,Local,,531.68,,,,,,,428.00,1087.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DILATION,7962477,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DILATION,7962477,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7962543,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7962543,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7927020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7927020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7695605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7695605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4256.46000,1234.37000,Aetna,Local,,1702.58,,,,,,,1534.45,3481.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4256.46000,1234.37000,Aetna,Local,,1702.58,,,,,,,1370.58,3481.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7909030,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7909030,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7909292,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7909292,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7866033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7866033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8168368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2125.28000,616.33000,Aetna,Local,,850.11,,,,,,,766.16,1738.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8168368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2125.28000,616.33000,Aetna,Local,,850.11,,,,,,,684.34,1738.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8168370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,485.36000,140.75000,Aetna,Local,,194.14,,,,,,,174.97,397.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8168370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,485.36000,140.75000,Aetna,Local,,194.14,,,,,,,156.29,397.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8168407,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3722.04000,1079.39000,Aetna,Local,,1488.82,,,,,,,1341.80,3044.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8168407,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3722.04000,1079.39000,Aetna,Local,,1488.82,,,,,,,1198.50,3044.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8168408,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,1990.40000,577.22000,Aetna,Local,,796.16,,,,,,,717.54,1628.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8168408,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,1990.40000,577.22000,Aetna,Local,,796.16,,,,,,,640.91,1628.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8168458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8168458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8168460,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1544.00000,447.76000,Aetna,Local,,617.60,,,,,,,556.61,1262.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8168460,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1544.00000,447.76000,Aetna,Local,,617.60,,,,,,,497.17,1262.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8661.15000,2511.73000,Aetna,Local,,3464.46,,,,,,,3122.34,7084.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8661.15000,2511.73000,Aetna,Local,,3464.46,,,,,,,2788.89,7084.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,350.41,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,312.98,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2932.00000,850.28000,Aetna,Local,,1172.80,,,,,,,1056.99,2398.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2932.00000,850.28000,Aetna,Local,,1172.80,,,,,,,944.10,2398.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2030.40000,588.82000,Aetna,Local,,812.16,,,,,,,731.96,1660.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2030.40000,588.82000,Aetna,Local,,812.16,,,,,,,653.79,1660.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7699100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7699100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7918647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7918647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7965424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,870.20,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7965424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,Local,,965.55,,,,,,,777.27,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8168527,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8168527,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8168528,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,179.80,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8168528,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,160.60,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8168542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,5515.65,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8168542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,Local,,6120.00,,,,,,,4926.60,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,8168544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23820.00000,6907.80000,Aetna,Local,,9528.00,,,,,,,8587.11,19484.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,8168544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23820.00000,6907.80000,Aetna,Local,,9528.00,,,,,,,7670.04,19484.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8168540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8168540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8168546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8168546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,8168550,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.75000,59.38000,Aetna,Local,,81.90,,,,,,,73.81,167.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,8168550,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.75000,59.38000,Aetna,Local,,81.90,,,,,,,65.93,167.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8168596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15325.00000,4444.25000,Aetna,Local,,6130.00,,,,,,,5524.66,12535.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8168596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15325.00000,4444.25000,Aetna,Local,,6130.00,,,,,,,4934.65,12535.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8168650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9258.00000,2684.82000,Aetna,Local,,3703.20,,,,,,,3337.51,7573.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8168650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9258.00000,2684.82000,Aetna,Local,,3703.20,,,,,,,2981.08,7573.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8168598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,949.50000,275.35000,Aetna,Local,,379.80,,,,,,,342.29,776.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8168598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,949.50000,275.35000,Aetna,Local,,379.80,,,,,,,305.74,776.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8168600,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2752.42,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8168600,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2458.47,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168602,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1932.00000,560.28000,Aetna,Local,,772.80,,,,,,,696.49,1580.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168602,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1932.00000,560.28000,Aetna,Local,,772.80,,,,,,,622.10,1580.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4007.50000,1162.18000,Aetna,Local,,1603.00,,,,,,,1444.70,3278.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4007.50000,1162.18000,Aetna,Local,,1603.00,,,,,,,1290.41,3278.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168606,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168606,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8168607,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8168607,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8168608,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8168608,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8168652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8168652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8168653,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8168653,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7939898,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7939898,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696308,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,11445.00000,3319.05000,Aetna,Local,,4578.00,,,,,,,4125.92,9362.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696308,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,11445.00000,3319.05000,Aetna,Local,,4578.00,,,,,,,3685.29,9362.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5436.69000,1576.64000,Aetna,Local,,2174.68,,,,,,,1959.93,4447.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5436.69000,1576.64000,Aetna,Local,,2174.68,,,,,,,1750.61,4447.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT EXTENDER,7699522,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT EXTENDER,7699522,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,980.73000,284.41000,Aetna,Local,,392.29,,,,,,,353.55,802.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,980.73000,284.41000,Aetna,Local,,392.29,,,,,,,315.80,802.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7910513,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7910513,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7935112,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7935112,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7910837,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7910837,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7694810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,814.73,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7694810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,727.72,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8168757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8168757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8168774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8168774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8168782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4370.63000,1267.48000,Aetna,Local,,1748.25,,,,,,,1575.61,3575.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8168782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4370.63000,1267.48000,Aetna,Local,,1748.25,,,,,,,1407.34,3575.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8168854,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8168854,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8168857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,802.11,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8168857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,716.45,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8168858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8168858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168859,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168859,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8168861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8168861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8168862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4039.00000,1171.31000,Aetna,Local,,1615.60,,,,,,,1456.06,3303.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8168862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4039.00000,1171.31000,Aetna,Local,,1615.60,,,,,,,1300.56,3303.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,927.00000,268.83000,Aetna,Local,,370.80,,,,,,,334.18,758.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,927.00000,268.83000,Aetna,Local,,370.80,,,,,,,298.49,758.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3444.00000,998.76000,Aetna,Local,,1377.60,,,,,,,1241.56,2817.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8168864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3444.00000,998.76000,Aetna,Local,,1377.60,,,,,,,1108.97,2817.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169163,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169163,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1454.17,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1298.87,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1454.17,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1298.87,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1454.17,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1298.87,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1454.17,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1298.87,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1454.17,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1298.87,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1454.17,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8168871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4033.75000,1169.79000,Aetna,Local,,1613.50,,,,,,,1298.87,3299.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8168872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8169168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8169168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,Local,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8169047,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8169047,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8169223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2099.00000,608.71000,Aetna,Local,,839.60,,,,,,,756.69,1716.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8169223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2099.00000,608.71000,Aetna,Local,,839.60,,,,,,,675.88,1716.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8169947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8169947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8169159,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8169159,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,8169161,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,8169161,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8169814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8169814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169816,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,17475.69,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169816,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,15609.35,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169817,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,17475.69,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169817,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,15609.35,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169818,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,17475.69,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169818,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,15609.35,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169819,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,17475.69,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169819,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,15609.35,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169820,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,18742.40,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169820,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,16740.78,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169821,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,17475.69,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169821,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,15609.35,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169822,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,18742.40,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169822,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,16740.78,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169823,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,17475.69,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169823,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,15609.35,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169824,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51190.20000,14845.16000,Aetna,Local,,20476.08,,,,,,,18454.07,41873.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169824,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51190.20000,14845.16000,Aetna,Local,,20476.08,,,,,,,16483.24,41873.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169825,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,17475.69,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169825,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,15609.35,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169826,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,17475.69,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169826,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,15609.35,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169827,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,18742.40,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169827,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,16740.78,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169828,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,17475.69,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169828,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,15609.35,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169829,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,18742.40,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169829,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,16740.78,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169830,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,17475.69,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169830,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,48476.25000,14058.11000,Aetna,Local,,19390.50,,,,,,,15609.35,39653.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169831,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,18742.40,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8169831,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,16740.78,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8169919,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,21625.00000,6271.25000,Aetna,Local,,8650.00,,,,,,,7795.81,17689.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8169919,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,21625.00000,6271.25000,Aetna,Local,,8650.00,,,,,,,6963.25,17689.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7920118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7920118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7912362,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7912362,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7736071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1971.44000,571.72000,Aetna,Local,,788.58,,,,,,,710.70,1612.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7736071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1971.44000,571.72000,Aetna,Local,,788.58,,,,,,,634.80,1612.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7917821,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7917821,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4256.46000,1234.37000,Aetna,Local,,1702.58,,,,,,,1534.45,3481.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4256.46000,1234.37000,Aetna,Local,,1702.58,,,,,,,1370.58,3481.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,7800035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,7800035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8109156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8109156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8117054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8117054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8117056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,1085.65,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8117056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,969.71,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7966221,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4544.46,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7966221,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4059.13,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,631.90,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,Local,,701.14,,,,,,,564.41,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.70000,1465.86000,Aetna,Local,,2021.88,,,,,,,1822.22,4134.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.70000,1465.86000,Aetna,Local,,2021.88,,,,,,,1627.61,4134.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8170032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8170032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8170045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5323.50000,1543.81000,Aetna,Local,,2129.40,,,,,,,1919.12,4354.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8170045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5323.50000,1543.81000,Aetna,Local,,2129.40,,,,,,,1714.17,4354.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170070,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1434.61,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170070,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1281.40,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170071,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1434.61,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170071,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1281.40,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170072,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1434.61,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170072,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1281.40,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8170078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8170078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170079,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1434.61,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170079,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1281.40,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170080,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1434.61,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170080,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1281.40,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170081,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1434.61,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170081,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1281.40,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170082,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1434.61,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170082,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1281.40,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170083,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1434.61,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8170083,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3979.50000,1154.05000,Aetna,Local,,1591.80,,,,,,,1281.40,3255.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT TESTICULAR,7966230,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7980.00000,2314.20000,Aetna,Local,,3192.00,,,,,,,2876.79,6527.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT TESTICULAR,7966230,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7980.00000,2314.20000,Aetna,Local,,3192.00,,,,,,,2569.56,6527.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7966237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,714.57,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7966237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,638.26,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7966238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7966238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,7966239,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,7966239,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1811.80000,525.42000,Aetna,Local,,724.72,,,,,,,653.15,1482.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1811.80000,525.42000,Aetna,Local,,724.72,,,,,,,583.40,1482.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE STRIP,8170084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4735.50000,1373.29000,Aetna,Local,,1894.20,,,,,,,1707.15,3873.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE STRIP,8170084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4735.50000,1373.29000,Aetna,Local,,1894.20,,,,,,,1524.83,3873.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,8170085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,8170085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,8170086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2292.00000,664.68000,Aetna,Local,,916.80,,,,,,,826.27,1874.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,8170086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2292.00000,664.68000,Aetna,Local,,916.80,,,,,,,738.02,1874.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7947960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3458.00000,1002.82000,Aetna,Local,,1383.20,,,,,,,1246.61,2828.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7947960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3458.00000,1002.82000,Aetna,Local,,1383.20,,,,,,,1113.48,2828.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7697052,CDM,278,RC,,,,,facility,inpatient,,,508.25000,147.39000,Aetna,Local,,203.30,,,,,,,183.22,415.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,7697052,CDM,278,RC,,,,,facility,outpatient,,,508.25000,147.39000,Aetna,Local,,203.30,,,,,,,163.66,415.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7698840,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,2104.22,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7698840,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,1879.50,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8170219,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8334.00000,2416.86000,Aetna,Local,,3333.60,,,,,,,3004.41,6817.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8170219,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8334.00000,2416.86000,Aetna,Local,,3333.60,,,,,,,2683.55,6817.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8170221,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8170221,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8170227,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6210.33000,1801.00000,Aetna,Local,,2484.13,,,,,,,2238.82,5080.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8170227,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6210.33000,1801.00000,Aetna,Local,,2484.13,,,,,,,1999.73,5080.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8170229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,Local,,2667.35,,,,,,,2403.95,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8170229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,Local,,2667.35,,,,,,,2147.22,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8170231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8170231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8170233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8170233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7707526,CDM,278,RC,C1755,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7707526,CDM,278,RC,C1755,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER FEMORAL,8170279,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER FEMORAL,8170279,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8170281,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8170281,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8170361,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2270.40000,658.42000,Aetna,Local,,908.16,,,,,,,818.48,1857.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8170361,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2270.40000,658.42000,Aetna,Local,,908.16,,,,,,,731.07,1857.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE SHUNT,7695715,CDM,278,RC,,,,,facility,inpatient,,,14507.85000,4207.28000,Aetna,Local,,5803.14,,,,,,,5230.08,11867.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE SHUNT,7695715,CDM,278,RC,,,,,facility,outpatient,,,14507.85000,4207.28000,Aetna,Local,,5803.14,,,,,,,4671.53,11867.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8170412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7932.00000,2300.28000,Aetna,Local,,3172.80,,,,,,,2859.49,6488.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8170412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7932.00000,2300.28000,Aetna,Local,,3172.80,,,,,,,2554.10,6488.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8170414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8170414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8170685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1291.62,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8170685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1153.68,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8170689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8170689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7804.86000,2263.41000,Aetna,Local,,3121.94,,,,,,,2813.65,6384.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7804.86000,2263.41000,Aetna,Local,,3121.94,,,,,,,2513.16,6384.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG TISSUE,8170764,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15425.00000,4473.25000,Aetna,Local,,6170.00,,,,,,,5560.71,12617.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG TISSUE,8170764,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15425.00000,4473.25000,Aetna,Local,,6170.00,,,,,,,4966.85,12617.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8170765,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,283.89,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8170765,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,253.57,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8170949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2393.00000,693.97000,Aetna,Local,,957.20,,,,,,,862.68,1957.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8170949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2393.00000,693.97000,Aetna,Local,,957.20,,,,,,,770.55,1957.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2841.60000,824.06000,Aetna,Local,,1136.64,,,,,,,1024.40,2324.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2841.60000,824.06000,Aetna,Local,,1136.64,,,,,,,915.00,2324.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8170946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5727.26000,1660.91000,Aetna,Local,,2290.90,,,,,,,2064.68,4684.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8170946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5727.26000,1660.91000,Aetna,Local,,2290.90,,,,,,,1844.18,4684.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2841.60000,824.06000,Aetna,Local,,1136.64,,,,,,,1024.40,2324.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8170952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2841.60000,824.06000,Aetna,Local,,1136.64,,,,,,,915.00,2324.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8170955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,474.05000,137.47000,Aetna,Local,,189.62,,,,,,,170.90,387.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8170955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,474.05000,137.47000,Aetna,Local,,189.62,,,,,,,152.64,387.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACELLULAR DERMIS,8170967,CDM,278,RC,Q4128,HCPCS,,,facility,inpatient,,,6427.05000,1863.84000,Aetna,Local,,2570.82,,,,,,,2316.95,5257.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACELLULAR DERMIS,8170967,CDM,278,RC,Q4128,HCPCS,,,facility,outpatient,,,6427.05000,1863.84000,Aetna,Local,,2570.82,,,,,,,124.65,5257.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8170968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,169.53,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8170968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,470.25000,136.37000,Aetna,Local,,188.10,,,,,,,151.42,384.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8170969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,713.79,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8170969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,637.56,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8171026,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8171026,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8171068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8171068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8171221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8171221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8171223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,Local,,1456.80,,,,,,,1312.94,2979.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8171223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,Local,,1456.80,,,,,,,1172.72,2979.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8171226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8171226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8171229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8171229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8171230,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8334.00000,2416.86000,Aetna,Local,,3333.60,,,,,,,3004.41,6817.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8171230,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8334.00000,2416.86000,Aetna,Local,,3333.60,,,,,,,2683.55,6817.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,134.94,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,120.52,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,134.94,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,120.52,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8171280,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1543.44,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8171280,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4281.38000,1241.60000,Aetna,Local,,1712.55,,,,,,,1378.60,3502.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8171283,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2936.27,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8171283,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2622.69,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,134.94,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,120.52,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8171475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8171475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8171791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8171791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8171733,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8171733,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,8171610,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,14142.00000,4101.18000,Aetna,Local,,5656.80,,,,,,,5098.19,11568.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,8171610,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,14142.00000,4101.18000,Aetna,Local,,5656.80,,,,,,,4553.72,11568.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8171840,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5183.50000,1503.22000,Aetna,Local,,2073.40,,,,,,,1868.65,4240.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8171840,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5183.50000,1503.22000,Aetna,Local,,2073.40,,,,,,,1669.09,4240.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8171842,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5183.50000,1503.22000,Aetna,Local,,2073.40,,,,,,,1868.65,4240.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8171842,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5183.50000,1503.22000,Aetna,Local,,2073.40,,,,,,,1669.09,4240.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8171854,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8171854,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8171856,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5183.50000,1503.22000,Aetna,Local,,2073.40,,,,,,,1868.65,4240.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8171856,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5183.50000,1503.22000,Aetna,Local,,2073.40,,,,,,,1669.09,4240.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8171858,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3437.00000,996.73000,Aetna,Local,,1374.80,,,,,,,1239.04,2811.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8171858,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3437.00000,996.73000,Aetna,Local,,1374.80,,,,,,,1106.71,2811.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8171860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8171860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8171862,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,191.63000,55.57000,Aetna,Local,,76.65,,,,,,,69.08,156.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8171862,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,191.63000,55.57000,Aetna,Local,,76.65,,,,,,,61.70,156.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8171863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8171864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8171864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8171865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8162.25000,2367.05000,Aetna,Local,,3264.90,,,,,,,2942.49,6676.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8171865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8162.25000,2367.05000,Aetna,Local,,3264.90,,,,,,,2628.24,6676.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8172024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.36000,912.44000,Aetna,Local,,1258.54,,,,,,,1134.26,2573.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8172024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.36000,912.44000,Aetna,Local,,1258.54,,,,,,,1013.13,2573.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8172025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10152.00000,2944.08000,Aetna,Local,,4060.80,,,,,,,3659.80,8304.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8172025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10152.00000,2944.08000,Aetna,Local,,4060.80,,,,,,,3268.94,8304.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8172043,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,801.38,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8172043,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,715.79,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8172044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8172044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8172045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8172045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8172042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8172042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8172176,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8172176,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8172178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.00000,537.08000,Aetna,Local,,740.80,,,,,,,667.65,1514.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8172178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.00000,537.08000,Aetna,Local,,740.80,,,,,,,596.34,1514.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8172180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8172180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8172182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5502.00000,1595.58000,Aetna,Local,,2200.80,,,,,,,1983.47,4500.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8172182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5502.00000,1595.58000,Aetna,Local,,2200.80,,,,,,,1771.64,4500.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8172184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8172184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7925798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7925798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8172219,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8334.00000,2416.86000,Aetna,Local,,3333.60,,,,,,,3004.41,6817.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8172219,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8334.00000,2416.86000,Aetna,Local,,3333.60,,,,,,,2683.55,6817.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8172221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8172221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8172223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8172223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8172225,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8172225,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8180844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,475.87,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8180844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,425.05,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8173854,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8173854,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8173856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8173856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8173858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31879.80000,9245.14000,Aetna,Local,,12751.92,,,,,,,11492.67,26077.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8173858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31879.80000,9245.14000,Aetna,Local,,12751.92,,,,,,,10265.30,26077.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8173860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8173860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8173866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5935.93000,1721.42000,Aetna,Local,,2374.37,,,,,,,2139.90,4855.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8173866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5935.93000,1721.42000,Aetna,Local,,2374.37,,,,,,,1911.37,4855.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8173869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,1075.11,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8173869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,960.29,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8173872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9705.00000,2814.45000,Aetna,Local,,3882.00,,,,,,,3498.65,7938.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8173872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9705.00000,2814.45000,Aetna,Local,,3882.00,,,,,,,3125.01,7938.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8173873,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,2224.35,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8173873,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,1986.80,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP HUMERAL,8173874,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.58000,1439.73000,Aetna,Local,,1985.83,,,,,,,1789.73,4061.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP HUMERAL,8173874,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.58000,1439.73000,Aetna,Local,,1985.83,,,,,,,1598.59,4061.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8181501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8181501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8173876,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8173876,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8173877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6210.33000,1801.00000,Aetna,Local,,2484.13,,,,,,,2238.82,5080.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8173877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6210.33000,1801.00000,Aetna,Local,,2484.13,,,,,,,1999.73,5080.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8173878,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8173878,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8173879,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8173879,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8173880,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8173880,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8173881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8173881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8173882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8173882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8173883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8173884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8173884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8180843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3080.08000,893.22000,Aetna,Local,,1232.03,,,,,,,1110.37,2519.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8180843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3080.08000,893.22000,Aetna,Local,,1232.03,,,,,,,991.79,2519.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8180845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8180845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8181458,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8181458,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,475.87,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,425.05,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8181459,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8181459,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8181460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,4351.96,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8181460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,3887.18,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8181461,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8181461,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8181462,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8181462,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8181463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1847.20,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8181463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1649.93,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8181464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5488.28000,1591.60000,Aetna,Local,,2195.31,,,,,,,1978.52,4489.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8181464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5488.28000,1591.60000,Aetna,Local,,2195.31,,,,,,,1767.23,4489.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8181465,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8181465,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMERAL,8181469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,865.20,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMERAL,8181469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,772.80,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8181476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8907.24000,2583.10000,Aetna,Local,,3562.90,,,,,,,3211.06,7286.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8181476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8907.24000,2583.10000,Aetna,Local,,3562.90,,,,,,,2868.13,7286.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8181608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8181608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8181609,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8181609,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8181610,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8181610,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8181612,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8181612,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8181837,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,1075.11,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8181837,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,960.29,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8181649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5935.93000,1721.42000,Aetna,Local,,2374.37,,,,,,,2139.90,4855.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8181649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5935.93000,1721.42000,Aetna,Local,,2374.37,,,,,,,1911.37,4855.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8181651,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8181651,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8181839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8181839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8181841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8181841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8181917,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8181917,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8181968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8181968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8181972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8182193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8182193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,Local,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8182195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25666.15000,7443.18000,Aetna,Local,,10266.46,,,,,,,9252.65,20994.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8182195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25666.15000,7443.18000,Aetna,Local,,10266.46,,,,,,,8264.50,20994.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8204015,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8204015,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8213968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8213968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8213970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8213970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8213972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8213972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8213974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8213974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8213976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,761.40000,220.81000,Aetna,Local,,304.56,,,,,,,274.48,622.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8213976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,761.40000,220.81000,Aetna,Local,,304.56,,,,,,,245.17,622.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8214063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8214063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8214065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8214065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8214067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8214067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8215236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8215236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8215238,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2091.92000,606.66000,Aetna,Local,,836.77,,,,,,,754.14,1711.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8215238,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2091.92000,606.66000,Aetna,Local,,836.77,,,,,,,673.60,1711.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8215240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8215240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8215243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8215243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8215245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8215245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8215247,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8215247,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8218496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8218496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8222112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8222112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8222114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8222114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8222116,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8222116,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8222118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8222118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8223967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8223967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8223969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8223969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8223971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8223971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,8223988,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,864.00000,250.56000,Aetna,Local,,345.60,,,,,,,311.47,706.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,8223988,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,864.00000,250.56000,Aetna,Local,,345.60,,,,,,,278.21,706.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8224024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,370.50000,107.44000,Aetna,Local,,148.20,,,,,,,133.57,303.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8224024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,370.50000,107.44000,Aetna,Local,,148.20,,,,,,,119.30,303.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8224026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8224026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8224027,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2584.00000,749.36000,Aetna,Local,,1033.60,,,,,,,931.53,2113.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8224027,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2584.00000,749.36000,Aetna,Local,,1033.60,,,,,,,832.05,2113.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8224029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12702.00000,3683.58000,Aetna,Local,,5080.80,,,,,,,4579.07,10390.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8224029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12702.00000,3683.58000,Aetna,Local,,5080.80,,,,,,,4090.04,10390.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8224031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12702.00000,3683.58000,Aetna,Local,,5080.80,,,,,,,4579.07,10390.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8224031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12702.00000,3683.58000,Aetna,Local,,5080.80,,,,,,,4090.04,10390.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8224117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25225.20000,7315.31000,Aetna,Local,,10090.08,,,,,,,9093.68,20634.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8224117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25225.20000,7315.31000,Aetna,Local,,10090.08,,,,,,,8122.51,20634.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8224119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2956.98,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8224119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2641.19,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8224121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8224121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8224123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8224123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8224125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8224125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD NEURO STIM,8224131,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,6492.50000,1882.82000,Aetna,Local,,2597.00,,,,,,,2340.55,5310.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD NEURO STIM,8224131,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,6492.50000,1882.82000,Aetna,Local,,2597.00,,,,,,,2090.59,5310.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8224132,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8224132,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8224133,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8224133,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8225827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8225827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8225829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8225829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8225831,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8225831,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225833,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,1106.01,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225833,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,987.90,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8225840,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8225840,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8225841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8225841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5198.20000,1507.48000,Aetna,Local,,2079.28,,,,,,,1873.95,4252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5198.20000,1507.48000,Aetna,Local,,2079.28,,,,,,,1673.82,4252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8225896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8225896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8225897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4515.97,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8225897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4033.68,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8225900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2903.18,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8225900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2593.13,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SPINAL,8225903,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14550.00000,4219.50000,Aetna,Local,,5820.00,,,,,,,5245.27,11901.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SPINAL,8225903,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14550.00000,4219.50000,Aetna,Local,,5820.00,,,,,,,4685.10,11901.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225904,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5502.00000,1595.58000,Aetna,Local,,2200.80,,,,,,,1983.47,4500.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225904,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5502.00000,1595.58000,Aetna,Local,,2200.80,,,,,,,1771.64,4500.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225905,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5502.00000,1595.58000,Aetna,Local,,2200.80,,,,,,,1983.47,4500.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225905,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5502.00000,1595.58000,Aetna,Local,,2200.80,,,,,,,1771.64,4500.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225906,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225906,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225907,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225907,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225908,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8225908,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8225992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8225992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8225994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8225994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8225996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2650.40000,768.62000,Aetna,Local,,1060.16,,,,,,,955.47,2168.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8225996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2650.40000,768.62000,Aetna,Local,,1060.16,,,,,,,853.43,2168.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8225998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8226000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8226000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8226002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3465.42000,1004.97000,Aetna,Local,,1386.17,,,,,,,1249.28,2834.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8226002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3465.42000,1004.97000,Aetna,Local,,1386.17,,,,,,,1115.87,2834.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8226004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8226004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8226006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8226006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8226008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8226008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8226010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3475.94,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8226010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3104.72,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8226012,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8226012,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8226014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8226014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8226018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,266.29,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8226018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,237.85,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8226019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,266.29,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8226019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,237.85,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8226020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4609.35,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8226020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4117.09,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8227867,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8227867,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8227868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1803.80,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8227868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1611.16,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8228014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8228014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8228018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8228018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8228020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8334.00000,2416.86000,Aetna,Local,,3333.60,,,,,,,3004.41,6817.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8228020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8334.00000,2416.86000,Aetna,Local,,3333.60,,,,,,,2683.55,6817.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8228030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8228030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8228149,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8228149,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8228150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,2224.35,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8228150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,1986.80,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8228216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8228216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228224,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3465.42000,1004.97000,Aetna,Local,,1386.17,,,,,,,1249.28,2834.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228224,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3465.42000,1004.97000,Aetna,Local,,1386.17,,,,,,,1115.87,2834.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8228218,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8228218,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8228368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5675.67000,1645.94000,Aetna,Local,,2270.27,,,,,,,2046.08,4642.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8228368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5675.67000,1645.94000,Aetna,Local,,2270.27,,,,,,,1827.57,4642.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8228397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2802.84000,812.82000,Aetna,Local,,1121.14,,,,,,,1010.42,2292.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8228397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2802.84000,812.82000,Aetna,Local,,1121.14,,,,,,,902.51,2292.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8228399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2497.96000,724.41000,Aetna,Local,,999.18,,,,,,,900.51,2043.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8228399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2497.96000,724.41000,Aetna,Local,,999.18,,,,,,,804.34,2043.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,266.29,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,237.85,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8228405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8228405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8228409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18861.60000,5469.86000,Aetna,Local,,7544.64,,,,,,,6799.61,15428.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8228409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18861.60000,5469.86000,Aetna,Local,,7544.64,,,,,,,6073.44,15428.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8228478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8228478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8228480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8228480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8228482,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8228482,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8228546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8228552,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8228552,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8228554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8228554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8228582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8228582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8228588,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8228588,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8228655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1151.87,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8228655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1028.85,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8228884,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8228884,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8228893,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8228893,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8228897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2760.60000,800.57000,Aetna,Local,,1104.24,,,,,,,995.20,2258.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8228897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2760.60000,800.57000,Aetna,Local,,1104.24,,,,,,,888.91,2258.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,303.91000,88.13000,Aetna,Local,,121.56,,,,,,,109.56,248.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8228899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,303.91000,88.13000,Aetna,Local,,121.56,,,,,,,97.86,248.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8229046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8786.25000,2548.01000,Aetna,Local,,3514.50,,,,,,,3167.44,7187.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8229046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8786.25000,2548.01000,Aetna,Local,,3514.50,,,,,,,2829.17,7187.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,8229106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,8229106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8229103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8229256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1562.00000,452.98000,Aetna,Local,,624.80,,,,,,,563.10,1277.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8229256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1562.00000,452.98000,Aetna,Local,,624.80,,,,,,,502.96,1277.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8229254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.33000,110.30000,Aetna,Local,,152.13,,,,,,,137.11,311.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8229254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.33000,110.30000,Aetna,Local,,152.13,,,,,,,122.47,311.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8229924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9426.00000,2733.54000,Aetna,Local,,3770.40,,,,,,,3398.07,7710.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8229924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9426.00000,2733.54000,Aetna,Local,,3770.40,,,,,,,3035.17,7710.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8230051,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,1106.01,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8230051,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,987.90,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8230053,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,11580.00000,3358.20000,Aetna,Local,,4632.00,,,,,,,4174.59,9472.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8230053,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,11580.00000,3358.20000,Aetna,Local,,4632.00,,,,,,,3728.76,9472.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8230054,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8230054,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8230057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8230057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8230060,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8230060,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8230062,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8230062,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HEMODIALYSIS,8230373,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HEMODIALYSIS,8230373,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8230375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8230375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8230377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8230377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8230379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8230379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8230381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8230381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8230383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,684.00000,198.36000,Aetna,Local,,273.60,,,,,,,246.58,559.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8230383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,684.00000,198.36000,Aetna,Local,,273.60,,,,,,,220.25,559.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8230909,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8230909,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8230923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8230923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLAR,8230911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLAR,8230911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8230913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8230913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8230915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8230915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8230918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8230918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8230921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8230921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8231122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8231122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8231124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8231124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8231128,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8231128,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,8231433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,8231433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8231434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8231434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8231435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8231435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFTLINK,8231589,CDM,278,RC,,,,,facility,inpatient,,,9135.60000,2649.32000,Aetna,Local,,3654.24,,,,,,,3293.38,7472.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFTLINK,8231589,CDM,278,RC,,,,,facility,outpatient,,,9135.60000,2649.32000,Aetna,Local,,3654.24,,,,,,,2941.66,7472.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8231590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8231590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8231594,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8231594,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1377.28000,399.41000,Aetna,Local,,550.91,,,,,,,496.51,1126.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1377.28000,399.41000,Aetna,Local,,550.91,,,,,,,443.48,1126.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8231598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10003.80000,2901.10000,Aetna,Local,,4001.52,,,,,,,3606.37,8183.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8231598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10003.80000,2901.10000,Aetna,Local,,4001.52,,,,,,,3221.22,8183.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,619.79000,179.74000,Aetna,Local,,247.92,,,,,,,223.43,506.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,619.79000,179.74000,Aetna,Local,,247.92,,,,,,,199.57,506.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1377.28000,399.41000,Aetna,Local,,550.91,,,,,,,496.51,1126.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1377.28000,399.41000,Aetna,Local,,550.91,,,,,,,443.48,1126.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8231604,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3211.25000,931.26000,Aetna,Local,,1284.50,,,,,,,1157.66,2626.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8231604,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3211.25000,931.26000,Aetna,Local,,1284.50,,,,,,,1034.02,2626.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8231606,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8304.00000,2408.16000,Aetna,Local,,3321.60,,,,,,,2993.59,6792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8231606,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8304.00000,2408.16000,Aetna,Local,,3321.60,,,,,,,2673.89,6792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8231608,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8231608,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8231610,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,Local,,20156.16,,,,,,,18165.74,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8231610,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,Local,,20156.16,,,,,,,16225.71,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8231612,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53270.40000,15448.42000,Aetna,Local,,21308.16,,,,,,,19203.98,43575.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8231612,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53270.40000,15448.42000,Aetna,Local,,21308.16,,,,,,,17153.07,43575.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8231592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8231592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231615,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.60000,90.94000,Aetna,Local,,125.44,,,,,,,113.05,256.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231615,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.60000,90.94000,Aetna,Local,,125.44,,,,,,,100.98,256.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8231843,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8231843,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8231844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8231844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,Local,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8231845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1803.80,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8231845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1611.16,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLADE FOR NAIL,8231846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,700.74,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLADE FOR NAIL,8231846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,625.90,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8231877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3213.00000,931.77000,Aetna,Local,,1285.20,,,,,,,1158.29,2628.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8231877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3213.00000,931.77000,Aetna,Local,,1285.20,,,,,,,1034.59,2628.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8231881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2756.60000,799.41000,Aetna,Local,,1102.64,,,,,,,993.75,2254.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8231881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2756.60000,799.41000,Aetna,Local,,1102.64,,,,,,,887.63,2254.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMERAL,8231887,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,865.20,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMERAL,8231887,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,772.80,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8231923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4136.27000,1199.52000,Aetna,Local,,1654.51,,,,,,,1491.13,3383.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8231923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4136.27000,1199.52000,Aetna,Local,,1654.51,,,,,,,1331.88,3383.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,303.91000,88.13000,Aetna,Local,,121.56,,,,,,,109.56,248.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,303.91000,88.13000,Aetna,Local,,121.56,,,,,,,97.86,248.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8231927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.20000,348.06000,Aetna,Local,,480.08,,,,,,,432.67,981.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8231927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.20000,348.06000,Aetna,Local,,480.08,,,,,,,386.46,981.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8231929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8231929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8231963,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8231963,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8231986,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2264.00000,656.56000,Aetna,Local,,905.60,,,,,,,816.17,1851.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8231986,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2264.00000,656.56000,Aetna,Local,,905.60,,,,,,,729.01,1851.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8231987,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8231987,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8231989,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8231989,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8231991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8231992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8231992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8232034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8232034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON SEPTAL,8232141,CDM,278,RC,L8047,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,201.16,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON SEPTAL,8232141,CDM,278,RC,L8047,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,179.68,1561.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8232143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8232143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8232145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8232145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8232147,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1303.16000,377.92000,Aetna,Local,,521.26,,,,,,,469.79,1065.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8232147,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1303.16000,377.92000,Aetna,Local,,521.26,,,,,,,419.62,1065.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8232233,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2676.00000,776.04000,Aetna,Local,,1070.40,,,,,,,964.70,2188.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8232233,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2676.00000,776.04000,Aetna,Local,,1070.40,,,,,,,861.67,2188.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8232240,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8232240,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8232241,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8232241,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8232242,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8304.00000,2408.16000,Aetna,Local,,3321.60,,,,,,,2993.59,6792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8232242,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8304.00000,2408.16000,Aetna,Local,,3321.60,,,,,,,2673.89,6792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,Local,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8232243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1631.80000,473.22000,Aetna,Local,,652.72,,,,,,,588.26,1334.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8232243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1631.80000,473.22000,Aetna,Local,,652.72,,,,,,,525.44,1334.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8232244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8232244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8232245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8232245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232516,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232516,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8232350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8232350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8232351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8232351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8232352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8232352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8232353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8232353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8232354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8232354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8232355,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8232355,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8232356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8232356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8232357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8232357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8232358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8232358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8232359,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8232359,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8232360,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8232360,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8232502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5894.70000,1709.46000,Aetna,Local,,2357.88,,,,,,,2125.04,4821.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8232502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5894.70000,1709.46000,Aetna,Local,,2357.88,,,,,,,1898.09,4821.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8232504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,51.10,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8232504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,Local,,56.70,,,,,,,45.64,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8232506,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8232506,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8232510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5864.57000,1700.73000,Aetna,Local,,2345.83,,,,,,,2114.18,4797.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8232510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5864.57000,1700.73000,Aetna,Local,,2345.83,,,,,,,1888.39,4797.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232517,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232517,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232513,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232513,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232515,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232515,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232514,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232514,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232518,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,322.39,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232518,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,287.96,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232519,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,322.39,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232519,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,287.96,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232520,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,322.39,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232520,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,287.96,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232521,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,322.39,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8232521,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,287.96,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8232618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8232620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8232620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8232622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8232622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8232624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8232624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8232626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8232626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,Local,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8232628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8232628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8232630,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,898.09000,260.45000,Aetna,Local,,359.24,,,,,,,323.76,734.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8232630,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,898.09000,260.45000,Aetna,Local,,359.24,,,,,,,289.18,734.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8234068,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8234068,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8234070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8234070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8234093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1469.63,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8234093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1312.67,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8234094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8234094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8234095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8234095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7700885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7993541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,442.75000,128.40000,Aetna,Local,,177.10,,,,,,,159.61,362.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7993541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,442.75000,128.40000,Aetna,Local,,177.10,,,,,,,142.57,362.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8234142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3921.37000,1137.20000,Aetna,Local,,1568.55,,,,,,,1413.65,3207.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8234142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3921.37000,1137.20000,Aetna,Local,,1568.55,,,,,,,1262.68,3207.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8234144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3921.37000,1137.20000,Aetna,Local,,1568.55,,,,,,,1413.65,3207.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8234144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3921.37000,1137.20000,Aetna,Local,,1568.55,,,,,,,1262.68,3207.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8234146,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8234146,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8234148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8234148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8234150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8234150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8234152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8234152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR STAPLE,8234139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3644.38,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR STAPLE,8234139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3255.18,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8236008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3089.84000,896.05000,Aetna,Local,,1235.94,,,,,,,1113.89,2527.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8236008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3089.84000,896.05000,Aetna,Local,,1235.94,,,,,,,994.93,2527.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8236010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4486.23000,1301.01000,Aetna,Local,,1794.49,,,,,,,1617.29,3669.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8236010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4486.23000,1301.01000,Aetna,Local,,1794.49,,,,,,,1444.57,3669.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8236012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8236012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8236014,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1734.59,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8236014,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1549.34,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8236016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5914.13000,1715.10000,Aetna,Local,,2365.65,,,,,,,2132.04,4837.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8236016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5914.13000,1715.10000,Aetna,Local,,2365.65,,,,,,,1904.35,4837.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8236564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8236564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8236485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8236485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8236486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8236486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8237199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,3076.87,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8237199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,Local,,3414.00,,,,,,,2748.27,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8237201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8237201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8237203,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8237203,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8237205,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,772.88000,224.14000,Aetna,Local,,309.15,,,,,,,278.62,632.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8237205,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,772.88000,224.14000,Aetna,Local,,309.15,,,,,,,248.87,632.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8237209,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8237209,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8237249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8237249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8237251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8237251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8237253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8237253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8237277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2968.72,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8237277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2651.67,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8237278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8237278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8237279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8237279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8237280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8237280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8237281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8237281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT MENISCAL ROOT SPACER INCLUDED IN KIT,8237287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4444.13000,1288.80000,Aetna,Local,,1777.65,,,,,,,1602.11,3635.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT MENISCAL ROOT SPACER INCLUDED IN KIT,8237287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4444.13000,1288.80000,Aetna,Local,,1777.65,,,,,,,1431.01,3635.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8237400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8237400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8237402,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8237402,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8237404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8237404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8238042,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8238042,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8238044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8238044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8238046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5320.00000,1542.80000,Aetna,Local,,2128.00,,,,,,,1917.86,4351.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8238046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5320.00000,1542.80000,Aetna,Local,,2128.00,,,,,,,1713.04,4351.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8238048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8238048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8134361,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3184.00000,923.36000,Aetna,Local,,1273.60,,,,,,,1147.83,2604.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8134361,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3184.00000,923.36000,Aetna,Local,,1273.60,,,,,,,1025.25,2604.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8134365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3213.00000,931.77000,Aetna,Local,,1285.20,,,,,,,1158.29,2628.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8134365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3213.00000,931.77000,Aetna,Local,,1285.20,,,,,,,1034.59,2628.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8134371,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7746.00000,2246.34000,Aetna,Local,,3098.40,,,,,,,2792.43,6336.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8134371,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7746.00000,2246.34000,Aetna,Local,,3098.40,,,,,,,2494.21,6336.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8134373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8134373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8134375,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,533.11,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8134375,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,Local,,591.52,,,,,,,476.17,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8134379,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12267.00000,3557.43000,Aetna,Local,,4906.80,,,,,,,4422.25,10034.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8134379,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12267.00000,3557.43000,Aetna,Local,,4906.80,,,,,,,3949.97,10034.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8134924,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,536.42,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8134924,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,479.14,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8134927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2304.00000,668.16000,Aetna,Local,,921.60,,,,,,,830.59,1884.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8134927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2304.00000,668.16000,Aetna,Local,,921.60,,,,,,,741.89,1884.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8134929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8136312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8136312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8136740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8136740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8136572,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8136572,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8136573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8136573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8136574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8136574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7707446,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7707446,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,8137059,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,8137059,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5013.75000,1453.99000,Aetna,Local,,2005.50,,,,,,,1807.46,4101.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5013.75000,1453.99000,Aetna,Local,,2005.50,,,,,,,1614.43,4101.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8136741,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8136741,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8136742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8136742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8137074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8137074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8137075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8137075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137076,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137076,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8137082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8137082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8137130,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8137130,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137137,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,6142.50000,1781.32000,Aetna,Local,,2457.00,,,,,,,2214.37,5024.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137137,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,6142.50000,1781.32000,Aetna,Local,,2457.00,,,,,,,1977.88,5024.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137138,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,6142.50000,1781.32000,Aetna,Local,,2457.00,,,,,,,2214.37,5024.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137138,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,6142.50000,1781.32000,Aetna,Local,,2457.00,,,,,,,1977.88,5024.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137139,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,6142.50000,1781.32000,Aetna,Local,,2457.00,,,,,,,2214.37,5024.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137139,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,6142.50000,1781.32000,Aetna,Local,,2457.00,,,,,,,1977.88,5024.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137140,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137140,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137141,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137141,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137142,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,6142.50000,1781.32000,Aetna,Local,,2457.00,,,,,,,2214.37,5024.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8137142,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,6142.50000,1781.32000,Aetna,Local,,2457.00,,,,,,,1977.88,5024.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8137199,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,39.27,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8137199,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,35.08,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8137190,CDM,278,RC,C2621,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8137190,CDM,278,RC,C2621,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4704.00000,1364.16000,Aetna,Local,,1881.60,,,,,,,1695.79,3847.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4704.00000,1364.16000,Aetna,Local,,1881.60,,,,,,,1514.69,3847.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8109.00000,2351.61000,Aetna,Local,,3243.60,,,,,,,2923.29,6633.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8109.00000,2351.61000,Aetna,Local,,3243.60,,,,,,,2611.10,6633.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1847.20,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1649.93,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8137224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4518.50000,1310.36000,Aetna,Local,,1807.40,,,,,,,1628.92,3696.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8137224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4518.50000,1310.36000,Aetna,Local,,1807.40,,,,,,,1454.96,3696.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1469.63,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1312.67,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8137225,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8137225,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8137226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7576.65000,2197.23000,Aetna,Local,,3030.66,,,,,,,2731.38,6197.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8137226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7576.65000,2197.23000,Aetna,Local,,3030.66,,,,,,,2439.68,6197.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8137258,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,7610.70000,2207.10000,Aetna,Local,,3044.28,,,,,,,2743.66,6225.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8137258,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,7610.70000,2207.10000,Aetna,Local,,3044.28,,,,,,,2450.65,6225.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8607.00000,2496.03000,Aetna,Local,,3442.80,,,,,,,3102.82,7040.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8607.00000,2496.03000,Aetna,Local,,3442.80,,,,,,,2771.45,7040.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1469.63,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1312.67,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8137403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2141.00000,620.89000,Aetna,Local,,856.40,,,,,,,771.83,1751.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8137403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2141.00000,620.89000,Aetna,Local,,856.40,,,,,,,689.40,1751.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8137405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8137405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4042.50000,1172.32000,Aetna,Local,,1617.00,,,,,,,1457.32,3306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8137400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4042.50000,1172.32000,Aetna,Local,,1617.00,,,,,,,1301.68,3306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,8137497,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,8137497,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.00000,516.20000,Aetna,Local,,712.00,,,,,,,641.69,1456.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.00000,516.20000,Aetna,Local,,712.00,,,,,,,573.16,1456.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.00000,516.20000,Aetna,Local,,712.00,,,,,,,641.69,1456.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.00000,516.20000,Aetna,Local,,712.00,,,,,,,573.16,1456.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8137503,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,6060.91,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8137503,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,5413.62,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8137735,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14143.50000,4101.62000,Aetna,Local,,5657.40,,,,,,,5098.73,11569.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8137735,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14143.50000,4101.62000,Aetna,Local,,5657.40,,,,,,,4554.21,11569.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8137737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8137737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8141084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8786.25000,2548.01000,Aetna,Local,,3514.50,,,,,,,3167.44,7187.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8141084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8786.25000,2548.01000,Aetna,Local,,3514.50,,,,,,,2829.17,7187.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8141167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,118.15,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8141167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,105.54,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8141174,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8141174,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8141176,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8141176,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION SYSTEM,8141178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION SYSTEM,8141178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,8141180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,8141180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8141193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8141193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8141195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8141195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8141197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,4346.82,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8141197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,3882.60,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8141331,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8141331,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,Local,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8141335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8141335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8141337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8141337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHERICAL IMPLANT,8141540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8421.00000,2442.09000,Aetna,Local,,3368.40,,,,,,,3035.77,6888.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHERICAL IMPLANT,8141540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8421.00000,2442.09000,Aetna,Local,,3368.40,,,,,,,2711.56,6888.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8141772,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,Local,,59.01,,,,,,,53.18,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8141772,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,Local,,59.01,,,,,,,47.50,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8141779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8141779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8141780,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8141780,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8141843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8142110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1395.50,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8142110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1246.46,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8142112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8142112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ANCHOR,8142114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,5497.62,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ANCHOR,8142114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,4910.50,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8142116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8142116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8142119,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8142119,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8142397,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8142397,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8142399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8142399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8142400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8142400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8142401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8077.50000,2342.48000,Aetna,Local,,3231.00,,,,,,,2911.94,6607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8142401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8077.50000,2342.48000,Aetna,Local,,3231.00,,,,,,,2600.95,6607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8142402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8142402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8142403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8142403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINE,8142404,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINE,8142404,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8142405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8142405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8142406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8142406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8142407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8142407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8142408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8142408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8142409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8142409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8142780,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8142780,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8142783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8142783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8142806,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8142806,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8142785,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12334.50000,3577.00000,Aetna,Local,,4933.80,,,,,,,4446.59,10089.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8142785,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12334.50000,3577.00000,Aetna,Local,,4933.80,,,,,,,3971.71,10089.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8142807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8142807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8143178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4518.50000,1310.36000,Aetna,Local,,1807.40,,,,,,,1628.92,3696.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8143178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4518.50000,1310.36000,Aetna,Local,,1807.40,,,,,,,1454.96,3696.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8143226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,6524.15,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8143226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18097.50000,5248.28000,Aetna,Local,,7239.00,,,,,,,5827.40,14803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8143222,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8143222,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8143224,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8143224,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,Local,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8143276,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8143276,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,Local,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8143278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8143278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8143279,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26625.00000,7721.25000,Aetna,Local,,10650.00,,,,,,,9598.31,21779.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8143279,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26625.00000,7721.25000,Aetna,Local,,10650.00,,,,,,,8573.25,21779.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2015.00000,584.35000,Aetna,Local,,806.00,,,,,,,726.41,1648.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2015.00000,584.35000,Aetna,Local,,806.00,,,,,,,648.83,1648.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8143327,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8143327,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8143334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8143334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR HUMERAL,8143335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,5497.62,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR HUMERAL,8143335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,4910.50,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8143336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8143336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8143409,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8143409,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8143483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8143483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8143484,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8143484,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8143485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8143485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8143486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8143487,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8143487,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8143488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3942.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8143488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3521.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8143489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8143489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8143490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1803.80,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8143490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1611.16,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8143491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8143491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2141.00000,620.89000,Aetna,Local,,856.40,,,,,,,771.83,1751.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2141.00000,620.89000,Aetna,Local,,856.40,,,,,,,689.40,1751.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2141.00000,620.89000,Aetna,Local,,856.40,,,,,,,771.83,1751.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2141.00000,620.89000,Aetna,Local,,856.40,,,,,,,689.40,1751.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145918,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145918,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8145914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8145914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8145916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8145916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8145925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8145925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,70.03,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,62.55,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOSPHERE,8145924,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,485.06,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOSPHERE,8145924,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,433.26,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8145928,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8145928,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8146879,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8146879,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8145931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7590.00000,2201.10000,Aetna,Local,,3036.00,,,,,,,2736.20,6208.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8145931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7590.00000,2201.10000,Aetna,Local,,3036.00,,,,,,,2443.98,6208.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8145932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8145932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8145933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1562.05,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8145933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4333.00000,1256.57000,Aetna,Local,,1733.20,,,,,,,1395.23,3544.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8145934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8145934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8145935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1734.59,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8145935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1549.34,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8146880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8146880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8146881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8146881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8145940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8145941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8145941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8145942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8145942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8145943,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8145943,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8145944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8145944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8145945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8145945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8145946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8145946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8145947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2903.18,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8145947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2593.13,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8145953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8145953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8145952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8145952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT NEURO STIM,8145948,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,11100.00000,3219.00000,Aetna,Local,,4440.00,,,,,,,4001.55,9079.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT NEURO STIM,8145948,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,11100.00000,3219.00000,Aetna,Local,,4440.00,,,,,,,3574.20,9079.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8145954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2708.08,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8145954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2418.86,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8145955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,6518.74,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8145955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,5822.56,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8145956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8145956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8145957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8145957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8145958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8145958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8145959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8145959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8145960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8145960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8147091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8147091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8147094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8147094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SUBSTITUTE IN KIT,8147338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11790.00000,3419.10000,Aetna,Local,,4716.00,,,,,,,4250.30,9644.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SUBSTITUTE IN KIT,8147338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11790.00000,3419.10000,Aetna,Local,,4716.00,,,,,,,3796.38,9644.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8147339,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8147339,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8147340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8147340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8147343,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8147343,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8147341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8147341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8147342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8147342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,8147434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,5497.62,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,8147434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,4910.50,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8147436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8147436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8147479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8147479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8147481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8147481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8147483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8147483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8147603,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8147603,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8147650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,254.69,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8147650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,227.49,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8147652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8147652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8147741,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8147741,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8147743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8147743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8147744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8147744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8147780,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2708.08,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8147780,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2418.86,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,8147782,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,7151.42,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,8147782,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,Local,,7935.00,,,,,,,6387.68,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8147785,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8147785,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8147787,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8147787,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8147789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8147789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8147892,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4906.76000,1422.96000,Aetna,Local,,1962.70,,,,,,,1768.89,4013.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8147892,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4906.76000,1422.96000,Aetna,Local,,1962.70,,,,,,,1579.98,4013.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8148051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6062.00000,1757.98000,Aetna,Local,,2424.80,,,,,,,2185.35,4958.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8148051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6062.00000,1757.98000,Aetna,Local,,2424.80,,,,,,,1951.96,4958.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7965251,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7965251,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NASAL IMPLANT,7987717,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9435.00000,2736.15000,Aetna,Local,,3774.00,,,,,,,3401.32,7717.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NASAL IMPLANT,7987717,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9435.00000,2736.15000,Aetna,Local,,3774.00,,,,,,,3038.07,7717.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDWIRE,8148054,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDWIRE,8148054,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8244287,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8244287,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8314043,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,351.50000,101.93000,Aetna,Local,,140.60,,,,,,,126.72,287.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8314043,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,351.50000,101.93000,Aetna,Local,,140.60,,,,,,,113.18,287.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER KT,8136110,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,355.59000,103.12000,Aetna,Local,,142.24,,,,,,,128.19,290.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER KT,8136110,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,355.59000,103.12000,Aetna,Local,,142.24,,,,,,,114.50,290.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER KT,8135904,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,440.80000,127.83000,Aetna,Local,,176.32,,,,,,,158.91,360.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER KT,8135904,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,440.80000,127.83000,Aetna,Local,,176.32,,,,,,,141.94,360.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,8322726,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,8322726,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8367231,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,32175.00000,9330.75000,Aetna,Local,,12870.00,,,,,,,11599.09,26319.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8367231,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,32175.00000,9330.75000,Aetna,Local,,12870.00,,,,,,,10360.35,26319.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,9226700,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,9226700,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8372556,CDM,278,RC,C2629,HCPCS,,,facility,inpatient,,,12630.00000,3662.70000,Aetna,Local,,5052.00,,,,,,,4553.11,10331.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8372556,CDM,278,RC,C2629,HCPCS,,,facility,outpatient,,,12630.00000,3662.70000,Aetna,Local,,5052.00,,,,,,,4066.86,10331.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8372557,CDM,278,RC,C2629,HCPCS,,,facility,inpatient,,,12630.00000,3662.70000,Aetna,Local,,5052.00,,,,,,,4553.11,10331.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8372557,CDM,278,RC,C2629,HCPCS,,,facility,outpatient,,,12630.00000,3662.70000,Aetna,Local,,5052.00,,,,,,,4066.86,10331.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8372558,CDM,278,RC,C2629,HCPCS,,,facility,inpatient,,,12630.00000,3662.70000,Aetna,Local,,5052.00,,,,,,,4553.11,10331.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8372558,CDM,278,RC,C2629,HCPCS,,,facility,outpatient,,,12630.00000,3662.70000,Aetna,Local,,5052.00,,,,,,,4066.86,10331.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8368312,CDM,278,RC,C2630,HCPCS,,,facility,inpatient,,,9900.00000,2871.00000,Aetna,Local,,3960.00,,,,,,,3568.95,8098.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8368312,CDM,278,RC,C2630,HCPCS,,,facility,outpatient,,,9900.00000,2871.00000,Aetna,Local,,9357.00,,,,,,,3187.80,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STENT,8415043,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415043,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415044,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415044,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415045,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415045,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415046,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415046,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415047,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415047,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415048,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415048,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415049,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415049,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415050,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415050,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415051,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415051,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415052,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415052,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415053,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415053,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415054,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415054,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415055,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415055,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415056,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415056,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415057,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415057,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415058,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415058,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415059,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415059,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415060,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415060,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8415308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3825.50000,1109.40000,Aetna,Local,,1530.20,,,,,,,1379.09,3129.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8415308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3825.50000,1109.40000,Aetna,Local,,1530.20,,,,,,,1231.81,3129.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8415289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,Local,,92.40,,,,,,,83.28,188.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8415289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,Local,,92.40,,,,,,,74.38,188.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8415292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,319.58,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8415292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,285.45,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8415294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,319.58,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8415294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,285.45,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8415296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,319.58,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8415296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,285.45,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8415298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1864.00000,540.56000,Aetna,Local,,745.60,,,,,,,671.97,1524.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8415298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1864.00000,540.56000,Aetna,Local,,745.60,,,,,,,600.21,1524.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8415300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,20217.50000,5863.08000,Aetna,Local,,8087.00,,,,,,,7288.41,16537.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8415300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,20217.50000,5863.08000,Aetna,Local,,8087.00,,,,,,,6510.03,16537.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8415309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8415309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8415310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,665.84,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8415310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,594.73,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8416011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8416011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8416012,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8416012,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8416013,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8416013,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8416014,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8416014,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8416015,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8416015,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8416016,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8416016,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8416017,CDM,278,RC,A4340,HCPCS,,,facility,inpatient,,,137.16000,39.78000,Aetna,Local,,54.86,,,,,,,49.45,112.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8416017,CDM,278,RC,A4340,HCPCS,,,facility,outpatient,,,137.16000,39.78000,Aetna,Local,,54.86,,,,,,,41.43,112.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8416347,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5421.85000,1572.34000,Aetna,Local,,2168.74,,,,,,,1954.58,4435.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8416347,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5421.85000,1572.34000,Aetna,Local,,2168.74,,,,,,,1745.84,4435.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8416349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8416349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8416351,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8416351,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8416353,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8416353,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3220.70000,934.00000,Aetna,Local,,1288.28,,,,,,,1161.06,2634.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3220.70000,934.00000,Aetna,Local,,1288.28,,,,,,,1037.07,2634.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,7695078,CDM,278,RC,C1888,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,7695078,CDM,278,RC,C1888,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8416418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1596.11,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8416418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1425.65,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8416489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8416489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8416490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8416490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8416491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8416491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8416492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8416492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8416493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8416493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8416772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8416774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8416774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8416837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8416837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8416839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8416839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8416841,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8416841,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8416842,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,7273.09,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8416842,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,6496.35,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8416844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8416844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,8416846,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,8416846,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8416848,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8416848,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8416850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8416850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION SYSTEM,8148303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION SYSTEM,8148303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8148305,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8148305,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8148307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5455.63000,1582.13000,Aetna,Local,,2182.25,,,,,,,1966.75,4462.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8148307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5455.63000,1582.13000,Aetna,Local,,2182.25,,,,,,,1756.71,4462.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,8148309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,8148309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8148311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8148311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8148313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8148313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8148794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8148794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8148796,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,11970.00000,3471.30000,Aetna,Local,,4788.00,,,,,,,4315.19,9791.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8148796,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,11970.00000,3471.30000,Aetna,Local,,4788.00,,,,,,,3854.34,9791.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8148866,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8148866,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8149203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8149203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8148867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8148867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8148868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8148868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8148869,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8148869,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8148870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8148870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8148874,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,1106.01,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8148874,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,987.90,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8148875,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,876.74,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8148875,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,Local,,972.80,,,,,,,783.10,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8148876,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8148876,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8148877,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8148877,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8149522,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8149522,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8148879,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8148879,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8148881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8149208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8149208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8149209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8149209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8149523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3660.65000,1061.59000,Aetna,Local,,1464.26,,,,,,,1319.66,2994.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8149523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3660.65000,1061.59000,Aetna,Local,,1464.26,,,,,,,1178.73,2994.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8149525,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8149525,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8149526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8149526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149586,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149586,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149588,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149588,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149589,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149589,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149590,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149590,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149591,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8149591,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8149592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5887.49000,1707.37000,Aetna,Local,,2355.00,,,,,,,2122.44,4815.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8149592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5887.49000,1707.37000,Aetna,Local,,2355.00,,,,,,,1895.77,4815.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8149593,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3638.95000,1055.30000,Aetna,Local,,1455.58,,,,,,,1311.84,2976.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8149593,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3638.95000,1055.30000,Aetna,Local,,1455.58,,,,,,,1171.74,2976.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8149594,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2512.00000,728.48000,Aetna,Local,,1004.80,,,,,,,905.58,2054.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8149594,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2512.00000,728.48000,Aetna,Local,,1004.80,,,,,,,808.86,2054.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8149595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1151.87,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8149595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1028.85,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8149683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8149683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8149688,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4039.74000,1171.52000,Aetna,Local,,1615.90,,,,,,,1456.33,3304.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8149688,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4039.74000,1171.52000,Aetna,Local,,1615.90,,,,,,,1300.80,3304.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8149689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8149689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8149560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8149560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8149567,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8149567,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8149569,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,164.06000,47.58000,Aetna,Local,,65.62,,,,,,,59.14,134.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8149569,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,164.06000,47.58000,Aetna,Local,,65.62,,,,,,,52.83,134.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8149571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8149571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8149572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8149572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8149836,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8149836,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8149839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8149839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8149841,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8149841,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8149838,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6219.85000,1803.76000,Aetna,Local,,2487.94,,,,,,,2242.26,5087.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8149838,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6219.85000,1803.76000,Aetna,Local,,2487.94,,,,,,,2002.79,5087.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8149876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,Local,,3434.40,,,,,,,3095.25,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8149876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,Local,,3434.40,,,,,,,2764.69,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8149878,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8149878,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8149880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8149880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8149882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8149882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8149884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8149884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8149886,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6210.33000,1801.00000,Aetna,Local,,2484.13,,,,,,,2238.82,5080.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8149886,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6210.33000,1801.00000,Aetna,Local,,2484.13,,,,,,,1999.73,5080.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1469.63,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1312.67,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8149895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8150101,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,39.27,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8150101,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,35.08,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8150106,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,39.27,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8150106,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,35.08,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8150108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8150108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR STAPLE,8149888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9479.25000,2748.98000,Aetna,Local,,3791.70,,,,,,,3417.27,7754.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR STAPLE,8149888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9479.25000,2748.98000,Aetna,Local,,3791.70,,,,,,,3052.32,7754.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR STAPLE,8150110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9479.25000,2748.98000,Aetna,Local,,3791.70,,,,,,,3417.27,7754.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR STAPLE,8150110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9479.25000,2748.98000,Aetna,Local,,3791.70,,,,,,,3052.32,7754.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8150111,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8150111,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8150112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8150112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8150180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8150180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8150182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8150182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TALUS CUSTOM,8150383,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,33637.50000,9754.88000,Aetna,Local,,13455.00,,,,,,,12126.32,27515.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TALUS CUSTOM,8150383,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,33637.50000,9754.88000,Aetna,Local,,13455.00,,,,,,,10831.27,27515.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,166.10,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,148.36,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,584.01,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,521.64,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2032.00000,589.28000,Aetna,Local,,812.80,,,,,,,732.54,1662.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2032.00000,589.28000,Aetna,Local,,812.80,,,,,,,654.30,1662.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,584.01,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,521.64,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8150854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8150854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8150856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8150856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8150858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8150858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8150860,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8150860,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8150861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8150861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1395.50,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8150934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1246.46,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8150936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8150937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8150937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP HUMERAL,7699127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1622.36,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP HUMERAL,7699127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1449.10,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8150973,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2893.01,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8150973,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,Local,,3210.00,,,,,,,2584.05,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8150974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8150974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,8151005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5842.55000,1694.34000,Aetna,Local,,2337.02,,,,,,,2106.24,4779.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,8151005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5842.55000,1694.34000,Aetna,Local,,2337.02,,,,,,,1881.30,4779.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEET TISSUE,8151042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5997.32000,1739.22000,Aetna,Local,,2398.93,,,,,,,2162.03,4905.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEET TISSUE,8151042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5997.32000,1739.22000,Aetna,Local,,2398.93,,,,,,,1931.14,4905.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8151036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8151036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,Local,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8151040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8162.25000,2367.05000,Aetna,Local,,3264.90,,,,,,,2942.49,6676.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8151040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8162.25000,2367.05000,Aetna,Local,,3264.90,,,,,,,2628.24,6676.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8151070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3437.00000,996.73000,Aetna,Local,,1374.80,,,,,,,1239.04,2811.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8151070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3437.00000,996.73000,Aetna,Local,,1374.80,,,,,,,1106.71,2811.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ASSEMBLY COMPONENT,8151087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ASSEMBLY COMPONENT,8151087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,134.94,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,Local,,149.72,,,,,,,120.52,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8151147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8151147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8151148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6637.02000,1924.74000,Aetna,Local,,2654.81,,,,,,,2392.65,5429.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8151148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6637.02000,1924.74000,Aetna,Local,,2654.81,,,,,,,2137.12,5429.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8151175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.95000,104.97000,Aetna,Local,,144.78,,,,,,,130.48,296.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8151175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.95000,104.97000,Aetna,Local,,144.78,,,,,,,116.55,296.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8151205,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8151205,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8151207,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8151207,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8151213,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8151213,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8151216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8151216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8151211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8151211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8151319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8151319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9360.00000,2714.40000,Aetna,Local,,3744.00,,,,,,,3374.28,7656.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9360.00000,2714.40000,Aetna,Local,,3744.00,,,,,,,3013.92,7656.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8151330,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,108.11000,31.35000,Aetna,Local,,43.24,,,,,,,38.97,88.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8151330,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,108.11000,31.35000,Aetna,Local,,43.24,,,,,,,34.81,88.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8151378,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7590.00000,2201.10000,Aetna,Local,,3036.00,,,,,,,2736.20,6208.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8151378,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7590.00000,2201.10000,Aetna,Local,,3036.00,,,,,,,2443.98,6208.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151379,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151379,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,344.57,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,955.80000,277.18000,Aetna,Local,,382.32,,,,,,,307.77,781.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8151386,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8151386,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8151388,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4135.95000,1199.43000,Aetna,Local,,1654.38,,,,,,,1491.01,3383.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8151388,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4135.95000,1199.43000,Aetna,Local,,1654.38,,,,,,,1331.78,3383.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8151390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7577.10000,2197.36000,Aetna,Local,,3030.84,,,,,,,2731.54,6198.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8151390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7577.10000,2197.36000,Aetna,Local,,3030.84,,,,,,,2439.83,6198.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8151391,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4309.20000,1249.67000,Aetna,Local,,1723.68,,,,,,,1553.47,3524.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8151391,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4309.20000,1249.67000,Aetna,Local,,1723.68,,,,,,,1387.56,3524.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8151462,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2588.00000,750.52000,Aetna,Local,,1035.20,,,,,,,932.97,2116.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8151462,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2588.00000,750.52000,Aetna,Local,,1035.20,,,,,,,833.34,2116.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8151463,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8151463,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,8151465,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,8151465,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8151569,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8151569,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8151466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8151466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8151472,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8151472,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8151473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8151473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8151474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2851.37,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8151474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2546.86,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8151476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8151476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8151570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8151573,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,801.38,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8151573,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,715.79,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8151647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8151647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8151649,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8151649,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8151678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3437.00000,996.73000,Aetna,Local,,1374.80,,,,,,,1239.04,2811.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8151678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3437.00000,996.73000,Aetna,Local,,1374.80,,,,,,,1106.71,2811.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8151680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8151680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2708.08,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8151792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2418.86,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL COMPONENT,8151794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,6518.74,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL COMPONENT,8151794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,5822.56,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8151964,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8151964,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8151966,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8151966,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8151969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8151969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8151971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8151971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8152018,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8152018,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8152022,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8152022,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8152025,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8152025,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8152115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8152115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152116,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152116,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152117,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152117,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152118,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152118,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8152199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20022.50000,5806.52000,Aetna,Local,,8009.00,,,,,,,7218.11,16378.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8152199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20022.50000,5806.52000,Aetna,Local,,8009.00,,,,,,,6447.24,16378.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8152200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8152200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152230,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152230,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152232,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152232,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152234,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8152234,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8152282,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8152282,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8152288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8152288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,Local,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8152284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,109.87,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8152284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,98.13,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7962617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7962617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703028,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703028,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8152339,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8152339,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8152343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8152345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4518.50000,1310.36000,Aetna,Local,,1807.40,,,,,,,1628.92,3696.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8152345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4518.50000,1310.36000,Aetna,Local,,1807.40,,,,,,,1454.96,3696.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8153805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8153805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8153807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8153807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8153943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8153943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,Local,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8153978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,954.68000,276.86000,Aetna,Local,,381.87,,,,,,,344.16,780.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8153978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,954.68000,276.86000,Aetna,Local,,381.87,,,,,,,307.41,780.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8154031,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8154031,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8154037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5183.50000,1503.22000,Aetna,Local,,2073.40,,,,,,,1868.65,4240.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8154037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5183.50000,1503.22000,Aetna,Local,,2073.40,,,,,,,1669.09,4240.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,8154039,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,8154039,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8154041,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14550.00000,4219.50000,Aetna,Local,,5820.00,,,,,,,5245.27,11901.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8154041,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14550.00000,4219.50000,Aetna,Local,,5820.00,,,,,,,4685.10,11901.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8154043,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14550.00000,4219.50000,Aetna,Local,,5820.00,,,,,,,5245.27,11901.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8154043,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14550.00000,4219.50000,Aetna,Local,,5820.00,,,,,,,4685.10,11901.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8154045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8154045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8154047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8154047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8154049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8154049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8154235,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8154235,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8154423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,Local,,722.00,,,,,,,650.70,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8154423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,Local,,722.00,,,,,,,581.21,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8154425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4738.13000,1374.06000,Aetna,Local,,1895.25,,,,,,,1708.10,3875.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8154425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4738.13000,1374.06000,Aetna,Local,,1895.25,,,,,,,1525.68,3875.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8154441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,338.17,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,302.06,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8154672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8154672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY,8154674,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY,8154674,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8154952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1876.22,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8154952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1675.85,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8154954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8154954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8154958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8154958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8154960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8154960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8155075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8155075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8155077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8155077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8155079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8155079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8155234,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,39.27,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8155234,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,35.08,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1448.00000,419.92000,Aetna,Local,,579.20,,,,,,,522.00,1184.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1448.00000,419.92000,Aetna,Local,,579.20,,,,,,,466.26,1184.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1448.00000,419.92000,Aetna,Local,,579.20,,,,,,,522.00,1184.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1448.00000,419.92000,Aetna,Local,,579.20,,,,,,,466.26,1184.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8155541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8155541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8155567,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8155567,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8155569,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8155569,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8155571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8155571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8155575,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8464.50000,2454.70000,Aetna,Local,,3385.80,,,,,,,3051.45,6923.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8155575,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8464.50000,2454.70000,Aetna,Local,,3385.80,,,,,,,2725.57,6923.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,608.94000,176.59000,Aetna,Local,,243.58,,,,,,,219.52,498.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,608.94000,176.59000,Aetna,Local,,243.58,,,,,,,196.08,498.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR SHELL,8155657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR SHELL,8155657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8155581,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8155581,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8155698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8155698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8155786,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8155786,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8155789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8155789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8155790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8155790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8155791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8155791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8155792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2851.37,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8155792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2546.86,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8155793,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,54990.00000,15947.10000,Aetna,Local,,21996.00,,,,,,,19823.90,44981.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8155793,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,54990.00000,15947.10000,Aetna,Local,,21996.00,,,,,,,17706.78,44981.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8155794,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,18742.40,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8155794,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51990.00000,15077.10000,Aetna,Local,,20796.00,,,,,,,16740.78,42527.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1734.59,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8155797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1549.34,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8155803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8156032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8156032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8156200,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8156200,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8156202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8156202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8156251,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8156251,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8156253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8156253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8156255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8156255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8156311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8156311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8156313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4190.20000,1215.16000,Aetna,Local,,1676.08,,,,,,,1510.57,3427.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8156313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4190.20000,1215.16000,Aetna,Local,,1676.08,,,,,,,1349.24,3427.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8156315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8156315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8156317,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8156317,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8157911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8157911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8157912,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8157912,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8157913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.00000,516.20000,Aetna,Local,,712.00,,,,,,,641.69,1456.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8157913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.00000,516.20000,Aetna,Local,,712.00,,,,,,,573.16,1456.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8157914,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,6060.91,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8157914,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,5413.62,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8157915,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,6060.91,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8157915,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,Local,,6725.00,,,,,,,5413.62,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8157971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,1072.65,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8157971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,958.09,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8157970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8157970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8158027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8158027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8158029,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6597.50000,1913.28000,Aetna,Local,,2639.00,,,,,,,2378.40,5396.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8158029,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6597.50000,1913.28000,Aetna,Local,,2639.00,,,,,,,2124.39,5396.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8158031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8158031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8158033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,4351.96,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8158033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,3887.18,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8158035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3213.00000,931.77000,Aetna,Local,,1285.20,,,,,,,1158.29,2628.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8158035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3213.00000,931.77000,Aetna,Local,,1285.20,,,,,,,1034.59,2628.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8158037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8158037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8158039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8158039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8158192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8158192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8158194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8158194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8160717,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,714.57,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8160717,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,638.26,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8158235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8158235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8159832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4346.76000,1260.56000,Aetna,Local,,1738.70,,,,,,,1567.01,3555.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8159832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4346.76000,1260.56000,Aetna,Local,,1738.70,,,,,,,1399.66,3555.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160431,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160431,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160433,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160433,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,8160435,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,8160435,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1945.24000,564.12000,Aetna,Local,,778.10,,,,,,,701.26,1591.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1945.24000,564.12000,Aetna,Local,,778.10,,,,,,,626.37,1591.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1222.30,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1091.76,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8160441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8160441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8160443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8160443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7695443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,762.39000,221.09000,Aetna,Local,,304.96,,,,,,,274.84,623.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7695443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,762.39000,221.09000,Aetna,Local,,304.96,,,,,,,245.49,623.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8160489,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8160489,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160558,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160558,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8580.00000,2488.20000,Aetna,Local,,3432.00,,,,,,,3093.09,7018.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8580.00000,2488.20000,Aetna,Local,,3432.00,,,,,,,2762.76,7018.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SUBSTITUTE IN KIT,8160510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15412.50000,4469.62000,Aetna,Local,,6165.00,,,,,,,5556.21,12607.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SUBSTITUTE IN KIT,8160510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15412.50000,4469.62000,Aetna,Local,,6165.00,,,,,,,4962.82,12607.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,7699515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,7699515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,7700848,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,7700848,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMBERAL,7701779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMBERAL,7701779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8160607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8160607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8160623,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8160623,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160630,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160630,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSS CONNECTOR,8160632,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSS CONNECTOR,8160632,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8160634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8160634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8160689,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8160689,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8238050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8238050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8238052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8238052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8238054,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8238054,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8238056,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5502.00000,1595.58000,Aetna,Local,,2200.80,,,,,,,1983.47,4500.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8238056,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5502.00000,1595.58000,Aetna,Local,,2200.80,,,,,,,1771.64,4500.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8238058,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8238058,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8238297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1873.70,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8238297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1673.60,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8238298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8238298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8238295,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7734.00000,2242.86000,Aetna,Local,,3093.60,,,,,,,2788.11,6326.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8238295,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7734.00000,2242.86000,Aetna,Local,,3093.60,,,,,,,2490.35,6326.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8238389,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8238389,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8238390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8238390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8238392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8238392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8238393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8238393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8238420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3475.94,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8238420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3104.72,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8238421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3475.94,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8238421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3104.72,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8238422,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8238422,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8239859,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,907.31,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8239859,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,810.41,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8239861,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,907.31,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8239861,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,810.41,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8239863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8239863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8239908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8239908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8240076,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8240076,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8240143,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21625.00000,6271.25000,Aetna,Local,,8650.00,,,,,,,7795.81,17689.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8240143,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21625.00000,6271.25000,Aetna,Local,,8650.00,,,,,,,6963.25,17689.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8240070,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8240070,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8240072,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8240072,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8240074,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8240074,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,8240077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,8240077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8240164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10182.00000,2952.78000,Aetna,Local,,4072.80,,,,,,,3670.61,8328.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8240164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10182.00000,2952.78000,Aetna,Local,,4072.80,,,,,,,3278.60,8328.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8240166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10182.00000,2952.78000,Aetna,Local,,4072.80,,,,,,,3670.61,8328.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8240166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10182.00000,2952.78000,Aetna,Local,,4072.80,,,,,,,3278.60,8328.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,648.90,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,579.60,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,648.90,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,579.60,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,648.90,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,579.60,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,648.90,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,579.60,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,648.90,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,579.60,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,648.90,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,579.60,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8240188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8240188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8240190,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8240190,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8240191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8240191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8240200,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8240200,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,169.87,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,151.73,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8240202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,605.93,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8240202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,541.22,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8240437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,18289.60000,5303.98000,Aetna,Local,,7315.84,,,,,,,6593.40,14960.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8240437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,18289.60000,5303.98000,Aetna,Local,,7315.84,,,,,,,5889.25,14960.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2280.00000,661.20000,Aetna,Local,,912.00,,,,,,,821.94,1865.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2280.00000,661.20000,Aetna,Local,,912.00,,,,,,,734.16,1865.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2280.00000,661.20000,Aetna,Local,,912.00,,,,,,,821.94,1865.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2280.00000,661.20000,Aetna,Local,,912.00,,,,,,,734.16,1865.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8240443,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5901.28000,1711.37000,Aetna,Local,,2360.51,,,,,,,2127.41,4827.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8240443,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5901.28000,1711.37000,Aetna,Local,,2360.51,,,,,,,1900.21,4827.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8240447,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1451.80000,421.02000,Aetna,Local,,580.72,,,,,,,523.37,1187.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8240447,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1451.80000,421.02000,Aetna,Local,,580.72,,,,,,,467.48,1187.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8240449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8240450,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,536.42,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8240450,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,479.14,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8240567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,684.41000,198.48000,Aetna,Local,,273.76,,,,,,,246.73,559.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8240567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,684.41000,198.48000,Aetna,Local,,273.76,,,,,,,220.38,559.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT REPAIR MENISCAL ROOT ANCHOR IN KIT,8240568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5914.13000,1715.10000,Aetna,Local,,2365.65,,,,,,,2132.04,4837.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT REPAIR MENISCAL ROOT ANCHOR IN KIT,8240568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5914.13000,1715.10000,Aetna,Local,,2365.65,,,,,,,1904.35,4837.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8240569,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8240569,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8240078,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8240078,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.60000,560.16000,Aetna,Local,,772.64,,,,,,,696.34,1580.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.60000,560.16000,Aetna,Local,,772.64,,,,,,,621.98,1580.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8243980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8243980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8242048,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8242048,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8242050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8242050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8242052,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1645.01,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8242052,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1469.33,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8242054,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8242054,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8242059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8242059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8242061,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8242061,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8242056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,432.25000,125.35000,Aetna,Local,,172.90,,,,,,,155.83,353.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8242056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,432.25000,125.35000,Aetna,Local,,172.90,,,,,,,139.18,353.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8242058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8242058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8242064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,303.91000,88.13000,Aetna,Local,,121.56,,,,,,,109.56,248.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8242064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,303.91000,88.13000,Aetna,Local,,121.56,,,,,,,97.86,248.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER,8242066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,814.28000,236.14000,Aetna,Local,,325.71,,,,,,,293.55,666.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER,8242066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,814.28000,236.14000,Aetna,Local,,325.71,,,,,,,262.20,666.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8242062,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8242062,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8242069,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8242069,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8242071,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8242071,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8242160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8242160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8242161,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53270.40000,15448.42000,Aetna,Local,,21308.16,,,,,,,19203.98,43575.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8242161,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53270.40000,15448.42000,Aetna,Local,,21308.16,,,,,,,17153.07,43575.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8242163,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,Local,,20156.16,,,,,,,18165.74,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8242163,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,Local,,20156.16,,,,,,,16225.71,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARTILAGE IMPLANT,8242166,CDM,278,RC,L8641,HCPCS,,,facility,inpatient,,,12264.00000,3556.56000,Aetna,Local,,4905.60,,,,,,,4421.17,10031.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARTILAGE IMPLANT,8242166,CDM,278,RC,L8641,HCPCS,,,facility,outpatient,,,12264.00000,3556.56000,Aetna,Local,,4905.60,,,,,,,428.55,10031.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8243883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8243883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8243884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8243884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8243974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,227.47,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8243974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.99000,182.99000,Aetna,Local,,252.40,,,,,,,203.18,516.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8243975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1314.51,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8243975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1174.12,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8243976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8243976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8243977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,116.29,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8243977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,Local,,129.03,,,,,,,103.87,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8243978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.10000,1821.52000,Aetna,Local,,2512.44,,,,,,,2264.34,5137.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8243978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.10000,1821.52000,Aetna,Local,,2512.44,,,,,,,2022.51,5137.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8243979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8243979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8243932,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8243932,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8244035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8244035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8244026,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8244026,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,Local,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8244118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8244118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8244121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8786.25000,2548.01000,Aetna,Local,,3514.50,,,,,,,3167.44,7187.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8244121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8786.25000,2548.01000,Aetna,Local,,3514.50,,,,,,,2829.17,7187.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8244193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19864.05000,5760.57000,Aetna,Local,,7945.62,,,,,,,7160.99,16248.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8244193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19864.05000,5760.57000,Aetna,Local,,7945.62,,,,,,,6396.22,16248.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8244213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8244213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8244214,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8244214,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8244220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5015.50000,1454.50000,Aetna,Local,,2006.20,,,,,,,1808.09,4102.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8244220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5015.50000,1454.50000,Aetna,Local,,2006.20,,,,,,,1614.99,4102.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8244221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8244221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8244269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8244269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8244288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8244288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8244289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8244289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8244291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8245842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8245842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,8245843,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,64602.00000,18734.58000,Aetna,Local,,25840.80,,,,,,,23289.02,52844.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,8245843,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,64602.00000,18734.58000,Aetna,Local,,25840.80,,,,,,,20801.84,52844.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,8245844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,33470.24000,9706.37000,Aetna,Local,,13388.10,,,,,,,12066.02,27378.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,8245844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,33470.24000,9706.37000,Aetna,Local,,13388.10,,,,,,,10777.42,27378.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8245845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,420.42000,121.92000,Aetna,Local,,168.17,,,,,,,151.56,343.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8245845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,420.42000,121.92000,Aetna,Local,,168.17,,,,,,,135.38,343.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8245899,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8245899,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8245900,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8245900,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8245962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8245962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8245988,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,33845.63000,9815.23000,Aetna,Local,,13538.25,,,,,,,12201.35,27685.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8245988,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,33845.63000,9815.23000,Aetna,Local,,13538.25,,,,,,,10898.29,27685.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8246037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8246037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8245996,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8245996,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8245997,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8245997,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8245998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8245998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8246152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2903.18,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8246152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,Local,,3221.28,,,,,,,2593.13,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8246153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8246153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8246154,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8246154,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8246155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1297.08,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8246155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1158.56,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8246226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3389.09000,982.84000,Aetna,Local,,1355.64,,,,,,,1221.77,2772.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8246226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3389.09000,982.84000,Aetna,Local,,1355.64,,,,,,,1091.29,2772.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8246265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8246265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8246266,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,536.42,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8246266,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,479.14,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8246267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8246267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,348.46,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,966.60000,280.31000,Aetna,Local,,386.64,,,,,,,311.25,790.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8246426,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9455.34000,2742.05000,Aetna,Local,,3782.14,,,,,,,3408.65,7734.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8246426,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9455.34000,2742.05000,Aetna,Local,,3782.14,,,,,,,3044.62,7734.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8246427,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17212.25000,4991.55000,Aetna,Local,,6884.90,,,,,,,6205.02,14079.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8246427,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17212.25000,4991.55000,Aetna,Local,,6884.90,,,,,,,5542.34,14079.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8246428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14409.57000,4178.78000,Aetna,Local,,5763.83,,,,,,,5194.65,11787.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8246428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14409.57000,4178.78000,Aetna,Local,,5763.83,,,,,,,4639.88,11787.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8246429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4372.20000,1267.94000,Aetna,Local,,1748.88,,,,,,,1576.18,3576.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8246429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4372.20000,1267.94000,Aetna,Local,,1748.88,,,,,,,1407.85,3576.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8246430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8079.30000,2343.00000,Aetna,Local,,3231.72,,,,,,,2912.59,6608.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8246430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8079.30000,2343.00000,Aetna,Local,,3231.72,,,,,,,2601.53,6608.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8246432,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8246432,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8246433,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8246433,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8246434,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8246434,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8246492,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8246492,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8246493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8246493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246494,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,657.86000,190.78000,Aetna,Local,,263.14,,,,,,,237.16,538.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246494,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,657.86000,190.78000,Aetna,Local,,263.14,,,,,,,211.83,538.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246495,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,657.86000,190.78000,Aetna,Local,,263.14,,,,,,,237.16,538.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246495,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,657.86000,190.78000,Aetna,Local,,263.14,,,,,,,211.83,538.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246496,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,657.86000,190.78000,Aetna,Local,,263.14,,,,,,,237.16,538.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246496,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,657.86000,190.78000,Aetna,Local,,263.14,,,,,,,211.83,538.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246497,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,657.86000,190.78000,Aetna,Local,,263.14,,,,,,,237.16,538.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246497,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,657.86000,190.78000,Aetna,Local,,263.14,,,,,,,211.83,538.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246498,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246498,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246499,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246499,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246500,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246500,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246501,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,220.03,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246501,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,196.53,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246502,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246502,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246503,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246503,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246504,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,711.95000,206.47000,Aetna,Local,,284.78,,,,,,,256.66,582.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246504,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,711.95000,206.47000,Aetna,Local,,284.78,,,,,,,229.25,582.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246505,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,711.95000,206.47000,Aetna,Local,,284.78,,,,,,,256.66,582.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246505,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,711.95000,206.47000,Aetna,Local,,284.78,,,,,,,229.25,582.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246506,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,711.95000,206.47000,Aetna,Local,,284.78,,,,,,,256.66,582.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246506,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,711.95000,206.47000,Aetna,Local,,284.78,,,,,,,229.25,582.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246507,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,711.95000,206.47000,Aetna,Local,,284.78,,,,,,,256.66,582.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246507,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,711.95000,206.47000,Aetna,Local,,284.78,,,,,,,229.25,582.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246508,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,752.72000,218.29000,Aetna,Local,,301.09,,,,,,,271.36,615.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIZATION COIL,8246508,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,752.72000,218.29000,Aetna,Local,,301.09,,,,,,,242.38,615.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8246599,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8246599,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8246600,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8246600,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8246601,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8246601,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8246602,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8246602,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8246628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8246628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8246629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8246629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8246630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8246630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8246662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1297.08,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8246662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1158.56,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8246741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8246741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8246742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8246742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8246743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8246743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8246868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8246868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8246880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1222.30,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8246880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1091.76,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8246881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8246881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8246967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8246967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8246970,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8246970,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8246972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8246972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8246974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8246974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8246976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8246976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7699542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1511.00000,438.19000,Aetna,Local,,604.40,,,,,,,544.72,1236.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7699542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1511.00000,438.19000,Aetna,Local,,604.40,,,,,,,486.54,1236.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8246979,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8246979,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8247055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8247055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8247067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,17067.90000,4949.69000,Aetna,Local,,6827.16,,,,,,,6152.98,13961.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8247067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,17067.90000,4949.69000,Aetna,Local,,6827.16,,,,,,,5495.86,13961.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8247068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11484.00000,3330.36000,Aetna,Local,,4593.60,,,,,,,4139.98,9393.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8247068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11484.00000,3330.36000,Aetna,Local,,4593.60,,,,,,,3697.85,9393.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8247069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2365.78,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8247069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2113.12,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8247070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6214.74000,1802.27000,Aetna,Local,,2485.90,,,,,,,2240.41,5083.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8247070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6214.74000,1802.27000,Aetna,Local,,2485.90,,,,,,,2001.15,5083.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8247099,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8247099,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8247100,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5634.61,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8247100,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5032.86,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8247173,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8247173,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8247843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1421.99,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8247843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1270.13,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8247850,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5634.61,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8247850,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5032.86,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8247924,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8247924,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8247925,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8247925,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8247927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8247929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2756.60000,799.41000,Aetna,Local,,1102.64,,,,,,,993.75,2254.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8247929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2756.60000,799.41000,Aetna,Local,,1102.64,,,,,,,887.63,2254.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8247965,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1876.22,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8247965,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1675.85,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8247966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8247966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8247964,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,2182.72,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8247964,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6054.69000,1755.86000,Aetna,Local,,2421.88,,,,,,,1949.61,4952.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,8247983,CDM,278,RC,C9354,HCPCS,,,facility,inpatient,,,1321.61000,383.27000,Aetna,Local,,528.64,,,,,,,476.44,1081.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,8247983,CDM,278,RC,C9354,HCPCS,,,facility,outpatient,,,1321.61000,383.27000,Aetna,Local,,528.64,,,,,,,425.56,1081.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,644.57,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1788.00000,518.52000,Aetna,Local,,715.20,,,,,,,575.74,1462.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8248508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8248508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,8248509,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5187.00000,1504.23000,Aetna,Local,,2074.80,,,,,,,1869.91,4242.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,8248509,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5187.00000,1504.23000,Aetna,Local,,2074.80,,,,,,,1670.21,4242.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8248510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1360.00000,394.40000,Aetna,Local,,544.00,,,,,,,490.28,1112.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8248510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1360.00000,394.40000,Aetna,Local,,544.00,,,,,,,437.92,1112.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8248511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8248511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8248512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1360.00000,394.40000,Aetna,Local,,544.00,,,,,,,490.28,1112.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8248512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1360.00000,394.40000,Aetna,Local,,544.00,,,,,,,437.92,1112.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8248513,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8248513,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8248514,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8248514,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8248515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8248515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8248507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8248507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,702.00000,203.58000,Aetna,Local,,280.80,,,,,,,253.07,574.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,702.00000,203.58000,Aetna,Local,,280.80,,,,,,,226.04,574.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8248574,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8248574,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8248625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8248625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8248628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8248629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8248629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,8248630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,819.95000,237.79000,Aetna,Local,,327.98,,,,,,,295.59,670.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,8248630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,819.95000,237.79000,Aetna,Local,,327.98,,,,,,,264.02,670.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8249887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8249887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8249888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8249888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8249889,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8249889,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8249890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8249890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8249911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8249911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8251849,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8251849,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8251852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6583.50000,1909.22000,Aetna,Local,,2633.40,,,,,,,2373.35,5385.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8251852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6583.50000,1909.22000,Aetna,Local,,2633.40,,,,,,,2119.89,5385.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8251912,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8251912,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8251935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8251935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8251941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5568.50000,1614.86000,Aetna,Local,,2227.40,,,,,,,2007.44,4555.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8251941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5568.50000,1614.86000,Aetna,Local,,2227.40,,,,,,,1793.06,4555.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8251946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8253852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8253852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8253891,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8253891,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8253892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8253892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8253893,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8253893,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,8253894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,8253894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,Local,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8253924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8253924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8253925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8253925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8253926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8253926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8253927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8253927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8253928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8253928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8253929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3706.82000,1074.98000,Aetna,Local,,1482.73,,,,,,,1336.31,3032.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8253929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3706.82000,1074.98000,Aetna,Local,,1482.73,,,,,,,1193.60,3032.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8253930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8253930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8253931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8253931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8255882,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8255882,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL CONE BODY,7698818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL CONE BODY,7698818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8255883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8255883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8255895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8255895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8255897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8255897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8255898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8255898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8255908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,Local,,1619.80,,,,,,,1459.84,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8255908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,Local,,1619.80,,,,,,,1303.94,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8256094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,Local,,1738.80,,,,,,,1567.09,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8256094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,Local,,1738.80,,,,,,,1399.73,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8256095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8256095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8256096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8256096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8256097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8256097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8256098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8256098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8256099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8256099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8256135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8256135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8256288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8256288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8256289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6132.00000,1778.28000,Aetna,Local,,2452.80,,,,,,,2210.59,5015.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8256289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6132.00000,1778.28000,Aetna,Local,,2452.80,,,,,,,1974.50,5015.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8256290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8256290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8256291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4576.29000,1327.12000,Aetna,Local,,1830.52,,,,,,,1649.75,3743.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8256291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4576.29000,1327.12000,Aetna,Local,,1830.52,,,,,,,1473.57,3743.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8256435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8256435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8256450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8256450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8256451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8256451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8257895,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8257895,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8256452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8256452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8256477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8256477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8257859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.52000,391.65000,Aetna,Local,,540.21,,,,,,,486.86,1104.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8257859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.52000,391.65000,Aetna,Local,,540.21,,,,,,,434.87,1104.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8257860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8257860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8257861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8257861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8257868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8257868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8257869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,6038.38,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8257869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,5393.50,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8259906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2092.00000,606.68000,Aetna,Local,,836.80,,,,,,,754.17,1711.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8259906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2092.00000,606.68000,Aetna,Local,,836.80,,,,,,,673.62,1711.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8259913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8259913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8259914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8259914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8259918,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8259918,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8259919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1654.80000,479.89000,Aetna,Local,,661.92,,,,,,,596.56,1353.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8259919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1654.80000,479.89000,Aetna,Local,,661.92,,,,,,,532.85,1353.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8259920,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8259920,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8259921,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8259921,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8260001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8260001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8260002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1314.51,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8260002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,Local,,1458.54,,,,,,,1174.12,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260003,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260003,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8259993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8259993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8260035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,Local,,936.00,,,,,,,843.57,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8260035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,Local,,936.00,,,,,,,753.48,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8260036,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2180.00000,632.20000,Aetna,Local,,872.00,,,,,,,785.89,1783.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8260036,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2180.00000,632.20000,Aetna,Local,,872.00,,,,,,,701.96,1783.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8260037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8260037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8260038,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8260038,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8260082,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8260082,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8260106,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8260106,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,8260136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,8260136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8260137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8260137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8260139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8260139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8261911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8261911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT BONE,8260218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1857.00000,538.53000,Aetna,Local,,742.80,,,,,,,669.45,1519.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT BONE,8260218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1857.00000,538.53000,Aetna,Local,,742.80,,,,,,,597.95,1519.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8260219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8260220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8260220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8260221,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8260221,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8262205,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3213.00000,931.77000,Aetna,Local,,1285.20,,,,,,,1158.29,2628.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8262205,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3213.00000,931.77000,Aetna,Local,,1285.20,,,,,,,1034.59,2628.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8261912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8261912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8261913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8261913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8261914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8261914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8261965,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8261965,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8261966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8261966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8261967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11684.25000,3388.43000,Aetna,Local,,4673.70,,,,,,,4212.17,9557.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8261967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11684.25000,3388.43000,Aetna,Local,,4673.70,,,,,,,3762.33,9557.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8261968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1211.28,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8261968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1081.92,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1648.00000,477.92000,Aetna,Local,,659.20,,,,,,,594.10,1348.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7703190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1648.00000,477.92000,Aetna,Local,,659.20,,,,,,,530.66,1348.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8261969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3105.96000,900.73000,Aetna,Local,,1242.38,,,,,,,1119.70,2540.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8261969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3105.96000,900.73000,Aetna,Local,,1242.38,,,,,,,1000.12,2540.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8261970,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8261970,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4676.00000,1356.04000,Aetna,Local,,1870.40,,,,,,,1685.70,3824.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4676.00000,1356.04000,Aetna,Local,,1870.40,,,,,,,1505.67,3824.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8262041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8262041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8262043,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8262043,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8262045,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8262045,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8262049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5341.63000,1549.07000,Aetna,Local,,2136.65,,,,,,,1925.66,4369.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8262049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5341.63000,1549.07000,Aetna,Local,,2136.65,,,,,,,1720.00,4369.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.87000,114.22000,Aetna,Local,,157.55,,,,,,,141.99,322.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.87000,114.22000,Aetna,Local,,157.55,,,,,,,126.83,322.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4676.00000,1356.04000,Aetna,Local,,1870.40,,,,,,,1685.70,3824.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4676.00000,1356.04000,Aetna,Local,,1870.40,,,,,,,1505.67,3824.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8262196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8262196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8262197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8262197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8262198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4014.50000,1164.20000,Aetna,Local,,1605.80,,,,,,,1447.23,3283.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8262198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4014.50000,1164.20000,Aetna,Local,,1605.80,,,,,,,1292.67,3283.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8262199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,4351.96,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8262199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,3887.18,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8262200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2144.00000,621.76000,Aetna,Local,,857.60,,,,,,,772.91,1753.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8262200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2144.00000,621.76000,Aetna,Local,,857.60,,,,,,,690.37,1753.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8262201,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5935.93000,1721.42000,Aetna,Local,,2374.37,,,,,,,2139.90,4855.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8262201,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5935.93000,1721.42000,Aetna,Local,,2374.37,,,,,,,1911.37,4855.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8262202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,2224.35,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8262202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,1986.80,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8262203,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8262203,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8262204,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8262204,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8262206,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8262206,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8262287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8262287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8262290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8262290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FHL SYSTEM ANCHOR,8262291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FHL SYSTEM ANCHOR,8262291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8262292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8262292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8262293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1151.87,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8262293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,Local,,1278.08,,,,,,,1028.85,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8262294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,1072.65,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8262294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,958.09,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8262295,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8262295,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSS CONNECTOR,8262296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSS CONNECTOR,8262296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8262297,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8262297,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8262298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8262299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8262299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8262300,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8262300,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8262386,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8262386,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8265850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,2224.35,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8265850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,1986.80,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8265851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8265851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8265852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8392.50000,2433.82000,Aetna,Local,,3357.00,,,,,,,3025.50,6865.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8265852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8392.50000,2433.82000,Aetna,Local,,3357.00,,,,,,,2702.39,6865.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8265853,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8304.00000,2408.16000,Aetna,Local,,3321.60,,,,,,,2993.59,6792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8265853,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8304.00000,2408.16000,Aetna,Local,,3321.60,,,,,,,2673.89,6792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8265854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3706.82000,1074.98000,Aetna,Local,,1482.73,,,,,,,1336.31,3032.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8265854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3706.82000,1074.98000,Aetna,Local,,1482.73,,,,,,,1193.60,3032.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8265855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5300.89000,1537.26000,Aetna,Local,,2120.36,,,,,,,1910.97,4336.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8265855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5300.89000,1537.26000,Aetna,Local,,2120.36,,,,,,,1706.89,4336.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8265856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5241.15000,1519.93000,Aetna,Local,,2096.46,,,,,,,1889.43,4287.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8265856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5241.15000,1519.93000,Aetna,Local,,2096.46,,,,,,,1687.65,4287.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8266002,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,772.88000,224.14000,Aetna,Local,,309.15,,,,,,,278.62,632.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8266002,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,772.88000,224.14000,Aetna,Local,,309.15,,,,,,,248.87,632.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8266013,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8266013,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8266014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3942.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8266014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3521.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8266015,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8266015,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8266016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8266016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8267867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8267867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8267868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8267868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8267869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8267869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8267870,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8267870,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8269858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8269858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8269873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3164.48000,917.70000,Aetna,Local,,1265.79,,,,,,,1140.80,2588.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8269873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3164.48000,917.70000,Aetna,Local,,1265.79,,,,,,,1018.96,2588.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,860.87,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,768.94,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8269875,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,634.50000,184.00000,Aetna,Local,,253.80,,,,,,,228.74,519.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8269875,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,634.50000,184.00000,Aetna,Local,,253.80,,,,,,,204.31,519.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1707.44000,495.16000,Aetna,Local,,682.98,,,,,,,615.53,1396.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1707.44000,495.16000,Aetna,Local,,682.98,,,,,,,549.80,1396.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8269878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4364.50000,1265.70000,Aetna,Local,,1745.80,,,,,,,1573.40,3570.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8269878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4364.50000,1265.70000,Aetna,Local,,1745.80,,,,,,,1405.37,3570.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8269924,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10178.13000,2951.66000,Aetna,Local,,4071.25,,,,,,,3669.22,8325.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8269924,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10178.13000,2951.66000,Aetna,Local,,4071.25,,,,,,,3277.36,8325.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8269946,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,1106.01,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8269946,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,987.90,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8269947,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8269947,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8269948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8269949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8269949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8270039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,6518.74,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8270039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,5822.56,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8270040,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8270040,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8270068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2708.08,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8270068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2418.86,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8270087,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8270087,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8270086,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8270086,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION STAPLE,8246415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3644.38,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION STAPLE,8246415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3255.18,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION STAPLE,8270130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3644.38,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION STAPLE,8270130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3255.18,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION STAPLE,8270131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3644.38,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION STAPLE,8270131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3255.18,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8270173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8270173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8270250,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8270250,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,860.87,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,768.94,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8270329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8270329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8270330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8270330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8270331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8270331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8270332,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8270332,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8270391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8270393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2380.26,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8270393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6602.65000,1914.77000,Aetna,Local,,2641.06,,,,,,,2126.05,5400.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8271980,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8271980,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8271983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8271983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8271985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8271985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8271987,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8271987,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8248505,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8248505,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8137506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8273871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8273871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8273870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8273870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8273872,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8273872,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8273896,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11670.00000,3384.30000,Aetna,Local,,4668.00,,,,,,,4207.03,9546.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8273896,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11670.00000,3384.30000,Aetna,Local,,4668.00,,,,,,,3757.74,9546.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8273897,CDM,278,RC,L8680,HCPCS,,,facility,inpatient,,,10962.00000,3178.98000,Aetna,Local,,4384.80,,,,,,,3951.80,8966.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8273897,CDM,278,RC,L8680,HCPCS,,,facility,outpatient,,,10962.00000,3178.98000,Aetna,Local,,4384.80,,,,,,,3529.76,8966.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8273904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,6038.38,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8273904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,5393.50,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8275870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8275870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8275872,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8304.00000,2408.16000,Aetna,Local,,3321.60,,,,,,,2993.59,6792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8275872,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8304.00000,2408.16000,Aetna,Local,,3321.60,,,,,,,2673.89,6792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8275873,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8275873,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8275922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9455.34000,2742.05000,Aetna,Local,,3782.14,,,,,,,3408.65,7734.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8275922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9455.34000,2742.05000,Aetna,Local,,3782.14,,,,,,,3044.62,7734.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8275923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17212.25000,4991.55000,Aetna,Local,,6884.90,,,,,,,6205.02,14079.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8275923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17212.25000,4991.55000,Aetna,Local,,6884.90,,,,,,,5542.34,14079.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8275871,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8275871,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION LEAD,8275957,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION LEAD,8275957,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8275958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5300.89000,1537.26000,Aetna,Local,,2120.36,,,,,,,1910.97,4336.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8275958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5300.89000,1537.26000,Aetna,Local,,2120.36,,,,,,,1706.89,4336.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8275959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1222.30,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8275959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1091.76,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8275983,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8275983,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8275984,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8275984,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8275985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5290.04000,1534.11000,Aetna,Local,,2116.02,,,,,,,1907.06,4327.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8275985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5290.04000,1534.11000,Aetna,Local,,2116.02,,,,,,,1703.39,4327.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,8277921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1329.12000,385.44000,Aetna,Local,,531.65,,,,,,,479.15,1087.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,8277921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1329.12000,385.44000,Aetna,Local,,531.65,,,,,,,427.98,1087.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8277922,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2381.84000,690.73000,Aetna,Local,,952.74,,,,,,,858.65,1948.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8277922,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2381.84000,690.73000,Aetna,Local,,952.74,,,,,,,766.95,1948.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8277925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8277925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8277926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5537.00000,1605.73000,Aetna,Local,,2214.80,,,,,,,1996.09,4529.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8277926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5537.00000,1605.73000,Aetna,Local,,2214.80,,,,,,,1782.91,4529.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8277990,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,182.54000,52.94000,Aetna,Local,,73.02,,,,,,,65.81,149.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8277990,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,182.54000,52.94000,Aetna,Local,,73.02,,,,,,,58.78,149.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8278073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8278073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278074,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278074,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8278076,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8278076,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278077,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278077,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278078,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278078,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8278146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8278146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,319.58,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,285.45,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8278420,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8278420,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5200.41000,1508.12000,Aetna,Local,,2080.16,,,,,,,1874.75,4253.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5200.41000,1508.12000,Aetna,Local,,2080.16,,,,,,,1674.53,4253.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5243.91000,1520.73000,Aetna,Local,,2097.56,,,,,,,1890.43,4289.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5243.91000,1520.73000,Aetna,Local,,2097.56,,,,,,,1688.54,4289.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278584,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5290.04000,1534.11000,Aetna,Local,,2116.02,,,,,,,1907.06,4327.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278584,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5290.04000,1534.11000,Aetna,Local,,2116.02,,,,,,,1703.39,4327.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338470,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338470,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338471,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338471,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338472,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338472,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338473,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338473,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338474,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338474,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART  VALVE,8338475,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART  VALVE,8338475,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338865,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,9472.14,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338865,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,8460.55,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338866,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,9472.14,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338866,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,8460.55,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338867,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,9472.14,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338867,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,8460.55,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338868,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,9472.14,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338868,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,8460.55,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338869,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,9472.14,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338869,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,8460.55,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338870,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,9472.14,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338870,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26275.00000,7619.75000,Aetna,Local,,10510.00,,,,,,,8460.55,21492.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8338479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5743.50000,1665.61000,Aetna,Local,,2297.40,,,,,,,2070.53,4698.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8338479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5743.50000,1665.61000,Aetna,Local,,2297.40,,,,,,,1849.41,4698.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338692,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,3212.05,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338692,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,2869.02,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338693,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,3212.05,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338693,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,2869.02,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338694,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,3212.05,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338694,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,2869.02,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338695,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338695,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,4491.90,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338696,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338696,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,4491.90,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338697,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338697,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,4491.90,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338698,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338698,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,4491.90,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338699,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338699,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,4491.90,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338700,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338700,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338701,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338701,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338702,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338702,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338703,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338703,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338704,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338704,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338705,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338705,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338706,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338706,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338707,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338707,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338708,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338708,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338709,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338709,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338710,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338710,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338711,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338711,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338712,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1582.99,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338712,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4391.10000,1273.42000,Aetna,Local,,1756.44,,,,,,,1413.93,3591.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338713,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338713,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338714,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338714,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338715,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338715,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338716,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338716,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338717,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338717,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338718,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338718,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338719,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338719,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338720,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338720,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338721,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338721,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338722,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8338722,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8338934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8338934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8338982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22380.50000,6490.34000,Aetna,Local,,8952.20,,,,,,,8068.17,18307.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8338982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22380.50000,6490.34000,Aetna,Local,,8952.20,,,,,,,7206.52,18307.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEGMENT,8338983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20917.50000,6066.08000,Aetna,Local,,8367.00,,,,,,,7540.76,17110.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEGMENT,8338983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20917.50000,6066.08000,Aetna,Local,,8367.00,,,,,,,6735.44,17110.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEGMENT,8338984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20917.50000,6066.08000,Aetna,Local,,8367.00,,,,,,,7540.76,17110.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEGMENT,8338984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20917.50000,6066.08000,Aetna,Local,,8367.00,,,,,,,6735.44,17110.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEGMENT,8338985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1203.76000,349.09000,Aetna,Local,,481.50,,,,,,,433.96,984.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEGMENT,8338985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1203.76000,349.09000,Aetna,Local,,481.50,,,,,,,387.61,984.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8338986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6381.55000,1850.65000,Aetna,Local,,2552.62,,,,,,,2300.55,5220.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8338986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6381.55000,1850.65000,Aetna,Local,,2552.62,,,,,,,2054.86,5220.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8338987,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6381.55000,1850.65000,Aetna,Local,,2552.62,,,,,,,2300.55,5220.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8338987,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6381.55000,1850.65000,Aetna,Local,,2552.62,,,,,,,2054.86,5220.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338725,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338725,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8339241,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8339241,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338726,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338726,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338727,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338727,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338728,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338728,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338730,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338730,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338731,CDM,278,RC,,,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338731,CDM,278,RC,,,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338732,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338732,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,Local,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338691,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338691,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8339242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8339242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8339244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8339244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8339245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8339245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8339246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8339246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8339247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8339247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8339248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8339248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8339249,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8339249,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8339250,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8339250,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8339322,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,458.41,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8339322,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,409.46,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8339324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8339324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,8339325,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,8339325,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8340171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8340171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3790.66,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3385.83,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3790.66,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3385.83,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3790.66,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3385.83,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340183,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3790.66,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340183,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3385.83,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340184,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3790.66,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340184,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3385.83,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3790.66,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3385.83,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340186,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3790.66,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340186,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,Local,,4206.00,,,,,,,3385.83,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3466.21,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3096.03,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340179,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3466.21,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340179,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3096.03,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3466.21,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3096.03,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340189,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3466.21,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340189,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3096.03,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340190,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3466.21,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340190,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3096.03,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340191,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3466.21,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340191,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3096.03,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3466.21,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3096.03,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340193,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3466.21,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8340193,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9615.00000,2788.35000,Aetna,Local,,3846.00,,,,,,,3096.03,7865.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD BLADE,8340264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2949.80000,855.44000,Aetna,Local,,1179.92,,,,,,,1063.40,2412.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD BLADE,8340264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2949.80000,855.44000,Aetna,Local,,1179.92,,,,,,,949.84,2412.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8340307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2309.00000,669.61000,Aetna,Local,,923.60,,,,,,,832.39,1888.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8340307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2309.00000,669.61000,Aetna,Local,,923.60,,,,,,,743.50,1888.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8340321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8340321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8340323,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8340323,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8340324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8340324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8340344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8340344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8340345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8340345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8340346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8340346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8342187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8342187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8342188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,526.16,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8342188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,Local,,583.81,,,,,,,469.97,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8342189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8342189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8342190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8342190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,8342191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,8342191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT SHOULDER,8342192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT SHOULDER,8342192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8342255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8342255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8342256,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8342256,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8342257,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8342257,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8342258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8342258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8342259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8342259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8342260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8342260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8342297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8342297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8342298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8342298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8342299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8342299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8342300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8342300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8342301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1469.63,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8342301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1312.67,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8342375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3451.88000,1001.05000,Aetna,Local,,1380.75,,,,,,,1244.40,2823.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8342375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3451.88000,1001.05000,Aetna,Local,,1380.75,,,,,,,1111.51,2823.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8342376,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8342376,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8344169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8344169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8344171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8344171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8344210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,1085.65,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8344210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,969.71,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8344212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1803.80,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8344212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,Local,,2001.44,,,,,,,1611.16,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8344213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,700.74,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8344213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1943.80000,563.70000,Aetna,Local,,777.52,,,,,,,625.90,1590.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8344214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8344214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8344215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8344215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8344216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8344216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8344217,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,7273.09,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8344217,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,6496.35,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8344218,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8344218,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8344369,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8344369,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URINARY CONTROL PUMP,8344371,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,24250.00000,7032.50000,Aetna,Local,,9700.00,,,,,,,8742.12,19836.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URINARY CONTROL PUMP,8344371,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,24250.00000,7032.50000,Aetna,Local,,9700.00,,,,,,,7808.50,19836.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8344373,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8344373,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8344458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8344458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8344461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8344461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344464,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344464,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8344489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8344489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8344796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8344796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8344797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9522.00000,2761.38000,Aetna,Local,,3808.80,,,,,,,3432.68,7789.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8344797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9522.00000,2761.38000,Aetna,Local,,3808.80,,,,,,,3066.08,7789.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8344820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8344820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8344821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5746.30000,1666.43000,Aetna,Local,,2298.52,,,,,,,2071.54,4700.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8344821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5746.30000,1666.43000,Aetna,Local,,2298.52,,,,,,,1850.31,4700.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8344840,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8344840,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8344841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8344841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344842,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344842,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344843,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344843,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8344844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8346169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4455.50000,1292.09000,Aetna,Local,,1782.20,,,,,,,1606.21,3644.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8346169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4455.50000,1292.09000,Aetna,Local,,1782.20,,,,,,,1434.67,3644.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8346171,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8346171,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8346208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8346208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8346209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,1085.65,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8346209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,969.71,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8346210,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8346210,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8346211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8346211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8346212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8346212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8346213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8346213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8346214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8346214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8346266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7904.25000,2292.23000,Aetna,Local,,3161.70,,,,,,,2849.48,6465.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8346266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7904.25000,2292.23000,Aetna,Local,,3161.70,,,,,,,2545.17,6465.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8346282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8346282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8346283,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8346283,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8346326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8346326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8346327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8346327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,322.88,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,288.40,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8346329,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8346329,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,322.88,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,288.40,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8346331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8303.40000,2407.99000,Aetna,Local,,3321.36,,,,,,,2993.38,6792.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8346331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8303.40000,2407.99000,Aetna,Local,,3321.36,,,,,,,2673.69,6792.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8346332,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8346332,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,219.00,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,195.62,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8346336,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8346336,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8346337,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8346337,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8346338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8346338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8346339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8346339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8346433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8346433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8346456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1779.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8346456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1589.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8346915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8347041,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8347041,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8347042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8347042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8346518,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8346518,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695649,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695649,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695650,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695650,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703279,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703279,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695651,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695651,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703280,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703280,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703281,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703281,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703282,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703282,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703283,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703283,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703284,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703284,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703285,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703285,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703286,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703286,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703287,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703287,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703288,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7703288,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8346912,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8346912,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8346507,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1574.88000,456.72000,Aetna,Local,,629.95,,,,,,,567.74,1288.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8346507,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1574.88000,456.72000,Aetna,Local,,629.95,,,,,,,507.11,1288.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8346508,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8346508,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8346509,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,841.21000,243.95000,Aetna,Local,,336.48,,,,,,,303.26,688.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8346509,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,841.21000,243.95000,Aetna,Local,,336.48,,,,,,,270.87,688.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8346510,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8346510,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8346511,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8346511,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8346914,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,915.30000,265.44000,Aetna,Local,,366.12,,,,,,,329.97,748.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8346914,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,915.30000,265.44000,Aetna,Local,,366.12,,,,,,,294.73,748.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8356490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8356490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8347436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8347436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8347437,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8347437,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8347455,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,385.23000,111.72000,Aetna,Local,,154.09,,,,,,,138.88,315.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8347455,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,385.23000,111.72000,Aetna,Local,,154.09,,,,,,,124.04,315.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8347508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8347508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8347509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8347509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,8347450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5985.00000,1735.65000,Aetna,Local,,2394.00,,,,,,,2157.59,4895.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,8347450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5985.00000,1735.65000,Aetna,Local,,2394.00,,,,,,,1927.17,4895.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,8347451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11160.00000,3236.40000,Aetna,Local,,4464.00,,,,,,,4023.18,9128.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,8347451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11160.00000,3236.40000,Aetna,Local,,4464.00,,,,,,,3593.52,9128.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,8347452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,17865.00000,5180.85000,Aetna,Local,,7146.00,,,,,,,6440.33,14613.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,8347452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,17865.00000,5180.85000,Aetna,Local,,7146.00,,,,,,,5752.53,14613.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8347464,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8347464,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8347465,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8347465,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8347466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8347466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8347467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8347467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8347469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8347469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8347470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8347470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8347471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8347471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8347488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8347488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8347493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1361.95,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8347493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,Local,,1511.18,,,,,,,1216.50,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8347514,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8347514,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8347532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8347532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8347545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8347545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8348932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8348932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8348933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,907.31,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8348933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2516.80000,729.87000,Aetna,Local,,1006.72,,,,,,,810.41,2058.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8348934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8348934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8348935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8348935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8348936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8348936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8348937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8348937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8348938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8348938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8348939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3617.25000,1049.00000,Aetna,Local,,1446.90,,,,,,,1304.02,2958.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8348939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3617.25000,1049.00000,Aetna,Local,,1446.90,,,,,,,1164.75,2958.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8348940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8348940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8348941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2309.00000,669.61000,Aetna,Local,,923.60,,,,,,,832.39,1888.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8348941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2309.00000,669.61000,Aetna,Local,,923.60,,,,,,,743.50,1888.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8348942,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2612.00000,757.48000,Aetna,Local,,1044.80,,,,,,,941.63,2136.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8348942,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2612.00000,757.48000,Aetna,Local,,1044.80,,,,,,,841.06,2136.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8348943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8348943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8348944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8348944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8349880,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1592.00000,461.68000,Aetna,Local,,636.80,,,,,,,573.92,1302.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8349880,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1592.00000,461.68000,Aetna,Local,,636.80,,,,,,,512.62,1302.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8349127,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,11175.00000,3240.75000,Aetna,Local,,4470.00,,,,,,,4028.59,9141.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8349127,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,11175.00000,3240.75000,Aetna,Local,,4470.00,,,,,,,3598.35,9141.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8349881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8349881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8349883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8349883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8349885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,322.88,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8349885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,288.40,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8349887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8349887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8349889,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8349889,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8349891,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8349891,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8349893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,322.88,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8349893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,288.40,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8349895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,322.88,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8349895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,288.40,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8349897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8349897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8349899,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2168.00000,628.72000,Aetna,Local,,867.20,,,,,,,781.56,1773.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8349899,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2168.00000,628.72000,Aetna,Local,,867.20,,,,,,,698.10,1773.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8349902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2905.68000,842.65000,Aetna,Local,,1162.27,,,,,,,1047.50,2376.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8349902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2905.68000,842.65000,Aetna,Local,,1162.27,,,,,,,935.63,2376.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8350290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1258.60000,364.99000,Aetna,Local,,503.44,,,,,,,453.73,1029.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8350290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1258.60000,364.99000,Aetna,Local,,503.44,,,,,,,405.27,1029.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8350291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8350291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8350292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8350292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8350293,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8350293,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STENT,8350551,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STENT,8350551,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8351535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8351535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8351537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8351537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8351539,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8351539,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8351541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8351541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8351543,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8351543,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8351545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8351545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8351547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8351547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8351549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8351549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8351551,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8351551,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8351552,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1560.00000,452.40000,Aetna,Local,,624.00,,,,,,,562.38,1276.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8351552,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1560.00000,452.40000,Aetna,Local,,624.00,,,,,,,502.32,1276.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8351553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8351553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT STIMULATOR,8351554,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,473.10000,137.20000,Aetna,Local,,189.24,,,,,,,170.55,387.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT STIMULATOR,8351554,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,473.10000,137.20000,Aetna,Local,,189.24,,,,,,,152.34,387.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD TEST STIMULATOR,8351555,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,235.20000,68.21000,Aetna,Local,,94.08,,,,,,,84.79,192.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD TEST STIMULATOR,8351555,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,235.20000,68.21000,Aetna,Local,,94.08,,,,,,,75.73,192.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8352509,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5060.13000,1467.44000,Aetna,Local,,2024.05,,,,,,,1824.18,4139.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8352509,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5060.13000,1467.44000,Aetna,Local,,2024.05,,,,,,,1629.36,4139.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8352511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1779.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8352511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1589.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8355362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8355362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8355360,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6247.50000,1811.78000,Aetna,Local,,2499.00,,,,,,,2252.22,5110.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8355360,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6247.50000,1811.78000,Aetna,Local,,2499.00,,,,,,,2011.69,5110.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8356363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8356363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8356366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8356366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8356368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8356368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8356370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8356370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8356372,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7734.60000,2243.03000,Aetna,Local,,3093.84,,,,,,,2788.32,6326.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8356372,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7734.60000,2243.03000,Aetna,Local,,3093.84,,,,,,,2490.54,6326.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8356374,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,801.38,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8356374,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,715.79,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8356376,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8356376,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8356381,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8356381,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8356491,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8304.00000,2408.16000,Aetna,Local,,3321.60,,,,,,,2993.59,6792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8356491,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8304.00000,2408.16000,Aetna,Local,,3321.60,,,,,,,2673.89,6792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8356492,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8356492,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8356493,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8356493,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8356497,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8356497,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8356727,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8356727,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8356556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1804.00000,523.16000,Aetna,Local,,721.60,,,,,,,650.34,1475.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8356556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1804.00000,523.16000,Aetna,Local,,721.60,,,,,,,580.89,1475.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8356729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2496.00000,723.84000,Aetna,Local,,998.40,,,,,,,899.81,2041.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8356729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2496.00000,723.84000,Aetna,Local,,998.40,,,,,,,803.71,2041.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8356731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8356731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8356733,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8356733,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8356735,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8356735,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8356737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1640.28,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8356737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1465.10,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8356739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1640.28,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8356739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1465.10,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8356743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,434.10000,125.89000,Aetna,Local,,173.64,,,,,,,156.49,355.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8356743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,434.10000,125.89000,Aetna,Local,,173.64,,,,,,,139.78,355.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8356744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,906.03000,262.75000,Aetna,Local,,362.41,,,,,,,326.62,741.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8356744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,906.03000,262.75000,Aetna,Local,,362.41,,,,,,,291.74,741.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8356745,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,884.61000,256.54000,Aetna,Local,,353.84,,,,,,,318.90,723.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8356745,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,884.61000,256.54000,Aetna,Local,,353.84,,,,,,,284.84,723.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUR HOLE COVER,8356746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1484.32000,430.45000,Aetna,Local,,593.73,,,,,,,535.10,1214.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUR HOLE COVER,8356746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1484.32000,430.45000,Aetna,Local,,593.73,,,,,,,477.95,1214.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8356747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,222.34000,64.48000,Aetna,Local,,88.94,,,,,,,80.15,181.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8356747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,222.34000,64.48000,Aetna,Local,,88.94,,,,,,,71.59,181.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8356879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8356879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8356880,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2264.00000,656.56000,Aetna,Local,,905.60,,,,,,,816.17,1851.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8356880,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2264.00000,656.56000,Aetna,Local,,905.60,,,,,,,729.01,1851.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8356881,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2904.00000,842.16000,Aetna,Local,,1161.60,,,,,,,1046.89,2375.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8356881,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2904.00000,842.16000,Aetna,Local,,1161.60,,,,,,,935.09,2375.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8356882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8356882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166286,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166286,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS GASTRO OESOPHAGEAL ANTI REFLUX,8166290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8358401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8358401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8358403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8358403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8358405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8358405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8358407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8358407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8358409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8358409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8358411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8358411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8358413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8358413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8358415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,7273.09,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8358415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,6496.35,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8358417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5510.02000,1597.91000,Aetna,Local,,2204.01,,,,,,,1986.36,4507.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8358417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5510.02000,1597.91000,Aetna,Local,,2204.01,,,,,,,1774.23,4507.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8358420,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1356.36000,393.34000,Aetna,Local,,542.54,,,,,,,488.97,1109.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8358420,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1356.36000,393.34000,Aetna,Local,,542.54,,,,,,,436.75,1109.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8358641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8358641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8358609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8358609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8358610,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8358610,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8358611,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8358611,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8358612,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8358612,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8358613,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8358613,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8358639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8358639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8358794,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8358794,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8358747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5618.62000,1629.40000,Aetna,Local,,2247.45,,,,,,,2025.51,4596.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8358747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5618.62000,1629.40000,Aetna,Local,,2247.45,,,,,,,1809.20,4596.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8358748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8358748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8358749,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8358749,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8358750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8358750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8358751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3026.24000,877.61000,Aetna,Local,,1210.50,,,,,,,1090.96,2475.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8358751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3026.24000,877.61000,Aetna,Local,,1210.50,,,,,,,974.45,2475.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8358795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3026.24000,877.61000,Aetna,Local,,1210.50,,,,,,,1090.96,2475.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8358795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3026.24000,877.61000,Aetna,Local,,1210.50,,,,,,,974.45,2475.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8358826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8358826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8358827,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8358827,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8358828,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8358828,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8358829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2905.68000,842.65000,Aetna,Local,,1162.27,,,,,,,1047.50,2376.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8358829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2905.68000,842.65000,Aetna,Local,,1162.27,,,,,,,935.63,2376.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8360174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8360174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,Local,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8360217,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8360217,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8360218,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8360218,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8360219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8360219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8360248,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8360248,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8360252,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8360252,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8360316,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,Local,,2471.00,,,,,,,2226.99,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8360316,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,Local,,2471.00,,,,,,,1989.15,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8360317,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8360317,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8360468,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8360468,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8360500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8360500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8360502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5658.28000,1640.90000,Aetna,Local,,2263.31,,,,,,,2039.81,4628.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8360502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5658.28000,1640.90000,Aetna,Local,,2263.31,,,,,,,1821.97,4628.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8360504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8360504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8360507,CDM,278,RC,,,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8360507,CDM,278,RC,,,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8360508,CDM,278,RC,,,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8360508,CDM,278,RC,,,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8360509,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,8939.50,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8360509,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,7984.80,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8360572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8360572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8360574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8360574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8360576,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8360576,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8360578,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8360578,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8360580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,7669.64,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8360580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,6850.55,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8360582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8360582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8360584,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8360584,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8360585,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8360585,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8360587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8360589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8360589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8360591,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8360591,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8362197,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8362197,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8362198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8362198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8362199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8362199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMP BODY AEQUALIS FLEX,8362200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17125.00000,4966.25000,Aetna,Local,,6850.00,,,,,,,6173.56,14008.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMP BODY AEQUALIS FLEX,8362200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17125.00000,4966.25000,Aetna,Local,,6850.00,,,,,,,5514.25,14008.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM DISTAL,8362201,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15850.00000,4596.50000,Aetna,Local,,6340.00,,,,,,,5713.93,12965.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM DISTAL,8362201,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15850.00000,4596.50000,Aetna,Local,,6340.00,,,,,,,5103.70,12965.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP AEQUALIS FLEX REVIVE LCKNG,8362202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2320.00000,672.80000,Aetna,Local,,928.00,,,,,,,836.36,1897.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP AEQUALIS FLEX REVIVE LCKNG,8362202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2320.00000,672.80000,Aetna,Local,,928.00,,,,,,,747.04,1897.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY REVERSE,8362204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1299.40,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY REVERSE,8362204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,Local,,1441.78,,,,,,,1160.63,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,8362205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,8362205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8362206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8362206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8362207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8362207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8362432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8362432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8362434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8362434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8362318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8362318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8362469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8362469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8362470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8362470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8362471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8362471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT JRNY II,8362472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT JRNY II,8362472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT JRNY II,8362473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT JRNY II,8362473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8362474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8362474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8362195,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8362195,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8362317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8362317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLADE HELICAL,8362597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,1085.65,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLADE HELICAL,8362597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,969.71,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8362598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8362598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8362599,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,726.53000,210.69000,Aetna,Local,,290.61,,,,,,,261.91,594.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8362599,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,726.53000,210.69000,Aetna,Local,,290.61,,,,,,,233.94,594.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8362716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8362716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8362717,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8362717,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8362718,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8362718,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8362719,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8362719,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362721,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1296.68000,376.04000,Aetna,Local,,518.67,,,,,,,467.45,1060.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362721,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1296.68000,376.04000,Aetna,Local,,518.67,,,,,,,417.53,1060.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6191.50000,1795.54000,Aetna,Local,,2476.60,,,,,,,2232.04,5064.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6191.50000,1795.54000,Aetna,Local,,2476.60,,,,,,,1993.66,5064.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8362724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10794.00000,3130.26000,Aetna,Local,,4317.60,,,,,,,3891.24,8829.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8362724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10794.00000,3130.26000,Aetna,Local,,4317.60,,,,,,,3475.67,8829.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8362725,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10719.00000,3108.51000,Aetna,Local,,4287.60,,,,,,,3864.20,8768.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8362725,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10719.00000,3108.51000,Aetna,Local,,4287.60,,,,,,,3451.52,8768.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8362727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8362727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8362728,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8362728,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8362729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,277.40,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8362729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,247.78,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8362730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,277.40,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8362730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,247.78,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8362875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8362875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8362877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8362877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8362881,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8362881,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8362925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8362925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8362929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8362929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374338,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374338,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374347,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374347,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390260,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390260,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390261,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390261,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390262,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390262,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390263,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390263,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390264,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390264,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390265,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390265,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390266,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390266,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390267,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390267,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390268,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390268,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390269,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390269,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390270,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390270,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390271,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390271,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390272,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390272,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390273,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390273,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390274,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390274,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390275,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390275,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390276,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390276,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390277,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390277,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390278,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390278,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390279,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390279,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390280,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390280,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390281,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390281,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390282,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390282,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390283,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390283,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390284,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390284,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390285,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390285,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390286,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390286,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390287,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390287,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390288,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390288,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390289,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390289,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390290,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390290,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390291,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390291,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390292,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390292,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390293,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390293,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390294,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390294,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390295,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390295,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390296,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390296,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390297,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390297,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390298,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390298,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390299,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390299,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390300,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390300,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390301,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390301,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390302,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390302,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390303,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390303,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390304,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390304,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390305,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390305,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390306,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390306,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390307,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390307,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390308,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390308,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390309,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390309,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390310,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390310,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390311,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390311,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390312,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390312,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390313,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390313,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390314,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390314,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390315,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390315,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390316,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390316,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390317,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390317,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390318,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8390318,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8402966,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8402966,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8402967,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8402967,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8402968,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8402968,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ICM LINQ II EVENT RECORDER,8403165,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15362.50000,4455.12000,Aetna,Local,,6145.00,,,,,,,5538.18,12566.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ICM LINQ II EVENT RECORDER,8403165,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15362.50000,4455.12000,Aetna,Local,,6145.00,,,,,,,4946.73,12566.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ICM LINQ II EVENT RECORDER,8403166,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15362.50000,4455.12000,Aetna,Local,,6145.00,,,,,,,5538.18,12566.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ICM LINQ II EVENT RECORDER,8403166,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15362.50000,4455.12000,Aetna,Local,,6145.00,,,,,,,4946.73,12566.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8407095,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8407095,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8407661,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,117.60000,34.10000,Aetna,Local,,47.04,,,,,,,42.39,96.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8407661,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,117.60000,34.10000,Aetna,Local,,47.04,,,,,,,37.87,96.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY INSERTION,8407939,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,877.41000,254.45000,Aetna,Local,,350.96,,,,,,,316.31,717.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY INSERTION,8407939,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,877.41000,254.45000,Aetna,Local,,9357.00,,,,,,,282.53,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STENT,8409069,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8409069,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8409070,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8409070,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,Local,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5338.94000,1548.29000,Aetna,Local,,2135.58,,,,,,,1924.69,4367.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5338.94000,1548.29000,Aetna,Local,,2135.58,,,,,,,1719.14,4367.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5200.41000,1508.12000,Aetna,Local,,2080.16,,,,,,,1874.75,4253.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5200.41000,1508.12000,Aetna,Local,,2080.16,,,,,,,1674.53,4253.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5243.91000,1520.73000,Aetna,Local,,2097.56,,,,,,,1890.43,4289.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5243.91000,1520.73000,Aetna,Local,,2097.56,,,,,,,1688.54,4289.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5338.94000,1548.29000,Aetna,Local,,2135.58,,,,,,,1924.69,4367.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5338.94000,1548.29000,Aetna,Local,,2135.58,,,,,,,1719.14,4367.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8278594,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,1106.01,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8278594,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,987.90,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8278596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3475.94,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8278596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3104.72,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278597,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278597,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3506.06000,1016.76000,Aetna,Local,,1402.42,,,,,,,1263.93,2867.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3506.06000,1016.76000,Aetna,Local,,1402.42,,,,,,,1128.95,2867.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8278600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8278601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8278601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8278699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8278699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8278602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8278602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8278603,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8278603,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2544.64000,737.95000,Aetna,Local,,1017.86,,,,,,,917.34,2081.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2544.64000,737.95000,Aetna,Local,,1017.86,,,,,,,819.37,2081.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2544.64000,737.95000,Aetna,Local,,1017.86,,,,,,,917.34,2081.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2544.64000,737.95000,Aetna,Local,,1017.86,,,,,,,819.37,2081.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2544.64000,737.95000,Aetna,Local,,1017.86,,,,,,,917.34,2081.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8278698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2544.64000,737.95000,Aetna,Local,,1017.86,,,,,,,819.37,2081.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8278770,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8278770,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8278771,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8278771,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278769,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278769,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8278844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8278844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278846,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8278846,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8278848,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,772.88000,224.14000,Aetna,Local,,309.15,,,,,,,278.62,632.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8278848,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,772.88000,224.14000,Aetna,Local,,309.15,,,,,,,248.87,632.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,8280258,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,2104.22,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,8280258,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,Local,,2334.78,,,,,,,1879.50,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8280244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8280244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8280246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8280246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8280249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,21775.00000,6314.75000,Aetna,Local,,8710.00,,,,,,,7849.89,17811.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8280249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,21775.00000,6314.75000,Aetna,Local,,8710.00,,,,,,,7011.55,17811.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8280251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8280251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8280253,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8280253,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8280260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18032.50000,5229.42000,Aetna,Local,,7213.00,,,,,,,6500.72,14750.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8280260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18032.50000,5229.42000,Aetna,Local,,7213.00,,,,,,,5806.47,14750.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8280428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5894.70000,1709.46000,Aetna,Local,,2357.88,,,,,,,2125.04,4821.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8280428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5894.70000,1709.46000,Aetna,Local,,2357.88,,,,,,,1898.09,4821.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,Local,,584.00,,,,,,,526.33,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,Local,,584.00,,,,,,,470.12,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8280430,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12125.25000,3516.32000,Aetna,Local,,4850.10,,,,,,,4371.15,9918.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8280430,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12125.25000,3516.32000,Aetna,Local,,4850.10,,,,,,,3904.33,9918.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8280554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8280554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8280555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8280555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8280567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8280601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8280680,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8280680,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8280681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8280681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8280682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8280682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8280683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8280683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8280712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8280712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8280714,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8280714,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8280716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8280716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8280718,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8280718,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8280720,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1392.66,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8280720,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1243.93,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8280722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,Local,,3864.00,,,,,,,3482.43,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8280722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,Local,,3864.00,,,,,,,3110.52,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8280724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3281.25000,951.56000,Aetna,Local,,1312.50,,,,,,,1182.89,2684.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8280724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3281.25000,951.56000,Aetna,Local,,1312.50,,,,,,,1056.56,2684.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8282169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8282169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT HEMI,8282173,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,34537.50000,10015.88000,Aetna,Local,,13815.00,,,,,,,12450.77,28251.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT HEMI,8282173,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,34537.50000,10015.88000,Aetna,Local,,13815.00,,,,,,,11121.08,28251.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ARTERY AORTORILIAC,8282327,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,60942.00000,17673.18000,Aetna,Local,,24376.80,,,,,,,21969.59,49850.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ARTERY AORTORILIAC,8282327,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,60942.00000,17673.18000,Aetna,Local,,24376.80,,,,,,,19623.32,49850.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8282328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8282328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8282329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8282329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8282331,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2360.00000,684.40000,Aetna,Local,,944.00,,,,,,,850.78,1930.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8282331,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2360.00000,684.40000,Aetna,Local,,944.00,,,,,,,759.92,1930.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8282333,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2360.00000,684.40000,Aetna,Local,,944.00,,,,,,,850.78,1930.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8282333,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2360.00000,684.40000,Aetna,Local,,944.00,,,,,,,759.92,1930.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8282335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8282335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8282337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8282337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8282339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8282339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8282341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8282341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8282526,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,46811.70000,13575.39000,Aetna,Local,,18724.68,,,,,,,16875.62,38291.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8282526,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,46811.70000,13575.39000,Aetna,Local,,18724.68,,,,,,,15073.37,38291.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8282528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,970.29000,281.38000,Aetna,Local,,388.12,,,,,,,349.79,793.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8282528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,970.29000,281.38000,Aetna,Local,,388.12,,,,,,,312.43,793.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8282530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,863.19000,250.33000,Aetna,Local,,345.28,,,,,,,311.18,706.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8282530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,863.19000,250.33000,Aetna,Local,,345.28,,,,,,,277.95,706.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8282532,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5680.26000,1647.28000,Aetna,Local,,2272.10,,,,,,,2047.73,4646.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8282532,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5680.26000,1647.28000,Aetna,Local,,2272.10,,,,,,,1829.04,4646.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMERAL,8282534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,865.20,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HUMERAL,8282534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,772.80,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8282536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8282536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNAR,8282538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNAR,8282538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8282616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.06000,86.73000,Aetna,Local,,119.62,,,,,,,107.81,244.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8282616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.06000,86.73000,Aetna,Local,,119.62,,,,,,,96.30,244.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8282617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15646.25000,4537.41000,Aetna,Local,,6258.50,,,,,,,5640.47,12798.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8282617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15646.25000,4537.41000,Aetna,Local,,6258.50,,,,,,,5038.09,12798.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8282618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9455.34000,2742.05000,Aetna,Local,,3782.14,,,,,,,3408.65,7734.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8282618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9455.34000,2742.05000,Aetna,Local,,3782.14,,,,,,,3044.62,7734.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER FEMORAL,8282619,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1766.48000,512.28000,Aetna,Local,,706.59,,,,,,,636.82,1444.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER FEMORAL,8282619,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1766.48000,512.28000,Aetna,Local,,706.59,,,,,,,568.81,1444.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8282996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8282996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8282871,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8282871,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8282872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8282872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER SPINAL,8282873,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER SPINAL,8282873,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8282874,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8282874,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8282875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8282875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8282997,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8282997,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8282998,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8282998,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8283043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1808.00000,524.32000,Aetna,Local,,723.20,,,,,,,651.78,1478.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8283043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1808.00000,524.32000,Aetna,Local,,723.20,,,,,,,582.18,1478.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8283365,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8283365,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8283362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8283362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8283363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8283363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8283364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8283364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8283469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5771.50000,1673.74000,Aetna,Local,,2308.60,,,,,,,2080.63,4721.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8283469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5771.50000,1673.74000,Aetna,Local,,2308.60,,,,,,,1858.42,4721.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8283470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8283470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8284199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8569.50000,2485.15000,Aetna,Local,,3427.80,,,,,,,3089.30,7009.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8284199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8569.50000,2485.15000,Aetna,Local,,3427.80,,,,,,,2759.38,7009.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8284213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5131.18000,1488.04000,Aetna,Local,,2052.47,,,,,,,1849.79,4197.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8284213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5131.18000,1488.04000,Aetna,Local,,2052.47,,,,,,,1652.24,4197.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,860.87,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,768.94,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,860.87,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,768.94,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8284216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9636.00000,2794.44000,Aetna,Local,,3854.40,,,,,,,3473.78,7882.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8284216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9636.00000,2794.44000,Aetna,Local,,3854.40,,,,,,,3102.79,7882.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8284218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8361.00000,2424.69000,Aetna,Local,,3344.40,,,,,,,3014.14,6839.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8284218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8361.00000,2424.69000,Aetna,Local,,3344.40,,,,,,,2692.24,6839.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8284219,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8284219,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8286479,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8286479,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS,8284280,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS,8284280,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS,8284281,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS,8284281,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8284308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8502.00000,2465.58000,Aetna,Local,,3400.80,,,,,,,3064.97,6954.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8284308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8502.00000,2465.58000,Aetna,Local,,3400.80,,,,,,,2737.64,6954.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8284415,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8284415,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8284416,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,Local,,20156.16,,,,,,,18165.74,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8284416,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,Local,,20156.16,,,,,,,16225.71,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,924.08000,267.98000,Aetna,Local,,369.63,,,,,,,333.13,755.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,924.08000,267.98000,Aetna,Local,,369.63,,,,,,,297.55,755.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8284598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5043.50000,1462.62000,Aetna,Local,,2017.40,,,,,,,1818.18,4125.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8284598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5043.50000,1462.62000,Aetna,Local,,2017.40,,,,,,,1624.01,4125.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8284600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,980.73000,284.41000,Aetna,Local,,392.29,,,,,,,353.55,802.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,980.73000,284.41000,Aetna,Local,,392.29,,,,,,,315.80,802.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8284788,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8284788,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8284789,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8284789,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8284790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8284790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BURRHOLE,7696438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.38000,143.37000,Aetna,Local,,197.75,,,,,,,178.22,404.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BURRHOLE,7696438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.38000,143.37000,Aetna,Local,,197.75,,,,,,,159.19,404.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BURRHOLE,7696439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.38000,143.37000,Aetna,Local,,197.75,,,,,,,178.22,404.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BURRHOLE,7696439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.38000,143.37000,Aetna,Local,,197.75,,,,,,,159.19,404.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BURRHOLE,7696440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,551.97000,160.07000,Aetna,Local,,220.79,,,,,,,198.99,451.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BURRHOLE,7696440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,551.97000,160.07000,Aetna,Local,,220.79,,,,,,,177.73,451.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BURRHOLE,7696437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.38000,143.37000,Aetna,Local,,197.75,,,,,,,178.22,404.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BURRHOLE,7696437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.38000,143.37000,Aetna,Local,,197.75,,,,,,,159.19,404.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8286425,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11205.00000,3249.45000,Aetna,Local,,4482.00,,,,,,,4039.40,9165.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8286425,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11205.00000,3249.45000,Aetna,Local,,4482.00,,,,,,,3608.01,9165.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8286429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8286429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION STAPLE,8286426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6163.50000,1787.42000,Aetna,Local,,2465.40,,,,,,,2221.94,5041.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION STAPLE,8286426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6163.50000,1787.42000,Aetna,Local,,2465.40,,,,,,,1984.65,5041.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8286428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8286428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8286430,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7656.00000,2220.24000,Aetna,Local,,3062.40,,,,,,,2759.99,6262.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8286430,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7656.00000,2220.24000,Aetna,Local,,3062.40,,,,,,,2465.23,6262.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7696804,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7656.00000,2220.24000,Aetna,Local,,3062.40,,,,,,,2759.99,6262.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7696804,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7656.00000,2220.24000,Aetna,Local,,3062.40,,,,,,,2465.23,6262.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,8286500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,8286500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,8286501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,8286501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8286502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8286502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8286509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,Local,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8286510,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4803.75000,1393.09000,Aetna,Local,,1921.50,,,,,,,1731.75,3929.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8286510,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4803.75000,1393.09000,Aetna,Local,,1921.50,,,,,,,1546.81,3929.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8288244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8288244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8290208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,794.54,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8290208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,Local,,881.60,,,,,,,709.69,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8290210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8290210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POST,8290211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5369.00000,1557.01000,Aetna,Local,,2147.60,,,,,,,1935.52,4391.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POST,8290211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5369.00000,1557.01000,Aetna,Local,,2147.60,,,,,,,1728.82,4391.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8288276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8288278,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8288278,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8288279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8288279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8292474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8292474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8292475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8292475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8292476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8292476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8292477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8292477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8292735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8292735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8292737,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1380.00000,400.20000,Aetna,Local,,552.00,,,,,,,497.49,1128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8292737,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,552.00,,,,,,,444.36,1128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8292739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8292739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8294177,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8294177,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8294170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4315.50000,1251.49000,Aetna,Local,,1726.20,,,,,,,1555.74,3530.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8294170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4315.50000,1251.49000,Aetna,Local,,1726.20,,,,,,,1389.59,3530.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8294228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8294228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8294310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8294310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8294409,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8294409,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8294411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8294411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8294425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8294476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8294476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8294478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8294478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8294480,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8294480,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8294482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8294482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8296466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8296466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8296477,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8296477,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLAR,8296478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLAR,8296478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8296489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8296489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8296491,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,318.87000,92.47000,Aetna,Local,,127.55,,,,,,,114.95,260.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8296491,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,318.87000,92.47000,Aetna,Local,,127.55,,,,,,,102.68,260.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8296492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,865.40000,250.97000,Aetna,Local,,346.16,,,,,,,311.98,707.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8296492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,865.40000,250.97000,Aetna,Local,,346.16,,,,,,,278.66,707.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8296502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6053.15000,1755.41000,Aetna,Local,,2421.26,,,,,,,2182.16,4951.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8296502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6053.15000,1755.41000,Aetna,Local,,2421.26,,,,,,,1949.11,4951.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUFF SYSTEM,8296835,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,22400.00000,6496.00000,Aetna,Local,,8960.00,,,,,,,8075.20,18323.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUFF SYSTEM,8296835,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,22400.00000,6496.00000,Aetna,Local,,8960.00,,,,,,,7212.80,18323.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION CLAMP,8296837,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION CLAMP,8296837,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION CLAMP,8296839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION CLAMP,8296839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8296841,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,Local,,2471.00,,,,,,,2226.99,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8296841,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,Local,,2471.00,,,,,,,1989.15,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,8296843,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,8296843,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8296844,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8296844,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8296846,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8296846,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8296848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7333.20000,2126.63000,Aetna,Local,,2933.28,,,,,,,2643.62,5998.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8296848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7333.20000,2126.63000,Aetna,Local,,2933.28,,,,,,,2361.29,5998.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8296866,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8296866,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8296868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3617.25000,1049.00000,Aetna,Local,,1446.90,,,,,,,1304.02,2958.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8296868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3617.25000,1049.00000,Aetna,Local,,1446.90,,,,,,,1164.75,2958.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8296869,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8296869,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,8296871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5183.50000,1503.22000,Aetna,Local,,2073.40,,,,,,,1868.65,4240.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,8296871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5183.50000,1503.22000,Aetna,Local,,2073.40,,,,,,,1669.09,4240.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,8296996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1622.36,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,8296996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1449.10,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8296997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8296997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPIPHYSIS ECCENTRIC,8296998,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPIPHYSIS ECCENTRIC,8296998,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8296999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8297002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8297002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8297003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8297003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8296969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8296969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8297009,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8297009,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8297117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10578.00000,3067.62000,Aetna,Local,,4231.20,,,,,,,3813.37,8652.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8297117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10578.00000,3067.62000,Aetna,Local,,4231.20,,,,,,,3406.12,8652.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8297119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8297119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8297120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10794.00000,3130.26000,Aetna,Local,,4317.60,,,,,,,3891.24,8829.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8297120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10794.00000,3130.26000,Aetna,Local,,4317.60,,,,,,,3475.67,8829.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,319.58,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,285.45,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8297122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5537.00000,1605.73000,Aetna,Local,,2214.80,,,,,,,1996.09,4529.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8297122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5537.00000,1605.73000,Aetna,Local,,2214.80,,,,,,,1782.91,4529.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8297125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10719.00000,3108.51000,Aetna,Local,,4287.60,,,,,,,3864.20,8768.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8297125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10719.00000,3108.51000,Aetna,Local,,4287.60,,,,,,,3451.52,8768.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8297132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8297132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8297133,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11205.00000,3249.45000,Aetna,Local,,4482.00,,,,,,,4039.40,9165.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8297133,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11205.00000,3249.45000,Aetna,Local,,4482.00,,,,,,,3608.01,9165.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8297136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8297136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8297137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8907.24000,2583.10000,Aetna,Local,,3562.90,,,,,,,3211.06,7286.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8297137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8907.24000,2583.10000,Aetna,Local,,3562.90,,,,,,,2868.13,7286.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8297138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5381.25000,1560.56000,Aetna,Local,,2152.50,,,,,,,1939.94,4401.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8297138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5381.25000,1560.56000,Aetna,Local,,2152.50,,,,,,,1732.76,4401.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8297139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4444.13000,1288.80000,Aetna,Local,,1777.65,,,,,,,1602.11,3635.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8297139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4444.13000,1288.80000,Aetna,Local,,1777.65,,,,,,,1431.01,3635.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8297140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8297140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8297141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8297141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8297142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8297142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8297163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8297163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8297164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8297164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8298189,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8298189,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,195.93000,56.82000,Aetna,Local,,78.37,,,,,,,70.63,160.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,195.93000,56.82000,Aetna,Local,,78.37,,,,,,,63.09,160.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8297313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8297313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3682.00000,1067.78000,Aetna,Local,,1472.80,,,,,,,1327.36,3011.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8297314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3682.00000,1067.78000,Aetna,Local,,1472.80,,,,,,,1185.60,3011.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8298227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8298227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,933.62000,270.75000,Aetna,Local,,373.45,,,,,,,336.57,763.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,933.62000,270.75000,Aetna,Local,,373.45,,,,,,,300.63,763.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,933.62000,270.75000,Aetna,Local,,373.45,,,,,,,336.57,763.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,933.62000,270.75000,Aetna,Local,,373.45,,,,,,,300.63,763.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,238.73,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,662.22000,192.04000,Aetna,Local,,264.89,,,,,,,213.23,541.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER HOLE,8229255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1329.52000,385.56000,Aetna,Local,,531.81,,,,,,,479.29,1087.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER HOLE,8229255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1329.52000,385.56000,Aetna,Local,,531.81,,,,,,,428.11,1087.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8298486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8298486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8298492,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8298492,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8298494,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8298494,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8298500,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8298500,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8298502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,322.88,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8298502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,288.40,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8298504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8298504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8298812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,802.11,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8298812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,716.45,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8298814,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,Local,,1779.28,,,,,,,1603.57,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8298814,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,Local,,1779.28,,,,,,,1432.32,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8298879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8298879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8298880,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8298880,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8298881,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8298881,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8298900,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8298900,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8298901,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8298901,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8298902,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8298902,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8298903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8299542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8299542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8299544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8299544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8299545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10383.00000,3011.07000,Aetna,Local,,4153.20,,,,,,,3743.07,8493.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8299545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10383.00000,3011.07000,Aetna,Local,,4153.20,,,,,,,3343.33,8493.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8299554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8299554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8299555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8299555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8299556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8299556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8300428,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8300428,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8300430,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8300430,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP SPINAL,8300432,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP SPINAL,8300432,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP SPINAL,8300434,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP SPINAL,8300434,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8300436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6437.03000,1866.74000,Aetna,Local,,2574.81,,,,,,,2320.55,5265.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8300436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6437.03000,1866.74000,Aetna,Local,,2574.81,,,,,,,2072.72,5265.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8300438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8300438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8301041,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5502.00000,1595.58000,Aetna,Local,,2200.80,,,,,,,1983.47,4500.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8301041,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5502.00000,1595.58000,Aetna,Local,,2200.80,,,,,,,1771.64,4500.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8301047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8301047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8301048,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8301048,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRADISCAL SHIM,8301049,CDM,278,RC,,,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRADISCAL SHIM,8301049,CDM,278,RC,,,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8301050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8301051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2854.60000,827.83000,Aetna,Local,,1141.84,,,,,,,1029.08,2335.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8301051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2854.60000,827.83000,Aetna,Local,,1141.84,,,,,,,919.18,2335.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8305696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8305696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8305699,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8305699,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8305701,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8305701,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8305703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8305703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8305705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8305705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8305707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8305707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8305709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8305709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8307098,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8307098,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8307500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8307500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRADISCAL SHIM,8307501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRADISCAL SHIM,8307501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8310266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2463.52000,714.42000,Aetna,Local,,985.41,,,,,,,888.10,2015.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8310266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2463.52000,714.42000,Aetna,Local,,985.41,,,,,,,793.25,2015.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM,8310286,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2741.60,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM,8310286,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,124.65,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8310300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22765.50000,6602.00000,Aetna,Local,,9106.20,,,,,,,8206.96,18622.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8310300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22765.50000,6602.00000,Aetna,Local,,9106.20,,,,,,,7330.49,18622.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8310301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4599.00000,1333.71000,Aetna,Local,,1839.60,,,,,,,1657.94,3761.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8310301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4599.00000,1333.71000,Aetna,Local,,1839.60,,,,,,,1480.88,3761.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8310302,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8310302,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8310303,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8310303,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8311100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2705.64000,784.64000,Aetna,Local,,1082.26,,,,,,,975.38,2213.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8311100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2705.64000,784.64000,Aetna,Local,,1082.26,,,,,,,871.22,2213.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8310294,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8064.00000,2338.56000,Aetna,Local,,3225.60,,,,,,,2907.07,6596.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8310294,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8064.00000,2338.56000,Aetna,Local,,3225.60,,,,,,,2596.61,6596.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8312094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8312094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8310296,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8064.00000,2338.56000,Aetna,Local,,3225.60,,,,,,,2907.07,6596.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8310296,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8064.00000,2338.56000,Aetna,Local,,3225.60,,,,,,,2596.61,6596.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8312095,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8312095,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE MATRIX,8312890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14026.05000,4067.55000,Aetna,Local,,5610.42,,,,,,,5056.39,11473.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE MATRIX,8312890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14026.05000,4067.55000,Aetna,Local,,5610.42,,,,,,,4516.39,11473.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8312891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8312891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8312892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8312892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8312893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3065.00000,888.85000,Aetna,Local,,1226.00,,,,,,,1104.93,2507.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8312893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3065.00000,888.85000,Aetna,Local,,1226.00,,,,,,,986.93,2507.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313663,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313663,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313665,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313665,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313667,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313667,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313669,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313669,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313671,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313671,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313673,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8313673,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8313681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8313681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8313682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8313682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8313683,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8313683,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8313684,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8313684,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM SURG PROC WITH SCREW,8313608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM SURG PROC WITH SCREW,8313608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8313688,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8026.80000,2327.77000,Aetna,Local,,3210.72,,,,,,,2893.66,6565.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8313688,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8026.80000,2327.77000,Aetna,Local,,3210.72,,,,,,,2584.63,6565.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8313766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.26000,96.36000,Aetna,Local,,132.90,,,,,,,119.78,271.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8313766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.26000,96.36000,Aetna,Local,,132.90,,,,,,,106.99,271.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8313898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8313898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8313788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8313788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8313940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8313940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8314006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8314006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8314007,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8314007,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8314002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8314002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8314003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4609.50000,1336.76000,Aetna,Local,,1843.80,,,,,,,1661.72,3770.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8314003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4609.50000,1336.76000,Aetna,Local,,1843.80,,,,,,,1484.26,3770.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8314004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8314004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8314044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.60000,3007.76000,Aetna,Local,,4148.64,,,,,,,3738.96,8483.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8314044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.60000,3007.76000,Aetna,Local,,4148.64,,,,,,,3339.66,8483.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8314045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1779.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8314045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1589.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.56000,380.64000,Aetna,Local,,525.02,,,,,,,473.18,1073.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.56000,380.64000,Aetna,Local,,525.02,,,,,,,422.64,1073.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8314118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1779.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8314118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1589.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8314119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.60000,3007.76000,Aetna,Local,,4148.64,,,,,,,3738.96,8483.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8314119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.60000,3007.76000,Aetna,Local,,4148.64,,,,,,,3339.66,8483.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8314120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8314120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8314121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8314121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8314122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8314122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8314123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8314123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8314241,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17859.38000,5179.22000,Aetna,Local,,7143.75,,,,,,,6438.31,14608.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8314241,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17859.38000,5179.22000,Aetna,Local,,7143.75,,,,,,,5750.72,14608.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8314249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8314249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8314250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8314250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8318388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8318388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8314251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8314251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8314252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8314252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,8318440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,365.80000,106.08000,Aetna,Local,,146.32,,,,,,,131.87,299.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,8318440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,365.80000,106.08000,Aetna,Local,,146.32,,,,,,,117.79,299.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8318441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,451.44000,130.92000,Aetna,Local,,180.58,,,,,,,162.74,369.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8318441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,451.44000,130.92000,Aetna,Local,,180.58,,,,,,,145.36,369.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8318442,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8318442,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8318443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10830.00000,3140.70000,Aetna,Local,,4332.00,,,,,,,3904.22,8858.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8318443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10830.00000,3140.70000,Aetna,Local,,4332.00,,,,,,,3487.26,8858.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8318444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6471.50000,1876.74000,Aetna,Local,,2588.60,,,,,,,2332.98,5293.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8318444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6471.50000,1876.74000,Aetna,Local,,2588.60,,,,,,,2083.82,5293.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8320191,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8320191,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8320181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2024.00000,586.96000,Aetna,Local,,809.60,,,,,,,729.65,1655.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8320181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2024.00000,586.96000,Aetna,Local,,809.60,,,,,,,651.73,1655.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8320185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,8320185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,8320187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,8320187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,8320188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,8320188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8320333,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8320333,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,8320305,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,8320305,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANN,8320196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANN,8320196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320291,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320291,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THREADED,8320304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8320346,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8320346,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8320879,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8320879,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8320885,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8320885,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANC,8321541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4588.50000,1330.66000,Aetna,Local,,1835.40,,,,,,,1654.15,3753.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANC,8321541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4588.50000,1330.66000,Aetna,Local,,1835.40,,,,,,,1477.50,3753.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE FEMORAL,8321542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE FEMORAL,8321542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8321543,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8321543,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POUCH BIODORBABLE,8321544,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4795.00000,1390.55000,Aetna,Local,,1918.00,,,,,,,1728.60,3922.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POUCH BIODORBABLE,8321544,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4795.00000,1390.55000,Aetna,Local,,1918.00,,,,,,,1543.99,3922.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320310,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320310,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320311,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320311,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320314,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320314,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320315,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320315,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320316,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320316,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320318,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320318,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320319,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320319,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320320,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320320,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320329,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320329,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320330,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8320330,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8322727,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8322727,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8322728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8322728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8322745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8322745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8322746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8322746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8322747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8322747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8322748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8322748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8322749,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8322749,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8322750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9201.00000,2668.29000,Aetna,Local,,3680.40,,,,,,,3316.96,7526.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8322750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9201.00000,2668.29000,Aetna,Local,,3680.40,,,,,,,2962.72,7526.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8323236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8323236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8323239,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8323239,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8323240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8323240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8324458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8324458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8323237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11873.25000,3443.24000,Aetna,Local,,4749.30,,,,,,,4280.31,9712.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8323237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11873.25000,3443.24000,Aetna,Local,,4749.30,,,,,,,3823.19,9712.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,8323238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,8323238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8324503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.60000,3007.76000,Aetna,Local,,4148.64,,,,,,,3738.96,8483.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8324503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.60000,3007.76000,Aetna,Local,,4148.64,,,,,,,3339.66,8483.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8324505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8324505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8324618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8324618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8324619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8324619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8324622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8326243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8326243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8326244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8326244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8326245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8326245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8326246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6583.50000,1909.22000,Aetna,Local,,2633.40,,,,,,,2373.35,5385.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8326246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6583.50000,1909.22000,Aetna,Local,,2633.40,,,,,,,2119.89,5385.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8326247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8326247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8326248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1268.00000,367.72000,Aetna,Local,,507.20,,,,,,,457.11,1037.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8326248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1268.00000,367.72000,Aetna,Local,,507.20,,,,,,,408.30,1037.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8328316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8328316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8328335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8328335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8328366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8328366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8328336,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,1106.01,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8328336,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,987.90,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8328337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8328337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8328381,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8328381,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER IN TRAY,8328399,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1409.20000,408.67000,Aetna,Local,,563.68,,,,,,,508.02,1152.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER IN TRAY,8328399,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1409.20000,408.67000,Aetna,Local,,563.68,,,,,,,453.76,1152.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8328482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9027.00000,2617.83000,Aetna,Local,,3610.80,,,,,,,3254.23,7384.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8328482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9027.00000,2617.83000,Aetna,Local,,3610.80,,,,,,,2906.69,7384.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8328483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17460.00000,5063.40000,Aetna,Local,,6984.00,,,,,,,6294.33,14282.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8328483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17460.00000,5063.40000,Aetna,Local,,6984.00,,,,,,,5622.12,14282.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8328484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21873.00000,6343.17000,Aetna,Local,,8749.20,,,,,,,7885.22,17892.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8328484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21873.00000,6343.17000,Aetna,Local,,8749.20,,,,,,,7043.11,17892.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8328485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5716.20000,1657.70000,Aetna,Local,,2286.48,,,,,,,2060.69,4675.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8328485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5716.20000,1657.70000,Aetna,Local,,2286.48,,,,,,,1840.62,4675.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8328486,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8830.80000,2560.93000,Aetna,Local,,3532.32,,,,,,,3183.50,7223.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8328486,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8830.80000,2560.93000,Aetna,Local,,3532.32,,,,,,,2843.52,7223.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8328487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11201.40000,3248.41000,Aetna,Local,,4480.56,,,,,,,4038.10,9162.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8328487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11201.40000,3248.41000,Aetna,Local,,4480.56,,,,,,,3606.85,9162.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8328488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5749.80000,1667.44000,Aetna,Local,,2299.92,,,,,,,2072.80,4703.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8328488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5749.80000,1667.44000,Aetna,Local,,2299.92,,,,,,,1851.44,4703.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8328489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8328489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8328490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8328490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8328491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8328491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8328542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13514.40000,3919.18000,Aetna,Local,,5405.76,,,,,,,4871.94,11054.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8328542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13514.40000,3919.18000,Aetna,Local,,5405.76,,,,,,,4351.64,11054.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8328554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8328554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8328584,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,47643.98000,13816.75000,Aetna,Local,,19057.59,,,,,,,17175.65,38972.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8328584,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,47643.98000,13816.75000,Aetna,Local,,19057.59,,,,,,,15341.36,38972.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8328585,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,54130.20000,15697.76000,Aetna,Local,,21652.08,,,,,,,19513.94,44278.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8328585,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,54130.20000,15697.76000,Aetna,Local,,21652.08,,,,,,,17429.92,44278.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8330207,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8330207,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14143.50000,4101.62000,Aetna,Local,,5657.40,,,,,,,5098.73,11569.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14143.50000,4101.62000,Aetna,Local,,5657.40,,,,,,,4554.21,11569.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8330349,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12528.90000,3633.38000,Aetna,Local,,5011.56,,,,,,,4516.67,10248.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8330349,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12528.90000,3633.38000,Aetna,Local,,5011.56,,,,,,,4034.31,10248.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8330338,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8330338,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8330339,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8330339,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8330340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8330340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8330268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3930.50000,1139.84000,Aetna,Local,,1572.20,,,,,,,1416.95,3215.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8330268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3930.50000,1139.84000,Aetna,Local,,1572.20,,,,,,,1265.62,3215.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8330425,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5689.29000,1649.89000,Aetna,Local,,2275.72,,,,,,,2050.99,4653.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8330425,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5689.29000,1649.89000,Aetna,Local,,2275.72,,,,,,,1831.95,4653.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8330394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8330394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8330435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8330435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8330436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8330436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8330494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8330494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330689,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330689,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5524.33000,1602.06000,Aetna,Local,,2209.73,,,,,,,1991.52,4518.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5524.33000,1602.06000,Aetna,Local,,2209.73,,,,,,,1778.83,4518.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5524.33000,1602.06000,Aetna,Local,,2209.73,,,,,,,1991.52,4518.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5524.33000,1602.06000,Aetna,Local,,2209.73,,,,,,,1778.83,4518.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5524.33000,1602.06000,Aetna,Local,,2209.73,,,,,,,1991.52,4518.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5524.33000,1602.06000,Aetna,Local,,2209.73,,,,,,,1778.83,4518.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,1017.48,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.40000,818.50000,Aetna,Local,,1128.96,,,,,,,908.81,2308.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8330694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8330695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1779.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8330695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1589.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8330696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8330696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8330697,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,289.57,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8330697,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,258.65,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8330698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8330698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8330765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8330765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8330789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8330789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330950,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330950,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2863.03,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7941.84000,2303.13000,Aetna,Local,,3176.74,,,,,,,2557.27,6496.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2963.30,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8330967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.97000,2383.79000,Aetna,Local,,3287.99,,,,,,,2646.83,6723.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8331246,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2984.96000,865.64000,Aetna,Local,,1193.98,,,,,,,1076.08,2441.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8331246,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2984.96000,865.64000,Aetna,Local,,1193.98,,,,,,,961.16,2441.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8331259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8331259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8331260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8331260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER STEM,8331261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER STEM,8331261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8331262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8331262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331286,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331286,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331287,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331287,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331288,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331288,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331289,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331289,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331290,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331290,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331291,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331291,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331292,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331292,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331293,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331293,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8332177,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8332177,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331294,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8331294,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8332184,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8332184,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8331457,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2365.78,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8331457,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2113.12,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,8169807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,830.52000,240.85000,Aetna,Local,,332.21,,,,,,,299.40,679.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,8169807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,830.52000,240.85000,Aetna,Local,,332.21,,,,,,,267.43,679.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,8231614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,852.08000,247.10000,Aetna,Local,,340.83,,,,,,,307.17,697.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,8231614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,852.08000,247.10000,Aetna,Local,,340.83,,,,,,,274.37,697.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,8169805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,842.13000,244.22000,Aetna,Local,,336.85,,,,,,,303.59,688.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,8169805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,842.13000,244.22000,Aetna,Local,,336.85,,,,,,,271.17,688.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8332171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8332171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,Local,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8332191,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8332191,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8332341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18861.60000,5469.86000,Aetna,Local,,7544.64,,,,,,,6799.61,15428.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8332341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18861.60000,5469.86000,Aetna,Local,,7544.64,,,,,,,6073.44,15428.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8332353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,1085.65,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8332353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,969.71,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8332491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8332491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8332516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8332516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8332517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8332517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8334205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8334205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10152.00000,2944.08000,Aetna,Local,,4060.80,,,,,,,3659.80,8304.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10152.00000,2944.08000,Aetna,Local,,4060.80,,,,,,,3268.94,8304.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8334203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2949.80000,855.44000,Aetna,Local,,1179.92,,,,,,,1063.40,2412.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8334203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2949.80000,855.44000,Aetna,Local,,1179.92,,,,,,,949.84,2412.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8334312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8334312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,564.98000,163.84000,Aetna,Local,,225.99,,,,,,,203.68,462.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,564.98000,163.84000,Aetna,Local,,225.99,,,,,,,181.92,462.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3575.46000,1036.88000,Aetna,Local,,1430.18,,,,,,,1288.95,2924.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3575.46000,1036.88000,Aetna,Local,,1430.18,,,,,,,1151.30,2924.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8334363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,1085.65,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8334363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,969.71,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5683.83000,1648.31000,Aetna,Local,,2273.53,,,,,,,2049.02,4649.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5683.83000,1648.31000,Aetna,Local,,2273.53,,,,,,,1830.19,4649.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,Local,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8334417,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8334417,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8334406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8334418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,513.00000,148.77000,Aetna,Local,,205.20,,,,,,,184.94,419.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8334418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,513.00000,148.77000,Aetna,Local,,205.20,,,,,,,165.19,419.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8334433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8334433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8334432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25666.15000,7443.18000,Aetna,Local,,10266.46,,,,,,,9252.65,20994.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8334432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25666.15000,7443.18000,Aetna,Local,,10266.46,,,,,,,8264.50,20994.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5013.75000,1453.99000,Aetna,Local,,2005.50,,,,,,,1807.46,4101.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5013.75000,1453.99000,Aetna,Local,,2005.50,,,,,,,1614.43,4101.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,921.29000,267.17000,Aetna,Local,,368.52,,,,,,,332.13,753.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,921.29000,267.17000,Aetna,Local,,368.52,,,,,,,296.66,753.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,747.59000,216.80000,Aetna,Local,,299.04,,,,,,,269.51,611.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8334542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,747.59000,216.80000,Aetna,Local,,299.04,,,,,,,240.72,611.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8334930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,1085.65,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8334930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,969.71,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8335296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8335296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8335282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8335282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,Local,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8335326,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8335326,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8335327,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8335327,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8335481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,4351.96,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8335481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,3887.18,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8335482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2144.00000,621.76000,Aetna,Local,,857.60,,,,,,,772.91,1753.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8335482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2144.00000,621.76000,Aetna,Local,,857.60,,,,,,,690.37,1753.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8336033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2949.80000,855.44000,Aetna,Local,,1179.92,,,,,,,1063.40,2412.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8336033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2949.80000,855.44000,Aetna,Local,,1179.92,,,,,,,949.84,2412.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8336034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2980.16000,864.25000,Aetna,Local,,1192.06,,,,,,,1074.35,2437.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8336034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2980.16000,864.25000,Aetna,Local,,1192.06,,,,,,,959.61,2437.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8336442,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8336442,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8336443,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8336443,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8336444,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8336444,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8336445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,1085.65,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL BLADE,8336445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,969.71,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8336521,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8336521,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8336518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1291.62,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8336518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1153.68,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8336520,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8336520,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8336519,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,8336519,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8336554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8336554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8336557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8336557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8336555,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3458.00000,1002.82000,Aetna,Local,,1383.20,,,,,,,1246.61,2828.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8336555,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3458.00000,1002.82000,Aetna,Local,,1383.20,,,,,,,1113.48,2828.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,8336556,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2107.84000,611.27000,Aetna,Local,,843.14,,,,,,,759.88,1724.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK,8336556,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2107.84000,611.27000,Aetna,Local,,843.14,,,,,,,678.72,1724.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8336605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1734.59,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8336605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1549.34,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8336745,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8336745,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8336607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8336607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8336746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8336746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8336604,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,39.27,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8336604,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,108.94000,31.59000,Aetna,Local,,43.58,,,,,,,35.08,89.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8336823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4444.13000,1288.80000,Aetna,Local,,1777.65,,,,,,,1602.11,3635.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8336823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4444.13000,1288.80000,Aetna,Local,,1777.65,,,,,,,1431.01,3635.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8336824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1873.70,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8336824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1673.60,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8336825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8336825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,8336826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6109.74000,1771.82000,Aetna,Local,,2443.90,,,,,,,2202.56,4997.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,8336826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6109.74000,1771.82000,Aetna,Local,,2443.90,,,,,,,1967.34,4997.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8338236,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8338236,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8338244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8338244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8338245,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8338245,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338263,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338263,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338264,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338264,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338394,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,8338394,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,Local,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8338395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5971.00000,1731.59000,Aetna,Local,,2388.40,,,,,,,2152.55,4884.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8338395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5971.00000,1731.59000,Aetna,Local,,2388.40,,,,,,,1922.66,4884.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8338397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8338445,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8338445,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8338446,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8338446,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCK FEMORAL,7736497,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1991.84000,577.63000,Aetna,Local,,796.74,,,,,,,718.06,1629.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCK FEMORAL,7736497,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1991.84000,577.63000,Aetna,Local,,796.74,,,,,,,641.37,1629.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8429785,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8429785,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8429787,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8429787,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8429786,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8429786,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8429788,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8429788,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8435775,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,Local,,832.00,,,,,,,749.84,1701.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8435775,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,Local,,9357.00,,,,,,,669.76,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SUTURE SYSTEM,8446220,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1452.00000,421.08000,Aetna,Local,,580.80,,,,,,,523.45,1187.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE SYSTEM,8446220,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1452.00000,421.08000,Aetna,Local,,580.80,,,,,,,467.54,1187.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8487989,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,1117.55,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8487989,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,Local,,1240.00,,,,,,,998.20,2535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEMBRANE,8490010,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3864.00000,1120.56000,Aetna,Local,,1545.60,,,,,,,1392.97,3160.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEMBRANE,8490010,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3864.00000,1120.56000,Aetna,Local,,1545.60,,,,,,,1244.21,3160.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM CEREBRAL,8485955,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM CEREBRAL,8485955,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8496707,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,277.40,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8496707,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,247.78,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8511932,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4542.30,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8511932,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4057.20,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8511933,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4542.30,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8511933,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4057.20,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8511934,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4542.30,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8511934,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4057.20,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8511935,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8511935,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8511936,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8511936,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8511937,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8511937,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8511938,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8511938,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8513936,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4542.30,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8513936,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4057.20,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8663930,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8663930,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATH PACING,8683929,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,578.25000,167.69000,Aetna,Local,,231.30,,,,,,,208.46,473.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATH PACING,8683929,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,578.25000,167.69000,Aetna,Local,,9357.00,,,,,,,186.20,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PACING CABLE,8683928,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,2100.00000,609.00000,Aetna,Local,,840.00,,,,,,,757.05,1717.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACING CABLE,8683928,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,840.00,,,,,,,676.20,1717.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Turnpike LP 5FR 135CM,8693932,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Turnpike LP 5FR 135CM,8693932,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8701925,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,578.25000,167.69000,Aetna,Local,,231.30,,,,,,,208.46,473.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8701925,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,578.25000,167.69000,Aetna,Local,,9357.00,,,,,,,186.20,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LEAD PACING,8711945,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,2100.00000,609.00000,Aetna,Local,,840.00,,,,,,,757.05,1717.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD PACING,8711945,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,840.00,,,,,,,676.20,1717.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM MITRACLIP,8770104,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,72000.00000,20880.00000,Aetna,Local,,28800.00,,,,,,,25956.00,58896.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM MITRACLIP,8770104,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,72000.00000,20880.00000,Aetna,Local,,28800.00,,,,,,,23184.00,58896.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ICD,8786164,CDM,278,RC,C1722,HCPCS,,,facility,inpatient,,,30487.50000,8841.38000,Aetna,Local,,12195.00,,,,,,,10990.74,24938.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ICD,8786164,CDM,278,RC,C1722,HCPCS,,,facility,outpatient,,,30487.50000,8841.38000,Aetna,Local,,12195.00,,,,,,,9816.98,24938.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8806084,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8806084,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8806085,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,306.38000,88.85000,Aetna,Local,,122.55,,,,,,,110.45,250.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8806085,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,306.38000,88.85000,Aetna,Local,,122.55,,,,,,,98.65,250.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ICM LINQ II EVENT RECORDER,8910497,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15362.50000,4455.12000,Aetna,Local,,6145.00,,,,,,,5538.18,12566.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ICM LINQ II EVENT RECORDER,8910497,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15362.50000,4455.12000,Aetna,Local,,6145.00,,,,,,,4946.73,12566.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8912128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,947.88,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8912128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,846.65,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8912129,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,947.88,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8912129,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,846.65,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8912130,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,947.88,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8912130,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,846.65,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8912140,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,87.57000,25.40000,Aetna,Local,,35.03,,,,,,,31.57,71.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8912140,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,87.57000,25.40000,Aetna,Local,,35.03,,,,,,,28.20,71.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8912143,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,Local,,1376.20,,,,,,,1240.30,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8912143,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,Local,,1376.20,,,,,,,1107.84,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8912142,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,Local,,1376.20,,,,,,,1240.30,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8912142,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,Local,,1376.20,,,,,,,1107.84,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8912141,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,105.00000,30.45000,Aetna,Local,,42.00,,,,,,,37.85,85.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8912141,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,Local,,42.00,,,,,,,33.81,85.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8910540,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,947.88,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8910540,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,846.65,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8910541,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,947.88,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8910541,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2629.36000,762.51000,Aetna,Local,,1051.74,,,,,,,846.65,2150.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8914218,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3601.50000,1044.44000,Aetna,Local,,1440.60,,,,,,,1298.34,2946.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8914218,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,Local,,1440.60,,,,,,,1159.68,2946.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,8916399,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,311.13000,90.23000,Aetna,Local,,124.45,,,,,,,112.16,254.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,8916399,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,311.13000,90.23000,Aetna,Local,,124.45,,,,,,,100.18,254.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,8916400,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,Local,,134.90,,,,,,,121.58,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,8916400,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,Local,,134.90,,,,,,,108.59,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916498,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916498,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916499,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916499,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916500,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916500,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916501,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916501,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916502,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916502,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916503,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916503,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916504,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916504,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916505,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916505,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916506,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916506,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916507,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916507,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916508,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916508,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916509,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ANGIOSCLPT,8916509,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8916497,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8916497,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8916489,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,105.00000,30.45000,Aetna,Local,,42.00,,,,,,,37.85,85.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8916489,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,Local,,42.00,,,,,,,33.81,85.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLAT LASER,8916762,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLAT LASER,8916762,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACCESS VERSACROSS,8924175,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,Local,,1673.00,,,,,,,1507.79,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACCESS VERSACROSS,8924175,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,Local,,1673.00,,,,,,,1346.77,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACCESS VERSACROSS,8924176,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4375.00000,1268.75000,Aetna,Local,,1750.00,,,,,,,1577.19,3578.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACCESS VERSACROSS,8924176,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4375.00000,1268.75000,Aetna,Local,,1750.00,,,,,,,1408.75,3578.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACCESS PROC WATCHMAN,8908287,CDM,278,RC,,,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACCESS PROC WATCHMAN,8908287,CDM,278,RC,,,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PASSER,8926331,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,Local,,1673.00,,,,,,,1507.79,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PASSER,8926331,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,Local,,1673.00,,,,,,,1346.77,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACCESS VERSACROSS,8926332,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,4375.00000,1268.75000,Aetna,Local,,1750.00,,,,,,,1577.19,3578.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACCESS VERSACROSS,8926332,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,4375.00000,1268.75000,Aetna,Local,,1750.00,,,,,,,1408.75,3578.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8924991,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1896.00000,549.84000,Aetna,Local,,758.40,,,,,,,683.51,1550.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8924991,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1896.00000,549.84000,Aetna,Local,,758.40,,,,,,,610.51,1550.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8946405,CDM,278,RC,C1759,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8946405,CDM,278,RC,C1759,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8947176,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8947176,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8916110,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,87.68000,25.43000,Aetna,Local,,35.07,,,,,,,31.61,71.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8916110,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,87.68000,25.43000,Aetna,Local,,35.07,,,,,,,28.23,71.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8416985,CDM,278,RC,,,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1596.11,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8416985,CDM,278,RC,,,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1425.65,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8416854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8416854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8417182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8417182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,Local,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8417194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8417194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8417196,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4547.55000,1318.79000,Aetna,Local,,1819.02,,,,,,,1639.39,3719.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8417196,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4547.55000,1318.79000,Aetna,Local,,1819.02,,,,,,,1464.31,3719.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8417198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8417198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8417179,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,91.88000,26.65000,Aetna,Local,,36.75,,,,,,,33.12,75.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8417179,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,91.88000,26.65000,Aetna,Local,,36.75,,,,,,,29.59,75.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8417200,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,91.88000,26.65000,Aetna,Local,,36.75,,,,,,,33.12,75.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8417200,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,91.88000,26.65000,Aetna,Local,,36.75,,,,,,,29.59,75.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8417201,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8417201,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8417202,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8417202,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8417207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8417295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8417295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8417296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8417296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8417297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,908.10,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8417297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,811.12,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8417335,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,10281.00000,2981.49000,Aetna,Local,,4112.40,,,,,,,3706.30,8409.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8417335,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,10281.00000,2981.49000,Aetna,Local,,4112.40,,,,,,,124.65,8409.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8417346,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8417346,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8417348,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8417348,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8417350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8417350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8417352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8417352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8417344,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8417344,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8417354,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8417354,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8417355,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8417355,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8417356,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8417356,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIMULATOR,8417357,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,59000.00000,17110.00000,Aetna,Local,,23600.00,,,,,,,21269.50,48262.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIMULATOR,8417357,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,59000.00000,17110.00000,Aetna,Local,,23600.00,,,,,,,18998.00,48262.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Anchor Kit,8417448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2741.60,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Anchor Kit,8417448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2448.81,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,8417460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11584.50000,3359.50000,Aetna,Local,,4633.80,,,,,,,4176.21,9476.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,8417460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11584.50000,3359.50000,Aetna,Local,,4633.80,,,,,,,3730.21,9476.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8417450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3605.00000,1045.45000,Aetna,Local,,1442.00,,,,,,,1299.60,2948.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8417450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3605.00000,1045.45000,Aetna,Local,,1442.00,,,,,,,1160.81,2948.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETERAL,8417446,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,530.66,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETERAL,8417446,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,473.98,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETERAL,8417443,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,530.66,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETERAL,8417443,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,473.98,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETERAL,8417442,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,530.66,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETERAL,8417442,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,473.98,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETERAL,8417444,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,530.66,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETERAL,8417444,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,473.98,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8417445,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,530.66,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8417445,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,473.98,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8417572,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8417572,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8417573,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8417573,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA,8417574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA,8417574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8417576,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8417576,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8417577,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8417577,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8417579,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8417579,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8417923,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8417923,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR ROD,8417938,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR ROD,8417938,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR ROD,8417940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR ROD,8417940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SET SCREW,8417942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SET SCREW,8417942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8417944,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8417944,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8417945,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8417945,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8417947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8417947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERTAK KIT,8417977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERTAK KIT,8417977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERTAK,8417978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.00000,578.26000,Aetna,Local,,797.60,,,,,,,718.84,1631.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERTAK,8417978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.00000,578.26000,Aetna,Local,,797.60,,,,,,,642.07,1631.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MINITAPE,8417979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MINITAPE,8417979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MINITAPE,8417980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MINITAPE,8417980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MINITAPE,8417981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MINITAPE,8417981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,8417982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,8417982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8419535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8419535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8419543,CDM,278,RC,C9359,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8419543,CDM,278,RC,C9359,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8419544,CDM,278,RC,C9359,HCPCS,,,facility,inpatient,,,3814.86000,1106.31000,Aetna,Local,,1525.94,,,,,,,1375.26,3120.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8419544,CDM,278,RC,C9359,HCPCS,,,facility,outpatient,,,3814.86000,1106.31000,Aetna,Local,,1525.94,,,,,,,1228.38,3120.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA,8419539,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA,8419539,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8419540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8419540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8419541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9378.00000,2719.62000,Aetna,Local,,3751.20,,,,,,,3380.77,7671.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8419541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9378.00000,2719.62000,Aetna,Local,,3751.20,,,,,,,3019.72,7671.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8419542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7746.00000,2246.34000,Aetna,Local,,3098.40,,,,,,,2792.43,6336.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8419542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7746.00000,2246.34000,Aetna,Local,,3098.40,,,,,,,2494.21,6336.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8423642,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8423642,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8421558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8421558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8419617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8419617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8419616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8419616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8421560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8421560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8421562,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2952.00000,856.08000,Aetna,Local,,1180.80,,,,,,,1064.20,2414.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8421562,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2952.00000,856.08000,Aetna,Local,,1180.80,,,,,,,950.54,2414.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8419615,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8419615,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8419619,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8419619,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8421595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5352.52000,1552.23000,Aetna,Local,,2141.01,,,,,,,1929.58,4378.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8421595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5352.52000,1552.23000,Aetna,Local,,2141.01,,,,,,,1723.51,4378.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8421597,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8421597,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,8423552,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,13680.00000,3967.20000,Aetna,Local,,5472.00,,,,,,,4931.64,11190.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,8423552,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,13680.00000,3967.20000,Aetna,Local,,5472.00,,,,,,,4404.96,11190.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8423553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8423553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8423555,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8423555,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8423557,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12747.00000,3696.63000,Aetna,Local,,5098.80,,,,,,,4595.29,10427.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8423557,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12747.00000,3696.63000,Aetna,Local,,5098.80,,,,,,,4104.53,10427.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8423559,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8423559,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8423561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2323.88000,673.93000,Aetna,Local,,929.55,,,,,,,837.76,1900.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8423561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2323.88000,673.93000,Aetna,Local,,929.55,,,,,,,748.29,1900.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8423562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,966.02000,280.15000,Aetna,Local,,386.41,,,,,,,348.25,790.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8423562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,966.02000,280.15000,Aetna,Local,,386.41,,,,,,,311.06,790.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8423581,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8423581,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8423582,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8423582,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8423583,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,530.66,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8423583,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,473.98,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8423644,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8423644,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8423650,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8423650,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8423646,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8423646,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8423651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8423651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8423652,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8423652,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8423653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8423653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8423654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8046.00000,2333.34000,Aetna,Local,,3218.40,,,,,,,2900.58,6581.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8423654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8046.00000,2333.34000,Aetna,Local,,3218.40,,,,,,,2590.81,6581.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8425590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8425590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8425547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8425547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8425548,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8425548,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8425586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8425586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8425588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8425588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8425652,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,38137.50000,11059.88000,Aetna,Local,,15255.00,,,,,,,13748.57,31196.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8425652,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,38137.50000,11059.88000,Aetna,Local,,15255.00,,,,,,,12280.27,31196.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8425654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3685.50000,1068.79000,Aetna,Local,,1474.20,,,,,,,1328.62,3014.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8425654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3685.50000,1068.79000,Aetna,Local,,1474.20,,,,,,,1186.73,3014.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8425658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3349.50000,971.35000,Aetna,Local,,1339.80,,,,,,,1207.49,2739.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8425658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3349.50000,971.35000,Aetna,Local,,1339.80,,,,,,,1078.54,2739.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8425660,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8425660,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1945.24000,564.12000,Aetna,Local,,778.10,,,,,,,701.26,1591.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1945.24000,564.12000,Aetna,Local,,778.10,,,,,,,626.37,1591.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8425668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2357.68000,683.73000,Aetna,Local,,943.07,,,,,,,849.94,1928.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8425668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2357.68000,683.73000,Aetna,Local,,943.07,,,,,,,759.17,1928.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8425669,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2543.68000,737.67000,Aetna,Local,,1017.47,,,,,,,917.00,2080.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8425669,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2543.68000,737.67000,Aetna,Local,,1017.47,,,,,,,819.06,2080.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8425670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2452.20000,711.14000,Aetna,Local,,980.88,,,,,,,884.02,2005.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8425670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2452.20000,711.14000,Aetna,Local,,980.88,,,,,,,789.61,2005.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,266.29,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,237.85,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,266.29,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,237.85,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,266.29,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8425675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,237.85,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8427454,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8427454,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8427455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8427455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8427456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8427456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8427457,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8427457,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8427458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8427458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427459,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427459,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427460,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427460,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427461,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,6529.56,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427461,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,5832.23,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8427463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2650.40000,768.62000,Aetna,Local,,1060.16,,,,,,,955.47,2168.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8427463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2650.40000,768.62000,Aetna,Local,,1060.16,,,,,,,853.43,2168.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8427464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8427464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8427465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8427465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8427585,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8427585,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8427587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8427587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427589,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,8939.50,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427589,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,7984.80,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427591,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,8939.50,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427591,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,7984.80,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BUR HOLE,8427596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.45000,282.01000,Aetna,Local,,388.98,,,,,,,350.57,795.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BUR HOLE,8427596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.45000,282.01000,Aetna,Local,,388.98,,,,,,,313.13,795.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,8427623,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,11850.00000,3436.50000,Aetna,Local,,4740.00,,,,,,,4271.93,9693.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,8427623,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,11850.00000,3436.50000,Aetna,Local,,4740.00,,,,,,,3815.70,9693.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8427643,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8427643,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427645,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8427645,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8427647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8427647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8427649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,314.23,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8427649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,280.67,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8427651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,314.23,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8427651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,280.67,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8427653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5529.13000,1603.45000,Aetna,Local,,2211.65,,,,,,,1993.25,4522.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8427653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5529.13000,1603.45000,Aetna,Local,,2211.65,,,,,,,1780.38,4522.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8427656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7827.00000,2269.83000,Aetna,Local,,3130.80,,,,,,,2821.63,6402.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8427656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7827.00000,2269.83000,Aetna,Local,,3130.80,,,,,,,2520.29,6402.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8427658,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8427658,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8427660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7827.00000,2269.83000,Aetna,Local,,3130.80,,,,,,,2821.63,6402.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8427660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7827.00000,2269.83000,Aetna,Local,,3130.80,,,,,,,2520.29,6402.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8427661,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8427661,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8427663,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8427663,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8427725,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8427725,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8427727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2968.72,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8427727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2651.67,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8427729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8427729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8427731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8427731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8427733,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8427733,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8427735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8427735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS TISSUE,8427738,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,418.00000,121.22000,Aetna,Local,,167.20,,,,,,,150.69,341.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS TISSUE,8427738,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,418.00000,121.22000,Aetna,Local,,167.20,,,,,,,124.65,341.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8429562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.00000,1246.42000,Aetna,Local,,1719.20,,,,,,,1549.43,3515.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8429562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.00000,1246.42000,Aetna,Local,,1719.20,,,,,,,1383.96,3515.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8429568,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8429568,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,8429641,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7682.52000,2227.93000,Aetna,Local,,3073.01,,,,,,,2769.55,6284.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,8429641,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7682.52000,2227.93000,Aetna,Local,,3073.01,,,,,,,2473.77,6284.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8429643,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9499.14000,2754.75000,Aetna,Local,,3799.66,,,,,,,3424.44,7770.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8429643,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9499.14000,2754.75000,Aetna,Local,,3799.66,,,,,,,3058.72,7770.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8429644,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5034.19000,1459.92000,Aetna,Local,,2013.68,,,,,,,1814.83,4117.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8429644,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5034.19000,1459.92000,Aetna,Local,,2013.68,,,,,,,1621.01,4117.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8429645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8429645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8429646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4059.86000,1177.36000,Aetna,Local,,1623.94,,,,,,,1463.58,3320.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8429646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4059.86000,1177.36000,Aetna,Local,,1623.94,,,,,,,1307.27,3320.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8429697,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8429697,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8429701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15850.00000,4596.50000,Aetna,Local,,6340.00,,,,,,,5713.93,12965.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8429701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15850.00000,4596.50000,Aetna,Local,,6340.00,,,,,,,5103.70,12965.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8429703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,4082.66,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8429703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,3646.65,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8429749,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8429749,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8429803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1748.00000,506.92000,Aetna,Local,,699.20,,,,,,,630.15,1429.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8429803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1748.00000,506.92000,Aetna,Local,,699.20,,,,,,,562.86,1429.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,795.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2208.00000,640.32000,Aetna,Local,,883.20,,,,,,,710.98,1806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8429790,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8429790,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8429805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8429805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8429904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8429904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8429905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8429905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8431778,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8431778,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8431898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8431898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8431900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8431900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8431902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8431902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8431904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8431904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8431906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8431906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8431908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8946.00000,2594.34000,Aetna,Local,,3578.40,,,,,,,3225.03,7317.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8431908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8946.00000,2594.34000,Aetna,Local,,3578.40,,,,,,,2880.61,7317.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8431910,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8431910,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8432018,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8432018,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8432019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8201.94000,2378.56000,Aetna,Local,,3280.78,,,,,,,2956.80,6709.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8432019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8201.94000,2378.56000,Aetna,Local,,3280.78,,,,,,,2641.02,6709.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8432064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8432064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8432065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8432065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8432068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8432068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8433792,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8433792,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433788,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433788,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433790,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433790,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8433784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8433784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8433786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8433786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8433795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4258.10000,1234.85000,Aetna,Local,,1703.24,,,,,,,1535.05,3483.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8433795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4258.10000,1234.85000,Aetna,Local,,1703.24,,,,,,,1371.11,3483.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8433829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8433829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8433863,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8433863,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8433873,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,3212.05,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8433873,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,2869.02,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8433864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8433864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433940,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433940,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433942,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433942,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433944,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433944,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433945,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433945,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433946,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433946,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433947,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433947,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433948,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433948,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433952,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433952,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433954,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433954,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433955,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433955,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433956,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433956,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433957,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8433957,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8433961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8433961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BURR HOLE,8433962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,814.28000,236.14000,Aetna,Local,,325.71,,,,,,,293.55,666.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER BURR HOLE,8433962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,814.28000,236.14000,Aetna,Local,,325.71,,,,,,,262.20,666.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8433963,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8433963,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8433964,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8433964,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8434098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4063.50000,1178.42000,Aetna,Local,,1625.40,,,,,,,1464.89,3323.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8434098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4063.50000,1178.42000,Aetna,Local,,1625.40,,,,,,,1308.45,3323.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8434099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1635.23,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8434099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1460.59,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,206.03,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,184.02,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,206.03,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8434105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,184.02,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8434106,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8434106,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE FILLER,8435729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2424.00000,702.96000,Aetna,Local,,969.60,,,,,,,873.85,1982.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE FILLER,8435729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2424.00000,702.96000,Aetna,Local,,969.60,,,,,,,780.53,1982.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8435761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,3062.33,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8435761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,2735.29,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,565.03,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,504.69,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE FOR SHUNT,8435773,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,15467.35000,4485.53000,Aetna,Local,,6186.94,,,,,,,5575.98,12652.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE FOR SHUNT,8435773,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,15467.35000,4485.53000,Aetna,Local,,6186.94,,,,,,,4980.49,12652.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1400.96000,406.28000,Aetna,Local,,560.38,,,,,,,505.05,1145.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1400.96000,406.28000,Aetna,Local,,560.38,,,,,,,451.11,1145.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1400.96000,406.28000,Aetna,Local,,560.38,,,,,,,505.05,1145.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1400.96000,406.28000,Aetna,Local,,560.38,,,,,,,451.11,1145.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1400.96000,406.28000,Aetna,Local,,560.38,,,,,,,505.05,1145.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1400.96000,406.28000,Aetna,Local,,560.38,,,,,,,451.11,1145.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE FOR SHUNT,8435779,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,15467.35000,4485.53000,Aetna,Local,,6186.94,,,,,,,5575.98,12652.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE FOR SHUNT,8435779,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,15467.35000,4485.53000,Aetna,Local,,6186.94,,,,,,,4980.49,12652.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8435827,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8435827,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8435885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,951.75000,276.01000,Aetna,Local,,380.70,,,,,,,343.11,778.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8435885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,951.75000,276.01000,Aetna,Local,,380.70,,,,,,,306.46,778.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,8435887,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,45012.38000,13053.59000,Aetna,Local,,18004.95,,,,,,,16226.96,36820.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,8435887,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,45012.38000,13053.59000,Aetna,Local,,18004.95,,,,,,,14493.99,36820.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8435892,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8435892,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8435893,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8435893,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRT D,8435923,CDM,278,RC,C1882,HCPCS,,,facility,inpatient,,,48825.00000,14159.25000,Aetna,Local,,19530.00,,,,,,,17601.41,39938.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRT D,8435923,CDM,278,RC,C1882,HCPCS,,,facility,outpatient,,,48825.00000,14159.25000,Aetna,Local,,19530.00,,,,,,,15721.65,39938.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8436066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8436066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8436068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8436068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8436070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4063.50000,1178.42000,Aetna,Local,,1625.40,,,,,,,1464.89,3323.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8436070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4063.50000,1178.42000,Aetna,Local,,1625.40,,,,,,,1308.45,3323.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436071,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,109.95,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436071,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,98.21,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8436151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8436151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8436152,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8436152,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8436244,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3292.31000,954.77000,Aetna,Local,,1316.92,,,,,,,1186.88,2693.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8436244,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3292.31000,954.77000,Aetna,Local,,1316.92,,,,,,,1060.12,2693.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436249,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436249,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436250,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436250,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8436251,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,791.78000,229.62000,Aetna,Local,,316.71,,,,,,,285.44,647.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8436251,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,791.78000,229.62000,Aetna,Local,,316.71,,,,,,,254.95,647.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8436272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8436272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8436291,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8436291,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8436294,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8436294,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8436295,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8436295,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8436273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8436273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8436298,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3292.31000,954.77000,Aetna,Local,,1316.92,,,,,,,1186.88,2693.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8436298,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3292.31000,954.77000,Aetna,Local,,1316.92,,,,,,,1060.12,2693.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8436299,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8436299,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8436499,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8436499,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8436501,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8436501,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8436503,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8436503,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8436505,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8436505,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8436507,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8436507,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8436509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,448.89,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8436509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1245.20000,361.11000,Aetna,Local,,498.08,,,,,,,400.95,1018.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8436529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8436529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8436535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8436535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8436676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8436676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7736161,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,70.03,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7736161,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,62.55,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7702883,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,631.80000,183.22000,Aetna,Local,,252.72,,,,,,,227.76,516.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7702883,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,631.80000,183.22000,Aetna,Local,,252.72,,,,,,,203.44,516.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8453927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8453927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8453928,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8453928,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8453929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8453929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453974,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453974,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8453976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8453976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8453978,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8453978,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8453980,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,7273.09,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8453980,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,6496.35,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8453982,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8453982,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8453985,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1364.96000,395.84000,Aetna,Local,,545.98,,,,,,,492.07,1116.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8453985,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1364.96000,395.84000,Aetna,Local,,545.98,,,,,,,439.52,1116.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,8453984,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,465.93000,135.12000,Aetna,Local,,186.37,,,,,,,167.97,381.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,8453984,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,465.93000,135.12000,Aetna,Local,,186.37,,,,,,,150.03,381.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8454062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8454062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8454064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8454064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8454067,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4641.00000,1345.89000,Aetna,Local,,1856.40,,,,,,,1673.08,3796.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8454067,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4641.00000,1345.89000,Aetna,Local,,1856.40,,,,,,,1494.40,3796.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8454069,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8454069,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8454072,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8454072,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8454070,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8121.00000,2355.09000,Aetna,Local,,3248.40,,,,,,,2927.62,6642.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8454070,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8121.00000,2355.09000,Aetna,Local,,3248.40,,,,,,,2614.96,6642.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8454074,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,30879.00000,8954.91000,Aetna,Local,,12351.60,,,,,,,11131.88,25259.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8454074,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,30879.00000,8954.91000,Aetna,Local,,12351.60,,,,,,,9943.04,25259.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8455806,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8455806,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8455794,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8455794,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8455796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.70000,1465.86000,Aetna,Local,,2021.88,,,,,,,1822.22,4134.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8455796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.70000,1465.86000,Aetna,Local,,2021.88,,,,,,,1627.61,4134.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8455798,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1721.60000,499.26000,Aetna,Local,,688.64,,,,,,,620.64,1408.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8455798,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1721.60000,499.26000,Aetna,Local,,688.64,,,,,,,554.36,1408.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8455800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.00000,1246.42000,Aetna,Local,,1719.20,,,,,,,1549.43,3515.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8455800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.00000,1246.42000,Aetna,Local,,1719.20,,,,,,,1383.96,3515.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8455802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8455802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8455804,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8455804,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8455928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8455928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8455883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8455883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8455884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8455884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8455920,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8455920,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8455922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9950.01000,2885.50000,Aetna,Local,,3980.00,,,,,,,3586.98,8139.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8455922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9950.01000,2885.50000,Aetna,Local,,3980.00,,,,,,,3203.90,8139.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8455924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9950.01000,2885.50000,Aetna,Local,,3980.00,,,,,,,3586.98,8139.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8455924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9950.01000,2885.50000,Aetna,Local,,3980.00,,,,,,,3203.90,8139.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8455926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24194.40000,7016.38000,Aetna,Local,,9677.76,,,,,,,8722.08,19791.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8455926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24194.40000,7016.38000,Aetna,Local,,9677.76,,,,,,,7790.60,19791.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8455863,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,322.88,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8455863,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,288.40,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8455864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8455864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8455865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8455865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ACETABULAR,8457766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,37485.00000,10870.65000,Aetna,Local,,14994.00,,,,,,,13513.34,30662.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ACETABULAR,8457766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,37485.00000,10870.65000,Aetna,Local,,14994.00,,,,,,,12070.17,30662.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8455932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8455932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8455934,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8455934,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8455945,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8455945,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8456029,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8456029,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8456031,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8061.39000,2337.80000,Aetna,Local,,3224.56,,,,,,,2906.13,6594.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8456031,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8061.39000,2337.80000,Aetna,Local,,3224.56,,,,,,,2595.77,6594.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8456033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,258.04,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8456033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,230.48,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8456035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,258.04,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8456035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,Local,,286.31,,,,,,,230.48,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8456037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,6529.56,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8456037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,5832.23,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8456041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8456041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8456062,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8456062,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8456063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8456063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8456064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8456064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8456065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8456065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,Local,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8456025,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8456025,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8456026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1392.66,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8456026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1243.93,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8456027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8456027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8456028,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8456028,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8457767,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14803.14000,4292.91000,Aetna,Local,,5921.26,,,,,,,5336.53,12108.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8457767,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14803.14000,4292.91000,Aetna,Local,,5921.26,,,,,,,4766.61,12108.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8457768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,475.87,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8457768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,425.05,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8457769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,475.87,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8457769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,425.05,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8457770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,3062.33,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8457770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,2735.29,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8457771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8457771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8457772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8457772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8457773,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8457773,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8457774,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8457774,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8457775,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8457775,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8457776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8457776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8457777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8457777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8458265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,860.87,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8458265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,768.94,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8458267,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8458267,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8458269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8458269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8458273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8458273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8458275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8458275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,8459825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1622.36,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,8459825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1449.10,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8459827,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8459827,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8459829,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8459829,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,8459831,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,8459831,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8459833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8459833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8459835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8459835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8459837,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8459837,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8459839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8459839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8459842,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,3098.50,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8459842,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,2767.59,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEMODIALYSIS CATHETER,8459816,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,694.40000,201.38000,Aetna,Local,,277.76,,,,,,,250.33,568.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEMODIALYSIS CATHETER,8459816,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,694.40000,201.38000,Aetna,Local,,277.76,,,,,,,223.60,568.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8459901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8459901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8461752,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8461752,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8461754,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8461754,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE GLENOID,8461756,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.40000,1439.68000,Aetna,Local,,1985.76,,,,,,,1789.67,4060.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE GLENOID,8461756,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.40000,1439.68000,Aetna,Local,,1985.76,,,,,,,1598.54,4060.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8461758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8461758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENIOD SPHERE,8461760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENIOD SPHERE,8461760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8461762,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8461762,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8461828,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8461828,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT SHOULDER,8461835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,1075.11,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT SHOULDER,8461835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,960.29,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8461837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8461837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8461839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8461839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7802466,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7802466,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7697028,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,594.90000,172.52000,Aetna,Local,,237.96,,,,,,,214.46,486.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7697028,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,594.90000,172.52000,Aetna,Local,,237.96,,,,,,,191.56,486.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7707514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,7707514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7893937,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,457.43000,132.65000,Aetna,Local,,182.97,,,,,,,164.90,374.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7893937,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,457.43000,132.65000,Aetna,Local,,182.97,,,,,,,147.29,374.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7989577,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,191.63000,55.57000,Aetna,Local,,76.65,,,,,,,69.08,156.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7989577,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,191.63000,55.57000,Aetna,Local,,76.65,,,,,,,61.70,156.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7697154,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,142.01000,41.18000,Aetna,Local,,56.80,,,,,,,51.19,116.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7697154,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,142.01000,41.18000,Aetna,Local,,56.80,,,,,,,45.73,116.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7698331,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,230.21000,66.76000,Aetna,Local,,92.08,,,,,,,82.99,188.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7698331,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,230.21000,66.76000,Aetna,Local,,92.08,,,,,,,74.13,188.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7836032,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,202.65000,58.77000,Aetna,Local,,81.06,,,,,,,73.06,165.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,7836032,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,202.65000,58.77000,Aetna,Local,,81.06,,,,,,,65.25,165.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8132018,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8132018,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8436730,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8436730,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8436731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8436731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8436732,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8436732,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8436733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8436733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8436734,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8436734,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8436740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3592.75000,1041.90000,Aetna,Local,,1437.10,,,,,,,1295.19,2938.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8436740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3592.75000,1041.90000,Aetna,Local,,1437.10,,,,,,,1156.87,2938.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8436748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8544.84000,2478.00000,Aetna,Local,,3417.94,,,,,,,3080.41,6989.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8436748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8544.84000,2478.00000,Aetna,Local,,3417.94,,,,,,,2751.44,6989.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8436937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8437310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8437310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL BASE,8437311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL BASE,8437311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABLUAR CUP,8437313,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8283.00000,2402.07000,Aetna,Local,,3313.20,,,,,,,2986.02,6775.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABLUAR CUP,8437313,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8283.00000,2402.07000,Aetna,Local,,3313.20,,,,,,,2667.13,6775.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR LINER,8437312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR LINER,8437312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nail,8437021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nail,8437021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tibial Plate,8437022,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tibial Plate,8437022,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8437024,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8437024,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8437302,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8437302,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBAIL INSERT,8437303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBAIL INSERT,8437303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8437304,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1876.22,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8437304,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1675.85,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8437305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8437305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8437306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.25000,2383.58000,Aetna,Local,,3287.70,,,,,,,2963.04,6723.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8437306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.25000,2383.58000,Aetna,Local,,3287.70,,,,,,,2646.60,6723.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8437736,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8437736,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8437941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3461.50000,1003.83000,Aetna,Local,,1384.60,,,,,,,1247.87,2831.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8437941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3461.50000,1003.83000,Aetna,Local,,1384.60,,,,,,,1114.60,2831.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8437943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11684.25000,3388.43000,Aetna,Local,,4673.70,,,,,,,4212.17,9557.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8437943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11684.25000,3388.43000,Aetna,Local,,4673.70,,,,,,,3762.33,9557.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8437942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8437942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8437940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8437940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8437944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8437944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8437945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8437945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,Local,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8437992,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8437992,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8437994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,355.06000,102.97000,Aetna,Local,,142.02,,,,,,,128.00,290.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8437994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,355.06000,102.97000,Aetna,Local,,142.02,,,,,,,114.33,290.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8437995,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8437995,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8437996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8437996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT CLUSTERHOLE,8437998,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT CLUSTERHOLE,8437998,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8438116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8438116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,355.06000,102.97000,Aetna,Local,,142.02,,,,,,,128.00,290.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,355.06000,102.97000,Aetna,Local,,142.02,,,,,,,114.33,290.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8438039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,1085.65,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8438039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,969.71,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8438263,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,16524.24,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8438263,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,Local,,18334.80,,,,,,,14759.51,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8438264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4609.35,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8438264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4117.09,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8438265,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,47556.00000,13791.24000,Aetna,Local,,19022.40,,,,,,,17143.94,38900.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8438265,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,47556.00000,13791.24000,Aetna,Local,,19022.40,,,,,,,15313.03,38900.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,8438269,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,38137.50000,11059.88000,Aetna,Local,,15255.00,,,,,,,13748.57,31196.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,8438269,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,38137.50000,11059.88000,Aetna,Local,,15255.00,,,,,,,12280.27,31196.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINE,8438270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINE,8438270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8438266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1562.00000,452.98000,Aetna,Local,,624.80,,,,,,,563.10,1277.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8438266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1562.00000,452.98000,Aetna,Local,,624.80,,,,,,,502.96,1277.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATOR,8438322,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,385.23000,111.72000,Aetna,Local,,154.09,,,,,,,138.88,315.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATOR,8438322,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,385.23000,111.72000,Aetna,Local,,154.09,,,,,,,124.04,315.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8438315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8438315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8438323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8438323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8438360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,19542.50000,5667.32000,Aetna,Local,,7817.00,,,,,,,7045.07,15985.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8438360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,19542.50000,5667.32000,Aetna,Local,,7817.00,,,,,,,6292.69,15985.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINE,8438361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3258.50000,944.96000,Aetna,Local,,1303.40,,,,,,,1174.69,2665.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINE,8438361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3258.50000,944.96000,Aetna,Local,,1303.40,,,,,,,1049.24,2665.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3258.50000,944.96000,Aetna,Local,,1303.40,,,,,,,1174.69,2665.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3258.50000,944.96000,Aetna,Local,,1303.40,,,,,,,1049.24,2665.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8438316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8438316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8438317,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8438317,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8438318,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8438318,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8438319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8438319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8438438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4063.50000,1178.42000,Aetna,Local,,1625.40,,,,,,,1464.89,3323.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8438438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4063.50000,1178.42000,Aetna,Local,,1625.40,,,,,,,1308.45,3323.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,206.03,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,184.02,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8438467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30026.25000,8707.61000,Aetna,Local,,12010.50,,,,,,,10824.46,24561.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8438467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30026.25000,8707.61000,Aetna,Local,,12010.50,,,,,,,9668.45,24561.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8438468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8438468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8438469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8438469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8438622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8438622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8438623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4004.00000,1161.16000,Aetna,Local,,1601.60,,,,,,,1443.44,3275.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8438623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4004.00000,1161.16000,Aetna,Local,,1601.60,,,,,,,1289.29,3275.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8438621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8438621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8438624,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8438624,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTOR,8438625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTOR,8438625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8439729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,37485.00000,10870.65000,Aetna,Local,,14994.00,,,,,,,13513.34,30662.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8439729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,37485.00000,10870.65000,Aetna,Local,,14994.00,,,,,,,12070.17,30662.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,109.95,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8438618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,98.21,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8439730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8439730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8439860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8439860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8439859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7827.00000,2269.83000,Aetna,Local,,3130.80,,,,,,,2821.63,6402.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8439859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7827.00000,2269.83000,Aetna,Local,,3130.80,,,,,,,2520.29,6402.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8439963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8439963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8439964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8439964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT SYSTEM,8439971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT SYSTEM,8439971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8439972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8439972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8439973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8439973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,8439974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,624.39,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,8439974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,557.70,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8439975,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1512.00000,438.48000,Aetna,Local,,604.80,,,,,,,545.08,1236.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8439975,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1512.00000,438.48000,Aetna,Local,,604.80,,,,,,,486.86,1236.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CORE,8440207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CORE,8440207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8440208,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8440208,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8440065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8440065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8440320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8440320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8440321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,892.60,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8440321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,797.27,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8440466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8440466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8440427,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8440427,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Screw,8440428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,330.96,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Screw,8440428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,295.61,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,330.96,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,295.61,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8440465,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8440465,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8440468,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8440468,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8440469,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8440469,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8440425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8440502,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8440502,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8440503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8440503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8441730,CDM,278,RC,Q4130,HCPCS,,,facility,inpatient,,,35955.00000,10426.95000,Aetna,Local,,14382.00,,,,,,,12961.78,29411.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8441730,CDM,278,RC,Q4130,HCPCS,,,facility,outpatient,,,35955.00000,10426.95000,Aetna,Local,,14382.00,,,,,,,124.65,29411.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8441731,CDM,278,RC,Q4130,HCPCS,,,facility,inpatient,,,43229.25000,12536.48000,Aetna,Local,,17291.70,,,,,,,15584.14,35361.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8441731,CDM,278,RC,Q4130,HCPCS,,,facility,outpatient,,,43229.25000,12536.48000,Aetna,Local,,17291.70,,,,,,,124.65,35361.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8441782,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8441782,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8441808,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8441808,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8441819,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8441819,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8441821,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8441821,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8441823,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8441823,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8441824,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1291.62,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8441824,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1153.68,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8441826,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8441826,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8441828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.79000,278.92000,Aetna,Local,,384.72,,,,,,,346.73,786.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8441828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.79000,278.92000,Aetna,Local,,384.72,,,,,,,309.70,786.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8441830,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2193.52000,636.12000,Aetna,Local,,877.41,,,,,,,790.76,1794.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8441830,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2193.52000,636.12000,Aetna,Local,,877.41,,,,,,,706.31,1794.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8441926,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10236.00000,2968.44000,Aetna,Local,,4094.40,,,,,,,3690.08,8373.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8441926,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10236.00000,2968.44000,Aetna,Local,,4094.40,,,,,,,3295.99,8373.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8441977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.81000,182.93000,Aetna,Local,,252.32,,,,,,,227.41,516.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8441977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.81000,182.93000,Aetna,Local,,252.32,,,,,,,203.12,516.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8441979,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8441979,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8441889,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8441889,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8441890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8441890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8441922,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8441922,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8441923,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8441923,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8441924,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8441924,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8441925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8441925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8441983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8441983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8441984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8441984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8442051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8442051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8442053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,Local,,255.60,,,,,,,230.36,522.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8442053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,255.60,,,,,,,205.76,522.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR CLOSURE DEVICE,8441981,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR CLOSURE DEVICE,8441981,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR CLOSURE DEVICE,8441982,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR CLOSURE DEVICE,8441982,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,Local,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8442073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8442073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8442133,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,1230.00000,356.70000,Aetna,Local,,492.00,,,,,,,443.42,1006.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8442133,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,1230.00000,356.70000,Aetna,Local,,492.00,,,,,,,396.06,1006.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,964.29,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,861.31,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,964.29,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,861.31,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,964.29,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,861.31,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8442192,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8442192,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,261.39,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,233.48,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8442198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8442198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2675.20000,775.81000,Aetna,Local,,1070.08,,,,,,,964.41,2188.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2675.20000,775.81000,Aetna,Local,,1070.08,,,,,,,861.41,2188.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8442206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8442206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8442208,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8442208,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8442210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8442210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8442211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8442211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8442353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14803.14000,4292.91000,Aetna,Local,,5921.26,,,,,,,5336.53,12108.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8442353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14803.14000,4292.91000,Aetna,Local,,5921.26,,,,,,,4766.61,12108.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8442390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8442390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8442391,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8442391,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8442392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8442392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8442394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5793.90000,1680.23000,Aetna,Local,,2317.56,,,,,,,2088.70,4739.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8442394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5793.90000,1680.23000,Aetna,Local,,2317.56,,,,,,,1865.64,4739.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8442397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8442398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8442398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8442489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5864.57000,1700.73000,Aetna,Local,,2345.83,,,,,,,2114.18,4797.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8442489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5864.57000,1700.73000,Aetna,Local,,2345.83,,,,,,,1888.39,4797.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442495,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8442495,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8442491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8442491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8443806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8443806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8443807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8443807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8443808,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8443808,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8443809,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8443809,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8443810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8931.00000,2589.99000,Aetna,Local,,3572.40,,,,,,,3219.63,7305.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8443810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8931.00000,2589.99000,Aetna,Local,,3572.40,,,,,,,2875.78,7305.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8443812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8443812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8443877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8443877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8443869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8443869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8443871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8443871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8443872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8443872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8443874,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8443874,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8443875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8443875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8443876,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8443876,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8443943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,839.97,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8443943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,750.26,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8443945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8443945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8443948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8443948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8443873,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8443873,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8443947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,395.96000,114.83000,Aetna,Local,,158.38,,,,,,,142.74,323.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8443947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,395.96000,114.83000,Aetna,Local,,158.38,,,,,,,127.50,323.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION SPINAL,8443870,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7980.00000,2314.20000,Aetna,Local,,3192.00,,,,,,,2876.79,6527.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION SPINAL,8443870,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7980.00000,2314.20000,Aetna,Local,,3192.00,,,,,,,2569.56,6527.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8443975,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,530.66,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8443975,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,473.98,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8443976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8443976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8443978,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8443978,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8443980,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8443980,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8444014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14803.14000,4292.91000,Aetna,Local,,5921.26,,,,,,,5336.53,12108.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8444014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14803.14000,4292.91000,Aetna,Local,,5921.26,,,,,,,4766.61,12108.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8445740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8445740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8445743,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8445743,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STIMULATOR NEURO,8445744,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,42836.63000,12422.62000,Aetna,Local,,17134.65,,,,,,,15442.61,35040.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STIMULATOR NEURO,8445744,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,42836.63000,12422.62000,Aetna,Local,,17134.65,,,,,,,13793.39,35040.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8445746,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8445746,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8445742,CDM,278,RC,Q4137,HCPCS,,,facility,inpatient,,,5436.38000,1576.55000,Aetna,Local,,2174.55,,,,,,,1959.81,4446.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8445742,CDM,278,RC,Q4137,HCPCS,,,facility,outpatient,,,5436.38000,1576.55000,Aetna,Local,,2174.55,,,,,,,124.65,4446.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8445747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8445747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8445748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8445748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8445749,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,746.91000,216.60000,Aetna,Local,,298.76,,,,,,,269.26,610.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8445749,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,746.91000,216.60000,Aetna,Local,,298.76,,,,,,,240.51,610.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIM PROGRAMMER,8445984,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,3594.15000,1042.30000,Aetna,Local,,1437.66,,,,,,,1295.69,2940.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIM PROGRAMMER,8445984,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,3594.15000,1042.30000,Aetna,Local,,1437.66,,,,,,,1157.32,2940.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8446058,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8446058,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8446060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2900.00000,841.00000,Aetna,Local,,1160.00,,,,,,,1045.45,2372.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8446060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2900.00000,841.00000,Aetna,Local,,1160.00,,,,,,,933.80,2372.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8446062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8446062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8446063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8446063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7698132,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,2415.04000,700.36000,Aetna,Local,,966.02,,,,,,,870.62,1975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7698132,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,2415.04000,700.36000,Aetna,Local,,966.02,,,,,,,777.64,1975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8446138,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8446138,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8446148,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,421.94000,122.36000,Aetna,Local,,168.78,,,,,,,152.11,345.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8446148,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,421.94000,122.36000,Aetna,Local,,168.78,,,,,,,135.86,345.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8446153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8446195,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,607.77000,176.25000,Aetna,Local,,243.11,,,,,,,219.10,497.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8446195,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,607.77000,176.25000,Aetna,Local,,243.11,,,,,,,195.70,497.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8446218,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8446218,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT URETERAL,8446221,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT URETERAL,8446221,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT URETERAL,8446222,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT URETERAL,8446222,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT URETERAL,8446223,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT URETERAL,8446223,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT URETERAL,8446224,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT URETERAL,8446224,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8446283,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8446283,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8446285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8283.00000,2402.07000,Aetna,Local,,3313.20,,,,,,,2986.02,6775.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8446285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8283.00000,2402.07000,Aetna,Local,,3313.20,,,,,,,2667.13,6775.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8447739,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8447739,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH TISSUE,8447753,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,11055.00000,3205.95000,Aetna,Local,,4422.00,,,,,,,3985.33,9042.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH TISSUE,8447753,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,11055.00000,3205.95000,Aetna,Local,,4422.00,,,,,,,3559.71,9042.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8447759,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8447759,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8447760,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8447760,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8447761,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8447761,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT IN KIT INTRACRANIAL PRESSURE MONITOR,8447807,CDM,278,RC,A9279,HCPCS,,,facility,inpatient,,,3632.34000,1053.38000,Aetna,Local,,1452.94,,,,,,,1309.46,2971.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT IN KIT INTRACRANIAL PRESSURE MONITOR,8447807,CDM,278,RC,A9279,HCPCS,,,facility,outpatient,,,3632.34000,1053.38000,Aetna,Local,,1452.94,,,,,,,1169.61,2971.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8447895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2550.44000,739.63000,Aetna,Local,,1020.18,,,,,,,919.43,2086.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8447895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2550.44000,739.63000,Aetna,Local,,1020.18,,,,,,,821.24,2086.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8447911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8447911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8447912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8447912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8447930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8447930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8447931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8447931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8448026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8448026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8448027,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8448027,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8448028,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8448028,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8448029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8448029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8449767,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8449767,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8449768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8449768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8449808,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8449808,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8449842,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8449842,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8449844,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8449844,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8449809,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8449809,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8449846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3441.87000,998.14000,Aetna,Local,,1376.75,,,,,,,1240.79,2815.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8449846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3441.87000,998.14000,Aetna,Local,,1376.75,,,,,,,1108.28,2815.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8449850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2544.00000,737.76000,Aetna,Local,,1017.60,,,,,,,917.11,2080.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8449850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2544.00000,737.76000,Aetna,Local,,1017.60,,,,,,,819.17,2080.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8449851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8449851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8449888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8449888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8449889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8449889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE FEMORAL,8449922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1909.56000,553.77000,Aetna,Local,,763.82,,,,,,,688.40,1562.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE FEMORAL,8449922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1909.56000,553.77000,Aetna,Local,,763.82,,,,,,,614.88,1562.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8449924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,2211.03,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8449924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,Local,,2453.29,,,,,,,1974.90,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8449891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8449891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8449929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8449929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8449931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8449931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8449953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8449953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8449954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8449954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8449987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8449987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8449988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8449988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8449989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8449989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8449990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6188.91000,1794.78000,Aetna,Local,,2475.56,,,,,,,2231.10,5062.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8449990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6188.91000,1794.78000,Aetna,Local,,2475.56,,,,,,,1992.83,5062.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT CATHETER INTRODUCER,8451765,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,183.75000,53.29000,Aetna,Local,,73.50,,,,,,,66.24,150.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT CATHETER INTRODUCER,8451765,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,183.75000,53.29000,Aetna,Local,,73.50,,,,,,,59.17,150.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8451766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10383.00000,3011.07000,Aetna,Local,,4153.20,,,,,,,3743.07,8493.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8451766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10383.00000,3011.07000,Aetna,Local,,4153.20,,,,,,,3343.33,8493.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1400.96000,406.28000,Aetna,Local,,560.38,,,,,,,505.05,1145.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1400.96000,406.28000,Aetna,Local,,560.38,,,,,,,451.11,1145.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1400.96000,406.28000,Aetna,Local,,560.38,,,,,,,505.05,1145.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1400.96000,406.28000,Aetna,Local,,560.38,,,,,,,451.11,1145.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8451783,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8451783,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8451823,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8451823,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT FECAL MANAGEMENT,8451780,CDM,278,RC,A4330,HCPCS,,,facility,inpatient,,,673.71000,195.38000,Aetna,Local,,269.48,,,,,,,242.87,551.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT FECAL MANAGEMENT,8451780,CDM,278,RC,A4330,HCPCS,,,facility,outpatient,,,673.71000,195.38000,Aetna,Local,,269.48,,,,,,,10.21,551.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,241.72,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,215.90,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,241.72,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.50000,194.44000,Aetna,Local,,268.20,,,,,,,215.90,548.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8451852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,18750.00000,5437.50000,Aetna,Local,,7500.00,,,,,,,6759.38,15337.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8451852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,18750.00000,5437.50000,Aetna,Local,,7500.00,,,,,,,6037.50,15337.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FOSSA,8451854,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16447.50000,4769.77000,Aetna,Local,,6579.00,,,,,,,5929.32,13454.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FOSSA,8451854,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16447.50000,4769.77000,Aetna,Local,,6579.00,,,,,,,5296.10,13454.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,616.50000,178.78000,Aetna,Local,,246.60,,,,,,,222.25,504.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,616.50000,178.78000,Aetna,Local,,246.60,,,,,,,198.51,504.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,616.50000,178.78000,Aetna,Local,,246.60,,,,,,,222.25,504.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8451860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,616.50000,178.78000,Aetna,Local,,246.60,,,,,,,198.51,504.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8451865,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1356.36000,393.34000,Aetna,Local,,542.54,,,,,,,488.97,1109.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8451865,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1356.36000,393.34000,Aetna,Local,,542.54,,,,,,,436.75,1109.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8451933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8451933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8451953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8451953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,7698926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,7698926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8451955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3465.42000,1004.97000,Aetna,Local,,1386.17,,,,,,,1249.28,2834.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8451955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3465.42000,1004.97000,Aetna,Local,,1386.17,,,,,,,1115.87,2834.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8451957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2057.00000,596.53000,Aetna,Local,,822.80,,,,,,,741.55,1682.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8451957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2057.00000,596.53000,Aetna,Local,,822.80,,,,,,,662.35,1682.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8451959,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8451959,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8451961,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8451961,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8452047,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8452047,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8452008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8452008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8453761,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8453761,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL SPOOL,8453837,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10503.00000,3045.87000,Aetna,Local,,4201.20,,,,,,,3786.33,8591.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL SPOOL,8453837,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10503.00000,3045.87000,Aetna,Local,,4201.20,,,,,,,3381.97,8591.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8453839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,6038.38,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8453839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,5393.50,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453841,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453841,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453843,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453843,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8453845,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8453845,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453908,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8453908,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8362931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8362931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8362933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8362933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2497.96000,724.41000,Aetna,Local,,999.18,,,,,,,900.51,2043.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2497.96000,724.41000,Aetna,Local,,999.18,,,,,,,804.34,2043.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8362947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9088.80000,2635.75000,Aetna,Local,,3635.52,,,,,,,3276.51,7434.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8362952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9088.80000,2635.75000,Aetna,Local,,3635.52,,,,,,,2926.59,7434.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8364265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8364265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8364266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8364266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8364267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8364267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8364268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8364268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8364269,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8364269,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8364338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8364338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER,8366269,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER,8366269,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8366308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8366308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8366309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8366309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,Local,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8366342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8366342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8366343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1779.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8366343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1589.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1640.28,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1465.10,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366345,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366345,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8366346,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8366346,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366397,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366397,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366923,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366923,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9885.00000,2866.65000,Aetna,Local,,3954.00,,,,,,,3563.54,8085.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9885.00000,2866.65000,Aetna,Local,,3954.00,,,,,,,3182.97,8085.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8366402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3475.94,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8366402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3104.72,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD BLADE,8366470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2949.80000,855.44000,Aetna,Local,,1179.92,,,,,,,1063.40,2412.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD BLADE,8366470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2949.80000,855.44000,Aetna,Local,,1179.92,,,,,,,949.84,2412.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366486,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366486,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1492.00000,432.68000,Aetna,Local,,596.80,,,,,,,537.87,1220.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8366488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1492.00000,432.68000,Aetna,Local,,596.80,,,,,,,480.42,1220.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8366491,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8366491,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8366492,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8366492,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8366676,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8366676,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366678,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3028.00000,878.12000,Aetna,Local,,1211.20,,,,,,,1091.59,2476.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366678,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3028.00000,878.12000,Aetna,Local,,1211.20,,,,,,,975.02,2476.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBULAR SHAFT,8366684,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4183.69000,1213.27000,Aetna,Local,,1673.48,,,,,,,1508.22,3422.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBULAR SHAFT,8366684,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4183.69000,1213.27000,Aetna,Local,,1673.48,,,,,,,1347.15,3422.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8366901,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8366901,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366903,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8366903,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8366905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8366905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8366907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8366907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366911,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366911,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,8366966,CDM,278,RC,C2622,HCPCS,,,facility,inpatient,,,34278.75000,9940.84000,Aetna,Local,,13711.50,,,,,,,12357.49,28040.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,8366966,CDM,278,RC,C2622,HCPCS,,,facility,outpatient,,,34278.75000,9940.84000,Aetna,Local,,13711.50,,,,,,,11037.76,28040.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,8366967,CDM,278,RC,C2622,HCPCS,,,facility,inpatient,,,37136.25000,10769.51000,Aetna,Local,,14854.50,,,,,,,13387.62,30377.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,8366967,CDM,278,RC,C2622,HCPCS,,,facility,outpatient,,,37136.25000,10769.51000,Aetna,Local,,14854.50,,,,,,,11957.87,30377.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,8366968,CDM,278,RC,C2622,HCPCS,,,facility,inpatient,,,37136.25000,10769.51000,Aetna,Local,,14854.50,,,,,,,13387.62,30377.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,8366968,CDM,278,RC,C2622,HCPCS,,,facility,outpatient,,,37136.25000,10769.51000,Aetna,Local,,14854.50,,,,,,,11957.87,30377.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8367050,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,413.25000,119.84000,Aetna,Local,,165.30,,,,,,,148.98,338.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8367050,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,413.25000,119.84000,Aetna,Local,,165.30,,,,,,,133.07,338.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8367051,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,451.25000,130.86000,Aetna,Local,,180.50,,,,,,,162.68,369.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8367051,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,451.25000,130.86000,Aetna,Local,,180.50,,,,,,,145.30,369.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8367057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8367057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5323.50000,1543.81000,Aetna,Local,,2129.40,,,,,,,1919.12,4354.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5323.50000,1543.81000,Aetna,Local,,2129.40,,,,,,,1714.17,4354.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7966.80000,2310.37000,Aetna,Local,,3186.72,,,,,,,2872.03,6516.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7966.80000,2310.37000,Aetna,Local,,3186.72,,,,,,,2565.31,6516.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8367174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1855.02,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8367174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1656.92,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8367175,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,3000.08,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8367175,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,2679.68,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8367176,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,3000.08,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8367176,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8322.00000,2413.38000,Aetna,Local,,3328.80,,,,,,,2679.68,6807.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8367177,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,7669.64,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8367177,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,6850.55,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8367178,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8367178,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8367179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8367179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8367230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8367230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8367739,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8367739,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8367682,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1924.00000,557.96000,Aetna,Local,,769.60,,,,,,,693.60,1573.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8367682,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1924.00000,557.96000,Aetna,Local,,769.60,,,,,,,619.53,1573.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8367684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8367684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8367686,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8367686,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8367687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,Local,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5727.26000,1660.91000,Aetna,Local,,2290.90,,,,,,,2064.68,4684.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5727.26000,1660.91000,Aetna,Local,,2290.90,,,,,,,1844.18,4684.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8367696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8367696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367756,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5768.00000,1672.72000,Aetna,Local,,2307.20,,,,,,,2079.36,4718.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367756,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5768.00000,1672.72000,Aetna,Local,,2307.20,,,,,,,1857.30,4718.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5768.00000,1672.72000,Aetna,Local,,2307.20,,,,,,,2079.36,4718.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8367757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5768.00000,1672.72000,Aetna,Local,,2307.20,,,,,,,1857.30,4718.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8367758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1779.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8367758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1589.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8368294,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8368294,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8368301,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8368301,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8368308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2357.68000,683.73000,Aetna,Local,,943.07,,,,,,,849.94,1928.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8368308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2357.68000,683.73000,Aetna,Local,,943.07,,,,,,,759.17,1928.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8368309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2357.68000,683.73000,Aetna,Local,,943.07,,,,,,,849.94,1928.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8368309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2357.68000,683.73000,Aetna,Local,,943.07,,,,,,,759.17,1928.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8368314,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8368314,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8453911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5007.10000,1452.06000,Aetna,Local,,2002.84,,,,,,,1805.06,4095.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8453911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5007.10000,1452.06000,Aetna,Local,,2002.84,,,,,,,1612.29,4095.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8368316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8862.00000,2569.98000,Aetna,Local,,3544.80,,,,,,,3194.75,7249.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8368316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8862.00000,2569.98000,Aetna,Local,,3544.80,,,,,,,2853.56,7249.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8368319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8368319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8368329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8368329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8368330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8368330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8368327,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14550.00000,4219.50000,Aetna,Local,,5820.00,,,,,,,5245.27,11901.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8368327,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14550.00000,4219.50000,Aetna,Local,,5820.00,,,,,,,4685.10,11901.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEEP BRAIN STIMULATOR,8368328,CDM,278,RC,L8679,HCPCS,,,facility,inpatient,,,50768.40000,14722.84000,Aetna,Local,,20307.36,,,,,,,18302.01,41528.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEEP BRAIN STIMULATOR,8368328,CDM,278,RC,L8679,HCPCS,,,facility,outpatient,,,50768.40000,14722.84000,Aetna,Local,,20307.36,,,,,,,10323.94,41528.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8368557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2912.64000,844.67000,Aetna,Local,,1165.06,,,,,,,1050.01,2382.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8368557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2912.64000,844.67000,Aetna,Local,,1165.06,,,,,,,937.87,2382.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8368561,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8368561,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8368563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8368565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8368565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8370177,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8370177,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON CLAVICLE,8370183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON CLAVICLE,8370183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER DEEP BRAIN STIM,8370325,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,2173.83,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER DEEP BRAIN STIM,8370325,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,1941.68,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8370186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2936.27,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8370186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2622.69,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8370196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8370196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8370188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8370188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENIOD,8370190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENIOD,8370190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8370192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8370192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8370198,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8370198,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8370199,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8370199,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8370203,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8370203,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8370276,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8370276,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8370278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,574.20000,166.52000,Aetna,Local,,229.68,,,,,,,207.00,469.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8370278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,574.20000,166.52000,Aetna,Local,,229.68,,,,,,,184.89,469.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8370280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,118.15,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8370280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,105.54,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8370284,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8370284,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8370319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1508.12000,437.35000,Aetna,Local,,603.25,,,,,,,543.68,1233.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8370319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1508.12000,437.35000,Aetna,Local,,603.25,,,,,,,485.61,1233.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8370365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5710.95000,1656.18000,Aetna,Local,,2284.38,,,,,,,2058.80,4671.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8370365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5710.95000,1656.18000,Aetna,Local,,2284.38,,,,,,,1838.93,4671.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8370390,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8370390,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,Local,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8370392,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8370392,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASE BOLT,8370519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASE BOLT,8370519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8370520,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8370520,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8370521,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8370521,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370522,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370522,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8370523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8370523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8370524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8370524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8370526,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8370526,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8370858,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8370858,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8370794,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8370794,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.06000,86.73000,Aetna,Local,,119.62,,,,,,,107.81,244.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.06000,86.73000,Aetna,Local,,119.62,,,,,,,96.30,244.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.75000,53.29000,Aetna,Local,,73.50,,,,,,,66.24,150.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.75000,53.29000,Aetna,Local,,73.50,,,,,,,59.17,150.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7694910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4344.41000,1259.88000,Aetna,Local,,1737.76,,,,,,,1566.16,3553.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7694910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4344.41000,1259.88000,Aetna,Local,,1737.76,,,,,,,1398.90,3553.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT,8370914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4911.55000,1424.35000,Aetna,Local,,1964.62,,,,,,,1770.61,4017.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT,8370914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4911.55000,1424.35000,Aetna,Local,,1964.62,,,,,,,1581.52,4017.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8370903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8370903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8370909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11076.00000,3212.04000,Aetna,Local,,4430.40,,,,,,,3992.90,9060.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8370909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11076.00000,3212.04000,Aetna,Local,,4430.40,,,,,,,3566.47,9060.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370910,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370910,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8370911,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8370911,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8370913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8370913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7893739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,6123.99,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7893739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,5469.98,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8372236,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15495.00000,4493.55000,Aetna,Local,,6198.00,,,,,,,5585.95,12674.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8372236,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15495.00000,4493.55000,Aetna,Local,,6198.00,,,,,,,4989.39,12674.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8372237,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,46811.70000,13575.39000,Aetna,Local,,18724.68,,,,,,,16875.62,38291.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8372237,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,46811.70000,13575.39000,Aetna,Local,,18724.68,,,,,,,15073.37,38291.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8372238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8372238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8372403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8372403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8372405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8372405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8370507,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11358.00000,3293.82000,Aetna,Local,,4543.20,,,,,,,4094.56,9290.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8370507,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11358.00000,3293.82000,Aetna,Local,,4543.20,,,,,,,3657.28,9290.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8370508,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11358.00000,3293.82000,Aetna,Local,,4543.20,,,,,,,4094.56,9290.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8370508,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11358.00000,3293.82000,Aetna,Local,,4543.20,,,,,,,3657.28,9290.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMER,8370510,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,6072.50000,1761.02000,Aetna,Local,,2429.00,,,,,,,2189.14,4967.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMER,8370510,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,6072.50000,1761.02000,Aetna,Local,,2429.00,,,,,,,1955.35,4967.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,8370512,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,29632.50000,8593.42000,Aetna,Local,,11853.00,,,,,,,10682.52,24239.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,8370512,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,29632.50000,8593.42000,Aetna,Local,,11853.00,,,,,,,9541.67,24239.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8370513,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11358.00000,3293.82000,Aetna,Local,,4543.20,,,,,,,4094.56,9290.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8370513,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11358.00000,3293.82000,Aetna,Local,,4543.20,,,,,,,3657.28,9290.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8370514,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11358.00000,3293.82000,Aetna,Local,,4543.20,,,,,,,4094.56,9290.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8370514,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11358.00000,3293.82000,Aetna,Local,,4543.20,,,,,,,3657.28,9290.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT,8372239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4692.10000,1360.71000,Aetna,Local,,1876.84,,,,,,,1691.50,3838.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT,8372239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4692.10000,1360.71000,Aetna,Local,,1876.84,,,,,,,1510.86,3838.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8370908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8372407,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8372407,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8372479,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,46811.70000,13575.39000,Aetna,Local,,18724.68,,,,,,,16875.62,38291.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8372479,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,46811.70000,13575.39000,Aetna,Local,,18724.68,,,,,,,15073.37,38291.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8372484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3349.50000,971.35000,Aetna,Local,,1339.80,,,,,,,1207.49,2739.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8372484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3349.50000,971.35000,Aetna,Local,,1339.80,,,,,,,1078.54,2739.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8372549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7736.40000,2243.56000,Aetna,Local,,3094.56,,,,,,,2788.97,6328.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8372549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7736.40000,2243.56000,Aetna,Local,,3094.56,,,,,,,2491.12,6328.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8372551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8372551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8372553,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8372553,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8372559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8372559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8372600,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8372600,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8372603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8372603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD HELICAL BLADE,8372599,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,1085.65,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD HELICAL BLADE,8372599,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3011.52000,873.34000,Aetna,Local,,1204.61,,,,,,,969.71,2463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7971875,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,1667.60000,483.60000,Aetna,Local,,667.04,,,,,,,601.17,1364.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7971875,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,1667.60000,483.60000,Aetna,Local,,667.04,,,,,,,536.97,1364.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8372867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8372867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8372868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,646.11000,187.37000,Aetna,Local,,258.44,,,,,,,232.92,528.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8372868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,646.11000,187.37000,Aetna,Local,,258.44,,,,,,,208.05,528.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8372882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8372882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8372883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8372883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8372884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RECHARGER,8372885,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,1383.26000,401.15000,Aetna,Local,,553.30,,,,,,,498.67,1131.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RECHARGER,8372885,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,1383.26000,401.15000,Aetna,Local,,553.30,,,,,,,445.41,1131.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD EXTENSION,8372886,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,1383.26000,401.15000,Aetna,Local,,553.30,,,,,,,498.67,1131.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD EXTENSION,8372886,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,1383.26000,401.15000,Aetna,Local,,553.30,,,,,,,445.41,1131.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER TIBIAL,8374198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8830.80000,2560.93000,Aetna,Local,,3532.32,,,,,,,3183.50,7223.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER TIBIAL,8374198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8830.80000,2560.93000,Aetna,Local,,3532.32,,,,,,,2843.52,7223.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8374200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5716.20000,1657.70000,Aetna,Local,,2286.48,,,,,,,2060.69,4675.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8374200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5716.20000,1657.70000,Aetna,Local,,2286.48,,,,,,,1840.62,4675.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8374202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15166.50000,4398.28000,Aetna,Local,,6066.60,,,,,,,5467.52,12406.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8374202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15166.50000,4398.28000,Aetna,Local,,6066.60,,,,,,,4883.61,12406.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,8374205,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,8374205,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CHARGING SYSTEM,8374206,CDM,278,RC,C1822,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CHARGING SYSTEM,8374206,CDM,278,RC,C1822,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,8374207,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,82000.00000,23780.00000,Aetna,Local,,32800.00,,,,,,,29561.00,67076.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,8374207,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,82000.00000,23780.00000,Aetna,Local,,32800.00,,,,,,,26404.00,67076.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374260,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,471.77000,136.81000,Aetna,Local,,188.71,,,,,,,170.07,385.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374260,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,471.77000,136.81000,Aetna,Local,,188.71,,,,,,,151.91,385.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374261,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,441.85000,128.14000,Aetna,Local,,176.74,,,,,,,159.29,361.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374261,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,441.85000,128.14000,Aetna,Local,,176.74,,,,,,,142.28,361.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374266,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,394.44000,114.39000,Aetna,Local,,157.78,,,,,,,142.20,322.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374266,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,394.44000,114.39000,Aetna,Local,,157.78,,,,,,,127.01,322.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE MINI GLENOID,8360506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4617.90000,1339.19000,Aetna,Local,,1847.16,,,,,,,1664.75,3777.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE MINI GLENOID,8360506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4617.90000,1339.19000,Aetna,Local,,1847.16,,,,,,,1486.96,3777.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8374271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6681.50000,1937.63000,Aetna,Local,,2672.60,,,,,,,2408.68,5465.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8374271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6681.50000,1937.63000,Aetna,Local,,2672.60,,,,,,,2151.44,5465.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374460,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,503.50000,146.01000,Aetna,Local,,201.40,,,,,,,181.51,411.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8374460,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,503.50000,146.01000,Aetna,Local,,201.40,,,,,,,162.13,411.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8374463,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8374463,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT HEAD HUMERAL,8374464,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3329.13000,965.45000,Aetna,Local,,1331.65,,,,,,,1200.15,2723.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT HEAD HUMERAL,8374464,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3329.13000,965.45000,Aetna,Local,,1331.65,,,,,,,1071.98,2723.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8374552,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7966.80000,2310.37000,Aetna,Local,,3186.72,,,,,,,2872.03,6516.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8374552,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7966.80000,2310.37000,Aetna,Local,,3186.72,,,,,,,2565.31,6516.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8374556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8374558,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8374558,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8374560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,751.50000,217.93000,Aetna,Local,,300.60,,,,,,,270.92,614.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8374560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,751.50000,217.93000,Aetna,Local,,300.60,,,,,,,241.98,614.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8374562,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8374562,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8374612,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8374612,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8374614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5669.30000,1644.10000,Aetna,Local,,2267.72,,,,,,,2043.78,4637.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8374614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5669.30000,1644.10000,Aetna,Local,,2267.72,,,,,,,1825.51,4637.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8374616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8374616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEVICE ABSORBABLE FIXATION,8374661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2360.00000,684.40000,Aetna,Local,,944.00,,,,,,,850.78,1930.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEVICE ABSORBABLE FIXATION,8374661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2360.00000,684.40000,Aetna,Local,,944.00,,,,,,,759.92,1930.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,8374674,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11745.00000,3406.05000,Aetna,Local,,4698.00,,,,,,,4234.07,9607.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,8374674,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11745.00000,3406.05000,Aetna,Local,,4698.00,,,,,,,3781.89,9607.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8376322,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8376322,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8376243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11684.25000,3388.43000,Aetna,Local,,4673.70,,,,,,,4212.17,9557.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8376243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11684.25000,3388.43000,Aetna,Local,,4673.70,,,,,,,3762.33,9557.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8376241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8376241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8376246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8376246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8376323,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8376323,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8376326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8376502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8376502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8376561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8376561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8376664,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8376664,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8376665,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8376665,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8376666,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8376666,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8376667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8376667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8376668,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,7273.09,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8376668,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,6496.35,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8376669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8376669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8376670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8376670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8376671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8376671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8376672,CDM,278,RC,C1765,HCPCS,,,facility,inpatient,,,4795.00000,1390.55000,Aetna,Local,,1918.00,,,,,,,1728.60,3922.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8376672,CDM,278,RC,C1765,HCPCS,,,facility,outpatient,,,4795.00000,1390.55000,Aetna,Local,,1918.00,,,,,,,1543.99,3922.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8376793,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8376793,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8376795,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8376795,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8376797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12867.00000,3731.43000,Aetna,Local,,5146.80,,,,,,,4638.55,10525.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8376797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12867.00000,3731.43000,Aetna,Local,,5146.80,,,,,,,4143.17,10525.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8376800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11684.25000,3388.43000,Aetna,Local,,4673.70,,,,,,,4212.17,9557.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8376800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11684.25000,3388.43000,Aetna,Local,,4673.70,,,,,,,3762.33,9557.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8378231,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8378231,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8378268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8378268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8378271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8378271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378277,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378277,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8378279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10755.00000,3118.95000,Aetna,Local,,4302.00,,,,,,,3877.18,8797.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8378279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10755.00000,3118.95000,Aetna,Local,,4302.00,,,,,,,3463.11,8797.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8378281,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,357.34000,103.63000,Aetna,Local,,142.94,,,,,,,128.82,292.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8378281,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,357.34000,103.63000,Aetna,Local,,142.94,,,,,,,115.06,292.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8378282,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1747.80000,506.86000,Aetna,Local,,699.12,,,,,,,630.08,1429.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8378282,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1747.80000,506.86000,Aetna,Local,,699.12,,,,,,,562.79,1429.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8378341,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8378341,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8378343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8378343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLOFEMORAL,8378347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,4133.49,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLOFEMORAL,8378347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,3692.05,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2708.08,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7512.00000,2178.48000,Aetna,Local,,3004.80,,,,,,,2418.86,6144.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8378351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,6518.74,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8378351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,5822.56,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8378412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8380190,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8380190,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8380299,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8380299,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8380300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4346.76000,1260.56000,Aetna,Local,,1738.70,,,,,,,1567.01,3555.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8380300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4346.76000,1260.56000,Aetna,Local,,1738.70,,,,,,,1399.66,3555.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8380298,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8380298,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8380374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8380374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8380376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2708.00000,785.32000,Aetna,Local,,1083.20,,,,,,,976.23,2215.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8380376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2708.00000,785.32000,Aetna,Local,,1083.20,,,,,,,871.98,2215.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8380379,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8380379,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8380381,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36110.25000,10471.97000,Aetna,Local,,14444.10,,,,,,,13017.75,29538.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8380381,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36110.25000,10471.97000,Aetna,Local,,14444.10,,,,,,,11627.50,29538.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8380382,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36110.25000,10471.97000,Aetna,Local,,14444.10,,,,,,,13017.75,29538.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8380382,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36110.25000,10471.97000,Aetna,Local,,14444.10,,,,,,,11627.50,29538.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8380383,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36110.25000,10471.97000,Aetna,Local,,14444.10,,,,,,,13017.75,29538.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8380383,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36110.25000,10471.97000,Aetna,Local,,14444.10,,,,,,,11627.50,29538.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8380384,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36110.25000,10471.97000,Aetna,Local,,14444.10,,,,,,,13017.75,29538.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8380384,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36110.25000,10471.97000,Aetna,Local,,14444.10,,,,,,,11627.50,29538.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8380385,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36110.25000,10471.97000,Aetna,Local,,14444.10,,,,,,,13017.75,29538.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8380385,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36110.25000,10471.97000,Aetna,Local,,14444.10,,,,,,,11627.50,29538.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,8380428,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,8380428,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8380430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8380430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8380472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8380472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8380473,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8380473,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8380474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8380474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD THE KIT,8380530,CDM,278,RC,L8680,HCPCS,,,facility,inpatient,,,54911.00000,15924.19000,Aetna,Local,,21964.40,,,,,,,19795.42,44917.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD THE KIT,8380530,CDM,278,RC,L8680,HCPCS,,,facility,outpatient,,,54911.00000,15924.19000,Aetna,Local,,21964.40,,,,,,,17681.34,44917.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2939.00000,852.31000,Aetna,Local,,1175.60,,,,,,,1059.51,2404.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2939.00000,852.31000,Aetna,Local,,1175.60,,,,,,,946.36,2404.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8380726,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8380726,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8380526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1930.48,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8380526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5355.00000,1552.95000,Aetna,Local,,2142.00,,,,,,,1724.31,4380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8380727,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2532.08000,734.30000,Aetna,Local,,1012.83,,,,,,,912.81,2071.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8380727,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2532.08000,734.30000,Aetna,Local,,1012.83,,,,,,,815.33,2071.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8380798,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,3136.35,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8380798,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,2801.40,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8380799,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8380799,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8380800,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8380800,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8380743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10494.00000,3043.26000,Aetna,Local,,4197.60,,,,,,,3783.09,8584.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8380743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10494.00000,3043.26000,Aetna,Local,,4197.60,,,,,,,3379.07,8584.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8380744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8380744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8380821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8380821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,Local,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8380845,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8380845,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8381126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8381126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,169.10,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,469.06000,136.03000,Aetna,Local,,187.62,,,,,,,151.04,383.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT WEDGE,8380861,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT WEDGE,8380861,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5530.00000,1603.70000,Aetna,Local,,2212.00,,,,,,,1993.57,4523.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5530.00000,1603.70000,Aetna,Local,,2212.00,,,,,,,1780.66,4523.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8380854,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9990.00000,2897.10000,Aetna,Local,,3996.00,,,,,,,3601.39,8171.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8380854,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9990.00000,2897.10000,Aetna,Local,,3996.00,,,,,,,3216.78,8171.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,109.95,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8380894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,98.21,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8380895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8380895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8381006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8381006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8381092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8381092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8381127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,953.52,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8381127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,851.69,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8381128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8381128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8381129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1734.59,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8381129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1549.34,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8382267,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1740.00000,504.60000,Aetna,Local,,696.00,,,,,,,627.27,1423.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8382267,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1740.00000,504.60000,Aetna,Local,,696.00,,,,,,,560.28,1423.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8382442,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8382442,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8382443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8382443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8382444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8382444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8382445,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8382445,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8382481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8382481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8382483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8382483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8382485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6485.50000,1880.79000,Aetna,Local,,2594.20,,,,,,,2338.02,5305.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8382485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6485.50000,1880.79000,Aetna,Local,,2594.20,,,,,,,2088.33,5305.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8382520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3524.61,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8382520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3148.19,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8382514,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8382514,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8382516,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8382516,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8382558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2496.48000,723.98000,Aetna,Local,,998.59,,,,,,,899.98,2042.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8382558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2496.48000,723.98000,Aetna,Local,,998.59,,,,,,,803.87,2042.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8382560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8382560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8382562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CORE,8384231,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18952.50000,5496.22000,Aetna,Local,,7581.00,,,,,,,6832.38,15503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CORE,8384231,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18952.50000,5496.22000,Aetna,Local,,7581.00,,,,,,,6102.70,15503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8384239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8384239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INCISION MANAGEMENT,7697583,CDM,278,RC,A6550,HCPCS,,,facility,inpatient,,,2142.80000,621.41000,Aetna,Local,,857.12,,,,,,,772.48,1752.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INCISION MANAGEMENT,7697583,CDM,278,RC,A6550,HCPCS,,,facility,outpatient,,,2142.80000,621.41000,Aetna,Local,,857.12,,,,,,,31.78,1752.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8384497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8384497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8384356,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8384356,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8384358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8384358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8384363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8384363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8384499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8384499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8384371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8384371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL EMBOLIZATION,8384501,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,Local,,2337.30,,,,,,,2106.49,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL EMBOLIZATION,8384501,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,Local,,2337.30,,,,,,,1881.53,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8384503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1847.20,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8384503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1649.93,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTACT EXT IN KIT,8384607,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTACT EXT IN KIT,8384607,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM FIXATION ORTHO,8384687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8637.00000,2504.73000,Aetna,Local,,3454.80,,,,,,,3113.64,7065.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM FIXATION ORTHO,8384687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8637.00000,2504.73000,Aetna,Local,,3454.80,,,,,,,2781.11,7065.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8384689,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8384689,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8384691,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8384691,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384694,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384694,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384695,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384695,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384696,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384696,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8384721,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8384721,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8384803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER STEM,8384804,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5187.00000,1504.23000,Aetna,Local,,2074.80,,,,,,,1869.91,4242.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER STEM,8384804,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5187.00000,1504.23000,Aetna,Local,,2074.80,,,,,,,1670.21,4242.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8384805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8384805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8384806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8384806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8384807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8384807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8384808,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8384808,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8384809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8384809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8384810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8384810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8385061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8385061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8385063,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8385063,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSS CONNECTOR,8385064,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSS CONNECTOR,8385064,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSS CONNECTOR,8385065,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSS CONNECTOR,8385065,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8385066,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8385066,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8386405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8386405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,289.57,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,258.65,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8386407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1298.00000,376.42000,Aetna,Local,,519.20,,,,,,,467.93,1061.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8386407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1298.00000,376.42000,Aetna,Local,,519.20,,,,,,,417.96,1061.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,289.57,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,258.65,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8386411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8386411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT RESTRICTOR,8386409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT RESTRICTOR,8386409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8386422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,901.40000,261.41000,Aetna,Local,,360.56,,,,,,,324.95,737.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8386422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,901.40000,261.41000,Aetna,Local,,360.56,,,,,,,290.25,737.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.35000,103.34000,Aetna,Local,,142.54,,,,,,,128.46,291.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.35000,103.34000,Aetna,Local,,142.54,,,,,,,114.74,291.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8386424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,799.52000,231.86000,Aetna,Local,,319.81,,,,,,,288.23,654.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8386424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,799.52000,231.86000,Aetna,Local,,319.81,,,,,,,257.45,654.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8386443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8386443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8386506,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8386506,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8386509,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8386509,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8386510,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8386510,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8386740,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,8939.50,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8386740,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,7984.80,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8386801,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1432.09,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8386801,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1279.14,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8386802,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1432.09,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8386802,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1279.14,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8386803,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1432.09,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8386803,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1279.14,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8386804,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1432.09,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8386804,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1279.14,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8386805,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1432.09,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8386805,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1279.14,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8386956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,7273.09,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8386956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,6496.35,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8386868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8386868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8386869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8386869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8386870,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8386870,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8386958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8386958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8386962,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8386962,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8386968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8386968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8386970,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8386970,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8386993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8386973,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,741.19,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8386973,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,662.03,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8387220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8387220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8387222,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8387222,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8387224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8387224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8387226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8387226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8387228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9088.80000,2635.75000,Aetna,Local,,3635.52,,,,,,,3276.51,7434.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8387228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9088.80000,2635.75000,Aetna,Local,,3635.52,,,,,,,2926.59,7434.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8388189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8388189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,8388190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,8388190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER SLEEVE,8388191,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER SLEEVE,8388191,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON DIVIDER,8387230,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON DIVIDER,8387230,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8388336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8388336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8388337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8388337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8388338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8388338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8388339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8388339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8388342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8388342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8388343,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8388343,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8388345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7362.00000,2134.98000,Aetna,Local,,2944.80,,,,,,,2654.00,6022.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8388345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7362.00000,2134.98000,Aetna,Local,,2944.80,,,,,,,2370.56,6022.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8388442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8388442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8388444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8388444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER SLEEVE,8388446,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER SLEEVE,8388446,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8388448,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8388448,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8388450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8388450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8388546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8388546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8388559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8388559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388561,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388561,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388562,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388562,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388563,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388563,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388564,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388564,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388565,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388565,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388566,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388566,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388567,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388567,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388568,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388568,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388569,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388569,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388646,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388646,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388647,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388647,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388648,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388648,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388649,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388649,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388650,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388650,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388651,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388651,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388652,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8388652,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388653,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388653,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388654,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388654,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388655,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388655,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388656,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388656,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388657,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388657,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388658,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388658,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388659,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388659,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388660,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388660,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388661,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388661,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388662,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388662,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388663,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388663,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388664,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388664,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388665,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388665,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388666,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388666,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388667,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,8730.00000,2531.70000,Aetna,Local,,3492.00,,,,,,,3147.16,7141.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388667,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,8730.00000,2531.70000,Aetna,Local,,3492.00,,,,,,,2811.06,7141.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388668,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388668,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388670,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388670,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8388679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8388679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8388680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10590.00000,3071.10000,Aetna,Local,,4236.00,,,,,,,3817.70,8662.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8388680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10590.00000,3071.10000,Aetna,Local,,4236.00,,,,,,,3409.98,8662.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8388683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOCARTLIAGE,8388684,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOCARTLIAGE,8388684,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8388704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1233.64000,357.76000,Aetna,Local,,493.46,,,,,,,444.73,1009.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8388704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1233.64000,357.76000,Aetna,Local,,493.46,,,,,,,397.23,1009.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388671,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388671,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388672,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388672,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388673,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,8730.00000,2531.70000,Aetna,Local,,3492.00,,,,,,,3147.16,7141.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388673,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,8730.00000,2531.70000,Aetna,Local,,3492.00,,,,,,,2811.06,7141.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388674,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388674,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8390251,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8390251,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388675,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388675,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388676,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388676,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,Local,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388677,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388677,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388678,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,8730.00000,2531.70000,Aetna,Local,,3492.00,,,,,,,3147.16,7141.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388678,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,8730.00000,2531.70000,Aetna,Local,,3492.00,,,,,,,2811.06,7141.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388690,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,7534.92000,2185.13000,Aetna,Local,,3013.97,,,,,,,2716.34,6163.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388690,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,7534.92000,2185.13000,Aetna,Local,,3013.97,,,,,,,2426.24,6163.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388691,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,7534.92000,2185.13000,Aetna,Local,,3013.97,,,,,,,2716.34,6163.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388691,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,7534.92000,2185.13000,Aetna,Local,,3013.97,,,,,,,2426.24,6163.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388692,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8965.17000,2599.90000,Aetna,Local,,3586.07,,,,,,,3231.94,7333.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388692,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8965.17000,2599.90000,Aetna,Local,,3586.07,,,,,,,2886.78,7333.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388693,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8965.17000,2599.90000,Aetna,Local,,3586.07,,,,,,,3231.94,7333.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388693,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8965.17000,2599.90000,Aetna,Local,,3586.07,,,,,,,2886.78,7333.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388694,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3317.55000,962.09000,Aetna,Local,,1327.02,,,,,,,1195.98,2713.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388694,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3317.55000,962.09000,Aetna,Local,,1327.02,,,,,,,1068.25,2713.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8390252,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3812.73000,1105.69000,Aetna,Local,,1525.09,,,,,,,1374.49,3118.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8390252,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3812.73000,1105.69000,Aetna,Local,,1525.09,,,,,,,1227.70,3118.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8390254,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4857.30000,1408.62000,Aetna,Local,,1942.92,,,,,,,1751.06,3973.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8390254,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4857.30000,1408.62000,Aetna,Local,,1942.92,,,,,,,1564.05,3973.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388695,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3317.55000,962.09000,Aetna,Local,,1327.02,,,,,,,1195.98,2713.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388695,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3317.55000,962.09000,Aetna,Local,,1327.02,,,,,,,1068.25,2713.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8390256,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4857.30000,1408.62000,Aetna,Local,,1942.92,,,,,,,1751.06,3973.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8390256,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4857.30000,1408.62000,Aetna,Local,,1942.92,,,,,,,1564.05,3973.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388696,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3317.55000,962.09000,Aetna,Local,,1327.02,,,,,,,1195.98,2713.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388696,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3317.55000,962.09000,Aetna,Local,,1327.02,,,,,,,1068.25,2713.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388697,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3812.73000,1105.69000,Aetna,Local,,1525.09,,,,,,,1374.49,3118.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8388697,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3812.73000,1105.69000,Aetna,Local,,1525.09,,,,,,,1227.70,3118.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388698,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388698,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388699,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388699,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388700,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388700,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388701,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388701,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388702,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388702,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388703,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8388703,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT CAGE,8390673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT CAGE,8390673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8390674,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8390674,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8390675,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8390675,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8390676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8390676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8390677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8390677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8390678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8390678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8390679,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,8939.50,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8390679,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,7984.80,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8390685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8392462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3712.24000,1076.55000,Aetna,Local,,1484.90,,,,,,,1338.26,3036.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8392462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3712.24000,1076.55000,Aetna,Local,,1484.90,,,,,,,1195.34,3036.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8392464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.54000,989.64000,Aetna,Local,,1365.02,,,,,,,1230.22,2791.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8392464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.54000,989.64000,Aetna,Local,,1365.02,,,,,,,1098.84,2791.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8392466,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8392466,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8392468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8392468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8392470,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,Local,,2337.30,,,,,,,2106.49,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8392470,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,Local,,2337.30,,,,,,,1881.53,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8392501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8392501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8392502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8392502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8392504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5447.54000,1579.79000,Aetna,Local,,2179.02,,,,,,,1963.84,4456.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8392504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5447.54000,1579.79000,Aetna,Local,,2179.02,,,,,,,1754.11,4456.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8392505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3514.00000,1019.06000,Aetna,Local,,1405.60,,,,,,,1266.80,2874.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8392505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3514.00000,1019.06000,Aetna,Local,,1405.60,,,,,,,1131.51,2874.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8392506,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8392506,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8392551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8392551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392553,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392553,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8392554,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,6529.56,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8392554,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,5832.23,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8392547,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8392547,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8392549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8392549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8392558,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1335.34000,387.25000,Aetna,Local,,534.14,,,,,,,481.39,1092.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8392558,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1335.34000,387.25000,Aetna,Local,,534.14,,,,,,,429.98,1092.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8392559,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1335.33000,387.25000,Aetna,Local,,534.13,,,,,,,481.39,1092.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8392559,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1335.33000,387.25000,Aetna,Local,,534.13,,,,,,,429.98,1092.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8392560,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1427.45000,413.96000,Aetna,Local,,570.98,,,,,,,514.60,1167.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8392560,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1427.45000,413.96000,Aetna,Local,,570.98,,,,,,,459.64,1167.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8392561,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1427.45000,413.96000,Aetna,Local,,570.98,,,,,,,514.60,1167.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8392561,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1427.45000,413.96000,Aetna,Local,,570.98,,,,,,,459.64,1167.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8392727,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8392727,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8392728,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8392728,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8392729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8392729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8392730,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8392730,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8392732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,703.26000,203.95000,Aetna,Local,,281.30,,,,,,,253.53,575.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8392732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,703.26000,203.95000,Aetna,Local,,281.30,,,,,,,226.45,575.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392725,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392725,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,6069.92,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8392726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16837.50000,4882.88000,Aetna,Local,,6735.00,,,,,,,5421.68,13773.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8394308,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8394308,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8394338,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,463.74000,134.48000,Aetna,Local,,185.50,,,,,,,167.18,379.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8394338,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,463.74000,134.48000,Aetna,Local,,185.50,,,,,,,149.32,379.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8394385,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8394385,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8394386,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8394386,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8394350,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8394350,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8394351,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8394351,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8394379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8394379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8394381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8394381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8394382,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8394382,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8394383,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8394383,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8394483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,289.57,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8394483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,258.65,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8394485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13755.00000,3988.95000,Aetna,Local,,5502.00,,,,,,,4958.68,11251.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8394485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13755.00000,3988.95000,Aetna,Local,,5502.00,,,,,,,4429.11,11251.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8394486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8396441,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8396441,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR CROSS,8396447,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR CROSS,8396447,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP LOCKING,8396448,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP LOCKING,8396448,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8396449,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8396449,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8396450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8396450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8396598,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,Local,,3864.00,,,,,,,3482.43,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8396598,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,Local,,3864.00,,,,,,,3110.52,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8396599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3850.00000,1116.50000,Aetna,Local,,1540.00,,,,,,,1387.92,3149.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8396599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3850.00000,1116.50000,Aetna,Local,,1540.00,,,,,,,1239.70,3149.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8396655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8396655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.25000,2383.58000,Aetna,Local,,3287.70,,,,,,,2963.04,6723.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.25000,2383.58000,Aetna,Local,,3287.70,,,,,,,2646.60,6723.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8396658,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,Local,,20156.16,,,,,,,18165.74,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8396658,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,Local,,20156.16,,,,,,,16225.71,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8396659,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,Local,,4589.28,,,,,,,4136.09,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8396659,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,Local,,4589.28,,,,,,,3694.37,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8396660,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8396660,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8396664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8396665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2339.40000,678.43000,Aetna,Local,,935.76,,,,,,,843.35,1913.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8396665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2339.40000,678.43000,Aetna,Local,,935.76,,,,,,,753.29,1913.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8396667,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8396667,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8396758,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8396758,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8398187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8398187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8398188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8398188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8398189,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8398189,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8398190,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8398190,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8398191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8398191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8398192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8398192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8398193,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8398193,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8398194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8398194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8398195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8398195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8398265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8398265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8398266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8398266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8398247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8398247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8398248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8398248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8398249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8398249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8398291,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8280.00000,2401.20000,Aetna,Local,,3312.00,,,,,,,2984.94,6773.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8398291,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8280.00000,2401.20000,Aetna,Local,,3312.00,,,,,,,2666.16,6773.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8398290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8398290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8398440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8398440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8400273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14143.50000,4101.62000,Aetna,Local,,5657.40,,,,,,,5098.73,11569.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8400273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14143.50000,4101.62000,Aetna,Local,,5657.40,,,,,,,4554.21,11569.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8400275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,166.10,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8400275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,Local,,184.30,,,,,,,148.36,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400277,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400277,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8400404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8400404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8400406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6114.33000,1773.16000,Aetna,Local,,2445.73,,,,,,,2204.22,5001.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8400406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6114.33000,1773.16000,Aetna,Local,,2445.73,,,,,,,1968.81,5001.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8400408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2956.98,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8400408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8202.45000,2378.71000,Aetna,Local,,3280.98,,,,,,,2641.19,6709.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8400410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9426.00000,2733.54000,Aetna,Local,,3770.40,,,,,,,3398.07,7710.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8400410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9426.00000,2733.54000,Aetna,Local,,3770.40,,,,,,,3035.17,7710.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8400530,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8400530,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8400531,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8400531,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,Local,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8400532,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8400532,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8400721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8400721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8400537,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6182.75000,1793.00000,Aetna,Local,,2473.10,,,,,,,2228.88,5057.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8400537,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6182.75000,1793.00000,Aetna,Local,,2473.10,,,,,,,1990.85,5057.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8400539,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14803.14000,4292.91000,Aetna,Local,,5921.26,,,,,,,5336.53,12108.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,8400539,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14803.14000,4292.91000,Aetna,Local,,5921.26,,,,,,,4766.61,12108.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8400540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4515.97,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8400540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,Local,,5010.78,,,,,,,4033.68,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8400528,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8400528,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8400587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8400587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8400711,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8400711,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8400712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5352.52000,1552.23000,Aetna,Local,,2141.01,,,,,,,1929.58,4378.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8400712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5352.52000,1552.23000,Aetna,Local,,2141.01,,,,,,,1723.51,4378.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8400715,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8400715,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAK,8400716,CDM,278,RC,,,,,facility,inpatient,,,344.38000,99.87000,Aetna,Local,,137.75,,,,,,,124.15,281.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAK,8400716,CDM,278,RC,,,,,facility,outpatient,,,344.38000,99.87000,Aetna,Local,,137.75,,,,,,,110.89,281.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAK,8400717,CDM,278,RC,,,,,facility,inpatient,,,518.94000,150.49000,Aetna,Local,,207.58,,,,,,,187.08,424.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAK,8400717,CDM,278,RC,,,,,facility,outpatient,,,518.94000,150.49000,Aetna,Local,,207.58,,,,,,,167.10,424.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8400718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,3076.60,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8400718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,2748.03,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8400719,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5787.51,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8400719,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5169.43,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8400720,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5007.10000,1452.06000,Aetna,Local,,2002.84,,,,,,,1805.06,4095.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8400720,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5007.10000,1452.06000,Aetna,Local,,2002.84,,,,,,,1612.29,4095.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8400722,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8400722,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8400812,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2130.00000,617.70000,Aetna,Local,,852.00,,,,,,,767.87,1742.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8400812,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2130.00000,617.70000,Aetna,Local,,852.00,,,,,,,685.86,1742.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8400855,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,364.47000,105.70000,Aetna,Local,,145.79,,,,,,,131.39,298.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8400855,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,364.47000,105.70000,Aetna,Local,,145.79,,,,,,,117.36,298.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8400864,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1432.09,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8400864,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,764.47,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8400865,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1432.09,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8400865,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,764.47,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8400866,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1432.09,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8400866,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,764.47,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8400859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8400859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8400860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8400860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400862,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,289.57,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400862,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,Local,,321.30,,,,,,,258.65,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400863,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400863,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,8400867,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,2940.04000,852.61000,Aetna,Local,,1176.02,,,,,,,1059.88,2404.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,8400867,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,2940.04000,852.61000,Aetna,Local,,1176.02,,,,,,,946.69,2404.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400986,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.25000,2383.58000,Aetna,Local,,3287.70,,,,,,,2963.04,6723.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400986,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.25000,2383.58000,Aetna,Local,,3287.70,,,,,,,2646.60,6723.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400987,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1374.05,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400987,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3811.50000,1105.34000,Aetna,Local,,1524.60,,,,,,,1227.30,3117.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400988,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8400988,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400989,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400989,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ANKLE,8400995,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18910.00000,5483.90000,Aetna,Local,,7564.00,,,,,,,6817.06,15468.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ANKLE,8400995,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18910.00000,5483.90000,Aetna,Local,,7564.00,,,,,,,6089.02,15468.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8400990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SHUNT,8402284,CDM,278,RC,,,,,facility,inpatient,,,1528.36000,443.22000,Aetna,Local,,611.34,,,,,,,550.97,1250.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SHUNT,8402284,CDM,278,RC,,,,,facility,outpatient,,,1528.36000,443.22000,Aetna,Local,,611.34,,,,,,,492.13,1250.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8402286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8402286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8402290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8402290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8402292,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8402292,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8402503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8402503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXT,8402498,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXT,8402498,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8402507,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8402507,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8402509,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8402509,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8402513,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8402513,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402516,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,605.93,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402516,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,Local,,672.32,,,,,,,541.22,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8402777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8402777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8402779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8402779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8402781,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8402781,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8402783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8402783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SUBSTITUTE,7902586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13200.00000,3828.00000,Aetna,Local,,5280.00,,,,,,,4758.60,10797.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SUBSTITUTE,7902586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13200.00000,3828.00000,Aetna,Local,,5280.00,,,,,,,4250.40,10797.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8402793,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8402793,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8402794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8402794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,Local,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,7703247,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1432.09,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,7703247,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1279.14,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,458.41,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,409.46,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,458.41,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,409.46,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8402938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8402938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8402940,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8402940,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,Local,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8402942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,Local,,4589.28,,,,,,,4136.09,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8402942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,Local,,4589.28,,,,,,,3694.37,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8402943,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8402943,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8402944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8402944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8402945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,7273.09,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8402945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,6496.35,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8402946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8402946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402948,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402948,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402950,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402950,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,Local,,3434.40,,,,,,,3095.25,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,Local,,3434.40,,,,,,,2764.69,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8402970,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8402970,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8402971,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8402971,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8402978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4063.50000,1178.42000,Aetna,Local,,1625.40,,,,,,,1464.89,3323.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4063.50000,1178.42000,Aetna,Local,,1625.40,,,,,,,1308.45,3323.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8705.16000,2524.50000,Aetna,Local,,3482.06,,,,,,,3138.21,7120.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8402972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8705.16000,2524.50000,Aetna,Local,,3482.06,,,,,,,2803.06,7120.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402973,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8402973,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8403249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8403249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8403251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8403251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8403196,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8403196,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8403197,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8403197,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8403199,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8403199,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8403201,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8403201,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8403202,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8403202,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403773,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403773,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8403203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8403203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8403257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8403257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8403472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9589.20000,2780.87000,Aetna,Local,,3835.68,,,,,,,3456.91,7843.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8403472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9589.20000,2780.87000,Aetna,Local,,3835.68,,,,,,,3087.72,7843.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8403477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8403477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8403478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8403478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8403480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8403480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8403632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8403632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8403633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,7273.09,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8403633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,6496.35,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8403635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8403635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8403636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8403636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8403637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8403637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8403638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8403638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8403639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8403639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8403640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8403640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXT,8403641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXT,8403641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXT,8403642,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXT,8403642,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8403645,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8403645,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8403646,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8403646,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8403647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8403648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8403738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8403738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER STEM,8403955,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER STEM,8403955,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8403957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8403957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR ACHILLES,8403959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,3076.60,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR ACHILLES,8403959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,2748.03,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403961,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403961,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403962,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403962,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403963,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403963,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403964,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403964,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403965,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403965,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403966,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8403966,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404338,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404338,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT CAGE,8404339,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT CAGE,8404339,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8404343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8404343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8404344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8404344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8404336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8404336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8404337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8404337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8404429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8404429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8404440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8404440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404442,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404442,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404443,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,6529.56,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404443,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,5832.23,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER IN KIT,8244060,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,3126.76000,906.76000,Aetna,Local,,1250.70,,,,,,,1127.20,2557.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER IN KIT,8244060,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,3126.76000,906.76000,Aetna,Local,,1250.70,,,,,,,1006.82,2557.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8404563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8404563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,964.29,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,861.31,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,964.29,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,861.31,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8404569,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9378.00000,2719.62000,Aetna,Local,,3751.20,,,,,,,3380.77,7671.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8404569,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9378.00000,2719.62000,Aetna,Local,,3751.20,,,,,,,3019.72,7671.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8404571,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4014.50000,1164.20000,Aetna,Local,,1605.80,,,,,,,1447.23,3283.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8404571,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4014.50000,1164.20000,Aetna,Local,,1605.80,,,,,,,1292.67,3283.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8404573,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8404573,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8404575,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8404575,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8404577,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8404577,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969163,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969163,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7986867,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7986867,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968120,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968120,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968231,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1254.66,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968231,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1120.67,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7968235,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7968235,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975102,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975102,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975103,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975103,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975106,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975106,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7968511,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7968511,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975109,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975109,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975110,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975110,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,7974090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,7974090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7983040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5971.00000,1731.59000,Aetna,Local,,2388.40,,,,,,,2152.55,4884.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7983040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5971.00000,1731.59000,Aetna,Local,,2388.40,,,,,,,1922.66,4884.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987520,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,4004.53000,1161.31000,Aetna,Local,,1601.81,,,,,,,1443.63,3275.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987520,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,4004.53000,1161.31000,Aetna,Local,,1601.81,,,,,,,1289.46,3275.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,728.50,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,650.70,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,728.50,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,650.70,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,728.50,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,Local,,808.32,,,,,,,650.70,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2142.40000,621.30000,Aetna,Local,,856.96,,,,,,,772.34,1752.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2142.40000,621.30000,Aetna,Local,,856.96,,,,,,,689.85,1752.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969008,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969008,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969009,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969009,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969003,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969003,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969006,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969006,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,Local,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969018,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969018,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,Local,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,Local,,1409.80,,,,,,,1270.58,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,Local,,1409.80,,,,,,,1134.89,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969027,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969027,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7982827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7982827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7980738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7980738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7987617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7987617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7972068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7972068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7978326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7978326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,Local,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7980593,CDM,278,RC,C1714,HCPCS,,,facility,inpatient,,,13185.00000,3823.65000,Aetna,Local,,5274.00,,,,,,,4753.19,10785.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7980593,CDM,278,RC,C1714,HCPCS,,,facility,outpatient,,,13185.00000,3823.65000,Aetna,Local,,5274.00,,,,,,,4245.57,10785.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969490,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969490,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969491,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969491,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969633,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969633,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969545,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969545,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974698,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974698,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7982854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7982854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7969721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7969721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7974184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7974184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7978413,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1855.02,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7978413,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,Local,,2058.28,,,,,,,1656.92,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969745,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969745,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7981169,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7981169,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7971891,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7971891,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7971894,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7971894,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7971892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7971892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7971893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7971893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7971874,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7971874,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,7969834,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,7969834,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972131,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972131,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972183,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972183,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972184,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972184,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972186,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972186,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972189,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972189,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972178,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972178,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972179,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972179,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7972279,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7972279,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7972226,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7972226,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7972227,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7972227,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,Local,,1818.04,,,,,,,1638.51,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,Local,,1818.04,,,,,,,1463.52,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,Local,,1818.04,,,,,,,1638.51,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,Local,,1818.04,,,,,,,1463.52,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,Local,,1818.04,,,,,,,1638.51,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,Local,,1818.04,,,,,,,1463.52,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3892.18000,1128.73000,Aetna,Local,,1556.87,,,,,,,1403.13,3183.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3892.18000,1128.73000,Aetna,Local,,1556.87,,,,,,,1253.28,3183.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3892.18000,1128.73000,Aetna,Local,,1556.87,,,,,,,1403.13,3183.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3892.18000,1128.73000,Aetna,Local,,1556.87,,,,,,,1253.28,3183.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3892.18000,1128.73000,Aetna,Local,,1556.87,,,,,,,1403.13,3183.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3892.18000,1128.73000,Aetna,Local,,1556.87,,,,,,,1253.28,3183.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972264,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972264,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972265,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972265,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972266,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972266,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972267,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972267,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7980584,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7980584,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974593,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974593,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8405125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6381.73000,1850.70000,Aetna,Local,,2552.69,,,,,,,2300.61,5220.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8405125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6381.73000,1850.70000,Aetna,Local,,2552.69,,,,,,,2054.92,5220.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404581,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404581,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8404582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8404582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8404583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1904.00000,552.16000,Aetna,Local,,761.60,,,,,,,686.39,1557.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8404583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1904.00000,552.16000,Aetna,Local,,761.60,,,,,,,613.09,1557.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8404647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8404647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404689,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404689,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,416.05000,120.65000,Aetna,Local,,166.42,,,,,,,149.99,340.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,416.05000,120.65000,Aetna,Local,,166.42,,,,,,,133.97,340.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5974.36000,1732.56000,Aetna,Local,,2389.74,,,,,,,2153.76,4887.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5974.36000,1732.56000,Aetna,Local,,2389.74,,,,,,,1923.74,4887.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1542.40000,447.30000,Aetna,Local,,616.96,,,,,,,556.04,1261.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1542.40000,447.30000,Aetna,Local,,616.96,,,,,,,496.65,1261.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.92000,466.01000,Aetna,Local,,642.77,,,,,,,579.29,1314.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.92000,466.01000,Aetna,Local,,642.77,,,,,,,517.43,1314.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1790.44000,519.23000,Aetna,Local,,716.18,,,,,,,645.45,1464.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1790.44000,519.23000,Aetna,Local,,716.18,,,,,,,576.52,1464.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2319.40000,672.63000,Aetna,Local,,927.76,,,,,,,836.14,1897.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2319.40000,672.63000,Aetna,Local,,927.76,,,,,,,746.85,1897.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404472,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1949.56000,565.37000,Aetna,Local,,779.82,,,,,,,702.82,1594.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404472,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1949.56000,565.37000,Aetna,Local,,779.82,,,,,,,627.76,1594.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7750.26000,2247.58000,Aetna,Local,,3100.10,,,,,,,2793.97,6339.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7750.26000,2247.58000,Aetna,Local,,3100.10,,,,,,,2495.58,6339.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2442.00000,708.18000,Aetna,Local,,976.80,,,,,,,880.34,1997.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2442.00000,708.18000,Aetna,Local,,976.80,,,,,,,786.32,1997.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2541.00000,736.89000,Aetna,Local,,1016.40,,,,,,,916.03,2078.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2541.00000,736.89000,Aetna,Local,,1016.40,,,,,,,818.20,2078.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2541.00000,736.89000,Aetna,Local,,1016.40,,,,,,,916.03,2078.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2541.00000,736.89000,Aetna,Local,,1016.40,,,,,,,818.20,2078.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,Local,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404490,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404490,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404492,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404492,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404497,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1542.49,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404497,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1377.76,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1542.49,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1377.76,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1542.49,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1377.76,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1542.49,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1377.76,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1542.49,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1377.76,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1542.49,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1377.76,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5378.49000,1559.76000,Aetna,Local,,2151.40,,,,,,,1938.95,4399.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5378.49000,1559.76000,Aetna,Local,,2151.40,,,,,,,1731.87,4399.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8404765,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8404765,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404766,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,8939.50,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8404766,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24797.50000,7191.28000,Aetna,Local,,9919.00,,,,,,,7984.80,20284.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8404767,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8404767,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8404768,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8404768,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404770,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404770,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8404771,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,908.10,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8404771,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,811.12,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8404772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8405132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8405132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404773,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4453.23000,1291.44000,Aetna,Local,,1781.29,,,,,,,1605.39,3642.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404773,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4453.23000,1291.44000,Aetna,Local,,1781.29,,,,,,,1433.94,3642.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4453.23000,1291.44000,Aetna,Local,,1781.29,,,,,,,1605.39,3642.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8404774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4453.23000,1291.44000,Aetna,Local,,1781.29,,,,,,,1433.94,3642.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4453.23000,1291.44000,Aetna,Local,,1781.29,,,,,,,1605.39,3642.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4453.23000,1291.44000,Aetna,Local,,1781.29,,,,,,,1433.94,3642.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8404775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8404775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8405127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8405127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8405128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8405128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8405129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.00000,559.99000,Aetna,Local,,772.40,,,,,,,696.13,1579.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8405129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.00000,559.99000,Aetna,Local,,772.40,,,,,,,621.78,1579.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8405131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,21239.15000,6159.35000,Aetna,Local,,8495.66,,,,,,,7656.71,17373.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8405131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,21239.15000,6159.35000,Aetna,Local,,8495.66,,,,,,,6839.01,17373.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8406140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8406140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8461841,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,2224.35,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8461841,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,1986.80,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT AUGMENT,8461843,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,3057.18,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT AUGMENT,8461843,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,Local,,3392.16,,,,,,,2730.69,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8461889,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8461889,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8461969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8461969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8461971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8461971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8461973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8461973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8461975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8461975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8461977,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8461977,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8461982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8461982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8462085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8462085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8462087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8462087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8462075,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8462075,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462079,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462079,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8462081,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8462081,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462083,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462083,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CANNULA SPINAL,8462058,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,360.48000,104.54000,Aetna,Local,,144.19,,,,,,,129.95,294.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CANNULA SPINAL,8462058,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,360.48000,104.54000,Aetna,Local,,144.19,,,,,,,116.07,294.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CANNULA SPINAL,8462059,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,3300.01,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CANNULA SPINAL,8462059,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,2947.58,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8462089,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8462089,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8462093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8462093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT KYPHOPLASTY BALLOON,7736522,CDM,278,RC,A4215,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,3300.01,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT KYPHOPLASTY BALLOON,7736522,CDM,278,RC,A4215,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,0.14445,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462173,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462173,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8462174,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8462174,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8462175,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8462175,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8462176,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8462176,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8462177,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,415.63000,120.53000,Aetna,Local,,166.25,,,,,,,149.83,339.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8462177,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,415.63000,120.53000,Aetna,Local,,166.25,,,,,,,133.83,339.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8462178,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8462178,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462179,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462179,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8462182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8462182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8462184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8462184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR TENDON LIGAMENT,8462187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR TENDON LIGAMENT,8462187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8462295,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8462295,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8462297,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8462297,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8463786,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8463786,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8462287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8462287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8462289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8462204,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8462204,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8462205,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2936.27,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8462205,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,Local,,3258.00,,,,,,,2622.69,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8462206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8462206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8462291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8462291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8462293,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,Local,,2241.68,,,,,,,2020.31,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8462293,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,Local,,2241.68,,,,,,,1804.55,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8462298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8462298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8463787,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1356.36000,393.34000,Aetna,Local,,542.54,,,,,,,488.97,1109.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8463787,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1356.36000,393.34000,Aetna,Local,,542.54,,,,,,,436.75,1109.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TRANSPROSTATIC,8462304,CDM,278,RC,C9739,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TRANSPROSTATIC,8462304,CDM,278,RC,C9739,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,3456.00,,,,,,,1662.33,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PLATE,8463794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9589.20000,2780.87000,Aetna,Local,,3835.68,,,,,,,3456.91,7843.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8463794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9589.20000,2780.87000,Aetna,Local,,3835.68,,,,,,,3087.72,7843.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8463789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8463789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8463790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8463790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8463791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8463791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8463792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8463792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8463793,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8463793,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8463859,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4375.00000,1268.75000,Aetna,Local,,1750.00,,,,,,,1577.19,3578.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8463859,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4375.00000,1268.75000,Aetna,Local,,1750.00,,,,,,,1408.75,3578.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8463860,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8055.00000,2335.95000,Aetna,Local,,3222.00,,,,,,,2903.83,6588.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8463860,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8055.00000,2335.95000,Aetna,Local,,3222.00,,,,,,,2593.71,6588.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8463861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1803.30000,522.96000,Aetna,Local,,721.32,,,,,,,650.09,1475.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8463861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1803.30000,522.96000,Aetna,Local,,721.32,,,,,,,580.66,1475.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPIINAL,8463862,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPIINAL,8463862,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8463863,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8463863,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8463864,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8463864,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8463865,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8463865,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8463866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8463866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8464371,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8464371,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8464389,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8464389,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8464353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8464353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN FIXATION,8464355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN FIXATION,8464355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8464357,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8464357,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8464857,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8464857,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8464859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8464859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8464867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8464869,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8464869,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8464871,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8464871,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8464873,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8464873,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8464874,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8464874,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8464876,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8464876,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8465072,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8465072,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8465073,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8465073,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8465074,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,38137.50000,11059.88000,Aetna,Local,,15255.00,,,,,,,13748.57,31196.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8465074,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,38137.50000,11059.88000,Aetna,Local,,15255.00,,,,,,,12280.27,31196.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8465075,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8465075,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8465076,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8465076,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8465774,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5634.61,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8465774,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,Local,,6252.00,,,,,,,5032.86,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8465810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8465810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8465812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8465812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8465814,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8465814,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8465816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8465816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8465819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8465819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8465822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4912.43000,1424.60000,Aetna,Local,,1964.97,,,,,,,1770.93,4018.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8465822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4912.43000,1424.60000,Aetna,Local,,1964.97,,,,,,,1581.80,4018.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8465824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4912.43000,1424.60000,Aetna,Local,,1964.97,,,,,,,1770.93,4018.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8465824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4912.43000,1424.60000,Aetna,Local,,1964.97,,,,,,,1581.80,4018.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8465826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5950.04000,1725.51000,Aetna,Local,,2380.02,,,,,,,2144.99,4867.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8465826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5950.04000,1725.51000,Aetna,Local,,2380.02,,,,,,,1915.91,4867.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8465828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5950.04000,1725.51000,Aetna,Local,,2380.02,,,,,,,2144.99,4867.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8465828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5950.04000,1725.51000,Aetna,Local,,2380.02,,,,,,,1915.91,4867.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8465830,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8465830,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.06000,86.73000,Aetna,Local,,119.62,,,,,,,107.81,244.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.06000,86.73000,Aetna,Local,,119.62,,,,,,,96.30,244.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8465835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1247.52000,361.78000,Aetna,Local,,499.01,,,,,,,449.73,1020.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8465835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1247.52000,361.78000,Aetna,Local,,499.01,,,,,,,401.70,1020.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8465842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5127.50000,1486.98000,Aetna,Local,,2051.00,,,,,,,1848.46,4194.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8465842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5127.50000,1486.98000,Aetna,Local,,2051.00,,,,,,,1651.06,4194.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8465922,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8465922,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8465926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7357.44000,2133.66000,Aetna,Local,,2942.98,,,,,,,2652.36,6018.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8465926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7357.44000,2133.66000,Aetna,Local,,2942.98,,,,,,,2369.10,6018.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8465928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2464.00000,714.56000,Aetna,Local,,985.60,,,,,,,888.27,2015.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8465928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2464.00000,714.56000,Aetna,Local,,985.60,,,,,,,793.41,2015.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT CEMENT,8465930,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,14220.00000,4123.80000,Aetna,Local,,5688.00,,,,,,,5126.31,11631.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT CEMENT,8465930,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,14220.00000,4123.80000,Aetna,Local,,5688.00,,,,,,,4578.84,11631.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8465932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7980.00000,2314.20000,Aetna,Local,,3192.00,,,,,,,2876.79,6527.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8465932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7980.00000,2314.20000,Aetna,Local,,3192.00,,,,,,,2569.56,6527.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8465934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8465934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8465944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8465944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8465948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8466068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8466068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8466070,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8466070,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8466072,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8466072,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8466076,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8466076,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8466077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8466077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8467762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.72000,167.25000,Aetna,Local,,230.69,,,,,,,207.91,471.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8467762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.72000,167.25000,Aetna,Local,,230.69,,,,,,,185.70,471.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8467764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3344.67000,969.95000,Aetna,Local,,1337.87,,,,,,,1205.75,2735.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8467764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3344.67000,969.95000,Aetna,Local,,1337.87,,,,,,,1076.98,2735.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8467766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1633.44000,473.70000,Aetna,Local,,653.38,,,,,,,588.86,1336.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8467766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1633.44000,473.70000,Aetna,Local,,653.38,,,,,,,525.97,1336.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8466129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8466129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8467744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8467744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8466132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8466132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8466131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8466131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8467768,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8467768,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8467769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,172.10,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8467769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,477.38000,138.44000,Aetna,Local,,190.95,,,,,,,153.72,390.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8467770,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8270.94000,2398.57000,Aetna,Local,,3308.38,,,,,,,2981.67,6765.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8467770,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8270.94000,2398.57000,Aetna,Local,,3308.38,,,,,,,2663.24,6765.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POST MODULAR,8467771,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3936.00000,1141.44000,Aetna,Local,,1574.40,,,,,,,1418.93,3219.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POST MODULAR,8467771,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3936.00000,1141.44000,Aetna,Local,,1574.40,,,,,,,1267.39,3219.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8467777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8467777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8467778,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8467778,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8467779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8467779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8467780,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8467780,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8467772,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8467772,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,8467773,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,7417.29,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,8467773,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,6625.15,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS ANKLE,8467774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,Local,,8640.00,,,,,,,7786.80,17668.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS ANKLE,8467774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,Local,,8640.00,,,,,,,6955.20,17668.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8467775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3360.22,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8467775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3001.36,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8468069,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8468069,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8468071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5999.00000,1739.71000,Aetna,Local,,2399.60,,,,,,,2162.64,4907.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8468071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5999.00000,1739.71000,Aetna,Local,,2399.60,,,,,,,1931.68,4907.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8468075,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2348.12,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8468075,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2097.35,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8468077,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8468077,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8468079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,1049.78,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8468079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,937.66,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS SHOULDER,8468081,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6083.00000,1764.07000,Aetna,Local,,2433.20,,,,,,,2192.92,4975.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS SHOULDER,8468081,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6083.00000,1764.07000,Aetna,Local,,2433.20,,,,,,,1958.73,4975.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8468083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1596.11,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8468083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1425.65,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8468087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8468087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8468272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8468272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8467776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8467776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8468160,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8468160,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8468161,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8468161,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8468162,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8468162,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,928.44000,269.25000,Aetna,Local,,371.38,,,,,,,334.70,759.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8468273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,928.44000,269.25000,Aetna,Local,,371.38,,,,,,,298.96,759.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8468274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8468274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8468480,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1356.36000,393.34000,Aetna,Local,,542.54,,,,,,,488.97,1109.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8468480,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1356.36000,393.34000,Aetna,Local,,542.54,,,,,,,436.75,1109.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8468481,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8468481,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8469913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8469913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8469914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8469914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8469915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8469915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8469916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8469916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8469874,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8469874,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8469912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4407.38000,1278.14000,Aetna,Local,,1762.95,,,,,,,1588.86,3605.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8469912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4407.38000,1278.14000,Aetna,Local,,1762.95,,,,,,,1419.18,3605.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8471862,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8471862,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8471864,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8471864,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT IN KIT,7840042,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,15850.50000,4596.64000,Aetna,Local,,6340.20,,,,,,,5714.11,12965.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT IN KIT,7840042,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,15850.50000,4596.64000,Aetna,Local,,6340.20,,,,,,,5103.86,12965.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT IN KIT,8471860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15850.50000,4596.64000,Aetna,Local,,6340.20,,,,,,,5714.11,12965.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT IN KIT,8471860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15850.50000,4596.64000,Aetna,Local,,6340.20,,,,,,,5103.86,12965.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8471774,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8471774,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8471776,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8471776,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8471778,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8471778,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8471731,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8471731,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8471730,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8471730,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8471729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8471729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8471780,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,17077.50000,4952.47000,Aetna,Local,,6831.00,,,,,,,6156.44,13969.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8471780,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,17077.50000,4952.47000,Aetna,Local,,6831.00,,,,,,,124.65,13969.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8471896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8471896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8471898,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8471898,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8471900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8471900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8471902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8471902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8471904,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,1106.01,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8471904,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3068.00000,889.72000,Aetna,Local,,1227.20,,,,,,,987.90,2509.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8473729,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8473729,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8473764,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8473764,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8473765,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8473765,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8473766,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8473766,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHERE GLENOID,8473771,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHERE GLENOID,8473771,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8473772,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8473772,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8473773,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8473773,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8473774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8473774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8473775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8473775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8473776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8473776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8473777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8473777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8473850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8473850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8473851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8265.00000,2396.85000,Aetna,Local,,3306.00,,,,,,,2979.53,6760.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8473851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8265.00000,2396.85000,Aetna,Local,,3306.00,,,,,,,2661.33,6760.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8473852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3248.00000,941.92000,Aetna,Local,,1299.20,,,,,,,1170.90,2656.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8473852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3248.00000,941.92000,Aetna,Local,,1299.20,,,,,,,1045.86,2656.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8473853,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8473853,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8473854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8473854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8473855,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8473855,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8473856,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8473856,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT HYBRID NEW AGE,8475777,CDM,278,RC,,,,,facility,inpatient,,,28125.00000,8156.25000,Aetna,Local,,11250.00,,,,,,,10139.06,23006.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT HYBRID NEW AGE,8475777,CDM,278,RC,,,,,facility,outpatient,,,28125.00000,8156.25000,Aetna,Local,,11250.00,,,,,,,9056.25,23006.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8475778,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8475778,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8475780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2929.08000,849.43000,Aetna,Local,,1171.63,,,,,,,1055.93,2395.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8475780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2929.08000,849.43000,Aetna,Local,,1171.63,,,,,,,943.16,2395.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8475895,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,713.79,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8475895,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,637.56,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8475896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8475896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8475897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3006.68000,871.94000,Aetna,Local,,1202.67,,,,,,,1083.91,2459.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8475897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3006.68000,871.94000,Aetna,Local,,1202.67,,,,,,,968.15,2459.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8475899,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8475899,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8475901,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8475901,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8477729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8477729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8477731,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8477731,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8477733,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8477733,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8477735,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8477735,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8477737,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8477737,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8477739,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6352.50000,1842.22000,Aetna,Local,,2541.00,,,,,,,2290.08,5196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8477739,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6352.50000,1842.22000,Aetna,Local,,2541.00,,,,,,,2045.51,5196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8477741,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8477741,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8477742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8477742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8477972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8477972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8477744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8477744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8477746,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8477746,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8477748,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8477748,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8477750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8477750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8477751,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8477751,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8477753,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,3001.16,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8477753,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,2680.65,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8477754,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8477754,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8477755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8477755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8477756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8477756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8477757,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8477757,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8477758,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,3001.16,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8477758,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,2680.65,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8477752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8477752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8477974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8477974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8477975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8477975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8477976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2348.12,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8477976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2097.35,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8477977,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,1049.78,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8477977,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,937.66,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8477978,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,1049.78,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8477978,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,937.66,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8477979,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6083.00000,1764.07000,Aetna,Local,,2433.20,,,,,,,2192.92,4975.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8477979,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6083.00000,1764.07000,Aetna,Local,,2433.20,,,,,,,1958.73,4975.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478388,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478388,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8478389,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8478389,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8478390,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8478390,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8478391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1868.00000,541.72000,Aetna,Local,,747.20,,,,,,,673.41,1528.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8478391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1868.00000,541.72000,Aetna,Local,,747.20,,,,,,,601.50,1528.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8478429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8478429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478431,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478431,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8478433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8478433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8478392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8478392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8478437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8478437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8478442,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,70.03,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8478442,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,194.25000,56.33000,Aetna,Local,,77.70,,,,,,,62.55,158.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8478443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8478443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8478504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8478504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8478506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11227.50000,3255.98000,Aetna,Local,,4491.00,,,,,,,4047.51,9184.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8478506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11227.50000,3255.98000,Aetna,Local,,4491.00,,,,,,,3615.26,9184.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,8478636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,8478636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8478629,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8478629,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8478630,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8478630,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8478631,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.63000,120.53000,Aetna,Local,,166.25,,,,,,,149.83,339.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8478631,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.63000,120.53000,Aetna,Local,,166.25,,,,,,,133.83,339.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHIM,8478632,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHIM,8478632,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE,8478633,CDM,278,RC,,,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE,8478633,CDM,278,RC,,,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MAT,8478634,CDM,278,RC,,,,,facility,inpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,677.74,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MAT,8478634,CDM,278,RC,,,,,facility,outpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,605.36,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8478635,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8478635,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8478628,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,22700.00000,6583.00000,Aetna,Local,,9080.00,,,,,,,8183.35,18568.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8478628,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,22700.00000,6583.00000,Aetna,Local,,9080.00,,,,,,,7309.40,18568.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8478638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8478638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8478640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8478640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,8478643,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,8478643,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8478641,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8478641,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8478642,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8478642,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,8478644,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,8478644,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3360.22,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8478646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3001.36,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOME,8478645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,Local,,8640.00,,,,,,,7786.80,17668.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOME,8478645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,Local,,8640.00,,,,,,,6955.20,17668.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8478647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8478647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8478648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2543.68000,737.67000,Aetna,Local,,1017.47,,,,,,,917.00,2080.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8478648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2543.68000,737.67000,Aetna,Local,,1017.47,,,,,,,819.06,2080.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8479730,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24750.00000,7177.50000,Aetna,Local,,9900.00,,,,,,,8922.38,20245.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8479730,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24750.00000,7177.50000,Aetna,Local,,9900.00,,,,,,,7969.50,20245.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8481909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8481909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8481911,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8481911,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8481913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8481913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8481915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8481915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8481917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8481917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8479731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8479731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8479751,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8479751,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8479753,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8479753,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8479732,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8479732,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8479756,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8479756,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8479758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8479758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8479760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8479760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8479787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8479787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8479788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8479788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8479789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8479789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8479790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8479790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8479791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8479791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8479762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,4133.49,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8479762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,3692.05,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8479764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,436.93,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8479764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,390.26,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8479780,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8479780,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8479783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8479783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8479770,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,415.63000,120.53000,Aetna,Local,,166.25,,,,,,,149.83,339.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8479770,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,415.63000,120.53000,Aetna,Local,,166.25,,,,,,,133.83,339.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8479772,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8479772,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8479774,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8479774,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8479776,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8479776,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8479778,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8479778,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8479767,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8479767,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8479769,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8479769,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP END,8479795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.58000,214.48000,Aetna,Local,,295.83,,,,,,,266.62,604.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP END,8479795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.58000,214.48000,Aetna,Local,,295.83,,,,,,,238.14,604.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8479784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8479784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8479785,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8479785,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8479786,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8479786,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8479782,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8479782,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8479792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8479792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8479793,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8479793,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ACETABULAR,8479794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1876.22,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ACETABULAR,8479794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1675.85,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8479781,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8479781,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8479796,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,21437.50000,6216.88000,Aetna,Local,,8575.00,,,,,,,7728.22,17535.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8479796,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,21437.50000,6216.88000,Aetna,Local,,8575.00,,,,,,,6902.88,17535.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8481919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8481919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8481921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,964.29,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8481921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,861.31,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8481923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8580.00000,2488.20000,Aetna,Local,,3432.00,,,,,,,3093.09,7018.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8481923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8580.00000,2488.20000,Aetna,Local,,3432.00,,,,,,,2762.76,7018.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8481967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3475.94,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8481967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3104.72,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8481968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8481968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8481969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8481969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8481972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3360.22,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8481972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3001.36,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8483925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,7417.29,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8483925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,6625.15,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT RESTRICTOR,8485947,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,219.00,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT RESTRICTOR,8485947,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,195.62,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8485931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6514.20000,1889.12000,Aetna,Local,,2605.68,,,,,,,2348.37,5328.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8485931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6514.20000,1889.12000,Aetna,Local,,2605.68,,,,,,,2097.57,5328.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8485933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17235.00000,4998.15000,Aetna,Local,,6894.00,,,,,,,6213.22,14098.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8485933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17235.00000,4998.15000,Aetna,Local,,6894.00,,,,,,,5549.67,14098.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8485935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7860.00000,2279.40000,Aetna,Local,,3144.00,,,,,,,2833.53,6429.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8485935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7860.00000,2279.40000,Aetna,Local,,3144.00,,,,,,,2530.92,6429.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8485937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2481.20000,719.55000,Aetna,Local,,992.48,,,,,,,894.47,2029.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8485937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2481.20000,719.55000,Aetna,Local,,992.48,,,,,,,798.95,2029.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BODY,8485939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17797.50000,5161.27000,Aetna,Local,,7119.00,,,,,,,6416.00,14558.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BODY,8485939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17797.50000,5161.27000,Aetna,Local,,7119.00,,,,,,,5730.80,14558.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8485941,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8485941,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8485945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8485945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8485949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,32460.68000,9413.60000,Aetna,Local,,12984.27,,,,,,,11702.08,26552.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8485949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,32460.68000,9413.60000,Aetna,Local,,12984.27,,,,,,,10452.34,26552.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8485951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8485951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8485953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8485953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8487990,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8487990,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8486000,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8486000,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8486002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8486002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8486004,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8486004,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8486006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8486006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8486008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8486008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8486010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5999.00000,1739.71000,Aetna,Local,,2399.60,,,,,,,2162.64,4907.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8486010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5999.00000,1739.71000,Aetna,Local,,2399.60,,,,,,,1931.68,4907.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8486011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2348.12,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8486011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2097.35,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8486012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,1049.78,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8486012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,937.66,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8487992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8487992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8487994,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8487994,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8488006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,7669.64,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8488006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,6850.55,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8487996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8487996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8487998,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8487998,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8488000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8488000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8488002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8488002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8488004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,865.20,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8488004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,772.80,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ACETABULAR,8490024,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,179.80,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ACETABULAR,8490024,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,160.60,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8489972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8489972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8489973,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8489973,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8489974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8489974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8490019,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8490019,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUSTOM TALAR,8488009,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,41737.50000,12103.88000,Aetna,Local,,16695.00,,,,,,,15046.37,34141.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUSTOM TALAR,8488009,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,41737.50000,12103.88000,Aetna,Local,,16695.00,,,,,,,13439.48,34141.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8490021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8490021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8493925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3475.94,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8493925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3104.72,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8493926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8493926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTOLAYNGOLOGY IMPLANT,8496708,CDM,278,RC,C1878,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTOLAYNGOLOGY IMPLANT,8496708,CDM,278,RC,C1878,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8496709,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8496709,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION SPINAL,8496710,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION SPINAL,8496710,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8496711,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8496711,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8496712,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8496712,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8496713,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8496713,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8496714,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8496714,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8496715,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8496715,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8496719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3404.66000,987.35000,Aetna,Local,,1361.86,,,,,,,1227.38,2785.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8496719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3404.66000,987.35000,Aetna,Local,,1361.86,,,,,,,1096.30,2785.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8496722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5043.15000,1462.51000,Aetna,Local,,2017.26,,,,,,,1818.06,4125.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8496722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5043.15000,1462.51000,Aetna,Local,,2017.26,,,,,,,1623.89,4125.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8496716,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8496716,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8496717,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8496717,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8496783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8496783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8496784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8496784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8496786,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8496786,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8497931,CDM,278,RC,,,,,facility,inpatient,,,19150.00000,5553.50000,Aetna,Local,,7660.00,,,,,,,6903.57,15664.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8497931,CDM,278,RC,,,,,facility,outpatient,,,19150.00000,5553.50000,Aetna,Local,,7660.00,,,,,,,6166.30,15664.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8497936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8497936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8497943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8497943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8497945,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8497945,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8497947,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8497947,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8497949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8497949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8497951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8497951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8497952,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,624.39,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8497952,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,557.70,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8497953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8497953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8497954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8497954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8499938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8499938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8499925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8499925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8499926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8499926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8499927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8499927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8499928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8499928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8499929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8499929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8499930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8499930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8499931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8499931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8499932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8499932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8499933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3892.88000,1128.94000,Aetna,Local,,1557.15,,,,,,,1403.38,3184.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8499933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3892.88000,1128.94000,Aetna,Local,,1557.15,,,,,,,1253.51,3184.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8499934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2348.12,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8499934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2097.35,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8499935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8499935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8499936,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8499936,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8499937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8499937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8499939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8499939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8502023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1211.28,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8502023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1081.92,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8502025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8502025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8502027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8502027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8502029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1734.59,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8502029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1549.34,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8502031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3100.40000,899.12000,Aetna,Local,,1240.16,,,,,,,1117.69,2536.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8502031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3100.40000,899.12000,Aetna,Local,,1240.16,,,,,,,998.33,2536.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8502035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8502035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8502037,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8502037,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8502039,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8502039,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8502041,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8502041,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,8502043,CDM,278,RC,C9353,HCPCS,,,facility,inpatient,,,12045.00000,3493.05000,Aetna,Local,,4818.00,,,,,,,4342.22,9852.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,8502043,CDM,278,RC,C9353,HCPCS,,,facility,outpatient,,,12045.00000,3493.05000,Aetna,Local,,4818.00,,,,,,,3878.49,9852.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8502033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8502033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8502045,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8502045,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8505925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8505925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8505927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8505927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8505929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8505929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8505931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8505931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,8505933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,8505933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8505935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8505935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8505937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8505937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8505939,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8505939,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8505941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8505941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8505943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8505943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8505945,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8505945,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,8505947,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,3489.78000,1012.04000,Aetna,Local,,1395.91,,,,,,,1258.07,2854.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,8505947,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,3489.78000,1012.04000,Aetna,Local,,1395.91,,,,,,,1123.71,2854.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8505949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8505949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8505951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8505951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8505953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8505953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8505956,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8505956,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8505995,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8505995,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8509925,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8509925,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8508000,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8508000,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8513929,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8513929,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8513930,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8513930,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8513937,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8513937,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8513931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8513931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8513933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8513933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8513925,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8513925,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8513927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8513927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8516822,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8516822,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8516824,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8516824,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8516825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8516825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8516827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8516827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8516829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8516829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8516831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8516831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8517955,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8517955,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8517966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17095.00000,4957.55000,Aetna,Local,,6838.00,,,,,,,6162.75,13983.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8517966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17095.00000,4957.55000,Aetna,Local,,6838.00,,,,,,,5504.59,13983.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8517968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8517968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN GUIDE,8517970,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1596.00000,462.84000,Aetna,Local,,638.40,,,,,,,575.36,1305.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN GUIDE,8517970,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1596.00000,462.84000,Aetna,Local,,638.40,,,,,,,513.91,1305.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LUMBAR CATHETER IN KIT,8517971,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1549.28000,449.29000,Aetna,Local,,619.71,,,,,,,558.52,1267.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LUMBAR CATHETER IN KIT,8517971,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1549.28000,449.29000,Aetna,Local,,619.71,,,,,,,498.87,1267.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8519925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,929.66000,269.60000,Aetna,Local,,371.86,,,,,,,335.14,760.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8519925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,929.66000,269.60000,Aetna,Local,,371.86,,,,,,,299.35,760.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8519926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3643.50000,1056.62000,Aetna,Local,,1457.40,,,,,,,1313.48,2980.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8519926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3643.50000,1056.62000,Aetna,Local,,1457.40,,,,,,,1173.21,2980.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8519927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8519927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8522118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5233.20000,1517.63000,Aetna,Local,,2093.28,,,,,,,1886.57,4280.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8522118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5233.20000,1517.63000,Aetna,Local,,2093.28,,,,,,,1685.09,4280.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8522121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8522121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8522123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8522123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8522125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8522125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8522127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8522127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8522129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8522129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8522137,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9900.00000,2871.00000,Aetna,Local,,3960.00,,,,,,,3568.95,8098.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8522137,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9900.00000,2871.00000,Aetna,Local,,3960.00,,,,,,,3187.80,8098.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8522143,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8522143,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG IN KIT,7695033,CDM,278,RC,,,,,facility,inpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG IN KIT,7695033,CDM,278,RC,,,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8523925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8523925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8523927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8523927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8523929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8523929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8523931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8523931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8523935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8523935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8523937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8523937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8523939,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8523939,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8523941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8523941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8526023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8526023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8526025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,109.95,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8526025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,98.21,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8526027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,109.95,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8526027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,122.00,,,,,,,98.21,249.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8526029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2162.56000,627.14000,Aetna,Local,,865.02,,,,,,,779.60,1768.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8526029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2162.56000,627.14000,Aetna,Local,,865.02,,,,,,,696.34,1768.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8526031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1635.23,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8526031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1460.59,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8526033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8526033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8527974,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8527974,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8527975,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,677.74,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8527975,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,605.36,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8531935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8531935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8527976,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3465.00000,1004.85000,Aetna,Local,,1386.00,,,,,,,1249.13,2834.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8527976,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3465.00000,1004.85000,Aetna,Local,,1386.00,,,,,,,1115.73,2834.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8527977,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3465.00000,1004.85000,Aetna,Local,,1386.00,,,,,,,1249.13,2834.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8527977,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3465.00000,1004.85000,Aetna,Local,,1386.00,,,,,,,1115.73,2834.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8532008,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3465.00000,1004.85000,Aetna,Local,,1386.00,,,,,,,1249.13,2834.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8532008,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3465.00000,1004.85000,Aetna,Local,,1386.00,,,,,,,1115.73,2834.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8527978,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8527978,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8527979,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8527979,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8527980,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8527980,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8527985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8527985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8527986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8527986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8527987,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8527987,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8527988,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7831.80000,2271.22000,Aetna,Local,,3132.72,,,,,,,2823.36,6406.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8527988,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7831.80000,2271.22000,Aetna,Local,,3132.72,,,,,,,2521.84,6406.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8527989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8527989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8527991,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8527991,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8532018,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,1356.36000,393.34000,Aetna,Local,,542.54,,,,,,,488.97,1109.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8532018,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,1356.36000,393.34000,Aetna,Local,,542.54,,,,,,,436.75,1109.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8532010,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8532010,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8532012,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8532012,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8532014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8532014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8532015,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8532015,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8532016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8532016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8532017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1395.50,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8532017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,Local,,1548.40,,,,,,,1246.46,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8532019,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8532019,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8532020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8532020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH BAG,8532033,CDM,278,RC,C1765,HCPCS,,,facility,inpatient,,,3920.00000,1136.80000,Aetna,Local,,1568.00,,,,,,,1413.16,3206.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH BAG,8532033,CDM,278,RC,C1765,HCPCS,,,facility,outpatient,,,3920.00000,1136.80000,Aetna,Local,,1568.00,,,,,,,1262.24,3206.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8534003,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8534003,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8534005,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8534005,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8534007,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8534007,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8534009,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8534009,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8534011,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8534011,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8534013,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8534013,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8534015,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8534015,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8533999,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8533999,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8534001,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,3001.16,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8534001,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,2680.65,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8539927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8539927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8539925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8539925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8539930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,1049.78,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8539930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,937.66,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8539932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8539932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8542279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8542279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8542281,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8542281,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8547929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8547929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8547931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8547931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8547933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8547933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8551925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8551925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8551927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8551927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8551929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4774.07000,1384.48000,Aetna,Local,,1909.63,,,,,,,1721.05,3905.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8551929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4774.07000,1384.48000,Aetna,Local,,1909.63,,,,,,,1537.25,3905.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8553925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8553925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8556206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,507.78000,147.26000,Aetna,Local,,203.11,,,,,,,183.05,415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8556206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,507.78000,147.26000,Aetna,Local,,203.11,,,,,,,163.51,415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8556208,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8556208,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8559938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2070.72000,600.51000,Aetna,Local,,828.29,,,,,,,746.49,1693.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8559938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2070.72000,600.51000,Aetna,Local,,828.29,,,,,,,666.77,1693.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8559940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6471.50000,1876.74000,Aetna,Local,,2588.60,,,,,,,2332.98,5293.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8559940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6471.50000,1876.74000,Aetna,Local,,2588.60,,,,,,,2083.82,5293.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8563930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8563930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8563932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8563932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8563934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8563934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8563937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1542.49,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8563937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4278.75000,1240.84000,Aetna,Local,,1711.50,,,,,,,1377.76,3500.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8563941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8563941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563951,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563951,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8563957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16407.25000,4758.10000,Aetna,Local,,6562.90,,,,,,,5914.81,13421.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8563957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16407.25000,4758.10000,Aetna,Local,,6562.90,,,,,,,5283.13,13421.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8563959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3064.40000,888.68000,Aetna,Local,,1225.76,,,,,,,1104.72,2506.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8563959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3064.40000,888.68000,Aetna,Local,,1225.76,,,,,,,986.74,2506.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8563969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8566062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1297.08,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8566062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1158.56,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8566063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8566063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8566064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8566064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8566065,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8566065,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8567931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26499.33000,7684.81000,Aetna,Local,,10599.73,,,,,,,9553.01,21676.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8567931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26499.33000,7684.81000,Aetna,Local,,10599.73,,,,,,,8532.78,21676.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8567934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2393.00000,693.97000,Aetna,Local,,957.20,,,,,,,862.68,1957.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8567934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2393.00000,693.97000,Aetna,Local,,957.20,,,,,,,770.55,1957.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8573942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8573942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8573944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8573944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8573946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8573946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8573948,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8573948,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8573950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8573950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8573952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8573952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8573954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8573954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8573956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5999.00000,1739.71000,Aetna,Local,,2399.60,,,,,,,2162.64,4907.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8573956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5999.00000,1739.71000,Aetna,Local,,2399.60,,,,,,,1931.68,4907.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8573958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2348.12,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8573958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2097.35,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8573960,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16150.00000,4683.50000,Aetna,Local,,6460.00,,,,,,,5822.07,13210.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8573960,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16150.00000,4683.50000,Aetna,Local,,6460.00,,,,,,,5200.30,13210.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8573962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,4346.82,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8573962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,3882.60,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8573965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8573965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8581925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1779.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8581925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1589.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8581927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8581927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8581929,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2588.00000,750.52000,Aetna,Local,,1035.20,,,,,,,932.97,2116.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8581929,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2588.00000,750.52000,Aetna,Local,,1035.20,,,,,,,833.34,2116.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8589925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,671.84,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8589925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,600.09,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8589928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2372.00000,687.88000,Aetna,Local,,948.80,,,,,,,855.11,1940.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8589928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2372.00000,687.88000,Aetna,Local,,948.80,,,,,,,763.78,1940.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8589930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8589930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8589932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,1049.78,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8589932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,937.66,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8593927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,3076.60,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8593927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,2748.03,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8595953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8595953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8595954,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8595954,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,Local,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8595955,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8595955,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8595956,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19125.00000,5546.25000,Aetna,Local,,7650.00,,,,,,,6894.56,15644.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8595956,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19125.00000,5546.25000,Aetna,Local,,7650.00,,,,,,,6158.25,15644.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8595982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8595982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8597933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3850.00000,1116.50000,Aetna,Local,,1540.00,,,,,,,1387.92,3149.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8597933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3850.00000,1116.50000,Aetna,Local,,1540.00,,,,,,,1239.70,3149.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8597935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8597935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8597937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8597937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8597939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8597939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8597941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5266.80000,1527.37000,Aetna,Local,,2106.72,,,,,,,1898.68,4308.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8597941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5266.80000,1527.37000,Aetna,Local,,2106.72,,,,,,,1695.91,4308.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8597943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3892.88000,1128.94000,Aetna,Local,,1557.15,,,,,,,1403.38,3184.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8597943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3892.88000,1128.94000,Aetna,Local,,1557.15,,,,,,,1253.51,3184.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8601929,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8601929,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8601931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8601931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8601933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8601933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601943,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601943,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8601945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8601947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8637.00000,2504.73000,Aetna,Local,,3454.80,,,,,,,3113.64,7065.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8601947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8637.00000,2504.73000,Aetna,Local,,3454.80,,,,,,,2781.11,7065.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8601949,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,38137.50000,11059.88000,Aetna,Local,,15255.00,,,,,,,13748.57,31196.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8601949,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,38137.50000,11059.88000,Aetna,Local,,15255.00,,,,,,,12280.27,31196.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8603980,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8603980,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8603981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8603981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8603982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8603982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8605947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8605947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8605951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8605951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8607986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8607986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8607992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8607992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8607994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1435.44000,416.28000,Aetna,Local,,574.18,,,,,,,517.48,1174.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8607994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1435.44000,416.28000,Aetna,Local,,574.18,,,,,,,462.21,1174.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DRAINAGE,8607996,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2059.64000,597.30000,Aetna,Local,,823.86,,,,,,,742.50,1684.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DRAINAGE,8607996,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2059.64000,597.30000,Aetna,Local,,823.86,,,,,,,663.20,1684.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DRAINAGE,7694134,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1484.32000,430.45000,Aetna,Local,,593.73,,,,,,,535.10,1214.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DRAINAGE,7694134,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1484.32000,430.45000,Aetna,Local,,593.73,,,,,,,477.95,1214.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8611928,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8611928,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8611931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8611931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8611933,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3977.89000,1153.59000,Aetna,Local,,1591.16,,,,,,,1434.03,3253.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8611933,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3977.89000,1153.59000,Aetna,Local,,1591.16,,,,,,,1280.88,3253.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8611934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8611934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8616103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8616103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8616105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8616105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8616107,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8616107,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8616109,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8616109,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8616111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8616111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8616113,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8616113,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8617926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8617926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8617928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8617928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8619936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8619936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONET,8619937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONET,8619937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8619938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8619938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8619940,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8619940,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8619939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8619939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8619943,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17235.00000,4998.15000,Aetna,Local,,6894.00,,,,,,,6213.22,14098.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8619943,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17235.00000,4998.15000,Aetna,Local,,6894.00,,,,,,,5549.67,14098.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8619944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8619944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD,8619945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11625.00000,3371.25000,Aetna,Local,,4650.00,,,,,,,4190.81,9509.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD,8619945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11625.00000,3371.25000,Aetna,Local,,4650.00,,,,,,,3743.25,9509.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NECK,8619946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3056.00000,886.24000,Aetna,Local,,1222.40,,,,,,,1101.69,2499.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NECK,8619946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3056.00000,886.24000,Aetna,Local,,1222.40,,,,,,,984.03,2499.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8619947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8619947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8623987,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8623987,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8623988,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8623988,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8623989,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8623989,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8623990,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8623990,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTOR SPINAL,8623991,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2700.00000,783.00000,Aetna,Local,,1080.00,,,,,,,973.35,2208.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTOR SPINAL,8623991,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2700.00000,783.00000,Aetna,Local,,1080.00,,,,,,,869.40,2208.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8623992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7860.00000,2279.40000,Aetna,Local,,3144.00,,,,,,,2833.53,6429.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8623992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7860.00000,2279.40000,Aetna,Local,,3144.00,,,,,,,2530.92,6429.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8619948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8619948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BILATERAL TMJ IMPLANT,8437324,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,50440.00000,14627.60000,Aetna,Local,,20176.00,,,,,,,18183.62,41259.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BILATERAL TMJ IMPLANT,8437324,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,50440.00000,14627.60000,Aetna,Local,,20176.00,,,,,,,16241.68,41259.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7702816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2880.00000,835.20000,Aetna,Local,,1152.00,,,,,,,1038.24,2355.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7702816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2880.00000,835.20000,Aetna,Local,,1152.00,,,,,,,927.36,2355.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8627938,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8627938,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8627940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1779.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8627940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1589.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8627942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8627942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8627944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8627944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8633928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8633928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8633930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8633930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8633932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10971.00000,3181.59000,Aetna,Local,,4388.40,,,,,,,3955.05,8974.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8633932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10971.00000,3181.59000,Aetna,Local,,4388.40,,,,,,,3532.66,8974.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,8633934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2892.00000,838.68000,Aetna,Local,,1156.80,,,,,,,1042.57,2365.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,8633934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2892.00000,838.68000,Aetna,Local,,1156.80,,,,,,,931.22,2365.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8633936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8633936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8638435,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8638435,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8638437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8638437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,132.88,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,368.60000,106.89000,Aetna,Local,,147.44,,,,,,,118.69,301.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8638443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5676.30000,1646.13000,Aetna,Local,,2270.52,,,,,,,2046.31,4643.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8638443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5676.30000,1646.13000,Aetna,Local,,2270.52,,,,,,,1827.77,4643.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638445,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638445,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8638451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8638453,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8638453,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8640003,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8640003,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8640005,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8640005,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8640007,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8640007,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8640009,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8640009,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8640011,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8640011,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8640013,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8640013,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8639993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,Local,,2471.00,,,,,,,2226.99,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8639993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,Local,,2471.00,,,,,,,1989.15,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8639995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3344.67000,969.95000,Aetna,Local,,1337.87,,,,,,,1205.75,2735.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8639995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3344.67000,969.95000,Aetna,Local,,1337.87,,,,,,,1076.98,2735.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8639997,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8639997,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8639999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8639999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8640001,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8640001,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8643934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8643934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,Local,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8643926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7746.00000,2246.34000,Aetna,Local,,3098.40,,,,,,,2792.43,6336.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8643926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7746.00000,2246.34000,Aetna,Local,,3098.40,,,,,,,2494.21,6336.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8643927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7746.00000,2246.34000,Aetna,Local,,3098.40,,,,,,,2792.43,6336.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8643927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7746.00000,2246.34000,Aetna,Local,,3098.40,,,,,,,2494.21,6336.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8643928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6191.50000,1795.54000,Aetna,Local,,2476.60,,,,,,,2232.04,5064.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8643928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6191.50000,1795.54000,Aetna,Local,,2476.60,,,,,,,1993.66,5064.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8643930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8643930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8643931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8643931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8643932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8643932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8643933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1659.30000,481.20000,Aetna,Local,,663.72,,,,,,,598.18,1357.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,8643933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1659.30000,481.20000,Aetna,Local,,663.72,,,,,,,534.29,1357.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8643941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8643941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643942,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643942,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643944,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643944,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643946,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643946,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8643947,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,677.74,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8643947,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,605.36,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8643948,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8643948,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8643949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8643949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8647925,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8647925,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643952,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643952,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8643954,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,677.74,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8643954,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,605.36,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643955,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643955,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643956,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643956,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643957,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8643957,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER SPINAL,8643958,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER SPINAL,8643958,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8647927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8647927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8647929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8647929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8647931,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2348.12,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8647931,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2097.35,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8647933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1696.00000,491.84000,Aetna,Local,,678.40,,,,,,,611.41,1387.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8647933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1696.00000,491.84000,Aetna,Local,,678.40,,,,,,,546.11,1387.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8647935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5999.00000,1739.71000,Aetna,Local,,2399.60,,,,,,,2162.64,4907.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8647935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5999.00000,1739.71000,Aetna,Local,,2399.60,,,,,,,1931.68,4907.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL BULKING SYSTEM,8516833,CDM,278,RC,L8606,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL BULKING SYSTEM,8516833,CDM,278,RC,L8606,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,268.67,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8649925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8649925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8649928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8649928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8649931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8649931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8649933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8649933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,8649935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,7417.29,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,8649935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,6625.15,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8649936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3360.22,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8649936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3001.36,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8651983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8651983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8651985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8651985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8651987,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8651987,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8651989,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8651989,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CANNULA,7736524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,371.76000,107.81000,Aetna,Local,,148.70,,,,,,,134.02,304.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CANNULA,7736524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,371.76000,107.81000,Aetna,Local,,148.70,,,,,,,119.71,304.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8655925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8655925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8659925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2000.00000,580.00000,Aetna,Local,,800.00,,,,,,,721.00,1636.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8659925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2000.00000,580.00000,Aetna,Local,,800.00,,,,,,,644.00,1636.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8659926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8659926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8659927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8659927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8667926,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8667926,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8667928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8667928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8667930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8667930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8667932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8667932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8667934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8667934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8667936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8667936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8667938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8667938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8667940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8667940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8667942,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4503.52000,1306.02000,Aetna,Local,,1801.41,,,,,,,1623.52,3683.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8667942,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4503.52000,1306.02000,Aetna,Local,,1801.41,,,,,,,1450.13,3683.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8667944,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8667944,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8667946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8667946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8667948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8667948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8667950,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,219.00,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8667950,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,195.62,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8667952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1322.00000,383.38000,Aetna,Local,,528.80,,,,,,,476.58,1081.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8667952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1322.00000,383.38000,Aetna,Local,,528.80,,,,,,,425.68,1081.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8667954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1322.00000,383.38000,Aetna,Local,,528.80,,,,,,,476.58,1081.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8667954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1322.00000,383.38000,Aetna,Local,,528.80,,,,,,,425.68,1081.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8667956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8667956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8667957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8667957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,Local,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8671934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8671934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8671936,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8671936,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8671938,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8671938,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8671939,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8671939,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8671940,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8671940,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8671941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8671941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8671925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8671925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8679925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8679925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8679927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8679927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8679929,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8679929,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8679931,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8679931,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8679933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8679933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8679935,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9675.00000,2805.75000,Aetna,Local,,3870.00,,,,,,,3487.84,7914.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8679935,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9675.00000,2805.75000,Aetna,Local,,3870.00,,,,,,,3115.35,7914.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8679937,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8679937,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8679939,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4140.57000,1200.77000,Aetna,Local,,1656.23,,,,,,,1492.68,3386.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8679939,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4140.57000,1200.77000,Aetna,Local,,1656.23,,,,,,,1333.26,3386.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8679940,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4308.92000,1249.59000,Aetna,Local,,1723.57,,,,,,,1553.37,3524.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8679940,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4308.92000,1249.59000,Aetna,Local,,1723.57,,,,,,,1387.47,3524.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8679941,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4308.92000,1249.59000,Aetna,Local,,1723.57,,,,,,,1553.37,3524.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8679941,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4308.92000,1249.59000,Aetna,Local,,1723.57,,,,,,,1387.47,3524.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8679942,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4642.26000,1346.26000,Aetna,Local,,1856.90,,,,,,,1673.53,3797.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8679942,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4642.26000,1346.26000,Aetna,Local,,1856.90,,,,,,,1494.81,3797.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8679985,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10928.25000,3169.19000,Aetna,Local,,4371.30,,,,,,,3939.63,8939.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8679985,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10928.25000,3169.19000,Aetna,Local,,4371.30,,,,,,,3518.90,8939.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8682002,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8682002,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8682003,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8682003,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8682004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8682004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8682005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3635.63000,1054.33000,Aetna,Local,,1454.25,,,,,,,1310.64,2973.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8682005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3635.63000,1054.33000,Aetna,Local,,1454.25,,,,,,,1170.67,2973.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8682258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8682258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8682253,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,11025.45000,3197.38000,Aetna,Local,,4410.18,,,,,,,3974.67,9018.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8682253,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,11025.45000,3197.38000,Aetna,Local,,4410.18,,,,,,,3550.19,9018.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8682257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3990.53000,1157.25000,Aetna,Local,,1596.21,,,,,,,1438.59,3264.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8682257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3990.53000,1157.25000,Aetna,Local,,1596.21,,,,,,,1284.95,3264.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8682260,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,11025.45000,3197.38000,Aetna,Local,,4410.18,,,,,,,3974.67,9018.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8682260,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,11025.45000,3197.38000,Aetna,Local,,4410.18,,,,,,,3550.19,9018.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8683952,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8683952,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8686213,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8686213,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8686214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8686214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL BASE,8686215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL BASE,8686215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONET,8686216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONET,8686216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,8686217,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2348.12,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,8686217,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6513.50000,1888.92000,Aetna,Local,,2605.40,,,,,,,2097.35,5328.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8686218,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,1049.78,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8686218,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2912.00000,844.48000,Aetna,Local,,1164.80,,,,,,,937.66,2382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8686219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,398.34000,115.52000,Aetna,Local,,159.34,,,,,,,143.60,325.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8686219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,398.34000,115.52000,Aetna,Local,,159.34,,,,,,,128.27,325.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8689925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8689925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8689927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8689927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8693925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8693925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,8693926,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,8693926,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8693927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1254.66,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8693927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,Local,,1392.13,,,,,,,1120.67,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABLULAR INSERT,8693928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABLULAR INSERT,8693928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8695955,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8695955,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONET,8697925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONET,8697925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8697927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8697927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE,8697929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE,8697929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,Local,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8701934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,450.62,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8701934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1250.00000,362.50000,Aetna,Local,,500.00,,,,,,,402.50,1022.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8701936,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8701936,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8701948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.06000,86.73000,Aetna,Local,,119.62,,,,,,,107.81,244.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8701948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.06000,86.73000,Aetna,Local,,119.62,,,,,,,96.30,244.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8705925,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,624.39,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8705925,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,557.70,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8705927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8705927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8707943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8707943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8709932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8709932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8709934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1291.62,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8709934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1153.68,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8709936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8709936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8709938,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8709938,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8713927,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8713927,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8713925,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8713925,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8719933,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8719933,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8719935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8719935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8719937,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8719937,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8719939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1211.28,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8719939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,Local,,1344.00,,,,,,,1081.92,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8719940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8719940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8719942,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8719942,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8719944,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8719944,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8719946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8719946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8726160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8726160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8726162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8726162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8726164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8726164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8726166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,860.87,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8726166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,768.94,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8726168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8726168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8726170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8726170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8726173,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8726173,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8730160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8730160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8730120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8730120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8732092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8732092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8736084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8736084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8736087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8736087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8740094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8740094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8742084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5029.50000,1458.55000,Aetna,Local,,2011.80,,,,,,,1813.13,4114.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8742084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5029.50000,1458.55000,Aetna,Local,,2011.80,,,,,,,1619.50,4114.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8742086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,3076.60,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8742086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,2748.03,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8742088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8742088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8742090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8742090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8746097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8746097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8750142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8750142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8754094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8754094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8754096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4137.00000,1199.73000,Aetna,Local,,1654.80,,,,,,,1491.39,3384.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8754096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4137.00000,1199.73000,Aetna,Local,,1654.80,,,,,,,1332.11,3384.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8754098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8754098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT BOX CABLE PLATE,8758089,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4973.50000,1442.31000,Aetna,Local,,1989.40,,,,,,,1792.95,4068.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT BOX CABLE PLATE,8758089,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4973.50000,1442.31000,Aetna,Local,,1989.40,,,,,,,1601.47,4068.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT BOX CABLE PLATE,8758090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5099.50000,1478.85000,Aetna,Local,,2039.80,,,,,,,1838.37,4171.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT BOX CABLE PLATE,8758090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5099.50000,1478.85000,Aetna,Local,,2039.80,,,,,,,1642.04,4171.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT BOX CABLE PLATE,8758091,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6611.50000,1917.33000,Aetna,Local,,2644.60,,,,,,,2383.45,5408.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT BOX CABLE PLATE,8758091,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6611.50000,1917.33000,Aetna,Local,,2644.60,,,,,,,2128.90,5408.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8760150,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8760150,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8760152,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8760152,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8760154,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8760154,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8760156,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8760156,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,Local,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8760158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5369.00000,1557.01000,Aetna,Local,,2147.60,,,,,,,1935.52,4391.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8760158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5369.00000,1557.01000,Aetna,Local,,2147.60,,,,,,,1728.82,4391.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8760160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8760160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8760162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8760162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8760164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2811.90,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8760164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2511.60,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8760166,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2099.00000,608.71000,Aetna,Local,,839.60,,,,,,,756.69,1716.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8760166,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2099.00000,608.71000,Aetna,Local,,839.60,,,,,,,675.88,1716.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8764085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5369.00000,1557.01000,Aetna,Local,,2147.60,,,,,,,1935.52,4391.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8764085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5369.00000,1557.01000,Aetna,Local,,2147.60,,,,,,,1728.82,4391.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8764088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8764088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8764090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8764090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8764092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8764092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8764094,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8764094,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8764096,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16150.00000,4683.50000,Aetna,Local,,6460.00,,,,,,,5822.07,13210.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8764096,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16150.00000,4683.50000,Aetna,Local,,6460.00,,,,,,,5200.30,13210.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8764087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8764087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8766235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8766235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8766237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8766237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8766239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8766239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8766241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4634.00000,1343.86000,Aetna,Local,,1853.60,,,,,,,1670.56,3790.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8766241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4634.00000,1343.86000,Aetna,Local,,1853.60,,,,,,,1492.15,3790.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8766243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8766243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8766247,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8766247,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8766249,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8766249,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8766245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8766245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8768240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8768240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WRENCH,8768242,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,3124.96000,906.24000,Aetna,Local,,1249.98,,,,,,,1126.55,2556.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WRENCH,8768242,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,3124.96000,906.24000,Aetna,Local,,1249.98,,,,,,,1006.24,2556.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8768243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,309.75000,89.83000,Aetna,Local,,123.90,,,,,,,111.66,253.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8768243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,309.75000,89.83000,Aetna,Local,,123.90,,,,,,,99.74,253.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTRACTOR,8768245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11227.35000,3255.93000,Aetna,Local,,4490.94,,,,,,,4047.46,9183.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTRACTOR,8768245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11227.35000,3255.93000,Aetna,Local,,4490.94,,,,,,,3615.21,9183.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696349,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,356.58000,103.41000,Aetna,Local,,142.63,,,,,,,128.55,291.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696349,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,356.58000,103.41000,Aetna,Local,,142.63,,,,,,,114.82,291.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8772096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8772096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8772097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8772097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8772098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8772098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8772095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8772095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8776135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8776135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8776139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17486.75000,5071.16000,Aetna,Local,,6994.70,,,,,,,6303.97,14304.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8776139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17486.75000,5071.16000,Aetna,Local,,6994.70,,,,,,,5630.73,14304.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8776141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8776141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8776143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8360.52000,2424.55000,Aetna,Local,,3344.21,,,,,,,3013.97,6838.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8776143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8360.52000,2424.55000,Aetna,Local,,3344.21,,,,,,,2692.09,6838.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8776145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8776145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8776165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8776165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8776147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22500.00000,6525.00000,Aetna,Local,,9000.00,,,,,,,8111.25,18405.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8776147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22500.00000,6525.00000,Aetna,Local,,9000.00,,,,,,,7245.00,18405.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,8776137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,8776137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8780084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,2171.47,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8780084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6023.50000,1746.81000,Aetna,Local,,2409.40,,,,,,,1939.57,4927.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8780086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8780086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8780088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8780088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8780090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8780090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8780092,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8780092,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8780094,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8780094,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8780110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1873.70,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8780110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,Local,,2079.00,,,,,,,1673.60,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8780111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8780111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8780112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8780112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM IMPLANT FHL,8780113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM IMPLANT FHL,8780113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8784138,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8784138,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8784139,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8784139,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8784141,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8784141,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8784144,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8784144,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8784146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,357.44000,103.66000,Aetna,Local,,142.98,,,,,,,128.86,292.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8784146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,357.44000,103.66000,Aetna,Local,,142.98,,,,,,,115.10,292.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8784148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.41000,95.53000,Aetna,Local,,131.76,,,,,,,118.75,269.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8784148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.41000,95.53000,Aetna,Local,,131.76,,,,,,,106.07,269.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8784150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,351.60000,101.96000,Aetna,Local,,140.64,,,,,,,126.75,287.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8784150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,351.60000,101.96000,Aetna,Local,,140.64,,,,,,,113.22,287.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8786162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8786162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8786163,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8786163,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8788104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8788104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8788108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8788108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8788110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8788110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8788113,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,7502.91,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8788113,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20812.50000,6035.62000,Aetna,Local,,8325.00,,,,,,,6701.62,17024.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8792085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8792085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8792087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4760.70000,1380.60000,Aetna,Local,,1904.28,,,,,,,1716.23,3894.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8792087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4760.70000,1380.60000,Aetna,Local,,1904.28,,,,,,,1532.95,3894.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8792089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8792089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8792091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8792091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8796087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8796087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8796089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8796089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8796091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8796091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8796093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1715.04000,497.36000,Aetna,Local,,686.02,,,,,,,618.27,1402.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8796093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1715.04000,497.36000,Aetna,Local,,686.02,,,,,,,552.24,1402.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8796095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2936.00000,851.44000,Aetna,Local,,1174.40,,,,,,,1058.43,2401.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8796095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2936.00000,851.44000,Aetna,Local,,1174.40,,,,,,,945.39,2401.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8796098,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,4658.50000,1350.96000,Aetna,Local,,1863.40,,,,,,,1679.39,3810.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,8796098,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,4658.50000,1350.96000,Aetna,Local,,1863.40,,,,,,,1500.04,3810.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8798136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8798136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8798139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8798139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8802084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2760.60000,800.57000,Aetna,Local,,1104.24,,,,,,,995.20,2258.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8802084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2760.60000,800.57000,Aetna,Local,,1104.24,,,,,,,888.91,2258.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,8802085,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,8802085,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8802086,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8802086,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8812084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8812084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8812086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1297.08,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8812086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1158.56,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8812088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8812088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8812090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8812090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8812092,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8812092,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8812094,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8812094,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8812096,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8812096,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8812098,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8812098,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8812100,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8812100,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8812102,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8812102,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8812104,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,488.12,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8812104,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,435.99,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8812105,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,488.12,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8812105,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,435.99,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8824084,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8824084,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824086,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824086,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824088,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824088,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824090,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824090,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824092,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824092,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824094,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824094,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824096,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824096,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824098,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824098,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824100,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824100,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824102,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824102,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824104,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824104,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824106,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824106,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824108,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,160.28,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824108,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,444.60000,128.93000,Aetna,Local,,177.84,,,,,,,143.16,363.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824110,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8824110,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8824112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8824112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8824114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8824114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8824116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8824116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8824118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8824118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8824120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8824120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8824122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8824122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8824128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,130.14,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8824128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,116.24,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698039,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,576.80,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698039,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,515.20,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8828088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,576.80,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8828088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,515.20,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8828090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8828090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8828092,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8828092,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8828094,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,Local,,1244.80,,,,,,,1121.88,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8828094,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,Local,,1244.80,,,,,,,1002.06,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8828098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1239.20000,359.37000,Aetna,Local,,495.68,,,,,,,446.73,1013.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8828098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1239.20000,359.37000,Aetna,Local,,495.68,,,,,,,399.02,1013.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8828099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6373.50000,1848.31000,Aetna,Local,,2549.40,,,,,,,2297.65,5213.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8828099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6373.50000,1848.31000,Aetna,Local,,2549.40,,,,,,,2052.27,5213.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8828100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4668.30000,1353.81000,Aetna,Local,,1867.32,,,,,,,1682.92,3818.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8828100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4668.30000,1353.81000,Aetna,Local,,1867.32,,,,,,,1503.19,3818.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8828101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8828101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8840084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8840084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8848084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,304.48000,88.30000,Aetna,Local,,121.79,,,,,,,109.77,249.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8848084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,304.48000,88.30000,Aetna,Local,,121.79,,,,,,,98.04,249.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8848099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5105.10000,1480.48000,Aetna,Local,,2042.04,,,,,,,1840.39,4175.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8848099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5105.10000,1480.48000,Aetna,Local,,2042.04,,,,,,,1643.84,4175.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8848104,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8848104,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8848111,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8848111,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8848117,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,949.73000,275.42000,Aetna,Local,,379.89,,,,,,,342.38,776.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8848117,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,949.73000,275.42000,Aetna,Local,,379.89,,,,,,,305.81,776.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,621.93,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1725.20000,500.31000,Aetna,Local,,690.08,,,,,,,555.51,1411.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8848113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,144.06000,41.78000,Aetna,Local,,57.62,,,,,,,51.93,117.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8848113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,144.06000,41.78000,Aetna,Local,,57.62,,,,,,,46.39,117.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8848110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8183.76000,2373.29000,Aetna,Local,,3273.50,,,,,,,2950.25,6694.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8848110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8183.76000,2373.29000,Aetna,Local,,3273.50,,,,,,,2635.17,6694.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1217.00000,352.93000,Aetna,Local,,486.80,,,,,,,438.73,995.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8848114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1217.00000,352.93000,Aetna,Local,,486.80,,,,,,,391.87,995.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,8856084,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,146.53000,42.49000,Aetna,Local,,58.61,,,,,,,52.82,119.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,8856084,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,146.53000,42.49000,Aetna,Local,,58.61,,,,,,,47.18,119.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8856085,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8856085,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8856087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8856087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8856089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8856089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8858268,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8858268,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8858270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8858270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8858272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8858272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8864099,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8864099,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8864101,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8864101,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8864104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8864104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8864106,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,801.38,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8864106,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,Local,,889.18,,,,,,,715.79,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8864108,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8864108,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8864110,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8864110,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8864112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8864112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8870084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8870084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8870085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8870085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8868084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8868084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8868085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7326.00000,2124.54000,Aetna,Local,,2930.40,,,,,,,2641.02,5992.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8868085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7326.00000,2124.54000,Aetna,Local,,2930.40,,,,,,,2358.97,5992.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8868086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8868086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8870086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8870086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER IN KIT,8870088,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER IN KIT,8870088,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER IN KIT,8870089,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,10080.00000,2923.20000,Aetna,Local,,4032.00,,,,,,,3633.84,8245.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER IN KIT,8870089,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,10080.00000,2923.20000,Aetna,Local,,4032.00,,,,,,,3245.76,8245.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8870090,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,18225.00000,5285.25000,Aetna,Local,,7290.00,,,,,,,6570.11,14908.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8870090,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,18225.00000,5285.25000,Aetna,Local,,7290.00,,,,,,,5868.45,14908.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8874084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8874084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8874086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.00000,1246.42000,Aetna,Local,,1719.20,,,,,,,1549.43,3515.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8874086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.00000,1246.42000,Aetna,Local,,1719.20,,,,,,,1383.96,3515.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8874088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10383.00000,3011.07000,Aetna,Local,,4153.20,,,,,,,3743.07,8493.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8874088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10383.00000,3011.07000,Aetna,Local,,4153.20,,,,,,,3343.33,8493.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8874091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,Local,,1100.00,,,,,,,991.38,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8874091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,Local,,1100.00,,,,,,,885.50,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8874093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,817.25,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8874093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2267.00000,657.43000,Aetna,Local,,906.80,,,,,,,729.97,1854.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8874104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8874104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8878092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6083.00000,1764.07000,Aetna,Local,,2433.20,,,,,,,2192.92,4975.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8878092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6083.00000,1764.07000,Aetna,Local,,2433.20,,,,,,,1958.73,4975.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8880107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8880107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8880108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1728.89,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8880108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4795.81000,1390.78000,Aetna,Local,,1918.32,,,,,,,1544.25,3922.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8880109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1771.97,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8880109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,Local,,1966.12,,,,,,,1582.73,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8886084,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8886084,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8886086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10881.90000,3155.75000,Aetna,Local,,4352.76,,,,,,,3922.92,8901.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8886086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10881.90000,3155.75000,Aetna,Local,,4352.76,,,,,,,3503.97,8901.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8886088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,671.84,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8886088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,600.09,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8886091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8886091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8890086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,645.57000,187.22000,Aetna,Local,,258.23,,,,,,,232.73,528.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8890086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,645.57000,187.22000,Aetna,Local,,258.23,,,,,,,207.87,528.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8890088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,645.57000,187.22000,Aetna,Local,,258.23,,,,,,,232.73,528.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8890088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,645.57000,187.22000,Aetna,Local,,258.23,,,,,,,207.87,528.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8892097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8892097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8892099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3524.61,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8892099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3148.19,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8892101,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8892101,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8904088,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8904088,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8904090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,6529.56,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8904090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,5832.23,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8906084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8906084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8906088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8906088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8906086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8906086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906089,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,4442.83000,1288.42000,Aetna,Local,,1777.13,,,,,,,1601.64,3634.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906089,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,4442.83000,1288.42000,Aetna,Local,,1777.13,,,,,,,1430.59,3634.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906090,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,3158.20000,915.88000,Aetna,Local,,1263.28,,,,,,,1138.53,2583.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906090,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,3158.20000,915.88000,Aetna,Local,,1263.28,,,,,,,1016.94,2583.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906091,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2363.64000,685.46000,Aetna,Local,,945.46,,,,,,,852.09,1933.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906091,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2363.64000,685.46000,Aetna,Local,,945.46,,,,,,,761.09,1933.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906092,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,3892.28000,1128.76000,Aetna,Local,,1556.91,,,,,,,1403.17,3183.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906092,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,3892.28000,1128.76000,Aetna,Local,,1556.91,,,,,,,1253.31,3183.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906093,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,5895.82000,1709.79000,Aetna,Local,,2358.33,,,,,,,2125.44,4822.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906093,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,5895.82000,1709.79000,Aetna,Local,,2358.33,,,,,,,1898.45,4822.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906094,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,1999.88000,579.97000,Aetna,Local,,799.95,,,,,,,720.96,1635.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8906094,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,1999.88000,579.97000,Aetna,Local,,799.95,,,,,,,643.96,1635.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,8908214,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1378.52000,399.77000,Aetna,Local,,551.41,,,,,,,496.96,1127.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,8908214,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1378.52000,399.77000,Aetna,Local,,551.41,,,,,,,443.88,1127.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8908230,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,127.05000,36.84000,Aetna,Local,,50.82,,,,,,,45.80,103.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8908230,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,127.05000,36.84000,Aetna,Local,,50.82,,,,,,,40.91,103.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8908250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8908250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8908251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8908251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8908252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,6038.38,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8908252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,5393.50,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8908253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8908253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7702151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1900.00000,551.00000,Aetna,Local,,760.00,,,,,,,684.95,1554.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7702151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1900.00000,551.00000,Aetna,Local,,760.00,,,,,,,611.80,1554.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE TYMPANOSTOMY,8908291,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE TYMPANOSTOMY,8908291,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8908292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8908292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8908293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8908293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8908294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8908294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8908295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8908295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8908296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8908296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8908297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8908297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8908298,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8908298,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8908334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8908334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8908335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8908335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8908336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8908336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8910335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28629.00000,8302.41000,Aetna,Local,,11451.60,,,,,,,10320.75,23418.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8910335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28629.00000,8302.41000,Aetna,Local,,11451.60,,,,,,,9218.54,23418.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8910366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8910366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8910369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.25000,162.47000,Aetna,Local,,224.10,,,,,,,201.97,458.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8910369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.25000,162.47000,Aetna,Local,,224.10,,,,,,,180.40,458.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8910371,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8910371,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,664.20000,192.62000,Aetna,Local,,265.68,,,,,,,239.44,543.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,664.20000,192.62000,Aetna,Local,,265.68,,,,,,,213.87,543.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8910452,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8910452,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8910453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8910453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8910454,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7590.00000,2201.10000,Aetna,Local,,3036.00,,,,,,,2736.20,6208.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8910454,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7590.00000,2201.10000,Aetna,Local,,3036.00,,,,,,,2443.98,6208.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,507.58,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,453.38,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8910458,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,488.12,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8910458,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,435.99,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8910499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8910499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSHERE,8910500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSHERE,8910500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8910512,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4828.25000,1400.19000,Aetna,Local,,1931.30,,,,,,,1740.58,3949.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8910512,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4828.25000,1400.19000,Aetna,Local,,1931.30,,,,,,,1554.70,3949.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8910536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8910536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8912132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,4082.66,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8912132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,3646.65,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8912133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,4082.66,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8912133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,3646.65,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8912134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8912134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PROSTHESIS,8912135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17125.00000,4966.25000,Aetna,Local,,6850.00,,,,,,,6173.56,14008.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PROSTHESIS,8912135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17125.00000,4966.25000,Aetna,Local,,6850.00,,,,,,,5514.25,14008.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PROSTHESIS,8912136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15850.00000,4596.50000,Aetna,Local,,6340.00,,,,,,,5713.93,12965.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PROSTHESIS,8912136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15850.00000,4596.50000,Aetna,Local,,6340.00,,,,,,,5103.70,12965.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8912144,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8912144,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8912145,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8912145,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8912146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8912146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8912147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8912147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8912148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8912148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8910542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8666.55000,2513.30000,Aetna,Local,,3466.62,,,,,,,3124.29,7089.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8910542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8666.55000,2513.30000,Aetna,Local,,3466.62,,,,,,,2790.63,7089.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858275,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858275,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858276,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858276,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858277,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858277,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858278,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858278,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858279,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858279,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858280,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858280,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858281,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858281,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858282,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858282,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858283,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858283,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858284,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858284,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858285,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858285,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858286,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858286,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858287,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858287,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858288,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858288,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858289,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858289,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858299,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858299,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858300,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858300,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858306,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858306,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858309,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858309,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858311,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858311,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858312,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858312,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858313,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858313,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858325,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858325,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858327,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858327,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858328,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858328,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858329,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858329,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858330,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858330,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8974105,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8974105,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD ADAPTER,8910543,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1505.60000,436.62000,Aetna,Local,,602.24,,,,,,,542.77,1231.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD ADAPTER,8910543,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1505.60000,436.62000,Aetna,Local,,602.24,,,,,,,484.80,1231.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8912137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,Local,,1100.00,,,,,,,991.38,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8912137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,Local,,1100.00,,,,,,,885.50,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8910544,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8910544,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8910545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3265.50000,946.99000,Aetna,Local,,1306.20,,,,,,,1177.21,2671.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8910545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3265.50000,946.99000,Aetna,Local,,1306.20,,,,,,,1051.49,2671.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8910646,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8910646,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8910647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8910647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8910648,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8910648,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8910679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2294.00000,665.26000,Aetna,Local,,917.60,,,,,,,826.99,1876.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8910679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2294.00000,665.26000,Aetna,Local,,917.60,,,,,,,738.67,1876.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8910680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2294.00000,665.26000,Aetna,Local,,917.60,,,,,,,826.99,1876.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8910680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2294.00000,665.26000,Aetna,Local,,917.60,,,,,,,738.67,1876.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8910681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8910681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8910683,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8910683,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8910684,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8910684,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8910711,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,31612.50000,9167.62000,Aetna,Local,,12645.00,,,,,,,11396.31,25859.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8910711,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,31612.50000,9167.62000,Aetna,Local,,12645.00,,,,,,,10179.23,25859.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8910712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8910714,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8910714,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8910715,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8910715,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8910716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8910716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8916176,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8916176,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8916177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2412.64000,699.67000,Aetna,Local,,965.06,,,,,,,869.76,1973.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8916177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2412.64000,699.67000,Aetna,Local,,965.06,,,,,,,776.87,1973.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,8916290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,Local,,8640.00,,,,,,,7786.80,17668.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,8916290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,Local,,8640.00,,,,,,,6955.20,17668.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3360.22,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3001.36,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8916309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8916309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE PATCH,8916310,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE PATCH,8916310,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916361,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916361,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4641.00000,1345.89000,Aetna,Local,,1856.40,,,,,,,1673.08,3796.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4641.00000,1345.89000,Aetna,Local,,1856.40,,,,,,,1494.40,3796.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4641.00000,1345.89000,Aetna,Local,,1856.40,,,,,,,1673.08,3796.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4641.00000,1345.89000,Aetna,Local,,1856.40,,,,,,,1494.40,3796.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,8916364,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,8916364,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4921.88000,1427.35000,Aetna,Local,,1968.75,,,,,,,1774.34,4026.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4921.88000,1427.35000,Aetna,Local,,1968.75,,,,,,,1584.85,4026.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8916373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,802.11,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8916373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,716.45,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARTRIDGE IMPLANT,8916346,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1640.28,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARTRIDGE IMPLANT,8916346,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1465.10,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8916477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8916477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8916589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8916589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLEOSPHERE,8916590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7860.00000,2279.40000,Aetna,Local,,3144.00,,,,,,,2833.53,6429.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLEOSPHERE,8916590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7860.00000,2279.40000,Aetna,Local,,3144.00,,,,,,,2530.92,6429.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8916591,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8916591,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL INSERT,8916592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL INSERT,8916592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,8916593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,8916593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8916594,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,21225.00000,6155.25000,Aetna,Local,,8490.00,,,,,,,7651.61,17362.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8916594,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,21225.00000,6155.25000,Aetna,Local,,8490.00,,,,,,,6834.45,17362.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEPARATOR,8916595,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2752.42,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEPARATOR,8916595,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2458.47,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8916647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8916647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8916648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15850.00000,4596.50000,Aetna,Local,,6340.00,,,,,,,5713.93,12965.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8916648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15850.00000,4596.50000,Aetna,Local,,6340.00,,,,,,,5103.70,12965.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8914860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8914860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8914861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2752.96,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8914861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7636.50000,2214.58000,Aetna,Local,,3054.60,,,,,,,2458.95,6246.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8916702,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8916702,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8916703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8916703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8916646,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,912.60000,264.65000,Aetna,Local,,365.04,,,,,,,328.99,746.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8916646,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,912.60000,264.65000,Aetna,Local,,365.04,,,,,,,293.86,746.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE AORTIC,8916479,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,14640.81,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE AORTIC,8916479,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,13077.23,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE AORTIC,8916481,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,14640.81,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE AORTIC,8916481,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,13077.23,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE AORTIC,8916483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,14640.81,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE AORTIC,8916483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,13077.23,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE AORTIC,8916485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,14640.81,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE AORTIC,8916485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,13077.23,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE AORTIC,8916487,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,14640.81,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE AORTIC,8916487,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,13077.23,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8916763,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,4082.66,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8916763,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,3646.65,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PROSTHESIS,8916764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17125.00000,4966.25000,Aetna,Local,,6850.00,,,,,,,6173.56,14008.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PROSTHESIS,8916764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17125.00000,4966.25000,Aetna,Local,,6850.00,,,,,,,5514.25,14008.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8916765,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15850.00000,4596.50000,Aetna,Local,,6340.00,,,,,,,5713.93,12965.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8916765,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15850.00000,4596.50000,Aetna,Local,,6340.00,,,,,,,5103.70,12965.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916766,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916766,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8916767,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8916767,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT THROMBECTOMY,8916690,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,21225.00000,6155.25000,Aetna,Local,,8490.00,,,,,,,7651.61,17362.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT THROMBECTOMY,8916690,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,21225.00000,6155.25000,Aetna,Local,,8490.00,,,,,,,6834.45,17362.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916691,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916691,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8914863,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8914863,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,Local,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916783,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916783,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8916784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8916784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1847.20,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,Local,,2049.60,,,,,,,1649.93,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8916793,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8916793,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8916794,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,6370.00000,1847.30000,Aetna,Local,,2548.00,,,,,,,2296.39,5210.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8916794,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,6370.00000,1847.30000,Aetna,Local,,2548.00,,,,,,,2051.14,5210.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1972.00000,571.88000,Aetna,Local,,788.80,,,,,,,710.91,1613.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1972.00000,571.88000,Aetna,Local,,788.80,,,,,,,634.98,1613.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10866.00000,3151.14000,Aetna,Local,,4346.40,,,,,,,3917.19,8888.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10866.00000,3151.14000,Aetna,Local,,4346.40,,,,,,,3498.85,8888.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8916820,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8916820,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8916821,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8916821,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,Local,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8916823,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,77.60,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8916823,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,69.31,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916824,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916824,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NASAL IMPLANT,8916699,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9435.00000,2736.15000,Aetna,Local,,3774.00,,,,,,,3401.32,7717.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NASAL IMPLANT,8916699,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9435.00000,2736.15000,Aetna,Local,,3774.00,,,,,,,3038.07,7717.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8914997,CDM,278,RC,,,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8914997,CDM,278,RC,,,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8914998,CDM,278,RC,,,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8914998,CDM,278,RC,,,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8916886,CDM,278,RC,,,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8916886,CDM,278,RC,,,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8916889,CDM,278,RC,,,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLIP LIGATING,8916889,CDM,278,RC,,,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,Local,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,Local,,3434.40,,,,,,,3095.25,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8916871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,Local,,3434.40,,,,,,,2764.69,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8916873,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8916873,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8916879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8916879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8916881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8916881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8916883,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21810.00000,6324.90000,Aetna,Local,,8724.00,,,,,,,7862.51,17840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8916883,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21810.00000,6324.90000,Aetna,Local,,8724.00,,,,,,,7022.82,17840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8916950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8916950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8916922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8916973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8917021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8917021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8917022,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,6529.56,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8917022,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,5832.23,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8917023,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8917023,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8917024,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8917024,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8917025,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8917025,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8917027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8917027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8917026,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8917026,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8917141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8917141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8917143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8917143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,7893984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,7893984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8917146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8917146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8917148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8917148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8917150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8917150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8918130,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8918130,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8918131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4444.13000,1288.80000,Aetna,Local,,1777.65,,,,,,,1602.11,3635.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8918131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4444.13000,1288.80000,Aetna,Local,,1777.65,,,,,,,1431.01,3635.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8918132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8918132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8918133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7333.20000,2126.63000,Aetna,Local,,2933.28,,,,,,,2643.62,5998.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8918133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7333.20000,2126.63000,Aetna,Local,,2933.28,,,,,,,2361.29,5998.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8918135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8918135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8918136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8918136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8918137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5569.76000,1615.23000,Aetna,Local,,2227.90,,,,,,,2007.90,4556.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8918137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5569.76000,1615.23000,Aetna,Local,,2227.90,,,,,,,1793.46,4556.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8918138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,497.63,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8918138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,444.49,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8918194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,497.63,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8918194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,444.49,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8918139,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8918139,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8918196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8918196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8918198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8918198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS TOTAL ELBOW,8918200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,3136.35,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS TOTAL ELBOW,8918200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,Local,,3480.00,,,,,,,2801.40,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS TOTAL ELBOW,8918202,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4914.00000,1425.06000,Aetna,Local,,1965.60,,,,,,,1771.50,4019.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS TOTAL ELBOW,8918202,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4914.00000,1425.06000,Aetna,Local,,1965.60,,,,,,,1582.31,4019.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8918204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8918204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,4491.90,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8918206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1945.68000,564.25000,Aetna,Local,,778.27,,,,,,,701.42,1591.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8918206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1945.68000,564.25000,Aetna,Local,,778.27,,,,,,,626.51,1591.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8918208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,933.62000,270.75000,Aetna,Local,,373.45,,,,,,,336.57,763.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8918208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,933.62000,270.75000,Aetna,Local,,373.45,,,,,,,300.63,763.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8918210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1745.20000,506.11000,Aetna,Local,,698.08,,,,,,,629.14,1427.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8918210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1745.20000,506.11000,Aetna,Local,,698.08,,,,,,,561.95,1427.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8920215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,7417.29,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8920215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,6625.15,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8920216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8920216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8920217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8920217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8920218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8920218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8920219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3635.63000,1054.33000,Aetna,Local,,1454.25,,,,,,,1310.64,2973.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8920219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3635.63000,1054.33000,Aetna,Local,,1454.25,,,,,,,1170.67,2973.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8920220,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8920220,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8920221,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8920221,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8920222,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8920222,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8920223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1635.23,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8920223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1460.59,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8607988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,702.00000,203.58000,Aetna,Local,,280.80,,,,,,,253.07,574.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8607988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,702.00000,203.58000,Aetna,Local,,280.80,,,,,,,226.04,574.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8607990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,702.00000,203.58000,Aetna,Local,,280.80,,,,,,,253.07,574.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8607990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,702.00000,203.58000,Aetna,Local,,280.80,,,,,,,226.04,574.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8918332,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8918332,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,764.47,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8920376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8920376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8920377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8920377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8920378,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8920378,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8918373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8918373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8918374,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8918374,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8918375,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2087.96000,605.51000,Aetna,Local,,835.18,,,,,,,752.71,1707.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8918375,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2087.96000,605.51000,Aetna,Local,,835.18,,,,,,,672.32,1707.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8918376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2939.00000,852.31000,Aetna,Local,,1175.60,,,,,,,1059.51,2404.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8918376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2939.00000,852.31000,Aetna,Local,,1175.60,,,,,,,946.36,2404.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8918377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8918377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8918378,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8918378,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8920375,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8920375,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8918415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8918415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8918418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,6038.38,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8918418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,5393.50,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8918435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8918435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,Local,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8918436,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8918436,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8918437,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8918437,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8918438,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8918438,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8918439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8918439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8920515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8920515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8924093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5447.54000,1579.79000,Aetna,Local,,2179.02,,,,,,,1963.84,4456.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8924093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5447.54000,1579.79000,Aetna,Local,,2179.02,,,,,,,1754.11,4456.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8922104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8922104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8922113,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8922113,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8922114,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8922114,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8922105,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8922105,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8922115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8922115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ACETABULAR,8922116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1876.22,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ACETABULAR,8922116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1675.85,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,7895653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,226.91000,65.80000,Aetna,Local,,90.76,,,,,,,81.80,185.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,7895653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,226.91000,65.80000,Aetna,Local,,90.76,,,,,,,73.07,185.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BODY PROXIMAL,8922134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17125.00000,4966.25000,Aetna,Local,,6850.00,,,,,,,6173.56,14008.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BODY PROXIMAL,8922134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17125.00000,4966.25000,Aetna,Local,,6850.00,,,,,,,5514.25,14008.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8922138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8922138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8922139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14673.00000,4255.17000,Aetna,Local,,5869.20,,,,,,,5289.62,12002.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8922139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14673.00000,4255.17000,Aetna,Local,,5869.20,,,,,,,4724.71,12002.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8922140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3420.78,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8922140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3055.46,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOME TALAR,8922141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19900.00000,5771.00000,Aetna,Local,,7960.00,,,,,,,7173.95,16278.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOME TALAR,8922141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19900.00000,5771.00000,Aetna,Local,,7960.00,,,,,,,6407.80,16278.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8922142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12594.00000,3652.26000,Aetna,Local,,5037.60,,,,,,,4540.14,10301.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8922142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12594.00000,3652.26000,Aetna,Local,,5037.60,,,,,,,4055.27,10301.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8926084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,793.10,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8926084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,708.40,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMER,8926085,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMER,8926085,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,Local,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8926086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8926086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8926088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5787.51,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8926088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16054.13000,4655.70000,Aetna,Local,,6421.65,,,,,,,5169.43,13132.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8926089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5007.10000,1452.06000,Aetna,Local,,2002.84,,,,,,,1805.06,4095.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8926089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5007.10000,1452.06000,Aetna,Local,,2002.84,,,,,,,1612.29,4095.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMUR,8926090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMUR,8926090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8926091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8926091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8926285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8926285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8926286,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8926286,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8926287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21810.00000,6324.90000,Aetna,Local,,8724.00,,,,,,,7862.51,17840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8926287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21810.00000,6324.90000,Aetna,Local,,8724.00,,,,,,,7022.82,17840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8926288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26000.00000,7540.00000,Aetna,Local,,10400.00,,,,,,,9373.00,21268.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8926288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26000.00000,7540.00000,Aetna,Local,,10400.00,,,,,,,8372.00,21268.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLAE SPINAL,8926289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLAE SPINAL,8926289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8926333,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8926333,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR SHELL,8926334,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR SHELL,8926334,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8926336,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8926336,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8926337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7360.47000,2134.54000,Aetna,Local,,2944.19,,,,,,,2653.45,6020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8926337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7360.47000,2134.54000,Aetna,Local,,2944.19,,,,,,,2370.07,6020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8924499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8924499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GELONSPHERE,8926389,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GELONSPHERE,8926389,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8926391,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8926391,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8926392,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8926392,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8926393,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,8926393,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8926394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8926394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8926449,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8926449,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8926451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8926451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8926452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8926452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8926453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8926453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8926454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8926454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8926455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8926455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8926456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8926456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8924536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4469.50000,1296.16000,Aetna,Local,,1787.80,,,,,,,1611.25,3656.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8924536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4469.50000,1296.16000,Aetna,Local,,1787.80,,,,,,,1439.18,3656.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8924537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8924537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8924538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8924538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8924587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT,8924587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8924603,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17090.00000,4956.10000,Aetna,Local,,6836.00,,,,,,,6160.94,13979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8924603,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17090.00000,4956.10000,Aetna,Local,,6836.00,,,,,,,5502.98,13979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,7701214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,7701214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924605,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924605,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8924588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8924588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8924627,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8924627,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8924628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8924628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE,8924630,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,7791.00000,2259.39000,Aetna,Local,,3116.40,,,,,,,2808.66,6373.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE,8924630,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,7791.00000,2259.39000,Aetna,Local,,3116.40,,,,,,,2508.70,6373.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3420.78,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3055.46,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8926554,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8926554,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8926555,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2998.40,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8926555,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8317.35000,2412.03000,Aetna,Local,,3326.94,,,,,,,2678.19,6803.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8926556,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8926556,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8926557,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8926557,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8926558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8926558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8926559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8926559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HEMOD,7693554,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,616.94000,178.91000,Aetna,Local,,246.78,,,,,,,222.41,504.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HEMOD,7693554,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,616.94000,178.91000,Aetna,Local,,246.78,,,,,,,198.65,504.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8924749,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8924749,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8924750,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8924750,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8924751,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8924751,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8924752,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7980.00000,2314.20000,Aetna,Local,,3192.00,,,,,,,2876.79,6527.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8924752,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7980.00000,2314.20000,Aetna,Local,,3192.00,,,,,,,2569.56,6527.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924753,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924753,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924754,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924754,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924757,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924757,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924758,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924758,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924759,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924759,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924760,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924760,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924761,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924761,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924762,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1640.28,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8924762,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1465.10,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP HUMERAL,8924763,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP HUMERAL,8924763,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8924764,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1779.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8924764,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4935.00000,1431.15000,Aetna,Local,,1974.00,,,,,,,1589.07,4036.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4003.13000,1160.91000,Aetna,Local,,1601.25,,,,,,,1443.13,3274.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4003.13000,1160.91000,Aetna,Local,,1601.25,,,,,,,1289.01,3274.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8924856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8924856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8924857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8924857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8924858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8924858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8924859,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8924859,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BUNDLE UNILATERAL,8924861,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,31761.00000,9210.69000,Aetna,Local,,12704.40,,,,,,,11449.84,25980.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BUNDLE UNILATERAL,8924861,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,31761.00000,9210.69000,Aetna,Local,,12704.40,,,,,,,10227.04,25980.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8927024,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11412.00000,3309.48000,Aetna,Local,,4564.80,,,,,,,4114.03,9335.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8927024,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11412.00000,3309.48000,Aetna,Local,,4564.80,,,,,,,3674.66,9335.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8927062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31353.75000,9092.59000,Aetna,Local,,12541.50,,,,,,,11303.03,25647.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8927062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31353.75000,9092.59000,Aetna,Local,,12541.50,,,,,,,10095.91,25647.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8927026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8927026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PROSTHESIS,8927027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17125.00000,4966.25000,Aetna,Local,,6850.00,,,,,,,6173.56,14008.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PROSTHESIS,8927027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17125.00000,4966.25000,Aetna,Local,,6850.00,,,,,,,5514.25,14008.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8926653,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,694.40000,201.38000,Aetna,Local,,277.76,,,,,,,250.33,568.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8926653,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,694.40000,201.38000,Aetna,Local,,277.76,,,,,,,223.60,568.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8926655,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,694.40000,201.38000,Aetna,Local,,277.76,,,,,,,250.33,568.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8926655,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,694.40000,201.38000,Aetna,Local,,277.76,,,,,,,223.60,568.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8924911,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8924911,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8924932,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1864.00000,540.56000,Aetna,Local,,745.60,,,,,,,671.97,1524.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8924932,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1864.00000,540.56000,Aetna,Local,,745.60,,,,,,,600.21,1524.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924934,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924934,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8924935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8924936,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8924936,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8924992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8924992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,8924995,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,8924995,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8924996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2384.00000,691.36000,Aetna,Local,,953.60,,,,,,,859.43,1950.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8924996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2384.00000,691.36000,Aetna,Local,,953.60,,,,,,,767.65,1950.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8924997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8924997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8945556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8945556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8945557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5771.50000,1673.74000,Aetna,Local,,2308.60,,,,,,,2080.63,4721.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8945557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5771.50000,1673.74000,Aetna,Local,,2308.60,,,,,,,1858.42,4721.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8945558,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8945558,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8945559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3644.38,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8945559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3255.18,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8927356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8927356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8927357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8927357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8945642,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,2861.08000,829.71000,Aetna,Local,,1144.43,,,,,,,1031.42,2340.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8945642,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,2861.08000,829.71000,Aetna,Local,,1144.43,,,,,,,921.27,2340.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8927379,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8927379,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8927380,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8927380,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8927381,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8927381,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8927382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8927382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8927383,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8927383,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8927402,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8927402,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8927434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8927434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8946406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8946406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8946407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8946407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8946408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28629.00000,8302.41000,Aetna,Local,,11451.60,,,,,,,10320.75,23418.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8946408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28629.00000,8302.41000,Aetna,Local,,11451.60,,,,,,,9218.54,23418.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8946457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4595.50000,1332.70000,Aetna,Local,,1838.20,,,,,,,1656.68,3759.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8946457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4595.50000,1332.70000,Aetna,Local,,1838.20,,,,,,,1479.75,3759.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8946462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8946462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8946463,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8946463,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8946464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4469.50000,1296.16000,Aetna,Local,,1787.80,,,,,,,1611.25,3656.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8946464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4469.50000,1296.16000,Aetna,Local,,1787.80,,,,,,,1439.18,3656.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8948085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8948085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8948086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8948086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8948087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8948087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8948088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4186.88000,1214.20000,Aetna,Local,,1674.75,,,,,,,1509.37,3424.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8948088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4186.88000,1214.20000,Aetna,Local,,1674.75,,,,,,,1348.18,3424.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8948104,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8948104,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,Local,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8948105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8948105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8948106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8948106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8946532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8946532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8946533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8948477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8948477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8948524,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3195.00000,926.55000,Aetna,Local,,1278.00,,,,,,,1151.80,2613.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8948524,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3195.00000,926.55000,Aetna,Local,,1278.00,,,,,,,1028.79,2613.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8948525,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8948525,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8948526,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8948526,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8948527,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8948527,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8948528,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8948528,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8948557,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8948557,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8948588,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8948588,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8948589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8948589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8948590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8948590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8946940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11805.00000,3423.45000,Aetna,Local,,4722.00,,,,,,,4255.70,9656.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8946940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11805.00000,3423.45000,Aetna,Local,,4722.00,,,,,,,3801.21,9656.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8946941,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8946941,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8946942,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8946942,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8946943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8946943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8946944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8946944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8946945,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,8946945,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISC,8946946,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1955.71,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISC,8946946,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5425.00000,1573.25000,Aetna,Local,,2170.00,,,,,,,1746.85,4437.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISC,8946947,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11775.00000,3414.75000,Aetna,Local,,4710.00,,,,,,,4244.89,9631.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISC,8946947,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11775.00000,3414.75000,Aetna,Local,,4710.00,,,,,,,3791.55,9631.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8946991,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8946991,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8950110,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8950110,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8950111,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1496.00000,433.84000,Aetna,Local,,598.40,,,,,,,539.31,1223.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8950111,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1496.00000,433.84000,Aetna,Local,,598.40,,,,,,,481.71,1223.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8950112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2236.00000,648.44000,Aetna,Local,,894.40,,,,,,,806.08,1829.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8950112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2236.00000,648.44000,Aetna,Local,,894.40,,,,,,,719.99,1829.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8950113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8950113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8950137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,5497.62,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8950137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,4910.50,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8950139,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,772.88000,224.14000,Aetna,Local,,309.15,,,,,,,278.62,632.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8950139,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,772.88000,224.14000,Aetna,Local,,309.15,,,,,,,248.87,632.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8950143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8950143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8947079,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8947079,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8947080,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8947080,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8947081,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8947081,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8947082,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8947082,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8947083,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8947083,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8947084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8947084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8947118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8947118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8950183,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10928.25000,3169.19000,Aetna,Local,,4371.30,,,,,,,3939.63,8939.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8950183,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10928.25000,3169.19000,Aetna,Local,,4371.30,,,,,,,3518.90,8939.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8947329,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8947329,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8947330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8947330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8947331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3149.00000,913.21000,Aetna,Local,,1259.60,,,,,,,1135.21,2575.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8947331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3149.00000,913.21000,Aetna,Local,,1259.60,,,,,,,1013.98,2575.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8947332,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17095.00000,4957.55000,Aetna,Local,,6838.00,,,,,,,6162.75,13983.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8947332,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17095.00000,4957.55000,Aetna,Local,,6838.00,,,,,,,5504.59,13983.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8947338,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8947338,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,764.47,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8947880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8947880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8947881,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8947881,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8947882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8947882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK SPINAL,8947883,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK SPINAL,8947883,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8950414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4469.50000,1296.16000,Aetna,Local,,1787.80,,,,,,,1611.25,3656.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8950414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4469.50000,1296.16000,Aetna,Local,,1787.80,,,,,,,1439.18,3656.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8947894,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8947894,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950431,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950431,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8950432,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8950432,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8950433,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8950433,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8950435,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8950435,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8950436,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8950436,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8950437,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8950437,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8950438,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8950438,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8950439,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8950439,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950440,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950440,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950442,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950442,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8950443,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8637.00000,2504.73000,Aetna,Local,,3454.80,,,,,,,3113.64,7065.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8950443,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8637.00000,2504.73000,Aetna,Local,,3454.80,,,,,,,2781.11,7065.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PASTE,8950466,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PASTE,8950466,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1374.94,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8950467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8950467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8950468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8950468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8965686,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8965686,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8950538,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8950538,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8950554,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8950554,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8950564,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8950564,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8950565,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6062.00000,1757.98000,Aetna,Local,,2424.80,,,,,,,2185.35,4958.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8950565,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6062.00000,1757.98000,Aetna,Local,,2424.80,,,,,,,1951.96,4958.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8950566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,3076.60,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8950566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,2748.03,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8950752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8950752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950753,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950753,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8950755,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1962.02,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8950755,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1752.48,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950756,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950756,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8950758,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8950758,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,849.11000,246.24000,Aetna,Local,,339.64,,,,,,,306.10,694.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,849.11000,246.24000,Aetna,Local,,339.64,,,,,,,273.41,694.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8950760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8950760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8950761,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8950761,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8965986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,7273.09,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8965986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,6496.35,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8965968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8965968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8965969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8965969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8950796,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,22258.15000,6454.86000,Aetna,Local,,8903.26,,,,,,,8024.06,18207.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8950796,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,22258.15000,6454.86000,Aetna,Local,,8903.26,,,,,,,7167.12,18207.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950798,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8950798,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM INTERVENTIONAL,8950799,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,14280.00000,4141.20000,Aetna,Local,,5712.00,,,,,,,5147.94,11681.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM INTERVENTIONAL,8950799,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,14280.00000,4141.20000,Aetna,Local,,5712.00,,,,,,,4598.16,11681.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8966251,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8966251,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE ALLODERM,8966252,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,9387.00000,2722.23000,Aetna,Local,,3754.80,,,,,,,3384.01,7678.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE ALLODERM,8966252,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,9387.00000,2722.23000,Aetna,Local,,3754.80,,,,,,,124.65,7678.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8968148,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,Local,,965.60,,,,,,,870.25,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8968148,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,Local,,965.60,,,,,,,777.31,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8968149,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,Local,,965.60,,,,,,,870.25,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8968149,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,Local,,965.60,,,,,,,777.31,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8968151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8968151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8968152,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8968152,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8968153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8968153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8968154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8968154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8968155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8968155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8968156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,648.00000,187.92000,Aetna,Local,,259.20,,,,,,,233.60,530.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8968156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,648.00000,187.92000,Aetna,Local,,259.20,,,,,,,208.66,530.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8968157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8968157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8972087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9101.25000,2639.36000,Aetna,Local,,3640.50,,,,,,,3281.00,7444.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8972087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9101.25000,2639.36000,Aetna,Local,,3640.50,,,,,,,2930.60,7444.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972088,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972088,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8972089,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8972089,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8972302,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8972302,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8972304,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8972304,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8972305,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,30375.00000,8808.75000,Aetna,Local,,12150.00,,,,,,,10950.19,24846.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8972305,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,30375.00000,8808.75000,Aetna,Local,,12150.00,,,,,,,9780.75,24846.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8972306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2600.12000,754.03000,Aetna,Local,,1040.05,,,,,,,937.34,2126.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8972306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2600.12000,754.03000,Aetna,Local,,1040.05,,,,,,,837.24,2126.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8972307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8972307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8972308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8972308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8972309,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21810.00000,6324.90000,Aetna,Local,,8724.00,,,,,,,7862.51,17840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8972309,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21810.00000,6324.90000,Aetna,Local,,8724.00,,,,,,,7022.82,17840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8974182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8974182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8974183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8974183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8974184,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8974184,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8974206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8974206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8974207,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8974207,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8974208,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8974208,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8974210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8974210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8974237,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8974237,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8974238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8974238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8974253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8974253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8972377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8972377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8972378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3416.25000,990.71000,Aetna,Local,,1366.50,,,,,,,1231.56,2794.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8972378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3416.25000,990.71000,Aetna,Local,,1366.50,,,,,,,1100.03,2794.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8974180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8974180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,Local,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8974181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8974181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8972394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4860.98000,1409.68000,Aetna,Local,,1944.39,,,,,,,1752.38,3976.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8972394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4860.98000,1409.68000,Aetna,Local,,1944.39,,,,,,,1565.24,3976.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8972395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4860.98000,1409.68000,Aetna,Local,,1944.39,,,,,,,1752.38,3976.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8972395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4860.98000,1409.68000,Aetna,Local,,1944.39,,,,,,,1565.24,3976.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8972396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8972396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972835,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972835,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972836,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972836,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972837,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972837,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972838,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972838,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8972839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8972839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8972840,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8972840,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8972841,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8972841,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8972842,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8972842,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972890,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972890,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8972891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8972891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972893,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8972893,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8972915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,210.00000,60.90000,Aetna,Local,,84.00,,,,,,,75.70,171.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8972915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,Local,,84.00,,,,,,,67.62,171.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8972916,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8972916,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8972917,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8972917,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8972918,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8972918,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8972929,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8972929,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8972930,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8972930,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8972931,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8972931,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8972932,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8972932,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8972933,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8972933,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8682255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4375.53000,1268.90000,Aetna,Local,,1750.21,,,,,,,1577.38,3579.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8682255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4375.53000,1268.90000,Aetna,Local,,1750.21,,,,,,,1408.92,3579.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8972958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8972960,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,17763.64,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8972960,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,Local,,19710.00,,,,,,,15866.55,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,7699136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,7699136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8973019,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8973019,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8973022,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8973022,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975138,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975138,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8975143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8975269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8975269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8973162,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8973162,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8975270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2288.00000,663.52000,Aetna,Local,,915.20,,,,,,,824.82,1871.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8975270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2288.00000,663.52000,Aetna,Local,,915.20,,,,,,,736.74,1871.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8975271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4003.13000,1160.91000,Aetna,Local,,1601.25,,,,,,,1443.13,3274.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8975271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4003.13000,1160.91000,Aetna,Local,,1601.25,,,,,,,1289.01,3274.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8975272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8975272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8975273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8975273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8975274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8975274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8973163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8973163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8973161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8973161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8975339,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8975339,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COLLAR,8973307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6514.20000,1889.12000,Aetna,Local,,2605.68,,,,,,,2348.37,5328.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COLLAR,8973307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6514.20000,1889.12000,Aetna,Local,,2605.68,,,,,,,2097.57,5328.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8973308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8973308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PROSTHESIS,8973309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20324.25000,5894.03000,Aetna,Local,,8129.70,,,,,,,7326.89,16625.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PROSTHESIS,8973309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20324.25000,5894.03000,Aetna,Local,,8129.70,,,,,,,6544.41,16625.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8973310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17235.00000,4998.15000,Aetna,Local,,6894.00,,,,,,,6213.22,14098.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8973310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17235.00000,4998.15000,Aetna,Local,,6894.00,,,,,,,5549.67,14098.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8973311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8973311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8973312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8973312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2481.20000,719.55000,Aetna,Local,,992.48,,,,,,,894.47,2029.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2481.20000,719.55000,Aetna,Local,,992.48,,,,,,,798.95,2029.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8973396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8973396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10629.00000,3082.41000,Aetna,Local,,4251.60,,,,,,,3831.75,8694.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10629.00000,3082.41000,Aetna,Local,,4251.60,,,,,,,3422.54,8694.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10629.00000,3082.41000,Aetna,Local,,4251.60,,,,,,,3831.75,8694.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10629.00000,3082.41000,Aetna,Local,,4251.60,,,,,,,3422.54,8694.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,436.93,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,390.26,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,436.93,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,390.26,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE VENT,8973401,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,79.62000,23.09000,Aetna,Local,,31.85,,,,,,,28.70,65.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE VENT,8973401,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,79.62000,23.09000,Aetna,Local,,31.85,,,,,,,25.64,332.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8973402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8973402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5974.36000,1732.56000,Aetna,Local,,2389.74,,,,,,,2153.76,4887.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5974.36000,1732.56000,Aetna,Local,,2389.74,,,,,,,1923.74,4887.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8973404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9101.25000,2639.36000,Aetna,Local,,3640.50,,,,,,,3281.00,7444.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8973404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9101.25000,2639.36000,Aetna,Local,,3640.50,,,,,,,2930.60,7444.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973717,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973717,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973716,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973716,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8975602,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,5497.62,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8975602,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,4910.50,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8975603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9070.20000,2630.36000,Aetna,Local,,3628.08,,,,,,,3269.81,7419.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8975603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9070.20000,2630.36000,Aetna,Local,,3628.08,,,,,,,2920.60,7419.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8975589,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,33072.75000,9591.10000,Aetna,Local,,13229.10,,,,,,,11922.73,27053.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8975589,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,33072.75000,9591.10000,Aetna,Local,,13229.10,,,,,,,10649.43,27053.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8975592,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8975592,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8975593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8975593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8975594,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8975594,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8975595,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8975595,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8975596,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8975596,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8975597,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8975597,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8975599,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9135.00000,2649.15000,Aetna,Local,,3654.00,,,,,,,3293.17,7472.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8975599,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9135.00000,2649.15000,Aetna,Local,,3654.00,,,,,,,2941.47,7472.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8975600,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8975600,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8975601,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10530.00000,3053.70000,Aetna,Local,,4212.00,,,,,,,3796.07,8613.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8975601,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10530.00000,3053.70000,Aetna,Local,,4212.00,,,,,,,3390.66,8613.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,8973778,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,7029.75,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,8973778,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,6279.00,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8973779,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8973779,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8973780,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8973780,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8973781,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8973781,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8973782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,77.60,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8973782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,Local,,86.10,,,,,,,69.31,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2496.00000,723.84000,Aetna,Local,,998.40,,,,,,,899.81,2041.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2496.00000,723.84000,Aetna,Local,,998.40,,,,,,,803.71,2041.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8973784,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8973784,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,Local,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4652.13000,1349.12000,Aetna,Local,,1860.85,,,,,,,1677.09,3805.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4652.13000,1349.12000,Aetna,Local,,1860.85,,,,,,,1497.99,3805.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10389.00000,3012.81000,Aetna,Local,,4155.60,,,,,,,3745.23,8498.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10389.00000,3012.81000,Aetna,Local,,4155.60,,,,,,,3345.26,8498.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8973787,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8973787,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,17433.30000,5055.66000,Aetna,Local,,6973.32,,,,,,,6284.70,14260.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,17433.30000,5055.66000,Aetna,Local,,6973.32,,,,,,,5613.52,14260.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER PATIENT,8973827,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3578.56000,1037.78000,Aetna,Local,,1431.42,,,,,,,1290.07,2927.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER PATIENT,8973827,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3578.56000,1037.78000,Aetna,Local,,1431.42,,,,,,,1152.30,2927.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5541.90000,1607.15000,Aetna,Local,,2216.76,,,,,,,1997.85,4533.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8973828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5541.90000,1607.15000,Aetna,Local,,2216.76,,,,,,,1784.49,4533.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8973829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8973830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8973830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8978834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8978834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8978835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8978835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8978836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8978836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8978837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8978837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982107,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982107,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982108,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982108,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8982109,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8982109,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982110,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982110,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8982133,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,8982133,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8982134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8982134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,Local,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8981452,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8981452,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8981453,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8981453,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8981454,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8981454,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8981455,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8981455,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8981456,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8981456,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8981457,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8981457,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5472.36000,1586.98000,Aetna,Local,,2188.94,,,,,,,1972.79,4476.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5472.36000,1586.98000,Aetna,Local,,2188.94,,,,,,,1762.10,4476.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8982313,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8982313,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982314,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982314,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8982315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,795.42000,230.67000,Aetna,Local,,318.17,,,,,,,286.75,650.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8982315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,795.42000,230.67000,Aetna,Local,,318.17,,,,,,,256.13,650.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8982316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,795.42000,230.67000,Aetna,Local,,318.17,,,,,,,286.75,650.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8982316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,795.42000,230.67000,Aetna,Local,,318.17,,,,,,,256.13,650.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8982317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,795.42000,230.67000,Aetna,Local,,318.17,,,,,,,286.75,650.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8982317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,795.42000,230.67000,Aetna,Local,,318.17,,,,,,,256.13,650.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8981547,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8981547,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8981548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17090.00000,4956.10000,Aetna,Local,,6836.00,,,,,,,6160.94,13979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8981548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17090.00000,4956.10000,Aetna,Local,,6836.00,,,,,,,5502.98,13979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8981549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8981549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982361,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982361,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982370,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982370,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8982373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.02000,255.21000,Aetna,Local,,352.01,,,,,,,317.25,719.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8982373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.02000,255.21000,Aetna,Local,,352.01,,,,,,,283.37,719.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8982374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.02000,255.21000,Aetna,Local,,352.01,,,,,,,317.25,719.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8982374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.02000,255.21000,Aetna,Local,,352.01,,,,,,,283.37,719.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8982416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1421.99,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8982416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,Local,,1577.80,,,,,,,1270.13,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8950181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8950182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8950182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8947160,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8947160,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8947161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8947161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,393.87000,114.22000,Aetna,Local,,157.55,,,,,,,141.99,322.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8947162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,393.87000,114.22000,Aetna,Local,,157.55,,,,,,,126.83,322.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8947163,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,12930.00000,3749.70000,Aetna,Local,,5172.00,,,,,,,4661.27,10576.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8947163,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,12930.00000,3749.70000,Aetna,Local,,5172.00,,,,,,,4163.46,10576.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8947165,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8947165,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8947182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4958.73000,1438.03000,Aetna,Local,,1983.49,,,,,,,1787.62,4056.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8947182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4958.73000,1438.03000,Aetna,Local,,1983.49,,,,,,,1596.71,4056.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8947183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,Local,,2625.52,,,,,,,2366.25,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8947183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,Local,,2625.52,,,,,,,2113.54,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8947184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24194.40000,7016.38000,Aetna,Local,,9677.76,,,,,,,8722.08,19791.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8947184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24194.40000,7016.38000,Aetna,Local,,9677.76,,,,,,,7790.60,19791.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8947185,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8947185,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8947231,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,772.88000,224.14000,Aetna,Local,,309.15,,,,,,,278.62,632.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8947231,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,772.88000,224.14000,Aetna,Local,,309.15,,,,,,,248.87,632.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8947232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8947232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,924.08000,267.98000,Aetna,Local,,369.63,,,,,,,333.13,755.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,924.08000,267.98000,Aetna,Local,,369.63,,,,,,,297.55,755.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8982558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8982558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982559,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982559,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8982560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8982560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8982574,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,5497.62,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8982574,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,4910.50,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982575,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982575,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982576,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2949.68000,855.41000,Aetna,Local,,1179.87,,,,,,,1063.36,2412.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982576,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2949.68000,855.41000,Aetna,Local,,1179.87,,,,,,,949.80,2412.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982577,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982577,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982578,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982578,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8619942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6514.20000,1889.12000,Aetna,Local,,2605.68,,,,,,,2348.37,5328.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8619942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6514.20000,1889.12000,Aetna,Local,,2605.68,,,,,,,2097.57,5328.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982639,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982639,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8982638,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,128.73000,37.33000,Aetna,Local,,51.49,,,,,,,46.41,105.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8982638,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,128.73000,37.33000,Aetna,Local,,51.49,,,,,,,41.45,105.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982732,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982732,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8982733,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8982733,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982734,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982734,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8981950,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,3098.50,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8981950,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,2767.59,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8981951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,3098.50,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8981951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,2767.59,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8981952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,Local,,1409.80,,,,,,,1270.58,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8981952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,Local,,1409.80,,,,,,,1134.89,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8981953,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10739.25000,3114.38000,Aetna,Local,,4295.70,,,,,,,3871.50,8784.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8981953,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10739.25000,3114.38000,Aetna,Local,,4295.70,,,,,,,3458.04,8784.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981957,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981957,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8981961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8982907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8982907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8982908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8982908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982944,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8982944,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8982997,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8982997,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982998,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8982998,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982999,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8982999,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983000,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983000,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983001,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983001,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8983002,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8983002,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8983059,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,2470.40000,716.42000,Aetna,Local,,988.16,,,,,,,890.58,2020.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8983059,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,2470.40000,716.42000,Aetna,Local,,988.16,,,,,,,795.47,2020.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8984230,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8984230,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8984231,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8984231,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE CUSTOM,8984234,CDM,278,RC,,,,,facility,inpatient,,,37237.50000,10798.88000,Aetna,Local,,14895.00,,,,,,,13424.12,30460.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE CUSTOM,8984234,CDM,278,RC,,,,,facility,outpatient,,,37237.50000,10798.88000,Aetna,Local,,14895.00,,,,,,,11990.48,30460.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8984236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,24625.00000,7141.25000,Aetna,Local,,9850.00,,,,,,,8877.31,20143.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8984236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,24625.00000,7141.25000,Aetna,Local,,9850.00,,,,,,,7929.25,20143.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8984237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4683.00000,1358.07000,Aetna,Local,,1873.20,,,,,,,1688.22,3830.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8984237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4683.00000,1358.07000,Aetna,Local,,1873.20,,,,,,,1507.93,3830.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,713.79,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,637.56,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,713.79,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,637.56,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1462.00000,423.98000,Aetna,Local,,584.80,,,,,,,527.05,1195.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1462.00000,423.98000,Aetna,Local,,584.80,,,,,,,470.76,1195.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1462.00000,423.98000,Aetna,Local,,584.80,,,,,,,527.05,1195.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1462.00000,423.98000,Aetna,Local,,584.80,,,,,,,470.76,1195.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8984254,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8984254,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8984256,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8984256,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8984257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8984257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE MESH,8984267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4483.50000,1300.21000,Aetna,Local,,1793.40,,,,,,,1616.30,3667.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE MESH,8984267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4483.50000,1300.21000,Aetna,Local,,1793.40,,,,,,,1443.69,3667.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984338,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984338,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8984261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11282.40000,3271.90000,Aetna,Local,,4512.96,,,,,,,4067.31,9229.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8984261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11282.40000,3271.90000,Aetna,Local,,4512.96,,,,,,,3632.93,9229.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8984262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6018.60000,1745.39000,Aetna,Local,,2407.44,,,,,,,2169.71,4923.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8984262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6018.60000,1745.39000,Aetna,Local,,2407.44,,,,,,,1937.99,4923.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8984339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8984339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT RAIDAL HEAD,8984340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2812.98,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT RAIDAL HEAD,8984340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2512.57,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8983208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8983208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8983309,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8983309,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8983310,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8983310,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8984495,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,20700.00000,6003.00000,Aetna,Local,,8280.00,,,,,,,7462.35,16932.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8984495,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,20700.00000,6003.00000,Aetna,Local,,8280.00,,,,,,,6665.40,16932.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983438,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983438,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983439,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2425.52000,703.40000,Aetna,Local,,970.21,,,,,,,874.40,1984.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983439,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2425.52000,703.40000,Aetna,Local,,970.21,,,,,,,781.02,1984.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8983440,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8983440,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8983441,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8983441,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8983442,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8983442,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8983443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8983443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8983445,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8983445,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983446,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,507.58,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983446,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,453.38,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8983448,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17859.38000,5179.22000,Aetna,Local,,7143.75,,,,,,,6438.31,14608.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8983448,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17859.38000,5179.22000,Aetna,Local,,7143.75,,,,,,,5750.72,14608.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8984728,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8984728,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984736,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984736,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984737,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984737,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8984739,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8984739,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8984738,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8984738,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8983759,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8983759,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8983760,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6514.20000,1889.12000,Aetna,Local,,2605.68,,,,,,,2348.37,5328.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8983760,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6514.20000,1889.12000,Aetna,Local,,2605.68,,,,,,,2097.57,5328.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,Local,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8983764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1864.00000,540.56000,Aetna,Local,,745.60,,,,,,,671.97,1524.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8983764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1864.00000,540.56000,Aetna,Local,,745.60,,,,,,,600.21,1524.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8983765,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8983765,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8983766,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8983766,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BODY,8983767,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20324.25000,5894.03000,Aetna,Local,,8129.70,,,,,,,7326.89,16625.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BODY,8983767,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20324.25000,5894.03000,Aetna,Local,,8129.70,,,,,,,6544.41,16625.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8983768,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8983768,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983769,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983769,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984805,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984805,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8984806,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2365.78,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8984806,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2113.12,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8984807,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8984807,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER CATHETER,8983905,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,826.29000,239.62000,Aetna,Local,,330.52,,,,,,,297.88,675.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER CATHETER,8983905,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,826.29000,239.62000,Aetna,Local,,330.52,,,,,,,266.07,675.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8984814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8984814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8984815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8984815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984816,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984816,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8984817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8984818,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8984818,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8984819,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8984819,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8984820,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8984820,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8984846,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8984846,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984847,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984847,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984848,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984848,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984849,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8984849,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8983946,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2851.37,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8983946,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7909.50000,2293.75000,Aetna,Local,,3163.80,,,,,,,2546.86,6469.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8983947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8983947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,Local,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983948,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983948,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8983949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8983949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8983951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8983951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8983962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8983962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983963,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8983963,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8983971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8983972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4855.03000,1407.96000,Aetna,Local,,1942.01,,,,,,,1750.24,3971.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8983972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4855.03000,1407.96000,Aetna,Local,,1942.01,,,,,,,1563.32,3971.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983973,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983973,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983974,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8983974,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8984011,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4277.25000,1240.40000,Aetna,Local,,1710.90,,,,,,,1541.95,3498.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8984011,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4277.25000,1240.40000,Aetna,Local,,1710.90,,,,,,,1377.27,3498.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8984041,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8984041,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8984056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5344.85000,1550.01000,Aetna,Local,,2137.94,,,,,,,1926.82,4372.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8984056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5344.85000,1550.01000,Aetna,Local,,2137.94,,,,,,,1721.04,4372.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8985032,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8985032,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT QUICKSET,8985033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11227.50000,3255.98000,Aetna,Local,,4491.00,,,,,,,4047.51,9184.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT QUICKSET,8985033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11227.50000,3255.98000,Aetna,Local,,4491.00,,,,,,,3615.26,9184.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8985035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8985035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8986150,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1595.00000,462.55000,Aetna,Local,,638.00,,,,,,,575.00,1304.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8986150,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1595.00000,462.55000,Aetna,Local,,638.00,,,,,,,513.59,1304.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8986159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8986159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8986162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8986162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14986.88000,4346.20000,Aetna,Local,,5994.75,,,,,,,5402.77,12259.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14986.88000,4346.20000,Aetna,Local,,5994.75,,,,,,,4825.78,12259.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP SYSTEM,8985089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,669.60000,194.18000,Aetna,Local,,267.84,,,,,,,241.39,547.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP SYSTEM,8985089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,669.60000,194.18000,Aetna,Local,,267.84,,,,,,,215.61,547.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8985090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8985090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8985091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8985091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,Local,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT REV ADAPTER,8985094,CDM,278,RC,,,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT REV ADAPTER,8985094,CDM,278,RC,,,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8985117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9101.25000,2639.36000,Aetna,Local,,3640.50,,,,,,,3281.00,7444.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8985117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9101.25000,2639.36000,Aetna,Local,,3640.50,,,,,,,2930.60,7444.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8985118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8985118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8985119,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,536.42,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8985119,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,479.14,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8985120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8985120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8985121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8985121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985147,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985147,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8985148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8985148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8985163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8985163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8986243,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8986243,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986244,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986244,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8986234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1442.18,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8986234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4000.50000,1160.14000,Aetna,Local,,1600.20,,,,,,,1288.16,3272.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8986238,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8986238,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8985205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,3062.33,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8985205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,2735.29,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986240,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,7480.38,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986240,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,6681.50,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8986288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7830.00000,2270.70000,Aetna,Local,,3132.00,,,,,,,2822.72,6404.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8986288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7830.00000,2270.70000,Aetna,Local,,3132.00,,,,,,,2521.26,6404.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8986290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8986290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8985263,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3139.88000,910.57000,Aetna,Local,,1255.95,,,,,,,1131.93,2568.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8985263,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3139.88000,910.57000,Aetna,Local,,1255.95,,,,,,,1011.04,2568.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8985264,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8985264,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8985265,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8985265,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8985266,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8985266,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8985268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3349.50000,971.35000,Aetna,Local,,1339.80,,,,,,,1207.49,2739.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8985268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3349.50000,971.35000,Aetna,Local,,1339.80,,,,,,,1078.54,2739.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8985269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8985269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8985271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8985272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8985272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8985273,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8985273,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8985274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8985274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8985275,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8985275,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8986361,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8986361,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8985277,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8985277,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8986362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8986362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GAMMA LAG SCREW,8986363,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,943.76,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GAMMA LAG SCREW,8986363,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,842.97,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GAMMA NAIL,8986364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GAMMA NAIL,8986364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986430,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986430,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8986434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8986434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1374.94,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8986435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5670.00000,1644.30000,Aetna,Local,,2268.00,,,,,,,2044.04,4638.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8986435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5670.00000,1644.30000,Aetna,Local,,2268.00,,,,,,,1825.74,4638.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,8986436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,8986436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1374.94,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8986437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10530.00000,3053.70000,Aetna,Local,,4212.00,,,,,,,3796.07,8613.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8986437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10530.00000,3053.70000,Aetna,Local,,4212.00,,,,,,,3390.66,8613.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8986438,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,8986438,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW FEMORAL,8986417,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW FEMORAL,8986417,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,8986418,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,8986418,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLACE CLAVICLE,8986413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10578.00000,3067.62000,Aetna,Local,,4231.20,,,,,,,3813.37,8652.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLACE CLAVICLE,8986413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10578.00000,3067.62000,Aetna,Local,,4231.20,,,,,,,3406.12,8652.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8986415,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8392.50000,2433.82000,Aetna,Local,,3357.00,,,,,,,3025.50,6865.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8986415,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8392.50000,2433.82000,Aetna,Local,,3357.00,,,,,,,2702.39,6865.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMOARL HEAD,8986416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMOARL HEAD,8986416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8986414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8986414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986439,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14547.00000,4218.63000,Aetna,Local,,5818.80,,,,,,,5244.19,11899.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986439,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14547.00000,4218.63000,Aetna,Local,,5818.80,,,,,,,4684.13,11899.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8986440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8986440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTOR,8986441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1680.00000,487.20000,Aetna,Local,,672.00,,,,,,,605.64,1374.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTOR,8986441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1680.00000,487.20000,Aetna,Local,,672.00,,,,,,,540.96,1374.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8986467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8986467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERUS,8986468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERUS,8986468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,671.84,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,600.09,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8986585,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8986585,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8986586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,20125.00000,5836.25000,Aetna,Local,,8050.00,,,,,,,7255.06,16462.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8986586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,20125.00000,5836.25000,Aetna,Local,,8050.00,,,,,,,6480.25,16462.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8984145,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8984145,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,9357.00,,,,,,,1121.37,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,8984144,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8984144,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,9357.00,,,,,,,1775.03,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXTENDER LEAD,8982415,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENDER LEAD,8982415,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9072801,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,189.00000,54.81000,Aetna,Local,,75.60,,,,,,,68.13,154.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9072801,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,,75.60,,,,,,,60.86,154.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,9060901,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,25625.00000,7431.25000,Aetna,Local,,10250.00,,,,,,,9237.81,20961.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,9060901,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,25625.00000,7431.25000,Aetna,Local,,9357.00,,,,,,,8251.25,20961.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER ABLATION,9060902,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,25625.00000,7431.25000,Aetna,Local,,10250.00,,,,,,,9237.81,20961.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,9060902,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,25625.00000,7431.25000,Aetna,Local,,9357.00,,,,,,,8251.25,20961.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SHEATH,9060903,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9060903,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER TRAPPER,8402792,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2620.00000,759.80000,Aetna,Local,,1048.00,,,,,,,944.51,2143.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER TRAPPER,8402792,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2620.00000,759.80000,Aetna,Local,,1048.00,,,,,,,843.64,2143.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT PERIPHERAL,9056589,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT PERIPHERAL,9056589,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catherter D 20cm,8982174,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,1297.00000,376.13000,Aetna,Local,,518.80,,,,,,,467.57,1060.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catherter D 20cm,8982174,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,1297.00000,376.13000,Aetna,Local,,518.80,,,,,,,417.63,1060.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Intravascular,9082195,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,3430.00000,994.70000,Aetna,Local,,1372.00,,,,,,,1236.52,2805.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Intravascular,9082195,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,3430.00000,994.70000,Aetna,Local,,1372.00,,,,,,,1104.46,2805.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER FINECROSS,9080273,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2770.00000,803.30000,Aetna,Local,,1108.00,,,,,,,998.59,2265.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER FINECROSS,9080273,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2770.00000,803.30000,Aetna,Local,,1108.00,,,,,,,891.94,2265.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9076438,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9076438,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8982198,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2180.00000,632.20000,Aetna,Local,,872.00,,,,,,,785.89,1783.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8982198,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2180.00000,632.20000,Aetna,Local,,872.00,,,,,,,701.96,1783.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAT HETER EXTRACTION,9032392,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,677.74,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAT HETER EXTRACTION,9032392,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1880.00000,545.20000,Aetna,Local,,752.00,,,,,,,605.36,1537.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER OPTISEAL,9042913,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER OPTISEAL,9042913,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9038246,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,929.30000,269.50000,Aetna,Local,,371.72,,,,,,,335.01,760.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9038246,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,929.30000,269.50000,Aetna,Local,,371.72,,,,,,,299.23,760.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9038248,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,929.30000,269.50000,Aetna,Local,,371.72,,,,,,,335.01,760.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9038248,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,929.30000,269.50000,Aetna,Local,,371.72,,,,,,,299.23,760.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9036282,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9036282,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9036283,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9036283,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROTATIONAL ARTHRECTOMY,8983901,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,7485.00000,2170.65000,Aetna,Local,,2994.00,,,,,,,2698.34,6122.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROTATIONAL ARTHRECTOMY,8983901,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,7485.00000,2170.65000,Aetna,Local,,2994.00,,,,,,,2410.17,6122.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROTATIONAL ARTHRECTOMY,8983902,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,7485.00000,2170.65000,Aetna,Local,,2994.00,,,,,,,2698.34,6122.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROTATIONAL ARTHRECTOMY,8983902,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,7485.00000,2170.65000,Aetna,Local,,2994.00,,,,,,,2410.17,6122.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROTATIONAL ARTHRECTOMY,8983903,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,7485.00000,2170.65000,Aetna,Local,,2994.00,,,,,,,2698.34,6122.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROTATIONAL ARTHRECTOMY,8983903,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,7485.00000,2170.65000,Aetna,Local,,2994.00,,,,,,,2410.17,6122.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER CATHETER,8986584,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,130.14,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER CATHETER,8986584,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,Local,,144.40,,,,,,,116.24,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8986975,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8986975,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,9357.00,,,,,,,159.07,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,8986976,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3797.50000,1101.27000,Aetna,Local,,1519.00,,,,,,,1369.00,3106.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8986976,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3797.50000,1101.27000,Aetna,Local,,9357.00,,,,,,,1222.80,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,8990275,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3916.50000,1135.78000,Aetna,Local,,1566.60,,,,,,,1411.90,3203.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8990275,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3916.50000,1135.78000,Aetna,Local,,1566.60,,,,,,,1261.11,3203.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8990223,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3797.50000,1101.27000,Aetna,Local,,1519.00,,,,,,,1369.00,3106.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8990223,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3797.50000,1101.27000,Aetna,Local,,9357.00,,,,,,,1222.80,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SCREW,8988116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8986588,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8986588,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986579,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986579,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMLANT,8986580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMLANT,8986580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8986581,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8986581,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8986583,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8986583,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8986554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8986554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER IMPLANT,8986631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,5497.62,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER IMPLANT,8986631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,4910.50,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986632,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986632,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VIRTUAL SURGICAL PLANNING BUNDLE,8986634,CDM,278,RC,,,,,facility,inpatient,,,3886.40000,1127.06000,Aetna,Local,,1554.56,,,,,,,1401.05,3179.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VIRTUAL SURGICAL PLANNING BUNDLE,8986634,CDM,278,RC,,,,,facility,outpatient,,,3886.40000,1127.06000,Aetna,Local,,1554.56,,,,,,,1251.42,3179.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8985565,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8985565,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8985570,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8985570,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8985571,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8985571,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8985574,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8985574,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8985575,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8985575,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ISOLATOR CLAMP,8986630,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,10800.00000,3132.00000,Aetna,Local,,4320.00,,,,,,,3893.40,8834.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ISOLATOR CLAMP,8986630,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,Local,,4320.00,,,,,,,3477.60,8834.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ISOLATOR CLAMP,7695642,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,10800.00000,3132.00000,Aetna,Local,,4320.00,,,,,,,3893.40,8834.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ISOLATOR CLAMP,7695642,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,Local,,4320.00,,,,,,,3477.60,8834.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINE,8986680,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2401.68000,696.49000,Aetna,Local,,960.67,,,,,,,865.81,1964.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINE,8986680,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2401.68000,696.49000,Aetna,Local,,960.67,,,,,,,773.34,1964.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINE,8986681,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2401.68000,696.49000,Aetna,Local,,960.67,,,,,,,865.81,1964.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINE,8986681,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2401.68000,696.49000,Aetna,Local,,960.67,,,,,,,773.34,1964.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8985579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8985579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8988121,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8988121,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,Local,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8988122,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8988122,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8988125,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8988125,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8988126,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,254.69,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8988126,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,227.49,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8988127,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,254.69,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8988127,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,227.49,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY FUSION,8988128,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY FUSION,8988128,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8988129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13050.00000,3784.50000,Aetna,Local,,5220.00,,,,,,,4704.52,10674.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8988129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13050.00000,3784.50000,Aetna,Local,,5220.00,,,,,,,4202.10,10674.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988123,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988123,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8986773,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,13050.00000,3784.50000,Aetna,Local,,5220.00,,,,,,,4704.52,10674.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8986773,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,13050.00000,3784.50000,Aetna,Local,,5220.00,,,,,,,4202.10,10674.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8988211,CDM,278,RC,,,,,facility,inpatient,,,21125.00000,6126.25000,Aetna,Local,,8450.00,,,,,,,7615.56,17280.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8988211,CDM,278,RC,,,,,facility,outpatient,,,21125.00000,6126.25000,Aetna,Local,,8450.00,,,,,,,6802.25,17280.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988223,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988223,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,923.31000,267.76000,Aetna,Local,,369.32,,,,,,,332.85,755.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,923.31000,267.76000,Aetna,Local,,369.32,,,,,,,297.31,755.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986779,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986779,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE FASTENER,8986781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4003.13000,1160.91000,Aetna,Local,,1601.25,,,,,,,1443.13,3274.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE FASTENER,8986781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4003.13000,1160.91000,Aetna,Local,,1601.25,,,,,,,1289.01,3274.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERWIRE,8986782,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,Local,,59.01,,,,,,,53.18,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERWIRE,8986782,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,Local,,59.01,,,,,,,47.50,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERLINK,8986783,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,210.49,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERLINK,8986783,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,583.88000,169.33000,Aetna,Local,,233.55,,,,,,,188.01,477.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERWIRE,8986784,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,Local,,59.01,,,,,,,53.18,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERWIRE,8986784,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,Local,,59.01,,,,,,,47.50,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERTAK,8986786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,953.52,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERTAK,8986786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,851.69,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,8986787,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,8986787,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8986788,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,4082.66,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8986788,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,3646.65,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ASSEMBLY,8986789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ASSEMBLY,8986789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986790,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986790,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986791,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986791,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERUS,8986792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18440.00000,5347.60000,Aetna,Local,,7376.00,,,,,,,6647.62,15083.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERUS,8986792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18440.00000,5347.60000,Aetna,Local,,7376.00,,,,,,,5937.68,15083.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,254.69,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,227.49,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1378.80000,399.85000,Aetna,Local,,551.52,,,,,,,497.06,1127.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1378.80000,399.85000,Aetna,Local,,551.52,,,,,,,443.97,1127.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1357.72000,393.74000,Aetna,Local,,543.09,,,,,,,489.46,1110.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1357.72000,393.74000,Aetna,Local,,543.09,,,,,,,437.19,1110.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986960,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8986960,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8986961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8986961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR SHELL,8986956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16087.50000,4665.38000,Aetna,Local,,6435.00,,,,,,,5799.54,13159.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR SHELL,8986956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16087.50000,4665.38000,Aetna,Local,,6435.00,,,,,,,5180.18,13159.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8990126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8990126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8990129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4921.88000,1427.35000,Aetna,Local,,1968.75,,,,,,,1774.34,4026.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8990129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4921.88000,1427.35000,Aetna,Local,,1968.75,,,,,,,1584.85,4026.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,537.14,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1490.00000,432.10000,Aetna,Local,,596.00,,,,,,,479.78,1218.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8990143,CDM,278,RC,,,,,facility,inpatient,,,37237.50000,10798.88000,Aetna,Local,,14895.00,,,,,,,13424.12,30460.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8990143,CDM,278,RC,,,,,facility,outpatient,,,37237.50000,10798.88000,Aetna,Local,,14895.00,,,,,,,11990.48,30460.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8990134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,24625.00000,7141.25000,Aetna,Local,,9850.00,,,,,,,8877.31,20143.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8990134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,24625.00000,7141.25000,Aetna,Local,,9850.00,,,,,,,7929.25,20143.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4683.00000,1358.07000,Aetna,Local,,1873.20,,,,,,,1688.22,3830.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4683.00000,1358.07000,Aetna,Local,,1873.20,,,,,,,1507.93,3830.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,713.79,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,637.56,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8990138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,183.75000,53.29000,Aetna,Local,,73.50,,,,,,,66.24,150.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8990138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,183.75000,53.29000,Aetna,Local,,73.50,,,,,,,59.17,150.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8990139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7582.74000,2198.99000,Aetna,Local,,3033.10,,,,,,,2733.58,6202.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8990139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7582.74000,2198.99000,Aetna,Local,,3033.10,,,,,,,2441.64,6202.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8990140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,4133.49,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8990140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,Local,,4586.40,,,,,,,3692.05,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8990141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,567.00000,164.43000,Aetna,Local,,226.80,,,,,,,204.40,463.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8990141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,567.00000,164.43000,Aetna,Local,,226.80,,,,,,,182.57,463.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8990144,CDM,278,RC,J7330,HCPCS,,,facility,inpatient,,,109212.00000,31671.48000,Aetna,Local,,43684.80,,,,,,,39370.93,89335.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8987128,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8987128,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATOSPHERE,8987129,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22292.50000,6464.82000,Aetna,Local,,8917.00,,,,,,,8036.45,18235.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATOSPHERE,8987129,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22292.50000,6464.82000,Aetna,Local,,8917.00,,,,,,,7178.19,18235.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987130,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987130,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987131,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987131,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP,8987132,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4109.00000,1191.61000,Aetna,Local,,1643.60,,,,,,,1481.29,3361.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP,8987132,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4109.00000,1191.61000,Aetna,Local,,1643.60,,,,,,,1323.10,3361.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,8990210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10530.00000,3053.70000,Aetna,Local,,4212.00,,,,,,,3796.07,8613.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,8990210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10530.00000,3053.70000,Aetna,Local,,4212.00,,,,,,,3390.66,8613.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8990211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5670.00000,1644.30000,Aetna,Local,,2268.00,,,,,,,2044.04,4638.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8990211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5670.00000,1644.30000,Aetna,Local,,2268.00,,,,,,,1825.74,4638.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,8990212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,8990212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8990213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8990213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1374.94,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8992162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8992162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8990215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8990215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8990216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8990216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,8987180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,8987180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8987181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,793.10,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8987181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,708.40,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL,8990279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL,8990279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8990277,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8990277,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8990278,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8990278,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8987308,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14547.00000,4218.63000,Aetna,Local,,5818.80,,,,,,,5244.19,11899.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8987308,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14547.00000,4218.63000,Aetna,Local,,5818.80,,,,,,,4684.13,11899.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8987309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9135.00000,2649.15000,Aetna,Local,,3654.00,,,,,,,3293.17,7472.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8987309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9135.00000,2649.15000,Aetna,Local,,3654.00,,,,,,,2941.47,7472.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,8987310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,8987310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP,8987311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP,8987311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,8992102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,8992102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAP,8992103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,940.50000,272.74000,Aetna,Local,,376.20,,,,,,,339.05,769.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAP,8992103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,940.50000,272.74000,Aetna,Local,,376.20,,,,,,,302.84,769.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8992104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8992104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8987345,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,339.39000,98.42000,Aetna,Local,,135.76,,,,,,,122.35,277.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8987345,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,339.39000,98.42000,Aetna,Local,,135.76,,,,,,,109.28,277.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRILIZER,8987351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRILIZER,8987351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POST HOFFMAN,8987341,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,756.00000,219.24000,Aetna,Local,,302.40,,,,,,,272.54,618.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POST HOFFMAN,8987341,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,756.00000,219.24000,Aetna,Local,,302.40,,,,,,,243.43,618.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8987343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,920.00,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8987343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,821.74,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TENDON,8987391,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1962.02,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TENDON,8987391,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1752.48,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,8987392,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,3098.50,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,8987392,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,2767.59,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8987484,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8987484,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8987485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4039.00000,1171.31000,Aetna,Local,,1615.60,,,,,,,1456.06,3303.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8987485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4039.00000,1171.31000,Aetna,Local,,1615.60,,,,,,,1300.56,3303.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8987486,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8987486,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,8987487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,8987487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987488,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8987488,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8987490,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8987490,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8987469,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8987469,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8987473,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8987473,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8987474,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8987474,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8987475,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8987475,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8987480,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8987480,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT BLOCK,8992269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT BLOCK,8992269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT BLOCK,8992270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT BLOCK,8992270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8992271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8992271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8992272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8992272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8992273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1596.11,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8992273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1425.65,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8992274,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8992274,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8992275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8992275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8996108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8996108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,254.69,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,227.49,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996110,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996110,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8996111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8996111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8994115,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8994115,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996112,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,442.06,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996112,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1226.24000,355.61000,Aetna,Local,,490.50,,,,,,,394.85,1003.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996113,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996113,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,8996114,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,8996114,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSSLINK,8994152,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2304.00000,668.16000,Aetna,Local,,921.60,,,,,,,830.59,1884.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSSLINK,8994152,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2304.00000,668.16000,Aetna,Local,,921.60,,,,,,,741.89,1884.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,8975306,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,8975306,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8996166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8996166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8996168,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,4276.25,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8996168,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,3819.56,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3643.50000,1056.62000,Aetna,Local,,1457.40,,,,,,,1313.48,2980.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3643.50000,1056.62000,Aetna,Local,,1457.40,,,,,,,1173.21,2980.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8996170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5670.00000,1644.30000,Aetna,Local,,2268.00,,,,,,,2044.04,4638.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8996170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5670.00000,1644.30000,Aetna,Local,,2268.00,,,,,,,1825.74,4638.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8996171,CDM,278,RC,C1784,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8996171,CDM,278,RC,C1784,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1374.94,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8996191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,8996191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996192,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8254.80000,2393.89000,Aetna,Local,,3301.92,,,,,,,2975.86,6752.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996192,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8254.80000,2393.89000,Aetna,Local,,3301.92,,,,,,,2658.05,6752.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL,8996196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,4351.96,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL,8996196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,3887.18,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4208.40000,1220.44000,Aetna,Local,,1683.36,,,,,,,1517.13,3442.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4208.40000,1220.44000,Aetna,Local,,1683.36,,,,,,,1355.10,3442.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEMLESS,8996204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13530.00000,3923.70000,Aetna,Local,,5412.00,,,,,,,4877.56,11067.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEMLESS,8996204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13530.00000,3923.70000,Aetna,Local,,5412.00,,,,,,,4356.66,11067.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994267,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994267,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8994268,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14547.00000,4218.63000,Aetna,Local,,5818.80,,,,,,,5244.19,11899.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8994268,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14547.00000,4218.63000,Aetna,Local,,5818.80,,,,,,,4684.13,11899.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEMLESS,8994269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEMLESS,8994269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8994270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8994270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8994271,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,8994271,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8994272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20125.00000,5836.25000,Aetna,Local,,8050.00,,,,,,,7255.06,16462.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8994272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20125.00000,5836.25000,Aetna,Local,,8050.00,,,,,,,6480.25,16462.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM RADIAL,8994274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM RADIAL,8994274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8994304,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8994304,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,8994305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,8994305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8994319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11628.00000,3372.12000,Aetna,Local,,4651.20,,,,,,,4191.89,9511.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8994319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11628.00000,3372.12000,Aetna,Local,,4651.20,,,,,,,3744.22,9511.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994307,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994307,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE WIRE,8994310,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,126.00000,36.54000,Aetna,Local,,50.40,,,,,,,45.42,103.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE WIRE,8994310,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,126.00000,36.54000,Aetna,Local,,50.40,,,,,,,40.57,103.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,8994313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8634.00000,2503.86000,Aetna,Local,,3453.60,,,,,,,3112.56,7062.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,8994313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8634.00000,2503.86000,Aetna,Local,,3453.60,,,,,,,2780.15,7062.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,498.93,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,445.65,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUNTERSINK,8994315,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,1328.00000,385.12000,Aetna,Local,,531.20,,,,,,,478.74,1086.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUNTERSINK,8994315,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,1328.00000,385.12000,Aetna,Local,,531.20,,,,,,,427.62,1086.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996268,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996268,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996269,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996269,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996270,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996270,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8994316,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,8994316,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUEMRAL,8994317,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUEMRAL,8994317,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,246.29,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,683.19000,198.13000,Aetna,Local,,273.28,,,,,,,219.99,558.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,507.58,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,453.38,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8994380,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8994380,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8994381,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8994381,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8994420,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8994420,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8994421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8994421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8994422,CDM,278,RC,C1772,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8994422,CDM,278,RC,C1772,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8994423,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9012.00000,2613.48000,Aetna,Local,,3604.80,,,,,,,3248.83,7371.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8994423,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9012.00000,2613.48000,Aetna,Local,,3604.80,,,,,,,2901.86,7371.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994428,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994428,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994429,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8994429,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8994476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8994476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8994478,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8994478,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIA,8994479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIA,8994479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT GLENOID,8994480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9135.00000,2649.15000,Aetna,Local,,3654.00,,,,,,,3293.17,7472.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT GLENOID,8994480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9135.00000,2649.15000,Aetna,Local,,3654.00,,,,,,,2941.47,7472.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSTRUMENT,8994732,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,153.83000,44.61000,Aetna,Local,,61.53,,,,,,,55.46,125.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSTRUMENT,8994732,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,153.83000,44.61000,Aetna,Local,,61.53,,,,,,,49.53,125.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERTAK,8996418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2162.00000,626.98000,Aetna,Local,,864.80,,,,,,,779.40,1768.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERTAK,8996418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2162.00000,626.98000,Aetna,Local,,864.80,,,,,,,696.16,1768.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2587.96000,750.51000,Aetna,Local,,1035.18,,,,,,,932.96,2116.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2587.96000,750.51000,Aetna,Local,,1035.18,,,,,,,833.32,2116.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1239.48000,359.45000,Aetna,Local,,495.79,,,,,,,446.83,1013.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1239.48000,359.45000,Aetna,Local,,495.79,,,,,,,399.11,1013.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.79000,278.92000,Aetna,Local,,384.72,,,,,,,346.73,786.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.79000,278.92000,Aetna,Local,,384.72,,,,,,,309.70,786.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1325.16000,384.30000,Aetna,Local,,530.06,,,,,,,477.72,1083.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1325.16000,384.30000,Aetna,Local,,530.06,,,,,,,426.70,1083.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8996417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8996419,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8996419,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMER,8996420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMER,8996420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8996421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8996421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8996464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8997057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8997057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1374.94,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8997058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6062.00000,1757.98000,Aetna,Local,,2424.80,,,,,,,2185.35,4958.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8997058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6062.00000,1757.98000,Aetna,Local,,2424.80,,,,,,,1951.96,4958.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,8997042,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,8997042,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8994803,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,12076.38000,3502.15000,Aetna,Local,,4830.55,,,,,,,4353.53,9878.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8994803,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,12076.38000,3502.15000,Aetna,Local,,4830.55,,,,,,,3888.59,9878.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8997059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8997059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL NAIL,8994740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL NAIL,8994740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL NAIL,8994742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL NAIL,8994742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8997205,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4039.00000,1171.31000,Aetna,Local,,1615.60,,,,,,,1456.06,3303.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8997205,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4039.00000,1171.31000,Aetna,Local,,1615.60,,,,,,,1300.56,3303.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8997206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8997206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8997210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8997210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8997211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8997211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8997212,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12204.00000,3539.16000,Aetna,Local,,4881.60,,,,,,,4399.54,9982.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8997212,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12204.00000,3539.16000,Aetna,Local,,4881.60,,,,,,,3929.69,9982.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY FUSION,8997396,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26435.00000,7666.15000,Aetna,Local,,10574.00,,,,,,,9529.82,21623.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERBODY FUSION,8997396,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26435.00000,7666.15000,Aetna,Local,,10574.00,,,,,,,8512.07,21623.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995032,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,147.26,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995032,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,131.54,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8997397,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8997397,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1374.94,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,319.58,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,285.45,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,319.58,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,285.45,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,8995084,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,8995084,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8995111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8995111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8997394,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8997394,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8997395,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8997395,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,8995025,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,15102.50000,4379.72000,Aetna,Local,,6041.00,,,,,,,5444.45,12353.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,8995025,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,15102.50000,4379.72000,Aetna,Local,,6041.00,,,,,,,4863.01,12353.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8997400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8997400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8997399,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8997399,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8997398,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8997398,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8999058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,814.73,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8999058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,727.72,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SURGICAL SUPPLIES,8999067,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SURGICAL SUPPLIES,8999067,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SURGICAL SUPPLIES,8999069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SURGICAL SUPPLIES,8999069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SURGICAL SUPPLIES,8999071,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,747.00000,216.63000,Aetna,Local,,298.80,,,,,,,269.29,611.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SURGICAL SUPPLIES,8999071,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,747.00000,216.63000,Aetna,Local,,298.80,,,,,,,240.53,611.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SURGICAL SUPPLIES,8999072,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,147.26,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SURGICAL SUPPLIES,8999072,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,408.50000,118.46000,Aetna,Local,,163.40,,,,,,,131.54,334.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT MINNIE TIES,7967975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,2170.21,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT MINNIE TIES,7967975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,1938.44,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,8999056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,8999056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE TAPE,8999059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,814.73,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE TAPE,8999059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,727.72,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,8999060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,8999060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,8999063,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,814.73,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,8999063,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,727.72,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,8999062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,814.73,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,8999062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,727.72,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SURGICAL NEEDLE,8999065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,236.85,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SURGICAL NEEDLE,8999065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,657.00000,190.53000,Aetna,Local,,262.80,,,,,,,211.55,537.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOOP INFINITY,8999066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOOP INFINITY,8999066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8999068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8999068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE ANCHOR,8999070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1444.00000,418.76000,Aetna,Local,,577.60,,,,,,,520.56,1181.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE ANCHOR,8999070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1444.00000,418.76000,Aetna,Local,,577.60,,,,,,,464.97,1181.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,920.00,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,821.74,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8999353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8999353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8999354,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8999354,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERLOCK,8999355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6649.13000,1928.25000,Aetna,Local,,2659.65,,,,,,,2397.01,5438.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERLOCK,8999355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6649.13000,1928.25000,Aetna,Local,,2659.65,,,,,,,2141.02,5438.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,8999358,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,8999358,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8995249,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,24062.50000,6978.12000,Aetna,Local,,9625.00,,,,,,,8674.53,19683.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8995249,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,24062.50000,6978.12000,Aetna,Local,,9625.00,,,,,,,7748.12,19683.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,8995285,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1596.11,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,8995285,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1425.65,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8995291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8995291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8995292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8995292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1777.64000,515.52000,Aetna,Local,,711.06,,,,,,,640.84,1454.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1777.64000,515.52000,Aetna,Local,,711.06,,,,,,,572.40,1454.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,8995293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,8995293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,8999420,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13530.00000,3923.70000,Aetna,Local,,5412.00,,,,,,,4877.56,11067.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,8999420,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13530.00000,3923.70000,Aetna,Local,,5412.00,,,,,,,4356.66,11067.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8999421,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8999421,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8999422,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8999422,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE BLOCK,8995327,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE BLOCK,8995327,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE BLOCK,8995328,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,14100.00000,4089.00000,Aetna,Local,,5640.00,,,,,,,5083.05,11533.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE BLOCK,8995328,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,14100.00000,4089.00000,Aetna,Local,,5640.00,,,,,,,4540.20,11533.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR BUTTON,8999423,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,98.07000,28.44000,Aetna,Local,,39.23,,,,,,,35.35,80.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR BUTTON,8999423,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,98.07000,28.44000,Aetna,Local,,39.23,,,,,,,31.58,332.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RETRO CUTTER,8999456,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,1368.20000,396.78000,Aetna,Local,,547.28,,,,,,,493.24,1119.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RETRO CUTTER,8999456,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,1368.20000,396.78000,Aetna,Local,,547.28,,,,,,,440.56,1119.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAP,8999455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2410.84000,699.14000,Aetna,Local,,964.34,,,,,,,869.11,1972.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAP,8999455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2410.84000,699.14000,Aetna,Local,,964.34,,,,,,,776.29,1972.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN AXIS,8995248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1864.00000,540.56000,Aetna,Local,,745.60,,,,,,,671.97,1524.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN AXIS,8995248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1864.00000,540.56000,Aetna,Local,,745.60,,,,,,,600.21,1524.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8995026,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17752.50000,5148.22000,Aetna,Local,,7101.00,,,,,,,6399.78,14521.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8995026,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17752.50000,5148.22000,Aetna,Local,,7101.00,,,,,,,5716.31,14521.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8995379,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8995379,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOAT FIBER,8999457,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5182.28000,1502.86000,Aetna,Local,,2072.91,,,,,,,1868.21,4239.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOAT FIBER,8999457,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5182.28000,1502.86000,Aetna,Local,,2072.91,,,,,,,1668.69,4239.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBER BOAT,8999458,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8676.00000,2516.04000,Aetna,Local,,3470.40,,,,,,,3127.70,7096.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBER BOAT,8999458,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8676.00000,2516.04000,Aetna,Local,,3470.40,,,,,,,2793.67,7096.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8999558,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8999558,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999559,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10767.60000,3122.60000,Aetna,Local,,4307.04,,,,,,,3881.72,8807.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999559,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10767.60000,3122.60000,Aetna,Local,,4307.04,,,,,,,3467.17,8807.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8995489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8995489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8995490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8995490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999564,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4920.30000,1426.89000,Aetna,Local,,1968.12,,,,,,,1773.77,4024.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999564,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4920.30000,1426.89000,Aetna,Local,,1968.12,,,,,,,1584.34,4024.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999565,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4197.90000,1217.39000,Aetna,Local,,1679.16,,,,,,,1513.34,3433.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999565,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4197.90000,1217.39000,Aetna,Local,,1679.16,,,,,,,1351.72,3433.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8999566,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8999566,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8999568,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8999568,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995493,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1636.00000,474.44000,Aetna,Local,,654.40,,,,,,,589.78,1338.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995493,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1636.00000,474.44000,Aetna,Local,,654.40,,,,,,,526.79,1338.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8999544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2871.56000,832.75000,Aetna,Local,,1148.62,,,,,,,1035.20,2348.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8999544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2871.56000,832.75000,Aetna,Local,,1148.62,,,,,,,924.64,2348.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8463.00000,2454.27000,Aetna,Local,,3385.20,,,,,,,3050.91,6922.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8463.00000,2454.27000,Aetna,Local,,3385.20,,,,,,,2725.09,6922.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RUBY COIL,8995488,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RUBY COIL,8995488,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8999552,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2416.25,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8999552,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2158.20,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL PACKING,8999553,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL PACKING,8999553,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8999551,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8999551,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8999550,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8999550,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8999549,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,8999549,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,8999535,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,8999535,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6272.00000,1818.88000,Aetna,Local,,2508.80,,,,,,,2261.06,5130.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6272.00000,1818.88000,Aetna,Local,,2508.80,,,,,,,2019.58,5130.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HUM HEAD,8999538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HUM HEAD,8999538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8999539,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8999539,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8999554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8999554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,365.75000,106.07000,Aetna,Local,,146.30,,,,,,,131.85,299.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,365.75000,106.07000,Aetna,Local,,146.30,,,,,,,117.77,299.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,365.75000,106.07000,Aetna,Local,,146.30,,,,,,,131.85,299.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,365.75000,106.07000,Aetna,Local,,146.30,,,,,,,117.77,299.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999615,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999615,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8999616,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3528.00000,1023.12000,Aetna,Local,,1411.20,,,,,,,1271.84,2885.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8999616,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3528.00000,1023.12000,Aetna,Local,,1411.20,,,,,,,1136.02,2885.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLDER,8999618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,465.03000,134.86000,Aetna,Local,,186.01,,,,,,,167.64,380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLDER,8999618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,465.03000,134.86000,Aetna,Local,,186.01,,,,,,,149.74,380.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALPHAVENT,8910682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,309.85,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALPHAVENT,8910682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,276.76,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,8999542,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,8999542,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,8999543,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,8999543,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999619,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2099.00000,608.71000,Aetna,Local,,839.60,,,,,,,756.69,1716.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8999619,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2099.00000,608.71000,Aetna,Local,,839.60,,,,,,,675.88,1716.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1143.51,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3172.00000,919.88000,Aetna,Local,,1268.80,,,,,,,1021.38,2594.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8999656,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8999656,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8999657,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8999657,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8999658,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8999658,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8999652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8999652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE T LIFT,8999653,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE T LIFT,8999653,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995633,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995633,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995634,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995634,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995635,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3656.10000,1060.27000,Aetna,Local,,1462.44,,,,,,,1318.02,2990.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995635,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3656.10000,1060.27000,Aetna,Local,,1462.44,,,,,,,1177.26,2990.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8995636,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8995636,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8995637,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8995637,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995638,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4487.00000,1301.23000,Aetna,Local,,1794.80,,,,,,,1617.56,3670.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995638,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4487.00000,1301.23000,Aetna,Local,,1794.80,,,,,,,1444.81,3670.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8995639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8995639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,8995681,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3783.50000,1097.21000,Aetna,Local,,1513.40,,,,,,,1363.95,3094.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,8995681,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3783.50000,1097.21000,Aetna,Local,,1513.40,,,,,,,1218.29,3094.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INBONE INSERT,8995682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11448.00000,3319.92000,Aetna,Local,,4579.20,,,,,,,4127.00,9364.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INBONE INSERT,8995682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11448.00000,3319.92000,Aetna,Local,,4579.20,,,,,,,3686.26,9364.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8999469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8999469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995696,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995696,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995697,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995697,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,Local,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8995698,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14547.00000,4218.63000,Aetna,Local,,5818.80,,,,,,,5244.19,11899.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8995698,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14547.00000,4218.63000,Aetna,Local,,5818.80,,,,,,,4684.13,11899.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8995699,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14547.00000,4218.63000,Aetna,Local,,5818.80,,,,,,,5244.19,11899.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8995699,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14547.00000,4218.63000,Aetna,Local,,5818.80,,,,,,,4684.13,11899.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8995700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8995700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT INFINITY,8995701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11805.00000,3423.45000,Aetna,Local,,4722.00,,,,,,,4255.70,9656.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT INFINITY,8995701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11805.00000,3423.45000,Aetna,Local,,4722.00,,,,,,,3801.21,9656.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3209.50000,930.75000,Aetna,Local,,1283.80,,,,,,,1157.02,2625.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8999540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3209.50000,930.75000,Aetna,Local,,1283.80,,,,,,,1033.46,2625.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,713.79,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,637.56,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,713.79,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,637.56,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8995711,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8995711,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8995712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1444.20,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,8995712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4006.10000,1161.77000,Aetna,Local,,1602.44,,,,,,,1289.96,3276.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8995723,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8995723,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLADE,8995724,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,372.07000,107.90000,Aetna,Local,,148.83,,,,,,,134.13,304.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLADE,8995724,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,372.07000,107.90000,Aetna,Local,,148.83,,,,,,,119.81,304.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT,8995725,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,765.45000,221.98000,Aetna,Local,,306.18,,,,,,,275.94,626.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT,8995725,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,765.45000,221.98000,Aetna,Local,,306.18,,,,,,,246.47,626.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8995750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8995750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8999892,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8999892,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8999893,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8999893,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8999894,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8999894,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8999895,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8999895,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8999896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8999896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
UNID TECH,8999613,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,2081.89,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
UNID TECH,8999613,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,1859.55,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8999557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,8999557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8995710,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,220.50000,63.94000,Aetna,Local,,88.20,,,,,,,79.49,180.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8995710,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,220.50000,63.94000,Aetna,Local,,88.20,,,,,,,71.00,180.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REVISION COMPLEX,8995680,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REVISION COMPLEX,8995680,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8995812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8995812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8995833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8995833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8995834,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8995834,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8995835,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT BREAST,8995835,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995836,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,347.16,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995836,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,310.09,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995837,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,347.16,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995837,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,310.09,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995838,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,347.16,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995838,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,310.09,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995839,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,347.16,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995839,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,310.09,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995840,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,347.16,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995840,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,310.09,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995841,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,347.16,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SIZER BREAST,8995841,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,Local,,385.20,,,,,,,310.09,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995876,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995876,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8995878,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8995878,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9000003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9000003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE,8995961,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,99.27000,28.79000,Aetna,Local,,39.71,,,,,,,35.79,81.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE,8995961,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,99.27000,28.79000,Aetna,Local,,39.71,,,,,,,31.96,81.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8995962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8995962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995963,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,4487.00000,1301.23000,Aetna,Local,,1794.80,,,,,,,1617.56,3670.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995963,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,4487.00000,1301.23000,Aetna,Local,,1794.80,,,,,,,1444.81,3670.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8995964,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8995964,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATOSPHERE,8995965,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,21107.50000,6121.17000,Aetna,Local,,8443.00,,,,,,,7609.25,17265.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATOSPHERE,8995965,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,21107.50000,6121.17000,Aetna,Local,,8443.00,,,,,,,6796.61,17265.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12768.00000,3702.72000,Aetna,Local,,5107.20,,,,,,,4602.86,10444.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12768.00000,3702.72000,Aetna,Local,,5107.20,,,,,,,4111.30,10444.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMMOBILIZER,8995969,CDM,278,RC,L1830,HCPCS,,,facility,inpatient,,,134.77000,39.08000,Aetna,Local,,53.91,,,,,,,48.58,110.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMMOBILIZER,8995969,CDM,278,RC,L1830,HCPCS,,,facility,outpatient,,,134.77000,39.08000,Aetna,Local,,53.91,,,,,,,43.40,110.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8995970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8995970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995972,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995972,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995973,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995973,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSSLINK,8995974,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2304.00000,668.16000,Aetna,Local,,921.60,,,,,,,830.59,1884.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSSLINK,8995974,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2304.00000,668.16000,Aetna,Local,,921.60,,,,,,,741.89,1884.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995024,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995024,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8995038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8995038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995977,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,2170.21,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8995977,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,1938.44,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8997061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8997061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8995979,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8995979,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASE TIBIA,8995982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASE TIBIA,8995982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8995983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8995983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8995984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PINNACLE,9000058,CDM,278,RC,,,,,facility,inpatient,,,922.05000,267.39000,Aetna,Local,,368.82,,,,,,,332.40,754.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PINNACLE,9000058,CDM,278,RC,,,,,facility,outpatient,,,922.05000,267.39000,Aetna,Local,,368.82,,,,,,,296.90,754.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8996074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8996074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8996073,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8996073,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8996069,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8996069,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8996070,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,8996070,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8996071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8996071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,8996072,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,953.52,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,8996072,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,851.69,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9000062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9000062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,Local,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9002089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,Local,,965.60,,,,,,,870.25,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9002089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,Local,,965.60,,,,,,,777.31,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9002086,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9002086,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT RDL HEAD,9002088,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT RDL HEAD,9002088,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9000059,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9000059,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000060,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000060,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9000061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9000061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,9002087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,9002087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,9000096,CDM,278,RC,C1784,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,9000096,CDM,278,RC,C1784,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,9002161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,9002161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9002164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9002164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9002175,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21412.50000,6209.62000,Aetna,Local,,8565.00,,,,,,,7719.21,17515.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9002175,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21412.50000,6209.62000,Aetna,Local,,8565.00,,,,,,,6894.82,17515.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002171,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002171,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9002173,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9002173,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9002172,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9002172,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9002174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9002174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP ADVANCED,9002176,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1294.88000,375.52000,Aetna,Local,,517.95,,,,,,,466.80,1059.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP ADVANCED,9002176,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1294.88000,375.52000,Aetna,Local,,517.95,,,,,,,416.95,1059.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002177,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,565.03,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002177,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,504.69,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL INTRAMED,9002179,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL INTRAMED,9002179,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002261,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,565.03,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002261,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,504.69,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9002242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9002242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9002262,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,3062.33,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9002262,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,2735.29,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9002241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9002241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9002244,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9002244,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,436.93,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,390.26,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002303,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3957.21,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002303,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3534.59,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9002304,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9002304,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,436.93,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,390.26,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9000265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9000265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9000266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,875.21000,253.81000,Aetna,Local,,350.08,,,,,,,315.51,715.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9000266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,875.21000,253.81000,Aetna,Local,,350.08,,,,,,,281.82,715.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9000267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9000267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9000268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9000268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9000269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,4351.96,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9000269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,3887.18,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,507.58,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,Local,,563.20,,,,,,,453.38,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9070.20000,2630.36000,Aetna,Local,,3628.08,,,,,,,3269.81,7419.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9070.20000,2630.36000,Aetna,Local,,3628.08,,,,,,,2920.60,7419.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9752.40000,2828.20000,Aetna,Local,,3900.96,,,,,,,3515.74,7977.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9752.40000,2828.20000,Aetna,Local,,3900.96,,,,,,,3140.27,7977.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9000332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5947.41000,1724.75000,Aetna,Local,,2378.96,,,,,,,2144.04,4864.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9000332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5947.41000,1724.75000,Aetna,Local,,2378.96,,,,,,,1915.07,4864.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REAMER,9000352,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REAMER,9000352,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9000342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,2133.62,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9000342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5918.50000,1716.36000,Aetna,Local,,2367.40,,,,,,,1905.76,4841.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9000343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9000343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8523.00000,2471.67000,Aetna,Local,,3409.20,,,,,,,3072.54,6971.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8523.00000,2471.67000,Aetna,Local,,3409.20,,,,,,,2744.41,6971.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9002399,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3250.45000,942.63000,Aetna,Local,,1300.18,,,,,,,1171.79,2658.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9002399,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3250.45000,942.63000,Aetna,Local,,1300.18,,,,,,,1046.64,2658.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,9000402,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2416.25,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,9000402,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2158.20,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9000404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9000404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER MICRO LANTERN,9000403,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER MICRO LANTERN,9000403,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9002436,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9002436,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9002437,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9002437,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9002440,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9002440,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9002441,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9002441,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9002444,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9002444,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9002445,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9002445,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT GLENOID,9002446,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9135.00000,2649.15000,Aetna,Local,,3654.00,,,,,,,3293.17,7472.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT GLENOID,9002446,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9135.00000,2649.15000,Aetna,Local,,3654.00,,,,,,,2941.47,7472.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9002514,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9002514,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9000552,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9000552,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9000553,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3970.84,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9000553,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11014.80000,3194.29000,Aetna,Local,,4405.92,,,,,,,3546.77,9010.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9000554,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17887.00000,5187.23000,Aetna,Local,,7154.80,,,,,,,6448.26,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9000554,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17887.00000,5187.23000,Aetna,Local,,7154.80,,,,,,,5759.61,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REAMER,9002917,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,4532.33000,1314.38000,Aetna,Local,,1812.93,,,,,,,1633.90,3707.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REAMER,9002917,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,4532.33000,1314.38000,Aetna,Local,,1812.93,,,,,,,1459.41,3707.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002918,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,475.87,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002918,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,425.05,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,9002919,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,475.87,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,9002919,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.04000,382.81000,Aetna,Local,,528.02,,,,,,,425.05,1079.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,9002920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2729.00000,791.41000,Aetna,Local,,1091.60,,,,,,,983.80,2232.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,9002920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2729.00000,791.41000,Aetna,Local,,1091.60,,,,,,,878.74,2232.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9002972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9002972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT RESTRICTOR,9003407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT RESTRICTOR,9003407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT RESTRICTOR,9003408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,178.09,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT RESTRICTOR,9003408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.00000,143.26000,Aetna,Local,,197.60,,,,,,,159.07,404.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT DISC W HEXALOBULAR,9003409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8022.00000,2326.38000,Aetna,Local,,3208.80,,,,,,,2891.93,6562.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT DISC W HEXALOBULAR,9003409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8022.00000,2326.38000,Aetna,Local,,3208.80,,,,,,,2583.08,6562.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,9003410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16445.00000,4769.05000,Aetna,Local,,6578.00,,,,,,,5928.42,13452.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,9003410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16445.00000,4769.05000,Aetna,Local,,6578.00,,,,,,,5295.29,13452.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNA,9003411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18557.50000,5381.67000,Aetna,Local,,7423.00,,,,,,,6689.98,15180.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNA,9003411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18557.50000,5381.67000,Aetna,Local,,7423.00,,,,,,,5975.52,15180.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9003448,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,7417.29,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9003448,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,6625.15,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9003449,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9003449,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PASSER SUTURE,8423563,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PASSER SUTURE,8423563,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9003447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9003447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TENDON,9003458,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1962.02,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TENDON,9003458,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1752.48,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9003459,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9003459,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,9003471,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,9003471,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,9003472,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,9003472,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9003502,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9003502,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9000816,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9000816,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000817,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000817,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1469.63,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,Local,,1630.65,,,,,,,1312.67,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REAMER,8342303,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,839.97,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REAMER,8342303,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,750.26,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8406040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8406040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,Local,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7976665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7976665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974757,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,666.58,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974757,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,Local,,739.62,,,,,,,595.39,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7974859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7974859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7974860,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7974860,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7976742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8406258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8786.25000,2548.01000,Aetna,Local,,3514.50,,,,,,,3167.44,7187.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8406258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8786.25000,2548.01000,Aetna,Local,,3514.50,,,,,,,2829.17,7187.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8406262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8406262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8406264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8406264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8406274,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8406274,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8406266,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8406266,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8406268,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8406268,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8406270,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8406270,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8406272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8406272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975079,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975079,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975080,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975080,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975088,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975088,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975089,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975089,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975090,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975090,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975091,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975091,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975095,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975095,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975120,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975120,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975112,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975112,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975111,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975111,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975114,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975114,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975115,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975115,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975116,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975116,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975117,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975117,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975118,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975118,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989201,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,330.96,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989201,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,295.61,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7976430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7976430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7976606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7976606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7976431,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7976431,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6167.00000,1788.43000,Aetna,Local,,2466.80,,,,,,,2223.20,5044.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6167.00000,1788.43000,Aetna,Local,,2466.80,,,,,,,1985.77,5044.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7978376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6167.00000,1788.43000,Aetna,Local,,2466.80,,,,,,,2223.20,5044.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7978376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6167.00000,1788.43000,Aetna,Local,,2466.80,,,,,,,1985.77,5044.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7976654,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7976654,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,Local,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976669,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976669,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,Local,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7976694,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7976694,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7976695,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7976695,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7982900,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7982900,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7976693,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7976693,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7982901,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7982901,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7982899,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7982899,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7978327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,577.91,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7978327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,516.19,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7978328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,577.91,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7978328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,516.19,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,577.91,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,Local,,641.23,,,,,,,516.19,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2616.04000,758.65000,Aetna,Local,,1046.42,,,,,,,943.08,2139.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2616.04000,758.65000,Aetna,Local,,1046.42,,,,,,,842.36,2139.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2781.96000,806.77000,Aetna,Local,,1112.78,,,,,,,1002.90,2275.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2781.96000,806.77000,Aetna,Local,,1112.78,,,,,,,895.79,2275.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2846.52000,825.49000,Aetna,Local,,1138.61,,,,,,,1026.17,2328.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2846.52000,825.49000,Aetna,Local,,1138.61,,,,,,,916.58,2328.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980847,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,62.32,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980847,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,55.67,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,62.32,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,Local,,69.15,,,,,,,55.67,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,Local,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,Local,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,338.17,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,Local,,375.23,,,,,,,302.06,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,Local,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,Local,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8406647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8406647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8406648,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,5264.00000,1526.56000,Aetna,Local,,2105.60,,,,,,,1897.67,4305.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8406648,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,5264.00000,1526.56000,Aetna,Local,,2105.60,,,,,,,1695.01,4305.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8406649,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8406649,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980883,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,596.03000,172.85000,Aetna,Local,,238.41,,,,,,,214.87,487.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980883,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,596.03000,172.85000,Aetna,Local,,238.41,,,,,,,191.92,487.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980884,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980884,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,Local,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,596.03000,172.85000,Aetna,Local,,238.41,,,,,,,214.87,487.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,596.03000,172.85000,Aetna,Local,,238.41,,,,,,,191.92,487.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8406655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1560.92000,452.67000,Aetna,Local,,624.37,,,,,,,562.71,1276.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8406655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1560.92000,452.67000,Aetna,Local,,624.37,,,,,,,502.62,1276.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8406656,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8406656,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8406657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8406657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON NASAL,8406658,CDM,278,RC,L8047,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,201.16,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON NASAL,8406658,CDM,278,RC,L8047,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,179.68,1561.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8406659,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8406659,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406661,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406661,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8406645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,3076.60,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8406645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,2748.03,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,8406698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,8406698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,8406699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,8406699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,8406700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,8406700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM IMPLANT KNOTLESS,8406761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7639.65000,2215.50000,Aetna,Local,,3055.86,,,,,,,2754.09,6249.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYSTEM IMPLANT KNOTLESS,8406761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7639.65000,2215.50000,Aetna,Local,,3055.86,,,,,,,2459.97,6249.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8406857,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8406857,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8406858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8406858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,Local,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8406883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8406883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406885,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406885,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER FEMORAL,8158233,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER FEMORAL,8158233,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8169227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,Local,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982376,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982376,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,Local,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8406915,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8406915,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8406916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8406916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982390,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982390,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5868.45000,1701.85000,Aetna,Local,,2347.38,,,,,,,2115.58,4800.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5868.45000,1701.85000,Aetna,Local,,2347.38,,,,,,,1889.64,4800.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5284.58000,1532.53000,Aetna,Local,,2113.83,,,,,,,1905.09,4322.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5284.58000,1532.53000,Aetna,Local,,2113.83,,,,,,,1701.63,4322.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,Local,,133.08,,,,,,,119.93,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,Local,,133.08,,,,,,,107.13,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,Local,,133.08,,,,,,,119.93,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,Local,,133.08,,,,,,,107.13,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,Local,,133.08,,,,,,,119.93,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,Local,,133.08,,,,,,,107.13,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,358.53000,103.97000,Aetna,Local,,143.41,,,,,,,129.25,293.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,358.53000,103.97000,Aetna,Local,,143.41,,,,,,,115.45,293.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7982464,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7982464,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,Local,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7983042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7983042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987623,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,873.04,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987623,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,779.81,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8406919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3475.94,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8406919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3104.72,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8406920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,Local,,2625.52,,,,,,,2366.25,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,Local,,2625.52,,,,,,,2113.54,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7989186,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,Local,,3252.00,,,,,,,2930.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7989186,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,Local,,3252.00,,,,,,,2617.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE WEDGE,7989187,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,Local,,3252.00,,,,,,,2930.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE WEDGE,7989187,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,Local,,3252.00,,,,,,,2617.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE WEDGE,7989184,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,Local,,3252.00,,,,,,,2930.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE WEDGE,7989184,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,Local,,3252.00,,,,,,,2617.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE WEDGE,7989239,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,Local,,3252.00,,,,,,,2930.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE WEDGE,7989239,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,Local,,3252.00,,,,,,,2617.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7955064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7955064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7967969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7967969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8407051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8407051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407052,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407052,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8407057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,7417.29,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL,8407057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,6625.15,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,8407058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21600.00000,6264.00000,Aetna,Local,,8640.00,,,,,,,7786.80,17668.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,8407058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,Local,,8640.00,,,,,,,6955.20,17668.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,8407059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3360.22,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,8407059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3001.36,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7975067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7975067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987579,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2382.00000,690.78000,Aetna,Local,,952.80,,,,,,,858.71,1948.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987579,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2382.00000,690.78000,Aetna,Local,,952.80,,,,,,,767.00,1948.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,873.04,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,Local,,968.70,,,,,,,779.81,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975122,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975122,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975123,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975123,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975124,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975124,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975125,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975125,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975126,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975126,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975127,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975127,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975129,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975129,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975130,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,234.67,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7975130,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,Local,,260.39,,,,,,,209.61,532.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8338170,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,536.42,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8338170,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,479.14,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8229104,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2768.00000,802.72000,Aetna,Local,,1107.20,,,,,,,997.86,2264.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8229104,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2768.00000,802.72000,Aetna,Local,,1107.20,,,,,,,891.30,2264.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8137223,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8137223,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8160715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8160715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8239907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8239907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8259999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2324.16000,674.01000,Aetna,Local,,929.66,,,,,,,837.86,1901.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8259999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2324.16000,674.01000,Aetna,Local,,929.66,,,,,,,748.38,1901.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8347468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,7669.64,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8347468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,6850.55,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8320179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8320179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8407099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8407099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8310295,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8064.00000,2338.56000,Aetna,Local,,3225.60,,,,,,,2907.07,6596.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,8310295,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8064.00000,2338.56000,Aetna,Local,,3225.60,,,,,,,2596.61,6596.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8320189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8331458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8331458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8366680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8370368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8370368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8407140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8407140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8407178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8407178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2168.00000,628.72000,Aetna,Local,,867.20,,,,,,,781.56,1773.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2168.00000,628.72000,Aetna,Local,,867.20,,,,,,,698.10,1773.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1498.44000,434.55000,Aetna,Local,,599.38,,,,,,,540.19,1225.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1498.44000,434.55000,Aetna,Local,,599.38,,,,,,,482.50,1225.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8407230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10178.13000,2951.66000,Aetna,Local,,4071.25,,,,,,,3669.22,8325.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8407230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10178.13000,2951.66000,Aetna,Local,,4071.25,,,,,,,3277.36,8325.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8407232,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14143.50000,4101.62000,Aetna,Local,,5657.40,,,,,,,5098.73,11569.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8407232,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14143.50000,4101.62000,Aetna,Local,,5657.40,,,,,,,4554.21,11569.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8407234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8407234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,Local,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8407236,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8407236,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407224,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407224,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407226,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407226,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8407315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8407315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8407320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,508.25000,147.39000,Aetna,Local,,203.30,,,,,,,183.22,415.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8407320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,508.25000,147.39000,Aetna,Local,,203.30,,,,,,,163.66,415.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8407321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8407321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407313,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407313,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8407314,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8407314,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8407424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8407424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8407678,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8407678,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8407835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8407835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE RIBBON,8407670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,1067.08,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE RIBBON,8407670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2960.00000,858.40000,Aetna,Local,,1184.00,,,,,,,953.12,2421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8407671,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8407671,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8407672,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8407672,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407675,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407675,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8407831,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8407831,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8407832,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8407832,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,8407833,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5187.00000,1504.23000,Aetna,Local,,2074.80,,,,,,,1869.91,4242.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,8407833,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5187.00000,1504.23000,Aetna,Local,,2074.80,,,,,,,1670.21,4242.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8407834,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8407834,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8407839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8407839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8407930,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8407930,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407973,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1605.20,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407973,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4452.70000,1291.28000,Aetna,Local,,1781.08,,,,,,,1433.77,3642.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8407932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,Local,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407934,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407934,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407974,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407974,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BURR HOLE COVER,8407936,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1215.20000,352.41000,Aetna,Local,,486.08,,,,,,,438.08,994.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BURR HOLE COVER,8407936,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1215.20000,352.41000,Aetna,Local,,486.08,,,,,,,391.29,994.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8407965,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,8706.51000,2524.89000,Aetna,Local,,3482.60,,,,,,,3138.70,7121.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8407965,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,8706.51000,2524.89000,Aetna,Local,,3482.60,,,,,,,2803.50,7121.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8407969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,Local,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8407971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4518.50000,1310.36000,Aetna,Local,,1807.40,,,,,,,1628.92,3696.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8407971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4518.50000,1310.36000,Aetna,Local,,1807.40,,,,,,,1454.96,3696.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407975,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407975,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407976,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1640.28,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407976,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1465.10,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407977,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407977,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407978,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1640.28,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407978,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1465.10,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407979,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1640.28,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407979,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1465.10,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407980,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12942.00000,3753.18000,Aetna,Local,,5176.80,,,,,,,4665.59,10586.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407980,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12942.00000,3753.18000,Aetna,Local,,5176.80,,,,,,,4167.32,10586.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407981,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12942.00000,3753.18000,Aetna,Local,,5176.80,,,,,,,4665.59,10586.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8407981,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12942.00000,3753.18000,Aetna,Local,,5176.80,,,,,,,4167.32,10586.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLAMP ROD TO ROD SPINAL,8407982,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2856.00000,828.24000,Aetna,Local,,1142.40,,,,,,,1029.59,2336.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLAMP ROD TO ROD SPINAL,8407982,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2856.00000,828.24000,Aetna,Local,,1142.40,,,,,,,919.63,2336.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8407983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8407983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8408124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8408124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8408175,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8408175,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8408176,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8408176,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408178,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408178,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8408179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8408179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408180,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408180,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8408182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8408182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8408183,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8408183,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8408199,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,339.39000,98.42000,Aetna,Local,,135.76,,,,,,,122.35,277.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8408199,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,339.39000,98.42000,Aetna,Local,,135.76,,,,,,,109.28,277.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408200,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408200,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT IN A KIT,7980451,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,322.39,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT IN A KIT,7980451,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,287.96,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8408292,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8408292,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8408327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1940.00000,562.60000,Aetna,Local,,776.00,,,,,,,699.37,1586.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8408327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1940.00000,562.60000,Aetna,Local,,776.00,,,,,,,624.68,1586.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8408328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8408328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8408341,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8408341,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6053.15000,1755.41000,Aetna,Local,,2421.26,,,,,,,2182.16,4951.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6053.15000,1755.41000,Aetna,Local,,2421.26,,,,,,,1949.11,4951.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8408468,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,7669.64,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8408468,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,6850.55,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8408470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8408470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8408471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8408471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8408472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8408472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8408473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8408473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8408474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8408474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8408475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,7273.09,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8408475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20175.00000,5850.75000,Aetna,Local,,8070.00,,,,,,,6496.35,16503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8408477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8408477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408467,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408467,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8408602,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8408602,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408478,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408478,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8408481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8408481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG VASCULAR,8408482,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG VASCULAR,8408482,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8408604,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8408604,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8408634,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8408634,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408635,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408635,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8408636,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11684.25000,3388.43000,Aetna,Local,,4673.70,,,,,,,4212.17,9557.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8408636,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11684.25000,3388.43000,Aetna,Local,,4673.70,,,,,,,3762.33,9557.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8408633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8408695,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8408695,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COMPONENT,8408707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM COMPONENT,8408707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT HUMERAL,8408709,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT HUMERAL,8408709,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408785,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408785,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8408786,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8408786,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION STAPLE,7703262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,489.01000,141.81000,Aetna,Local,,195.60,,,,,,,176.29,400.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION STAPLE,7703262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,489.01000,141.81000,Aetna,Local,,195.60,,,,,,,157.46,400.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESTRICTOR CEMENT,8408818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1215.20000,352.41000,Aetna,Local,,486.08,,,,,,,438.08,994.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESTRICTOR CEMENT,8408818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1215.20000,352.41000,Aetna,Local,,486.08,,,,,,,391.29,994.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIMULATOR,8408787,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIMULATOR,8408787,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8408789,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8408789,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8408853,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8408853,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408851,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8408851,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8408852,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8408852,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8408900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8408900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8408902,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8408902,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8464.05000,2454.57000,Aetna,Local,,3385.62,,,,,,,3051.29,6923.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8464.05000,2454.57000,Aetna,Local,,3385.62,,,,,,,2725.42,6923.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8408957,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,9072.00000,2630.88000,Aetna,Local,,3628.80,,,,,,,3270.46,7420.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8408957,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,9072.00000,2630.88000,Aetna,Local,,3628.80,,,,,,,2921.18,7420.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2496.00000,723.84000,Aetna,Local,,998.40,,,,,,,899.81,2041.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2496.00000,723.84000,Aetna,Local,,998.40,,,,,,,803.71,2041.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2496.00000,723.84000,Aetna,Local,,998.40,,,,,,,899.81,2041.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8408959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2496.00000,723.84000,Aetna,Local,,998.40,,,,,,,803.71,2041.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8408960,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8408960,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8408999,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8408999,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8409009,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8409009,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8409027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8409027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8409020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8409020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,Local,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8409029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8409029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8409030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8409030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8409109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8409109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8409111,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8409111,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8409194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8271.00000,2398.59000,Aetna,Local,,3308.40,,,,,,,2981.70,6765.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8409194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8271.00000,2398.59000,Aetna,Local,,3308.40,,,,,,,2663.26,6765.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8409195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8409195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8409196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10125.00000,2936.25000,Aetna,Local,,4050.00,,,,,,,3650.06,8282.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8409196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10125.00000,2936.25000,Aetna,Local,,4050.00,,,,,,,3260.25,8282.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8409197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8409197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8409470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8409470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8409456,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8409456,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8409458,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8409458,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8409466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8409466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE FEMORAL,8409467,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3056.00000,886.24000,Aetna,Local,,1222.40,,,,,,,1101.69,2499.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE FEMORAL,8409467,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3056.00000,886.24000,Aetna,Local,,1222.40,,,,,,,984.03,2499.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE HUMERAL STEM,8409530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE HUMERAL STEM,8409530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,Local,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8409532,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8409532,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8409534,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8409534,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8409536,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8409536,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8409538,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8409538,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8409540,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5530.00000,1603.70000,Aetna,Local,,2212.00,,,,,,,1993.57,4523.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8409540,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5530.00000,1603.70000,Aetna,Local,,2212.00,,,,,,,1780.66,4523.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8409638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8409638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8409639,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8409639,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8409790,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8409790,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,764.47,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8409792,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,7590.00000,2201.10000,Aetna,Local,,3036.00,,,,,,,2736.20,6208.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8409792,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,7590.00000,2201.10000,Aetna,Local,,3036.00,,,,,,,764.47,6208.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8409794,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,7590.00000,2201.10000,Aetna,Local,,3036.00,,,,,,,2736.20,6208.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,8409794,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,7590.00000,2201.10000,Aetna,Local,,3036.00,,,,,,,764.47,6208.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8409941,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8409941,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8409943,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8409943,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8409949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8409949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409952,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,314.23,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409952,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,280.67,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,314.23,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,280.67,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409956,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,314.23,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8409956,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,280.67,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8410045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5134.01000,1488.86000,Aetna,Local,,2053.60,,,,,,,1850.81,4199.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8410045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5134.01000,1488.86000,Aetna,Local,,2053.60,,,,,,,1653.15,4199.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8410049,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8410049,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8410060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8410060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8410061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8410061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8410062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8410062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8410063,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8410063,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8410064,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8410064,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8410194,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,8410194,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8410195,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8410195,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8410196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8781.00000,2546.49000,Aetna,Local,,3512.40,,,,,,,3165.55,7182.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8410196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8781.00000,2546.49000,Aetna,Local,,3512.40,,,,,,,2827.48,7182.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8409329,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8409329,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,9357.00,,,,,,,1121.37,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER GUIDE,8410215,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410215,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410216,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410216,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410217,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410217,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410218,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410218,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410219,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410219,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410220,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410220,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410221,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8410221,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,8410397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,8410397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,327.18000,94.88000,Aetna,Local,,130.87,,,,,,,117.95,267.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,327.18000,94.88000,Aetna,Local,,130.87,,,,,,,105.35,267.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410404,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410404,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8410402,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,71.92,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,8410402,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,199.50000,57.86000,Aetna,Local,,79.80,,,,,,,64.24,163.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8410403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8410403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8410509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3644.38,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8410509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3255.18,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8410511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.00000,559.99000,Aetna,Local,,772.40,,,,,,,696.13,1579.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,8410511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.00000,559.99000,Aetna,Local,,772.40,,,,,,,621.78,1579.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8410428,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8410428,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR IN KIT,8410516,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,47362.50000,13735.12000,Aetna,Local,,18945.00,,,,,,,17074.18,38742.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR IN KIT,8410516,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,47362.50000,13735.12000,Aetna,Local,,18945.00,,,,,,,15250.73,38742.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REMOTE CONTROL IN KIT,8410517,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REMOTE CONTROL IN KIT,8410517,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8410679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8410679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8410680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8410680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,Local,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8410681,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,8410681,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8410683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8410703,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8410703,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8410704,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8410704,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8410705,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8410705,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,Local,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8410910,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8410910,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8410912,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1291.62,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8410912,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1153.68,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8410916,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8410916,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8410937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8410937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8410947,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,8410947,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8411014,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8411014,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8411015,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,6529.56,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8411015,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,5832.23,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8411016,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8411016,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8411017,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8411017,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8411018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8411018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8411019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8411019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8411020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,8411020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.56000,196.78000,Aetna,Local,,271.42,,,,,,,244.62,555.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.56000,196.78000,Aetna,Local,,271.42,,,,,,,218.50,555.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.56000,196.78000,Aetna,Local,,271.42,,,,,,,244.62,555.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.56000,196.78000,Aetna,Local,,271.42,,,,,,,218.50,555.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8411023,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8411023,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8411090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8411090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8411091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8411091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8411086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8411086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8411087,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8411087,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8411088,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8411088,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8411089,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8411089,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8411194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2811.90,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8411194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2511.60,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8411196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3825.50000,1109.40000,Aetna,Local,,1530.20,,,,,,,1379.09,3129.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8411196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3825.50000,1109.40000,Aetna,Local,,1530.20,,,,,,,1231.81,3129.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8411186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8411186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8411187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8411187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8411626,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8411626,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8411189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8411189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8411190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,8411190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8411192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3957.21,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8411192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3534.59,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8411193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8619.00000,2499.51000,Aetna,Local,,3447.60,,,,,,,3107.15,7050.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8411193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8619.00000,2499.51000,Aetna,Local,,3447.60,,,,,,,2775.32,7050.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NASAL IMPLANT,8148052,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NASAL IMPLANT,8148052,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1374.94,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8411185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8411185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8411299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1734.59,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8411299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4811.63000,1395.37000,Aetna,Local,,1924.65,,,,,,,1549.34,3935.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8411300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8411300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8411302,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8411302,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8411303,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8411303,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8411304,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8411304,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER FEMORAL,8411305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5187.00000,1504.23000,Aetna,Local,,2074.80,,,,,,,1869.91,4242.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER FEMORAL,8411305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5187.00000,1504.23000,Aetna,Local,,2074.80,,,,,,,1670.21,4242.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8411301,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8411301,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8411323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8411323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,Local,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8411438,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,8411438,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8411390,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8411390,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8411463,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8411463,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8411464,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,4351.96,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8411464,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,3887.18,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8411465,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,536.42,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8411465,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1488.00000,431.52000,Aetna,Local,,595.20,,,,,,,479.14,1217.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8411466,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8411466,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,105.33,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,292.17000,84.73000,Aetna,Local,,116.87,,,,,,,94.08,239.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,221.29000,64.17000,Aetna,Local,,88.52,,,,,,,79.78,181.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,221.29000,64.17000,Aetna,Local,,88.52,,,,,,,71.26,181.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411469,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,266.29,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411469,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,738.68000,214.22000,Aetna,Local,,295.47,,,,,,,237.85,604.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2650.40000,768.62000,Aetna,Local,,1060.16,,,,,,,955.47,2168.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2650.40000,768.62000,Aetna,Local,,1060.16,,,,,,,853.43,2168.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8411471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8411628,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8411628,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8411630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8411630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8411632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8411632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8411634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8411634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411636,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411636,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8411640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8411640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8411642,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8411642,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8411644,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1291.62,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8411644,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1153.68,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8411646,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8411646,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD TO ROD COUPLER,8411650,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,2348.00000,680.92000,Aetna,Local,,939.20,,,,,,,846.45,1920.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD TO ROD COUPLER,8411650,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,2348.00000,680.92000,Aetna,Local,,939.20,,,,,,,756.06,1920.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411731,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8411731,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8412008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8412008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8412010,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8412010,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8412011,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8412011,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8412033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8412033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8412032,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1359.54,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8412032,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3771.25000,1093.66000,Aetna,Local,,1508.50,,,,,,,1214.34,3084.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8412057,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6662.25000,1932.05000,Aetna,Local,,2664.90,,,,,,,2401.74,5449.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,8412057,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6662.25000,1932.05000,Aetna,Local,,2664.90,,,,,,,2145.24,5449.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8412058,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8412058,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8412072,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8412072,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8412073,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8412073,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,8412074,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,8412074,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,8412119,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,8412119,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8412120,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8412120,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8412110,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8412110,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8412151,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8412151,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,Local,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8412153,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8412153,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INFLATION DEVICE,8412155,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,222.29000,64.46000,Aetna,Local,,88.92,,,,,,,80.14,181.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INFLATION DEVICE,8412155,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,222.29000,64.46000,Aetna,Local,,88.92,,,,,,,71.58,181.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8413574,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,7749.00000,2247.21000,Aetna,Local,,3099.60,,,,,,,2793.51,6338.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8413574,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,7749.00000,2247.21000,Aetna,Local,,3099.60,,,,,,,2495.18,6338.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8413715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8413715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8413981,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,206.03,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8413981,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,184.02,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8413971,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,118.15,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8413971,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,105.54,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8413972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,8413972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8413817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8413817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8413819,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8413819,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8413647,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8413647,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8413649,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8413649,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8413651,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8413651,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8413653,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8413653,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8413655,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8413655,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8413657,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8413657,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8413748,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1920.00000,556.80000,Aetna,Local,,768.00,,,,,,,692.16,1570.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8413748,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1920.00000,556.80000,Aetna,Local,,768.00,,,,,,,618.24,1570.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8413749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,3076.60,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8413749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,2748.03,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8413750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8413750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Screw,8413718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Screw,8413718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8413751,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8413751,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8413752,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8413752,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8413753,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8413753,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8413719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3000.44000,870.13000,Aetna,Local,,1200.18,,,,,,,1081.66,2454.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8413719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3000.44000,870.13000,Aetna,Local,,1200.18,,,,,,,966.14,2454.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8413820,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8413820,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8413982,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT SPINAL,8413982,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8413983,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8413983,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8413984,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8413984,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8413985,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8413985,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8414051,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8414051,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8414055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4609.50000,1336.76000,Aetna,Local,,1843.80,,,,,,,1661.72,3770.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8414055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4609.50000,1336.76000,Aetna,Local,,1843.80,,,,,,,1484.26,3770.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414059,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414059,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19962.50000,5789.12000,Aetna,Local,,7985.00,,,,,,,7196.48,16329.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19962.50000,5789.12000,Aetna,Local,,7985.00,,,,,,,6427.93,16329.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414063,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414063,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414124,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414124,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414126,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414126,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ACETABULAR,8414129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10236.00000,2968.44000,Aetna,Local,,4094.40,,,,,,,3690.08,8373.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ACETABULAR,8414129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10236.00000,2968.44000,Aetna,Local,,4094.40,,,,,,,3295.99,8373.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8414131,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5253.50000,1523.52000,Aetna,Local,,2101.40,,,,,,,1893.89,4297.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8414131,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5253.50000,1523.52000,Aetna,Local,,2101.40,,,,,,,1691.63,4297.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8414133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8414133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8414137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8414137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414138,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414138,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8414222,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8414222,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,7669.64,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,6850.55,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8414227,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5686.89,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,8414227,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15775.00000,4574.75000,Aetna,Local,,6310.00,,,,,,,5079.55,12903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8414228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8414228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8414229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,3285.60,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8414229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9114.00000,2643.06000,Aetna,Local,,3645.60,,,,,,,2934.71,7455.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8414230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8414230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8414231,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8414231,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8413818,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8413818,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Plate,8414328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2488.40000,721.64000,Aetna,Local,,995.36,,,,,,,897.07,2035.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Plate,8414328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2488.40000,721.64000,Aetna,Local,,995.36,,,,,,,801.26,2035.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8414329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.60000,706.32000,Aetna,Local,,974.24,,,,,,,878.03,1992.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8414329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.60000,706.32000,Aetna,Local,,974.24,,,,,,,784.26,1992.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8414323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8414323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cage,8414324,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cage,8414324,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8414325,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8414325,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414436,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414436,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Insert,8414326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Insert,8414326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414327,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414327,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,Local,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,7669.64,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,6850.55,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8414382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,Local,,1779.28,,,,,,,1603.57,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8414382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,Local,,1779.28,,,,,,,1432.32,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNAR,8414443,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNAR,8414443,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,8414444,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,8414444,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8414445,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8414445,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414441,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414441,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8414442,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8414442,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8414380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,Local,,1779.28,,,,,,,1603.57,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8414380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,Local,,1779.28,,,,,,,1432.32,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414439,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414439,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414608,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,7790.40,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414608,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21610.00000,6266.90000,Aetna,Local,,8644.00,,,,,,,6958.42,17676.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414577,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,7669.64,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414577,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21275.00000,6169.75000,Aetna,Local,,8510.00,,,,,,,6850.55,17402.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8414578,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,3238.01,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8414578,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8982.00000,2604.78000,Aetna,Local,,3592.80,,,,,,,2892.20,7347.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414581,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8414581,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8414468,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,8414468,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8414630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3475.94,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8414630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9642.00000,2796.18000,Aetna,Local,,3856.80,,,,,,,3104.72,7887.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414631,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414631,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414634,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414634,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8414655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8414655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8414745,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2503.76000,726.09000,Aetna,Local,,1001.50,,,,,,,902.61,2048.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8414745,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2503.76000,726.09000,Aetna,Local,,1001.50,,,,,,,806.21,2048.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8414746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8414774,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,114.73,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8414774,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,102.48,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8414798,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6721.52,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,8414798,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18645.00000,5407.05000,Aetna,Local,,7458.00,,,,,,,6003.69,15251.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8414800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,665.84,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,8414800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,594.73,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414847,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,8414847,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR GENERATOR,8414848,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,25042.50000,7262.32000,Aetna,Local,,10017.00,,,,,,,9027.82,20484.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR GENERATOR,8414848,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,25042.50000,7262.32000,Aetna,Local,,10017.00,,,,,,,8063.69,20484.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8414849,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8414849,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,Local,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414879,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5633.71,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8414879,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15627.50000,4531.97000,Aetna,Local,,6251.00,,,,,,,5032.06,12783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8414882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3380.30000,980.29000,Aetna,Local,,1352.12,,,,,,,1218.60,2765.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8414882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3380.30000,980.29000,Aetna,Local,,1352.12,,,,,,,1088.46,2765.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8414884,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,7029.75,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8414884,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,6279.00,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8414886,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8414886,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8414900,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8414900,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8414933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8414933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8414935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8414937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8414937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8414938,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8414938,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8414940,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8414940,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8414942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8899.50000,2580.86000,Aetna,Local,,3559.80,,,,,,,3208.27,7279.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8414942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8899.50000,2580.86000,Aetna,Local,,3559.80,,,,,,,2865.64,7279.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8414944,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8414944,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8415027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,3076.60,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8415027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,Local,,3413.70,,,,,,,2748.03,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8415029,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8415029,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,8415031,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,38137.50000,11059.88000,Aetna,Local,,15255.00,,,,,,,13748.57,31196.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,8415031,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,38137.50000,11059.88000,Aetna,Local,,15255.00,,,,,,,12280.27,31196.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8415025,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8415025,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415033,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415033,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415034,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415034,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415035,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415035,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415036,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415036,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415037,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415037,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415038,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415038,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415039,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415039,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415040,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415040,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415041,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415041,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415042,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1198.66,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8415042,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,3325.00000,964.25000,Aetna,Local,,1330.00,,,,,,,1070.65,2719.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9000818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9000818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1635.23,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1460.59,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9000868,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9000868,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9000869,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9000869,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9000870,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9000870,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9000871,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,4082.66,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9000871,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,3646.65,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9000872,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9000872,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9000903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,430.87000,124.95000,Aetna,Local,,172.35,,,,,,,155.33,352.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9000903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,430.87000,124.95000,Aetna,Local,,172.35,,,,,,,138.74,352.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9003562,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9003562,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9000923,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9000923,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000924,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,317.52,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000924,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,880.79000,255.43000,Aetna,Local,,352.32,,,,,,,283.61,720.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,9000925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4517.63000,1310.11000,Aetna,Local,,1807.05,,,,,,,1628.61,3695.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,9000925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4517.63000,1310.11000,Aetna,Local,,1807.05,,,,,,,1454.68,3695.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9000950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9000950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9000951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9000951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9000952,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9000952,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9000953,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9000953,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000954,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3775.10000,1094.78000,Aetna,Local,,1510.04,,,,,,,1360.92,3088.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9000954,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3775.10000,1094.78000,Aetna,Local,,1510.04,,,,,,,1215.58,3088.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9000970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,2146.24,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9000970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,1917.03,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9003633,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9003633,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9003635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9003635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9003636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1811.62,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9003636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1618.15,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1370.40000,397.42000,Aetna,Local,,548.16,,,,,,,494.03,1120.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1370.40000,397.42000,Aetna,Local,,548.16,,,,,,,441.27,1120.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9003638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9003638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9003639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9003639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9003640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9003640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,9013416,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,80000.00000,23200.00000,Aetna,Local,,32000.00,,,,,,,28840.00,65440.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,9013416,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,80000.00000,23200.00000,Aetna,Local,,32000.00,,,,,,,25760.00,65440.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,9013417,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,80000.00000,23200.00000,Aetna,Local,,32000.00,,,,,,,28840.00,65440.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,9013417,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,80000.00000,23200.00000,Aetna,Local,,32000.00,,,,,,,25760.00,65440.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,9013418,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,80000.00000,23200.00000,Aetna,Local,,32000.00,,,,,,,28840.00,65440.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,9013418,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,80000.00000,23200.00000,Aetna,Local,,32000.00,,,,,,,25760.00,65440.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,9013419,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,80000.00000,23200.00000,Aetna,Local,,32000.00,,,,,,,28840.00,65440.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEART VALVE,9013419,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,80000.00000,23200.00000,Aetna,Local,,32000.00,,,,,,,25760.00,65440.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9016229,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9016229,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9024174,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9024174,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9024175,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9024175,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9024176,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9024176,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9024177,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9024177,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9020813,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9020813,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9020814,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9020814,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9020815,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9020815,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER MAP,9020816,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER MAP,9020816,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHTER TACTI,9022252,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHTER TACTI,9022252,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,Local,,9357.00,,,,,,,4491.90,11411.10,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9024095,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,609.75000,176.83000,Aetna,Local,,243.90,,,,,,,219.81,498.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9024095,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,609.75000,176.83000,Aetna,Local,,243.90,,,,,,,196.34,498.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994744,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994744,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994745,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994745,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994746,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994746,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994747,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994747,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994748,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994748,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994749,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994749,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994750,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994750,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994751,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994751,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994752,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994752,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994753,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994753,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994754,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994754,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994755,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994755,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994756,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994756,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994757,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994757,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994758,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994758,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994759,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994759,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994760,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8994760,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARDIAC CATHETER,8995007,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3797.50000,1101.27000,Aetna,Local,,1519.00,,,,,,,1369.00,3106.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARDIAC CATHETER,8995007,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3797.50000,1101.27000,Aetna,Local,,9357.00,,,,,,,1222.80,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CARDIAC CATHETER,8995008,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,Local,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARDIAC CATHETER,8995008,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,Local,,9357.00,,,,,,,895.16,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SHEATH,8995631,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8995631,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,Local,,1379.00,,,,,,,1110.10,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,8995632,CDM,278,RC,C1817,HCPCS,,,facility,inpatient,,,29351.25000,8511.86000,Aetna,Local,,11740.50,,,,,,,10581.13,24009.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,8995632,CDM,278,RC,C1817,HCPCS,,,facility,outpatient,,,29351.25000,8511.86000,Aetna,Local,,11740.50,,,,,,,9451.10,24009.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VENTURE,8999989,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VENTURE,8999989,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE NEEDLES,9002185,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE NEEDLES,9002185,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9002186,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9002186,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9002187,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,1556.00000,451.24000,Aetna,Local,,622.40,,,,,,,560.94,1272.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9002187,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,1556.00000,451.24000,Aetna,Local,,622.40,,,,,,,501.03,1272.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8996067,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8996067,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,Local,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9003641,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1811.62,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9003641,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1618.15,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9003644,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9003644,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9003645,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.40000,1439.68000,Aetna,Local,,1985.76,,,,,,,1789.67,4060.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9003645,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.40000,1439.68000,Aetna,Local,,1985.76,,,,,,,1598.54,4060.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1370.40000,397.42000,Aetna,Local,,548.16,,,,,,,494.03,1120.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1370.40000,397.42000,Aetna,Local,,548.16,,,,,,,441.27,1120.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9003648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9003648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9003649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1811.62,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9003649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1618.15,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2561.60000,742.86000,Aetna,Local,,1024.64,,,,,,,923.46,2095.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2561.60000,742.86000,Aetna,Local,,1024.64,,,,,,,824.84,2095.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9003651,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9003651,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,398.34000,115.52000,Aetna,Local,,159.34,,,,,,,143.60,325.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9000969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,398.34000,115.52000,Aetna,Local,,159.34,,,,,,,128.27,325.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SET,9001025,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SET,9001025,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9001026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9001026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE,9001049,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,113.93000,33.04000,Aetna,Local,,45.57,,,,,,,41.07,93.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE,9001049,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,113.93000,33.04000,Aetna,Local,,45.57,,,,,,,36.69,332.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INJECTOR NEEDLE,9001051,CDM,278,RC,A4215,HCPCS,,,facility,inpatient,,,372.92000,108.15000,Aetna,Local,,149.17,,,,,,,134.44,305.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INJECTOR NEEDLE,9001051,CDM,278,RC,A4215,HCPCS,,,facility,outpatient,,,372.92000,108.15000,Aetna,Local,,149.17,,,,,,,0.14445,305.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001035,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1517.25,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001035,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1355.22,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001036,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1517.25,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001036,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1355.22,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001037,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1517.25,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001037,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1355.22,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001038,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1517.25,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001038,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1355.22,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001039,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1517.25,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001039,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1355.22,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001040,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1517.25,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001040,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1355.22,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001041,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1517.25,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001041,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1355.22,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001042,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1517.25,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOWEL,9001042,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4208.75000,1220.54000,Aetna,Local,,1683.50,,,,,,,1355.22,3442.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP ADVANCED,9001103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1294.88000,375.52000,Aetna,Local,,517.95,,,,,,,466.80,1059.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP ADVANCED,9001103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1294.88000,375.52000,Aetna,Local,,517.95,,,,,,,416.95,1059.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,565.03,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,504.69,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9001106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17486.75000,5071.16000,Aetna,Local,,6994.70,,,,,,,6303.97,14304.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9001106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17486.75000,5071.16000,Aetna,Local,,6994.70,,,,,,,5630.73,14304.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11521.50000,3341.23000,Aetna,Local,,4608.60,,,,,,,4153.50,9424.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11521.50000,3341.23000,Aetna,Local,,4608.60,,,,,,,3709.92,9424.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9001109,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9001109,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RHINOLARYNGOSCOPE,9001110,CDM,278,RC,C2631,HCPCS,,,facility,inpatient,,,320.63000,92.98000,Aetna,Local,,128.25,,,,,,,115.59,262.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RHINOLARYNGOSCOPE,9001110,CDM,278,RC,C2631,HCPCS,,,facility,outpatient,,,320.63000,92.98000,Aetna,Local,,128.25,,,,,,,103.24,262.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003918,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003918,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9003921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9003921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER DISTAL,9003922,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER DISTAL,9003922,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9003923,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9003923,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9003924,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,4276.25,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9003924,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,3819.56,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003925,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003925,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9003913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,9003915,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,18652.27,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,9003915,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,Local,,20696.00,,,,,,,16660.28,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9001387,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9001387,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9001388,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9001388,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,9001404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,9001404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9001405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9001405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,565.03,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,504.69,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9001408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9001408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9004151,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4699.03000,1362.72000,Aetna,Local,,1879.61,,,,,,,1694.00,3843.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9004151,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4699.03000,1362.72000,Aetna,Local,,1879.61,,,,,,,1513.09,3843.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9004152,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9004152,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9004154,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9004154,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,9004153,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,9004153,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9004238,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9004238,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9004249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9004249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9004250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9004250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9004251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9004251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9004252,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9004252,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHANK TRACTION,9004253,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1551.88000,450.05000,Aetna,Local,,620.75,,,,,,,559.45,1269.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHANK TRACTION,9004253,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1551.88000,450.05000,Aetna,Local,,620.75,,,,,,,499.71,1269.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHANK TRACTION,9004254,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1551.88000,450.05000,Aetna,Local,,620.75,,,,,,,559.45,1269.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHANK TRACTION,9004254,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1551.88000,450.05000,Aetna,Local,,620.75,,,,,,,499.71,1269.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9004268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5947.41000,1724.75000,Aetna,Local,,2378.96,,,,,,,2144.04,4864.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9004268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5947.41000,1724.75000,Aetna,Local,,2378.96,,,,,,,1915.07,4864.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER DISTAL,9004272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,549.68000,159.41000,Aetna,Local,,219.87,,,,,,,198.16,449.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CENTRALIZER DISTAL,9004272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,549.68000,159.41000,Aetna,Local,,219.87,,,,,,,177.00,449.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9004273,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7380.00000,2140.20000,Aetna,Local,,2952.00,,,,,,,2660.49,6036.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9004273,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7380.00000,2140.20000,Aetna,Local,,2952.00,,,,,,,2376.36,6036.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9004274,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2750.40000,797.62000,Aetna,Local,,1100.16,,,,,,,991.52,2249.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9004274,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2750.40000,797.62000,Aetna,Local,,1100.16,,,,,,,885.63,2249.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9004275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8382.00000,2430.78000,Aetna,Local,,3352.80,,,,,,,3021.71,6856.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9004275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8382.00000,2430.78000,Aetna,Local,,3352.80,,,,,,,2699.00,6856.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6112.16000,1772.53000,Aetna,Local,,2444.86,,,,,,,2203.43,4999.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6112.16000,1772.53000,Aetna,Local,,2444.86,,,,,,,1968.12,4999.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9001526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9001526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9001590,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9001590,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9001591,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9001591,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9001594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,49446.00000,14339.34000,Aetna,Local,,19778.40,,,,,,,17825.28,40446.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9001594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,49446.00000,14339.34000,Aetna,Local,,19778.40,,,,,,,15921.61,40446.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,461.13000,133.73000,Aetna,Local,,184.45,,,,,,,166.24,377.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,461.13000,133.73000,Aetna,Local,,184.45,,,,,,,148.48,377.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9001596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,6038.38,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9001596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,5393.50,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER,9001592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,830.52000,240.85000,Aetna,Local,,332.21,,,,,,,299.40,679.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER,9001592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,830.52000,240.85000,Aetna,Local,,332.21,,,,,,,267.43,679.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRANIAL HALF,9001614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3920.00000,1136.80000,Aetna,Local,,1568.00,,,,,,,1413.16,3206.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRANIAL HALF,9001614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3920.00000,1136.80000,Aetna,Local,,1568.00,,,,,,,1262.24,3206.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8791.20000,2549.45000,Aetna,Local,,3516.48,,,,,,,3169.23,7191.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8791.20000,2549.45000,Aetna,Local,,3516.48,,,,,,,2830.77,7191.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7552.80000,2190.31000,Aetna,Local,,3021.12,,,,,,,2722.78,6178.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7552.80000,2190.31000,Aetna,Local,,3021.12,,,,,,,2432.00,6178.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001657,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001657,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001658,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9072.00000,2630.88000,Aetna,Local,,3628.80,,,,,,,3270.46,7420.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001658,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9072.00000,2630.88000,Aetna,Local,,3628.80,,,,,,,2921.18,7420.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001660,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,943.76,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001660,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,842.97,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9004540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,7417.29,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9004540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,6625.15,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,659.79000,191.34000,Aetna,Local,,263.92,,,,,,,237.85,539.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,659.79000,191.34000,Aetna,Local,,263.92,,,,,,,212.45,539.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9004542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2162.56000,627.14000,Aetna,Local,,865.02,,,,,,,779.60,1768.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9004542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2162.56000,627.14000,Aetna,Local,,865.02,,,,,,,696.34,1768.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9004543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2403.44000,697.00000,Aetna,Local,,961.38,,,,,,,866.44,1966.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9004543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2403.44000,697.00000,Aetna,Local,,961.38,,,,,,,773.91,1966.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9004544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17095.00000,4957.55000,Aetna,Local,,6838.00,,,,,,,6162.75,13983.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9004544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17095.00000,4957.55000,Aetna,Local,,6838.00,,,,,,,5504.59,13983.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9004545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9004545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9001702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,2146.24,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9001702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,1917.03,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9004605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9004605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2403.60000,697.04000,Aetna,Local,,961.44,,,,,,,866.50,1966.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2403.60000,697.04000,Aetna,Local,,961.44,,,,,,,773.96,1966.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9004615,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,10077.00000,2922.33000,Aetna,Local,,4030.80,,,,,,,3632.76,8242.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9004615,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,10077.00000,2922.33000,Aetna,Local,,4030.80,,,,,,,3244.79,8242.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004616,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004616,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8986778,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,10077.00000,2922.33000,Aetna,Local,,4030.80,,,,,,,3632.76,8242.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,8986778,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,10077.00000,2922.33000,Aetna,Local,,4030.80,,,,,,,3244.79,8242.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004635,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004635,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9004634,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,179.80,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9004634,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,160.60,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9004636,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9004636,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9004637,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9004637,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9004638,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9004638,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,17494.25000,5073.33000,Aetna,Local,,6997.70,,,,,,,6306.68,14310.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,17494.25000,5073.33000,Aetna,Local,,6997.70,,,,,,,5633.15,14310.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9001838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9001839,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9001839,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,Local,,3463.20,,,,,,,3121.21,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,Local,,3463.20,,,,,,,2787.88,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004717,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004717,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9004720,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9004720,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,Local,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9004719,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1580.00000,458.20000,Aetna,Local,,632.00,,,,,,,569.59,1292.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9004719,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1580.00000,458.20000,Aetna,Local,,632.00,,,,,,,508.76,1292.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9002018,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9002018,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002019,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002019,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9002020,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9002020,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4426.00000,1283.54000,Aetna,Local,,1770.40,,,,,,,1595.57,3620.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4426.00000,1283.54000,Aetna,Local,,1770.40,,,,,,,1425.17,3620.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9002022,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,Local,,33.60,,,,,,,30.28,68.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9002022,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,33.60,,,,,,,27.05,68.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002028,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5015.50000,1454.50000,Aetna,Local,,2006.20,,,,,,,1808.09,4102.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002028,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5015.50000,1454.50000,Aetna,Local,,2006.20,,,,,,,1614.99,4102.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9002029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002030,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9002030,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLY INSERT,9004818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3360.22,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLY INSERT,9004818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3001.36,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9004819,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9004819,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9004820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9004820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9004821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6501.71000,1885.50000,Aetna,Local,,2600.68,,,,,,,2343.87,5318.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9004821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6501.71000,1885.50000,Aetna,Local,,2600.68,,,,,,,2093.55,5318.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BRACE,9004822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5120.33000,1484.90000,Aetna,Local,,2048.13,,,,,,,1845.88,4188.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BRACE,9004822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5120.33000,1484.90000,Aetna,Local,,2048.13,,,,,,,1648.75,4188.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,964.29,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,861.31,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8438617,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5941.78000,1723.12000,Aetna,Local,,2376.71,,,,,,,2142.01,4860.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8438617,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5941.78000,1723.12000,Aetna,Local,,2376.71,,,,,,,1913.25,4860.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9004890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9004891,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9004891,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9004908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,5497.62,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9004908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,Local,,6100.00,,,,,,,4910.50,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8966268,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8966268,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858301,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858301,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858302,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858302,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9006217,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5462.80000,1584.21000,Aetna,Local,,2185.12,,,,,,,1969.34,4468.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9006217,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5462.80000,1584.21000,Aetna,Local,,2185.12,,,,,,,1759.02,4468.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9006250,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2512.00000,728.48000,Aetna,Local,,1004.80,,,,,,,905.58,2054.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9006250,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2512.00000,728.48000,Aetna,Local,,1004.80,,,,,,,808.86,2054.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,9006247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8634.00000,2503.86000,Aetna,Local,,3453.60,,,,,,,3112.56,7062.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,9006247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8634.00000,2503.86000,Aetna,Local,,3453.60,,,,,,,2780.15,7062.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,Local,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9006249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,2170.21,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9006249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,1938.44,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9006282,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9006282,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9006283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1468.00000,425.72000,Aetna,Local,,587.20,,,,,,,529.21,1200.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9006283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1468.00000,425.72000,Aetna,Local,,587.20,,,,,,,472.70,1200.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9006284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,352.03,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9006284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,314.43,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1276.00000,370.04000,Aetna,Local,,510.40,,,,,,,460.00,1043.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1276.00000,370.04000,Aetna,Local,,510.40,,,,,,,410.87,1043.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1276.00000,370.04000,Aetna,Local,,510.40,,,,,,,460.00,1043.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1276.00000,370.04000,Aetna,Local,,510.40,,,,,,,410.87,1043.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006289,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006289,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858326,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858326,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9006369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4426.45000,1283.67000,Aetna,Local,,1770.58,,,,,,,1595.74,3620.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9006369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4426.45000,1283.67000,Aetna,Local,,1770.58,,,,,,,1425.32,3620.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9006370,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9006370,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006372,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006372,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9006373,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9006373,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9006375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9006375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9006376,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20125.00000,5836.25000,Aetna,Local,,8050.00,,,,,,,7255.06,16462.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9006376,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20125.00000,5836.25000,Aetna,Local,,8050.00,,,,,,,6480.25,16462.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006367,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006367,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005110,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005110,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MANUAL,8400819,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MANUAL,8400819,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8986398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8986398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8917152,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3084.24000,894.43000,Aetna,Local,,1233.70,,,,,,,1111.87,2522.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE,8917152,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3084.24000,894.43000,Aetna,Local,,1233.70,,,,,,,993.13,2522.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STYLET KIT,8784152,CDM,278,RC,A4212,HCPCS,,,facility,inpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,52.99,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STYLET KIT,8784152,CDM,278,RC,A4212,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,58.80,,,,,,,47.33,120.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8926092,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8926092,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8455930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3984.75000,1155.58000,Aetna,Local,,1593.90,,,,,,,1436.50,3259.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8455930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3984.75000,1155.58000,Aetna,Local,,1593.90,,,,,,,1283.09,3259.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8459754,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1291.62,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,8459754,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3582.85000,1039.03000,Aetna,Local,,1433.14,,,,,,,1153.68,2930.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8368315,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8368315,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858290,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858290,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858291,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858291,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858292,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858292,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858293,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858293,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858294,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858294,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858295,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858295,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858296,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858296,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858297,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858297,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858298,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858298,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858303,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858303,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858304,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858304,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858305,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858305,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858307,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858307,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858308,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858308,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858310,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858310,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858314,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858314,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858315,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858315,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858316,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858316,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858317,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858317,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858318,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858318,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858319,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858319,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858320,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858320,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858321,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858321,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858322,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858322,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858323,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858323,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858324,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8858324,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8972892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8972892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4965.73000,1440.06000,Aetna,Local,,1986.29,,,,,,,1790.15,4061.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8986582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4965.73000,1440.06000,Aetna,Local,,1986.29,,,,,,,1598.97,4061.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8990214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8996165,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8996165,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8994419,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12334.50000,3577.00000,Aetna,Local,,4933.80,,,,,,,4446.59,10089.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8994419,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12334.50000,3577.00000,Aetna,Local,,4933.80,,,,,,,3971.71,10089.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8972888,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8972888,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8972889,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8972889,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,8999064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,8999064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8995975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT PATELLAR,8995978,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT PATELLAR,8995978,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,9002396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9479.25000,2748.98000,Aetna,Local,,3791.70,,,,,,,3417.27,7754.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,9002396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9479.25000,2748.98000,Aetna,Local,,3791.70,,,,,,,3052.32,7754.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8413969,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8413969,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9003634,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.40000,1439.68000,Aetna,Local,,1985.76,,,,,,,1789.67,4060.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9003634,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.40000,1439.68000,Aetna,Local,,1985.76,,,,,,,1598.54,4060.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9003914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3644.38,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9003914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10109.25000,2931.68000,Aetna,Local,,4043.70,,,,,,,3255.18,8269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TALUS,8995692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,37237.50000,10798.88000,Aetna,Local,,14895.00,,,,,,,13424.12,30460.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TALUS,8995692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,37237.50000,10798.88000,Aetna,Local,,14895.00,,,,,,,11990.48,30460.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9006659,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9006659,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9006640,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9006640,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9005307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9005307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,9005308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,9005308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9005309,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9005309,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006718,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9006718,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9006868,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9006868,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9006865,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5299.70000,1536.91000,Aetna,Local,,2119.88,,,,,,,1910.54,4335.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9006865,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5299.70000,1536.91000,Aetna,Local,,2119.88,,,,,,,1706.50,4335.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9006866,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5299.70000,1536.91000,Aetna,Local,,2119.88,,,,,,,1910.54,4335.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9006866,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5299.70000,1536.91000,Aetna,Local,,2119.88,,,,,,,1706.50,4335.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9006867,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9006867,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9005616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9005616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9005617,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9005617,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9005618,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2700.00000,783.00000,Aetna,Local,,1080.00,,,,,,,973.35,2208.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9005618,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2700.00000,783.00000,Aetna,Local,,1080.00,,,,,,,869.40,2208.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9005619,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2700.00000,783.00000,Aetna,Local,,1080.00,,,,,,,973.35,2208.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9005619,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2700.00000,783.00000,Aetna,Local,,1080.00,,,,,,,869.40,2208.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9008099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9008099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9008100,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10629.00000,3082.41000,Aetna,Local,,4251.60,,,,,,,3831.75,8694.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9008100,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10629.00000,3082.41000,Aetna,Local,,4251.60,,,,,,,3422.54,8694.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9008101,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9008101,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9008103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9008103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9008104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9008104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9008105,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9008105,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE FEMORAL,9005674,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,109.87,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE FEMORAL,9005674,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,98.13,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,498.93,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,445.65,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9005698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11628.00000,3372.12000,Aetna,Local,,4651.20,,,,,,,4191.89,9511.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9005698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11628.00000,3372.12000,Aetna,Local,,4651.20,,,,,,,3744.22,9511.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9005699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,7018.94,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9005699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,6269.34,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,584.01,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9005700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,521.64,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9005701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9005701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9005702,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9005702,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9005703,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9005703,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9005704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9005704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9008228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9008228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9005744,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9005744,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT MEDIAL,9005742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT MEDIAL,9005742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9005743,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9005743,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9010119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12540.00000,3636.60000,Aetna,Local,,5016.00,,,,,,,4520.67,10257.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9010119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12540.00000,3636.60000,Aetna,Local,,5016.00,,,,,,,4037.88,10257.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9010120,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9010120,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,9012139,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3939.25000,1142.38000,Aetna,Local,,1575.70,,,,,,,1420.10,3222.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,9012139,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3939.25000,1142.38000,Aetna,Local,,1575.70,,,,,,,1268.44,3222.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9010159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9010159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9010160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9010160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9010161,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9010161,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9010166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9010166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9010167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9010167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9010118,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5947.41000,1724.75000,Aetna,Local,,2378.96,,,,,,,2144.04,4864.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9010118,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5947.41000,1724.75000,Aetna,Local,,2378.96,,,,,,,1915.07,4864.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9012284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9012284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9012282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.70000,2383.71000,Aetna,Local,,3287.88,,,,,,,2963.20,6723.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9012282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.70000,2383.71000,Aetna,Local,,3287.88,,,,,,,2646.74,6723.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,210.00000,60.90000,Aetna,Local,,84.00,,,,,,,75.70,171.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,Local,,84.00,,,,,,,67.62,171.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9012279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9012279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9010320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9010320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9010321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9010321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010322,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010322,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9010324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9010324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9010325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,764.87000,221.81000,Aetna,Local,,305.95,,,,,,,275.74,625.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9010325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,764.87000,221.81000,Aetna,Local,,305.95,,,,,,,246.29,625.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL SHELL,9010328,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL SHELL,9010328,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1370.40000,397.42000,Aetna,Local,,548.16,,,,,,,494.03,1120.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1370.40000,397.42000,Aetna,Local,,548.16,,,,,,,441.27,1120.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9010329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9010329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9004901,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,201.16,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9004901,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,179.68,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9004902,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,639.47000,185.45000,Aetna,Local,,255.79,,,,,,,230.53,523.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9004902,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,639.47000,185.45000,Aetna,Local,,255.79,,,,,,,205.91,523.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9008184,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,Local,,1376.20,,,,,,,1240.30,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9008184,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,Local,,1376.20,,,,,,,1107.84,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9008185,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,Local,,1376.20,,,,,,,1240.30,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9008185,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,Local,,1376.20,,,,,,,1107.84,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9012338,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9012338,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9012339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9012339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9012340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9012340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9010383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8799.00000,2551.71000,Aetna,Local,,3519.60,,,,,,,3172.04,7197.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9010383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8799.00000,2551.71000,Aetna,Local,,3519.60,,,,,,,2833.28,7197.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9010384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9010384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,486.57,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1349.72000,391.42000,Aetna,Local,,539.89,,,,,,,434.61,1104.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK SPINAL SM,9010392,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,2384.00000,691.36000,Aetna,Local,,953.60,,,,,,,859.43,1950.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK SPINAL SM,9010392,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,2384.00000,691.36000,Aetna,Local,,953.60,,,,,,,767.65,1950.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK SPINAL LG,9010393,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,2384.00000,691.36000,Aetna,Local,,953.60,,,,,,,859.43,1950.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK SPINAL LG,9010393,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,2384.00000,691.36000,Aetna,Local,,953.60,,,,,,,767.65,1950.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8926390,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17090.00000,4956.10000,Aetna,Local,,6836.00,,,,,,,6160.94,13979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,8926390,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17090.00000,4956.10000,Aetna,Local,,6836.00,,,,,,,5502.98,13979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9164.25000,2657.63000,Aetna,Local,,3665.70,,,,,,,3303.71,7496.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9164.25000,2657.63000,Aetna,Local,,3665.70,,,,,,,2950.89,7496.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,9010416,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,9010416,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,458.41,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,409.46,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,458.41,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1271.60000,368.76000,Aetna,Local,,508.64,,,,,,,409.46,1040.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9010449,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9010449,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9010450,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,877.82,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9010450,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2435.00000,706.15000,Aetna,Local,,974.00,,,,,,,784.07,1991.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9010455,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9010455,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9010457,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9010457,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9010456,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9010456,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,Local,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9010474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24312.50000,7050.62000,Aetna,Local,,9725.00,,,,,,,8764.66,19887.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9010474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24312.50000,7050.62000,Aetna,Local,,9725.00,,,,,,,7828.62,19887.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,9010458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,9010458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9010453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9010453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9010454,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9010454,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,Local,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9012578,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,13734.00000,3982.86000,Aetna,Local,,5493.60,,,,,,,4951.11,11234.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9012578,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,13734.00000,3982.86000,Aetna,Local,,5493.60,,,,,,,4422.35,11234.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9012466,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9012466,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9012619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9012619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,9012620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,1075.11,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,9012620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,960.29,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FIBULA,9010618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,Local,,3463.20,,,,,,,3121.21,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FIBULA,9010618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,Local,,3463.20,,,,,,,2787.88,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9010619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9010619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9012650,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9012650,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012651,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012651,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9012654,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9012654,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CONNECTOR,8282171,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1528.00000,443.12000,Aetna,Local,,611.20,,,,,,,550.84,1249.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CONNECTOR,8282171,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1528.00000,443.12000,Aetna,Local,,611.20,,,,,,,492.02,1249.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FIBULA,9012665,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8799.00000,2551.71000,Aetna,Local,,3519.60,,,,,,,3172.04,7197.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FIBULA,9012665,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8799.00000,2551.71000,Aetna,Local,,3519.60,,,,,,,2833.28,7197.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8973809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,8973809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GASTRONOMY PLACEMENT,8413594,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,753.71000,218.58000,Aetna,Local,,301.48,,,,,,,271.71,616.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GASTRONOMY PLACEMENT,8413594,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,753.71000,218.58000,Aetna,Local,,301.48,,,,,,,242.69,616.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9012705,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9012705,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9012706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9012706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9012707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9012707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8157.00000,2365.53000,Aetna,Local,,3262.80,,,,,,,2940.60,6672.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8157.00000,2365.53000,Aetna,Local,,3262.80,,,,,,,2626.55,6672.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7662.00000,2221.98000,Aetna,Local,,3064.80,,,,,,,2762.15,6267.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7662.00000,2221.98000,Aetna,Local,,3064.80,,,,,,,2467.16,6267.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,854.10000,247.69000,Aetna,Local,,341.64,,,,,,,307.90,698.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,854.10000,247.69000,Aetna,Local,,341.64,,,,,,,275.02,698.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,809.78000,234.84000,Aetna,Local,,323.91,,,,,,,291.93,662.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,809.78000,234.84000,Aetna,Local,,323.91,,,,,,,260.75,662.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11007.00000,3192.03000,Aetna,Local,,4402.80,,,,,,,3968.02,9003.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11007.00000,3192.03000,Aetna,Local,,4402.80,,,,,,,3544.25,9003.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9012744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9012744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,Local,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
JOINT,9012745,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
JOINT,9012745,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,Local,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9012746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,326.52000,94.69000,Aetna,Local,,130.61,,,,,,,117.71,267.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9012746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,326.52000,94.69000,Aetna,Local,,130.61,,,,,,,105.14,267.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9012747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9012747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5558.70000,1612.02000,Aetna,Local,,2223.48,,,,,,,2003.91,4547.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5558.70000,1612.02000,Aetna,Local,,2223.48,,,,,,,1789.90,4547.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9012814,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9012814,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9012748,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,7368.00000,2136.72000,Aetna,Local,,2947.20,,,,,,,2656.16,6027.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9012748,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,7368.00000,2136.72000,Aetna,Local,,2947.20,,,,,,,2372.50,6027.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,498.93,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,445.65,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,1061.31,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,947.97,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9012840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9012840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,Local,,3699.60,,,,,,,3334.26,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9012842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,Local,,3699.60,,,,,,,2978.18,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,330.96,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,Local,,367.22,,,,,,,295.61,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9012846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9010894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9010894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9010896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9010896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9010897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9010897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9013315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8052.00000,2335.08000,Aetna,Local,,3220.80,,,,,,,2902.75,6586.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9013315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8052.00000,2335.08000,Aetna,Local,,3220.80,,,,,,,2592.74,6586.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9013316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9013316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010926,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,1061.31,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010926,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,947.97,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9010927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,326.52000,94.69000,Aetna,Local,,130.61,,,,,,,117.71,267.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9010927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,326.52000,94.69000,Aetna,Local,,130.61,,,,,,,105.14,267.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,1061.31,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,947.97,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9010962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9010962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9013380,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9013380,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9013381,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9013381,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7460.70000,2163.60000,Aetna,Local,,2984.28,,,,,,,2689.58,6102.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7460.70000,2163.60000,Aetna,Local,,2984.28,,,,,,,2402.35,6102.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8397.90000,2435.39000,Aetna,Local,,3359.16,,,,,,,3027.44,6869.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8397.90000,2435.39000,Aetna,Local,,3359.16,,,,,,,2704.12,6869.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18371.00000,5327.59000,Aetna,Local,,7348.40,,,,,,,6622.75,15027.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18371.00000,5327.59000,Aetna,Local,,7348.40,,,,,,,5915.46,15027.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9013406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12084.00000,3504.36000,Aetna,Local,,4833.60,,,,,,,4356.28,9884.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9013406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12084.00000,3504.36000,Aetna,Local,,4833.60,,,,,,,3891.05,9884.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9013407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13635.00000,3954.15000,Aetna,Local,,5454.00,,,,,,,4915.42,11153.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9013407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13635.00000,3954.15000,Aetna,Local,,5454.00,,,,,,,4390.47,11153.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9013408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12084.00000,3504.36000,Aetna,Local,,4833.60,,,,,,,4356.28,9884.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9013408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12084.00000,3504.36000,Aetna,Local,,4833.60,,,,,,,3891.05,9884.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9011127,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9011127,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9011128,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9011128,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9013398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7326.00000,2124.54000,Aetna,Local,,2930.40,,,,,,,2641.02,5992.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9013398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7326.00000,2124.54000,Aetna,Local,,2930.40,,,,,,,2358.97,5992.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15425.00000,4473.25000,Aetna,Local,,6170.00,,,,,,,5560.71,12617.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15425.00000,4473.25000,Aetna,Local,,6170.00,,,,,,,4966.85,12617.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9013400,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9013400,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,9013409,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7620.00000,2209.80000,Aetna,Local,,3048.00,,,,,,,2747.01,6233.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,9013409,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7620.00000,2209.80000,Aetna,Local,,3048.00,,,,,,,2453.64,6233.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,9013401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12090.00000,3506.10000,Aetna,Local,,4836.00,,,,,,,4358.44,9889.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,9013401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12090.00000,3506.10000,Aetna,Local,,4836.00,,,,,,,3892.98,9889.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9011228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9011228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP,9011230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1294.88000,375.52000,Aetna,Local,,517.95,,,,,,,466.80,1059.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP,9011230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1294.88000,375.52000,Aetna,Local,,517.95,,,,,,,416.95,1059.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9011232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13543.32000,3927.56000,Aetna,Local,,5417.33,,,,,,,4882.37,11078.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9011232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13543.32000,3927.56000,Aetna,Local,,5417.33,,,,,,,4360.95,11078.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9011233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5293.72000,1535.18000,Aetna,Local,,2117.49,,,,,,,1908.39,4330.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9011233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5293.72000,1535.18000,Aetna,Local,,2117.49,,,,,,,1704.58,4330.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9011234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25606.63000,7425.92000,Aetna,Local,,10242.65,,,,,,,9231.19,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9011234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25606.63000,7425.92000,Aetna,Local,,10242.65,,,,,,,8245.33,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9011235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,Local,,2625.52,,,,,,,2366.25,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9011235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,Local,,2625.52,,,,,,,2113.54,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9011236,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9011236,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9011237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9011237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9011238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9011238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9011240,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9011240,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9011241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,Local,,1066.40,,,,,,,961.09,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9011241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,Local,,1066.40,,,,,,,858.45,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9011239,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9011239,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9013476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9013476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9013477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9013477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9011203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8265.00000,2396.85000,Aetna,Local,,3306.00,,,,,,,2979.53,6760.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9011203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8265.00000,2396.85000,Aetna,Local,,3306.00,,,,,,,2661.33,6760.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9011325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9011325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8495925,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,277.40,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8495925,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,Local,,307.80,,,,,,,247.78,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8417924,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3610.05,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8417924,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10014.00000,2904.06000,Aetna,Local,,4005.60,,,,,,,3224.51,8191.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429750,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8429750,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435931,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8435931,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8437307,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8437307,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8523933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6693.75000,1941.19000,Aetna,Local,,2677.50,,,,,,,2413.10,5475.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8523933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6693.75000,1941.19000,Aetna,Local,,2677.50,,,,,,,2155.39,5475.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9004888,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9210.00000,2670.90000,Aetna,Local,,3684.00,,,,,,,3320.20,7533.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9004888,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9210.00000,2670.90000,Aetna,Local,,3684.00,,,,,,,2965.62,7533.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8453910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,8453910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010662,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010662,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9013547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.80000,244.70000,Aetna,Local,,337.52,,,,,,,304.19,690.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9013547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.80000,244.70000,Aetna,Local,,337.52,,,,,,,271.70,690.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9013551,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,844.65000,244.95000,Aetna,Local,,337.86,,,,,,,304.50,690.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9013551,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,844.65000,244.95000,Aetna,Local,,337.86,,,,,,,271.98,690.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9013552,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9013552,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9013553,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9013553,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9011344,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9011344,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9011345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,793.10,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9011345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,Local,,880.00,,,,,,,708.40,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERLOCK CEMENTED,9013554,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13552.50000,3930.22000,Aetna,Local,,5421.00,,,,,,,4885.68,11085.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERLOCK CEMENTED,9013554,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13552.50000,3930.22000,Aetna,Local,,5421.00,,,,,,,4363.90,11085.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9011348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9011348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9013549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9070.20000,2630.36000,Aetna,Local,,3628.08,,,,,,,3269.81,7419.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9013549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9070.20000,2630.36000,Aetna,Local,,3628.08,,,,,,,2920.60,7419.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9013634,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,Local,,1066.40,,,,,,,961.09,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9013634,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,Local,,1066.40,,,,,,,858.45,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9013621,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9013621,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9013622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9013622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9013624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9011500,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8607.00000,2496.03000,Aetna,Local,,3442.80,,,,,,,3102.82,7040.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9011500,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8607.00000,2496.03000,Aetna,Local,,3442.80,,,,,,,2771.45,7040.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,Local,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9011503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9011503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9011504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9011504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011505,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011505,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,518.94000,150.49000,Aetna,Local,,207.58,,,,,,,187.08,424.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,518.94000,150.49000,Aetna,Local,,207.58,,,,,,,167.10,424.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9011509,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9011509,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013837,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013837,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9011537,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,624.39,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9011537,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,557.70,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9011538,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9011538,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,Local,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9011540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9011540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011541,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011541,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011545,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011545,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,Local,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9011546,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,962.55000,279.14000,Aetna,Local,,385.02,,,,,,,347.00,787.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9011546,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,962.55000,279.14000,Aetna,Local,,385.02,,,,,,,309.94,787.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9013833,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9013833,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,Local,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9013832,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1924.00000,557.96000,Aetna,Local,,769.60,,,,,,,693.60,1573.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9013832,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1924.00000,557.96000,Aetna,Local,,769.60,,,,,,,619.53,1573.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9013859,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1241.07,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9013859,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1108.53,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9013860,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1241.07,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9013860,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1108.53,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9013861,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1241.07,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9013861,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1108.53,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9013862,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1241.07,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9013862,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1108.53,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT ENDOVASCULAR,9011547,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT ENDOVASCULAR,9011547,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,Local,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013829,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,565.03,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013829,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,504.69,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9013942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9013942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013941,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9013941,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID HUMERAL,9013939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID HUMERAL,9013939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9013949,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9022.50000,2616.52000,Aetna,Local,,3609.00,,,,,,,3252.61,7380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9013949,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9022.50000,2616.52000,Aetna,Local,,3609.00,,,,,,,2905.24,7380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETERAL,9013943,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,962.55000,279.14000,Aetna,Local,,385.02,,,,,,,347.00,787.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETERAL,9013943,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,962.55000,279.14000,Aetna,Local,,385.02,,,,,,,309.94,787.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9013944,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,844.65000,244.95000,Aetna,Local,,337.86,,,,,,,304.50,690.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9013944,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,844.65000,244.95000,Aetna,Local,,337.86,,,,,,,271.98,690.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8617930,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1622.28000,470.46000,Aetna,Local,,648.91,,,,,,,584.83,1327.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8617930,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1622.28000,470.46000,Aetna,Local,,648.91,,,,,,,522.37,1327.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISSECTOR,9006639,CDM,278,RC,A4649,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISSECTOR,9006639,CDM,278,RC,A4649,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014056,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,254.69,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014056,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,227.49,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9014059,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7980.00000,2314.20000,Aetna,Local,,3192.00,,,,,,,2876.79,6527.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9014059,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7980.00000,2314.20000,Aetna,Local,,3192.00,,,,,,,2569.56,6527.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1640.28,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1465.10,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,943.76,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,842.97,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9014065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1645.01,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9014065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,Local,,1825.25,,,,,,,1469.33,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING LOCKING,9014066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,Local,,994.72,,,,,,,896.49,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING LOCKING,9014066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,Local,,994.72,,,,,,,800.75,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9014067,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9014067,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9014124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15646.25000,4537.41000,Aetna,Local,,6258.50,,,,,,,5640.47,12798.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9014124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15646.25000,4537.41000,Aetna,Local,,6258.50,,,,,,,5038.09,12798.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT FIXATION,9014126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1748.32000,507.01000,Aetna,Local,,699.33,,,,,,,630.27,1430.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT FIXATION,9014126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1748.32000,507.01000,Aetna,Local,,699.33,,,,,,,562.96,1430.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9014128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1766.48000,512.28000,Aetna,Local,,706.59,,,,,,,636.82,1444.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9014128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1766.48000,512.28000,Aetna,Local,,706.59,,,,,,,568.81,1444.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,Local,,639.68,,,,,,,576.51,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,Local,,639.68,,,,,,,514.94,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,Local,,639.68,,,,,,,576.51,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,Local,,639.68,,,,,,,514.94,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9014132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15006.83000,4351.98000,Aetna,Local,,6002.73,,,,,,,5409.96,12275.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9014132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15006.83000,4351.98000,Aetna,Local,,6002.73,,,,,,,4832.20,12275.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9014133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11391.93000,3303.66000,Aetna,Local,,4556.77,,,,,,,4106.79,9318.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9014133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11391.93000,3303.66000,Aetna,Local,,4556.77,,,,,,,3668.20,9318.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9014134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10402.77000,3016.80000,Aetna,Local,,4161.11,,,,,,,3750.20,8509.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9014134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10402.77000,3016.80000,Aetna,Local,,4161.11,,,,,,,3349.69,8509.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMUR MODULAR,9014135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19791.55000,5739.55000,Aetna,Local,,7916.62,,,,,,,7134.85,16189.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMUR MODULAR,9014135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19791.55000,5739.55000,Aetna,Local,,7916.62,,,,,,,6372.88,16189.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9014136,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9014136,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9014137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9014137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014138,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014138,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014139,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014139,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL,9014214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1297.08,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL,9014214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1158.56,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,9014215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,9014215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,Local,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011795,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,Local,,639.68,,,,,,,576.51,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011795,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,Local,,639.68,,,,,,,514.94,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,254.69,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,227.49,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4487.00000,1301.23000,Aetna,Local,,1794.80,,,,,,,1617.56,3670.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4487.00000,1301.23000,Aetna,Local,,1794.80,,,,,,,1444.81,3670.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9014223,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9014223,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9014224,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9014224,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9013830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,Local,,1066.40,,,,,,,961.09,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9013830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,Local,,1066.40,,,,,,,858.45,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9014237,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,2081.89,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9014237,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,1859.55,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014266,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,892.60,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014266,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,797.27,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROTRANSMITTER,9014316,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,54920.00000,15926.80000,Aetna,Local,,21968.00,,,,,,,19798.66,44924.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROTRANSMITTER,9014316,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,54920.00000,15926.80000,Aetna,Local,,21968.00,,,,,,,17684.24,44924.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,9014318,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,9014318,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,2081.89,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,1859.55,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9014347,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9014347,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,943.76,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9011849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,842.97,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,584.01,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,521.64,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9014366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9014366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9016094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1480.00000,429.20000,Aetna,Local,,592.00,,,,,,,533.54,1210.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9016094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1480.00000,429.20000,Aetna,Local,,592.00,,,,,,,476.56,1210.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1520.41,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4217.50000,1223.07000,Aetna,Local,,1687.00,,,,,,,1358.04,3449.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENSIONER,9016097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1595.00000,462.55000,Aetna,Local,,638.00,,,,,,,575.00,1304.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENSIONER,9016097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1595.00000,462.55000,Aetna,Local,,638.00,,,,,,,513.59,1304.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9016105,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9016105,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9016106,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9016106,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014528,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5369.00000,1557.01000,Aetna,Local,,2147.60,,,,,,,1935.52,4391.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014528,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5369.00000,1557.01000,Aetna,Local,,2147.60,,,,,,,1728.82,4391.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9014529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9014529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9016176,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9016176,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9016175,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9016175,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE INFLATABLE,9014587,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,37001.25000,10730.36000,Aetna,Local,,14800.50,,,,,,,13338.95,30267.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE INFLATABLE,9014587,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,37001.25000,10730.36000,Aetna,Local,,14800.50,,,,,,,11914.40,30267.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9016178,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9455.34000,2742.05000,Aetna,Local,,3782.14,,,,,,,3408.65,7734.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9016178,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9455.34000,2742.05000,Aetna,Local,,3782.14,,,,,,,3044.62,7734.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9016230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9016230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9016232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,2170.21,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9016232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,1938.44,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL KNEE,9014678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1270.00000,368.30000,Aetna,Local,,508.00,,,,,,,457.83,1038.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL KNEE,9014678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1270.00000,368.30000,Aetna,Local,,508.00,,,,,,,408.94,1038.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL KNEE,9014679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,629.33000,182.51000,Aetna,Local,,251.73,,,,,,,226.87,514.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL KNEE,9014679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,629.33000,182.51000,Aetna,Local,,251.73,,,,,,,202.64,514.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9014682,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9014682,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1724.00000,499.96000,Aetna,Local,,689.60,,,,,,,621.50,1410.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1724.00000,499.96000,Aetna,Local,,689.60,,,,,,,555.13,1410.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1724.00000,499.96000,Aetna,Local,,689.60,,,,,,,621.50,1410.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1724.00000,499.96000,Aetna,Local,,689.60,,,,,,,555.13,1410.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,254.69,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.50000,204.88000,Aetna,Local,,282.60,,,,,,,227.49,577.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014676,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4497.50000,1304.27000,Aetna,Local,,1799.00,,,,,,,1621.35,3678.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014676,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4497.50000,1304.27000,Aetna,Local,,1799.00,,,,,,,1448.19,3678.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014753,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,115.16,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014753,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,319.44000,92.64000,Aetna,Local,,127.78,,,,,,,102.86,261.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014754,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014754,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP EXETER,9014755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1876.22,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP EXETER,9014755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,Local,,2081.80,,,,,,,1675.85,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9014756,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9014756,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9014757,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8283.00000,2402.07000,Aetna,Local,,3313.20,,,,,,,2986.02,6775.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9014757,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8283.00000,2402.07000,Aetna,Local,,3313.20,,,,,,,2667.13,6775.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,1061.31,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,947.97,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4039.00000,1171.31000,Aetna,Local,,1615.60,,,,,,,1456.06,3303.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4039.00000,1171.31000,Aetna,Local,,1615.60,,,,,,,1300.56,3303.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9016385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,920.00,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9016385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2552.00000,740.08000,Aetna,Local,,1020.80,,,,,,,821.74,2087.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT,9016387,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT,9016387,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9014801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4455.50000,1292.09000,Aetna,Local,,1782.20,,,,,,,1606.21,3644.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9014801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4455.50000,1292.09000,Aetna,Local,,1782.20,,,,,,,1434.67,3644.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9014802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4455.50000,1292.09000,Aetna,Local,,1782.20,,,,,,,1606.21,3644.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9014802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4455.50000,1292.09000,Aetna,Local,,1782.20,,,,,,,1434.67,3644.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014810,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014810,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014811,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014811,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9016455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9016455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9014820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9014820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9014821,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9014821,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9014824,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9014824,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016480,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2904.16000,842.21000,Aetna,Local,,1161.66,,,,,,,1046.95,2375.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016480,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2904.16000,842.21000,Aetna,Local,,1161.66,,,,,,,935.14,2375.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,651.73,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,582.12,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9016485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9016485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9014858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26000.00000,7540.00000,Aetna,Local,,10400.00,,,,,,,9373.00,21268.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9014858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26000.00000,7540.00000,Aetna,Local,,10400.00,,,,,,,8372.00,21268.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9016520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9016520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9016522,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9016522,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9016523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9016523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1454.28000,421.74000,Aetna,Local,,581.71,,,,,,,524.27,1189.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9014877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1454.28000,421.74000,Aetna,Local,,581.71,,,,,,,468.28,1189.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,943.76,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,842.97,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9014884,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,2081.89,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9014884,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,1859.55,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014885,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,565.03,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014885,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,504.69,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9016555,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,2081.89,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9016555,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,1859.55,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9016557,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9016557,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9016558,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9016558,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE FEMORAL,9016559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE FEMORAL,9016559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014917,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014917,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9014920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VERSACROSS,9014932,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1596.11,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VERSACROSS,9014932,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1425.65,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016596,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3024.00000,876.96000,Aetna,Local,,1209.60,,,,,,,1090.15,2473.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016596,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3024.00000,876.96000,Aetna,Local,,1209.60,,,,,,,973.73,2473.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE FEMORAL,9014933,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3942.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE FEMORAL,9014933,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3521.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016608,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016608,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1955.00000,566.95000,Aetna,Local,,782.00,,,,,,,704.78,1599.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1955.00000,566.95000,Aetna,Local,,782.00,,,,,,,629.51,1599.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1955.00000,566.95000,Aetna,Local,,782.00,,,,,,,704.78,1599.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1955.00000,566.95000,Aetna,Local,,782.00,,,,,,,629.51,1599.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016612,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,1061.31,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016612,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,947.97,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,1061.31,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,947.97,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9016614,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9016614,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9016647,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3250.45000,942.63000,Aetna,Local,,1300.18,,,,,,,1171.79,2658.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9016647,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3250.45000,942.63000,Aetna,Local,,1300.18,,,,,,,1046.64,2658.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9016650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9016650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9016652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9016652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,9016653,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,9016653,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,9016654,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1622.36,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,9016654,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1449.10,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9016655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9016655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,9016657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1622.36,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,9016657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1449.10,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9016669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9016669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9016670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29351.25000,8511.86000,Aetna,Local,,11740.50,,,,,,,10581.13,24009.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9016670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29351.25000,8511.86000,Aetna,Local,,11740.50,,,,,,,9451.10,24009.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9016672,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9016672,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,Local,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9016734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9016734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9016735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9016735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9016736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9016736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9016737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6125.67000,1776.44000,Aetna,Local,,2450.27,,,,,,,2208.30,5010.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9016737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6125.67000,1776.44000,Aetna,Local,,2450.27,,,,,,,1972.47,5010.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUPLER FEMORAL,9016738,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4454.14000,1291.70000,Aetna,Local,,1781.66,,,,,,,1605.72,3643.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUPLER FEMORAL,9016738,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4454.14000,1291.70000,Aetna,Local,,1781.66,,,,,,,1434.23,3643.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9016739,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9016739,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,Local,,3699.60,,,,,,,3334.26,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,Local,,3699.60,,,,,,,2978.18,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,584.01,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9016743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,521.64,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9016740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9016740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,Local,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUPLER FEMORAL,9016741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4454.14000,1291.70000,Aetna,Local,,1781.66,,,,,,,1605.72,3643.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COUPLER FEMORAL,9016741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4454.14000,1291.70000,Aetna,Local,,1781.66,,,,,,,1434.23,3643.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5092.50000,1476.82000,Aetna,Local,,2037.00,,,,,,,1835.85,4165.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5092.50000,1476.82000,Aetna,Local,,2037.00,,,,,,,1639.79,4165.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016782,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5233.20000,1517.63000,Aetna,Local,,2093.28,,,,,,,1886.57,4280.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9016782,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5233.20000,1517.63000,Aetna,Local,,2093.28,,,,,,,1685.09,4280.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9016777,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,802.11,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9016777,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,716.45,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9016778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9016778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9020090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9020090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9020084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,663.75000,192.49000,Aetna,Local,,265.50,,,,,,,239.28,542.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9020084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,663.75000,192.49000,Aetna,Local,,265.50,,,,,,,213.73,542.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018153,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.88000,578.52000,Aetna,Local,,797.95,,,,,,,719.15,1631.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018153,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.88000,578.52000,Aetna,Local,,797.95,,,,,,,642.35,1631.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9020138,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45099.00000,13078.71000,Aetna,Local,,18039.60,,,,,,,16258.19,36890.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9020138,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45099.00000,13078.71000,Aetna,Local,,18039.60,,,,,,,14521.88,36890.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9020139,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53951.98000,15646.07000,Aetna,Local,,21580.79,,,,,,,19449.69,44132.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9020139,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53951.98000,15646.07000,Aetna,Local,,21580.79,,,,,,,17372.54,44132.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9020140,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,53951.98000,15646.07000,Aetna,Local,,21580.79,,,,,,,19449.69,44132.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9020140,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,53951.98000,15646.07000,Aetna,Local,,21580.79,,,,,,,17372.54,44132.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8502.00000,2465.58000,Aetna,Local,,3400.80,,,,,,,3064.97,6954.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8502.00000,2465.58000,Aetna,Local,,3400.80,,,,,,,2737.64,6954.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9020142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9020142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018322,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11076.00000,3212.04000,Aetna,Local,,4430.40,,,,,,,3992.90,9060.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018322,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11076.00000,3212.04000,Aetna,Local,,4430.40,,,,,,,3566.47,9060.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9020165,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,11369.25000,3297.08000,Aetna,Local,,4547.70,,,,,,,4098.61,9300.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9020165,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,11369.25000,3297.08000,Aetna,Local,,4547.70,,,,,,,3660.90,9300.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4937.10000,1431.76000,Aetna,Local,,1974.84,,,,,,,1779.82,4038.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4937.10000,1431.76000,Aetna,Local,,1974.84,,,,,,,1589.75,4038.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.82000,1338.88000,Aetna,Local,,1846.73,,,,,,,1664.36,3776.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.82000,1338.88000,Aetna,Local,,1846.73,,,,,,,1486.62,3776.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9018333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,165.48000,47.99000,Aetna,Local,,66.19,,,,,,,59.66,135.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9018333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,165.48000,47.99000,Aetna,Local,,66.19,,,,,,,53.28,135.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018334,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018334,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8934.00000,2590.86000,Aetna,Local,,3573.60,,,,,,,3220.71,7308.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8934.00000,2590.86000,Aetna,Local,,3573.60,,,,,,,2876.75,7308.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9018341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9018347,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,8674.32000,2515.55000,Aetna,Local,,3469.73,,,,,,,3127.09,7095.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9018347,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,8674.32000,2515.55000,Aetna,Local,,3469.73,,,,,,,2793.13,7095.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT ESOPAGEAL,9018345,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10928.25000,3169.19000,Aetna,Local,,4371.30,,,,,,,3939.63,8939.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT ESOPAGEAL,9018345,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10928.25000,3169.19000,Aetna,Local,,4371.30,,,,,,,3518.90,8939.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GASTRO,9018346,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16956.28000,4917.32000,Aetna,Local,,6782.51,,,,,,,6112.74,13870.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GASTRO,9018346,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16956.28000,4917.32000,Aetna,Local,,6782.51,,,,,,,5459.92,13870.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10668.00000,3093.72000,Aetna,Local,,4267.20,,,,,,,3845.81,8726.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10668.00000,3093.72000,Aetna,Local,,4267.20,,,,,,,3435.10,8726.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER INDIGO,9018429,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,10301.29,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER INDIGO,9018429,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,9201.15,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9018432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9018432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,Local,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9018434,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9018434,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9018435,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9018435,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9018436,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9018436,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL DEVICE,9018430,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,12015.00000,3484.35000,Aetna,Local,,4806.00,,,,,,,4331.41,9828.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL DEVICE,9018430,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,12015.00000,3484.35000,Aetna,Local,,4806.00,,,,,,,3868.83,9828.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL DEVICED,9018431,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,12525.00000,3632.25000,Aetna,Local,,5010.00,,,,,,,4515.26,10245.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL DEVICED,9018431,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,12525.00000,3632.25000,Aetna,Local,,5010.00,,,,,,,4033.05,10245.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9018449,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9018449,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9018450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9018450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,Local,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9018451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5472.36000,1586.98000,Aetna,Local,,2188.94,,,,,,,1972.79,4476.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9018451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5472.36000,1586.98000,Aetna,Local,,2188.94,,,,,,,1762.10,4476.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9018490,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1241.07,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9018490,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1108.53,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,24077.50000,6982.48000,Aetna,Local,,9631.00,,,,,,,8679.94,19695.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9018519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,24077.50000,6982.48000,Aetna,Local,,9631.00,,,,,,,7752.95,19695.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL DEVICE,9020359,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL DEVICE,9020359,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL DEVICE,9020360,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL DEVICE,9020360,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL DEVICE,9020361,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL DEVICE,9020361,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN MATRIX,9020404,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,29137.50000,8449.88000,Aetna,Local,,11655.00,,,,,,,10504.07,23834.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN MATRIX,9020404,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,29137.50000,8449.88000,Aetna,Local,,11655.00,,,,,,,124.65,23834.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN MATRIX,9020405,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,22415.00000,6500.35000,Aetna,Local,,8966.00,,,,,,,8080.61,18335.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN MATRIX,9020405,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,22415.00000,6500.35000,Aetna,Local,,8966.00,,,,,,,124.65,18335.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN MATRIX,9020406,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,7710.00000,2235.90000,Aetna,Local,,3084.00,,,,,,,2779.45,6306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN MATRIX,9020406,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,7710.00000,2235.90000,Aetna,Local,,3084.00,,,,,,,124.65,6306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THROMBECTOMY,9018518,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,24350.00000,7061.50000,Aetna,Local,,9740.00,,,,,,,8778.17,19918.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THROMBECTOMY,9018518,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,24350.00000,7061.50000,Aetna,Local,,9740.00,,,,,,,7840.70,19918.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9020388,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9020388,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9018557,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,174.66,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9018557,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,484.50000,140.50000,Aetna,Local,,193.80,,,,,,,156.01,396.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9018558,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9018558,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9018559,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9018559,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9020407,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1241.07,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT VASCULAR,9020407,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3442.64000,998.37000,Aetna,Local,,1377.06,,,,,,,1108.53,2816.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT ESOPAGEAL,9019999,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10928.25000,3169.19000,Aetna,Local,,4371.30,,,,,,,3939.63,8939.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT ESOPAGEAL,9019999,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10928.25000,3169.19000,Aetna,Local,,4371.30,,,,,,,3518.90,8939.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9019985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9019985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9019992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,525.09,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9019992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,469.01,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9019993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,525.09,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9019993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,469.01,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9019994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9019994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9019995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9019995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,Local,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9019996,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9019996,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9019997,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9019997,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9019986,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9019986,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN MATRIX,9019998,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,32478.75000,9418.84000,Aetna,Local,,12991.50,,,,,,,11708.59,26567.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN MATRIX,9019998,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,32478.75000,9418.84000,Aetna,Local,,12991.50,,,,,,,124.65,26567.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020554,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7929.00000,2299.41000,Aetna,Local,,3171.60,,,,,,,2858.40,6485.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020554,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7929.00000,2299.41000,Aetna,Local,,3171.60,,,,,,,2553.14,6485.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020555,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7929.00000,2299.41000,Aetna,Local,,3171.60,,,,,,,2858.40,6485.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020555,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7929.00000,2299.41000,Aetna,Local,,3171.60,,,,,,,2553.14,6485.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,309.85,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,276.76,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,309.85,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,276.76,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,309.85,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,276.76,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020563,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,309.85,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020563,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,276.76,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020564,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,309.85,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020564,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,276.76,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,350.41,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,312.98,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,350.41,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,312.98,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9020567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,351.50000,101.93000,Aetna,Local,,140.60,,,,,,,126.72,287.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9020567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,351.50000,101.93000,Aetna,Local,,140.60,,,,,,,113.18,287.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9020568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,370.50000,107.44000,Aetna,Local,,148.20,,,,,,,133.57,303.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9020568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,370.50000,107.44000,Aetna,Local,,148.20,,,,,,,119.30,303.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9020569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,118.15,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9020569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,Local,,131.10,,,,,,,105.54,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020574,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020574,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1484.00000,430.36000,Aetna,Local,,593.60,,,,,,,534.98,1213.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1484.00000,430.36000,Aetna,Local,,593.60,,,,,,,477.85,1213.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020576,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1484.00000,430.36000,Aetna,Local,,593.60,,,,,,,534.98,1213.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020576,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1484.00000,430.36000,Aetna,Local,,593.60,,,,,,,477.85,1213.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1748.00000,506.92000,Aetna,Local,,699.20,,,,,,,630.15,1429.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1748.00000,506.92000,Aetna,Local,,699.20,,,,,,,562.86,1429.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,940.50000,272.74000,Aetna,Local,,376.20,,,,,,,339.05,769.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,940.50000,272.74000,Aetna,Local,,376.20,,,,,,,302.84,769.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020580,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,940.50000,272.74000,Aetna,Local,,376.20,,,,,,,339.05,769.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020580,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,940.50000,272.74000,Aetna,Local,,376.20,,,,,,,302.84,769.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9020065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9020065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9020066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9020066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020081,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,350.41,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020081,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,312.98,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,497.63,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,444.49,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9022152,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9022152,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9022151,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1729.86,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9022151,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4798.50000,1391.56000,Aetna,Local,,1919.40,,,,,,,1545.12,3925.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9022153,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9022153,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9020686,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2811.90,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9020686,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,Local,,3120.00,,,,,,,2511.60,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9020687,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9020687,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3957.21,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3534.59,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9020683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9020683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9020734,CDM,278,RC,L8688,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9020734,CDM,278,RC,L8688,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020735,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020735,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020739,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020739,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020740,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020740,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5015.50000,1454.50000,Aetna,Local,,2006.20,,,,,,,1808.09,4102.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5015.50000,1454.50000,Aetna,Local,,2006.20,,,,,,,1614.99,4102.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020742,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4469.50000,1296.16000,Aetna,Local,,1787.80,,,,,,,1611.25,3656.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020742,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4469.50000,1296.16000,Aetna,Local,,1787.80,,,,,,,1439.18,3656.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020743,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5015.50000,1454.50000,Aetna,Local,,2006.20,,,,,,,1808.09,4102.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020743,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5015.50000,1454.50000,Aetna,Local,,2006.20,,,,,,,1614.99,4102.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020744,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020744,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020745,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020745,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020747,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020747,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020684,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020684,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9020799,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9020799,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
THROMBECTOMY CATHETER,9020800,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,10301.29,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
THROMBECTOMY CATHETER,9020800,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,9201.15,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020802,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,1075.11,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020802,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,960.29,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MORCELLATOR,9020803,CDM,278,RC,C1782,HCPCS,,,facility,inpatient,,,1848.88000,536.18000,Aetna,Local,,739.55,,,,,,,666.52,1512.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MORCELLATOR,9020803,CDM,278,RC,C1782,HCPCS,,,facility,outpatient,,,1848.88000,536.18000,Aetna,Local,,739.55,,,,,,,595.34,1512.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,9020804,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,8408.25000,2438.39000,Aetna,Local,,3363.30,,,,,,,3031.17,6877.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,9020804,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,8408.25000,2438.39000,Aetna,Local,,3363.30,,,,,,,2707.46,6877.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020772,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020772,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9020817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9020817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9020870,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,15487.50000,4491.38000,Aetna,Local,,6195.00,,,,,,,5583.24,12668.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9020870,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,15487.50000,4491.38000,Aetna,Local,,6195.00,,,,,,,4986.98,12668.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9019984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9019984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,9020901,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER PROSTHESIS,9020901,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10629.00000,3082.41000,Aetna,Local,,4251.60,,,,,,,3831.75,8694.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10629.00000,3082.41000,Aetna,Local,,4251.60,,,,,,,3422.54,8694.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10629.00000,3082.41000,Aetna,Local,,4251.60,,,,,,,3831.75,8694.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10629.00000,3082.41000,Aetna,Local,,4251.60,,,,,,,3422.54,8694.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9020904,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9020904,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,1072.65,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,958.09,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1626.40,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9020906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4511.50000,1308.33000,Aetna,Local,,1804.60,,,,,,,1452.70,3690.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7746.75000,2246.56000,Aetna,Local,,3098.70,,,,,,,2792.70,6336.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7746.75000,2246.56000,Aetna,Local,,3098.70,,,,,,,2494.45,6336.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9020921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,3062.33,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9020921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,2735.29,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9020922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9020922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9020923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9020923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9020924,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9020924,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9020980,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9020980,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9020981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9020981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9020982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9020982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID XL,9020988,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID XL,9020988,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEMLESS,9020989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEMLESS,9020989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9020990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1962.02,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9020990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1752.48,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESTRICTOR CEMENT,9020991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESTRICTOR CEMENT,9020991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,9020992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16445.00000,4769.05000,Aetna,Local,,6578.00,,,,,,,5928.42,13452.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,9020992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16445.00000,4769.05000,Aetna,Local,,6578.00,,,,,,,5295.29,13452.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNA W BEARING,9020993,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17657.50000,5120.67000,Aetna,Local,,7063.00,,,,,,,6365.53,14443.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNA W BEARING,9020993,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17657.50000,5120.67000,Aetna,Local,,7063.00,,,,,,,5685.72,14443.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9020998,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9020998,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9021050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9021050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER TRANSCAROTID,9021049,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,Local,,782.40,,,,,,,705.14,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER TRANSCAROTID,9021049,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,Local,,782.40,,,,,,,629.83,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9021047,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9021047,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE,9022442,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE,9022442,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9024096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1480.00000,429.20000,Aetna,Local,,592.00,,,,,,,533.54,1210.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9024096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1480.00000,429.20000,Aetna,Local,,592.00,,,,,,,476.56,1210.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9024097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.18000,193.19000,Aetna,Local,,266.47,,,,,,,240.16,544.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9024097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.18000,193.19000,Aetna,Local,,266.47,,,,,,,214.51,544.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9024112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9024112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9024113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9024113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1364.92000,395.83000,Aetna,Local,,545.97,,,,,,,492.05,1116.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1364.92000,395.83000,Aetna,Local,,545.97,,,,,,,439.50,1116.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,2081.89,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,1859.55,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9024116,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9024116,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9024117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9024117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9022444,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9022444,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,Local,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,Local,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE INFLATABLE,9021144,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,37856.25000,10978.31000,Aetna,Local,,15142.50,,,,,,,13647.18,30966.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE INFLATABLE,9021144,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,37856.25000,10978.31000,Aetna,Local,,15142.50,,,,,,,12189.71,30966.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9021146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9021146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1565.16000,453.90000,Aetna,Local,,626.06,,,,,,,564.24,1280.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1565.16000,453.90000,Aetna,Local,,626.06,,,,,,,503.98,1280.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1217.00000,352.93000,Aetna,Local,,486.80,,,,,,,438.73,995.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1217.00000,352.93000,Aetna,Local,,486.80,,,,,,,391.87,995.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,432.92,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,386.68,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,432.92,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,386.68,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,432.92,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,386.68,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9024192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,79.02,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9024192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,219.19000,63.57000,Aetna,Local,,87.68,,,,,,,70.58,179.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024195,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,514.43,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024195,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1427.00000,413.83000,Aetna,Local,,570.80,,,,,,,459.49,1167.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,432.92,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1200.88000,348.26000,Aetna,Local,,480.35,,,,,,,386.68,982.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9021356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8183.76000,2373.29000,Aetna,Local,,3273.50,,,,,,,2950.25,6694.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9021356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8183.76000,2373.29000,Aetna,Local,,3273.50,,,,,,,2635.17,6694.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,Local,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9024427,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,598.05000,173.43000,Aetna,Local,,239.22,,,,,,,215.60,489.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9024427,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,598.05000,173.43000,Aetna,Local,,239.22,,,,,,,192.57,489.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9024324,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,475.04000,137.76000,Aetna,Local,,190.02,,,,,,,171.25,388.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9024324,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,475.04000,137.76000,Aetna,Local,,190.02,,,,,,,152.96,388.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.40000,730.63000,Aetna,Local,,1007.76,,,,,,,908.24,2060.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.40000,730.63000,Aetna,Local,,1007.76,,,,,,,811.25,2060.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9024434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9024434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9024435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9024435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021600,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021600,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,Local,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9021602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,582.57,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9021602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,Local,,646.40,,,,,,,520.35,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9024480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9024480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,263.78,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,731.70000,212.19000,Aetna,Local,,292.68,,,,,,,235.61,598.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024483,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024483,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9024484,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4163.92000,1207.54000,Aetna,Local,,1665.57,,,,,,,1501.09,3406.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9024484,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4163.92000,1207.54000,Aetna,Local,,1665.57,,,,,,,1340.78,3406.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,9024486,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1622.36,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,9024486,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,Local,,1800.12,,,,,,,1449.10,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9024487,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9024487,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9024488,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9024488,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ANSIS,9024531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1491.92000,432.66000,Aetna,Local,,596.77,,,,,,,537.84,1220.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ANSIS,9024531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1491.92000,432.66000,Aetna,Local,,596.77,,,,,,,480.40,1220.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ANSIS,9024532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ANSIS,9024532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9024533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,519.22000,150.57000,Aetna,Local,,207.69,,,,,,,187.18,424.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9024533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,519.22000,150.57000,Aetna,Local,,207.69,,,,,,,167.19,424.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3957.21,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3534.59,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE CUP,9024679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.58000,1439.73000,Aetna,Local,,1985.83,,,,,,,1789.73,4061.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE CUP,9024679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.58000,1439.73000,Aetna,Local,,1985.83,,,,,,,1598.59,4061.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9021884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8270.94000,2398.57000,Aetna,Local,,3308.38,,,,,,,2981.67,6765.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9021884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8270.94000,2398.57000,Aetna,Local,,3308.38,,,,,,,2663.24,6765.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POST MODULAR,9021885,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3936.00000,1141.44000,Aetna,Local,,1574.40,,,,,,,1418.93,3219.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POST MODULAR,9021885,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3936.00000,1141.44000,Aetna,Local,,1574.40,,,,,,,1267.39,3219.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,9024680,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8734.41000,2532.98000,Aetna,Local,,3493.76,,,,,,,3148.75,7144.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,9024680,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8734.41000,2532.98000,Aetna,Local,,3493.76,,,,,,,2812.48,7144.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021928,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021928,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SPACER,9024741,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SPACER,9024741,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN GLENOID,9024677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN GLENOID,9024677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REAMER GLENOID,9024678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
REAMER GLENOID,9024678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9021971,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9021971,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,9021972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY HUMERAL,9021972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024848,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024848,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9021962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,Local,,4589.28,,,,,,,4136.09,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9021962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,Local,,4589.28,,,,,,,3694.37,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9021964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9021964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9021965,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2512.00000,728.48000,Aetna,Local,,1004.80,,,,,,,905.58,2054.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9021965,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2512.00000,728.48000,Aetna,Local,,1004.80,,,,,,,808.86,2054.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING LOCKING,9021969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,Local,,994.72,,,,,,,896.49,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING LOCKING,9021969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,Local,,994.72,,,,,,,800.75,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9021968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,Local,,2241.68,,,,,,,2020.31,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9021968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,Local,,2241.68,,,,,,,1804.55,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9021970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9021970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,Local,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9021967,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9021967,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1916.60,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9021966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5316.50000,1541.78000,Aetna,Local,,2126.60,,,,,,,1711.91,4348.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9024928,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,30026.25000,8707.61000,Aetna,Local,,12010.50,,,,,,,10824.46,24561.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9024928,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,30026.25000,8707.61000,Aetna,Local,,12010.50,,,,,,,9668.45,24561.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9021961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9021961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9024849,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9024849,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEFLUX INJECTION,9022306,CDM,278,RC,L8604,HCPCS,,,facility,inpatient,,,11782.38000,3416.89000,Aetna,Local,,4712.95,,,,,,,4247.55,9637.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEFLUX INJECTION,9022306,CDM,278,RC,L8604,HCPCS,,,facility,outpatient,,,11782.38000,3416.89000,Aetna,Local,,4712.95,,,,,,,3793.93,9637.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,Local,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11054.25000,3205.73000,Aetna,Local,,4421.70,,,,,,,3985.06,9042.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11054.25000,3205.73000,Aetna,Local,,4421.70,,,,,,,3559.47,9042.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11054.25000,3205.73000,Aetna,Local,,4421.70,,,,,,,3985.06,9042.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9024978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11054.25000,3205.73000,Aetna,Local,,4421.70,,,,,,,3559.47,9042.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER TRANSCAROTID,9024982,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,Local,,782.40,,,,,,,705.14,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER TRANSCAROTID,9024982,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,Local,,782.40,,,,,,,629.83,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9024983,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9024983,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9024984,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9024984,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9024985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9024985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9024987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9026120,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9026120,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9026122,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5432.00000,1575.28000,Aetna,Local,,2172.80,,,,,,,1958.24,4443.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9026122,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5432.00000,1575.28000,Aetna,Local,,2172.80,,,,,,,1749.10,4443.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026124,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026124,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026126,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026126,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9026128,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4329.50000,1255.55000,Aetna,Local,,1731.80,,,,,,,1560.78,3541.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9026128,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4329.50000,1255.55000,Aetna,Local,,1731.80,,,,,,,1394.10,3541.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1736.00000,503.44000,Aetna,Local,,694.40,,,,,,,625.83,1420.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1736.00000,503.44000,Aetna,Local,,694.40,,,,,,,558.99,1420.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9026142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,953.52,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9026142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,851.69,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9026166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9026166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9026164,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,6562.00,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9026164,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,5861.20,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9026165,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9026165,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,453.87,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1259.00000,365.11000,Aetna,Local,,503.60,,,,,,,405.40,1029.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP HUMERAL,9025176,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.58000,1439.73000,Aetna,Local,,1985.83,,,,,,,1789.73,4061.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP HUMERAL,9025176,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.58000,1439.73000,Aetna,Local,,1985.83,,,,,,,1598.59,4061.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9025177,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8734.41000,2532.98000,Aetna,Local,,3493.76,,,,,,,3148.75,7144.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9025177,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8734.41000,2532.98000,Aetna,Local,,3493.76,,,,,,,2812.48,7144.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,1075.11,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2982.28000,864.86000,Aetna,Local,,1192.91,,,,,,,960.29,2439.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9025179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4078.31000,1182.71000,Aetna,Local,,1631.32,,,,,,,1470.23,3336.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9025179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4078.31000,1182.71000,Aetna,Local,,1631.32,,,,,,,1313.22,3336.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRUNNION 41MM,9025180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8595.09000,2492.58000,Aetna,Local,,3438.04,,,,,,,3098.53,7030.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRUNNION 41MM,9025180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8595.09000,2492.58000,Aetna,Local,,3438.04,,,,,,,2767.62,7030.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9025181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8489.49000,2461.95000,Aetna,Local,,3395.80,,,,,,,3060.46,6944.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9025181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8489.49000,2461.95000,Aetna,Local,,3395.80,,,,,,,2733.62,6944.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT GLENOID,9025182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,Local,,2225.88,,,,,,,2006.07,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT GLENOID,9025182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,Local,,2225.88,,,,,,,1791.83,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9025183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9025183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9025184,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1124.76,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9025184,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,Local,,1248.00,,,,,,,1004.64,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,350.41,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,312.98,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,350.41,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,312.98,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,350.41,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,312.98,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,350.41,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,972.00000,281.88000,Aetna,Local,,388.80,,,,,,,312.98,795.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9025203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9025203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9025204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,304.00000,88.16000,Aetna,Local,,121.60,,,,,,,109.59,248.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9025204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,304.00000,88.16000,Aetna,Local,,121.60,,,,,,,97.89,248.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025205,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025205,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,940.50000,272.74000,Aetna,Local,,376.20,,,,,,,339.05,769.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9025209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,940.50000,272.74000,Aetna,Local,,376.20,,,,,,,302.84,769.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9026289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4544.46,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9026289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,Local,,5042.40,,,,,,,4059.13,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9026290,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1222.76000,354.60000,Aetna,Local,,489.10,,,,,,,440.80,1000.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9026290,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1222.76000,354.60000,Aetna,Local,,489.10,,,,,,,393.73,1000.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9026292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9026292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLADE HELICAL,9005741,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3153.64000,914.56000,Aetna,Local,,1261.46,,,,,,,1136.89,2579.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLADE HELICAL,9005741,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3153.64000,914.56000,Aetna,Local,,1261.46,,,,,,,1015.47,2579.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028094,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028094,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN GLENOID,9028095,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1379.60000,400.08000,Aetna,Local,,551.84,,,,,,,497.35,1128.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN GLENOID,9028095,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1379.60000,400.08000,Aetna,Local,,551.84,,,,,,,444.23,1128.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN GLENOID,9028096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,896.40000,259.96000,Aetna,Local,,358.56,,,,,,,323.15,733.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN GLENOID,9028096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,896.40000,259.96000,Aetna,Local,,358.56,,,,,,,288.64,733.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028097,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1246.40000,361.46000,Aetna,Local,,498.56,,,,,,,449.33,1019.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028097,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1246.40000,361.46000,Aetna,Local,,498.56,,,,,,,401.34,1019.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9028098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1811.62,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9028098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1618.15,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,9028099,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,9028099,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9028100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3524.61,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9028100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3148.19,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,Local,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,565.03,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,504.69,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9028106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9028106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9028093,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9028093,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP REVERS CAP COATED 33 +2 LT UNIV,9028124,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4964.58000,1439.73000,Aetna,Local,,1985.83,,,,,,,1789.73,4061.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP REVERS CAP COATED 33 +2 LT UNIV,9028124,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4964.58000,1439.73000,Aetna,Local,,1985.83,,,,,,,1598.59,4061.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9028125,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8270.94000,2398.57000,Aetna,Local,,3308.38,,,,,,,2981.67,6765.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9028125,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8270.94000,2398.57000,Aetna,Local,,3308.38,,,,,,,2663.24,6765.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9028126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,865.20,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9028126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,772.80,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9028127,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9028127,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,Local,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9028128,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,2224.35,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9028128,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6170.19000,1789.36000,Aetna,Local,,2468.08,,,,,,,1986.80,5047.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9028129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11797.20000,3421.19000,Aetna,Local,,4718.88,,,,,,,4252.89,9650.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9028129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11797.20000,3421.19000,Aetna,Local,,4718.88,,,,,,,3798.70,9650.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM REDAPT,9028131,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30026.25000,8707.61000,Aetna,Local,,12010.50,,,,,,,10824.46,24561.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM REDAPT,9028131,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30026.25000,8707.61000,Aetna,Local,,12010.50,,,,,,,9668.45,24561.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9028130,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5023.20000,1456.73000,Aetna,Local,,2009.28,,,,,,,1810.86,4108.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9028130,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5023.20000,1456.73000,Aetna,Local,,2009.28,,,,,,,1617.47,4108.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2389.25,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6627.60000,1922.00000,Aetna,Local,,2651.04,,,,,,,2134.09,5421.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9028137,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,114.73,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9028137,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,102.48,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028143,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1370.40000,397.42000,Aetna,Local,,548.16,,,,,,,494.03,1120.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028143,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1370.40000,397.42000,Aetna,Local,,548.16,,,,,,,441.27,1120.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9028144,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9028144,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9028145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1811.62,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9028145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1618.15,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9028146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9028146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HERNIA MESH,9028141,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17565.00000,5093.85000,Aetna,Local,,7026.00,,,,,,,6332.18,14368.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HERNIA MESH,9028141,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17565.00000,5093.85000,Aetna,Local,,7026.00,,,,,,,5655.93,14368.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HERNIA MESH,9028142,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,25000.00000,7250.00000,Aetna,Local,,10000.00,,,,,,,9012.50,20450.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HERNIA MESH,9028142,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,25000.00000,7250.00000,Aetna,Local,,10000.00,,,,,,,8050.00,20450.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER HOLE,9028165,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,116.87000,33.89000,Aetna,Local,,46.75,,,,,,,42.13,95.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER HOLE,9028165,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,116.87000,33.89000,Aetna,Local,,46.75,,,,,,,37.63,95.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BRACE,9028132,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BRACE,9028132,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9028216,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9028216,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9028214,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9028214,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9028215,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9028215,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9028237,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9028237,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9028239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,Local,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9028240,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,4276.25,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9028240,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,3819.56,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HELICAL BLADE,9028256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3714.83000,1077.30000,Aetna,Local,,1485.93,,,,,,,1339.20,3038.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HELICAL BLADE,9028256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3714.83000,1077.30000,Aetna,Local,,1485.93,,,,,,,1196.18,3038.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9028257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2272.00000,658.88000,Aetna,Local,,908.80,,,,,,,819.06,1858.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9028257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2272.00000,658.88000,Aetna,Local,,908.80,,,,,,,731.58,1858.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026449,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026449,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9026450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9026450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9026452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.90000,85.52000,Aetna,Local,,117.96,,,,,,,106.31,241.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9026452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.90000,85.52000,Aetna,Local,,117.96,,,,,,,94.96,241.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSSLINK CONNECTOR,9026469,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2652.00000,769.08000,Aetna,Local,,1060.80,,,,,,,956.05,2169.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROSSLINK CONNECTOR,9026469,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2652.00000,769.08000,Aetna,Local,,1060.80,,,,,,,853.94,2169.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN MATRIX,9026470,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,14091.00000,4086.39000,Aetna,Local,,5636.40,,,,,,,5079.81,11526.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN MATRIX,9026470,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,14091.00000,4086.39000,Aetna,Local,,5636.40,,,,,,,124.65,11526.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026487,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026487,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9026489,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,7372.23,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9026489,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20450.00000,5930.50000,Aetna,Local,,8180.00,,,,,,,6584.90,16728.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9026490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9026490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9026482,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9026482,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE MATRIX,9028292,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,13734.00000,3982.86000,Aetna,Local,,5493.60,,,,,,,4951.11,11234.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE MATRIX,9028292,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,13734.00000,3982.86000,Aetna,Local,,5493.60,,,,,,,4422.35,11234.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE MATRIX,9028293,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,15935.00000,4621.15000,Aetna,Local,,6374.00,,,,,,,5744.57,13034.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE MATRIX,9028293,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,15935.00000,4621.15000,Aetna,Local,,6374.00,,,,,,,5131.07,13034.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER TRANSCAROTID,9026518,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,Local,,782.40,,,,,,,705.14,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER TRANSCAROTID,9026518,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,Local,,782.40,,,,,,,629.83,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN GLENOID,9026519,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1379.60000,400.08000,Aetna,Local,,551.84,,,,,,,497.35,1128.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN GLENOID,9026519,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1379.60000,400.08000,Aetna,Local,,551.84,,,,,,,444.23,1128.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN FIXATION,9026520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN FIXATION,9026520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026570,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026570,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CONNECTOR,9026571,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,624.39,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CONNECTOR,9026571,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1732.00000,502.28000,Aetna,Local,,692.80,,,,,,,557.70,1416.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9026572,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9026572,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,9026587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,9026587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9026596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9026596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9026609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9026609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9026611,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9026611,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9026637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3957.21,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9026637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,Local,,4390.80,,,,,,,3534.59,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026638,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,436.93,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026638,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1212.00000,351.48000,Aetna,Local,,484.80,,,,,,,390.26,991.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG SMOOTH,9026639,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG SMOOTH,9026639,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9028396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9028396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9028399,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,6562.00,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9028399,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,5861.20,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9026668,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9026668,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9026669,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1811.62,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9026669,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1618.15,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9026670,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9026670,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9026675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9026676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24547.50000,7118.78000,Aetna,Local,,9819.00,,,,,,,8849.37,20079.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9026676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24547.50000,7118.78000,Aetna,Local,,9819.00,,,,,,,7904.30,20079.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9026677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24547.50000,7118.78000,Aetna,Local,,9819.00,,,,,,,8849.37,20079.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9026677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24547.50000,7118.78000,Aetna,Local,,9819.00,,,,,,,7904.30,20079.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PORT INDWELLING,9030095,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PORT INDWELLING,9030095,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THORACIC,9032091,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,172.23000,49.95000,Aetna,Local,,68.89,,,,,,,62.09,140.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THORACIC,9032091,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,172.23000,49.95000,Aetna,Local,,68.89,,,,,,,55.46,140.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9028438,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9028438,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9028439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9028439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9032084,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9032084,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,9032086,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CENTRALIZER,9032086,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9032087,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,860.87,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9032087,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2388.00000,692.52000,Aetna,Local,,955.20,,,,,,,768.94,1953.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9032088,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9032088,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9030090,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9030090,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9030091,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,7259.57,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9030091,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20137.50000,5839.88000,Aetna,Local,,8055.00,,,,,,,6484.27,16472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9030092,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9030092,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9030093,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9030093,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9030096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9030096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9014822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,964.29,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9020748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,861.31,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001593,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,608.67000,176.51000,Aetna,Local,,243.47,,,,,,,219.43,497.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9001593,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,608.67000,176.51000,Aetna,Local,,243.47,,,,,,,195.99,497.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9032206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9032206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRES,9032165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRES,9032165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9032166,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9032166,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9032167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9032167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9032207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,648.90,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9032207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,720.00,,,,,,,579.60,1472.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CONDYLAR,9032208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2451.12000,710.82000,Aetna,Local,,980.45,,,,,,,883.63,2005.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CONDYLAR,9032208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2451.12000,710.82000,Aetna,Local,,980.45,,,,,,,789.26,2005.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9032210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9032210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9032211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9032211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERTER,9032212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERTER,9032212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9032265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9032265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9032266,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9032266,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9032267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9032267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9034160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9034160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9034161,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9034161,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9034162,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9034162,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9034163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8283.00000,2402.07000,Aetna,Local,,3313.20,,,,,,,2986.02,6775.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9034163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8283.00000,2402.07000,Aetna,Local,,3313.20,,,,,,,2667.13,6775.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9032286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1203.71,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9032286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3339.00000,968.31000,Aetna,Local,,1335.60,,,,,,,1075.16,2731.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9034199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9034199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9034200,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9034200,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9034201,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9034201,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9034297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9034297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9034298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,943.76,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9034298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,842.97,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,9032397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRAY TIBIAL,9032397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING TIBIAL,9032398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING TIBIAL,9032398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9032399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9032399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9032407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4609.35,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9032407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4117.09,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATOSPHERE,9032408,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21107.50000,6121.17000,Aetna,Local,,8443.00,,,,,,,7609.25,17265.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATOSPHERE,9032408,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21107.50000,6121.17000,Aetna,Local,,8443.00,,,,,,,6796.61,17265.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9032794,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9032794,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,9032795,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,9032795,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TRIATHLON ASYMMETRIC 40X11MM,9035117,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,937.30,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TRIATHLON ASYMMETRIC 40X11MM,9035117,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2600.00000,754.00000,Aetna,Local,,1040.00,,,,,,,837.20,2126.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9032844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8385.30000,2431.74000,Aetna,Local,,3354.12,,,,,,,3022.90,6859.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9032844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8385.30000,2431.74000,Aetna,Local,,3354.12,,,,,,,2700.07,6859.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE STAPLE,9032845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6468.00000,1875.72000,Aetna,Local,,2587.20,,,,,,,2331.71,5290.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE STAPLE,9032845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6468.00000,1875.72000,Aetna,Local,,2587.20,,,,,,,2082.70,5290.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9032846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11628.00000,3372.12000,Aetna,Local,,4651.20,,,,,,,4191.89,9511.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9032846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11628.00000,3372.12000,Aetna,Local,,4651.20,,,,,,,3744.22,9511.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9035155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9035155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9035156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9035156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9035157,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9035157,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9035158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8523.00000,2471.67000,Aetna,Local,,3409.20,,,,,,,3072.54,6971.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9035158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8523.00000,2471.67000,Aetna,Local,,3409.20,,,,,,,2744.41,6971.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9035144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9035144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9035182,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9035182,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9035183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9035183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9035186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4634.00000,1343.86000,Aetna,Local,,1853.60,,,,,,,1670.56,3790.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9035186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4634.00000,1343.86000,Aetna,Local,,1853.60,,,,,,,1492.15,3790.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9035347,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9035347,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9035348,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9035348,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,764.47,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9036157,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7326.00000,2124.54000,Aetna,Local,,2930.40,,,,,,,2641.02,5992.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9036157,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7326.00000,2124.54000,Aetna,Local,,2930.40,,,,,,,2358.97,5992.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9036168,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9036168,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9036170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9036170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9036171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9036171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9036172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4457.57000,1292.70000,Aetna,Local,,1783.03,,,,,,,1606.95,3646.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9036172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4457.57000,1292.70000,Aetna,Local,,1783.03,,,,,,,1435.34,3646.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9036173,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1284.64000,372.55000,Aetna,Local,,513.86,,,,,,,463.11,1050.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9036173,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1284.64000,372.55000,Aetna,Local,,513.86,,,,,,,413.65,1050.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9036174,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1284.64000,372.55000,Aetna,Local,,513.86,,,,,,,463.11,1050.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9036174,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1284.64000,372.55000,Aetna,Local,,513.86,,,,,,,413.65,1050.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9036253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1962.02,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9036253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1752.48,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,9036254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8634.00000,2503.86000,Aetna,Local,,3453.60,,,,,,,3112.56,7062.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,9036254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8634.00000,2503.86000,Aetna,Local,,3453.60,,,,,,,2780.15,7062.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9036255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9036255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9036257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,572.76000,166.10000,Aetna,Local,,229.10,,,,,,,206.48,468.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9036257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,572.76000,166.10000,Aetna,Local,,229.10,,,,,,,184.43,468.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9036258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1782.88000,517.04000,Aetna,Local,,713.15,,,,,,,642.73,1458.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9036258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1782.88000,517.04000,Aetna,Local,,713.15,,,,,,,574.09,1458.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9035410,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9035410,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9035414,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,6529.56,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9035414,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18112.50000,5252.62000,Aetna,Local,,7245.00,,,,,,,5832.23,14816.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9036262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1222.30,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9036262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3390.56000,983.26000,Aetna,Local,,1356.22,,,,,,,1091.76,2773.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9035411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9035411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9036296,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17687.50000,5129.38000,Aetna,Local,,7075.00,,,,,,,6376.34,14468.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9036296,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17687.50000,5129.38000,Aetna,Local,,7075.00,,,,,,,5695.38,14468.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9036300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9036300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9036294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9036294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9036295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1962.02,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9036295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1752.48,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9036299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3689.35000,1069.91000,Aetna,Local,,1475.74,,,,,,,1330.01,3017.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9036299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3689.35000,1069.91000,Aetna,Local,,1475.74,,,,,,,1187.97,3017.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9036306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24547.50000,7118.78000,Aetna,Local,,9819.00,,,,,,,8849.37,20079.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9036306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24547.50000,7118.78000,Aetna,Local,,9819.00,,,,,,,7904.30,20079.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9035496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9038156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9038156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9040156,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24547.50000,7118.78000,Aetna,Local,,9819.00,,,,,,,8849.37,20079.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9040156,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24547.50000,7118.78000,Aetna,Local,,9819.00,,,,,,,7904.30,20079.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9040157,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9040157,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9040158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9040158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,755.39,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,674.72,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9038157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,755.39,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9038157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,674.72,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1364.70,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3785.57000,1097.82000,Aetna,Local,,1514.23,,,,,,,1218.95,3096.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9040182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9040182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANTERIOR,9040172,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,6430.42,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANTERIOR,9040172,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17837.50000,5172.88000,Aetna,Local,,7135.00,,,,,,,5743.68,14591.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9040175,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9040175,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11076.00000,3212.04000,Aetna,Local,,4430.40,,,,,,,3992.90,9060.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11076.00000,3212.04000,Aetna,Local,,4430.40,,,,,,,3566.47,9060.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9040184,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9040184,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9040185,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,2146.24,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9040185,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,1917.03,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNOTLESS AC REPAIR SYS,9040171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8156.25000,2365.31000,Aetna,Local,,3262.50,,,,,,,2940.33,6671.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNOTLESS AC REPAIR SYS,9040171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8156.25000,2365.31000,Aetna,Local,,3262.50,,,,,,,2626.31,6671.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE II,9040258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2939.84000,852.55000,Aetna,Local,,1175.94,,,,,,,1059.81,2404.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE II,9040258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2939.84000,852.55000,Aetna,Local,,1175.94,,,,,,,946.63,2404.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE II,9040259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2141.00000,620.89000,Aetna,Local,,856.40,,,,,,,771.83,1751.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE II,9040259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2141.00000,620.89000,Aetna,Local,,856.40,,,,,,,689.40,1751.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9040261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9040261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1635.23,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1460.59,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,9038265,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,9038265,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9038266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9038266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9038268,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9038268,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR THORACIC,9038269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR THORACIC,9038269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9038270,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9038270,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9038271,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9038271,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH DYNAMIC,9040275,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5044.17000,1462.81000,Aetna,Local,,2017.67,,,,,,,1818.42,4126.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH DYNAMIC,9040275,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5044.17000,1462.81000,Aetna,Local,,2017.67,,,,,,,1624.22,4126.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT SLF TAP,9040276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,62.68,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORT SLF TAP,9040276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,173.88000,50.43000,Aetna,Local,,69.55,,,,,,,55.99,142.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT ASF CPS,9040300,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT ASF CPS,9040300,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9040301,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,6562.00,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9040301,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,5861.20,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9042208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9042208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9042193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3335.50000,967.30000,Aetna,Local,,1334.20,,,,,,,1202.45,2728.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9042193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3335.50000,967.30000,Aetna,Local,,1334.20,,,,,,,1074.03,2728.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9042192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9042192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PSN,9042243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,2199.23,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PSN,9042243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6100.50000,1769.14000,Aetna,Local,,2440.20,,,,,,,1964.36,4990.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9042235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9042235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT POLY,9042240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11448.00000,3319.92000,Aetna,Local,,4579.20,,,,,,,4127.00,9364.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT POLY,9042240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11448.00000,3319.92000,Aetna,Local,,4579.20,,,,,,,3686.26,9364.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,1061.31,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,947.97,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040347,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,1061.31,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040347,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,947.97,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9040348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,326.52000,94.69000,Aetna,Local,,130.61,,,,,,,117.71,267.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9040348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,326.52000,94.69000,Aetna,Local,,130.61,,,,,,,105.14,267.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9040349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,5416.16,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9040349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,Local,,6009.61,,,,,,,4837.74,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9042242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,6562.00,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9042242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,5861.20,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9042244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9042244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9042250,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,651.73,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9042250,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,582.12,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9042287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,4082.66,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9042287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11325.00000,3284.25000,Aetna,Local,,4530.00,,,,,,,3646.65,9263.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9042288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24312.50000,7050.62000,Aetna,Local,,9725.00,,,,,,,8764.66,19887.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9042288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24312.50000,7050.62000,Aetna,Local,,9725.00,,,,,,,7828.62,19887.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9040365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,908.10,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9040365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,811.12,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9042749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8489.49000,2461.95000,Aetna,Local,,3395.80,,,,,,,3060.46,6944.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9042749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8489.49000,2461.95000,Aetna,Local,,3395.80,,,,,,,2733.62,6944.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9042750,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4078.31000,1182.71000,Aetna,Local,,1631.32,,,,,,,1470.23,3336.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9042750,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4078.31000,1182.71000,Aetna,Local,,1631.32,,,,,,,1313.22,3336.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRUNNION 47MM,9042751,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.09000,2492.58000,Aetna,Local,,3438.04,,,,,,,3098.53,7030.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRUNNION 47MM,9042751,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.09000,2492.58000,Aetna,Local,,3438.04,,,,,,,2767.62,7030.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT GLENOID,9042753,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8744.73000,2535.97000,Aetna,Local,,3497.89,,,,,,,3152.48,7153.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT GLENOID,9042753,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8744.73000,2535.97000,Aetna,Local,,3497.89,,,,,,,2815.80,7153.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL HUMERUS,9042747,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4518.50000,1310.36000,Aetna,Local,,1807.40,,,,,,,1628.92,3696.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL HUMERUS,9042747,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4518.50000,1310.36000,Aetna,Local,,1807.40,,,,,,,1454.96,3696.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9042760,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18952.50000,5496.22000,Aetna,Local,,7581.00,,,,,,,6832.38,15503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9042760,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18952.50000,5496.22000,Aetna,Local,,7581.00,,,,,,,6102.70,15503.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9042761,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9042761,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DRIVE LCKNG,9042762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DRIVE LCKNG,9042762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DRIVE NON LK,9042763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DRIVE NON LK,9042763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DRIVE NON LK,9042764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DRIVE NON LK,9042764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DRIVE NON LK,9042765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DRIVE NON LK,9042765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FRACTURE,9040605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20275.00000,5879.75000,Aetna,Local,,8110.00,,,,,,,7309.14,16584.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FRACTURE,9040605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20275.00000,5879.75000,Aetna,Local,,8110.00,,,,,,,6528.55,16584.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE GAST,9042793,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,623.66000,180.86000,Aetna,Local,,249.46,,,,,,,224.83,510.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE GAST,9042793,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,623.66000,180.86000,Aetna,Local,,249.46,,,,,,,200.82,510.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9040628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9040628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040630,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,26035.00000,7550.15000,Aetna,Local,,10414.00,,,,,,,9385.62,21296.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040630,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,26035.00000,7550.15000,Aetna,Local,,10414.00,,,,,,,8383.27,21296.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9042809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3486.76,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9042809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,Local,,3868.80,,,,,,,3114.38,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9040635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24312.50000,7050.62000,Aetna,Local,,9725.00,,,,,,,8764.66,19887.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9040635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24312.50000,7050.62000,Aetna,Local,,9725.00,,,,,,,7828.62,19887.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9040637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,7018.94,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9040637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,6269.34,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9040712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9040712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9040713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9040713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9042845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9042845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9042853,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9042853,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9042854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9042854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9042855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1248.00000,361.92000,Aetna,Local,,499.20,,,,,,,449.90,1020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9042855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1248.00000,361.92000,Aetna,Local,,499.20,,,,,,,401.86,1020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9042858,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26499.33000,7684.81000,Aetna,Local,,10599.73,,,,,,,9553.01,21676.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9042858,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26499.33000,7684.81000,Aetna,Local,,10599.73,,,,,,,8532.78,21676.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9042859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9042859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD TAPERED,9040757,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD TAPERED,9040757,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9040758,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9040758,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9040759,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9040759,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1220.74,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9040788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1090.37,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9040789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9041052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9041052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9041053,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9041053,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9041055,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9041055,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TPNG,9041057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TPNG,9041057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TPNG,9041058,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TPNG,9041058,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TPNG,9041059,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,337.36,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SLF TPNG,9041059,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,935.82000,271.39000,Aetna,Local,,374.33,,,,,,,301.33,765.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9041060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20748.10000,6016.95000,Aetna,Local,,8299.24,,,,,,,7479.69,16971.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9041060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20748.10000,6016.95000,Aetna,Local,,8299.24,,,,,,,6680.89,16971.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL HUMERAL,9041061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL HUMERAL,9041061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT QUICKSET 8CC,9041062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2968.72,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT QUICKSET 8CC,9041062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2651.67,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9043287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9043287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL ACETABULAR,9043288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL ACETABULAR,9043288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9043289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9043289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9043290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9043290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH BONE,9043291,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8084.88000,2344.62000,Aetna,Local,,3233.95,,,,,,,2914.60,6613.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH BONE,9043291,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8084.88000,2344.62000,Aetna,Local,,3233.95,,,,,,,2603.33,6613.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FOOT AND ANKLE KIT,9043293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FOOT AND ANKLE KIT,9043293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9043294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5546.63000,1608.52000,Aetna,Local,,2218.65,,,,,,,1999.56,4537.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9043294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5546.63000,1608.52000,Aetna,Local,,2218.65,,,,,,,1786.01,4537.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9043286,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,802.11,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9043286,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,716.45,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9043309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9043309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,Local,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9043310,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9043310,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9043333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9043333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9043334,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9043334,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9043335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9043335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9043336,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17090.00000,4956.10000,Aetna,Local,,6836.00,,,,,,,6160.94,13979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9043336,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17090.00000,4956.10000,Aetna,Local,,6836.00,,,,,,,5502.98,13979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9043337,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10299.30000,2986.80000,Aetna,Local,,4119.72,,,,,,,3712.90,8424.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9043337,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10299.30000,2986.80000,Aetna,Local,,4119.72,,,,,,,3316.37,8424.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9043338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20275.00000,5879.75000,Aetna,Local,,8110.00,,,,,,,7309.14,16584.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9043338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20275.00000,5879.75000,Aetna,Local,,8110.00,,,,,,,6528.55,16584.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9043340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9043340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9043342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9043342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9041324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9041324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9041325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9041325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9041326,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9041326,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE FEMORAL,9041333,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1297.08,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE FEMORAL,9041333,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1158.56,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9043409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9043409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9041347,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9041347,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1448.00000,419.92000,Aetna,Local,,579.20,,,,,,,522.00,1184.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1448.00000,419.92000,Aetna,Local,,579.20,,,,,,,466.26,1184.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE KNOTLESS,9043543,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8219.25000,2383.58000,Aetna,Local,,3287.70,,,,,,,2963.04,6723.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE KNOTLESS,9043543,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8219.25000,2383.58000,Aetna,Local,,3287.70,,,,,,,2646.60,6723.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043544,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043544,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9043545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9043545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9043546,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9043546,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,Local,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9043547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9043547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TUBULAR,9043548,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3853.50000,1117.51000,Aetna,Local,,1541.40,,,,,,,1389.19,3152.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TUBULAR,9043548,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3853.50000,1117.51000,Aetna,Local,,1541.40,,,,,,,1240.83,3152.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON LCKNG,9044244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON LCKNG,9044244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DRESSING BIO MESHED,9043615,CDM,278,RC,Q4158,HCPCS,,,facility,inpatient,,,6233.50000,1807.72000,Aetna,Local,,2493.40,,,,,,,2247.18,5099.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DRESSING BIO MESHED,9043615,CDM,278,RC,Q4158,HCPCS,,,facility,outpatient,,,6233.50000,1807.72000,Aetna,Local,,2493.40,,,,,,,124.65,5099.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9043616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,7018.94,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9043616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,6269.34,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL ACETABULER,9043617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3524.61,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL ACETABULER,9043617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3148.19,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON LCKNG,9044314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON LCKNG,9044314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9044317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9044317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,Local,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE TLIF,9044318,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE TLIF,9044318,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9044319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9044319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044320,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9675.00000,2805.75000,Aetna,Local,,3870.00,,,,,,,3487.84,7914.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044320,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9675.00000,2805.75000,Aetna,Local,,3870.00,,,,,,,3115.35,7914.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SPINAL,9044321,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SPINAL,9044321,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER SHLDR,9044322,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1811.62,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER SHLDR,9044322,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1618.15,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9044323,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9044323,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9044324,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9044324,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1290.14,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1152.36,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9044361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9044361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9044362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,802.11,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9044362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,Local,,890.00,,,,,,,716.45,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044364,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4487.00000,1301.23000,Aetna,Local,,1794.80,,,,,,,1617.56,3670.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044364,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4487.00000,1301.23000,Aetna,Local,,1794.80,,,,,,,1444.81,3670.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PNS SINGLE LEAD,9044373,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,6038.38,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PNS SINGLE LEAD,9044373,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,Local,,6700.00,,,,,,,5393.50,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PNS DUAL LEAD,9044374,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,8652.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PNS DUAL LEAD,9044374,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,24000.00000,6960.00000,Aetna,Local,,9600.00,,,,,,,7728.00,19632.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT W BEARING,9044377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16445.00000,4769.05000,Aetna,Local,,6578.00,,,,,,,5928.42,13452.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT W BEARING,9044377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16445.00000,4769.05000,Aetna,Local,,6578.00,,,,,,,5295.29,13452.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNA W BEARING,9044378,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17657.50000,5120.67000,Aetna,Local,,7063.00,,,,,,,6365.53,14443.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNA W BEARING,9044378,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17657.50000,5120.67000,Aetna,Local,,7063.00,,,,,,,5685.72,14443.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,9043678,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,9043678,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9043697,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4641.00000,1345.89000,Aetna,Local,,1856.40,,,,,,,1673.08,3796.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9043697,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4641.00000,1345.89000,Aetna,Local,,1856.40,,,,,,,1494.40,3796.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9043698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9043698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER RETENTIVE,9043699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1811.62,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER RETENTIVE,9043699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1618.15,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID CEMENTED,9043701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13200.00000,3828.00000,Aetna,Local,,5280.00,,,,,,,4758.60,10797.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID CEMENTED,9043701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13200.00000,3828.00000,Aetna,Local,,5280.00,,,,,,,4250.40,10797.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,826.20000,239.60000,Aetna,Local,,330.48,,,,,,,297.85,675.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,826.20000,239.60000,Aetna,Local,,330.48,,,,,,,266.04,675.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9043703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5289.90000,1534.07000,Aetna,Local,,2115.96,,,,,,,1907.01,4327.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9043703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5289.90000,1534.07000,Aetna,Local,,2115.96,,,,,,,1703.35,4327.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9043704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9044428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9044428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9044429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3725.77,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9044429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10335.00000,2997.15000,Aetna,Local,,4134.00,,,,,,,3327.87,8454.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,9043734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,9043734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE FEMORAL,9043735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3942.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE FEMORAL,9043735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3521.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9043736,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6693.75000,1941.19000,Aetna,Local,,2677.50,,,,,,,2413.10,5475.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9043736,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6693.75000,1941.19000,Aetna,Local,,2677.50,,,,,,,2155.39,5475.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9043737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,2146.24,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9043737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,1917.03,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE TLIF,9044638,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE TLIF,9044638,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISC SPINAL,9044639,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18800.00000,5452.00000,Aetna,Local,,7520.00,,,,,,,6777.40,15378.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISC SPINAL,9044639,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18800.00000,5452.00000,Aetna,Local,,7520.00,,,,,,,6053.60,15378.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL BEARING,9044640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL BEARING,9044640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9044641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,261.18,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9044641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,724.50000,210.10000,Aetna,Local,,289.80,,,,,,,233.29,592.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9044078,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4540.73000,1316.81000,Aetna,Local,,1816.29,,,,,,,1636.93,3714.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9044078,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4540.73000,1316.81000,Aetna,Local,,1816.29,,,,,,,1462.12,3714.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9044753,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9044753,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9044754,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,6507.04,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9044754,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18050.05000,5234.51000,Aetna,Local,,7220.02,,,,,,,5812.12,14764.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9044755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9044755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1746.40000,506.46000,Aetna,Local,,698.56,,,,,,,629.58,1428.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1746.40000,506.46000,Aetna,Local,,698.56,,,,,,,562.34,1428.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9044861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9044861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9044862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,755.39,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9044862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,674.72,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9044868,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1360.00000,394.40000,Aetna,Local,,544.00,,,,,,,490.28,1112.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9044868,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1360.00000,394.40000,Aetna,Local,,544.00,,,,,,,437.92,1112.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9044140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10530.00000,3053.70000,Aetna,Local,,4212.00,,,,,,,3796.07,8613.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9044140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10530.00000,3053.70000,Aetna,Local,,4212.00,,,,,,,3390.66,8613.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE LOWER,9046257,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE LOWER,9046257,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9046258,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9046258,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,Local,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE UPPER,9046259,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE UPPER,9046259,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9046260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9046260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9044904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1724.00000,499.96000,Aetna,Local,,689.60,,,,,,,621.50,1410.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9044904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1724.00000,499.96000,Aetna,Local,,689.60,,,,,,,555.13,1410.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044905,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,Local,,3699.60,,,,,,,3334.26,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044905,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,Local,,3699.60,,,,,,,2978.18,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9044906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,584.01,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9044906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,521.64,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9044907,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,584.01,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9044907,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,521.64,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9044908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3612.46000,1047.61000,Aetna,Local,,1444.98,,,,,,,1302.29,2954.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9044908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3612.46000,1047.61000,Aetna,Local,,1444.98,,,,,,,1163.21,2954.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9044909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9044909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9044910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9044910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9044911,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9044911,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4039.00000,1171.31000,Aetna,Local,,1615.60,,,,,,,1456.06,3303.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4039.00000,1171.31000,Aetna,Local,,1615.60,,,,,,,1300.56,3303.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9044957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9044957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9044968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING PSN,9044971,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING PSN,9044971,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9044978,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9044978,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9044979,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15882.00000,4605.78000,Aetna,Local,,6352.80,,,,,,,5725.46,12991.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9044979,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15882.00000,4605.78000,Aetna,Local,,6352.80,,,,,,,5114.00,12991.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9044980,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9044980,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9044981,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9044981,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9044982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9044982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER  VENTRICULAR,9044984,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2781.76000,806.71000,Aetna,Local,,1112.70,,,,,,,1002.82,2275.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER  VENTRICULAR,9044984,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2781.76000,806.71000,Aetna,Local,,1112.70,,,,,,,895.73,2275.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SCREW,9045005,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SCREW,9045005,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9045006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4078.31000,1182.71000,Aetna,Local,,1631.32,,,,,,,1470.23,3336.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9045006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4078.31000,1182.71000,Aetna,Local,,1631.32,,,,,,,1313.22,3336.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9045007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9045007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,Local,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT FLEX,9046388,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT FLEX,9046388,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,Local,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9045040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2750.40000,797.62000,Aetna,Local,,1100.16,,,,,,,991.52,2249.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9045040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2750.40000,797.62000,Aetna,Local,,1100.16,,,,,,,885.63,2249.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9045032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9045032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ACETABULAR,9045033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,47.83,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ACETABULAR,9045033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.67000,38.47000,Aetna,Local,,53.07,,,,,,,42.72,108.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CHAMFERED,9045034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5369.00000,1557.01000,Aetna,Local,,2147.60,,,,,,,1935.52,4391.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CHAMFERED,9045034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5369.00000,1557.01000,Aetna,Local,,2147.60,,,,,,,1728.82,4391.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9045035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9045035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9046385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9046385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9046386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,651.73,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9046386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,582.12,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9046387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2312.00000,670.48000,Aetna,Local,,924.80,,,,,,,833.48,1891.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9046387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2312.00000,670.48000,Aetna,Local,,924.80,,,,,,,744.46,1891.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT POLY,9045041,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14673.00000,4255.17000,Aetna,Local,,5869.20,,,,,,,5289.62,12002.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT POLY,9045041,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14673.00000,4255.17000,Aetna,Local,,5869.20,,,,,,,4724.71,12002.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9045042,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,1061.31,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9045042,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,947.97,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9045043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,1061.31,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9045043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2944.00000,853.76000,Aetna,Local,,1177.60,,,,,,,947.97,2408.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM ULNAR,9046434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15307.50000,4439.17000,Aetna,Local,,6123.00,,,,,,,5518.35,12521.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM ULNAR,9046434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15307.50000,4439.17000,Aetna,Local,,6123.00,,,,,,,4929.02,12521.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9046435,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9046435,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER INNER BODY,9046436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER INNER BODY,9046436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9046433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20222.50000,5864.52000,Aetna,Local,,8089.00,,,,,,,7290.21,16542.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9046433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20222.50000,5864.52000,Aetna,Local,,8089.00,,,,,,,6511.65,16542.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER INTERBODY,9046473,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8334.00000,2416.86000,Aetna,Local,,3333.60,,,,,,,3004.41,6817.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER INTERBODY,9046473,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8334.00000,2416.86000,Aetna,Local,,3333.60,,,,,,,2683.55,6817.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9046474,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9046474,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9046475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8392.50000,2433.82000,Aetna,Local,,3357.00,,,,,,,3025.50,6865.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9046475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8392.50000,2433.82000,Aetna,Local,,3357.00,,,,,,,2702.39,6865.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9046476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2015.00000,584.35000,Aetna,Local,,806.00,,,,,,,726.41,1648.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9046476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2015.00000,584.35000,Aetna,Local,,806.00,,,,,,,648.83,1648.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9046516,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19000.00000,5510.00000,Aetna,Local,,7600.00,,,,,,,6849.50,15542.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9046516,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19000.00000,5510.00000,Aetna,Local,,7600.00,,,,,,,6118.00,15542.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9046517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9046517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9046518,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9046518,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE UPPER,9046519,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,Local,,1673.00,,,,,,,1507.79,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE UPPER,9046519,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,Local,,1673.00,,,,,,,1346.77,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE LOWER,9046520,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,Local,,1673.00,,,,,,,1507.79,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE LOWER,9046520,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,Local,,1673.00,,,,,,,1346.77,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CEMENT SYSTEM,9046530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5418.18000,1571.27000,Aetna,Local,,2167.27,,,,,,,1953.25,4432.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CEMENT SYSTEM,9046530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5418.18000,1571.27000,Aetna,Local,,2167.27,,,,,,,1744.65,4432.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9046521,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4453.23000,1291.44000,Aetna,Local,,1781.29,,,,,,,1605.39,3642.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9046521,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4453.23000,1291.44000,Aetna,Local,,1781.29,,,,,,,1433.94,3642.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9045244,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9045244,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9045259,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7326.00000,2124.54000,Aetna,Local,,2930.40,,,,,,,2641.02,5992.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9045259,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7326.00000,2124.54000,Aetna,Local,,2930.40,,,,,,,2358.97,5992.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9045260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1290.14,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9045260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1152.36,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL RETRO T2,9045261,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL RETRO T2,9045261,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9045262,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,860.66,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9045262,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2387.40000,692.35000,Aetna,Local,,954.96,,,,,,,768.74,1952.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9045263,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9045263,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL DISC,9046560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18800.00000,5452.00000,Aetna,Local,,7520.00,,,,,,,6777.40,15378.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL DISC,9046560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18800.00000,5452.00000,Aetna,Local,,7520.00,,,,,,,6053.60,15378.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE ANCHOR,9046561,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3250.45000,942.63000,Aetna,Local,,1300.18,,,,,,,1171.79,2658.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE ANCHOR,9046561,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3250.45000,942.63000,Aetna,Local,,1300.18,,,,,,,1046.64,2658.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
XBRAID NO NEEDLE,9045328,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
XBRAID NO NEEDLE,9045328,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERUS PROXIMAL,9045329,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16585.00000,4809.65000,Aetna,Local,,6634.00,,,,,,,5978.89,13566.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERUS PROXIMAL,9045329,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16585.00000,4809.65000,Aetna,Local,,6634.00,,,,,,,5340.37,13566.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045245,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045245,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045246,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045246,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045247,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045247,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045248,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045248,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045249,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045249,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045250,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045250,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045251,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045251,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045252,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045252,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045253,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045253,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045254,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045254,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045255,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9045255,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9045340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9045340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9045341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9045341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,Local,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE ANCHOR,9045342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1962.02,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE ANCHOR,9045342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1752.48,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9045343,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9045343,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR KNOTLESS,9045385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3542.18000,1027.23000,Aetna,Local,,1416.87,,,,,,,1276.96,2897.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR KNOTLESS,9045385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3542.18000,1027.23000,Aetna,Local,,1416.87,,,,,,,1140.58,2897.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9045380,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9045380,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9045381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9045381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9045382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,525.09,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9045382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,469.01,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9045383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,498.93,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9045383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,445.65,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR KNOTLESS,9045504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR KNOTLESS,9045504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9046736,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9046736,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9045687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6270.39000,1818.41000,Aetna,Local,,2508.16,,,,,,,2260.48,5129.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9045687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6270.39000,1818.41000,Aetna,Local,,2508.16,,,,,,,2019.07,5129.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANCHOR,9047089,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANCHOR,9047089,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PRESSFIT,9047090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM PRESSFIT,9047090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE INHANCE,9045896,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE INHANCE,9045896,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER HUMERAL,9045897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1811.62,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER HUMERAL,9045897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1618.15,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PERITONEAL,9045903,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1963.32000,569.36000,Aetna,Local,,785.33,,,,,,,707.78,1606.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PERITONEAL,9045903,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1963.32000,569.36000,Aetna,Local,,785.33,,,,,,,632.19,1606.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,9046017,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,5602.49000,1624.72000,Aetna,Local,,2241.00,,,,,,,2019.70,4582.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,9046017,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,5602.49000,1624.72000,Aetna,Local,,2241.00,,,,,,,1804.00,4582.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9045992,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9045992,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9045993,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9045993,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,Local,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9045994,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16137.50000,4679.88000,Aetna,Local,,6455.00,,,,,,,5817.57,13200.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9045994,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16137.50000,4679.88000,Aetna,Local,,6455.00,,,,,,,5196.27,13200.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9045995,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9045995,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9046001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,755.39,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9046001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,674.72,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9046002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,755.39,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9046002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,674.72,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9046003,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9046003,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE TIBIAL,9046020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19627.50000,5691.98000,Aetna,Local,,7851.00,,,,,,,7075.71,16055.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE TIBIAL,9046020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19627.50000,5691.98000,Aetna,Local,,7851.00,,,,,,,6320.06,16055.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9046050,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20222.50000,5864.52000,Aetna,Local,,8089.00,,,,,,,7290.21,16542.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9046050,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20222.50000,5864.52000,Aetna,Local,,8089.00,,,,,,,6511.65,16542.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE TLIF,9046051,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE TLIF,9046051,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9046052,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9046052,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING TIBIAL,9046053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING TIBIAL,9046053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION HALF PIN,9046054,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,370.50000,107.44000,Aetna,Local,,148.20,,,,,,,133.57,303.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION HALF PIN,9046054,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,370.50000,107.44000,Aetna,Local,,148.20,,,,,,,119.30,303.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION PIN,9046055,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,370.50000,107.44000,Aetna,Local,,148.20,,,,,,,133.57,303.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION PIN,9046055,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,370.50000,107.44000,Aetna,Local,,148.20,,,,,,,119.30,303.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9046060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9046060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9046061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9046061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9046062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9046062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9046063,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9046063,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9047256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9047256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TUBULAR,9047257,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2652.00000,769.08000,Aetna,Local,,1060.80,,,,,,,956.05,2169.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TUBULAR,9047257,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2652.00000,769.08000,Aetna,Local,,1060.80,,,,,,,853.94,2169.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE OFFSET,9047258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3076.00000,892.04000,Aetna,Local,,1230.40,,,,,,,1108.90,2516.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE OFFSET,9047258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3076.00000,892.04000,Aetna,Local,,1230.40,,,,,,,990.47,2516.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HUMERAL,9047259,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3446.74,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HUMERAL,9047259,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9561.00000,2772.69000,Aetna,Local,,3824.40,,,,,,,3078.64,7820.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDEZILLA,9048181,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,Local,,746.00,,,,,,,672.33,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDEZILLA,9048181,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,Local,,746.00,,,,,,,600.53,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9047274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9047274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9047275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9047275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LAG,9048167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3141.20000,910.95000,Aetna,Local,,1256.48,,,,,,,1132.40,2569.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LAG,9048167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3141.20000,910.95000,Aetna,Local,,1256.48,,,,,,,1011.47,2569.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON LCKNG,9048168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,288.76,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON LCKNG,9048168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.00000,232.29000,Aetna,Local,,320.40,,,,,,,257.92,655.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LCKG,9048169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LCKG,9048169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9048170,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9048170,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,Local,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH REINFORCED,9048174,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,13800.00000,4002.00000,Aetna,Local,,5520.00,,,,,,,4974.90,11288.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH REINFORCED,9048174,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,13800.00000,4002.00000,Aetna,Local,,5520.00,,,,,,,4443.60,11288.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9048171,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9048171,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LCKG,9048172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LCKG,9048172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,9048176,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3360.22,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,9048176,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3001.36,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9048177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,651.73,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9048177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,582.12,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9048178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,Local,,961.60,,,,,,,866.64,1966.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9048178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,961.60,,,,,,,774.09,1966.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE BONE FIXATION,9048182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9015.00000,2614.35000,Aetna,Local,,3606.00,,,,,,,3249.91,7374.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE BONE FIXATION,9048182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9015.00000,2614.35000,Aetna,Local,,3606.00,,,,,,,2902.83,7374.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE EASYFUSE,9048183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8634.00000,2503.86000,Aetna,Local,,3453.60,,,,,,,3112.56,7062.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE EASYFUSE,9048183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8634.00000,2503.86000,Aetna,Local,,3453.60,,,,,,,2780.15,7062.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9048243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9048243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR Y KNOT,9048175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR Y KNOT,9048175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9048221,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9048221,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERSTITCH,9048255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.84000,797.74000,Aetna,Local,,1100.34,,,,,,,991.68,2250.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBERSTITCH,9048255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.84000,797.74000,Aetna,Local,,1100.34,,,,,,,885.77,2250.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9048276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9048276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,Local,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETB,9048277,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETB,9048277,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,Local,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE COMPRESSION,9048278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3265.50000,946.99000,Aetna,Local,,1306.20,,,,,,,1177.21,2671.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE COMPRESSION,9048278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3265.50000,946.99000,Aetna,Local,,1306.20,,,,,,,1051.49,2671.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,9048279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,9048279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VALVULOPLASTY,9050253,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VALVULOPLASTY,9050253,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9048292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9048292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR STIMULATOR,9048293,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,558.23000,161.89000,Aetna,Local,,223.29,,,,,,,201.24,456.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR STIMULATOR,9048293,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,558.23000,161.89000,Aetna,Local,,223.29,,,,,,,179.75,456.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD OCTRODE,9048309,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD OCTRODE,9048309,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9048310,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,597.15000,173.17000,Aetna,Local,,238.86,,,,,,,215.27,488.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9048310,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,597.15000,173.17000,Aetna,Local,,238.86,,,,,,,192.28,488.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOTAL HIP KIT,9048311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1740.00000,504.60000,Aetna,Local,,696.00,,,,,,,627.27,1423.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOTAL HIP KIT,9048311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1740.00000,504.60000,Aetna,Local,,696.00,,,,,,,560.28,1423.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,9048331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,9048331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,Local,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9048332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9048332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9048333,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9048333,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR HEMASHIELD,9048334,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,848.93000,246.19000,Aetna,Local,,339.57,,,,,,,306.04,694.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR HEMASHIELD,9048334,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,848.93000,246.19000,Aetna,Local,,339.57,,,,,,,273.36,694.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LAG,9050283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,943.76,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LAG,9050283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,842.97,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HIP,9048472,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,892.60,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HIP,9048472,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,Local,,990.40,,,,,,,797.27,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9048473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,929.25000,269.48000,Aetna,Local,,371.70,,,,,,,334.99,760.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9048473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,929.25000,269.48000,Aetna,Local,,371.70,,,,,,,299.22,760.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD THORACOLUMBAR,9048474,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD THORACOLUMBAR,9048474,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9048475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9048475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,Local,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SACRAL,9048476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SACRAL,9048476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THORACOLUMBAR,9048477,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW THORACOLUMBAR,9048477,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9048478,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9048478,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRUSS OSTEOTOMY,9048479,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,6518.74,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRUSS OSTEOTOMY,9048479,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,Local,,7233.00,,,,,,,5822.56,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9048503,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9048503,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9048506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9048506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HUMERUS,9048507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5676.30000,1646.13000,Aetna,Local,,2270.52,,,,,,,2046.31,4643.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HUMERUS,9048507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5676.30000,1646.13000,Aetna,Local,,2270.52,,,,,,,1827.77,4643.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9048508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9048508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,96.66,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9048525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,671.84,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9048525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,600.09,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9048522,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9048522,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9048523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9048523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9048530,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9048530,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9048531,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1290.14,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9048531,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1152.36,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9048532,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9048532,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,9048533,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5289.90000,1534.07000,Aetna,Local,,2115.96,,,,,,,1907.01,4327.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,9048533,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5289.90000,1534.07000,Aetna,Local,,2115.96,,,,,,,1703.35,4327.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9048534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9048534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9048537,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9048537,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9048538,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9048538,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL  ACETABULAR,9048539,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3524.61,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL  ACETABULAR,9048539,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,Local,,3910.80,,,,,,,3148.19,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9048540,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9048540,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER STINGRAY,9052182,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,9819.00000,2847.51000,Aetna,Local,,3927.60,,,,,,,3539.75,8031.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER STINGRAY,9052182,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,9819.00000,2847.51000,Aetna,Local,,3927.60,,,,,,,3161.72,8031.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9052183,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9052183,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER MICRO,9052184,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,Local,,1123.20,,,,,,,1012.28,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER MICRO,9052184,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,Local,,1123.20,,,,,,,904.18,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9048625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9048625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,9048627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,9048627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9048628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9048628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISC INTERVERTEBRAL,9048629,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18800.00000,5452.00000,Aetna,Local,,7520.00,,,,,,,6777.40,15378.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISC INTERVERTEBRAL,9048629,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18800.00000,5452.00000,Aetna,Local,,7520.00,,,,,,,6053.60,15378.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9048637,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4609.35,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9048637,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4117.09,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9048638,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9048638,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9052185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9052185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9052186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9052186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MICROCATHETER CARAVEL,9044895,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MICROCATHETER CARAVEL,9044895,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MICROCATHETER CORSAIR,9044896,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MICROCATHETER CORSAIR,9044896,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE FIELDER,9044897,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE FIELDER,9044897,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE GLADIUS,9044898,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE GLADIUS,9044898,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER METACROSS,9045502,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1712.00000,496.48000,Aetna,Local,,684.80,,,,,,,617.18,1400.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER METACROSS,9045502,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1712.00000,496.48000,Aetna,Local,,684.80,,,,,,,551.26,1400.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER METACROSS,9045503,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1712.00000,496.48000,Aetna,Local,,684.80,,,,,,,617.18,1400.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER METACROSS,9045503,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1712.00000,496.48000,Aetna,Local,,684.80,,,,,,,551.26,1400.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER NAVICROSS,9045501,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,488.12,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER NAVICROSS,9045501,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,435.99,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9052187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9052187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9052188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9052188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9052189,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9052189,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,9048639,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,9048639,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW MULTI AXIAL,9052191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW MULTI AXIAL,9052191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9054159,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9054159,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9048827,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45099.00000,13078.71000,Aetna,Local,,18039.60,,,,,,,16258.19,36890.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9048827,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45099.00000,13078.71000,Aetna,Local,,18039.60,,,,,,,14521.88,36890.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9048828,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9048828,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9048829,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9048829,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FRACTURE,9048830,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20275.00000,5879.75000,Aetna,Local,,8110.00,,,,,,,7309.14,16584.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FRACTURE,9048830,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20275.00000,5879.75000,Aetna,Local,,8110.00,,,,,,,6528.55,16584.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ANTERIOR,9048824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ANTERIOR,9048824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANTERIOR,9048825,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANTERIOR,9048825,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANTERIOR,9048826,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANTERIOR,9048826,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT ENDOVASCULAR,9048832,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT ENDOVASCULAR,9048832,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,Local,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD REVERSE,9048833,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD REVERSE,9048833,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM TIBIAL,9054178,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM TIBIAL,9054178,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NOVOSORB BTM,9048877,CDM,278,RC,Q4104,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NOVOSORB BTM,9048877,CDM,278,RC,Q4104,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,56.25,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PANCREATIC STENT,9048890,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,457.90000,132.79000,Aetna,Local,,183.16,,,,,,,165.07,374.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PANCREATIC STENT,9048890,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,457.90000,132.79000,Aetna,Local,,183.16,,,,,,,147.44,374.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9048886,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9048886,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9048887,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9048887,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9048888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9048888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9048889,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9048889,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEPIN,9054203,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEPIN,9054203,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,Local,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANCELLOUS,9054204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1419.20000,411.57000,Aetna,Local,,567.68,,,,,,,511.62,1160.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANCELLOUS,9054204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1419.20000,411.57000,Aetna,Local,,567.68,,,,,,,456.98,1160.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9054206,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8571.60000,2485.76000,Aetna,Local,,3428.64,,,,,,,3090.06,7011.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9054206,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8571.60000,2485.76000,Aetna,Local,,3428.64,,,,,,,2760.06,7011.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DISTAL,9054207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DISTAL,9054207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DISTAL,9054208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DISTAL,9054208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DISTAL,9054209,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DISTAL,9054209,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DISTAL,9054210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW DISTAL,9054210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,Local,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLAR TRIATHLON,9054211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLAR TRIATHLON,9054211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9054212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9054212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9054213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9054213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH PROTRIEVE,9054300,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH PROTRIEVE,9054300,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,Local,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG PORT,9048979,CDM,278,RC,L9900,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG PORT,9048979,CDM,278,RC,L9900,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9048996,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9048996,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9048997,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9048997,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9048998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9048998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CLAVICLE,9048999,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CLAVICLE,9048999,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9049000,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9049000,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9049001,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1220.74,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9049001,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1090.37,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID HYBRID,9049002,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13200.00000,3828.00000,Aetna,Local,,5280.00,,,,,,,4758.60,10797.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID HYBRID,9049002,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13200.00000,3828.00000,Aetna,Local,,5280.00,,,,,,,4250.40,10797.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9049003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9049003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SWIVELOCK,9049004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2415.68000,700.55000,Aetna,Local,,966.27,,,,,,,870.85,1976.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SWIVELOCK,9049004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2415.68000,700.55000,Aetna,Local,,966.27,,,,,,,777.85,1976.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9049006,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9049006,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LORDOTIC,9049008,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LORDOTIC,9049008,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9049009,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9049009,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9049010,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9049010,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9056157,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9056157,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT DISTAL,9056478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT DISTAL,9056478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,9049037,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,9049037,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,9049038,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,9049038,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,9049039,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,9049039,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9056479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9056479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9056480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,4351.96,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9056480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12072.00000,3500.88000,Aetna,Local,,4828.80,,,,,,,3887.18,9874.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9049426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9049426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,9049427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,9049427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9056531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9056531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9056532,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9056532,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9056533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23136.75000,6709.66000,Aetna,Local,,9254.70,,,,,,,8340.80,18925.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9056533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23136.75000,6709.66000,Aetna,Local,,9254.70,,,,,,,7450.03,18925.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9056534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4599.00000,1333.71000,Aetna,Local,,1839.60,,,,,,,1657.94,3761.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9056534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4599.00000,1333.71000,Aetna,Local,,1839.60,,,,,,,1480.88,3761.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9056535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12272.10000,3558.91000,Aetna,Local,,4908.84,,,,,,,4424.09,10038.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9056535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12272.10000,3558.91000,Aetna,Local,,4908.84,,,,,,,3951.62,10038.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRPHALANGEAL,9056536,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRPHALANGEAL,9056536,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9056537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20917.50000,6066.08000,Aetna,Local,,8367.00,,,,,,,7540.76,17110.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9056537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20917.50000,6066.08000,Aetna,Local,,8367.00,,,,,,,6735.44,17110.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9056538,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9056538,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9056539,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9056539,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9049432,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9049432,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9049433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9049433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9056599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9056599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VENTRICULAR,9056600,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1462.52000,424.13000,Aetna,Local,,585.01,,,,,,,527.24,1196.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VENTRICULAR,9056600,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1462.52000,424.13000,Aetna,Local,,585.01,,,,,,,470.93,1196.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9056601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9056601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL COMPONENT,9056602,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL COMPONENT,9056602,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9058158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9058158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9058159,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9058159,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,764.47,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9058160,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9058160,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,764.47,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9058161,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9058161,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,764.47,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIM,9056616,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIM,9056616,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,9056617,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,9056617,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PULSE GENERATOR,9056618,CDM,278,RC,C1822,HCPCS,,,facility,inpatient,,,97342.00000,28229.18000,Aetna,Local,,38936.80,,,,,,,35091.79,79625.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PULSE GENERATOR,9056618,CDM,278,RC,C1822,HCPCS,,,facility,outpatient,,,97342.00000,28229.18000,Aetna,Local,,38936.80,,,,,,,31344.12,79625.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9056619,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18255.00000,5293.95000,Aetna,Local,,7302.00,,,,,,,6580.93,14932.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9056619,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18255.00000,5293.95000,Aetna,Local,,7302.00,,,,,,,5878.11,14932.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ELBOW PROSTHESIS,9056620,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10503.00000,3045.87000,Aetna,Local,,4201.20,,,,,,,3786.33,8591.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ELBOW PROSTHESIS,9056620,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10503.00000,3045.87000,Aetna,Local,,4201.20,,,,,,,3381.97,8591.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSARTICULAR FIXATION,9056660,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSARTICULAR FIXATION,9056660,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSARTICULAR FIXATION,9056661,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSARTICULAR FIXATION,9056661,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSARTICULAR FIXATION,9056662,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSARTICULAR FIXATION,9056662,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM ULNAR,9058235,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15307.50000,4439.17000,Aetna,Local,,6123.00,,,,,,,5518.35,12521.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM ULNAR,9058235,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15307.50000,4439.17000,Aetna,Local,,6123.00,,,,,,,4929.02,12521.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9056676,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9056676,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW MATRIX,9056678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,671.84,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW MATRIX,9056678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,600.09,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9056679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9056679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HOOK,9056681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4315.50000,1251.49000,Aetna,Local,,1726.20,,,,,,,1555.74,3530.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HOOK,9056681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4315.50000,1251.49000,Aetna,Local,,1726.20,,,,,,,1389.59,3530.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW KREULOCK,9056683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW KREULOCK,9056683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMUR,9056685,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMUR,9056685,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9056686,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9056686,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIMULATION,9056797,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,52152.00000,15124.08000,Aetna,Local,,20860.80,,,,,,,18800.80,42660.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIMULATION,9056797,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,52152.00000,15124.08000,Aetna,Local,,20860.80,,,,,,,16792.94,42660.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CEREBROFLO,9056845,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,3297.65000,956.32000,Aetna,Local,,1319.06,,,,,,,1188.80,2697.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CEREBROFLO,9056845,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,3297.65000,956.32000,Aetna,Local,,1319.06,,,,,,,1061.84,2697.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADVANTAGE WASHER,9056850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1282.80000,372.01000,Aetna,Local,,513.12,,,,,,,462.45,1049.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADVANTAGE WASHER,9056850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1282.80000,372.01000,Aetna,Local,,513.12,,,,,,,413.06,1049.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CABLE,9056851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1541.52000,447.04000,Aetna,Local,,616.61,,,,,,,555.72,1260.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CABLE,9056851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1541.52000,447.04000,Aetna,Local,,616.61,,,,,,,496.37,1260.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP ORTHO LOCK,9056852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1714.00000,497.06000,Aetna,Local,,685.60,,,,,,,617.90,1402.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP ORTHO LOCK,9056852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1714.00000,497.06000,Aetna,Local,,685.60,,,,,,,551.91,1402.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE INTERNAL FIXATION,9056853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14589.18000,4230.86000,Aetna,Local,,5835.67,,,,,,,5259.40,11933.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE INTERNAL FIXATION,9056853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14589.18000,4230.86000,Aetna,Local,,5835.67,,,,,,,4697.72,11933.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9058335,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9058335,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9056982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1220.74,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9056982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1090.37,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEEP BRAIN STIMIULATOR,9056983,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,2173.83,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEEP BRAIN STIMIULATOR,9056983,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,Local,,2412.02,,,,,,,1941.68,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BRAIN STIMULATOR RECHARGE,9056985,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,7824.69000,2269.16000,Aetna,Local,,3129.88,,,,,,,2820.80,6400.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BRAIN STIMULATOR RECHARGE,9056985,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,7824.69000,2269.16000,Aetna,Local,,3129.88,,,,,,,2519.55,6400.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9056987,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9056987,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL PROSTHESIS,9056988,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,7417.29,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL PROSTHESIS,9056988,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20575.00000,5966.75000,Aetna,Local,,8230.00,,,,,,,6625.15,16830.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL COMPONENT,9056989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL COMPONENT,9056989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEADLESS,9056990,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEADLESS,9056990,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD STRAIGHT,9056992,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD STRAIGHT,9056992,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL COMPONENT,9057001,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL COMPONENT,9057001,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9057003,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9057003,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR SYSTEM,9056984,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,62965.20000,18259.91000,Aetna,Local,,25186.08,,,,,,,22698.95,51505.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR SYSTEM,9056984,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,62965.20000,18259.91000,Aetna,Local,,25186.08,,,,,,,20274.79,51505.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM STANDARD,9060249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20275.00000,5879.75000,Aetna,Local,,8110.00,,,,,,,7309.14,16584.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM STANDARD,9060249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20275.00000,5879.75000,Aetna,Local,,8110.00,,,,,,,6528.55,16584.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9060250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9060250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM OFFSET,9060251,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1390.00000,403.10000,Aetna,Local,,556.00,,,,,,,501.10,1137.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM OFFSET,9060251,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1390.00000,403.10000,Aetna,Local,,556.00,,,,,,,447.58,1137.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LUMBAR,9060256,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LUMBAR,9060256,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9060257,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9060257,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT BEARING,9057010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT BEARING,9057010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9057011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9057011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,9057026,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11805.00000,3423.45000,Aetna,Local,,4722.00,,,,,,,4255.70,9656.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,9057026,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11805.00000,3423.45000,Aetna,Local,,4722.00,,,,,,,3801.21,9656.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9057027,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9057027,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9060288,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9060288,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,Local,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE 3 HOLE,9060295,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1586.60000,460.11000,Aetna,Local,,634.64,,,,,,,571.97,1297.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE 3 HOLE,9060295,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1586.60000,460.11000,Aetna,Local,,634.64,,,,,,,510.89,1297.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VENTRICULOPERITONEAL,9060337,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,3290.18000,954.15000,Aetna,Local,,1316.07,,,,,,,1186.11,2691.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VENTRICULOPERITONEAL,9060337,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,3290.18000,954.15000,Aetna,Local,,1316.07,,,,,,,1059.44,2691.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE MANDIBULAR,9060338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3291.96000,954.67000,Aetna,Local,,1316.78,,,,,,,1186.75,2692.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE MANDIBULAR,9060338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3291.96000,954.67000,Aetna,Local,,1316.78,,,,,,,1060.01,2692.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9057181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9057181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ACP,9057182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW ACP,9057182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9057183,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1220.74,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9057183,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1090.37,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9060340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9060340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9060341,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9060341,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT CROSS LINK,9060343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11448.00000,3319.92000,Aetna,Local,,4579.20,,,,,,,4127.00,9364.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT CROSS LINK,9060343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11448.00000,3319.92000,Aetna,Local,,4579.20,,,,,,,3686.26,9364.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TALAR,9060344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12519.00000,3630.51000,Aetna,Local,,5007.60,,,,,,,4513.10,10240.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TALAR,9060344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12519.00000,3630.51000,Aetna,Local,,5007.60,,,,,,,4031.12,10240.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOME TALAR,9060345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19900.00000,5771.00000,Aetna,Local,,7960.00,,,,,,,7173.95,16278.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOME TALAR,9060345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19900.00000,5771.00000,Aetna,Local,,7960.00,,,,,,,6407.80,16278.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9057188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9057188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9057189,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,584.01,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9057189,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,521.64,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9057190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9057190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,Local,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9057191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9057191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SPACER,9057192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SPACER,9057192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER LIPPED,9057193,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13668.00000,3963.72000,Aetna,Local,,5467.20,,,,,,,4927.31,11180.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER LIPPED,9057193,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13668.00000,3963.72000,Aetna,Local,,5467.20,,,,,,,4401.10,11180.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9057236,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9057236,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE GLENOID,9057250,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5778.50000,1675.76000,Aetna,Local,,2311.40,,,,,,,2083.15,4726.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE GLENOID,9057250,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5778.50000,1675.76000,Aetna,Local,,2311.40,,,,,,,1860.68,4726.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9057251,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9057251,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9057252,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3825.50000,1109.40000,Aetna,Local,,1530.20,,,,,,,1379.09,3129.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9057252,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3825.50000,1109.40000,Aetna,Local,,1530.20,,,,,,,1231.81,3129.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9057253,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9057253,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9057254,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9057254,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9057264,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3132.80000,908.51000,Aetna,Local,,1253.12,,,,,,,1129.37,2562.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9057264,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3132.80000,908.51000,Aetna,Local,,1253.12,,,,,,,1008.76,2562.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9057265,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3132.80000,908.51000,Aetna,Local,,1253.12,,,,,,,1129.37,2562.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9057265,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3132.80000,908.51000,Aetna,Local,,1253.12,,,,,,,1008.76,2562.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FRACTURE,9057290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,20275.00000,5879.75000,Aetna,Local,,8110.00,,,,,,,7309.14,16584.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FRACTURE,9057290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,20275.00000,5879.75000,Aetna,Local,,8110.00,,,,,,,6528.55,16584.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9057291,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9057291,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HUMERUS,9057292,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7966.80000,2310.37000,Aetna,Local,,3186.72,,,,,,,2872.03,6516.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HUMERUS,9057292,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7966.80000,2310.37000,Aetna,Local,,3186.72,,,,,,,2565.31,6516.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9057293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,258.91,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9057293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.20000,208.28000,Aetna,Local,,287.28,,,,,,,231.26,587.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9060433,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9060433,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9060434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9060434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9057295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9057295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9057336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9057336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9057337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9057337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9057334,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9057334,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,9057333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2597.28000,753.21000,Aetna,Local,,1038.91,,,,,,,936.32,2124.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,9057333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2597.28000,753.21000,Aetna,Local,,1038.91,,,,,,,836.32,2124.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9057338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1635.23,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9057338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1460.59,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9057339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9057339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9057340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9057340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD STRAIGHT,9057341,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD STRAIGHT,9057341,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,Local,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR QUARTEX,9057342,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR QUARTEX,9057342,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9057343,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9057343,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9057344,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9057344,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9057345,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9057345,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9060516,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9060516,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9060535,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9060535,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9060534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9060534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,9060536,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,670.53,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,9060536,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,598.92,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL ADAPTOR,9060538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL ADAPTOR,9060538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER ACETABULAR,7987260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,116.87000,33.89000,Aetna,Local,,46.75,,,,,,,42.13,95.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER ACETABULAR,7987260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,116.87000,33.89000,Aetna,Local,,46.75,,,,,,,37.63,95.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9060638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9060638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9060639,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9060639,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9060640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9060640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9060641,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9060641,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8994318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8994318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9060650,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8270.94000,2398.57000,Aetna,Local,,3308.38,,,,,,,2981.67,6765.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9060650,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8270.94000,2398.57000,Aetna,Local,,3308.38,,,,,,,2663.24,6765.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9060651,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9060651,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9057724,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9057724,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,Local,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9057727,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1220.74,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9057727,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1090.37,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM ULNAR,9057588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15307.50000,4439.17000,Aetna,Local,,6123.00,,,,,,,5518.35,12521.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM ULNAR,9057588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15307.50000,4439.17000,Aetna,Local,,6123.00,,,,,,,4929.02,12521.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9057589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9057589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9057590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9057590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9057728,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,47556.00000,13791.24000,Aetna,Local,,19022.40,,,,,,,17143.94,38900.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9057728,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,47556.00000,13791.24000,Aetna,Local,,19022.40,,,,,,,15313.03,38900.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW IFUSE,9057729,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW IFUSE,9057729,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9057805,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9057805,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CONICAL,9060959,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,4276.25,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CONICAL,9060959,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,3819.56,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL TRIDENT,9060960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,3155.82,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL TRIDENT,9060960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8754.00000,2538.66000,Aetna,Local,,3501.60,,,,,,,2818.79,7160.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9060961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,755.39,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9060961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,674.72,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9060962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,755.39,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9060962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,674.72,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9060963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,755.39,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9060963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2095.40000,607.67000,Aetna,Local,,838.16,,,,,,,674.72,1714.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9060964,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,6562.00,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9060964,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,5861.20,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD COVERED,9060965,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD COVERED,9060965,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9060966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9060966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9060967,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9060967,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9057964,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9057964,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9057965,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29128.50000,8447.26000,Aetna,Local,,11651.40,,,,,,,10500.82,23827.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9057965,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29128.50000,8447.26000,Aetna,Local,,11651.40,,,,,,,9379.38,23827.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9061011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,525.09,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9061011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,469.01,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER CATALYFT,9061012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,6562.00,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER CATALYFT,9061012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18202.50000,5278.72000,Aetna,Local,,7281.00,,,,,,,5861.20,14889.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9062157,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9062157,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,9062158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,9062158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9062159,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9062159,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9062160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9062160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9062161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9062161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,Local,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,9062162,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,9062162,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9062163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,Local,,11651.76,,,,,,,10501.15,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9062163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,Local,,11651.76,,,,,,,9379.67,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9062164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9062164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE COVERED,9057987,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1224.56000,355.12000,Aetna,Local,,489.82,,,,,,,441.45,1001.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE COVERED,9057987,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1224.56000,355.12000,Aetna,Local,,489.82,,,,,,,394.31,1001.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,9057988,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,734.58000,213.03000,Aetna,Local,,293.83,,,,,,,264.82,600.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,9057988,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,734.58000,213.03000,Aetna,Local,,293.83,,,,,,,236.53,600.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9057981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9057981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9057982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9057982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,9057983,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5793.90000,1680.23000,Aetna,Local,,2317.56,,,,,,,2088.70,4739.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,9057983,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5793.90000,1680.23000,Aetna,Local,,2317.56,,,,,,,1865.64,4739.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON LOCKING,9057984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,169.87,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON LOCKING,9057984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,471.20000,136.65000,Aetna,Local,,188.48,,,,,,,151.73,385.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CEMENTED,9057985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CEMENTED,9057985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXT,9057986,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19627.50000,5691.98000,Aetna,Local,,7851.00,,,,,,,7075.71,16055.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXT,9057986,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19627.50000,5691.98000,Aetna,Local,,7851.00,,,,,,,6320.06,16055.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9064207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4078.31000,1182.71000,Aetna,Local,,1631.32,,,,,,,1470.23,3336.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9064207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4078.31000,1182.71000,Aetna,Local,,1631.32,,,,,,,1313.22,3336.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRUNNION 39MM,9064208,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.09000,2492.58000,Aetna,Local,,3438.04,,,,,,,3098.53,7030.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRUNNION 39MM,9064208,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.09000,2492.58000,Aetna,Local,,3438.04,,,,,,,2767.62,7030.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9064209,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR POLARSTEM,9064209,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9064210,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6826.97,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9064210,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18937.50000,5491.88000,Aetna,Local,,7575.00,,,,,,,6097.88,15490.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9064211,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9064211,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9064212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5015.50000,1454.50000,Aetna,Local,,2006.20,,,,,,,1808.09,4102.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9064212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5015.50000,1454.50000,Aetna,Local,,2006.20,,,,,,,1614.99,4102.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM RADIAL,9064213,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM RADIAL,9064213,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9062270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9062270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9062271,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,965.85,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9062271,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2679.20000,776.97000,Aetna,Local,,1071.68,,,,,,,862.70,2191.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER INTERBODY,9062272,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER INTERBODY,9062272,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LONG,9062273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11004.00000,3191.16000,Aetna,Local,,4401.60,,,,,,,3966.94,9001.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LONG,9062273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11004.00000,3191.16000,Aetna,Local,,4401.60,,,,,,,3543.29,9001.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,9062274,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3360.22,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANKLE PROSTHESIS,9062274,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3001.36,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9062276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9062276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9062279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9062279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9062280,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9062280,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9062440,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER PTA,9062440,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POSTFREE DISTRACTION,9064429,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POSTFREE DISTRACTION,9064429,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR BUTTON,9066156,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,86.50000,25.08000,Aetna,Local,,34.60,,,,,,,31.18,70.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAR BUTTON,9066156,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,86.50000,25.08000,Aetna,Local,,34.60,,,,,,,27.85,332.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9068180,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9068180,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH DYNAMIC,9068181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5039.65000,1461.50000,Aetna,Local,,2015.86,,,,,,,1816.79,4122.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH DYNAMIC,9068181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5039.65000,1461.50000,Aetna,Local,,2015.86,,,,,,,1622.77,4122.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,9068182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,9068182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM LATITUDE,9068186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15307.50000,4439.17000,Aetna,Local,,6123.00,,,,,,,5518.35,12521.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM LATITUDE,9068186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15307.50000,4439.17000,Aetna,Local,,6123.00,,,,,,,4929.02,12521.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD HEX,9068187,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD HEX,9068187,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9068188,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8283.00000,2402.07000,Aetna,Local,,3313.20,,,,,,,2986.02,6775.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9068188,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8283.00000,2402.07000,Aetna,Local,,3313.20,,,,,,,2667.13,6775.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ARCHON,9068196,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,1072.65,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ARCHON,9068196,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,Local,,1190.18,,,,,,,958.09,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9068197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9068197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,Local,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9068287,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9068287,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH DYNAMIC,9068286,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8020.47000,2325.94000,Aetna,Local,,3208.19,,,,,,,2891.38,6560.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH DYNAMIC,9068286,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8020.47000,2325.94000,Aetna,Local,,3208.19,,,,,,,2582.59,6560.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH HERNIA,9068288,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,12487.50000,3621.37000,Aetna,Local,,4995.00,,,,,,,4501.74,10214.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH HERNIA,9068288,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,12487.50000,3621.37000,Aetna,Local,,4995.00,,,,,,,4020.97,10214.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9068289,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9068289,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,Local,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE INTERBODY,9068290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1411.24,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE INTERBODY,9068290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3914.68000,1135.26000,Aetna,Local,,1565.87,,,,,,,1260.53,3202.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9068291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9068291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,Local,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9068292,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9068292,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LEFT,9068293,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1361.16000,394.74000,Aetna,Local,,544.46,,,,,,,490.70,1113.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LEFT,9068293,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1361.16000,394.74000,Aetna,Local,,544.46,,,,,,,438.29,1113.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE RIGHT,9068294,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1361.16000,394.74000,Aetna,Local,,544.46,,,,,,,490.70,1113.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE RIGHT,9068294,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1361.16000,394.74000,Aetna,Local,,544.46,,,,,,,438.29,1113.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9068295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9068295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM DISTAL,9068296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,4276.25,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM DISTAL,9068296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,3819.56,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9068297,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9068297,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIRTHING KIT,9072244,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3920.00000,1136.80000,Aetna,Local,,1568.00,,,,,,,1413.16,3206.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIRTHING KIT,9072244,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3920.00000,1136.80000,Aetna,Local,,1568.00,,,,,,,1262.24,3206.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9068352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9068352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9068353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2226.68000,645.74000,Aetna,Local,,890.67,,,,,,,802.72,1821.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9068353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2226.68000,645.74000,Aetna,Local,,890.67,,,,,,,716.99,1821.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9068484,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9068484,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9068485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9068485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9068486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9068486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP,9068487,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4109.00000,1191.61000,Aetna,Local,,1643.60,,,,,,,1481.29,3361.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDCAP,9068487,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4109.00000,1191.61000,Aetna,Local,,1643.60,,,,,,,1323.10,3361.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATOSPHERE,9068488,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22292.50000,6464.82000,Aetna,Local,,8917.00,,,,,,,8036.45,18235.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATOSPHERE,9068488,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22292.50000,6464.82000,Aetna,Local,,8917.00,,,,,,,7178.19,18235.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT AORTIC,9068489,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,19155.53,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT AORTIC,9068489,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,53136.00000,15409.44000,Aetna,Local,,21254.40,,,,,,,17109.79,43465.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9068490,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9068490,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9068525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7582.74000,2198.99000,Aetna,Local,,3033.10,,,,,,,2733.58,6202.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9068525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7582.74000,2198.99000,Aetna,Local,,3033.10,,,,,,,2441.64,6202.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9068526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9068526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9068527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9068527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9068528,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9068528,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9068529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,565.03,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9068529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1567.36000,454.53000,Aetna,Local,,626.94,,,,,,,504.69,1282.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9074228,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9074228,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9072296,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9072296,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL HELICAL,9072297,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,Local,,2337.30,,,,,,,2106.49,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL HELICAL,9072297,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,Local,,2337.30,,,,,,,1881.53,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACETABULAR,9074161,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2928.00000,849.12000,Aetna,Local,,1171.20,,,,,,,1055.54,2395.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACETABULAR,9074161,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2928.00000,849.12000,Aetna,Local,,1171.20,,,,,,,942.82,2395.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9074162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,651.73,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9074162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,582.12,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHERE EMBOLIZATION,9074163,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPHERE EMBOLIZATION,9074163,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH INTRODUCER,9072299,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH INTRODUCER,9072299,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9072300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9072300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9072301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9072301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9074238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9074238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEADLESS,9074239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEADLESS,9074239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9074240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9074240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9074241,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9074241,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9074242,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2520.00000,730.80000,Aetna,Local,,1008.00,,,,,,,908.46,2061.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9074242,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2520.00000,730.80000,Aetna,Local,,1008.00,,,,,,,811.44,2061.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CLAVICLE,9074243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.22000,1054.50000,Aetna,Local,,1454.49,,,,,,,1310.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CLAVICLE,9074243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.22000,1054.50000,Aetna,Local,,1454.49,,,,,,,1170.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9074405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,639.00000,185.31000,Aetna,Local,,255.60,,,,,,,230.36,522.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9074405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,255.60,,,,,,,205.76,522.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE GLENOID,9074396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5778.50000,1675.76000,Aetna,Local,,2311.40,,,,,,,2083.15,4726.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE GLENOID,9074396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5778.50000,1675.76000,Aetna,Local,,2311.40,,,,,,,1860.68,4726.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9074397,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9074397,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9074398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9074398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG LOCKING,9074399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG LOCKING,9074399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9074400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9258.00000,2684.82000,Aetna,Local,,3703.20,,,,,,,3337.51,7573.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9074400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9258.00000,2684.82000,Aetna,Local,,3703.20,,,,,,,2981.08,7573.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9074406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9074406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,Local,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9074407,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9074407,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9074505,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9074505,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACETABULAR,9072507,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2312.00000,670.48000,Aetna,Local,,924.80,,,,,,,833.48,1891.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACETABULAR,9072507,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2312.00000,670.48000,Aetna,Local,,924.80,,,,,,,744.46,1891.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPRING,9072508,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1510.56000,438.06000,Aetna,Local,,604.22,,,,,,,544.56,1235.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPRING,9072508,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1510.56000,438.06000,Aetna,Local,,604.22,,,,,,,486.40,1235.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8986318,CDM,278,RC,C1761,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4542.30,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8986318,CDM,278,RC,C1761,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4057.20,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLAR TRIATHLON,9072675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLAR TRIATHLON,9072675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE MATRIX,9074519,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,4543.00000,1317.47000,Aetna,Local,,1817.20,,,,,,,1637.75,3716.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE MATRIX,9074519,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,4543.00000,1317.47000,Aetna,Local,,1817.20,,,,,,,124.65,3716.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COUNTERSINK,9072682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,Local,,584.00,,,,,,,526.33,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COUNTERSINK,9072682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,Local,,584.00,,,,,,,470.12,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9072529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2196.64000,637.03000,Aetna,Local,,878.66,,,,,,,791.89,1796.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9072529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2196.64000,637.03000,Aetna,Local,,878.66,,,,,,,707.32,1796.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9072530,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9072530,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9072531,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9072531,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9072532,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,865.20,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9072532,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,772.80,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LUMBAR,9072533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LUMBAR,9072533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH GUIDING,9072597,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,Local,,584.00,,,,,,,526.33,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH GUIDING,9072597,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,Local,,584.00,,,,,,,470.12,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9072598,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1560.00000,452.40000,Aetna,Local,,624.00,,,,,,,562.38,1276.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9072598,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1560.00000,452.40000,Aetna,Local,,624.00,,,,,,,502.32,1276.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLAR TRIATHLON,9072676,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLAR TRIATHLON,9072676,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9072683,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9072683,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9072684,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9072684,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9072685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9072685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEMLESS,9072686,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEMLESS,9072686,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9072687,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9072687,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYNDESMOTIC FIXATION DEVICE,8380191,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4658.50000,1350.96000,Aetna,Local,,1863.40,,,,,,,1679.39,3810.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SYNDESMOTIC FIXATION DEVICE,8380191,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4658.50000,1350.96000,Aetna,Local,,1863.40,,,,,,,1500.04,3810.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9072778,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9072778,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE MATRIX,9072795,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17725.00000,5140.25000,Aetna,Local,,7090.00,,,,,,,6389.86,14499.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE MATRIX,9072795,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17725.00000,5140.25000,Aetna,Local,,7090.00,,,,,,,5707.45,14499.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9074747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9074747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE GLENOID,9072796,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,2170.21,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE GLENOID,9072796,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,1938.44,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP END,9072797,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP END,9072797,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SPINAL,9072798,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,6331.28,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE SPINAL,9072798,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17562.50000,5093.12000,Aetna,Local,,7025.00,,,,,,,5655.12,14366.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9072799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9072799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9078170,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,2081.89,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9078170,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5775.00000,1674.75000,Aetna,Local,,2310.00,,,,,,,1859.55,4723.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9078168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4453.23000,1291.44000,Aetna,Local,,1781.29,,,,,,,1605.39,3642.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9078168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4453.23000,1291.44000,Aetna,Local,,1781.29,,,,,,,1433.94,3642.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9078169,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9078169,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FRACTURE,9078171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3764.81000,1091.79000,Aetna,Local,,1505.92,,,,,,,1357.21,3079.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FRACTURE,9078171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3764.81000,1091.79000,Aetna,Local,,1505.92,,,,,,,1212.27,3079.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER GUIDE,9076189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4617.90000,1339.19000,Aetna,Local,,1847.16,,,,,,,1664.75,3777.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER GUIDE,9076189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4617.90000,1339.19000,Aetna,Local,,1847.16,,,,,,,1486.96,3777.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9076190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9384.00000,2721.36000,Aetna,Local,,3753.60,,,,,,,3382.93,7676.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9076190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9384.00000,2721.36000,Aetna,Local,,3753.60,,,,,,,3021.65,7676.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9076434,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9076434,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9076435,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9076435,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9076436,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9076436,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9076437,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9076437,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,Local,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9076327,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9076327,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR KNOTLESS,9076336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1609.36000,466.71000,Aetna,Local,,643.74,,,,,,,580.17,1316.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR KNOTLESS,9076336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1609.36000,466.71000,Aetna,Local,,643.74,,,,,,,518.21,1316.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9076337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5043.15000,1462.51000,Aetna,Local,,2017.26,,,,,,,1818.06,4125.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9076337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5043.15000,1462.51000,Aetna,Local,,2017.26,,,,,,,1623.89,4125.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9076329,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9076329,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9076330,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,Local,,11651.76,,,,,,,10501.15,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9076330,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,Local,,11651.76,,,,,,,9379.67,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9076338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9076338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9076331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,Local,,11651.76,,,,,,,10501.15,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9076331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,Local,,11651.76,,,,,,,9379.67,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THROMBECTOMY,9076340,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,10301.29,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THROMBECTOMY,9076340,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,9201.15,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9076341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,303.91000,88.13000,Aetna,Local,,121.56,,,,,,,109.56,248.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9076341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,303.91000,88.13000,Aetna,Local,,121.56,,,,,,,97.86,248.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9078601,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9078601,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CERVICAL,9078602,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CERVICAL,9078602,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CERVICAL,9078603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3270.75000,948.52000,Aetna,Local,,1308.30,,,,,,,1179.11,2675.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CERVICAL,9078603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3270.75000,948.52000,Aetna,Local,,1308.30,,,,,,,1053.18,2675.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9078605,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9078605,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9078606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9078606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9078607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3223.50000,934.82000,Aetna,Local,,1289.40,,,,,,,1162.07,2636.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9078607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3223.50000,934.82000,Aetna,Local,,1289.40,,,,,,,1037.97,2636.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9078608,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9078608,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9078609,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,714.57,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9078609,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,638.26,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9078701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9078701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9076721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9076721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN FIXATION,9078700,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN FIXATION,9078700,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FRACTURE,9076737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4084.64000,1184.55000,Aetna,Local,,1633.86,,,,,,,1472.51,3341.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FRACTURE,9076737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4084.64000,1184.55000,Aetna,Local,,1633.86,,,,,,,1315.25,3341.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE VARIABLE,9076738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7804.26000,2263.24000,Aetna,Local,,3121.70,,,,,,,2813.44,6383.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE VARIABLE,9076738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7804.26000,2263.24000,Aetna,Local,,3121.70,,,,,,,2512.97,6383.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9082199,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9082199,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER CATHETER,9078752,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COVER CATHETER,9078752,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9078753,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9078753,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE KIT,9078754,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,12375.00000,3588.75000,Aetna,Local,,4950.00,,,,,,,4461.19,10122.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE KIT,9078754,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,12375.00000,3588.75000,Aetna,Local,,4950.00,,,,,,,3984.75,10122.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE KIT,9078755,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE KIT,9078755,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,9078759,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,9078759,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9076790,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANNULATED,9076790,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ORTHOLOC,9076791,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11628.00000,3372.12000,Aetna,Local,,4651.20,,,,,,,4191.89,9511.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ORTHOLOC,9076791,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11628.00000,3372.12000,Aetna,Local,,4651.20,,,,,,,3744.22,9511.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9080167,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9080167,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FEMUR,9080169,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,34292.70000,9944.88000,Aetna,Local,,13717.08,,,,,,,12362.52,28051.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FEMUR,9080169,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,34292.70000,9944.88000,Aetna,Local,,13717.08,,,,,,,11042.25,28051.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080171,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080171,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON CANNULATED,9080172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.00000,537.08000,Aetna,Local,,740.80,,,,,,,667.65,1514.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON CANNULATED,9080172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.00000,537.08000,Aetna,Local,,740.80,,,,,,,596.34,1514.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON CANNULATED,9080173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.00000,537.08000,Aetna,Local,,740.80,,,,,,,667.65,1514.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON CANNULATED,9080173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.00000,537.08000,Aetna,Local,,740.80,,,,,,,596.34,1514.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9080174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2992.44000,867.81000,Aetna,Local,,1196.98,,,,,,,1078.77,2447.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9080174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2992.44000,867.81000,Aetna,Local,,1196.98,,,,,,,963.57,2447.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9082198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,9082198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,Local,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9082200,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9082200,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT CONSTRAINED,9082201,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT CONSTRAINED,9082201,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9082202,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9082202,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW SPINAL,9080198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW SPINAL,9080198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9076789,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9076789,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,Local,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9080175,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9080175,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9080176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9080176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9082280,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9082280,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD GLENOID,9082282,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD GLENOID,9082282,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,Local,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FACIAL,9080274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,24616.08000,7138.66000,Aetna,Local,,9846.43,,,,,,,8874.10,20135.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FACIAL,9080274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,24616.08000,7138.66000,Aetna,Local,,9846.43,,,,,,,7926.38,20135.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9080275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,329.41000,95.53000,Aetna,Local,,131.76,,,,,,,118.75,269.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9080275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,329.41000,95.53000,Aetna,Local,,131.76,,,,,,,106.07,269.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE MANDIBULAR,9080276,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4243.86000,1230.72000,Aetna,Local,,1697.54,,,,,,,1529.91,3471.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE MANDIBULAR,9080276,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4243.86000,1230.72000,Aetna,Local,,1697.54,,,,,,,1366.52,3471.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,9080277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1228.96000,356.40000,Aetna,Local,,491.58,,,,,,,443.04,1005.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,9080277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1228.96000,356.40000,Aetna,Local,,491.58,,,,,,,395.73,1005.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT CONSTRAINED,9080279,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT CONSTRAINED,9080279,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9080281,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,826.20000,239.60000,Aetna,Local,,330.48,,,,,,,297.85,675.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9080281,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,826.20000,239.60000,Aetna,Local,,330.48,,,,,,,266.04,675.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9080282,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9080282,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9080283,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9080283,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9080284,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9080284,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9076788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF TAP,9076788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL LEFT TALLO,9082160,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,41737.50000,12103.88000,Aetna,Local,,16695.00,,,,,,,15046.37,34141.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL LEFT TALLO,9082160,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,41737.50000,12103.88000,Aetna,Local,,16695.00,,,,,,,13439.48,34141.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080351,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080351,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080354,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080354,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9080368,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9080368,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9080369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,865.40000,250.97000,Aetna,Local,,346.16,,,,,,,311.98,707.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9080369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,865.40000,250.97000,Aetna,Local,,346.16,,,,,,,278.66,707.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CRANIO,9080375,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2155.44000,625.08000,Aetna,Local,,862.18,,,,,,,777.04,1763.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CRANIO,9080375,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2155.44000,625.08000,Aetna,Local,,862.18,,,,,,,694.05,1763.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERSTIM STIMULATOR LEAD,9082367,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,235.20000,68.21000,Aetna,Local,,94.08,,,,,,,84.79,192.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERSTIM STIMULATOR LEAD,9082367,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,235.20000,68.21000,Aetna,Local,,94.08,,,,,,,75.73,192.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERSTIM STIMULATOR TEST,9082368,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,314.45000,91.19000,Aetna,Local,,125.78,,,,,,,113.36,257.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTERSTIM STIMULATOR TEST,9082368,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,314.45000,91.19000,Aetna,Local,,125.78,,,,,,,101.25,257.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9082371,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9082371,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LATERAL,9082372,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3299.59000,956.88000,Aetna,Local,,1319.84,,,,,,,1189.50,2699.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LATERAL,9082372,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3299.59000,956.88000,Aetna,Local,,1319.84,,,,,,,1062.47,2699.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DORSAL,9082373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3299.59000,956.88000,Aetna,Local,,1319.84,,,,,,,1189.50,2699.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DORSAL,9082373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3299.59000,956.88000,Aetna,Local,,1319.84,,,,,,,1062.47,2699.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9082374,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9082374,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW AXS,9082396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.35000,103.34000,Aetna,Local,,142.54,,,,,,,128.46,291.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW AXS,9082396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.35000,103.34000,Aetna,Local,,142.54,,,,,,,114.74,291.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9082404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9082404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CERVICAL,9080470,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CERVICAL,9080470,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CONTOURED,9080471,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CONTOURED,9080471,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,Local,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9080525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9080525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL RUBY,9080519,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL RUBY,9080519,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL RUBY,9080520,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL RUBY,9080520,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL RUBY,9080521,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL RUBY,9080521,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL PACKING,9080522,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL PACKING,9080522,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CEMENTED,9080523,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12966.00000,3760.14000,Aetna,Local,,5186.40,,,,,,,4674.24,10606.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM CEMENTED,9080523,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12966.00000,3760.14000,Aetna,Local,,5186.40,,,,,,,4175.05,10606.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL HINGE,9080524,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14424.00000,4182.96000,Aetna,Local,,5769.60,,,,,,,5199.85,11798.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL HINGE,9080524,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14424.00000,4182.96000,Aetna,Local,,5769.60,,,,,,,4644.53,11798.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM RADIAL,9080526,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10719.00000,3108.51000,Aetna,Local,,4287.60,,,,,,,3864.20,8768.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM RADIAL,9080526,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10719.00000,3108.51000,Aetna,Local,,4287.60,,,,,,,3451.52,8768.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,9080527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10794.00000,3130.26000,Aetna,Local,,4317.60,,,,,,,3891.24,8829.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD RADIAL,9080527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10794.00000,3130.26000,Aetna,Local,,4317.60,,,,,,,3475.67,8829.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,9080528,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3444.00000,998.76000,Aetna,Local,,1377.60,,,,,,,1241.56,2817.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,9080528,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3444.00000,998.76000,Aetna,Local,,1377.60,,,,,,,1108.97,2817.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,9080529,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,9080529,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT PSN,9080530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT PSN,9080530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9080537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9080537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9080538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9080538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9080539,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9080539,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9080540,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE TIBIAL,9080540,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9080542,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9080542,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER ANSEL,9080652,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER ANSEL,9080652,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9080630,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10530.00000,3053.70000,Aetna,Local,,4212.00,,,,,,,3796.07,8613.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9080630,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10530.00000,3053.70000,Aetna,Local,,4212.00,,,,,,,3390.66,8613.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE GLENOID,9080631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,2170.21,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE GLENOID,9080631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,1938.44,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9080632,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9080632,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9080633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,202.23,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SELF DRILL,9080633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,180.63,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE RIGHT,9080641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1552.00000,450.08000,Aetna,Local,,620.80,,,,,,,559.50,1269.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE RIGHT,9080641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1552.00000,450.08000,Aetna,Local,,620.80,,,,,,,499.74,1269.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LEFT,9080642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1481.28000,429.57000,Aetna,Local,,592.51,,,,,,,534.00,1211.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LEFT,9080642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1481.28000,429.57000,Aetna,Local,,592.51,,,,,,,476.97,1211.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CERVICAL,9080643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3270.75000,948.52000,Aetna,Local,,1308.30,,,,,,,1179.11,2675.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CERVICAL,9080643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3270.75000,948.52000,Aetna,Local,,1308.30,,,,,,,1053.18,2675.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CERVICAL,9080644,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CERVICAL,9080644,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9080645,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9080645,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,Local,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9080646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8481.00000,2459.49000,Aetna,Local,,3392.40,,,,,,,3057.40,6937.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9080646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8481.00000,2459.49000,Aetna,Local,,3392.40,,,,,,,2730.88,6937.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9080647,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9080647,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9080649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9080649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9080650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9080650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE WIRE,9080651,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2047.56000,593.79000,Aetna,Local,,819.02,,,,,,,738.15,1674.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE WIRE,9080651,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2047.56000,593.79000,Aetna,Local,,819.02,,,,,,,659.31,1674.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9080653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2904.16000,842.21000,Aetna,Local,,1161.66,,,,,,,1046.95,2375.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9080653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2904.16000,842.21000,Aetna,Local,,1161.66,,,,,,,935.14,2375.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9082582,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9082582,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9082584,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9082584,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,Local,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE MATRIX,9082585,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,109.87,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE MATRIX,9082585,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,304.76000,88.38000,Aetna,Local,,121.90,,,,,,,98.13,249.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9082583,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9082583,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9082586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9082586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9082587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2798.76000,811.64000,Aetna,Local,,1119.50,,,,,,,1008.95,2289.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9082587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2798.76000,811.64000,Aetna,Local,,1119.50,,,,,,,901.20,2289.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9082588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9082588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9082589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9082589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9082590,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9082590,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9082591,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9082591,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9082592,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9082592,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9082593,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9082593,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CERVICAL,9082594,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD CERVICAL,9082594,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9082595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9082595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE ALLOGRAFT,9082597,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE ALLOGRAFT,9082597,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER NON BALLOON,9082599,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2047.44000,593.76000,Aetna,Local,,818.98,,,,,,,738.10,1674.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER NON BALLOON,9082599,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2047.44000,593.76000,Aetna,Local,,818.98,,,,,,,659.28,1674.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD HEX,9080746,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1740.00000,504.60000,Aetna,Local,,696.00,,,,,,,627.27,1423.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD HEX,9080746,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1740.00000,504.60000,Aetna,Local,,696.00,,,,,,,560.28,1423.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9084241,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,1976.00000,573.04000,Aetna,Local,,790.40,,,,,,,712.35,1616.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9084241,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,1976.00000,573.04000,Aetna,Local,,790.40,,,,,,,636.27,1616.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PULSE GENERATOR,9084221,CDM,278,RC,C1826,HCPCS,,,facility,inpatient,,,53948.00000,15644.92000,Aetna,Local,,21579.20,,,,,,,19448.25,44129.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PULSE GENERATOR,9084221,CDM,278,RC,C1826,HCPCS,,,facility,outpatient,,,53948.00000,15644.92000,Aetna,Local,,21579.20,,,,,,,17371.26,44129.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEVICE PROGRAMMER,9084222,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3594.15000,1042.30000,Aetna,Local,,1437.66,,,,,,,1295.69,2940.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEVICE PROGRAMMER,9084222,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3594.15000,1042.30000,Aetna,Local,,1437.66,,,,,,,1157.32,2940.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084225,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,830.25000,240.77000,Aetna,Local,,332.10,,,,,,,299.31,679.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084225,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,830.25000,240.77000,Aetna,Local,,332.10,,,,,,,267.34,679.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTEX,9084226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTEX,9084226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTEX,9084227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTEX,9084227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084229,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084229,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084230,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084230,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084232,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084232,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9084237,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9084237,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,9084238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE MODULUS,9084238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE TIBIAL,9084239,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE TIBIAL,9084239,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9084240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9084240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,Local,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN FIXATION,9084244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1343.60000,389.64000,Aetna,Local,,537.44,,,,,,,484.37,1099.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN FIXATION,9084244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1343.60000,389.64000,Aetna,Local,,537.44,,,,,,,432.64,1099.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9084246,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9084246,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,518.94000,150.49000,Aetna,Local,,207.58,,,,,,,187.08,424.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9084247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,518.94000,150.49000,Aetna,Local,,207.58,,,,,,,167.10,424.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PIN,9084248,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6289.50000,1823.96000,Aetna,Local,,2515.80,,,,,,,2267.36,5144.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PIN,9084248,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6289.50000,1823.96000,Aetna,Local,,2515.80,,,,,,,2025.22,5144.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL STRAIGHT,9084249,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12204.00000,3539.16000,Aetna,Local,,4881.60,,,,,,,4399.54,9982.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL STRAIGHT,9084249,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12204.00000,3539.16000,Aetna,Local,,4881.60,,,,,,,3929.69,9982.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTEX,9082849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTEX,9082849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FEMORAL,9084236,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13170.00000,3819.30000,Aetna,Local,,5268.00,,,,,,,4747.78,10773.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FEMORAL,9084236,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13170.00000,3819.30000,Aetna,Local,,5268.00,,,,,,,4240.74,10773.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9084715,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9084715,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084333,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084333,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,764.47,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAT IMPLANT,9084334,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAT IMPLANT,9084334,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,764.47,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084335,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084335,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,764.47,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084336,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084336,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,764.47,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084337,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084337,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,764.47,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084338,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084338,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,764.47,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084339,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9084339,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,764.47,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9083222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9083222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID HYBRID,9082850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13200.00000,3828.00000,Aetna,Local,,5280.00,,,,,,,4758.60,10797.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID HYBRID,9082850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13200.00000,3828.00000,Aetna,Local,,5280.00,,,,,,,4250.40,10797.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON PTA,9084716,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON PTA,9084716,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON PTA,9084717,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON PTA,9084717,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON PTA,9084718,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON PTA,9084718,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9084804,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9084804,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9084803,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9084803,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LEFT,9084801,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4346.76000,1260.56000,Aetna,Local,,1738.70,,,,,,,1567.01,3555.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LEFT,9084801,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4346.76000,1260.56000,Aetna,Local,,1738.70,,,,,,,1399.66,3555.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9083417,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9083417,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9084799,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20291.63000,5884.57000,Aetna,Local,,8116.65,,,,,,,7315.13,16598.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9084799,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20291.63000,5884.57000,Aetna,Local,,8116.65,,,,,,,6533.90,16598.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9084800,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7579.59000,2198.08000,Aetna,Local,,3031.84,,,,,,,2732.44,6200.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9084800,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7579.59000,2198.08000,Aetna,Local,,3031.84,,,,,,,2440.63,6200.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLADE SPIRAL,9083371,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1869.28000,542.09000,Aetna,Local,,747.71,,,,,,,673.88,1529.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLADE SPIRAL,9083371,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1869.28000,542.09000,Aetna,Local,,747.71,,,,,,,601.91,1529.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER INTERSPACE,9083373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER INTERSPACE,9083373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER INTERSPACE,9084820,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER INTERSPACE,9084820,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2188.00000,634.52000,Aetna,Local,,875.20,,,,,,,788.77,1789.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2188.00000,634.52000,Aetna,Local,,875.20,,,,,,,704.54,1789.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2188.00000,634.52000,Aetna,Local,,875.20,,,,,,,788.77,1789.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2188.00000,634.52000,Aetna,Local,,875.20,,,,,,,704.54,1789.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084823,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084823,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084826,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084826,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9084827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,Local,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE T SHAPE,9084828,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4371.50000,1267.73000,Aetna,Local,,1748.60,,,,,,,1575.93,3575.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE T SHAPE,9084828,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4371.50000,1267.73000,Aetna,Local,,1748.60,,,,,,,1407.62,3575.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9084830,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9084830,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9083422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8151.00000,2363.79000,Aetna,Local,,3260.40,,,,,,,2938.44,6667.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9083422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8151.00000,2363.79000,Aetna,Local,,3260.40,,,,,,,2624.62,6667.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9083423,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1924.00000,557.96000,Aetna,Local,,769.60,,,,,,,693.60,1573.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9083423,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1924.00000,557.96000,Aetna,Local,,769.60,,,,,,,619.53,1573.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9083424,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9083424,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,Local,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL RETRO,9083425,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL RETRO,9083425,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,566.71,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1572.00000,455.88000,Aetna,Local,,628.80,,,,,,,506.18,1285.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SINUS PROPEL,9083257,CDM,278,RC,J7402,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9083372,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11239.20000,3259.37000,Aetna,Local,,4495.68,,,,,,,4051.73,9193.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9083372,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11239.20000,3259.37000,Aetna,Local,,4495.68,,,,,,,3619.02,9193.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8988111,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1722.29,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8988111,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4777.50000,1385.48000,Aetna,Local,,1911.00,,,,,,,1538.36,3907.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSARTICULAR FIXATION,9083510,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSARTICULAR FIXATION,9083510,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9083511,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9083511,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW STANDARD,9084965,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW STANDARD,9084965,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9084966,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7893.00000,2288.97000,Aetna,Local,,3157.20,,,,,,,2845.43,6456.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9084966,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7893.00000,2288.97000,Aetna,Local,,3157.20,,,,,,,2541.55,6456.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9084968,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9084968,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8440424,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8440424,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON CANNULATED,9083686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON CANNULATED,9083686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON CANNULATED,9083687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,258.86,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW NON CANNULATED,9083687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,718.07000,208.24000,Aetna,Local,,287.23,,,,,,,231.22,587.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ARTERY,9083688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23797.50000,6901.28000,Aetna,Local,,9519.00,,,,,,,8579.00,19466.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ARTERY,9083688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23797.50000,6901.28000,Aetna,Local,,9519.00,,,,,,,7662.80,19466.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TROCHANTERIC,9085007,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,2146.24,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TROCHANTERIC,9085007,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,1917.03,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISC SPINAL,9085009,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18800.00000,5452.00000,Aetna,Local,,7520.00,,,,,,,6777.40,15378.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISC SPINAL,9085009,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18800.00000,5452.00000,Aetna,Local,,7520.00,,,,,,,6053.60,15378.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9085010,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9085010,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9085011,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9085011,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9085012,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9085012,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9085013,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9085013,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9085016,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9085016,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9085053,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9085053,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,9083755,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,2984.00000,865.36000,Aetna,Local,,1193.60,,,,,,,1075.73,2440.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,9083755,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,2984.00000,865.36000,Aetna,Local,,1193.60,,,,,,,960.85,2440.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,9083756,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,7920.00000,2296.80000,Aetna,Local,,3168.00,,,,,,,2855.16,6478.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,9083756,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,7920.00000,2296.80000,Aetna,Local,,3168.00,,,,,,,2550.24,6478.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9083757,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,9135.00000,2649.15000,Aetna,Local,,3654.00,,,,,,,3293.17,7472.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9083757,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,9135.00000,2649.15000,Aetna,Local,,3654.00,,,,,,,124.65,7472.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX LARGE,9083758,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,13500.00000,3915.00000,Aetna,Local,,5400.00,,,,,,,4866.75,11043.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX LARGE,9083758,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,13500.00000,3915.00000,Aetna,Local,,5400.00,,,,,,,124.65,11043.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HIP,9083759,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HIP,9083759,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9083760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10635.00000,3084.15000,Aetna,Local,,4254.00,,,,,,,3833.92,8699.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9083760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10635.00000,3084.15000,Aetna,Local,,4254.00,,,,,,,3424.47,8699.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,498.93,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,445.65,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,498.93,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1384.00000,401.36000,Aetna,Local,,553.60,,,,,,,445.65,1132.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9083766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM DISTAL,9085055,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,4276.25,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM DISTAL,9085055,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,3819.56,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER CERVICAL,9085182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER CERVICAL,9085182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9085176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9085176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9085177,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9085177,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9085178,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,518.94000,150.49000,Aetna,Local,,207.58,,,,,,,187.08,424.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9085178,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,518.94000,150.49000,Aetna,Local,,207.58,,,,,,,167.10,424.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9085180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9085180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9085181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW RELINE,9085181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9083945,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4609.61000,1336.79000,Aetna,Local,,1843.84,,,,,,,1661.76,3770.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9083945,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4609.61000,1336.79000,Aetna,Local,,1843.84,,,,,,,1484.29,3770.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9083946,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,872.10000,252.91000,Aetna,Local,,348.84,,,,,,,314.39,713.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9083946,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,872.10000,252.91000,Aetna,Local,,348.84,,,,,,,280.82,713.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9083947,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,872.10000,252.91000,Aetna,Local,,348.84,,,,,,,314.39,713.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9083947,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,872.10000,252.91000,Aetna,Local,,348.84,,,,,,,280.82,713.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9083948,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,872.10000,252.91000,Aetna,Local,,348.84,,,,,,,314.39,713.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW SPINAL,9083948,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,872.10000,252.91000,Aetna,Local,,348.84,,,,,,,280.82,713.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9083949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8799.18000,2551.76000,Aetna,Local,,3519.67,,,,,,,3172.10,7197.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE SPINAL,9083949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8799.18000,2551.76000,Aetna,Local,,3519.67,,,,,,,2833.34,7197.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9083950,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9083950,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,9083970,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16562.50000,4803.12000,Aetna,Local,,6625.00,,,,,,,5970.78,13548.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,9083970,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16562.50000,4803.12000,Aetna,Local,,6625.00,,,,,,,5333.12,13548.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9083971,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9083971,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9083972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12867.00000,3731.43000,Aetna,Local,,5146.80,,,,,,,4638.55,10525.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9083972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12867.00000,3731.43000,Aetna,Local,,5146.80,,,,,,,4143.17,10525.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9083973,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9083973,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9083974,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9083974,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9083975,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1290.14,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACP,9083975,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1152.36,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9083976,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5915.35000,1715.45000,Aetna,Local,,2366.14,,,,,,,2132.48,4838.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9083976,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5915.35000,1715.45000,Aetna,Local,,2366.14,,,,,,,1904.74,4838.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9083977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9083977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,Local,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,9085244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3453.35000,1001.47000,Aetna,Local,,1381.34,,,,,,,1244.93,2824.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,9085244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3453.35000,1001.47000,Aetna,Local,,1381.34,,,,,,,1111.98,2824.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086283,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4542.30,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086283,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4057.20,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,359.91000,104.37000,Aetna,Local,,143.96,,,,,,,129.75,294.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,359.91000,104.37000,Aetna,Local,,143.96,,,,,,,115.89,294.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,395.11000,114.58000,Aetna,Local,,158.04,,,,,,,142.44,323.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,395.11000,114.58000,Aetna,Local,,158.04,,,,,,,127.23,323.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.14000,110.82000,Aetna,Local,,152.86,,,,,,,137.76,312.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.14000,110.82000,Aetna,Local,,152.86,,,,,,,123.05,312.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.14000,110.82000,Aetna,Local,,152.86,,,,,,,137.76,312.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.14000,110.82000,Aetna,Local,,152.86,,,,,,,123.05,312.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9086326,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9086326,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9086327,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9086327,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9086306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9086306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9085405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2697.20000,782.19000,Aetna,Local,,1078.88,,,,,,,972.34,2206.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9085405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2697.20000,782.19000,Aetna,Local,,1078.88,,,,,,,868.50,2206.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,653.23,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,724.80,,,,,,,583.46,1482.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9084022,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9084022,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9084023,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9084023,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,Local,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9086227,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9086227,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,Local,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085381,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,108.65,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085381,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,301.39000,87.40000,Aetna,Local,,120.56,,,,,,,97.05,246.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085382,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085382,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9085383,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9085383,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9085384,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9085384,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9085385,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9085385,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE ANCHOR,9085386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE ANCHOR,9085386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE ANCHOR,9085387,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUTURE ANCHOR,9085387,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9085388,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9085388,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086256,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086256,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086257,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086257,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086258,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,340.67,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086258,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,945.00000,274.05000,Aetna,Local,,378.00,,,,,,,304.29,773.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9086259,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9086259,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9086260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2365.78,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9086260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,Local,,2625.00,,,,,,,2113.12,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9086261,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR,9086261,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,Local,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONET,9086255,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONET,9086255,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086316,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,2156.00000,625.24000,Aetna,Local,,862.40,,,,,,,777.24,1763.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086316,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,2156.00000,625.24000,Aetna,Local,,9357.00,,,,,,,694.23,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9086317,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086317,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,9357.00,,,,,,,3139.50,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9086318,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086318,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,9357.00,,,,,,,3139.50,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9086319,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086319,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,9357.00,,,,,,,3139.50,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9086320,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,4861.50000,1409.83000,Aetna,Local,,1944.60,,,,,,,1752.57,3976.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086320,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,4861.50000,1409.83000,Aetna,Local,,9357.00,,,,,,,1565.40,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9086321,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,Local,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086321,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,Local,,9357.00,,,,,,,4991.00,12679.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9086322,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,15572.50000,4516.02000,Aetna,Local,,6229.00,,,,,,,5613.89,12738.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086322,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,15572.50000,4516.02000,Aetna,Local,,9357.00,,,,,,,5014.35,12738.31,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9086323,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,11160.00000,3236.40000,Aetna,Local,,4464.00,,,,,,,4023.18,9128.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086323,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,11160.00000,3236.40000,Aetna,Local,,9357.00,,,,,,,3593.52,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9086324,CDM,278,RC,C1759,HCPCS,,,facility,inpatient,,,10731.00000,3111.99000,Aetna,Local,,4292.40,,,,,,,3868.53,8777.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9086324,CDM,278,RC,C1759,HCPCS,,,facility,outpatient,,,10731.00000,3111.99000,Aetna,Local,,4292.40,,,,,,,3455.38,8777.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9086325,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4483.50000,1300.21000,Aetna,Local,,1793.40,,,,,,,1616.30,3667.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9086325,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4483.50000,1300.21000,Aetna,Local,,1793.40,,,,,,,1443.69,3667.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONET,9086303,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONET,9086303,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SWIVELOCK,9086304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3948.00000,1144.92000,Aetna,Local,,1579.20,,,,,,,1423.25,3229.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SWIVELOCK,9086304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3948.00000,1144.92000,Aetna,Local,,1579.20,,,,,,,1271.26,3229.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085343,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085343,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9086328,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9086328,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MIDFACE,9085401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,2170.21,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MIDFACE,9085401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,Local,,2408.00,,,,,,,1938.44,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSARTICULAR FIXATION,9086454,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSARTICULAR FIXATION,9086454,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3024.48000,877.10000,Aetna,Local,,1209.79,,,,,,,1090.33,2474.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3024.48000,877.10000,Aetna,Local,,1209.79,,,,,,,973.88,2474.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9086444,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,4429.82,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9086444,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12288.00000,3563.52000,Aetna,Local,,4915.20,,,,,,,3956.74,10051.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9086451,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9086451,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086449,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086449,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9086448,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,7025.24,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9086448,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19487.50000,5651.38000,Aetna,Local,,7795.00,,,,,,,6274.98,15940.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9086447,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26499.33000,7684.81000,Aetna,Local,,10599.73,,,,,,,9553.01,21676.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9086447,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26499.33000,7684.81000,Aetna,Local,,10599.73,,,,,,,8532.78,21676.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9086446,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,714.57,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9086446,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,638.26,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9086445,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,714.57,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9086445,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1982.16000,574.83000,Aetna,Local,,792.86,,,,,,,638.26,1621.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085675,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9085675,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,Local,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Graft,9086443,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Graft,9086443,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,Local,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9086442,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1290.14,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9086442,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1152.36,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9085674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9085674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,Local,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9086480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9086480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,651.73,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9086481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,582.12,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL NAIL,9086482,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL NAIL,9086482,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDECATH,9088194,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDECATH,9088194,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2099.00000,608.71000,Aetna,Local,,839.60,,,,,,,756.69,1716.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2099.00000,608.71000,Aetna,Local,,839.60,,,,,,,675.88,1716.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9088203,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9088203,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,9088204,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,9088204,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090210,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090210,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090211,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090211,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090212,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090212,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9090215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12177.00000,3531.33000,Aetna,Local,,4870.80,,,,,,,4389.81,9960.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9090215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12177.00000,3531.33000,Aetna,Local,,4870.80,,,,,,,3920.99,9960.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9090338,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,13050.00000,3784.50000,Aetna,Local,,5220.00,,,,,,,4704.52,10674.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9090338,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,13050.00000,3784.50000,Aetna,Local,,5220.00,,,,,,,4202.10,10674.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9090339,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9090339,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9088277,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,179.80,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9088277,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,Local,,9357.00,,,,,,,160.60,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTRODUCER,9088278,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,304.48000,88.30000,Aetna,Local,,121.79,,,,,,,109.77,249.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9088278,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,304.48000,88.30000,Aetna,Local,,121.79,,,,,,,98.04,249.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MICROCATHETER,9088279,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MICROCATHETER,9088279,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9088280,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9088280,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9088281,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9088281,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9088282,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9088282,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,9357.00,,,,,,,1944.08,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SHEATH,9088283,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4483.50000,1300.21000,Aetna,Local,,1793.40,,,,,,,1616.30,3667.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9088283,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4483.50000,1300.21000,Aetna,Local,,1793.40,,,,,,,1443.69,3667.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9088284,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,107.63000,31.21000,Aetna,Local,,43.05,,,,,,,38.80,88.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9088284,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,107.63000,31.21000,Aetna,Local,,43.05,,,,,,,34.66,88.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9088285,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3601.50000,1044.44000,Aetna,Local,,1440.60,,,,,,,1298.34,2946.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9088285,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,Local,,1440.60,,,,,,,1159.68,2946.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INNATE,9088270,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8004.00000,2321.16000,Aetna,Local,,3201.60,,,,,,,2885.44,6547.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INNATE,9088270,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8004.00000,2321.16000,Aetna,Local,,3201.60,,,,,,,2577.29,6547.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,Local,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9090297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12330.00000,3575.70000,Aetna,Local,,4932.00,,,,,,,4444.97,10085.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9090297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12330.00000,3575.70000,Aetna,Local,,4932.00,,,,,,,3970.26,10085.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9088262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14673.60000,4255.34000,Aetna,Local,,5869.44,,,,,,,5289.83,12003.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9088262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14673.60000,4255.34000,Aetna,Local,,5869.44,,,,,,,4724.90,12003.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL NAIL,9090298,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL NAIL,9090298,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9090299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8221.02000,2384.10000,Aetna,Local,,3288.41,,,,,,,2963.68,6724.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9090299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8221.02000,2384.10000,Aetna,Local,,3288.41,,,,,,,2647.17,6724.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,651.73,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9090300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,582.12,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,9090358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1595.00000,462.55000,Aetna,Local,,638.00,,,,,,,575.00,1304.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,9090358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1595.00000,462.55000,Aetna,Local,,638.00,,,,,,,513.59,1304.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088311,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088311,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088312,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088312,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8157.09000,2365.56000,Aetna,Local,,3262.84,,,,,,,2940.63,6672.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8157.09000,2365.56000,Aetna,Local,,3262.84,,,,,,,2626.58,6672.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FOBERTAPE,9088314,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FOBERTAPE,9088314,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088411,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088411,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088412,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088412,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088413,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088413,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088414,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088414,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088415,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088415,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088416,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,9088416,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARDIOVERTER ICD,9090495,CDM,278,RC,C1721,HCPCS,,,facility,inpatient,,,41726.25000,12100.61000,Aetna,Local,,16690.50,,,,,,,15042.31,34132.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARDIOVERTER ICD,9090495,CDM,278,RC,C1721,HCPCS,,,facility,outpatient,,,41726.25000,12100.61000,Aetna,Local,,16690.50,,,,,,,13435.85,34132.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE STAPLE,9090504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE STAPLE,9090504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9090384,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9090384,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9090385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9090385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9088410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,352.03,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
K WIRE,9088410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,976.50000,283.18000,Aetna,Local,,390.60,,,,,,,314.43,798.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VENTRICULAR,9090447,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1624.61000,471.14000,Aetna,Local,,649.84,,,,,,,585.67,1328.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER VENTRICULAR,9090447,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1624.61000,471.14000,Aetna,Local,,649.84,,,,,,,523.12,1328.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANTERIOR,9090448,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANTERIOR,9090448,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9090449,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3062.00000,887.98000,Aetna,Local,,1224.80,,,,,,,1103.85,2504.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9090449,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3062.00000,887.98000,Aetna,Local,,1224.80,,,,,,,985.96,2504.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9090451,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9090451,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9090452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,Local,,3699.60,,,,,,,3334.26,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9090452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,Local,,3699.60,,,,,,,2978.18,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9090453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9090453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9088534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9088534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,Local,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9088535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,Local,,1456.80,,,,,,,1312.94,2979.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9088535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,Local,,1456.80,,,,,,,1172.72,2979.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACETABULAR,9088536,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,741.19,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE ACETABULAR,9088536,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,Local,,822.40,,,,,,,662.03,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088539,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,517.64000,150.12000,Aetna,Local,,207.06,,,,,,,186.61,423.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088539,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,517.64000,150.12000,Aetna,Local,,207.06,,,,,,,166.68,423.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9088541,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9088541,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FIBULA,9090503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8799.00000,2551.71000,Aetna,Local,,3519.60,,,,,,,3172.04,7197.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FIBULA,9090503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8799.00000,2551.71000,Aetna,Local,,3519.60,,,,,,,2833.28,7197.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEADLESS,9088558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1588.54,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW HEADLESS,9088558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4406.50000,1277.88000,Aetna,Local,,1762.60,,,,,,,1418.89,3604.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9088560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9088560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,Local,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NOVOSORB BTM,9040254,CDM,278,RC,A2006,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NOVOSORB BTM,9040254,CDM,278,RC,A2006,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,124.65,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9088621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9088621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9090502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9090502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Anchor,9088706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2099.00000,608.71000,Aetna,Local,,839.60,,,,,,,756.69,1716.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Anchor,9088706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2099.00000,608.71000,Aetna,Local,,839.60,,,,,,,675.88,1716.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9088611,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9088611,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,9090450,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL STEM,9090450,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9090383,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1528.00000,443.12000,Aetna,Local,,611.20,,,,,,,550.84,1249.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9090383,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1528.00000,443.12000,Aetna,Local,,611.20,,,,,,,492.02,1249.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088734,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10569.00000,3065.01000,Aetna,Local,,4227.60,,,,,,,3810.12,8645.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088734,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10569.00000,3065.01000,Aetna,Local,,4227.60,,,,,,,3403.22,8645.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9091159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9091159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9088612,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,6601.66,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9088612,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18312.50000,5310.62000,Aetna,Local,,7325.00,,,,,,,5896.62,14979.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL NAIL,9088732,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL NAIL,9088732,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9088698,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9088698,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5534.45000,1604.99000,Aetna,Local,,2213.78,,,,,,,1995.17,4527.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5534.45000,1604.99000,Aetna,Local,,2213.78,,,,,,,1782.09,4527.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9088704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9088704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9088703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,4276.25,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9088703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11862.00000,3439.98000,Aetna,Local,,4744.80,,,,,,,3819.56,9703.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9091164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9091164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088735,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088735,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9088737,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9088737,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1343.76,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3727.50000,1080.97000,Aetna,Local,,1491.00,,,,,,,1200.26,3049.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088738,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,958.93,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088738,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2660.00000,771.40000,Aetna,Local,,1064.00,,,,,,,856.52,2175.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9088742,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12330.00000,3575.70000,Aetna,Local,,4932.00,,,,,,,4444.97,10085.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9088742,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12330.00000,3575.70000,Aetna,Local,,4932.00,,,,,,,3970.26,10085.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9088740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11448.00000,3319.92000,Aetna,Local,,4579.20,,,,,,,4127.00,9364.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9088740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11448.00000,3319.92000,Aetna,Local,,4579.20,,,,,,,3686.26,9364.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9090638,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9090638,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,764.47,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9090639,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9090639,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,764.47,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL ROD,9088699,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL ROD,9088699,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL ROD,9088700,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL ROD,9088700,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088721,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088721,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,9088726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11925.00000,3458.25000,Aetna,Local,,4770.00,,,,,,,4298.96,9754.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,9088726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11925.00000,3458.25000,Aetna,Local,,4770.00,,,,,,,3839.85,9754.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9091168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,572.76000,166.10000,Aetna,Local,,229.10,,,,,,,206.48,468.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9091168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,572.76000,166.10000,Aetna,Local,,229.10,,,,,,,184.43,468.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088739,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088739,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9091292,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,6083.44,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9091292,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16875.00000,4893.75000,Aetna,Local,,6750.00,,,,,,,5433.75,13803.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088914,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088914,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11412.00000,3309.48000,Aetna,Local,,4564.80,,,,,,,4114.03,9335.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11412.00000,3309.48000,Aetna,Local,,4564.80,,,,,,,3674.66,9335.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9088917,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,908.10,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9088917,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,811.12,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2963.20000,859.33000,Aetna,Local,,1185.28,,,,,,,1068.23,2423.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9088971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2963.20000,859.33000,Aetna,Local,,1185.28,,,,,,,954.15,2423.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9088972,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3810.21000,1104.96000,Aetna,Local,,1524.08,,,,,,,1373.58,3116.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9088972,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3810.21000,1104.96000,Aetna,Local,,1524.08,,,,,,,1226.89,3116.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9091362,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9091362,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HUMERAL,9088973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11829.00000,3430.41000,Aetna,Local,,4731.60,,,,,,,4264.35,9676.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE HUMERAL,9088973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11829.00000,3430.41000,Aetna,Local,,4731.60,,,,,,,3808.94,9676.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9088974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9088974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088975,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088975,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9088977,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4469.50000,1296.16000,Aetna,Local,,1787.80,,,,,,,1611.25,3656.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9088977,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4469.50000,1296.16000,Aetna,Local,,1787.80,,,,,,,1439.18,3656.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9088978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9088978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANCELLOUS,9088979,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANCELLOUS,9088979,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANCELLOUS,9088980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANCELLOUS,9088980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9088981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9088981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,Local,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9088982,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9088982,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,Local,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9088983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,472.98,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9088983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1312.00000,380.48000,Aetna,Local,,524.80,,,,,,,422.46,1073.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9088984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9088984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,Local,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9088985,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9088985,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091385,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091385,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9091439,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9091439,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9091440,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9091440,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,Local,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9092591,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7741.50000,2245.04000,Aetna,Local,,3096.60,,,,,,,2790.81,6332.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9092591,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7741.50000,2245.04000,Aetna,Local,,3096.60,,,,,,,2492.76,6332.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9091635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9091635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9091636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9091636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9091637,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9091637,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT URETERAL,9092609,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT URETERAL,9092609,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9091711,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9091711,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9091686,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9091686,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,Local,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9092694,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9092694,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9092685,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9092685,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9092686,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10218.00000,2963.22000,Aetna,Local,,4087.20,,,,,,,3683.59,8358.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9092686,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10218.00000,2963.22000,Aetna,Local,,4087.20,,,,,,,3290.20,8358.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9092687,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9092687,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9092688,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9092688,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9092689,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9092689,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW MULTIAXIAL,9092690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW MULTIAXIAL,9092690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,Local,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9092691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9092691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9092692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9092692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,9092693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,9092693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9094190,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9094190,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9092608,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9092608,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRYO PROBE,9091657,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,10200.00000,2958.00000,Aetna,Local,,4080.00,,,,,,,3677.10,8343.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRYO PROBE,9091657,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,10200.00000,2958.00000,Aetna,Local,,4080.00,,,,,,,3284.40,8343.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT PSN,9076339,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT PSN,9076339,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ZIPFIX STERNAL,9094192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2456.00000,712.24000,Aetna,Local,,982.40,,,,,,,885.39,2009.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ZIPFIX STERNAL,9094192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2456.00000,712.24000,Aetna,Local,,982.40,,,,,,,790.83,2009.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POST MODULAR,9094194,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3936.00000,1141.44000,Aetna,Local,,1574.40,,,,,,,1418.93,3219.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POST MODULAR,9094194,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3936.00000,1141.44000,Aetna,Local,,1574.40,,,,,,,1267.39,3219.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL ACETABULAR,9094195,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16087.50000,4665.38000,Aetna,Local,,6435.00,,,,,,,5799.54,13159.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL ACETABULAR,9094195,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16087.50000,4665.38000,Aetna,Local,,6435.00,,,,,,,5180.18,13159.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9094196,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9094196,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT DUAL,9094197,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT DUAL,9094197,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM MONOBLOCK,9094198,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26499.33000,7684.81000,Aetna,Local,,10599.73,,,,,,,9553.01,21676.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM MONOBLOCK,9094198,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26499.33000,7684.81000,Aetna,Local,,10599.73,,,,,,,8532.78,21676.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9094199,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9094199,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANTERIOR,9094201,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE ANTERIOR,9094201,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,125.00,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,346.75000,100.56000,Aetna,Local,,138.70,,,,,,,111.65,283.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9094204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,519.22000,150.57000,Aetna,Local,,207.69,,,,,,,187.18,424.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9094204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,519.22000,150.57000,Aetna,Local,,207.69,,,,,,,167.19,424.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9094205,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9094205,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,Local,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER DUAL,9094206,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER DUAL,9094206,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER INSERT,9094207,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER INSERT,9094207,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9094208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13193.73000,3826.18000,Aetna,Local,,5277.49,,,,,,,4756.34,10792.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,9094208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13193.73000,3826.18000,Aetna,Local,,5277.49,,,,,,,4248.38,10792.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9094210,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9094210,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9094212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9094212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9094215,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9094215,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN SELF DRILL,7968102,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN SELF DRILL,7968102,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING TIBIAL,9091721,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING TIBIAL,9091721,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CLAVICLE,9092804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5029.50000,1458.55000,Aetna,Local,,2011.80,,,,,,,1813.13,4114.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CLAVICLE,9092804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5029.50000,1458.55000,Aetna,Local,,2011.80,,,,,,,1619.50,4114.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091380,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,10080.00000,2923.20000,Aetna,Local,,4032.00,,,,,,,3633.84,8245.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091380,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,10080.00000,2923.20000,Aetna,Local,,4032.00,,,,,,,3245.76,8245.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091381,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,10080.00000,2923.20000,Aetna,Local,,4032.00,,,,,,,3633.84,8245.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091381,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,10080.00000,2923.20000,Aetna,Local,,4032.00,,,,,,,3245.76,8245.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091382,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,8385.00000,2431.65000,Aetna,Local,,3354.00,,,,,,,3022.79,6858.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091382,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,8385.00000,2431.65000,Aetna,Local,,3354.00,,,,,,,2699.97,6858.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091384,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091384,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9092805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5404.11000,1567.19000,Aetna,Local,,2161.64,,,,,,,1948.18,4420.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9092805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5404.11000,1567.19000,Aetna,Local,,2161.64,,,,,,,1740.12,4420.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091386,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091386,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LLD ACCESSORY,9091387,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,3026.67000,877.73000,Aetna,Local,,1210.67,,,,,,,1091.11,2475.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LLD ACCESSORY,9091387,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,3026.67000,877.73000,Aetna,Local,,1210.67,,,,,,,974.59,2475.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEVICE LEAD LOCKING,9091388,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,3026.67000,877.73000,Aetna,Local,,1210.67,,,,,,,1091.11,2475.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEVICE LEAD LOCKING,9091388,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,3026.67000,877.73000,Aetna,Local,,1210.67,,,,,,,974.59,2475.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LLD DEVICE,9091389,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,3026.67000,877.73000,Aetna,Local,,1210.67,,,,,,,1091.11,2475.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LLD DEVICE,9091389,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,3026.67000,877.73000,Aetna,Local,,1210.67,,,,,,,974.59,2475.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT ACCESSORY,9091390,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,283.89,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT ACCESSORY,9091390,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,253.57,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9092834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9092834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9092829,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9092829,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.90000,232.55000,Aetna,Local,,320.76,,,,,,,289.08,655.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.90000,232.55000,Aetna,Local,,320.76,,,,,,,258.21,655.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE MINI,9092833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2779.04000,805.92000,Aetna,Local,,1111.62,,,,,,,1001.84,2273.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE MINI,9092833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2779.04000,805.92000,Aetna,Local,,1111.62,,,,,,,894.85,2273.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9094461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2936.00000,851.44000,Aetna,Local,,1174.40,,,,,,,1058.43,2401.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9094461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2936.00000,851.44000,Aetna,Local,,1174.40,,,,,,,945.39,2401.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9094501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9455.34000,2742.05000,Aetna,Local,,3782.14,,,,,,,3408.65,7734.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9094501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9455.34000,2742.05000,Aetna,Local,,3782.14,,,,,,,3044.62,7734.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9094478,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9094478,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESTRICTOR,9094479,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESTRICTOR,9094479,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9094480,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,Local,,11651.76,,,,,,,10501.15,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9094480,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,Local,,11651.76,,,,,,,9379.67,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9094544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9094544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9092831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,671.84,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9092831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,Local,,745.46,,,,,,,600.09,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9092967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9092967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9092970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1603.68,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9092970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.50000,1290.06000,Aetna,Local,,1779.40,,,,,,,1432.42,3638.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9094580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18915.00000,5485.35000,Aetna,Local,,7566.00,,,,,,,6818.86,15472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9094580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18915.00000,5485.35000,Aetna,Local,,7566.00,,,,,,,6090.63,15472.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9094581,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9094581,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091383,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,8385.00000,2431.65000,Aetna,Local,,3354.00,,,,,,,3022.79,6858.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9091383,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,8385.00000,2431.65000,Aetna,Local,,3354.00,,,,,,,2699.97,6858.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9092828,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1392.66,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9092828,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3863.13000,1120.31000,Aetna,Local,,1545.25,,,,,,,1243.93,3160.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE MANDIBLE,9092832,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,18751.75000,5438.01000,Aetna,Local,,7500.70,,,,,,,6760.01,15338.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE MANDIBLE,9092832,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,18751.75000,5438.01000,Aetna,Local,,7500.70,,,,,,,6038.06,15338.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9094458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.90000,232.55000,Aetna,Local,,320.76,,,,,,,289.08,655.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9094458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.90000,232.55000,Aetna,Local,,320.76,,,,,,,258.21,655.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9094460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3790.50000,1099.24000,Aetna,Local,,1516.20,,,,,,,1366.48,3100.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9094460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3790.50000,1099.24000,Aetna,Local,,1516.20,,,,,,,1220.54,3100.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9093007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9093007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9094670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9094670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9094671,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,405.33000,117.55000,Aetna,Local,,162.13,,,,,,,146.12,331.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,9094671,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,405.33000,117.55000,Aetna,Local,,162.13,,,,,,,130.52,331.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9094674,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9094674,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9094675,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9094675,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,Local,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9094677,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10635.00000,3084.15000,Aetna,Local,,4254.00,,,,,,,3833.92,8699.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9094677,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10635.00000,3084.15000,Aetna,Local,,4254.00,,,,,,,3424.47,8699.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094681,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094681,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094682,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,179.80,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094682,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,160.60,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9094683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9094683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,Local,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9094676,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4828.25000,1400.19000,Aetna,Local,,1931.30,,,,,,,1740.58,3949.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9094676,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4828.25000,1400.19000,Aetna,Local,,1931.30,,,,,,,1554.70,3949.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9093072,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9093072,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9093073,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9093073,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094763,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1457.00000,422.53000,Aetna,Local,,582.80,,,,,,,525.25,1191.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094763,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1457.00000,422.53000,Aetna,Local,,582.80,,,,,,,469.15,1191.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9094764,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9094764,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE W SIPHONGUARD,7917826,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,15615.75000,4528.57000,Aetna,Local,,6246.30,,,,,,,5629.48,12773.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE W SIPHONGUARD,7917826,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,15615.75000,4528.57000,Aetna,Local,,6246.30,,,,,,,5028.27,12773.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESTRICTOR,9048626,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESTRICTOR,9048626,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9094883,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9094883,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,Local,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093184,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4088.00000,1185.52000,Aetna,Local,,1635.20,,,,,,,1473.72,3343.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093184,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4088.00000,1185.52000,Aetna,Local,,1635.20,,,,,,,1316.34,3343.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9086253,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9086253,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT COLLAR,9094837,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT COLLAR,9094837,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9094882,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9094882,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING,9094884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING,9094884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8366494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2264.53,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8366494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6281.63000,1821.67000,Aetna,Local,,2512.65,,,,,,,2022.68,5138.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9093190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9093190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,9094817,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3056.00000,886.24000,Aetna,Local,,1222.40,,,,,,,1101.69,2499.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,9094817,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3056.00000,886.24000,Aetna,Local,,1222.40,,,,,,,984.03,2499.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAM,9094818,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11625.00000,3371.25000,Aetna,Local,,4650.00,,,,,,,4190.81,9509.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAM,9094818,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11625.00000,3371.25000,Aetna,Local,,4650.00,,,,,,,3743.25,9509.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093197,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,314.23,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093197,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,280.67,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093198,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,314.23,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093198,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,280.67,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093199,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,314.23,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093199,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,871.65000,252.78000,Aetna,Local,,348.66,,,,,,,280.67,713.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4676.00000,1356.04000,Aetna,Local,,1870.40,,,,,,,1685.70,3824.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4676.00000,1356.04000,Aetna,Local,,1870.40,,,,,,,1505.67,3824.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094838,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4676.00000,1356.04000,Aetna,Local,,1870.40,,,,,,,1685.70,3824.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094838,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4676.00000,1356.04000,Aetna,Local,,1870.40,,,,,,,1505.67,3824.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR LINER,9094898,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR LINER,9094898,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENET,9094899,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1925.04000,558.26000,Aetna,Local,,770.02,,,,,,,693.98,1574.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENET,9094899,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1925.04000,558.26000,Aetna,Local,,770.02,,,,,,,619.86,1574.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL SLEEVE,9094897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30026.25000,8707.61000,Aetna,Local,,12010.50,,,,,,,10824.46,24561.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL SLEEVE,9094897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30026.25000,8707.61000,Aetna,Local,,12010.50,,,,,,,9668.45,24561.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR SHELL,9094896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13716.60000,3977.81000,Aetna,Local,,5486.64,,,,,,,4944.83,11220.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR SHELL,9094896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13716.60000,3977.81000,Aetna,Local,,5486.64,,,,,,,4416.75,11220.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9094880,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9094880,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9094779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,Local,,965.60,,,,,,,870.25,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9094779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,Local,,965.60,,,,,,,777.31,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9094819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9094819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9094961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,651.38000,188.90000,Aetna,Local,,260.55,,,,,,,234.82,532.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9094961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,651.38000,188.90000,Aetna,Local,,260.55,,,,,,,209.74,532.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9094962,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,570.38000,165.41000,Aetna,Local,,228.15,,,,,,,205.62,466.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9094962,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,570.38000,165.41000,Aetna,Local,,228.15,,,,,,,183.66,466.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088691,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,525.09,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9088691,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,Local,,582.62,,,,,,,469.01,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8999061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2092.00000,606.68000,Aetna,Local,,836.80,,,,,,,754.17,1711.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8999061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2092.00000,606.68000,Aetna,Local,,836.80,,,,,,,673.62,1711.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING TIBIAL,9092969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING TIBIAL,9092969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9098366,CDM,278,RC,C1817,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9098366,CDM,278,RC,C1817,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9094877,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,5320.00000,1542.80000,Aetna,Local,,2128.00,,,,,,,1917.86,4351.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9094877,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,5320.00000,1542.80000,Aetna,Local,,2128.00,,,,,,,1713.04,4351.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9094878,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9094878,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9094879,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9094879,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9094881,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9094881,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095000,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095000,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095001,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095001,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095003,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095003,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9093359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5390.00000,1563.10000,Aetna,Local,,2156.00,,,,,,,1943.10,4409.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9093359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5390.00000,1563.10000,Aetna,Local,,2156.00,,,,,,,1735.58,4409.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095019,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,11247.00000,3261.63000,Aetna,Local,,4498.80,,,,,,,4054.54,9200.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095019,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,11247.00000,3261.63000,Aetna,Local,,4498.80,,,,,,,3621.53,9200.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAROTID CATHETER,9095008,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,14217.00000,4122.93000,Aetna,Local,,5686.80,,,,,,,5125.23,11629.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAROTID CATHETER,9095008,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,14217.00000,4122.93000,Aetna,Local,,5686.80,,,,,,,4577.87,11629.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDE CATHETER,9095020,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,347.61000,100.81000,Aetna,Local,,139.04,,,,,,,125.31,284.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDE CATHETER,9095020,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,347.61000,100.81000,Aetna,Local,,139.04,,,,,,,111.93,284.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK CATHETER,9095021,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOOK CATHETER,9095021,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,Local,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095022,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,309.46000,89.74000,Aetna,Local,,123.78,,,,,,,111.56,253.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095022,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,309.46000,89.74000,Aetna,Local,,123.78,,,,,,,99.65,253.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095023,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,309.46000,89.74000,Aetna,Local,,123.78,,,,,,,111.56,253.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095023,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,309.46000,89.74000,Aetna,Local,,123.78,,,,,,,99.65,253.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095024,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095024,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,711.58,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1973.88000,572.43000,Aetna,Local,,789.55,,,,,,,635.59,1614.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,9093360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,Local,,832.00,,,,,,,749.84,1701.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,9093360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,Local,,832.00,,,,,,,669.76,1701.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,9095028,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,9095028,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9095005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9095005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,Local,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9095006,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9095006,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,9095007,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,9095007,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,Local,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9094889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5120.50000,1484.94000,Aetna,Local,,2048.20,,,,,,,1845.94,4188.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9094889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5120.50000,1484.94000,Aetna,Local,,2048.20,,,,,,,1648.80,4188.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9094890,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5390.00000,1563.10000,Aetna,Local,,2156.00,,,,,,,1943.10,4409.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9094890,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5390.00000,1563.10000,Aetna,Local,,2156.00,,,,,,,1735.58,4409.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094892,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094892,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9095004,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1220.74,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9095004,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1090.37,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9093446,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8449.50000,2450.36000,Aetna,Local,,3379.80,,,,,,,3046.04,6911.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9093446,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8449.50000,2450.36000,Aetna,Local,,3379.80,,,,,,,2720.74,6911.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL INSERT,9093447,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL INSERT,9093447,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095002,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9095002,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9046200,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9046200,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9046201,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,7029.75,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9046201,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,6279.00,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9093628,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5530.00000,1603.70000,Aetna,Local,,2212.00,,,,,,,1993.57,4523.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9093628,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5530.00000,1603.70000,Aetna,Local,,9357.00,,,,,,,1780.66,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9093629,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5768.00000,1672.72000,Aetna,Local,,2307.20,,,,,,,2079.36,4718.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9093629,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5768.00000,1672.72000,Aetna,Local,,9357.00,,,,,,,1857.30,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9093840,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,5530.00000,1603.70000,Aetna,Local,,2212.00,,,,,,,1993.57,4523.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9093840,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,5530.00000,1603.70000,Aetna,Local,,9357.00,,,,,,,1780.66,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SCREW,9101005,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9101005,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9101064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1220.74,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9101064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3386.25000,982.01000,Aetna,Local,,1354.50,,,,,,,1090.37,2769.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9101065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9101065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9101066,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,9101066,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9099399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3024.48000,877.10000,Aetna,Local,,1209.79,,,,,,,1090.33,2474.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9099399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3024.48000,877.10000,Aetna,Local,,1209.79,,,,,,,973.88,2474.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9099400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14670.00000,4254.30000,Aetna,Local,,5868.00,,,,,,,5288.53,12000.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9099400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14670.00000,4254.30000,Aetna,Local,,5868.00,,,,,,,4723.74,12000.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNAR,9099401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ULNAR,9099401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9101112,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9101112,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,Local,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9101113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,9101113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9101114,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9101114,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9101115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9101115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9101116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9101116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9101117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9101117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9101118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9101118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9101119,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,943.76,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9101119,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,842.97,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9101129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9101129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9101131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,839.97,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9101131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,750.26,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID COMPONENT,9101132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID COMPONENT,9101132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL SYSTEM,9101133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17100.00000,4959.00000,Aetna,Local,,6840.00,,,,,,,6164.55,13987.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL SYSTEM,9101133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17100.00000,4959.00000,Aetna,Local,,6840.00,,,,,,,5506.20,13987.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9101134,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9101134,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT TRANSCAROTID,9101135,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT TRANSCAROTID,9101135,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMUR PROSTHESIS,9103526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMUR PROSTHESIS,9103526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,9103527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5029.50000,1458.55000,Aetna,Local,,2011.80,,,,,,,1813.13,4114.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,9103527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5029.50000,1458.55000,Aetna,Local,,2011.80,,,,,,,1619.50,4114.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9103528,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4078.31000,1182.71000,Aetna,Local,,1631.32,,,,,,,1470.23,3336.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9103528,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4078.31000,1182.71000,Aetna,Local,,1631.32,,,,,,,1313.22,3336.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRUNNION 45MM,9103529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.09000,2492.58000,Aetna,Local,,3438.04,,,,,,,3098.53,7030.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRUNNION 45MM,9103529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.09000,2492.58000,Aetna,Local,,3438.04,,,,,,,2767.62,7030.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9103530,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,7018.94,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9103530,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,6269.34,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9103531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8382.00000,2430.78000,Aetna,Local,,3352.80,,,,,,,3021.71,6856.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9103531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8382.00000,2430.78000,Aetna,Local,,3352.80,,,,,,,2699.00,6856.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9103532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9103532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9103533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9103533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9103534,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9103534,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9101267,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9101267,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9101268,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,6646.72,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9101268,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18437.50000,5346.88000,Aetna,Local,,7375.00,,,,,,,5936.88,15081.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9101269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9101269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9101270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW,9101270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9101271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9101271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9101272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9101272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9101273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1165.86,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9101273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3234.00000,937.86000,Aetna,Local,,1293.60,,,,,,,1041.35,2645.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SHOCKWAVE,9093507,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4542.30,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SHOCKWAVE,9093507,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4057.20,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SHOCKWAVE,9093508,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4542.30,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SHOCKWAVE,9093508,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,12600.00000,3654.00000,Aetna,Local,,5040.00,,,,,,,4057.20,10306.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9101313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9101313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9101314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW COMPRESSION,9101314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9101315,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9101315,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,9101316,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13596.00000,3942.84000,Aetna,Local,,5438.40,,,,,,,4901.36,11121.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DISTAL,9101316,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13596.00000,3942.84000,Aetna,Local,,5438.40,,,,,,,4377.91,11121.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING ACETABULAR,9101311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1533.03,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING ACETABULAR,9101311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4252.50000,1233.22000,Aetna,Local,,1701.00,,,,,,,1369.31,3478.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9101312,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9101312,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CVAC ASPIRATOR SYS,9101531,CDM,278,RC,C1747,HCPCS,,,facility,inpatient,,,12735.00000,3693.15000,Aetna,Local,,5094.00,,,,,,,4590.97,10417.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CVAC ASPIRATOR SYS,9101531,CDM,278,RC,C1747,HCPCS,,,facility,outpatient,,,12735.00000,3693.15000,Aetna,Local,,5094.00,,,,,,,4100.67,10417.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9101365,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9101365,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9103708,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9103708,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9103709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9103709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9103707,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9103707,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9101292,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,19478.25000,5648.69000,Aetna,Local,,7791.30,,,,,,,7021.91,15933.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9101292,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,19478.25000,5648.69000,Aetna,Local,,7791.30,,,,,,,6272.00,15933.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,9104149,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,9104149,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,9104150,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,9104150,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INLAY,9104151,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INLAY,9104151,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9104153,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9104153,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,Local,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9104154,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,4346.82,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9104154,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12057.75000,3496.75000,Aetna,Local,,4823.10,,,,,,,3882.60,9863.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FEMUR,9104155,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16255.00000,4713.95000,Aetna,Local,,6502.00,,,,,,,5859.93,13296.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE FEMUR,9104155,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16255.00000,4713.95000,Aetna,Local,,6502.00,,,,,,,5234.11,13296.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9104156,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9104156,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9104157,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9104157,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,Local,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTEX,9104160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTEX,9104160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9104161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,9104161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6240.50000,1809.74000,Aetna,Local,,2496.20,,,,,,,2249.70,5104.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6240.50000,1809.74000,Aetna,Local,,2496.20,,,,,,,2009.44,5104.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9104407,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2477.00000,718.33000,Aetna,Local,,990.80,,,,,,,892.96,2026.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,9104407,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2477.00000,718.33000,Aetna,Local,,990.80,,,,,,,797.59,2026.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9104408,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9104408,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9104217,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9723.00000,2819.67000,Aetna,Local,,3889.20,,,,,,,3505.14,7953.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9104217,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9723.00000,2819.67000,Aetna,Local,,3889.20,,,,,,,3130.81,7953.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9104218,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9104218,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9104219,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9104219,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9104415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,236.04,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9104415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,654.75000,189.88000,Aetna,Local,,261.90,,,,,,,210.83,535.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9104416,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,3098.50,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9104416,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,Local,,3438.00,,,,,,,2767.59,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9104458,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9104458,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9104459,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9104459,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104461,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104461,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104462,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5540.50000,1606.74000,Aetna,Local,,2216.20,,,,,,,1997.35,4532.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104462,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5540.50000,1606.74000,Aetna,Local,,2216.20,,,,,,,1784.04,4532.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16255.00000,4713.95000,Aetna,Local,,6502.00,,,,,,,5859.93,13296.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16255.00000,4713.95000,Aetna,Local,,6502.00,,,,,,,5234.11,13296.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104466,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104466,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9094663,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,908.10,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9094663,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,811.12,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9104580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9104580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,Local,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9104594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,2209.32,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL TIBIAL,9104594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6128.50000,1777.26000,Aetna,Local,,2451.40,,,,,,,1973.38,5013.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,943.76,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2617.92000,759.20000,Aetna,Local,,1047.17,,,,,,,842.97,2141.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9104629,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VERTEBRAL PROSTHESIS,9104629,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9104630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,7018.94,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9104630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,6269.34,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104636,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5266.80000,1527.37000,Aetna,Local,,2106.72,,,,,,,1898.68,4308.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104636,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5266.80000,1527.37000,Aetna,Local,,2106.72,,,,,,,1695.91,4308.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PUMP,9104628,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,45663.75000,13242.49000,Aetna,Local,,18265.50,,,,,,,16461.78,37352.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PUMP,9104628,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,45663.75000,13242.49000,Aetna,Local,,18265.50,,,,,,,14703.73,37352.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PUMP KIT,9104627,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1703.36,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PUMP KIT,9104627,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,4725.00000,1370.25000,Aetna,Local,,1890.00,,,,,,,1521.45,3865.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104673,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104673,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9104674,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9104674,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9106475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9106475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9106476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9106476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9106477,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9106477,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL PRIME,9106479,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL PRIME,9106479,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9106480,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9106480,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,Local,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9012704,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,3212.05,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9012704,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,2869.02,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,9104730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2404.00000,697.16000,Aetna,Local,,961.60,,,,,,,866.64,1966.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR SUTURE,9104730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,961.60,,,,,,,774.09,1966.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9104731,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9104731,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9104732,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9104732,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108393,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108393,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE EASYFUSE,9010164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8634.00000,2503.86000,Aetna,Local,,3453.60,,,,,,,3112.56,7062.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE EASYFUSE,9010164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8634.00000,2503.86000,Aetna,Local,,3453.60,,,,,,,2780.15,7062.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER LASER,9005676,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,11247.00000,3261.63000,Aetna,Local,,4498.80,,,,,,,4054.54,9200.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER LASER,9005676,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,11247.00000,3261.63000,Aetna,Local,,4498.80,,,,,,,3621.53,9200.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER LASER,9005677,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,11247.00000,3261.63000,Aetna,Local,,4498.80,,,,,,,4054.54,9200.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER LASER,9005677,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,11247.00000,3261.63000,Aetna,Local,,4498.80,,,,,,,3621.53,9200.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER LASER,9005678,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,11247.00000,3261.63000,Aetna,Local,,4498.80,,,,,,,4054.54,9200.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER LASER,9005678,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,11247.00000,3261.63000,Aetna,Local,,4498.80,,,,,,,3621.53,9200.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER LASER,9005679,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,11247.00000,3261.63000,Aetna,Local,,4498.80,,,,,,,4054.54,9200.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER LASER,9005679,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,11247.00000,3261.63000,Aetna,Local,,4498.80,,,,,,,3621.53,9200.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9021126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16237.50000,4708.88000,Aetna,Local,,6495.00,,,,,,,5853.62,13282.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9021126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16237.50000,4708.88000,Aetna,Local,,6495.00,,,,,,,5228.48,13282.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER HUMERAL,9056621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1811.62,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER HUMERAL,9056621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5025.30000,1457.34000,Aetna,Local,,2010.12,,,,,,,1618.15,4110.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080350,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,598.43,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CORTICAL,9080350,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,664.00,,,,,,,534.52,1357.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9091160,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9091160,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT HUMERUS,9094313,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,29335.50000,8507.30000,Aetna,Local,,11734.20,,,,,,,10575.45,23996.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT HUMERUS,9094313,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,29335.50000,8507.30000,Aetna,Local,,11734.20,,,,,,,9446.03,23996.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8997060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,8997060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9010895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,9050225,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,9050225,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1065.02,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9060537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9060537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT PSN ASF,9076188,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT PSN ASF,9076188,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINE ACETABULAR,9080349,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINE ACETABULAR,9080349,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9083638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9083638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9104736,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,Local,,33.60,,,,,,,30.28,68.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9104736,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,33.60,,,,,,,27.05,68.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9108403,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9108403,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104804,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2770.80000,803.53000,Aetna,Local,,1108.32,,,,,,,998.87,2266.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104804,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2770.80000,803.53000,Aetna,Local,,1108.32,,,,,,,892.20,2266.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3012.88000,873.74000,Aetna,Local,,1205.15,,,,,,,1086.14,2464.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3012.88000,873.74000,Aetna,Local,,1205.15,,,,,,,970.15,2464.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9108398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL LONG,9108398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9104823,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9104823,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9104824,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9104824,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT RADIAL,9108483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2812.98,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT RADIAL,9108483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,Local,,3121.20,,,,,,,2512.57,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,Local,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,309.85,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,276.76,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,261.39,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,Local,,290.04,,,,,,,233.48,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9104859,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9104859,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,309.85,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,276.76,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104851,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104851,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,Local,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Screw,9104856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Screw,9104856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16255.00000,4713.95000,Aetna,Local,,6502.00,,,,,,,5859.93,13296.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16255.00000,4713.95000,Aetna,Local,,6502.00,,,,,,,5234.11,13296.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104865,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104865,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104867,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104867,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108598,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,201.16,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108598,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,179.68,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108599,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,201.16,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108599,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,179.68,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9104953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9894.00000,2869.26000,Aetna,Local,,3957.60,,,,,,,3566.79,8093.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9104953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9894.00000,2869.26000,Aetna,Local,,3957.60,,,,,,,3185.87,8093.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT TIBIAL,9108632,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4963.00000,1439.27000,Aetna,Local,,1985.20,,,,,,,1789.16,4059.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT TIBIAL,9108632,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4963.00000,1439.27000,Aetna,Local,,1985.20,,,,,,,1598.09,4059.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9104954,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9104954,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9104956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9104956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9104957,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9104957,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9104958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9104958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9104959,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9104959,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1962.02,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9104960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1752.48,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1356.00000,393.24000,Aetna,Local,,542.40,,,,,,,488.84,1109.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1356.00000,393.24000,Aetna,Local,,542.40,,,,,,,436.63,1109.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR GRAFT,9108634,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,6123.99,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR GRAFT,9108634,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,Local,,6795.00,,,,,,,5469.98,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104994,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9104994,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,Local,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108685,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108685,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108686,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108686,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,9108688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,9108688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9108689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9108689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9108690,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9108690,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,9108691,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE PIN,9108691,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108692,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,309.85,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108692,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,276.76,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108700,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108700,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108694,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108694,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108701,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108701,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108702,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108702,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108703,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,6308.75,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108703,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17500.00000,5075.00000,Aetna,Local,,7000.00,,,,,,,5635.00,14315.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,Local,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9108687,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17725.00000,5140.25000,Aetna,Local,,7090.00,,,,,,,6389.86,14499.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9108687,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17725.00000,5140.25000,Aetna,Local,,7090.00,,,,,,,5707.45,14499.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9105022,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9105022,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9114686,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9114686,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9110106,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9110106,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9116392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.00000,1121.43000,Aetna,Local,,1546.80,,,,,,,1394.05,3163.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9116392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.00000,1121.43000,Aetna,Local,,1546.80,,,,,,,1245.17,3163.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9116414,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,13776.00000,3995.04000,Aetna,Local,,5510.40,,,,,,,4966.25,11268.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9116414,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,13776.00000,3995.04000,Aetna,Local,,5510.40,,,,,,,4435.87,11268.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9116416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9116416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9116415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1134.13,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9116415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3146.00000,912.34000,Aetna,Local,,1258.40,,,,,,,1013.01,2573.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9114752,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9114752,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL SHELL,9114810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,3298.57,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL SHELL,9114810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,Local,,3660.00,,,,,,,2946.30,7484.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9114811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9114811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ARTICULARTING SURFACE,9116537,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ARTICULARTING SURFACE,9116537,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9116492,CDM,278,RC,C1817,HCPCS,,,facility,inpatient,,,29351.25000,8511.86000,Aetna,Local,,11740.50,,,,,,,10581.13,24009.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9116492,CDM,278,RC,C1817,HCPCS,,,facility,outpatient,,,29351.25000,8511.86000,Aetna,Local,,11740.50,,,,,,,9451.10,24009.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9116493,CDM,278,RC,C1817,HCPCS,,,facility,inpatient,,,29351.25000,8511.86000,Aetna,Local,,11740.50,,,,,,,10581.13,24009.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9116493,CDM,278,RC,C1817,HCPCS,,,facility,outpatient,,,29351.25000,8511.86000,Aetna,Local,,11740.50,,,,,,,9451.10,24009.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9110107,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,36816.75000,10676.86000,Aetna,Local,,14726.70,,,,,,,13272.44,30116.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9110107,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,36816.75000,10676.86000,Aetna,Local,,14726.70,,,,,,,11854.99,30116.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116394,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116394,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116395,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116395,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116396,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116396,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116397,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116397,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116398,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116398,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116399,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116399,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116400,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116400,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116401,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116401,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116402,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116402,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116403,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116403,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116404,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116404,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116405,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116405,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116406,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116406,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116407,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116407,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116408,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5691.39,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116408,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15787.50000,4578.38000,Aetna,Local,,6315.00,,,,,,,5083.57,12914.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116409,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21687.50000,6289.38000,Aetna,Local,,8675.00,,,,,,,7818.34,17740.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116409,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21687.50000,6289.38000,Aetna,Local,,8675.00,,,,,,,6983.38,17740.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116410,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21687.50000,6289.38000,Aetna,Local,,8675.00,,,,,,,7818.34,17740.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116410,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21687.50000,6289.38000,Aetna,Local,,8675.00,,,,,,,6983.38,17740.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116411,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21687.50000,6289.38000,Aetna,Local,,8675.00,,,,,,,7818.34,17740.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116411,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21687.50000,6289.38000,Aetna,Local,,8675.00,,,,,,,6983.38,17740.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VAVLE,9116412,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21687.50000,6289.38000,Aetna,Local,,8675.00,,,,,,,7818.34,17740.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VAVLE,9116412,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21687.50000,6289.38000,Aetna,Local,,8675.00,,,,,,,6983.38,17740.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116413,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21687.50000,6289.38000,Aetna,Local,,8675.00,,,,,,,7818.34,17740.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,9116413,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21687.50000,6289.38000,Aetna,Local,,8675.00,,,,,,,6983.38,17740.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9116494,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9116494,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,Local,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT,9116495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT,9116495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,Local,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,9116655,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3594.15000,1042.30000,Aetna,Local,,1437.66,,,,,,,1295.69,2940.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,9116655,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3594.15000,1042.30000,Aetna,Local,,1437.66,,,,,,,1157.32,2940.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9116661,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9116661,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9114979,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,7609.00000,2206.61000,Aetna,Local,,3043.60,,,,,,,2743.04,6224.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9114979,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,7609.00000,2206.61000,Aetna,Local,,3043.60,,,,,,,2450.10,6224.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9114980,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.00000,559.99000,Aetna,Local,,772.40,,,,,,,696.13,1579.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9114980,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.00000,559.99000,Aetna,Local,,772.40,,,,,,,621.78,1579.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9116670,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,Local,,1066.40,,,,,,,961.09,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9116670,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,Local,,1066.40,,,,,,,858.45,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9116797,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9116797,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,9116796,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,9116796,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,9116795,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,9116795,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,Local,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9115103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10719.00000,3108.51000,Aetna,Local,,4287.60,,,,,,,3864.20,8768.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9115103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10719.00000,3108.51000,Aetna,Local,,4287.60,,,,,,,3451.52,8768.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115105,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2436.00000,706.44000,Aetna,Local,,974.40,,,,,,,878.18,1992.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115105,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2436.00000,706.44000,Aetna,Local,,974.40,,,,,,,784.39,1992.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9115107,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9115107,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,Local,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,9115108,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,9115108,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,Local,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9116835,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9116835,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9116836,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9116836,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115104,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,309.85,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115104,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,859.50000,249.26000,Aetna,Local,,343.80,,,,,,,276.76,703.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
UROLIFT 2,9056981,CDM,278,RC,C9739,HCPCS,,,facility,inpatient,,,5075.00000,1471.75000,Aetna,Local,,2030.00,,,,,,,1829.54,4151.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
UROLIFT 2,9056981,CDM,278,RC,C9739,HCPCS,,,facility,outpatient,,,5075.00000,1471.75000,Aetna,Local,,3456.00,,,,,,,1634.15,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
UROLIFT,8916347,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1640.28,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
UROLIFT,8916347,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4550.00000,1319.50000,Aetna,Local,,1820.00,,,,,,,1465.10,3721.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOBRACE,9116838,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,16997.50000,4929.27000,Aetna,Local,,6799.00,,,,,,,6127.60,13903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOBRACE,9116838,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,16997.50000,4929.27000,Aetna,Local,,6799.00,,,,,,,5473.19,13903.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,9114812,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,730.35000,211.80000,Aetna,Local,,292.14,,,,,,,263.29,597.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,9114812,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,730.35000,211.80000,Aetna,Local,,292.14,,,,,,,235.17,597.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,9116503,CDM,278,RC,,,,,facility,inpatient,,,625.05000,181.26000,Aetna,Local,,250.02,,,,,,,225.33,511.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,9116503,CDM,278,RC,,,,,facility,outpatient,,,625.05000,181.26000,Aetna,Local,,250.02,,,,,,,201.27,511.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115182,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115182,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1635.23,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4536.00000,1315.44000,Aetna,Local,,1814.40,,,,,,,1460.59,3710.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115184,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115184,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,9108707,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,7596.00000,2202.84000,Aetna,Local,,3038.40,,,,,,,2738.36,6213.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,9108707,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,7596.00000,2202.84000,Aetna,Local,,3038.40,,,,,,,2445.91,6213.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108758,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8254.80000,2393.89000,Aetna,Local,,3301.92,,,,,,,2975.86,6752.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108758,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8254.80000,2393.89000,Aetna,Local,,3301.92,,,,,,,2658.05,6752.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108760,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108760,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108761,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9108761,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,Local,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108762,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1290.14,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108762,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1152.36,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANTABLE TISSUE MARKER,9011866,CDM,278,RC,A4648,HCPCS,,,facility,inpatient,,,93.66000,27.16000,Aetna,Local,,37.46,,,,,,,33.76,76.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANTABLE TISSUE MARKER,9011866,CDM,278,RC,A4648,HCPCS,,,facility,outpatient,,,93.66000,27.16000,Aetna,Local,,37.46,,,,,,,30.16,76.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9105164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9105164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,Local,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9108784,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9108784,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4238.50000,1229.16000,Aetna,Local,,1695.40,,,,,,,1527.98,3467.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4238.50000,1229.16000,Aetna,Local,,1695.40,,,,,,,1364.80,3467.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5715.50000,1657.50000,Aetna,Local,,2286.20,,,,,,,2060.44,4675.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5715.50000,1657.50000,Aetna,Local,,2286.20,,,,,,,1840.39,4675.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108789,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3296.76000,956.06000,Aetna,Local,,1318.70,,,,,,,1188.48,2696.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9108789,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3296.76000,956.06000,Aetna,Local,,1318.70,,,,,,,1061.56,2696.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105112,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105112,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105113,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105113,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105114,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105114,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105115,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105115,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105116,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105116,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105117,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105117,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,Local,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3460.80,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3091.20,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105119,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3460.80,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105119,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3091.20,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105120,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3460.80,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9105120,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3091.20,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9108755,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3460.80,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9108755,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3091.20,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9108756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3460.80,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9108756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,Local,,3840.00,,,,,,,3091.20,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9105247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5539.91000,1606.57000,Aetna,Local,,2215.96,,,,,,,1997.14,4531.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE TIBIAL,9105247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5539.91000,1606.57000,Aetna,Local,,2215.96,,,,,,,1783.85,4531.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9105248,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9105248,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,Local,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9105331,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3024.48000,877.10000,Aetna,Local,,1209.79,,,,,,,1090.33,2474.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9105331,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3024.48000,877.10000,Aetna,Local,,1209.79,,,,,,,973.88,2474.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9105335,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9105335,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9105353,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9105353,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9105354,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9105354,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,9105355,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8676.00000,2516.04000,Aetna,Local,,3470.40,,,,,,,3127.70,7096.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,9105355,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8676.00000,2516.04000,Aetna,Local,,3470.40,,,,,,,2793.67,7096.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9105356,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9105356,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9105336,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2936.00000,851.44000,Aetna,Local,,1174.40,,,,,,,1058.43,2401.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9105336,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2936.00000,851.44000,Aetna,Local,,1174.40,,,,,,,945.39,2401.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,801.90000,232.55000,Aetna,Local,,320.76,,,,,,,289.08,655.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9108940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,801.90000,232.55000,Aetna,Local,,320.76,,,,,,,258.21,655.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9105362,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9105362,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9105358,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9105358,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9105361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9105361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9105360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,3018.47,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9105360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8373.00000,2428.17000,Aetna,Local,,3349.20,,,,,,,2696.11,6849.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,9105434,CDM,278,RC,C2622,HCPCS,,,facility,inpatient,,,56810.00000,16474.90000,Aetna,Local,,22724.00,,,,,,,20480.01,46470.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,9105434,CDM,278,RC,C2622,HCPCS,,,facility,outpatient,,,56810.00000,16474.90000,Aetna,Local,,22724.00,,,,,,,18292.82,46470.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,9109055,CDM,278,RC,C2622,HCPCS,,,facility,inpatient,,,56810.00000,16474.90000,Aetna,Local,,22724.00,,,,,,,20480.01,46470.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,9109055,CDM,278,RC,C2622,HCPCS,,,facility,outpatient,,,56810.00000,16474.90000,Aetna,Local,,22724.00,,,,,,,18292.82,46470.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9109056,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,6300.00000,1827.00000,Aetna,Local,,2520.00,,,,,,,2271.15,5153.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9109056,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,6300.00000,1827.00000,Aetna,Local,,2520.00,,,,,,,2028.60,5153.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9109061,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,Local,,2471.00,,,,,,,2226.99,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9109061,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,Local,,2471.00,,,,,,,1989.15,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9109062,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9109062,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9109063,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9109063,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9109064,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL STEM,9109064,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9109065,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,893.46,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9109065,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2478.40000,718.74000,Aetna,Local,,991.36,,,,,,,798.04,2027.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9109067,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17357.50000,5033.67000,Aetna,Local,,6943.00,,,,,,,6257.38,14198.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9109067,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17357.50000,5033.67000,Aetna,Local,,6943.00,,,,,,,5589.11,14198.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9105357,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9105357,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9105359,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9105359,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH GUIDING,9109114,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1802.68000,522.78000,Aetna,Local,,721.07,,,,,,,649.87,1474.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH GUIDING,9109114,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1802.68000,522.78000,Aetna,Local,,721.07,,,,,,,580.46,1474.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9109115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5979.82000,1734.15000,Aetna,Local,,2391.93,,,,,,,2155.73,4891.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9109115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5979.82000,1734.15000,Aetna,Local,,2391.93,,,,,,,1925.50,4891.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9112392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5835.87000,1692.40000,Aetna,Local,,2334.35,,,,,,,2103.83,4773.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9112392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5835.87000,1692.40000,Aetna,Local,,2334.35,,,,,,,1879.15,4773.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9112393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9112393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9112394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9112394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,Local,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9109167,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9109167,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9109168,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9109168,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9109169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9109169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9109170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9109170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9109171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9109171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9112469,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9112469,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,9357.00,,,,,,,3332.70,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
KNEE WEDGE,9109423,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE WEDGE,9109423,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE WEDGE,9112483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1718.50,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE WEDGE,9112483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4767.00000,1382.43000,Aetna,Local,,1906.80,,,,,,,1534.97,3899.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9112484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9112484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9112485,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9112485,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9112492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9112492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9112493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9112493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,Local,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID TAP,9109428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID TAP,9109428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER KIT,9109429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10410.00000,3018.90000,Aetna,Local,,4164.00,,,,,,,3752.80,8515.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER KIT,9109429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10410.00000,3018.90000,Aetna,Local,,4164.00,,,,,,,3352.02,8515.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRYO PROBE,9091656,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,9900.00000,2871.00000,Aetna,Local,,3960.00,,,,,,,3568.95,8098.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRYO PROBE,9091656,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,9900.00000,2871.00000,Aetna,Local,,3960.00,,,,,,,3187.80,8098.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9109495,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12231.00000,3546.99000,Aetna,Local,,4892.40,,,,,,,4409.28,10004.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9109495,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12231.00000,3546.99000,Aetna,Local,,4892.40,,,,,,,3938.38,10004.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9114430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12231.00000,3546.99000,Aetna,Local,,4892.40,,,,,,,4409.28,10004.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9114430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12231.00000,3546.99000,Aetna,Local,,4892.40,,,,,,,3938.38,10004.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,Local,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9109496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,878.67000,254.81000,Aetna,Local,,351.47,,,,,,,316.76,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9109496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,878.67000,254.81000,Aetna,Local,,351.47,,,,,,,282.93,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9109508,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9109508,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9114457,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,9114457,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,Local,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9114458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9114458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,Local,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9114459,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9114459,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9114463,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9114463,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIP,9114504,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3832.50000,1111.42000,Aetna,Local,,1533.00,,,,,,,1381.62,3134.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CHIP,9114504,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3832.50000,1111.42000,Aetna,Local,,1533.00,,,,,,,1234.07,3134.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9109539,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15676.38000,4546.15000,Aetna,Local,,6270.55,,,,,,,5651.33,12823.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9109539,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15676.38000,4546.15000,Aetna,Local,,6270.55,,,,,,,5047.79,12823.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9109538,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15676.38000,4546.15000,Aetna,Local,,6270.55,,,,,,,5651.33,12823.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9109538,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15676.38000,4546.15000,Aetna,Local,,6270.55,,,,,,,5047.79,12823.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9114470,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16956.28000,4917.32000,Aetna,Local,,6782.51,,,,,,,6112.74,13870.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9114470,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16956.28000,4917.32000,Aetna,Local,,6782.51,,,,,,,5459.92,13870.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9114471,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16956.28000,4917.32000,Aetna,Local,,6782.51,,,,,,,6112.74,13870.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9114471,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16956.28000,4917.32000,Aetna,Local,,6782.51,,,,,,,5459.92,13870.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9109542,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9109542,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9114472,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16956.28000,4917.32000,Aetna,Local,,6782.51,,,,,,,6112.74,13870.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9114472,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16956.28000,4917.32000,Aetna,Local,,6782.51,,,,,,,5459.92,13870.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969878,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,4284.00000,1242.36000,Aetna,Local,,1713.60,,,,,,,1544.38,3504.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7969878,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,4284.00000,1242.36000,Aetna,Local,,1713.60,,,,,,,1379.45,3504.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINE SEALANT,8366683,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,3000.00000,870.00000,Aetna,Local,,1200.00,,,,,,,1081.50,2454.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINE SEALANT,8366683,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,3000.00000,870.00000,Aetna,Local,,1200.00,,,,,,,966.00,2454.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9109991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1511.00000,438.19000,Aetna,Local,,604.40,,,,,,,544.72,1236.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9109991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1511.00000,438.19000,Aetna,Local,,604.40,,,,,,,486.54,1236.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATOR,9109992,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1514.64000,439.25000,Aetna,Local,,605.86,,,,,,,546.03,1238.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATOR,9109992,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1514.64000,439.25000,Aetna,Local,,605.86,,,,,,,487.71,1238.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9114583,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9114583,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9110015,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9110015,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114589,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1955.00000,566.95000,Aetna,Local,,782.00,,,,,,,704.78,1599.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114589,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1955.00000,566.95000,Aetna,Local,,782.00,,,,,,,629.51,1599.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114594,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4882.50000,1415.92000,Aetna,Local,,1953.00,,,,,,,1760.14,3993.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114594,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4882.50000,1415.92000,Aetna,Local,,1953.00,,,,,,,1572.16,3993.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9110038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9110038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9110037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9110037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR CLOSURE,9114590,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1360.00000,394.40000,Aetna,Local,,544.00,,,,,,,490.28,1112.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR CLOSURE,9114590,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1360.00000,394.40000,Aetna,Local,,544.00,,,,,,,437.92,1112.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE ANCHOR,9114582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5362.88000,1555.24000,Aetna,Local,,2145.15,,,,,,,1933.32,4386.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE ANCHOR,9114582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5362.88000,1555.24000,Aetna,Local,,2145.15,,,,,,,1726.85,4386.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9110039,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,530.66,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9110039,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,473.98,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETHRAL,9110040,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,530.66,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETHRAL,9110040,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,473.98,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETHRAL,9110041,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,530.66,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH URETHRAL,9110041,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1472.00000,426.88000,Aetna,Local,,588.80,,,,,,,473.98,1204.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT BLOCK FEMORAL,9114677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1297.08,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT BLOCK FEMORAL,9114677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1158.56,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9114678,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9114678,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9114679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1972.08000,571.90000,Aetna,Local,,788.83,,,,,,,710.93,1613.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9114679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1972.08000,571.90000,Aetna,Local,,788.83,,,,,,,635.01,1613.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9110095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,7018.94,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9110095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19470.00000,5646.30000,Aetna,Local,,7788.00,,,,,,,6269.34,15926.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9110096,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1274.90,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9110096,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3536.47000,1025.58000,Aetna,Local,,1414.59,,,,,,,1138.74,2892.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9110098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9110098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,Local,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9114688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPONENT,9114688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,Local,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9114689,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9114689,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114690,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3270.75000,948.52000,Aetna,Local,,1308.30,,,,,,,1179.11,2675.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9114690,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3270.75000,948.52000,Aetna,Local,,1308.30,,,,,,,1053.18,2675.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9114681,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9114681,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9114682,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9114682,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9114683,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9114683,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9114684,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9114684,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9114685,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9114685,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,9188859,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,56.93000,16.51000,Aetna,Local,,22.77,,,,,,,20.52,46.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,9188859,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,56.93000,16.51000,Aetna,Local,,22.77,,,,,,,18.33,46.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,9188860,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,12375.00000,3588.75000,Aetna,Local,,4950.00,,,,,,,4461.19,10122.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,9188860,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,12375.00000,3588.75000,Aetna,Local,,4950.00,,,,,,,3984.75,10122.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9188861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9188861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9188862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9188862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9188863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9188863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9188864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,281.25,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9188864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,780.17000,226.25000,Aetna,Local,,312.07,,,,,,,251.21,638.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192619,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192619,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192620,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192620,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192621,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192621,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192622,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,464.32,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192622,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1288.00000,373.52000,Aetna,Local,,515.20,,,,,,,414.74,1053.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192623,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192623,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192624,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192624,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192625,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192625,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192626,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192626,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192627,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192627,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192628,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192628,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192629,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192629,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,Local,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
278058466,9192618,CDM,278,RC,C9806,HCPCS,,,facility,inpatient,,,2724.00000,789.96000,Aetna,Local,,1089.60,,,,,,,982.00,2228.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
278058466,9192618,CDM,278,RC,C9806,HCPCS,,,facility,outpatient,,,2724.00000,789.96000,Aetna,Local,,1089.60,,,,,,,877.13,2228.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEALTH,9198531,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,516.60000,149.81000,Aetna,Local,,206.64,,,,,,,186.23,422.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEALTH,9198531,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,516.60000,149.81000,Aetna,Local,,206.64,,,,,,,166.35,422.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7968103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7968103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,Local,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9200516,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3601.50000,1044.44000,Aetna,Local,,1440.60,,,,,,,1298.34,2946.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9200516,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,Local,,1440.60,,,,,,,1159.68,2946.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200517,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,Local,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200517,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,Local,,9357.00,,,,,,,4491.90,11411.10,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SCREW,9200489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,497.63,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9200489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,Local,,552.16,,,,,,,444.49,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9206443,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5858.12,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9206443,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,6500.00,,,,,,,5232.50,13292.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NASAL PACKING,9206436,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,895.50000,259.70000,Aetna,Local,,358.20,,,,,,,322.83,732.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NASAL PACKING,9206436,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,895.50000,259.70000,Aetna,Local,,358.20,,,,,,,288.35,732.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9206527,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,182.11,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9206527,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,162.66,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9206528,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,182.11,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9206528,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,162.66,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9206529,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,19487.00000,5651.23000,Aetna,Local,,7794.80,,,,,,,7025.06,15940.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9206529,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,19487.00000,5651.23000,Aetna,Local,,7794.80,,,,,,,6274.81,15940.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9206530,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,19487.00000,5651.23000,Aetna,Local,,7794.80,,,,,,,7025.06,15940.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9206530,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,19487.00000,5651.23000,Aetna,Local,,7794.80,,,,,,,6274.81,15940.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDESHEATH,9212619,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDESHEATH,9212619,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDESHEATH,9212618,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDESHEATH,9212618,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEALANT,9212684,CDM,278,RC,C2615,HCPCS,,,facility,inpatient,,,4582.90000,1329.04000,Aetna,Local,,1833.16,,,,,,,1652.14,3748.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEALANT,9212684,CDM,278,RC,C2615,HCPCS,,,facility,outpatient,,,4582.90000,1329.04000,Aetna,Local,,1833.16,,,,,,,1475.69,3748.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9212685,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,326.04000,94.55000,Aetna,Local,,130.42,,,,,,,117.54,266.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9212685,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,326.04000,94.55000,Aetna,Local,,130.42,,,,,,,104.98,266.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9214430,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9214430,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,9214431,CDM,278,RC,C1822,HCPCS,,,facility,inpatient,,,62000.00000,17980.00000,Aetna,Local,,24800.00,,,,,,,22351.00,50716.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,9214431,CDM,278,RC,C1822,HCPCS,,,facility,outpatient,,,62000.00000,17980.00000,Aetna,Local,,24800.00,,,,,,,19964.00,50716.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9214433,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9214433,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9218439,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9218439,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,Local,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9218440,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1432.09,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9218440,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3972.50000,1152.02000,Aetna,Local,,1589.00,,,,,,,1279.14,3249.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9218445,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,5320.00000,1542.80000,Aetna,Local,,2128.00,,,,,,,1917.86,4351.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9218445,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,5320.00000,1542.80000,Aetna,Local,,2128.00,,,,,,,1713.04,4351.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9218446,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9218446,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FUSION IMPLANT KIT,9220488,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,76000.00000,22040.00000,Aetna,Local,,30400.00,,,,,,,27398.00,62168.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FUSION IMPLANT KIT,9220488,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,76000.00000,22040.00000,Aetna,Local,,30400.00,,,,,,,24472.00,62168.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9218441,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9218441,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,Local,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,9218485,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,609.75000,176.83000,Aetna,Local,,243.90,,,,,,,219.81,498.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,9218485,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,609.75000,176.83000,Aetna,Local,,243.90,,,,,,,196.34,498.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARTIMAX FA,9218486,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARTIMAX FA,9218486,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,Local,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MONITOR,9218506,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MONITOR,9218506,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9218507,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9218507,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9218510,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9218510,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9218511,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9218511,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220538,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,322.39,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220538,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,287.96,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220539,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220539,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220540,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220540,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220541,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220541,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220542,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220542,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220543,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220543,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220544,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220544,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220545,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220545,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220546,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,182.11,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220546,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,162.66,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220547,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,182.11,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220547,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,162.66,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220548,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,182.11,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220548,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,162.66,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220549,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,182.11,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220549,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,162.66,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220550,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,182.11,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220550,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,162.66,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220551,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220551,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220552,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220552,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220553,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220553,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220554,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220554,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220555,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,165.12,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9220555,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,458.04000,132.83000,Aetna,Local,,183.22,,,,,,,147.49,374.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9220575,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2744.00000,795.76000,Aetna,Local,,1097.60,,,,,,,989.21,2244.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9220575,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2744.00000,795.76000,Aetna,Local,,1097.60,,,,,,,883.57,2244.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9224458,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,7948.35000,2305.02000,Aetna,Local,,3179.34,,,,,,,2865.38,6501.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9224458,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,7948.35000,2305.02000,Aetna,Local,,3179.34,,,,,,,2559.37,6501.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9228506,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9228506,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,Local,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9086252,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9086252,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9086254,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9086254,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9226566,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9226566,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9226567,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9226567,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135967,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,81.95000,23.77000,Aetna,Local,,32.78,,,,,,,29.54,67.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135967,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,81.95000,23.77000,Aetna,Local,,32.78,,,,,,,26.39,67.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
UROLOGICAL SET,9226530,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
UROLOGICAL SET,9226530,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,Local,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FASTEMER KIT,9226565,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,18987.50000,5506.38000,Aetna,Local,,7595.00,,,,,,,6844.99,15531.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FASTEMER KIT,9226565,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,18987.50000,5506.38000,Aetna,Local,,7595.00,,,,,,,6113.98,15531.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERUS,9230523,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,20332.50000,5896.42000,Aetna,Local,,8133.00,,,,,,,7329.87,16631.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERUS,9230523,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,20332.50000,5896.42000,Aetna,Local,,8133.00,,,,,,,6547.06,16631.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230555,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230555,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230556,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230556,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230557,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230557,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230558,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230558,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,9115189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12915.00000,3745.35000,Aetna,Local,,5166.00,,,,,,,4655.86,10564.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,9115189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12915.00000,3745.35000,Aetna,Local,,5166.00,,,,,,,4158.63,10564.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL COMPONENT,9115190,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13543.32000,3927.56000,Aetna,Local,,5417.33,,,,,,,4882.37,11078.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL COMPONENT,9115190,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13543.32000,3927.56000,Aetna,Local,,5417.33,,,,,,,4360.95,11078.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL STEM,9115191,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19962.50000,5789.12000,Aetna,Local,,7985.00,,,,,,,7196.48,16329.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL STEM,9115191,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19962.50000,5789.12000,Aetna,Local,,7985.00,,,,,,,6427.93,16329.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,9115179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26499.33000,7684.81000,Aetna,Local,,10599.73,,,,,,,9553.01,21676.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,9115179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26499.33000,7684.81000,Aetna,Local,,10599.73,,,,,,,8532.78,21676.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9115170,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,908.10,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9115170,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.00000,730.51000,Aetna,Local,,1007.60,,,,,,,811.12,2060.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,9115163,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,46425.00000,13463.25000,Aetna,Local,,18570.00,,,,,,,16736.21,37975.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE PROSTHESIS,9115163,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,46425.00000,13463.25000,Aetna,Local,,18570.00,,,,,,,14948.85,37975.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP STEM,9115171,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP STEM,9115171,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9115172,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9115172,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPENENT,9115173,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL COMPENENT,9115173,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBAIL INSERT,9115174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBAIL INSERT,9115174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9115214,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6501.71000,1885.50000,Aetna,Local,,2600.68,,,,,,,2343.87,5318.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9115214,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6501.71000,1885.50000,Aetna,Local,,2600.68,,,,,,,2093.55,5318.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9115215,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6501.71000,1885.50000,Aetna,Local,,2600.68,,,,,,,2343.87,5318.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9115215,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6501.71000,1885.50000,Aetna,Local,,2600.68,,,,,,,2093.55,5318.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115217,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6175.37000,1790.86000,Aetna,Local,,2470.15,,,,,,,2226.22,5051.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115217,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6175.37000,1790.86000,Aetna,Local,,2470.15,,,,,,,1988.47,5051.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6376.30000,1849.13000,Aetna,Local,,2550.52,,,,,,,2298.66,5215.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6376.30000,1849.13000,Aetna,Local,,2550.52,,,,,,,2053.17,5215.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115164,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115164,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9115165,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,82.01000,23.78000,Aetna,Local,,32.80,,,,,,,29.56,67.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9115165,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,82.01000,23.78000,Aetna,Local,,32.80,,,,,,,26.41,67.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9115166,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,82.01000,23.78000,Aetna,Local,,32.80,,,,,,,29.56,67.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9115166,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,82.01000,23.78000,Aetna,Local,,32.80,,,,,,,26.41,67.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9115167,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,82.01000,23.78000,Aetna,Local,,32.80,,,,,,,29.56,67.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9115167,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,82.01000,23.78000,Aetna,Local,,32.80,,,,,,,26.41,67.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9115168,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,82.01000,23.78000,Aetna,Local,,32.80,,,,,,,29.56,67.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9115168,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,82.01000,23.78000,Aetna,Local,,32.80,,,,,,,26.41,67.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9115169,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,82.01000,23.78000,Aetna,Local,,32.80,,,,,,,29.56,67.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9115169,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,82.01000,23.78000,Aetna,Local,,32.80,,,,,,,26.41,67.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115192,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2697.20000,782.19000,Aetna,Local,,1078.88,,,,,,,972.34,2206.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9115192,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2697.20000,782.19000,Aetna,Local,,1078.88,,,,,,,868.50,2206.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115194,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115194,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115196,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9115196,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,Local,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT SYSTEM,9118491,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1962.02,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT SYSTEM,9118491,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5442.50000,1578.32000,Aetna,Local,,2177.00,,,,,,,1752.48,4451.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9117121,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9117121,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9118487,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1290.14,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9118487,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1152.36,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD,9118492,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD,9118492,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9118493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9118493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9118494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9118494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9117139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9117139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9117140,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,9117140,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERUS,9117141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17100.00000,4959.00000,Aetna,Local,,6840.00,,,,,,,6164.55,13987.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERUS,9117141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17100.00000,4959.00000,Aetna,Local,,6840.00,,,,,,,5506.20,13987.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9117142,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9117142,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEEDLE,9117161,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,509.49000,147.75000,Aetna,Local,,203.80,,,,,,,183.67,416.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEEDLE,9117161,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,509.49000,147.75000,Aetna,Local,,203.80,,,,,,,164.06,416.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEEDLE,9117162,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,601.83000,174.53000,Aetna,Local,,240.73,,,,,,,216.96,492.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEEDLE,9117162,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,601.83000,174.53000,Aetna,Local,,240.73,,,,,,,193.79,492.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEEDLE,9117163,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,469.35000,136.11000,Aetna,Local,,187.74,,,,,,,169.20,383.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEEDLE,9117163,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,469.35000,136.11000,Aetna,Local,,187.74,,,,,,,151.13,383.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEEDLE,9117164,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,469.35000,136.11000,Aetna,Local,,187.74,,,,,,,169.20,383.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEEDLE,9117164,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,469.35000,136.11000,Aetna,Local,,187.74,,,,,,,151.13,383.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT,9117118,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,24194.40000,7016.38000,Aetna,Local,,9677.76,,,,,,,8722.08,19791.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT,9117118,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,24194.40000,7016.38000,Aetna,Local,,9677.76,,,,,,,7790.60,19791.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL SPACER,9118484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5293.72000,1535.18000,Aetna,Local,,2117.49,,,,,,,1908.39,4330.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL SPACER,9118484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5293.72000,1535.18000,Aetna,Local,,2117.49,,,,,,,1704.58,4330.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9117143,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9117143,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9117240,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9117240,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9117241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9117241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9117242,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,641.62,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9117242,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1779.80000,516.14000,Aetna,Local,,711.92,,,,,,,573.10,1455.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL BLADE,9117228,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3153.64000,914.56000,Aetna,Local,,1261.46,,,,,,,1136.89,2579.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL BLADE,9117228,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3153.64000,914.56000,Aetna,Local,,1261.46,,,,,,,1015.47,2579.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9117233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9117233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,Local,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9117243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1292.00000,374.68000,Aetna,Local,,516.80,,,,,,,465.77,1056.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9117243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1292.00000,374.68000,Aetna,Local,,516.80,,,,,,,416.02,1056.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT WEDGE,9120435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1297.08,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT WEDGE,9120435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,Local,,1439.20,,,,,,,1158.56,2943.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE,9120436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3942.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE,9120436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,Local,,4374.00,,,,,,,3521.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9117288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1848.00000,535.92000,Aetna,Local,,739.20,,,,,,,666.20,1511.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9117288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1848.00000,535.92000,Aetna,Local,,739.20,,,,,,,595.06,1511.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9117289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9117289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9120488,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9120488,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,9120489,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,769.31,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,9120489,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2134.00000,618.86000,Aetna,Local,,853.60,,,,,,,687.15,1745.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9117290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9117290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,Local,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9120490,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,9120490,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,Local,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9122408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9122408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9122409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9122409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9122410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.84000,578.50000,Aetna,Local,,797.94,,,,,,,719.14,1631.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9122410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.84000,578.50000,Aetna,Local,,797.94,,,,,,,642.34,1631.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9120523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9120523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9120524,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9120524,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,9120525,CDM,278,RC,L8679,HCPCS,,,facility,inpatient,,,47652.75000,13819.30000,Aetna,Local,,19061.10,,,,,,,17178.82,38979.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,9120525,CDM,278,RC,L8679,HCPCS,,,facility,outpatient,,,47652.75000,13819.30000,Aetna,Local,,19061.10,,,,,,,10323.94,38979.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9124447,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5760.00000,1670.40000,Aetna,Local,,2304.00,,,,,,,2076.48,4711.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9124447,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5760.00000,1670.40000,Aetna,Local,,2304.00,,,,,,,1854.72,4711.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9124448,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9124448,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9124449,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9124449,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9124631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2795.68,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9124631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7755.00000,2248.95000,Aetna,Local,,3102.00,,,,,,,2497.11,6343.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ARTICULAR SURFACE,9126396,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ARTICULAR SURFACE,9126396,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9126392,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8736.00000,2533.44000,Aetna,Local,,3494.40,,,,,,,3149.33,7146.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9126392,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8736.00000,2533.44000,Aetna,Local,,3494.40,,,,,,,2812.99,7146.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9126393,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9126393,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9126394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,665.24000,192.92000,Aetna,Local,,266.10,,,,,,,239.82,544.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9126394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,665.24000,192.92000,Aetna,Local,,266.10,,,,,,,214.21,544.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9126395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,665.24000,192.92000,Aetna,Local,,266.10,,,,,,,239.82,544.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9126395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,665.24000,192.92000,Aetna,Local,,266.10,,,,,,,214.21,544.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9126431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1289.24000,373.88000,Aetna,Local,,515.70,,,,,,,464.77,1054.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9126431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1289.24000,373.88000,Aetna,Local,,515.70,,,,,,,415.14,1054.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9126426,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9144.09000,2651.79000,Aetna,Local,,3657.64,,,,,,,3296.44,7479.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9126426,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9144.09000,2651.79000,Aetna,Local,,3657.64,,,,,,,2944.40,7479.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL WEDGE,9126427,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5675.25000,1645.82000,Aetna,Local,,2270.10,,,,,,,2045.93,4642.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL WEDGE,9126427,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5675.25000,1645.82000,Aetna,Local,,2270.10,,,,,,,1827.43,4642.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9126428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9126428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9126430,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9126430,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9128416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9128416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9128417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9128417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9128418,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9128418,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,Local,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9128419,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9128419,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9128420,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,695.12000,201.58000,Aetna,Local,,278.05,,,,,,,250.59,568.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9128420,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,695.12000,201.58000,Aetna,Local,,278.05,,,,,,,223.83,568.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9128421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9128421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9128423,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,9128423,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9128474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9128474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9128472,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6180.00000,1792.20000,Aetna,Local,,2472.00,,,,,,,2227.89,5055.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9128472,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6180.00000,1792.20000,Aetna,Local,,2472.00,,,,,,,1989.96,5055.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9117174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL INSERT,9117174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9128473,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9128473,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9132397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2675.00000,775.75000,Aetna,Local,,1070.00,,,,,,,964.34,2188.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9132397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2675.00000,775.75000,Aetna,Local,,1070.00,,,,,,,861.35,2188.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9132398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,964.29,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9132398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2674.88000,775.72000,Aetna,Local,,1069.95,,,,,,,861.31,2188.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9134415,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9134415,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9130453,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,549.40,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9130453,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1524.00000,441.96000,Aetna,Local,,609.60,,,,,,,490.73,1246.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9134411,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9134411,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,Local,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9134412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9134412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,217.35,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING PEG,9134475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING PEG,9134475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9134476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9134476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9134477,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9134477,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,Local,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9132455,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9132455,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9132458,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9132458,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL COMPONENT,9132459,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,16445.00000,4769.05000,Aetna,Local,,6578.00,,,,,,,5928.42,13452.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL COMPONENT,9132459,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,16445.00000,4769.05000,Aetna,Local,,6578.00,,,,,,,5295.29,13452.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNA COMPONENT,9132460,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,17657.50000,5120.67000,Aetna,Local,,7063.00,,,,,,,6365.53,14443.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNA COMPONENT,9132460,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,17657.50000,5120.67000,Aetna,Local,,7063.00,,,,,,,5685.72,14443.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING PEG,9134474,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING PEG,9134474,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,Local,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9142526,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,2146.24,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9142526,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5953.50000,1726.52000,Aetna,Local,,2381.40,,,,,,,1917.03,4869.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9142534,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9142534,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9142535,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.28000,961.43000,Aetna,Local,,1326.11,,,,,,,1195.16,2711.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9142535,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.28000,961.43000,Aetna,Local,,1326.11,,,,,,,1067.52,2711.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9142165,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,502.05,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9142165,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1392.64000,403.87000,Aetna,Local,,557.06,,,,,,,448.43,1139.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9142523,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2264.03,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9142523,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6280.26000,1821.28000,Aetna,Local,,2512.10,,,,,,,2022.24,5137.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9142525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,411.68000,119.39000,Aetna,Local,,164.67,,,,,,,148.41,336.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9142525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,411.68000,119.39000,Aetna,Local,,164.67,,,,,,,132.56,336.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9142532,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,202.23,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9142532,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,560.97000,162.68000,Aetna,Local,,224.39,,,,,,,180.63,458.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9142533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9142533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,Local,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL INSERT,9142584,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.54000,1344.89000,Aetna,Local,,1855.02,,,,,,,1671.83,3793.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL INSERT,9142584,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.54000,1344.89000,Aetna,Local,,1855.02,,,,,,,1493.29,3793.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9142610,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,100.33000,29.10000,Aetna,Local,,40.13,,,,,,,36.17,82.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9142610,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,100.33000,29.10000,Aetna,Local,,40.13,,,,,,,32.31,82.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9142164,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9142164,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEMBRANE,9150429,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,7407.00000,2148.03000,Aetna,Local,,2962.80,,,,,,,2670.22,6058.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEMBRANE,9150429,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,7407.00000,2148.03000,Aetna,Local,,2962.80,,,,,,,2385.05,6058.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATCH,9145019,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2968.72,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATCH,9145019,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2651.67,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATCH,9145020,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATCH,9145020,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9154548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9154548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,Local,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE AUGMENT,9154549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1722.60000,499.55000,Aetna,Local,,689.04,,,,,,,621.00,1409.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE AUGMENT,9154549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1722.60000,499.55000,Aetna,Local,,689.04,,,,,,,554.68,1409.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEM DIST,9154550,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,442.46000,128.31000,Aetna,Local,,176.98,,,,,,,159.51,361.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEM DIST,9154550,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,442.46000,128.31000,Aetna,Local,,176.98,,,,,,,142.47,361.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9154551,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.63000,120.53000,Aetna,Local,,166.25,,,,,,,149.83,339.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9154551,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.63000,120.53000,Aetna,Local,,166.25,,,,,,,133.83,339.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE SPACER,9154553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1730.00000,501.70000,Aetna,Local,,692.00,,,,,,,623.66,1415.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KNEE SPACER,9154553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1730.00000,501.70000,Aetna,Local,,692.00,,,,,,,557.06,1415.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9154556,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2578.00000,747.62000,Aetna,Local,,1031.20,,,,,,,929.37,2108.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9154556,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2578.00000,747.62000,Aetna,Local,,1031.20,,,,,,,830.12,2108.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE,9158405,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1535.96000,445.43000,Aetna,Local,,614.38,,,,,,,553.71,1256.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE,9158405,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1535.96000,445.43000,Aetna,Local,,614.38,,,,,,,494.58,1256.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9160489,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9160489,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,Local,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9168404,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,776.12000,225.07000,Aetna,Local,,310.45,,,,,,,279.79,634.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9168404,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,776.12000,225.07000,Aetna,Local,,310.45,,,,,,,249.91,634.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT KIT,9168405,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,322.39,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT KIT,9168405,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,894.29000,259.34000,Aetna,Local,,357.72,,,,,,,287.96,731.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9168406,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,182.11,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9168406,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,162.66,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9168407,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,182.11,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9168407,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,505.16000,146.50000,Aetna,Local,,202.06,,,,,,,162.66,413.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DELIVERY SYSTEM,9168408,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,473.91000,137.43000,Aetna,Local,,189.56,,,,,,,170.84,387.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DELIVERY SYSTEM,9168408,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,473.91000,137.43000,Aetna,Local,,189.56,,,,,,,152.60,387.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DELIVERY SYSTEM,9168409,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,473.91000,137.43000,Aetna,Local,,189.56,,,,,,,170.84,387.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DELIVERY SYSTEM,9168409,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,473.91000,137.43000,Aetna,Local,,189.56,,,,,,,152.60,387.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9176421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,953.52,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9176421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2645.00000,767.05000,Aetna,Local,,1058.00,,,,,,,851.69,2163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8170945,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1595.00000,462.55000,Aetna,Local,,638.00,,,,,,,575.00,1304.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8170945,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1595.00000,462.55000,Aetna,Local,,638.00,,,,,,,513.59,1304.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9176422,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,23600.00000,6844.00000,Aetna,Local,,9440.00,,,,,,,8507.80,19304.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9176422,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,23600.00000,6844.00000,Aetna,Local,,9440.00,,,,,,,7599.20,19304.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETERSCOPE,9176468,CDM,278,RC,C1747,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETERSCOPE,9176468,CDM,278,RC,C1747,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,9178558,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,14640.81,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,9178558,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,13077.23,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,9178560,CDM,278,RC,C1605,HCPCS,,,facility,inpatient,,,112500.00000,32625.00000,Aetna,Local,,45000.00,,,,,,,40556.25,92025.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,9178560,CDM,278,RC,C1605,HCPCS,,,facility,outpatient,,,112500.00000,32625.00000,Aetna,Local,,45000.00,,,,,,,36225.00,92025.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,9178559,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,36900.00000,10701.00000,Aetna,Local,,14760.00,,,,,,,13302.45,30184.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,9178559,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,36900.00000,10701.00000,Aetna,Local,,14760.00,,,,,,,11881.80,30184.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PULMONARY VALVE,9178561,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,53228.25000,15436.19000,Aetna,Local,,21291.30,,,,,,,19188.78,43540.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PULMONARY VALVE,9178561,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,53228.25000,15436.19000,Aetna,Local,,21291.30,,,,,,,17139.50,43540.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PULMONARY VALVE,9178562,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,53228.25000,15436.19000,Aetna,Local,,21291.30,,,,,,,19188.78,43540.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PULMONARY VALVE,9178562,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,53228.25000,15436.19000,Aetna,Local,,21291.30,,,,,,,17139.50,43540.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PULMONARY VALVE,9178563,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,35887.50000,10407.38000,Aetna,Local,,14355.00,,,,,,,12937.44,29355.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PULMONARY VALVE,9178563,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,35887.50000,10407.38000,Aetna,Local,,14355.00,,,,,,,11555.77,29355.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC VALVE,9178564,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,53228.25000,15436.19000,Aetna,Local,,21291.30,,,,,,,19188.78,43540.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC VALVE,9178564,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,53228.25000,15436.19000,Aetna,Local,,21291.30,,,,,,,17139.50,43540.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC VALVE,9178565,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC VALVE,9178565,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC VALVE,9178566,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC VALVE,9178566,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,Local,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP,9180544,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,63112.50000,18302.62000,Aetna,Local,,25245.00,,,,,,,22752.06,51626.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP,9180544,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,63112.50000,18302.62000,Aetna,Local,,25245.00,,,,,,,20322.22,51626.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9180602,CDM,278,RC,Q4125,HCPCS,,,facility,inpatient,,,7987.50000,2316.38000,Aetna,Local,,3195.00,,,,,,,2879.49,6533.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9180602,CDM,278,RC,Q4125,HCPCS,,,facility,outpatient,,,7987.50000,2316.38000,Aetna,Local,,3195.00,,,,,,,124.65,6533.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9182564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9182564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9180630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3420.78,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,9180630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,Local,,3795.60,,,,,,,3055.46,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9180628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.80000,818.03000,Aetna,Local,,1128.32,,,,,,,1016.90,2307.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9180628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.80000,818.03000,Aetna,Local,,1128.32,,,,,,,908.30,2307.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9180626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9180626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,Local,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT,9180624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13059.00000,3787.11000,Aetna,Local,,5223.60,,,,,,,4707.77,10682.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT,9180624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13059.00000,3787.11000,Aetna,Local,,5223.60,,,,,,,4205.00,10682.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VENT TUBE,9115121,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,109.25000,31.68000,Aetna,Local,,43.70,,,,,,,39.38,89.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VENT TUBE,9115121,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,109.25000,31.68000,Aetna,Local,,43.70,,,,,,,35.18,332.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,9182690,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,12879.00000,3734.91000,Aetna,Local,,5151.60,,,,,,,4642.88,10535.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,9182690,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,12879.00000,3734.91000,Aetna,Local,,5151.60,,,,,,,4147.04,10535.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETERAL SHEATH,9180777,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETERAL SHEATH,9180777,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
UTERERAL SHEATH,9180778,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
UTERERAL SHEATH,9180778,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,Local,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186523,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186523,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186524,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186524,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186525,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186525,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,9142528,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,9142528,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer,9142529,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer,9142529,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pacemaker,9142530,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,34762.50000,10081.12000,Aetna,Local,,13905.00,,,,,,,12531.88,28435.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pacemaker,9142530,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,34762.50000,10081.12000,Aetna,Local,,13905.00,,,,,,,11193.52,28435.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pacemaker,9142531,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pacemaker,9142531,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,Local,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer,9142527,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer,9142527,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter guide,9142162,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter guide,9142162,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATION CATHETER,9182729,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATION CATHETER,9182729,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186526,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186526,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186527,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186527,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186528,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186528,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186529,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186529,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186530,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,9186530,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE REINFORCED MATRIX,9188444,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,24450.00000,7090.50000,Aetna,Local,,9780.00,,,,,,,8814.23,20000.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE REINFORCED MATRIX,9188444,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,24450.00000,7090.50000,Aetna,Local,,9780.00,,,,,,,7872.90,20000.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9186566,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9186566,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9186567,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,9186567,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,Local,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9188868,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9188868,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,9188835,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,67050.00000,19444.50000,Aetna,Local,,26820.00,,,,,,,24171.53,54846.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,9188835,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,67050.00000,19444.50000,Aetna,Local,,26820.00,,,,,,,21590.10,54846.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,9188836,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2920.05,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,9188836,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,Local,,3240.00,,,,,,,2608.20,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188706,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,3352.65,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188706,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,2994.60,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188707,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,3352.65,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188707,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,2994.60,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188708,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,3352.65,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188708,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,2994.60,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188700,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,3352.65,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188700,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,2994.60,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188701,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,3352.65,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188701,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,2994.60,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188702,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,3352.65,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188702,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,2994.60,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188703,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,3352.65,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188703,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,2994.60,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188704,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,3352.65,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANNULOPLASTY RING,9188704,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9300.00000,2697.00000,Aetna,Local,,3720.00,,,,,,,2994.60,7607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9202429,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2456.00000,712.24000,Aetna,Local,,982.40,,,,,,,885.39,2009.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9202429,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2456.00000,712.24000,Aetna,Local,,982.40,,,,,,,790.83,2009.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9188971,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1484.00000,430.36000,Aetna,Local,,593.60,,,,,,,534.98,1213.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9188971,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1484.00000,430.36000,Aetna,Local,,593.60,,,,,,,477.85,1213.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200469,CDM,278,RC,C1759,HCPCS,,,facility,inpatient,,,4165.00000,1207.85000,Aetna,Local,,1666.00,,,,,,,1501.48,3406.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200469,CDM,278,RC,C1759,HCPCS,,,facility,outpatient,,,4165.00000,1207.85000,Aetna,Local,,1666.00,,,,,,,1341.13,3406.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200468,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,4287.00000,1243.23000,Aetna,Local,,1714.80,,,,,,,1545.46,3506.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200468,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,4287.00000,1243.23000,Aetna,Local,,9357.00,,,,,,,1380.41,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9200467,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,633.83000,183.81000,Aetna,Local,,253.53,,,,,,,228.50,518.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200467,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,633.83000,183.81000,Aetna,Local,,9357.00,,,,,,,204.09,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9200466,CDM,278,RC,C1731,HCPCS,,,facility,inpatient,,,1338.76000,388.24000,Aetna,Local,,535.50,,,,,,,482.62,1095.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200466,CDM,278,RC,C1731,HCPCS,,,facility,outpatient,,,1338.76000,388.24000,Aetna,Local,,9357.00,,,,,,,431.08,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9200465,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,Local,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200465,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,Local,,9357.00,,,,,,,1831.38,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9200464,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200464,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,9357.00,,,,,,,72.69,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9200463,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,206.27000,59.82000,Aetna,Local,,82.51,,,,,,,74.36,168.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200463,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,206.27000,59.82000,Aetna,Local,,9357.00,,,,,,,66.42,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTRODUCER,9200462,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2696.52000,781.99000,Aetna,Local,,1078.61,,,,,,,972.10,2205.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9200462,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2696.52000,781.99000,Aetna,Local,,1078.61,,,,,,,868.28,2205.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200461,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200461,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,9357.00,,,,,,,260.82,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTRODUCER,9200460,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9200460,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9202430,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9202430,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,9357.00,,,,,,,72.69,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9200459,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,733.50000,212.71000,Aetna,Local,,293.40,,,,,,,264.43,600.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9200459,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,733.50000,212.71000,Aetna,Local,,9357.00,,,,,,,236.19,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9206538,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,699.53000,202.86000,Aetna,Local,,279.81,,,,,,,252.18,572.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9206538,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,699.53000,202.86000,Aetna,Local,,9357.00,,,,,,,225.25,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9206539,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,3307.50000,959.18000,Aetna,Local,,1323.00,,,,,,,1192.35,2705.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9206539,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,3307.50000,959.18000,Aetna,Local,,9357.00,,,,,,,1065.02,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9206540,CDM,278,RC,C1759,HCPCS,,,facility,inpatient,,,5628.00000,1632.12000,Aetna,Local,,2251.20,,,,,,,2028.89,4603.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9206540,CDM,278,RC,C1759,HCPCS,,,facility,outpatient,,,5628.00000,1632.12000,Aetna,Local,,2251.20,,,,,,,1812.22,4603.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212435,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212435,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,9357.00,,,,,,,978.88,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9212436,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212436,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,9357.00,,,,,,,978.88,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9212437,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212437,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212438,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212438,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212439,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212439,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212440,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212440,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212441,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212441,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212442,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212442,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212443,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212443,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212444,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,77.79,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9212444,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,215.78000,62.58000,Aetna,Local,,86.31,,,,,,,69.48,176.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9212620,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,774.90000,224.72000,Aetna,Local,,309.96,,,,,,,279.35,633.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,9212620,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,774.90000,224.72000,Aetna,Local,,309.96,,,,,,,249.52,633.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9210522,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,9888.00000,2867.52000,Aetna,Local,,3955.20,,,,,,,3564.62,8088.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9210522,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,9888.00000,2867.52000,Aetna,Local,,9357.00,,,,,,,3183.94,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9210558,CDM,278,RC,C1732,HCPCS,,,facility,inpatient,,,13002.00000,3770.58000,Aetna,Local,,5200.80,,,,,,,4687.22,10635.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9210558,CDM,278,RC,C1732,HCPCS,,,facility,outpatient,,,13002.00000,3770.58000,Aetna,Local,,9357.00,,,,,,,4186.64,10635.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PACEMAKER,9210766,CDM,278,RC,C1824,HCPCS,,,facility,inpatient,,,64000.00000,18560.00000,Aetna,Local,,25600.00,,,,,,,23072.00,52352.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,9210766,CDM,278,RC,C1824,HCPCS,,,facility,outpatient,,,64000.00000,18560.00000,Aetna,Local,,25600.00,,,,,,,20608.00,52352.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDERS,9220446,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,14235.24,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDERS,9220446,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,12714.98,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9220447,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,14235.24,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9220447,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,12714.98,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9220448,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,14235.24,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9220448,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,12714.98,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9220459,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9220459,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9224436,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,14235.24,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9224436,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,12714.98,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9224437,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,14235.24,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9224437,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,12714.98,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9224438,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,14235.24,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9224438,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,12714.98,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9224439,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,14235.24,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9224439,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,12714.98,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9224440,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,14235.24,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,9224440,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,39487.50000,11451.38000,Aetna,Local,,15795.00,,,,,,,12714.98,32300.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230559,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230559,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,Local,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOCATHETER,9230566,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9984.00000,2895.36000,Aetna,Local,,3993.60,,,,,,,3599.23,8166.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOCATHETER,9230566,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9984.00000,2895.36000,Aetna,Local,,3993.60,,,,,,,3214.85,8166.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOCATHETER,9230567,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9984.00000,2895.36000,Aetna,Local,,3993.60,,,,,,,3599.23,8166.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOCATHETER,9230567,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9984.00000,2895.36000,Aetna,Local,,3993.60,,,,,,,3214.85,8166.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,9230560,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,6107.50000,1771.18000,Aetna,Local,,2443.00,,,,,,,2201.75,4995.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,9230560,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,6107.50000,1771.18000,Aetna,Local,,2443.00,,,,,,,1966.62,4995.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,9230561,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,12795.00000,3710.55000,Aetna,Local,,5118.00,,,,,,,4612.60,10466.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,9230561,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,12795.00000,3710.55000,Aetna,Local,,5118.00,,,,,,,4119.99,10466.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,9230562,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,16850.00000,4886.50000,Aetna,Local,,6740.00,,,,,,,6074.43,13783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,9230562,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,16850.00000,4886.50000,Aetna,Local,,6740.00,,,,,,,5425.70,13783.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,9230563,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,19937.50000,5781.88000,Aetna,Local,,7975.00,,,,,,,7187.47,16308.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT BONE,9230563,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,19937.50000,5781.88000,Aetna,Local,,7975.00,,,,,,,6419.88,16308.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,9230473,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,115.50000,33.49000,Aetna,Local,,46.20,,,,,,,41.64,94.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,9230473,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,115.50000,33.49000,Aetna,Local,,46.20,,,,,,,37.19,94.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230647,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,23600.00000,6844.00000,Aetna,Local,,9440.00,,,,,,,8507.80,19304.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9230647,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,23600.00000,6844.00000,Aetna,Local,,9440.00,,,,,,,7599.20,19304.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9230648,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1580.88000,458.46000,Aetna,Local,,632.35,,,,,,,569.91,1293.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9230648,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1580.88000,458.46000,Aetna,Local,,632.35,,,,,,,509.04,1293.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9230649,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,796.01000,230.84000,Aetna,Local,,318.40,,,,,,,286.96,651.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9230649,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,796.01000,230.84000,Aetna,Local,,318.40,,,,,,,256.32,651.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE HELIX PRO,9230650,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2160.68000,626.60000,Aetna,Local,,864.27,,,,,,,778.93,1767.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE HELIX PRO,9230650,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2160.68000,626.60000,Aetna,Local,,864.27,,,,,,,695.74,1767.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,9230670,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10800.00000,3132.00000,Aetna,Local,,4320.00,,,,,,,3893.40,8834.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,9230670,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,Local,,4320.00,,,,,,,3477.60,8834.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194482,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194482,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194483,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194483,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194484,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194484,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194485,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194485,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194486,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194486,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194487,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194487,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194488,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194488,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194489,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194489,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194490,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194490,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194491,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194491,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194492,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194492,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194493,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9194493,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192476,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192476,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192477,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192477,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192478,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192478,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192479,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192479,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192480,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192480,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192481,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192481,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192482,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192482,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192483,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192483,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192484,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192484,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192485,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192485,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192486,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192486,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192487,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192487,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192488,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192488,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192489,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192489,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192490,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192490,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192491,CDM,278,RC,C9610,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9192491,CDM,278,RC,C9610,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,Local,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE HORNET,9068267,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,648.00000,187.92000,Aetna,Local,,259.20,,,,,,,233.60,530.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE HORNET,9068267,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,648.00000,187.92000,Aetna,Local,,259.20,,,,,,,208.66,530.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATOR VERCROSS,9068268,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1596.11,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATOR VERCROSS,9068268,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,Local,,1771.00,,,,,,,1425.65,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEVICE CLOSURE WATCHMAN,9117235,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,45112.50000,13082.62000,Aetna,Local,,18045.00,,,,,,,16263.06,36902.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEVICE CLOSURE WATCHMAN,9117235,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,45112.50000,13082.62000,Aetna,Local,,18045.00,,,,,,,14526.23,36902.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACCESS WATCHMAN,9117236,CDM,278,RC,C1817,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACCESS WATCHMAN,9117236,CDM,278,RC,C1817,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TENT,9093621,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1693.52,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TENT,9093621,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,Local,,1879.08,,,,,,,1512.66,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING,9093511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEARING,9093511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,9093509,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,14640.81,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,9093509,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,40612.50000,11777.62000,Aetna,Local,,16245.00,,,,,,,13077.23,33221.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9093627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,690.62000,200.28000,Aetna,Local,,276.25,,,,,,,248.97,564.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,9093627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,690.62000,200.28000,Aetna,Local,,276.25,,,,,,,222.38,564.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT ANKLE,9093618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3360.22,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT ANKLE,9093618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9321.00000,2703.09000,Aetna,Local,,3728.40,,,,,,,3001.36,7624.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT EVOLUTION,9095262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2844.34,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT EVOLUTION,9095262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7890.00000,2288.10000,Aetna,Local,,3156.00,,,,,,,2540.58,6454.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT JRNY,9093516,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT JRNY,9093516,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,Local,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT ACCESSORY,9093644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,231.46000,67.12000,Aetna,Local,,92.58,,,,,,,83.44,189.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KIT ACCESSORY,9093644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,231.46000,67.12000,Aetna,Local,,92.58,,,,,,,74.53,189.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,9095247,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5012.00000,1453.48000,Aetna,Local,,2004.80,,,,,,,1806.83,4099.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE BONE,9095247,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5012.00000,1453.48000,Aetna,Local,,2004.80,,,,,,,1613.86,4099.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DIST,9093641,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5540.50000,1606.74000,Aetna,Local,,2216.20,,,,,,,1997.35,4532.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE DIST,9093641,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5540.50000,1606.74000,Aetna,Local,,2216.20,,,,,,,1784.04,4532.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LUMBAR,9093643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LUMBAR,9093643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE POST,9095243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10989.00000,3186.81000,Aetna,Local,,4395.60,,,,,,,3961.53,8989.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE POST,9095243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10989.00000,3186.81000,Aetna,Local,,4395.60,,,,,,,3538.46,8989.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE VOLAR,9095245,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4819.50000,1397.66000,Aetna,Local,,1927.80,,,,,,,1737.43,3942.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE VOLAR,9095245,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4819.50000,1397.66000,Aetna,Local,,1927.80,,,,,,,1551.88,3942.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANN,9095244,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW CANN,9095244,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW TORX,9093620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW TORX,9093620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9093515,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,186.65,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9093515,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,517.75000,150.15000,Aetna,Local,,207.10,,,,,,,166.72,423.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9093514,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW BONE,9093514,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,510.47,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1416.00000,410.64000,Aetna,Local,,566.40,,,,,,,455.95,1158.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,651.73,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1807.84000,524.27000,Aetna,Local,,723.14,,,,,,,582.12,1478.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095241,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095241,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093642,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093642,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095242,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095242,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095240,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4676.00000,1356.04000,Aetna,Local,,1870.40,,,,,,,1685.70,3824.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095240,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4676.00000,1356.04000,Aetna,Local,,1870.40,,,,,,,1505.67,3824.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9095261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1748.79,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9095261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4851.00000,1406.79000,Aetna,Local,,1940.40,,,,,,,1562.02,3968.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9093510,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9093510,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9093512,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,9093512,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9095421,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,839.97,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9095421,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,Local,,932.00,,,,,,,750.26,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9095424,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9095424,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9095428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10410.00000,3018.90000,Aetna,Local,,4164.00,,,,,,,3752.80,8515.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9095428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10410.00000,3018.90000,Aetna,Local,,4164.00,,,,,,,3352.02,8515.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095429,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4882.50000,1415.92000,Aetna,Local,,1953.00,,,,,,,1760.14,3993.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095429,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4882.50000,1415.92000,Aetna,Local,,1953.00,,,,,,,1572.16,3993.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095430,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095430,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095431,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095431,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095432,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095432,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9093734,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4050.38000,1174.61000,Aetna,Local,,1620.15,,,,,,,1460.16,3313.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,9093734,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4050.38000,1174.61000,Aetna,Local,,1620.15,,,,,,,1304.22,3313.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL,9093735,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,66260.00000,19215.40000,Aetna,Local,,26504.00,,,,,,,23886.73,54200.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL,9093735,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,66260.00000,19215.40000,Aetna,Local,,26504.00,,,,,,,21335.72,54200.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9093736,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,9093736,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9093737,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9093737,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9093738,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,468.65,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9093738,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1300.00000,377.00000,Aetna,Local,,520.00,,,,,,,418.60,1063.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,Local,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9095609,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,3206.47,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9095609,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8894.52000,2579.41000,Aetna,Local,,3557.81,,,,,,,2864.04,7275.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9095602,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7743.00000,2245.47000,Aetna,Local,,3097.20,,,,,,,2791.35,6333.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9095602,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7743.00000,2245.47000,Aetna,Local,,3097.20,,,,,,,2493.25,6333.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9095603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8163.00000,2367.27000,Aetna,Local,,3265.20,,,,,,,2942.76,6677.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9095603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8163.00000,2367.27000,Aetna,Local,,3265.20,,,,,,,2628.49,6677.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095606,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,527.77,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9095606,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1464.00000,424.56000,Aetna,Local,,585.60,,,,,,,471.41,1197.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9095607,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9095607,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9095610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1290.14,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9095610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3578.75000,1037.84000,Aetna,Local,,1431.50,,,,,,,1152.36,2927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9093880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9093881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9093881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,Local,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9093882,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,9093882,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL BOLT,9095703,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL BOLT,9095703,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL AUGMENT,9095704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8176.92000,2371.31000,Aetna,Local,,3270.77,,,,,,,2947.78,6688.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL AUGMENT,9095704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8176.92000,2371.31000,Aetna,Local,,3270.77,,,,,,,2632.97,6688.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9094999,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9094999,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEFIBRILLATOR,9093889,CDM,278,RC,C1722,HCPCS,,,facility,inpatient,,,36346.50000,10540.48000,Aetna,Local,,14538.60,,,,,,,13102.91,29731.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DEFIBRILLATOR,9093889,CDM,278,RC,C1722,HCPCS,,,facility,outpatient,,,36346.50000,10540.48000,Aetna,Local,,14538.60,,,,,,,11703.57,29731.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9095744,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9095744,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL SLING,9095705,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,3892.00000,1128.68000,Aetna,Local,,1556.80,,,,,,,1403.07,3183.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URETHRAL SLING,9095705,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,3892.00000,1128.68000,Aetna,Local,,1556.80,,,,,,,1253.22,3183.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL GRAFT,9093902,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9606.00000,2785.74000,Aetna,Local,,3842.40,,,,,,,3462.96,7857.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL GRAFT,9093902,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9606.00000,2785.74000,Aetna,Local,,3842.40,,,,,,,3093.13,7857.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9095748,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2415.68000,700.55000,Aetna,Local,,966.27,,,,,,,870.85,1976.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9095748,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2415.68000,700.55000,Aetna,Local,,966.27,,,,,,,777.85,1976.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9095749,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,9095749,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9093903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM HUMERAL,9093903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,Local,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7939434,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,29.34,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7939434,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,81.38000,23.60000,Aetna,Local,,32.55,,,,,,,26.20,66.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8999057,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2092.00000,606.68000,Aetna,Local,,836.80,,,,,,,754.17,1711.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,8999057,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2092.00000,606.68000,Aetna,Local,,836.80,,,,,,,673.62,1711.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9094029,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9094029,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9094030,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,5446.25,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,9094030,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15107.50000,4381.17000,Aetna,Local,,6043.00,,,,,,,4864.61,12357.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1721.60000,499.26000,Aetna,Local,,688.64,,,,,,,620.64,1408.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1721.60000,499.26000,Aetna,Local,,688.64,,,,,,,554.36,1408.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094032,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1721.60000,499.26000,Aetna,Local,,688.64,,,,,,,620.64,1408.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094032,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1721.60000,499.26000,Aetna,Local,,688.64,,,,,,,554.36,1408.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094033,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1721.60000,499.26000,Aetna,Local,,688.64,,,,,,,620.64,1408.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094033,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1721.60000,499.26000,Aetna,Local,,688.64,,,,,,,554.36,1408.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9094034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4339.16000,1258.36000,Aetna,Local,,1735.66,,,,,,,1564.27,3549.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9094034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4339.16000,1258.36000,Aetna,Local,,1735.66,,,,,,,1397.21,3549.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9094035,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4339.16000,1258.36000,Aetna,Local,,1735.66,,,,,,,1564.27,3549.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9094035,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4339.16000,1258.36000,Aetna,Local,,1735.66,,,,,,,1397.21,3549.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094040,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094040,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9094042,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,9094042,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,Local,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094043,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1356.00000,393.24000,Aetna,Local,,542.40,,,,,,,488.84,1109.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094043,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1356.00000,393.24000,Aetna,Local,,542.40,,,,,,,436.63,1109.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094044,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1356.00000,393.24000,Aetna,Local,,542.40,,,,,,,488.84,1109.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9094044,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1356.00000,393.24000,Aetna,Local,,542.40,,,,,,,436.63,1109.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9094046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KWIRE,9094046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR GRAFT,9012701,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,10242.00000,2970.18000,Aetna,Local,,4096.80,,,,,,,3692.24,8377.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR GRAFT,9012701,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,10242.00000,2970.18000,Aetna,Local,,4096.80,,,,,,,3297.92,8377.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9012702,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,3212.05,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,9012702,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8910.00000,2583.90000,Aetna,Local,,3564.00,,,,,,,2869.02,7288.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9094041,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,9094041,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,Local,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TIBIAL,9096189,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9606.00000,2785.74000,Aetna,Local,,3842.40,,,,,,,3462.96,7857.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TIBIAL,9096189,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9606.00000,2785.74000,Aetna,Local,,3842.40,,,,,,,3093.13,7857.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9096339,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9096339,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,Local,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,9096340,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,3559.50000,1032.25000,Aetna,Local,,1423.80,,,,,,,1283.20,2911.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,9096340,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,3559.50000,1032.25000,Aetna,Local,,1423.80,,,,,,,1146.16,2911.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,9098323,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1556.00000,451.24000,Aetna,Local,,622.40,,,,,,,560.94,1272.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE CERVICAL,9098323,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1556.00000,451.24000,Aetna,Local,,622.40,,,,,,,501.03,1272.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE ANCHOR,9095416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3451.88000,1001.05000,Aetna,Local,,1380.75,,,,,,,1244.40,2823.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE ANCHOR,9095416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3451.88000,1001.05000,Aetna,Local,,1380.75,,,,,,,1111.51,2823.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098324,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.25000,86.78000,Aetna,Local,,119.70,,,,,,,107.88,244.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098324,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.25000,86.78000,Aetna,Local,,119.70,,,,,,,96.36,244.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098325,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,299.25000,86.78000,Aetna,Local,,119.70,,,,,,,107.88,244.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098325,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,299.25000,86.78000,Aetna,Local,,119.70,,,,,,,96.36,244.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,605.28,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.00000,486.91000,Aetna,Local,,671.60,,,,,,,540.64,1373.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRANITE IMPLANT SYSTEM,9098367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRANITE IMPLANT SYSTEM,9098367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9096386,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9096386,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9096387,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9096387,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9096366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9096366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT,9096367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT,9096367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,Local,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9098375,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9098375,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,Local,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9098373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1560.00000,452.40000,Aetna,Local,,624.00,,,,,,,562.38,1276.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9098373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1560.00000,452.40000,Aetna,Local,,624.00,,,,,,,502.32,1276.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9098374,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,9098374,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL SYSTEM,9098376,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17100.00000,4959.00000,Aetna,Local,,6840.00,,,,,,,6164.55,13987.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL SYSTEM,9098376,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17100.00000,4959.00000,Aetna,Local,,6840.00,,,,,,,5506.20,13987.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9098377,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9098377,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE MATRIX,9098378,CDM,278,RC,Q4116,HCPCS,,,facility,inpatient,,,21555.00000,6250.95000,Aetna,Local,,8622.00,,,,,,,7770.58,17631.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE MATRIX,9098378,CDM,278,RC,Q4116,HCPCS,,,facility,outpatient,,,21555.00000,6250.95000,Aetna,Local,,8622.00,,,,,,,124.65,17631.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,9098379,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1665.51,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,9098379,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4620.00000,1339.80000,Aetna,Local,,1848.00,,,,,,,1487.64,3779.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9096354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9096354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9096451,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
POLARSTEM,9096451,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,Local,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9096452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9096452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,Local,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9096454,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2839.07,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9096454,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7875.36000,2283.85000,Aetna,Local,,3150.14,,,,,,,2535.87,6442.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9098390,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,3062.33,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL FEMORAL,9098390,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8494.68000,2463.46000,Aetna,Local,,3397.87,,,,,,,2735.29,6948.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9096453,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9096453,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,Local,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT SCAFFOLD,9086251,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT SCAFFOLD,9086251,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9098469,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9098469,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9098470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3493.00000,1012.97000,Aetna,Local,,1397.20,,,,,,,1259.23,2857.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9098470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3493.00000,1012.97000,Aetna,Local,,1397.20,,,,,,,1124.75,2857.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9098471,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,332.11,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,9098471,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,921.24000,267.16000,Aetna,Local,,368.50,,,,,,,296.64,753.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098454,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,584.01,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098454,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1620.00000,469.80000,Aetna,Local,,648.00,,,,,,,521.64,1325.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9098483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9098483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,Local,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9098484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,23400.00000,6786.00000,Aetna,Local,,9360.00,,,,,,,8435.70,19141.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,9098484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,23400.00000,6786.00000,Aetna,Local,,9360.00,,,,,,,7534.80,19141.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ASSEMBLY,9098485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,40878.00000,11854.62000,Aetna,Local,,16351.20,,,,,,,14736.52,33438.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ASSEMBLY,9098485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,40878.00000,11854.62000,Aetna,Local,,16351.20,,,,,,,13162.72,33438.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9098455,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,9098455,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,Local,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9098515,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,3297.49,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9098515,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9147.00000,2652.63000,Aetna,Local,,3658.80,,,,,,,2945.33,7482.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9098516,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28732.50000,8332.42000,Aetna,Local,,11493.00,,,,,,,10358.07,23503.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,9098516,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28732.50000,8332.42000,Aetna,Local,,11493.00,,,,,,,9251.86,23503.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SINUS,9035115,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SINUS,9035115,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,Local,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9100567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9100567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9098523,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,3305.93,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT HUMERAL,9098523,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9170.40000,2659.42000,Aetna,Local,,3668.16,,,,,,,2952.87,7501.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9098620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,9098620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,Local,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,9098621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,9098621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,Local,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID TAP,9098622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID TAP,9098622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,Local,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE TIBIAL,9098624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONE TIBIAL,9098624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,Local,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098625,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,322.88,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,9098625,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,895.64000,259.74000,Aetna,Local,,358.26,,,,,,,288.40,732.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,9098882,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5798.10000,1681.45000,Aetna,Local,,2319.24,,,,,,,2090.22,4742.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,9098882,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5798.10000,1681.45000,Aetna,Local,,2319.24,,,,,,,1866.99,4742.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9098883,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14673.60000,4255.34000,Aetna,Local,,5869.44,,,,,,,5289.83,12003.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,9098883,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14673.60000,4255.34000,Aetna,Local,,5869.44,,,,,,,4724.90,12003.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,9098884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5798.10000,1681.45000,Aetna,Local,,2319.24,,,,,,,2090.22,4742.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,9098884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5798.10000,1681.45000,Aetna,Local,,2319.24,,,,,,,1866.99,4742.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9098885,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12330.00000,3575.70000,Aetna,Local,,4932.00,,,,,,,4444.97,10085.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9098885,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12330.00000,3575.70000,Aetna,Local,,4932.00,,,,,,,3970.26,10085.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9098886,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,7191.98,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE LUMBAR,9098886,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19950.00000,5785.50000,Aetna,Local,,7980.00,,,,,,,6423.90,16319.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9098887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,865.20,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE LOCKING,9098887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2400.00000,696.00000,Aetna,Local,,960.00,,,,,,,772.80,1963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9098888,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT TIBIAL,9098888,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,Local,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR PROXIMAL,9098891,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,18232.50000,5287.42000,Aetna,Local,,7293.00,,,,,,,6572.82,14914.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR PROXIMAL,9098891,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,18232.50000,5287.42000,Aetna,Local,,7293.00,,,,,,,5870.86,14914.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9100774,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3640.00000,1055.60000,Aetna,Local,,1456.00,,,,,,,1312.22,2977.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,9100774,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3640.00000,1055.60000,Aetna,Local,,1456.00,,,,,,,1172.08,2977.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST EXPANDER,8975307,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST EXPANDER,8975307,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST EXPANDER,8975308,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST EXPANDER,8975308,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9100992,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4609.35,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM FEMORAL,9100992,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12786.00000,3707.94000,Aetna,Local,,5114.40,,,,,,,4117.09,10458.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9099194,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,9099194,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,Local,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9100991,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6501.71000,1885.50000,Aetna,Local,,2600.68,,,,,,,2343.87,5318.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,9100991,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6501.71000,1885.50000,Aetna,Local,,2600.68,,,,,,,2093.55,5318.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9100946,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9100946,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9100947,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9100947,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9100948,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9100948,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9100973,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9100973,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9100974,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT TISSUE,9100974,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW SPINAL,9100976,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW SPINAL,9100976,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW SPINAL,9100977,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SCREW SPINAL,9100977,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,Local,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9099192,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA PROSTHESIS,9099192,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,Local,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,9099193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1505.27,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,9099193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4175.50000,1210.90000,Aetna,Local,,1670.20,,,,,,,1344.51,3415.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9100981,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9100981,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9100982,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1780.46,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,9100982,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4938.85000,1432.27000,Aetna,Local,,1975.54,,,,,,,1590.31,4039.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9101048,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9101048,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9101049,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDING,9101049,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,Local,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9099300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1492.00000,432.68000,Aetna,Local,,596.80,,,,,,,537.87,1220.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,9099300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1492.00000,432.68000,Aetna,Local,,596.80,,,,,,,480.42,1220.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9220460,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,9220460,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TEMP PACER LEAD,7694843,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TEMP PACER LEAD,7694843,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,Local,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8986412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCK CHARGE EPIDURAL,8437018,CDM,278,RC,,,,,facility,inpatient,,,1911.00000,554.19000,Aetna,Local,,764.40,,,,,,,688.92,1563.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCK CHARGE EPIDURAL,8437018,CDM,278,RC,,,,,facility,outpatient,,,1911.00000,554.19000,Aetna,Local,,764.40,,,,,,,615.34,1563.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSURGICAL PROCEDURE KIT,9042870,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSURGICAL PROCEDURE KIT,9042870,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,Local,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Balloon 10mm,8438480,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,3300.01,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Balloon 10mm,8438480,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,2947.58,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Balloon 15mm,8438482,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,3300.01,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Balloon 15mm,8438482,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,2947.58,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Guide H 6Fr,8438484,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Guide H 6Fr,8438484,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Guide M 6Fr,8438486,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Guide M 6Fr,8438486,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Guide R 6Fr,8438488,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Guide R 6Fr,8438488,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Avaflex Kit,8438490,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9472.89000,2747.14000,Aetna,Local,,3789.16,,,,,,,3414.98,7748.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Avaflex Kit,8438490,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9472.89000,2747.14000,Aetna,Local,,3789.16,,,,,,,3050.27,7748.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tissue Location Device Additional Clip,8438498,CDM,278,RC,C1819,HCPCS,,,facility,inpatient,,,456.57000,132.41000,Aetna,Local,,182.63,,,,,,,164.59,373.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tissue Location Device Additional Clip,8438498,CDM,278,RC,C1819,HCPCS,,,facility,outpatient,,,456.57000,132.41000,Aetna,Local,,182.63,,,,,,,147.02,373.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tissue Location Device Wire,8442299,CDM,278,RC,C1819,HCPCS,,,facility,inpatient,,,315.88000,91.61000,Aetna,Local,,126.35,,,,,,,113.87,258.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tissue Location Device Wire,8442299,CDM,278,RC,C1819,HCPCS,,,facility,outpatient,,,315.88000,91.61000,Aetna,Local,,126.35,,,,,,,101.71,258.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tissue Location Device Additional Wire,8442302,CDM,278,RC,C1819,HCPCS,,,facility,inpatient,,,315.88000,91.61000,Aetna,Local,,126.35,,,,,,,113.87,258.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tissue Location Device Additional Wire,8442302,CDM,278,RC,C1819,HCPCS,,,facility,outpatient,,,315.88000,91.61000,Aetna,Local,,126.35,,,,,,,101.71,258.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tissue Location Device Clip,8438496,CDM,278,RC,C1819,HCPCS,,,facility,inpatient,,,456.57000,132.41000,Aetna,Local,,182.63,,,,,,,164.59,373.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tissue Location Device Clip,8438496,CDM,278,RC,C1819,HCPCS,,,facility,outpatient,,,456.57000,132.41000,Aetna,Local,,182.63,,,,,,,147.02,373.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN STENT NEPH 8F,607049,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN STENT NEPH 8F,607049,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN INTRODUCER MET,607028,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,287.85000,83.48000,Aetna,Local,,115.14,,,,,,,103.77,235.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN INTRODUCER MET,607028,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,287.85000,83.48000,Aetna,Local,,115.14,,,,,,,92.69,235.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 035 X 150 GSS,606961,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 035 X 150 GSS,606961,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 038 X 150 G,606959,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.75000,59.38000,Aetna,Local,,81.90,,,,,,,73.81,167.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 038 X 150 G,606959,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.75000,59.38000,Aetna,Local,,81.90,,,,,,,65.93,167.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 035 X 260 G,606958,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,Local,,134.90,,,,,,,121.58,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 035 X 260 G,606958,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,Local,,134.90,,,,,,,108.59,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire GSS,606960,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,368.13000,106.76000,Aetna,Local,,147.25,,,,,,,132.71,301.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire GSS,606960,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,368.13000,106.76000,Aetna,Local,,147.25,,,,,,,118.54,301.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire B,606968,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,131.20000,38.05000,Aetna,Local,,52.48,,,,,,,47.30,107.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire B,606968,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,131.20000,38.05000,Aetna,Local,,52.48,,,,,,,42.25,107.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filter Retrieval T,8126645,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,665.84,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filter Retrieval T,8126645,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1847.00000,535.63000,Aetna,Local,,738.80,,,,,,,594.73,1510.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer D 5F,8126713,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,473.62000,137.35000,Aetna,Local,,189.45,,,,,,,170.74,387.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer D 5F,8126713,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,473.62000,137.35000,Aetna,Local,,189.45,,,,,,,152.51,387.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire BMW 190cm,8126661,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire BMW 190cm,8126661,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Meier 180cm,8126695,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,375.25000,108.82000,Aetna,Local,,150.10,,,,,,,135.28,306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Meier 180cm,8126695,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,375.25000,108.82000,Aetna,Local,,150.10,,,,,,,120.83,306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire N,3232842,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.71000,107.51000,Aetna,Local,,148.28,,,,,,,133.64,303.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire N,3232842,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.71000,107.51000,Aetna,Local,,148.28,,,,,,,119.37,303.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Nitrex 80cm,8126701,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.71000,107.51000,Aetna,Local,,148.28,,,,,,,133.64,303.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Nitrex 80cm,8126701,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.71000,107.51000,Aetna,Local,,148.28,,,,,,,119.37,303.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire J 145cm,8126685,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,100.33000,29.10000,Aetna,Local,,40.13,,,,,,,36.17,82.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire J 145cm,8126685,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,100.33000,29.10000,Aetna,Local,,40.13,,,,,,,32.31,82.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Ureteral 6F x 22cm,8126801,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Ureteral 6F x 22cm,8126801,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Dual Lumen Ureteral 10F,8126791,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,381.71000,110.70000,Aetna,Local,,152.68,,,,,,,137.61,312.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Dual Lumen Ureteral 10F,8126791,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,381.71000,110.70000,Aetna,Local,,152.68,,,,,,,122.91,312.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN DRAIN PERITONEAL,3232850,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2706.00000,784.74000,Aetna,Local,,1082.40,,,,,,,975.51,2213.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN DRAIN PERITONEAL,3232850,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2706.00000,784.74000,Aetna,Local,,1082.40,,,,,,,871.33,2213.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Peritoneal,8126821,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2706.00000,784.74000,Aetna,Local,,1082.40,,,,,,,975.51,2213.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Peritoneal,8126821,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2706.00000,784.74000,Aetna,Local,,1082.40,,,,,,,871.33,2213.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Pleural,8126823,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2706.00000,784.74000,Aetna,Local,,1082.40,,,,,,,975.51,2213.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Pleural,8126823,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2706.00000,784.74000,Aetna,Local,,1082.40,,,,,,,871.33,2213.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Transjugular Liver Access 200,8126325,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,814.73,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Transjugular Liver Access 200,8126325,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2260.00000,655.40000,Aetna,Local,,904.00,,,,,,,727.72,1848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 9F x 30cm,8126777,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,350.55000,101.66000,Aetna,Local,,140.22,,,,,,,126.37,286.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 9F x 30cm,8126777,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,350.55000,101.66000,Aetna,Local,,140.22,,,,,,,112.88,286.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer L 5F,8126717,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,341.34000,98.99000,Aetna,Local,,136.54,,,,,,,123.05,279.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer L 5F,8126717,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,341.34000,98.99000,Aetna,Local,,136.54,,,,,,,109.91,279.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain APD,8126831,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain APD,8126831,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 018 X 150 G,3601876,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 018 X 150 G,3601876,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Angled 150cm,8126655,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Angled 150cm,8126655,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 018 X 260 G,3601878,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,501.13000,145.33000,Aetna,Local,,200.45,,,,,,,180.66,409.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 018 X 260 G,3601878,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,501.13000,145.33000,Aetna,Local,,200.45,,,,,,,161.36,409.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glidewire 260cm,8126681,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,501.13000,145.33000,Aetna,Local,,200.45,,,,,,,180.66,409.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glidewire 260cm,8126681,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,501.13000,145.33000,Aetna,Local,,200.45,,,,,,,161.36,409.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire G,3601880,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.75000,59.38000,Aetna,Local,,81.90,,,,,,,73.81,167.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire G,3601880,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.75000,59.38000,Aetna,Local,,81.90,,,,,,,65.93,167.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide 150cm,8126671,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.75000,59.38000,Aetna,Local,,81.90,,,,,,,73.81,167.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide 150cm,8126671,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.75000,59.38000,Aetna,Local,,81.90,,,,,,,65.93,167.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 038 X 150 GSS,3601882,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 038 X 150 GSS,3601882,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer A,3601886,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,508.25000,147.39000,Aetna,Local,,203.30,,,,,,,183.22,415.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer A,3601886,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,508.25000,147.39000,Aetna,Local,,203.30,,,,,,,163.66,415.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN PORT 6 FS,3601894,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,576.80,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN PORT 6 FS,3601894,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,515.20,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line 6FR PP,8126456,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,576.80,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line 6FR PP,8126456,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,515.20,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN PORT 8 F,3601896,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,576.80,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN PORT 8 F,3601896,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,515.20,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line 8FR PP,8126458,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,576.80,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line 8FR PP,8126458,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1600.00000,464.00000,Aetna,Local,,640.00,,,,,,,515.20,1308.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath Curved 10F,8126763,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,542.21000,157.24000,Aetna,Local,,216.88,,,,,,,195.47,443.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath Curved 10F,8126763,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,542.21000,157.24000,Aetna,Local,,216.88,,,,,,,174.59,443.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN DRAINAGE YC,3687840,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,145.48000,42.19000,Aetna,Local,,58.19,,,,,,,52.45,119.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN DRAINAGE YC,3687840,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,145.48000,42.19000,Aetna,Local,,58.19,,,,,,,46.84,119.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer MS,5565840,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,293.55000,85.13000,Aetna,Local,,117.42,,,,,,,105.82,240.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer MS,5565840,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,293.55000,85.13000,Aetna,Local,,117.42,,,,,,,94.52,240.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer Micropuncture With Sheath,8126721,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,293.55000,85.13000,Aetna,Local,,117.42,,,,,,,105.82,240.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer Micropuncture With Sheath,8126721,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,293.55000,85.13000,Aetna,Local,,117.42,,,,,,,94.52,240.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 65cm,9057682,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 65cm,9057682,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter SF 5F 90cm,8126449,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,35.30,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter SF 5F 90cm,8126449,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,31.53,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter C 16F,8126372,CDM,278,RC,A4344,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,32.41,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter C 16F,8126372,CDM,278,RC,A4344,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,20.67,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filter UC,8126647,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5718.83000,1658.46000,Aetna,Local,,2287.53,,,,,,,2061.64,4678.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filter UC,8126647,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5718.83000,1658.46000,Aetna,Local,,2287.53,,,,,,,1841.46,4678.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filter T,8126643,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5100.20000,1479.06000,Aetna,Local,,2040.08,,,,,,,1838.62,4171.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filter T,8126643,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5100.20000,1479.06000,Aetna,Local,,2040.08,,,,,,,1642.26,4171.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Transend 190cm,8126709,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,503.26,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Transend 190cm,8126709,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,558.40,,,,,,,449.51,1141.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire J 80cm,8126693,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,95.76000,27.77000,Aetna,Local,,38.30,,,,,,,34.52,78.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire J 80cm,8126693,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,95.76000,27.77000,Aetna,Local,,38.30,,,,,,,30.83,78.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 035 X 80 A,5563886,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,160.07000,46.42000,Aetna,Local,,64.03,,,,,,,57.71,130.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE 035 X 80 A,5563886,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,160.07000,46.42000,Aetna,Local,,64.03,,,,,,,51.54,130.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Amplatz,8126653,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,160.07000,46.42000,Aetna,Local,,64.03,,,,,,,57.71,130.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Amplatz,8126653,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,160.07000,46.42000,Aetna,Local,,64.03,,,,,,,51.54,130.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire B,5563888,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,155.87000,45.20000,Aetna,Local,,62.35,,,,,,,56.19,127.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire B,5563888,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,155.87000,45.20000,Aetna,Local,,62.35,,,,,,,50.19,127.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Bentson,8126659,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,155.87000,45.20000,Aetna,Local,,62.35,,,,,,,56.19,127.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Bentson,8126659,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,155.87000,45.20000,Aetna,Local,,62.35,,,,,,,50.19,127.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE CSS,5563890,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,231.68000,67.19000,Aetna,Local,,92.67,,,,,,,83.52,189.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE CSS,5563890,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,231.68000,67.19000,Aetna,Local,,92.67,,,,,,,74.60,189.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Cope,8126667,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,231.68000,67.19000,Aetna,Local,,92.67,,,,,,,83.52,189.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Cope,8126667,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,231.68000,67.19000,Aetna,Local,,92.67,,,,,,,74.60,189.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire GDA,8126683,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,442.69,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire GDA,8126683,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1228.00000,356.12000,Aetna,Local,,491.20,,,,,,,395.42,1004.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire PP,8126705,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,489.25000,141.88000,Aetna,Local,,195.70,,,,,,,176.37,400.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire PP,8126705,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,489.25000,141.88000,Aetna,Local,,195.70,,,,,,,157.54,400.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Marker 150cm,8126432,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2020.00000,585.80000,Aetna,Local,,808.00,,,,,,,728.21,1652.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Marker 150cm,8126432,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2020.00000,585.80000,Aetna,Local,,808.00,,,,,,,650.44,1652.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter R 150cm,8126430,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter R 150cm,8126430,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,Local,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 7F x 11cm,8126771,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,127.05000,36.84000,Aetna,Local,,50.82,,,,,,,45.80,103.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 7F x 11cm,8126771,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,127.05000,36.84000,Aetna,Local,,50.82,,,,,,,40.91,103.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN SHEATH 9 CURVED,5565870,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,542.21000,157.24000,Aetna,Local,,216.88,,,,,,,195.47,443.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN SHEATH 9 CURVED,5565870,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,542.21000,157.24000,Aetna,Local,,216.88,,,,,,,174.59,443.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath Curved 9F,8126765,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,542.21000,157.24000,Aetna,Local,,216.88,,,,,,,195.47,443.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath Curved 9F,8126765,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,542.21000,157.24000,Aetna,Local,,216.88,,,,,,,174.59,443.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 9F 35cm,8126761,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 9F 35cm,8126761,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare A 25mm,8126783,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare A 25mm,8126783,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare E 18 to 30,8126787,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,Local,,587.60,,,,,,,529.57,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare E 18 to 30,8126787,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,Local,,587.60,,,,,,,473.02,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 4 x 4 x 75,8126335,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 4 x 4 x 75,8126335,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Balloon 11 x 10cm,8126723,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,3300.01,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Balloon 11 x 10cm,8126723,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,2947.58,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Balloon 11 x 15cm,8126725,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,3300.01,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Balloon 11 x 15cm,8126725,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,2947.58,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire GSS,7926852,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,190.05000,55.11000,Aetna,Local,,76.02,,,,,,,68.51,155.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire GSS,7926852,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,190.05000,55.11000,Aetna,Local,,76.02,,,,,,,61.20,155.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide SS 80cm,8126679,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,190.05000,55.11000,Aetna,Local,,76.02,,,,,,,68.51,155.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide SS 80cm,8126679,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,190.05000,55.11000,Aetna,Local,,76.02,,,,,,,61.20,155.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE GLIDE 035 X 80 G,7926854,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AN GUIDEWIRE GLIDE 035 X 80 G,7926854,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide 80cm,8126673,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide 80cm,8126673,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter SF 5F 65cm,8126446,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,35.30,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter SF 5F 65cm,8126446,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,31.53,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter C 20F,8126376,CDM,278,RC,A4344,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,32.41,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter C 20F,8126376,CDM,278,RC,A4344,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,Local,,35.96,,,,,,,20.67,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter C 22F,8126378,CDM,278,RC,A4344,HCPCS,,,facility,inpatient,,,123.27000,35.75000,Aetna,Local,,49.31,,,,,,,44.44,100.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter C 22F,8126378,CDM,278,RC,A4344,HCPCS,,,facility,outpatient,,,123.27000,35.75000,Aetna,Local,,49.31,,,,,,,20.67,100.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter C 18F,8126374,CDM,278,RC,A4344,HCPCS,,,facility,inpatient,,,85.68000,24.85000,Aetna,Local,,34.27,,,,,,,30.89,70.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter C 18F,8126374,CDM,278,RC,A4344,HCPCS,,,facility,outpatient,,,85.68000,24.85000,Aetna,Local,,34.27,,,,,,,20.67,70.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter O 5F,8126416,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,35.30,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter O 5F,8126416,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.91000,28.39000,Aetna,Local,,39.16,,,,,,,31.53,80.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire J 145cm,8126687,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,103.69000,30.07000,Aetna,Local,,41.48,,,,,,,37.38,84.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire J 145cm,8126687,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,103.69000,30.07000,Aetna,Local,,41.48,,,,,,,33.39,84.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter S2 5F,8126442,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,114.98000,33.34000,Aetna,Local,,45.99,,,,,,,41.45,94.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter S2 5F,8126442,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,114.98000,33.34000,Aetna,Local,,45.99,,,,,,,37.02,94.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter S3 5F,8126444,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,114.98000,33.34000,Aetna,Local,,45.99,,,,,,,41.45,94.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter S3 5F,8126444,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,114.98000,33.34000,Aetna,Local,,45.99,,,,,,,37.02,94.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter S1 5F,8126440,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,158.55000,45.98000,Aetna,Local,,63.42,,,,,,,57.16,129.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter S1 5F,8126440,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,158.55000,45.98000,Aetna,Local,,63.42,,,,,,,51.05,129.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 6F 11cm,8126745,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 6F 11cm,8126745,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 5F 11cm,8126741,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 5F 11cm,8126741,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 7F 11cm,8126751,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 7F 11cm,8126751,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 8F 11cm,8126753,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 8F 11cm,8126753,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 9F 11cm,8126759,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 9F 11cm,8126759,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,Local,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire J 260cm,8126689,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,160.76000,46.62000,Aetna,Local,,64.30,,,,,,,57.95,131.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire J 260cm,8126689,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,160.76000,46.62000,Aetna,Local,,64.30,,,,,,,51.76,131.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Coons,8126665,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,156.19000,45.30000,Aetna,Local,,62.48,,,,,,,56.31,127.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Coons,8126665,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,156.19000,45.30000,Aetna,Local,,62.48,,,,,,,50.29,127.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 6F 23cm,8126747,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 6F 23cm,8126747,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 7F 23cm,8126749,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 7F 23cm,8126749,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 9F 23cm,8126757,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 9F 23cm,8126757,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 8F 23cm,8126755,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,61.62,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath BT 8F 23cm,8126755,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.94000,49.57000,Aetna,Local,,68.38,,,,,,,55.04,139.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire A,606807,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,214.62000,62.24000,Aetna,Local,,85.85,,,,,,,77.37,175.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire A,606807,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,214.62000,62.24000,Aetna,Local,,85.85,,,,,,,69.11,175.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Amplatz,8126651,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,214.62000,62.24000,Aetna,Local,,85.85,,,,,,,77.37,175.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Amplatz,8126651,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,214.62000,62.24000,Aetna,Local,,85.85,,,,,,,69.11,175.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Nible,8126697,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,Local,,92.40,,,,,,,83.28,188.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Nible,8126697,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,Local,,92.40,,,,,,,74.38,188.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Feeding Tube Cecostomy Adapter,8126629,CDM,278,RC,,,,,facility,inpatient,,,220.45000,63.93000,Aetna,Local,,88.18,,,,,,,79.47,180.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Feeding Tube Cecostomy Adapter,8126629,CDM,278,RC,,,,,facility,outpatient,,,220.45000,63.93000,Aetna,Local,,88.18,,,,,,,70.98,180.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Nitinol,8126699,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.71000,107.51000,Aetna,Local,,148.28,,,,,,,133.64,303.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Nitinol,8126699,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.71000,107.51000,Aetna,Local,,148.28,,,,,,,119.37,303.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Glide 5F 100cm,8126412,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Glide 5F 100cm,8126412,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Glide 5F 65cm,8126364,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Glide 5F 65cm,8126364,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Straight 5F 65cm,8126395,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Straight 5F 65cm,8126395,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Angeled 4F 65cm,8126393,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Angeled 4F 65cm,8126393,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Mini Pig 6F,8126844,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Mini Pig 6F,8126844,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,Local,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6F 55cm,8126414,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6F 55cm,8126414,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6F 55cm,8126397,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6F 55cm,8126397,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Canulla,8126731,CDM,278,RC,,,,,facility,inpatient,,,371.76000,107.81000,Aetna,Local,,148.70,,,,,,,134.02,304.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Canulla,8126731,CDM,278,RC,,,,,facility,outpatient,,,371.76000,107.81000,Aetna,Local,,148.70,,,,,,,119.71,304.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 7F x 30cm,8126773,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,350.55000,101.66000,Aetna,Local,,140.22,,,,,,,126.37,286.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 7F x 30cm,8126773,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,350.55000,101.66000,Aetna,Local,,140.22,,,,,,,112.88,286.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 8F x 45cm,8126835,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 8F x 45cm,8126835,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire BMW,8126663,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire BMW,8126663,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,Local,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Bililary 8F,8126842,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Bililary 8F,8126842,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line M 12F x 20cm,8126468,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,428.23000,124.19000,Aetna,Local,,171.29,,,,,,,154.38,350.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line M 12F x 20cm,8126468,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,428.23000,124.19000,Aetna,Local,,171.29,,,,,,,137.89,350.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line M 12F x 24cm,8126470,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,428.23000,124.19000,Aetna,Local,,171.29,,,,,,,154.38,350.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line M 12F x 24cm,8126470,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,428.23000,124.19000,Aetna,Local,,171.29,,,,,,,137.89,350.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 12F,8126827,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 12F,8126827,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 10F,8126825,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 10F,8126825,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 14F,8126829,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 14F,8126829,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 8F,8126833,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,234.19,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 8F,8126833,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.62000,188.39000,Aetna,Local,,259.85,,,,,,,209.18,531.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126884,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,220.03,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126884,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,196.53,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126579,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,220.03,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126579,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,196.53,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126585,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,220.03,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126585,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,196.53,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126581,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,220.03,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126581,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,610.34000,177.00000,Aetna,Local,,244.14,,,,,,,196.53,499.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126587,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126587,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126583,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126583,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126589,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126589,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126593,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126593,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126591,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,229.53,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,8126591,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,636.71000,184.65000,Aetna,Local,,254.68,,,,,,,205.02,520.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Nephroureteral 8F x 24cm,8126795,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Nephroureteral 8F x 24cm,8126795,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Nephroureteral 8F x 26cm,8126797,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Nephroureteral 8F x 26cm,8126797,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Nephroureteral 8F x 28cm,8126799,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,217.38,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Nephroureteral 8F x 28cm,8126799,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,603.00000,174.87000,Aetna,Local,,241.20,,,,,,,194.17,493.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line Triple Lumen,8126813,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line Triple Lumen,8126813,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Ureteral 6F x 24cm,8126803,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Ureteral 6F x 24cm,8126803,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Ureteral 6F x 26cm,8126805,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Ureteral 6F x 26cm,8126805,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Ureteral 6F x 28 cm,8126807,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,265.53,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Ureteral 6F x 28 cm,8126807,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,736.56000,213.60000,Aetna,Local,,294.62,,,,,,,237.17,602.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter PICC Single Lumen 4F,8126418,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,864.00000,250.56000,Aetna,Local,,345.60,,,,,,,311.47,706.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter PICC Single Lumen 4F,8126418,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,864.00000,250.56000,Aetna,Local,,345.60,,,,,,,278.21,706.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line PICC 5F,8126478,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,261.59,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line PICC 5F,8126478,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,725.63000,210.43000,Aetna,Local,,290.25,,,,,,,233.65,593.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil Pusher,8126595,CDM,278,RC,,,,,facility,inpatient,,,985.50000,285.79000,Aetna,Local,,394.20,,,,,,,355.27,806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil Pusher,8126595,CDM,278,RC,,,,,facility,outpatient,,,985.50000,285.79000,Aetna,Local,,394.20,,,,,,,317.33,806.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 9F x 11cm,8126775,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,124.43000,36.08000,Aetna,Local,,49.77,,,,,,,44.86,101.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 9F x 11cm,8126775,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,124.43000,36.08000,Aetna,Local,,49.77,,,,,,,40.07,101.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 5 x 4 x 75,8126337,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 5 x 4 x 75,8126337,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 6 x 4 x 75,8126339,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 6 x 4 x 75,8126339,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 7 x 4 x 75,8126341,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 7 x 4 x 75,8126341,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 8 x 4 x 75,8126343,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 8 x 4 x 75,8126343,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 9 x 4 x 75,8126346,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 9 x 4 x 75,8126346,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 10 x 4 x 75,8126329,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 10 x 4 x 75,8126329,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 12 x 4 x 75,8126331,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 12 x 4 x 75,8126331,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 3 x 4 x 75,8126333,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 3 x 4 x 75,8126333,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,Local,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter U 5F 135x5cm,8126451,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter U 5F 135x5cm,8126451,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line PICC 6F,8126480,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,928.80000,269.35000,Aetna,Local,,371.52,,,,,,,334.83,759.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line PICC 6F,8126480,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,928.80000,269.35000,Aetna,Local,,371.52,,,,,,,299.07,759.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter CS,8126382,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1312.92000,380.75000,Aetna,Local,,525.17,,,,,,,473.31,1073.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter CS,8126382,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1312.92000,380.75000,Aetna,Local,,525.17,,,,,,,422.76,1073.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Feeding Tube Cecostomy 24cm,8126625,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1311.96000,380.47000,Aetna,Local,,524.78,,,,,,,472.96,1073.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Feeding Tube Cecostomy 24cm,8126625,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1311.96000,380.47000,Aetna,Local,,524.78,,,,,,,422.45,1073.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Feeding Tube Cecostomy 20cm,8126623,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1301.96000,377.57000,Aetna,Local,,520.78,,,,,,,469.36,1065.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Feeding Tube Cecostomy 20cm,8126623,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1301.96000,377.57000,Aetna,Local,,520.78,,,,,,,419.23,1065.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chest Tube Thoracic Vent,8126817,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1352.00000,392.08000,Aetna,Local,,540.80,,,,,,,487.40,1105.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chest Tube Thoracic Vent,8126817,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1352.00000,392.08000,Aetna,Local,,540.80,,,,,,,435.34,1105.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Particles 300 to 500,8126617,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,485.06,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Particles 300 to 500,8126617,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,433.26,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Particles 500 to 700,8126619,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,485.06,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Particles 500 to 700,8126619,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,433.26,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Particles 700 to 900,8126621,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,485.06,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Particles 700 to 900,8126621,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,433.26,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Particles 100 to 300,8126615,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,485.06,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Particles 100 to 300,8126615,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1345.52000,390.20000,Aetna,Local,,538.21,,,,,,,433.26,1100.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line Tunneled P 6F,8126815,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1444.00000,418.76000,Aetna,Local,,577.60,,,,,,,520.56,1181.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line Tunneled P 6F,8126815,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1444.00000,418.76000,Aetna,Local,,577.60,,,,,,,464.97,1181.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Fathom,8126669,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1740.00000,504.60000,Aetna,Local,,696.00,,,,,,,627.27,1423.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Fathom,8126669,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1740.00000,504.60000,Aetna,Local,,696.00,,,,,,,560.28,1423.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 12F x 11cm,8126769,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,122.87000,35.63000,Aetna,Local,,49.15,,,,,,,44.29,100.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 12F x 11cm,8126769,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,122.87000,35.63000,Aetna,Local,,49.15,,,,,,,39.56,100.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare A 35mm,8126785,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare A 35mm,8126785,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare A 10mm,8126781,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare A 10mm,8126781,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare Ensnare,8126789,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,Local,,587.60,,,,,,,529.57,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare Ensnare,8126789,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,Local,,587.60,,,,,,,473.02,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Transponder Implants,8126733,CDM,278,RC,A4648,HCPCS,,,facility,inpatient,,,2224.00000,644.96000,Aetna,Local,,889.60,,,,,,,801.75,1819.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Transponder Implants,8126733,CDM,278,RC,A4648,HCPCS,,,facility,outpatient,,,2224.00000,644.96000,Aetna,Local,,889.60,,,,,,,716.13,1819.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter R 135cm,8126428,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter R 135cm,8126428,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter R 115cm,8126426,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter R 115cm,8126426,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,Local,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty HV Cement,8126729,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3806.69000,1103.94000,Aetna,Local,,1522.68,,,,,,,1372.31,3113.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty HV Cement,8126729,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3806.69000,1103.94000,Aetna,Local,,1522.68,,,,,,,1225.75,3113.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W 8 x 40cm,8126518,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3960.25000,1148.47000,Aetna,Local,,1584.10,,,,,,,1427.67,3239.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W 8 x 40cm,8126518,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3960.25000,1148.47000,Aetna,Local,,1584.10,,,,,,,1275.20,3239.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W 10 x 68cm,8126502,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4707.99000,1365.32000,Aetna,Local,,1883.20,,,,,,,1697.23,3851.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W 10 x 68cm,8126502,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4707.99000,1365.32000,Aetna,Local,,1883.20,,,,,,,1515.97,3851.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filter UT,8126649,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5100.20000,1479.06000,Aetna,Local,,2040.08,,,,,,,1838.62,4171.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filter UT,8126649,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5100.20000,1479.06000,Aetna,Local,,2040.08,,,,,,,1642.26,4171.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Uncovered 10 x 60cm,8126496,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2329.43,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Uncovered 10 x 60cm,8126496,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2080.66,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Uncovered 10 x 80cm,8126498,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2329.43,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Uncovered 10 x 80cm,8126498,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,6461.67000,1873.88000,Aetna,Local,,2584.67,,,,,,,2080.66,5285.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Full Covered 10 x 80cm,8126486,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3414.53,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Full Covered 10 x 80cm,8126486,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3049.87,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Full Covered 10 x 60cm,8126484,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3414.53,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Full Covered 10 x 60cm,8126484,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3049.87,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Wallfex Part Covered 10 x 60cm,8126492,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9262.38000,2686.09000,Aetna,Local,,3704.95,,,,,,,3339.09,7576.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Wallfex Part Covered 10 x 60cm,8126492,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9262.38000,2686.09000,Aetna,Local,,3704.95,,,,,,,2982.49,7576.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Part Covered 10 x 80cm,8126488,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9262.38000,2686.09000,Aetna,Local,,3704.95,,,,,,,3339.09,7576.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Part Covered 10 x 80cm,8126488,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9262.38000,2686.09000,Aetna,Local,,3704.95,,,,,,,2982.49,7576.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Full Covered 10 x 40cm,8126482,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3414.53,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent W Full Covered 10 x 40cm,8126482,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,Local,,3788.66,,,,,,,3049.87,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent V 6 x 2 x 75cm,8126809,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18667.50000,5413.58000,Aetna,Local,,7467.00,,,,,,,6729.63,15270.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent V 6 x 2 x 75cm,8126809,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18667.50000,5413.58000,Aetna,Local,,7467.00,,,,,,,6010.94,15270.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent V 8 x 2 x 75cm,8126811,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17740.00000,5144.60000,Aetna,Local,,7096.00,,,,,,,6395.27,14511.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent V 8 x 2 x 75cm,8126811,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17740.00000,5144.60000,Aetna,Local,,7096.00,,,,,,,5712.28,14511.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line G 8F,8126460,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,981.00000,284.49000,Aetna,Local,,392.40,,,,,,,353.65,802.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line G 8F,8126460,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,981.00000,284.49000,Aetna,Local,,392.40,,,,,,,315.88,802.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line Groshong,8126462,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,Local,,584.00,,,,,,,526.33,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Central Line Groshong,8126462,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,Local,,584.00,,,,,,,470.12,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire NS,8442312,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,549.41000,159.33000,Aetna,Local,,219.76,,,,,,,198.06,449.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire NS,8442312,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,549.41000,159.33000,Aetna,Local,,219.76,,,,,,,176.91,449.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer CT,8442315,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,136.45000,39.57000,Aetna,Local,,54.58,,,,,,,49.19,111.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer CT,8442315,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,136.45000,39.57000,Aetna,Local,,54.58,,,,,,,43.94,111.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide 0 point18 x 150cm,8647979,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide 0 point18 x 150cm,8647979,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,Local,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath V 6Fr x 4cm,8982449,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,175.88000,51.01000,Aetna,Local,,70.35,,,,,,,63.40,143.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath V 6Fr x 4cm,8982449,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,175.88000,51.01000,Aetna,Local,,70.35,,,,,,,56.63,143.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer Micropuncture S,8981676,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,191.36000,55.49000,Aetna,Local,,76.54,,,,,,,68.99,156.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer Micropuncture S,8981676,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,191.36000,55.49000,Aetna,Local,,76.54,,,,,,,61.62,156.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Q 65cm,8982187,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1252.00000,363.08000,Aetna,Local,,500.80,,,,,,,451.35,1024.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Q 65cm,8982187,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1252.00000,363.08000,Aetna,Local,,500.80,,,,,,,403.14,1024.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Q 90cm,8981433,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1252.00000,363.08000,Aetna,Local,,500.80,,,,,,,451.35,1024.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Q 90cm,8981433,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1252.00000,363.08000,Aetna,Local,,500.80,,,,,,,403.14,1024.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Q 135cm,8982185,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1252.00000,363.08000,Aetna,Local,,500.80,,,,,,,451.35,1024.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Q 135cm,8982185,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1252.00000,363.08000,Aetna,Local,,500.80,,,,,,,403.14,1024.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 4mm x 20cm,8982267,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 4mm x 20cm,8982267,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 4mm x 35cm,8981505,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 4mm x 35cm,8981505,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 4mm x 40cm,8981521,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 4mm x 40cm,8981521,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 5mm x 17cm,8981507,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 5mm x 17cm,8981507,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 5mm x 40cm,8981509,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 5mm x 40cm,8981509,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 5mm x 40cm,8982269,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 5mm x 40cm,8982269,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 6mm x 20cm,8981511,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 6mm x 20cm,8981511,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 6mm x 35cm,8982243,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 6mm x 35cm,8982243,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 6mm x 50cm,8982245,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 6mm x 50cm,8982245,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 6mm x 50cm,8981523,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 6mm x 50cm,8981523,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 7mm x 20cm,8982247,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 7mm x 20cm,8982247,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 7mm x 50cm,8981513,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 7mm x 50cm,8981513,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 7mm x 50cm,8982271,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 7mm x 50cm,8982271,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 8mm x 45cm,8982249,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 8mm x 45cm,8982249,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 8mm x 65cm,8981515,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 8mm x 65cm,8981515,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 8mm x 65cm,8982275,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 8mm x 65cm,8982275,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 9mm x 30cm,8981517,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 9mm x 30cm,8981517,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 9mm x 65cm,8982251,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 9mm x 65cm,8982251,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 10mm x 45cm,8982209,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 10mm x 45cm,8982209,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PC 10mmx45cm,8982211,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PC 10mmx45cm,8982211,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 10mm x 65cm,8982261,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 10mm x 65cm,8982261,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 12mm x 45cm,8981485,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 12mm x 45cm,8981485,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PC 12mmx65cm,8981487,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PC 12mmx65cm,8981487,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 14mm x 45cm,8982217,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 14mm x 45cm,8982217,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 14mm x 65cm,8982219,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 14mm x 65cm,8982219,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 16mm x 65cm,8981491,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 16mm x 65cm,8981491,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 18mm x 65cm,8981495,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 18mm x 65cm,8981495,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 20mm x 65cm,8982225,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 20mm x 65cm,8982225,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 22mm x 65cm,8981497,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 22mm x 65cm,8981497,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 24mm x 65cm,8981501,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 24mm x 65cm,8981501,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9005469,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9005469,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9005473,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9005473,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9006815,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9006815,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Transjugular 19G,9005542,CDM,278,RC,A4215,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Transjugular 19G,9005542,CDM,278,RC,A4215,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,0.14445,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Transjugular 18G,9005544,CDM,278,RC,A4215,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Transjugular 18G,9005544,CDM,278,RC,A4215,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1104.00,,,,,,,0.14445,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 16F,9005567,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,647.24000,187.70000,Aetna,Local,,258.90,,,,,,,233.33,529.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 16F,9005567,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,647.24000,187.70000,Aetna,Local,,258.90,,,,,,,208.41,529.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter M 5Frx80cm,8981431,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,97.97000,28.41000,Aetna,Local,,39.19,,,,,,,35.32,80.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter M 5Frx80cm,8981431,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,97.97000,28.41000,Aetna,Local,,39.19,,,,,,,31.55,80.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter O 5Frx65cm,8982183,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,176.72000,51.25000,Aetna,Local,,70.69,,,,,,,63.71,144.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter O 5Frx65cm,8982183,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,176.72000,51.25000,Aetna,Local,,70.69,,,,,,,56.90,144.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter JB1 5Fr x 65cm,8982181,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,128.73000,37.33000,Aetna,Local,,51.49,,,,,,,46.41,105.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter JB1 5Fr x 65cm,8982181,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,128.73000,37.33000,Aetna,Local,,51.49,,,,,,,41.45,105.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter J 5Frx100,8982179,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,297.35000,86.23000,Aetna,Local,,118.94,,,,,,,107.19,243.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter J 5Frx100,8982179,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,297.35000,86.23000,Aetna,Local,,118.94,,,,,,,95.75,243.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9006833,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9006833,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 4mm x 13cm,8982239,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 4mm x 13cm,8982239,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 8mm x 30cm,8982273,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 8mm x 30cm,8982273,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent PDP 8Fr x 28cm,8981706,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent PDP 8Fr x 28cm,8981706,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 0 035 x 75cm,8981652,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 0 035 x 75cm,8981652,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath DS 1 point 25mm,8981435,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12435.00000,3606.15000,Aetna,Local,,4974.00,,,,,,,4482.82,10171.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath DS 1 point 25mm,8981435,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12435.00000,3606.15000,Aetna,Local,,4974.00,,,,,,,4004.07,10171.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire VF Tip 0 point 018 x 335cm,8981658,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,720.00000,208.80000,Aetna,Local,,288.00,,,,,,,259.56,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire VF Tip 0 point 018 x 335cm,8981658,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,720.00000,208.80000,Aetna,Local,,288.00,,,,,,,231.84,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath FB 6Fr x 40cm,8982428,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,463.74000,134.48000,Aetna,Local,,185.50,,,,,,,167.18,379.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath FB 6Fr x 40cm,8982428,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,463.74000,134.48000,Aetna,Local,,185.50,,,,,,,149.32,379.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath FB 8Fr x 40cm,8982431,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,463.74000,134.48000,Aetna,Local,,185.50,,,,,,,167.18,379.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath FB 8Fr x 40cm,8982431,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,463.74000,134.48000,Aetna,Local,,185.50,,,,,,,149.32,379.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath Ch 14Fr x 45cm,8981682,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,856.94000,248.51000,Aetna,Local,,342.78,,,,,,,308.93,700.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath Ch 14Fr x 45cm,8981682,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,856.94000,248.51000,Aetna,Local,,342.78,,,,,,,275.93,700.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter A 5Frx65cm,8981417,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter A 5Frx65cm,8981417,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,Local,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter B 5Frx100cm,8982170,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,89.25000,25.88000,Aetna,Local,,35.70,,,,,,,32.17,73.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter B 5Frx100cm,8982170,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,89.25000,25.88000,Aetna,Local,,35.70,,,,,,,28.74,73.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Biliary R 10Fr,8982189,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,422.75000,122.60000,Aetna,Local,,169.10,,,,,,,152.40,345.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Biliary R 10Fr,8982189,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,422.75000,122.60000,Aetna,Local,,169.10,,,,,,,136.13,345.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Biliary R 12Fr,8981437,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,422.75000,122.60000,Aetna,Local,,169.10,,,,,,,152.40,345.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Biliary R 12Fr,8981437,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,422.75000,122.60000,Aetna,Local,,169.10,,,,,,,136.13,345.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Biliary R 14Fr,8981439,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,422.75000,122.60000,Aetna,Local,,169.10,,,,,,,152.40,345.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Biliary R 14Fr,8981439,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,422.75000,122.60000,Aetna,Local,,169.10,,,,,,,136.13,345.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Biliary R 8Fr,8981441,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,422.75000,122.60000,Aetna,Local,,169.10,,,,,,,152.40,345.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Biliary R 8Fr,8981441,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,422.75000,122.60000,Aetna,Local,,169.10,,,,,,,136.13,345.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath D 8Fr x 45cm,8981688,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath D 8Fr x 45cm,8981688,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath D 8Fr x 65cm,8981690,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,663.75000,192.49000,Aetna,Local,,265.50,,,,,,,239.28,542.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath D 8Fr x 65cm,8981690,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,663.75000,192.49000,Aetna,Local,,265.50,,,,,,,213.73,542.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath D 8Fr x 90cm,8981692,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath D 8Fr x 90cm,8981692,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Biliary VH 10mm x 6cm,8981704,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Biliary VH 10mm x 6cm,8981704,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Biliary VH 10mm x 8cm,8982455,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12045.00000,3493.05000,Aetna,Local,,4818.00,,,,,,,4342.22,9852.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Biliary VH 10mm x 8cm,8982455,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12045.00000,3493.05000,Aetna,Local,,4818.00,,,,,,,3878.49,9852.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Biliary VNH 10mm x 6cm,8982453,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Biliary VNH 10mm x 6cm,8982453,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,Local,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Biliary VNH 10mm x 8cm,8982457,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12960.00000,3758.40000,Aetna,Local,,5184.00,,,,,,,4672.08,10601.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Biliary VNH 10mm x 8cm,8982457,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12960.00000,3758.40000,Aetna,Local,,5184.00,,,,,,,4173.12,10601.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 3mm x 5cm,8981618,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 3mm x 5cm,8981618,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 3mm x 12cm,8981614,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 3mm x 12cm,8981614,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 3mm x 20cm,8981616,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 3mm x 20cm,8981616,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 4mm x 10cm,8982399,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 4mm x 10cm,8982399,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 4mm x 20cm,8981622,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 4mm x 20cm,8981622,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 4mm x 35cm,8981624,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 4mm x 35cm,8981624,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Ruby Complex Std 5mm x 12cm,8981626,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Ruby Complex Std 5mm x 12cm,8981626,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 5mm x 30cm,8982401,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 5mm x 30cm,8982401,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 6mm x 20cm,8982403,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 6mm x 20cm,8982403,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 6mm x 30cm,8982405,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 6mm x 30cm,8982405,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBO COIL,8981628,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBO COIL,8981628,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 8mm x 25cm,8981630,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 8mm x 25cm,8981630,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 8mm x 40cm,8981632,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 8mm x 40cm,8981632,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 10mm x 35cm,8981600,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 10mm x 35cm,8981600,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 12mm x 60cm,8981602,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 12mm x 60cm,8981602,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 14mm x 60cm,8981604,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 14mm x 60cm,8981604,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 16mm x 60cm,8982393,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 16mm x 60cm,8982393,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 18mm x 60cm,8982395,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 18mm x 60cm,8982395,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 20mm x 60cm,8981606,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 20mm x 60cm,8981606,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil P 5cm,8982197,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil P 5cm,8982197,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil P 60cm,8981451,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil P 60cm,8981451,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 28mm x 60cm,8981610,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 28mm x 60cm,8981610,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Ruby Complex Std 32mm x 60cm,8981612,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Ruby Complex Std 32mm x 60cm,8981612,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 36mm x 60cm,8982397,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 36mm x 60cm,8982397,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 40mm x 60cm,8981620,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 40mm x 60cm,8981620,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 2mm x 1cm,8981586,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 2mm x 1cm,8981586,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 2mm x 2cm,8981588,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 2mm x 2cm,8981588,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 2mm x 4cm,8982385,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 2mm x 4cm,8982385,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 3mm x 5cm,8981592,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 3mm x 5cm,8981592,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 3mm x 15cm,8981590,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 3mm x 15cm,8981590,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 4mm x 6cm,8981596,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 4mm x 6cm,8981596,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Ruby Complex Soft 4mm x 15cm,8981594,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Ruby Complex Soft 4mm x 15cm,8981594,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 6mm x 20cm,8981598,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 6mm x 20cm,8981598,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 6mm x 30cm,8982387,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 6mm x 30cm,8982387,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Ruby Complex Soft 8mm x 35cm,8982389,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Ruby Complex Soft 8mm x 35cm,8982389,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 8mm x 60cm,8982391,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 8mm x 60cm,8982391,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Ruby Complex RCS 16MM X 50CM,8981573,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Ruby Complex RCS 16MM X 50CM,8981573,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 20mm x 60cm,8981580,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCS 20mm x 60cm,8981580,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 8 10mm x 60cm,8982283,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2416.25,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 8 10mm x 60cm,8982283,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2158.20,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 10 to 12mm x 60cm,8981525,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2416.25,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 10 to 12mm x 60cm,8981525,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2158.20,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 12 to14mm x 60cm,8981527,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2416.25,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 12 to14mm x 60cm,8981527,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2158.20,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 3 x 20cm,8981529,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2416.25,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 3 x 20cm,8981529,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2158.20,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 3 25 4mm x 30cm,8982277,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2416.25,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 3 25 4mm x 30cm,8982277,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2158.20,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 4 5mm x 30cm,8982279,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2416.25,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 4 5mm x 30cm,8982279,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2158.20,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 5 6mm x 50cm,8982281,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2416.25,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 5 6mm x 50cm,8982281,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2158.20,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 6 to 8mm x 60cm,8981531,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2416.25,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PD 6 to 8mm x 60cm,8981531,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6702.50000,1943.72000,Aetna,Local,,2681.00,,,,,,,2158.20,5482.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil P 15cm,8982193,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil P 15cm,8982193,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil P30cm,8981449,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil P30cm,8981449,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil P 45cm,8982195,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil P 45cm,8982195,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Separator L200CM,8982422,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Separator L200CM,8982422,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 5x40 135cm,8982159,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 5x40 135cm,8982159,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 6x20mm 135cm,8981401,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 6x20mm 135cm,8981401,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 6x20mm 75cm,8981403,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 6x20mm 75cm,8981403,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 6x40mm 75cm,8981405,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 6x40mm 75cm,8981405,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 6x100mm 75cm,8981399,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 6x100mm 75cm,8981399,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 7x20mm 75cm,8981407,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 7x20mm 75cm,8981407,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 7x40mm 135cm,8982161,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 7x40mm 135cm,8982161,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 7x40mm 75cm,8981409,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 7x40mm 75cm,8981409,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 7x80mm 75cm,8982163,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 7x80mm 75cm,8982163,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 8x20mm 75cm,8981411,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 8x20mm 75cm,8981411,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 8x40 135cm,8981413,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 8x40 135cm,8981413,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 8x40mm 75cm,8982166,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 8x40mm 75cm,8982166,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 9x40mm 75cm,8981415,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 9x40mm 75cm,8981415,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 10x20mm 75cm,8982155,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 10x20mm 75cm,8982155,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ballloon M 10x40mm 135cm,8981393,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ballloon M 10x40mm 135cm,8981393,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 10x40mm 75CM,8981395,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 10x40mm 75CM,8981395,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 12x40mm 75cm,8981397,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 12x40mm 75cm,8981397,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 100 x 10mm,8981708,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 100 x 10mm,8981708,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA  60 x 12mm,8981718,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA  60 x 12mm,8981718,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 100 x 12mm,8981710,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 100 x 12mm,8981710,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 150 x 12mm,8981716,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,3001.16,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 150 x 12mm,8981716,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,2680.65,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 60 x 14mm,8982465,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 60 x 14mm,8982465,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 120 x 14mm,8981712,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 120 x 14mm,8981712,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 150 x 14mm,8982461,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,3001.16,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 150 x 14mm,8982461,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,8325.00000,2414.25000,Aetna,Local,,3330.00,,,,,,,2680.65,6809.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 180 x 16mm,8982463,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 180 x 16mm,8982463,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 120 x 16mm,8982459,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 120 x 16mm,8982459,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 80 x 20mm,8982467,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 80 x 20mm,8982467,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 120 x 20mm,8981714,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2784.86,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent VSEA 120 x 20mm,8981714,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,7725.00000,2240.25000,Aetna,Local,,3090.00,,,,,,,2487.45,6319.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 18Fr,8982434,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,325.33000,94.35000,Aetna,Local,,130.13,,,,,,,117.28,266.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath PA 18Fr,8982434,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,325.33000,94.35000,Aetna,Local,,130.13,,,,,,,104.76,266.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer Micropuncture 5Fr,8981674,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,316.78000,91.87000,Aetna,Local,,126.71,,,,,,,114.20,259.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer Micropuncture 5Fr,8981674,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,316.78000,91.87000,Aetna,Local,,126.71,,,,,,,102.00,259.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 4x20mm 135cm,8982157,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 4x20mm 135cm,8982157,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 140cm,8982413,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 140cm,8982413,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 6fr,9057624,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 6fr,9057624,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,Local,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Separator I 200cm,8982420,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Separator I 200cm,8982420,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sperator 4,9060678,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sperator 4,9060678,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,Local,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Separator I 150cm,8981672,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2752.42,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Separator I 150cm,8981672,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,Local,,3054.00,,,,,,,2458.47,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 12Fr 100cm XTORQ,8982411,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,21225.00000,6155.25000,Aetna,Local,,8490.00,,,,,,,7651.61,17362.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 12Fr 100cm XTORQ,8982411,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,21225.00000,6155.25000,Aetna,Local,,8490.00,,,,,,,6834.45,17362.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 12Fr 115cm HTORQ,8981660,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,21225.00000,6155.25000,Aetna,Local,,8490.00,,,,,,,7651.61,17362.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 12Fr 115cm HTORQ,8981660,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,21225.00000,6155.25000,Aetna,Local,,8490.00,,,,,,,6834.45,17362.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 8Fr 115cm XTORQ,8981662,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,18725.00000,5430.25000,Aetna,Local,,7490.00,,,,,,,6750.36,15317.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 8Fr 115cm XTORQ,8981662,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,18725.00000,5430.25000,Aetna,Local,,7490.00,,,,,,,6029.45,15317.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire NS 0 018 x 60cm,8981656,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.71000,107.51000,Aetna,Local,,148.28,,,,,,,133.64,303.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire NS 0 018 x 60cm,8981656,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.71000,107.51000,Aetna,Local,,148.28,,,,,,,119.37,303.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire NA 0 018 x 60cm,8981654,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,370.71000,107.51000,Aetna,Local,,148.28,,,,,,,133.64,303.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire NA 0 018 x 60cm,8981654,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,370.71000,107.51000,Aetna,Local,,148.28,,,,,,,119.37,303.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 18F,9005569,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,647.24000,187.70000,Aetna,Local,,258.90,,,,,,,233.33,529.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 18F,9005569,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,647.24000,187.70000,Aetna,Local,,258.90,,,,,,,208.41,529.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 16F,9006729,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,513.24000,148.84000,Aetna,Local,,205.30,,,,,,,185.02,419.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 16F,9006729,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,513.24000,148.84000,Aetna,Local,,205.30,,,,,,,165.26,419.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 18F,9006731,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.76000,188.43000,Aetna,Local,,259.90,,,,,,,234.24,531.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 18F,9006731,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.76000,188.43000,Aetna,Local,,259.90,,,,,,,209.22,531.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 20F,9006733,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,649.76000,188.43000,Aetna,Local,,259.90,,,,,,,234.24,531.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 20F,9006733,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,649.76000,188.43000,Aetna,Local,,259.90,,,,,,,209.22,531.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 150cm,9021389,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,488.12,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 150cm,9021389,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,435.99,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 150cm,9024294,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,488.12,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 150cm,9024294,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,435.99,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 150cm,9021274,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,206.03,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 150cm,9021274,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,184.02,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9024215,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,206.03,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9024215,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,571.50000,165.74000,Aetna,Local,,228.60,,,,,,,184.02,467.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021310,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021310,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021312,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021312,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,9021314,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,9021314,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021320,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021320,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021324,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021324,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9021270,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,283.89,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9021270,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,787.50000,228.37000,Aetna,Local,,315.00,,,,,,,253.57,644.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9024211,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9024211,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9021266,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9021266,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9021272,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9021272,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,Local,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9021268,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2412.00000,699.48000,Aetna,Local,,964.80,,,,,,,869.53,1973.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9021268,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2412.00000,699.48000,Aetna,Local,,964.80,,,,,,,776.66,1973.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9024217,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,201.16,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 300cm,9024217,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,179.68,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 6F,9005475,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 6F,9005475,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 8F,9005477,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 8F,9005477,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,Local,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 10F,9005471,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,Local,,199.12,,,,,,,179.46,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 10F,9005471,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,Local,,199.12,,,,,,,160.29,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare 2mm,9021304,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare 2mm,9021304,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare 7mm,9021306,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare 7mm,9021306,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 22F,9006817,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,325.33000,94.35000,Aetna,Local,,130.13,,,,,,,117.28,266.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 22F,9006817,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,325.33000,94.35000,Aetna,Local,,130.13,,,,,,,104.76,266.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 12F,9005465,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,355.59000,103.12000,Aetna,Local,,142.24,,,,,,,128.19,290.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 12F,9005465,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,355.59000,103.12000,Aetna,Local,,142.24,,,,,,,114.50,290.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006715,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,716.18000,207.69000,Aetna,Local,,286.47,,,,,,,258.18,585.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006715,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,716.18000,207.69000,Aetna,Local,,286.47,,,,,,,230.61,585.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006713,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,753.71000,218.58000,Aetna,Local,,301.48,,,,,,,271.71,616.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006713,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,753.71000,218.58000,Aetna,Local,,301.48,,,,,,,242.69,616.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005387,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,716.18000,207.69000,Aetna,Local,,286.47,,,,,,,258.18,585.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005387,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,716.18000,207.69000,Aetna,Local,,286.47,,,,,,,230.61,585.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005379,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,906.71000,262.95000,Aetna,Local,,362.68,,,,,,,326.87,741.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005379,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,906.71000,262.95000,Aetna,Local,,362.68,,,,,,,291.96,741.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006711,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,834.48000,242.00000,Aetna,Local,,333.79,,,,,,,300.83,682.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006711,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,834.48000,242.00000,Aetna,Local,,333.79,,,,,,,268.70,682.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005373,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,834.48000,242.00000,Aetna,Local,,333.79,,,,,,,300.83,682.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005373,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,834.48000,242.00000,Aetna,Local,,333.79,,,,,,,268.70,682.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter CVSL,9005395,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1364.00000,395.56000,Aetna,Local,,545.60,,,,,,,491.72,1115.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter CVSL,9005395,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1364.00000,395.56000,Aetna,Local,,545.60,,,,,,,439.21,1115.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 24F,9006837,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,325.33000,94.35000,Aetna,Local,,130.13,,,,,,,117.28,266.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 24F,9006837,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,325.33000,94.35000,Aetna,Local,,130.13,,,,,,,104.76,266.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer 4F,9021288,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,191.36000,55.49000,Aetna,Local,,76.54,,,,,,,68.99,156.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer 4F,9021288,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,191.36000,55.49000,Aetna,Local,,76.54,,,,,,,61.62,156.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer,9021279,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer,9021279,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,Local,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain R 8 point 5Fr,8981447,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,410.02000,118.91000,Aetna,Local,,164.01,,,,,,,147.81,335.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain R 8 point 5Fr,8981447,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,410.02000,118.91000,Aetna,Local,,164.01,,,,,,,132.03,335.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,9072200,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,9072200,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 6Fr x 10cm RO II,8981696,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,178.50000,51.76000,Aetna,Local,,71.40,,,,,,,64.35,146.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 6Fr x 10cm RO II,8981696,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,178.50000,51.76000,Aetna,Local,,71.40,,,,,,,57.48,146.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 6Fr x 25cm RO II,8981698,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,220.50000,63.94000,Aetna,Local,,88.20,,,,,,,79.49,180.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 6Fr x 25cm RO II,8981698,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,220.50000,63.94000,Aetna,Local,,88.20,,,,,,,71.00,180.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 7Fr x 10cm,8982442,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,86.63000,25.12000,Aetna,Local,,34.65,,,,,,,31.23,70.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 7Fr x 10cm,8982442,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,86.63000,25.12000,Aetna,Local,,34.65,,,,,,,27.89,70.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 8Fr x 10cm,8981700,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,86.63000,25.12000,Aetna,Local,,34.65,,,,,,,31.23,70.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 8Fr x 10cm,8981700,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,86.63000,25.12000,Aetna,Local,,34.65,,,,,,,27.89,70.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 8Fr x 25cm,8982445,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 8Fr x 25cm,8982445,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 9Fr x 10cm,8982447,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,86.63000,25.12000,Aetna,Local,,34.65,,,,,,,31.23,70.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 9Fr x 10cm,8982447,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,86.63000,25.12000,Aetna,Local,,34.65,,,,,,,27.89,70.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 10Fr x 10cm,8982437,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,86.63000,25.12000,Aetna,Local,,34.65,,,,,,,31.23,70.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 10Fr x 10cm,8982437,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,86.63000,25.12000,Aetna,Local,,34.65,,,,,,,27.89,70.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 10Fr x 25cm,8981694,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath P 10Fr x 25cm,8981694,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tramsponders BC,8982168,CDM,278,RC,,,,,facility,inpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,735.42,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tramsponders BC,8982168,CDM,278,RC,,,,,facility,outpatient,,,2040.00000,591.60000,Aetna,Local,,816.00,,,,,,,656.88,1668.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dialysis 15cm,9005548,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,1297.00000,376.13000,Aetna,Local,,518.80,,,,,,,467.57,1060.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dialysis 15cm,9005548,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,1297.00000,376.13000,Aetna,Local,,518.80,,,,,,,417.63,1060.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dialysis 20cm,9006872,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,1297.00000,376.13000,Aetna,Local,,518.80,,,,,,,467.57,1060.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dialysis 20cm,9006872,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,1297.00000,376.13000,Aetna,Local,,518.80,,,,,,,417.63,1060.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dialysis 24cm,9006870,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,1297.00000,376.13000,Aetna,Local,,518.80,,,,,,,467.57,1060.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dialysis 24cm,9006870,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,1297.00000,376.13000,Aetna,Local,,518.80,,,,,,,417.63,1060.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dialysis 30cm,9005546,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,1297.00000,376.13000,Aetna,Local,,518.80,,,,,,,467.57,1060.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dialysis 30cm,9005546,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,1297.00000,376.13000,Aetna,Local,,518.80,,,,,,,417.63,1060.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021333,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9735.00000,2823.15000,Aetna,Local,,3894.00,,,,,,,3509.47,7963.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021333,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9735.00000,2823.15000,Aetna,Local,,3894.00,,,,,,,3134.67,7963.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,9021328,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,9021328,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021335,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9735.00000,2823.15000,Aetna,Local,,3894.00,,,,,,,3509.47,7963.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021335,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9735.00000,2823.15000,Aetna,Local,,3894.00,,,,,,,3134.67,7963.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,9024254,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,9024254,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9005461,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9005461,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 11mm x 37cm,8982213,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 11mm x 37cm,8982213,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 12mm x 40cm,8982215,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 12mm x 40cm,8982215,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9021258,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9021258,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,Local,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9024207,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9024207,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9072202,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9072202,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9068355,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9068355,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9068357,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9068357,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9068359,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9068359,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5fr,8126436,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,88.20000,25.58000,Aetna,Local,,35.28,,,,,,,31.80,72.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5fr,8126436,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,88.20000,25.58000,Aetna,Local,,35.28,,,,,,,28.40,72.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5fr,8126438,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,88.20000,25.58000,Aetna,Local,,35.28,,,,,,,31.80,72.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5fr,8126438,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,88.20000,25.58000,Aetna,Local,,35.28,,,,,,,28.40,72.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 1mm x 3cm,9082493,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 1mm x 3cm,9082493,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath Ch 16fr x 13cm,9080603,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,731.21000,212.05000,Aetna,Local,,292.48,,,,,,,263.60,598.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath Ch 16fr x 13cm,9080603,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,731.21000,212.05000,Aetna,Local,,292.48,,,,,,,235.45,598.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9021383,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,171.24,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9021383,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,475.00000,137.75000,Aetna,Local,,190.00,,,,,,,152.95,388.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Closure Device,9005565,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,346.76,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Closure Device,9005565,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,961.88000,278.95000,Aetna,Local,,384.75,,,,,,,309.73,786.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 75cm,9005371,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 75cm,9005371,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8Fr,9057656,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8Fr,9057656,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Amplatz,9060712,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Amplatz,9060712,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent H,9057634,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent H,9057634,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 90cm,9060718,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,297.35000,86.23000,Aetna,Local,,118.94,,,,,,,107.19,243.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 90cm,9060718,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,297.35000,86.23000,Aetna,Local,,118.94,,,,,,,95.75,243.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cactheter 16fr,9057626,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,10301.29,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cactheter 16fr,9057626,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,9201.15,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent V,9057628,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9735.00000,2823.15000,Aetna,Local,,3894.00,,,,,,,3509.47,7963.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent V,9057628,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9735.00000,2823.15000,Aetna,Local,,3894.00,,,,,,,3134.67,7963.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent V,9057630,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9735.00000,2823.15000,Aetna,Local,,3894.00,,,,,,,3509.47,7963.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent V,9057630,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9735.00000,2823.15000,Aetna,Local,,3894.00,,,,,,,3134.67,7963.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Viabahn Stent,9060684,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Viabahn Stent,9060684,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bone Cement,9057644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1679.84000,487.15000,Aetna,Local,,671.94,,,,,,,605.58,1374.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bone Cement,9057644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1679.84000,487.15000,Aetna,Local,,671.94,,,,,,,540.91,1374.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Spine Needle,9057646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15850.50000,4596.64000,Aetna,Local,,6340.20,,,,,,,5714.11,12965.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Spine Needle,9057646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15850.50000,4596.64000,Aetna,Local,,6340.20,,,,,,,5103.86,12965.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare,9057658,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare,9057658,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare,9057660,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare,9057660,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare,9060708,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Snare,9060708,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,Local,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 150cm,9057664,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,488.12,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 150cm,9057664,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,435.99,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 90cm,9057666,CDM,278,RC,C1877,HCPCS,,,facility,inpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,488.12,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 90cm,9057666,CDM,278,RC,C1877,HCPCS,,,facility,outpatient,,,1354.00000,392.66000,Aetna,Local,,541.60,,,,,,,435.99,1107.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Amplatz,9060714,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Amplatz,9060714,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,Local,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Bentson,9057668,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,148.68000,43.12000,Aetna,Local,,59.47,,,,,,,53.60,121.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Bentson,9057668,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,148.68000,43.12000,Aetna,Local,,59.47,,,,,,,47.87,121.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide,9060716,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1294.00000,375.26000,Aetna,Local,,517.60,,,,,,,466.49,1058.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide,9060716,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1294.00000,375.26000,Aetna,Local,,517.60,,,,,,,416.67,1058.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide,9057670,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide,9057670,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Rosen,9057672,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,103.79000,30.10000,Aetna,Local,,41.52,,,,,,,37.42,84.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Rosen,9057672,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,103.79000,30.10000,Aetna,Local,,41.52,,,,,,,33.42,84.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Guide,9057674,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1608.00000,466.32000,Aetna,Local,,643.20,,,,,,,579.68,1315.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Guide,9057674,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1608.00000,466.32000,Aetna,Local,,643.20,,,,,,,517.78,1315.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Guide,9057676,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1682.00000,487.78000,Aetna,Local,,672.80,,,,,,,606.36,1375.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Guide,9057676,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1682.00000,487.78000,Aetna,Local,,672.80,,,,,,,541.60,1375.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Sportacore,9057678,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,201.16,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Sportacore,9057678,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,558.00000,161.82000,Aetna,Local,,223.20,,,,,,,179.68,456.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 6fr,9057680,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,156.96,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 6fr,9057680,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,435.39000,126.26000,Aetna,Local,,174.16,,,,,,,140.20,356.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9006808,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9006808,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 130 cm,9005412,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,Local,,1123.20,,,,,,,1012.28,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 130 cm,9005412,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,Local,,1123.20,,,,,,,904.18,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 150 cm,9006759,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,Local,,1123.20,,,,,,,1012.28,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 150 cm,9006759,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,Local,,1123.20,,,,,,,904.18,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9021375,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,219.00,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9021375,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,607.50000,176.18000,Aetna,Local,,243.00,,,,,,,195.62,496.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9024306,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1768.00000,512.72000,Aetna,Local,,707.20,,,,,,,637.36,1446.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9024306,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1768.00000,512.72000,Aetna,Local,,707.20,,,,,,,569.30,1446.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5F,9024308,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5F,9024308,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9024310,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9024310,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9024304,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9024304,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5F,9005377,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5F,9005377,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5F,9005375,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5F,9005375,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,Local,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 12F,9005631,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,461.42000,133.81000,Aetna,Local,,184.57,,,,,,,166.34,377.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 12F,9005631,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,461.42000,133.81000,Aetna,Local,,184.57,,,,,,,148.58,377.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5F 70 cm,9006642,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1508.00000,437.32000,Aetna,Local,,603.20,,,,,,,543.63,1233.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5F 70 cm,9006642,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1508.00000,437.32000,Aetna,Local,,603.20,,,,,,,485.58,1233.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5F 70 cm,9005297,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,439.85000,127.56000,Aetna,Local,,175.94,,,,,,,158.57,359.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5F 70 cm,9005297,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,439.85000,127.56000,Aetna,Local,,175.94,,,,,,,141.63,359.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Pigtail 5Fr x 90cm:Catheter Pigtail 5Fr x 90cm,9005393,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,176.72000,51.25000,Aetna,Local,,70.69,,,,,,,63.71,144.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Pigtail 5Fr x 90cm:Catheter Pigtail 5Fr x 90cm,9005393,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,176.72000,51.25000,Aetna,Local,,70.69,,,,,,,56.90,144.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 130 cm,9005414,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1667.20000,483.49000,Aetna,Local,,666.88,,,,,,,601.03,1363.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 130 cm,9005414,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1667.20000,483.49000,Aetna,Local,,666.88,,,,,,,536.84,1363.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 10F,9005467,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,461.42000,133.81000,Aetna,Local,,184.57,,,,,,,166.34,377.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 10F,9005467,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,461.42000,133.81000,Aetna,Local,,184.57,,,,,,,148.58,377.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 200cm,9024213,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1740.00000,504.60000,Aetna,Local,,696.00,,,,,,,627.27,1423.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 200cm,9024213,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1740.00000,504.60000,Aetna,Local,,696.00,,,,,,,560.28,1423.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005385,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005385,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005383,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005383,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005381,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005381,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,Local,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006717,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006717,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005391,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005391,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005389,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005389,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,234.74,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 15 mm,9005633,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9689.58000,2809.98000,Aetna,Local,,3875.83,,,,,,,3493.09,7926.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 15 mm,9005633,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9689.58000,2809.98000,Aetna,Local,,3875.83,,,,,,,3120.04,7926.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 20 mm,9005635,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9689.58000,2809.98000,Aetna,Local,,3875.83,,,,,,,3493.09,7926.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 20 mm,9005635,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9689.58000,2809.98000,Aetna,Local,,3875.83,,,,,,,3120.04,7926.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 260 cm,9006896,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,114.73,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire 260 cm,9006896,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,318.25000,92.29000,Aetna,Local,,127.30,,,,,,,102.48,260.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 5F,9024269,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,81.38,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain 5F,9024269,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,225.75000,65.47000,Aetna,Local,,90.30,,,,,,,72.69,184.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 130cm,9024292,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1667.20000,483.49000,Aetna,Local,,666.88,,,,,,,601.03,1363.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 130cm,9024292,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1667.20000,483.49000,Aetna,Local,,666.88,,,,,,,536.84,1363.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 130cm,9021385,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1667.20000,483.49000,Aetna,Local,,666.88,,,,,,,601.03,1363.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 130cm,9021385,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1667.20000,483.49000,Aetna,Local,,666.88,,,,,,,536.84,1363.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021326,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021326,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 7F,9021302,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 7F,9021302,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,50.72,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 5F,9021300,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,86.63000,25.12000,Aetna,Local,,34.65,,,,,,,31.23,70.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 5F,9021300,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,86.63000,25.12000,Aetna,Local,,34.65,,,,,,,27.89,70.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon AXT,9005295,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon AXT,9005295,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,Local,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 7F,9024288,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 7F,9024288,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 6F,9021367,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 6F,9021367,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 5F,9024285,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 5F,9024285,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 4F,9021365,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 4F,9021365,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006679,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006679,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006677,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006677,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005323,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005323,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9006671,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9006671,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9005321,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9005321,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9006669,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9006669,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 6F,9005319,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 6F,9005319,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006667,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9006667,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005317,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005317,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005315,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8F,9005315,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 9F,9005313,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 9F,9005313,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9006665,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9006665,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9006663,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9006663,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9006661,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 7F,9006661,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 9F,9005311,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 9F,9005311,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Port,9060844,CDM,278,RC,C1788,HCPCS,,,facility,inpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,713.79,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Port,9060844,CDM,278,RC,C1788,HCPCS,,,facility,outpatient,,,1980.00000,574.20000,Aetna,Local,,792.00,,,,,,,637.56,1619.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath Intro Dryseal 16frx33cm,9076761,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,Local,,1244.80,,,,,,,1121.88,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath Intro Dryseal 16frx33cm,9076761,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,Local,,1244.80,,,,,,,1002.06,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glidesheath Slender SS 6frx10cm,9078785,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glidesheath Slender SS 6frx10cm,9078785,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,Local,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 11mm x 45cm,9080605,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 11mm x 45cm,9080605,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 10x80x75,9082505,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 10x80x75,9082505,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 12x80mm 75cm,9082507,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon M 12x80mm 75cm,9082507,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 16fr HTORQ,9082509,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,10301.29,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 16fr HTORQ,9082509,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,9201.15,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 16fr HTORQ,9082511,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,10301.29,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter I 16fr HTORQ,9082511,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,9201.15,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Cement,9080725,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4078.45000,1182.75000,Aetna,Local,,1631.38,,,,,,,1470.28,3336.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty Cement,9080725,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4078.45000,1182.75000,Aetna,Local,,1631.38,,,,,,,1313.26,3336.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 11fr,9082608,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,Local,,33.60,,,,,,,30.28,68.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 11fr,9082608,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,33.60,,,,,,,27.05,68.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 6fr 45cm,9082610,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 6fr 45cm,9082610,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 6fr 45cm Rdc,9080761,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 6fr 45cm Rdc,9080761,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 6fr 65cm Str,9082612,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,663.75000,192.49000,Aetna,Local,,265.50,,,,,,,239.28,542.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 6fr 65cm Str,9082612,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,663.75000,192.49000,Aetna,Local,,265.50,,,,,,,213.73,542.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 6fr 90cm Str,9080763,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 6fr 90cm Str,9080763,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,Local,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 7fr 45cm,9080765,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 7fr 45cm,9080765,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,Local,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 12fr,9082614,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,490.20000,142.16000,Aetna,Local,,196.08,,,,,,,176.72,400.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 12fr,9082614,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,490.20000,142.16000,Aetna,Local,,196.08,,,,,,,157.84,400.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 16fr long,9082616,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,726.53000,210.69000,Aetna,Local,,290.61,,,,,,,261.91,594.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 16fr long,9082616,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,726.53000,210.69000,Aetna,Local,,290.61,,,,,,,233.94,594.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 5fr,9091681,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,84.00000,24.36000,Aetna,Local,,33.60,,,,,,,30.28,68.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath 5fr,9091681,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,33.60,,,,,,,27.05,68.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6fr,9092643,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6fr,9092643,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,Local,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5fr,9091685,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,231.00000,66.99000,Aetna,Local,,92.40,,,,,,,83.28,188.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5fr,9091685,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,Local,,92.40,,,,,,,74.38,188.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon Kit,9092884,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,3300.01,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon Kit,9092884,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9153.99000,2654.66000,Aetna,Local,,3661.60,,,,,,,2947.58,7487.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer,9094448,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,220.50000,63.94000,Aetna,Local,,88.20,,,,,,,79.49,180.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer,9094448,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,220.50000,63.94000,Aetna,Local,,88.20,,,,,,,71.00,180.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9092886,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9092886,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nephroureteral Stent,9093110,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,719.51000,208.66000,Aetna,Local,,287.80,,,,,,,259.38,588.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nephroureteral Stent,9093110,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,719.51000,208.66000,Aetna,Local,,287.80,,,,,,,231.68,588.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nephroureteral Stent,9094741,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,762.71000,221.19000,Aetna,Local,,305.08,,,,,,,274.96,623.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nephroureteral Stent,9094741,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,762.71000,221.19000,Aetna,Local,,305.08,,,,,,,245.59,623.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Micropuncture 4Fr,9095032,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Micropuncture 4Fr,9095032,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,Local,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5fr,9093367,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5fr,9093367,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5Fr,9093369,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5Fr,9093369,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6Fr,9093371,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6Fr,9093371,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6Fr,9095034,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6Fr,9095034,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5Fr,9095036,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 5Fr,9095036,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6Fr,9093373,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6Fr,9093373,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6Fr,9093375,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 6Fr,9093375,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 100cm,9109954,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,58.67,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 100cm,9109954,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,162.75000,47.20000,Aetna,Local,,65.10,,,,,,,52.41,133.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thrombectomy Supplies,9114554,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,31612.00000,9167.48000,Aetna,Local,,12644.80,,,,,,,11396.13,25858.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thrombectomy Supplies,9114554,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,31612.00000,9167.48000,Aetna,Local,,12644.80,,,,,,,10179.06,25858.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9116448,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9116448,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9114758,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,9114758,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,Local,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,9114754,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,7480.38,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,9114754,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,6681.50,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,9116446,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,7480.38,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,9116446,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,6681.50,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Line 4Fr,9150394,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,684.00000,198.36000,Aetna,Local,,273.60,,,,,,,246.58,559.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Line 4Fr,9150394,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,684.00000,198.36000,Aetna,Local,,273.60,,,,,,,220.25,559.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Line 5Fr,9150396,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,319.58,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Line 5Fr,9150396,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,886.50000,257.08000,Aetna,Local,,354.60,,,,,,,285.45,725.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Line 5Fr,9145005,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Line 5Fr,9145005,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,Local,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty S 5 point 8mm,8981680,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13832.88000,4011.54000,Aetna,Local,,5533.15,,,,,,,4986.75,11315.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty S 5 point 8mm,8981680,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13832.88000,4011.54000,Aetna,Local,,5533.15,,,,,,,4454.19,11315.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty S 5 0mm,8981678,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13832.88000,4011.54000,Aetna,Local,,5533.15,,,,,,,4986.75,11315.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty S 5 0mm,8981678,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13832.88000,4011.54000,Aetna,Local,,5533.15,,,,,,,4454.19,11315.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty S 4 2mm,8982424,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13832.88000,4011.54000,Aetna,Local,,5533.15,,,,,,,4986.75,11315.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kyphoplasty S 4 2mm,8982424,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13832.88000,4011.54000,Aetna,Local,,5533.15,,,,,,,4454.19,11315.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization CoilPC 1 5mmx3cm,8982205,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization CoilPC 1 5mmx3cm,8982205,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 1 5mm x 8cm,8982207,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 1 5mm x 8cm,8982207,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 2mm x 4cm,8982231,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 2mm x 4cm,8982231,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 2mm x 6cm,8981503,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 2mm x 6cm,8981503,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 2mm x 8cm,8982233,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 2mm x 8cm,8982233,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PH 2mm x 8 cm,8982263,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil PH 2mm x 8 cm,8982263,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 3mm x 10cm,8982235,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 3mm x 10cm,8982235,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 3mm x 15cm,8982265,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PH 3mm x 15cm,8982265,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 3mm x 20cm,8982237,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 3mm x 20cm,8982237,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 4mm x 20cm,8982241,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil Prestige Complex 4mm x 20cm,8982241,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 2mm x 12cm,8982229,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil PC 2mm x 12cm,8982229,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,Local,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 16 Fr,9021379,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,10301.29,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 16 Fr,9021379,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,28575.00000,8286.75000,Aetna,Local,,11430.00,,,,,,,9201.15,23374.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9024205,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9024205,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 24mm x 60cm,8981608,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embo Coil RCSD 24mm x 60cm,8981608,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,Local,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9005463,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9005463,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9006806,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9006806,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,Local,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9006831,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9006831,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,Local,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Closure Device,8947189,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,504.70,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Closure Device,8947189,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,450.80,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Closure Device,8950251,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,504.70,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Closure Device,8950251,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,450.80,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8947191,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8947191,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8950253,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8950253,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8947193,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8947193,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Microcatheter,8950255,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1838.00000,533.02000,Aetna,Local,,735.20,,,,,,,662.60,1503.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Microcatheter,8950255,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1838.00000,533.02000,Aetna,Local,,735.20,,,,,,,591.84,1503.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Microcatheter,8950257,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,Local,,1123.20,,,,,,,1012.28,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Microcatheter,8950257,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,Local,,1123.20,,,,,,,904.18,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vena Cava Filter,8947195,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vena Cava Filter,8947195,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire,8947197,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,577.47000,167.47000,Aetna,Local,,230.99,,,,,,,208.18,472.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire,8947197,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,577.47000,167.47000,Aetna,Local,,230.99,,,,,,,185.95,472.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire,8950261,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,728.10000,211.15000,Aetna,Local,,291.24,,,,,,,262.48,595.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire,8950261,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,728.10000,211.15000,Aetna,Local,,291.24,,,,,,,234.45,595.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ablation Antenna,8982145,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,12941.10000,3752.92000,Aetna,Local,,5176.44,,,,,,,4665.27,10585.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ablation Antenna,8982145,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,12941.10000,3752.92000,Aetna,Local,,5176.44,,,,,,,4167.03,10585.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ablation Antenna,8982147,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,12941.10000,3752.92000,Aetna,Local,,5176.44,,,,,,,4665.27,10585.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ablation Antenna,8982147,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,12941.10000,3752.92000,Aetna,Local,,5176.44,,,,,,,4167.03,10585.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ablation Antenna,8981389,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,13914.45000,4035.19000,Aetna,Local,,5565.78,,,,,,,5016.16,11382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ablation Antenna,8981389,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,13914.45000,4035.19000,Aetna,Local,,5565.78,,,,,,,4480.45,11382.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Catheter,8981443,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,410.02000,118.91000,Aetna,Local,,164.01,,,,,,,147.81,335.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Catheter,8981443,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,410.02000,118.91000,Aetna,Local,,164.01,,,,,,,132.03,335.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Catheter 12Fr,8982191,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,410.02000,118.91000,Aetna,Local,,164.01,,,,,,,147.81,335.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Catheter 12Fr,8982191,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,410.02000,118.91000,Aetna,Local,,164.01,,,,,,,132.03,335.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain catheter 14Fr,8981445,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,410.02000,118.91000,Aetna,Local,,164.01,,,,,,,147.81,335.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain catheter 14Fr,8981445,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,410.02000,118.91000,Aetna,Local,,164.01,,,,,,,132.03,335.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 8mm,8981648,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 8mm,8981648,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular Plug G 10mm,8981636,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular Plug G 10mm,8981636,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 12mm,8981638,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 12mm,8981638,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 14mm,8981640,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 14mm,8981640,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 16mm,8981642,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 16mm,8981642,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 18mm,8981644,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 18mm,8981644,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 20mm,8982407,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 20mm,8982407,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 22mm,8981646,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vascular G Plug 22mm,8981646,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,Local,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,8982469,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18667.50000,5413.58000,Aetna,Local,,7467.00,,,,,,,6729.63,15270.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,8982469,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18667.50000,5413.58000,Aetna,Local,,7467.00,,,,,,,6010.94,15270.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,8982471,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,19530.00000,5663.70000,Aetna,Local,,7812.00,,,,,,,7040.56,15975.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,8982471,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,19530.00000,5663.70000,Aetna,Local,,7812.00,,,,,,,6288.66,15975.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,8982473,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,18667.50000,5413.58000,Aetna,Local,,7467.00,,,,,,,6729.63,15270.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,8982473,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,18667.50000,5413.58000,Aetna,Local,,7467.00,,,,,,,6010.94,15270.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,8981720,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,19235.00000,5578.15000,Aetna,Local,,7694.00,,,,,,,6934.22,15734.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,8981720,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,19235.00000,5578.15000,Aetna,Local,,7694.00,,,,,,,6193.67,15734.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,8982475,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17740.00000,5144.60000,Aetna,Local,,7096.00,,,,,,,6395.27,14511.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,8982475,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17740.00000,5144.60000,Aetna,Local,,7096.00,,,,,,,5712.28,14511.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Closure Device,8982149,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,504.70,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Closure Device,8982149,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,450.80,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Closure Device,8982151,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,504.70,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Closure Device,8982151,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,Local,,560.00,,,,,,,450.80,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vena Cava Filter,8982409,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vena Cava Filter,8982409,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vena Cava Filter,8981650,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vena Cava Filter,8981650,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8981427,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8981427,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8981429,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8981429,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8982177,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,759.93,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8982177,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,843.20,,,,,,,678.78,1724.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath,8981684,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath,8981684,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8981419,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,7029.75,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter,8981419,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,6279.00,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath,8981686,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath,8981686,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,Local,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath,8982451,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,175.88000,51.01000,Aetna,Local,,70.35,,,,,,,63.40,143.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath,8982451,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,175.88000,51.01000,Aetna,Local,,70.35,,,,,,,56.63,143.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,8982153,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,222.77,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,8982153,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,198.98,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,8981391,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,222.77,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon,8981391,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,198.98,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9021260,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization Coil,9021260,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,Local,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021308,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021308,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,9160396,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent,9160396,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021318,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021318,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021322,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021322,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter radial,9021413,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter radial,9021413,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter radial,9021415,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter radial,9021415,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,Local,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9024226,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9024226,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gastrostomy Tube,9021298,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,753.71000,218.58000,Aetna,Local,,301.48,,,,,,,271.71,616.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gastrostomy Tube,9021298,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,753.71000,218.58000,Aetna,Local,,301.48,,,,,,,242.69,616.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gastrostomy,9060686,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,753.71000,218.58000,Aetna,Local,,301.48,,,,,,,271.71,616.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gastrostomy,9060686,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,753.71000,218.58000,Aetna,Local,,301.48,,,,,,,242.69,616.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 12F,9021371,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,7029.75,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 12F,9021371,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,6279.00,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9024209,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 5F,9024209,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cryo,9057636,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,7935.00000,2301.15000,Aetna,Local,,3174.00,,,,,,,2860.57,6490.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cryo,9057636,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,Local,,3174.00,,,,,,,2555.07,6490.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer 5F,9005540,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,780.75000,226.42000,Aetna,Local,,312.30,,,,,,,281.46,638.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer 5F,9005540,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,780.75000,226.42000,Aetna,Local,,312.30,,,,,,,251.40,638.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021399,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021399,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021391,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021391,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021393,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021393,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024271,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024271,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,Local,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021349,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021349,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021395,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021395,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024275,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024275,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021397,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021397,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021341,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021341,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021343,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021343,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021345,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021345,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021347,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021347,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024273,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024273,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021351,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021351,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021353,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021353,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024277,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024277,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024279,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024279,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021355,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021355,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024281,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9024281,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021359,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,210.89,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon A,9021359,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,234.00,,,,,,,188.37,478.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer,9021284,CDM,278,RC,,,,,facility,inpatient,,,2456.00000,712.24000,Aetna,Local,,982.40,,,,,,,885.39,2009.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Introducer,9021284,CDM,278,RC,,,,,facility,outpatient,,,2456.00000,712.24000,Aetna,Local,,982.40,,,,,,,790.83,2009.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter CVTL,9005397,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter CVTL,9005397,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,Local,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 7F,9024283,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 7F,9024283,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 7F,9021361,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 7F,9021361,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 8F,9021363,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 8F,9021363,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 130cm,9021387,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3477.25000,1008.40000,Aetna,Local,,1390.90,,,,,,,1253.55,2844.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 130cm,9021387,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3477.25000,1008.40000,Aetna,Local,,1390.90,,,,,,,1119.67,2844.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 15cm,9021337,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,4977.00000,1443.33000,Aetna,Local,,1990.80,,,,,,,1794.21,4071.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 15cm,9021337,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,4977.00000,1443.33000,Aetna,Local,,1990.80,,,,,,,1602.59,4071.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Resolve 6 5Fr,9021377,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,410.02000,118.91000,Aetna,Local,,164.01,,,,,,,147.81,335.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Drain Resolve 6 5Fr,9021377,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,410.02000,118.91000,Aetna,Local,,164.01,,,,,,,132.03,335.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Inflation Device,9021262,CDM,278,RC,,,,,facility,inpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,62.46,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Inflation Device,9021262,CDM,278,RC,,,,,facility,outpatient,,,173.25000,50.24000,Aetna,Local,,69.30,,,,,,,55.79,141.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021330,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
stent,9021330,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent V,9060682,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent V,9060682,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,Local,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Kit,9060680,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,10080.00000,2923.20000,Aetna,Local,,4032.00,,,,,,,3633.84,8245.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter Kit,9060680,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,10080.00000,2923.20000,Aetna,Local,,4032.00,,,,,,,3245.76,8245.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thrombectomy catheter,9024222,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,6370.00000,1847.30000,Aetna,Local,,2548.00,,,,,,,2296.39,5210.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thrombectomy catheter,9024222,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,6370.00000,1847.30000,Aetna,Local,,2548.00,,,,,,,2051.14,5210.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath V 7Fr x 4cm,8981702,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,175.88000,51.01000,Aetna,Local,,70.35,,,,,,,63.40,143.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sheath V 7Fr x 4cm,8981702,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,175.88000,51.01000,Aetna,Local,,70.35,,,,,,,56.63,143.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 120cm,9021405,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 120cm,9021405,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 120cm,9024300,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 120cm,9024300,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 120cm,9021409,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 120cm,9021409,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9021401,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9021401,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 120cm,9024296,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 120cm,9024296,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9024298,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9024298,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 120cm,9021403,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 120cm,9021403,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9021407,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9021407,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9024302,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9024302,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,Local,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9021411,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 75cm,9021411,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,Local,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 4F,9021381,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,222.77,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 4F,9021381,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,198.98,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 4F,9024290,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,222.77,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balloon 4F,9024290,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,Local,,247.18,,,,,,,198.98,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vena Cava Filter,9021264,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vena Cava Filter,9021264,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 125cm,9057632,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,9900.00000,2871.00000,Aetna,Local,,3960.00,,,,,,,3568.95,8098.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
catheter 125cm,9057632,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,9900.00000,2871.00000,Aetna,Local,,3960.00,,,,,,,3187.80,8098.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Markers,9182905,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Markers,9182905,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,Local,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8fr,9182907,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,906.71000,262.95000,Aetna,Local,,362.68,,,,,,,326.87,741.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent 8fr,9182907,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,906.71000,262.95000,Aetna,Local,,362.68,,,,,,,291.96,741.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 4fr,9182909,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,131.00,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter 4fr,9182909,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,363.38000,105.38000,Aetna,Local,,145.35,,,,,,,117.01,297.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter XL,9196882,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,7480.38,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Catheter XL,9196882,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,Local,,8300.00,,,,,,,6681.50,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9212545,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9212545,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9210585,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9210585,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9210851,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9210851,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Nephroureteral 8F x 22cm,8126793,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,215.76,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Stent Nephroureteral 8F x 22cm,8126793,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,598.50000,173.56000,Aetna,Local,,239.40,,,,,,,192.72,489.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Transjugular RTPS 100,8126327,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2579.96000,748.19000,Aetna,Local,,1031.98,,,,,,,930.08,2110.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Transjugular RTPS 100,8126327,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2579.96000,748.19000,Aetna,Local,,1031.98,,,,,,,830.75,2110.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire GSS,8126675,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire GSS,8126675,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide SS,8126677,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,368.13000,106.76000,Aetna,Local,,147.25,,,,,,,132.71,301.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guidewire Glide SS,8126677,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,368.13000,106.76000,Aetna,Local,,147.25,,,,,,,118.54,301.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Venipuncture,7892200,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
Blood Drawn from Central Line Yes,7897018,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,Local,,135.56,,,,,,,106.80,2860.00,percent of total billed charges,
Blood Collection From Line,7903646,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,Local,,135.56,,,,,,,106.80,2860.00,percent of total billed charges,
Blood Draw from line,8290500,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,Local,,135.56,,,,,,,106.80,2860.00,percent of total billed charges,
Blood Draw from Line PICC or Central Line,8997131,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,Local,,135.56,,,,,,,106.80,2860.00,percent of total billed charges,
Blood draw from line PICC or Central line,9088523,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,Local,,135.56,,,,,,,106.80,2860.00,percent of total billed charges,
Blood draw from line bce,9088530,CDM,300,RC,36592,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,Local,,135.56,,,,,,,106.80,2860.00,percent of total billed charges,
Venipuncture,7957594,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
Venipuncture,8290498,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
Venipuncture,8997130,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
Venipuncture bce,9088531,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
Venipuncture,9120409,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
Blood collection from device Port a Cath,8290499,CDM,300,RC,36591,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,4.00,2860.00,percent of total billed charges,
Blood Collection from Device Port a Cath,8997132,CDM,300,RC,36591,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,4.00,2860.00,percent of total billed charges,
Blood Collection from Device Port a Cath,9088529,CDM,300,RC,36591,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,4.00,2860.00,percent of total billed charges,
Blood collection from device Port a Cath,9090464,CDM,300,RC,36591,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,4.00,2860.00,percent of total billed charges,
NB Metabolic Lab,7932190,CDM,300,RC,,,,,facility,outpatient,,,299.00000,86.71000,Aetna,Local,,151.80,,,,,,,107.79,244.58,percent of total billed charges,
ER Venipuncture,602334,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
ER Venipuncture,7897012,CDM,300,RC,36591,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,4.00,2860.00,percent of total billed charges,
Allergen Food Pistachio IgE,9142392,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,4.84,125.15,percent of total billed charges,
FINGERSTICK,636686,CDM,300,RC,36416,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
FINGERSTICK,638310,CDM,300,RC,36416,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
FINGERSTICK,638674,CDM,300,RC,36416,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
VENIPUNCTURE,596672,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
VENIPUNCTURE,636689,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
VENIPUNCTURE,638313,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
VENIPUNCTURE,638677,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
VENIPUNCTURE,646764,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
VENIPUNCTURE,646778,CDM,300,RC,36415,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,21.02,percent of total billed charges,
PLATELET COUNT BLOOD COUNT,596022,CDM,300,RC,85049,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,4.15,81.80,percent of total billed charges,
AUTOMATED PLATELET COUNT,8246770,CDM,300,RC,85049,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,4.15,81.80,percent of total billed charges,
NASAL EOSINOPHIL,596034,CDM,300,RC,89190,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,Local,,33.00,,,,,,,5.37,53.17,percent of total billed charges,
HEPARIN INDUCED THROMBOCYTOPENIA,5831839,CDM,300,RC,86022,HCPCS,,,facility,outpatient,,,544.00000,157.76000,Aetna,Local,,276.19,,,,,,,17.03,444.99,percent of total billed charges,
OBSTETRIC PANEL,627340,CDM,300,RC,80055,HCPCS,,,facility,outpatient,,,532.00000,154.28000,Aetna,Local,,270.10,,,,,,,38.90,435.18,percent of total billed charges,
BONE MARROW STAIN ONLY,636197,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,122.36,,,,,,,53.93,353.14,percent of total billed charges,
BUFFY COAT SLIDE,596025,CDM,300,RC,85009,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,4.70,94.89,percent of total billed charges,
HEMOGRAM NO DIFFERENTIAL,596023,CDM,300,RC,85027,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,Local,,71.59,,,,,,,5.99,115.34,percent of total billed charges,
CBC WITH DIFFERENTIAL,594812,CDM,300,RC,85025,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,7.20,144.79,percent of total billed charges,
BLD SMEAR MICRO EXAM,596033,CDM,300,RC,85007,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,3.52,64.62,percent of total billed charges,
EOSINOPHIL COUNT,596035,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,3.96,85.07,percent of total billed charges,
EOSINOPHIL COUNT,602303,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,3.96,85.07,percent of total billed charges,
FETAL STAIN,614648,CDM,300,RC,85460,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,Local,,128.96,,,,,,,7.17,207.77,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,596021,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,597370,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,7946077,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
HEMATOCRIT,8246794,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT,8367779,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT OTHER,596046,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMATOCRIT OTHER,604204,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
CSF HEMATOCRIT,636145,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMOGLOBIN,596020,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMOGLOBIN,597371,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
BLOOD COUNT HEMOGLOBIN,7946075,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
HEMOGLOBIN,8246793,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
BLOOOD COUNT HEMOGLOBIN,8367791,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
THROMBIN TIME,604090,CDM,300,RC,85670,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,5.35,119.43,percent of total billed charges,
WHITE BLOOD CELL COUNT,596024,CDM,300,RC,85048,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,2.36,73.62,percent of total billed charges,
ESR WESTERGREN SED RATE,596039,CDM,300,RC,85652,HCPCS,,,facility,outpatient,,,126.00000,36.54000,Aetna,Local,,63.97,,,,,,,2.50,103.07,percent of total billed charges,
FIBRIN DIMER SPLIT PRODUCTS,596406,CDM,300,RC,85378,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,Local,,116.77,,,,,,,9.01,188.14,percent of total billed charges,
FIBRIN DIMER SPLIT PRODUCTS,658963,CDM,300,RC,85378,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,Local,,116.77,,,,,,,9.01,188.14,percent of total billed charges,
Fibrin Dimer,8246772,CDM,300,RC,85378,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,Local,,116.77,,,,,,,9.01,188.14,percent of total billed charges,
Fibrin Dimer Split Products,9012084,CDM,300,RC,85378,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,Local,,116.77,,,,,,,9.01,188.14,percent of total billed charges,
PROTHROMBIN TIME,2892835,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME,596412,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME,658920,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME,658961,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME,8246801,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME,8433729,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,3.98,81.80,percent of total billed charges,
PROTHROMBIN TIME 1 TO 1 MIX,613104,CDM,300,RC,85611,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,3.66,81.80,percent of total billed charges,
HEPARIN ASSAY,2892836,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,Local,,115.76,,,,,,,12.13,186.50,percent of total billed charges,
HEPARIN ASSAY,596407,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,Local,,115.76,,,,,,,12.13,186.50,percent of total billed charges,
HEPARIN ASSAY,596408,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,Local,,115.76,,,,,,,12.13,186.50,percent of total billed charges,
PARTIAL THROMBOPLASTIN TIME,596414,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,5.57,94.07,percent of total billed charges,
PARTIAL THROMBOPLASTIN TIME,658921,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,5.57,94.07,percent of total billed charges,
PARTIAL THROMBOPLASTIN TIME,658962,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,5.57,94.07,percent of total billed charges,
THROMBOPLASTIN TIME PARTIAL,8246799,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,5.57,94.07,percent of total billed charges,
APTT 1 TO 1 MIX,613105,CDM,300,RC,85732,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,Local,,67.02,,,,,,,5.99,107.98,percent of total billed charges,
IMMATURE PLT FRACTION,8170610,CDM,300,RC,85055,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,23.12,159.51,percent of total billed charges,
COMPLETE CBC W AUTO DIFF WBC,8134949,CDM,300,RC,85025,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,7.20,144.79,percent of total billed charges,
Hematocrit Addl,8229413,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,GY,34.02,,,,,,,2.19,54.81,percent of total billed charges,
Hemoglobin Addl,8229202,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,GY,34.02,,,,,,,2.19,54.81,percent of total billed charges,
CBC without Diff Addl,8229204,CDM,300,RC,85025,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,GY,89.86,,,,,,,7.20,144.79,percent of total billed charges,
Heparin Assay Addl,8229205,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,Local,GY,115.76,,,,,,,12.13,186.50,percent of total billed charges,
Eosinophil count Addl,8230229,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,3.96,85.07,percent of total billed charges,
RETICULOCYTE,596037,CDM,300,RC,85045,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,3.70,94.07,percent of total billed charges,
FIBRINOGEN,596405,CDM,300,RC,85384,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,Local,,87.83,,,,,,,9.01,141.51,percent of total billed charges,
FIBRINOGEN,658958,CDM,300,RC,85384,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,Local,,87.83,,,,,,,9.01,141.51,percent of total billed charges,
FIBRINOGEN ACTIVITY,8246773,CDM,300,RC,85384,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,Local,,87.83,,,,,,,9.01,141.51,percent of total billed charges,
OB Panel w HIV,9002332,CDM,300,RC,80081,HCPCS,,,facility,outpatient,,,640.00000,185.60000,Aetna,Local,,324.93,,,,,,,69.39,523.52,percent of total billed charges,
BACTERIAL CULTURE MEDICAL DEVICE,593517,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE RESPIRATORY,593516,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE RESPIRATORY,593524,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE WOUND,593521,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BETA STREP CULTURE,593535,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,6.15,94.89,percent of total billed charges,
BETA STREP A SCREEN,7902430,CDM,300,RC,87430,HCPCS,,,facility,outpatient,,,99.00000,28.71000,Aetna,Local,,50.26,,,,,,,15.58,80.98,percent of total billed charges,
BACTERIAL CULTURE BLOOD,593510,CDM,300,RC,87040,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,Local,,138.60,,,,,,,9.57,223.31,percent of total billed charges,
Bacterial Culture for Blood,8948141,CDM,300,RC,87040,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,Local,,138.60,,,,,,,9.57,223.31,percent of total billed charges,
Bacterial Culture Blood,9114569,CDM,300,RC,87040,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,Local,,138.60,,,,,,,9.57,223.31,percent of total billed charges,
BACTERIAL CULTURE FECES,593565,CDM,300,RC,87045,HCPCS,,,facility,outpatient,,,414.00000,120.06000,Aetna,Local,,210.19,,,,,,,8.76,338.65,percent of total billed charges,
0081271 Sickle Solubility Bill ARUP,3190954,CDM,300,RC,85660,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,5.11,94.07,percent of total billed charges,
Crypto,3190980,CDM,300,RC,87328,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,12.81,116.97,percent of total billed charges,
CAMPYLOBACTER BY EIA,7902416,CDM,300,RC,87449,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,Local,,108.14,,,,,,,11.10,174.23,percent of total billed charges,
PH GASTRIC,7902422,CDM,300,RC,83986,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,Local,,64.48,,,,,,,3.32,103.89,percent of total billed charges,
87899 Dir IA Shiga Toxin,2532898,CDM,300,RC,87427,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,11.10,132.52,percent of total billed charges,
87427 Shiga like toxin ag eia,3373839,CDM,300,RC,87427,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,11.10,132.52,percent of total billed charges,
DIRECT IMMUNOASSAY SHIGA TOXIN,7902429,CDM,300,RC,87427,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,11.10,132.52,percent of total billed charges,
Shiga like Toxin CSCTRULE,8948136,CDM,300,RC,87427,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,11.10,132.52,percent of total billed charges,
LACTOFERRIN FECAL QUAL,7902420,CDM,300,RC,83630,HCPCS,,,facility,outpatient,,,249.00000,72.21000,Aetna,Local,,126.42,,,,,,,15.52,203.68,percent of total billed charges,
BIOCHEMICAL YEAST,7972033,CDM,300,RC,87106,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,9.57,40.90,percent of total billed charges,
BIOCHEMICAL OTHER,620801,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7972034,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7972035,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7972036,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7980772,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7989523,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7989524,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,7.49,143.15,percent of total billed charges,
BIOCHEMICAL OTHER,7989525,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,7.49,143.15,percent of total billed charges,
RapID Staphylococci Identification,8260120,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,7.49,143.15,percent of total billed charges,
RESTISTANCE TESTING,7741537,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,4.80,85.07,percent of total billed charges,
MACROSCOPIC PARASITE EXAM,7897023,CDM,300,RC,87169,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,Local,,36.05,,,,,,,4.00,58.08,percent of total billed charges,
CRYPTOCOCCUS ANTIGEN,7902419,CDM,300,RC,87327,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,12.44,144.79,percent of total billed charges,
MALARIA ANTIGEN SCREEN,7926831,CDM,300,RC,87899,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,Local,,81.74,,,,,,,14.89,131.70,percent of total billed charges,
INFECTIOUS AGENT AG DETECTION,8228698,CDM,300,RC,87899,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,Local,,81.74,,,,,,,14.89,131.70,percent of total billed charges,
INFECTIOUS AGENT AG DETECTION,8228699,CDM,300,RC,87899,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,Local,,81.74,,,,,,,14.89,131.70,percent of total billed charges,
BLOOD CULTURE FOR FUNGUS,593542,CDM,300,RC,87103,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,,171.60,,,,,,,10.17,276.48,percent of total billed charges,
CONCENTRATION INFECTIOUS AGENT,649079,CDM,300,RC,87015,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,6.19,73.62,percent of total billed charges,
MONONUCLEOSIS SCREEN,7902425,CDM,300,RC,86308,HCPCS,,,facility,outpatient,,,113.00000,32.77000,Aetna,Local,,57.37,,,,,,,4.80,92.43,percent of total billed charges,
BACTERIAL CULTURE BODY FLUID,593511,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
CULTURE BLOOD CATHETER,593537,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE EAR,593513,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE EYE,593514,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
GENITAL CULTURE,593515,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE TISSUE,593519,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE OTHER,593512,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE OTHER,593536,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE THROAT NOSE,593518,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
BACTERIAL CULTURE URINE,593520,CDM,300,RC,87086,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,Local,,116.77,,,,,,,7.48,188.14,percent of total billed charges,
BACTERIAL CULTURE ANAEROBIC,593509,CDM,300,RC,87075,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,Local,,156.37,,,,,,,8.78,251.94,percent of total billed charges,
FUNGUS CULTURE,593563,CDM,300,RC,87102,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,7.80,265.85,percent of total billed charges,
RESPIRATORY SYNC VIRUS ANTIGEN,7902427,CDM,300,RC,87420,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,Local,,109.16,,,,,,,12.90,175.87,percent of total billed charges,
Influ B,636324,CDM,300,RC,87804,HCPCS,,,facility,outpatient,,,167.00000,48.43000,Aetna,Local,,84.79,,,,,,,15.35,136.61,percent of total billed charges,
Influ Ag,648082,CDM,300,RC,87804,HCPCS,,,facility,outpatient,,,167.00000,48.43000,Aetna,Local,,84.79,,,,,,,15.35,136.61,percent of total billed charges,
Gonorrhea Culture,593564,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,6.15,94.89,percent of total billed charges,
Giardia,644366,CDM,300,RC,87329,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,11.10,116.97,percent of total billed charges,
Crypto,644367,CDM,300,RC,87329,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,11.10,116.97,percent of total billed charges,
GIARDIA ANTIGEN SCREEN,7902423,CDM,300,RC,87329,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,11.10,116.97,percent of total billed charges,
GRAM STAIN,593522,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,3.96,85.07,percent of total billed charges,
GRAM STAIN,594243,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,3.96,85.07,percent of total billed charges,
GRAM STAIN,6155895,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,3.96,85.07,percent of total billed charges,
ID EXTRA ADD ON,620793,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,Local,,60.42,,,,,,,7.49,97.34,percent of total billed charges,
API AEROBIC IDENTIFICATION,7980328,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,Local,,60.42,,,,,,,7.49,97.34,percent of total billed charges,
TISSUE GRINDING CHARGE,620800,CDM,300,RC,87176,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,5.45,59.71,percent of total billed charges,
BETA LACTAMASE,593980,CDM,300,RC,87185,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,Local,,36.05,,,,,,,4.41,58.08,percent of total billed charges,
MOLD IDENTIFICATION CHARGE,644330,CDM,300,RC,87107,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,,72.09,,,,,,,9.57,116.16,percent of total billed charges,
FECAL OCCULT BLOOD NEOPLASM SCREENING,7902421,CDM,300,RC,82270,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,Local,,33.00,,,,,,,3.37,53.17,percent of total billed charges,
GASTRIC BLOOD,7902426,CDM,300,RC,82271,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,Local,,33.00,,,,,,,4.03,53.17,percent of total billed charges,
HELICOBACTER PYLORI SCREEN UREASE,7902418,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,6.15,94.89,percent of total billed charges,
SUSCEPTIBILITY INDIVIDUAL,294945,CDM,300,RC,87181,HCPCS,,,facility,outpatient,,,81.00000,23.49000,Aetna,Local,,41.12,,,,,,,4.41,66.26,percent of total billed charges,
MINIMUM INHIBITORY CONCENTRATION,294946,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,193.00000,55.97000,Aetna,Local,,97.99,,,,,,,8.02,157.87,percent of total billed charges,
WET PREP SALINE,593529,CDM,300,RC,87210,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,5.40,89.16,percent of total billed charges,
CULTURE SCREENING ONLY,1429845,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,6.15,94.89,percent of total billed charges,
CULTURE SCREENING ONLY,1429846,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,6.15,94.89,percent of total billed charges,
CULTURE SCREENING ONLY,593532,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,6.15,94.89,percent of total billed charges,
C difficile Toxin Assay,8155516,CDM,300,RC,87324,HCPCS,,,facility,outpatient,,,252.00000,73.08000,Aetna,Local,,127.94,,,,,,,11.10,206.14,percent of total billed charges,
FECAL OCCULT BLOOD GI BLEED,8214084,CDM,300,RC,82272,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,Local,,28.94,,,,,,,3.92,46.63,percent of total billed charges,
BLOOD CULTURE FOR BACTERIA,8134952,CDM,300,RC,87040,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,Local,,138.60,,,,,,,9.57,223.31,percent of total billed charges,
SHIGA LIKE TOXIN AG IA,8134953,CDM,300,RC,87427,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,11.10,132.52,percent of total billed charges,
Culture Anaerobic Addl,8229218,CDM,300,RC,87075,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,Local,GY,156.37,,,,,,,8.78,251.94,percent of total billed charges,
Fungus Culture Addl,8229878,CDM,300,RC,87102,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,GY,165.00,,,,,,,7.80,265.85,percent of total billed charges,
AFB Stain Addl,8229214,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GY,61.94,,,,,,,5.00,99.80,percent of total billed charges,
Culture Body Fluid Addl,8230210,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
Culture Blood catheter Addl,8230211,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
Culture Miscellaneous Addl,8230217,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
Culture Ear addl,8230213,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
Culture Eye addl,8230214,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
Genital Culture Addl,8230215,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
Culture Medical Device Addl,8230216,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
Culture Respiratory Addl,8230218,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
CULTURE OTHR SPECIMN AEROBIC,8230219,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
Culture Tissue Addl,8230220,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
Culture Wound Addl,8230221,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,7.99,229.04,percent of total billed charges,
Bacterial Culture Anaerobic Addl,8230222,CDM,300,RC,87075,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,Local,,156.37,,,,,,,8.78,251.94,percent of total billed charges,
Fungus Culture Addl,8230223,CDM,300,RC,87102,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,7.80,265.85,percent of total billed charges,
Culture Screening only Addl,8230225,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,6.15,94.89,percent of total billed charges,
Beta Strep Culture Addl,8230226,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,6.15,94.89,percent of total billed charges,
Helicobacter pylori screen Addl,8230227,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,6.15,94.89,percent of total billed charges,
Gram Stain Addl,8230228,CDM,300,RC,87205,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,3.96,85.07,percent of total billed charges,
AFB Stain Addl,8230230,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,5.00,99.80,percent of total billed charges,
AFB Culture Addl,8230235,CDM,300,RC,87116,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,Local,,128.96,,,,,,,10.01,207.77,percent of total billed charges,
AFB Stain Only,593533,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,5.00,99.80,percent of total billed charges,
AFB STAIN ONLY,594242,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,5.00,99.80,percent of total billed charges,
KIRBY BAUER,294944,CDM,300,RC,87184,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,Local,,64.48,,,,,,,6.93,103.89,percent of total billed charges,
Fungus Culture Skin Hair Nails,8326250,CDM,300,RC,87101,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,Local,,87.83,,,,,,,7.15,141.51,percent of total billed charges,
Influenza Antigen A and B,7902424,CDM,300,RC,87400,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,7.98,88.34,percent of total billed charges,
87400 Influenza Antigen,8408268,CDM,300,RC,87400,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,7.98,88.34,percent of total billed charges,
Concentrated Infectious Agent,9010371,CDM,300,RC,88108,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,34.46,213.50,percent of total billed charges,
Bacterial Culture Respiratory,9028384,CDM,300,RC,87071,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,9.17,229.04,percent of total billed charges,
Bacterial Culture Respiratory,9194450,CDM,300,RC,87071,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,9.17,229.04,percent of total billed charges,
C DIFFICILE TOXIN BY IMMUNOASSAY,9226551,CDM,300,RC,87324,HCPCS,,,facility,outpatient,,,181.00000,52.49000,Aetna,Local,,91.89,,,,,,,11.10,148.06,percent of total billed charges,
C DIFF ANTIGEN TOXIN,9230468,CDM,300,RC,87449,HCPCS,,,facility,outpatient,,,204.00000,59.16000,Aetna,Local,,103.57,,,,,,,11.10,166.87,percent of total billed charges,
hCG Urine,3018937,CDM,300,RC,81025,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,7.98,108.79,percent of total billed charges,
hCG Urine,4631840,CDM,300,RC,81025,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,7.98,108.79,percent of total billed charges,
Hepatitis C Antibody,9049011,CDM,300,RC,86803,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,Local,,106.11,,,,,,,13.23,170.96,percent of total billed charges,
HEPATITIS C AB TEST,9090233,CDM,300,RC,86803,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,Local,,106.11,,,,,,,13.23,170.96,percent of total billed charges,
CALCIUM IONIZED,599730,CDM,300,RC,82330,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,8.54,144.79,percent of total billed charges,
Calcium,8246774,CDM,300,RC,82330,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,8.54,144.79,percent of total billed charges,
CALCIUM IONIZED,8367782,CDM,300,RC,82330,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,8.54,144.79,percent of total billed charges,
HEPATITIS B CORE ANTIBODY IGM,605665,CDM,300,RC,86705,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,Local,,109.16,,,,,,,10.91,175.87,percent of total billed charges,
HEPATITIS B SURF AG,605664,CDM,300,RC,87340,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,Local,,94.43,,,,,,,9.58,152.15,percent of total billed charges,
Hepatitis B surface Antigen,9088219,CDM,300,RC,87340,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,Local,,94.43,,,,,,,9.58,152.15,percent of total billed charges,
HEPATITIS B SURFACE ANTIBODY,605666,CDM,300,RC,86706,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,Local,,89.36,,,,,,,9.96,143.97,percent of total billed charges,
HEP B SURFACE ANTIBODY,9088217,CDM,300,RC,86706,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,Local,,89.36,,,,,,,9.96,143.97,percent of total billed charges,
HEPATITIS A IGM ANTIBODY,605667,CDM,300,RC,86709,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,10.43,159.51,percent of total billed charges,
HEPATITIS PANEL ACUTE,599697,CDM,300,RC,80074,HCPCS,,,facility,outpatient,,,649.00000,188.21000,Aetna,Local,,329.50,,,,,,,44.16,530.88,percent of total billed charges,
UREA NITROGEN URINE,596767,CDM,300,RC,84540,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,Local,,44.17,,,,,,,5.15,71.17,percent of total billed charges,
UREA NITROGEN URINE,596768,CDM,300,RC,84540,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,Local,,44.17,,,,,,,5.15,71.17,percent of total billed charges,
ALBUMIN LEVEL,596689,CDM,300,RC,82040,HCPCS,,,facility,outpatient,,,81.00000,23.49000,Aetna,Local,,41.12,,,,,,,4.59,66.26,percent of total billed charges,
ALBUMIN LEVEL,597161,CDM,300,RC,82040,HCPCS,,,facility,outpatient,,,81.00000,23.49000,Aetna,Local,,41.12,,,,,,,4.59,66.26,percent of total billed charges,
ALBUMIN LEVEL,599684,CDM,300,RC,82040,HCPCS,,,facility,outpatient,,,81.00000,23.49000,Aetna,Local,,41.12,,,,,,,4.59,66.26,percent of total billed charges,
PTH INTACT,2872841,CDM,300,RC,83970,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,Local,,184.80,,,,,,,38.26,297.75,percent of total billed charges,
PTH INTACT,605514,CDM,300,RC,83970,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,Local,,184.80,,,,,,,38.26,297.75,percent of total billed charges,
PTH INTACT,8324476,CDM,300,RC,83970,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,Local,,184.80,,,,,,,38.26,297.75,percent of total billed charges,
FETAL MEMBRANE RUPTURE,1976824,CDM,300,RC,84112,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,Local,,128.96,,,,,,,90.95,259.99,percent of total billed charges,
ARTERIAL BLOOD GAS FOR CLIENT,2126824,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
Arterial Blood Gas Client Addl,8229334,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,GY,160.43,,,,,,,7.68,258.49,percent of total billed charges,
LDL CHOLESTEROL LIPOPROTEIN,2548834,CDM,300,RC,83721,HCPCS,,,facility,outpatient,,,110.00000,31.90000,Aetna,Local,,55.85,,,,,,,9.73,89.98,percent of total billed charges,
HEP B CORE AB TOTAL,3060839,CDM,300,RC,86704,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,11.18,94.07,percent of total billed charges,
Hep B Core Antibody Total,8410737,CDM,300,RC,86704,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,11.18,94.07,percent of total billed charges,
HEP B CORE ANTIBODY TOTAL,9088218,CDM,300,RC,86704,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,11.18,94.07,percent of total billed charges,
SYPHILIS ANTIBODY,7962633,CDM,300,RC,86780,HCPCS,,,facility,outpatient,,,114.00000,33.06000,Aetna,Local,,57.88,,,,,,,12.28,93.25,percent of total billed charges,
86780 Syphilis Antibody,7962635,CDM,300,RC,86780,HCPCS,,,facility,outpatient,,,114.00000,33.06000,Aetna,Local,,57.88,,,,,,,12.28,93.25,percent of total billed charges,
PROCALCITONIN,7976685,CDM,300,RC,84145,HCPCS,,,facility,outpatient,,,433.00000,125.57000,Aetna,Local,,219.83,,,,,,,25.23,354.19,percent of total billed charges,
86335 Urine Immunofixation,8117511,CDM,300,RC,86335,HCPCS,,,facility,outpatient,,,302.00000,87.58000,Aetna,Local,,153.33,,,,,,,27.21,247.04,percent of total billed charges,
RPR Qualitative,8122550,CDM,300,RC,86592,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,Local,,71.59,,,,,,,3.96,115.34,percent of total billed charges,
RPR Qualitative,8122551,CDM,300,RC,86592,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,Local,,71.59,,,,,,,3.96,115.34,percent of total billed charges,
RPR TITER 1,8122547,CDM,300,RC,86593,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,,72.09,,,,,,,4.08,116.16,percent of total billed charges,
VITAMIN D 25 HYDROXY,5981857,CDM,300,RC,82306,HCPCS,,,facility,outpatient,,,221.00000,64.09000,Aetna,Local,,112.20,,,,,,,27.44,180.78,percent of total billed charges,
PROTEIN E PHORESIS SERUM,7023839,CDM,300,RC,84165,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,Local,,97.48,,,,,,,9.96,157.06,percent of total billed charges,
IMMUNOFIX E PHORESIS SERUM,7023840,CDM,300,RC,86334,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,Local,,133.02,,,,,,,20.71,214.32,percent of total billed charges,
HIV AG AND ANTIBODIES,7732029,CDM,300,RC,87389,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,22.32,144.79,percent of total billed charges,
BETA HYDROXYBUTYRATE,7911344,CDM,300,RC,82010,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,Local,,87.32,,,,,,,7.57,140.70,percent of total billed charges,
URINE DRUG SCREEN,7921223,CDM,300,RC,80306,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,15.89,85.07,percent of total billed charges,
ELECTROLYTE PANEL,596657,CDM,300,RC,80051,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,Local,,137.59,,,,,,,6.50,221.68,percent of total billed charges,
ELECTROLYTE PANEL,658418,CDM,300,RC,80051,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,Local,,137.59,,,,,,,6.50,221.68,percent of total billed charges,
BASIC METABOLIC PANEL,596652,CDM,300,RC,80048,HCPCS,,,facility,outpatient,,,311.00000,90.19000,Aetna,Local,,157.89,,,,,,,7.84,254.40,percent of total billed charges,
HEPATIC FUNCTION PANEL,596653,CDM,300,RC,80076,HCPCS,,,facility,outpatient,,,268.00000,77.72000,Aetna,Local,,136.06,,,,,,,7.57,219.22,percent of total billed charges,
HEPATIC FUNCTION PANEL,8948137,CDM,300,RC,80076,HCPCS,,,facility,outpatient,,,268.00000,77.72000,Aetna,Local,,136.06,,,,,,,7.57,219.22,percent of total billed charges,
METHEMOGLOBIN,596781,CDM,300,RC,83050,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,Local,,64.48,,,,,,,7.60,103.89,percent of total billed charges,
ACETAMINOPHEN LEVEL,596679,CDM,300,RC,80143,HCPCS,,,facility,outpatient,,,225.00000,65.25000,Aetna,Local,,114.23,,,,,,,17.28,184.05,percent of total billed charges,
ALBUMIN LEVEL BODY FLUID,596669,CDM,300,RC,82042,HCPCS,,,facility,outpatient,,,89.00000,25.81000,Aetna,Local,,45.19,,,,,,,3.83,72.80,percent of total billed charges,
ALBUMIN LEVEL BODY FLUID,596804,CDM,300,RC,82042,HCPCS,,,facility,outpatient,,,89.00000,25.81000,Aetna,Local,,45.19,,,,,,,3.83,72.80,percent of total billed charges,
Albumin Level,635102,CDM,300,RC,82042,HCPCS,,,facility,outpatient,,,89.00000,25.81000,Aetna,Local,,45.19,,,,,,,3.83,72.80,percent of total billed charges,
ETHANOL BLOOD,596773,CDM,300,RC,82077,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,Local,,89.36,,,,,,,16.01,143.97,percent of total billed charges,
ALKALINE PHOSPHATASE,596735,CDM,300,RC,84075,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,4.80,111.25,percent of total billed charges,
ALKALINE PHOSPHATASE,599670,CDM,300,RC,84075,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,4.80,111.25,percent of total billed charges,
AMMONIA LEVEL,596691,CDM,300,RC,82140,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,13.50,164.42,percent of total billed charges,
AMYLASE BLOOD,596692,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,Local,,87.32,,,,,,,6.00,140.70,percent of total billed charges,
AMYLASE RANDOM URINE,596658,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,Local,,87.32,,,,,,,6.00,140.70,percent of total billed charges,
AMYLASE RANDOM URINE,596659,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,Local,,87.32,,,,,,,6.00,140.70,percent of total billed charges,
Amylase Random Urine,613077,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,Local,,87.32,,,,,,,6.00,140.70,percent of total billed charges,
BODY FLUID AMYLASE,596799,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,Local,,87.32,,,,,,,6.00,140.70,percent of total billed charges,
BHCG QUANTITATIVE,3339839,CDM,300,RC,84702,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,Local,,94.43,,,,,,,13.96,152.15,percent of total billed charges,
BHCG QUANTITATIVE,596775,CDM,300,RC,84702,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,Local,,94.43,,,,,,,13.96,152.15,percent of total billed charges,
BILIRUBIN TOTAL,596693,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,Local,,62.45,,,,,,,4.66,100.61,percent of total billed charges,
BILIRUBIN TOTAL,599673,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,Local,,62.45,,,,,,,4.66,100.61,percent of total billed charges,
BILIRUBIN TOTAL,8324477,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,Local,,62.45,,,,,,,4.66,100.61,percent of total billed charges,
BILIRUBIN TOTAL,8324478,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,Local,,62.45,,,,,,,4.66,100.61,percent of total billed charges,
BILIRUBIN DIRECT,596694,CDM,300,RC,82248,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,Local,,62.45,,,,,,,4.66,100.61,percent of total billed charges,
BILIRUBIN DIRECT,8324561,CDM,300,RC,82248,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,Local,,62.45,,,,,,,4.66,100.61,percent of total billed charges,
COMPREHENSIVE METABOLIC PANEL,596650,CDM,300,RC,80053,HCPCS,,,facility,outpatient,,,445.00000,129.05000,Aetna,Local,,225.93,,,,,,,9.79,364.01,percent of total billed charges,
COMPREHENSIVE METABOLIC PANEL,797800,CDM,300,RC,80053,HCPCS,,,facility,outpatient,,,445.00000,129.05000,Aetna,Local,,225.93,,,,,,,9.79,364.01,percent of total billed charges,
ARTERIAL BLOOD GASES,596708,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,596713,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,596717,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,6345842,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
ARTERIAL BLOOD GASES,8367784,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
Arterial Blood Gases,9100397,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
VENOUS BLOOD GASES,596709,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
VENOUS BLOOD GASES,596715,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
VENOUS BLOOD GASES,596716,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
B TYPE NATRIURETIC PEPTIDE,596721,CDM,300,RC,83880,HCPCS,,,facility,outpatient,,,313.00000,90.77000,Aetna,Local,,158.91,,,,,,,36.39,256.03,percent of total billed charges,
BLOOD UREA NITROGEN,596648,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.67,73.62,percent of total billed charges,
BLOOD UREA NITROGEN,596765,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.67,73.62,percent of total billed charges,
BLOOD UREA NITROGEN,599674,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.67,73.62,percent of total billed charges,
BLOOD UREA NITROGEN,599688,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.67,73.62,percent of total billed charges,
UREA NITROGEN CLEAR,596766,CDM,300,RC,84545,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,6.19,128.43,percent of total billed charges,
CRP CARDIO AND INFLAMMATORY,628517,CDM,300,RC,86141,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,12.01,143.15,percent of total billed charges,
CALCIUM LEVEL TOTAL,596695,CDM,300,RC,82310,HCPCS,,,facility,outpatient,,,95.00000,27.55000,Aetna,Local,,48.23,,,,,,,4.78,77.71,percent of total billed charges,
CALCIUM LEVEL TOTAL,599675,CDM,300,RC,82310,HCPCS,,,facility,outpatient,,,95.00000,27.55000,Aetna,Local,,48.23,,,,,,,4.78,77.71,percent of total billed charges,
CALCIUM LEVEL TOTAL,599689,CDM,300,RC,82310,HCPCS,,,facility,outpatient,,,95.00000,27.55000,Aetna,Local,,48.23,,,,,,,4.78,77.71,percent of total billed charges,
CALCIUM,8324545,CDM,300,RC,82310,HCPCS,,,facility,outpatient,,,95.00000,27.55000,Aetna,Local,,48.23,,,,,,,4.78,77.71,percent of total billed charges,
CANCER ANTIGEN 125 II,605670,CDM,300,RC,86304,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,13.15,208.59,percent of total billed charges,
CARCINOEMBRYONIC ANTIGEN,596697,CDM,300,RC,82378,HCPCS,,,facility,outpatient,,,252.00000,73.08000,Aetna,Local,,127.94,,,,,,,17.57,206.14,percent of total billed charges,
DIGOXIN LEVEL,596776,CDM,300,RC,80162,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,Local,,100.02,,,,,,,12.31,161.15,percent of total billed charges,
DIGOXIN LEVEL,596777,CDM,300,RC,80162,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,Local,,100.02,,,,,,,12.31,161.15,percent of total billed charges,
DIGOXIN LEVEL,596778,CDM,300,RC,80162,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,Local,,100.02,,,,,,,12.31,161.15,percent of total billed charges,
CARBON DIOXIDE BLOOD,596710,CDM,300,RC,82374,HCPCS,,,facility,outpatient,,,196.00000,56.84000,Aetna,Local,,99.51,,,,,,,4.52,160.33,percent of total billed charges,
CARBON MONOXIDE QUANT,596774,CDM,300,RC,82375,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,Local,,87.83,,,,,,,7.68,141.51,percent of total billed charges,
Carbon Monoxide,9100400,CDM,300,RC,82375,HCPCS,,,facility,outpatient,,,173.00000,50.17000,Aetna,Local,,87.83,,,,,,,7.68,141.51,percent of total billed charges,
CHLORIDE BLOOD,596698,CDM,300,RC,82435,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,Local,,28.94,,,,,,,4.26,46.63,percent of total billed charges,
CHLORIDE URINE,596661,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,5.34,79.35,percent of total billed charges,
CHLORIDE URINE,596699,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,5.34,79.35,percent of total billed charges,
CHLORIDE URINE,602500,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,5.34,79.35,percent of total billed charges,
CHLORIDE URINE,613070,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,5.34,79.35,percent of total billed charges,
CHLORIDE URINE,636118,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,5.34,79.35,percent of total billed charges,
CHOLESTEROL,596701,CDM,300,RC,82465,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,Local,,47.72,,,,,,,4.04,76.89,percent of total billed charges,
CHOLESTEROL,596810,CDM,300,RC,82465,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,Local,,47.72,,,,,,,4.04,76.89,percent of total billed charges,
CHOLESTEROL,599683,CDM,300,RC,82465,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,Local,,47.72,,,,,,,4.04,76.89,percent of total billed charges,
COMPLEMENT COMPONENT C3,605614,CDM,300,RC,86160,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.12,164.42,percent of total billed charges,
COMPLEMENT C3,8324479,CDM,300,RC,86160,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.12,164.42,percent of total billed charges,
COMPLEMENT COMPONENT C4,605615,CDM,300,RC,86160,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.12,164.42,percent of total billed charges,
COMPLEMENT 4,8324506,CDM,300,RC,86160,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.12,164.42,percent of total billed charges,
CORTISOL TOTAL,599748,CDM,300,RC,82533,HCPCS,,,facility,outpatient,,,222.00000,64.38000,Aetna,Local,,112.71,,,,,,,15.11,181.60,percent of total billed charges,
CORTISOL TOTAL,873798,CDM,300,RC,82533,HCPCS,,,facility,outpatient,,,222.00000,64.38000,Aetna,Local,,112.71,,,,,,,15.11,181.60,percent of total billed charges,
CORTISOL TOTAL,873799,CDM,300,RC,82533,HCPCS,,,facility,outpatient,,,222.00000,64.38000,Aetna,Local,,112.71,,,,,,,15.11,181.60,percent of total billed charges,
CREATININE BLOOD,596705,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,96.00000,27.84000,Aetna,Local,,48.74,,,,,,,4.75,78.53,percent of total billed charges,
CREATININE BLOOD,599676,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,96.00000,27.84000,Aetna,Local,,48.74,,,,,,,4.75,78.53,percent of total billed charges,
CREATININE BLOOD,599691,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,96.00000,27.84000,Aetna,Local,,48.74,,,,,,,4.75,78.53,percent of total billed charges,
CREATININE BLOOD,7948676,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,96.00000,27.84000,Aetna,Local,,48.74,,,,,,,4.75,78.53,percent of total billed charges,
CREATININE CLEARANCE,1019800,CDM,300,RC,82575,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,Local,,128.96,,,,,,,8.77,207.77,percent of total billed charges,
CREATININE CLEARANCE,596706,CDM,300,RC,82575,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,Local,,128.96,,,,,,,8.77,207.77,percent of total billed charges,
CREATININE OTHER,1545907,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,4.80,86.71,percent of total billed charges,
CREATININE OTHER,596662,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,4.80,86.71,percent of total billed charges,
CREATININE OTHER,596663,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,4.80,86.71,percent of total billed charges,
CREATININE OTHER,596802,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,4.80,86.71,percent of total billed charges,
Creatinine Random Urine,613068,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,4.80,86.71,percent of total billed charges,
Body Fluid Creatinine,613078,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,4.80,86.71,percent of total billed charges,
CREATININE OTHER,663099,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,4.80,86.71,percent of total billed charges,
CREATININE,8336480,CDM,300,RC,82570,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,4.80,86.71,percent of total billed charges,
CK Isoenzyme,613102,CDM,300,RC,82553,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,Local,,104.08,,,,,,,10.71,167.69,percent of total billed charges,
PHENYTOIN DILANTIN LEVEL,596784,CDM,300,RC,80185,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,Local,,108.65,,,,,,,12.29,175.05,percent of total billed charges,
PHENYTOIN DILANTIN LEVEL,596785,CDM,300,RC,80185,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,Local,,108.65,,,,,,,12.29,175.05,percent of total billed charges,
ESTRADIOL,604448,CDM,300,RC,82670,HCPCS,,,facility,outpatient,,,289.00000,83.81000,Aetna,Local,,146.73,,,,,,,25.90,236.40,percent of total billed charges,
FERRITIN,604594,CDM,300,RC,82728,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,,103.06,,,,,,,12.64,166.05,percent of total billed charges,
Ferritin Level,9082180,CDM,300,RC,82728,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,,103.06,,,,,,,12.64,166.05,percent of total billed charges,
FETAL FIBRONECTIN FFN,596707,CDM,300,RC,82731,HCPCS,,,facility,outpatient,,,564.00000,163.56000,Aetna,Local,,286.34,,,,,,,59.71,461.35,percent of total billed charges,
FOLIC ACID SERUM,604597,CDM,300,RC,82746,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,Local,,93.42,,,,,,,13.63,150.51,percent of total billed charges,
GAMMA GLUTAMYL TRANSPEPTIDASE,596729,CDM,300,RC,82977,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,Local,,64.48,,,,,,,6.67,103.89,percent of total billed charges,
GLUCOSE LEVEL OTHER,596718,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE LEVEL OTHER,596753,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,596749,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,599677,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,599692,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE LEVEL BLOOD,7911339,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE BLOOD,8367783,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
CEREBRAL SPINAL FLUID GLUCOSE,596815,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
BODY FLUID GLUCOSE,596793,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
GLUCOSE 3 HOUR,596825,CDM,300,RC,82952,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.64,73.62,percent of total billed charges,
GLUCOSE 3 HOUR,7854056,CDM,300,RC,82952,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.64,73.62,percent of total billed charges,
Glucose Tol Test,7844075,CDM,300,RC,82951,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,11.93,73.62,percent of total billed charges,
Glucose Tol Test,7844076,CDM,300,RC,82951,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,11.93,73.62,percent of total billed charges,
Glucose 1 Hour Gestational,7844074,CDM,300,RC,82950,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,4.41,73.62,percent of total billed charges,
HAPTOGLOBIN,605486,CDM,300,RC,83010,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,Local,,96.46,,,,,,,11.66,155.42,percent of total billed charges,
IMMUNOGLOBULIN G,605477,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,Local,,83.77,,,,,,,8.18,134.97,percent of total billed charges,
IMMUNOGLOBULIN G,605478,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,Local,,83.77,,,,,,,8.18,134.97,percent of total billed charges,
IgA,1175851,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,Local,,83.77,,,,,,,8.18,134.97,percent of total billed charges,
IMMUNOGLOBULIN A,605476,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,Local,,83.77,,,,,,,8.18,134.97,percent of total billed charges,
IMMUNOGLOBULIN A,613038,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,Local,,83.77,,,,,,,8.18,134.97,percent of total billed charges,
IMMUNOGLOBULIN M,604615,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,Local,,83.77,,,,,,,8.18,134.97,percent of total billed charges,
IMMUNOGLOBULIN M,613037,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,Local,,83.77,,,,,,,8.18,134.97,percent of total billed charges,
IRON TOTAL,596722,CDM,300,RC,83540,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,5.99,110.43,percent of total billed charges,
IRON TOTAL,596723,CDM,300,RC,83540,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,5.99,110.43,percent of total billed charges,
Iron Level,8347449,CDM,300,RC,83540,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,5.99,110.43,percent of total billed charges,
UIBC,613082,CDM,300,RC,83550,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,Local,,69.55,,,,,,,8.11,112.07,percent of total billed charges,
HDL CHOLESTEROL,596700,CDM,300,RC,83718,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,Local,,69.55,,,,,,,7.59,112.07,percent of total billed charges,
HDL CHOLESTEROL,596728,CDM,300,RC,83718,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,Local,,69.55,,,,,,,7.59,112.07,percent of total billed charges,
RENAL FUNCTION PANEL,596651,CDM,300,RC,80069,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,Local,,130.99,,,,,,,8.04,211.04,percent of total billed charges,
LACTATE,2942846,CDM,300,RC,83605,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,Local,,92.40,,,,,,,10.72,148.88,percent of total billed charges,
LACTATE,596724,CDM,300,RC,83605,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,Local,,92.40,,,,,,,10.72,148.88,percent of total billed charges,
LACTATE,6345860,CDM,300,RC,83605,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,Local,,92.40,,,,,,,10.72,148.88,percent of total billed charges,
BODY FLUID LD,596795,CDM,300,RC,83615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,5.60,112.88,percent of total billed charges,
LACTATE DEHYDROGENASE,596725,CDM,300,RC,83615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,5.60,112.88,percent of total billed charges,
LIPASE,596726,CDM,300,RC,83690,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,6.19,108.79,percent of total billed charges,
LIPID PANEL CHOL TRIG HDL LDL,596727,CDM,300,RC,80061,HCPCS,,,facility,outpatient,,,309.00000,89.61000,Aetna,Local,,156.88,,,,,,,12.41,252.76,percent of total billed charges,
METABOLIC PANEL TOTAL CA,8134945,CDM,300,RC,80048,HCPCS,,,facility,outpatient,,,311.00000,90.19000,Aetna,Local,,157.89,,,,,,,7.84,254.40,percent of total billed charges,
HEPATIC FUNCTION PANEL,8134944,CDM,300,RC,80076,HCPCS,,,facility,outpatient,,,268.00000,77.72000,Aetna,Local,,136.06,,,,,,,7.57,219.22,percent of total billed charges,
CREATINE MB FRACTION,8134946,CDM,300,RC,82553,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,Local,,104.08,,,,,,,10.71,167.69,percent of total billed charges,
ASSAY GLUCOSE BLOOD QUANT,8142650,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
ASSAY OF TROPONIN QUANT,8134948,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.39,164.42,percent of total billed charges,
LITHIUM LEVEL,596779,CDM,300,RC,80178,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,6.13,94.07,percent of total billed charges,
LITHIUM LEVEL,596780,CDM,300,RC,80178,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,6.13,94.07,percent of total billed charges,
Myoglobin,613103,CDM,300,RC,83874,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,11.98,144.79,percent of total billed charges,
MAGNESIUM LEVEL,596791,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,Local,,60.42,,,,,,,6.21,97.34,percent of total billed charges,
MAGNESIUM LEVEL,596792,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,Local,,60.42,,,,,,,6.21,97.34,percent of total billed charges,
MAGNESIUM LEVEL,599678,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,Local,,60.42,,,,,,,6.21,97.34,percent of total billed charges,
MAGNESIUM LEVEL,599693,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,Local,,60.42,,,,,,,6.21,97.34,percent of total billed charges,
MICROALBUMIN CREATININE RATIO,1073830,CDM,300,RC,82043,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,3.83,124.34,percent of total billed charges,
MICROALBUMIN CREATININE RATIO,1073831,CDM,300,RC,82043,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,3.83,124.34,percent of total billed charges,
MICROALBUMIN CREATININE RATIO,628526,CDM,300,RC,82043,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,3.83,124.34,percent of total billed charges,
MICROALBUMIN,8326170,CDM,300,RC,82043,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,3.83,124.34,percent of total billed charges,
OSMOLALITY BLOOD,596731,CDM,300,RC,83930,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,6.13,112.88,percent of total billed charges,
BODY FLUID PH,596794,CDM,300,RC,83986,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,Local,,64.48,,,,,,,3.32,103.89,percent of total billed charges,
PHOSPHOROUS URINE,596666,CDM,300,RC,84105,HCPCS,,,facility,outpatient,,,103.00000,29.87000,Aetna,Local,,52.29,,,,,,,5.36,84.25,percent of total billed charges,
PHOSPHOROUS URINE,596737,CDM,300,RC,84105,HCPCS,,,facility,outpatient,,,103.00000,29.87000,Aetna,Local,,52.29,,,,,,,5.36,84.25,percent of total billed charges,
Acetaminophen Level Addl,8229179,CDM,300,RC,80143,HCPCS,,,facility,outpatient,,,225.00000,65.25000,Aetna,Local,GY,114.23,,,,,,,17.28,184.05,percent of total billed charges,
Ethanol Addl,8229177,CDM,300,RC,82077,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,Local,GY,89.36,,,,,,,16.01,143.97,percent of total billed charges,
hCG Quant Addl,8229417,CDM,300,RC,84702,HCPCS,,,facility,outpatient,,,185.00000,53.65000,Aetna,Local,GY,93.92,,,,,,,13.96,151.33,percent of total billed charges,
Arterial Blood gas Addl,8229333,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,GY,160.43,,,,,,,7.68,258.49,percent of total billed charges,
Venous Blood Gas Addl,8229336,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,GY,160.43,,,,,,,7.68,258.49,percent of total billed charges,
BUN Addl,8229401,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,GY,45.69,,,,,,,3.67,73.62,percent of total billed charges,
Glucose Blood Addl,8229363,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,GY,45.69,,,,,,,3.65,73.62,percent of total billed charges,
Potassium Level Addl,8229375,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,GY,31.48,,,,,,,4.41,50.72,percent of total billed charges,
Salicylate Level Addl,8229178,CDM,300,RC,80179,HCPCS,,,facility,outpatient,,,204.00000,59.16000,Aetna,Local,GY,103.57,,,,,,,17.28,166.87,percent of total billed charges,
Sodium Addl,8229415,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,GY,42.65,,,,,,,4.46,68.71,percent of total billed charges,
METABOLIC PANEL TOTAL CA Addl,8229168,CDM,300,RC,80048,HCPCS,,,facility,outpatient,,,311.00000,90.19000,Aetna,Local,GY,157.89,,,,,,,7.84,254.40,percent of total billed charges,
ELECTROLYTE PANEL Addl,8229169,CDM,300,RC,80051,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,Local,GY,137.59,,,,,,,6.50,221.68,percent of total billed charges,
Bili Total Addl,8229184,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,123.00000,35.67000,Aetna,Local,GY,62.45,,,,,,,4.66,100.61,percent of total billed charges,
Chloride Addl,8229186,CDM,300,RC,82435,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,Local,GY,28.94,,,,,,,4.26,46.63,percent of total billed charges,
Creatinine Blood Addl,8229187,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,96.00000,27.84000,Aetna,Local,GY,48.74,,,,,,,4.75,78.53,percent of total billed charges,
Body fluid glucose Addl,8229189,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,GY,45.69,,,,,,,3.65,73.62,percent of total billed charges,
T4 Addl,8229194,CDM,300,RC,84436,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,GY,72.09,,,,,,,6.37,116.16,percent of total billed charges,
AST Addl,8229195,CDM,300,RC,84450,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,GY,38.08,,,,,,,4.80,61.35,percent of total billed charges,
ALT Addl,8229196,CDM,300,RC,84460,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,GY,39.09,,,,,,,4.91,62.99,percent of total billed charges,
Troponin I Addl,8229950,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.39,164.42,percent of total billed charges,
POTASSIUM LEVEL,596740,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.41,50.72,percent of total billed charges,
POTASSIUM LEVEL,658420,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.41,50.72,percent of total billed charges,
POTASSIUM LEVEL,7946072,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.41,50.72,percent of total billed charges,
POTASSIUM BLOOD,8367781,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.41,50.72,percent of total billed charges,
POTASSIUM URINE,596667,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.39,50.72,percent of total billed charges,
POTASSIUM URINE,596738,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.39,50.72,percent of total billed charges,
POTASSIUM URINE,602501,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.39,50.72,percent of total billed charges,
POTASSIUM URINE,610827,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.39,50.72,percent of total billed charges,
POTASSIUM URINE,613069,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.39,50.72,percent of total billed charges,
PREALBUMIN,596739,CDM,300,RC,84134,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,85.29,,,,,,,13.52,137.42,percent of total billed charges,
CREATININE KINASE TOTAL,596703,CDM,300,RC,82550,HCPCS,,,facility,outpatient,,,196.00000,56.84000,Aetna,Local,,99.51,,,,,,,6.04,160.33,percent of total billed charges,
CK Total,613100,CDM,300,RC,82550,HCPCS,,,facility,outpatient,,,196.00000,56.84000,Aetna,Local,,99.51,,,,,,,6.04,160.33,percent of total billed charges,
SYNOVIAL FLUID GLUCOSE,596817,CDM,300,RC,82945,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
URINE OSMOLALITY,596732,CDM,300,RC,83935,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,Local,,69.55,,,,,,,6.32,112.07,percent of total billed charges,
URINE OSMOLALITY,596733,CDM,300,RC,83935,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,Local,,69.55,,,,,,,6.32,112.07,percent of total billed charges,
PHOSPHOROUS BLOOD,596736,CDM,300,RC,84100,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,Local,,47.72,,,,,,,4.40,76.89,percent of total billed charges,
PHOSPHOROUS BLOOD,599679,CDM,300,RC,84100,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,Local,,47.72,,,,,,,4.40,76.89,percent of total billed charges,
PHOSPHOROUS BLOOD,599694,CDM,300,RC,84100,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,Local,,47.72,,,,,,,4.40,76.89,percent of total billed charges,
CEREBRAL SPINAL FLUID PROTEIN,596814,CDM,300,RC,84157,HCPCS,,,facility,outpatient,,,93.00000,26.97000,Aetna,Local,,47.22,,,,,,,3.71,76.07,percent of total billed charges,
BODY FLUID PROTEIN,596812,CDM,300,RC,84157,HCPCS,,,facility,outpatient,,,93.00000,26.97000,Aetna,Local,,47.22,,,,,,,3.71,76.07,percent of total billed charges,
BODY FLUID PROTEIN,656538,CDM,300,RC,84157,HCPCS,,,facility,outpatient,,,93.00000,26.97000,Aetna,Local,,47.22,,,,,,,3.71,76.07,percent of total billed charges,
PROTEIN URINE,596744,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN URINE,596745,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN URINE,596746,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN URINE,663098,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,3.40,89.16,percent of total billed charges,
ASPARTATE AMINOTRANSFERASE,596758,CDM,300,RC,84450,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,4.80,61.35,percent of total billed charges,
ASPARTATE AMINOTRANSFERASE,599672,CDM,300,RC,84450,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,4.80,61.35,percent of total billed charges,
HEMOGLOBIN A1C,605755,CDM,300,RC,83036,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,9.00,127.61,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN DIAGNOS,596741,CDM,300,RC,84153,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,Local,,108.65,,,,,,,17.05,175.05,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN DIAGNOS,646394,CDM,300,RC,84153,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,Local,,108.65,,,,,,,17.05,175.05,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN SCREEN,596742,CDM,300,RC,G0103,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,Local,,108.65,,,,,,,17.90,175.05,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN FREE,629514,CDM,300,RC,84154,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,Local,,96.46,,,,,,,17.05,155.42,percent of total billed charges,
PROSTATE SPECIFIC ANTIGEN FREE,849798,CDM,300,RC,84154,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,Local,,96.46,,,,,,,17.05,155.42,percent of total billed charges,
PROTEIN TOTAL,596743,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN TOTAL,597159,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN TOTAL,599680,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN TOTAL,613072,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,3.40,89.16,percent of total billed charges,
PROTEIN URINE,8326171,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,3.40,89.16,percent of total billed charges,
RHEUMATOID FACTOR,605674,CDM,300,RC,86431,HCPCS,,,facility,outpatient,,,125.00000,36.25000,Aetna,Local,,63.46,,,,,,,5.25,102.25,percent of total billed charges,
SALICYLATE LEVEL,596786,CDM,300,RC,80179,HCPCS,,,facility,outpatient,,,204.00000,59.16000,Aetna,Local,,103.57,,,,,,,17.28,166.87,percent of total billed charges,
SODIUM LEVEL,596747,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.46,68.71,percent of total billed charges,
SODIUM LEVEL,656682,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.46,68.71,percent of total billed charges,
SODIUM LEVEL,658421,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.46,68.71,percent of total billed charges,
SODIUM LEVEL,7946073,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.46,68.71,percent of total billed charges,
SODIUM BLOOD,8367780,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.46,68.71,percent of total billed charges,
ALANINE AMINOTRANSFERASE,596759,CDM,300,RC,84460,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,4.91,62.99,percent of total billed charges,
ALANINE AMINOTRANSFERASE,599671,CDM,300,RC,84460,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,4.91,62.99,percent of total billed charges,
Coronavirus 19 SARS CoV 2 IgG,8338457,CDM,300,RC,86769,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,39.06,132.52,percent of total billed charges,
SODIUM URINE,596665,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.69,68.71,percent of total billed charges,
SODIUM URINE,596670,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.69,68.71,percent of total billed charges,
SODIUM URINE,596748,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.69,68.71,percent of total billed charges,
SODIUM URINE,602502,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.69,68.71,percent of total billed charges,
SODIUM URINE,610828,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.69,68.71,percent of total billed charges,
Sodium Random Urine,617727,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.69,68.71,percent of total billed charges,
THYROXINE TOTAL,596720,CDM,300,RC,84436,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,,72.09,,,,,,,6.37,116.16,percent of total billed charges,
THYROXINE TOTAL,663030,CDM,300,RC,84436,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,,72.09,,,,,,,6.37,116.16,percent of total billed charges,
FREE THYROXINE,596756,CDM,300,RC,84439,HCPCS,,,facility,outpatient,,,232.00000,67.28000,Aetna,Local,,117.79,,,,,,,8.36,189.78,percent of total billed charges,
T3 TOTAL,605607,CDM,300,RC,84480,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,Local,,96.46,,,,,,,13.14,155.42,percent of total billed charges,
T3 FREE,604473,CDM,300,RC,84481,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,Local,,128.45,,,,,,,15.71,206.95,percent of total billed charges,
Total Volume 24 Hr Urine,613071,CDM,300,RC,81050,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,Local,,20.31,,,,,,,3.38,32.72,percent of total billed charges,
TOTAL VOLUME TIMED URINE,644493,CDM,300,RC,81050,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,Local,,20.31,,,,,,,3.38,32.72,percent of total billed charges,
TRANSFERRIN,606218,CDM,300,RC,84466,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,,81.23,,,,,,,11.82,130.88,percent of total billed charges,
TRIGLYCERIDES,596760,CDM,300,RC,84478,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,Local,,60.92,,,,,,,5.33,98.16,percent of total billed charges,
TRIGLYCERIDES,596811,CDM,300,RC,84478,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,Local,,60.92,,,,,,,5.33,98.16,percent of total billed charges,
TRIGLYCERIDES,599681,CDM,300,RC,84478,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,Local,,60.92,,,,,,,5.33,98.16,percent of total billed charges,
TRIGLYCERIDES,599695,CDM,300,RC,84478,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,Local,,60.92,,,,,,,5.33,98.16,percent of total billed charges,
VANCOMYCIN LEVEL,596685,CDM,300,RC,80202,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,Local,,133.02,,,,,,,12.56,214.32,percent of total billed charges,
VANCOMYCIN LEVEL,596686,CDM,300,RC,80202,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,Local,,133.02,,,,,,,12.56,214.32,percent of total billed charges,
VANCOMYCIN LEVEL,7948500,CDM,300,RC,80202,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,Local,,133.02,,,,,,,12.56,214.32,percent of total billed charges,
Troponin I,613101,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.39,164.42,percent of total billed charges,
Troponin I  HighSensitivity,8926116,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.39,164.42,percent of total billed charges,
Troponin I CSCTRULE,8948140,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.39,164.42,percent of total billed charges,
THYROID STIMULATING HORMONE,596757,CDM,300,RC,84443,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,Local,,109.16,,,,,,,15.57,175.87,percent of total billed charges,
THYROID STIMULATING HORMONE,663031,CDM,300,RC,84443,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,Local,,109.16,,,,,,,15.57,175.87,percent of total billed charges,
THYROID STIMULATING HORMONE,8324475,CDM,300,RC,84443,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,Local,,109.16,,,,,,,15.57,175.87,percent of total billed charges,
URIC ACID BLOOD,596769,CDM,300,RC,84550,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,4.19,112.88,percent of total billed charges,
VALPROIC ACID LEVEL,596674,CDM,300,RC,80164,HCPCS,,,facility,outpatient,,,282.00000,81.78000,Aetna,Local,,143.17,,,,,,,12.56,230.68,percent of total billed charges,
VALPROIC ACID LEVEL,596675,CDM,300,RC,80164,HCPCS,,,facility,outpatient,,,282.00000,81.78000,Aetna,Local,,143.17,,,,,,,12.56,230.68,percent of total billed charges,
VITAMIN B12,599751,CDM,300,RC,82607,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,Local,,100.02,,,,,,,13.98,161.15,percent of total billed charges,
ASSAY ALKALINE PHOSPHATASE Addl,8229192,CDM,300,RC,84075,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,GY,69.05,,,,,,,4.80,111.25,percent of total billed charges,
CRYSTALLIZATION TEST AMNIO,1810824,CDM,300,RC,Q0114,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,9.03,99.80,percent of total billed charges,
diff,1461798,CDM,300,RC,89051,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,,103.06,,,,,,,5.19,166.05,percent of total billed charges,
diff,614938,CDM,300,RC,89051,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,,103.06,,,,,,,5.19,166.05,percent of total billed charges,
Diff,646173,CDM,300,RC,89051,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,,103.06,,,,,,,5.19,166.05,percent of total billed charges,
Cell Count Fluid No Diff,595908,CDM,300,RC,89050,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,Local,,80.22,,,,,,,4.38,129.24,percent of total billed charges,
CELL COUNT FLUID NO DIFF,646174,CDM,300,RC,89050,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,Local,,80.22,,,,,,,4.38,129.24,percent of total billed charges,
BILE FLUID ANALYSIS,597206,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,6.80,99.80,percent of total billed charges,
FECAL VOLUME 24 HR,605908,CDM,300,RC,81050,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,Local,,20.31,,,,,,,3.38,32.72,percent of total billed charges,
HEMOSIDERIN,604439,CDM,300,RC,83070,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,4.41,44.17,percent of total billed charges,
BODY FLUID CRYSTAL,596047,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,6.80,99.80,percent of total billed charges,
BODY FLUID CRYSTAL,596050,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,6.80,99.80,percent of total billed charges,
BILL UA PLUS MC,605152,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,2.94,73.62,percent of total billed charges,
BILL UA PLUS MC,614931,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,2.94,73.62,percent of total billed charges,
BILL UA PLUS MC,8569925,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,2.94,73.62,percent of total billed charges,
UA Scope Foley,8878110,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,2.94,73.62,percent of total billed charges,
BILL UA PLUS MC,8995880,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,2.94,73.62,percent of total billed charges,
URINALYSIS WITHOUT MICRO,599584,CDM,300,RC,81003,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,2.09,44.17,percent of total billed charges,
Urinalysis Auto without Scope,605214,CDM,300,RC,81003,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,2.09,44.17,percent of total billed charges,
UA w Micro Addl,8229181,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,GY,45.69,,,,,,,2.94,73.62,percent of total billed charges,
UA no micro Addl,8229182,CDM,300,RC,81003,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,GY,27.42,,,,,,,2.09,44.17,percent of total billed charges,
Body Fluid Cell Count Addl,8229215,CDM,300,RC,89051,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,GY,103.06,,,,,,,5.19,166.05,percent of total billed charges,
Synovial Crystals Addl,8229216,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GY,61.94,,,,,,,6.80,99.80,percent of total billed charges,
Bill UA w Mic Addl,8230203,CDM,300,RC,81001,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,2.94,73.62,percent of total billed charges,
Urinalysis WO micro Addl,8230204,CDM,300,RC,81003,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,2.09,44.17,percent of total billed charges,
DIFF Fluid  Addl,8230231,CDM,300,RC,89051,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,,103.06,,,,,,,5.19,166.05,percent of total billed charges,
Bile Fluid Analysis Addl,8230232,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,6.80,99.80,percent of total billed charges,
Fern Test Addl,8230234,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,6.80,99.80,percent of total billed charges,
URINE MICROSCOPIC ONLY,605193,CDM,300,RC,81015,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,Local,,32.49,,,,,,,2.83,52.35,percent of total billed charges,
Body Fluid Crystal Addl,8230233,CDM,300,RC,89060,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,6.80,99.80,percent of total billed charges,
BAL Differential Cell Count,9180652,CDM,300,RC,88106,HCPCS,,,facility,outpatient,,,226.00000,65.54000,Aetna,Local,,114.74,,,,,,,21.51,184.87,percent of total billed charges,
BLOOD ALCOHOL CLINICAL REF LAB,596008,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,1650.00000,478.50000,Aetna,Local,,837.71,,,,,,,106.08,1349.70,percent of total billed charges,
TOX NON DOT,596010,CDM,300,RC,99001,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,,13.00,,,,,,,13.00,101.43,fee schedule,
TOX DOT,596011,CDM,300,RC,99001,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,,13.00,,,,,,,13.00,101.43,fee schedule,
TOXICOLOGY SPECIMEN COLLECTION,596016,CDM,300,RC,99001,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,,13.00,,,,,,,13.00,101.43,fee schedule,
BREATH ALCOHOL SCREENING,596012,CDM,300,RC,82075,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,16.04,79.50,percent of total billed charges,
TOXICOLOGY MRO SERVICES,660740,CDM,300,RC,,,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,9.73,22.09,percent of total billed charges,
BREATH ALCOHOL CONFIRMATION,596014,CDM,300,RC,82075,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,16.04,79.50,percent of total billed charges,
BREATH ALCOHOL COURT TIME,596015,CDM,300,RC,,,,,facility,outpatient,,,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,14.06,31.90,percent of total billed charges,
TOX NON DOT STAT NKC,771798,CDM,300,RC,80305,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,11.68,121.06,percent of total billed charges,
CHLORIDE BLOOD POINT OF CARE,1663806,CDM,300,RC,82435,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,Local,,28.94,,,,,,,4.26,46.63,percent of total billed charges,
BLOOD GAS POINT OF CARE,1545821,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,2760856,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,2776876,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,5705843,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,6649840,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,6649846,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
BLOOD GAS POINT OF CARE,6649850,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,7.68,258.49,percent of total billed charges,
HEMATOCRIT POINT OF CARE,1667821,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
POTASSIUM BLOOD POINT OF CARE,1545814,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.41,50.72,percent of total billed charges,
POTASSIUM BLOOD POINT OF CARE,2764840,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,4.41,50.72,percent of total billed charges,
SODIUM BLOOD POINT OF CARE,1545813,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.46,68.71,percent of total billed charges,
SODIUM BLOOD POINT OF CARE,2802842,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,,42.65,,,,,,,4.46,68.71,percent of total billed charges,
ACTIVATED CLOTTING TIME,636253,CDM,300,RC,85347,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,3.97,65.44,percent of total billed charges,
Activated Clotting Time,8948131,CDM,300,RC,85347,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,3.97,65.44,percent of total billed charges,
HEPCON ACT BILL ONLY TEST,599591,CDM,300,RC,85347,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,3.97,65.44,percent of total billed charges,
Hepcon Activated Clotting Time,8948132,CDM,300,RC,85347,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,3.97,65.44,percent of total billed charges,
IONIZED CALCIUM POINT OF CARE,1661804,CDM,300,RC,82330,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,8.54,144.79,percent of total billed charges,
IONIZED CALCIUM POINT OF CARE,2764851,CDM,300,RC,82330,HCPCS,,,facility,outpatient,,,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,8.54,144.79,percent of total billed charges,
HEPARIN ASSAY,599594,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,Local,,115.76,,,,,,,12.13,186.50,percent of total billed charges,
HEPARIN DOSE RESPONSE,599597,CDM,300,RC,85530,HCPCS,,,facility,outpatient,,,44.00000,12.76000,Aetna,Local,,22.34,,,,,,,12.13,35.99,percent of total billed charges,
GLUCOSE BLOOD POINT OF CARE,1545817,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.65,73.62,percent of total billed charges,
Glucose Point of Care Addl,8229364,CDM,300,RC,82947,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,GY,45.69,,,,,,,3.65,73.62,percent of total billed charges,
BLOOD UREA NITROGEN POINT OF CARE,1667809,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,3.67,73.62,percent of total billed charges,
TROPONIN POINT OF CARE,1780824,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.39,164.42,percent of total billed charges,
POC Troponin iSTAT CSCTRULE,8948139,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.39,164.42,percent of total billed charges,
LACTATE POINT OF CARE,4813839,CDM,300,RC,83605,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,Local,,92.40,,,,,,,10.72,148.88,percent of total billed charges,
HEMOGLOBIN POINT OF CARE,2760860,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
HEMOGLOBIN POINT OF CARE,7919068,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,2.19,54.81,percent of total billed charges,
BHCG POC,7935639,CDM,300,RC,84702,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,Local,,94.43,,,,,,,13.96,152.15,percent of total billed charges,
COAGULATION TIME ACTIVATED,8134950,CDM,300,RC,85347,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,3.97,65.44,percent of total billed charges,
Blood Gas Point of Care Addl,8229335,CDM,300,RC,82803,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,GY,160.43,,,,,,,7.68,258.49,percent of total billed charges,
Hematocrit Point of Care Addl,8229414,CDM,300,RC,85014,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,GY,34.02,,,,,,,2.19,54.81,percent of total billed charges,
Sodium Point of Care Addl,8229416,CDM,300,RC,84295,HCPCS,,,facility,outpatient,,,84.00000,24.36000,Aetna,Local,GY,42.65,,,,,,,4.46,68.71,percent of total billed charges,
Blood Urea Nitrogen Point of Care Addl,8229402,CDM,300,RC,84520,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,GY,45.69,,,,,,,3.67,73.62,percent of total billed charges,
Hemoglobin Point of Care Addl,8229203,CDM,300,RC,85018,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,GY,34.02,,,,,,,2.19,54.81,percent of total billed charges,
HCG QUANT Point of Care Addl,8229418,CDM,300,RC,84702,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,Local,GY,94.43,,,,,,,13.96,152.15,percent of total billed charges,
Potassium Point of Care Addl,8229193,CDM,300,RC,84132,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,GY,31.48,,,,,,,4.41,50.72,percent of total billed charges,
Troponin I Point of Care Addl,8229951,CDM,300,RC,84484,HCPCS,,,facility,outpatient,,,201.00000,58.29000,Aetna,Local,,102.05,,,,,,,11.39,164.42,percent of total billed charges,
RF CONSULT HEM PATH,624903,CDM,300,RC,88325,HCPCS,,,facility,outpatient,,,379.00000,109.91000,Aetna,Local,,192.42,,,,,,,150.47,452.20,percent of total billed charges,
RF CONSULT WORK UP,624904,CDM,300,RC,88323,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,Local,,121.85,,,,,,,46.92,196.32,percent of total billed charges,
RF BILL IHC MAWD,624905,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,Local,,121.85,,,,,,,84.70,452.20,percent of total billed charges,
RF CONSULT,624906,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,379.00000,109.91000,Aetna,Local,,192.42,,,,,,,34.46,310.02,percent of total billed charges,
Tiss Cult,613075,CDM,300,RC,88237,HCPCS,,,facility,outpatient,,,249.00000,72.21000,Aetna,Local,,126.42,,,,,,,32.36,380.94,percent of total billed charges,
RECEPTOR ASSAY PROGESTERONE,1061799,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,311.00000,90.19000,Aetna,Local,,157.89,,,,,,,104.47,452.20,percent of total billed charges,
RECEPTOR ASSAY ESTROGEN,1061798,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,311.00000,90.19000,Aetna,Local,,157.89,,,,,,,104.47,452.20,percent of total billed charges,
RF BILL SURG LEVEL IV,624897,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,444.00000,128.76000,Aetna,Local,,225.42,,,,,,,46.92,363.19,percent of total billed charges,
RF Surg Level IV,8948127,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,Local,,104.08,,,,,,,46.92,167.69,percent of total billed charges,
RF BILL GROUP II MAWD,6155847,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,199.00000,57.71000,Aetna,Local,,101.03,,,,,,,53.93,353.14,percent of total billed charges,
RF BILL SURG IPX MAYO,624902,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,84.70,452.20,percent of total billed charges,
RF BILL SURG CONSULT MD ANDERSON,624910,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,Local,,302.08,,,,,,,34.46,486.71,percent of total billed charges,
RF GROUP II MAYO,624908,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,53.93,353.14,percent of total billed charges,
RF BILL SURG CONSULT KU,624907,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,Local,,302.08,,,,,,,34.46,486.71,percent of total billed charges,
RF BILL SURG CONSULT UNIV OF NE,624911,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,Local,,302.08,,,,,,,34.46,486.71,percent of total billed charges,
RF BILL SURG CONSULT ST LUKES,624912,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,Local,,302.08,,,,,,,34.46,486.71,percent of total billed charges,
RF BILL SURG CONSULT MASS GEN,624913,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,595.00000,172.55000,Aetna,Local,,302.08,,,,,,,34.46,486.71,percent of total billed charges,
RF BILL CYTO NONGYN SMR MAWD,645753,CDM,300,RC,88104,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,34.46,159.51,percent of total billed charges,
RF BILL CYTO NONGYN TECH MAWD,644293,CDM,300,RC,88112,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,Local,,83.77,,,,,,,46.92,176.63,percent of total billed charges,
RF BILL SURG ERT,644294,CDM,300,RC,87230,HCPCS,,,facility,outpatient,,,163.00000,47.27000,Aetna,Local,,82.76,,,,,,,18.30,133.33,percent of total billed charges,
RF BILL SURG IHC MAWD,652163,CDM,300,RC,88361,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,Local,,125.91,,,,,,,116.56,951.40,percent of total billed charges,
RF ISH MAYO,652158,CDM,300,RC,88365,HCPCS,,,facility,outpatient,,,823.00000,238.67000,Aetna,Local,,417.84,,,,,,,121.31,673.21,percent of total billed charges,
HER 2 NEU,4375839,CDM,300,RC,83950,HCPCS,,,facility,outpatient,,,575.00000,166.75000,Aetna,Local,,291.93,,,,,,,59.71,470.35,percent of total billed charges,
RF BILL ISH MANUAL MAWD,5789839,CDM,300,RC,88368,HCPCS,,,facility,outpatient,,,234.00000,67.86000,Aetna,Local,,118.80,,,,,,,109.98,951.40,percent of total billed charges,
RF BILL SPECIAL STAIN NEPHROPATH,6327841,CDM,300,RC,88312,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,122.36,,,,,,,46.92,197.14,percent of total billed charges,
RF BILL CYTO SMEAR MAWD,6155842,CDM,300,RC,88160,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,,103.06,,,,,,,21.51,166.05,percent of total billed charges,
RF BILL NEEDLE ASP INTERP MAWD,6155844,CDM,300,RC,88173,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,Local,,137.59,,,,,,,46.92,221.68,percent of total billed charges,
RF BILL SURG LEVEL IV MAWD,6155846,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,46.92,150.74,percent of total billed charges,
Micro Analysis MAWD CSCTRULE,8948126,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,46.92,150.74,percent of total billed charges,
RF BILL TUMOR IHC MAWD,6155848,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,104.47,452.20,percent of total billed charges,
RF BILL HPV DNA AMP PROBE MAWD,6155839,CDM,300,RC,87624,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,32.53,116.97,percent of total billed charges,
RF BILL CV PATH INTERP MAWD,6155840,CDM,300,RC,88141,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,21.36,128.43,percent of total billed charges,
RF BILL CV AUTO FLUID MAWD,6155841,CDM,300,RC,88175,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,Local,,68.03,,,,,,,24.67,109.61,percent of total billed charges,
RF BILL FNA ADEQUACY MAWD,6155843,CDM,300,RC,88172,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,49.26,452.20,percent of total billed charges,
RF BILL FNA ADDL INTERP MAWD,6155845,CDM,300,RC,88177,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,26.63,111.25,percent of total billed charges,
RF BILL MICRODISSECTION MAWD,6155849,CDM,300,RC,88381,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,154.85,,,,,,,109.95,306.33,percent of total billed charges,
RF BILL STAIN ON TISS BLOCK MAYO,6323843,CDM,300,RC,88314,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,91.46,208.59,percent of total billed charges,
RF BILL STAINS GROUP III MAYO,6323844,CDM,300,RC,88319,HCPCS,,,facility,outpatient,,,270.00000,78.30000,Aetna,Local,,137.08,,,,,,,126.90,2138.50,percent of total billed charges,
RF BILL IRON LIVER TISSUE MAYO,6323845,CDM,300,RC,83540,HCPCS,,,facility,outpatient,,,263.00000,76.27000,Aetna,Local,,133.53,,,,,,,5.99,215.13,percent of total billed charges,
RF BILL SURG LEVEL IV MAYO,6323842,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,539.00000,156.31000,Aetna,Local,,273.65,,,,,,,46.92,440.90,percent of total billed charges,
RF Surg Level IV Mayo,8948128,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,539.00000,156.31000,Aetna,Local,,273.65,,,,,,,46.92,440.90,percent of total billed charges,
RF BILL IHC MAYO,646653,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,84.70,452.20,percent of total billed charges,
RF BILL C TRACH MAWD,6271840,CDM,300,RC,87491,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,32.53,116.97,percent of total billed charges,
RF BILL N GORNORRHOEAE MAWD,6271839,CDM,300,RC,87591,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,32.53,116.97,percent of total billed charges,
RF MOL CYTOGEN DNA PROBE MAYO,3233446,CDM,300,RC,88271,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,19.86,125.97,percent of total billed charges,
RF MOL CYTOGEN DNA PROBE MAYO,3247839,CDM,300,RC,88271,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,19.86,125.97,percent of total billed charges,
RF MOL CYTOGEN DNA PROBE MAYO,6471839,CDM,300,RC,88271,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,19.86,125.97,percent of total billed charges,
RF BILL SURG IHC NEPHROPATH,624909,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,270.00000,78.30000,Aetna,Local,,137.08,,,,,,,84.70,452.20,percent of total billed charges,
RF BILL SURG LEVEL IV NEPHROPATH,2894853,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,Local,,104.08,,,,,,,46.92,167.69,percent of total billed charges,
RF Surg Level IV Neph,8948129,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,Local,,104.08,,,,,,,46.92,167.69,percent of total billed charges,
Immunoassay Other,657701,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,16.01,126.79,percent of total billed charges,
ARSENIC BLOOD,657782,CDM,300,RC,82175,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,Local,,28.94,,,,,,,17.58,50.27,percent of total billed charges,
BILL TOUCH PREP FROZEN SECTION,592817,CDM,300,RC,88331,HCPCS,,,facility,outpatient,,,220.00000,63.80000,Aetna,Local,,111.69,,,,,,,85.33,452.20,percent of total billed charges,
RF BILL HER 2 IHC CSI,7965322,CDM,300,RC,88361,HCPCS,,,facility,outpatient,,,229.00000,66.41000,Aetna,Local,,116.26,,,,,,,107.63,951.40,percent of total billed charges,
RF BILL ALK FISH MAWD,7965323,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,Local,,253.85,,,,,,,150.47,452.20,percent of total billed charges,
RF BILL PD L1 CSI,7965324,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,229.00000,66.41000,Aetna,Local,,116.26,,,,,,,104.47,452.20,percent of total billed charges,
RF BILL C KIT CSI,7968015,CDM,300,RC,81272,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,Local,,184.80,,,,,,,171.08,873.20,percent of total billed charges,
ISH FIRST PROBE,7987316,CDM,300,RC,88365,HCPCS,,,facility,outpatient,,,388.00000,112.52000,Aetna,Local,,196.99,,,,,,,121.31,452.20,percent of total billed charges,
ISH ADDITIONAL PROBE,7987317,CDM,300,RC,88364,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,,160.43,,,,,,,113.92,258.49,percent of total billed charges,
MORPHOMETRIC IHC MANUAL,7987315,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,104.47,452.20,percent of total billed charges,
RF BILL SURG EM NEPHROPATH,2894856,CDM,300,RC,88348,HCPCS,,,facility,outpatient,,,674.00000,195.46000,Aetna,Local,,342.19,,,,,,,316.78,2138.50,percent of total billed charges,
RF BILL SURG DIF NEPHROPATH,2894855,CDM,300,RC,88346,HCPCS,,,facility,outpatient,,,288.00000,83.52000,Aetna,Local,,146.22,,,,,,,88.98,452.20,percent of total billed charges,
RF BILL SURG STN II NEPHROPATH,2894854,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,53.93,353.14,percent of total billed charges,
RF BILL GROUP I MAWD,5789840,CDM,300,RC,88312,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,46.92,194.68,percent of total billed charges,
RF GROUP I MICRO MAYO,6409842,CDM,300,RC,88312,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,Local,,116.77,,,,,,,46.92,188.14,percent of total billed charges,
RF ISH MANUAL MAYO,6409844,CDM,300,RC,88368,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,Local,,172.11,,,,,,,140.64,951.40,percent of total billed charges,
RF DIF MAYO,6409845,CDM,300,RC,88346,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,72.85,452.20,percent of total billed charges,
RF IN SITU HYBRID MAYO,6471840,CDM,300,RC,88275,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,47.45,135.65,percent of total billed charges,
RF CYTO MOLE INTERP MAYO,6471841,CDM,300,RC,88291,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,Local,,68.03,,,,,,,25.72,109.61,percent of total billed charges,
KRAS GENE ANALYSIS MAWD ZB4S1,7005842,CDM,300,RC,81275,HCPCS,,,facility,outpatient,,,424.00000,122.96000,Aetna,Local,,215.26,,,,,,,179.15,512.11,percent of total billed charges,
MICROSATELLITE INSTABILITY MAWD ZB4S5,7005843,CDM,300,RC,81301,HCPCS,,,facility,outpatient,,,653.00000,189.37000,Aetna,Local,,331.53,,,,,,,306.91,923.68,percent of total billed charges,
BRAF GENE ANALYSIS MAWD ZB4S2,7005844,CDM,300,RC,81210,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,131.60,464.81,percent of total billed charges,
EGFR GENE ANALYSIS MAWD ZB4S3,7005841,CDM,300,RC,81235,HCPCS,,,facility,outpatient,,,424.00000,122.96000,Aetna,Local,,215.26,,,,,,,199.28,1154.35,percent of total billed charges,
ROS1 BY FISH MAWD,7523981,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,Local,,253.85,,,,,,,150.47,452.20,percent of total billed charges,
Immunohistochemistry quant,7719216,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,104.47,452.20,percent of total billed charges,
MULTIPLEX ANTIBODY STAIN,7806064,CDM,300,RC,88344,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,Local,,172.11,,,,,,,159.33,951.40,percent of total billed charges,
RF BILL IHC ADDL NEPHROPATH,7806063,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,85.80,194.68,percent of total billed charges,
RF BILL IHC ADDL NEPHROPATH,7806067,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,85.80,194.68,percent of total billed charges,
RF BILL IHC ADDL MAWD,7806068,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,Local,,120.32,,,,,,,85.44,193.87,percent of total billed charges,
RF BILL IHC ADDL MAYO,7806069,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,91.93,208.59,percent of total billed charges,
ADDITIONAL IHC ANTIBODY STAIN,7806070,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,379.00000,109.91000,Aetna,Local,,192.42,,,,,,,96.30,310.02,percent of total billed charges,
RF BILL ISH ADDL MAYO,7806072,CDM,300,RC,88364,HCPCS,,,facility,outpatient,,,823.00000,238.67000,Aetna,Local,,417.84,,,,,,,139.10,673.21,percent of total billed charges,
RF BILL MORPH ISH ADDL MAWD,7806074,CDM,300,RC,88373,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,Local,,81.74,,,,,,,58.04,131.70,percent of total billed charges,
RF BILL MORPH ISH ADDL MAYO,7806075,CDM,300,RC,88373,HCPCS,,,facility,outpatient,,,336.00000,97.44000,Aetna,Local,,170.59,,,,,,,86.20,274.85,percent of total billed charges,
RF BILL MORPH ISH MULTI MAYO,7806076,CDM,300,RC,88374,HCPCS,,,facility,outpatient,,,336.00000,97.44000,Aetna,Local,,170.59,,,,,,,150.47,452.20,percent of total billed charges,
RF BILL MORPH ISH MULTI MAWD,7806077,CDM,300,RC,88374,HCPCS,,,facility,outpatient,,,428.00000,124.12000,Aetna,Local,,217.30,,,,,,,150.47,452.20,percent of total billed charges,
RF BILL MAN ISH ADDL MAYO,7806081,CDM,300,RC,88369,HCPCS,,,facility,outpatient,,,290.00000,84.10000,Aetna,Local,,147.23,,,,,,,104.55,237.22,percent of total billed charges,
RF BILL MORPH ISH ADDL MAWD,7806079,CDM,300,RC,88369,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,100.94,229.04,percent of total billed charges,
RF BILL MAN ISH MULTI MAYO,7806200,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,1046.00000,303.34000,Aetna,Local,,531.05,,,,,,,150.47,855.63,percent of total billed charges,
RF BILL MAN ISH MULTI MAWD,7806201,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,609.00000,176.61000,Aetna,Local,,309.19,,,,,,,150.47,498.16,percent of total billed charges,
RF BILL DIAGNOSTIC IHC CSI,7838032,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,Local,,93.42,,,,,,,84.70,452.20,percent of total billed charges,
RF BILL IHC ADDL CSI,7838033,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,Local,,93.42,,,,,,,66.33,150.51,percent of total billed charges,
Manual Multiplix Stain CSI,7894064,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,408.00000,118.32000,Aetna,Local,,207.14,,,,,,,150.47,452.20,percent of total billed charges,
FISH CSI,7935096,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,408.00000,118.32000,Aetna,Local,,207.14,,,,,,,150.47,452.20,percent of total billed charges,
MORPH ANALYSIS MANUAL CSI,7894032,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,221.00000,64.09000,Aetna,Local,,112.20,,,,,,,103.87,452.20,percent of total billed charges,
IN SITU HYBRIDIZATION CSI,7894034,CDM,300,RC,88365,HCPCS,,,facility,outpatient,,,247.00000,71.63000,Aetna,Local,,125.40,,,,,,,116.09,452.20,percent of total billed charges,
NRAS GENE ANALYSIS MAWD ZB4S4,7894030,CDM,300,RC,81311,HCPCS,,,facility,outpatient,,,424.00000,122.96000,Aetna,Local,,215.26,,,,,,,199.28,783.84,percent of total billed charges,
BILL TOUCH PREP ADDL,7911714,CDM,300,RC,88334,HCPCS,,,facility,outpatient,,,181.00000,52.49000,Aetna,Local,,91.89,,,,,,,44.26,148.06,percent of total billed charges,
IMMUNOFLUORESCENCE ADDL NEPHRO,7959502,CDM,300,RC,88350,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,100.94,229.04,percent of total billed charges,
CYTO GYN THIN PREP,592813,CDM,300,RC,G0123,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,Local,,60.42,,,,,,,18.78,97.34,percent of total billed charges,
CYTO NON GYN SMEAR,295380,CDM,300,RC,88104,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,34.46,126.79,percent of total billed charges,
TISSUE EXAM BY PATHOLOGIST,8134955,CDM,300,RC,88304,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,Local,,156.37,,,,,,,46.92,251.94,percent of total billed charges,
TISSUE EXAM BY PATHOLOGIST,8134956,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,46.92,348.47,percent of total billed charges,
TISSUE EXAM BY PATHOLOGIST,8134957,CDM,300,RC,88307,HCPCS,,,facility,outpatient,,,618.00000,179.22000,Aetna,Local,,313.76,,,,,,,174.61,951.40,percent of total billed charges,
Surg BM Clot Addl,8229955,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,46.92,348.47,percent of total billed charges,
Surg Level IV Addl,8229956,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,46.92,348.47,percent of total billed charges,
RF Bill Surg Level IV MAWD Addl,8229957,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,Local,,89.36,,,,,,,46.92,150.74,percent of total billed charges,
RF Bill Surg Level IV Addl,8229958,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,447.00000,129.63000,Aetna,Local,,226.94,,,,,,,46.92,365.65,percent of total billed charges,
RF Bill Surg Level IV Nephropath Addl,8229959,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,Local,,104.08,,,,,,,46.92,167.69,percent of total billed charges,
RF Bill Surg Level IV Mayo Addl,8229960,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,,353.87,,,,,,,46.92,570.15,percent of total billed charges,
Bill Surg Decal Addl,8230236,CDM,300,RC,88311,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,17.63,59.71,percent of total billed charges,
SURG LEVEL I,295346,CDM,300,RC,88300,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,19.63,111.25,percent of total billed charges,
SURG LEVEL II,295348,CDM,300,RC,88302,HCPCS,,,facility,outpatient,,,223.00000,64.67000,Aetna,Local,,113.22,,,,,,,34.46,182.41,percent of total billed charges,
SURG LEVEL III,295350,CDM,300,RC,88304,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,Local,,156.37,,,,,,,46.92,251.94,percent of total billed charges,
Surg Level III,8948122,CDM,300,RC,88304,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,Local,,156.37,,,,,,,46.92,251.94,percent of total billed charges,
SURG LEVEL IV,295352,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,46.92,348.47,percent of total billed charges,
Surg Level IV,8948125,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,46.92,348.47,percent of total billed charges,
SURG LEVEL V,295354,CDM,300,RC,88307,HCPCS,,,facility,outpatient,,,618.00000,179.22000,Aetna,Local,,313.76,,,,,,,174.61,951.40,percent of total billed charges,
Surg Level V,8948123,CDM,300,RC,88307,HCPCS,,,facility,outpatient,,,618.00000,179.22000,Aetna,Local,,313.76,,,,,,,174.61,951.40,percent of total billed charges,
SURG LEVEL VI,295356,CDM,300,RC,88309,HCPCS,,,facility,outpatient,,,825.00000,239.25000,Aetna,Local,,418.85,,,,,,,244.61,2138.50,percent of total billed charges,
SURG DECAL,295360,CDM,300,RC,88311,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,17.63,59.71,percent of total billed charges,
SURG CONSULT,295358,CDM,300,RC,88321,HCPCS,,,facility,outpatient,,,216.00000,62.64000,Aetna,Local,,109.66,,,,,,,34.46,176.69,percent of total billed charges,
SURG CONSULT SLIDES W PREP,592821,CDM,300,RC,88323,HCPCS,,,facility,outpatient,,,388.00000,112.52000,Aetna,Local,,196.99,,,,,,,46.92,317.38,percent of total billed charges,
SURG CONSULT COMPREHENSIVE,592819,CDM,300,RC,88325,HCPCS,,,facility,outpatient,,,2485.00000,720.65000,Aetna,Local,,1261.63,,,,,,,150.47,2032.73,percent of total billed charges,
SURG DIF,594645,CDM,300,RC,88346,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,Local,,172.11,,,,,,,88.98,452.20,percent of total billed charges,
SURG STAINS GROUP I MICRO,295362,CDM,300,RC,88312,HCPCS,,,facility,outpatient,,,216.00000,62.64000,Aetna,Local,,109.66,,,,,,,46.92,176.69,percent of total billed charges,
SURG STAINS GROUP II OTHER,295364,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,,81.23,,,,,,,53.93,353.14,percent of total billed charges,
SURG IHC FIRST ANTIBODY,295366,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,279.00000,80.91000,Aetna,Local,,141.65,,,,,,,84.70,452.20,percent of total billed charges,
Prostate Biopsy Two Methods,8948107,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Three Methods,8948108,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Four Methods,8948109,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Five Methods,8948110,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Six Methods,8948111,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Seven Methods,8948112,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Eight Methods,8948113,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Nine Methods,8948114,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Ten Methods,8948115,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Eleven Methods,8948116,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Twelve Methods,8948117,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Thirteen Methods,8948118,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Fourteen Methods,8948119,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Fifteen Methods,8948120,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
Prostate Biopsy Sixteen Methods,8948121,CDM,300,RC,G0416,HCPCS,,,facility,outpatient,,,805.00000,233.45000,Aetna,Local,,408.70,,,,,,,315.85,807.79,percent of total billed charges,
CYTO FNA INTERP,295388,CDM,300,RC,88173,HCPCS,,,facility,outpatient,,,329.00000,95.41000,Aetna,Local,,167.03,,,,,,,46.92,269.12,percent of total billed charges,
CYTO NON GYN CONC TECH,592809,CDM,300,RC,88108,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,Local,,137.59,,,,,,,34.46,221.68,percent of total billed charges,
CYTO NON GYN OTHER SOURCE,656038,CDM,300,RC,88160,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,Local,,64.48,,,,,,,21.51,103.89,percent of total billed charges,
SURG TOUCH PREP,594561,CDM,300,RC,88333,HCPCS,,,facility,outpatient,,,811.00000,235.19000,Aetna,Local,,411.74,,,,,,,84.98,2138.50,percent of total billed charges,
SURG B M CLOT,594641,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,46.92,348.47,percent of total billed charges,
Bone Marrow Clot,8948124,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,46.92,348.47,percent of total billed charges,
SURG TRANSFUSION REACTION,597052,CDM,300,RC,86078,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,51.71,452.20,percent of total billed charges,
88365 RF Bill ISH Initial Stain MAWD,9114584,CDM,300,RC,88365,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,Local,,138.60,,,,,,,121.31,452.20,percent of total billed charges,
88364 RF Bill ISH Addl Stain MAWD,9110010,CDM,300,RC,88364,HCPCS,,,facility,outpatient,,,273.00000,79.17000,Aetna,Local,,138.60,,,,,,,98.42,223.31,percent of total billed charges,
CROSSMATCH ELECTRONIC,4574097,CDM,300,RC,86923,HCPCS,,,facility,outpatient,,,171.00000,49.59000,Aetna,Local,,86.82,,,,,,,80.37,452.20,percent of total billed charges,
BB BILL GRAD SEP REFERENCE,5987846,CDM,300,RC,86972,HCPCS,,,facility,outpatient,,,371.00000,107.59000,Aetna,Local,,188.36,,,,,,,75.96,452.20,percent of total billed charges,
BB BILL INHIBITION REFERENCE,5987847,CDM,300,RC,86977,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,Local,,121.85,,,,,,,75.96,452.20,percent of total billed charges,
BB BILL AB PNL ADS REFERENCE,5987849,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,272.00000,78.88000,Aetna,Local,,138.09,,,,,,,28.92,951.40,percent of total billed charges,
BB BILL AB SCREEN RARE REFERENCE,5987850,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,Local,,110.68,,,,,,,9.77,178.32,percent of total billed charges,
BB BILL PRE WARM REFERENCE,5987851,CDM,300,RC,86999,HCPCS,,,facility,outpatient,,,131.00000,37.99000,Aetna,Local,,66.51,,,,,,,21.51,107.16,percent of total billed charges,
DIRECT COOMBS SOLID PHASE,662025,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,5.39,61.35,percent of total billed charges,
DIRECT COOMBS SOLID PHASE,662059,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,5.39,61.35,percent of total billed charges,
BB BILL AB ID RARE REFERENCE,5987853,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,242.00000,70.18000,Aetna,Local,,122.86,,,,,,,28.92,951.40,percent of total billed charges,
BB BILL SALINE RPLMT REFERENCE,5987854,CDM,300,RC,86999,HCPCS,,,facility,outpatient,,,131.00000,37.99000,Aetna,Local,,66.51,,,,,,,21.51,107.16,percent of total billed charges,
BB BILL PRETREAT CHEM DRUG REFERE,5987855,CDM,300,RC,86975,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,192.93,,,,,,,75.96,1185.74,percent of total billed charges,
BB BILL AB ID REFERENCE,5987844,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,242.00000,70.18000,Aetna,Local,,122.86,,,,,,,28.92,951.40,percent of total billed charges,
BB BILL AB SCREEN REFERENCE,5987843,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,9.77,118.61,percent of total billed charges,
BB BILL ANTIGEN TYPE PT REFERENCE,5987840,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,3.83,358.78,percent of total billed charges,
BB BILL DAT POLY REFERENCE,5987841,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,Local,,25.89,,,,,,,5.39,59.24,percent of total billed charges,
BB BILL ELUTION REFERENCE,5987842,CDM,300,RC,86860,HCPCS,,,facility,outpatient,,,247.00000,71.63000,Aetna,Local,,125.40,,,,,,,33.03,452.20,percent of total billed charges,
BB BILL RH TYPE REFERENCE,595629,CDM,300,RC,86901,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,2.99,121.06,percent of total billed charges,
BB BILL ABO TYPING REFERENCE,5987839,CDM,300,RC,86900,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,2.99,128.57,percent of total billed charges,
PLASMA EXCHANGE THERAPEUTIC,595633,CDM,300,RC,36514,HCPCS,,,facility,outpatient,,,3737.00000,1083.73000,Aetna,Local,,2076.00,,,,,,,1439.38,3509.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BB BILL PRETREATMENT REFERENCE,595630,CDM,300,RC,86971,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,17.35,452.20,percent of total billed charges,
BLOOD TYPE ABO,595784,CDM,300,RC,86900,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,2.99,128.57,percent of total billed charges,
BLOOD TYPE ABO,594592,CDM,300,RC,86900,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,2.99,128.57,percent of total billed charges,
BLOOD TYPE ABO,7964598,CDM,300,RC,86900,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,2.99,128.57,percent of total billed charges,
BLOOD TYPE RH,636655,CDM,300,RC,86901,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,Local,,33.51,,,,,,,2.99,53.99,percent of total billed charges,
PRETREATMENT ENZYMES,638994,CDM,300,RC,86971,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,Local,,165.51,,,,,,,17.35,452.20,percent of total billed charges,
Pretreatment,642407,CDM,300,RC,86971,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,Local,,165.51,,,,,,,17.35,452.20,percent of total billed charges,
ANTIBODY ID SERUM,639127,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,Local,,165.51,,,,,,,28.92,951.40,percent of total billed charges,
ANTIBODY ID SERUM,639128,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,Local,,165.51,,,,,,,28.92,951.40,percent of total billed charges,
ANTIBODY ID SERUM,639129,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,Local,,165.51,,,,,,,28.92,951.40,percent of total billed charges,
ANTIBODY ID SERUM,639130,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,Local,,165.51,,,,,,,28.92,951.40,percent of total billed charges,
Panel,639136,CDM,300,RC,86870,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,Local,,165.51,,,,,,,28.92,951.40,percent of total billed charges,
AB SCRN INC TECH,2212824,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,,59.40,,,,,,,9.77,95.71,percent of total billed charges,
AB SCRN INC TECH,594607,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,,59.40,,,,,,,9.77,95.71,percent of total billed charges,
AB SCRN INC TECH,594609,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,,59.40,,,,,,,9.77,95.71,percent of total billed charges,
AB SCRN INC TECH,595595,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,,59.40,,,,,,,9.77,95.71,percent of total billed charges,
AB SCRN INC TECH,639057,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,,59.40,,,,,,,9.77,95.71,percent of total billed charges,
AB SCRN INC TECH,7964596,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,,59.40,,,,,,,9.77,95.71,percent of total billed charges,
RBC ANTIBODY SCREEN,8441798,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,,59.40,,,,,,,9.77,95.71,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,639120,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,641259,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,641260,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,641261,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
Antigen Type per unit,641296,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,309.00000,89.61000,Aetna,Local,,156.88,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648144,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648145,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648146,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648147,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648148,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648149,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648150,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
BLOOD TYPING ANTIGEN DONOR EA,648151,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,6.35,358.78,percent of total billed charges,
ANTIGEN TYPE PATIENT,639119,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,3.83,358.78,percent of total billed charges,
ANTIGEN TYPE PATIENT,641250,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,3.83,358.78,percent of total billed charges,
ANTIGEN TYPE PATIENT,641251,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,3.83,358.78,percent of total billed charges,
ANTIGEN TYPE PATIENT,641252,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,3.83,358.78,percent of total billed charges,
Antigen Type patient,641295,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,309.00000,89.61000,Aetna,Local,,156.88,,,,,,,3.83,358.78,percent of total billed charges,
COOMBS DIRECT,595458,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,85.00000,24.65000,Aetna,Local,,43.15,,,,,,,5.39,69.53,percent of total billed charges,
COOMBS DIRECT,595794,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,85.00000,24.65000,Aetna,Local,,43.15,,,,,,,5.39,69.53,percent of total billed charges,
COOMBS DIRECT,7964626,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,85.00000,24.65000,Aetna,Local,,43.15,,,,,,,5.39,69.53,percent of total billed charges,
COOMBS DIRECT,7964680,CDM,300,RC,86880,HCPCS,,,facility,outpatient,,,85.00000,24.65000,Aetna,Local,,43.15,,,,,,,5.39,69.53,percent of total billed charges,
CROSSMATCH IS TECHNIQUE,592980,CDM,300,RC,86920,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH IS TECHNIQUE,595426,CDM,300,RC,86920,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH IS TECHNIQUE,639021,CDM,300,RC,86920,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595819,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595820,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595802,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,595806,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,7964622,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH INC TECHNIQUE,7964677,CDM,300,RC,86921,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,34.70,452.20,percent of total billed charges,
CROSSMATCH IC TECHNIQUE,639022,CDM,300,RC,86922,HCPCS,,,facility,outpatient,,,162.00000,46.98000,Aetna,Local,,82.25,,,,,,,34.70,452.20,percent of total billed charges,
ELUTION,595619,CDM,300,RC,86860,HCPCS,,,facility,outpatient,,,164.00000,47.56000,Aetna,Local,,83.26,,,,,,,33.03,452.20,percent of total billed charges,
IRRADIATED,636050,CDM,300,RC,86945,HCPCS,,,facility,outpatient,,,171.00000,49.59000,Aetna,Local,,86.82,,,,,,,34.46,139.88,percent of total billed charges,
FETAL SCREEN,595602,CDM,300,RC,86941,HCPCS,,,facility,outpatient,,,164.00000,47.56000,Aetna,Local,,83.26,,,,,,,11.23,134.15,percent of total billed charges,
THAWING FEE,638906,CDM,300,RC,86927,HCPCS,,,facility,outpatient,,,265.00000,76.85000,Aetna,Local,,134.54,,,,,,,2.75,452.20,percent of total billed charges,
HEA PANEL ADD ON CBC ZB04H,7974998,CDM,300,RC,81403,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,Local,,184.80,,,,,,,171.08,490.78,percent of total billed charges,
PLATELET ANTIBODY SCREEN IRL,7989144,CDM,300,RC,86022,HCPCS,,,facility,outpatient,,,287.00000,83.23000,Aetna,Local,,145.71,,,,,,,17.03,234.77,percent of total billed charges,
PLATELET ANTIBODY SCREEN IRL,596410,CDM,300,RC,86023,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,Local,,110.68,,,,,,,11.55,178.32,percent of total billed charges,
PLATELET BOUND IGG IRL,657858,CDM,300,RC,86023,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,Local,,110.68,,,,,,,11.55,178.32,percent of total billed charges,
WBC DEPLETION,5291840,CDM,300,RC,36511,HCPCS,,,facility,outpatient,,,5086.00000,1474.94000,Aetna,Local,,2076.00,,,,,,,1439.38,4160.35,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BB BILL COM SEROLOGIC PAN REFEREN,6633842,CDM,300,RC,86906,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,Local,,85.29,,,,,,,7.75,137.42,percent of total billed charges,
BB BILL NEAT UNTYPED REFERENCE,6605847,CDM,300,RC,86904,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,Local,,125.91,,,,,,,6.19,202.86,percent of total billed charges,
BB BILL NEAT AG NEG REFERENCE,6605850,CDM,300,RC,86904,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,6.19,121.88,percent of total billed charges,
BB BILL IAT REFERENCE,6605851,CDM,300,RC,86885,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,5.72,170.93,percent of total billed charges,
BB BILL SEROLOGIC PANEL REFERENCE,6633840,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,88.00000,25.52000,Aetna,Local,,44.68,,,,,,,3.83,358.78,percent of total billed charges,
BB BILL AUTO AB ID REFERENCE,6969839,CDM,300,RC,86940,HCPCS,,,facility,outpatient,,,49.00000,14.21000,Aetna,Local,,24.88,,,,,,,8.13,40.08,percent of total billed charges,
BB BILL AUTO AB ID REFERENCE,6969840,CDM,300,RC,86940,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,Local,,25.89,,,,,,,8.13,41.72,percent of total billed charges,
BB BILL AB ID REFERENCE,6969841,CDM,300,RC,86941,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,Local,,36.05,,,,,,,11.23,58.08,percent of total billed charges,
BB BILL RED CELL EXCHANGE,7141839,CDM,300,RC,36512,HCPCS,,,facility,outpatient,,,3631.00000,1052.99000,Aetna,Local,,2076.00,,,,,,,1439.38,3509.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BB BILL EGA TREATMENT REFERENCE,7734603,CDM,300,RC,86970,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,52.15,156.59,percent of total billed charges,
BB BILL ANTIBODY TITRATION REF,5103840,CDM,300,RC,86886,HCPCS,,,facility,outpatient,,,217.00000,62.93000,Aetna,Local,,110.17,,,,,,,5.18,177.51,percent of total billed charges,
RBC Pretrtmt inc w enzyme,8232065,CDM,300,RC,86971,HCPCS,,,facility,outpatient,,,326.00000,94.54000,Aetna,Local,,165.51,,,,,,,17.35,452.20,percent of total billed charges,
RBC typing adsorption,8232066,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,3.83,358.78,percent of total billed charges,
Typed Donor Units 7 Percent,8471788,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,6.35,358.78,percent of total billed charges,
Typed Donor Units 4 to 6 percent,8471794,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,Local,,133.02,,,,,,,6.35,358.78,percent of total billed charges,
Typed Donor Units 3 Percent,8471800,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,328.00000,95.12000,Aetna,Local,,166.53,,,,,,,6.35,358.78,percent of total billed charges,
Typed Donor Units 2 percent,8471801,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,440.00000,127.60000,Aetna,Local,,223.39,,,,,,,6.35,359.92,percent of total billed charges,
Typed Donor Units 1 percentc,8471812,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,515.00000,149.35000,Aetna,Local,,261.47,,,,,,,6.35,421.27,percent of total billed charges,
Typed Donor Units less than 1 percent,8471818,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,573.00000,166.17000,Aetna,Local,,290.91,,,,,,,6.35,468.71,percent of total billed charges,
Low Incident Antigen Unit,8471824,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,166.00000,48.14000,Aetna,Local,,84.28,,,,,,,6.35,358.78,percent of total billed charges,
Rare Antigen Unit,8471830,CDM,300,RC,86902,HCPCS,,,facility,outpatient,,,431.00000,124.99000,Aetna,Local,,218.82,,,,,,,6.35,358.78,percent of total billed charges,
Bill Genotype RHD weak partial D CBC Z00A2,8987502,CDM,300,RC,81403,HCPCS,,,facility,outpatient,,,455.00000,131.95000,Aetna,Local,,231.00,,,,,,,171.68,490.78,percent of total billed charges,
Genotype RHD CBC Z00A2,9093819,CDM,300,RC,81403,HCPCS,,,facility,outpatient,,,473.00000,137.17000,Aetna,Local,,240.14,,,,,,,171.68,490.78,percent of total billed charges,
Rh genotyping RHD Grifols Z0019,9093830,CDM,300,RC,0198U,HCPCS,,,facility,outpatient,,,509.00000,147.61000,Aetna,Local,,258.42,,,,,,,203.60,636.48,percent of total billed charges,
ENTEROVIRUS PCR,4793840,CDM,300,RC,87498,HCPCS,,,facility,outpatient,,,302.00000,87.58000,Aetna,Local,,153.33,,,,,,,32.53,247.04,percent of total billed charges,
Bordetella pertussis parapertussis PCR,8471758,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,Local,,106.11,,,,,,,32.53,170.96,percent of total billed charges,
Bordetella PCR,8471763,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,Local,,106.11,,,,,,,32.53,170.96,percent of total billed charges,
C DIFF AMPLIFIED PROBE,4793839,CDM,300,RC,87493,HCPCS,,,facility,outpatient,,,223.00000,64.67000,Aetna,Local,,113.22,,,,,,,34.55,182.41,percent of total billed charges,
87798 Respiratory Pathogens Gr 3,7971880,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,209.00000,60.61000,Aetna,Local,,106.11,,,,,,,32.53,170.96,percent of total billed charges,
INFLUENZA AB RAPID PCR,7969531,CDM,300,RC,87502,HCPCS,,,facility,outpatient,,,445.00000,129.05000,Aetna,Local,,225.93,,,,,,,88.81,364.01,percent of total billed charges,
Strep Group A Rapid PCR,8125256,CDM,300,RC,87651,HCPCS,,,facility,outpatient,,,207.00000,60.03000,Aetna,Local,,105.09,,,,,,,32.53,169.33,percent of total billed charges,
Strep Group B PCR,8125257,CDM,300,RC,87150,HCPCS,,,facility,outpatient,,,272.00000,78.88000,Aetna,Local,,138.09,,,,,,,32.53,222.50,percent of total billed charges,
Blood Culture DNA RNA AMPLIFIED PROBE,8370648,CDM,300,RC,87150,HCPCS,,,facility,outpatient,,,272.00000,78.88000,Aetna,Local,,138.09,,,,,,,32.53,222.50,percent of total billed charges,
Blood Culture DNA RNA AMPLIFIED PROBE,8370649,CDM,300,RC,87150,HCPCS,,,facility,outpatient,,,272.00000,78.88000,Aetna,Local,,138.09,,,,,,,32.53,222.50,percent of total billed charges,
Blood Culture DNA RNA AMPLIFIED PROBE,8370650,CDM,300,RC,87150,HCPCS,,,facility,outpatient,,,272.00000,78.88000,Aetna,Local,,138.09,,,,,,,32.53,222.50,percent of total billed charges,
MRSA DNA AMP PROBE,4793841,CDM,300,RC,87641,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,Local,,126.92,,,,,,,32.53,204.50,percent of total billed charges,
C TRACHOMATIC DNA PROBE,7935464,CDM,300,RC,87491,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,32.53,128.43,percent of total billed charges,
N GONORRHOEAE DNA PROBE,7935468,CDM,300,RC,87591,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,Local,,80.22,,,,,,,32.53,129.24,percent of total billed charges,
Encephalitis Panel CSF by PCR,8338740,CDM,300,RC,87483,HCPCS,,,facility,outpatient,,,2108.00000,611.32000,Aetna,Local,,1070.23,,,,,,,386.35,1724.34,percent of total billed charges,
COV 2019 CORONAVIRUS,8336076,CDM,300,RC,87635,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,Local,,51.31,,,,,,,47.57,150.51,fee schedule,
Influenza A and B  and RSV PCR,8328328,CDM,300,RC,87631,HCPCS,,,facility,outpatient,,,531.00000,153.99000,Aetna,Local,,269.59,,,,,,,132.22,434.36,percent of total billed charges,
RSV RAPID PCR,8366451,CDM,300,RC,87634,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,,103.06,,,,,,,65.08,186.03,percent of total billed charges,
Infectious disease bacterial or viral respiratory tract inf,8370647,CDM,300,RC,87633,HCPCS,,,facility,outpatient,,,1848.00000,535.92000,Aetna,Local,,938.23,,,,,,,386.35,1511.66,percent of total billed charges,
Influenza CoVID 19 RSV PCR,8398214,CDM,300,RC,87637,HCPCS,,,facility,outpatient,,,531.00000,153.99000,Aetna,Local,,269.59,,,,,,,132.22,434.36,percent of total billed charges,
N gonorrhoeae DNA PROBE,8453852,CDM,300,RC,87591,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,Local,,80.22,,,,,,,32.53,129.24,percent of total billed charges,
C trachomatis DNA PROBE,8453851,CDM,300,RC,87491,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,32.53,128.43,percent of total billed charges,
Enteric Pathogen Panel PCR,8914517,CDM,300,RC,87507,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,411.24,,,,,,,380.70,1104.47,percent of total billed charges,
Trichomonas vaginalis probe,8995201,CDM,300,RC,87661,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,Local,,108.65,,,,,,,32.53,175.05,percent of total billed charges,
Bacterial Vaginitis Probe,8995202,CDM,300,RC,81515,HCPCS,,,facility,outpatient,,,277.00000,80.33000,Aetna,Local,,140.63,,,,,,,130.19,696.92,percent of total billed charges,
HBV Quant by NAAT,8143458,CDM,300,RC,87517,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,Local,,130.99,,,,,,,39.72,211.04,percent of total billed charges,
ADRENOCORTICOTROPHIC,3184886,CDM,300,RC,82024,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,35.80,110.43,percent of total billed charges,
HEPATITIS DELTA ANTIBODY,7784330,CDM,300,RC,86692,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,15.90,121.88,percent of total billed charges,
ACETONE SERUM,597253,CDM,300,RC,80320,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,,95.96,,,,,,,0.01485,154.60,percent of total billed charges,
Isopropanol Blood,8239842,CDM,300,RC,80320,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,,95.96,,,,,,,0.01485,154.60,percent of total billed charges,
ALDOSTERONE 24 HOUR,3206893,CDM,300,RC,82088,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,37.78,128.43,percent of total billed charges,
BK VIRUS QUANT,3214920,CDM,300,RC,87799,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,Local,,116.77,,,,,,,39.72,188.14,percent of total billed charges,
PLATELIA ASPERGILLUS ANTIGEN,3214896,CDM,300,RC,87305,HCPCS,,,facility,outpatient,,,181.00000,52.49000,Aetna,Local,,91.89,,,,,,,11.10,148.06,percent of total billed charges,
HEPATITIS A TOTAL,3192844,CDM,300,RC,86708,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,11.48,120.25,percent of total billed charges,
NEUROLOGY ABS BY IFA,759805,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,126.00000,36.54000,Aetna,Local,,63.97,,,,,,,11.18,103.07,percent of total billed charges,
HEPATITIS BE ANTIGEN,3206839,CDM,300,RC,87350,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,10.69,122.70,percent of total billed charges,
CATECHOLAMINES URINE,3188946,CDM,300,RC,82384,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,23.41,114.52,percent of total billed charges,
TISSUE CULTURE BM BLOOD CSI,7844100,CDM,300,RC,88237,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,Local,,100.02,,,,,,,32.36,380.94,percent of total billed charges,
CORTISOL URINE FREE,3206876,CDM,300,RC,82530,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,15.49,124.34,percent of total billed charges,
VARICELLA ZOSTER VIRUS ANTIBODIES,3216840,CDM,300,RC,86787,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,11.94,63.80,percent of total billed charges,
VARICELLA ZOSTER VIRUS ANTIBODIES,991819,CDM,300,RC,86787,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,11.94,63.80,percent of total billed charges,
HEPATITIS BE ANTIBODY,3196842,CDM,300,RC,86707,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,,76.66,,,,,,,10.72,123.52,percent of total billed charges,
EPSTEIN BARR CAPSID VCA,3188874,CDM,300,RC,86665,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,Local,,21.83,,,,,,,16.82,48.07,percent of total billed charges,
HCV Quant by NAAT with Reflex to Sequencing,8119533,CDM,300,RC,87522,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,39.72,194.68,percent of total billed charges,
3000572 Hepatitis C Virus by Quantitative NAAT ARUP,8124828,CDM,300,RC,87522,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,39.72,194.68,percent of total billed charges,
FRUCTOSAMINE,3192850,CDM,300,RC,82985,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,15.53,118.61,percent of total billed charges,
BLASTOMIC,613051,CDM,300,RC,86612,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,Local,,18.78,,,,,,,6.68,34.19,percent of total billed charges,
FUNGAL ANTIBODY PANEL,3214839,CDM,300,RC,86698,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,Local,,20.31,,,,,,,12.78,36.54,percent of total billed charges,
HELICOBACTER PYLORI AG DETECTION,7243847,CDM,300,RC,87338,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,13.33,126.79,percent of total billed charges,
HEPATITIS B SURF AG NEUTRAL,3481850,CDM,300,RC,87341,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,9.58,117.79,percent of total billed charges,
ASSAY OF SERUM ALBUMIN,613062,CDM,300,RC,82040,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,Local,,11.17,,,,,,,4.59,18.00,percent of total billed charges,
HERPES SIMPLEX ANTIBODY,3184945,CDM,300,RC,86695,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,12.23,127.61,percent of total billed charges,
Herp 1,613113,CDM,300,RC,86695,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,12.23,127.61,percent of total billed charges,
HERPES SIMPLEX 2,3184946,CDM,300,RC,86696,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,17.94,126.79,percent of total billed charges,
HISTOPLASMA ANTIGEN URINE,3190989,CDM,300,RC,87385,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,12.29,159.51,percent of total billed charges,
HLA B27 ANTIGEN,3218879,CDM,300,RC,86812,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,23.93,114.52,percent of total billed charges,
IGG SUBCLASS,1549815,CDM,300,RC,82787,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,Local,,21.83,,,,,,,7.44,35.17,percent of total billed charges,
ALDOSTERONE,3184848,CDM,300,RC,82088,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,37.78,127.61,percent of total billed charges,
LIPOPROTEIN A,3214932,CDM,300,RC,83695,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,13.28,127.61,percent of total billed charges,
MUMPS VIRUS ANTIBODY IGG,3178879,CDM,300,RC,86735,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,12.10,127.61,percent of total billed charges,
LIPASE FLUID,4349840,CDM,300,RC,83690,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,6.19,127.61,percent of total billed charges,
Thyroglobulin,6061984,CDM,300,RC,84432,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,14.88,159.51,percent of total billed charges,
THYROGLOBULIN LC MS MS,6145846,CDM,300,RC,84432,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,14.88,159.51,percent of total billed charges,
BILIRUBIN TOTAL FLUID,1153806,CDM,300,RC,82247,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,4.66,126.79,percent of total billed charges,
GROWTH HORMONE,3206873,CDM,300,RC,83003,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,,76.66,,,,,,,15.45,123.52,percent of total billed charges,
HISTAMINE PLASMA,7243843,CDM,300,RC,83088,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,27.38,111.25,percent of total billed charges,
HISTONE AB,7243839,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,10.69,120.25,percent of total billed charges,
ALKALINE PHOSPHATASE,613044,CDM,300,RC,84075,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,Local,,20.31,,,,,,,4.80,32.72,percent of total billed charges,
ALK PHOSE ISOENZYMES,3191024,CDM,300,RC,84080,HCPCS,,,facility,outpatient,,,113.00000,32.77000,Aetna,Local,,57.37,,,,,,,13.70,92.43,percent of total billed charges,
HIV 1 Quant by NAAT,8146997,CDM,300,RC,87536,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,Local,,124.39,,,,,,,78.89,225.51,percent of total billed charges,
HIV 1 QUANT,8275875,CDM,300,RC,87536,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,Local,,124.39,,,,,,,78.89,225.51,percent of total billed charges,
HIV 1 GENOTYPING WITH VIRTUAL PHE,8442363,CDM,300,RC,87901,HCPCS,,,facility,outpatient,,,379.00000,109.91000,Aetna,Local,,192.42,,,,,,,178.13,682.24,percent of total billed charges,
IMMUNOGLOBULIN D,3207059,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,8.18,128.43,percent of total billed charges,
IMMUNOGLOBULIN G SUBCLASSES PANEL,3208996,CDM,300,RC,82787,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,Local,,21.83,,,,,,,7.44,35.17,percent of total billed charges,
ALPHA FETOPROTEIN NONPREG,3180842,CDM,300,RC,82105,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,15.54,121.06,percent of total billed charges,
Maternal Serum Screen AFP,8161657,CDM,300,RC,82105,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,15.54,121.06,percent of total billed charges,
ALUMINUM,7177840,CDM,300,RC,82108,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,23.62,121.06,percent of total billed charges,
RF INSULIN TOTAL,3184845,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,10.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748031,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,10.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748032,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,10.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748033,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,10.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748034,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,10.60,127.61,percent of total billed charges,
RF INSULIN TOTAL,7748035,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,10.60,127.61,percent of total billed charges,
Insulin Random ARUP,8170373,CDM,300,RC,83525,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,10.60,127.61,percent of total billed charges,
INSULIN ANTIBODIES,7177850,CDM,300,RC,86337,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,19.85,121.88,percent of total billed charges,
INTRINSIC FACTOR BLOCKING ANTIBDY,3218856,CDM,300,RC,86340,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,Local,,80.22,,,,,,,13.98,129.24,percent of total billed charges,
EPSTEIN BARR VIRUS DNA QT REAL TM,3198952,CDM,300,RC,87799,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,Local,,110.68,,,,,,,39.72,178.32,percent of total billed charges,
LAMOTRIGINE LEVEL,3198911,CDM,300,RC,80175,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,12.29,124.34,percent of total billed charges,
AMYLASE ISOENZYMES,3209005,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,Local,,38.59,,,,,,,6.00,62.17,percent of total billed charges,
CHLAMYDIA,7790508,CDM,300,RC,86631,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,10.81,31.32,percent of total billed charges,
CHLAMYDIA,7790527,CDM,300,RC,86631,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,10.81,31.32,percent of total billed charges,
ALBUMIN CSF,1453800,CDM,300,RC,82042,HCPCS,,,facility,outpatient,,,35.00000,10.15000,Aetna,Local,,17.77,,,,,,,3.83,28.63,percent of total billed charges,
EHRLICHIA,1453801,CDM,300,RC,86666,HCPCS,,,facility,outpatient,,,68.00000,19.72000,Aetna,Local,,34.52,,,,,,,9.43,55.62,percent of total billed charges,
EHRLICHIA,3188904,CDM,300,RC,86666,HCPCS,,,facility,outpatient,,,68.00000,19.72000,Aetna,Local,,34.52,,,,,,,9.43,55.62,percent of total billed charges,
LDH,1453805,CDM,300,RC,83615,HCPCS,,,facility,outpatient,,,49.00000,14.21000,Aetna,Local,,24.88,,,,,,,5.60,40.08,percent of total billed charges,
JC VIRUS PCR,3214941,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,Local,,123.88,,,,,,,32.53,199.59,percent of total billed charges,
AMYLASE ISO,759806,CDM,300,RC,82150,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,Local,,38.59,,,,,,,6.00,62.17,percent of total billed charges,
CARDIOLIPID ANTIBODY,3190994,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,22.56,67.44,percent of total billed charges,
CARDIO AB,613048,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,22.56,67.44,percent of total billed charges,
CARDIOLIPIN ANTIBODY,8256399,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,22.56,67.44,percent of total billed charges,
RESPIRATORY SYNCYTIAL VIRUS,3218874,CDM,300,RC,87280,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,12.44,111.25,percent of total billed charges,
LEAD BLD,3188848,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,11.23,125.97,percent of total billed charges,
LEAD BLD,7933752,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,11.23,125.97,percent of total billed charges,
BETA D GLUCAN,7111839,CDM,300,RC,87449,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,Local,,117.28,,,,,,,11.10,188.96,percent of total billed charges,
IMMUNOASSAY TUMOR OTHER,8366174,CDM,300,RC,86316,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,13.15,118.61,percent of total billed charges,
IMMUNOASSAY TUMOR OTHER,8461765,CDM,300,RC,86316,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,13.15,118.61,percent of total billed charges,
IMMUNOASSAY TUMOR OTHER,8461767,CDM,300,RC,86316,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,13.15,118.61,percent of total billed charges,
KAPPA LAMBDA LIGHT CHAINS,3214904,CDM,300,RC,83521,HCPCS,,,facility,outpatient,,,83.00000,24.07000,Aetna,Local,,42.14,,,,,,,16.01,67.89,percent of total billed charges,
KAPPA LAMBDA LIGHT CHAIN,1549817,CDM,300,RC,83521,HCPCS,,,facility,outpatient,,,83.00000,24.07000,Aetna,Local,,42.14,,,,,,,16.01,67.89,percent of total billed charges,
C TRACH N GONORRHOEAE BY AMD,3200851,CDM,300,RC,87491,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,32.53,92.99,percent of total billed charges,
N GONOR DNA AMP PROBE,1714802,CDM,300,RC,87591,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,32.53,92.99,percent of total billed charges,
IMMUNOASSAY QUANT NOS,1429800,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,Local,,20.82,,,,,,,16.01,45.77,percent of total billed charges,
IMMUNOASSAY QUANT NOS,5391874,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,Local,,20.82,,,,,,,16.01,45.77,percent of total billed charges,
CARDIOLIPIN ANTIBODIES SCREEN,3178845,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,23.60,119.43,percent of total billed charges,
CARDIOLIPIN ANTIBODY,8256309,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,23.60,119.43,percent of total billed charges,
CARDIOLIPIN ANTIBODY,8256316,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,23.60,119.43,percent of total billed charges,
PHOSPHOLIPIDS,3206858,CDM,300,RC,84311,HCPCS,,,facility,outpatient,,,159.00000,46.11000,Aetna,Local,,80.72,,,,,,,7.51,130.06,percent of total billed charges,
GBM ANTIBODY,3190853,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,10.69,111.25,percent of total billed charges,
ANGIOTENSIN 1 CONVERTING,3188943,CDM,300,RC,82164,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,13.53,126.79,percent of total billed charges,
ANGIOTENSIN 1 CONVERTING,3196845,CDM,300,RC,82164,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,13.53,126.79,percent of total billed charges,
SJOGREN ANTIBODIES SSA AND SSB,3214893,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,45.00000,13.05000,Aetna,Local,,22.85,,,,,,,16.62,47.51,percent of total billed charges,
SJOGREN ANTIBODIES SSA AND SSB,3214992,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,45.00000,13.05000,Aetna,Local,,22.85,,,,,,,16.62,47.51,percent of total billed charges,
LIDOCAINE LEVEL,599708,CDM,300,RC,80176,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,13.62,108.79,percent of total billed charges,
LIVER KIDNEY LKM1 AB IGM,3216879,CDM,300,RC,86376,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,13.49,122.70,percent of total billed charges,
PLATELET NEUTRALIZATION LUPUS ANT,3341841,CDM,300,RC,85597,HCPCS,,,facility,outpatient,,,44.00000,12.76000,Aetna,Local,,22.34,,,,,,,16.67,47.65,percent of total billed charges,
Lyme disease C6 Peptide Ab,9011398,CDM,300,RC,86618,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,15.79,119.43,percent of total billed charges,
Lyme 1st Tier Testing,9044144,CDM,300,RC,86618,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,15.79,119.43,percent of total billed charges,
50255 Borrelia burgdorferi Ab IgG by Immunoblot ARUP,8117903,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,14.36,124.34,percent of total billed charges,
B Burgdorferi Ab IgG IgM CSCTRULE,8948133,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,14.36,124.34,percent of total billed charges,
PTT LUPUS,613046,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,Local,,21.32,,,,,,,5.57,34.36,percent of total billed charges,
CHLAMYDIA IGM,7790528,CDM,300,RC,86632,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,11.75,33.60,percent of total billed charges,
ANA REFLEX BILL,3173065,CDM,300,RC,86039,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,10.34,119.43,percent of total billed charges,
Antinuclear Ab with HEp2 Substrate IgG by IFA,8146939,CDM,300,RC,86039,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,10.34,119.43,percent of total billed charges,
Antinuclear Ab with HEp2 Substrate IgG by IFA,8146989,CDM,300,RC,86039,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,10.34,119.43,percent of total billed charges,
ANA SCREEN,3173050,CDM,300,RC,86038,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,11.21,124.34,percent of total billed charges,
THYROID PEROXIDASE AND THRYOGLOB,3188926,CDM,300,RC,86376,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,13.49,59.71,percent of total billed charges,
METHYLMALONIC ACID,3190886,CDM,300,RC,83921,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,19.66,110.43,percent of total billed charges,
THYROGLOBULIN ANTIBODY,3196864,CDM,300,RC,86800,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,14.75,127.61,percent of total billed charges,
THYROGLOBULIN ANTIBODY,6061848,CDM,300,RC,86800,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,14.75,127.61,percent of total billed charges,
METANEPHRINSE FRACTIONED URINE,6875878,CDM,300,RC,83835,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,15.71,111.25,percent of total billed charges,
METANEPHRINES PLASMA,3192856,CDM,300,RC,83835,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,Local,,67.02,,,,,,,15.71,107.98,percent of total billed charges,
MAGNESIUM OTHER,3214929,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,6.21,118.61,percent of total billed charges,
MAGNESIUM OTHER,3218843,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,6.21,118.61,percent of total billed charges,
METHANOL,604347,CDM,300,RC,80320,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,,95.96,,,,,,,0.01485,154.60,percent of total billed charges,
TREPONEMA PALLIDUM,3198917,CDM,300,RC,86780,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,12.28,118.61,percent of total billed charges,
TREPONEMA PALLIDUM,3521842,CDM,300,RC,86780,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,12.28,120.25,percent of total billed charges,
METHOTREXATE LEVEL,605916,CDM,300,RC,80204,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,Local,,71.59,,,,,,,35.75,115.34,percent of total billed charges,
PROTHROMBIN TIME,3178898,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,31.00000,8.99000,Aetna,Local,,15.74,,,,,,,3.98,25.36,percent of total billed charges,
PTT SUB PLASMA FRACT,3186863,CDM,300,RC,85732,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,5.99,22.09,percent of total billed charges,
HEPARIN NEUT,3186866,CDM,300,RC,85525,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,10.98,40.90,percent of total billed charges,
FACTOR V LEIDEN ZB10C,3178848,CDM,300,RC,81241,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,68.01,194.43,percent of total billed charges,
FACTOR V LEIDEN ZB10C,7730126,CDM,300,RC,81241,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,68.01,194.43,percent of total billed charges,
STONE ANALYSIS,7724048,CDM,300,RC,82365,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,11.96,125.97,percent of total billed charges,
HERPES SIMPLEX 2 AG,3180854,CDM,300,RC,87273,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,11.10,57.26,percent of total billed charges,
HERPES SIMPLEX I AG,3180875,CDM,300,RC,87274,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,11.10,57.26,percent of total billed charges,
VARICELLA ZOSTER AG,3180876,CDM,300,RC,87290,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,12.44,64.62,percent of total billed charges,
Virus Inoculate,3186853,CDM,300,RC,87253,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,18.73,111.25,percent of total billed charges,
Culture HSV w Reflex Typing,8387024,CDM,300,RC,87253,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,Local,,29.45,,,,,,,18.73,53.53,percent of total billed charges,
MITOCHONDRIAL ANTIBODIES,3180910,CDM,300,RC,86381,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,23.60,121.06,percent of total billed charges,
BETA 2 MICROGLOBULIN BLOOD,3184862,CDM,300,RC,82232,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,15.00,121.06,percent of total billed charges,
CHLORIDE URINE SUPERSAT PROF,7507978,CDM,300,RC,82436,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,5.34,15.24,percent of total billed charges,
ACETYLCHOLINE BINDING AG,3188940,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,,72.09,,,,,,,17.06,116.16,percent of total billed charges,
HEMOCHROMATOSIS MUTATIONS ZB10H,3190955,CDM,300,RC,81256,HCPCS,,,facility,outpatient,,,242.00000,70.18000,Aetna,Local,,122.86,,,,,,,60.58,197.96,percent of total billed charges,
HEMOGLOBIN EVALUATION,3188851,CDM,300,RC,83021,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,11.66,111.25,percent of total billed charges,
HEMOGLOBIN EVALUATION,3190839,CDM,300,RC,83021,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,11.66,111.25,percent of total billed charges,
HGB EVALUATION PANEL,8265873,CDM,300,RC,83021,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,11.66,111.25,percent of total billed charges,
IMMUNOGLOB SERUM CRYOPRECIP,3190956,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,15.00000,4.35000,Aetna,Local,,7.62,,,,,,,7.05,24.64,percent of total billed charges,
IMMUNOGLOB SERUM CRYOPRECIP,3190975,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,15.00000,4.35000,Aetna,Local,,7.62,,,,,,,7.05,24.64,percent of total billed charges,
LYME DIS DNA AMP PROBE,3191041,CDM,300,RC,87476,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,Local,,100.02,,,,,,,32.53,161.15,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3481847,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,11.18,118.61,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3481848,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,11.18,118.61,percent of total billed charges,
THIOPURINE METHYLTRANSFERASE,3196893,CDM,300,RC,84433,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,Local,,116.77,,,,,,,20.55,188.14,percent of total billed charges,
ESTROGEN FRACTIONATED,3198904,CDM,300,RC,82671,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,29.94,117.79,percent of total billed charges,
JAK2 MUTATION QUAL ZB1HR,3200855,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,275.00000,79.75000,Aetna,Local,,139.62,,,,,,,84.96,242.90,percent of total billed charges,
PHENYTOIN TOTAL,3207134,CDM,300,RC,80185,HCPCS,,,facility,outpatient,,,69.00000,20.01000,Aetna,Local,,35.03,,,,,,,12.29,56.44,percent of total billed charges,
VARICELLA ZOSTER BY PCR,3216846,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,Local,,100.02,,,,,,,32.53,161.15,percent of total billed charges,
DRUG CONF FENTANYL METAB UR,3232944,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,Local,,94.94,,,,,,,74.80,257.47,percent of total billed charges,
OSTEOCALCIN BY ECIA,3216851,CDM,300,RC,83937,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,27.68,121.88,percent of total billed charges,
BILE ACIDS FRACT AND TOTAL,3218892,CDM,300,RC,83789,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,Local,,80.22,,,,,,,11.66,129.24,percent of total billed charges,
PSEUDOCHOLINESTERASE TOTAL,3218840,CDM,300,RC,82480,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,5.09,121.88,percent of total billed charges,
COLLAGEN CROSSLINKS,3218903,CDM,300,RC,82523,HCPCS,,,facility,outpatient,,,169.00000,49.01000,Aetna,Local,,85.80,,,,,,,17.31,138.24,percent of total billed charges,
PORPHOBIL DEAMINASE RBC,3218906,CDM,300,RC,82657,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,Local,,97.48,,,,,,,11.66,157.06,percent of total billed charges,
PORPHYRINS TOTAL PLASMA,5785839,CDM,300,RC,84311,HCPCS,,,facility,outpatient,,,277.00000,80.33000,Aetna,Local,,140.63,,,,,,,7.51,226.59,percent of total billed charges,
PORPHYRINS FRACTION PLASMA,3247840,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,307.00000,89.03000,Aetna,Local,,155.86,,,,,,,11.66,251.13,percent of total billed charges,
PORPHYRINS FRACTION PLASMA,6537839,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,307.00000,89.03000,Aetna,Local,,155.86,,,,,,,11.66,251.13,percent of total billed charges,
DNA ANTIBODY,3184889,CDM,300,RC,86225,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,12.74,119.43,percent of total billed charges,
ANNA IFA TITER,3327846,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,Local,,60.92,,,,,,,11.18,98.16,percent of total billed charges,
SICKLE SOLUBILITY TEST,1605803,CDM,300,RC,85660,HCPCS,,,facility,outpatient,,,129.00000,37.41000,Aetna,Local,,65.49,,,,,,,5.11,105.52,percent of total billed charges,
PURKINSE CELL AB TITER IGG,3327848,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,Local,,60.92,,,,,,,11.18,98.16,percent of total billed charges,
ENDOMYSIAL AB IGA TITER,3327850,CDM,300,RC,86231,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,11.21,111.25,percent of total billed charges,
EPSTEIN BARR ANTIBODY,3427839,CDM,300,RC,86663,HCPCS,,,facility,outpatient,,,30.00000,8.70000,Aetna,Local,,15.23,,,,,,,12.16,34.77,percent of total billed charges,
PSA ULTRASENSITIVE,3481849,CDM,300,RC,84153,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,17.05,125.97,percent of total billed charges,
CARDIOLIPID ANTIBODY,3973871,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,23.60,67.44,percent of total billed charges,
CARDIOLIPID ANTIBODY,7726055,CDM,300,RC,86147,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,23.60,67.44,percent of total billed charges,
CARCINOEMBRYONIC AG BODY FL,4349839,CDM,300,RC,82378,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,17.57,124.34,percent of total billed charges,
BLOOD PLATELET AGGREGATION,4563839,CDM,300,RC,85576,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,Local,,33.51,,,,,,,23.09,66.01,percent of total billed charges,
BLOOD PLATELET AGGREGATION,4563841,CDM,300,RC,85576,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,Local,,33.51,,,,,,,23.09,66.01,percent of total billed charges,
HEXAGONAL PHOSPHOLIPID,3180845,CDM,300,RC,85598,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,Local,,97.48,,,,,,,16.67,157.06,percent of total billed charges,
HEXAGONAL PHOSPHOLIPID,3341842,CDM,300,RC,85598,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,Local,,97.48,,,,,,,16.67,157.06,percent of total billed charges,
WEST NILE VIRUS AB BLOOD IGM,657873,CDM,300,RC,86788,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,15.63,62.99,percent of total billed charges,
DEHYDROEPIANDROSTERONE DHEA,4937943,CDM,300,RC,82626,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,23.42,110.43,percent of total billed charges,
DS DNA ANTIBODY 1GG TITER,3327845,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,11.18,111.25,percent of total billed charges,
MYCOPLASMA AB IGM,5235839,CDM,300,RC,86738,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,12.28,118.61,percent of total billed charges,
3000400 QuantiFERON TB Gold Plus 1 Tube ARUP,8118233,CDM,300,RC,86480,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,Local,,67.02,,,,,,,57.45,164.25,percent of total billed charges,
IMMUNOASSAY QUANT NOS,5391853,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,8.46,45.77,percent of total billed charges,
IMMUNOASSAY QUANT NOS,5391855,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,8.46,45.77,percent of total billed charges,
C REACTIVE PROTEIN,5391856,CDM,300,RC,86140,HCPCS,,,facility,outpatient,,,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.82,13.73,percent of total billed charges,
BB BILL ANTIGEN TYPE REFERENCE,595625,CDM,300,RC,86905,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,3.83,358.78,percent of total billed charges,
BB BILL RH PHENOTYPING REFERENCE,5987845,CDM,300,RC,86906,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,Local,,142.66,,,,,,,7.75,229.86,percent of total billed charges,
BB BILL AB SCREEN ADS REFERENCE,5987848,CDM,300,RC,86850,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,,81.23,,,,,,,9.77,130.88,percent of total billed charges,
MUMPS ANTIBODY,3210841,CDM,300,RC,86735,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,12.10,120.25,percent of total billed charges,
MYCOPLASMA AB IGG,3206842,CDM,300,RC,86738,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,12.28,118.61,percent of total billed charges,
BRUCELLA IGG IGM EIA,3232941,CDM,300,RC,86622,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,8.28,120.25,percent of total billed charges,
C PEPTIDE,3188901,CDM,300,RC,84681,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,19.29,119.43,percent of total billed charges,
MYELIN BASIC PROTEIN CSF,3190889,CDM,300,RC,83873,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,15.94,112.88,percent of total billed charges,
CALCITONIN LEVEL,3209019,CDM,300,RC,82308,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,24.83,128.43,percent of total billed charges,
CANCER ANTIGEN 15 3,3216854,CDM,300,RC,86300,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,13.15,121.06,percent of total billed charges,
CARBOHYDRATE AG 19 9,3180848,CDM,300,RC,86301,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,13.15,119.43,percent of total billed charges,
CA 27 29 BIOMIRA,3180839,CDM,300,RC,86300,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,13.15,119.43,percent of total billed charges,
MYOGLOBIN,3191015,CDM,300,RC,83874,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,11.98,120.25,percent of total billed charges,
MYOGLOBIN,7950123,CDM,300,RC,83874,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,11.98,120.25,percent of total billed charges,
OSMOLALITY FECES ZB4GK,3209061,CDM,300,RC,84999,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,56.24,127.61,percent of total billed charges,
CATECHOLAMINES PLASMA,3196848,CDM,300,RC,82384,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,23.41,118.61,percent of total billed charges,
NICOTINE BLOOD,4129840,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,55.20,257.47,percent of total billed charges,
NICOTINE AND METABOLITES URINE,7286008,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,57.60,257.47,percent of total billed charges,
OLIGOCLONAL BANDING,3188966,CDM,300,RC,83916,HCPCS,,,facility,outpatient,,,159.00000,46.11000,Aetna,Local,,80.72,,,,,,,25.39,130.06,percent of total billed charges,
OXCARBAZEPINE,3198933,CDM,300,RC,80183,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,12.29,110.43,percent of total billed charges,
CERULOPLASMIN,3182883,CDM,300,RC,82390,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,9.96,126.79,percent of total billed charges,
PARVOVIRUS B19 IGG ONLY,3218859,CDM,300,RC,86747,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,13.94,121.06,percent of total billed charges,
PARVOVIRUS B19 IGM ONLY,3218860,CDM,300,RC,86747,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,13.94,121.06,percent of total billed charges,
PARVOVIRUS B19 IGG AND IGM,3209022,CDM,300,RC,86747,HCPCS,,,facility,outpatient,,,68.00000,19.72000,Aetna,Local,,34.52,,,,,,,13.94,55.62,percent of total billed charges,
PARVOVIRUS AB,613110,CDM,300,RC,86747,HCPCS,,,facility,outpatient,,,68.00000,19.72000,Aetna,Local,,34.52,,,,,,,13.94,55.62,percent of total billed charges,
TISSUE PLASMINOGEN ACTIVATOR,3481842,CDM,300,RC,85415,HCPCS,,,facility,outpatient,,,170.00000,49.30000,Aetna,Local,,86.31,,,,,,,15.93,139.06,percent of total billed charges,
PLASMINOGEN ACTIVATOR INHIBITOR,3207065,CDM,300,RC,85415,HCPCS,,,facility,outpatient,,,170.00000,49.30000,Aetna,Local,,86.31,,,,,,,15.93,139.06,percent of total billed charges,
CLOZAPINE,7933960,CDM,300,RC,80159,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,18.68,128.43,percent of total billed charges,
PHENYBARB,613087,CDM,300,RC,80184,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,14.18,58.90,percent of total billed charges,
PORPHOBILINOGEN 24 HOUR,3209040,CDM,300,RC,84110,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,Local,,71.59,,,,,,,7.83,115.34,percent of total billed charges,
PORPHYRINS URINE,3196981,CDM,300,RC,84120,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,13.64,111.25,percent of total billed charges,
FECAL POTASSIUM ZB4GR,3196881,CDM,300,RC,84999,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,52.99,120.25,percent of total billed charges,
COPPER,3170880,CDM,300,RC,82525,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,11.51,125.15,percent of total billed charges,
COPPER,3192847,CDM,300,RC,82525,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,11.51,125.15,percent of total billed charges,
PRIMIDONE,3209045,CDM,300,RC,80188,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,15.38,64.62,percent of total billed charges,
COUMADIN,3216883,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,Local,,97.48,,,,,,,76.80,257.47,percent of total billed charges,
VARICELLA ZOSTER VIRUS IGG ANTIBD,3198895,CDM,300,RC,86787,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,11.94,118.61,percent of total billed charges,
VARICELLA ZOSTER ANTIBODY,8260154,CDM,300,RC,86787,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,11.94,118.61,percent of total billed charges,
IMMUNOGLOBULIN G CSF,3188909,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,Local,,20.82,,,,,,,8.18,33.54,percent of total billed charges,
IMMUNOGLOBULIN A,8147425,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,Local,,20.82,,,,,,,8.18,33.54,percent of total billed charges,
CYCLOSPORIN LEVEL,605905,CDM,300,RC,80158,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,11.64,117.79,percent of total billed charges,
CYTOMEGALOVIRUS IGG,3196860,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,13.34,118.61,percent of total billed charges,
CMV IGG,613063,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,13.34,118.61,percent of total billed charges,
CMV IgG,635122,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,13.34,118.61,percent of total billed charges,
CYTOMEGALOVIRUS IGM,3190842,CDM,300,RC,86645,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,15.63,118.61,percent of total billed charges,
Cytomegalovirus by Quant NAAT Plasma,8984933,CDM,300,RC,87497,HCPCS,,,facility,outpatient,,,270.00000,78.30000,Aetna,Local,,137.08,,,,,,,39.72,220.86,percent of total billed charges,
PROTEIN S ANTIGEN,3191021,CDM,300,RC,85305,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,10.76,128.43,percent of total billed charges,
PROTEIN C ANTIGEN,3191018,CDM,300,RC,85302,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,11.13,128.43,percent of total billed charges,
CRYOGLOBULIN SERUM,3191102,CDM,300,RC,82595,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,5.99,126.79,percent of total billed charges,
ACTIVATED PROTEIN C RESISTANCE,3198901,CDM,300,RC,85307,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,14.20,127.61,percent of total billed charges,
ACTIVATED PROTEIN C RESISTANCE,7726056,CDM,300,RC,85307,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,14.20,127.61,percent of total billed charges,
C1 INHIBITOR FUNCTIONAL,3208993,CDM,300,RC,86161,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,11.12,110.43,percent of total billed charges,
PTH RELATED PROTEIN,7732383,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,181.00000,52.49000,Aetna,Local,,91.89,,,,,,,17.06,148.06,percent of total billed charges,
RAPAMYCIN,3196869,CDM,300,RC,80195,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,11.77,121.88,percent of total billed charges,
IMMUNE COMPLEX C1Q,7177855,CDM,300,RC,86332,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,22.59,125.15,percent of total billed charges,
PLASMA RENIN ACTIVITY,3184851,CDM,300,RC,84244,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,20.38,125.97,percent of total billed charges,
Cyclic Citrullinated Peptide Ab,9011531,CDM,300,RC,86200,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,12.01,122.70,percent of total billed charges,
RISTOCETIN COFACTOR,7856055,CDM,300,RC,85245,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,Local,,70.57,,,,,,,21.27,113.70,percent of total billed charges,
ROCKY MT SPOTTED FEVER ANTIBODIES,3192863,CDM,300,RC,86757,HCPCS,,,facility,outpatient,,,82.00000,23.78000,Aetna,Local,,41.63,,,,,,,17.94,67.08,percent of total billed charges,
ROCKY MT SPOTTED FEVER ANTIBODIES,3192883,CDM,300,RC,86757,HCPCS,,,facility,outpatient,,,82.00000,23.78000,Aetna,Local,,41.63,,,,,,,17.94,67.08,percent of total billed charges,
RMSF,647051,CDM,300,RC,86757,HCPCS,,,facility,outpatient,,,82.00000,23.78000,Aetna,Local,,41.63,,,,,,,17.94,67.08,percent of total billed charges,
DHEA SULFATE,3190859,CDM,300,RC,82627,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,20.61,127.61,percent of total billed charges,
REFLEX RMSF TYPHUS FEVER IGM,646393,CDM,300,RC,86757,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,Local,,36.05,,,,,,,17.94,58.08,percent of total billed charges,
ROTAVIRUS EIA,3214901,CDM,300,RC,87425,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,11.10,121.06,percent of total billed charges,
RUBELLA VIRUS AB AGM,3481840,CDM,300,RC,86762,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,13.34,118.61,percent of total billed charges,
RUBELLA VIRUS IGG AB,6033839,CDM,300,RC,86762,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,13.34,127.61,percent of total billed charges,
Rubeola A,613116,CDM,300,RC,86765,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,11.94,125.15,percent of total billed charges,
RUBEOLA A,6557840,CDM,300,RC,86765,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,11.94,125.15,percent of total billed charges,
SEROTONIN BLOOD,3209050,CDM,300,RC,84260,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,,72.09,,,,,,,24.77,116.16,percent of total billed charges,
SEROTONIN BLOOD,7948571,CDM,300,RC,84260,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,,72.09,,,,,,,24.77,116.16,percent of total billed charges,
HIAA 24 HOUR URINE,3188931,CDM,300,RC,83497,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,11.96,125.15,percent of total billed charges,
SMOOTH MUSCLE ACTIN ANTIBODY,7954688,CDM,300,RC,86015,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,11.18,120.25,percent of total billed charges,
SOMATOMEDIN C,7971977,CDM,300,RC,84305,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,19.70,124.34,percent of total billed charges,
FECAL SODIUM,3196878,CDM,300,RC,84302,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,4.50,120.25,percent of total billed charges,
STRIATED MUSCLE AB SCREEN,7119839,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,11.18,122.70,percent of total billed charges,
STRIATED MUSCLE AB TITER,3255842,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,56.00000,16.24000,Aetna,Local,,28.43,,,,,,,11.18,45.81,percent of total billed charges,
Striated Muscle Ab Titer,759803,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,56.00000,16.24000,Aetna,Local,,28.43,,,,,,,11.18,45.81,percent of total billed charges,
FLUORESCENT AB NONINFECTIOUS,6875890,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,Local,,71.59,,,,,,,11.18,115.34,percent of total billed charges,
Reflex PCCA/ANNA by IFA Serum ARUP,9117301,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,Local,,71.59,,,,,,,11.18,115.34,percent of total billed charges,
VITAMIN B1 THIAMIN PYROPHOSPH,3192868,CDM,300,RC,84425,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,19.68,119.43,percent of total billed charges,
DRUG SCREEN CMH GASTRIC ADD ON,605880,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,Local,,128.45,,,,,,,101.20,257.47,percent of total billed charges,
THYROID PEROXIDASE ANTIBODIES,3196865,CDM,300,RC,86376,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,13.49,127.61,percent of total billed charges,
DRUG SCREEN CMH URINE ONLY,605869,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,Local,,128.45,,,,,,,101.20,257.47,percent of total billed charges,
PNEUMOCYSTIS JIROVECII PCR,7111864,CDM,300,RC,87594,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,163.99,,,,,,,32.53,264.21,percent of total billed charges,
Thyroid Stimulating Immunoglobulin,8310218,CDM,300,RC,84445,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,47.14,134.78,percent of total billed charges,
EHRLICHIA CHAFF AB IFA,7794104,CDM,300,RC,86666,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,9.43,121.06,percent of total billed charges,
TOBRAMYCIN LEVEL,596683,CDM,300,RC,80200,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,Local,,71.59,,,,,,,14.96,115.34,percent of total billed charges,
TOBRAMYCIN LEVEL,596684,CDM,300,RC,80200,HCPCS,,,facility,outpatient,,,141.00000,40.89000,Aetna,Local,,71.59,,,,,,,14.96,115.34,percent of total billed charges,
TOPIRAMATE LEVEL,3216863,CDM,300,RC,80201,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,Local,,70.57,,,,,,,11.05,113.70,percent of total billed charges,
TYPHUS ANTIBODY WITH REFLEX,3192906,CDM,300,RC,86757,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,Local,,36.05,,,,,,,17.94,58.08,percent of total billed charges,
SM AND RNP ANTIBODIES,3200854,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,16.62,121.06,percent of total billed charges,
ENA AB,3200852,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,16.62,121.06,percent of total billed charges,
THROMBIN TIME,3186865,CDM,300,RC,85670,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,5.35,20.45,percent of total billed charges,
ESTRONE LEVEL,7897073,CDM,300,RC,82679,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,23.13,117.79,percent of total billed charges,
ESTRIOL,7913612,CDM,300,RC,82677,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,22.41,121.06,percent of total billed charges,
PLASMINOGEN ACTIVITY,3178876,CDM,300,RC,85420,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,6.06,126.79,percent of total billed charges,
EB CAPSID VCA,613056,CDM,300,RC,86665,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,Local,,21.83,,,,,,,16.82,48.07,percent of total billed charges,
EB V NUCLEAR ANTIGEN,613058,CDM,300,RC,86664,HCPCS,,,facility,outpatient,,,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,14.17,40.52,percent of total billed charges,
ERYTHROPOIETIN,7953965,CDM,300,RC,82668,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,Local,,68.03,,,,,,,17.42,109.61,percent of total billed charges,
ETHYLENE GLYCOL LEVEL,661848,CDM,300,RC,82693,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,Local,,117.28,,,,,,,13.81,188.96,percent of total billed charges,
TOXOPLASMA ANTIBODY,3214848,CDM,300,RC,86778,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,13.36,63.80,percent of total billed charges,
TOXOPLASMA ANTIBODY IGG,613117,CDM,300,RC,86777,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,13.34,63.80,percent of total billed charges,
FECAL FAT QUALITATIVE,3188843,CDM,300,RC,82705,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,4.73,124.34,percent of total billed charges,
FECAL LIPIDS TOTAL,3521839,CDM,300,RC,82710,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,15.57,120.25,percent of total billed charges,
FECAL LIPIDS TOTAL,3521840,CDM,300,RC,82710,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,15.57,120.25,percent of total billed charges,
FECAL LIPIDS TOTAL,3521841,CDM,300,RC,82710,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,15.57,120.25,percent of total billed charges,
BB BILL THAW REFERENCE,5987852,CDM,300,RC,86999,HCPCS,,,facility,outpatient,,,131.00000,37.99000,Aetna,Local,,66.51,,,,,,,21.51,107.16,percent of total billed charges,
BB BILL DILUTION REFERENCE,5987856,CDM,300,RC,86976,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,Local,,106.62,,,,,,,21.51,171.78,percent of total billed charges,
BB BILL PRETREAT WITH DRUGS REFER,5987857,CDM,300,RC,86970,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,52.15,156.59,percent of total billed charges,
BB BILL ABSORPTION REFERENCE,595623,CDM,300,RC,86978,HCPCS,,,facility,outpatient,,,282.00000,81.78000,Aetna,Local,,143.17,,,,,,,52.15,230.68,percent of total billed charges,
TISSUE TRANSGLUTAMINASE ANTIBODY,3184854,CDM,300,RC,86364,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,10.69,120.25,percent of total billed charges,
TISSUE TRANSGLUTAMINASE ANTIBODY,3481845,CDM,300,RC,86364,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,10.69,120.25,percent of total billed charges,
TISSUE TRANSGLUTAMINASE ANTIBODY,3481846,CDM,300,RC,86364,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,10.69,120.25,percent of total billed charges,
SOLUBLE TRANSFERRIN RECEPTOR,3214917,CDM,300,RC,84238,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,33.90,128.43,percent of total billed charges,
COLD AGGLUTININS,7111844,CDM,300,RC,86157,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,7.47,121.06,percent of total billed charges,
CYTOMEGALOVIRUS BY PCR,7121843,CDM,300,RC,87496,HCPCS,,,facility,outpatient,,,270.00000,78.30000,Aetna,Local,,137.08,,,,,,,32.53,220.86,percent of total billed charges,
M TUBERCULOSIS AMP PROBE,7726075,CDM,300,RC,87564,HCPCS,,,facility,outpatient,,,315.00000,91.35000,Aetna,Local,,159.93,,,,,,,71.16,257.67,percent of total billed charges,
M TUBERCULOSIS AMP PROBE,9101340,CDM,300,RC,87564,HCPCS,,,facility,outpatient,,,315.00000,91.35000,Aetna,Local,,159.93,,,,,,,71.16,257.67,percent of total billed charges,
ASSAY FOR CALPROTECTIN FECAL,8366173,CDM,300,RC,83993,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,Local,,120.32,,,,,,,18.20,193.87,percent of total billed charges,
HISTOPLASMA ANTIGEN SERUM,7111851,CDM,300,RC,87385,HCPCS,,,facility,outpatient,,,191.00000,55.39000,Aetna,Local,,96.97,,,,,,,12.29,156.24,percent of total billed charges,
THYROGLOBULIN CIA,6145847,CDM,300,RC,84432,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,14.88,127.61,percent of total billed charges,
IRON LIVER TISSUE,8280333,CDM,300,RC,83540,HCPCS,,,facility,outpatient,,,263.00000,76.27000,Aetna,Local,,133.53,,,,,,,5.99,215.13,percent of total billed charges,
VOLTAGE GATED CALCIUM CHANNEL AB,6297841,CDM,300,RC,86596,HCPCS,,,facility,outpatient,,,313.00000,90.77000,Aetna,Local,,158.91,,,,,,,11.18,256.03,percent of total billed charges,
TRICYCLIC ANTIDEPRESSANT DETECTIO,3206890,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,58.00,257.47,percent of total billed charges,
CHYMOTRYPSIN STOOL,7177859,CDM,300,RC,84311,HCPCS,,,facility,outpatient,,,275.00000,79.75000,Aetna,Local,,139.62,,,,,,,7.51,224.95,percent of total billed charges,
LEVETIRACETAM LEVEL,3207062,CDM,300,RC,80177,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,12.29,122.70,percent of total billed charges,
LEGION PNEUMOPHILIA AG,3210840,CDM,300,RC,87278,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,14.46,118.61,percent of total billed charges,
GLYCOPROTEIN ANTIBODY,3207191,CDM,300,RC,86146,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,Local,,80.22,,,,,,,23.60,129.24,percent of total billed charges,
ANDROSTENEDIONE,3232940,CDM,300,RC,82157,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,27.14,117.79,percent of total billed charges,
IMMUNODIF OUCHTERLONY,2340824,CDM,300,RC,86331,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,11.10,31.75,percent of total billed charges,
IMMUNODIF OUCHTERLONY,3206845,CDM,300,RC,86331,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,11.10,31.75,percent of total billed charges,
ENZYME ACTIVITY IN PERIPHERAL RBC,2386825,CDM,300,RC,84433,HCPCS,,,facility,outpatient,,,299.00000,86.71000,Aetna,Local,,151.80,,,,,,,20.55,244.58,percent of total billed charges,
CHEMILUMINESCENT ASSAY,2388833,CDM,300,RC,82397,HCPCS,,,facility,outpatient,,,15.00000,4.35000,Aetna,Local,,7.62,,,,,,,7.05,37.42,percent of total billed charges,
MYELOPEROXIDASE AB,3186908,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,Local,,33.00,,,,,,,10.69,53.17,percent of total billed charges,
PROTEINASE 3 AB,2460826,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,10.69,54.81,percent of total billed charges,
TRYPTASE,3216876,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,,76.66,,,,,,,16.01,123.52,percent of total billed charges,
88305 Surg IV Arkana,8070002,CDM,300,RC,88305,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,Local,,104.08,,,,,,,46.92,167.69,percent of total billed charges,
VANILLYLMANDELIC ACID URINE 24 HR,3190879,CDM,300,RC,84585,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,,76.66,,,,,,,14.37,123.52,percent of total billed charges,
VDRL CSF,3184881,CDM,300,RC,86592,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,3.96,125.15,percent of total billed charges,
VDRL CSF,7969183,CDM,300,RC,86592,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,3.96,125.15,percent of total billed charges,
VASOACTIVE INTESTINAL POLYPEPT,3209053,CDM,300,RC,84586,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,32.75,118.61,percent of total billed charges,
VIRAL AB,613114,CDM,300,RC,86788,HCPCS,,,facility,outpatient,,,83.00000,24.07000,Aetna,Local,,42.14,,,,,,,15.63,67.89,percent of total billed charges,
VISCOSITY SERUM,3214884,CDM,300,RC,85810,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,10.81,118.61,percent of total billed charges,
VITAMIN A RETINOL,3216866,CDM,300,RC,84590,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,10.76,121.06,percent of total billed charges,
VITAMIN B6,3191033,CDM,300,RC,84207,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,26.05,122.70,percent of total billed charges,
FOLIC ACID RBC,3190865,CDM,300,RC,82747,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,16.37,125.97,percent of total billed charges,
VITAMIN E TOCOPHEROL,3209056,CDM,300,RC,84446,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,13.14,126.79,percent of total billed charges,
VITAMIN D 1 25 DIHYDROXY,3182847,CDM,300,RC,82652,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,Local,,80.22,,,,,,,35.69,129.24,percent of total billed charges,
ASPERGILL,613050,CDM,300,RC,86606,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,Local,,21.83,,,,,,,13.96,39.88,percent of total billed charges,
COCCIDIOIDES ANTIBODY CF,613052,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,33.00000,9.57000,Aetna,Local,,16.75,,,,,,,6.68,30.40,percent of total billed charges,
COCCIDIOIDES ANTIBODY CF,8142380,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,33.00000,9.57000,Aetna,Local,,16.75,,,,,,,6.68,30.40,percent of total billed charges,
SR CA URINE,613088,CDM,300,RC,82340,HCPCS,,,facility,outpatient,,,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.59,15.98,percent of total billed charges,
SR OXALATE,613089,CDM,300,RC,83945,HCPCS,,,facility,outpatient,,,38.00000,11.02000,Aetna,Local,,19.29,,,,,,,13.40,38.29,percent of total billed charges,
URIC ACID OTHER SOURCE,613090,CDM,300,RC,84560,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,4.71,13.46,percent of total billed charges,
SR CITRATE,613091,CDM,300,RC,82507,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,25.77,73.67,percent of total billed charges,
SR PH UR,613092,CDM,300,RC,83986,HCPCS,,,facility,outpatient,,,9.00000,2.61000,Aetna,Local,,4.57,,,,,,,3.32,9.49,percent of total billed charges,
SR SODIUM URINE,613094,CDM,300,RC,84300,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,4.69,13.41,percent of total billed charges,
SR SULFATE URINE,613095,CDM,300,RC,84392,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,5.09,14.55,percent of total billed charges,
SR PO4 URINE,613096,CDM,300,RC,84105,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,5.36,15.32,percent of total billed charges,
SR MG URINE,613097,CDM,300,RC,83735,HCPCS,,,facility,outpatient,,,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,6.21,17.75,percent of total billed charges,
GASTRIN,3188898,CDM,300,RC,82941,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,16.35,121.88,percent of total billed charges,
SR POTASSIUM URINE,613099,CDM,300,RC,84133,HCPCS,,,facility,outpatient,,,12.00000,3.48000,Aetna,Local,,6.09,,,,,,,4.39,12.53,percent of total billed charges,
HYDROXYPROGESTERONE,3214935,CDM,300,RC,83498,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,25.18,128.43,percent of total billed charges,
ALLERGY EVALUATION,657931,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,4.70,13.83,percent of total billed charges,
ARGINE VASOPRESSIN,3214890,CDM,300,RC,84588,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,31.47,112.88,percent of total billed charges,
CELIAC DISEASE DIAGNOSTIC PANEL,7281858,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,8.18,120.25,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7904829,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,10.69,58.90,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7904832,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,10.69,58.90,percent of total billed charges,
LEAD BLOOD,7798031,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,229.00000,66.41000,Aetna,Local,,116.26,,,,,,,11.23,187.32,percent of total billed charges,
HEAVY METALS EVALUATION BLOOD,3207054,CDM,300,RC,83825,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,15.07,43.09,percent of total billed charges,
JO 1 ANTIBODY,3216873,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,16.62,128.43,percent of total billed charges,
SCLERODERMA ANTIBODIES,3196866,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,16.62,121.06,percent of total billed charges,
WEST NILE VIRUS AB BLOOD IGG,3188888,CDM,300,RC,86789,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,Local,,33.51,,,,,,,13.34,53.99,percent of total billed charges,
GLUCAGON,3214938,CDM,300,RC,82943,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,13.25,127.61,percent of total billed charges,
Culture Varicella Zoster Virus,8387017,CDM,300,RC,87252,HCPCS,,,facility,outpatient,,,45.00000,13.05000,Aetna,Local,,22.85,,,,,,,21.15,69.09,percent of total billed charges,
GLUTAMIC ACID DECARBOXYLASE,3191100,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,21.85,118.61,percent of total billed charges,
Encephalopathy Panel Serum,8916115,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,21.85,99.80,percent of total billed charges,
Autoimmune Dementia Paraneoplastic Eval Serum,9004978,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,21.85,99.80,percent of total billed charges,
PROTHROMBIN F2 G20210A ZB10B,3180904,CDM,300,RC,81240,HCPCS,,,facility,outpatient,,,167.00000,48.43000,Aetna,Local,,84.79,,,,,,,60.89,174.08,percent of total billed charges,
COAG FACTOR V ACTIVITY,3209012,CDM,300,RC,85220,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,Local,,80.22,,,,,,,16.37,129.24,percent of total billed charges,
COAG FACTOR VIII ACTIVITY,3209015,CDM,300,RC,85240,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,16.59,128.43,percent of total billed charges,
Factor VIII,613066,CDM,300,RC,85240,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,16.59,128.43,percent of total billed charges,
PLATELET AGGREGATION,596409,CDM,300,RC,85576,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,Local,,21.83,,,,,,,20.21,66.01,percent of total billed charges,
PLATELET AGGREGATION,8229030,CDM,300,RC,85576,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,Local,,21.83,,,,,,,20.21,66.01,percent of total billed charges,
ANTITHROMBIN III ACT,3178945,CDM,300,RC,85300,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,3.83,128.43,percent of total billed charges,
COMPLEMENT TOTAL CH50,8335518,CDM,300,RC,86162,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,,76.66,,,,,,,18.84,123.52,percent of total billed charges,
DELTA AMINOLEVULINIC ACID 24 HOUR,3218887,CDM,300,RC,82135,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,Local,,68.03,,,,,,,15.25,109.61,percent of total billed charges,
ALDOLASE,3184839,CDM,300,RC,82085,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,9.00,126.79,percent of total billed charges,
IMMUNOGLOBULIN G SUBCLASS 4,7917340,CDM,300,RC,82787,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,,76.66,,,,,,,7.44,123.52,percent of total billed charges,
RPR TITER,7969189,CDM,300,RC,86593,HCPCS,,,facility,outpatient,,,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,4.08,29.45,percent of total billed charges,
5 A DIHYDROTESTOSTERONE 1,7948142,CDM,300,RC,82642,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,27.14,117.79,percent of total billed charges,
ASPERGILLUS ANTIBODY BY CF,7946089,CDM,300,RC,86606,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,13.96,118.61,percent of total billed charges,
COENZYME Q10 TOTAL,7948396,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,192.00000,55.68000,Aetna,Local,,97.48,,,,,,,11.66,157.06,percent of total billed charges,
SUBSTANCE P,7948552,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,16.01,194.68,percent of total billed charges,
FLUOXETINE AND METABOLITE,7953933,CDM,300,RC,84311,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,Local,,121.85,,,,,,,7.51,196.32,percent of total billed charges,
TICK BORNE DISEASE PANEL PCR,7955046,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,32.53,92.99,percent of total billed charges,
TICK BORNE DISEASE PANEL PCR,7955053,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,32.53,92.99,percent of total billed charges,
5 NUCLEOTIDASE,7962058,CDM,300,RC,83915,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,10.34,121.06,percent of total billed charges,
DENGUE VIRUS BY PCR,7964316,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,32.53,92.99,percent of total billed charges,
87798 Dengue Virus Subtypes,8920419,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,32.53,92.99,percent of total billed charges,
CHIKUNGUNYA BY PCR,7964360,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,284.00000,82.36000,Aetna,Local,,144.19,,,,,,,32.53,232.31,percent of total billed charges,
APOE FOR ALZHEIMER RISK ZB2UW,7964309,CDM,300,RC,81401,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,122.36,,,,,,,113.27,363.05,percent of total billed charges,
THYROGLOBULIN LC MS,7964305,CDM,300,RC,84432,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,14.88,159.51,percent of total billed charges,
HCV NS5A DRUG RESISTANCE,7954211,CDM,300,RC,87902,HCPCS,,,facility,outpatient,,,799.00000,231.71000,Aetna,Local,,405.65,,,,,,,238.66,682.24,percent of total billed charges,
HCV RNA GENOTYPE,3190862,CDM,300,RC,87902,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,Local,,123.88,,,,,,,114.68,682.24,percent of total billed charges,
HCV RNA GENOTYPE,7964392,CDM,300,RC,87902,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,Local,,123.88,,,,,,,114.68,682.24,percent of total billed charges,
PROTEIN ELECTRO FRACTIONATION,7966155,CDM,300,RC,84165,HCPCS,,,facility,outpatient,,,112.00000,32.48000,Aetna,Local,,56.86,,,,,,,9.96,91.62,percent of total billed charges,
AFP TOTAL AND L3 PERCENT,7964461,CDM,300,RC,82107,HCPCS,,,facility,outpatient,,,214.00000,62.06000,Aetna,Local,,108.65,,,,,,,59.71,175.05,percent of total billed charges,
S PNEUMONIAE ABS IGG,7948308,CDM,300,RC,86581,HCPCS,,,facility,outpatient,,,183.00000,53.07000,Aetna,Local,,92.91,,,,,,,86.01,243.88,percent of total billed charges,
98519 Itraconazole Quantitative by LC MS MS ARUP,7966306,CDM,300,RC,80189,HCPCS,,,facility,outpatient,,,167.00000,48.43000,Aetna,Local,,84.79,,,,,,,25.13,136.61,percent of total billed charges,
80055 Carotene Serum Total ARUP,7966296,CDM,300,RC,82380,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,8.55,121.88,percent of total billed charges,
ALPHA GAL FOOD PANEL,7966191,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,Local,,11.17,,,,,,,4.84,18.00,percent of total billed charges,
2013107 HIV Types 1 and 2 Ab Differentiation Supplemental AR,7966166,CDM,300,RC,86701,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,8.24,81.80,percent of total billed charges,
DYSAUTONOMIA EVAL BY RIA,7966179,CDM,300,RC,86702,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,12.54,121.88,percent of total billed charges,
2014546 Norovirus Groups 1 and 2 by PCR ARUP,7966326,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,32.53,128.43,percent of total billed charges,
87798 Norovirus Groups,8918452,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,32.53,128.43,percent of total billed charges,
VITAMIN K SERUM,7968785,CDM,300,RC,84597,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,12.72,112.88,percent of total billed charges,
SELENIUM URINE,7968792,CDM,300,RC,84255,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,23.67,122.70,percent of total billed charges,
PARVOVIRUS B19 QUANT BY PCR,7969209,CDM,300,RC,87799,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,Local,,123.88,,,,,,,39.72,199.59,percent of total billed charges,
CMV AB IGG AVIDITY,7971965,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,221.00000,64.09000,Aetna,Local,,112.20,,,,,,,13.34,180.78,percent of total billed charges,
HEA CBC ZB04H,7974997,CDM,300,RC,81403,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,Local,,184.80,,,,,,,171.08,490.78,percent of total billed charges,
MECONIUM DRUG SCREEN,7994150,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,Local,,67.02,,,,,,,52.80,257.47,percent of total billed charges,
COCAINE AND METABOLITES,7998873,CDM,300,RC,80353,HCPCS,,,facility,outpatient,,,197.00000,57.13000,Aetna,Local,,100.02,,,,,,,0.01485,161.15,percent of total billed charges,
AMPHETAMINE DRUG SCREENING,7994261,CDM,300,RC,80324,HCPCS,,,facility,outpatient,,,99.00000,28.71000,Aetna,Local,,50.26,,,,,,,0.01485,80.98,percent of total billed charges,
80359 methlenedioxyamphetamine,7994282,CDM,300,RC,80359,HCPCS,,,facility,outpatient,,,99.00000,28.71000,Aetna,Local,,50.26,,,,,,,0.01485,80.98,percent of total billed charges,
PCP CONFIRMATION MECONIUM,8001651,CDM,300,RC,83992,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,Local,,117.28,,,,,,,19.56,188.96,percent of total billed charges,
CARBOXY THC CONFIRMATION,8001663,CDM,300,RC,80349,HCPCS,,,facility,outpatient,,,193.00000,55.97000,Aetna,Local,,97.99,,,,,,,0.01485,157.87,percent of total billed charges,
OPIATE CONFIRMATION,8001345,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,46.00,257.47,percent of total billed charges,
80365 Oxycodone Confirmation,8001369,CDM,300,RC,80365,HCPCS,,,facility,outpatient,,,99.00000,28.71000,Aetna,Local,,50.26,,,,,,,0.01485,80.98,percent of total billed charges,
HMGCR ANTIBODY,7976407,CDM,300,RC,82397,HCPCS,,,facility,outpatient,,,234.00000,67.86000,Aetna,Local,,118.80,,,,,,,13.09,191.41,percent of total billed charges,
PERTUSSIS PARAPETUSSIS,7976416,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,111.00000,32.19000,Aetna,Local,,56.35,,,,,,,32.53,92.99,percent of total billed charges,
87798 Bordetella pertussis parapertussis,8920417,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,111.00000,32.19000,Aetna,Local,,56.35,,,,,,,32.53,92.99,percent of total billed charges,
ADAMTS13 INHIBITOR,7980427,CDM,300,RC,85335,HCPCS,,,facility,outpatient,,,291.00000,84.39000,Aetna,Local,,147.74,,,,,,,11.64,238.04,percent of total billed charges,
ADAMTS13 ANTIBODY,7980433,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,436.00000,126.44000,Aetna,Local,,221.36,,,,,,,16.01,356.65,percent of total billed charges,
Alpha Internexin CBA Serum,8914135,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
PNH INTERPRETATION CSI,7987163,CDM,300,RC,88187,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,Local,,67.02,,,,,,,47.59,107.98,percent of total billed charges,
REFLEX NO AQP4 TITER MAYO,8002080,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,34.98,99.98,percent of total billed charges,
REFLEX NO AQP4 TITER MAYO,8003386,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,34.98,99.98,percent of total billed charges,
GAD65 AB SERUM MAYO,7993976,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,327.00000,94.83000,Aetna,Local,,166.02,,,,,,,21.85,267.49,percent of total billed charges,
PROTEIN WESTERN BLOT TEST,8278514,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,298.00000,86.42000,Aetna,Local,,151.29,,,,,,,23.95,243.76,percent of total billed charges,
NMDA R AB CBA,8002088,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
NMDA R AB CBA,8003284,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8002166,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8002172,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8003290,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8003296,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
mGluR1 Ab CBA Serum,8914181,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
DPPX Ab CBA Serum,8916164,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
IgLON5 CBA Serum,8916184,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
NIF Heavy Chain CBA Serum,8916205,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
NIF Light Chain CBA Serum,8916221,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,11.18,417.18,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8002375,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8002381,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8002542,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8003356,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8003368,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
AUTOANTIBODY IF TITER MAYO,8003374,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
GFAP IFA Titer Serum,8914158,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
IgLON5 IFA Titer Serum,8914175,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
DPPX Ab IFA Titer Serum,8916172,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
NIF IFA Titer Serum,8916213,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
Neurochondrin IFA Titer CSF,9000407,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
AP3B2 IFA Titer CSF,9002421,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
Septin 7 IFA Titer CSF,9002426,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
CRMP 5 IGG WBLOT SERUM,8003392,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,385.00000,111.65000,Aetna,Local,,195.46,,,,,,,23.95,314.93,percent of total billed charges,
CRMWC CRMP 5 IgG Western Blot CSF MAYO,8002062,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,491.00000,142.39000,Aetna,Local,,249.28,,,,,,,23.95,401.64,percent of total billed charges,
GD65C GAD65 Ab Assay CSF MAYO,7994174,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,527.00000,152.83000,Aetna,Local,,267.56,,,,,,,21.85,431.09,percent of total billed charges,
VGKCC VGKC complex Ab IPA CSF MAYO,8002572,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,Local,,200.54,,,,,,,17.06,323.11,percent of total billed charges,
MOGFS Myelin Oligodendrocyte Glycoprotein IgG1 Serum MAYO,7993982,CDM,300,RC,86363,HCPCS,,,facility,outpatient,,,982.00000,284.78000,Aetna,Local,,498.56,,,,,,,34.98,803.28,percent of total billed charges,
TOXACARA ANTIBODY BY ELISA,8070812,CDM,300,RC,86682,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,12.06,212.68,percent of total billed charges,
2013436 Spinal Muscular Atrophy SMA Copy Number Analysis A,8119034,CDM,300,RC,81329,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,Local,,187.85,,,,,,,127.00,363.05,percent of total billed charges,
Saccharomyces cerevisiae Abs  IgG and IgA,8117644,CDM,300,RC,86671,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,6.68,63.80,percent of total billed charges,
S CEREBISIAE AB,8117647,CDM,300,RC,86671,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,6.68,63.80,percent of total billed charges,
2001601 RNA Polymerase III Antibody IgG ARUP,8117752,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,164.00000,47.56000,Aetna,Local,,83.26,,,,,,,10.69,134.15,percent of total billed charges,
2003040 PM Scl 100 Antibody IgG by Immunoblot ARUP,8117758,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,16.62,143.15,percent of total billed charges,
2005287 Chromatin Antibody IgG ARUP,8117733,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,10.69,125.97,percent of total billed charges,
2012173 Fibrillarin U3 RNP Antibody IgG ARUP,8117746,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,Local,,126.92,,,,,,,16.62,204.50,percent of total billed charges,
PCABP Purkinje Cell Cytoplasmic Ab Type 1 MAYO,8119030,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,11.18,126.79,percent of total billed charges,
Acetylcholine receptor binding antibody,8403757,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,322.00000,93.38000,Aetna,Local,,163.48,,,,,,,17.06,263.40,percent of total billed charges,
GANG AChR Ganglionic Neuronal Ab Serum MAYO,8119022,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,17.06,126.79,percent of total billed charges,
VGKC Neuronal V G Kplus Channel Ab Serum MAYO,8119026,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,Local,,200.54,,,,,,,17.06,323.11,percent of total billed charges,
2006898 Hepatitis C Virus High Resolution Genotype by Sequen,8119572,CDM,300,RC,87902,HCPCS,,,facility,outpatient,,,461.00000,133.69000,Aetna,Local,,234.05,,,,,,,216.67,682.24,percent of total billed charges,
ENCEPHALOPATHY AUTOIMMUNE PANEL CSF,8278733,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,21.85,99.80,percent of total billed charges,
EPILEPSY ABS,8280225,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,11.18,121.88,percent of total billed charges,
PCAB2 Purkinje Cell Cytoplasmic Ab Type 2 MAYO,8122525,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,Local,,107.63,,,,,,,11.18,173.42,percent of total billed charges,
PCATR Purkinje Cell Cytoplasmic Ab Type Tr MAYO,8122530,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,Local,,107.63,,,,,,,11.18,173.42,percent of total billed charges,
ANN3S Anti Neuronal Ab Type 3 MAYO,8122535,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,Local,,107.63,,,,,,,11.18,173.42,percent of total billed charges,
ANN2S Anti Neuronal Nuclear Ab Type 2 MAYO,8122558,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,Local,,107.63,,,,,,,11.18,173.42,percent of total billed charges,
FYABW Yo Antibody by Western Blot MAYO,8123708,CDM,300,RC,84181,HCPCS,,,facility,outpatient,,,115.00000,33.35000,Aetna,Local,,58.39,,,,,,,15.79,94.07,percent of total billed charges,
FYABT Yo Antibody Titer MAYO,8123702,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,46.00000,13.34000,Aetna,Local,,23.35,,,,,,,11.18,37.63,percent of total billed charges,
2007081 Cotinine Screen Urine ARUP,8123943,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,61.60,257.47,percent of total billed charges,
ALLERGENS FOOD FISH,7948720,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,24.00000,6.96000,Aetna,Local,,12.18,,,,,,,4.84,19.63,percent of total billed charges,
ALLERGENS FOOD FISH,7948735,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,24.00000,6.96000,Aetna,Local,,12.18,,,,,,,4.84,19.63,percent of total billed charges,
ALLERGENS FOOD FISH,7974731,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,24.00000,6.96000,Aetna,Local,,12.18,,,,,,,4.84,19.63,percent of total billed charges,
86003 Allergens Food Fish IgE ARUP,7974746,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,24.00000,6.96000,Aetna,Local,,12.18,,,,,,,4.84,19.63,percent of total billed charges,
"Allergen, Food, Fish Profile 2 IgE",9090538,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,24.00000,6.96000,Aetna,Local,,12.18,,,,,,,4.84,19.63,percent of total billed charges,
HLA B 57 01 ABACAVIR SENSITIVITY ZB10D,7950194,CDM,300,RC,81381,HCPCS,,,facility,outpatient,,,226.00000,65.54000,Aetna,Local,,114.74,,,,,,,106.22,450.24,percent of total billed charges,
FACTOR IX ACTIVITY,7948820,CDM,300,RC,85250,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,17.65,118.61,percent of total billed charges,
PANCREASTATIN,7948530,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,Local,,142.66,,,,,,,17.06,229.86,percent of total billed charges,
LIBRIUM AND NORDIAZEPAM,7948796,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,58.00,257.47,percent of total billed charges,
FACTOR X ACTIVITY,7948807,CDM,300,RC,85260,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,16.59,111.25,percent of total billed charges,
CLOMIPRAMINE AND METABOLITE,7948577,CDM,300,RC,80335,HCPCS,,,facility,outpatient,,,159.00000,46.11000,Aetna,Local,,80.72,,,,,,,0.01485,130.06,percent of total billed charges,
2014069 Zika Virus by PCR Urine ARUP,7966045,CDM,300,RC,87662,HCPCS,,,facility,outpatient,,,299.00000,86.71000,Aetna,Local,,151.80,,,,,,,47.57,244.58,percent of total billed charges,
2014065 Zika Virus by PCR Blood ARUP,7966055,CDM,300,RC,87662,HCPCS,,,facility,outpatient,,,299.00000,86.71000,Aetna,Local,,151.80,,,,,,,47.57,244.58,percent of total billed charges,
GLUCOSE 6 PHOSPHATE,3214911,CDM,300,RC,82955,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,8.99,125.97,percent of total billed charges,
FOLLICLE STIMULATING HORMONE,6029839,CDM,300,RC,83001,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,17.22,126.79,percent of total billed charges,
PROLACTIN,6025840,CDM,300,RC,84146,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,17.96,118.61,percent of total billed charges,
HOMOCYSTEINE,6035855,CDM,300,RC,83090,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,16.61,125.97,percent of total billed charges,
THEOPHYLLINE LEVEL,5981853,CDM,300,RC,80198,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,13.11,112.88,percent of total billed charges,
LUTEINIZING HORMONE,6035848,CDM,300,RC,83002,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,17.17,128.43,percent of total billed charges,
PHENOBARBITAL LEVEL,6059849,CDM,300,RC,80184,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,14.18,125.97,percent of total billed charges,
CARBAMAZEPINE TEGRETOL LEVEL,6063844,CDM,300,RC,80156,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,13.50,127.61,percent of total billed charges,
GENTAMICIN ASSAY,6059839,CDM,300,RC,80170,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,15.18,118.61,percent of total billed charges,
GENTAMICIN ASSAY,6059844,CDM,300,RC,80170,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,15.18,118.61,percent of total billed charges,
PROGESTERONE,7127839,CDM,300,RC,84144,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,19.33,127.61,percent of total billed charges,
88348 EM Arkana 1,8070005,CDM,300,RC,88348,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,,432.56,,,,,,,393.37,2138.50,percent of total billed charges,
88346 DIF Arkana,8070004,CDM,300,RC,88346,HCPCS,,,facility,outpatient,,,288.00000,83.52000,Aetna,Local,,146.22,,,,,,,88.98,452.20,percent of total billed charges,
88313 STN II Arkana,8070003,CDM,300,RC,88313,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,53.93,353.14,percent of total billed charges,
87081 Legionella Culture ARUP,8387247,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,6.15,114.52,percent of total billed charges,
MOPATH LVI II CROHNS PROG ZB25L,6509840,CDM,300,RC,81401,HCPCS,,,facility,outpatient,,,357.00000,103.53000,Aetna,Local,,181.25,,,,,,,127.00,363.05,percent of total billed charges,
ZB23L MOPATH LVI II TPMT GENETICS ZB23L,2386824,CDM,300,RC,81335,HCPCS,,,facility,outpatient,,,537.00000,155.73000,Aetna,Local,,272.63,,,,,,,162.05,463.25,percent of total billed charges,
MOPATH LVI II NOD2 CARD15 ZB23M,2386832,CDM,300,RC,81401,HCPCS,,,facility,outpatient,,,442.00000,128.18000,Aetna,Local,,224.40,,,,,,,127.00,363.05,percent of total billed charges,
MOPATH LVI I LACOTYPE ZB25N,2386831,CDM,300,RC,81400,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,Local,,204.60,,,,,,,59.29,329.65,percent of total billed charges,
IBD SGI DIAGNOSTIC ZB25M,6509844,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,9.73,22.09,percent of total billed charges,
HLA TYPING CELIAC GENETICS ZB25K,2386829,CDM,300,RC,81382,HCPCS,,,facility,outpatient,,,442.00000,128.18000,Aetna,Local,,224.40,,,,,,,114.65,361.56,percent of total billed charges,
HLA TYPING CELIAC GENETICS ZB25K,6509851,CDM,300,RC,81382,HCPCS,,,facility,outpatient,,,442.00000,128.18000,Aetna,Local,,224.40,,,,,,,114.65,361.56,percent of total billed charges,
MTHFR 2 MUTATIONS ZB10E,3209030,CDM,300,RC,81291,HCPCS,,,facility,outpatient,,,206.00000,59.74000,Aetna,Local,,104.59,,,,,,,60.57,173.15,percent of total billed charges,
BB BILL ABSORBED AG NEG REFERNCE,6605849,CDM,300,RC,86904,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,6.19,121.88,percent of total billed charges,
RESP VIRUS MINI PANEL,4107839,CDM,300,RC,87631,HCPCS,,,facility,outpatient,,,297.00000,86.13000,Aetna,Local,,150.79,,,,,,,132.22,377.97,percent of total billed charges,
MYELIN ASSOC GLYCO AB,7117856,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,10.69,126.79,percent of total billed charges,
GANGLIOSIDE ANTIBODIES,3218861,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,Local,,23.86,,,,,,,10.69,38.45,percent of total billed charges,
GANGLIOSIDE ANTIBODIES,7897158,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,Local,,23.86,,,,,,,10.69,38.45,percent of total billed charges,
GANGLIOSIDE ANTIBODIES,7900269,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,Local,,23.86,,,,,,,10.69,38.45,percent of total billed charges,
ACHR Blocking,7117846,CDM,300,RC,86042,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,Local,,44.17,,,,,,,17.06,71.17,percent of total billed charges,
ACETYLCHOLINE REC AB MODULATING,3255839,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,10.69,122.70,percent of total billed charges,
TITIN ANTIBODY,7117847,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,Local,,29.45,,,,,,,10.69,47.44,percent of total billed charges,
MUSK QUANT ANTIBODY,7117860,CDM,300,RC,86366,HCPCS,,,facility,outpatient,,,935.00000,271.15000,Aetna,Local,,474.70,,,,,,,17.06,764.83,percent of total billed charges,
MUSK QUANT ANTIBODY,8001931,CDM,300,RC,86366,HCPCS,,,facility,outpatient,,,935.00000,271.15000,Aetna,Local,,474.70,,,,,,,17.06,764.83,percent of total billed charges,
SULFATIDE AUTOANTIBODY,7117864,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,16.01,420.45,percent of total billed charges,
SULFATIDE AUTOANTIBODY,7117866,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,16.01,420.45,percent of total billed charges,
SULFATIDE AUTOANTIBODY,8005030,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,16.01,420.45,percent of total billed charges,
TRB GENE REARRANGEMENT MAYO ZB1Z7,7159845,CDM,300,RC,81340,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,Local,,335.59,,,,,,,193.67,553.64,percent of total billed charges,
TRG GENE REARRAGEMENT MAYO ZB1Z7,7159846,CDM,300,RC,81342,HCPCS,,,facility,outpatient,,,638.00000,185.02000,Aetna,Local,,323.91,,,,,,,186.79,533.98,percent of total billed charges,
BB BILL SUPER DAT REFERENCE,7165847,CDM,300,RC,86999,HCPCS,,,facility,outpatient,,,337.00000,97.73000,Aetna,Local,,171.09,,,,,,,21.51,275.67,percent of total billed charges,
88184 Flow First Marker,7728001,CDM,300,RC,88184,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,Local,,172.11,,,,,,,47.66,951.40,percent of total billed charges,
FLOW CYTOMETRY FIRST MARKER,7838048,CDM,300,RC,88184,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,Local,,172.11,,,,,,,47.66,951.40,percent of total billed charges,
FLOW CYTOMETRY ADDL MARKER,7281839,CDM,300,RC,88185,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,Local,,14.22,,,,,,,10.09,36.19,percent of total billed charges,
B CELLS TOTAL COUNT,7303845,CDM,300,RC,86355,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,Local,,29.45,,,,,,,27.26,99.98,percent of total billed charges,
B Cell Subset Analysis,9001557,CDM,300,RC,86355,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,Local,,29.45,,,,,,,27.26,99.98,percent of total billed charges,
NATURAL KILLER CELLS TOTAL,7303841,CDM,300,RC,86357,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,Local,,29.45,,,,,,,27.26,99.98,percent of total billed charges,
T CELLS TOTAL COUNT,7303842,CDM,300,RC,86359,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,Local,,33.51,,,,,,,31.02,99.98,percent of total billed charges,
T CELLS TOTAL COUNT,7303846,CDM,300,RC,86359,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,Local,,33.51,,,,,,,31.02,99.98,percent of total billed charges,
T CELLS ABS CD4 CD8 W RATIO,7303843,CDM,300,RC,86360,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,37.60,124.50,percent of total billed charges,
MONONUCLEAR CELL AG QUANT,7303844,CDM,300,RC,86356,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,22.56,70.97,percent of total billed charges,
MONONUCLEAR CELL AG QUANT,7303847,CDM,300,RC,86356,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,22.56,70.97,percent of total billed charges,
T CELLS ABSOLUTE CD4 COUNT,7303848,CDM,300,RC,86361,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,22.87,116.97,percent of total billed charges,
CALCIUM URINE,7383839,CDM,300,RC,82340,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,5.59,126.79,percent of total billed charges,
GASTRIC PARIETAL CELL ANTIBODY,7850078,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,10.69,127.61,percent of total billed charges,
21 Hydroxylase Autoantibodies Serum,8310209,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,10.69,117.79,percent of total billed charges,
BB BILL COLD AB TITER REFERENCE,7734601,CDM,300,RC,86157,HCPCS,,,facility,outpatient,,,217.00000,62.93000,Aetna,Local,,110.17,,,,,,,7.47,177.51,percent of total billed charges,
PLATELET ASSOCIATED ABS,7435839,CDM,300,RC,86023,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,11.55,64.62,percent of total billed charges,
PLATELET ASSOCIATED ABS,7435876,CDM,300,RC,86023,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,11.55,64.62,percent of total billed charges,
HEPARIN DEPENDANT PLATELET AB,7726074,CDM,300,RC,86022,HCPCS,,,facility,outpatient,,,277.00000,80.33000,Aetna,Local,,140.63,,,,,,,17.03,226.59,percent of total billed charges,
MALARIA PCR,7744345,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,32.53,92.99,percent of total billed charges,
MALARIA PCR,7744374,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,32.53,92.99,percent of total billed charges,
RUBEOLA ABS IGG AND IGM,7744346,CDM,300,RC,86765,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,11.94,62.99,percent of total billed charges,
RUBEOLA ABS IGG AND IGM,7798057,CDM,300,RC,86765,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,11.94,62.99,percent of total billed charges,
Ova and Parasite Exam Fecal,8310280,CDM,300,RC,87177,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,8.25,39.26,percent of total billed charges,
TRICHROME STAIN,7742206,CDM,300,RC,87209,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,16.67,79.35,percent of total billed charges,
AMIKACIN,7754130,CDM,300,RC,80150,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,Local,,93.42,,,,,,,13.98,150.51,percent of total billed charges,
AMIKACIN,7754136,CDM,300,RC,80150,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,Local,,93.42,,,,,,,13.98,150.51,percent of total billed charges,
Amikacin Level,8999857,CDM,300,RC,80150,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,Local,,93.42,,,,,,,13.98,150.51,percent of total billed charges,
LEUKOCYTE ALKALINE PHOSPHATASE,7748188,CDM,300,RC,85540,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,7.97,127.61,percent of total billed charges,
ARSENIC BLOOD,7754140,CDM,300,RC,82175,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,17.58,122.70,percent of total billed charges,
CHLAMYDIA PNEUMONIAE,7798038,CDM,300,RC,87486,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,Local,,123.88,,,,,,,32.53,199.59,percent of total billed charges,
HAEMOPHILIUS INFLUENZA B AB,7794096,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,13.89,119.43,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7776198,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,11.10,112.88,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786197,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,11.10,112.88,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786198,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,11.10,112.88,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786199,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,11.10,112.88,percent of total billed charges,
DENGUE FEVER,7794372,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,11.94,59.71,percent of total billed charges,
DENGUE FEVER,7794379,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,11.94,59.71,percent of total billed charges,
EHRLICHIA AND ANAPLASMA PCR,7756747,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,25.38,92.99,percent of total billed charges,
EHRLICHIA AND ANAPLASMA PCR,7768113,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,25.38,92.99,percent of total billed charges,
TESTOSTERONE TOTAL,3182886,CDM,300,RC,84403,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,23.93,118.61,percent of total billed charges,
TESTOSTERONE FREE ADULT MALE,7768187,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,23.61,120.25,percent of total billed charges,
CULTURE CHLAMYDIA,7776186,CDM,300,RC,87110,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,Local,,53.31,,,,,,,14.11,85.89,percent of total billed charges,
CULTURE TYPING CHLAMYDIA,7776191,CDM,300,RC,87140,HCPCS,,,facility,outpatient,,,30.00000,8.70000,Aetna,Local,,15.23,,,,,,,5.16,24.54,percent of total billed charges,
DIPTHERIA OR TETANUS AB,7790463,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,Local,,36.05,,,,,,,13.89,58.08,percent of total billed charges,
DIPTHERIA OR TETANUS AB,7790468,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,Local,,36.05,,,,,,,13.89,58.08,percent of total billed charges,
ENTEROVIRUS ANTIBODY,7794160,CDM,300,RC,86658,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,Local,,21.32,,,,,,,6.68,34.53,percent of total billed charges,
COCCIDIODES ANTIBODY,7790214,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,6.68,118.61,percent of total billed charges,
COCCIDIODES ANTIBODY,8141154,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,6.68,118.61,percent of total billed charges,
YERSINIA ANTIBODY,7786194,CDM,300,RC,86793,HCPCS,,,facility,outpatient,,,110.00000,31.90000,Aetna,Local,,55.85,,,,,,,12.23,89.98,percent of total billed charges,
YERSINIA ANTIBODY,7786236,CDM,300,RC,86793,HCPCS,,,facility,outpatient,,,110.00000,31.90000,Aetna,Local,,55.85,,,,,,,12.23,89.98,percent of total billed charges,
WEST NILE VIRUS CSF,7790486,CDM,300,RC,86788,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,15.63,128.43,percent of total billed charges,
STREPTOCOCCUS PNEUMO AG CSF,7794108,CDM,300,RC,87899,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,14.89,118.61,percent of total billed charges,
TETANUS ANTIBODY,7784307,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,13.89,122.70,percent of total billed charges,
LISTERIA ANTIBODY,7784303,CDM,300,RC,86723,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,Local,,94.43,,,,,,,12.23,152.15,percent of total billed charges,
GIARDIA LAMBLIA AB,7784163,CDM,300,RC,86674,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,13.65,59.71,percent of total billed charges,
GIARDIA LAMBLIA AB,7784167,CDM,300,RC,86674,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,13.65,59.71,percent of total billed charges,
HEPATITIS E VIRUS AB,7852056,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,11.94,86.71,percent of total billed charges,
HEPATITIS E VIRUS AB,7876561,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,11.94,86.71,percent of total billed charges,
LEGIONELLA,7856061,CDM,300,RC,87541,HCPCS,,,facility,outpatient,,,125.00000,36.25000,Aetna,Local,,63.46,,,,,,,32.53,102.25,percent of total billed charges,
LEGIONELLA AMPLIFIED PROBE,7856071,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,129.00000,37.41000,Aetna,Local,,65.49,,,,,,,32.53,105.52,percent of total billed charges,
PROTEIN C,7726054,CDM,300,RC,85303,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,12.83,57.26,percent of total billed charges,
PROTEIN S,7726064,CDM,300,RC,85306,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,14.20,63.80,percent of total billed charges,
MATERNAL SERUM SCREEN ZB1OC,7980982,CDM,300,RC,81511,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,68.62,406.77,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794352,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,11.94,128.43,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794353,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,11.94,128.43,percent of total billed charges,
HEPATITIS E VIRUS QUANT BY PCR,7800074,CDM,300,RC,87799,HCPCS,,,facility,outpatient,,,351.00000,101.79000,Aetna,Local,,178.20,,,,,,,39.72,287.12,percent of total billed charges,
CHROMIUM SERUM,7896929,CDM,300,RC,82495,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,18.80,124.34,percent of total billed charges,
HEPATITIS DELTA ANTIGEN,7808094,CDM,300,RC,87380,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,Local,,108.14,,,,,,,17.02,174.23,percent of total billed charges,
HEMOGLOBIN A1C REFERENCE,3481841,CDM,300,RC,83036,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,9.00,118.61,percent of total billed charges,
ANTI NMDA ANTIBODY IGG CSF,7822217,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,277.00000,80.33000,Aetna,Local,,140.63,,,,,,,11.18,226.59,percent of total billed charges,
2006311 N methyl D Aspartate Receptor Bill ARUP,7822223,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,,76.66,,,,,,,11.18,123.52,percent of total billed charges,
TOXOPLASMA GONDII PCR,7820119,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,244.00000,70.76000,Aetna,Local,,123.88,,,,,,,32.53,199.59,percent of total billed charges,
NMO AQP4 IGG CBA CSF,7935085,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,625.00000,181.25000,Aetna,Local,,317.31,,,,,,,34.98,511.25,percent of total billed charges,
NMO AQP4 IGG CBA CSF,8002074,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,625.00000,181.25000,Aetna,Local,,317.31,,,,,,,34.98,511.25,percent of total billed charges,
NMO AQP4 IGG CBA CSF,8003380,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,625.00000,181.25000,Aetna,Local,,317.31,,,,,,,34.98,511.25,percent of total billed charges,
FHSAG MVista Histoplasma Ag CSF MAYO,8117653,CDM,300,RC,87385,HCPCS,,,facility,outpatient,,,217.00000,62.93000,Aetna,Local,,110.17,,,,,,,12.29,177.51,percent of total billed charges,
88280 Additional Karotypes CSI,7844059,CDM,300,RC,88280,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,31.02,125.15,percent of total billed charges,
TISSUE CULTURE LYMPHOCYTE CSI,7844058,CDM,300,RC,88230,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,Local,,120.32,,,,,,,32.36,308.70,percent of total billed charges,
CHROMOSOME ANALYSIS CSI,7844060,CDM,300,RC,88264,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,68.15,383.22,percent of total billed charges,
B CELL GENE ARRANGEMENT CSI ZB4I7,7844048,CDM,300,RC,81261,HCPCS,,,facility,outpatient,,,224.00000,64.96000,Aetna,Local,,113.72,,,,,,,105.28,524.67,percent of total billed charges,
BCR ABL QUNAT ANALYSIS CSI ZB4IC,7844117,CDM,300,RC,81206,HCPCS,,,facility,outpatient,,,256.00000,74.24000,Aetna,Local,,129.97,,,,,,,120.32,434.49,percent of total billed charges,
JAK2 MUTATION CSI ZB4ID,7844107,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,289.00000,83.81000,Aetna,Local,,146.73,,,,,,,84.96,242.90,percent of total billed charges,
JAK2 MUTATION CSI ZB4ID,9104196,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,289.00000,83.81000,Aetna,Local,,146.73,,,,,,,84.96,242.90,percent of total billed charges,
T CELL GENE ARRANGEMENT CSI ZB4IG,7846211,CDM,300,RC,81342,HCPCS,,,facility,outpatient,,,371.00000,107.59000,Aetna,Local,,188.36,,,,,,,174.37,533.98,percent of total billed charges,
MORPH ANALYSIS CSI,7894065,CDM,300,RC,88361,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,Local,,125.91,,,,,,,116.56,951.40,percent of total billed charges,
SSA ANTIBODY IGG,7852142,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,16.62,60.53,percent of total billed charges,
ENA ANTIBODY IGG,7880415,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,16.62,60.53,percent of total billed charges,
ENA ANTIBODY,8262186,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,16.62,60.53,percent of total billed charges,
NUCLEAR ANTIGEN ANTIBODY,8344447,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,16.62,60.53,percent of total billed charges,
HPV HIGH RISK CSI,7894031,CDM,300,RC,87624,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,Local,,124.39,,,,,,,32.53,200.41,percent of total billed charges,
COCCIDIOIDES AB PANEL,7790212,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,69.00000,20.01000,Aetna,Local,,35.03,,,,,,,6.68,56.44,percent of total billed charges,
COCCIDIOIDES AB PANEL,7897016,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,69.00000,20.01000,Aetna,Local,,35.03,,,,,,,6.68,56.44,percent of total billed charges,
HEPATITIS BE AG PANEL,7896938,CDM,300,RC,87350,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,10.69,57.26,percent of total billed charges,
HEPATITIS BE AB PANEL,7896944,CDM,300,RC,86707,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,10.72,57.26,percent of total billed charges,
IODINE SERUM,7897099,CDM,300,RC,83018,HCPCS,,,facility,outpatient,,,191.00000,55.39000,Aetna,Local,,96.97,,,,,,,20.35,156.24,percent of total billed charges,
COBALT BLOOD,7896954,CDM,300,RC,83018,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,20.35,125.97,percent of total billed charges,
MANGANESE RBC,7897152,CDM,300,RC,83785,HCPCS,,,facility,outpatient,,,247.00000,71.63000,Aetna,Local,,125.40,,,,,,,24.71,202.05,percent of total billed charges,
ALPHA 1 ANTITRYPSIN TOTAL,7902337,CDM,300,RC,82103,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,12.46,65.44,percent of total billed charges,
ALPHA 1 ANTITRYPSIN TOTAL,7902388,CDM,300,RC,82103,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,12.46,65.44,percent of total billed charges,
ALPHA 1 ANTITRYPSIN PHENOTYPE,7897147,CDM,300,RC,82104,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,13.40,112.88,percent of total billed charges,
0089006 A1A Phenotype Reflex Bill ARUP,7902410,CDM,300,RC,82104,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,13.40,112.88,percent of total billed charges,
ALPHA 1 ANTITRYPSIIN SERPINA 1 ZB1HO,7902405,CDM,300,RC,81332,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,Local,,128.96,,,,,,,40.47,207.77,percent of total billed charges,
ENA ANTIBODIES,7902896,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,Local,,14.22,,,,,,,13.16,47.51,percent of total billed charges,
ENA ANTIBODIES,7902903,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,Local,,14.22,,,,,,,13.16,47.51,percent of total billed charges,
ENA ANTIBODIES,7903251,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,Local,,14.22,,,,,,,13.16,47.51,percent of total billed charges,
RIBOSOMAL P PROTEIN ANTIBODY,7902949,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,10.69,128.43,percent of total billed charges,
CENTROMERE ANTIBODY IGG,7903167,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,,76.66,,,,,,,10.69,123.52,percent of total billed charges,
BCR ABL MINOR POINT BREAK ZBG82,7903078,CDM,300,RC,81207,HCPCS,,,facility,outpatient,,,436.00000,126.44000,Aetna,Local,,221.36,,,,,,,134.27,383.83,percent of total billed charges,
NATALIZUB ANTIBODIES,7903086,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,487.00000,141.23000,Aetna,Local,,247.25,,,,,,,10.69,398.37,percent of total billed charges,
IMMUNOHISTOCHEMICAL CSI,7903706,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,Local,,125.91,,,,,,,84.70,452.20,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7903758,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,56.00000,16.24000,Aetna,Local,,28.43,,,,,,,10.69,45.81,percent of total billed charges,
FLUORESCENT AB TITER,7902944,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,11.18,119.43,percent of total billed charges,
FLUORESCENT AB TITER,7954692,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,11.18,119.43,percent of total billed charges,
AMPHIPHYSIN ANTIBODY,7905259,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,236.00000,68.44000,Aetna,Local,,119.82,,,,,,,10.69,193.05,percent of total billed charges,
REVERSE T3,7905840,CDM,300,RC,84482,HCPCS,,,facility,outpatient,,,159.00000,46.11000,Aetna,Local,,80.72,,,,,,,14.61,130.06,percent of total billed charges,
PARANEOPLASTIC EVAL CSF M,7905683,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,11.18,85.07,percent of total billed charges,
PARANEOPLASTIC EVAL CSF M,8001942,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,104.00000,30.16000,Aetna,Local,,52.80,,,,,,,11.18,85.07,percent of total billed charges,
ALLERGEN FOOD IGE,7908250,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,4.84,18.81,percent of total billed charges,
ALLERGEN FOOD IGE,7935663,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,4.84,18.81,percent of total billed charges,
Allergen Food Peanut Components IgE ARUP,7976373,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,4.84,18.81,percent of total billed charges,
"Allergen, Food, Tree Nuts Components Reflex",9101323,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,4.84,18.81,percent of total billed charges,
GAMMAGLOBULIN IGE,7908197,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,Local,,21.32,,,,,,,8.18,43.62,percent of total billed charges,
ALLERGEN ENVIRONMENTAL,7910592,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,4.84,13.83,percent of total billed charges,
ALLERGEN ENVIRONMENTAL,7910627,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,4.84,13.83,percent of total billed charges,
ALLERGEN FOOD MILK IGE,8256168,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,4.84,13.83,percent of total billed charges,
ALLERGEN QUALITATIVE,7910628,CDM,300,RC,86005,HCPCS,,,facility,outpatient,,,21.00000,6.09000,Aetna,Local,,10.66,,,,,,,7.39,21.12,percent of total billed charges,
PREGNENOLONE,7908525,CDM,300,RC,84140,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,Local,,70.57,,,,,,,19.16,113.70,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7908698,CDM,300,RC,86698,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,Local,,23.86,,,,,,,12.78,38.45,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7908706,CDM,300,RC,86698,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,Local,,23.86,,,,,,,12.78,38.45,percent of total billed charges,
BONE SPECIFIC AIK PHOSPHATASE,7908692,CDM,300,RC,84080,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,,76.66,,,,,,,13.70,123.52,percent of total billed charges,
ANTI MULLERIAN HORMONE,7908686,CDM,300,RC,82166,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,Local,,92.40,,,,,,,35.80,148.88,percent of total billed charges,
ALLERGEN FOOD ALPHA GAL IGE,7910154,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,4.84,116.97,percent of total billed charges,
AMINO ACID QUANT BLOOD,7910858,CDM,300,RC,82139,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,Local,,124.39,,,,,,,15.64,200.41,percent of total billed charges,
IMMUNOFLUORESCENT INITIAL,7910656,CDM,300,RC,88346,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,Local,,176.17,,,,,,,88.98,452.20,percent of total billed charges,
IMMUNOFLUORESCENCE EACH ADDL,7910658,CDM,300,RC,88350,HCPCS,,,facility,outpatient,,,265.00000,76.85000,Aetna,Local,,134.54,,,,,,,95.53,216.77,percent of total billed charges,
CHROMATOGRAPHY W MASS SPEC,1425800,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,Local,,186.33,,,,,,,11.66,300.21,percent of total billed charges,
BARTONELLA SEROLOGY,7910483,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,38.00000,11.02000,Aetna,Local,,19.29,,,,,,,9.43,31.08,percent of total billed charges,
BARTONELLA SEROLOGY,7910496,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,38.00000,11.02000,Aetna,Local,,19.29,,,,,,,9.43,31.08,percent of total billed charges,
ARSENIC URINE,7911488,CDM,300,RC,82175,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,17.58,50.27,percent of total billed charges,
LEAD URINE,7911529,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,11.23,32.09,percent of total billed charges,
MERCURY URINE,7911530,CDM,300,RC,83825,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,15.07,43.09,percent of total billed charges,
CADMIUM URINE,7911531,CDM,300,RC,82300,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,21.92,62.65,percent of total billed charges,
ARSENIC FRACTIONATED URINE,7911571,CDM,300,RC,82175,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,Local,,121.85,,,,,,,17.58,196.32,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7910781,CDM,300,RC,86698,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,12.78,63.80,percent of total billed charges,
HISTOPLASMA ANTIBODIES,7910784,CDM,300,RC,86698,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,12.78,63.80,percent of total billed charges,
EVEROLIMUS,7910774,CDM,300,RC,80169,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,Local,,109.16,,,,,,,12.73,175.87,percent of total billed charges,
PROINSULIN INTACT,7910825,CDM,300,RC,84206,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,22.41,114.52,percent of total billed charges,
TSH RECEPTOR,7910852,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,,72.09,,,,,,,16.01,116.16,percent of total billed charges,
17 KETOSTEROIDS URINE,7911699,CDM,300,RC,83586,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,11.87,112.88,percent of total billed charges,
HELMINTH ANTIBODY,7912096,CDM,300,RC,86682,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,12.06,127.61,percent of total billed charges,
HELMINTH ANTIBODY,7912102,CDM,300,RC,86682,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,12.06,127.61,percent of total billed charges,
CYTOMEGALOVIRUS IGM,7911390,CDM,300,RC,86645,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,Local,,18.78,,,,,,,15.63,44.65,percent of total billed charges,
HSV ANTIBODIES,7911389,CDM,300,RC,86694,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,13.34,38.13,percent of total billed charges,
RUBELLA ANTIBODIES,7911393,CDM,300,RC,86762,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,13.34,38.13,percent of total billed charges,
TOXOPLASMA IGM,7911382,CDM,300,RC,86778,HCPCS,,,facility,outpatient,,,32.00000,9.28000,Aetna,Local,,16.25,,,,,,,13.36,38.19,percent of total billed charges,
CMV IGG,7911456,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,13.34,38.13,percent of total billed charges,
TOXOPLASMA IGG,7911462,CDM,300,RC,86777,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,13.34,38.13,percent of total billed charges,
INHIBIN B A,7911733,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,Local,,120.32,,,,,,,16.01,193.87,percent of total billed charges,
INHIBIN B A,7912090,CDM,300,RC,86336,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,13.30,111.25,percent of total billed charges,
Q FEVER ANTIBODIES,7904951,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,6.68,57.26,percent of total billed charges,
Q FEVER ANTIBODIES,7905150,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,6.68,57.26,percent of total billed charges,
Q FEVER ANTIBODIES,7912072,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,6.68,57.26,percent of total billed charges,
REFLEX Q FEVER IGG ANTIBODIES,7904960,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,Local,,20.82,,,,,,,6.68,33.54,percent of total billed charges,
REFLEX Q FEVER IGG ANTIBODIES,7904964,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,Local,,20.82,,,,,,,6.68,33.54,percent of total billed charges,
REFLEX Q FEVER IGM ANTIBODIES,7905189,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,Local,,20.82,,,,,,,6.68,33.54,percent of total billed charges,
REFLEX Q FEVER IGM ANTIBODIES,7905193,CDM,300,RC,86638,HCPCS,,,facility,outpatient,,,41.00000,11.89000,Aetna,Local,,20.82,,,,,,,6.68,33.54,percent of total billed charges,
PLATELET AGGREGATION P2Y12,7912254,CDM,300,RC,85576,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,Local,,124.39,,,,,,,23.09,200.41,percent of total billed charges,
C DIFFICULE CYTOTOXIN CELL,7912598,CDM,300,RC,87230,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,18.30,111.25,percent of total billed charges,
VITAMIN C ASCORBIC ACID PLASMA,7912841,CDM,300,RC,82180,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,5.46,127.61,percent of total billed charges,
OXALATE URINE,7913603,CDM,300,RC,83945,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,13.40,125.97,percent of total billed charges,
VITAMIN B2 RIBOFLAVIN,7913827,CDM,300,RC,84252,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,18.77,125.15,percent of total billed charges,
BARTONELLA HENSELAE ABS,7916456,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,9.43,63.80,percent of total billed charges,
BARTONELLA HENSELAE ABS,7916459,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,9.43,63.80,percent of total billed charges,
ZONISAMIDE,7916507,CDM,300,RC,80203,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,12.29,125.97,percent of total billed charges,
C1 ESTERASE INHIBITOR,7916635,CDM,300,RC,86160,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,11.12,110.43,percent of total billed charges,
ALLERGENS IGE,7916858,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,4.70,13.83,percent of total billed charges,
ALLERGENS IGE,7916919,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,4.70,13.83,percent of total billed charges,
Hypersensitivity Pneumonitis Extended Panel,8171764,CDM,300,RC,86005,HCPCS,,,facility,outpatient,,,12.00000,3.48000,Aetna,Local,,6.09,,,,,,,5.64,21.12,percent of total billed charges,
IMMUNODIFFUSION GEL,7917271,CDM,300,RC,86331,HCPCS,,,facility,outpatient,,,19.00000,5.51000,Aetna,Local,,9.65,,,,,,,8.93,31.75,percent of total billed charges,
ASPERGILLUS ANTIBODY,7917270,CDM,300,RC,86606,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,10.81,39.88,percent of total billed charges,
PROTEIN S FREE AG,7948300,CDM,300,RC,85306,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,14.20,118.61,percent of total billed charges,
Bird Fanciers Precipitin Panel I MAYO,7921273,CDM,300,RC,86331,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,10.81,31.75,percent of total billed charges,
86331 Immunodiffusion Ouchterlony,7934944,CDM,300,RC,86331,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,10.81,31.75,percent of total billed charges,
BABESIA SPECIES BY PCR,7921226,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,,59.40,,,,,,,32.53,95.71,percent of total billed charges,
88350 IF Additional Arkana,8070006,CDM,300,RC,88350,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,100.94,229.04,percent of total billed charges,
VORICONAZOLE QUANT,7933863,CDM,300,RC,80285,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,Local,,81.74,,,,,,,25.13,131.70,percent of total billed charges,
CYSTIC FIBROSIS VARIANTS PANEL ZB2XT,7935002,CDM,300,RC,81220,HCPCS,,,facility,outpatient,,,560.00000,162.40000,Aetna,Local,,284.31,,,,,,,263.20,1474.99,percent of total billed charges,
GABAPENTIN,7934996,CDM,300,RC,80171,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,20.09,124.34,percent of total billed charges,
APOLIPOPROTEIN E GENOTYPING CR ZB2UV,7934987,CDM,300,RC,81401,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,122.36,,,,,,,113.27,363.05,percent of total billed charges,
FLUORESCENT AGENT SCREEN,7935373,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,Local,,33.00,,,,,,,11.18,53.17,percent of total billed charges,
"Paraneoplastic Autoantibody Eval, Serum",8002684,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,113.00000,32.77000,Aetna,Local,,57.37,,,,,,,11.18,92.43,percent of total billed charges,
FELBAMATE,7945916,CDM,300,RC,80167,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,17.28,125.15,percent of total billed charges,
ADAMTS13 ACTIVITY,7945931,CDM,300,RC,85397,HCPCS,,,facility,outpatient,,,259.00000,75.11000,Aetna,Local,,131.49,,,,,,,28.60,211.86,percent of total billed charges,
ADAMTS13 ACTIVITY,7980423,CDM,300,RC,85397,HCPCS,,,facility,outpatient,,,259.00000,75.11000,Aetna,Local,,131.49,,,,,,,28.60,211.86,percent of total billed charges,
AMITRIPTYLINE AND NORTRIPTYLINE,7945963,CDM,300,RC,80335,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,0.01485,112.88,percent of total billed charges,
HYPOGLYCEMIA PANEL URINE,7950203,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,246.00000,71.34000,Aetna,Local,,124.89,,,,,,,98.40,257.47,percent of total billed charges,
ALLERGENS FOOD IGG,7950256,CDM,300,RC,86001,HCPCS,,,facility,outpatient,,,32.00000,9.28000,Aetna,Local,,16.25,,,,,,,6.95,26.18,percent of total billed charges,
ALLERGENS FOOD IGG,7950314,CDM,300,RC,86001,HCPCS,,,facility,outpatient,,,32.00000,9.28000,Aetna,Local,,16.25,,,,,,,6.95,26.18,percent of total billed charges,
IMMUNOGLOBULIN QUANT,7954564,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,8.18,126.79,percent of total billed charges,
IMMUNOGLOBULIN QUANT,7954568,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,8.18,126.79,percent of total billed charges,
IMMUNOGLOBULIN QUANT,7954572,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,8.18,126.79,percent of total billed charges,
DNASE B ANTIBODY,7177863,CDM,300,RC,86215,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,12.29,118.61,percent of total billed charges,
STREPTOLYSIN O ANTIBODY,3198898,CDM,300,RC,86060,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,6.77,118.61,percent of total billed charges,
COAG FACTOR VII ACTIVITY,3214887,CDM,300,RC,85230,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,16.59,112.88,percent of total billed charges,
HEMOGLOBIN PLASMA FREE,7475959,CDM,300,RC,83051,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,5.46,120.25,percent of total billed charges,
MALARIA SMEAR,7935889,CDM,300,RC,87207,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,Local,,68.03,,,,,,,5.55,109.61,percent of total billed charges,
ALPHA 1 ANTITRYPSIN,3184842,CDM,300,RC,82103,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,12.46,117.79,percent of total billed charges,
DRUG SCREEN CMH BLOOD ADD ON,605879,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,221.00000,64.09000,Aetna,Local,,112.20,,,,,,,88.40,257.47,percent of total billed charges,
LACTATE DEHYDROGENASE ISOENZ,3191002,CDM,300,RC,83625,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,Local,,53.31,,,,,,,8.63,85.89,percent of total billed charges,
Somatostatin Quantitative Plasma ARUP,8141145,CDM,300,RC,84307,HCPCS,,,facility,outpatient,,,290.00000,84.10000,Aetna,Local,,147.23,,,,,,,16.94,237.22,percent of total billed charges,
AMPHETAMINE DRUG SCREENING,8142281,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,55.20,257.47,percent of total billed charges,
Beta 2 Transferrin ARUP,8141113,CDM,300,RC,86335,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,Local,,106.62,,,,,,,27.21,171.78,percent of total billed charges,
Methylenedioxyamphetamine,8142685,CDM,300,RC,80359,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,0.01485,61.35,percent of total billed charges,
HSV Subtype by PCR,8147023,CDM,300,RC,87529,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,Local,,60.42,,,,,,,32.53,97.34,percent of total billed charges,
87529 HSV Subtype,8920421,CDM,300,RC,87529,HCPCS,,,facility,outpatient,,,119.00000,34.51000,Aetna,Local,,60.42,,,,,,,32.53,97.34,percent of total billed charges,
Relapsing Fever Borrelia Sp by PCR,8147237,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,257.00000,74.53000,Aetna,Local,,130.48,,,,,,,32.53,210.23,percent of total billed charges,
Prostate Health Index,8147279,CDM,300,RC,84153,HCPCS,,,facility,outpatient,,,200.00000,58.00000,Aetna,Local,,101.54,,,,,,,17.05,163.60,percent of total billed charges,
86008 Peanut Components IgE,8152009,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,16.62,58.90,percent of total billed charges,
86008 Allergen Food Nut Component,8918476,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,16.62,58.90,percent of total billed charges,
Allergen Food Nut Components,8920423,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,16.62,58.90,percent of total billed charges,
HTLV I and II Antibodies with Reflex to Confirmation,8169045,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,11.94,119.43,percent of total billed charges,
HTLV Types I II Western Blot ARUP,8169127,CDM,300,RC,86689,HCPCS,,,facility,outpatient,,,205.00000,59.45000,Aetna,Local,,104.08,,,,,,,17.94,167.69,percent of total billed charges,
Trypanosoma cruzi Ab,8161538,CDM,300,RC,86753,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,7.68,126.79,percent of total billed charges,
Islet Antigen 2 IA 2 Autoantibody Serum,8172076,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,263.00000,76.27000,Aetna,Local,,133.53,,,,,,,21.85,215.13,percent of total billed charges,
DETECT AGENT NOS DNA AMP,8161858,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,275.00000,79.75000,Aetna,Local,,139.62,,,,,,,32.53,224.95,percent of total billed charges,
Allergen Occupational Latex IgE Enhanced ARUP,8168799,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,4.84,125.15,percent of total billed charges,
Allergen Food Chocolate,8978805,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,4.84,125.15,percent of total billed charges,
Allergen Food  Peanut with Reflex to Components,9001682,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,4.84,125.15,percent of total billed charges,
Allergen Food Sesame Seed,9044143,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,4.84,125.15,percent of total billed charges,
Cashew IgE,9092972,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,4.84,125.15,percent of total billed charges,
Walnut IgE,9094760,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,4.84,125.15,percent of total billed charges,
Benzodiazepines Urine Quantitatitve ARUP,8168808,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,59.60,257.47,percent of total billed charges,
Phencyclidine PCP Urine Quantitative ARUP,8169150,CDM,300,RC,83992,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,Local,,94.94,,,,,,,19.56,152.97,percent of total billed charges,
Cocaine Metabolite Urine Quantitative ARUP,8169136,CDM,300,RC,80353,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,0.01485,117.79,percent of total billed charges,
80365 Oxycodone Urine,8172066,CDM,300,RC,80365,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,0.01485,54.81,percent of total billed charges,
Drug Confirmation Opiates Urine,3196861,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,46.40,257.47,percent of total billed charges,
Flunitrazepam and Metabolites Urine,8170446,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,279.00000,80.91000,Aetna,Local,,141.65,,,,,,,106.08,257.47,percent of total billed charges,
Gamma Hydroxybutyric Acid GHB Urine Screen,8171656,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,291.00000,84.39000,Aetna,Local,,147.74,,,,,,,106.08,257.47,percent of total billed charges,
Gamma Hydroxybutyric Acid Confirmation,8171683,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.40000,257.47,percent of total billed charges,
Allergens Hymenoptera Bee Venom Profile ARUP,8170382,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,4.84,22.09,percent of total billed charges,
86003 Allergen Bee Venom,8170399,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,4.84,22.09,percent of total billed charges,
ALLERGEN SPECIFIC IGE,8280608,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,4.84,22.09,percent of total billed charges,
Allergens Food  Mollusks Profile IgE,9080484,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,4.84,22.09,percent of total billed charges,
86003 Mollusks IgE,9082418,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,4.84,22.09,percent of total billed charges,
HERPES SIMPLEX ANTIBODY,3209018,CDM,300,RC,86695,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,12.23,50.72,percent of total billed charges,
HERPES SIMPLEX 2,646387,CDM,300,RC,86696,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,17.94,73.62,percent of total billed charges,
IMMUNOGLOBULIN E,3190845,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,8.18,126.79,percent of total billed charges,
VIRUS ISOL SHELL VIAL EACH,3186843,CDM,300,RC,87254,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,15.98,51.83,percent of total billed charges,
SJOGREN ANTIBODIES SSA AND SSB,3216839,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,16.62,121.06,percent of total billed charges,
LYME DISEASE IGG AND IGM WB,3188883,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,14.36,58.90,percent of total billed charges,
LYME DISEASE IGG AND IGM WB,613054,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,14.36,58.90,percent of total billed charges,
LYME DISEASE IGG AND IGM WB,8948134,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,14.36,58.90,percent of total billed charges,
Reflex Lyme Standard 2 Tier CSF 2nd Tier,9043530,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,14.36,58.90,percent of total billed charges,
Lyme Ab IB,9044145,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,14.36,58.90,percent of total billed charges,
RUSSELL VIPER VENOM,3178851,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,8.88,54.81,percent of total billed charges,
RUSSELL VIPER VENOM,3186893,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,Local,,11.17,,,,,,,8.88,25.39,percent of total billed charges,
dRVVT Mix and Confirm Bill,9041356,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,Local,,11.17,,,,,,,8.88,25.39,percent of total billed charges,
85613 dRVVT Confirm,9041360,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,Local,,11.17,,,,,,,8.88,25.39,percent of total billed charges,
RUSSELL VIPER VENOM,3186864,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,Local,,23.86,,,,,,,8.88,38.45,percent of total billed charges,
THYROGLOBULIN ANTIBODY,613060,CDM,300,RC,86800,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,14.75,64.62,percent of total billed charges,
ACETYLCHOLINE BINDING AG,7117839,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,Local,,44.17,,,,,,,17.06,71.17,percent of total billed charges,
HEMOGLOBIN EVALUATION,7281867,CDM,300,RC,83020,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,Local,,21.32,,,,,,,8.54,34.36,percent of total billed charges,
SEX HORMONE BINDING GLOBULIN,3216882,CDM,300,RC,84270,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,20.15,121.06,percent of total billed charges,
GLYCOPROTEIN ANTIBODY,2164824,CDM,300,RC,86146,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,23.60,67.44,percent of total billed charges,
GLYCOPROTEIN ANTIBODY,3207190,CDM,300,RC,86146,HCPCS,,,facility,outpatient,,,70.00000,20.30000,Aetna,Local,,35.54,,,,,,,23.60,67.44,percent of total billed charges,
URIC ACID OTHER SOURCE,5721862,CDM,300,RC,84560,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,4.71,125.97,percent of total billed charges,
CITRATE ACID URINE,7177867,CDM,300,RC,82507,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,25.77,120.25,percent of total billed charges,
LEAD BLOOD,657783,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,Local,,18.78,,,,,,,11.23,32.09,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786195,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,11.10,40.90,percent of total billed charges,
2001784 B pertussis Abs IgG IgM w Reflex ARUP,7786196,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,11.10,40.90,percent of total billed charges,
BORDETELLA PERTUSSIS ANTIBODY,7786250,CDM,300,RC,86615,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,11.10,40.90,percent of total billed charges,
COCCIDIODES ANTIBODY,7790213,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,6.68,30.40,percent of total billed charges,
COCCIDIODES ANTIBODY,7790255,CDM,300,RC,86635,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,6.68,30.40,percent of total billed charges,
PROTEIN C,3178939,CDM,300,RC,85303,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,12.83,108.79,percent of total billed charges,
PROTEIN C FUNCTIONAL,8263982,CDM,300,RC,85303,HCPCS,,,facility,outpatient,,,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,12.83,108.79,percent of total billed charges,
PROTEIN S,3178951,CDM,300,RC,85306,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,14.20,121.88,percent of total billed charges,
IMMUNOASSAY NONINFECTIOUS,7903261,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,8.46,30.55,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794351,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,Local,,66.00,,,,,,,11.94,106.34,percent of total billed charges,
CHIKUNGUNYA ANTIBODY,7794363,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,Local,,66.00,,,,,,,11.94,106.34,percent of total billed charges,
HEPATITIS E VIRUS AB,7784142,CDM,300,RC,86790,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,11.94,119.43,percent of total billed charges,
LAB IGG CBA MAYO,8002615,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,295.00000,85.55000,Aetna,Local,,149.77,,,,,,,11.18,241.31,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8002650,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,295.00000,85.55000,Aetna,Local,,149.77,,,,,,,11.18,241.31,percent of total billed charges,
AUTOANTIBODY CBA MAYO,8003398,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,295.00000,85.55000,Aetna,Local,,149.77,,,,,,,11.18,241.31,percent of total billed charges,
IGG CBA MAYO,8003404,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,295.00000,85.55000,Aetna,Local,,149.77,,,,,,,11.18,241.31,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3192839,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,11.18,63.80,percent of total billed charges,
GLIADIN PEPTIDE ANTIBODIES,3192884,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,11.18,63.80,percent of total billed charges,
Inhibitor Assay PT,8239986,CDM,300,RC,85610,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,,76.66,,,,,,,3.98,123.52,percent of total billed charges,
PT Inhibitor Screen,8239995,CDM,300,RC,85611,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,3.66,22.09,percent of total billed charges,
PTT Inhibitor Screen,8240012,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,5.57,119.43,percent of total billed charges,
PTT Inhibitor Screen,8240031,CDM,300,RC,85732,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,5.99,22.09,percent of total billed charges,
PTT Inhibitor 1 Hour Incubation,8240046,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,5.57,15.93,percent of total billed charges,
85732 PTT Inhibitor Screen Incubation,2238839,CDM,300,RC,85732,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,5.99,22.09,percent of total billed charges,
PTT Inhibitor Screen Incubation,8240062,CDM,300,RC,85732,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,5.99,22.09,percent of total billed charges,
Allergen Region 8 Respiratory Panel IgE,8239878,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,Local,,14.22,,,,,,,8.18,43.62,percent of total billed charges,
Immunoglobulin E,8239929,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,28.00000,8.12000,Aetna,Local,,14.22,,,,,,,8.18,43.62,percent of total billed charges,
HUMAN EPIDIDYMIS PROTEIN 4,8247887,CDM,300,RC,86305,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,Local,,124.39,,,,,,,19.29,200.41,percent of total billed charges,
ALLERGEN EGG IGE,8247908,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,4.84,13.91,percent of total billed charges,
ALLERGENS FOOD,8262162,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,4.84,13.91,percent of total billed charges,
Allergen Food 10 IgE,9085018,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,4.84,13.91,percent of total billed charges,
86003 Allergen Food Tree Nut IgE,9085486,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,4.84,13.91,percent of total billed charges,
"Allergens, Food, Tree Nuts Profile IgE",9086331,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,4.84,13.91,percent of total billed charges,
ALLERGEN FOOD COMPONENT IGE,8247896,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,59.00000,17.11000,Aetna,Local,,29.95,,,,,,,16.62,48.26,percent of total billed charges,
ALLERGEN Food COMPONENT IGE,8247907,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,59.00000,17.11000,Aetna,Local,,29.95,,,,,,,16.62,48.26,percent of total billed charges,
17 Hydroxypregnenolone Quant by LC MS MS,8256185,CDM,300,RC,84143,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,21.15,114.52,percent of total billed charges,
CADMIUM,8256343,CDM,300,RC,82300,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,21.92,121.88,percent of total billed charges,
APTT,8256401,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,12.00000,3.48000,Aetna,Local,,6.09,,,,,,,5.57,15.93,percent of total billed charges,
RUSSELL VIPER VENOM,8256402,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,8.46,25.39,percent of total billed charges,
ANTITHROMBIN ANTIGEN,8256352,CDM,300,RC,85301,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,10.02,127.61,percent of total billed charges,
THC METABOLITE,8256239,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,57.60,257.47,percent of total billed charges,
Marijuana Metabolite Umbilical Cord Qual,8858104,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,54.00,257.47,percent of total billed charges,
BILE ACIDS TOTAL,8256194,CDM,300,RC,82239,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,15.87,121.06,percent of total billed charges,
PHOSPHATIDYLSERINE ANTIBODY,8256361,CDM,300,RC,86148,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,14.89,42.59,percent of total billed charges,
PHOSPHATIDYLSERINE ANTIBODY,8256368,CDM,300,RC,86148,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,14.89,42.59,percent of total billed charges,
FOLLICLE STIMULATION HORMONE,8256298,CDM,300,RC,83001,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,Local,,38.59,,,,,,,17.22,62.17,percent of total billed charges,
Luteinizing Hormone and Follicle Stimulating Hormone,8256271,CDM,300,RC,83002,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,17.17,61.35,percent of total billed charges,
ALCOHOLS BIOMARKERS 1OR 2,8256155,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,58.80,257.47,percent of total billed charges,
HEPATITIS B SURFACE AB,8260195,CDM,300,RC,86706,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,9.96,126.79,percent of total billed charges,
MERCURY,8260166,CDM,300,RC,83825,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,15.07,118.61,percent of total billed charges,
ASSAY NEPHELOMETRY NOT SPEC,8134947,CDM,300,RC,83883,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,12.61,112.88,percent of total billed charges,
LYME DISEASE ANTIBODY,8134951,CDM,300,RC,86617,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,14.36,120.25,percent of total billed charges,
TISSUE CULTURE BONE MARROW,8134954,CDM,300,RC,88237,HCPCS,,,facility,outpatient,,,204.00000,59.16000,Aetna,Local,,103.57,,,,,,,32.36,380.94,percent of total billed charges,
Ehrlichia Addl,8229208,CDM,300,RC,86666,HCPCS,,,facility,outpatient,,,66.00000,19.14000,Aetna,Local,GY,33.51,,,,,,,9.43,53.99,percent of total billed charges,
Methotrexate Level Addl,8229175,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,GY,69.05,,,,,,,17.28,111.25,percent of total billed charges,
Mycoplasma pneumoniae Ab Addl,8229211,CDM,300,RC,86738,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,GY,71.08,,,,,,,12.28,114.52,percent of total billed charges,
Mycoplasma pneumoniae Ab Addl,8229210,CDM,300,RC,86738,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,GY,71.08,,,,,,,12.28,114.52,percent of total billed charges,
Warfarin Level Addl,8229171,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,185.00000,53.65000,Aetna,Local,GY,93.92,,,,,,,17.28,151.33,percent of total billed charges,
Drug Screen CMH Urine Addl,8229180,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,243.00000,70.47000,Aetna,Local,GY,123.37,,,,,,,87.60,198.77,percent of total billed charges,
Ehrlichia Addl,8229209,CDM,300,RC,86666,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,GY,72.60,,,,,,,9.43,116.97,percent of total billed charges,
Itraconizole Quant Addl,8229174,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,Local,GY,81.74,,,,,,,17.28,131.70,percent of total billed charges,
Bartonella Addl,8229206,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,Local,GY,18.78,,,,,,,9.43,30.27,percent of total billed charges,
Bartonella Addl,8229207,CDM,300,RC,86611,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,Local,GY,38.59,,,,,,,9.43,62.17,percent of total billed charges,
Voriconazole Quant Addl,8229172,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,161.00000,46.69000,Aetna,Local,GY,81.74,,,,,,,17.28,131.70,percent of total billed charges,
T3 Uptake Addl,8229197,CDM,300,RC,84479,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,GY,75.14,,,,,,,5.99,121.06,percent of total billed charges,
Kappa Lambda Light Chain Addl,8230207,CDM,300,RC,83883,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,12.61,112.88,percent of total billed charges,
Assay Nephelometry Not Spec Addl,8230208,CDM,300,RC,83883,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,12.61,112.88,percent of total billed charges,
Kappa Lambda Quant Addl,8230209,CDM,300,RC,83883,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,12.61,112.88,percent of total billed charges,
Legionella Culture Addl,8230224,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,6.15,114.52,percent of total billed charges,
87081 Carbapenem Resistant Organism,8388216,CDM,300,RC,87081,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,6.15,114.52,percent of total billed charges,
Allergens Food Common Adult Food IgE Addl,8231054,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,Local,GY,21.32,,,,,,,8.18,34.36,percent of total billed charges,
ALLERGENS LATEX CROSS REACTIVE FOOD PANEL IGE,8280364,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,Local,,21.32,,,,,,,8.18,43.62,percent of total billed charges,
Immunoglobulin E Addl,8231055,CDM,300,RC,82785,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,GY,75.65,,,,,,,8.18,121.88,percent of total billed charges,
Lupus Anticoagulant Reflexive Panel Addl,8231057,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,Local,GY,33.00,,,,,,,8.88,53.17,percent of total billed charges,
DRVVT 1to1 Mix Bill Addl,8231058,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,22.00000,6.38000,Aetna,Local,GY,11.17,,,,,,,7.93,19.63,percent of total billed charges,
DRVVT Confirmation Bill Addl,8231059,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,32.00000,9.28000,Aetna,Local,GY,16.25,,,,,,,8.88,26.18,percent of total billed charges,
FACTOR VIII ACTIVITY,7935654,CDM,300,RC,85240,HCPCS,,,facility,outpatient,,,60.00000,17.40000,Aetna,Local,,30.46,,,,,,,16.59,49.08,percent of total billed charges,
VON WILLEBRAND FACTOR ANTIGEN,7935648,CDM,300,RC,85246,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,21.27,62.99,percent of total billed charges,
von Willebrand Panel with Reflex,9093115,CDM,300,RC,85246,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,21.27,62.99,percent of total billed charges,
RISTOCETIN COFACTOR,7935655,CDM,300,RC,85245,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,21.27,62.99,percent of total billed charges,
86671 S cerevisiae Antibody,7944540,CDM,300,RC,86671,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,6.68,63.80,percent of total billed charges,
PHENYTOIN FREE,3206883,CDM,300,RC,80186,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,12.75,58.90,percent of total billed charges,
Protein,613045,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,Local,,18.78,,,,,,,3.40,30.27,percent of total billed charges,
Protein Electrophoresis Serum ARUP,7954220,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,Local,,18.78,,,,,,,3.40,30.27,percent of total billed charges,
BARBITURATES,8260173,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,166.00000,48.14000,Aetna,Local,,84.28,,,,,,,66.40,257.47,percent of total billed charges,
METHADONE,8260204,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,60.00,257.47,percent of total billed charges,
ZINC PROTOPORPHYINS,8261907,CDM,300,RC,84202,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,13.31,125.97,percent of total billed charges,
LEAD,8261920,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,11.23,50.72,percent of total billed charges,
PROTOPORPHRYIN RBC,8261928,CDM,300,RC,84202,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,13.31,59.71,percent of total billed charges,
JAK2 V617F Mutation by ddPCR Quant ARUP ZB20D,8441771,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,585.00000,169.65000,Aetna,Local,,297.00,,,,,,,84.96,478.53,percent of total billed charges,
EPSTEIN BARR CAPSID VCA,8261886,CDM,300,RC,86665,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,16.82,118.61,percent of total billed charges,
RUBELLA ANTIBODY,8261893,CDM,300,RC,86762,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,13.34,62.99,percent of total billed charges,
RUBELLA ANTIBODY,8261896,CDM,300,RC,86762,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,13.34,62.99,percent of total billed charges,
ALPHA THALASSEMIA HBA1 AND HBA2 BILL ZB2QF,8265946,CDM,300,RC,81259,HCPCS,,,facility,outpatient,,,1139.00000,330.31000,Aetna,Local,,578.27,,,,,,,535.33,1590.00,percent of total billed charges,
FACTOR XIII ACTIVITY,8264144,CDM,300,RC,85290,HCPCS,,,facility,outpatient,,,242.00000,70.18000,Aetna,Local,,122.86,,,,,,,15.15,197.96,percent of total billed charges,
ALPHA GLOBIN HBA1 AND HBA2 DD ZB2R0,8265964,CDM,300,RC,81269,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,Local,,192.93,,,,,,,178.60,536.36,percent of total billed charges,
BETA GLOBIN GENE SEQUENCING ZB2QI,8265937,CDM,300,RC,81364,HCPCS,,,facility,outpatient,,,1000.00000,290.00000,Aetna,Local,,507.70,,,,,,,300.88,860.14,percent of total billed charges,
BETA GLOBIN DEL DUP ZB34A,8265973,CDM,300,RC,81363,HCPCS,,,facility,outpatient,,,858.00000,248.82000,Aetna,Local,,435.61,,,,,,,187.62,701.84,percent of total billed charges,
PHOSPHOLIPASE A2 RECEPTOR,8265846,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,234.00000,67.86000,Aetna,Local,,118.80,,,,,,,11.18,191.41,percent of total billed charges,
PHOSPHOLIPASE A2 RECEPTOR AB TITER,8265864,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,11.18,194.68,percent of total billed charges,
FACTOR II,8264135,CDM,300,RC,85210,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,12.03,124.34,percent of total billed charges,
ASSAY OF BLOOD LIPOPROTEIN,8280653,CDM,300,RC,83721,HCPCS,,,facility,outpatient,,,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,9.73,29.45,percent of total billed charges,
ANCA ASSOCIATE VASCULITIS PROFILE,8442123,CDM,300,RC,86036,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,Local,,25.89,,,,,,,11.18,41.72,percent of total billed charges,
CREATINE KINASE MB,8263974,CDM,300,RC,82553,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,10.71,122.70,percent of total billed charges,
CREATINE MB FRACTION,8948138,CDM,300,RC,82553,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,10.71,122.70,percent of total billed charges,
TESTOSTERONE FREE,8271845,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,23.61,120.25,percent of total billed charges,
TESTOSTERONE FREE,8275891,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,49.00000,14.21000,Aetna,Local,,24.88,,,,,,,23.03,67.50,percent of total billed charges,
TESTOSTERONE TOTAL,8275884,CDM,300,RC,84403,HCPCS,,,facility,outpatient,,,49.00000,14.21000,Aetna,Local,,24.88,,,,,,,23.03,68.40,percent of total billed charges,
THYROXINE FREE,8270389,CDM,300,RC,84439,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,Local,,70.57,,,,,,,8.36,113.70,percent of total billed charges,
HSV TYPING,8277910,CDM,300,RC,87140,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,5.16,61.35,percent of total billed charges,
Herpes Simplex Virus Typing,8387181,CDM,300,RC,87140,HCPCS,,,facility,outpatient,,,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,5.16,58.90,percent of total billed charges,
ESTRADIOL BY TMS,8270382,CDM,300,RC,82670,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,Local,,70.57,,,,,,,25.90,113.70,percent of total billed charges,
PNEUMOCYSTIC CARANII AG IF,3209027,CDM,300,RC,87015,HCPCS,,,facility,outpatient,,,52.00000,15.08000,Aetna,Local,,26.40,,,,,,,6.19,42.54,percent of total billed charges,
P JIROVECII,8270277,CDM,300,RC,87281,HCPCS,,,facility,outpatient,,,93.00000,26.97000,Aetna,Local,,47.22,,,,,,,11.10,76.07,percent of total billed charges,
TESTOSTERONE FREE,3190870,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,55.00000,15.95000,Aetna,Local,,27.92,,,,,,,23.61,67.50,percent of total billed charges,
TESTOSTERONE FREE,3481853,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,55.00000,15.95000,Aetna,Local,,27.92,,,,,,,23.61,67.50,percent of total billed charges,
TESTOSTERONE FREE,4907839,CDM,300,RC,84402,HCPCS,,,facility,outpatient,,,55.00000,15.95000,Aetna,Local,,27.92,,,,,,,23.61,67.50,percent of total billed charges,
TESTOSTERONE TOTAL,8270312,CDM,300,RC,84403,HCPCS,,,facility,outpatient,,,55.00000,15.95000,Aetna,Local,,27.92,,,,,,,23.93,68.40,percent of total billed charges,
SHGB,8270313,CDM,300,RC,84270,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,Local,,23.86,,,,,,,20.15,57.58,percent of total billed charges,
CNS DEMYELINATING DISEASE EVAL PANEL,8277875,CDM,300,RC,86363,HCPCS,,,facility,outpatient,,,759.00000,220.11000,Aetna,Local,,385.34,,,,,,,34.98,620.86,percent of total billed charges,
AUTOIMMUNE MYELOPATHY EVAL CSF,8278488,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,120.83,,,,,,,21.85,194.68,percent of total billed charges,
ASSAY OF CPK IN BLOOD,8280607,CDM,300,RC,82552,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,Local,,53.31,,,,,,,11.51,85.89,percent of total billed charges,
ASSAY OF CK CPK,8280652,CDM,300,RC,82550,HCPCS,,,facility,outpatient,,,52.00000,15.08000,Aetna,Local,,26.40,,,,,,,6.04,42.54,percent of total billed charges,
ENCEPHALOPATHY ABS,8278756,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,Local,,30.97,,,,,,,11.18,49.90,percent of total billed charges,
ASSAY OF CHROMIUM,8280575,CDM,300,RC,82495,HCPCS,,,facility,outpatient,,,544.00000,157.76000,Aetna,Local,,276.19,,,,,,,18.80,444.99,percent of total billed charges,
ASSAY OF ARSENIC,8286211,CDM,300,RC,82175,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,Local,,21.32,,,,,,,17.58,50.27,percent of total billed charges,
ASSAY OF CADMIUM,8286181,CDM,300,RC,82300,HCPCS,,,facility,outpatient,,,52.00000,15.08000,Aetna,Local,,26.40,,,,,,,21.92,62.65,percent of total billed charges,
ASSAY OF LEAD,8286212,CDM,300,RC,83655,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,11.23,32.09,percent of total billed charges,
ASSAY OF MERCURY,8286213,CDM,300,RC,83825,HCPCS,,,facility,outpatient,,,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,15.07,43.09,percent of total billed charges,
Urine Protein,8310239,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,15.00000,4.35000,Aetna,Local,,7.62,,,,,,,3.40,12.27,percent of total billed charges,
84156 Total Protein Urine,8975473,CDM,300,RC,84156,HCPCS,,,facility,outpatient,,,15.00000,4.35000,Aetna,Local,,7.62,,,,,,,3.40,12.27,percent of total billed charges,
Immunofixation,8310248,CDM,300,RC,86335,HCPCS,,,facility,outpatient,,,113.00000,32.77000,Aetna,Local,,57.37,,,,,,,27.21,92.43,percent of total billed charges,
Immunoassay Quant Urine,8310249,CDM,300,RC,83521,HCPCS,,,facility,outpatient,,,68.00000,19.72000,Aetna,Local,,34.52,,,,,,,16.01,55.62,percent of total billed charges,
Coronavirus 2019 SARS Cov2,8334462,CDM,300,RC,87635,HCPCS,,,facility,outpatient,,,198.00000,57.42000,Aetna,Local,,51.31,,,,,,,47.57,161.96,fee schedule,
HERPES SIMPLEX NES ANTBDY,8286182,CDM,300,RC,86694,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,13.34,121.88,percent of total billed charges,
Culture Cytomegalovirus Rapid,8387022,CDM,300,RC,87254,HCPCS,,,facility,outpatient,,,175.00000,50.75000,Aetna,Local,,88.85,,,,,,,18.13,143.15,percent of total billed charges,
Serum Protein Electrophoresis with Reflex ARUP,7954544,CDM,300,RC,84155,HCPCS,,,facility,outpatient,,,37.00000,10.73000,Aetna,Local,,18.78,,,,,,,3.40,30.27,percent of total billed charges,
SPEP,8344350,CDM,300,RC,84165,HCPCS,,,facility,outpatient,,,112.00000,32.48000,Aetna,Local,,56.86,,,,,,,9.96,91.62,percent of total billed charges,
Immunofix Electrophoresis Bill,7954558,CDM,300,RC,86334,HCPCS,,,facility,outpatient,,,127.00000,36.83000,Aetna,Local,,64.48,,,,,,,20.71,103.89,percent of total billed charges,
GIARDIA AG IA,8372350,CDM,300,RC,87329,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,11.10,122.70,percent of total billed charges,
CRYPTOSPORIDIUM AG IA,8372351,CDM,300,RC,87328,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,12.81,128.43,percent of total billed charges,
PROTEIN WESTERN BLOT TEST,8372349,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,59.00000,17.11000,Aetna,Local,,29.95,,,,,,,23.95,77.41,percent of total billed charges,
PROTEIN WESTERN BLOT TEST,8372367,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,59.00000,17.11000,Aetna,Local,,29.95,,,,,,,23.95,77.41,percent of total billed charges,
AFB Culture,8387232,CDM,300,RC,87116,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,10.01,116.97,percent of total billed charges,
87206 AFB Stain ARUP,8388172,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,5.00,27.81,percent of total billed charges,
SMEAR FLUORESCENT ACID STAI,8396254,CDM,300,RC,87206,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,5.00,27.81,percent of total billed charges,
Bill AFB Concentration 2010182 ARUP,8388840,CDM,300,RC,87015,HCPCS,,,facility,outpatient,,,33.00000,9.57000,Aetna,Local,,16.75,,,,,,,6.19,26.99,percent of total billed charges,
Bill M tuberculosis by DNA Probe 60459 ARUP,8388846,CDM,300,RC,87149,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,15.50,53.13,percent of total billed charges,
Bill AFB ID by DNA Sequencing 61208 ARUP,8388852,CDM,300,RC,87153,HCPCS,,,facility,outpatient,,,266.00000,77.14000,Aetna,Local,,135.05,,,,,,,106.93,305.70,percent of total billed charges,
Bill M tuberculosis Susceptibility 60409 ARUP,8388858,CDM,300,RC,87188,HCPCS,,,facility,outpatient,,,349.00000,101.21000,Aetna,Local,,177.19,,,,,,,6.16,285.48,percent of total billed charges,
Bill Single Drug Susceptibility by Broth Dilution 62229 ARUP,8388864,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,8.02,159.51,percent of total billed charges,
Bill AFB Nocardia Susceptibility by Broth Dilution,8388910,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,8.02,159.51,percent of total billed charges,
Bill AFB Isolation 60725 ARUP,8388877,CDM,300,RC,87015,HCPCS,,,facility,outpatient,,,308.00000,89.32000,Aetna,Local,,156.37,,,,,,,6.19,251.94,percent of total billed charges,
Bill Ethambutol Resistance by Sequencing 2011789 ARUP,8388883,CDM,300,RC,87153,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,163.99,,,,,,,106.93,305.70,percent of total billed charges,
Bill Fungal ID by MALDI TOF 2007693 ARUP,8388634,CDM,300,RC,83789,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,Local,,94.94,,,,,,,11.66,152.97,percent of total billed charges,
Bill AFB ID by MALDI 2009960 ARUP,8388889,CDM,300,RC,83789,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,Local,,94.94,,,,,,,11.66,152.97,percent of total billed charges,
87070 Unusual Organism Culture ARUP,8387278,CDM,300,RC,87070,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,7.99,122.70,percent of total billed charges,
87252 Respiratory Viral Culture,8388192,CDM,300,RC,87252,HCPCS,,,facility,outpatient,,,182.00000,52.78000,Aetna,Local,,92.40,,,,,,,24.16,148.88,percent of total billed charges,
87252 Non Respiratory Viral Culture,8388202,CDM,300,RC,87252,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,24.16,125.97,percent of total billed charges,
Bill Tuberculosis species ID 2014218 ARUP,8388896,CDM,300,RC,87150,HCPCS,,,facility,outpatient,,,320.00000,92.80000,Aetna,Local,,162.46,,,,,,,32.53,261.76,percent of total billed charges,
Bill Histoplasma capsulatum DNA Probe ARUP,8388640,CDM,300,RC,87149,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,15.50,229.04,percent of total billed charges,
Bill Blastomyces dermatitdis DNA Probe ARUP,8388902,CDM,300,RC,87149,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,15.50,229.04,percent of total billed charges,
Bill Coccidioides immitis DNA Probe ARUP,8388916,CDM,300,RC,87149,HCPCS,,,facility,outpatient,,,280.00000,81.20000,Aetna,Local,,142.16,,,,,,,15.50,229.04,percent of total billed charges,
Bill Viral Culture ID 2006696 ARUP,8388592,CDM,300,RC,87253,HCPCS,,,facility,outpatient,,,53.00000,15.37000,Aetna,Local,,26.91,,,,,,,18.73,53.53,percent of total billed charges,
DNA RNA SEQUENCING,8396257,CDM,300,RC,87153,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,Local,,121.85,,,,,,,106.93,305.70,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396266,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,8.02,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396273,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,8.02,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396275,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,8.02,159.51,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396251,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396252,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396256,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396258,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396260,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396264,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396265,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,7.49,126.79,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396268,CDM,300,RC,87077,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,7.49,126.79,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396269,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,8.02,118.61,percent of total billed charges,
MICROBE SUSCEPTIBLE ENZYME,8396271,CDM,300,RC,87185,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,4.41,125.15,percent of total billed charges,
MICROBE SUSCEPTIBLE DISK,8396272,CDM,300,RC,87184,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,6.93,120.25,percent of total billed charges,
MICROBE SUSCEPTIBLE DISK,8396274,CDM,300,RC,87184,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,6.93,120.25,percent of total billed charges,
DNA RNA SEQUENCING,8396262,CDM,300,RC,87153,HCPCS,,,facility,outpatient,,,287.00000,83.23000,Aetna,Local,,145.71,,,,,,,106.93,305.70,percent of total billed charges,
MICROBE SUSCEPTIBLE DIFFUSE,8396279,CDM,300,RC,87181,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,4.41,159.51,percent of total billed charges,
CULTURE AEROBIC IDENTIFY,8396253,CDM,300,RC,83789,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,Local,,94.94,,,,,,,11.66,152.97,percent of total billed charges,
CULTURE ANAEROBE IDENT EACH,8396255,CDM,300,RC,83789,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,Local,,94.94,,,,,,,11.66,152.97,percent of total billed charges,
MR STAPH DNA AMP PROBE,8396281,CDM,300,RC,87641,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,122.36,,,,,,,32.53,197.14,percent of total billed charges,
MICROBE SUSCEPTIBLE ENZYME,8396276,CDM,300,RC,87184,HCPCS,,,facility,outpatient,,,147.00000,42.63000,Aetna,Local,,74.63,,,,,,,6.93,120.25,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396277,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,4.80,117.79,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396267,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,4.80,121.88,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396270,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,219.00000,63.51000,Aetna,Local,,111.19,,,,,,,4.80,179.14,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396259,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,137.00000,39.73000,Aetna,Local,,69.55,,,,,,,4.80,112.07,percent of total billed charges,
CULTURE TYPE IMMUNOLOGIC,8396263,CDM,300,RC,87147,HCPCS,,,facility,outpatient,,,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,4.80,117.79,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396280,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,279.00000,80.91000,Aetna,Local,,141.65,,,,,,,8.02,228.22,percent of total billed charges,
FUNGI IDENTIFICATION YEAST,8396278,CDM,300,RC,87106,HCPCS,,,facility,outpatient,,,207.00000,60.03000,Aetna,Local,,105.09,,,,,,,9.57,169.33,percent of total billed charges,
FUNGI IDENTIFICATION MOLD,8396261,CDM,300,RC,87107,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,Local,,121.85,,,,,,,9.57,196.32,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396469,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,Local,,115.76,,,,,,,8.02,186.50,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,8396560,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,8.02,159.51,percent of total billed charges,
MICROBE SUSCEPTIBLE MLC,8396561,CDM,300,RC,87187,HCPCS,,,facility,outpatient,,,195.00000,56.55000,Aetna,Local,,99.00,,,,,,,9.53,159.51,percent of total billed charges,
Herpes Simplex Virus by PCR Neonate,8398281,CDM,300,RC,87529,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,Local,,120.32,,,,,,,32.53,193.87,percent of total billed charges,
IMMUNOASSAY QUANT NOS NONAB,8410360,CDM,300,RC,83529,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,Local,,107.63,,,,,,,16.01,173.42,percent of total billed charges,
Immunofixation Electrophoresis Serum,8414194,CDM,300,RC,86334,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,20.71,125.15,percent of total billed charges,
Lysozyme Serum,8414204,CDM,300,RC,85549,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,17.39,125.15,percent of total billed charges,
Bill 88280 Cytogenetics CSI,8415387,CDM,300,RC,88280,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,31.02,125.15,percent of total billed charges,
Bill 88368 FISH CSI,8415380,CDM,300,RC,88368,HCPCS,,,facility,outpatient,,,277.00000,80.33000,Aetna,Local,,140.63,,,,,,,130.19,951.40,percent of total billed charges,
T Cell receptor Beta Gene Rearrangement CSI ZB4IH,8415408,CDM,300,RC,81340,HCPCS,,,facility,outpatient,,,425.00000,123.25000,Aetna,Local,,215.77,,,,,,,193.67,553.64,percent of total billed charges,
IDH IDH2 Mutation Detection CSI ZBA8A,8415399,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,451.00000,130.79000,Aetna,Local,,228.97,,,,,,,162.59,368.92,percent of total billed charges,
B Cell IGK Gene Rearrangement CSI ZB4I6,8415440,CDM,300,RC,81264,HCPCS,,,facility,outpatient,,,256.00000,74.24000,Aetna,Local,,129.97,,,,,,,120.32,457.73,percent of total billed charges,
Bill 88182 Flow Cytometry Marker CSI,8415393,CDM,300,RC,88182,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,Local,,125.91,,,,,,,46.92,202.86,percent of total billed charges,
Bill 88261 Cytogenetics CSI,8415374,CDM,300,RC,88261,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,Local,,120.32,,,,,,,111.39,700.50,percent of total billed charges,
MYD88 Mutation Analysis CSI ZBA0X,8415570,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,91.93,208.59,percent of total billed charges,
MGMT Promoter Methylation CSI ZB2O2,8415564,CDM,300,RC,81287,HCPCS,,,facility,outpatient,,,298.00000,86.42000,Aetna,Local,,151.29,,,,,,,115.55,330.30,percent of total billed charges,
IGVH Mutation Analysis CSI ZBX4C,8415485,CDM,300,RC,81263,HCPCS,,,facility,outpatient,,,587.00000,170.23000,Aetna,Local,,298.02,,,,,,,273.02,780.48,percent of total billed charges,
MPL Mutation CSI ZB51I,8415578,CDM,300,RC,81338,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,Local,,117.28,,,,,,,108.57,398.37,percent of total billed charges,
Hematology Complete Profile CSI Z01VW,8415585,CDM,300,RC,81455,HCPCS,,,facility,outpatient,,,3230.00000,936.70000,Aetna,Local,,1639.87,,,,,,,1518.10,7736.94,percent of total billed charges,
CALR Mutation CSI ZB51H,8415680,CDM,300,RC,81219,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,Local,,108.14,,,,,,,100.11,322.32,percent of total billed charges,
PDGFRA CSI ZB3Y2,8415686,CDM,300,RC,81314,HCPCS,,,facility,outpatient,,,383.00000,111.07000,Aetna,Local,,194.45,,,,,,,180.01,873.20,percent of total billed charges,
Bill 88230 Cytogenetics CSI,8415798,CDM,300,RC,88230,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,Local,,120.32,,,,,,,32.36,308.70,percent of total billed charges,
Bill 88285 Cytogenetics CSI,8415804,CDM,300,RC,88285,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,24.95,125.15,percent of total billed charges,
Bill 88271 Cytogentics CSI,8415812,CDM,300,RC,88271,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,19.86,125.97,percent of total billed charges,
STRIATED MUSCLE AB SCREEN,7117845,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,Local,,29.45,,,,,,,11.18,47.44,percent of total billed charges,
Striated Muscle Ab Scr,759802,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,58.00000,16.82000,Aetna,Local,,29.45,,,,,,,11.18,47.44,percent of total billed charges,
SYPHILIS TEST NON TREP QUANT,3184947,CDM,300,RC,86593,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,Local,,21.32,,,,,,,4.08,34.36,percent of total billed charges,
SYPHILIS TEST NON TREP QUANT,7904119,CDM,300,RC,86593,HCPCS,,,facility,outpatient,,,42.00000,12.18000,Aetna,Local,,21.32,,,,,,,4.08,34.36,percent of total billed charges,
Allergen IgE,7966184,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,16.62,60.53,percent of total billed charges,
FRANCISELLA TULARENSIS,8366175,CDM,300,RC,86668,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,10.64,64.62,percent of total billed charges,
FRANCISELLA TULARENSIS,8366187,CDM,300,RC,86668,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,10.64,64.62,percent of total billed charges,
MG Evaluation with MuSK Reflex,8433930,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,322.00000,93.38000,Aetna,Local,,163.48,,,,,,,17.06,263.40,percent of total billed charges,
MPO and PR3 Abs with Reflex,8442361,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,10.69,54.81,percent of total billed charges,
MPO Antibodies,8526022,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,10.69,54.81,percent of total billed charges,
Lacosamide,8461766,CDM,300,RC,80235,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,122.36,,,,,,,25.13,197.14,percent of total billed charges,
83516 Immunoassay NonAb,8464205,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,10.69,30.55,percent of total billed charges,
86235 Nuclear Ab Ag,8464206,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,38.00000,11.02000,Aetna,Local,,19.29,,,,,,,16.62,47.51,percent of total billed charges,
MOGTS MOG FACS IgG1 Titer Serum MAYO,7994144,CDM,300,RC,86363,HCPCS,,,facility,outpatient,,,97.00000,28.13000,Aetna,Local,,49.25,,,,,,,34.98,99.98,percent of total billed charges,
86053 CNS Demyelinating Eval Panel,8277878,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,759.00000,220.11000,Aetna,Local,,385.34,,,,,,,34.98,620.86,percent of total billed charges,
Pancreatic Elastase Fecal by Immunoassay,8366177,CDM,300,RC,82653,HCPCS,,,facility,outpatient,,,237.00000,68.73000,Aetna,Local,,120.32,,,,,,,21.29,193.87,percent of total billed charges,
Anti Neutrophil Cytoplasmic Ab IgG,8442362,CDM,300,RC,86036,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,11.18,122.70,percent of total billed charges,
NMO Antibodies,8526041,CDM,300,RC,86053,HCPCS,,,facility,outpatient,,,417.00000,120.93000,Aetna,Local,,211.71,,,,,,,34.98,341.11,percent of total billed charges,
Thyroid Hormone,8750084,CDM,300,RC,84479,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,5.99,60.53,percent of total billed charges,
84436 Thyroxine Total,8750094,CDM,300,RC,84436,HCPCS,,,facility,outpatient,,,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,6.37,62.99,percent of total billed charges,
Alpha Defensin Synovial Fluid,8890092,CDM,300,RC,83518,HCPCS,,,facility,outpatient,,,804.00000,233.16000,Aetna,Local,,408.19,,,,,,,8.94,657.67,percent of total billed charges,
Bacterial Detection by PCR,8868088,CDM,300,RC,87801,HCPCS,,,facility,outpatient,,,491.00000,142.39000,Aetna,Local,,249.28,,,,,,,65.08,401.64,percent of total billed charges,
Cortisol Free by ED LC MS MS,8910302,CDM,300,RC,82530,HCPCS,,,facility,outpatient,,,167.00000,48.43000,Aetna,Local,,84.79,,,,,,,15.49,136.61,percent of total billed charges,
WEST NILE VIRUS AB CSF IGG IGM,3190848,CDM,300,RC,86789,HCPCS,,,facility,outpatient,,,71.00000,20.59000,Aetna,Local,,36.05,,,,,,,13.34,58.08,percent of total billed charges,
WEST NILE VIRUS RNA RT PCR CSF,3196903,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,268.00000,77.72000,Aetna,Local,,136.06,,,,,,,32.53,219.22,percent of total billed charges,
Kratom Screen with Reflex to Confirmation Urine,8910290,CDM,300,RC,80307,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,57.61,208.59,percent of total billed charges,
Kratom Confirmation Quant Urine,8910300,CDM,300,RC,80323,HCPCS,,,facility,outpatient,,,90.00000,26.10000,Aetna,Local,,45.69,,,,,,,0.01485,73.62,percent of total billed charges,
Bath Salts Qualitative Panel Urine,8908352,CDM,300,RC,80371,HCPCS,,,facility,outpatient,,,216.00000,62.64000,Aetna,Local,,109.66,,,,,,,0.01485,176.69,percent of total billed charges,
Synthetic Cannabinoid Metabolites Qualitative,8908344,CDM,300,RC,80352,HCPCS,,,facility,outpatient,,,187.00000,54.23000,Aetna,Local,,94.94,,,,,,,0.01485,152.97,percent of total billed charges,
Bath Salts Qual Panel,8914725,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,265.00000,76.85000,Aetna,Local,,134.54,,,,,,,106.00,257.47,percent of total billed charges,
Imipramine and Desipramine Serum or Plasma,8914841,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,62.80,257.47,percent of total billed charges,
ANNA 1 Immunoblot Serum,8916154,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,Local,,115.76,,,,,,,23.95,186.50,percent of total billed charges,
ANNA 2 Immunoblot Serum,8916156,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,Local,,115.76,,,,,,,23.95,186.50,percent of total billed charges,
PCA 1 Immunoblot Serum,8916228,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,Local,,115.76,,,,,,,23.95,186.50,percent of total billed charges,
PCA Tr Immunoblot Serum,8916237,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,228.00000,66.12000,Aetna,Local,,115.76,,,,,,,23.95,186.50,percent of total billed charges,
ZINC LEVEL SERUM,3196875,CDM,300,RC,84630,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,10.56,125.97,percent of total billed charges,
Pancreatic Polypeptide,8914867,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,249.00000,72.21000,Aetna,Local,,126.42,,,,,,,17.06,203.68,percent of total billed charges,
Tricyclic Antidepressants Quant,8915034,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,58.00,257.47,percent of total billed charges,
Stachybotrys chartarum atra Panel,8918182,CDM,300,RC,86001,HCPCS,,,facility,outpatient,,,92.00000,26.68000,Aetna,Local,,46.71,,,,,,,6.95,75.26,percent of total billed charges,
86003 Stachybotrys chartarum atra Panel,8918190,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,Local,,30.97,,,,,,,4.84,49.90,percent of total billed charges,
Brivaracetam Quantitative Serum or Plasma,8918191,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,236.00000,68.44000,Aetna,Local,,119.82,,,,,,,94.40,257.47,percent of total billed charges,
F tularensis Ab by Agglutination,8366176,CDM,300,RC,86000,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,6.47,39.26,percent of total billed charges,
Interleukin 2 Receptor Soluble Serum,8920458,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,212.00000,61.48000,Aetna,Local,,107.63,,,,,,,16.01,173.42,percent of total billed charges,
Aspergillus Species by PCR,8968088,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,198.00000,57.42000,Aetna,Local,,100.52,,,,,,,32.53,161.96,percent of total billed charges,
87798 Aspergillus Species,8968098,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,198.00000,57.42000,Aetna,Local,,100.52,,,,,,,32.53,161.96,percent of total billed charges,
Orthopoxvirus Monkeypox by PCR,8927075,CDM,300,RC,87593,HCPCS,,,facility,outpatient,,,224.00000,64.96000,Aetna,Local,,113.72,,,,,,,47.57,183.23,percent of total billed charges,
87255 HSV Culture,8277896,CDM,300,RC,87255,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,31.38,111.25,percent of total billed charges,
Culture Herpes Simplex Virus,8387023,CDM,300,RC,87255,HCPCS,,,facility,outpatient,,,131.00000,37.99000,Aetna,Local,,66.51,,,,,,,31.38,107.16,percent of total billed charges,
82172 Apolipoprotein,8950563,CDM,300,RC,82172,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,19.55,63.80,percent of total billed charges,
Apolipoprotein BA Ratio,8965749,CDM,300,RC,82172,HCPCS,,,facility,outpatient,,,78.00000,22.62000,Aetna,Local,,39.60,,,,,,,19.55,63.80,percent of total billed charges,
Cortisol Saliva,8968106,CDM,300,RC,82533,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,15.11,124.34,percent of total billed charges,
84166 Protein Electrophoresis Urine,8975474,CDM,300,RC,84166,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,16.53,60.53,percent of total billed charges,
Monoclonal Protein Study 24 Hour Urine,8973314,CDM,300,RC,86335,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,,61.94,,,,,,,27.21,99.80,percent of total billed charges,
NIPT ARUP Z01UZ,8978826,CDM,300,RC,81420,HCPCS,,,facility,outpatient,,,680.00000,197.20000,Aetna,Local,,345.24,,,,,,,319.60,2011.48,percent of total billed charges,
Kratom Umbilical Cord Tissue Qual,8984925,CDM,300,RC,80323,HCPCS,,,facility,outpatient,,,298.00000,86.42000,Aetna,Local,,151.29,,,,,,,0.01485,243.76,percent of total billed charges,
Hypoglycemia Panel Serum or Plasma,8984934,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,Local,,110.68,,,,,,,87.20,257.47,percent of total billed charges,
Measles Virus PCR Throat,9042908,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,Local,,402.10,,,,,,,32.53,647.86,percent of total billed charges,
AMH with Menopausal Status,9044141,CDM,300,RC,82166,HCPCS,,,facility,outpatient,,,216.00000,62.64000,Aetna,Local,,109.66,,,,,,,35.80,176.69,percent of total billed charges,
Allergen Food Sesame rSes i 1 Component,9044142,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,16.62,125.15,percent of total billed charges,
Adalimumab Ab to Adalimumab Quant,9044146,CDM,300,RC,80145,HCPCS,,,facility,outpatient,,,385.00000,111.65000,Aetna,Local,,195.46,,,,,,,35.75,314.93,percent of total billed charges,
Adalimumab Ab to Quant,9046333,CDM,300,RC,82397,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,,72.09,,,,,,,13.09,116.16,percent of total billed charges,
Infliximab,9044147,CDM,300,RC,80230,HCPCS,,,facility,outpatient,,,385.00000,111.65000,Aetna,Local,,195.46,,,,,,,35.75,314.93,percent of total billed charges,
82397 Infliximab,9044992,CDM,300,RC,82397,HCPCS,,,facility,outpatient,,,142.00000,41.18000,Aetna,Local,,72.09,,,,,,,13.09,116.16,percent of total billed charges,
BCR ABL1 Minor Quant ARUP ZBG82,7900258,CDM,300,RC,81207,HCPCS,,,facility,outpatient,,,436.00000,126.44000,Aetna,Local,,221.36,,,,,,,134.27,383.83,percent of total billed charges,
Reflexed to PTT Ratio Treated Bill ARUP,9041349,CDM,300,RC,85730,HCPCS,,,facility,outpatient,,,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,5.57,39.26,percent of total billed charges,
Reflexed to dRVVT Screen Ratio Treated Bill,9041351,CDM,300,RC,85613,HCPCS,,,facility,outpatient,,,47.00000,13.63000,Aetna,Local,,23.86,,,,,,,8.88,38.45,percent of total billed charges,
Reflex to Anti Xa Qual Interp Bill,9043438,CDM,300,RC,85520,HCPCS,,,facility,outpatient,,,65.00000,18.85000,Aetna,Local,,33.00,,,,,,,12.13,53.17,percent of total billed charges,
Hepzyme Treatment Bill,9043443,CDM,300,RC,85525,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,10.98,40.90,percent of total billed charges,
Lyme Disease Reflexive Panel CSF,7756197,CDM,300,RC,86618,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,15.79,125.97,percent of total billed charges,
Culture Blood Fungus,9058156,CDM,300,RC,87103,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,10.17,114.52,percent of total billed charges,
Bill SusceptibilityNocardiaBrothDilution,9058162,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,118.00000,34.22000,Aetna,Local,,59.91,,,,,,,8.02,96.52,percent of total billed charges,
Aldosterone 3005949 ARUP,9074651,CDM,300,RC,82088,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,37.78,128.43,percent of total billed charges,
Renin Activity,9074657,CDM,300,RC,84244,HCPCS,,,facility,outpatient,,,222.00000,64.38000,Aetna,Local,,112.71,,,,,,,20.38,181.60,percent of total billed charges,
Body Fluid Urea Nitrogen,9076716,CDM,300,RC,84540,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,5.15,126.79,percent of total billed charges,
TSPOT TB,9083466,CDM,300,RC,86481,HCPCS,,,facility,outpatient,,,139.00000,40.31000,Aetna,Local,,70.57,,,,,,,65.33,265.00,percent of total billed charges,
Tacrolimus by Tandem Mass Spectrometry,9082381,CDM,300,RC,80197,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,11.64,110.43,percent of total billed charges,
86003 Crustacean IgE,9080478,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,4.84,31.90,percent of total billed charges,
Allergens Food Crustacean Profile IgE,9082412,CDM,300,RC,86003,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,4.84,31.90,percent of total billed charges,
HLA B 58 01 Typing ARUP ZO1AK,8990305,CDM,300,RC,81381,HCPCS,,,facility,outpatient,,,408.00000,118.32000,Aetna,Local,,207.14,,,,,,,157.50,450.24,percent of total billed charges,
86039 ANA Ab Titer,8990299,CDM,300,RC,86039,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,10.34,54.81,percent of total billed charges,
86235 ENA Abs,8987202,CDM,300,RC,86235,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,16.62,64.62,percent of total billed charges,
Comprehensive Systemic Sclerosis Panel,8990291,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,10.69,54.81,percent of total billed charges,
HLA B Genotype ARUP ZB6W2,8990306,CDM,300,RC,81380,HCPCS,,,facility,outpatient,,,417.00000,120.93000,Aetna,Local,,211.71,,,,,,,164.32,469.71,percent of total billed charges,
B Cell Gene Rearrangement IGH Neogenomics ZBQ39,8987410,CDM,300,RC,81261,HCPCS,,,facility,outpatient,,,404.00000,117.16000,Aetna,Local,,205.11,,,,,,,183.54,524.67,percent of total billed charges,
B Cell Gene Rearrangement IGK Neogenomics ZBQ39,8987411,CDM,300,RC,81264,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,155.10,457.73,percent of total billed charges,
TRB Gene Rearrangement Neogenomics ZB4T6,8987412,CDM,300,RC,81340,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,Local,,335.59,,,,,,,193.67,553.64,percent of total billed charges,
TRG Gene Rearrangement Neogenomics ZBY91,8987417,CDM,300,RC,81342,HCPCS,,,facility,outpatient,,,421.00000,122.09000,Aetna,Local,,213.74,,,,,,,186.79,533.98,percent of total billed charges,
CALR Mutation Analysis Neogenomics ZBX2Z,8992189,CDM,300,RC,81219,HCPCS,,,facility,outpatient,,,513.00000,148.77000,Aetna,Local,,260.45,,,,,,,112.75,419.63,percent of total billed charges,
KIT c KIT Neogenomics ZBQ09,8992194,CDM,300,RC,81272,HCPCS,,,facility,outpatient,,,445.00000,129.05000,Aetna,Local,,225.93,,,,,,,209.15,873.20,percent of total billed charges,
CXCR4 Mutation Analysis Neogenomics ZB41R,8992196,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,573.00000,166.17000,Aetna,Local,,290.91,,,,,,,206.57,468.71,percent of total billed charges,
IDH and IDH2 Mutation Analysis Neogenomics ZBQ14,8992198,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,486.00000,140.94000,Aetna,Local,,246.74,,,,,,,175.20,397.55,percent of total billed charges,
IgVH Mutation Analysis Neogenomics ZBO89,8992199,CDM,300,RC,81263,HCPCS,,,facility,outpatient,,,614.00000,178.06000,Aetna,Local,,311.73,,,,,,,273.02,780.48,percent of total billed charges,
JAK2 V617F Mutation Analysis Neogenomics ZBY95,8992200,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,427.00000,123.83000,Aetna,Local,,216.79,,,,,,,84.96,349.29,percent of total billed charges,
JAK2 V617F Mutation Analysis Neogenomics ZBY95,9090321,CDM,300,RC,81270,HCPCS,,,facility,outpatient,,,427.00000,123.83000,Aetna,Local,,216.79,,,,,,,84.96,349.29,percent of total billed charges,
JAK2 Exon 12 14 Mutation Analysis Neogenomics ZBY94,8987442,CDM,300,RC,81279,HCPCS,,,facility,outpatient,,,513.00000,148.77000,Aetna,Local,,260.45,,,,,,,171.68,490.78,percent of total billed charges,
MGMT Promoter Methylation Analysis Neogenomic ZBX6H,8992205,CDM,300,RC,81287,HCPCS,,,facility,outpatient,,,588.00000,170.52000,Aetna,Local,,298.53,,,,,,,115.55,480.98,percent of total billed charges,
MPL Mutation Neogenomics ZB3EP,8987449,CDM,300,RC,81339,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,Local,,206.13,,,,,,,171.68,490.78,percent of total billed charges,
MYD88 Mutation Neogenomics ZBZR7,8987450,CDM,300,RC,81305,HCPCS,,,facility,outpatient,,,532.00000,154.28000,Aetna,Local,,270.10,,,,,,,162.60,464.81,percent of total billed charges,
PDGFRa Mutation Neogenomics ZBQ20,8987452,CDM,300,RC,81314,HCPCS,,,facility,outpatient,,,734.00000,212.86000,Aetna,Local,,372.65,,,,,,,305.46,873.20,percent of total billed charges,
PIK3CA Mutation Neogenomics ZB3EJ,8987458,CDM,300,RC,81309,HCPCS,,,facility,outpatient,,,702.00000,203.58000,Aetna,Local,,356.41,,,,,,,254.77,728.30,percent of total billed charges,
SF3B1 Mutation Neogenomics ZBQ28,8992216,CDM,300,RC,81347,HCPCS,,,facility,outpatient,,,434.00000,125.86000,Aetna,Local,,220.34,,,,,,,179.15,512.11,percent of total billed charges,
STAT3 Mutation Neogenomics ZB7B9,8992217,CDM,300,RC,81405,HCPCS,,,facility,outpatient,,,665.00000,192.85000,Aetna,Local,,337.62,,,,,,,279.36,798.58,percent of total billed charges,
88377 FISH Neogenomics,8992223,CDM,300,RC,88377,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,150.47,452.20,percent of total billed charges,
Bill 88368 FISH Neogenomics,8992229,CDM,300,RC,88368,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,119.85,951.40,percent of total billed charges,
Bill 88369 FISH Neogenomics,8987468,CDM,300,RC,88369,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,91.93,208.59,percent of total billed charges,
Bill 88367 FISH Neogenomics,8992235,CDM,300,RC,88367,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,119.85,951.40,percent of total billed charges,
Bill 88374 FISH Neogenomics,8992236,CDM,300,RC,88374,HCPCS,,,facility,outpatient,,,510.00000,147.90000,Aetna,Local,,258.93,,,,,,,150.47,452.20,percent of total billed charges,
BCR ABL1 Quant Major BP ARUP ZBG81,7913833,CDM,300,RC,81206,HCPCS,,,facility,outpatient,,,493.00000,142.97000,Aetna,Local,,250.30,,,,,,,151.99,434.49,percent of total billed charges,
Babesia Species by PCR,7921216,CDM,300,RC,87469,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,,59.40,,,,,,,32.53,95.71,percent of total billed charges,
87468 Tick Borne Disease Panel,8997407,CDM,300,RC,87468,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,32.53,92.99,percent of total billed charges,
87484 Tick Borne Disease Panel,8995146,CDM,300,RC,87484,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,32.53,92.99,percent of total billed charges,
87469 Tick Borne Disease Panel,8997408,CDM,300,RC,87469,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,32.53,92.99,percent of total billed charges,
87468 Ehrlichia and Anaplasma by PCR,8997417,CDM,300,RC,87468,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,25.38,92.99,percent of total billed charges,
87484 Ehrlichia and Anaplasma by PCR,8997418,CDM,300,RC,87484,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,25.38,92.99,percent of total billed charges,
BCR ABL Major Break Point ARUP ZB078,7900203,CDM,300,RC,81206,HCPCS,,,facility,outpatient,,,165.00000,47.85000,Aetna,Local,,83.77,,,,,,,77.55,434.49,percent of total billed charges,
81207 BCR ABL Minor BP ARUP ZB078,8999667,CDM,300,RC,81207,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,68.15,383.83,percent of total billed charges,
81208 BCR ABL ARUP ZB078,8999666,CDM,300,RC,81208,HCPCS,,,facility,outpatient,,,215.00000,62.35000,Aetna,Local,,109.16,,,,,,,101.05,568.74,percent of total billed charges,
Epstein Barr  Qualitative PCR,8999941,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,184.00000,53.36000,Aetna,Local,,93.42,,,,,,,32.53,150.51,percent of total billed charges,
BK Virus by Quantitative NAAT Urine,9002090,CDM,300,RC,87799,HCPCS,,,facility,outpatient,,,230.00000,66.70000,Aetna,Local,,116.77,,,,,,,39.72,188.14,percent of total billed charges,
86317 14 3 3 Protein Tau CSF,9002104,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,33.00000,9.57000,Aetna,Local,,16.75,,,,,,,13.89,39.72,percent of total billed charges,
14 3 3 Protein Tau Total CSF,9000099,CDM,300,RC,0035U,HCPCS,,,facility,outpatient,,,1056.00000,306.24000,Aetna,Local,,536.13,,,,,,,422.40,1217.23,percent of total billed charges,
86356 B Cell Subset Analysis,9004382,CDM,300,RC,86356,HCPCS,,,facility,outpatient,,,43.00000,12.47000,Aetna,Local,,21.83,,,,,,,20.21,70.97,percent of total billed charges,
Phosphatidylethanol Peth Whole Blood,9004392,CDM,300,RC,G0480,HCPCS,,,facility,outpatient,,,254.00000,73.66000,Aetna,Local,,128.96,,,,,,,101.60,257.47,percent of total billed charges,
Autoimmune Stiff Person Disorders CSF,9001747,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,Local,,124.39,,,,,,,21.85,200.41,percent of total billed charges,
Autoimmune Stiff Person Disorders Serum,9004577,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,245.00000,71.05000,Aetna,Local,,124.39,,,,,,,21.85,200.41,percent of total billed charges,
84182 Autoimmune Stiff Person Disorders,9004584,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,306.00000,88.74000,Aetna,Local,,155.36,,,,,,,23.95,250.31,percent of total billed charges,
"DPPX IgG Ab Titer, CSF",9001764,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,315.00000,91.35000,Aetna,Local,,159.93,,,,,,,11.18,257.67,percent of total billed charges,
"DPPX IgG Ab Titer, Serum",9004599,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,315.00000,91.35000,Aetna,Local,,159.93,,,,,,,11.18,257.67,percent of total billed charges,
86255 Autoimmune Stiff Person Disorders,9001734,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,129.00000,37.41000,Aetna,Local,,65.49,,,,,,,11.18,105.52,percent of total billed charges,
MuSK Ab IgG with Reflex to Titer Serum,9002034,CDM,300,RC,86366,HCPCS,,,facility,outpatient,,,536.00000,155.44000,Aetna,Local,,272.13,,,,,,,17.06,438.45,percent of total billed charges,
MuSK IgG Ab Titer Serum,9002038,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,11.18,212.68,percent of total billed charges,
Myasthenia Gravis Reflexive Panel,9002040,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,91.00000,26.39000,Aetna,Local,,46.20,,,,,,,17.06,74.44,percent of total billed charges,
83516 Myasthenia Gravis Reflexive Panel,9004779,CDM,300,RC,86042,HCPCS,,,facility,outpatient,,,91.00000,26.39000,Aetna,Local,,46.20,,,,,,,17.06,74.44,percent of total billed charges,
Drug Detection Umbilical Cord Qual,8858115,CDM,300,RC,G0482,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,Local,,121.85,,,,,,,96.00,447.17,percent of total billed charges,
Fatty Acids Profile Essential,9010208,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,617.00000,178.93000,Aetna,Local,,313.25,,,,,,,11.66,504.71,percent of total billed charges,
HIV Types 1 and 2 Ab Differentiation,9005680,CDM,300,RC,86701,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,Local,,50.77,,,,,,,8.24,81.80,percent of total billed charges,
86702 HIV2 Ab,9005685,CDM,300,RC,86702,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,12.54,121.88,percent of total billed charges,
JC Virus Ab by ELISA,9008200,CDM,300,RC,86711,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,15.66,112.88,percent of total billed charges,
JC Virus Inhibition Assay,9008214,CDM,300,RC,86711,HCPCS,,,facility,outpatient,,,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.47000,44.76,percent of total billed charges,
MOG Antibody IgG,9012473,CDM,300,RC,86362,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,Local,,130.99,,,,,,,11.18,211.04,percent of total billed charges,
86362 MOG by CBA,9012506,CDM,300,RC,86362,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,Local,,130.99,,,,,,,11.18,211.04,percent of total billed charges,
Autoimmune CNS Demyelinating Disease Reflexive Panel,9012503,CDM,300,RC,86052,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,Local,,130.99,,,,,,,11.18,211.04,percent of total billed charges,
MOG Ab IgG Titer,9010459,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,Local,,135.56,,,,,,,11.18,218.41,percent of total billed charges,
Aquaporin 4 IgG Titer,9012491,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,Local,,87.32,,,,,,,11.18,140.70,percent of total billed charges,
Aquaporin 4 IgG Serum,9012486,CDM,300,RC,86052,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,Local,,163.99,,,,,,,11.18,264.21,percent of total billed charges,
87900 HIV Drug Resistance,9010834,CDM,300,RC,87900,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,,95.96,,,,,,,88.83,345.43,percent of total billed charges,
87906 HIV Drug Resistance,9010835,CDM,300,RC,87906,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,,95.96,,,,,,,88.83,341.13,percent of total billed charges,
CYTOMEGALOVIRUS IGG,3190856,CDM,300,RC,86644,HCPCS,,,facility,outpatient,,,63.00000,18.27000,Aetna,Local,,31.99,,,,,,,13.34,51.53,percent of total billed charges,
CYTOMEGALOVIRUS IGM,635121,CDM,300,RC,86645,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,15.63,60.53,percent of total billed charges,
RUBEOLA A,7744347,CDM,300,RC,86765,HCPCS,,,facility,outpatient,,,148.00000,42.92000,Aetna,Local,,75.14,,,,,,,11.94,121.06,percent of total billed charges,
VITAMIN B1 Plasma,8271856,CDM,300,RC,84425,HCPCS,,,facility,outpatient,,,136.00000,39.44000,Aetna,Local,,69.05,,,,,,,19.68,111.25,percent of total billed charges,
GAMMAGLOBULIN,2386830,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,63.00000,18.27000,Aetna,Local,,31.99,,,,,,,8.18,51.53,percent of total billed charges,
86258 Prometheus Celiac Panel,9010847,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,83.00000,24.07000,Aetna,Local,,42.14,,,,,,,11.18,67.89,percent of total billed charges,
86364 Prometheus Celiac Panel,9010848,CDM,300,RC,86364,HCPCS,,,facility,outpatient,,,79.00000,22.91000,Aetna,Local,,40.11,,,,,,,10.69,64.62,percent of total billed charges,
86231 Prometheus Celiac Panel,9010849,CDM,300,RC,86231,HCPCS,,,facility,outpatient,,,83.00000,24.07000,Aetna,Local,,42.14,,,,,,,11.21,67.89,percent of total billed charges,
EPILEPSY EVAL CSF,8280203,CDM,300,RC,86341,HCPCS,,,facility,outpatient,,,279.00000,80.91000,Aetna,Local,,141.65,,,,,,,21.85,228.22,percent of total billed charges,
Acetylcholine Clocking Antibody,3196839,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,10.69,116.97,percent of total billed charges,
Testosterone Female or Child,3210839,CDM,300,RC,84403,HCPCS,,,facility,outpatient,,,152.00000,44.08000,Aetna,Local,,77.17,,,,,,,23.93,124.34,percent of total billed charges,
ANCA ANTIBODY,8264168,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,10.69,40.90,percent of total billed charges,
86008 Milk Components,9013243,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,16.62,60.53,percent of total billed charges,
Rfx Allergen Food Peanut Components IgE,9050255,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,16.62,60.53,percent of total billed charges,
86008 Reflex Peanut Components IgE,9050261,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,16.62,60.53,percent of total billed charges,
86008 Hazelnut component,9101389,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,74.00000,21.46000,Aetna,Local,,37.57,,,,,,,16.62,60.53,percent of total billed charges,
HELMINTH ANTIBODY,7913622,CDM,300,RC,86682,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,12.06,114.52,percent of total billed charges,
86258 Prometheus Celiac Plus,9013269,CDM,300,RC,86258,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,Local,,25.89,,,,,,,11.18,41.72,percent of total billed charges,
Prometheus Celiac Plus,2386828,CDM,300,RC,86364,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,Local,,25.89,,,,,,,10.69,41.72,percent of total billed charges,
86231 Prometheus Celiac Plus,9010883,CDM,300,RC,86231,HCPCS,,,facility,outpatient,,,51.00000,14.79000,Aetna,Local,,25.89,,,,,,,11.21,41.72,percent of total billed charges,
82784 Prometheus Celiac Plus,9013270,CDM,300,RC,82784,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,8.18,24.64,percent of total billed charges,
81382 Prometheus Celiac Plus ZB25K,9010884,CDM,300,RC,81382,HCPCS,,,facility,outpatient,,,537.00000,155.73000,Aetna,Local,,272.63,,,,,,,114.65,439.27,percent of total billed charges,
Reflex Lyme Modified 2 Tier Testing,9013646,CDM,300,RC,86618,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,15.79,59.71,percent of total billed charges,
86618 Lyme Modified Two Tier Testing,9013647,CDM,300,RC,86618,HCPCS,,,facility,outpatient,,,73.00000,21.17000,Aetna,Local,,37.06,,,,,,,15.79,59.71,percent of total billed charges,
Thiopurine Metabolites,9013653,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,219.00000,63.51000,Aetna,Local,,111.19,,,,,,,17.28,179.14,percent of total billed charges,
Voltage Gated Potassium Channel Ab,9011734,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,354.00000,102.66000,Aetna,Local,,179.73,,,,,,,17.06,289.57,percent of total billed charges,
VGKC Ab with Reflex,9014540,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,354.00000,102.66000,Aetna,Local,,179.73,,,,,,,17.06,289.57,percent of total billed charges,
Bill 88342 IHC Initial Stain Neogenomics,9014173,CDM,300,RC,88342,HCPCS,,,facility,outpatient,,,252.00000,73.08000,Aetna,Local,,127.94,,,,,,,84.70,452.20,percent of total billed charges,
Bill 88341 IHC Additional Stain Neogenomics,9011763,CDM,300,RC,88341,HCPCS,,,facility,outpatient,,,252.00000,73.08000,Aetna,Local,,127.94,,,,,,,90.85,206.14,percent of total billed charges,
Bill 88364 IHC by ISH Additional Neogenomics,9011770,CDM,300,RC,88364,HCPCS,,,facility,outpatient,,,428.00000,124.12000,Aetna,Local,,217.30,,,,,,,139.10,350.10,percent of total billed charges,
Bill 88365 IHC by ISH Neogenomics,9014186,CDM,300,RC,88365,HCPCS,,,facility,outpatient,,,428.00000,124.12000,Aetna,Local,,217.30,,,,,,,121.31,452.20,percent of total billed charges,
Bill 88360 IHC Quant Neogenomics,9014192,CDM,300,RC,88360,HCPCS,,,facility,outpatient,,,306.00000,88.74000,Aetna,Local,,155.36,,,,,,,104.47,452.20,percent of total billed charges,
Vitamin B3,9014320,CDM,300,RC,84591,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,Local,,130.99,,,,,,,15.43,211.04,percent of total billed charges,
"Copper, Liver, Tissue",9011890,CDM,300,RC,82525,HCPCS,,,facility,outpatient,,,268.00000,77.72000,Aetna,Local,,136.06,,,,,,,11.51,219.22,percent of total billed charges,
86255 LGI1 and CASPRA2 IgG,9014551,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,,95.96,,,,,,,11.18,154.60,percent of total billed charges,
"LGI1 and CASPR2 Abs, IgG by CBA-IFA with Reflex to Titer, Se",9016155,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,,95.96,,,,,,,11.18,154.60,percent of total billed charges,
CASPR2 IgG Titer,9014558,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,219.00000,63.51000,Aetna,Local,,111.19,,,,,,,11.18,179.14,percent of total billed charges,
LGI1 Ab IgG Titer,9016167,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,242.00000,70.18000,Aetna,Local,,122.86,,,,,,,11.18,197.96,percent of total billed charges,
LipoFit by NMR,9016179,CDM,300,RC,83704,HCPCS,,,facility,outpatient,,,102.00000,29.58000,Aetna,Local,,51.79,,,,,,,23.54,90.60,percent of total billed charges,
80061 LipoFit by NMR,9014577,CDM,300,RC,80061,HCPCS,,,facility,outpatient,,,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,12.41,35.48,percent of total billed charges,
NMDA Receptor Ab,9016218,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,232.00000,67.28000,Aetna,Local,,117.79,,,,,,,11.18,189.78,percent of total billed charges,
Autoimmune Neuromuscular Junction Reflexive Panel,9016248,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,11.18,110.43,percent of total billed charges,
83519 Autoimmune Neuromuscular Junction Panel,9014619,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,202.00000,58.58000,Aetna,Local,,102.56,,,,,,,17.06,165.24,percent of total billed charges,
83516 Autoimmune Neuromuscular Junction Panel,9014620,CDM,300,RC,83516,HCPCS,,,facility,outpatient,,,121.00000,35.09000,Aetna,Local,,61.43,,,,,,,10.69,98.98,percent of total billed charges,
86596 Autoimmune Neuromuscular Junction Panel,9016262,CDM,300,RC,86596,HCPCS,,,facility,outpatient,,,135.00000,39.15000,Aetna,Local,,68.54,,,,,,,11.18,110.43,percent of total billed charges,
AChR Modulation Flow Cytometry Serum,8433966,CDM,300,RC,86043,HCPCS,,,facility,outpatient,,,231.00000,66.99000,Aetna,Local,,117.28,,,,,,,11.18,188.96,percent of total billed charges,
86041 Autoimmune Neuromuscular Junction Panel,9042795,CDM,300,RC,86041,HCPCS,,,facility,outpatient,,,202.00000,58.58000,Aetna,Local,,102.56,,,,,,,17.06,165.24,percent of total billed charges,
86042 Autoimmune Neuromuscular Junction Panel,9040626,CDM,300,RC,86042,HCPCS,,,facility,outpatient,,,202.00000,58.58000,Aetna,Local,,102.56,,,,,,,17.06,165.24,percent of total billed charges,
BCR ABL1 Diagnostic Non Standard p230 Qual Neogenomics ZB49L,9090307,CDM,300,RC,81208,HCPCS,,,facility,outpatient,,,412.00000,119.48000,Aetna,Local,,209.17,,,,,,,193.64,568.74,percent of total billed charges,
BCR ABL1 Kinase Domain Mutation Analysis Neogenomics ZBY98,9090317,CDM,300,RC,81170,HCPCS,,,facility,outpatient,,,731.00000,211.99000,Aetna,Local,,371.13,,,,,,,278.10,795.00,percent of total billed charges,
Mumps Virus Qualitative PCR,9088663,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,Local,,126.92,,,,,,,32.53,204.50,percent of total billed charges,
HIV 1 and 2 by Qualitative NAAT,9092926,CDM,300,RC,87535,HCPCS,,,facility,outpatient,,,118.00000,34.22000,Aetna,Local,,59.91,,,,,,,32.53,96.52,percent of total billed charges,
KLHL11Ab IgG CBA IFA Serum,9103694,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,11.18,305.93,percent of total billed charges,
KLHL11 Ab IgG CBA IFA CSF,9103695,CDM,300,RC,86255,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,11.18,305.93,percent of total billed charges,
KLHL11 Ab IgG CBA IFA Titer CSF,9103699,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,435.00000,126.15000,Aetna,Local,,220.85,,,,,,,11.18,355.83,percent of total billed charges,
KLHL11 Ab IgG CBA IFA Titer Serum,9103700,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,435.00000,126.15000,Aetna,Local,,220.85,,,,,,,11.18,355.83,percent of total billed charges,
Coxsackie A Antibodies,9103525,CDM,300,RC,86658,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,6.68,34.53,percent of total billed charges,
86658 Coxsackie Ab,9103535,CDM,300,RC,86658,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,6.68,34.53,percent of total billed charges,
84182 Protein Western Blot,9104887,CDM,300,RC,84182,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,Local,,32.49,,,,,,,23.95,77.41,percent of total billed charges,
Extended Myositis Panel,8464159,CDM,300,RC,86039,HCPCS,,,facility,outpatient,,,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,10.34,29.57,percent of total billed charges,
Vaginosis Panel by TMA,8344406,CDM,300,RC,81513,HCPCS,,,facility,outpatient,,,164.00000,47.56000,Aetna,Local,,83.26,,,,,,,77.08,377.97,percent of total billed charges,
87481 Candida Species by TMA,8344420,CDM,300,RC,87481,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,Local,,20.31,,,,,,,18.80,92.99,percent of total billed charges,
87661 Trichomonas vaginalis by TMA,8344421,CDM,300,RC,87661,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,Local,,20.31,,,,,,,18.80,92.99,percent of total billed charges,
"Alzheimer?s Disease Evaluation, CSF",8346295,CDM,300,RC,84393,HCPCS,,,facility,outpatient,,,732.00000,212.28000,Aetna,Local,,371.64,,,,,,,128.92,598.78,percent of total billed charges,
84394 Alzheimer's Disease Eval,9101318,CDM,300,RC,84394,HCPCS,,,facility,outpatient,,,732.00000,212.28000,Aetna,Local,,371.64,,,,,,,128.92,598.78,percent of total billed charges,
82234 Alzheimer's Disease Eval,9103652,CDM,300,RC,82234,HCPCS,,,facility,outpatient,,,732.00000,212.28000,Aetna,Local,,371.64,,,,,,,128.92,598.78,percent of total billed charges,
Bill erm41Molecular Detection,9101347,CDM,300,RC,87999,HCPCS,,,facility,outpatient,,,663.00000,192.27000,Aetna,Local,,336.61,,,,,,,239.01,542.33,percent of total billed charges,
JAK2 Exon 12 Analysis CSI ZB6SB,9104403,CDM,300,RC,81279,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,Local,,108.14,,,,,,,100.11,490.78,percent of total billed charges,
"14 3 3 eta Protein, Serum",8247878,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,16.01,126.79,percent of total billed charges,
5 Flucytosine Serum,9092959,CDM,300,RC,80299,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,Local,,108.14,,,,,,,17.28,174.23,percent of total billed charges,
Cystatin and Creatinine with eGFR,9092950,CDM,300,RC,82610,HCPCS,,,facility,outpatient,,,120.00000,34.80000,Aetna,Local,,60.92,,,,,,,17.17,98.16,percent of total billed charges,
82565 Cystatin and Creatinine with eGFR,9092951,CDM,300,RC,82565,HCPCS,,,facility,outpatient,,,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,4.75,27.81,percent of total billed charges,
Cashew Component rAna o3,9094578,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,16.62,122.70,percent of total billed charges,
Walnut Component IgE,9094762,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,16.62,122.70,percent of total billed charges,
Walnut Component IgE,9094766,CDM,300,RC,86008,HCPCS,,,facility,outpatient,,,150.00000,43.50000,Aetna,Local,,76.16,,,,,,,16.62,122.70,percent of total billed charges,
von Willebrand Factor Multimers,9093122,CDM,300,RC,85247,HCPCS,,,facility,outpatient,,,172.00000,49.88000,Aetna,Local,,87.32,,,,,,,21.27,140.70,percent of total billed charges,
87538 HIV 2 Probe,9093843,CDM,300,RC,87538,HCPCS,,,facility,outpatient,,,118.00000,34.22000,Aetna,Local,,59.91,,,,,,,32.53,96.52,percent of total billed charges,
Osmotic Fragility Erythrocyte,9105265,CDM,300,RC,85555,HCPCS,,,facility,outpatient,,,186.00000,53.94000,Aetna,Local,,94.43,,,,,,,6.92,152.15,percent of total billed charges,
RBC Band 3 Protein Reduction in Hereditary Spherocytosis,9105266,CDM,300,RC,88184,HCPCS,,,facility,outpatient,,,258.00000,74.82000,Aetna,Local,,130.99,,,,,,,47.66,951.40,percent of total billed charges,
Solid Tumor Profile NGS Z01SA,9108886,CDM,300,RC,81479,HCPCS,,,facility,outpatient,,,3230.00000,936.70000,Aetna,Local,,1639.87,,,,,,,1164.41,2642.14,percent of total billed charges,
HPV High Risk Rflx to Genotype,9109069,CDM,300,RC,87624,HCPCS,,,facility,outpatient,,,153.00000,44.37000,Aetna,Local,,77.68,,,,,,,32.53,125.15,percent of total billed charges,
HPV Genotype 16 18.45,9109070,CDM,300,RC,87625,HCPCS,,,facility,outpatient,,,145.00000,42.05000,Aetna,Local,,73.62,,,,,,,37.59,118.61,percent of total billed charges,
PAP Pathologist Review,9109013,CDM,300,RC,88141,HCPCS,,,facility,outpatient,,,158.00000,45.82000,Aetna,Local,,80.22,,,,,,,21.36,129.24,percent of total billed charges,
Neurofilament Lighe Chain Plasma,9109513,CDM,300,RC,0361U,HCPCS,,,facility,outpatient,,,1461.00000,423.69000,Aetna,Local,,741.75,,,,,,,526.69,1195.10,percent of total billed charges,
Powassan Virus PCR Serum,9118490,CDM,300,RC,87798,HCPCS,,,facility,outpatient,,,911.00000,264.19000,Aetna,Local,,462.51,,,,,,,32.53,745.20,percent of total billed charges,
"Phospho Tau 217,Plasma",9122399,CDM,300,RC,84393,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,128.92,593.05,percent of total billed charges,
"Anti Mutated Citrullinated Vimentin,Ab",9122398,CDM,300,RC,83520,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,Local,,128.45,,,,,,,16.01,206.95,percent of total billed charges,
Hemoglobin S Sickle Solubility,9122395,CDM,300,RC,85660,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,Local,,68.03,,,,,,,5.11,109.61,percent of total billed charges,
Chromosome Analysis Peripheral Blood,3232942,CDM,300,RC,88262,HCPCS,,,facility,outpatient,,,288.00000,83.52000,Aetna,Local,,146.22,,,,,,,116.33,332.55,percent of total billed charges,
88230 Tissue Cult Lymph,9132514,CDM,300,RC,88230,HCPCS,,,facility,outpatient,,,265.00000,76.85000,Aetna,Local,,134.54,,,,,,,32.36,308.70,percent of total billed charges,
Bill Lymph Non Neo Processing Fee 93267,9132524,CDM,300,RC,88230,HCPCS,,,facility,outpatient,,,116.00000,33.64000,Aetna,Local,,58.89,,,,,,,32.36,308.70,percent of total billed charges,
Bill Counts 5 1 Karyotype 93261,9132525,CDM,300,RC,88261,HCPCS,,,facility,outpatient,,,264.00000,76.56000,Aetna,Local,,134.03,,,,,,,124.08,700.50,percent of total billed charges,
Bill/Interp and Reporting 93252,9132526,CDM,300,RC,88291,HCPCS,,,facility,outpatient,,,105.00000,30.45000,Aetna,Local,,53.31,,,,,,,25.72,85.89,percent of total billed charges,
Bill 88369 FISH-CSI,9132395,CDM,300,RC,88369,HCPCS,,,facility,outpatient,,,223.00000,64.67000,Aetna,Local,,113.22,,,,,,,80.39,182.41,percent of total billed charges,
Neisseria gonorrhoeae by TMA,8297037,CDM,300,RC,87591,HCPCS,,,facility,outpatient,,,149.00000,43.21000,Aetna,Local,,75.65,,,,,,,32.53,121.88,percent of total billed charges,
MICROBE SUSCEPTIBLE MIC,9132532,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,Local,,126.92,,,,,,,8.02,204.50,percent of total billed charges,
"Vedolizumab Quant w Antibodies, Serum",9132502,CDM,300,RC,80280,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,35.75,288.75,percent of total billed charges,
82397 Vedolizumab,9142151,CDM,300,RC,82397,HCPCS,,,facility,outpatient,,,128.00000,37.12000,Aetna,Local,,64.99,,,,,,,13.09,104.70,percent of total billed charges,
Bill/Susceptibility single drug by broth dilution,9142228,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,,103.06,,,,,,,8.02,166.05,percent of total billed charges,
Bill/Susceptibility broth dilution auto read,9142229,CDM,300,RC,87186,HCPCS,,,facility,outpatient,,,203.00000,58.87000,Aetna,Local,,103.06,,,,,,,8.02,166.05,percent of total billed charges,
APOLIPOPROTEIN B,8356387,CDM,300,RC,82172,HCPCS,,,facility,outpatient,,,146.00000,42.34000,Aetna,Local,,74.12,,,,,,,19.55,119.43,percent of total billed charges,
Helicobacter pylori Urea Breath Test,8342253,CDM,300,RC,83013,HCPCS,,,facility,outpatient,,,183.00000,53.07000,Aetna,Local,,92.91,,,,,,,62.44,178.50,percent of total billed charges,
Amyloid Beta,9176399,CDM,300,RC,83519,HCPCS,,,facility,outpatient,,,527.00000,152.83000,Aetna,Local,,267.56,,,,,,,17.06,431.09,percent of total billed charges,
Copeptin proAVP,8451941,CDM,300,RC,84588,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,Local,,78.69,,,,,,,31.47,126.79,percent of total billed charges,
PAP Digital Imaging Review,9190449,CDM,300,RC,88175,HCPCS,,,facility,outpatient,,,156.00000,45.24000,Aetna,Local,,79.20,,,,,,,24.67,127.61,percent of total billed charges,
Leishmania Ab IgG,9180614,CDM,300,RC,86717,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,7.68,88.34,percent of total billed charges,
Valproic Acid Total,8356297,CDM,300,RC,80164,HCPCS,,,facility,outpatient,,,86.00000,24.94000,Aetna,Local,,43.66,,,,,,,12.56,70.35,percent of total billed charges,
PAP Manual Review,9190450,CDM,300,RC,88142,HCPCS,,,facility,outpatient,,,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,10.39,128.43,percent of total billed charges,
HPV Screen PCR,9192443,CDM,300,RC,87626,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,65.08,305.93,percent of total billed charges,
Prion Markers 1433 Gamma Bill,9210716,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,13.89,114.52,percent of total billed charges,
Prion Markers Total Tau Bill,9210715,CDM,300,RC,86317,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,13.89,114.52,percent of total billed charges,
REFLEX LYMPHOCYTE NON NEOPLASIC BILL,9222442,CDM,300,RC,88230,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,Local,,126.92,,,,,,,32.36,308.70,percent of total billed charges,
"REFLEX COUNT 5,1 KARYOTYPE BILL",9222443,CDM,300,RC,88261,HCPCS,,,facility,outpatient,,,249.00000,72.21000,Aetna,Local,,126.42,,,,,,,117.03,700.50,percent of total billed charges,
REFLEX INTERPRETATION AND REPORTING BILL,9222444,CDM,300,RC,88291,HCPCS,,,facility,outpatient,,,250.00000,72.50000,Aetna,Local,,126.92,,,,,,,25.72,204.50,percent of total billed charges,
Fatty Acids Profile,9178429,CDM,300,RC,82542,HCPCS,,,facility,outpatient,,,617.00000,178.93000,Aetna,Local,,313.25,,,,,,,11.66,504.71,percent of total billed charges,
81405 Prometheus IBD sgi diagnositic ZB25M,9180514,CDM,300,RC,81405,HCPCS,,,facility,outpatient,,,302.00000,87.58000,Aetna,Local,,153.33,,,,,,,141.94,798.58,percent of total billed charges,
80165 Valproic Acid Free,9184458,CDM,300,RC,80165,HCPCS,,,facility,outpatient,,,86.00000,24.94000,Aetna,Local,,43.66,,,,,,,12.56,70.35,percent of total billed charges,
T Uptake ARUP,9002340,CDM,300,RC,84479,HCPCS,,,facility,outpatient,,,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,5.99,125.97,percent of total billed charges,
mGluR1 Ab IFA Titer Serum,8914185,CDM,300,RC,86256,HCPCS,,,facility,outpatient,,,108.00000,31.32000,Aetna,Local,,54.83,,,,,,,11.18,88.34,percent of total billed charges,
THERAPIST ABG DRAW,8070818,CDM,300,RC,36600,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,Local,,96.46,,,,,,,76.00,2860.00,percent of total billed charges,
DYSAUTONOMIA EVAL BY RIA,8121236,CDM,300,RC,,,,,facility,outpatient,,,221.00000,64.09000,Aetna,Local,,112.20,,,,,,,79.67,180.78,percent of total billed charges,
Pain Management Fluoro 320,8151453,CDM,320,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,432.60,981.60,percent of total billed charges,
Fluoro Guidance,8062811,CDM,320,RC,,,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,761.55,,,,,,,540.75,1227.00,percent of total billed charges,
RA Mandible Minimum 4 Views,613973,CDM,320,RC,70110,HCPCS,,,facility,outpatient,,,588.00000,170.52000,Aetna,Local,,298.53,,,,,,,23.44,480.98,percent of total billed charges,
RA Orbits Foreign Body,614071,CDM,320,RC,70030,HCPCS,,,facility,outpatient,,,313.00000,90.77000,Aetna,Local,,158.91,,,,,,,15.64,256.03,percent of total billed charges,
RA Sinuses 1 or 2 Views,614223,CDM,320,RC,70210,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,Local,,204.60,,,,,,,23.44,329.65,percent of total billed charges,
RA Sinuses Minimum 3 Views,614229,CDM,320,RC,70220,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,Local,,335.59,,,,,,,29.48,540.70,percent of total billed charges,
RA Neck Soft Tissue,614040,CDM,320,RC,70360,HCPCS,,,facility,outpatient,,,393.00000,113.97000,Aetna,Local,,199.53,,,,,,,15.64,321.47,percent of total billed charges,
RA Chest Single View,8001025,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Ribs Unilateral Right,7920867,CDM,320,RC,71101,HCPCS,,,facility,outpatient,,,572.00000,165.88000,Aetna,Local,RT,290.40,,,,,,,25.22,467.90,percent of total billed charges,
RA Ribs Unilateral Left,7920859,CDM,320,RC,71101,HCPCS,,,facility,outpatient,,,572.00000,165.88000,Aetna,Local,LT,290.40,,,,,,,25.22,467.90,percent of total billed charges,
RA Mandible Less than 4 Views,613979,CDM,320,RC,70100,HCPCS,,,facility,outpatient,,,413.00000,119.77000,Aetna,Local,,209.68,,,,,,,19.19,337.83,percent of total billed charges,
RA Ribs Bilateral w PA Chest,7920875,CDM,320,RC,71111,HCPCS,,,facility,outpatient,,,763.00000,221.27000,Aetna,Local,,387.38,,,,,,,33.74,624.13,percent of total billed charges,
RA Sternum Minimum 2 Views,614259,CDM,320,RC,71120,HCPCS,,,facility,outpatient,,,454.00000,131.66000,Aetna,Local,,230.50,,,,,,,24.51,371.37,percent of total billed charges,
RA Ankle 2 Views Right,2052836,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,Local,RT,200.54,,,,,,,18.12,323.11,percent of total billed charges,
RA Ankle 2 Views Left,2052834,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,Local,LT,200.54,,,,,,,18.12,323.11,percent of total billed charges,
RA Facial Bones 1 or 2 Views,613736,CDM,320,RC,70140,HCPCS,,,facility,outpatient,,,473.00000,137.17000,Aetna,Local,,240.14,,,,,,,23.44,386.91,percent of total billed charges,
RA Spine 1 View,2052838,CDM,320,RC,72020,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,Local,,204.60,,,,,,,15.64,329.65,percent of total billed charges,
RA Spine 1 View,6043847,CDM,320,RC,72020,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,Local,,204.60,,,,,,,15.64,329.65,percent of total billed charges,
RA Spine 1 View,613633,CDM,320,RC,72020,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,Local,,204.60,,,,,,,15.64,329.65,percent of total billed charges,
RA Spine 1 View,7908918,CDM,320,RC,72020,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,Local,,204.60,,,,,,,15.64,329.65,percent of total billed charges,
RA Facial Bones Minimum 3 Views,613734,CDM,320,RC,70150,HCPCS,,,facility,outpatient,,,692.00000,200.68000,Aetna,Local,,351.33,,,,,,,29.48,566.06,percent of total billed charges,
RA Nasal Bones Minimum 3 Views,614036,CDM,320,RC,70160,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,Local,,238.62,,,,,,,19.19,384.46,percent of total billed charges,
RA Sterno Clavicular Joints Minimum 3V,614255,CDM,320,RC,71130,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,,193.94,,,,,,,26.65,312.48,percent of total billed charges,
RA Hip Arthrogram Left,7253886,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Hip Arthrogram Left,7957020,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Orbits Minimum 4 Views,614063,CDM,320,RC,70200,HCPCS,,,facility,outpatient,,,556.00000,161.24000,Aetna,Local,,282.28,,,,,,,29.48,454.81,percent of total billed charges,
RA Skull Less than 4 Views,614237,CDM,320,RC,70250,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,23.44,420.45,percent of total billed charges,
RA Skull Minimum 4 Views,614233,CDM,320,RC,70260,HCPCS,,,facility,outpatient,,,733.00000,212.57000,Aetna,Local,,372.14,,,,,,,33.74,599.59,percent of total billed charges,
RA Temporal Mandibular Joint,614269,CDM,320,RC,70330,HCPCS,,,facility,outpatient,,,556.00000,161.24000,Aetna,Local,,282.28,,,,,,,31.62,454.81,percent of total billed charges,
RA Thoracolumbar 2 Views,3661907,CDM,320,RC,72080,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,25.22,420.45,percent of total billed charges,
RA Osseous Survery Complete,613998,CDM,320,RC,77075,HCPCS,,,facility,outpatient,,,733.00000,212.57000,Aetna,Local,,372.14,,,,,,,93.38,599.59,percent of total billed charges,
RA Osseous Survey Complete,661540,CDM,320,RC,77075,HCPCS,,,facility,outpatient,,,733.00000,212.57000,Aetna,Local,,372.14,,,,,,,93.38,599.59,percent of total billed charges,
RA Bone Mineral Analysis Dexa,7544174,CDM,320,RC,77075,HCPCS,,,facility,outpatient,,,733.00000,212.57000,Aetna,Local,,372.14,,,,,,,93.38,599.59,percent of total billed charges,
RA Knee 3 Views Left,7253922,CDM,320,RC,73562,HCPCS,,,facility,outpatient,,,464.00000,134.56000,Aetna,Local,LT,235.57,,,,,,,21.67,379.55,percent of total billed charges,
RA Knee Right 4 or More Views,7235923,CDM,320,RC,73564,HCPCS,,,facility,outpatient,,,560.00000,162.40000,Aetna,Local,RT,284.31,,,,,,,23.44,458.08,percent of total billed charges,
RA Knee Left 4 or More Views,7235919,CDM,320,RC,73564,HCPCS,,,facility,outpatient,,,560.00000,162.40000,Aetna,Local,LT,284.31,,,,,,,23.44,458.08,percent of total billed charges,
RA Ribs Unilateral Right 2 Views,7920871,CDM,320,RC,71100,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,RT,223.90,,,,,,,21.67,360.74,percent of total billed charges,
RA Ribs Unilateral Left 2 Views,7920863,CDM,320,RC,71100,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,LT,223.90,,,,,,,21.67,360.74,percent of total billed charges,
RA Ribs Bilateral 3 Views,7920879,CDM,320,RC,71110,HCPCS,,,facility,outpatient,,,529.00000,153.41000,Aetna,Local,,268.57,,,,,,,29.48,432.72,percent of total billed charges,
RA Thoracic Spine 2 Views,7790074,CDM,320,RC,72070,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,24.51,420.45,percent of total billed charges,
RA Scoliosis Study 2 or 3 Views,614199,CDM,320,RC,72082,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,,223.90,,,,,,,65.38,360.74,percent of total billed charges,
RA Lumbar Spine Minimum 6 Views,7903303,CDM,320,RC,72114,HCPCS,,,facility,outpatient,,,880.00000,255.20000,Aetna,Local,,446.78,,,,,,,44.41,719.84,percent of total billed charges,
RA Cervical Spine 6 or more Views,6439864,CDM,320,RC,72052,HCPCS,,,facility,outpatient,,,821.00000,238.09000,Aetna,Local,,416.82,,,,,,,42.28,671.58,percent of total billed charges,
RA Ankle Arthrogram Left,7253859,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Ankle Arthrogram Left,7957003,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Joint Aspiration Left,7253898,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Ankle Arthrogram Right,7235862,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Ankle Arthrogram Right,7957005,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Elbow Right Minimum 3 Views,7235866,CDM,320,RC,73080,HCPCS,,,facility,outpatient,,,443.00000,128.47000,Aetna,Local,RT,224.91,,,,,,,21.67,362.37,percent of total billed charges,
RA Elbow Arthrogram Right,7235868,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Elbow Arthrogram Right,7957014,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Foot 2 Views Right,7235872,CDM,320,RC,73620,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,RT,193.94,,,,,,,18.12,312.48,percent of total billed charges,
RA Hand 2 Views Right,7253879,CDM,320,RC,73120,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,Local,RT,186.33,,,,,,,18.12,300.21,percent of total billed charges,
RA Hip Arthrogram Right,7235878,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Hip Arthrogram Right,7957022,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Joint Aspiration Right,7235890,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Knee Arthrogram Right,7235894,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Knee Arthrogram Right,7957030,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Shoulder Arthrogram Right,7235898,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Shoulder Arthrogram Right,7957038,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Shoulder 1 View Right,7235902,CDM,320,RC,73020,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,RT,193.94,,,,,,,17.41,312.48,percent of total billed charges,
RA Wrist 2 Views Right,7235906,CDM,320,RC,73100,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,RT,193.94,,,,,,,18.12,312.48,percent of total billed charges,
RA Wrist Arthrogram Right,7235911,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Wrist Arthrogram Right,7957046,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Joint Injection Fluoroscopy Guide,7286039,CDM,320,RC,,,,,facility,outpatient,,,5214.00000,1512.06000,Aetna,Local,,2647.15,,,,,,,1879.65,4265.05,percent of total billed charges,
RA Cervical Spine 2 or 3 Views,7790082,CDM,320,RC,72040,HCPCS,,,facility,outpatient,,,674.00000,195.46000,Aetna,Local,,342.19,,,,,,,22.73,551.33,percent of total billed charges,
RA Cervical Spine 4 or 5 Views,613625,CDM,320,RC,72050,HCPCS,,,facility,outpatient,,,821.00000,238.09000,Aetna,Local,,416.82,,,,,,,33.74,671.58,percent of total billed charges,
RA Thoracic Spine 3 Views,7790078,CDM,320,RC,72072,HCPCS,,,facility,outpatient,,,600.00000,174.00000,Aetna,Local,,304.62,,,,,,,27.71,490.80,percent of total billed charges,
RA Lumbar Spine 2 or 3 Views,7903293,CDM,320,RC,72100,HCPCS,,,facility,outpatient,,,572.00000,165.88000,Aetna,Local,,290.40,,,,,,,25.22,467.90,percent of total billed charges,
RA Lumbar Spine Minimum 4 Views,7903299,CDM,320,RC,72110,HCPCS,,,facility,outpatient,,,808.00000,234.32000,Aetna,Local,,410.22,,,,,,,34.46,660.94,percent of total billed charges,
RA Lumbar Spine Bending 2 or 3 Views,613952,CDM,320,RC,72120,HCPCS,,,facility,outpatient,,,572.00000,165.88000,Aetna,Local,,290.40,,,,,,,33.74,467.90,percent of total billed charges,
RA Pelvis 1 or 2 Views,613831,CDM,320,RC,72170,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,19.19,348.47,percent of total billed charges,
RA Pelvis 1 or 2 Views,7908906,CDM,320,RC,72170,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,19.19,348.47,percent of total billed charges,
RA Ankle Left 1 View,7938559,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,"LT,52",160.43,,,,,,,18.12,258.49,percent of total billed charges,
RA Ankle Right 1 View,7938563,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,316.00000,91.64000,Aetna,Local,"RT,52",160.43,,,,,,,18.12,258.49,percent of total billed charges,
RA Elbow Left 1 View,7938567,CDM,320,RC,73070,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,"52,LT",154.85,,,,,,,19.19,249.49,percent of total billed charges,
RA Elbow Right 1 View,7938571,CDM,320,RC,73070,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,"52,RT",154.85,,,,,,,19.19,249.49,percent of total billed charges,
RA Foot Left 1 View,7938575,CDM,320,RC,73620,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,"52,LT",154.85,,,,,,,18.12,249.49,percent of total billed charges,
RA Foot Right 1 View,7938579,CDM,320,RC,73620,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,"52,RT",154.85,,,,,,,18.12,249.49,percent of total billed charges,
RA Forearm Left 1 View,7938583,CDM,320,RC,73090,HCPCS,,,facility,outpatient,,,340.00000,98.60000,Aetna,Local,"LT,52",172.62,,,,,,,19.19,278.12,percent of total billed charges,
RA Forearm Right 1 View,7938587,CDM,320,RC,73090,HCPCS,,,facility,outpatient,,,340.00000,98.60000,Aetna,Local,"52,RT",172.62,,,,,,,19.19,278.12,percent of total billed charges,
RA Hand Left 1 View,7938591,CDM,320,RC,73120,HCPCS,,,facility,outpatient,,,293.00000,84.97000,Aetna,Local,"52,LT",148.76,,,,,,,18.12,283.84,percent of total billed charges,
RA Hand Right 1 View,7938595,CDM,320,RC,73120,HCPCS,,,facility,outpatient,,,293.00000,84.97000,Aetna,Local,"RT,52",148.76,,,,,,,18.12,283.84,percent of total billed charges,
RA Humerus Left 1 View,7938599,CDM,320,RC,73060,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,"52,LT",223.90,,,,,,,21.67,360.74,percent of total billed charges,
RA Humerus Right 1 View,7938603,CDM,320,RC,73060,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,"52,RT",223.90,,,,,,,21.67,360.74,percent of total billed charges,
RA Lower Leg Left 1 View,7938607,CDM,320,RC,73590,HCPCS,,,facility,outpatient,,,357.00000,103.53000,Aetna,Local,"52,LT",181.25,,,,,,,19.19,292.03,percent of total billed charges,
RA Lower Leg Right 1 View,7938611,CDM,320,RC,73590,HCPCS,,,facility,outpatient,,,357.00000,103.53000,Aetna,Local,"52,RT",181.25,,,,,,,19.19,292.03,percent of total billed charges,
RA Wrist Left 1 View,7938615,CDM,320,RC,73100,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,"LT,52",154.85,,,,,,,18.12,249.49,percent of total billed charges,
RA Wrist Right 1 View,7938619,CDM,320,RC,73100,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,"RT,52",154.85,,,,,,,18.12,249.49,percent of total billed charges,
RA Clavicle Left 1 View,7938623,CDM,320,RC,73000,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,"LT,52",223.90,,,,,,,19.19,360.74,percent of total billed charges,
RA Clavicle Right 1 View,7938627,CDM,320,RC,73000,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,"52,RT",223.90,,,,,,,19.19,360.74,percent of total billed charges,
RA Fingers Left 1 View,7938631,CDM,320,RC,73140,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,Local,"52,LT",142.66,,,,,,,15.64,235.00,percent of total billed charges,
RA Fingers Right 1 View,7938635,CDM,320,RC,73140,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,Local,"52,RT",142.66,,,,,,,15.64,235.00,percent of total billed charges,
RA Heel Left 1 View,7938639,CDM,320,RC,73650,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,"LT,52",154.85,,,,,,,17.41,249.49,percent of total billed charges,
RA Heel Right 1 View,7938643,CDM,320,RC,73650,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,"RT,52",154.85,,,,,,,17.41,249.49,percent of total billed charges,
RA Lower Extremity Infant Left 1 View,7938436,CDM,320,RC,73592,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,Local,"52,LT",137.59,,,,,,,18.12,235.00,percent of total billed charges,
RA Lower Extremity Infant Right 1 View,7938440,CDM,320,RC,73592,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,Local,"RT,52",137.59,,,,,,,18.12,235.00,percent of total billed charges,
RA Toes Left 1 View,7938445,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,Local,"LT,52",137.59,,,,,,,15.64,235.00,percent of total billed charges,
RA Toes Right 1 View,7938449,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,271.00000,78.59000,Aetna,Local,"52,RT",137.59,,,,,,,15.64,235.00,percent of total billed charges,
RA Upper Extremity Infant Left 1 View,7938452,CDM,320,RC,73092,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,Local,"52,LT",142.66,,,,,,,18.12,283.84,percent of total billed charges,
RA Upper Extremity Infant LT Minimum 2V,7938457,CDM,320,RC,73092,HCPCS,,,facility,outpatient,,,352.00000,102.08000,Aetna,Local,"RT,52",178.71,,,,,,,18.12,287.94,percent of total billed charges,
RA Pelvis Minimum 3 Views,7908910,CDM,320,RC,72190,HCPCS,,,facility,outpatient,,,542.00000,157.18000,Aetna,Local,,275.17,,,,,,,25.22,443.36,percent of total billed charges,
RA Sacro  Iliac Joints 1 or 2 Views,654419,CDM,320,RC,72200,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,Local,,186.33,,,,,,,19.19,300.21,percent of total billed charges,
RA Sacro Iliac Joints 3 Views,614173,CDM,320,RC,72202,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,Local,,238.62,,,,,,,23.44,384.46,percent of total billed charges,
RA Sacrum and Coccyx Minimum 2 Views,614181,CDM,320,RC,72220,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,Local,,238.62,,,,,,,21.67,384.46,percent of total billed charges,
RA Knee 4 views Bilat,8156274,CDM,320,RC,73564,HCPCS,,,facility,outpatient,,,1120.00000,324.80000,Aetna,Local,,568.62,,,,,,,23.44,916.16,percent of total billed charges,
RA Femur Min 2 Views Bilat,8156282,CDM,320,RC,73552,HCPCS,,,facility,outpatient,,,924.00000,267.96000,Aetna,Local,,469.11,,,,,,,32.46,755.83,percent of total billed charges,
RA Lower Extremity Infant Bilat Min 2V,8160991,CDM,320,RC,73592,HCPCS,,,facility,outpatient,,,678.00000,196.62000,Aetna,Local,,344.22,,,,,,,18.12,554.60,percent of total billed charges,
RA Shunt Survey,624996,CDM,320,RC,70250,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,23.44,420.45,percent of total billed charges,
RA Shunt Survey Spine,8001064,CDM,320,RC,72020,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,Local,,204.60,,,,,,,15.64,329.65,percent of total billed charges,
RA Shunt Survey Chest,8001065,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Shunt Survey Abdomen,8001066,CDM,320,RC,74018,HCPCS,,,facility,outpatient,,,412.00000,119.48000,Aetna,Local,,209.17,,,,,,,26.31,337.02,percent of total billed charges,
RA Sitzmark Study Initial Day,7974965,CDM,320,RC,74019,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,48.77,420.45,percent of total billed charges,
RA Chest 1 View,6043855,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,6043859,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,613659,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,641725,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,642145,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,7903287,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,7903291,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,7903307,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,7903311,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 1 View,7908818,CDM,320,RC,71045,HCPCS,,,facility,outpatient,,,353.00000,102.37000,Aetna,Local,,179.22,,,,,,,15.50,288.75,percent of total billed charges,
RA Chest 2 Views,6043867,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,613639,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,613651,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,613653,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,613661,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,614117,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 2 Views,7908822,CDM,320,RC,71046,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,28.38,348.47,percent of total billed charges,
RA Chest 4 Views,613645,CDM,320,RC,71048,HCPCS,,,facility,outpatient,,,533.00000,154.57000,Aetna,Local,,270.60,,,,,,,93.38,435.99,percent of total billed charges,
RA Abdomen 1 View,6043851,CDM,320,RC,74018,HCPCS,,,facility,outpatient,,,412.00000,119.48000,Aetna,Local,,209.17,,,,,,,26.31,337.02,percent of total billed charges,
RA Abdomen 1 View,613564,CDM,320,RC,74018,HCPCS,,,facility,outpatient,,,412.00000,119.48000,Aetna,Local,,209.17,,,,,,,26.31,337.02,percent of total billed charges,
RA Abdomen 2 Views,613566,CDM,320,RC,74019,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,48.77,420.45,percent of total billed charges,
RA Abdomen 2 Views,7900404,CDM,320,RC,74019,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,48.77,420.45,percent of total billed charges,
RA Abdomen 3 Views,1099805,CDM,320,RC,74021,HCPCS,,,facility,outpatient,,,542.00000,157.18000,Aetna,Local,,275.17,,,,,,,57.11,443.36,percent of total billed charges,
RA ERCP,7575990,CDM,320,RC,,,,,facility,outpatient,,,1217.00000,352.93000,Aetna,Local,,617.87,,,,,,,438.73,995.51,percent of total billed charges,
RA Knees Bilateral AP Standing Only,7920883,CDM,320,RC,73565,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,Local,,206.13,,,,,,,18.12,332.11,percent of total billed charges,
RA Scoliosis Study 1 View,7908914,CDM,320,RC,72081,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,,223.90,,,,,,,36.00,360.74,percent of total billed charges,
RA Hip Right 1 View,7908830,CDM,320,RC,73501,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,RT,171.60,,,,,,,28.91,276.48,percent of total billed charges,
RA Hip Right 1 View,7908854,CDM,320,RC,73501,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,RT,171.60,,,,,,,28.91,276.48,percent of total billed charges,
RA Hip Left 2 or 3 Views,7908834,CDM,320,RC,73502,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,Local,LT,200.54,,,,,,,42.59,323.11,percent of total billed charges,
RA Hip Left 2 or 3 Views,7908858,CDM,320,RC,73502,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,Local,LT,200.54,,,,,,,42.59,323.11,percent of total billed charges,
RA Hip Right 2 or 3 Views,7908838,CDM,320,RC,73502,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,Local,RT,200.54,,,,,,,42.59,323.11,percent of total billed charges,
RA HIp Right 2 or 3 Views,7908862,CDM,320,RC,73502,HCPCS,,,facility,outpatient,,,395.00000,114.55000,Aetna,Local,RT,200.54,,,,,,,42.59,323.11,percent of total billed charges,
RA Hips Bilateral 2 Views,7908842,CDM,320,RC,73521,HCPCS,,,facility,outpatient,,,790.00000,229.10000,Aetna,Local,,401.08,,,,,,,40.05,646.22,percent of total billed charges,
RA Hips Bilateral 3 to 4 Views,7908846,CDM,320,RC,73522,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,617.36,,,,,,,47.65,994.69,percent of total billed charges,
RA Femur Left 1 View,7908866,CDM,320,RC,73551,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,Local,LT,186.33,,,,,,,27.38,300.21,percent of total billed charges,
RA Femur Right 1 View,7908870,CDM,320,RC,73551,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,Local,RT,186.33,,,,,,,27.38,300.21,percent of total billed charges,
RA Femur Left Minimum 2 Views,7908874,CDM,320,RC,73552,HCPCS,,,facility,outpatient,,,462.00000,133.98000,Aetna,Local,LT,234.56,,,,,,,32.46,377.92,percent of total billed charges,
RA Femur Right Minimum 2 Views,7908878,CDM,320,RC,73552,HCPCS,,,facility,outpatient,,,462.00000,133.98000,Aetna,Local,RT,234.56,,,,,,,32.46,377.92,percent of total billed charges,
RA Hip Left 1 View,7908826,CDM,320,RC,73501,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,LT,171.60,,,,,,,28.91,276.48,percent of total billed charges,
RA Hip Left 1 View,7908850,CDM,320,RC,73501,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,LT,171.60,,,,,,,28.91,276.48,percent of total billed charges,
RA Clavicle Right,613667,CDM,320,RC,73000,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,RT,223.90,,,,,,,19.19,360.74,percent of total billed charges,
RA Clavicle Left,613665,CDM,320,RC,73000,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,LT,223.90,,,,,,,19.19,360.74,percent of total billed charges,
RA Scapula Right,614193,CDM,320,RC,73010,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,Local,RT,238.62,,,,,,,19.19,384.46,percent of total billed charges,
RA Scapula Left,614191,CDM,320,RC,73010,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,Local,LT,238.62,,,,,,,19.19,384.46,percent of total billed charges,
RA Shoulder 1 View Left,7253910,CDM,320,RC,73020,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,LT,193.94,,,,,,,17.41,312.48,percent of total billed charges,
RA Shoulder Right Minimum 2 Views,7912750,CDM,320,RC,73030,HCPCS,,,facility,outpatient,,,485.00000,140.65000,Aetna,Local,RT,246.23,,,,,,,21.67,396.73,percent of total billed charges,
RA Shoulder Left Minimum 2 Views,7912746,CDM,320,RC,73030,HCPCS,,,facility,outpatient,,,485.00000,140.65000,Aetna,Local,LT,246.23,,,,,,,21.67,396.73,percent of total billed charges,
RA Shoulder Arthrogram Left,7253906,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Shoulder Arthrogram Left,7957036,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Acromio Clavicular Joints,613570,CDM,320,RC,73050,HCPCS,,,facility,outpatient,,,431.00000,124.99000,Aetna,Local,,218.82,,,,,,,25.22,352.56,percent of total billed charges,
RA Humerus Right Minimum 2 Views,613839,CDM,320,RC,73060,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,RT,223.90,,,,,,,21.67,360.74,percent of total billed charges,
RA Humerus Left Minimum 2 Views,613835,CDM,320,RC,73060,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,LT,223.90,,,,,,,21.67,360.74,percent of total billed charges,
RA Elbow Right 2 Views,7912726,CDM,320,RC,73070,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,RT,193.94,,,,,,,19.19,312.48,percent of total billed charges,
RA Elbow Left 2 Views,7912722,CDM,320,RC,73070,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,LT,193.94,,,,,,,19.19,312.48,percent of total billed charges,
RA Elbow Left Minimum 3 Views,7253867,CDM,320,RC,73080,HCPCS,,,facility,outpatient,,,443.00000,128.47000,Aetna,Local,LT,224.91,,,,,,,21.67,362.37,percent of total billed charges,
RA Elbow Arthrogram Left,7253871,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Elbow Arthrogram Left,7957012,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Forearm Right 2 Views,613781,CDM,320,RC,73090,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,RT,216.28,,,,,,,19.19,348.47,percent of total billed charges,
RA Forearm Left 2 Views,613779,CDM,320,RC,73090,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,LT,216.28,,,,,,,19.19,348.47,percent of total billed charges,
RA Upper Extremity Infant RT Minimum 2V,614295,CDM,320,RC,73092,HCPCS,,,facility,outpatient,,,352.00000,102.08000,Aetna,Local,RT,178.71,,,,,,,18.12,287.94,percent of total billed charges,
RA Upper Extremity Infant LT Minimum 2V,614291,CDM,320,RC,73092,HCPCS,,,facility,outpatient,,,352.00000,102.08000,Aetna,Local,LT,178.71,,,,,,,18.12,287.94,percent of total billed charges,
RA Wrist 2 Views Left,7253914,CDM,320,RC,73100,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,LT,193.94,,,,,,,18.12,312.48,percent of total billed charges,
RA Wrist Right Minimum 3 Views,7912771,CDM,320,RC,73110,HCPCS,,,facility,outpatient,,,454.00000,131.66000,Aetna,Local,RT,230.50,,,,,,,19.55,371.37,percent of total billed charges,
RA Wrist Left Minimum 3 Views,7912767,CDM,320,RC,73110,HCPCS,,,facility,outpatient,,,454.00000,131.66000,Aetna,Local,LT,230.50,,,,,,,19.55,371.37,percent of total billed charges,
RA Wrist Arthrogram Left,7253918,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Wrist Arthrogram Left,7957044,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Hand 2 Views Left,7253881,CDM,320,RC,73120,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,Local,LT,186.33,,,,,,,18.12,300.21,percent of total billed charges,
RA Hand Right Minimum 3 Views,7912742,CDM,320,RC,73130,HCPCS,,,facility,outpatient,,,454.00000,131.66000,Aetna,Local,RT,230.50,,,,,,,19.55,371.37,percent of total billed charges,
RA Hand Left Minimum 3 Views,7912738,CDM,320,RC,73130,HCPCS,,,facility,outpatient,,,454.00000,131.66000,Aetna,Local,LT,230.50,,,,,,,19.55,371.37,percent of total billed charges,
RA Fingers Right Minimum 2 Views,613749,CDM,320,RC,73140,HCPCS,,,facility,outpatient,,,352.00000,102.08000,Aetna,Local,RT,178.71,,,,,,,15.64,287.94,percent of total billed charges,
RA Fingers Left Minimum 2 Views,613753,CDM,320,RC,73140,HCPCS,,,facility,outpatient,,,352.00000,102.08000,Aetna,Local,LT,178.71,,,,,,,15.64,287.94,percent of total billed charges,
RA Knee Right 1 or 2 Views,7908894,CDM,320,RC,73560,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,Local,RT,206.13,,,,,,,19.19,332.11,percent of total billed charges,
RA Knee Right 1 or 2 Views,7908902,CDM,320,RC,73560,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,Local,RT,206.13,,,,,,,19.19,332.11,percent of total billed charges,
RA Knee Left 1 or 2 Views,7908890,CDM,320,RC,73560,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,Local,LT,206.13,,,,,,,19.19,332.11,percent of total billed charges,
RA Knee Left 1 or 2 Views,7908898,CDM,320,RC,73560,HCPCS,,,facility,outpatient,,,406.00000,117.74000,Aetna,Local,LT,206.13,,,,,,,19.19,332.11,percent of total billed charges,
RA Knee 3 Views Right,7235915,CDM,320,RC,73562,HCPCS,,,facility,outpatient,,,464.00000,134.56000,Aetna,Local,RT,235.57,,,,,,,21.67,379.55,percent of total billed charges,
RA Knee Arthrogram Left,7253902,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Knee Arthrogram Left,7957028,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Lower Leg Right 2 Views,613935,CDM,320,RC,73590,HCPCS,,,facility,outpatient,,,447.00000,129.63000,Aetna,Local,RT,226.94,,,,,,,19.19,365.65,percent of total billed charges,
RA Lower Leg Left 2 Views,613928,CDM,320,RC,73590,HCPCS,,,facility,outpatient,,,447.00000,129.63000,Aetna,Local,LT,226.94,,,,,,,19.19,365.65,percent of total billed charges,
RA Lower Extremity Infant RT Minimum 2V,613921,CDM,320,RC,73592,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,Local,RT,172.11,,,,,,,18.12,277.30,percent of total billed charges,
RA Lower Extremity Infant LT Minimum 2V,613917,CDM,320,RC,73592,HCPCS,,,facility,outpatient,,,339.00000,98.31000,Aetna,Local,LT,172.11,,,,,,,18.12,277.30,percent of total billed charges,
RA Ankle Right Minimum 3 Views,7912716,CDM,320,RC,73610,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,Local,RT,238.62,,,,,,,19.55,384.46,percent of total billed charges,
RA Ankle Left Minimum 3 Views,7912712,CDM,320,RC,73610,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,Local,LT,238.62,,,,,,,19.55,384.46,percent of total billed charges,
RA Foot 2 Views Left,7253875,CDM,320,RC,73620,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,LT,193.94,,,,,,,18.12,312.48,percent of total billed charges,
RA Foot Right Minimum 3 Views,7912734,CDM,320,RC,73630,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,Local,RT,238.62,,,,,,,19.55,384.46,percent of total billed charges,
RA Foot Left Minimum 3 Views,7912730,CDM,320,RC,73630,HCPCS,,,facility,outpatient,,,470.00000,136.30000,Aetna,Local,LT,238.62,,,,,,,19.55,384.46,percent of total billed charges,
RA Heel Right Minimum 2 Views,613809,CDM,320,RC,73650,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,RT,193.94,,,,,,,17.41,312.48,percent of total billed charges,
RA Heel Left Minimum 2 Views,613805,CDM,320,RC,73650,HCPCS,,,facility,outpatient,,,382.00000,110.78000,Aetna,Local,LT,193.94,,,,,,,17.41,312.48,percent of total billed charges,
RA Toes Right Minimum 2 Views,614281,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,RT,171.60,,,,,,,15.64,276.48,percent of total billed charges,
RA Toes Left Minimum 2 Views,614279,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,LT,171.60,,,,,,,15.64,276.48,percent of total billed charges,
Fluoroscopy with xray,8147154,CDM,320,RC,76000,HCPCS,,,facility,outpatient,,,300.00000,87.00000,Aetna,Local,,152.31,,,,,,,49.03,672.09,percent of total billed charges,
RA Acute Abd Series,6043863,CDM,320,RC,74022,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,Local,,335.59,,,,,,,27.71,540.70,percent of total billed charges,
RA Acute Abd Series,613574,CDM,320,RC,74022,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,Local,,335.59,,,,,,,27.71,540.70,percent of total billed charges,
RA Knee 1 or 2 Views Bilat,8149643,CDM,320,RC,73560,HCPCS,,,facility,outpatient,,,812.00000,235.48000,Aetna,Local,,412.25,,,,,,,19.19,664.22,percent of total billed charges,
RA Shoulder Min 2 Views Bilat,8149651,CDM,320,RC,73030,HCPCS,,,facility,outpatient,,,970.00000,281.30000,Aetna,Local,,492.47,,,,,,,21.67,793.46,percent of total billed charges,
RA Lower Leg Bilat 2 View,8149659,CDM,320,RC,73590,HCPCS,,,facility,outpatient,,,894.00000,259.26000,Aetna,Local,,453.88,,,,,,,19.19,731.29,percent of total billed charges,
RA Knee 3 Views Bilat,8149667,CDM,320,RC,73562,HCPCS,,,facility,outpatient,,,928.00000,269.12000,Aetna,Local,,471.15,,,,,,,21.67,759.10,percent of total billed charges,
RA Elbow 2 Views Bilat,9004148,CDM,320,RC,73070,HCPCS,,,facility,outpatient,,,764.00000,221.56000,Aetna,Local,,387.88,,,,,,,19.19,624.95,percent of total billed charges,
RA Ankle Min 3 Views Bilat,8150262,CDM,320,RC,73610,HCPCS,,,facility,outpatient,,,940.00000,272.60000,Aetna,Local,,477.24,,,,,,,19.55,768.92,percent of total billed charges,
RA Fluoro,8150218,CDM,320,RC,,,,,facility,outpatient,,,1188.00000,344.52000,Aetna,Local,,603.15,,,,,,,428.27,971.78,percent of total billed charges,
RA Wrist Min 3 Views Bilat,8150662,CDM,320,RC,73110,HCPCS,,,facility,outpatient,,,908.00000,263.32000,Aetna,Local,,460.99,,,,,,,19.55,742.74,percent of total billed charges,
RA Hand Min 3 Views Bilat,8152094,CDM,320,RC,73130,HCPCS,,,facility,outpatient,,,908.00000,263.32000,Aetna,Local,,460.99,,,,,,,19.55,742.74,percent of total billed charges,
RA Foot Min 3 Views Bilat,8152093,CDM,320,RC,73630,HCPCS,,,facility,outpatient,,,940.00000,272.60000,Aetna,Local,,477.24,,,,,,,19.55,768.92,percent of total billed charges,
RA Hip Bilat 2 Views,8228484,CDM,320,RC,73521,HCPCS,,,facility,outpatient,,,790.00000,229.10000,Aetna,Local,,401.08,,,,,,,40.05,646.22,percent of total billed charges,
RA Hand Bilat 2 View,8228592,CDM,320,RC,73120,HCPCS,,,facility,outpatient,,,734.00000,212.86000,Aetna,Local,,372.65,,,,,,,18.12,600.41,percent of total billed charges,
RA Modified Barium Swallow,613518,CDM,320,RC,74230,HCPCS,,,facility,outpatient,,,1030.00000,298.70000,Aetna,Local,,522.93,,,,,,,49.03,842.54,percent of total billed charges,
RA Upper GI Single Contrast,7900284,CDM,320,RC,74240,HCPCS,,,facility,outpatient,,,1583.00000,459.07000,Aetna,Local,,803.69,,,,,,,54.72,1294.89,percent of total billed charges,
RA Small Bowel Follow Thru,614245,CDM,320,RC,74250,HCPCS,,,facility,outpatient,,,1174.00000,340.46000,Aetna,Local,,596.04,,,,,,,49.03,960.33,percent of total billed charges,
Small Bowel Follow Thru,8284744,CDM,320,RC,74248,HCPCS,,,facility,outpatient,,,1174.00000,340.46000,Aetna,Local,,596.04,,,,,,,120.48,960.33,percent of total billed charges,
RA Barium Enema,613588,CDM,320,RC,74270,HCPCS,,,facility,outpatient,,,1541.00000,446.89000,Aetna,Local,,782.37,,,,,,,64.29,1260.54,percent of total billed charges,
RA Barium Enema,613688,CDM,320,RC,74270,HCPCS,,,facility,outpatient,,,1541.00000,446.89000,Aetna,Local,,782.37,,,,,,,64.29,1260.54,percent of total billed charges,
RA Barium Enema Air Contrast,613590,CDM,320,RC,74280,HCPCS,,,facility,outpatient,,,1541.00000,446.89000,Aetna,Local,,782.37,,,,,,,84.20,1260.54,percent of total billed charges,
RA Esophagus Single Contrast,8284688,CDM,320,RC,74220,HCPCS,,,facility,outpatient,,,742.00000,215.18000,Aetna,Local,,376.71,,,,,,,44.41,606.96,percent of total billed charges,
RA Esophagus Double Contrast,8284686,CDM,320,RC,74221,HCPCS,,,facility,outpatient,,,762.00000,220.98000,Aetna,Local,,386.87,,,,,,,156.31,623.32,percent of total billed charges,
RA Upper GI Double Contrast w SBFT,8284708,CDM,320,RC,74246,HCPCS,,,facility,outpatient,,,1466.00000,425.14000,Aetna,Local,,744.29,,,,,,,61.81,1199.19,percent of total billed charges,
RA Upper GI Double Contrast,8284704,CDM,320,RC,74246,HCPCS,,,facility,outpatient,,,1466.00000,425.14000,Aetna,Local,,744.29,,,,,,,61.81,1199.19,percent of total billed charges,
RA Upper GI Single Contrast w SBFT,8284710,CDM,320,RC,74240,HCPCS,,,facility,outpatient,,,1583.00000,459.07000,Aetna,Local,,803.69,,,,,,,54.72,1294.89,percent of total billed charges,
RA Intro Gastrointestinal Tube,642503,CDM,320,RC,,,,,facility,outpatient,,,1703.00000,493.87000,Aetna,Local,,864.61,,,,,,,613.93,1393.05,percent of total billed charges,
RA Fingers Bilat Min 2 Views,8248016,CDM,320,RC,73140,HCPCS,,,facility,outpatient,,,704.00000,204.16000,Aetna,Local,,357.42,,,,,,,15.64,575.87,percent of total billed charges,
RA Foot 2 Views Bilat,8246100,CDM,320,RC,73620,HCPCS,,,facility,outpatient,,,764.00000,221.56000,Aetna,Local,,387.88,,,,,,,18.12,624.95,percent of total billed charges,
RA Heel Bilat 2 Views,8263933,CDM,320,RC,73650,HCPCS,,,facility,outpatient,,,764.00000,221.56000,Aetna,Local,,387.88,,,,,,,17.41,624.95,percent of total billed charges,
RA Forearm Bilat,8270108,CDM,320,RC,73090,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,,432.56,,,,,,,19.19,696.94,percent of total billed charges,
RA Hip Bilat 3 to 4 Views,8409336,CDM,320,RC,73522,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,Local,,617.36,,,,,,,47.65,994.69,percent of total billed charges,
RA Intravenous Pyelogram,613887,CDM,320,RC,74400,HCPCS,,,facility,outpatient,,,1470.00000,426.30000,Aetna,Local,,746.32,,,,,,,63.58,1202.46,percent of total billed charges,
RA Loopogram,613909,CDM,320,RC,,,,,facility,outpatient,,,2010.00000,582.90000,Aetna,Local,,1020.48,,,,,,,724.61,1644.18,percent of total billed charges,
RA Cystogram,613672,CDM,320,RC,,,,,facility,outpatient,,,1685.00000,488.65000,Aetna,Local,,855.47,,,,,,,607.44,1378.33,percent of total billed charges,
RA Urethrogram Retrograde,614303,CDM,320,RC,,,,,facility,outpatient,,,2343.00000,679.47000,Aetna,Local,,1189.54,,,,,,,844.65,1916.57,percent of total billed charges,
RA Urethrogram Voiding,614307,CDM,320,RC,,,,,facility,outpatient,,,1772.00000,513.88000,Aetna,Local,,899.64,,,,,,,638.81,1449.50,percent of total billed charges,
RA Urethrogram Voiding,614315,CDM,320,RC,,,,,facility,outpatient,,,1772.00000,513.88000,Aetna,Local,,899.64,,,,,,,638.81,1449.50,percent of total billed charges,
RA Joint Survey,8456050,CDM,320,RC,77074,HCPCS,,,facility,outpatient,,,572.00000,165.88000,Aetna,Local,,290.40,,,,,,,73.11,467.90,percent of total billed charges,
RA Hysterosalpingogram,613846,CDM,320,RC,,,,,facility,outpatient,,,1787.00000,518.23000,Aetna,Local,,907.26,,,,,,,644.21,1461.77,percent of total billed charges,
RA Toes 1 view bilat,9088259,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,676.00000,196.04000,Aetna,Local,,343.21,,,,,,,15.64,552.97,percent of total billed charges,
RA Ankle 2 Views Bilat,9109874,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,790.00000,229.10000,Aetna,Local,,401.08,,,,,,,18.12,646.22,percent of total billed charges,
RA Ankle 1 Views Bilat,9114505,CDM,320,RC,73600,HCPCS,,,facility,outpatient,,,632.00000,183.28000,Aetna,Local,,320.87,,,,,,,18.12,516.98,percent of total billed charges,
RA Toes 2 Views Bilat bce,9089061,CDM,320,RC,73660,HCPCS,,,facility,outpatient,,,676.00000,196.04000,Aetna,Local,,343.21,,,,,,,15.64,552.97,percent of total billed charges,
RA Timed Esophagram with Pill,9158470,CDM,320,RC,74220,HCPCS,,,facility,outpatient,,,742.00000,215.18000,Aetna,Local,,376.71,,,,,,,44.41,606.96,percent of total billed charges,
RA Fluoroscopy with Image,8146789,CDM,320,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,432.60,981.60,percent of total billed charges,
RA Fluoroscopy with Images,8147064,CDM,320,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,432.60,981.60,percent of total billed charges,
RA Bone Age,613604,CDM,320,RC,77072,HCPCS,,,facility,outpatient,,,403.00000,116.87000,Aetna,Local,,204.60,,,,,,,23.67,329.65,percent of total billed charges,
RA Bone Length,642501,CDM,320,RC,77073,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,50.13,420.45,percent of total billed charges,
RA Sinus Tract Injection,642505,CDM,320,RC,,,,,facility,outpatient,,,1117.00000,323.93000,Aetna,Local,,567.10,,,,,,,402.68,913.71,percent of total billed charges,
RA Bone Survey Infant,613617,CDM,320,RC,77076,HCPCS,,,facility,outpatient,,,485.00000,140.65000,Aetna,Local,,246.23,,,,,,,68.24,396.73,percent of total billed charges,
RA Bone Survey Infant Less than 1 year,7544178,CDM,320,RC,77076,HCPCS,,,facility,outpatient,,,485.00000,140.65000,Aetna,Local,,246.23,,,,,,,68.24,396.73,percent of total billed charges,
Bone Length Study,613891,CDM,320,RC,77073,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,50.13,420.45,percent of total billed charges,
RA Bone Mineral Analysis Dexa,613612,CDM,320,RC,77080,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,Local,,335.59,,,,,,,93.38,540.70,percent of total billed charges,
Radiologic Guidance,613353,CDM,320,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,2132.34,,,,,,,1514.10,3435.60,percent of total billed charges,
RA Fluoroscopy,648719,CDM,320,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,432.60,981.60,percent of total billed charges,
RA Fluoroscopy with Images,613763,CDM,320,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,432.60,981.60,percent of total billed charges,
Chemo Infusion Concurrent Drug,9094186,CDM,330,RC,96549,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,,456.93,,,,,,,40.51,736.20,percent of total billed charges,
Chemo Infusion Sequential Drug,9092698,CDM,330,RC,96417,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,,456.93,,,,,,,62.50,736.20,percent of total billed charges,
Chemo Infusion Each Hour,9094185,CDM,330,RC,96415,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,,456.93,,,,,,,62.50,736.20,percent of total billed charges,
Chemo Infusion First Hr First Drg,9092657,CDM,330,RC,96413,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,761.55,,,,,,,291.24,1227.00,percent of total billed charges,
Chemo Infusion Gt 8Hrs Using Pump,9094319,CDM,330,RC,96416,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,913.86,,,,,,,291.24,1472.40,percent of total billed charges,
Chemo Iv Push Each Addl Drug,9094318,CDM,330,RC,96411,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,,456.93,,,,,,,62.50,736.20,percent of total billed charges,
Chemo Iv Push Initial Or Single,9091696,CDM,330,RC,96409,HCPCS,,,facility,outpatient,,,950.00000,275.50000,Aetna,Local,,482.31,,,,,,,291.24,930.39,percent of total billed charges,
Chemo Refill And Maint Port Pump,7295869,CDM,330,RC,96521,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,185.00,654.40,percent of total billed charges,
Chemo Refill And Maint Port Pump,7957586,CDM,330,RC,96521,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,185.00,654.40,percent of total billed charges,
Chemo Refill And Maint Port Pump,8061981,CDM,330,RC,96521,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,185.00,654.40,percent of total billed charges,
Chemo Refill Implanted Pump,7295868,CDM,330,RC,96522,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,185.00,654.40,percent of total billed charges,
Chemo Refill Implanted Pump,7957587,CDM,330,RC,96522,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,185.00,654.40,percent of total billed charges,
Chemo Refill Implanted Pump,8061982,CDM,330,RC,96522,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,185.00,654.40,percent of total billed charges,
Initial Chemo Sub Q Im Hormonal AntiNeopl,9092753,CDM,330,RC,96402,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,Local,,253.85,,,,,,,62.50,409.00,percent of total billed charges,
Chemo Sub Q Im Hormonal AntiNeopl,9094165,CDM,330,RC,96402,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,Local,,253.85,,,,,,,62.50,409.00,percent of total billed charges,
Initial Chemo SubQ IM NonHormonal AntiNeopl,9092750,CDM,330,RC,96401,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,Local,,253.85,,,,,,,62.50,409.00,percent of total billed charges,
Chemo SubQ IM NonHormonal AntiNeopl,9094164,CDM,330,RC,96401,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,Local,,253.85,,,,,,,62.50,409.00,percent of total billed charges,
Chemo Inf Init Hr Of Pts Own Med,9094160,CDM,330,RC,96413,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,FB,761.55,,,,,,,291.24,1227.00,percent of total billed charges,
Chemo Inf Ea Hr Of Pts Own Med,9092755,CDM,330,RC,96415,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,FB,456.93,,,,,,,62.50,736.20,percent of total billed charges,
Chemo Push Initial of Pts Own Med,9094159,CDM,330,RC,96409,HCPCS,,,facility,outpatient,,,950.00000,275.50000,Aetna,Local,FB,482.31,,,,,,,291.24,885.31,percent of total billed charges,
Chemo Push Addl Med Of Pts Own,9092754,CDM,330,RC,96411,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,FB,456.93,,,,,,,62.50,736.20,percent of total billed charges,
Chemo SubQ Hormonal AntiNeopl of Pts Own Med,9094316,CDM,330,RC,96402,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,Local,FB,253.85,,,,,,,62.50,409.00,percent of total billed charges,
Chemo SubQ Hormonal AntiNeopl of Pts Own Med,9094317,CDM,330,RC,96402,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,Local,FB,253.85,,,,,,,62.50,409.00,percent of total billed charges,
Chemo SubQ IM NonHormone AntiNeopl of Pts Own Med,9092751,CDM,330,RC,96401,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,Local,FB,253.85,,,,,,,62.50,409.00,percent of total billed charges,
Chemo SubQ IM NonHormone AntiNeopl of Pts Own Med,9092752,CDM,330,RC,96401,HCPCS,,,facility,outpatient,,,500.00000,145.00000,Aetna,Local,FB,253.85,,,,,,,62.50,409.00,percent of total billed charges,
Chemo Infusion Sequential Drug Pts Own Med,9186697,CDM,330,RC,96417,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,,456.93,,,,,,,62.50,736.20,percent of total billed charges,
Chemo Infusion Concurrent Drug Pts Own Med,9188729,CDM,330,RC,96549,HCPCS,,,facility,outpatient,,,900.00000,261.00000,Aetna,Local,,456.93,,,,,,,40.51,736.20,percent of total billed charges,
Chemo IV Infusion 8Hrs or More,9186782,CDM,330,RC,96416,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,913.86,,,,,,,291.24,1472.40,percent of total billed charges,
Chemo Extended IV Infusion w CADD,9188634,CDM,330,RC,G0498,HCPCS,,,facility,outpatient,,,1800.00000,522.00000,Aetna,Local,,913.86,,,,,,,291.24,1472.40,percent of total billed charges,
With Intrathecal Chemo,9078314,CDM,331,RC,,,,,facility,outpatient,,,1140.00000,330.60000,Aetna,Local,,578.78,,,,,,,410.97,932.52,percent of total billed charges,
IGRT,2452825,CDM,333,RC,77387,HCPCS,,,facility,outpatient,,,1828.00000,530.12000,Aetna,Local,,928.08,,,,,,,219.84,1495.30,percent of total billed charges,
MLC Device Design And Construct,3172896,CDM,333,RC,77338,HCPCS,,,facility,outpatient,,,3301.00000,957.29000,Aetna,Local,,1675.92,,,,,,,229.63,2700.22,percent of total billed charges,
Treatment Stereo Brain,8062056,CDM,333,RC,77372,HCPCS,,,facility,outpatient,,,21448.00000,6219.92000,Aetna,Local,,10889.15,,,,,,,1596.68,20403.84,percent of total billed charges,
Treatment Stereo Body,8062057,CDM,333,RC,77373,HCPCS,,,facility,outpatient,,,8758.00000,2539.82000,Aetna,Local,,4446.44,,,,,,,1541.79,7164.04,percent of total billed charges,
Simulation 4D,8062058,CDM,333,RC,77293,HCPCS,,,facility,outpatient,,,5052.00000,1465.08000,Aetna,Local,,2564.90,,,,,,,503.50,4132.54,percent of total billed charges,
IMRT Complex,8062059,CDM,333,RC,77386,HCPCS,,,facility,outpatient,,,4600.00000,1334.00000,Aetna,Local,,2335.42,,,,,,,1544.00,3762.80,percent of total billed charges,
IMRT Complex Prostate Or Breast,8062060,CDM,333,RC,77385,HCPCS,,,facility,outpatient,,,4600.00000,1334.00000,Aetna,Local,,2335.42,,,,,,,1544.00,3762.80,percent of total billed charges,
Radiotherapy Dose Plan Imrt B,8062061,CDM,333,RC,77301,HCPCS,,,facility,outpatient,,,23288.00000,6753.52000,Aetna,Local,,11823.32,,,,,,,1047.77,19049.58,percent of total billed charges,
Simulation Simple w GZ CTR,9192549,CDM,333,RC,77280,HCPCS,,,facility,outpatient,,,3810.00000,1104.90000,Aetna,Local,GZ,1934.34,,,,,,,116.59,3116.58,percent of total billed charges,
Manual Calculations w XU CTR,9194578,CDM,333,RC,77300,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,XU,627.52,,,,,,,50.10,1011.05,percent of total billed charges,
Isodose Planning Complex w GZ CTR,9192550,CDM,333,RC,77307,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,Local,GZ,1274.33,,,,,,,189.84,2053.18,percent of total billed charges,
Treatment Device Complex w XU CTR,9194580,CDM,333,RC,77334,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,Local,XU,1274.33,,,,,,,121.87,2053.18,percent of total billed charges,
Isodose Planning Complex w XU CTR,9194579,CDM,333,RC,77307,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,Local,XU,1274.33,,,,,,,189.84,2053.18,percent of total billed charges,
Physics QA Support w GZ CTR,9194581,CDM,333,RC,77336,HCPCS,,,facility,outpatient,,,1368.00000,396.72000,Aetna,Local,GZ,694.53,,,,,,,111.92,1119.02,percent of total billed charges,
Physics QA Support w XU CTR,9194582,CDM,333,RC,77336,HCPCS,,,facility,outpatient,,,1368.00000,396.72000,Aetna,Local,XU,694.53,,,,,,,111.92,1119.02,percent of total billed charges,
MLC Device Design and Construct w XU CTR,9194583,CDM,333,RC,77338,HCPCS,,,facility,outpatient,,,3301.00000,957.29000,Aetna,Local,XU,1675.92,,,,,,,229.63,2700.22,percent of total billed charges,
Simulation Simple,602781,CDM,333,RC,77280,HCPCS,,,facility,outpatient,,,3810.00000,1104.90000,Aetna,Local,,1934.34,,,,,,,116.59,3116.58,percent of total billed charges,
Simulation Complex,602785,CDM,333,RC,77290,HCPCS,,,facility,outpatient,,,6002.00000,1740.58000,Aetna,Local,,3047.22,,,,,,,244.44,4909.64,percent of total billed charges,
3D Isodose Plan,602787,CDM,333,RC,77295,HCPCS,,,facility,outpatient,,,11874.00000,3443.46000,Aetna,Local,,6028.43,,,,,,,1047.77,9712.93,percent of total billed charges,
Manual Calculations,602789,CDM,333,RC,77300,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,Local,,627.52,,,,,,,50.10,1011.05,percent of total billed charges,
Radiotherapy Dose Plan Imrt,647071,CDM,333,RC,77301,HCPCS,,,facility,outpatient,,,13159.00000,3816.11000,Aetna,Local,,6680.82,,,,,,,1047.77,10764.06,percent of total billed charges,
Isodose Planning Simple,602791,CDM,333,RC,77306,HCPCS,,,facility,outpatient,,,1190.00000,345.10000,Aetna,Local,,604.16,,,,,,,109.99,977.09,percent of total billed charges,
ISODOSE PLANNING COMPLEX,602795,CDM,333,RC,77307,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,Local,,1274.33,,,,,,,189.84,2053.18,percent of total billed charges,
Special Treatment Port Plan,602797,CDM,333,RC,77321,HCPCS,,,facility,outpatient,,,1555.00000,450.95000,Aetna,Local,,789.47,,,,,,,151.36,1271.99,percent of total billed charges,
Treatment Device Simple,602807,CDM,333,RC,77332,HCPCS,,,facility,outpatient,,,1368.00000,396.72000,Aetna,Local,,694.53,,,,,,,50.10,1119.02,percent of total billed charges,
Treatment Device Intermediate,602809,CDM,333,RC,77333,HCPCS,,,facility,outpatient,,,1694.00000,491.26000,Aetna,Local,,860.04,,,,,,,71.41,1385.69,percent of total billed charges,
Treatment Device Complex,602811,CDM,333,RC,77334,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,Local,,1274.33,,,,,,,121.87,2053.18,percent of total billed charges,
Physics QA Support,602813,CDM,333,RC,77336,HCPCS,,,facility,outpatient,,,1368.00000,396.72000,Aetna,Local,,694.53,,,,,,,111.92,1119.02,percent of total billed charges,
Physics Special Consult,602815,CDM,333,RC,77370,HCPCS,,,facility,outpatient,,,2192.00000,635.68000,Aetna,Local,,1112.88,,,,,,,116.59,1793.06,percent of total billed charges,
Daily Treatment Simple,602817,CDM,333,RC,77402,HCPCS,,,facility,outpatient,,,913.00000,264.77000,Aetna,Local,,463.53,,,,,,,67.13,746.83,percent of total billed charges,
Daily Treatment Complex,602821,CDM,333,RC,77412,HCPCS,,,facility,outpatient,,,2510.00000,727.90000,Aetna,Local,,1274.33,,,,,,,87.75,2053.18,percent of total billed charges,
Port Films Verified,602823,CDM,333,RC,77417,HCPCS,,,facility,outpatient,,,550.00000,159.50000,Aetna,Local,,279.24,,,,,,,22.37,449.90,percent of total billed charges,
Special Treatment,602825,CDM,333,RC,77470,HCPCS,,,facility,outpatient,,,5482.00000,1589.78000,Aetna,Local,,2783.21,,,,,,,418.18,4484.28,percent of total billed charges,
CAR NM RESTING MYOCARDIAL PERFUSI,7363901,CDM,341,RC,78451,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,Local,,2161.79,,,,,,,141.62,3646.69,percent of total billed charges,
CAR NM MUGA,7363902,CDM,341,RC,78472,HCPCS,,,facility,outpatient,,,3703.00000,1073.87000,Aetna,Local,,1880.01,,,,,,,207.13,3029.05,percent of total billed charges,
CAR NM SPECT MYOCARDIAL IMAGING,7363898,CDM,341,RC,78452,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,Local,,2161.79,,,,,,,273.63,3646.69,percent of total billed charges,
CAR NM SPECT MYOCARDIAL IMAGING,7363899,CDM,341,RC,78452,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,Local,,2161.79,,,,,,,273.63,3646.69,percent of total billed charges,
CAR NM SPECT MYOCARDIAL IMAGING,7363900,CDM,341,RC,78452,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,Local,,2161.79,,,,,,,273.63,3646.69,percent of total billed charges,
CAR NM THALLIUM VIABILITY,7363897,CDM,341,RC,78452,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,Local,,2161.79,,,,,,,273.63,3646.69,percent of total billed charges,
NM VQ Scan,1557808,CDM,341,RC,78582,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,249.86,2777.11,percent of total billed charges,
NM Bone Marrow,3661942,CDM,341,RC,78104,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,152.77,2099.81,percent of total billed charges,
NM GB Biliary Tract w CCK,3661944,CDM,341,RC,78227,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,269.54,2777.11,percent of total billed charges,
NM Adrenal,7286032,CDM,341,RC,78075,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,203.59,3646.69,percent of total billed charges,
NM Shunt Right to Left,8148515,CDM,341,RC,78428,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,84.91,2777.11,percent of total billed charges,
NM DATScan Exam,8155221,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
NM GB Biliary Tract w Boost,8876098,CDM,341,RC,78226,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,269.54,2777.11,percent of total billed charges,
NM Cerebral Flow Study,624515,CDM,341,RC,78601,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,127.55,2777.11,percent of total billed charges,
NM Cisternogram,624530,CDM,341,RC,78630,HCPCS,,,facility,outpatient,,,2952.00000,856.08000,Aetna,Local,,1498.73,,,,,,,189.02,2414.74,percent of total billed charges,
NM CSF Shunt Evaluation,624538,CDM,341,RC,78645,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,128.62,2777.11,percent of total billed charges,
NM CSF Shunt Evaluation,624540,CDM,341,RC,78645,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,128.62,2777.11,percent of total billed charges,
NM GI Bleeding Scan,624563,CDM,341,RC,78278,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,182.28,2777.11,percent of total billed charges,
NM Liver Spleen Scan,624574,CDM,341,RC,78215,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,109.80,2099.81,percent of total billed charges,
NM Meckels Imaging,624588,CDM,341,RC,78290,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,114.40,2777.11,percent of total billed charges,
NM Metastatic Body Survey,624592,CDM,341,RC,78018,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,203.59,2777.11,percent of total billed charges,
NM Thyroid Carcinoma Whole Body,624608,CDM,341,RC,78018,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,203.59,2777.11,percent of total billed charges,
NM Thyroid Whole Body Thyrogen,624670,CDM,341,RC,78018,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,203.59,2777.11,percent of total billed charges,
NM Thyroid Whole Body Thyrogen,8297157,CDM,341,RC,78018,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,203.59,2777.11,percent of total billed charges,
NM Parathyroid Planar Imaging,624603,CDM,341,RC,78070,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,156.09,2777.11,percent of total billed charges,
NM Parathyroid Planar Imaging,655844,CDM,341,RC,78070,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,156.09,2777.11,percent of total billed charges,
NM Pulmonary Perfusion,624610,CDM,341,RC,78580,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,128.62,2777.11,percent of total billed charges,
NM Pulmonary Ventilation,624612,CDM,341,RC,78579,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,161.47,2099.81,percent of total billed charges,
NM Renal Mag 3,624629,CDM,341,RC,78707,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,167.35,2777.11,percent of total billed charges,
NM Thyroid Uptake,624683,CDM,341,RC,78012,HCPCS,,,facility,outpatient,,,1839.00000,533.31000,Aetna,Local,,933.66,,,,,,,102.90,1504.30,percent of total billed charges,
NM Bone Scan Whole Body,1557804,CDM,341,RC,78306,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,159.89,2777.11,percent of total billed charges,
NM Bone Scan Whole Body,624504,CDM,341,RC,78306,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,159.89,2777.11,percent of total billed charges,
NM Thyroid Uptake and Scan,624685,CDM,341,RC,78014,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,320.23,2777.11,percent of total billed charges,
NM Tc99M Thyroid,624664,CDM,341,RC,78013,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,254.38,2777.11,percent of total billed charges,
NM RBC Blood Volume,624618,CDM,341,RC,78121,HCPCS,,,facility,outpatient,,,3380.00000,980.20000,Aetna,Local,,1716.03,,,,,,,108.73,2764.84,percent of total billed charges,
NM Thyroid Thyrogen Carcinoma Therapy,7917891,CDM,341,RC,79005,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,98.42,2777.11,percent of total billed charges,
NM GB Biliary Tract wo CCK,624561,CDM,341,RC,78226,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,269.54,2777.11,percent of total billed charges,
NM Localize Inflamation Whole Body,624518,CDM,341,RC,78802,HCPCS,,,facility,outpatient,,,3887.00000,1127.23000,Aetna,Local,,1973.43,,,,,,,207.84,3484.44,percent of total billed charges,
NM Indium WBC Imaging,624568,CDM,341,RC,78802,HCPCS,,,facility,outpatient,,,3887.00000,1127.23000,Aetna,Local,,1973.43,,,,,,,207.84,3484.44,percent of total billed charges,
NM Testicular Scan with Flow,624668,CDM,341,RC,78761,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,120.09,2099.81,percent of total billed charges,
NM Lymphoscintigrapy,624583,CDM,341,RC,78195,HCPCS,,,facility,outpatient,,,4470.00000,1296.30000,Aetna,Local,,2269.42,,,,,,,152.77,3656.46,percent of total billed charges,
NM Liver Imaging SPECT,624621,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
NM SPECT Liver,624657,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
NM Salivary Gland,624636,CDM,341,RC,78231,HCPCS,,,facility,outpatient,,,1839.00000,533.31000,Aetna,Local,,933.66,,,,,,,119.03,1504.30,percent of total billed charges,
NM Esophageal Reflux Aspiration,624546,CDM,341,RC,78262,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,159.17,2099.81,percent of total billed charges,
NM Gastric Emptying,7943875,CDM,341,RC,78264,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,154.91,2777.11,percent of total billed charges,
NM Shunt Patency,624649,CDM,341,RC,78291,HCPCS,,,facility,outpatient,,,1839.00000,533.31000,Aetna,Local,,933.66,,,,,,,114.76,1504.30,percent of total billed charges,
NM 3 Phase Bone Scan,624494,CDM,341,RC,78315,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,179.07,2777.11,percent of total billed charges,
NM SPECT Bone,624652,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
NM SPECT Bone,8001078,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
NM Split Function Lung,624662,CDM,341,RC,78597,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,182.07,2777.11,percent of total billed charges,
NM Cystogram,624544,CDM,341,RC,78740,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,79.94,2099.81,percent of total billed charges,
NM Renal w Lasix,624631,CDM,341,RC,78708,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,167.35,2777.11,percent of total billed charges,
NM SPECT Tumor,624659,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
NM SPECT Tumor,8001079,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
NM Spect Tumor,8001077,CDM,341,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
NM Octreoscan Tumor Img,624601,CDM,341,RC,78804,HCPCS,,,facility,outpatient,,,4224.00000,1224.96000,Aetna,Local,,2144.52,,,,,,,404.97,3484.44,percent of total billed charges,
NM Tumor Localization Whole Body,624692,CDM,341,RC,78804,HCPCS,,,facility,outpatient,,,4224.00000,1224.96000,Aetna,Local,,2144.52,,,,,,,404.97,3484.44,percent of total billed charges,
NM Lymphoma Imaging Bexxar,661243,CDM,341,RC,78804,HCPCS,,,facility,outpatient,,,4224.00000,1224.96000,Aetna,Local,,2144.52,,,,,,,404.97,3484.44,percent of total billed charges,
NM Gallium Citrate Imaging,624553,CDM,341,RC,78802,HCPCS,,,facility,outpatient,,,3887.00000,1127.23000,Aetna,Local,,1973.43,,,,,,,207.84,3484.44,percent of total billed charges,
NM Lymphoma Imaging,624579,CDM,341,RC,78802,HCPCS,,,facility,outpatient,,,3887.00000,1127.23000,Aetna,Local,,1973.43,,,,,,,207.84,3484.44,percent of total billed charges,
NM Lymphoma Zevalin Imaging,7544149,CDM,341,RC,78802,HCPCS,,,facility,outpatient,,,3887.00000,1127.23000,Aetna,Local,,1973.43,,,,,,,207.84,3484.44,percent of total billed charges,
NM Radium Therapy,7858138,CDM,342,RC,79101,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,98.42,2099.81,percent of total billed charges,
NM Lutcieum Prostate Therapy,9083669,CDM,342,RC,79101,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,98.42,2099.81,percent of total billed charges,
NM Lutathera Therapy,9083667,CDM,342,RC,79101,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,98.42,2099.81,percent of total billed charges,
NM Radiopharm Therapy Oral Administration,624681,CDM,342,RC,79005,HCPCS,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,98.42,2777.11,percent of total billed charges,
NM Radiopharm Therapy IV Admin,624507,CDM,342,RC,79101,HCPCS,,,facility,outpatient,,,2567.00000,744.43000,Aetna,Local,,1303.27,,,,,,,98.42,2099.81,percent of total billed charges,
Gallium Dotatate,8119563,CDM,343,RC,A9587,HCPCS,,,facility,outpatient,,,14793.00000,4289.97000,Aetna,Local,,7510.41,,,,,,,49.63,12100.67,percent of total billed charges,
NM Copper CU64,8412046,CDM,343,RC,A9592,HCPCS,,,facility,outpatient,,,14055.00000,4075.95000,Aetna,Local,,7135.72,,,,,,,594.28,11496.99,percent of total billed charges,
Piflufolastat F 18,8457867,CDM,343,RC,A9595,HCPCS,,,facility,outpatient,,,20838.00000,6043.02000,Aetna,Local,,10579.45,,,,,,,308.18,17045.48,percent of total billed charges,
NM Non HEU Source TC-99m per dose,9090500,CDM,343,RC,Q9969,HCPCS,,,facility,outpatient,,,35.00000,10.15000,Aetna,Local,,17.77,,,,,,,12.62,28.63,percent of total billed charges,
F18 Flucicovine,8119561,CDM,343,RC,A9588,HCPCS,,,facility,outpatient,,,17587.00000,5100.23000,Aetna,Local,,8928.92,,,,,,,322.27,14386.17,percent of total billed charges,
Gallium Ga68 Gozetotide Diagnostic,8973054,CDM,343,RC,A9596,HCPCS,,,facility,outpatient,,,16250.00000,4712.50000,Aetna,Local,,8250.12,,,,,,,478.52,13292.50,percent of total billed charges,
F18 Posluma,9116450,CDM,343,RC,A9608,HCPCS,,,facility,outpatient,,,18082.88000,5244.04000,Aetna,Local,,9180.68,,,,,,,671.22,14791.80,percent of total billed charges,
NM RADIUM 223 1 UCI,7858034,CDM,344,RC,A9606,HCPCS,,,facility,outpatient,,,892.00000,258.68000,Aetna,Local,,452.87,,,,,,,171.92,729.66,percent of total billed charges,
Lutetium LU VipiVotide,9084991,CDM,344,RC,A9607,HCPCS,,,facility,outpatient,,,796.53000,230.99000,Aetna,Local,,404.40,,,,,,,259.32,842.27,percent of total billed charges,
Lutetium Lu 177 dotatate,9083671,CDM,344,RC,A9513,HCPCS,,,facility,outpatient,,,978.18000,283.67000,Aetna,Local,,496.62,,,,,,,320.77,1034.31,percent of total billed charges,
CAR NM Amyloidosis Planar,8227929,CDM,349,RC,78800,HCPCS,,,facility,outpatient,,,3220.00000,933.80000,Aetna,Local,,1634.79,,,,,,,127.55,2633.96,percent of total billed charges,
Card Amyloidosis,9134447,CDM,349,RC,78800,HCPCS,,,facility,outpatient,,,3220.00000,933.80000,Aetna,Local,,1634.79,,,,,,,127.55,2633.96,percent of total billed charges,
CAR NM Amyloidosis Planar W Spect,8227928,CDM,349,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
Card Amyloid w Spect,9134448,CDM,349,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
NM Cardiac Amyloidosis,8436578,CDM,349,RC,78800,HCPCS,,,facility,outpatient,,,3220.00000,933.80000,Aetna,Local,,1634.79,,,,,,,127.55,2633.96,percent of total billed charges,
NM Cardiac Amyloidosis SPECT,8436176,CDM,349,RC,78803,HCPCS,,,facility,outpatient,,,4858.00000,1408.82000,Aetna,Local,,2466.41,,,,,,,245.86,3973.84,percent of total billed charges,
NM Sentinal Node Non Imag,624647,CDM,349,RC,,,,,facility,outpatient,,,3395.00000,984.55000,Aetna,Local,,1723.64,,,,,,,1223.90,2777.11,percent of total billed charges,
CT Colonography w Contrast,7741559,CDM,350,RC,74262,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Colonography wo Contrast,7741561,CDM,350,RC,74261,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Orbits w Contrast,1443807,CDM,351,RC,70481,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Orbit Ear Fossa w Contrast,654668,CDM,351,RC,70481,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Head wo Contrast,3110839,CDM,351,RC,70450,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Head wo Contrast,613391,CDM,351,RC,70450,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Head wo Contrast,7523980,CDM,351,RC,70450,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Head w Contrast,613383,CDM,351,RC,70460,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Head w Contrast,7523978,CDM,351,RC,70460,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Head w wo Contrast,613387,CDM,351,RC,70470,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Head w wo Contrast,7523979,CDM,351,RC,70470,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Soft Tissue Neck wo Contrast,613702,CDM,351,RC,70490,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Soft Tissue Neck w Contrast,613694,CDM,351,RC,70491,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Soft Tissue Neck w wo Contrast,613700,CDM,351,RC,70492,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Head,1513815,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Head,2300825,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CTA HEAD W CONTRAST,3136871,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Head,7938005,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Head,7988045,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Maxillofacial w Contrast,613481,CDM,351,RC,70487,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Sinuses w Contrast,7285917,CDM,351,RC,70487,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Maxillofacial wo Contrast,613485,CDM,351,RC,70486,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Sinuses wo Contrast,613674,CDM,351,RC,70486,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Stealth Sinuses wo Contrast,7920891,CDM,351,RC,70486,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Angio Neck,2300826,CDM,351,RC,70498,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Neck,8001036,CDM,351,RC,70498,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Neck BCE,9040800,CDM,351,RC,70498,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Perfusion,8366954,CDM,351,RC,0042T,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,771.47,1750.52,case rate,
CT Angio Perfusion Head Code Stroke,8366931,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Perfusion Head and Neck Code Stroke,8366933,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Venous Head Code Stroke,8416708,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Venous Head and Neck Code Stroke,8416712,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Prfn Venous Head Code Stroke,8416702,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Perf Venous Head Neck Code Stroke,8416681,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Prfn Venous Head and Neck Code Stroke CT Exam 1,8416704,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Venous Head and Neck,8416710,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Venous Head,8416706,CDM,351,RC,70496,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Parathyroid 4D Neck w wo Contrast,8910355,CDM,351,RC,70492,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Orbits wo Contrast,613708,CDM,351,RC,70480,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Orbit Ear Fossa wo Contrast,654658,CDM,351,RC,70480,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Orbits w wo Contrast,613714,CDM,351,RC,70482,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Orbit Ear Fossa w wo Contrast,654622,CDM,351,RC,70482,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Sinuses w wo Contrast,654666,CDM,351,RC,70488,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Maxillofacial w wo Contrast,654689,CDM,351,RC,70488,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Upper Extremity Right w Contrast,1053802,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,RT,1382.00,,,,,,,221.71,1516.57,case rate,
CT Upper Extremity Right w Contrast,7913755,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,RT,1382.00,,,,,,,221.71,1516.57,case rate,
CT Upper Extremity Right w Contrast,7991376,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,RT,1382.00,,,,,,,221.71,1516.57,case rate,
CT Upper Extremity Right w Contrast,7991400,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,RT,1382.00,,,,,,,221.71,1516.57,case rate,
CT Upper Extremity Right w wo Contrast,1053808,CDM,352,RC,73202,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,RT,1382.00,,,,,,,156.31,1750.52,case rate,
CT Upper Extremity Left w Contrast,1053822,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,LT,1382.00,,,,,,,221.71,1516.57,case rate,
CT Upper Extremity Left w Contrast,7913751,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,LT,1382.00,,,,,,,221.71,1516.57,case rate,
CT Upper Extremity Left w Contrast,7991372,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,LT,1382.00,,,,,,,221.71,1516.57,case rate,
CT Wrist Left Post Arthrogram,7991396,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,LT,1382.00,,,,,,,221.71,1516.57,case rate,
CT Upper Extremity Left w wo Contrast,1083812,CDM,352,RC,73202,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,LT,1382.00,,,,,,,156.31,1750.52,case rate,
CT Lower Extremity Right w Contrast,1053824,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,RT,1382.00,,,,,,,156.31,1516.57,case rate,
CT Lower Extremity Right w Contrast,7991368,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,RT,1382.00,,,,,,,156.31,1516.57,case rate,
CT Lower Extremity Right w Contrast,7991384,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,RT,1382.00,,,,,,,156.31,1516.57,case rate,
CT Lower Extremity Right w Contrast,7991392,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,RT,1382.00,,,,,,,156.31,1516.57,case rate,
CT Lower Extremity Right w wo Contrast,1083816,CDM,352,RC,73702,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,RT,1382.00,,,,,,,156.31,1750.52,case rate,
CT Lower Extremity Left w Contrast,1063831,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,LT,1382.00,,,,,,,156.31,1516.57,case rate,
CT Lower Extremity Left w Contrast,7991364,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,LT,1382.00,,,,,,,156.31,1516.57,case rate,
CT Lower Extremity w Contrast,7991380,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,LT,1382.00,,,,,,,156.31,1516.57,case rate,
CT Lower Extremity Left w Contrast,7991388,CDM,352,RC,73701,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,LT,1382.00,,,,,,,156.31,1516.57,case rate,
CT Lower Extremity Left w wo Contrast,1063833,CDM,352,RC,73702,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,LT,1382.00,,,,,,,156.31,1750.52,case rate,
CT Chest Partial During Coronary w wo Contrast,7976458,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Chest Partial During Coronary w wo Contrast,8166094,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Chest Partial During Coronary w Contrast,7976457,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Chest Partial During Coronary w Contrast,8166092,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Chest Partial During Coronary wo Contrast,7976459,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Chest Partial During Coronary wo Contrast,8166093,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Coronary Angio without Evaluation,7976456,CDM,352,RC,75574,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,313.58,1750.52,case rate,
CT Coronary Angio wo Evaluation,8166096,CDM,352,RC,75574,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,313.58,1750.52,case rate,
CT Coronary Angio with Evaluation,7976455,CDM,352,RC,75574,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,313.58,1750.52,case rate,
CT Coronary Angio w Evaluation,8166095,CDM,352,RC,75574,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,313.58,1750.52,case rate,
CT Angio Abdomen Pelvis,1513813,CDM,352,RC,74174,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,Local,,1382.00,,,,,,,313.58,3500.22,case rate,
CT Angio Abd Pelv w Contrast,8001028,CDM,352,RC,74174,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,Local,,1382.00,,,,,,,313.58,3500.22,case rate,
CT Abdomen wo Contrast,613231,CDM,352,RC,74150,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Abdomen wo Contrast,7920887,CDM,352,RC,74150,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Abdomen wo Contrast,8001030,CDM,352,RC,74150,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Abdomen w Contrast,613317,CDM,352,RC,74160,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Abdomen w Contrast,7920895,CDM,352,RC,74160,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Abdomen w Contrast,8001031,CDM,352,RC,74160,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Abdomen w wo Contrast,613321,CDM,352,RC,74170,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Abdomen w wo Contrast,7903279,CDM,352,RC,74170,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Abdomen w wo Contrast,8001032,CDM,352,RC,74170,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Pelvis wo Contrast,613368,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT PELVIS WO CONTRAST,7790106,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Pelvis w Contrast,613726,CDM,352,RC,72193,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Pelvis w wo Contrast,613728,CDM,352,RC,72194,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Chest wo Contrast,1371811,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Chest wo Contrast,1371823,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Chest wo Contrast,2052850,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Chest wo Contrast,613224,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Chest wo Contrast,7900400,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Chest wo Contrast,7913760,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Chest w Contrast,1371817,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Chest w Contrast,1371819,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Chest w Contrast,1447807,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Chest w Contrast,1447813,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Chest w Contrast,3136873,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Chest w Contrast,3661973,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Chest w Contrast,613431,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Chest w wo Contrast,1371809,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Chest w wo Contrast,1371813,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Chest w wo Contrast,1447809,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Chest w wo Contrast,1447811,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Chest w wo Contrast,613435,CDM,352,RC,71270,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Cervical Spine wo Contrast,613359,CDM,352,RC,72125,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Cervical Spine w wo Contrast,613408,CDM,352,RC,72127,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Thoracic Spine wo Contrast,613889,CDM,352,RC,72128,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Thoracic Spine w wo Contrast,613885,CDM,352,RC,72130,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT LUMBAR SPINE WO CONTRAST,613629,CDM,352,RC,72131,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lumbar Spine wo Contrast,613647,CDM,352,RC,72131,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lumbar Spine w wo Contrast,613643,CDM,352,RC,72133,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Chest,1411836,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Chest,1513811,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Chest,1513817,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Chest,2052853,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Chest,7908926,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Chest,989820,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Lumbar Spine w Contrast,613623,CDM,352,RC,72132,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,265.06,1516.57,case rate,
CT Lumbar Spine w Contrast,613637,CDM,352,RC,72132,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,265.06,1516.57,case rate,
CT Thoracic Spine w Contrast,613841,CDM,352,RC,72129,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Thoracic Spine w Contrast,613881,CDM,352,RC,72129,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Cervical Spine w Contrast,613401,CDM,352,RC,72126,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,265.06,1516.57,case rate,
CT Cervical Spine w Contrast,613414,CDM,352,RC,72126,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,265.06,1516.57,case rate,
CT Angio Abdomen,2300824,CDM,352,RC,74175,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Abdomen,2300827,CDM,352,RC,74175,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Abdomen w Contrast,8001034,CDM,352,RC,74175,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Lower Extremity Left wo Contrast,1063835,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Left wo Contrast,5841882,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Left wo Contrast,613351,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Left wo Contrast,613487,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Left wo Contrast,613499,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Left wo Contrast,613558,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Left wo Contrast,613596,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Left wo Contrast,613608,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Ankle Left Prophecy,7943866,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Ankle Right Prophecy,7943870,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity wo Contrast,8001035,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Left wo Contrast,8148236,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Right wo Contrast,1053826,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Right wo Contrast,5841884,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Right wo Contrast,613355,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Right wo Contrast,613489,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Right wo Contrast,613504,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Right wo Contrast,613560,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Right wo Contrast,613598,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremtiy Right wo Contrast,613610,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity wo Contrast,8001037,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Right wo Contrast,8148237,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Angio Runoff,2300828,CDM,352,RC,75635,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Upper Extremity Left,5543848,CDM,352,RC,73206,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,LT,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Upper Extremity Right,5543844,CDM,352,RC,73206,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,RT,1382.00,,,,,,,156.31,1750.52,case rate,
CT Abd Pel wo Contrast,1371825,CDM,352,RC,74176,HCPCS,,,facility,outpatient,,,3139.00000,910.31000,Aetna,Local,,1382.00,,,,,,,123.60,2567.70,case rate,
CT Abd Pelv wo Contrast,8001043,CDM,352,RC,74176,HCPCS,,,facility,outpatient,,,3139.00000,910.31000,Aetna,Local,,1382.00,,,,,,,123.60,2567.70,case rate,
CT Abd Pel w Contrast,1371821,CDM,352,RC,74177,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,Local,,1382.00,,,,,,,235.67,3033.14,case rate,
CT Abd Pelv w Contrast,7285879,CDM,352,RC,74177,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,Local,,1382.00,,,,,,,235.67,3033.14,case rate,
CT Abd Pel w Contrast,7920899,CDM,352,RC,74177,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,Local,,1382.00,,,,,,,235.67,3033.14,case rate,
CT Abd Pel w Contrast,8001044,CDM,352,RC,74177,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,Local,,1382.00,,,,,,,235.67,3033.14,case rate,
CT Abd Pel w wo Contrast,1371815,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,Local,,1382.00,,,,,,,311.43,3500.22,case rate,
CT Abd Pel w wo Contrast,1447817,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,Local,,1382.00,,,,,,,311.43,3500.22,case rate,
CT Abd Pelv w wo Contrast,7285922,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,Local,,1382.00,,,,,,,311.43,3500.22,case rate,
CT Abd Pelv w wo Contrast,8001045,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,Local,,1382.00,,,,,,,311.43,3500.22,case rate,
CT Lung Cancer Screening,8320177,CDM,352,RC,71271,HCPCS,,,facility,outpatient,,,1499.00000,434.71000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Heart TAVR wo Contrast,7938008,CDM,352,RC,75571,HCPCS,,,facility,outpatient,,,1494.00000,433.26000,Aetna,Local,,1382.00,,,,,,,56.24,1474.00,case rate,
CT Lower Extremity Bilat wo Contrast,613556,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,Local,,1382.00,,,,,,,93.38,2565.25,case rate,
CT Lower Extremity Bilat wo Contrast,613592,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,Local,,1382.00,,,,,,,93.38,2565.25,case rate,
CT Lower Extremity Bilat wo Contrast,8148159,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,Local,,1382.00,,,,,,,93.38,2565.25,case rate,
CT Upper Extremity Bilat wo Contrast,613862,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,Local,,1382.00,,,,,,,93.38,2565.25,case rate,
CT Upper Extremity Bilat wo Contrast,8148158,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,Local,,1382.00,,,,,,,93.38,2565.25,case rate,
CT Angio Lower Extremity Right,7991332,CDM,352,RC,73706,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,RT,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Lower Extremity Left,7991336,CDM,352,RC,73706,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,LT,1382.00,,,,,,,156.31,1750.52,case rate,
CT Heart TAVR w Contrast,7858050,CDM,352,RC,75572,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,161.98,1516.57,case rate,
CT TAVR Angio Chest,7858048,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Chest wo Contrast High Resolution,8246688,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Chest w Contrast High Resolution,8246684,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Hip Stryker Left wo Contrast,8282227,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Hip Stryker Right wo Contrast,8282231,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Hip Stryker Bilateral wo Contrast,8282223,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,Local,,1382.00,,,,,,,93.38,2565.25,case rate,
CT TAVR Chest w Contrast,8282210,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Lower Extremity LT Partial,8282190,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,"LT,52",1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity RT Partial,8282189,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,"RT,52",1382.00,,,,,,,93.38,1474.00,case rate,
CT Angio Chest Abd w or wo Pel w Contrast,8436129,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Chest Abd Pel w or wo Contrast,8436133,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Abd w wo Pel w contrast,1447815,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,Local,,1382.00,,,,,,,311.43,3500.22,case rate,
CT Abd w wo Pel w Contrast,8436171,CDM,352,RC,74178,HCPCS,,,facility,outpatient,,,4279.00000,1240.91000,Aetna,Local,,1382.00,,,,,,,311.43,3500.22,case rate,
CT Hip Right for Torsion wo Contrast,8438392,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Hip Left forTorsion wo Contrast,8438390,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Device Right,8475816,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Device LT,8475814,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Device RT,8475812,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,Local,RT,1382.00,,,,,,,93.38,2565.25,case rate,
CT Lower Extremity Device RT,8475782,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,"RT,52",1382.00,,,,,,,93.38,1474.00,case rate,
CT Lower Extremity Device LT,8475783,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,"LT,52",1382.00,,,,,,,93.38,1474.00,case rate,
CT Pelvis Anteversion,8515979,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Hip Right w Partial Knee Eval,8515992,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Hip Left w Partial Knee Eval,8515988,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Hip Bilat w Partial Knee Eval,8515984,CDM,352,RC,73700,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,Local,,1382.00,,,,,,,93.38,2565.25,case rate,
CT Upper Extremity Bilat w Contrast,8442476,CDM,352,RC,73201,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,Local,,1382.00,,,,,,,221.71,3033.14,case rate,
CT Watchman Chest w Contrast,8975193,CDM,352,RC,71260,HCPCS,,,facility,outpatient,,,1854.00000,537.66000,Aetna,Local,,1382.00,,,,,,,156.31,1516.57,case rate,
CT Watchman Chest wo Contrast,8975211,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Angio Pelvis:CT Exam 1,9093171,CDM,352,RC,72191,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
Radiology:CT Angio Pelvis,9094802,CDM,352,RC,72191,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Hip Ortho Bilateral MAKO,9034211,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,3136.00000,909.44000,Aetna,Local,,1382.00,,,,,,,93.38,2565.25,case rate,
CT Hip Ortho Left MAKO,9034213,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Hip Ortho Right MAKO,9032366,CDM,352,RC,72192,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,,1382.00,,,,,,,93.38,1474.00,case rate,
CT Post Bariatric CT Abd Pel w Contrast:CT Exam 1,9045933,CDM,352,RC,74177,HCPCS,,,facility,outpatient,,,3708.00000,1075.32000,Aetna,Local,,1382.00,,,,,,,235.67,3033.14,case rate,
CT Angio Runoff,9202440,CDM,352,RC,75635,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Angio Chest,9202519,CDM,352,RC,71275,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,Local,,1382.00,,,,,,,156.31,1750.52,case rate,
CT Upper Extremity Right wo Contrast,1083810,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Right wo Contrast,613446,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Right wo Contrast,613475,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Right wo Contrast,613514,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Right wo Contrast,613532,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Right wo Contrast,613572,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Right wo Contrast,613871,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Right wo Contrast,613911,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Right wo Contrast,8148235,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Shoulder Biomet Zimmer Right,8153827,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,RT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Left wo Contrast,1083814,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Left wo Contrast,613442,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Left wo Contrast,613469,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Left wo Contrast,613512,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Left wo Contrast,613530,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Left wo Contrast,613568,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Left wo Contrast,613866,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Left wo Contrast,613907,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Upper Extremity Left wo Contrast,8148234,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Shoulder Biomet Zimmer Left,8153825,CDM,352,RC,73200,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,Local,LT,1382.00,,,,,,,93.38,1474.00,case rate,
CT Chest Low Dose Follow Up,9072581,CDM,352,RC,71250,HCPCS,,,facility,outpatient,,,1882.00000,545.78000,Aetna,Local,,1382.00,,,,,,,93.38,1539.48,case rate,
CT Ablation Guidance,8001027,CDM,359,RC,,,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,Local,,1965.31,,,,,,,1395.50,3166.48,percent of total billed charges,
CT Guide for Needle Biopsy,8001033,CDM,359,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,2132.34,,,,,,,1514.10,3435.60,percent of total billed charges,
CT Guided Thoracentesis,6439868,CDM,359,RC,,,,,facility,outpatient,,,4208.00000,1220.32000,Aetna,Local,,2136.40,,,,,,,1516.98,3442.14,percent of total billed charges,
CT Denver Drain Placement Pleural,6439876,CDM,359,RC,,,,,facility,outpatient,,,5923.00000,1717.67000,Aetna,Local,,3007.11,,,,,,,2135.24,4845.01,percent of total billed charges,
CT Guided Chest Tube Placement,7069842,CDM,359,RC,,,,,facility,outpatient,,,5400.00000,1566.00000,Aetna,Local,,2741.58,,,,,,,1946.70,4417.20,percent of total billed charges,
CT Guided Chest Tube Placement,8001054,CDM,359,RC,,,,,facility,outpatient,,,5400.00000,1566.00000,Aetna,Local,,2741.58,,,,,,,1946.70,4417.20,percent of total billed charges,
CT Guided Injection,7285909,CDM,359,RC,,,,,facility,outpatient,,,2881.00000,835.49000,Aetna,Local,,1462.68,,,,,,,1038.60,2356.66,percent of total billed charges,
CT Guided Wire Localization,7285913,CDM,359,RC,,,,,facility,outpatient,,,2643.00000,766.47000,Aetna,Local,,1341.85,,,,,,,952.80,2161.97,percent of total billed charges,
CT Denver Drain Placement Peritoneal,7544100,CDM,359,RC,,,,,facility,outpatient,,,5286.00000,1532.94000,Aetna,Local,,2683.70,,,,,,,1905.60,4323.95,percent of total billed charges,
CT Guidance IR,9038230,CDM,359,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,432.60,981.60,percent of total billed charges,
CT Guidance,9158419,CDM,359,RC,,,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,761.55,,,,,,,540.75,1227.00,percent of total billed charges,
CT Guidance,8001026,CDM,359,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,432.60,981.60,percent of total billed charges,
EXTREMITY BLOCK CHARGE,9088208,CDM,360,RC,,,,,facility,outpatient,,,2545.00000,738.05000,Aetna,Local,,4610.00,,,,,,,917.47,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE JOINT,8404436,CDM,360,RC,,,,,facility,outpatient,,,2533.00000,734.57000,Aetna,Local,,4610.00,,,,,,,913.15,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK EXTREMITY,9098451,CDM,360,RC,,,,,facility,outpatient,,,2533.00000,734.57000,Aetna,Local,,4610.00,,,,,,,913.15,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK OTHER,9098452,CDM,360,RC,,,,,facility,outpatient,,,2533.00000,734.57000,Aetna,Local,,4610.00,,,,,,,913.15,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply Low Sub Feet Addl 25,8411844,CDM,360,RC,C5276,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,1610.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
FEMORAL NERVE BLOCK,7720094,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
FEMORAL NERVE BLOCK,7950175,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOOD PATCH,7720070,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OB Blood Patch,9020353,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTERSCALENE BLOCK,7720100,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE,7950176,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CENTRAL LINE PLACEMENT,7720074,CDM,360,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,Local,,4610.00,,,,,,,628.35,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Surgery Procedure Level 1,8981724,CDM,360,RC,,,,,facility,outpatient,,,10213.00000,2961.77000,Aetna,Local,,4610.00,,,,,,,1232.85,8354.23,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Surgery Procedure Level 2,8981723,CDM,360,RC,,,,,facility,outpatient,,,11131.00000,3227.99000,Aetna,Local,,4610.00,,,,,,,1232.85,9105.16,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Surgery Procedure Level 3,8981722,CDM,360,RC,,,,,facility,outpatient,,,11358.00000,3293.82000,Aetna,Local,,4610.00,,,,,,,1232.85,9290.84,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Surgery Procedure Level 4,8982482,CDM,360,RC,,,,,facility,outpatient,,,11585.00000,3359.65000,Aetna,Local,,4610.00,,,,,,,1232.85,9476.53,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Surgery Procedure Level 5,8982481,CDM,360,RC,,,,,facility,outpatient,,,11819.00000,3427.51000,Aetna,Local,,4610.00,,,,,,,1232.85,9667.94,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Surgery Procedure Level 1 Add On,8981721,CDM,360,RC,,,,,facility,outpatient,,,1930.00000,559.70000,Aetna,Local,,4610.00,,,,,,,695.76,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Surgery Procedure Level 2 Add On,8161222,CDM,360,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,Local,,4610.00,,,,,,,746.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Surgery Procedure Level 3 Add On,8981725,CDM,360,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,4610.00,,,,,,,757.05,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Surgery Procedure Level 4 Add On,8168892,CDM,360,RC,,,,,facility,outpatient,,,2255.00000,653.95000,Aetna,Local,,4610.00,,,,,,,812.93,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Surgery Procedure Level 5 Add On,8981727,CDM,360,RC,,,,,facility,outpatient,,,2370.00000,687.30000,Aetna,Local,,4610.00,,,,,,,854.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SUPRACLAVICULAR BLOCK,7950179,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
POPLITEAL BLOCK,7950178,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AXILLARY BLOCK,7950174,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ADDUCTOR CANCAL BLOCK,7950173,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TAP BLOCK CHARGE,7987721,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTERSCALENE BLOCK,7950177,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE FASCIA ILIAC BLOCK,8146878,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE ADDUCTOR CANAL CONTINUES,8146877,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE SUPRACLAVICULAR CONTINUES,8150938,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE ERECTOR SPINAE,8154827,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTERCOSTAL BRACHIAL BLOCK,8247187,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PENG BLOCK,8503930,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE SUPERFICIAL CERVICAL PLEXUS,8972084,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE INFRACLAVICULAR NERVE,9002009,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE ERECTOR SPINAE CONTINUOUS,9004817,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE MEDIAN NERVE BLOCK,9020750,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE RADIAL,9021136,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MUSCULOCUTANEOUS BLOCK,9032195,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ULNAR NERVE BLOCK,9032196,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLOCK CHARGE LATERAL FEMORAL,9046064,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BRACHIAL PLUXUS,9046065,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LEFT LATERAL FEMORAL,9046066,CDM,360,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
IntraOp Monitoring  Ea Addtl 15,9106484,CDM,360,RC,G0453,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,4610.00,,,,,,,27.04,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ULTRASOUND IMAGES SAVED,9226702,CDM,360,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,4610.00,,,,,,,432.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ANES Ultrasound Guidance Block Line Placement Epidural,8435934,CDM,360,RC,,,,,facility,outpatient,,,425.00000,123.25000,Aetna,Local,,4610.00,,,,,,,153.21,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Retrograde Pyelogram,614157,CDM,360,RC,,,,,facility,outpatient,,,2096.00000,607.84000,Aetna,Local,,4610.00,,,,,,,755.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp Inj Intermediate Jnt LT,9092773,CDM,360,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,Local,,4610.00,,,,,,,719.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Liver Ablation CT Guided,9076300,CDM,360,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,Local,,4610.00,,,,,,,1232.85,13822.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bone Marrow Biopsy And Aspiration,1327800,CDM,361,RC,,,,,facility,outpatient,,,2593.00000,751.97000,Aetna,Local,,4610.00,,,,,,,934.78,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bone Marrow Biopsy And Aspiration,7295870,CDM,361,RC,,,,,facility,outpatient,,,2593.00000,751.97000,Aetna,Local,,4610.00,,,,,,,934.78,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bone Marrow Biopsy And Aspiration,7957595,CDM,361,RC,,,,,facility,outpatient,,,2593.00000,751.97000,Aetna,Local,,4610.00,,,,,,,934.78,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Paracentesis,1327817,CDM,361,RC,,,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,4610.00,,,,,,,994.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Paracentesis,7295846,CDM,361,RC,,,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,4610.00,,,,,,,994.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Lumbar Puncture,1327812,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,Local,,4610.00,,,,,,,746.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Lumbar Puncture,7275857,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,Local,,4610.00,,,,,,,746.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Lumbar Puncture,7295861,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,Local,,4610.00,,,,,,,746.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Lumbar Puncture,7942791,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,Local,,4610.00,,,,,,,746.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Thoracentesis,1327819,CDM,361,RC,,,,,facility,outpatient,,,3008.00000,872.32000,Aetna,Local,,4610.00,,,,,,,1084.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Thoracentesis,7295848,CDM,361,RC,,,,,facility,outpatient,,,3008.00000,872.32000,Aetna,Local,,4610.00,,,,,,,1084.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERT CHEST TUBE,7295863,CDM,361,RC,,,,,facility,outpatient,,,1522.00000,441.38000,Aetna,Local,,4610.00,,,,,,,548.68,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Insert Chest Tube,7942785,CDM,361,RC,,,,,facility,outpatient,,,1522.00000,441.38000,Aetna,Local,,4610.00,,,,,,,548.68,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Insert Laryngoscopy And Or Trach,7295862,CDM,361,RC,,,,,facility,outpatient,,,2535.00000,735.15000,Aetna,Local,,4610.00,,,,,,,913.87,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Flexible Cystoscopy,7295865,CDM,361,RC,,,,,facility,outpatient,,,3037.00000,880.73000,Aetna,Local,,4610.00,,,,,,,1094.84,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Flexible Cystoscopy,8171790,CDM,361,RC,,,,,facility,outpatient,,,3037.00000,880.73000,Aetna,Local,,4610.00,,,,,,,1094.84,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Replace Central Venous Catheter,7295852,CDM,361,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,4610.00,,,,,,,497.49,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Replace Central Venous Catheter,7957592,CDM,361,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,4610.00,,,,,,,497.49,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Insert Central Venous Catheter,7295864,CDM,361,RC,,,,,facility,outpatient,,,1801.00000,522.29000,Aetna,Local,,4610.00,,,,,,,649.26,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Or Arthrocentesis,7295871,CDM,361,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,Local,,4610.00,,,,,,,628.35,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Place Dialysis Catheter,7457912,CDM,361,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,4610.00,,,,,,,497.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Place dialysis catheter,8171789,CDM,361,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,4610.00,,,,,,,497.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Place Central Line,8156502,CDM,361,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,Local,,4610.00,,,,,,,628.35,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Place Icp Monitoring Device,7457910,CDM,361,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,Local,,4610.00,,,,,,,418.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Lumbar Drain,7457908,CDM,361,RC,,,,,facility,outpatient,,,238.00000,69.02000,Aetna,Local,,4610.00,,,,,,,85.80,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Place Intracerebral Drain,7457909,CDM,361,RC,,,,,facility,outpatient,,,3052.00000,885.08000,Aetna,Local,,4610.00,,,,,,,1100.25,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Drain Abscess Cyst Or Lesion,7295867,CDM,361,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,Local,,4610.00,,,,,,,274.70,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Drain abscess cyst or lesion,8171372,CDM,361,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,Local,,4610.00,,,,,,,274.70,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Epidural,8172036,CDM,361,RC,,,,,facility,outpatient,,,2324.00000,673.96000,Aetna,Local,,4610.00,,,,,,,837.80,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Treatment Of Hypothermia,7457916,CDM,361,RC,,,,,facility,outpatient,,,3631.00000,1052.99000,Aetna,Local,,4610.00,,,,,,,1308.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Pleural Drainage And Cath Place,6847839,CDM,361,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,Local,,4610.00,,,,,,,418.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Pleural Drainage And Cath Place,7295854,CDM,361,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,Local,,4610.00,,,,,,,418.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Denver Drain Exchange,7457913,CDM,361,RC,,,,,facility,outpatient,,,509.00000,147.61000,Aetna,Local,,4610.00,,,,,,,183.49,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Denver Drain Exchange,7957588,CDM,361,RC,,,,,facility,outpatient,,,509.00000,147.61000,Aetna,Local,,4610.00,,,,,,,183.49,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy,7902565,CDM,361,RC,,,,,facility,outpatient,,,3080.00000,893.20000,Aetna,Local,,4610.00,,,,,,,1110.34,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVE IAB,7902567,CDM,361,RC,,,,,facility,outpatient,,,5695.00000,1651.55000,Aetna,Local,,4610.00,,,,,,,2053.05,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Orthopedic Treatment,7457900,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,4610.00,,,,,,,326.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Orthopedic Treatment,7457917,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,4610.00,,,,,,,326.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Orthopedic Treatment,7894476,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,4610.00,,,,,,,326.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Orthopedic Treatment,7894477,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,4610.00,,,,,,,326.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Orthopedic Treatment,7894482,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,4610.00,,,,,,,326.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Swan Ganz Insertion,7295849,CDM,361,RC,,,,,facility,outpatient,,,3994.00000,1158.26000,Aetna,Local,,4610.00,,,,,,,1439.84,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Swan Ganz Insertion,7457906,CDM,361,RC,,,,,facility,outpatient,,,3994.00000,1158.26000,Aetna,Local,,4610.00,,,,,,,1439.84,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Place Ventriculostomy,7457905,CDM,361,RC,,,,,facility,outpatient,,,2906.00000,842.74000,Aetna,Local,,4610.00,,,,,,,1047.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Plasma Exchange,8141860,CDM,361,RC,,,,,facility,outpatient,,,1664.00000,482.56000,Aetna,Local,,4610.00,,,,,,,599.87,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NB Circumcision,7939799,CDM,361,RC,,,,,facility,outpatient,,,1545.00000,448.05000,Aetna,Local,,4610.00,,,,,,,556.97,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NB Circumcision,7987281,CDM,361,RC,,,,,facility,outpatient,,,1545.00000,448.05000,Aetna,Local,,4610.00,,,,,,,556.97,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NB Insert Venous Umbilical Cath,7942789,CDM,361,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,4610.00,,,,,,,497.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NB Intubation,7942790,CDM,361,RC,,,,,facility,outpatient,,,2276.00000,660.04000,Aetna,Local,,4610.00,,,,,,,820.50,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NB Needle Aspiration,7942793,CDM,361,RC,,,,,facility,outpatient,,,872.00000,252.88000,Aetna,Local,,4610.00,,,,,,,314.36,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NB Exchange Transfusion Partial,7943093,CDM,361,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,Local,,4610.00,,,,,,,628.35,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NB Skin Tag Removal,7942794,CDM,361,RC,,,,,facility,outpatient,,,289.00000,83.81000,Aetna,Local,,4610.00,,,,,,,104.18,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NB Frenulectomy Or Frenectomy,7942783,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,4610.00,,,,,,,326.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NB Insert Arterial Umbilical Cath,7942784,CDM,361,RC,,,,,facility,outpatient,,,518.00000,150.22000,Aetna,Local,,4610.00,,,,,,,186.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Insert Picc Line,7894580,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,Local,,4610.00,,,,,,,1333.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Insert Picc Line,7942786,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,Local,,4610.00,,,,,,,1333.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Insert Picc Line,7942788,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,Local,,4610.00,,,,,,,1333.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PICC Insertion Successful,8950541,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,Local,,4610.00,,,,,,,1333.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PICC insertion by VAT team successful,9094037,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,Local,,4610.00,,,,,,,1333.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Midline Insertion,7920029,CDM,361,RC,,,,,facility,outpatient,,,1372.00000,397.88000,Aetna,Local,,4610.00,,,,,,,494.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Insert Laryngoscopy And Or Trach,2152832,CDM,361,RC,,,,,facility,outpatient,,,2535.00000,735.15000,Aetna,Local,,4610.00,,,,,,,913.87,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Orthopedic Treatment,7275862,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,4610.00,,,,,,,326.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Orthopedic Treatment,7894475,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,4610.00,,,,,,,326.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Orthopedic Treatment,7894504,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,4610.00,,,,,,,326.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Orthopedic Treatment,7894505,CDM,361,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,4610.00,,,,,,,326.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
I And D Complex,602594,CDM,361,RC,10061,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
I And D Complex,7958310,CDM,361,RC,10061,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Chemical Cautery Of Wound,602652,CDM,361,RC,17250,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Chemical Cautery Of Wound,7958354,CDM,361,RC,17250,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
I And D Simple,602592,CDM,361,RC,10060,HCPCS,,,facility,outpatient,,,1013.00000,293.77000,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
I And D Simple,7958308,CDM,361,RC,10060,HCPCS,,,facility,outpatient,,,1013.00000,293.77000,Aetna,Local,,1610.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Skin Subq First 20 Cm,4201840,CDM,361,RC,11042,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,2076.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Skin Subq First 20 Cm,7958311,CDM,361,RC,11042,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,2076.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Skin Subq Addl 20 Cm,4201839,CDM,361,RC,11045,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,1610.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Skin Subq Addl 20 Cm,7958313,CDM,361,RC,11045,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,1610.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Muscle Fascia First20,4201841,CDM,361,RC,11043,HCPCS,,,facility,outpatient,,,1866.00000,541.14000,Aetna,Local,,2076.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Muscle Fascia First20,7958315,CDM,361,RC,11043,HCPCS,,,facility,outpatient,,,1866.00000,541.14000,Aetna,Local,,2076.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Excision Of Nail,3172901,CDM,361,RC,11750,HCPCS,,,facility,outpatient,,,1050.00000,304.50000,Aetna,Local,,1610.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Excision Of Nail,7958352,CDM,361,RC,11750,HCPCS,,,facility,outpatient,,,1050.00000,304.50000,Aetna,Local,,1610.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Trim Of Nondys Nails,602624,CDM,361,RC,11719,HCPCS,,,facility,outpatient,,,345.00000,100.05000,Aetna,Local,,4610.00,,,,,,,25.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Trim Of Nondys Nails,7958344,CDM,361,RC,11719,HCPCS,,,facility,outpatient,,,345.00000,100.05000,Aetna,Local,,4610.00,,,,,,,25.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debride Of Nails 1 To 5,602626,CDM,361,RC,11720,HCPCS,,,facility,outpatient,,,345.00000,100.05000,Aetna,Local,,1610.00,,,,,,,52.15,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debride Of Nails 1 To 5,7958346,CDM,361,RC,11720,HCPCS,,,facility,outpatient,,,345.00000,100.05000,Aetna,Local,,1610.00,,,,,,,52.15,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debride Of Nails 6 Plus,602628,CDM,361,RC,11721,HCPCS,,,facility,outpatient,,,418.00000,121.22000,Aetna,Local,,1610.00,,,,,,,52.15,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debride Of Nails 6 Plus,7958348,CDM,361,RC,11721,HCPCS,,,facility,outpatient,,,418.00000,121.22000,Aetna,Local,,1610.00,,,,,,,52.15,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Avul Of Nail Plate Single,602630,CDM,361,RC,11730,HCPCS,,,facility,outpatient,,,623.00000,180.67000,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Avul Of Nail Plate Single,7958350,CDM,361,RC,11730,HCPCS,,,facility,outpatient,,,623.00000,180.67000,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Muscle Fascia Addl 20,4283839,CDM,361,RC,11046,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,1610.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Muscle Fascia Addl 20,7958316,CDM,361,RC,11046,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,1610.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Bone First 20 Sq Cm,4205845,CDM,361,RC,11044,HCPCS,,,facility,outpatient,,,4865.00000,1410.85000,Aetna,Local,,2076.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Bone First 20 Sq Cm,7958317,CDM,361,RC,11044,HCPCS,,,facility,outpatient,,,4865.00000,1410.85000,Aetna,Local,,2076.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Bone Addl 20 Sq Cm,7389880,CDM,361,RC,11047,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Bone Addl 20 Sq Cm,7958318,CDM,361,RC,11047,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Dress Debride P Thick Burn Medium,5385843,CDM,361,RC,16025,HCPCS,,,facility,outpatient,,,776.00000,225.04000,Aetna,Local,,2076.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Dress Debride P Thick Burn Medium,7959587,CDM,361,RC,16025,HCPCS,,,facility,outpatient,,,776.00000,225.04000,Aetna,Local,,2076.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Dress Debride P Thick Burn Small,5385844,CDM,361,RC,16020,HCPCS,,,facility,outpatient,,,550.00000,159.50000,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Dress Debride P Thick Burn Small,7959586,CDM,361,RC,16020,HCPCS,,,facility,outpatient,,,550.00000,159.50000,Aetna,Local,,1610.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Amputation Partial Toe Rt,8137559,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,RT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Partial Toe Amputation Right,8411590,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,RT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Partial Toe Amp RT,8411834,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,RT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub T A L Init 25,7417872,CDM,361,RC,15271,HCPCS,,,facility,outpatient,,,5800.00000,1682.00000,Aetna,Local,,2076.00,,,,,,,215.16,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub T A L Init 25,7958321,CDM,361,RC,15271,HCPCS,,,facility,outpatient,,,5800.00000,1682.00000,Aetna,Local,,2076.00,,,,,,,215.16,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub T A L Addl 25,7417873,CDM,361,RC,15272,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,1610.00,,,,,,,78.54,3926.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub T A L Addl 25,7958325,CDM,361,RC,15272,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,1610.00,,,,,,,78.54,3926.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub T A L Init 100,7417874,CDM,361,RC,15273,HCPCS,,,facility,outpatient,,,9400.00000,2726.00000,Aetna,Local,,2076.00,,,,,,,328.02,9771.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub T A L Init 100,7958329,CDM,361,RC,15273,HCPCS,,,facility,outpatient,,,9400.00000,2726.00000,Aetna,Local,,2076.00,,,,,,,328.02,9771.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub T A L Addl 100,7417875,CDM,361,RC,15274,HCPCS,,,facility,outpatient,,,9400.00000,2726.00000,Aetna,Local,,1610.00,,,,,,,215.16,7689.20,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub T A L Addl 100,7958333,CDM,361,RC,15274,HCPCS,,,facility,outpatient,,,9400.00000,2726.00000,Aetna,Local,,1610.00,,,,,,,215.16,7689.20,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub F H F Init 25,7417876,CDM,361,RC,15275,HCPCS,,,facility,outpatient,,,1991.00000,577.39000,Aetna,Local,,2076.00,,,,,,,215.16,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub F H F Addl 25,7417877,CDM,361,RC,15276,HCPCS,,,facility,outpatient,,,1991.00000,577.39000,Aetna,Local,,1610.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Resection Metatarsal,7958301,CDM,361,RC,28140,HCPCS,,,facility,outpatient,,,9559.00000,2772.11000,Aetna,Local,,3307.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Amputation Full Toe Rt,8137558,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,RT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Full toe Amputation Right,8411594,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,RT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Full Toe Amputation RT,8411832,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,RT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Amputation Full Toe Lt,8137557,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,LT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Full Toe Amputation Left,8411592,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,LT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Full Toe Amputation LT,8411833,CDM,361,RC,28820,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,LT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Amputation Partial Toe Lt,8137556,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,LT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Partial Toe Amputation Left,8411588,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,LT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Partial Toe Amp LT,8411835,CDM,361,RC,28825,HCPCS,,,facility,outpatient,,,8450.00000,2450.50000,Aetna,Local,LT,2076.00,,,,,,,1458.60,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Application Total Contact Cast Lt,7943797,CDM,361,RC,29445,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,Local,LT,4610.00,,,,,,,169.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Application Total Contact Cast Lt,7958322,CDM,361,RC,29445,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,Local,LT,4610.00,,,,,,,169.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration or Inject Joint Bursa,8137560,CDM,361,RC,20605,HCPCS,,,facility,outpatient,,,2533.00000,734.57000,Aetna,Local,,1610.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Tangential Biopsy Of Skin Single Lesion,8153919,CDM,361,RC,11102,HCPCS,,,facility,outpatient,,,1390.00000,403.10000,Aetna,Local,,1610.00,,,,,,,174.47,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Tangential Biopsy Single Lesion,8156015,CDM,361,RC,11102,HCPCS,,,facility,outpatient,,,1390.00000,403.10000,Aetna,Local,,1610.00,,,,,,,174.47,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Tangential Biopsy Of Skin Each Addl,8153925,CDM,361,RC,11103,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,Local,,1610.00,,,,,,,125.09,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Tangential Biopsy Addl Lesion,8156017,CDM,361,RC,11103,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,Local,,1610.00,,,,,,,125.09,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Punch Biopsy Of Skin Single Lesion,8153931,CDM,361,RC,11104,HCPCS,,,facility,outpatient,,,1432.00000,415.28000,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Punch Biopsy Of Skin Single Lesion,8156019,CDM,361,RC,11104,HCPCS,,,facility,outpatient,,,1432.00000,415.28000,Aetna,Local,,1610.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Punch Biopsy Of Skin Ea Addl,8153937,CDM,361,RC,11105,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,Local,,1610.00,,,,,,,125.09,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Punch Biopsy Of Skin Each Addl,8156021,CDM,361,RC,11105,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,Local,,1610.00,,,,,,,125.09,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Incisional Biopsy Of Skin Single Lesion,8153950,CDM,361,RC,11106,HCPCS,,,facility,outpatient,,,1867.00000,541.43000,Aetna,Local,,1610.00,,,,,,,537.48,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Incisional Bx Of Skin Single Lesion,8156023,CDM,361,RC,11106,HCPCS,,,facility,outpatient,,,1867.00000,541.43000,Aetna,Local,,1610.00,,,,,,,537.48,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Incisional Biopsy Of Skin Ea Addl,8153956,CDM,361,RC,11107,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,Local,,1610.00,,,,,,,125.09,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Incisional Bx Of Skin Each Addl,8156025,CDM,361,RC,11107,HCPCS,,,facility,outpatient,,,347.00000,100.63000,Aetna,Local,,1610.00,,,,,,,125.09,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub Feet Addl 100,8411851,CDM,361,RC,15278,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,1610.00,,,,,,,215.16,3926.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC I and D of hematoma seroma or fluid collection,8411602,CDM,361,RC,10140,HCPCS,,,facility,outpatient,,,3329.00000,965.41000,Aetna,Local,,1610.00,,,,,,,866.58,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
I and D Hematoma,8411852,CDM,361,RC,10140,HCPCS,,,facility,outpatient,,,3329.00000,965.41000,Aetna,Local,,1610.00,,,,,,,866.58,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Paring cutting benign hyperkeratotic lesion,8411604,CDM,361,RC,11055,HCPCS,,,facility,outpatient,,,520.00000,150.80000,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Trim Skin Lesion,8411854,CDM,361,RC,11055,HCPCS,,,facility,outpatient,,,520.00000,150.80000,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Pare cut benign hyperkeratotic les 2 to 4,8411606,CDM,361,RC,11056,HCPCS,,,facility,outpatient,,,665.00000,192.85000,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Trim Skin Lesion 2 to 4,8411855,CDM,361,RC,11056,HCPCS,,,facility,outpatient,,,665.00000,192.85000,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Avul of Nail Plate Add On,8411620,CDM,361,RC,11732,HCPCS,,,facility,outpatient,,,455.00000,131.95000,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Avulsion of Nail Plate Add On,8411849,CDM,361,RC,11732,HCPCS,,,facility,outpatient,,,455.00000,131.95000,Aetna,Local,,1610.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub Feet Initial 100,7958323,CDM,361,RC,15277,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,2076.00,,,,,,,328.02,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub Feet Initial 100,8411850,CDM,361,RC,15277,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,2076.00,,,,,,,328.02,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply High Sub Feet Addl 100,7958327,CDM,361,RC,15278,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,1610.00,,,,,,,215.16,3926.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply Low Sub Legs Initial 25,8411842,CDM,361,RC,C5271,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,2076.00,,,,,,,315.00,2209.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply Low Sub Feet Initital 25,8411843,CDM,361,RC,C5275,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,2076.00,,,,,,,315.00,2209.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply Low Sub Legs Addl 25,8411841,CDM,361,RC,C5272,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,Local,,1610.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply Low Sub Legs Initial 100,8411848,CDM,361,RC,C5273,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,2076.00,,,,,,,1730.40,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply Low Sub Feet Initial 100,8411846,CDM,361,RC,C5277,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,2076.00,,,,,,,315.00,3926.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply Low Sub Legs Addl 100,8411847,CDM,361,RC,C5274,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,1610.00,,,,,,,315.00,3926.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply Low Sub Feet Addl 100,8411845,CDM,361,RC,C5278,HCPCS,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,1610.00,,,,,,,315.00,3926.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Dress Debride P Thick Burn L,8411784,CDM,361,RC,16030,HCPCS,,,facility,outpatient,,,1034.00000,299.86000,Aetna,Local,,2076.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Biopsy of Bone,8411608,CDM,361,RC,20220,HCPCS,,,facility,outpatient,,,4250.00000,1232.50000,Aetna,Local,,1610.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy of Bone,8411839,CDM,361,RC,20220,HCPCS,,,facility,outpatient,,,4250.00000,1232.50000,Aetna,Local,,1610.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Remove Foregn Body Simple,8411830,CDM,361,RC,10120,HCPCS,,,facility,outpatient,,,1050.00000,304.50000,Aetna,Local,,1610.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Remove Foreign Body Complex,8411831,CDM,361,RC,10121,HCPCS,,,facility,outpatient,,,2524.00000,731.96000,Aetna,Local,,2076.00,,,,,,,936.91,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Deep Muscle Biopsy,9040169,CDM,361,RC,20205,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3307.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Deep Muscle Biopsy,9043763,CDM,361,RC,20205,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,Local,,3307.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Excision of Benign Lesion scalp neck hands feet,9021658,CDM,361,RC,11421,HCPCS,,,facility,outpatient,,,4500.00000,1305.00000,Aetna,Local,,2076.00,,,,,,,545.82,3681.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Excision Benign Lesion trunk arm legs,9022163,CDM,361,RC,11406,HCPCS,,,facility,outpatient,,,4500.00000,1305.00000,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Excision Benign Lesion,9024453,CDM,361,RC,11406,HCPCS,,,facility,outpatient,,,4500.00000,1305.00000,Aetna,Local,,2076.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
WHC Excision Malignant Lesion Trunk Arms Legs,9010174,CDM,361,RC,11604,HCPCS,,,facility,outpatient,,,4500.00000,1305.00000,Aetna,Local,,2076.00,,,,,,,545.82,3681.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TPA Administation Or Declot,599448,CDM,361,RC,,,,,facility,outpatient,,,707.00000,205.03000,Aetna,Local,,4610.00,,,,,,,254.87,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TPA Administation Or Declot,7902208,CDM,361,RC,,,,,facility,outpatient,,,707.00000,205.03000,Aetna,Local,,4610.00,,,,,,,254.87,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TPA Administation Or Declot,7902275,CDM,361,RC,,,,,facility,outpatient,,,707.00000,205.03000,Aetna,Local,,4610.00,,,,,,,254.87,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LITHOTRIPSY,7720029,CDM,361,RC,,,,,facility,outpatient,,,16035.00000,4650.15000,Aetna,Local,,4610.00,,,,,,,4610.00,13116.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Epidural Injection,613706,CDM,361,RC,,,,,facility,outpatient,,,2761.00000,800.69000,Aetna,Local,,4610.00,,,,,,,995.34,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Ablation Bone Tumor,8147143,CDM,361,RC,,,,,facility,outpatient,,,7428.00000,2154.12000,Aetna,Local,,4610.00,,,,,,,2677.79,6076.10,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Injection for Hysterosalpingogram,8001040,CDM,361,RC,,,,,facility,outpatient,,,1451.00000,420.79000,Aetna,Local,,4610.00,,,,,,,523.09,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Injection for Arthrogram,8001041,CDM,361,RC,,,,,facility,outpatient,,,1451.00000,420.79000,Aetna,Local,,4610.00,,,,,,,523.09,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Injection for Procedure,8001042,CDM,361,RC,,,,,facility,outpatient,,,1451.00000,420.79000,Aetna,Local,,4610.00,,,,,,,523.09,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Myelogram Cervical,9062217,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Myelogram Thoracic,9062220,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Myelogram Lumbar,9062219,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Myelogram Cervical Thoracic,9062218,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Myelogram Thoracic Lumbar,9062221,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Myelogram Cervical Lumbar,9064201,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Myelogram Total Spine,9064202,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Lumbar Puncture,624491,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,Local,,4610.00,,,,,,,746.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Axillary Biopsy Right,8001069,CDM,361,RC,,,,,facility,outpatient,,,3000.00000,870.00000,Aetna,Local,,4610.00,,,,,,,1081.50,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Each Additional Lesion Fine Needle,8154200,CDM,361,RC,,,,,facility,outpatient,,,3317.00000,961.93000,Aetna,Local,,4610.00,,,,,,,1195.78,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Gall Bladder Operative,613785,CDM,361,RC,,,,,facility,outpatient,,,1089.00000,315.81000,Aetna,Local,,4610.00,,,,,,,392.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Percutaneous Cholangiogram,2888832,CDM,361,RC,,,,,facility,outpatient,,,4374.00000,1268.46000,Aetna,Local,,4610.00,,,,,,,1576.83,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Nephrostogram,2888831,CDM,361,RC,,,,,facility,outpatient,,,5254.00000,1523.66000,Aetna,Local,,4610.00,,,,,,,1894.07,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Radiologic Guidance,8001074,CDM,361,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,4610.00,,,,,,,432.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Bone Biopsy,7918032,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Biopsy Abdominal Mass,3661971,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Renal,9198582,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Other,9196961,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SONO GUIDED BREAST LOC ADDL SITE,6043878,CDM,361,RC,,,,,facility,outpatient,,,2992.00000,867.68000,Aetna,Local,,4610.00,,,,,,,1078.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Breast Limited Bilateral,654595,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SONO GUIDED BREAST BIOPSY ADDL,6043876,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Localization,654590,CDM,361,RC,,,,,facility,outpatient,,,3863.00000,1120.27000,Aetna,Local,,4610.00,,,,,,,1392.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SONO GUIDED MAMMOTOME BIOPSY ADDL,6043874,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guide Inject Tendon Ligament Left,7991406,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,Local,,4610.00,,,,,,,746.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guide Inject Tendon Ligament Right,7991410,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,Local,,4610.00,,,,,,,746.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Localization Right,8181312,CDM,361,RC,,,,,facility,outpatient,,,4211.00000,1221.19000,Aetna,Local,,4610.00,,,,,,,1518.07,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Localization Left,8181320,CDM,361,RC,,,,,facility,outpatient,,,4211.00000,1221.19000,Aetna,Local,,4610.00,,,,,,,1518.07,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Localization Bilateral,8181322,CDM,361,RC,,,,,facility,outpatient,,,8422.00000,2442.38000,Aetna,Local,,4610.00,,,,,,,3036.13,6889.20,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Amniocentesis,7913740,CDM,361,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,Local,,4610.00,,,,,,,418.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Cordocentesis,7913744,CDM,361,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,Local,,4610.00,,,,,,,418.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp Inj Small Joint LT,9092776,CDM,361,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,Local,,4610.00,,,,,,,719.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp Inj Small Joint RT,9092777,CDM,361,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,Local,,4610.00,,,,,,,719.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp/Inj Intermediate Right,9094377,CDM,361,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,Local,,4610.00,,,,,,,719.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp Inj Major Joint Left,9092774,CDM,361,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,Local,,4610.00,,,,,,,719.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp Inj Major Joint RT,9092775,CDM,361,RC,,,,,facility,outpatient,,,1997.00000,579.13000,Aetna,Local,,4610.00,,,,,,,719.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Addl Lesion Fine Needle,8154198,CDM,361,RC,,,,,facility,outpatient,,,3682.00000,1067.78000,Aetna,Local,,4610.00,,,,,,,1327.36,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guide Injection Tendon Ligament Bilateral,8436137,CDM,361,RC,,,,,facility,outpatient,,,1972.00000,571.88000,Aetna,Local,,4610.00,,,,,,,710.91,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp Injection Intermediate Joint Bilateral,9094376,CDM,361,RC,,,,,facility,outpatient,,,1832.00000,531.28000,Aetna,Local,,4610.00,,,,,,,660.44,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp Inj Major Joint Left,9094378,CDM,361,RC,,,,,facility,outpatient,,,1832.00000,531.28000,Aetna,Local,,4610.00,,,,,,,660.44,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guide Inject Tendon Ligament Right,8436172,CDM,361,RC,,,,,facility,outpatient,,,1972.00000,571.88000,Aetna,Local,,4610.00,,,,,,,710.91,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp Injection Intermediate Joint Right,8436173,CDM,361,RC,,,,,facility,outpatient,,,1599.00000,463.71000,Aetna,Local,,4610.00,,,,,,,576.44,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp/Inj Small Joint Left,9094379,CDM,361,RC,,,,,facility,outpatient,,,1832.00000,531.28000,Aetna,Local,,4610.00,,,,,,,660.44,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp Injection Small Joint Right,8436174,CDM,361,RC,,,,,facility,outpatient,,,1900.00000,551.00000,Aetna,Local,,4610.00,,,,,,,684.95,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Asp Injection Major Joint Right,8436175,CDM,361,RC,,,,,facility,outpatient,,,1900.00000,551.00000,Aetna,Local,,4610.00,,,,,,,684.95,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Loc Bilat Pellet,8945730,CDM,361,RC,,,,,facility,outpatient,,,7086.00000,2054.94000,Aetna,Local,,4610.00,,,,,,,2554.50,5796.35,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Loc Left Pellet,8927458,CDM,361,RC,,,,,facility,outpatient,,,4211.00000,1221.19000,Aetna,Local,,4610.00,,,,,,,1518.07,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Loc Right Pellet,8927460,CDM,361,RC,,,,,facility,outpatient,,,3544.00000,1027.76000,Aetna,Local,,4610.00,,,,,,,1277.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Biopsy Left,9158474,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,4610.00,,,,,,,757.05,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Biopsy Right,9160461,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,4610.00,,,,,,,757.05,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Biopsy Bilateral,9160465,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Cyst Aspiration LT,9158489,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,4610.00,,,,,,,757.05,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Cyst Aspiration RT,9158491,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,4610.00,,,,,,,757.05,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Breast Cyst Aspiration Bilat,9158493,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Mammotome Biopsy LT,9160467,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,4610.00,,,,,,,757.05,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Mammotome Biopsy RT,9160479,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,4610.00,,,,,,,757.05,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Mammotome Biopsy Bilat,9160481,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Localization,9198651,CDM,361,RC,,,,,facility,outpatient,,,1332.00000,386.28000,Aetna,Local,,4610.00,,,,,,,480.19,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Thoracentesis,9198606,CDM,361,RC,,,,,facility,outpatient,,,4208.00000,1220.32000,Aetna,Local,,4610.00,,,,,,,1516.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Paracentesis with Guidance,614061,CDM,361,RC,,,,,facility,outpatient,,,3960.00000,1148.40000,Aetna,Local,,4610.00,,,,,,,1427.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Paracentesis,9196891,CDM,361,RC,,,,,facility,outpatient,,,4197.00000,1217.13000,Aetna,Local,,4610.00,,,,,,,1513.02,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Thyroid Needle Biopsy,9196929,CDM,361,RC,,,,,facility,outpatient,,,4908.00000,1423.32000,Aetna,Local,,4610.00,,,,,,,1769.33,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy,9198641,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Pancreas,9198542,CDM,361,RC,,,,,facility,outpatient,,,2593.00000,751.97000,Aetna,Local,,4610.00,,,,,,,934.78,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Abdominal Mass,9196946,CDM,361,RC,,,,,facility,outpatient,,,2593.00000,751.97000,Aetna,Local,,4610.00,,,,,,,934.78,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Renal Mass,9196918,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Renal,3661953,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Biopsy Other,3661967,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Bone Marrow Biopsy,7918036,CDM,361,RC,,,,,facility,outpatient,,,4656.00000,1350.24000,Aetna,Local,,4610.00,,,,,,,1678.49,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Biopsy Bone Marrow,8001038,CDM,361,RC,,,,,facility,outpatient,,,4656.00000,1350.24000,Aetna,Local,,4610.00,,,,,,,1678.49,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CT Guided Pleura Biopsy,3661955,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CT Guided Addl Lesion Fine Needle,8154202,CDM,361,RC,,,,,facility,outpatient,,,3926.00000,1138.54000,Aetna,Local,,4610.00,,,,,,,1415.32,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Bone,3661965,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CT Guided Lung Biopsy,3661959,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Liver,3661961,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Pancreas,3661957,CDM,361,RC,,,,,facility,outpatient,,,3000.00000,870.00000,Aetna,Local,,4610.00,,,,,,,1081.50,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Renal Mass,3661951,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MR Guided Mammotome Biopsy,3661945,CDM,361,RC,,,,,facility,outpatient,,,6889.00000,1997.81000,Aetna,Local,,4610.00,,,,,,,2483.48,5635.20,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MAMMO GUIDED BREAST LOC ADDL SITE,6043882,CDM,361,RC,,,,,facility,outpatient,,,4075.00000,1181.75000,Aetna,Local,,4610.00,,,,,,,1469.04,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MAMMO GUIDED BREAST BIOPSY ADDL,6043880,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MM Biopsy Breast Stereotactic Left,9158515,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,4610.00,,,,,,,757.05,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MM Biopsy Breast Stereotactic Right,9162392,CDM,361,RC,,,,,facility,outpatient,,,2100.00000,609.00000,Aetna,Local,,4610.00,,,,,,,757.05,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MM Biopsy Breast Stereotactic Bilat,9162394,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MM Preop Breast Localization Left,9162400,CDM,361,RC,,,,,facility,outpatient,,,4211.00000,1221.19000,Aetna,Local,,4610.00,,,,,,,1518.07,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MM Preop Breast Localization Right,9162401,CDM,361,RC,,,,,facility,outpatient,,,4211.00000,1221.19000,Aetna,Local,,4610.00,,,,,,,1518.07,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MM Preop Breast Localization Bilat,9164395,CDM,361,RC,,,,,facility,outpatient,,,8422.00000,2442.38000,Aetna,Local,,4610.00,,,,,,,3036.13,6889.20,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Kyphoplasty Each Add Vertebrae,1053806,CDM,361,RC,,,,,facility,outpatient,,,17570.00000,5095.30000,Aetna,Local,,4610.00,,,,,,,4610.00,14372.26,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Ablation Bone,3661989,CDM,361,RC,,,,,facility,outpatient,,,8178.00000,2371.62000,Aetna,Local,,4610.00,,,,,,,2948.17,6689.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AFC GENERIC ADD-ON,9076525,CDM,361,RC,,,,,facility,outpatient,,,8178.00000,2371.62000,Aetna,Local,,4610.00,,,,,,,2948.17,6689.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Ablation Liver,3661991,CDM,361,RC,,,,,facility,outpatient,,,8178.00000,2371.62000,Aetna,Local,,4610.00,,,,,,,2948.17,6689.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Ablation Renal Bilateral,3661995,CDM,361,RC,,,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,4610.00,,,,,,,4610.00,14724.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Port A Cath Removal,2044835,CDM,361,RC,,,,,facility,outpatient,,,5040.00000,1461.60000,Aetna,Local,,4610.00,,,,,,,1816.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided MammoSite Placement,2032825,CDM,361,RC,,,,,facility,outpatient,,,30000.00000,8700.00000,Aetna,Local,,4610.00,,,,,,,4610.00,24540.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Dialysis Cath Placement Temporary,3665839,CDM,361,RC,,,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,Local,,4610.00,,,,,,,3893.40,8834.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Tunneled Line Removal,3661981,CDM,361,RC,,,,,facility,outpatient,,,3563.00000,1033.27000,Aetna,Local,,4610.00,,,,,,,1284.46,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Ureteral Stent Placement,3661979,CDM,361,RC,,,,,facility,outpatient,,,11040.00000,3201.60000,Aetna,Local,,4610.00,,,,,,,3979.92,9030.72,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN IVC Filter Removal,2890858,CDM,361,RC,,,,,facility,outpatient,,,11437.00000,3316.73000,Aetna,Local,,4610.00,,,,,,,4123.04,9355.47,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Central Line Placement,2890847,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,Local,,4610.00,,,,,,,3590.58,8147.28,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Chest Tube Placement,3661939,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Transjugular Liver Biopsy,3662005,CDM,361,RC,,,,,facility,outpatient,,,6073.00000,1761.17000,Aetna,Local,,4610.00,,,,,,,2189.32,4967.71,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN JTube Exchange,2890854,CDM,361,RC,,,,,facility,outpatient,,,7747.00000,2246.63000,Aetna,Local,,4610.00,,,,,,,2792.79,6337.05,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Nephrostomy Tube Placement,3662003,CDM,361,RC,,,,,facility,outpatient,,,6360.00000,1844.40000,Aetna,Local,,4610.00,,,,,,,2292.78,5202.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Nephrostomy Tube Placement,8001039,CDM,361,RC,,,,,facility,outpatient,,,6360.00000,1844.40000,Aetna,Local,,4610.00,,,,,,,2292.78,5202.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Dialysis Cath Placement Permanent,3661999,CDM,361,RC,,,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,Local,,4610.00,,,,,,,3893.40,8834.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Ablation Pulmonary,3661993,CDM,361,RC,,,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,Local,,4610.00,,,,,,,4610.00,14724.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN VERTEBROPLASTY EACH ADDL LEVEL,7265840,CDM,361,RC,,,,,facility,outpatient,,,15198.00000,4407.42000,Aetna,Local,,4610.00,,,,,,,4610.00,12431.96,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Cecostomy Tube Exchange,6825867,CDM,361,RC,,,,,facility,outpatient,,,11432.00000,3315.28000,Aetna,Local,,4610.00,,,,,,,4121.24,9351.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Tube Check,2890843,CDM,361,RC,,,,,facility,outpatient,,,1678.00000,486.62000,Aetna,Local,,4610.00,,,,,,,604.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Gastrostomy Tube Exchange,7285861,CDM,361,RC,,,,,facility,outpatient,,,11432.00000,3315.28000,Aetna,Local,,4610.00,,,,,,,4121.24,9351.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN GJ Tube Exchnage,7285865,CDM,361,RC,,,,,facility,outpatient,,,5911.00000,1714.19000,Aetna,Local,,4610.00,,,,,,,2130.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Fluoro Guided Beacon Placement Liver,7920903,CDM,361,RC,,,,,facility,outpatient,,,5230.00000,1516.70000,Aetna,Local,,4610.00,,,,,,,1885.41,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Biopsy and Aspriation,3661963,CDM,361,RC,,,,,facility,outpatient,,,11237.00000,3258.73000,Aetna,Local,,4610.00,,,,,,,4050.94,9191.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Gastrostomy Tube Placement,8945702,CDM,361,RC,,,,,facility,outpatient,,,6000.00000,1740.00000,Aetna,Local,,4610.00,,,,,,,2163.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN GJ Tube Placement,8945704,CDM,361,RC,,,,,facility,outpatient,,,6000.00000,1740.00000,Aetna,Local,,4610.00,,,,,,,2163.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Gastrostomy to GJ Conversion,8945698,CDM,361,RC,,,,,facility,outpatient,,,6000.00000,1740.00000,Aetna,Local,,4610.00,,,,,,,2163.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Injection,8927432,CDM,361,RC,,,,,facility,outpatient,,,1999.00000,579.71000,Aetna,Local,,4610.00,,,,,,,720.64,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Sacroplasty Unilateral,8975125,CDM,361,RC,,,,,facility,outpatient,,,22800.00000,6612.00000,Aetna,Local,,4610.00,,,,,,,4610.00,18650.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Sacroplasty Bilateral,8973008,CDM,361,RC,,,,,facility,outpatient,,,22800.00000,6612.00000,Aetna,Local,,4610.00,,,,,,,4610.00,18650.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Lymphangiogram,8975131,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,Local,,4610.00,,,,,,,3590.58,8147.28,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biliary Drain Check Change Upsize,9078237,CDM,361,RC,,,,,facility,outpatient,,,5306.00000,1538.74000,Aetna,Local,,4610.00,,,,,,,1912.81,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biliary Drain Removal,9076228,CDM,361,RC,,,,,facility,outpatient,,,2718.00000,788.22000,Aetna,Local,,4610.00,,,,,,,979.84,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biliary Dilation,9076230,CDM,361,RC,,,,,facility,outpatient,,,1742.00000,505.18000,Aetna,Local,,4610.00,,,,,,,627.99,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biliary Stent Placement,9078239,CDM,361,RC,,,,,facility,outpatient,,,18301.00000,5307.29000,Aetna,Local,,4610.00,,,,,,,4610.00,14970.22,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biliary Stone Removal,9076232,CDM,361,RC,,,,,facility,outpatient,,,7026.00000,2037.54000,Aetna,Local,,4610.00,,,,,,,2532.87,5747.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biliary Biopsy,9078241,CDM,361,RC,,,,,facility,outpatient,,,3000.00000,870.00000,Aetna,Local,,4610.00,,,,,,,1081.50,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TIPS Placement,9078243,CDM,361,RC,,,,,facility,outpatient,,,7874.00000,2283.46000,Aetna,Local,,4610.00,,,,,,,2838.58,6440.93,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Thoracic augment,9076242,CDM,361,RC,,,,,facility,outpatient,,,19172.00000,5559.88000,Aetna,Local,,4610.00,,,,,,,4610.00,15682.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Lumbar Augment,9078256,CDM,361,RC,,,,,facility,outpatient,,,17430.00000,5054.70000,Aetna,Local,,4610.00,,,,,,,4610.00,14257.74,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sacral augment,9076244,CDM,361,RC,,,,,facility,outpatient,,,17430.00000,5054.70000,Aetna,Local,,4610.00,,,,,,,4610.00,14257.74,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Liver Ablation,9076246,CDM,361,RC,,,,,facility,outpatient,,,7502.00000,2175.58000,Aetna,Local,,4610.00,,,,,,,2704.47,6136.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Right Nephrostomy Tube Check,9078258,CDM,361,RC,,,,,facility,outpatient,,,4208.00000,1220.32000,Aetna,Local,,4610.00,,,,,,,1516.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Left Nephrostomy Tube Check,9076248,CDM,361,RC,,,,,facility,outpatient,,,4208.00000,1220.32000,Aetna,Local,,4610.00,,,,,,,1516.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bilateral Nephrostomy Tube Check,9078260,CDM,361,RC,,,,,facility,outpatient,,,4208.00000,1220.32000,Aetna,Local,,4610.00,,,,,,,1516.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Right Nephrostomy Tube Exchange,9078262,CDM,361,RC,,,,,facility,outpatient,,,5777.00000,1675.33000,Aetna,Local,,4610.00,,,,,,,2082.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Left Nephrostomy Tube Exchange,9078264,CDM,361,RC,,,,,facility,outpatient,,,5777.00000,1675.33000,Aetna,Local,,4610.00,,,,,,,2082.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bilateral Nephrostomy Tube Exchange,9078266,CDM,361,RC,,,,,facility,outpatient,,,11031.00000,3198.99000,Aetna,Local,,4610.00,,,,,,,3976.68,9023.36,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Cholecystostomy Tube Placement,9076250,CDM,361,RC,,,,,facility,outpatient,,,3269.00000,948.01000,Aetna,Local,,4610.00,,,,,,,1178.47,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Cholecystostomy Check Change Upsize,9078272,CDM,361,RC,,,,,facility,outpatient,,,3269.00000,948.01000,Aetna,Local,,4610.00,,,,,,,1178.47,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Abscess Drain Check Change Upsize,9078274,CDM,361,RC,,,,,facility,outpatient,,,1465.00000,424.85000,Aetna,Local,,4610.00,,,,,,,528.13,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Abscess Drain Check Change Upsize,9078783,CDM,361,RC,,,,,facility,outpatient,,,1465.00000,424.85000,Aetna,Local,,4610.00,,,,,,,528.13,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Thoracic Kyphoplasty,9076292,CDM,361,RC,,,,,facility,outpatient,,,20710.00000,6005.90000,Aetna,Local,,4610.00,,,,,,,4610.00,16940.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Lumbar Kyphoplasty,9076294,CDM,361,RC,,,,,facility,outpatient,,,20710.00000,6005.90000,Aetna,Local,,4610.00,,,,,,,4610.00,16940.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Each Additional Level for Kyphoplasty,9078304,CDM,361,RC,,,,,facility,outpatient,,,15960.00000,4628.40000,Aetna,Local,,4610.00,,,,,,,4610.00,13055.28,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Liver Ablation Sono Guided,9076298,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,Local,,4610.00,,,,,,,4610.00,13822.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Thyroid Ablation Sono Guided,9076296,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,Local,,4610.00,,,,,,,4610.00,13822.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Renal Unilateral Ablation Sono Gudied,9078306,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,Local,,4610.00,,,,,,,4610.00,13822.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Cholecystostomy Tube Placement CT Guided,9078278,CDM,361,RC,,,,,facility,outpatient,,,5308.00000,1539.32000,Aetna,Local,,4610.00,,,,,,,1913.53,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Cholecystostomy Check Change Upsize,9076254,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,Local,,4610.00,,,,,,,3590.58,8147.28,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Abcess Drain Check Change or Upsize,9076256,CDM,361,RC,,,,,facility,outpatient,,,5354.00000,1552.66000,Aetna,Local,,4610.00,,,,,,,1930.12,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Abcess Drain Placement CT Guided,9076258,CDM,361,RC,,,,,facility,outpatient,,,6343.00000,1839.47000,Aetna,Local,,4610.00,,,,,,,2286.65,5188.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Drain Check Change or Upsize,9076260,CDM,361,RC,,,,,facility,outpatient,,,3269.00000,948.01000,Aetna,Local,,4610.00,,,,,,,1178.47,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Drain Placement,9078280,CDM,361,RC,,,,,facility,outpatient,,,3269.00000,948.01000,Aetna,Local,,4610.00,,,,,,,1178.47,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Renal Cyst CT Guided,9078282,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,Local,,4610.00,,,,,,,726.77,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Seroma CT Guided,9078284,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,Local,,4610.00,,,,,,,726.77,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Abdominal CT Guided,9076262,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,Local,,4610.00,,,,,,,726.77,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Groin CT Guided,9076264,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,Local,,4610.00,,,,,,,726.77,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Renal Cyst Sono Guided,9078286,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,Local,,4610.00,,,,,,,726.77,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Renal Bilateral Sono Guided,9076324,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,Local,,4610.00,,,,,,,4610.00,13822.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Renal Unilateral Ablation CT Gudied,9076302,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,Local,,4610.00,,,,,,,4610.00,13822.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Renal Bilateral CT Guided,9078322,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,Local,,4610.00,,,,,,,4610.00,13822.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bone Ablation CT Guided,9076304,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,Local,,4610.00,,,,,,,4610.00,13822.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Lung Unilateral Ablation CT Guided,9078308,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,Local,,4610.00,,,,,,,4610.00,13822.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Lung Bilateral Ablation CT Guided,9076326,CDM,361,RC,,,,,facility,outpatient,,,16898.00000,4900.42000,Aetna,Local,,4610.00,,,,,,,4610.00,13822.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Parathyroid Sampling,9076226,CDM,361,RC,,,,,facility,outpatient,,,3842.00000,1114.18000,Aetna,Local,,4610.00,,,,,,,1385.04,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Adrenal Vein Sampling,9078233,CDM,361,RC,,,,,facility,outpatient,,,3842.00000,1114.18000,Aetna,Local,,4610.00,,,,,,,1385.04,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Line Replacement,9076252,CDM,361,RC,,,,,facility,outpatient,,,1747.00000,506.63000,Aetna,Local,,4610.00,,,,,,,629.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bilateral Nephrostomy Tube Placememt,9078270,CDM,361,RC,,,,,facility,outpatient,,,11031.00000,3198.99000,Aetna,Local,,4610.00,,,,,,,3976.68,9023.36,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Each Additional Drain,9076316,CDM,361,RC,,,,,facility,outpatient,,,2059.00000,597.11000,Aetna,Local,,4610.00,,,,,,,742.27,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Ea Additional Drain CT,9078318,CDM,361,RC,,,,,facility,outpatient,,,3996.00000,1158.84000,Aetna,Local,,4610.00,,,,,,,1440.56,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Each Additional Chest Tube,9078320,CDM,361,RC,,,,,facility,outpatient,,,2646.00000,767.34000,Aetna,Local,,4610.00,,,,,,,953.88,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EA Additional Chest Tube CT,9076318,CDM,361,RC,,,,,facility,outpatient,,,2646.00000,767.34000,Aetna,Local,,4610.00,,,,,,,953.88,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Disc,9076320,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,Local,,4610.00,,,,,,,726.77,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Disc CT Guided,9076322,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,Local,,4610.00,,,,,,,726.77,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Axillary Bilateral Biopsy,9076272,CDM,361,RC,,,,,facility,outpatient,,,6000.00000,1740.00000,Aetna,Local,,4610.00,,,,,,,2163.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Axillary Left Biopsy,9076268,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Right Cervical Biopsy,9078296,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Right Groin Biopsy,9078292,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Right Inguinal Biopsy,9076278,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Right Supraclavicular Biopsy,9076284,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Right Nephrostomy Tube Placement,9076647,CDM,361,RC,,,,,facility,outpatient,,,5777.00000,1675.33000,Aetna,Local,,4610.00,,,,,,,2082.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Left Nephrostomy Tube Placement,9076651,CDM,361,RC,,,,,facility,outpatient,,,5777.00000,1675.33000,Aetna,Local,,4610.00,,,,,,,2082.61,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Lumbar Puncture,9074544,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,Local,,4610.00,,,,,,,746.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AFC GENERIC ADD-ON,9076366,CDM,361,RC,,,,,facility,outpatient,,,2071.00000,600.59000,Aetna,Local,,4610.00,,,,,,,746.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Pseudo Aneurysm Treatment,9076288,CDM,361,RC,,,,,facility,outpatient,,,2256.00000,654.24000,Aetna,Local,,4610.00,,,,,,,813.29,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Thrombin Injection,9198609,CDM,361,RC,,,,,facility,outpatient,,,2256.00000,654.24000,Aetna,Local,,4610.00,,,,,,,813.29,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Denver Drain Placement Peritoneal,9198625,CDM,361,RC,,,,,facility,outpatient,,,8292.00000,2404.68000,Aetna,Local,,4610.00,,,,,,,2989.27,6782.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Denver Drain Placement Pleural,9198632,CDM,361,RC,,,,,facility,outpatient,,,8292.00000,2404.68000,Aetna,Local,,4610.00,,,,,,,2989.27,6782.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Denver Drain Removal,9074596,CDM,361,RC,,,,,facility,outpatient,,,2718.00000,788.22000,Aetna,Local,,4610.00,,,,,,,979.84,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Stent placement,9078223,CDM,361,RC,,,,,facility,outpatient,,,7907.00000,2293.03000,Aetna,Local,,4610.00,,,,,,,2850.47,6467.93,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Thrombectomy,9076308,CDM,361,RC,,,,,facility,outpatient,,,18840.00000,5463.60000,Aetna,Local,,4610.00,,,,,,,4610.00,15411.12,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Y90 Treatment,9076310,CDM,361,RC,,,,,facility,outpatient,,,712.00000,206.48000,Aetna,Local,,4610.00,,,,,,,256.68,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Y90 Mapping,9078310,CDM,361,RC,,,,,facility,outpatient,,,31446.00000,9119.34000,Aetna,Local,,4610.00,,,,,,,4610.00,25722.83,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Trans Arterial Chemo Embolization,9076312,CDM,361,RC,,,,,facility,outpatient,,,25200.00000,7308.00000,Aetna,Local,,4610.00,,,,,,,4610.00,20613.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Retrograde Transvenous Obliteration,9078312,CDM,361,RC,,,,,facility,outpatient,,,25200.00000,7308.00000,Aetna,Local,,4610.00,,,,,,,4610.00,20613.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TIPS Check and Treat,9076234,CDM,361,RC,,,,,facility,outpatient,,,3386.00000,981.94000,Aetna,Local,,4610.00,,,,,,,1220.65,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TIPS Takedown,9076314,CDM,361,RC,,,,,facility,outpatient,,,16338.00000,4738.02000,Aetna,Local,,4610.00,,,,,,,4610.00,13364.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Blood Patch,9078316,CDM,361,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,4610.00,,,,,,,1095.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Myelogram Cervical,9078248,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Myelogram Thoracic,9078250,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Myelogram Lumbar,9076236,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Myelogram Total,9078254,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Portacath Replacement,9078276,CDM,361,RC,,,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,Local,,4610.00,,,,,,,1741.21,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Seroma Sono Guided,9076266,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,Local,,4610.00,,,,,,,726.77,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Abdominal Sono Guided,9078288,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,Local,,4610.00,,,,,,,726.77,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration Groin Sono Guided,9078290,CDM,361,RC,,,,,facility,outpatient,,,2016.00000,584.64000,Aetna,Local,,4610.00,,,,,,,726.77,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Arteriogram,9076306,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,Local,,4610.00,,,,,,,3590.58,8147.28,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Angioplasty,9078221,CDM,361,RC,,,,,facility,outpatient,,,9151.00000,2653.79000,Aetna,Local,,4610.00,,,,,,,3298.94,7485.52,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Thrombolysis,9078225,CDM,361,RC,,,,,facility,outpatient,,,4576.00000,1327.04000,Aetna,Local,,4610.00,,,,,,,1649.65,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Axillary Right Biopsy,9076270,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Left Groin Biopsy,9076274,CDM,361,RC,,,,,facility,outpatient,,,4849.00000,1406.21000,Aetna,Local,,4610.00,,,,,,,1748.06,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bilateral Groin Biopsy,9076276,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Left Inguinal Biopsy,9076280,CDM,361,RC,,,,,facility,outpatient,,,4849.00000,1406.21000,Aetna,Local,,4610.00,,,,,,,1748.06,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bilateral Inguinal Biopsy,9078294,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Left Cervical Lymph Node Biopsy,9076282,CDM,361,RC,,,,,facility,outpatient,,,4849.00000,1406.21000,Aetna,Local,,4610.00,,,,,,,1748.06,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bilateral Cervical Biopsy,9078298,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Left Supraclavicular Biopsy,9078300,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bilateral Supraclavicular Biopsy,9076286,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Myelogram Cervical/Lumbar,9076238,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Myelogram Cervical/Thoracic,9076240,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Myelogram Thoracic/Lumbar,9078252,CDM,361,RC,,,,,facility,outpatient,,,4532.00000,1314.28000,Aetna,Local,,4610.00,,,,,,,1633.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Embolization,9078227,CDM,361,RC,,,,,facility,outpatient,,,25200.00000,7308.00000,Aetna,Local,,4610.00,,,,,,,4610.00,20613.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aortogram with Runoff,9076218,CDM,361,RC,,,,,facility,outpatient,,,8716.00000,2527.64000,Aetna,Local,,4610.00,,,,,,,3142.12,7129.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Venogram,9078229,CDM,361,RC,,,,,facility,outpatient,,,4578.00000,1327.62000,Aetna,Local,,4610.00,,,,,,,1650.37,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Foreign Body Retreival,9078231,CDM,361,RC,,,,,facility,outpatient,,,7576.00000,2197.04000,Aetna,Local,,4610.00,,,,,,,2731.15,6197.17,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Venous Pressures,9076220,CDM,361,RC,,,,,facility,outpatient,,,5710.00000,1655.90000,Aetna,Local,,4610.00,,,,,,,2058.45,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
IVC Filter Removal,9076222,CDM,361,RC,,,,,facility,outpatient,,,10800.00000,3132.00000,Aetna,Local,,4610.00,,,,,,,3893.40,8834.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
IVC Filter Placement,9076224,CDM,361,RC,,,,,facility,outpatient,,,9517.00000,2759.93000,Aetna,Local,,4610.00,,,,,,,3430.88,7784.91,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biliary Drain Placement,9078235,CDM,361,RC,,,,,facility,outpatient,,,5572.00000,1615.88000,Aetna,Local,,4610.00,,,,,,,2008.71,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Suprapubic Catheter Placement CT Guided,9078805,CDM,361,RC,,,,,facility,outpatient,,,6343.00000,1839.47000,Aetna,Local,,4610.00,,,,,,,2286.65,5188.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Each Additional Nephrostomy Tube,9076806,CDM,361,RC,,,,,facility,outpatient,,,4007.00000,1162.03000,Aetna,Local,,4610.00,,,,,,,1444.52,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Each Additional Ureteral Stent,9076808,CDM,361,RC,,,,,facility,outpatient,,,6955.00000,2016.95000,Aetna,Local,,4610.00,,,,,,,2507.28,5689.19,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Abscess Drain Placement,9082487,CDM,361,RC,,,,,facility,outpatient,,,3269.00000,948.01000,Aetna,Local,,4610.00,,,,,,,1178.47,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Nephrostomy Tube Removal Right,9080599,CDM,361,RC,,,,,facility,outpatient,,,2519.00000,730.51000,Aetna,Local,,4610.00,,,,,,,908.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Nephrostomy Tube Removal Left,9082489,CDM,361,RC,,,,,facility,outpatient,,,2519.00000,730.51000,Aetna,Local,,4610.00,,,,,,,908.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Nephrostomy Tube Removal Bilateral,9082491,CDM,361,RC,,,,,facility,outpatient,,,2519.00000,730.51000,Aetna,Local,,4610.00,,,,,,,908.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Submandibular Biopsy,9080601,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Parotid Mass Biopsy,9196916,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Drain Removal:Drain Removal,9083655,CDM,361,RC,,,,,facility,outpatient,,,2718.00000,788.22000,Aetna,Local,,4610.00,,,,,,,979.84,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Guided Chest Tube Placement,9196930,CDM,361,RC,,,,,facility,outpatient,,,5400.00000,1566.00000,Aetna,Local,,4610.00,,,,,,,1946.70,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bone Biopsy,9094511,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bone Biopsy CT Guided,9094513,CDM,361,RC,,,,,facility,outpatient,,,5200.00000,1508.00000,Aetna,Local,,4610.00,,,,,,,1874.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Liver Biopsy CT Guided,9092928,CDM,361,RC,,,,,facility,outpatient,,,5200.00000,1508.00000,Aetna,Local,,4610.00,,,,,,,1874.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Renal Biopsy CT Guided,9092930,CDM,361,RC,,,,,facility,outpatient,,,5200.00000,1508.00000,Aetna,Local,,4610.00,,,,,,,1874.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Lung Biopsy CT Guided,9092932,CDM,361,RC,,,,,facility,outpatient,,,5200.00000,1508.00000,Aetna,Local,,4610.00,,,,,,,1874.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Cholangiogram,9095030,CDM,361,RC,,,,,facility,outpatient,,,4570.00000,1325.30000,Aetna,Local,,4610.00,,,,,,,1647.48,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Vertebroplasty,9108866,CDM,361,RC,,,,,facility,outpatient,,,20898.00000,6060.42000,Aetna,Local,,4610.00,,,,,,,4610.00,17094.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Fluoro Guidance,9158417,CDM,361,RC,,,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,4610.00,,,,,,,540.75,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Ablation,9158456,CDM,361,RC,,,,,facility,outpatient,,,14082.00000,4083.78000,Aetna,Local,,4610.00,,,,,,,4610.00,11519.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Ablation,9158458,CDM,361,RC,,,,,facility,outpatient,,,14082.00000,4083.78000,Aetna,Local,,4610.00,,,,,,,4610.00,11519.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Fistulogram with Stent Placement,9210579,CDM,361,RC,,,,,facility,outpatient,,,7907.00000,2293.03000,Aetna,Local,,4610.00,,,,,,,2850.47,6467.93,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Fistulogram with Angioplasty,9210581,CDM,361,RC,,,,,facility,outpatient,,,9151.00000,2653.79000,Aetna,Local,,4610.00,,,,,,,3298.94,7485.52,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Fistulogram,9210583,CDM,361,RC,,,,,facility,outpatient,,,4578.00000,1327.62000,Aetna,Local,,4610.00,,,,,,,1650.37,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN PICC Line Reposition,661600,CDM,361,RC,,,,,facility,outpatient,,,5040.00000,1461.60000,Aetna,Local,,4610.00,,,,,,,1816.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN PICC Line Replacement,661598,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,Local,,4610.00,,,,,,,1333.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN PICC Line Placement,613309,CDM,361,RC,,,,,facility,outpatient,,,3700.00000,1073.00000,Aetna,Local,,4610.00,,,,,,,1333.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Tunneled Line Placement,661602,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,Local,,4610.00,,,,,,,3590.58,8147.28,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Fluoro Guided Biopsy,642078,CDM,361,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,4610.00,,,,,,,1514.10,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Vertebroplasty Thoracic,613299,CDM,361,RC,,,,,facility,outpatient,,,20898.00000,6060.42000,Aetna,Local,,4610.00,,,,,,,4610.00,17094.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Vertebroplasty Lumbar,613554,CDM,361,RC,,,,,facility,outpatient,,,20898.00000,6060.42000,Aetna,Local,,4610.00,,,,,,,4610.00,17094.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Port A Cath Insertion,661604,CDM,361,RC,,,,,facility,outpatient,,,9960.00000,2888.40000,Aetna,Local,,4610.00,,,,,,,3590.58,8147.28,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RA Tube Check,614287,CDM,361,RC,,,,,facility,outpatient,,,1597.00000,463.13000,Aetna,Local,,4610.00,,,,,,,575.72,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN Biopsy Deep Bone,613204,CDM,361,RC,,,,,facility,outpatient,,,4000.00000,1160.00000,Aetna,Local,,4610.00,,,,,,,1442.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AN IVC Filter Placement,613275,CDM,361,RC,,,,,facility,outpatient,,,17160.00000,4976.40000,Aetna,Local,,4610.00,,,,,,,4610.00,14036.88,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Insert Laryngoscopy And Or Trach,8062055,CDM,361,RC,31575,HCPCS,,,facility,outpatient,,,2791.00000,809.39000,Aetna,Local,,2076.00,,,,,,,122.76,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Done With Bronchoscopy,5465959,CDM,361,RC,,,,,facility,outpatient,,,4444.00000,1288.76000,Aetna,Local,,4610.00,,,,,,,1602.06,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Biopsy Done With Bronchoscopy,5571857,CDM,361,RC,,,,,facility,outpatient,,,4444.00000,1288.76000,Aetna,Local,,4610.00,,,,,,,1602.06,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Trach Tube Change,4417847,CDM,361,RC,,,,,facility,outpatient,,,276.00000,80.04000,Aetna,Local,,4610.00,,,,,,,99.50,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bronchoscopy,5571840,CDM,361,RC,,,,,facility,outpatient,,,4444.00000,1288.76000,Aetna,Local,,4610.00,,,,,,,1602.06,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Bronchoscopy,7900308,CDM,361,RC,,,,,facility,outpatient,,,4444.00000,1288.76000,Aetna,Local,,4610.00,,,,,,,1602.06,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Conscious Sedation,8995219,CDM,370,RC,99152,HCPCS,,,facility,outpatient,,,438.00000,127.02000,Aetna,Local,,222.37,,,,,,,157.90,358.28,percent of total billed charges,
Conscious Sedation Initial 15 Mins,9010086,CDM,370,RC,99153,HCPCS,,,facility,outpatient,,,438.00000,127.02000,Aetna,Local,,222.37,,,,,,,157.90,358.28,percent of total billed charges,
Conscious Sedation Initial 15 Mins,9012097,CDM,370,RC,99152,HCPCS,,,facility,outpatient,,,438.00000,127.02000,Aetna,Local,,222.37,,,,,,,157.90,358.28,percent of total billed charges,
Conscious Sedatin Addl 15 Mins,9010088,CDM,370,RC,99153,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,122.36,,,,,,,86.88,197.14,percent of total billed charges,
Mat Anesthesia With Supplies,7939784,CDM,370,RC,,,,,facility,outpatient,,,2599.00000,753.71000,Aetna,Local,,1319.51,,,,,,,936.94,2125.98,percent of total billed charges,
Anesthesia General 30 min,8147913,CDM,370,RC,,,,,facility,outpatient,,,1394.00000,404.26000,Aetna,Local,,707.73,,,,,,,502.54,1140.29,percent of total billed charges,
Anesthesia General Ea Addl 15 min,8147908,CDM,370,RC,,,,,facility,outpatient,,,106.00000,30.74000,Aetna,Local,,53.82,,,,,,,38.21,86.71,percent of total billed charges,
MODERATE SEDATION,7720028,CDM,370,RC,,,,,facility,outpatient,,,890.00000,258.10000,Aetna,Local,,451.85,,,,,,,320.85,728.02,percent of total billed charges,
Cath Lab Conscious Sedation Initial 15 Mins,9012134,CDM,370,RC,99152,HCPCS,,,facility,outpatient,,,438.00000,127.02000,Aetna,Local,,222.37,,,,,,,157.90,358.28,percent of total billed charges,
Cath Lab Conscious Sedation Addl 15 Mins,9012133,CDM,370,RC,99153,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,122.36,,,,,,,86.88,197.14,percent of total billed charges,
LRPC Washed,4327839,CDM,390,RC,P9022,HCPCS,,,facility,outpatient,,,679.00000,196.91000,Aetna,Local,,344.73,,,,,,,252.04,1059.29,percent of total billed charges,
LRPC QUAD IRRAD,2644864,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,684.00000,198.36000,Aetna,Local,,347.27,,,,,,,224.60,682.75,percent of total billed charges,
CRYOPRECIPITATE,1856825,CDM,390,RC,P9012,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,40.46,169.67,percent of total billed charges,
CRYOPRECIPITATE,7962047,CDM,390,RC,P9012,HCPCS,,,facility,outpatient,,,113.00000,32.77000,Aetna,Local,,57.37,,,,,,,41.95,169.67,percent of total billed charges,
Fresh Frozen Plasma,1427804,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,1870826,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,1870828,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,1870829,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,2350824,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,2350825,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma CPD Th,3599840,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma CPDA 1 Th,3599844,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma CP2D Th,3599848,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apher ACD A Th,3599856,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apher NaCitrate Th,3599864,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Fresh Frozen Plasma,3599872,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma CPDA 1 Th,3683841,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apheresis ACD A Th,4313841,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apheresis ACD A Dv Th,4313842,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,614777,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma CP2D,6241845,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,638930,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,7251842,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
FRESH FROZEN PLASMA,7251844,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7734036,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7734038,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7734039,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7734042,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7738959,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7742092,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7742093,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7754301,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apheresis,7846077,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Apheresis,7846079,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7852108,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7852109,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7852110,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph 1st ACD A Frz 24h Th,7852111,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph,7852112,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Thawed,8282307,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Thawed,8282308,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338191,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338192,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338193,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Convalescent COV19 Thawed,8338197,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Convalescent Plasma COVID 19,8380456,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
Plasma Aph ACD-A Frz 24h Th Dv E2284,9112429,CDM,390,RC,P9059,HCPCS,,,facility,outpatient,,,138.00000,40.02000,Aetna,Local,,70.06,,,,,,,51.23,189.76,percent of total billed charges,
PLATELETS PHERESIS LEUKORED REDUC,2502825,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
PLATELETS PHERESIS LEUKORED REDUC,614807,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
PLATELETS PHERESIS LEUKORED REDUC,614808,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Platelets pheresis leukocytes reduced each unit,8282343,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Platelets pheresis leukocytes reduced each unit,8282344,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR less than 3 X log 11,8372252,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR Bact Monitor 7D,8436691,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 1 Bact Monitor 7D,8436741,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 1st less than 3E11 Bact Monitor7D,8436751,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 2nd less than 3E11 Bact Monitor7D,8436752,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR Bact Monitor 7D,8436755,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 2 Bact Monitor 7D,8436757,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 3rd less than 3E11 Bact Monitor7D,8436759,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
Aph Plt ACDA LR 3 Bact Monitor 7D,8436762,CDM,390,RC,P9035,HCPCS,,,facility,outpatient,,,1570.00000,455.30000,Aetna,Local,,797.09,,,,,,,427.71,1300.12,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,2502826,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
Plate pheres leukoredu irrad,2644865,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607839,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607840,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607841,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607842,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
PLTS PHERESIS LEUKOCYTES IRRAD,3607843,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 3 Bact Monitor 7D,8436753,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr less than 3E11 Bact Monitor7D,8436754,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 2nd less than 3E11 Bact Monit,8436756,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 3rd less than 3E11 Bact Monit,8436758,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 1st less than 3E11 Bact Monit,8436760,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr Bact Monitor 7D,8436761,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 1 Bact Monitor 7D,8436763,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
Aph Plt ACDA LR Irr 2 Bact Monitor 7D,8436764,CDM,390,RC,P9037,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1803.40,percent of total billed charges,
LRPC IRRAD,1037811,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
LRPC IRRAD,1037812,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
LRPC IRRAD,2644838,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
LRPC IRRAD,614792,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
LRPC Aph Irr AS1,7782063,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
LRPC IRRAD,7968682,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
LRPC IRRAD,7991271,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
LRPC Irradiated,8166085,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074168,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074171,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074175,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074180,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074185,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074186,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074189,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074190,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074194,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074195,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074200,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074205,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074210,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074214,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074217,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074218,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074220,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074221,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074223,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
RBC leukoreduced irradiated,9074226,CDM,390,RC,P9040,HCPCS,,,facility,outpatient,,,786.00000,227.94000,Aetna,Local,,399.05,,,,,,,224.60,682.75,percent of total billed charges,
LRPC,614787,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,614788,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,7782064,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,791798,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,791799,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,7968681,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
LRPC,7968815,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282272,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282273,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282274,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282275,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
Red blood cells leukocytes reduced each unit,8282276,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
LRPC CPD 500mL,8986922,CDM,390,RC,P9016,HCPCS,,,facility,outpatient,,,664.00000,192.56000,Aetna,Local,,337.11,,,,,,,159.80,543.15,percent of total billed charges,
Split Fee,2644858,CDM,390,RC,86985,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,,81.23,,,,,,,30.37,457.39,percent of total billed charges,
Split Fee LRPC Irrad 1st,2644860,CDM,390,RC,86985,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,,81.23,,,,,,,30.37,457.39,percent of total billed charges,
SPLIT BLOOD PRODUCTS,2644861,CDM,390,RC,86985,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,,81.23,,,,,,,30.37,457.39,percent of total billed charges,
RBC Deglyc LR,6699839,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,Local,,702.15,,,,,,,306.86,1744.90,percent of total billed charges,
RBC Deglyc,7153865,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,Local,,702.15,,,,,,,306.86,1744.90,percent of total billed charges,
RBC Deglyc Aph LR,8148752,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,Local,,702.15,,,,,,,306.86,1744.90,percent of total billed charges,
RBC Deglyc Aph LR,8148753,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,Local,,702.15,,,,,,,306.86,1744.90,percent of total billed charges,
RBC Deglyc Aph LR,8148754,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,Local,,702.15,,,,,,,306.86,1744.90,percent of total billed charges,
RBC Deglyc Aph LR Irr,8148755,CDM,390,RC,P9057,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,Local,,702.15,,,,,,,414.40,1295.51,percent of total billed charges,
RBC Deglyc Aph LR Irr,8148756,CDM,390,RC,P9057,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,Local,,702.15,,,,,,,414.40,1295.51,percent of total billed charges,
RBC Deglyc Aph LR Irr,8148757,CDM,390,RC,P9057,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,Local,,702.15,,,,,,,414.40,1295.51,percent of total billed charges,
RBC deglycerolized,9074209,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,Local,,702.15,,,,,,,306.86,1744.90,percent of total billed charges,
RBC deglycerolized,9074215,CDM,390,RC,P9039,HCPCS,,,facility,outpatient,,,1383.00000,401.07000,Aetna,Local,,702.15,,,,,,,306.86,1744.90,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294242,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294243,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294244,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294245,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294246,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294247,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294248,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294249,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8294250,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8438587,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Aph Plt ACDA less than PASC LR 3,8438595,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8438596,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8438597,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440034,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440035,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440036,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440037,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440532,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440533,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440534,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Platelets pheresis pathogen reduced each unit,8440535,CDM,390,RC,P9073,HCPCS,,,facility,outpatient,,,1144.00000,331.76000,Aetna,Local,,580.81,,,,,,,424.65,1567.49,percent of total billed charges,
Transfusion Of Blood Products,1327806,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,Local,,1610.00,,,,,,,383.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Transfusion Of Blood Products,7457914,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,Local,,1610.00,,,,,,,383.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Transfusion Of Blood Products,7942782,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,Local,,1610.00,,,,,,,383.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Transfusion Of Blood Products,7957584,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,Local,,1610.00,,,,,,,383.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Transfusion of Blood Products,8924116,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,Local,,1610.00,,,,,,,383.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Transfusion of Blood Product,8997125,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,Local,,1610.00,,,,,,,383.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ER Transfusion Of Blood Products,602490,CDM,391,RC,36430,HCPCS,,,facility,outpatient,,,2546.00000,738.34000,Aetna,Local,,1610.00,,,,,,,383.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Mammo Bilateral Diagnostic Digital,1299805,CDM,401,RC,77066,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,Local,,184.80,,,,,,,135.12,307.99,percent of total billed charges,
Mammo Bilateral Diagnostic Digital,7910092,CDM,401,RC,77066,HCPCS,,,facility,outpatient,,,364.00000,105.56000,Aetna,Local,,184.80,,,,,,,135.12,307.99,percent of total billed charges,
Mammo Unilateral Right Diagnostic Digital,7846196,CDM,401,RC,77065,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,RT,167.54,,,,,,,108.86,269.94,percent of total billed charges,
Mammmo Unilateral Right Diagnostic Digital,7910104,CDM,401,RC,77065,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,RT,167.54,,,,,,,108.86,269.94,percent of total billed charges,
Mammo Unilateral Left Diagnostic Digital,7846194,CDM,401,RC,77065,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,LT,167.54,,,,,,,108.86,269.94,percent of total billed charges,
Mammo Unilateral Left Diagnostic Digital,7910100,CDM,401,RC,77065,HCPCS,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,LT,167.54,,,,,,,108.86,269.94,percent of total billed charges,
Mammo Left Diagnostic Tomosynthesis,8001062,CDM,401,RC,G0279,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,29.70,80.73,percent of total billed charges,
Mammo Right Diagnostic Tomosynthesis,8001063,CDM,401,RC,G0279,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,29.70,80.73,percent of total billed charges,
Mammo Bilateral Diagnostic Tomosynthesis,8001068,CDM,401,RC,G0279,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,29.70,80.73,percent of total billed charges,
Echo Guidance by Anesthesia,8786161,CDM,402,RC,,,,,facility,outpatient,,,425.00000,123.25000,Aetna,Local,,215.77,,,,,,,153.21,347.65,percent of total billed charges,
Sono Neonatal Head,7762494,CDM,402,RC,76506,HCPCS,,,facility,outpatient,,,1011.00000,293.19000,Aetna,Local,,513.28,,,,,,,53.29,827.00,percent of total billed charges,
Sono Soft Tissue Lower Back,7900438,CDM,402,RC,76705,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,Local,,701.64,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Abdomen Limited,7900442,CDM,402,RC,76705,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,Local,,701.64,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Vaginal OB,7762498,CDM,402,RC,76817,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,56.16,1219.64,percent of total billed charges,
Sono OB Transvaginal,7774178,CDM,402,RC,76817,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,56.16,1219.64,percent of total billed charges,
Sono OB Transvaginal,7774182,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,53.29,1219.64,percent of total billed charges,
SONO OB TRANSVAGINAL,7818042,CDM,402,RC,76817,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,56.16,1219.64,percent of total billed charges,
Sono OB Transvaginal,8001029,CDM,402,RC,76817,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,56.16,1219.64,percent of total billed charges,
Sono Pelvis Limited,7900177,CDM,402,RC,76857,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,62.92,870.35,percent of total billed charges,
Sono Pelvis Limited,7900181,CDM,402,RC,76857,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,62.92,870.35,percent of total billed charges,
Sono Pelvis Limited,7900434,CDM,402,RC,76857,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,62.92,870.35,percent of total billed charges,
Sono Obstetrical Follow Up,7774186,CDM,402,RC,76816,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,,432.56,,,,,,,41.57,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,7774190,CDM,402,RC,76816,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,,432.56,,,,,,,41.57,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,7774194,CDM,402,RC,76816,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,,432.56,,,,,,,41.57,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,7913724,CDM,402,RC,76816,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,,432.56,,,,,,,41.57,696.94,percent of total billed charges,
Sono Obstetrical Follow Up,8001052,CDM,402,RC,76816,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,,432.56,,,,,,,41.57,696.94,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762477,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762478,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762482,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7762484,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB 12 to 14 Weeks Twins,7900194,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks,7900197,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB less than 14 weeks,8148590,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB less than 14 Weeks,8148592,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB less than 14 weeks w TV,8148593,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB less than 14 weeks,8158019,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono Guidance,8001053,CDM,402,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,432.60,981.60,percent of total billed charges,
Sono Guided Localization,8001076,CDM,402,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,432.60,981.60,percent of total billed charges,
SONO OB PELVIS LT14WKS ADDL,7145842,CDM,402,RC,76802,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,41.51,348.47,percent of total billed charges,
Sono OB Pelvis LT 14 Weeks Additional,8001055,CDM,402,RC,76802,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,41.51,348.47,percent of total billed charges,
Sono OB Detailed,7913715,CDM,402,RC,76811,HCPCS,,,facility,outpatient,,,1379.00000,399.91000,Aetna,Local,,700.12,,,,,,,96.14,1128.02,percent of total billed charges,
SONO OB DETAILED ADDITIONAL,7913716,CDM,402,RC,76812,HCPCS,,,facility,outpatient,,,613.00000,177.77000,Aetna,Local,,311.22,,,,,,,51.52,501.43,percent of total billed charges,
Sono OB Detailed Additional Fetus,8001056,CDM,402,RC,76812,HCPCS,,,facility,outpatient,,,613.00000,177.77000,Aetna,Local,,311.22,,,,,,,51.52,501.43,percent of total billed charges,
Sono Abdominal Aortic Aneurysm Screening,6095843,CDM,402,RC,76706,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,324.42,,,,,,,93.38,522.70,percent of total billed charges,
Sono Abdominal Aortic Aneurysm Screening,8150278,CDM,402,RC,76706,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,324.42,,,,,,,93.38,522.70,percent of total billed charges,
Sono Obstetrical Biophysical Profile,8001057,CDM,402,RC,76819,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,60.74,1219.64,percent of total billed charges,
Sono Hips Infant with Manipulation,7964738,CDM,402,RC,76885,HCPCS,,,facility,outpatient,,,388.00000,112.52000,Aetna,Local,,196.99,,,,,,,57.54,317.38,percent of total billed charges,
Sono Hips Infant without Manipulation,7964742,CDM,402,RC,76886,HCPCS,,,facility,outpatient,,,388.00000,112.52000,Aetna,Local,,196.99,,,,,,,53.29,317.38,percent of total billed charges,
Sono Extremity Complete Bilateral,7917956,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,2458.00000,712.82000,Aetna,Local,,1247.93,,,,,,,80.94,2010.64,percent of total billed charges,
Sono Extremity Complete Bilateral,7918015,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,2458.00000,712.82000,Aetna,Local,,1247.93,,,,,,,80.94,2010.64,percent of total billed charges,
Sono Extremity Complete Bilat,8148163,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,2458.00000,712.82000,Aetna,Local,,1247.93,,,,,,,80.94,2010.64,percent of total billed charges,
Sono Breast Limited Bilateral,7790371,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,Local,,676.26,,,,,,,77.31,1089.58,percent of total billed charges,
Sono Breaat Limited Bilat,8148162,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,Local,,676.26,,,,,,,77.31,1089.58,percent of total billed charges,
Sono Breast Complete Bilateral,7790367,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,1782.00000,516.78000,Aetna,Local,,904.72,,,,,,,93.38,1457.68,percent of total billed charges,
Sono Breast Bilat Complete,8148161,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,1782.00000,516.78000,Aetna,Local,,904.72,,,,,,,93.38,1457.68,percent of total billed charges,
Sono Breast Automated Complete Bilat,9060801,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,1782.00000,516.78000,Aetna,Local,,904.72,,,,,,,93.38,1457.68,percent of total billed charges,
Sono Extremity Limited Bilateral,7856090,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,865.12,,,,,,,9.63,1393.87,percent of total billed charges,
Sono Extremity Limited Bilateral,7917991,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,865.12,,,,,,,9.63,1393.87,percent of total billed charges,
Sono Extremity Bilateral Limited,7918003,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,865.12,,,,,,,9.63,1393.87,percent of total billed charges,
Sono Extremity Bilateral Limited,7938015,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,865.12,,,,,,,9.63,1393.87,percent of total billed charges,
Sono Extremity Bilat Limited,8148160,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,Local,,865.12,,,,,,,9.63,1393.87,percent of total billed charges,
Sono Axilla Breast Bilateral,8181328,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,Local,,676.26,,,,,,,77.31,1089.58,percent of total billed charges,
Sono Axilla Breast Right,8181324,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,RT,338.13,,,,,,,77.89,544.79,percent of total billed charges,
Sono Axilla Breast Left,8181326,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,Local,LT,338.13,,,,,,,77.89,544.79,percent of total billed charges,
Sono Chest Upper Back Limited,7900426,CDM,402,RC,76604,HCPCS,,,facility,outpatient,,,961.00000,278.69000,Aetna,Local,,487.90,,,,,,,49.03,786.10,percent of total billed charges,
Sono Chest Upper Back Limited,7900430,CDM,402,RC,76604,HCPCS,,,facility,outpatient,,,961.00000,278.69000,Aetna,Local,,487.90,,,,,,,49.03,786.10,percent of total billed charges,
Sono Retroperitoneal Limited,613948,CDM,402,RC,76775,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,Local,,701.64,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Retroperitoneal Limited,7900185,CDM,402,RC,76775,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,Local,,701.64,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Extremity Right Limited,7790347,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,RT,432.56,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Limited Right,7917995,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,RT,432.56,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Right Limited,7918007,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,RT,432.56,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Limited Right,7949919,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,RT,432.56,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Right Limited,8148239,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,RT,432.56,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Left Limited,7790351,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,LT,432.56,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Limited Left,7917999,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,LT,432.56,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Left Limited,7918011,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,LT,432.56,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Limited Left,7949916,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,LT,432.56,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Left Limited,8148238,CDM,402,RC,76882,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,LT,432.56,,,,,,,9.63,696.94,percent of total billed charges,
Sono Extremity Complete Right,7917983,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,Local,RT,623.96,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Extremity Right Complete,7918019,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,Local,RT,623.96,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Extremity Complete Right,8148243,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,Local,RT,623.96,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Extremity Complete Left,7917987,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,Local,LT,623.96,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Extremity Left Complete,7918023,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,Local,LT,623.96,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Extremity Complete Left,8148242,CDM,402,RC,76881,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,Local,LT,623.96,,,,,,,80.94,1005.32,percent of total billed charges,
Sono Perinatal OB Fetal MCA Doppler,7913736,CDM,402,RC,76821,HCPCS,,,facility,outpatient,,,484.00000,140.36000,Aetna,Local,,245.73,,,,,,,61.43,663.49,percent of total billed charges,
Sono Perinatal Fetal MCA Doppler,7913748,CDM,402,RC,76821,HCPCS,,,facility,outpatient,,,484.00000,140.36000,Aetna,Local,,245.73,,,,,,,61.43,663.49,percent of total billed charges,
SONO OB TRANSABD GT14WKS ADDL,7145844,CDM,402,RC,76810,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,44.95,348.47,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks Additional,8001070,CDM,402,RC,76810,HCPCS,,,facility,outpatient,,,426.00000,123.54000,Aetna,Local,,216.28,,,,,,,44.95,348.47,percent of total billed charges,
Sono OB Transabd GT 14 Weeks,7762470,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7762472,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7762473,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7762474,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabd GT 14 Weeks,7762483,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7790356,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7790360,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
Sono OB Transabdominal GT 14 Weeks,7790364,CDM,402,RC,76805,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,79.23,1219.64,percent of total billed charges,
SONO OB UMBILICAL DOPPLER,7844138,CDM,402,RC,76820,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,324.42,,,,,,,61.43,522.70,percent of total billed charges,
Sono OB Umbilical Doppler,7913732,CDM,402,RC,76820,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,324.42,,,,,,,61.43,522.70,percent of total billed charges,
Sono Umbilical Doppler,8001072,CDM,402,RC,76820,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,324.42,,,,,,,61.43,522.70,percent of total billed charges,
Sono Breast Complete Left,7790331,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,LT,452.36,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Left Complete,8148240,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,LT,452.36,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast LT Complete,8245914,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,LT,452.36,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Automated Complete LT,9057731,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,LT,452.36,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Limited,7790335,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,Local,LT,676.26,,,,,,,77.89,1089.58,percent of total billed charges,
Sono Breast Limited Left,8148697,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,Local,LT,676.26,,,,,,,77.89,1089.58,percent of total billed charges,
Sono Breast LT Limited,8245960,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,Local,LT,676.26,,,,,,,77.89,1089.58,percent of total billed charges,
Sono Breast Complete Right,7790339,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,RT,452.36,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Right Complete,8148241,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,RT,452.36,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast RT Complete,8245915,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,RT,452.36,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Automated Complete RT,9060802,CDM,402,RC,76641,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,Local,RT,452.36,,,,,,,101.63,728.84,percent of total billed charges,
Sono Breast Limited,7790343,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,Local,RT,676.26,,,,,,,77.89,1089.58,percent of total billed charges,
Sono Breast Limited Right,8148704,CDM,402,RC,76642,HCPCS,,,facility,outpatient,,,1332.00000,386.28000,Aetna,Local,RT,676.26,,,,,,,77.89,1089.58,percent of total billed charges,
Sono Temporal Artery Doppler Right,8973070,CDM,402,RC,93882,HCPCS,,,facility,outpatient,,,978.00000,283.62000,Aetna,Local,,494.00,,,,,,,93.38,800.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Temporal Artery Doppler Left,8973068,CDM,402,RC,93882,HCPCS,,,facility,outpatient,,,978.00000,283.62000,Aetna,Local,,494.00,,,,,,,93.38,800.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Temporal Artery Doppler Left,8975182,CDM,402,RC,93882,HCPCS,,,facility,outpatient,,,978.00000,283.62000,Aetna,Local,,494.00,,,,,,,93.38,800.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Temporal Artery Doppler Bilateral,8973066,CDM,402,RC,93882,HCPCS,,,facility,outpatient,,,978.00000,283.62000,Aetna,Local,,494.00,,,,,,,93.38,800.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Obstetrical Limited,7762486,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762488,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762490,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762491,CDM,402,RC,76820,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,61.43,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762496,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7762497,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774174,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774198,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774202,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774206,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774210,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7774226,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7808059,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7808063,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7846226,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7846228,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Obstetrical Limited,7900201,CDM,402,RC,76801,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,79.23,870.35,percent of total billed charges,
Sono Obstetrical Limited,7913720,CDM,402,RC,76815,HCPCS,,,facility,outpatient,,,1064.00000,308.56000,Aetna,Local,,540.19,,,,,,,53.29,870.35,percent of total billed charges,
Sono Abdomen,2052844,CDM,402,RC,76700,HCPCS,,,facility,outpatient,,,1895.00000,549.55000,Aetna,Local,,962.09,,,,,,,74.25,1550.11,percent of total billed charges,
Sono Abdomen,2052848,CDM,402,RC,76700,HCPCS,,,facility,outpatient,,,1895.00000,549.55000,Aetna,Local,,962.09,,,,,,,74.25,1550.11,percent of total billed charges,
Sono Abdomen,613923,CDM,402,RC,76700,HCPCS,,,facility,outpatient,,,1895.00000,549.55000,Aetna,Local,,962.09,,,,,,,74.25,1550.11,percent of total billed charges,
Sono Retroperitoneal Complete,614089,CDM,402,RC,76770,HCPCS,,,facility,outpatient,,,1895.00000,549.55000,Aetna,Local,,962.09,,,,,,,74.25,1550.11,percent of total billed charges,
Sono Retroperitoneal Complete,7900416,CDM,402,RC,76770,HCPCS,,,facility,outpatient,,,1895.00000,549.55000,Aetna,Local,,962.09,,,,,,,74.25,1550.11,percent of total billed charges,
Sono Vaginal Non OB,1519811,CDM,402,RC,76830,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,57.54,1219.64,percent of total billed charges,
Sono Vaginal NonOB,8001075,CDM,402,RC,76830,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,57.54,1219.64,percent of total billed charges,
Sono Vaginal Non OB,8148208,CDM,402,RC,76830,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,756.98,,,,,,,57.54,1219.64,percent of total billed charges,
Sono Soft Tissue Head and Neck,614125,CDM,402,RC,76536,HCPCS,,,facility,outpatient,,,1278.00000,370.62000,Aetna,Local,,648.84,,,,,,,53.29,1045.40,percent of total billed charges,
Sono Soft Tissue Head and Neck,614159,CDM,402,RC,76536,HCPCS,,,facility,outpatient,,,1278.00000,370.62000,Aetna,Local,,648.84,,,,,,,53.29,1045.40,percent of total billed charges,
Sono Soft Tissue Head and Neck,7900422,CDM,402,RC,76536,HCPCS,,,facility,outpatient,,,1278.00000,370.62000,Aetna,Local,,648.84,,,,,,,53.29,1045.40,percent of total billed charges,
Sono Testicle with Doppler,614153,CDM,402,RC,76870,HCPCS,,,facility,outpatient,,,1174.00000,340.46000,Aetna,Local,,596.04,,,,,,,57.54,960.33,percent of total billed charges,
Sono Abdomen Limited,2052846,CDM,402,RC,76705,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,Local,,701.64,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Abdomen Limited,613937,CDM,402,RC,76705,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,Local,,701.64,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Abdomen Limited,614143,CDM,402,RC,76705,HCPCS,,,facility,outpatient,,,1382.00000,400.78000,Aetna,Local,,701.64,,,,,,,53.29,1130.48,percent of total billed charges,
Sono Pelvis,613975,CDM,402,RC,76856,HCPCS,,,facility,outpatient,,,1062.00000,307.98000,Aetna,Local,,539.18,,,,,,,57.54,868.72,percent of total billed charges,
Sono Pelvis,7740859,CDM,402,RC,76856,HCPCS,,,facility,outpatient,,,1062.00000,307.98000,Aetna,Local,,539.18,,,,,,,57.54,868.72,percent of total billed charges,
Sono Pelvis Limited,7900418,CDM,402,RC,76857,HCPCS,,,facility,outpatient,,,1062.00000,307.98000,Aetna,Local,,539.18,,,,,,,62.92,868.72,percent of total billed charges,
Sono Guidance in Surgery,646951,CDM,402,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,432.60,981.60,percent of total billed charges,
Sono Carotid Duplex,614000,CDM,402,RC,93880,HCPCS,,,facility,outpatient,,,1943.00000,563.47000,Aetna,Local,,494.00,,,,,,,212.24,1589.37,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Pseudoaneurysm Compression,614135,CDM,402,RC,76936,HCPCS,,,facility,outpatient,,,1180.00000,342.20000,Aetna,Local,,599.09,,,,,,,150.37,965.24,percent of total billed charges,
Sono Chest,614006,CDM,402,RC,76604,HCPCS,,,facility,outpatient,,,961.00000,278.69000,Aetna,Local,,487.90,,,,,,,49.03,786.10,percent of total billed charges,
Ultrasound Guidance,9160404,CDM,402,RC,,,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,761.55,,,,,,,540.75,1227.00,percent of total billed charges,
MM Mammo Same Day Screening 3D,8159811,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,Local,,143.68,,,,,,,105.05,247.47,percent of total billed charges,
Mammo Screening Digital,1299801,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,Local,,143.68,,,,,,,105.05,247.47,percent of total billed charges,
Mammogram Screening Digital,7910096,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,Local,,143.68,,,,,,,105.05,247.47,percent of total billed charges,
MM Mammo 3D Screening with Sono As Needed,8380179,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,Local,,143.68,,,,,,,105.05,247.47,percent of total billed charges,
Mammo Screening Tomosynthesis,8001067,CDM,403,RC,77063,HCPCS,,,facility,outpatient,,,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,29.70,101.41,percent of total billed charges,
MM Mammo 3D Screening Left,9162396,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,Local,,143.68,,,,,,,105.05,247.47,percent of total billed charges,
MM Mammo 3D Screening Right,9164392,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,Local,,143.68,,,,,,,105.05,247.47,percent of total billed charges,
MM Screening Digital Left,9162402,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,Local,,143.68,,,,,,,105.05,247.47,percent of total billed charges,
MM Screening Digital Right,9162404,CDM,403,RC,77067,HCPCS,,,facility,outpatient,,,283.00000,82.07000,Aetna,Local,,143.68,,,,,,,105.05,247.47,percent of total billed charges,
CAR NM PET CT FDG VIABILITY,7363918,CDM,404,RC,78429,HCPCS,,,facility,outpatient,,,10558.00000,3061.82000,Aetna,Local,,2605.00,,,,,,,1280.72,8636.44,case rate,
CAR NM PET CT CARDIAC,7363919,CDM,404,RC,78431,HCPCS,,,facility,outpatient,,,14948.00000,4334.92000,Aetna,Local,,2605.00,,,,,,,1474.00,12227.46,case rate,
CAR NM PET CT Cardiac,8298200,CDM,404,RC,78431,HCPCS,,,facility,outpatient,,,14948.00000,4334.92000,Aetna,Local,,2605.00,,,,,,,1474.00,12227.46,case rate,
CAR NM PET CT CARDIAC SINGLE STDY,7524082,CDM,404,RC,78430,HCPCS,,,facility,outpatient,,,13963.00000,4049.27000,Aetna,Local,,2605.00,,,,,,,1280.72,11421.73,case rate,
PET CT Mycocardial Blood Flow,8148537,CDM,404,RC,78434,HCPCS,,,facility,outpatient,,,3934.00000,1140.86000,Aetna,Local,,2605.00,,,,,,,1418.21,3218.01,case rate,
PET CT Mycocardial Blood Flow,8298199,CDM,404,RC,78434,HCPCS,,,facility,outpatient,,,3934.00000,1140.86000,Aetna,Local,,2605.00,,,,,,,1418.21,3218.01,case rate,
FDG Viability with Rb Study,8290448,CDM,404,RC,78433,HCPCS,,,facility,outpatient,,,13963.00000,4049.27000,Aetna,Local,,2605.00,,,,,,,1474.00,11421.73,case rate,
PET CT Sarcoidosis Study,8997039,CDM,404,RC,78433,HCPCS,,,facility,outpatient,,,13963.00000,4049.27000,Aetna,Local,,2605.00,,,,,,,1474.00,11421.73,case rate,
PET CT Dotatate Skull Thigh,8121821,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PI,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT Brain Metabolic Eval Initial,3136854,CDM,404,RC,78608,HCPCS,,,facility,outpatient,,,9962.00000,2888.98000,Aetna,Local,PI,2605.00,,,,,,,1280.72,8148.92,case rate,
PET CT Brain Metabolic Eval Restaging,3136856,CDM,404,RC,78608,HCPCS,,,facility,outpatient,,,9962.00000,2888.98000,Aetna,Local,PS,2605.00,,,,,,,1280.72,8148.92,case rate,
PET CT Tumor Imaging Limited Initial,3136866,CDM,404,RC,78814,HCPCS,,,facility,outpatient,,,9962.00000,2888.98000,Aetna,Local,PI,2605.00,,,,,,,1280.72,8148.92,case rate,
PET CT Tumor Imaging Limited Restaging,3136868,CDM,404,RC,78814,HCPCS,,,facility,outpatient,,,9962.00000,2888.98000,Aetna,Local,PS,2605.00,,,,,,,1280.72,8148.92,case rate,
PET CT Tumor Image Skull Thigh Initial,3136858,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PI,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT Tumor Image Skull Thigh Restaging,3136860,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PS,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT Tumor Image Whole Body Initial,3136862,CDM,404,RC,78816,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PI,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT Whole Body Bone Scan Initial,7544165,CDM,404,RC,78816,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PI,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT Tumor Image Whole Body Restaging,3136864,CDM,404,RC,78816,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PS,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT Whole Body Bone Scan Restaging,7544170,CDM,404,RC,78816,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PS,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT Dotatate Skull Thigh Restaging,8237892,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PS,2605.00,,,,,,,1280.72,10774.70,case rate,
PET Exam,8237905,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PI,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT Beta Amyloid Imaging,7918028,CDM,404,RC,78814,HCPCS,,,facility,outpatient,,,9962.00000,2888.98000,Aetna,Local,Q1,2605.00,,,,,,,1280.72,8148.92,case rate,
PET Exam,8237915,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PS,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT Dotatate Skull Thigh Initial,8237883,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PI,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT Trailblazer Brain,8435857,CDM,404,RC,,,,,facility,outpatient,,,6000.00000,1740.00000,Aetna,Local,,3046.20,,,,,,,2163.00,4908.00,percent of total billed charges,
PET CT F18 PSMA Skull to Thigh Initial,8456055,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PI,2605.00,,,,,,,1280.72,10774.70,case rate,
PET CT F 18 PSMA Skull to Thigh Restaging,8456060,CDM,404,RC,78815,HCPCS,,,facility,outpatient,,,13172.00000,3819.88000,Aetna,Local,PS,2605.00,,,,,,,1280.72,10774.70,case rate,
Pentamidine Treatment,5571854,CDM,410,RC,94642,HCPCS,,,facility,outpatient,,,528.00000,153.12000,Aetna,Local,,268.07,,,,,,,190.00,542.88,percent of total billed charges,
Pentamidine Treatment,715807,CDM,410,RC,94642,HCPCS,,,facility,outpatient,,,528.00000,153.12000,Aetna,Local,,268.07,,,,,,,190.00,542.88,percent of total billed charges,
Pentamidine Treatment,7892189,CDM,410,RC,94642,HCPCS,,,facility,outpatient,,,528.00000,153.12000,Aetna,Local,,268.07,,,,,,,190.00,542.88,percent of total billed charges,
Surfactant Administration,5460081,CDM,410,RC,94610,HCPCS,,,facility,outpatient,,,303.00000,87.87000,Aetna,Local,,153.83,,,,,,,112.47,542.88,percent of total billed charges,
Surfactant Administration,7796098,CDM,410,RC,94610,HCPCS,,,facility,outpatient,,,303.00000,87.87000,Aetna,Local,,153.83,,,,,,,112.47,542.88,percent of total billed charges,
SURFACTANT ADMINISTRATION,7796105,CDM,410,RC,94610,HCPCS,,,facility,outpatient,,,303.00000,87.87000,Aetna,Local,,153.83,,,,,,,112.47,542.88,percent of total billed charges,
P D And V Subsequent,3191092,CDM,410,RC,94668,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,96.51,344.05,percent of total billed charges,
P D And V Subsequent,7944218,CDM,410,RC,94668,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,96.51,344.05,percent of total billed charges,
P D And V Subsequent,7945905,CDM,410,RC,94668,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,96.51,344.05,percent of total billed charges,
Cpap Bipap Set Up And 1St Day,612607,CDM,410,RC,94660,HCPCS,,,facility,outpatient,,,1968.00000,570.72000,Aetna,Local,,999.15,,,,,,,178.59,1609.82,percent of total billed charges,
Cpap Bipap Set Up And 1St Day,7892318,CDM,410,RC,94660,HCPCS,,,facility,outpatient,,,1968.00000,570.72000,Aetna,Local,,999.15,,,,,,,178.59,1609.82,percent of total billed charges,
Mechanical Chest Wall Oscillation,7403872,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Mechanical Chest Wall Oscillation,7944172,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Mechanical Chest Wall Oscillation,7944173,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Mechanical Chest Wall Oscillation,7945901,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Mechanical Chest Wall Oscillation,7945906,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Mechanical Chest Wall Oscillation,8150442,CDM,410,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Continuous Vent Set Up And First Day,7892198,CDM,410,RC,94002,HCPCS,,,facility,outpatient,,,2383.00000,691.07000,Aetna,Local,,1209.85,,,,,,,190.00,1949.29,percent of total billed charges,
Continuous Vent Daily,612627,CDM,410,RC,94003,HCPCS,,,facility,outpatient,,,2383.00000,691.07000,Aetna,Local,,1209.85,,,,,,,190.00,1949.29,percent of total billed charges,
Continuous Vent Daily,7892196,CDM,410,RC,94003,HCPCS,,,facility,outpatient,,,2383.00000,691.07000,Aetna,Local,,1209.85,,,,,,,190.00,1949.29,percent of total billed charges,
P D And V Initial,613013,CDM,410,RC,94667,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,96.51,344.05,percent of total billed charges,
P D And V Initial,7944217,CDM,410,RC,94667,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,96.51,344.05,percent of total billed charges,
P D And V Initial,7945900,CDM,410,RC,94667,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,96.51,344.05,percent of total billed charges,
ED Continuous 1-Hour,9036250,CDM,410,RC,94644,HCPCS,,,facility,outpatient,,,233.00000,67.57000,Aetna,Local,,118.29,,,,,,,86.49,344.05,percent of total billed charges,
ED Cont. Subsequent Hour,9036249,CDM,410,RC,94645,HCPCS,,,facility,outpatient,,,233.00000,67.57000,Aetna,Local,,118.29,,,,,,,84.00,225.00,percent of total billed charges,
INTUBATION ASSIST,5460062,CDM,410,RC,31500,HCPCS,,,facility,outpatient,,,1599.00000,463.71000,Aetna,Local,,1610.00,,,,,,,190.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Cpap Bipap Subsequent Day,612745,CDM,410,RC,94660,HCPCS,,,facility,outpatient,,,1968.00000,570.72000,Aetna,Local,,999.15,,,,,,,178.59,1609.82,percent of total billed charges,
Cpap Bipap Subsequent Day,7892317,CDM,410,RC,94660,HCPCS,,,facility,outpatient,,,1968.00000,570.72000,Aetna,Local,,999.15,,,,,,,178.59,1609.82,percent of total billed charges,
Hyperbaric Oxy Therapy 30 Min,602684,CDM,413,RC,G0277,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,660.52,,,,,,,121.09,1064.22,percent of total billed charges,
Hyperbaric Oxy Therapy 30 Min,7958302,CDM,413,RC,G0277,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,Local,,660.52,,,,,,,121.09,1064.22,percent of total billed charges,
PTS Woundcare Select Deb Ea Adl20,4925828,CDM,420,RC,97598,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,GP,1610.00,,,,,,,59.03,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PTS Woundcare Nonselective Debrid,4938021,CDM,420,RC,97602,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,GP,342.70,,,,,,,97.85,552.15,percent of total billed charges,
PTS Therapeutic Exercise 15 Min,4925759,CDM,420,RC,97110,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,GP,81.23,,,,,,,26.07,225.00,percent of total billed charges,
PTS Fluidotherapy,4938080,CDM,420,RC,97022,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,GP,62.95,,,,,,,13.96,225.00,percent of total billed charges,
PTS Electrical Stim Attend 15Min,4925764,CDM,420,RC,97032,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,12.94,225.00,percent of total billed charges,
PTS Aquatic Therapy 15 Min,4925761,CDM,420,RC,97113,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,30.28,225.00,percent of total billed charges,
PTS Orthotic Initial Train 15Min,4925757,CDM,420,RC,97760,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,29.55,225.00,percent of total billed charges,
PTS Prosthetic Init Train 15Min,4925782,CDM,420,RC,97761,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,GP,76.66,,,,,,,27.08,225.00,percent of total billed charges,
PTS Adl Management Train 15 Min,4925778,CDM,420,RC,97535,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,28.51,225.00,percent of total billed charges,
PTS Wheelchair Management 15 Min,4925787,CDM,420,RC,97542,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,26.73,225.00,percent of total billed charges,
PTS Therapeutic Activities 15 Min,4925768,CDM,420,RC,97530,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,GP,81.23,,,,,,,27.79,225.00,percent of total billed charges,
PTS Manual Therapy 15 Min,4925774,CDM,420,RC,97140,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,24.62,225.00,percent of total billed charges,
PTS Massage 15 Min,4925784,CDM,420,RC,97124,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,21.30,225.00,percent of total billed charges,
PTS Neuromuscular Re Ed 15 Min,4925780,CDM,420,RC,97112,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,27.80,225.00,percent of total billed charges,
PTS Gait Training 15 Min,4925762,CDM,420,RC,97116,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,23.49,225.00,percent of total billed charges,
PTS Iontophoresis 15 Min,4925770,CDM,420,RC,97033,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,16.94,225.00,percent of total billed charges,
PTS ORTHOTIC PROSTH CHECKOUT 15MIN,4925766,CDM,420,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,GP,76.66,,,,,,,44.95,225.00,percent of total billed charges,
PTS Electrical Stim Unattended,4939850,CDM,420,RC,G0283,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,Local,,89.36,,,,,,,17.84,225.00,percent of total billed charges,
PTS Canalith Repositioning,4938085,CDM,420,RC,95992,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,GP,154.85,,,,,,,40.55,249.49,percent of total billed charges,
PTS Work Task Analysis 15 Min,4925789,CDM,420,RC,97537,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,GP,62.95,,,,,,,26.02,225.00,percent of total billed charges,
PTS Vasopneumatic Device,4937972,CDM,420,RC,97016,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,GP,62.95,,,,,,,10.55,225.00,percent of total billed charges,
PTS Ultrasound 15 Min,4925776,CDM,420,RC,97035,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,11.57,225.00,percent of total billed charges,
PTS Traction Mechanical,4937999,CDM,420,RC,97012,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GP,61.94,,,,,,,12.94,225.00,percent of total billed charges,
PTS Paraffin Bath,4938013,CDM,420,RC,97018,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,GP,62.95,,,,,,,5.52,225.00,percent of total billed charges,
PT Group,4937992,CDM,420,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GP,59.40,,,,,,,16.60,225.00,percent of total billed charges,
PT Group,4937993,CDM,420,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GP,59.40,,,,,,,16.60,225.00,percent of total billed charges,
PT Group,4937994,CDM,420,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GP,59.40,,,,,,,16.60,225.00,percent of total billed charges,
PT Group,4937995,CDM,420,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GP,59.40,,,,,,,16.60,225.00,percent of total billed charges,
PT Group Therapy,8263920,CDM,420,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GP,59.40,,,,,,,16.60,225.00,percent of total billed charges,
PT Aquatic Therapy by assistant,8282687,CDM,420,RC,97113,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CQ,GP",61.94,,,,,,,30.28,225.00,percent of total billed charges,
PT Canalith Repositioning by assistant,8283329,CDM,420,RC,95992,HCPCS,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,"CQ,GP",154.85,,,,,,,40.55,249.49,percent of total billed charges,
PT Elec Stim Attended by assistant,8282679,CDM,420,RC,97032,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"GP,CQ",61.94,,,,,,,12.94,225.00,percent of total billed charges,
PT Elec Stim Unattended by assistant,8283351,CDM,420,RC,G0283,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,Local,,89.36,,,,,,,17.84,225.00,percent of total billed charges,
PT Fluidotherapy by assistant,8283433,CDM,420,RC,97022,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,"CQ,GP",62.95,,,,,,,13.96,225.00,percent of total billed charges,
PT Gait Training by assistant,8282689,CDM,420,RC,97116,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"GP,CQ",61.94,,,,,,,23.49,225.00,percent of total billed charges,
PT Iontophoresis by assistant,8282681,CDM,420,RC,97033,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CQ,GP",61.94,,,,,,,16.94,225.00,percent of total billed charges,
PT Manual Therapy Charge Units by assistant,8282693,CDM,420,RC,97140,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"GP,CQ",61.94,,,,,,,24.62,225.00,percent of total billed charges,
PT Massage by assistant,8282691,CDM,420,RC,97124,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CQ,GP",61.94,,,,,,,21.30,225.00,percent of total billed charges,
PT Neuromusc Re Education by assistant,8282697,CDM,420,RC,97112,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"GP,CQ",61.94,,,,,,,27.80,225.00,percent of total billed charges,
PT Orthotic Fit Train by assistant,8282703,CDM,420,RC,97760,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CQ,GP",61.94,,,,,,,29.55,225.00,percent of total billed charges,
PT Orthotic Prosthetic Check by assistant,8282707,CDM,420,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,"CQ,GP",76.66,,,,,,,44.95,225.00,percent of total billed charges,
PT Prosthetic Training by assistant,8282705,CDM,420,RC,97761,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,"CQ,GP",76.66,,,,,,,27.08,225.00,percent of total billed charges,
PT Self Care Home Management Charge Units by assistant,8282699,CDM,420,RC,97535,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CQ,GP",61.94,,,,,,,28.51,225.00,percent of total billed charges,
PT Ther Act Functional Mobiliity by assistant,8282695,CDM,420,RC,97530,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,"GP,CQ",81.23,,,,,,,27.79,225.00,percent of total billed charges,
PT Therapeutic Exercise Charge Units by assistant,8282685,CDM,420,RC,97110,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,"CQ,GP",81.23,,,,,,,26.07,225.00,percent of total billed charges,
PT Traction Mechanical by assistant,8283315,CDM,420,RC,97012,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"GP,CQ",61.94,,,,,,,12.94,225.00,percent of total billed charges,
PT Ultrasound by assistant,8282683,CDM,420,RC,97035,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CQ,GP",61.94,,,,,,,11.57,225.00,percent of total billed charges,
PT Wheelchair Management Assistant Units,8282701,CDM,420,RC,97542,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"GP,CQ",61.94,,,,,,,26.73,225.00,percent of total billed charges,
Dry Needling 3 or More Muscles,8686212,CDM,420,RC,20561,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,GP,1610.00,,,,,,,45.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Dry Needling 1 or 2 Muscles,8686204,CDM,420,RC,20560,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,Local,GP,1610.00,,,,,,,24.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PT Caregiver Training Initial 30 Charge,9040367,CDM,420,RC,97550,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,Local,,125.91,,,,,,,57.09,225.00,percent of total billed charges,
PT Caregiver Training Initial 30 Charge,9042293,CDM,420,RC,97550,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,Local,,125.91,,,,,,,57.09,225.00,percent of total billed charges,
PT Caregiver Training Addl 15 Unit,9040369,CDM,420,RC,97551,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,,62.95,,,,,,,30.25,225.00,percent of total billed charges,
PT Caregiver Training Addl 15 Unit,9042295,CDM,420,RC,97551,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,,62.95,,,,,,,30.25,225.00,percent of total billed charges,
PT NO PT PRSNT TRAIN INITIAL 30,9101500,CDM,420,RC,G0541,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,Local,,66.00,,,,,,,28.97,225.00,percent of total billed charges,
PT NO PT PRSNT TRAIN INITIAL 30 BY ASSIST,9103988,CDM,420,RC,G0541,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,Local,,66.00,,,,,,,28.97,225.00,percent of total billed charges,
PT NO PT PRSNT TRAIN ADD 15,9101412,CDM,420,RC,G0542,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,Local,,32.49,,,,,,,30.08,225.00,percent of total billed charges,
PT NO PT PRSNT TRAIN ADD 15 BY ASSIST,9103753,CDM,420,RC,G0542,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,Local,,32.49,,,,,,,30.08,225.00,percent of total billed charges,
PT GROUP TRAIN WO PATEINT,9104029,CDM,420,RC,G0543,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,25.38,225.00,percent of total billed charges,
PT GROUP TRAIN WO PATEINT BY ASSIST,9101529,CDM,420,RC,G0543,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,25.38,225.00,percent of total billed charges,
PTS Re Evaluation,5039840,CDM,424,RC,97164,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,Local,GP,108.14,,,,,,,61.07,225.00,percent of total billed charges,
PTS Evaluation Low Complexity,7941922,CDM,424,RC,97161,HCPCS,,,facility,outpatient,,,313.00000,90.77000,Aetna,Local,GP,158.91,,,,,,,88.77,256.03,percent of total billed charges,
PTS Evaluation Moderate Complex,7941923,CDM,424,RC,97162,HCPCS,,,facility,outpatient,,,340.00000,98.60000,Aetna,Local,GP,172.62,,,,,,,88.77,278.12,percent of total billed charges,
PTS Evaluation High Complexity,7941921,CDM,424,RC,97163,HCPCS,,,facility,outpatient,,,328.00000,95.12000,Aetna,Local,GP,166.53,,,,,,,88.77,268.30,percent of total billed charges,
OTS Therapeutic Exercise 15 Min,4922244,CDM,430,RC,97110,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,GO,81.23,,,,,,,26.07,225.00,percent of total billed charges,
OTS Iontophoresis 15 Min,4922263,CDM,430,RC,97033,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,16.94,225.00,percent of total billed charges,
OTS Fluidotherapy,4941868,CDM,430,RC,97022,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,GO,62.95,,,,,,,13.96,225.00,percent of total billed charges,
OTS Electrical Stim Attend 15Min,4922258,CDM,430,RC,97032,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,12.94,225.00,percent of total billed charges,
OTS Aquatic Therapy 15 Min,4922266,CDM,430,RC,97113,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,30.28,225.00,percent of total billed charges,
OTS Orthotic Initial Train 15Min,4922248,CDM,430,RC,97760,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,29.55,225.00,percent of total billed charges,
OT Orthotic Prosthetic Manage Train Units,8185049,CDM,430,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,GO,76.66,,,,,,,44.95,225.00,percent of total billed charges,
OTS Adl Management Train 15Min,4922250,CDM,430,RC,97535,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,28.51,225.00,percent of total billed charges,
OTS Cognitive Treatment Initital 15 min,4922270,CDM,430,RC,97129,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,19.86,225.00,percent of total billed charges,
OT Cognitive Treatment Initial Charge,8282841,CDM,430,RC,97129,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,19.86,225.00,percent of total billed charges,
OTS Electrical Stim Unattended,4941874,CDM,430,RC,G0283,HCPCS,,,facility,outpatient,,,176.00000,51.04000,Aetna,Local,,89.36,,,,,,,17.84,225.00,percent of total billed charges,
OTS Therapeutic Activities 15 Min,4922256,CDM,430,RC,97530,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,GO,81.23,,,,,,,27.79,225.00,percent of total billed charges,
OTS Manual Therapy 15 Min,4922252,CDM,430,RC,97140,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,24.62,225.00,percent of total billed charges,
OTS L Dex Measurement,4958179,CDM,430,RC,93702,HCPCS,,,facility,outpatient,,,185.00000,53.65000,Aetna,Local,GO,93.92,,,,,,,86.95,417.59,percent of total billed charges,
OTS Work Task Analysis 15 Min,4922276,CDM,430,RC,97537,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,GO,62.95,,,,,,,26.02,225.00,percent of total billed charges,
OTS Wound Care Selective Lt 20 Cm,4932425,CDM,430,RC,97597,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,GO,1610.00,,,,,,,46.38,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OTS Ultrasound 15 Min,4922268,CDM,430,RC,97035,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,11.57,225.00,percent of total billed charges,
OTS Wound Care Nonselective,4941877,CDM,430,RC,97602,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,GO,342.70,,,,,,,97.85,552.15,percent of total billed charges,
OTS Orthotic Prosth Train 15min,4922260,CDM,430,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,GO,76.66,,,,,,,44.95,225.00,percent of total billed charges,
OTS Vasopneumatic Device,4941846,CDM,430,RC,97016,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,GO,62.95,,,,,,,10.55,225.00,percent of total billed charges,
OTS Paraffin Bath,4941848,CDM,430,RC,97018,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,GO,62.95,,,,,,,5.52,225.00,percent of total billed charges,
OTS Multi Layer Com Afhf Bilat,7939211,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,1093.00000,316.97000,Aetna,Local,"GO,50",554.92,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Multi Layer Comp Afhf Rt,7939209,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,546.00000,158.34000,Aetna,Local,"GO,RT",277.20,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Multi Layer Comp Afhf Lt,7939210,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,546.00000,158.34000,Aetna,Local,"GO,LT",277.20,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Multi Layer Comp Lef Bilat,7939226,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,Local,"50,GO",607.21,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Multi Layer Comp Lef Rt,7939224,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,"RT,GO",303.60,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Multi Layer Compress Lef Lt,7939225,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,"GO,LT",303.60,,,,,,,97.85,2860.00,percent of total billed charges,
OTS Massage 15 Min,4922246,CDM,430,RC,97124,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,21.30,225.00,percent of total billed charges,
OTS Neuromuscular Re Ed 15 Min,4922265,CDM,430,RC,97112,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,27.80,225.00,percent of total billed charges,
OTS Wheelchair Management 15 Min,4922254,CDM,430,RC,97542,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,26.73,225.00,percent of total billed charges,
OTS Prosthetic Init Train 15Min,4922272,CDM,430,RC,97761,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,GO,76.66,,,,,,,27.08,225.00,percent of total billed charges,
OTS Wound Care Selective Gt 20Cm,4922296,CDM,430,RC,97598,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,GO,1610.00,,,,,,,59.03,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OT Group,4941857,CDM,430,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GO,59.40,,,,,,,16.60,225.00,percent of total billed charges,
OT Group,4941860,CDM,430,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GO,59.40,,,,,,,16.60,225.00,percent of total billed charges,
OT Group,4941863,CDM,430,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GO,59.40,,,,,,,16.60,225.00,percent of total billed charges,
OT Group,4943849,CDM,430,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GO,59.40,,,,,,,16.60,225.00,percent of total billed charges,
OT Group Therapy Charge,8236128,CDM,430,RC,97150,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GO,59.40,,,,,,,16.60,225.00,percent of total billed charges,
OTS Cognitive Treatment ea Addl 15 min,8282791,CDM,430,RC,97130,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GO,61.94,,,,,,,18.97,225.00,percent of total billed charges,
OTS Biofeedback Perianal Initial 15 min,8283272,CDM,430,RC,90912,HCPCS,,,facility,outpatient,,,189.00000,54.81000,Aetna,Local,GO,95.96,,,,,,,88.83,225.00,percent of total billed charges,
OTS Biofeedback Perianal Addl 15 min,8282775,CDM,430,RC,90913,HCPCS,,,facility,outpatient,,,190.00000,55.10000,Aetna,Local,GO,96.46,,,,,,,89.30,225.00,percent of total billed charges,
L Dex measurement by assistant,8283077,CDM,430,RC,93702,HCPCS,,,facility,outpatient,,,185.00000,53.65000,Aetna,Local,"GO,CO",93.92,,,,,,,86.95,417.59,percent of total billed charges,
Manual Therapy Techniques by assistant,8282755,CDM,430,RC,97140,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CO,GO",61.94,,,,,,,24.62,225.00,percent of total billed charges,
Neuromuscular Reeducation by assistant,8282751,CDM,430,RC,97112,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CO,GO",61.94,,,,,,,27.80,225.00,percent of total billed charges,
OT  Compression Pump by assistant,8283097,CDM,430,RC,97016,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,"GO,CO",62.95,,,,,,,10.55,225.00,percent of total billed charges,
OT Active Wound Care by assistant,8283006,CDM,430,RC,97597,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,"GO,CO",1610.00,,,,,,,46.38,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OT Aquatic Therapy by assistant,8282797,CDM,430,RC,97113,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CO,GO",61.94,,,,,,,30.28,225.00,percent of total billed charges,
OT Rt Leg ankle foot by assistant,8282805,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,"RT,GO,CO",303.60,,,,,,,97.85,2860.00,percent of total billed charges,
OT B Leg ankle foot by assistant,8282809,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,Local,"50,GO,CO",607.21,,,,,,,97.85,2860.00,percent of total billed charges,
OT B Upperarm forearm hand fingers by assistant,8282815,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,1093.00000,316.97000,Aetna,Local,"CO,50,GO",554.92,,,,,,,97.85,2860.00,percent of total billed charges,
OT Cognitive Skills Dev Assistant Units,8290456,CDM,430,RC,97129,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CO,GO",61.94,,,,,,,19.86,225.00,percent of total billed charges,
OT Cognitive Tx addl by assistant,8282793,CDM,430,RC,97130,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"GO,CO",61.94,,,,,,,18.97,225.00,percent of total billed charges,
OT Debridement Each additional 20 cm charge by assistant,8283014,CDM,430,RC,97598,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,"CO,GO",1610.00,,,,,,,59.03,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OT Electrical Stim Attended Charge Units by assistant,8282743,CDM,430,RC,97032,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CO,GO",61.94,,,,,,,12.94,225.00,percent of total billed charges,
OT Rt upperarm forearm hand fingers by assistant,8282811,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,546.00000,158.34000,Aetna,Local,"GO,RT,CO",277.20,,,,,,,97.85,2860.00,percent of total billed charges,
OT Electrical Stim Unattended by assistant,8282733,CDM,430,RC,G0283,HCPCS,,,facility,outpatient,,,140.00000,40.60000,Aetna,Local,,71.08,,,,,,,17.84,225.00,percent of total billed charges,
OT Fluidotherapy by assistant,8283155,CDM,430,RC,97022,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,"CO,GO",62.95,,,,,,,13.96,225.00,percent of total billed charges,
OT Iontophoresis by assistant,8282745,CDM,430,RC,97033,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CO,GO",61.94,,,,,,,16.94,225.00,percent of total billed charges,
OT Lt Leg ankle foot by assistant,8282807,CDM,430,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,"LT,GO,CO",303.60,,,,,,,97.85,2860.00,percent of total billed charges,
OT Lt Upperarm forearm hand fingers by assistant,8282813,CDM,430,RC,29584,HCPCS,,,facility,outpatient,,,546.00000,158.34000,Aetna,Local,"CO,LT,GO",277.20,,,,,,,97.85,2860.00,percent of total billed charges,
OT Massage by assistant,8282753,CDM,430,RC,97124,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"GO,CO",61.94,,,,,,,21.30,225.00,percent of total billed charges,
OT Orthotic Fit and Training Charge Units by assistant,8282765,CDM,430,RC,97760,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"GO,CO",61.94,,,,,,,29.55,225.00,percent of total billed charges,
OT Orthotic Prosthetic Checkout Charge Units by assistant,8282769,CDM,430,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,"CO,GO",76.66,,,,,,,44.95,225.00,percent of total billed charges,
OT Paraffin Bath by assistant,8283132,CDM,430,RC,97018,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,"CO,GO",62.95,,,,,,,5.52,225.00,percent of total billed charges,
OT Prosthetic Training by assistant,8282767,CDM,430,RC,97761,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,"GO,CO",76.66,,,,,,,27.08,225.00,percent of total billed charges,
OT Self Care Home Management by Assistant,8282761,CDM,430,RC,97535,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CO,GO",61.94,,,,,,,28.51,225.00,percent of total billed charges,
OT Ther Act Functional Mobility by Assistant,8282757,CDM,430,RC,97530,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,"CO,GO",81.23,,,,,,,27.79,225.00,percent of total billed charges,
OT Ultrasound by Assistant,8282747,CDM,430,RC,97035,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CO,GO",61.94,,,,,,,11.57,225.00,percent of total billed charges,
OT Wheelchair Mgmt Training by Assistant,8282763,CDM,430,RC,97542,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,"CO,GO",61.94,,,,,,,26.73,225.00,percent of total billed charges,
OT Work Task Analysis Unit by Assistant,8282779,CDM,430,RC,97537,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,"CO,GO",62.95,,,,,,,26.02,225.00,percent of total billed charges,
OT Orthotic Prosthetic Checkout Charge Units by Assistant,8283004,CDM,430,RC,97763,HCPCS,,,facility,outpatient,,,151.00000,43.79000,Aetna,Local,"CO,GO",76.66,,,,,,,44.95,225.00,percent of total billed charges,
OT Therapeutic Exercise by Assistant,8282749,CDM,430,RC,97110,HCPCS,,,facility,outpatient,,,160.00000,46.40000,Aetna,Local,"CO,GO",81.23,,,,,,,26.07,225.00,percent of total billed charges,
Dry Needling 1 or 2 Muscles,9192644,CDM,430,RC,20560,HCPCS,,,facility,outpatient,,,40.00000,11.60000,Aetna,Local,GO,1610.00,,,,,,,24.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Dry Needling 3 or More Muscles,9196676,CDM,430,RC,20561,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,GO,1610.00,,,,,,,45.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OT Caregiver Training Initial 30 Charge,9040371,CDM,430,RC,97550,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,Local,"GO,CO",125.91,,,,,,,97.85,225.00,percent of total billed charges,
OT Caregiver Training Initial 30 Charge,9042297,CDM,430,RC,97550,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,Local,GO,125.91,,,,,,,97.85,225.00,percent of total billed charges,
OT Caregiver Training Addl 15 Unit,9040374,CDM,430,RC,97551,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,,62.95,,,,,,,30.25,225.00,percent of total billed charges,
OT Caregiver Training Addl 15 Unit,9040376,CDM,430,RC,97551,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,,62.95,,,,,,,30.25,225.00,percent of total billed charges,
OT NO PT PRSNT TRAIN INITIAL 30,9104046,CDM,430,RC,G0541,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,Local,,66.00,,,,,,,28.97,225.00,percent of total billed charges,
OT NO PT PRSNT TRAIN INITIAL 30 BY ASSIST,9101665,CDM,430,RC,G0541,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,Local,,66.00,,,,,,,28.97,225.00,percent of total billed charges,
OT NO PT PRSNT TRAIN ADD 15,9103749,CDM,430,RC,G0542,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,Local,,32.49,,,,,,,30.08,225.00,percent of total billed charges,
OT NO PT PRSNT TRAIN ADD 15 BY ASSIST,9103751,CDM,430,RC,G0542,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,Local,,32.49,,,,,,,30.08,225.00,percent of total billed charges,
OT GROUP TRAIN WO PATEINT,9101769,CDM,430,RC,G0543,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,25.38,225.00,percent of total billed charges,
OT GROUP TRAIN WO PATEINT BY ASSIST,9101782,CDM,430,RC,G0543,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,25.38,225.00,percent of total billed charges,
OTS Re Evaluation,4941851,CDM,434,RC,97168,HCPCS,,,facility,outpatient,,,213.00000,61.77000,Aetna,Local,GO,108.14,,,,,,,62.80,225.00,percent of total billed charges,
OTS Evaluation Low Complexity,7941933,CDM,434,RC,97165,HCPCS,,,facility,outpatient,,,313.00000,90.77000,Aetna,Local,GO,158.91,,,,,,,91.04,256.03,percent of total billed charges,
OTS Evaluation Moderate Complex,7941934,CDM,434,RC,97166,HCPCS,,,facility,outpatient,,,320.00000,92.80000,Aetna,Local,GO,162.46,,,,,,,91.04,261.76,percent of total billed charges,
OTS Evaluation High Complexity,7941932,CDM,434,RC,97167,HCPCS,,,facility,outpatient,,,328.00000,95.12000,Aetna,Local,GO,166.53,,,,,,,91.04,268.30,percent of total billed charges,
ST Group 30 Mins,4937857,CDM,440,RC,92508,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GN,59.40,,,,,,,21.33,225.00,percent of total billed charges,
STS Eval Swallow,7542256,CDM,440,RC,92610,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,GN,260.96,,,,,,,75.57,420.45,percent of total billed charges,
STS Video Swallow Study,7542261,CDM,440,RC,92611,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,GN,260.96,,,,,,,80.49,420.45,percent of total billed charges,
STS Video Swallow Study,8994299,CDM,440,RC,92611,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,,260.96,,,,,,,80.49,420.45,percent of total billed charges,
ST Aphasia Assessment,4936753,CDM,440,RC,96105,HCPCS,,,facility,outpatient,,,531.00000,153.99000,Aetna,Local,GN,269.59,,,,,,,69.19,434.36,percent of total billed charges,
STS Aphasia Assessment Hr,7467870,CDM,440,RC,96105,HCPCS,,,facility,outpatient,,,531.00000,153.99000,Aetna,Local,GN,269.59,,,,,,,69.19,434.36,percent of total billed charges,
ST Group 15 Mins,4916255,CDM,440,RC,92508,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GN,59.40,,,,,,,21.33,225.00,percent of total billed charges,
ST Group 15 Mins,4937856,CDM,440,RC,92508,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GN,59.40,,,,,,,21.33,225.00,percent of total billed charges,
STS Cognitive Treatment Initial 15 min,7467871,CDM,440,RC,97129,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GN,61.94,,,,,,,19.86,225.00,percent of total billed charges,
STS Cognitive Treatment Initial 15 min,8282823,CDM,440,RC,97129,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GN,61.94,,,,,,,19.86,225.00,percent of total billed charges,
STS Eval Cognition,7467869,CDM,440,RC,96125,HCPCS,,,facility,outpatient,,,458.00000,132.82000,Aetna,Local,GN,232.53,,,,,,,88.00,374.64,percent of total billed charges,
SLP Cog Perf Testing Unit,8215280,CDM,440,RC,96125,HCPCS,,,facility,outpatient,,,458.00000,132.82000,Aetna,Local,GN,232.53,,,,,,,88.00,374.64,percent of total billed charges,
STS Eval Voice Prosthesis,7951877,CDM,440,RC,92597,HCPCS,,,facility,outpatient,,,377.00000,109.33000,Aetna,Local,GN,191.40,,,,,,,64.66,308.39,percent of total billed charges,
STS Swallow Treament,7922814,CDM,440,RC,92526,HCPCS,,,facility,outpatient,,,445.00000,129.05000,Aetna,Local,GN,225.93,,,,,,,75.05,364.01,percent of total billed charges,
STS Eval Voice,7922811,CDM,440,RC,92524,HCPCS,,,facility,outpatient,,,535.00000,155.15000,Aetna,Local,GN,271.62,,,,,,,97.03,437.63,percent of total billed charges,
STS Eval Language Only,7922805,CDM,440,RC,92523,HCPCS,,,facility,outpatient,,,740.00000,214.60000,Aetna,Local,GN,375.70,,,,,,,97.85,605.32,percent of total billed charges,
STS Eval Speech And Language,7922808,CDM,440,RC,92523,HCPCS,,,facility,outpatient,,,740.00000,214.60000,Aetna,Local,GN,375.70,,,,,,,97.85,605.32,percent of total billed charges,
STS EVAL SOUND PRODUCTION,7922798,CDM,440,RC,92522,HCPCS,,,facility,outpatient,,,367.00000,106.43000,Aetna,Local,GN,186.33,,,,,,,97.85,300.21,percent of total billed charges,
STS Eval Fluency,7922795,CDM,440,RC,92521,HCPCS,,,facility,outpatient,,,441.00000,127.89000,Aetna,Local,GN,223.90,,,,,,,97.85,360.74,percent of total billed charges,
STS Speech Treatment,7922792,CDM,440,RC,92507,HCPCS,,,facility,outpatient,,,290.00000,84.10000,Aetna,Local,GN,147.23,,,,,,,59.17,237.22,percent of total billed charges,
STS Cognitive Treatment Ea Addl 15 min,8282825,CDM,440,RC,97130,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GN,61.94,,,,,,,18.97,225.00,percent of total billed charges,
STS Community Work Reintegration,8282829,CDM,440,RC,97537,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,GN,62.95,,,,,,,26.02,225.00,percent of total billed charges,
STS Self Care Home Skills,8282827,CDM,440,RC,97535,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,Local,GN,61.94,,,,,,,28.51,225.00,percent of total billed charges,
SLP Group Therapy,8263914,CDM,440,RC,92508,HCPCS,,,facility,outpatient,,,117.00000,33.93000,Aetna,Local,GN,59.40,,,,,,,21.33,225.00,percent of total billed charges,
SLP Caregiver Training Initial 30 Charge,9040378,CDM,440,RC,97550,HCPCS,,,facility,outpatient,,,248.00000,71.92000,Aetna,Local,,125.91,,,,,,,57.09,225.00,percent of total billed charges,
SLP Caregiver Training Addl 15 Unit,9042299,CDM,440,RC,97551,HCPCS,,,facility,outpatient,,,124.00000,35.96000,Aetna,Local,,62.95,,,,,,,30.25,225.00,percent of total billed charges,
ST Endoscopy Swallow Fees Vid,9042187,CDM,440,RC,92612,HCPCS,,,facility,outpatient,,,514.00000,149.06000,Aetna,Local,GN,260.96,,,,,,,97.85,466.24,percent of total billed charges,
SLP NO PT PRSNT TRAIN INITIAL 30,9101795,CDM,440,RC,G0541,HCPCS,,,facility,outpatient,,,130.00000,37.70000,Aetna,Local,,66.00,,,,,,,28.97,225.00,percent of total billed charges,
SLP NO PT PRSNT TRAIN ADD 15,9101414,CDM,440,RC,G0542,HCPCS,,,facility,outpatient,,,64.00000,18.56000,Aetna,Local,,32.49,,,,,,,30.08,225.00,percent of total billed charges,
SLP GROUP TRAIN WO PATEINT,9101806,CDM,440,RC,G0543,HCPCS,,,facility,outpatient,,,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,13.43,225.00,percent of total billed charges,
ER Bladder Scan,7275875,CDM,450,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,52.15,2860.00,percent of total billed charges,
INTEGUMENTRY PROCEDURE,7275860,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
INTEGUMENTRY PROCEDURE,7295866,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
ER Orthopedic Treatment,7982969,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894478,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894481,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894489,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
ER Declot Implanted Device,7901654,CDM,450,RC,36593,HCPCS,,,facility,outpatient,,,1110.00000,321.90000,Aetna,Local,,1610.00,,,,,,,291.24,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ER Ent Procedure,7275856,CDM,450,RC,,,,,facility,outpatient,,,518.00000,150.22000,Aetna,Local,,262.99,,,,,,,186.74,1462.32,percent of total billed charges,
Gastric Procedure,7275861,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
ER Insert Ng Tube,7901656,CDM,450,RC,43752,HCPCS,,,facility,outpatient,,,1133.00000,328.57000,Aetna,Local,,2076.00,,,,,,,350.38,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ER Optic Treatment,7275849,CDM,450,RC,,,,,facility,outpatient,,,433.00000,125.57000,Aetna,Local,,219.83,,,,,,,156.10,1462.32,percent of total billed charges,
ER Tongue And Mouth Surgery,7275850,CDM,450,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,Local,,386.87,,,,,,,274.70,1462.32,percent of total billed charges,
ER Thoracentesis,7901658,CDM,450,RC,,,,,facility,outpatient,,,3008.00000,872.32000,Aetna,Local,,1527.16,,,,,,,1084.38,2460.54,percent of total billed charges,
ER Insert Chest Tube,7918377,CDM,450,RC,,,,,facility,outpatient,,,1396.00000,404.84000,Aetna,Local,,708.75,,,,,,,503.26,1462.32,percent of total billed charges,
Insert replace trach intubation tube,7901657,CDM,450,RC,,,,,facility,outpatient,,,2276.00000,660.04000,Aetna,Local,,1155.53,,,,,,,820.50,1861.77,percent of total billed charges,
Injection SubQ IM,7261847,CDM,450,RC,96372,HCPCS,,,facility,outpatient,,,375.00000,108.75000,Aetna,Local,,190.39,,,,,,,62.50,1462.32,percent of total billed charges,
IV Infusion Concurrent Drug,1431866,CDM,450,RC,96368,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,134.83,1462.32,percent of total billed charges,
ED IV Infusion Concurrent Drug,1445823,CDM,450,RC,96368,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,134.83,1462.32,percent of total billed charges,
IV Infusion Initial First Hr,7261843,CDM,450,RC,96365,HCPCS,,,facility,outpatient,,,662.00000,191.98000,Aetna,Local,,336.10,,,,,,,185.00,1462.32,percent of total billed charges,
IV Infusion First Drug Ea Hr,7261844,CDM,450,RC,96366,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,40.51,1462.32,percent of total billed charges,
IV Infusion Sequential Drug,7261845,CDM,450,RC,96367,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,62.50,1462.32,percent of total billed charges,
IV Push,7261849,CDM,450,RC,96375,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,Local,,189.37,,,,,,,40.51,1462.32,percent of total billed charges,
IV Push Initial,7261848,CDM,450,RC,96374,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,Local,,335.59,,,,,,,185.00,1462.32,percent of total billed charges,
ED IV Push Initial,927805,CDM,450,RC,96374,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,Local,,335.59,,,,,,,185.00,1462.32,percent of total billed charges,
ER Integumentry Procedure,2144850,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
ER Integumentry Procedure,7275858,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
ER Integumentry Procedure,7275863,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
IV Push Sequential,7261850,CDM,450,RC,96376,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,Local,,189.37,,,,,,,134.47,1462.32,percent of total billed charges,
Orthopedic Treatment,7894479,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894487,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894488,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
Orthopedic Treatment,7894494,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
ER Orthopedic Treatment,7902957,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
Urinary catheter insertion Foley,7959496,CDM,450,RC,51702,HCPCS,,,facility,outpatient,,,387.00000,112.23000,Aetna,Local,,1610.00,,,,,,,113.19,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ER Insert Cath Straight,7959497,CDM,450,RC,51701,HCPCS,,,facility,outpatient,,,239.00000,69.31000,Aetna,Local,,1610.00,,,,,,,95.60,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ER Declot Implanted Device,7902973,CDM,450,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,Local,,614.32,,,,,,,436.20,1462.32,percent of total billed charges,
ER Anoscopy,3030879,CDM,450,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,Local,,386.87,,,,,,,274.70,1462.32,percent of total billed charges,
ER Anoscopy,7275878,CDM,450,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,Local,,386.87,,,,,,,274.70,1462.32,percent of total billed charges,
ER Cardiac Procedure,7275854,CDM,450,RC,,,,,facility,outpatient,,,2450.00000,710.50000,Aetna,Local,,1243.87,,,,,,,883.23,2004.10,percent of total billed charges,
ER Cardiac Procedure,7902968,CDM,450,RC,,,,,facility,outpatient,,,2450.00000,710.50000,Aetna,Local,,1243.87,,,,,,,883.23,2004.10,percent of total billed charges,
ER Ent Procedure,7902955,CDM,450,RC,,,,,facility,outpatient,,,518.00000,150.22000,Aetna,Local,,262.99,,,,,,,186.74,1462.32,percent of total billed charges,
ER Gastric Procedure,2152825,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
ER Gastric Procedure,7275869,CDM,450,RC,,,,,facility,outpatient,,,906.00000,262.74000,Aetna,Local,,459.98,,,,,,,326.61,1462.32,percent of total billed charges,
ER Hazmat Decontamination,602332,CDM,450,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,Local,,884.92,,,,,,,628.35,1462.32,percent of total billed charges,
ER Hazmat Decontamination,7275866,CDM,450,RC,,,,,facility,outpatient,,,1562.00000,452.98000,Aetna,Local,,793.03,,,,,,,563.10,1462.32,percent of total billed charges,
ER Incision Of Windpipe,2152827,CDM,450,RC,,,,,facility,outpatient,,,1743.00000,505.47000,Aetna,Local,,884.92,,,,,,,628.35,1462.32,percent of total billed charges,
ER Insert Ng Tube,2152835,CDM,450,RC,43752,HCPCS,,,facility,outpatient,,,1133.00000,328.57000,Aetna,Local,,2076.00,,,,,,,350.38,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ER Insert Ng Tube,5757849,CDM,450,RC,43752,HCPCS,,,facility,outpatient,,,1133.00000,328.57000,Aetna,Local,,2076.00,,,,,,,350.38,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ER Optic Treatment,602382,CDM,450,RC,,,,,facility,outpatient,,,433.00000,125.57000,Aetna,Local,,219.83,,,,,,,156.10,1462.32,percent of total billed charges,
ER Puncture Peritoneal Cavity,2152841,CDM,450,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,Local,,386.87,,,,,,,274.70,1462.32,percent of total billed charges,
ER Tongue And Mouth Surgery,2152851,CDM,450,RC,,,,,facility,outpatient,,,762.00000,220.98000,Aetna,Local,,386.87,,,,,,,274.70,1462.32,percent of total billed charges,
ER Urinary Procedure,2152834,CDM,450,RC,,,,,facility,outpatient,,,1639.00000,475.31000,Aetna,Local,,832.12,,,,,,,590.86,1462.32,percent of total billed charges,
ER Urinary Procedure,2152837,CDM,450,RC,,,,,facility,outpatient,,,1639.00000,475.31000,Aetna,Local,,832.12,,,,,,,590.86,1462.32,percent of total billed charges,
ER Insert Central Venous Catheter,2152831,CDM,450,RC,,,,,facility,outpatient,,,1801.00000,522.29000,Aetna,Local,,914.37,,,,,,,649.26,1473.22,percent of total billed charges,
ER Insert Chest Tube,2152830,CDM,450,RC,,,,,facility,outpatient,,,1522.00000,441.38000,Aetna,Local,,772.72,,,,,,,548.68,1462.32,percent of total billed charges,
ER Spinal Fluid Tap,2152848,CDM,450,RC,,,,,facility,outpatient,,,982.00000,284.78000,Aetna,Local,,498.56,,,,,,,354.01,1462.32,percent of total billed charges,
IV Hydration Initial 1st hr,8997071,CDM,450,RC,96360,HCPCS,,,facility,outpatient,,,575.00000,166.75000,Aetna,Local,,291.93,,,,,,,185.00,1462.32,percent of total billed charges,
IV Hydration Addl Ea Hr,8994799,CDM,450,RC,96361,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,Local,,189.88,,,,,,,40.51,1462.32,percent of total billed charges,
Change of Cystostomy Tube Simple,9011808,CDM,450,RC,51705,HCPCS,,,facility,outpatient,,,302.00000,87.58000,Aetna,Local,,1610.00,,,,,,,120.80,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ER Level 1,7261851,CDM,450,RC,99281,HCPCS,,,facility,outpatient,,,480.00000,139.20000,Aetna,Local,,464.00,,,,,,,77.31,1462.32,case rate,
ER Level 2,7261852,CDM,450,RC,99282,HCPCS,,,facility,outpatient,,,790.00000,229.10000,Aetna,Local,,701.00,,,,,,,139.04,1462.32,case rate,
ER Level 3,7261853,CDM,450,RC,99283,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,Local,,1391.00,,,,,,,243.12,2478.00,case rate,
ER Level 4,7261854,CDM,450,RC,99284,HCPCS,,,facility,outpatient,,,2315.00000,671.35000,Aetna,Local,,1701.00,,,,,,,373.89,3070.00,case rate,
ER Level 5,7261855,CDM,450,RC,99285,HCPCS,,,facility,outpatient,,,3646.00000,1057.34000,Aetna,Local,,,50.77,,2744.0,2741.6500000000005,2744.0,14,538.34,3070.00,percent of total billed charges,"Not to exceed $2,744"
ER Level 6,7261856,CDM,450,RC,99291,HCPCS,,,facility,outpatient,,,5253.00000,1523.37000,Aetna,Local,,2666.95,,,,,,,739.86,4296.95,percent of total billed charges,
Sane Level 1,602472,CDM,450,RC,99499,HCPCS,,,facility,outpatient,,,262.00000,75.98000,Aetna,Local,,133.02,,,,,,,94.45,1462.32,percent of total billed charges,
Sane Level 2,602474,CDM,450,RC,99499,HCPCS,,,facility,outpatient,,,797.00000,231.13000,Aetna,Local,,404.64,,,,,,,287.32,1462.32,percent of total billed charges,
Sane Level 3,602476,CDM,450,RC,99499,HCPCS,,,facility,outpatient,,,1934.00000,560.86000,Aetna,Local,,981.89,,,,,,,697.21,1582.01,percent of total billed charges,
OTHER BLOCK CHARGE,9088206,CDM,460,RC,,,,,facility,outpatient,,,2545.00000,738.05000,Aetna,Local,,1292.10,,,,,,,917.47,2081.81,percent of total billed charges,
Stress Test 6 Minutes Simple,7860031,CDM,460,RC,94618,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,,432.56,,,,,,,113.19,696.94,percent of total billed charges,
Demo Eval Gen Neb Inh Device,5466009,CDM,460,RC,94664,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Evaluate Patient Use of Inhaler,657753,CDM,460,RC,94664,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Aerobika Daily Charge,8996766,CDM,460,RC,94664,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Vital Capacity Test,3191093,CDM,460,RC,94150,HCPCS,,,facility,outpatient,,,299.00000,86.71000,Aetna,Local,,151.80,,,,,,,110.99,417.59,percent of total billed charges,
Vital Capacity Test,5471878,CDM,460,RC,94150,HCPCS,,,facility,outpatient,,,299.00000,86.71000,Aetna,Local,,151.80,,,,,,,110.99,417.59,percent of total billed charges,
Sm Volume Nebulizer First Daily,5389871,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,27.84,542.88,percent of total billed charges,
Sm Volume Nebulizer First Daily,7637985,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,27.84,542.88,percent of total billed charges,
Sm Volume Nebulizer First Daily,9190478,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,27.84,542.88,percent of total billed charges,
Nitrogen Washout Or Frc,5389884,CDM,460,RC,94727,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,137.38,593.05,percent of total billed charges,
Nitrogen Washout Or Frc,5471883,CDM,460,RC,94727,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,137.38,593.05,percent of total billed charges,
Thoracic Gas Volume,5389885,CDM,460,RC,94726,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,269.12,840.96,percent of total billed charges,
Thoracic Gas Volume,5471879,CDM,460,RC,94726,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,269.12,840.96,percent of total billed charges,
Resistance To Airflow W N2 Volume,7967854,CDM,460,RC,94726,HCPCS,,,facility,outpatient,,,1450.00000,420.50000,Aetna,Local,,736.16,,,,,,,273.42,1186.10,percent of total billed charges,
Sm Volume Nebulizer Subseq Daily,5389872,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,27.84,542.88,percent of total billed charges,
Sm Volume Nebulizer Subseq Daily,7637984,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,27.84,542.88,percent of total billed charges,
Exercise Oximetry,7930098,CDM,460,RC,94618,HCPCS,,,facility,outpatient,,,852.00000,247.08000,Aetna,Local,,432.56,,,,,,,113.19,696.94,percent of total billed charges,
Spirometry,5471881,CDM,460,RC,94010,HCPCS,,,facility,outpatient,,,644.00000,186.76000,Aetna,Local,,326.96,,,,,,,137.38,526.79,percent of total billed charges,
Spirometry,5471888,CDM,460,RC,94010,HCPCS,,,facility,outpatient,,,644.00000,186.76000,Aetna,Local,,326.96,,,,,,,137.38,526.79,percent of total billed charges,
Spirometry,612663,CDM,460,RC,94010,HCPCS,,,facility,outpatient,,,644.00000,186.76000,Aetna,Local,,326.96,,,,,,,137.38,526.79,percent of total billed charges,
Spirometry,612735,CDM,460,RC,94010,HCPCS,,,facility,outpatient,,,644.00000,186.76000,Aetna,Local,,326.96,,,,,,,137.38,526.79,percent of total billed charges,
Spirometry Pre And Post,5471880,CDM,460,RC,94060,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,415.81,,,,,,,273.42,840.96,percent of total billed charges,
Spirometry Pre And Post,612667,CDM,460,RC,94060,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,415.81,,,,,,,273.42,840.96,percent of total billed charges,
Diffusion Capacity,5471886,CDM,460,RC,94729,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,415.81,,,,,,,295.25,669.94,percent of total billed charges,
Diffusion Capacity,612671,CDM,460,RC,94729,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,Local,,415.81,,,,,,,295.25,669.94,percent of total billed charges,
Resistance To Airflow,5471882,CDM,460,RC,94726,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,269.12,840.96,percent of total billed charges,
Resistance To Airflow,612677,CDM,460,RC,94726,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,269.12,840.96,percent of total billed charges,
Methacoline Challenge,5471884,CDM,460,RC,94070,HCPCS,,,facility,outpatient,,,2087.00000,605.23000,Aetna,Local,,1059.57,,,,,,,273.42,1707.17,percent of total billed charges,
Sm Volume Nebulizer Initial,8244299,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,GZ,38.08,,,,,,,27.04,542.88,percent of total billed charges,
Continuous High Freq Oscillation Initial,8414037,CDM,460,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Continuous High Freq Oscillation Subsequent,8414038,CDM,460,RC,94669,HCPCS,,,facility,outpatient,,,294.00000,85.26000,Aetna,Local,,149.26,,,,,,,109.13,542.88,percent of total billed charges,
Maximum Voluntary Ventilation,5471885,CDM,460,RC,94200,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,Local,,187.85,,,,,,,52.15,302.66,percent of total billed charges,
Maximum Voluntary Ventilation,5757855,CDM,460,RC,94200,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,Local,,187.85,,,,,,,52.15,302.66,percent of total billed charges,
Maximum Voluntary Ventilation,612701,CDM,460,RC,94200,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,Local,,187.85,,,,,,,52.15,302.66,percent of total billed charges,
Metered Treatment Initial,7944332,CDM,460,RC,94640,HCPCS,,,facility,outpatient,,,75.00000,21.75000,Aetna,Local,,38.08,,,,,,,27.84,542.88,percent of total billed charges,
Nocturnal Oximetry,5111861,CDM,460,RC,94762,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,128.88,593.05,percent of total billed charges,
Nocturnal Oximetry,5470370,CDM,460,RC,94762,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,128.88,593.05,percent of total billed charges,
Continuous Pulse Ox,5571843,CDM,460,RC,94762,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,128.88,593.05,percent of total billed charges,
Continuous Pulse Ox,5745855,CDM,460,RC,94762,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,128.88,593.05,percent of total billed charges,
Continuous Pulse Ox,5745857,CDM,460,RC,94762,HCPCS,,,facility,outpatient,,,725.00000,210.25000,Aetna,Local,,368.08,,,,,,,128.88,593.05,percent of total billed charges,
CEN Positional Nystagmus,617804,CDM,471,RC,92542,HCPCS,,,facility,outpatient,,,409.00000,118.61000,Aetna,Local,,207.65,,,,,,,53.64,344.05,percent of total billed charges,
CEN Oscillating Tracking,617803,CDM,471,RC,92545,HCPCS,,,facility,outpatient,,,409.00000,118.61000,Aetna,Local,,207.65,,,,,,,37.89,831.14,percent of total billed charges,
Cardioversion,1327801,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,Local,,1893.21,,,,,,,1344.30,3050.32,percent of total billed charges,
Cardioversion,7295845,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,Local,,1893.21,,,,,,,1344.30,3050.32,percent of total billed charges,
Tilt Table,7860029,CDM,480,RC,93660,HCPCS,,,facility,outpatient,,,4683.00000,1358.07000,Aetna,Local,,2377.56,,,,,,,373.76,3830.69,percent of total billed charges,
Cardioversion,7289842,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,Local,,1893.21,,,,,,,1344.30,3050.32,percent of total billed charges,
Cardioversion,7401840,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,Local,,1893.21,,,,,,,1344.30,3050.32,percent of total billed charges,
Cardioversion,8147861,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,Local,,1893.21,,,,,,,1344.30,3050.32,percent of total billed charges,
COLOR FLOW,8003078,CDM,480,RC,93325,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,528.00,,,,,,,287.88,1161.56,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Color Flow,8147860,CDM,480,RC,93325,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,528.00,,,,,,,287.88,1161.56,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Echo Intracardiac,7289846,CDM,480,RC,,,,,facility,outpatient,,,10727.00000,3110.83000,Aetna,Local,,5446.10,,,,,,,3867.08,8774.69,percent of total billed charges,
Myocardial Strain Imaging,7993616,CDM,480,RC,93356,HCPCS,,,facility,outpatient,,,985.00000,285.65000,Aetna,Local,,500.08,,,,,,,355.09,805.73,percent of total billed charges,
Cardioversion External Elective,8062919,CDM,480,RC,,,,,facility,outpatient,,,3729.00000,1081.41000,Aetna,Local,,1893.21,,,,,,,1344.30,3050.32,percent of total billed charges,
Resuscitation,5463843,CDM,480,RC,92950,HCPCS,,,facility,outpatient,,,2675.00000,775.75000,Aetna,Local,,1358.10,,,,,,,216.27,2188.15,percent of total billed charges,
Resuscitation,612639,CDM,480,RC,92950,HCPCS,,,facility,outpatient,,,2675.00000,775.75000,Aetna,Local,,1358.10,,,,,,,216.27,2188.15,percent of total billed charges,
NB Resuscitation,8994591,CDM,480,RC,99465,HCPCS,,,facility,outpatient,,,2675.00000,775.75000,Aetna,Local,,1358.10,,,,,,,574.59,2188.15,percent of total billed charges,
IVC Filter Placement W Venogram,8062812,CDM,481,RC,,,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,7615.50,,,,,,,5407.50,12270.00,percent of total billed charges,
IVC Filter Removal,8062813,CDM,481,RC,,,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,4569.30,,,,,,,3244.50,10865.00,percent of total billed charges,
Insert Arterial Impella,8142185,CDM,481,RC,,,,,facility,outpatient,,,12397.00000,3595.13000,Aetna,Local,,6293.96,,,,,,,4469.12,10865.00,percent of total billed charges,
Balloon Aortic Valvuloplasty,8062816,CDM,481,RC,,,,,facility,outpatient,,,21281.00000,6171.49000,Aetna,Local,,10804.36,,,,,,,7671.80,17407.86,percent of total billed charges,
Implant LAA Closure Device,8062817,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Reprogramming Of Icd,8062818,CDM,481,RC,,,,,facility,outpatient,,,646.00000,187.34000,Aetna,Local,,327.97,,,,,,,232.88,10865.00,percent of total billed charges,
Closure Patent Ductus,8062819,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,Local,,23354.20,,,,,,,9200.00,37628.00,percent of total billed charges,
Heart Cath Rt W Sensor Implant,8142184,CDM,481,RC,,,,,facility,outpatient,,,87400.00000,25346.00000,Aetna,Local,,44372.98,,,,,,,9200.00,71493.20,percent of total billed charges,
Place Stent Addtl Nonlower,8062884,CDM,481,RC,,,,,facility,outpatient,,,41323.00000,11983.67000,Aetna,Local,,20979.69,,,,,,,9200.00,33802.21,percent of total billed charges,
Place Stent and PTCA Single Major AR,8062968,CDM,481,RC,,,,,facility,outpatient,,,41323.00000,11983.67000,Aetna,Local,,20979.69,,,,,,,9200.00,33802.21,percent of total billed charges,
Place Stent,8142488,CDM,481,RC,,,,,facility,outpatient,,,41323.00000,11983.67000,Aetna,Local,,20979.69,,,,,,,9200.00,33802.21,percent of total billed charges,
Reposition Ventricular Lead w Anti Micobial Pouch,8225890,CDM,481,RC,,,,,facility,outpatient,,,16298.00000,4726.42000,Aetna,Local,,8274.49,,,,,,,5875.43,13331.76,percent of total billed charges,
TAVR Procedure,8436576,CDM,481,RC,,,,,facility,outpatient,,,29604.00000,8585.16000,Aetna,Local,,15029.95,,,,,,,9200.00,24216.07,percent of total billed charges,
Transcatheter Mitral Valve Repair,8948552,CDM,481,RC,,,,,facility,outpatient,,,29604.00000,8585.16000,Aetna,Local,,15029.95,,,,,,,9200.00,24216.07,percent of total billed charges,
Intravascular Lithotripsy,9000387,CDM,481,RC,,,,,facility,outpatient,,,32811.00000,9515.19000,Aetna,Local,,16658.14,,,,,,,9200.00,26839.40,percent of total billed charges,
INSERT OR REPLACE SUBQ DEFIBRILLATOR,9090469,CDM,481,RC,,,,,facility,outpatient,,,60000.00000,17400.00000,Aetna,Local,,30462.00,,,,,,,9200.00,49080.00,percent of total billed charges,
Device Interrogation,8997182,CDM,481,RC,,,,,facility,outpatient,,,305.00000,88.45000,Aetna,Local,,154.85,,,,,,,109.95,10865.00,percent of total billed charges,
Pacemaker Leadless Insert Or Repl,8156532,CDM,481,RC,,,,,facility,outpatient,,,51000.00000,14790.00000,Aetna,Local,,25892.70,,,,,,,9200.00,41718.00,percent of total billed charges,
Insert or Replace Cardiac Modulation,9210779,CDM,481,RC,,,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,Local,,6092.40,,,,,,,4326.00,10865.00,percent of total billed charges,
Insert Drug Coated Balloon,9198712,CDM,481,RC,,,,,facility,outpatient,,,41323.00000,11983.67000,Aetna,Local,,20979.69,,,,,,,9200.00,33802.21,percent of total billed charges,
Pericardiocentesis Initl,8062820,CDM,481,RC,,,,,facility,outpatient,,,8109.00000,2351.61000,Aetna,Local,,4116.94,,,,,,,2923.29,10865.00,percent of total billed charges,
Pericardiocentesis Subsequent,8062821,CDM,481,RC,,,,,facility,outpatient,,,1992.00000,577.68000,Aetna,Local,,1011.34,,,,,,,718.12,10865.00,percent of total billed charges,
Insert Replace PM Atrial,8062822,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Insert Replace PM Ventr,8062823,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Insert Replace PM Atrial And Ventr,8062824,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Insert Replace Temp Single PM,8062825,CDM,481,RC,,,,,facility,outpatient,,,26450.00000,7670.50000,Aetna,Local,,13428.67,,,,,,,9200.00,21636.10,percent of total billed charges,
Insertgen Only Existing Single,8062826,CDM,481,RC,,,,,facility,outpatient,,,28000.00000,8120.00000,Aetna,Local,,14215.60,,,,,,,9200.00,22904.00,percent of total billed charges,
Insert Gen Only Existing Dual,8062827,CDM,481,RC,,,,,facility,outpatient,,,32200.00000,9338.00000,Aetna,Local,,16347.94,,,,,,,9200.00,26339.60,percent of total billed charges,
Upgrade Single Pm To Dual Pm,8062828,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Reposition Rt Ventr Atrial Lead,8062829,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
Insert Lead One,8062830,CDM,481,RC,,,,,facility,outpatient,,,26450.00000,7670.50000,Aetna,Local,,13428.67,,,,,,,9200.00,21636.10,percent of total billed charges,
Insert Lead Two,8062831,CDM,481,RC,,,,,facility,outpatient,,,26450.00000,7670.50000,Aetna,Local,,13428.67,,,,,,,9200.00,21636.10,percent of total billed charges,
Repair Lead One,8062832,CDM,481,RC,,,,,facility,outpatient,,,14879.00000,4314.91000,Aetna,Local,,7554.07,,,,,,,5363.88,12171.02,percent of total billed charges,
Insert Gen Only Existing Multiple,8062833,CDM,481,RC,,,,,facility,outpatient,,,51000.00000,14790.00000,Aetna,Local,,25892.70,,,,,,,9200.00,41718.00,percent of total billed charges,
Revision Relocate Of Skin Pocket,8062805,CDM,481,RC,,,,,facility,outpatient,,,8109.00000,2351.61000,Aetna,Local,,4116.94,,,,,,,2923.29,10865.00,percent of total billed charges,
Revision Relocate Of Skin Pocket,8062806,CDM,481,RC,,,,,facility,outpatient,,,6131.00000,1777.99000,Aetna,Local,,3112.71,,,,,,,2210.23,10865.00,percent of total billed charges,
Add Lt Ventr Lead to Existing Pm,8062834,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Insert Lt Ventr Lead At Time Of P,8062835,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Reposition Lt Ventricular Lead,8062836,CDM,481,RC,,,,,facility,outpatient,,,11263.00000,3266.27000,Aetna,Local,,5718.23,,,,,,,4060.31,10865.00,percent of total billed charges,
Replace Pm Gen Existng Single,8062837,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Replace Pm Gen Existng Dual Lead,8062838,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Replace Pm Gen Existng Multple,8062839,CDM,481,RC,,,,,facility,outpatient,,,58650.00000,17008.50000,Aetna,Local,,29776.60,,,,,,,9200.00,47975.70,percent of total billed charges,
Insert Of Icd Gen Only Dual,8062840,CDM,481,RC,,,,,facility,outpatient,,,62000.00000,17980.00000,Aetna,Local,,31477.40,,,,,,,9200.00,50716.00,percent of total billed charges,
Insert Of Icd Gen Only Multiple,8062841,CDM,481,RC,,,,,facility,outpatient,,,86000.00000,24940.00000,Aetna,Local,,43662.20,,,,,,,9200.00,70348.00,percent of total billed charges,
Remove Perm Pm Pulse Gen Only,8062842,CDM,481,RC,,,,,facility,outpatient,,,26450.00000,7670.50000,Aetna,Local,,13428.67,,,,,,,9200.00,21636.10,percent of total billed charges,
Remove Transv Lead Single,8062843,CDM,481,RC,,,,,facility,outpatient,,,12649.00000,3668.21000,Aetna,Local,,6421.90,,,,,,,4559.96,10865.00,percent of total billed charges,
Remove Of Transv Lead Dual,8062844,CDM,481,RC,,,,,facility,outpatient,,,12766.00000,3702.14000,Aetna,Local,,6481.30,,,,,,,4602.14,10865.00,percent of total billed charges,
Insert Of Icd Gen Only Single,8062845,CDM,481,RC,,,,,facility,outpatient,,,62000.00000,17980.00000,Aetna,Local,,31477.40,,,,,,,9200.00,50716.00,percent of total billed charges,
Remove ICD Gen Only,8062846,CDM,481,RC,,,,,facility,outpatient,,,14895.00000,4319.55000,Aetna,Local,,7562.19,,,,,,,5369.65,12184.11,percent of total billed charges,
Remove Electrode Transvenous,8062847,CDM,481,RC,,,,,facility,outpatient,,,12649.00000,3668.21000,Aetna,Local,,6421.90,,,,,,,4559.96,10865.00,percent of total billed charges,
Insert Pulse Gen And Lead,8062848,CDM,481,RC,,,,,facility,outpatient,,,98900.00000,28681.00000,Aetna,Local,,50211.53,,,,,,,9200.00,80900.20,percent of total billed charges,
Replace Icd Gen Existng Single,8062849,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,Local,,36199.01,,,,,,,9200.00,58323.40,percent of total billed charges,
Replace Icd Gen Existng Dual,8062850,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,Local,,36199.01,,,,,,,9200.00,58323.40,percent of total billed charges,
Replace Icd Gen Existng Multiple,8062851,CDM,481,RC,,,,,facility,outpatient,,,98900.00000,28681.00000,Aetna,Local,,50211.53,,,,,,,9200.00,80900.20,percent of total billed charges,
Insert Loop Event Recorder,8062852,CDM,481,RC,,,,,facility,outpatient,,,20268.00000,5877.72000,Aetna,Local,,10290.06,,,,,,,7306.61,16579.22,percent of total billed charges,
Remove Loop Recorder,8062853,CDM,481,RC,,,,,facility,outpatient,,,8109.00000,2351.61000,Aetna,Local,,4116.94,,,,,,,2923.29,10865.00,percent of total billed charges,
Insert Balloon Pump,8062854,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
Remove Balloon Pump,8062855,CDM,481,RC,,,,,facility,outpatient,,,6690.00000,1940.10000,Aetna,Local,,3396.51,,,,,,,2411.74,10865.00,percent of total billed charges,
Reposition At Separate Session,8062856,CDM,481,RC,,,,,facility,outpatient,,,12649.00000,3668.21000,Aetna,Local,,6421.90,,,,,,,4559.96,10865.00,percent of total billed charges,
Brachiocephalic Initl Vessel,8062857,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,Local,,6223.89,,,,,,,4419.37,10865.00,percent of total billed charges,
Brachiocephalic Each Additl Vesse,8062858,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,Local,,6223.89,,,,,,,4419.37,10865.00,percent of total billed charges,
Place Cath Rt Or Pulm Art,8062859,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Place Catheter Rt Or Lt Pulm Art,8062860,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Place Catheter Segmntl Pulm Art,8062861,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Place Catheter In Artery Brachial,8062862,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Place Catheter in Extremity,8062863,CDM,481,RC,,,,,facility,outpatient,,,6082.00000,1763.78000,Aetna,Local,,3087.83,,,,,,,2192.56,10865.00,percent of total billed charges,
Place Catheter In Femoral Or Brac,8062864,CDM,481,RC,,,,,facility,outpatient,,,6082.00000,1763.78000,Aetna,Local,,3087.83,,,,,,,2192.56,10865.00,percent of total billed charges,
Each 1St Order Above Diaghram,8062865,CDM,481,RC,,,,,facility,outpatient,,,6082.00000,1763.78000,Aetna,Local,,3087.83,,,,,,,2192.56,10865.00,percent of total billed charges,
Initial 2nd Order Above Diaphragm,8062866,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Initl 3rd Order Above Diaghram,8062867,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Addtl 2nd Order Above Diaphragm,8062868,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Nonselect Great Vessels,8062869,CDM,481,RC,,,,,facility,outpatient,,,18241.00000,5289.89000,Aetna,Local,,9260.96,,,,,,,6575.88,14921.14,percent of total billed charges,
Carotid Intracranial Unilat,8062870,CDM,481,RC,,,,,facility,outpatient,,,18022.00000,5226.38000,Aetna,Local,,9149.77,,,,,,,6496.93,14742.00,percent of total billed charges,
Vertebral Unilatw Select,8062871,CDM,481,RC,,,,,facility,outpatient,,,13793.00000,3999.97000,Aetna,Local,,7002.71,,,,,,,4972.38,11282.67,percent of total billed charges,
Each 1st Order Below Diaphragm,8062872,CDM,481,RC,,,,,facility,outpatient,,,6082.00000,1763.78000,Aetna,Local,,3087.83,,,,,,,2192.56,10865.00,percent of total billed charges,
Initl 2nd Order Above Diaghram,8062873,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Initl 3rd Order Above Diaghram,8062874,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Addtl 2nd Order Below Diaphragm,8062875,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Renal Select Unilat,8062876,CDM,481,RC,,,,,facility,outpatient,,,10727.00000,3110.83000,Aetna,Local,,5446.10,,,,,,,3867.08,10865.00,percent of total billed charges,
Renal Select Bilat,8062877,CDM,481,RC,,,,,facility,outpatient,,,19153.00000,5554.37000,Aetna,Local,,9723.98,,,,,,,6904.66,15667.15,percent of total billed charges,
1st Art Thrombect Initl Vessel,8062878,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,Local,,23354.20,,,,,,,9200.00,37628.00,percent of total billed charges,
1st Art Thrombect 2nd Vessel,8062879,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,Local,,6223.89,,,,,,,4419.37,10865.00,percent of total billed charges,
2nd Arterial Thrombectomy,8062880,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,Local,,6223.89,,,,,,,4419.37,10865.00,percent of total billed charges,
Perc Retrieval Of Foreign Body,8062881,CDM,481,RC,,,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,4569.30,,,,,,,3244.50,10865.00,percent of total billed charges,
Infusion For Other Than Thrombo,8062882,CDM,481,RC,,,,,facility,outpatient,,,5364.00000,1555.56000,Aetna,Local,,2723.30,,,,,,,1933.72,10865.00,percent of total billed charges,
Place Stent Initl Vessel Nonlower,8062883,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Angioplasty Only Iliac Artery Init,8062885,CDM,481,RC,,,,,facility,outpatient,,,23409.00000,6788.61000,Aetna,Local,,11884.75,,,,,,,8438.94,19148.56,percent of total billed charges,
Place Stent Wwo Angio Iliac Art,8062886,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Angioplasty Iliac Artery Addtl,8062887,CDM,481,RC,,,,,facility,outpatient,,,16858.00000,4888.82000,Aetna,Local,,8558.81,,,,,,,6077.31,13789.84,percent of total billed charges,
Place Stent Wwo Angio Iliac Addtl,8062888,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Angio Only Fem Pop Artery Unilat,8062889,CDM,481,RC,,,,,facility,outpatient,,,23409.00000,6788.61000,Aetna,Local,,11884.75,,,,,,,8438.94,19148.56,percent of total billed charges,
Atherect Only Fem Pop W Angio,8062890,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,Local,,23354.20,,,,,,,9200.00,37628.00,percent of total billed charges,
Place Stent Wwo Angio Fem Pop,8062891,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Place Stent and Atherect Wwo Angio,8062892,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Angio Only Tibial Peroneal Art,8062893,CDM,481,RC,,,,,facility,outpatient,,,29000.00000,8410.00000,Aetna,Local,,14723.30,,,,,,,9200.00,23722.00,percent of total billed charges,
Atherct Tib Per W Angio Initl,8062894,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,Local,,23354.20,,,,,,,9200.00,37628.00,percent of total billed charges,
Place Stent Wwo Angio Tib Per Ini,8062895,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Place Stent W Atherect Wwo Angio,8062807,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Angio Only Tibial Peroneal Art Ea,8062896,CDM,481,RC,,,,,facility,outpatient,,,16858.00000,4888.82000,Aetna,Local,,8558.81,,,,,,,6077.31,13789.84,percent of total billed charges,
Atherct Only Tib Per Addtl Vessel,8062897,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Place Stent Wwo Angio Tib Per Add,8062898,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Place Stent W Atherect Wwo Angio,8062808,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
IVUS Noncoronary Initl Vessel,8062899,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
IVUS Noncoronary Addtl Vessel,8062900,CDM,481,RC,,,,,facility,outpatient,,,8045.00000,2333.05000,Aetna,Local,,4084.45,,,,,,,2900.22,10865.00,percent of total billed charges,
Descend Thoracic Aorto Single,8062901,CDM,481,RC,,,,,facility,outpatient,,,8300.00000,2407.00000,Aetna,Local,,4213.91,,,,,,,2992.15,10865.00,percent of total billed charges,
Descend Thoracic Aorto Multiple,8062902,CDM,481,RC,,,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,Local,,7615.50,,,,,,,5407.50,12270.00,percent of total billed charges,
Abd Aortogram,8062903,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
Abd Aortogrm W Bilat Runoff,8062904,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
Unilat Extremity Upper Or Lower,8062905,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
Bilateral Extremity Upper or Lower,8062906,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
Pulm Angiogram Unilat Select,8062907,CDM,481,RC,,,,,facility,outpatient,,,8892.00000,2578.68000,Aetna,Local,,4514.47,,,,,,,3205.57,10865.00,percent of total billed charges,
Pulm Angiogram Bilat Select,8062908,CDM,481,RC,,,,,facility,outpatient,,,8892.00000,2578.68000,Aetna,Local,,4514.47,,,,,,,3205.57,10865.00,percent of total billed charges,
Pulm Angiogram Nonselect,8062909,CDM,481,RC,,,,,facility,outpatient,,,8300.00000,2407.00000,Aetna,Local,,4213.91,,,,,,,2992.15,10865.00,percent of total billed charges,
Internal Mammary,8062910,CDM,481,RC,,,,,facility,outpatient,,,8300.00000,2407.00000,Aetna,Local,,4213.91,,,,,,,2992.15,10865.00,percent of total billed charges,
Inferior Venocavogram,8062911,CDM,481,RC,,,,,facility,outpatient,,,22987.00000,6666.23000,Aetna,Local,,11670.50,,,,,,,8286.81,18803.37,percent of total billed charges,
Superior Venocavogram,8062912,CDM,481,RC,,,,,facility,outpatient,,,22987.00000,6666.23000,Aetna,Local,,11670.50,,,,,,,8286.81,18803.37,percent of total billed charges,
PTCA Single Artery Or Branch,8062914,CDM,481,RC,,,,,facility,outpatient,,,21281.00000,6171.49000,Aetna,Local,,10804.36,,,,,,,7671.80,17407.86,percent of total billed charges,
PTCA Each Addtl Branch,8062915,CDM,481,RC,,,,,facility,outpatient,,,21281.00000,6171.49000,Aetna,Local,,10804.36,,,,,,,7671.80,17407.86,percent of total billed charges,
Atherect And Ptca Art Or Branch,8062916,CDM,481,RC,,,,,facility,outpatient,,,41323.00000,11983.67000,Aetna,Local,,20979.69,,,,,,,9200.00,33802.21,percent of total billed charges,
Atherect And Ptca Addtl Branch,8062917,CDM,481,RC,,,,,facility,outpatient,,,31246.00000,9061.34000,Aetna,Local,,15863.59,,,,,,,9200.00,25559.23,percent of total billed charges,
Resuscitation,8062918,CDM,481,RC,,,,,facility,outpatient,,,2675.00000,775.75000,Aetna,Local,,1358.10,,,,,,,964.34,10865.00,percent of total billed charges,
Coronary Thrombectomy,8062920,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
Intracoronary Thrombolysis,8062921,CDM,481,RC,,,,,facility,outpatient,,,8045.00000,2333.05000,Aetna,Local,,4084.45,,,,,,,2900.22,10865.00,percent of total billed charges,
IVUS Initial Vessel,8062922,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
IVUS Addtl Vessel,8062923,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
Pulm Artery Angio Single Vessel,8062924,CDM,481,RC,,,,,facility,outpatient,,,29000.00000,8410.00000,Aetna,Local,,14723.30,,,,,,,9200.00,23722.00,percent of total billed charges,
Pulm Artery Angio Addtl Vessel,8062925,CDM,481,RC,,,,,facility,outpatient,,,14879.00000,4314.91000,Aetna,Local,,7554.07,,,,,,,5363.88,12171.02,percent of total billed charges,
Eval Implantable Loop Recorder System,8062926,CDM,481,RC,,,,,facility,outpatient,,,646.00000,187.34000,Aetna,Local,,327.97,,,,,,,232.88,10865.00,percent of total billed charges,
Eval Of Implantable System,8062927,CDM,481,RC,,,,,facility,outpatient,,,646.00000,187.34000,Aetna,Local,,327.97,,,,,,,232.88,10865.00,percent of total billed charges,
Heart Cath Rt,8062928,CDM,481,RC,,,,,facility,outpatient,,,20005.00000,5801.45000,Aetna,Local,,10156.54,,,,,,,7211.80,16364.09,percent of total billed charges,
Heart Cath Lt,8062929,CDM,481,RC,,,,,facility,outpatient,,,25965.00000,7529.85000,Aetna,Local,,13182.43,,,,,,,9200.00,21239.37,percent of total billed charges,
Heart Cath Rt And Lt,8062930,CDM,481,RC,,,,,facility,outpatient,,,28778.00000,8345.62000,Aetna,Local,,14610.59,,,,,,,9200.00,23540.40,percent of total billed charges,
Heart Cath Cors,8062931,CDM,481,RC,,,,,facility,outpatient,,,22984.00000,6665.36000,Aetna,Local,,11668.98,,,,,,,8285.73,18800.91,percent of total billed charges,
Heart Cath Cors And Grafts,8062932,CDM,481,RC,,,,,facility,outpatient,,,25965.00000,7529.85000,Aetna,Local,,13182.43,,,,,,,9200.00,21239.37,percent of total billed charges,
Heart Cath Rt And Cors,8062933,CDM,481,RC,,,,,facility,outpatient,,,30806.00000,8933.74000,Aetna,Local,,15640.21,,,,,,,9200.00,25199.31,percent of total billed charges,
Heart Cath Rt And Cors And Grafts,8062934,CDM,481,RC,,,,,facility,outpatient,,,35061.00000,10167.69000,Aetna,Local,,17800.47,,,,,,,9200.00,28679.90,percent of total billed charges,
Heart Cath Lt And Cors,8062935,CDM,481,RC,,,,,facility,outpatient,,,32225.00000,9345.25000,Aetna,Local,,16360.63,,,,,,,9200.00,26360.05,percent of total billed charges,
Heart Cath Lt And Cors And Grafts,8062936,CDM,481,RC,,,,,facility,outpatient,,,34048.00000,9873.92000,Aetna,Local,,17286.17,,,,,,,9200.00,27851.26,percent of total billed charges,
Heart Cath Rt And Lt And Cors,8062937,CDM,481,RC,,,,,facility,outpatient,,,36279.00000,10520.91000,Aetna,Local,,18418.85,,,,,,,9200.00,29676.22,percent of total billed charges,
Heart Cath Rt And Lt And Cors And Grafts,8062938,CDM,481,RC,,,,,facility,outpatient,,,39320.00000,11402.80000,Aetna,Local,,19962.76,,,,,,,9200.00,32163.76,percent of total billed charges,
Heart Cath Rt And Lt Retro,8062939,CDM,481,RC,,,,,facility,outpatient,,,22067.00000,6399.43000,Aetna,Local,,11203.42,,,,,,,7955.15,18050.81,percent of total billed charges,
Heart Cath Rt And Lt Trans,8062940,CDM,481,RC,,,,,facility,outpatient,,,27890.00000,8088.10000,Aetna,Local,,14159.75,,,,,,,9200.00,22814.02,percent of total billed charges,
Select Rt Ventric Rt Atrial Angio,8062941,CDM,481,RC,,,,,facility,outpatient,,,6082.00000,1763.78000,Aetna,Local,,3087.83,,,,,,,2192.56,10865.00,percent of total billed charges,
Closure Atrial Septal Defect,8062942,CDM,481,RC,,,,,facility,outpatient,,,52900.00000,15341.00000,Aetna,Local,,26857.33,,,,,,,9200.00,43272.20,percent of total billed charges,
Closure Ventricular Septal Defect,8062943,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,Local,,23354.20,,,,,,,9200.00,37628.00,percent of total billed charges,
Bundle of HIS Recording,8062944,CDM,481,RC,,,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,Local,,11677.10,,,,,,,8291.50,18814.00,percent of total billed charges,
Intraatrial Recording,8062945,CDM,481,RC,,,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,Local,,11677.10,,,,,,,8291.50,18814.00,percent of total billed charges,
Rt Ventricular Recording,8062946,CDM,481,RC,,,,,facility,outpatient,,,9194.00000,2666.26000,Aetna,Local,,4667.79,,,,,,,3314.44,10865.00,percent of total billed charges,
Mapping of Tachycardia,8062947,CDM,481,RC,,,,,facility,outpatient,,,17023.00000,4936.67000,Aetna,Local,,8642.58,,,,,,,6136.79,13924.81,percent of total billed charges,
Intraatrial Pacing,8062948,CDM,481,RC,,,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,Local,,11677.10,,,,,,,8291.50,18814.00,percent of total billed charges,
Intraventricular Pacing,8062949,CDM,481,RC,,,,,facility,outpatient,,,20000.00000,5800.00000,Aetna,Local,,10154.00,,,,,,,7210.00,16360.00,percent of total billed charges,
3D Mapping Of Tachycardia,8062950,CDM,481,RC,,,,,facility,outpatient,,,17023.00000,4936.67000,Aetna,Local,,8642.58,,,,,,,6136.79,13924.81,percent of total billed charges,
Induction Of Arrhythmia,8062951,CDM,481,RC,,,,,facility,outpatient,,,10638.00000,3085.02000,Aetna,Local,,5400.91,,,,,,,3835.00,10865.00,percent of total billed charges,
Rt Atria Rt Ventric And HIS Bundle,8062809,CDM,481,RC,,,,,facility,outpatient,,,20000.00000,5800.00000,Aetna,Local,,10154.00,,,,,,,7210.00,16360.00,percent of total billed charges,
Rt Atria Rt Ventric And HIS Bundle,8062810,CDM,481,RC,,,,,facility,outpatient,,,23409.00000,6788.61000,Aetna,Local,,11884.75,,,,,,,8438.94,19148.56,percent of total billed charges,
Lt Atrial Pacing From Cor Sinus,8062952,CDM,481,RC,,,,,facility,outpatient,,,21281.00000,6171.49000,Aetna,Local,,10804.36,,,,,,,7671.80,17407.86,percent of total billed charges,
Lt Ventricular Pacing and Recording,8062953,CDM,481,RC,,,,,facility,outpatient,,,12185.00000,3533.65000,Aetna,Local,,6186.32,,,,,,,4392.69,10865.00,percent of total billed charges,
Stimulation and Pace After Iv Drug,8062954,CDM,481,RC,,,,,facility,outpatient,,,16115.00000,4673.35000,Aetna,Local,,8181.59,,,,,,,5809.46,13182.07,percent of total billed charges,
Ep Eval Of Single Or Dual Icd Lea,8062955,CDM,481,RC,,,,,facility,outpatient,,,12185.00000,3533.65000,Aetna,Local,,6186.32,,,,,,,4392.69,10865.00,percent of total billed charges,
Ep Eval Of Single Or Dual Icdlead,8062956,CDM,481,RC,,,,,facility,outpatient,,,12185.00000,3533.65000,Aetna,Local,,6186.32,,,,,,,4392.69,10865.00,percent of total billed charges,
Ep Eval Of Single Or Dual Icd Gen,8062957,CDM,481,RC,,,,,facility,outpatient,,,12185.00000,3533.65000,Aetna,Local,,6186.32,,,,,,,4392.69,10865.00,percent of total billed charges,
Ablation AV Node Function Block,8062958,CDM,481,RC,,,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,Local,,11677.10,,,,,,,8291.50,18814.00,percent of total billed charges,
Ablation Svt W Comp Ep Study,8062959,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,Local,,36199.01,,,,,,,9200.00,58323.40,percent of total billed charges,
Ablation VT W Comp EP Study,8062960,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,Local,,36199.01,,,,,,,9200.00,58323.40,percent of total billed charges,
Ablation Separate Mechanism Of Ar,8062961,CDM,481,RC,,,,,facility,outpatient,,,20661.00000,5991.69000,Aetna,Local,,10489.59,,,,,,,7448.29,16900.70,percent of total billed charges,
Ablation By Pulm Isolation W Ep S,8062962,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,Local,,36199.01,,,,,,,9200.00,58323.40,percent of total billed charges,
Addtl Ablation Of Lt Or Rt Atrium,8062963,CDM,481,RC,,,,,facility,outpatient,,,71300.00000,20677.00000,Aetna,Local,,36199.01,,,,,,,9200.00,58323.40,percent of total billed charges,
Intraccardiac Echocardiogram,8062964,CDM,481,RC,,,,,facility,outpatient,,,14186.00000,4113.94000,Aetna,Local,,7202.23,,,,,,,5114.05,11604.15,percent of total billed charges,
Brachiocephalic Trunk And Branches,8062966,CDM,481,RC,,,,,facility,outpatient,,,29000.00000,8410.00000,Aetna,Local,,14723.30,,,,,,,9200.00,23722.00,percent of total billed charges,
Periph Atherectomy Iliac Artery,8062967,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,Local,,23354.20,,,,,,,9200.00,37628.00,percent of total billed charges,
Place Stent AndPtca Each Addtl Bran,8062969,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Atherect And Place Stent And Ptca Art,8062970,CDM,481,RC,,,,,facility,outpatient,,,46000.00000,13340.00000,Aetna,Local,,23354.20,,,,,,,9200.00,37628.00,percent of total billed charges,
Atherect And Place Stent And Ptca Addt,8062971,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Perc Revasc Of Bypass Graft,8062972,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Perc Revasc Of Branch Of Bypass,8062973,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Revasc Of Occlusion During Acute,8062974,CDM,481,RC,,,,,facility,outpatient,,,39354.00000,11412.66000,Aetna,Local,,19980.03,,,,,,,9200.00,32191.57,percent of total billed charges,
Revasc Of Chronic Occlusion,8062975,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Revasc Chronic Occlusion Addtl,8062976,CDM,481,RC,,,,,facility,outpatient,,,29757.00000,8629.53000,Aetna,Local,,15107.63,,,,,,,9200.00,24341.23,percent of total billed charges,
Placement of Closure Device,8062977,CDM,481,RC,,,,,facility,outpatient,,,1532.00000,444.28000,Aetna,Local,,777.80,,,,,,,552.29,10865.00,percent of total billed charges,
Nonselect Renal S At Time Of Cath,8062978,CDM,481,RC,,,,,facility,outpatient,,,6131.00000,1777.99000,Aetna,Local,,3112.71,,,,,,,2210.23,10865.00,percent of total billed charges,
Nonselect Iliac S At Time Of Cath,8062979,CDM,481,RC,,,,,facility,outpatient,,,10132.00000,2938.28000,Aetna,Local,,5144.02,,,,,,,3652.59,10865.00,percent of total billed charges,
Supravalvular Aortography,8062987,CDM,481,RC,,,,,facility,outpatient,,,19678.00000,5706.62000,Aetna,Local,,9990.52,,,,,,,7093.92,16096.60,percent of total billed charges,
Pulm Angiogram,8062988,CDM,481,RC,,,,,facility,outpatient,,,14879.00000,4314.91000,Aetna,Local,,7554.07,,,,,,,5363.88,12171.02,percent of total billed charges,
Lt Cath Transseptal,8062989,CDM,481,RC,,,,,facility,outpatient,,,19923.00000,5777.67000,Aetna,Local,,10114.91,,,,,,,7182.24,16297.01,percent of total billed charges,
Place Line,8062990,CDM,481,RC,,,,,facility,outpatient,,,20268.00000,5877.72000,Aetna,Local,,10290.06,,,,,,,7306.61,16579.22,percent of total billed charges,
Visceral Renal Initl Vessel,8062991,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,Local,,6223.89,,,,,,,4419.37,10865.00,percent of total billed charges,
Visceral Renal Each Addtl Vessel,8062992,CDM,481,RC,,,,,facility,outpatient,,,12259.00000,3555.11000,Aetna,Local,,6223.89,,,,,,,4419.37,10865.00,percent of total billed charges,
FFR IFR Measure,8062995,CDM,481,RC,,,,,facility,outpatient,,,8515.00000,2469.35000,Aetna,Local,,4323.07,,,,,,,3069.66,10865.00,percent of total billed charges,
Injection Proc For Extrem Veno,8062996,CDM,481,RC,,,,,facility,outpatient,,,8045.00000,2333.05000,Aetna,Local,,4084.45,,,,,,,2900.22,10865.00,percent of total billed charges,
Venography Extrem Unilat,8062997,CDM,481,RC,,,,,facility,outpatient,,,4598.00000,1333.42000,Aetna,Local,,2334.40,,,,,,,1657.58,10865.00,percent of total billed charges,
Treadmill Bruce Thallium Stress,7762029,CDM,482,RC,93017,HCPCS,,,facility,outpatient,,,3247.00000,941.63000,Aetna,Local,,528.00,,,,,,,216.27,2656.05,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Treadmill Bruce Thallium Stress,7866069,CDM,482,RC,93017,HCPCS,,,facility,outpatient,,,3247.00000,941.63000,Aetna,Local,,528.00,,,,,,,216.27,2656.05,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Pharmacological Stress,7866071,CDM,482,RC,93017,HCPCS,,,facility,outpatient,,,3247.00000,941.63000,Aetna,Local,,528.00,,,,,,,216.27,2656.05,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Pharmalogical Stress,8298340,CDM,482,RC,93017,HCPCS,,,facility,outpatient,,,3247.00000,941.63000,Aetna,Local,,528.00,,,,,,,216.27,2656.05,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Tee Cardoversion,8403239,CDM,483,RC,93312,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,Local,,528.00,,,,,,,481.44,5047.88,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Echo Limited Wo Contrast,7289844,CDM,483,RC,93308,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,528.00,,,,,,,212.24,1219.64,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
3D Tee,8927197,CDM,483,RC,93319,HCPCS,,,facility,outpatient,,,1113.00000,322.77000,Aetna,Local,,528.00,,,,,,,401.24,910.43,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Complete Echo,7289848,CDM,483,RC,93306,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,Local,,528.00,,,,,,,481.44,5047.88,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Complete Echo With Contrast,7289847,CDM,483,RC,C8929,HCPCS,,,facility,outpatient,,,7615.00000,2208.35000,Aetna,Local,,3866.14,,,,,,,693.72,6229.07,percent of total billed charges,
Dobutamine Stress Echo,7289858,CDM,483,RC,93351,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,Local,,528.00,,,,,,,481.44,5047.88,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Dobut Stress Echo With Contrast,7289856,CDM,483,RC,C8930,HCPCS,,,facility,outpatient,,,7615.00000,2208.35000,Aetna,Local,,3866.14,,,,,,,693.72,6229.07,percent of total billed charges,
Exercise Stress Echo,7289854,CDM,483,RC,93351,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,Local,,528.00,,,,,,,481.44,5047.88,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Exercise Stress Echo,8151169,CDM,483,RC,93351,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,Local,,528.00,,,,,,,481.44,5047.88,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Exercise Echo Stress Only,7289855,CDM,483,RC,93351,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,Local,,528.00,,,,,,,481.44,5047.88,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Exercise Stress Echo W Contrast,7289853,CDM,483,RC,C8930,HCPCS,,,facility,outpatient,,,7615.00000,2208.35000,Aetna,Local,,3866.14,,,,,,,693.72,6229.07,percent of total billed charges,
Echo Doppler Limited,8404520,CDM,483,RC,93321,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,528.00,,,,,,,143.40,1219.64,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Echo Limited With Contrast,7289843,CDM,483,RC,C8924,HCPCS,,,facility,outpatient,,,2355.00000,682.95000,Aetna,Local,,1195.63,,,,,,,313.58,1926.39,percent of total billed charges,
SPECTRAL DOPPLER,8003079,CDM,483,RC,93320,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,528.00,,,,,,,498.63,1219.64,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Transesophageal Echo Intraop,7289859,CDM,483,RC,93318,HCPCS,,,facility,outpatient,,,5366.00000,1556.14000,Aetna,Local,,528.00,,,,,,,296.50,4389.39,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Dobut Stress Echo Stress Only,7289857,CDM,483,RC,93351,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,Local,,528.00,,,,,,,481.44,5047.88,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Transesophageal Echo Wo,7289861,CDM,483,RC,93312,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,Local,,528.00,,,,,,,481.44,5047.88,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Transesophageal Echo Wo,8999424,CDM,483,RC,93312,HCPCS,,,facility,outpatient,,,6171.00000,1789.59000,Aetna,Local,,528.00,,,,,,,481.44,5047.88,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Transesophageal Echo Guidance,7963889,CDM,483,RC,93355,HCPCS,,,facility,outpatient,,,5366.00000,1556.14000,Aetna,Local,,479.00,,,,,,,479.00,4389.39,fee schedule,
Echo Pediatric Complete,8400321,CDM,483,RC,93320,HCPCS,,,facility,outpatient,,,1491.00000,432.39000,Aetna,Local,,528.00,,,,,,,498.63,1219.64,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Echo Pediatric Limited,8400322,CDM,483,RC,93320,HCPCS,,,facility,outpatient,,,1016.00000,294.64000,Aetna,Local,,528.00,,,,,,,366.27,831.09,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sclerotherapy,9099344,CDM,490,RC,,,,,facility,outpatient,,,4316.00000,1251.64000,Aetna,Local,,4610.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sclerotherapy Intravascular,9099346,CDM,490,RC,,,,,facility,outpatient,,,1062.00000,307.98000,Aetna,Local,,4610.00,,,,,,,382.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Vertebroplasty,9108868,CDM,490,RC,,,,,facility,outpatient,,,20898.00000,6060.42000,Aetna,Local,,4610.00,,,,,,,1232.85,17094.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration,9116452,CDM,490,RC,,,,,facility,outpatient,,,1680.00000,487.20000,Aetna,Local,,4610.00,,,,,,,605.64,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration,9114763,CDM,490,RC,,,,,facility,outpatient,,,1680.00000,487.20000,Aetna,Local,,4610.00,,,,,,,605.64,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Aspiration,9114761,CDM,490,RC,,,,,facility,outpatient,,,1680.00000,487.20000,Aetna,Local,,4610.00,,,,,,,605.64,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Clinic Visit,7417968,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,7874157,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,8270107,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit Charge Transitional Care,8997126,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,9084099,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,9085347,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
Insert Cath Foley Indwelling,7957589,CDM,510,RC,,,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,173.63,,,,,,,100.00,279.76,percent of total billed charges,
Insert Foley Catheter Indwelling,8997123,CDM,510,RC,,,,,facility,outpatient,,,342.00000,99.18000,Aetna,Local,,173.63,,,,,,,100.00,279.76,percent of total billed charges,
Insert Cath For Urine Collection,7957590,CDM,510,RC,P9612,HCPCS,,,facility,outpatient,,,44.00000,12.76000,Aetna,Local,,1610.00,,,,,,,8.43,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Insert Cath for Urine Collection,8997122,CDM,510,RC,P9612,HCPCS,,,facility,outpatient,,,44.00000,12.76000,Aetna,Local,,1610.00,,,,,,,8.43,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Declot Vascular Device EG Ultaplace,8997080,CDM,510,RC,36593,HCPCS,,,facility,outpatient,,,1110.00000,321.90000,Aetna,Local,,1610.00,,,,,,,291.24,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Insert Cath Foley Indwelling,8151096,CDM,510,RC,51702,HCPCS,,,facility,outpatient,,,387.00000,112.23000,Aetna,Local,,1610.00,,,,,,,113.19,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Clinic Visit,7419867,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,7959538,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
CLINIC VISIT,7692067,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
PMS CLINIC VISIT,7826049,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit PreOp,9010378,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
CLINIC VISIT,9010380,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
NM Attempted Proced,624502,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
Clinic Visit,8062792,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
CLINIC VISIT,7960082,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
CLINIC VISIT,9010381,CDM,510,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
MR Upper Extremity Joint Lt wo Contrast,613773,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Joint Lt wo Contrast,614275,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Joint Lt wo Contrast,614421,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Rt wo Contrast,6117877,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Rt wo Contrast,613657,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Rt wo Contrast,614024,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Rt wo Contrast,614075,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Rt wo Contrast,7741567,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Rt wo Contrast,7840082,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Rt wo Contrast,7991360,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Rt wo Contrast,8148232,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Left w wo Contrast,1053853,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Left w wo Contrast,613848,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Left w wo Contrast,614175,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Left w wo Contrast,614399,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Breast Right wo Contrast,7938485,CDM,610,RC,77046,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Breast Bilateral wo Contrast,2532851,CDM,610,RC,77047,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,Local,,2076.00,,,,,,,212.24,3844.60,case rate,
MRI Breast Right w Contrast,7938477,CDM,610,RC,C8903,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,1220.51,,,,,,,156.31,1966.47,percent of total billed charges,
MR Breast Bilateral w Contrast,2532848,CDM,610,RC,C8906,HCPCS,,,facility,outpatient,,,4808.00000,1394.32000,Aetna,Local,,2441.02,,,,,,,313.58,3932.94,percent of total billed charges,
MR Breast Right w wo Contrast,7938481,CDM,610,RC,C8905,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,1278.39,,,,,,,313.58,2059.72,percent of total billed charges,
MR Breast Bilateral w wo Contrast,2532849,CDM,610,RC,C8908,HCPCS,,,facility,outpatient,,,5036.00000,1460.44000,Aetna,Local,,2556.78,,,,,,,313.58,4119.45,percent of total billed charges,
MR Abdomen w Contrast,7520020,CDM,610,RC,74182,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Temporal Mandibular Joint,614329,CDM,610,RC,70336,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Guided Breast Localization,3661947,CDM,610,RC,,,,,facility,outpatient,,,5568.00000,1614.72000,Aetna,Local,,2826.87,,,,,,,2007.26,4554.62,percent of total billed charges,
MR Chest wo Contrast,7544137,CDM,610,RC,71550,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Chest wo Contrast,7734636,CDM,610,RC,71550,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Orbit Face Neck w Contrast,7524014,CDM,610,RC,70542,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Orbit Face Neck w Contrast,7544104,CDM,610,RC,70542,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Orbits w Contrast,8001046,CDM,610,RC,70542,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Right Partial,8001047,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,1790.00000,519.10000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Left Partial,8001048,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,1790.00000,519.10000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MRCP done with MR Abdomen,8001049,CDM,610,RC,76376,HCPCS,,,facility,outpatient,,,3180.00000,922.20000,Aetna,Local,,2076.00,,,,,,,124.81,2601.24,case rate,
MR Breast CAD,8001050,CDM,610,RC,C8937,HCPCS,,,facility,outpatient,,,266.00000,77.14000,Aetna,Local,,135.05,,,,,,,95.89,217.59,percent of total billed charges,
MR Orbit Face Neck wo Contrast,7285970,CDM,610,RC,70540,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Orbit Face Neck wo Contrast,7524018,CDM,610,RC,70540,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Orbits wo Contrast,8001051,CDM,610,RC,70540,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Pelvis wo Contrast,7285978,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Pelvis wo Contrast,7285986,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Pelvis wo Contrast,7285994,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Pelvis wo Contrast,7523989,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Pelvis wo Contrast,7964754,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Pelvis wo Contrast,7964766,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Chest w Contrast,7586019,CDM,610,RC,71551,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,497.61,2209.00,case rate,
MR Chest w wo Contrast,7586017,CDM,610,RC,71552,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Chest w wo Contrast,7734632,CDM,610,RC,71552,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w wo Contrast,7285998,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w wo Contrast,7523994,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w wo Contrast,7523998,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w wo Contrast,7524002,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w wo Contrast,7964750,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w wo Contrast,7964762,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Cardiac wo Contrast,7285942,CDM,610,RC,75557,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Lt w Contrast,613627,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Lt w Contrast,614004,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Lt w Contrast,614046,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Lt w Contrast,7285926,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Lt w Contrast,7285954,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Lt w Contrast,7285962,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Lt w Contrast,7991340,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint LT w Contrast,8148229,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Rt w Contrast,613641,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Rt w Contrast,614012,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Rt w Contrast,614067,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Rt w Contrast,7285930,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Rt w Contrast,7285958,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Rt w Contrast,7285966,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Rt w Contrast,7991352,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Lower Extremity Joint Rt w Contrast,8148230,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Lt wo Contrast,613765,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Lt w Contrast,614297,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Lt w Contrast,614417,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Lt w Contrast,7285946,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Lt w Contrast,7286002,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Lt w Contrast,7286019,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Rt w Contrast,613777,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Rt w Contrast,614305,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Rt w Contrast,614423,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Rt w Contrast,7285950,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Rt w Contrast,7286006,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Upper Extremity Joint Rt w Contrast,7286023,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,495.89,2209.00,case rate,
MR Breast Left w Contrast,7938461,CDM,610,RC,C8903,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,1220.51,,,,,,,156.31,1966.47,percent of total billed charges,
MR Breast Left wo Contrast,7938471,CDM,610,RC,77046,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Breast Left w wo Contrast,7938467,CDM,610,RC,C8905,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,1278.39,,,,,,,313.58,2059.72,percent of total billed charges,
MR Pelvis w Contrast,7285982,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w Contrast,7285990,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w Contrast,7544106,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w Contrast,7544112,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w Contrast,7964746,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Pelvis w Contrast,7964758,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Bilat w wo Contrast,613987,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,5036.00000,1460.44000,Aetna,Local,,2076.00,,,,,,,313.58,4119.45,case rate,
MR Lower Extremity w wo Contrast,8148157,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,5036.00000,1460.44000,Aetna,Local,,2076.00,,,,,,,313.58,4119.45,case rate,
MR Lower Extremity Joint Bilat wo Contrast,613996,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,Local,,2076.00,,,,,,,212.24,3844.60,case rate,
MR Lower Extremity Joint Bilat wo Contrast,8148284,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,Local,,2076.00,,,,,,,212.24,3844.60,case rate,
MR Lower Extremity Joint Bilat w Contrast,613983,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,4808.00000,1394.32000,Aetna,Local,,2076.00,,,,,,,495.89,3932.94,case rate,
MR Lower Extremity Joint Bilot w Contrast,8148154,CDM,610,RC,73722,HCPCS,,,facility,outpatient,,,4808.00000,1394.32000,Aetna,Local,,2076.00,,,,,,,495.89,3932.94,case rate,
MR Cardiac w wo Contrast,614221,CDM,610,RC,75561,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Cardiac w wo Contrast,7926863,CDM,610,RC,75561,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Orbit Face Neck w wo Contrast,7285974,CDM,610,RC,70543,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Orbit Face Neck w wo Contrast,7544141,CDM,610,RC,70543,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Orbits w wo Contrast,8001073,CDM,610,RC,70543,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Joint Rt wo Contrast,613787,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Joint Rt wo Contrast,614323,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Joint Rt wo Contrast,614427,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Right wo Contrast,613522,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Right wo Contrast,613751,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Right wo Contrast,613825,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Right wo Contrast,613977,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Right wo Contrast,614271,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Right wo Contrast,614347,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Right wo Contrast,614371,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Right w Contrast,613743,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w Contrast,613813,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w Contrast,613961,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w Contrast,614103,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w Contrast,614263,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w Contrast,614343,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w Contrast,614367,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left wo Contrast,613520,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Left wo Contrast,613738,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Left wo Contrast,613807,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Left wo Contrast,613950,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Left wo Contrast,614261,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Left wo Contrast,614341,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Left wo Contrast,614365,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Upper Extremity Left w Contrast,613724,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w Contrast,613797,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity w Contrast,613933,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w Contrast,614093,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w Contrast,614251,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w Contrast,614337,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w Contrast,614361,CDM,610,RC,73219,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Joint Rt w wo Contrast,613783,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Joint Rt w wo Contrast,614311,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Joint Rt w wo Contrast,614425,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Joint Lt w wo Contrast,613769,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Joint Lt w wo Contrast,614301,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Joint Lt w wo Contrast,614419,CDM,610,RC,73223,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w wo Contrast,613747,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w wo Contrast,613819,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Hand Right w wo Contrast,613967,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w wo Contrast,614109,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w wo Contrast,614267,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w wo Contrast,614345,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Right w wo Contrast,614369,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w wo Contrast,613732,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w wo Contrast,613801,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity w wo Contrast,613939,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w wo Contrast,614095,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w wo Contrast,614257,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w wo Contrast,614339,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity Left w wo Contrast,614363,CDM,610,RC,73220,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Rt w wo Contrast,613649,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Rt w wo Contrast,614018,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Rt w wo Contrast,614073,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Rt w wo Contrast,7991356,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Rt w wo Contrast,8148233,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Lt w wo Contrast,613631,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Lt w wo Contrast,614008,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Lt w wo Contrast,614053,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Lt w wo Contrast,7991344,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint LT w wo Contrast,8148497,CDM,610,RC,73723,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Joint Lt wo Contrast,6117875,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Lt wo Contrast,613635,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Lt wo Contrast,614010,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Lt wo Contrast,614059,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Lt wo Contrast,7741565,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Lt wo Contrast,7840076,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint Lt wo Contrast,7991348,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Joint LT wo Contrast,8148231,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Right wo Contrast,1063803,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Right wo Contrast,613858,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Right wo Contrast,614195,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Right wo Contrast,614407,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Right w Contrast,613854,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Right w Contrast,614187,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Right w Contrast,614403,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Right w Contrast,7586023,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Right w wo Contrast,1063805,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Right w wo Contrast,613856,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Right w wo Contrast,614189,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Right w wo Contrast,614405,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,RT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Left wo Contrast,1053851,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Left wo Contrast,613852,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremty Left wo Contrast,614183,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Left wo Contrast,614401,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lower Extremity Left w Contrast,613843,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Left w Contrast,614169,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Left w Contrast,614397,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lower Extremity Left w Contrast,7586021,CDM,610,RC,73719,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,LT,2076.00,,,,,,,313.58,2209.00,case rate,
MR Abdomen w wo Contrast,7520024,CDM,610,RC,74183,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Abdomen w wo Contrast,927861,CDM,610,RC,74183,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Abdomen wo Contrast,613524,CDM,610,RC,74181,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Abdomen wo Contrast,614215,CDM,610,RC,74181,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Abdomen wo Contrast,7520018,CDM,610,RC,74181,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Abdomen wo Contrast,7903283,CDM,610,RC,74181,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Abdomen w Contrast,613526,CDM,610,RC,74182,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MRI Lower Extremity wo Contrast Bilat,8150244,CDM,610,RC,73718,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,Local,,2076.00,,,,,,,212.24,3844.60,case rate,
MRI Lower Extremity w wo Contrast Bilat,8150674,CDM,610,RC,73720,HCPCS,,,facility,outpatient,,,5036.00000,1460.44000,Aetna,Local,,2076.00,,,,,,,313.58,4119.45,case rate,
MRI Breast LT w wo Cont w CAD,8153990,CDM,610,RC,77048,HCPCS,,,facility,outpatient,,,2784.00000,807.36000,Aetna,Local,LT,2076.00,,,,,,,421.18,2277.31,case rate,
MRI Breast RT w wo Cont w CAD,8153968,CDM,610,RC,77048,HCPCS,,,facility,outpatient,,,2784.00000,807.36000,Aetna,Local,RT,2076.00,,,,,,,421.18,2277.31,case rate,
MRI Breast Bil w wo Cont w CAD,8153999,CDM,610,RC,77049,HCPCS,,,facility,outpatient,,,5568.00000,1614.72000,Aetna,Local,,2076.00,,,,,,,419.13,4554.62,case rate,
MR Upper Extremity Joint Bilat wo Contrast,8161791,CDM,610,RC,73221,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,Local,,2076.00,,,,,,,212.24,3844.60,case rate,
MRI Breast Lt for Bilat Study,8171067,CDM,610,RC,C8905,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,Local,,2386.19,,,,,,,313.58,3844.60,percent of total billed charges,
MRI Breast Rt for Bilat Study,8171066,CDM,610,RC,C8905,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,Local,,2386.19,,,,,,,313.58,3844.60,percent of total billed charges,
MR Hip Left wo Contrast Extended,8246692,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,LT,2076.00,,,,,,,212.24,2209.00,case rate,
MR Hip Right wo Contrast Extended,8246696,CDM,610,RC,73721,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,RT,2076.00,,,,,,,212.24,2209.00,case rate,
MRI Upper Extremity Joint Bilat w Contrast,8284388,CDM,610,RC,73222,HCPCS,,,facility,outpatient,,,4808.00000,1394.32000,Aetna,Local,,2076.00,,,,,,,495.89,3932.94,case rate,
MR Rectal Staging w or wo Contrast,8452000,CDM,610,RC,72197,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Rectal Staging wo Contrast,8452002,CDM,610,RC,72195,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Rectal Staging w Contrast,8451998,CDM,610,RC,72196,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Upper Extremity WO contrast Bilat,9134465,CDM,610,RC,73218,HCPCS,,,facility,outpatient,,,4700.00000,1363.00000,Aetna,Local,,2076.00,,,,,,,212.24,3844.60,case rate,
MR Brain wo Contrast,2890862,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Brain wo Contrast,613682,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Brain wo Contrast,7285934,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Brain wo Contrast,7812062,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Brain wo Contrast,7949881,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Brain wo Contrast,7956997,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Brain wo Contrast,8121791,CDM,611,RC,70551,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Brain w Contrast,613676,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w Contrast,613678,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w Contrast,7524006,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w Contrast,7524010,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w Contrast,7812058,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w Contrast,7956995,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w Contrast,8121783,CDM,611,RC,70552,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w wo Contrast,2890860,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w wo Contrast,613680,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w wo Contrast,7285938,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w wo Contrast,7812066,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w wo Contrast,7908922,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w wo Contrast,7949877,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w wo Contrast,7949885,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Brain w wo Contrast,8121787,CDM,611,RC,70553,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Trailblazer Brain wo Contrast,8435861,CDM,611,RC,,,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,1193.10,,,,,,,847.17,1922.30,percent of total billed charges,
MR Cervical Spine wo Contrast,613696,CDM,612,RC,72141,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Cervical Spine w Contrast,613684,CDM,612,RC,72142,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Thoracic Spine wo Contrast,614335,CDM,612,RC,72146,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Thoracic Spine w Contrast,614331,CDM,612,RC,72147,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lumbar Spine wo Contrast,614207,CDM,612,RC,72148,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Lumbar Spine w Contrast,614197,CDM,612,RC,72149,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Cervical Spine w wo Contrast,613690,CDM,612,RC,72156,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Thoracic Spine w wo Contrast,614333,CDM,612,RC,72157,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Lumbar Spine w wo Contrast,614201,CDM,612,RC,72158,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Angio Head wo Contrast,613419,CDM,615,RC,70544,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Angio Head wo Contrast,613542,CDM,615,RC,70544,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Angio Head wo Contrast,614409,CDM,615,RC,70544,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Angio Neck wo Contrast,613440,CDM,615,RC,70547,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Angio Neck w Contrast,655779,CDM,615,RC,70548,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Angio Neck w wo Contrast,613437,CDM,615,RC,70549,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Angio Head w Contrast,8440452,CDM,615,RC,70545,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Angio Head w and wo Contrast,8440454,CDM,615,RC,70546,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,2076.00,,,,,,,313.58,2209.00,case rate,
MR Angio Head wo Contrast,8440456,CDM,615,RC,70544,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,2076.00,,,,,,,212.24,2209.00,case rate,
MR Angio Lower Extremity Left w or wo Contrast,1063829,CDM,616,RC,C8914,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,1278.39,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Lower Extremity Right w or wo Contrast,7586002,CDM,616,RC,C8912,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,1220.51,,,,,,,313.58,1966.47,percent of total billed charges,
MR Angio Lower Extremity Right w or wo Contrast,7586003,CDM,616,RC,C8913,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,1220.51,,,,,,,212.24,1966.47,percent of total billed charges,
MR Angio Lower Extremity Left w or wo Contrast,7586005,CDM,616,RC,C8912,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,1220.51,,,,,,,313.58,1966.47,percent of total billed charges,
MR Angio Lower Extremity Left w or wo Contrast,7586007,CDM,616,RC,C8913,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,1220.51,,,,,,,212.24,1966.47,percent of total billed charges,
MR Angio Lower Extremity Right w or wo Contrast,1083818,CDM,616,RC,C8914,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,1278.39,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Upper Extremity Left w Contrast,7544133,CDM,618,RC,C8934,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,1220.51,,,,,,,313.58,1966.47,percent of total billed charges,
MR Angio Upper Extremity Right w Contrast,7544129,CDM,618,RC,C8934,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,1220.51,,,,,,,313.58,1966.47,percent of total billed charges,
MR Angio Abdomen wo Contrast,3136869,CDM,618,RC,C8901,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,1193.10,,,,,,,212.24,1922.30,percent of total billed charges,
MR Angio Chest w Contrast,613538,CDM,618,RC,C8909,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,1220.51,,,,,,,313.58,1966.47,percent of total billed charges,
MR Angio Abdomen w wo Contrast,7585994,CDM,618,RC,C8902,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,1278.39,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Chest w wo Contrast,7585998,CDM,618,RC,C8911,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,1278.39,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Chest wo Contrast,7585996,CDM,618,RC,C8910,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,1193.10,,,,,,,212.24,1922.30,percent of total billed charges,
MR Angio Upper Extremity Left wo Contrast,7586009,CDM,618,RC,C8935,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,1193.10,,,,,,,212.24,1922.30,percent of total billed charges,
MR Angio Upper Extremity Left w wo Contrast,7586011,CDM,618,RC,C8936,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,1278.39,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Upper Extremity Right wo Contrast,7586013,CDM,618,RC,C8935,HCPCS,,,facility,outpatient,,,2350.00000,681.50000,Aetna,Local,,1193.10,,,,,,,212.24,1922.30,percent of total billed charges,
MR Angio Upper Extremity Right w wo Contrast,7586015,CDM,618,RC,C8936,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,1278.39,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Spinal Canal,613602,CDM,618,RC,C8931,HCPCS,,,facility,outpatient,,,2518.00000,730.22000,Aetna,Local,,1278.39,,,,,,,313.58,2059.72,percent of total billed charges,
MR Angio Abdomen w Contrast,613405,CDM,618,RC,C8900,HCPCS,,,facility,outpatient,,,2404.00000,697.16000,Aetna,Local,,1220.51,,,,,,,313.58,1966.47,percent of total billed charges,
COLLAGEN POWDER,9026163,CDM,623,RC,A6010,HCPCS,,,facility,outpatient,,,5670.00000,1644.30000,Aetna,Local,,2878.66,,,,,,,44.14,4638.06,percent of total billed charges,
COLLAGEN POWDER,9026162,CDM,623,RC,A6010,HCPCS,,,facility,outpatient,,,2020.00000,585.80000,Aetna,Local,,1025.55,,,,,,,44.14,1652.36,percent of total billed charges,
COLLAGEN POWDER,9090501,CDM,623,RC,A6010,HCPCS,,,facility,outpatient,,,399.48000,115.85000,Aetna,Local,,202.82,,,,,,,44.14,326.77,percent of total billed charges,
COLLAGEN POWDER,9091189,CDM,623,RC,A6010,HCPCS,,,facility,outpatient,,,671.85000,194.84000,Aetna,Local,,341.10,,,,,,,44.14,549.57,percent of total billed charges,
COLLAGEN DRESSING,9096351,CDM,623,RC,A6010,HCPCS,,,facility,outpatient,,,121.48000,35.23000,Aetna,Local,,61.68,,,,,,,43.79,99.37,percent of total billed charges,
Contrast Visipaque 320 1Ml,8062814,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,2.00000,0.58000,Aetna,Local,,0.80000,,,,,,,0.72100,1.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Contrast Visipaque 320 1Ml Wasted,8062815,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,2.00000,0.58000,Aetna,Local,,0.80000,,,,,,,0.72100,1.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS,7902709,CDM,636,RC,Q4125,HCPCS,,,facility,inpatient,,,13200.00000,3828.00000,Aetna,Local,,5280.00,,,,,,,4758.60,10797.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS,7902709,CDM,636,RC,Q4125,HCPCS,,,facility,outpatient,,,13200.00000,3828.00000,Aetna,Local,,5280.00,,,,,,,124.65,10797.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 2X4CM,7694892,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,670.53,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 2X4CM,7694892,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,Local,,744.00,,,,,,,124.65,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 4X12CM,7694423,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,8589.00000,2490.81000,Aetna,Local,,3435.60,,,,,,,3096.33,7025.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 4X12CM,7694423,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,8589.00000,2490.81000,Aetna,Local,,3435.60,,,,,,,124.65,7025.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 4X16CM,7697282,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,9387.00000,2722.23000,Aetna,Local,,3754.80,,,,,,,3384.01,7678.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 4X16CM,7697282,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,9387.00000,2722.23000,Aetna,Local,,3754.80,,,,,,,124.65,7678.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 6X12CM,7697300,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,10281.00000,2981.49000,Aetna,Local,,4112.40,,,,,,,3706.30,8409.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 6X12CM,7697300,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,10281.00000,2981.49000,Aetna,Local,,4112.40,,,,,,,124.65,8409.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM,7810033,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,17857.50000,5178.67000,Aetna,Local,,7143.00,,,,,,,6437.63,14607.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM,7810033,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,17857.50000,5178.67000,Aetna,Local,,7143.00,,,,,,,124.65,14607.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM,7790162,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,17467.50000,5065.58000,Aetna,Local,,6987.00,,,,,,,6297.03,14288.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM,7790162,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,17467.50000,5065.58000,Aetna,Local,,6987.00,,,,,,,124.65,14288.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AMNIOMATRIX 1CM FOR 2X12CM,7736490,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,5207.30000,1510.12000,Aetna,Local,,2082.92,,,,,,,1877.23,4259.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AMNIOMATRIX 1CM FOR 2X12CM,7736490,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,5207.30000,1510.12000,Aetna,Local,,2082.92,,,,,,,55.68,4259.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MATRIX,7700390,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,1842.25000,534.25000,Aetna,Local,,736.90,,,,,,,664.13,1506.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MATRIX,7700390,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,1842.25000,534.25000,Aetna,Local,,736.90,,,,,,,55.68,1506.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7926786,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,1763.24000,511.34000,Aetna,Local,,705.30,,,,,,,635.65,1442.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7926786,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,1763.24000,511.34000,Aetna,Local,,705.30,,,,,,,55.68,1442.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MATRIX,7694915,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,2837.32000,822.82000,Aetna,Local,,1134.93,,,,,,,1022.85,2320.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MATRIX,7694915,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,2837.32000,822.82000,Aetna,Local,,1134.93,,,,,,,55.68,2320.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MATRIX,7699911,CDM,636,RC,Q4104,HCPCS,,,facility,inpatient,,,10110.36000,2932.00000,Aetna,Local,,4044.14,,,,,,,3644.78,8270.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MATRIX,7699911,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,10110.36000,2932.00000,Aetna,Local,,4044.14,,,,,,,56.25,8270.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MATRIX,7902347,CDM,636,RC,Q4104,HCPCS,,,facility,inpatient,,,34995.83000,10148.79000,Aetna,Local,,13998.33,,,,,,,12616.00,28626.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MATRIX,7902347,CDM,636,RC,Q4104,HCPCS,,,facility,outpatient,,,34995.83000,10148.79000,Aetna,Local,,13998.33,,,,,,,56.25,28626.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7697305,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,50790.00000,14729.10000,Aetna,Local,,20316.00,,,,,,,18309.79,41546.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7697305,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,50790.00000,14729.10000,Aetna,Local,,20316.00,,,,,,,124.65,41546.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7696116,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,17432.50000,5055.42000,Aetna,Local,,6973.00,,,,,,,6284.42,14259.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7696116,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,17432.50000,5055.42000,Aetna,Local,,6973.00,,,,,,,124.65,14259.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7696117,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,30136.50000,8739.58000,Aetna,Local,,12054.60,,,,,,,10864.21,24651.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7696117,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,30136.50000,8739.58000,Aetna,Local,,12054.60,,,,,,,124.65,24651.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7696397,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,11559.00000,3352.11000,Aetna,Local,,4623.60,,,,,,,4167.02,9455.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7696397,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,11559.00000,3352.11000,Aetna,Local,,4623.60,,,,,,,124.65,9455.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7700822,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7700822,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,Local,,2486.40,,,,,,,124.65,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7696115,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,14298.00000,4146.42000,Aetna,Local,,5719.20,,,,,,,5154.43,11695.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7696115,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,14298.00000,4146.42000,Aetna,Local,,5719.20,,,,,,,124.65,11695.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT JACKET,7702862,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,10821.00000,3138.09000,Aetna,Local,,4328.40,,,,,,,3900.97,8851.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT JACKET,7702862,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,10821.00000,3138.09000,Aetna,Local,,4328.40,,,,,,,97.38,8851.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GUIDE,7696718,CDM,636,RC,C9352,HCPCS,,,facility,inpatient,,,9672.30000,2804.97000,Aetna,Local,,3868.92,,,,,,,3486.86,7911.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GUIDE,7696718,CDM,636,RC,C9352,HCPCS,,,facility,outpatient,,,9672.30000,2804.97000,Aetna,Local,,3868.92,,,,,,,3486.86,7911.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903795,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903795,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903800,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2968.72,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903800,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2968.72,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,7700814,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,9303.00000,2697.87000,Aetna,Local,,3721.20,,,,,,,3353.73,7609.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,7700814,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,9303.00000,2697.87000,Aetna,Local,,3721.20,,,,,,,3353.73,7609.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,7701054,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,9739.80000,2824.54000,Aetna,Local,,3895.92,,,,,,,3511.20,7967.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,7701054,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,9739.80000,2824.54000,Aetna,Local,,3895.92,,,,,,,3511.20,7967.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7694973,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,2488.20000,721.58000,Aetna,Local,,995.28,,,,,,,897.00,2035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7694973,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,2488.20000,721.58000,Aetna,Local,,995.28,,,,,,,897.00,2035.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7696227,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,2923.32000,847.76000,Aetna,Local,,1169.33,,,,,,,1053.86,2391.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7696227,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,2923.32000,847.76000,Aetna,Local,,1169.33,,,,,,,1053.86,2391.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7703390,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,695.07000,201.57000,Aetna,Local,,278.03,,,,,,,250.57,568.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7703390,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,695.07000,201.57000,Aetna,Local,,278.03,,,,,,,250.57,568.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7694904,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,3543.51000,1027.62000,Aetna,Local,,1417.40,,,,,,,1277.44,2898.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7694904,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,3543.51000,1027.62000,Aetna,Local,,1417.40,,,,,,,1277.44,2898.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE FILLER,7844126,CDM,636,RC,C9359,HCPCS,,,facility,inpatient,,,10080.00000,2923.20000,Aetna,Local,,4032.00,,,,,,,3633.84,8245.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE FILLER,7844126,CDM,636,RC,C9359,HCPCS,,,facility,outpatient,,,10080.00000,2923.20000,Aetna,Local,,4032.00,,,,,,,3633.84,8245.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE FILLER,7700201,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,9503.34000,2755.97000,Aetna,Local,,3801.34,,,,,,,3425.95,7773.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE FILLER,7700201,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,9503.34000,2755.97000,Aetna,Local,,3801.34,,,,,,,3425.95,7773.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7700517,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7700517,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,Local,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 16X20CM,7937654,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,35158.50000,10195.96000,Aetna,Local,,14063.40,,,,,,,12674.64,28759.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 16X20CM,7937654,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,35158.50000,10195.96000,Aetna,Local,,14063.40,,,,,,,124.65,28759.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE FILLER,7916969,CDM,636,RC,C9362,HCPCS,,,facility,inpatient,,,5178.60000,1501.79000,Aetna,Local,,2071.44,,,,,,,1866.89,4236.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE FILLER,7916969,CDM,636,RC,C9362,HCPCS,,,facility,outpatient,,,5178.60000,1501.79000,Aetna,Local,,2071.44,,,,,,,1866.89,4236.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT JACKET,7702861,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT JACKET,7702861,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,Local,,3180.00,,,,,,,97.38,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT JACKET,7804029,CDM,636,RC,Q4107,HCPCS,,,facility,inpatient,,,10002.00000,2900.58000,Aetna,Local,,4000.80,,,,,,,3605.72,8181.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT JACKET,7804029,CDM,636,RC,Q4107,HCPCS,,,facility,outpatient,,,10002.00000,2900.58000,Aetna,Local,,4000.80,,,,,,,97.38,8181.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEALANT,7950499,CDM,636,RC,,,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEALANT,7950499,CDM,636,RC,,,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,Local,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7944205,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,70184.00000,20353.36000,Aetna,Local,,28073.60,,,,,,,25301.33,57410.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7944205,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,70184.00000,20353.36000,Aetna,Local,,28073.60,,,,,,,124.65,57410.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903764,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903764,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903771,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,5250.00000,1522.50000,Aetna,Local,,2100.00,,,,,,,1892.62,4294.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903771,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,5250.00000,1522.50000,Aetna,Local,,2100.00,,,,,,,1892.62,4294.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,7948221,CDM,636,RC,C9359,HCPCS,,,facility,inpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,7948221,CDM,636,RC,C9359,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,270.00,,,,,,,243.34,552.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,7948222,CDM,636,RC,C9359,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,7948222,CDM,636,RC,C9359,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,Local,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,7948223,CDM,636,RC,C9359,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,7948223,CDM,636,RC,C9359,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,Local,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM,7950033,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,18230.00000,5286.70000,Aetna,Local,,7292.00,,,,,,,6571.91,14912.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM,7950033,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,18230.00000,5286.70000,Aetna,Local,,7292.00,,,,,,,124.65,14912.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 16X20CM,7950035,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,35158.50000,10195.96000,Aetna,Local,,14063.40,,,,,,,12674.64,28759.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 16X20CM,7950035,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,35158.50000,10195.96000,Aetna,Local,,14063.40,,,,,,,124.65,28759.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7950502,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,2224.00000,644.96000,Aetna,Local,,889.60,,,,,,,801.75,1819.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7950502,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,2224.00000,644.96000,Aetna,Local,,889.60,,,,,,,801.75,1819.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7950503,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,6520.50000,1890.94000,Aetna,Local,,2608.20,,,,,,,2350.64,5333.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7950503,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,6520.50000,1890.94000,Aetna,Local,,2608.20,,,,,,,2350.64,5333.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7950504,CDM,636,RC,C1713,HCPCS,,,facility,inpatient,,,9621.00000,2790.09000,Aetna,Local,,3848.40,,,,,,,3468.37,7869.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7950504,CDM,636,RC,C1713,HCPCS,,,facility,outpatient,,,9621.00000,2790.09000,Aetna,Local,,3848.40,,,,,,,3468.37,7869.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 8X16CM,7955810,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,17077.50000,4952.47000,Aetna,Local,,6831.00,,,,,,,6156.44,13969.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 8X16CM,7955810,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,17077.50000,4952.47000,Aetna,Local,,6831.00,,,,,,,124.65,13969.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON PROTECTOR,7964375,CDM,636,RC,C9356,HCPCS,,,facility,inpatient,,,11354.40000,3292.78000,Aetna,Local,,4541.76,,,,,,,4093.26,9287.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON PROTECTOR,7964375,CDM,636,RC,C9356,HCPCS,,,facility,outpatient,,,11354.40000,3292.78000,Aetna,Local,,4541.76,,,,,,,4093.26,9287.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 16X20CM,7972596,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,36816.75000,10676.86000,Aetna,Local,,14726.70,,,,,,,13272.44,30116.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 16X20CM,7972596,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,36816.75000,10676.86000,Aetna,Local,,14726.70,,,,,,,124.65,30116.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 4X12CM,7974910,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,5659.50000,1641.26000,Aetna,Local,,2263.80,,,,,,,2040.25,4629.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 4X12CM,7974910,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,5659.50000,1641.26000,Aetna,Local,,2263.80,,,,,,,124.65,4629.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 4X12CM,7697299,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2741.60,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 4X12CM,7697299,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,124.65,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 4X12CM,7736636,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,2741.60,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 4X12CM,7736636,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,7605.00000,2205.45000,Aetna,Local,,3042.00,,,,,,,124.65,6220.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7700823,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,17432.50000,5055.42000,Aetna,Local,,6973.00,,,,,,,6284.42,14259.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7700823,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,17432.50000,5055.42000,Aetna,Local,,6973.00,,,,,,,124.65,14259.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7700824,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,30136.50000,8739.58000,Aetna,Local,,12054.60,,,,,,,10864.21,24651.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRATTICE,7700824,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,30136.50000,8739.58000,Aetna,Local,,12054.60,,,,,,,124.65,24651.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GUIDE,7696719,CDM,636,RC,C9352,HCPCS,,,facility,inpatient,,,9672.30000,2804.97000,Aetna,Local,,3868.92,,,,,,,3486.86,7911.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GUIDE,7696719,CDM,636,RC,C9352,HCPCS,,,facility,outpatient,,,9672.30000,2804.97000,Aetna,Local,,3868.92,,,,,,,3486.86,7911.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GUIDE,7696720,CDM,636,RC,C9352,HCPCS,,,facility,inpatient,,,9672.30000,2804.97000,Aetna,Local,,3868.92,,,,,,,3486.86,7911.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GUIDE,7696720,CDM,636,RC,C9352,HCPCS,,,facility,outpatient,,,9672.30000,2804.97000,Aetna,Local,,3868.92,,,,,,,3486.86,7911.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GUIDE,7696721,CDM,636,RC,C9352,HCPCS,,,facility,inpatient,,,9672.30000,2804.97000,Aetna,Local,,3868.92,,,,,,,3486.86,7911.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GUIDE,7696721,CDM,636,RC,C9352,HCPCS,,,facility,outpatient,,,9672.30000,2804.97000,Aetna,Local,,3868.92,,,,,,,3486.86,7911.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903796,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903796,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903797,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903797,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903798,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903798,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903799,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903799,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,Local,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903801,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,11448.00000,3319.92000,Aetna,Local,,4579.20,,,,,,,4127.00,9364.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903801,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,11448.00000,3319.92000,Aetna,Local,,4579.20,,,,,,,4127.00,9364.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903802,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2968.72,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903802,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,8235.00000,2388.15000,Aetna,Local,,3294.00,,,,,,,2968.72,6736.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903803,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,9525.00000,2762.25000,Aetna,Local,,3810.00,,,,,,,3433.76,7791.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE PROTECTOR,7903803,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,9525.00000,2762.25000,Aetna,Local,,3810.00,,,,,,,3433.76,7791.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,7707509,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,9739.80000,2824.54000,Aetna,Local,,3895.92,,,,,,,3511.20,7967.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,7707509,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,9739.80000,2824.54000,Aetna,Local,,3895.92,,,,,,,3511.20,7967.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7694891,CDM,636,RC,C9359,HCPCS,,,facility,inpatient,,,2648.00000,767.92000,Aetna,Local,,1059.20,,,,,,,954.60,2166.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7694891,CDM,636,RC,C9359,HCPCS,,,facility,outpatient,,,2648.00000,767.92000,Aetna,Local,,1059.20,,,,,,,954.60,2166.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903774,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,8832.00000,2561.28000,Aetna,Local,,3532.80,,,,,,,3183.94,7224.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903774,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,8832.00000,2561.28000,Aetna,Local,,3532.80,,,,,,,3183.94,7224.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903775,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,8832.00000,2561.28000,Aetna,Local,,3532.80,,,,,,,3183.94,7224.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903775,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,8832.00000,2561.28000,Aetna,Local,,3532.80,,,,,,,3183.94,7224.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 6X12CM,7982869,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,10281.00000,2981.49000,Aetna,Local,,4112.40,,,,,,,3706.30,8409.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM FOR 6X12CM,7982869,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,10281.00000,2981.49000,Aetna,Local,,4112.40,,,,,,,124.65,8409.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE ALLODERM,8124397,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,36816.75000,10676.86000,Aetna,Local,,14726.70,,,,,,,13272.44,30116.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE ALLODERM,8124397,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,36816.75000,10676.86000,Aetna,Local,,14726.70,,,,,,,124.65,30116.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACELLULAR DERMIS,8170966,CDM,636,RC,Q4128,HCPCS,,,facility,inpatient,,,7559.10000,2192.14000,Aetna,Local,,3023.64,,,,,,,2725.06,6183.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACELLULAR DERMIS,8170966,CDM,636,RC,Q4128,HCPCS,,,facility,outpatient,,,7559.10000,2192.14000,Aetna,Local,,3023.64,,,,,,,124.65,6183.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8228673,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,30831.75000,8941.21000,Aetna,Local,,12332.70,,,,,,,11114.85,25220.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8228673,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,30831.75000,8941.21000,Aetna,Local,,12332.70,,,,,,,124.65,25220.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8228674,CDM,636,RC,Q4130,HCPCS,,,facility,inpatient,,,44313.75000,12850.99000,Aetna,Local,,17725.50,,,,,,,15975.11,36248.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8228674,CDM,636,RC,Q4130,HCPCS,,,facility,outpatient,,,44313.75000,12850.99000,Aetna,Local,,17725.50,,,,,,,124.65,36248.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM,8145963,CDM,636,RC,Q4116,HCPCS,,,facility,inpatient,,,38133.00000,11058.57000,Aetna,Local,,15253.20,,,,,,,13746.95,31192.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLODERM 1CM,8145963,CDM,636,RC,Q4116,HCPCS,,,facility,outpatient,,,38133.00000,11058.57000,Aetna,Local,,15253.20,,,,,,,124.65,31192.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903765,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903765,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903766,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903766,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903767,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903767,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903768,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903768,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903769,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903769,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903770,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903770,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,4270.00000,1238.30000,Aetna,Local,,1708.00,,,,,,,1539.34,3492.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903772,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,5250.00000,1522.50000,Aetna,Local,,2100.00,,,,,,,1892.62,4294.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903772,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,5250.00000,1522.50000,Aetna,Local,,2100.00,,,,,,,1892.62,4294.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903773,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,8832.00000,2561.28000,Aetna,Local,,3532.80,,,,,,,3183.94,7224.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903773,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,8832.00000,2561.28000,Aetna,Local,,3532.80,,,,,,,3183.94,7224.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT NERVE CONN,7903776,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,5250.00000,1522.50000,Aetna,Local,,2100.00,,,,,,,1892.62,4294.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT NERVE CONN,7903776,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,5250.00000,1522.50000,Aetna,Local,,2100.00,,,,,,,1892.62,4294.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903777,CDM,636,RC,C9355,HCPCS,,,facility,inpatient,,,5250.00000,1522.50000,Aetna,Local,,2100.00,,,,,,,1892.62,4294.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE CONNECT,7903777,CDM,636,RC,C9355,HCPCS,,,facility,outpatient,,,5250.00000,1522.50000,Aetna,Local,,2100.00,,,,,,,1892.62,4294.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,8478440,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUTTY,8478440,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,Local,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
putty,8478441,CDM,636,RC,C1762,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
putty,8478441,CDM,636,RC,C1762,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,Local,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,9024733,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,7933.95000,2300.85000,Aetna,Local,,3173.58,,,,,,,2860.19,6489.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,9024733,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,7933.95000,2300.85000,Aetna,Local,,3173.58,,,,,,,2860.19,6489.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,9024737,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,8859.60000,2569.28000,Aetna,Local,,3543.84,,,,,,,3193.89,7247.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,9024737,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,8859.60000,2569.28000,Aetna,Local,,3543.84,,,,,,,3193.89,7247.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,9024734,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,7933.95000,2300.85000,Aetna,Local,,3173.58,,,,,,,2860.19,6489.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,9024734,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,7933.95000,2300.85000,Aetna,Local,,3173.58,,,,,,,2860.19,6489.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,9024735,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,10030.05000,2908.71000,Aetna,Local,,4012.02,,,,,,,3615.83,8204.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,9024735,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,10030.05000,2908.71000,Aetna,Local,,4012.02,,,,,,,3615.83,8204.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,9024736,CDM,636,RC,C9353,HCPCS,,,facility,inpatient,,,7933.95000,2300.85000,Aetna,Local,,3173.58,,,,,,,2860.19,6489.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE WRAP,9024736,CDM,636,RC,C9353,HCPCS,,,facility,outpatient,,,7933.95000,2300.85000,Aetna,Local,,3173.58,,,,,,,2860.19,6489.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEALANT,8182180,CDM,636,RC,C9250,HCPCS,,,facility,inpatient,,,837.32000,242.82000,Aetna,Local,,334.93,,,,,,,301.85,684.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEALANT,8182180,CDM,636,RC,C9250,HCPCS,,,facility,outpatient,,,837.32000,242.82000,Aetna,Local,,334.93,,,,,,,142.48,824.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEALANT,8182192,CDM,636,RC,C9250,HCPCS,,,facility,inpatient,,,1972.08000,571.90000,Aetna,Local,,788.83,,,,,,,710.93,1613.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEALANT,8182192,CDM,636,RC,C9250,HCPCS,,,facility,outpatient,,,1972.08000,571.90000,Aetna,Local,,788.83,,,,,,,142.48,1613.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Apligraft 1 Sq Cm Used,2330824,CDM,636,RC,Q4101,HCPCS,,,facility,inpatient,,,101.00000,29.29000,Aetna,Local,,40.40,,,,,,,36.41,82.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Apligraft 1 Sq Cm Used,2330824,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,101.00000,29.29000,Aetna,Local,,40.40,,,,,,,37.37,128.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Apligraft 1 Sq Cm Used,7958341,CDM,636,RC,Q4101,HCPCS,,,facility,inpatient,,,101.00000,29.29000,Aetna,Local,,40.40,,,,,,,36.41,82.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Apligraft 1 Sq Cm Used,7958341,CDM,636,RC,Q4101,HCPCS,,,facility,outpatient,,,101.00000,29.29000,Aetna,Local,,40.40,,,,,,,37.37,128.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Primatrix Per Sq Cm,7417871,CDM,636,RC,Q4110,HCPCS,,,facility,inpatient,,,298.00000,86.42000,Aetna,Local,,119.20,,,,,,,107.43,243.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Primatrix Per Sq Cm,7417871,CDM,636,RC,Q4110,HCPCS,,,facility,outpatient,,,298.00000,86.42000,Aetna,Local,,119.20,,,,,,,110.26,243.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kerecis 1 Sq Cm Used,7940831,CDM,636,RC,Q4158,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,Local,,96.40,,,,,,,86.88,197.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kerecis 1 Sq Cm Used,7940831,CDM,636,RC,Q4158,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,96.40,,,,,,,89.17,197.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kerecis 1 Sq Cm Used,7958353,CDM,636,RC,Q4158,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,Local,,96.40,,,,,,,86.88,197.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Kerecis 1 Sq Cm Used,7958353,CDM,636,RC,Q4158,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,96.40,,,,,,,89.17,197.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KERECIS 1 SQ CM USED,7958356,CDM,636,RC,Q4158,HCPCS,,,facility,inpatient,,,241.00000,69.89000,Aetna,Local,,96.40,,,,,,,86.88,197.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KERECIS 1 SQ CM USED,7958356,CDM,636,RC,Q4158,HCPCS,,,facility,outpatient,,,241.00000,69.89000,Aetna,Local,,96.40,,,,,,,89.17,197.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omnigraft 1 sqcm Used,8411612,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,460.00000,133.40000,Aetna,Local,,184.00,,,,,,,165.83,376.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omnigraft 1 sqcm Used,8411612,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,460.00000,133.40000,Aetna,Local,,184.00,,,,,,,55.68,376.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omnigraft per 1sqcm Used,8411836,CDM,636,RC,Q4105,HCPCS,,,facility,inpatient,,,460.00000,133.40000,Aetna,Local,,184.00,,,,,,,165.83,376.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omnigraft per 1sqcm Used,8411836,CDM,636,RC,Q4105,HCPCS,,,facility,outpatient,,,460.00000,133.40000,Aetna,Local,,184.00,,,,,,,55.68,376.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NM THYROGEN SINGLE DOSE,607176,CDM,636,RC,J3240,HCPCS,,,facility,inpatient,,,7140.00000,2070.60000,Aetna,Local,,2856.00,,,,,,,2573.97,5840.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NM CHOLECYSTOKINEN 5MCG,651559,CDM,636,RC,J2805,HCPCS,,,facility,inpatient,,,396.36000,114.94000,Aetna,Local,,158.54,,,,,,,142.89,324.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9158415,CDM,636,RC,,,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9158415,CDM,636,RC,,,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9160402,CDM,636,RC,,,,,facility,inpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9160402,CDM,636,RC,,,,,facility,outpatient,,,810.00000,234.90000,Aetna,Local,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9158411,CDM,636,RC,,,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,7029.75,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9158411,CDM,636,RC,,,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,7029.75,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9160400,CDM,636,RC,,,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9160400,CDM,636,RC,,,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9158413,CDM,636,RC,,,,,facility,inpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,7029.75,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9158413,CDM,636,RC,,,,,facility,outpatient,,,19500.00000,5655.00000,Aetna,Local,,7800.00,,,,,,,7029.75,15951.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9160398,CDM,636,RC,,,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Embolization,9160398,CDM,636,RC,,,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,Local,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prochlorperazine Edisylate 10mg/2mL I,8724036,CDM,636,RC,J0780,HCPCS,,,facility,inpatient,,,35.48000,10.29000,Aetna,Local,,14.19,,,,,,,12.79,29.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mycophenolate Mofetil 500 mg T,8724382,CDM,636,RC,J7517,HCPCS,,,facility,inpatient,,,11.37000,3.30000,Aetna,Local,,4.55,,,,,,,4.10,9.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Linezolid 600mg P,8723689,CDM,636,RC,J2020,HCPCS,,,facility,inpatient,,,481.17000,139.54000,Aetna,Local,,192.47,,,,,,,173.46,393.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 20mg/10mL Inj,8723407,CDM,636,RC,J1327,HCPCS,,,facility,inpatient,,,187.52000,54.38000,Aetna,Local,,75.01,,,,,,,67.60,153.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Palonosetron 0.25 mg/5 mL I(Aloxi),8724204,CDM,636,RC,J2469,HCPCS,,,facility,inpatient,,,160.58000,46.57000,Aetna,Local,,64.23,,,,,,,57.89,131.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Caffeine Citra 60mg/3mL I(Cafcit),8724290,CDM,636,RC,J0706,HCPCS,,,facility,inpatient,,,229.00000,66.41000,Aetna,Local,,91.60,,,,,,,82.55,187.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bortezomib 3.5mg Inj,8724142,CDM,636,RC,J9041,HCPCS,,,facility,inpatient,,,531.49000,154.13000,Aetna,Local,,212.60,,,,,,,191.60,434.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methacholine Challenge Kit,8724337,CDM,636,RC,J7674,HCPCS,,,facility,inpatient,,,3613.45000,1047.90000,Aetna,Local,,1445.38,,,,,,,1302.65,2955.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DAPTOmycin 500 mg Inj,8724270,CDM,636,RC,J0878,HCPCS,,,facility,inpatient,,,476.98000,138.32000,Aetna,Local,,190.79,,,,,,,171.95,390.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrALAZINE 20mg/mL I(Apresoline),8723849,CDM,636,RC,J0360,HCPCS,,,facility,inpatient,,,90.26000,26.18000,Aetna,Local,,36.10,,,,,,,32.54,73.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
acetaZOLAMIDE 500mg I,8724111,CDM,636,RC,J1120,HCPCS,,,facility,inpatient,,,399.64000,115.90000,Aetna,Local,,159.86,,,,,,,144.07,326.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Gluconate 1g/10mL I,8723427,CDM,636,RC,J0612,HCPCS,,,facility,inpatient,,,101.42000,29.41000,Aetna,Local,,40.57,,,,,,,36.56,82.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorouracil 500mg/10mL I,8723452,CDM,636,RC,J9190,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,Local,,30.00,,,,,,,27.04,61.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glucagon 1mg/1mL Inj,8725579,CDM,636,RC,J1610,HCPCS,,,facility,inpatient,,,1155.32000,335.04000,Aetna,Local,,462.13,,,,,,,416.49,945.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ibandronate 3mg/3mL IS (Boniva),8725523,CDM,636,RC,J1740,HCPCS,,,facility,inpatient,,,1862.37000,540.09000,Aetna,Local,,744.95,,,,,,,671.38,1523.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Abatacept 250mg I(Orencia),8724477,CDM,636,RC,J0129,HCPCS,,,facility,inpatient,,,11216.23000,3252.71000,Aetna,Local,,4486.49,,,,,,,4043.45,9174.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus IG 250U I(Bay-Tet),8723983,CDM,636,RC,J1670,HCPCS,,,facility,inpatient,,,2406.70000,697.94000,Aetna,Local,,962.68,,,,,,,867.62,1968.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250 mL,8723687,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,100.34000,29.10000,Aetna,Local,,40.14,,,,,,,36.17,82.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 50mL,8723597,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,Local,,20.00,,,,,,,18.02,40.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),8724476,CDM,636,RC,J1953,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,Local,,20.00,,,,,,,18.02,40.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ziprasidone 20mg Inj. (Geodon),8724693,CDM,636,RC,J3486,HCPCS,,,facility,inpatient,,,209.89000,60.87000,Aetna,Local,,83.96,,,,,,,75.67,171.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dexrazoxane 500mg Inj,8724687,CDM,636,RC,J1190,HCPCS,,,facility,inpatient,,,3059.80000,887.34000,Aetna,Local,,1223.92,,,,,,,1103.06,2502.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 4mg/5mL I(Zometa),8724836,CDM,636,RC,J3489,HCPCS,,,facility,inpatient,,,423.00000,122.67000,Aetna,Local,,169.20,,,,,,,152.49,346.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 5mg/100mL IVPB,8724822,CDM,636,RC,J3489,HCPCS,,,facility,inpatient,,,2818.80000,817.45000,Aetna,Local,,1127.52,,,,,,,1016.18,2305.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),8724818,CDM,636,RC,J2185,HCPCS,,,facility,inpatient,,,56.73000,16.45000,Aetna,Local,,22.69,,,,,,,20.45,46.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 2.5 mg/0.5 mL I,8724441,CDM,636,RC,J1652,HCPCS,,,facility,inpatient,,,290.30000,84.19000,Aetna,Local,,116.12,,,,,,,104.65,237.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
romiPLOStim 250mcg Inj,8724902,CDM,636,RC,J2802,HCPCS,,,facility,inpatient,,,11158.05000,3235.83000,Aetna,Local,,4463.22,,,,,,,4022.48,9127.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 100mL(Mini-Bag+),8723638,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,67.07000,19.45000,Aetna,Local,,26.83,,,,,,,24.18,54.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Chloride 3% IVPB 250mL,8724011,CDM,636,RC,J7131,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,Local,,40.00,,,,,,,36.05,81.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Regadenoson 0.4mg/5mL I (LexiScan),8724917,CDM,636,RC,J2785,HCPCS,,,facility,inpatient,,,1187.00000,344.23000,Aetna,Local,,474.80,,,,,,,427.91,970.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOPamine 400mg/D5W 250mL,8723999,CDM,636,RC,J1265,HCPCS,,,facility,inpatient,,,144.90000,42.02000,Aetna,Local,,57.96,,,,,,,52.24,118.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
azaCITIDine 100mg Inj,8724713,CDM,636,RC,J9025,HCPCS,,,facility,inpatient,,,2966.30000,860.23000,Aetna,Local,,1186.52,,,,,,,1069.35,2426.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Iron Dextran 100mg/2mL I(Infed),8724027,CDM,636,RC,J1750,HCPCS,,,facility,inpatient,,,558.67000,162.01000,Aetna,Local,,223.47,,,,,,,201.40,456.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  750mg/150mL P,8724502,CDM,636,RC,J1956,HCPCS,,,facility,inpatient,,,77.19000,22.39000,Aetna,Local,,30.88,,,,,,,27.83,63.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 40mcg/10mL I(Ddavp),8723448,CDM,636,RC,J2597,HCPCS,,,facility,inpatient,,,5787.53000,1678.38000,Aetna,Local,,2315.01,,,,,,,2086.40,4734.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLItaxel PROT-bnd 100mg,8724282,CDM,636,RC,J9264,HCPCS,,,facility,inpatient,,,7866.10000,2281.17000,Aetna,Local,,3146.44,,,,,,,2835.73,6434.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Goserelin 10.8 mg Impl,8724420,CDM,636,RC,J9202,HCPCS,,,facility,inpatient,,,8294.30000,2405.35000,Aetna,Local,,3317.72,,,,,,,2990.10,6784.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bendamustine 100mg I(Treanda),8724842,CDM,636,RC,J9033,HCPCS,,,facility,inpatient,,,3157.00000,915.53000,Aetna,Local,,1262.80,,,,,,,1138.10,2582.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,8723994,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,,,88.76000,25.74000,Aetna,Local,,35.50,,,,,,,32.00,72.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NS 1,000mL",8723973,CDM,636,RC,J7030,HCPCS,,,facility,inpatient,,,100.04000,29.01000,Aetna,Local,,40.02,,,,,,,36.06,81.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 10unit/mL 1mL Inj,8723525,CDM,636,RC,J2590,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOBUTamine 250mg/D5W 250mL,8724254,CDM,636,RC,J1250,HCPCS,,,facility,inpatient,,,230.35000,66.80000,Aetna,Local,,92.14,,,,,,,83.04,188.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250mL PVC Free,8724365,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,102.04000,29.59000,Aetna,Local,,40.82,,,,,,,36.79,83.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 100mL,8723637,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,50.41000,14.62000,Aetna,Local,,20.16,,,,,,,18.17,41.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acyclovir 50mg/mL Inj 20mL,8725520,CDM,636,RC,J0133,HCPCS,,,facility,inpatient,,,238.00000,69.02000,Aetna,Local,,95.20,,,,,,,85.80,194.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Iron Sucrose 100mg/5mL I(Venofer),8724371,CDM,636,RC,J1756,HCPCS,,,facility,inpatient,,,563.09000,163.30000,Aetna,Local,,225.24,,,,,,,202.99,460.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Oxacillin 100mg/mL IV Infusion,8725013,CDM,636,RC,J2700,HCPCS,,,facility,inpatient,,,112.15000,32.52000,Aetna,Local,,44.86,,,,,,,40.43,91.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 25,000 unit/ 250mL IVPB",8725006,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,100.10000,29.03000,Aetna,Local,,40.04,,,,,,,36.09,81.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine 2g / D5W 250mL,8723686,CDM,636,RC,J2002,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,Local,,40.00,,,,,,,36.05,81.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetylcysteine 6000mg/ 30mL I,8724318,CDM,636,RC,J0132,HCPCS,,,facility,inpatient,,,930.00000,269.70000,Aetna,Local,,372.00,,,,,,,335.26,760.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 40mg PF Inj,8725812,CDM,636,RC,J2919,HCPCS,,,facility,inpatient,,,41.30000,11.98000,Aetna,Local,,16.52,,,,,,,14.89,33.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 4g/Water 100mL,8724405,CDM,636,RC,J3475,HCPCS,,,facility,inpatient,,,80.42000,23.32000,Aetna,Local,,32.17,,,,,,,28.99,65.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 2 g I (Mexfoxin),8724275,CDM,636,RC,J0694,HCPCS,,,facility,inpatient,,,102.33000,29.68000,Aetna,Local,,40.93,,,,,,,36.89,83.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 125mg,8723821,CDM,636,RC,J2919,HCPCS,,,facility,inpatient,,,66.92000,19.41000,Aetna,Local,,26.77,,,,,,,24.12,54.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin I(10,000/10mL)",8723969,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 100mg I,8723430,CDM,636,RC,J1938,HCPCS,,,facility,inpatient,,,56.05000,16.25000,Aetna,Local,,22.42,,,,,,,20.21,45.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,8723508,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,61.33000,17.79000,Aetna,Local,,24.53,,,,,,,22.11,50.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% Epidural,8723449,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,369.40000,107.13000,Aetna,Local,,147.76,,,,,,,133.17,302.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,8723548,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,32.35000,9.38000,Aetna,Local,,12.94,,,,,,,11.66,26.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg/100mL P,8723628,CDM,636,RC,J1956,HCPCS,,,facility,inpatient,,,110.89000,32.16000,Aetna,Local,,44.36,,,,,,,39.98,90.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KCl 10mEq / 100mL IVPB,8723631,CDM,636,RC,J3480,HCPCS,,,facility,inpatient,,,50.05000,14.51000,Aetna,Local,,20.02,,,,,,,18.04,40.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KCl 20mEq/Water 100mL,8723632,CDM,636,RC,J3480,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,Local,,20.00,,,,,,,18.02,40.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOBUTamine 1g/D5W 250mL,8723992,CDM,636,RC,J1250,HCPCS,,,facility,inpatient,,,291.07000,84.41000,Aetna,Local,,116.43,,,,,,,104.93,238.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),8723676,CDM,636,RC,J1450,HCPCS,,,facility,inpatient,,,142.80000,41.41000,Aetna,Local,,57.12,,,,,,,51.48,116.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g /200mL  IVPB,8724496,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,,,283.00000,82.07000,Aetna,Local,,113.20,,,,,,,102.02,231.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,8724465,CDM,636,RC,J3475,HCPCS,,,facility,inpatient,,,130.80000,37.93000,Aetna,Local,,52.32,,,,,,,47.15,106.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine 1mg/10mL IS,8723397,CDM,636,RC,J0461,HCPCS,,,facility,inpatient,,,58.26000,16.90000,Aetna,Local,,23.30,,,,,,,21.00,47.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 500mg I,8723831,CDM,636,RC,J2919,HCPCS,,,facility,inpatient,,,1585.55000,459.81000,Aetna,Local,,634.22,,,,,,,571.59,1296.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),8724112,CDM,636,RC,J1885,HCPCS,,,facility,inpatient,,,33.62000,9.75000,Aetna,Local,,13.45,,,,,,,12.12,27.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 5 mg/1mL I PF (Versed),8724356,CDM,636,RC,J2250,HCPCS,,,facility,inpatient,,,35.00000,10.15000,Aetna,Local,,14.00,,,,,,,12.62,28.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Neostigmine 1mg/mL 10mL Inj,8725560,CDM,636,RC,J2710,HCPCS,,,facility,inpatient,,,105.16000,30.50000,Aetna,Local,,42.06,,,,,,,37.91,86.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 1g I,8723829,CDM,636,RC,J2919,HCPCS,,,facility,inpatient,,,320.97000,93.08000,Aetna,Local,,128.39,,,,,,,115.71,262.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Potassium Cl 2mEq/mL I,8723498,CDM,636,RC,J3480,HCPCS,,,facility,inpatient,,,100.67000,29.19000,Aetna,Local,,40.27,,,,,,,36.29,82.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Magnesium SO4 10g/20mL I,8723425,CDM,636,RC,J3475,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,Local,,40.00,,,,,,,36.05,81.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine SO4 1mg/mL 1mL I,8724028,CDM,636,RC,J0461,HCPCS,,,facility,inpatient,,,80.20000,23.26000,Aetna,Local,,32.08,,,,,,,28.91,65.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aminophylline 500mg/20mL I,8723512,CDM,636,RC,J0280,HCPCS,,,facility,inpatient,,,118.92000,34.49000,Aetna,Local,,47.57,,,,,,,42.87,97.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Factor VIIa I (NovoSeven RT),8725010,CDM,636,RC,J7189,HCPCS,,,facility,inpatient,,,19410.87000,5629.15000,Aetna,Local,,7764.35,,,,,,,6997.62,15878.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",8723434,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,41.49000,12.03000,Aetna,Local,,16.60,,,,,,,14.96,33.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1g/ Water Syr (Ancef),8725050,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,62.00000,17.98000,Aetna,Local,,24.80,,,,,,,22.35,50.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 2g/ Water  Syr (Ancef),8725049,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,95.00000,27.55000,Aetna,Local,,38.00,,,,,,,34.25,77.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 3,000 unit/mL Inj",8725038,CDM,636,RC,J0885,HCPCS,,,facility,inpatient,,,298.90000,86.68000,Aetna,Local,,119.56,,,,,,,107.75,244.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000u/NS 1,030mL  P",8725043,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,Local,,40.00,,,,,,,36.05,81.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
chlorproMAZINE 25mg/mL 2mL I(Thoraz,8723854,CDM,636,RC,J3230,HCPCS,,,facility,inpatient,,,205.46000,59.58000,Aetna,Local,,82.18,,,,,,,74.07,168.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,8723503,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",8723504,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,25.98000,7.53000,Aetna,Local,,10.39,,,,,,,9.37,21.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,8723579,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,36.55000,10.60000,Aetna,Local,,14.62,,,,,,,13.18,29.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",8723580,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,83.15000,24.11000,Aetna,Local,,33.26,,,,,,,29.98,68.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,8723505,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,26.80000,7.77000,Aetna,Local,,10.72,,,,,,,9.66,21.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",8723507,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,29.05000,8.42000,Aetna,Local,,11.62,,,,,,,10.47,23.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cycloPHOSphamide 500mg I,8724350,CDM,636,RC,J9075,HCPCS,,,facility,inpatient,,,3143.79000,911.70000,Aetna,Local,,1257.52,,,,,,,1133.34,2571.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1:1000 I 1mL,8723995,CDM,636,RC,J0165,HCPCS,,,facility,inpatient,,,95.55000,27.71000,Aetna,Local,,38.22,,,,,,,34.45,78.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 350mg/mL Inj 500mL MDV,8725093,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,4.75000,1.38000,Aetna,Local,,1.90,,,,,,,1.71,3.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 240mg/mL Inj 10mL,8725103,CDM,636,RC,Q9966,HCPCS,,,facility,inpatient,,,266.75000,77.36000,Aetna,Local,,106.70,,,,,,,96.16,218.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,8725007,CDM,636,RC,C9254,HCPCS,,,facility,inpatient,,,587.65000,170.42000,Aetna,Local,,235.06,,,,,,,211.85,480.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,8725007,CDM,636,RC,C9254,HCPCS,,,facility,outpatient,,,587.65000,170.42000,Aetna,Local,,235.06,,,,,,,0.37557,480.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 300mg/mL Inj 50mL,8724981,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,274.30000,79.55000,Aetna,Local,,109.72,,,,,,,98.89,224.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- iodixanol 270mg/mL I 50mL,8724982,CDM,636,RC,Q9966,HCPCS,,,facility,inpatient,,,293.25000,85.04000,Aetna,Local,,117.30,,,,,,,105.72,239.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000 unit/30mL",8723554,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,Local,,40.00,,,,,,,36.05,81.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin Na MDV I (Ancef),8724121,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,106.10000,30.77000,Aetna,Local,,42.44,,,,,,,38.25,86.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),8723967,CDM,636,RC,J1938,HCPCS,,,facility,inpatient,,,26.85000,7.79000,Aetna,Local,,10.74,,,,,,,9.68,21.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 500mg/10mL I(CereBYX),8723390,CDM,636,RC,Q2009,HCPCS,,,facility,inpatient,,,243.85000,70.72000,Aetna,Local,,97.54,,,,,,,87.91,199.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50mg/5mL Inj - 45mL vial,8724353,CDM,636,RC,J9045,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,Local,,30.00,,,,,,,27.04,61.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 10mL IS PF - Anesthesia,8985542,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone 4mg 21 Dose Pk,8723946,CDM,636,RC,J7509,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,Local,,4.00,,,,,,,3.60,8.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 2000mg Inj,8994849,CDM,636,RC,J9201,HCPCS,,,facility,inpatient,,,632.10000,183.31000,Aetna,Local,,252.84,,,,,,,227.87,517.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg T(Zofran),8724794,CDM,636,RC,Q0162,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,Local,,4.00,,,,,,,3.60,8.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosaprepitant 150mg I (Emend),8724913,CDM,636,RC,J1453,HCPCS,,,facility,inpatient,,,477.54000,138.49000,Aetna,Local,,191.02,,,,,,,172.15,390.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetaminophen 1g/100mL Inj,8725196,CDM,636,RC,J0131,HCPCS,,,facility,inpatient,,,141.14000,40.93000,Aetna,Local,,56.46,,,,,,,50.88,115.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mepivacaine 2% PF I 20mL,8725225,CDM,636,RC,J0670,HCPCS,,,facility,inpatient,,,33.35000,9.67000,Aetna,Local,,13.34,,,,,,,12.02,27.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Immune Globulin 20g/200mL I,8724539,CDM,636,RC,J1569,HCPCS,,,facility,inpatient,,,25330.85000,7345.95000,Aetna,Local,,10132.34,,,,,,,9131.77,20720.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levOCARNitine 200mg/1mL I 5mL Vial,8724714,CDM,636,RC,J1955,HCPCS,,,facility,inpatient,,,238.85000,69.27000,Aetna,Local,,95.54,,,,,,,86.11,195.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chlorothiazide Na 500mg Inj.,8724685,CDM,636,RC,J1205,HCPCS,,,facility,inpatient,,,1376.05000,399.05000,Aetna,Local,,550.42,,,,,,,496.07,1125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Thiosulfate 12.5g/50mL Inj,8724690,CDM,636,RC,J0209,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,179.80,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TACROLIMUS 5MG/ML INJ,8724691,CDM,636,RC,J7525,HCPCS,,,facility,inpatient,,,4849.80000,1406.44000,Aetna,Local,,1939.92,,,,,,,1748.35,3967.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Vaccine-P.Chick Embryo I(RabAvert),8725327,CDM,636,RC,90675,HCPCS,,,facility,inpatient,,,1877.50000,544.47000,Aetna,Local,,751.00,,,,,,,676.84,1535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Vaccine-P.Chick Embryo I(RabAvert),8725327,CDM,636,RC,90675,HCPCS,,,facility,outpatient,,,1877.50000,544.47000,Aetna,Local,,751.00,,,,,,,307.92,1535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Calcium Gluconate 0.465mEq/mL Inj,8725329,CDM,636,RC,J0612,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,Local,,40.00,,,,,,,36.05,81.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL 10mcg/mL Cont Inf.,8725259,CDM,636,RC,J3010,HCPCS,,,facility,inpatient,,,212.50000,61.62000,Aetna,Local,,85.00,,,,,,,76.61,173.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 1.5% 2000mL,8724960,CDM,636,RC,A4722,HCPCS,,,facility,inpatient,,,230.52000,66.85000,Aetna,Local,,92.21,,,,,,,83.10,188.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 1.5% 2000mL,8724960,CDM,636,RC,A4722,HCPCS,,,facility,outpatient,,,230.52000,66.85000,Aetna,Local,,92.21,,,,,,,83.10,188.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 2.5% 2000mL,8724961,CDM,636,RC,A4722,HCPCS,,,facility,inpatient,,,255.32000,74.04000,Aetna,Local,,102.13,,,,,,,92.04,208.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 2.5% 2000mL,8724961,CDM,636,RC,A4722,HCPCS,,,facility,outpatient,,,255.32000,74.04000,Aetna,Local,,102.13,,,,,,,92.04,208.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,8723830,CDM,636,RC,J1050,HCPCS,,,facility,inpatient,,,305.78000,88.68000,Aetna,Local,,122.31,,,,,,,110.23,250.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),8725278,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine SO4 0.4mg/mL 1mL I,8725289,CDM,636,RC,J0461,HCPCS,,,facility,inpatient,,,51.10000,14.82000,Aetna,Local,,20.44,,,,,,,18.42,41.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Acyclovir 7mg/mL IV,8724945,CDM,636,RC,J0133,HCPCS,,,facility,inpatient,,,313.78000,91.00000,Aetna,Local,,125.51,,,,,,,113.12,256.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Penicillin GK 3MU/50mL P,8724497,CDM,636,RC,J2540,HCPCS,,,facility,inpatient,,,121.25000,35.16000,Aetna,Local,,48.50,,,,,,,43.71,99.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,8725274,CDM,636,RC,J1953,HCPCS,,,facility,inpatient,,,178.05000,51.63000,Aetna,Local,,71.22,,,,,,,64.19,145.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,8724438,CDM,636,RC,J2543,HCPCS,,,facility,inpatient,,,64.17000,18.61000,Aetna,Local,,25.67,,,,,,,23.13,52.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 25mg/NS 250mL PF PB,8725397,CDM,636,RC,J2371,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,Local,,40.00,,,,,,,36.05,81.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 0.3 mg Syringe,8725400,CDM,636,RC,J0165,HCPCS,,,facility,inpatient,,,806.25000,233.81000,Aetna,Local,,322.50,,,,,,,290.65,659.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 0.15mg Syringe,8725399,CDM,636,RC,J0165,HCPCS,,,facility,inpatient,,,806.25000,233.81000,Aetna,Local,,322.50,,,,,,,290.65,659.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,8725439,CDM,636,RC,J2371,HCPCS,,,facility,inpatient,,,127.50000,36.97000,Aetna,Local,,51.00,,,,,,,45.96,104.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL 10mcg/mL /NS PCA 100mL,8924969,CDM,636,RC,J3010,HCPCS,,,facility,inpatient,,,246.73000,71.55000,Aetna,Local,,98.69,,,,,,,88.95,201.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 0.2mg/mL /NS PCA,8725503,CDM,636,RC,J1171,HCPCS,,,facility,inpatient,,,205.72000,59.66000,Aetna,Local,,82.29,,,,,,,74.16,168.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 1mg/mL / NS PCA,8924968,CDM,636,RC,J2270,HCPCS,,,facility,inpatient,,,151.52000,43.94000,Aetna,Local,,60.61,,,,,,,54.62,123.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),8723514,CDM,636,RC,J2704,HCPCS,,,facility,inpatient,,,37.16000,10.78000,Aetna,Local,,14.86,,,,,,,13.40,30.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),8723647,CDM,636,RC,J2704,HCPCS,,,facility,inpatient,,,307.53000,89.18000,Aetna,Local,,123.01,,,,,,,110.86,251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),8723585,CDM,636,RC,J2704,HCPCS,,,facility,inpatient,,,135.35000,39.25000,Aetna,Local,,54.14,,,,,,,48.79,110.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine HCl 0.2% PF Infusion,8924970,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,922.30000,267.47000,Aetna,Local,,368.92,,,,,,,332.49,754.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 750mg Inj,8725512,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,,,94.45000,27.39000,Aetna,Local,,37.78,,,,,,,34.05,77.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 3g/ NS 115mL P (Ancef),8725528,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,87.40000,25.35000,Aetna,Local,,34.96,,,,,,,31.51,71.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Heparin 100 unit/mL IS(Hep-LocK),8723553,CDM,636,RC,J1642,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 500mg I (Merrem),8725539,CDM,636,RC,J2185,HCPCS,,,facility,inpatient,,,50.23000,14.57000,Aetna,Local,,20.09,,,,,,,18.11,41.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 4 mg/NS 250mL IVPB,8726013,CDM,636,RC,J0165,HCPCS,,,facility,inpatient,,,212.50000,61.62000,Aetna,Local,,85.00,,,,,,,76.61,173.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1mg/10mL IS,8723399,CDM,636,RC,J0168,HCPCS,,,facility,inpatient,,,63.80000,18.50000,Aetna,Local,,25.52,,,,,,,23.00,52.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Denosumab 60mg/1mL IS(Prolia),8725582,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,7661.75000,2221.91000,Aetna,Local,,3064.70,,,,,,,2762.06,6267.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acyclovir 50mg/mL Inj 10mL,8725662,CDM,636,RC,J0133,HCPCS,,,facility,inpatient,,,180.50000,52.34000,Aetna,Local,,72.20,,,,,,,65.07,147.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Magnesium Sulf 50% I 10mL,8725663,CDM,636,RC,J3475,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,Local,,40.00,,,,,,,36.05,81.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 20mL I,8725666,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,98.75000,28.64000,Aetna,Local,,39.50,,,,,,,35.60,80.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ceftolozane-Tazobactam 1.5g Inj,8725675,CDM,636,RC,J0695,HCPCS,,,facility,inpatient,,,1442.40000,418.30000,Aetna,Local,,576.96,,,,,,,519.99,1179.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Succinylcholine 20mg/mL NS 10mL IS,8725683,CDM,636,RC,J0330,HCPCS,,,facility,inpatient,,,148.24000,42.99000,Aetna,Local,,59.30,,,,,,,53.44,121.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- iodixanol 270mg/mL I 100mL,8725707,CDM,636,RC,Q9966,HCPCS,,,facility,inpatient,,,526.85000,152.79000,Aetna,Local,,210.74,,,,,,,189.93,430.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RHo (D) Immune Globulin 300mcg/2mL Inj,8725718,CDM,636,RC,J2791,HCPCS,,,facility,inpatient,,,799.05000,231.72000,Aetna,Local,,319.62,,,,,,,288.06,653.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylene Blue 0.5% 10mL I,8725737,CDM,636,RC,Q9968,HCPCS,,,facility,inpatient,,,1133.96000,328.85000,Aetna,Local,,453.58,,,,,,,408.79,927.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylene Blue 0.5% 10mL I,8725737,CDM,636,RC,Q9968,HCPCS,,,facility,outpatient,,,1133.96000,328.85000,Aetna,Local,,453.58,,,,,,,5.42,927.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrOXYzine HCl 50mg/1mL Inj,8723781,CDM,636,RC,J3410,HCPCS,,,facility,inpatient,,,200.78000,58.23000,Aetna,Local,,80.31,,,,,,,72.38,164.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 1mg/1mL  Inj,8725753,CDM,636,RC,J1171,HCPCS,,,facility,inpatient,,,35.04000,10.16000,Aetna,Local,,14.02,,,,,,,12.63,28.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Panitumumab 100mg/5mL I(Vectibix),8724846,CDM,636,RC,J9303,HCPCS,,,facility,inpatient,,,9969.95000,2891.29000,Aetna,Local,,3987.98,,,,,,,3594.17,8155.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pertuzumab 420 mg/14 mL I(Perjeta),8725277,CDM,636,RC,J9306,HCPCS,,,facility,inpatient,,,37017.65000,10735.12000,Aetna,Local,,14807.06,,,,,,,13344.86,30280.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bivalirudin 250mg I(Angiomax),8724151,CDM,636,RC,J0583,HCPCS,,,facility,inpatient,,,7562.21000,2193.04000,Aetna,Local,,3024.88,,,,,,,2726.18,6185.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 10mg/5mL I,8723898,CDM,636,RC,J9000,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,Local,,30.00,,,,,,,27.04,61.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 50mg/25mL I,8723870,CDM,636,RC,J9000,HCPCS,,,facility,inpatient,,,189.40000,54.93000,Aetna,Local,,75.76,,,,,,,68.28,154.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate Na 250mg/10mL I PF,8723451,CDM,636,RC,J9260,HCPCS,,,facility,inpatient,,,89.70000,26.01000,Aetna,Local,,35.88,,,,,,,32.34,73.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate 1g/40mL I PF,8724347,CDM,636,RC,J9260,HCPCS,,,facility,inpatient,,,343.60000,99.64000,Aetna,Local,,137.44,,,,,,,123.87,281.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
vinCRIStine 2mg/2mL Inj,8723899,CDM,636,RC,J9370,HCPCS,,,facility,inpatient,,,141.39000,41.00000,Aetna,Local,,56.56,,,,,,,50.97,115.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mepolizumab 100mg Inj,8725764,CDM,636,RC,J2182,HCPCS,,,facility,inpatient,,,14425.17000,4183.30000,Aetna,Local,,5770.07,,,,,,,5200.27,11799.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vedolizumab 300mg I(Entyvio),8725765,CDM,636,RC,J3380,HCPCS,,,facility,inpatient,,,67578.40000,19597.74000,Aetna,Local,,27031.36,,,,,,,24362.01,55279.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Alteplase 10mg/10mL Bolus Syringe,8725714,CDM,636,RC,J2997,HCPCS,,,facility,inpatient,,,4529.45000,1313.54000,Aetna,Local,,1811.78,,,,,,,1632.87,3705.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),8725767,CDM,636,RC,Q9950,HCPCS,,,facility,inpatient,,,746.49000,216.48000,Aetna,Local,,298.60,,,,,,,269.11,610.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 10mL",8725771,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,25.30000,7.34000,Aetna,Local,,10.12,,,,,,,9.12,20.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL I PF,8725786,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 1mg/5mL Inj,8725794,CDM,636,RC,J1596,HCPCS,,,facility,inpatient,,,70.87000,20.55000,Aetna,Local,,28.35,,,,,,,25.55,57.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab 150mg I(Herceptin),8725817,CDM,636,RC,J9355,HCPCS,,,facility,inpatient,,,8602.45000,2494.71000,Aetna,Local,,3440.98,,,,,,,3101.18,7036.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Alteplase 0.5mg/1mL Inj Syr,8725820,CDM,636,RC,J2997,HCPCS,,,facility,inpatient,,,385.60000,111.82000,Aetna,Local,,154.24,,,,,,,139.01,315.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Labor Room Epidural 100mL,8725822,CDM,636,RC,J3010,HCPCS,,,facility,inpatient,,,204.43000,59.28000,Aetna,Local,,81.77,,,,,,,73.70,167.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Denosumab 120mg/1.7mL I (Xgeva),8725825,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,13933.80000,4040.80000,Aetna,Local,,5573.52,,,,,,,5023.13,11397.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dalbavancin 500mg I (Dalvance),8725826,CDM,636,RC,J0875,HCPCS,,,facility,inpatient,,,12996.75000,3769.06000,Aetna,Local,,5198.70,,,,,,,4685.33,10631.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadobutrol 604.72mg/1mL Inj,8725605,CDM,636,RC,A9585,HCPCS,,,facility,inpatient,,,53.00000,15.37000,Aetna,Local,,21.20,,,,,,,19.11,43.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadoxetate 181.43mg/mL I 10mL,8725236,CDM,636,RC,A9581,HCPCS,,,facility,inpatient,,,740.75000,214.82000,Aetna,Local,,296.30,,,,,,,267.04,605.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- iodixanol 320mg/mL Inj 100mL,8725698,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,506.20000,146.80000,Aetna,Local,,202.48,,,,,,,182.49,414.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 180mg/mL Inj 10mL,8725699,CDM,636,RC,Q9965,HCPCS,,,facility,inpatient,,,245.62000,71.23000,Aetna,Local,,98.25,,,,,,,88.55,200.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 180mg/mL Inj 20mL,8725700,CDM,636,RC,Q9965,HCPCS,,,facility,inpatient,,,311.35000,90.29000,Aetna,Local,,124.54,,,,,,,112.24,254.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 350mg/mL Inj 100mL,8725760,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,551.91000,160.05000,Aetna,Local,,220.76,,,,,,,198.96,451.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 350mg/mL Inj 50mL,8725607,CDM,636,RC,Q9967,HCPCS,,,facility,inpatient,,,408.30000,118.41000,Aetna,Local,,163.32,,,,,,,147.19,333.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pfizer Covid Vaccine Medication Dose 1,8429711,CDM,636,RC,91300,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pfizer Covid Vaccine Medication Dose 1,8429711,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pfizer Covid Vaccine Medication Dose 2,8429710,CDM,636,RC,91300,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pfizer Covid Vaccine Medication Dose 2,8429710,CDM,636,RC,91300,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEMEtrexed 500mg Rec Inj,8724346,CDM,636,RC,J9305,HCPCS,,,facility,inpatient,,,682.28000,197.86000,Aetna,Local,,272.91,,,,,,,245.96,558.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Ampicillin 100mg/mL IV Syr,8725452,CDM,636,RC,J0290,HCPCS,,,facility,inpatient,,,35.91000,10.41000,Aetna,Local,,14.36,,,,,,,12.95,29.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prothrombin Complex-Human I(Kcentra),8725461,CDM,636,RC,J7168,HCPCS,,,facility,inpatient,,,21.57000,6.26000,Aetna,Local,,8.63,,,,,,,7.78,17.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aztreonam 2g I (Azactam),8725498,CDM,636,RC,J0457,HCPCS,,,facility,inpatient,,,591.49000,171.53000,Aetna,Local,,236.60,,,,,,,213.23,483.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CISplatin 10mg/10mL I,8725650,CDM,636,RC,J9060,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,Local,,30.00,,,,,,,27.04,61.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etoposide 10mg/0.5mL Inj,8725629,CDM,636,RC,J9181,HCPCS,,,facility,inpatient,,,4.87000,1.41000,Aetna,Local,,1.95,,,,,,,1.76,3.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 1mg Inj,8725644,CDM,636,RC,J9267,HCPCS,,,facility,inpatient,,,12.65000,3.67000,Aetna,Local,,5.06,,,,,,,4.56,10.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
vinBLAStine 1mg/mL Inj,8725636,CDM,636,RC,J9360,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,Local,,30.00,,,,,,,27.04,61.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mesna 200mg/2mL I (Mesnex),8725643,CDM,636,RC,J9209,HCPCS,,,facility,inpatient,,,135.30000,39.24000,Aetna,Local,,54.12,,,,,,,48.78,110.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250mL Inj IVR,8725555,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,100.96000,29.28000,Aetna,Local,,40.38,,,,,,,36.40,82.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 100mL Inj,8725556,CDM,636,RC,J7050,HCPCS,,,facility,inpatient,,,50.62000,14.68000,Aetna,Local,,20.25,,,,,,,18.25,41.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- cefTAZidime 50mg/mL IS,8725569,CDM,636,RC,J0713,HCPCS,,,facility,inpatient,,,52.00000,15.08000,Aetna,Local,,20.80,,,,,,,18.75,42.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
idaruCIZUmab  2.5g/50mL I(Praxbind),8725584,CDM,636,RC,C9399,HCPCS,,,facility,inpatient,,,18555.70000,5381.15000,Aetna,Local,,7422.28,,,,,,,6689.33,15178.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
idaruCIZUmab  2.5g/50mL I(Praxbind),8725584,CDM,636,RC,C9399,HCPCS,,,facility,outpatient,,,18555.70000,5381.15000,Aetna,Local,,7422.28,,,,,,,6689.33,15178.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% (5mg/1mL) I,8725588,CDM,636,RC,J2795,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vasopressin 20units/1mL- For IV Set,8725589,CDM,636,RC,J2598,HCPCS,,,facility,inpatient,,,490.00000,142.10000,Aetna,Local,,196.00,,,,,,,176.65,400.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hyaluronidase 150units/1mL Inj.,8725611,CDM,636,RC,J3470,HCPCS,,,facility,inpatient,,,330.30000,95.79000,Aetna,Local,,132.12,,,,,,,119.07,270.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 2mg/2.5 mL Oral Soln,8725924,CDM,636,RC,Q0162,HCPCS,,,facility,inpatient,,,84.90000,24.62000,Aetna,Local,,33.96,,,,,,,30.61,69.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metroNIDAZOLE 500mg P,8723633,CDM,636,RC,J1836,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,Local,,20.00,,,,,,,18.02,40.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitroglycerin 50mg/10mL I,8723429,CDM,636,RC,J2305,HCPCS,,,facility,inpatient,,,158.65000,46.01000,Aetna,Local,,63.46,,,,,,,57.19,129.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chloroprocaine HCl 3% 20mL PfI(Nesacain,8723550,CDM,636,RC,J2401,HCPCS,,,facility,inpatient,,,143.45000,41.60000,Aetna,Local,,57.38,,,,,,,51.71,117.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Promethazine HCl 25mg/1mL I,8722806,CDM,636,RC,J2550,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 40g/Water 1000mL,8725828,CDM,636,RC,J3475,HCPCS,,,facility,inpatient,,,961.36000,278.79000,Aetna,Local,,384.54,,,,,,,346.57,786.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Immune Glob 300IU/1mL Inj,8725832,CDM,636,RC,90375,HCPCS,,,facility,inpatient,,,3019.15000,875.55000,Aetna,Local,,1207.66,,,,,,,1088.40,2469.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Immune Glob 300IU/1mL Inj,8725832,CDM,636,RC,90375,HCPCS,,,facility,outpatient,,,3019.15000,875.55000,Aetna,Local,,1207.66,,,,,,,269.59,2469.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ocrelizumab 300mg/10mL I(Ocrevus),8725847,CDM,636,RC,J2350,HCPCS,,,facility,inpatient,,,148801.95000,43152.57000,Aetna,Local,,59520.78,,,,,,,53643.10,121720.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,8723547,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,75.30000,21.84000,Aetna,Local,,30.12,,,,,,,27.15,61.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ceftazidime-Avibactam2-0.5g Inj,8725843,CDM,636,RC,J0714,HCPCS,,,facility,inpatient,,,3181.46000,922.62000,Aetna,Local,,1272.58,,,,,,,1146.92,2602.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eculizumab- Pt Own Supply,8725899,CDM,636,RC,J1299,HCPCS,,,facility,inpatient,,,372.90000,108.14000,Aetna,Local,,149.16,,,,,,,134.43,305.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 10mL Inj,8725850,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NICU- PENICILLIN GK 100,000 UNIT/ML IM",8725865,CDM,636,RC,J2540,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Alpha 1-Proteinase Inhbitor Human 10mg I(Prolastin),8725866,CDM,636,RC,J0256,HCPCS,,,facility,inpatient,,,28.07000,8.14000,Aetna,Local,,11.23,,,,,,,10.12,22.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ocrelizumab- Pt Own Supply,8725879,CDM,636,RC,J2350,HCPCS,,,facility,inpatient,,,0.09000,0.03000,Aetna,Local,,0.03600,,,,,,,0.03245,0.07362,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab- Pt Own Supply,8725880,CDM,636,RC,J1745,HCPCS,,,facility,inpatient,,,0.01000,,Aetna,Local,,0.00400,,,,,,,0.00361,0.00818,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Natalizumab - Pt Own Supply,8725881,CDM,636,RC,J2323,HCPCS,,,facility,inpatient,,,0.15000,0.04000,Aetna,Local,,0.06000,,,,,,,0.05407,0.12270,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Benralizumab- Pt Own Supply,8725886,CDM,636,RC,J0517,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Brivaracetam 10mg/mL Inj 5mL,8725877,CDM,636,RC,,,,,facility,inpatient,,,568.30000,164.81000,Aetna,Local,,227.32,,,,,,,204.87,464.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Brivaracetam 10mg/mL Inj 5mL,8725877,CDM,636,RC,,,,,facility,outpatient,,,568.30000,164.81000,Aetna,Local,,227.32,,,,,,,204.87,464.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omalizumab 150mg- Pt Own Supply,8726081,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omalizumab 75mg- Pt Own Supply,8726080,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omalizumab 150mg/mL IS(Xolair),8725885,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,5831.85000,1691.24000,Aetna,Local,,2332.74,,,,,,,2102.38,4770.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omalizumab 75mg/0.5mL IS(Xolair),8725882,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,3010.95000,873.18000,Aetna,Local,,1204.38,,,,,,,1085.45,2462.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Chloride 3% IV 500mL,8725889,CDM,636,RC,J7131,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,Local,,40.00,,,,,,,36.05,81.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haloperidol Decanoate 100mg/1mL Inj,8725890,CDM,636,RC,J1631,HCPCS,,,facility,inpatient,,,187.52000,54.38000,Aetna,Local,,75.01,,,,,,,67.60,153.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-cbqv 6mg/0.6mL Inj Syr,8725937,CDM,636,RC,Q5111,HCPCS,,,facility,inpatient,,,16823.20000,4878.73000,Aetna,Local,,6729.28,,,,,,,6064.76,13761.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-cbqv 6mg/0.6mL Inj Syr,8725937,CDM,636,RC,Q5111,HCPCS,,,facility,outpatient,,,16823.20000,4878.73000,Aetna,Local,,6729.28,,,,,,,156.00,13761.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 500mg I(Rocephin),8725561,CDM,636,RC,J0696,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine 0.5% 50mL PF I,8724335,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,92.45000,26.81000,Aetna,Local,,36.98,,,,,,,33.33,75.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Argatroban 50mg/50mL I,8726133,CDM,636,RC,J0883,HCPCS,,,facility,inpatient,,,930.00000,269.70000,Aetna,Local,,372.00,,,,,,,335.26,760.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Levothyroxine 100 mcg Inj (20mcg/mL),8726143,CDM,636,RC,J0651,HCPCS,,,facility,inpatient,,,778.80000,225.85000,Aetna,Local,,311.52,,,,,,,280.76,637.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,8726096,CDM,636,RC,J0612,HCPCS,,,facility,inpatient,,,186.01000,53.94000,Aetna,Local,,74.40,,,,,,,67.06,152.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Milrinone 20mg/D5W 100mL,8726113,CDM,636,RC,J2260,HCPCS,,,facility,inpatient,,,153.41000,44.49000,Aetna,Local,,61.36,,,,,,,55.30,125.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 200mg- Pt Own Supply,8726116,CDM,636,RC,C9399,HCPCS,,,facility,inpatient,,,0.04000,0.01000,Aetna,Local,,0.01600,,,,,,,0.01442,0.03272,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 200mg- Pt Own Supply,8726116,CDM,636,RC,C9399,HCPCS,,,facility,outpatient,,,0.04000,0.01000,Aetna,Local,,0.01600,,,,,,,0.01442,0.03272,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 100mg/NS 100mL IV,8726120,CDM,636,RC,J2250,HCPCS,,,facility,inpatient,,,223.53000,64.82000,Aetna,Local,,89.41,,,,,,,80.58,182.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pembrolizumab 25mg/mL Inj 4mL,8726129,CDM,636,RC,J9271,HCPCS,,,facility,inpatient,,,31410.25000,9108.97000,Aetna,Local,,12564.10,,,,,,,11323.40,25693.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nalbuphine 10mg/mL I (Nubain),8725074,CDM,636,RC,J2300,HCPCS,,,facility,inpatient,,,29.76000,8.63000,Aetna,Local,,11.90,,,,,,,10.73,24.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tezepelumab-ekko 210mg Inj (Tezspire),8924941,CDM,636,RC,J2356,HCPCS,,,facility,inpatient,,,17595.95000,5102.83000,Aetna,Local,,7038.38,,,,,,,6343.34,14393.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pneumococcal 20-Valent Conjugate Vaccine,8924967,CDM,636,RC,90677,HCPCS,,,facility,inpatient,,,1264.62000,366.74000,Aetna,Local,,505.85,,,,,,,455.90,1034.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pneumococcal 20-Valent Conjugate Vaccine,8924967,CDM,636,RC,90677,HCPCS,,,facility,outpatient,,,1264.62000,366.74000,Aetna,Local,,505.85,,,,,,,301.32,1034.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
romiPLOStim 125mcg Inj,8924973,CDM,636,RC,J2802,HCPCS,,,facility,inpatient,,,5674.10000,1645.49000,Aetna,Local,,2269.64,,,,,,,2045.51,4641.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 2g Inj (Ancef),8924974,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,58.50000,16.96000,Aetna,Local,,23.40,,,,,,,21.09,47.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,8924975,CDM,636,RC,J1953,HCPCS,,,facility,inpatient,,,385.93000,111.92000,Aetna,Local,,154.37,,,,,,,139.13,315.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
leuprolide 22.5mg/3 month(Eligard),8947246,CDM,636,RC,J9217,HCPCS,,,facility,inpatient,,,5588.60000,1620.69000,Aetna,Local,,2235.44,,,,,,,2014.69,4571.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ravulizumab-cwvz- Pt Own Supply,8970141,CDM,636,RC,J1303,HCPCS,,,facility,inpatient,,,0.13000,0.04000,Aetna,Local,,0.05200,,,,,,,0.04686,0.10634,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 30 unit/500 mL-NaCl 0.9%,8975604,CDM,636,RC,J2590,HCPCS,,,facility,inpatient,,,278.63000,80.80000,Aetna,Local,,111.45,,,,,,,100.45,227.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
micafungin 100mg Inj,8984065,CDM,636,RC,J2248,HCPCS,,,facility,inpatient,,,441.20000,127.95000,Aetna,Local,,176.48,,,,,,,159.05,360.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lurbinectedin 4mg Inj (Zepzelca),8985202,CDM,636,RC,J9223,HCPCS,,,facility,inpatient,,,58579.00000,16987.91000,Aetna,Local,,23431.60,,,,,,,21117.73,47917.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-apgf 6 mg/0.6 mL Inj Syr,8986793,CDM,636,RC,Q5122,HCPCS,,,facility,inpatient,,,30805.00000,8933.45000,Aetna,Local,,12322.00,,,,,,,11105.20,25198.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-apgf 6 mg/0.6 mL Inj Syr,8986793,CDM,636,RC,Q5122,HCPCS,,,facility,outpatient,,,30805.00000,8933.45000,Aetna,Local,,12322.00,,,,,,,128.13,25198.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- qyyp 420mg Inj,8986794,CDM,636,RC,Q5116,HCPCS,,,facility,inpatient,,,18498.85000,5364.67000,Aetna,Local,,7399.54,,,,,,,6668.84,15132.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- qyyp 420mg Inj,8986794,CDM,636,RC,Q5116,HCPCS,,,facility,outpatient,,,18498.85000,5364.67000,Aetna,Local,,7399.54,,,,,,,7.91,15132.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- qyyp 150mg Inj,8986795,CDM,636,RC,Q5116,HCPCS,,,facility,inpatient,,,6726.95000,1950.82000,Aetna,Local,,2690.78,,,,,,,2425.07,5502.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- qyyp 150mg Inj,8986795,CDM,636,RC,Q5116,HCPCS,,,facility,outpatient,,,6726.95000,1950.82000,Aetna,Local,,2690.78,,,,,,,7.91,5502.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,8986952,CDM,636,RC,Q5108,HCPCS,,,facility,inpatient,,,9823.39000,2848.78000,Aetna,Local,,3929.36,,,,,,,3541.33,8035.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,8986952,CDM,636,RC,Q5108,HCPCS,,,facility,outpatient,,,9823.39000,2848.78000,Aetna,Local,,3929.36,,,,,,,95.21,8035.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filgrastim- aafi 300mcg Inj Syr,8988270,CDM,636,RC,Q5110,HCPCS,,,facility,inpatient,,,1125.83000,326.49000,Aetna,Local,,450.33,,,,,,,405.86,920.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filgrastim- aafi 300mcg Inj Syr,8988270,CDM,636,RC,Q5110,HCPCS,,,facility,outpatient,,,1125.83000,326.49000,Aetna,Local,,450.33,,,,,,,0.26964,920.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filgrastim- aafi 480mcg Inj Syr,8986962,CDM,636,RC,Q5110,HCPCS,,,facility,inpatient,,,1586.00000,459.94000,Aetna,Local,,634.40,,,,,,,571.75,1297.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filgrastim- aafi 480mcg Inj Syr,8986962,CDM,636,RC,Q5110,HCPCS,,,facility,outpatient,,,1586.00000,459.94000,Aetna,Local,,634.40,,,,,,,0.26964,1297.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diatrizoate Meglumine 30% I 100mL,8995784,CDM,636,RC,Q9958,HCPCS,,,facility,inpatient,,,309.00000,89.61000,Aetna,Local,,123.60,,,,,,,111.39,252.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methocarbamol 1g/10mL Inj,8723383,CDM,636,RC,J2800,HCPCS,,,facility,inpatient,,,76.80000,22.27000,Aetna,Local,,30.72,,,,,,,27.69,62.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Inclisiran 284mg/1.5 mL IS (Leqvio),9000458,CDM,636,RC,J1306,HCPCS,,,facility,inpatient,,,13629.70000,3952.61000,Aetna,Local,,5451.88,,,,,,,4913.51,11149.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab - axxq 100mg Inj,9000600,CDM,636,RC,Q5121,HCPCS,,,facility,inpatient,,,3787.00000,1098.23000,Aetna,Local,,1514.80,,,,,,,1365.21,3097.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab - axxq 100mg Inj,9000600,CDM,636,RC,Q5121,HCPCS,,,facility,outpatient,,,3787.00000,1098.23000,Aetna,Local,,1514.80,,,,,,,22.93,3097.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eravacycline 100mg REC Inj,9003760,CDM,636,RC,J0122,HCPCS,,,facility,inpatient,,,997.00000,289.13000,Aetna,Local,,398.80,,,,,,,359.42,815.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab - abda 100mg Inj,9004122,CDM,636,RC,Q5104,HCPCS,,,facility,inpatient,,,5611.45000,1627.32000,Aetna,Local,,2244.58,,,,,,,2022.93,4590.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab - abda 100mg Inj,9004122,CDM,636,RC,Q5104,HCPCS,,,facility,outpatient,,,5611.45000,1627.32000,Aetna,Local,,2244.58,,,,,,,26.72,4590.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorouracil 2.5g/50mL Inj,9005006,CDM,636,RC,J9190,HCPCS,,,facility,inpatient,,,140.65000,40.79000,Aetna,Local,,56.26,,,,,,,50.70,115.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate 50mg/2mL Inj,9006348,CDM,636,RC,J9260,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,Local,,30.00,,,,,,,27.04,61.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 300mg/2mL Inj,9010087,CDM,636,RC,C9399,HCPCS,,,facility,inpatient,,,8144.80000,2361.99000,Aetna,Local,,3257.92,,,,,,,2936.20,6662.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 300mg/2mL Inj,9010087,CDM,636,RC,C9399,HCPCS,,,facility,outpatient,,,8144.80000,2361.99000,Aetna,Local,,3257.92,,,,,,,2936.20,6662.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
golimumab 50mg/4mL Inj,9011879,CDM,636,RC,J1602,HCPCS,,,facility,inpatient,,,14581.20000,4228.55000,Aetna,Local,,5832.48,,,,,,,5256.52,11927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cangrelor 50mg Inj,9025117,CDM,636,RC,C9460,HCPCS,,,facility,inpatient,,,7395.65000,2144.74000,Aetna,Local,,2958.26,,,,,,,2666.13,6049.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Certolizumab Pegol Lypholized Kit,9024406,CDM,636,RC,J0717,HCPCS,,,facility,inpatient,,,19375.20000,5618.81000,Aetna,Local,,7750.08,,,,,,,6984.76,15848.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lecanemab - irmb 500mg Inj,9021927,CDM,636,RC,J0174,HCPCS,,,facility,inpatient,,,4822.13000,1398.42000,Aetna,Local,,1928.85,,,,,,,1738.38,3944.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lecanemab - irmb 200mg Inj,9024790,CDM,636,RC,J0174,HCPCS,,,facility,inpatient,,,2071.06000,600.61000,Aetna,Local,,828.42,,,,,,,746.62,1694.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 5mg/10mL PF I,8723436,CDM,636,RC,J2274,HCPCS,,,facility,inpatient,,,198.64000,57.61000,Aetna,Local,,79.46,,,,,,,71.61,162.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 10mg/10mL PF,8723433,CDM,636,RC,J2274,HCPCS,,,facility,inpatient,,,199.18000,57.76000,Aetna,Local,,79.67,,,,,,,71.80,162.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mannitol 25% I 50mL,8723584,CDM,636,RC,J2150,HCPCS,,,facility,inpatient,,,32.53000,9.43000,Aetna,Local,,13.01,,,,,,,11.73,26.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pembrolizumab 100mg/4mL Inj - Pt Own Supply,9044858,CDM,636,RC,J9271,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pertuzumab 420 mg Inj- Pt Own Supply,9044856,CDM,636,RC,J9306,HCPCS,,,facility,inpatient,,,0.15000,0.04000,Aetna,Local,,0.06000,,,,,,,0.05407,0.12270,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab-pvvr 100mg- Pt Own Supply,9046659,CDM,636,RC,Q5119,HCPCS,,,facility,inpatient,,,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab-pvvr 100mg- Pt Own Supply,9046659,CDM,636,RC,Q5119,HCPCS,,,facility,outpatient,,,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03700,40.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
nirsevimab - alip 50mg/0.5mL PF IS,9044695,CDM,636,RC,90380,HCPCS,,,facility,inpatient,,,2405.65000,697.64000,Aetna,Local,,962.26,,,,,,,867.24,1967.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
nirsevimab - alip 50mg/0.5mL PF IS,9044695,CDM,636,RC,90380,HCPCS,,,facility,outpatient,,,2405.65000,697.64000,Aetna,Local,,962.26,,,,,,,600.62,1967.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
daratumumab-hyaluronidase fihj Inj - Pt Own Supply,9044863,CDM,636,RC,J9144,HCPCS,,,facility,inpatient,,,0.15000,0.04000,Aetna,Local,,0.06000,,,,,,,0.05407,0.12270,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nivolumab 120mg Inj - Pt Own Supply,9074454,CDM,636,RC,J9299,HCPCS,,,facility,inpatient,,,0.13000,0.04000,Aetna,Local,,0.05200,,,,,,,0.04686,0.10634,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nivolumab 240mg Inj - Pt Own Supply,9046662,CDM,636,RC,J9299,HCPCS,,,facility,inpatient,,,0.25000,0.07000,Aetna,Local,,0.10000,,,,,,,0.09012,0.20450,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab-pvvr 500mg- Pt Own Supply,9057005,CDM,636,RC,Q5119,HCPCS,,,facility,inpatient,,,0.50000,0.14000,Aetna,Local,,0.20000,,,,,,,0.18025,0.40900,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab-pvvr 500mg- Pt Own Supply,9057005,CDM,636,RC,Q5119,HCPCS,,,facility,outpatient,,,0.50000,0.14000,Aetna,Local,,0.20000,,,,,,,0.18500,40.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tezepelumab-ekko - Pt Own Supply,9044865,CDM,636,RC,J2356,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Denosumab 120mg Inj - Pt Own Supply,9046522,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Alpha 1-Proteinase inhibitor human 10mg I(Zemaira),9060183,CDM,636,RC,J0256,HCPCS,,,facility,inpatient,,,44.41000,12.88000,Aetna,Local,,17.76,,,,,,,16.01,36.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 300mg- Pt Own Supply,9057587,CDM,636,RC,C9399,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 300mg- Pt Own Supply,9057587,CDM,636,RC,C9399,HCPCS,,,facility,outpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Romosozumag-aqqg 105mg - Pt Own Supply,9068266,CDM,636,RC,J3111,HCPCS,,,facility,inpatient,,,0.03000,0.01000,Aetna,Local,,0.01200,,,,,,,0.01081,0.02454,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
omalizumab 300mg/2mL IS(Xolair),9068278,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,11473.65000,3327.36000,Aetna,Local,,4589.46,,,,,,,4136.25,9385.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 1mL I,9068276,CDM,636,RC,J3010,HCPCS,,,facility,inpatient,,,35.00000,10.15000,Aetna,Local,,14.00,,,,,,,12.62,28.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- dkst 150mg Inj,9074395,CDM,636,RC,Q5114,HCPCS,,,facility,inpatient,,,5265.75000,1527.07000,Aetna,Local,,2106.30,,,,,,,1898.30,4307.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- dkst 150mg Inj,9074395,CDM,636,RC,Q5114,HCPCS,,,facility,outpatient,,,5265.75000,1527.07000,Aetna,Local,,2106.30,,,,,,,36.31,4307.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- dkst 420mg Inj,9074394,CDM,636,RC,Q5114,HCPCS,,,facility,inpatient,,,14362.30000,4165.07000,Aetna,Local,,5744.92,,,,,,,5177.61,11748.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- dkst 420mg Inj,9074394,CDM,636,RC,Q5114,HCPCS,,,facility,outpatient,,,14362.30000,4165.07000,Aetna,Local,,5744.92,,,,,,,36.31,11748.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Canakinumab 150 mg/mL - Pt Own Supply,9072486,CDM,636,RC,J0638,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lecanemab-irmb 200mg- Pt Own Supply,9074459,CDM,636,RC,J0174,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lecanemab-irmb 500mg- Pt Own Supply,9072487,CDM,636,RC,J0174,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omalizumab 300mg- Pt Own Supply,9072488,CDM,636,RC,J2357,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
durvalumab 500mg/10mL Inj - Pt Own Supply,9076540,CDM,636,RC,J9173,HCPCS,,,facility,inpatient,,,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Benralizumab 30mg IS (Fasenra),9076702,CDM,636,RC,J0517,HCPCS,,,facility,inpatient,,,22806.20000,6613.80000,Aetna,Local,,9122.48,,,,,,,8221.64,18655.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 1mg/0.5mL Inj - Alum Free,9080753,CDM,636,RC,J3430,HCPCS,,,facility,inpatient,,,144.14000,41.80000,Aetna,Local,,57.66,,,,,,,51.96,117.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ublituximab - xiiy 150mg- Pt Own Supply,9082778,CDM,636,RC,J2329,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,Local,,30.00,,,,,,,27.04,61.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
polatuzumab vedotin - piiq 30mg I(Polivy),9085020,CDM,636,RC,J9309,HCPCS,,,facility,inpatient,,,28901.85000,8381.54000,Aetna,Local,,11560.74,,,,,,,10419.12,23641.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
polatuzumab vedotin - piiq 140mg I(Polivy),9085021,CDM,636,RC,J9309,HCPCS,,,facility,inpatient,,,134189.20000,38914.87000,Aetna,Local,,53675.68,,,,,,,48375.21,109766.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ipilimumab 50mg/10mL I(Yervoy),9085022,CDM,636,RC,J9228,HCPCS,,,facility,inpatient,,,64907.71000,18823.24000,Aetna,Local,,25963.08,,,,,,,23399.23,53094.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Influenza Virus Vaccine, Inact Trivalent Inj",9083697,CDM,636,RC,90656,HCPCS,,,facility,inpatient,,,126.05000,36.55000,Aetna,Local,,50.42,,,,,,,45.44,103.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Influenza Virus Vaccine, Inact Trivalent Inj",9083697,CDM,636,RC,90656,HCPCS,,,facility,outpatient,,,126.05000,36.55000,Aetna,Local,,50.42,,,,,,,14.13,103.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
durvalumab 500mg/10mL (Imfinzi),9085110,CDM,636,RC,J9173,HCPCS,,,facility,inpatient,,,30229.52000,8766.56000,Aetna,Local,,12091.81,,,,,,,10897.74,24727.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:200,000 Inj 20mL",8723506,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,37.03000,10.74000,Aetna,Local,,14.81,,,,,,,13.35,30.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
belimumab 120mg REC Inj(Benlysta),9024968,CDM,636,RC,J0490,HCPCS,,,facility,inpatient,,,3672.70000,1065.08000,Aetna,Local,,1469.08,,,,,,,1324.01,3004.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
belimumab 400mg REC Inj (Benlysta),9022076,CDM,636,RC,J0490,HCPCS,,,facility,inpatient,,,11840.30000,3433.69000,Aetna,Local,,4736.12,,,,,,,4268.43,9685.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"daratumumab-hyaluronidase fihj 1800 mg-30,000 units/15 mL I",9041323,CDM,636,RC,J9144,HCPCS,,,facility,inpatient,,,54309.25000,15749.68000,Aetna,Local,,21723.70,,,,,,,19578.48,44424.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Denosumab 60mg/1mL - Pt Own Supply,9043569,CDM,636,RC,J0897,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- DexAMETHasone 0.1mg/mL IV in D5W,9044404,CDM,636,RC,J1100,HCPCS,,,facility,inpatient,,,98.20000,28.48000,Aetna,Local,,39.28,,,,,,,35.40,80.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Influenza Virus Vaccine, Inact High-Dose-Trivalent PF Inj",9086429,CDM,636,RC,90662,HCPCS,,,facility,inpatient,,,450.80000,130.73000,Aetna,Local,,180.32,,,,,,,162.51,368.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Influenza Virus Vaccine, Inact High-Dose-Trivalent PF Inj",9086429,CDM,636,RC,90662,HCPCS,,,facility,outpatient,,,450.80000,130.73000,Aetna,Local,,180.32,,,,,,,94.53,368.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab - axxq - Pt Own Supply,9044864,CDM,636,RC,Q5121,HCPCS,,,facility,inpatient,,,0.03000,0.01000,Aetna,Local,,0.01200,,,,,,,0.01081,0.02454,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab - axxq - Pt Own Supply,9044864,CDM,636,RC,Q5121,HCPCS,,,facility,outpatient,,,0.03000,0.01000,Aetna,Local,,0.01200,,,,,,,0.01110,73.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cemiplimab - rwlc 350 mg/7 mL Soln,9091655,CDM,636,RC,J9119,HCPCS,,,facility,inpatient,,,58082.12000,16843.81000,Aetna,Local,,23232.85,,,,,,,20938.60,47511.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nivolumab 120mg/12mL I(Opdivo),9094916,CDM,636,RC,J9299,HCPCS,,,facility,inpatient,,,21458.95000,6223.10000,Aetna,Local,,8583.58,,,,,,,7735.95,17553.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
efgartigimod alfa-hyaluronidase qvfc Inj - Pt Own Supply,9093230,CDM,636,RC,J9334,HCPCS,,,facility,inpatient,,,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bevacizumab - adcd 400mg Inj,9093250,CDM,636,RC,Q5129,HCPCS,,,facility,inpatient,,,14818.85000,4297.47000,Aetna,Local,,5927.54,,,,,,,5342.20,12121.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bevacizumab - adcd 400mg Inj,9093250,CDM,636,RC,Q5129,HCPCS,,,facility,outpatient,,,14818.85000,4297.47000,Aetna,Local,,5927.54,,,,,,,36.75,12121.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bevacizumab - adcd 100mg Inj,9093249,CDM,636,RC,Q5129,HCPCS,,,facility,inpatient,,,4375.00000,1268.75000,Aetna,Local,,1750.00,,,,,,,1577.19,3578.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bevacizumab - adcd 100mg Inj,9093249,CDM,636,RC,Q5129,HCPCS,,,facility,outpatient,,,4375.00000,1268.75000,Aetna,Local,,1750.00,,,,,,,36.75,3578.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
enfortumab vedotin-ejfv 30mg I(Padcev),9100469,CDM,636,RC,J9177,HCPCS,,,facility,inpatient,,,22939.90000,6652.57000,Aetna,Local,,9175.96,,,,,,,8269.83,18764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
enfortumab vedotin-ejfv 20mg I(Padcev),9098881,CDM,636,RC,J9177,HCPCS,,,facility,inpatient,,,15355.60000,4453.12000,Aetna,Local,,6142.24,,,,,,,5535.69,12560.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
atezolizumab 840mg/14mL Inj(Tecentriq),9101837,CDM,636,RC,J9022,HCPCS,,,facility,inpatient,,,47444.65000,13758.95000,Aetna,Local,,18977.86,,,,,,,17103.80,38809.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Panitumumab 400mg/20mL I(Vectibix),9104162,CDM,636,RC,J9303,HCPCS,,,facility,inpatient,,,39318.65000,11402.41000,Aetna,Local,,15727.46,,,,,,,14174.37,32162.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PHENobarbital 130mg/1mL  Inj,8724035,CDM,636,RC,J2560,HCPCS,,,facility,inpatient,,,513.70000,148.97000,Aetna,Local,,205.48,,,,,,,185.19,420.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
tocilizumab- Pt Own Supply,9104640,CDM,636,RC,J3262,HCPCS,,,facility,inpatient,,,0.12000,0.03000,Aetna,Local,,0.04800,,,,,,,0.04326,0.09816,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hemin 350mg Inj,9110073,CDM,636,RC,J1640,HCPCS,,,facility,inpatient,,,78958.55000,22897.98000,Aetna,Local,,31583.42,,,,,,,28464.56,64588.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
risankizumab-rzaa- Pt Own Supply,9120431,CDM,636,RC,J2327,HCPCS,,,facility,inpatient,,,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
romiPLOStim 125mcg I - Pt Own Supply,9120516,CDM,636,RC,J2802,HCPCS,,,facility,inpatient,,,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
pertuz/trastuz/hyal 10mL I-Maint. Dose,9124637,CDM,636,RC,J9316,HCPCS,,,facility,inpatient,,,66983.75000,19425.29000,Aetna,Local,,26793.50,,,,,,,24147.64,54792.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
donanemab - azbt 350mg I,9142540,CDM,636,RC,J0175,HCPCS,,,facility,inpatient,,,5242.69000,1520.38000,Aetna,Local,,2097.08,,,,,,,1889.99,4288.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
guselkumab 200mg I - Pt Own Supply,9142543,CDM,636,RC,J1628,HCPCS,,,facility,inpatient,,,0.20000,0.06000,Aetna,Local,,0.08000,,,,,,,0.07210,0.16360,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dalbavancin 500mg I - Pt Own Supply,9160458,CDM,636,RC,J0875,HCPCS,,,facility,inpatient,,,0.03000,0.01000,Aetna,Local,,0.01200,,,,,,,0.01081,0.02454,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tremelimumab- actl- Pt Own Supply,9160457,CDM,636,RC,J9347,HCPCS,,,facility,inpatient,,,0.15000,0.04000,Aetna,Local,,0.06000,,,,,,,0.05407,0.12270,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 200mg/1.14mL Inj,9176537,CDM,636,RC,C9399,HCPCS,,,facility,inpatient,,,8144.80000,2361.99000,Aetna,Local,,3257.92,,,,,,,2936.20,6662.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 200mg/1.14mL Inj,9176537,CDM,636,RC,C9399,HCPCS,,,facility,outpatient,,,8144.80000,2361.99000,Aetna,Local,,3257.92,,,,,,,2936.20,6662.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLItaxel PROTein-bound 100mg - Pt Own Supply,9182618,CDM,636,RC,J9264,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bortezomib 3.5mg Inj- Pt Own Supply,9184441,CDM,636,RC,J9041,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,Local,,30.00,,,,,,,27.04,61.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cemiplimab-rwlc 350mg/7mL I - Pt Own Supply,9184513,CDM,636,RC,J9119,HCPCS,,,facility,inpatient,,,25.09000,7.28000,Aetna,Local,,10.04,,,,,,,9.04,20.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atezolizumab 1200 mg- Pt Own Supply(Tecentriq),9208476,CDM,636,RC,J9022,HCPCS,,,facility,inpatient,,,0.20000,0.06000,Aetna,Local,,0.08000,,,,,,,0.07210,0.16360,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Elotuzumab 300mg-Pt Own Supply,9212500,CDM,636,RC,J9176,HCPCS,,,facility,inpatient,,,0.02000,0.01000,Aetna,Local,,0.00800,,,,,,,0.00721,0.01636,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Iron Sucrose 200mg/NS,9210781,CDM,636,RC,J1756,HCPCS,,,facility,inpatient,,,968.30000,280.81000,Aetna,Local,,387.32,,,,,,,349.07,792.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Iron Sucrose 300mg/NS,9216514,CDM,636,RC,J1756,HCPCS,,,facility,inpatient,,,1413.55000,409.93000,Aetna,Local,,565.42,,,,,,,509.58,1156.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DENOSUMAB-BBDZ 60MG/1ML(JUBBONTI),9218509,CDM,636,RC,Q5136,HCPCS,,,facility,inpatient,,,6580.90000,1908.46000,Aetna,Local,,2632.36,,,,,,,2372.41,5383.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DENOSUMAB-BBDZ 60MG/1ML(JUBBONTI),9218509,CDM,636,RC,Q5136,HCPCS,,,facility,outpatient,,,6580.90000,1908.46000,Aetna,Local,,2632.36,,,,,,,27.19,5383.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEVACIZUMAB - BVZR 400MG INJ,9220617,CDM,636,RC,Q5118,HCPCS,,,facility,inpatient,,,13436.45000,3896.57000,Aetna,Local,,5374.58,,,,,,,4843.84,10991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEVACIZUMAB - BVZR 400MG INJ,9220617,CDM,636,RC,Q5118,HCPCS,,,facility,outpatient,,,13436.45000,3896.57000,Aetna,Local,,5374.58,,,,,,,24.85,10991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEVACIZUMAB - BVZR 100MG INJ,9220616,CDM,636,RC,Q5118,HCPCS,,,facility,inpatient,,,3499.40000,1014.83000,Aetna,Local,,1399.76,,,,,,,1261.53,2862.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BEVACIZUMAB - BVZR 100MG INJ,9220616,CDM,636,RC,Q5118,HCPCS,,,facility,outpatient,,,3499.40000,1014.83000,Aetna,Local,,1399.76,,,,,,,24.85,2862.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DENOSUMAB-BMWO 60MG/1ML(STOBOCLO),9226539,CDM,636,RC,Q5157,HCPCS,,,facility,inpatient,,,7288.15000,2113.56000,Aetna,Local,,2915.26,,,,,,,2627.38,5961.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DENOSUMAB-BMWO 60MG/1ML(STOBOCLO),9226539,CDM,636,RC,Q5157,HCPCS,,,facility,outpatient,,,7288.15000,2113.56000,Aetna,Local,,2915.26,,,,,,,28.13,5961.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEFAZOLIN 3G INJ (ANCEF),9230530,CDM,636,RC,J0690,HCPCS,,,facility,inpatient,,,84.25000,24.43000,Aetna,Local,,33.70,,,,,,,30.37,68.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IFOSFAMIDE 1G INJ (IFEX),8724327,CDM,636,RC,J9208,HCPCS,,,facility,inpatient,,,525.65000,152.44000,Aetna,Local,,210.26,,,,,,,189.50,429.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),8723629,CDM,636,RC,J1450,HCPCS,,,facility,inpatient,,,67.70000,19.63000,Aetna,Local,,27.08,,,,,,,24.41,55.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diphenhydrAMINE 50mg/mL Inj,8723853,CDM,636,RC,J1200,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),8724123,CDM,636,RC,J1110,HCPCS,,,facility,inpatient,,,775.35000,224.85000,Aetna,Local,,310.14,,,,,,,279.51,634.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 10mg/1mL PF Inj,8725868,CDM,636,RC,J2274,HCPCS,,,facility,inpatient,,,35.00000,10.15000,Aetna,Local,,14.00,,,,,,,12.62,28.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Succinylcholine HCl 20mg/mL 10mL I,8723402,CDM,636,RC,J0330,HCPCS,,,facility,inpatient,,,127.55000,36.99000,Aetna,Local,,51.02,,,,,,,45.98,104.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 3,000units/mL PF Inj",8725942,CDM,636,RC,Q5106,HCPCS,,,facility,inpatient,,,213.30000,61.86000,Aetna,Local,,85.32,,,,,,,76.89,174.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 3,000units/mL PF Inj",8725942,CDM,636,RC,Q5106,HCPCS,,,facility,outpatient,,,213.30000,61.86000,Aetna,Local,,85.32,,,,,,,7.29,174.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 4,000units/mL PF Inj",8725943,CDM,636,RC,Q5106,HCPCS,,,facility,inpatient,,,274.40000,79.58000,Aetna,Local,,109.76,,,,,,,98.92,224.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 4,000units/mL PF Inj",8725943,CDM,636,RC,Q5106,HCPCS,,,facility,outpatient,,,274.40000,79.58000,Aetna,Local,,109.76,,,,,,,7.29,224.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 10,000units/mL PF Inj",8725944,CDM,636,RC,Q5106,HCPCS,,,facility,inpatient,,,646.93000,187.61000,Aetna,Local,,258.77,,,,,,,233.22,529.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 10,000units/mL PF Inj",8725944,CDM,636,RC,Q5106,HCPCS,,,facility,outpatient,,,646.93000,187.61000,Aetna,Local,,258.77,,,,,,,7.29,529.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 40,000units/mL PF Inj",8725945,CDM,636,RC,Q5106,HCPCS,,,facility,inpatient,,,1947.75000,564.85000,Aetna,Local,,779.10,,,,,,,702.16,1593.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 40,000units/mL PF Inj",8725945,CDM,636,RC,Q5106,HCPCS,,,facility,outpatient,,,1947.75000,564.85000,Aetna,Local,,779.10,,,,,,,7.29,1593.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nivolumab 40mg/4mL I(Opdivo),8725946,CDM,636,RC,J9299,HCPCS,,,facility,inpatient,,,7335.80000,2127.38000,Aetna,Local,,2934.32,,,,,,,2644.56,6000.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mepolizumab 100mg/1mL IS (Nucala),8725948,CDM,636,RC,J2182,HCPCS,,,facility,inpatient,,,15327.20000,4444.89000,Aetna,Local,,6130.88,,,,,,,5525.46,12537.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Levonorgestrel 52mg IUD(Mirena),8725956,CDM,636,RC,J7298,HCPCS,,,facility,inpatient,,,7689.45000,2229.94000,Aetna,Local,,3075.78,,,,,,,2772.05,6289.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mepolizumab Syringe- Pt Own Supply,9013953,CDM,636,RC,J2182,HCPCS,,,facility,inpatient,,,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone 1mg Tab UD,8726003,CDM,636,RC,J8540,HCPCS,,,facility,inpatient,,,10.00000,2.90000,Aetna,Local,,4.00,,,,,,,3.60,8.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Insulin(R) 100unit/100mL NS,8726015,CDM,636,RC,J1815,HCPCS,,,facility,inpatient,,,351.00000,101.79000,Aetna,Local,,140.40,,,,,,,126.54,287.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 1.5% 6000mL,8725976,CDM,636,RC,A4726,HCPCS,,,facility,inpatient,,,415.75000,120.57000,Aetna,Local,,166.30,,,,,,,149.88,340.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 1.5% 6000mL,8725976,CDM,636,RC,A4726,HCPCS,,,facility,outpatient,,,415.75000,120.57000,Aetna,Local,,166.30,,,,,,,149.88,340.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 2.5% 6000mL,8725977,CDM,636,RC,A4726,HCPCS,,,facility,inpatient,,,423.85000,122.92000,Aetna,Local,,169.54,,,,,,,152.80,346.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 2.5% 6000mL,8725977,CDM,636,RC,A4726,HCPCS,,,facility,outpatient,,,423.85000,122.92000,Aetna,Local,,169.54,,,,,,,152.80,346.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 4.25% 6000mL,8725978,CDM,636,RC,A4726,HCPCS,,,facility,inpatient,,,434.65000,126.05000,Aetna,Local,,173.86,,,,,,,156.69,355.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 4.25% 6000mL,8725978,CDM,636,RC,A4726,HCPCS,,,facility,outpatient,,,434.65000,126.05000,Aetna,Local,,173.86,,,,,,,156.69,355.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Remdesivir 100mg Inj,8726025,CDM,636,RC,J0248,HCPCS,,,facility,inpatient,,,4757.95000,1379.81000,Aetna,Local,,1903.18,,,,,,,1715.24,3892.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Minocycline HCl 100mg Inj,8726028,CDM,636,RC,J2265,HCPCS,,,facility,inpatient,,,2048.20000,593.98000,Aetna,Local,,819.28,,,,,,,738.38,1675.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
eptinezumab - jjmr 100mg Inj,8726031,CDM,636,RC,J3032,HCPCS,,,facility,inpatient,,,10951.00000,3175.79000,Aetna,Local,,4380.40,,,,,,,3947.84,8957.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
atezolizumab 1200 mg/20 mL Inj (Tecentriq),8726040,CDM,636,RC,J9022,HCPCS,,,facility,inpatient,,,60946.80000,17674.57000,Aetna,Local,,24378.72,,,,,,,21971.32,49854.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
eptinezumab-jjmr 100mg Inj - Pt Own Supply,8726041,CDM,636,RC,J3032,HCPCS,,,facility,inpatient,,,0.02000,0.01000,Aetna,Local,,0.00800,,,,,,,0.00721,0.01636,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,8726046,CDM,636,RC,J1953,HCPCS,,,facility,inpatient,,,306.22000,88.80000,Aetna,Local,,122.49,,,,,,,110.39,250.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etonogestrel 68 mg Implant,8726048,CDM,636,RC,J7307,HCPCS,,,facility,inpatient,,,6567.80000,1904.66000,Aetna,Local,,2627.12,,,,,,,2367.69,5372.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Romosozumab-aqqg 105mg Inj Syr (Evenity),8726059,CDM,636,RC,J3111,HCPCS,,,facility,inpatient,,,5350.83000,1551.74000,Aetna,Local,,2140.33,,,,,,,1928.97,4376.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab - pvvr 500mg/50mL Inj,8726072,CDM,636,RC,Q5119,HCPCS,,,facility,inpatient,,,25991.80000,7537.62000,Aetna,Local,,10396.72,,,,,,,9370.04,21261.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab - pvvr 500mg/50mL Inj,8726072,CDM,636,RC,Q5119,HCPCS,,,facility,outpatient,,,25991.80000,7537.62000,Aetna,Local,,10396.72,,,,,,,12.78,21261.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab - pvvr 100mg/10mL Inj,8726071,CDM,636,RC,Q5119,HCPCS,,,facility,inpatient,,,5348.00000,1550.92000,Aetna,Local,,2139.20,,,,,,,1927.95,4374.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab - pvvr 100mg/10mL Inj,8726071,CDM,636,RC,Q5119,HCPCS,,,facility,outpatient,,,5348.00000,1550.92000,Aetna,Local,,2139.20,,,,,,,12.78,4374.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 20,000 units/mL Inj",8726083,CDM,636,RC,Q5106,HCPCS,,,facility,inpatient,,,1656.87000,480.49000,Aetna,Local,,662.75,,,,,,,597.30,1355.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 20,000 units/mL Inj",8726083,CDM,636,RC,Q5106,HCPCS,,,facility,outpatient,,,1656.87000,480.49000,Aetna,Local,,662.75,,,,,,,7.29,1355.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Immune Globulin 5g/50mL I,8726085,CDM,636,RC,J1569,HCPCS,,,facility,inpatient,,,6600.53000,1914.15000,Aetna,Local,,2640.21,,,,,,,2379.49,5399.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Immune Globulin 10g/100mL I,8724540,CDM,636,RC,J1569,HCPCS,,,facility,inpatient,,,12758.95000,3700.10000,Aetna,Local,,5103.58,,,,,,,4599.60,10436.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Immune Globulin 30g/300mL I,8726086,CDM,636,RC,J1569,HCPCS,,,facility,inpatient,,,37902.80000,10991.81000,Aetna,Local,,15161.12,,,,,,,13663.96,31004.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Doxercalciferol 4mcg/2mL Inj,8726087,CDM,636,RC,J1270,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gentamicin Sulf 80mg/NS 100mL,8723634,CDM,636,RC,J1580,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,Local,,20.00,,,,,,,18.02,40.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,8723688,CDM,636,RC,P9045,HCPCS,,,facility,inpatient,,,937.27000,271.81000,Aetna,Local,,374.91,,,,,,,337.89,766.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitroglycerin 25mg/D5W 250mL,8723709,CDM,636,RC,J2305,HCPCS,,,facility,inpatient,,,209.00000,60.61000,Aetna,Local,,83.60,,,,,,,75.34,170.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",8723545,CDM,636,RC,J2004,HCPCS,,,facility,inpatient,,,98.20000,28.48000,Aetna,Local,,39.28,,,,,,,35.40,80.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin Flush 1,000 unit/NS500",8723713,CDM,636,RC,J1644,HCPCS,,,facility,inpatient,,,100.00000,29.00000,Aetna,Local,,40.00,,,,,,,36.05,81.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,8723412,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,37.73000,10.94000,Aetna,Local,,15.09,,,,,,,13.60,30.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50 mg/5mL I - 15mL,8724336,CDM,636,RC,J9045,HCPCS,,,facility,inpatient,,,75.00000,21.75000,Aetna,Local,,30.00,,,,,,,27.04,61.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/50mL PB,8723592,CDM,636,RC,J0736,HCPCS,,,facility,inpatient,,,112.45000,32.61000,Aetna,Local,,44.98,,,,,,,40.54,91.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 900mg/ 50mL PB,8723593,CDM,636,RC,J0736,HCPCS,,,facility,inpatient,,,133.15000,38.61000,Aetna,Local,,53.26,,,,,,,48.00,108.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUMETANIDE MDV I - IV ROOM USE,8723568,CDM,636,RC,J1939,HCPCS,,,facility,inpatient,,,2.37000,0.69000,Aetna,Local,,0.94800,,,,,,,0.85438,1.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,8723581,CDM,636,RC,J2003,HCPCS,,,facility,inpatient,,,26.75000,7.76000,Aetna,Local,,10.70,,,,,,,9.64,21.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diazePAM 5mg/mL 2mL I(Valium),8724130,CDM,636,RC,J3360,HCPCS,,,facility,inpatient,,,286.67000,83.13000,Aetna,Local,,114.67,,,,,,,103.34,234.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),8725053,CDM,636,RC,J1885,HCPCS,,,facility,inpatient,,,25.00000,7.25000,Aetna,Local,,10.00,,,,,,,9.01,20.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 40mg/mL I(DEPO-Medrol,8723832,CDM,636,RC,J1010,HCPCS,,,facility,inpatient,,,68.66000,19.91000,Aetna,Local,,27.46,,,,,,,24.75,56.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 100mg/10mL I(Brevibloc),8723437,CDM,636,RC,J1805,HCPCS,,,facility,inpatient,,,46.55000,13.50000,Aetna,Local,,18.62,,,,,,,16.78,38.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RITUXIMAB 100MG/10ML I,8723450,CDM,636,RC,J9312,HCPCS,,,facility,inpatient,,,6951.55000,2015.95000,Aetna,Local,,2780.62,,,,,,,2506.03,5686.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RiTUXimab 500mg/50mL I,8723602,CDM,636,RC,J9312,HCPCS,,,facility,inpatient,,,34009.75000,9862.83000,Aetna,Local,,13603.90,,,,,,,12260.51,27819.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 25% 50mL I,8723603,CDM,636,RC,P9047,HCPCS,,,facility,inpatient,,,527.80000,153.06000,Aetna,Local,,211.12,,,,,,,190.27,431.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 80mg/mL I(DEPO-Medrol),8723833,CDM,636,RC,J1010,HCPCS,,,facility,inpatient,,,113.05000,32.78000,Aetna,Local,,45.22,,,,,,,40.75,92.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tenecteplase 50mg Inj,9002120,CDM,636,RC,J3101,HCPCS,,,facility,inpatient,,,33246.30000,9641.43000,Aetna,Local,,13298.52,,,,,,,11985.29,27195.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haemophilus B Conj (PRP-T) Vac I,8724246,CDM,636,RC,90648,HCPCS,,,facility,inpatient,,,84.05000,24.37000,Aetna,Local,,33.62,,,,,,,30.30,68.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haemophilus B Conj (PRP-T) Vac I,8724246,CDM,636,RC,90648,HCPCS,,,facility,outpatient,,,84.05000,24.37000,Aetna,Local,,33.62,,,,,,,14.65,68.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxaliplatin 100mg/20mL I,8724448,CDM,636,RC,J9263,HCPCS,,,facility,inpatient,,,2733.30000,792.66000,Aetna,Local,,1093.32,,,,,,,985.35,2235.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,8724203,CDM,636,RC,J1956,HCPCS,,,facility,inpatient,,,52.17000,15.13000,Aetna,Local,,20.87,,,,,,,18.81,42.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus-Diphtheria Toxoids 0.5mL IS,8724243,CDM,636,RC,90714,HCPCS,,,facility,inpatient,,,246.17000,71.39000,Aetna,Local,,98.47,,,,,,,88.74,201.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus-Diphtheria Toxoids 0.5mL IS,8724243,CDM,636,RC,90714,HCPCS,,,facility,outpatient,,,246.17000,71.39000,Aetna,Local,,98.47,,,,,,,37.53,201.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OLANZapine 10mg Inj (ZyPREXA),8724743,CDM,636,RC,J2359,HCPCS,,,facility,inpatient,,,218.66000,63.41000,Aetna,Local,,87.46,,,,,,,78.83,178.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),8724773,CDM,636,RC,90700,HCPCS,,,facility,inpatient,,,185.15000,53.69000,Aetna,Local,,74.06,,,,,,,66.75,151.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),8724773,CDM,636,RC,90700,HCPCS,,,facility,outpatient,,,185.15000,53.69000,Aetna,Local,,74.06,,,,,,,32.84,151.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Octreotide 20mg I Kit (SandoSTATIN LAR),8724780,CDM,636,RC,J2353,HCPCS,,,facility,inpatient,,,18581.35000,5388.59000,Aetna,Local,,7432.54,,,,,,,6698.58,15199.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydroxocobalamin 5g Kit,8725860,CDM,636,RC,J3424,HCPCS,,,facility,inpatient,,,4863.10000,1410.30000,Aetna,Local,,1945.24,,,,,,,1753.15,3978.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Erythromycin Lact.500mg I,8724886,CDM,636,RC,J1364,HCPCS,,,facility,inpatient,,,1474.00000,427.46000,Aetna,Local,,589.60,,,,,,,531.38,1205.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Goserelin 3.6mg Impl,8724925,CDM,636,RC,J9202,HCPCS,,,facility,inpatient,,,2889.45000,837.94000,Aetna,Local,,1155.78,,,,,,,1041.65,2363.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Gentamicin Sulf 5mg/mL IV,8724934,CDM,636,RC,J1580,HCPCS,,,facility,inpatient,,,50.00000,14.50000,Aetna,Local,,20.00,,,,,,,18.02,40.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Vancomycin 5mg/mL IV,8724940,CDM,636,RC,J3373,HCPCS,,,facility,inpatient,,,138.95000,40.30000,Aetna,Local,,55.58,,,,,,,50.09,113.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Ampicillin 500mg/2mL IM,8724939,CDM,636,RC,J0290,HCPCS,,,facility,inpatient,,,53.20000,15.43000,Aetna,Local,,21.28,,,,,,,19.18,43.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NICU- Penicillin GK 50,000 unit/mL IV",8724943,CDM,636,RC,J2540,HCPCS,,,facility,inpatient,,,30.00000,8.70000,Aetna,Local,,12.00,,,,,,,10.81,24.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Azithromycin 500mg/NS 250mL P,8725030,CDM,636,RC,J0456,HCPCS,,,facility,inpatient,,,177.50000,51.47000,Aetna,Local,,71.00,,,,,,,63.99,145.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 100mcg/mL NS Syr 10mL,8725037,CDM,636,RC,J2371,HCPCS,,,facility,inpatient,,,25.57000,7.42000,Aetna,Local,,10.23,,,,,,,9.22,20.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 240mg/mL Inj 20mL,8724317,CDM,636,RC,Q9966,HCPCS,,,facility,inpatient,,,279.55000,81.07000,Aetna,Local,,111.82,,,,,,,100.78,228.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
niCARdipine 25mg/10mL I,8724338,CDM,636,RC,J2404,HCPCS,,,facility,inpatient,,,213.92000,62.04000,Aetna,Local,,85.57,,,,,,,77.12,174.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,8725282,CDM,636,RC,90715,HCPCS,,,facility,inpatient,,,293.70000,85.17000,Aetna,Local,,117.48,,,,,,,105.88,240.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,8725282,CDM,636,RC,90715,HCPCS,,,facility,outpatient,,,293.70000,85.17000,Aetna,Local,,117.48,,,,,,,38.22,240.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 2.5g/250mL P(Brevibloc),8724436,CDM,636,RC,J1805,HCPCS,,,facility,inpatient,,,2058.68000,597.02000,Aetna,Local,,823.47,,,,,,,742.15,1684.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 7.5 mg/0.6 mL I,8724443,CDM,636,RC,J1652,HCPCS,,,facility,inpatient,,,591.17000,171.44000,Aetna,Local,,236.47,,,,,,,213.12,483.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FONDAPARINUX 10 MG/0.8 ML I,8724444,CDM,636,RC,J1652,HCPCS,,,facility,inpatient,,,417.50000,121.07000,Aetna,Local,,167.00,,,,,,,150.51,341.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrALAZINE 10mg T(Apresoline),8723955,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),8723953,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),8723954,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),8723958,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),8724802,CDM,637,RC,,,,,facility,outpatient,,,117.61000,34.11000,Aetna,Local,,59.71,,,,,,,42.40,96.20,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),8724801,CDM,637,RC,,,,,facility,outpatient,,,139.75000,40.53000,Aetna,Local,,70.95,,,,,,,50.38,114.32,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),8724796,CDM,637,RC,,,,,facility,outpatient,,,126.87000,36.79000,Aetna,Local,,64.41,,,,,,,45.74,103.78,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),8723957,CDM,637,RC,,,,,facility,outpatient,,,30.70000,8.90000,Aetna,Local,,15.59,,,,,,,11.07,25.11,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",8724321,CDM,637,RC,,,,,facility,outpatient,,,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,5.05,11.45,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),8724045,CDM,637,RC,,,,,facility,outpatient,,,16.58000,4.81000,Aetna,Local,,8.42,,,,,,,5.98,13.56,percent of total billed charges,
Haloperidol 1mg T(Haldol),8724041,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,8723778,CDM,637,RC,,,,,facility,outpatient,,,544.85000,158.01000,Aetna,Local,,276.62,,,,,,,196.42,445.69,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,8725554,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Haloperidol 1mg/0.5mL LC UD,8725145,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Haloperidol 0.5mg/0.25mL LC UD,8725146,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Magic Mouthwash 5mL  L UD,8725147,CDM,637,RC,,,,,facility,outpatient,,,22.45000,6.51000,Aetna,Local,,11.40,,,,,,,8.09,18.36,percent of total billed charges,
Magic Mouthwash 15mL L UD,8725148,CDM,637,RC,,,,,facility,outpatient,,,67.25000,19.50000,Aetna,Local,,34.14,,,,,,,24.24,55.01,percent of total billed charges,
Potassium Cl 10mEq/7.5 mL L UD,8725152,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),8725154,CDM,637,RC,,,,,facility,outpatient,,,174.43000,50.58000,Aetna,Local,,88.56,,,,,,,62.88,142.68,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,8725165,CDM,637,RC,,,,,facility,outpatient,,,48.35000,14.02000,Aetna,Local,,24.55,,,,,,,17.43,39.55,percent of total billed charges,
oxyBUTYnin 5mg/5mL L UD,8725164,CDM,637,RC,,,,,facility,outpatient,,,18.45000,5.35000,Aetna,Local,,9.37,,,,,,,6.65,15.09,percent of total billed charges,
Valproic Acid 250 mg/5 mL Liq UD,8725163,CDM,637,RC,,,,,facility,outpatient,,,219.67000,63.70000,Aetna,Local,,111.53,,,,,,,79.19,179.69,percent of total billed charges,
Ticagrelor 90mg T,8725174,CDM,637,RC,,,,,facility,outpatient,,,65.85000,19.10000,Aetna,Local,,33.43,,,,,,,23.74,53.87,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,8725178,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,8725177,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Furosemide 40mg T(Lasix),8724012,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,8725172,CDM,637,RC,,,,,facility,outpatient,,,30.86000,8.95000,Aetna,Local,,15.67,,,,,,,11.13,25.24,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,8725171,CDM,637,RC,,,,,facility,outpatient,,,25.75000,7.47000,Aetna,Local,,13.07,,,,,,,9.28,21.06,percent of total billed charges,
Diphenoxylate - Atrop 5mL UD Oral Liq,8725170,CDM,637,RC,,,,,facility,outpatient,,,56.00000,16.24000,Aetna,Local,,28.43,,,,,,,20.19,45.81,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,8725169,CDM,637,RC,,,,,facility,outpatient,,,14.75000,4.28000,Aetna,Local,,7.49,,,,,,,5.32,12.07,percent of total billed charges,
Tolvaptan 15mg T (Samsca),8725227,CDM,637,RC,,,,,facility,outpatient,,,2963.62000,859.45000,Aetna,Local,,1504.63,,,,,,,1068.39,2424.24,percent of total billed charges,
Benzocaine 20% Top Spray 0.5mL UD,8725180,CDM,637,RC,,,,,facility,outpatient,,,38.10000,11.05000,Aetna,Local,,19.34,,,,,,,13.74,31.17,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),8725190,CDM,637,RC,,,,,facility,outpatient,,,161.35000,46.79000,Aetna,Local,,81.92,,,,,,,58.17,131.98,percent of total billed charges,
Losartan 100mg T (Cozaar),8725197,CDM,637,RC,,,,,facility,outpatient,,,10.12000,2.93000,Aetna,Local,,5.14,,,,,,,3.65,8.28,percent of total billed charges,
NICU- Ferrous Sulfate 2.25mg/0.15mL L UD,8725200,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
NICU- Ferrous Sulfate 3.75mg/0.25mL L UD,8725201,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),8725205,CDM,637,RC,,,,,facility,outpatient,,,11.86000,3.44000,Aetna,Local,,6.02,,,,,,,4.28,9.70,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),8725206,CDM,637,RC,,,,,facility,outpatient,,,52.63000,15.26000,Aetna,Local,,26.72,,,,,,,18.97,43.05,percent of total billed charges,
Cetirizine 5 mg Tab,8725207,CDM,637,RC,,,,,facility,outpatient,,,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),8725216,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),8725215,CDM,637,RC,,,,,facility,outpatient,,,10.85000,3.15000,Aetna,Local,,5.51,,,,,,,3.91,8.88,percent of total billed charges,
Escitalopram 5mg T(Lexapro),8725221,CDM,637,RC,,,,,facility,outpatient,,,29.40000,8.53000,Aetna,Local,,14.93,,,,,,,10.60,24.05,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,8725214,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),8725220,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),8725219,CDM,637,RC,,,,,facility,outpatient,,,24.10000,6.99000,Aetna,Local,,12.24,,,,,,,8.69,19.71,percent of total billed charges,
Modafinil 100mg T(Provigil),8725209,CDM,637,RC,,,,,facility,outpatient,,,112.22000,32.54000,Aetna,Local,,56.97,,,,,,,40.46,91.80,percent of total billed charges,
Sertraline HCl 25mg T,8725211,CDM,637,RC,,,,,facility,outpatient,,,10.24000,2.97000,Aetna,Local,,5.20,,,,,,,3.69,8.38,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,8725213,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),8725231,CDM,637,RC,,,,,facility,outpatient,,,88.19000,25.58000,Aetna,Local,,44.77,,,,,,,31.79,72.14,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),8725237,CDM,637,RC,,,,,facility,outpatient,,,161.35000,46.79000,Aetna,Local,,81.92,,,,,,,58.17,131.98,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,8725240,CDM,637,RC,,,,,facility,outpatient,,,1531.90000,444.25000,Aetna,Local,,777.75,,,,,,,552.25,1253.09,percent of total billed charges,
Fluticasone Prop 250mcg/INH Diskus,8725241,CDM,637,RC,,,,,facility,outpatient,,,1858.45000,538.95000,Aetna,Local,,943.54,,,,,,,669.97,1520.21,percent of total billed charges,
Morphine 5mg/1.25 mL Oral Liq,8725247,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Cetirizine 5mg/5mL L UD,8725139,CDM,637,RC,,,,,facility,outpatient,,,17.51000,5.08000,Aetna,Local,,8.89,,,,,,,6.31,14.32,percent of total billed charges,
SITagliptin 50 mg T(Januvia),8724507,CDM,637,RC,,,,,facility,outpatient,,,93.50000,27.12000,Aetna,Local,,47.47,,,,,,,33.71,76.48,percent of total billed charges,
Desmopressin 0.1 mg Tab,8724514,CDM,637,RC,,,,,facility,outpatient,,,37.45000,10.86000,Aetna,Local,,19.01,,,,,,,13.50,30.63,percent of total billed charges,
Cilostazol 100 mg Tab,8724522,CDM,637,RC,,,,,facility,outpatient,,,15.89000,4.61000,Aetna,Local,,8.07,,,,,,,5.73,13.00,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),8724530,CDM,637,RC,,,,,facility,outpatient,,,226.10000,65.57000,Aetna,Local,,114.79,,,,,,,81.51,184.95,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),8724532,CDM,637,RC,,,,,facility,outpatient,,,220.72000,64.01000,Aetna,Local,,112.06,,,,,,,79.57,180.55,percent of total billed charges,
Dipyridamole 25mg T(Persantine),8724031,CDM,637,RC,,,,,facility,outpatient,,,10.10000,2.93000,Aetna,Local,,5.13,,,,,,,3.64,8.26,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,8724538,CDM,637,RC,,,,,facility,outpatient,,,967.25000,280.50000,Aetna,Local,,491.07,,,,,,,348.69,791.21,percent of total billed charges,
Alfuzosin 10 mg ER Tab,8724543,CDM,637,RC,,,,,facility,outpatient,,,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
Aliskiren 150mg T(Tekturna),8724795,CDM,637,RC,,,,,facility,outpatient,,,53.00000,15.37000,Aetna,Local,,26.91,,,,,,,19.11,43.35,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,8724728,CDM,637,RC,,,,,facility,outpatient,,,18.80000,5.45000,Aetna,Local,,9.54,,,,,,,6.78,15.38,percent of total billed charges,
Baclofen 20mg T,8724548,CDM,637,RC,,,,,facility,outpatient,,,16.34000,4.74000,Aetna,Local,,8.30,,,,,,,5.89,13.37,percent of total billed charges,
Bisoprolol 5 mg Tab,8724550,CDM,637,RC,,,,,facility,outpatient,,,15.42000,4.47000,Aetna,Local,,7.83,,,,,,,5.56,12.61,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,8724552,CDM,637,RC,,,,,facility,outpatient,,,176.00000,51.04000,Aetna,Local,,89.36,,,,,,,63.45,143.97,percent of total billed charges,
Minocycline HCl 50mg C,8724555,CDM,637,RC,,,,,facility,outpatient,,,12.05000,3.49000,Aetna,Local,,6.12,,,,,,,4.34,9.86,percent of total billed charges,
Haloperidol 5mg T(Haldol),8724043,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Famciclovir 250 mg T (Famvir),8724571,CDM,637,RC,,,,,facility,outpatient,,,44.80000,12.99000,Aetna,Local,,22.74,,,,,,,16.15,36.65,percent of total billed charges,
Glimepiride 1mg T (Amaryl),8724575,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Hydrocortisone 5mg T,8724788,CDM,637,RC,,,,,facility,outpatient,,,13.66000,3.96000,Aetna,Local,,6.94,,,,,,,4.92,11.17,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),8724582,CDM,637,RC,,,,,facility,outpatient,,,10.10000,2.93000,Aetna,Local,,5.13,,,,,,,3.64,8.26,percent of total billed charges,
Ivermectin 3 mg T(Stomectol),8724584,CDM,637,RC,,,,,facility,outpatient,,,35.20000,10.21000,Aetna,Local,,17.87,,,,,,,12.69,28.79,percent of total billed charges,
Leflunomide 10 mg T(Arava),8724588,CDM,637,RC,,,,,facility,outpatient,,,66.22000,19.20000,Aetna,Local,,33.62,,,,,,,23.87,54.17,percent of total billed charges,
Letrozole 2.5 mg T(Femara),8724589,CDM,637,RC,,,,,facility,outpatient,,,128.30000,37.21000,Aetna,Local,,65.14,,,,,,,46.25,104.95,percent of total billed charges,
Lithium Carb 450mg ER T,8724591,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Lithium Carb 150mg C,8724592,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),8724596,CDM,637,RC,,,,,facility,outpatient,,,53.13000,15.41000,Aetna,Local,,26.97,,,,,,,19.15,43.46,percent of total billed charges,
Meloxicam 7.5 mg T,8724597,CDM,637,RC,,,,,facility,outpatient,,,21.95000,6.37000,Aetna,Local,,11.14,,,,,,,7.91,17.96,percent of total billed charges,
Methenamine Hippurate 1 g T,8724599,CDM,637,RC,,,,,facility,outpatient,,,14.85000,4.31000,Aetna,Local,,7.54,,,,,,,5.35,12.15,percent of total billed charges,
Nitazoxanide 500mg Tab,8724609,CDM,637,RC,,,,,facility,outpatient,,,1011.85000,293.44000,Aetna,Local,,513.72,,,,,,,364.77,827.69,percent of total billed charges,
Norethindrone 5mg T,8724610,CDM,637,RC,,,,,facility,outpatient,,,18.80000,5.45000,Aetna,Local,,9.54,,,,,,,6.78,15.38,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),8724613,CDM,637,RC,,,,,facility,outpatient,,,216.35000,62.74000,Aetna,Local,,109.84,,,,,,,77.99,176.97,percent of total billed charges,
PARoxetine 10mg T(Paxil),8724615,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),8724621,CDM,637,RC,,,,,facility,outpatient,,,20.04000,5.81000,Aetna,Local,,10.17,,,,,,,7.22,16.39,percent of total billed charges,
Potassium  Citrate 10mEq ER T,8724710,CDM,637,RC,,,,,facility,outpatient,,,17.40000,5.05000,Aetna,Local,,8.83,,,,,,,6.27,14.23,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),8724623,CDM,637,RC,,,,,facility,outpatient,,,10.14000,2.94000,Aetna,Local,,5.15,,,,,,,3.66,8.29,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),8724624,CDM,637,RC,,,,,facility,outpatient,,,20.56000,5.96000,Aetna,Local,,10.44,,,,,,,7.41,16.82,percent of total billed charges,
Progesterone 100mg C(Prometrium),8724625,CDM,637,RC,,,,,facility,outpatient,,,16.91000,4.90000,Aetna,Local,,8.59,,,,,,,6.10,13.83,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),8724626,CDM,637,RC,,,,,facility,outpatient,,,70.80000,20.53000,Aetna,Local,,35.95,,,,,,,25.52,57.91,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),8724630,CDM,637,RC,,,,,facility,outpatient,,,176.90000,51.30000,Aetna,Local,,89.81,,,,,,,63.77,144.70,percent of total billed charges,
Riluzole 50mg T(Rilutek),8724637,CDM,637,RC,,,,,facility,outpatient,,,258.10000,74.85000,Aetna,Local,,131.04,,,,,,,93.05,211.13,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),8724640,CDM,637,RC,,,,,facility,outpatient,,,10.10000,2.93000,Aetna,Local,,5.13,,,,,,,3.64,8.26,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),8724641,CDM,637,RC,,,,,facility,outpatient,,,10.77000,3.12000,Aetna,Local,,5.47,,,,,,,3.88,8.81,percent of total billed charges,
Sertraline 100mg T,8724647,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),8724650,CDM,637,RC,,,,,facility,outpatient,,,24.52000,7.11000,Aetna,Local,,12.45,,,,,,,8.84,20.06,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),8724652,CDM,637,RC,,,,,facility,outpatient,,,180.45000,52.33000,Aetna,Local,,91.61,,,,,,,65.05,147.61,percent of total billed charges,
Emtricitabine-Tenofovir 200-300mg T(Truvada),8724655,CDM,637,RC,,,,,facility,outpatient,,,465.65000,135.04000,Aetna,Local,,236.41,,,,,,,167.87,380.90,percent of total billed charges,
Tenofovir 300mg T(Viread),8724658,CDM,637,RC,,,,,facility,outpatient,,,281.70000,81.69000,Aetna,Local,,143.02,,,,,,,101.55,230.43,percent of total billed charges,
Terbinafine 250mg T(LamISIL),8724659,CDM,637,RC,,,,,facility,outpatient,,,92.26000,26.76000,Aetna,Local,,46.84,,,,,,,33.26,75.47,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),8724663,CDM,637,RC,,,,,facility,outpatient,,,20.70000,6.00000,Aetna,Local,,10.51,,,,,,,7.46,16.93,percent of total billed charges,
Torsemide 5mg T,8724664,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),8724668,CDM,637,RC,,,,,facility,outpatient,,,438.23000,127.09000,Aetna,Local,,222.49,,,,,,,157.98,358.47,percent of total billed charges,
Voriconazole 200mg T(VFEND),8724670,CDM,637,RC,,,,,facility,outpatient,,,523.50000,151.82000,Aetna,Local,,265.78,,,,,,,188.72,428.22,percent of total billed charges,
Zonisamide 100mg C,8724672,CDM,637,RC,,,,,facility,outpatient,,,12.23000,3.55000,Aetna,Local,,6.21,,,,,,,4.41,10.00,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,8724678,CDM,637,RC,,,,,facility,outpatient,,,413.90000,120.03000,Aetna,Local,,210.14,,,,,,,149.21,338.57,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,8724680,CDM,637,RC,,,,,facility,outpatient,,,350.70000,101.70000,Aetna,Local,,178.05,,,,,,,126.43,286.87,percent of total billed charges,
Ketoconazole 2% Top Shampoo 120mL,8724696,CDM,637,RC,,,,,facility,outpatient,,,214.05000,62.07000,Aetna,Local,,108.67,,,,,,,77.17,175.09,percent of total billed charges,
Mesalamine 1000mg Supp (Canasa),8724698,CDM,637,RC,,,,,facility,outpatient,,,290.20000,84.16000,Aetna,Local,,147.33,,,,,,,104.62,237.38,percent of total billed charges,
Testosterone 1% TG 2.5G UD,8724705,CDM,637,RC,,,,,facility,outpatient,,,82.70000,23.98000,Aetna,Local,,41.99,,,,,,,29.81,67.65,percent of total billed charges,
Triamcinolone 0.025% TC 80g,8724706,CDM,637,RC,,,,,facility,outpatient,,,78.95000,22.90000,Aetna,Local,,40.08,,,,,,,28.46,64.58,percent of total billed charges,
Triamcinolone 0.1% TC 80g,8724707,CDM,637,RC,,,,,facility,outpatient,,,103.05000,29.88000,Aetna,Local,,52.32,,,,,,,37.15,84.29,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,8724731,CDM,637,RC,,,,,facility,outpatient,,,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
Levalbuterol HFA 45 mcg/inh,8724738,CDM,637,RC,,,,,facility,outpatient,,,488.10000,141.55000,Aetna,Local,,247.81,,,,,,,175.96,399.27,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),8725279,CDM,637,RC,,,,,facility,outpatient,,,36.77000,10.66000,Aetna,Local,,18.67,,,,,,,13.26,30.08,percent of total billed charges,
Fluticasone Prop 50mcg/INH Diskus,8725285,CDM,637,RC,,,,,facility,outpatient,,,1467.30000,425.52000,Aetna,Local,,744.95,,,,,,,528.96,1200.25,percent of total billed charges,
"NICU- Nystatin 100,000unit/1mL L",8725290,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Apixaban 2.5mg Tab (Eliquis),8725299,CDM,637,RC,,,,,facility,outpatient,,,85.90000,24.91000,Aetna,Local,,43.61,,,,,,,30.97,70.27,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),8725300,CDM,637,RC,,,,,facility,outpatient,,,85.90000,24.91000,Aetna,Local,,43.61,,,,,,,30.97,70.27,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),8725302,CDM,637,RC,,,,,facility,outpatient,,,161.35000,46.79000,Aetna,Local,,81.92,,,,,,,58.17,131.98,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,8725305,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Lurasidone 40mg T(Latuda),8725348,CDM,637,RC,,,,,facility,outpatient,,,317.62000,92.11000,Aetna,Local,,161.26,,,,,,,114.50,259.81,percent of total billed charges,
Gabapentin 300mg/6mL Oral Liq UD,8725337,CDM,637,RC,,,,,facility,outpatient,,,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Naltrexone 50mg Tab,8725342,CDM,637,RC,,,,,facility,outpatient,,,17.88000,5.19000,Aetna,Local,,9.08,,,,,,,6.45,14.63,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,8725377,CDM,637,RC,,,,,facility,outpatient,,,90.35000,26.20000,Aetna,Local,,45.87,,,,,,,32.57,73.91,percent of total billed charges,
Mineral Oil 100% Enema,8725368,CDM,637,RC,,,,,facility,outpatient,,,18.55000,5.38000,Aetna,Local,,9.42,,,,,,,6.69,15.17,percent of total billed charges,
Cholestyramine 4g Lt Pkt,8725963,CDM,637,RC,,,,,facility,outpatient,,,23.75000,6.89000,Aetna,Local,,12.06,,,,,,,8.56,19.43,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",8723759,CDM,637,RC,,,,,facility,outpatient,,,261.50000,75.83000,Aetna,Local,,132.76,,,,,,,94.27,213.91,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),8723483,CDM,637,RC,,,,,facility,outpatient,,,107.50000,31.17000,Aetna,Local,,54.58,,,,,,,38.75,87.94,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,8724057,CDM,637,RC,,,,,facility,outpatient,,,1042.25000,302.25000,Aetna,Local,,529.15,,,,,,,375.73,852.56,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,8723474,CDM,637,RC,,,,,facility,outpatient,,,639.25000,185.38000,Aetna,Local,,324.55,,,,,,,230.45,522.91,percent of total billed charges,
Levothyroxine Sodium 50mcg T,8724019,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),8723855,CDM,637,RC,,,,,facility,outpatient,,,376.35000,109.14000,Aetna,Local,,191.07,,,,,,,135.67,307.85,percent of total billed charges,
Erythromycin 0.5% 3.5g Ophth Oint,8722117,CDM,637,RC,,,,,facility,outpatient,,,134.55000,39.02000,Aetna,Local,,68.31,,,,,,,48.51,110.06,percent of total billed charges,
Thyroid 30mg T,8724054,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Thyroid 120mg T,8724025,CDM,637,RC,,,,,facility,outpatient,,,14.40000,4.18000,Aetna,Local,,7.31,,,,,,,5.19,11.78,percent of total billed charges,
Fosfomycin 3g Packet,8725719,CDM,637,RC,,,,,facility,outpatient,,,652.93000,189.35000,Aetna,Local,,331.49,,,,,,,235.38,534.10,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,8725732,CDM,637,RC,,,,,facility,outpatient,,,178.89000,51.88000,Aetna,Local,,90.82,,,,,,,64.49,146.33,percent of total billed charges,
Mycophenolate Mofetil 500mg/2.5mL Susp,8725730,CDM,637,RC,,,,,facility,outpatient,,,160.40000,46.52000,Aetna,Local,,81.44,,,,,,,57.82,131.21,percent of total billed charges,
PARoxetine 20mg/10mL Oral Liq.,8725728,CDM,637,RC,,,,,facility,outpatient,,,60.80000,17.63000,Aetna,Local,,30.87,,,,,,,21.92,49.73,percent of total billed charges,
Haloperidol 5mg/2.5mL LC UD,8725724,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Tetracaine HCl 0.5% 4mL Ophth Soln,8725742,CDM,637,RC,,,,,facility,outpatient,,,117.95000,34.21000,Aetna,Local,,59.88,,,,,,,42.52,96.48,percent of total billed charges,
Sulfamethoxazole-Trimethoprim DS 800-160mg T,8725738,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Ferric Subsulfate 8mL TS(Monsel's),8725743,CDM,637,RC,,,,,facility,outpatient,,,99.90000,28.97000,Aetna,Local,,50.72,,,,,,,36.01,81.72,percent of total billed charges,
Patiromer 8.4g REC Packet (Veltassa),8725762,CDM,637,RC,,,,,facility,outpatient,,,386.15000,111.98000,Aetna,Local,,196.05,,,,,,,139.21,315.87,percent of total billed charges,
Mupirocin/Nystatin/Betameth/Antifungal Oint.,8725775,CDM,637,RC,,,,,facility,outpatient,,,603.95000,175.15000,Aetna,Local,,306.63,,,,,,,217.72,494.03,percent of total billed charges,
Ciproflox-Fluoc 0.3-0.025% Otic Soln,8725777,CDM,637,RC,,,,,facility,outpatient,,,164.75000,47.78000,Aetna,Local,,83.64,,,,,,,59.39,134.77,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),8723951,CDM,637,RC,,,,,facility,outpatient,,,110.40000,32.02000,Aetna,Local,,56.05,,,,,,,39.80,90.31,percent of total billed charges,
Vortioxetine 10mg Tab,8725797,CDM,637,RC,,,,,facility,outpatient,,,145.65000,42.24000,Aetna,Local,,73.95,,,,,,,52.51,119.14,percent of total billed charges,
Ticagrelor 60mg Tab,8725801,CDM,637,RC,,,,,facility,outpatient,,,65.85000,19.10000,Aetna,Local,,33.43,,,,,,,23.74,53.87,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,8725802,CDM,637,RC,,,,,facility,outpatient,,,35.30000,10.24000,Aetna,Local,,17.92,,,,,,,12.73,28.88,percent of total billed charges,
Sodium Hypochlor 0.125% TS 473mL,8725818,CDM,637,RC,,,,,facility,outpatient,,,131.00000,37.99000,Aetna,Local,,66.51,,,,,,,47.23,107.16,percent of total billed charges,
Mupirocin 2% Top Oint 1g UD,8725819,CDM,637,RC,,,,,facility,outpatient,,,36.30000,10.53000,Aetna,Local,,18.43,,,,,,,13.09,29.69,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,8724143,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
SITagliptin 25 mg T (Januvia),8725370,CDM,637,RC,,,,,facility,outpatient,,,93.50000,27.12000,Aetna,Local,,47.47,,,,,,,33.71,76.48,percent of total billed charges,
Ammonium Lactate 12% Lotion,8725387,CDM,637,RC,,,,,facility,outpatient,,,129.15000,37.45000,Aetna,Local,,65.57,,,,,,,46.56,105.64,percent of total billed charges,
PHENobarbital 40mg/10mL Soln,8725391,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
LORazepam 1mg/0.5mL Oral Conc,8725390,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Gabapentin 100mg/2mL Oral Liq UD,8725388,CDM,637,RC,,,,,facility,outpatient,,,11.80000,3.42000,Aetna,Local,,5.99,,,,,,,4.25,9.65,percent of total billed charges,
Gabapentin 200mg/4mL Oral Liq UD,8725389,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Mirabegron 25mg ER T,8725444,CDM,637,RC,,,,,facility,outpatient,,,117.35000,34.03000,Aetna,Local,,59.58,,,,,,,42.30,95.99,percent of total billed charges,
Linaclotide 145mcg C(Linzess),8725445,CDM,637,RC,,,,,facility,outpatient,,,160.85000,46.65000,Aetna,Local,,81.66,,,,,,,57.99,131.58,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,8725450,CDM,637,RC,,,,,facility,outpatient,,,86.25000,25.01000,Aetna,Local,,43.79,,,,,,,31.09,70.55,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),8725455,CDM,637,RC,,,,,facility,outpatient,,,255.60000,74.12000,Aetna,Local,,129.77,,,,,,,92.14,209.08,percent of total billed charges,
Lurasidone 20 mg T(Latuda),8725458,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Silodosin 4mg Cap,8725508,CDM,637,RC,,,,,facility,outpatient,,,63.55000,18.43000,Aetna,Local,,32.26,,,,,,,22.91,51.98,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),8725510,CDM,637,RC,,,,,facility,outpatient,,,103.55000,30.03000,Aetna,Local,,52.57,,,,,,,37.33,84.70,percent of total billed charges,
Methadone 100mg/10mL Oral Conc,8725513,CDM,637,RC,,,,,facility,outpatient,,,67.60000,19.60000,Aetna,Local,,34.32,,,,,,,24.37,55.30,percent of total billed charges,
Methadone 50mg/5mL Oral Conc,8725514,CDM,637,RC,,,,,facility,outpatient,,,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,47.95,108.79,percent of total billed charges,
GI Cocktail 50mL UD - ED Use,8726033,CDM,637,RC,,,,,facility,outpatient,,,48.15000,13.96000,Aetna,Local,,24.45,,,,,,,17.36,39.39,percent of total billed charges,
Hydrocortisone 2.5%-Pramox 1% Top Oint,8725533,CDM,637,RC,,,,,facility,outpatient,,,1789.25000,518.88000,Aetna,Local,,908.40,,,,,,,645.02,1463.61,percent of total billed charges,
Tapentadol 50mg Tab UD,8725541,CDM,637,RC,,,,,facility,outpatient,,,116.90000,33.90000,Aetna,Local,,59.35,,,,,,,42.14,95.62,percent of total billed charges,
Balsam Peru-Castor Oil Topical Oint,8726101,CDM,637,RC,,,,,facility,outpatient,,,236.85000,68.69000,Aetna,Local,,120.25,,,,,,,85.38,193.74,percent of total billed charges,
Fidaxomicin 200mg T(Dificid),8725559,CDM,637,RC,,,,,facility,outpatient,,,1871.50000,542.74000,Aetna,Local,,950.16,,,,,,,674.68,1530.89,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),8725563,CDM,637,RC,,,,,facility,outpatient,,,58.15000,16.86000,Aetna,Local,,29.52,,,,,,,20.96,47.57,percent of total billed charges,
Ivabradine 5mg Tab,8725567,CDM,637,RC,,,,,facility,outpatient,,,88.72000,25.73000,Aetna,Local,,45.04,,,,,,,31.98,72.57,percent of total billed charges,
Milnacipran 50mg T(Savella),8725571,CDM,637,RC,,,,,facility,outpatient,,,72.50000,21.02000,Aetna,Local,,36.81,,,,,,,26.14,59.30,percent of total billed charges,
Sacubitril-Valsartan 24-26mg Tab,8725575,CDM,637,RC,,,,,facility,outpatient,,,99.22000,28.77000,Aetna,Local,,50.37,,,,,,,35.77,81.16,percent of total billed charges,
Sacubitril-Valsartan 49-51mg Tab,8725576,CDM,637,RC,,,,,facility,outpatient,,,94.62000,27.44000,Aetna,Local,,48.04,,,,,,,34.11,77.40,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,8725577,CDM,637,RC,,,,,facility,outpatient,,,97.91000,28.39000,Aetna,Local,,49.71,,,,,,,35.30,80.09,percent of total billed charges,
HYDROmorphone 5mg/5mL Oral Soln,8725651,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Vilazodone 20mg T(Viibryd),8725667,CDM,637,RC,,,,,facility,outpatient,,,78.01000,22.62000,Aetna,Local,,39.61,,,,,,,28.12,63.81,percent of total billed charges,
miSOPROStol 25mcg/0.25 Tab,8725665,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
NICU- Morphine 0.4mg/mLOral Liq,8725710,CDM,637,RC,,,,,facility,outpatient,,,39.60000,11.48000,Aetna,Local,,20.10,,,,,,,14.28,32.39,percent of total billed charges,
Cholestyramine 5g/ZincOxide 20% TP,8725705,CDM,637,RC,,,,,facility,outpatient,,,77.35000,22.43000,Aetna,Local,,39.27,,,,,,,27.88,63.27,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,8723462,CDM,637,RC,,,,,facility,outpatient,,,75.36000,21.85000,Aetna,Local,,38.26,,,,,,,27.17,61.64,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,8723535,CDM,637,RC,,,,,facility,outpatient,,,64.69000,18.76000,Aetna,Local,,32.84,,,,,,,23.32,52.92,percent of total billed charges,
Amoxicillin 250mg/5mL L,8723645,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Nystatin Oral Susp 5mL UD,8723609,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Microfibrillar 1g TP(Avitene),8724093,CDM,637,RC,,,,,facility,outpatient,,,1758.20000,509.88000,Aetna,Local,,892.64,,,,,,,633.83,1438.21,percent of total billed charges,
Furosemide 40mg/4mL (Lasix),8726122,CDM,637,RC,,,,,facility,outpatient,,,21.80000,6.32000,Aetna,Local,,11.07,,,,,,,7.86,17.83,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),8723484,CDM,637,RC,,,,,facility,outpatient,,,377.20000,109.39000,Aetna,Local,,191.50,,,,,,,135.98,308.55,percent of total billed charges,
Desvenlafaxine 100mg ER T,8725839,CDM,637,RC,,,,,facility,outpatient,,,79.95000,23.19000,Aetna,Local,,40.59,,,,,,,28.82,65.40,percent of total billed charges,
Dolutegravir 50mg Tab,8725841,CDM,637,RC,,,,,facility,outpatient,,,605.50000,175.60000,Aetna,Local,,307.41,,,,,,,218.28,495.30,percent of total billed charges,
elviteg/cobic/emtrici/teno 150-150-200-10mg T,8725851,CDM,637,RC,,,,,facility,outpatient,,,1031.05000,299.00000,Aetna,Local,,523.46,,,,,,,371.69,843.40,percent of total billed charges,
Emtricitabine-Tenofovir 200-25mg Tab,8725852,CDM,637,RC,,,,,facility,outpatient,,,575.60000,166.92000,Aetna,Local,,292.23,,,,,,,207.50,470.84,percent of total billed charges,
LinaCLOtide 72mcg C (Linzess),8725846,CDM,637,RC,,,,,facility,outpatient,,,160.85000,46.65000,Aetna,Local,,81.66,,,,,,,57.99,131.58,percent of total billed charges,
Mesalamine 800mg EC Tab,8725845,CDM,637,RC,,,,,facility,outpatient,,,74.44000,21.59000,Aetna,Local,,37.79,,,,,,,26.84,60.89,percent of total billed charges,
Zonisamide 25mg Cap,8725842,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Bromocriptine 2.5mg Tab,8725836,CDM,637,RC,,,,,facility,outpatient,,,29.30000,8.50000,Aetna,Local,,14.88,,,,,,,10.56,23.97,percent of total billed charges,
NUTR- Isosource 1.5 (250mL),8725909,CDM,637,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,18.02,40.90,percent of total billed charges,
NUTR- Isosource 1.5 (1L),8725910,CDM,637,RC,,,,,facility,outpatient,,,65.15000,18.89000,Aetna,Local,,33.08,,,,,,,23.49,53.29,percent of total billed charges,
Potassium Chloride 20mEq ER T,8725856,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Abacavir/Dolut/Lamiv 600-50-300mg T,8725869,CDM,637,RC,,,,,facility,outpatient,,,959.95000,278.39000,Aetna,Local,,487.37,,,,,,,346.06,785.24,percent of total billed charges,
Spacer for Inhaler,8725893,CDM,637,RC,,,,,facility,outpatient,,,143.05000,41.48000,Aetna,Local,,72.63,,,,,,,51.57,117.01,percent of total billed charges,
NUTR- Novasource Renal (237mL),8725913,CDM,637,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,18.02,40.90,percent of total billed charges,
NUTR- Novasource Renal(1L),8725914,CDM,637,RC,,,,,facility,outpatient,,,161.80000,46.92000,Aetna,Local,,82.15,,,,,,,58.33,132.35,percent of total billed charges,
NUTR- Nutren 2.0 (250mL),8725915,CDM,637,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,18.02,40.90,percent of total billed charges,
NUTR- Nutren 2.0 (1L),8725928,CDM,637,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,18.02,40.90,percent of total billed charges,
NUTR- Peptamen 1.5 (1L),8725918,CDM,637,RC,,,,,facility,outpatient,,,321.75000,93.31000,Aetna,Local,,163.35,,,,,,,115.99,263.19,percent of total billed charges,
NUTR- Peptamen AF (1L),8725919,CDM,637,RC,,,,,facility,outpatient,,,315.65000,91.54000,Aetna,Local,,160.26,,,,,,,113.79,258.20,percent of total billed charges,
NUTR- Peptamen Intense VHP(1L),8725920,CDM,637,RC,,,,,facility,outpatient,,,345.90000,100.31000,Aetna,Local,,175.61,,,,,,,124.70,282.95,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,8726012,CDM,637,RC,,,,,facility,outpatient,,,14.09000,4.09000,Aetna,Local,,7.15,,,,,,,5.08,11.53,percent of total billed charges,
Albuterol 90 mcg/Inh,8724355,CDM,637,RC,,,,,facility,outpatient,,,592.70000,171.88000,Aetna,Local,,300.91,,,,,,,213.67,484.83,percent of total billed charges,
Opium 10% (Deod Opium Tinc),8723654,CDM,637,RC,,,,,facility,outpatient,,,50.20000,14.56000,Aetna,Local,,25.49,,,,,,,18.10,41.06,percent of total billed charges,
prednisoLONE 0.12% 5mL Ophth Susp(Pred Mild),8724116,CDM,637,RC,,,,,facility,outpatient,,,1164.05000,337.57000,Aetna,Local,,590.99,,,,,,,419.64,952.19,percent of total billed charges,
Lithium Carb 300mg CR T,8723984,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Empagliflozin 10mg Tab,8726130,CDM,637,RC,,,,,facility,outpatient,,,180.70000,52.40000,Aetna,Local,,91.74,,,,,,,65.14,147.81,percent of total billed charges,
benzocaine-menthol Topical Spray,8726097,CDM,637,RC,,,,,facility,outpatient,,,45.55000,13.21000,Aetna,Local,,23.13,,,,,,,16.42,37.26,percent of total billed charges,
Zinc Oxide 20% Topical Paste,8726108,CDM,637,RC,,,,,facility,outpatient,,,680.60000,197.37000,Aetna,Local,,345.54,,,,,,,245.36,556.73,percent of total billed charges,
naloxegol 25mg Tab UD,8726109,CDM,637,RC,,,,,facility,outpatient,,,123.40000,35.79000,Aetna,Local,,62.65,,,,,,,44.49,100.94,percent of total billed charges,
Brivaracetam 25 mg Tab,8726111,CDM,637,RC,,,,,facility,outpatient,,,233.95000,67.85000,Aetna,Local,,118.78,,,,,,,84.34,191.37,percent of total billed charges,
brimonidine 0.2% Ophth Soln,8726144,CDM,637,RC,,,,,facility,outpatient,,,85.00000,24.65000,Aetna,Local,,43.15,,,,,,,30.64,69.53,percent of total billed charges,
Gentamicin 0.1% TC,8726147,CDM,637,RC,,,,,facility,outpatient,,,339.95000,98.59000,Aetna,Local,,172.59,,,,,,,122.55,278.08,percent of total billed charges,
bictegr/emtric/tenofov 50-200-25 mg Tab,8924939,CDM,637,RC,,,,,facility,outpatient,,,1031.05000,299.00000,Aetna,Local,,523.46,,,,,,,371.69,843.40,percent of total billed charges,
Rivaroxaban 2.5mg T(Xarelto),8924943,CDM,637,RC,,,,,facility,outpatient,,,80.70000,23.40000,Aetna,Local,,40.97,,,,,,,29.09,66.01,percent of total billed charges,
Entecavir 0.5mg Tab,8924945,CDM,637,RC,,,,,facility,outpatient,,,195.24000,56.62000,Aetna,Local,,99.12,,,,,,,70.38,159.71,percent of total billed charges,
darun/cobic/emtric/tenof 800-150-200-10mg T,8924947,CDM,637,RC,,,,,facility,outpatient,,,1142.85000,331.43000,Aetna,Local,,580.22,,,,,,,412.00,934.85,percent of total billed charges,
Empagliflozin 25mg Tab,8924948,CDM,637,RC,,,,,facility,outpatient,,,180.70000,52.40000,Aetna,Local,,91.74,,,,,,,65.14,147.81,percent of total billed charges,
LamoTRIgine 25mg ODT,8924950,CDM,637,RC,,,,,facility,outpatient,,,63.35000,18.37000,Aetna,Local,,32.16,,,,,,,22.84,51.82,percent of total billed charges,
Tenofovir 25mg T(Vemlidy),8924952,CDM,637,RC,,,,,facility,outpatient,,,411.30000,119.28000,Aetna,Local,,208.82,,,,,,,148.27,336.44,percent of total billed charges,
Cariprazine 1.5mg C(Vraylar),8924954,CDM,637,RC,,,,,facility,outpatient,,,409.40000,118.73000,Aetna,Local,,207.85,,,,,,,147.59,334.89,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,8924957,CDM,637,RC,,,,,facility,outpatient,,,60.82000,17.64000,Aetna,Local,,30.88,,,,,,,21.93,49.75,percent of total billed charges,
Metoprolol 12.5mg T(Lopressor),8924976,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Indomethacin 100mg Rectal Supp,8975006,CDM,637,RC,,,,,facility,outpatient,,,1809.00000,524.61000,Aetna,Local,,918.43,,,,,,,652.14,1479.76,percent of total billed charges,
Torsemide 100mg T,8972940,CDM,637,RC,,,,,facility,outpatient,,,20.50000,5.94000,Aetna,Local,,10.41,,,,,,,7.39,16.77,percent of total billed charges,
sodium polystyrene sulfonate 15g Oral Rec Pwd,8985000,CDM,637,RC,,,,,facility,outpatient,,,111.95000,32.47000,Aetna,Local,,56.84,,,,,,,40.36,91.58,percent of total billed charges,
artemether-lumefantrine 20mg-120mg Tab,8985001,CDM,637,RC,,,,,facility,outpatient,,,47.75000,13.85000,Aetna,Local,,24.24,,,,,,,17.21,39.06,percent of total billed charges,
Lidocaine 4% TD Patch,9001413,CDM,637,RC,,,,,facility,outpatient,,,10.65000,3.09000,Aetna,Local,,5.41,,,,,,,3.84,8.71,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,9001639,CDM,637,RC,,,,,facility,outpatient,,,111.70000,32.39000,Aetna,Local,,56.71,,,,,,,40.27,91.37,percent of total billed charges,
Zonisamide 100 mg/5 mL Oral Susp,9004505,CDM,637,RC,,,,,facility,outpatient,,,118.03000,34.23000,Aetna,Local,,59.92,,,,,,,42.55,96.55,percent of total billed charges,
Paliperidone 1.5mg ER T(Invega),9021075,CDM,637,RC,,,,,facility,outpatient,,,216.10000,62.67000,Aetna,Local,,109.71,,,,,,,77.90,176.77,percent of total billed charges,
NUTR- PROSource TF20 60mL,9024836,CDM,637,RC,,,,,facility,outpatient,,,22.55000,6.54000,Aetna,Local,,11.45,,,,,,,8.13,18.45,percent of total billed charges,
Digoxin 125mcg/2.5mL (0.125mg/2.5mL) L UD,8723986,CDM,637,RC,,,,,facility,outpatient,,,12.35000,3.58000,Aetna,Local,,6.27,,,,,,,4.45,10.10,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,8723867,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),8723947,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,8723619,CDM,637,RC,,,,,facility,outpatient,,,51.35000,14.89000,Aetna,Local,,26.07,,,,,,,18.51,42.00,percent of total billed charges,
dapagliflozin 10mg Tab UD,9061017,CDM,637,RC,,,,,facility,outpatient,,,169.85000,49.26000,Aetna,Local,,86.23,,,,,,,61.23,138.94,percent of total billed charges,
NUTR- Juven 23g/1 packet,9072160,CDM,637,RC,,,,,facility,outpatient,,,15.25000,4.42000,Aetna,Local,,7.74,,,,,,,5.50,12.47,percent of total billed charges,
Droxidopa 100mg Cap,9072465,CDM,637,RC,,,,,facility,outpatient,,,251.65000,72.98000,Aetna,Local,,127.76,,,,,,,90.72,205.85,percent of total billed charges,
clonazePAM 2mg T(KlonoPIN),9040372,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
PHENobarbital 32.4 mg Tab,9041249,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Levothyroxine Sodium 125mcg T,8724020,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
busPIRone 10mg T,8723936,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
mirabegron 50mg ER T,9091179,CDM,637,RC,,,,,facility,outpatient,,,117.35000,34.03000,Aetna,Local,,59.58,,,,,,,42.30,95.99,percent of total billed charges,
lacosamide 50mg/5mL Oral Soln,9091712,CDM,637,RC,,,,,facility,outpatient,,,78.91000,22.88000,Aetna,Local,,40.06,,,,,,,28.45,64.55,percent of total billed charges,
cloBAZam 10mg Tab UD,9091697,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
PHENobarbital 64.8mg Tab,9104311,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
PHENobarbital 97.2 mg Tab,9104486,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Cefpodoxime 200mg Tab,9124632,CDM,637,RC,,,,,facility,outpatient,,,59.90000,17.37000,Aetna,Local,,30.41,,,,,,,21.59,49.00,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,8723856,CDM,637,RC,,,,,facility,outpatient,,,217.30000,63.02000,Aetna,Local,,110.32,,,,,,,78.34,177.75,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,8723786,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,8723669,CDM,637,RC,,,,,facility,outpatient,,,15.30000,4.44000,Aetna,Local,,7.77,,,,,,,5.52,12.52,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,8723930,CDM,637,RC,,,,,facility,outpatient,,,12.49000,3.62000,Aetna,Local,,6.34,,,,,,,4.50,10.22,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),8723937,CDM,637,RC,,,,,facility,outpatient,,,10.38000,3.01000,Aetna,Local,,5.27,,,,,,,3.74,8.49,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),8723942,CDM,637,RC,,,,,facility,outpatient,,,13.90000,4.03000,Aetna,Local,,7.06,,,,,,,5.01,11.37,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,8723551,CDM,637,RC,,,,,facility,outpatient,,,28.45000,8.25000,Aetna,Local,,14.44,,,,,,,10.26,23.27,percent of total billed charges,
guaiFENesin 600mg ER T,8724010,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),8723912,CDM,637,RC,,,,,facility,outpatient,,,14.86000,4.31000,Aetna,Local,,7.54,,,,,,,5.36,12.16,percent of total billed charges,
Levothyroxine Sodium 25mcg T,8724013,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),8723472,CDM,637,RC,,,,,facility,outpatient,,,303.75000,88.09000,Aetna,Local,,154.21,,,,,,,109.50,248.47,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,8723920,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",8723764,CDM,637,RC,,,,,facility,outpatient,,,12.00000,3.48000,Aetna,Local,,6.09,,,,,,,4.33,9.82,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),8723612,CDM,637,RC,,,,,facility,outpatient,,,171.95000,49.87000,Aetna,Local,,87.30,,,,,,,61.99,140.66,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),8723938,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Tiotropium 2.5mcg/1INH Aerosol,8725949,CDM,637,RC,,,,,facility,outpatient,,,587.20000,170.29000,Aetna,Local,,298.12,,,,,,,211.69,480.33,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",8725995,CDM,637,RC,,,,,facility,outpatient,,,36.50000,10.58000,Aetna,Local,,18.53,,,,,,,13.16,29.86,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,8726011,CDM,637,RC,,,,,facility,outpatient,,,12.35000,3.58000,Aetna,Local,,6.27,,,,,,,4.45,10.10,percent of total billed charges,
Loxapine Succinate 10mg,8726038,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Norgestimate-ethinyl estradiol,8726079,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sus(Cortispor,8723420,CDM,637,RC,,,,,facility,outpatient,,,1042.25000,302.25000,Aetna,Local,,529.15,,,,,,,375.73,852.56,percent of total billed charges,
Cefixime 400mg C (Suprax),8725430,CDM,637,RC,,,,,facility,outpatient,,,166.55000,48.30000,Aetna,Local,,84.56,,,,,,,60.04,136.24,percent of total billed charges,
Ibuprofen 800mg T(Motrin),8724052,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),8723990,CDM,637,RC,,,,,facility,outpatient,,,10.65000,3.09000,Aetna,Local,,5.41,,,,,,,3.84,8.71,percent of total billed charges,
Levothyroxine Sodium 175mcg T,8724022,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Terazosin 1mg C(Hytrin),8724046,CDM,637,RC,,,,,facility,outpatient,,,11.40000,3.31000,Aetna,Local,,5.79,,,,,,,4.11,9.33,percent of total billed charges,
Terazosin 5mg C(Hytrin),8724047,CDM,637,RC,,,,,facility,outpatient,,,11.40000,3.31000,Aetna,Local,,5.79,,,,,,,4.11,9.33,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),8723701,CDM,637,RC,,,,,facility,outpatient,,,14.51000,4.21000,Aetna,Local,,7.37,,,,,,,5.23,11.87,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),8724090,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,8723769,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),8724462,CDM,637,RC,,,,,facility,outpatient,,,135.95000,39.43000,Aetna,Local,,69.02,,,,,,,49.01,111.21,percent of total billed charges,
rOPINIRole 1 mg T(Requip),8724481,CDM,637,RC,,,,,facility,outpatient,,,10.16000,2.95000,Aetna,Local,,5.16,,,,,,,3.66,8.31,percent of total billed charges,
rOPINIRole 2 mg T(Requip),8724482,CDM,637,RC,,,,,facility,outpatient,,,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Divalproex 500 mg ER T/24hr,8724485,CDM,637,RC,,,,,facility,outpatient,,,14.29000,4.14000,Aetna,Local,,7.26,,,,,,,5.15,11.69,percent of total billed charges,
rifAXIMin 200 mg T(Xifaxan),8724490,CDM,637,RC,,,,,facility,outpatient,,,95.40000,27.67000,Aetna,Local,,48.43,,,,,,,34.39,78.04,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),8724494,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),8724493,CDM,637,RC,,,,,facility,outpatient,,,14.24000,4.13000,Aetna,Local,,7.23,,,,,,,5.13,11.65,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),8724500,CDM,637,RC,,,,,facility,outpatient,,,48.42000,14.04000,Aetna,Local,,24.58,,,,,,,17.46,39.61,percent of total billed charges,
Cephalexin 250mg/5mL L,8723646,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),8723381,CDM,637,RC,,,,,facility,outpatient,,,92.55000,26.84000,Aetna,Local,,46.99,,,,,,,33.36,75.71,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,8723767,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),8724349,CDM,637,RC,,,,,facility,outpatient,,,10.78000,3.13000,Aetna,Local,,5.47,,,,,,,3.89,8.82,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,8723770,CDM,637,RC,,,,,facility,outpatient,,,15.49000,4.49000,Aetna,Local,,7.86,,,,,,,5.58,12.67,percent of total billed charges,
busPIRone 5mg T(Buspar),8723935,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),8724061,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),8723907,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Temazepam 7.5mg C(Restoril),8724103,CDM,637,RC,,,,,facility,outpatient,,,41.96000,12.17000,Aetna,Local,,21.30,,,,,,,15.13,34.32,percent of total billed charges,
Na Citrate-Citric Acid 30mL L(Bicit,8723544,CDM,637,RC,,,,,facility,outpatient,,,43.74000,12.68000,Aetna,Local,,22.21,,,,,,,15.77,35.78,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),8725039,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),8724009,CDM,637,RC,,,,,facility,outpatient,,,11.80000,3.42000,Aetna,Local,,5.99,,,,,,,4.25,9.65,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,8725073,CDM,637,RC,,,,,facility,outpatient,,,389.92000,113.08000,Aetna,Local,,197.96,,,,,,,140.57,318.95,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),8725072,CDM,637,RC,,,,,facility,outpatient,,,74.23000,21.53000,Aetna,Local,,37.69,,,,,,,26.76,60.72,percent of total billed charges,
Desvenlafaxine 50 mg ER T,8725065,CDM,637,RC,,,,,facility,outpatient,,,19.17000,5.56000,Aetna,Local,,9.73,,,,,,,6.91,15.68,percent of total billed charges,
Vancomycin 125mg/2.5mL Oral Soln,8725810,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),8725095,CDM,637,RC,,,,,facility,outpatient,,,30.25000,8.77000,Aetna,Local,,15.36,,,,,,,10.91,24.74,percent of total billed charges,
Lisinopril 20mg T (Zestril),8725089,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),8725096,CDM,637,RC,,,,,facility,outpatient,,,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),8725097,CDM,637,RC,,,,,facility,outpatient,,,16.01000,4.64000,Aetna,Local,,8.13,,,,,,,5.77,13.10,percent of total billed charges,
Lacosamide 50mg T (Vimpat),8725099,CDM,637,RC,,,,,facility,outpatient,,,25.54000,7.41000,Aetna,Local,,12.97,,,,,,,9.21,20.89,percent of total billed charges,
Donepezil 23mg T (Aricept),8725100,CDM,637,RC,,,,,facility,outpatient,,,73.75000,21.39000,Aetna,Local,,37.44,,,,,,,26.59,60.33,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),8724322,CDM,637,RC,,,,,facility,outpatient,,,164.35000,47.66000,Aetna,Local,,83.44,,,,,,,59.25,134.44,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,8725133,CDM,637,RC,,,,,facility,outpatient,,,53.06000,15.39000,Aetna,Local,,26.94,,,,,,,19.13,43.40,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,8725140,CDM,637,RC,,,,,facility,outpatient,,,21.66000,6.28000,Aetna,Local,,11.00,,,,,,,7.81,17.72,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),8724323,CDM,637,RC,,,,,facility,outpatient,,,163.75000,47.49000,Aetna,Local,,83.14,,,,,,,59.03,133.95,percent of total billed charges,
Metoclopramide 5mg/5mL L UD,8725125,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,8725130,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,8725135,CDM,637,RC,,,,,facility,outpatient,,,32.20000,9.34000,Aetna,Local,,16.35,,,,,,,11.61,26.34,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,8725136,CDM,637,RC,,,,,facility,outpatient,,,10.40000,3.02000,Aetna,Local,,5.28,,,,,,,3.75,8.51,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,8725137,CDM,637,RC,,,,,facility,outpatient,,,119.46000,34.64000,Aetna,Local,,60.65,,,,,,,43.07,97.72,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),8724051,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),8725313,CDM,637,RC,,,,,facility,outpatient,,,31.35000,9.09000,Aetna,Local,,15.92,,,,,,,11.30,25.64,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),8723939,CDM,637,RC,,,,,facility,outpatient,,,13.66000,3.96000,Aetna,Local,,6.94,,,,,,,4.92,11.17,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),8723772,CDM,637,RC,,,,,facility,outpatient,,,11.80000,3.42000,Aetna,Local,,5.99,,,,,,,4.25,9.65,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),8723959,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Oral Colonic Lavage 4000 mL,8723755,CDM,637,RC,,,,,facility,outpatient,,,149.55000,43.37000,Aetna,Local,,75.93,,,,,,,53.91,122.33,percent of total billed charges,
Sucralfate 1g/10mL L UD,8723443,CDM,637,RC,,,,,facility,outpatient,,,74.33000,21.56000,Aetna,Local,,37.74,,,,,,,26.80,60.80,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,8723530,CDM,637,RC,,,,,facility,outpatient,,,3285.40000,952.77000,Aetna,Local,,1668.00,,,,,,,1184.39,2687.46,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,8723528,CDM,637,RC,,,,,facility,outpatient,,,2121.15000,615.13000,Aetna,Local,,1076.91,,,,,,,764.67,1735.10,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,8723529,CDM,637,RC,,,,,facility,outpatient,,,2566.35000,744.24000,Aetna,Local,,1302.94,,,,,,,925.17,2099.27,percent of total billed charges,
Midazolam HCl 5mg/2.5mL L UD,8723655,CDM,637,RC,,,,,facility,outpatient,,,51.20000,14.85000,Aetna,Local,,25.99,,,,,,,18.46,41.88,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,8725315,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,8723963,CDM,637,RC,,,,,facility,outpatient,,,44.22000,12.82000,Aetna,Local,,22.45,,,,,,,15.94,36.17,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,8724147,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Salmeterol 50 mcg Pwd/Inh,8724155,CDM,637,RC,,,,,facility,outpatient,,,2866.45000,831.27000,Aetna,Local,,1455.30,,,,,,,1033.36,2344.76,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,8724156,CDM,637,RC,,,,,facility,outpatient,,,677.25000,196.40000,Aetna,Local,,343.84,,,,,,,244.15,553.99,percent of total billed charges,
Valsartan 80 mg T(Diovan),8724194,CDM,637,RC,,,,,facility,outpatient,,,10.37000,3.01000,Aetna,Local,,5.26,,,,,,,3.74,8.48,percent of total billed charges,
Valsartan 160 mg T(Diovan),8724197,CDM,637,RC,,,,,facility,outpatient,,,10.78000,3.13000,Aetna,Local,,5.47,,,,,,,3.89,8.82,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),8724195,CDM,637,RC,,,,,facility,outpatient,,,79.07000,22.93000,Aetna,Local,,40.14,,,,,,,28.50,64.68,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),8724199,CDM,637,RC,,,,,facility,outpatient,,,31.04000,9.00000,Aetna,Local,,15.76,,,,,,,11.19,25.39,percent of total billed charges,
Escitalopram 20 mg T(lexapro),8724198,CDM,637,RC,,,,,facility,outpatient,,,32.39000,9.39000,Aetna,Local,,16.44,,,,,,,11.68,26.50,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,8724207,CDM,637,RC,,,,,facility,outpatient,,,89.06000,25.83000,Aetna,Local,,45.22,,,,,,,32.11,72.85,percent of total billed charges,
metFORMIN 500mg ER T,8724213,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Azithromycin 100mg/5mL L,8724221,CDM,637,RC,,,,,facility,outpatient,,,82.35000,23.88000,Aetna,Local,,41.81,,,,,,,29.69,67.36,percent of total billed charges,
Hydroxychloroquine 200mg T,8724224,CDM,637,RC,,,,,facility,outpatient,,,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),8724225,CDM,637,RC,,,,,facility,outpatient,,,79.05000,22.92000,Aetna,Local,,40.13,,,,,,,28.50,64.66,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),8724226,CDM,637,RC,,,,,facility,outpatient,,,34.84000,10.10000,Aetna,Local,,17.69,,,,,,,12.56,28.50,percent of total billed charges,
Metoprolol 25mg T(Lopressor),8724227,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Triamcinolone 0.1% TO 80g,8724234,CDM,637,RC,,,,,facility,outpatient,,,89.80000,26.04000,Aetna,Local,,45.59,,,,,,,32.37,73.46,percent of total billed charges,
Triamcinolone 0.1% TC 15g,8724237,CDM,637,RC,,,,,facility,outpatient,,,41.30000,11.98000,Aetna,Local,,20.97,,,,,,,14.89,33.78,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),8724248,CDM,637,RC,,,,,facility,outpatient,,,17.26000,5.01000,Aetna,Local,,8.76,,,,,,,6.22,14.12,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),8724249,CDM,637,RC,,,,,facility,outpatient,,,131.25000,38.06000,Aetna,Local,,66.64,,,,,,,47.32,107.36,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),8724251,CDM,637,RC,,,,,facility,outpatient,,,55.90000,16.21000,Aetna,Local,,28.38,,,,,,,20.15,45.73,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),8724252,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,8724261,CDM,637,RC,,,,,facility,outpatient,,,10.96000,3.18000,Aetna,Local,,5.56,,,,,,,3.95,8.97,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),8724255,CDM,637,RC,,,,,facility,outpatient,,,276.80000,80.27000,Aetna,Local,,140.53,,,,,,,99.79,226.42,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),8724262,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
lamoTRIgine 100mg Tablet,8724263,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),8724264,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),8724265,CDM,637,RC,,,,,facility,outpatient,,,18.60000,5.39000,Aetna,Local,,9.44,,,,,,,6.71,15.21,percent of total billed charges,
Topiramate 25 mg T(Topamax),8724266,CDM,637,RC,,,,,facility,outpatient,,,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Topiramate 100 mg T(Topamax),8724267,CDM,637,RC,,,,,facility,outpatient,,,49.32000,14.30000,Aetna,Local,,25.04,,,,,,,17.78,40.34,percent of total billed charges,
Etodolac 200 mg C (Lodine),8724271,CDM,637,RC,,,,,facility,outpatient,,,10.20000,2.96000,Aetna,Local,,5.18,,,,,,,3.68,8.34,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),8724273,CDM,637,RC,,,,,facility,outpatient,,,36.20000,10.50000,Aetna,Local,,18.38,,,,,,,13.05,29.61,percent of total billed charges,
Dapsone 100 mg Tab,8724274,CDM,637,RC,,,,,facility,outpatient,,,21.45000,6.22000,Aetna,Local,,10.89,,,,,,,7.73,17.55,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),8724276,CDM,637,RC,,,,,facility,outpatient,,,748.45000,217.05000,Aetna,Local,,379.99,,,,,,,269.82,612.23,percent of total billed charges,
SUMAtriptan 20mg/spray NS,8724760,CDM,637,RC,,,,,facility,outpatient,,,413.95000,120.05000,Aetna,Local,,210.16,,,,,,,149.23,338.61,percent of total billed charges,
levoFLOXacin  25mg/mL L,8724823,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
K-Phos-Na Phos Neutral 250mg T,8724811,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,8724814,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,8724849,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
carBAMazepine 100 mg ER C,8724283,CDM,637,RC,,,,,facility,outpatient,,,13.95000,4.05000,Aetna,Local,,7.08,,,,,,,5.03,11.41,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,8724859,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,8724867,CDM,637,RC,,,,,facility,outpatient,,,980.15000,284.24000,Aetna,Local,,497.62,,,,,,,353.34,801.76,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,8724869,CDM,637,RC,,,,,facility,outpatient,,,102.00000,29.58000,Aetna,Local,,51.79,,,,,,,36.77,83.44,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),8724884,CDM,637,RC,,,,,facility,outpatient,,,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,12.98,29.45,percent of total billed charges,
fluvoxaMINE 100mg T,8724885,CDM,637,RC,,,,,facility,outpatient,,,18.65000,5.41000,Aetna,Local,,9.47,,,,,,,6.72,15.26,percent of total billed charges,
LamiVUDine 10mg/1mL Oral L(Epivir),8724891,CDM,637,RC,,,,,facility,outpatient,,,8.34000,2.42000,Aetna,Local,,4.23,,,,,,,3.01,6.82,percent of total billed charges,
Raltegravir 400mg T (Isentress),8724896,CDM,637,RC,,,,,facility,outpatient,,,289.15000,83.85000,Aetna,Local,,146.80,,,,,,,104.24,236.52,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),8724897,CDM,637,RC,,,,,facility,outpatient,,,373.35000,108.27000,Aetna,Local,,189.55,,,,,,,134.59,305.40,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),8724909,CDM,637,RC,,,,,facility,outpatient,,,226.10000,65.57000,Aetna,Local,,114.79,,,,,,,81.51,184.95,percent of total billed charges,
Fenofibrate 160mg T(Tricor),8724932,CDM,637,RC,,,,,facility,outpatient,,,33.74000,9.78000,Aetna,Local,,17.13,,,,,,,12.16,27.60,percent of total billed charges,
Nebivolol 5mg T (Bystolic),8724920,CDM,637,RC,,,,,facility,outpatient,,,26.21000,7.60000,Aetna,Local,,13.31,,,,,,,9.45,21.44,percent of total billed charges,
NICU- Chlorothiazide 50mg/mL L,8724930,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
NICU- FERROUS SULFATE 15MG/1ML L,8724935,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Cephalexin 125mg/2.5mL L,8723652,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,8724954,CDM,637,RC,,,,,facility,outpatient,,,23.98000,6.95000,Aetna,Local,,12.17,,,,,,,8.64,19.62,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),8724292,CDM,637,RC,,,,,facility,outpatient,,,70.80000,20.53000,Aetna,Local,,35.95,,,,,,,25.52,57.91,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),8724295,CDM,637,RC,,,,,facility,outpatient,,,16.50000,4.78000,Aetna,Local,,8.38,,,,,,,5.95,13.50,percent of total billed charges,
Dronedarone 400mg T,8724977,CDM,637,RC,,,,,facility,outpatient,,,104.48000,30.30000,Aetna,Local,,53.04,,,,,,,37.67,85.46,percent of total billed charges,
Prasugrel 10mg T,8724978,CDM,637,RC,,,,,facility,outpatient,,,118.06000,34.24000,Aetna,Local,,59.94,,,,,,,42.56,96.57,percent of total billed charges,
Prasugrel 5mg T,8724979,CDM,637,RC,,,,,facility,outpatient,,,116.90000,33.90000,Aetna,Local,,59.35,,,,,,,42.14,95.62,percent of total billed charges,
Magic Mouthwash 10mL L UD,8724980,CDM,637,RC,,,,,facility,outpatient,,,44.85000,13.01000,Aetna,Local,,22.77,,,,,,,16.17,36.69,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),8724993,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,8724995,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Sevelamer HCl 800 mg T(Renagel),8724297,CDM,637,RC,,,,,facility,outpatient,,,64.98000,18.84000,Aetna,Local,,32.99,,,,,,,23.43,53.15,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),8725026,CDM,637,RC,,,,,facility,outpatient,,,82.15000,23.82000,Aetna,Local,,41.71,,,,,,,29.62,67.20,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),8724302,CDM,637,RC,,,,,facility,outpatient,,,28.03000,8.13000,Aetna,Local,,14.23,,,,,,,10.10,22.93,percent of total billed charges,
Midodrine 5 mg T(Proamatine),8724303,CDM,637,RC,,,,,facility,outpatient,,,10.90000,3.16000,Aetna,Local,,5.53,,,,,,,3.93,8.92,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),8724306,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Torsemide 20mg T,8724312,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,8724319,CDM,637,RC,,,,,facility,outpatient,,,1651.65000,478.98000,Aetna,Local,,838.54,,,,,,,595.42,1351.05,percent of total billed charges,
Lisinopril 40 mg T(Zestril),8724325,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
fentaNYL 12 mcg/hr TD,8724326,CDM,637,RC,,,,,facility,outpatient,,,154.23000,44.73000,Aetna,Local,,78.30,,,,,,,55.60,126.16,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),8724328,CDM,637,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),8724369,CDM,637,RC,,,,,facility,outpatient,,,54.84000,15.90000,Aetna,Local,,27.84,,,,,,,19.77,44.86,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),8724370,CDM,637,RC,,,,,facility,outpatient,,,55.60000,16.12000,Aetna,Local,,28.23,,,,,,,20.04,45.48,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),8724373,CDM,637,RC,,,,,facility,outpatient,,,10.24000,2.97000,Aetna,Local,,5.20,,,,,,,3.69,8.38,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),8724374,CDM,637,RC,,,,,facility,outpatient,,,24.20000,7.02000,Aetna,Local,,12.29,,,,,,,8.72,19.80,percent of total billed charges,
Nitroglycerin 2% TO 1g,8724368,CDM,637,RC,,,,,facility,outpatient,,,21.45000,6.22000,Aetna,Local,,10.89,,,,,,,7.73,17.55,percent of total billed charges,
Imatinib 100 mg T(Gleevac),8724375,CDM,637,RC,,,,,facility,outpatient,,,685.70000,198.85000,Aetna,Local,,348.13,,,,,,,247.19,560.90,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),8724377,CDM,637,RC,,,,,facility,outpatient,,,21.31000,6.18000,Aetna,Local,,10.82,,,,,,,7.68,17.43,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),8724380,CDM,637,RC,,,,,facility,outpatient,,,216.77000,62.86000,Aetna,Local,,110.05,,,,,,,78.15,177.32,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),8724384,CDM,637,RC,,,,,facility,outpatient,,,23.45000,6.80000,Aetna,Local,,11.91,,,,,,,8.45,19.18,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),8724385,CDM,637,RC,,,,,facility,outpatient,,,23.45000,6.80000,Aetna,Local,,11.91,,,,,,,8.45,19.18,percent of total billed charges,
Entacapone 200 mg T(Comtan),8724386,CDM,637,RC,,,,,facility,outpatient,,,33.44000,9.70000,Aetna,Local,,16.98,,,,,,,12.06,27.35,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),8724388,CDM,637,RC,,,,,facility,outpatient,,,42.85000,12.43000,Aetna,Local,,21.75,,,,,,,15.45,35.05,percent of total billed charges,
Eplerenone 25 mg T(Inspra),8724389,CDM,637,RC,,,,,facility,outpatient,,,35.32000,10.24000,Aetna,Local,,17.93,,,,,,,12.73,28.89,percent of total billed charges,
Colesevelam 625 mg T(Welchol),8724390,CDM,637,RC,,,,,facility,outpatient,,,23.74000,6.88000,Aetna,Local,,12.05,,,,,,,8.56,19.42,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),8724395,CDM,637,RC,,,,,facility,outpatient,,,11.86000,3.44000,Aetna,Local,,6.02,,,,,,,4.28,9.70,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),8724396,CDM,637,RC,,,,,facility,outpatient,,,12.34000,3.58000,Aetna,Local,,6.27,,,,,,,4.45,10.09,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),8724399,CDM,637,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,8724400,CDM,637,RC,,,,,facility,outpatient,,,12.52000,3.63000,Aetna,Local,,6.36,,,,,,,4.51,10.24,percent of total billed charges,
Pregabalin 25mg C(Lyrica),8724406,CDM,637,RC,,,,,facility,outpatient,,,26.28000,7.62000,Aetna,Local,,13.34,,,,,,,9.47,21.50,percent of total billed charges,
Pregabalin 50mg C(Lyrica),8724407,CDM,637,RC,,,,,facility,outpatient,,,30.70000,8.90000,Aetna,Local,,15.59,,,,,,,11.07,25.11,percent of total billed charges,
Pregabalin 75mg C(Lyrica),8724408,CDM,637,RC,,,,,facility,outpatient,,,28.15000,8.16000,Aetna,Local,,14.29,,,,,,,10.15,23.03,percent of total billed charges,
Pregabalin 100mg C(Lyrica),8724409,CDM,637,RC,,,,,facility,outpatient,,,28.93000,8.39000,Aetna,Local,,14.69,,,,,,,10.43,23.66,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,8725811,CDM,637,RC,,,,,facility,outpatient,,,96.05000,27.85000,Aetna,Local,,48.76,,,,,,,34.63,78.57,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),8724413,CDM,637,RC,,,,,facility,outpatient,,,33.84000,9.81000,Aetna,Local,,17.18,,,,,,,12.20,27.68,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),8724423,CDM,637,RC,,,,,facility,outpatient,,,26.11000,7.57000,Aetna,Local,,13.26,,,,,,,9.41,21.36,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),8724424,CDM,637,RC,,,,,facility,outpatient,,,10.35000,3.00000,Aetna,Local,,5.25,,,,,,,3.73,8.47,percent of total billed charges,
Ramipril 1.25 mg C(Altace),8724427,CDM,637,RC,,,,,facility,outpatient,,,10.85000,3.15000,Aetna,Local,,5.51,,,,,,,3.91,8.88,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),8724429,CDM,637,RC,,,,,facility,outpatient,,,13.50000,3.91000,Aetna,Local,,6.85,,,,,,,4.87,11.04,percent of total billed charges,
Memantine HCl 5mg T(Namenda),8724430,CDM,637,RC,,,,,facility,outpatient,,,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
Memantine HCl 10mg T(Namenda),8724431,CDM,637,RC,,,,,facility,outpatient,,,10.11000,2.93000,Aetna,Local,,5.13,,,,,,,3.64,8.27,percent of total billed charges,
ER Trauma Activation,7904020,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,8281.00000,2401.49000,Aetna,Local,,4204.26,,,,,,,1335.06,6773.86,percent of total billed charges,
ER Trauma Alert,7904019,CDM,682,RC,,,,,facility,outpatient,,,7821.00000,2268.09000,Aetna,Local,,3970.72,,,,,,,2819.47,6397.58,percent of total billed charges,
Trauma Activation Level 1,8625952,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,7200.00000,2088.00000,Aetna,Local,,3655.44,,,,,,,1335.06,5889.60,percent of total billed charges,
Trauma Activation Level 2,8625953,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,6800.00000,1972.00000,Aetna,Local,,3452.36,,,,,,,1335.06,5562.40,percent of total billed charges,
Trauma Activation I with Critical Care,9010915,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,7200.00000,2088.00000,Aetna,Local,,3655.44,,,,,,,1335.06,5889.60,percent of total billed charges,
Trauma Activation 1 W Critical Care W Prehospital Notice,9101301,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,7200.00000,2088.00000,Aetna,Local,,3655.44,,,,,,,1335.06,5889.60,percent of total billed charges,
Trauma Activation I without Critical Care,9010916,CDM,682,RC,,,,,facility,outpatient,,,7200.00000,2088.00000,Aetna,Local,,3655.44,,,,,,,2595.60,5889.60,percent of total billed charges,
Trauma Activation 1 WO Critical Care W Prehospital N,9101299,CDM,682,RC,,,,,facility,outpatient,,,7200.00000,2088.00000,Aetna,Local,,3655.44,,,,,,,2595.60,5889.60,percent of total billed charges,
Trauma Activation II with Critical Care,9010917,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,6800.00000,1972.00000,Aetna,Local,,3452.36,,,,,,,1335.06,5562.40,percent of total billed charges,
Trauma Activation 2 W Critical Care W Prehospital Notice,9101297,CDM,682,RC,G0390,HCPCS,,,facility,outpatient,,,6800.00000,1972.00000,Aetna,Local,,3452.36,,,,,,,1335.06,5562.40,percent of total billed charges,
Trauma Activation II without Critical Care,9010918,CDM,682,RC,,,,,facility,outpatient,,,6800.00000,1972.00000,Aetna,Local,,3452.36,,,,,,,2451.40,5562.40,percent of total billed charges,
Trauma Activation 2 WO Critical Care W Prehospital Notice,9103634,CDM,682,RC,,,,,facility,outpatient,,,6800.00000,1972.00000,Aetna,Local,,3452.36,,,,,,,2451.40,5562.40,percent of total billed charges,
Mat Recovery,7939185,CDM,710,RC,,,,,facility,outpatient,,,1624.00000,470.96000,Aetna,Local,,824.50,,,,,,,585.45,1328.43,percent of total billed charges,
Mat Recovery,7939255,CDM,710,RC,,,,,facility,outpatient,,,1624.00000,470.96000,Aetna,Local,,824.50,,,,,,,585.45,1328.43,percent of total billed charges,
MC C Section Recovery,889798,CDM,710,RC,,,,,facility,outpatient,,,1624.00000,470.96000,Aetna,Local,,824.50,,,,,,,585.45,1328.43,percent of total billed charges,
PACU 1 to 30 Min,8161131,CDM,710,RC,,,,,facility,outpatient,,,750.00000,217.50000,Aetna,Local,,380.77,,,,,,,270.38,613.50,percent of total billed charges,
PACU each Addl 15 min,8161132,CDM,710,RC,,,,,facility,outpatient,,,94.00000,27.26000,Aetna,Local,,47.72,,,,,,,33.89,76.89,percent of total billed charges,
Mat Amnioinfusion,7932241,CDM,720,RC,59070,HCPCS,,,facility,outpatient,,,1066.00000,309.14000,Aetna,Local,,1610.00,,,,,,,267.10,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Mat Treat Postpartum Hemmo,7942646,CDM,720,RC,,,,,facility,outpatient,,,1036.00000,300.44000,Aetna,Local,,525.98,,,,,,,373.48,847.45,percent of total billed charges,
Mat Treat Postpartum Hemmo,7954815,CDM,720,RC,,,,,facility,outpatient,,,1036.00000,300.44000,Aetna,Local,,525.98,,,,,,,373.48,847.45,percent of total billed charges,
Intrauterine Pressure Catheter,9005280,CDM,720,RC,59050,HCPCS,,,facility,outpatient,,,400.00000,116.00000,Aetna,Local,,203.08,,,,,,,144.20,2860.00,percent of total billed charges,
Fetal Scalp Electrode,9005275,CDM,720,RC,59050,HCPCS,,,facility,outpatient,,,400.00000,116.00000,Aetna,Local,,203.08,,,,,,,144.20,2860.00,percent of total billed charges,
Mat Cervical Ripening,7939789,CDM,720,RC,,,,,facility,outpatient,,,1036.00000,300.44000,Aetna,Local,,525.98,,,,,,,373.48,847.45,percent of total billed charges,
Mat Labor Room 0 To 4 Hours,8158159,CDM,721,RC,,,,,facility,outpatient,,,1617.00000,468.93000,Aetna,Local,,820.95,,,,,,,582.93,1322.71,percent of total billed charges,
Mat Labor Room Each Addl Hour,8158160,CDM,721,RC,,,,,facility,outpatient,,,433.00000,125.57000,Aetna,Local,,219.83,,,,,,,156.10,354.19,percent of total billed charges,
Mat Vaginal Delivery,7936480,CDM,722,RC,,,,,facility,outpatient,,,7581.00000,2198.49000,Aetna,Local,,3848.87,,,,,,,2732.95,6201.26,percent of total billed charges,
Mat Vaginal Delivery,7936481,CDM,722,RC,,,,,facility,outpatient,,,7581.00000,2198.49000,Aetna,Local,,3848.87,,,,,,,2732.95,6201.26,percent of total billed charges,
Mat Vaginal Delivery,7936482,CDM,722,RC,,,,,facility,outpatient,,,7581.00000,2198.49000,Aetna,Local,,3848.87,,,,,,,2732.95,6201.26,percent of total billed charges,
Mat Vaginal Delivery,7936483,CDM,722,RC,,,,,facility,outpatient,,,7581.00000,2198.49000,Aetna,Local,,3848.87,,,,,,,2732.95,6201.26,percent of total billed charges,
Vaginal Manual Extraction,9005272,CDM,722,RC,59414,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,Local,,1624.64,,,,,,,1187.84,8486.44,percent of total billed charges,
RT Attendance at Delivery,8996890,CDM,722,RC,99464,HCPCS,,,facility,outpatient,,,132.00000,38.28000,Aetna,Local,,67.02,,,,,,,47.59,107.98,percent of total billed charges,
EKG,2154824,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,Local,,528.00,,,,,,,52.15,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ED EKG,8347478,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,Local,,528.00,,,,,,,52.15,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ED EKG,8347481,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,Local,,528.00,,,,,,,52.15,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ED EKG,927801,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,Local,,528.00,,,,,,,52.15,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EKG,599382,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,Local,,528.00,,,,,,,52.15,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EKG,8347445,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,Local,,528.00,,,,,,,52.15,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EKG After Hours,8347490,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,Local,,528.00,,,,,,,52.15,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Cardiology EKG,8356873,CDM,730,RC,93005,HCPCS,,,facility,outpatient,,,671.00000,194.59000,Aetna,Local,,528.00,,,,,,,52.15,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Rhythym Strip Tracing,599396,CDM,730,RC,93041,HCPCS,,,facility,outpatient,,,640.00000,185.60000,Aetna,Local,,528.00,,,,,,,52.15,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Rhythm Strip Tracing,9101084,CDM,730,RC,93041,HCPCS,,,facility,outpatient,,,640.00000,185.60000,Aetna,Local,,528.00,,,,,,,52.15,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Holter Recording,599392,CDM,731,RC,93225,HCPCS,,,facility,outpatient,,,659.00000,191.11000,Aetna,Local,,528.00,,,,,,,113.19,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CEK Holter Recording,617798,CDM,731,RC,93225,HCPCS,,,facility,outpatient,,,659.00000,191.11000,Aetna,Local,,528.00,,,,,,,113.19,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Holter Recording,7936142,CDM,731,RC,93225,HCPCS,,,facility,outpatient,,,659.00000,191.11000,Aetna,Local,,528.00,,,,,,,113.19,563.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Holter Scanning,599394,CDM,731,RC,93226,HCPCS,,,facility,outpatient,,,2587.00000,750.23000,Aetna,Local,,528.00,,,,,,,52.15,2116.17,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CEK Holter Scanning,617799,CDM,731,RC,93226,HCPCS,,,facility,outpatient,,,2587.00000,750.23000,Aetna,Local,,528.00,,,,,,,52.15,2116.17,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Holter Scanning,7897215,CDM,731,RC,93226,HCPCS,,,facility,outpatient,,,2587.00000,750.23000,Aetna,Local,,528.00,,,,,,,52.15,2116.17,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Holter Acquisition Scanning,7936143,CDM,731,RC,93226,HCPCS,,,facility,outpatient,,,2587.00000,750.23000,Aetna,Local,,528.00,,,,,,,52.15,2116.17,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Holter Acquisition Scanning bce,8994534,CDM,731,RC,93226,HCPCS,,,facility,outpatient,,,2587.00000,750.23000,Aetna,Local,,528.00,,,,,,,52.15,2116.17,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EEG 41 to 60 Mins,8999433,CDM,740,RC,95812,HCPCS,,,facility,outpatient,,,2096.00000,607.84000,Aetna,Local,,1064.14,,,,,,,216.27,1714.53,percent of total billed charges,
EEG 41 to 60 Mins,9001531,CDM,740,RC,95812,HCPCS,,,facility,outpatient,,,2096.00000,607.84000,Aetna,Local,,1064.14,,,,,,,216.27,1714.53,percent of total billed charges,
EEG 61 to 119 Mins,8995349,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,Local,,1445.42,,,,,,,216.27,2328.85,percent of total billed charges,
EEG 61 to 119 Mins,9001530,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,Local,,1445.42,,,,,,,216.27,2328.85,percent of total billed charges,
EEG 20 to 40 Mins Awake,8995348,CDM,740,RC,95816,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 20 to 40 Min Awake,9001532,CDM,740,RC,95816,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 20 to 40 Mins Awake and Asleep or Asleep,8995347,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 20 to 40 Min Awake and Asleep or Asleep,9001529,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 2 to 12 Hrs 8 plus Channel No Video,9001533,CDM,740,RC,95705,HCPCS,,,facility,outpatient,,,1232.00000,357.28000,Aetna,Local,,625.49,,,,,,,216.27,1007.78,percent of total billed charges,
EEG 2 to 12 Hours 8 or More Channels No Video,9004109,CDM,740,RC,95705,HCPCS,,,facility,outpatient,,,1232.00000,357.28000,Aetna,Local,,625.49,,,,,,,216.27,1007.78,percent of total billed charges,
EEG Greater Than 12 Hrs,9001528,CDM,740,RC,95708,HCPCS,,,facility,outpatient,,,2466.00000,715.14000,Aetna,Local,,1251.99,,,,,,,373.76,2017.19,percent of total billed charges,
EEG Greater Than 12 Hours,9004110,CDM,740,RC,95708,HCPCS,,,facility,outpatient,,,2466.00000,715.14000,Aetna,Local,,1251.99,,,,,,,373.76,2017.19,percent of total billed charges,
EEG,599346,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,216.27,1766.06,percent of total billed charges,
EEG,7957125,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,216.27,1766.06,percent of total billed charges,
EEG Awake and Asleep,8282899,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,216.27,1766.06,percent of total billed charges,
Visual Evoked Potentials,599350,CDM,740,RC,95930,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,Local,,1131.66,,,,,,,216.27,1823.32,percent of total billed charges,
Visual Evoked Potentials,7957297,CDM,740,RC,95930,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,Local,,1131.66,,,,,,,216.27,1823.32,percent of total billed charges,
EEG More Than 1 Hr,599360,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,Local,,1445.42,,,,,,,216.27,2328.85,percent of total billed charges,
EEG More Than 1 Hr,7957142,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,Local,,1445.42,,,,,,,216.27,2328.85,percent of total billed charges,
EEG More Than 1 Hr,7957300,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,Local,,1445.42,,,,,,,216.27,2328.85,percent of total billed charges,
EEG 61 to 119mins,8426932,CDM,740,RC,95813,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,Local,,1445.42,,,,,,,216.27,2328.85,percent of total billed charges,
EEG Cerebral Death,599364,CDM,740,RC,95824,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,Local,,1270.27,,,,,,,373.76,2046.64,percent of total billed charges,
EEG Cerebral Death,7957298,CDM,740,RC,95824,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,Local,,1270.27,,,,,,,373.76,2046.64,percent of total billed charges,
EEG During Surgery,599366,CDM,740,RC,95955,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,Local,,1270.27,,,,,,,901.97,2046.64,percent of total billed charges,
EEG During Surgery,7957301,CDM,740,RC,95955,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,Local,,1270.27,,,,,,,901.97,2046.64,percent of total billed charges,
EEG Ambulatory Each 24 Hours,7957295,CDM,740,RC,95708,HCPCS,,,facility,outpatient,,,2466.00000,715.14000,Aetna,Local,,1251.99,,,,,,,373.76,2017.19,percent of total billed charges,
EEG Ambulatory Each 24 Hours,8159873,CDM,740,RC,95708,HCPCS,,,facility,outpatient,,,2466.00000,715.14000,Aetna,Local,,1251.99,,,,,,,373.76,2017.19,percent of total billed charges,
EEG Coma Or Sleep Only,7846076,CDM,740,RC,95822,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,Local,,1270.27,,,,,,,216.27,2046.64,percent of total billed charges,
EEG Coma Or Sleep Only,7957299,CDM,740,RC,95822,HCPCS,,,facility,outpatient,,,2502.00000,725.58000,Aetna,Local,,1270.27,,,,,,,216.27,2046.64,percent of total billed charges,
EEG Extended Monitoring 41 to 60Min,7963895,CDM,740,RC,95812,HCPCS,,,facility,outpatient,,,1897.00000,550.13000,Aetna,Local,,963.11,,,,,,,216.27,1551.75,percent of total billed charges,
EEG 20 to 40mins awake and sleepy,8426922,CDM,740,RC,95819,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,216.27,1766.06,percent of total billed charges,
EEG Attended,7963896,CDM,740,RC,95700,HCPCS,,,facility,outpatient,,,5625.00000,1631.25000,Aetna,Local,,2855.81,,,,,,,137.38,4601.25,percent of total billed charges,
LTM EEG set up by EEG Tech,8414878,CDM,740,RC,95700,HCPCS,,,facility,outpatient,,,5625.00000,1631.25000,Aetna,Local,,2855.81,,,,,,,137.38,4601.25,percent of total billed charges,
EEG Unattended,7963897,CDM,740,RC,95714,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,Local,,1849.04,,,,,,,373.76,2979.16,percent of total billed charges,
EEG Unattended,8166241,CDM,740,RC,95714,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,Local,,1849.04,,,,,,,373.76,2979.16,percent of total billed charges,
LTM w Video 95714,8414876,CDM,740,RC,95714,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,Local,,1849.04,,,,,,,373.76,2979.16,percent of total billed charges,
LTM w Video 95714,8427295,CDM,740,RC,95714,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,Local,,1849.04,,,,,,,373.76,2979.16,percent of total billed charges,
LTM EEG set up by EEG Tech,8426945,CDM,740,RC,95700,HCPCS,,,facility,outpatient,,,5625.00000,1631.25000,Aetna,Local,,2855.81,,,,,,,137.38,4601.25,percent of total billed charges,
EEG Awake and Drowsy,8282900,CDM,740,RC,95816,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 20 to 40mins awake and drowsy,8426917,CDM,740,RC,95816,HCPCS,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,216.27,1766.06,percent of total billed charges,
EEG 12 to 26 Hours,8410991,CDM,740,RC,95714,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,Local,,1849.04,,,,,,,373.76,2979.16,percent of total billed charges,
EEG 2 to 12 Hours,8410992,CDM,740,RC,95711,HCPCS,,,facility,outpatient,,,3239.00000,939.31000,Aetna,Local,,1644.44,,,,,,,216.27,2649.50,percent of total billed charges,
LTM w Video 95711,8414877,CDM,740,RC,95711,HCPCS,,,facility,outpatient,,,3239.00000,939.31000,Aetna,Local,,1644.44,,,,,,,216.27,2649.50,percent of total billed charges,
LTM w Video 95711,8427296,CDM,740,RC,95711,HCPCS,,,facility,outpatient,,,3239.00000,939.31000,Aetna,Local,,1644.44,,,,,,,216.27,2649.50,percent of total billed charges,
EEG 2 to 12hrs 8 less than channels no video,8426927,CDM,740,RC,95705,HCPCS,,,facility,outpatient,,,1232.00000,357.28000,Aetna,Local,,625.49,,,,,,,216.27,1007.78,percent of total billed charges,
EEG 12 to 26hrs 8 less than channels no video,8426912,CDM,740,RC,95708,HCPCS,,,facility,outpatient,,,2466.00000,715.14000,Aetna,Local,,1251.99,,,,,,,373.76,2017.19,percent of total billed charges,
ANOSCOPY SN,7691983,CDM,750,RC,,,,,facility,outpatient,,,692.00000,200.68000,Aetna,Local,,351.33,,,,,,,249.47,566.06,percent of total billed charges,
Anoscopy SN,8328370,CDM,750,RC,,,,,facility,outpatient,,,692.00000,200.68000,Aetna,Local,,351.33,,,,,,,249.47,566.06,percent of total billed charges,
STRICTUREPLASTY,9182901,CDM,750,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,700.63,,,,,,,497.49,1128.84,percent of total billed charges,
TRIGGER POINT PROCEDURE,7692085,CDM,750,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,2132.34,,,,,,,1514.10,3435.60,percent of total billed charges,
ENTEROSCOPY,7692008,CDM,750,RC,,,,,facility,outpatient,,,3799.00000,1101.71000,Aetna,Local,,1928.75,,,,,,,1369.54,3107.58,percent of total billed charges,
ILEOPSCOPY,7692020,CDM,750,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,Local,,1489.59,,,,,,,1057.71,2400.01,percent of total billed charges,
EGD,7692013,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,Local,,876.29,,,,,,,622.22,1411.87,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Removal with Esopha,7756871,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,Local,,876.29,,,,,,,622.22,1411.87,percent of total billed charges,
EGD,8246767,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,Local,,876.29,,,,,,,622.22,1411.87,percent of total billed charges,
COLONOSCOPY,7692005,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,778.32,1766.06,percent of total billed charges,
COLONOSCOPY,7923326,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,778.32,1766.06,percent of total billed charges,
COLONOSCOPY,8246766,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,778.32,1766.06,percent of total billed charges,
Colonoscopy Screening SN,8786157,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,778.32,1766.06,percent of total billed charges,
ERCP,7691986,CDM,750,RC,,,,,facility,outpatient,,,6904.00000,2002.16000,Aetna,Local,,3505.16,,,,,,,2488.89,5647.47,percent of total billed charges,
ERCP,9212541,CDM,750,RC,,,,,facility,outpatient,,,6904.00000,2002.16000,Aetna,Local,,3505.16,,,,,,,2488.89,5647.47,percent of total billed charges,
CAPSULE ENDOSCOPY,7692006,CDM,750,RC,91110,HCPCS,,,facility,outpatient,,,5067.00000,1469.43000,Aetna,Local,,2572.52,,,,,,,682.44,4144.81,percent of total billed charges,
EG TUBE PLACEMENT OTHER,7692047,CDM,750,RC,,,,,facility,outpatient,,,1553.00000,450.37000,Aetna,Local,,788.46,,,,,,,559.86,1270.35,percent of total billed charges,
EG TUBE PLACEMENT OTHER,9000946,CDM,750,RC,,,,,facility,outpatient,,,1553.00000,450.37000,Aetna,Local,,788.46,,,,,,,559.86,1270.35,percent of total billed charges,
LOWER ENDOSCOPY WITH ULTRASOUND,7692027,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,Local,,2628.87,,,,,,,1866.67,4235.60,percent of total billed charges,
UPPER ENDOSCOPY WITH ULTRASOUND,7692031,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,Local,,2628.87,,,,,,,1866.67,4235.60,percent of total billed charges,
Upper Endoscopy w Ultrasound,8153962,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,Local,,2628.87,,,,,,,1866.67,4235.60,percent of total billed charges,
UPPER ENDOSCOPIC ULTRASOUND,8246852,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,Local,,2628.87,,,,,,,1866.67,4235.60,percent of total billed charges,
EUS NEEDLE ASPIRATION,7692030,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EUS NEEDLE ASPIRATION,7692036,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EUS FINE NEEDLE BIOPSY,9154468,CDM,750,RC,,,,,facility,outpatient,,,1267.00000,367.43000,Aetna,Local,,643.26,,,,,,,456.75,1036.41,percent of total billed charges,
EUS FINE NEEDLE BIOPSY,9154469,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
Ultrasound Upper Endoscopic Celiac Plexis Block,7692034,CDM,750,RC,,,,,facility,outpatient,,,706.00000,204.74000,Aetna,Local,,358.44,,,,,,,254.51,577.51,percent of total billed charges,
EUS BLOCK OR NEUROLYSIS,7692035,CDM,750,RC,,,,,facility,outpatient,,,706.00000,204.74000,Aetna,Local,,358.44,,,,,,,254.51,577.51,percent of total billed charges,
BALLOON ENTEROSCOPY,7692007,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,Local,,2628.87,,,,,,,1866.67,4235.60,percent of total billed charges,
COLONOSCOPY WITH POLYP OR BIOPSY,7147843,CDM,750,RC,,,,,facility,outpatient,,,3539.00000,1026.31000,Aetna,Local,,1796.75,,,,,,,1275.81,2894.90,percent of total billed charges,
EGD WITH POLYP OR BIOPSY,7147841,CDM,750,RC,,,,,facility,outpatient,,,3107.00000,901.03000,Aetna,Local,,1577.42,,,,,,,1120.07,2541.53,percent of total billed charges,
EGD WITH DILATION,7147840,CDM,750,RC,,,,,facility,outpatient,,,2470.00000,716.30000,Aetna,Local,,1254.02,,,,,,,890.43,2020.46,percent of total billed charges,
COL APC PROCEDURE,7691996,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,Local,,1753.09,,,,,,,1244.81,2824.55,percent of total billed charges,
EG APC PROCEDURE,7692037,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,Local,,1753.09,,,,,,,1244.81,2824.55,percent of total billed charges,
COL BICAP,7691997,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,Local,,614.32,,,,,,,436.20,989.78,percent of total billed charges,
EG BICAP,7692038,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,Local,,614.32,,,,,,,436.20,989.78,percent of total billed charges,
COL DILITATION,7692001,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,Local,,614.32,,,,,,,436.20,989.78,percent of total billed charges,
EG DILITATION,7692042,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,Local,,614.32,,,,,,,436.20,989.78,percent of total billed charges,
ERC DILITATION,7691987,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,Local,,614.32,,,,,,,436.20,989.78,percent of total billed charges,
COL MUCOSAL RESECTION,7692002,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,Local,,1753.09,,,,,,,1244.81,2824.55,percent of total billed charges,
EG MUCOSAL RESECTION,7692044,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,Local,,1753.09,,,,,,,1244.81,2824.55,percent of total billed charges,
COL FOREIGN BODY REMOVAL,7692003,CDM,750,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,Local,,589.95,,,,,,,418.90,950.52,percent of total billed charges,
EG FOREIGN BODY REMOVAL,7692043,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EG VARIX LIGATION,7692009,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,Local,,1753.09,,,,,,,1244.81,2824.55,percent of total billed charges,
ERC SCLEROTHERAPY,7691991,CDM,750,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,Local,,589.95,,,,,,,418.90,950.52,percent of total billed charges,
EG SCLEROTHERAPY,7692045,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
COL SCLEROTHERAPY,7692004,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
ERC POLYPECTOMY OR BIOPSY,7691988,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
ERC POLYPECTOMY OR BIOPSY,7692028,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
ERC POLYPECTOMY OR BIOPSY,7692032,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EG POLYPECTOMY OR BIOPSY,7692039,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
COL POLYPECTOMY OR BIOPSY,7691998,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
ERC STENT PLACEMENT,7691993,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EG STENT PLACEMENT,7692046,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
ESOPHAGOSCOPY,7692014,CDM,750,RC,,,,,facility,outpatient,,,1812.00000,525.48000,Aetna,Local,,919.95,,,,,,,653.23,1482.22,percent of total billed charges,
LOCAL STEROID INJECTION SOFT TISSUE,7772187,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,Local,,368.59,,,,,,,261.72,593.87,percent of total billed charges,
ERC CAUTERY,7880398,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,Local,,368.59,,,,,,,261.72,593.87,percent of total billed charges,
COL STENT PLACEMENT,7741221,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
ERC LITHOTRIPSY,7901473,CDM,750,RC,,,,,facility,outpatient,,,3306.00000,958.74000,Aetna,Local,,1678.46,,,,,,,1191.81,2704.31,percent of total billed charges,
Upper Endoscopy w Ultrasound FNA and or Biopsy,8117252,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,Local,,3329.50,,,,,,,2364.16,5364.44,percent of total billed charges,
Upper Endoscopy w Ultrasound FNA and or Biopsy,8150640,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,Local,,3329.50,,,,,,,2364.16,5364.44,percent of total billed charges,
Lower Endoscopy w Ultrasound FNA and or Biopsy,8150653,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,Local,,3329.50,,,,,,,2364.16,5364.44,percent of total billed charges,
Lower Endoscopy w Ultrasound FNA and or Biopsy,9154557,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,Local,,3329.50,,,,,,,2364.16,5364.44,percent of total billed charges,
PH CAPSULE MONITORING,7691985,CDM,750,RC,91035,HCPCS,,,facility,outpatient,,,4247.00000,1231.63000,Aetna,Local,,2156.20,,,,,,,269.28,3474.05,percent of total billed charges,
ESOPHAGEAL MANOMETRY WITH IMPEDANCE TEST,8143316,CDM,750,RC,91034,HCPCS,,,facility,outpatient,,,2634.00000,763.86000,Aetna,Local,,1337.28,,,,,,,269.28,2154.61,percent of total billed charges,
EGD,8149948,CDM,750,RC,,,,,facility,outpatient,,,1452.00000,421.08000,Aetna,Local,,737.18,,,,,,,523.45,1187.74,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Placement with Esop,7756868,CDM,750,RC,,,,,facility,outpatient,,,5593.00000,1621.97000,Aetna,Local,,2839.57,,,,,,,2016.28,4575.07,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Replacement with Es,7756869,CDM,750,RC,,,,,facility,outpatient,,,5593.00000,1621.97000,Aetna,Local,,2839.57,,,,,,,2016.28,4575.07,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Replacement without,7756870,CDM,750,RC,,,,,facility,outpatient,,,5593.00000,1621.97000,Aetna,Local,,2839.57,,,,,,,2016.28,4575.07,percent of total billed charges,
Esophageal pH with Impedance Test,8496862,CDM,750,RC,91034,HCPCS,,,facility,outpatient,,,2634.00000,763.86000,Aetna,Local,,1337.28,,,,,,,269.28,2154.61,percent of total billed charges,
Radiofrequency Ablation GI Lab,8414865,CDM,750,RC,,,,,facility,outpatient,,,5695.00000,1651.55000,Aetna,Local,,2891.35,,,,,,,2053.05,4658.51,percent of total billed charges,
Upper EUS,9182825,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,Local,,2628.87,,,,,,,1866.67,4235.60,percent of total billed charges,
Lower EUS,9184442,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,Local,,2628.87,,,,,,,1866.67,4235.60,percent of total billed charges,
EUS STENT,9182826,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EUS DILATION,9180597,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,Local,,614.32,,,,,,,436.20,989.78,percent of total billed charges,
EUS DILATION,9182827,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,Local,,614.32,,,,,,,436.20,989.78,percent of total billed charges,
EUS BIOPSY,9184443,CDM,750,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,700.63,,,,,,,497.49,1128.84,percent of total billed charges,
EUS NECROSECTOMY,9184444,CDM,750,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,700.63,,,,,,,497.49,1128.84,percent of total billed charges,
EUS CAUTERY,7535999,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,Local,,368.59,,,,,,,261.72,593.87,percent of total billed charges,
EUS CAUTERY,9186573,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,Local,,368.59,,,,,,,261.72,593.87,percent of total billed charges,
EUD STENT UPPER,9182472,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
Upper EUS with Stent,9184518,CDM,750,RC,,,,,facility,outpatient,,,6559.00000,1902.11000,Aetna,Local,,3330.00,,,,,,,2364.52,5365.26,percent of total billed charges,
Upper EUS With Dilation,9182937,CDM,750,RC,,,,,facility,outpatient,,,6388.00000,1852.52000,Aetna,Local,,3243.19,,,,,,,2302.87,5225.38,percent of total billed charges,
Upper EUS with Dilation,9182938,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,Local,,3329.50,,,,,,,2364.16,5364.44,percent of total billed charges,
Upper EUS with Necrosectomy,9182939,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,Local,,3329.50,,,,,,,2364.16,5364.44,percent of total billed charges,
EUS NECROSECTOMY UPPER,9186439,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,Local,,3329.50,,,,,,,2364.16,5364.44,percent of total billed charges,
Upper EUS With Cautery,9184519,CDM,750,RC,,,,,facility,outpatient,,,5904.00000,1712.16000,Aetna,Local,,2997.46,,,,,,,2128.39,4829.47,percent of total billed charges,
Lower EUS With Stent,9182940,CDM,750,RC,,,,,facility,outpatient,,,6559.00000,1902.11000,Aetna,Local,,3330.00,,,,,,,2364.52,5365.26,percent of total billed charges,
Lower EUS With Dilation,9182941,CDM,750,RC,,,,,facility,outpatient,,,6388.00000,1852.52000,Aetna,Local,,3243.19,,,,,,,2302.87,5225.38,percent of total billed charges,
Lower EUS With Biopsy,9184520,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,Local,,3329.50,,,,,,,2364.16,5364.44,percent of total billed charges,
Lower EUS With Necrosectomy,9182942,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,Local,,3329.50,,,,,,,2364.16,5364.44,percent of total billed charges,
EUS NECROSECTOMY LOWER,9186440,CDM,750,RC,,,,,facility,outpatient,,,6558.00000,1901.82000,Aetna,Local,,3329.50,,,,,,,2364.16,5364.44,percent of total billed charges,
Lower EUS With Cautery,9184521,CDM,750,RC,,,,,facility,outpatient,,,5904.00000,1712.16000,Aetna,Local,,2997.46,,,,,,,2128.39,4829.47,percent of total billed charges,
Neurolysis Celiac Plexus,9196728,CDM,750,RC,,,,,facility,outpatient,,,3063.00000,888.27000,Aetna,Local,,1555.09,,,,,,,1104.21,2505.53,percent of total billed charges,
Block Celiac Plexus,9196768,CDM,750,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,1095.92,2486.72,percent of total billed charges,
CAPSULE ENDOSCOPY,9202443,CDM,750,RC,91110,HCPCS,,,facility,outpatient,,,5067.00000,1469.43000,Aetna,Local,,2572.52,,,,,,,682.44,4144.81,percent of total billed charges,
FUNDOPLICATION TRANSORAL INCISIONLESS (TIF),9228447,CDM,750,RC,,,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,4569.30,,,,,,,3244.50,7362.00,percent of total billed charges,
FUNDOPLICATION TRANSORAL INCISIONLESS (TIF),9228448,CDM,750,RC,,,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,Local,,4569.30,,,,,,,3244.50,7362.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC GASTRIC (POEM)????????? ??????,9228449,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,Local,,7107.80,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC GASTRIC?(POEM)?????? ????????,9226454,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,Local,,7107.80,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC ZENKER?S (POEM),9226451,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,Local,,7107.80,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC ZENKER?S (POEM),9226455,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,Local,,7107.80,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC (POEM),9226452,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,Local,,7107.80,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC (POEM),9226456,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,Local,,7107.80,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC DIVERTICULUM (POEM)?,9226453,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,Local,,7107.80,,,,,,,5047.00,11452.00,percent of total billed charges,
MYOTOMY PERORAL ENDOSCOPIC DIVERTICULUM (POEM)?,9226457,CDM,750,RC,,,,,facility,outpatient,,,14000.00000,4060.00000,Aetna,Local,,7107.80,,,,,,,5047.00,11452.00,percent of total billed charges,
EGD W ENDOFLIP,9228463,CDM,750,RC,,,,,facility,outpatient,,,1018.00000,295.22000,Aetna,Local,,516.84,,,,,,,366.99,832.72,percent of total billed charges,
EGD W ENDOFLIP,9228464,CDM,750,RC,,,,,facility,outpatient,,,1018.00000,295.22000,Aetna,Local,,516.84,,,,,,,366.99,832.72,percent of total billed charges,
COLON ENDOSCOPIC SUBMUCOSAL DISSECTION,9226513,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,Local,,1753.09,,,,,,,1244.81,2824.55,percent of total billed charges,
COLON ENDOSCOPIC SUBMUCOSAL DISSECTION,9228483,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,Local,,1753.09,,,,,,,1244.81,2824.55,percent of total billed charges,
UPPER ENDOSCOPIC SUBMUCOSAL DISSECTION,9228484,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,Local,,1753.09,,,,,,,1244.81,2824.55,percent of total billed charges,
UPPER ENDOSCOPIC SUBMUCOSAL DISSECTION,9226520,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,Local,,1753.09,,,,,,,1244.81,2824.55,percent of total billed charges,
EGD W/ STRICTUREPLASTY,9184486,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,Local,,876.29,,,,,,,622.22,1411.87,percent of total billed charges,
EGD WITH DEBRIDEMENT,9188442,CDM,750,RC,,,,,facility,outpatient,,,3106.00000,900.74000,Aetna,Local,,1576.92,,,,,,,1119.71,2540.71,percent of total billed charges,
OVERSTITCH,9118499,CDM,750,RC,,,,,facility,outpatient,,,11000.00000,3190.00000,Aetna,Local,,5584.70,,,,,,,3965.50,8998.00,percent of total billed charges,
EGD W OVERSTICH,9206506,CDM,750,RC,,,,,facility,outpatient,,,12583.00000,3649.07000,Aetna,Local,,6388.39,,,,,,,4536.17,10292.89,percent of total billed charges,
EUS CAUTERY UPPER,9188538,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,Local,,368.59,,,,,,,261.72,593.87,percent of total billed charges,
EUS STENT PLACEMENT LOWER,9188536,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EUS STENT REMOVAL LOWER,9188537,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EUS CYSTOGASTROSTOMY,9180586,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EUS STENT REMOVAL UPPER,9188520,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
COLONOSCOPY,9186430,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,778.32,1766.06,percent of total billed charges,
Colonoscopy Screening SN,9210514,CDM,750,RC,,,,,facility,outpatient,,,2159.00000,626.11000,Aetna,Local,,1096.12,,,,,,,778.32,1766.06,percent of total billed charges,
Percutaneous Endoscopic Gastrostomy Tube Placement with Esop,9186436,CDM,750,RC,,,,,facility,outpatient,,,5593.00000,1621.97000,Aetna,Local,,2839.57,,,,,,,2016.28,4575.07,percent of total billed charges,
Upper Endoscopic Foreign Body Removal,9186438,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EG STENT PLACEMENT,9188435,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
EGD,9186433,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,Local,,876.29,,,,,,,622.22,1411.87,percent of total billed charges,
Enteroscopy,9186431,CDM,750,RC,,,,,facility,outpatient,,,3799.00000,1101.71000,Aetna,Local,,1928.75,,,,,,,1369.54,3107.58,percent of total billed charges,
ESOPHAGEAL MANOMETRYR,9188432,CDM,750,RC,91010,HCPCS,,,facility,outpatient,,,2635.00000,764.15000,Aetna,Local,,1610.00,,,,,,,269.28,2155.43,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PARACENTESIS,9186435,CDM,750,RC,,,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1401.25,,,,,,,994.98,2257.68,percent of total billed charges,
SIGMOIDOSCOPY,9188433,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,Local,,876.29,,,,,,,622.22,1411.87,percent of total billed charges,
LOWER ENDOSCOPY WITH ULTRASOUND,9186437,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,Local,,2628.87,,,,,,,1866.67,4235.60,percent of total billed charges,
UPPER ENDOSCOPY WITH ULTRASOUND,9188434,CDM,750,RC,,,,,facility,outpatient,,,5178.00000,1501.62000,Aetna,Local,,2628.87,,,,,,,1866.67,4235.60,percent of total billed charges,
ERCP,9186845,CDM,750,RC,,,,,facility,outpatient,,,6904.00000,2002.16000,Aetna,Local,,3505.16,,,,,,,2488.89,5647.47,percent of total billed charges,
ENTEROSCOPY  BIOPSY,9196830,CDM,750,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,700.63,,,,,,,497.49,1128.84,percent of total billed charges,
ENTEROSCOPY  CAUTERY,9196831,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,Local,,368.59,,,,,,,261.72,593.87,percent of total billed charges,
ENTEROSCOPY  DILATION,9196832,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,Local,,614.32,,,,,,,436.20,989.78,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE BIOPSY,9198527,CDM,750,RC,,,,,facility,outpatient,,,1380.00000,400.20000,Aetna,Local,,700.63,,,,,,,497.49,1128.84,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE CAUTERY,9196833,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,Local,,368.59,,,,,,,261.72,593.87,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE DILATION,9196834,CDM,750,RC,,,,,facility,outpatient,,,1210.00000,350.90000,Aetna,Local,,614.32,,,,,,,436.20,989.78,percent of total billed charges,
EGD CAUTERY,9198528,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,Local,,368.59,,,,,,,261.72,593.87,percent of total billed charges,
EGD CAUTERY,9198529,CDM,750,RC,,,,,facility,outpatient,,,726.00000,210.54000,Aetna,Local,,368.59,,,,,,,261.72,593.87,percent of total billed charges,
COLONOSCOPY STENT,9196835,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
COLONOSCOPY STENT,9196836,CDM,750,RC,,,,,facility,outpatient,,,1381.00000,400.49000,Aetna,Local,,701.13,,,,,,,497.85,1129.66,percent of total billed charges,
ENTEROSCOPY WITH BIOPSY,9208477,CDM,750,RC,,,,,facility,outpatient,,,5179.00000,1501.91000,Aetna,Local,,2629.38,,,,,,,1867.03,4236.42,percent of total billed charges,
ENTEROSCOPY  WITH CAUTERY,9208478,CDM,750,RC,,,,,facility,outpatient,,,4525.00000,1312.25000,Aetna,Local,,2297.34,,,,,,,1631.26,3701.45,percent of total billed charges,
ENTEROSCOPY WITH DILATION,9206473,CDM,750,RC,,,,,facility,outpatient,,,5009.00000,1452.61000,Aetna,Local,,2543.07,,,,,,,1805.74,4097.36,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE WITH BIOPSY,9208479,CDM,750,RC,,,,,facility,outpatient,,,3106.00000,900.74000,Aetna,Local,,1576.92,,,,,,,1119.71,2540.71,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE WITH CAUTERY,9206474,CDM,750,RC,,,,,facility,outpatient,,,2452.00000,711.08000,Aetna,Local,,1244.88,,,,,,,883.95,2005.74,percent of total billed charges,
FLEXIBLE SIGMOIDOSCOPE WITH DILATION,9206475,CDM,750,RC,,,,,facility,outpatient,,,2936.00000,851.44000,Aetna,Local,,1490.61,,,,,,,1058.43,2401.65,percent of total billed charges,
EGD WITH CAUTERY INPATIENT,9206500,CDM,750,RC,,,,,facility,outpatient,,,2452.00000,711.08000,Aetna,Local,,1244.88,,,,,,,883.95,2005.74,percent of total billed charges,
COLONOSCOPY WITH STENT OUTPATIENT,9208480,CDM,750,RC,,,,,facility,outpatient,,,3540.00000,1026.60000,Aetna,Local,,1797.26,,,,,,,1276.17,2895.72,percent of total billed charges,
COLONOSCOPY WITH STENT INPATIENT,9208490,CDM,750,RC,,,,,facility,outpatient,,,3540.00000,1026.60000,Aetna,Local,,1797.26,,,,,,,1276.17,2895.72,percent of total billed charges,
Endoscopic Mucosal Resection Outpatient,9212530,CDM,750,RC,,,,,facility,outpatient,,,3453.00000,1001.37000,Aetna,Local,,1753.09,,,,,,,1244.81,2824.55,percent of total billed charges,
SIGMOIDOSCOPY,7692025,CDM,750,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,Local,,876.29,,,,,,,622.22,1411.87,percent of total billed charges,
COL HEMORRHOID BANDING,7692019,CDM,750,RC,,,,,facility,outpatient,,,1162.00000,336.98000,Aetna,Local,,589.95,,,,,,,418.90,950.52,percent of total billed charges,
ESOPHAGEAL MANOMETRYR,7692021,CDM,750,RC,91010,HCPCS,,,facility,outpatient,,,2635.00000,764.15000,Aetna,Local,,1610.00,,,,,,,269.28,2155.43,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PH MONITORING,7692026,CDM,750,RC,91034,HCPCS,,,facility,outpatient,,,2316.00000,671.64000,Aetna,Local,,1175.83,,,,,,,269.28,1894.49,percent of total billed charges,
LIVER BIOPSY,7691984,CDM,750,RC,,,,,facility,outpatient,,,2901.00000,841.29000,Aetna,Local,,1472.84,,,,,,,1045.81,2373.02,percent of total billed charges,
ERC SPHINCTEROTOMY,7691992,CDM,750,RC,,,,,facility,outpatient,,,2589.00000,750.81000,Aetna,Local,,1314.44,,,,,,,933.33,2117.80,percent of total billed charges,
EGD WITH TUBE INSERTION,7692010,CDM,750,RC,,,,,facility,outpatient,,,3279.00000,950.91000,Aetna,Local,,1664.75,,,,,,,1182.08,2682.22,percent of total billed charges,
ERC STONE EXTRACTION,7691995,CDM,750,RC,,,,,facility,outpatient,,,3306.00000,958.74000,Aetna,Local,,1678.46,,,,,,,1191.81,2704.31,percent of total billed charges,
EG PEG TUBE REMOVAL WITH SCOPE,7692011,CDM,750,RC,,,,,facility,outpatient,,,3279.00000,950.91000,Aetna,Local,,1664.75,,,,,,,1182.08,2682.22,percent of total billed charges,
PEG TUBE REPLACE SIMPLE,7692017,CDM,750,RC,,,,,facility,outpatient,,,1132.00000,328.28000,Aetna,Local,,574.72,,,,,,,408.09,925.98,percent of total billed charges,
PEG TUBE INSERT,8246768,CDM,750,RC,,,,,facility,outpatient,,,1132.00000,328.28000,Aetna,Local,,574.72,,,,,,,408.09,925.98,percent of total billed charges,
EG JEJUNAL TUBE INSERTION,7692012,CDM,750,RC,,,,,facility,outpatient,,,1452.00000,421.08000,Aetna,Local,,737.18,,,,,,,523.45,1187.74,percent of total billed charges,
PARACENTESIS,7692022,CDM,750,RC,,,,,facility,outpatient,,,2760.00000,800.40000,Aetna,Local,,1401.25,,,,,,,994.98,2257.68,percent of total billed charges,
Apply multilayer Compression Lt,8282369,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,LT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Left Dressing,8997128,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,LT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Rt,8282371,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,RT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Right Dressing,8997129,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,RT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilat,8282370,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,Local,,607.21,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilateral Dressing,8997127,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,Local,,607.21,,,,,,,138.56,2860.00,percent of total billed charges,
BLOCK CHARGE,8999490,CDM,761,RC,,,,,facility,outpatient,,,2533.00000,734.57000,Aetna,Local,,1286.00,,,,,,,100.00,2071.99,percent of total billed charges,
Neg Press Wnd Tx Lt 50Cm,1099798,CDM,761,RC,97605,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,,353.87,,,,,,,32.86,570.15,percent of total billed charges,
Neg Press Wnd Tx Lt 50Cm,7959854,CDM,761,RC,97605,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,,353.87,,,,,,,32.86,570.15,percent of total billed charges,
Neg Press Wnd Tx LT 50CM,8282403,CDM,761,RC,97605,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,,353.87,,,,,,,32.86,570.15,percent of total billed charges,
Neg Press Wnd Tx Gt 50Cm,1099799,CDM,761,RC,97606,HCPCS,,,facility,outpatient,,,1244.00000,360.76000,Aetna,Local,,631.58,,,,,,,35.39,1066.38,percent of total billed charges,
Neg Press Wnd Tx Gt 50Cm,7959855,CDM,761,RC,97606,HCPCS,,,facility,outpatient,,,1244.00000,360.76000,Aetna,Local,,631.58,,,,,,,35.39,1066.38,percent of total billed charges,
Neg Press Wnd Tx GT 50 CM,8282404,CDM,761,RC,97606,HCPCS,,,facility,outpatient,,,1244.00000,360.76000,Aetna,Local,,631.58,,,,,,,35.39,1066.38,percent of total billed charges,
Application Total Contact Cast Rt,1655829,CDM,761,RC,29445,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,Local,RT,402.10,,,,,,,285.52,2860.00,percent of total billed charges,
Application Total Contact Cast Rt,7958320,CDM,761,RC,29445,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,Local,RT,402.10,,,,,,,285.52,2860.00,percent of total billed charges,
Debridement Open Wound First 20Cm,4201842,CDM,761,RC,97597,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,,1610.00,,,,,,,46.38,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Open Wound First 20Cm,7958307,CDM,761,RC,97597,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,,1610.00,,,,,,,46.38,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Nonselective Debridement,1792826,CDM,761,RC,97602,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,342.70,,,,,,,100.00,552.15,percent of total billed charges,
Nonselective Debridement,7958319,CDM,761,RC,97602,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,342.70,,,,,,,100.00,552.15,percent of total billed charges,
Nonselective Debridement,8282400,CDM,761,RC,97602,HCPCS,,,facility,outpatient,,,675.00000,195.75000,Aetna,Local,,342.70,,,,,,,100.00,552.15,percent of total billed charges,
Debridement Open Wound Addl 20 Cm,4205848,CDM,761,RC,97598,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,,1610.00,,,,,,,59.03,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Debridement Open Wound Addl 20 Cm,7958309,CDM,761,RC,97598,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,,1610.00,,,,,,,59.03,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Apply Unna Boot Bilateral,3172898,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,Local,,707.73,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Unna Boot Bilateral,7958330,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,Local,,707.73,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Unna Boot Bilateral,7958336,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,Local,,707.73,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Unna Boot Bilat,8148068,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,Local,,707.73,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Unna Boot Bilateral,8282406,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,Local,,707.73,,,,,,,138.56,2860.00,percent of total billed charges,
WHC Apply Unna Boot Iimmpregnated Wrap Bilat,8411618,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,Local,,707.73,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Una Boot Impregnated Wrap Bilat,8411856,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,1394.00000,404.26000,Aetna,Local,,707.73,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Multilayer Compression Rt,3172899,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,RT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Rt,7935309,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,RT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Rt,7958338,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,RT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Rt,8148228,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,RT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Unil,8282407,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,RT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilat,3172900,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,Local,,607.21,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilat,7958342,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,Local,,607.21,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilat,8148067,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,Local,,607.21,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Multilayer Compression Bilateral,8282408,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,1196.00000,346.84000,Aetna,Local,,607.21,,,,,,,138.56,2860.00,percent of total billed charges,
Apply Unna Boot Rt,7935311,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,RT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Rt,7958326,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,RT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Rt,7958332,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,RT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Unilateral,8282405,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,RT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
WHC Apply Unna Boot Impregnated Wrap RT,8411614,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,RT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Impregnated Wrap RT,8411858,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,RT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
Neg Press Wnd Tx W Pico Lt 50Cm,7917314,CDM,761,RC,97607,HCPCS,,,facility,outpatient,,,1188.00000,344.52000,Aetna,Local,,603.15,,,,,,,100.00,1066.38,percent of total billed charges,
Neg Press Wnd Tx W Pico Lt 50Cm,7959856,CDM,761,RC,97607,HCPCS,,,facility,outpatient,,,1188.00000,344.52000,Aetna,Local,,603.15,,,,,,,100.00,1066.38,percent of total billed charges,
Neg Press Wnd Tx W Incisional Wound Bac LT 50 CM,8282401,CDM,761,RC,97607,HCPCS,,,facility,outpatient,,,1188.00000,344.52000,Aetna,Local,,603.15,,,,,,,100.00,1066.38,percent of total billed charges,
Neg Press Wnd Tx W Pico Gt 50Cm,7917315,CDM,761,RC,97608,HCPCS,,,facility,outpatient,,,1213.00000,351.77000,Aetna,Local,,615.84,,,,,,,100.00,1066.38,percent of total billed charges,
Neg Press Wnd Tx W Pico Gt 50Cm,7959857,CDM,761,RC,97608,HCPCS,,,facility,outpatient,,,1213.00000,351.77000,Aetna,Local,,615.84,,,,,,,100.00,1066.38,percent of total billed charges,
Negative pressure wound tx with incisional wound greater,8298387,CDM,761,RC,97608,HCPCS,,,facility,outpatient,,,1213.00000,351.77000,Aetna,Local,,615.84,,,,,,,100.00,1066.38,percent of total billed charges,
Apply Unna Boot Lt,7935312,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,LT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Lt,7958328,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,LT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Unna Boot Lt,7958334,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,LT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
WHC Apply Unna Boot Impregnated Wrap LT,8411616,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,LT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Una Boot Impregnated Wrap LT,8411857,CDM,761,RC,29580,HCPCS,,,facility,outpatient,,,697.00000,202.13000,Aetna,Local,LT,353.87,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Lt,7935310,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,LT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Apply Multilayer Compression Lt,7958340,CDM,761,RC,29581,HCPCS,,,facility,outpatient,,,598.00000,173.42000,Aetna,Local,LT,303.60,,,,,,,207.83,2860.00,percent of total billed charges,
Application Total Contact Cast Bilat,7958324,CDM,761,RC,29445,HCPCS,,,facility,outpatient,,,1584.00000,459.36000,Aetna,Local,,804.20,,,,,,,233.19,2860.00,percent of total billed charges,
GENICULAR NERVE BLOCK,7902230,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
Pain Mgmt Px w Fluoro bce,8151063,CDM,761,RC,,,,,facility,outpatient,,,4140.00000,1200.60000,Aetna,Local,,2101.88,,,,,,,100.00,3386.52,percent of total billed charges,
Pain Management Block,8151452,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
PMS ASPIRATION FLUID,8388545,CDM,761,RC,,,,,facility,outpatient,,,1508.00000,437.32000,Aetna,Local,,765.61,,,,,,,100.00,1233.54,percent of total billed charges,
BLOCK OBTURATOR AND FEMORAL NERVE,8152281,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
Injection Sternal Costalcondral Joint,7882891,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
Ultrasound Guidance SN,8999446,CDM,761,RC,,,,,facility,outpatient,,,1358.00000,393.82000,Aetna,Local,,689.46,,,,,,,100.00,1110.84,percent of total billed charges,
Medial Nerve Block Bilat,9182680,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
PMS RADIOFREQUENCY ABLATION BILAT,9182681,CDM,761,RC,,,,,facility,outpatient,,,12540.00000,3636.60000,Aetna,Local,,6366.56,,,,,,,100.00,10257.72,percent of total billed charges,
PMS TRANSFORMINAL INJECTION BILAT,9180801,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
SI JOINT INJECTION BILAT,9182682,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
HIP INJECTION BILAT,9180802,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
FACET JOINT INJECTION BILAT,9182683,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
CELIAC PEXUS BLOCK BILAT,9182684,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
GENICULAR NERVE BLOCK BILAT,9180803,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
OCCIPITAL NERVE BLOCK BILAT,9182685,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
SELECTIVE NERVE ROOT INJECTION BILAT,9182686,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
BURSA BLOCK BILAT,9182687,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
KNEE INJECTION BILAT,9180804,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
Ilioiinguinal Nerve Block Bilat,9192510,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
Coccygeal Joint Injection Bilat,9194523,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
Shoulder Injection Bilat,9194524,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
Thermal Ablation Each Additional Vertebral Body,9046250,CDM,761,RC,,,,,facility,outpatient,,,4800.00000,1392.00000,Aetna,Local,,2436.96,,,,,,,100.00,3926.40,percent of total billed charges,
NEUROSURGICAL PROCEDURE KIT,9042872,CDM,761,RC,C1889,HCPCS,,,facility,outpatient,,,3100.00000,899.00000,Aetna,Local,,1573.87,,,,,,,100.00,2535.80,percent of total billed charges,
PAIN NERVE STIMULATION,9060237,CDM,761,RC,,,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,Local,,10966.32,,,,,,,100.00,17668.80,percent of total billed charges,
INTRACEPT,9046199,CDM,761,RC,,,,,facility,outpatient,,,19200.00000,5568.00000,Aetna,Local,,9747.84,,,,,,,100.00,15705.60,percent of total billed charges,
PAIN MANAGEMENT FLUORO IMAGING,9228443,CDM,761,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,100.00,981.60,percent of total billed charges,
UNILATERAL JOINT BLOCK,9222435,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
JOINT BLOCK BILATERAL,9220565,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
PERIFORMIS INJECTION,7692062,CDM,761,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,2132.34,,,,,,,100.00,3435.60,percent of total billed charges,
KNEE INJECTION,7692088,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
FEMORAL NERVE BLOCK,7764039,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
BLOOD PATCH,7692078,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
SYMPATHETIC NERVE BLOCK,7692060,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
Block Thoracic Sympathetic,7965420,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
CERVICAL EPIDURAL BLOCK,7692081,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
LUMBAR EPIDURAL BLOCK,7692082,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
THORACIC EPIDURAL BLOCK,7692083,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
CAUDAL EPIDURAL BLOCK,7692080,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
OCCIPITAL NERVE BLOCK,7692048,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
OCCIPITAL NERVE BLOCK,7692061,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
TRIGEMINAL NERVE BLOCK,7692065,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
ILIOIINGUINAL NERVE BLOCK,7692056,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
STELLATE BLOCK,7692064,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
INTERSCALENE BLOCK,7692058,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
INTERCOSTAL BLOCK,7692057,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
FACET JOINT INJECTION,7692053,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
INTRATHECAL INJECTION,7692087,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
ABLATION,7692098,CDM,761,RC,,,,,facility,outpatient,,,6270.00000,1818.30000,Aetna,Local,,3183.28,,,,,,,100.00,5128.86,percent of total billed charges,
PMS RADIOFREQUENCY ABLATION,7692099,CDM,761,RC,,,,,facility,outpatient,,,6270.00000,1818.30000,Aetna,Local,,3183.28,,,,,,,100.00,5128.86,percent of total billed charges,
PMS TRANSFORMINAL INJECTION,7692084,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
PMS TRANSFORMINAL NERVE INJECTION,7966345,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
MEDIAL NERVE BLOCK,7691978,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
PMS MEDIAL NERVE INJECTION,7966342,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
SELECTIVE NERVE ROOT INJECTION,7692063,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
CELIAC PEXUS BLOCK,7692052,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
ANALYZE PUMP WO PROGRAMMING,7692069,CDM,761,RC,,,,,facility,outpatient,,,960.00000,278.40000,Aetna,Local,,487.39,,,,,,,100.00,785.28,percent of total billed charges,
VERTEBROPLASTY,7692105,CDM,761,RC,22510,HCPCS,,,facility,outpatient,,,32252.00000,9353.08000,Aetna,Local,,3456.00,,,,,,,2848.95,26382.14,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ANALYZE PUMP WITH PROGRAMMING,7692072,CDM,761,RC,,,,,facility,outpatient,,,1398.00000,405.42000,Aetna,Local,,709.76,,,,,,,100.00,1143.56,percent of total billed charges,
HIP INJECTION,7692054,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
EPIDURAL CATHETER INSERTION,7692096,CDM,761,RC,,,,,facility,outpatient,,,7111.00000,2062.19000,Aetna,Local,,3610.25,,,,,,,100.00,5816.80,percent of total billed charges,
SHOULDER INJECTION,7692100,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
INSERT TEMP SPINAL STIM,7692086,CDM,761,RC,,,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,Local,,10966.32,,,,,,,100.00,17668.80,percent of total billed charges,
INSERT TEMP SPINAL STIM,7692095,CDM,761,RC,,,,,facility,outpatient,,,21600.00000,6264.00000,Aetna,Local,,10966.32,,,,,,,100.00,17668.80,percent of total billed charges,
PMS VERTEBROPLASTY ADDTL LEVEL,7742108,CDM,761,RC,,,,,facility,outpatient,,,13943.00000,4043.47000,Aetna,Local,,7078.86,,,,,,,100.00,11405.37,percent of total billed charges,
PMS ABLATION ADDL,7742107,CDM,761,RC,,,,,facility,outpatient,,,5320.00000,1542.80000,Aetna,Local,,2700.96,,,,,,,100.00,4351.76,percent of total billed charges,
DISCOGRAM,7692066,CDM,761,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,2132.34,,,,,,,100.00,3435.60,percent of total billed charges,
DISCOGRAM,7692090,CDM,761,RC,62290,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,1610.00,,,,,,,1514.10,3435.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DISCOGRAM,7692104,CDM,761,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,2132.34,,,,,,,100.00,3435.60,percent of total billed charges,
Injection for Discogram,8147111,CDM,761,RC,,,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,Local,,2132.34,,,,,,,100.00,3435.60,percent of total billed charges,
MILD PROCEDURE BILAT INIT,7692092,CDM,761,RC,,,,,facility,outpatient,,,22800.00000,6612.00000,Aetna,Local,,11575.56,,,,,,,100.00,18650.40,percent of total billed charges,
PMS MILD PROCEDURE BILAT ADDTL,7742105,CDM,761,RC,,,,,facility,outpatient,,,16337.00000,4737.73000,Aetna,Local,,8294.29,,,,,,,100.00,13363.67,percent of total billed charges,
MILD PROCEDURE UNILAT INITIAL,7692093,CDM,761,RC,,,,,facility,outpatient,,,11400.00000,3306.00000,Aetna,Local,,5787.78,,,,,,,100.00,9325.20,percent of total billed charges,
PMS MILD PROCEDURE UNILAT ADDTL,7742106,CDM,761,RC,C1889,HCPCS,,,facility,outpatient,,,8168.00000,2368.72000,Aetna,Local,,4146.89,,,,,,,100.00,6681.42,percent of total billed charges,
PMS DISCOGRAM ADDITIONAL LEVEL,7742103,CDM,761,RC,,,,,facility,outpatient,,,2470.00000,716.30000,Aetna,Local,,1254.02,,,,,,,100.00,2020.46,percent of total billed charges,
PMS KYPHOPLASTY ADDITIONAL LEVEL,7742104,CDM,761,RC,,,,,facility,outpatient,,,17570.00000,5095.30000,Aetna,Local,,8920.29,,,,,,,100.00,14372.26,percent of total billed charges,
PMS ADDITIONAL LEVEL,7703402,CDM,761,RC,,,,,facility,outpatient,,,1518.00000,440.22000,Aetna,Local,,770.69,,,,,,,100.00,1241.72,percent of total billed charges,
COCCYGEAL JOINT INJECTION,7692074,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
CLINIC PUMP DYE STUDY,7692071,CDM,761,RC,G0463,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,Local,,132.51,,,,,,,96.88,343.96,percent of total billed charges,
GANGLIA IMPAR BLOCK,7692077,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
ILEOINGUINAL HYPOGAST BLOCK,7692055,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
ILEOINGUINAL HYPOGAST BLOCK,7692103,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
ANALYZE AND REFILL PUMP,7692073,CDM,761,RC,,,,,facility,outpatient,,,1710.00000,495.90000,Aetna,Local,,868.17,,,,,,,100.00,1398.78,percent of total billed charges,
KYPHOPLASTY,7692089,CDM,761,RC,,,,,facility,outpatient,,,22800.00000,6612.00000,Aetna,Local,,11575.56,,,,,,,100.00,18650.40,percent of total billed charges,
EPIDURAL CATHETER INJECTION,7692075,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
SI JOINT INJECTION,7692079,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
PMS SI JOINT INJECTION,7966344,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
BIER BLOCK,7692050,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
BURSA BLOCK,7692051,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
JOINT BLOCK,7692059,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
JOINT BLOCK,7692102,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
SPHENOPALATINE BLOCK,7692101,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
ANKLE INJECTION,7692049,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
EPIDURAL WITH RACZ,7692076,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
INSERT PUMP TRIAL INTRATHECAL,7692097,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
ABLATION COOLED,7744602,CDM,761,RC,,,,,facility,outpatient,,,9500.00000,2755.00000,Aetna,Local,,4823.15,,,,,,,100.00,7771.00,percent of total billed charges,
PMS ABLATION COOLED,8413679,CDM,761,RC,,,,,facility,outpatient,,,9500.00000,2755.00000,Aetna,Local,,4823.15,,,,,,,100.00,7771.00,percent of total billed charges,
UNILATERAL MEDIAL NERVE BLOCK,9198672,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL PMS RADIOFREQUENCY ABLATION,9198673,CDM,761,RC,,,,,facility,outpatient,,,6270.00000,1818.30000,Aetna,Local,,3183.28,,,,,,,100.00,5128.86,percent of total billed charges,
Unilateral PMS Transforminal Injection,9198680,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL SI JOINT INJECTION,9198681,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL HIP INJECTION,9198682,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL FACET JOINT INJECTION,9198674,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL CELIAC PEXUS BLOCK,9198683,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL GENICULAR NERVE BLOCK,9198675,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL OCCIPITAL NERVE BLOCK,9198676,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL SELECTIVE NERVE ROOT INJECTION,9198684,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL BURSA BLOCK,9198685,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL KNEE INJECTION,9198677,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL ILIOIINGUINAL NERVE BLOCK,9198678,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
UNILATERAL COCCYGEAL JOINT INJECTION,9198679,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
Unilateral Shoulder Injection,9198686,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
MEDIAL NERVE BLOCK  BILATERAL,9212560,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
PMS RADIOFREQUENCY ABALATION  BILATERAL,9210618,CDM,761,RC,,,,,facility,outpatient,,,12540.00000,3636.60000,Aetna,Local,,6366.56,,,,,,,100.00,10257.72,percent of total billed charges,
PMS TRANSFORMINAL INJECTION  BILATERAL,9212561,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
SI JOINT INJECTION  BILATERAL,9212562,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
HIP INJECTION  BILATERAL,9212563,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
FACET JOINT INJECTION  BILATERAL,9210619,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
CELIAC PEXUS BLOCK  BILATERAL,9212564,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
GENICULAR NERVE BLOCK  BILATERAL,9210620,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
OCCIPITAL NERVE BLOCK  BILATERAL,9210621,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
SELECTIVE NERVE ROOT INJECTION  BILATERAL,9212565,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
BURSA BLOCK  BILATERAL,9212566,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
KNEE INJECTION  BILATERAL,9212567,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
ILIOIINGUINAL NERVE BLOCK  BILATERAL,9212568,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
COCCYGEAL JOINT INJECTION  BILATERAL,9210622,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
SHOULDER INJECTION  BILATERAL,9210623,CDM,761,RC,,,,,facility,outpatient,,,6080.00000,1763.20000,Aetna,Local,,3086.82,,,,,,,100.00,4973.44,percent of total billed charges,
BLOCK CHARGE RECTUS SHEATH,8414116,CDM,761,RC,,,,,facility,outpatient,,,3040.00000,881.60000,Aetna,Local,,1543.41,,,,,,,100.00,2486.72,percent of total billed charges,
RA Steroid Injection Right,7943878,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,Local,,1489.59,,,,,,,100.00,2400.01,percent of total billed charges,
RA Steroid Injection Left,7943882,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,Local,,1489.59,,,,,,,100.00,2400.01,percent of total billed charges,
RA Steroid Injection Right,7943886,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,Local,,1489.59,,,,,,,100.00,2400.01,percent of total billed charges,
RA Steroid Injection,7957052,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,Local,,1489.59,,,,,,,100.00,2400.01,percent of total billed charges,
RA Steroid Injection,7957054,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,Local,,1489.59,,,,,,,100.00,2400.01,percent of total billed charges,
RA Steroid Injection Left,8147184,CDM,761,RC,,,,,facility,outpatient,,,2934.00000,850.86000,Aetna,Local,,1489.59,,,,,,,100.00,2400.01,percent of total billed charges,
RA Foot Steroid Injection,9005754,CDM,761,RC,,,,,facility,outpatient,,,2266.00000,657.14000,Aetna,Local,,1150.45,,,,,,,100.00,1853.59,percent of total billed charges,
RA Foot Steroid Injection,9005777,CDM,761,RC,,,,,facility,outpatient,,,2266.00000,657.14000,Aetna,Local,,1150.45,,,,,,,100.00,1853.59,percent of total billed charges,
RA Foot Steroid Injection Add,9005776,CDM,761,RC,,,,,facility,outpatient,,,2266.00000,657.14000,Aetna,Local,,1150.45,,,,,,,100.00,1853.59,percent of total billed charges,
RA Foot Steroid Injection,9005745,CDM,761,RC,,,,,facility,outpatient,,,2266.00000,657.14000,Aetna,Local,,1150.45,,,,,,,100.00,1853.59,percent of total billed charges,
RA OR Pain Management Fluoro Imaging,8160760,CDM,761,RC,,,,,facility,outpatient,,,1200.00000,348.00000,Aetna,Local,,609.24,,,,,,,100.00,981.60,percent of total billed charges,
ELASTOGRAPHY LIVER,7935095,CDM,761,RC,91200,HCPCS,,,facility,outpatient,,,679.00000,196.91000,Aetna,Local,,344.73,,,,,,,100.00,555.42,percent of total billed charges,
Fibroscan/Vibration Controlled Transient Elastography,9188431,CDM,761,RC,91200,HCPCS,,,facility,outpatient,,,679.00000,196.91000,Aetna,Local,,344.73,,,,,,,100.00,555.42,percent of total billed charges,
Direct Admit to Observation,8137552,CDM,762,RC,G0379,HCPCS,,,facility,outpatient,,,690.00000,200.10000,Aetna,Local,,,50.77,,,,,0,276.00,7424.10,percent of total billed charges,"Not to exceed $2,400; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
Observation,1327815,CDM,762,RC,G0378,HCPCS,,,facility,outpatient,,,199.00000,57.71000,Aetna,Local,,,50.77,,,,,0,58.12,7424.10,percent of total billed charges,"Not to exceed $2,400; there were no paid claims found for this combination of service, payer, and plan within the prior 12-15 months of this file's publishing"
Administration of Vaccine Addl,8150967,CDM,771,RC,90472,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Flu Vaccine,7950051,CDM,771,RC,G0008,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,20.50,265.85,percent of total billed charges,
Administration Of Pneumo Vaccine,7950052,CDM,771,RC,G0009,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,46.90,265.85,percent of total billed charges,
Administration Of Vaccine,7950049,CDM,771,RC,90471,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,62.50,265.85,percent of total billed charges,
Administration Of Hep B Vaccine,7950050,CDM,771,RC,G0010,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,46.90,265.85,percent of total billed charges,
Administration Regeneron,8426818,CDM,771,RC,M0243,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,288.40,654.40,percent of total billed charges,
Administration Of Pfizer Covid Vaccine 5y thru11y Dose 1,8478329,CDM,771,RC,0001A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,117.16,265.85,percent of total billed charges,
Admin Of Pfizer Covid Vaccine 6m thru 4y Dose 1,8924187,CDM,771,RC,0001A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine 5y thru 11y Dose 2,8478330,CDM,771,RC,0001A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,117.16,265.85,percent of total billed charges,
Administration of Sotrovimab,8547937,CDM,771,RC,M0247,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,288.40,654.40,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Bivalent Booster,8975065,CDM,771,RC,0124A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 1,8982651,CDM,771,RC,0001A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 2,8982652,CDM,771,RC,0002A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Bivalent Booster,8982653,CDM,771,RC,0124A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,117.16,265.85,percent of total billed charges,
Admin Tocilizumab 1st Dose,8440193,CDM,771,RC,M0249,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,296.96,654.40,percent of total billed charges,
Admin Tocilizumab 2nd Dose,8440194,CDM,771,RC,M0250,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,296.96,654.40,percent of total billed charges,
Administration Charge Bebtelovimab,8918346,CDM,771,RC,M0222,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,288.40,654.40,percent of total billed charges,
Administration Charge Cilgavimab Tixagevimab,8920380,CDM,771,RC,M0220,HCPCS,,,facility,outpatient,,,800.00000,232.00000,Aetna,Local,,406.16,,,,,,,288.40,654.40,percent of total billed charges,
Administration Of Flu Vaccine,8975011,CDM,771,RC,G0008,HCPCS,,,facility,outpatient,,,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.71,123.14,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 1,8433884,CDM,771,RC,0001A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,117.16,265.85,percent of total billed charges,
Administration Of Pfizer Covid Vaccine Dose 2,8433885,CDM,771,RC,0002A,HCPCS,,,facility,outpatient,,,325.00000,94.25000,Aetna,Local,,165.00,,,,,,,117.16,265.85,percent of total billed charges,
NUR CRRT,7911611,CDM,801,RC,,,,,facility,outpatient,,,2472.00000,716.88000,Aetna,Local,,1255.03,,,,,,,891.16,2022.10,percent of total billed charges,
NUR CRRT,7911615,CDM,801,RC,,,,,facility,outpatient,,,2472.00000,716.88000,Aetna,Local,,1255.03,,,,,,,891.16,2022.10,percent of total billed charges,
NUR CRRT Cartridge Change,7887355,CDM,801,RC,,,,,facility,outpatient,,,1511.00000,438.19000,Aetna,Local,,767.13,,,,,,,544.72,1236.00,percent of total billed charges,
Continuous Cycling Peritoneal Dialysis,8297104,CDM,801,RC,,,,,facility,outpatient,,,3066.00000,889.14000,Aetna,Local,,1556.61,,,,,,,1105.29,2507.99,percent of total billed charges,
Continuous Cycling Peritoned Dialysis CCPD,8360510,CDM,801,RC,,,,,facility,outpatient,,,3066.00000,889.14000,Aetna,Local,,1556.61,,,,,,,1105.29,2507.99,percent of total billed charges,
Hemodialysis,599436,CDM,801,RC,,,,,facility,outpatient,,,1401.00000,406.29000,Aetna,Local,,711.29,,,,,,,505.06,1146.02,percent of total billed charges,
Hemodialysis,7902271,CDM,801,RC,,,,,facility,outpatient,,,1401.00000,406.29000,Aetna,Local,,711.29,,,,,,,505.06,1146.02,percent of total billed charges,
Peritoneal CAPD,7939048,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939049,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939050,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939051,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939052,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939053,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939054,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,7939055,CDM,803,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,118.97,269.94,percent of total billed charges,
Peritoneal CAPD,1327818,CDM,880,RC,,,,,facility,outpatient,,,330.00000,95.70000,Aetna,Local,,167.54,,,,,,,118.97,754.78,percent of total billed charges,
Navigator PIN Services 60 min,9192582,CDM,900,RC,G0023,HCPCS,,,facility,outpatient,,,218.00000,63.22000,Aetna,Local,,110.68,,,,,,,80.92,246.90,percent of total billed charges,
Navigator PIN Services Addl 30 min,9196429,CDM,900,RC,G0024,HCPCS,,,facility,outpatient,,,109.00000,31.61000,Aetna,Local,,55.34,,,,,,,39.29,89.16,percent of total billed charges,
Bladder Scan,1327798,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,7310963,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,7310964,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,7311846,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,7311847,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,7957581,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,52.15,2860.00,percent of total billed charges,
Bladder Scan,8997124,CDM,920,RC,51798,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,Local,,132.00,,,,,,,52.15,2860.00,percent of total billed charges,
Electronic Uterine Monitoring,5975845,CDM,920,RC,59025,HCPCS,,,facility,outpatient,,,1543.00000,447.47000,Aetna,Local,,783.38,,,,,,,176.65,2860.00,percent of total billed charges,
Mat Fetal Non Stress Test,7932403,CDM,920,RC,59025,HCPCS,,,facility,outpatient,,,1543.00000,447.47000,Aetna,Local,,783.38,,,,,,,176.65,2860.00,percent of total billed charges,
Fetal Non Stress Test,9020167,CDM,920,RC,59025,HCPCS,,,facility,outpatient,,,1543.00000,447.47000,Aetna,Local,,783.38,,,,,,,176.65,2860.00,percent of total billed charges,
Fetal Non Stress Test,9020168,CDM,920,RC,59025,HCPCS,,,facility,outpatient,,,1543.00000,447.47000,Aetna,Local,,783.38,,,,,,,176.65,2860.00,percent of total billed charges,
Mat Version,7932258,CDM,920,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,Local,,876.29,,,,,,,622.22,1411.87,percent of total billed charges,
Mat Version,8156195,CDM,920,RC,,,,,facility,outpatient,,,1726.00000,500.54000,Aetna,Local,,876.29,,,,,,,622.22,1411.87,percent of total billed charges,
Short Latency Somatosens EP Std Upr Low Limb bce,9110074,CDM,920,RC,95938,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,Local,,1445.42,,,,,,,465.90,2328.85,percent of total billed charges,
Ctr Motr EP Std Transcrnl Motr Stim Upr and Low Limb bce,9110075,CDM,920,RC,95939,HCPCS,,,facility,outpatient,,,2847.00000,825.63000,Aetna,Local,,1445.42,,,,,,,860.13,2715.51,percent of total billed charges,
Neuromuscular Junct Tstg EA Nrv Any one Meth bce,9114654,CDM,920,RC,95937,HCPCS,,,facility,outpatient,,,776.00000,225.04000,Aetna,Local,,393.98,,,,,,,128.88,634.77,percent of total billed charges,
Sl Home Sleep Test Type 3,6047847,CDM,920,RC,G0399,HCPCS,,,facility,outpatient,,,1806.00000,523.74000,Aetna,Local,,916.91,,,,,,,216.27,1477.31,percent of total billed charges,"Not to exceed $1,824"
Home Sleep Test Type 3,8410286,CDM,920,RC,G0399,HCPCS,,,facility,outpatient,,,1806.00000,523.74000,Aetna,Local,,916.91,,,,,,,216.27,1477.31,percent of total billed charges,"Not to exceed $1,824"
Sl Cpap Titration Study,7719223,CDM,920,RC,95811,HCPCS,,,facility,outpatient,,,5190.00000,1505.10000,Aetna,Local,,2634.96,,,,,,,860.13,4245.42,percent of total billed charges,"Not to exceed $1,824"
CPAP Titration Study,8410260,CDM,920,RC,95811,HCPCS,,,facility,outpatient,,,5190.00000,1505.10000,Aetna,Local,,2634.96,,,,,,,860.13,4245.42,percent of total billed charges,"Not to exceed $1,824"
SL Device Analysis and Simple Programming,8441868,CDM,920,RC,95976,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,Local,,68.03,,,,,,,32.74,109.61,percent of total billed charges,
Device Analysis Simple Program 3 or fewer adj,8994606,CDM,920,RC,95976,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,Local,,68.03,,,,,,,32.74,109.61,percent of total billed charges,
SL Device Analysis and Complex Programming,8441869,CDM,920,RC,95977,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,,171.60,,,,,,,80.60,276.48,percent of total billed charges,
Device Interrogation Complex Program,8994612,CDM,920,RC,95977,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,,171.60,,,,,,,80.60,276.48,percent of total billed charges,
Short Home Sleep Test Type 3,8798123,CDM,920,RC,G0399,HCPCS,,,facility,outpatient,,,1024.00000,296.96000,Aetna,Local,,519.88,,,,,,,216.27,837.63,percent of total billed charges,"Not to exceed $1,824"
Sl Polysomnography Attended,612743,CDM,920,RC,95810,HCPCS,,,facility,outpatient,,,8897.00000,2580.13000,Aetna,Local,,4517.01,,,,,,,860.13,7277.75,percent of total billed charges,"Not to exceed $1,824"
Multi Channel Poly PSG,8410231,CDM,920,RC,95810,HCPCS,,,facility,outpatient,,,8897.00000,2580.13000,Aetna,Local,,4517.01,,,,,,,860.13,7277.75,percent of total billed charges,"Not to exceed $1,824"
Sl Sleep Latency,612749,CDM,920,RC,95805,HCPCS,,,facility,outpatient,,,5808.00000,1684.32000,Aetna,Local,,2948.72,,,,,,,465.90,4750.94,percent of total billed charges,"Not to exceed $1,824"
Sleep Latency MSLT,8410253,CDM,920,RC,95805,HCPCS,,,facility,outpatient,,,5808.00000,1684.32000,Aetna,Local,,2948.72,,,,,,,465.90,4750.94,percent of total billed charges,"Not to exceed $1,824"
Sl Polysom With Cpap Bipap,612751,CDM,920,RC,95811,HCPCS,,,facility,outpatient,,,10257.00000,2974.53000,Aetna,Local,,5207.48,,,,,,,860.13,8390.23,percent of total billed charges,"Not to exceed $1,824"
Polysom with PAP Titration or Split Night,8410239,CDM,920,RC,95811,HCPCS,,,facility,outpatient,,,10257.00000,2974.53000,Aetna,Local,,5207.48,,,,,,,860.13,8390.23,percent of total billed charges,"Not to exceed $1,824"
Sl Ventilatory Monitor Sleep Stdy,644560,CDM,920,RC,95807,HCPCS,,,facility,outpatient,,,4326.00000,1254.54000,Aetna,Local,,2196.31,,,,,,,373.76,3538.67,percent of total billed charges,"Not to exceed $1,824"
Vent Monitor Sleep Study,8410275,CDM,920,RC,95807,HCPCS,,,facility,outpatient,,,4326.00000,1254.54000,Aetna,Local,,2196.31,,,,,,,373.76,3538.67,percent of total billed charges,"Not to exceed $1,824"
Multi CH Poly Short Study less than 6 hrs,8410246,CDM,920,RC,95810,HCPCS,,,facility,outpatient,,,4201.00000,1218.29000,Aetna,Local,,2132.85,,,,,,,860.13,3436.42,percent of total billed charges,"Not to exceed $1,824"
Sl Mwt Wakefulness Test,644559,CDM,920,RC,95805,HCPCS,,,facility,outpatient,,,5808.00000,1684.32000,Aetna,Local,,2948.72,,,,,,,465.90,4750.94,percent of total billed charges,"Not to exceed $1,824"
Wakefulness Test MWT,8410268,CDM,920,RC,95805,HCPCS,,,facility,outpatient,,,5808.00000,1684.32000,Aetna,Local,,2948.72,,,,,,,465.90,4750.94,percent of total billed charges,"Not to exceed $1,824"
NAS Multi Level,1792832,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,Local,,494.00,,,,,,,137.38,1823.32,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NAS Multi Level,7959543,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,Local,,494.00,,,,,,,137.38,1823.32,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NAS Multi Levels,602682,CDM,921,RC,93922,HCPCS,,,facility,outpatient,,,1622.00000,470.38000,Aetna,Local,,494.00,,,,,,,113.19,1326.80,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TcPO ABI unilat 1 to 2 levels,7959545,CDM,921,RC,93922,HCPCS,,,facility,outpatient,,,1622.00000,470.38000,Aetna,Local,,494.00,,,,,,,113.19,1326.80,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NAS Multi Levels,7959560,CDM,921,RC,93922,HCPCS,,,facility,outpatient,,,1622.00000,470.38000,Aetna,Local,,494.00,,,,,,,113.19,1326.80,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Miscellaneous Noninvasive Proced,7943837,CDM,921,RC,93998,HCPCS,,,facility,outpatient,,,622.00000,180.38000,Aetna,Local,,494.00,,,,,,,21.51,525.00,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Art Pvr Lowers W Exercise,599274,CDM,921,RC,93924,HCPCS,,,facility,outpatient,,,2452.00000,711.08000,Aetna,Local,,494.00,,,,,,,137.38,2005.74,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Art Pvr Lowers W Exercise,7957284,CDM,921,RC,93924,HCPCS,,,facility,outpatient,,,2452.00000,711.08000,Aetna,Local,,494.00,,,,,,,137.38,2005.74,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Art Pvr Uppers,599272,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,Local,,494.00,,,,,,,137.38,1823.32,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Art Pvr Uppers,599280,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,Local,,494.00,,,,,,,137.38,1823.32,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Art Pvr Uppers,7957283,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,Local,,494.00,,,,,,,137.38,1823.32,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Art Unilateral Study,599298,CDM,921,RC,93922,HCPCS,,,facility,outpatient,,,1622.00000,470.38000,Aetna,Local,,494.00,,,,,,,113.19,1326.80,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Art Unilateral Study,7963886,CDM,921,RC,93922,HCPCS,,,facility,outpatient,,,1622.00000,470.38000,Aetna,Local,,494.00,,,,,,,113.19,1326.80,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Art Pvr Lowers Rest,599302,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,Local,,494.00,,,,,,,137.38,1823.32,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Art Pvr Lowers Rest,7957285,CDM,921,RC,93923,HCPCS,,,facility,outpatient,,,2229.00000,646.41000,Aetna,Local,,494.00,,,,,,,137.38,1823.32,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Upper Extremity Limited,7949906,CDM,921,RC,93931,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Upper Extremity Limited,7949910,CDM,921,RC,93931,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Right,7235927,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,RT,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Right,7273891,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,RT,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Right,7949935,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,RT,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Right,7949943,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,RT,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Left,7235931,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,LT,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Left,7235935,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,LT,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Left,7949931,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,LT,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Left,7949939,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,LT,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Bilateral,7235939,CDM,921,RC,93970,HCPCS,,,facility,outpatient,,,4257.00000,1234.53000,Aetna,Local,,494.00,,,,,,,212.24,3482.23,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Bilateral,7273892,CDM,921,RC,93970,HCPCS,,,facility,outpatient,,,4257.00000,1234.53000,Aetna,Local,,494.00,,,,,,,212.24,3482.23,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Bilateral,7812050,CDM,921,RC,93970,HCPCS,,,facility,outpatient,,,4257.00000,1234.53000,Aetna,Local,,494.00,,,,,,,212.24,3482.23,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Venous Duplex Bilateral,7812054,CDM,921,RC,93970,HCPCS,,,facility,outpatient,,,4257.00000,1234.53000,Aetna,Local,,494.00,,,,,,,212.24,3482.23,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Upper Extremity Complete,7949902,CDM,921,RC,93930,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,Local,,494.00,,,,,,,212.24,1915.76,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Abdomen Duplex Scan Limited,7938489,CDM,921,RC,93976,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,Local,,494.00,,,,,,,93.38,1005.32,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Duplex Scan,8001071,CDM,921,RC,93975,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,Local,,494.00,,,,,,,212.24,1005.32,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Ultrasound Duplex,8436725,CDM,921,RC,93975,HCPCS,,,facility,outpatient,,,1229.00000,356.41000,Aetna,Local,,494.00,,,,,,,212.24,1005.32,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Leg Bilateral Limited,9162411,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,Local,,494.00,,,,,,,93.38,3483.04,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Leg Right Limited,9164403,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Leg Left Limited,9164401,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Arm Bilateral Limited,9162407,CDM,921,RC,93931,HCPCS,,,facility,outpatient,,,4258.00000,1234.82000,Aetna,Local,,494.00,,,,,,,93.38,3483.04,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Arm Right Limited,9164399,CDM,921,RC,93931,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Arm Left Limited,9186638,CDM,921,RC,93931,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Abdomen Duplex Complete,7520004,CDM,921,RC,93975,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,Local,,494.00,,,,,,,212.24,1915.76,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Abdomen Duplex Complete,7520008,CDM,921,RC,93975,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,Local,,494.00,,,,,,,212.24,1915.76,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Abdomen Duplex Complete,7520012,CDM,921,RC,93975,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,Local,,494.00,,,,,,,212.24,1915.76,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Saphenous Vein Mapping,614149,CDM,921,RC,93971,HCPCS,,,facility,outpatient,,,2027.00000,587.83000,Aetna,Local,,494.00,,,,,,,93.38,1658.09,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Lower Extremity Complete,7856094,CDM,921,RC,93925,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,Local,,494.00,,,,,,,212.24,1915.76,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Lower Extremity Complete,7949891,CDM,921,RC,93925,HCPCS,,,facility,outpatient,,,2342.00000,679.18000,Aetna,Local,,494.00,,,,,,,212.24,1915.76,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Lower Extremity Limited,7949894,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Lower Extremity Limited,7949898,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Lower Extremity Limited,7949923,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Sono Arterial Duplex Lower Extremity Limited,7949927,CDM,921,RC,93926,HCPCS,,,facility,outpatient,,,2129.00000,617.41000,Aetna,Local,,494.00,,,,,,,93.38,1741.52,fee schedule,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Auditory Potentials,599358,CDM,922,RC,92653,HCPCS,,,facility,outpatient,,,1465.00000,424.85000,Aetna,Local,,743.78,,,,,,,216.27,1198.37,percent of total billed charges,
Auditory Evoked Potentials,8426907,CDM,922,RC,92653,HCPCS,,,facility,outpatient,,,1465.00000,424.85000,Aetna,Local,,743.78,,,,,,,216.27,1198.37,percent of total billed charges,
Needle EMG One Extremity,599316,CDM,922,RC,95860,HCPCS,,,facility,outpatient,,,830.00000,240.70000,Aetna,Local,,421.39,,,,,,,113.19,678.94,percent of total billed charges,
Needle EMG One Extremity,7957145,CDM,922,RC,95860,HCPCS,,,facility,outpatient,,,830.00000,240.70000,Aetna,Local,,421.39,,,,,,,113.19,678.94,percent of total billed charges,
Needle EMG One Extremity,7957530,CDM,922,RC,95860,HCPCS,,,facility,outpatient,,,830.00000,240.70000,Aetna,Local,,421.39,,,,,,,113.19,678.94,percent of total billed charges,
Needle EMG Two Extremities,599318,CDM,922,RC,95861,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,842.78,,,,,,,113.19,1357.88,percent of total billed charges,
Needle EMG Two Extremities,7957531,CDM,922,RC,95861,HCPCS,,,facility,outpatient,,,1660.00000,481.40000,Aetna,Local,,842.78,,,,,,,113.19,1357.88,percent of total billed charges,
Repetetive Stimulation Each Nerve,7957144,CDM,922,RC,95937,HCPCS,,,facility,outpatient,,,892.00000,258.68000,Aetna,Local,,452.87,,,,,,,128.88,729.66,percent of total billed charges,
Repetetive Stimulation Each Nerve,971814,CDM,922,RC,95937,HCPCS,,,facility,outpatient,,,892.00000,258.68000,Aetna,Local,,452.87,,,,,,,128.88,729.66,percent of total billed charges,
Motor F Wave Study,931800,CDM,922,RC,95905,HCPCS,,,facility,outpatient,,,460.00000,133.40000,Aetna,Local,,233.54,,,,,,,170.75,1065.07,percent of total billed charges,
EMG Thoracic Paraspinal,2490836,CDM,922,RC,95869,HCPCS,,,facility,outpatient,,,743.00000,215.47000,Aetna,Local,,377.22,,,,,,,216.27,831.14,percent of total billed charges,
EMG Thoracic Paraspinal,7957147,CDM,922,RC,95869,HCPCS,,,facility,outpatient,,,743.00000,215.47000,Aetna,Local,,377.22,,,,,,,216.27,831.14,percent of total billed charges,
EMG With Nerve Comp Each Ext,5517839,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,Local,,600.10,,,,,,,426.11,966.88,percent of total billed charges,
EMG With Nerve Comp Each Ext,7957148,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,Local,,600.10,,,,,,,426.11,966.88,percent of total billed charges,
Right,9016283,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,Local,RT,600.10,,,,,,,426.11,966.88,percent of total billed charges,
Left,9016284,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,Local,LT,600.10,,,,,,,426.11,966.88,percent of total billed charges,
Bilateral,9016285,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,Local,,600.10,,,,,,,426.11,966.88,percent of total billed charges,
EMG With Nerve Limited Each Ext,7957149,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,Local,,300.05,,,,,,,213.06,483.44,percent of total billed charges,
Right,9014663,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,Local,RT,300.05,,,,,,,213.06,483.44,percent of total billed charges,
Bilateral,9014664,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,Local,,300.05,,,,,,,213.06,483.44,percent of total billed charges,
Left,9016292,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,Local,LT,300.05,,,,,,,213.06,483.44,percent of total billed charges,
EMG Cranial Nerve,5517841,CDM,922,RC,95887,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,Local,,300.05,,,,,,,213.06,483.44,percent of total billed charges,
EMG Cranial Nerve,7957146,CDM,922,RC,95887,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,Local,,300.05,,,,,,,213.06,483.44,percent of total billed charges,
Nerve Conduction 1 To 2,7957543,CDM,922,RC,95907,HCPCS,,,facility,outpatient,,,1013.00000,293.77000,Aetna,Local,,514.30,,,,,,,137.38,828.63,percent of total billed charges,
Nerve Conduction 3 To 4,7957544,CDM,922,RC,95908,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,Local,,720.93,,,,,,,216.27,1161.56,percent of total billed charges,
Nerve Conduction 5 To 6,7957545,CDM,922,RC,95909,HCPCS,,,facility,outpatient,,,1762.00000,510.98000,Aetna,Local,,894.57,,,,,,,216.27,1441.32,percent of total billed charges,
Nerve Conduction 7 To 8,7957546,CDM,922,RC,95910,HCPCS,,,facility,outpatient,,,2635.00000,764.15000,Aetna,Local,,1337.79,,,,,,,273.42,2155.43,percent of total billed charges,
Nerve Conduction 9 To 10,7957547,CDM,922,RC,95911,HCPCS,,,facility,outpatient,,,3243.00000,940.47000,Aetna,Local,,1646.47,,,,,,,373.76,2652.77,percent of total billed charges,
Nerve Conduction 11 To 12,7957548,CDM,922,RC,95912,HCPCS,,,facility,outpatient,,,3852.00000,1117.08000,Aetna,Local,,1955.66,,,,,,,373.76,3150.94,percent of total billed charges,
Nerve Conduction 13 Or More,7957549,CDM,922,RC,95913,HCPCS,,,facility,outpatient,,,4461.00000,1293.69000,Aetna,Local,,2264.85,,,,,,,373.76,3649.10,percent of total billed charges,
Blink Reflex Nerve Conduction,7963892,CDM,922,RC,95933,HCPCS,,,facility,outpatient,,,520.00000,150.80000,Aetna,Local,,264.00,,,,,,,59.09,425.36,percent of total billed charges,
EMG With Nerve Limited Each Right Ext,9016681,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,Local,RT,300.05,,,,,,,213.06,483.44,percent of total billed charges,
EMG With Nerve Limited Each Left Ext,9014980,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,Local,LT,300.05,,,,,,,213.06,483.44,percent of total billed charges,
EMG With Nerve Limited Each Bilateral,9016683,CDM,922,RC,95885,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,Local,,600.10,,,,,,,426.11,966.88,percent of total billed charges,
EMG With Nerve Comp Each Right Ext,9016677,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,Local,RT,300.05,,,,,,,213.06,483.44,percent of total billed charges,
EMG With Nerve Comp Each Left Ext,9014978,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,591.00000,171.39000,Aetna,Local,LT,300.05,,,,,,,213.06,483.44,percent of total billed charges,
EMG With Nerve Comp Each Bilateral,9016679,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,Local,,600.10,,,,,,,426.11,966.88,percent of total billed charges,
EMG w Nerve Comp Ea Bilteral,9041348,CDM,922,RC,95886,HCPCS,,,facility,outpatient,,,1182.00000,342.78000,Aetna,Local,,600.10,,,,,,,426.11,966.88,percent of total billed charges,
Injection SubQ IM,9094184,CDM,940,RC,96372,HCPCS,,,facility,outpatient,,,375.00000,108.75000,Aetna,Local,,190.39,,,,,,,62.50,306.75,percent of total billed charges,
OP Initial Injection SubQ IM,9106494,CDM,940,RC,96372,HCPCS,,,facility,outpatient,,,375.00000,108.75000,Aetna,Local,,190.39,,,,,,,62.50,306.75,percent of total billed charges,
Phlebotomy,7457902,CDM,940,RC,99195,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,324.42,,,,,,,113.19,522.70,percent of total billed charges,
Phlebotomy,7957593,CDM,940,RC,99195,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,324.42,,,,,,,113.19,522.70,percent of total billed charges,
Phlebotomy Therapeutic,8997121,CDM,940,RC,99195,HCPCS,,,facility,outpatient,,,639.00000,185.31000,Aetna,Local,,324.42,,,,,,,113.19,522.70,percent of total billed charges,
CR Periph Art Dx Rehab,7982780,CDM,940,RC,93668,HCPCS,,,facility,outpatient,,,255.00000,73.95000,Aetna,Local,,129.46,,,,,,,52.15,208.59,percent of total billed charges,
OP Injection SubQ IM of Patients Own Med,9092744,CDM,940,RC,96372,HCPCS,,,facility,outpatient,,,375.00000,108.75000,Aetna,Local,FB,190.39,,,,,,,62.50,306.75,percent of total billed charges,
OP Initial Injection SubQ IM of Patients Own Med,9106495,CDM,940,RC,96372,HCPCS,,,facility,outpatient,,,375.00000,108.75000,Aetna,Local,FB,190.39,,,,,,,62.50,306.75,percent of total billed charges,
DSME RD Individual,8437087,CDM,942,RC,G0108,HCPCS,,,facility,outpatient,,,183.00000,53.07000,Aetna,Local,,92.91,,,,,,,48.16,149.69,percent of total billed charges,
DSME RD Group,8437099,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,Local,,30.97,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Individual,7786274,CDM,942,RC,G0108,HCPCS,,,facility,outpatient,,,183.00000,53.07000,Aetna,Local,,92.91,,,,,,,48.16,149.69,percent of total billed charges,
DSME CDCES Follow Up,8437123,CDM,942,RC,G0108,HCPCS,,,facility,outpatient,,,183.00000,53.07000,Aetna,Local,,92.91,,,,,,,48.16,149.69,percent of total billed charges,
DSME CDCES Group,8123144,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,Local,,30.97,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8123145,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,Local,,30.97,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8123146,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,Local,,30.97,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8123147,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,Local,,30.97,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8123148,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,Local,,30.97,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8123149,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,Local,,30.97,,,,,,,13.78,49.90,percent of total billed charges,
DSME CDCES Group,8437127,CDM,942,RC,G0109,HCPCS,,,facility,outpatient,,,61.00000,17.69000,Aetna,Local,,30.97,,,,,,,13.78,49.90,percent of total billed charges,
MNT Initial,8437103,CDM,942,RC,97802,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,Local,,44.17,,,,,,,17.07,71.17,percent of total billed charges,
MNT Follow Up,8437107,CDM,942,RC,97803,HCPCS,,,facility,outpatient,,,87.00000,25.23000,Aetna,Local,,44.17,,,,,,,17.07,71.17,percent of total billed charges,
MNT Group,8437119,CDM,942,RC,97804,HCPCS,,,facility,outpatient,,,57.00000,16.53000,Aetna,Local,,28.94,,,,,,,6.75,46.63,percent of total billed charges,
CR Exercise Without Monitor,6717839,CDM,943,RC,93797,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,,171.60,,,,,,,110.55,336.06,percent of total billed charges,
CR Exercise And Monitor,1327802,CDM,943,RC,93798,HCPCS,,,facility,outpatient,,,338.00000,98.02000,Aetna,Local,,171.60,,,,,,,110.55,336.06,percent of total billed charges,
PR Pulmonary Rehab,5263839,CDM,948,RC,94625,HCPCS,,,facility,outpatient,,,335.00000,97.15000,Aetna,Local,,170.08,,,,,,,52.15,274.03,percent of total billed charges,
PR Pulmon Rehab Procedure 15Min,5757841,CDM,948,RC,G0239,HCPCS,,,facility,outpatient,,,453.00000,131.37000,Aetna,Local,,229.99,,,,,,,37.41,370.55,percent of total billed charges,
PR Resp Therapy Group,5757840,CDM,948,RC,G0239,HCPCS,,,facility,outpatient,,,439.00000,127.31000,Aetna,Local,,222.88,,,,,,,37.41,359.10,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,23155048901,NDC,,,facility,outpatient,1,EA,37.40000,10.85000,Aetna,Local,,18.99,,,,,,,13.48,30.59,percent of total billed charges,
NUTR- Peptamen AF (1L),800040931,CDM,637,RC,98716066380,NDC,,,facility,outpatient,1,EA,315.65000,91.54000,Aetna,Local,,160.26,,,,,,,113.79,258.20,percent of total billed charges,
NUTR- Nutren 2.0 (1L),800040927,CDM,637,RC,98716033147,NDC,,,facility,outpatient,1,EA,54.90000,15.92000,Aetna,Local,,27.87,,,,,,,19.79,44.91,percent of total billed charges,
NUTR- Peptamen 1.5 (1L),800040930,CDM,637,RC,98716018194,NDC,,,facility,outpatient,1,EA,321.70000,93.29000,Aetna,Local,,163.33,,,,,,,115.97,263.15,percent of total billed charges,
NUTR- Nutren 2.0 (250mL),800040926,CDM,637,RC,98716006230,NDC,,,facility,outpatient,1,EA,16.25000,4.71000,Aetna,Local,,8.25,,,,,,,5.86,13.29,percent of total billed charges,
NUTR- PROSource TF20 60mL,800046575,CDM,637,RC,94688014406,NDC,,,facility,outpatient,1,EA,22.50000,6.52000,Aetna,Local,,11.42,,,,,,,8.11,18.41,percent of total billed charges,
HYDROmorphone 0.2mg/mL /NS PCA,800019908,CDM,636,RC,J1171,HCPCS,88888772031,NDC,facility,inpatient,20,ME,204.70000,59.36000,Aetna,Local,,81.88,,,,,,,73.79,167.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,87701040072,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,83634050082,NDC,facility,inpatient,4,GM,57.40000,16.65000,Aetna,Local,,22.96,,,,,,,20.69,46.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,83634050081,NDC,facility,inpatient,2,GM,53.15000,15.41000,Aetna,Local,,21.26,,,,,,,19.16,43.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,83634045101,NDC,facility,inpatient,0.004,ME,388.10000,112.55000,Aetna,Local,,155.24,,,,,,,139.91,317.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,83634040010,NDC,facility,inpatient,250,ME,846.00000,245.34000,Aetna,Local,,338.40,,,,,,,304.98,692.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,83634030204,NDC,facility,inpatient,40,ME,11.50000,3.34000,Aetna,Local,,4.60,,,,,,,4.15,9.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Chloride 7% Inhalation Soln,800046518,CDM,250,RC,83490020760,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,Local,,3.17,,,,,,,2.25,5.11,percent of total billed charges,
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,800046526,CDM,636,RC,Q5108,HCPCS,83257000541,NDC,facility,inpatient,6,ME,8506.60000,2466.91000,Aetna,Local,,3402.64,,,,,,,3066.63,6958.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,800046526,CDM,636,RC,Q5108,HCPCS,83257000541,NDC,facility,outpatient,6,ME,8506.60000,2466.91000,Aetna,Local,,3402.64,,,,,,,95.21,6958.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- dkst 420mg Inj,800051055,CDM,636,RC,Q5114,HCPCS,83257000412,NDC,facility,inpatient,420,ME,14362.25000,4165.05000,Aetna,Local,,5744.90,,,,,,,5177.59,11748.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- dkst 420mg Inj,800051055,CDM,636,RC,Q5114,HCPCS,83257000412,NDC,facility,outpatient,420,ME,14362.25000,4165.05000,Aetna,Local,,5744.90,,,,,,,36.31,11748.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- dkst 150mg Inj,800051054,CDM,636,RC,Q5114,HCPCS,83257000111,NDC,facility,inpatient,150,ME,5265.75000,1527.07000,Aetna,Local,,2106.30,,,,,,,1898.30,4307.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- dkst 150mg Inj,800051054,CDM,636,RC,Q5114,HCPCS,83257000111,NDC,facility,outpatient,150,ME,5265.75000,1527.07000,Aetna,Local,,2106.30,,,,,,,36.31,4307.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
naloxegol 25mg Tab UD,800046420,CDM,637,RC,82625880201,NDC,,,facility,outpatient,1,EA,123.60000,35.84000,Aetna,Local,,62.75,,,,,,,44.56,101.10,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,82036427401,NDC,,,facility,outpatient,1,EA,477.75000,138.55000,Aetna,Local,,242.55,,,,,,,172.23,390.80,percent of total billed charges,
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,81952011210,NDC,facility,inpatient,30000,UN,119.30000,34.60000,Aetna,Local,,47.72,,,,,,,43.01,97.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,81665020025,NDC,,,facility,outpatient,1,EA,155.55000,45.11000,Aetna,Local,,78.97,,,,,,,56.08,127.24,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,81298965903,NDC,,,facility,outpatient,1,EA,274.20000,79.52000,Aetna,Local,,139.21,,,,,,,98.85,224.30,percent of total billed charges,
Norepinephrine 8mg/NS 250mL-Dbl Conc,800051974,CDM,250,RC,81298965503,NDC,,,facility,outpatient,1,EA,379.80000,110.14000,Aetna,Local,,192.82,,,,,,,136.92,310.68,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,81298811001,NDC,facility,inpatient,500,ME,1007.40000,292.15000,Aetna,Local,,402.96,,,,,,,363.17,824.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,81298578105,NDC,facility,inpatient,40,ME,33.50000,9.72000,Aetna,Local,,13.40,,,,,,,12.08,27.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,81298501003,NDC,,,facility,inpatient,1,EA,352.05000,102.09000,Aetna,Local,,140.82,,,,,,,126.91,287.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,81298501003,NDC,,,facility,outpatient,1,EA,352.05000,102.09000,Aetna,Local,,140.82,,,,,,,126.91,287.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,81284061210,NDC,,,facility,outpatient,1,EA,36.50000,10.58000,Aetna,Local,,18.53,,,,,,,13.16,29.86,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,81284061110,NDC,,,facility,outpatient,1,EA,52.80000,15.31000,Aetna,Local,,26.81,,,,,,,19.03,43.19,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,81284041110,NDC,facility,inpatient,1,ME,399.00000,115.71000,Aetna,Local,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,81033051250,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,Local,,4.75,,,,,,,3.37,7.65,percent of total billed charges,
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,800046390,CDM,636,RC,J0612,HCPCS,80830236202,NDC,facility,inpatient,1,GM,201.45000,58.42000,Aetna,Local,,80.58,,,,,,,72.62,164.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tranexamic Acid 1g/100mL Bolus,800062092,CDM,250,RC,80830232903,NDC,,,facility,outpatient,1,EA,208.90000,60.58000,Aetna,Local,,106.06,,,,,,,75.31,170.88,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,80830169102,NDC,,,facility,outpatient,1,EA,445.00000,129.05000,Aetna,Local,,225.93,,,,,,,160.42,364.01,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,79854051281,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,Local,,0.15231,,,,,,,0.10815,0.24540,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,78670013002,NDC,facility,inpatient,0.3,ME,663.00000,192.27000,Aetna,Local,,265.20,,,,,,,239.01,542.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab - abda 100mg Inj,800046544,CDM,636,RC,Q5104,HCPCS,78206016201,NDC,facility,inpatient,100,ME,5611.40000,1627.31000,Aetna,Local,,2244.56,,,,,,,2022.91,4590.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab - abda 100mg Inj,800046544,CDM,636,RC,Q5104,HCPCS,78206016201,NDC,facility,outpatient,100,ME,5611.40000,1627.31000,Aetna,Local,,2244.56,,,,,,,26.72,4590.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etonogestrel 68 mg Implant,800062083,CDM,636,RC,J7307,HCPCS,78206014501,NDC,facility,inpatient,68,ME,7689.40000,2229.93000,Aetna,Local,,3075.76,,,,,,,2772.03,6289.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,78206012302,NDC,,,facility,outpatient,1,EA,51.90000,15.05000,Aetna,Local,,26.35,,,,,,,18.71,42.45,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,78206012202,NDC,,,facility,outpatient,1,EA,38.05000,11.03000,Aetna,Local,,19.32,,,,,,,13.72,31.12,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,78206012201,NDC,,,facility,outpatient,1,EA,38.05000,11.03000,Aetna,Local,,19.32,,,,,,,13.72,31.12,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,78206012101,NDC,,,facility,outpatient,1,EA,28.40000,8.24000,Aetna,Local,,14.42,,,,,,,10.24,23.23,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,78206011801,NDC,facility,inpatient,30,ME,267.35000,77.53000,Aetna,Local,,106.94,,,,,,,96.38,218.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,78112073623,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,Local,,25.03,,,,,,,17.77,40.33,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,78112073621,NDC,,,facility,outpatient,1,EA,56.80000,16.47000,Aetna,Local,,28.84,,,,,,,20.48,46.46,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,76439030910,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,Local,,3.93,,,,,,,2.79,6.34,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,76439030210,NDC,,,facility,outpatient,1,EA,36.40000,10.56000,Aetna,Local,,18.48,,,,,,,13.12,29.78,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,76385013401,NDC,,,facility,outpatient,1,EA,28.05000,8.13000,Aetna,Local,,14.24,,,,,,,10.11,22.94,percent of total billed charges,
Lidocaine 4% Topical Trach Kit,800025652,CDM,250,RC,76329630005,NDC,,,facility,outpatient,1,EA,253.45000,73.50000,Aetna,Local,,128.68,,,,,,,91.37,207.32,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,76329339001,NDC,,,facility,inpatient,1,EA,57.20000,16.59000,Aetna,Local,,22.88,,,,,,,20.62,46.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,76329339001,NDC,,,facility,outpatient,1,EA,57.20000,16.59000,Aetna,Local,,22.88,,,,,,,20.62,46.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,76329336901,NDC,facility,inpatient,2,ME,204.85000,59.41000,Aetna,Local,,81.94,,,,,,,73.85,167.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Bicarb 50mEq/50mL IS,800018007,CDM,250,RC,76329335201,NDC,,,facility,outpatient,1,EA,125.70000,36.45000,Aetna,Local,,63.82,,,,,,,45.31,102.82,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,76329334001,NDC,facility,inpatient,1,ME,73.10000,21.20000,Aetna,Local,,29.24,,,,,,,26.35,59.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,76329333901,NDC,facility,inpatient,1,ME,57.45000,16.66000,Aetna,Local,,22.98,,,,,,,20.71,46.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,76329331801,NDC,facility,inpatient,1,ME,87.70000,25.43000,Aetna,Local,,35.08,,,,,,,31.62,71.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,76329331601,NDC,facility,inpatient,1,ME,62.90000,18.24000,Aetna,Local,,25.16,,,,,,,22.68,51.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,76329330401,NDC,,,facility,outpatient,1,EA,67.05000,19.44000,Aetna,Local,,34.04,,,,,,,24.17,54.85,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,76329146901,NDC,facility,inpatient,2,ME,108.20000,31.38000,Aetna,Local,,43.28,,,,,,,39.01,88.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,76329124005,NDC,facility,inpatient,1,ME,27.15000,7.87000,Aetna,Local,,10.86,,,,,,,9.79,22.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,1,ME,144.15000,41.80000,Aetna,Local,,57.66,,,,,,,51.97,117.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 1mg/0.5mL Inj - Alum Free,800051071,CDM,636,RC,J3430,HCPCS,76329124001,NDC,facility,inpatient,1,ME,144.15000,41.80000,Aetna,Local,,57.66,,,,,,,51.97,117.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,76297000141,NDC,facility,inpatient,1,EA,93.95000,27.25000,Aetna,Local,,37.58,,,,,,,33.87,76.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,76297000131,NDC,facility,inpatient,1,EA,51.85000,15.04000,Aetna,Local,,20.74,,,,,,,18.69,42.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,76297000121,NDC,facility,inpatient,1,EA,46.30000,13.43000,Aetna,Local,,18.52,,,,,,,16.69,37.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,76154047415,NDC,,,facility,outpatient,1,EA,178.50000,51.76000,Aetna,Local,,90.62,,,,,,,64.35,146.01,percent of total billed charges,
EPINEPHrine 4 mg/NS 250mL IVPB,800020060,CDM,636,RC,J0165,HCPCS,76154046615,NDC,facility,inpatient,4,ME,212.50000,61.62000,Aetna,Local,,85.00,,,,,,,76.61,173.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,76125079025,NDC,facility,inpatient,12.5,GM,642.80000,186.41000,Aetna,Local,,257.12,,,,,,,231.73,525.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,76045020420,NDC,facility,inpatient,10,ME,234.40000,67.98000,Aetna,Local,,93.76,,,,,,,84.50,191.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,76045001010,NDC,facility,inpatient,2,ME,34.55000,10.02000,Aetna,Local,,13.82,,,,,,,12.46,28.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,76045000910,NDC,facility,inpatient,1,ME,34.55000,10.02000,Aetna,Local,,13.82,,,,,,,12.46,28.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,76045000120,NDC,facility,inpatient,2,ME,30.15000,8.74000,Aetna,Local,,12.06,,,,,,,10.87,24.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,76014090310,NDC,facility,inpatient,10,ME,106.55000,30.90000,Aetna,Local,,42.62,,,,,,,38.41,87.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,76014000525,NDC,,,facility,outpatient,1,EA,263.10000,76.30000,Aetna,Local,,133.58,,,,,,,94.85,215.22,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,76014000410,NDC,facility,inpatient,50,ME,226.85000,65.79000,Aetna,Local,,90.74,,,,,,,81.78,185.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,76014000310,NDC,facility,inpatient,10,ME,117.20000,33.99000,Aetna,Local,,46.88,,,,,,,42.25,95.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,75907004601,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,Local,,18.51,,,,,,,13.14,29.82,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,75907004301,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,Local,,8.38,,,,,,,5.95,13.50,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,75907002548,NDC,,,facility,outpatient,1,EA,510.90000,148.16000,Aetna,Local,,259.38,,,,,,,184.18,417.92,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,75907002448,NDC,,,facility,outpatient,1,EA,379.45000,110.04000,Aetna,Local,,192.65,,,,,,,136.79,310.39,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,75907002348,NDC,,,facility,outpatient,1,EA,233.20000,67.63000,Aetna,Local,,118.40,,,,,,,84.07,190.76,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,75907000530,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,Local,,26.71,,,,,,,18.96,43.03,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,75834031101,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,Local,,3.76,,,,,,,2.67,6.05,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,800055060,CDM,637,RC,75834028030,NDC,,,facility,outpatient,1,EA,28.45000,8.25000,Aetna,Local,,14.44,,,,,,,10.26,23.27,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,75834015801,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,Local,,5.18,,,,,,,3.68,8.34,percent of total billed charges,
Balsam Peru-Castor Oil Topical Oint,800025588,CDM,637,RC,75834013960,NDC,,,facility,outpatient,1,EA,261.75000,75.91000,Aetna,Local,,132.89,,,,,,,94.36,214.11,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,75834012401,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,Local,,0.48231,,,,,,,0.34247,0.77710,percent of total billed charges,
PHENobarbital 97.2 mg Tab,800051981,CDM,637,RC,75826014210,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
PHENobarbital 64.8mg Tab,800051980,CDM,637,RC,75826014110,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,Local,,0.76155,,,,,,,0.54075,1.23,percent of total billed charges,
PHENobarbital 32.4 mg Tab,800051123,CDM,637,RC,75826013910,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,Local,,0.71078,,,,,,,0.50470,1.15,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,75826011410,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,74300008186,NDC,,,facility,outpatient,1,EA,45.05000,13.06000,Aetna,Local,,22.87,,,,,,,16.24,36.85,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,74300000530,NDC,,,facility,outpatient,1,EA,44.25000,12.83000,Aetna,Local,,22.47,,,,,,,15.95,36.20,percent of total billed charges,
Indomethacin 100mg Rectal Supp,800046501,CDM,637,RC,73702014071,NDC,,,facility,outpatient,1,EA,1809.00000,524.61000,Aetna,Local,,918.43,,,,,,,652.14,1479.76,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,73702013410,NDC,facility,inpatient,200,ME,141.05000,40.90000,Aetna,Local,,56.42,,,,,,,50.85,115.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,73702012915,NDC,,,facility,outpatient,1,EA,61.25000,17.76000,Aetna,Local,,31.10,,,,,,,22.08,50.10,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,73702012510,NDC,facility,inpatient,1,ME,23.80000,6.90000,Aetna,Local,,9.52,,,,,,,8.58,19.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
efgartigimod alfa-hyaluronidase qvfc Inj - Pt Own Supply,800051962,CDM,636,RC,J9334,HCPCS,73475310203,NDC,facility,inpatient,1,EA,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,73293000101,NDC,,,facility,inpatient,1,EA,15.70000,4.55000,Aetna,Local,,6.28,,,,,,,5.66,12.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,73293000101,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,Local,,6.28,,,,,,,5.66,12.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ublituximab - xiiy 150mg- Pt Own Supply,800051074,CDM,636,RC,J2329,HCPCS,73150015006,NDC,facility,inpatient,150,ME,0.50000,0.14000,Aetna,Local,,0.20000,,,,,,,0.18025,0.40900,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,72888014938,NDC,,,facility,outpatient,1,EA,713.10000,206.80000,Aetna,Local,,362.04,,,,,,,257.07,583.32,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,72888009401,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,72888008001,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,72888001201,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,72819018509,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,Local,,5.28,,,,,,,3.75,8.51,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,72611076510,NDC,facility,inpatient,1,GM,57.50000,16.67000,Aetna,Local,,23.00,,,,,,,20.73,47.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,72611076110,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,72611074010,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,Local,,3.17,,,,,,,2.25,5.11,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,72611072225,NDC,facility,inpatient,30,ME,7.15000,2.07000,Aetna,Local,,2.86,,,,,,,2.58,5.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,72611071925,NDC,facility,inpatient,15,ME,6.70000,1.94000,Aetna,Local,,2.68,,,,,,,2.42,5.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,72611071601,NDC,facility,inpatient,500,ME,3059.80000,887.34000,Aetna,Local,,1223.92,,,,,,,1103.06,2502.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bevacizumab - adcd 400mg Inj,800051963,CDM,636,RC,Q5129,HCPCS,72606001201,NDC,facility,inpatient,400,ME,14818.85000,4297.47000,Aetna,Local,,5927.54,,,,,,,5342.20,12121.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bevacizumab - adcd 400mg Inj,800051963,CDM,636,RC,Q5129,HCPCS,72606001201,NDC,facility,outpatient,400,ME,14818.85000,4297.47000,Aetna,Local,,5927.54,,,,,,,36.75,12121.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bevacizumab - adcd 100mg Inj,800051964,CDM,636,RC,Q5129,HCPCS,72606001101,NDC,facility,inpatient,100,ME,3844.95000,1115.04000,Aetna,Local,,1537.98,,,,,,,1386.10,3145.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bevacizumab - adcd 100mg Inj,800051964,CDM,636,RC,Q5129,HCPCS,72606001101,NDC,facility,outpatient,100,ME,3844.95000,1115.04000,Aetna,Local,,1537.98,,,,,,,36.75,3145.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,72578009301,NDC,,,facility,outpatient,1,EA,413.15000,119.81000,Aetna,Local,,209.76,,,,,,,148.94,337.96,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,72578004001,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,72578000201,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,72516001601,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,72508020410,NDC,,,facility,outpatient,1,EA,51.40000,14.91000,Aetna,Local,,26.10,,,,,,,18.53,42.05,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,72508020407,NDC,,,facility,outpatient,1,EA,51.30000,14.88000,Aetna,Local,,26.05,,,,,,,18.49,41.96,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,72485067031,NDC,,,facility,outpatient,1,EA,141.85000,41.14000,Aetna,Local,,72.02,,,,,,,51.14,116.03,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,72485062513,NDC,,,facility,outpatient,1,EA,948.35000,275.02000,Aetna,Local,,481.48,,,,,,,341.88,775.75,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,72485050810,NDC,,,facility,outpatient,1,EA,28.90000,8.38000,Aetna,Local,,14.67,,,,,,,10.42,23.64,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,72485050725,NDC,facility,inpatient,200,ME,39.60000,11.48000,Aetna,Local,,15.84,,,,,,,14.28,32.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,72485050510,NDC,facility,inpatient,50,ME,101.50000,29.44000,Aetna,Local,,40.60,,,,,,,36.59,83.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,72485042210,NDC,facility,inpatient,2,GM,68.25000,19.79000,Aetna,Local,,27.30,,,,,,,24.60,55.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,72485042110,NDC,facility,inpatient,1,GM,46.45000,13.47000,Aetna,Local,,18.58,,,,,,,16.75,38.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,72485041710,NDC,facility,inpatient,3,GM,50.90000,14.76000,Aetna,Local,,20.36,,,,,,,18.35,41.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,72485041610,NDC,facility,inpatient,1.5,GM,30.25000,8.77000,Aetna,Local,,12.10,,,,,,,10.91,24.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,72485040610,NDC,facility,inpatient,2,GM,98.70000,28.62000,Aetna,Local,,39.48,,,,,,,35.58,80.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,72485040410,NDC,facility,inpatient,4.5,GM,173.60000,50.34000,Aetna,Local,,69.44,,,,,,,62.58,142.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,72485040310,NDC,facility,inpatient,3.375,GM,137.10000,39.76000,Aetna,Local,,54.84,,,,,,,49.42,112.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,72485030501,NDC,,,facility,outpatient,1,EA,103.75000,30.09000,Aetna,Local,,52.67,,,,,,,37.40,84.87,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,72485011610,NDC,facility,inpatient,25,ME,239.00000,69.31000,Aetna,Local,,95.60,,,,,,,86.16,195.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,72485011010,NDC,,,facility,outpatient,1,EA,169.05000,49.02000,Aetna,Local,,85.83,,,,,,,60.94,138.28,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,72485010825,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,Local,,16.88,,,,,,,11.99,27.20,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,72485010625,NDC,facility,inpatient,500,ME,24.00000,6.96000,Aetna,Local,,9.60,,,,,,,8.65,19.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,72485010501,NDC,,,facility,outpatient,1,EA,210.10000,60.93000,Aetna,Local,,106.67,,,,,,,75.74,171.86,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,72485010401,NDC,facility,inpatient,60,ME,96.00000,27.84000,Aetna,Local,,38.40,,,,,,,34.61,78.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,72485010125,NDC,facility,inpatient,50,ME,10.20000,2.96000,Aetna,Local,,4.08,,,,,,,3.68,8.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,72485010105,NDC,facility,inpatient,50,ME,19.15000,5.55000,Aetna,Local,,7.66,,,,,,,6.90,15.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,72266025301,NDC,facility,inpatient,10,ME,38.40000,11.14000,Aetna,Local,,15.36,,,,,,,13.84,31.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,72266023425,NDC,facility,inpatient,15,ME,6.45000,1.87000,Aetna,Local,,2.58,,,,,,,2.33,5.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,72266020410,NDC,facility,inpatient,10,ME,29.30000,8.50000,Aetna,Local,,11.72,,,,,,,10.56,23.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,72266019701,NDC,,,facility,outpatient,1,EA,127.45000,36.96000,Aetna,Local,,64.71,,,,,,,45.95,104.25,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,72266016306,NDC,,,facility,outpatient,1,EA,601.80000,174.52000,Aetna,Local,,305.53,,,,,,,216.95,492.27,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,72266016201,NDC,facility,inpatient,100,ME,238.00000,69.02000,Aetna,Local,,95.20,,,,,,,85.80,194.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,72266016042,NDC,facility,inpatient,20,ME,203.65000,59.06000,Aetna,Local,,81.46,,,,,,,73.42,166.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,72266016010,NDC,facility,inpatient,20,ME,203.65000,59.06000,Aetna,Local,,81.46,,,,,,,73.42,166.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,72266015910,NDC,facility,inpatient,1,GM,710.00000,205.90000,Aetna,Local,,284.00,,,,,,,255.96,580.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,72266015905,NDC,facility,inpatient,1,GM,710.00000,205.90000,Aetna,Local,,284.00,,,,,,,255.96,580.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,72266015201,NDC,facility,inpatient,5,ME,1019.40000,295.63000,Aetna,Local,,407.76,,,,,,,367.49,833.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,72266014610,NDC,,,facility,outpatient,1,EA,28.35000,8.22000,Aetna,Local,,14.39,,,,,,,10.22,23.19,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,72266012705,NDC,facility,inpatient,20,ME,156.30000,45.33000,Aetna,Local,,62.52,,,,,,,56.35,127.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,72266012325,NDC,facility,inpatient,4,ME,5.50000,1.60000,Aetna,Local,,2.20,,,,,,,1.98,4.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,72266012225,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,Local,,4.21,,,,,,,2.99,6.79,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,72266012205,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,Local,,3.07,,,,,,,2.18,4.95,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,72266011825,NDC,facility,inpatient,30,ME,11.15000,3.23000,Aetna,Local,,4.46,,,,,,,4.02,9.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,72266010101,NDC,facility,inpatient,500,ME,3488.25000,1011.59000,Aetna,Local,,1395.30,,,,,,,1257.51,2853.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,72205026507,NDC,facility,inpatient,50,ME,51.00000,14.79000,Aetna,Local,,20.40,,,,,,,18.39,41.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,72205022007,NDC,facility,inpatient,200,ME,373.00000,108.17000,Aetna,Local,,149.20,,,,,,,134.47,305.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,72205022007,NDC,facility,outpatient,200,ME,373.00000,108.17000,Aetna,Local,,149.20,,,,,,,0.37557,305.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,72205020830,NDC,,,facility,outpatient,1,EA,347.05000,100.64000,Aetna,Local,,176.20,,,,,,,125.11,283.89,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),800015427,CDM,637,RC,72205020030,NDC,,,facility,outpatient,1,EA,87.65000,25.42000,Aetna,Local,,44.50,,,,,,,31.60,71.70,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,72205017072,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,Local,,16.91,,,,,,,12.00,27.24,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,72205010107,NDC,facility,inpatient,1,ME,16.60000,4.81000,Aetna,Local,,6.64,,,,,,,5.98,13.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,72205005401,NDC,facility,inpatient,150,ME,2114.50000,613.20000,Aetna,Local,,845.80,,,,,,,762.28,1729.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,72205004411,NDC,,,facility,outpatient,1,EA,109.45000,31.74000,Aetna,Local,,55.57,,,,,,,39.46,89.53,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,72205004160,NDC,,,facility,outpatient,1,EA,69.00000,20.01000,Aetna,Local,,35.03,,,,,,,24.87,56.44,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,72205004060,NDC,,,facility,outpatient,1,EA,69.00000,20.01000,Aetna,Local,,35.03,,,,,,,24.87,56.44,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,72205003960,NDC,,,facility,outpatient,1,EA,69.00000,20.01000,Aetna,Local,,35.03,,,,,,,24.87,56.44,percent of total billed charges,
NEOnatal TPN Starter Bag,800062119,CDM,258,RC,72196041601,NDC,,,facility,outpatient,1,EA,213.00000,61.77000,Aetna,Local,,108.14,,,,,,,76.79,174.23,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,72078003401,NDC,,,facility,outpatient,1,EA,603.80000,175.10000,Aetna,Local,,306.55,,,,,,,217.67,493.91,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,72078003302,NDC,facility,inpatient,6,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,72078002510,NDC,facility,inpatient,20,ME,187.50000,54.37000,Aetna,Local,,75.00,,,,,,,67.59,153.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,72078000204,NDC,,,facility,outpatient,1,EA,111.45000,32.32000,Aetna,Local,,56.58,,,,,,,40.18,91.17,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,71930005712,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,Local,,1.50,,,,,,,1.06,2.41,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,71839012325,NDC,facility,inpatient,0.2,ME,55.05000,15.96000,Aetna,Local,,22.02,,,,,,,19.85,45.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eravacycline 100mg REC Inj,800046541,CDM,636,RC,J0122,HCPCS,71773010012,NDC,facility,inpatient,100,ME,997.00000,289.13000,Aetna,Local,,398.80,,,,,,,359.42,815.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Potassium Iodide 300mg/0.3mL Oral Liq,800055060,CDM,637,RC,71740011230,NDC,,,facility,outpatient,1,EA,40.45000,11.73000,Aetna,Local,,20.54,,,,,,,14.58,33.09,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,71656002150,NDC,,,facility,outpatient,1,EA,53.40000,15.49000,Aetna,Local,,27.11,,,,,,,19.25,43.68,percent of total billed charges,
aminolevulinic acid 50mL REC Pwd Oral Soln,800046391,CDM,250,RC,71469023101,NDC,,,facility,outpatient,1,EA,17287.75000,5013.45000,Aetna,Local,,8776.99,,,,,,,6232.23,14141.38,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,800019997,CDM,636,RC,J2795,HCPCS,71449012483,NDC,facility,inpatient,1,EA,742.00000,215.18000,Aetna,Local,,296.80,,,,,,,267.49,606.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,71449000411,NDC,,,facility,outpatient,1,EA,70.20000,20.36000,Aetna,Local,,35.64,,,,,,,25.31,57.42,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,71399748005,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,71351002325,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,Local,,6.80,,,,,,,6.13,13.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,71351002325,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,Local,,6.80,,,,,,,6.13,13.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Balsam Peru-Castor Oil Topical Oint,800025588,CDM,637,RC,71351001460,NDC,,,facility,outpatient,1,EA,236.80000,68.67000,Aetna,Local,,120.22,,,,,,,85.37,193.70,percent of total billed charges,
Doxercalciferol 4mcg/2mL Inj,800062124,CDM,636,RC,J1270,HCPCS,71288080203,NDC,facility,inpatient,0.004,ME,19.15000,5.55000,Aetna,Local,,7.66,,,,,,,6.90,15.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,71288072096,NDC,,,facility,outpatient,1,EA,33.15000,9.61000,Aetna,Local,,16.83,,,,,,,11.95,27.12,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,71288071610,NDC,facility,inpatient,1,GM,86.40000,25.06000,Aetna,Local,,34.56,,,,,,,31.15,70.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,71288071206,NDC,,,facility,outpatient,1,EA,122.40000,35.50000,Aetna,Local,,62.14,,,,,,,44.13,100.12,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,71288060011,NDC,facility,inpatient,40,ME,18.95000,5.50000,Aetna,Local,,7.58,,,,,,,6.83,15.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haloperidol Decanoate 100mg/1mL Inj,800040916,CDM,636,RC,J1631,HCPCS,71288050302,NDC,facility,inpatient,100,ME,187.50000,54.37000,Aetna,Local,,75.00,,,,,,,67.59,153.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,71288043392,NDC,facility,inpatient,40,ME,17.95000,5.21000,Aetna,Local,,7.18,,,,,,,6.47,14.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,71288042711,NDC,facility,inpatient,250,ME,670.00000,194.30000,Aetna,Local,,268.00,,,,,,,241.53,548.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,71288041403,NDC,facility,inpatient,0.2,ME,15.95000,4.63000,Aetna,Local,,6.38,,,,,,,5.75,13.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,71288041403,NDC,facility,inpatient,1,ME,79.80000,23.14000,Aetna,Local,,31.92,,,,,,,28.77,65.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,71288040905,NDC,facility,inpatient,0.25,ME,57.45000,16.66000,Aetna,Local,,22.98,,,,,,,20.71,46.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,71288040231,NDC,facility,inpatient,30000,UN,71.40000,20.71000,Aetna,Local,,28.56,,,,,,,25.74,58.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,71288040211,NDC,facility,inpatient,10000,UN,25.30000,7.34000,Aetna,Local,,10.12,,,,,,,9.12,20.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,71288030302,NDC,facility,inpatient,1,ME,11.35000,3.29000,Aetna,Local,,4.54,,,,,,,4.09,9.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,71288020311,NDC,facility,inpatient,100,ME,12.75000,3.70000,Aetna,Local,,5.10,,,,,,,4.60,10.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,71288020305,NDC,facility,inpatient,40,ME,8.60000,2.49000,Aetna,Local,,3.44,,,,,,,3.10,7.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,71288020303,NDC,facility,inpatient,20,ME,6.40000,1.86000,Aetna,Local,,2.56,,,,,,,2.31,5.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,71288020202,NDC,,,facility,outpatient,1,EA,187.50000,54.37000,Aetna,Local,,95.19,,,,,,,67.59,153.38,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,71288020185,NDC,facility,inpatient,0.4,ME,127.70000,37.03000,Aetna,Local,,51.08,,,,,,,46.04,104.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEMEtrexed 500mg Rec Inj,800022535,CDM,636,RC,J9305,HCPCS,71288016795,NDC,facility,inpatient,500,ME,391.05000,113.40000,Aetna,Local,,156.42,,,,,,,140.97,319.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEMEtrexed 500mg Rec Inj,800022535,CDM,636,RC,J9305,HCPCS,71288016750,NDC,facility,inpatient,500,ME,987.00000,286.23000,Aetna,Local,,394.80,,,,,,,355.81,807.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,71288016330,NDC,facility,inpatient,350,ME,247.00000,71.63000,Aetna,Local,,98.80,,,,,,,89.04,202.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 2000mg Inj,800016348,CDM,636,RC,J9201,HCPCS,71288011754,NDC,facility,inpatient,2000,ME,331.70000,96.19000,Aetna,Local,,132.68,,,,,,,119.58,271.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,71288011530,NDC,facility,inpatient,100,ME,335.00000,97.15000,Aetna,Local,,134.00,,,,,,,120.77,274.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bendamustine 100mg I(Treanda),800012530,CDM,636,RC,J9033,HCPCS,71288010320,NDC,facility,inpatient,100,ME,2077.00000,602.33000,Aetna,Local,,830.80,,,,,,,748.76,1698.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,71288003221,NDC,facility,inpatient,3,GM,78.45000,22.75000,Aetna,Local,,31.38,,,,,,,28.28,64.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,71288003121,NDC,facility,inpatient,1.5,GM,49.25000,14.28000,Aetna,Local,,19.70,,,,,,,17.75,40.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,71288002321,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,71288001695,NDC,facility,inpatient,500,ME,143.05000,41.48000,Aetna,Local,,57.22,,,,,,,51.57,117.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,71288001615,NDC,facility,inpatient,500,ME,283.00000,82.07000,Aetna,Local,,113.20,,,,,,,102.02,231.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,71288000630,NDC,facility,inpatient,3,GM,78.45000,22.75000,Aetna,Local,,31.38,,,,,,,28.28,64.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,71288000520,NDC,facility,inpatient,1.5,GM,49.25000,14.28000,Aetna,Local,,19.70,,,,,,,17.75,40.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,71225012606,NDC,,,facility,outpatient,1,EA,580.00000,168.20000,Aetna,Local,,294.47,,,,,,,209.09,474.44,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,71093012204,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,71093011104,NDC,,,facility,outpatient,1,EA,17.85000,5.18000,Aetna,Local,,9.06,,,,,,,6.43,14.60,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,70954056510,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
lacosamide 50mg/5mL Oral Soln,800051955,CDM,637,RC,70954048810,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,Local,,40.08,,,,,,,28.46,64.58,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,70954048430,NDC,,,facility,outpatient,1,EA,43.60000,12.64000,Aetna,Local,,22.14,,,,,,,15.72,35.66,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,70954048420,NDC,,,facility,outpatient,1,EA,44.45000,12.89000,Aetna,Local,,22.57,,,,,,,16.02,36.36,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,70954045510,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,Local,,8.10,,,,,,,5.75,13.05,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,70954044420,NDC,,,facility,outpatient,1,EA,10.10000,2.93000,Aetna,Local,,5.13,,,,,,,3.64,8.26,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,70954044320,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,70954044310,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
PARoxetine 20mg/10mL Oral Liq.,800021981,CDM,637,RC,70954031910,NDC,,,facility,outpatient,1,EA,111.70000,32.39000,Aetna,Local,,56.71,,,,,,,40.27,91.37,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),800065135,CDM,637,RC,70954026110,NDC,,,facility,outpatient,1,EA,10.65000,3.09000,Aetna,Local,,5.41,,,,,,,3.84,8.71,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,70954021210,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,70954018810,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,Local,,16.91,,,,,,,12.00,27.24,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,70954013610,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,Local,,10.86,,,,,,,7.71,17.51,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,70860080282,NDC,facility,inpatient,5,ME,1000.50000,290.14000,Aetna,Local,,400.20,,,,,,,360.68,818.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Valproate Na 500mg I,800074855,CDM,250,RC,70860078405,NDC,,,facility,outpatient,1,EA,48.00000,13.92000,Aetna,Local,,24.37,,,,,,,17.30,39.26,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,70860077802,NDC,facility,inpatient,10,ME,40.55000,11.76000,Aetna,Local,,16.22,,,,,,,14.62,33.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,70860077720,NDC,facility,inpatient,4,ME,9.60000,2.78000,Aetna,Local,,3.84,,,,,,,3.46,7.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,70860077602,NDC,facility,inpatient,4,ME,3.20000,0.93000,Aetna,Local,,1.28,,,,,,,1.15,2.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,70860075102,NDC,facility,inpatient,20,ME,5.50000,1.60000,Aetna,Local,,2.20,,,,,,,1.98,4.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,70860070101,NDC,facility,inpatient,30,ME,12.15000,3.52000,Aetna,Local,,4.86,,,,,,,4.38,9.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,70860070002,NDC,facility,inpatient,15,ME,11.50000,3.34000,Aetna,Local,,4.60,,,,,,,4.15,9.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,70860060482,NDC,facility,inpatient,1500,ME,749.00000,217.21000,Aetna,Local,,299.60,,,,,,,270.01,612.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,70860060382,NDC,facility,inpatient,1000,ME,542.00000,157.18000,Aetna,Local,,216.80,,,,,,,195.39,443.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,70860060282,NDC,facility,inpatient,500,ME,319.00000,92.51000,Aetna,Local,,127.60,,,,,,,115.00,260.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,70860045410,NDC,facility,inpatient,0.04,ME,3967.00000,1150.43000,Aetna,Local,,1586.80,,,,,,,1430.10,3245.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,70860045401,NDC,facility,inpatient,0.004,ME,313.15000,90.81000,Aetna,Local,,125.26,,,,,,,112.89,256.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,70860040610,NDC,facility,inpatient,0.25,ME,2.35000,0.68000,Aetna,Local,,0.94000,,,,,,,0.84718,1.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,70860040504,NDC,facility,inpatient,1,ME,14.50000,4.20000,Aetna,Local,,5.80,,,,,,,5.23,11.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,70860040210,NDC,facility,inpatient,250,ME,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 100mg I,800013344,CDM,636,RC,J1938,HCPCS,70860030210,NDC,facility,inpatient,100,ME,23.05000,6.68000,Aetna,Local,,9.22,,,,,,,8.31,18.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,70860030202,NDC,facility,inpatient,20,ME,6.40000,1.86000,Aetna,Local,,2.56,,,,,,,2.31,5.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,70860030105,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,Local,,9.11,,,,,,,6.47,14.68,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,70860030005,NDC,,,facility,outpatient,1,EA,11.50000,3.34000,Aetna,Local,,5.84,,,,,,,4.15,9.41,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,70860020050,NDC,facility,inpatient,6,ME,18.40000,5.34000,Aetna,Local,,7.36,,,,,,,6.63,15.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,70860020017,NDC,facility,inpatient,6,ME,18.45000,5.35000,Aetna,Local,,7.38,,,,,,,6.65,15.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,70860012620,NDC,facility,inpatient,1,EA,124.30000,36.05000,Aetna,Local,,49.72,,,,,,,44.81,101.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,70860011726,NDC,facility,inpatient,2,GM,208.30000,60.41000,Aetna,Local,,83.32,,,,,,,75.09,170.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,70860010520,NDC,facility,inpatient,1,GM,72.00000,20.88000,Aetna,Local,,28.80,,,,,,,25.96,58.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Minocycline HCl 100mg Inj,800062068,CDM,636,RC,J2265,HCPCS,70842016010,NDC,facility,inpatient,100,ME,2048.20000,593.98000,Aetna,Local,,819.28,,,,,,,738.38,1675.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,70839015030,NDC,,,facility,outpatient,1,EA,89.70000,26.01000,Aetna,Local,,45.54,,,,,,,32.34,73.37,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,70756070360,NDC,,,facility,outpatient,1,EA,45.50000,13.19000,Aetna,Local,,23.10,,,,,,,16.40,37.22,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,800046518,CDM,250,RC,70756066460,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,Local,,3.02,,,,,,,2.14,4.87,percent of total billed charges,
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,70756064825,NDC,,,facility,inpatient,1,EA,49.80000,14.44000,Aetna,Local,,19.92,,,,,,,17.95,40.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,70756064825,NDC,,,facility,outpatient,1,EA,49.80000,14.44000,Aetna,Local,,19.92,,,,,,,17.95,40.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,70756064625,NDC,,,facility,inpatient,1,EA,39.80000,11.54000,Aetna,Local,,15.92,,,,,,,14.35,32.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,70756064625,NDC,,,facility,outpatient,1,EA,39.80000,11.54000,Aetna,Local,,15.92,,,,,,,14.35,32.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,70756064025,NDC,,,facility,inpatient,1,EA,15.05000,4.36000,Aetna,Local,,6.02,,,,,,,5.43,12.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,70756064025,NDC,,,facility,outpatient,1,EA,15.05000,4.36000,Aetna,Local,,6.02,,,,,,,5.43,12.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,70756062210,NDC,facility,inpatient,50,ME,226.20000,65.60000,Aetna,Local,,90.48,,,,,,,81.55,185.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,70756061125,NDC,,,facility,outpatient,1,EA,238.10000,69.05000,Aetna,Local,,120.88,,,,,,,85.84,194.77,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,70756060730,NDC,,,facility,outpatient,1,EA,467.75000,135.65000,Aetna,Local,,237.48,,,,,,,168.62,382.62,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,70756060525,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,Local,,16.88,,,,,,,11.99,27.20,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,70756021590,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,Local,,8.55,,,,,,,6.07,13.78,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,70756021490,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,70756020511,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,6.49,14.72,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,70756020111,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,70756001402,NDC,,,facility,outpatient,1,EA,183.95000,53.35000,Aetna,Local,,93.39,,,,,,,66.31,150.47,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,70752013812,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,Local,,3.66,,,,,,,2.60,5.89,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,70752011303,NDC,,,facility,outpatient,1,EA,1893.75000,549.19000,Aetna,Local,,961.46,,,,,,,682.70,1549.09,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,70710188606,NDC,facility,inpatient,200,ME,196.60000,57.01000,Aetna,Local,,78.64,,,,,,,70.87,160.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,70710188606,NDC,facility,outpatient,200,ME,196.60000,57.01000,Aetna,Local,,78.64,,,,,,,0.37557,160.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,70710183805,NDC,facility,inpatient,50,ME,1123.80000,325.90000,Aetna,Local,,449.52,,,,,,,405.13,919.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,70710183805,NDC,facility,outpatient,50,ME,1123.80000,325.90000,Aetna,Local,,449.52,,,,,,,5.42,919.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,70710171001,NDC,,,facility,outpatient,1,EA,15.25000,4.42000,Aetna,Local,,7.74,,,,,,,5.50,12.47,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70710166307,NDC,facility,inpatient,1,ME,17.50000,5.07000,Aetna,Local,,7.00,,,,,,,6.31,14.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,70710164307,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,Local,,16.88,,,,,,,11.99,27.20,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,70710137702,NDC,facility,inpatient,200,ME,127.55000,36.99000,Aetna,Local,,51.02,,,,,,,45.98,104.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,70710135906,NDC,facility,inpatient,200,ME,588.30000,170.61000,Aetna,Local,,235.32,,,,,,,212.08,481.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,70710135906,NDC,facility,outpatient,200,ME,588.30000,170.61000,Aetna,Local,,235.32,,,,,,,0.37557,481.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,70710128901,NDC,,,facility,outpatient,1,EA,29.35000,8.51000,Aetna,Local,,14.90,,,,,,,10.58,24.01,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,70710123301,NDC,,,facility,outpatient,1,EA,304.50000,88.30000,Aetna,Local,,154.59,,,,,,,109.77,249.08,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,70710122901,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,6.49,14.72,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,70710122601,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,70710121001,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,70710120901,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
mirabegron 50mg ER T,800051952,CDM,637,RC,70710116003,NDC,,,facility,outpatient,1,EA,117.30000,34.02000,Aetna,Local,,59.55,,,,,,,42.29,95.95,percent of total billed charges,
Mirabegron 25mg ER T,800025525,CDM,637,RC,70710115903,NDC,,,facility,outpatient,1,EA,117.30000,34.02000,Aetna,Local,,59.55,,,,,,,42.29,95.95,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,70710101002,NDC,,,facility,outpatient,1,EA,109.45000,31.74000,Aetna,Local,,55.57,,,,,,,39.46,89.53,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,70710100802,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,Local,,50.97,,,,,,,36.19,82.13,percent of total billed charges,
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,70700090225,NDC,facility,inpatient,1,ME,229.80000,66.64000,Aetna,Local,,91.92,,,,,,,82.84,187.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosfomycin 3g Packet,800021964,CDM,637,RC,70700026894,NDC,,,facility,outpatient,1,EA,650.25000,188.57000,Aetna,Local,,330.13,,,,,,,234.42,531.90,percent of total billed charges,
Fluorouracil 2.5g/50mL Inj,800046552,CDM,636,RC,J9190,HCPCS,70700018822,NDC,facility,inpatient,2500,ME,270.85000,78.55000,Aetna,Local,,108.34,,,,,,,97.64,221.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,70700018623,NDC,facility,inpatient,500,ME,127.50000,36.97000,Aetna,Local,,51.00,,,,,,,45.96,104.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,70700017223,NDC,facility,inpatient,10,ME,119.70000,34.71000,Aetna,Local,,47.88,,,,,,,43.15,97.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,70700016725,NDC,facility,inpatient,1,ME,229.80000,66.64000,Aetna,Local,,91.92,,,,,,,82.84,187.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,70700016201,NDC,,,facility,outpatient,1,EA,36.60000,10.61000,Aetna,Local,,18.58,,,,,,,13.19,29.94,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,70700010616,NDC,,,facility,outpatient,1,EA,1604.55000,465.32000,Aetna,Local,,814.63,,,,,,,578.44,1312.52,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,70655000206,NDC,facility,inpatient,200,ME,61.20000,17.75000,Aetna,Local,,24.48,,,,,,,22.06,50.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,70594012302,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,70594011202,NDC,,,facility,inpatient,1,EA,245.35000,71.15000,Aetna,Local,,98.14,,,,,,,88.45,200.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,70594011202,NDC,,,facility,outpatient,1,EA,245.35000,71.15000,Aetna,Local,,98.14,,,,,,,88.45,200.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,70594011102,NDC,facility,inpatient,6000,ME,580.00000,168.20000,Aetna,Local,,232.00,,,,,,,209.09,474.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,70594008902,NDC,facility,inpatient,1,GM,55.20000,16.01000,Aetna,Local,,22.08,,,,,,,19.90,45.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,70594007902,NDC,facility,inpatient,3.375,GM,105.60000,30.62000,Aetna,Local,,42.24,,,,,,,38.07,86.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,70594007602,NDC,facility,inpatient,1,GM,192.00000,55.68000,Aetna,Local,,76.80,,,,,,,69.22,157.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,70594004801,NDC,facility,inpatient,1,GM,205.60000,59.62000,Aetna,Local,,82.24,,,,,,,74.12,168.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,70594003401,NDC,facility,inpatient,500,ME,542.00000,157.18000,Aetna,Local,,216.80,,,,,,,195.39,443.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,70515026010,NDC,facility,inpatient,0.5,ME,721.35000,209.19000,Aetna,Local,,288.54,,,,,,,260.05,590.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,70512084325,NDC,facility,inpatient,30,ME,10.10000,2.93000,Aetna,Local,,4.04,,,,,,,3.64,8.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70512084025,NDC,facility,inpatient,1,ME,23.65000,6.86000,Aetna,Local,,9.46,,,,,,,8.53,19.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,70436020201,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,Local,,4.54,,,,,,,3.23,7.32,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,70436018301,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,Local,,4.54,,,,,,,3.23,7.32,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,70436014781,NDC,facility,inpatient,20,ME,239.60000,69.48000,Aetna,Local,,95.84,,,,,,,86.38,195.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,70436011056,NDC,,,facility,outpatient,1,EA,565.30000,163.94000,Aetna,Local,,287.00,,,,,,,203.79,462.42,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,70436009205,NDC,,,facility,outpatient,1,EA,59.60000,17.28000,Aetna,Local,,30.26,,,,,,,21.49,48.75,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,70436005901,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,70436005801,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,70436005106,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,Local,,6.55,,,,,,,4.65,10.55,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,70436002880,NDC,,,facility,outpatient,1,EA,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,47.95,108.79,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,70436002680,NDC,facility,inpatient,20,ME,671.55000,194.75000,Aetna,Local,,268.62,,,,,,,242.09,549.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,70436002582,NDC,facility,inpatient,250,ME,7582.25000,2198.85000,Aetna,Local,,3032.90,,,,,,,2733.40,6202.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,70436002382,NDC,facility,inpatient,1,GM,208.80000,60.55000,Aetna,Local,,83.52,,,,,,,75.27,170.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,70436002182,NDC,facility,inpatient,1,GM,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,70436001304,NDC,,,facility,outpatient,1,EA,77.95000,22.61000,Aetna,Local,,39.58,,,,,,,28.10,63.76,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,70436001204,NDC,,,facility,outpatient,1,EA,77.95000,22.61000,Aetna,Local,,39.58,,,,,,,28.10,63.76,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,70436000704,NDC,,,facility,outpatient,1,EA,218.50000,63.36000,Aetna,Local,,110.93,,,,,,,78.77,178.73,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,70377011512,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,Local,,3.73,,,,,,,2.65,6.01,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,70377011412,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,70377006112,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,Local,,4.09,,,,,,,2.90,6.58,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,70377000712,NDC,,,facility,outpatient,1,EA,63.25000,18.34000,Aetna,Local,,32.11,,,,,,,22.80,51.74,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,70347002502,NDC,,,facility,outpatient,1,EA,11.15000,3.23000,Aetna,Local,,5.66,,,,,,,4.02,9.12,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,70257056302,NDC,facility,inpatient,40,ME,3955.45000,1147.08000,Aetna,Local,,1582.18,,,,,,,1425.94,3235.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,70121172009,NDC,facility,inpatient,4,GM,63.75000,18.49000,Aetna,Local,,25.50,,,,,,,22.98,52.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,70121171909,NDC,facility,inpatient,2,GM,127.50000,36.97000,Aetna,Local,,51.00,,,,,,,45.96,104.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,70121168007,NDC,,,facility,inpatient,1,EA,1460.85000,423.65000,Aetna,Local,,584.34,,,,,,,526.64,1194.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,70121168007,NDC,,,facility,outpatient,1,EA,1460.85000,423.65000,Aetna,Local,,584.34,,,,,,,526.64,1194.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121165105,NDC,facility,inpatient,40,ME,54.25000,15.73000,Aetna,Local,,21.70,,,,,,,19.56,44.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121165101,NDC,facility,inpatient,40,ME,54.25000,15.73000,Aetna,Local,,21.70,,,,,,,19.56,44.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,70121158007,NDC,facility,inpatient,10,ME,47.90000,13.89000,Aetna,Local,,19.16,,,,,,,17.27,39.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,70121157807,NDC,facility,inpatient,50,ME,206.45000,59.87000,Aetna,Local,,82.58,,,,,,,74.43,168.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,70121157607,NDC,,,facility,outpatient,1,EA,115.05000,33.36000,Aetna,Local,,58.41,,,,,,,41.48,94.11,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,70121157405,NDC,facility,inpatient,80,ME,104.20000,30.22000,Aetna,Local,,41.68,,,,,,,37.56,85.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,70121157305,NDC,facility,inpatient,40,ME,61.50000,17.83000,Aetna,Local,,24.60,,,,,,,22.17,50.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,70121155205,NDC,facility,inpatient,80,ME,104.20000,30.22000,Aetna,Local,,41.68,,,,,,,37.56,85.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,70121155201,NDC,facility,inpatient,80,ME,104.15000,30.20000,Aetna,Local,,41.66,,,,,,,37.55,85.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,70121148001,NDC,facility,inpatient,150,ME,530.05000,153.71000,Aetna,Local,,212.02,,,,,,,191.08,433.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,70121147907,NDC,facility,inpatient,10,ME,164.40000,47.68000,Aetna,Local,,65.76,,,,,,,59.27,134.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,70121146302,NDC,facility,inpatient,250,ME,1684.00000,488.36000,Aetna,Local,,673.60,,,,,,,607.08,1377.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,70121145407,NDC,facility,inpatient,500,ME,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,70121145307,NDC,facility,inpatient,1,GM,105.60000,30.62000,Aetna,Local,,42.24,,,,,,,38.07,86.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,70121122101,NDC,facility,inpatient,20,ME,238.00000,69.02000,Aetna,Local,,95.20,,,,,,,85.80,194.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,70121118901,NDC,,,facility,outpatient,1,EA,155.70000,45.15000,Aetna,Local,,79.05,,,,,,,56.13,127.36,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121104905,NDC,facility,inpatient,40,ME,54.25000,15.73000,Aetna,Local,,21.70,,,,,,,19.56,44.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,70121104902,NDC,facility,inpatient,40,ME,54.25000,15.73000,Aetna,Local,,21.70,,,,,,,19.56,44.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,70121100201,NDC,facility,inpatient,20,ME,548.40000,159.04000,Aetna,Local,,219.36,,,,,,,197.70,448.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-cbqv 6mg/0.6mL Inj Syr,800040939,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,inpatient,6,ME,16823.20000,4878.73000,Aetna,Local,,6729.28,,,,,,,6064.76,13761.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-cbqv 6mg/0.6mL Inj Syr,800040939,CDM,636,RC,Q5111,HCPCS,70114010101,NDC,facility,outpatient,6,ME,16823.20000,4878.73000,Aetna,Local,,6729.28,,,,,,,156.00,13761.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Indocyanine Green 25 mg I,800080225,CDM,250,RC,70100042402,NDC,,,facility,outpatient,1,EA,1035.55000,300.31000,Aetna,Local,,525.75,,,,,,,373.32,847.08,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,800019997,CDM,636,RC,J2795,HCPCS,70092958838,NDC,facility,inpatient,1,EA,1419.95000,411.79000,Aetna,Local,,567.98,,,,,,,511.89,1161.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 0.2mg/mL /NS PCA,800019908,CDM,636,RC,J1171,HCPCS,70092911536,NDC,facility,inpatient,20,ME,408.00000,118.32000,Aetna,Local,,163.20,,,,,,,147.08,333.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70092208746,NDC,facility,inpatient,200,ME,214.55000,62.22000,Aetna,Local,,85.82,,,,,,,77.35,175.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,70092165005,NDC,,,facility,outpatient,1,EA,231.50000,67.13000,Aetna,Local,,117.53,,,,,,,83.46,189.37,percent of total billed charges,
ROPivacaine HCl 0.2% PF Infusion,800019997,CDM,636,RC,J2795,HCPCS,70092158838,NDC,facility,inpatient,1,EA,969.75000,281.23000,Aetna,Local,,387.90,,,,,,,349.59,793.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 125mg /125mL Premix IVPB,800081302,CDM,250,RC,70092157536,NDC,,,facility,outpatient,1,EA,240.35000,69.70000,Aetna,Local,,122.03,,,,,,,86.65,196.61,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,70092145244,NDC,,,facility,outpatient,1,EA,94.10000,27.29000,Aetna,Local,,47.77,,,,,,,33.92,76.97,percent of total billed charges,
Midazolam 100mg/NS 100mL IV,800046429,CDM,636,RC,J2250,HCPCS,70092141836,NDC,facility,inpatient,100,ME,277.95000,80.61000,Aetna,Local,,111.18,,,,,,,100.20,227.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 1mg/mL / NS PCA,800019960,CDM,636,RC,J2274,HCPCS,70092138036,NDC,facility,inpatient,100,ME,153.00000,44.37000,Aetna,Local,,61.20,,,,,,,55.16,125.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,70092119146,NDC,facility,inpatient,1,ME,27.45000,7.96000,Aetna,Local,,10.98,,,,,,,9.90,22.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70092118446,NDC,facility,inpatient,200,ME,129.30000,37.50000,Aetna,Local,,51.72,,,,,,,46.61,105.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine-NaHCO1%-8.4% IS 10mL,800062126,CDM,250,RC,70092117546,NDC,,,facility,outpatient,1,EA,51.60000,14.96000,Aetna,Local,,26.20,,,,,,,18.60,42.21,percent of total billed charges,
Lidocaine HCl 1% 10mL IS PF - Anesthesia,800015334,CDM,636,RC,70092116946,NDC,,,facility,inpatient,1,EA,67.20000,19.49000,Aetna,Local,,26.88,,,,,,,24.23,54.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 10mL IS PF - Anesthesia,800015334,CDM,636,RC,70092116946,NDC,,,facility,outpatient,1,EA,67.20000,19.49000,Aetna,Local,,26.88,,,,,,,24.23,54.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
sodium citrate 4%(120mg/3mL) IS,800046529,CDM,250,RC,70092114843,NDC,,,facility,outpatient,1,EA,81.45000,23.62000,Aetna,Local,,41.35,,,,,,,29.36,66.63,percent of total billed charges,
Lido 40mg/Epi 0.5mg/Tetr 5mg Top Gel 3mL,800082551,CDM,250,RC,70092113544,NDC,,,facility,outpatient,1,EA,84.70000,24.56000,Aetna,Local,,43.00,,,,,,,30.53,69.28,percent of total billed charges,
HYDROmorphone 0.2mg/mL /NS PCA,800019908,CDM,636,RC,J1171,HCPCS,70092111536,NDC,facility,inpatient,20,ME,207.65000,60.22000,Aetna,Local,,83.06,,,,,,,74.86,169.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Labor Room Epidural 100mL,800022091,CDM,636,RC,J3010,HCPCS,70092110436,NDC,facility,inpatient,1,EA,260.30000,75.49000,Aetna,Local,,104.12,,,,,,,93.84,212.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL 10mcg/mL /NS PCA 100mL,800019907,CDM,636,RC,J3010,HCPCS,70092109236,NDC,facility,inpatient,1,ME,221.60000,64.26000,Aetna,Local,,88.64,,,,,,,79.89,181.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70092108746,NDC,facility,inpatient,200,ME,210.60000,61.07000,Aetna,Local,,84.24,,,,,,,75.92,172.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,70092107344,NDC,,,facility,outpatient,1,EA,62.45000,18.11000,Aetna,Local,,31.71,,,,,,,22.51,51.08,percent of total billed charges,
Oxytocin 30 unit/500 mL-NaCl 0.9%,800046507,CDM,636,RC,J2590,HCPCS,70092106807,NDC,facility,inpatient,30,UN,279.40000,81.03000,Aetna,Local,,111.76,,,,,,,100.72,228.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,70092104646,NDC,facility,inpatient,1,ME,57.70000,16.73000,Aetna,Local,,23.08,,,,,,,20.80,47.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,70092103305,NDC,,,facility,outpatient,1,EA,169.40000,49.13000,Aetna,Local,,86.00,,,,,,,61.07,138.57,percent of total billed charges,
dilTIAZem 125mg /125mL Premix IVPB,800081302,CDM,250,RC,70092100736,NDC,,,facility,outpatient,1,EA,361.10000,104.72000,Aetna,Local,,183.33,,,,,,,130.18,295.38,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,70069080610,NDC,facility,inpatient,10,ME,49.90000,14.47000,Aetna,Local,,19.96,,,,,,,17.99,40.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,70069078804,NDC,facility,inpatient,6000,ME,539.20000,156.37000,Aetna,Local,,215.68,,,,,,,194.38,441.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,70069074725,NDC,,,facility,outpatient,1,EA,451.95000,131.07000,Aetna,Local,,229.46,,,,,,,162.93,369.70,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,70069050101,NDC,,,facility,outpatient,1,EA,593.05000,171.98000,Aetna,Local,,301.09,,,,,,,213.79,485.11,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,70069049101,NDC,,,facility,outpatient,1,EA,126.15000,36.58000,Aetna,Local,,64.05,,,,,,,45.48,103.19,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,70069042101,NDC,,,facility,outpatient,1,EA,617.60000,179.10000,Aetna,Local,,313.56,,,,,,,222.64,505.20,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,70069027125,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,Local,,16.88,,,,,,,11.99,27.20,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,70069026101,NDC,,,facility,outpatient,1,EA,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,47.95,108.79,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,70069023101,NDC,,,facility,outpatient,1,EA,88.50000,25.66000,Aetna,Local,,44.93,,,,,,,31.90,72.39,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,70069014110,NDC,,,facility,outpatient,1,EA,142.80000,41.41000,Aetna,Local,,72.50,,,,,,,51.48,116.81,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,70069013101,NDC,,,facility,outpatient,1,EA,44.25000,12.83000,Aetna,Local,,22.47,,,,,,,15.95,36.20,percent of total billed charges,
Tropicamide 1% Ophth Soln(Mydriacyl),800061415,CDM,637,RC,70069012101,NDC,,,facility,outpatient,1,EA,249.45000,72.34000,Aetna,Local,,126.65,,,,,,,89.93,204.05,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,70069010125,NDC,facility,inpatient,1,GM,59.60000,17.28000,Aetna,Local,,23.84,,,,,,,21.49,48.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,70069007110,NDC,facility,inpatient,0.4,ME,99.60000,28.88000,Aetna,Local,,39.84,,,,,,,35.91,81.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,70069006425,NDC,facility,inpatient,150,ME,56.55000,16.40000,Aetna,Local,,22.62,,,,,,,20.39,46.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,70069006401,NDC,facility,inpatient,150,ME,56.55000,16.40000,Aetna,Local,,22.62,,,,,,,20.39,46.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,70069006225,NDC,facility,inpatient,40,ME,57.20000,16.59000,Aetna,Local,,22.88,,,,,,,20.62,46.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,70069006210,NDC,facility,inpatient,40,ME,57.55000,16.69000,Aetna,Local,,23.02,,,,,,,20.75,47.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,70069001325,NDC,facility,inpatient,1,ME,72.90000,21.14000,Aetna,Local,,29.16,,,,,,,26.28,59.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,70069001125,NDC,facility,inpatient,0.2,ME,17.80000,5.16000,Aetna,Local,,7.12,,,,,,,6.42,14.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70069000510,NDC,facility,inpatient,1,ME,23.65000,6.86000,Aetna,Local,,9.46,,,,,,,8.53,19.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,70069000501,NDC,facility,inpatient,1,ME,23.65000,6.86000,Aetna,Local,,9.46,,,,,,,8.53,19.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,70010078201,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,70010078101,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,Local,,4.54,,,,,,,3.23,7.32,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,70010078001,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,Local,,4.54,,,,,,,3.23,7.32,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,70010077001,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,70010075401,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,70010049109,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,Local,,3.07,,,,,,,2.18,4.95,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,70010014901,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,70010013701,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,70010006309,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,70010006301,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,70010000201,NDC,,,facility,outpatient,1,EA,55.95000,16.23000,Aetna,Local,,28.41,,,,,,,20.17,45.77,percent of total billed charges,
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70004091029,NDC,facility,inpatient,200,ME,63.55000,18.43000,Aetna,Local,,25.42,,,,,,,22.91,51.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Succinylcholine 20mg/mL NS 10mL IS,800021355,CDM,636,RC,J0330,HCPCS,70004090812,NDC,facility,inpatient,200,ME,182.45000,52.91000,Aetna,Local,,72.98,,,,,,,65.77,149.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,70004085009,NDC,,,facility,outpatient,1,EA,48.15000,13.96000,Aetna,Local,,24.45,,,,,,,17.36,39.39,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,70004081012,NDC,facility,inpatient,1,ME,40.20000,11.66000,Aetna,Local,,16.08,,,,,,,14.49,32.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,70004077140,NDC,,,facility,outpatient,1,EA,202.30000,58.67000,Aetna,Local,,102.71,,,,,,,72.93,165.48,percent of total billed charges,
Lidocaine HCl 1% 10mL IS PF - Anesthesia,800015334,CDM,636,RC,70004072012,NDC,,,facility,inpatient,1,EA,23.40000,6.79000,Aetna,Local,,9.36,,,,,,,8.44,19.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 10mL IS PF - Anesthesia,800015334,CDM,636,RC,70004072012,NDC,,,facility,outpatient,1,EA,23.40000,6.79000,Aetna,Local,,9.36,,,,,,,8.44,19.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketamine 10mg/mL Inj 10mL,800051999,CDM,250,RC,70004043512,NDC,,,facility,outpatient,1,EA,88.00000,25.52000,Aetna,Local,,44.68,,,,,,,31.72,71.98,percent of total billed charges,
Labor Room Epidural 100mL,800022091,CDM,636,RC,J3010,HCPCS,70004023132,NDC,facility,inpatient,1,EA,149.60000,43.38000,Aetna,Local,,59.84,,,,,,,53.93,122.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Morphine 0.4mg/mLOral Liq,800025701,CDM,637,RC,70004013282,NDC,,,facility,outpatient,1,EA,39.60000,11.48000,Aetna,Local,,20.10,,,,,,,14.28,32.39,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,70003030065,NDC,,,facility,outpatient,1,EA,1425.30000,413.34000,Aetna,Local,,723.62,,,,,,,513.82,1165.90,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,70000055502,NDC,,,facility,outpatient,1,EA,116.75000,33.86000,Aetna,Local,,59.27,,,,,,,42.09,95.50,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,70000034001,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,Local,,1.35,,,,,,,0.95532,2.17,percent of total billed charges,
Mineral Oil 100% Enema,800018020,CDM,637,RC,70000010901,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,Local,,8.96,,,,,,,6.36,14.44,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,70000007001,NDC,,,facility,outpatient,1,EA,72.00000,20.88000,Aetna,Local,,36.55,,,,,,,25.96,58.90,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,69918090111,NDC,facility,inpatient,0.04,ME,2501.15000,725.33000,Aetna,Local,,1000.46,,,,,,,901.66,2045.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,69918090110,NDC,facility,inpatient,0.04,ME,3031.00000,878.99000,Aetna,Local,,1212.40,,,,,,,1092.68,2479.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,69918089911,NDC,facility,inpatient,0.004,ME,197.65000,57.32000,Aetna,Local,,79.06,,,,,,,71.25,161.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,69918089910,NDC,facility,inpatient,0.004,ME,233.80000,67.80000,Aetna,Local,,93.52,,,,,,,84.28,191.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,69918073510,NDC,,,facility,outpatient,1,EA,1266.00000,367.14000,Aetna,Local,,642.75,,,,,,,456.39,1035.59,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,69918050105,NDC,,,facility,outpatient,1,EA,1485.90000,430.91000,Aetna,Local,,754.39,,,,,,,535.67,1215.47,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,69918030130,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,Local,,18.73,,,,,,,13.30,30.18,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,69918010101,NDC,,,facility,outpatient,1,EA,37.40000,10.85000,Aetna,Local,,18.99,,,,,,,13.48,30.59,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,69865021002,NDC,,,facility,outpatient,1,EA,73.75000,21.39000,Aetna,Local,,37.44,,,,,,,26.59,60.33,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,69680014412,NDC,,,facility,outpatient,1,EA,26.70000,7.74000,Aetna,Local,,13.56,,,,,,,9.63,21.84,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,69680011225,NDC,facility,inpatient,1,ME,20.55000,5.96000,Aetna,Local,,8.22,,,,,,,7.41,16.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,69680011210,NDC,facility,inpatient,1,ME,28.75000,8.34000,Aetna,Local,,11.50,,,,,,,10.36,23.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carisoprodol 350mg T,800071349,CDM,637,RC,69584011110,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,69543045510,NDC,facility,inpatient,200,ME,697.55000,202.29000,Aetna,Local,,279.02,,,,,,,251.47,570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,69543045510,NDC,facility,outpatient,200,ME,697.55000,202.29000,Aetna,Local,,279.02,,,,,,,0.37557,570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,69543038810,NDC,,,facility,outpatient,1,EA,15.25000,4.42000,Aetna,Local,,7.74,,,,,,,5.50,12.47,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,69543038625,NDC,facility,inpatient,30,ME,31.90000,9.25000,Aetna,Local,,12.76,,,,,,,11.50,26.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,69543026010,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,69452023320,NDC,,,facility,outpatient,1,EA,14.50000,4.20000,Aetna,Local,,7.36,,,,,,,5.23,11.86,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,69452015825,NDC,,,facility,outpatient,1,EA,26.50000,7.68000,Aetna,Local,,13.45,,,,,,,9.55,21.68,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,69452015020,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,Local,,3.02,,,,,,,2.14,4.87,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,69387010701,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,Local,,1.50,,,,,,,1.06,2.41,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,69367033801,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,69367032709,NDC,,,facility,outpatient,1,EA,67.40000,19.55000,Aetna,Local,,34.22,,,,,,,24.30,55.13,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,69367031401,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,69367013304,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,69339020919,NDC,,,facility,outpatient,1,EA,76.45000,22.17000,Aetna,Local,,38.81,,,,,,,27.56,62.54,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,69339017703,NDC,,,facility,outpatient,1,EA,58.20000,16.88000,Aetna,Local,,29.55,,,,,,,20.98,47.61,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,69339016019,NDC,,,facility,outpatient,1,EA,35.50000,10.30000,Aetna,Local,,18.02,,,,,,,12.80,29.04,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,800021977,CDM,637,RC,69339015917,NDC,,,facility,outpatient,1,EA,208.30000,60.41000,Aetna,Local,,105.75,,,,,,,75.09,170.39,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,69339015717,NDC,,,facility,outpatient,1,EA,48.85000,14.17000,Aetna,Local,,24.80,,,,,,,17.61,39.96,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,69339014819,NDC,,,facility,outpatient,1,EA,76.45000,22.17000,Aetna,Local,,38.81,,,,,,,27.56,62.54,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,69339013819,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,69339013634,NDC,facility,inpatient,10,ME,234.55000,68.02000,Aetna,Local,,93.82,,,,,,,84.56,191.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,69315091001,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,69315090505,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,69315090501,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,3.40,,,,,,,2.42,5.48,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,69315090405,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,69315090401,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,69315030615,NDC,,,facility,outpatient,1,EA,164.80000,47.79000,Aetna,Local,,83.67,,,,,,,59.41,134.81,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,69315015501,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,69315013601,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,69315012701,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,69315011701,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,69315011610,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,69315011601,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,69238207801,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,69238207701,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,69238160502,NDC,,,facility,outpatient,1,EA,448.75000,130.14000,Aetna,Local,,227.83,,,,,,,161.77,367.08,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,69238154001,NDC,,,facility,outpatient,1,EA,52.05000,15.09000,Aetna,Local,,26.43,,,,,,,18.76,42.58,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,69238153405,NDC,,,facility,outpatient,1,EA,314.70000,91.26000,Aetna,Local,,159.77,,,,,,,113.45,257.42,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,69238153203,NDC,,,facility,outpatient,1,EA,1587.75000,460.45000,Aetna,Local,,806.10,,,,,,,572.38,1298.78,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,69238149001,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,Local,,9.70,,,,,,,6.89,15.62,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,69238148901,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,69238147103,NDC,,,facility,outpatient,1,EA,59.40000,17.23000,Aetna,Local,,30.16,,,,,,,21.41,48.59,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,69238142103,NDC,,,facility,outpatient,1,EA,63.55000,18.43000,Aetna,Local,,32.26,,,,,,,22.91,51.98,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,69238131309,NDC,,,facility,outpatient,1,EA,67.40000,19.55000,Aetna,Local,,34.22,,,,,,,24.30,55.13,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,69238131209,NDC,,,facility,outpatient,1,EA,67.40000,19.55000,Aetna,Local,,34.22,,,,,,,24.30,55.13,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,69238131109,NDC,,,facility,outpatient,1,EA,67.40000,19.55000,Aetna,Local,,34.22,,,,,,,24.30,55.13,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,69238131009,NDC,,,facility,outpatient,1,EA,67.40000,19.55000,Aetna,Local,,34.22,,,,,,,24.30,55.13,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,69238110002,NDC,,,facility,outpatient,1,EA,68.10000,19.75000,Aetna,Local,,34.57,,,,,,,24.55,55.71,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,69102031901,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,Local,,17.08,,,,,,,12.13,27.53,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,69102030101,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,Local,,14.95,,,,,,,10.62,24.09,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,69097096507,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,Local,,4.80,,,,,,,3.41,7.73,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,69097094605,NDC,,,facility,outpatient,1,EA,39.90000,11.57000,Aetna,Local,,20.26,,,,,,,14.38,32.64,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,69097094505,NDC,,,facility,outpatient,1,EA,38.45000,11.15000,Aetna,Local,,19.52,,,,,,,13.86,31.45,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,69097094405,NDC,,,facility,outpatient,1,EA,27.95000,8.11000,Aetna,Local,,14.19,,,,,,,10.08,22.86,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,69097092735,NDC,facility,inpatient,0.25,ME,685.90000,198.91000,Aetna,Local,,274.36,,,,,,,247.27,561.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,69097089905,NDC,,,facility,outpatient,1,EA,39.90000,11.57000,Aetna,Local,,20.26,,,,,,,14.38,32.64,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,69097086107,NDC,,,facility,outpatient,1,EA,15.50000,4.50000,Aetna,Local,,7.87,,,,,,,5.59,12.68,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,69097085907,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,Local,,46.99,,,,,,,33.36,75.71,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,69097085902,NDC,,,facility,outpatient,1,EA,92.20000,26.74000,Aetna,Local,,46.81,,,,,,,33.24,75.42,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,69097084805,NDC,,,facility,outpatient,1,EA,37.10000,10.76000,Aetna,Local,,18.84,,,,,,,13.37,30.35,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,69097084705,NDC,,,facility,outpatient,1,EA,30.95000,8.98000,Aetna,Local,,15.71,,,,,,,11.16,25.32,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,69097084607,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,Local,,4.16,,,,,,,2.96,6.71,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,69097084407,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,69097083805,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,Local,,8.58,,,,,,,6.09,13.82,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,69097083715,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,69097083705,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,69097083605,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,69097082502,NDC,,,facility,outpatient,1,EA,50.45000,14.63000,Aetna,Local,,25.61,,,,,,,18.19,41.27,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,69097082103,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,69097081207,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,69097073102,NDC,,,facility,outpatient,1,EA,92.20000,26.74000,Aetna,Local,,46.81,,,,,,,33.24,75.42,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,69097070996,NDC,facility,inpatient,1,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosfomycin 3g Packet,800021964,CDM,637,RC,69097057967,NDC,,,facility,outpatient,1,EA,650.25000,188.57000,Aetna,Local,,330.13,,,,,,,234.42,531.90,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,69097053596,NDC,facility,inpatient,50,ME,227.00000,65.83000,Aetna,Local,,90.80,,,,,,,81.83,185.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,69097052444,NDC,,,facility,outpatient,1,EA,359.95000,104.39000,Aetna,Local,,182.75,,,,,,,129.76,294.44,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,69097052235,NDC,,,facility,outpatient,1,EA,4012.00000,1163.48000,Aetna,Local,,2036.89,,,,,,,1446.33,3281.82,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,69097042207,NDC,,,facility,outpatient,1,EA,32.70000,9.48000,Aetna,Local,,16.60,,,,,,,11.79,26.75,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,69097042107,NDC,,,facility,outpatient,1,EA,53.65000,15.56000,Aetna,Local,,27.24,,,,,,,19.34,43.89,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,69097028270,NDC,,,facility,outpatient,1,EA,119.00000,34.51000,Aetna,Local,,60.42,,,,,,,42.90,97.34,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,69097015812,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,Local,,11.37,,,,,,,8.08,18.32,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,69097015807,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,Local,,11.40,,,,,,,8.09,18.36,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,69097014260,NDC,,,facility,outpatient,1,EA,490.05000,142.11000,Aetna,Local,,248.80,,,,,,,176.66,400.86,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,69097012805,NDC,,,facility,outpatient,1,EA,16.80000,4.87000,Aetna,Local,,8.53,,,,,,,6.06,13.74,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,69097012705,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,69097012605,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,69097012203,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,69076047501,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,Local,,4.72,,,,,,,3.35,7.61,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,69076014601,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,68982062302,NDC,facility,inpatient,12.5,GM,563.00000,163.27000,Aetna,Local,,225.20,,,,,,,202.96,460.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lithium Carb 300mg CR T,800045558,CDM,637,RC,68968449201,NDC,,,facility,outpatient,1,EA,25.60000,7.42000,Aetna,Local,,13.00,,,,,,,9.23,20.94,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68850001202,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68850001201,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,68817013450,NDC,facility,inpatient,100,ME,8719.30000,2528.60000,Aetna,Local,,3487.72,,,,,,,3143.31,7132.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,68774012260,NDC,,,facility,outpatient,1,EA,30.00000,8.70000,Aetna,Local,,15.23,,,,,,,10.81,24.54,percent of total billed charges,
Lurbinectedin 4mg Inj (Zepzelca),800046519,CDM,636,RC,J9223,HCPCS,68727071201,NDC,facility,inpatient,4,ME,58579.00000,16987.91000,Aetna,Local,,23431.60,,,,,,,21117.73,47917.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,68682099398,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,Local,,3.35,,,,,,,2.38,5.40,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,68682081305,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,Local,,47.44,,,,,,,33.69,76.44,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,68682040910,NDC,,,facility,outpatient,1,EA,36.40000,10.56000,Aetna,Local,,18.48,,,,,,,13.12,29.78,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,68682037090,NDC,,,facility,outpatient,1,EA,11.70000,3.39000,Aetna,Local,,5.94,,,,,,,4.22,9.57,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,68682036890,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,68682030210,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,68682017030,NDC,,,facility,outpatient,1,EA,447.30000,129.72000,Aetna,Local,,227.09,,,,,,,161.25,365.89,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,68682010810,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,Local,,4.62,,,,,,,3.28,7.44,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,68546014256,NDC,,,facility,outpatient,1,EA,290.10000,84.13000,Aetna,Local,,147.28,,,,,,,104.58,237.30,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,68516521607,NDC,facility,inpatient,12.5,GM,424.40000,123.08000,Aetna,Local,,169.76,,,,,,,153.00,347.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,68516521601,NDC,facility,inpatient,12.5,GM,668.00000,193.72000,Aetna,Local,,267.20,,,,,,,240.81,546.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,68516521401,NDC,facility,inpatient,12.5,GM,497.05000,144.14000,Aetna,Local,,198.82,,,,,,,179.19,406.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,68516521302,NDC,facility,inpatient,12.5,GM,668.00000,193.72000,Aetna,Local,,267.20,,,,,,,240.81,546.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,68516521101,NDC,facility,inpatient,12.5,GM,563.00000,163.27000,Aetna,Local,,225.20,,,,,,,202.96,460.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,68462085001,NDC,,,facility,outpatient,1,EA,24.50000,7.10000,Aetna,Local,,12.44,,,,,,,8.83,20.04,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,68462062264,NDC,facility,inpatient,500,ME,437.00000,126.73000,Aetna,Local,,174.80,,,,,,,157.54,357.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,68462062154,NDC,facility,inpatient,100,ME,94.50000,27.40000,Aetna,Local,,37.80,,,,,,,34.07,77.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,68462056201,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,Local,,18.51,,,,,,,13.14,29.82,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,68462046954,NDC,facility,inpatient,1,ME,14.50000,4.20000,Aetna,Local,,5.80,,,,,,,5.23,11.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,68462043318,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,68462041820,NDC,,,facility,outpatient,1,EA,1893.65000,549.16000,Aetna,Local,,961.41,,,,,,,682.66,1549.01,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,68462040860,NDC,,,facility,outpatient,1,EA,55.90000,16.21000,Aetna,Local,,28.38,,,,,,,20.15,45.73,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,68462040601,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,68462040560,NDC,,,facility,outpatient,1,EA,59.15000,17.15000,Aetna,Local,,30.03,,,,,,,21.32,48.38,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,68462038160,NDC,,,facility,outpatient,1,EA,230.15000,66.74000,Aetna,Local,,116.85,,,,,,,82.97,188.26,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,68462036101,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,68462035801,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,Local,,4.95,,,,,,,3.51,7.98,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,68462033290,NDC,,,facility,outpatient,1,EA,23.65000,6.86000,Aetna,Local,,12.01,,,,,,,8.53,19.35,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,68462033090,NDC,,,facility,outpatient,1,EA,23.65000,6.86000,Aetna,Local,,12.01,,,,,,,8.53,19.35,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,68462031435,NDC,,,facility,outpatient,1,EA,980.10000,284.23000,Aetna,Local,,497.60,,,,,,,353.33,801.72,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,68462030450,NDC,,,facility,outpatient,1,EA,18.75000,5.44000,Aetna,Local,,9.52,,,,,,,6.76,15.34,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,68462029817,NDC,,,facility,outpatient,1,EA,381.70000,110.69000,Aetna,Local,,193.79,,,,,,,137.60,312.23,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,68462029735,NDC,,,facility,outpatient,1,EA,574.30000,166.55000,Aetna,Local,,291.57,,,,,,,207.04,469.78,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,68462029301,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,Local,,5.18,,,,,,,3.68,8.34,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,68462029201,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,68462029112,NDC,,,facility,outpatient,1,EA,1114.90000,323.32000,Aetna,Local,,566.03,,,,,,,401.92,911.99,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,68462027501,NDC,,,facility,outpatient,1,EA,52.10000,15.11000,Aetna,Local,,26.45,,,,,,,18.78,42.62,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,68462026430,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,Local,,32.16,,,,,,,22.84,51.82,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,68462026290,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,Local,,32.16,,,,,,,22.84,51.82,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,68462025501,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,Local,,9.01,,,,,,,6.40,14.52,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,68462023401,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,68462022301,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,68462022001,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68462019690,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,11.75,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68462019605,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,11.75,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68462019590,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68462019505,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,68462018801,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,68462018022,NDC,,,facility,outpatient,1,EA,296.30000,85.93000,Aetna,Local,,150.43,,,,,,,106.82,242.37,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68462016505,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68462016501,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68462016405,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68462016401,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,68462016305,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,68462016301,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,68462016205,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,68462016201,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68462015901,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,68462014645,NDC,,,facility,outpatient,1,EA,53.65000,15.56000,Aetna,Local,,27.24,,,,,,,19.34,43.89,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,68462014625,NDC,,,facility,outpatient,1,EA,31.60000,9.16000,Aetna,Local,,16.04,,,,,,,11.39,25.85,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,68462012801,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,68462012605,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,68462012601,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68462010860,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,Local,,7.97,,,,,,,5.66,12.84,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,68462010530,NDC,facility,inpatient,4,ME,173.45000,50.30000,Aetna,Local,,69.38,,,,,,,62.53,141.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,68462010230,NDC,,,facility,outpatient,1,EA,62.35000,18.08000,Aetna,Local,,31.66,,,,,,,22.48,51.00,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,68382079901,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,Local,,4.09,,,,,,,2.90,6.58,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,68382079805,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,68382079801,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,800046545,CDM,637,RC,68382077277,NDC,,,facility,outpatient,1,EA,111.70000,32.39000,Aetna,Local,,56.71,,,,,,,40.27,91.37,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,68382076214,NDC,,,facility,outpatient,1,EA,42.60000,12.35000,Aetna,Local,,21.63,,,,,,,15.36,34.85,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,68382066001,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,68382065001,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,68382064928,NDC,,,facility,outpatient,1,EA,54.95000,15.94000,Aetna,Local,,27.90,,,,,,,19.81,44.95,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,68382059816,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,Local,,9.54,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,68382059616,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,68382059516,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,Local,,4.32,,,,,,,3.06,6.95,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,68382054507,NDC,,,facility,outpatient,1,EA,41.95000,12.17000,Aetna,Local,,21.30,,,,,,,15.12,34.32,percent of total billed charges,
Cholestyramine 4g Lt Pkt,800018217,CDM,637,RC,68382052960,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,Local,,12.06,,,,,,,8.56,19.43,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,68382043528,NDC,,,facility,outpatient,1,EA,65.65000,19.04000,Aetna,Local,,33.33,,,,,,,23.67,53.70,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68382037001,NDC,,,facility,outpatient,1,EA,199.25000,57.78000,Aetna,Local,,101.16,,,,,,,71.83,162.99,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,68382031601,NDC,,,facility,outpatient,1,EA,12.05000,3.49000,Aetna,Local,,6.12,,,,,,,4.34,9.86,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,68382025501,NDC,,,facility,outpatient,1,EA,23.30000,6.76000,Aetna,Local,,11.83,,,,,,,8.40,19.06,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,68382024701,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,68382022714,NDC,,,facility,outpatient,1,EA,23.50000,6.82000,Aetna,Local,,11.93,,,,,,,8.47,19.22,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,68382022705,NDC,,,facility,outpatient,1,EA,22.85000,6.63000,Aetna,Local,,11.60,,,,,,,8.24,18.69,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,68382019816,NDC,,,facility,outpatient,1,EA,22.95000,6.66000,Aetna,Local,,11.65,,,,,,,8.27,18.77,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,68382019616,NDC,,,facility,outpatient,1,EA,22.95000,6.66000,Aetna,Local,,11.65,,,,,,,8.27,18.77,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,68382018701,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,68382018101,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,68382018001,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,68382014014,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,Local,,25.03,,,,,,,17.77,40.33,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,68382014005,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,Local,,25.03,,,,,,,17.77,40.33,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68382013814,NDC,,,facility,outpatient,1,EA,18.10000,5.25000,Aetna,Local,,9.19,,,,,,,6.53,14.81,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68382013805,NDC,,,facility,outpatient,1,EA,18.10000,5.25000,Aetna,Local,,9.19,,,,,,,6.53,14.81,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,68382013716,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,Local,,11.07,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,68382013616,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,68382013210,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,68382013201,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,68382011414,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,Local,,16.35,,,,,,,11.61,26.34,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,68382011214,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,Local,,14.01,,,,,,,9.95,22.58,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,68382010601,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,68382009801,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,Local,,9.82,,,,,,,6.98,15.83,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68382009505,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,68382009501,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68382009405,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,68382009401,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,68382009301,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,68382009201,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,68382007901,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68382007116,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,11.75,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68382007016,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,68382005201,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,68382005001,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,Local,,11.40,,,,,,,8.09,18.36,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,68382003606,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,12.98,29.45,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68382002810,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68382002805,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,68382002801,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,68382002301,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,68382002201,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,68382001901,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,Local,,7.18,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,68382001801,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,68382000801,NDC,,,facility,outpatient,1,EA,36.75000,10.66000,Aetna,Local,,18.66,,,,,,,13.25,30.06,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,68382000601,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,Local,,16.35,,,,,,,11.61,26.34,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,68382000514,NDC,,,facility,outpatient,1,EA,20.70000,6.00000,Aetna,Local,,10.51,,,,,,,7.46,16.93,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,68308050547,NDC,,,facility,outpatient,1,EA,4.10000,1.19000,Aetna,Local,,2.08,,,,,,,1.48,3.35,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68308015260,NDC,,,facility,outpatient,1,EA,115.70000,33.55000,Aetna,Local,,58.74,,,,,,,41.71,94.64,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68308015230,NDC,,,facility,outpatient,1,EA,143.95000,41.75000,Aetna,Local,,73.08,,,,,,,51.89,117.75,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,68308015215,NDC,,,facility,outpatient,1,EA,155.40000,45.07000,Aetna,Local,,78.90,,,,,,,56.02,127.12,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,68220011510,NDC,,,facility,outpatient,1,EA,34.70000,10.06000,Aetna,Local,,17.62,,,,,,,12.51,28.38,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,68220011310,NDC,,,facility,outpatient,1,EA,20.30000,5.89000,Aetna,Local,,10.31,,,,,,,7.32,16.61,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,68180098101,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,68180098001,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,68180097901,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,Local,,5.58,,,,,,,3.97,9.00,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,68180097401,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,68180097201,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,68180096901,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,68180096801,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,68180096709,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,68180096701,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,68180096601,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,68180096301,NDC,,,facility,outpatient,1,EA,394.75000,114.48000,Aetna,Local,,200.41,,,,,,,142.31,322.91,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,68180085211,NDC,,,facility,outpatient,1,EA,255.55000,74.11000,Aetna,Local,,129.74,,,,,,,92.13,209.04,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,68180074006,NDC,,,facility,outpatient,1,EA,63.55000,18.43000,Aetna,Local,,32.26,,,,,,,22.91,51.98,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,68180071160,NDC,,,facility,outpatient,1,EA,36.20000,10.50000,Aetna,Local,,18.38,,,,,,,13.05,29.61,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,68180067711,NDC,,,facility,outpatient,1,EA,109.45000,31.74000,Aetna,Local,,55.57,,,,,,,39.46,89.53,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,68180067511,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,Local,,50.97,,,,,,,36.19,82.13,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,68180067106,NDC,,,facility,outpatient,1,EA,350.50000,101.64000,Aetna,Local,,177.95,,,,,,,126.36,286.71,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,68180065907,NDC,,,facility,outpatient,1,EA,32.50000,9.42000,Aetna,Local,,16.50,,,,,,,11.72,26.59,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,68180064410,NDC,facility,inpatient,2,GM,435.90000,126.41000,Aetna,Local,,174.36,,,,,,,157.14,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,68180063310,NDC,facility,inpatient,1,GM,358.00000,103.82000,Aetna,Local,,143.20,,,,,,,129.06,292.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,68180060207,NDC,,,facility,outpatient,1,EA,50.70000,14.70000,Aetna,Local,,25.74,,,,,,,18.28,41.47,percent of total billed charges,
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,68180059306,NDC,,,facility,outpatient,1,EA,81.25000,23.56000,Aetna,Local,,41.25,,,,,,,29.29,66.46,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,68180059206,NDC,,,facility,outpatient,1,EA,81.25000,23.56000,Aetna,Local,,41.25,,,,,,,29.29,66.46,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,68180059002,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,68180059001,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,68180058801,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,Local,,5.51,,,,,,,3.91,8.88,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,68180052406,NDC,,,facility,outpatient,1,EA,103.85000,30.12000,Aetna,Local,,52.72,,,,,,,37.44,84.95,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,68180051701,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,Local,,5.58,,,,,,,3.97,9.00,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,68180051501,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,68180051401,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,68180051201,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,Local,,2.34,,,,,,,1.66,3.76,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,68180050101,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,Local,,11.40,,,,,,,8.09,18.36,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,68180048609,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,11.75,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68180048509,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,68180048502,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,68180044101,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,Local,,5.18,,,,,,,3.68,8.34,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,68180044101,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Cefixime 400mg C (Suprax),800063049,CDM,637,RC,68180042311,NDC,,,facility,outpatient,1,EA,101.95000,29.57000,Aetna,Local,,51.76,,,,,,,36.75,83.40,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,68180036309,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,Local,,8.55,,,,,,,6.07,13.78,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,68180036209,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,68180035407,NDC,,,facility,outpatient,1,EA,45.50000,13.19000,Aetna,Local,,23.10,,,,,,,16.40,37.22,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,68180035309,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,Local,,10.26,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,68180035306,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,Local,,10.26,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,68180035302,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,Local,,10.26,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,68180035209,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,Local,,10.26,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,68180035206,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,Local,,10.26,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,68180035202,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,Local,,10.26,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline HCl 25mg T,800015414,CDM,637,RC,68180035109,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,Local,,10.26,,,,,,,7.28,16.52,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,68180033607,NDC,,,facility,outpatient,1,EA,122.10000,35.41000,Aetna,Local,,61.99,,,,,,,44.02,99.88,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,68180031909,NDC,,,facility,outpatient,1,EA,33.80000,9.80000,Aetna,Local,,17.16,,,,,,,12.18,27.65,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,68180031906,NDC,,,facility,outpatient,1,EA,33.80000,9.80000,Aetna,Local,,17.16,,,,,,,12.18,27.65,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,68180030260,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,68180030220,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,68180029609,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,Local,,28.23,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,68180029606,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,Local,,28.23,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,68180029509,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,Local,,28.23,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,68180029407,NDC,,,facility,outpatient,1,EA,49.55000,14.37000,Aetna,Local,,25.16,,,,,,,17.86,40.53,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68180028101,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,Local,,6.42,,,,,,,4.56,10.35,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,68180026701,NDC,,,facility,outpatient,1,EA,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,8.29,18.81,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,68180026601,NDC,,,facility,outpatient,1,EA,12.50000,3.62000,Aetna,Local,,6.35,,,,,,,4.51,10.22,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,68180023007,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,Local,,21.93,,,,,,,15.57,35.34,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,68180022907,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,Local,,21.93,,,,,,,15.57,35.34,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,68180012401,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,Local,,5.18,,,,,,,3.68,8.34,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,68180012301,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,Local,,2.13,,,,,,,1.51,3.44,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,68180012202,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,4.42,,,,,,,3.14,7.12,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,68180012101,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,68180011316,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,68180011216,NDC,,,facility,outpatient,1,EA,20.35000,5.90000,Aetna,Local,,10.33,,,,,,,7.34,16.65,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,68094085362,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,Local,,9.82,,,,,,,6.98,15.83,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,68094085261,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,68094081662,NDC,,,facility,outpatient,1,EA,48.70000,14.12000,Aetna,Local,,24.72,,,,,,,17.56,39.84,percent of total billed charges,
Ondansetron 2mg/2.5 mL Oral Soln,800025699,CDM,636,RC,Q0162,HCPCS,68094076362,NDC,facility,inpatient,4,ME,54.25000,15.73000,Aetna,Local,,21.70,,,,,,,19.56,44.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 40mg/4mL (Lasix),800037134,CDM,637,RC,68094075662,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,Local,,11.07,,,,,,,7.86,17.83,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,800022076,CDM,637,RC,68094075062,NDC,,,facility,outpatient,1,EA,36.80000,10.67000,Aetna,Local,,18.68,,,,,,,13.27,30.10,percent of total billed charges,
Cetirizine 5mg/5mL L UD,800015481,CDM,637,RC,68094072062,NDC,,,facility,outpatient,1,EA,14.75000,4.28000,Aetna,Local,,7.49,,,,,,,5.32,12.07,percent of total billed charges,
Cetirizine 5mg/5mL L UD,800015481,CDM,637,RC,68094072059,NDC,,,facility,outpatient,1,EA,10.95000,3.18000,Aetna,Local,,5.56,,,,,,,3.95,8.96,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,68094070162,NDC,,,facility,outpatient,1,EA,10.55000,3.06000,Aetna,Local,,5.36,,,,,,,3.80,8.63,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,68094070159,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,Local,,5.33,,,,,,,3.79,8.59,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094060061,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,68094059962,NDC,,,facility,outpatient,1,EA,12.00000,3.48000,Aetna,Local,,6.09,,,,,,,4.33,9.82,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,68094059961,NDC,,,facility,outpatient,1,EA,11.70000,3.39000,Aetna,Local,,5.94,,,,,,,4.22,9.57,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094052862,NDC,,,facility,outpatient,1,EA,29.75000,8.63000,Aetna,Local,,15.10,,,,,,,10.72,24.34,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094052861,NDC,,,facility,outpatient,1,EA,29.90000,8.67000,Aetna,Local,,15.18,,,,,,,10.78,24.46,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,68094050362,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,Local,,5.25,,,,,,,3.73,8.47,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,68094050361,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,Local,,5.23,,,,,,,3.71,8.43,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094049461,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094049458,NDC,,,facility,outpatient,1,EA,19.70000,5.71000,Aetna,Local,,10.00,,,,,,,7.10,16.11,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,68094030162,NDC,,,facility,outpatient,1,EA,25.70000,7.45000,Aetna,Local,,13.05,,,,,,,9.26,21.02,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094025061,NDC,,,facility,outpatient,1,EA,29.90000,8.67000,Aetna,Local,,15.18,,,,,,,10.78,24.46,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,68094021462,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,Local,,16.35,,,,,,,11.61,26.34,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,68094021459,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,Local,,16.35,,,,,,,11.61,26.34,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094017162,NDC,,,facility,outpatient,1,EA,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,28.84,65.44,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094017161,NDC,,,facility,outpatient,1,EA,79.70000,23.11000,Aetna,Local,,40.46,,,,,,,28.73,65.19,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094017159,NDC,,,facility,outpatient,1,EA,79.70000,23.11000,Aetna,Local,,40.46,,,,,,,28.73,65.19,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,68094006362,NDC,,,facility,outpatient,1,EA,40.50000,11.74000,Aetna,Local,,20.56,,,,,,,14.60,33.13,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,68094004861,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,Local,,3.81,,,,,,,2.70,6.13,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,68094004362,NDC,,,facility,outpatient,1,EA,77.25000,22.40000,Aetna,Local,,39.22,,,,,,,27.85,63.19,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,68094003758,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,68094002862,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,Local,,9.57,,,,,,,6.80,15.42,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,68094002861,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,Local,,8.58,,,,,,,6.09,13.82,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,68094000862,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,Local,,16.35,,,,,,,11.61,26.34,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,68094000762,NDC,,,facility,outpatient,1,EA,25.70000,7.45000,Aetna,Local,,13.05,,,,,,,9.26,21.02,percent of total billed charges,
Cetirizine 5mg/5mL L UD,800015481,CDM,637,RC,68094000462,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,Local,,9.47,,,,,,,6.72,15.26,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,68084099601,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,Local,,6.42,,,,,,,4.56,10.35,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,68084096425,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,Local,,12.08,,,,,,,8.58,19.47,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,68084092932,NDC,,,facility,outpatient,1,EA,52.45000,15.21000,Aetna,Local,,26.63,,,,,,,18.91,42.90,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,68084092825,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,Local,,10.79,,,,,,,7.66,17.38,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,68084089625,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,Local,,7.44,,,,,,,5.28,11.98,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,68084089509,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,68084089501,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,68084088409,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,Local,,4.47,,,,,,,3.17,7.20,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,68084087501,NDC,,,facility,outpatient,1,EA,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,14.06,31.90,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,68084086921,NDC,,,facility,outpatient,1,EA,143.20000,41.53000,Aetna,Local,,72.70,,,,,,,51.62,117.14,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,68084085301,NDC,,,facility,outpatient,1,EA,19.50000,5.65000,Aetna,Local,,9.90,,,,,,,7.03,15.95,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,68084085101,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,Local,,3.93,,,,,,,2.79,6.34,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,68084084501,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,68084084401,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,Local,,7.18,,,,,,,5.10,11.57,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,68084082725,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,Local,,4.67,,,,,,,3.32,7.53,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,68084082321,NDC,,,facility,outpatient,1,EA,15.90000,4.61000,Aetna,Local,,8.07,,,,,,,5.73,13.01,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,68084081309,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,68084080801,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,68084078825,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,68084078301,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,68084078261,NDC,,,facility,outpatient,1,EA,22.85000,6.63000,Aetna,Local,,11.60,,,,,,,8.24,18.69,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,68084077601,NDC,,,facility,outpatient,1,EA,12.45000,3.61000,Aetna,Local,,6.32,,,,,,,4.49,10.18,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,68084077201,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,68084076521,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,68084076201,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,Local,,4.95,,,,,,,3.51,7.98,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,68084075365,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,68084075325,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,Local,,4.49,,,,,,,3.19,7.24,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,68084075025,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,Local,,3.55,,,,,,,2.52,5.73,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,68084074201,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,68084073801,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,68084073601,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,Local,,1.52,,,,,,,1.08,2.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,68084071301,NDC,,,facility,outpatient,1,EA,32.35000,9.38000,Aetna,Local,,16.42,,,,,,,11.66,26.46,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,68084070901,NDC,,,facility,outpatient,1,EA,29.70000,8.61000,Aetna,Local,,15.08,,,,,,,10.71,24.29,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,68084070301,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,68084069801,NDC,,,facility,outpatient,1,EA,26.50000,7.68000,Aetna,Local,,13.45,,,,,,,9.55,21.68,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,68084069701,NDC,,,facility,outpatient,1,EA,11.80000,3.42000,Aetna,Local,,5.99,,,,,,,4.25,9.65,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,68084069201,NDC,,,facility,outpatient,1,EA,54.50000,15.80000,Aetna,Local,,27.67,,,,,,,19.65,44.58,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,68084068301,NDC,,,facility,outpatient,1,EA,54.50000,15.80000,Aetna,Local,,27.67,,,,,,,19.65,44.58,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,68084067201,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,68084065801,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,68084065501,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,Local,,2.72,,,,,,,1.93,4.38,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,68084065401,NDC,,,facility,outpatient,1,EA,16.45000,4.77000,Aetna,Local,,8.35,,,,,,,5.93,13.46,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,68084064701,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,68084064501,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,68084064001,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,68084062221,NDC,,,facility,outpatient,1,EA,143.20000,41.53000,Aetna,Local,,72.70,,,,,,,51.62,117.14,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,68084062121,NDC,,,facility,outpatient,1,EA,210.85000,61.15000,Aetna,Local,,107.05,,,,,,,76.01,172.48,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,68084061801,NDC,,,facility,outpatient,1,EA,32.55000,9.44000,Aetna,Local,,16.53,,,,,,,11.73,26.63,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,68084060621,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,Local,,10.86,,,,,,,7.71,17.51,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,68084060501,NDC,,,facility,outpatient,1,EA,17.80000,5.16000,Aetna,Local,,9.04,,,,,,,6.42,14.56,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,68084059701,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,Local,,6.42,,,,,,,4.56,10.35,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,68084057201,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,Local,,3.60,,,,,,,2.56,5.81,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,68084054921,NDC,,,facility,outpatient,1,EA,66.80000,19.37000,Aetna,Local,,33.91,,,,,,,24.08,54.64,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,68084054101,NDC,,,facility,outpatient,1,EA,29.65000,8.60000,Aetna,Local,,15.05,,,,,,,10.69,24.25,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,68084053901,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,Local,,3.02,,,,,,,2.14,4.87,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,68084053825,NDC,,,facility,outpatient,1,EA,323.65000,93.86000,Aetna,Local,,164.32,,,,,,,116.68,264.75,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,68084053725,NDC,,,facility,outpatient,1,EA,190.25000,55.17000,Aetna,Local,,96.59,,,,,,,68.59,155.62,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,68084053601,NDC,,,facility,outpatient,1,EA,48.25000,13.99000,Aetna,Local,,24.50,,,,,,,17.39,39.47,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,68084048721,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,68084048001,NDC,,,facility,outpatient,1,EA,21.30000,6.18000,Aetna,Local,,10.81,,,,,,,7.68,17.42,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,68084047201,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,68084044821,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,Local,,7.44,,,,,,,5.28,11.98,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,68084044701,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,68084044601,NDC,,,facility,outpatient,1,EA,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,68084042301,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,68084040401,NDC,,,facility,outpatient,1,EA,26.65000,7.73000,Aetna,Local,,13.53,,,,,,,9.61,21.80,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,68084040301,NDC,,,facility,outpatient,1,EA,14.75000,4.28000,Aetna,Local,,7.49,,,,,,,5.32,12.07,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,68084040001,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,68084039901,NDC,,,facility,outpatient,1,EA,23.60000,6.84000,Aetna,Local,,11.98,,,,,,,8.51,19.30,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,68084039665,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,Local,,7.01,,,,,,,4.97,11.29,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,68084038101,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,68084038001,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,Local,,0.76155,,,,,,,0.54075,1.23,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,68084037201,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,68084036801,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,68084036009,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,68084035901,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,68084035401,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,68084034801,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,Local,,11.07,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,68084034701,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,Local,,8.10,,,,,,,5.75,13.05,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,68084034601,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,Local,,6.04,,,,,,,4.29,9.73,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,68084034401,NDC,,,facility,outpatient,1,EA,43.90000,12.73000,Aetna,Local,,22.29,,,,,,,15.83,35.91,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,68084034201,NDC,,,facility,outpatient,1,EA,14.85000,4.31000,Aetna,Local,,7.54,,,,,,,5.35,12.15,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,68084034197,NDC,,,facility,outpatient,1,EA,18.05000,5.23000,Aetna,Local,,9.16,,,,,,,6.51,14.76,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,68084033997,NDC,,,facility,outpatient,1,EA,18.05000,5.23000,Aetna,Local,,9.16,,,,,,,6.51,14.76,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,68084032821,NDC,,,facility,outpatient,1,EA,50.50000,14.64000,Aetna,Local,,25.64,,,,,,,18.21,41.31,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,68084031901,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,68084031801,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,68084031301,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,68084029901,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,68084029521,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,Local,,4.90,,,,,,,3.48,7.89,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,68084029121,NDC,,,facility,outpatient,1,EA,30.55000,8.86000,Aetna,Local,,15.51,,,,,,,11.01,24.99,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,68084028801,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,68084028401,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,Local,,3.96,,,,,,,2.81,6.38,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,68084028301,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,68084028201,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,68084028101,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,68084028001,NDC,,,facility,outpatient,1,EA,11.50000,3.34000,Aetna,Local,,5.84,,,,,,,4.15,9.41,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,68084027501,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,68084027201,NDC,,,facility,outpatient,1,EA,32.15000,9.32000,Aetna,Local,,16.32,,,,,,,11.59,26.30,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,68084027001,NDC,,,facility,outpatient,1,EA,27.55000,7.99000,Aetna,Local,,13.99,,,,,,,9.93,22.54,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,68084026901,NDC,,,facility,outpatient,1,EA,31.10000,9.02000,Aetna,Local,,15.79,,,,,,,11.21,25.44,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,68084024701,NDC,,,facility,outpatient,1,EA,23.60000,6.84000,Aetna,Local,,11.98,,,,,,,8.51,19.30,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,68084024301,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,68084022601,NDC,,,facility,outpatient,1,EA,26.50000,7.68000,Aetna,Local,,13.45,,,,,,,9.55,21.68,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,68084022501,NDC,,,facility,outpatient,1,EA,26.50000,7.68000,Aetna,Local,,13.45,,,,,,,9.55,21.68,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,68084022001,NDC,facility,inpatient,4,ME,6.35000,1.84000,Aetna,Local,,2.54,,,,,,,2.29,5.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,68084021501,NDC,,,facility,outpatient,1,EA,28.15000,8.16000,Aetna,Local,,14.29,,,,,,,10.15,23.03,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,68084021401,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,68084020401,NDC,,,facility,outpatient,1,EA,12.00000,3.48000,Aetna,Local,,6.09,,,,,,,4.33,9.82,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,68084020301,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,68084020201,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,68084019901,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,68084018901,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,68084010309,NDC,,,facility,outpatient,1,EA,59.95000,17.39000,Aetna,Local,,30.44,,,,,,,21.61,49.04,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,68084010001,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,Local,,2.34,,,,,,,1.66,3.76,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,68084009901,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,Local,,3.07,,,,,,,2.18,4.95,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,68084009801,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,Local,,3.07,,,,,,,2.18,4.95,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,68084009701,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,68084009401,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,3.40,,,,,,,2.42,5.48,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,68084009301,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,68084008801,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,68084008201,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,Local,,4.49,,,,,,,3.19,7.24,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,68084006501,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,68084004590,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,Local,,9.82,,,,,,,6.98,15.83,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,68084004101,NDC,,,facility,outpatient,1,EA,19.30000,5.60000,Aetna,Local,,9.80,,,,,,,6.96,15.79,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,68084004001,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,Local,,8.91,,,,,,,6.33,14.36,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,68084003101,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,68084002801,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,68084002701,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,68084001901,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,68084001801,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,68047025501,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,Local,,3.17,,,,,,,2.25,5.11,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,68047025301,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,Local,,1.70,,,,,,,1.21,2.74,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,68013001801,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,Local,,3.93,,,,,,,2.79,6.34,percent of total billed charges,
Ceftolozane-Tazobactam 1.5g Inj,800021332,CDM,636,RC,J0695,HCPCS,67919003001,NDC,facility,inpatient,1.5,GM,1442.40000,418.30000,Aetna,Local,,576.96,,,,,,,519.99,1179.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,67919001201,NDC,facility,inpatient,500,ME,3394.55000,984.42000,Aetna,Local,,1357.82,,,,,,,1223.74,2776.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,67919001101,NDC,facility,inpatient,500,ME,3394.50000,984.40000,Aetna,Local,,1357.80,,,,,,,1223.72,2776.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg Tab,800054501,CDM,637,RC,67877084201,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,Local,,8.71,,,,,,,6.18,14.03,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,67877075158,NDC,,,facility,outpatient,1,EA,30.80000,8.93000,Aetna,Local,,15.64,,,,,,,11.10,25.19,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,67877074957,NDC,,,facility,outpatient,1,EA,638.90000,185.28000,Aetna,Local,,324.37,,,,,,,230.32,522.62,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,67877073101,NDC,,,facility,outpatient,1,EA,276.55000,80.20000,Aetna,Local,,140.40,,,,,,,99.70,226.22,percent of total billed charges,
Droxidopa 100mg Cap,800051058,CDM,637,RC,67877070490,NDC,,,facility,outpatient,1,EA,251.65000,72.98000,Aetna,Local,,127.76,,,,,,,90.72,205.85,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,67877063930,NDC,,,facility,outpatient,1,EA,350.25000,101.57000,Aetna,Local,,177.82,,,,,,,126.27,286.50,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,67877063830,NDC,,,facility,outpatient,1,EA,350.25000,101.57000,Aetna,Local,,177.82,,,,,,,126.27,286.50,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,67877063533,NDC,,,facility,outpatient,1,EA,2957.85000,857.78000,Aetna,Local,,1501.70,,,,,,,1066.30,2419.52,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,67877063502,NDC,,,facility,outpatient,1,EA,2957.85000,857.78000,Aetna,Local,,1501.70,,,,,,,1066.30,2419.52,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,67877061701,NDC,,,facility,outpatient,1,EA,8.25000,2.39000,Aetna,Local,,4.19,,,,,,,2.97,6.75,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,67877058901,NDC,,,facility,outpatient,1,EA,47.70000,13.83000,Aetna,Local,,24.22,,,,,,,17.20,39.02,percent of total billed charges,
Cefixime 400mg C (Suprax),800063049,CDM,637,RC,67877058450,NDC,,,facility,outpatient,1,EA,166.55000,48.30000,Aetna,Local,,84.56,,,,,,,60.04,136.24,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,67877057301,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,67877054588,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,Local,,4.11,,,,,,,2.92,6.63,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,67877050651,NDC,,,facility,outpatient,1,EA,27.95000,8.11000,Aetna,Local,,14.19,,,,,,,10.08,22.86,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,67877049090,NDC,,,facility,outpatient,1,EA,73.10000,21.20000,Aetna,Local,,37.11,,,,,,,26.35,59.80,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,67877049030,NDC,,,facility,outpatient,1,EA,72.80000,21.11000,Aetna,Local,,36.96,,,,,,,26.24,59.55,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,67877049005,NDC,,,facility,outpatient,1,EA,72.80000,21.11000,Aetna,Local,,36.96,,,,,,,26.24,59.55,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,67877047750,NDC,,,facility,outpatient,1,EA,676.80000,196.27000,Aetna,Local,,343.61,,,,,,,243.99,553.62,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,67877047379,NDC,,,facility,outpatient,1,EA,1816.10000,526.67000,Aetna,Local,,922.03,,,,,,,654.70,1485.57,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,67877046290,NDC,,,facility,outpatient,1,EA,63.65000,18.46000,Aetna,Local,,32.32,,,,,,,22.95,52.07,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,67877041984,NDC,,,facility,outpatient,1,EA,1114.85000,323.31000,Aetna,Local,,566.01,,,,,,,401.90,911.95,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,67877041920,NDC,,,facility,outpatient,1,EA,1114.85000,323.31000,Aetna,Local,,566.01,,,,,,,401.90,911.95,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,67877041790,NDC,,,facility,outpatient,1,EA,33.45000,9.70000,Aetna,Local,,16.98,,,,,,,12.06,27.36,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,67877041390,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,67877032105,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,67877032101,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,67877032001,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,1.32,2.99,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,67877031901,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,67877031212,NDC,,,facility,outpatient,1,EA,50.55000,14.66000,Aetna,Local,,25.66,,,,,,,18.22,41.35,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,67877029605,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,67877029505,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,67877028660,NDC,,,facility,outpatient,1,EA,258.05000,74.83000,Aetna,Local,,131.01,,,,,,,93.03,211.08,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,67877025930,NDC,,,facility,outpatient,1,EA,176.90000,51.30000,Aetna,Local,,89.81,,,,,,,63.77,144.70,percent of total billed charges,
Triamcinolone 0.1% TC 80g,800017794,CDM,637,RC,67877025180,NDC,,,facility,outpatient,1,EA,103.00000,29.87000,Aetna,Local,,52.29,,,,,,,37.13,84.25,percent of total billed charges,
Triamcinolone 0.1% TC 454g,800077205,CDM,637,RC,67877025145,NDC,,,facility,outpatient,1,EA,219.65000,63.70000,Aetna,Local,,111.52,,,,,,,79.18,179.67,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,67877025115,NDC,,,facility,outpatient,1,EA,41.30000,11.98000,Aetna,Local,,20.97,,,,,,,14.89,33.78,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,67877025001,NDC,,,facility,outpatient,1,EA,48.55000,14.08000,Aetna,Local,,24.65,,,,,,,17.50,39.71,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,67877024201,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,Local,,14.37,,,,,,,10.20,23.15,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,67877022401,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,67877022305,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,67877022301,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,67877022210,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,67877022205,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,67877022201,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,67877022001,NDC,,,facility,outpatient,1,EA,6.20000,1.80000,Aetna,Local,,3.15,,,,,,,2.24,5.07,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,67877021905,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,67877021901,NDC,,,facility,outpatient,1,EA,13.95000,4.05000,Aetna,Local,,7.08,,,,,,,5.03,11.41,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,67877019990,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,Local,,8.55,,,,,,,6.07,13.78,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,67877019905,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,Local,,8.55,,,,,,,6.07,13.78,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,67877019890,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,Local,,6.42,,,,,,,4.56,10.35,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,67877019805,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,Local,,6.42,,,,,,,4.56,10.35,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,67877016930,NDC,facility,inpatient,4,ME,175.15000,50.79000,Aetna,Local,,70.06,,,,,,,63.14,143.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metFORMIN 500mg ER T,800080589,CDM,637,RC,67877015901,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,67877012485,NDC,,,facility,outpatient,1,EA,231.15000,67.03000,Aetna,Local,,117.35,,,,,,,83.33,189.08,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,67877010505,NDC,,,facility,outpatient,1,EA,16.05000,4.65000,Aetna,Local,,8.15,,,,,,,5.79,13.13,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,67877010501,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,67850015025,NDC,facility,inpatient,40,ME,26.60000,7.71000,Aetna,Local,,10.64,,,,,,,9.59,21.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,67850004110,NDC,,,facility,outpatient,1,EA,275.50000,79.90000,Aetna,Local,,139.87,,,,,,,99.32,225.36,percent of total billed charges,
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,67850003210,NDC,facility,inpatient,2,GM,207.25000,60.10000,Aetna,Local,,82.90,,,,,,,74.71,169.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,67850002210,NDC,facility,inpatient,2,GM,126.40000,36.66000,Aetna,Local,,50.56,,,,,,,45.57,103.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,67767015301,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,Local,,5.00,,,,,,,3.55,8.06,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,67767014190,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,Local,,18.76,,,,,,,13.32,30.23,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,67767014130,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,Local,,18.76,,,,,,,13.32,30.23,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,67767013360,NDC,,,facility,outpatient,1,EA,20.60000,5.97000,Aetna,Local,,10.46,,,,,,,7.43,16.85,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,67767012318,NDC,,,facility,outpatient,1,EA,469.95000,136.29000,Aetna,Local,,238.59,,,,,,,169.42,384.42,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,67767012218,NDC,,,facility,outpatient,1,EA,361.70000,104.89000,Aetna,Local,,183.64,,,,,,,130.39,295.87,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,67767012118,NDC,,,facility,outpatient,1,EA,241.60000,70.06000,Aetna,Local,,122.66,,,,,,,87.10,197.63,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,67767012018,NDC,,,facility,outpatient,1,EA,133.20000,38.63000,Aetna,Local,,67.63,,,,,,,48.02,108.96,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,67767011215,NDC,,,facility,outpatient,1,EA,195.70000,56.75000,Aetna,Local,,99.36,,,,,,,70.55,160.08,percent of total billed charges,
Ethiodized Oil 480 mg/mL Inj Soln 10mL,800046530,CDM,250,RC,67684190102,NDC,,,facility,outpatient,1,EA,4628.20000,1342.18000,Aetna,Local,,2349.74,,,,,,,1668.47,3785.87,percent of total billed charges,
Nitazoxanide 500mg Tab,800017652,CDM,637,RC,67546011132,NDC,,,facility,outpatient,1,EA,133.10000,38.60000,Aetna,Local,,67.57,,,,,,,47.98,108.88,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,67467064301,NDC,facility,inpatient,12.5,GM,489.50000,141.95000,Aetna,Local,,195.80,,,,,,,176.46,400.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,67467062302,NDC,facility,inpatient,12.5,GM,563.00000,163.27000,Aetna,Local,,225.20,,,,,,,202.96,460.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,67457094010,NDC,facility,inpatient,1000,ME,373.00000,108.17000,Aetna,Local,,149.20,,,,,,,134.47,305.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,67457092005,NDC,facility,inpatient,4,ME,407.60000,118.20000,Aetna,Local,,163.04,,,,,,,146.94,333.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,67457088799,NDC,facility,inpatient,150,ME,212.90000,61.74000,Aetna,Local,,85.16,,,,,,,76.75,174.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,67457085930,NDC,facility,inpatient,6,ME,83.40000,24.19000,Aetna,Local,,33.36,,,,,,,30.07,68.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,67457085502,NDC,facility,inpatient,6,ME,39.90000,11.57000,Aetna,Local,,15.96,,,,,,,14.38,32.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,67457085350,NDC,facility,inpatient,500,ME,373.00000,108.17000,Aetna,Local,,149.20,,,,,,,134.47,305.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,67457085204,NDC,,,facility,outpatient,1,EA,116.10000,33.67000,Aetna,Local,,58.94,,,,,,,41.85,94.97,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,67457083902,NDC,,,facility,outpatient,1,EA,1264.50000,366.70000,Aetna,Local,,641.99,,,,,,,455.85,1034.36,percent of total billed charges,
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,800046526,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,inpatient,6,ME,16823.20000,4878.73000,Aetna,Local,,6729.28,,,,,,,6064.76,13761.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-jmdb 6mg/0.6mL Inj Syr,800046526,CDM,636,RC,Q5108,HCPCS,67457083306,NDC,facility,outpatient,6,ME,16823.20000,4878.73000,Aetna,Local,,6729.28,,,,,,,95.21,13761.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,67457079410,NDC,facility,inpatient,5,ME,1049.50000,304.35000,Aetna,Local,,419.80,,,,,,,378.34,858.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,67457079005,NDC,facility,inpatient,500,ME,100.80000,29.23000,Aetna,Local,,40.32,,,,,,,36.34,82.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,67457065725,NDC,facility,inpatient,2.5,GM,3469.50000,1006.16000,Aetna,Local,,1387.80,,,,,,,1250.75,2838.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,67457064502,NDC,facility,inpatient,0.4,ME,126.20000,36.60000,Aetna,Local,,50.48,,,,,,,45.50,103.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,67457064099,NDC,facility,inpatient,10,ME,118.10000,34.25000,Aetna,Local,,47.24,,,,,,,42.58,96.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,67457063110,NDC,facility,inpatient,75,ME,930.00000,269.70000,Aetna,Local,,372.00,,,,,,,335.26,760.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,67457062910,NDC,facility,inpatient,20,ME,187.50000,54.37000,Aetna,Local,,75.00,,,,,,,67.59,153.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,67457062199,NDC,facility,inpatient,40,ME,56.75000,16.46000,Aetna,Local,,22.70,,,,,,,20.46,46.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,67457061910,NDC,facility,inpatient,5,ME,2020.00000,585.80000,Aetna,Local,,808.00,,,,,,,728.21,1652.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,67457058406,NDC,facility,inpatient,7.5,ME,581.30000,168.58000,Aetna,Local,,232.52,,,,,,,209.56,475.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,67457057110,NDC,,,facility,outpatient,1,EA,31.90000,9.25000,Aetna,Local,,16.20,,,,,,,11.50,26.09,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,67457055400,NDC,facility,inpatient,4,GM,66.35000,19.24000,Aetna,Local,,26.54,,,,,,,23.92,54.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,67457055300,NDC,facility,inpatient,2,GM,133.75000,38.79000,Aetna,Local,,53.50,,,,,,,48.22,109.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,67457053035,NDC,facility,inpatient,350,ME,247.00000,71.63000,Aetna,Local,,98.80,,,,,,,89.04,202.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,67457052433,NDC,facility,inpatient,3,ME,1867.25000,541.50000,Aetna,Local,,746.90,,,,,,,673.14,1527.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,67457052237,NDC,facility,inpatient,3.375,GM,133.15000,38.61000,Aetna,Local,,53.26,,,,,,,48.00,108.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,67457051701,NDC,facility,inpatient,500,ME,441.20000,127.95000,Aetna,Local,,176.48,,,,,,,159.05,360.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,67457051625,NDC,facility,inpatient,100,ME,95.75000,27.77000,Aetna,Local,,38.30,,,,,,,34.52,78.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,67457047710,NDC,,,facility,outpatient,1,EA,62.65000,18.17000,Aetna,Local,,31.81,,,,,,,22.59,51.25,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,67457046799,NDC,facility,inpatient,50,ME,34.30000,9.95000,Aetna,Local,,13.72,,,,,,,12.37,28.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,67457046201,NDC,facility,inpatient,1000,ME,533.00000,154.57000,Aetna,Local,,213.20,,,,,,,192.15,435.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,67457044753,NDC,,,facility,outpatient,1,EA,43.40000,12.59000,Aetna,Local,,22.03,,,,,,,15.65,35.50,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,67457044022,NDC,facility,inpatient,4,ME,3.85000,1.12000,Aetna,Local,,1.54,,,,,,,1.39,3.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,67457043810,NDC,,,facility,outpatient,1,EA,31.90000,9.25000,Aetna,Local,,16.20,,,,,,,11.50,26.09,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,67457043322,NDC,facility,inpatient,20,ME,5.70000,1.65000,Aetna,Local,,2.28,,,,,,,2.05,4.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,67457042612,NDC,facility,inpatient,5,ME,7.65000,2.22000,Aetna,Local,,3.06,,,,,,,2.76,6.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,67457042312,NDC,facility,inpatient,4,ME,5.25000,1.52000,Aetna,Local,,2.10,,,,,,,1.89,4.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,67457042254,NDC,facility,inpatient,1,ME,0.95000,0.28000,Aetna,Local,,0.38000,,,,,,,0.34247,0.77710,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,67457041901,NDC,facility,inpatient,4,ME,4.95000,1.44000,Aetna,Local,,1.98,,,,,,,1.78,4.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,67457041805,NDC,facility,inpatient,1,ME,0.95000,0.28000,Aetna,Local,,0.38000,,,,,,,0.34247,0.77710,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,67457039054,NDC,facility,inpatient,4,ME,423.00000,122.67000,Aetna,Local,,169.20,,,,,,,152.49,346.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,67457038599,NDC,facility,inpatient,10000,UN,26.45000,7.67000,Aetna,Local,,10.58,,,,,,,9.54,21.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,67457038499,NDC,facility,inpatient,30000,UN,79.75000,23.13000,Aetna,Local,,31.90,,,,,,,28.75,65.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,67457035210,NDC,facility,inpatient,2,GM,127.35000,36.93000,Aetna,Local,,50.94,,,,,,,45.91,104.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,67457035110,NDC,facility,inpatient,1,GM,78.90000,22.88000,Aetna,Local,,31.56,,,,,,,28.44,64.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,67457034910,NDC,facility,inpatient,3,GM,122.95000,35.66000,Aetna,Local,,49.18,,,,,,,44.32,100.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,67457034903,NDC,facility,inpatient,3,GM,122.95000,35.66000,Aetna,Local,,49.18,,,,,,,44.32,100.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,67457034815,NDC,facility,inpatient,1.5,GM,65.10000,18.88000,Aetna,Local,,26.04,,,,,,,23.47,53.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,67457034810,NDC,facility,inpatient,1.5,GM,65.10000,18.88000,Aetna,Local,,26.04,,,,,,,23.47,53.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,67457034210,NDC,facility,inpatient,1,GM,205.60000,59.62000,Aetna,Local,,82.24,,,,,,,74.12,168.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,67457034001,NDC,facility,inpatient,1,GM,154.00000,44.66000,Aetna,Local,,61.60,,,,,,,55.52,125.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,67457033950,NDC,facility,inpatient,500,ME,77.20000,22.39000,Aetna,Local,,30.88,,,,,,,27.83,63.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,67457031105,NDC,facility,inpatient,250,ME,3811.20000,1105.25000,Aetna,Local,,1524.48,,,,,,,1373.94,3117.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,67457029202,NDC,facility,inpatient,0.4,ME,126.20000,36.60000,Aetna,Local,,50.48,,,,,,,45.50,103.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,67457029101,NDC,facility,inpatient,20,ME,577.90000,167.59000,Aetna,Local,,231.16,,,,,,,208.33,472.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,67457026330,NDC,facility,inpatient,500,ME,1376.05000,399.05000,Aetna,Local,,550.42,,,,,,,496.07,1125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,67457025610,NDC,facility,inpatient,250,ME,7582.25000,2198.85000,Aetna,Local,,3032.90,,,,,,,2733.40,6202.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,67457025510,NDC,facility,inpatient,500,ME,134.40000,38.98000,Aetna,Local,,53.76,,,,,,,48.45,109.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,67457022805,NDC,,,facility,outpatient,1,EA,32.25000,9.35000,Aetna,Local,,16.37,,,,,,,11.63,26.38,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,67457022702,NDC,facility,inpatient,0.25,ME,494.20000,143.32000,Aetna,Local,,197.68,,,,,,,178.16,404.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,67457022615,NDC,facility,inpatient,3,GM,50.90000,14.76000,Aetna,Local,,20.36,,,,,,,18.35,41.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,inpatient,50,ME,5027.35000,1457.93000,Aetna,Local,,2010.94,,,,,,,1812.36,4112.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,67457022005,NDC,facility,outpatient,50,ME,5027.35000,1457.93000,Aetna,Local,,2010.94,,,,,,,5.42,4112.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,67457019803,NDC,,,facility,outpatient,1,EA,552.85000,160.33000,Aetna,Local,,280.68,,,,,,,199.30,452.23,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,67457019710,NDC,,,facility,outpatient,1,EA,645.50000,187.20000,Aetna,Local,,327.72,,,,,,,232.70,528.02,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,67457019602,NDC,facility,inpatient,200,ME,56.75000,16.46000,Aetna,Local,,22.70,,,,,,,20.46,46.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,67457018210,NDC,facility,inpatient,100,ME,46.55000,13.50000,Aetna,Local,,18.62,,,,,,,16.78,38.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,67457015303,NDC,facility,inpatient,150,ME,42.25000,12.25000,Aetna,Local,,16.90,,,,,,,15.23,34.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,67457000110,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,Local,,3.55,,,,,,,2.52,5.73,percent of total billed charges,
Ketamine 500mg/NS 250mL IV,800052000,CDM,250,RC,67457000100,NDC,,,facility,outpatient,1,EA,81.70000,23.69000,Aetna,Local,,41.48,,,,,,,29.45,66.83,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,67405060203,NDC,,,facility,outpatient,1,EA,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,22.35,50.72,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,67386071155,NDC,facility,inpatient,500,ME,1915.15000,555.39000,Aetna,Local,,766.06,,,,,,,690.41,1566.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
eptinezumab - jjmr 100mg Inj,800062069,CDM,636,RC,J3032,HCPCS,67386013051,NDC,facility,inpatient,100,ME,10951.00000,3175.79000,Aetna,Local,,4380.40,,,,,,,3947.84,8957.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,67286081203,NDC,facility,inpatient,25,ME,1536.15000,445.48000,Aetna,Local,,614.46,,,,,,,553.78,1256.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,67253090010,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,67253066010,NDC,,,facility,outpatient,1,EA,20.25000,5.87000,Aetna,Local,,10.28,,,,,,,7.30,16.56,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,67253065110,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,67253062010,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,67253042010,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,67253038110,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,67253038010,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,67253020110,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,67253014846,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,67253014310,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,67253000760,NDC,,,facility,outpatient,1,EA,36.20000,10.50000,Aetna,Local,,18.38,,,,,,,13.05,29.61,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,67211010201,NDC,facility,inpatient,100,ME,2625.10000,761.28000,Aetna,Local,,1050.04,,,,,,,946.35,2147.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,67159011203,NDC,,,facility,outpatient,1,EA,28.55000,8.28000,Aetna,Local,,14.49,,,,,,,10.29,23.35,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,66993095077,NDC,,,facility,outpatient,1,EA,121.20000,35.15000,Aetna,Local,,61.53,,,,,,,43.69,99.14,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,66993089815,NDC,,,facility,outpatient,1,EA,240.05000,69.61000,Aetna,Local,,121.87,,,,,,,86.54,196.36,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,800015438,CDM,637,RC,66993079197,NDC,,,facility,outpatient,1,EA,1469.55000,426.17000,Aetna,Local,,746.09,,,,,,,529.77,1202.09,percent of total billed charges,
Fluticasone Prop 50mcg/INH Diskus,800017934,CDM,637,RC,66993079097,NDC,,,facility,outpatient,1,EA,1408.15000,408.36000,Aetna,Local,,714.92,,,,,,,507.64,1151.87,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,66993066430,NDC,,,facility,outpatient,1,EA,55.55000,16.11000,Aetna,Local,,28.20,,,,,,,20.03,45.44,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,66993066330,NDC,,,facility,outpatient,1,EA,55.55000,16.11000,Aetna,Local,,28.20,,,,,,,20.03,45.44,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,66993066130,NDC,,,facility,outpatient,1,EA,50.40000,14.62000,Aetna,Local,,25.59,,,,,,,18.17,41.23,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,66993058697,NDC,,,facility,outpatient,1,EA,3253.85000,943.62000,Aetna,Local,,1651.98,,,,,,,1173.01,2661.65,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,66993058597,NDC,,,facility,outpatient,1,EA,2542.35000,737.28000,Aetna,Local,,1290.75,,,,,,,916.52,2079.64,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,66993041730,NDC,,,facility,outpatient,1,EA,50.40000,14.62000,Aetna,Local,,25.59,,,,,,,18.17,41.23,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,66993040732,NDC,,,facility,outpatient,1,EA,13.90000,4.03000,Aetna,Local,,7.06,,,,,,,5.01,11.37,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,66993037179,NDC,facility,inpatient,150,ME,530.05000,153.71000,Aetna,Local,,212.02,,,,,,,191.08,433.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,66993024150,NDC,,,facility,outpatient,1,EA,1425.30000,413.34000,Aetna,Local,,723.62,,,,,,,513.82,1165.90,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,66993016502,NDC,,,facility,outpatient,1,EA,47.70000,13.83000,Aetna,Local,,24.22,,,,,,,17.20,39.02,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,66993016030,NDC,,,facility,outpatient,1,EA,116.15000,33.68000,Aetna,Local,,58.97,,,,,,,41.87,95.01,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,66993012130,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,Local,,18.73,,,,,,,13.30,30.18,percent of total billed charges,
SUMAtriptan 20mg/spray NS,800081034,CDM,637,RC,66993008269,NDC,,,facility,outpatient,1,EA,413.95000,120.05000,Aetna,Local,,210.16,,,,,,,149.23,338.61,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,66993006880,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,66993005702,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,66993002501,NDC,,,facility,outpatient,1,EA,1539.45000,446.44000,Aetna,Local,,781.58,,,,,,,554.97,1259.27,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,66993001968,NDC,,,facility,outpatient,1,EA,164.55000,47.72000,Aetna,Local,,83.54,,,,,,,59.32,134.60,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,66993000960,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,Local,,6.55,,,,,,,4.65,10.55,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,66993000210,NDC,,,facility,outpatient,1,EA,1860.85000,539.65000,Aetna,Local,,944.75,,,,,,,670.84,1522.18,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,66870040215,NDC,,,facility,outpatient,1,EA,117.25000,34.00000,Aetna,Local,,59.53,,,,,,,42.27,95.91,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,66860007302,NDC,facility,inpatient,1,GM,346.50000,100.48000,Aetna,Local,,138.60,,,,,,,124.91,283.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,66860002001,NDC,facility,inpatient,1,ME,1.60000,0.46000,Aetna,Local,,0.64000,,,,,,,0.57680,1.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,66860000203,NDC,facility,inpatient,1000,ME,22.40000,6.50000,Aetna,Local,,8.96,,,,,,,8.08,18.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,66794021943,NDC,facility,inpatient,600,ME,182.40000,52.90000,Aetna,Local,,72.96,,,,,,,65.76,149.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,66794021342,NDC,facility,inpatient,1,GM,14.50000,4.20000,Aetna,Local,,5.80,,,,,,,5.23,11.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,66794020741,NDC,facility,inpatient,3,GM,60.00000,17.40000,Aetna,Local,,24.00,,,,,,,21.63,49.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,66794020641,NDC,facility,inpatient,1.5,GM,41.30000,11.98000,Aetna,Local,,16.52,,,,,,,14.89,33.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,66794020442,NDC,facility,inpatient,1,ME,25.55000,7.41000,Aetna,Local,,10.22,,,,,,,9.21,20.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,66794015701,NDC,facility,inpatient,40,ME,4604.55000,1335.32000,Aetna,Local,,1841.82,,,,,,,1659.94,3766.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isoflurane Inhl Sol 100mL,800081217,CDM,250,RC,66794001710,NDC,,,facility,outpatient,1,EA,169.90000,49.27000,Aetna,Local,,86.26,,,,,,,61.25,138.98,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,66758020854,NDC,,,facility,outpatient,1,EA,151.50000,43.93000,Aetna,Local,,76.92,,,,,,,54.62,123.93,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,66758019013,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,66689079050,NDC,,,facility,outpatient,1,EA,99.15000,28.75000,Aetna,Local,,50.34,,,,,,,35.74,81.10,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,66689079001,NDC,,,facility,outpatient,1,EA,99.15000,28.75000,Aetna,Local,,50.34,,,,,,,35.74,81.10,percent of total billed charges,
Methadone 50mg/5mL Oral Conc,800025566,CDM,637,RC,66689069430,NDC,,,facility,outpatient,1,EA,133.00000,38.57000,Aetna,Local,,67.52,,,,,,,47.95,108.79,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,66689033950,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,Local,,4.47,,,,,,,3.17,7.20,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,66689006242,NDC,,,facility,outpatient,1,EA,286.75000,83.16000,Aetna,Local,,145.58,,,,,,,103.37,234.56,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,66689004850,NDC,,,facility,outpatient,1,EA,203.15000,58.91000,Aetna,Local,,103.14,,,,,,,73.24,166.18,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,66689004750,NDC,,,facility,outpatient,1,EA,131.70000,38.19000,Aetna,Local,,66.86,,,,,,,47.48,107.73,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,66689003850,NDC,,,facility,outpatient,1,EA,11.85000,3.44000,Aetna,Local,,6.02,,,,,,,4.27,9.69,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,66689003799,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,66689003750,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,Local,,5.53,,,,,,,3.93,8.92,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,66689003650,NDC,,,facility,outpatient,1,EA,61.15000,17.73000,Aetna,Local,,31.05,,,,,,,22.04,50.02,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,66689002050,NDC,,,facility,outpatient,1,EA,49.80000,14.44000,Aetna,Local,,25.28,,,,,,,17.95,40.74,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,66689002001,NDC,,,facility,outpatient,1,EA,30.10000,8.73000,Aetna,Local,,15.28,,,,,,,10.85,24.62,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,66689000950,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,Local,,4.47,,,,,,,3.17,7.20,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,66689000816,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,800018013,CDM,637,RC,66689000550,NDC,,,facility,outpatient,1,EA,37.90000,10.99000,Aetna,Local,,19.24,,,,,,,13.66,31.00,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,66685101200,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,66685100202,NDC,,,facility,outpatient,1,EA,26.00000,7.54000,Aetna,Local,,13.20,,,,,,,9.37,21.27,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,66685100200,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,Local,,13.61,,,,,,,9.66,21.92,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,66685100101,NDC,,,facility,outpatient,1,EA,34.70000,10.06000,Aetna,Local,,17.62,,,,,,,12.51,28.38,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,66685100100,NDC,,,facility,outpatient,1,EA,35.75000,10.37000,Aetna,Local,,18.15,,,,,,,12.89,29.24,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,66591084142,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,66591019941,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,Local,,41.78,,,,,,,29.67,67.32,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,66591018442,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,Local,,41.78,,,,,,,29.67,67.32,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,66582041454,NDC,,,facility,outpatient,1,EA,97.70000,28.33000,Aetna,Local,,49.60,,,,,,,35.22,79.92,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,66582041431,NDC,,,facility,outpatient,1,EA,97.70000,28.33000,Aetna,Local,,49.60,,,,,,,35.22,79.92,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,66490004101,NDC,facility,inpatient,1,ME,4878.20000,1414.68000,Aetna,Local,,1951.28,,,,,,,1758.59,3990.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,66479054325,NDC,,,facility,outpatient,1,EA,41.65000,12.08000,Aetna,Local,,21.15,,,,,,,15.01,34.07,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,66479054310,NDC,,,facility,outpatient,1,EA,59.45000,17.24000,Aetna,Local,,30.18,,,,,,,21.43,48.63,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,66479054125,NDC,,,facility,outpatient,1,EA,19.65000,5.70000,Aetna,Local,,9.98,,,,,,,7.08,16.07,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,66479054025,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,Local,,5.00,,,,,,,3.55,8.06,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,66479054010,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,Local,,5.51,,,,,,,3.91,8.88,percent of total billed charges,
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,66479024725,NDC,facility,inpatient,350,ME,1593.75000,462.19000,Aetna,Local,,637.50,,,,,,,574.55,1303.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,66220020730,NDC,facility,inpatient,6000,ME,263.75000,76.49000,Aetna,Local,,105.50,,,,,,,95.08,215.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,66220010730,NDC,facility,inpatient,6000,ME,1485.75000,430.87000,Aetna,Local,,594.30,,,,,,,535.61,1215.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65939038742,NDC,,,facility,outpatient,1,EA,32.50000,9.42000,Aetna,Local,,16.50,,,,,,,11.72,26.59,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,800046545,CDM,637,RC,65862089678,NDC,,,facility,outpatient,1,EA,111.70000,32.39000,Aetna,Local,,56.71,,,,,,,40.27,91.37,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,65862084401,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,Local,,4.75,,,,,,,3.37,7.65,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,65862083030,NDC,,,facility,outpatient,1,EA,116.85000,33.89000,Aetna,Local,,59.32,,,,,,,42.12,95.58,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,65862082930,NDC,,,facility,outpatient,1,EA,116.85000,33.89000,Aetna,Local,,59.32,,,,,,,42.12,95.58,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,65862080530,NDC,,,facility,outpatient,1,EA,58.10000,16.85000,Aetna,Local,,29.50,,,,,,,20.95,47.53,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,65862078201,NDC,,,facility,outpatient,1,EA,14.80000,4.29000,Aetna,Local,,7.51,,,,,,,5.34,12.11,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,65862073205,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,Local,,12.16,,,,,,,8.63,19.59,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862069960,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862069920,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,65862069790,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,12.98,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,65862069730,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,12.98,29.45,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,65862069201,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,65862067701,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,65862067601,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,65862065401,NDC,,,facility,outpatient,1,EA,32.15000,9.32000,Aetna,Local,,16.32,,,,,,,11.59,26.30,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,65862064860,NDC,,,facility,outpatient,1,EA,33.00000,9.57000,Aetna,Local,,16.75,,,,,,,11.90,26.99,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,65862059801,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,65862059501,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,Local,,14.65,,,,,,,10.40,23.60,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,65862057290,NDC,,,facility,outpatient,1,EA,35.40000,10.27000,Aetna,Local,,17.97,,,,,,,12.76,28.96,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,65862057190,NDC,,,facility,outpatient,1,EA,32.90000,9.54000,Aetna,Local,,16.70,,,,,,,11.86,26.91,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,65862056099,NDC,,,facility,outpatient,1,EA,37.30000,10.82000,Aetna,Local,,18.94,,,,,,,13.45,30.51,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,65862056090,NDC,,,facility,outpatient,1,EA,37.30000,10.82000,Aetna,Local,,18.94,,,,,,,13.45,30.51,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,65862055260,NDC,,,facility,outpatient,1,EA,50.65000,14.69000,Aetna,Local,,25.72,,,,,,,18.26,41.43,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),800015332,CDM,637,RC,65862053820,NDC,,,facility,outpatient,1,EA,252.40000,73.20000,Aetna,Local,,128.14,,,,,,,90.99,206.46,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,65862053475,NDC,,,facility,outpatient,1,EA,22.10000,6.41000,Aetna,Local,,11.22,,,,,,,7.97,18.08,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,65862053450,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,65862052890,NDC,,,facility,outpatient,1,EA,33.05000,9.58000,Aetna,Local,,16.78,,,,,,,11.91,27.03,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,65862052790,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,Local,,14.98,,,,,,,10.63,24.13,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,65862052730,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,Local,,14.98,,,,,,,10.63,24.13,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,65862052301,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,65862050320,NDC,,,facility,outpatient,1,EA,35.90000,10.41000,Aetna,Local,,18.23,,,,,,,12.94,29.37,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,65862050220,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,Local,,13.61,,,,,,,9.66,21.92,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,800072524,CDM,637,RC,65862049647,NDC,,,facility,outpatient,1,EA,64.50000,18.70000,Aetna,Local,,32.75,,,,,,,23.25,52.76,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,65862047601,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,65862047501,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,Local,,6.50,,,,,,,4.61,10.47,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,65862047401,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,Local,,5.51,,,,,,,3.91,8.88,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,65862041901,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,Local,,2.39,,,,,,,1.69,3.84,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,65862037501,NDC,,,facility,outpatient,1,EA,34.85000,10.11000,Aetna,Local,,17.69,,,,,,,12.56,28.51,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,65862037401,NDC,,,facility,outpatient,1,EA,33.40000,9.69000,Aetna,Local,,16.96,,,,,,,12.04,27.32,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,65862037301,NDC,,,facility,outpatient,1,EA,31.95000,9.27000,Aetna,Local,,16.22,,,,,,,11.52,26.14,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,65862029630,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,Local,,32.16,,,,,,,22.84,51.82,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,65862029490,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,Local,,32.16,,,,,,,22.84,51.82,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,65862025047,NDC,,,facility,outpatient,1,EA,23.05000,6.68000,Aetna,Local,,11.70,,,,,,,8.31,18.85,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,65862022801,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,Local,,17.08,,,,,,,12.13,27.53,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,65862022701,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,Local,,14.95,,,,,,,10.62,24.09,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,65862020390,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,Local,,11.07,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,65862020330,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,Local,,11.07,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,65862020299,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,65862020290,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,65862020230,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,65862020190,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,Local,,6.04,,,,,,,4.29,9.73,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,65862019301,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,Local,,9.60,,,,,,,6.81,15.46,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,65862019201,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,Local,,9.34,,,,,,,6.63,15.05,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65862019105,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65862019101,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,Local,,4.04,,,,,,,2.87,6.50,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,65862019001,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,Local,,6.19,,,,,,,4.40,9.98,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,65862018730,NDC,facility,inpatient,4,ME,171.35000,49.69000,Aetna,Local,,68.54,,,,,,,61.77,140.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,65862017760,NDC,,,facility,outpatient,1,EA,36.15000,10.48000,Aetna,Local,,18.35,,,,,,,13.03,29.57,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,65862017601,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,65862016901,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,65862014990,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,65862014836,NDC,,,facility,outpatient,1,EA,180.40000,52.32000,Aetna,Local,,91.59,,,,,,,65.03,147.57,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,65862014636,NDC,,,facility,outpatient,1,EA,193.00000,55.97000,Aetna,Local,,97.99,,,,,,,69.58,157.87,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,65862014501,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,Local,,7.01,,,,,,,4.97,11.29,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,65862014201,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,Local,,7.01,,,,,,,4.97,11.29,percent of total billed charges,
Cefpodoxime 200mg Tab,800051990,CDM,637,RC,51990,HCPCS,65862009620,NDC,facility,outpatient,200,ME,59.90000,17.37000,Aetna,Local,,3875.00,,,,,,,23.96,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,65862007930,NDC,,,facility,outpatient,1,EA,90.50000,26.24000,Aetna,Local,,45.95,,,,,,,32.63,74.03,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,65862006201,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
LamiVUDine 10mg/1mL Oral L(Epivir),800081138,CDM,637,RC,65862005524,NDC,,,facility,outpatient,1,EA,8.35000,2.42000,Aetna,Local,,4.24,,,,,,,3.01,6.83,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,65862004201,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,Local,,5.53,,,,,,,3.93,8.92,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,65862003901,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862003460,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,65862003420,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,65862003130,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,Local,,9.70,,,,,,,6.89,15.62,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,65862002901,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,800015404,CDM,637,RC,65862002801,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,65862001901,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,65862001701,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,65862001205,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,Local,,10.23,,,,,,,7.26,16.48,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,65862000801,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,Local,,2.56,,,,,,,1.82,4.13,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),800017683,CDM,637,RC,65726026315,NDC,,,facility,outpatient,1,EA,57.70000,16.73000,Aetna,Local,,29.29,,,,,,,20.80,47.20,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,65726026225,NDC,,,facility,outpatient,1,EA,47.15000,13.67000,Aetna,Local,,23.94,,,,,,,17.00,38.57,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,65726026215,NDC,,,facility,outpatient,1,EA,57.25000,16.60000,Aetna,Local,,29.07,,,,,,,20.64,46.83,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,65726026125,NDC,,,facility,outpatient,1,EA,35.80000,10.38000,Aetna,Local,,18.18,,,,,,,12.91,29.28,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,65726026115,NDC,,,facility,outpatient,1,EA,45.20000,13.11000,Aetna,Local,,22.95,,,,,,,16.29,36.97,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,65649041124,NDC,,,facility,outpatient,1,EA,521.00000,151.09000,Aetna,Local,,264.51,,,,,,,187.82,426.18,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,65649041112,NDC,,,facility,outpatient,1,EA,521.00000,151.09000,Aetna,Local,,264.51,,,,,,,187.82,426.18,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,65649040130,NDC,,,facility,outpatient,1,EA,1368.15000,396.76000,Aetna,Local,,694.61,,,,,,,493.22,1119.15,percent of total billed charges,
NICU- Chlorothiazide 50mg/mL L,800081184,CDM,637,RC,65649031112,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
rifAXIMin 200 mg T(Xifaxan),800070021,CDM,637,RC,65649030141,NDC,,,facility,outpatient,1,EA,113.55000,32.93000,Aetna,Local,,57.65,,,,,,,40.93,92.88,percent of total billed charges,
rifAXIMin 200 mg T(Xifaxan),800070021,CDM,637,RC,65649030103,NDC,,,facility,outpatient,1,EA,95.40000,27.67000,Aetna,Local,,48.43,,,,,,,34.39,78.04,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,65628020810,NDC,,,facility,outpatient,1,EA,40.15000,11.64000,Aetna,Local,,20.38,,,,,,,14.47,32.84,percent of total billed charges,
Vancomycin 125mg/2.5mL Oral Soln,800072448,CDM,637,RC,65628020110,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,65628020110,NDC,,,facility,outpatient,1,EA,19.95000,5.79000,Aetna,Local,,10.13,,,,,,,7.19,16.32,percent of total billed charges,
Magic Mouthwash 10mL L UD,800081240,CDM,637,RC,65628005001,NDC,,,facility,outpatient,1,EA,44.80000,12.99000,Aetna,Local,,22.74,,,,,,,16.15,36.65,percent of total billed charges,
Magic Mouthwash 5mL  L UD,800015325,CDM,637,RC,65628005001,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,Local,,11.37,,,,,,,8.08,18.32,percent of total billed charges,
Magic Mouthwash 15mL L UD,800015326,CDM,637,RC,65628005001,NDC,,,facility,outpatient,1,EA,67.20000,19.49000,Aetna,Local,,34.12,,,,,,,24.23,54.97,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,65628001610,NDC,,,facility,outpatient,1,EA,30.70000,8.90000,Aetna,Local,,15.59,,,,,,,11.07,25.11,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,65597070118,NDC,,,facility,outpatient,1,EA,31.60000,9.16000,Aetna,Local,,16.04,,,,,,,11.39,25.85,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,65580064371,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,65483070210,NDC,,,facility,outpatient,1,EA,148.25000,42.99000,Aetna,Local,,75.27,,,,,,,53.44,121.27,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,65473070301,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,65293000101,NDC,facility,inpatient,250,ME,7795.00000,2260.55000,Aetna,Local,,3118.00,,,,,,,2810.10,6376.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
etomidate 2mg/mL 20mL Inj,800046520,CDM,250,RC,65219044720,NDC,,,facility,outpatient,1,EA,40.55000,11.76000,Aetna,Local,,20.59,,,,,,,14.62,33.17,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,65219044510,NDC,,,facility,outpatient,1,EA,35.10000,10.18000,Aetna,Local,,17.82,,,,,,,12.65,28.71,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,65219043315,NDC,facility,inpatient,40,ME,31.15000,9.03000,Aetna,Local,,12.46,,,,,,,11.23,25.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- iodixanol 320mg/mL Inj 100mL,800022113,CDM,636,RC,Q9967,HCPCS,65219038310,NDC,facility,inpatient,1,EA,506.20000,146.80000,Aetna,Local,,202.48,,,,,,,182.49,414.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- iodixanol 270mg/mL I 100mL,800021696,CDM,636,RC,Q9966,HCPCS,65219038110,NDC,facility,inpatient,1,EA,464.55000,134.72000,Aetna,Local,,185.82,,,,,,,167.47,380.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,65219036802,NDC,facility,inpatient,2,ME,13.55000,3.93000,Aetna,Local,,5.42,,,,,,,4.88,11.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,65219029510,NDC,facility,inpatient,0.04,ME,1257.00000,364.53000,Aetna,Local,,502.80,,,,,,,453.15,1028.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,65219029301,NDC,facility,inpatient,0.004,ME,95.75000,27.77000,Aetna,Local,,38.30,,,,,,,34.52,78.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,65219028965,NDC,facility,inpatient,1,EA,37.10000,10.76000,Aetna,Local,,14.84,,,,,,,13.37,30.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,65219025945,NDC,facility,inpatient,4.5,GM,101.55000,29.45000,Aetna,Local,,40.62,,,,,,,36.61,83.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,65219025701,NDC,,,facility,outpatient,1,EA,74.80000,21.69000,Aetna,Local,,37.98,,,,,,,26.97,61.19,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,65219022225,NDC,facility,inpatient,1,EA,35.70000,10.35000,Aetna,Local,,14.28,,,,,,,12.87,29.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,65219020420,NDC,facility,inpatient,200,ME,373.00000,108.17000,Aetna,Local,,149.20,,,,,,,134.47,305.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,65219020420,NDC,facility,outpatient,200,ME,373.00000,108.17000,Aetna,Local,,149.20,,,,,,,0.37557,305.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,800046390,CDM,636,RC,J0612,HCPCS,65219016210,NDC,facility,inpatient,1,GM,201.45000,58.42000,Aetna,Local,,80.58,,,,,,,72.62,164.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,65219014410,NDC,,,facility,outpatient,1,EA,59.05000,17.12000,Aetna,Local,,29.98,,,,,,,21.29,48.30,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,65219013520,NDC,facility,inpatient,500,ME,1483.00000,430.07000,Aetna,Local,,593.20,,,,,,,534.62,1213.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,65219005429,NDC,,,facility,outpatient,1,EA,471.65000,136.78000,Aetna,Local,,239.46,,,,,,,170.03,385.81,percent of total billed charges,
Potassium Phosphate Inj 5mL,800022009,CDM,250,RC,65219005229,NDC,,,facility,outpatient,1,EA,152.70000,44.28000,Aetna,Local,,77.53,,,,,,,55.05,124.91,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,65219001810,NDC,facility,inpatient,1,GM,56.65000,16.43000,Aetna,Local,,22.66,,,,,,,20.42,46.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,65219001610,NDC,facility,inpatient,500,ME,23.60000,6.84000,Aetna,Local,,9.44,,,,,,,8.51,19.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,65162089803,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,Local,,114.77,,,,,,,81.49,184.91,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,65162089709,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,Local,,114.77,,,,,,,81.49,184.91,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,65162089703,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,Local,,114.77,,,,,,,81.49,184.91,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,65162089609,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,Local,,114.77,,,,,,,81.49,184.91,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,65162089603,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,Local,,114.77,,,,,,,81.49,184.91,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,65162083366,NDC,,,facility,outpatient,1,EA,373.30000,108.26000,Aetna,Local,,189.52,,,,,,,134.57,305.36,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,65162082634,NDC,,,facility,outpatient,1,EA,119.65000,34.70000,Aetna,Local,,60.75,,,,,,,43.13,97.87,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,65162082534,NDC,,,facility,outpatient,1,EA,119.65000,34.70000,Aetna,Local,,60.75,,,,,,,43.13,97.87,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,65162080710,NDC,,,facility,outpatient,1,EA,36.60000,10.61000,Aetna,Local,,18.58,,,,,,,13.19,29.94,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,65162077810,NDC,,,facility,outpatient,1,EA,176.00000,51.04000,Aetna,Local,,89.36,,,,,,,63.45,143.97,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,65162075710,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,Local,,14.65,,,,,,,10.40,23.60,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,65162075510,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,Local,,8.83,,,,,,,6.27,14.23,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,65162075003,NDC,,,facility,outpatient,1,EA,42.80000,12.41000,Aetna,Local,,21.73,,,,,,,15.43,35.01,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,65162071110,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,Local,,3.66,,,,,,,2.60,5.89,percent of total billed charges,
Gabapentin 200mg/4mL Oral Liq UD,800025503,CDM,637,RC,65162069890,NDC,,,facility,outpatient,1,EA,8.90000,2.58000,Aetna,Local,,4.52,,,,,,,3.21,7.28,percent of total billed charges,
Ondansetron 2mg/2.5 mL Oral Soln,800025699,CDM,636,RC,Q0162,HCPCS,65162069179,NDC,facility,inpatient,4,ME,84.90000,24.62000,Aetna,Local,,33.96,,,,,,,30.61,69.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,65162068110,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,Local,,9.70,,,,,,,6.89,15.62,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,65162067684,NDC,,,facility,outpatient,1,EA,902.30000,261.67000,Aetna,Local,,458.10,,,,,,,325.28,738.08,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,65162067384,NDC,,,facility,outpatient,1,EA,35.95000,10.43000,Aetna,Local,,18.25,,,,,,,12.96,29.41,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,65162066910,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,Local,,4.21,,,,,,,2.99,6.79,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,65162064210,NDC,,,facility,outpatient,1,EA,28.40000,8.24000,Aetna,Local,,14.42,,,,,,,10.24,23.23,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,65162062750,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,65162062710,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,65162059606,NDC,,,facility,outpatient,1,EA,59.15000,17.15000,Aetna,Local,,30.03,,,,,,,21.32,48.38,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,65162055410,NDC,,,facility,outpatient,1,EA,66.55000,19.30000,Aetna,Local,,33.79,,,,,,,23.99,54.44,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,65162055310,NDC,,,facility,outpatient,1,EA,42.40000,12.30000,Aetna,Local,,21.53,,,,,,,15.29,34.68,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,65162054510,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,65162054410,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65162054150,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,65162054110,NDC,,,facility,outpatient,1,EA,8.00000,2.32000,Aetna,Local,,4.06,,,,,,,2.88,6.54,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,65162053610,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,65162051710,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,65162051110,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,65162047505,NDC,,,facility,outpatient,1,EA,18.75000,5.44000,Aetna,Local,,9.52,,,,,,,6.76,15.34,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,65162046410,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,65162036110,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,Local,,1.19,,,,,,,0.84718,1.92,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,65162035109,NDC,,,facility,outpatient,1,EA,141.60000,41.06000,Aetna,Local,,71.89,,,,,,,51.05,115.83,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,65162030209,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,Local,,7.18,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,65162030009,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,Local,,1.27,,,,,,,0.90125,2.04,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,65162028103,NDC,,,facility,outpatient,1,EA,216.30000,62.73000,Aetna,Local,,109.82,,,,,,,77.98,176.93,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,65162027110,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,65162022710,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,65162018810,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,65162017510,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,65162005703,NDC,,,facility,outpatient,1,EA,50.45000,14.63000,Aetna,Local,,25.61,,,,,,,18.19,41.27,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,65162000750,NDC,,,facility,outpatient,1,EA,13.45000,3.90000,Aetna,Local,,6.83,,,,,,,4.85,11.00,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,65145012925,NDC,facility,inpatient,200,ME,39.00000,11.31000,Aetna,Local,,15.60,,,,,,,14.06,31.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitazoxanide 500mg Tab,800017652,CDM,637,RC,64980052660,NDC,,,facility,outpatient,1,EA,1011.85000,293.44000,Aetna,Local,,513.72,,,,,,,364.77,827.69,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,64980051505,NDC,,,facility,outpatient,1,EA,467.75000,135.65000,Aetna,Local,,237.48,,,,,,,168.62,382.62,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,64980051501,NDC,,,facility,outpatient,1,EA,452.40000,131.20000,Aetna,Local,,229.68,,,,,,,163.09,370.06,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,64980051405,NDC,,,facility,outpatient,1,EA,120.35000,34.90000,Aetna,Local,,61.10,,,,,,,43.39,98.45,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,64980051305,NDC,,,facility,outpatient,1,EA,106.20000,30.80000,Aetna,Local,,53.92,,,,,,,38.29,86.87,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,64980051301,NDC,,,facility,outpatient,1,EA,98.25000,28.49000,Aetna,Local,,49.88,,,,,,,35.42,80.37,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,64980032005,NDC,,,facility,outpatient,1,EA,530.00000,153.70000,Aetna,Local,,269.08,,,,,,,191.06,433.54,percent of total billed charges,
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,64980019106,NDC,,,facility,outpatient,1,EA,258.15000,74.86000,Aetna,Local,,131.06,,,,,,,93.06,211.17,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,64980017903,NDC,,,facility,outpatient,1,EA,539.00000,156.31000,Aetna,Local,,273.65,,,,,,,194.31,440.90,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,64980017901,NDC,,,facility,outpatient,1,EA,539.00000,156.31000,Aetna,Local,,273.65,,,,,,,194.31,440.90,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,64980015701,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,Local,,5.23,,,,,,,3.71,8.43,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,64980013901,NDC,,,facility,outpatient,1,EA,20.00000,5.80000,Aetna,Local,,10.15,,,,,,,7.21,16.36,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,64980013801,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,Local,,2.72,,,,,,,1.93,4.38,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,64980013301,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,64980013101,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,Local,,4.72,,,,,,,3.35,7.61,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,64980011901,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,Local,,6.42,,,,,,,4.56,10.35,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,64980011101,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
K-Phos-Na Phos Neutral 250mg T,800081073,CDM,637,RC,64980010401,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,64950021710,NDC,,,facility,outpatient,1,EA,24.80000,7.19000,Aetna,Local,,12.59,,,,,,,8.94,20.29,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,64860010407,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,64850050501,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,64850050401,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,64850050001,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Vortioxetine 10mg Tab,800022073,CDM,637,RC,64764073030,NDC,,,facility,outpatient,1,EA,145.60000,42.22000,Aetna,Local,,73.92,,,,,,,52.49,119.10,percent of total billed charges,
Vedolizumab 300mg I(Entyvio),800022032,CDM,636,RC,J3380,HCPCS,64764030020,NDC,facility,inpatient,300,ME,67578.35000,19597.72000,Aetna,Local,,27031.34,,,,,,,24362.00,55279.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,64764024060,NDC,,,facility,outpatient,1,EA,52.55000,15.24000,Aetna,Local,,26.68,,,,,,,18.94,42.99,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,64764024010,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,Local,,11.80,,,,,,,8.38,19.02,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,64764011907,NDC,,,facility,outpatient,1,EA,61.10000,17.72000,Aetna,Local,,31.02,,,,,,,22.03,49.98,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,64764011901,NDC,,,facility,outpatient,1,EA,61.10000,17.72000,Aetna,Local,,31.02,,,,,,,22.03,49.98,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,64727329901,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,64720033210,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,Local,,2.06,,,,,,,1.46,3.31,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,64720033105,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,64720032110,NDC,,,facility,outpatient,1,EA,34.65000,10.05000,Aetna,Local,,17.59,,,,,,,12.49,28.34,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,64720020410,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,Local,,8.91,,,,,,,6.33,14.36,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,64720020310,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,Local,,8.91,,,,,,,6.33,14.36,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,64720020110,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,Local,,8.91,,,,,,,6.33,14.36,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,64720015906,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,Local,,6.55,,,,,,,4.65,10.55,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,64720013910,NDC,,,facility,outpatient,1,EA,14.80000,4.29000,Aetna,Local,,7.51,,,,,,,5.34,12.11,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,64720013510,NDC,,,facility,outpatient,1,EA,16.45000,4.77000,Aetna,Local,,8.35,,,,,,,5.93,13.46,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,64720013010,NDC,,,facility,outpatient,1,EA,16.45000,4.77000,Aetna,Local,,8.35,,,,,,,5.93,13.46,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,64720012810,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,64720012410,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,64720010350,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,64720010310,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,64679099001,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,Local,,7.44,,,,,,,5.28,11.98,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,64679098302,NDC,facility,inpatient,1,GM,346.50000,100.48000,Aetna,Local,,138.60,,,,,,,124.91,283.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,64679096601,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,64679096101,NDC,,,facility,outpatient,1,EA,55.00000,15.95000,Aetna,Local,,27.92,,,,,,,19.83,44.99,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,64679094201,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,Local,,5.53,,,,,,,3.93,8.92,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,64679093603,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,64679093602,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,64679093601,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,64679092901,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,3.40,,,,,,,2.42,5.48,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,64679092701,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,Local,,2.34,,,,,,,1.66,3.76,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,64679092602,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,Local,,9.95,,,,,,,7.07,16.03,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,64679092502,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,64679092402,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,Local,,6.65,,,,,,,4.72,10.72,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,64679092302,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,Local,,5.23,,,,,,,3.71,8.43,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,64679092102,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,64679075903,NDC,facility,inpatient,100,ME,21.60000,6.26000,Aetna,Local,,8.64,,,,,,,7.79,17.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,64679075702,NDC,facility,inpatient,15,ME,9.30000,2.70000,Aetna,Local,,3.72,,,,,,,3.35,7.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,64679075701,NDC,facility,inpatient,15,ME,9.30000,2.70000,Aetna,Local,,3.72,,,,,,,3.35,7.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,64679072901,NDC,facility,inpatient,100,ME,95.75000,27.77000,Aetna,Local,,38.30,,,,,,,34.52,78.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,64679072701,NDC,facility,inpatient,4,ME,185.90000,53.91000,Aetna,Local,,74.36,,,,,,,67.02,152.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,64679072601,NDC,facility,inpatient,4,ME,123.65000,35.86000,Aetna,Local,,49.46,,,,,,,44.58,101.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,64679072502,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,Local,,10.61,,,,,,,7.53,17.10,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,64679071804,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,12.98,29.45,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,64679071801,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,12.98,29.45,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,64679071704,NDC,,,facility,outpatient,1,EA,33.05000,9.58000,Aetna,Local,,16.78,,,,,,,11.91,27.03,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,64679071604,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,Local,,14.98,,,,,,,10.63,24.13,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,64679071601,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,Local,,14.98,,,,,,,10.63,24.13,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,64679070302,NDC,facility,inpatient,2,GM,443.70000,128.67000,Aetna,Local,,177.48,,,,,,,159.95,362.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,64679070301,NDC,facility,inpatient,2,GM,431.50000,125.14000,Aetna,Local,,172.60,,,,,,,155.56,352.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,64679063102,NDC,facility,inpatient,25,ME,200.95000,58.28000,Aetna,Local,,80.38,,,,,,,72.44,164.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,64679043402,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,64679042301,NDC,,,facility,outpatient,1,EA,16.80000,4.87000,Aetna,Local,,8.53,,,,,,,6.06,13.74,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,64679042201,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,64679042101,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,64679020902,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,Local,,46.99,,,,,,,33.36,75.71,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,64679020901,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,Local,,46.99,,,,,,,33.36,75.71,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,64679005601,NDC,facility,inpatient,3.375,GM,174.05000,50.47000,Aetna,Local,,69.62,,,,,,,62.75,142.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,64679003401,NDC,facility,inpatient,2.25,GM,116.00000,33.64000,Aetna,Local,,46.40,,,,,,,41.82,94.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,64679001201,NDC,facility,inpatient,4.5,GM,219.65000,63.70000,Aetna,Local,,87.86,,,,,,,79.18,179.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,64455073030,NDC,,,facility,outpatient,1,EA,59.20000,17.17000,Aetna,Local,,30.06,,,,,,,21.34,48.43,percent of total billed charges,
Natalizumab - Pt Own Supply,800040903,CDM,636,RC,J2323,HCPCS,64406000801,NDC,facility,inpatient,300,ME,0.15000,0.04000,Aetna,Local,,0.06000,,,,,,,0.05407,0.12270,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydrocortisone 5mg T,800017611,CDM,637,RC,64380097025,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,Local,,3.66,,,,,,,2.60,5.89,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,64380088304,NDC,,,facility,outpatient,1,EA,216.70000,62.84000,Aetna,Local,,110.02,,,,,,,78.12,177.26,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,64380079901,NDC,,,facility,outpatient,1,EA,109.45000,31.74000,Aetna,Local,,55.57,,,,,,,39.46,89.53,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,64380079701,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,Local,,50.97,,,,,,,36.19,82.13,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,64380076921,NDC,,,facility,outpatient,1,EA,469.75000,136.23000,Aetna,Local,,238.49,,,,,,,169.34,384.26,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,64380074207,NDC,,,facility,outpatient,1,EA,9.25000,2.68000,Aetna,Local,,4.70,,,,,,,3.33,7.57,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,64380074107,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,Local,,2.69,,,,,,,1.91,4.34,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,64380074106,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,64380073706,NDC,,,facility,outpatient,1,EA,13.95000,4.05000,Aetna,Local,,7.08,,,,,,,5.03,11.41,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,64380073506,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,64380073406,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,64380072506,NDC,facility,inpatient,500,ME,56.10000,16.27000,Aetna,Local,,22.44,,,,,,,20.22,45.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,64380071206,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,64380015102,NDC,,,facility,outpatient,1,EA,116.65000,33.83000,Aetna,Local,,59.22,,,,,,,42.05,95.42,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,64376013790,NDC,,,facility,outpatient,1,EA,25.40000,7.37000,Aetna,Local,,12.90,,,,,,,9.16,20.78,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,64376013712,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,64376013612,NDC,,,facility,outpatient,1,EA,20.35000,5.90000,Aetna,Local,,10.33,,,,,,,7.34,16.65,percent of total billed charges,
Methacholine Challenge Kit,800010977,CDM,636,RC,J7674,HCPCS,64281010006,NDC,facility,inpatient,1,EA,3613.40000,1047.89000,Aetna,Local,,1445.36,,,,,,,1302.63,2955.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methacholine Challenge Kit,800010977,CDM,636,RC,J7674,HCPCS,64281010000,NDC,facility,inpatient,1,EA,426.70000,123.74000,Aetna,Local,,170.68,,,,,,,153.83,349.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,64253090091,NDC,,,facility,outpatient,1,EA,63.85000,18.52000,Aetna,Local,,32.42,,,,,,,23.02,52.23,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,64253090036,NDC,,,facility,outpatient,1,EA,57.45000,16.66000,Aetna,Local,,29.17,,,,,,,20.71,46.99,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,64253033335,NDC,facility,inpatient,500,UN,19.75000,5.73000,Aetna,Local,,7.90,,,,,,,7.12,16.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,64253020230,NDC,facility,outpatient,1,EA,7.65000,2.22000,Aetna,Local,,3.88,,,,,,,0.63000,6.26,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,64253011130,NDC,facility,outpatient,1,EA,19.40000,5.63000,Aetna,Local,,9.85,,,,,,,0.63000,15.87,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,64125090301,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,64125090101,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,Local,,0.15231,,,,,,,0.10815,0.24540,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,64125013201,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,Local,,5.64,,,,,,,4.00,9.08,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,64125010401,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,63851050102,NDC,facility,inpatient,1,EA,1287.70000,373.43000,Aetna,Local,,515.08,,,,,,,464.22,1053.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,63851050102,NDC,facility,outpatient,1,EA,1287.70000,373.43000,Aetna,Local,,515.08,,,,,,,307.92,1053.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,63851050101,NDC,facility,inpatient,1,EA,1204.95000,349.44000,Aetna,Local,,481.98,,,,,,,434.38,985.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,63851050101,NDC,facility,outpatient,1,EA,1204.95000,349.44000,Aetna,Local,,481.98,,,,,,,307.92,986.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prothrombin Complex-Human I(Kcentra),800025539,CDM,636,RC,J7168,HCPCS,63833038702,NDC,facility,inpatient,1,UN,28.55000,8.28000,Aetna,Local,,11.42,,,,,,,10.29,23.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prothrombin Complex-Human I(Kcentra),800025539,CDM,636,RC,J7168,HCPCS,63833038602,NDC,facility,inpatient,1,UN,28.55000,8.28000,Aetna,Local,,11.42,,,,,,,10.29,23.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,63824005736,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,63824005718,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,63824005640,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,63824005634,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000850,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000840,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000820,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000813,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63824000810,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,63807060055,NDC,facility,inpatient,500,UN,2.65000,0.77000,Aetna,Local,,1.06,,,,,,,0.95532,2.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,63807060005,NDC,facility,inpatient,500,UN,6.80000,1.97000,Aetna,Local,,2.72,,,,,,,2.45,5.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,63807010001,NDC,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,0.63000,4.78,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,63739099510,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,63739099210,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,63739099110,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,Local,,1.02,,,,,,,0.72100,1.64,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,63739098410,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,63739097310,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,Local,,3.10,,,,,,,2.20,4.99,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,63739094310,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,Local,,1.19,,,,,,,0.84718,1.92,percent of total billed charges,
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63739093128,NDC,facility,inpatient,10000,UN,23.85000,6.92000,Aetna,Local,,9.54,,,,,,,8.60,19.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,63739090310,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,Local,,0.71078,,,,,,,0.50470,1.15,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,63739087710,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,Local,,0.63462,,,,,,,0.45062,1.02,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,63739079510,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,63739079110,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,63739072450,NDC,,,facility,outpatient,1,EA,70.50000,20.44000,Aetna,Local,,35.79,,,,,,,25.42,57.67,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,63739069810,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739069110,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,Local,,0.43155,,,,,,,0.30643,0.69530,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739069101,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,Local,,0.43155,,,,,,,0.30643,0.69530,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739068410,NDC,,,facility,outpatient,1,EA,0.80000,0.23000,Aetna,Local,,0.40616,,,,,,,0.28840,0.65440,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739068401,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,Local,,0.33000,,,,,,,0.23433,0.53170,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,63739067310,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739067210,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739067201,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,63739067110,NDC,,,facility,outpatient,1,EA,0.70000,0.20000,Aetna,Local,,0.35539,,,,,,,0.25235,0.57260,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,63739067010,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,Local,,0.88848,,,,,,,0.63087,1.43,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,63739066910,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,63739064510,NDC,,,facility,outpatient,1,EA,0.75000,0.22000,Aetna,Local,,0.38077,,,,,,,0.27037,0.61350,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,63739064410,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,63739063456,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,Local,,3.35,,,,,,,2.38,5.40,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,63739059110,NDC,,,facility,outpatient,1,EA,0.75000,0.22000,Aetna,Local,,0.38077,,,,,,,0.27037,0.61350,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,63739056910,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,Local,,3.17,,,,,,,2.25,5.11,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,63739056410,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,63739054973,NDC,,,facility,outpatient,1,EA,47.60000,13.80000,Aetna,Local,,24.17,,,,,,,17.16,38.94,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,63739054410,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,63739053950,NDC,,,facility,outpatient,1,EA,19.50000,5.65000,Aetna,Local,,9.90,,,,,,,7.03,15.95,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,63739053710,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,63739053210,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,63739053110,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,Local,,0.33000,,,,,,,0.23433,0.53170,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,63739052610,NDC,,,facility,outpatient,1,EA,37.15000,10.77000,Aetna,Local,,18.86,,,,,,,13.39,30.39,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,63739050832,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,Local,,14.01,,,,,,,9.95,22.58,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,63739050010,NDC,,,facility,outpatient,1,EA,0.90000,0.26000,Aetna,Local,,0.45693,,,,,,,0.32445,0.73620,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,63739049910,NDC,,,facility,outpatient,1,EA,0.75000,0.22000,Aetna,Local,,0.38077,,,,,,,0.27037,0.61350,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,63739048610,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,63739047910,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,63739044710,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,Local,,3.35,,,,,,,2.38,5.40,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739044410,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739044310,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739044210,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,63739041110,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,63739041010,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,63739038710,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,Local,,12.16,,,,,,,8.63,19.59,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,63739038410,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,63739036510,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,Local,,1.50,,,,,,,1.06,2.41,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,63739032810,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,63739032710,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,63739032610,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,63739027510,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,63739026910,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,Local,,2.06,,,,,,,1.46,3.31,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,63739026310,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,Local,,3.27,,,,,,,2.33,5.28,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,63739023610,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,63739023110,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,63739017830,NDC,,,facility,outpatient,1,EA,112.90000,32.74000,Aetna,Local,,57.32,,,,,,,40.70,92.35,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,63739015510,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,63739015410,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,63739014310,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,Local,,2.06,,,,,,,1.46,3.31,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739013710,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,63739013701,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739013610,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,63739013601,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739013510,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,63739013501,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,63739012710,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,63739010810,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,63739010310,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,Local,,0.48231,,,,,,,0.34247,0.77710,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,63739009810,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,63739008610,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,1.32,2.99,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,63739008010,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,Local,,1.02,,,,,,,0.72100,1.64,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,63739007910,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,Local,,0.63462,,,,,,,0.45062,1.02,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,63739007310,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,Local,,0.88848,,,,,,,0.63087,1.43,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,63739006702,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,63739006610,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,Local,,4.90,,,,,,,3.48,7.89,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,63739006010,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,63739005910,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,63739005269,NDC,,,facility,outpatient,1,EA,14.40000,4.18000,Aetna,Local,,7.31,,,,,,,5.19,11.78,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,63739005110,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,63739004910,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,63739001971,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,Local,,11.80,,,,,,,8.38,19.02,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,63739001510,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,Local,,1.50,,,,,,,1.06,2.41,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,63739001110,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,63739000410,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,63653133203,NDC,,,facility,outpatient,1,EA,157.15000,45.57000,Aetna,Local,,79.79,,,,,,,56.65,128.55,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,63653133202,NDC,,,facility,outpatient,1,EA,218.55000,63.38000,Aetna,Local,,110.96,,,,,,,78.79,178.77,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117106,NDC,,,facility,outpatient,1,EA,54.75000,15.88000,Aetna,Local,,27.80,,,,,,,19.74,44.79,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117104,NDC,,,facility,outpatient,1,EA,33.20000,9.63000,Aetna,Local,,16.86,,,,,,,11.97,27.16,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117103,NDC,,,facility,outpatient,1,EA,54.75000,15.88000,Aetna,Local,,27.80,,,,,,,19.74,44.79,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,63653117101,NDC,,,facility,outpatient,1,EA,54.75000,15.88000,Aetna,Local,,27.80,,,,,,,19.74,44.79,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,63481068447,NDC,,,facility,outpatient,1,EA,434.10000,125.89000,Aetna,Local,,220.39,,,,,,,156.49,355.09,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,63481020516,NDC,,,facility,outpatient,1,EA,21.50000,6.24000,Aetna,Local,,10.92,,,,,,,7.75,17.59,percent of total billed charges,
Bendamustine 100mg I(Treanda),800012530,CDM,636,RC,J9033,HCPCS,63459039120,NDC,facility,inpatient,100,ME,16234.70000,4708.06000,Aetna,Local,,6493.88,,,,,,,5852.61,13279.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,63459020530,NDC,,,facility,outpatient,1,EA,107.80000,31.26000,Aetna,Local,,54.73,,,,,,,38.86,88.18,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,63459010130,NDC,,,facility,outpatient,1,EA,506.75000,146.96000,Aetna,Local,,257.28,,,,,,,182.68,414.52,percent of total billed charges,
Levalbuterol HFA 45 mcg/inh,800017835,CDM,637,RC,63402051001,NDC,,,facility,outpatient,1,EA,562.75000,163.20000,Aetna,Local,,285.71,,,,,,,202.87,460.33,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,63402030430,NDC,,,facility,outpatient,1,EA,385.05000,111.66000,Aetna,Local,,195.49,,,,,,,138.81,314.97,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,63402030410,NDC,,,facility,outpatient,1,EA,367.45000,106.56000,Aetna,Local,,186.55,,,,,,,132.47,300.57,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,63402030230,NDC,,,facility,outpatient,1,EA,385.05000,111.66000,Aetna,Local,,195.49,,,,,,,138.81,314.97,percent of total billed charges,
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,63323098321,NDC,facility,inpatient,3.375,GM,133.15000,38.61000,Aetna,Local,,53.26,,,,,,,48.00,108.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,63323098121,NDC,facility,inpatient,2.25,GM,88.80000,25.75000,Aetna,Local,,35.52,,,,,,,32.01,72.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Potassium Cl 2mEq/mL I,800013427,CDM,636,RC,J3480,HCPCS,63323096520,NDC,facility,inpatient,1,EA,26.70000,7.74000,Aetna,Local,,10.68,,,,,,,9.63,21.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,63323096330,NDC,facility,inpatient,6000,ME,1014.00000,294.06000,Aetna,Local,,405.60,,,,,,,365.55,829.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,63323093001,NDC,facility,inpatient,20,UN,147.05000,42.64000,Aetna,Local,,58.82,,,,,,,53.01,120.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,63323092430,NDC,,,facility,outpatient,1,EA,28.15000,8.16000,Aetna,Local,,14.29,,,,,,,10.15,23.03,percent of total billed charges,
NS Bacteriostatic 0.9% 10mL I,800046448,CDM,250,RC,63323092410,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Levothyroxine 100 mcg Inj (20mcg/mL),800046383,CDM,636,RC,J0651,HCPCS,63323088514,NDC,facility,inpatient,0.1,ME,667.45000,193.56000,Aetna,Local,,266.98,,,,,,,240.62,545.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Levothyroxine 100 mcg Inj (20mcg/mL),800046383,CDM,636,RC,J0651,HCPCS,63323088510,NDC,facility,inpatient,0.1,ME,778.80000,225.85000,Aetna,Local,,311.52,,,,,,,280.76,637.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Phosphate Inj,800053081,CDM,250,RC,63323088406,NDC,,,facility,outpatient,1,EA,564.05000,163.57000,Aetna,Local,,286.37,,,,,,,203.34,461.39,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,63323088330,NDC,facility,inpatient,50,ME,253.00000,73.37000,Aetna,Local,,101.20,,,,,,,91.21,206.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,63323085225,NDC,facility,inpatient,1,ME,34.55000,10.02000,Aetna,Local,,13.82,,,,,,,12.46,28.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D10W 1000mL,800012362,CDM,258,RC,63323082476,NDC,,,facility,outpatient,1,EA,66.15000,19.18000,Aetna,Local,,33.58,,,,,,,23.85,54.11,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,63323082474,NDC,,,facility,outpatient,1,EA,48.25000,13.99000,Aetna,Local,,24.50,,,,,,,17.39,39.47,percent of total billed charges,
Bortezomib 3.5mg Inj- Pt Own Supply,800052008,CDM,636,RC,J9041,HCPCS,63323082110,NDC,facility,inpatient,3.5,ME,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,63323082110,NDC,facility,inpatient,3.5,ME,1807.00000,524.03000,Aetna,Local,,722.80,,,,,,,651.42,1478.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,63323081320,NDC,facility,inpatient,1000,ME,112.15000,32.52000,Aetna,Local,,44.86,,,,,,,40.43,91.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,63323080602,NDC,facility,inpatient,0.1,ME,22.00000,6.38000,Aetna,Local,,8.80,,,,,,,7.93,18.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 1mL I,800051051,CDM,636,RC,J3010,HCPCS,63323080601,NDC,facility,inpatient,0.05,ME,21.20000,6.15000,Aetna,Local,,8.48,,,,,,,7.64,17.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,63323078110,NDC,,,facility,outpatient,1,EA,33.20000,9.63000,Aetna,Local,,16.86,,,,,,,11.97,27.16,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,63323075105,NDC,facility,inpatient,50,ME,226.70000,65.74000,Aetna,Local,,90.68,,,,,,,81.73,185.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,63323073916,NDC,facility,inpatient,20,ME,4.65000,1.35000,Aetna,Local,,1.86,,,,,,,1.68,3.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,63323073912,NDC,facility,inpatient,20,ME,5.75000,1.67000,Aetna,Local,,2.30,,,,,,,2.07,4.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mesna 200mg/2mL I (Mesnex),800025637,CDM,636,RC,J9209,HCPCS,63323073311,NDC,facility,inpatient,200,ME,135.25000,39.22000,Aetna,Local,,54.10,,,,,,,48.76,110.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,63323072910,NDC,facility,inpatient,100,ME,441.20000,127.95000,Aetna,Local,,176.48,,,,,,,159.05,360.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,63323072303,NDC,,,facility,outpatient,1,EA,653.80000,189.60000,Aetna,Local,,331.93,,,,,,,235.69,534.81,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,63323068610,NDC,,,facility,outpatient,1,EA,48.45000,14.05000,Aetna,Local,,24.60,,,,,,,17.47,39.63,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,63323066501,NDC,facility,inpatient,1,ME,125.75000,36.47000,Aetna,Local,,50.30,,,,,,,45.33,102.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,63323066401,NDC,facility,inpatient,50,ME,19.20000,5.57000,Aetna,Local,,7.68,,,,,,,6.92,15.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,63323066005,NDC,,,facility,outpatient,1,EA,14.10000,4.09000,Aetna,Local,,7.16,,,,,,,5.08,11.53,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,63323065827,NDC,facility,inpatient,500,ME,1376.05000,399.05000,Aetna,Local,,550.42,,,,,,,496.07,1125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,63323065820,NDC,facility,inpatient,500,ME,1376.05000,399.05000,Aetna,Local,,550.42,,,,,,,496.07,1125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323065599,NDC,facility,inpatient,120,ME,70.80000,20.53000,Aetna,Local,,28.32,,,,,,,25.52,57.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,63323065210,NDC,facility,inpatient,100,ME,114.65000,33.25000,Aetna,Local,,45.86,,,,,,,41.33,93.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,63323065130,NDC,facility,inpatient,6,ME,82.60000,23.95000,Aetna,Local,,33.04,,,,,,,29.78,67.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,63323065102,NDC,facility,inpatient,6,ME,69.90000,20.27000,Aetna,Local,,27.96,,,,,,,25.20,57.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,63323064220,NDC,facility,inpatient,10,GM,92.30000,26.77000,Aetna,Local,,36.92,,,,,,,33.27,75.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,63323062655,NDC,,,facility,outpatient,1,EA,40.80000,11.83000,Aetna,Local,,20.71,,,,,,,14.71,33.37,percent of total billed charges,
0.45% Sodium Cl 250mL,800081202,CDM,258,RC,63323062625,NDC,,,facility,outpatient,1,EA,34.70000,10.06000,Aetna,Local,,17.62,,,,,,,12.51,28.38,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,63323062610,NDC,,,facility,outpatient,1,EA,46.50000,13.48000,Aetna,Local,,23.61,,,,,,,16.76,38.04,percent of total billed charges,
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,63323062374,NDC,facility,inpatient,1,EA,34.70000,10.06000,Aetna,Local,,13.88,,,,,,,12.51,28.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,63323061603,NDC,facility,inpatient,150,ME,19.20000,5.57000,Aetna,Local,,7.68,,,,,,,6.92,15.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,63323061455,NDC,facility,inpatient,20,ME,76.60000,22.21000,Aetna,Local,,30.64,,,,,,,27.61,62.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,63323061401,NDC,facility,inpatient,20,ME,91.40000,26.51000,Aetna,Local,,36.56,,,,,,,32.95,74.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323060990,NDC,facility,inpatient,120,ME,151.95000,44.07000,Aetna,Local,,60.78,,,,,,,54.78,124.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323060798,NDC,facility,inpatient,60,ME,38.45000,11.15000,Aetna,Local,,15.38,,,,,,,13.86,31.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323060788,NDC,facility,inpatient,60,ME,76.15000,22.08000,Aetna,Local,,30.46,,,,,,,27.45,62.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323060594,NDC,facility,inpatient,100,ME,126.90000,36.80000,Aetna,Local,,50.76,,,,,,,45.75,103.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323060584,NDC,facility,inpatient,100,ME,126.90000,36.80000,Aetna,Local,,50.76,,,,,,,45.75,103.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059616,NDC,facility,inpatient,1,ME,683.80000,198.30000,Aetna,Local,,273.52,,,,,,,246.51,559.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059613,NDC,facility,inpatient,1,ME,1196.70000,347.04000,Aetna,Local,,478.68,,,,,,,431.41,978.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059403,NDC,facility,inpatient,1,ME,683.80000,198.30000,Aetna,Local,,273.52,,,,,,,246.51,559.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,63323059303,NDC,facility,inpatient,1,ME,1196.70000,347.04000,Aetna,Local,,478.68,,,,,,,431.41,978.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323058994,NDC,facility,inpatient,150,ME,89.10000,25.84000,Aetna,Local,,35.64,,,,,,,32.12,72.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323058696,NDC,facility,inpatient,100,ME,59.50000,17.26000,Aetna,Local,,23.80,,,,,,,21.45,48.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323058665,NDC,facility,inpatient,100,ME,59.50000,17.26000,Aetna,Local,,23.80,,,,,,,21.45,48.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323058499,NDC,facility,inpatient,80,ME,47.25000,13.70000,Aetna,Local,,18.90,,,,,,,17.03,38.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323058465,NDC,facility,inpatient,80,ME,47.25000,13.70000,Aetna,Local,,18.90,,,,,,,17.03,38.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323056999,NDC,facility,inpatient,120,ME,151.95000,44.07000,Aetna,Local,,60.78,,,,,,,54.78,124.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323056995,NDC,facility,inpatient,150,ME,186.40000,54.06000,Aetna,Local,,74.56,,,,,,,67.20,152.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,63323056990,NDC,facility,inpatient,120,ME,151.95000,44.07000,Aetna,Local,,60.78,,,,,,,54.78,124.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323056984,NDC,facility,inpatient,150,ME,186.40000,54.06000,Aetna,Local,,74.56,,,,,,,67.20,152.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323056899,NDC,facility,inpatient,80,ME,101.50000,29.44000,Aetna,Local,,40.60,,,,,,,36.59,83.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323056898,NDC,facility,inpatient,60,ME,76.15000,22.08000,Aetna,Local,,30.46,,,,,,,27.45,62.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056896,NDC,facility,inpatient,40,ME,50.70000,14.70000,Aetna,Local,,20.28,,,,,,,18.28,41.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,63323056895,NDC,facility,inpatient,100,ME,126.90000,36.80000,Aetna,Local,,50.76,,,,,,,45.75,103.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323056894,NDC,facility,inpatient,30,ME,38.10000,11.05000,Aetna,Local,,15.24,,,,,,,13.74,31.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056887,NDC,facility,inpatient,40,ME,50.70000,14.70000,Aetna,Local,,20.28,,,,,,,18.28,41.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323056883,NDC,facility,inpatient,30,ME,39.70000,11.51000,Aetna,Local,,15.88,,,,,,,14.31,32.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,63323056698,NDC,facility,inpatient,60,ME,36.85000,10.69000,Aetna,Local,,14.74,,,,,,,13.28,30.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056497,NDC,facility,inpatient,40,ME,23.50000,6.82000,Aetna,Local,,9.40,,,,,,,8.47,19.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323056465,NDC,facility,inpatient,40,ME,23.50000,6.82000,Aetna,Local,,9.40,,,,,,,8.47,19.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,63323056310,NDC,,,facility,outpatient,1,EA,192.00000,55.68000,Aetna,Local,,97.48,,,,,,,69.22,157.06,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,63323056210,NDC,facility,inpatient,250,ME,1308.00000,379.32000,Aetna,Local,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323055993,NDC,facility,inpatient,30,ME,17.70000,5.13000,Aetna,Local,,7.08,,,,,,,6.38,14.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323055965,NDC,facility,inpatient,30,ME,16.50000,4.78000,Aetna,Local,,6.60,,,,,,,5.95,13.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054067,NDC,facility,inpatient,10000,UN,13.65000,3.96000,Aetna,Local,,5.46,,,,,,,4.92,11.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054057,NDC,facility,inpatient,10000,UN,48.35000,14.02000,Aetna,Local,,19.34,,,,,,,17.43,39.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin I(10,000/10mL)",800013343,CDM,636,RC,J1644,HCPCS,63323054057,NDC,facility,inpatient,10000,UN,48.35000,14.02000,Aetna,Local,,19.34,,,,,,,17.43,39.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,63323054036,NDC,facility,inpatient,30000,UN,72.75000,21.10000,Aetna,Local,,29.10,,,,,,,26.23,59.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,63323054031,NDC,facility,inpatient,30000,UN,72.75000,21.10000,Aetna,Local,,29.10,,,,,,,26.23,59.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054015,NDC,facility,inpatient,10000,UN,46.40000,13.46000,Aetna,Local,,18.56,,,,,,,16.73,37.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,63323054011,NDC,facility,inpatient,10000,UN,48.35000,14.02000,Aetna,Local,,19.34,,,,,,,17.43,39.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin I(10,000/10mL)",800013343,CDM,636,RC,J1644,HCPCS,63323054011,NDC,facility,inpatient,10000,UN,48.35000,14.02000,Aetna,Local,,19.34,,,,,,,17.43,39.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,63323053784,NDC,facility,inpatient,150,ME,186.40000,54.06000,Aetna,Local,,74.56,,,,,,,67.20,152.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323053598,NDC,facility,inpatient,40,ME,25.60000,7.42000,Aetna,Local,,10.24,,,,,,,9.23,20.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,63323053587,NDC,facility,inpatient,40,ME,50.70000,14.70000,Aetna,Local,,20.28,,,,,,,18.28,41.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,63323053393,NDC,facility,inpatient,30,ME,19.20000,5.57000,Aetna,Local,,7.68,,,,,,,6.92,15.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323053198,NDC,facility,inpatient,80,ME,51.25000,14.86000,Aetna,Local,,20.50,,,,,,,18.48,41.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,63323053190,NDC,facility,inpatient,80,ME,101.50000,29.44000,Aetna,Local,,40.60,,,,,,,36.59,83.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Chloride 3% IV 500mL,800040915,CDM,636,RC,J7131,HCPCS,63323053075,NDC,facility,inpatient,1,EA,40.80000,11.83000,Aetna,Local,,16.32,,,,,,,14.71,33.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,63323052374,NDC,facility,inpatient,25000,UN,109.25000,31.68000,Aetna,Local,,43.70,,,,,,,39.38,89.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,63323050831,NDC,facility,inpatient,1,GM,56.65000,16.43000,Aetna,Local,,22.66,,,,,,,20.42,46.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,63323050830,NDC,facility,inpatient,1,GM,56.65000,16.43000,Aetna,Local,,22.66,,,,,,,20.42,46.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,63323050725,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,63323050721,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,63323050720,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323049697,NDC,,,facility,inpatient,1,EA,44.25000,12.83000,Aetna,Local,,17.70,,,,,,,15.95,36.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323049697,NDC,,,facility,outpatient,1,EA,44.25000,12.83000,Aetna,Local,,17.70,,,,,,,15.95,36.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,63323049507,NDC,,,facility,inpatient,1,EA,22.90000,6.64000,Aetna,Local,,9.16,,,,,,,8.26,18.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,63323049507,NDC,,,facility,outpatient,1,EA,22.90000,6.64000,Aetna,Local,,9.16,,,,,,,8.26,18.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Valproate Na 500mg I,800074855,CDM,250,RC,63323049416,NDC,,,facility,outpatient,1,EA,19.80000,5.74000,Aetna,Local,,10.05,,,,,,,7.14,16.20,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,63323049405,NDC,,,facility,outpatient,1,EA,67.00000,19.43000,Aetna,Local,,34.02,,,,,,,24.15,54.81,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,63323049289,NDC,,,facility,inpatient,1,EA,15.45000,4.48000,Aetna,Local,,6.18,,,,,,,5.57,12.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,63323049289,NDC,,,facility,outpatient,1,EA,15.45000,4.48000,Aetna,Local,,6.18,,,,,,,5.57,12.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049280,NDC,,,facility,inpatient,1,EA,11.45000,3.32000,Aetna,Local,,4.58,,,,,,,4.13,9.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049280,NDC,,,facility,outpatient,1,EA,11.45000,3.32000,Aetna,Local,,4.58,,,,,,,4.13,9.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,63323049257,NDC,,,facility,inpatient,1,EA,25.10000,7.28000,Aetna,Local,,10.04,,,,,,,9.05,20.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,63323049257,NDC,,,facility,outpatient,1,EA,25.10000,7.28000,Aetna,Local,,10.04,,,,,,,9.05,20.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049237,NDC,,,facility,inpatient,1,EA,75.25000,21.82000,Aetna,Local,,30.10,,,,,,,27.13,61.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049237,NDC,,,facility,outpatient,1,EA,75.25000,21.82000,Aetna,Local,,30.10,,,,,,,27.13,61.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049231,NDC,,,facility,inpatient,1,EA,60.45000,17.53000,Aetna,Local,,24.18,,,,,,,21.79,49.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049231,NDC,,,facility,outpatient,1,EA,60.45000,17.53000,Aetna,Local,,24.18,,,,,,,21.79,49.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049230,NDC,,,facility,inpatient,1,EA,54.55000,15.82000,Aetna,Local,,21.82,,,,,,,19.67,44.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,63323049230,NDC,,,facility,outpatient,1,EA,54.55000,15.82000,Aetna,Local,,21.82,,,,,,,19.67,44.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049227,NDC,,,facility,inpatient,1,EA,15.05000,4.36000,Aetna,Local,,6.02,,,,,,,5.43,12.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049227,NDC,,,facility,outpatient,1,EA,15.05000,4.36000,Aetna,Local,,6.02,,,,,,,5.43,12.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049202,NDC,,,facility,inpatient,1,EA,10.85000,3.15000,Aetna,Local,,4.34,,,,,,,3.91,8.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,63323049202,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,Local,,4.34,,,,,,,3.91,8.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine 0.5% 50mL PF I,800044361,CDM,636,RC,63323049157,NDC,,,facility,inpatient,1,EA,92.45000,26.81000,Aetna,Local,,36.98,,,,,,,33.33,75.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine 0.5% 50mL PF I,800044361,CDM,636,RC,63323049157,NDC,,,facility,outpatient,1,EA,92.45000,26.81000,Aetna,Local,,36.98,,,,,,,33.33,75.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,63323049089,NDC,,,facility,inpatient,1,EA,40.15000,11.64000,Aetna,Local,,16.06,,,,,,,14.47,32.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,63323049089,NDC,,,facility,outpatient,1,EA,40.15000,11.64000,Aetna,Local,,16.06,,,,,,,14.47,32.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048927,NDC,,,facility,inpatient,1,EA,131.55000,38.15000,Aetna,Local,,52.62,,,,,,,47.42,107.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048927,NDC,,,facility,outpatient,1,EA,131.55000,38.15000,Aetna,Local,,52.62,,,,,,,47.42,107.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048921,NDC,,,facility,inpatient,1,EA,81.85000,23.74000,Aetna,Local,,32.74,,,,,,,29.51,66.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048921,NDC,,,facility,outpatient,1,EA,81.85000,23.74000,Aetna,Local,,32.74,,,,,,,29.51,66.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048920,NDC,,,facility,inpatient,1,EA,83.65000,24.26000,Aetna,Local,,33.46,,,,,,,30.16,68.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,63323048920,NDC,,,facility,outpatient,1,EA,83.65000,24.26000,Aetna,Local,,33.46,,,,,,,30.16,68.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048737,NDC,,,facility,inpatient,1,EA,98.20000,28.48000,Aetna,Local,,39.28,,,,,,,35.40,80.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048737,NDC,,,facility,outpatient,1,EA,98.20000,28.48000,Aetna,Local,,39.28,,,,,,,35.40,80.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048731,NDC,,,facility,inpatient,1,EA,65.00000,18.85000,Aetna,Local,,26.00,,,,,,,23.43,53.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048731,NDC,,,facility,outpatient,1,EA,65.00000,18.85000,Aetna,Local,,26.00,,,,,,,23.43,53.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048730,NDC,,,facility,inpatient,1,EA,65.70000,19.05000,Aetna,Local,,26.28,,,,,,,23.68,53.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,63323048730,NDC,,,facility,outpatient,1,EA,65.70000,19.05000,Aetna,Local,,26.28,,,,,,,23.68,53.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,63323048657,NDC,,,facility,inpatient,1,EA,45.50000,13.19000,Aetna,Local,,18.20,,,,,,,16.40,37.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,63323048657,NDC,,,facility,outpatient,1,EA,45.50000,13.19000,Aetna,Local,,18.20,,,,,,,16.40,37.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048627,NDC,,,facility,inpatient,1,EA,24.50000,7.10000,Aetna,Local,,9.80,,,,,,,8.83,20.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048627,NDC,,,facility,outpatient,1,EA,24.50000,7.10000,Aetna,Local,,9.80,,,,,,,8.83,20.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048620,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,Local,,7.10,,,,,,,6.40,14.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048620,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,Local,,7.10,,,,,,,6.40,14.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323048617,NDC,,,facility,inpatient,1,EA,19.15000,5.55000,Aetna,Local,,7.66,,,,,,,6.90,15.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323048617,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,Local,,7.66,,,,,,,6.90,15.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048617,NDC,,,facility,inpatient,1,EA,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,63323048617,NDC,,,facility,outpatient,1,EA,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323048610,NDC,,,facility,inpatient,1,EA,15.95000,4.63000,Aetna,Local,,6.38,,,,,,,5.75,13.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,63323048610,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,Local,,6.38,,,,,,,5.75,13.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,63323048557,NDC,,,facility,inpatient,1,EA,36.50000,10.58000,Aetna,Local,,14.60,,,,,,,13.16,29.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,63323048557,NDC,,,facility,outpatient,1,EA,36.50000,10.58000,Aetna,Local,,14.60,,,,,,,13.16,29.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,63323048527,NDC,,,facility,inpatient,1,EA,21.65000,6.28000,Aetna,Local,,8.66,,,,,,,7.80,17.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,63323048527,NDC,,,facility,outpatient,1,EA,21.65000,6.28000,Aetna,Local,,8.66,,,,,,,7.80,17.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,63323048327,NDC,,,facility,inpatient,1,EA,36.25000,10.51000,Aetna,Local,,14.50,,,,,,,13.07,29.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,63323048327,NDC,,,facility,outpatient,1,EA,36.25000,10.51000,Aetna,Local,,14.50,,,,,,,13.07,29.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,63323048257,NDC,,,facility,inpatient,1,EA,83.10000,24.10000,Aetna,Local,,33.24,,,,,,,29.96,67.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,63323048257,NDC,,,facility,outpatient,1,EA,83.10000,24.10000,Aetna,Local,,33.24,,,,,,,29.96,67.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,63323048227,NDC,,,facility,inpatient,1,EA,35.75000,10.37000,Aetna,Local,,14.30,,,,,,,12.89,29.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,63323048227,NDC,,,facility,outpatient,1,EA,35.75000,10.37000,Aetna,Local,,14.30,,,,,,,12.89,29.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 10mL",800022038,CDM,636,RC,63323048217,NDC,,,facility,inpatient,1,EA,25.30000,7.34000,Aetna,Local,,10.12,,,,,,,9.12,20.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 10mL",800022038,CDM,636,RC,63323048217,NDC,,,facility,outpatient,1,EA,25.30000,7.34000,Aetna,Local,,10.12,,,,,,,9.12,20.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,63323047827,NDC,facility,inpatient,600,ME,143.45000,41.60000,Aetna,Local,,57.38,,,,,,,51.71,117.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,63323047410,NDC,facility,inpatient,5,ME,36.70000,10.64000,Aetna,Local,,14.68,,,,,,,13.23,30.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,63323047401,NDC,facility,inpatient,5,ME,38.25000,11.09000,Aetna,Local,,15.30,,,,,,,13.79,31.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,63323047302,NDC,,,facility,outpatient,1,EA,25.10000,7.28000,Aetna,Local,,12.74,,,,,,,9.05,20.53,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,63323046837,NDC,,,facility,outpatient,1,EA,77.25000,22.40000,Aetna,Local,,39.22,,,,,,,27.85,63.19,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,63323046830,NDC,,,facility,outpatient,1,EA,40.95000,11.88000,Aetna,Local,,20.79,,,,,,,14.76,33.50,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,63323046637,NDC,,,facility,outpatient,1,EA,50.45000,14.63000,Aetna,Local,,25.61,,,,,,,18.19,41.27,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,63323046630,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,Local,,16.91,,,,,,,12.00,27.24,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,63323046617,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,Local,,18.51,,,,,,,13.14,29.82,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,63323046610,NDC,,,facility,outpatient,1,EA,24.25000,7.03000,Aetna,Local,,12.31,,,,,,,8.74,19.84,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,63323046437,NDC,,,facility,outpatient,1,EA,52.35000,15.18000,Aetna,Local,,26.58,,,,,,,18.87,42.82,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,63323046431,NDC,,,facility,outpatient,1,EA,44.10000,12.79000,Aetna,Local,,22.39,,,,,,,15.90,36.07,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,63323046237,NDC,,,facility,outpatient,1,EA,83.20000,24.13000,Aetna,Local,,42.24,,,,,,,29.99,68.06,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,63323046231,NDC,,,facility,outpatient,1,EA,52.75000,15.30000,Aetna,Local,,26.78,,,,,,,19.02,43.15,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,63323046230,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,Local,,7.46,,,,,,,5.30,12.02,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,63323046230,NDC,,,facility,outpatient,1,EA,44.10000,12.79000,Aetna,Local,,22.39,,,,,,,15.90,36.07,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,63323046217,NDC,,,facility,outpatient,1,EA,50.05000,14.51000,Aetna,Local,,25.41,,,,,,,18.04,40.94,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,63323046210,NDC,,,facility,outpatient,1,EA,26.55000,7.70000,Aetna,Local,,13.48,,,,,,,9.57,21.72,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,63323043400,NDC,facility,inpatient,1000,ME,97.90000,28.39000,Aetna,Local,,39.16,,,,,,,35.29,80.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,63323042610,NDC,,,facility,outpatient,1,EA,41.50000,12.03000,Aetna,Local,,21.07,,,,,,,14.96,33.95,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,63323042605,NDC,,,facility,outpatient,1,EA,43.25000,12.54000,Aetna,Local,,21.96,,,,,,,15.59,35.38,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,63323042405,NDC,,,facility,outpatient,1,EA,47.35000,13.73000,Aetna,Local,,24.04,,,,,,,17.07,38.73,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,63323041820,NDC,,,facility,outpatient,1,EA,2299.90000,666.97000,Aetna,Local,,1167.66,,,,,,,829.11,1881.32,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,63323041510,NDC,facility,inpatient,10,ME,175.95000,51.03000,Aetna,Local,,70.38,,,,,,,63.43,143.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,63323041125,NDC,facility,inpatient,5,ME,31.10000,9.02000,Aetna,Local,,12.44,,,,,,,11.21,25.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,63323041112,NDC,facility,inpatient,2,ME,12.50000,3.62000,Aetna,Local,,5.00,,,,,,,4.51,10.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,63323040703,NDC,facility,inpatient,60,ME,293.20000,85.03000,Aetna,Local,,117.28,,,,,,,105.70,239.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,63323040603,NDC,,,facility,outpatient,1,EA,362.35000,105.08000,Aetna,Local,,183.97,,,,,,,130.63,296.40,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,63323040310,NDC,facility,inpatient,500,ME,243.85000,70.72000,Aetna,Local,,97.54,,,,,,,87.91,199.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,63323040302,NDC,facility,inpatient,100,ME,34.90000,10.12000,Aetna,Local,,13.96,,,,,,,12.58,28.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,63323040230,NDC,facility,inpatient,2,GM,435.60000,126.32000,Aetna,Local,,174.24,,,,,,,157.03,356.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,63323040220,NDC,facility,inpatient,2,GM,653.80000,189.60000,Aetna,Local,,261.52,,,,,,,235.69,534.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,63323040126,NDC,facility,inpatient,1,GM,221.65000,64.28000,Aetna,Local,,88.66,,,,,,,79.90,181.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,63323040120,NDC,facility,inpatient,1,GM,337.70000,97.93000,Aetna,Local,,135.08,,,,,,,121.74,276.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,63323040009,NDC,facility,inpatient,500,ME,172.80000,50.11000,Aetna,Local,,69.12,,,,,,,62.29,141.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,63323040005,NDC,facility,inpatient,500,ME,75.75000,21.97000,Aetna,Local,,30.30,,,,,,,27.31,61.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,63323039923,NDC,facility,inpatient,2,GM,76.25000,22.11000,Aetna,Local,,30.50,,,,,,,27.49,62.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,63323038910,NDC,facility,inpatient,1,GM,56.65000,16.43000,Aetna,Local,,22.66,,,,,,,20.42,46.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,63323038810,NDC,facility,inpatient,500,ME,23.60000,6.84000,Aetna,Local,,9.44,,,,,,,8.51,19.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefoTEtan 1g I(Cefotan),800070042,CDM,637,RC,63323038510,NDC,,,facility,outpatient,1,EA,231.00000,66.99000,Aetna,Local,,117.28,,,,,,,83.28,188.96,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,63323037420,NDC,facility,inpatient,4,ME,19.45000,5.64000,Aetna,Local,,7.78,,,,,,,7.01,15.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,63323037302,NDC,facility,inpatient,4,ME,14.35000,4.16000,Aetna,Local,,5.74,,,,,,,5.17,11.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,63323037119,NDC,facility,inpatient,500,ME,3394.50000,984.40000,Aetna,Local,,1357.80,,,,,,,1223.72,2776.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,63323036920,NDC,facility,inpatient,3,GM,74.00000,21.46000,Aetna,Local,,29.60,,,,,,,26.68,60.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,63323036820,NDC,facility,inpatient,1.5,GM,37.35000,10.83000,Aetna,Local,,14.94,,,,,,,13.46,30.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,63323036019,NDC,facility,inpatient,1,GM,102.20000,29.64000,Aetna,Local,,40.88,,,,,,,36.84,83.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,63323035565,NDC,facility,inpatient,500,ME,120.00000,34.80000,Aetna,Local,,48.00,,,,,,,43.26,98.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,63323035560,NDC,facility,inpatient,750,ME,124.80000,36.19000,Aetna,Local,,49.92,,,,,,,44.99,102.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,63323034720,NDC,facility,inpatient,2,GM,49.80000,14.44000,Aetna,Local,,19.92,,,,,,,17.95,40.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,63323034610,NDC,facility,inpatient,1,GM,37.45000,10.86000,Aetna,Local,,14.98,,,,,,,13.50,30.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,63323034225,NDC,facility,inpatient,2,GM,134.00000,38.86000,Aetna,Local,,53.60,,,,,,,48.31,109.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,63323034220,NDC,facility,inpatient,2,GM,122.40000,35.50000,Aetna,Local,,48.96,,,,,,,44.13,100.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,63323034125,NDC,facility,inpatient,1,GM,67.10000,19.46000,Aetna,Local,,26.84,,,,,,,24.19,54.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,63323034120,NDC,facility,inpatient,1,GM,89.80000,26.04000,Aetna,Local,,35.92,,,,,,,32.37,73.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,63323034050,NDC,facility,inpatient,2,GM,303.55000,88.03000,Aetna,Local,,121.42,,,,,,,109.43,248.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,63323034020,NDC,facility,inpatient,2,GM,104.05000,30.17000,Aetna,Local,,41.62,,,,,,,37.51,85.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,63323032820,NDC,facility,inpatient,2,GM,273.00000,79.17000,Aetna,Local,,109.20,,,,,,,98.42,223.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,63323032620,NDC,facility,inpatient,1,GM,55.70000,16.15000,Aetna,Local,,22.28,,,,,,,20.08,45.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acyclovir 50mg/mL Inj 20mL,800013250,CDM,636,RC,J0133,HCPCS,63323032520,NDC,facility,inpatient,1000,ME,328.00000,95.12000,Aetna,Local,,131.20,,,,,,,118.24,268.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acyclovir 50mg/mL Inj 10mL,800020914,CDM,636,RC,J0133,HCPCS,63323032510,NDC,facility,inpatient,500,ME,180.50000,52.34000,Aetna,Local,,72.20,,,,,,,65.07,147.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,63323032050,NDC,facility,inpatient,4.5,GM,168.60000,48.89000,Aetna,Local,,67.44,,,,,,,60.78,137.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,63323031468,NDC,facility,inpatient,1,GM,204.25000,59.23000,Aetna,Local,,81.70,,,,,,,73.63,167.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,63323031461,NDC,facility,inpatient,1,GM,204.25000,59.23000,Aetna,Local,,81.70,,,,,,,73.63,167.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,63323031119,NDC,facility,inpatient,1,GM,71.60000,20.76000,Aetna,Local,,28.64,,,,,,,25.81,58.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Calcium Gluconate 0.465mEq/mL Inj,800017966,CDM,636,RC,J0612,HCPCS,63323031119,NDC,facility,inpatient,1,EA,71.60000,20.76000,Aetna,Local,,28.64,,,,,,,25.81,58.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,63323031110,NDC,facility,inpatient,1,GM,55.10000,15.98000,Aetna,Local,,22.04,,,,,,,19.86,45.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Calcium Gluconate 0.465mEq/mL Inj,800017966,CDM,636,RC,J0612,HCPCS,63323031110,NDC,facility,inpatient,1,EA,26.10000,7.57000,Aetna,Local,,10.44,,,,,,,9.41,21.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,63323030920,NDC,facility,inpatient,2.25,GM,88.80000,25.75000,Aetna,Local,,35.52,,,,,,,32.01,72.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,63323030602,NDC,facility,inpatient,80,ME,32.55000,9.44000,Aetna,Local,,13.02,,,,,,,11.73,26.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,63323030351,NDC,,,facility,outpatient,1,EA,649.10000,188.24000,Aetna,Local,,329.55,,,,,,,234.00,530.96,percent of total billed charges,
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,63323030201,NDC,facility,inpatient,20,UN,228.00000,66.12000,Aetna,Local,,91.20,,,,,,,82.19,186.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,63323030030,NDC,facility,inpatient,3.375,GM,133.15000,38.61000,Aetna,Local,,53.26,,,,,,,48.00,108.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mepivacaine 2% PF I 20mL,800016887,CDM,636,RC,J0670,HCPCS,63323029427,NDC,facility,inpatient,1,EA,78.90000,22.88000,Aetna,Local,,31.56,,,,,,,28.44,64.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,63323029210,NDC,facility,inpatient,10,ME,103.10000,29.90000,Aetna,Local,,41.24,,,,,,,37.17,84.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,63323029110,NDC,facility,inpatient,5,ME,101.55000,29.45000,Aetna,Local,,40.62,,,,,,,36.61,83.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028695,NDC,facility,inpatient,150,ME,32.30000,9.37000,Aetna,Local,,12.92,,,,,,,11.64,26.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% (5mg/1mL) I,800025669,CDM,636,RC,J2795,HCPCS,63323028663,NDC,facility,inpatient,1,ME,0.80000,0.23000,Aetna,Local,,0.32000,,,,,,,0.28840,0.65440,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028635,NDC,facility,inpatient,150,ME,144.60000,41.93000,Aetna,Local,,57.84,,,,,,,52.13,118.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028631,NDC,facility,inpatient,150,ME,139.55000,40.47000,Aetna,Local,,55.82,,,,,,,50.31,114.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,63323028630,NDC,facility,inpatient,150,ME,139.55000,40.47000,Aetna,Local,,55.82,,,,,,,50.31,114.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 20mL I,800021331,CDM,636,RC,J2795,HCPCS,63323028623,NDC,facility,inpatient,100,ME,105.40000,30.57000,Aetna,Local,,42.16,,,,,,,38.00,86.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 20mL I,800021331,CDM,636,RC,J2795,HCPCS,63323028620,NDC,facility,inpatient,100,ME,92.45000,26.81000,Aetna,Local,,36.98,,,,,,,33.33,75.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,63323028565,NDC,facility,inpatient,200,ME,405.35000,117.55000,Aetna,Local,,162.14,,,,,,,146.13,331.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,63323028561,NDC,facility,inpatient,200,ME,385.85000,111.90000,Aetna,Local,,154.34,,,,,,,139.10,315.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,63323028523,NDC,facility,inpatient,40,ME,70.50000,20.44000,Aetna,Local,,28.20,,,,,,,25.42,57.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,63323028520,NDC,facility,inpatient,40,ME,61.80000,17.92000,Aetna,Local,,24.72,,,,,,,22.28,50.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,63323028420,NDC,facility,inpatient,1,GM,152.65000,44.27000,Aetna,Local,,61.06,,,,,,,55.03,124.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,63323028204,NDC,facility,inpatient,600,ME,35.40000,10.27000,Aetna,Local,,14.16,,,,,,,12.76,28.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,63323028010,NDC,facility,inpatient,100,ME,20.45000,5.93000,Aetna,Local,,8.18,,,,,,,7.37,16.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,63323028004,NDC,facility,inpatient,40,ME,17.90000,5.19000,Aetna,Local,,7.16,,,,,,,6.45,14.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,63323028002,NDC,facility,inpatient,20,ME,13.40000,3.89000,Aetna,Local,,5.36,,,,,,,4.83,10.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
vinBLAStine 1mg/mL Inj,800025626,CDM,636,RC,J9360,HCPCS,63323027810,NDC,facility,inpatient,1,ME,41.95000,12.17000,Aetna,Local,,16.78,,,,,,,15.12,34.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323027065,NDC,facility,inpatient,1,GM,283.80000,82.30000,Aetna,Local,,113.52,,,,,,,102.31,232.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,63323027050,NDC,facility,inpatient,0.5,GM,142.80000,41.41000,Aetna,Local,,57.12,,,,,,,51.48,116.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323027025,NDC,facility,inpatient,200,ME,35.75000,10.37000,Aetna,Local,,14.30,,,,,,,12.89,29.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323027020,NDC,facility,inpatient,200,ME,35.75000,10.37000,Aetna,Local,,14.30,,,,,,,12.89,29.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323026969,NDC,facility,inpatient,1,GM,122.40000,35.50000,Aetna,Local,,48.96,,,,,,,44.13,100.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323026967,NDC,facility,inpatient,1,GM,315.00000,91.35000,Aetna,Local,,126.00,,,,,,,113.56,257.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,63323026965,NDC,facility,inpatient,1,GM,315.00000,91.35000,Aetna,Local,,126.00,,,,,,,113.56,257.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,63323026957,NDC,facility,inpatient,0.5,GM,142.80000,41.41000,Aetna,Local,,57.12,,,,,,,51.48,116.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,63323026950,NDC,facility,inpatient,0.5,GM,159.40000,46.23000,Aetna,Local,,63.76,,,,,,,57.46,130.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323026937,NDC,facility,inpatient,200,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323026929,NDC,facility,inpatient,200,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,63323026920,NDC,facility,inpatient,200,ME,39.90000,11.57000,Aetna,Local,,15.96,,,,,,,14.38,32.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,63323026530,NDC,facility,inpatient,1,GM,321.00000,93.09000,Aetna,Local,,128.40,,,,,,,115.72,262.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,63323025930,NDC,,,facility,outpatient,1,EA,16.45000,4.77000,Aetna,Local,,8.35,,,,,,,5.93,13.46,percent of total billed charges,
Mineral Oil Light 10mL(Muri-Lube),800035815,CDM,250,RC,63323025410,NDC,,,facility,outpatient,1,EA,194.85000,56.51000,Aetna,Local,,98.93,,,,,,,70.24,159.39,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,63323023861,NDC,facility,inpatient,2,GM,346.30000,100.43000,Aetna,Local,,138.52,,,,,,,124.84,283.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,63323023710,NDC,facility,inpatient,1000,ME,15.25000,4.42000,Aetna,Local,,6.10,,,,,,,5.50,12.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,63323022994,NDC,facility,inpatient,50,ME,86.40000,25.06000,Aetna,Local,,34.56,,,,,,,31.15,70.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Protamine Sulfate 250mg/25mL Inj,800013349,CDM,636,RC,J2720,HCPCS,63323022935,NDC,facility,inpatient,250,ME,309.80000,89.84000,Aetna,Local,,123.92,,,,,,,111.68,253.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Protamine Sulfate 250mg/25mL Inj,800013349,CDM,636,RC,J2720,HCPCS,63323022930,NDC,facility,inpatient,250,ME,482.45000,139.91000,Aetna,Local,,192.98,,,,,,,173.92,394.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,63323022915,NDC,facility,inpatient,50,ME,86.40000,25.06000,Aetna,Local,,34.56,,,,,,,31.15,70.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,63323022905,NDC,facility,inpatient,50,ME,148.60000,43.09000,Aetna,Local,,59.44,,,,,,,53.57,121.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,63323022110,NDC,facility,inpatient,500,ME,67.20000,19.49000,Aetna,Local,,26.88,,,,,,,24.23,54.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 10mL Inj,800040882,CDM,636,RC,63323020110,NDC,,,facility,inpatient,1,EA,17.00000,4.93000,Aetna,Local,,6.80,,,,,,,6.13,13.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 10mL Inj,800040882,CDM,636,RC,63323020110,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,Local,,6.80,,,,,,,6.13,13.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Chloride 23.4% Inj 30mL,800017960,CDM,250,RC,63323018730,NDC,,,facility,outpatient,1,EA,45.80000,13.28000,Aetna,Local,,23.25,,,,,,,16.51,37.46,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,63323018610,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,Local,,3.76,,,,,,,2.67,6.05,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,63323018550,NDC,facility,outpatient,1,EA,54.05000,15.67000,Aetna,Local,,27.44,,,,,,,0.63000,44.21,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,63323018510,NDC,facility,outpatient,1,EA,31.90000,9.25000,Aetna,Local,,16.20,,,,,,,0.63000,26.09,percent of total billed charges,
Pyridoxine HCl 100mg/mL 1mL I(Vit B6),800056795,CDM,636,RC,J3415,HCPCS,63323018001,NDC,facility,inpatient,100,ME,139.70000,40.51000,Aetna,Local,,55.88,,,,,,,50.36,114.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,63323017215,NDC,facility,inpatient,50,ME,70.20000,20.36000,Aetna,Local,,28.08,,,,,,,25.31,57.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Phosphate Inj,800053081,CDM,250,RC,63323017015,NDC,,,facility,outpatient,1,EA,331.90000,96.25000,Aetna,Local,,168.51,,,,,,,119.65,271.49,percent of total billed charges,
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,63323016530,NDC,facility,inpatient,1,ME,1.15000,0.33000,Aetna,Local,,0.46000,,,,,,,0.41458,0.94070,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,63323016505,NDC,facility,inpatient,4,ME,3.30000,0.96000,Aetna,Local,,1.32,,,,,,,1.19,2.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,63323016505,NDC,facility,inpatient,1,ME,3.30000,0.96000,Aetna,Local,,1.32,,,,,,,1.19,2.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,63323016501,NDC,facility,inpatient,4,ME,18.40000,5.34000,Aetna,Local,,7.36,,,,,,,6.63,15.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,63323016212,NDC,facility,inpatient,30,ME,4.45000,1.29000,Aetna,Local,,1.78,,,,,,,1.60,3.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,63323016201,NDC,facility,inpatient,30,ME,36.40000,10.56000,Aetna,Local,,14.56,,,,,,,13.12,29.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,63323016112,NDC,facility,inpatient,15,ME,4.50000,1.30000,Aetna,Local,,1.80,,,,,,,1.62,3.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,63323016101,NDC,facility,inpatient,15,ME,23.95000,6.95000,Aetna,Local,,9.58,,,,,,,8.63,19.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,63323014212,NDC,facility,inpatient,1000,ME,525.60000,152.42000,Aetna,Local,,210.24,,,,,,,189.48,429.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,63323014210,NDC,facility,inpatient,1000,ME,525.60000,152.42000,Aetna,Local,,210.24,,,,,,,189.48,429.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cladribine 10mg/10mL I(Leustatin),800022003,CDM,636,RC,J9065,HCPCS,63323014010,NDC,facility,inpatient,10,ME,3319.00000,962.51000,Aetna,Local,,1327.60,,,,,,,1196.50,2714.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,63323012550,NDC,facility,inpatient,1000,ME,987.00000,286.23000,Aetna,Local,,394.80,,,,,,,355.81,807.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorouracil 2.5g/50mL Inj,800046552,CDM,636,RC,J9190,HCPCS,63323011759,NDC,facility,inpatient,2500,ME,89.40000,25.93000,Aetna,Local,,35.76,,,,,,,32.23,73.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorouracil 2.5g/50mL Inj,800046552,CDM,636,RC,J9190,HCPCS,63323011751,NDC,facility,inpatient,2500,ME,140.65000,40.79000,Aetna,Local,,56.26,,,,,,,50.70,115.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,63323011719,NDC,facility,inpatient,500,ME,26.40000,7.66000,Aetna,Local,,10.56,,,,,,,9.52,21.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,63323011710,NDC,facility,inpatient,500,ME,32.85000,9.53000,Aetna,Local,,13.14,,,,,,,11.84,26.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 40g/Water 1000mL,800040853,CDM,636,RC,J3475,HCPCS,63323010610,NDC,facility,inpatient,40,GM,1010.30000,292.99000,Aetna,Local,,404.12,,,,,,,364.21,826.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,63323010605,NDC,facility,inpatient,2,GM,130.85000,37.95000,Aetna,Local,,52.34,,,,,,,47.17,107.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,63323010601,NDC,facility,inpatient,4,GM,81.10000,23.52000,Aetna,Local,,32.44,,,,,,,29.24,66.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,63323010364,NDC,facility,inpatient,10,ME,39.50000,11.46000,Aetna,Local,,15.80,,,,,,,14.24,32.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,63323010351,NDC,facility,inpatient,10,ME,39.50000,11.46000,Aetna,Local,,15.80,,,,,,,14.24,32.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,63323010210,NDC,facility,inpatient,200,ME,229.00000,66.41000,Aetna,Local,,91.60,,,,,,,82.55,187.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Chloride 23.4% Inj 30mL,800017960,CDM,250,RC,63323009330,NDC,,,facility,outpatient,1,EA,78.05000,22.63000,Aetna,Local,,39.63,,,,,,,28.14,63.84,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,63323008950,NDC,,,facility,outpatient,1,EA,253.45000,73.50000,Aetna,Local,,128.68,,,,,,,91.37,207.32,percent of total billed charges,
Potassium Phosphate Inj 5mL,800022009,CDM,250,RC,63323008605,NDC,,,facility,outpatient,1,EA,94.55000,27.42000,Aetna,Local,,48.00,,,,,,,34.09,77.34,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,63323008305,NDC,,,facility,outpatient,1,EA,224.75000,65.18000,Aetna,Local,,114.11,,,,,,,81.02,183.85,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,63323006420,NDC,facility,inpatient,10,GM,73.35000,21.27000,Aetna,Local,,29.34,,,,,,,26.44,60.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Magnesium Sulf 50% I 10mL,800020916,CDM,636,RC,J3475,HCPCS,63323006411,NDC,facility,inpatient,5,GM,28.75000,8.34000,Aetna,Local,,11.50,,,,,,,10.36,23.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,63323006410,NDC,facility,inpatient,10,GM,35.30000,10.24000,Aetna,Local,,14.12,,,,,,,12.73,28.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,63323004401,NDC,facility,inpatient,1,ME,44.10000,12.79000,Aetna,Local,,17.64,,,,,,,15.90,36.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,63323002605,NDC,,,facility,outpatient,1,EA,24.50000,7.10000,Aetna,Local,,12.44,,,,,,,8.83,20.04,percent of total billed charges,
Mannitol 25% I 50mL,800050889,CDM,636,RC,J2150,HCPCS,63323002425,NDC,facility,inpatient,12.5,GM,38.70000,11.22000,Aetna,Local,,15.48,,,,,,,13.95,31.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,63323001309,NDC,facility,inpatient,200,ME,27.55000,7.99000,Aetna,Local,,11.02,,,,,,,9.93,22.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,63323001302,NDC,facility,inpatient,200,ME,63.50000,18.42000,Aetna,Local,,25.40,,,,,,,22.89,51.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001212,NDC,facility,inpatient,10,UN,9.50000,2.76000,Aetna,Local,,3.80,,,,,,,3.42,7.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001211,NDC,facility,inpatient,10,UN,22.00000,6.38000,Aetna,Local,,8.80,,,,,,,7.93,18.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001207,NDC,facility,inpatient,10,UN,9.60000,2.78000,Aetna,Local,,3.84,,,,,,,3.46,7.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,63323001201,NDC,facility,inpatient,10,UN,9.50000,2.76000,Aetna,Local,,3.80,,,,,,,3.42,7.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gentamicin Sulf Mdv I,800015120,CDM,636,RC,J1580,HCPCS,63323001096,NDC,facility,inpatient,800,ME,155.50000,45.10000,Aetna,Local,,62.20,,,,,,,56.06,127.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gentamicin Sulf Mdv I,800015120,CDM,636,RC,J1580,HCPCS,63323001020,NDC,facility,inpatient,800,ME,312.80000,90.71000,Aetna,Local,,125.12,,,,,,,112.76,255.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,63323001002,NDC,facility,inpatient,80,ME,44.55000,12.92000,Aetna,Local,,17.82,,,,,,,16.06,36.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,63304097904,NDC,,,facility,outpatient,1,EA,24.40000,7.08000,Aetna,Local,,12.39,,,,,,,8.80,19.96,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,63304095901,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,3.40,,,,,,,2.42,5.48,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,63304094110,NDC,facility,inpatient,2,GM,287.05000,83.24000,Aetna,Local,,114.82,,,,,,,103.48,234.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,63304090430,NDC,,,facility,outpatient,1,EA,51.15000,14.83000,Aetna,Local,,25.97,,,,,,,18.44,41.84,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,63304083701,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,Local,,5.48,,,,,,,3.89,8.83,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,63304083501,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,63304082990,NDC,,,facility,outpatient,1,EA,40.90000,11.86000,Aetna,Local,,20.76,,,,,,,14.74,33.46,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,63304082890,NDC,,,facility,outpatient,1,EA,40.90000,11.86000,Aetna,Local,,20.76,,,,,,,14.74,33.46,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,63304082790,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,Local,,14.55,,,,,,,10.33,23.44,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,63304075160,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,63304072660,NDC,,,facility,outpatient,1,EA,32.00000,9.28000,Aetna,Local,,16.25,,,,,,,11.54,26.18,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,63304071320,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,Local,,13.61,,,,,,,9.66,21.92,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,63304069401,NDC,,,facility,outpatient,1,EA,12.05000,3.49000,Aetna,Local,,6.12,,,,,,,4.34,9.86,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,63304069201,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,Local,,4.29,,,,,,,3.05,6.91,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,63304065601,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,63304062501,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,63304062401,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,63304062201,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,63304062101,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,63304059690,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,11.75,,,,,,,8.35,18.94,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,63304057901,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,63304054001,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,Local,,2.18,,,,,,,1.55,3.52,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,63304053901,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,63304050920,NDC,,,facility,outpatient,1,EA,35.75000,10.37000,Aetna,Local,,18.15,,,,,,,12.89,29.24,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,63304050901,NDC,,,facility,outpatient,1,EA,35.45000,10.28000,Aetna,Local,,18.00,,,,,,,12.78,29.00,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,63304048901,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,Local,,5.18,,,,,,,3.68,8.34,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,63304045830,NDC,facility,inpatient,4,ME,175.45000,50.88000,Aetna,Local,,70.18,,,,,,,63.25,143.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,63304043601,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,63304029601,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),800075274,CDM,637,RC,63304020518,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,Local,,4.47,,,,,,,3.17,7.20,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,63304020302,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,Local,,3.66,,,,,,,2.60,5.89,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,63304020301,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,63304016601,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,Local,,10.26,,,,,,,7.28,16.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,63304016501,NDC,,,facility,outpatient,1,EA,20.20000,5.86000,Aetna,Local,,10.26,,,,,,,7.28,16.52,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,63304009919,NDC,,,facility,outpatient,1,EA,180.40000,52.32000,Aetna,Local,,91.59,,,,,,,65.03,147.57,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,63304009719,NDC,,,facility,outpatient,1,EA,200.90000,58.26000,Aetna,Local,,102.00,,,,,,,72.42,164.34,percent of total billed charges,
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,63261025021,NDC,facility,inpatient,50,ME,2717.20000,787.99000,Aetna,Local,,1086.88,,,,,,,979.55,2222.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,63261025021,NDC,facility,outpatient,50,ME,2717.20000,787.99000,Aetna,Local,,1086.88,,,,,,,5.42,2222.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,63044062201,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
fentaNYL 10mcg/mL /NS PCA 100mL,800019907,CDM,636,RC,J3010,HCPCS,63037010005,NDC,facility,inpatient,1,ME,328.00000,95.12000,Aetna,Local,,131.20,,,,,,,118.24,268.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,63020004901,NDC,facility,inpatient,3.5,ME,8843.20000,2564.53000,Aetna,Local,,3537.28,,,,,,,3187.97,7233.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
leuprolide 22.5mg/3 month(Eligard),800046491,CDM,636,RC,J9217,HCPCS,62935022710,NDC,facility,inpatient,22.5,ME,5588.60000,1620.69000,Aetna,Local,,2235.44,,,,,,,2014.69,4571.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
leuprolide 22.5mg/3 month(Eligard),800046491,CDM,636,RC,J9217,HCPCS,62935022305,NDC,facility,inpatient,22.5,ME,5588.60000,1620.69000,Aetna,Local,,2235.44,,,,,,,2014.69,4571.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,62856079701,NDC,facility,inpatient,0.25,ME,986.80000,286.17000,Aetna,Local,,394.72,,,,,,,355.74,807.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zonisamide 100mg C,800017740,CDM,637,RC,62856068010,NDC,,,facility,outpatient,1,EA,63.60000,18.44000,Aetna,Local,,32.29,,,,,,,22.93,52.02,percent of total billed charges,
Donepezil 23mg T (Aricept),800072470,CDM,637,RC,62856024730,NDC,,,facility,outpatient,1,EA,116.45000,33.77000,Aetna,Local,,59.12,,,,,,,41.98,95.26,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,62856024590,NDC,,,facility,outpatient,1,EA,143.35000,41.57000,Aetna,Local,,72.78,,,,,,,51.68,117.26,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,62856024541,NDC,,,facility,outpatient,1,EA,130.40000,37.82000,Aetna,Local,,66.20,,,,,,,47.01,106.67,percent of total billed charges,
Lecanemab-irmb 500mg- Pt Own Supply,800051061,CDM,636,RC,J0174,HCPCS,62856021501,NDC,facility,inpatient,500,ME,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lecanemab - irmb 500mg Inj,800046571,CDM,636,RC,J0174,HCPCS,62856021501,NDC,facility,inpatient,500,ME,4842.60000,1404.35000,Aetna,Local,,1937.04,,,,,,,1745.76,3961.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lecanemab - irmb 200mg Inj,800046572,CDM,636,RC,J0174,HCPCS,62856021201,NDC,facility,inpatient,200,ME,2049.20000,594.27000,Aetna,Local,,819.68,,,,,,,738.74,1676.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,62794014510,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,62756095501,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,Local,,9.11,,,,,,,6.47,14.68,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,62756082640,NDC,facility,inpatient,50,ME,254.20000,73.72000,Aetna,Local,,101.68,,,,,,,91.64,207.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,62756079888,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,62756079788,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,Local,,6.27,,,,,,,4.45,10.10,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,62756079713,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,Local,,6.27,,,,,,,4.45,10.10,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,62756075164,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,62756071860,NDC,,,facility,outpatient,1,EA,169.90000,49.27000,Aetna,Local,,86.26,,,,,,,61.25,138.98,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,62756070786,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,Local,,9.11,,,,,,,6.47,14.68,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,62756059088,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,Local,,3.73,,,,,,,2.65,6.01,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,62756058988,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,62756055483,NDC,,,facility,outpatient,1,EA,140.85000,40.85000,Aetna,Local,,71.51,,,,,,,50.78,115.22,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,62756052940,NDC,facility,inpatient,0.04,ME,4466.45000,1295.27000,Aetna,Local,,1786.58,,,,,,,1610.16,3653.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,62756052288,NDC,,,facility,outpatient,1,EA,180.45000,52.33000,Aetna,Local,,91.61,,,,,,,65.05,147.61,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,62756052269,NDC,,,facility,outpatient,1,EA,180.45000,52.33000,Aetna,Local,,91.61,,,,,,,65.05,147.61,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,62756052069,NDC,,,facility,outpatient,1,EA,193.00000,55.97000,Aetna,Local,,97.99,,,,,,,69.58,157.87,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,62756051988,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,3.40,,,,,,,2.42,5.48,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,62756051888,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,62756051788,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,62756051344,NDC,facility,inpatient,500,ME,322.05000,93.39000,Aetna,Local,,128.82,,,,,,,116.10,263.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,62756051340,NDC,facility,inpatient,500,ME,343.00000,99.47000,Aetna,Local,,137.20,,,,,,,123.65,280.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,62756046188,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,62756045788,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,Local,,6.50,,,,,,,4.61,10.47,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,62756044602,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,62756040201,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,62756026002,NDC,,,facility,outpatient,1,EA,15.50000,4.50000,Aetna,Local,,7.87,,,,,,,5.59,12.68,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,62756025802,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Amphotericin B LIPO 50mg I,800010922,CDM,636,RC,J0289,HCPCS,62756023301,NDC,facility,inpatient,50,ME,2021.15000,586.13000,Aetna,Local,,808.46,,,,,,,728.62,1653.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,62756020201,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,62756018488,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,Local,,9.49,,,,,,,6.74,15.30,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,62756018388,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,62756016088,NDC,,,facility,outpatient,1,EA,29.80000,8.64000,Aetna,Local,,15.13,,,,,,,10.74,24.38,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,62756014586,NDC,,,facility,outpatient,1,EA,29.90000,8.67000,Aetna,Local,,15.18,,,,,,,10.78,24.46,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,62756014201,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,62756013902,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,62756013805,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,Local,,4.80,,,,,,,3.41,7.73,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,62756013705,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,62756013702,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,62756012944,NDC,facility,inpatient,40,ME,45.20000,13.11000,Aetna,Local,,18.08,,,,,,,16.29,36.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,62584099401,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,62584098801,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,62584098401,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,62584097790,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,Local,,9.54,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,62584097730,NDC,,,facility,outpatient,1,EA,19.05000,5.52000,Aetna,Local,,9.67,,,,,,,6.87,15.58,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,62584097590,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,62584097501,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,Local,,5.18,,,,,,,3.68,8.34,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,62584097401,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,Local,,4.29,,,,,,,3.05,6.91,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,62584089701,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,62584088601,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,62584074701,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,62584055901,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,62584026601,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,Local,,0.48231,,,,,,,0.34247,0.77710,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,62584026501,NDC,,,facility,outpatient,1,EA,0.75000,0.22000,Aetna,Local,,0.38077,,,,,,,0.27037,0.61350,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,62584015901,NDC,,,facility,outpatient,1,EA,75.30000,21.84000,Aetna,Local,,38.23,,,,,,,27.15,61.60,percent of total billed charges,
Vancomycin 250mg/5mL Oral Soln,800082163,CDM,637,RC,62559083003,NDC,,,facility,outpatient,1,EA,96.00000,27.84000,Aetna,Local,,48.74,,,,,,,34.61,78.53,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,62559074401,NDC,,,facility,outpatient,1,EA,14.35000,4.16000,Aetna,Local,,7.29,,,,,,,5.17,11.74,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,62559052001,NDC,,,facility,outpatient,1,EA,508.25000,147.39000,Aetna,Local,,258.04,,,,,,,183.22,415.75,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),800017619,CDM,637,RC,62559051001,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,62559042401,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,62559042007,NDC,,,facility,outpatient,1,EA,172.90000,50.14000,Aetna,Local,,87.78,,,,,,,62.33,141.43,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,62559027630,NDC,,,facility,outpatient,1,EA,40.20000,11.66000,Aetna,Local,,20.41,,,,,,,14.49,32.88,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,62559023001,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,62559016001,NDC,,,facility,outpatient,1,EA,18.60000,5.39000,Aetna,Local,,9.44,,,,,,,6.71,15.21,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,62559015304,NDC,,,facility,outpatient,1,EA,50.15000,14.54000,Aetna,Local,,25.46,,,,,,,18.08,41.02,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,62559015116,NDC,,,facility,outpatient,1,EA,11.40000,3.31000,Aetna,Local,,5.79,,,,,,,4.11,9.33,percent of total billed charges,
Urea 15g Oral Rec Powder,800062042,CDM,250,RC,62530000011,NDC,,,facility,outpatient,1,EA,30.80000,8.93000,Aetna,Local,,15.64,,,,,,,11.10,25.19,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,62332051805,NDC,,,facility,outpatient,1,EA,238.60000,69.19000,Aetna,Local,,121.14,,,,,,,86.02,195.17,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,62332046431,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,62332042631,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,62332041310,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,Local,,50.97,,,,,,,36.19,82.13,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,62332038590,NDC,,,facility,outpatient,1,EA,176.00000,51.04000,Aetna,Local,,89.36,,,,,,,63.45,143.97,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,62332038530,NDC,,,facility,outpatient,1,EA,176.55000,51.20000,Aetna,Local,,89.63,,,,,,,63.65,144.42,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,62332037931,NDC,,,facility,outpatient,1,EA,79.50000,23.06000,Aetna,Local,,40.36,,,,,,,28.66,65.03,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),800015397,CDM,637,RC,62332036506,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,Local,,5.28,,,,,,,3.75,8.51,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,62332023330,NDC,,,facility,outpatient,1,EA,59.50000,17.26000,Aetna,Local,,30.21,,,,,,,21.45,48.67,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,62332017160,NDC,,,facility,outpatient,1,EA,86.00000,24.94000,Aetna,Local,,43.66,,,,,,,31.00,70.35,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,62332011431,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,62332011231,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,62332004590,NDC,,,facility,outpatient,1,EA,32.60000,9.45000,Aetna,Local,,16.55,,,,,,,11.75,26.67,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,62332003331,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,62332000191,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,62332000131,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,62175061743,NDC,,,facility,outpatient,1,EA,28.70000,8.32000,Aetna,Local,,14.57,,,,,,,10.35,23.48,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,62175049064,NDC,,,facility,outpatient,1,EA,26.75000,7.76000,Aetna,Local,,13.58,,,,,,,9.64,21.88,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,62175044601,NDC,,,facility,outpatient,1,EA,88.65000,25.71000,Aetna,Local,,45.01,,,,,,,31.96,72.52,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,62175027037,NDC,,,facility,outpatient,1,EA,21.75000,6.31000,Aetna,Local,,11.04,,,,,,,7.84,17.79,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,62175026037,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,Local,,4.80,,,,,,,3.41,7.73,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,62175018146,NDC,,,facility,outpatient,1,EA,28.70000,8.32000,Aetna,Local,,14.57,,,,,,,10.35,23.48,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,62175018143,NDC,,,facility,outpatient,1,EA,28.70000,8.32000,Aetna,Local,,14.57,,,,,,,10.35,23.48,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,62175012837,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,1.32,2.99,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,62175010201,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,62135096001,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,6.13,13.91,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,62135075047,NDC,,,facility,outpatient,1,EA,9.00000,2.61000,Aetna,Local,,4.57,,,,,,,3.24,7.36,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,62135048142,NDC,,,facility,outpatient,1,EA,127.45000,36.96000,Aetna,Local,,64.71,,,,,,,45.95,104.25,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,62135043690,NDC,,,facility,outpatient,1,EA,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,12.26,27.81,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,62037084601,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,Local,,9.82,,,,,,,6.98,15.83,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,62037084530,NDC,,,facility,outpatient,1,EA,18.55000,5.38000,Aetna,Local,,9.42,,,,,,,6.69,15.17,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,62037083201,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,62037083101,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,62037083001,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,62037059890,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,62037059790,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,Local,,4.32,,,,,,,3.06,6.95,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,62037057101,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,61990061102,NDC,,,facility,outpatient,1,EA,199.60000,57.88000,Aetna,Local,,101.34,,,,,,,71.96,163.27,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,61990041102,NDC,facility,inpatient,1,ME,775.30000,224.84000,Aetna,Local,,310.12,,,,,,,279.50,634.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,61990012002,NDC,facility,inpatient,3.375,GM,57.00000,16.53000,Aetna,Local,,22.80,,,,,,,20.55,46.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Remdesivir 100mg Inj,800062067,CDM,636,RC,J0248,HCPCS,61958290102,NDC,facility,inpatient,100,ME,4757.90000,1379.79000,Aetna,Local,,1903.16,,,,,,,1715.22,3891.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Remdesivir 100mg Inj,800062067,CDM,636,RC,J0248,HCPCS,61958290101,NDC,facility,inpatient,100,ME,3931.00000,1139.99000,Aetna,Local,,1572.40,,,,,,,1417.13,3215.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
bictegr/emtric/tenofov 50-200-25 mg Tab,800046451,CDM,637,RC,61958250101,NDC,,,facility,outpatient,1,EA,1031.05000,299.00000,Aetna,Local,,523.46,,,,,,,371.69,843.40,percent of total billed charges,
Tenofovir 25mg T(Vemlidy),800046464,CDM,637,RC,61958230101,NDC,,,facility,outpatient,1,EA,411.30000,119.28000,Aetna,Local,,208.82,,,,,,,148.27,336.44,percent of total billed charges,
Emtricitabine-Tenofovir 200-25mg Tab,800040867,CDM,637,RC,61958200201,NDC,,,facility,outpatient,1,EA,575.60000,166.92000,Aetna,Local,,292.23,,,,,,,207.50,470.84,percent of total billed charges,
elviteg/cobic/emtrici/teno 150-150-200-10mg T,800040866,CDM,637,RC,61958190101,NDC,,,facility,outpatient,1,EA,1031.05000,299.00000,Aetna,Local,,523.46,,,,,,,371.69,843.40,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,61958100301,NDC,,,facility,outpatient,1,EA,58.20000,16.88000,Aetna,Local,,29.55,,,,,,,20.98,47.61,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,61958100101,NDC,,,facility,outpatient,1,EA,32.05000,9.29000,Aetna,Local,,16.27,,,,,,,11.55,26.22,percent of total billed charges,
Emtricitabine-Tenofovir 200-300mg T(Truvada),800017719,CDM,637,RC,61958070101,NDC,,,facility,outpatient,1,EA,488.05000,141.53000,Aetna,Local,,247.78,,,,,,,175.94,399.22,percent of total billed charges,
Tenofovir 300mg T(Viread),800017725,CDM,637,RC,61958040101,NDC,,,facility,outpatient,1,EA,344.85000,100.01000,Aetna,Local,,175.08,,,,,,,124.32,282.09,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,61953000201,NDC,facility,inpatient,12.5,GM,668.00000,193.72000,Aetna,Local,,267.20,,,,,,,240.81,546.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cariprazine 1.5mg C(Vraylar),800046466,CDM,637,RC,61874011530,NDC,,,facility,outpatient,1,EA,409.40000,118.73000,Aetna,Local,,207.85,,,,,,,147.59,334.89,percent of total billed charges,
Cariprazine 1.5mg C(Vraylar),800046466,CDM,637,RC,61874011520,NDC,,,facility,outpatient,1,EA,409.40000,118.73000,Aetna,Local,,207.85,,,,,,,147.59,334.89,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,61787044202,NDC,,,facility,outpatient,1,EA,90.05000,26.11000,Aetna,Local,,45.72,,,,,,,32.46,73.66,percent of total billed charges,
cemiplimab - rwlc 350 mg/7 mL Soln,800051954,CDM,636,RC,J9119,HCPCS,61755000801,NDC,facility,inpatient,350,ME,59181.80000,17162.72000,Aetna,Local,,23672.72,,,,,,,21335.04,48410.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
rifAMPin 300mg C,800018357,CDM,637,RC,61748001860,NDC,,,facility,outpatient,1,EA,14.25000,4.13000,Aetna,Local,,7.23,,,,,,,5.14,11.66,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,61748001830,NDC,,,facility,outpatient,1,EA,14.30000,4.15000,Aetna,Local,,7.26,,,,,,,5.16,11.70,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,61748001801,NDC,,,facility,outpatient,1,EA,14.25000,4.13000,Aetna,Local,,7.23,,,,,,,5.14,11.66,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,61748001406,NDC,,,facility,outpatient,1,EA,12.60000,3.65000,Aetna,Local,,6.40,,,,,,,4.54,10.31,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,61748001401,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,Local,,5.33,,,,,,,3.79,8.59,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,61748001211,NDC,,,facility,outpatient,1,EA,46.00000,13.34000,Aetna,Local,,23.35,,,,,,,16.58,37.63,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,61748001201,NDC,,,facility,outpatient,1,EA,43.60000,12.64000,Aetna,Local,,22.14,,,,,,,15.72,35.66,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,61703042381,NDC,,,facility,outpatient,1,EA,74.80000,21.69000,Aetna,Local,,37.98,,,,,,,26.97,61.19,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,61703042282,NDC,,,facility,outpatient,1,EA,125.95000,36.53000,Aetna,Local,,63.94,,,,,,,45.40,103.03,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,61703042281,NDC,,,facility,outpatient,1,EA,93.75000,27.19000,Aetna,Local,,47.60,,,,,,,33.80,76.69,percent of total billed charges,
Methotrexate 1g/40mL I PF,800022022,CDM,636,RC,J9260,HCPCS,61703040841,NDC,facility,inpatient,1000,ME,343.55000,99.63000,Aetna,Local,,137.42,,,,,,,123.85,281.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,61703036322,NDC,facility,inpatient,100,ME,835.80000,242.38000,Aetna,Local,,334.32,,,,,,,301.31,683.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,61703036050,NDC,facility,inpatient,50,ME,39.40000,11.43000,Aetna,Local,,15.76,,,,,,,14.20,32.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate 50mg/2mL Inj,800046553,CDM,636,RC,J9260,HCPCS,61703035038,NDC,facility,inpatient,50,ME,56.70000,16.44000,Aetna,Local,,22.68,,,,,,,20.44,46.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate 50mg/2mL Inj,800046553,CDM,636,RC,J9260,HCPCS,61703035010,NDC,facility,inpatient,50,ME,56.70000,16.44000,Aetna,Local,,22.68,,,,,,,20.44,46.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,61703034909,NDC,facility,inpatient,100,ME,210.75000,61.12000,Aetna,Local,,84.30,,,,,,,75.98,172.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,61703034222,NDC,facility,inpatient,6,ME,13.15000,3.81000,Aetna,Local,,5.26,,,,,,,4.74,10.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,61703033950,NDC,facility,inpatient,50,ME,40.85000,11.85000,Aetna,Local,,16.34,,,,,,,14.73,33.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,61703033922,NDC,facility,inpatient,50,ME,60.40000,17.52000,Aetna,Local,,24.16,,,,,,,21.77,49.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,61703030925,NDC,facility,inpatient,2,ME,132.60000,38.45000,Aetna,Local,,53.04,,,,,,,47.80,108.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,61703030916,NDC,facility,inpatient,2,ME,120.10000,34.83000,Aetna,Local,,48.04,,,,,,,43.30,98.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,61703030906,NDC,facility,inpatient,2,ME,268.60000,77.89000,Aetna,Local,,107.44,,,,,,,96.83,219.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,61703026205,NDC,facility,inpatient,50,ME,40.85000,11.85000,Aetna,Local,,16.34,,,,,,,14.73,33.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,61570041605,NDC,facility,inpatient,10,UN,8.85000,2.57000,Aetna,Local,,3.54,,,,,,,3.19,7.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,61570030361,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,Local,,14.37,,,,,,,10.20,23.15,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,61570019001,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,61570017262,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,Local,,9.70,,,,,,,6.89,15.62,percent of total billed charges,
Pen G Benzathine 1.2 (Bicillin LA)2mL,800014282,CDM,636,RC,J0561,HCPCS,61570014710,NDC,facility,inpatient,1,EA,239.00000,69.31000,Aetna,Local,,95.60,,,,,,,86.16,195.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,61570013185,NDC,,,facility,outpatient,1,EA,217.30000,63.02000,Aetna,Local,,110.32,,,,,,,78.34,177.75,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,61570011256,NDC,,,facility,outpatient,1,EA,17.45000,5.06000,Aetna,Local,,8.86,,,,,,,6.29,14.27,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,61570011201,NDC,,,facility,outpatient,1,EA,56.70000,16.44000,Aetna,Local,,28.79,,,,,,,20.44,46.38,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,61570011101,NDC,,,facility,outpatient,1,EA,54.00000,15.66000,Aetna,Local,,27.42,,,,,,,19.47,44.17,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,61570011001,NDC,,,facility,outpatient,1,EA,45.75000,13.27000,Aetna,Local,,23.23,,,,,,,16.49,37.42,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,61570004935,NDC,,,facility,outpatient,1,EA,289.75000,84.03000,Aetna,Local,,147.11,,,,,,,104.45,237.02,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,800018689,CDM,637,RC,61570003410,NDC,,,facility,outpatient,1,EA,740.30000,214.69000,Aetna,Local,,375.85,,,,,,,266.88,605.57,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,61553036472,NDC,facility,inpatient,200,ME,99.75000,28.93000,Aetna,Local,,39.90,,,,,,,35.96,81.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,61553032170,NDC,,,facility,outpatient,1,EA,212.85000,61.73000,Aetna,Local,,108.06,,,,,,,76.73,174.11,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,61553030772,NDC,facility,inpatient,1,ME,53.20000,15.43000,Aetna,Local,,21.28,,,,,,,19.18,43.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 25mg/NS 250mL PF PB,800019789,CDM,636,RC,J2371,HCPCS,61553015961,NDC,facility,inpatient,25,ME,99.20000,28.77000,Aetna,Local,,39.68,,,,,,,35.76,81.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 2g/ Water  Syr (Ancef),800013628,CDM,636,RC,J0690,HCPCS,61553001473,NDC,facility,inpatient,2,GM,94.95000,27.54000,Aetna,Local,,37.98,,,,,,,34.23,77.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1g/ Water Syr (Ancef),800013627,CDM,636,RC,J0690,HCPCS,61553001272,NDC,facility,inpatient,1,GM,62.00000,17.98000,Aetna,Local,,24.80,,,,,,,22.35,50.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Belladonna-Opium Supp(60mg Of Opium),800017087,CDM,637,RC,61451501607,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,Local,,14.55,,,,,,,10.33,23.44,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,61442032110,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,Local,,0.71078,,,,,,,0.50470,1.15,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,61442032105,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,61442032101,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,61442012110,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,Local,,7.46,,,,,,,5.30,12.02,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,61442012101,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,Local,,7.46,,,,,,,5.30,12.02,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,61442011101,NDC,,,facility,outpatient,1,EA,20.65000,5.99000,Aetna,Local,,10.48,,,,,,,7.44,16.89,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,61314064305,NDC,,,facility,outpatient,1,EA,238.70000,69.22000,Aetna,Local,,121.19,,,,,,,86.05,195.26,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,61314063710,NDC,,,facility,outpatient,1,EA,376.05000,109.05000,Aetna,Local,,190.92,,,,,,,135.57,307.61,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,61314063705,NDC,,,facility,outpatient,1,EA,376.35000,109.14000,Aetna,Local,,191.07,,,,,,,135.67,307.85,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,61314063136,NDC,,,facility,outpatient,1,EA,304.50000,88.30000,Aetna,Local,,154.59,,,,,,,109.77,249.08,percent of total billed charges,
Neo-Poly-Dex 5mL Ophth Susp(Maxitrol),800019117,CDM,637,RC,61314063006,NDC,,,facility,outpatient,1,EA,304.50000,88.30000,Aetna,Local,,154.59,,,,,,,109.77,249.08,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,61314062810,NDC,,,facility,outpatient,1,EA,123.35000,35.77000,Aetna,Local,,62.62,,,,,,,44.47,100.90,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,61314054703,NDC,,,facility,outpatient,1,EA,617.60000,179.10000,Aetna,Local,,313.56,,,,,,,222.64,505.20,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,61314054701,NDC,,,facility,outpatient,1,EA,617.60000,179.10000,Aetna,Local,,313.56,,,,,,,222.64,505.20,percent of total billed charges,
Tropicamide 1% Ophth Soln(Mydriacyl),800061415,CDM,637,RC,61314035501,NDC,,,facility,outpatient,1,EA,465.60000,135.02000,Aetna,Local,,236.39,,,,,,,167.85,380.86,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,61314030302,NDC,,,facility,outpatient,1,EA,76.00000,22.04000,Aetna,Local,,38.59,,,,,,,27.40,62.17,percent of total billed charges,
dexaMETHasone 0.1% 5mL Ophth Soln,800036904,CDM,637,RC,61314029405,NDC,,,facility,outpatient,1,EA,149.40000,43.33000,Aetna,Local,,75.85,,,,,,,53.86,122.21,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,61314022715,NDC,,,facility,outpatient,1,EA,115.05000,33.36000,Aetna,Local,,58.41,,,,,,,41.48,94.11,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,61314022710,NDC,,,facility,outpatient,1,EA,114.50000,33.20000,Aetna,Local,,58.13,,,,,,,41.28,93.66,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,61314022705,NDC,,,facility,outpatient,1,EA,120.35000,34.90000,Aetna,Local,,61.10,,,,,,,43.39,98.45,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,61314022605,NDC,,,facility,outpatient,1,EA,106.20000,30.80000,Aetna,Local,,53.92,,,,,,,38.29,86.87,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,61314020315,NDC,,,facility,outpatient,1,EA,639.25000,185.38000,Aetna,Local,,324.55,,,,,,,230.45,522.91,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,61314014315,NDC,,,facility,outpatient,1,EA,43.30000,12.56000,Aetna,Local,,21.98,,,,,,,15.61,35.42,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,61314014305,NDC,,,facility,outpatient,1,EA,84.95000,24.64000,Aetna,Local,,43.13,,,,,,,30.62,69.49,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,61314012610,NDC,,,facility,outpatient,1,EA,675.90000,196.01000,Aetna,Local,,343.15,,,,,,,243.66,552.89,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,61314012605,NDC,,,facility,outpatient,1,EA,678.70000,196.82000,Aetna,Local,,344.58,,,,,,,244.67,555.18,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,61314001910,NDC,,,facility,outpatient,1,EA,445.85000,129.30000,Aetna,Local,,226.36,,,,,,,160.73,364.71,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,61314001601,NDC,,,facility,outpatient,1,EA,303.75000,88.09000,Aetna,Local,,154.21,,,,,,,109.50,248.47,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,61269098937,NDC,,,facility,outpatient,1,EA,113.50000,32.92000,Aetna,Local,,57.62,,,,,,,40.92,92.84,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,61269073556,NDC,,,facility,outpatient,1,EA,21.70000,6.29000,Aetna,Local,,11.02,,,,,,,7.82,17.75,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,61269073041,NDC,,,facility,outpatient,1,EA,50.55000,14.66000,Aetna,Local,,25.66,,,,,,,18.22,41.35,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,61269033956,NDC,,,facility,outpatient,1,EA,12.00000,3.48000,Aetna,Local,,6.09,,,,,,,4.33,9.82,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,61269022041,NDC,,,facility,outpatient,1,EA,34.00000,9.86000,Aetna,Local,,17.26,,,,,,,12.26,27.81,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,61269017934,NDC,,,facility,outpatient,1,EA,58.75000,17.04000,Aetna,Local,,29.83,,,,,,,21.18,48.06,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,60977015501,NDC,facility,inpatient,0.2,ME,8.15000,2.36000,Aetna,Local,,3.26,,,,,,,2.94,6.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,60977015071,NDC,facility,inpatient,1,GM,134.25000,38.93000,Aetna,Local,,53.70,,,,,,,48.40,109.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,60977015001,NDC,facility,inpatient,1,GM,328.00000,95.12000,Aetna,Local,,131.20,,,,,,,118.24,268.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,60977011201,NDC,facility,inpatient,2,ME,16.65000,4.83000,Aetna,Local,,6.66,,,,,,,6.00,13.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,60977001701,NDC,facility,inpatient,10,ME,72.95000,21.16000,Aetna,Local,,29.18,,,,,,,26.30,59.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,60977001673,NDC,facility,inpatient,5,ME,18.55000,5.38000,Aetna,Local,,7.42,,,,,,,6.69,15.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,60976034747,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,Local,,3.76,,,,,,,2.67,6.05,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,60951060768,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,Local,,3.66,,,,,,,2.60,5.89,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,60951060568,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,60951060368,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,Local,,2.56,,,,,,,1.82,4.13,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,60793085601,NDC,,,facility,outpatient,1,EA,9.60000,2.78000,Aetna,Local,,4.87,,,,,,,3.46,7.85,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,60793085501,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,Local,,4.80,,,,,,,3.41,7.73,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,60793085301,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,Local,,4.14,,,,,,,2.94,6.67,percent of total billed charges,
Pen G Benzathine 1.2 (Bicillin LA)2mL,800014282,CDM,636,RC,J0561,HCPCS,60793070110,NDC,facility,inpatient,1,EA,1660.25000,481.47000,Aetna,Local,,664.10,,,,,,,598.52,1358.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Thrombin Bovine 20,000IUTp Kit",800050970,CDM,250,RC,60793021722,NDC,,,facility,outpatient,1,EA,2370.15000,687.34000,Aetna,Local,,1203.33,,,,,,,854.44,1938.78,percent of total billed charges,
"Thrombin Bovine 20,000IUTp Kit",800050970,CDM,250,RC,60793021721,NDC,,,facility,outpatient,1,EA,2370.15000,687.34000,Aetna,Local,,1203.33,,,,,,,854.44,1938.78,percent of total billed charges,
Thrombin Bovine 5000 IU,800016857,CDM,250,RC,60793021505,NDC,,,facility,outpatient,1,EA,592.90000,171.94000,Aetna,Local,,301.02,,,,,,,213.74,484.99,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,60793013605,NDC,,,facility,outpatient,1,EA,90.30000,26.19000,Aetna,Local,,45.85,,,,,,,32.55,73.87,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,60793013601,NDC,,,facility,outpatient,1,EA,90.30000,26.19000,Aetna,Local,,45.85,,,,,,,32.55,73.87,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,60793011601,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,60793011501,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,60758090810,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,Local,,46.99,,,,,,,33.36,75.71,percent of total billed charges,
Fluorometholone 0.1% 5mL Ophth Susp,800018804,CDM,637,RC,60758088005,NDC,,,facility,outpatient,1,EA,605.00000,175.45000,Aetna,Local,,307.16,,,,,,,218.10,494.89,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60758080210,NDC,,,facility,outpatient,1,EA,26.35000,7.64000,Aetna,Local,,13.38,,,,,,,9.50,21.55,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60758080205,NDC,,,facility,outpatient,1,EA,25.35000,7.35000,Aetna,Local,,12.87,,,,,,,9.14,20.74,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,60758080105,NDC,,,facility,outpatient,1,EA,46.45000,13.47000,Aetna,Local,,23.58,,,,,,,16.75,38.00,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,60758011910,NDC,,,facility,outpatient,1,EA,361.00000,104.69000,Aetna,Local,,183.28,,,,,,,130.14,295.30,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,60758011905,NDC,,,facility,outpatient,1,EA,361.00000,104.69000,Aetna,Local,,183.28,,,,,,,130.14,295.30,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,60687086801,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,60687083801,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,60687083601,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,60687083301,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,60687082601,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,Local,,3.17,,,,,,,2.25,5.11,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,60687082201,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,60687081501,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,Local,,2.23,,,,,,,1.59,3.60,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,60687081201,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,60687080701,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,60687080017,NDC,,,facility,outpatient,1,EA,16.15000,4.68000,Aetna,Local,,8.20,,,,,,,5.82,13.21,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,60687079501,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,Local,,0.71078,,,,,,,0.50470,1.15,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,60687079201,NDC,,,facility,outpatient,1,EA,47.85000,13.88000,Aetna,Local,,24.29,,,,,,,17.25,39.14,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,60687078201,NDC,,,facility,outpatient,1,EA,15.75000,4.57000,Aetna,Local,,8.00,,,,,,,5.68,12.88,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,60687077701,NDC,,,facility,outpatient,1,EA,28.20000,8.18000,Aetna,Local,,14.32,,,,,,,10.17,23.07,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,60687076821,NDC,,,facility,outpatient,1,EA,13.55000,3.93000,Aetna,Local,,6.88,,,,,,,4.88,11.08,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,60687075821,NDC,,,facility,outpatient,1,EA,36.35000,10.54000,Aetna,Local,,18.45,,,,,,,13.10,29.73,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,60687075609,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,60687075021,NDC,,,facility,outpatient,1,EA,36.50000,10.58000,Aetna,Local,,18.53,,,,,,,13.16,29.86,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,60687074721,NDC,,,facility,outpatient,1,EA,36.20000,10.50000,Aetna,Local,,18.38,,,,,,,13.05,29.61,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,60687074601,NDC,,,facility,outpatient,1,EA,19.30000,5.60000,Aetna,Local,,9.80,,,,,,,6.96,15.79,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,60687074501,NDC,,,facility,outpatient,1,EA,54.50000,15.80000,Aetna,Local,,27.67,,,,,,,19.65,44.58,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,60687074421,NDC,,,facility,outpatient,1,EA,101.75000,29.51000,Aetna,Local,,51.66,,,,,,,36.68,83.23,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,60687074265,NDC,,,facility,outpatient,1,EA,13.25000,3.84000,Aetna,Local,,6.73,,,,,,,4.78,10.84,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,60687073856,NDC,,,facility,outpatient,1,EA,77.20000,22.39000,Aetna,Local,,39.19,,,,,,,27.83,63.15,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,60687073665,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,60687073501,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,Local,,8.91,,,,,,,6.33,14.36,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,60687073401,NDC,,,facility,outpatient,1,EA,54.50000,15.80000,Aetna,Local,,27.67,,,,,,,19.65,44.58,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,60687072721,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,Local,,40.08,,,,,,,28.46,64.58,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,60687072321,NDC,,,facility,outpatient,1,EA,57.80000,16.76000,Aetna,Local,,29.35,,,,,,,20.84,47.28,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,60687071701,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,Local,,1.88,,,,,,,1.33,3.03,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,60687071521,NDC,,,facility,outpatient,1,EA,35.45000,10.28000,Aetna,Local,,18.00,,,,,,,12.78,29.00,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,60687069501,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,60687068101,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,60687067801,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,60687067701,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,60687067657,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,Local,,9.57,,,,,,,6.80,15.42,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,60687067501,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,60687067265,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,Local,,7.01,,,,,,,4.97,11.29,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,60687066621,NDC,,,facility,outpatient,1,EA,50.50000,14.64000,Aetna,Local,,25.64,,,,,,,18.21,41.31,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,60687066101,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,60687065701,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,60687065621,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,60687065521,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,Local,,4.67,,,,,,,3.32,7.53,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,60687065121,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,Local,,5.58,,,,,,,3.97,9.00,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,60687064121,NDC,,,facility,outpatient,1,EA,24.85000,7.21000,Aetna,Local,,12.62,,,,,,,8.96,20.33,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,60687064001,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,Local,,2.23,,,,,,,1.59,3.60,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,60687063994,NDC,,,facility,outpatient,1,EA,45.70000,13.25000,Aetna,Local,,23.20,,,,,,,16.47,37.38,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,60687063801,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,60687063601,NDC,facility,inpatient,4,ME,169.50000,49.15000,Aetna,Local,,67.80,,,,,,,61.10,138.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,60687063401,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,60687063365,NDC,,,facility,outpatient,1,EA,30.35000,8.80000,Aetna,Local,,15.41,,,,,,,10.94,24.83,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,60687063021,NDC,,,facility,outpatient,1,EA,11.75000,3.41000,Aetna,Local,,5.97,,,,,,,4.24,9.61,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,60687062872,NDC,,,facility,outpatient,1,EA,183.90000,53.33000,Aetna,Local,,93.37,,,,,,,66.30,150.43,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,60687062871,NDC,,,facility,outpatient,1,EA,118.25000,34.29000,Aetna,Local,,60.04,,,,,,,42.63,96.73,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,60687062701,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,60687062401,NDC,,,facility,outpatient,1,EA,23.35000,6.77000,Aetna,Local,,11.85,,,,,,,8.42,19.10,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,60687062301,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,Local,,4.65,,,,,,,3.30,7.48,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,60687062001,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,60687061701,NDC,,,facility,outpatient,1,EA,9.90000,2.87000,Aetna,Local,,5.03,,,,,,,3.57,8.10,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,60687060721,NDC,,,facility,outpatient,1,EA,18.20000,5.28000,Aetna,Local,,9.24,,,,,,,6.56,14.89,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,60687060501,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,Local,,1.12,,,,,,,0.79310,1.80,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,60687060201,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,60687059801,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,60687059632,NDC,,,facility,outpatient,1,EA,114.70000,33.26000,Aetna,Local,,58.23,,,,,,,41.35,93.82,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,60687059501,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,60687059301,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,60687059101,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,Local,,4.95,,,,,,,3.51,7.98,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,60687059001,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,60687058701,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,60687058601,NDC,,,facility,outpatient,1,EA,15.80000,4.58000,Aetna,Local,,8.02,,,,,,,5.70,12.92,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,60687058421,NDC,,,facility,outpatient,1,EA,24.20000,7.02000,Aetna,Local,,12.29,,,,,,,8.72,19.80,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,60687058201,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,Local,,7.18,,,,,,,5.10,11.57,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,60687058121,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,Local,,3.60,,,,,,,2.56,5.81,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,60687058001,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,60687057901,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,60687057701,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Midazolam HCl 5mg/2.5mL L UD,800078849,CDM,637,RC,60687057610,NDC,,,facility,outpatient,1,EA,51.20000,14.85000,Aetna,Local,,25.99,,,,,,,18.46,41.88,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,60687056801,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,Local,,1.35,,,,,,,0.95532,2.17,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,60687056301,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,Local,,3.10,,,,,,,2.20,4.99,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,60687056201,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,60687055901,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,60687055801,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,Local,,0.76155,,,,,,,0.54075,1.23,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,60687055301,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,Local,,4.75,,,,,,,3.37,7.65,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,60687055001,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,60687054921,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,Local,,6.04,,,,,,,4.29,9.73,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,60687054401,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,60687053478,NDC,,,facility,outpatient,1,EA,249.05000,72.22000,Aetna,Local,,126.44,,,,,,,89.78,203.72,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,60687052521,NDC,,,facility,outpatient,1,EA,219.00000,63.51000,Aetna,Local,,111.19,,,,,,,78.95,179.14,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,60687051365,NDC,,,facility,outpatient,1,EA,14.25000,4.13000,Aetna,Local,,7.23,,,,,,,5.14,11.66,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,60687051101,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,Local,,7.18,,,,,,,5.10,11.57,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,60687050701,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,Local,,8.71,,,,,,,6.18,14.03,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,60687050601,NDC,,,facility,outpatient,1,EA,12.95000,3.76000,Aetna,Local,,6.57,,,,,,,4.67,10.59,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,60687050401,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,Local,,6.50,,,,,,,4.61,10.47,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,60687050301,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,60687049701,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,60687049501,NDC,,,facility,outpatient,1,EA,12.95000,3.76000,Aetna,Local,,6.57,,,,,,,4.67,10.59,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,60687049301,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,60687048601,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,60687048401,NDC,,,facility,outpatient,1,EA,12.95000,3.76000,Aetna,Local,,6.57,,,,,,,4.67,10.59,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,60687048021,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,Local,,4.90,,,,,,,3.48,7.89,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,60687047901,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,60687047501,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,60687047301,NDC,,,facility,outpatient,1,EA,12.95000,3.76000,Aetna,Local,,6.57,,,,,,,4.67,10.59,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,60687046801,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,60687046501,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,60687046401,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,60687045701,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,60687045401,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,60687045301,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,60687045201,NDC,,,facility,outpatient,1,EA,110.35000,32.00000,Aetna,Local,,56.02,,,,,,,39.78,90.27,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,60687045121,NDC,,,facility,outpatient,1,EA,35.40000,10.27000,Aetna,Local,,17.97,,,,,,,12.76,28.96,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,60687045001,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,60687044701,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,60687044601,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,60687044301,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,60687043901,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,60687043701,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,Local,,2.18,,,,,,,1.55,3.52,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,60687043301,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,1.32,2.99,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,60687042865,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,Local,,3.45,,,,,,,2.45,5.56,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,60687042501,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,Local,,4.49,,,,,,,3.19,7.24,percent of total billed charges,
cloBAZam 10mg Tab UD,800051956,CDM,637,RC,60687042321,NDC,,,facility,outpatient,1,EA,24.95000,7.24000,Aetna,Local,,12.67,,,,,,,8.99,20.41,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,60687041801,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,Local,,4.47,,,,,,,3.17,7.20,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,60687041501,NDC,,,facility,outpatient,1,EA,24.50000,7.10000,Aetna,Local,,12.44,,,,,,,8.83,20.04,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,60687041301,NDC,,,facility,outpatient,1,EA,11.85000,3.44000,Aetna,Local,,6.02,,,,,,,4.27,9.69,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,60687040825,NDC,,,facility,outpatient,1,EA,116.10000,33.67000,Aetna,Local,,58.94,,,,,,,41.85,94.97,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,60687040677,NDC,,,facility,outpatient,1,EA,56.65000,16.43000,Aetna,Local,,28.76,,,,,,,20.42,46.34,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,60687040401,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,60687040265,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,Local,,3.07,,,,,,,2.18,4.95,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,60687040101,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,60687039801,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,60687039601,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,60687039001,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,60687038921,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,Local,,40.08,,,,,,,28.46,64.58,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,60687038801,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,60687038525,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,Local,,14.37,,,,,,,10.20,23.15,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,60687038401,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,Local,,4.67,,,,,,,3.32,7.53,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,60687038194,NDC,,,facility,outpatient,1,EA,531.55000,154.15000,Aetna,Local,,269.87,,,,,,,191.62,434.81,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,60687037701,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,60687037001,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,60687036901,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,60687036221,NDC,,,facility,outpatient,1,EA,58.55000,16.98000,Aetna,Local,,29.73,,,,,,,21.11,47.89,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,60687035601,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,60687035501,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,60687034601,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,60687034501,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,Local,,3.17,,,,,,,2.25,5.11,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,60687034172,NDC,,,facility,outpatient,1,EA,183.90000,53.33000,Aetna,Local,,93.37,,,,,,,66.30,150.43,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,60687034171,NDC,,,facility,outpatient,1,EA,118.25000,34.29000,Aetna,Local,,60.04,,,,,,,42.63,96.73,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,60687033301,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,60687032501,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,60687031921,NDC,,,facility,outpatient,1,EA,85.30000,24.74000,Aetna,Local,,43.31,,,,,,,30.75,69.78,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,60687031201,NDC,,,facility,outpatient,1,EA,33.00000,9.57000,Aetna,Local,,16.75,,,,,,,11.90,26.99,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,60687029301,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,Local,,3.17,,,,,,,2.25,5.11,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,60687029201,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,60687028621,NDC,,,facility,outpatient,1,EA,58.60000,16.99000,Aetna,Local,,29.75,,,,,,,21.13,47.93,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,60687028265,NDC,,,facility,outpatient,1,EA,13.25000,3.84000,Aetna,Local,,6.73,,,,,,,4.78,10.84,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,60687027566,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,Local,,28.89,,,,,,,20.51,46.54,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,60687027294,NDC,,,facility,outpatient,1,EA,29.20000,8.47000,Aetna,Local,,14.82,,,,,,,10.53,23.89,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,60687026256,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,Local,,3.60,,,,,,,2.56,5.81,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,60687025301,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,60687024977,NDC,,,facility,outpatient,1,EA,50.30000,14.59000,Aetna,Local,,25.54,,,,,,,18.13,41.15,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,60687024565,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,Local,,4.95,,,,,,,3.51,7.98,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,60687024501,NDC,,,facility,outpatient,1,EA,50.60000,14.67000,Aetna,Local,,25.69,,,,,,,18.24,41.39,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,800015336,CDM,637,RC,60687024477,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,Local,,25.33,,,,,,,17.99,40.82,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,800015336,CDM,637,RC,60687024467,NDC,,,facility,outpatient,1,EA,47.25000,13.70000,Aetna,Local,,23.99,,,,,,,17.03,38.65,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,60687024201,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Sertraline HCl 25mg T,800015414,CDM,637,RC,60687023101,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,60687023001,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,60687022801,NDC,,,facility,outpatient,1,EA,18.95000,5.50000,Aetna,Local,,9.62,,,,,,,6.83,15.50,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,60687022601,NDC,,,facility,outpatient,1,EA,17.35000,5.03000,Aetna,Local,,8.81,,,,,,,6.25,14.19,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,60687022401,NDC,,,facility,outpatient,1,EA,16.40000,4.76000,Aetna,Local,,8.33,,,,,,,5.91,13.42,percent of total billed charges,
Entecavir 0.5mg Tab,800046457,CDM,637,RC,60687021625,NDC,,,facility,outpatient,1,EA,157.85000,45.78000,Aetna,Local,,80.14,,,,,,,56.90,129.12,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,60687021501,NDC,,,facility,outpatient,1,EA,15.45000,4.48000,Aetna,Local,,7.84,,,,,,,5.57,12.64,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,60687021401,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,60687020601,NDC,,,facility,outpatient,1,EA,6.85000,1.99000,Aetna,Local,,3.48,,,,,,,2.47,5.60,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,60687019501,NDC,,,facility,outpatient,1,EA,6.85000,1.99000,Aetna,Local,,3.48,,,,,,,2.47,5.60,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,60687019221,NDC,,,facility,outpatient,1,EA,31.65000,9.18000,Aetna,Local,,16.07,,,,,,,11.41,25.89,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,60687018821,NDC,,,facility,outpatient,1,EA,35.00000,10.15000,Aetna,Local,,17.77,,,,,,,12.62,28.63,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,60687017357,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,60687016301,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,60687015501,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,60687015201,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,Local,,2.56,,,,,,,1.82,4.13,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,60687013801,NDC,,,facility,outpatient,1,EA,36.10000,10.47000,Aetna,Local,,18.33,,,,,,,13.01,29.53,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,60687011301,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,60687011221,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,Local,,7.44,,,,,,,5.28,11.98,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,60687010421,NDC,,,facility,outpatient,1,EA,51.80000,15.02000,Aetna,Local,,26.30,,,,,,,18.67,42.37,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,60505708402,NDC,,,facility,outpatient,1,EA,589.00000,170.81000,Aetna,Local,,299.04,,,,,,,212.33,481.80,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,60505708302,NDC,,,facility,outpatient,1,EA,453.15000,131.41000,Aetna,Local,,230.06,,,,,,,163.36,370.68,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,60505708202,NDC,,,facility,outpatient,1,EA,304.60000,88.33000,Aetna,Local,,154.65,,,,,,,109.81,249.16,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505708102,NDC,,,facility,outpatient,1,EA,170.15000,49.34000,Aetna,Local,,86.39,,,,,,,61.34,139.18,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,60505700902,NDC,,,facility,outpatient,1,EA,589.00000,170.81000,Aetna,Local,,299.04,,,,,,,212.33,481.80,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,60505700802,NDC,,,facility,outpatient,1,EA,453.15000,131.41000,Aetna,Local,,230.06,,,,,,,163.36,370.68,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,60505700800,NDC,,,facility,outpatient,1,EA,453.15000,131.41000,Aetna,Local,,230.06,,,,,,,163.36,370.68,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,60505700702,NDC,,,facility,outpatient,1,EA,304.60000,88.33000,Aetna,Local,,154.65,,,,,,,109.81,249.16,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505700602,NDC,,,facility,outpatient,1,EA,170.15000,49.34000,Aetna,Local,,86.39,,,,,,,61.34,139.18,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505700600,NDC,,,facility,outpatient,1,EA,170.15000,49.34000,Aetna,Local,,86.39,,,,,,,61.34,139.18,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,60505700102,NDC,,,facility,outpatient,1,EA,170.15000,49.34000,Aetna,Local,,86.39,,,,,,,61.34,139.18,percent of total billed charges,
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,60505628704,NDC,facility,inpatient,100,ME,867.00000,251.43000,Aetna,Local,,346.80,,,,,,,312.55,709.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,60505628203,NDC,facility,inpatient,50,ME,79.95000,23.19000,Aetna,Local,,31.98,,,,,,,28.82,65.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,60505627700,NDC,facility,inpatient,10,ME,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 2g Inj (Ancef),800046483,CDM,636,RC,J0690,HCPCS,60505623105,NDC,facility,inpatient,2,GM,58.50000,16.96000,Aetna,Local,,23.40,,,,,,,21.09,47.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,60505622601,NDC,,,facility,outpatient,1,EA,377.20000,109.39000,Aetna,Local,,191.50,,,,,,,135.98,308.55,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,60505619604,NDC,facility,inpatient,1,GM,1000.15000,290.04000,Aetna,Local,,400.06,,,,,,,360.55,818.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,60505619301,NDC,facility,inpatient,0.25,ME,731.75000,212.21000,Aetna,Local,,292.70,,,,,,,263.80,598.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,60505616901,NDC,,,facility,outpatient,1,EA,202.00000,58.58000,Aetna,Local,,102.56,,,,,,,72.82,165.24,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,60505615904,NDC,facility,inpatient,4.5,GM,174.00000,50.46000,Aetna,Local,,69.60,,,,,,,62.73,142.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,60505615704,NDC,facility,inpatient,3.375,GM,137.40000,39.85000,Aetna,Local,,54.96,,,,,,,49.53,112.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505615604,NDC,facility,inpatient,2.25,GM,91.60000,26.56000,Aetna,Local,,36.64,,,,,,,33.02,74.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505615600,NDC,facility,inpatient,2.25,GM,94.70000,27.46000,Aetna,Local,,37.88,,,,,,,34.14,77.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,60505614904,NDC,facility,inpatient,2,GM,435.45000,126.28000,Aetna,Local,,174.18,,,,,,,156.98,356.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505614704,NDC,facility,inpatient,2,GM,315.65000,91.54000,Aetna,Local,,126.26,,,,,,,113.79,258.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505614604,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,Local,,65.06,,,,,,,58.64,133.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505614600,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,Local,,65.06,,,,,,,58.64,133.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505614504,NDC,facility,inpatient,2,GM,315.65000,91.54000,Aetna,Local,,126.26,,,,,,,113.79,258.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505614400,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,Local,,65.06,,,,,,,58.64,133.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505614205,NDC,facility,inpatient,1000,ME,20.90000,6.06000,Aetna,Local,,8.36,,,,,,,7.53,17.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,60505613207,NDC,facility,inpatient,100,ME,867.00000,251.43000,Aetna,Local,,346.80,,,,,,,312.55,709.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,60505613005,NDC,facility,inpatient,4,ME,3.85000,1.12000,Aetna,Local,,1.54,,,,,,,1.39,3.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,60505611600,NDC,facility,inpatient,0.4,ME,1187.00000,344.23000,Aetna,Local,,474.80,,,,,,,427.91,970.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,60505611000,NDC,facility,inpatient,4,ME,5990.50000,1737.24000,Aetna,Local,,2396.20,,,,,,,2159.58,4900.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,60505610204,NDC,facility,inpatient,2,GM,435.45000,126.28000,Aetna,Local,,174.18,,,,,,,156.98,356.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,60505609700,NDC,facility,inpatient,3,ME,1867.25000,541.50000,Aetna,Local,,746.90,,,,,,,673.14,1527.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,60505609401,NDC,facility,inpatient,2,GM,209.50000,60.76000,Aetna,Local,,83.80,,,,,,,75.52,171.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505609305,NDC,facility,inpatient,1000,ME,20.90000,6.06000,Aetna,Local,,8.36,,,,,,,7.53,17.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,60505608004,NDC,facility,inpatient,7.5,ME,581.30000,168.58000,Aetna,Local,,232.52,,,,,,,209.56,475.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,60505607804,NDC,facility,inpatient,2.5,ME,277.10000,80.36000,Aetna,Local,,110.84,,,,,,,99.89,226.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505603104,NDC,facility,inpatient,2,GM,315.65000,91.54000,Aetna,Local,,126.26,,,,,,,113.79,258.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,60505477303,NDC,,,facility,outpatient,1,EA,80.30000,23.29000,Aetna,Local,,40.77,,,,,,,28.95,65.69,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,60505470400,NDC,,,facility,outpatient,1,EA,3154.10000,914.69000,Aetna,Local,,1601.34,,,,,,,1137.05,2580.05,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,60505464303,NDC,,,facility,outpatient,1,EA,116.85000,33.89000,Aetna,Local,,59.32,,,,,,,42.12,95.58,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,60505464203,NDC,,,facility,outpatient,1,EA,116.85000,33.89000,Aetna,Local,,59.32,,,,,,,42.12,95.58,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,60505437303,NDC,,,facility,outpatient,1,EA,80.30000,23.29000,Aetna,Local,,40.77,,,,,,,28.95,65.69,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,60505434706,NDC,,,facility,outpatient,1,EA,26.70000,7.74000,Aetna,Local,,13.56,,,,,,,9.63,21.84,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,60505387703,NDC,,,facility,outpatient,1,EA,42.85000,12.43000,Aetna,Local,,21.75,,,,,,,15.45,35.05,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,60505378009,NDC,,,facility,outpatient,1,EA,38.10000,11.05000,Aetna,Local,,19.34,,,,,,,13.74,31.17,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,60505377909,NDC,,,facility,outpatient,1,EA,35.00000,10.15000,Aetna,Local,,17.77,,,,,,,12.62,28.63,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,60505377903,NDC,,,facility,outpatient,1,EA,34.95000,10.14000,Aetna,Local,,17.74,,,,,,,12.60,28.59,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,60505366303,NDC,,,facility,outpatient,1,EA,52.35000,15.18000,Aetna,Local,,26.58,,,,,,,18.87,42.82,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,60505327500,NDC,,,facility,outpatient,1,EA,101.05000,29.30000,Aetna,Local,,51.30,,,,,,,36.43,82.66,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,60505324703,NDC,,,facility,outpatient,1,EA,98.75000,28.64000,Aetna,Local,,50.14,,,,,,,35.60,80.78,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,60505324603,NDC,,,facility,outpatient,1,EA,49.20000,14.27000,Aetna,Local,,24.98,,,,,,,17.74,40.25,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,60505313301,NDC,,,facility,outpatient,1,EA,48.55000,14.08000,Aetna,Local,,24.65,,,,,,,17.50,39.71,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,60505313001,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,Local,,14.37,,,,,,,10.20,23.15,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,60505311003,NDC,,,facility,outpatient,1,EA,79.30000,23.00000,Aetna,Local,,40.26,,,,,,,28.59,64.87,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,60505311000,NDC,,,facility,outpatient,1,EA,79.30000,23.00000,Aetna,Local,,40.26,,,,,,,28.59,64.87,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,60505307503,NDC,,,facility,outpatient,1,EA,226.30000,65.63000,Aetna,Local,,114.89,,,,,,,81.58,185.11,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,60505285001,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,60505280507,NDC,,,facility,outpatient,1,EA,13.90000,4.03000,Aetna,Local,,7.06,,,,,,,5.01,11.37,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,60505268106,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,60505268102,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,60505267403,NDC,,,facility,outpatient,1,EA,226.30000,65.63000,Aetna,Local,,114.89,,,,,,,81.58,185.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,60505267303,NDC,,,facility,outpatient,1,EA,226.30000,65.63000,Aetna,Local,,114.89,,,,,,,81.58,185.11,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,60505266401,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,Local,,17.08,,,,,,,12.13,27.53,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,60505266301,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,Local,,14.95,,,,,,,10.62,24.09,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,60505265605,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,60505265601,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,60505265401,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,Local,,5.00,,,,,,,3.55,8.06,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,60505265301,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,60505260801,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,60505260601,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,60505260500,NDC,,,facility,outpatient,1,EA,37.15000,10.77000,Aetna,Local,,18.86,,,,,,,13.39,30.39,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,60505260400,NDC,,,facility,outpatient,1,EA,37.15000,10.77000,Aetna,Local,,18.86,,,,,,,13.39,30.39,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,60505258605,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,Local,,16.35,,,,,,,11.61,26.34,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,60505258406,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,Local,,14.01,,,,,,,9.95,22.58,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,60505258009,NDC,,,facility,outpatient,1,EA,40.90000,11.86000,Aetna,Local,,20.76,,,,,,,14.74,33.46,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,60505255105,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,60505255101,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,60505254701,NDC,,,facility,outpatient,1,EA,15.55000,4.51000,Aetna,Local,,7.89,,,,,,,5.61,12.72,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,60505252201,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,Local,,6.55,,,,,,,4.65,10.55,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,60505251602,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,60505250201,NDC,,,facility,outpatient,1,EA,116.15000,33.68000,Aetna,Local,,58.97,,,,,,,41.87,95.01,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,60505132101,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,60505100302,NDC,,,facility,outpatient,1,EA,686.30000,199.03000,Aetna,Local,,348.43,,,,,,,247.41,561.39,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,60505084703,NDC,,,facility,outpatient,1,EA,558.40000,161.94000,Aetna,Local,,283.50,,,,,,,201.30,456.77,percent of total billed charges,
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505083404,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,Local,,65.06,,,,,,,58.64,133.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,60505083400,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,Local,,65.06,,,,,,,58.64,133.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,60505083305,NDC,,,facility,outpatient,1,EA,677.25000,196.40000,Aetna,Local,,343.84,,,,,,,244.15,553.99,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,60505082901,NDC,,,facility,outpatient,1,EA,558.40000,161.94000,Aetna,Local,,283.50,,,,,,,201.30,456.77,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,60505082601,NDC,,,facility,outpatient,1,EA,713.10000,206.80000,Aetna,Local,,362.04,,,,,,,257.07,583.32,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,60505082306,NDC,,,facility,outpatient,1,EA,751.45000,217.92000,Aetna,Local,,381.51,,,,,,,270.90,614.69,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,60505081500,NDC,,,facility,outpatient,1,EA,1535.95000,445.43000,Aetna,Local,,779.80,,,,,,,553.71,1256.41,percent of total billed charges,
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,60505079604,NDC,facility,inpatient,120,ME,114.90000,33.32000,Aetna,Local,,45.96,,,,,,,41.42,93.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,60505079504,NDC,facility,inpatient,100,ME,95.75000,27.77000,Aetna,Local,,38.30,,,,,,,34.52,78.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,60505079404,NDC,facility,inpatient,80,ME,76.60000,22.21000,Aetna,Local,,30.64,,,,,,,27.61,62.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,60505079304,NDC,facility,inpatient,60,ME,57.45000,16.66000,Aetna,Local,,22.98,,,,,,,20.71,46.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,60505079204,NDC,facility,inpatient,40,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,60505079200,NDC,facility,inpatient,40,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,60505076900,NDC,facility,inpatient,2,GM,209.50000,60.76000,Aetna,Local,,83.80,,,,,,,75.52,171.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,60505076005,NDC,facility,inpatient,2,GM,180.00000,52.20000,Aetna,Local,,72.00,,,,,,,64.89,147.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,60505075905,NDC,facility,inpatient,1,GM,89.80000,26.04000,Aetna,Local,,35.92,,,,,,,32.37,73.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,60505075304,NDC,facility,inpatient,2,GM,435.45000,126.28000,Aetna,Local,,174.18,,,,,,,156.98,356.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,60505075204,NDC,facility,inpatient,1,GM,357.65000,103.72000,Aetna,Local,,143.06,,,,,,,128.93,292.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505074905,NDC,facility,inpatient,1000,ME,20.90000,6.06000,Aetna,Local,,8.36,,,,,,,7.53,17.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,60505074904,NDC,facility,inpatient,1000,ME,20.90000,6.06000,Aetna,Local,,8.36,,,,,,,7.53,17.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,60505074406,NDC,facility,inpatient,4,ME,192.30000,55.77000,Aetna,Local,,76.92,,,,,,,69.32,157.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,60505068804,NDC,facility,inpatient,4.5,GM,174.00000,50.46000,Aetna,Local,,69.60,,,,,,,62.73,142.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,60505068704,NDC,facility,inpatient,3.375,GM,137.40000,39.85000,Aetna,Local,,54.96,,,,,,,49.53,112.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505068604,NDC,facility,inpatient,2.25,GM,91.60000,26.56000,Aetna,Local,,36.64,,,,,,,33.02,74.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,60505068601,NDC,facility,inpatient,2.25,GM,91.60000,26.56000,Aetna,Local,,36.64,,,,,,,33.02,74.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505068104,NDC,facility,inpatient,2,GM,315.65000,91.54000,Aetna,Local,,126.26,,,,,,,113.79,258.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,60505068100,NDC,facility,inpatient,2,GM,315.70000,91.55000,Aetna,Local,,126.28,,,,,,,113.81,258.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,60505066701,NDC,,,facility,outpatient,1,EA,424.15000,123.00000,Aetna,Local,,215.34,,,,,,,152.91,346.95,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,60505059801,NDC,,,facility,outpatient,1,EA,127.45000,36.96000,Aetna,Local,,64.71,,,,,,,45.95,104.25,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60505059701,NDC,,,facility,outpatient,1,EA,123.70000,35.87000,Aetna,Local,,62.80,,,,,,,44.59,101.19,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,60505058604,NDC,,,facility,outpatient,1,EA,1091.05000,316.40000,Aetna,Local,,553.93,,,,,,,393.32,892.48,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,60505056701,NDC,,,facility,outpatient,1,EA,446.25000,129.41000,Aetna,Local,,226.56,,,,,,,160.87,365.03,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,60505056000,NDC,,,facility,outpatient,1,EA,148.25000,42.99000,Aetna,Local,,75.27,,,,,,,53.44,121.27,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,60505055202,NDC,,,facility,outpatient,1,EA,106.20000,30.80000,Aetna,Local,,53.92,,,,,,,38.29,86.87,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,60505055102,NDC,,,facility,outpatient,1,EA,120.35000,34.90000,Aetna,Local,,61.10,,,,,,,43.39,98.45,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,60505026001,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,60505025701,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,Local,,10.86,,,,,,,7.71,17.51,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,60505025302,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,Local,,25.03,,,,,,,17.77,40.33,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,60505025203,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,Local,,5.25,,,,,,,3.73,8.47,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,60505025103,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,60505023401,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,60505019402,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,60505019000,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,60505018103,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,60505017101,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,60505016909,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,11.75,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,60505016809,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,60505016601,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,Local,,9.49,,,,,,,6.74,15.30,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,60505015900,NDC,,,facility,outpatient,1,EA,24.20000,7.02000,Aetna,Local,,12.29,,,,,,,8.72,19.80,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,60505015801,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,60505015701,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,Local,,3.81,,,,,,,2.70,6.13,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,60505014100,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,60505013201,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,Local,,6.50,,,,,,,4.61,10.47,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,60505013101,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,60505011700,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,60505011500,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,60505011405,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,60505011401,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,60505011301,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,60505011201,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,60505009702,NDC,,,facility,outpatient,1,EA,18.55000,5.38000,Aetna,Local,,9.42,,,,,,,6.69,15.17,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,60505009701,NDC,,,facility,outpatient,1,EA,18.55000,5.38000,Aetna,Local,,9.42,,,,,,,6.69,15.17,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,60505009400,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,60505009300,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,60505008302,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,Local,,9.82,,,,,,,6.98,15.83,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,60505008000,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,Local,,9.21,,,,,,,6.54,14.85,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,60505005207,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,Local,,5.48,,,,,,,3.89,8.83,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,60505005107,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,60505005007,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,60505004907,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,60505004206,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
Etodolac 200 mg C (Lodine),800080985,CDM,637,RC,60505003901,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,Local,,5.15,,,,,,,3.66,8.30,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,60505003408,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,Local,,4.26,,,,,,,3.03,6.87,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,60505003404,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,Local,,4.47,,,,,,,3.17,7.20,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,60505001506,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,60505001406,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,Local,,4.09,,,,,,,2.90,6.58,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,60432060804,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,Local,,2.23,,,,,,,1.59,3.60,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,60432060616,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,60432053760,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Selenium 2.5% 120mL Lotion,800065887,CDM,250,RC,60432052804,NDC,,,facility,outpatient,1,EA,142.55000,41.34000,Aetna,Local,,72.37,,,,,,,51.39,116.61,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,60432046551,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,Local,,3.45,,,,,,,2.45,5.56,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,60432015004,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,800023340,CDM,637,RC,60432013108,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,60432012916,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,60432012608,NDC,,,facility,outpatient,1,EA,42.45000,12.31000,Aetna,Local,,21.55,,,,,,,15.30,34.72,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,60432006575,NDC,,,facility,outpatient,1,EA,30.55000,8.86000,Aetna,Local,,15.51,,,,,,,11.01,24.99,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,800053917,CDM,637,RC,60432006575,NDC,,,facility,outpatient,1,EA,15.30000,4.44000,Aetna,Local,,7.77,,,,,,,5.52,12.52,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,800053917,CDM,637,RC,60432006547,NDC,,,facility,outpatient,1,EA,15.00000,4.35000,Aetna,Local,,7.62,,,,,,,5.41,12.27,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,60432006500,NDC,,,facility,outpatient,1,EA,30.60000,8.87000,Aetna,Local,,15.54,,,,,,,11.03,25.03,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,60432003816,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,Local,,0.20308,,,,,,,0.14420,0.32720,percent of total billed charges,
Sodium Thiosulfate 12.5g/50mL Inj,800017828,CDM,636,RC,J0209,HCPCS,60267070550,NDC,facility,inpatient,12.5,GM,498.75000,144.64000,Aetna,Local,,199.50,,,,,,,179.80,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,60258085001,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,60258080215,NDC,,,facility,outpatient,1,ML,19.80000,5.74000,Aetna,Local,,10.05,,,,,,,7.14,16.20,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,60258016201,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,60219126401,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,Local,,50.97,,,,,,,36.19,82.13,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,59930153202,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,59930150201,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,59923070205,NDC,facility,inpatient,100,ME,247.00000,71.63000,Aetna,Local,,98.80,,,,,,,89.04,202.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,59911589801,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,59911586901,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,Local,,4.49,,,,,,,3.19,7.24,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,59911547101,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,Local,,4.54,,,,,,,3.23,7.32,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,59911547001,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,Local,,3.88,,,,,,,2.76,6.26,percent of total billed charges,
NUTR- Juven 23g/1 packet,800051052,CDM,637,RC,59781066695,NDC,,,facility,outpatient,1,EA,15.20000,4.41000,Aetna,Local,,7.72,,,,,,,5.48,12.43,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,59772246201,NDC,,,facility,outpatient,1,EA,7.30000,2.12000,Aetna,Local,,3.71,,,,,,,2.63,5.97,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,59772002603,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59762503101,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,59762502701,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,800015357,CDM,637,RC,59762502501,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,59762502301,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,59762501101,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,59762500802,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,Local,,4.32,,,,,,,3.06,6.95,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,59762500801,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,Local,,4.32,,,,,,,3.06,6.95,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,59762500701,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,59762500006,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,59762500005,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,59762500001,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,59762491004,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,59762490004,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,Local,,1.02,,,,,,,0.72100,1.64,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,59762453701,NDC,facility,inpatient,150,ME,463.70000,134.47000,Aetna,Local,,185.48,,,,,,,167.16,379.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,59762374001,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,Local,,1.12,,,,,,,0.79310,1.80,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,59762372603,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,59762372001,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,Local,,3.02,,,,,,,2.14,4.87,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,59762371901,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,59762371809,NDC,,,facility,outpatient,1,EA,29.35000,8.51000,Aetna,Local,,14.90,,,,,,,10.58,24.01,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,59762371804,NDC,,,facility,outpatient,1,EA,29.35000,8.51000,Aetna,Local,,14.90,,,,,,,10.58,24.01,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,59762332801,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,Local,,4.29,,,,,,,3.05,6.91,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,59762330403,NDC,,,facility,outpatient,1,EA,183.95000,53.35000,Aetna,Local,,93.39,,,,,,,66.31,150.47,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,59762330401,NDC,,,facility,outpatient,1,EA,83.30000,24.16000,Aetna,Local,,42.29,,,,,,,30.03,68.14,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,59762311001,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,Local,,41.78,,,,,,,29.67,67.32,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,59762306002,NDC,,,facility,outpatient,1,EA,18.05000,5.23000,Aetna,Local,,9.16,,,,,,,6.51,14.76,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,59762200401,NDC,,,facility,outpatient,1,EA,76.15000,22.08000,Aetna,Local,,38.66,,,,,,,27.45,62.29,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,59762200101,NDC,,,facility,outpatient,1,EA,62.75000,18.20000,Aetna,Local,,31.86,,,,,,,22.62,51.33,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,59762181002,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,Local,,9.49,,,,,,,6.74,15.30,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,59762171003,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,Local,,14.98,,,,,,,10.63,24.13,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,59762171002,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,Local,,14.98,,,,,,,10.63,24.13,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,59762171001,NDC,,,facility,outpatient,1,EA,29.00000,8.41000,Aetna,Local,,14.72,,,,,,,10.45,23.72,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,59762153701,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,59762153002,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,Local,,0.88848,,,,,,,0.63087,1.43,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,59762151701,NDC,,,facility,outpatient,1,EA,53.65000,15.56000,Aetna,Local,,27.24,,,,,,,19.34,43.89,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,59762151601,NDC,,,facility,outpatient,1,EA,32.70000,9.48000,Aetna,Local,,16.60,,,,,,,11.79,26.75,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,59762141503,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,Local,,9.47,,,,,,,6.72,15.26,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,59762130701,NDC,,,facility,outpatient,1,EA,1114.90000,323.32000,Aetna,Local,,566.03,,,,,,,401.92,911.99,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,59762108102,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,59762106101,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59762054001,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,59762045001,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,Local,,4.54,,,,,,,3.23,7.32,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,59762033302,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,Local,,10.79,,,,,,,7.66,17.38,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,59762033301,NDC,,,facility,outpatient,1,EA,619.30000,179.60000,Aetna,Local,,314.42,,,,,,,223.26,506.59,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,59762026002,NDC,,,facility,outpatient,1,EA,27.80000,8.06000,Aetna,Local,,14.11,,,,,,,10.02,22.74,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,59762026001,NDC,,,facility,outpatient,1,EA,27.85000,8.08000,Aetna,Local,,14.14,,,,,,,10.04,22.78,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,59762024504,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,Local,,1.88,,,,,,,1.33,3.03,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,59762024502,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,Local,,1.88,,,,,,,1.33,3.03,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,59762018202,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,12.98,29.45,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,59762015701,NDC,,,facility,outpatient,1,EA,38.95000,11.30000,Aetna,Local,,19.77,,,,,,,14.04,31.86,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,59762015601,NDC,,,facility,outpatient,1,EA,38.90000,11.28000,Aetna,Local,,19.75,,,,,,,14.02,31.82,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,59762011901,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,59762011701,NDC,,,facility,outpatient,1,EA,29.65000,8.60000,Aetna,Local,,15.05,,,,,,,10.69,24.25,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,59762007401,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,Local,,2.06,,,,,,,1.46,3.31,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,59762007301,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,59746038506,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,59746038306,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,59746032430,NDC,,,facility,outpatient,1,EA,51.15000,14.83000,Aetna,Local,,25.97,,,,,,,18.44,41.84,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,59746024601,NDC,,,facility,outpatient,1,EA,33.55000,9.73000,Aetna,Local,,17.03,,,,,,,12.09,27.44,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,59746024501,NDC,,,facility,outpatient,1,EA,29.35000,8.51000,Aetna,Local,,14.90,,,,,,,10.58,24.01,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,59746017706,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,Local,,4.16,,,,,,,2.96,6.71,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,59746000103,NDC,facility,inpatient,4,ME,11.70000,3.39000,Aetna,Local,,4.68,,,,,,,4.22,9.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
darun/cobic/emtric/tenof 800-150-200-10mg T,800046459,CDM,637,RC,59676080030,NDC,,,facility,outpatient,1,EA,1142.80000,331.41000,Aetna,Local,,580.20,,,,,,,411.98,934.81,percent of total billed charges,
"Epoetin 40,000 unit/mL I",800010965,CDM,636,RC,J0885,HCPCS,59676034001,NDC,facility,inpatient,40000,UN,4448.90000,1290.18000,Aetna,Local,,1779.56,,,,,,,1603.83,3639.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 10,000 unit Inj",800010933,CDM,636,RC,J0885,HCPCS,59676031002,NDC,facility,inpatient,10000,UN,1254.70000,363.86000,Aetna,Local,,501.88,,,,,,,452.32,1026.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 10,000 unit Inj",800010933,CDM,636,RC,J0885,HCPCS,59676031001,NDC,facility,inpatient,10000,UN,1254.70000,363.86000,Aetna,Local,,501.88,,,,,,,452.32,1026.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,59676030402,NDC,facility,inpatient,4000,UN,388.40000,112.64000,Aetna,Local,,155.36,,,,,,,140.02,317.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,59676030401,NDC,facility,inpatient,4000,UN,580.05000,168.21000,Aetna,Local,,232.02,,,,,,,209.11,474.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 3,000 unit/mL Inj",800013635,CDM,636,RC,J0885,HCPCS,59676030301,NDC,facility,inpatient,3000,UN,456.65000,132.43000,Aetna,Local,,182.66,,,,,,,164.62,373.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cladribine 10mg/10mL I(Leustatin),800022003,CDM,636,RC,J9065,HCPCS,59676020101,NDC,facility,inpatient,10,ME,6474.30000,1877.55000,Aetna,Local,,2589.72,,,,,,,2333.99,5295.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59651078030,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
clonazePAM 2mg T(KlonoPIN),800051122,CDM,637,RC,59651072401,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,Local,,4.80,,,,,,,3.41,7.73,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,59651072201,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,59651053901,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,Local,,12.06,,,,,,,8.56,19.43,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,59651045360,NDC,,,facility,outpatient,1,EA,20.70000,6.00000,Aetna,Local,,10.51,,,,,,,7.46,16.93,percent of total billed charges,
Zonisamide 25mg Cap,800040873,CDM,637,RC,59651037801,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,59651033101,NDC,,,facility,outpatient,1,EA,539.00000,156.31000,Aetna,Local,,273.65,,,,,,,194.31,440.90,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,59651030601,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,Local,,3.88,,,,,,,2.76,6.26,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,59651026830,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,59651025701,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,Local,,8.38,,,,,,,5.95,13.50,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,59651025601,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,59651021430,NDC,,,facility,outpatient,1,EA,677.25000,196.40000,Aetna,Local,,343.84,,,,,,,244.15,553.99,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,59651015201,NDC,,,facility,outpatient,1,EA,14.85000,4.31000,Aetna,Local,,7.54,,,,,,,5.35,12.15,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,59651012060,NDC,,,facility,outpatient,1,EA,60.65000,17.59000,Aetna,Local,,30.79,,,,,,,21.86,49.61,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,59651002601,NDC,,,facility,outpatient,1,EA,30.60000,8.87000,Aetna,Local,,15.54,,,,,,,11.03,25.03,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,59630030065,NDC,,,facility,outpatient,1,EA,1442.40000,418.30000,Aetna,Local,,732.31,,,,,,,519.99,1179.88,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,59630020010,NDC,,,facility,outpatient,1,EA,50.15000,14.54000,Aetna,Local,,25.46,,,,,,,18.08,41.02,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,59572010201,NDC,facility,inpatient,100,ME,3085.05000,894.66000,Aetna,Local,,1234.02,,,,,,,1112.16,2523.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,59390002317,NDC,,,facility,outpatient,1,EA,19.55000,5.67000,Aetna,Local,,9.93,,,,,,,7.05,15.99,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,59366281703,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,59366280702,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,59366269206,NDC,,,facility,outpatient,1,EA,48.35000,14.02000,Aetna,Local,,24.55,,,,,,,17.43,39.55,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,59310057922,NDC,,,facility,outpatient,1,EA,461.55000,133.85000,Aetna,Local,,234.33,,,,,,,166.39,377.55,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,59310057920,NDC,,,facility,outpatient,1,EA,205.45000,59.58000,Aetna,Local,,104.31,,,,,,,74.06,168.06,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,59148002050,NDC,,,facility,outpatient,1,EA,3456.10000,1002.27000,Aetna,Local,,1754.66,,,,,,,1245.92,2827.09,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,59148000813,NDC,,,facility,outpatient,1,EA,165.35000,47.95000,Aetna,Local,,83.95,,,,,,,59.61,135.26,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,59148000735,NDC,,,facility,outpatient,1,EA,249.75000,72.43000,Aetna,Local,,126.80,,,,,,,90.03,204.30,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,59148000713,NDC,,,facility,outpatient,1,EA,165.35000,47.95000,Aetna,Local,,83.95,,,,,,,59.61,135.26,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,59148000613,NDC,,,facility,outpatient,1,EA,165.35000,47.95000,Aetna,Local,,83.95,,,,,,,59.61,135.26,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,59148000216,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
aminolevulinic acid 50mL REC Pwd Oral Soln,800046391,CDM,250,RC,59137023101,NDC,,,facility,outpatient,1,EA,19767.80000,5732.66000,Aetna,Local,,10036.11,,,,,,,7126.29,16170.06,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,59075069010,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,59075068010,NDC,,,facility,outpatient,1,EA,17.25000,5.00000,Aetna,Local,,8.76,,,,,,,6.22,14.11,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,59075059415,NDC,,,facility,outpatient,1,EA,11.55000,3.35000,Aetna,Local,,5.86,,,,,,,4.16,9.45,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,59075059215,NDC,,,facility,outpatient,1,EA,9.60000,2.78000,Aetna,Local,,4.87,,,,,,,3.46,7.85,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),800081290,CDM,637,RC,59011081510,NDC,,,facility,outpatient,1,EA,25.75000,7.47000,Aetna,Local,,13.07,,,,,,,9.28,21.06,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,59011045401,NDC,,,facility,outpatient,1,EA,25.85000,7.50000,Aetna,Local,,13.12,,,,,,,9.32,21.15,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,59011045210,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,Local,,8.83,,,,,,,6.27,14.23,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,59011045201,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,6.13,13.91,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,59011044225,NDC,facility,inpatient,2,ME,13.75000,3.99000,Aetna,Local,,5.50,,,,,,,4.96,11.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,59011044210,NDC,facility,inpatient,2,ME,14.45000,4.19000,Aetna,Local,,5.78,,,,,,,5.21,11.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011042020,NDC,,,facility,outpatient,1,EA,104.05000,30.17000,Aetna,Local,,52.83,,,,,,,37.51,85.11,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011042010,NDC,,,facility,outpatient,1,EA,101.45000,29.42000,Aetna,Local,,51.51,,,,,,,36.57,82.99,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),800081290,CDM,637,RC,59011041520,NDC,,,facility,outpatient,1,EA,82.15000,23.82000,Aetna,Local,,41.71,,,,,,,29.62,67.20,percent of total billed charges,
oxyCODONE 15mg/12hr ER T(OxyCONTIN),800081290,CDM,637,RC,59011041510,NDC,,,facility,outpatient,1,EA,80.05000,23.21000,Aetna,Local,,40.64,,,,,,,28.86,65.48,percent of total billed charges,
oxyCODONE 10mg/12hr ER T(OxyCONTIN),800073865,CDM,637,RC,59011041020,NDC,,,facility,outpatient,1,EA,55.85000,16.20000,Aetna,Local,,28.36,,,,,,,20.13,45.69,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011010325,NDC,,,facility,outpatient,1,EA,27.15000,7.87000,Aetna,Local,,13.78,,,,,,,9.79,22.21,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,59011010320,NDC,,,facility,outpatient,1,EA,33.75000,9.79000,Aetna,Local,,17.13,,,,,,,12.17,27.61,percent of total billed charges,
oxyCODONE 10mg/12hr ER T(OxyCONTIN),800073865,CDM,637,RC,59011010025,NDC,,,facility,outpatient,1,EA,14.20000,4.12000,Aetna,Local,,7.21,,,,,,,5.12,11.62,percent of total billed charges,
oxyCODONE 10mg/12hr ER T(OxyCONTIN),800073865,CDM,637,RC,59011010020,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,Local,,8.96,,,,,,,6.36,14.44,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,58980082405,NDC,,,facility,outpatient,1,EA,116.90000,33.90000,Aetna,Local,,59.35,,,,,,,42.14,95.62,percent of total billed charges,
Mesalamine 1000mg Supp (Canasa),800017778,CDM,637,RC,58914050156,NDC,,,facility,outpatient,1,EA,320.80000,93.03000,Aetna,Local,,162.87,,,,,,,115.65,262.41,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,58914017110,NDC,,,facility,outpatient,1,EA,42.15000,12.22000,Aetna,Local,,21.40,,,,,,,15.20,34.48,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,58914008052,NDC,facility,inpatient,20,ME,475.30000,137.84000,Aetna,Local,,190.12,,,,,,,171.35,388.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,58887001976,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,Local,,0.96463,,,,,,,0.68495,1.55,percent of total billed charges,
prednisoLONE 0.12% 5mL Ophth Susp(Pred Mild),800043967,CDM,637,RC,58768087505,NDC,,,facility,outpatient,1,EA,1050.05000,304.51000,Aetna,Local,,533.11,,,,,,,378.54,858.94,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,58657070101,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,58657070001,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,58657062301,NDC,,,facility,outpatient,1,EA,17.85000,5.18000,Aetna,Local,,9.06,,,,,,,6.43,14.60,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,58657061230,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,Local,,11.07,,,,,,,7.86,17.83,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,58602000739,NDC,,,facility,outpatient,1,EA,74.75000,21.68000,Aetna,Local,,37.95,,,,,,,26.95,61.15,percent of total billed charges,
Methotrexate Na 250mg/10mL I PF,800022021,CDM,636,RC,J9260,HCPCS,58406068316,NDC,facility,inpatient,250,ME,133.10000,38.60000,Aetna,Local,,53.24,,,,,,,47.98,108.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,58406068315,NDC,facility,inpatient,50,ME,30.90000,8.96000,Aetna,Local,,12.36,,,,,,,11.14,25.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,58281056301,NDC,facility,inpatient,40,ME,3955.45000,1147.08000,Aetna,Local,,1582.18,,,,,,,1425.94,3235.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,58281056104,NDC,facility,inpatient,40,ME,3357.30000,973.62000,Aetna,Local,,1342.92,,,,,,,1210.31,2746.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,58177062511,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,58177062111,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,58177062011,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,58177036904,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,58177036804,NDC,,,facility,outpatient,1,EA,9.60000,2.78000,Aetna,Local,,4.87,,,,,,,3.46,7.85,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,58177033104,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,58177032418,NDC,,,facility,outpatient,1,EA,32.30000,9.37000,Aetna,Local,,16.40,,,,,,,11.64,26.42,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,58177031304,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,58177030104,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,Local,,3.35,,,,,,,2.38,5.40,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,58177029304,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,58177026704,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,58177026404,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,58177025504,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,Local,,1.04,,,,,,,0.73903,1.68,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,58177023704,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,58177022204,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,Local,,4.65,,,,,,,3.30,7.48,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,58177020508,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,58177009104,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,58177003106,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,58177003104,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,58160096412,NDC,facility,inpatient,1,EA,1700.10000,493.03000,Aetna,Local,,680.04,,,,,,,612.89,1390.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,58160096412,NDC,facility,outpatient,1,EA,1700.10000,493.03000,Aetna,Local,,680.04,,,,,,,307.92,1390.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Influenza Virus Vaccine, Inact Trivalent Inj",800051083,CDM,636,RC,90656,HCPCS,58160088452,NDC,facility,inpatient,1,EA,125.15000,36.29000,Aetna,Local,,50.06,,,,,,,45.12,102.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Influenza Virus Vaccine, Inact Trivalent Inj",800051083,CDM,636,RC,90656,HCPCS,58160088452,NDC,facility,outpatient,1,EA,125.15000,36.29000,Aetna,Local,,50.06,,,,,,,14.13,102.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160085901,NDC,facility,inpatient,0.01,ME,139.70000,40.51000,Aetna,Local,,55.88,,,,,,,50.36,114.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160085901,NDC,facility,outpatient,0.01,ME,139.70000,40.51000,Aetna,Local,,55.88,,,,,,,21.65,114.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,800082171,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,inpatient,1,EA,293.70000,85.17000,Aetna,Local,,117.48,,,,,,,105.88,240.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,800082171,CDM,636,RC,90715,HCPCS,58160084252,NDC,facility,outpatient,1,EA,293.70000,85.17000,Aetna,Local,,117.48,,,,,,,38.22,240.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,800082171,CDM,636,RC,90715,HCPCS,58160084211,NDC,facility,inpatient,1,EA,293.70000,85.17000,Aetna,Local,,117.48,,,,,,,105.88,240.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus/Diphth/Pertu (Tdap)Adult/Adol 0.5 mL I,800082171,CDM,636,RC,90715,HCPCS,58160084211,NDC,facility,outpatient,1,EA,293.70000,85.17000,Aetna,Local,,117.48,,,,,,,38.22,240.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160084046,NDC,facility,inpatient,1,EA,140.50000,40.74000,Aetna,Local,,56.20,,,,,,,50.65,114.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160084046,NDC,facility,outpatient,1,EA,140.50000,40.74000,Aetna,Local,,56.20,,,,,,,32.84,114.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160084011,NDC,facility,inpatient,1,EA,124.45000,36.09000,Aetna,Local,,49.78,,,,,,,44.86,101.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160084011,NDC,facility,outpatient,1,EA,124.45000,36.09000,Aetna,Local,,49.78,,,,,,,32.84,105.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160082052,NDC,facility,inpatient,0.01,ME,183.20000,53.13000,Aetna,Local,,73.28,,,,,,,66.04,149.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160082052,NDC,facility,outpatient,0.01,ME,183.20000,53.13000,Aetna,Local,,73.28,,,,,,,21.65,149.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160082011,NDC,facility,inpatient,0.01,ME,129.25000,37.48000,Aetna,Local,,51.70,,,,,,,46.59,105.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hepatitis B Vac 10mcg/.5mL I Ped.,800069384,CDM,636,RC,90744,HCPCS,58160082011,NDC,facility,outpatient,0.01,ME,129.25000,37.48000,Aetna,Local,,51.70,,,,,,,21.65,105.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,58160081811,NDC,facility,inpatient,1,EA,84.05000,24.37000,Aetna,Local,,33.62,,,,,,,30.30,68.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,58160081811,NDC,facility,outpatient,1,EA,84.05000,24.37000,Aetna,Local,,33.62,,,,,,,14.65,68.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160081052,NDC,facility,inpatient,1,EA,185.15000,53.69000,Aetna,Local,,74.06,,,,,,,66.75,151.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160081052,NDC,facility,outpatient,1,EA,185.15000,53.69000,Aetna,Local,,74.06,,,,,,,32.84,151.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160081046,NDC,facility,inpatient,1,EA,144.70000,41.96000,Aetna,Local,,57.88,,,,,,,52.16,118.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diphth-Tet-Pertus (DTaP) 0.5 mL (Pediatric),800081038,CDM,636,RC,90700,HCPCS,58160081046,NDC,facility,outpatient,1,EA,144.70000,41.96000,Aetna,Local,,57.88,,,,,,,32.84,118.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,58160072615,NDC,facility,inpatient,1,EA,84.05000,24.37000,Aetna,Local,,33.62,,,,,,,30.30,68.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,58160072615,NDC,facility,outpatient,1,EA,84.05000,24.37000,Aetna,Local,,33.62,,,,,,,14.65,68.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenytoin Na 30mg Sr C(Dilantin),800071703,CDM,637,RC,58151011801,NDC,,,facility,outpatient,1,EA,12.70000,3.68000,Aetna,Local,,6.45,,,,,,,4.58,10.39,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,58063079725,NDC,facility,inpatient,0.25,ME,1552.55000,450.24000,Aetna,Local,,621.02,,,,,,,559.69,1269.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,58063070510,NDC,,,facility,outpatient,1,EA,14.25000,4.13000,Aetna,Local,,7.23,,,,,,,5.14,11.66,percent of total billed charges,
Dalbavancin 500mg I (Dalvance),800022094,CDM,636,RC,J0875,HCPCS,57970010001,NDC,facility,inpatient,500,ME,12996.75000,3769.06000,Aetna,Local,,5198.70,,,,,,,4685.33,10631.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,57896048914,NDC,,,facility,outpatient,1,EA,50.55000,14.66000,Aetna,Local,,25.66,,,,,,,18.22,41.35,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,57896014001,NDC,,,facility,outpatient,1,EA,84.80000,24.59000,Aetna,Local,,43.05,,,,,,,30.57,69.37,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,57896011603,NDC,,,facility,outpatient,1,EA,35.90000,10.41000,Aetna,Local,,18.23,,,,,,,12.94,29.37,percent of total billed charges,
guselkumab 200mg I - Pt Own Supply,800051995,CDM,636,RC,J1628,HCPCS,57894065002,NDC,facility,inpatient,200,ME,0.20000,0.06000,Aetna,Local,,0.08000,,,,,,,0.07210,0.16360,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
daratumumab-hyaluronidase fihj Inj - Pt Own Supply,800051023,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,inpatient,1800,ME,0.15000,0.04000,Aetna,Local,,0.06000,,,,,,,0.05407,0.12270,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"daratumumab-hyaluronidase fihj 1800 mg-30,000 units/15 mL I",800051124,CDM,636,RC,J9144,HCPCS,57894050301,NDC,facility,inpatient,1800,ME,54309.20000,15749.67000,Aetna,Local,,21723.68,,,,,,,19578.47,44424.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
golimumab 50mg/4mL Inj,800046557,CDM,636,RC,J1602,HCPCS,57894035001,NDC,facility,inpatient,50,ME,14581.20000,4228.55000,Aetna,Local,,5832.48,,,,,,,5256.52,11927.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab 100mg/10mL I,800010935,CDM,636,RC,J1745,HCPCS,57894016001,NDC,facility,inpatient,100,ME,3607.00000,1046.03000,Aetna,Local,,1442.80,,,,,,,1300.32,2950.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab 100mg/10mL I,800010935,CDM,636,RC,J1745,HCPCS,57894003001,NDC,facility,inpatient,100,ME,8595.30000,2492.64000,Aetna,Local,,3438.12,,,,,,,3098.61,7030.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,57844069298,NDC,,,facility,outpatient,1,EA,35.45000,10.28000,Aetna,Local,,18.00,,,,,,,12.78,29.00,percent of total billed charges,
naloxegol 25mg Tab UD,800046420,CDM,637,RC,57841130103,NDC,,,facility,outpatient,1,EA,112.10000,32.51000,Aetna,Local,,56.91,,,,,,,40.41,91.70,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,57782039726,NDC,,,facility,outpatient,1,EA,91.35000,26.49000,Aetna,Local,,46.38,,,,,,,32.93,74.72,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,57664068788,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,Local,,0.66001,,,,,,,0.46865,1.06,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,57664068357,NDC,facility,inpatient,600,ME,584.90000,169.62000,Aetna,Local,,233.96,,,,,,,210.86,478.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,57664064888,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,57664056999,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,57664051288,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,Local,,11.37,,,,,,,8.08,18.32,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,57664051083,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,Local,,9.47,,,,,,,6.72,15.26,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,57664050658,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,Local,,0.96463,,,,,,,0.68495,1.55,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,57664050652,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,Local,,0.96463,,,,,,,0.68495,1.55,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,57664050608,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,Local,,0.96463,,,,,,,0.68495,1.55,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,57664050389,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,Local,,5.25,,,,,,,3.73,8.47,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,57664050289,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,57664049983,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,Local,,9.75,,,,,,,6.92,15.71,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,57664047752,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,57664043788,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,57664039751,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,57664039388,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,Local,,7.18,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,57664039288,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,57664037713,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,57664037708,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,3.40,,,,,,,2.42,5.48,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,57664034288,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,57664029288,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,Local,,3.93,,,,,,,2.79,6.34,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,57664024788,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,Local,,7.59,,,,,,,5.39,12.23,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,57664024588,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,Local,,7.59,,,,,,,5.39,12.23,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,57664024488,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,Local,,7.59,,,,,,,5.39,12.23,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,57664017688,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,57664016708,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,57664016618,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,57664015213,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,Local,,0.15231,,,,,,,0.10815,0.24540,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,57664012688,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,57664001472,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,57317023210,NDC,facility,inpatient,6,ME,394.70000,114.46000,Aetna,Local,,157.88,,,,,,,142.29,322.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,57237023201,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,Local,,2.39,,,,,,,1.69,3.84,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,57237018290,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,Local,,10.61,,,,,,,7.53,17.10,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,57237018090,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,Local,,10.61,,,,,,,7.53,17.10,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,57237017301,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,Local,,7.18,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,57237017201,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,57237017130,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,Local,,32.16,,,,,,,22.84,51.82,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,57237011490,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,57237009960,NDC,,,facility,outpatient,1,EA,36.20000,10.50000,Aetna,Local,,18.38,,,,,,,13.05,29.61,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,57237004801,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,57237004701,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,Local,,6.27,,,,,,,4.45,10.10,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,57237001930,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,Local,,28.23,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,57237001890,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,Local,,28.23,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,57237001830,NDC,,,facility,outpatient,1,EA,55.60000,16.12000,Aetna,Local,,28.23,,,,,,,20.04,45.48,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,57237001760,NDC,,,facility,outpatient,1,EA,49.55000,14.37000,Aetna,Local,,25.16,,,,,,,17.86,40.53,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,57237001405,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,57237001401,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,57237000830,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,Local,,9.70,,,,,,,6.89,15.62,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,57237000430,NDC,,,facility,outpatient,1,EA,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,22.35,50.72,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,55953073440,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,55953071670,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,55953071640,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,55953034340,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,55953021470,NDC,,,facility,outpatient,1,EA,19.45000,5.64000,Aetna,Local,,9.87,,,,,,,7.01,15.91,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,55953021440,NDC,,,facility,outpatient,1,EA,19.65000,5.70000,Aetna,Local,,9.98,,,,,,,7.08,16.07,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,55953011470,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,55953011440,NDC,,,facility,outpatient,1,EA,8.90000,2.58000,Aetna,Local,,4.52,,,,,,,3.21,7.28,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,55953008440,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Citric Acid/MgOx/Na pico Oral Soln,800040895,CDM,250,RC,55566680001,NDC,,,facility,outpatient,1,EA,1395.45000,404.68000,Aetna,Local,,708.47,,,,,,,503.06,1141.48,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,55566504001,NDC,facility,inpatient,0.04,ME,3557.55000,1031.69000,Aetna,Local,,1423.02,,,,,,,1282.50,2910.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dinoprostone 10mg VS(Cervidil),800073303,CDM,252,RC,55566280001,NDC,,,facility,inpatient,1,EA,3638.90000,1055.28000,Aetna,Local,,1455.56,,,,,,,1346.39,2976.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dinoprostone 10mg VS(Cervidil),800073303,CDM,252,RC,55566280001,NDC,,,facility,outpatient,1,EA,3638.90000,1055.28000,Aetna,Local,,1847.47,,,,,,,1311.82,2976.62,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,55566250000,NDC,,,facility,outpatient,1,EA,3185.80000,923.88000,Aetna,Local,,1617.43,,,,,,,1148.48,2605.98,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,55566210002,NDC,,,facility,outpatient,1,EA,41.05000,11.90000,Aetna,Local,,20.84,,,,,,,14.80,33.58,percent of total billed charges,
Romosozumab-aqqg 105mg Inj Syr (Evenity),800062094,CDM,636,RC,J3111,HCPCS,55513099802,NDC,facility,inpatient,105,ME,5426.80000,1573.77000,Aetna,Local,,2170.72,,,,,,,1956.36,4439.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Panitumumab 400mg/20mL I(Vectibix),800051978,CDM,636,RC,J9303,HCPCS,55513095601,NDC,facility,inpatient,400,ME,39318.65000,11402.41000,Aetna,Local,,15727.46,,,,,,,14174.37,32162.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Panitumumab 100mg/5mL I(Vectibix),800022004,CDM,636,RC,J9303,HCPCS,55513095401,NDC,facility,inpatient,100,ME,9969.90000,2891.27000,Aetna,Local,,3987.96,,,,,,,3594.15,8155.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Romosozumab-aqqg 105mg Inj Syr (Evenity),800062094,CDM,636,RC,J3111,HCPCS,55513088002,NDC,facility,inpatient,105,ME,5426.80000,1573.77000,Aetna,Local,,2170.72,,,,,,,1956.36,4439.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ivabradine 5mg Tab,800025653,CDM,637,RC,55513080060,NDC,,,facility,outpatient,1,EA,88.65000,25.71000,Aetna,Local,,45.01,,,,,,,31.96,72.52,percent of total billed charges,
Denosumab 120mg/1.7mL I (Xgeva),800022092,CDM,636,RC,J0897,HCPCS,55513073001,NDC,facility,inpatient,120,ME,13933.75000,4040.79000,Aetna,Local,,5573.50,,,,,,,5023.12,11397.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Denosumab 60mg/1mL IS(Prolia),800020909,CDM,636,RC,J0897,HCPCS,55513071001,NDC,facility,inpatient,60,ME,7661.70000,2221.89000,Aetna,Local,,3064.68,,,,,,,2762.04,6267.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab - axxq 100mg Inj,800046538,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,inpatient,100,ME,3787.00000,1098.23000,Aetna,Local,,1514.80,,,,,,,1365.21,3097.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
inFLIXimab - axxq 100mg Inj,800046538,CDM,636,RC,Q5121,HCPCS,55513067001,NDC,facility,outpatient,100,ME,3787.00000,1098.23000,Aetna,Local,,1514.80,,,,,,,22.93,3097.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 3,000 unit/mL Inj",800013635,CDM,636,RC,J0885,HCPCS,55513026710,NDC,facility,inpatient,3000,UN,298.85000,86.67000,Aetna,Local,,119.54,,,,,,,107.74,244.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 3,000 unit/mL Inj",800013635,CDM,636,RC,J0885,HCPCS,55513026701,NDC,facility,inpatient,3000,UN,220.25000,63.87000,Aetna,Local,,88.10,,,,,,,79.40,180.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
romiPLOStim 125mcg Inj,800046482,CDM,636,RC,J2802,HCPCS,55513022301,NDC,facility,inpatient,0.125,ME,5674.10000,1645.49000,Aetna,Local,,2269.64,,,,,,,2045.51,4641.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
romiPLOStim 250mcg Inj,800012181,CDM,636,RC,J2802,HCPCS,55513022101,NDC,facility,inpatient,0.25,ME,11158.05000,3235.83000,Aetna,Local,,4463.22,,,,,,,4022.48,9127.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim 6mg/0.6mL Inj,800079110,CDM,636,RC,J2506,HCPCS,55513019001,NDC,facility,inpatient,6,ME,42805.45000,12413.58000,Aetna,Local,,17122.18,,,,,,,15431.36,35014.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,55513014810,NDC,facility,inpatient,4000,UN,384.80000,111.59000,Aetna,Local,,153.92,,,,,,,138.72,314.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 4,000 unit/mL I",800010893,CDM,636,RC,J0885,HCPCS,55513014801,NDC,facility,inpatient,4000,UN,289.90000,84.07000,Aetna,Local,,115.96,,,,,,,104.51,237.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin 10,000 unit Inj",800010933,CDM,636,RC,J0885,HCPCS,55513014410,NDC,facility,inpatient,10000,UN,850.05000,246.51000,Aetna,Local,,340.02,,,,,,,306.44,695.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tezepelumab-ekko 210mg Inj (Tezspire),800046454,CDM,636,RC,J2356,HCPCS,55513011201,NDC,facility,inpatient,210,ME,17595.95000,5102.83000,Aetna,Local,,7038.38,,,,,,,6343.34,14393.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,55513007330,NDC,,,facility,outpatient,1,EA,227.30000,65.92000,Aetna,Local,,115.40,,,,,,,81.94,185.93,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,55390076210,NDC,,,facility,outpatient,1,EA,70.55000,20.46000,Aetna,Local,,35.82,,,,,,,25.43,57.71,percent of total billed charges,
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,55390050010,NDC,facility,inpatient,0.25,ME,4.80000,1.39000,Aetna,Local,,1.92,,,,,,,1.73,3.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,55390050005,NDC,facility,inpatient,1,ME,11.15000,3.23000,Aetna,Local,,4.46,,,,,,,4.02,9.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,55390048101,NDC,facility,inpatient,30,ME,9.60000,2.78000,Aetna,Local,,3.84,,,,,,,3.46,7.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,55390047510,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,55390046001,NDC,facility,inpatient,500,ME,341.50000,99.04000,Aetna,Local,,136.60,,,,,,,123.11,279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,55390040420,NDC,facility,inpatient,600,ME,92.55000,26.84000,Aetna,Local,,37.02,,,,,,,33.36,75.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,55390035803,NDC,,,facility,outpatient,1,EA,169.90000,49.27000,Aetna,Local,,86.26,,,,,,,61.25,138.98,percent of total billed charges,
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,55390031110,NDC,facility,inpatient,1,GM,21.10000,6.12000,Aetna,Local,,8.44,,,,,,,7.61,17.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,55390025901,NDC,facility,inpatient,1,GM,256.75000,74.46000,Aetna,Local,,102.70,,,,,,,92.56,210.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,55390025801,NDC,facility,inpatient,500,ME,932.00000,270.28000,Aetna,Local,,372.80,,,,,,,335.99,762.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,55390025201,NDC,facility,inpatient,20,ME,933.00000,270.57000,Aetna,Local,,373.20,,,,,,,336.35,763.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,55390023701,NDC,facility,inpatient,50,ME,404.30000,117.25000,Aetna,Local,,161.72,,,,,,,145.75,330.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,55390023510,NDC,facility,inpatient,10,ME,85.80000,24.88000,Aetna,Local,,34.32,,,,,,,30.93,70.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,55390022801,NDC,facility,inpatient,400,ME,117.30000,34.02000,Aetna,Local,,46.92,,,,,,,42.29,95.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,55390022701,NDC,facility,inpatient,200,ME,102.00000,29.58000,Aetna,Local,,40.80,,,,,,,36.77,83.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,55390021901,NDC,facility,inpatient,1,GM,256.75000,74.46000,Aetna,Local,,102.70,,,,,,,92.56,210.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,55390021801,NDC,facility,inpatient,500,ME,130.00000,37.70000,Aetna,Local,,52.00,,,,,,,46.87,106.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,55390018401,NDC,facility,inpatient,2,ME,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,55390017610,NDC,facility,inpatient,500,ME,177.60000,51.50000,Aetna,Local,,71.04,,,,,,,64.02,145.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,55390017510,NDC,facility,inpatient,100,ME,29.95000,8.69000,Aetna,Local,,11.98,,,,,,,10.80,24.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,55390016810,NDC,facility,inpatient,2,ME,10.25000,2.97000,Aetna,Local,,4.10,,,,,,,3.70,8.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,55390014710,NDC,facility,inpatient,5,ME,14.35000,4.16000,Aetna,Local,,5.74,,,,,,,5.17,11.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,55390013801,NDC,facility,inpatient,5,ME,14.40000,4.18000,Aetna,Local,,5.76,,,,,,,5.19,11.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,55390013705,NDC,facility,inpatient,5,ME,14.40000,4.18000,Aetna,Local,,5.76,,,,,,,5.19,11.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,55390013702,NDC,facility,inpatient,2,ME,9.60000,2.78000,Aetna,Local,,3.84,,,,,,,3.46,7.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cladribine 10mg/10mL I(Leustatin),800022003,CDM,636,RC,J9065,HCPCS,55390012401,NDC,facility,inpatient,10,ME,3074.20000,891.52000,Aetna,Local,,1229.68,,,,,,,1108.25,2514.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,55390012110,NDC,facility,inpatient,4,ME,9.60000,2.78000,Aetna,Local,,3.84,,,,,,,3.46,7.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,55390010499,NDC,facility,inpatient,1,GM,106.25000,30.81000,Aetna,Local,,42.50,,,,,,,38.30,86.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,55390010450,NDC,facility,inpatient,0.5,GM,280.70000,81.40000,Aetna,Local,,112.28,,,,,,,101.19,229.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,55390010420,NDC,facility,inpatient,200,ME,70.70000,20.50000,Aetna,Local,,28.28,,,,,,,25.49,57.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,55390010110,NDC,facility,inpatient,1,ME,25.55000,7.41000,Aetna,Local,,10.22,,,,,,,9.21,20.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,55390009210,NDC,,,facility,outpatient,1,EA,47.90000,13.89000,Aetna,Local,,24.32,,,,,,,17.27,39.18,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,55390007710,NDC,facility,inpatient,10,ME,29.35000,8.51000,Aetna,Local,,11.74,,,,,,,10.58,24.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,55390007310,NDC,,,facility,outpatient,1,EA,12.75000,3.70000,Aetna,Local,,6.47,,,,,,,4.60,10.43,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,55390006710,NDC,facility,inpatient,6,ME,58.10000,16.85000,Aetna,Local,,23.24,,,,,,,20.95,47.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,55390006610,NDC,facility,inpatient,20,ME,91.30000,26.48000,Aetna,Local,,36.52,,,,,,,32.91,74.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,55390006210,NDC,facility,inpatient,100,ME,33.20000,9.63000,Aetna,Local,,13.28,,,,,,,11.97,27.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,55390006002,NDC,facility,inpatient,500,ME,3142.30000,911.27000,Aetna,Local,,1256.92,,,,,,,1132.80,2570.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,55390005910,NDC,facility,inpatient,60,ME,109.05000,31.62000,Aetna,Local,,43.62,,,,,,,39.31,89.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,55390005710,NDC,facility,inpatient,150,ME,20.00000,5.80000,Aetna,Local,,8.00,,,,,,,7.21,16.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,55390005401,NDC,facility,inpatient,350,ME,292.00000,84.68000,Aetna,Local,,116.80,,,,,,,105.27,238.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,55390003710,NDC,,,facility,outpatient,1,EA,41.25000,11.96000,Aetna,Local,,20.94,,,,,,,14.87,33.74,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,55390003110,NDC,facility,inpatient,50,ME,31.20000,9.05000,Aetna,Local,,12.48,,,,,,,11.25,25.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,55390002910,NDC,facility,inpatient,20,ME,7.60000,2.20000,Aetna,Local,,3.04,,,,,,,2.74,6.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,55390001310,NDC,facility,inpatient,1,ME,182.70000,52.98000,Aetna,Local,,73.08,,,,,,,65.86,149.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,55390001110,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,55390001010,NDC,,,facility,outpatient,1,EA,42.75000,12.40000,Aetna,Local,,21.70,,,,,,,15.41,34.97,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,55390000710,NDC,,,facility,outpatient,1,EA,34.55000,10.02000,Aetna,Local,,17.54,,,,,,,12.46,28.26,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,55390000210,NDC,,,facility,outpatient,1,EA,29.35000,8.51000,Aetna,Local,,14.90,,,,,,,10.58,24.01,percent of total billed charges,
hemin 350mg Inj,800051985,CDM,636,RC,J1640,HCPCS,55292070255,NDC,facility,inpatient,350,ME,80770.35000,23423.40000,Aetna,Local,,32308.14,,,,,,,29117.71,66070.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,55150047006,NDC,,,facility,outpatient,1,EA,565.30000,163.94000,Aetna,Local,,287.00,,,,,,,203.79,462.42,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,55150044301,NDC,facility,inpatient,0.4,ME,158.60000,45.99000,Aetna,Local,,63.44,,,,,,,57.18,129.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,55150043701,NDC,facility,inpatient,500,ME,4136.25000,1199.51000,Aetna,Local,,1654.50,,,,,,,1491.12,3383.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,55150042510,NDC,,,facility,outpatient,1,EA,24.25000,7.03000,Aetna,Local,,12.31,,,,,,,8.74,19.84,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,55150042010,NDC,facility,inpatient,2.5,GM,1264.30000,366.65000,Aetna,Local,,505.72,,,,,,,455.78,1034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,55150040025,NDC,facility,inpatient,20,ME,43.40000,12.59000,Aetna,Local,,17.36,,,,,,,15.65,35.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bendamustine 100mg I(Treanda),800012530,CDM,636,RC,J9033,HCPCS,55150039201,NDC,facility,inpatient,100,ME,3157.00000,915.53000,Aetna,Local,,1262.80,,,,,,,1138.10,2582.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,55150037125,NDC,facility,inpatient,20,UN,778.25000,225.69000,Aetna,Local,,311.30,,,,,,,280.56,636.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,55150037025,NDC,facility,inpatient,20,UN,175.95000,51.03000,Aetna,Local,,70.38,,,,,,,63.43,143.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,55150037024,NDC,facility,inpatient,20,UN,429.80000,124.64000,Aetna,Local,,171.92,,,,,,,154.94,351.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amphotericin B LIPO 50mg I,800010922,CDM,636,RC,J0289,HCPCS,55150036501,NDC,facility,inpatient,50,ME,2021.20000,586.15000,Aetna,Local,,808.48,,,,,,,728.64,1653.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,55150036425,NDC,facility,inpatient,1,ME,21.70000,6.29000,Aetna,Local,,8.68,,,,,,,7.82,17.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,55150034510,NDC,facility,inpatient,2,ME,196.20000,56.90000,Aetna,Local,,78.48,,,,,,,70.73,160.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,55150034401,NDC,facility,inpatient,500,ME,283.00000,82.07000,Aetna,Local,,113.20,,,,,,,102.02,231.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,55150033701,NDC,facility,inpatient,3.5,ME,315.20000,91.41000,Aetna,Local,,126.08,,,,,,,113.63,257.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,55150033001,NDC,facility,inpatient,150,ME,403.90000,117.13000,Aetna,Local,,161.56,,,,,,,145.61,330.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,55150032710,NDC,facility,inpatient,0.4,ME,79.55000,23.07000,Aetna,Local,,31.82,,,,,,,28.68,65.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,55150032425,NDC,facility,inpatient,100,ME,25.55000,7.41000,Aetna,Local,,10.22,,,,,,,9.21,20.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,55150032225,NDC,facility,inpatient,20,ME,16.75000,4.86000,Aetna,Local,,6.70,,,,,,,6.04,13.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,55150030801,NDC,facility,inpatient,10,ME,219.00000,63.51000,Aetna,Local,,87.60,,,,,,,78.95,179.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,55150030110,NDC,facility,inpatient,50,ME,204.00000,59.16000,Aetna,Local,,81.60,,,,,,,73.54,166.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,55150029901,NDC,facility,inpatient,150,ME,584.00000,169.36000,Aetna,Local,,233.60,,,,,,,210.53,477.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,55150029710,NDC,,,facility,outpatient,1,EA,512.50000,148.62000,Aetna,Local,,260.20,,,,,,,184.76,419.23,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,55150028710,NDC,facility,inpatient,20,ME,155.05000,44.96000,Aetna,Local,,62.02,,,,,,,55.90,126.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,55150028220,NDC,facility,inpatient,1,GM,542.00000,157.18000,Aetna,Local,,216.80,,,,,,,195.39,443.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,55150028209,NDC,facility,inpatient,1,GM,710.00000,205.90000,Aetna,Local,,284.00,,,,,,,255.96,580.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,55150025930,NDC,facility,inpatient,6000,ME,519.25000,150.58000,Aetna,Local,,207.70,,,,,,,187.19,424.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,55150025650,NDC,,,facility,inpatient,1,EA,49.80000,14.44000,Aetna,Local,,19.92,,,,,,,17.95,40.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,55150025650,NDC,,,facility,outpatient,1,EA,49.80000,14.44000,Aetna,Local,,19.92,,,,,,,17.95,40.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,55150025520,NDC,,,facility,inpatient,1,EA,26.80000,7.77000,Aetna,Local,,10.72,,,,,,,9.66,21.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,55150025520,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,Local,,10.72,,,,,,,9.66,21.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,55150025350,NDC,,,facility,inpatient,1,EA,39.90000,11.57000,Aetna,Local,,15.96,,,,,,,14.38,32.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,55150025350,NDC,,,facility,outpatient,1,EA,39.90000,11.57000,Aetna,Local,,15.96,,,,,,,14.38,32.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,55150025220,NDC,,,facility,inpatient,1,EA,23.60000,6.84000,Aetna,Local,,9.44,,,,,,,8.51,19.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,55150025220,NDC,,,facility,outpatient,1,EA,23.60000,6.84000,Aetna,Local,,9.44,,,,,,,8.51,19.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 10mL Inj,800040882,CDM,636,RC,55150025110,NDC,,,facility,inpatient,1,EA,17.25000,5.00000,Aetna,Local,,6.90,,,,,,,6.22,14.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 10mL Inj,800040882,CDM,636,RC,55150025110,NDC,,,facility,outpatient,1,EA,17.25000,5.00000,Aetna,Local,,6.90,,,,,,,6.22,14.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,55150024747,NDC,facility,inpatient,1000,ME,443.00000,128.47000,Aetna,Local,,177.20,,,,,,,159.70,362.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,55150024647,NDC,facility,inpatient,500,ME,262.75000,76.20000,Aetna,Local,,105.10,,,,,,,94.72,214.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,55150024251,NDC,facility,inpatient,600,ME,134.40000,38.98000,Aetna,Local,,53.76,,,,,,,48.45,109.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,55150024110,NDC,facility,inpatient,50,ME,2091.25000,606.46000,Aetna,Local,,836.50,,,,,,,753.90,1710.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,55150024005,NDC,facility,inpatient,50,ME,4257.00000,1234.53000,Aetna,Local,,1702.80,,,,,,,1534.65,3482.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,55150024005,NDC,facility,outpatient,50,ME,4257.00000,1234.53000,Aetna,Local,,1702.80,,,,,,,5.42,3482.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,55150023805,NDC,facility,inpatient,1,ME,0.80000,0.23000,Aetna,Local,,0.32000,,,,,,,0.28840,0.65440,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,55150023511,NDC,,,facility,outpatient,1,EA,25.30000,7.34000,Aetna,Local,,12.84,,,,,,,9.12,20.70,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,55150023510,NDC,,,facility,outpatient,1,EA,35.10000,10.18000,Aetna,Local,,17.82,,,,,,,12.65,28.71,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,55150022505,NDC,,,facility,outpatient,1,EA,55.85000,16.20000,Aetna,Local,,28.36,,,,,,,20.13,45.69,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,55150022310,NDC,facility,inpatient,1,GM,96.00000,27.84000,Aetna,Local,,38.40,,,,,,,34.61,78.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,55150022110,NDC,,,facility,outpatient,1,EA,51.05000,14.80000,Aetna,Local,,25.92,,,,,,,18.40,41.76,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,55150021910,NDC,facility,inpatient,20,ME,274.30000,79.55000,Aetna,Local,,109.72,,,,,,,98.89,224.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,55150021010,NDC,facility,inpatient,250,ME,930.00000,269.70000,Aetna,Local,,372.00,,,,,,,335.26,760.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,55150020830,NDC,facility,inpatient,1,GM,105.60000,30.62000,Aetna,Local,,42.24,,,,,,,38.07,86.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,55150020720,NDC,facility,inpatient,500,ME,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,55150020210,NDC,facility,inpatient,40,ME,19.15000,5.55000,Aetna,Local,,7.66,,,,,,,6.90,15.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,55150019830,NDC,facility,inpatient,150,ME,51.05000,14.80000,Aetna,Local,,20.42,,,,,,,18.40,41.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 20mL I,800021331,CDM,636,RC,J2795,HCPCS,55150019720,NDC,facility,inpatient,100,ME,35.75000,10.37000,Aetna,Local,,14.30,,,,,,,12.89,29.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,55150019699,NDC,facility,inpatient,200,ME,580.00000,168.20000,Aetna,Local,,232.00,,,,,,,209.09,474.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,55150019520,NDC,facility,inpatient,40,ME,86.20000,25.00000,Aetna,Local,,34.48,,,,,,,31.08,70.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,55150019410,NDC,facility,inpatient,100,ME,46.80000,13.57000,Aetna,Local,,18.72,,,,,,,16.87,38.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,55150019183,NDC,facility,inpatient,3,ME,1850.00000,536.50000,Aetna,Local,,740.00,,,,,,,666.92,1513.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,55150018810,NDC,,,facility,outpatient,1,EA,57.60000,16.70000,Aetna,Local,,29.24,,,,,,,20.76,47.12,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,55150018703,NDC,facility,inpatient,60,ME,313.00000,90.77000,Aetna,Local,,125.20,,,,,,,112.84,256.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,55150018605,NDC,facility,inpatient,0.25,ME,127.70000,37.03000,Aetna,Local,,51.08,,,,,,,46.04,104.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,55150018311,NDC,facility,inpatient,25,ME,194.95000,56.54000,Aetna,Local,,77.98,,,,,,,70.28,159.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,55150018310,NDC,facility,inpatient,25,ME,218.85000,63.47000,Aetna,Local,,87.54,,,,,,,78.90,179.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,55150018003,NDC,facility,inpatient,150,ME,24.00000,6.96000,Aetna,Local,,9.60,,,,,,,8.65,19.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,55150017705,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,55150017030,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,Local,,9.57,,,,,,,6.80,15.42,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,55150016910,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,Local,,9.72,,,,,,,6.90,15.66,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,55150016830,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,6.13,13.91,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,55150016710,NDC,,,facility,outpatient,1,EA,16.60000,4.81000,Aetna,Local,,8.43,,,,,,,5.98,13.58,percent of total billed charges,
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,55150016330,NDC,,,facility,inpatient,1,EA,23.15000,6.71000,Aetna,Local,,9.26,,,,,,,8.35,18.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,55150016330,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,9.26,,,,,,,8.35,18.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,55150016205,NDC,,,facility,inpatient,1,EA,21.55000,6.25000,Aetna,Local,,8.62,,,,,,,7.77,17.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,55150016205,NDC,,,facility,outpatient,1,EA,21.55000,6.25000,Aetna,Local,,8.62,,,,,,,7.77,17.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,55150016102,NDC,,,facility,inpatient,1,EA,16.35000,4.74000,Aetna,Local,,6.54,,,,,,,5.89,13.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,55150016102,NDC,,,facility,outpatient,1,EA,16.35000,4.74000,Aetna,Local,,6.54,,,,,,,5.89,13.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,55150015974,NDC,,,facility,inpatient,1,EA,14.20000,4.12000,Aetna,Local,,5.68,,,,,,,5.12,11.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,55150015974,NDC,,,facility,outpatient,1,EA,14.20000,4.12000,Aetna,Local,,5.68,,,,,,,5.12,11.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,55150015872,NDC,,,facility,inpatient,1,EA,10.50000,3.04000,Aetna,Local,,4.20,,,,,,,3.79,8.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,55150015872,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,Local,,4.20,,,,,,,3.79,8.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acyclovir 50mg/mL Inj 20mL,800013250,CDM,636,RC,J0133,HCPCS,55150015520,NDC,facility,inpatient,1000,ME,238.00000,69.02000,Aetna,Local,,95.20,,,,,,,85.80,194.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acyclovir 50mg/mL Inj 10mL,800020914,CDM,636,RC,J0133,HCPCS,55150015411,NDC,facility,inpatient,500,ME,128.00000,37.12000,Aetna,Local,,51.20,,,,,,,46.14,104.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acyclovir 50mg/mL Inj 10mL,800020914,CDM,636,RC,J0133,HCPCS,55150015410,NDC,facility,inpatient,500,ME,128.00000,37.12000,Aetna,Local,,51.20,,,,,,,46.14,104.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,55150012715,NDC,facility,inpatient,1000,ME,116.00000,33.64000,Aetna,Local,,46.40,,,,,,,41.82,94.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,55150012620,NDC,facility,inpatient,4,ME,20.00000,5.80000,Aetna,Local,,8.00,,,,,,,7.21,16.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,55150012502,NDC,facility,inpatient,4,ME,12.75000,3.70000,Aetna,Local,,5.10,,,,,,,4.60,10.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,55150012316,NDC,facility,inpatient,2,GM,120.00000,34.80000,Aetna,Local,,48.00,,,,,,,43.26,98.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,55150012315,NDC,facility,inpatient,2,GM,120.00000,34.80000,Aetna,Local,,48.00,,,,,,,43.26,98.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,55150012150,NDC,facility,inpatient,4.5,GM,62.40000,18.10000,Aetna,Local,,24.96,,,,,,,22.50,51.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,55150012030,NDC,facility,inpatient,3.375,GM,52.80000,15.31000,Aetna,Local,,21.12,,,,,,,19.03,43.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,55150011930,NDC,facility,inpatient,2.25,GM,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,55150011720,NDC,facility,inpatient,3,GM,116.80000,33.87000,Aetna,Local,,46.72,,,,,,,42.11,95.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,55150011620,NDC,facility,inpatient,1.5,GM,61.90000,17.95000,Aetna,Local,,24.76,,,,,,,22.31,50.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,55150011420,NDC,facility,inpatient,2,GM,127.30000,36.92000,Aetna,Local,,50.92,,,,,,,45.89,104.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,55150011310,NDC,facility,inpatient,1,GM,65.65000,19.04000,Aetna,Local,,26.26,,,,,,,23.67,53.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,55150011210,NDC,facility,inpatient,500,ME,33.50000,9.72000,Aetna,Local,,13.40,,,,,,,12.08,27.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,55111079835,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,55111073809,NDC,,,facility,outpatient,1,EA,193.00000,55.97000,Aetna,Local,,97.99,,,,,,,69.58,157.87,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,55111073709,NDC,,,facility,outpatient,1,EA,180.40000,52.32000,Aetna,Local,,91.59,,,,,,,65.03,147.57,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,55111073390,NDC,,,facility,outpatient,1,EA,14.75000,4.28000,Aetna,Local,,7.49,,,,,,,5.32,12.07,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,55111073001,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,55111072901,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,55111069407,NDC,facility,inpatient,0.25,ME,114.90000,33.32000,Aetna,Local,,45.96,,,,,,,41.42,93.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,55111068852,NDC,facility,inpatient,5,ME,2527.00000,732.83000,Aetna,Local,,1010.80,,,,,,,910.98,2067.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,55111068507,NDC,facility,inpatient,4,ME,668.00000,193.72000,Aetna,Local,,267.20,,,,,,,240.81,546.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,55111068301,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,Local,,1.04,,,,,,,0.73903,1.68,percent of total billed charges,
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,55111068002,NDC,facility,inpatient,7.5,ME,608.75000,176.54000,Aetna,Local,,243.50,,,,,,,219.45,497.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,55111067802,NDC,facility,inpatient,2.5,ME,290.25000,84.17000,Aetna,Local,,116.10,,,,,,,104.64,237.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,55111067131,NDC,,,facility,outpatient,1,EA,198.20000,57.48000,Aetna,Local,,100.63,,,,,,,71.45,162.13,percent of total billed charges,
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,55111065237,NDC,facility,inpatient,250,ME,930.00000,269.70000,Aetna,Local,,372.00,,,,,,,335.26,760.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,55111065001,NDC,,,facility,outpatient,1,EA,34.65000,10.05000,Aetna,Local,,17.59,,,,,,,12.49,28.34,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,55111064801,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,Local,,4.72,,,,,,,3.35,7.61,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,55111053401,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,Local,,14.65,,,,,,,10.40,23.60,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,55111053301,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,Local,,8.83,,,,,,,6.27,14.23,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,55111053201,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,Local,,4.04,,,,,,,2.87,6.50,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,55111046801,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,55111046705,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,55111046701,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,55111046601,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,55111035260,NDC,,,facility,outpatient,1,EA,30.05000,8.71000,Aetna,Local,,15.26,,,,,,,10.83,24.58,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,55111033390,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Donepezil 23mg T (Aricept),800072470,CDM,637,RC,55111030230,NDC,,,facility,outpatient,1,EA,80.40000,23.32000,Aetna,Local,,40.82,,,,,,,28.98,65.77,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,55111029198,NDC,,,facility,outpatient,1,EA,193.00000,55.97000,Aetna,Local,,97.99,,,,,,,69.58,157.87,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),800015332,CDM,637,RC,55111028130,NDC,,,facility,outpatient,1,EA,180.00000,52.20000,Aetna,Local,,91.39,,,,,,,64.89,147.24,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,55111028050,NDC,,,facility,outpatient,1,EA,142.25000,41.25000,Aetna,Local,,72.22,,,,,,,51.28,116.36,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,55111027950,NDC,,,facility,outpatient,1,EA,124.10000,35.99000,Aetna,Local,,63.01,,,,,,,44.74,101.51,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,55111026281,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,Local,,7.46,,,,,,,5.30,12.02,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,55111025960,NDC,,,facility,outpatient,1,EA,76.15000,22.08000,Aetna,Local,,38.66,,,,,,,27.45,62.29,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,55111025660,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,55111022101,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,Local,,17.08,,,,,,,12.13,27.53,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,55111022001,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,Local,,14.95,,,,,,,10.62,24.09,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,55111019690,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,Local,,25.03,,,,,,,17.77,40.33,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,55111018015,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,Local,,5.25,,,,,,,3.73,8.47,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,55111017915,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,55111016630,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,Local,,4.29,,,,,,,3.05,6.91,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,55111016330,NDC,,,facility,outpatient,1,EA,79.30000,23.00000,Aetna,Local,,40.26,,,,,,,28.59,64.87,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,55111015330,NDC,facility,inpatient,4,ME,175.40000,50.87000,Aetna,Local,,70.16,,,,,,,63.23,143.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,55111012205,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,Local,,20.74,,,,,,,14.73,33.42,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,55111011901,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,54879000201,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,54879000200,NDC,,,facility,outpatient,1,EA,11.50000,3.34000,Aetna,Local,,5.84,,,,,,,4.15,9.41,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,54838050615,NDC,,,facility,outpatient,1,ML,18.90000,5.48000,Aetna,Local,,9.60,,,,,,,6.81,15.46,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,54838050280,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,54838001150,NDC,,,facility,outpatient,1,EA,0.80000,0.23000,Aetna,Local,,0.40616,,,,,,,0.28840,0.65440,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,54766079904,NDC,,,facility,outpatient,1,EA,2165.20000,627.91000,Aetna,Local,,1099.27,,,,,,,780.55,1771.13,percent of total billed charges,
Hydrocortisone 2.5%-Pramox 1% Top Oint,800025581,CDM,637,RC,54766077704,NDC,,,facility,outpatient,1,EA,1808.55000,524.48000,Aetna,Local,,918.20,,,,,,,651.98,1479.39,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,54643900701,NDC,,,facility,outpatient,1,EA,103.15000,29.91000,Aetna,Local,,52.37,,,,,,,37.19,84.38,percent of total billed charges,
Multiple Vitamin Inj,800062975,CDM,250,RC,54643564901,NDC,,,facility,outpatient,1,EA,156.90000,45.50000,Aetna,Local,,79.66,,,,,,,56.56,128.34,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,54629012810,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,Local,,0.20308,,,,,,,0.14420,0.32720,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,54629012800,NDC,,,facility,outpatient,1,EA,0.10000,0.03000,Aetna,Local,,0.05077,,,,,,,0.03605,0.08180,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,54505033210,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,Local,,2.06,,,,,,,1.46,3.31,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,54505033105,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,54505010202,NDC,facility,inpatient,0.3,ME,1010.05000,292.91000,Aetna,Local,,404.02,,,,,,,364.12,826.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levOCARNitine 200mg/1mL I 5mL Vial,800017796,CDM,636,RC,J1955,HCPCS,54482014701,NDC,facility,inpatient,1000,ME,238.85000,69.27000,Aetna,Local,,95.54,,,,,,,86.11,195.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Alcohol (Dehydrated) - 5g/5mL Inj,800061613,CDM,250,RC,54288010515,NDC,,,facility,outpatient,1,EA,4154.10000,1204.69000,Aetna,Local,,2109.04,,,,,,,1497.55,3398.05,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,54288010310,NDC,facility,inpatient,1,ME,93.10000,27.00000,Aetna,Local,,37.24,,,,,,,33.56,76.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mineral Oil 100% Enema,800018020,CDM,637,RC,54162017505,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,Local,,9.47,,,,,,,6.72,15.26,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,54092041912,NDC,,,facility,outpatient,1,EA,11.15000,3.23000,Aetna,Local,,5.66,,,,,,,4.02,9.12,percent of total billed charges,
Mesalamine 250mg CR C(Pentasa),800077536,CDM,637,RC,54092018981,NDC,,,facility,outpatient,1,EA,25.80000,7.48000,Aetna,Local,,13.10,,,,,,,9.30,21.10,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,54092017112,NDC,,,facility,outpatient,1,EA,15.05000,4.36000,Aetna,Local,,7.64,,,,,,,5.43,12.31,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),800080654,CDM,637,RC,54092006301,NDC,,,facility,outpatient,1,EA,70.25000,20.37000,Aetna,Local,,35.67,,,,,,,25.33,57.46,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,54092000401,NDC,,,facility,outpatient,1,EA,20.95000,6.08000,Aetna,Local,,10.64,,,,,,,7.55,17.14,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,53746071101,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,Local,,3.66,,,,,,,2.60,5.89,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,53746066901,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,Local,,4.21,,,,,,,2.99,6.79,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,53746064201,NDC,,,facility,outpatient,1,EA,28.40000,8.24000,Aetna,Local,,14.42,,,,,,,10.24,23.23,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,53746054501,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,53746054401,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,53746051101,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,53746046605,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,53746046505,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,53746046401,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Sulfamethoxazole-Trimethoprim DS 800-160mg T,800021992,CDM,637,RC,53746027201,NDC,,,facility,outpatient,1,EA,9.95000,2.89000,Aetna,Local,,5.05,,,,,,,3.59,8.14,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,53746027101,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,53746018801,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,53746017801,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,53746010301,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,53746010205,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,53746010201,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,53746010101,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,53489064801,NDC,,,facility,outpatient,1,EA,79.50000,23.06000,Aetna,Local,,40.36,,,,,,,28.66,65.03,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,53489055201,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,Local,,8.38,,,,,,,5.95,13.50,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,53489055101,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,53489051101,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,53489038701,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,Local,,4.65,,,,,,,3.30,7.48,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,53489038601,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,53489036901,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,53489036801,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,53489036601,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,53489021501,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,53489015601,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,53489014901,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,Local,,1.27,,,,,,,0.90125,2.04,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,53489014501,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,Local,,2.39,,,,,,,1.69,3.84,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,53489014301,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,53489013601,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,53489012701,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,53489011905,NDC,,,facility,outpatient,1,EA,43.50000,12.61000,Aetna,Local,,22.08,,,,,,,15.68,35.58,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,53489011902,NDC,,,facility,outpatient,1,EA,43.50000,12.61000,Aetna,Local,,22.08,,,,,,,15.68,35.58,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,53489010401,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,Local,,0.66001,,,,,,,0.46865,1.06,percent of total billed charges,
Patiromer 8.4g REC Packet (Veltassa),800022030,CDM,637,RC,53436008404,NDC,,,facility,outpatient,1,EA,386.10000,111.97000,Aetna,Local,,196.02,,,,,,,139.19,315.83,percent of total billed charges,
Microfibrillar 1g TP(Avitene),800034537,CDM,637,RC,53276101002,NDC,,,facility,outpatient,1,EA,1758.20000,509.88000,Aetna,Local,,892.64,,,,,,,633.83,1438.21,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,53265028310,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,53265026610,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,53014097571,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,Local,,9.47,,,,,,,6.72,15.26,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,53014054867,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,Local,,16.88,,,,,,,11.99,27.20,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,53014054801,NDC,,,facility,outpatient,1,EA,60.30000,17.49000,Aetna,Local,,30.61,,,,,,,21.74,49.33,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,53014053007,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,Local,,3.60,,,,,,,2.56,5.81,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,53014003010,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,Local,,2.72,,,,,,,1.93,4.38,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,53014001210,NDC,,,facility,outpatient,1,EA,4.10000,1.19000,Aetna,Local,,2.08,,,,,,,1.48,3.35,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,52817081701,NDC,,,facility,outpatient,1,EA,967.20000,280.49000,Aetna,Local,,491.05,,,,,,,348.68,791.17,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,52817033010,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,52817032410,NDC,,,facility,outpatient,1,EA,26.45000,7.67000,Aetna,Local,,13.43,,,,,,,9.54,21.64,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,52817032110,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,Local,,18.43,,,,,,,13.09,29.69,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,52817027030,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,Local,,8.10,,,,,,,5.75,13.05,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,52817027010,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,Local,,8.10,,,,,,,5.75,13.05,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,52817021010,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,52817012110,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,52769025105,NDC,facility,inpatient,12.5,GM,727.50000,210.98000,Aetna,Local,,291.00,,,,,,,262.26,595.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,52761055245,NDC,,,facility,outpatient,1,EA,34.40000,9.98000,Aetna,Local,,17.46,,,,,,,12.40,28.14,percent of total billed charges,
Zonisamide 100 mg/5 mL Oral Susp,800046548,CDM,637,RC,52652800101,NDC,,,facility,outpatient,1,EA,118.80000,34.45000,Aetna,Local,,60.31,,,,,,,42.83,97.18,percent of total billed charges,
"Thrombin Bovine 20,000IUTp Kit",800050970,CDM,250,RC,52604710502,NDC,,,facility,outpatient,1,EA,2172.20000,629.94000,Aetna,Local,,1102.83,,,,,,,783.08,1776.86,percent of total billed charges,
Thrombin Bovine 5000 IU,800016857,CDM,250,RC,52604710201,NDC,,,facility,outpatient,1,EA,585.45000,169.78000,Aetna,Local,,297.23,,,,,,,211.05,478.90,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,52604512501,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,1.32,2.99,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,52604341601,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,Local,,3.45,,,,,,,2.45,5.56,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,52604341401,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,Local,,2.18,,,,,,,1.55,3.52,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,52604109501,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,52604109401,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
Triamcinolone 0.1% TC 80g,800017794,CDM,637,RC,52565005680,NDC,,,facility,outpatient,1,EA,103.00000,29.87000,Aetna,Local,,52.29,,,,,,,37.13,84.25,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,52565005615,NDC,,,facility,outpatient,1,EA,41.30000,11.98000,Aetna,Local,,20.97,,,,,,,14.89,33.78,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,52565000950,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,Local,,4.65,,,,,,,3.30,7.48,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,52565000814,NDC,,,facility,outpatient,1,EA,1893.65000,549.16000,Aetna,Local,,961.41,,,,,,,682.66,1549.01,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,52544095701,NDC,,,facility,outpatient,1,EA,18.50000,5.36000,Aetna,Local,,9.39,,,,,,,6.67,15.13,percent of total billed charges,
Iron Dextran 100mg/2mL I(Infed),800012496,CDM,636,RC,J1750,HCPCS,52544093102,NDC,facility,inpatient,100,ME,275.90000,80.01000,Aetna,Local,,110.36,,,,,,,99.46,225.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,52544090401,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,Local,,1.19,,,,,,,0.84718,1.92,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,52544079601,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,52544079401,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,52544078001,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,52544077601,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,52544077501,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,Local,,1.70,,,,,,,1.21,2.74,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,52544069301,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,52544065801,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,52544058301,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,Local,,8.38,,,,,,,5.95,13.50,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,52544049850,NDC,,,facility,outpatient,1,EA,9.70000,2.81000,Aetna,Local,,4.92,,,,,,,3.50,7.93,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,52544046301,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,52544044401,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,52544043701,NDC,,,facility,outpatient,1,EA,8.00000,2.32000,Aetna,Local,,4.06,,,,,,,2.88,6.54,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,52544040401,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,52544034501,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,52544015130,NDC,,,facility,outpatient,1,EA,70.60000,20.47000,Aetna,Local,,35.84,,,,,,,25.45,57.75,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,52536030065,NDC,,,facility,outpatient,1,EA,1319.30000,382.60000,Aetna,Local,,669.81,,,,,,,475.61,1079.19,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,52536018003,NDC,,,facility,outpatient,1,EA,59.40000,17.23000,Aetna,Local,,30.16,,,,,,,21.41,48.59,percent of total billed charges,
Vancomycin 125mg/2.5mL Oral Soln,800072448,CDM,637,RC,52536010810,NDC,,,facility,outpatient,1,EA,16.75000,4.86000,Aetna,Local,,8.50,,,,,,,6.04,13.70,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,800025528,CDM,637,RC,52376002102,NDC,,,facility,outpatient,1,EA,40.60000,11.77000,Aetna,Local,,20.61,,,,,,,14.64,33.21,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,52268030201,NDC,,,facility,outpatient,1,EA,167.35000,48.53000,Aetna,Local,,84.96,,,,,,,60.33,136.89,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,52268010001,NDC,,,facility,outpatient,1,EA,211.60000,61.36000,Aetna,Local,,107.43,,,,,,,76.28,173.09,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,52183019914,NDC,,,facility,outpatient,1,EA,125.20000,36.31000,Aetna,Local,,63.56,,,,,,,45.13,102.41,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,52152053830,NDC,facility,inpatient,4,ME,176.20000,51.10000,Aetna,Local,,70.48,,,,,,,63.52,144.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,52152034002,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,Local,,7.46,,,,,,,5.30,12.02,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,52152013902,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,52152006002,NDC,,,facility,outpatient,1,EA,20.00000,5.80000,Aetna,Local,,10.15,,,,,,,7.21,16.36,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,52152001802,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
Fidaxomicin 200mg T(Dificid),800025643,CDM,637,RC,52015008001,NDC,,,facility,outpatient,1,EA,1871.50000,542.74000,Aetna,Local,,950.16,,,,,,,674.68,1530.89,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,51991098317,NDC,,,facility,outpatient,1,EA,55.80000,16.18000,Aetna,Local,,28.33,,,,,,,20.12,45.64,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,51991096158,NDC,,,facility,outpatient,1,EA,33.55000,9.73000,Aetna,Local,,17.03,,,,,,,12.09,27.44,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,51991094117,NDC,facility,inpatient,1,GM,60.00000,17.40000,Aetna,Local,,24.00,,,,,,,21.63,49.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Entecavir 0.5mg Tab,800046457,CDM,637,RC,51991089533,NDC,,,facility,outpatient,1,EA,307.40000,89.15000,Aetna,Local,,156.07,,,,,,,110.82,251.45,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,51991083801,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,51991081801,NDC,,,facility,outpatient,1,EA,17.05000,4.94000,Aetna,Local,,8.66,,,,,,,6.15,13.95,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,51991081701,NDC,,,facility,outpatient,1,EA,14.55000,4.22000,Aetna,Local,,7.39,,,,,,,5.25,11.90,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,51991081403,NDC,,,facility,outpatient,1,EA,677.00000,196.33000,Aetna,Local,,343.71,,,,,,,244.06,553.79,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,51991079306,NDC,,,facility,outpatient,1,EA,33.00000,9.57000,Aetna,Local,,16.75,,,,,,,11.90,26.99,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,51991075933,NDC,,,facility,outpatient,1,EA,128.25000,37.19000,Aetna,Local,,65.11,,,,,,,46.23,104.91,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,51991074890,NDC,,,facility,outpatient,1,EA,53.40000,15.49000,Aetna,Local,,27.11,,,,,,,19.25,43.68,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,51991062033,NDC,,,facility,outpatient,1,EA,94.50000,27.40000,Aetna,Local,,47.98,,,,,,,34.07,77.30,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,51991052601,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,Local,,46.99,,,,,,,33.36,75.71,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,51991046801,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,Local,,4.16,,,,,,,2.96,6.71,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,51991045758,NDC,,,facility,outpatient,1,EA,144.80000,41.99000,Aetna,Local,,73.51,,,,,,,52.20,118.45,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,51991040601,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,51991031233,NDC,,,facility,outpatient,1,EA,81.20000,23.55000,Aetna,Local,,41.23,,,,,,,29.27,66.42,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,51991031190,NDC,,,facility,outpatient,1,EA,81.20000,23.55000,Aetna,Local,,41.23,,,,,,,29.27,66.42,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,51991031133,NDC,,,facility,outpatient,1,EA,81.20000,23.55000,Aetna,Local,,41.23,,,,,,,29.27,66.42,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,51991029301,NDC,,,facility,outpatient,1,EA,18.60000,5.39000,Aetna,Local,,9.44,,,,,,,6.71,15.21,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,51991029201,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,Local,,5.18,,,,,,,3.68,8.34,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,51991018831,NDC,facility,inpatient,4,ME,3.70000,1.07000,Aetna,Local,,1.48,,,,,,,1.33,3.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,51991014417,NDC,facility,inpatient,0.2,ME,126.15000,36.58000,Aetna,Local,,50.46,,,,,,,45.48,103.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trimethoprim 100mg T,800017746,CDM,637,RC,51862048601,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,Local,,8.38,,,,,,,5.95,13.50,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,51862044960,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,51862033001,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,Local,,18.51,,,,,,,13.14,29.82,percent of total billed charges,
dilTIAZem 90mg SR C(CardiZEM),800057751,CDM,637,RC,51862032901,NDC,,,facility,outpatient,1,EA,27.95000,8.11000,Aetna,Local,,14.19,,,,,,,10.08,22.86,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,51862032101,NDC,,,facility,outpatient,1,EA,17.60000,5.10000,Aetna,Local,,8.94,,,,,,,6.34,14.40,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,51862032001,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,51862031578,NDC,,,facility,outpatient,1,EA,241.60000,70.06000,Aetna,Local,,122.66,,,,,,,87.10,197.63,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,51862024030,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,Local,,26.71,,,,,,,18.96,43.03,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,51862015430,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,Local,,26.71,,,,,,,18.96,43.03,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,51862007901,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,800015247,CDM,637,RC,51801000130,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,Local,,1.70,,,,,,,1.21,2.74,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,51754506001,NDC,facility,inpatient,30,ME,245.35000,71.15000,Aetna,Local,,98.14,,,,,,,88.45,200.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,51754500105,NDC,,,facility,outpatient,1,EA,89.25000,25.88000,Aetna,Local,,45.31,,,,,,,32.17,73.01,percent of total billed charges,
ePHEDrine sulfate 25mg/5mL IS,800051986,CDM,250,RC,51754425003,NDC,,,facility,outpatient,1,EA,78.85000,22.87000,Aetna,Local,,40.03,,,,,,,28.43,64.50,percent of total billed charges,
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,51754400003,NDC,facility,inpatient,50,ME,226.85000,65.79000,Aetna,Local,,90.74,,,,,,,81.78,185.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,51754122003,NDC,facility,inpatient,10,ME,117.20000,33.99000,Aetna,Local,,46.88,,,,,,,42.25,95.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,51754050303,NDC,,,facility,outpatient,1,EA,20.40000,5.92000,Aetna,Local,,10.36,,,,,,,7.35,16.69,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,51754050201,NDC,facility,inpatient,60,ME,229.00000,66.41000,Aetna,Local,,91.60,,,,,,,82.55,187.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,51754050103,NDC,,,facility,outpatient,1,EA,101.95000,29.57000,Aetna,Local,,51.76,,,,,,,36.75,83.40,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,51754050001,NDC,facility,inpatient,60,ME,115.20000,33.41000,Aetna,Local,,46.08,,,,,,,41.53,94.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,51754020304,NDC,,,facility,outpatient,1,EA,31.90000,9.25000,Aetna,Local,,16.20,,,,,,,11.50,26.09,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,51754020302,NDC,,,facility,outpatient,1,EA,31.90000,9.25000,Aetna,Local,,16.20,,,,,,,11.50,26.09,percent of total billed charges,
Tranexamic Acid 1g/100mL Bolus,800062092,CDM,250,RC,51754010803,NDC,,,facility,outpatient,1,EA,214.60000,62.23000,Aetna,Local,,108.95,,,,,,,77.36,175.54,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,51672413101,NDC,,,facility,outpatient,1,EA,36.40000,10.56000,Aetna,Local,,18.48,,,,,,,13.12,29.78,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,51672413001,NDC,,,facility,outpatient,1,EA,31.85000,9.24000,Aetna,Local,,16.17,,,,,,,11.48,26.05,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,51672411704,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,51672411101,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,51672410601,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,Local,,9.49,,,,,,,6.74,15.30,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,800023340,CDM,637,RC,51672406901,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,51672405506,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,Local,,26.71,,,,,,,18.96,43.03,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,51672404801,NDC,,,facility,outpatient,1,EA,217.15000,62.97000,Aetna,Local,,110.25,,,,,,,78.28,177.63,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,51672404709,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,51672404101,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,51672404001,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,Local,,9.95,,,,,,,7.07,16.03,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,51672403901,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,51672402504,NDC,,,facility,outpatient,1,EA,23.40000,6.79000,Aetna,Local,,11.88,,,,,,,8.44,19.14,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,51672402301,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,Local,,1.50,,,,,,,1.06,2.41,percent of total billed charges,
Etodolac 200 mg C (Lodine),800080985,CDM,637,RC,51672401601,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,Local,,5.15,,,,,,,3.66,8.30,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,51672400205,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,Local,,0.63462,,,,,,,0.45062,1.02,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,51672400201,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,Local,,5.28,,,,,,,3.75,8.51,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,51672400101,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,51672302009,NDC,,,facility,outpatient,1,EA,1893.65000,549.16000,Aetna,Local,,961.41,,,,,,,682.66,1549.01,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,51672300302,NDC,,,facility,outpatient,1,EA,72.45000,21.01000,Aetna,Local,,36.78,,,,,,,26.12,59.26,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,51672204402,NDC,,,facility,outpatient,1,EA,48.55000,14.08000,Aetna,Local,,24.65,,,,,,,17.50,39.71,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,51672203506,NDC,,,facility,outpatient,1,EA,81.05000,23.50000,Aetna,Local,,41.15,,,,,,,29.22,66.30,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,51672201302,NDC,,,facility,outpatient,1,EA,41.15000,11.93000,Aetna,Local,,20.89,,,,,,,14.83,33.66,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,51672200306,NDC,,,facility,outpatient,1,EA,56.65000,16.43000,Aetna,Local,,28.76,,,,,,,20.42,46.34,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,51672200201,NDC,,,facility,outpatient,1,EA,60.20000,17.46000,Aetna,Local,,30.56,,,,,,,21.70,49.24,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,51672200102,NDC,,,facility,outpatient,1,EA,51.00000,14.79000,Aetna,Local,,25.89,,,,,,,18.39,41.72,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,51672131802,NDC,,,facility,outpatient,1,EA,350.70000,101.70000,Aetna,Local,,178.05,,,,,,,126.43,286.87,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,51672131201,NDC,,,facility,outpatient,1,EA,179.55000,52.07000,Aetna,Local,,91.16,,,,,,,64.73,146.87,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,51672131200,NDC,,,facility,outpatient,1,EA,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,63.81,144.79,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,51672129802,NDC,,,facility,outpatient,1,EA,671.55000,194.75000,Aetna,Local,,340.95,,,,,,,242.09,549.33,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,51672129801,NDC,,,facility,outpatient,1,EA,822.80000,238.61000,Aetna,Local,,417.74,,,,,,,296.62,673.05,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,51672129702,NDC,,,facility,outpatient,1,EA,404.80000,117.39000,Aetna,Local,,205.52,,,,,,,145.93,331.13,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,51672128901,NDC,,,facility,outpatient,1,EA,124.25000,36.03000,Aetna,Local,,63.08,,,,,,,44.79,101.64,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,51672128408,NDC,,,facility,outpatient,1,EA,93.60000,27.14000,Aetna,Local,,47.52,,,,,,,33.74,76.56,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,51672128401,NDC,,,facility,outpatient,1,EA,14.75000,4.28000,Aetna,Local,,7.49,,,,,,,5.32,12.07,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,51672128202,NDC,,,facility,outpatient,1,EA,29.75000,8.63000,Aetna,Local,,15.10,,,,,,,10.72,24.34,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,51672127501,NDC,,,facility,outpatient,1,EA,141.15000,40.93000,Aetna,Local,,71.66,,,,,,,50.88,115.46,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,51672126705,NDC,,,facility,outpatient,1,EA,530.00000,153.70000,Aetna,Local,,269.08,,,,,,,191.06,433.54,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,51672126302,NDC,,,facility,outpatient,1,EA,980.10000,284.23000,Aetna,Local,,497.60,,,,,,,353.33,801.72,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,51672125902,NDC,,,facility,outpatient,1,EA,1604.55000,465.32000,Aetna,Local,,814.63,,,,,,,578.44,1312.52,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,51672125802,NDC,,,facility,outpatient,1,EA,1587.85000,460.48000,Aetna,Local,,806.15,,,,,,,572.42,1298.86,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,51672125401,NDC,,,facility,outpatient,1,EA,331.90000,96.25000,Aetna,Local,,168.51,,,,,,,119.65,271.49,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,51672125301,NDC,,,facility,outpatient,1,EA,314.70000,91.26000,Aetna,Local,,159.77,,,,,,,113.45,257.42,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,51660099628,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,Local,,3.96,,,,,,,2.81,6.38,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,51660078701,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,51660078501,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,Local,,0.15231,,,,,,,0.10815,0.24540,percent of total billed charges,
Acetic Acid 3% TS 30mL,800022043,CDM,250,RC,51552005106,NDC,,,facility,outpatient,1,EA,30.15000,8.74000,Aetna,Local,,15.31,,,,,,,10.87,24.66,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,51525029403,NDC,,,facility,outpatient,1,EA,677.00000,196.33000,Aetna,Local,,343.71,,,,,,,244.06,553.79,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,51525011501,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,Local,,3.55,,,,,,,2.52,5.73,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,51479005530,NDC,facility,inpatient,2,GM,335.80000,97.38000,Aetna,Local,,134.32,,,,,,,121.06,274.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,51479005430,NDC,facility,inpatient,1,GM,173.60000,50.34000,Aetna,Local,,69.44,,,,,,,62.58,142.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,51479004701,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,51479004115,NDC,facility,inpatient,1,GM,318.85000,92.47000,Aetna,Local,,127.54,,,,,,,114.95,260.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,51293080101,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,Local,,9.70,,,,,,,6.89,15.62,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,51293061101,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,Local,,9.70,,,,,,,6.89,15.62,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,51293060701,NDC,,,facility,outpatient,1,EA,36.40000,10.56000,Aetna,Local,,18.48,,,,,,,13.12,29.78,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,51285091602,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,51285054002,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,51285042410,NDC,,,facility,outpatient,1,EA,51.55000,14.95000,Aetna,Local,,26.17,,,,,,,18.58,42.17,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,51285016288,NDC,,,facility,outpatient,1,EA,268.35000,77.82000,Aetna,Local,,136.24,,,,,,,96.74,219.51,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,51224020650,NDC,,,facility,outpatient,1,EA,24.30000,7.05000,Aetna,Local,,12.34,,,,,,,8.76,19.88,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,51224001325,NDC,facility,inpatient,500,ME,55.00000,15.95000,Aetna,Local,,22.00,,,,,,,19.83,44.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
enfortumab vedotin-ejfv 30mg I(Padcev),800051970,CDM,636,RC,J9177,HCPCS,51144003001,NDC,facility,inpatient,30,ME,22939.90000,6652.57000,Aetna,Local,,9175.96,,,,,,,8269.83,18764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
enfortumab vedotin-ejfv 20mg I(Padcev),800051972,CDM,636,RC,J9177,HCPCS,51144002001,NDC,facility,inpatient,20,ME,15355.60000,4453.12000,Aetna,Local,,6142.24,,,,,,,5535.69,12560.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fluvoxaMINE 100mg T,800081134,CDM,637,RC,51079099320,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,Local,,9.49,,,,,,,6.74,15.30,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,51079099120,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,51079098620,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,51079098520,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,51079097820,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,Local,,3.35,,,,,,,2.38,5.40,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,51079097220,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,51079095820,NDC,,,facility,outpatient,1,EA,26.60000,7.71000,Aetna,Local,,13.50,,,,,,,9.59,21.76,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,51079094420,NDC,,,facility,outpatient,1,EA,13.90000,4.03000,Aetna,Local,,7.06,,,,,,,5.01,11.37,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,51079093220,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,51079093120,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,51079092920,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,51079092420,NDC,,,facility,outpatient,1,EA,28.15000,8.16000,Aetna,Local,,14.29,,,,,,,10.15,23.03,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,51079092320,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,Local,,6.27,,,,,,,4.45,10.10,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,51079092120,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,Local,,4.75,,,,,,,3.37,7.65,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,51079089120,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,Local,,1.04,,,,,,,0.73903,1.68,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,51079088620,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,51079088121,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,51079088120,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,51079084610,NDC,,,facility,outpatient,1,EA,15.60000,4.52000,Aetna,Local,,7.92,,,,,,,5.62,12.76,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,51079082120,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,51079081920,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,51079081320,NDC,,,facility,outpatient,1,EA,51.15000,14.83000,Aetna,Local,,25.97,,,,,,,18.44,41.84,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,51079080120,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,Local,,2.06,,,,,,,1.46,3.31,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,51079078920,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,Local,,3.10,,,,,,,2.20,4.99,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,51079078820,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,51079078720,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,Local,,3.73,,,,,,,2.65,6.01,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,51079077721,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,51079077120,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,51079076820,NDC,,,facility,outpatient,1,EA,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,5.05,11.45,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,51079076708,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,Local,,14.65,,,,,,,10.40,23.60,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,51079075920,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,51079075320,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,51079073620,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,Local,,3.93,,,,,,,2.79,6.34,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,51079073420,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,51079073320,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,51079072520,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,Local,,18.76,,,,,,,13.32,30.23,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,51079072420,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,Local,,18.76,,,,,,,13.32,30.23,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,51079072220,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,Local,,11.80,,,,,,,8.38,19.02,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,51079068420,NDC,,,facility,outpatient,1,EA,6.30000,1.83000,Aetna,Local,,3.20,,,,,,,2.27,5.15,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,51079064420,NDC,,,facility,outpatient,1,EA,6.85000,1.99000,Aetna,Local,,3.48,,,,,,,2.47,5.60,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,51079063020,NDC,,,facility,outpatient,1,EA,12.85000,3.73000,Aetna,Local,,6.52,,,,,,,4.63,10.51,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,51079062820,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,51079060520,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,51079060420,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,Local,,3.02,,,,,,,2.14,4.87,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,51079059820,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,Local,,4.14,,,,,,,2.94,6.67,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,51079058420,NDC,,,facility,outpatient,1,EA,19.55000,5.67000,Aetna,Local,,9.93,,,,,,,7.05,15.99,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,51079056620,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,51079056103,NDC,,,facility,outpatient,1,EA,210.85000,61.15000,Aetna,Local,,107.05,,,,,,,76.01,172.48,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,51079055803,NDC,,,facility,outpatient,1,EA,182.30000,52.87000,Aetna,Local,,92.55,,,,,,,65.72,149.12,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,51079055720,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,51079052056,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,51079052020,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,51079051620,NDC,,,facility,outpatient,1,EA,157.45000,45.66000,Aetna,Local,,79.94,,,,,,,56.76,128.79,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,51079045320,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,Local,,9.75,,,,,,,6.92,15.71,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,51079044420,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,51079044320,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,51079044220,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,Local,,2.39,,,,,,,1.69,3.84,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,51079044120,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,51079044020,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,51079042820,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,51079041820,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,51079041720,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,51079039220,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,Local,,6.50,,,,,,,4.61,10.47,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,51079038621,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,51079038620,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,51079037520,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,51079030710,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,Local,,4.04,,,,,,,2.87,6.50,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,51079029920,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,51079029808,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,51079028520,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
diazePAM 2mg T(Valium),800050533,CDM,637,RC,51079028420,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,51079028220,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,51079028120,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
Metoprolol 12.5mg T(Lopressor),800046484,CDM,637,RC,51079025520,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,51079025520,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,51079022020,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,51079021320,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,Local,,6.55,,,,,,,4.65,10.55,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,51079021020,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,Local,,1.88,,,,,,,1.33,3.03,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,51079020820,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,51079020620,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,Local,,2.72,,,,,,,1.93,4.38,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,51079020520,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,Local,,1.35,,,,,,,0.95532,2.17,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,51079020519,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,Local,,1.35,,,,,,,0.95532,2.17,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,51079019020,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,51079019019,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,51079017103,NDC,,,facility,outpatient,1,EA,12.45000,3.61000,Aetna,Local,,6.32,,,,,,,4.49,10.18,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,51079017020,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,Local,,4.21,,,,,,,2.99,6.79,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,51079016920,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,Local,,4.21,,,,,,,2.99,6.79,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,51079016520,NDC,,,facility,outpatient,1,EA,323.65000,93.86000,Aetna,Local,,164.32,,,,,,,116.68,264.75,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,51079016503,NDC,,,facility,outpatient,1,EA,357.25000,103.60000,Aetna,Local,,181.38,,,,,,,128.79,292.23,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,51079016120,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,51079014220,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,Local,,2.72,,,,,,,1.93,4.38,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,51079014120,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,Local,,2.72,,,,,,,1.93,4.38,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,51079013120,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,51079011820,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,51079010720,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,51079010320,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,51079009520,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,51079008620,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,Local,,9.75,,,,,,,6.92,15.71,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,51079008320,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,Local,,4.62,,,,,,,3.28,7.44,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,51079007620,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,51079007520,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,51079007420,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,Local,,1.50,,,,,,,1.06,2.41,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,51079007320,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,51079007220,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,51079007219,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,Local,,0.76155,,,,,,,0.54075,1.23,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,51079006720,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,51079005820,NDC,,,facility,outpatient,1,EA,16.25000,4.71000,Aetna,Local,,8.25,,,,,,,5.86,13.29,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,51079005520,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,51079005120,NDC,,,facility,outpatient,1,EA,37.30000,10.82000,Aetna,Local,,18.94,,,,,,,13.45,30.51,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,51079004120,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,51079002320,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,Local,,11.80,,,,,,,8.38,19.02,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,51079002003,NDC,,,facility,outpatient,1,EA,161.45000,46.82000,Aetna,Local,,81.97,,,,,,,58.20,132.07,percent of total billed charges,
Neomycin 500mg T,800016609,CDM,637,RC,51079001520,NDC,,,facility,outpatient,1,EA,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,5.05,11.45,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,50962047560,NDC,,,facility,outpatient,1,EA,67.95000,19.71000,Aetna,Local,,34.50,,,,,,,24.50,55.58,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,50962022560,NDC,,,facility,outpatient,1,EA,11.80000,3.42000,Aetna,Local,,5.99,,,,,,,4.25,9.65,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,50742063360,NDC,,,facility,outpatient,1,EA,122.10000,35.41000,Aetna,Local,,61.99,,,,,,,44.02,99.88,percent of total billed charges,
Nitroglycerin 0.3mg/hr TD(Nitro-Dur),800074251,CDM,637,RC,50742051530,NDC,,,facility,outpatient,1,EA,426.60000,123.71000,Aetna,Local,,216.58,,,,,,,153.79,348.96,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,50742050524,NDC,,,facility,outpatient,1,EA,162.65000,47.17000,Aetna,Local,,82.58,,,,,,,58.64,133.05,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,50742050510,NDC,,,facility,outpatient,1,EA,162.65000,47.17000,Aetna,Local,,82.58,,,,,,,58.64,133.05,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,50742048401,NDC,facility,inpatient,3.5,ME,1807.00000,524.03000,Aetna,Local,,722.80,,,,,,,651.42,1478.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,50742044745,NDC,facility,inpatient,50,ME,174.75000,50.68000,Aetna,Local,,69.90,,,,,,,63.00,142.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,50742026001,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,50742024990,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,50742024930,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,50742024001,NDC,,,facility,outpatient,1,EA,21.45000,6.22000,Aetna,Local,,10.89,,,,,,,7.73,17.55,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,50742023901,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,Local,,9.11,,,,,,,6.47,14.68,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,50742017901,NDC,,,facility,outpatient,1,EA,28.40000,8.24000,Aetna,Local,,14.42,,,,,,,10.24,23.23,percent of total billed charges,
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,50673025021,NDC,facility,inpatient,50,ME,825.35000,239.35000,Aetna,Local,,330.14,,,,,,,297.54,675.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isosulfan Blue 10mg/mL 5mL I(Lympha,800013315,CDM,636,RC,Q9968,HCPCS,50673025021,NDC,facility,outpatient,50,ME,825.35000,239.35000,Aetna,Local,,330.14,,,,,,,5.42,675.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydroxocobalamin 5g Kit,800081127,CDM,636,RC,J3424,HCPCS,50633031011,NDC,facility,inpatient,5,GM,7372.60000,2138.05000,Aetna,Local,,2949.04,,,,,,,2657.82,6030.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,50632001001,NDC,facility,inpatient,1,EA,1921.50000,557.24000,Aetna,Local,,768.60,,,,,,,692.70,1571.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Vaccine-P.Chick Embryo I(RabAvert),800017965,CDM,636,RC,90675,HCPCS,50632001001,NDC,facility,outpatient,1,EA,1921.50000,557.24000,Aetna,Local,,768.60,,,,,,,307.92,1571.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,50532011510,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,Local,,3.55,,,,,,,2.52,5.73,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,50532011310,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,50484001030,NDC,,,facility,outpatient,1,EA,2128.15000,617.16000,Aetna,Local,,1080.46,,,,,,,767.20,1740.83,percent of total billed charges,
Brivaracetam 10mg/mL Inj 5mL,800040910,CDM,636,RC,50474097075,NDC,,,facility,inpatient,1,EA,568.30000,164.81000,Aetna,Local,,227.32,,,,,,,204.87,464.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Brivaracetam 10mg/mL Inj 5mL,800040910,CDM,636,RC,50474097075,NDC,,,facility,outpatient,1,EA,568.30000,164.81000,Aetna,Local,,227.32,,,,,,,204.87,464.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Certolizumab Pegol Lypholized Kit,800046570,CDM,636,RC,J0717,HCPCS,50474070062,NDC,facility,inpatient,200,ME,19375.20000,5618.81000,Aetna,Local,,7750.08,,,,,,,6984.76,15848.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,50474059540,NDC,,,facility,outpatient,1,EA,86.00000,24.94000,Aetna,Local,,43.66,,,,,,,31.00,70.35,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,50474059440,NDC,,,facility,outpatient,1,EA,70.35000,20.40000,Aetna,Local,,35.72,,,,,,,25.36,57.55,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,50474059240,NDC,,,facility,outpatient,1,EA,20.65000,5.99000,Aetna,Local,,10.48,,,,,,,7.44,16.89,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,50474059140,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,Local,,8.58,,,,,,,6.09,13.82,percent of total billed charges,
Brivaracetam 25 mg Tab,800046422,CDM,637,RC,50474047066,NDC,,,facility,outpatient,1,EA,233.95000,67.85000,Aetna,Local,,118.78,,,,,,,84.34,191.37,percent of total billed charges,
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,50474000263,NDC,facility,inpatient,500,ME,611.10000,177.22000,Aetna,Local,,244.44,,,,,,,220.30,499.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,50458092550,NDC,,,facility,outpatient,1,EA,252.15000,73.12000,Aetna,Local,,128.02,,,,,,,90.90,206.26,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,50458092050,NDC,,,facility,outpatient,1,EA,203.10000,58.90000,Aetna,Local,,103.11,,,,,,,73.22,166.14,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,50458082004,NDC,,,facility,outpatient,1,EA,50.55000,14.66000,Aetna,Local,,25.66,,,,,,,18.22,41.35,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,50458082002,NDC,,,facility,outpatient,1,EA,73.75000,21.39000,Aetna,Local,,37.44,,,,,,,26.59,60.33,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,50458064565,NDC,,,facility,outpatient,1,EA,64.95000,18.84000,Aetna,Local,,32.98,,,,,,,23.41,53.13,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,50458064165,NDC,,,facility,outpatient,1,EA,154.80000,44.89000,Aetna,Local,,78.59,,,,,,,55.81,126.63,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,50458063965,NDC,,,facility,outpatient,1,EA,56.80000,16.47000,Aetna,Local,,28.84,,,,,,,20.48,46.46,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,50458059601,NDC,,,facility,outpatient,1,EA,34.50000,10.00000,Aetna,Local,,17.52,,,,,,,12.44,28.22,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458059260,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,Local,,5.48,,,,,,,3.89,8.83,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458059210,NDC,,,facility,outpatient,1,EA,16.65000,4.83000,Aetna,Local,,8.45,,,,,,,6.00,13.62,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,50458059060,NDC,,,facility,outpatient,1,EA,9.25000,2.68000,Aetna,Local,,4.70,,,,,,,3.33,7.57,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),800015373,CDM,637,RC,50458058090,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,Local,,81.89,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),800015373,CDM,637,RC,50458058030,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,Local,,81.89,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 10mg T(Xarelto),800015373,CDM,637,RC,50458058010,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,Local,,81.89,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),800017952,CDM,637,RC,50458057990,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,Local,,81.89,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),800017952,CDM,637,RC,50458057930,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,Local,,81.89,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 20mg T(Xarelto),800017952,CDM,637,RC,50458057910,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,Local,,81.89,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),800015432,CDM,637,RC,50458057890,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,Local,,81.89,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),800015432,CDM,637,RC,50458057830,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,Local,,81.89,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 15mg T(Xarelto),800015432,CDM,637,RC,50458057810,NDC,,,facility,outpatient,1,EA,161.30000,46.78000,Aetna,Local,,81.89,,,,,,,58.15,131.94,percent of total billed charges,
Rivaroxaban 2.5mg T(Xarelto),800046453,CDM,637,RC,50458057710,NDC,,,facility,outpatient,1,EA,80.65000,23.39000,Aetna,Local,,40.95,,,,,,,29.07,65.97,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,50458055010,NDC,,,facility,outpatient,1,EA,331.40000,96.11000,Aetna,Local,,168.25,,,,,,,119.47,271.09,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,50458055001,NDC,,,facility,outpatient,1,EA,106.25000,30.81000,Aetna,Local,,53.94,,,,,,,38.30,86.91,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,50458051360,NDC,,,facility,outpatient,1,EA,11.80000,3.42000,Aetna,Local,,5.99,,,,,,,4.25,9.65,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,50458030503,NDC,,,facility,outpatient,1,EA,46.50000,13.48000,Aetna,Local,,23.61,,,,,,,16.76,38.04,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,50458030150,NDC,,,facility,outpatient,1,EA,75.45000,21.88000,Aetna,Local,,38.31,,,,,,,27.20,61.72,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,50458030104,NDC,,,facility,outpatient,1,EA,83.00000,24.07000,Aetna,Local,,42.14,,,,,,,29.92,67.89,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458030006,NDC,,,facility,outpatient,1,EA,41.65000,12.08000,Aetna,Local,,21.15,,,,,,,15.01,34.07,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,50458030001,NDC,,,facility,outpatient,1,EA,41.65000,12.08000,Aetna,Local,,21.15,,,,,,,15.01,34.07,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,800021977,CDM,637,RC,50458029515,NDC,,,facility,outpatient,1,EA,195.40000,56.67000,Aetna,Local,,99.20,,,,,,,70.44,159.84,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,50458025501,NDC,facility,inpatient,5,ME,131.75000,38.21000,Aetna,Local,,52.70,,,,,,,47.50,107.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,50458022115,NDC,,,facility,outpatient,1,EA,1678.70000,486.82000,Aetna,Local,,852.28,,,,,,,605.17,1373.18,percent of total billed charges,
levoFLOXacin  25mg/mL L,800081070,CDM,637,RC,50458017001,NDC,,,facility,outpatient,1,ML,13.20000,3.83000,Aetna,Local,,6.70,,,,,,,4.76,10.80,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,50458016801,NDC,facility,inpatient,500,ME,202.25000,58.65000,Aetna,Local,,80.90,,,,,,,72.91,165.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,50458016701,NDC,facility,inpatient,250,ME,102.35000,29.68000,Aetna,Local,,40.94,,,,,,,36.90,83.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,50458016601,NDC,facility,inpatient,750,ME,264.65000,76.75000,Aetna,Local,,105.86,,,,,,,95.41,216.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,50458009005,NDC,,,facility,outpatient,1,EA,355.30000,103.04000,Aetna,Local,,180.39,,,,,,,128.09,290.64,percent of total billed charges,
SUFentanil 50mcg/mL 1mL I,800049758,CDM,250,RC,50458005001,NDC,,,facility,outpatient,1,EA,117.20000,33.99000,Aetna,Local,,59.50,,,,,,,42.25,95.87,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,50458003705,NDC,,,facility,outpatient,1,EA,151.75000,44.01000,Aetna,Local,,77.04,,,,,,,54.71,124.13,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,50458003605,NDC,,,facility,outpatient,1,EA,631.25000,183.06000,Aetna,Local,,320.49,,,,,,,227.57,516.36,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,50458003505,NDC,,,facility,outpatient,1,EA,484.95000,140.64000,Aetna,Local,,246.21,,,,,,,174.82,396.69,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,50458003405,NDC,,,facility,outpatient,1,EA,224.05000,64.97000,Aetna,Local,,113.75,,,,,,,80.77,183.27,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,50458003305,NDC,,,facility,outpatient,1,EA,123.05000,35.68000,Aetna,Local,,62.47,,,,,,,44.36,100.65,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,50419045204,NDC,,,facility,outpatient,1,EA,162.05000,46.99000,Aetna,Local,,82.27,,,,,,,58.42,132.56,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,50419045104,NDC,,,facility,outpatient,1,EA,162.05000,46.99000,Aetna,Local,,82.27,,,,,,,58.42,132.56,percent of total billed charges,
Levonorgestrel 52mg IUD(Mirena),800062031,CDM,636,RC,J7298,HCPCS,50419042301,NDC,facility,inpatient,52,ME,7689.40000,2229.93000,Aetna,Local,,3075.76,,,,,,,2772.03,6289.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032537,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,Local,,21.20,,,,,,,19.11,43.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032519,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,Local,,21.20,,,,,,,19.11,43.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032518,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,Local,,21.20,,,,,,,19.11,43.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032513,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,Local,,21.20,,,,,,,19.11,43.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032512,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,Local,,21.20,,,,,,,19.11,43.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadobutrol 604.72mg/1mL Inj,800022110,CDM,636,RC,A9585,HCPCS,50419032511,NDC,facility,inpatient,1,EA,53.00000,15.37000,Aetna,Local,,21.20,,,,,,,19.11,43.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadoxetate 181.43mg/mL I 10mL,800022111,CDM,636,RC,A9581,HCPCS,50419032005,NDC,facility,inpatient,1,EA,740.75000,214.82000,Aetna,Local,,296.30,,,,,,,267.04,605.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Gadoxetate 181.43mg/mL I 10mL,800022111,CDM,636,RC,A9581,HCPCS,50419032001,NDC,facility,inpatient,1,EA,710.75000,206.12000,Aetna,Local,,284.30,,,,,,,256.23,581.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,50419010511,NDC,,,facility,outpatient,1,EA,22.20000,6.44000,Aetna,Local,,11.27,,,,,,,8.00,18.16,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,50419010510,NDC,,,facility,outpatient,1,EA,33.70000,9.77000,Aetna,Local,,17.11,,,,,,,12.15,27.57,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,50383093335,NDC,,,facility,outpatient,1,EA,1809.00000,524.61000,Aetna,Local,,918.43,,,,,,,652.14,1479.76,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,50383081016,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,Local,,16.91,,,,,,,12.00,27.24,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,50383080716,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,Local,,5.53,,,,,,,3.93,8.92,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,50383080116,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,50383079616,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,50383079516,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,50383077931,NDC,,,facility,outpatient,1,EA,21.10000,6.12000,Aetna,Local,,10.71,,,,,,,7.61,17.26,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,800062055,CDM,637,RC,50383077917,NDC,,,facility,outpatient,1,EA,17.80000,5.16000,Aetna,Local,,9.04,,,,,,,6.42,14.56,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,50383077517,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,Local,,3.88,,,,,,,2.76,6.26,percent of total billed charges,
GI Cocktail 50mL UD - ED Use,800025577,CDM,637,RC,50383077515,NDC,,,facility,outpatient,1,EA,48.15000,13.96000,Aetna,Local,,24.45,,,,,,,17.36,39.39,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,50383072017,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,Local,,4.11,,,,,,,2.92,6.63,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,50383072016,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,Local,,1.19,,,,,,,0.84718,1.92,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,50383070016,NDC,,,facility,outpatient,1,EA,552.65000,160.27000,Aetna,Local,,280.58,,,,,,,199.23,452.07,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,50383062750,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,Local,,0.63462,,,,,,,0.45062,1.02,percent of total billed charges,
NICU- Ferrous Sulfate 2.25mg/0.15mL L UD,800015385,CDM,637,RC,50383062750,NDC,,,facility,outpatient,1,EA,0.20000,0.06000,Aetna,Local,,0.10154,,,,,,,0.07210,0.16360,percent of total billed charges,
NICU- Ferrous Sulfate 3.75mg/0.25mL L UD,800015387,CDM,637,RC,50383062750,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,Local,,0.15231,,,,,,,0.10815,0.24540,percent of total billed charges,
Gabapentin 300mg/6mL Oral Liq UD,800017998,CDM,637,RC,50383031109,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,800015357,CDM,637,RC,50383031107,NDC,,,facility,outpatient,1,EA,14.75000,4.28000,Aetna,Local,,7.49,,,,,,,5.32,12.07,percent of total billed charges,
levoFLOXacin  25mg/mL L,800081070,CDM,637,RC,50383028616,NDC,,,facility,outpatient,1,ML,9.80000,2.84000,Aetna,Local,,4.98,,,,,,,3.53,8.02,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,50383026730,NDC,,,facility,outpatient,1,EA,1587.75000,460.45000,Aetna,Local,,806.10,,,,,,,572.38,1298.78,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,50383024116,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,50383024106,NDC,,,facility,outpatient,1,EA,48.65000,14.11000,Aetna,Local,,24.70,,,,,,,17.54,39.80,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,50383023210,NDC,,,facility,outpatient,1,EA,446.15000,129.38000,Aetna,Local,,226.51,,,,,,,160.84,364.95,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,800072518,CDM,637,RC,50383008712,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,50268081915,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,50268081615,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,Local,,6.19,,,,,,,4.40,9.98,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,50268079815,NDC,,,facility,outpatient,1,EA,14.60000,4.23000,Aetna,Local,,7.41,,,,,,,5.26,11.94,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,50268079715,NDC,,,facility,outpatient,1,EA,54.10000,15.69000,Aetna,Local,,27.47,,,,,,,19.50,44.25,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,50268077915,NDC,,,facility,outpatient,1,EA,7.85000,2.28000,Aetna,Local,,3.99,,,,,,,2.83,6.42,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,50268077515,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,50268077213,NDC,,,facility,outpatient,1,EA,37.25000,10.80000,Aetna,Local,,18.91,,,,,,,13.43,30.47,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,50268077015,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,50268076615,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,50268076415,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,50268076015,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,50268075915,NDC,,,facility,outpatient,1,EA,12.40000,3.60000,Aetna,Local,,6.30,,,,,,,4.47,10.14,percent of total billed charges,
Tenofovir 300mg T(Viread),800017725,CDM,637,RC,50268075812,NDC,,,facility,outpatient,1,EA,40.05000,11.61000,Aetna,Local,,20.33,,,,,,,14.44,32.76,percent of total billed charges,
Torsemide 100mg T,800046505,CDM,637,RC,50268075715,NDC,,,facility,outpatient,1,EA,20.50000,5.94000,Aetna,Local,,10.41,,,,,,,7.39,16.77,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,50268075615,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,50268075415,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,50268074514,NDC,,,facility,outpatient,1,EA,60.90000,17.66000,Aetna,Local,,30.92,,,,,,,21.95,49.82,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,50268074415,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,50268074315,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,50268074115,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,Local,,2.13,,,,,,,1.51,3.44,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,50268074015,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,Local,,1.70,,,,,,,1.21,2.74,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,50268073212,NDC,,,facility,outpatient,1,EA,86.25000,25.01000,Aetna,Local,,43.79,,,,,,,31.09,70.55,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,50268072515,NDC,,,facility,outpatient,1,EA,24.50000,7.10000,Aetna,Local,,12.44,,,,,,,8.83,20.04,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,50268072215,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,50268071115,NDC,,,facility,outpatient,1,EA,11.25000,3.26000,Aetna,Local,,5.71,,,,,,,4.06,9.20,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,50268070915,NDC,,,facility,outpatient,1,EA,9.70000,2.81000,Aetna,Local,,4.92,,,,,,,3.50,7.93,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,50268069415,NDC,,,facility,outpatient,1,EA,50.45000,14.63000,Aetna,Local,,25.61,,,,,,,18.19,41.27,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,50268068715,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,50268068615,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,50268067415,NDC,,,facility,outpatient,1,EA,105.05000,30.46000,Aetna,Local,,53.33,,,,,,,37.87,85.93,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,50268066615,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,Local,,8.96,,,,,,,6.36,14.44,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,50268066315,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,50268065415,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,4.42,,,,,,,3.14,7.12,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,50268065212,NDC,,,facility,outpatient,1,EA,23.90000,6.93000,Aetna,Local,,12.13,,,,,,,8.62,19.55,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,50268064015,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,50268063915,NDC,,,facility,outpatient,1,EA,28.50000,8.26000,Aetna,Local,,14.47,,,,,,,10.27,23.31,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,50268063215,NDC,,,facility,outpatient,1,EA,45.75000,13.27000,Aetna,Local,,23.23,,,,,,,16.49,37.42,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,50268063015,NDC,,,facility,outpatient,1,EA,26.30000,7.63000,Aetna,Local,,13.35,,,,,,,9.48,21.51,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,50268062715,NDC,,,facility,outpatient,1,EA,21.75000,6.31000,Aetna,Local,,11.04,,,,,,,7.84,17.79,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,50268062515,NDC,,,facility,outpatient,1,EA,30.35000,8.80000,Aetna,Local,,15.41,,,,,,,10.94,24.83,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,50268062315,NDC,,,facility,outpatient,1,EA,31.30000,9.08000,Aetna,Local,,15.89,,,,,,,11.28,25.60,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,50268061513,NDC,,,facility,outpatient,1,EA,98.95000,28.70000,Aetna,Local,,50.24,,,,,,,35.67,80.94,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,50268060415,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,Local,,2.13,,,,,,,1.51,3.44,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,50268060315,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,50268059715,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,Local,,4.72,,,,,,,3.35,7.61,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,50268059415,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,50268058813,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,50268057515,NDC,,,facility,outpatient,1,EA,35.25000,10.22000,Aetna,Local,,17.90,,,,,,,12.71,28.83,percent of total billed charges,
Mupirocin 2% Top Oint 1g UD,800022088,CDM,637,RC,50268057260,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,Local,,18.43,,,,,,,13.09,29.69,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,50268056215,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,Local,,3.73,,,,,,,2.65,6.01,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,50268055313,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,Local,,7.01,,,,,,,4.97,11.29,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,50268055015,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,Local,,2.23,,,,,,,1.59,3.60,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,50268054215,NDC,,,facility,outpatient,1,EA,11.85000,3.44000,Aetna,Local,,6.02,,,,,,,4.27,9.69,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,50268054115,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,Local,,3.96,,,,,,,2.81,6.38,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,50268054015,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,Local,,3.96,,,,,,,2.81,6.38,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,50268053115,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,Local,,4.80,,,,,,,3.41,7.73,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,50268052515,NDC,,,facility,outpatient,1,EA,21.95000,6.37000,Aetna,Local,,11.14,,,,,,,7.91,17.96,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,50268052115,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,50268052015,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,50268050615,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,50268050515,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,50268050415,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,50268047715,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,Local,,21.58,,,,,,,15.32,34.77,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,50268047013,NDC,,,facility,outpatient,1,EA,48.65000,14.11000,Aetna,Local,,24.70,,,,,,,17.54,39.80,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,50268045115,NDC,,,facility,outpatient,1,EA,11.65000,3.38000,Aetna,Local,,5.91,,,,,,,4.20,9.53,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,50268043015,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,50268041112,NDC,,,facility,outpatient,1,EA,102.10000,29.61000,Aetna,Local,,51.84,,,,,,,36.81,83.52,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,50268040815,NDC,,,facility,outpatient,1,EA,12.50000,3.62000,Aetna,Local,,6.35,,,,,,,4.51,10.22,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,50268040515,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,Local,,7.01,,,,,,,4.97,11.29,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,50268040315,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,Local,,4.04,,,,,,,2.87,6.50,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,50268040115,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,Local,,4.04,,,,,,,2.87,6.50,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,50268035815,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,50268035115,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,Local,,8.55,,,,,,,6.07,13.78,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,50268035015,NDC,,,facility,outpatient,1,EA,8.25000,2.39000,Aetna,Local,,4.19,,,,,,,2.97,6.75,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,50268033715,NDC,,,facility,outpatient,1,EA,67.50000,19.58000,Aetna,Local,,34.27,,,,,,,24.33,55.22,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,50268033015,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,50268032315,NDC,,,facility,outpatient,1,EA,22.30000,6.47000,Aetna,Local,,11.32,,,,,,,8.04,18.24,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,50268032115,NDC,,,facility,outpatient,1,EA,42.30000,12.27000,Aetna,Local,,21.48,,,,,,,15.25,34.60,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,50268031415,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,50268031315,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,Local,,18.43,,,,,,,13.09,29.69,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,50268031215,NDC,,,facility,outpatient,1,EA,12.05000,3.49000,Aetna,Local,,6.12,,,,,,,4.34,9.86,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,50268030613,NDC,,,facility,outpatient,1,EA,45.85000,13.30000,Aetna,Local,,23.28,,,,,,,16.53,37.51,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,50268029915,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,50268029812,NDC,,,facility,outpatient,1,EA,87.75000,25.45000,Aetna,Local,,44.55,,,,,,,31.63,71.78,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,50268029515,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,Local,,21.58,,,,,,,15.32,34.77,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,50268028813,NDC,,,facility,outpatient,1,EA,41.95000,12.17000,Aetna,Local,,21.30,,,,,,,15.12,34.32,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,50268028213,NDC,,,facility,outpatient,1,EA,42.80000,12.41000,Aetna,Local,,21.73,,,,,,,15.43,35.01,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,50268027815,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,Local,,14.37,,,,,,,10.20,23.15,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,50268027013,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,Local,,6.19,,,,,,,4.40,9.98,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,50268026013,NDC,,,facility,outpatient,1,EA,11.65000,3.38000,Aetna,Local,,5.91,,,,,,,4.20,9.53,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,50268025915,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,Local,,2.23,,,,,,,1.59,3.60,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,50268022015,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,Local,,10.79,,,,,,,7.66,17.38,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,50268019560,NDC,,,facility,outpatient,1,EA,70.45000,20.43000,Aetna,Local,,35.77,,,,,,,25.40,57.63,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,50268019115,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,Local,,0.76155,,,,,,,0.54075,1.23,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,50268019015,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,4.42,,,,,,,3.14,7.12,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,50268018915,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,50268018715,NDC,,,facility,outpatient,1,EA,50.95000,14.78000,Aetna,Local,,25.87,,,,,,,18.37,41.68,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,50268018412,NDC,,,facility,outpatient,1,EA,136.40000,39.56000,Aetna,Local,,69.25,,,,,,,49.17,111.58,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,50268017715,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,Local,,8.10,,,,,,,5.75,13.05,percent of total billed charges,
clonazePAM 2mg T(KlonoPIN),800051122,CDM,637,RC,50268017515,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,50268017315,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,50268016915,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,50268015215,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,50268013015,NDC,,,facility,outpatient,1,EA,10.75000,3.12000,Aetna,Local,,5.46,,,,,,,3.88,8.79,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,50268010615,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,Local,,2.23,,,,,,,1.59,3.60,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,50268009715,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,Local,,26.71,,,,,,,18.96,43.03,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,50268009315,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,50268008415,NDC,,,facility,outpatient,1,EA,24.65000,7.15000,Aetna,Local,,12.51,,,,,,,8.89,20.16,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,50268007515,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,Local,,7.44,,,,,,,5.28,11.98,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,50268007413,NDC,,,facility,outpatient,1,EA,8.90000,2.58000,Aetna,Local,,4.52,,,,,,,3.21,7.28,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,50268005015,NDC,,,facility,outpatient,1,EA,12.60000,3.65000,Aetna,Local,,6.40,,,,,,,4.54,10.31,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,50268003715,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Atezolizumab 840mg- Pt Own Supply,800052010,CDM,636,RC,J9022,HCPCS,50242091801,NDC,facility,inpatient,840,ME,0.15000,0.04000,Aetna,Local,,0.06000,,,,,,,0.05407,0.12270,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
atezolizumab 1200 mg/20 mL Inj (Tecentriq),800062075,CDM,636,RC,J9022,HCPCS,50242091701,NDC,facility,inpatient,1200,ME,60946.75000,17674.56000,Aetna,Local,,24378.70,,,,,,,21971.30,49854.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
pertuz/trastuz/hyal 10mL I-Maint. Dose,800051992,CDM,636,RC,J9316,HCPCS,50242026001,NDC,facility,inpatient,1,EA,66983.70000,19425.27000,Aetna,Local,,26793.48,,,,,,,24147.62,54792.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
omalizumab 300mg/2mL IS(Xolair),800051050,CDM,636,RC,J2357,HCPCS,50242022701,NDC,facility,inpatient,300,ME,11473.65000,3327.36000,Aetna,Local,,4589.46,,,,,,,4136.25,9385.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omalizumab 150mg/mL IS(Xolair),800040913,CDM,636,RC,J2357,HCPCS,50242021503,NDC,facility,inpatient,150,ME,5831.80000,1691.22000,Aetna,Local,,2332.72,,,,,,,2102.36,4770.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omalizumab 150mg/mL IS(Xolair),800040913,CDM,636,RC,J2357,HCPCS,50242021501,NDC,facility,inpatient,150,ME,5831.80000,1691.22000,Aetna,Local,,2332.72,,,,,,,2102.36,4770.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omalizumab 75mg/0.5mL IS(Xolair),800040914,CDM,636,RC,J2357,HCPCS,50242021403,NDC,facility,inpatient,75,ME,3010.90000,873.16000,Aetna,Local,,1204.36,,,,,,,1085.43,2462.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Omalizumab 75mg/0.5mL IS(Xolair),800040914,CDM,636,RC,J2357,HCPCS,50242021401,NDC,facility,inpatient,75,ME,3010.90000,873.16000,Aetna,Local,,1204.36,,,,,,,1085.43,2462.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ocrelizumab 300mg/10mL I(Ocrevus),800040862,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,inpatient,300,ME,148801.90000,43152.55000,Aetna,Local,,59520.76,,,,,,,53643.08,121719.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ocrelizumab- Pt Own Supply,800040901,CDM,636,RC,J2350,HCPCS,50242015001,NDC,facility,inpatient,300,ME,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pertuzumab 420 mg Inj- Pt Own Supply,800051015,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,inpatient,420,ME,0.15000,0.04000,Aetna,Local,,0.06000,,,,,,,0.05407,0.12270,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pertuzumab 420 mg/14 mL I(Perjeta),800022005,CDM,636,RC,J9306,HCPCS,50242014501,NDC,facility,inpatient,420,ME,37017.65000,10735.12000,Aetna,Local,,14807.06,,,,,,,13344.86,30280.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
tocilizumab- Pt Own Supply,800051984,CDM,636,RC,J3262,HCPCS,50242013501,NDC,facility,inpatient,80,ME,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab 150mg I(Herceptin),800022087,CDM,636,RC,J9355,HCPCS,50242013201,NDC,facility,inpatient,150,ME,8602.45000,2494.71000,Aetna,Local,,3440.98,,,,,,,3101.18,7036.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tenecteplase 50mg Inj,800079383,CDM,636,RC,J3101,HCPCS,50242012047,NDC,facility,inpatient,50,ME,33246.30000,9641.43000,Aetna,Local,,13298.52,,,,,,,11985.29,27195.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
polatuzumab vedotin - piiq 140mg I(Polivy),800051076,CDM,636,RC,J9309,HCPCS,50242010501,NDC,facility,inpatient,140,ME,134189.15000,38914.85000,Aetna,Local,,53675.66,,,,,,,48375.19,109766.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
polatuzumab vedotin - piiq 30mg I(Polivy),800051075,CDM,636,RC,J9309,HCPCS,50242010301,NDC,facility,inpatient,30,ME,28901.80000,8381.52000,Aetna,Local,,11560.72,,,,,,,10419.10,23641.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab 100mg/10mL I,800074699,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,inpatient,100,ME,6951.55000,2015.95000,Aetna,Local,,2780.62,,,,,,,2506.03,5686.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RiTUXimab 500mg/50mL I,800074707,CDM,636,RC,J9312,HCPCS,50242005306,NDC,facility,inpatient,500,ME,34009.70000,9862.81000,Aetna,Local,,13603.88,,,,,,,12260.50,27819.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab 100mg/10mL I,800074699,CDM,636,RC,J9312,HCPCS,50242005121,NDC,facility,inpatient,100,ME,6951.55000,2015.95000,Aetna,Local,,2780.62,,,,,,,2506.03,5686.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Alteplase 2mg/2mL I(Cathflo),800010875,CDM,636,RC,J2997,HCPCS,50242004164,NDC,facility,inpatient,2,ME,1520.20000,440.86000,Aetna,Local,,608.08,,,,,,,548.03,1243.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,50228048201,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,Local,,5.64,,,,,,,4.00,9.08,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,50228048101,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,50228046101,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,Local,,6.50,,,,,,,4.61,10.47,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,50228046001,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,50228045701,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,50228037930,NDC,,,facility,outpatient,1,EA,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,28.84,65.44,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,50228017501,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,50228010901,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,50111099001,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,50111091701,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,50111091501,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,50111085201,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,Local,,3.17,,,,,,,2.25,5.11,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,50111085101,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,50111079320,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,Local,,41.78,,,,,,,29.67,67.32,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,50111078710,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,Local,,27.97,,,,,,,19.86,45.07,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,50111065201,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,50111064801,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,Local,,9.60,,,,,,,6.81,15.46,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,50111064701,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,Local,,9.34,,,,,,,6.63,15.05,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,50111060801,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,50111056301,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,Local,,4.11,,,,,,,2.92,6.63,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,50111056101,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,Local,,5.00,,,,,,,3.55,8.06,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,50111056001,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,50111053402,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,Local,,1.27,,,,,,,0.90125,2.04,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,50111053401,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,Local,,1.27,,,,,,,0.90125,2.04,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,50111051702,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,50111051701,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,50111046801,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,50111046701,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,50111045602,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,50111045601,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,50111043402,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,Local,,4.75,,,,,,,3.37,7.65,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,50111043401,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,Local,,5.00,,,,,,,3.55,8.06,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,50111043301,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,50111039801,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,50111039301,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,50111033402,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,50111033401,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,50111032801,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,50111032701,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,50111032401,NDC,,,facility,outpatient,1,EA,14.20000,4.12000,Aetna,Local,,7.21,,,,,,,5.12,11.62,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,50111031401,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,Local,,1.52,,,,,,,1.08,2.45,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,50111030801,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,50102059140,NDC,facility,inpatient,150,ME,496.75000,144.06000,Aetna,Local,,198.70,,,,,,,179.08,406.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dapsone 100 mg Tab,800081017,CDM,637,RC,49938010130,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,Local,,12.08,,,,,,,8.58,19.47,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,49938010101,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,Local,,10.79,,,,,,,7.66,17.38,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,49884092101,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,Local,,2.69,,,,,,,1.91,4.34,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,49884090738,NDC,,,facility,outpatient,1,EA,42.45000,12.31000,Aetna,Local,,21.55,,,,,,,15.30,34.72,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,49884083209,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,Local,,9.54,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,49884083011,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,49884083009,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,49884082911,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,49884082909,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,Local,,4.32,,,,,,,3.06,6.95,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,49884078353,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,Local,,5.25,,,,,,,3.73,8.47,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,49884078253,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,49884077901,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,49884077805,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,49884077686,NDC,,,facility,outpatient,1,EA,449.10000,130.24000,Aetna,Local,,228.01,,,,,,,161.90,367.36,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,49884077586,NDC,,,facility,outpatient,1,EA,334.10000,96.89000,Aetna,Local,,169.62,,,,,,,120.44,273.29,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,49884077101,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
Tolvaptan 15mg T (Samsca),800015358,CDM,637,RC,49884076854,NDC,,,facility,outpatient,1,EA,3138.85000,910.27000,Aetna,Local,,1593.59,,,,,,,1131.56,2567.58,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,49884076478,NDC,,,facility,outpatient,1,EA,469.95000,136.29000,Aetna,Local,,238.59,,,,,,,169.42,384.42,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,49884076378,NDC,,,facility,outpatient,1,EA,361.70000,104.89000,Aetna,Local,,183.64,,,,,,,130.39,295.87,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,49884076278,NDC,,,facility,outpatient,1,EA,241.60000,70.06000,Aetna,Local,,122.66,,,,,,,87.10,197.63,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,49884076178,NDC,,,facility,outpatient,1,EA,133.20000,38.63000,Aetna,Local,,67.63,,,,,,,48.02,108.96,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,49884075101,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,Local,,9.60,,,,,,,6.81,15.46,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,49884072703,NDC,,,facility,outpatient,1,EA,16.75000,4.86000,Aetna,Local,,8.50,,,,,,,6.04,13.70,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,49884072401,NDC,,,facility,outpatient,1,EA,9.05000,2.62000,Aetna,Local,,4.59,,,,,,,3.26,7.40,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,49884070801,NDC,,,facility,outpatient,1,EA,10.10000,2.93000,Aetna,Local,,5.13,,,,,,,3.64,8.26,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,49884070701,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,49884069501,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,Local,,9.82,,,,,,,6.98,15.83,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,49884067701,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,Local,,5.00,,,,,,,3.55,8.06,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,49884065301,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,49884065101,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,49884064901,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,Local,,4.67,,,,,,,3.32,7.53,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,49884064101,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,49884064001,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,49884060810,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,49884060801,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,49884060301,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,49884060085,NDC,,,facility,outpatient,1,EA,5056.40000,1466.36000,Aetna,Local,,2567.13,,,,,,,1822.83,4136.14,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,49884058701,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,4.42,,,,,,,3.14,7.12,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,49884057201,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,49884056001,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,Local,,5.58,,,,,,,3.97,9.00,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,49884055801,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,49884051401,NDC,,,facility,outpatient,1,EA,16.30000,4.73000,Aetna,Local,,8.28,,,,,,,5.88,13.33,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,49884050101,NDC,,,facility,outpatient,1,EA,133.40000,38.69000,Aetna,Local,,67.73,,,,,,,48.09,109.12,percent of total billed charges,
LamoTRIgine 25mg ODT,800046462,CDM,637,RC,49884048411,NDC,,,facility,outpatient,1,EA,62.85000,18.23000,Aetna,Local,,31.91,,,,,,,22.66,51.41,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,49884042411,NDC,,,facility,outpatient,1,EA,52.95000,15.36000,Aetna,Local,,26.88,,,,,,,19.09,43.31,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,49884040601,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,49884040501,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,49884040401,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,49884032801,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,Local,,5.58,,,,,,,3.97,9.00,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,49884032055,NDC,,,facility,outpatient,1,EA,101.05000,29.30000,Aetna,Local,,51.30,,,,,,,36.43,82.66,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),800015397,CDM,637,RC,49884030702,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,Local,,5.28,,,,,,,3.75,8.51,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,49884028201,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,49884027101,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,49884025701,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,49884025601,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,49884023537,NDC,,,facility,outpatient,1,EA,26.75000,7.76000,Aetna,Local,,13.58,,,,,,,9.64,21.88,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,49884023533,NDC,,,facility,outpatient,1,EA,26.05000,7.55000,Aetna,Local,,13.23,,,,,,,9.39,21.31,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),800017683,CDM,637,RC,49884021102,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,Local,,35.95,,,,,,,25.52,57.91,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,49884021002,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,Local,,35.95,,,,,,,25.52,57.91,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,49884016401,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,49884016111,NDC,,,facility,outpatient,1,EA,751.45000,217.92000,Aetna,Local,,381.51,,,,,,,270.90,614.69,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,49884012201,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,49884011302,NDC,,,facility,outpatient,1,EA,55.90000,16.21000,Aetna,Local,,28.38,,,,,,,20.15,45.73,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,49884010601,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,49884009902,NDC,,,facility,outpatient,1,EA,55.90000,16.21000,Aetna,Local,,28.38,,,,,,,20.15,45.73,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,49884006501,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,Local,,4.72,,,,,,,3.35,7.61,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,49884002801,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,49884002701,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,49884002101,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,Local,,3.88,,,,,,,2.76,6.26,percent of total billed charges,
Abacavir/Dolut/Lamiv 600-50-300mg T,800040898,CDM,637,RC,49702023113,NDC,,,facility,outpatient,1,EA,959.90000,278.37000,Aetna,Local,,487.34,,,,,,,346.04,785.20,percent of total billed charges,
Dolutegravir 50mg Tab,800040863,CDM,637,RC,49702022813,NDC,,,facility,outpatient,1,EA,605.50000,175.60000,Aetna,Local,,307.41,,,,,,,218.28,495.30,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,49669521302,NDC,facility,inpatient,12.5,GM,18337.00000,5317.73000,Aetna,Local,,7334.80,,,,,,,6610.49,14999.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,49669521101,NDC,facility,inpatient,12.5,GM,668.00000,193.72000,Aetna,Local,,267.20,,,,,,,240.81,546.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 0.15mg Syringe,800019822,CDM,636,RC,J0165,HCPCS,49502050102,NDC,facility,inpatient,0.15,ME,1402.35000,406.68000,Aetna,Local,,560.94,,,,,,,505.55,1147.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,49502050002,NDC,facility,inpatient,0.3,ME,1402.35000,406.68000,Aetna,Local,,560.94,,,,,,,505.55,1147.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,49502050001,NDC,facility,inpatient,0.3,ME,468.65000,135.91000,Aetna,Local,,187.46,,,,,,,168.95,383.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Poractant 240mg/3mL Intratrach Inj,800017811,CDM,252,RC,49502018003,NDC,,,facility,inpatient,1,EA,2802.55000,812.74000,Aetna,Local,,1121.02,,,,,,,1036.94,2292.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Poractant 240mg/3mL Intratrach Inj,800017811,CDM,252,RC,49502018003,NDC,,,facility,outpatient,1,EA,2802.55000,812.74000,Aetna,Local,,1422.85,,,,,,,1010.32,2292.49,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,49502010202,NDC,facility,inpatient,0.3,ME,806.25000,233.81000,Aetna,Local,,322.50,,,,,,,290.65,659.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 0.15mg Syringe,800019822,CDM,636,RC,J0165,HCPCS,49502010102,NDC,facility,inpatient,0.15,ME,806.25000,233.81000,Aetna,Local,,322.50,,,,,,,290.65,659.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bismuth Subgallate Pwd,800068840,CDM,250,RC,49452115501,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,Local,,9.72,,,,,,,6.90,15.66,percent of total billed charges,
belimumab 400mg REC Inj (Benlysta),800051111,CDM,636,RC,J0490,HCPCS,49401010201,NDC,facility,inpatient,400,ME,11840.25000,3433.67000,Aetna,Local,,4736.10,,,,,,,4268.41,9685.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
belimumab 120mg REC Inj(Benlysta),800051110,CDM,636,RC,J0490,HCPCS,49401010101,NDC,facility,inpatient,120,ME,3683.25000,1068.14000,Aetna,Local,,1473.30,,,,,,,1327.81,3012.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,49281075222,NDC,facility,inpatient,5,UN,54.85000,15.91000,Aetna,Local,,21.94,,,,,,,19.77,44.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,49281075222,NDC,facility,outpatient,5,UN,54.85000,15.91000,Aetna,Local,,21.94,,,,,,,9.58,65.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,49281075221,NDC,facility,inpatient,5,UN,70.35000,20.40000,Aetna,Local,,28.14,,,,,,,25.36,57.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,49281075221,NDC,facility,outpatient,5,UN,70.35000,20.40000,Aetna,Local,,28.14,,,,,,,9.58,65.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
nirsevimab - alip 50mg/0.5mL PF IS,800051021,CDM,636,RC,90380,HCPCS,49281057515,NDC,facility,inpatient,50,ME,2405.65000,697.64000,Aetna,Local,,962.26,,,,,,,867.24,1967.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
nirsevimab - alip 50mg/0.5mL PF IS,800051021,CDM,636,RC,90380,HCPCS,49281057515,NDC,facility,outpatient,50,ME,2405.65000,697.64000,Aetna,Local,,962.26,,,,,,,600.62,1967.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,49281054505,NDC,facility,inpatient,1,EA,180.00000,52.20000,Aetna,Local,,72.00,,,,,,,64.89,147.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haemophilus B Conj (PRP-T) Vac I,800079656,CDM,636,RC,90648,HCPCS,49281054505,NDC,facility,outpatient,1,EA,180.00000,52.20000,Aetna,Local,,72.00,,,,,,,14.65,147.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281029110,NDC,facility,inpatient,1,EA,155.00000,44.95000,Aetna,Local,,62.00,,,,,,,55.88,126.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281029110,NDC,facility,outpatient,1,EA,155.00000,44.95000,Aetna,Local,,62.00,,,,,,,37.53,126.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281021515,NDC,facility,inpatient,1,EA,245.70000,71.25000,Aetna,Local,,98.28,,,,,,,88.57,200.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281021515,NDC,facility,outpatient,1,EA,245.70000,71.25000,Aetna,Local,,98.28,,,,,,,37.53,200.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281021510,NDC,facility,inpatient,1,EA,245.70000,71.25000,Aetna,Local,,98.28,,,,,,,88.57,200.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus-Diphtheria Toxoids 0.5mL IS,800080779,CDM,636,RC,90714,HCPCS,49281021510,NDC,facility,outpatient,1,EA,245.70000,71.25000,Aetna,Local,,98.28,,,,,,,37.53,200.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Influenza Virus Vaccine, Inact High-Dose-Trivalent PF Inj",800051127,CDM,636,RC,90662,HCPCS,49281012465,NDC,facility,inpatient,1,EA,420.65000,121.99000,Aetna,Local,,168.26,,,,,,,151.64,344.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Influenza Virus Vaccine, Inact High-Dose-Trivalent PF Inj",800051127,CDM,636,RC,90662,HCPCS,49281012465,NDC,facility,outpatient,1,EA,420.65000,121.99000,Aetna,Local,,168.26,,,,,,,94.53,344.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chlorhexidine Gluc 0.12% TS 480mL,800025528,CDM,637,RC,48878062001,NDC,,,facility,outpatient,1,EA,45.05000,13.06000,Aetna,Local,,22.87,,,,,,,16.24,36.85,percent of total billed charges,
Ferric Subsulfate 8mL TS(Monsel's),800021997,CDM,637,RC,48783011208,NDC,,,facility,outpatient,1,EA,99.90000,28.97000,Aetna,Local,,50.72,,,,,,,36.01,81.72,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,48582051201,NDC,,,facility,outpatient,1,EA,74.60000,21.63000,Aetna,Local,,37.87,,,,,,,26.89,61.02,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,800066885,CDM,250,RC,48433023015,NDC,,,facility,outpatient,1,EA,319.40000,92.63000,Aetna,Local,,162.16,,,,,,,115.14,261.27,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,48433021740,NDC,,,facility,outpatient,1,EA,67.95000,19.71000,Aetna,Local,,34.50,,,,,,,24.50,55.58,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,48102005711,NDC,,,facility,outpatient,1,EA,83.25000,24.14000,Aetna,Local,,42.27,,,,,,,30.01,68.10,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,48102000811,NDC,,,facility,outpatient,1,EA,61.55000,17.85000,Aetna,Local,,31.25,,,,,,,22.19,50.35,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,48102000335,NDC,,,facility,outpatient,1,EA,141.45000,41.02000,Aetna,Local,,71.81,,,,,,,50.99,115.71,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,47781060191,NDC,,,facility,outpatient,1,EA,186.25000,54.01000,Aetna,Local,,94.56,,,,,,,67.14,152.35,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,47781059791,NDC,facility,inpatient,1,GM,57.50000,16.67000,Aetna,Local,,23.00,,,,,,,20.73,47.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,47781059507,NDC,facility,inpatient,6,ME,8.60000,2.49000,Aetna,Local,,3.44,,,,,,,3.10,7.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,47781059307,NDC,facility,inpatient,6,ME,16.40000,4.76000,Aetna,Local,,6.56,,,,,,,5.91,13.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,47781058717,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,Local,,3.17,,,,,,,2.25,5.11,percent of total billed charges,
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,47781058468,NDC,facility,inpatient,30,ME,7.15000,2.07000,Aetna,Local,,2.86,,,,,,,2.58,5.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,47781058368,NDC,facility,inpatient,15,ME,6.70000,1.94000,Aetna,Local,,2.68,,,,,,,2.42,5.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,47781057807,NDC,facility,inpatient,500,ME,3059.80000,887.34000,Aetna,Local,,1223.92,,,,,,,1103.06,2502.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,47781042847,NDC,,,facility,outpatient,1,EA,589.00000,170.81000,Aetna,Local,,299.04,,,,,,,212.33,481.80,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,47781042747,NDC,,,facility,outpatient,1,EA,453.15000,131.41000,Aetna,Local,,230.06,,,,,,,163.36,370.68,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,47781042647,NDC,,,facility,outpatient,1,EA,304.60000,88.33000,Aetna,Local,,154.65,,,,,,,109.81,249.16,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,47781042447,NDC,,,facility,outpatient,1,EA,170.15000,49.34000,Aetna,Local,,86.39,,,,,,,61.34,139.18,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,47781042347,NDC,,,facility,outpatient,1,EA,162.40000,47.10000,Aetna,Local,,82.45,,,,,,,58.55,132.84,percent of total billed charges,
Dapsone 100 mg Tab,800081017,CDM,637,RC,47781033431,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,Local,,10.86,,,,,,,7.71,17.51,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,47781030701,NDC,,,facility,outpatient,1,EA,16.10000,4.67000,Aetna,Local,,8.17,,,,,,,5.80,13.17,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,47781030503,NDC,,,facility,outpatient,1,EA,114.70000,33.26000,Aetna,Local,,58.23,,,,,,,41.35,93.82,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,47781030403,NDC,,,facility,outpatient,1,EA,114.70000,33.26000,Aetna,Local,,58.23,,,,,,,41.35,93.82,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,47781030301,NDC,,,facility,outpatient,1,EA,27.00000,7.83000,Aetna,Local,,13.71,,,,,,,9.73,22.09,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,47781020904,NDC,,,facility,outpatient,1,EA,156.45000,45.37000,Aetna,Local,,79.43,,,,,,,56.40,127.98,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,47781020604,NDC,,,facility,outpatient,1,EA,156.45000,45.37000,Aetna,Local,,79.43,,,,,,,56.40,127.98,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,47781017901,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,47781017801,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,47781017401,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,47781010444,NDC,,,facility,outpatient,1,EA,2010.55000,583.06000,Aetna,Local,,1020.76,,,,,,,724.80,1644.63,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,47781001101,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,47335099301,NDC,facility,inpatient,500,ME,27.40000,7.95000,Aetna,Local,,10.96,,,,,,,9.88,22.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,47335099201,NDC,facility,inpatient,2,GM,133.70000,38.77000,Aetna,Local,,53.48,,,,,,,48.20,109.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,47335093144,NDC,,,facility,outpatient,1,EA,54.25000,15.73000,Aetna,Local,,27.54,,,,,,,19.56,44.38,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,47335090288,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,Local,,14.37,,,,,,,10.20,23.15,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,47335089413,NDC,,,facility,outpatient,1,EA,49.20000,14.27000,Aetna,Local,,24.98,,,,,,,17.74,40.25,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,47335078891,NDC,,,facility,outpatient,1,EA,1535.95000,445.43000,Aetna,Local,,779.80,,,,,,,553.71,1256.41,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,47335077991,NDC,,,facility,outpatient,1,EA,677.00000,196.33000,Aetna,Local,,343.71,,,,,,,244.06,553.79,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,47335076583,NDC,,,facility,outpatient,1,EA,216.10000,62.67000,Aetna,Local,,109.71,,,,,,,77.90,176.77,percent of total billed charges,
Paliperidone 1.5mg ER T(Invega),800046569,CDM,637,RC,47335074483,NDC,,,facility,outpatient,1,EA,216.10000,62.67000,Aetna,Local,,109.71,,,,,,,77.90,176.77,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,47335073713,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,47335067881,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,Local,,9.54,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,47335067681,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,47335067581,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,Local,,4.32,,,,,,,3.06,6.95,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,47335061544,NDC,,,facility,outpatient,1,EA,55.80000,16.18000,Aetna,Local,,28.33,,,,,,,20.12,45.64,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,47335060488,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,47335060388,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,47335058583,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,Local,,32.16,,,,,,,22.84,51.82,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,47335048583,NDC,,,facility,outpatient,1,EA,131.20000,38.05000,Aetna,Local,,66.61,,,,,,,47.30,107.32,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,47335047281,NDC,,,facility,outpatient,1,EA,685.65000,198.84000,Aetna,Local,,348.10,,,,,,,247.18,560.86,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,47335038383,NDC,,,facility,outpatient,1,EA,55.50000,16.10000,Aetna,Local,,28.18,,,,,,,20.01,45.40,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,47335033040,NDC,facility,inpatient,500,ME,566.55000,164.30000,Aetna,Local,,226.62,,,,,,,204.24,463.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naltrexone 50mg Tab,800017999,CDM,637,RC,47335032683,NDC,,,facility,outpatient,1,EA,30.25000,8.77000,Aetna,Local,,15.36,,,,,,,10.91,24.74,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,47335032286,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,Local,,21.91,,,,,,,15.56,35.30,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,47335032186,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,Local,,21.91,,,,,,,15.56,35.30,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,47335029044,NDC,,,facility,outpatient,1,EA,169.05000,49.02000,Aetna,Local,,85.83,,,,,,,60.94,138.28,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,47335029040,NDC,,,facility,outpatient,1,EA,169.05000,49.02000,Aetna,Local,,85.83,,,,,,,60.94,138.28,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,47335028940,NDC,facility,inpatient,60,ME,313.00000,90.77000,Aetna,Local,,125.20,,,,,,,112.84,256.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,47335015340,NDC,facility,inpatient,200,ME,729.00000,211.41000,Aetna,Local,,291.60,,,,,,,262.80,596.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,47335006386,NDC,,,facility,outpatient,1,EA,60.65000,17.59000,Aetna,Local,,30.79,,,,,,,21.86,49.61,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,47335006286,NDC,,,facility,outpatient,1,EA,60.65000,17.59000,Aetna,Local,,30.79,,,,,,,21.86,49.61,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,47335006186,NDC,,,facility,outpatient,1,EA,60.65000,17.59000,Aetna,Local,,30.79,,,,,,,21.86,49.61,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,47335000788,NDC,,,facility,outpatient,1,EA,32.15000,9.32000,Aetna,Local,,16.32,,,,,,,11.59,26.30,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,46581083001,NDC,,,facility,outpatient,1,EA,18.60000,5.39000,Aetna,Local,,9.44,,,,,,,6.71,15.21,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,46122055705,NDC,,,facility,outpatient,1,EA,53.75000,15.59000,Aetna,Local,,27.29,,,,,,,19.38,43.97,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,45963076552,NDC,facility,inpatient,80,ME,5947.00000,1724.63000,Aetna,Local,,2378.80,,,,,,,2143.89,4864.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,45963073355,NDC,facility,inpatient,10,ME,78.00000,22.62000,Aetna,Local,,31.20,,,,,,,28.12,63.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,45963070911,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,45963067711,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,45963067611,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,45963061959,NDC,facility,inpatient,1000,ME,927.00000,268.83000,Aetna,Local,,370.80,,,,,,,334.18,758.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,45963057008,NDC,,,facility,outpatient,1,EA,37.30000,10.82000,Aetna,Local,,18.94,,,,,,,13.45,30.51,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,45963053830,NDC,facility,inpatient,4,ME,176.20000,51.10000,Aetna,Local,,70.48,,,,,,,63.52,144.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,45963043963,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,45963043864,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,45963041806,NDC,,,facility,outpatient,1,EA,50.35000,14.60000,Aetna,Local,,25.56,,,,,,,18.15,41.19,percent of total billed charges,
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,45945015702,NDC,facility,inpatient,40,ME,3616.25000,1048.71000,Aetna,Local,,1446.50,,,,,,,1303.66,2958.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Baclofen (2000mcg/mL) 40mg/20mL IT(Gablofen),800010900,CDM,636,RC,J0475,HCPCS,45945015701,NDC,facility,inpatient,40,ME,3875.20000,1123.81000,Aetna,Local,,1550.08,,,,,,,1397.01,3169.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,45802095301,NDC,,,facility,outpatient,1,EA,104.10000,30.19000,Aetna,Local,,52.85,,,,,,,37.53,85.15,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,45802088094,NDC,,,facility,outpatient,1,EA,247.25000,71.70000,Aetna,Local,,125.53,,,,,,,89.13,202.25,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,45802086802,NDC,,,facility,outpatient,1,EA,64.20000,18.62000,Aetna,Local,,32.59,,,,,,,23.14,52.52,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,45802077078,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,45802075830,NDC,,,facility,outpatient,1,EA,125.35000,36.35000,Aetna,Local,,63.64,,,,,,,45.19,102.54,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,45802072530,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,45802058062,NDC,,,facility,outpatient,1,EA,162.85000,47.23000,Aetna,Local,,82.68,,,,,,,58.71,133.21,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,45802058046,NDC,,,facility,outpatient,1,EA,162.85000,47.23000,Aetna,Local,,82.68,,,,,,,58.71,133.21,percent of total billed charges,
Ammonium Lactate 12% Lotion,800025491,CDM,637,RC,45802052555,NDC,,,facility,outpatient,1,EA,129.15000,37.45000,Aetna,Local,,65.57,,,,,,,46.56,105.64,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,45802047264,NDC,,,facility,outpatient,1,EA,967.25000,280.50000,Aetna,Local,,491.07,,,,,,,348.69,791.21,percent of total billed charges,
Ketoconazole 2% Top Shampoo 120mL,800017775,CDM,637,RC,45802046564,NDC,,,facility,outpatient,1,EA,214.05000,62.07000,Aetna,Local,,108.67,,,,,,,77.17,175.09,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,45802043870,NDC,,,facility,outpatient,1,EA,25.45000,7.38000,Aetna,Local,,12.92,,,,,,,9.17,20.82,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,45802043803,NDC,,,facility,outpatient,1,EA,30.25000,8.77000,Aetna,Local,,15.36,,,,,,,10.91,24.74,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,45802043401,NDC,,,facility,outpatient,1,EA,42.40000,12.30000,Aetna,Local,,21.53,,,,,,,15.29,34.68,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,45802037635,NDC,,,facility,outpatient,1,EA,32.80000,9.51000,Aetna,Local,,16.65,,,,,,,11.82,26.83,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,45802026937,NDC,,,facility,outpatient,1,EA,752.90000,218.34000,Aetna,Local,,382.25,,,,,,,271.42,615.87,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,45802021002,NDC,,,facility,outpatient,1,EA,853.65000,247.56000,Aetna,Local,,433.40,,,,,,,307.74,698.29,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,45802021001,NDC,,,facility,outpatient,1,EA,1425.30000,413.34000,Aetna,Local,,723.62,,,,,,,513.82,1165.90,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,45802017453,NDC,,,facility,outpatient,1,EA,27.30000,7.92000,Aetna,Local,,13.86,,,,,,,9.84,22.33,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,45802014303,NDC,,,facility,outpatient,1,EA,44.15000,12.80000,Aetna,Local,,22.41,,,,,,,15.92,36.11,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,45802013811,NDC,,,facility,outpatient,1,EA,383.50000,111.21000,Aetna,Local,,194.70,,,,,,,138.25,313.70,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,45802011665,NDC,,,facility,outpatient,1,EA,82.65000,23.97000,Aetna,Local,,41.96,,,,,,,29.80,67.61,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,45802011222,NDC,,,facility,outpatient,1,EA,81.05000,23.50000,Aetna,Local,,41.15,,,,,,,29.22,66.30,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,45802009851,NDC,,,facility,outpatient,1,EA,171.95000,49.87000,Aetna,Local,,87.30,,,,,,,61.99,140.66,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,45802009735,NDC,,,facility,outpatient,1,EA,565.30000,163.94000,Aetna,Local,,287.00,,,,,,,203.79,462.42,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,45802006435,NDC,,,facility,outpatient,1,EA,27.55000,7.99000,Aetna,Local,,13.99,,,,,,,9.93,22.54,percent of total billed charges,
Triamcinolone 0.1% TC 454g,800077205,CDM,637,RC,45802006405,NDC,,,facility,outpatient,1,EA,165.20000,47.91000,Aetna,Local,,83.87,,,,,,,59.55,135.13,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,45802006103,NDC,,,facility,outpatient,1,EA,44.15000,12.80000,Aetna,Local,,22.41,,,,,,,15.92,36.11,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,45802006003,NDC,,,facility,outpatient,1,EA,37.15000,10.77000,Aetna,Local,,18.86,,,,,,,13.39,30.39,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,45802005935,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,Local,,62.90,,,,,,,44.67,101.35,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,45802005536,NDC,,,facility,outpatient,1,EA,90.90000,26.36000,Aetna,Local,,46.15,,,,,,,32.77,74.36,percent of total billed charges,
Triamcinolone 0.025% TO 80g,800017793,CDM,637,RC,45802005436,NDC,,,facility,outpatient,1,EA,71.60000,20.76000,Aetna,Local,,36.35,,,,,,,25.81,58.57,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,45802004835,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,Local,,62.90,,,,,,,44.67,101.35,percent of total billed charges,
Selenium 2.5% 120mL Lotion,800065887,CDM,250,RC,45802004064,NDC,,,facility,outpatient,1,EA,140.20000,40.66000,Aetna,Local,,71.18,,,,,,,50.54,114.68,percent of total billed charges,
Betamethasone Dipr 0.05% 60mL TL,800058635,CDM,637,RC,45802002146,NDC,,,facility,outpatient,1,EA,311.10000,90.22000,Aetna,Local,,157.95,,,,,,,112.15,254.48,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,45802000403,NDC,,,facility,outpatient,1,EA,81.90000,23.75000,Aetna,Local,,41.58,,,,,,,29.52,66.99,percent of total billed charges,
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,44567082010,NDC,facility,inpatient,1,GM,1169.65000,339.20000,Aetna,Local,,467.86,,,,,,,421.66,956.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,44567081110,NDC,facility,inpatient,2.5,GM,1093.80000,317.20000,Aetna,Local,,437.52,,,,,,,394.31,894.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,44567080310,NDC,facility,inpatient,4.5,GM,65.30000,18.94000,Aetna,Local,,26.12,,,,,,,23.54,53.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,44567080210,NDC,facility,inpatient,3.375,GM,49.35000,14.31000,Aetna,Local,,19.74,,,,,,,17.79,40.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,44567080110,NDC,facility,inpatient,2.25,GM,28.70000,8.32000,Aetna,Local,,11.48,,,,,,,10.35,23.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,44567070810,NDC,facility,inpatient,2,GM,105.60000,30.62000,Aetna,Local,,42.24,,,,,,,38.07,86.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,44567070725,NDC,facility,inpatient,1000,ME,15.85000,4.60000,Aetna,Local,,6.34,,,,,,,5.71,12.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,44567070225,NDC,facility,inpatient,2,GM,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,44567070125,NDC,facility,inpatient,1,GM,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Norepinephrine 8mg/NS 250mL-Dbl Conc,800051974,CDM,250,RC,44567064110,NDC,,,facility,outpatient,1,EA,481.00000,139.49000,Aetna,Local,,244.20,,,,,,,173.40,393.46,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,44567064010,NDC,,,facility,outpatient,1,EA,370.20000,107.36000,Aetna,Local,,187.95,,,,,,,133.46,302.82,percent of total billed charges,
Calcium Gluc 1g/50mL-NaCl 0.67% IVPB,800046390,CDM,636,RC,J0612,HCPCS,44567062024,NDC,facility,inpatient,1,GM,201.45000,58.42000,Aetna,Local,,80.58,,,,,,,72.62,164.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 100mg/NS 100mL IV,800046429,CDM,636,RC,J2250,HCPCS,44567061110,NDC,facility,inpatient,100,ME,220.95000,64.08000,Aetna,Local,,88.38,,,,,,,79.65,180.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,44567050501,NDC,facility,inpatient,6,ME,15.40000,4.47000,Aetna,Local,,6.16,,,,,,,5.55,12.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,44567050310,NDC,facility,inpatient,1500,ME,154.65000,44.85000,Aetna,Local,,61.86,,,,,,,55.75,126.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,44567050110,NDC,facility,inpatient,500,ME,78.55000,22.78000,Aetna,Local,,31.42,,,,,,,28.32,64.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,44567045010,NDC,facility,inpatient,2.5,GM,870.60000,252.47000,Aetna,Local,,348.24,,,,,,,313.85,712.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,44567043724,NDC,facility,inpatient,750,ME,54.45000,15.79000,Aetna,Local,,21.78,,,,,,,19.63,44.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,44567043624,NDC,facility,inpatient,500,ME,47.40000,13.75000,Aetna,Local,,18.96,,,,,,,17.09,38.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,44567043524,NDC,facility,inpatient,250,ME,32.25000,9.35000,Aetna,Local,,12.90,,,,,,,11.63,26.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,44567042124,NDC,facility,inpatient,4,GM,91.30000,26.48000,Aetna,Local,,36.52,,,,,,,32.91,74.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,44567042024,NDC,facility,inpatient,2,GM,170.85000,49.55000,Aetna,Local,,68.34,,,,,,,61.59,139.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,44567040110,NDC,facility,inpatient,1,GM,283.00000,82.07000,Aetna,Local,,113.20,,,,,,,102.02,231.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,44567031110,NDC,facility,inpatient,1,EA,43.60000,12.64000,Aetna,Local,,17.44,,,,,,,15.72,35.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,44567024625,NDC,facility,inpatient,2,GM,191.50000,55.54000,Aetna,Local,,76.60,,,,,,,69.04,156.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,44567024525,NDC,facility,inpatient,1,GM,95.50000,27.69000,Aetna,Local,,38.20,,,,,,,34.43,78.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,44567024110,NDC,facility,inpatient,2,GM,94.10000,27.29000,Aetna,Local,,37.64,,,,,,,33.92,76.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,44567024010,NDC,facility,inpatient,1,GM,54.70000,15.86000,Aetna,Local,,21.88,,,,,,,19.72,44.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,44567023525,NDC,facility,inpatient,1,GM,43.20000,12.53000,Aetna,Local,,17.28,,,,,,,15.57,35.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,44567022210,NDC,facility,inpatient,2,GM,211.00000,61.19000,Aetna,Local,,84.40,,,,,,,76.07,172.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,44567021110,NDC,facility,inpatient,3,GM,153.10000,44.40000,Aetna,Local,,61.24,,,,,,,55.19,125.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,44567021010,NDC,facility,inpatient,1.5,GM,76.30000,22.13000,Aetna,Local,,30.52,,,,,,,27.51,62.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,44567010310,NDC,facility,inpatient,2,GM,105.60000,30.62000,Aetna,Local,,42.24,,,,,,,38.07,86.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,44567010110,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,44206031025,NDC,facility,inpatient,12.5,GM,444.00000,128.76000,Aetna,Local,,177.60,,,,,,,160.06,363.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RHo (D) Immune Globulin 300mcg/2mL Inj,800021963,CDM,636,RC,J2791,HCPCS,44206030010,NDC,facility,inpatient,0.3,ME,799.05000,231.72000,Aetna,Local,,319.62,,,,,,,288.06,653.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,44206025105,NDC,facility,inpatient,12.5,GM,444.00000,128.76000,Aetna,Local,,177.60,,,,,,,160.06,363.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,43975035003,NDC,,,facility,outpatient,1,EA,103.85000,30.12000,Aetna,Local,,52.72,,,,,,,37.44,84.95,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,43975032209,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,Local,,28.89,,,,,,,20.51,46.54,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,43975032203,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,Local,,28.89,,,,,,,20.51,46.54,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),800017619,CDM,637,RC,43975021710,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
NUTR- Peptamen Intense VHP(1L),800040932,CDM,637,RC,43900072395,NDC,,,facility,outpatient,1,EA,345.90000,100.31000,Aetna,Local,,175.61,,,,,,,124.70,282.95,percent of total billed charges,
NUTR- Novasource Renal(1L),800040925,CDM,637,RC,43900035180,NDC,,,facility,outpatient,1,EA,161.75000,46.91000,Aetna,Local,,82.12,,,,,,,58.31,132.31,percent of total billed charges,
NUTR- Novasource Renal (237mL),800040924,CDM,637,RC,43900035110,NDC,,,facility,outpatient,1,EA,33.20000,9.63000,Aetna,Local,,16.86,,,,,,,11.97,27.16,percent of total billed charges,
NUTR- Isosource HN (1L),800040879,CDM,636,RC,43900018480,NDC,,,facility,inpatient,1,EA,656.50000,190.38000,Aetna,Local,,262.60,,,,,,,236.67,537.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUTR- Isosource HN (1L),800040879,CDM,636,RC,43900018480,NDC,,,facility,outpatient,1,EA,656.50000,190.38000,Aetna,Local,,262.60,,,,,,,236.67,537.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUTR- Isosource HN (250mL),800040892,CDM,250,RC,43900018457,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,Local,,5.28,,,,,,,3.75,8.51,percent of total billed charges,
NUTR- Isosource 1.5 (1L),800040891,CDM,637,RC,43900018181,NDC,,,facility,outpatient,1,EA,65.10000,18.88000,Aetna,Local,,33.05,,,,,,,23.47,53.25,percent of total billed charges,
NUTR- Isosource 1.5 (250mL),800040890,CDM,637,RC,43900018150,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,43825010201,NDC,facility,inpatient,1000,ME,464.30000,134.65000,Aetna,Local,,185.72,,,,,,,167.38,379.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,43598097710,NDC,,,facility,outpatient,1,EA,101.80000,29.52000,Aetna,Local,,51.68,,,,,,,36.70,83.27,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,43598091758,NDC,,,facility,inpatient,1,EA,1460.85000,423.65000,Aetna,Local,,584.34,,,,,,,526.64,1194.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,43598091758,NDC,,,facility,outpatient,1,EA,1460.85000,423.65000,Aetna,Local,,584.34,,,,,,,526.64,1194.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,43598090111,NDC,facility,inpatient,1,GM,867.00000,251.43000,Aetna,Local,,346.80,,,,,,,312.55,709.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,43598084858,NDC,facility,inpatient,20,ME,284.65000,82.55000,Aetna,Local,,113.86,,,,,,,102.62,232.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,43598083936,NDC,facility,inpatient,1,GM,96.00000,27.84000,Aetna,Local,,38.40,,,,,,,34.61,78.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,43598075910,NDC,facility,inpatient,1500,ME,397.00000,115.13000,Aetna,Local,,158.80,,,,,,,143.12,324.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,43598075710,NDC,facility,inpatient,1000,ME,301.00000,87.29000,Aetna,Local,,120.40,,,,,,,108.51,246.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,43598075510,NDC,facility,inpatient,500,ME,177.60000,51.50000,Aetna,Local,,71.04,,,,,,,64.02,145.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43598075160,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43598075101,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,800011361,CDM,250,RC,43598072525,NDC,,,facility,outpatient,1,EA,147.85000,42.88000,Aetna,Local,,75.06,,,,,,,53.30,120.94,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,43598072101,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,43598071901,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,43598069858,NDC,,,facility,inpatient,1,EA,1460.85000,423.65000,Aetna,Local,,584.34,,,,,,,526.64,1194.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,43598069858,NDC,,,facility,outpatient,1,EA,1460.85000,423.65000,Aetna,Local,,584.34,,,,,,,526.64,1194.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 1500mg/100mL-NaCl 0.54% IVPB,800046485,CDM,636,RC,J1953,HCPCS,43598063752,NDC,facility,inpatient,1500,ME,397.00000,115.13000,Aetna,Local,,158.80,,,,,,,143.12,324.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 1000mg/100mL-NaCl 0.75% IVPB,800062081,CDM,636,RC,J1953,HCPCS,43598063610,NDC,facility,inpatient,1000,ME,301.00000,87.29000,Aetna,Local,,120.40,,,,,,,108.51,246.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/100mL-NaCl 0.82% IVPB,800019227,CDM,636,RC,J1953,HCPCS,43598063510,NDC,facility,inpatient,500,ME,177.60000,51.50000,Aetna,Local,,71.04,,,,,,,64.02,145.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,43598061611,NDC,facility,inpatient,0.4,ME,479.65000,139.10000,Aetna,Local,,191.86,,,,,,,172.91,392.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,43598061111,NDC,facility,inpatient,20,ME,458.00000,132.82000,Aetna,Local,,183.20,,,,,,,165.11,374.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,43598061040,NDC,facility,inpatient,80,ME,1627.00000,471.83000,Aetna,Local,,650.80,,,,,,,586.53,1330.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,43598060902,NDC,facility,inpatient,7.5,ME,344.25000,99.83000,Aetna,Local,,137.70,,,,,,,124.10,281.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,43598060702,NDC,facility,inpatient,2.5,ME,149.80000,43.44000,Aetna,Local,,59.92,,,,,,,54.00,122.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,43598058723,NDC,,,facility,outpatient,1,EA,127.70000,37.03000,Aetna,Local,,64.83,,,,,,,46.04,104.46,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,43598054910,NDC,facility,inpatient,1,GM,283.80000,82.30000,Aetna,Local,,113.52,,,,,,,102.31,232.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,43598054821,NDC,facility,inpatient,0.5,GM,142.80000,41.41000,Aetna,Local,,57.12,,,,,,,51.48,116.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43598053660,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,43598043611,NDC,,,facility,outpatient,1,EA,182.05000,52.79000,Aetna,Local,,92.43,,,,,,,65.63,148.92,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,43598040516,NDC,facility,inpatient,10,ME,262.70000,76.18000,Aetna,Local,,105.08,,,,,,,94.70,214.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,43598033111,NDC,facility,inpatient,5,ME,1878.85000,544.87000,Aetna,Local,,751.54,,,,,,,677.33,1536.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,43598033011,NDC,facility,inpatient,4,ME,668.00000,193.72000,Aetna,Local,,267.20,,,,,,,240.81,546.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,43598032675,NDC,,,facility,outpatient,1,EA,1651.60000,478.96000,Aetna,Local,,838.52,,,,,,,595.40,1351.01,percent of total billed charges,
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,43598030562,NDC,facility,inpatient,100,ME,1267.00000,367.43000,Aetna,Local,,506.80,,,,,,,456.75,1036.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,43598021085,NDC,,,facility,outpatient,1,EA,189.15000,54.85000,Aetna,Local,,96.03,,,,,,,68.19,154.72,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,43598020452,NDC,,,facility,outpatient,1,EA,51.40000,14.91000,Aetna,Local,,26.10,,,,,,,18.53,42.05,percent of total billed charges,
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,43598020451,NDC,,,facility,outpatient,1,EA,51.30000,14.88000,Aetna,Local,,26.05,,,,,,,18.49,41.96,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,43598016630,NDC,,,facility,outpatient,1,EA,141.00000,40.89000,Aetna,Local,,71.59,,,,,,,50.83,115.34,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,43598016430,NDC,,,facility,outpatient,1,EA,93.55000,27.13000,Aetna,Local,,47.50,,,,,,,33.72,76.52,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,43598016053,NDC,,,facility,outpatient,1,EA,107.05000,31.04000,Aetna,Local,,54.35,,,,,,,38.59,87.57,percent of total billed charges,
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,43598013074,NDC,facility,inpatient,1,GM,305.50000,88.60000,Aetna,Local,,122.20,,,,,,,110.13,249.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,43598012811,NDC,facility,inpatient,500,ME,1454.20000,421.72000,Aetna,Local,,581.68,,,,,,,524.24,1189.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,43598010610,NDC,facility,inpatient,10,ME,234.50000,68.00000,Aetna,Local,,93.80,,,,,,,84.54,191.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,43598008525,NDC,facility,inpatient,20,UN,814.50000,236.20000,Aetna,Local,,325.80,,,,,,,293.63,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,43598005311,NDC,facility,inpatient,0.04,ME,3967.00000,1150.43000,Aetna,Local,,1586.80,,,,,,,1430.10,3245.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,43598005025,NDC,facility,inpatient,200,ME,40.85000,11.85000,Aetna,Local,,16.34,,,,,,,14.73,33.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,43598002114,NDC,,,facility,outpatient,1,EA,509.65000,147.80000,Aetna,Local,,258.75,,,,,,,183.73,416.89,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,43547063925,NDC,facility,inpatient,0.2,ME,17.35000,5.03000,Aetna,Local,,6.94,,,,,,,6.25,14.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,43547054325,NDC,facility,inpatient,0.2,ME,17.35000,5.03000,Aetna,Local,,6.94,,,,,,,6.25,14.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,43547052509,NDC,,,facility,outpatient,1,EA,33.55000,9.73000,Aetna,Local,,17.03,,,,,,,12.09,27.44,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,43547040610,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,43547040510,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,43547040210,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,43547040110,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,43547036909,NDC,,,facility,outpatient,1,EA,36.50000,10.58000,Aetna,Local,,18.53,,,,,,,13.16,29.86,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,43547036809,NDC,,,facility,outpatient,1,EA,34.20000,9.92000,Aetna,Local,,17.36,,,,,,,12.33,27.98,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,43547035410,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,Local,,3.81,,,,,,,2.70,6.13,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,43547034703,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,Local,,9.60,,,,,,,6.81,15.46,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,43547028810,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,43547028210,NDC,,,facility,outpatient,1,EA,32.00000,9.28000,Aetna,Local,,16.25,,,,,,,11.54,26.18,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,43547028110,NDC,,,facility,outpatient,1,EA,30.65000,8.89000,Aetna,Local,,15.56,,,,,,,11.05,25.07,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,43547028010,NDC,,,facility,outpatient,1,EA,29.40000,8.53000,Aetna,Local,,14.93,,,,,,,10.60,24.05,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,43547027509,NDC,,,facility,outpatient,1,EA,61.30000,17.78000,Aetna,Local,,31.12,,,,,,,22.10,50.14,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,43547027503,NDC,,,facility,outpatient,1,EA,61.30000,17.78000,Aetna,Local,,31.12,,,,,,,22.10,50.14,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,43547027110,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,43547027010,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,43547026810,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,43547025750,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,43547025710,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,43547025610,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,43547025550,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,43547025510,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,43547025410,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,43547022215,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,43538060030,NDC,,,facility,outpatient,1,EA,167.20000,48.49000,Aetna,Local,,84.89,,,,,,,60.28,136.77,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,43478090188,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,Local,,8.58,,,,,,,6.09,13.82,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,43478090088,NDC,,,facility,outpatient,1,EA,14.45000,4.19000,Aetna,Local,,7.34,,,,,,,5.21,11.82,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,43386077101,NDC,,,facility,outpatient,1,EA,539.00000,156.31000,Aetna,Local,,273.65,,,,,,,194.31,440.90,percent of total billed charges,
Levonorgestrel 1.5mg T(My Way),800025531,CDM,637,RC,43386062230,NDC,,,facility,outpatient,1,EA,255.55000,74.11000,Aetna,Local,,129.74,,,,,,,92.13,209.04,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,43386053001,NDC,,,facility,outpatient,1,EA,264.70000,76.76000,Aetna,Local,,134.39,,,,,,,95.42,216.52,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,43386051087,NDC,,,facility,outpatient,1,EA,172.90000,50.14000,Aetna,Local,,87.78,,,,,,,62.33,141.43,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,43386048026,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,Local,,7.97,,,,,,,5.66,12.84,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,43386048024,NDC,,,facility,outpatient,1,EA,16.35000,4.74000,Aetna,Local,,8.30,,,,,,,5.89,13.37,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,43386044024,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,Local,,4.62,,,,,,,3.28,7.44,percent of total billed charges,
Nitazoxanide 500mg Tab,800017652,CDM,637,RC,43386040512,NDC,,,facility,outpatient,1,EA,1011.85000,293.44000,Aetna,Local,,513.72,,,,,,,364.77,827.69,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,43386036021,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,43386033001,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,43386031208,NDC,,,facility,outpatient,1,EA,99.35000,28.81000,Aetna,Local,,50.44,,,,,,,35.82,81.27,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,43386016106,NDC,,,facility,outpatient,1,EA,10.10000,2.93000,Aetna,Local,,5.13,,,,,,,3.64,8.26,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,43386016101,NDC,,,facility,outpatient,1,EA,10.10000,2.93000,Aetna,Local,,5.13,,,,,,,3.64,8.26,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,43386016012,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,43386016006,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
miSOPROStol 25mcg/0.25 Tab,800025693,CDM,637,RC,43386016006,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,43386014028,NDC,,,facility,outpatient,1,EA,448.50000,130.06000,Aetna,Local,,227.70,,,,,,,161.68,366.87,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,43386014001,NDC,,,facility,outpatient,1,EA,51.85000,15.04000,Aetna,Local,,26.32,,,,,,,18.69,42.41,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,43386009661,NDC,,,facility,outpatient,1,EA,1604.55000,465.32000,Aetna,Local,,814.63,,,,,,,578.44,1312.52,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,43386009019,NDC,,,facility,outpatient,1,EA,149.55000,43.37000,Aetna,Local,,75.93,,,,,,,53.91,122.33,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,43386006019,NDC,,,facility,outpatient,1,EA,208.70000,60.52000,Aetna,Local,,105.96,,,,,,,75.24,170.72,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,43199002124,NDC,,,facility,outpatient,1,EA,13.95000,4.05000,Aetna,Local,,7.08,,,,,,,5.03,11.41,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,43199002112,NDC,,,facility,outpatient,1,EA,16.15000,4.68000,Aetna,Local,,8.20,,,,,,,5.82,13.21,percent of total billed charges,
Methenamine Hippurate 1 g T,800017641,CDM,637,RC,43199002001,NDC,,,facility,outpatient,1,EA,14.80000,4.29000,Aetna,Local,,7.51,,,,,,,5.34,12.11,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,43199001101,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,43066099710,NDC,,,facility,outpatient,1,EA,31.90000,9.25000,Aetna,Local,,16.20,,,,,,,11.50,26.09,percent of total billed charges,
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,43066099524,NDC,facility,inpatient,900,ME,133.10000,38.60000,Aetna,Local,,53.24,,,,,,,47.98,108.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,43066055712,NDC,,,facility,outpatient,1,EA,760.00000,220.40000,Aetna,Local,,385.85,,,,,,,273.98,621.68,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,43066015210,NDC,facility,inpatient,200,ME,223.10000,64.70000,Aetna,Local,,89.24,,,,,,,80.43,182.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,43066009025,NDC,facility,inpatient,10,ME,33.85000,9.82000,Aetna,Local,,13.54,,,,,,,12.20,27.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,43066002310,NDC,facility,inpatient,150,ME,51.10000,14.82000,Aetna,Local,,20.44,,,,,,,18.42,41.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,43066001510,NDC,facility,inpatient,40,ME,31.95000,9.27000,Aetna,Local,,12.78,,,,,,,11.52,26.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,43066000710,NDC,,,facility,outpatient,1,EA,23.60000,6.84000,Aetna,Local,,11.98,,,,,,,8.51,19.30,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,42998040205,NDC,,,facility,outpatient,1,EA,12883.50000,3736.21000,Aetna,Local,,6540.95,,,,,,,4644.50,10538.70,percent of total billed charges,
Isoproterenol HCl 1mg/5mL Inj - for IV Set,800025518,CDM,250,RC,42998040205,NDC,,,facility,outpatient,1,EA,12883.50000,3736.21000,Aetna,Local,,6540.95,,,,,,,4644.50,10538.70,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,42998030202,NDC,,,facility,outpatient,1,EA,3380.45000,980.33000,Aetna,Local,,1716.25,,,,,,,1218.65,2765.21,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,42865030002,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,42858080201,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,42858080101,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
HYDROmorphone 1mg/1mL Oral Soln,800025664,CDM,250,RC,42858030416,NDC,,,facility,outpatient,1,ML,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,42858030301,NDC,,,facility,outpatient,1,EA,7.30000,2.12000,Aetna,Local,,3.71,,,,,,,2.63,5.97,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,42858030225,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,42858030201,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,42858030125,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,42858030101,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,42858000110,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,42806071401,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,42806050301,NDC,,,facility,outpatient,1,EA,52.05000,15.09000,Aetna,Local,,26.43,,,,,,,18.76,42.58,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,42806014731,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,Local,,41.78,,,,,,,29.67,67.32,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,42806014301,NDC,,,facility,outpatient,1,EA,133.10000,38.60000,Aetna,Local,,67.57,,,,,,,47.98,108.88,percent of total billed charges,
Ivermectin 3 mg T(Stomectol),800017621,CDM,637,RC,42799080601,NDC,,,facility,outpatient,1,EA,35.20000,10.21000,Aetna,Local,,17.87,,,,,,,12.69,28.79,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,42799021701,NDC,,,facility,outpatient,1,EA,50.25000,14.57000,Aetna,Local,,25.51,,,,,,,18.12,41.10,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,42794001902,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,Local,,3.73,,,,,,,2.65,6.01,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,42794001802,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,42582030010,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,6.13,13.91,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,42571016242,NDC,,,facility,outpatient,1,EA,35.75000,10.37000,Aetna,Local,,18.15,,,,,,,12.89,29.24,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,42571014126,NDC,,,facility,outpatient,1,EA,446.15000,129.38000,Aetna,Local,,226.51,,,,,,,160.84,364.95,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,42571013726,NDC,,,facility,outpatient,1,EA,681.50000,197.64000,Aetna,Local,,346.00,,,,,,,245.68,557.47,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,42571013725,NDC,,,facility,outpatient,1,EA,681.50000,197.64000,Aetna,Local,,346.00,,,,,,,245.68,557.47,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,42543040701,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,Local,,8.83,,,,,,,6.27,14.23,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,42543005261,NDC,,,facility,outpatient,1,EA,195.70000,56.75000,Aetna,Local,,99.36,,,,,,,70.55,160.08,percent of total billed charges,
PHENobarbital 130mg/1mL  Inj,800051979,CDM,636,RC,J2560,HCPCS,42494044225,NDC,facility,inpatient,130,ME,513.70000,148.97000,Aetna,Local,,205.48,,,,,,,185.19,420.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PHENobarbital 65mg/1mL Inj,800077015,CDM,636,RC,J2560,HCPCS,42494044125,NDC,facility,inpatient,65,ME,132.75000,38.50000,Aetna,Local,,53.10,,,,,,,47.86,108.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PHENobarbital 130mg/1mL  Inj,800051979,CDM,636,RC,J2560,HCPCS,42494041625,NDC,facility,inpatient,130,ME,513.70000,148.97000,Aetna,Local,,205.48,,,,,,,185.19,420.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PHENobarbital 65mg/1mL Inj,800077015,CDM,636,RC,J2560,HCPCS,42494041525,NDC,facility,inpatient,65,ME,209.40000,60.73000,Aetna,Local,,83.76,,,,,,,75.49,171.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Emtricitabine-Tenofovir 200-300mg T(Truvada),800017719,CDM,637,RC,42385095330,NDC,,,facility,outpatient,1,EA,465.65000,135.04000,Aetna,Local,,236.41,,,,,,,167.87,380.90,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,42292004120,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,42292004020,NDC,,,facility,outpatient,1,EA,6.20000,1.80000,Aetna,Local,,3.15,,,,,,,2.24,5.07,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,42292003820,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,Local,,2.18,,,,,,,1.55,3.52,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,42291080815,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,42291036601,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,Local,,14.95,,,,,,,10.62,24.09,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,42291035190,NDC,,,facility,outpatient,1,EA,654.30000,189.75000,Aetna,Local,,332.19,,,,,,,235.88,535.22,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,42192080101,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,Local,,9.70,,,,,,,6.89,15.62,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,42192061701,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Gabapentin 100mg/2mL Oral Liq UD,800025502,CDM,637,RC,42192060816,NDC,,,facility,outpatient,1,EA,11.80000,3.42000,Aetna,Local,,5.99,,,,,,,4.25,9.65,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,42192060510,NDC,,,facility,outpatient,1,EA,294.25000,85.33000,Aetna,Local,,149.39,,,,,,,106.08,240.70,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,42192032901,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,Local,,3.76,,,,,,,2.67,6.05,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,42192032801,NDC,,,facility,outpatient,1,EA,15.05000,4.36000,Aetna,Local,,7.64,,,,,,,5.43,12.31,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,42043014105,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,4.42,,,,,,,3.14,7.12,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,42037010479,NDC,,,facility,outpatient,1,EA,71.00000,20.59000,Aetna,Local,,36.05,,,,,,,25.60,58.08,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,42037010478,NDC,,,facility,outpatient,1,EA,62.30000,18.07000,Aetna,Local,,31.63,,,,,,,22.46,50.96,percent of total billed charges,
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,42023023010,NDC,facility,inpatient,100,ME,1253.90000,363.63000,Aetna,Local,,501.56,,,,,,,452.03,1025.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,42023022110,NDC,facility,inpatient,1,GM,1000.15000,290.04000,Aetna,Local,,400.06,,,,,,,360.55,818.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,42023021410,NDC,facility,inpatient,50,ME,226.20000,65.60000,Aetna,Local,,90.48,,,,,,,81.55,185.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,42023018910,NDC,facility,inpatient,10,ME,265.10000,76.88000,Aetna,Local,,106.04,,,,,,,95.57,216.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023016801,NDC,facility,inpatient,1,ME,1.90000,0.55000,Aetna,Local,,0.76000,,,,,,,0.68495,1.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,42023016425,NDC,facility,inpatient,20,UN,127.70000,37.03000,Aetna,Local,,51.08,,,,,,,46.04,104.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,42023016301,NDC,facility,inpatient,5,ME,1611.05000,467.20000,Aetna,Local,,644.42,,,,,,,580.78,1317.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023015925,NDC,facility,inpatient,1,ME,95.50000,27.69000,Aetna,Local,,38.20,,,,,,,34.43,78.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,42023015101,NDC,facility,inpatient,4,ME,577.45000,167.46000,Aetna,Local,,230.98,,,,,,,208.17,472.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,42023014025,NDC,facility,inpatient,10,UN,5.95000,1.73000,Aetna,Local,,2.38,,,,,,,2.14,4.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,42023013810,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,Local,,2.13,,,,,,,1.51,3.44,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023012225,NDC,facility,inpatient,1,ME,12.15000,3.52000,Aetna,Local,,4.86,,,,,,,4.38,9.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,42023011725,NDC,facility,inpatient,20,UN,27.25000,7.90000,Aetna,Local,,10.90,,,,,,,9.82,22.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,42023011625,NDC,facility,inpatient,10,UN,23.00000,6.67000,Aetna,Local,,9.20,,,,,,,8.29,18.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,42023011410,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,42023010405,NDC,facility,inpatient,5,UN,54.85000,15.91000,Aetna,Local,,21.94,,,,,,,19.77,44.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,42023010405,NDC,facility,outpatient,5,UN,54.85000,15.91000,Aetna,Local,,21.94,,,,,,,9.58,65.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,42023010401,NDC,facility,inpatient,5,UN,70.35000,20.40000,Aetna,Local,,28.14,,,,,,,25.36,57.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,42023010401,NDC,facility,outpatient,5,UN,70.35000,20.40000,Aetna,Local,,28.14,,,,,,,9.58,65.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1:1000 Topical Soln 30mL,800081136,CDM,250,RC,42023010301,NDC,,,facility,outpatient,1,EA,1812.45000,525.61000,Aetna,Local,,920.18,,,,,,,653.39,1482.58,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,42023010110,NDC,facility,inpatient,1,ME,1.55000,0.45000,Aetna,Local,,0.62000,,,,,,,0.55878,1.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,41616093144,NDC,,,facility,outpatient,1,EA,56.55000,16.40000,Aetna,Local,,28.71,,,,,,,20.39,46.26,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,41616088244,NDC,facility,inpatient,25,ME,1815.85000,526.60000,Aetna,Local,,726.34,,,,,,,654.61,1485.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,41616022090,NDC,,,facility,outpatient,1,EA,683.05000,198.08000,Aetna,Local,,346.78,,,,,,,246.24,558.73,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,41167057303,NDC,,,facility,outpatient,1,EA,151.45000,43.92000,Aetna,Local,,76.89,,,,,,,54.60,123.89,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,41100082073,NDC,,,facility,outpatient,1,EA,59.55000,17.27000,Aetna,Local,,30.23,,,,,,,21.47,48.71,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,40085021560,NDC,,,facility,outpatient,1,EA,752.90000,218.34000,Aetna,Local,,382.25,,,,,,,271.42,615.87,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,40042005101,NDC,facility,inpatient,0.2,ME,28.10000,8.15000,Aetna,Local,,11.24,,,,,,,10.13,22.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,39822904501,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,Local,,2.34,,,,,,,1.66,3.76,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,39822620002,NDC,facility,inpatient,0.004,ME,133.00000,38.57000,Aetna,Local,,53.20,,,,,,,47.95,108.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Magnesium Sulf 50% I 10mL,800020916,CDM,636,RC,J3475,HCPCS,39822402502,NDC,facility,inpatient,5,GM,22.45000,6.51000,Aetna,Local,,8.98,,,,,,,8.09,18.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,39822400001,NDC,facility,inpatient,500,ME,30.00000,8.70000,Aetna,Local,,12.00,,,,,,,10.81,24.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,39822301501,NDC,,,facility,outpatient,1,EA,132.75000,38.50000,Aetna,Local,,67.40,,,,,,,47.86,108.59,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,39822100107,NDC,,,facility,outpatient,1,EA,289.30000,83.90000,Aetna,Local,,146.88,,,,,,,104.29,236.65,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,39822100001,NDC,,,facility,outpatient,1,EA,60.00000,17.40000,Aetna,Local,,30.46,,,,,,,21.63,49.08,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,39822041206,NDC,,,facility,outpatient,1,EA,1206.00000,349.74000,Aetna,Local,,612.29,,,,,,,434.76,986.51,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),800080191,CDM,250,RC,39822041201,NDC,,,facility,outpatient,1,EA,648.00000,187.92000,Aetna,Local,,328.99,,,,,,,233.60,530.06,percent of total billed charges,
Neomycin 500mg T,800016609,CDM,637,RC,39822031005,NDC,,,facility,outpatient,1,EA,12.00000,3.48000,Aetna,Local,,6.09,,,,,,,4.33,9.82,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,39822020501,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,Local,,3.10,,,,,,,2.20,4.99,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,39822019007,NDC,facility,inpatient,500,ME,386.50000,112.08000,Aetna,Local,,154.60,,,,,,,139.33,316.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,39822019001,NDC,facility,inpatient,500,ME,308.35000,89.42000,Aetna,Local,,123.34,,,,,,,111.16,252.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,39822012706,NDC,facility,inpatient,4.5,GM,124.80000,36.19000,Aetna,Local,,49.92,,,,,,,44.99,102.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,39822012504,NDC,facility,inpatient,3.375,GM,96.00000,27.84000,Aetna,Local,,38.40,,,,,,,34.61,78.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,39822012302,NDC,facility,inpatient,2.25,GM,67.20000,19.49000,Aetna,Local,,26.88,,,,,,,24.23,54.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,39328053099,NDC,,,facility,outpatient,1,EA,30.10000,8.73000,Aetna,Local,,15.28,,,,,,,10.85,24.62,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,39328053016,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,Local,,2.69,,,,,,,1.91,4.34,percent of total billed charges,
Sodium Hypochlor 0.125% TS 473mL,800022086,CDM,637,RC,39328006412,NDC,,,facility,outpatient,1,EA,130.95000,37.98000,Aetna,Local,,66.48,,,,,,,47.21,107.12,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,39328005750,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,Local,,0.63462,,,,,,,0.45062,1.02,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,39328004715,NDC,,,facility,outpatient,1,ML,18.80000,5.45000,Aetna,Local,,9.54,,,,,,,6.78,15.38,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,39328002415,NDC,,,facility,outpatient,1,EA,212.40000,61.60000,Aetna,Local,,107.84,,,,,,,76.57,173.74,percent of total billed charges,
Bismuth Subgallate Pwd,800068840,CDM,250,RC,38779104605,NDC,,,facility,outpatient,1,EA,16.80000,4.87000,Aetna,Local,,8.53,,,,,,,6.06,13.74,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,800066885,CDM,250,RC,38779059808,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,38245077410,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,Local,,4.21,,,,,,,2.99,6.79,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,37205045705,NDC,,,facility,outpatient,1,EA,28.25000,8.19000,Aetna,Local,,14.34,,,,,,,10.18,23.11,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,37205027510,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,37000000701,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,36000036401,NDC,facility,inpatient,0.4,ME,158.60000,45.99000,Aetna,Local,,63.44,,,,,,,57.18,129.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,36000030810,NDC,facility,inpatient,0.4,ME,31.90000,9.25000,Aetna,Local,,12.76,,,,,,,11.50,26.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,36000028806,NDC,facility,inpatient,400,ME,101.30000,29.38000,Aetna,Local,,40.52,,,,,,,36.52,82.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,36000028706,NDC,facility,inpatient,200,ME,66.30000,19.23000,Aetna,Local,,26.52,,,,,,,23.90,54.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,36000028425,NDC,facility,inpatient,100,ME,10.40000,3.02000,Aetna,Local,,4.16,,,,,,,3.75,8.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,36000028325,NDC,facility,inpatient,40,ME,7.35000,2.13000,Aetna,Local,,2.94,,,,,,,2.65,6.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,36000028225,NDC,facility,inpatient,20,ME,4.35000,1.26000,Aetna,Local,,1.74,,,,,,,1.57,3.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,36000016210,NDC,,,facility,outpatient,1,EA,53.10000,15.40000,Aetna,Local,,26.96,,,,,,,19.14,43.44,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,36000014810,NDC,,,facility,outpatient,1,EA,45.25000,13.12000,Aetna,Local,,22.97,,,,,,,16.31,37.01,percent of total billed charges,
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,36000007210,NDC,facility,inpatient,1,GM,46.00000,13.34000,Aetna,Local,,18.40,,,,,,,16.58,37.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,36000007110,NDC,facility,inpatient,500,ME,22.50000,6.52000,Aetna,Local,,9.00,,,,,,,8.11,18.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,36000006505,NDC,facility,inpatient,100,ME,22.50000,6.52000,Aetna,Local,,9.00,,,,,,,8.11,18.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,36000006405,NDC,facility,inpatient,40,ME,20.05000,5.81000,Aetna,Local,,8.02,,,,,,,7.23,16.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,36000006301,NDC,facility,inpatient,20,ME,12.90000,3.74000,Aetna,Local,,5.16,,,,,,,4.65,10.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,36000004824,NDC,facility,inpatient,750,ME,62.40000,18.10000,Aetna,Local,,24.96,,,,,,,22.50,51.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,36000004724,NDC,facility,inpatient,500,ME,48.00000,13.92000,Aetna,Local,,19.20,,,,,,,17.30,39.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,36000004624,NDC,facility,inpatient,250,ME,40.00000,11.60000,Aetna,Local,,16.00,,,,,,,14.42,32.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,36000003310,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,36000001301,NDC,facility,inpatient,4,ME,2.60000,0.75000,Aetna,Local,,1.04,,,,,,,0.93730,2.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,36000001225,NDC,facility,inpatient,4,ME,5.85000,1.70000,Aetna,Local,,2.34,,,,,,,2.11,4.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,36000000306,NDC,facility,inpatient,400,ME,77.35000,22.43000,Aetna,Local,,30.94,,,,,,,27.88,63.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,36000000210,NDC,facility,inpatient,200,ME,49.75000,14.43000,Aetna,Local,,19.90,,,,,,,17.93,40.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,36000000206,NDC,facility,inpatient,200,ME,66.30000,19.23000,Aetna,Local,,26.52,,,,,,,23.90,54.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,36000000124,NDC,facility,inpatient,500,ME,38.65000,11.21000,Aetna,Local,,15.46,,,,,,,13.93,31.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,35573042880,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
Enteral Feeding Tube Declogging Kit,800051053,CDM,272,RC,35077045609,NDC,,,facility,outpatient,1,EA,112.00000,32.48000,Aetna,Local,,56.86,,,,,,,40.38,91.62,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,33406991501,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,Local,,4.14,,,,,,,2.94,6.67,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,33342033380,NDC,,,facility,outpatient,1,EA,89.75000,26.03000,Aetna,Local,,45.57,,,,,,,32.35,73.42,percent of total billed charges,
Triamcinolone 0.025% TO 80g,800017793,CDM,637,RC,33342033180,NDC,,,facility,outpatient,1,EA,71.60000,20.76000,Aetna,Local,,36.35,,,,,,,25.81,58.57,percent of total billed charges,
Triamcinolone 0.025% TC 80g,800017792,CDM,637,RC,33342032780,NDC,,,facility,outpatient,1,EA,71.60000,20.76000,Aetna,Local,,36.35,,,,,,,25.81,58.57,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,33342025666,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,Local,,50.97,,,,,,,36.19,82.13,percent of total billed charges,
Tenofovir 300mg T(Viread),800017725,CDM,637,RC,33342009607,NDC,,,facility,outpatient,1,EA,281.70000,81.69000,Aetna,Local,,143.02,,,,,,,101.55,230.43,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,33342008307,NDC,,,facility,outpatient,1,EA,99.10000,28.74000,Aetna,Local,,50.31,,,,,,,35.73,81.06,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,33342002607,NDC,,,facility,outpatient,1,EA,89.85000,26.06000,Aetna,Local,,45.62,,,,,,,32.39,73.50,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,33342002507,NDC,,,facility,outpatient,1,EA,44.75000,12.98000,Aetna,Local,,22.72,,,,,,,16.13,36.61,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,31722083710,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,Local,,35.95,,,,,,,25.52,57.91,percent of total billed charges,
Entecavir 0.5mg Tab,800046457,CDM,637,RC,31722083330,NDC,,,facility,outpatient,1,EA,307.35000,89.13000,Aetna,Local,,156.04,,,,,,,110.80,251.41,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),800017736,CDM,637,RC,31722083260,NDC,,,facility,outpatient,1,EA,431.55000,125.15000,Aetna,Local,,219.10,,,,,,,155.57,353.01,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,31722075360,NDC,,,facility,outpatient,1,EA,50.70000,14.70000,Aetna,Local,,25.74,,,,,,,18.28,41.47,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,31722074920,NDC,,,facility,outpatient,1,EA,1114.90000,323.32000,Aetna,Local,,566.03,,,,,,,401.92,911.99,percent of total billed charges,
Ranolazine 500mg ER T(Ranexa),800070025,CDM,637,RC,31722066860,NDC,,,facility,outpatient,1,EA,52.40000,15.20000,Aetna,Local,,26.60,,,,,,,18.89,42.86,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,31722063530,NDC,,,facility,outpatient,1,EA,66.65000,19.33000,Aetna,Local,,33.84,,,,,,,24.03,54.52,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,31722063031,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,Local,,50.97,,,,,,,36.19,82.13,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,31722062921,NDC,,,facility,outpatient,1,EA,262.05000,75.99000,Aetna,Local,,133.04,,,,,,,94.47,214.36,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,31722062830,NDC,,,facility,outpatient,1,EA,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,28.84,65.44,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,31722054401,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,31722054201,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,31722053712,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,31722053612,NDC,,,facility,outpatient,1,EA,20.35000,5.90000,Aetna,Local,,10.33,,,,,,,7.34,16.65,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,31722053401,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,31722053101,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,31722052901,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,31722052101,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,31722052001,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,31722051901,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,31722040505,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,31722030801,NDC,facility,inpatient,10,ME,219.00000,63.51000,Aetna,Local,,87.60,,,,,,,78.95,179.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,31722030201,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,31722028301,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,Local,,4.16,,,,,,,2.96,6.71,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,31722028201,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,31722028060,NDC,,,facility,outpatient,1,EA,48.75000,14.14000,Aetna,Local,,24.75,,,,,,,17.57,39.88,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,31722027860,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,31722025301,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,31722023990,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,Local,,8.58,,,,,,,6.09,13.82,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,31722023890,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,31722023810,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,31722023790,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,31722022801,NDC,,,facility,outpatient,1,EA,15.50000,4.50000,Aetna,Local,,7.87,,,,,,,5.59,12.68,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,31722022560,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,31722022505,NDC,,,facility,outpatient,1,EA,16.40000,4.76000,Aetna,Local,,8.33,,,,,,,5.91,13.42,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,31722022105,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,31722021601,NDC,facility,inpatient,500,ME,3394.25000,984.33000,Aetna,Local,,1357.70,,,,,,,1223.63,2776.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,31722020930,NDC,,,facility,outpatient,1,EA,92.20000,26.74000,Aetna,Local,,46.81,,,,,,,33.24,75.42,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,31722020901,NDC,,,facility,outpatient,1,EA,92.55000,26.84000,Aetna,Local,,46.99,,,,,,,33.36,75.71,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,31722020410,NDC,facility,inpatient,40,ME,29.15000,8.45000,Aetna,Local,,11.66,,,,,,,10.51,23.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,31722020320,NDC,facility,inpatient,200,ME,75.45000,21.88000,Aetna,Local,,30.18,,,,,,,27.20,61.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,31722020320,NDC,facility,outpatient,200,ME,75.45000,21.88000,Aetna,Local,,30.18,,,,,,,0.37557,61.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,31722013190,NDC,,,facility,outpatient,1,EA,42.85000,12.43000,Aetna,Local,,21.75,,,,,,,15.45,35.05,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,31722013130,NDC,,,facility,outpatient,1,EA,42.85000,12.43000,Aetna,Local,,21.75,,,,,,,15.45,35.05,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,31722013001,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,Local,,8.83,,,,,,,6.27,14.23,percent of total billed charges,
Itraconazole 100mg/10mL Oral Liq,800021977,CDM,637,RC,31722000631,NDC,,,facility,outpatient,1,EA,174.70000,50.66000,Aetna,Local,,88.70,,,,,,,62.98,142.90,percent of total billed charges,
Mesalamine 1000mg Supp (Canasa),800017778,CDM,637,RC,31722000530,NDC,,,facility,outpatient,1,EA,290.15000,84.14000,Aetna,Local,,147.31,,,,,,,104.60,237.34,percent of total billed charges,
carBAMazepine 100 mg ER C,800081082,CDM,637,RC,30698041912,NDC,,,facility,outpatient,1,EA,14.45000,4.19000,Aetna,Local,,7.34,,,,,,,5.21,11.82,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,30698006001,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,Local,,4.72,,,,,,,3.35,7.61,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,29336054006,NDC,facility,inpatient,60,ME,151.95000,44.07000,Aetna,Local,,60.78,,,,,,,54.78,124.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,29300042301,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,6.49,14.72,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,29300035916,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,Local,,12.16,,,,,,,8.63,19.59,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,29300022705,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,29300022019,NDC,,,facility,outpatient,1,EA,40.05000,11.61000,Aetna,Local,,20.33,,,,,,,14.44,32.76,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,29300017216,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,Local,,21.91,,,,,,,15.56,35.30,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,29300017116,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,Local,,21.91,,,,,,,15.56,35.30,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,29300016815,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,29300014901,NDC,,,facility,outpatient,1,EA,48.55000,14.08000,Aetna,Local,,24.65,,,,,,,17.50,39.71,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,29300013505,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,29300013501,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,29300012601,NDC,,,facility,outpatient,1,EA,9.95000,2.89000,Aetna,Local,,5.05,,,,,,,3.59,8.14,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,29300011516,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,Local,,9.11,,,,,,,6.47,14.68,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,29033000305,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,29033000301,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,28595012049,NDC,,,facility,outpatient,1,EA,1425.30000,413.34000,Aetna,Local,,723.62,,,,,,,513.82,1165.90,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,27808015801,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,Local,,32.16,,,,,,,22.84,51.82,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,27808008602,NDC,,,facility,outpatient,1,EA,26.05000,7.55000,Aetna,Local,,13.23,,,,,,,9.39,21.31,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,27808008601,NDC,,,facility,outpatient,1,EA,26.75000,7.76000,Aetna,Local,,13.58,,,,,,,9.64,21.88,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,27808006502,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
risperiDONE 1mg/mL L (RisperDAL),800081133,CDM,637,RC,27808000201,NDC,,,facility,outpatient,1,EA,39.55000,11.47000,Aetna,Local,,20.08,,,,,,,14.26,32.35,percent of total billed charges,
Cefixime 400mg C (Suprax),800063049,CDM,637,RC,27437020811,NDC,,,facility,outpatient,1,EA,197.10000,57.16000,Aetna,Local,,100.07,,,,,,,71.05,161.23,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,27437005057,NDC,,,facility,outpatient,1,EA,494.20000,143.32000,Aetna,Local,,250.91,,,,,,,178.16,404.26,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,27437005056,NDC,,,facility,outpatient,1,EA,493.90000,143.23000,Aetna,Local,,250.75,,,,,,,178.05,404.01,percent of total billed charges,
LamoTRIgine 25mg ODT,800046462,CDM,637,RC,27241018330,NDC,,,facility,outpatient,1,EA,63.35000,18.37000,Aetna,Local,,32.16,,,,,,,22.84,51.82,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,27241015919,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,Local,,35.95,,,,,,,25.52,57.91,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,27241015504,NDC,,,facility,outpatient,1,EA,23.30000,6.76000,Aetna,Local,,11.83,,,,,,,8.40,19.06,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,27241014401,NDC,,,facility,outpatient,1,EA,63.55000,18.43000,Aetna,Local,,32.26,,,,,,,22.91,51.98,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,27241006303,NDC,,,facility,outpatient,1,EA,523.45000,151.80000,Aetna,Local,,265.76,,,,,,,188.70,428.18,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,27241000206,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,Local,,14.01,,,,,,,9.95,22.58,percent of total billed charges,
ravulizumab-cwvz- Pt Own Supply,800046500,CDM,636,RC,J1303,HCPCS,25682002801,NDC,facility,inpatient,1100,ME,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eculizumab- Pt Own Supply,800040879,CDM,636,RC,J1299,HCPCS,25682000101,NDC,facility,inpatient,300,ME,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Indocyanine Green 25 mg I,800080225,CDM,250,RC,25431042402,NDC,,,facility,outpatient,1,EA,494.90000,143.52000,Aetna,Local,,251.26,,,,,,,178.41,404.83,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,25208000305,NDC,,,facility,outpatient,1,EA,300.20000,87.06000,Aetna,Local,,152.41,,,,,,,108.22,245.56,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,25021083082,NDC,facility,inpatient,5,ME,2917.00000,845.93000,Aetna,Local,,1166.80,,,,,,,1051.58,2386.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,25021082761,NDC,facility,inpatient,3,ME,1186.00000,343.94000,Aetna,Local,,474.40,,,,,,,427.55,970.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,25021082583,NDC,facility,inpatient,750,ME,105.60000,30.62000,Aetna,Local,,42.24,,,,,,,38.07,86.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,25021082582,NDC,facility,inpatient,500,ME,111.60000,32.36000,Aetna,Local,,44.64,,,,,,,40.23,91.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,25021082581,NDC,facility,inpatient,250,ME,71.00000,20.59000,Aetna,Local,,28.40,,,,,,,25.60,58.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,25021081710,NDC,facility,inpatient,500,ME,373.00000,108.17000,Aetna,Local,,149.20,,,,,,,134.47,305.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,25021081630,NDC,facility,inpatient,350,ME,626.00000,181.54000,Aetna,Local,,250.40,,,,,,,225.67,512.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,25021081230,NDC,facility,inpatient,6000,ME,930.00000,269.70000,Aetna,Local,,372.00,,,,,,,335.26,760.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,25021080601,NDC,facility,inpatient,5,ME,22.35000,6.48000,Aetna,Local,,8.94,,,,,,,8.06,18.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,25021080166,NDC,facility,inpatient,4,ME,1483.00000,430.07000,Aetna,Local,,593.20,,,,,,,534.62,1213.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,25021079120,NDC,facility,inpatient,200,ME,587.60000,170.40000,Aetna,Local,,235.04,,,,,,,211.83,480.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,25021079120,NDC,facility,outpatient,200,ME,587.60000,170.40000,Aetna,Local,,235.04,,,,,,,0.37557,480.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,25021079002,NDC,facility,inpatient,10,ME,33.85000,9.82000,Aetna,Local,,13.54,,,,,,,12.20,27.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,25021078220,NDC,facility,inpatient,4,ME,14.40000,4.18000,Aetna,Local,,5.76,,,,,,,5.19,11.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,25021078005,NDC,facility,inpatient,500,ME,24.00000,6.96000,Aetna,Local,,9.60,,,,,,,8.65,19.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,25021077702,NDC,facility,inpatient,4,ME,7.65000,2.22000,Aetna,Local,,3.06,,,,,,,2.76,6.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,25021075110,NDC,facility,inpatient,40,ME,22.35000,6.48000,Aetna,Local,,8.94,,,,,,,8.06,18.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,25021070101,NDC,facility,inpatient,30,ME,31.85000,9.24000,Aetna,Local,,12.74,,,,,,,11.48,26.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,25021070001,NDC,facility,inpatient,15,ME,23.90000,6.93000,Aetna,Local,,9.56,,,,,,,8.62,19.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,25021068510,NDC,,,facility,outpatient,1,EA,28.10000,8.15000,Aetna,Local,,14.27,,,,,,,10.13,22.99,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,25021068310,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,Local,,4.62,,,,,,,3.28,7.44,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,25021067410,NDC,,,facility,outpatient,1,EA,92.75000,26.90000,Aetna,Local,,47.09,,,,,,,33.44,75.87,percent of total billed charges,
Lidocaine 2% Topical Jelly w/ Appl,800046502,CDM,250,RC,25021067376,NDC,,,facility,outpatient,1,EA,50.55000,14.66000,Aetna,Local,,25.66,,,,,,,18.22,41.35,percent of total billed charges,
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,25021067182,NDC,facility,inpatient,200,ME,385.85000,111.90000,Aetna,Local,,154.34,,,,,,,139.10,315.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,25021067166,NDC,facility,inpatient,200,ME,253.15000,73.41000,Aetna,Local,,101.26,,,,,,,91.26,207.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,25021066205,NDC,,,facility,outpatient,1,EA,38.30000,11.11000,Aetna,Local,,19.44,,,,,,,13.81,31.33,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,25021066205,NDC,,,facility,outpatient,1,EA,51.05000,14.80000,Aetna,Local,,25.92,,,,,,,18.40,41.76,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,25021065710,NDC,,,facility,outpatient,1,EA,51.05000,14.80000,Aetna,Local,,25.92,,,,,,,18.40,41.76,percent of total billed charges,
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,25021065601,NDC,facility,inpatient,5,ME,12.00000,3.48000,Aetna,Local,,4.80,,,,,,,4.33,9.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,25021065505,NDC,facility,inpatient,5,ME,12.00000,3.48000,Aetna,Local,,4.80,,,,,,,4.33,9.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,25021065502,NDC,facility,inpatient,2,ME,6.35000,1.84000,Aetna,Local,,2.54,,,,,,,2.29,5.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% (5mg/1mL) I,800025669,CDM,636,RC,J2795,HCPCS,25021065287,NDC,facility,inpatient,1,ME,0.80000,0.23000,Aetna,Local,,0.32000,,,,,,,0.28840,0.65440,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% (5mg/1mL) I,800025669,CDM,636,RC,J2795,HCPCS,25021065282,NDC,facility,inpatient,1,ME,0.80000,0.23000,Aetna,Local,,0.32000,,,,,,,0.28840,0.65440,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,25021065231,NDC,facility,inpatient,150,ME,164.40000,47.68000,Aetna,Local,,65.76,,,,,,,59.27,134.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,25021065230,NDC,facility,inpatient,150,ME,164.40000,47.68000,Aetna,Local,,65.76,,,,,,,59.27,134.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,25021065102,NDC,facility,inpatient,60,ME,76.60000,22.21000,Aetna,Local,,30.64,,,,,,,27.61,62.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,25021061281,NDC,facility,inpatient,2,GM,130.85000,37.95000,Aetna,Local,,52.34,,,,,,,47.17,107.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,25021060851,NDC,facility,inpatient,1,GM,283.80000,82.30000,Aetna,Local,,113.52,,,,,,,102.31,232.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,25021060850,NDC,facility,inpatient,0.5,GM,148.95000,43.20000,Aetna,Local,,59.58,,,,,,,53.70,121.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,25021060820,NDC,facility,inpatient,200,ME,37.10000,10.76000,Aetna,Local,,14.84,,,,,,,13.37,30.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,25021060203,NDC,,,facility,outpatient,1,EA,169.90000,49.27000,Aetna,Local,,86.26,,,,,,,61.25,138.98,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,25021060103,NDC,facility,inpatient,60,ME,192.00000,55.68000,Aetna,Local,,76.80,,,,,,,69.22,157.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,25021060005,NDC,,,facility,outpatient,1,EA,38.30000,11.11000,Aetna,Local,,19.44,,,,,,,13.81,31.33,percent of total billed charges,
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,25021050002,NDC,facility,inpatient,200,ME,63.50000,18.42000,Aetna,Local,,25.40,,,,,,,22.89,51.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,25021048101,NDC,facility,inpatient,50,ME,7.50000,2.17000,Aetna,Local,,3.00,,,,,,,2.70,6.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,25021046110,NDC,facility,inpatient,0.04,ME,2498.20000,724.48000,Aetna,Local,,999.28,,,,,,,900.60,2043.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,25021046001,NDC,facility,inpatient,0.004,ME,197.35000,57.23000,Aetna,Local,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,25021041450,NDC,facility,inpatient,50,ME,1555.00000,450.95000,Aetna,Local,,622.00,,,,,,,560.58,1271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,25021041170,NDC,facility,inpatient,120,ME,76.60000,22.21000,Aetna,Local,,30.64,,,,,,,27.61,62.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,25021041077,NDC,facility,inpatient,60,ME,34.30000,9.95000,Aetna,Local,,13.72,,,,,,,12.37,28.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,25021041076,NDC,facility,inpatient,40,ME,23.50000,6.82000,Aetna,Local,,9.40,,,,,,,8.47,19.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,25021040910,NDC,facility,inpatient,20,ME,498.00000,144.42000,Aetna,Local,,199.20,,,,,,,179.53,407.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,25021040067,NDC,facility,inpatient,10000,UN,10.15000,2.94000,Aetna,Local,,4.06,,,,,,,3.66,8.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,25021040030,NDC,facility,inpatient,30000,UN,69.35000,20.11000,Aetna,Local,,27.74,,,,,,,25.00,56.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,25021040010,NDC,facility,inpatient,10000,UN,23.00000,6.67000,Aetna,Local,,9.20,,,,,,,8.29,18.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,25021031905,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,Local,,9.11,,,,,,,6.47,14.68,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,25021031382,NDC,facility,inpatient,20,ME,96.90000,28.10000,Aetna,Local,,38.76,,,,,,,34.93,79.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,25021031110,NDC,facility,inpatient,100,ME,10.20000,2.96000,Aetna,Local,,4.08,,,,,,,3.68,8.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,25021031104,NDC,facility,inpatient,40,ME,12.75000,3.70000,Aetna,Local,,5.10,,,,,,,4.60,10.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,25021031102,NDC,facility,inpatient,20,ME,9.60000,2.78000,Aetna,Local,,3.84,,,,,,,3.46,7.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,25021031066,NDC,,,facility,outpatient,1,EA,471.95000,136.87000,Aetna,Local,,239.61,,,,,,,170.14,386.06,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,25021031002,NDC,,,facility,outpatient,1,EA,685.90000,198.91000,Aetna,Local,,348.23,,,,,,,247.27,561.07,percent of total billed charges,
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,25021030884,NDC,facility,inpatient,2.5,GM,1476.00000,428.04000,Aetna,Local,,590.40,,,,,,,532.10,1207.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,25021030566,NDC,facility,inpatient,500,ME,197.25000,57.20000,Aetna,Local,,78.90,,,,,,,71.11,161.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,25021030520,NDC,facility,inpatient,500,ME,352.05000,102.09000,Aetna,Local,,140.82,,,,,,,126.91,287.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,25021030305,NDC,,,facility,outpatient,1,EA,18.20000,5.28000,Aetna,Local,,9.24,,,,,,,6.56,14.89,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,25021030172,NDC,facility,inpatient,6,ME,102.15000,29.62000,Aetna,Local,,40.86,,,,,,,36.83,83.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,25021030102,NDC,facility,inpatient,6,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,25021025517,NDC,facility,inpatient,6,ME,14.00000,4.06000,Aetna,Local,,5.60,,,,,,,5.05,11.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,25021024504,NDC,facility,inpatient,80,ME,750.00000,217.50000,Aetna,Local,,300.00,,,,,,,270.38,613.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,25021023410,NDC,facility,inpatient,200,ME,94.00000,27.26000,Aetna,Local,,37.60,,,,,,,33.89,76.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,25021022204,NDC,facility,inpatient,80,ME,5947.00000,1724.63000,Aetna,Local,,2378.80,,,,,,,2143.89,4864.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,25021021350,NDC,facility,inpatient,6,ME,20.30000,5.89000,Aetna,Local,,8.12,,,,,,,7.32,16.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,25021020725,NDC,facility,inpatient,50,ME,189.40000,54.93000,Aetna,Local,,75.76,,,,,,,68.28,154.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,25021020245,NDC,facility,inpatient,50,ME,65.00000,18.85000,Aetna,Local,,26.00,,,,,,,23.43,53.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,25021020215,NDC,facility,inpatient,50,ME,65.00000,18.85000,Aetna,Local,,26.00,,,,,,,23.43,53.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mesna 200mg/2mL I (Mesnex),800025637,CDM,636,RC,J9209,HCPCS,25021020110,NDC,facility,inpatient,200,ME,40.80000,11.83000,Aetna,Local,,16.32,,,,,,,14.71,33.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,25021019111,NDC,facility,inpatient,100,ME,1533.40000,444.69000,Aetna,Local,,613.36,,,,,,,552.79,1254.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,25021018487,NDC,facility,inpatient,400,ME,142.80000,41.41000,Aetna,Local,,57.12,,,,,,,51.48,116.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,25021018482,NDC,facility,inpatient,200,ME,91.80000,26.62000,Aetna,Local,,36.72,,,,,,,33.09,75.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,25021018467,NDC,facility,inpatient,400,ME,142.80000,41.41000,Aetna,Local,,57.12,,,,,,,51.48,116.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,25021018466,NDC,facility,inpatient,200,ME,40.85000,11.85000,Aetna,Local,,16.34,,,,,,,14.73,33.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,25021017750,NDC,facility,inpatient,4.5,GM,149.75000,43.43000,Aetna,Local,,59.90,,,,,,,53.98,122.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,25021017620,NDC,facility,inpatient,3.375,GM,84.50000,24.50000,Aetna,Local,,33.80,,,,,,,30.46,69.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,25021017520,NDC,facility,inpatient,2.25,GM,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,25021016648,NDC,facility,inpatient,4.5,GM,139.20000,40.37000,Aetna,Local,,55.68,,,,,,,50.18,113.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,25021016530,NDC,facility,inpatient,3.375,GM,105.60000,30.62000,Aetna,Local,,42.24,,,,,,,38.07,86.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,25021016430,NDC,facility,inpatient,2.25,GM,67.20000,19.49000,Aetna,Local,,26.88,,,,,,,24.23,54.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,25021015899,NDC,facility,inpatient,1,GM,95.05000,27.56000,Aetna,Local,,38.02,,,,,,,34.27,77.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,25021014610,NDC,facility,inpatient,1000,ME,108.00000,31.32000,Aetna,Local,,43.20,,,,,,,38.93,88.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,25021014330,NDC,facility,inpatient,3,GM,86.40000,25.06000,Aetna,Local,,34.56,,,,,,,31.15,70.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,25021014220,NDC,facility,inpatient,1.5,GM,52.80000,15.31000,Aetna,Local,,21.12,,,,,,,19.03,43.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,25021014010,NDC,facility,inpatient,2,GM,215.50000,62.50000,Aetna,Local,,86.20,,,,,,,77.69,176.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,25021013720,NDC,facility,inpatient,2,GM,72.00000,20.88000,Aetna,Local,,28.80,,,,,,,25.96,58.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,25021013610,NDC,facility,inpatient,1,GM,48.00000,13.92000,Aetna,Local,,19.20,,,,,,,17.30,39.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,25021013510,NDC,facility,inpatient,500,ME,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,25021013283,NDC,facility,inpatient,750,ME,105.60000,30.62000,Aetna,Local,,42.24,,,,,,,38.07,86.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,25021013282,NDC,facility,inpatient,500,ME,56.00000,16.24000,Aetna,Local,,22.40,,,,,,,20.19,45.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,25021013281,NDC,facility,inpatient,250,ME,40.40000,11.72000,Aetna,Local,,16.16,,,,,,,14.56,33.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,25021013182,NDC,facility,inpatient,500,ME,26.95000,7.82000,Aetna,Local,,10.78,,,,,,,9.72,22.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,25021012720,NDC,facility,inpatient,1,GM,49.90000,14.47000,Aetna,Local,,19.96,,,,,,,17.99,40.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,25021012267,NDC,facility,inpatient,2,GM,96.00000,27.84000,Aetna,Local,,38.40,,,,,,,34.61,78.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,25021012250,NDC,facility,inpatient,2,GM,96.00000,27.84000,Aetna,Local,,38.40,,,,,,,34.61,78.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,25021012166,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,25021012120,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,25021011504,NDC,facility,inpatient,600,ME,38.75000,11.24000,Aetna,Local,,15.50,,,,,,,13.97,31.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,25021011387,NDC,facility,inpatient,400,ME,142.80000,41.41000,Aetna,Local,,57.12,,,,,,,51.48,116.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,25021011382,NDC,facility,inpatient,200,ME,91.80000,26.62000,Aetna,Local,,36.72,,,,,,,33.09,75.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,25021011020,NDC,facility,inpatient,2,GM,96.00000,27.84000,Aetna,Local,,38.40,,,,,,,34.61,78.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,25021010910,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,25021010610,NDC,facility,inpatient,1,GM,23.05000,6.68000,Aetna,Local,,9.22,,,,,,,8.31,18.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,25021010299,NDC,facility,inpatient,2,GM,48.60000,14.09000,Aetna,Local,,19.44,,,,,,,17.52,39.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,25021010110,NDC,facility,inpatient,1000,ME,7.50000,2.17000,Aetna,Local,,3.00,,,,,,,2.70,6.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,25010081356,NDC,,,facility,outpatient,1,EA,1368.15000,396.76000,Aetna,Local,,694.61,,,,,,,493.22,1119.15,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,25010040515,NDC,,,facility,outpatient,1,EA,71.15000,20.63000,Aetna,Local,,36.12,,,,,,,25.65,58.20,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,24987037810,NDC,facility,inpatient,1,GM,113.85000,33.02000,Aetna,Local,,45.54,,,,,,,41.04,93.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,24987026010,NDC,facility,inpatient,0.5,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,24987024255,NDC,,,facility,outpatient,1,EA,20.40000,5.92000,Aetna,Local,,10.36,,,,,,,7.35,16.69,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,24979021104,NDC,,,facility,outpatient,1,EA,20.65000,5.99000,Aetna,Local,,10.48,,,,,,,7.44,16.89,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,24979002907,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,24979002707,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,Local,,3.66,,,,,,,2.60,5.89,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,24979002607,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
Donepezil 23mg T (Aricept),800072470,CDM,637,RC,24979000406,NDC,,,facility,outpatient,1,EA,73.70000,21.37000,Aetna,Local,,37.42,,,,,,,26.57,60.29,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,24658026060,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,24658026018,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,Local,,0.48231,,,,,,,0.34247,0.77710,percent of total billed charges,
PrismaSol BGK 4/2.5 - 5L,800017935,CDM,250,RC,24571010505,NDC,,,facility,outpatient,1,EA,490.00000,142.10000,Aetna,Local,,248.77,,,,,,,176.65,400.82,percent of total billed charges,
PrismaSol BGK 2/3.5 - 5L,800025462,CDM,250,RC,24571010305,NDC,,,facility,outpatient,1,EA,490.00000,142.10000,Aetna,Local,,248.77,,,,,,,176.65,400.82,percent of total billed charges,
Tapentadol 50mg Tab UD,800025585,CDM,637,RC,24510005010,NDC,,,facility,outpatient,1,EA,116.85000,33.89000,Aetna,Local,,59.32,,,,,,,42.12,95.58,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,24486060210,NDC,,,facility,outpatient,1,EA,11.45000,3.32000,Aetna,Local,,5.81,,,,,,,4.13,9.37,percent of total billed charges,
Hyoscyamine 0.125 mg SL T,800080068,CDM,637,RC,24486060110,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,Local,,3.10,,,,,,,2.20,4.99,percent of total billed charges,
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,24477003025,NDC,facility,inpatient,25,ME,1844.65000,534.95000,Aetna,Local,,737.86,,,,,,,665.00,1508.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,24385014126,NDC,,,facility,outpatient,1,EA,1464.60000,424.73000,Aetna,Local,,743.58,,,,,,,527.99,1198.04,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,24357070130,NDC,,,facility,outpatient,1,EA,106.20000,30.80000,Aetna,Local,,53.92,,,,,,,38.29,86.87,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,24357070115,NDC,,,facility,outpatient,1,EA,135.95000,39.43000,Aetna,Local,,69.02,,,,,,,49.01,111.21,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,24338012213,NDC,,,facility,outpatient,1,EA,62.50000,18.12000,Aetna,Local,,31.73,,,,,,,22.53,51.12,percent of total billed charges,
Erythromycin 250mg T(Base),800013481,CDM,637,RC,24338012203,NDC,,,facility,outpatient,1,EA,72.50000,21.02000,Aetna,Local,,36.81,,,,,,,26.14,59.30,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,24208091019,NDC,,,facility,outpatient,1,EA,87.90000,25.49000,Aetna,Local,,44.63,,,,,,,31.69,71.90,percent of total billed charges,
Neo-Poly-Dex 5mL Ophth Susp(Maxitrol),800019117,CDM,637,RC,24208083060,NDC,,,facility,outpatient,1,EA,140.60000,40.77000,Aetna,Local,,71.38,,,,,,,50.69,115.01,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,24208079535,NDC,,,facility,outpatient,1,EA,140.60000,40.77000,Aetna,Local,,71.38,,,,,,,50.69,115.01,percent of total billed charges,
Neo-Poly-Bac-Hc 3.5g Ophth Oint(Cortispor,800019588,CDM,637,RC,24208078555,NDC,,,facility,outpatient,1,EA,435.50000,126.29000,Aetna,Local,,221.10,,,,,,,157.00,356.24,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,24208078055,NDC,,,facility,outpatient,1,EA,386.25000,112.01000,Aetna,Local,,196.10,,,,,,,139.24,315.95,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,24208075006,NDC,,,facility,outpatient,1,EA,89.35000,25.91000,Aetna,Local,,45.36,,,,,,,32.21,73.09,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,24208073006,NDC,,,facility,outpatient,1,EA,292.10000,84.71000,Aetna,Local,,148.30,,,,,,,105.30,238.94,percent of total billed charges,
dexaMETHasone 0.1% 5mL Ophth Soln,800036904,CDM,637,RC,24208072002,NDC,,,facility,outpatient,1,EA,433.25000,125.64000,Aetna,Local,,219.96,,,,,,,156.19,354.40,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,24208067615,NDC,,,facility,outpatient,1,EA,168.55000,48.88000,Aetna,Local,,85.57,,,,,,,60.76,137.87,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sus(Cortispor,800062843,CDM,637,RC,24208063562,NDC,,,facility,outpatient,1,EA,1042.25000,302.25000,Aetna,Local,,529.15,,,,,,,375.73,852.56,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,800018689,CDM,637,RC,24208063110,NDC,,,facility,outpatient,1,EA,1042.25000,302.25000,Aetna,Local,,529.15,,,,,,,375.73,852.56,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),800018655,CDM,637,RC,24208060564,NDC,,,facility,outpatient,1,EA,581.75000,168.71000,Aetna,Local,,295.35,,,,,,,209.72,475.87,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,24208055555,NDC,,,facility,outpatient,1,EA,203.50000,59.01000,Aetna,Local,,103.32,,,,,,,73.36,166.46,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,24208048510,NDC,,,facility,outpatient,1,EA,316.95000,91.92000,Aetna,Local,,160.92,,,,,,,114.26,259.27,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,24208046325,NDC,,,facility,outpatient,1,EA,172.60000,50.05000,Aetna,Local,,87.63,,,,,,,62.22,141.19,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,24208043405,NDC,,,facility,outpatient,1,EA,173.65000,50.36000,Aetna,Local,,88.16,,,,,,,62.60,142.05,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,24208041105,NDC,,,facility,outpatient,1,EA,130.65000,37.89000,Aetna,Local,,66.33,,,,,,,47.10,106.87,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,24208039830,NDC,,,facility,outpatient,1,EA,315.25000,91.42000,Aetna,Local,,160.05,,,,,,,113.65,257.87,percent of total billed charges,
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,24208034205,NDC,,,facility,outpatient,1,EA,1536.00000,445.44000,Aetna,Local,,779.83,,,,,,,553.73,1256.45,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,24208032405,NDC,,,facility,outpatient,1,EA,44.15000,12.80000,Aetna,Local,,22.41,,,,,,,15.92,36.11,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,24208031510,NDC,,,facility,outpatient,1,EA,95.15000,27.59000,Aetna,Local,,48.31,,,,,,,34.30,77.83,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,24208029525,NDC,,,facility,outpatient,1,EA,767.20000,222.49000,Aetna,Local,,389.51,,,,,,,276.58,627.57,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,24208029505,NDC,,,facility,outpatient,1,EA,768.95000,223.00000,Aetna,Local,,390.40,,,,,,,277.21,629.00,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,24208029005,NDC,,,facility,outpatient,1,EA,169.20000,49.07000,Aetna,Local,,85.90,,,,,,,61.00,138.41,percent of total billed charges,
Fluorometholone 0.1% 5mL Ophth Susp,800018804,CDM,637,RC,24208028805,NDC,,,facility,outpatient,1,EA,111.85000,32.44000,Aetna,Local,,56.79,,,,,,,40.32,91.49,percent of total billed charges,
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,24201011024,NDC,facility,inpatient,1000,ME,84.15000,24.40000,Aetna,Local,,33.66,,,,,,,30.34,68.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,24201010024,NDC,facility,inpatient,1000,ME,110.65000,32.09000,Aetna,Local,,44.26,,,,,,,39.89,90.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Norepinephrine 4mg/NS 250mL PF,800025496,CDM,250,RC,24200111610,NDC,,,facility,outpatient,1,EA,283.00000,82.07000,Aetna,Local,,143.68,,,,,,,102.02,231.49,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,24090047188,NDC,,,facility,outpatient,1,EA,175.50000,50.90000,Aetna,Local,,89.10,,,,,,,63.27,143.56,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,23635052460,NDC,,,facility,outpatient,1,EA,57.30000,16.62000,Aetna,Local,,29.09,,,,,,,20.66,46.87,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,23360015250,NDC,facility,inpatient,1,GM,62.25000,18.05000,Aetna,Local,,24.90,,,,,,,22.44,50.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,23360001402,NDC,facility,inpatient,80,ME,19.85000,5.76000,Aetna,Local,,7.94,,,,,,,7.16,16.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,23317032128,NDC,,,facility,outpatient,1,EA,188.70000,54.72000,Aetna,Local,,95.80,,,,,,,68.03,154.36,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,23317016515,NDC,,,facility,outpatient,1,EA,12.75000,3.70000,Aetna,Local,,6.47,,,,,,,4.60,10.43,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,23317016015,NDC,,,facility,outpatient,1,EA,154.00000,44.66000,Aetna,Local,,78.19,,,,,,,55.52,125.97,percent of total billed charges,
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,23155088331,NDC,facility,inpatient,6,ME,15.40000,4.47000,Aetna,Local,,6.16,,,,,,,5.55,12.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,23155088231,NDC,facility,inpatient,6,ME,15.60000,4.52000,Aetna,Local,,6.24,,,,,,,5.62,12.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Torsemide 5mg T,800017732,CDM,637,RC,23155087101,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155083410,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155083401,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,23155083301,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,23155077301,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,Local,,9.95,,,,,,,7.07,16.03,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,23155077201,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,23155076401,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,23155073501,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,23155070501,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,Local,,6.65,,,,,,,4.72,10.72,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,23155070401,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,Local,,5.23,,,,,,,3.71,8.43,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,23155066201,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,23155066142,NDC,,,facility,outpatient,1,EA,1266.00000,367.14000,Aetna,Local,,642.75,,,,,,,456.39,1035.59,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,23155060601,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,Local,,4.72,,,,,,,3.35,7.61,percent of total billed charges,
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,23155054931,NDC,facility,inpatient,4,ME,8.40000,2.44000,Aetna,Local,,3.36,,,,,,,3.03,6.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,23155054742,NDC,facility,inpatient,4,ME,2.95000,0.86000,Aetna,Local,,1.18,,,,,,,1.06,2.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,23155054741,NDC,facility,inpatient,4,ME,3.05000,0.88000,Aetna,Local,,1.22,,,,,,,1.10,2.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,23155051901,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,Local,,12.06,,,,,,,8.56,19.43,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,23155050101,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,23155049742,NDC,facility,inpatient,10,ME,118.10000,34.25000,Aetna,Local,,47.24,,,,,,,42.58,96.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,23155048901,NDC,,,facility,outpatient,1,EA,37.40000,10.85000,Aetna,Local,,18.99,,,,,,,13.48,30.59,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,23155048601,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,23155048551,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,Local,,16.91,,,,,,,12.00,27.24,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,23155047342,NDC,facility,inpatient,40,ME,22.55000,6.54000,Aetna,Local,,9.02,,,,,,,8.13,18.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,23155047341,NDC,facility,inpatient,20,ME,17.45000,5.06000,Aetna,Local,,6.98,,,,,,,6.29,14.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,23155034543,NDC,facility,inpatient,1,GM,282.85000,82.03000,Aetna,Local,,113.14,,,,,,,101.97,231.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,23155031331,NDC,facility,inpatient,500,ME,370.30000,107.39000,Aetna,Local,,148.12,,,,,,,133.49,302.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,23155029442,NDC,facility,inpatient,10,ME,35.75000,10.37000,Aetna,Local,,14.30,,,,,,,12.89,29.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,23155028801,NDC,,,facility,outpatient,1,EA,20.40000,5.92000,Aetna,Local,,10.36,,,,,,,7.35,16.69,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,23155025832,NDC,facility,inpatient,6,ME,70.80000,20.53000,Aetna,Local,,28.32,,,,,,,25.52,57.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,23155024701,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,Local,,7.18,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,23155024609,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,23155024601,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,23155024041,NDC,facility,inpatient,10,ME,14.05000,4.07000,Aetna,Local,,5.62,,,,,,,5.07,11.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,23155022901,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,23155019642,NDC,facility,inpatient,4,ME,5.90000,1.71000,Aetna,Local,,2.36,,,,,,,2.13,4.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,23155019401,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,23155018631,NDC,facility,inpatient,5,ME,6648.50000,1928.06000,Aetna,Local,,2659.40,,,,,,,2396.78,5438.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,23155017031,NDC,facility,inpatient,4,ME,211.00000,61.19000,Aetna,Local,,84.40,,,,,,,76.07,172.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,23155016831,NDC,facility,inpatient,4,ME,4.80000,1.39000,Aetna,Local,,1.92,,,,,,,1.73,3.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,23155016641,NDC,,,facility,outpatient,1,EA,39.35000,11.41000,Aetna,Local,,19.98,,,,,,,14.19,32.19,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,23155014601,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,23155013701,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,23155012401,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,Local,,9.01,,,,,,,6.40,14.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,23155012301,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,Local,,9.01,,,,,,,6.40,14.52,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,23155012101,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,Local,,9.01,,,,,,,6.40,14.52,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,23155011803,NDC,,,facility,outpatient,1,EA,9.05000,2.62000,Aetna,Local,,4.59,,,,,,,3.26,7.40,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,23155011801,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,23155011101,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,23155011001,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,23155010601,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,23155010205,NDC,,,facility,outpatient,1,EA,0.25000,0.07000,Aetna,Local,,0.12693,,,,,,,0.09012,0.20450,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,23155007101,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,23155007001,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,23155006505,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,23155006501,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,23155005901,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,23155005701,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,800015404,CDM,637,RC,23155005601,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,23155004901,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,23155004801,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,23155004303,NDC,,,facility,outpatient,1,EA,116.30000,33.73000,Aetna,Local,,59.05,,,,,,,41.93,95.13,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,23155002701,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,23155002401,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,23155002301,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,23155000801,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155000310,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,23155000301,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,23155000201,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,23155000101,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,21922006204,NDC,,,facility,outpatient,1,EA,41.30000,11.98000,Aetna,Local,,20.97,,,,,,,14.89,33.78,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,21922002107,NDC,,,facility,outpatient,1,EA,748.45000,217.05000,Aetna,Local,,379.99,,,,,,,269.82,612.23,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,21922001952,NDC,,,facility,outpatient,1,EA,116.65000,33.83000,Aetna,Local,,59.22,,,,,,,42.05,95.42,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,21922001705,NDC,,,facility,outpatient,1,EA,1551.75000,450.01000,Aetna,Local,,787.82,,,,,,,559.41,1269.33,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,21922001605,NDC,,,facility,outpatient,1,EA,1587.80000,460.46000,Aetna,Local,,806.13,,,,,,,572.40,1298.82,percent of total billed charges,
"Influenza Virus Vaccine, Inact Trivalent Inj",800051083,CDM,636,RC,90656,HCPCS,19515081052,NDC,facility,inpatient,1,EA,125.15000,36.29000,Aetna,Local,,50.06,,,,,,,45.12,102.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Influenza Virus Vaccine, Inact Trivalent Inj",800051083,CDM,636,RC,90656,HCPCS,19515081052,NDC,facility,outpatient,1,EA,125.15000,36.29000,Aetna,Local,,50.06,,,,,,,14.13,102.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hyaluronidase 150units/1mL Inj.,800025673,CDM,636,RC,J3470,HCPCS,18657011704,NDC,facility,inpatient,150,UN,330.25000,95.77000,Aetna,Local,,132.10,,,,,,,119.06,270.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,18393027253,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,17478095302,NDC,facility,inpatient,6,ME,39.60000,11.48000,Aetna,Local,,15.84,,,,,,,14.28,32.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,17478093705,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,Local,,9.47,,,,,,,6.72,15.26,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,17478093415,NDC,facility,inpatient,20,ME,59.85000,17.36000,Aetna,Local,,23.94,,,,,,,21.58,48.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,17478093401,NDC,facility,inpatient,20,ME,270.25000,78.37000,Aetna,Local,,108.10,,,,,,,97.43,221.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ophthalmic Irr Soln15mL(BSS),800018655,CDM,637,RC,17478092019,NDC,,,facility,outpatient,1,EA,38.10000,11.05000,Aetna,Local,,19.34,,,,,,,13.74,31.17,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,17478076610,NDC,,,facility,outpatient,1,EA,14.85000,4.31000,Aetna,Local,,7.54,,,,,,,5.35,12.15,percent of total billed charges,
brimonidine 0.2% Ophth Soln,800046442,CDM,637,RC,17478071510,NDC,,,facility,outpatient,1,EA,229.85000,66.66000,Aetna,Local,,116.69,,,,,,,82.86,188.02,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,17478071310,NDC,,,facility,outpatient,1,EA,148.25000,42.99000,Aetna,Local,,75.27,,,,,,,53.44,121.27,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,17478070311,NDC,,,facility,outpatient,1,EA,91.10000,26.42000,Aetna,Local,,46.25,,,,,,,32.84,74.52,percent of total billed charges,
Indocyanine Green 25 mg I,800080225,CDM,250,RC,17478070102,NDC,,,facility,outpatient,1,EA,643.80000,186.70000,Aetna,Local,,326.86,,,,,,,232.09,526.63,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,17478062512,NDC,,,facility,outpatient,1,EA,137.65000,39.92000,Aetna,Local,,69.88,,,,,,,49.62,112.60,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,17478054225,NDC,facility,inpatient,6,ME,35.90000,10.41000,Aetna,Local,,14.36,,,,,,,12.94,29.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,17478054202,NDC,facility,inpatient,6,ME,39.55000,11.47000,Aetna,Local,,15.82,,,,,,,14.26,32.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,17478053802,NDC,facility,inpatient,60,ME,118.15000,34.26000,Aetna,Local,,47.26,,,,,,,42.59,96.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,17478050101,NDC,facility,inpatient,0.2,ME,45.65000,13.24000,Aetna,Local,,18.26,,,,,,,16.46,37.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,17478041940,NDC,facility,inpatient,500,ME,566.55000,164.30000,Aetna,Local,,226.62,,,,,,,204.24,463.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorescein Ophth Test Strip,800081069,CDM,250,RC,17478040401,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,17478029010,NDC,,,facility,outpatient,1,EA,103.10000,29.90000,Aetna,Local,,52.34,,,,,,,37.17,84.34,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,17478028810,NDC,,,facility,outpatient,1,EA,120.35000,34.90000,Aetna,Local,,61.10,,,,,,,43.39,98.45,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,17478026312,NDC,,,facility,outpatient,1,EA,303.65000,88.06000,Aetna,Local,,154.16,,,,,,,109.47,248.39,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,17478023835,NDC,,,facility,outpatient,1,EA,184.10000,53.39000,Aetna,Local,,93.47,,,,,,,66.37,150.59,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,17478023535,NDC,,,facility,outpatient,1,EA,375.90000,109.01000,Aetna,Local,,190.84,,,,,,,135.51,307.49,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,17478022312,NDC,,,facility,outpatient,1,EA,616.45000,178.77000,Aetna,Local,,312.97,,,,,,,222.23,504.26,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,17478021515,NDC,,,facility,outpatient,1,EA,374.50000,108.60000,Aetna,Local,,190.13,,,,,,,135.01,306.34,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,17478020919,NDC,,,facility,outpatient,1,EA,533.80000,154.80000,Aetna,Local,,271.01,,,,,,,192.43,436.65,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,17478020911,NDC,,,facility,outpatient,1,EA,686.30000,199.03000,Aetna,Local,,348.43,,,,,,,247.41,561.39,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,17478020910,NDC,,,facility,outpatient,1,EA,686.35000,199.04000,Aetna,Local,,348.46,,,,,,,247.43,561.43,percent of total billed charges,
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,17478012150,NDC,facility,inpatient,600,ME,70.15000,20.34000,Aetna,Local,,28.06,,,,,,,25.29,57.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,17478008130,NDC,facility,inpatient,150,ME,39.90000,11.57000,Aetna,Local,,15.96,,,,,,,14.38,32.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,17478007031,NDC,,,facility,outpatient,1,EA,72.35000,20.98000,Aetna,Local,,36.73,,,,,,,26.08,59.18,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,17478006914,NDC,facility,inpatient,40,ME,19.25000,5.58000,Aetna,Local,,7.70,,,,,,,6.94,15.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,17478004001,NDC,facility,inpatient,2,ME,32.50000,9.42000,Aetna,Local,,13.00,,,,,,,11.72,26.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,17478003002,NDC,facility,inpatient,0.1,ME,19.60000,5.68000,Aetna,Local,,7.84,,,,,,,7.07,16.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,17478001502,NDC,facility,inpatient,20,ME,433.20000,125.63000,Aetna,Local,,173.28,,,,,,,156.17,354.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,17474300201,NDC,facility,outpatient,1,EA,18.45000,5.35000,Aetna,Local,,9.37,,,,,,,0.63000,15.09,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,17474012505,NDC,facility,inpatient,500,UN,18.10000,5.25000,Aetna,Local,,7.24,,,,,,,6.53,14.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,17314940003,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,Local,,6.19,,,,,,,4.40,9.98,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,17314940002,NDC,,,facility,outpatient,1,EA,14.30000,4.15000,Aetna,Local,,7.26,,,,,,,5.16,11.70,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,17314940001,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,17314920001,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,Local,,4.16,,,,,,,2.96,6.71,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,17314850001,NDC,,,facility,outpatient,1,EA,29.20000,8.47000,Aetna,Local,,14.82,,,,,,,10.53,23.89,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,17271070107,NDC,facility,inpatient,1,EA,93.50000,27.12000,Aetna,Local,,37.40,,,,,,,33.71,76.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,17271070102,NDC,facility,inpatient,1,EA,62.20000,18.04000,Aetna,Local,,24.88,,,,,,,22.42,50.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorescein Ophth Test Strip,800081069,CDM,250,RC,17238090030,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
Fluorescein Ophth Test Strip,800081069,CDM,250,RC,17238090011,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Indocyanine Green 25 mg I,800080225,CDM,250,RC,17238042406,NDC,,,facility,outpatient,1,EA,468.50000,135.86000,Aetna,Local,,237.86,,,,,,,168.89,383.23,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,17236061001,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,17236026701,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,Local,,0.15231,,,,,,,0.10815,0.24540,percent of total billed charges,
benzocaine-menthol Topical Spray,800046392,CDM,637,RC,16864068003,NDC,,,facility,outpatient,1,EA,45.10000,13.08000,Aetna,Local,,22.90,,,,,,,16.26,36.89,percent of total billed charges,
benzocaine-menthol Topical Spray,800046392,CDM,637,RC,16864068001,NDC,,,facility,outpatient,1,EA,45.55000,13.21000,Aetna,Local,,23.13,,,,,,,16.42,37.26,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,16837085514,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,16837085508,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,16729053308,NDC,facility,inpatient,1,ME,45.35000,13.15000,Aetna,Local,,18.14,,,,,,,16.35,37.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine SO4 0.4mg/mL 1mL I,800019204,CDM,636,RC,J0461,HCPCS,16729052508,NDC,facility,inpatient,0.4,ME,76.60000,22.21000,Aetna,Local,,30.64,,,,,,,27.61,62.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,16729050243,NDC,facility,inpatient,100,ME,22.50000,6.52000,Aetna,Local,,9.00,,,,,,,8.11,18.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,16729050008,NDC,facility,inpatient,20,ME,15.20000,4.41000,Aetna,Local,,6.08,,,,,,,5.48,12.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,16729048501,NDC,,,facility,outpatient,1,EA,28.80000,8.35000,Aetna,Local,,14.62,,,,,,,10.38,23.56,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,16729047901,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,Local,,4.11,,,,,,,2.92,6.63,percent of total billed charges,
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,16729047731,NDC,facility,inpatient,0.4,ME,1187.00000,344.23000,Aetna,Local,,474.80,,,,,,,427.91,970.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,16729047108,NDC,facility,inpatient,0.2,ME,38.90000,11.28000,Aetna,Local,,15.56,,,,,,,14.02,31.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,16729046503,NDC,facility,inpatient,50,ME,204.00000,59.16000,Aetna,Local,,81.60,,,,,,,73.54,166.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,16729044315,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,Local,,18.76,,,,,,,13.32,30.23,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,16729044310,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,Local,,18.76,,,,,,,13.32,30.23,percent of total billed charges,
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,16729043011,NDC,facility,inpatient,50,ME,1734.40000,502.98000,Aetna,Local,,693.76,,,,,,,625.25,1418.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,16729041401,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,16729036566,NDC,facility,inpatient,0.25,ME,1814.10000,526.09000,Aetna,Local,,725.64,,,,,,,653.98,1483.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,16729029805,NDC,facility,inpatient,4,ME,7.55000,2.19000,Aetna,Local,,3.02,,,,,,,2.72,6.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CISplatin 10mg/10mL I,800025595,CDM,636,RC,J9060,HCPCS,16729028811,NDC,facility,inpatient,10,ME,36.00000,10.44000,Aetna,Local,,14.40,,,,,,,12.98,29.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate 1g/40mL I PF,800022022,CDM,636,RC,J9260,HCPCS,16729027735,NDC,facility,inpatient,1000,ME,321.70000,93.29000,Aetna,Local,,128.68,,,,,,,115.97,263.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,16729027730,NDC,facility,inpatient,50,ME,31.85000,9.24000,Aetna,Local,,12.74,,,,,,,11.48,26.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,16729027668,NDC,facility,inpatient,500,ME,127.50000,36.97000,Aetna,Local,,51.00,,,,,,,45.96,104.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,16729027567,NDC,facility,inpatient,250,ME,7582.25000,2198.85000,Aetna,Local,,3032.90,,,,,,,2733.40,6202.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,16729026764,NDC,facility,inpatient,80,ME,8950.60000,2595.67000,Aetna,Local,,3580.24,,,,,,,3226.69,7321.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,16729026763,NDC,facility,inpatient,20,ME,2377.90000,689.59000,Aetna,Local,,951.16,,,,,,,857.23,1945.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,16729026231,NDC,facility,inpatient,10,ME,4.45000,1.29000,Aetna,Local,,1.78,,,,,,,1.60,3.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,16729024711,NDC,facility,inpatient,20,ME,840.10000,243.63000,Aetna,Local,,336.04,,,,,,,302.86,687.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,16729021815,NDC,,,facility,outpatient,1,EA,49.30000,14.30000,Aetna,Local,,25.03,,,,,,,17.77,40.33,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,16729021715,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,Local,,10.23,,,,,,,7.26,16.48,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,16729021201,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,16729021101,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,16729020201,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,16729020001,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,16729018301,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,16729018217,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,16729018201,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,Local,,1.52,,,,,,,1.08,2.45,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,16729017501,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,6.49,14.72,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,16729017201,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,16729017101,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,16729017001,NDC,,,facility,outpatient,1,EA,34.85000,10.11000,Aetna,Local,,17.69,,,,,,,12.56,28.51,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,16729016801,NDC,,,facility,outpatient,1,EA,31.95000,9.27000,Aetna,Local,,16.22,,,,,,,11.52,26.14,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,16729013616,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,16729013501,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,16729013401,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,16729011711,NDC,facility,inpatient,1000,ME,434.00000,125.86000,Aetna,Local,,173.60,,,,,,,156.46,355.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,16729011431,NDC,facility,inpatient,10,ME,7.40000,2.15000,Aetna,Local,,2.96,,,,,,,2.67,6.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,16729010811,NDC,facility,inpatient,20,ME,3372.20000,977.94000,Aetna,Local,,1348.88,,,,,,,1215.68,2758.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,16729009203,NDC,facility,inpatient,200,ME,301.00000,87.29000,Aetna,Local,,120.40,,,,,,,108.51,246.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,16729009010,NDC,,,facility,outpatient,1,EA,22.05000,6.39000,Aetna,Local,,11.19,,,,,,,7.95,18.04,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,16729009001,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,16729006529,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,16729003510,NDC,,,facility,outpatient,1,EA,94.20000,27.32000,Aetna,Local,,47.83,,,,,,,33.96,77.06,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,16729003410,NDC,,,facility,outpatient,1,EA,127.80000,37.06000,Aetna,Local,,64.88,,,,,,,46.07,104.54,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,16729002310,NDC,,,facility,outpatient,1,EA,129.95000,37.69000,Aetna,Local,,65.98,,,,,,,46.85,106.30,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,16729002301,NDC,,,facility,outpatient,1,EA,129.95000,37.69000,Aetna,Local,,65.98,,,,,,,46.85,106.30,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,16729001901,NDC,facility,inpatient,500,ME,55.55000,16.11000,Aetna,Local,,22.22,,,,,,,20.03,45.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,16729000101,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,16714075301,NDC,,,facility,outpatient,1,EA,29.65000,8.60000,Aetna,Local,,15.05,,,,,,,10.69,24.25,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,16714013025,NDC,facility,inpatient,40,ME,54.25000,15.73000,Aetna,Local,,21.70,,,,,,,19.56,44.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Probenecid 500mg T,800032549,CDM,637,RC,16571083101,NDC,,,facility,outpatient,1,EA,26.40000,7.66000,Aetna,Local,,13.40,,,,,,,9.52,21.60,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,16571077810,NDC,,,facility,outpatient,1,EA,61.25000,17.76000,Aetna,Local,,31.10,,,,,,,22.08,50.10,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,16571077809,NDC,,,facility,outpatient,1,EA,61.25000,17.76000,Aetna,Local,,31.10,,,,,,,22.08,50.10,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,16571075453,NDC,,,facility,outpatient,1,EA,386.25000,112.01000,Aetna,Local,,196.10,,,,,,,139.24,315.95,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,16571073528,NDC,,,facility,outpatient,1,EA,471.20000,136.65000,Aetna,Local,,239.23,,,,,,,169.87,385.44,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,16571073521,NDC,,,facility,outpatient,1,EA,471.45000,136.72000,Aetna,Local,,239.36,,,,,,,169.96,385.65,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,16571067621,NDC,,,facility,outpatient,1,EA,160.35000,46.50000,Aetna,Local,,81.41,,,,,,,57.81,131.17,percent of total billed charges,
PHENobarbital 32.4 mg Tab,800051123,CDM,637,RC,16571067301,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,Local,,2.72,,,,,,,1.93,4.38,percent of total billed charges,
PHENobarbital 97.2 mg Tab,800051981,CDM,637,RC,16571066801,NDC,,,facility,outpatient,1,EA,9.45000,2.74000,Aetna,Local,,4.80,,,,,,,3.41,7.73,percent of total billed charges,
PHENobarbital 64.8mg Tab,800051980,CDM,637,RC,16571066701,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,3.40,,,,,,,2.42,5.48,percent of total billed charges,
Cetirizine 5 mg Tab,800015396,CDM,637,RC,16571040110,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,Local,,8.96,,,,,,,6.36,14.44,percent of total billed charges,
Diclofenac Na 25mg EC T,800058437,CDM,637,RC,16571020310,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,16571016010,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,16571014150,NDC,,,facility,outpatient,1,EA,120.35000,34.90000,Aetna,Local,,61.10,,,,,,,43.39,98.45,percent of total billed charges,
Timolol 0.25%  Ophth Soln(Timoptic,800039197,CDM,637,RC,16571014050,NDC,,,facility,outpatient,1,EA,106.20000,30.80000,Aetna,Local,,53.92,,,,,,,38.29,86.87,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,16252059299,NDC,,,facility,outpatient,1,EA,186.75000,54.16000,Aetna,Local,,94.81,,,,,,,67.32,152.76,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,16252059099,NDC,,,facility,outpatient,1,EA,199.80000,57.94000,Aetna,Local,,101.44,,,,,,,72.03,163.44,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,16252057201,NDC,,,facility,outpatient,1,EA,12.75000,3.70000,Aetna,Local,,6.47,,,,,,,4.60,10.43,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,16252057101,NDC,,,facility,outpatient,1,EA,12.15000,3.52000,Aetna,Local,,6.17,,,,,,,4.38,9.94,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,16252057030,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,Local,,5.23,,,,,,,3.71,8.43,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,16252052790,NDC,,,facility,outpatient,1,EA,22.90000,6.64000,Aetna,Local,,11.63,,,,,,,8.26,18.73,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,15330002801,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,Local,,3.02,,,,,,,2.14,4.87,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,15330002501,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,14832001103,NDC,,,facility,outpatient,1,EA,118.65000,34.41000,Aetna,Local,,60.24,,,,,,,42.77,97.06,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,14832001101,NDC,,,facility,outpatient,1,EA,172.35000,49.98000,Aetna,Local,,87.50,,,,,,,62.13,140.98,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,14789070002,NDC,facility,inpatient,10,ME,114.90000,33.32000,Aetna,Local,,45.96,,,,,,,41.42,93.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,14789040005,NDC,facility,inpatient,500,ME,172.80000,50.11000,Aetna,Local,,69.12,,,,,,,62.29,141.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Erythromycin Lact.500mg I,800081135,CDM,636,RC,J1364,HCPCS,14789011605,NDC,facility,inpatient,500,ME,1627.00000,471.83000,Aetna,Local,,650.80,,,,,,,586.53,1330.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,14789010910,NDC,facility,inpatient,1,EA,397.00000,115.13000,Aetna,Local,,158.80,,,,,,,143.12,324.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,14789010810,NDC,facility,inpatient,1,EA,397.00000,115.13000,Aetna,Local,,158.80,,,,,,,143.12,324.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,14789001505,NDC,,,facility,outpatient,1,EA,4870.00000,1412.30000,Aetna,Local,,2472.50,,,,,,,1755.63,3983.66,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,14789001202,NDC,,,facility,outpatient,1,EA,455.70000,132.15000,Aetna,Local,,231.36,,,,,,,164.28,372.76,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,14550051302,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,14550051204,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,14550051202,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,14550051104,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,13811068130,NDC,,,facility,outpatient,1,EA,226.30000,65.63000,Aetna,Local,,114.89,,,,,,,81.58,185.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,13811068030,NDC,,,facility,outpatient,1,EA,226.30000,65.63000,Aetna,Local,,114.89,,,,,,,81.58,185.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,13811068010,NDC,,,facility,outpatient,1,EA,226.05000,65.55000,Aetna,Local,,114.77,,,,,,,81.49,184.91,percent of total billed charges,
ARIPiprazole 2mg T(Abilify),800081158,CDM,637,RC,13811067930,NDC,,,facility,outpatient,1,EA,223.90000,64.93000,Aetna,Local,,113.67,,,,,,,80.72,183.15,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,13811052501,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,13668059501,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,Local,,62.90,,,,,,,44.67,101.35,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),800080654,CDM,637,RC,13668045301,NDC,,,facility,outpatient,1,EA,79.05000,22.92000,Aetna,Local,,40.13,,,,,,,28.50,64.66,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,13668027101,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,13668018930,NDC,,,facility,outpatient,1,EA,67.60000,19.60000,Aetna,Local,,34.32,,,,,,,24.37,55.30,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,13668013501,NDC,,,facility,outpatient,1,EA,29.30000,8.50000,Aetna,Local,,14.88,,,,,,,10.56,23.97,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,13668013301,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,13668011390,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,Local,,6.04,,,,,,,4.29,9.73,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,13668010401,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,Local,,12.06,,,,,,,8.56,19.43,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,13668009390,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,Local,,10.61,,,,,,,7.53,17.10,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,13668009190,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,Local,,10.61,,,,,,,7.53,17.10,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,13668008190,NDC,,,facility,outpatient,1,EA,35.60000,10.32000,Aetna,Local,,18.07,,,,,,,12.83,29.12,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,13668004701,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,Local,,17.08,,,,,,,12.13,27.53,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,13668004501,NDC,,,facility,outpatient,1,EA,29.40000,8.53000,Aetna,Local,,14.93,,,,,,,10.60,24.05,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,13668003560,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,Local,,14.01,,,,,,,9.95,22.58,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,13668001990,NDC,,,facility,outpatient,1,EA,33.05000,9.58000,Aetna,Local,,16.78,,,,,,,11.91,27.03,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,13668001512,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,13668001412,NDC,,,facility,outpatient,1,EA,20.35000,5.90000,Aetna,Local,,10.33,,,,,,,7.34,16.65,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,13668000801,NDC,,,facility,outpatient,1,EA,37.00000,10.73000,Aetna,Local,,18.78,,,,,,,13.34,30.27,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,13668000774,NDC,,,facility,outpatient,1,EA,37.15000,10.77000,Aetna,Local,,18.86,,,,,,,13.39,30.39,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,13668000701,NDC,,,facility,outpatient,1,EA,37.00000,10.73000,Aetna,Local,,18.78,,,,,,,13.34,30.27,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,13551020101,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,Local,,7.46,,,,,,,5.30,12.02,percent of total billed charges,
Alpha 1-Proteinase Inhbitor Human 10mg I(Prolastin),800040897,CDM,636,RC,J0256,HCPCS,13533070501,NDC,facility,inpatient,10,ME,36.80000,10.67000,Aetna,Local,,14.72,,,,,,,13.27,30.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,13533069220,NDC,facility,inpatient,12.5,GM,426.55000,123.70000,Aetna,Local,,170.62,,,,,,,153.77,348.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,13533068525,NDC,facility,inpatient,12.5,GM,453.05000,131.38000,Aetna,Local,,181.22,,,,,,,163.32,370.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,13533068420,NDC,facility,inpatient,12.5,GM,426.55000,123.70000,Aetna,Local,,170.62,,,,,,,153.77,348.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,13533063603,NDC,facility,inpatient,1,EA,419.10000,121.54000,Aetna,Local,,167.64,,,,,,,151.09,342.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,13533063602,NDC,facility,inpatient,1,EA,377.80000,109.56000,Aetna,Local,,151.12,,,,,,,136.20,309.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus IG 250U I(Bay-Tet),800011759,CDM,636,RC,J1670,HCPCS,13533063402,NDC,facility,inpatient,250,UN,2406.70000,697.94000,Aetna,Local,,962.68,,,,,,,867.62,1968.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Immune Glob 300IU/1mL Inj,800040856,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,inpatient,300,F2,3019.10000,875.54000,Aetna,Local,,1207.64,,,,,,,1088.39,2469.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rabies Immune Glob 300IU/1mL Inj,800040856,CDM,636,RC,90375,HCPCS,13533031801,NDC,facility,outpatient,300,F2,3019.10000,875.54000,Aetna,Local,,1207.64,,,,,,,269.59,2469.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Colchicine 0.6mg T,800011790,CDM,637,RC,13310011907,NDC,,,facility,outpatient,1,EA,41.20000,11.95000,Aetna,Local,,20.92,,,,,,,14.85,33.70,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,13310011901,NDC,,,facility,outpatient,1,EA,41.20000,11.95000,Aetna,Local,,20.92,,,,,,,14.85,33.70,percent of total billed charges,
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,13143030136,NDC,facility,inpatient,12.5,GM,458.00000,132.82000,Aetna,Local,,183.20,,,,,,,165.11,374.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,13107015530,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,Local,,9.49,,,,,,,6.74,15.30,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,13107015430,NDC,,,facility,outpatient,1,EA,18.55000,5.38000,Aetna,Local,,9.42,,,,,,,6.69,15.17,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,13107014401,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,Local,,7.01,,,,,,,4.97,11.29,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,13107008405,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,13107008401,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,13107007301,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,13107007201,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,13107003134,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,Local,,9.70,,,,,,,6.89,15.62,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,13107000130,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,Local,,9.47,,,,,,,6.72,15.26,percent of total billed charges,
Mirtazapine 7.5mg T(Remeron),800015407,CDM,637,RC,13107000105,NDC,,,facility,outpatient,1,EA,18.65000,5.41000,Aetna,Local,,9.47,,,,,,,6.72,15.26,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12870000102,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12870000101,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12165010003,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
Silver Nitrate Appl.Stick,800032473,CDM,637,RC,12165010001,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Ofloxacin 0.3% Ophth Soln(Ocuflox),800073881,CDM,637,RC,11980077905,NDC,,,facility,outpatient,1,EA,920.70000,267.00000,Aetna,Local,,467.44,,,,,,,331.91,753.13,percent of total billed charges,
Fluorometholone 0.1% 5mL Ophth Susp,800018804,CDM,637,RC,11980021105,NDC,,,facility,outpatient,1,EA,1311.65000,380.38000,Aetna,Local,,665.92,,,,,,,472.85,1072.93,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,11980018010,NDC,,,facility,outpatient,1,EA,938.10000,272.05000,Aetna,Local,,476.27,,,,,,,338.19,767.37,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,11980018005,NDC,,,facility,outpatient,1,EA,1164.05000,337.57000,Aetna,Local,,590.99,,,,,,,419.64,952.19,percent of total billed charges,
prednisoLONE 0.12% 5mL Ophth Susp(Pred Mild),800043967,CDM,637,RC,11980017405,NDC,,,facility,outpatient,1,EA,1164.05000,337.57000,Aetna,Local,,590.99,,,,,,,419.64,952.19,percent of total billed charges,
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,11793752202,NDC,facility,inpatient,5,UN,8.85000,2.57000,Aetna,Local,,3.54,,,,,,,3.19,7.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tuberculin Inj,800066653,CDM,636,RC,86580,HCPCS,11793752202,NDC,facility,outpatient,5,UN,8.85000,2.57000,Aetna,Local,,3.54,,,,,,,3.27,65.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydroxocobalamin 5g Kit,800081127,CDM,636,RC,J3424,HCPCS,11704037001,NDC,facility,inpatient,5,GM,4863.10000,1410.30000,Aetna,Local,,1945.24,,,,,,,1753.15,3978.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zinc Oxide 20% Topical Paste,800046419,CDM,637,RC,11701005033,NDC,,,facility,outpatient,1,EA,680.60000,197.37000,Aetna,Local,,345.54,,,,,,,245.36,556.73,percent of total billed charges,
Zinc Oxide 20% Topical Paste,800046419,CDM,637,RC,11701005032,NDC,,,facility,outpatient,1,EA,32.10000,9.31000,Aetna,Local,,16.30,,,,,,,11.57,26.26,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,11534019701,NDC,,,facility,outpatient,1,EA,276.55000,80.20000,Aetna,Local,,140.40,,,,,,,99.70,226.22,percent of total billed charges,
sodium polystyrene sulfonate 15g Oral Rec Pwd,800046514,CDM,637,RC,11534016616,NDC,,,facility,outpatient,1,EA,111.95000,32.47000,Aetna,Local,,56.84,,,,,,,40.36,91.58,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,11534016501,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
droPERidol 2.5mg/mL 2mL I,800011791,CDM,636,RC,J1790,HCPCS,11098001002,NDC,facility,inpatient,5,ME,30.50000,8.84000,Aetna,Local,,12.20,,,,,,,11.00,24.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,10702010001,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,10702001801,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,10702001101,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,10702000601,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,10572010101,NDC,,,facility,outpatient,1,EA,116.70000,33.84000,Aetna,Local,,59.25,,,,,,,42.07,95.46,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,10572010001,NDC,,,facility,outpatient,1,EA,195.05000,56.56000,Aetna,Local,,99.03,,,,,,,70.32,159.55,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,10370083011,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,10370083009,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,10370082909,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,Local,,4.32,,,,,,,3.06,6.95,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,10370051110,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,Local,,14.65,,,,,,,10.40,23.60,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,10370051010,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,10370010103,NDC,,,facility,outpatient,1,EA,33.80000,9.80000,Aetna,Local,,17.16,,,,,,,12.18,27.65,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,10310032280,NDC,,,facility,outpatient,1,EA,29.60000,8.58000,Aetna,Local,,15.03,,,,,,,10.67,24.21,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,10147095203,NDC,,,facility,outpatient,1,EA,93.55000,27.13000,Aetna,Local,,47.50,,,,,,,33.72,76.52,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,10147095201,NDC,,,facility,outpatient,1,EA,215.85000,62.60000,Aetna,Local,,109.59,,,,,,,77.81,176.57,percent of total billed charges,
Haloperidol Decanoate 100mg/1mL Inj,800040916,CDM,636,RC,J1631,HCPCS,10147092205,NDC,facility,inpatient,100,ME,296.85000,86.09000,Aetna,Local,,118.74,,,,,,,107.01,242.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,10147076100,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,Local,,10.61,,,,,,,7.53,17.10,percent of total billed charges,
Ketoconazole 2% Top Shampoo 120mL,800017775,CDM,637,RC,10147075004,NDC,,,facility,outpatient,1,EA,197.80000,57.36000,Aetna,Local,,100.42,,,,,,,71.31,161.80,percent of total billed charges,
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,10139090510,NDC,facility,inpatient,0.25,ME,472.95000,137.16000,Aetna,Local,,189.18,,,,,,,170.50,386.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,10139050120,NDC,facility,inpatient,1,GM,120.00000,34.80000,Aetna,Local,,48.00,,,,,,,43.26,98.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,10139023511,NDC,,,facility,outpatient,1,EA,22.35000,6.48000,Aetna,Local,,11.35,,,,,,,8.06,18.28,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,10139023510,NDC,,,facility,outpatient,1,EA,59.05000,17.12000,Aetna,Local,,29.98,,,,,,,21.29,48.30,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,10139023010,NDC,facility,inpatient,60,ME,106.40000,30.86000,Aetna,Local,,42.56,,,,,,,38.36,87.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,10139023002,NDC,facility,inpatient,60,ME,106.40000,30.86000,Aetna,Local,,42.56,,,,,,,38.36,87.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,10139007011,NDC,facility,inpatient,1.5,GM,62.50000,18.12000,Aetna,Local,,25.00,,,,,,,22.53,51.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,10139006311,NDC,facility,inpatient,500,ME,27.50000,7.98000,Aetna,Local,,11.00,,,,,,,9.91,22.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,10139006202,NDC,facility,inpatient,50,ME,30.55000,8.86000,Aetna,Local,,12.22,,,,,,,11.01,24.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,10139006045,NDC,facility,inpatient,50,ME,81.25000,23.56000,Aetna,Local,,32.50,,,,,,,29.29,66.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,10139006015,NDC,facility,inpatient,50,ME,86.60000,25.11000,Aetna,Local,,34.64,,,,,,,31.22,70.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cangrelor 50mg Inj,800046560,CDM,636,RC,C9460,HCPCS,10122062010,NDC,facility,inpatient,50,ME,7395.65000,2144.74000,Aetna,Local,,2958.26,,,,,,,2666.13,6049.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Poractant 240mg/3mL Intratrach Inj,800017811,CDM,252,RC,10122051003,NDC,,,facility,inpatient,1,EA,4895.45000,1419.68000,Aetna,Local,,1958.18,,,,,,,1811.32,4004.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Poractant 240mg/3mL Intratrach Inj,800017811,CDM,252,RC,10122051003,NDC,,,facility,outpatient,1,EA,4895.45000,1419.68000,Aetna,Local,,2485.42,,,,,,,1764.81,4004.48,percent of total billed charges,
Poractant 120mg/1.5mL Intratrach I(Curosurf),800022090,CDM,250,RC,10122051001,NDC,,,facility,outpatient,1,EA,2576.25000,747.11000,Aetna,Local,,1307.96,,,,,,,928.74,2107.37,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,10019099959,NDC,,,facility,outpatient,1,EA,159.40000,46.23000,Aetna,Local,,80.93,,,,,,,57.46,130.39,percent of total billed charges,
Bortezomib 3.5mg Inj,800010964,CDM,636,RC,J9041,HCPCS,10019099101,NDC,facility,inpatient,3.5,ME,454.40000,131.78000,Aetna,Local,,181.76,,,,,,,163.81,371.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,10019095501,NDC,facility,inpatient,500,ME,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,10019093801,NDC,facility,inpatient,500,ME,2824.00000,818.96000,Aetna,Local,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,10019092582,NDC,facility,inpatient,1000,ME,275.50000,79.90000,Aetna,Local,,110.20,,,,,,,99.32,225.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ifosfamide 1g Inj (Ifex),800053420,CDM,636,RC,J9208,HCPCS,10019092501,NDC,facility,inpatient,1000,ME,349.80000,101.44000,Aetna,Local,,139.92,,,,,,,126.10,286.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,10019067210,NDC,facility,inpatient,2.5,GM,3837.85000,1112.98000,Aetna,Local,,1535.14,,,,,,,1383.54,3139.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,10019063002,NDC,facility,inpatient,3,GM,118.00000,34.22000,Aetna,Local,,47.20,,,,,,,42.54,96.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,10019063001,NDC,facility,inpatient,1.5,GM,62.50000,18.12000,Aetna,Local,,25.00,,,,,,,22.53,51.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,10019061110,NDC,facility,inpatient,1000,ME,7.70000,2.23000,Aetna,Local,,3.08,,,,,,,2.78,6.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,10019061103,NDC,facility,inpatient,1000,ME,14.50000,4.20000,Aetna,Local,,5.80,,,,,,,5.23,11.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055388,NDC,,,facility,outpatient,1,EA,84.25000,24.43000,Aetna,Local,,42.77,,,,,,,30.37,68.92,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055304,NDC,,,facility,outpatient,1,EA,183.15000,53.11000,Aetna,Local,,92.99,,,,,,,66.03,149.82,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055303,NDC,,,facility,outpatient,1,EA,183.15000,53.11000,Aetna,Local,,92.99,,,,,,,66.03,149.82,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055302,NDC,,,facility,outpatient,1,EA,183.15000,53.11000,Aetna,Local,,92.99,,,,,,,66.03,149.82,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,10019055301,NDC,,,facility,outpatient,1,EA,183.15000,53.11000,Aetna,Local,,92.99,,,,,,,66.03,149.82,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,10019050645,NDC,facility,inpatient,1,ME,14.50000,4.20000,Aetna,Local,,5.80,,,,,,,5.23,11.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,10019050610,NDC,facility,inpatient,0.25,ME,2.35000,0.68000,Aetna,Local,,0.94000,,,,,,,0.84718,1.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,10019045002,NDC,facility,inpatient,10,ME,2.85000,0.83000,Aetna,Local,,1.14,,,,,,,1.03,2.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isoflurane Inhl Sol 100mL,800081217,CDM,250,RC,10019036040,NDC,,,facility,outpatient,1,EA,204.35000,59.26000,Aetna,Local,,103.75,,,,,,,73.67,167.16,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,10019032101,NDC,,,facility,outpatient,1,EA,75.75000,21.97000,Aetna,Local,,38.46,,,,,,,27.31,61.96,percent of total billed charges,
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,10019029102,NDC,facility,inpatient,10,UN,6.70000,1.94000,Aetna,Local,,2.68,,,,,,,2.42,5.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine SO4 1mg/mL 1mL I,800013438,CDM,636,RC,J0461,HCPCS,10019025112,NDC,facility,inpatient,1,ME,10.25000,2.97000,Aetna,Local,,4.10,,,,,,,3.70,8.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,10019015901,NDC,facility,inpatient,25,ME,10.00000,2.90000,Aetna,Local,,4.00,,,,,,,3.60,8.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,10019013301,NDC,facility,inpatient,150,ME,19.45000,5.64000,Aetna,Local,,7.78,,,,,,,7.01,15.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,10019012001,NDC,facility,inpatient,100,ME,77.65000,22.52000,Aetna,Local,,31.06,,,,,,,27.99,63.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,10019011501,NDC,facility,inpatient,100,ME,137.35000,39.83000,Aetna,Local,,54.94,,,,,,,49.51,112.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,10019010201,NDC,facility,inpatient,2,ME,7.20000,2.09000,Aetna,Local,,2.88,,,,,,,2.60,5.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,10019006303,NDC,facility,inpatient,6,ME,84.80000,24.59000,Aetna,Local,,33.92,,,,,,,30.57,69.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,10019006302,NDC,facility,inpatient,6,ME,81.40000,23.61000,Aetna,Local,,32.56,,,,,,,29.34,66.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 2.5g/250mL P(Brevibloc),800082395,CDM,636,RC,J1805,HCPCS,10019005561,NDC,facility,inpatient,2.5,GM,1178.65000,341.81000,Aetna,Local,,471.46,,,,,,,424.90,964.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,10019004502,NDC,facility,inpatient,20,ME,4.70000,1.36000,Aetna,Local,,1.88,,,,,,,1.69,3.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,10019004501,NDC,facility,inpatient,20,ME,5.90000,1.71000,Aetna,Local,,2.36,,,,,,,2.13,4.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,10019003867,NDC,facility,inpatient,0.1,ME,15.35000,4.45000,Aetna,Local,,6.14,,,,,,,5.53,12.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,10019003727,NDC,facility,inpatient,0.1,ME,14.65000,4.25000,Aetna,Local,,5.86,,,,,,,5.28,11.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,10019002902,NDC,facility,inpatient,15,ME,7.10000,2.06000,Aetna,Local,,2.84,,,,,,,2.56,5.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,10019002805,NDC,facility,inpatient,5,ME,13.35000,3.87000,Aetna,Local,,5.34,,,,,,,4.81,10.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,10019002804,NDC,facility,inpatient,2,ME,6.25000,1.81000,Aetna,Local,,2.50,,,,,,,2.25,5.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,10019002803,NDC,facility,inpatient,2,ME,5.75000,1.67000,Aetna,Local,,2.30,,,,,,,2.07,4.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,10019002801,NDC,facility,inpatient,2,ME,6.25000,1.81000,Aetna,Local,,2.50,,,,,,,2.25,5.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,10019001681,NDC,facility,inpatient,0.2,ME,10.15000,2.94000,Aetna,Local,,4.06,,,,,,,3.66,8.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,10019001571,NDC,facility,inpatient,100,ME,860.65000,249.59000,Aetna,Local,,344.26,,,,,,,310.26,704.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,10019001303,NDC,facility,inpatient,1,GM,447.85000,129.88000,Aetna,Local,,179.14,,,,,,,161.45,366.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,10019001302,NDC,facility,inpatient,0.5,GM,232.50000,67.42000,Aetna,Local,,93.00,,,,,,,83.82,190.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,10019001301,NDC,facility,inpatient,200,ME,57.90000,16.79000,Aetna,Local,,23.16,,,,,,,20.87,47.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,10019000673,NDC,facility,inpatient,5,ME,19.30000,5.60000,Aetna,Local,,7.72,,,,,,,6.96,15.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,08881590125,NDC,facility,inpatient,500,UN,3.60000,1.04000,Aetna,Local,,1.44,,,,,,,1.30,2.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08881579121,NDC,facility,outpatient,1,EA,24.95000,7.24000,Aetna,Local,,12.67,,,,,,,0.63000,20.41,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08881570121,NDC,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,0.63000,4.78,percent of total billed charges,
Spacer for Inhaler,800040918,CDM,637,RC,A4627,HCPCS,08373747800,NDC,facility,outpatient,1,EA,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,51.55,116.97,percent of total billed charges,
NS (Sterile Field) IS 10mL,800022041,CDM,250,RC,08290306553,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,Local,,3.35,,,,,,,2.38,5.40,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08290306551,NDC,facility,outpatient,1,EA,4.30000,1.25000,Aetna,Local,,2.18,,,,,,,0.63000,4.78,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08290306547,NDC,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,0.63000,4.78,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),800081162,CDM,258,RC,A4216,HCPCS,08290306546,NDC,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,0.63000,4.78,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,08290306513,NDC,facility,inpatient,500,UN,3.80000,1.10000,Aetna,Local,,1.52,,,,,,,1.37,3.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,08290306424,NDC,facility,inpatient,500,UN,4.40000,1.28000,Aetna,Local,,1.76,,,,,,,1.59,3.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,800041391,CDM,250,RC,08065183085,NDC,,,facility,outpatient,1,EA,1167.50000,338.58000,Aetna,Local,,592.74,,,,,,,420.88,955.01,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,800041391,CDM,250,RC,05047450842,NDC,,,facility,outpatient,1,EA,751.80000,218.02000,Aetna,Local,,381.69,,,,,,,271.02,614.97,percent of total billed charges,
Belladonna-Opium Supp(60mg Of Opium),800017087,CDM,637,RC,00998501675,NDC,,,facility,outpatient,1,EA,24.15000,7.00000,Aetna,Local,,12.26,,,,,,,8.71,19.75,percent of total billed charges,
Microfibrillar 1g TP(Avitene),800034537,CDM,637,RC,00998101002,NDC,,,facility,outpatient,1,EA,1354.85000,392.91000,Aetna,Local,,687.86,,,,,,,488.42,1108.27,percent of total billed charges,
Tobramycin 0.3% 5mL Ophth Soln(Tobrex),800040823,CDM,637,RC,00998064305,NDC,,,facility,outpatient,1,EA,417.75000,121.15000,Aetna,Local,,212.09,,,,,,,150.60,341.72,percent of total billed charges,
prednisoLONE 1% Ophth Susp (Econopred P),800019398,CDM,637,RC,00998063710,NDC,,,facility,outpatient,1,EA,215.70000,62.55000,Aetna,Local,,109.51,,,,,,,77.76,176.44,percent of total billed charges,
Neo-Poly-Dex 5mL Ophth Susp(Maxitrol),800019117,CDM,637,RC,00998063006,NDC,,,facility,outpatient,1,EA,846.85000,245.59000,Aetna,Local,,429.95,,,,,,,305.29,692.72,percent of total billed charges,
Pilocarpine 1% 15mL Ophth Soln,800018978,CDM,637,RC,00998020315,NDC,,,facility,outpatient,1,EA,677.80000,196.56000,Aetna,Local,,344.12,,,,,,,244.35,554.44,percent of total billed charges,
Proparacaine HCl 0.5% 15mL OS(Alcaine),800056423,CDM,637,RC,00998001615,NDC,,,facility,outpatient,1,EA,341.50000,99.04000,Aetna,Local,,173.38,,,,,,,123.11,279.35,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00990798509,NDC,,,facility,outpatient,1,EA,61.80000,17.92000,Aetna,Local,,31.38,,,,,,,22.28,50.55,percent of total billed charges,
0.45% Sodium Cl 250mL,800081202,CDM,258,RC,00990798502,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,Local,,27.97,,,,,,,19.86,45.07,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00990798436,NDC,facility,inpatient,1,EA,28.50000,8.26000,Aetna,Local,,11.40,,,,,,,10.27,23.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00990798413,NDC,facility,inpatient,1,EA,36.50000,10.58000,Aetna,Local,,14.60,,,,,,,13.16,29.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00990798309,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,Local,,21.42,,,,,,,19.30,43.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00990798302,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,Local,,21.42,,,,,,,19.30,43.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D10W 1000mL,800012362,CDM,258,RC,00990793009,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,Local,,27.19,,,,,,,19.30,43.80,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00990793002,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,Local,,27.19,,,,,,,19.30,43.80,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00990790209,NDC,,,facility,outpatient,1,EA,74.40000,21.58000,Aetna,Local,,37.77,,,,,,,26.82,60.86,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00990767009,NDC,,,facility,outpatient,1,EA,55.25000,16.02000,Aetna,Local,,28.05,,,,,,,19.92,45.19,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00990711509,NDC,,,facility,outpatient,1,EA,69.95000,20.29000,Aetna,Local,,35.51,,,,,,,25.22,57.22,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00990710709,NDC,,,facility,outpatient,1,EA,72.50000,21.02000,Aetna,Local,,36.81,,,,,,,26.14,59.30,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00990707526,NDC,facility,inpatient,1,EA,52.50000,15.22000,Aetna,Local,,21.00,,,,,,,18.93,42.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00990707426,NDC,facility,inpatient,1,EA,50.60000,14.67000,Aetna,Local,,20.24,,,,,,,18.24,41.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00955173530,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,Local,,21.58,,,,,,,15.32,34.77,percent of total billed charges,
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00955102104,NDC,facility,inpatient,80,ME,3319.00000,962.51000,Aetna,Local,,1327.60,,,,,,,1196.50,2714.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00955102001,NDC,facility,inpatient,20,ME,937.20000,271.79000,Aetna,Local,,374.88,,,,,,,337.86,766.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00955101510,NDC,facility,inpatient,150,ME,199.40000,57.83000,Aetna,Local,,79.76,,,,,,,71.88,163.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00955101210,NDC,facility,inpatient,120,ME,162.30000,47.07000,Aetna,Local,,64.92,,,,,,,58.51,132.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00955101010,NDC,facility,inpatient,100,ME,137.60000,39.90000,Aetna,Local,,55.04,,,,,,,49.60,112.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00955100810,NDC,facility,inpatient,80,ME,109.10000,31.64000,Aetna,Local,,43.64,,,,,,,39.33,89.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00955100410,NDC,facility,inpatient,40,ME,54.50000,15.80000,Aetna,Local,,21.80,,,,,,,19.65,44.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,00955025050,NDC,,,facility,outpatient,1,EA,13.55000,3.93000,Aetna,Local,,6.88,,,,,,,4.88,11.08,percent of total billed charges,
Immune Globulin 30g/300mL I,800062123,CDM,636,RC,J1569,HCPCS,00944270007,NDC,facility,inpatient,30,GM,37902.75000,10991.80000,Aetna,Local,,15161.10,,,,,,,13663.94,31004.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Immune Globulin 20g/200mL I,800017442,CDM,636,RC,J1569,HCPCS,00944270006,NDC,facility,inpatient,20,GM,25330.85000,7345.95000,Aetna,Local,,10132.34,,,,,,,9131.77,20720.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Immune Globulin 10g/100mL I,800062122,CDM,636,RC,J1569,HCPCS,00944270005,NDC,facility,inpatient,10,GM,12758.90000,3700.08000,Aetna,Local,,5103.56,,,,,,,4599.58,10436.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Immune Globulin 5g/50mL I,800062121,CDM,636,RC,J1569,HCPCS,00944270004,NDC,facility,inpatient,5,GM,6472.95000,1877.16000,Aetna,Local,,2589.18,,,,,,,2333.50,5294.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,00944049505,NDC,facility,inpatient,12.5,GM,1192.40000,345.80000,Aetna,Local,,476.96,,,,,,,429.86,975.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,00944049303,NDC,facility,inpatient,12.5,GM,504.60000,146.33000,Aetna,Local,,201.84,,,,,,,181.91,412.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,00944049301,NDC,facility,inpatient,12.5,GM,524.00000,151.96000,Aetna,Local,,209.60,,,,,,,188.90,428.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,00944049101,NDC,facility,inpatient,12.5,GM,809.15000,234.65000,Aetna,Local,,323.66,,,,,,,291.70,661.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Na Citrate 4% 500mL Inj,800076314,CDM,250,RC,00942950410,NDC,,,facility,outpatient,1,EA,97.40000,28.25000,Aetna,Local,,49.45,,,,,,,35.11,79.67,percent of total billed charges,
Anticoag Citr Dextr-A 1L (ACDA),800072509,CDM,250,RC,00942064104,NDC,,,facility,outpatient,1,EA,118.90000,34.48000,Aetna,Local,,60.37,,,,,,,42.86,97.26,percent of total billed charges,
Dianeal LCA Soln 4.25% 6000mL,800062049,CDM,636,RC,A4726,HCPCS,00941045901,NDC,facility,inpatient,1,EA,434.65000,126.05000,Aetna,Local,,173.86,,,,,,,156.69,355.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 4.25% 6000mL,800062049,CDM,636,RC,A4726,HCPCS,00941045901,NDC,facility,outpatient,1,EA,434.65000,126.05000,Aetna,Local,,173.86,,,,,,,156.69,355.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 2.5% 6000mL,800062048,CDM,636,RC,A4726,HCPCS,00941045701,NDC,facility,inpatient,1,EA,423.85000,122.92000,Aetna,Local,,169.54,,,,,,,152.80,346.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 2.5% 6000mL,800062048,CDM,636,RC,A4726,HCPCS,00941045701,NDC,facility,outpatient,1,EA,423.85000,122.92000,Aetna,Local,,169.54,,,,,,,152.80,346.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 2.5% 2000mL,800018439,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,inpatient,1,EA,255.30000,74.04000,Aetna,Local,,102.12,,,,,,,92.04,208.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 2.5% 2000mL,800018439,CDM,636,RC,A4722,HCPCS,00941043052,NDC,facility,outpatient,1,EA,255.30000,74.04000,Aetna,Local,,102.12,,,,,,,92.04,208.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 1.5% 2000mL,800018421,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,inpatient,1,EA,230.50000,66.84000,Aetna,Local,,92.20,,,,,,,83.10,188.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 1.5% 2000mL,800018421,CDM,636,RC,A4722,HCPCS,00941042452,NDC,facility,outpatient,1,EA,230.50000,66.84000,Aetna,Local,,92.20,,,,,,,83.10,188.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 1.5% 6000mL,800062047,CDM,636,RC,A4726,HCPCS,00941040901,NDC,facility,inpatient,1,EA,415.75000,120.57000,Aetna,Local,,166.30,,,,,,,149.88,340.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dianeal LCA Soln 1.5% 6000mL,800062047,CDM,636,RC,A4726,HCPCS,00941040901,NDC,facility,outpatient,1,EA,415.75000,120.57000,Aetna,Local,,166.30,,,,,,,149.88,340.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00904880531,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,Local,,10.79,,,,,,,7.66,17.38,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00904794660,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,Local,,0.20308,,,,,,,0.14420,0.32720,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,00904792260,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,00904786560,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00904782236,NDC,,,facility,outpatient,1,EA,37.45000,10.86000,Aetna,Local,,19.01,,,,,,,13.50,30.63,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00904780961,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00904775960,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904773760,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00904773445,NDC,,,facility,outpatient,1,EA,83.45000,24.20000,Aetna,Local,,42.37,,,,,,,30.08,68.26,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00904762331,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,Local,,11.37,,,,,,,8.08,18.32,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00904750504,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00904750161,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00904749804,NDC,,,facility,outpatient,1,EA,26.65000,7.73000,Aetna,Local,,13.53,,,,,,,9.61,21.80,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00904747095,NDC,,,facility,outpatient,1,EA,76.40000,22.16000,Aetna,Local,,38.79,,,,,,,27.54,62.50,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00904746806,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00904746273,NDC,,,facility,outpatient,1,EA,61.60000,17.86000,Aetna,Local,,31.27,,,,,,,22.21,50.39,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00904746187,NDC,,,facility,outpatient,1,EA,68.45000,19.85000,Aetna,Local,,34.75,,,,,,,24.68,55.99,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,00904744861,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,Local,,1.02,,,,,,,0.72100,1.64,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,00904744761,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00904741761,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00904740161,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,00904738961,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,00904736761,NDC,,,facility,outpatient,1,EA,152.95000,44.36000,Aetna,Local,,77.65,,,,,,,55.14,125.11,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,00904736261,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,Local,,1.52,,,,,,,1.08,2.45,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,00904736061,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,Local,,1.04,,,,,,,0.73903,1.68,percent of total billed charges,
Lurasidone 40mg T(Latuda),800017976,CDM,637,RC,00904735661,NDC,,,facility,outpatient,1,EA,7.85000,2.28000,Aetna,Local,,3.99,,,,,,,2.83,6.42,percent of total billed charges,
Lurasidone 20 mg T(Latuda),800025537,CDM,637,RC,00904735504,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904735061,NDC,,,facility,outpatient,1,EA,17.80000,5.16000,Aetna,Local,,9.04,,,,,,,6.42,14.56,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904735006,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,Local,,5.33,,,,,,,3.79,8.59,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00904733761,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00904733706,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00904733661,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00904732861,NDC,,,facility,outpatient,1,EA,26.55000,7.70000,Aetna,Local,,13.48,,,,,,,9.57,21.72,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00904731706,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00904730761,NDC,,,facility,outpatient,1,EA,0.80000,0.23000,Aetna,Local,,0.40616,,,,,,,0.28840,0.65440,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00904730661,NDC,,,facility,outpatient,1,EA,0.90000,0.26000,Aetna,Local,,0.45693,,,,,,,0.32445,0.73620,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00904729361,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00904728861,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,00904728306,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,Local,,1.52,,,,,,,1.08,2.45,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00904727692,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,Local,,5.28,,,,,,,3.75,8.51,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00904727061,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,Local,,3.76,,,,,,,2.67,6.05,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00904726918,NDC,,,facility,outpatient,1,EA,60.90000,17.66000,Aetna,Local,,30.92,,,,,,,21.95,49.82,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00904726261,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00904725761,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,00904724468,NDC,,,facility,outpatient,1,EA,11.80000,3.42000,Aetna,Local,,5.99,,,,,,,4.25,9.65,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00904724161,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,Local,,2.39,,,,,,,1.69,3.84,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904722761,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00904722461,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00904722061,NDC,,,facility,outpatient,1,EA,15.45000,4.48000,Aetna,Local,,7.84,,,,,,,5.57,12.64,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00904721461,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00904720061,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00904719361,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,Local,,0.33000,,,,,,,0.23433,0.53170,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00904718904,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,Local,,12.08,,,,,,,8.58,19.47,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00904718761,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00904718461,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,1.32,2.99,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00904718261,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,Local,,8.88,,,,,,,6.31,14.31,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00904718245,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,Local,,10.86,,,,,,,7.71,17.51,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904717961,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,Local,,0.71078,,,,,,,0.50470,1.15,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00904717861,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,Local,,0.33000,,,,,,,0.23433,0.53170,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00904717761,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,Local,,0.33000,,,,,,,0.23433,0.53170,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00904716806,NDC,,,facility,outpatient,1,EA,41.65000,12.08000,Aetna,Local,,21.15,,,,,,,15.01,34.07,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00904716261,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904715361,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,Local,,2.13,,,,,,,1.51,3.44,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00904714004,NDC,,,facility,outpatient,1,EA,13.65000,3.96000,Aetna,Local,,6.93,,,,,,,4.92,11.17,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00904713861,NDC,,,facility,outpatient,1,EA,26.55000,7.70000,Aetna,Local,,13.48,,,,,,,9.57,21.72,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00904713761,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,Local,,9.95,,,,,,,7.07,16.03,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00904713261,NDC,,,facility,outpatient,1,EA,106.10000,30.77000,Aetna,Local,,53.87,,,,,,,38.25,86.79,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00904712804,NDC,,,facility,outpatient,1,EA,22.85000,6.63000,Aetna,Local,,11.60,,,,,,,8.24,18.69,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00904712661,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,Local,,3.02,,,,,,,2.14,4.87,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00904712361,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00904712261,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00904712161,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,Local,,0.76155,,,,,,,0.54075,1.23,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00904712004,NDC,,,facility,outpatient,1,EA,40.75000,11.82000,Aetna,Local,,20.69,,,,,,,14.69,33.33,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,800022076,CDM,637,RC,00904711793,NDC,,,facility,outpatient,1,EA,35.25000,10.22000,Aetna,Local,,17.90,,,,,,,12.71,28.83,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00904711061,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00904710961,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00904710761,NDC,,,facility,outpatient,1,EA,27.90000,8.09000,Aetna,Local,,14.16,,,,,,,10.06,22.82,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00904710310,NDC,,,facility,outpatient,1,EA,45.25000,13.12000,Aetna,Local,,22.97,,,,,,,16.31,37.01,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00904710304,NDC,,,facility,outpatient,1,EA,77.90000,22.59000,Aetna,Local,,39.55,,,,,,,28.08,63.72,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00904708961,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00904708761,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,Local,,4.04,,,,,,,2.87,6.50,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00904708661,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00904708645,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,Local,,3.60,,,,,,,2.56,5.81,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00904708461,NDC,,,facility,outpatient,1,EA,15.75000,4.57000,Aetna,Local,,8.00,,,,,,,5.68,12.88,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00904708404,NDC,,,facility,outpatient,1,EA,11.20000,3.25000,Aetna,Local,,5.69,,,,,,,4.04,9.16,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,00904707957,NDC,,,facility,outpatient,1,EA,41.60000,12.06000,Aetna,Local,,21.12,,,,,,,15.00,34.03,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00904707861,NDC,facility,inpatient,500,ME,8.05000,2.33000,Aetna,Local,,3.22,,,,,,,2.90,6.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00904707761,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00904707661,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00904707561,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00904707161,NDC,,,facility,outpatient,1,EA,35.20000,10.21000,Aetna,Local,,17.87,,,,,,,12.69,28.79,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00904707107,NDC,,,facility,outpatient,1,EA,30.70000,8.90000,Aetna,Local,,15.59,,,,,,,11.07,25.11,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,00904706704,NDC,,,facility,outpatient,1,EA,242.65000,70.37000,Aetna,Local,,123.19,,,,,,,87.48,198.49,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00904706453,NDC,,,facility,outpatient,1,EA,137.15000,39.77000,Aetna,Local,,69.63,,,,,,,49.44,112.19,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00904706296,NDC,,,facility,outpatient,1,EA,195.85000,56.80000,Aetna,Local,,99.43,,,,,,,70.60,160.21,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00904706260,NDC,,,facility,outpatient,1,EA,125.05000,36.26000,Aetna,Local,,63.49,,,,,,,45.08,102.29,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00904706187,NDC,,,facility,outpatient,1,EA,68.45000,19.85000,Aetna,Local,,34.75,,,,,,,24.68,55.99,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,00904706094,NDC,,,facility,outpatient,1,EA,30.55000,8.86000,Aetna,Local,,15.51,,,,,,,11.01,24.99,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00904705861,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00904705761,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,00904705699,NDC,,,facility,outpatient,1,EA,89.70000,26.01000,Aetna,Local,,45.54,,,,,,,32.34,73.37,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00904704961,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00904704861,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00904704761,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00904704561,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,Local,,6.19,,,,,,,4.40,9.98,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,00904704361,NDC,,,facility,outpatient,1,EA,13.65000,3.96000,Aetna,Local,,6.93,,,,,,,4.92,11.17,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,00904704304,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,Local,,6.27,,,,,,,4.45,10.10,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00904704161,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Naltrexone 50mg Tab,800017999,CDM,637,RC,00904703604,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00904703587,NDC,,,facility,outpatient,1,EA,14.65000,4.25000,Aetna,Local,,7.44,,,,,,,5.28,11.98,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00904703580,NDC,,,facility,outpatient,1,EA,13.80000,4.00000,Aetna,Local,,7.01,,,,,,,4.97,11.29,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00904702661,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00904702061,NDC,,,facility,outpatient,1,EA,11.45000,3.32000,Aetna,Local,,5.81,,,,,,,4.13,9.37,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00904701661,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,Local,,5.28,,,,,,,3.75,8.51,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,00904700861,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,00904700761,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,00904700161,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,Local,,4.09,,,,,,,2.90,6.58,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,00904700061,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,Local,,3.73,,,,,,,2.65,6.01,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00904699361,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,Local,,1.27,,,,,,,0.90125,2.04,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,00904699261,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,00904699161,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,00904699104,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,Local,,6.42,,,,,,,4.56,10.35,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00904698761,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00904696661,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00904695761,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00904695561,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00904695461,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00904695361,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00904695261,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00904695161,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00904695061,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00904694961,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,00904693961,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,Local,,4.16,,,,,,,2.96,6.71,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00904693806,NDC,,,facility,outpatient,1,EA,15.35000,4.45000,Aetna,Local,,7.79,,,,,,,5.53,12.56,percent of total billed charges,
Paliperidone 3 mg ER T(Invega),800017658,CDM,637,RC,00904693561,NDC,,,facility,outpatient,1,EA,115.95000,33.63000,Aetna,Local,,58.87,,,,,,,41.80,94.85,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00904692761,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00904692661,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00904692561,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Sertraline HCl 25mg T,800015414,CDM,637,RC,00904692461,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,Local,,1.50,,,,,,,1.06,2.41,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00904691661,NDC,,,facility,outpatient,1,EA,26.55000,7.70000,Aetna,Local,,13.48,,,,,,,9.57,21.72,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904690706,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00904690204,NDC,,,facility,outpatient,1,EA,56.70000,16.44000,Aetna,Local,,28.79,,,,,,,20.44,46.38,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,00904690004,NDC,,,facility,outpatient,1,EA,16.80000,4.87000,Aetna,Local,,8.53,,,,,,,6.06,13.74,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,00904688210,NDC,,,facility,outpatient,1,EA,663.10000,192.30000,Aetna,Local,,336.66,,,,,,,239.05,542.42,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00904687204,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,Local,,14.01,,,,,,,9.95,22.58,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00904686961,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,Local,,0.76155,,,,,,,0.54075,1.23,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00904686861,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00904686190,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00904686161,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00904686061,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Metaxalone 800mg T(Skelaxin),800080662,CDM,637,RC,00904683104,NDC,,,facility,outpatient,1,EA,46.75000,13.56000,Aetna,Local,,23.73,,,,,,,16.85,38.24,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00904683061,NDC,,,facility,outpatient,1,EA,8.75000,2.54000,Aetna,Local,,4.44,,,,,,,3.15,7.16,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00904683006,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00904682894,NDC,,,facility,outpatient,1,EA,42.10000,12.21000,Aetna,Local,,21.37,,,,,,,15.18,34.44,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00904682561,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,Local,,2.06,,,,,,,1.46,3.31,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00904682461,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00904682361,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,Local,,1.50,,,,,,,1.06,2.41,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00904681861,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,Local,,3.73,,,,,,,2.65,6.01,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00904681806,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00904681004,NDC,,,facility,outpatient,1,EA,22.85000,6.63000,Aetna,Local,,11.60,,,,,,,8.24,18.69,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00904680861,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00904680806,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00904680061,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00904679961,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00904679861,NDC,,,facility,outpatient,1,EA,0.45000,0.13000,Aetna,Local,,0.22847,,,,,,,0.16223,0.36810,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),800017736,CDM,637,RC,00904679610,NDC,,,facility,outpatient,1,EA,192.65000,55.87000,Aetna,Local,,97.81,,,,,,,69.45,157.59,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,00904679104,NDC,,,facility,outpatient,1,EA,89.50000,25.96000,Aetna,Local,,45.44,,,,,,,32.26,73.21,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00904678861,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00904678261,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,Local,,3.27,,,,,,,2.33,5.28,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,00904678161,NDC,,,facility,outpatient,1,EA,11.50000,3.34000,Aetna,Local,,5.84,,,,,,,4.15,9.41,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,00904677961,NDC,,,facility,outpatient,1,EA,11.65000,3.38000,Aetna,Local,,5.91,,,,,,,4.20,9.53,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904672852,NDC,,,facility,outpatient,1,EA,0.45000,0.13000,Aetna,Local,,0.22847,,,,,,,0.16223,0.36810,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904672846,NDC,,,facility,outpatient,1,EA,0.70000,0.20000,Aetna,Local,,0.35539,,,,,,,0.25235,0.57260,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00904671839,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904670861,NDC,,,facility,outpatient,1,EA,17.80000,5.16000,Aetna,Local,,9.04,,,,,,,6.42,14.56,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00904670806,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,Local,,5.33,,,,,,,3.79,8.59,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00904670561,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00904670506,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,1.32,2.99,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00904668961,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,00904668308,NDC,,,facility,outpatient,1,EA,44.75000,12.98000,Aetna,Local,,22.72,,,,,,,16.13,36.61,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,00904668208,NDC,,,facility,outpatient,1,EA,44.30000,12.85000,Aetna,Local,,22.49,,,,,,,15.97,36.24,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00904668108,NDC,,,facility,outpatient,1,EA,43.85000,12.72000,Aetna,Local,,22.26,,,,,,,15.81,35.87,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,00904667106,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,00904667104,NDC,,,facility,outpatient,1,EA,9.85000,2.86000,Aetna,Local,,5.00,,,,,,,3.55,8.06,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00904666761,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,Local,,0.88848,,,,,,,0.63087,1.43,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00904666661,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,Local,,0.71078,,,,,,,0.50470,1.15,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00904666561,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00904666404,NDC,,,facility,outpatient,1,EA,93.55000,27.13000,Aetna,Local,,47.50,,,,,,,33.72,76.52,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,00904666361,NDC,,,facility,outpatient,1,EA,30.70000,8.90000,Aetna,Local,,15.59,,,,,,,11.07,25.11,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,00904664061,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,00904663861,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00904663761,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00904663661,NDC,,,facility,outpatient,1,EA,13.90000,4.03000,Aetna,Local,,7.06,,,,,,,5.01,11.37,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00904663561,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00904662735,NDC,,,facility,outpatient,1,EA,16.05000,4.65000,Aetna,Local,,8.15,,,,,,,5.79,13.13,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00904662261,NDC,,,facility,outpatient,1,EA,11.40000,3.31000,Aetna,Local,,5.79,,,,,,,4.11,9.33,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00904661961,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00904661761,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,00904661561,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00904659204,NDC,,,facility,outpatient,1,EA,77.05000,22.34000,Aetna,Local,,39.12,,,,,,,27.78,63.03,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00904658561,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,00904658304,NDC,,,facility,outpatient,1,EA,65.40000,18.97000,Aetna,Local,,33.20,,,,,,,23.58,53.50,percent of total billed charges,
PHENobarbital 32.4 mg Tab,800051123,CDM,637,RC,00904657561,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,1.32,2.99,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00904657261,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00904657161,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00904657061,NDC,,,facility,outpatient,1,EA,19.45000,5.64000,Aetna,Local,,9.87,,,,,,,7.01,15.91,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00904657006,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,Local,,12.08,,,,,,,8.58,19.47,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00904657004,NDC,,,facility,outpatient,1,EA,29.15000,8.45000,Aetna,Local,,14.80,,,,,,,10.51,23.84,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00904656761,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00904656561,NDC,,,facility,outpatient,1,EA,20.70000,6.00000,Aetna,Local,,10.51,,,,,,,7.46,16.93,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904656461,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,Local,,2.13,,,,,,,1.51,3.44,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00904656460,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00904656061,NDC,,,facility,outpatient,1,EA,33.65000,9.76000,Aetna,Local,,17.08,,,,,,,12.13,27.53,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00904655861,NDC,,,facility,outpatient,1,EA,12.00000,3.48000,Aetna,Local,,6.09,,,,,,,4.33,9.82,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,00904655761,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,Local,,5.58,,,,,,,3.97,9.00,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00904655661,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,Local,,2.13,,,,,,,1.51,3.44,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00904655304,NDC,,,facility,outpatient,1,EA,1111.15000,322.23000,Aetna,Local,,564.13,,,,,,,400.57,908.92,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,00904655161,NDC,facility,inpatient,4,ME,5.25000,1.52000,Aetna,Local,,2.10,,,,,,,1.89,4.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00904655061,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,Local,,1.27,,,,,,,0.90125,2.04,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00904653806,NDC,,,facility,outpatient,1,EA,15.35000,4.45000,Aetna,Local,,7.79,,,,,,,5.53,12.56,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00904653061,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00904651961,NDC,,,facility,outpatient,1,EA,20.25000,5.87000,Aetna,Local,,10.28,,,,,,,7.30,16.56,percent of total billed charges,
ARIPiprazole 10 mg Tab (Abilify),800017394,CDM,637,RC,00904651106,NDC,,,facility,outpatient,1,EA,71.10000,20.62000,Aetna,Local,,36.10,,,,,,,25.63,58.16,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,00904651061,NDC,,,facility,outpatient,1,EA,163.95000,47.55000,Aetna,Local,,83.24,,,,,,,59.10,134.11,percent of total billed charges,
ARIPiprazole 5 mg Tab (Abilify),800017396,CDM,637,RC,00904651006,NDC,,,facility,outpatient,1,EA,71.10000,20.62000,Aetna,Local,,36.10,,,,,,,25.63,58.16,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00904650661,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00904650606,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00904650561,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00904650361,NDC,,,facility,outpatient,1,EA,53.65000,15.56000,Aetna,Local,,27.24,,,,,,,19.34,43.89,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00904650261,NDC,,,facility,outpatient,1,EA,30.90000,8.96000,Aetna,Local,,15.69,,,,,,,11.14,25.28,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00904650061,NDC,,,facility,outpatient,1,EA,68.75000,19.94000,Aetna,Local,,34.90,,,,,,,24.78,56.24,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00904650006,NDC,,,facility,outpatient,1,EA,11.25000,3.26000,Aetna,Local,,5.71,,,,,,,4.06,9.20,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00904647761,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00904647661,NDC,,,facility,outpatient,1,EA,7.70000,2.23000,Aetna,Local,,3.91,,,,,,,2.78,6.30,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00904647561,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00904647461,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,00904647104,NDC,,,facility,outpatient,1,EA,220.75000,64.02000,Aetna,Local,,112.07,,,,,,,79.58,180.57,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00904647061,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00904646961,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00904646861,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,00904646710,NDC,,,facility,outpatient,1,EA,69.50000,20.15000,Aetna,Local,,35.29,,,,,,,25.05,56.85,percent of total billed charges,
Clopidogrel Bisulfate 300mg T(Plavix),800011952,CDM,637,RC,00904646707,NDC,,,facility,outpatient,1,EA,136.40000,39.56000,Aetna,Local,,69.25,,,,,,,49.17,111.58,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00904645461,NDC,,,facility,outpatient,1,EA,41.95000,12.17000,Aetna,Local,,21.30,,,,,,,15.12,34.32,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,00904645361,NDC,,,facility,outpatient,1,EA,41.95000,12.17000,Aetna,Local,,21.30,,,,,,,15.12,34.32,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00904644961,NDC,,,facility,outpatient,1,EA,11.75000,3.41000,Aetna,Local,,5.97,,,,,,,4.24,9.61,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00904644461,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
hydrALAZINE 50mg T(Apresoline),800010610,CDM,637,RC,00904644261,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,00904644161,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
hydrALAZINE 10mg T(Apresoline),800010594,CDM,637,RC,00904644061,NDC,,,facility,outpatient,1,EA,0.90000,0.26000,Aetna,Local,,0.45693,,,,,,,0.32445,0.73620,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00904643604,NDC,,,facility,outpatient,1,EA,37.85000,10.98000,Aetna,Local,,19.22,,,,,,,13.64,30.96,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00904642761,NDC,,,facility,outpatient,1,EA,32.35000,9.38000,Aetna,Local,,16.42,,,,,,,11.66,26.46,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00904642661,NDC,,,facility,outpatient,1,EA,31.00000,8.99000,Aetna,Local,,15.74,,,,,,,11.18,25.36,percent of total billed charges,
Modafinil 100mg T(Provigil),800015408,CDM,637,RC,00904642304,NDC,,,facility,outpatient,1,EA,196.20000,56.90000,Aetna,Local,,99.61,,,,,,,70.73,160.49,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00904642161,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,4.42,,,,,,,3.14,7.12,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00904641961,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,Local,,2.39,,,,,,,1.69,3.84,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,00904641861,NDC,,,facility,outpatient,1,EA,12.50000,3.62000,Aetna,Local,,6.35,,,,,,,4.51,10.22,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00904640161,NDC,,,facility,outpatient,1,EA,29.80000,8.64000,Aetna,Local,,15.13,,,,,,,10.74,24.38,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00904637761,NDC,,,facility,outpatient,1,EA,93.55000,27.13000,Aetna,Local,,47.50,,,,,,,33.72,76.52,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00904637661,NDC,,,facility,outpatient,1,EA,93.55000,27.13000,Aetna,Local,,47.50,,,,,,,33.72,76.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00904637461,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,00904637361,NDC,,,facility,outpatient,1,EA,4.20000,1.22000,Aetna,Local,,2.13,,,,,,,1.51,3.44,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,00904637161,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,Local,,8.10,,,,,,,5.75,13.05,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00904637061,NDC,,,facility,outpatient,1,EA,11.65000,3.38000,Aetna,Local,,5.91,,,,,,,4.20,9.53,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,00904636961,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00904636861,NDC,,,facility,outpatient,1,EA,41.95000,12.17000,Aetna,Local,,21.30,,,,,,,15.12,34.32,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904636561,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00904636461,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,Local,,8.88,,,,,,,6.31,14.31,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00904636361,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,Local,,5.58,,,,,,,3.97,9.00,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00904636345,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
risperiDONE 1mg T(RisperDAL),800071562,CDM,637,RC,00904635961,NDC,,,facility,outpatient,1,EA,32.30000,9.37000,Aetna,Local,,16.40,,,,,,,11.64,26.42,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,00904635761,NDC,,,facility,outpatient,1,EA,25.35000,7.35000,Aetna,Local,,12.87,,,,,,,9.14,20.74,percent of total billed charges,
levoFLOXacin  750mg T(Levaquin),800015332,CDM,637,RC,00904635361,NDC,,,facility,outpatient,1,EA,174.25000,50.53000,Aetna,Local,,88.47,,,,,,,62.82,142.54,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,00904635261,NDC,,,facility,outpatient,1,EA,119.10000,34.54000,Aetna,Local,,60.47,,,,,,,42.94,97.42,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,00904635161,NDC,,,facility,outpatient,1,EA,104.25000,30.23000,Aetna,Local,,52.93,,,,,,,37.58,85.28,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00904634261,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,Local,,3.27,,,,,,,2.33,5.28,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00904634161,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,00904634061,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,Local,,1.02,,,,,,,0.72100,1.64,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,00904632461,NDC,,,facility,outpatient,1,EA,13.20000,3.83000,Aetna,Local,,6.70,,,,,,,4.76,10.80,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00904632361,NDC,,,facility,outpatient,1,EA,8.75000,2.54000,Aetna,Local,,4.44,,,,,,,3.15,7.16,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00904632261,NDC,,,facility,outpatient,1,EA,8.75000,2.54000,Aetna,Local,,4.44,,,,,,,3.15,7.16,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00904632206,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00904630361,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00904630261,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00904630161,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00904630061,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,00904629461,NDC,,,facility,outpatient,1,EA,30.90000,8.96000,Aetna,Local,,15.69,,,,,,,11.14,25.28,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00904629261,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00904629206,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,Local,,1.04,,,,,,,0.73903,1.68,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00904629161,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,Local,,1.88,,,,,,,1.33,3.03,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00904629061,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00904629006,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,Local,,0.96463,,,,,,,0.68495,1.55,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00904628361,NDC,,,facility,outpatient,1,EA,79.30000,23.00000,Aetna,Local,,40.26,,,,,,,28.59,64.87,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00904627245,NDC,,,facility,outpatient,1,EA,23.45000,6.80000,Aetna,Local,,11.91,,,,,,,8.45,19.18,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00904627208,NDC,,,facility,outpatient,1,EA,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,27.76,62.99,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,00904626945,NDC,,,facility,outpatient,1,EA,23.45000,6.80000,Aetna,Local,,11.91,,,,,,,8.45,19.18,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00904623861,NDC,,,facility,outpatient,1,EA,6.05000,1.75000,Aetna,Local,,3.07,,,,,,,2.18,4.95,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00904623761,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00904623561,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00904622160,NDC,,,facility,outpatient,1,EA,11.50000,3.34000,Aetna,Local,,5.84,,,,,,,4.15,9.41,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00904622106,NDC,,,facility,outpatient,1,EA,20.65000,5.99000,Aetna,Local,,10.48,,,,,,,7.44,16.89,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00904618761,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904611961,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904610161,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00904608361,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,Local,,0.43155,,,,,,,0.30643,0.69530,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00904608261,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,Local,,0.43155,,,,,,,0.30643,0.69530,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,00904606050,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,Local,,0.43155,,,,,,,0.30643,0.69530,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,00904605261,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,Local,,11.37,,,,,,,8.08,18.32,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00904605161,NDC,,,facility,outpatient,1,EA,18.30000,5.31000,Aetna,Local,,9.29,,,,,,,6.60,14.97,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00904601960,NDC,,,facility,outpatient,1,EA,131.40000,38.11000,Aetna,Local,,66.71,,,,,,,47.37,107.49,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00904601946,NDC,,,facility,outpatient,1,EA,116.55000,33.80000,Aetna,Local,,59.17,,,,,,,42.02,95.34,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,00904600860,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00904600760,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Ammonium Lactate 12% Lotion,800025491,CDM,637,RC,00904598426,NDC,,,facility,outpatient,1,EA,264.70000,76.76000,Aetna,Local,,134.39,,,,,,,95.42,216.52,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,00904598161,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,Local,,3.73,,,,,,,2.65,6.01,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00904598061,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00904595961,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00904592961,NDC,,,facility,outpatient,1,EA,24.70000,7.16000,Aetna,Local,,12.54,,,,,,,8.90,20.20,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00904592861,NDC,,,facility,outpatient,1,EA,16.15000,4.68000,Aetna,Local,,8.20,,,,,,,5.82,13.21,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00904592561,NDC,,,facility,outpatient,1,EA,12.55000,3.64000,Aetna,Local,,6.37,,,,,,,4.52,10.27,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00904592161,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00904589261,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,Local,,8.96,,,,,,,6.36,14.44,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00904589161,NDC,,,facility,outpatient,1,EA,20.50000,5.94000,Aetna,Local,,10.41,,,,,,,7.39,16.77,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,00904588061,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00904586861,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,Local,,12.06,,,,,,,8.56,19.43,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00904585961,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00904585861,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904585561,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00904585461,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904585361,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00904579761,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,Local,,0.48231,,,,,,,0.34247,0.77710,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00904578961,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,Local,,5.51,,,,,,,3.91,8.88,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00904578561,NDC,,,facility,outpatient,1,EA,17.60000,5.10000,Aetna,Local,,8.94,,,,,,,6.34,14.40,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00904578461,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,Local,,8.71,,,,,,,6.18,14.03,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00904578017,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00904567761,NDC,,,facility,outpatient,1,EA,20.80000,6.03000,Aetna,Local,,10.56,,,,,,,7.50,17.01,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00904567661,NDC,,,facility,outpatient,1,EA,19.95000,5.79000,Aetna,Local,,10.13,,,,,,,7.19,16.32,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00904565661,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00904561161,NDC,,,facility,outpatient,1,EA,16.25000,4.71000,Aetna,Local,,8.25,,,,,,,5.86,13.29,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00904561061,NDC,,,facility,outpatient,1,EA,11.45000,3.32000,Aetna,Local,,5.81,,,,,,,4.13,9.37,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00904561060,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,Local,,3.76,,,,,,,2.67,6.05,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,00904560961,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,Local,,5.23,,,,,,,3.71,8.43,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00904555960,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00904555661,NDC,,,facility,outpatient,1,EA,7.30000,2.12000,Aetna,Local,,3.71,,,,,,,2.63,5.97,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00904555380,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,Local,,6.19,,,,,,,4.40,9.98,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00904552361,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00904552261,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,Local,,3.66,,,,,,,2.60,5.89,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00904550261,NDC,,,facility,outpatient,1,EA,10.95000,3.18000,Aetna,Local,,5.56,,,,,,,3.95,8.96,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00904550260,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00904539260,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904534261,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00904534240,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00904530920,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00904528261,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,00904522760,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,Local,,1.12,,,,,,,0.79310,1.80,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00904522060,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904518761,NDC,,,facility,outpatient,1,EA,0.70000,0.20000,Aetna,Local,,0.35539,,,,,,,0.25235,0.57260,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904518760,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Ibuprofen 800mg T(Motrin),800063262,CDM,637,RC,00904518740,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,Local,,1.04,,,,,,,0.73903,1.68,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00904518661,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00904518640,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
hydrALAZINE 25mg T(Apresoline),800010602,CDM,637,RC,00904517060,NDC,,,facility,outpatient,1,EA,0.35000,0.10000,Aetna,Local,,0.17769,,,,,,,0.12618,0.28630,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904512559,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,Local,,0.20308,,,,,,,0.14420,0.32720,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00904512546,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00904399061,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,00904385461,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00904322035,NDC,,,facility,outpatient,1,EA,17.55000,5.09000,Aetna,Local,,8.91,,,,,,,6.33,14.36,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00904292461,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,Local,,2.69,,,,,,,1.91,4.34,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00904282161,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,Local,,2.39,,,,,,,1.69,3.84,percent of total billed charges,
Sulfamethoxazole-Trimethoprim DS 800-160mg T,800021992,CDM,637,RC,00904272561,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,Local,,1.35,,,,,,,0.95532,2.17,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,800015247,CDM,637,RC,00904272046,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,Local,,1.19,,,,,,,0.84718,1.92,percent of total billed charges,
Calamine-Zinc Oxide 8% Topical Lotion,800018168,CDM,250,RC,00904253321,NDC,,,facility,outpatient,1,EA,16.65000,4.83000,Aetna,Local,,8.45,,,,,,,6.00,13.62,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00904236560,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00904236460,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,Local,,1.27,,,,,,,0.90125,2.04,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00904215160,NDC,,,facility,outpatient,1,EA,0.15000,0.04000,Aetna,Local,,0.07616,,,,,,,0.05407,0.12270,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00904209660,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,Local,,0.48231,,,,,,,0.34247,0.77710,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904174861,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904174860,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00904174840,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,00904098950,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00904073431,NDC,,,facility,outpatient,1,EA,23.35000,6.77000,Aetna,Local,,11.85,,,,,,,8.42,19.10,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00904056060,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,Local,,3.55,,,,,,,2.52,5.73,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042861,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042851,NDC,,,facility,outpatient,1,EA,39.15000,11.35000,Aetna,Local,,19.88,,,,,,,14.11,32.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042806,NDC,,,facility,outpatient,1,EA,17.35000,5.03000,Aetna,Local,,8.81,,,,,,,6.25,14.19,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00904042804,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,Local,,9.21,,,,,,,6.54,14.85,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,00904029160,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00904020161,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00904009160,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,Local,,1.27,,,,,,,0.90125,2.04,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00832712401,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00832602000,NDC,,,facility,outpatient,1,EA,105.40000,30.57000,Aetna,Local,,53.51,,,,,,,38.00,86.22,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00832532515,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00832532511,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00832532510,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00832152001,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00832121801,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00832121800,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,00832121601,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00832121301,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,00832121201,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00832121189,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00832121101,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00832108000,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00832102500,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,Local,,18.43,,,,,,,13.09,29.69,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00832102400,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,Local,,8.88,,,,,,,6.31,14.31,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,00832100800,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
Propafenone HCl 425mg ER C(Rythmol SR),800017683,CDM,637,RC,00832074260,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,Local,,35.95,,,,,,,25.52,57.91,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,00832074160,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,Local,,35.95,,,,,,,25.52,57.91,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00832074060,NDC,,,facility,outpatient,1,EA,55.90000,16.21000,Aetna,Local,,28.38,,,,,,,20.15,45.73,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,00832051101,NDC,,,facility,outpatient,1,EA,14.20000,4.12000,Aetna,Local,,7.21,,,,,,,5.12,11.62,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,00832051100,NDC,,,facility,outpatient,1,EA,14.20000,4.12000,Aetna,Local,,7.21,,,,,,,5.12,11.62,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00832046560,NDC,,,facility,outpatient,1,EA,230.05000,66.71000,Aetna,Local,,116.80,,,,,,,82.93,188.18,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00832046515,NDC,,,facility,outpatient,1,EA,261.50000,75.83000,Aetna,Local,,132.76,,,,,,,94.27,213.91,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00832035711,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00832030300,NDC,,,facility,outpatient,1,EA,105.40000,30.57000,Aetna,Local,,53.51,,,,,,,38.00,86.22,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00832004309,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00832003801,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00832003800,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,00781940895,NDC,facility,inpatient,2,GM,134.00000,38.86000,Aetna,Local,,53.60,,,,,,,48.31,109.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00781940795,NDC,facility,inpatient,500,ME,35.30000,10.24000,Aetna,Local,,14.12,,,,,,,12.73,28.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,00781940495,NDC,facility,inpatient,1,GM,69.10000,20.04000,Aetna,Local,,27.64,,,,,,,24.91,56.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781936795,NDC,facility,inpatient,4.5,GM,187.10000,54.26000,Aetna,Local,,74.84,,,,,,,67.45,153.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781935095,NDC,facility,inpatient,3.375,GM,147.70000,42.83000,Aetna,Local,,59.08,,,,,,,53.25,120.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781934495,NDC,facility,inpatient,2.25,GM,98.45000,28.55000,Aetna,Local,,39.38,,,,,,,35.49,80.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,00781931780,NDC,facility,inpatient,100,ME,2733.30000,792.66000,Aetna,Local,,1093.32,,,,,,,985.35,2235.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,00781925394,NDC,facility,inpatient,100,ME,2966.30000,860.23000,Aetna,Local,,1186.52,,,,,,,1069.35,2426.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00781922209,NDC,facility,inpatient,900,ME,154.05000,44.67000,Aetna,Local,,61.62,,,,,,,55.54,126.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00781922109,NDC,facility,inpatient,600,ME,126.15000,36.58000,Aetna,Local,,50.46,,,,,,,45.48,103.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781921495,NDC,facility,inpatient,4.5,GM,187.10000,54.26000,Aetna,Local,,74.84,,,,,,,67.45,153.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781921395,NDC,facility,inpatient,3.375,GM,147.70000,42.83000,Aetna,Local,,59.08,,,,,,,53.25,120.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781921095,NDC,facility,inpatient,2.25,GM,98.45000,28.55000,Aetna,Local,,39.38,,,,,,,35.49,80.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,00781915895,NDC,facility,inpatient,250,ME,7582.25000,2198.85000,Aetna,Local,,3032.90,,,,,,,2733.40,6202.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00781905395,NDC,facility,inpatient,200,ME,127.55000,36.99000,Aetna,Local,,51.02,,,,,,,45.98,104.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00781903795,NDC,,,facility,outpatient,1,EA,142.30000,41.27000,Aetna,Local,,72.25,,,,,,,51.30,116.40,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00781808931,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,Local,,27.97,,,,,,,19.86,45.07,percent of total billed charges,
Armodafinil 50mg Tab (Nuvigil),800025645,CDM,637,RC,00781802931,NDC,,,facility,outpatient,1,EA,58.10000,16.85000,Aetna,Local,,29.50,,,,,,,20.95,47.53,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,00781730931,NDC,,,facility,outpatient,1,EA,119.65000,34.70000,Aetna,Local,,60.75,,,,,,,43.13,97.87,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00781729685,NDC,,,facility,outpatient,1,EA,310.95000,90.18000,Aetna,Local,,157.87,,,,,,,112.10,254.36,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00781724255,NDC,,,facility,outpatient,1,EA,210.90000,61.16000,Aetna,Local,,107.07,,,,,,,76.03,172.52,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00781724055,NDC,,,facility,outpatient,1,EA,162.40000,47.10000,Aetna,Local,,82.45,,,,,,,58.55,132.84,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,00781713354,NDC,,,facility,outpatient,1,EA,164.30000,47.65000,Aetna,Local,,83.42,,,,,,,59.23,134.40,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00781711455,NDC,,,facility,outpatient,1,EA,411.90000,119.45000,Aetna,Local,,209.12,,,,,,,148.49,336.93,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00781711355,NDC,,,facility,outpatient,1,EA,314.85000,91.31000,Aetna,Local,,159.85,,,,,,,113.50,257.55,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00781711255,NDC,,,facility,outpatient,1,EA,210.90000,61.16000,Aetna,Local,,107.07,,,,,,,76.03,172.52,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,00781710454,NDC,,,facility,outpatient,1,EA,164.30000,47.65000,Aetna,Local,,83.42,,,,,,,59.23,134.40,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00781705839,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,Local,,28.89,,,,,,,20.51,46.54,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00781705805,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,Local,,28.89,,,,,,,20.51,46.54,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00781632079,NDC,,,facility,outpatient,1,EA,751.45000,217.92000,Aetna,Local,,381.51,,,,,,,270.90,614.69,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,00781618667,NDC,,,facility,outpatient,1,EA,1708.55000,495.48000,Aetna,Local,,867.43,,,,,,,615.93,1397.59,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00781613595,NDC,facility,inpatient,1,EA,127.00000,36.83000,Aetna,Local,,50.80,,,,,,,45.78,103.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,00781604146,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781599401,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,Local,,3.66,,,,,,,2.60,5.89,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00781580710,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,Local,,11.07,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781580692,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781580631,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00781580592,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,Local,,6.04,,,,,,,4.29,9.73,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00781577631,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,Local,,27.97,,,,,,,19.86,45.07,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00781572005,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00781570292,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,Local,,11.07,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00781570210,NDC,,,facility,outpatient,1,EA,21.80000,6.32000,Aetna,Local,,11.07,,,,,,,7.86,17.83,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781570192,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781570131,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00781570110,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00781570092,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,Local,,6.04,,,,,,,4.29,9.73,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00781569092,NDC,,,facility,outpatient,1,EA,18.50000,5.36000,Aetna,Local,,9.39,,,,,,,6.67,15.13,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00781561892,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,Local,,18.73,,,,,,,13.30,30.18,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,00781550301,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00781540931,NDC,,,facility,outpatient,1,EA,131.40000,38.11000,Aetna,Local,,66.71,,,,,,,47.37,107.49,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00781540901,NDC,,,facility,outpatient,1,EA,131.40000,38.11000,Aetna,Local,,66.71,,,,,,,47.37,107.49,percent of total billed charges,
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,00781540331,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,00781540192,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
LORazepam 1mg T(Ativan),800052299,CDM,637,RC,00781537701,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,00781532531,NDC,,,facility,outpatient,1,EA,44.40000,12.88000,Aetna,Local,,22.54,,,,,,,16.01,36.32,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,00781532501,NDC,,,facility,outpatient,1,EA,44.25000,12.83000,Aetna,Local,,22.47,,,,,,,15.95,36.20,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,00781525092,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,Local,,10.61,,,,,,,7.53,17.10,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00781523292,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,11.75,,,,,,,8.35,18.94,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00781519192,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00781518892,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,Local,,3.02,,,,,,,2.14,4.87,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00781518692,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00781518592,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00781518492,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00781518401,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00781518392,NDC,,,facility,outpatient,1,EA,4.10000,1.19000,Aetna,Local,,2.08,,,,,,,1.48,3.35,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00781518292,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,Local,,2.06,,,,,,,1.46,3.31,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00781518201,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00781518192,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,1.32,2.99,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00781518101,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00781518092,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00781517501,NDC,facility,inpatient,500,ME,56.20000,16.30000,Aetna,Local,,22.48,,,,,,,20.26,45.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00781505631,NDC,,,facility,outpatient,1,EA,116.30000,33.73000,Aetna,Local,,59.05,,,,,,,41.93,95.13,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00781505001,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,00781504501,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,00781503201,NDC,,,facility,outpatient,1,EA,11.65000,3.38000,Aetna,Local,,5.91,,,,,,,4.20,9.53,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00781502207,NDC,facility,inpatient,4,ME,4.75000,1.38000,Aetna,Local,,1.90,,,,,,,1.71,3.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00781501501,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00781375595,NDC,,,facility,outpatient,1,EA,81.35000,23.59000,Aetna,Local,,41.30,,,,,,,29.33,66.54,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00781365569,NDC,facility,inpatient,150,ME,555.90000,161.21000,Aetna,Local,,222.36,,,,,,,200.40,454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00781354325,NDC,facility,inpatient,30000,UN,72.25000,20.95000,Aetna,Local,,28.90,,,,,,,26.05,59.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,00781353191,NDC,facility,inpatient,100,ME,7866.05000,2281.15000,Aetna,Local,,3146.42,,,,,,,2835.71,6434.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00781350069,NDC,facility,inpatient,100,ME,392.15000,113.72000,Aetna,Local,,156.86,,,,,,,141.37,320.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00781345895,NDC,facility,inpatient,50,ME,235.00000,68.15000,Aetna,Local,,94.00,,,,,,,84.72,192.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00781345295,NDC,facility,inpatient,2,GM,458.00000,132.82000,Aetna,Local,,183.20,,,,,,,165.11,374.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00781345196,NDC,facility,inpatient,1000,ME,60.00000,17.40000,Aetna,Local,,24.00,,,,,,,21.63,49.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 500mg I (Ancef),800062014,CDM,636,RC,J0690,HCPCS,00781345095,NDC,facility,inpatient,500,ME,77.90000,22.59000,Aetna,Local,,31.16,,,,,,,28.08,63.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,00781344095,NDC,facility,inpatient,0.25,ME,456.75000,132.46000,Aetna,Local,,182.70,,,,,,,164.66,373.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00781343395,NDC,facility,inpatient,600,ME,182.40000,52.90000,Aetna,Local,,72.96,,,,,,,65.76,149.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00781342868,NDC,facility,inpatient,80,ME,321.90000,93.35000,Aetna,Local,,128.76,,,,,,,116.04,263.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,00781341575,NDC,facility,inpatient,0.25,ME,1317.95000,382.21000,Aetna,Local,,527.18,,,,,,,475.12,1078.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00781341195,NDC,facility,inpatient,200,ME,127.55000,36.99000,Aetna,Local,,51.02,,,,,,,45.98,104.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,00781340895,NDC,facility,inpatient,2,GM,134.00000,38.86000,Aetna,Local,,53.60,,,,,,,48.31,109.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00781340795,NDC,facility,inpatient,500,ME,35.25000,10.22000,Aetna,Local,,14.10,,,,,,,12.71,28.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,00781340495,NDC,facility,inpatient,1,GM,69.10000,20.04000,Aetna,Local,,27.64,,,,,,,24.91,56.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781336795,NDC,facility,inpatient,4.5,GM,187.10000,54.26000,Aetna,Local,,74.84,,,,,,,67.45,153.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00781335666,NDC,facility,inpatient,60,ME,249.10000,72.24000,Aetna,Local,,99.64,,,,,,,89.80,203.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781335095,NDC,facility,inpatient,3.375,GM,147.70000,42.83000,Aetna,Local,,59.08,,,,,,,53.25,120.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00781334695,NDC,facility,inpatient,2,GM,287.00000,83.23000,Aetna,Local,,114.80,,,,,,,103.46,234.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781334495,NDC,facility,inpatient,2.25,GM,98.45000,28.55000,Aetna,Local,,39.38,,,,,,,35.49,80.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00781334209,NDC,facility,inpatient,500,ME,132.30000,38.37000,Aetna,Local,,52.92,,,,,,,47.69,108.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00781334109,NDC,facility,inpatient,250,ME,69.30000,20.10000,Aetna,Local,,27.72,,,,,,,24.98,56.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Palonosetron 0.25 mg/5 mL I(Aloxi),800010945,CDM,636,RC,J2469,HCPCS,00781331275,NDC,facility,inpatient,0.25,ME,1317.95000,382.21000,Aetna,Local,,527.18,,,,,,,475.12,1078.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00781329969,NDC,facility,inpatient,150,ME,216.10000,62.67000,Aetna,Local,,86.44,,,,,,,77.90,176.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00781329868,NDC,facility,inpatient,120,ME,175.65000,50.94000,Aetna,Local,,70.26,,,,,,,63.32,143.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00781329009,NDC,facility,inpatient,900,ME,154.05000,44.67000,Aetna,Local,,61.62,,,,,,,55.54,126.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00781328909,NDC,facility,inpatient,600,ME,126.15000,36.58000,Aetna,Local,,50.46,,,,,,,45.48,103.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,00781328379,NDC,facility,inpatient,1000,ME,3788.05000,1098.53000,Aetna,Local,,1515.22,,,,,,,1365.59,3098.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,00781328275,NDC,facility,inpatient,200,ME,887.25000,257.30000,Aetna,Local,,354.90,,,,,,,319.85,725.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00781326869,NDC,facility,inpatient,100,ME,148.70000,43.12000,Aetna,Local,,59.48,,,,,,,53.61,121.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00781326795,NDC,facility,inpatient,1,GM,537.65000,155.92000,Aetna,Local,,215.06,,,,,,,193.82,439.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00781326268,NDC,facility,inpatient,80,ME,118.90000,34.48000,Aetna,Local,,47.56,,,,,,,42.86,97.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00781325666,NDC,facility,inpatient,60,ME,89.20000,25.87000,Aetna,Local,,35.68,,,,,,,32.16,72.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
azaCITIDine 100mg Inj,800012473,CDM,636,RC,J9025,HCPCS,00781325394,NDC,facility,inpatient,100,ME,2966.30000,860.23000,Aetna,Local,,1186.52,,,,,,,1069.35,2426.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00781324664,NDC,facility,inpatient,40,ME,59.40000,17.23000,Aetna,Local,,23.76,,,,,,,21.41,48.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,00781323863,NDC,facility,inpatient,30,ME,44.55000,12.92000,Aetna,Local,,17.82,,,,,,,16.06,36.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,00781323394,NDC,facility,inpatient,500,ME,2659.20000,771.17000,Aetna,Local,,1063.68,,,,,,,958.64,2175.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00781323295,NDC,facility,inpatient,40,ME,32.60000,9.45000,Aetna,Local,,13.04,,,,,,,11.75,26.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00781322464,NDC,facility,inpatient,40,ME,170.50000,49.44000,Aetna,Local,,68.20,,,,,,,61.47,139.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00781322295,NDC,facility,inpatient,1,GM,162.65000,47.17000,Aetna,Local,,65.06,,,,,,,58.64,133.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00781322095,NDC,,,facility,outpatient,1,EA,104.60000,30.33000,Aetna,Local,,53.11,,,,,,,37.71,85.56,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00781322092,NDC,,,facility,outpatient,1,EA,100.45000,29.13000,Aetna,Local,,51.00,,,,,,,36.21,82.17,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,00781322075,NDC,,,facility,outpatient,1,EA,104.60000,30.33000,Aetna,Local,,53.11,,,,,,,37.71,85.56,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00781322070,NDC,,,facility,outpatient,1,EA,100.45000,29.13000,Aetna,Local,,51.00,,,,,,,36.21,82.17,percent of total billed charges,
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00781320995,NDC,facility,inpatient,2,GM,435.90000,126.41000,Aetna,Local,,174.36,,,,,,,157.14,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00781320895,NDC,facility,inpatient,1,GM,358.00000,103.82000,Aetna,Local,,143.20,,,,,,,129.06,292.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00781320795,NDC,facility,inpatient,500,ME,143.60000,41.64000,Aetna,Local,,57.44,,,,,,,51.77,117.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00781320495,NDC,facility,inpatient,25,ME,1834.10000,531.89000,Aetna,Local,,733.64,,,,,,,661.19,1500.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00781318895,NDC,facility,inpatient,1,GM,96.00000,27.84000,Aetna,Local,,38.40,,,,,,,34.61,78.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00781317796,NDC,facility,inpatient,1,GM,83.95000,24.35000,Aetna,Local,,33.58,,,,,,,30.26,68.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,00781315972,NDC,facility,inpatient,10,ME,214.05000,62.07000,Aetna,Local,,85.62,,,,,,,77.17,175.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bivalirudin 250mg I(Angiomax),800022012,CDM,636,RC,J0583,HCPCS,00781315895,NDC,facility,inpatient,250,ME,7582.25000,2198.85000,Aetna,Local,,3032.90,,,,,,,2733.40,6202.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,00781315695,NDC,facility,inpatient,1000,ME,368.25000,106.79000,Aetna,Local,,147.30,,,,,,,132.75,301.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00781315395,NDC,,,facility,outpatient,1,EA,2410.10000,698.93000,Aetna,Local,,1223.61,,,,,,,868.84,1971.46,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00781315095,NDC,,,facility,outpatient,1,EA,153.20000,44.43000,Aetna,Local,,77.78,,,,,,,55.23,125.32,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,00781313363,NDC,facility,inpatient,30,ME,129.55000,37.57000,Aetna,Local,,51.82,,,,,,,46.70,105.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00781312595,NDC,facility,inpatient,2,GM,225.40000,65.37000,Aetna,Local,,90.16,,,,,,,81.26,184.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00781312585,NDC,facility,inpatient,2,GM,134.00000,38.86000,Aetna,Local,,53.60,,,,,,,48.31,109.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00781311495,NDC,facility,inpatient,4.5,GM,65.90000,19.11000,Aetna,Local,,26.36,,,,,,,23.76,53.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00781311395,NDC,facility,inpatient,3.375,GM,49.45000,14.34000,Aetna,Local,,19.78,,,,,,,17.83,40.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00781311095,NDC,facility,inpatient,2.25,GM,33.00000,9.57000,Aetna,Local,,13.20,,,,,,,11.90,26.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Oxacillin 100mg/mL IV Infusion,800013293,CDM,636,RC,J2700,HCPCS,00781309995,NDC,facility,inpatient,1000,ME,116.80000,33.87000,Aetna,Local,,46.72,,,,,,,42.11,95.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00781309896,NDC,facility,inpatient,1,GM,286.20000,83.00000,Aetna,Local,,114.48,,,,,,,103.18,234.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00781309895,NDC,facility,inpatient,1,GM,286.20000,83.00000,Aetna,Local,,114.48,,,,,,,103.18,234.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00781307195,NDC,,,facility,outpatient,1,EA,24.35000,7.06000,Aetna,Local,,12.36,,,,,,,8.78,19.92,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,00781306675,NDC,facility,inpatient,100,ME,4329.10000,1255.44000,Aetna,Local,,1731.64,,,,,,,1560.64,3541.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00781305995,NDC,facility,inpatient,0.5,ME,39.75000,11.53000,Aetna,Local,,15.90,,,,,,,14.33,32.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
pyRIDostigmine 10mg/2mL I,800081421,CDM,250,RC,00781304095,NDC,,,facility,outpatient,1,EA,102.15000,29.62000,Aetna,Local,,51.86,,,,,,,36.83,83.56,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00781303395,NDC,facility,inpatient,3,GM,122.95000,35.66000,Aetna,Local,,49.18,,,,,,,44.32,100.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00781303295,NDC,facility,inpatient,1.5,GM,65.15000,18.89000,Aetna,Local,,26.06,,,,,,,23.49,53.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00781301095,NDC,facility,inpatient,4,ME,127.95000,37.11000,Aetna,Local,,51.18,,,,,,,46.13,104.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00781300995,NDC,facility,inpatient,200,ME,20.05000,5.81000,Aetna,Local,,8.02,,,,,,,7.23,16.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00781300392,NDC,,,facility,outpatient,1,EA,443.70000,128.67000,Aetna,Local,,225.27,,,,,,,159.95,362.95,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00781300095,NDC,facility,inpatient,500,ME,145.70000,42.25000,Aetna,Local,,58.28,,,,,,,52.52,119.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00781282201,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,Local,,9.57,,,,,,,6.80,15.42,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00781263113,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00781261460,NDC,,,facility,outpatient,1,EA,30.05000,8.71000,Aetna,Local,,15.26,,,,,,,10.83,24.58,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00781261305,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00781261301,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00781250201,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,00781217660,NDC,,,facility,outpatient,1,EA,36.20000,10.50000,Aetna,Local,,18.38,,,,,,,13.05,29.61,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,00781216460,NDC,,,facility,outpatient,1,EA,62.75000,18.20000,Aetna,Local,,31.86,,,,,,,22.62,51.33,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00781211201,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,Local,,4.29,,,,,,,3.05,6.91,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00781207601,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,00781205301,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,00781205101,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00781196610,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00781196260,NDC,,,facility,outpatient,1,EA,42.60000,12.35000,Aetna,Local,,21.63,,,,,,,15.36,34.85,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00781183120,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,Local,,13.61,,,,,,,9.66,21.92,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00781181801,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,Local,,0.48231,,,,,,,0.34247,0.77710,percent of total billed charges,
Diclofenac Na 25mg EC T,800058437,CDM,637,RC,00781178501,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00781175001,NDC,,,facility,outpatient,1,EA,56.20000,16.30000,Aetna,Local,,28.53,,,,,,,20.26,45.97,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00781171813,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,Local,,3.35,,,,,,,2.38,5.40,percent of total billed charges,
chlorproMAZINE 100mg T(Thorazine),800022067,CDM,637,RC,00781171801,NDC,,,facility,outpatient,1,EA,14.40000,4.18000,Aetna,Local,,7.31,,,,,,,5.19,11.78,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,00781165501,NDC,,,facility,outpatient,1,EA,8.25000,2.39000,Aetna,Local,,4.19,,,,,,,2.97,6.75,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,00781162401,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00781159910,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00781159901,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00781155601,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,Local,,3.88,,,,,,,2.76,6.26,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00781150610,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00781150601,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00781149631,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,Local,,27.97,,,,,,,19.86,45.07,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,00781149001,NDC,,,facility,outpatient,1,EA,10.10000,2.93000,Aetna,Local,,5.13,,,,,,,3.64,8.26,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00781148710,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00781148701,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,00781148601,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,Local,,0.66001,,,,,,,0.46865,1.06,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00781145601,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,Local,,1.12,,,,,,,0.79310,1.80,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00781145210,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00781145201,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781140797,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781140705,NDC,,,facility,outpatient,1,EA,7.30000,2.12000,Aetna,Local,,3.71,,,,,,,2.63,5.97,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00781140701,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,Local,,3.93,,,,,,,2.79,6.34,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00781139613,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00781139601,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00781139201,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,00781139101,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00781135413,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00781126201,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00781122801,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00781122301,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00781118201,NDC,,,facility,outpatient,1,EA,28.40000,8.24000,Aetna,Local,,14.42,,,,,,,10.24,23.23,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,00781116301,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00781114601,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
glyBURIDE 1.25mg T(Diabeta/Micronase,800015404,CDM,637,RC,00781113801,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00781112301,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00781107801,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00781107705,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00781107701,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00781106401,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,Local,,3.45,,,,,,,2.45,5.56,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00781106101,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00781105301,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00781105001,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,00781101401,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00777310533,NDC,,,facility,outpatient,1,EA,34.75000,10.08000,Aetna,Local,,17.64,,,,,,,12.53,28.43,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00777310502,NDC,,,facility,outpatient,1,EA,123.95000,35.95000,Aetna,Local,,62.93,,,,,,,44.68,101.39,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00777310402,NDC,,,facility,outpatient,1,EA,120.55000,34.96000,Aetna,Local,,61.20,,,,,,,43.46,98.61,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00766080155,NDC,,,facility,outpatient,1,EA,109.75000,31.83000,Aetna,Local,,55.72,,,,,,,39.56,89.78,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00766080135,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,Local,,8.55,,,,,,,6.07,13.78,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00766080100,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,Local,,47.44,,,,,,,33.69,76.44,percent of total billed charges,
Colesevelam 625 mg T(Welchol),800081983,CDM,637,RC,00713093681,NDC,,,facility,outpatient,1,EA,28.00000,8.12000,Aetna,Local,,14.22,,,,,,,10.09,22.90,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,00713068615,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,Local,,62.90,,,,,,,44.67,101.35,percent of total billed charges,
Gentamicin 0.1% TC,800046445,CDM,637,RC,00713068315,NDC,,,facility,outpatient,1,EA,339.90000,98.57000,Aetna,Local,,172.57,,,,,,,122.53,278.04,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,00713065540,NDC,,,facility,outpatient,1,EA,544.80000,157.99000,Aetna,Local,,276.59,,,,,,,196.40,445.65,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00713053612,NDC,,,facility,outpatient,1,EA,125.35000,36.35000,Aetna,Local,,63.64,,,,,,,45.19,102.54,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00713050324,NDC,,,facility,outpatient,1,EA,152.30000,44.17000,Aetna,Local,,77.32,,,,,,,54.90,124.58,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00713050312,NDC,,,facility,outpatient,1,EA,160.35000,46.50000,Aetna,Local,,81.41,,,,,,,57.81,131.17,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00713035125,NDC,facility,inpatient,10,ME,29.55000,8.57000,Aetna,Local,,11.82,,,,,,,10.65,24.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,00713028304,NDC,,,facility,outpatient,1,EA,24.70000,7.16000,Aetna,Local,,12.54,,,,,,,8.90,20.20,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00713028031,NDC,,,facility,outpatient,1,EA,24.20000,7.02000,Aetna,Local,,12.29,,,,,,,8.72,19.80,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00713026831,NDC,,,facility,outpatient,1,EA,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00713025237,NDC,,,facility,outpatient,1,EA,60.90000,17.66000,Aetna,Local,,30.92,,,,,,,21.95,49.82,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,00713022880,NDC,,,facility,outpatient,1,EA,89.75000,26.03000,Aetna,Local,,45.57,,,,,,,32.35,73.42,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,00713022515,NDC,,,facility,outpatient,1,EA,39.00000,11.31000,Aetna,Local,,19.80,,,,,,,14.06,31.90,percent of total billed charges,
Prochlorperazine 25mg Supp(Compazine,800017137,CDM,637,RC,00713013512,NDC,,,facility,outpatient,1,EA,86.80000,25.17000,Aetna,Local,,44.07,,,,,,,31.29,71.00,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00703940204,NDC,facility,inpatient,80,ME,19.00000,5.51000,Aetna,Local,,7.60,,,,,,,6.85,15.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00703910503,NDC,facility,inpatient,2,GM,216.40000,62.76000,Aetna,Local,,86.56,,,,,,,78.01,177.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00703906033,NDC,facility,inpatient,600,ME,519.65000,150.70000,Aetna,Local,,207.86,,,,,,,187.33,425.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,00703877103,NDC,facility,inpatient,6,ME,86.20000,25.00000,Aetna,Local,,34.48,,,,,,,31.08,70.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00703868023,NDC,facility,inpatient,80,ME,101.50000,29.44000,Aetna,Local,,40.60,,,,,,,36.59,83.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00703861023,NDC,facility,inpatient,120,ME,151.95000,44.07000,Aetna,Local,,60.78,,,,,,,54.78,124.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00703858023,NDC,facility,inpatient,100,ME,126.90000,36.80000,Aetna,Local,,50.76,,,,,,,45.75,103.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00703856023,NDC,facility,inpatient,60,ME,76.15000,22.08000,Aetna,Local,,30.46,,,,,,,27.45,62.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00703854023,NDC,facility,inpatient,40,ME,50.70000,14.70000,Aetna,Local,,20.28,,,,,,,18.28,41.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00703854021,NDC,facility,inpatient,40,ME,45.95000,13.33000,Aetna,Local,,18.38,,,,,,,16.56,37.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00703851023,NDC,facility,inpatient,150,ME,186.40000,54.06000,Aetna,Local,,74.56,,,,,,,67.20,152.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00703851021,NDC,facility,inpatient,150,ME,170.40000,49.42000,Aetna,Local,,68.16,,,,,,,61.43,139.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00703841101,NDC,,,facility,outpatient,1,EA,22.35000,6.48000,Aetna,Local,,11.35,,,,,,,8.06,18.28,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00703722104,NDC,facility,inpatient,4,ME,12.75000,3.70000,Aetna,Local,,5.10,,,,,,,4.60,10.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00703722102,NDC,facility,inpatient,4,ME,12.75000,3.70000,Aetna,Local,,5.10,,,,,,,4.60,10.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haloperidol Decanoate 100mg/1mL Inj,800040916,CDM,636,RC,J1631,HCPCS,00703713103,NDC,facility,inpatient,100,ME,267.55000,77.59000,Aetna,Local,,107.02,,,,,,,96.45,218.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00703710104,NDC,facility,inpatient,100,ME,9.60000,2.78000,Aetna,Local,,3.84,,,,,,,3.46,7.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,00703704103,NDC,facility,inpatient,5,ME,18.85000,5.47000,Aetna,Local,,7.54,,,,,,,6.80,15.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00703681121,NDC,facility,inpatient,150,ME,239.60000,69.48000,Aetna,Local,,95.84,,,,,,,86.38,195.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00703680101,NDC,facility,inpatient,150,ME,274.30000,79.55000,Aetna,Local,,109.72,,,,,,,98.89,224.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,00703627104,NDC,facility,inpatient,10,UN,7.65000,2.22000,Aetna,Local,,3.06,,,,,,,2.76,6.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,00703565301,NDC,facility,inpatient,10,ME,7.30000,2.12000,Aetna,Local,,2.92,,,,,,,2.63,5.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,00703514591,NDC,facility,inpatient,350,ME,166.95000,48.42000,Aetna,Local,,66.78,,,,,,,60.19,136.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,00703514501,NDC,facility,inpatient,350,ME,189.50000,54.96000,Aetna,Local,,75.80,,,,,,,68.31,155.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,00703507937,NDC,,,facility,outpatient,1,EA,179.95000,52.19000,Aetna,Local,,91.36,,,,,,,64.87,147.20,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00703505401,NDC,facility,inpatient,0.004,ME,39.25000,11.38000,Aetna,Local,,15.70,,,,,,,14.15,32.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,00703505401,NDC,facility,inpatient,0.04,ME,4472.45000,1297.01000,Aetna,Local,,1788.98,,,,,,,1612.32,3658.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00703505103,NDC,facility,inpatient,0.004,ME,349.55000,101.37000,Aetna,Local,,139.82,,,,,,,126.01,285.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00703504601,NDC,facility,inpatient,50,ME,348.20000,100.98000,Aetna,Local,,139.28,,,,,,,125.53,284.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,00703476601,NDC,facility,inpatient,6,ME,20.20000,5.86000,Aetna,Local,,8.08,,,,,,,7.28,16.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,00703476401,NDC,facility,inpatient,6,ME,18.30000,5.31000,Aetna,Local,,7.32,,,,,,,6.60,14.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00703450294,NDC,facility,inpatient,10,ME,5.75000,1.67000,Aetna,Local,,2.30,,,,,,,2.07,4.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00703450204,NDC,facility,inpatient,10,ME,21.40000,6.21000,Aetna,Local,,8.56,,,,,,,7.71,17.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
vinCRIStine 2mg/2mL Inj,800022023,CDM,636,RC,J9370,HCPCS,00703440211,NDC,facility,inpatient,2,ME,229.70000,66.61000,Aetna,Local,,91.88,,,,,,,82.81,187.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,00703424891,NDC,facility,inpatient,50,ME,56.35000,16.34000,Aetna,Local,,22.54,,,,,,,20.31,46.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,00703424601,NDC,facility,inpatient,50,ME,54.60000,15.83000,Aetna,Local,,21.84,,,,,,,19.68,44.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate 1g/40mL I PF,800022022,CDM,636,RC,J9260,HCPCS,00703367801,NDC,facility,inpatient,1000,ME,312.25000,90.55000,Aetna,Local,,124.90,,,,,,,112.57,255.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,00703367103,NDC,facility,inpatient,50,ME,80.75000,23.42000,Aetna,Local,,32.30,,,,,,,29.11,66.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,00703324811,NDC,facility,inpatient,50,ME,128.20000,37.18000,Aetna,Local,,51.28,,,,,,,46.22,104.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLitaxel 6mg Inj,800025621,CDM,636,RC,J9267,HCPCS,00703321301,NDC,facility,inpatient,6,ME,15.60000,4.52000,Aetna,Local,,6.24,,,,,,,5.62,12.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluorouracil 500mg/10mL I,800011445,CDM,636,RC,J9190,HCPCS,00703301513,NDC,facility,inpatient,500,ME,53.30000,15.46000,Aetna,Local,,21.32,,,,,,,19.21,43.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00703291403,NDC,,,facility,outpatient,1,EA,40.20000,11.66000,Aetna,Local,,20.41,,,,,,,14.49,32.88,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00703285903,NDC,facility,inpatient,1,GM,112.20000,32.54000,Aetna,Local,,44.88,,,,,,,40.45,91.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00703285809,NDC,facility,inpatient,0.5,GM,135.30000,39.24000,Aetna,Local,,54.12,,,,,,,48.78,110.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00703285604,NDC,facility,inpatient,200,ME,37.30000,10.82000,Aetna,Local,,14.92,,,,,,,13.45,30.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00703208503,NDC,,,facility,outpatient,1,EA,346.10000,100.37000,Aetna,Local,,175.71,,,,,,,124.77,283.11,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00703204503,NDC,,,facility,outpatient,1,EA,2299.90000,666.97000,Aetna,Local,,1167.66,,,,,,,829.11,1881.32,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00703203303,NDC,,,facility,outpatient,1,EA,142.80000,41.41000,Aetna,Local,,72.50,,,,,,,51.48,116.81,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00703133203,NDC,facility,inpatient,150,ME,23.05000,6.68000,Aetna,Local,,9.22,,,,,,,8.31,18.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00703127104,NDC,facility,inpatient,1,ME,19.15000,5.55000,Aetna,Local,,7.66,,,,,,,6.90,15.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00703117901,NDC,facility,inpatient,75,ME,3856.45000,1118.37000,Aetna,Local,,1542.58,,,,,,,1390.25,3154.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,00703116501,NDC,facility,inpatient,20,ME,761.55000,220.85000,Aetna,Local,,304.62,,,,,,,274.54,622.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00703115303,NDC,,,facility,outpatient,1,EA,115.05000,33.36000,Aetna,Local,,58.41,,,,,,,41.48,94.11,percent of total billed charges,
Norepinephrine 8mg/8mL Inj - IV Set Use,800025520,CDM,250,RC,00703115303,NDC,,,facility,outpatient,1,EA,361.00000,104.69000,Aetna,Local,,183.28,,,,,,,130.14,295.30,percent of total billed charges,
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00703102930,NDC,facility,inpatient,200,ME,178.50000,51.76000,Aetna,Local,,71.40,,,,,,,64.35,146.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levOCARNitine 200mg/1mL I 5mL Vial,800017796,CDM,636,RC,J1955,HCPCS,00703040402,NDC,facility,inpatient,1000,ME,67.65000,19.62000,Aetna,Local,,27.06,,,,,,,24.39,55.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00703033504,NDC,facility,inpatient,1,GM,52.50000,15.22000,Aetna,Local,,21.00,,,,,,,18.93,42.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00703024101,NDC,facility,inpatient,40,ME,51.65000,14.98000,Aetna,Local,,20.66,,,,,,,18.62,42.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DAPTOmycin 500 mg Inj,800010982,CDM,636,RC,J0878,HCPCS,00703012501,NDC,facility,inpatient,500,ME,906.00000,262.74000,Aetna,Local,,362.40,,,,,,,326.61,741.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00703006301,NDC,facility,inpatient,80,ME,91.30000,26.48000,Aetna,Local,,36.52,,,,,,,32.91,74.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00703005104,NDC,facility,inpatient,80,ME,91.30000,26.48000,Aetna,Local,,36.52,,,,,,,32.91,74.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00703005101,NDC,facility,inpatient,80,ME,91.30000,26.48000,Aetna,Local,,36.52,,,,,,,32.91,74.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00703003104,NDC,facility,inpatient,40,ME,55.55000,16.11000,Aetna,Local,,22.22,,,,,,,20.03,45.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00703003101,NDC,facility,inpatient,40,ME,55.55000,16.11000,Aetna,Local,,22.22,,,,,,,20.03,45.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00689112001,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00677181501,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00677176901,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,Local,,4.65,,,,,,,3.30,7.48,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00677176801,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,Local,,4.65,,,,,,,3.30,7.48,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00677170906,NDC,,,facility,outpatient,1,EA,16.60000,4.81000,Aetna,Local,,8.43,,,,,,,5.98,13.58,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00677170201,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,Local,,2.56,,,,,,,1.82,4.13,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,00677165303,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00677148301,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00677148210,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00677147201,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,Local,,3.45,,,,,,,2.45,5.56,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00677132301,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,Local,,1.19,,,,,,,0.84718,1.92,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00677124701,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
Triamcinolone 0.1% 5g Top Paste,800015198,CDM,637,RC,00677120036,NDC,,,facility,outpatient,1,EA,101.25000,29.36000,Aetna,Local,,51.40,,,,,,,36.50,82.82,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,00677082401,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00677081601,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00677062506,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00677062501,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00677058901,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00677056202,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,00641921710,NDC,,,facility,outpatient,1,EA,13.90000,4.03000,Aetna,Local,,7.06,,,,,,,5.01,11.37,percent of total billed charges,
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00641628225,NDC,facility,inpatient,50,ME,3.55000,1.03000,Aetna,Local,,1.42,,,,,,,1.28,2.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,00641626510,NDC,facility,inpatient,10,ME,14.05000,4.07000,Aetna,Local,,5.62,,,,,,,5.07,11.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 1mL I,800051051,CDM,636,RC,J3010,HCPCS,00641624725,NDC,facility,inpatient,0.05,ME,18.70000,5.42000,Aetna,Local,,7.48,,,,,,,6.74,15.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00641624410,NDC,facility,inpatient,10,ME,234.50000,68.00000,Aetna,Local,,93.80,,,,,,,84.54,191.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ePHEDrine sulfate 25mg/5mL IS,800051986,CDM,250,RC,00641623610,NDC,,,facility,outpatient,1,EA,78.85000,22.87000,Aetna,Local,,40.03,,,,,,,28.43,64.50,percent of total billed charges,
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,00641623125,NDC,facility,inpatient,20,ME,89.40000,25.93000,Aetna,Local,,35.76,,,,,,,32.23,73.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,00641622825,NDC,facility,inpatient,200,ME,63.50000,18.42000,Aetna,Local,,25.40,,,,,,,22.89,51.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641621725,NDC,facility,inpatient,1,GM,76.80000,22.27000,Aetna,Local,,30.72,,,,,,,27.69,62.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641621710,NDC,facility,inpatient,1,GM,76.80000,22.27000,Aetna,Local,,30.72,,,,,,,27.69,62.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,00641620510,NDC,facility,inpatient,2,ME,196.20000,56.90000,Aetna,Local,,78.48,,,,,,,70.73,160.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00641619610,NDC,facility,inpatient,1,GM,303.00000,87.87000,Aetna,Local,,121.20,,,,,,,109.23,247.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00641619410,NDC,facility,inpatient,200,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00641619110,NDC,facility,inpatient,2,ME,24.75000,7.18000,Aetna,Local,,9.90,,,,,,,8.92,20.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00641618810,NDC,facility,inpatient,50,ME,204.00000,59.16000,Aetna,Local,,81.60,,,,,,,73.54,166.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641618425,NDC,facility,inpatient,0.5,ME,35.10000,10.18000,Aetna,Local,,14.04,,,,,,,12.65,28.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00641618225,NDC,facility,inpatient,60,ME,99.60000,28.88000,Aetna,Local,,39.84,,,,,,,35.91,81.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00641618210,NDC,facility,inpatient,60,ME,99.60000,28.88000,Aetna,Local,,39.84,,,,,,,35.91,81.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00641616210,NDC,facility,inpatient,1,ME,6.30000,1.83000,Aetna,Local,,2.52,,,,,,,2.27,5.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00641616201,NDC,facility,inpatient,0.25,ME,2.35000,0.68000,Aetna,Local,,0.94000,,,,,,,0.84718,1.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00641616110,NDC,facility,inpatient,1,ME,14.50000,4.20000,Aetna,Local,,5.80,,,,,,,5.23,11.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00641615125,NDC,facility,inpatient,2,ME,28.80000,8.35000,Aetna,Local,,11.52,,,,,,,10.38,23.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,00641614910,NDC,facility,inpatient,10,ME,57.45000,16.66000,Aetna,Local,,22.98,,,,,,,20.71,46.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,00641614710,NDC,facility,outpatient,1,EA,19.90000,5.77000,Aetna,Local,,10.10,,,,,,,0.63000,16.28,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,00641614525,NDC,facility,inpatient,4,ME,6.30000,1.83000,Aetna,Local,,2.52,,,,,,,2.27,5.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00641613710,NDC,facility,inpatient,500,ME,437.00000,126.73000,Aetna,Local,,174.80,,,,,,,157.54,357.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00641613625,NDC,facility,inpatient,100,ME,94.50000,27.40000,Aetna,Local,,37.80,,,,,,,34.07,77.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00641613525,NDC,facility,inpatient,10,ME,46.30000,13.43000,Aetna,Local,,18.52,,,,,,,16.69,37.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00641613225,NDC,facility,inpatient,0.4,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 10mg/1mL PF Inj,800059971,CDM,636,RC,J2274,HCPCS,00641612725,NDC,facility,inpatient,10,ME,24.45000,7.09000,Aetna,Local,,9.78,,,,,,,8.81,20.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00641612525,NDC,facility,inpatient,4,ME,23.95000,6.95000,Aetna,Local,,9.58,,,,,,,8.63,19.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00641611710,NDC,facility,inpatient,3,GM,73.15000,21.21000,Aetna,Local,,29.26,,,,,,,26.37,59.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00641611610,NDC,facility,inpatient,1.5,GM,40.30000,11.69000,Aetna,Local,,16.12,,,,,,,14.53,32.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641610325,NDC,facility,inpatient,1,GM,265.00000,76.85000,Aetna,Local,,106.00,,,,,,,95.53,216.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00641610310,NDC,facility,inpatient,1,GM,110.40000,32.02000,Aetna,Local,,44.16,,,,,,,39.80,90.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00641608025,NDC,facility,inpatient,4,ME,6.05000,1.75000,Aetna,Local,,2.42,,,,,,,2.18,4.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00641607901,NDC,facility,inpatient,4,ME,7.55000,2.19000,Aetna,Local,,3.02,,,,,,,2.72,6.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00641607825,NDC,facility,inpatient,4,ME,6.20000,1.80000,Aetna,Local,,2.48,,,,,,,2.24,5.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00641605225,NDC,facility,inpatient,25,ME,24.35000,7.06000,Aetna,Local,,9.74,,,,,,,8.78,19.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00641604825,NDC,facility,inpatient,2,ME,12.40000,3.60000,Aetna,Local,,4.96,,,,,,,4.47,10.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00641604425,NDC,facility,inpatient,2,ME,13.65000,3.96000,Aetna,Local,,5.46,,,,,,,4.92,11.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00641604225,NDC,facility,inpatient,30,ME,10.10000,2.93000,Aetna,Local,,4.04,,,,,,,3.64,8.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00641603325,NDC,facility,inpatient,0.2,ME,10.15000,2.94000,Aetna,Local,,4.06,,,,,,,3.66,8.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00641602725,NDC,facility,inpatient,0.1,ME,20.95000,6.08000,Aetna,Local,,8.38,,,,,,,7.55,17.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00641602410,NDC,facility,inpatient,0.1,ME,15.35000,4.45000,Aetna,Local,,6.14,,,,,,,5.53,12.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,00641602225,NDC,facility,inpatient,20,ME,6.10000,1.77000,Aetna,Local,,2.44,,,,,,,2.20,4.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,00641602010,NDC,facility,inpatient,5,ME,273.65000,79.36000,Aetna,Local,,109.46,,,,,,,98.65,223.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00641601910,NDC,facility,inpatient,10,ME,273.65000,79.36000,Aetna,Local,,109.46,,,,,,,98.65,223.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 5mg/mL Inj 5mL,800040854,CDM,250,RC,00641601310,NDC,,,facility,outpatient,1,EA,21.85000,6.34000,Aetna,Local,,11.09,,,,,,,7.88,17.87,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00641600810,NDC,facility,inpatient,1,ME,19.30000,5.60000,Aetna,Local,,7.72,,,,,,,6.96,15.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00641600710,NDC,facility,inpatient,0.25,ME,3.15000,0.91000,Aetna,Local,,1.26,,,,,,,1.14,2.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00641600125,NDC,facility,inpatient,2,ME,18.25000,5.29000,Aetna,Local,,7.30,,,,,,,6.58,14.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,00641296545,NDC,facility,inpatient,100,ME,67.05000,19.44000,Aetna,Local,,26.82,,,,,,,24.17,54.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Esmolol 100mg/10mL I(Brevibloc),800073659,CDM,636,RC,J1805,HCPCS,00641296541,NDC,facility,inpatient,100,ME,117.40000,34.05000,Aetna,Local,,46.96,,,,,,,42.32,96.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Protamine Sulfate 250mg/25mL Inj,800013349,CDM,636,RC,J2720,HCPCS,00641255441,NDC,facility,inpatient,250,ME,2060.50000,597.54000,Aetna,Local,,824.20,,,,,,,742.81,1685.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00641245045,NDC,facility,inpatient,30000,UN,19.15000,5.55000,Aetna,Local,,7.66,,,,,,,6.90,15.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,00641244345,NDC,facility,inpatient,500,UN,1.75000,0.51000,Aetna,Local,,0.70000,,,,,,,0.63087,1.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,00641244045,NDC,facility,inpatient,10000,UN,5.30000,1.54000,Aetna,Local,,2.12,,,,,,,1.91,4.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin I(10,000/10mL)",800013343,CDM,636,RC,J1644,HCPCS,00641244045,NDC,facility,inpatient,10000,UN,5.30000,1.54000,Aetna,Local,,2.12,,,,,,,1.91,4.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gentamicin Sulf Mdv I,800015120,CDM,636,RC,J1580,HCPCS,00641233143,NDC,facility,inpatient,800,ME,127.60000,37.00000,Aetna,Local,,51.04,,,,,,,46.00,104.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Protamine Sulfate 50mg/5mL Inj,800015125,CDM,636,RC,J2720,HCPCS,00641149435,NDC,facility,inpatient,50,ME,32.40000,9.40000,Aetna,Local,,12.96,,,,,,,11.68,26.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,00641143835,NDC,,,facility,outpatient,1,EA,631.75000,183.21000,Aetna,Local,,320.74,,,,,,,227.75,516.77,percent of total billed charges,
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641141036,NDC,facility,inpatient,0.5,ME,23.20000,6.73000,Aetna,Local,,9.28,,,,,,,8.36,18.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641141035,NDC,facility,inpatient,0.5,ME,35.10000,10.18000,Aetna,Local,,14.04,,,,,,,12.65,28.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Digoxin 500mcg/2mL (0.5mg/2mL) I,800012047,CDM,636,RC,J1160,HCPCS,00641141031,NDC,facility,inpatient,0.5,ME,6.50000,1.88000,Aetna,Local,,2.60,,,,,,,2.34,5.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
chlorproMAZINE 25mg/mL 2mL I(Thoraz,800013680,CDM,636,RC,J3230,HCPCS,00641139835,NDC,facility,inpatient,50,ME,205.45000,59.58000,Aetna,Local,,82.18,,,,,,,74.06,168.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
chlorproMAZINE 25mg/mL 2mL I(Thoraz,800013680,CDM,636,RC,J3230,HCPCS,00641139735,NDC,facility,inpatient,50,ME,300.80000,87.23000,Aetna,Local,,120.32,,,,,,,108.44,246.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00641111633,NDC,facility,inpatient,0.1,ME,16.50000,4.78000,Aetna,Local,,6.60,,,,,,,5.95,13.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00641111433,NDC,facility,inpatient,10,ME,73.85000,21.42000,Aetna,Local,,29.54,,,,,,,26.62,60.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,00641061025,NDC,facility,inpatient,200,ME,10.65000,3.09000,Aetna,Local,,4.26,,,,,,,3.84,8.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00641049125,NDC,facility,inpatient,10,ME,16.65000,4.83000,Aetna,Local,,6.66,,,,,,,6.00,13.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00641049121,NDC,facility,inpatient,10,ME,48.85000,14.17000,Aetna,Local,,19.54,,,,,,,17.61,39.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PHENobarbital 130mg/1mL  Inj,800051979,CDM,636,RC,J2560,HCPCS,00641047725,NDC,facility,inpatient,130,ME,513.70000,148.97000,Aetna,Local,,205.48,,,,,,,185.19,420.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PHENobarbital 65mg/1mL Inj,800077015,CDM,636,RC,J2560,HCPCS,00641047625,NDC,facility,inpatient,65,ME,228.80000,66.35000,Aetna,Local,,91.52,,,,,,,82.48,187.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00641039525,NDC,facility,inpatient,80,ME,12.75000,3.70000,Aetna,Local,,5.10,,,,,,,4.60,10.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00641037625,NDC,facility,inpatient,50,ME,7.50000,2.17000,Aetna,Local,,3.00,,,,,,,2.70,6.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00641037621,NDC,facility,inpatient,50,ME,6.15000,1.78000,Aetna,Local,,2.46,,,,,,,2.22,5.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00641037125,NDC,facility,inpatient,10,ME,22.50000,6.52000,Aetna,Local,,9.00,,,,,,,8.11,18.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00641012521,NDC,,,facility,outpatient,1,EA,66.50000,19.28000,Aetna,Local,,33.76,,,,,,,23.97,54.40,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00641012125,NDC,facility,inpatient,2,ME,13.80000,4.00000,Aetna,Local,,5.52,,,,,,,4.97,11.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00615257913,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00603812718,NDC,,,facility,outpatient,1,EA,4.10000,1.19000,Aetna,Local,,2.08,,,,,,,1.48,3.35,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00603812711,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Triamcinolone 0.025% TC 80g,800017792,CDM,637,RC,00603786190,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,Local,,40.08,,,,,,,28.46,64.58,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00603781874,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,Local,,62.90,,,,,,,44.67,101.35,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00603780550,NDC,,,facility,outpatient,1,EA,52.00000,15.08000,Aetna,Local,,26.40,,,,,,,18.75,42.54,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00603616121,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,00603605421,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,00603580121,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,00603577021,NDC,,,facility,outpatient,1,EA,24.20000,7.02000,Aetna,Local,,12.29,,,,,,,8.72,19.80,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00603576921,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,Local,,9.21,,,,,,,6.54,14.85,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00603554328,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,00603544921,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,Local,,8.38,,,,,,,5.95,13.50,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00603544825,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00603537221,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00603537121,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00603536921,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Phenazopyridine HCl 100mg T(Pyridium),800018142,CDM,637,RC,00603514121,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00603499021,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00603497528,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00603497521,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00603465502,NDC,,,facility,outpatient,1,EA,40.05000,11.61000,Aetna,Local,,20.33,,,,,,,14.44,32.76,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00603459315,NDC,facility,inpatient,4,ME,112.50000,32.62000,Aetna,Local,,45.00,,,,,,,40.56,92.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00603448621,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00603448521,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00603421221,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00603421202,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00603421128,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00603411021,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00603396821,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00603390021,NDC,,,facility,outpatient,1,EA,4.10000,1.19000,Aetna,Local,,2.08,,,,,,,1.48,3.35,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,00603389919,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00603385621,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00603373921,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00603348119,NDC,,,facility,outpatient,1,EA,9.95000,2.89000,Aetna,Local,,5.05,,,,,,,3.59,8.14,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00603344328,NDC,,,facility,outpatient,1,EA,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,8.29,18.81,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,00603318021,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,Local,,4.72,,,,,,,3.35,7.61,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00603316221,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00603307928,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00603307921,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,Local,,4.16,,,,,,,2.96,6.71,percent of total billed charges,
Cyclobenzaprine HCl 5mg T (Flexeril),800015398,CDM,637,RC,00603307821,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00603305221,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00603294821,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00603271421,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00603258221,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00603254721,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00603254421,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00603243321,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00603240721,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,Local,,18.43,,,,,,,13.09,29.69,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00603240628,NDC,,,facility,outpatient,1,EA,16.00000,4.64000,Aetna,Local,,8.12,,,,,,,5.77,13.09,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00603240621,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,Local,,8.88,,,,,,,6.31,14.31,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,00603221621,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,6.49,14.72,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00603221321,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,00603221221,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00603211621,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00603211521,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,00603211002,NDC,,,facility,outpatient,1,EA,18.95000,5.50000,Aetna,Local,,9.62,,,,,,,6.83,15.50,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,00603158558,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,00603158458,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Potassium Cl 10mEq/7.5 mL L UD,800015331,CDM,637,RC,00603153458,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00603148149,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00603139447,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00603137858,NDC,,,facility,outpatient,1,EA,0.50000,0.14000,Aetna,Local,,0.25385,,,,,,,0.18025,0.40900,percent of total billed charges,
Hyoscyamine 0.125mg/mL L,800017422,CDM,637,RC,00603131473,NDC,,,facility,outpatient,1,ML,19.80000,5.74000,Aetna,Local,,10.05,,,,,,,7.14,16.20,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),800065135,CDM,637,RC,00603116158,NDC,,,facility,outpatient,1,EA,10.65000,3.09000,Aetna,Local,,5.41,,,,,,,3.84,8.71,percent of total billed charges,
NICU- Ferrous Sulfate 15mg/1mL L,800081186,CDM,637,RC,00603076247,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,Local,,0.33000,,,,,,,0.23433,0.53170,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,00603064888,NDC,,,facility,outpatient,1,EA,116.80000,33.87000,Aetna,Local,,59.30,,,,,,,42.11,95.54,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00603064450,NDC,,,facility,outpatient,1,EA,46.60000,13.51000,Aetna,Local,,23.66,,,,,,,16.80,38.12,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00603053550,NDC,,,facility,outpatient,1,EA,19.90000,5.77000,Aetna,Local,,10.10,,,,,,,7.17,16.28,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00603053450,NDC,,,facility,outpatient,1,EA,16.35000,4.74000,Aetna,Local,,8.30,,,,,,,5.89,13.37,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597035556,NDC,,,facility,outpatient,1,EA,28.10000,8.15000,Aetna,Local,,14.27,,,,,,,10.13,22.99,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597035509,NDC,,,facility,outpatient,1,EA,28.10000,8.15000,Aetna,Local,,14.27,,,,,,,10.13,22.99,percent of total billed charges,
idaruCIZUmab  2.5g/50mL I(Praxbind),800025665,CDM,636,RC,C9399,HCPCS,00597019705,NDC,facility,inpatient,2.5,GM,18555.70000,5381.15000,Aetna,Local,,7422.28,,,,,,,6689.33,15178.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
idaruCIZUmab  2.5g/50mL I(Praxbind),800025665,CDM,636,RC,C9399,HCPCS,00597019705,NDC,facility,outpatient,2.5,GM,18555.70000,5381.15000,Aetna,Local,,7422.28,,,,,,,6689.33,15178.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,00597018590,NDC,,,facility,outpatient,1,EA,58.60000,16.99000,Aetna,Local,,29.75,,,,,,,21.13,47.93,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00597018390,NDC,,,facility,outpatient,1,EA,58.60000,16.99000,Aetna,Local,,29.75,,,,,,,21.13,47.93,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00597016601,NDC,,,facility,outpatient,1,EA,53.30000,15.46000,Aetna,Local,,27.06,,,,,,,19.21,43.60,percent of total billed charges,
Empagliflozin 25mg Tab,800046460,CDM,637,RC,00597015390,NDC,,,facility,outpatient,1,EA,180.65000,52.39000,Aetna,Local,,91.72,,,,,,,65.12,147.77,percent of total billed charges,
Empagliflozin 25mg Tab,800046460,CDM,637,RC,00597015337,NDC,,,facility,outpatient,1,EA,180.65000,52.39000,Aetna,Local,,91.72,,,,,,,65.12,147.77,percent of total billed charges,
Empagliflozin 10mg Tab,800046380,CDM,637,RC,00597015290,NDC,,,facility,outpatient,1,EA,180.65000,52.39000,Aetna,Local,,91.72,,,,,,,65.12,147.77,percent of total billed charges,
Empagliflozin 10mg Tab,800046380,CDM,637,RC,00597015237,NDC,,,facility,outpatient,1,EA,180.65000,52.39000,Aetna,Local,,91.72,,,,,,,65.12,147.77,percent of total billed charges,
Empagliflozin 10mg Tab,800046380,CDM,637,RC,00597015230,NDC,,,facility,outpatient,1,EA,180.65000,52.39000,Aetna,Local,,91.72,,,,,,,65.12,147.77,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597014960,NDC,,,facility,outpatient,1,EA,55.70000,16.15000,Aetna,Local,,28.28,,,,,,,20.08,45.56,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597010760,NDC,,,facility,outpatient,1,EA,30.95000,8.98000,Aetna,Local,,15.71,,,,,,,11.16,25.32,percent of total billed charges,
Dabigatran 75mg C (Pradaxa),800072458,CDM,637,RC,00597010754,NDC,,,facility,outpatient,1,EA,30.95000,8.98000,Aetna,Local,,15.71,,,,,,,11.16,25.32,percent of total billed charges,
Tiotropium 2.5mcg/1INH Aerosol,800062012,CDM,637,RC,00597010061,NDC,,,facility,outpatient,1,EA,3499.95000,1014.99000,Aetna,Local,,1776.92,,,,,,,1261.73,2862.96,percent of total billed charges,
Tiotropium 2.5mcg/1INH Aerosol,800062012,CDM,637,RC,00597010051,NDC,,,facility,outpatient,1,EA,587.20000,170.29000,Aetna,Local,,298.12,,,,,,,211.69,480.33,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00597008353,NDC,,,facility,outpatient,1,EA,13.20000,3.83000,Aetna,Local,,6.70,,,,,,,4.76,10.80,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,00597008130,NDC,,,facility,outpatient,1,EA,992.85000,287.93000,Aetna,Local,,504.07,,,,,,,357.92,812.15,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,00597006761,NDC,,,facility,outpatient,1,EA,9.00000,2.61000,Aetna,Local,,4.57,,,,,,,3.24,7.36,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00597005801,NDC,,,facility,outpatient,1,EA,82.65000,23.97000,Aetna,Local,,41.96,,,,,,,29.80,67.61,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,00597003334,NDC,,,facility,outpatient,1,EA,1181.20000,342.55000,Aetna,Local,,599.70,,,,,,,425.82,966.22,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00597003234,NDC,,,facility,outpatient,1,EA,908.10000,263.35000,Aetna,Local,,461.04,,,,,,,327.37,742.83,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00597003212,NDC,,,facility,outpatient,1,EA,300.25000,87.07000,Aetna,Local,,152.44,,,,,,,108.24,245.60,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00597003134,NDC,,,facility,outpatient,1,EA,549.05000,159.22000,Aetna,Local,,278.75,,,,,,,197.93,449.12,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00597003112,NDC,,,facility,outpatient,1,EA,184.90000,53.62000,Aetna,Local,,93.87,,,,,,,66.66,151.25,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00597002901,NDC,,,facility,outpatient,1,EA,82.20000,23.84000,Aetna,Local,,41.73,,,,,,,29.63,67.24,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00597000601,NDC,,,facility,outpatient,1,EA,23.05000,6.68000,Aetna,Local,,11.70,,,,,,,8.31,18.85,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,00597000160,NDC,,,facility,outpatient,1,EA,79.85000,23.16000,Aetna,Local,,40.54,,,,,,,28.79,65.32,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00591588301,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,Local,,4.29,,,,,,,3.05,6.91,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00591588201,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00591578701,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00591578601,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00591573101,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,Local,,3.96,,,,,,,2.81,6.38,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00591573001,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,Local,,2.18,,,,,,,1.55,3.52,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00591570801,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,Local,,4.29,,,,,,,3.05,6.91,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,00591569401,NDC,,,facility,outpatient,1,EA,12.05000,3.49000,Aetna,Local,,6.12,,,,,,,4.34,9.86,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00591565805,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00591565801,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,Local,,4.14,,,,,,,2.94,6.67,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,00591564301,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,Local,,4.65,,,,,,,3.30,7.48,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,00591564201,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
diazePAM 2mg T(Valium),800050533,CDM,637,RC,00591562101,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00591560001,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00591559901,NDC,,,facility,outpatient,1,EA,0.65000,0.19000,Aetna,Local,,0.33000,,,,,,,0.23433,0.53170,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,00591557101,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00591555501,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00591555401,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00591555250,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,Local,,2.56,,,,,,,1.82,4.13,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00591554401,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00591554301,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00591552301,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00591551301,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00591544050,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,Local,,11.80,,,,,,,8.38,19.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00591544005,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,Local,,11.80,,,,,,,8.38,19.02,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,00591543001,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00591538201,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00591534701,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,00591533501,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,Local,,0.66001,,,,,,,0.46865,1.06,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00591532101,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00591521601,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,00591401201,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00591401105,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00591396801,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00591387560,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,Local,,21.93,,,,,,,15.57,35.34,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00591387544,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,Local,,21.93,,,,,,,15.57,35.34,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00591387060,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,Local,,21.93,,,,,,,15.57,35.34,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00591387044,NDC,,,facility,outpatient,1,EA,43.20000,12.53000,Aetna,Local,,21.93,,,,,,,15.57,35.34,percent of total billed charges,
Tranexamic Acid 650mg T(Lysteda),800017931,CDM,637,RC,00591372030,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,Local,,18.76,,,,,,,13.32,30.23,percent of total billed charges,
Ezetimibe 10 mg T(Zetia),800080365,CDM,637,RC,00591371330,NDC,,,facility,outpatient,1,EA,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,28.84,65.44,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00591368501,NDC,,,facility,outpatient,1,EA,16.10000,4.67000,Aetna,Local,,8.17,,,,,,,5.80,13.17,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00591354160,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00591354060,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00591343710,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00591343701,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00591333130,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,Local,,18.76,,,,,,,13.32,30.23,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00591323001,NDC,,,facility,outpatient,1,EA,22.40000,6.50000,Aetna,Local,,11.37,,,,,,,8.08,18.32,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00591322247,NDC,facility,inpatient,60,ME,119.70000,34.71000,Aetna,Local,,47.88,,,,,,,43.15,97.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,00591321630,NDC,,,facility,outpatient,1,EA,116.65000,33.83000,Aetna,Local,,59.22,,,,,,,42.05,95.42,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00591321472,NDC,,,facility,outpatient,1,EA,411.90000,119.45000,Aetna,Local,,209.12,,,,,,,148.49,336.93,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00591321372,NDC,,,facility,outpatient,1,EA,314.85000,91.31000,Aetna,Local,,159.85,,,,,,,113.50,257.55,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00591321272,NDC,,,facility,outpatient,1,EA,210.90000,61.16000,Aetna,Local,,107.07,,,,,,,76.03,172.52,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00591319872,NDC,,,facility,outpatient,1,EA,115.45000,33.48000,Aetna,Local,,58.61,,,,,,,41.62,94.44,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00591319101,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00591315901,NDC,,,facility,outpatient,1,EA,52.05000,15.09000,Aetna,Local,,26.43,,,,,,,18.76,42.58,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00591304105,NDC,,,facility,outpatient,1,EA,27.50000,7.98000,Aetna,Local,,13.96,,,,,,,9.91,22.50,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00591298539,NDC,,,facility,outpatient,1,EA,125.35000,36.35000,Aetna,Local,,63.64,,,,,,,45.19,102.54,percent of total billed charges,
Levalbuterol HFA 45 mcg/inh,800017835,CDM,637,RC,00591292754,NDC,,,facility,outpatient,1,EA,488.10000,141.55000,Aetna,Local,,247.81,,,,,,,175.96,399.27,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00591283001,NDC,,,facility,outpatient,1,EA,15.40000,4.47000,Aetna,Local,,7.82,,,,,,,5.55,12.60,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00591271301,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00591269201,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00591261205,NDC,,,facility,outpatient,1,EA,6.25000,1.81000,Aetna,Local,,3.17,,,,,,,2.25,5.11,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,00591257920,NDC,,,facility,outpatient,1,EA,70.80000,20.53000,Aetna,Local,,35.95,,,,,,,25.52,57.91,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00591252001,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,Local,,3.88,,,,,,,2.76,6.26,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00591247260,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,00591246401,NDC,,,facility,outpatient,1,EA,37.40000,10.85000,Aetna,Local,,18.99,,,,,,,13.48,30.59,percent of total billed charges,
Cinacalcet 30 mg T(Sensipar),800081884,CDM,637,RC,00591241630,NDC,,,facility,outpatient,1,EA,216.70000,62.84000,Aetna,Local,,110.02,,,,,,,78.12,177.26,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00591222805,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00591222801,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00591213668,NDC,facility,inpatient,1,GM,288.60000,83.69000,Aetna,Local,,115.44,,,,,,,104.04,236.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00591213651,NDC,facility,inpatient,0.5,GM,145.35000,42.15000,Aetna,Local,,58.14,,,,,,,52.40,118.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00591111730,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,Local,,9.75,,,,,,,6.92,15.71,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00591094401,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,00591090030,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00591085860,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00591083960,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00591083925,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,Local,,5.64,,,,,,,4.00,9.08,percent of total billed charges,
Silver SulfaDIAZINE 1% 85g TC,800052968,CDM,637,RC,00591081085,NDC,,,facility,outpatient,1,EA,189.15000,54.85000,Aetna,Local,,96.03,,,,,,,68.19,154.72,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,00591079601,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00591079401,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00591078701,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00591078601,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00591078005,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00591078001,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00591069801,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,4.42,,,,,,,3.14,7.12,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00591067101,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,Local,,5.48,,,,,,,3.89,8.83,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00591067001,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00591065801,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00591065701,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00591060605,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00591060601,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,Local,,2.56,,,,,,,1.82,4.13,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00591060501,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,00591058301,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,Local,,8.38,,,,,,,5.95,13.50,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00591058201,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00591048701,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00591046301,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00591046001,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,Local,,1.35,,,,,,,0.95532,2.17,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00591044401,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00591042405,NDC,,,facility,outpatient,1,EA,2.50000,0.72000,Aetna,Local,,1.27,,,,,,,0.90125,2.04,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00591042401,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00591040901,NDC,,,facility,outpatient,1,EA,10.95000,3.18000,Aetna,Local,,5.56,,,,,,,3.95,8.96,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00591040701,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,Local,,3.55,,,,,,,2.52,5.73,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,00591040401,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00591034501,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00591030101,NDC,,,facility,outpatient,1,EA,0.35000,0.10000,Aetna,Local,,0.17769,,,,,,,0.12618,0.28630,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00591030001,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00591024001,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00591001419,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,11.75,,,,,,,8.35,18.94,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00591001319,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,00590036805,NDC,facility,inpatient,2,ME,80.65000,23.39000,Aetna,Local,,32.26,,,,,,,29.07,65.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00590035810,NDC,facility,inpatient,0.4,ME,7.05000,2.04000,Aetna,Local,,2.82,,,,,,,2.54,5.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00585097572,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,00585067103,NDC,,,facility,outpatient,1,EA,325.85000,94.50000,Aetna,Local,,165.43,,,,,,,117.47,266.55,percent of total billed charges,
hydrocodone-chlorpheniramine L(Tussionex) 5mL,800030790,CDM,637,RC,00585054867,NDC,,,facility,outpatient,1,EA,17.10000,4.96000,Aetna,Local,,8.68,,,,,,,6.16,13.99,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00574723612,NDC,,,facility,outpatient,1,EA,27.55000,7.99000,Aetna,Local,,13.99,,,,,,,9.93,22.54,percent of total billed charges,
Prochlorperazine 25mg Supp(Compazine,800017137,CDM,637,RC,00574722612,NDC,,,facility,outpatient,1,EA,89.10000,25.84000,Aetna,Local,,45.24,,,,,,,32.12,72.88,percent of total billed charges,
Belladonna-Opium Supp(60mg Of Opium),800017087,CDM,637,RC,00574704012,NDC,,,facility,outpatient,1,EA,263.90000,76.53000,Aetna,Local,,133.98,,,,,,,95.14,215.87,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,00574416035,NDC,,,facility,outpatient,1,EA,107.25000,31.10000,Aetna,Local,,54.45,,,,,,,38.66,87.73,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sol(Cortispor,800018689,CDM,637,RC,00574410010,NDC,,,facility,outpatient,1,EA,131.00000,37.99000,Aetna,Local,,66.51,,,,,,,47.23,107.16,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,00574403105,NDC,,,facility,outpatient,1,EA,594.85000,172.51000,Aetna,Local,,302.01,,,,,,,214.44,486.59,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,00574402450,NDC,,,facility,outpatient,1,EA,61.55000,17.85000,Aetna,Local,,31.25,,,,,,,22.19,50.35,percent of total billed charges,
Bac-Poly 3.5g Ophth Oint(Polysporin),800019729,CDM,250,RC,00574402135,NDC,,,facility,outpatient,1,EA,186.85000,54.19000,Aetna,Local,,94.86,,,,,,,67.36,152.84,percent of total billed charges,
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00574200815,NDC,,,facility,outpatient,1,EA,164.80000,47.79000,Aetna,Local,,83.67,,,,,,,59.41,134.81,percent of total billed charges,
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,00574085010,NDC,facility,inpatient,1,ME,662.00000,191.98000,Aetna,Local,,264.80,,,,,,,238.65,541.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,00574085005,NDC,facility,inpatient,1,ME,692.10000,200.71000,Aetna,Local,,276.84,,,,,,,249.50,566.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,00574082301,NDC,facility,inpatient,60,ME,355.25000,103.02000,Aetna,Local,,142.10,,,,,,,128.07,290.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,00574081530,NDC,facility,inpatient,6000,ME,1656.40000,480.36000,Aetna,Local,,662.56,,,,,,,597.13,1354.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetylcysteine 6000mg/ 30mL I,800013320,CDM,636,RC,J0132,HCPCS,00574080530,NDC,facility,inpatient,6000,ME,1014.00000,294.06000,Aetna,Local,,405.60,,,,,,,365.55,829.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00574079201,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,00574041202,NDC,,,facility,outpatient,1,EA,144.40000,41.88000,Aetna,Local,,73.31,,,,,,,52.06,118.12,percent of total billed charges,
Hyoscyamine Sulf 0.375mg ER T,800077049,CDM,637,RC,00574025101,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,00574022201,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Liothyronine Na 5mcg T(Cytomel),800059674,CDM,637,RC,00574022001,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
"Ergocalciferol 1.25mg (50,000IU) C(Vit D2)",800013218,CDM,637,RC,00574019401,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Caffeine Citrate 20mg/mL L 3mL,800081116,CDM,637,RC,00574015210,NDC,,,facility,outpatient,1,EA,316.05000,91.65000,Aetna,Local,,160.46,,,,,,,113.94,258.53,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00574010770,NDC,,,facility,outpatient,1,EA,11.40000,3.31000,Aetna,Local,,5.79,,,,,,,4.11,9.33,percent of total billed charges,
Bromocriptine 2.5mg Tab,800040878,CDM,637,RC,00574010603,NDC,,,facility,outpatient,1,EA,29.30000,8.50000,Aetna,Local,,14.88,,,,,,,10.56,23.97,percent of total billed charges,
Glucose 15g Gel(Glutose 15),800053933,CDM,250,RC,00574007030,NDC,,,facility,outpatient,1,EA,27.95000,8.11000,Aetna,Local,,14.19,,,,,,,10.08,22.86,percent of total billed charges,
Glucose 15g Gel(Glutose 15),800053933,CDM,250,RC,00574006930,NDC,,,facility,outpatient,1,EA,43.55000,12.63000,Aetna,Local,,22.11,,,,,,,15.70,35.62,percent of total billed charges,
Norgestimate-ethinyl estradiol,800062117,CDM,637,RC,00555901658,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,Local,,4.14,,,,,,,2.94,6.67,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00555112810,NDC,facility,inpatient,10,ME,120.40000,34.92000,Aetna,Local,,48.16,,,,,,,43.40,98.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,00555101116,NDC,,,facility,outpatient,1,EA,510.90000,148.16000,Aetna,Local,,259.38,,,,,,,184.18,417.92,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00555101016,NDC,,,facility,outpatient,1,EA,379.45000,110.04000,Aetna,Local,,192.65,,,,,,,136.79,310.39,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00555100916,NDC,,,facility,outpatient,1,EA,233.20000,67.63000,Aetna,Local,,118.40,,,,,,,84.07,190.76,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00555099702,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,00555097302,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,00555097102,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Ethambutol HCl 400mg T(Myambutol),800016351,CDM,637,RC,00555092302,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,Local,,6.42,,,,,,,4.56,10.35,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00555091709,NDC,,,facility,outpatient,1,EA,23.70000,6.87000,Aetna,Local,,12.03,,,,,,,8.54,19.39,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00555088604,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,Local,,2.39,,,,,,,1.69,3.84,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00555088602,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,00555088202,NDC,,,facility,outpatient,1,EA,10.45000,3.03000,Aetna,Local,,5.31,,,,,,,3.77,8.55,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00555087702,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,Local,,9.60,,,,,,,6.81,15.46,percent of total billed charges,
medroxyPROGESTERone 2.5mg T(Provera,800053891,CDM,637,RC,00555087202,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,Local,,1.12,,,,,,,0.79310,1.80,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,00555077702,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,00555076702,NDC,,,facility,outpatient,1,EA,42.30000,12.27000,Aetna,Local,,21.48,,,,,,,15.25,34.60,percent of total billed charges,
Dextroamphetamine-Amphetamine 15mg T,800081076,CDM,637,RC,00555076602,NDC,,,facility,outpatient,1,EA,42.30000,12.27000,Aetna,Local,,21.48,,,,,,,15.25,34.60,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,00555070102,NDC,,,facility,outpatient,1,EA,74.90000,21.72000,Aetna,Local,,38.03,,,,,,,27.00,61.27,percent of total billed charges,
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00555061762,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
Pramipexole Dihydrochl 0.5mg T(Mirapex),800017677,CDM,637,RC,00555061314,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00555058504,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00555058502,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00555044609,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00555030138,NDC,facility,inpatient,4,ME,3.70000,1.07000,Aetna,Local,,1.48,,,,,,,1.33,3.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,00555025202,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,Local,,3.81,,,,,,,2.70,6.13,percent of total billed charges,
Norethindrone 5mg T,800017653,CDM,637,RC,00555021110,NDC,,,facility,outpatient,1,EA,18.75000,5.44000,Aetna,Local,,9.52,,,,,,,6.76,15.34,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00555015904,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00555015902,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
clonazePAM 0.25mg ODT (KlonoPIN),800015397,CDM,637,RC,00555009596,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,Local,,5.28,,,,,,,3.75,8.51,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00555007102,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,Local,,1.12,,,,,,,0.79310,1.80,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00555007101,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00555003302,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
Neostigmine 1mg/mL 10mL Inj,800013397,CDM,636,RC,J2710,HCPCS,00548960200,NDC,facility,inpatient,10,ME,114.90000,33.32000,Aetna,Local,,45.96,,,,,,,41.42,93.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00548906100,NDC,facility,inpatient,1,ME,1.00000,0.29000,Aetna,Local,,0.40000,,,,,,,0.36050,0.81800,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,00548590000,NDC,facility,inpatient,0.25,ME,578.60000,167.79000,Aetna,Local,,231.44,,,,,,,208.59,473.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00548571100,NDC,facility,inpatient,150,ME,326.10000,94.57000,Aetna,Local,,130.44,,,,,,,117.56,266.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00548570100,NDC,facility,inpatient,150,ME,158.60000,45.99000,Aetna,Local,,63.44,,,,,,,57.18,129.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00548560700,NDC,facility,inpatient,150,ME,144.15000,41.80000,Aetna,Local,,57.66,,,,,,,51.97,117.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00548560600,NDC,facility,inpatient,120,ME,114.90000,33.32000,Aetna,Local,,45.96,,,,,,,41.42,93.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00548560500,NDC,facility,inpatient,100,ME,95.75000,27.77000,Aetna,Local,,38.30,,,,,,,34.52,78.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00548560300,NDC,facility,inpatient,60,ME,57.45000,16.66000,Aetna,Local,,22.98,,,,,,,20.71,46.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00548560200,NDC,facility,inpatient,40,ME,38.30000,11.11000,Aetna,Local,,15.32,,,,,,,13.81,31.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00548540000,NDC,facility,inpatient,150,ME,158.60000,45.99000,Aetna,Local,,63.44,,,,,,,57.18,129.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00548339000,NDC,,,facility,inpatient,1,EA,25.55000,7.41000,Aetna,Local,,10.22,,,,,,,9.21,20.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00548339000,NDC,,,facility,outpatient,1,EA,25.55000,7.41000,Aetna,Local,,10.22,,,,,,,9.21,20.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 2mg/2 mL IS (Narcan),800013430,CDM,636,RC,J2312,HCPCS,00548336900,NDC,facility,inpatient,2,ME,108.20000,31.38000,Aetna,Local,,43.28,,,,,,,39.01,88.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00548333900,NDC,facility,inpatient,1,ME,25.55000,7.41000,Aetna,Local,,10.22,,,,,,,9.21,20.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00548331600,NDC,facility,inpatient,1,ME,25.55000,7.41000,Aetna,Local,,10.22,,,,,,,9.21,20.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00548330400,NDC,,,facility,outpatient,1,EA,25.55000,7.41000,Aetna,Local,,12.97,,,,,,,9.21,20.90,percent of total billed charges,
D50W 50mL Inj Syr,800011221,CDM,258,RC,00548330100,NDC,,,facility,outpatient,1,EA,38.30000,11.11000,Aetna,Local,,19.44,,,,,,,13.81,31.33,percent of total billed charges,
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00548124000,NDC,facility,inpatient,1,ME,27.15000,7.87000,Aetna,Local,,10.86,,,,,,,9.79,22.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00548114000,NDC,facility,inpatient,1,ME,28.35000,8.22000,Aetna,Local,,11.34,,,,,,,10.22,23.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
oxyBUTYnin 5mg T(Ditropan),800035310,CDM,637,RC,00536567201,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
sulfaSALAzine 500mg T(Azulfidine),800082031,CDM,637,RC,00536461701,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,00536351501,NDC,,,facility,outpatient,1,EA,0.30000,0.09000,Aetna,Local,,0.15231,,,,,,,0.10815,0.24540,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00536300094,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,6.49,14.72,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,00536252525,NDC,,,facility,outpatient,1,EA,70.45000,20.43000,Aetna,Local,,35.77,,,,,,,25.40,57.63,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00536140795,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,Local,,6.65,,,,,,,4.72,10.72,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00536137904,NDC,,,facility,outpatient,1,EA,152.85000,44.33000,Aetna,Local,,77.60,,,,,,,55.10,125.03,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00536137575,NDC,,,facility,outpatient,1,EA,39.55000,11.47000,Aetna,Local,,20.08,,,,,,,14.26,32.35,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),800081199,CDM,250,RC,00536134957,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,Local,,14.55,,,,,,,10.33,23.44,percent of total billed charges,
Guaifenesin-Pseudoeph 600-60mg ER T,800081253,CDM,637,RC,00536133321,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00536130723,NDC,,,facility,outpatient,1,EA,118.85000,34.47000,Aetna,Local,,60.34,,,,,,,42.85,97.22,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00536129801,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,Local,,0.43155,,,,,,,0.30643,0.69530,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,00536129497,NDC,,,facility,outpatient,1,EA,108.40000,31.44000,Aetna,Local,,55.03,,,,,,,39.08,88.67,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00536127803,NDC,,,facility,outpatient,1,EA,102.65000,29.77000,Aetna,Local,,52.12,,,,,,,37.01,83.97,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00536127780,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,Local,,6.65,,,,,,,4.72,10.72,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00536126720,NDC,,,facility,outpatient,1,EA,78.85000,22.87000,Aetna,Local,,40.03,,,,,,,28.43,64.50,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00536126526,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,Local,,3.27,,,,,,,2.33,5.28,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00536126511,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,Local,,5.64,,,,,,,4.00,9.08,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00536125628,NDC,,,facility,outpatient,1,EA,16.10000,4.67000,Aetna,Local,,8.17,,,,,,,5.80,13.17,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,00536120215,NDC,,,facility,outpatient,1,EA,10.65000,3.09000,Aetna,Local,,5.41,,,,,,,3.84,8.71,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,00536120207,NDC,,,facility,outpatient,1,EA,9.25000,2.68000,Aetna,Local,,4.70,,,,,,,3.33,7.57,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,800017818,CDM,250,RC,00536116137,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,Local,,2.18,,,,,,,1.55,3.52,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,00536105224,NDC,,,facility,outpatient,1,EA,77.80000,22.56000,Aetna,Local,,39.50,,,,,,,28.05,63.64,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00536101294,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,Local,,20.74,,,,,,,14.73,33.42,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00527600480,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,Local,,4.65,,,,,,,3.30,7.48,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,00527459313,NDC,,,facility,outpatient,1,EA,109.45000,31.74000,Aetna,Local,,55.57,,,,,,,39.46,89.53,percent of total billed charges,
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,00527459113,NDC,,,facility,outpatient,1,EA,100.40000,29.12000,Aetna,Local,,50.97,,,,,,,36.19,82.13,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00527260137,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00527221537,NDC,,,facility,outpatient,1,EA,17.35000,5.03000,Aetna,Local,,8.81,,,,,,,6.25,14.19,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00527169501,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00527163810,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00527163801,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,00527144201,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,Local,,2.39,,,,,,,1.69,3.84,percent of total billed charges,
Loxapine Succinate 10mg,800062072,CDM,637,RC,00527139501,NDC,,,facility,outpatient,1,EA,9.00000,2.61000,Aetna,Local,,4.57,,,,,,,3.24,7.36,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00527136701,NDC,,,facility,outpatient,1,EA,26.40000,7.66000,Aetna,Local,,13.40,,,,,,,9.52,21.60,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00527135001,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00527134710,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00527134701,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00527134601,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,Local,,2.34,,,,,,,1.66,3.76,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00527134501,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00527134401,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00527134301,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00527134201,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00527134110,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00527134101,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00527132601,NDC,,,facility,outpatient,1,EA,52.05000,15.09000,Aetna,Local,,26.43,,,,,,,18.76,42.58,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00527132410,NDC,,,facility,outpatient,1,EA,13.45000,3.90000,Aetna,Local,,6.83,,,,,,,4.85,11.00,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00527132401,NDC,,,facility,outpatient,1,EA,16.30000,4.73000,Aetna,Local,,8.28,,,,,,,5.88,13.33,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00527131530,NDC,,,facility,outpatient,1,EA,32.50000,9.42000,Aetna,Local,,16.50,,,,,,,11.72,26.59,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00527131301,NDC,,,facility,outpatient,1,EA,12.85000,3.73000,Aetna,Local,,6.52,,,,,,,4.63,10.51,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00527130105,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00527130101,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00527123101,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00527058610,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00527058601,NDC,,,facility,outpatient,1,EA,3.20000,0.93000,Aetna,Local,,1.62,,,,,,,1.15,2.62,percent of total billed charges,
droPERidol 2.5mg/mL 2mL I,800011791,CDM,636,RC,J1790,HCPCS,00517970225,NDC,facility,inpatient,5,ME,67.85000,19.68000,Aetna,Local,,27.14,,,,,,,24.46,55.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
trace elements (Cu/Mn/Se/Zn) 0.3mg-55mcg-60mcg-3mg/mL I,800046540,CDM,250,RC,00517930525,NDC,,,facility,outpatient,1,EA,170.05000,49.31000,Aetna,Local,,86.33,,,,,,,61.30,139.10,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,800042530,CDM,250,RC,00517671010,NDC,,,facility,outpatient,1,EA,206.25000,59.81000,Aetna,Local,,104.71,,,,,,,74.35,168.71,percent of total billed charges,
Furosemide 100mg I,800013344,CDM,636,RC,J1938,HCPCS,00517571025,NDC,facility,inpatient,100,ME,22.50000,6.52000,Aetna,Local,,9.00,,,,,,,8.11,18.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,00517571025,NDC,facility,inpatient,100,ME,14.95000,4.34000,Aetna,Local,,5.98,,,,,,,5.39,12.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00517570425,NDC,facility,inpatient,40,ME,11.65000,3.38000,Aetna,Local,,4.66,,,,,,,4.20,9.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,00517570225,NDC,facility,inpatient,20,ME,10.00000,2.90000,Aetna,Local,,4.00,,,,,,,3.60,8.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrOXYzine HCl 50mg/1mL Inj,800021995,CDM,636,RC,J3410,HCPCS,00517560125,NDC,facility,inpatient,50,ME,200.80000,58.23000,Aetna,Local,,80.32,,,,,,,72.39,164.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Thiosulfate 12.5g/50mL Inj,800017828,CDM,636,RC,J0209,HCPCS,00517501901,NDC,facility,inpatient,12.5,GM,114.90000,33.32000,Aetna,Local,,45.96,,,,,,,41.42,93.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone NaPhos I MDV,800019208,CDM,636,RC,J1100,HCPCS,00517490525,NDC,facility,inpatient,1,ME,0.85000,0.25000,Aetna,Local,,0.34000,,,,,,,0.30643,0.69530,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,00517490125,NDC,facility,inpatient,4,ME,5.55000,1.61000,Aetna,Local,,2.22,,,,,,,2.00,4.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitroglycerin 50mg/10mL I,800040484,CDM,636,RC,J2305,HCPCS,00517481025,NDC,facility,inpatient,50,ME,158.60000,45.99000,Aetna,Local,,63.44,,,,,,,57.18,129.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitroglycerin 50mg/10mL I,800040484,CDM,636,RC,J2305,HCPCS,00517481010,NDC,facility,inpatient,50,ME,119.85000,34.76000,Aetna,Local,,47.94,,,,,,,43.21,98.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,00517460525,NDC,facility,inpatient,1,ME,278.60000,80.79000,Aetna,Local,,111.44,,,,,,,100.44,227.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00517460125,NDC,facility,inpatient,0.2,ME,86.45000,25.07000,Aetna,Local,,34.58,,,,,,,31.17,70.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,00517430001,NDC,facility,inpatient,100,ME,9037.40000,2620.85000,Aetna,Local,,3614.96,,,,,,,3257.98,7392.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mannitol 25% I 50mL,800050889,CDM,636,RC,J2150,HCPCS,00517405025,NDC,facility,inpatient,12.5,GM,17.55000,5.09000,Aetna,Local,,7.02,,,,,,,6.33,14.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Gluconate 1g/10mL I,800011311,CDM,636,RC,J0612,HCPCS,00517391025,NDC,facility,inpatient,1,GM,115.60000,33.52000,Aetna,Local,,46.24,,,,,,,41.67,94.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Calcium Gluconate 0.465mEq/mL Inj,800017966,CDM,636,RC,J0612,HCPCS,00517391025,NDC,facility,inpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.02,,,,,,,2.72,6.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aminophylline 500mg/20mL I,800013441,CDM,636,RC,J0280,HCPCS,00517382025,NDC,facility,inpatient,500,ME,7.10000,2.06000,Aetna,Local,,2.84,,,,,,,2.56,5.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00517360525,NDC,facility,inpatient,500,ME,134.80000,39.09000,Aetna,Local,,53.92,,,,,,,48.60,110.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Phosphate Inj,800053081,CDM,250,RC,00517341525,NDC,,,facility,outpatient,1,EA,249.00000,72.21000,Aetna,Local,,126.42,,,,,,,89.76,203.68,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,00517340525,NDC,,,facility,outpatient,1,EA,87.65000,25.42000,Aetna,Local,,44.50,,,,,,,31.60,71.70,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,00517305025,NDC,facility,outpatient,1,EA,9.30000,2.70000,Aetna,Local,,4.72,,,,,,,0.63000,7.61,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,800042530,CDM,250,RC,00517271025,NDC,,,facility,outpatient,1,EA,197.10000,57.16000,Aetna,Local,,100.07,,,,,,,71.05,161.23,percent of total billed charges,
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,00517261025,NDC,facility,inpatient,10,GM,26.55000,7.70000,Aetna,Local,,10.62,,,,,,,9.57,21.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517234025,NDC,facility,inpatient,100,ME,567.70000,164.63000,Aetna,Local,,227.08,,,,,,,204.66,464.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517234010,NDC,facility,inpatient,100,ME,567.70000,164.63000,Aetna,Local,,227.08,,,,,,,204.66,464.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517234001,NDC,facility,inpatient,100,ME,500.00000,145.00000,Aetna,Local,,200.00,,,,,,,180.25,409.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00517231525,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,Local,,21.58,,,,,,,15.32,34.77,percent of total billed charges,
Iron Sucrose 100mg/5mL I(Venofer),800013289,CDM,636,RC,J1756,HCPCS,00517231001,NDC,facility,inpatient,100,ME,519.60000,150.68000,Aetna,Local,,207.84,,,,,,,187.32,425.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00517210225,NDC,,,facility,outpatient,1,EA,471.55000,136.75000,Aetna,Local,,239.41,,,,,,,169.99,385.73,percent of total billed charges,
NICU- Sodium Acetate 2mEq/mL Inj,800072480,CDM,250,RC,00517209625,NDC,,,facility,outpatient,1,EA,34.55000,10.02000,Aetna,Local,,17.54,,,,,,,12.46,28.26,percent of total billed charges,
Chlorothiazide Na 500mg Inj.,800017800,CDM,636,RC,J1205,HCPCS,00517182001,NDC,facility,inpatient,500,ME,854.00000,247.66000,Aetna,Local,,341.60,,,,,,,307.87,698.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00517135525,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00517107125,NDC,facility,inpatient,1,ME,22.35000,6.48000,Aetna,Local,,8.94,,,,,,,8.06,18.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vasopressin 20unit/mL I,800054915,CDM,636,RC,J2598,HCPCS,00517102025,NDC,facility,inpatient,20,UN,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vasopressin 20units/1mL- For IV Set,800025670,CDM,636,RC,J2599,HCPCS,00517102025,NDC,facility,inpatient,20,UN,490.00000,142.10000,Aetna,Local,,196.00,,,,,,,176.65,400.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine SO4 1mg/mL 1mL I,800013438,CDM,636,RC,J0461,HCPCS,00517101025,NDC,facility,inpatient,1,ME,80.20000,23.26000,Aetna,Local,,32.08,,,,,,,28.91,65.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,00517096010,NDC,,,facility,outpatient,1,EA,199.85000,57.96000,Aetna,Local,,101.46,,,,,,,72.05,163.48,percent of total billed charges,
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,00517095501,NDC,facility,inpatient,10,ME,242.40000,70.30000,Aetna,Local,,96.96,,,,,,,87.39,198.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrALAZINE 20mg/mL I(Apresoline),800011032,CDM,636,RC,J0360,HCPCS,00517090125,NDC,facility,inpatient,20,ME,95.75000,27.77000,Aetna,Local,,38.30,,,,,,,34.52,78.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00517079101,NDC,facility,inpatient,30,ME,308.00000,89.32000,Aetna,Local,,123.20,,,,,,,111.03,251.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00517078110,NDC,,,facility,outpatient,1,EA,33.25000,9.64000,Aetna,Local,,16.88,,,,,,,11.99,27.20,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00517078010,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,Local,,25.33,,,,,,,17.99,40.82,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,00517074020,NDC,facility,inpatient,0.2,ME,194.90000,56.52000,Aetna,Local,,77.96,,,,,,,70.26,159.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00517073510,NDC,facility,inpatient,25,ME,310.10000,89.93000,Aetna,Local,,124.04,,,,,,,111.79,253.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00517072001,NDC,facility,inpatient,30,ME,334.00000,96.86000,Aetna,Local,,133.60,,,,,,,120.41,273.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00517062625,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,Local,,2.64,,,,,,,2.38,5.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00517062625,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,Local,,2.64,,,,,,,2.38,5.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00517062525,NDC,,,facility,inpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.32,,,,,,,2.09,4.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00517062525,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.32,,,,,,,2.09,4.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00517040525,NDC,facility,inpatient,50,ME,127.50000,36.97000,Aetna,Local,,51.00,,,,,,,45.96,104.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine SO4 0.4mg/mL 1mL I,800019204,CDM,636,RC,J0461,HCPCS,00517040125,NDC,facility,inpatient,0.4,ME,51.05000,14.80000,Aetna,Local,,20.42,,,,,,,18.40,41.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,00517038105,NDC,facility,inpatient,50,ME,1123.80000,325.90000,Aetna,Local,,449.52,,,,,,,405.13,919.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,00517038105,NDC,facility,outpatient,50,ME,1123.80000,325.90000,Aetna,Local,,449.52,,,,,,,5.42,919.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,00517037405,NDC,facility,inpatient,50,ME,1123.80000,325.90000,Aetna,Local,,449.52,,,,,,,405.13,919.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylene Blue 0.5% 10mL I,800021990,CDM,636,RC,Q9968,HCPCS,00517037405,NDC,facility,outpatient,50,ME,1123.80000,325.90000,Aetna,Local,,449.52,,,,,,,5.42,919.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenylephrine 50mg/5mL - for IV Set Use,800019854,CDM,636,RC,J2371,HCPCS,00517029925,NDC,facility,inpatient,50,ME,127.50000,36.97000,Aetna,Local,,51.00,,,,,,,45.96,104.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Iron Dextran 100mg/2mL I(Infed),800012496,CDM,636,RC,J1750,HCPCS,00517023410,NDC,facility,inpatient,100,ME,350.50000,101.64000,Aetna,Local,,140.20,,,,,,,126.36,286.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,00517013005,NDC,facility,inpatient,1,ME,23.70000,6.87000,Aetna,Local,,9.48,,,,,,,8.54,19.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,00517003125,NDC,facility,inpatient,1,ME,46.50000,13.48000,Aetna,Local,,18.60,,,,,,,16.76,38.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,00517002010,NDC,facility,inpatient,60,ME,180.00000,52.20000,Aetna,Local,,72.00,,,,,,,64.89,147.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,00501379801,NDC,,,facility,outpatient,1,EA,80.00000,23.20000,Aetna,Local,,40.62,,,,,,,28.84,65.44,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,00496095305,NDC,,,facility,outpatient,1,EA,336.45000,97.57000,Aetna,Local,,170.82,,,,,,,121.29,275.22,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00496088230,NDC,,,facility,outpatient,1,EA,192.75000,55.90000,Aetna,Local,,97.86,,,,,,,69.49,157.67,percent of total billed charges,
Lidocaine 4% 15g TC(L-M-X 4),800069990,CDM,637,RC,00496088215,NDC,,,facility,outpatient,1,EA,207.20000,60.09000,Aetna,Local,,105.20,,,,,,,74.70,169.49,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,00496080004,NDC,,,facility,outpatient,1,EA,603.60000,175.04000,Aetna,Local,,306.45,,,,,,,217.60,493.74,percent of total billed charges,
Hydrocortisone 2.5%-Pramox1% RC 30G,800017410,CDM,637,RC,00496079904,NDC,,,facility,outpatient,1,EA,1421.30000,412.18000,Aetna,Local,,721.59,,,,,,,512.38,1162.62,percent of total billed charges,
Hydrocortisone 2.5%-Pramox 1% Top Oint,800025581,CDM,637,RC,00496077704,NDC,,,facility,outpatient,1,EA,1115.90000,323.61000,Aetna,Local,,566.54,,,,,,,402.28,912.81,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,800046518,CDM,250,RC,00487900760,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
K-Phos-Na Phos Neutral 250mg T,800081073,CDM,637,RC,00486112501,NDC,,,facility,outpatient,1,EA,6.30000,1.83000,Aetna,Local,,3.20,,,,,,,2.27,5.15,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,00480924201,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Mesalamine 800mg EC Tab,800040870,CDM,637,RC,00480775080,NDC,,,facility,outpatient,1,EA,75.90000,22.01000,Aetna,Local,,38.53,,,,,,,27.36,62.09,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,00480413806,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,Local,,25.33,,,,,,,17.99,40.82,percent of total billed charges,
PACLItaxel PROT-bnd 100mg,800012514,CDM,636,RC,J9264,HCPCS,00480329001,NDC,facility,inpatient,100,ME,8827.00000,2559.83000,Aetna,Local,,3530.80,,,,,,,3182.13,7220.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,00472500260,NDC,,,facility,outpatient,1,EA,13.65000,3.96000,Aetna,Local,,6.93,,,,,,,4.92,11.17,percent of total billed charges,
Codeine-Promethazine 5mL Liq UD,800015347,CDM,637,RC,00472162716,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00472136016,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00472132016,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,4.42,,,,,,,3.14,7.12,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00472127094,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,Local,,1.70,,,,,,,1.21,2.74,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,00472077116,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,Local,,0.20308,,,,,,,0.14420,0.32720,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00472073556,NDC,,,facility,outpatient,1,EA,24.70000,7.16000,Aetna,Local,,12.54,,,,,,,8.90,20.20,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00472073542,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,Local,,12.16,,,,,,,8.63,19.59,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00472073063,NDC,,,facility,outpatient,1,EA,77.75000,22.55000,Aetna,Local,,39.47,,,,,,,28.03,63.60,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00472073041,NDC,,,facility,outpatient,1,EA,81.30000,23.58000,Aetna,Local,,41.28,,,,,,,29.31,66.50,percent of total billed charges,
Hydrocortisone 25mg S(Anusol-HC),800017012,CDM,637,RC,00472051124,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,00472046730,NDC,,,facility,outpatient,1,EA,574.30000,166.55000,Aetna,Local,,291.57,,,,,,,207.04,469.78,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,00472040130,NDC,,,facility,outpatient,1,EA,4299.20000,1246.77000,Aetna,Local,,2182.70,,,,,,,1549.86,3516.75,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,00472038115,NDC,,,facility,outpatient,1,EA,346.75000,100.56000,Aetna,Local,,176.04,,,,,,,125.00,283.64,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,00472038015,NDC,,,facility,outpatient,1,EA,288.75000,83.74000,Aetna,Local,,146.60,,,,,,,104.09,236.20,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,00472037915,NDC,,,facility,outpatient,1,EA,269.95000,78.29000,Aetna,Local,,137.05,,,,,,,97.32,220.82,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00472033956,NDC,,,facility,outpatient,1,EA,26.40000,7.66000,Aetna,Local,,13.40,,,,,,,9.52,21.60,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,00472033730,NDC,,,facility,outpatient,1,EA,77.90000,22.59000,Aetna,Local,,39.55,,,,,,,28.08,63.72,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,00472030115,NDC,,,facility,outpatient,1,EA,30.10000,8.73000,Aetna,Local,,15.28,,,,,,,10.85,24.62,percent of total billed charges,
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,00472024260,NDC,,,facility,outpatient,1,EA,780.50000,226.34000,Aetna,Local,,396.26,,,,,,,281.37,638.45,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,00472022063,NDC,,,facility,outpatient,1,EA,84.95000,24.64000,Aetna,Local,,43.13,,,,,,,30.62,69.49,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,00472022041,NDC,,,facility,outpatient,1,EA,84.95000,24.64000,Aetna,Local,,43.13,,,,,,,30.62,69.49,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00472016315,NDC,,,facility,outpatient,1,EA,123.90000,35.93000,Aetna,Local,,62.90,,,,,,,44.67,101.35,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,00472008216,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,Local,,16.91,,,,,,,12.00,27.24,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00472003616,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
Adenosine 6mg/2mL I(Adenocard),800019964,CDM,636,RC,J0153,HCPCS,00469823412,NDC,facility,inpatient,6,ME,222.40000,64.50000,Aetna,Local,,88.96,,,,,,,80.18,181.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Regadenoson 0.4mg/5mL I (LexiScan),800012439,CDM,636,RC,J2785,HCPCS,00469650189,NDC,facility,inpatient,0.4,ME,1216.90000,352.90000,Aetna,Local,,486.76,,,,,,,438.69,995.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
micafungin 100mg Inj,800046515,CDM,636,RC,J2248,HCPCS,00469321110,NDC,facility,inpatient,100,ME,1533.40000,444.69000,Aetna,Local,,613.36,,,,,,,552.79,1254.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00469314061,NDC,facility,inpatient,1,GM,362.50000,105.12000,Aetna,Local,,145.00,,,,,,,130.68,296.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amphotericin B LIPO 50mg I,800010922,CDM,636,RC,J0289,HCPCS,00469305130,NDC,facility,inpatient,50,ME,2478.80000,718.85000,Aetna,Local,,991.52,,,,,,,893.61,2027.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tacrolimus 5mg/mL Inj,800017829,CDM,636,RC,J7525,HCPCS,00469301601,NDC,facility,inpatient,5,ME,2179.20000,631.97000,Aetna,Local,,871.68,,,,,,,785.60,1782.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mirabegron 25mg ER T,800025525,CDM,637,RC,00469260130,NDC,,,facility,outpatient,1,EA,130.35000,37.80000,Aetna,Local,,66.18,,,,,,,46.99,106.63,percent of total billed charges,
Mineral Oil Light 10mL(Muri-Lube),800035815,CDM,250,RC,00469225425,NDC,,,facility,outpatient,1,EA,14.85000,4.31000,Aetna,Local,,7.54,,,,,,,5.35,12.15,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,00469221030,NDC,facility,inpatient,500,ME,70.00000,20.30000,Aetna,Local,,28.00,,,,,,,25.23,57.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thiamine 200mg/2mL I(Vit B1),800012470,CDM,636,RC,J3411,HCPCS,00469101325,NDC,facility,inpatient,200,ME,5.65000,1.64000,Aetna,Local,,2.26,,,,,,,2.04,4.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxytocin 10unit/mL 1mL Inj,800012757,CDM,636,RC,J2590,HCPCS,00469101215,NDC,facility,inpatient,10,UN,6.10000,1.77000,Aetna,Local,,2.44,,,,,,,2.20,4.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pyridoxine HCl 100mg/mL 1mL I(Vit B6),800056795,CDM,636,RC,J3415,HCPCS,00469001825,NDC,facility,inpatient,100,ME,240.55000,69.76000,Aetna,Local,,96.22,,,,,,,86.72,196.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosfomycin 3g Packet,800021964,CDM,637,RC,00456430008,NDC,,,facility,outpatient,1,EA,481.45000,139.62000,Aetna,Local,,244.43,,,,,,,173.56,393.83,percent of total billed charges,
Fosfomycin 3g Packet,800021964,CDM,637,RC,00456430001,NDC,,,facility,outpatient,1,EA,701.15000,203.33000,Aetna,Local,,355.97,,,,,,,252.76,573.54,percent of total billed charges,
Dinoprostone 10mg VS(Cervidil),800073303,CDM,252,RC,00456412363,NDC,,,facility,inpatient,1,EA,2152.00000,624.08000,Aetna,Local,,860.80,,,,,,,796.24,1760.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dinoprostone 10mg VS(Cervidil),800073303,CDM,252,RC,00456412363,NDC,,,facility,outpatient,1,EA,2152.00000,624.08000,Aetna,Local,,1092.57,,,,,,,775.80,1760.34,percent of total billed charges,
Memantine HCl 10mg T(Namenda),800082346,CDM,637,RC,00456321060,NDC,,,facility,outpatient,1,EA,63.00000,18.27000,Aetna,Local,,31.99,,,,,,,22.71,51.53,percent of total billed charges,
Memantine HCl 5mg T(Namenda),800082338,CDM,637,RC,00456320560,NDC,,,facility,outpatient,1,EA,63.00000,18.27000,Aetna,Local,,31.99,,,,,,,22.71,51.53,percent of total billed charges,
Ceftazidime-Avibactam2-0.5g Inj,800040874,CDM,636,RC,J0714,HCPCS,00456270010,NDC,facility,inpatient,2.5,GM,3177.65000,921.52000,Aetna,Local,,1271.06,,,,,,,1145.54,2599.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00456202001,NDC,,,facility,outpatient,1,EA,136.30000,39.53000,Aetna,Local,,69.20,,,,,,,49.14,111.49,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00456201001,NDC,,,facility,outpatient,1,EA,130.65000,37.89000,Aetna,Local,,66.33,,,,,,,47.10,106.87,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,00456200501,NDC,,,facility,outpatient,1,EA,124.95000,36.24000,Aetna,Local,,63.44,,,,,,,45.04,102.21,percent of total billed charges,
Milnacipran 50mg T(Savella),800025654,CDM,637,RC,00456155060,NDC,,,facility,outpatient,1,EA,72.45000,21.01000,Aetna,Local,,36.78,,,,,,,26.12,59.26,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140590,NDC,,,facility,outpatient,1,EA,54.35000,15.76000,Aetna,Local,,27.59,,,,,,,19.59,44.46,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140563,NDC,,,facility,outpatient,1,EA,50.25000,14.57000,Aetna,Local,,25.51,,,,,,,18.12,41.10,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140530,NDC,,,facility,outpatient,1,EA,51.75000,15.01000,Aetna,Local,,26.27,,,,,,,18.66,42.33,percent of total billed charges,
Nebivolol 5mg T (Bystolic),800081174,CDM,637,RC,00456140501,NDC,,,facility,outpatient,1,EA,24.05000,6.97000,Aetna,Local,,12.21,,,,,,,8.67,19.67,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00456133001,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00456132901,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00456132601,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,Local,,1.35,,,,,,,0.95532,2.17,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00456132401,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00456132301,NDC,,,facility,outpatient,1,EA,1.95000,0.57000,Aetna,Local,,0.99001,,,,,,,0.70298,1.60,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00456132201,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,Local,,0.96463,,,,,,,0.68495,1.55,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00456132101,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00456132001,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
LinaCLOtide 72mcg C (Linzess),800040869,CDM,637,RC,00456120330,NDC,,,facility,outpatient,1,EA,160.85000,46.65000,Aetna,Local,,81.66,,,,,,,57.99,131.58,percent of total billed charges,
Linaclotide 145mcg C(Linzess),800025526,CDM,637,RC,00456120130,NDC,,,facility,outpatient,1,EA,160.85000,46.65000,Aetna,Local,,81.66,,,,,,,57.99,131.58,percent of total billed charges,
Vilazodone 20mg T(Viibryd),800025690,CDM,637,RC,00456112030,NDC,,,facility,outpatient,1,EA,103.30000,29.96000,Aetna,Local,,52.45,,,,,,,37.24,84.50,percent of total billed charges,
Thyroid 120mg T,800019983,CDM,637,RC,00456046101,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,Local,,8.88,,,,,,,6.31,14.31,percent of total billed charges,
Thyroid 30mg T,800019967,CDM,637,RC,00456045801,NDC,,,facility,outpatient,1,EA,8.60000,2.49000,Aetna,Local,,4.37,,,,,,,3.10,7.03,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00456033001,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,Local,,0.63462,,,,,,,0.45062,1.02,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00456032901,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00456032601,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00456032401,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00456032301,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00456032201,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00456032101,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,Local,,1.12,,,,,,,0.79310,1.80,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00456032001,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,Local,,0.48231,,,,,,,0.34247,0.77710,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),800015427,CDM,637,RC,00456009530,NDC,,,facility,outpatient,1,EA,73.05000,21.18000,Aetna,Local,,37.09,,,,,,,26.33,59.75,percent of total billed charges,
Sodium Hypochlor 0.125% TS 473mL,800022086,CDM,637,RC,00436067216,NDC,,,facility,outpatient,1,EA,121.05000,35.10000,Aetna,Local,,61.46,,,,,,,43.64,99.02,percent of total billed charges,
Estradiol 42g Vaginal Cr(Estrace),800058056,CDM,637,RC,00430375414,NDC,,,facility,outpatient,1,EA,2386.80000,692.17000,Aetna,Local,,1211.78,,,,,,,860.44,1952.40,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,00430075327,NDC,,,facility,outpatient,1,EA,22.95000,6.66000,Aetna,Local,,11.65,,,,,,,8.27,18.77,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00430072124,NDC,,,facility,outpatient,1,EA,46.30000,13.43000,Aetna,Local,,23.51,,,,,,,16.69,37.87,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,00409973510,NDC,facility,inpatient,2,GM,96.50000,27.98000,Aetna,Local,,38.60,,,,,,,34.79,78.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00409963104,NDC,facility,inpatient,40,ME,85.90000,24.91000,Aetna,Local,,34.36,,,,,,,30.97,70.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00409956610,NDC,facility,inpatient,1,GM,58.45000,16.95000,Aetna,Local,,23.38,,,,,,,21.07,47.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409955849,NDC,,,facility,outpatient,1,EA,23.55000,6.83000,Aetna,Local,,11.96,,,,,,,8.49,19.26,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,800015319,CDM,250,RC,00409955849,NDC,,,facility,outpatient,1,EA,28.35000,8.22000,Aetna,Local,,14.39,,,,,,,10.22,23.19,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409955810,NDC,,,facility,outpatient,1,EA,22.85000,6.63000,Aetna,Local,,11.60,,,,,,,8.24,18.69,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409955805,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,Local,,12.06,,,,,,,8.56,19.43,percent of total billed charges,
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00409930130,NDC,facility,inpatient,150,ME,44.50000,12.90000,Aetna,Local,,17.80,,,,,,,16.04,36.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00409930020,NDC,facility,inpatient,40,ME,23.55000,6.83000,Aetna,Local,,9.42,,,,,,,8.49,19.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00409915825,NDC,facility,inpatient,10,ME,289.80000,84.04000,Aetna,Local,,115.92,,,,,,,104.47,237.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00409915801,NDC,facility,inpatient,10,ME,294.85000,85.51000,Aetna,Local,,117.94,,,,,,,106.29,241.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00409915725,NDC,facility,inpatient,1,ME,26.95000,7.82000,Aetna,Local,,10.78,,,,,,,9.72,22.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00409915701,NDC,facility,inpatient,1,ME,30.30000,8.79000,Aetna,Local,,12.12,,,,,,,10.92,24.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909422,NDC,facility,inpatient,0.1,ME,14.80000,4.29000,Aetna,Local,,5.92,,,,,,,5.34,12.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909411,NDC,facility,inpatient,0.1,ME,7.70000,2.23000,Aetna,Local,,3.08,,,,,,,2.78,6.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909332,NDC,facility,inpatient,0.1,ME,3.00000,0.87000,Aetna,Local,,1.20,,,,,,,1.08,2.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409909311,NDC,facility,inpatient,0.1,ME,6.65000,1.93000,Aetna,Local,,2.66,,,,,,,2.40,5.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409904601,NDC,,,facility,outpatient,1,EA,24.75000,7.18000,Aetna,Local,,12.57,,,,,,,8.92,20.25,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409904502,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,00409904501,NDC,,,facility,outpatient,1,EA,16.90000,4.90000,Aetna,Local,,8.58,,,,,,,6.09,13.82,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409904217,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409904210,NDC,,,facility,outpatient,1,EA,27.40000,7.95000,Aetna,Local,,13.91,,,,,,,9.88,22.41,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409904202,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,Local,,9.21,,,,,,,6.54,14.85,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409806201,NDC,,,facility,outpatient,1,EA,109.25000,31.68000,Aetna,Local,,55.47,,,,,,,39.38,89.37,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00409799009,NDC,facility,outpatient,1,EA,53.55000,15.53000,Aetna,Local,,27.19,,,,,,,3.80,43.80,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00409798509,NDC,,,facility,outpatient,1,EA,46.85000,13.59000,Aetna,Local,,23.79,,,,,,,16.89,38.32,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,00409798503,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,Local,,27.19,,,,,,,19.30,43.80,percent of total billed charges,
0.45% Sodium Cl 250mL,800081202,CDM,258,RC,00409798502,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,Local,,27.19,,,,,,,19.30,43.80,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00409798437,NDC,facility,inpatient,1,EA,18.45000,5.35000,Aetna,Local,,7.38,,,,,,,6.65,15.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00409798436,NDC,facility,inpatient,1,EA,13.90000,4.03000,Aetna,Local,,5.56,,,,,,,5.01,11.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00409798423,NDC,facility,inpatient,1,EA,22.35000,6.48000,Aetna,Local,,8.94,,,,,,,8.06,18.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00409798413,NDC,facility,inpatient,1,EA,23.60000,6.84000,Aetna,Local,,9.44,,,,,,,8.51,19.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00409798325,NDC,facility,inpatient,1,EA,46.85000,13.59000,Aetna,Local,,18.74,,,,,,,16.89,38.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00409798309,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,Local,,21.42,,,,,,,19.30,43.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00409798302,NDC,facility,inpatient,1,EA,53.55000,15.53000,Aetna,Local,,21.42,,,,,,,19.30,43.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00409796709,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,Local,,27.19,,,,,,,19.30,43.80,percent of total billed charges,
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00409793932,NDC,facility,inpatient,2,GM,77.40000,22.45000,Aetna,Local,,30.96,,,,,,,27.90,63.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D10W 1000mL,800012362,CDM,258,RC,00409793009,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,Local,,27.19,,,,,,,19.30,43.80,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00409793002,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,Local,,27.19,,,,,,,19.30,43.80,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00409790209,NDC,,,facility,outpatient,1,EA,66.30000,19.23000,Aetna,Local,,33.66,,,,,,,23.90,54.23,percent of total billed charges,
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409781137,NDC,facility,inpatient,500,ME,15.80000,4.58000,Aetna,Local,,6.32,,,,,,,5.70,12.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409781124,NDC,facility,inpatient,500,ME,19.60000,5.68000,Aetna,Local,,7.84,,,,,,,7.07,16.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409781110,NDC,facility,inpatient,500,ME,18.55000,5.38000,Aetna,Local,,7.42,,,,,,,6.69,15.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOPamine 400mg/D5W 250mL,800012469,CDM,636,RC,J1265,HCPCS,00409780922,NDC,facility,inpatient,400,ME,161.90000,46.95000,Aetna,Local,,64.76,,,,,,,58.36,132.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00409779362,NDC,facility,inpatient,25000,UN,98.15000,28.46000,Aetna,Local,,39.26,,,,,,,35.38,80.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mannitol 20% 500mL,800022060,CDM,250,RC,00409771503,NDC,,,facility,outpatient,1,EA,194.30000,56.35000,Aetna,Local,,98.65,,,,,,,70.05,158.94,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00409767009,NDC,,,facility,outpatient,1,EA,53.55000,15.53000,Aetna,Local,,27.19,,,,,,,19.30,43.80,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00409762003,NDC,facility,inpatient,1000,UN,56.05000,16.25000,Aetna,Local,,22.42,,,,,,,20.21,45.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D50W 50mL Inj Syr,800011221,CDM,258,RC,00409751716,NDC,,,facility,outpatient,1,EA,125.90000,36.51000,Aetna,Local,,63.92,,,,,,,45.39,102.99,percent of total billed charges,
Sodium Phosphate Inj,800053081,CDM,250,RC,00409739172,NDC,,,facility,outpatient,1,EA,401.00000,116.29000,Aetna,Local,,203.59,,,,,,,144.56,328.02,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00409733820,NDC,facility,inpatient,500,ME,6.15000,1.78000,Aetna,Local,,2.46,,,,,,,2.22,5.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00409733801,NDC,facility,inpatient,500,ME,6.15000,1.78000,Aetna,Local,,2.46,,,,,,,2.22,5.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00409733604,NDC,facility,inpatient,2,GM,50.90000,14.76000,Aetna,Local,,20.36,,,,,,,18.35,41.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00409733520,NDC,facility,inpatient,2,GM,18.45000,5.35000,Aetna,Local,,7.38,,,,,,,6.65,15.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00409733503,NDC,facility,inpatient,2,GM,18.45000,5.35000,Aetna,Local,,7.38,,,,,,,6.65,15.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00409733220,NDC,facility,inpatient,1,GM,14.60000,4.23000,Aetna,Local,,5.84,,,,,,,5.26,11.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00409733201,NDC,facility,inpatient,1,GM,14.60000,4.23000,Aetna,Local,,5.84,,,,,,,5.26,11.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Sodium Acetate 2mEq/mL Inj,800072480,CDM,250,RC,00409729973,NDC,,,facility,outpatient,1,EA,6.30000,1.83000,Aetna,Local,,3.20,,,,,,,2.27,5.15,percent of total billed charges,
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00409729501,NDC,,,facility,outpatient,1,EA,150.85000,43.75000,Aetna,Local,,76.59,,,,,,,54.38,123.40,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,00409724803,NDC,,,facility,outpatient,1,EA,420.60000,121.97000,Aetna,Local,,213.54,,,,,,,151.63,344.05,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00409724125,NDC,facility,inpatient,1,ME,13.30000,3.86000,Aetna,Local,,5.32,,,,,,,4.79,10.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00409724101,NDC,facility,inpatient,1,ME,13.40000,3.89000,Aetna,Local,,5.36,,,,,,,4.83,10.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00409711509,NDC,,,facility,outpatient,1,EA,69.95000,20.29000,Aetna,Local,,35.51,,,,,,,25.22,57.22,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00409710709,NDC,,,facility,outpatient,1,EA,66.65000,19.33000,Aetna,Local,,33.84,,,,,,,24.03,54.52,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00409707526,NDC,facility,inpatient,1,EA,51.40000,14.91000,Aetna,Local,,20.56,,,,,,,18.53,42.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00409707426,NDC,facility,inpatient,1,EA,50.00000,14.50000,Aetna,Local,,20.00,,,,,,,18.02,40.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00409677802,NDC,facility,inpatient,2,ME,16.35000,4.74000,Aetna,Local,,6.54,,,,,,,5.89,13.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,00409672924,NDC,facility,inpatient,2,GM,165.20000,47.91000,Aetna,Local,,66.08,,,,,,,59.55,135.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00409672923,NDC,facility,inpatient,4,GM,81.90000,23.75000,Aetna,Local,,32.76,,,,,,,29.52,66.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 40g/Water 1000mL,800040853,CDM,636,RC,J3475,HCPCS,00409672909,NDC,facility,inpatient,40,GM,85.95000,24.93000,Aetna,Local,,34.38,,,,,,,30.98,70.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409669510,NDC,,,facility,outpatient,1,EA,34.90000,10.12000,Aetna,Local,,17.72,,,,,,,12.58,28.55,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409669502,NDC,,,facility,outpatient,1,EA,33.10000,9.60000,Aetna,Local,,16.80,,,,,,,11.93,27.08,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00409669501,NDC,,,facility,outpatient,1,EA,36.05000,10.45000,Aetna,Local,,18.30,,,,,,,13.00,29.49,percent of total billed charges,
Potassium Cl 2mEq/mL I,800013427,CDM,636,RC,J3480,HCPCS,00409665305,NDC,facility,inpatient,1,EA,51.55000,14.95000,Aetna,Local,,20.62,,,,,,,18.58,42.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D50W 50mL,800067479,CDM,258,RC,00409664802,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,Local,,12.08,,,,,,,8.58,19.47,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409663734,NDC,,,facility,outpatient,1,EA,52.20000,15.14000,Aetna,Local,,26.50,,,,,,,18.82,42.70,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,800018007,CDM,250,RC,00409663734,NDC,,,facility,outpatient,1,EA,69.15000,20.05000,Aetna,Local,,35.11,,,,,,,24.93,56.56,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,800018007,CDM,250,RC,00409663714,NDC,,,facility,outpatient,1,EA,136.05000,39.45000,Aetna,Local,,69.07,,,,,,,49.05,111.29,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00409662902,NDC,facility,inpatient,200,ME,123.65000,35.86000,Aetna,Local,,49.46,,,,,,,44.58,101.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662535,NDC,,,facility,outpatient,1,EA,93.40000,27.09000,Aetna,Local,,47.42,,,,,,,33.67,76.40,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662525,NDC,,,facility,outpatient,1,EA,92.45000,26.81000,Aetna,Local,,46.94,,,,,,,33.33,75.62,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662514,NDC,,,facility,outpatient,1,EA,100.35000,29.10000,Aetna,Local,,50.95,,,,,,,36.18,82.09,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00409662502,NDC,,,facility,outpatient,1,EA,99.35000,28.81000,Aetna,Local,,50.44,,,,,,,35.82,81.27,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00409660902,NDC,,,facility,outpatient,1,EA,73.25000,21.24000,Aetna,Local,,37.19,,,,,,,26.41,59.92,percent of total billed charges,
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,00409653401,NDC,facility,inpatient,500,ME,52.10000,15.11000,Aetna,Local,,20.84,,,,,,,18.78,42.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653349,NDC,facility,inpatient,1,GM,154.00000,44.66000,Aetna,Local,,61.60,,,,,,,55.52,125.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653331,NDC,facility,inpatient,1,GM,35.85000,10.40000,Aetna,Local,,14.34,,,,,,,12.92,29.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653321,NDC,facility,inpatient,1,GM,156.30000,45.33000,Aetna,Local,,62.52,,,,,,,56.35,127.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00409653301,NDC,facility,inpatient,1,GM,154.75000,44.88000,Aetna,Local,,61.90,,,,,,,55.79,126.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 750mg Inj,800019998,CDM,636,RC,J3373,HCPCS,00409653102,NDC,facility,inpatient,750,ME,94.40000,27.38000,Aetna,Local,,37.76,,,,,,,34.03,77.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00409651001,NDC,facility,inpatient,1,GM,208.50000,60.46000,Aetna,Local,,83.40,,,,,,,75.16,170.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Erythromycin Lact.500mg I,800081135,CDM,636,RC,J1364,HCPCS,00409648201,NDC,facility,inpatient,500,ME,943.00000,273.47000,Aetna,Local,,377.20,,,,,,,339.95,771.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Erythromycin Lact.500mg I,800081135,CDM,636,RC,J1364,HCPCS,00409647644,NDC,facility,inpatient,500,ME,746.35000,216.44000,Aetna,Local,,298.54,,,,,,,269.06,610.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,00409610227,NDC,facility,inpatient,100,ME,31.95000,9.27000,Aetna,Local,,12.78,,,,,,,11.52,26.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00409610226,NDC,facility,inpatient,40,ME,18.75000,5.44000,Aetna,Local,,7.50,,,,,,,6.76,15.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,00409610225,NDC,facility,inpatient,20,ME,21.85000,6.34000,Aetna,Local,,8.74,,,,,,,7.88,17.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 100mg I,800013344,CDM,636,RC,J1938,HCPCS,00409610210,NDC,facility,inpatient,100,ME,56.05000,16.25000,Aetna,Local,,22.42,,,,,,,20.21,45.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 10mL I(Lasix),800015141,CDM,636,RC,J1940,HCPCS,00409610210,NDC,facility,inpatient,100,ME,37.25000,10.80000,Aetna,Local,,14.90,,,,,,,13.43,30.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00409610204,NDC,facility,inpatient,40,ME,18.75000,5.44000,Aetna,Local,,7.50,,,,,,,6.76,15.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Furosemide 10mg/mL 2mL I(Lasix),800061860,CDM,636,RC,J1938,HCPCS,00409610202,NDC,facility,inpatient,20,ME,26.70000,7.74000,Aetna,Local,,10.68,,,,,,,9.63,21.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00409601025,NDC,facility,inpatient,200,ME,27.60000,8.00000,Aetna,Local,,11.04,,,,,,,9.95,22.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aminophylline 500mg/20mL I,800013441,CDM,636,RC,J0280,HCPCS,00409592201,NDC,facility,inpatient,500,ME,123.55000,35.83000,Aetna,Local,,49.42,,,,,,,44.54,101.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00409568523,NDC,facility,inpatient,125,ME,21.60000,6.26000,Aetna,Local,,8.64,,,,,,,7.79,17.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00409555502,NDC,,,facility,outpatient,1,EA,74.35000,21.56000,Aetna,Local,,37.75,,,,,,,26.80,60.82,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00409555501,NDC,,,facility,outpatient,1,EA,74.35000,21.56000,Aetna,Local,,37.75,,,,,,,26.80,60.82,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00409508216,NDC,facility,inpatient,1,GM,40.95000,11.88000,Aetna,Local,,16.38,,,,,,,14.76,33.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00409501701,NDC,facility,inpatient,1,GM,208.50000,60.46000,Aetna,Local,,83.40,,,,,,,75.16,170.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00409493301,NDC,facility,inpatient,1,ME,65.15000,18.89000,Aetna,Local,,26.06,,,,,,,23.49,53.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00409492834,NDC,,,facility,outpatient,1,EA,109.15000,31.65000,Aetna,Local,,55.42,,,,,,,39.35,89.28,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00409492134,NDC,facility,inpatient,1,ME,34.05000,9.87000,Aetna,Local,,13.62,,,,,,,12.28,27.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00409491134,NDC,facility,inpatient,1,ME,117.85000,34.18000,Aetna,Local,,47.14,,,,,,,42.48,96.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00409490434,NDC,,,facility,inpatient,1,EA,139.90000,40.57000,Aetna,Local,,55.96,,,,,,,50.43,114.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00409490434,NDC,,,facility,outpatient,1,EA,139.90000,40.57000,Aetna,Local,,55.96,,,,,,,50.43,114.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00409490334,NDC,,,facility,inpatient,1,EA,48.45000,14.05000,Aetna,Local,,19.38,,,,,,,17.47,39.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00409490334,NDC,,,facility,outpatient,1,EA,48.45000,14.05000,Aetna,Local,,19.38,,,,,,,17.47,39.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D50W 50mL Inj Syr,800011221,CDM,258,RC,00409490234,NDC,,,facility,outpatient,1,EA,117.05000,33.94000,Aetna,Local,,59.43,,,,,,,42.20,95.75,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,800049618,CDM,250,RC,00409490034,NDC,,,facility,outpatient,1,EA,89.70000,26.01000,Aetna,Local,,45.54,,,,,,,32.34,73.37,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,800049618,CDM,250,RC,00409490014,NDC,,,facility,outpatient,1,EA,195.75000,56.77000,Aetna,Local,,99.38,,,,,,,70.57,160.12,percent of total billed charges,
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00409488850,NDC,facility,inpatient,1,EA,34.00000,9.86000,Aetna,Local,,13.60,,,,,,,12.26,27.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 10mL PF Inj,800050731,CDM,258,RC,00409488812,NDC,,,facility,outpatient,1,EA,13.45000,3.90000,Aetna,Local,,6.83,,,,,,,4.85,11.00,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,00409488810,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,00409488750,NDC,facility,outpatient,1,EA,45.05000,13.06000,Aetna,Local,,22.87,,,,,,,0.63000,36.85,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,00409488710,NDC,facility,outpatient,1,EA,21.85000,6.34000,Aetna,Local,,11.09,,,,,,,0.63000,17.87,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00409485710,NDC,facility,inpatient,500,ME,39.95000,11.59000,Aetna,Local,,15.98,,,,,,,14.40,32.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00409485702,NDC,facility,inpatient,100,ME,8.50000,2.46000,Aetna,Local,,3.40,,,,,,,3.06,6.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00409485605,NDC,facility,inpatient,100,ME,15.35000,4.45000,Aetna,Local,,6.14,,,,,,,5.53,12.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00409475901,NDC,facility,inpatient,4,ME,6.90000,2.00000,Aetna,Local,,2.76,,,,,,,2.49,5.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409475503,NDC,facility,inpatient,4,ME,8.20000,2.38000,Aetna,Local,,3.28,,,,,,,2.96,6.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409475502,NDC,facility,inpatient,4,ME,6.15000,1.78000,Aetna,Local,,2.46,,,,,,,2.22,5.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409475501,NDC,facility,inpatient,4,ME,2.95000,0.86000,Aetna,Local,,1.18,,,,,,,1.06,2.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,00409471332,NDC,,,facility,inpatient,1,EA,8.20000,2.38000,Aetna,Local,,3.28,,,,,,,2.96,6.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,00409471332,NDC,,,facility,outpatient,1,EA,8.20000,2.38000,Aetna,Local,,3.28,,,,,,,2.96,6.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00409471302,NDC,,,facility,inpatient,1,EA,10.90000,3.16000,Aetna,Local,,4.36,,,,,,,3.93,8.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00409471302,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,Local,,4.36,,,,,,,3.93,8.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00409469933,NDC,facility,inpatient,0.5,GM,110.15000,31.94000,Aetna,Local,,44.06,,,,,,,39.71,90.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00409469930,NDC,facility,inpatient,200,ME,27.60000,8.00000,Aetna,Local,,11.04,,,,,,,9.95,22.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00409469924,NDC,facility,inpatient,1,GM,222.30000,64.47000,Aetna,Local,,88.92,,,,,,,80.14,181.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00409468823,NDC,facility,inpatient,200,ME,119.90000,34.77000,Aetna,Local,,47.96,,,,,,,43.22,98.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00409468818,NDC,facility,inpatient,200,ME,76.10000,22.07000,Aetna,Local,,30.44,,,,,,,27.43,62.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00409468802,NDC,facility,inpatient,400,ME,91.85000,26.64000,Aetna,Local,,36.74,,,,,,,33.11,75.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00409452030,NDC,facility,inpatient,25000,UN,113.40000,32.89000,Aetna,Local,,45.36,,,,,,,40.88,92.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00409434835,NDC,facility,inpatient,150,ME,16.45000,4.77000,Aetna,Local,,6.58,,,,,,,5.93,13.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 500mg I,800075415,CDM,636,RC,J3373,HCPCS,00409433201,NDC,facility,inpatient,500,ME,78.35000,22.72000,Aetna,Local,,31.34,,,,,,,28.25,64.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,00409428301,NDC,,,facility,inpatient,1,EA,30.85000,8.95000,Aetna,Local,,12.34,,,,,,,11.12,25.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,00409428301,NDC,,,facility,outpatient,1,EA,30.85000,8.95000,Aetna,Local,,12.34,,,,,,,11.12,25.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00409428202,NDC,,,facility,inpatient,1,EA,46.15000,13.38000,Aetna,Local,,18.46,,,,,,,16.64,37.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00409428202,NDC,,,facility,outpatient,1,EA,46.15000,13.38000,Aetna,Local,,18.46,,,,,,,16.64,37.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,00409427902,NDC,,,facility,inpatient,1,EA,20.90000,6.06000,Aetna,Local,,8.36,,,,,,,7.53,17.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,00409427902,NDC,,,facility,outpatient,1,EA,20.90000,6.06000,Aetna,Local,,8.36,,,,,,,7.53,17.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine 0.5% 50mL PF I,800044361,CDM,636,RC,00409427801,NDC,,,facility,inpatient,1,EA,27.60000,8.00000,Aetna,Local,,11.04,,,,,,,9.95,22.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine 0.5% 50mL PF I,800044361,CDM,636,RC,00409427801,NDC,,,facility,outpatient,1,EA,27.60000,8.00000,Aetna,Local,,11.04,,,,,,,9.95,22.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00409427702,NDC,,,facility,inpatient,1,EA,26.75000,7.76000,Aetna,Local,,10.70,,,,,,,9.64,21.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00409427702,NDC,,,facility,outpatient,1,EA,26.75000,7.76000,Aetna,Local,,10.70,,,,,,,9.64,21.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00409427701,NDC,,,facility,inpatient,1,EA,25.35000,7.35000,Aetna,Local,,10.14,,,,,,,9.14,20.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00409427701,NDC,,,facility,outpatient,1,EA,25.35000,7.35000,Aetna,Local,,10.14,,,,,,,9.14,20.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00409427602,NDC,,,facility,inpatient,1,EA,20.30000,5.89000,Aetna,Local,,8.12,,,,,,,7.32,16.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00409427602,NDC,,,facility,outpatient,1,EA,20.30000,5.89000,Aetna,Local,,8.12,,,,,,,7.32,16.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00409427601,NDC,,,facility,inpatient,1,EA,20.25000,5.87000,Aetna,Local,,8.10,,,,,,,7.30,16.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00409427601,NDC,,,facility,outpatient,1,EA,20.25000,5.87000,Aetna,Local,,8.10,,,,,,,7.30,16.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409420810,NDC,,,facility,outpatient,1,EA,37.75000,10.95000,Aetna,Local,,19.17,,,,,,,13.61,30.88,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00409412150,NDC,facility,inpatient,4,GM,81.95000,23.77000,Aetna,Local,,32.78,,,,,,,29.54,67.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cupric Cl (Copper) I 10mL,800017803,CDM,250,RC,00409409201,NDC,,,facility,outpatient,1,EA,197.40000,57.25000,Aetna,Local,,100.22,,,,,,,71.16,161.47,percent of total billed charges,
Zinc Chloride 1mg/mL I 10mL,800081010,CDM,250,RC,00409409001,NDC,,,facility,outpatient,1,EA,151.05000,43.80000,Aetna,Local,,76.69,,,,,,,54.45,123.56,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00409405812,NDC,facility,inpatient,10,ME,23.05000,6.68000,Aetna,Local,,9.22,,,,,,,8.31,18.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,00409405101,NDC,facility,inpatient,600,ME,31.95000,9.27000,Aetna,Local,,12.78,,,,,,,11.52,26.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mannitol 25% I 50mL,800050889,CDM,636,RC,J2150,HCPCS,00409403101,NDC,facility,inpatient,12.5,GM,38.80000,11.25000,Aetna,Local,,15.52,,,,,,,13.99,31.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409401101,NDC,,,facility,outpatient,1,EA,58.40000,16.94000,Aetna,Local,,29.65,,,,,,,21.05,47.77,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00409381512,NDC,facility,inpatient,10,ME,201.80000,58.52000,Aetna,Local,,80.72,,,,,,,72.75,165.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 5mg/10mL PF I,800050319,CDM,636,RC,J2274,HCPCS,00409381412,NDC,facility,inpatient,5,ME,203.45000,59.00000,Aetna,Local,,81.38,,,,,,,73.34,166.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409379501,NDC,facility,inpatient,30,ME,41.70000,12.09000,Aetna,Local,,16.68,,,,,,,15.03,34.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,00409379301,NDC,facility,inpatient,15,ME,19.20000,5.57000,Aetna,Local,,7.68,,,,,,,6.92,15.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOBUTamine 1g/D5W 250mL,800013360,CDM,636,RC,J1250,HCPCS,00409372432,NDC,facility,inpatient,1,GM,293.40000,85.09000,Aetna,Local,,117.36,,,,,,,105.77,240.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00409371801,NDC,facility,inpatient,500,ME,22.40000,6.50000,Aetna,Local,,8.96,,,,,,,8.08,18.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00409361301,NDC,,,facility,outpatient,1,EA,18.20000,5.28000,Aetna,Local,,9.24,,,,,,,6.56,14.89,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00409357801,NDC,facility,inpatient,80,ME,28.65000,8.31000,Aetna,Local,,11.46,,,,,,,10.33,23.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00409350601,NDC,facility,inpatient,1,GM,111.95000,32.47000,Aetna,Local,,44.78,,,,,,,40.36,91.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00409350501,NDC,facility,inpatient,500,ME,55.70000,16.15000,Aetna,Local,,22.28,,,,,,,20.08,45.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00409341401,NDC,facility,inpatient,10,ME,7.95000,2.31000,Aetna,Local,,3.18,,,,,,,2.87,6.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00409339004,NDC,facility,inpatient,4.5,GM,133.85000,38.82000,Aetna,Local,,53.54,,,,,,,48.25,109.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00409338513,NDC,facility,inpatient,3.375,GM,100.40000,29.12000,Aetna,Local,,40.16,,,,,,,36.19,82.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00409338302,NDC,facility,inpatient,2.25,GM,66.90000,19.40000,Aetna,Local,,26.76,,,,,,,24.12,54.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUFentanil 50mcg/mL 1mL I,800049758,CDM,250,RC,00409338221,NDC,,,facility,outpatient,1,EA,125.90000,36.51000,Aetna,Local,,63.92,,,,,,,45.39,102.99,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00409337504,NDC,,,facility,outpatient,1,EA,144.00000,41.76000,Aetna,Local,,73.11,,,,,,,51.91,117.79,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409336501,NDC,facility,inpatient,2,ME,15.05000,4.36000,Aetna,Local,,6.02,,,,,,,5.43,12.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409335601,NDC,facility,inpatient,2,ME,14.40000,4.18000,Aetna,Local,,5.76,,,,,,,5.19,11.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00409333024,NDC,facility,inpatient,500,ME,56.50000,16.38000,Aetna,Local,,22.60,,,,,,,20.37,46.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00409321805,NDC,facility,inpatient,125,ME,22.15000,6.42000,Aetna,Local,,8.86,,,,,,,7.99,18.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00409318910,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,Local,,12.06,,,,,,,8.56,19.43,percent of total billed charges,
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,00409318301,NDC,,,facility,inpatient,1,EA,32.20000,9.34000,Aetna,Local,,12.88,,,,,,,11.61,26.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,00409318301,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,Local,,12.88,,,,,,,11.61,26.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00409318201,NDC,,,facility,inpatient,1,EA,21.30000,6.18000,Aetna,Local,,8.52,,,,,,,7.68,17.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00409318201,NDC,,,facility,outpatient,1,EA,21.30000,6.18000,Aetna,Local,,8.52,,,,,,,7.68,17.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,00409317803,NDC,,,facility,inpatient,1,EA,50.85000,14.75000,Aetna,Local,,20.34,,,,,,,18.33,41.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,00409317803,NDC,,,facility,outpatient,1,EA,50.85000,14.75000,Aetna,Local,,20.34,,,,,,,18.33,41.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00409317801,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,Local,,6.06,,,,,,,5.46,12.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00409317801,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,6.06,,,,,,,5.46,12.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 40g/Water 1000mL,800040853,CDM,636,RC,J3475,HCPCS,00409316412,NDC,facility,inpatient,40,GM,85.95000,24.93000,Aetna,Local,,34.38,,,,,,,30.98,70.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00409302401,NDC,,,facility,outpatient,1,EA,339.85000,98.56000,Aetna,Local,,172.54,,,,,,,122.52,278.00,percent of total billed charges,
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00409299803,NDC,facility,inpatient,3,GM,35.15000,10.19000,Aetna,Local,,14.06,,,,,,,12.67,28.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00409298801,NDC,facility,inpatient,1.5,GM,19.90000,5.77000,Aetna,Local,,7.96,,,,,,,7.17,16.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00409272003,NDC,facility,inpatient,30000,UN,79.30000,23.00000,Aetna,Local,,31.72,,,,,,,28.59,64.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,00409272002,NDC,facility,inpatient,10000,UN,21.55000,6.25000,Aetna,Local,,8.62,,,,,,,7.77,17.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00409258501,NDC,facility,inpatient,1000,ME,26.25000,7.61000,Aetna,Local,,10.50,,,,,,,9.46,21.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,00409255201,NDC,facility,inpatient,1,ME,26.00000,7.54000,Aetna,Local,,10.40,,,,,,,9.37,21.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOBUTamine 250mg/D5W 250mL,800012791,CDM,636,RC,J1250,HCPCS,00409234632,NDC,facility,inpatient,250,ME,226.15000,65.58000,Aetna,Local,,90.46,,,,,,,81.53,184.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,00409230849,NDC,facility,inpatient,5,ME,11.00000,3.19000,Aetna,Local,,4.40,,,,,,,3.97,9.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 5 mg/1mL I PF (Versed),800013385,CDM,636,RC,J2250,HCPCS,00409230801,NDC,facility,inpatient,5,ME,11.15000,3.23000,Aetna,Local,,4.46,,,,,,,4.02,9.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230662,NDC,facility,inpatient,2,ME,14.10000,4.09000,Aetna,Local,,5.64,,,,,,,5.08,11.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230612,NDC,facility,inpatient,2,ME,18.30000,5.31000,Aetna,Local,,7.32,,,,,,,6.60,14.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,00409230550,NDC,facility,inpatient,5,ME,10.35000,3.00000,Aetna,Local,,4.14,,,,,,,3.73,8.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230521,NDC,facility,inpatient,2,ME,5.25000,1.52000,Aetna,Local,,2.10,,,,,,,1.89,4.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230517,NDC,facility,inpatient,2,ME,10.30000,2.99000,Aetna,Local,,4.12,,,,,,,3.71,8.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,00409230505,NDC,facility,inpatient,5,ME,10.90000,3.16000,Aetna,Local,,4.36,,,,,,,3.93,8.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam 1mg/mL 2mL I(Versed),800014006,CDM,636,RC,J2250,HCPCS,00409230502,NDC,facility,inpatient,2,ME,4.85000,1.41000,Aetna,Local,,1.94,,,,,,,1.75,3.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00409229031,NDC,facility,inpatient,50,ME,11.10000,3.22000,Aetna,Local,,4.44,,,,,,,4.00,9.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diphenhydrAMINE 50mg/mL Inj,800055540,CDM,636,RC,J1200,HCPCS,00409229011,NDC,facility,inpatient,50,ME,6.85000,1.99000,Aetna,Local,,2.74,,,,,,,2.47,5.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228731,NDC,facility,inpatient,30,ME,23.35000,6.77000,Aetna,Local,,9.34,,,,,,,8.42,19.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228723,NDC,facility,inpatient,30,ME,26.80000,7.77000,Aetna,Local,,10.72,,,,,,,9.66,21.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228722,NDC,facility,inpatient,30,ME,10.80000,3.13000,Aetna,Local,,4.32,,,,,,,3.89,8.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00409228721,NDC,facility,inpatient,30,ME,9.35000,2.71000,Aetna,Local,,3.74,,,,,,,3.37,7.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00409228505,NDC,,,facility,outpatient,1,EA,13.85000,4.02000,Aetna,Local,,7.03,,,,,,,4.99,11.33,percent of total billed charges,
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00409226501,NDC,facility,inpatient,0.004,ME,65.65000,19.04000,Aetna,Local,,26.26,,,,,,,23.67,53.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00409222024,NDC,facility,inpatient,250,ME,40.90000,11.86000,Aetna,Local,,16.36,,,,,,,14.74,33.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00409217332,NDC,facility,inpatient,10,ME,5.00000,1.45000,Aetna,Local,,2.00,,,,,,,1.80,4.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,00409216877,NDC,facility,inpatient,10,GM,93.00000,26.97000,Aetna,Local,,37.20,,,,,,,33.53,76.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Magnesium SO4 10g/20mL I,800013433,CDM,636,RC,J3475,HCPCS,00409216802,NDC,facility,inpatient,10,GM,38.65000,11.21000,Aetna,Local,,15.46,,,,,,,13.93,31.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00409212202,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,Local,,9.82,,,,,,,6.98,15.83,percent of total billed charges,
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,00409206605,NDC,,,facility,inpatient,1,EA,17.45000,5.06000,Aetna,Local,,6.98,,,,,,,6.29,14.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,00409206605,NDC,,,facility,outpatient,1,EA,17.45000,5.06000,Aetna,Local,,6.98,,,,,,,6.29,14.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,00409205310,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,00409204510,NDC,facility,inpatient,20,ME,163.50000,47.42000,Aetna,Local,,65.40,,,,,,,58.94,133.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00409201125,NDC,facility,inpatient,500,ME,37.30000,10.82000,Aetna,Local,,14.92,,,,,,,13.45,30.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00409198530,NDC,facility,inpatient,2,ME,34.45000,9.99000,Aetna,Local,,13.78,,,,,,,12.42,28.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LORazepam 2mg/mL I(Ativan),800077585,CDM,636,RC,J2060,HCPCS,00409198505,NDC,facility,inpatient,2,ME,19.30000,5.60000,Aetna,Local,,7.72,,,,,,,6.96,15.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,00409196607,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,Local,,7.46,,,,,,,5.30,12.02,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,00409196605,NDC,,,facility,outpatient,1,EA,14.00000,4.06000,Aetna,Local,,7.11,,,,,,,5.05,11.45,percent of total billed charges,
Morphine 10mg/1mL PF Inj,800059971,CDM,636,RC,J2274,HCPCS,00409189301,NDC,facility,inpatient,10,ME,22.15000,6.42000,Aetna,Local,,8.86,,,,,,,7.99,18.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00409189101,NDC,facility,inpatient,4,ME,18.70000,5.42000,Aetna,Local,,7.48,,,,,,,6.74,15.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00409189023,NDC,facility,inpatient,2,ME,41.15000,11.93000,Aetna,Local,,16.46,,,,,,,14.83,33.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00409189001,NDC,facility,inpatient,2,ME,20.45000,5.93000,Aetna,Local,,8.18,,,,,,,7.37,16.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00409188602,NDC,facility,inpatient,500,ME,37.30000,10.82000,Aetna,Local,,14.92,,,,,,,13.45,30.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409178269,NDC,facility,inpatient,0.4,ME,98.55000,28.58000,Aetna,Local,,39.42,,,,,,,35.53,80.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00409177835,NDC,,,facility,outpatient,1,EA,33.50000,9.72000,Aetna,Local,,17.01,,,,,,,12.08,27.40,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00409177805,NDC,,,facility,outpatient,1,EA,8.25000,2.39000,Aetna,Local,,4.19,,,,,,,2.97,6.75,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00409176230,NDC,facility,inpatient,2,ME,14.40000,4.18000,Aetna,Local,,5.76,,,,,,,5.19,11.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00409176162,NDC,,,facility,outpatient,1,EA,9.30000,2.70000,Aetna,Local,,4.72,,,,,,,3.35,7.61,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00409176102,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00409174929,NDC,,,facility,outpatient,1,EA,62.65000,18.17000,Aetna,Local,,31.81,,,,,,,22.59,51.25,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,00409174910,NDC,,,facility,outpatient,1,EA,43.55000,12.63000,Aetna,Local,,22.11,,,,,,,15.70,35.62,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409174630,NDC,,,facility,outpatient,1,EA,74.05000,21.47000,Aetna,Local,,37.60,,,,,,,26.70,60.57,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,00409166010,NDC,,,facility,outpatient,1,EA,490.00000,142.10000,Aetna,Local,,248.77,,,,,,,176.65,400.82,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00409163201,NDC,,,facility,outpatient,1,EA,46.85000,13.59000,Aetna,Local,,23.79,,,,,,,16.89,38.32,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00409163110,NDC,,,facility,outpatient,1,EA,80.55000,23.36000,Aetna,Local,,40.90,,,,,,,29.04,65.89,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,800042530,CDM,250,RC,00409163110,NDC,,,facility,outpatient,1,EA,69.20000,20.07000,Aetna,Local,,35.13,,,,,,,24.95,56.61,percent of total billed charges,
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00409163010,NDC,facility,inpatient,1,ME,65.55000,19.01000,Aetna,Local,,26.22,,,,,,,23.63,53.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,00409162610,NDC,facility,inpatient,2,ME,46.25000,13.41000,Aetna,Local,,18.50,,,,,,,16.67,37.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,00409162601,NDC,facility,inpatient,2,ME,133.20000,38.63000,Aetna,Local,,53.28,,,,,,,48.02,108.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00409156029,NDC,,,facility,outpatient,1,EA,34.35000,9.96000,Aetna,Local,,17.44,,,,,,,12.38,28.10,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00409156010,NDC,,,facility,outpatient,1,EA,33.15000,9.61000,Aetna,Local,,16.83,,,,,,,11.95,27.12,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00409155930,NDC,,,facility,outpatient,1,EA,32.60000,9.45000,Aetna,Local,,16.55,,,,,,,11.75,26.67,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00409155910,NDC,,,facility,outpatient,1,EA,28.15000,8.16000,Aetna,Local,,14.29,,,,,,,10.15,23.03,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00409154110,NDC,,,facility,outpatient,1,EA,74.05000,21.47000,Aetna,Local,,37.60,,,,,,,26.70,60.57,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00409148303,NDC,facility,inpatient,25,ME,47.75000,13.85000,Aetna,Local,,19.10,,,,,,,17.21,39.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00409148302,NDC,facility,inpatient,25,ME,83.75000,24.29000,Aetna,Local,,33.50,,,,,,,30.19,68.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nalbuphine 10mg/mL I (Nubain),800046443,CDM,636,RC,J2300,HCPCS,00409146349,NDC,facility,inpatient,10,ME,28.20000,8.18000,Aetna,Local,,11.28,,,,,,,10.17,23.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nalbuphine 10mg/mL I (Nubain),800046443,CDM,636,RC,J2300,HCPCS,00409146301,NDC,facility,inpatient,10,ME,28.45000,8.25000,Aetna,Local,,11.38,,,,,,,10.26,23.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00409144304,NDC,,,facility,outpatient,1,EA,129.15000,37.45000,Aetna,Local,,65.57,,,,,,,46.56,105.64,percent of total billed charges,
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00409141249,NDC,facility,inpatient,1,ME,16.25000,4.71000,Aetna,Local,,6.50,,,,,,,5.86,13.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00409141210,NDC,facility,inpatient,0.25,ME,3.20000,0.93000,Aetna,Local,,1.28,,,,,,,1.15,2.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide 1mg/4mL I,800052604,CDM,636,RC,J1939,HCPCS,00409141204,NDC,facility,inpatient,1,ME,13.60000,3.94000,Aetna,Local,,5.44,,,,,,,4.90,11.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,00409141005,NDC,,,facility,outpatient,1,EA,567.25000,164.50000,Aetna,Local,,287.99,,,,,,,204.49,464.01,percent of total billed charges,
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00409139122,NDC,facility,inpatient,1,GM,198.75000,57.64000,Aetna,Local,,79.50,,,,,,,71.65,162.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00409136201,NDC,facility,inpatient,25,ME,93.45000,27.10000,Aetna,Local,,37.38,,,,,,,33.69,76.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Doxercalciferol 4mcg/2mL Inj,800062124,CDM,636,RC,J1270,HCPCS,00409133001,NDC,facility,inpatient,0.004,ME,25.90000,7.51000,Aetna,Local,,10.36,,,,,,,9.34,21.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00409132305,NDC,,,facility,inpatient,1,EA,46.40000,13.46000,Aetna,Local,,18.56,,,,,,,16.73,37.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00409132305,NDC,,,facility,outpatient,1,EA,46.40000,13.46000,Aetna,Local,,18.56,,,,,,,16.73,37.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00409131901,NDC,facility,inpatient,1,GM,208.50000,60.46000,Aetna,Local,,83.40,,,,,,,75.16,170.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409131230,NDC,facility,inpatient,2,ME,32.30000,9.37000,Aetna,Local,,12.92,,,,,,,11.64,26.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00409131210,NDC,facility,inpatient,2,ME,26.30000,7.63000,Aetna,Local,,10.52,,,,,,,9.48,21.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,00409128331,NDC,facility,inpatient,1,ME,24.95000,7.24000,Aetna,Local,,9.98,,,,,,,8.99,20.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HYDROmorphone 1mg/1mL  Inj,800021998,CDM,636,RC,J1171,HCPCS,00409128310,NDC,facility,inpatient,1,ME,24.60000,7.13000,Aetna,Local,,9.84,,,,,,,8.87,20.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00409127632,NDC,facility,inpatient,0.1,ME,22.20000,6.44000,Aetna,Local,,8.88,,,,,,,8.00,18.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00409127332,NDC,facility,inpatient,10,ME,315.95000,91.63000,Aetna,Local,,126.38,,,,,,,113.90,258.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00409127305,NDC,facility,inpatient,10,ME,20.40000,5.92000,Aetna,Local,,8.16,,,,,,,7.35,16.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00409125830,NDC,facility,inpatient,4,ME,18.90000,5.48000,Aetna,Local,,7.56,,,,,,,6.81,15.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409121525,NDC,facility,inpatient,0.4,ME,99.55000,28.87000,Aetna,Local,,39.82,,,,,,,35.89,81.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409121501,NDC,facility,inpatient,0.4,ME,101.05000,29.30000,Aetna,Local,,40.42,,,,,,,36.43,82.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Naloxone 0.4mg/mL 1mL I(Narcan),800061977,CDM,636,RC,J2312,HCPCS,00409121201,NDC,facility,inpatient,0.4,ME,26.45000,7.67000,Aetna,Local,,10.58,,,,,,,9.54,21.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00409120725,NDC,facility,inpatient,80,ME,8.60000,2.49000,Aetna,Local,,3.44,,,,,,,3.10,7.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00409120703,NDC,facility,inpatient,80,ME,34.70000,10.06000,Aetna,Local,,13.88,,,,,,,12.51,28.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
droPERidol 2.5mg/mL 2mL I,800011791,CDM,636,RC,J1790,HCPCS,00409118701,NDC,facility,inpatient,5,ME,15.45000,4.48000,Aetna,Local,,6.18,,,,,,,5.57,12.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00409117630,NDC,facility,inpatient,25,ME,58.00000,16.82000,Aetna,Local,,23.20,,,,,,,20.91,47.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00409116210,NDC,,,facility,outpatient,1,EA,14.25000,4.13000,Aetna,Local,,7.23,,,,,,,5.14,11.66,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00409116202,NDC,,,facility,outpatient,1,EA,17.10000,4.96000,Aetna,Local,,8.68,,,,,,,6.16,13.99,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00409116201,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,Local,,8.96,,,,,,,6.36,14.44,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00409115910,NDC,,,facility,outpatient,1,EA,11.05000,3.20000,Aetna,Local,,5.61,,,,,,,3.98,9.04,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00409115902,NDC,,,facility,outpatient,1,EA,15.50000,4.50000,Aetna,Local,,7.87,,,,,,,5.59,12.68,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00409115901,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Heparin 100 unit/mL IS(Hep-LocK),800020017,CDM,636,RC,J1642,HCPCS,00409115278,NDC,facility,inpatient,500,UN,0.80000,0.23000,Aetna,Local,,0.32000,,,,,,,0.28840,0.65440,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409114410,NDC,,,facility,outpatient,1,EA,93.75000,27.19000,Aetna,Local,,47.60,,,,,,,33.80,76.69,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409114405,NDC,,,facility,outpatient,1,EA,93.75000,27.19000,Aetna,Local,,47.60,,,,,,,33.80,76.69,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00409114401,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00409112062,NDC,facility,inpatient,4,ME,8.25000,2.39000,Aetna,Local,,3.30,,,,,,,2.97,6.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00409110301,NDC,,,facility,outpatient,1,EA,2321.00000,673.09000,Aetna,Local,,1178.37,,,,,,,836.72,1898.58,percent of total billed charges,
Mepivacaine 2% PF I 20mL,800016887,CDM,636,RC,J0670,HCPCS,00409106720,NDC,facility,inpatient,1,EA,33.30000,9.66000,Aetna,Local,,13.32,,,,,,,12.00,27.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,00409083001,NDC,facility,inpatient,2,GM,600.40000,174.12000,Aetna,Local,,240.16,,,,,,,216.44,491.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,00409082901,NDC,facility,inpatient,1,GM,318.90000,92.48000,Aetna,Local,,127.56,,,,,,,114.96,260.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00409080601,NDC,facility,inpatient,2,GM,80.85000,23.45000,Aetna,Local,,32.34,,,,,,,29.15,66.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00409080501,NDC,facility,inpatient,1000,ME,10.55000,3.06000,Aetna,Local,,4.22,,,,,,,3.80,8.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00409036701,NDC,facility,inpatient,80,ME,2196.80000,637.07000,Aetna,Local,,878.72,,,,,,,791.95,1796.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00409036601,NDC,facility,inpatient,20,ME,624.15000,181.00000,Aetna,Local,,249.66,,,,,,,225.01,510.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,00409022001,NDC,facility,inpatient,2,GM,87.65000,25.42000,Aetna,Local,,35.06,,,,,,,31.60,71.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00409021901,NDC,facility,inpatient,1,GM,49.55000,14.37000,Aetna,Local,,19.82,,,,,,,17.86,40.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 2000mg Inj,800016348,CDM,636,RC,J9201,HCPCS,00409018225,NDC,facility,inpatient,2000,ME,632.10000,183.31000,Aetna,Local,,252.84,,,,,,,227.87,517.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00409015224,NDC,facility,inpatient,500,ME,21.55000,6.25000,Aetna,Local,,8.62,,,,,,,7.77,17.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00409014710,NDC,,,facility,inpatient,1,EA,21.30000,6.18000,Aetna,Local,,8.52,,,,,,,7.68,17.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00409014710,NDC,,,facility,outpatient,1,EA,21.30000,6.18000,Aetna,Local,,8.52,,,,,,,7.68,17.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00409006410,NDC,,,facility,inpatient,1,EA,574.05000,166.47000,Aetna,Local,,229.62,,,,,,,206.95,469.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00409006410,NDC,,,facility,outpatient,1,EA,574.05000,166.47000,Aetna,Local,,229.62,,,,,,,206.95,469.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00409000710,NDC,,,facility,inpatient,1,EA,15.15000,4.39000,Aetna,Local,,6.06,,,,,,,5.46,12.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00409000710,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,6.06,,,,,,,5.46,12.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- iodixanol 320mg/mL Inj 100mL,800022113,CDM,636,RC,Q9967,HCPCS,00407222364,NDC,facility,inpatient,1,EA,615.50000,178.49000,Aetna,Local,,246.20,,,,,,,221.89,503.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- iodixanol 320mg/mL Inj 100mL,800022113,CDM,636,RC,Q9967,HCPCS,00407222317,NDC,facility,inpatient,1,EA,575.60000,166.92000,Aetna,Local,,230.24,,,,,,,207.50,470.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- iodixanol 270mg/mL I 100mL,800021696,CDM,636,RC,Q9966,HCPCS,00407222217,NDC,facility,inpatient,1,EA,526.80000,152.77000,Aetna,Local,,210.72,,,,,,,189.91,430.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- iodixanol 270mg/mL I 50mL,800015112,CDM,636,RC,Q9966,HCPCS,00407222216,NDC,facility,inpatient,1,EA,293.20000,85.03000,Aetna,Local,,117.28,,,,,,,105.70,239.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 350mg/mL Inj 500mL MDV,800014519,CDM,636,RC,Q9967,HCPCS,00407141498,NDC,facility,inpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.08,,,,,,,1.87,4.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 350mg/mL Inj 100mL,800022120,CDM,636,RC,Q9967,HCPCS,00407141491,NDC,facility,inpatient,1,EA,552.50000,160.22000,Aetna,Local,,221.00,,,,,,,199.18,451.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 350mg/mL Inj 50mL,800022121,CDM,636,RC,Q9967,HCPCS,00407141489,NDC,facility,inpatient,1,EA,408.30000,118.41000,Aetna,Local,,163.32,,,,,,,147.19,333.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 350mg/mL Inj 100mL,800022120,CDM,636,RC,Q9967,HCPCS,00407141484,NDC,facility,inpatient,1,EA,539.15000,156.35000,Aetna,Local,,215.66,,,,,,,194.36,441.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 350mg/mL Inj 50mL,800022121,CDM,636,RC,Q9967,HCPCS,00407141482,NDC,facility,inpatient,1,EA,398.65000,115.61000,Aetna,Local,,159.46,,,,,,,143.71,326.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 350mg/mL Inj 50mL,800022121,CDM,636,RC,Q9967,HCPCS,00407141450,NDC,facility,inpatient,1,EA,397.55000,115.29000,Aetna,Local,,159.02,,,,,,,143.32,325.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 300mg/mL Inj 50mL,800015111,CDM,636,RC,Q9967,HCPCS,00407141386,NDC,facility,inpatient,1,EA,274.30000,79.55000,Aetna,Local,,109.72,,,,,,,98.89,224.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 300mg/mL Inj 50mL,800015111,CDM,636,RC,Q9967,HCPCS,00407141361,NDC,facility,inpatient,1,EA,280.65000,81.39000,Aetna,Local,,112.26,,,,,,,101.17,229.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 300mg/mL Inj 50mL,800015111,CDM,636,RC,Q9967,HCPCS,00407141350,NDC,facility,inpatient,1,EA,274.30000,79.55000,Aetna,Local,,109.72,,,,,,,98.89,224.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 240mg/mL Inj 20mL,800081454,CDM,636,RC,Q9966,HCPCS,00407141220,NDC,facility,inpatient,1,EA,279.55000,81.07000,Aetna,Local,,111.82,,,,,,,100.78,228.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 240mg/mL Inj 20mL,800081454,CDM,636,RC,Q9966,HCPCS,00407141210,NDC,facility,inpatient,1,EA,505.85000,146.70000,Aetna,Local,,202.34,,,,,,,182.36,413.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 240mg/mL Inj 10mL,800014718,CDM,636,RC,Q9966,HCPCS,00407141210,NDC,facility,inpatient,1,EA,266.70000,77.34000,Aetna,Local,,106.68,,,,,,,96.15,218.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 180mg/mL Inj 20mL,800022118,CDM,636,RC,Q9965,HCPCS,00407141120,NDC,facility,inpatient,1,EA,311.35000,90.29000,Aetna,Local,,124.54,,,,,,,112.24,254.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Iohexol 180mg/mL Inj 10mL,800022115,CDM,636,RC,Q9965,HCPCS,00407141110,NDC,facility,inpatient,1,EA,245.60000,71.22000,Aetna,Local,,98.24,,,,,,,88.54,200.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00406996001,NDC,,,facility,outpatient,1,EA,79.50000,23.06000,Aetna,Local,,40.36,,,,,,,28.66,65.03,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00406991501,NDC,,,facility,outpatient,1,EA,278.55000,80.78000,Aetna,Local,,141.42,,,,,,,100.42,227.85,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00406917576,NDC,,,facility,outpatient,1,EA,314.55000,91.22000,Aetna,Local,,159.70,,,,,,,113.40,257.30,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00406915076,NDC,,,facility,outpatient,1,EA,210.70000,61.10000,Aetna,Local,,106.97,,,,,,,75.96,172.35,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00406912576,NDC,,,facility,outpatient,1,EA,115.35000,33.45000,Aetna,Local,,58.56,,,,,,,41.58,94.36,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00406911276,NDC,,,facility,outpatient,1,EA,162.40000,47.10000,Aetna,Local,,82.45,,,,,,,58.55,132.84,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00406907576,NDC,,,facility,outpatient,1,EA,314.55000,91.22000,Aetna,Local,,159.70,,,,,,,113.40,257.30,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00406905076,NDC,,,facility,outpatient,1,EA,210.70000,61.10000,Aetna,Local,,106.97,,,,,,,75.96,172.35,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00406902576,NDC,,,facility,outpatient,1,EA,115.35000,33.45000,Aetna,Local,,58.56,,,,,,,41.58,94.36,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00406901276,NDC,,,facility,outpatient,1,EA,162.40000,47.10000,Aetna,Local,,82.45,,,,,,,58.55,132.84,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00406900076,NDC,,,facility,outpatient,1,EA,411.50000,119.34000,Aetna,Local,,208.92,,,,,,,148.35,336.61,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00406839062,NDC,,,facility,outpatient,1,EA,72.70000,21.08000,Aetna,Local,,36.91,,,,,,,26.21,59.47,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00406839001,NDC,,,facility,outpatient,1,EA,73.60000,21.34000,Aetna,Local,,37.37,,,,,,,26.53,60.20,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00406833062,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,Local,,14.95,,,,,,,10.62,24.09,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00406833001,NDC,,,facility,outpatient,1,EA,25.40000,7.37000,Aetna,Local,,12.90,,,,,,,9.16,20.78,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,00406831562,NDC,,,facility,outpatient,1,EA,16.30000,4.73000,Aetna,Local,,8.28,,,,,,,5.88,13.33,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00406717162,NDC,,,facility,outpatient,1,EA,6.30000,1.83000,Aetna,Local,,3.20,,,,,,,2.27,5.15,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00406577162,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,00406575562,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00406345434,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,00406324901,NDC,,,facility,outpatient,1,EA,14.30000,4.15000,Aetna,Local,,7.26,,,,,,,5.16,11.70,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00406324401,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,00406324301,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00406202301,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00406202201,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00406114401,NDC,,,facility,outpatient,1,EA,8.35000,2.42000,Aetna,Local,,4.24,,,,,,,3.01,6.83,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00406114210,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,Local,,1.35,,,,,,,0.95532,2.17,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00406114201,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00406112201,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00406112101,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,Local,,1.35,,,,,,,0.95532,2.17,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00406066303,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,Local,,9.57,,,,,,,6.80,15.42,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00406066301,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00406066101,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,Local,,9.34,,,,,,,6.63,15.05,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00406055262,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00406055201,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00406048462,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,Local,,5.15,,,,,,,3.66,8.30,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00406048401,NDC,,,facility,outpatient,1,EA,11.40000,3.31000,Aetna,Local,,5.79,,,,,,,4.11,9.33,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00406036762,NDC,,,facility,outpatient,1,EA,8.80000,2.55000,Aetna,Local,,4.47,,,,,,,3.17,7.20,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00406036562,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Bismuth Subgallate Pwd,800068840,CDM,250,RC,00406030401,NDC,,,facility,outpatient,1,EA,62.85000,18.23000,Aetna,Local,,31.91,,,,,,,22.66,51.41,percent of total billed charges,
Hydrocodone-Acet 10/325mg T UD,800017956,CDM,637,RC,00406012562,NDC,,,facility,outpatient,1,EA,13.45000,3.90000,Aetna,Local,,6.83,,,,,,,4.85,11.00,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00406012362,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,Local,,4.49,,,,,,,3.19,7.24,percent of total billed charges,
Hydrocodone-Acet 5/325mg T UD(Norco),800072401,CDM,637,RC,00406012301,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,800066885,CDM,250,RC,00395277516,NDC,,,facility,outpatient,1,EA,17.60000,5.10000,Aetna,Local,,8.94,,,,,,,6.34,14.40,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),800081744,CDM,250,RC,00395103196,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Calamine-Zinc Oxide 8% Topical Lotion,800018168,CDM,250,RC,00395041396,NDC,,,facility,outpatient,1,EA,35.35000,10.25000,Aetna,Local,,17.95,,,,,,,12.74,28.92,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000111,NDC,,,facility,outpatient,1,EA,225.60000,65.42000,Aetna,Local,,114.54,,,,,,,81.33,184.54,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000106,NDC,,,facility,outpatient,1,EA,209.95000,60.89000,Aetna,Local,,106.59,,,,,,,75.69,171.74,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000104,NDC,,,facility,outpatient,1,EA,278.75000,80.84000,Aetna,Local,,141.52,,,,,,,100.49,228.02,percent of total billed charges,
Ethyl Chloride TS(Gebauers),800060839,CDM,637,RC,00386000102,NDC,,,facility,outpatient,1,EA,228.60000,66.29000,Aetna,Local,,116.06,,,,,,,82.41,186.99,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,00378964532,NDC,,,facility,outpatient,1,EA,576.85000,167.29000,Aetna,Local,,292.87,,,,,,,207.95,471.86,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00378932232,NDC,,,facility,outpatient,1,EA,3285.40000,952.77000,Aetna,Local,,1668.00,,,,,,,1184.39,2687.46,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00378932132,NDC,,,facility,outpatient,1,EA,2566.35000,744.24000,Aetna,Local,,1302.94,,,,,,,925.17,2099.27,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00378932032,NDC,,,facility,outpatient,1,EA,2121.10000,615.12000,Aetna,Local,,1076.88,,,,,,,764.66,1735.06,percent of total billed charges,
fentaNYL 100mcg/hr TD,800068881,CDM,637,RC,00378912498,NDC,,,facility,outpatient,1,EA,411.50000,119.34000,Aetna,Local,,208.92,,,,,,,148.35,336.61,percent of total billed charges,
fentaNYL 75mcg/hr TD,800066273,CDM,637,RC,00378912398,NDC,,,facility,outpatient,1,EA,314.55000,91.22000,Aetna,Local,,159.70,,,,,,,113.40,257.30,percent of total billed charges,
fentaNYL 50 mcg/hr TD,800066281,CDM,637,RC,00378912298,NDC,,,facility,outpatient,1,EA,210.70000,61.10000,Aetna,Local,,106.97,,,,,,,75.96,172.35,percent of total billed charges,
fentaNYL 25mcg/hr TD,800066265,CDM,637,RC,00378912198,NDC,,,facility,outpatient,1,EA,115.35000,33.45000,Aetna,Local,,58.56,,,,,,,41.58,94.36,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00378911998,NDC,,,facility,outpatient,1,EA,162.40000,47.10000,Aetna,Local,,82.45,,,,,,,58.55,132.84,percent of total billed charges,
fentaNYL 12 mcg/hr TD,800081504,CDM,637,RC,00378911916,NDC,,,facility,outpatient,1,EA,110.40000,32.02000,Aetna,Local,,56.05,,,,,,,39.80,90.31,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,00378800801,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Etodolac 200 mg C (Lodine),800080985,CDM,637,RC,00378720001,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,Local,,4.11,,,,,,,2.92,6.63,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,00378715501,NDC,,,facility,outpatient,1,EA,133.40000,38.69000,Aetna,Local,,67.73,,,,,,,48.09,109.12,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00378710177,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,Local,,8.55,,,,,,,6.07,13.78,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,00378710077,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00378700293,NDC,,,facility,outpatient,1,EA,19.35000,5.61000,Aetna,Local,,9.82,,,,,,,6.98,15.83,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00378700193,NDC,,,facility,outpatient,1,EA,18.55000,5.38000,Aetna,Local,,9.42,,,,,,,6.69,15.17,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00378700110,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,Local,,0.48231,,,,,,,0.34247,0.77710,percent of total billed charges,
Lansoprazole 30 mg ODT Tab UD,800046545,CDM,637,RC,00378698288,NDC,,,facility,outpatient,1,EA,111.70000,32.39000,Aetna,Local,,56.71,,,,,,,40.27,91.37,percent of total billed charges,
Zonisamide 100mg C,800017740,CDM,637,RC,00378672701,NDC,,,facility,outpatient,1,EA,15.50000,4.50000,Aetna,Local,,7.87,,,,,,,5.59,12.68,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00378668910,NDC,,,facility,outpatient,1,EA,37.30000,10.82000,Aetna,Local,,18.94,,,,,,,13.45,30.51,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00378660501,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,Local,,11.80,,,,,,,8.38,19.02,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,00378647099,NDC,,,facility,outpatient,1,EA,143.00000,41.47000,Aetna,Local,,72.60,,,,,,,51.55,116.97,percent of total billed charges,
Scopolamine 1mg/72hr TD(Transderm-Scop),800040963,CDM,637,RC,00378647044,NDC,,,facility,outpatient,1,EA,162.65000,47.17000,Aetna,Local,,82.58,,,,,,,58.64,133.05,percent of total billed charges,
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,00378618001,NDC,,,facility,outpatient,1,EA,10.95000,3.18000,Aetna,Local,,5.56,,,,,,,3.95,8.96,percent of total billed charges,
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00378617201,NDC,,,facility,outpatient,1,EA,18.25000,5.29000,Aetna,Local,,9.27,,,,,,,6.58,14.93,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,00378616001,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,00378612001,NDC,,,facility,outpatient,1,EA,33.45000,9.70000,Aetna,Local,,16.98,,,,,,,12.06,27.36,percent of total billed charges,
dilTIAZem 90mg SR C(CardiZEM),800057751,CDM,637,RC,00378609001,NDC,,,facility,outpatient,1,EA,25.65000,7.44000,Aetna,Local,,13.02,,,,,,,9.25,20.98,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,00378606001,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,Local,,11.40,,,,,,,8.09,18.36,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00378581477,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,Local,,18.73,,,,,,,13.30,30.18,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00378581377,NDC,,,facility,outpatient,1,EA,34.30000,9.95000,Aetna,Local,,17.41,,,,,,,12.37,28.06,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,00378571093,NDC,,,facility,outpatient,1,EA,92.45000,26.81000,Aetna,Local,,46.94,,,,,,,33.33,75.62,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00378563059,NDC,,,facility,outpatient,1,EA,193.05000,55.98000,Aetna,Local,,98.01,,,,,,,69.59,157.91,percent of total billed charges,
levETIRAcetam 500 mg T(Keppra),800081793,CDM,637,RC,00378561578,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00378561378,NDC,,,facility,outpatient,1,EA,20.35000,5.90000,Aetna,Local,,10.33,,,,,,,7.34,16.65,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,00378551093,NDC,,,facility,outpatient,1,EA,99.95000,28.99000,Aetna,Local,,50.74,,,,,,,36.03,81.76,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00378550201,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00378550101,NDC,,,facility,outpatient,1,EA,17.70000,5.13000,Aetna,Local,,8.99,,,,,,,6.38,14.48,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00378531001,NDC,,,facility,outpatient,1,EA,36.95000,10.72000,Aetna,Local,,18.76,,,,,,,13.32,30.23,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00378528001,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00378522001,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,Local,,4.09,,,,,,,2.90,6.58,percent of total billed charges,
amLODIPIine 10mg T (Norvasc),800072466,CDM,637,RC,00378521077,NDC,,,facility,outpatient,1,EA,16.80000,4.87000,Aetna,Local,,8.53,,,,,,,6.06,13.74,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00378520977,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
amLODIPine 2.5mg T (Norvasc),800072465,CDM,637,RC,00378520877,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00378501201,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00378501101,NDC,,,facility,outpatient,1,EA,10.70000,3.10000,Aetna,Local,,5.43,,,,,,,3.86,8.75,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00378488201,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,Local,,7.18,,,,,,,5.10,11.57,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00378488101,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,00378459777,NDC,,,facility,outpatient,1,EA,12.45000,3.61000,Aetna,Local,,6.32,,,,,,,4.49,10.18,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00378459677,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,Local,,4.21,,,,,,,2.99,6.79,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00378459577,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,Local,,4.21,,,,,,,2.99,6.79,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00378427593,NDC,,,facility,outpatient,1,EA,51.15000,14.83000,Aetna,Local,,25.97,,,,,,,18.44,41.84,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00378427577,NDC,,,facility,outpatient,1,EA,51.15000,14.83000,Aetna,Local,,25.97,,,,,,,18.44,41.84,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00378422001,NDC,,,facility,outpatient,1,EA,14.40000,4.18000,Aetna,Local,,7.31,,,,,,,5.19,11.78,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00378418893,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,Local,,10.23,,,,,,,7.26,16.48,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00378418801,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,Local,,10.23,,,,,,,7.26,16.48,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00378418793,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,Local,,10.23,,,,,,,7.26,16.48,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00378418701,NDC,,,facility,outpatient,1,EA,20.15000,5.84000,Aetna,Local,,10.23,,,,,,,7.26,16.48,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00378415101,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,3.40,,,,,,,2.42,5.48,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00378402201,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00378402101,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,00378401001,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00378395277,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,Local,,20.74,,,,,,,14.73,33.42,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00378395205,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,Local,,20.74,,,,,,,14.73,33.42,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00378395105,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,Local,,20.74,,,,,,,14.73,33.42,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00378395077,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,Local,,14.55,,,,,,,10.33,23.44,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00378395005,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,Local,,14.55,,,,,,,10.33,23.44,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00378385777,NDC,,,facility,outpatient,1,EA,31.95000,9.27000,Aetna,Local,,16.22,,,,,,,11.52,26.14,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00378385677,NDC,,,facility,outpatient,1,EA,30.60000,8.87000,Aetna,Local,,15.54,,,,,,,11.03,25.03,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00378385610,NDC,,,facility,outpatient,1,EA,30.60000,8.87000,Aetna,Local,,15.54,,,,,,,11.03,25.03,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,00378385577,NDC,,,facility,outpatient,1,EA,29.25000,8.48000,Aetna,Local,,14.85,,,,,,,10.54,23.93,percent of total billed charges,
Cetirizine 5 mg Tab,800015396,CDM,637,RC,00378363501,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,Local,,8.96,,,,,,,6.36,14.44,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00378363405,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00378363401,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00378363301,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00378363201,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00378363105,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00378363101,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,00378362793,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
Clopidogrel Bisulfate 75mg T(Plavix),800075217,CDM,637,RC,00378362777,NDC,,,facility,outpatient,1,EA,49.20000,14.27000,Aetna,Local,,24.98,,,,,,,17.74,40.25,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00378351593,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,Local,,9.75,,,,,,,6.92,15.71,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00378347501,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00378342201,NDC,,,facility,outpatient,1,EA,22.70000,6.58000,Aetna,Local,,11.52,,,,,,,8.18,18.57,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00378340293,NDC,,,facility,outpatient,1,EA,56.85000,16.49000,Aetna,Local,,28.86,,,,,,,20.49,46.50,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00378335801,NDC,,,facility,outpatient,1,EA,8.35000,2.42000,Aetna,Local,,4.24,,,,,,,3.01,6.83,percent of total billed charges,
Estradiol 0.1 mg/24 hr wkly TD(Climara),800072503,CDM,637,RC,00378335299,NDC,,,facility,outpatient,1,EA,164.30000,47.65000,Aetna,Local,,83.42,,,,,,,59.23,134.40,percent of total billed charges,
Estradiol 0.05 mg/24 hr wkly TD(Climara),800072495,CDM,637,RC,00378335099,NDC,,,facility,outpatient,1,EA,164.30000,47.65000,Aetna,Local,,83.42,,,,,,,59.23,134.40,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00378315193,NDC,,,facility,outpatient,1,EA,22.05000,6.39000,Aetna,Local,,11.19,,,,,,,7.95,18.04,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00378315177,NDC,,,facility,outpatient,1,EA,22.05000,6.39000,Aetna,Local,,11.19,,,,,,,7.95,18.04,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00378311001,NDC,,,facility,outpatient,1,EA,79.50000,23.06000,Aetna,Local,,40.36,,,,,,,28.66,65.03,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00378302401,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00378302005,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00378302001,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Amitriptyline HCl 100mg T(Elavil),800013465,CDM,637,RC,00378268501,NDC,,,facility,outpatient,1,EA,18.00000,5.22000,Aetna,Local,,9.14,,,,,,,6.49,14.72,percent of total billed charges,
Amitriptyline HCl 25mg T(Elavil),800013432,CDM,637,RC,00378262501,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
Amitriptyline HCl 10mg T(Elavil),800013424,CDM,637,RC,00378261001,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00378258701,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,00378226801,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00378220001,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,Local,,3.27,,,,,,,2.33,5.28,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,00378218001,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,Local,,9.72,,,,,,,6.90,15.66,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00378214605,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00378214601,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00378212177,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,Local,,20.74,,,,,,,14.73,33.42,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00378207601,NDC,,,facility,outpatient,1,EA,11.00000,3.19000,Aetna,Local,,5.58,,,,,,,3.97,9.00,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00378207510,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Lisinopril 20mg T (Zestril),800072460,CDM,637,RC,00378207501,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00378207401,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,00378207201,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00378201777,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,Local,,20.74,,,,,,,14.73,33.42,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00378201577,NDC,,,facility,outpatient,1,EA,28.65000,8.31000,Aetna,Local,,14.55,,,,,,,10.33,23.44,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00378190201,NDC,,,facility,outpatient,1,EA,17.10000,4.96000,Aetna,Local,,8.68,,,,,,,6.16,13.99,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00378182377,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00378182310,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00378182301,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00378181777,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00378181701,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00378181377,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00378181301,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00378181177,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,Local,,2.34,,,,,,,1.66,3.76,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00378181105,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00378181101,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00378180977,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00378180910,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00378180901,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00378180777,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00378180701,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00378180577,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00378180501,NDC,,,facility,outpatient,1,EA,3.90000,1.13000,Aetna,Local,,1.98,,,,,,,1.41,3.19,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00378180377,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00378180301,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00378180077,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00378180010,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00378180001,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00378165001,NDC,,,facility,outpatient,1,EA,14.10000,4.09000,Aetna,Local,,7.16,,,,,,,5.08,11.53,percent of total billed charges,
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,00378164093,NDC,,,facility,outpatient,1,EA,323.65000,93.86000,Aetna,Local,,164.32,,,,,,,116.68,264.75,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00378161005,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00378161001,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00378156001,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00378145401,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00378145001,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00378135201,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,00378130001,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,00378127093,NDC,,,facility,outpatient,1,EA,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,63.81,144.79,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00378125891,NDC,,,facility,outpatient,1,EA,55.90000,16.21000,Aetna,Local,,28.38,,,,,,,20.15,45.73,percent of total billed charges,
Acebutolol 200mg C(Sectral),800017585,CDM,637,RC,00378120001,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00378117101,NDC,,,facility,outpatient,1,EA,28.10000,8.15000,Aetna,Local,,14.27,,,,,,,10.13,22.99,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00378116001,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00378115001,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00378114001,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,00378112001,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00378110101,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00378105401,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,Local,,9.95,,,,,,,7.07,16.03,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00378105301,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00378105201,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,Local,,6.65,,,,,,,4.72,10.72,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,00378105101,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,Local,,5.23,,,,,,,3.71,8.43,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00378104501,NDC,,,facility,outpatient,1,EA,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,8.29,18.81,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00378104401,NDC,,,facility,outpatient,1,EA,12.50000,3.62000,Aetna,Local,,6.35,,,,,,,4.51,10.22,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,00378103077,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,Local,,14.98,,,,,,,10.63,24.13,percent of total billed charges,
cloNIDine 0.3mg TD(Catapres-3),800051911,CDM,637,RC,00378087399,NDC,,,facility,outpatient,1,EA,510.35000,148.00000,Aetna,Local,,259.10,,,,,,,183.98,417.47,percent of total billed charges,
cloNIDine 0.2mg TD(Catapres-2),800051903,CDM,637,RC,00378087299,NDC,,,facility,outpatient,1,EA,379.05000,109.92000,Aetna,Local,,192.44,,,,,,,136.65,310.06,percent of total billed charges,
cloNIDine 0.1mg TD(Catapres-1),800051887,CDM,637,RC,00378087199,NDC,,,facility,outpatient,1,EA,232.95000,67.56000,Aetna,Local,,118.27,,,,,,,83.98,190.55,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00378077201,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Cyclobenzaprine HCl 10mg T(Flexeril),800035401,CDM,637,RC,00378075101,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,Local,,3.93,,,,,,,2.79,6.34,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,00378072419,NDC,,,facility,outpatient,1,EA,18.05000,5.23000,Aetna,Local,,9.16,,,,,,,6.51,14.76,percent of total billed charges,
tiZANidine 2 mg T(Zanaflex),800082049,CDM,637,RC,00378072219,NDC,,,facility,outpatient,1,EA,15.05000,4.36000,Aetna,Local,,7.64,,,,,,,5.43,12.31,percent of total billed charges,
Thioridazine 25mg T(Mellaril),800017752,CDM,637,RC,00378061401,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,Local,,3.02,,,,,,,2.14,4.87,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00378052393,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,Local,,8.10,,,,,,,5.75,13.05,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00378048001,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00378047301,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,Local,,14.65,,,,,,,10.40,23.60,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00378047201,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,Local,,8.83,,,,,,,6.27,14.23,percent of total billed charges,
Triamt 37.5/Hctz 25 T(Maxzide-25),800071786,CDM,637,RC,00378046401,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00378043501,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,Local,,3.81,,,,,,,2.70,6.13,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00378043301,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00378041501,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,Local,,3.55,,,,,,,2.52,5.73,percent of total billed charges,
fluvoxaMINE 100mg T,800081134,CDM,637,RC,00378041401,NDC,,,facility,outpatient,1,EA,18.70000,5.42000,Aetna,Local,,9.49,,,,,,,6.74,15.30,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00378037301,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00378037001,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Haloperidol 0.5mg T(Haldol),800014471,CDM,637,RC,00378035101,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Haloperidol 5mg T(Haldol),800017455,CDM,637,RC,00378032701,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00378032101,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,00378031001,NDC,,,facility,outpatient,1,EA,14.10000,4.09000,Aetna,Local,,7.16,,,,,,,5.08,11.53,percent of total billed charges,
Haloperidol 1mg T(Haldol),800014489,CDM,637,RC,00378025701,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00378024501,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00378023101,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Chlorthalidone 25mg T(Hygroton),800060706,CDM,637,RC,00378022201,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00378021801,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00378021610,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,Local,,0.63462,,,,,,,0.45062,1.02,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00378021601,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,Local,,0.63462,,,,,,,0.45062,1.02,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00378020810,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00378020801,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00378018301,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00378018201,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00378018101,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00378015601,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,Local,,4.11,,,,,,,2.92,6.63,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00378015201,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00378014491,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,00378014301,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00378013701,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00378009401,NDC,,,facility,outpatient,1,EA,13.45000,3.90000,Aetna,Local,,6.83,,,,,,,4.85,11.00,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,00378008801,NDC,,,facility,outpatient,1,EA,7.00000,2.03000,Aetna,Local,,3.55,,,,,,,2.52,5.73,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,00378007801,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Indapamide 1.25 mg T(Lozol),800017619,CDM,637,RC,00378006901,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00378004701,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,00378004501,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,Local,,5.64,,,,,,,4.00,9.08,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00378003210,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00378003201,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,00378002301,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,00378001805,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Metoprolol 25mg T(Lopressor),800080670,CDM,637,RC,00378001801,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Neo-Poly-HC 10mL Otic Sus(Cortispor,800062843,CDM,637,RC,00364737454,NDC,,,facility,outpatient,1,EA,440.60000,127.77000,Aetna,Local,,223.69,,,,,,,158.84,360.41,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00364672846,NDC,facility,inpatient,40,ME,271.00000,78.59000,Aetna,Local,,108.40,,,,,,,97.70,221.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
hydrOXYzine HCl 50mg/1mL Inj,800021995,CDM,636,RC,J3410,HCPCS,00364671954,NDC,facility,inpatient,50,ME,9.20000,2.67000,Aetna,Local,,3.68,,,,,,,3.32,7.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00364283001,NDC,,,facility,outpatient,1,EA,15.40000,4.47000,Aetna,Local,,7.82,,,,,,,5.55,12.60,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00364273401,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,Local,,5.48,,,,,,,3.89,8.83,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00364250901,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00364250801,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00364238990,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00364233701,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,Local,,4.29,,,,,,,3.05,6.91,percent of total billed charges,
Minoxidil 10mg T(Loniten),800038942,CDM,637,RC,00364217301,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,Local,,4.65,,,,,,,3.30,7.48,percent of total billed charges,
Minoxidil 2.5mg T(Loniten),800038926,CDM,637,RC,00364217201,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
TraZODone 100mg T(Desyrel),800040997,CDM,637,RC,00364211001,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
traZODone 50mg T(Desyrel),800040989,CDM,637,RC,00364210901,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,00364206801,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00364076605,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Ibuprofen 400mg T(Motrin),800057272,CDM,637,RC,00364076505,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00364075701,NDC,,,facility,outpatient,1,EA,1.90000,0.55000,Aetna,Local,,0.96463,,,,,,,0.68495,1.55,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00364075601,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,Local,,0.88848,,,,,,,0.63087,1.43,percent of total billed charges,
Allopurinol 300mg T(Zyloprim),800021062,CDM,637,RC,00364063301,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Allopurinol 100mg T(Zyloprim),800021088,CDM,637,RC,00364063201,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,Local,,0.66001,,,,,,,0.46865,1.06,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00364049501,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00364047501,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,00364040801,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,Local,,0.66001,,,,,,,0.46865,1.06,percent of total billed charges,
AcetaZOLAMIDE 250mg T(Diamox),800012624,CDM,637,RC,00364040001,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,Local,,1.02,,,,,,,0.72100,1.64,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00364036601,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00364034701,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00364034601,NDC,,,facility,outpatient,1,EA,2.65000,0.77000,Aetna,Local,,1.35,,,,,,,0.95532,2.17,percent of total billed charges,
Probenecid 500mg T,800032549,CDM,637,RC,00364031401,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00364013701,NDC,,,facility,outpatient,1,EA,0.85000,0.25000,Aetna,Local,,0.43155,,,,,,,0.30643,0.69530,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00364007401,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00338979140,NDC,facility,inpatient,1,EA,43.70000,12.67000,Aetna,Local,,17.48,,,,,,,15.75,35.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00338979140,NDC,facility,inpatient,1,EA,43.70000,12.67000,Aetna,Local,,17.48,,,,,,,15.75,35.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00338955810,NDC,facility,inpatient,75,ME,846.00000,245.34000,Aetna,Local,,338.40,,,,,,,304.98,692.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,00338955712,NDC,,,facility,outpatient,1,EA,201.95000,58.57000,Aetna,Local,,102.53,,,,,,,72.80,165.20,percent of total billed charges,
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00338954305,NDC,facility,inpatient,1,EA,50.50000,14.64000,Aetna,Local,,20.20,,,,,,,18.21,41.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00338954302,NDC,facility,inpatient,1,EA,52.45000,15.21000,Aetna,Local,,20.98,,,,,,,18.91,42.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00338954006,NDC,,,facility,outpatient,1,EA,196.30000,56.93000,Aetna,Local,,99.66,,,,,,,70.77,160.57,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338915930,NDC,facility,inpatient,1,EA,69.15000,20.05000,Aetna,Local,,27.66,,,,,,,24.93,56.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00338630402,NDC,facility,inpatient,1,EA,38.15000,11.06000,Aetna,Local,,15.26,,,,,,,13.75,31.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00338630402,NDC,facility,inpatient,1,EA,38.15000,11.06000,Aetna,Local,,15.26,,,,,,,13.75,31.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00338604648,NDC,facility,inpatient,200,ME,190.35000,55.20000,Aetna,Local,,76.14,,,,,,,68.62,155.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00338604537,NDC,facility,inpatient,400,ME,212.30000,61.57000,Aetna,Local,,84.92,,,,,,,76.53,173.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00338381424,NDC,facility,inpatient,900,ME,133.10000,38.60000,Aetna,Local,,53.24,,,,,,,47.98,108.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00338361224,NDC,facility,inpatient,600,ME,108.95000,31.60000,Aetna,Local,,43.58,,,,,,,39.28,89.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g /200mL  IVPB,800013370,CDM,636,RC,J3373,HCPCS,00338355248,NDC,facility,inpatient,1,GM,283.00000,82.07000,Aetna,Local,,113.20,,,,,,,102.02,231.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00338171540,NDC,facility,inpatient,4,GM,63.65000,18.46000,Aetna,Local,,25.46,,,,,,,22.95,52.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,00338170840,NDC,facility,inpatient,2,GM,128.40000,37.24000,Aetna,Local,,51.36,,,,,,,46.29,105.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mesna 200mg/2mL I (Mesnex),800025637,CDM,636,RC,J9209,HCPCS,00338130501,NDC,facility,inpatient,200,ME,51.00000,14.79000,Aetna,Local,,20.40,,,,,,,18.39,41.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOBUTamine 1g/D5W 250mL,800013360,CDM,636,RC,J1250,HCPCS,00338107702,NDC,facility,inpatient,1,GM,295.55000,85.71000,Aetna,Local,,118.22,,,,,,,106.55,241.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOBUTamine 250mg/D5W 250mL,800012791,CDM,636,RC,J1250,HCPCS,00338107302,NDC,facility,inpatient,250,ME,230.50000,66.84000,Aetna,Local,,92.20,,,,,,,83.10,188.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00338105548,NDC,facility,inpatient,500,ME,23.40000,6.79000,Aetna,Local,,9.36,,,,,,,8.44,19.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00338104702,NDC,facility,inpatient,25,ME,208.95000,60.60000,Aetna,Local,,83.58,,,,,,,75.33,170.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Penicillin GK 3MU/50mL P,800019217,CDM,636,RC,J2540,HCPCS,00338102541,NDC,facility,inpatient,1,EA,121.25000,35.16000,Aetna,Local,,48.50,,,,,,,43.71,99.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOPamine 400mg/D5W 250mL,800012469,CDM,636,RC,J1265,HCPCS,00338100702,NDC,facility,inpatient,400,ME,144.90000,42.02000,Aetna,Local,,57.96,,,,,,,52.24,118.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00338080304,NDC,,,facility,outpatient,1,EA,108.45000,31.45000,Aetna,Local,,55.06,,,,,,,39.10,88.71,percent of total billed charges,
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00338070948,NDC,facility,inpatient,1,EA,40.25000,11.67000,Aetna,Local,,16.10,,,,,,,14.51,32.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00338070548,NDC,facility,inpatient,1,EA,41.65000,12.08000,Aetna,Local,,16.66,,,,,,,15.01,34.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00338069104,NDC,,,facility,outpatient,1,EA,108.45000,31.45000,Aetna,Local,,55.06,,,,,,,39.10,88.71,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00338067104,NDC,,,facility,outpatient,1,EA,60.25000,17.47000,Aetna,Local,,30.59,,,,,,,21.72,49.28,percent of total billed charges,
NS 100mL(Mini-Bag+),800012288,CDM,636,RC,J7050,HCPCS,00338055318,NDC,facility,inpatient,1,EA,69.75000,20.23000,Aetna,Local,,27.90,,,,,,,25.14,57.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00338051909,NDC,,,facility,outpatient,1,EA,196.30000,56.93000,Aetna,Local,,99.66,,,,,,,70.77,160.57,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00338051902,NDC,,,facility,outpatient,1,EA,150.20000,43.56000,Aetna,Local,,76.26,,,,,,,54.15,122.86,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,800064963,CDM,636,RC,J1580,HCPCS,00338050348,NDC,facility,inpatient,80,ME,40.70000,11.80000,Aetna,Local,,16.28,,,,,,,14.67,33.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00338043103,NDC,facility,inpatient,1000,UN,51.75000,15.01000,Aetna,Local,,20.70,,,,,,,18.66,42.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00338042418,NDC,facility,inpatient,1000,UN,51.75000,15.01000,Aetna,Local,,20.70,,,,,,,18.66,42.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00338041102,NDC,facility,inpatient,2,GM,88.20000,25.58000,Aetna,Local,,35.28,,,,,,,31.80,72.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mannitol 20% 500mL,800022060,CDM,250,RC,00338035703,NDC,,,facility,outpatient,1,EA,607.55000,176.19000,Aetna,Local,,308.45,,,,,,,219.02,496.98,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00338022104,NDC,,,facility,outpatient,1,EA,173.75000,50.39000,Aetna,Local,,88.21,,,,,,,62.64,142.13,percent of total billed charges,
Insulin(R) 100unit/100mL NS,800062046,CDM,636,RC,J1815,HCPCS,00338012612,NDC,facility,inpatient,100,UN,351.00000,101.79000,Aetna,Local,,140.40,,,,,,,126.54,287.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 30mg/mL 1mL I(Toradol),800013383,CDM,636,RC,J1885,HCPCS,00338007225,NDC,facility,inpatient,30,ME,11.15000,3.23000,Aetna,Local,,4.46,,,,,,,4.02,9.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketorolac 15mg/mL 1mL I(Toradol),800072430,CDM,636,RC,J1885,HCPCS,00338006910,NDC,facility,inpatient,15,ME,8.00000,2.32000,Aetna,Local,,3.20,,,,,,,2.88,6.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Chloride 3% IVPB 250mL,800012312,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,inpatient,1,EA,28.70000,8.32000,Aetna,Local,,11.48,,,,,,,10.35,23.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Chloride 3% IV 500mL,800040915,CDM,636,RC,J7131,HCPCS,00338005403,NDC,facility,inpatient,1,EA,58.90000,17.08000,Aetna,Local,,23.56,,,,,,,21.23,48.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 1000mL Irrigation Bag-Sterile,800012254,CDM,258,RC,00338005144,NDC,,,facility,outpatient,1,EA,1037.65000,300.92000,Aetna,Local,,526.81,,,,,,,374.07,848.80,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338004948,NDC,facility,inpatient,1,EA,28.65000,8.31000,Aetna,Local,,11.46,,,,,,,10.33,23.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00338004941,NDC,facility,inpatient,1,EA,24.45000,7.09000,Aetna,Local,,9.78,,,,,,,8.81,20.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338004938,NDC,facility,inpatient,1,EA,26.85000,7.79000,Aetna,Local,,10.74,,,,,,,9.68,21.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00338004931,NDC,facility,inpatient,1,EA,24.65000,7.15000,Aetna,Local,,9.86,,,,,,,8.89,20.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00338004918,NDC,facility,inpatient,1,EA,27.60000,8.00000,Aetna,Local,,11.04,,,,,,,9.95,22.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 100mL Inj,800025641,CDM,636,RC,J7050,HCPCS,00338004918,NDC,facility,inpatient,1,EA,21.30000,6.18000,Aetna,Local,,8.52,,,,,,,7.68,17.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00338004911,NDC,facility,inpatient,1,EA,27.60000,8.00000,Aetna,Local,,11.04,,,,,,,9.95,22.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00338004904,NDC,facility,inpatient,1,EA,50.25000,14.57000,Aetna,Local,,20.10,,,,,,,18.12,41.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00338004902,NDC,facility,inpatient,1,EA,43.70000,12.67000,Aetna,Local,,17.48,,,,,,,15.75,35.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 1000mL Irrigation Bag-Sterile,800012254,CDM,258,RC,00338004804,NDC,,,facility,outpatient,1,EA,46.75000,13.56000,Aetna,Local,,23.73,,,,,,,16.85,38.24,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00338004304,NDC,,,facility,outpatient,1,EA,63.85000,18.52000,Aetna,Local,,32.42,,,,,,,23.02,52.23,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,00338004303,NDC,,,facility,outpatient,1,EA,48.05000,13.93000,Aetna,Local,,24.39,,,,,,,17.32,39.30,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00338002304,NDC,,,facility,outpatient,1,EA,77.00000,22.33000,Aetna,Local,,39.09,,,,,,,27.76,62.99,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00338002302,NDC,,,facility,outpatient,1,EA,64.75000,18.78000,Aetna,Local,,32.87,,,,,,,23.34,52.97,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00338001304,NDC,facility,outpatient,1,EA,98.45000,28.55000,Aetna,Local,,49.98,,,,,,,3.80,80.53,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,00332417732,NDC,,,facility,outpatient,1,EA,614.55000,178.22000,Aetna,Local,,312.01,,,,,,,221.55,502.70,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,00332417532,NDC,,,facility,outpatient,1,EA,135.40000,39.27000,Aetna,Local,,68.74,,,,,,,48.81,110.76,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00316022115,NDC,,,facility,outpatient,1,EA,124.25000,36.03000,Aetna,Local,,63.08,,,,,,,44.79,101.64,percent of total billed charges,
dapagliflozin 10mg Tab UD,800051047,CDM,637,RC,00310621039,NDC,,,facility,outpatient,1,EA,169.85000,49.26000,Aetna,Local,,86.23,,,,,,,61.23,138.94,percent of total billed charges,
durvalumab 500mg/10mL Inj - Pt Own Supply,800051068,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,inpatient,500,ME,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
durvalumab 500mg/10mL (Imfinzi),800051084,CDM,636,RC,J9173,HCPCS,00310461150,NDC,facility,inpatient,500,ME,31108.55000,9021.48000,Aetna,Local,,12443.42,,,,,,,11214.63,25446.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tremelimumab- actl- Pt Own Supply,800052003,CDM,636,RC,J9347,HCPCS,00310453530,NDC,facility,inpatient,300,ME,0.15000,0.04000,Aetna,Local,,0.06000,,,,,,,0.05407,0.12270,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Benralizumab 30mg IS (Fasenra),800051069,CDM,636,RC,J0517,HCPCS,00310173030,NDC,facility,inpatient,30,ME,22806.15000,6613.78000,Aetna,Local,,9122.46,,,,,,,8221.62,18655.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Goserelin 10.8 mg Impl,800012528,CDM,636,RC,J9202,HCPCS,00310095130,NDC,facility,inpatient,10.8,ME,8294.30000,2405.35000,Aetna,Local,,3317.72,,,,,,,2990.10,6784.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Goserelin 3.6mg Impl,800081180,CDM,636,RC,J9202,HCPCS,00310095036,NDC,facility,inpatient,3.6,ME,2889.45000,837.94000,Aetna,Local,,1155.78,,,,,,,1041.65,2363.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rosuvastatin 40mg T (Crestor),800015392,CDM,637,RC,00310075430,NDC,,,facility,outpatient,1,EA,78.30000,22.71000,Aetna,Local,,39.75,,,,,,,28.23,64.05,percent of total billed charges,
Rosuvastatin 10mg T(Crestor),800017703,CDM,637,RC,00310075190,NDC,,,facility,outpatient,1,EA,78.30000,22.71000,Aetna,Local,,39.75,,,,,,,28.23,64.05,percent of total billed charges,
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,00310072050,NDC,facility,inpatient,250,ME,3420.15000,991.84000,Aetna,Local,,1368.06,,,,,,,1232.96,2797.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,00310072010,NDC,facility,inpatient,250,ME,4052.60000,1175.25000,Aetna,Local,,1621.04,,,,,,,1460.96,3315.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00310070530,NDC,,,facility,outpatient,1,EA,163.40000,47.39000,Aetna,Local,,82.96,,,,,,,58.91,133.66,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00310070510,NDC,,,facility,outpatient,1,EA,140.15000,40.64000,Aetna,Local,,71.15,,,,,,,50.52,114.64,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00310060060,NDC,,,facility,outpatient,1,EA,15.20000,4.41000,Aetna,Local,,7.72,,,,,,,5.48,12.43,percent of total billed charges,
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00310032520,NDC,facility,inpatient,500,ME,315.05000,91.36000,Aetna,Local,,126.02,,,,,,,113.58,257.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00310032130,NDC,facility,inpatient,1,GM,601.70000,174.49000,Aetna,Local,,240.68,,,,,,,216.91,492.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 0.5g/50mL I(Diprivan),800019987,CDM,636,RC,J2704,HCPCS,00310030050,NDC,facility,inpatient,0.5,GM,404.20000,117.22000,Aetna,Local,,161.68,,,,,,,145.71,330.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00310030022,NDC,facility,inpatient,200,ME,103.40000,29.99000,Aetna,Local,,41.36,,,,,,,37.28,84.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00310030011,NDC,facility,inpatient,1,GM,43369.50000,12577.16000,Aetna,Local,,17347.80,,,,,,,15634.70,35476.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,00310027510,NDC,,,facility,outpatient,1,EA,33.00000,9.57000,Aetna,Local,,16.75,,,,,,,11.90,26.99,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,00310027110,NDC,,,facility,outpatient,1,EA,56.65000,16.43000,Aetna,Local,,28.76,,,,,,,20.42,46.34,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,00310020137,NDC,,,facility,outpatient,1,EA,91.80000,26.62000,Aetna,Local,,46.61,,,,,,,33.09,75.09,percent of total billed charges,
Anastrozole 1 mg T(Arimidex),800080795,CDM,637,RC,00310020130,NDC,,,facility,outpatient,1,EA,122.90000,35.64000,Aetna,Local,,62.40,,,,,,,44.31,100.53,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00310013139,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,Local,,4.26,,,,,,,3.03,6.87,percent of total billed charges,
Roflumilast 500mcg T(Daliresp),800015427,CDM,637,RC,00310009530,NDC,,,facility,outpatient,1,EA,129.45000,37.54000,Aetna,Local,,65.72,,,,,,,46.67,105.89,percent of total billed charges,
Benzocaine 20% Top Spray 0.5mL UD,800015359,CDM,637,RC,00283061026,NDC,,,facility,outpatient,1,EA,37.65000,10.92000,Aetna,Local,,19.11,,,,,,,13.57,30.80,percent of total billed charges,
Nitroglycerin 2% TO 1g,800081827,CDM,637,RC,00281032608,NDC,,,facility,outpatient,1,GM,21.45000,6.22000,Aetna,Local,,10.89,,,,,,,7.73,17.55,percent of total billed charges,
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),800022035,CDM,636,RC,Q9950,HCPCS,00270709973,NDC,facility,inpatient,1,EA,754.70000,218.86000,Aetna,Local,,301.88,,,,,,,272.07,617.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),800022035,CDM,636,RC,Q9950,HCPCS,00270709916,NDC,facility,inpatient,1,EA,741.40000,215.01000,Aetna,Local,,296.56,,,,,,,267.27,606.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RAD- Sulfur Hexafluoride Inj 5mL(Lumason),800022035,CDM,636,RC,Q9950,HCPCS,00270709707,NDC,facility,inpatient,1,EA,755.85000,219.20000,Aetna,Local,,302.34,,,,,,,272.48,618.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Diatrizoate Meglumine 30% I 100mL,800046535,CDM,636,RC,Q9958,HCPCS,00270014960,NDC,facility,inpatient,1,EA,308.95000,89.60000,Aetna,Local,,123.58,,,,,,,111.38,252.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00264987210,NDC,facility,inpatient,1000,UN,45.40000,13.17000,Aetna,Local,,18.16,,,,,,,16.37,37.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00264959820,NDC,facility,inpatient,2,GM,86.90000,25.20000,Aetna,Local,,34.76,,,,,,,31.33,71.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00264958720,NDC,facility,inpatient,25000,UN,159.65000,46.30000,Aetna,Local,,63.86,,,,,,,57.55,130.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00264937988,NDC,,,facility,outpatient,1,EA,15.60000,4.52000,Aetna,Local,,7.92,,,,,,,5.62,12.76,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00264786500,NDC,,,facility,outpatient,1,EA,55.50000,16.10000,Aetna,Local,,28.18,,,,,,,20.01,45.40,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00264785000,NDC,facility,outpatient,1,EA,47.75000,13.85000,Aetna,Local,,24.24,,,,,,,3.80,39.06,percent of total billed charges,
Sodium Chloride 3% IVPB 250mL,800012312,CDM,636,RC,J7131,HCPCS,00264780510,NDC,facility,inpatient,1,EA,28.85000,8.37000,Aetna,Local,,11.54,,,,,,,10.40,23.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250mL PVC Free,800012825,CDM,636,RC,J7050,HCPCS,00264780020,NDC,facility,inpatient,1,EA,19.90000,5.77000,Aetna,Local,,7.96,,,,,,,7.17,16.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00264780000,NDC,facility,inpatient,1,EA,27.90000,8.09000,Aetna,Local,,11.16,,,,,,,10.06,22.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00264763500,NDC,,,facility,outpatient,1,EA,50.00000,14.50000,Aetna,Local,,25.39,,,,,,,18.02,40.90,percent of total billed charges,
Mannitol 20% 500mL,800022060,CDM,250,RC,00264757810,NDC,,,facility,outpatient,1,EA,443.75000,128.69000,Aetna,Local,,225.29,,,,,,,159.97,362.99,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00264752020,NDC,,,facility,outpatient,1,EA,44.45000,12.89000,Aetna,Local,,22.57,,,,,,,16.02,36.36,percent of total billed charges,
D10W 1000mL,800012362,CDM,258,RC,00264752000,NDC,,,facility,outpatient,1,EA,17.85000,5.18000,Aetna,Local,,9.06,,,,,,,6.43,14.60,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,800064963,CDM,636,RC,J1580,HCPCS,00264580832,NDC,facility,inpatient,80,ME,34.55000,10.02000,Aetna,Local,,13.82,,,,,,,12.46,28.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00264553532,NDC,facility,inpatient,500,ME,32.65000,9.47000,Aetna,Local,,13.06,,,,,,,11.77,26.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lipids (fat emulsion) IV 20% 250mL,800069997,CDM,250,RC,00264446030,NDC,,,facility,outpatient,1,EA,119.70000,34.71000,Aetna,Local,,60.77,,,,,,,43.15,97.91,percent of total billed charges,
Mag Sulfate 4g/Water 100mL,800013328,CDM,636,RC,J3475,HCPCS,00264420654,NDC,facility,inpatient,4,GM,35.90000,10.41000,Aetna,Local,,14.36,,,,,,,12.94,29.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mag Sulfate 2g/Water 50mL,800013371,CDM,636,RC,J3475,HCPCS,00264420452,NDC,facility,inpatient,2,GM,45.10000,13.08000,Aetna,Local,,18.04,,,,,,,16.26,36.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 1000mL Irrigation Bag-Sterile,800012254,CDM,258,RC,00264220100,NDC,,,facility,outpatient,1,EA,44.20000,12.82000,Aetna,Local,,22.44,,,,,,,15.93,36.16,percent of total billed charges,
Hetastarch 6% -NS 500mL,800011207,CDM,250,RC,00264196510,NDC,,,facility,outpatient,1,EA,265.90000,77.11000,Aetna,Local,,135.00,,,,,,,95.86,217.51,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00264180032,NDC,facility,inpatient,1,EA,26.10000,7.57000,Aetna,Local,,10.44,,,,,,,9.41,21.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 100mL Inj,800025641,CDM,636,RC,J7050,HCPCS,00264180032,NDC,facility,inpatient,1,EA,23.80000,6.90000,Aetna,Local,,9.52,,,,,,,8.58,19.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00264180031,NDC,facility,inpatient,1,EA,25.90000,7.51000,Aetna,Local,,10.36,,,,,,,9.34,21.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00258369090,NDC,,,facility,outpatient,1,EA,16.30000,4.73000,Aetna,Local,,8.28,,,,,,,5.88,13.33,percent of total billed charges,
Benzonatate 100mg C(Tessalon),800054279,CDM,637,RC,00258365401,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,00256018505,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,00256018504,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Multiple Vitamin C(Nephrocap),800065721,CDM,637,RC,00256018501,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00254531235,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00254391928,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,Local,,1.04,,,,,,,0.73903,1.68,percent of total billed charges,
Lubiprostone 24mcg C(Amitiza),800017638,CDM,637,RC,00254302902,NDC,,,facility,outpatient,1,EA,47.30000,13.72000,Aetna,Local,,24.01,,,,,,,17.05,38.69,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00254273228,NDC,,,facility,outpatient,1,EA,0.25000,0.07000,Aetna,Local,,0.12693,,,,,,,0.09012,0.20450,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00254200801,NDC,,,facility,outpatient,1,EA,47.70000,13.83000,Aetna,Local,,24.22,,,,,,,17.20,39.02,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00254100752,NDC,,,facility,outpatient,1,EA,490.05000,142.11000,Aetna,Local,,248.80,,,,,,,176.66,400.86,percent of total billed charges,
Potassium Bicarb 25mEq EFF Tab,800015247,CDM,637,RC,00245532630,NDC,,,facility,outpatient,1,EA,11.15000,3.23000,Aetna,Local,,5.66,,,,,,,4.02,9.12,percent of total billed charges,
Potassium Chloride 20mEq ER T,800040893,CDM,637,RC,00245531901,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00245021211,NDC,,,facility,outpatient,1,EA,29.40000,8.53000,Aetna,Local,,14.93,,,,,,,10.60,24.05,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00245021201,NDC,,,facility,outpatient,1,EA,31.75000,9.21000,Aetna,Local,,16.12,,,,,,,11.45,25.97,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00245018111,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00245014715,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,Local,,25.33,,,,,,,17.99,40.82,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00245014701,NDC,,,facility,outpatient,1,EA,56.25000,16.31000,Aetna,Local,,28.56,,,,,,,20.28,46.01,percent of total billed charges,
Amiodarone 100 mg T(Cordarone),800015393,CDM,637,RC,00245014430,NDC,,,facility,outpatient,1,EA,52.60000,15.25000,Aetna,Local,,26.71,,,,,,,18.96,43.03,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,00245007111,NDC,,,facility,outpatient,1,EA,19.55000,5.67000,Aetna,Local,,9.93,,,,,,,7.05,15.99,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00245001201,NDC,,,facility,outpatient,1,EA,18.45000,5.35000,Aetna,Local,,9.37,,,,,,,6.65,15.09,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00245000835,NDC,,,facility,outpatient,1,EA,664.15000,192.60000,Aetna,Local,,337.19,,,,,,,239.43,543.27,percent of total billed charges,
Potassium Iodide 300mg/0.3mL Oral Liq,800055060,CDM,637,RC,00245000331,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00228300350,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00228300311,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00228299611,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,00228289803,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
hydroCHLOROthiazide 12.5mg T,800079441,CDM,637,RC,00228282011,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00228280311,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00228280111,NDC,,,facility,outpatient,1,EA,10.75000,3.12000,Aetna,Local,,5.46,,,,,,,3.88,8.79,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,00228277811,NDC,,,facility,outpatient,1,EA,14.55000,4.22000,Aetna,Local,,7.39,,,,,,,5.25,11.90,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00228271311,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00228266750,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00228266711,NDC,,,facility,outpatient,1,EA,11.30000,3.28000,Aetna,Local,,5.74,,,,,,,4.07,9.24,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00228266650,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00228266611,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00228266550,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00228266511,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00228263650,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00228263611,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00228258809,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,Local,,4.32,,,,,,,3.06,6.95,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00228258803,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00228257909,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,Local,,9.54,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00228257709,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00228254010,NDC,,,facility,outpatient,1,EA,7.85000,2.28000,Aetna,Local,,3.99,,,,,,,2.83,6.42,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00228253910,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,00228253810,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,00228249710,NDC,,,facility,outpatient,1,EA,7.55000,2.19000,Aetna,Local,,3.83,,,,,,,2.72,6.18,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,00228234810,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00228212750,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00228212710,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,00228207610,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
LORazepam 0.5mg T(Ativan),800052281,CDM,637,RC,00228205710,NDC,,,facility,outpatient,1,EA,5.40000,1.57000,Aetna,Local,,2.74,,,,,,,1.95,4.42,percent of total billed charges,
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00228202910,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00206885516,NDC,facility,inpatient,4.5,GM,119.85000,34.76000,Aetna,Local,,47.94,,,,,,,43.21,98.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00206885416,NDC,facility,inpatient,3.375,GM,98.90000,28.68000,Aetna,Local,,39.56,,,,,,,35.65,80.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00206885216,NDC,facility,inpatient,2.25,GM,59.90000,17.37000,Aetna,Local,,23.96,,,,,,,21.59,49.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00206845525,NDC,facility,inpatient,4.5,GM,219.65000,63.70000,Aetna,Local,,87.86,,,,,,,79.18,179.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 3.375g Inj,800015131,CDM,636,RC,J2543,HCPCS,00206845455,NDC,facility,inpatient,3.375,GM,149.10000,43.24000,Aetna,Local,,59.64,,,,,,,53.75,121.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 4.5g Inj,800015115,CDM,636,RC,J2543,HCPCS,00206410002,NDC,facility,inpatient,4.5,GM,193.35000,56.07000,Aetna,Local,,77.34,,,,,,,69.70,158.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Piperacillin-Taz 2.25g Inj,800019233,CDM,636,RC,J2543,HCPCS,00206240402,NDC,facility,inpatient,2.25,GM,101.75000,29.51000,Aetna,Local,,40.70,,,,,,,36.68,83.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg Tab,800054501,CDM,637,RC,00187442030,NDC,,,facility,outpatient,1,EA,112.35000,32.58000,Aetna,Local,,57.04,,,,,,,40.50,91.90,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00187442010,NDC,,,facility,outpatient,1,EA,112.35000,32.58000,Aetna,Local,,57.04,,,,,,,40.50,91.90,percent of total billed charges,
Isoproterenol HCl 1mg/5mL I,800011916,CDM,250,RC,00187433005,NDC,,,facility,outpatient,1,EA,14152.85000,4104.33000,Aetna,Local,,7185.40,,,,,,,5102.10,11577.03,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00187430202,NDC,,,facility,outpatient,1,EA,1385.20000,401.71000,Aetna,Local,,703.27,,,,,,,499.36,1133.09,percent of total billed charges,
ChlordiazePOX-Clid C(Librax),800017372,CDM,637,RC,00187410010,NDC,,,facility,outpatient,1,EA,400.75000,116.22000,Aetna,Local,,203.46,,,,,,,144.47,327.81,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,00187355410,NDC,,,facility,outpatient,1,EA,515.10000,149.38000,Aetna,Local,,261.52,,,,,,,185.69,421.35,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00187301030,NDC,,,facility,outpatient,1,EA,185.75000,53.87000,Aetna,Local,,94.31,,,,,,,66.96,151.94,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,00187170405,NDC,,,facility,outpatient,1,EA,468.70000,135.92000,Aetna,Local,,237.96,,,,,,,168.97,383.40,percent of total billed charges,
Glucose 15g Gel(Glutose 15),800053933,CDM,250,RC,00187074633,NDC,,,facility,outpatient,1,EA,58.50000,16.96000,Aetna,Local,,29.70,,,,,,,21.09,47.85,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00187014390,NDC,,,facility,outpatient,1,EA,273.45000,79.30000,Aetna,Local,,138.83,,,,,,,98.58,223.68,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00186730005,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Morphine 10mg/10mL PF,800050327,CDM,636,RC,J2274,HCPCS,00186115102,NDC,facility,inpatient,10,ME,92.25000,26.75000,Aetna,Local,,36.90,,,,,,,33.26,75.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol XL 100mg ER T(Toprol-XL),800070002,CDM,637,RC,00186109205,NDC,,,facility,outpatient,1,EA,15.25000,4.42000,Aetna,Local,,7.74,,,,,,,5.50,12.47,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00186109005,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,Local,,5.15,,,,,,,3.66,8.30,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00186108805,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,Local,,5.15,,,,,,,3.66,8.30,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,800041227,CDM,250,RC,00186103412,NDC,,,facility,outpatient,1,EA,223.65000,64.86000,Aetna,Local,,113.55,,,,,,,80.63,182.95,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00186103312,NDC,,,facility,outpatient,1,EA,24.25000,7.03000,Aetna,Local,,12.31,,,,,,,8.74,19.84,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00186103201,NDC,,,facility,outpatient,1,EA,42.70000,12.38000,Aetna,Local,,21.68,,,,,,,15.39,34.93,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00186103012,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,11.75,,,,,,,8.35,18.94,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00186103001,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,Local,,5.23,,,,,,,3.71,8.43,percent of total billed charges,
BUPivacaine 0.75%/D8.25 2mL I PF Spinal,800058692,CDM,250,RC,00186102603,NDC,,,facility,outpatient,1,EA,25.10000,7.28000,Aetna,Local,,12.74,,,,,,,9.05,20.53,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,00186099466,NDC,facility,inpatient,600,ME,69.60000,20.18000,Aetna,Local,,27.84,,,,,,,25.09,56.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,00186099266,NDC,facility,inpatient,600,ME,148.85000,43.17000,Aetna,Local,,59.54,,,,,,,53.66,121.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00186086369,NDC,facility,inpatient,150,ME,99.00000,28.71000,Aetna,Local,,39.60,,,,,,,35.69,80.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00186086361,NDC,facility,inpatient,150,ME,97.05000,28.14000,Aetna,Local,,38.82,,,,,,,34.99,79.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.5% 30mL I,800013351,CDM,636,RC,J2795,HCPCS,00186086354,NDC,facility,inpatient,150,ME,79.95000,23.19000,Aetna,Local,,31.98,,,,,,,28.82,65.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% Epidural,800013350,CDM,636,RC,J2795,HCPCS,00186085981,NDC,facility,inpatient,200,ME,232.30000,67.37000,Aetna,Local,,92.92,,,,,,,83.74,190.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00186085954,NDC,facility,inpatient,40,ME,49.00000,14.21000,Aetna,Local,,19.60,,,,,,,17.66,40.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00186085951,NDC,facility,inpatient,40,ME,48.95000,14.20000,Aetna,Local,,19.58,,,,,,,17.65,40.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ticagrelor 90mg T,800015340,CDM,637,RC,00186077760,NDC,,,facility,outpatient,1,EA,65.80000,19.08000,Aetna,Local,,33.41,,,,,,,23.72,53.82,percent of total billed charges,
Ticagrelor 90mg T,800015340,CDM,637,RC,00186077739,NDC,,,facility,outpatient,1,EA,65.80000,19.08000,Aetna,Local,,33.41,,,,,,,23.72,53.82,percent of total billed charges,
Ticagrelor 60mg Tab,800022075,CDM,637,RC,00186077660,NDC,,,facility,outpatient,1,EA,65.80000,19.08000,Aetna,Local,,33.41,,,,,,,23.72,53.82,percent of total billed charges,
Budesonide 3mg EC (Entocort EC) Cap,800017437,CDM,637,RC,00186070210,NDC,,,facility,outpatient,1,EA,196.75000,57.06000,Aetna,Local,,99.89,,,,,,,70.93,160.94,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00186061101,NDC,,,facility,inpatient,1,EA,13.40000,3.89000,Aetna,Local,,5.36,,,,,,,4.83,10.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00186061101,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,5.36,,,,,,,4.83,10.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00186045158,NDC,,,facility,outpatient,1,EA,9.90000,2.87000,Aetna,Local,,5.03,,,,,,,3.57,8.10,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00186045058,NDC,,,facility,outpatient,1,EA,12.50000,3.62000,Aetna,Local,,6.35,,,,,,,4.51,10.22,percent of total billed charges,
Felodipine 2.5mg ER T(Plendil),800075779,CDM,637,RC,00186045031,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00186032001,NDC,,,facility,outpatient,1,EA,64.80000,18.79000,Aetna,Local,,32.90,,,,,,,23.36,53.01,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,00186031521,NDC,,,facility,outpatient,1,EA,1865.70000,541.05000,Aetna,Local,,947.22,,,,,,,672.58,1526.14,percent of total billed charges,
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186026002,NDC,,,facility,inpatient,1,EA,70.60000,20.47000,Aetna,Local,,28.24,,,,,,,25.45,57.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186026002,NDC,,,facility,outpatient,1,EA,70.60000,20.47000,Aetna,Local,,28.24,,,,,,,25.45,57.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,00186025502,NDC,,,facility,inpatient,1,EA,61.55000,17.85000,Aetna,Local,,24.62,,,,,,,22.19,50.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 30mL PF I,800040864,CDM,636,RC,00186025502,NDC,,,facility,outpatient,1,EA,61.55000,17.85000,Aetna,Local,,24.62,,,,,,,22.19,50.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00186024002,NDC,,,facility,inpatient,1,EA,35.40000,10.27000,Aetna,Local,,14.16,,,,,,,12.76,28.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00186024002,NDC,,,facility,outpatient,1,EA,35.40000,10.27000,Aetna,Local,,14.16,,,,,,,12.76,28.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,00186023503,NDC,,,facility,inpatient,1,EA,40.15000,11.64000,Aetna,Local,,16.06,,,,,,,14.47,32.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 4% PF 5mL Inj,800060946,CDM,636,RC,00186023503,NDC,,,facility,outpatient,1,EA,40.15000,11.64000,Aetna,Local,,16.06,,,,,,,14.47,32.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00186023003,NDC,,,facility,inpatient,1,EA,15.45000,4.48000,Aetna,Local,,6.18,,,,,,,5.57,12.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00186023003,NDC,,,facility,outpatient,1,EA,15.45000,4.48000,Aetna,Local,,6.18,,,,,,,5.57,12.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,00186021003,NDC,,,facility,inpatient,1,EA,11.90000,3.45000,Aetna,Local,,4.76,,,,,,,4.29,9.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 2mL PF I,800014019,CDM,636,RC,00186021003,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,Local,,4.76,,,,,,,4.29,9.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00186015501,NDC,,,facility,inpatient,1,EA,6.60000,1.91000,Aetna,Local,,2.64,,,,,,,2.38,5.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00186015501,NDC,,,facility,outpatient,1,EA,6.60000,1.91000,Aetna,Local,,2.64,,,,,,,2.38,5.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,00186015001,NDC,,,facility,inpatient,1,EA,6.65000,1.93000,Aetna,Local,,2.66,,,,,,,2.40,5.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%- 1:100,000 Inj 50mL MDV",800014068,CDM,636,RC,00186015001,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,2.66,,,,,,,2.40,5.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00186014501,NDC,,,facility,inpatient,1,EA,26.45000,7.67000,Aetna,Local,,10.58,,,,,,,9.54,21.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00186014501,NDC,,,facility,outpatient,1,EA,26.45000,7.67000,Aetna,Local,,10.58,,,,,,,9.54,21.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00186012501,NDC,,,facility,inpatient,1,EA,4.05000,1.17000,Aetna,Local,,1.62,,,,,,,1.46,3.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:100,000 Inj 20mL MDV",800014084,CDM,636,RC,00186012501,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,Local,,1.62,,,,,,,1.46,3.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,00186012201,NDC,,,facility,inpatient,1,EA,16.75000,4.86000,Aetna,Local,,6.70,,,,,,,6.04,13.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 2%-1:200,000 Inj 20mL",800051085,CDM,636,RC,00186012201,NDC,,,facility,outpatient,1,EA,16.75000,4.86000,Aetna,Local,,6.70,,,,,,,6.04,13.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00186012001,NDC,,,facility,inpatient,1,EA,17.75000,5.15000,Aetna,Local,,7.10,,,,,,,6.40,14.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00186012001,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,Local,,7.10,,,,,,,6.40,14.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00186011501,NDC,,,facility,inpatient,1,EA,19.90000,5.77000,Aetna,Local,,7.96,,,,,,,7.17,16.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:100,000 Inj 20mL MDV",800014043,CDM,636,RC,00186011501,NDC,,,facility,outpatient,1,EA,19.90000,5.77000,Aetna,Local,,7.96,,,,,,,7.17,16.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186011491,NDC,,,facility,inpatient,1,EA,65.00000,18.85000,Aetna,Local,,26.00,,,,,,,23.43,53.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186011491,NDC,,,facility,outpatient,1,EA,65.00000,18.85000,Aetna,Local,,26.00,,,,,,,23.43,53.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186011401,NDC,,,facility,inpatient,1,EA,1340.40000,388.72000,Aetna,Local,,536.16,,,,,,,483.21,1096.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Lido-Epi 1%-1:200,000 Inj 30mL PF",800069392,CDM,636,RC,00186011401,NDC,,,facility,outpatient,1,EA,1340.40000,388.72000,Aetna,Local,,536.16,,,,,,,483.21,1096.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00186011001,NDC,,,facility,inpatient,1,EA,15.70000,4.55000,Aetna,Local,,6.28,,,,,,,5.66,12.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00186011001,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,Local,,6.28,,,,,,,5.66,12.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metOLazone 2.5mg T(Zaroxolyn),800068972,CDM,637,RC,00185505001,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,Local,,7.46,,,,,,,5.30,12.02,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,00185441601,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
tiZANidine 4 mg T(Zanaflex),800082056,CDM,637,RC,00185440051,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,Local,,5.25,,,,,,,3.73,8.47,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00185435030,NDC,,,facility,outpatient,1,EA,15.75000,4.57000,Aetna,Local,,8.00,,,,,,,5.68,12.88,percent of total billed charges,
Isoniazid 300mg T,800014984,CDM,637,RC,00185435001,NDC,,,facility,outpatient,1,EA,15.75000,4.57000,Aetna,Local,,8.00,,,,,,,5.68,12.88,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00185079930,NDC,,,facility,outpatient,1,EA,32.50000,9.42000,Aetna,Local,,16.50,,,,,,,11.72,26.59,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00185079901,NDC,,,facility,outpatient,1,EA,32.50000,9.42000,Aetna,Local,,16.50,,,,,,,11.72,26.59,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00185077130,NDC,,,facility,outpatient,1,EA,8.65000,2.51000,Aetna,Local,,4.39,,,,,,,3.12,7.08,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00185041560,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00185041501,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00185041060,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00185041001,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Dextroamphetamine-Amphetamine 20mg T,800081106,CDM,637,RC,00185040101,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00185031101,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,3.40,,,,,,,2.42,5.48,percent of total billed charges,
Metoprolol XL 50mg ER T(Toprol-XL),800070812,CDM,637,RC,00185028201,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00185028110,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Metoprolol XL 25mg ER T(TopROL- XL),800080837,CDM,637,RC,00185028101,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,00185022360,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,Local,,6.55,,,,,,,4.65,10.55,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00185021401,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,Local,,5.48,,,,,,,3.89,8.83,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00185021301,NDC,,,facility,outpatient,1,EA,5.00000,1.45000,Aetna,Local,,2.54,,,,,,,1.80,4.09,percent of total billed charges,
methIMAzole 10mg Tab,800019421,CDM,637,RC,00185021001,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,00185020501,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00185017101,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,Local,,9.21,,,,,,,6.54,14.85,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00185014701,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00185014505,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,4.42,,,,,,,3.14,7.12,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00185014501,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,Local,,4.67,,,,,,,3.32,7.53,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00185014460,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,Local,,12.16,,,,,,,8.63,19.59,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00185014409,NDC,,,facility,outpatient,1,EA,22.90000,6.64000,Aetna,Local,,11.63,,,,,,,8.26,18.73,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00185014405,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,Local,,12.16,,,,,,,8.63,19.59,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00185012901,NDC,,,facility,outpatient,1,EA,7.70000,2.23000,Aetna,Local,,3.91,,,,,,,2.78,6.30,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00185012801,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,Local,,3.88,,,,,,,2.76,6.26,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00185012201,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,Local,,2.23,,,,,,,1.59,3.60,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00185011701,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00185010401,NDC,,,facility,outpatient,1,EA,11.15000,3.23000,Aetna,Local,,5.66,,,,,,,4.02,9.12,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00185010101,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,Local,,3.60,,,,,,,2.56,5.81,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00185009105,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Dextroamphetamine-Amphetamine 5mg T,800081077,CDM,637,RC,00185008401,NDC,,,facility,outpatient,1,EA,13.70000,3.97000,Aetna,Local,,6.96,,,,,,,4.94,11.21,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00185006301,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00185004301,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,Local,,8.71,,,,,,,6.18,14.03,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00185002401,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,Local,,1.88,,,,,,,1.33,3.03,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00185002201,NDC,,,facility,outpatient,1,EA,15.45000,4.48000,Aetna,Local,,7.84,,,,,,,5.57,12.64,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00185001001,NDC,,,facility,outpatient,1,EA,3.65000,1.06000,Aetna,Local,,1.85,,,,,,,1.32,2.99,percent of total billed charges,
Selenium 2.5% 120mL Lotion,800065887,CDM,250,RC,00182608837,NDC,,,facility,outpatient,1,EA,82.10000,23.81000,Aetna,Local,,41.68,,,,,,,29.60,67.16,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00182607240,NDC,,,facility,outpatient,1,EA,0.50000,0.14000,Aetna,Local,,0.25385,,,,,,,0.18025,0.40900,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00182602464,NDC,,,facility,outpatient,1,EA,21.15000,6.13000,Aetna,Local,,10.74,,,,,,,7.62,17.30,percent of total billed charges,
Capsaicin 0.025% 60g TC(Zostrix),800058775,CDM,250,RC,00182512852,NDC,,,facility,outpatient,1,EA,49.20000,14.27000,Aetna,Local,,24.98,,,,,,,17.74,40.25,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00182268926,NDC,,,facility,outpatient,1,EA,31.15000,9.03000,Aetna,Local,,15.81,,,,,,,11.23,25.48,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00182194989,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00182194489,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00182189801,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,Local,,1.19,,,,,,,0.84718,1.92,percent of total billed charges,
Ibuprofen 600mg T(Motrin),800057256,CDM,637,RC,00182181089,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,00182173151,NDC,,,facility,outpatient,1,EA,62.65000,18.17000,Aetna,Local,,31.81,,,,,,,22.59,51.25,percent of total billed charges,
hydrOXYzine HCl 2mg/mL Oral Liq,800048628,CDM,637,RC,00182137640,NDC,,,facility,outpatient,1,EA,0.35000,0.10000,Aetna,Local,,0.17769,,,,,,,0.12618,0.28630,percent of total billed charges,
Benztropine Mesylate 0.5mg T(Cogentin),800011725,CDM,637,RC,00182129901,NDC,,,facility,outpatient,1,EA,0.70000,0.20000,Aetna,Local,,0.35539,,,,,,,0.25235,0.57260,percent of total billed charges,
guaiFENesin 600mg ER T,800055532,CDM,637,RC,00182118801,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
chlordiazePOXIDE 25mg C(Librium),800057413,CDM,637,RC,00182097989,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
chlordiazePOXIDE 10mg C(Librium),800015437,CDM,637,RC,00182097889,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,Local,,0.88848,,,,,,,0.63087,1.43,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00182055689,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00182050789,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Bethanechol Cl 10mg T(Urecholine),800020544,CDM,637,RC,00182045489,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,Local,,0.66001,,,,,,,0.46865,1.06,percent of total billed charges,
Potassium  Citrate 10mEq ER T,800017675,CDM,637,RC,00178061001,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,Local,,9.21,,,,,,,6.54,14.85,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,00173300101,NDC,,,facility,outpatient,1,EA,168.65000,48.91000,Aetna,Local,,85.62,,,,,,,60.80,137.96,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00173099156,NDC,,,facility,outpatient,1,EA,17.45000,5.06000,Aetna,Local,,8.86,,,,,,,6.29,14.27,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00173099155,NDC,,,facility,outpatient,1,EA,24.90000,7.22000,Aetna,Local,,12.64,,,,,,,8.98,20.37,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,00173095396,NDC,,,facility,outpatient,1,EA,21.85000,6.34000,Aetna,Local,,11.09,,,,,,,7.88,17.87,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00173094755,NDC,,,facility,outpatient,1,EA,62.40000,18.10000,Aetna,Local,,31.68,,,,,,,22.50,51.04,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093356,NDC,,,facility,outpatient,1,EA,113.20000,32.83000,Aetna,Local,,57.47,,,,,,,40.81,92.60,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093310,NDC,,,facility,outpatient,1,EA,114.05000,33.07000,Aetna,Local,,57.90,,,,,,,41.12,93.29,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093308,NDC,,,facility,outpatient,1,EA,114.05000,33.07000,Aetna,Local,,57.90,,,,,,,41.12,93.29,percent of total billed charges,
valACYclovir 500 mg T(Valtrex),800081850,CDM,637,RC,00173093303,NDC,,,facility,outpatient,1,EA,28.55000,8.28000,Aetna,Local,,14.49,,,,,,,10.29,23.35,percent of total billed charges,
Mepolizumab 100mg/1mL IS (Nucala),800062011,CDM,636,RC,J2182,HCPCS,00173089242,NDC,facility,inpatient,100,ME,15478.50000,4488.76000,Aetna,Local,,6191.40,,,,,,,5580.00,12661.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mepolizumab 100mg Inj,800022031,CDM,636,RC,J2182,HCPCS,00173088101,NDC,facility,inpatient,100,ME,14543.65000,4217.66000,Aetna,Local,,5817.46,,,,,,,5242.99,11896.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00173082318,NDC,,,facility,outpatient,1,EA,103.40000,29.99000,Aetna,Local,,52.50,,,,,,,37.28,84.58,percent of total billed charges,
Propafenone HCl 325 mg ER C(Rythmol SR),800081215,CDM,637,RC,00173078801,NDC,,,facility,outpatient,1,EA,60.60000,17.57000,Aetna,Local,,30.77,,,,,,,21.85,49.57,percent of total billed charges,
Propafenone HCl 225 mg ER C(Rythmol SR),800080829,CDM,637,RC,00173078601,NDC,,,facility,outpatient,1,EA,47.80000,13.86000,Aetna,Local,,24.27,,,,,,,17.23,39.10,percent of total billed charges,
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,00173073701,NDC,,,facility,outpatient,1,EA,592.45000,171.81000,Aetna,Local,,300.79,,,,,,,213.58,484.62,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00173073500,NDC,,,facility,outpatient,1,EA,289.30000,83.90000,Aetna,Local,,146.88,,,,,,,104.29,236.65,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00173073002,NDC,,,facility,outpatient,1,EA,46.55000,13.50000,Aetna,Local,,23.63,,,,,,,16.78,38.08,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00173073001,NDC,,,facility,outpatient,1,EA,36.80000,10.67000,Aetna,Local,,18.68,,,,,,,13.27,30.10,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,00173071215,NDC,,,facility,outpatient,1,EA,81.15000,23.53000,Aetna,Local,,41.20,,,,,,,29.25,66.38,percent of total billed charges,
Dutasteride 0.5 mg C(Avodart),800081967,CDM,637,RC,00173071204,NDC,,,facility,outpatient,1,EA,81.15000,23.53000,Aetna,Local,,41.20,,,,,,,29.25,66.38,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00173069704,NDC,,,facility,outpatient,1,EA,6745.90000,1956.31000,Aetna,Local,,3424.89,,,,,,,2431.90,5518.15,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00173069702,NDC,,,facility,outpatient,1,EA,1939.30000,562.40000,Aetna,Local,,984.58,,,,,,,699.12,1586.35,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00173069700,NDC,,,facility,outpatient,1,EA,1902.10000,551.61000,Aetna,Local,,965.70,,,,,,,685.71,1555.92,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00173069604,NDC,,,facility,outpatient,1,EA,4249.15000,1232.25000,Aetna,Local,,2157.29,,,,,,,1531.82,3475.80,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00173069602,NDC,,,facility,outpatient,1,EA,1509.65000,437.80000,Aetna,Local,,766.45,,,,,,,544.23,1234.89,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00173069504,NDC,,,facility,outpatient,1,EA,4249.15000,1232.25000,Aetna,Local,,2157.29,,,,,,,1531.82,3475.80,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00173069502,NDC,,,facility,outpatient,1,EA,1488.95000,431.80000,Aetna,Local,,755.94,,,,,,,536.77,1217.96,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00173069500,NDC,,,facility,outpatient,1,EA,1134.50000,329.00000,Aetna,Local,,575.99,,,,,,,408.99,928.02,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00173068224,NDC,,,facility,outpatient,1,EA,161.65000,46.88000,Aetna,Local,,82.07,,,,,,,58.27,132.23,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00173068221,NDC,,,facility,outpatient,1,EA,138.60000,40.19000,Aetna,Local,,70.37,,,,,,,49.97,113.37,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00173068220,NDC,,,facility,outpatient,1,EA,182.60000,52.95000,Aetna,Local,,92.71,,,,,,,65.83,149.37,percent of total billed charges,
lamoTRIgine 100mg Tablet,800080902,CDM,637,RC,00173064255,NDC,,,facility,outpatient,1,EA,97.05000,28.14000,Aetna,Local,,49.27,,,,,,,34.99,79.39,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,00173063302,NDC,,,facility,outpatient,1,EA,91.25000,26.46000,Aetna,Local,,46.33,,,,,,,32.90,74.64,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,800015438,CDM,637,RC,00173060202,NDC,,,facility,outpatient,1,EA,1531.90000,444.25000,Aetna,Local,,777.75,,,,,,,552.25,1253.09,percent of total billed charges,
Fluticasone Prop 100mcg/INH Diskus,800015438,CDM,637,RC,00173060200,NDC,,,facility,outpatient,1,EA,1795.15000,520.59000,Aetna,Local,,911.40,,,,,,,647.15,1468.43,percent of total billed charges,
Fluticasone Prop 250mcg/INH Diskus,800015439,CDM,637,RC,00173060102,NDC,,,facility,outpatient,1,EA,1858.45000,538.95000,Aetna,Local,,943.54,,,,,,,669.97,1520.21,percent of total billed charges,
Fluticasone Prop 250mcg/INH Diskus,800015439,CDM,637,RC,00173060100,NDC,,,facility,outpatient,1,EA,2307.35000,669.13000,Aetna,Local,,1171.44,,,,,,,831.80,1887.41,percent of total billed charges,
Fluticasone Prop 50mcg/INH Diskus,800017934,CDM,637,RC,00173060002,NDC,,,facility,outpatient,1,EA,1467.25000,425.50000,Aetna,Local,,744.92,,,,,,,528.94,1200.21,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00173054700,NDC,,,facility,outpatient,1,EA,276.80000,80.27000,Aetna,Local,,140.53,,,,,,,99.79,226.42,percent of total billed charges,
SUMAtriptan 20mg/spray NS,800081034,CDM,637,RC,00173052300,NDC,,,facility,outpatient,1,EA,716.30000,207.73000,Aetna,Local,,363.67,,,,,,,258.23,585.93,percent of total billed charges,
Salmeterol 50 mcg Pwd/Inh,800080076,CDM,637,RC,00173052100,NDC,,,facility,outpatient,1,EA,2866.40000,831.26000,Aetna,Local,,1455.27,,,,,,,1033.34,2344.72,percent of total billed charges,
Salmeterol 50 mcg Pwd/Inh,800080076,CDM,637,RC,00173052000,NDC,,,facility,outpatient,1,EA,3455.45000,1002.08000,Aetna,Local,,1754.33,,,,,,,1245.69,2826.56,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,00173048300,NDC,,,facility,outpatient,1,EA,99.65000,28.90000,Aetna,Local,,50.59,,,,,,,35.92,81.51,percent of total billed charges,
LamiVUDine 10mg/1mL Oral L(Epivir),800081138,CDM,637,RC,00173047100,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
lamiVUDine 150mg T(Epivir),800073915,CDM,637,RC,00173047001,NDC,,,facility,outpatient,1,EA,54.05000,15.67000,Aetna,Local,,27.44,,,,,,,19.49,44.21,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00173046002,NDC,,,facility,outpatient,1,EA,149.25000,43.28000,Aetna,Local,,75.77,,,,,,,53.80,122.09,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,00173045301,NDC,,,facility,outpatient,1,EA,661.55000,191.85000,Aetna,Local,,335.87,,,,,,,238.49,541.15,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,00173044600,NDC,facility,inpatient,4,ME,198.65000,57.61000,Aetna,Local,,79.46,,,,,,,71.61,162.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00173044202,NDC,facility,inpatient,4,ME,137.65000,39.92000,Aetna,Local,,55.06,,,,,,,49.62,112.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00173044200,NDC,facility,inpatient,4,ME,195.80000,56.78000,Aetna,Local,,78.32,,,,,,,70.59,160.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00173038742,NDC,,,facility,outpatient,1,EA,42.00000,12.18000,Aetna,Local,,21.32,,,,,,,15.14,34.36,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00173038701,NDC,,,facility,outpatient,1,EA,38.10000,11.05000,Aetna,Local,,19.34,,,,,,,13.74,31.17,percent of total billed charges,
Cefuroxime Axetil 250mg T(Ceftin),800054592,CDM,637,RC,00173038700,NDC,,,facility,outpatient,1,EA,133.20000,38.63000,Aetna,Local,,67.63,,,,,,,48.02,108.96,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00173037835,NDC,facility,inpatient,1,GM,113.80000,33.00000,Aetna,Local,,45.52,,,,,,,41.02,93.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00173037810,NDC,facility,inpatient,1,GM,113.85000,33.02000,Aetna,Local,,45.54,,,,,,,41.04,93.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00173034643,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00173024255,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Neo-Poly-Bac-Hc 3.5g Ophth Oint(Cortispor,800019588,CDM,637,RC,00173019786,NDC,,,facility,outpatient,1,EA,88.45000,25.65000,Aetna,Local,,44.91,,,,,,,31.89,72.35,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00173013555,NDC,,,facility,outpatient,1,EA,66.90000,19.40000,Aetna,Local,,33.97,,,,,,,24.12,54.72,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00172572880,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,Local,,8.71,,,,,,,6.18,14.03,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00172572870,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,Local,,8.71,,,,,,,6.18,14.03,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00172572860,NDC,,,facility,outpatient,1,EA,17.15000,4.97000,Aetna,Local,,8.71,,,,,,,6.18,14.03,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00172566460,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00172566360,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00172566310,NDC,,,facility,outpatient,1,EA,5.55000,1.61000,Aetna,Local,,2.82,,,,,,,2.00,4.54,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00172541160,NDC,,,facility,outpatient,1,EA,58.90000,17.08000,Aetna,Local,,29.90,,,,,,,21.23,48.18,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00172541146,NDC,,,facility,outpatient,1,EA,62.00000,17.98000,Aetna,Local,,31.48,,,,,,,22.35,50.72,percent of total billed charges,
Anagrelide 0.5mg C(Agrylin),800080654,CDM,637,RC,00172524160,NDC,,,facility,outpatient,1,EA,79.05000,22.92000,Aetna,Local,,40.13,,,,,,,28.50,64.66,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00172443160,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00172443149,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00172443059,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00172443049,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
Labetalol 200mg T(Normodyne),800052745,CDM,637,RC,00172436560,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,Local,,4.09,,,,,,,2.90,6.58,percent of total billed charges,
Labetalol 100mg T(Normodyne),800052737,CDM,637,RC,00172436460,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00172436060,NDC,,,facility,outpatient,1,EA,23.55000,6.83000,Aetna,Local,,11.96,,,,,,,8.49,19.26,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00172435960,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,Local,,4.62,,,,,,,3.28,7.44,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,00172433660,NDC,,,facility,outpatient,1,EA,12.10000,3.51000,Aetna,Local,,6.14,,,,,,,4.36,9.90,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00172433160,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,00172428660,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,Local,,5.18,,,,,,,3.68,8.34,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,00172428560,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00172426660,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00172423660,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00172423360,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00172423260,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00172419860,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,Local,,5.51,,,,,,,3.91,8.88,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00172419760,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00172419660,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Baclofen 20mg T,800017423,CDM,637,RC,00172409760,NDC,,,facility,outpatient,1,EA,36.30000,10.53000,Aetna,Local,,18.43,,,,,,,13.09,29.69,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00172409660,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,Local,,8.88,,,,,,,6.31,14.31,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00172407470,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00172407460,NDC,,,facility,outpatient,1,EA,10.60000,3.07000,Aetna,Local,,5.38,,,,,,,3.82,8.67,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00172407370,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00172407360,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,00172402960,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
diphenoxylate-atropine 2.5-0.025mg T,800015551,CDM,637,RC,00172396660,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
diazePAM 5mg T(Valium),800061746,CDM,637,RC,00172392660,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
diazePAM 2mg T(Valium),800050533,CDM,637,RC,00172392560,NDC,,,facility,outpatient,1,EA,1.00000,0.29000,Aetna,Local,,0.50770,,,,,,,0.36050,0.81800,percent of total billed charges,
Lisinopril 40 mg T(Zestril),800081496,CDM,637,RC,00172376160,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,Local,,5.53,,,,,,,3.93,8.92,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00172375960,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00172368660,NDC,,,facility,outpatient,1,EA,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
glipiZIDE 5mg T(Glucotrol),800049733,CDM,637,RC,00172364960,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,Local,,0.20308,,,,,,,0.14420,0.32720,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00172300760,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00172298548,NDC,,,facility,outpatient,1,EA,1.15000,0.33000,Aetna,Local,,0.58386,,,,,,,0.41458,0.94070,percent of total billed charges,
Cyproheptadine HCl 4mg T(Periactin),800017326,CDM,637,RC,00172292960,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,Local,,1.52,,,,,,,1.08,2.45,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00172290860,NDC,,,facility,outpatient,1,EA,1.10000,0.32000,Aetna,Local,,0.55847,,,,,,,0.39655,0.89980,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00172290760,NDC,,,facility,outpatient,1,EA,1.25000,0.36000,Aetna,Local,,0.63462,,,,,,,0.45062,1.02,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00172213070,NDC,,,facility,outpatient,1,EA,4.80000,1.39000,Aetna,Local,,2.44,,,,,,,1.73,3.93,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00172213060,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,Local,,3.93,,,,,,,2.79,6.34,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00172208380,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00172208360,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
Factor VIIa I (NovoSeven RT),800013451,CDM,636,RC,J7189,HCPCS,00169720101,NDC,facility,inpatient,1,ME,19483.00000,5650.07000,Aetna,Local,,7793.20,,,,,,,7023.62,15937.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glucagon 1mg/1mL Inj,800011536,CDM,636,RC,J1610,HCPCS,00169706515,NDC,facility,inpatient,1,ME,1415.90000,410.61000,Aetna,Local,,566.36,,,,,,,510.43,1158.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Factor VIIa I (NovoSeven RT),800013451,CDM,636,RC,J7189,HCPCS,00169701001,NDC,facility,inpatient,1,ME,19483.00000,5650.07000,Aetna,Local,,7793.20,,,,,,,7023.62,15937.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00168035756,NDC,,,facility,outpatient,1,EA,341.10000,98.92000,Aetna,Local,,173.18,,,,,,,122.97,279.02,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,800017777,CDM,250,RC,00168035755,NDC,,,facility,outpatient,1,EA,70.20000,20.36000,Aetna,Local,,35.64,,,,,,,25.31,57.42,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,00168035222,NDC,,,facility,outpatient,1,EA,269.65000,78.20000,Aetna,Local,,136.90,,,,,,,97.21,220.57,percent of total billed charges,
Nitroglycerin 2% TO 1g,800081827,CDM,637,RC,00168032608,NDC,,,facility,outpatient,1,GM,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Ciclopirox Olamine 0.77% TC 30g,800017765,CDM,637,RC,00168031330,NDC,,,facility,outpatient,1,EA,351.25000,101.86000,Aetna,Local,,178.33,,,,,,,126.63,287.32,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,00168030130,NDC,,,facility,outpatient,1,EA,850.35000,246.60000,Aetna,Local,,431.72,,,,,,,306.55,695.59,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,00168025815,NDC,,,facility,outpatient,1,EA,143.25000,41.54000,Aetna,Local,,72.73,,,,,,,51.64,117.18,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,00168024615,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,Local,,21.58,,,,,,,15.32,34.77,percent of total billed charges,
Lidocaine HCl 5% Topical Oint,800016055,CDM,637,RC,00168020437,NDC,,,facility,outpatient,1,EA,1809.00000,524.61000,Aetna,Local,,918.43,,,,,,,652.14,1479.76,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,00168017215,NDC,,,facility,outpatient,1,EA,10.55000,3.06000,Aetna,Local,,5.36,,,,,,,3.80,8.63,percent of total billed charges,
Clobetasol Prop 0.05% 30g TC(Temovate),800075381,CDM,637,RC,00168016330,NDC,,,facility,outpatient,1,EA,1587.75000,460.45000,Aetna,Local,,806.10,,,,,,,572.38,1298.78,percent of total billed charges,
Clobetasol Prop 0.05% 30g TO(Temovate),800075399,CDM,637,RC,00168016230,NDC,,,facility,outpatient,1,EA,1604.55000,465.32000,Aetna,Local,,814.63,,,,,,,578.44,1312.52,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00168015431,NDC,,,facility,outpatient,1,EA,35.95000,10.43000,Aetna,Local,,18.25,,,,,,,12.96,29.41,percent of total billed charges,
Fluocinonide 0.05% 15g TC(Lidex),800065507,CDM,637,RC,00168013915,NDC,,,facility,outpatient,1,EA,75.10000,21.78000,Aetna,Local,,38.13,,,,,,,27.07,61.43,percent of total billed charges,
Clotrimazole 1% 15g TC(Lotrimin),800015230,CDM,250,RC,00168013315,NDC,,,facility,outpatient,1,EA,140.90000,40.86000,Aetna,Local,,71.53,,,,,,,50.79,115.26,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,00168009915,NDC,,,facility,outpatient,1,EA,218.30000,63.31000,Aetna,Local,,110.83,,,,,,,78.70,178.57,percent of total billed charges,
Nystatin-Triamcinolone TC 30g,800081114,CDM,637,RC,00168008130,NDC,,,facility,outpatient,1,EA,980.05000,284.21000,Aetna,Local,,497.57,,,,,,,353.31,801.68,percent of total billed charges,
Hydrocortisone 2.5% 30g TC,800071083,CDM,637,RC,00168008031,NDC,,,facility,outpatient,1,EA,77.90000,22.59000,Aetna,Local,,39.55,,,,,,,28.08,63.72,percent of total billed charges,
Erythromycin 0.5% Ophth Oint 1g,800076231,CDM,637,RC,00168007011,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,Local,,14.98,,,,,,,10.63,24.13,percent of total billed charges,
Betamethasone Dipr 0.05% 60mL TL,800058635,CDM,637,RC,00168005760,NDC,,,facility,outpatient,1,EA,330.75000,95.92000,Aetna,Local,,167.92,,,,,,,119.24,270.55,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,00168005646,NDC,,,facility,outpatient,1,EA,284.70000,82.56000,Aetna,Local,,144.54,,,,,,,102.63,232.88,percent of total billed charges,
Betamethasone Dipr 0.05% TO 15g,800017760,CDM,637,RC,00168005615,NDC,,,facility,outpatient,1,EA,413.85000,120.02000,Aetna,Local,,210.11,,,,,,,149.19,338.53,percent of total billed charges,
Betamethasone Dipr 0.05%  TC 15g,800017761,CDM,637,RC,00168005515,NDC,,,facility,outpatient,1,EA,361.20000,104.75000,Aetna,Local,,183.38,,,,,,,130.21,295.46,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00168005430,NDC,,,facility,outpatient,1,EA,92.90000,26.94000,Aetna,Local,,47.17,,,,,,,33.49,75.99,percent of total billed charges,
Nystatin 15g TC,800049543,CDM,637,RC,00168005415,NDC,,,facility,outpatient,1,EA,21.25000,6.16000,Aetna,Local,,10.79,,,,,,,7.66,17.38,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00168003760,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
"NICU- Nystatin 100,000unit/1mL L",800017943,CDM,637,RC,00168003760,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Neo-Poly-Bac-Hc 3.5g Ophth Oint(Cortispor,800019588,CDM,637,RC,00168002938,NDC,,,facility,outpatient,1,EA,115.60000,33.52000,Aetna,Local,,58.69,,,,,,,41.67,94.56,percent of total billed charges,
Bac-Neo-Poly 3.5g Ophth Oint(Neosporin),800019711,CDM,250,RC,00168002738,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,Local,,5.15,,,,,,,3.66,8.30,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,00168002131,NDC,,,facility,outpatient,1,EA,84.30000,24.45000,Aetna,Local,,42.80,,,,,,,30.39,68.96,percent of total billed charges,
Hydrocortisone 1% 30g TC,800053263,CDM,250,RC,00168001531,NDC,,,facility,outpatient,1,EA,53.95000,15.65000,Aetna,Local,,27.39,,,,,,,19.45,44.13,percent of total billed charges,
Bac-Neo-Poly 28g TO(Triple Abx),800015594,CDM,250,RC,00168001231,NDC,,,facility,outpatient,1,EA,50.05000,14.51000,Aetna,Local,,25.41,,,,,,,18.04,40.94,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00168001135,NDC,,,facility,outpatient,1,EA,51.75000,15.01000,Aetna,Local,,26.27,,,,,,,18.66,42.33,percent of total billed charges,
Bacitracin 28g TO,800014480,CDM,250,RC,00168001131,NDC,,,facility,outpatient,1,EA,38.65000,11.21000,Aetna,Local,,19.62,,,,,,,13.93,31.62,percent of total billed charges,
Nystatin 15g TO,800015446,CDM,637,RC,00168000715,NDC,,,facility,outpatient,1,EA,118.95000,34.50000,Aetna,Local,,60.39,,,,,,,42.88,97.30,percent of total billed charges,
Triamcinolone 0.1% TO 80g,800080704,CDM,637,RC,00168000680,NDC,,,facility,outpatient,1,EA,98.70000,28.62000,Aetna,Local,,50.11,,,,,,,35.58,80.74,percent of total billed charges,
Triamcinolone 0.025% TO 80g,800017793,CDM,637,RC,00168000580,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,Local,,40.08,,,,,,,28.46,64.58,percent of total billed charges,
Triamcinolone 0.1% TC 80g,800017794,CDM,637,RC,00168000480,NDC,,,facility,outpatient,1,EA,59.45000,17.24000,Aetna,Local,,30.18,,,,,,,21.43,48.63,percent of total billed charges,
Triamcinolone 0.1% TC 454g,800077205,CDM,637,RC,00168000416,NDC,,,facility,outpatient,1,EA,179.65000,52.10000,Aetna,Local,,91.21,,,,,,,64.76,146.95,percent of total billed charges,
Triamcinolone 0.1% TC 15g,800080712,CDM,637,RC,00168000415,NDC,,,facility,outpatient,1,EA,25.50000,7.40000,Aetna,Local,,12.95,,,,,,,9.19,20.86,percent of total billed charges,
Triamcinolone 0.025% TC 80g,800017792,CDM,637,RC,00168000380,NDC,,,facility,outpatient,1,EA,78.95000,22.90000,Aetna,Local,,40.08,,,,,,,28.46,64.58,percent of total billed charges,
Nitrofurantoin Monohydrate-Macro 100mg C,800081212,CDM,637,RC,00149071001,NDC,,,facility,outpatient,1,EA,30.30000,8.79000,Aetna,Local,,15.38,,,,,,,10.92,24.79,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00149000805,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00143999301,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00143998391,NDC,facility,inpatient,2,GM,192.00000,55.68000,Aetna,Local,,76.80,,,,,,,69.22,157.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00143998303,NDC,facility,inpatient,2,GM,106.10000,30.77000,Aetna,Local,,42.44,,,,,,,38.25,86.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,00143998250,NDC,,,facility,outpatient,1,EA,26.75000,7.76000,Aetna,Local,,13.58,,,,,,,9.64,21.88,percent of total billed charges,
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00143992490,NDC,facility,inpatient,1000,ME,13.15000,3.81000,Aetna,Local,,5.26,,,,,,,4.74,10.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 500mg I (Ancef),800062014,CDM,636,RC,J0690,HCPCS,00143992390,NDC,facility,inpatient,500,ME,19.20000,5.57000,Aetna,Local,,7.68,,,,,,,6.92,15.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00143989906,NDC,facility,inpatient,200,ME,158.80000,46.05000,Aetna,Local,,63.52,,,,,,,57.25,129.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00143989705,NDC,,,facility,outpatient,1,EA,8.50000,2.46000,Aetna,Local,,4.32,,,,,,,3.06,6.95,percent of total billed charges,
Ondansetron 4mg/2mL IS(Zofran),800010895,CDM,636,RC,J2405,HCPCS,00143989105,NDC,facility,inpatient,4,ME,7.60000,2.20000,Aetna,Local,,3.04,,,,,,,2.74,6.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ondansetron Mdv I,800015173,CDM,636,RC,J2405,HCPCS,00143989001,NDC,facility,inpatient,4,ME,7.55000,2.19000,Aetna,Local,,3.02,,,,,,,2.72,6.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,00143988901,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
cefOXitin 2 g I (Mexfoxin),800013332,CDM,636,RC,J0694,HCPCS,00143987725,NDC,facility,inpatient,2,GM,76.80000,22.27000,Aetna,Local,,30.72,,,,,,,27.69,62.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00143987525,NDC,facility,inpatient,150,ME,19.20000,5.57000,Aetna,Local,,7.68,,,,,,,6.92,15.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00143987510,NDC,facility,inpatient,150,ME,20.00000,5.80000,Aetna,Local,,8.00,,,,,,,7.21,16.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00143987325,NDC,,,facility,outpatient,1,EA,2.05000,0.59000,Aetna,Local,,1.04,,,,,,,0.73903,1.68,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00143987310,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
CefTRIAXone 500mg I(Rocephin),800040962,CDM,636,RC,J0696,HCPCS,00143985825,NDC,facility,inpatient,500,ME,8.00000,2.32000,Aetna,Local,,3.20,,,,,,,2.88,6.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00143985725,NDC,facility,inpatient,1,GM,19.20000,5.57000,Aetna,Local,,7.68,,,,,,,6.92,15.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CefTRIAXone 2g I(Rocephin),800018758,CDM,636,RC,J0696,HCPCS,00143985625,NDC,facility,inpatient,2,GM,19.15000,5.55000,Aetna,Local,,7.66,,,,,,,6.90,15.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,00143985101,NDC,facility,inpatient,1,GM,389.90000,113.07000,Aetna,Local,,155.96,,,,,,,140.56,318.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,00143985001,NDC,facility,inpatient,500,ME,1518.50000,440.36000,Aetna,Local,,607.40,,,,,,,547.42,1242.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00143980350,NDC,,,facility,outpatient,1,EA,39.15000,11.35000,Aetna,Local,,19.88,,,,,,,14.11,32.02,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00143978825,NDC,facility,inpatient,100,ME,9.60000,2.78000,Aetna,Local,,3.84,,,,,,,3.46,7.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00143978710,NDC,,,facility,outpatient,1,EA,38.30000,11.11000,Aetna,Local,,19.44,,,,,,,13.81,31.33,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00143978610,NDC,,,facility,outpatient,1,EA,60.55000,17.56000,Aetna,Local,,30.74,,,,,,,21.83,49.53,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,00143978510,NDC,,,facility,outpatient,1,EA,67.20000,19.49000,Aetna,Local,,34.12,,,,,,,24.23,54.97,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00143978410,NDC,,,facility,outpatient,1,EA,43.25000,12.54000,Aetna,Local,,21.96,,,,,,,15.59,35.38,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00143978210,NDC,facility,inpatient,500,ME,66.00000,19.14000,Aetna,Local,,26.40,,,,,,,23.79,53.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00143974610,NDC,facility,inpatient,1,ME,25.55000,7.41000,Aetna,Local,,10.22,,,,,,,9.21,20.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00143972224,NDC,facility,inpatient,250,ME,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00143972201,NDC,facility,inpatient,250,ME,69.30000,20.10000,Aetna,Local,,27.72,,,,,,,24.98,56.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00143972101,NDC,facility,inpatient,500,ME,262.30000,76.07000,Aetna,Local,,104.92,,,,,,,94.56,214.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00143972024,NDC,facility,inpatient,750,ME,59.90000,17.37000,Aetna,Local,,23.96,,,,,,,21.59,49.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00143972001,NDC,facility,inpatient,750,ME,59.85000,17.36000,Aetna,Local,,23.94,,,,,,,21.58,48.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Milrinone 20mg/D5W 100mL,800046424,CDM,636,RC,J2260,HCPCS,00143971910,NDC,facility,inpatient,20,ME,155.05000,44.96000,Aetna,Local,,62.02,,,,,,,55.90,126.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00143968910,NDC,facility,inpatient,25,ME,260.00000,75.40000,Aetna,Local,,104.00,,,,,,,93.73,212.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00143968410,NDC,,,facility,outpatient,1,EA,41.50000,12.03000,Aetna,Local,,21.07,,,,,,,14.96,33.95,percent of total billed charges,
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00143968225,NDC,facility,inpatient,0.2,ME,16.60000,4.81000,Aetna,Local,,6.64,,,,,,,5.98,13.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,00143968025,NDC,facility,inpatient,1,ME,63.85000,18.52000,Aetna,Local,,25.54,,,,,,,23.02,52.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143967325,NDC,facility,inpatient,500,ME,38.40000,11.14000,Aetna,Local,,15.36,,,,,,,13.84,31.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143967310,NDC,facility,inpatient,500,ME,100.80000,29.23000,Aetna,Local,,40.32,,,,,,,36.34,82.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00143966806,NDC,facility,inpatient,400,ME,140.70000,40.80000,Aetna,Local,,56.28,,,,,,,50.72,115.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00143966010,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,00143963710,NDC,,,facility,outpatient,1,EA,165.95000,48.13000,Aetna,Local,,84.25,,,,,,,59.82,135.75,percent of total billed charges,
Cyanocobalamin 1mg/mL I(Vit B12),800010918,CDM,636,RC,J3420,HCPCS,00143962125,NDC,facility,inpatient,1,ME,44.20000,12.82000,Aetna,Local,,17.68,,,,,,,15.93,36.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00143959525,NDC,,,facility,inpatient,1,EA,15.70000,4.55000,Aetna,Local,,6.28,,,,,,,5.66,12.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00143959525,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,Local,,6.28,,,,,,,5.66,12.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,00143959425,NDC,,,facility,inpatient,1,EA,14.10000,4.09000,Aetna,Local,,5.64,,,,,,,5.08,11.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL I PF,800022057,CDM,636,RC,00143959425,NDC,,,facility,outpatient,1,EA,14.10000,4.09000,Aetna,Local,,5.64,,,,,,,5.08,11.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
niCARdipine 25mg/10mL I,800081595,CDM,636,RC,J2404,HCPCS,00143959310,NDC,facility,inpatient,25,ME,205.45000,59.58000,Aetna,Local,,82.18,,,,,,,74.06,168.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 0.2mg/1mL I(Robinu,800072164,CDM,636,RC,J1596,HCPCS,00143958725,NDC,facility,inpatient,0.2,ME,17.90000,5.19000,Aetna,Local,,7.16,,,,,,,6.45,14.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Glycopyrrolate 1mg/5mL Inj,800022063,CDM,636,RC,J1596,HCPCS,00143958525,NDC,facility,inpatient,1,ME,70.20000,20.36000,Aetna,Local,,28.08,,,,,,,25.31,57.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sertraline 100mg T,800017708,CDM,637,RC,00143958009,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,Local,,9.34,,,,,,,6.63,15.05,percent of total billed charges,
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00143957710,NDC,,,facility,inpatient,1,EA,17.80000,5.16000,Aetna,Local,,7.12,,,,,,,6.42,14.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00143957710,NDC,,,facility,outpatient,1,EA,17.80000,5.16000,Aetna,Local,,7.12,,,,,,,6.42,14.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00143957510,NDC,,,facility,inpatient,1,EA,23.50000,6.82000,Aetna,Local,,9.40,,,,,,,8.47,19.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00143957510,NDC,,,facility,outpatient,1,EA,23.50000,6.82000,Aetna,Local,,9.40,,,,,,,8.47,19.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143957425,NDC,facility,inpatient,500,ME,17.30000,5.02000,Aetna,Local,,6.92,,,,,,,6.24,14.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levETIRAcetam 500mg/5mL I(Keppra),800011902,CDM,636,RC,J1953,HCPCS,00143957410,NDC,facility,inpatient,500,ME,100.80000,29.23000,Aetna,Local,,40.32,,,,,,,36.34,82.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,00143955901,NDC,facility,inpatient,50,ME,1734.40000,502.98000,Aetna,Local,,693.76,,,,,,,625.25,1418.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Leucovorin Ca 350mg Inj,800012489,CDM,636,RC,J0640,HCPCS,00143955201,NDC,facility,inpatient,350,ME,247.00000,71.63000,Aetna,Local,,98.80,,,,,,,89.04,202.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00143954901,NDC,facility,inpatient,10,ME,62.40000,18.10000,Aetna,Local,,24.96,,,,,,,22.50,51.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00143954701,NDC,facility,inpatient,50,ME,265.00000,76.85000,Aetna,Local,,106.00,,,,,,,95.53,216.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00143953410,NDC,facility,inpatient,600,ME,134.40000,38.98000,Aetna,Local,,53.76,,,,,,,48.45,109.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexmedeTOMIDine 4mcg/mL IV 100mL,800017962,CDM,250,RC,00143952510,NDC,,,facility,outpatient,1,EA,322.20000,93.44000,Aetna,Local,,163.58,,,,,,,116.15,263.56,percent of total billed charges,
Methotrexate Na 50mg/2mL I PF,800022020,CDM,636,RC,J9260,HCPCS,00143951910,NDC,facility,inpatient,50,ME,27.30000,7.92000,Aetna,Local,,10.92,,,,,,,9.84,22.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,00143951001,NDC,facility,inpatient,10,ME,7.30000,2.12000,Aetna,Local,,2.92,,,,,,,2.63,5.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,00143950810,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00143950610,NDC,,,facility,outpatient,1,EA,39.70000,11.51000,Aetna,Local,,20.16,,,,,,,14.31,32.47,percent of total billed charges,
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,00143950301,NDC,facility,inpatient,500,ME,407.25000,118.10000,Aetna,Local,,162.90,,,,,,,146.81,333.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,00143950125,NDC,facility,inpatient,5,ME,10.20000,2.96000,Aetna,Local,,4.08,,,,,,,3.68,8.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00143943110,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,00143939810,NDC,facility,inpatient,1,GM,373.00000,108.17000,Aetna,Local,,149.20,,,,,,,134.47,305.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00143939601,NDC,,,facility,outpatient,1,EA,60.70000,17.60000,Aetna,Local,,30.82,,,,,,,21.88,49.65,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,00143939110,NDC,,,facility,outpatient,1,EA,552.50000,160.22000,Aetna,Local,,280.50,,,,,,,199.18,451.94,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00143938725,NDC,facility,inpatient,40,ME,33.20000,9.63000,Aetna,Local,,13.28,,,,,,,11.97,27.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Acetaminophen 1g/100mL Inj,800016841,CDM,636,RC,J0131,HCPCS,00143938610,NDC,facility,inpatient,1000,ME,122.40000,35.50000,Aetna,Local,,48.96,,,,,,,44.13,100.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00143938401,NDC,facility,inpatient,150,ME,390.80000,113.33000,Aetna,Local,,156.32,,,,,,,140.88,319.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Argatroban 50mg/50mL I,800046376,CDM,636,RC,J0883,HCPCS,00143937701,NDC,facility,inpatient,50,ME,930.00000,269.70000,Aetna,Local,,372.00,,,,,,,335.26,760.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etoposide 10mg/0.5mL Inj,800025611,CDM,636,RC,J9181,HCPCS,00143937601,NDC,facility,inpatient,10,ME,3.90000,1.13000,Aetna,Local,,1.56,,,,,,,1.41,3.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00143937510,NDC,facility,inpatient,1,ME,8.30000,2.41000,Aetna,Local,,3.32,,,,,,,2.99,6.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00143935901,NDC,facility,inpatient,1,GM,205.60000,59.62000,Aetna,Local,,82.24,,,,,,,74.12,168.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00143935710,NDC,facility,inpatient,1,GM,152.65000,44.27000,Aetna,Local,,61.06,,,,,,,55.03,124.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00143933410,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,Local,,9.72,,,,,,,6.90,15.66,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00143933310,NDC,,,facility,outpatient,1,EA,19.15000,5.55000,Aetna,Local,,9.72,,,,,,,6.90,15.66,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00143933110,NDC,,,facility,outpatient,1,EA,15.95000,4.63000,Aetna,Local,,8.10,,,,,,,5.75,13.05,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,800071620,CDM,250,RC,00143933010,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00143931810,NDC,,,facility,outpatient,1,EA,92.05000,26.69000,Aetna,Local,,46.73,,,,,,,33.18,75.30,percent of total billed charges,
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00143931724,NDC,facility,inpatient,750,ME,21.20000,6.15000,Aetna,Local,,8.48,,,,,,,7.64,17.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00143931624,NDC,facility,inpatient,500,ME,20.00000,5.80000,Aetna,Local,,8.00,,,,,,,7.21,16.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00143931524,NDC,facility,inpatient,250,ME,14.80000,4.29000,Aetna,Local,,5.92,,,,,,,5.34,12.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
etomidate 2mg/mL 20mL Inj,800046520,CDM,250,RC,00143931110,NDC,,,facility,outpatient,1,EA,25.55000,7.41000,Aetna,Local,,12.97,,,,,,,9.21,20.90,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00143931010,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00143930010,NDC,facility,inpatient,40,ME,21.70000,6.29000,Aetna,Local,,8.68,,,,,,,7.82,17.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00143928410,NDC,facility,inpatient,40,ME,41.50000,12.03000,Aetna,Local,,16.60,,,,,,,14.96,33.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,00143927901,NDC,facility,inpatient,20,ME,2941.00000,852.89000,Aetna,Local,,1176.40,,,,,,,1060.23,2405.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dihydroergotamine Mesylate 1mg/mL I(DHE 45),800058528,CDM,636,RC,J1110,HCPCS,00143927310,NDC,facility,inpatient,1,ME,571.30000,165.68000,Aetna,Local,,228.52,,,,,,,205.95,467.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROPivacaine 0.2% 20mL Inj,800013345,CDM,636,RC,J2795,HCPCS,00143926310,NDC,facility,inpatient,40,ME,55.60000,16.12000,Aetna,Local,,22.24,,,,,,,20.04,45.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00143926225,NDC,facility,inpatient,1000,ME,10.10000,2.93000,Aetna,Local,,4.04,,,,,,,3.64,8.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin Na MDV I (Ancef),800015137,CDM,636,RC,J0690,HCPCS,00143926110,NDC,facility,inpatient,2,GM,81.60000,23.66000,Aetna,Local,,32.64,,,,,,,29.42,66.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00143925010,NDC,,,facility,outpatient,1,EA,32.80000,9.51000,Aetna,Local,,16.65,,,,,,,11.82,26.83,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00143923410,NDC,,,facility,outpatient,1,EA,32.85000,9.53000,Aetna,Local,,16.68,,,,,,,11.84,26.87,percent of total billed charges,
Chloroprocaine HCl 3% 20mL PfI(Nesacain,800040641,CDM,636,RC,J2401,HCPCS,00143921010,NDC,facility,inpatient,600,ME,143.45000,41.60000,Aetna,Local,,57.38,,,,,,,51.71,117.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00143916401,NDC,facility,inpatient,1,GM,500.00000,145.00000,Aetna,Local,,200.00,,,,,,,180.25,409.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00143916210,NDC,facility,inpatient,1,GM,57.60000,16.70000,Aetna,Local,,23.04,,,,,,,20.76,47.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,00143913501,NDC,facility,inpatient,20,ME,747.00000,216.63000,Aetna,Local,,298.80,,,,,,,269.29,611.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fulvestrant 250mg/5mL I(Faslodex),800010939,CDM,636,RC,J9395,HCPCS,00143902202,NDC,facility,inpatient,250,ME,300.20000,87.06000,Aetna,Local,,120.08,,,,,,,108.22,245.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
acetaZOLAMIDE 500mg I,800011247,CDM,636,RC,J1120,HCPCS,00143900601,NDC,facility,inpatient,500,ME,310.00000,89.90000,Aetna,Local,,124.00,,,,,,,111.75,253.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lithium Carb 150mg C,800017633,CDM,637,RC,00143318801,NDC,,,facility,outpatient,1,EA,0.95000,0.28000,Aetna,Local,,0.48231,,,,,,,0.34247,0.77710,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00143314250,NDC,,,facility,outpatient,1,EA,39.15000,11.35000,Aetna,Local,,19.88,,,,,,,14.11,32.02,percent of total billed charges,
Doxycycline 100mg C(Vibramycin),800020809,CDM,637,RC,00143314205,NDC,,,facility,outpatient,1,EA,12.05000,3.49000,Aetna,Local,,6.12,,,,,,,4.34,9.86,percent of total billed charges,
Dicyclomine HCl 10mg C(Bentyl),800011071,CDM,637,RC,00143312601,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00143223001,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00143212801,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,Local,,3.96,,,,,,,2.81,6.38,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00143178701,NDC,,,facility,outpatient,1,EA,11.95000,3.47000,Aetna,Local,,6.07,,,,,,,4.31,9.78,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00143177101,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,Local,,3.88,,,,,,,2.76,6.26,percent of total billed charges,
Trihexyphenidyl 2mg T(Artane),800010735,CDM,637,RC,00143176401,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,Local,,0.66001,,,,,,,0.46865,1.06,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,00143150001,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Primidone 250mg T(Mysoline),800016476,CDM,637,RC,00143148401,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00143148205,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Primidone 50mg T(Mysoline),800016468,CDM,637,RC,00143148201,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Propylthiouracil 50mg T(Ptu),800018050,CDM,637,RC,00143148001,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,Local,,2.69,,,,,,,1.91,4.34,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,00143145805,NDC,,,facility,outpatient,1,EA,3.00000,0.87000,Aetna,Local,,1.52,,,,,,,1.08,2.45,percent of total billed charges,
PHENobarbital 100mg T,800017573,CDM,637,RC,00143145801,NDC,,,facility,outpatient,1,EA,5.95000,1.73000,Aetna,Local,,3.02,,,,,,,2.14,4.87,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,00143145005,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
PHENobarbital 30mg T,800015585,CDM,637,RC,00143145001,NDC,,,facility,outpatient,1,EA,3.40000,0.99000,Aetna,Local,,1.73,,,,,,,1.23,2.78,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,00143134601,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00143129205,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00143129201,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00143129005,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
Methocarbamol 500mg T(Robaxin),800018415,CDM,637,RC,00143129001,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00143127701,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,Local,,1.88,,,,,,,1.33,3.03,percent of total billed charges,
Lisinopril 2.5mg T(Zestril),800015406,CDM,637,RC,00143126501,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00143125601,NDC,,,facility,outpatient,1,EA,0.60000,0.17000,Aetna,Local,,0.30462,,,,,,,0.21630,0.49080,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00143124810,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Folic Acid 1mg T,800031905,CDM,637,RC,00143124801,NDC,,,facility,outpatient,1,EA,2.45000,0.71000,Aetna,Local,,1.24,,,,,,,0.88323,2.00,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00143124001,NDC,,,facility,outpatient,1,EA,16.30000,4.73000,Aetna,Local,,8.28,,,,,,,5.88,13.33,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00143120125,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Colchicine 0.6mg T,800011790,CDM,637,RC,00143120101,NDC,,,facility,outpatient,1,EA,0.75000,0.22000,Aetna,Local,,0.38077,,,,,,,0.27037,0.61350,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00135020003,NDC,,,facility,outpatient,1,EA,218.80000,63.45000,Aetna,Local,,111.08,,,,,,,78.88,178.98,percent of total billed charges,
Docosanol 10%  2g TC,800081645,CDM,250,RC,00135020001,NDC,,,facility,outpatient,1,EA,218.85000,63.47000,Aetna,Local,,111.11,,,,,,,78.90,179.02,percent of total billed charges,
Mineral Oil 100% Enema,800018020,CDM,637,RC,00132030140,NDC,,,facility,outpatient,1,EA,18.50000,5.36000,Aetna,Local,,9.39,,,,,,,6.67,15.13,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,00131247760,NDC,,,facility,outpatient,1,EA,127.50000,36.97000,Aetna,Local,,64.73,,,,,,,45.96,104.30,percent of total billed charges,
Lacosamide 50mg T (Vimpat),800072468,CDM,637,RC,00131247735,NDC,,,facility,outpatient,1,EA,115.90000,33.61000,Aetna,Local,,58.84,,,,,,,41.78,94.81,percent of total billed charges,
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,inpatient,200,ME,859.85000,249.36000,Aetna,Local,,343.94,,,,,,,309.98,703.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lacosamide 200mg/20mL I,800015110,CDM,636,RC,C9254,HCPCS,00131181067,NDC,facility,outpatient,200,ME,859.85000,249.36000,Aetna,Local,,343.94,,,,,,,0.37557,703.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00126027116,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,00121495040,NDC,,,facility,outpatient,1,EA,54.55000,15.82000,Aetna,Local,,27.70,,,,,,,19.67,44.62,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00121483940,NDC,,,facility,outpatient,1,EA,59.05000,17.12000,Aetna,Local,,29.98,,,,,,,21.29,48.30,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00121482740,NDC,,,facility,outpatient,1,EA,59.45000,17.24000,Aetna,Local,,30.18,,,,,,,21.43,48.63,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121481040,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,Local,,6.04,,,,,,,4.29,9.73,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121481000,NDC,,,facility,outpatient,1,EA,11.70000,3.39000,Aetna,Local,,5.94,,,,,,,4.22,9.57,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,00121480205,NDC,,,facility,outpatient,1,EA,66.20000,19.20000,Aetna,Local,,33.61,,,,,,,23.87,54.15,percent of total billed charges,
levETIRAcetam 500mg/5mL L UD,800072499,CDM,637,RC,00121479905,NDC,,,facility,outpatient,1,EA,53.25000,15.44000,Aetna,Local,,27.04,,,,,,,19.20,43.56,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,800072524,CDM,637,RC,00121479320,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,Local,,14.37,,,,,,,10.20,23.15,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121478505,NDC,,,facility,outpatient,1,EA,8.95000,2.60000,Aetna,Local,,4.54,,,,,,,3.23,7.32,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00121477610,NDC,,,facility,outpatient,1,EA,32.05000,9.29000,Aetna,Local,,16.27,,,,,,,11.55,26.22,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,00121477410,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,Local,,4.14,,,,,,,2.94,6.67,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00121477405,NDC,,,facility,outpatient,1,EA,13.30000,3.86000,Aetna,Local,,6.75,,,,,,,4.79,10.88,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,800018013,CDM,637,RC,00121477210,NDC,,,facility,outpatient,1,EA,64.15000,18.60000,Aetna,Local,,32.57,,,,,,,23.13,52.47,percent of total billed charges,
FLUoxetine 20mg/5mL L UD,800015336,CDM,637,RC,00121472105,NDC,,,facility,outpatient,1,EA,48.30000,14.01000,Aetna,Local,,24.52,,,,,,,17.41,39.51,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,00121467510,NDC,,,facility,outpatient,1,EA,17.90000,5.19000,Aetna,Local,,9.09,,,,,,,6.45,14.64,percent of total billed charges,
Valproic Acid 250 mg/5 mL Liq UD,800015339,CDM,637,RC,00121467505,NDC,,,facility,outpatient,1,EA,229.05000,66.42000,Aetna,Local,,116.29,,,,,,,82.57,187.36,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,800062055,CDM,637,RC,00121457715,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121252040,NDC,,,facility,outpatient,1,EA,165.60000,48.02000,Aetna,Local,,84.08,,,,,,,59.70,135.46,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121189600,NDC,,,facility,outpatient,1,EA,157.10000,45.56000,Aetna,Local,,79.76,,,,,,,56.63,128.51,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,00121189494,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,Local,,16.35,,,,,,,11.61,26.34,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00121183605,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
Ibuprofen 200mg/10mL L UD,800072523,CDM,637,RC,00121182800,NDC,,,facility,outpatient,1,EA,10.35000,3.00000,Aetna,Local,,5.25,,,,,,,3.73,8.47,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,800072518,CDM,637,RC,00121177510,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
carBAMazepine 200mg/10mL Oral L UD,800072521,CDM,637,RC,00121172430,NDC,,,facility,outpatient,1,EA,32.20000,9.34000,Aetna,Local,,16.35,,,,,,,11.61,26.34,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00121168040,NDC,,,facility,outpatient,1,EA,107.75000,31.25000,Aetna,Local,,54.70,,,,,,,38.84,88.14,percent of total billed charges,
GuaiFENesin-Codeine 10mL L UD,800072518,CDM,637,RC,00121155000,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Hydrocodone-Acet 5-217mg/10mL L UD,800018013,CDM,637,RC,00121154440,NDC,,,facility,outpatient,1,EA,90.30000,26.19000,Aetna,Local,,45.85,,,,,,,32.55,73.87,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121146530,NDC,,,facility,outpatient,1,EA,43.65000,12.66000,Aetna,Local,,22.16,,,,,,,15.74,35.71,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00121146515,NDC,,,facility,outpatient,1,EA,38.35000,11.12000,Aetna,Local,,19.47,,,,,,,13.83,31.37,percent of total billed charges,
Valproic Acid 500mg/10mL L UD,800072502,CDM,637,RC,00121135000,NDC,,,facility,outpatient,1,EA,21.85000,6.34000,Aetna,Local,,11.09,,,,,,,7.88,17.87,percent of total billed charges,
Na Citrate-Citric Acid 30mL L(Bicit,800072313,CDM,637,RC,00121119000,NDC,,,facility,outpatient,1,EA,44.90000,13.02000,Aetna,Local,,22.80,,,,,,,16.19,36.73,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,00121115440,NDC,,,facility,outpatient,1,EA,17.40000,5.05000,Aetna,Local,,8.83,,,,,,,6.27,14.23,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00121097494,NDC,,,facility,outpatient,1,EA,76.90000,22.30000,Aetna,Local,,39.04,,,,,,,27.72,62.90,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00121097251,NDC,,,facility,outpatient,1,EA,9.15000,2.65000,Aetna,Local,,4.65,,,,,,,3.30,7.48,percent of total billed charges,
Lidocaine 4% TD Patch,800046543,CDM,637,RC,00121097030,NDC,,,facility,outpatient,1,EA,16.60000,4.81000,Aetna,Local,,8.43,,,,,,,5.98,13.58,percent of total billed charges,
carBAMazepine 100mg/5mL Oral L UD,800015355,CDM,637,RC,00121094794,NDC,,,facility,outpatient,1,EA,25.70000,7.45000,Aetna,Local,,13.05,,,,,,,9.26,21.02,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00121094540,NDC,,,facility,outpatient,1,EA,47.60000,13.80000,Aetna,Local,,24.17,,,,,,,17.16,38.94,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00121094500,NDC,,,facility,outpatient,1,EA,35.50000,10.30000,Aetna,Local,,18.02,,,,,,,12.80,29.04,percent of total billed charges,
Promethazine HCl 12.5mg/10mL Liq,800015344,CDM,637,RC,00121092716,NDC,,,facility,outpatient,1,EA,7.20000,2.09000,Aetna,Local,,3.66,,,,,,,2.60,5.89,percent of total billed charges,
Ibuprofen 100mg/5mL L UD,800077379,CDM,250,RC,00121091700,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
diazePAM 5mg/5mL UD Oral Soln,800022076,CDM,637,RC,00121090594,NDC,,,facility,outpatient,1,EA,36.80000,10.67000,Aetna,Local,,18.68,,,,,,,13.27,30.10,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,00121090340,NDC,,,facility,outpatient,1,EA,33.10000,9.60000,Aetna,Local,,16.80,,,,,,,11.93,27.08,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00121089842,NDC,,,facility,outpatient,1,EA,286.75000,83.16000,Aetna,Local,,145.58,,,,,,,103.37,234.56,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00121089340,NDC,,,facility,outpatient,1,EA,16.15000,4.68000,Aetna,Local,,8.20,,,,,,,5.82,13.21,percent of total billed charges,
Phenytoin 100mg/4mL L UD,800023332,CDM,637,RC,00121089250,NDC,,,facility,outpatient,1,EA,61.15000,17.73000,Aetna,Local,,31.05,,,,,,,22.04,50.02,percent of total billed charges,
Atovaquone 750 mg/5 mL Susp UD (Mepron),800080860,CDM,637,RC,00121088842,NDC,,,facility,outpatient,1,EA,286.75000,83.16000,Aetna,Local,,145.58,,,,,,,103.37,234.56,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121086850,NDC,,,facility,outpatient,1,EA,16.65000,4.83000,Aetna,Local,,8.45,,,,,,,6.00,13.62,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121086800,NDC,,,facility,outpatient,1,EA,16.05000,4.65000,Aetna,Local,,8.15,,,,,,,5.79,13.13,percent of total billed charges,
Sulfamethoxazole-Trimetho 800-160 mg/20mL L,800072524,CDM,637,RC,00121085340,NDC,,,facility,outpatient,1,EA,145.05000,42.06000,Aetna,Local,,73.64,,,,,,,52.29,118.65,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00121081016,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,4.42,,,,,,,3.14,7.12,percent of total billed charges,
LORazepam 1mg/0.5mL Oral Conc,800025501,CDM,637,RC,00121077001,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00121074740,NDC,,,facility,outpatient,1,EA,86.25000,25.01000,Aetna,Local,,43.79,,,,,,,31.09,70.55,percent of total billed charges,
Sucralfate 1g/10mL L UD,800075688,CDM,637,RC,00121074710,NDC,,,facility,outpatient,1,EA,71.20000,20.65000,Aetna,Local,,36.15,,,,,,,25.67,58.24,percent of total billed charges,
oxyBUTYnin 5mg/5mL L UD,800015338,CDM,637,RC,00121067105,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,Local,,9.34,,,,,,,6.63,15.05,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,00121064616,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,Local,,5.53,,,,,,,3.93,8.92,percent of total billed charges,
Amantadine 100mg/10mL Oral Liq UD,800015354,CDM,637,RC,00121064610,NDC,,,facility,outpatient,1,EA,34.95000,10.14000,Aetna,Local,,17.74,,,,,,,12.60,28.59,percent of total billed charges,
Na Citrate-Citric Acid 30mL L(Bicit,800072313,CDM,637,RC,00121059530,NDC,,,facility,outpatient,1,EA,21.10000,6.12000,Aetna,Local,,10.71,,,,,,,7.61,17.26,percent of total billed charges,
Haloperidol 1mg/0.5mL LC UD,800015323,CDM,637,RC,00121058104,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Haloperidol 0.5mg/0.25mL LC UD,800015324,CDM,637,RC,00121058104,NDC,,,facility,outpatient,1,EA,0.80000,0.23000,Aetna,Local,,0.40616,,,,,,,0.28840,0.65440,percent of total billed charges,
Haloperidol 5mg/2.5mL LC UD,800021986,CDM,637,RC,00121058104,NDC,,,facility,outpatient,1,EA,8.00000,2.32000,Aetna,Local,,4.06,,,,,,,2.88,6.54,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00121057716,NDC,,,facility,outpatient,1,EA,0.50000,0.14000,Aetna,Local,,0.25385,,,,,,,0.18025,0.40900,percent of total billed charges,
PHENobarbital 40mg/10mL Soln,800025499,CDM,637,RC,00121053116,NDC,,,facility,outpatient,1,EA,4.00000,1.16000,Aetna,Local,,2.03,,,,,,,1.44,3.27,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00121046530,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Lactulose 10g/15mL Oral Liq UD,800062055,CDM,637,RC,00116400540,NDC,,,facility,outpatient,1,EA,12.40000,3.60000,Aetna,Local,,6.30,,,,,,,4.47,10.14,percent of total billed charges,
Lactulose 20g/30mL Oral Liq UD,800040955,CDM,637,RC,00116400530,NDC,,,facility,outpatient,1,EA,13.95000,4.05000,Aetna,Local,,7.08,,,,,,,5.03,11.41,percent of total billed charges,
Chlorhexidine Gluc 0.12% TS 480mL,800025528,CDM,637,RC,00116200116,NDC,,,facility,outpatient,1,EA,86.20000,25.00000,Aetna,Local,,43.76,,,,,,,31.08,70.51,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00116200116,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00116200115,NDC,,,facility,outpatient,1,EA,23.00000,6.67000,Aetna,Local,,11.68,,,,,,,8.29,18.81,percent of total billed charges,
Chlorhexidine Gluc 0.12% 15mL L(Peridex),800067651,CDM,637,RC,00116200107,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Digoxin 125mcg (0.125mg) T,800015270,CDM,637,RC,00115981101,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00115821101,NDC,,,facility,outpatient,1,EA,29.80000,8.64000,Aetna,Local,,15.13,,,,,,,10.74,24.38,percent of total billed charges,
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,00115703501,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00115703302,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,Local,,2.69,,,,,,,1.91,4.34,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00115703301,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,Local,,2.69,,,,,,,1.91,4.34,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00115681110,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,Local,,18.73,,,,,,,13.30,30.18,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00115592201,NDC,,,facility,outpatient,1,EA,11.45000,3.32000,Aetna,Local,,5.81,,,,,,,4.13,9.37,percent of total billed charges,
Fenofibrate 160mg T(Tricor),800081169,CDM,637,RC,00115552210,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,Local,,8.55,,,,,,,6.07,13.78,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,00115551110,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,00115521218,NDC,,,facility,outpatient,1,EA,27.85000,8.08000,Aetna,Local,,14.14,,,,,,,10.04,22.78,percent of total billed charges,
Colestipol 1g T(Colestid),800073097,CDM,637,RC,00115521116,NDC,,,facility,outpatient,1,EA,8.75000,2.54000,Aetna,Local,,4.44,,,,,,,3.15,7.16,percent of total billed charges,
Midodrine 5 mg T(Proamatine),800081322,CDM,637,RC,00115422201,NDC,,,facility,outpatient,1,EA,17.10000,4.96000,Aetna,Local,,8.68,,,,,,,6.16,13.99,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00115391101,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,Local,,6.50,,,,,,,4.61,10.47,percent of total billed charges,
pyRIDostigmine Br 60mg T(Mestinon),800032291,CDM,637,RC,00115351101,NDC,,,facility,outpatient,1,EA,9.05000,2.62000,Aetna,Local,,4.59,,,,,,,3.26,7.40,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,00115211101,NDC,,,facility,outpatient,1,EA,65.45000,18.98000,Aetna,Local,,33.23,,,,,,,23.59,53.54,percent of total billed charges,
Orphenadrine Citrate 100mg CR T,800060284,CDM,637,RC,00115201101,NDC,,,facility,outpatient,1,EA,15.40000,4.47000,Aetna,Local,,7.82,,,,,,,5.55,12.60,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00115169701,NDC,,,facility,outpatient,1,EA,4.05000,1.17000,Aetna,Local,,2.06,,,,,,,1.46,3.31,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,00115169606,NDC,,,facility,outpatient,1,EA,2.40000,0.70000,Aetna,Local,,1.22,,,,,,,0.86520,1.96,percent of total billed charges,
EPINEPHrine 0.3 mg Syringe,800019821,CDM,636,RC,J0165,HCPCS,00115169449,NDC,facility,inpatient,0.3,ME,1010.05000,292.91000,Aetna,Local,,404.02,,,,,,,364.12,826.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propranolol HCl 20mg T(Inderal),800014885,CDM,637,RC,00115166001,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Propranolol HCl 10mg T(Inderal),800014877,CDM,637,RC,00115165901,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,00115107001,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,800081112,CDM,250,RC,00113030602,NDC,,,facility,outpatient,1,EA,52.30000,15.17000,Aetna,Local,,26.55,,,,,,,18.85,42.78,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00093977401,NDC,,,facility,outpatient,1,EA,8.30000,2.41000,Aetna,Local,,4.21,,,,,,,2.99,6.79,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00093970201,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00093943301,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00093938001,NDC,,,facility,outpatient,1,EA,6.55000,1.90000,Aetna,Local,,3.33,,,,,,,2.36,5.36,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00093913352,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,Local,,1.12,,,,,,,0.79310,1.80,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00093913306,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00093894093,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Acyclovir 200mg C(Zovirax),800051101,CDM,637,RC,00093894001,NDC,,,facility,outpatient,1,EA,6.90000,2.00000,Aetna,Local,,3.50,,,,,,,2.49,5.64,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,00093874001,NDC,,,facility,outpatient,1,EA,21.45000,6.22000,Aetna,Local,,10.89,,,,,,,7.73,17.55,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,00093873901,NDC,,,facility,outpatient,1,EA,17.95000,5.21000,Aetna,Local,,9.11,,,,,,,6.47,14.68,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00093834301,NDC,,,facility,outpatient,1,EA,3.25000,0.94000,Aetna,Local,,1.65,,,,,,,1.17,2.66,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00093824434,NDC,,,facility,outpatient,1,EA,1114.90000,323.32000,Aetna,Local,,566.03,,,,,,,401.92,911.99,percent of total billed charges,
NIFEdipine 10mg C(Adalat/Procardia),800060136,CDM,637,RC,00093817101,NDC,,,facility,outpatient,1,EA,4.75000,1.38000,Aetna,Local,,2.41,,,,,,,1.71,3.89,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00093812101,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00093812001,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00093811956,NDC,,,facility,outpatient,1,EA,89.85000,26.06000,Aetna,Local,,45.62,,,,,,,32.39,73.50,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,00093811856,NDC,,,facility,outpatient,1,EA,44.75000,12.98000,Aetna,Local,,22.72,,,,,,,16.13,36.61,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00093777293,NDC,,,facility,outpatient,1,EA,24.25000,7.03000,Aetna,Local,,12.31,,,,,,,8.74,19.84,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00093777201,NDC,,,facility,outpatient,1,EA,23.55000,6.83000,Aetna,Local,,11.96,,,,,,,8.49,19.26,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00093768432,NDC,,,facility,outpatient,1,EA,1146.65000,332.53000,Aetna,Local,,582.15,,,,,,,413.37,937.96,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,00093762998,NDC,,,facility,outpatient,1,EA,654.30000,189.75000,Aetna,Local,,332.19,,,,,,,235.88,535.22,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,00093762056,NDC,,,facility,outpatient,1,EA,128.40000,37.24000,Aetna,Local,,65.19,,,,,,,46.29,105.03,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00093754456,NDC,,,facility,outpatient,1,EA,11.55000,3.35000,Aetna,Local,,5.86,,,,,,,4.16,9.45,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00093747701,NDC,facility,inpatient,500,ME,56.20000,16.30000,Aetna,Local,,22.48,,,,,,,20.26,45.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ramipril 5mg C(Altace),800070994,CDM,637,RC,00093743701,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,00093743601,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,Local,,6.50,,,,,,,4.61,10.47,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00093743398,NDC,,,facility,outpatient,1,EA,36.90000,10.70000,Aetna,Local,,18.73,,,,,,,13.30,30.18,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00093743298,NDC,,,facility,outpatient,1,EA,34.30000,9.95000,Aetna,Local,,17.41,,,,,,,12.37,28.06,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00093738698,NDC,,,facility,outpatient,1,EA,36.00000,10.44000,Aetna,Local,,18.28,,,,,,,12.98,29.45,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00093738598,NDC,,,facility,outpatient,1,EA,33.05000,9.58000,Aetna,Local,,16.78,,,,,,,11.91,27.03,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00093738556,NDC,,,facility,outpatient,1,EA,33.05000,9.58000,Aetna,Local,,16.78,,,,,,,11.91,27.03,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00093738498,NDC,,,facility,outpatient,1,EA,29.50000,8.56000,Aetna,Local,,14.98,,,,,,,10.63,24.13,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00093738001,NDC,,,facility,outpatient,1,EA,14.15000,4.10000,Aetna,Local,,7.18,,,,,,,5.10,11.57,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00093736698,NDC,,,facility,outpatient,1,EA,1.45000,0.42000,Aetna,Local,,0.73616,,,,,,,0.52272,1.19,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00093736598,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00093736556,NDC,,,facility,outpatient,1,EA,1.05000,0.30000,Aetna,Local,,0.53309,,,,,,,0.37853,0.85890,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00093736498,NDC,,,facility,outpatient,1,EA,11.90000,3.45000,Aetna,Local,,6.04,,,,,,,4.29,9.73,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735598,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735556,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735505,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093735501,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Tamsulosin 0.4mg C(Flomax),800074665,CDM,637,RC,00093733801,NDC,,,facility,outpatient,1,EA,29.85000,8.66000,Aetna,Local,,15.15,,,,,,,10.76,24.42,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,00093733606,NDC,,,facility,outpatient,1,EA,20.70000,6.00000,Aetna,Local,,10.51,,,,,,,7.46,16.93,percent of total billed charges,
Desmopressin 0.1 mg Tab,800017366,CDM,637,RC,00093731601,NDC,,,facility,outpatient,1,EA,37.40000,10.85000,Aetna,Local,,18.99,,,,,,,13.48,30.59,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00093729056,NDC,,,facility,outpatient,1,EA,50.45000,14.63000,Aetna,Local,,25.61,,,,,,,18.19,41.27,percent of total billed charges,
levETIRAcetam 250 mg T(Keppra),800081785,CDM,637,RC,00093728589,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
metFORMIN 500mg ER T,800080589,CDM,637,RC,00093726701,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Glimepiride 1mg T (Amaryl),800017610,CDM,637,RC,00093725401,NDC,,,facility,outpatient,1,EA,7.65000,2.22000,Aetna,Local,,3.88,,,,,,,2.76,6.26,percent of total billed charges,
Cilostazol 100 mg Tab,800017385,CDM,637,RC,00093723106,NDC,,,facility,outpatient,1,EA,12.90000,3.74000,Aetna,Local,,6.55,,,,,,,4.65,10.55,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,00093721906,NDC,,,facility,outpatient,1,EA,1.40000,0.41000,Aetna,Local,,0.71078,,,,,,,0.50470,1.15,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00093720656,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,Local,,9.75,,,,,,,6.92,15.71,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00093720356,NDC,,,facility,outpatient,1,EA,62.35000,18.08000,Aetna,Local,,31.66,,,,,,,22.48,51.00,percent of total billed charges,
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00093720198,NDC,,,facility,outpatient,1,EA,23.15000,6.71000,Aetna,Local,,11.75,,,,,,,8.35,18.94,percent of total billed charges,
Sertraline 100mg T,800017708,CDM,637,RC,00093717756,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,Local,,9.75,,,,,,,6.92,15.71,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00093717656,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,Local,,9.75,,,,,,,6.92,15.71,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00093716755,NDC,,,facility,outpatient,1,EA,12.25000,3.55000,Aetna,Local,,6.22,,,,,,,4.42,10.02,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00093716356,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,Local,,28.89,,,,,,,20.51,46.54,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00093715806,NDC,,,facility,outpatient,1,EA,32.00000,9.28000,Aetna,Local,,16.25,,,,,,,11.54,26.18,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,00093714823,NDC,,,facility,outpatient,1,EA,82.65000,23.97000,Aetna,Local,,41.96,,,,,,,29.80,67.61,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00093714656,NDC,,,facility,outpatient,1,EA,55.10000,15.98000,Aetna,Local,,27.97,,,,,,,19.86,45.07,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,00093712901,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,00093712701,NDC,,,facility,outpatient,1,EA,4.50000,1.30000,Aetna,Local,,2.28,,,,,,,1.62,3.68,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00093711498,NDC,,,facility,outpatient,1,EA,17.85000,5.18000,Aetna,Local,,9.06,,,,,,,6.43,14.60,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,00093688871,NDC,,,facility,outpatient,1,EA,180.60000,52.37000,Aetna,Local,,91.69,,,,,,,65.11,147.73,percent of total billed charges,
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,00093590786,NDC,,,facility,outpatient,1,EA,31.30000,9.08000,Aetna,Local,,15.89,,,,,,,11.28,25.60,percent of total billed charges,
Escitalopram 20 mg T(lexapro),800080381,CDM,637,RC,00093585201,NDC,,,facility,outpatient,1,EA,31.95000,9.27000,Aetna,Local,,16.22,,,,,,,11.52,26.14,percent of total billed charges,
Escitalopram 10 mg T(Lexapro),800080373,CDM,637,RC,00093585101,NDC,,,facility,outpatient,1,EA,30.65000,8.89000,Aetna,Local,,15.56,,,,,,,11.05,25.07,percent of total billed charges,
Escitalopram 5mg T(Lexapro),800015399,CDM,637,RC,00093585001,NDC,,,facility,outpatient,1,EA,29.30000,8.50000,Aetna,Local,,14.88,,,,,,,10.56,23.97,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093582556,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00093582501,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00093576756,NDC,,,facility,outpatient,1,EA,1.65000,0.48000,Aetna,Local,,0.83771,,,,,,,0.59483,1.35,percent of total billed charges,
oxyCODONE 20mg/12hr ER T(OxyCONTIN),800073568,CDM,637,RC,00093573201,NDC,,,facility,outpatient,1,EA,45.10000,13.08000,Aetna,Local,,22.90,,,,,,,16.26,36.89,percent of total billed charges,
buPROPion 150mg SR/12 hr T(Wellbutrin SR),800073477,CDM,637,RC,00093550201,NDC,,,facility,outpatient,1,EA,12.80000,3.71000,Aetna,Local,,6.50,,,,,,,4.61,10.47,percent of total billed charges,
buPROPion 100mg SR/12 hr T(Wellbutrin SR),800073550,CDM,637,RC,00093550101,NDC,,,facility,outpatient,1,EA,19.95000,5.79000,Aetna,Local,,10.13,,,,,,,7.19,16.32,percent of total billed charges,
buPROPion 150mg XL / 24 hr T,800082080,CDM,637,RC,00093535056,NDC,,,facility,outpatient,1,EA,33.80000,9.80000,Aetna,Local,,17.16,,,,,,,12.18,27.65,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00093528501,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,Local,,9.01,,,,,,,6.40,14.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00093528401,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,Local,,9.01,,,,,,,6.40,14.52,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00093527056,NDC,,,facility,outpatient,1,EA,8.60000,2.49000,Aetna,Local,,4.37,,,,,,,3.10,7.03,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,00093524565,NDC,,,facility,outpatient,1,EA,101.05000,29.30000,Aetna,Local,,51.30,,,,,,,36.43,82.66,percent of total billed charges,
oxyBUTYnin 5mg XL T(Ditropan XL),800077031,CDM,637,RC,00093520601,NDC,,,facility,outpatient,1,EA,23.30000,6.76000,Aetna,Local,,11.83,,,,,,,8.40,19.06,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,00093519501,NDC,,,facility,outpatient,1,EA,2.80000,0.81000,Aetna,Local,,1.42,,,,,,,1.01,2.29,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00093511998,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,Local,,9.54,,,,,,,6.78,15.38,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00093511798,NDC,,,facility,outpatient,1,EA,10.25000,2.97000,Aetna,Local,,5.20,,,,,,,3.70,8.38,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00093505998,NDC,,,facility,outpatient,1,EA,75.75000,21.97000,Aetna,Local,,38.46,,,,,,,27.31,61.96,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00093505898,NDC,,,facility,outpatient,1,EA,75.75000,21.97000,Aetna,Local,,38.46,,,,,,,27.31,61.96,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00093505698,NDC,,,facility,outpatient,1,EA,53.10000,15.40000,Aetna,Local,,26.96,,,,,,,19.14,43.44,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00093444305,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,6.13,13.91,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00093436001,NDC,,,facility,outpatient,1,EA,23.55000,6.83000,Aetna,Local,,11.96,,,,,,,8.49,19.26,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00093435993,NDC,,,facility,outpatient,1,EA,9.35000,2.71000,Aetna,Local,,4.75,,,,,,,3.37,7.65,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00093435901,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,Local,,4.62,,,,,,,3.28,7.44,percent of total billed charges,
FLUoxetine HCl 20mg C(PROzac),800071026,CDM,637,RC,00093435601,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,Local,,9.60,,,,,,,6.81,15.46,percent of total billed charges,
Terazosin 5mg C(Hytrin),800065952,CDM,637,RC,00093433801,NDC,,,facility,outpatient,1,EA,11.35000,3.29000,Aetna,Local,,5.76,,,,,,,4.09,9.28,percent of total billed charges,
Nadolol 40mg T(Corgard),800038694,CDM,637,RC,00093423601,NDC,,,facility,outpatient,1,EA,28.10000,8.15000,Aetna,Local,,14.27,,,,,,,10.13,22.99,percent of total billed charges,
Bumetanide 1mg T(Bumex),800047745,CDM,637,RC,00093423301,NDC,,,facility,outpatient,1,EA,9.70000,2.81000,Aetna,Local,,4.92,,,,,,,3.50,7.93,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00093423201,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Cephalexin 250mg/5mL L,800070077,CDM,637,RC,00093417773,NDC,,,facility,outpatient,1,EA,10.20000,2.96000,Aetna,Local,,5.18,,,,,,,3.68,8.34,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,00093417773,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,Local,,1.70,,,,,,,1.21,2.74,percent of total billed charges,
Cephalexin 125mg/2.5mL L,800081187,CDM,637,RC,00093417573,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Amoxicillin 250mg/5mL L,800026103,CDM,637,RC,00093415573,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00093406701,NDC,,,facility,outpatient,1,EA,6.75000,1.96000,Aetna,Local,,3.43,,,,,,,2.43,5.52,percent of total billed charges,
Indomethacin 25mg C(Indocin),800014919,CDM,637,RC,00093402901,NDC,,,facility,outpatient,1,EA,2.70000,0.78000,Aetna,Local,,1.37,,,,,,,0.97335,2.21,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,00093365522,NDC,,,facility,outpatient,1,EA,471.45000,136.72000,Aetna,Local,,239.36,,,,,,,169.96,385.65,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00093317431,NDC,,,facility,outpatient,1,EA,394.75000,114.48000,Aetna,Local,,200.41,,,,,,,142.31,322.91,percent of total billed charges,
Clindamycin HCl 150mg C(Cleocin),800011717,CDM,637,RC,00093317101,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
Minocycline HCl 50mg C,800017449,CDM,637,RC,00093316501,NDC,,,facility,outpatient,1,EA,2.25000,0.65000,Aetna,Local,,1.14,,,,,,,0.81112,1.84,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00093314705,NDC,,,facility,outpatient,1,EA,9.55000,2.77000,Aetna,Local,,4.85,,,,,,,3.44,7.81,percent of total billed charges,
Cephalexin 500mg C(Keflex),800070036,CDM,637,RC,00093314701,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,Local,,4.95,,,,,,,3.51,7.98,percent of total billed charges,
Cephalexin 250mg C(Keflex),800070028,CDM,637,RC,00093314501,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00093310953,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Amoxicillin 500mg C,800010396,CDM,637,RC,00093310905,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Rasagiline 0.5mg T(Azilect),800017687,CDM,637,RC,00093306056,NDC,,,facility,outpatient,1,EA,177.00000,51.33000,Aetna,Local,,89.86,,,,,,,63.81,144.79,percent of total billed charges,
Aspirin-Dipyridamole 25-200mg ERC,800080464,CDM,637,RC,00093304006,NDC,,,facility,outpatient,1,EA,49.05000,14.22000,Aetna,Local,,24.90,,,,,,,17.68,40.12,percent of total billed charges,
Amox-Clav 400mg-57mg/5 mL L,800017799,CDM,637,RC,00093227973,NDC,,,facility,outpatient,1,EA,24.40000,7.08000,Aetna,Local,,12.39,,,,,,,8.80,19.96,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,00093227534,NDC,,,facility,outpatient,1,EA,35.75000,10.37000,Aetna,Local,,18.15,,,,,,,12.89,29.24,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00093227434,NDC,,,facility,outpatient,1,EA,26.80000,7.77000,Aetna,Local,,13.61,,,,,,,9.66,21.92,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00093221005,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00093221001,NDC,,,facility,outpatient,1,EA,5.70000,1.65000,Aetna,Local,,2.89,,,,,,,2.05,4.66,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00093220405,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,Local,,1.19,,,,,,,0.84718,1.92,percent of total billed charges,
Metoclopramide HCl 5mg T(Reglan),800052174,CDM,637,RC,00093220401,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,Local,,1.19,,,,,,,0.84718,1.92,percent of total billed charges,
Liothyronine Na 25mcg T(Cytomel),800062041,CDM,637,RC,00093217801,NDC,,,facility,outpatient,1,EA,20.45000,5.93000,Aetna,Local,,10.38,,,,,,,7.37,16.73,percent of total billed charges,
Trimethoprim 100mg T,800017746,CDM,637,RC,00093215801,NDC,,,facility,outpatient,1,EA,4.85000,1.41000,Aetna,Local,,2.46,,,,,,,1.75,3.97,percent of total billed charges,
Nitrofurantoin Macro 50mg C,800015668,CDM,637,RC,00093213001,NDC,,,facility,outpatient,1,EA,15.10000,4.38000,Aetna,Local,,7.67,,,,,,,5.44,12.35,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00093205098,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,Local,,28.89,,,,,,,20.51,46.54,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00093205056,NDC,,,facility,outpatient,1,EA,56.90000,16.50000,Aetna,Local,,28.89,,,,,,,20.51,46.54,percent of total billed charges,
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,00093202723,NDC,,,facility,outpatient,1,EA,82.30000,23.87000,Aetna,Local,,41.78,,,,,,,29.67,67.32,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00093172301,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00093171401,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,00093171301,NDC,,,facility,outpatient,1,EA,4.55000,1.32000,Aetna,Local,,2.31,,,,,,,1.64,3.72,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00093171201,NDC,,,facility,outpatient,1,EA,4.35000,1.26000,Aetna,Local,,2.21,,,,,,,1.57,3.56,percent of total billed charges,
Neomycin 500mg T,800016609,CDM,637,RC,00093117701,NDC,,,facility,outpatient,1,EA,10.55000,3.06000,Aetna,Local,,5.36,,,,,,,3.80,8.63,percent of total billed charges,
Penicillin VK 500mg Tab,800020759,CDM,637,RC,00093117401,NDC,,,facility,outpatient,1,EA,14.30000,4.15000,Aetna,Local,,7.26,,,,,,,5.16,11.70,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00093111301,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Sotalol HCl 80mg T(Betapace),800072735,CDM,637,RC,00093106101,NDC,,,facility,outpatient,1,EA,16.60000,4.81000,Aetna,Local,,8.43,,,,,,,5.98,13.58,percent of total billed charges,
Sotalol HCl 120mg T(Betapace),800017712,CDM,637,RC,00093106001,NDC,,,facility,outpatient,1,EA,22.15000,6.42000,Aetna,Local,,11.25,,,,,,,7.99,18.12,percent of total billed charges,
FLUoxetine HCl 10mg C(PROzac),800072289,CDM,637,RC,00093104201,NDC,,,facility,outpatient,1,EA,18.40000,5.34000,Aetna,Local,,9.34,,,,,,,6.63,15.05,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00093103905,NDC,,,facility,outpatient,1,EA,9.40000,2.73000,Aetna,Local,,4.77,,,,,,,3.39,7.69,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00093103805,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00093102101,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,Local,,4.14,,,,,,,2.94,6.67,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00093101501,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,Local,,4.67,,,,,,,3.32,7.53,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,00093101042,NDC,,,facility,outpatient,1,EA,559.85000,162.36000,Aetna,Local,,284.24,,,,,,,201.83,457.96,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00093089601,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00093085253,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,Local,,2.56,,,,,,,1.82,4.13,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00093085205,NDC,,,facility,outpatient,1,EA,7.45000,2.16000,Aetna,Local,,3.78,,,,,,,2.69,6.09,percent of total billed charges,
Ketoconazole 2% 15g TC(Nizoral),800054642,CDM,637,RC,00093084015,NDC,,,facility,outpatient,1,EA,218.30000,63.31000,Aetna,Local,,110.83,,,,,,,78.70,178.57,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00093083205,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
clonazePAM 0.5mg T(KlonoPIN),800069046,CDM,637,RC,00093083201,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00093081901,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,Local,,4.90,,,,,,,3.48,7.89,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00093081101,NDC,,,facility,outpatient,1,EA,10.40000,3.02000,Aetna,Local,,5.28,,,,,,,3.75,8.51,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00093081001,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00093078710,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Atenolol 25mg T(Tenormin),800071687,CDM,637,RC,00093078701,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00093078406,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
carBAMazepine 100mg T(TEGretol),800051317,CDM,637,RC,00093077801,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00093077198,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
Atenolol 50mg T(Tenormin),800040427,CDM,637,RC,00093075201,NDC,,,facility,outpatient,1,EA,5.90000,1.71000,Aetna,Local,,3.00,,,,,,,2.13,4.83,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00093073898,NDC,,,facility,outpatient,1,EA,61.35000,17.79000,Aetna,Local,,31.15,,,,,,,22.12,50.18,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00093073856,NDC,,,facility,outpatient,1,EA,61.30000,17.78000,Aetna,Local,,31.12,,,,,,,22.10,50.14,percent of total billed charges,
Donepezil 5mg T(Aricept),800075050,CDM,637,RC,00093073805,NDC,,,facility,outpatient,1,EA,61.35000,17.79000,Aetna,Local,,31.15,,,,,,,22.12,50.18,percent of total billed charges,
Metoprolol 100mg T(Lopressor),800037464,CDM,637,RC,00093073401,NDC,,,facility,outpatient,1,EA,5.65000,1.64000,Aetna,Local,,2.87,,,,,,,2.04,4.62,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00093073310,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
Metoprolol 50mg T(Lopressor),800037456,CDM,637,RC,00093073301,NDC,,,facility,outpatient,1,EA,3.95000,1.15000,Aetna,Local,,2.01,,,,,,,1.42,3.23,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,00093067006,NDC,,,facility,outpatient,1,EA,17.20000,4.99000,Aetna,Local,,8.73,,,,,,,6.20,14.07,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,00093067005,NDC,,,facility,outpatient,1,EA,16.40000,4.76000,Aetna,Local,,8.33,,,,,,,5.91,13.42,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00093065701,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00093054201,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,00093031901,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,Local,,5.64,,,,,,,4.00,9.08,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,00093031801,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,00093031401,NDC,,,facility,outpatient,1,EA,15.25000,4.42000,Aetna,Local,,7.74,,,,,,,5.50,12.47,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00093029401,NDC,,,facility,outpatient,1,EA,10.65000,3.09000,Aetna,Local,,5.41,,,,,,,3.84,8.71,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00093029301,NDC,,,facility,outpatient,1,EA,8.35000,2.42000,Aetna,Local,,4.24,,,,,,,3.01,6.83,percent of total billed charges,
Carbidopa-Levo 10-100 T(Sinemet),800032788,CDM,637,RC,00093029201,NDC,,,facility,outpatient,1,EA,7.40000,2.15000,Aetna,Local,,3.76,,,,,,,2.67,6.05,percent of total billed charges,
buPROPion 100mg T(Wellbutrin),800054295,CDM,637,RC,00093029001,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,Local,,3.45,,,,,,,2.45,5.56,percent of total billed charges,
buPROPion 75mg T(Wellbutrin),800054287,CDM,637,RC,00093028001,NDC,,,facility,outpatient,1,EA,5.10000,1.48000,Aetna,Local,,2.59,,,,,,,1.84,4.17,percent of total billed charges,
Ondansetron 4mg T(Zofran),800016710,CDM,636,RC,Q0162,HCPCS,00093023356,NDC,facility,inpatient,4,ME,172.50000,50.02000,Aetna,Local,,69.00,,,,,,,62.19,141.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SUMAtriptan 100mg T(Imitrex),800017716,CDM,637,RC,00093022490,NDC,,,facility,outpatient,1,EA,180.45000,52.33000,Aetna,Local,,91.61,,,,,,,65.05,147.61,percent of total billed charges,
SUMAtriptan 25mg T(Imitrex),800073121,CDM,637,RC,00093022290,NDC,,,facility,outpatient,1,EA,193.05000,55.98000,Aetna,Local,,98.01,,,,,,,69.59,157.91,percent of total billed charges,
risperiDONE 0.25mg T(RisperDAL),800077403,CDM,637,RC,00093022106,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,Local,,1.70,,,,,,,1.21,2.74,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00093022056,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
Bicalutamide 50 mg T(Casodex),800080803,CDM,637,RC,00093022001,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00093019901,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00093017356,NDC,,,facility,outpatient,1,EA,7.10000,2.06000,Aetna,Local,,3.60,,,,,,,2.56,5.81,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,00093015506,NDC,,,facility,outpatient,1,EA,18.10000,5.25000,Aetna,Local,,9.19,,,,,,,6.53,14.81,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00093015001,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Naproxen 250mg T(Naprosyn),800031541,CDM,637,RC,00093014701,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Sulfamethoxazole-Trimethoprim SS 400-80mg T,800034909,CDM,637,RC,00093008801,NDC,,,facility,outpatient,1,EA,4.70000,1.36000,Aetna,Local,,2.39,,,,,,,1.69,3.84,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00093005801,NDC,,,facility,outpatient,1,EA,6.65000,1.93000,Aetna,Local,,3.38,,,,,,,2.40,5.44,percent of total billed charges,
busPIRone 10mg T,800051861,CDM,637,RC,00093005401,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00093005305,NDC,,,facility,outpatient,1,EA,5.30000,1.54000,Aetna,Local,,2.69,,,,,,,1.91,4.34,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00093005301,NDC,,,facility,outpatient,1,EA,5.45000,1.58000,Aetna,Local,,2.77,,,,,,,1.96,4.46,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00093005101,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
lamoTRIgine 25 mg T(LaMICtal),800080894,CDM,637,RC,00093003901,NDC,,,facility,outpatient,1,EA,29.45000,8.54000,Aetna,Local,,14.95,,,,,,,10.62,24.09,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00093002901,NDC,,,facility,outpatient,1,EA,19.60000,5.68000,Aetna,Local,,9.95,,,,,,,7.07,16.03,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00093002801,NDC,,,facility,outpatient,1,EA,13.75000,3.99000,Aetna,Local,,6.98,,,,,,,4.96,11.25,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00093002701,NDC,,,facility,outpatient,1,EA,13.10000,3.80000,Aetna,Local,,6.65,,,,,,,4.72,10.72,percent of total billed charges,
Enalapril 2.5 mg T(Vasotec),800082262,CDM,637,RC,00093002601,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,Local,,5.23,,,,,,,3.71,8.43,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00093001298,NDC,,,facility,outpatient,1,EA,28.95000,8.40000,Aetna,Local,,14.70,,,,,,,10.44,23.68,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00091744963,NDC,,,facility,outpatient,1,EA,19.80000,5.74000,Aetna,Local,,10.05,,,,,,,7.14,16.20,percent of total billed charges,
Oral Colonic Lavage 4000 mL,800075308,CDM,637,RC,00091703623,NDC,,,facility,outpatient,1,EA,245.85000,71.30000,Aetna,Local,,124.82,,,,,,,88.63,201.11,percent of total billed charges,
Orphenadrine Citrate 30mg/mL 2mL I,800052075,CDM,636,RC,J2360,HCPCS,00089054006,NDC,facility,inpatient,60,ME,157.70000,45.73000,Aetna,Local,,63.08,,,,,,,56.85,129.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,00089030710,NDC,,,facility,outpatient,1,EA,30.20000,8.76000,Aetna,Local,,15.33,,,,,,,10.89,24.70,percent of total billed charges,
Leflunomide 10 mg T(Arava),800017627,CDM,637,RC,00088216030,NDC,,,facility,outpatient,1,EA,403.45000,117.00000,Aetna,Local,,204.83,,,,,,,145.44,330.02,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00088179849,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,Local,,11.40,,,,,,,8.09,18.36,percent of total billed charges,
dilTIAZem 300mg/24hr CD C,800071166,CDM,637,RC,00088179842,NDC,,,facility,outpatient,1,EA,23.80000,6.90000,Aetna,Local,,12.08,,,,,,,8.58,19.47,percent of total billed charges,
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00088179642,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
dilTIAZem 120mg/24hr CD C,800069616,CDM,637,RC,00088179530,NDC,,,facility,outpatient,1,EA,6.45000,1.87000,Aetna,Local,,3.27,,,,,,,2.33,5.28,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,00088177949,NDC,,,facility,outpatient,1,EA,7.95000,2.31000,Aetna,Local,,4.04,,,,,,,2.87,6.50,percent of total billed charges,
dilTIAZem 120mg SR C(CardiZEM),800053511,CDM,637,RC,00088177947,NDC,,,facility,outpatient,1,EA,11.55000,3.35000,Aetna,Local,,5.86,,,,,,,4.16,9.45,percent of total billed charges,
dilTIAZem 90mg SR C(CardiZEM),800057751,CDM,637,RC,00088177849,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
dilTIAZem 60mg SR C(CardiZEM),800065150,CDM,637,RC,00088177749,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,Local,,2.72,,,,,,,1.93,4.38,percent of total billed charges,
dilTIAZem 60mg T(CardiZEM),800044197,CDM,637,RC,00088177249,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,Local,,2.23,,,,,,,1.59,3.60,percent of total billed charges,
dilTIAZem 30mg T(CardiZEM),800044189,CDM,637,RC,00088177149,NDC,,,facility,outpatient,1,EA,2.85000,0.83000,Aetna,Local,,1.45,,,,,,,1.03,2.33,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00088171249,NDC,,,facility,outpatient,1,EA,7.70000,2.23000,Aetna,Local,,3.91,,,,,,,2.78,6.30,percent of total billed charges,
Sucralfate 1g T(Carafate),800040286,CDM,637,RC,00088171247,NDC,,,facility,outpatient,1,EA,8.35000,2.42000,Aetna,Local,,4.24,,,,,,,3.01,6.83,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),800019851,CDM,250,RC,00088102105,NDC,,,facility,outpatient,1,EA,232.15000,67.32000,Aetna,Local,,117.86,,,,,,,83.69,189.90,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00087606010,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,Local,,4.26,,,,,,,3.03,6.87,percent of total billed charges,
metFORMIN 500mg T(Glucophage),800072511,CDM,637,RC,00087606005,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,Local,,4.26,,,,,,,3.03,6.87,percent of total billed charges,
NICU- Caffeine Citra 60mg/3mL I(Cafcit),800010949,CDM,636,RC,J0706,HCPCS,00087601142,NDC,facility,inpatient,60,ME,379.25000,109.98000,Aetna,Local,,151.70,,,,,,,136.72,310.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
busPIRone 10mg T,800051861,CDM,637,RC,00087081941,NDC,,,facility,outpatient,1,EA,15.15000,4.39000,Aetna,Local,,7.69,,,,,,,5.46,12.39,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00087081843,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
busPIRone 5mg T(Buspar),800071356,CDM,637,RC,00087081841,NDC,,,facility,outpatient,1,EA,8.10000,2.35000,Aetna,Local,,4.11,,,,,,,2.92,6.63,percent of total billed charges,
Estradiol 1mg T(Estrace),800058064,CDM,637,RC,00087075501,NDC,,,facility,outpatient,1,EA,2.20000,0.64000,Aetna,Local,,1.12,,,,,,,0.79310,1.80,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00085432001,NDC,facility,inpatient,30,ME,230.30000,66.79000,Aetna,Local,,92.12,,,,,,,83.02,188.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitroglycerin 0.3mg/hr TD(Nitro-Dur),800074251,CDM,637,RC,00085331535,NDC,,,facility,outpatient,1,EA,44.60000,12.93000,Aetna,Local,,22.64,,,,,,,16.08,36.48,percent of total billed charges,
Nitroglycerin 0.3mg/hr TD(Nitro-Dur),800074251,CDM,637,RC,00085331530,NDC,,,facility,outpatient,1,EA,44.60000,12.93000,Aetna,Local,,22.64,,,,,,,16.08,36.48,percent of total billed charges,
Isosorbide Mono 30mg ER T(Imdur),800072404,CDM,637,RC,00085137401,NDC,,,facility,outpatient,1,EA,25.85000,7.50000,Aetna,Local,,13.12,,,,,,,9.32,21.15,percent of total billed charges,
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,00085117705,NDC,facility,inpatient,20,ME,776.80000,225.27000,Aetna,Local,,310.72,,,,,,,280.04,635.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 20mg/10mL Inj,800010899,CDM,636,RC,J1327,HCPCS,00085117701,NDC,facility,inpatient,20,ME,882.60000,255.95000,Aetna,Local,,353.04,,,,,,,318.18,721.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00085113602,NDC,facility,inpatient,75,ME,4051.30000,1174.88000,Aetna,Local,,1620.52,,,,,,,1460.49,3313.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Eptifibatide 75mg/100mL Inj PB,800010951,CDM,636,RC,J1327,HCPCS,00085113601,NDC,facility,inpatient,75,ME,4433.60000,1285.74000,Aetna,Local,,1773.44,,,,,,,1598.31,3626.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00085113204,NDC,,,facility,outpatient,1,EA,621.75000,180.31000,Aetna,Local,,315.66,,,,,,,224.14,508.59,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00085113201,NDC,,,facility,outpatient,1,EA,621.70000,180.29000,Aetna,Local,,315.64,,,,,,,224.12,508.55,percent of total billed charges,
Clotrimazole-Beta 15g TC(Lotrisone),800050160,CDM,637,RC,00085092401,NDC,,,facility,outpatient,1,EA,466.80000,135.37000,Aetna,Local,,236.99,,,,,,,168.28,381.84,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,800039932,CDM,250,RC,00085088709,NDC,,,facility,outpatient,1,EA,51.00000,14.79000,Aetna,Local,,25.89,,,,,,,18.39,41.72,percent of total billed charges,
Betamethasone 6mg/mL 5mL I(Celeston,800013437,CDM,636,RC,J0702,HCPCS,00085056605,NDC,facility,inpatient,30,ME,230.30000,66.79000,Aetna,Local,,92.12,,,,,,,83.02,188.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methylphenidate HCl 5mg T(Ritalin),800018373,CDM,637,RC,00083000730,NDC,,,facility,outpatient,1,EA,5.20000,1.51000,Aetna,Local,,2.64,,,,,,,1.87,4.25,percent of total billed charges,
Methylphenidate HCl 10mg T(Ritalin),800018399,CDM,637,RC,00083000330,NDC,,,facility,outpatient,1,EA,2.90000,0.84000,Aetna,Local,,1.47,,,,,,,1.05,2.37,percent of total billed charges,
Acyclovir Oral Susp(Zovirax),800070796,CDM,637,RC,00081095396,NDC,,,facility,outpatient,1,EA,9.75000,2.83000,Aetna,Local,,4.95,,,,,,,3.51,7.98,percent of total billed charges,
Baci-Poly 30g TO(Polysporin),800015685,CDM,250,RC,00081079887,NDC,,,facility,outpatient,1,EA,47.20000,13.69000,Aetna,Local,,23.96,,,,,,,17.02,38.61,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00081054047,NDC,,,facility,outpatient,1,EA,690.65000,200.29000,Aetna,Local,,350.64,,,,,,,248.98,564.95,percent of total billed charges,
Inclisiran 284mg/1.5 mL IS (Leqvio),800046537,CDM,636,RC,J1306,HCPCS,00078100060,NDC,facility,inpatient,284,ME,13629.65000,3952.60000,Aetna,Local,,5451.86,,,,,,,4913.49,11149.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Octreotide 20mg I Kit (SandoSTATIN LAR),800081045,CDM,636,RC,J2353,HCPCS,00078081881,NDC,facility,inpatient,20,ME,18581.35000,5388.59000,Aetna,Local,,7432.54,,,,,,,6698.58,15199.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tobramycin 0.3% 3.5g Ophth Oint(Tobrex),800041185,CDM,637,RC,00078081301,NDC,,,facility,outpatient,1,EA,1991.90000,577.65000,Aetna,Local,,1011.29,,,,,,,718.08,1629.37,percent of total billed charges,
Sacubitril-Valsartan 49-51mg Tab,800025659,CDM,637,RC,00078077735,NDC,,,facility,outpatient,1,EA,59.65000,17.30000,Aetna,Local,,30.28,,,,,,,21.50,48.79,percent of total billed charges,
Sacubitril-Valsartan 49-51mg Tab,800025659,CDM,637,RC,00078077720,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,Local,,50.69,,,,,,,36.00,81.68,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,800025660,CDM,637,RC,00078069667,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,Local,,50.69,,,,,,,36.00,81.68,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,800025660,CDM,637,RC,00078069635,NDC,,,facility,outpatient,1,EA,59.65000,17.30000,Aetna,Local,,30.28,,,,,,,21.50,48.79,percent of total billed charges,
Sacubitril-Valsartan 97-103mg Tab,800025660,CDM,637,RC,00078069620,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,Local,,50.69,,,,,,,36.00,81.68,percent of total billed charges,
Sacubitril-Valsartan 24-26mg Tab,800025658,CDM,637,RC,00078065935,NDC,,,facility,outpatient,1,EA,59.65000,17.30000,Aetna,Local,,30.28,,,,,,,21.50,48.79,percent of total billed charges,
Sacubitril-Valsartan 24-26mg Tab,800025658,CDM,637,RC,00078065920,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,Local,,50.69,,,,,,,36.00,81.68,percent of total billed charges,
artemether-lumefantrine 20mg-120mg Tab,800046516,CDM,637,RC,00078056845,NDC,,,facility,outpatient,1,EA,47.70000,13.83000,Aetna,Local,,24.22,,,,,,,17.20,39.02,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,00078050261,NDC,,,facility,outpatient,1,EA,195.50000,56.69000,Aetna,Local,,99.26,,,,,,,70.48,159.92,percent of total billed charges,
Rivastigmine 9.5mg/24hr TD (Exelon),800011951,CDM,637,RC,00078050215,NDC,,,facility,outpatient,1,EA,195.55000,56.71000,Aetna,Local,,99.28,,,,,,,70.50,159.96,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,00078050161,NDC,,,facility,outpatient,1,EA,195.50000,56.69000,Aetna,Local,,99.26,,,,,,,70.48,159.92,percent of total billed charges,
Rivastigmine 4.6mg/24hr TD (Exelon),800011950,CDM,637,RC,00078050115,NDC,,,facility,outpatient,1,EA,195.55000,56.71000,Aetna,Local,,99.28,,,,,,,70.50,159.96,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,00078048535,NDC,,,facility,outpatient,1,EA,29.40000,8.53000,Aetna,Local,,14.93,,,,,,,10.60,24.05,percent of total billed charges,
Aliskiren 150mg T(Tekturna),800017415,CDM,637,RC,00078048515,NDC,,,facility,outpatient,1,EA,38.65000,11.21000,Aetna,Local,,19.62,,,,,,,13.93,31.62,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00078045605,NDC,,,facility,outpatient,1,EA,49.45000,14.34000,Aetna,Local,,25.11,,,,,,,17.83,40.45,percent of total billed charges,
Zoledronic Acid 5mg/100mL IVPB,800011999,CDM,636,RC,J3489,HCPCS,00078043561,NDC,facility,inpatient,5,ME,8640.90000,2505.86000,Aetna,Local,,3456.36,,,,,,,3115.04,7068.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,00078040134,NDC,,,facility,outpatient,1,EA,717.00000,207.93000,Aetna,Local,,364.02,,,,,,,258.48,586.51,percent of total billed charges,
Imatinib 100 mg T(Gleevac),800081835,CDM,637,RC,00078040105,NDC,,,facility,outpatient,1,EA,240.35000,69.70000,Aetna,Local,,122.03,,,,,,,86.65,196.61,percent of total billed charges,
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00078040001,NDC,,,facility,outpatient,1,EA,112.60000,32.65000,Aetna,Local,,57.17,,,,,,,40.59,92.11,percent of total billed charges,
Zoledronic Acid 4mg/5mL I(Zometa),800011996,CDM,636,RC,J3489,HCPCS,00078038725,NDC,facility,inpatient,4,ME,6828.90000,1980.38000,Aetna,Local,,2731.56,,,,,,,2461.82,5586.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00078036815,NDC,,,facility,outpatient,1,EA,181.00000,52.49000,Aetna,Local,,91.89,,,,,,,65.25,148.06,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,00078036715,NDC,,,facility,outpatient,1,EA,91.45000,26.52000,Aetna,Local,,46.43,,,,,,,32.97,74.81,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00078035934,NDC,,,facility,outpatient,1,EA,86.55000,25.10000,Aetna,Local,,43.94,,,,,,,31.20,70.80,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00078035906,NDC,,,facility,outpatient,1,EA,25.70000,7.45000,Aetna,Local,,13.05,,,,,,,9.26,21.02,percent of total billed charges,
Valsartan 160 mg T(Diovan),800080340,CDM,637,RC,00078035905,NDC,,,facility,outpatient,1,EA,13.35000,3.87000,Aetna,Local,,6.78,,,,,,,4.81,10.92,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00078035834,NDC,,,facility,outpatient,1,EA,80.50000,23.34000,Aetna,Local,,40.87,,,,,,,29.02,65.85,percent of total billed charges,
Valsartan 80 mg T(Diovan),800080332,CDM,637,RC,00078035805,NDC,,,facility,outpatient,1,EA,12.40000,3.60000,Aetna,Local,,6.30,,,,,,,4.47,10.14,percent of total billed charges,
Octreotide 20mg I Kit (SandoSTATIN LAR),800081045,CDM,636,RC,J2353,HCPCS,00078034161,NDC,facility,inpatient,20,ME,17520.55000,5080.96000,Aetna,Local,,7008.22,,,,,,,6316.16,14331.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,00078033705,NDC,,,facility,outpatient,1,EA,90.35000,26.20000,Aetna,Local,,45.87,,,,,,,32.57,73.91,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00078033605,NDC,,,facility,outpatient,1,EA,10.15000,2.94000,Aetna,Local,,5.15,,,,,,,3.66,8.30,percent of total billed charges,
Entacapone 200 mg T(Comtan),800081942,CDM,637,RC,00078032705,NDC,,,facility,outpatient,1,EA,65.50000,18.99000,Aetna,Local,,33.25,,,,,,,23.61,53.58,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00078032344,NDC,,,facility,outpatient,1,EA,44.20000,12.82000,Aetna,Local,,22.44,,,,,,,15.93,36.16,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00078032315,NDC,,,facility,outpatient,1,EA,24.15000,7.00000,Aetna,Local,,12.26,,,,,,,8.71,19.75,percent of total billed charges,
Rivastigmine 1.5 mg C(Exelon),800081314,CDM,637,RC,00078032306,NDC,,,facility,outpatient,1,EA,36.60000,10.61000,Aetna,Local,,18.58,,,,,,,13.19,29.94,percent of total billed charges,
Ursodiol 300mg C(Actigall),800054840,CDM,637,RC,00078031905,NDC,,,facility,outpatient,1,EA,27.50000,7.98000,Aetna,Local,,13.96,,,,,,,9.91,22.50,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00078031190,NDC,,,facility,outpatient,1,EA,1038.05000,301.03000,Aetna,Local,,527.02,,,,,,,374.22,849.12,percent of total billed charges,
Calcitonin 200 IU/Spr NS(Fortical),800072370,CDM,637,RC,00078031154,NDC,,,facility,outpatient,1,EA,1950.15000,565.54000,Aetna,Local,,990.09,,,,,,,703.03,1595.22,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,00078024915,NDC,,,facility,outpatient,1,EA,229.40000,66.53000,Aetna,Local,,116.47,,,,,,,82.70,187.65,percent of total billed charges,
Terbinafine 250mg T(LamISIL),800017726,CDM,637,RC,00078017915,NDC,,,facility,outpatient,1,EA,210.10000,60.93000,Aetna,Local,,106.67,,,,,,,75.74,171.86,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00078014006,NDC,,,facility,outpatient,1,EA,7.35000,2.13000,Aetna,Local,,3.73,,,,,,,2.65,6.01,percent of total billed charges,
Temazepam 7.5mg C(Restoril),800072065,CDM,637,RC,00078014005,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
CloZAPine 100mg T(Clozaril),800049378,CDM,637,RC,00078012706,NDC,,,facility,outpatient,1,EA,23.70000,6.87000,Aetna,Local,,12.03,,,,,,,8.54,19.39,percent of total billed charges,
CloZAPine 25mg T(Clozaril),800049360,CDM,637,RC,00078012606,NDC,,,facility,outpatient,1,EA,39.05000,11.32000,Aetna,Local,,19.83,,,,,,,14.08,31.94,percent of total billed charges,
Temazepam 15mg C(Restoril),800057066,CDM,637,RC,00078009813,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,Local,,2.23,,,,,,,1.59,3.60,percent of total billed charges,
Nortriptyline HCl 25mg C(Pamelor),800036359,CDM,637,RC,00078008706,NDC,,,facility,outpatient,1,EA,9.10000,2.64000,Aetna,Local,,4.62,,,,,,,3.28,7.44,percent of total billed charges,
Nortriptyline HCl 10mg C(Pamelor),800051705,CDM,637,RC,00078008606,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Butalbital-APAP-Caff T(Fioricet),800058726,CDM,637,RC,00078008405,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,00078005406,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
Methylergonovine Mal 0.2mg T(Methergine),800016047,CDM,637,RC,00078005405,NDC,,,facility,outpatient,1,EA,12.10000,3.51000,Aetna,Local,,6.14,,,,,,,4.36,9.90,percent of total billed charges,
Methylergonovine Mal 0.2mg/mL 1mL I,800012302,CDM,636,RC,J2210,HCPCS,00078005303,NDC,facility,inpatient,0.2,ME,50.25000,14.57000,Aetna,Local,,20.10,,,,,,,18.12,41.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00075800404,NDC,facility,inpatient,80,ME,16763.85000,4861.52000,Aetna,Local,,6705.54,,,,,,,6043.37,13712.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00075800301,NDC,facility,inpatient,20,ME,3954.55000,1146.82000,Aetna,Local,,1581.82,,,,,,,1425.62,3234.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 80mg/4mL I Conc.,800013034,CDM,636,RC,J9171,HCPCS,00075800180,NDC,facility,inpatient,80,ME,21753.15000,6308.41000,Aetna,Local,,8701.26,,,,,,,7842.01,17794.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOCEtaxel 20mg/mL I Conc.,800013037,CDM,636,RC,J9171,HCPCS,00075800120,NDC,facility,inpatient,20,ME,2855.55000,828.11000,Aetna,Local,,1142.22,,,,,,,1029.43,2335.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Riluzole 50mg T(Rilutek),800017694,CDM,637,RC,00075770060,NDC,,,facility,outpatient,1,EA,122.50000,35.52000,Aetna,Local,,62.19,,,,,,,44.16,100.20,percent of total billed charges,
Enoxaparin 150mg Inj(Lovenox),800012539,CDM,636,RC,J1650,HCPCS,00075291501,NDC,facility,inpatient,150,ME,659.45000,191.24000,Aetna,Local,,263.78,,,,,,,237.73,539.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 120mg I(Lovenox),800012538,CDM,636,RC,J1650,HCPCS,00075291201,NDC,facility,inpatient,120,ME,545.55000,158.21000,Aetna,Local,,218.22,,,,,,,196.67,446.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin 0.01% 5mL Nas Spr (DDAVP),800038355,CDM,637,RC,00075245201,NDC,,,facility,outpatient,1,EA,2441.60000,708.06000,Aetna,Local,,1239.60,,,,,,,880.20,1997.23,percent of total billed charges,
Desmopressin Acetate 40mcg/10mL I(Ddavp),800012511,CDM,636,RC,J2597,HCPCS,00075245153,NDC,facility,inpatient,0.04,ME,4584.35000,1329.46000,Aetna,Local,,1833.74,,,,,,,1652.66,3750.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desmopressin Acetate 4mcg/mL I(Ddavp),800012486,CDM,636,RC,J2597,HCPCS,00075245101,NDC,facility,inpatient,0.004,ME,353.70000,102.57000,Aetna,Local,,141.48,,,,,,,127.51,289.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitroglycerin 0.4mg/Spr 4.9g Spray,800054709,CDM,637,RC,00075085084,NDC,,,facility,outpatient,1,EA,986.55000,286.10000,Aetna,Local,,500.87,,,,,,,355.65,807.00,percent of total billed charges,
Enoxaparin 30mg I(Lovenox),800012540,CDM,636,RC,J1650,HCPCS,00075062430,NDC,facility,inpatient,30,ME,157.50000,45.68000,Aetna,Local,,63.00,,,,,,,56.78,128.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 100mg I(Lovenox),800012537,CDM,636,RC,J1650,HCPCS,00075062300,NDC,facility,inpatient,100,ME,470.15000,136.34000,Aetna,Local,,188.06,,,,,,,169.49,384.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 80mg I(Lovenox),800012544,CDM,636,RC,J1650,HCPCS,00075062280,NDC,facility,inpatient,80,ME,384.35000,111.46000,Aetna,Local,,153.74,,,,,,,138.56,314.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 60mg I(Lovenox),800012543,CDM,636,RC,J1650,HCPCS,00075062160,NDC,facility,inpatient,60,ME,298.50000,86.56000,Aetna,Local,,119.40,,,,,,,107.61,244.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enoxaparin 40mg I(Lovenox),800012542,CDM,636,RC,J1650,HCPCS,00075062040,NDC,facility,inpatient,40,ME,205.30000,59.54000,Aetna,Local,,82.12,,,,,,,74.01,167.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dilTIAZem 180mg/24 hr CD C,800070945,CDM,637,RC,00075025162,NDC,,,facility,outpatient,1,EA,10.90000,3.16000,Aetna,Local,,5.53,,,,,,,3.93,8.92,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00074929690,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00074915801,NDC,facility,inpatient,10,ME,30.25000,8.77000,Aetna,Local,,12.10,,,,,,,10.91,24.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL Citr 50 mcg/mL 2mL I,800065457,CDM,636,RC,J3010,HCPCS,00074909332,NDC,facility,inpatient,0.1,ME,5.20000,1.51000,Aetna,Local,,2.08,,,,,,,1.87,4.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00074806201,NDC,,,facility,outpatient,1,EA,123.05000,35.68000,Aetna,Local,,62.47,,,,,,,44.36,100.65,percent of total billed charges,
Sterile Water 1000mL,800021704,CDM,258,RC,A4217,HCPCS,00074799009,NDC,facility,outpatient,1,EA,19.20000,5.57000,Aetna,Local,,9.75,,,,,,,3.80,15.71,percent of total billed charges,
0.45% Sodium Cl 1000mL,800011421,CDM,258,RC,00074798509,NDC,,,facility,outpatient,1,EA,13.20000,3.83000,Aetna,Local,,6.70,,,,,,,4.76,10.80,percent of total billed charges,
0.45% Sodium Cl 500mL,800011413,CDM,258,RC,00074798503,NDC,,,facility,outpatient,1,EA,6.15000,1.78000,Aetna,Local,,3.12,,,,,,,2.22,5.03,percent of total billed charges,
NS 100mL,800013055,CDM,636,RC,J7050,HCPCS,00074798423,NDC,facility,inpatient,1,EA,16.90000,4.90000,Aetna,Local,,6.76,,,,,,,6.09,13.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 50mL,800011892,CDM,636,RC,J7050,HCPCS,00074798413,NDC,facility,inpatient,1,EA,14.15000,4.10000,Aetna,Local,,5.66,,,,,,,5.10,11.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NS 1,000mL",800012701,CDM,636,RC,J7030,HCPCS,00074798309,NDC,facility,inpatient,1,EA,13.00000,3.77000,Aetna,Local,,5.20,,,,,,,4.69,10.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250 mL,800011850,CDM,636,RC,J7050,HCPCS,00074798302,NDC,facility,inpatient,1,EA,1210.00000,350.90000,Aetna,Local,,484.00,,,,,,,436.20,989.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Normosol R (PlasmaLyte A) 1000 mL,800011512,CDM,258,RC,00074796709,NDC,,,facility,outpatient,1,EA,33.85000,9.82000,Aetna,Local,,17.19,,,,,,,12.20,27.69,percent of total billed charges,
Lidocaine 2g / D5W 250mL,800013314,CDM,636,RC,J2002,HCPCS,00074793932,NDC,facility,inpatient,2,GM,61.95000,17.97000,Aetna,Local,,24.78,,,,,,,22.33,50.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D10W 1000mL,800012362,CDM,258,RC,00074793009,NDC,,,facility,outpatient,1,EA,16.50000,4.78000,Aetna,Local,,8.38,,,,,,,5.95,13.50,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,800011348,CDM,258,RC,00074790209,NDC,,,facility,outpatient,1,EA,18.35000,5.32000,Aetna,Local,,9.32,,,,,,,6.62,15.01,percent of total billed charges,
Gentamicin Sulf 80mg/NS 100mL,800064963,CDM,636,RC,J1580,HCPCS,00074788423,NDC,facility,inpatient,80,ME,1452.00000,421.08000,Aetna,Local,,580.80,,,,,,,523.45,1187.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
metroNIDAZOLE 500mg P,800040351,CDM,636,RC,J1836,HCPCS,00074781137,NDC,facility,inpatient,500,ME,23047.50000,6683.78000,Aetna,Local,,9219.00,,,,,,,8308.62,18852.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOPamine 400mg/D5W 250mL,800012469,CDM,636,RC,J1265,HCPCS,00074780922,NDC,facility,inpatient,400,ME,159.80000,46.34000,Aetna,Local,,63.92,,,,,,,57.61,130.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mannitol 20% 500mL,800022060,CDM,250,RC,00074771503,NDC,,,facility,outpatient,1,EA,170.75000,49.52000,Aetna,Local,,86.69,,,,,,,61.56,139.67,percent of total billed charges,
"Heparin Flush 1,000 unit/NS500",800069533,CDM,636,RC,J1644,HCPCS,00074762003,NDC,facility,inpatient,1000,UN,7372.50000,2138.02000,Aetna,Local,,2949.00,,,,,,,2657.79,6030.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Potassium Phosphate Inj 15mL,800043637,CDM,250,RC,00074729501,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
EPINEPHrine 1:1000 I 1mL,800014284,CDM,636,RC,J0165,HCPCS,00074724101,NDC,facility,inpatient,1,ME,3.40000,0.99000,Aetna,Local,,1.36,,,,,,,1.23,2.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Divalproex 500 mg ER T/24hr,800070016,CDM,637,RC,00074712613,NDC,,,facility,outpatient,1,EA,52.25000,15.15000,Aetna,Local,,26.53,,,,,,,18.84,42.74,percent of total billed charges,
NS + 20mEq KCl 1000mL,800012684,CDM,258,RC,00074711509,NDC,,,facility,outpatient,1,EA,73.20000,21.23000,Aetna,Local,,37.16,,,,,,,26.39,59.88,percent of total billed charges,
D5NS+20 mEq KCl/L,800012692,CDM,258,RC,00074710709,NDC,,,facility,outpatient,1,EA,35.35000,10.25000,Aetna,Local,,17.95,,,,,,,12.74,28.92,percent of total billed charges,
KCl 20mEq/Water 100mL,800013356,CDM,636,RC,J3480,HCPCS,00074707526,NDC,facility,inpatient,1,EA,1403.00000,406.87000,Aetna,Local,,561.20,,,,,,,505.78,1147.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
KCl 10mEq / 100mL IVPB,800013355,CDM,636,RC,J3480,HCPCS,00074707426,NDC,facility,inpatient,1,EA,22.35000,6.48000,Aetna,Local,,8.94,,,,,,,8.06,18.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00074707090,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00074706890,NDC,,,facility,outpatient,1,EA,14.10000,4.09000,Aetna,Local,,7.16,,,,,,,5.08,11.53,percent of total billed charges,
Levothyroxine Sodium 125mcg T,800051168,CDM,637,RC,00074706813,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,Local,,2.56,,,,,,,1.82,4.13,percent of total billed charges,
hydroCHLOROthiazide  25mg T,800013796,CDM,637,RC,00074697801,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,Local,,0.20308,,,,,,,0.14420,0.32720,percent of total billed charges,
Potassium Cl 2mEq/mL I,800013427,CDM,636,RC,J3480,HCPCS,00074665305,NDC,facility,inpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.52,,,,,,,1.37,3.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D50W 50mL,800067479,CDM,258,RC,00074664802,NDC,,,facility,outpatient,1,EA,650.50000,188.64000,Aetna,Local,,330.26,,,,,,,234.51,532.11,percent of total billed charges,
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00074663722,NDC,,,facility,outpatient,1,EA,22.50000,6.52000,Aetna,Local,,11.42,,,,,,,8.11,18.41,percent of total billed charges,
Succinylcholine HCl 20mg/mL 10mL I,800061217,CDM,636,RC,J0330,HCPCS,00074662902,NDC,facility,inpatient,200,ME,14.80000,4.29000,Aetna,Local,,5.92,,,,,,,5.34,12.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Bica 50mEq/50mL I,800080035,CDM,250,RC,00074662502,NDC,,,facility,outpatient,1,EA,5.85000,1.70000,Aetna,Local,,2.97,,,,,,,2.11,4.79,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00074662490,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
Levothyroxine Sodium 100mcg T,800019306,CDM,637,RC,00074662411,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
Sodium Bicarb 2.5mEq/5mL,800065754,CDM,250,RC,00074660902,NDC,,,facility,outpatient,1,EA,30.25000,8.77000,Aetna,Local,,15.36,,,,,,,10.91,24.74,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00074659490,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
Vancomycin HCl 1g Inj,800012576,CDM,636,RC,J3373,HCPCS,00074653301,NDC,facility,inpatient,1,GM,56.10000,16.27000,Aetna,Local,,22.44,,,,,,,20.22,45.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Erythromycin 250mg T(Base),800013481,CDM,637,RC,00074630413,NDC,,,facility,outpatient,1,EA,7.75000,2.25000,Aetna,Local,,3.93,,,,,,,2.79,6.34,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00074621513,NDC,,,facility,outpatient,1,EA,60.25000,17.47000,Aetna,Local,,30.59,,,,,,,21.72,49.28,percent of total billed charges,
Divalproex 500mg DR T(Depakote),800071463,CDM,637,RC,00074621511,NDC,,,facility,outpatient,1,EA,18.05000,5.23000,Aetna,Local,,9.16,,,,,,,6.51,14.76,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00074621453,NDC,,,facility,outpatient,1,EA,34.30000,9.95000,Aetna,Local,,17.41,,,,,,,12.37,28.06,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00074621413,NDC,,,facility,outpatient,1,EA,34.30000,9.95000,Aetna,Local,,17.41,,,,,,,12.37,28.06,percent of total billed charges,
Divalproex 250mg DR T(Depakote),800071299,CDM,637,RC,00074621411,NDC,,,facility,outpatient,1,EA,9.25000,2.68000,Aetna,Local,,4.70,,,,,,,3.33,7.57,percent of total billed charges,
Divalproex 125mg ER C(Depakote),800017373,CDM,637,RC,00074611413,NDC,,,facility,outpatient,1,EA,16.65000,4.83000,Aetna,Local,,8.45,,,,,,,6.00,13.62,percent of total billed charges,
Furosemide 10mg/mL 4mL I(Lasix),800015142,CDM,636,RC,J1938,HCPCS,00074610204,NDC,facility,inpatient,40,ME,4.30000,1.25000,Aetna,Local,,1.72,,,,,,,1.55,3.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Valproic Acid 250mg C(Depakene),800036813,CDM,637,RC,00074568113,NDC,,,facility,outpatient,1,EA,42.30000,12.27000,Aetna,Local,,21.48,,,,,,,15.25,34.60,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00074518290,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00074518211,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
cefTAZidime 1g I (Fortaz),800015133,CDM,636,RC,J0713,HCPCS,00074508216,NDC,facility,inpatient,1,GM,93.45000,27.10000,Aetna,Local,,37.38,,,,,,,33.69,76.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
risankizumab-rzaa- Pt Own Supply,800051987,CDM,636,RC,J2327,HCPCS,00074501501,NDC,facility,inpatient,600,ME,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00074492834,NDC,,,facility,outpatient,1,EA,19.40000,5.63000,Aetna,Local,,9.85,,,,,,,6.99,15.87,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,800060391,CDM,250,RC,00074492801,NDC,,,facility,outpatient,1,EA,14.90000,4.32000,Aetna,Local,,7.56,,,,,,,5.37,12.19,percent of total billed charges,
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00074492134,NDC,facility,inpatient,1,ME,13.45000,3.90000,Aetna,Local,,5.38,,,,,,,4.85,11.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EPINEPHrine 1mg/10mL IS,800020065,CDM,636,RC,J0168,HCPCS,00074492101,NDC,facility,inpatient,1,ME,129.30000,37.50000,Aetna,Local,,51.72,,,,,,,46.61,105.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00074491134,NDC,facility,inpatient,1,ME,19.05000,5.52000,Aetna,Local,,7.62,,,,,,,6.87,15.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Atropine 1mg/10mL IS,800013376,CDM,636,RC,J0461,HCPCS,00074491101,NDC,facility,inpatient,1,ME,737.85000,213.98000,Aetna,Local,,295.14,,,,,,,265.99,603.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
D50W 50mL Inj Syr,800011221,CDM,258,RC,00074490222,NDC,,,facility,outpatient,1,EA,713.25000,206.84000,Aetna,Local,,362.12,,,,,,,257.13,583.44,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,800049618,CDM,250,RC,00074490001,NDC,,,facility,outpatient,1,EA,68.75000,19.94000,Aetna,Local,,34.90,,,,,,,24.78,56.24,percent of total billed charges,
NS 10mL PF Inj,800050731,CDM,258,RC,00074488810,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Water For Inj 50mL I,800015134,CDM,258,RC,A4216,HCPCS,00074488750,NDC,facility,outpatient,1,EA,6.05000,1.75000,Aetna,Local,,3.07,,,,,,,0.63000,4.95,percent of total billed charges,
Water For Inj 10mL I,800054147,CDM,258,RC,A4216,HCPCS,00074488710,NDC,facility,outpatient,1,EA,2.20000,0.64000,Aetna,Local,,1.12,,,,,,,0.63000,4.78,percent of total billed charges,
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00074471302,NDC,,,facility,inpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.44,,,,,,,1.30,2.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCL 1% 5mL PF I,800060938,CDM,636,RC,00074471302,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.44,,,,,,,1.30,2.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00074468823,NDC,facility,inpatient,200,ME,202.15000,58.62000,Aetna,Local,,80.86,,,,,,,72.88,165.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00074468802,NDC,facility,inpatient,400,ME,301.00000,87.29000,Aetna,Local,,120.40,,,,,,,108.51,246.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00074455290,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00074455213,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Levothyroxine Sodium 50mcg T,800019298,CDM,637,RC,00074455211,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
Remifentanil 1mg/3mL I (Ultiva),800081053,CDM,250,RC,00074449803,NDC,,,facility,outpatient,1,EA,248.90000,72.18000,Aetna,Local,,126.37,,,,,,,89.73,203.60,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,800062063,CDM,250,RC,00074438220,NDC,,,facility,outpatient,1,EA,2506.55000,726.90000,Aetna,Local,,1272.58,,,,,,,903.61,2050.36,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00074438010,NDC,,,facility,outpatient,1,EA,140.25000,40.67000,Aetna,Local,,71.20,,,,,,,50.56,114.72,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00074437836,NDC,,,facility,outpatient,1,EA,1407.00000,408.03000,Aetna,Local,,714.33,,,,,,,507.22,1150.93,percent of total billed charges,
Cisatracurium 10mg/5mL I(Nimbex),800072321,CDM,250,RC,00074437805,NDC,,,facility,outpatient,1,EA,159.90000,46.37000,Aetna,Local,,81.18,,,,,,,57.64,130.80,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00074434190,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00074434113,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,Local,,1.70,,,,,,,1.21,2.74,percent of total billed charges,
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00074428202,NDC,,,facility,inpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.24,,,,,,,2.02,4.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 10mL I PF,800070697,CDM,636,RC,00074428202,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.24,,,,,,,2.02,4.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00074427702,NDC,,,facility,inpatient,1,EA,8.70000,2.52000,Aetna,Local,,3.48,,,,,,,3.14,7.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 50mL I,800072156,CDM,636,RC,00074427702,NDC,,,facility,outpatient,1,EA,8.70000,2.52000,Aetna,Local,,3.48,,,,,,,3.14,7.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00074427701,NDC,,,facility,inpatient,1,EA,6.70000,1.94000,Aetna,Local,,2.68,,,,,,,2.42,5.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 20mL I,800014076,CDM,636,RC,00074427701,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,2.68,,,,,,,2.42,5.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00074427602,NDC,,,facility,inpatient,1,EA,5.05000,1.46000,Aetna,Local,,2.02,,,,,,,1.82,4.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 50mL I,800014050,CDM,636,RC,00074427602,NDC,,,facility,outpatient,1,EA,5.05000,1.46000,Aetna,Local,,2.02,,,,,,,1.82,4.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00074427601,NDC,,,facility,inpatient,1,EA,2.00000,0.58000,Aetna,Local,,0.80000,,,,,,,0.72100,1.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 1% 20mL I MDV,800014035,CDM,636,RC,00074427601,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,Local,,0.80000,,,,,,,0.72100,1.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cupric Cl (Copper) I 10mL,800017803,CDM,250,RC,00074409201,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
Fenofibrate 54mg T(Tricor),800081170,CDM,637,RC,00074400990,NDC,,,facility,outpatient,1,EA,6.20000,1.80000,Aetna,Local,,3.15,,,,,,,2.24,5.07,percent of total billed charges,
Divalproex Na 250 mg ER T/24hr,800080852,CDM,637,RC,00074382613,NDC,,,facility,outpatient,1,EA,29.70000,8.61000,Aetna,Local,,15.08,,,,,,,10.71,24.29,percent of total billed charges,
Terazosin 1mg C(Hytrin),800065945,CDM,637,RC,00074380513,NDC,,,facility,outpatient,1,EA,16.85000,4.89000,Aetna,Local,,8.55,,,,,,,6.07,13.78,percent of total billed charges,
Cefdinir 300 mg C (Omnicef),800081009,CDM,637,RC,00074376960,NDC,,,facility,outpatient,1,EA,43.80000,12.70000,Aetna,Local,,22.24,,,,,,,15.79,35.83,percent of total billed charges,
Levothyroxine Sodium 137 mcg T,800015418,CDM,637,RC,00074372790,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
DOBUTamine 1g/D5W 250mL,800013360,CDM,636,RC,J1250,HCPCS,00074372432,NDC,facility,inpatient,1,GM,171.35000,49.69000,Aetna,Local,,68.54,,,,,,,61.77,140.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00074357801,NDC,facility,inpatient,80,ME,19.60000,5.68000,Aetna,Local,,7.84,,,,,,,7.07,16.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Nitroprusside 50mg/2mL I,800012468,CDM,250,RC,00074302401,NDC,,,facility,outpatient,1,EA,79.25000,22.98000,Aetna,Local,,40.24,,,,,,,28.57,64.83,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00074258660,NDC,,,facility,outpatient,1,EA,72.60000,21.05000,Aetna,Local,,36.86,,,,,,,26.17,59.39,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00074258611,NDC,,,facility,outpatient,1,EA,58.00000,16.82000,Aetna,Local,,29.45,,,,,,,20.91,47.44,percent of total billed charges,
DOBUTamine 250mg/D5W 250mL,800012791,CDM,636,RC,J1250,HCPCS,00074234632,NDC,facility,inpatient,250,ME,85.75000,24.87000,Aetna,Local,,34.30,,,,,,,30.91,70.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00074231660,NDC,,,facility,outpatient,1,EA,392.80000,113.91000,Aetna,Local,,199.42,,,,,,,141.60,321.31,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00074212202,NDC,,,facility,outpatient,1,EA,40.85000,11.85000,Aetna,Local,,20.74,,,,,,,14.73,33.42,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,800043785,CDM,250,RC,00074196607,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00074176230,NDC,facility,inpatient,2,ME,8.70000,2.52000,Aetna,Local,,3.48,,,,,,,3.14,7.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bupivacaine-Epi 0.5% 30mL I PF,800040682,CDM,250,RC,00074174929,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,Local,,12.16,,,,,,,8.63,19.59,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,800061563,CDM,250,RC,00074174630,NDC,,,facility,outpatient,1,EA,813.15000,235.81000,Aetna,Local,,412.84,,,,,,,293.14,665.16,percent of total billed charges,
Valproate Na 500mg I,800074855,CDM,250,RC,00074156410,NDC,,,facility,outpatient,1,EA,298.45000,86.55000,Aetna,Local,,151.52,,,,,,,107.59,244.13,percent of total billed charges,
D10W 250mL,800012370,CDM,258,RC,00074153002,NDC,,,facility,outpatient,1,EA,1571.25000,455.66000,Aetna,Local,,797.72,,,,,,,566.44,1285.28,percent of total billed charges,
Nitroglycerin 25mg/D5W 250mL,800067636,CDM,636,RC,J2305,HCPCS,00074148303,NDC,facility,inpatient,25,ME,34.70000,10.06000,Aetna,Local,,13.88,,,,,,,12.51,28.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Norepinephrine Bit, 4000mcg/4mL I",800012104,CDM,250,RC,00074144304,NDC,,,facility,outpatient,1,EA,449.35000,130.31000,Aetna,Local,,228.13,,,,,,,161.99,367.57,percent of total billed charges,
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00074132305,NDC,,,facility,inpatient,1,EA,11.10000,3.22000,Aetna,Local,,4.44,,,,,,,4.00,9.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lidocaine HCl 2% 5mL PF IS,800012146,CDM,636,RC,00074132305,NDC,,,facility,outpatient,1,EA,11.10000,3.22000,Aetna,Local,,4.44,,,,,,,4.00,9.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
diazePAM 5mg/mL 2mL I(Valium),800072421,CDM,636,RC,J3360,HCPCS,00074127332,NDC,facility,inpatient,10,ME,20.30000,5.89000,Aetna,Local,,8.12,,,,,,,7.32,16.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00074125830,NDC,facility,inpatient,4,ME,9.05000,2.62000,Aetna,Local,,3.62,,,,,,,3.26,7.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gentamicin Sulf 40mg/mL 2mL I,800011502,CDM,636,RC,J1580,HCPCS,00074120703,NDC,facility,inpatient,80,ME,6.70000,1.94000,Aetna,Local,,2.68,,,,,,,2.42,5.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00074117630,NDC,facility,inpatient,25,ME,8.40000,2.44000,Aetna,Local,,3.36,,,,,,,3.03,6.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUPivacaine 0.5% 30mL I PF,800040708,CDM,250,RC,00074116202,NDC,,,facility,outpatient,1,EA,10.50000,3.04000,Aetna,Local,,5.33,,,,,,,3.79,8.59,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00074116201,NDC,,,facility,outpatient,1,EA,12.40000,3.60000,Aetna,Local,,6.30,,,,,,,4.47,10.14,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,800040690,CDM,250,RC,00074115902,NDC,,,facility,outpatient,1,EA,966.90000,280.40000,Aetna,Local,,490.90,,,,,,,348.57,790.92,percent of total billed charges,
Verapamil 2.5mg/mL 2mL I(Isoptin),800040518,CDM,250,RC,00074114401,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,Local,,3.10,,,,,,,2.20,4.99,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,800060920,CDM,250,RC,00071458210,NDC,,,facility,outpatient,1,EA,18.15000,5.26000,Aetna,Local,,9.21,,,,,,,6.54,14.85,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00071400810,NDC,facility,inpatient,500,ME,642.30000,186.27000,Aetna,Local,,256.92,,,,,,,231.55,525.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00071400705,NDC,facility,inpatient,100,ME,130.35000,37.80000,Aetna,Local,,52.14,,,,,,,46.99,106.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phenytoin Na 30mg Sr C(Dilantin),800071703,CDM,637,RC,00071374066,NDC,,,facility,outpatient,1,EA,12.70000,3.68000,Aetna,Local,,6.45,,,,,,,4.58,10.39,percent of total billed charges,
Phenytoin 25mg/1mL Oral Liq,800023340,CDM,637,RC,00071221420,NDC,,,facility,outpatient,1,EA,6.10000,1.77000,Aetna,Local,,3.10,,,,,,,2.20,4.99,percent of total billed charges,
Gabapentin 250mg/5mL Oral Liq UD,800015357,CDM,637,RC,00071201223,NDC,,,facility,outpatient,1,EA,37.60000,10.90000,Aetna,Local,,19.09,,,,,,,13.55,30.76,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,00071101568,NDC,,,facility,outpatient,1,EA,92.50000,26.82000,Aetna,Local,,46.96,,,,,,,33.35,75.67,percent of total billed charges,
Pregabalin 100mg C(Lyrica),800082148,CDM,637,RC,00071101541,NDC,,,facility,outpatient,1,EA,106.85000,30.99000,Aetna,Local,,54.25,,,,,,,38.52,87.40,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,00071101468,NDC,,,facility,outpatient,1,EA,92.50000,26.82000,Aetna,Local,,46.96,,,,,,,33.35,75.67,percent of total billed charges,
Pregabalin 75mg C(Lyrica),800082130,CDM,637,RC,00071101441,NDC,,,facility,outpatient,1,EA,106.85000,30.99000,Aetna,Local,,54.25,,,,,,,38.52,87.40,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,00071101368,NDC,,,facility,outpatient,1,EA,92.50000,26.82000,Aetna,Local,,46.96,,,,,,,33.35,75.67,percent of total billed charges,
Pregabalin 50mg C(Lyrica),800082122,CDM,637,RC,00071101341,NDC,,,facility,outpatient,1,EA,106.85000,30.99000,Aetna,Local,,54.25,,,,,,,38.52,87.40,percent of total billed charges,
Pregabalin 25mg C(Lyrica),800082114,CDM,637,RC,00071101268,NDC,,,facility,outpatient,1,EA,92.50000,26.82000,Aetna,Local,,46.96,,,,,,,33.35,75.67,percent of total billed charges,
Gabapentin 400mg C(Neurontin),800078146,CDM,637,RC,00071080624,NDC,,,facility,outpatient,1,EA,75.25000,21.82000,Aetna,Local,,38.20,,,,,,,27.13,61.55,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00071080540,NDC,,,facility,outpatient,1,EA,39.25000,11.38000,Aetna,Local,,19.93,,,,,,,14.15,32.11,percent of total billed charges,
Gabapentin 300mg C(Neurontin),800073436,CDM,637,RC,00071080524,NDC,,,facility,outpatient,1,EA,62.70000,18.18000,Aetna,Local,,31.83,,,,,,,22.60,51.29,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00071080340,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Gabapentin 100mg C(Neurontin),800073444,CDM,637,RC,00071080324,NDC,,,facility,outpatient,1,EA,25.10000,7.28000,Aetna,Local,,12.74,,,,,,,9.05,20.53,percent of total billed charges,
Gabapentin 600 mg T(Neurontin),800082072,CDM,637,RC,00071051324,NDC,,,facility,outpatient,1,EA,119.15000,34.55000,Aetna,Local,,60.49,,,,,,,42.95,97.46,percent of total billed charges,
Nitroglycerin 0.4mg SL T,800016732,CDM,637,RC,00071041813,NDC,,,facility,outpatient,1,EA,334.10000,96.89000,Aetna,Local,,169.62,,,,,,,120.44,273.29,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036940,NDC,,,facility,outpatient,1,EA,16.25000,4.71000,Aetna,Local,,8.25,,,,,,,5.86,13.29,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036924,NDC,,,facility,outpatient,1,EA,14.70000,4.26000,Aetna,Local,,7.46,,,,,,,5.30,12.02,percent of total billed charges,
Phenytoin Na 30mg Sr C(Dilantin),800071703,CDM,637,RC,00071036524,NDC,,,facility,outpatient,1,EA,2.75000,0.80000,Aetna,Local,,1.40,,,,,,,0.99138,2.25,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036240,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
Phenytoin Na 100mg ER C,800012855,CDM,637,RC,00071036224,NDC,,,facility,outpatient,1,EA,2.35000,0.68000,Aetna,Local,,1.19,,,,,,,0.84718,1.92,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,00071035060,NDC,,,facility,outpatient,1,EA,21.70000,6.29000,Aetna,Local,,11.02,,,,,,,7.82,17.75,percent of total billed charges,
Phenelzine Sulfate 15mg T(Nardil),800045707,CDM,637,RC,00071027024,NDC,,,facility,outpatient,1,EA,3.85000,1.12000,Aetna,Local,,1.95,,,,,,,1.39,3.15,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00071015773,NDC,,,facility,outpatient,1,EA,127.00000,36.83000,Aetna,Local,,64.48,,,,,,,45.78,103.89,percent of total billed charges,
Atorvastatin 40mg T (Lipitor),800081248,CDM,637,RC,00071015723,NDC,,,facility,outpatient,1,EA,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,56.60,128.43,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00071015640,NDC,,,facility,outpatient,1,EA,157.00000,45.53000,Aetna,Local,,79.71,,,,,,,56.60,128.43,percent of total billed charges,
Atorvastatin 20mg T(Lipitor),800075357,CDM,637,RC,00071015623,NDC,,,facility,outpatient,1,EA,149.55000,43.37000,Aetna,Local,,75.93,,,,,,,53.91,122.33,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00071015540,NDC,,,facility,outpatient,1,EA,102.85000,29.83000,Aetna,Local,,52.22,,,,,,,37.08,84.13,percent of total billed charges,
Atorvastatin 10mg T(Lipitor),800075340,CDM,637,RC,00071015523,NDC,,,facility,outpatient,1,EA,113.40000,32.89000,Aetna,Local,,57.57,,,,,,,40.88,92.76,percent of total billed charges,
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00069600125,NDC,facility,inpatient,100,ME,247.85000,71.88000,Aetna,Local,,99.14,,,,,,,89.35,202.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00069600121,NDC,facility,inpatient,500,ME,1033.10000,299.60000,Aetna,Local,,413.24,,,,,,,372.43,845.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,00069582061,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,Local,,7.59,,,,,,,5.39,12.23,percent of total billed charges,
Dofetilide 500 mcg C(Tikosyn),800079060,CDM,637,RC,00069582043,NDC,,,facility,outpatient,1,EA,94.15000,27.30000,Aetna,Local,,47.80,,,,,,,33.94,77.01,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,00069581061,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,Local,,7.59,,,,,,,5.39,12.23,percent of total billed charges,
Dofetilide 250 mcg C(Tikosyn),800079052,CDM,637,RC,00069581043,NDC,,,facility,outpatient,1,EA,94.15000,27.30000,Aetna,Local,,47.80,,,,,,,33.94,77.01,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00069580061,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,Local,,7.59,,,,,,,5.39,12.23,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00069580060,NDC,,,facility,outpatient,1,EA,95.10000,27.58000,Aetna,Local,,48.28,,,,,,,34.28,77.79,percent of total billed charges,
Dofetilide 125 mcg C(Tikosyn),800079078,CDM,637,RC,00069580043,NDC,,,facility,outpatient,1,EA,94.15000,27.30000,Aetna,Local,,47.80,,,,,,,33.94,77.01,percent of total billed charges,
Fosphenytoin 500mg/10mL I(CereBYX),800015175,CDM,636,RC,Q2009,HCPCS,00069547402,NDC,facility,inpatient,500,ME,726.25000,210.61000,Aetna,Local,,290.50,,,,,,,261.81,594.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosphenytoin 100mg/2mL I(CereBYX),800015176,CDM,636,RC,Q2009,HCPCS,00069547102,NDC,facility,inpatient,100,ME,171.95000,49.87000,Aetna,Local,,68.78,,,,,,,61.99,140.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
nirmatrelvir-ritonavir 300mg-100mg Dose Tab,800046441,CDM,250,RC,00069532130,NDC,,,facility,outpatient,1,EA,1091.80000,316.62000,Aetna,Local,,554.31,,,,,,,393.59,893.09,percent of total billed charges,
nirmatrelvir-ritonavir 150 mg-100 mg (Renal Dose) Tab,800051949,CDM,250,RC,00069531720,NDC,,,facility,outpatient,1,EA,1091.80000,316.62000,Aetna,Local,,554.31,,,,,,,393.59,893.09,percent of total billed charges,
dexaMETHasone NaPhos 4mg/mL I,800013395,CDM,636,RC,J1100,HCPCS,00069454702,NDC,facility,inpatient,4,ME,5.25000,1.52000,Aetna,Local,,2.10,,,,,,,1.89,4.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prazosin HCl 1mg C(Minipress),800017928,CDM,637,RC,00069431071,NDC,,,facility,outpatient,1,EA,19.65000,5.70000,Aetna,Local,,9.98,,,,,,,7.08,16.07,percent of total billed charges,
Sildenafil citrate 20 mg T(Revatio),800070024,CDM,637,RC,00069419068,NDC,,,facility,outpatient,1,EA,469.80000,136.24000,Aetna,Local,,238.52,,,,,,,169.36,384.30,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00069406189,NDC,,,facility,outpatient,1,EA,29.30000,8.50000,Aetna,Local,,14.88,,,,,,,10.56,23.97,percent of total billed charges,
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00069403201,NDC,facility,inpatient,50,ME,266.30000,77.23000,Aetna,Local,,106.52,,,,,,,96.00,217.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00069403001,NDC,facility,inpatient,10,ME,78.40000,22.74000,Aetna,Local,,31.36,,,,,,,28.26,64.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Azithromycin 100mg/5mL L,800080613,CDM,637,RC,00069311019,NDC,,,facility,outpatient,1,EA,75.20000,21.81000,Aetna,Local,,38.18,,,,,,,27.11,61.51,percent of total billed charges,
Azithromycin 250 mg T(Zithromax),800071059,CDM,637,RC,00069306030,NDC,,,facility,outpatient,1,EA,18.35000,5.32000,Aetna,Local,,9.32,,,,,,,6.62,15.01,percent of total billed charges,
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00069303020,NDC,facility,inpatient,10,ME,79.15000,22.95000,Aetna,Local,,31.66,,,,,,,28.53,64.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00069265066,NDC,,,facility,outpatient,1,EA,56.15000,16.28000,Aetna,Local,,28.51,,,,,,,20.24,45.93,percent of total billed charges,
NIFEdipine 30mg XLT(Adalat/Procard,800054253,CDM,637,RC,00069265041,NDC,,,facility,outpatient,1,EA,18.10000,5.25000,Aetna,Local,,9.19,,,,,,,6.53,14.81,percent of total billed charges,
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00069260101,NDC,facility,inpatient,1,GM,543.70000,157.67000,Aetna,Local,,217.48,,,,,,,196.00,444.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Vancomycin HCl Inj MDV,800013347,CDM,636,RC,J3373,HCPCS,00069259999,NDC,facility,inpatient,1,GM,496.65000,144.03000,Aetna,Local,,198.66,,,,,,,179.04,406.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00069153072,NDC,,,facility,outpatient,1,EA,61.05000,17.70000,Aetna,Local,,31.00,,,,,,,22.01,49.94,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00069153068,NDC,,,facility,outpatient,1,EA,73.40000,21.29000,Aetna,Local,,37.27,,,,,,,26.46,60.04,percent of total billed charges,
amLODIPine 5mg T(Norvasc),800069806,CDM,637,RC,00069153066,NDC,,,facility,outpatient,1,EA,11.70000,3.39000,Aetna,Local,,5.94,,,,,,,4.22,9.57,percent of total billed charges,
"Epoetin alfa - epbx 20,000 units/mL Inj",800062118,CDM,636,RC,Q5106,HCPCS,00069131110,NDC,facility,inpatient,20000,UN,1068.85000,309.97000,Aetna,Local,,427.54,,,,,,,385.32,874.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 20,000 units/mL Inj",800062118,CDM,636,RC,Q5106,HCPCS,00069131110,NDC,facility,outpatient,20000,UN,1068.85000,309.97000,Aetna,Local,,427.54,,,,,,,7.29,874.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 40,000units/mL PF Inj",800062006,CDM,636,RC,Q5106,HCPCS,00069130904,NDC,facility,inpatient,40000,UN,1947.75000,564.85000,Aetna,Local,,779.10,,,,,,,702.16,1593.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 40,000units/mL PF Inj",800062006,CDM,636,RC,Q5106,HCPCS,00069130904,NDC,facility,outpatient,40000,UN,1947.75000,564.85000,Aetna,Local,,779.10,,,,,,,7.29,1593.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 10,000units/mL PF Inj",800062004,CDM,636,RC,Q5106,HCPCS,00069130810,NDC,facility,inpatient,10000,UN,595.60000,172.72000,Aetna,Local,,238.24,,,,,,,214.71,487.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 10,000units/mL PF Inj",800062004,CDM,636,RC,Q5106,HCPCS,00069130810,NDC,facility,outpatient,10000,UN,595.60000,172.72000,Aetna,Local,,238.24,,,,,,,7.29,487.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 4,000units/mL PF Inj",800062003,CDM,636,RC,Q5106,HCPCS,00069130710,NDC,facility,inpatient,4000,UN,269.70000,78.21000,Aetna,Local,,107.88,,,,,,,97.23,220.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 4,000units/mL PF Inj",800062003,CDM,636,RC,Q5106,HCPCS,00069130710,NDC,facility,outpatient,4000,UN,269.70000,78.21000,Aetna,Local,,107.88,,,,,,,7.29,220.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 3,000units/mL PF Inj",800062001,CDM,636,RC,Q5106,HCPCS,00069130610,NDC,facility,inpatient,3000,UN,205.40000,59.57000,Aetna,Local,,82.16,,,,,,,74.05,168.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Epoetin alfa - epbx 3,000units/mL PF Inj",800062001,CDM,636,RC,Q5106,HCPCS,00069130610,NDC,facility,outpatient,3000,UN,205.40000,59.57000,Aetna,Local,,82.16,,,,,,,7.29,168.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 10mg/5mL I,800022014,CDM,636,RC,J9000,HCPCS,00069035820,NDC,facility,inpatient,10,ME,79.15000,22.95000,Aetna,Local,,31.66,,,,,,,28.53,64.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DOXOrubicin 50mg/25mL I,800022015,CDM,636,RC,J9000,HCPCS,00069034302,NDC,facility,inpatient,50,ME,189.90000,55.07000,Aetna,Local,,75.96,,,,,,,68.46,155.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-apgf 6 mg/0.6 mL Inj Syr,800046522,CDM,636,RC,Q5122,HCPCS,00069032401,NDC,facility,inpatient,6,ME,30805.00000,8933.45000,Aetna,Local,,12322.00,,,,,,,11105.20,25198.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pegfilgrastim-apgf 6 mg/0.6 mL Inj Syr,800046522,CDM,636,RC,Q5122,HCPCS,00069032401,NDC,facility,outpatient,6,ME,30805.00000,8933.45000,Aetna,Local,,12322.00,,,,,,,128.13,25198.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 1g I (Merrem),800012010,CDM,636,RC,J2185,HCPCS,00069031410,NDC,facility,inpatient,1,GM,275.25000,79.82000,Aetna,Local,,110.10,,,,,,,99.23,225.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meropenem 500mg I (Merrem),800020026,CDM,636,RC,J2185,HCPCS,00069031310,NDC,facility,inpatient,500,ME,139.20000,40.37000,Aetna,Local,,55.68,,,,,,,50.18,113.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- qyyp 150mg Inj,800046524,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,inpatient,150,ME,6726.95000,1950.82000,Aetna,Local,,2690.78,,,,,,,2425.07,5502.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- qyyp 150mg Inj,800046524,CDM,636,RC,Q5116,HCPCS,00069030801,NDC,facility,outpatient,150,ME,6726.95000,1950.82000,Aetna,Local,,2690.78,,,,,,,7.91,5502.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- qyyp 420mg Inj,800046523,CDM,636,RC,Q5116,HCPCS,00069030501,NDC,facility,inpatient,420,ME,18498.85000,5364.67000,Aetna,Local,,7399.54,,,,,,,6668.84,15132.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Trastuzumab- qyyp 420mg Inj,800046523,CDM,636,RC,Q5116,HCPCS,00069030501,NDC,facility,outpatient,420,ME,18498.85000,5364.67000,Aetna,Local,,7399.54,,,,,,,7.91,15132.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filgrastim- aafi 480mcg Inj Syr,800046528,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,inpatient,0.48,ME,1586.00000,459.94000,Aetna,Local,,634.40,,,,,,,571.75,1297.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Filgrastim- aafi 480mcg Inj Syr,800046528,CDM,636,RC,Q5110,HCPCS,00069029201,NDC,facility,outpatient,0.48,ME,1586.00000,459.94000,Aetna,Local,,634.40,,,,,,,0.26964,1297.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab-pvvr 500mg- Pt Own Supply,800051027,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,inpatient,500,ME,0.50000,0.14000,Aetna,Local,,0.20000,,,,,,,0.18025,0.40900,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab-pvvr 500mg- Pt Own Supply,800051027,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,500,ME,0.50000,0.14000,Aetna,Local,,0.20000,,,,,,,0.18500,40.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab - pvvr 500mg/50mL Inj,800062099,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,inpatient,500,ME,25991.80000,7537.62000,Aetna,Local,,10396.72,,,,,,,9370.04,21261.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab - pvvr 500mg/50mL Inj,800062099,CDM,636,RC,Q5119,HCPCS,00069024901,NDC,facility,outpatient,500,ME,25991.80000,7537.62000,Aetna,Local,,10396.72,,,,,,,12.78,21261.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 1g/100mL I (Diprivan),800019985,CDM,636,RC,J2704,HCPCS,00069024810,NDC,facility,inpatient,1,GM,222.30000,64.47000,Aetna,Local,,88.92,,,,,,,80.14,181.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab-pvvr 100mg- Pt Own Supply,800051017,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,inpatient,100,ME,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab-pvvr 100mg- Pt Own Supply,800051017,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,100,ME,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03700,40.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab - pvvr 100mg/10mL Inj,800062100,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,inpatient,100,ME,5347.95000,1550.91000,Aetna,Local,,2139.18,,,,,,,1927.94,4374.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
riTUXimab - pvvr 100mg/10mL Inj,800062100,CDM,636,RC,Q5119,HCPCS,00069023801,NDC,facility,outpatient,100,ME,5347.95000,1550.91000,Aetna,Local,,2139.18,,,,,,,12.78,4374.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propofol 200mg/20mL I (Diprivan),800019972,CDM,636,RC,J2704,HCPCS,00069020910,NDC,facility,inpatient,200,ME,27.60000,8.00000,Aetna,Local,,11.04,,,,,,,9.95,22.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Methotrexate Na 250mg/10mL I PF,800022021,CDM,636,RC,J9260,HCPCS,00069014801,NDC,facility,inpatient,250,ME,89.70000,26.01000,Aetna,Local,,35.88,,,,,,,32.34,73.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 30,000 unit/30mL",800015117,CDM,636,RC,J1644,HCPCS,00069013703,NDC,facility,inpatient,30000,UN,79.30000,23.00000,Aetna,Local,,31.72,,,,,,,28.59,64.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,00069012102,NDC,facility,inpatient,20,ME,5.70000,1.65000,Aetna,Local,,2.28,,,,,,,2.05,4.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00069010503,NDC,,,facility,outpatient,1,EA,43.40000,12.59000,Aetna,Local,,22.03,,,,,,,15.65,35.50,percent of total billed charges,
Tobramycin Sulfate 80mg/2mL I,800055169,CDM,636,RC,J3260,HCPCS,00069008802,NDC,facility,inpatient,80,ME,19.00000,5.51000,Aetna,Local,,7.60,,,,,,,6.85,15.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 1,000 unit/mL 10mL I",800013611,CDM,636,RC,J1644,HCPCS,00069005801,NDC,facility,inpatient,10000,UN,21.55000,6.25000,Aetna,Local,,8.62,,,,,,,7.77,17.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00069004503,NDC,facility,inpatient,400,ME,130.00000,37.70000,Aetna,Local,,52.00,,,,,,,46.87,106.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00069003803,NDC,facility,inpatient,200,ME,85.70000,24.85000,Aetna,Local,,34.28,,,,,,,30.89,70.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Etomidate 2mg/mL 10mL Inj,800047521,CDM,250,RC,00069000601,NDC,,,facility,outpatient,1,EA,62.65000,18.17000,Aetna,Local,,31.81,,,,,,,22.59,51.25,percent of total billed charges,
Dicyclomine HCl 20mg/2mL I(Bentyl),800010447,CDM,636,RC,J0500,HCPCS,00068080923,NDC,facility,inpatient,20,ME,136.45000,39.57000,Aetna,Local,,54.58,,,,,,,49.19,111.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
rifAMPin 300mg C,800018357,CDM,637,RC,00068050861,NDC,,,facility,outpatient,1,EA,37.10000,10.76000,Aetna,Local,,18.84,,,,,,,13.37,30.35,percent of total billed charges,
rifAMPin 300mg C,800018357,CDM,637,RC,00068050830,NDC,,,facility,outpatient,1,EA,22.80000,6.61000,Aetna,Local,,11.58,,,,,,,8.22,18.65,percent of total billed charges,
Dicyclomine HCl 10mg/5mL Oral L(Bentyl),800065135,CDM,637,RC,00068012516,NDC,,,facility,outpatient,1,EA,3.15000,0.91000,Aetna,Local,,1.60,,,,,,,1.14,2.58,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,00067815203,NDC,,,facility,outpatient,1,EA,176.80000,51.27000,Aetna,Local,,89.76,,,,,,,63.74,144.62,percent of total billed charges,
Diclofenac 1% TG 100G (Voltaren),800081145,CDM,637,RC,00067621597,NDC,,,facility,outpatient,1,EA,204.90000,59.42000,Aetna,Local,,104.03,,,,,,,73.87,167.61,percent of total billed charges,
Ciprofloxacin-Dexa Otic Susp 7.5mL,800081470,CDM,637,RC,00065853302,NDC,,,facility,outpatient,1,EA,1803.45000,523.00000,Aetna,Local,,915.61,,,,,,,650.14,1475.22,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00065815001,NDC,,,facility,outpatient,1,EA,126.15000,36.58000,Aetna,Local,,64.05,,,,,,,45.48,103.19,percent of total billed charges,
Ophthalmic Irr Soln15mL(BSS),800018655,CDM,637,RC,00065079515,NDC,,,facility,outpatient,1,EA,107.45000,31.16000,Aetna,Local,,54.55,,,,,,,38.74,87.89,percent of total billed charges,
Tetracaine HCl 0.5% 4mL Ophth Soln,800021991,CDM,637,RC,00065074114,NDC,,,facility,outpatient,1,EA,117.90000,34.19000,Aetna,Local,,59.86,,,,,,,42.50,96.44,percent of total billed charges,
Tobra-Dex 3.5g Ophth Oint(Tobradex),800053479,CDM,637,RC,00065064835,NDC,,,facility,outpatient,1,EA,1676.15000,486.08000,Aetna,Local,,850.98,,,,,,,604.25,1371.09,percent of total billed charges,
Tobra-Dex 5mL Ophth Susp(Tobradex),800053453,CDM,637,RC,00065064705,NDC,,,facility,outpatient,1,EA,1205.30000,349.54000,Aetna,Local,,611.93,,,,,,,434.51,985.94,percent of total billed charges,
Tobramycin 0.3% 3.5g Ophth Oint(Tobrex),800041185,CDM,637,RC,00065064435,NDC,,,facility,outpatient,1,EA,1591.75000,461.61000,Aetna,Local,,808.13,,,,,,,573.83,1302.05,percent of total billed charges,
Neo-Poly-Dex  3.5g Ophth Oint(Maxitrol),800019646,CDM,637,RC,00065063136,NDC,,,facility,outpatient,1,EA,1473.05000,427.18000,Aetna,Local,,747.87,,,,,,,531.03,1204.95,percent of total billed charges,
Tropicamide 1% Ophth Soln(Mydriacyl),800061415,CDM,637,RC,00065035503,NDC,,,facility,outpatient,1,EA,65.70000,19.05000,Aetna,Local,,33.36,,,,,,,23.68,53.74,percent of total billed charges,
Atropine SO4 1% Ophth Soln(Atropisol),800039270,CDM,637,RC,00065030355,NDC,,,facility,outpatient,1,EA,460.05000,133.41000,Aetna,Local,,233.57,,,,,,,165.85,376.32,percent of total billed charges,
Olopatadine 0.2% Ophth Soln 2.5mL,800072436,CDM,637,RC,00065027225,NDC,,,facility,outpatient,1,EA,1422.75000,412.60000,Aetna,Local,,722.33,,,,,,,512.90,1163.81,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00064501030,NDC,,,facility,outpatient,1,EA,1533.45000,444.70000,Aetna,Local,,778.53,,,,,,,552.81,1254.36,percent of total billed charges,
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00064501015,NDC,,,facility,outpatient,1,EA,816.05000,236.65000,Aetna,Local,,414.31,,,,,,,294.19,667.53,percent of total billed charges,
Miconazole Nitrate 2% 45g VC(Monistat),800065697,CDM,637,RC,00062542601,NDC,,,facility,outpatient,1,EA,1985.80000,575.88000,Aetna,Local,,1008.19,,,,,,,715.88,1624.38,percent of total billed charges,
Carbidopa-Levo 25-100 T(Sinemet),800050228,CDM,637,RC,00056065068,NDC,,,facility,outpatient,1,EA,8.05000,2.33000,Aetna,Local,,4.09,,,,,,,2.90,6.58,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,00056060128,NDC,,,facility,outpatient,1,EA,7.80000,2.26000,Aetna,Local,,3.96,,,,,,,2.81,6.38,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00056052168,NDC,,,facility,outpatient,1,EA,12.10000,3.51000,Aetna,Local,,6.14,,,,,,,4.36,9.90,percent of total billed charges,
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00056052128,NDC,,,facility,outpatient,1,EA,15.70000,4.55000,Aetna,Local,,7.97,,,,,,,5.66,12.84,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00056017675,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,Local,,9.57,,,,,,,6.80,15.42,percent of total billed charges,
Warfarin Sodium 2.5mg Tab,800012087,CDM,637,RC,00056017670,NDC,,,facility,outpatient,1,EA,18.85000,5.47000,Aetna,Local,,9.57,,,,,,,6.80,15.42,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00056017375,NDC,,,facility,outpatient,1,EA,26.20000,7.60000,Aetna,Local,,13.30,,,,,,,9.45,21.43,percent of total billed charges,
Warfarin Sodium 7.5mg Tab,800069993,CDM,637,RC,00056017370,NDC,,,facility,outpatient,1,EA,26.20000,7.60000,Aetna,Local,,13.30,,,,,,,9.45,21.43,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,00056017275,NDC,,,facility,outpatient,1,EA,19.65000,5.70000,Aetna,Local,,9.98,,,,,,,7.08,16.07,percent of total billed charges,
Warfarin Sodium 5mg Tab,800012095,CDM,637,RC,00056017270,NDC,,,facility,outpatient,1,EA,19.65000,5.70000,Aetna,Local,,9.98,,,,,,,7.08,16.07,percent of total billed charges,
Warfarin Sodium 2mg Tab,800012079,CDM,637,RC,00056017075,NDC,,,facility,outpatient,1,EA,18.30000,5.31000,Aetna,Local,,9.29,,,,,,,6.60,14.97,percent of total billed charges,
Warfarin Sodium 1mg Tab,800055672,CDM,637,RC,00056016975,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,Local,,8.88,,,,,,,6.31,14.31,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,00054885925,NDC,,,facility,outpatient,1,EA,21.95000,6.37000,Aetna,Local,,11.14,,,,,,,7.91,17.96,percent of total billed charges,
Morphine 30mg/8 to 12hr SR T(Oramorph SR),800074582,CDM,637,RC,00054880524,NDC,,,facility,outpatient,1,EA,13.60000,3.94000,Aetna,Local,,6.90,,,,,,,4.90,11.12,percent of total billed charges,
Morphine 100mg/8 to 12hr SR T(Oramorph SR),800073402,CDM,637,RC,00054879311,NDC,,,facility,outpatient,1,EA,41.65000,12.08000,Aetna,Local,,21.15,,,,,,,15.01,34.07,percent of total billed charges,
Morphine 15mg/8 to 12hr SR T(Oramorph SR),800074574,CDM,637,RC,00054879024,NDC,,,facility,outpatient,1,EA,7.15000,2.07000,Aetna,Local,,3.63,,,,,,,2.58,5.85,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00054874425,NDC,,,facility,outpatient,1,EA,0.55000,0.16000,Aetna,Local,,0.27924,,,,,,,0.19828,0.44990,percent of total billed charges,
Potassium Cl 20mEq/15mL L UD,800025857,CDM,637,RC,00054871404,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,Local,,1.50,,,,,,,1.06,2.41,percent of total billed charges,
Potassium Cl 40mEq/30mL L UD,800025873,CDM,637,RC,00054871304,NDC,,,facility,outpatient,1,EA,30.10000,8.73000,Aetna,Local,,15.28,,,,,,,10.85,24.62,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,00054858224,NDC,,,facility,outpatient,1,EA,2.60000,0.75000,Aetna,Local,,1.32,,,,,,,0.93730,2.13,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00054855424,NDC,,,facility,outpatient,1,EA,3.50000,1.01000,Aetna,Local,,1.78,,,,,,,1.26,2.86,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,00054855324,NDC,,,facility,outpatient,1,EA,3.10000,0.90000,Aetna,Local,,1.57,,,,,,,1.12,2.54,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,00054852625,NDC,,,facility,outpatient,1,EA,1.35000,0.39000,Aetna,Local,,0.68539,,,,,,,0.48668,1.10,percent of total billed charges,
Lidocaine 2% 15mL L(Viscous),800070032,CDM,637,RC,00054850016,NDC,,,facility,outpatient,1,EA,8.90000,2.58000,Aetna,Local,,4.52,,,,,,,3.21,7.28,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00054839424,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,00054839224,NDC,,,facility,outpatient,1,EA,3.75000,1.09000,Aetna,Local,,1.90,,,,,,,1.35,3.07,percent of total billed charges,
Digoxin 125mcg/2.5mL (0.125mg/2.5mL) L UD,800048289,CDM,637,RC,00054819216,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
dexaMETHasone 1mg Tab UD,800062045,CDM,636,RC,J8540,HCPCS,00054817425,NDC,facility,inpatient,1,ME,2.65000,0.77000,Aetna,Local,,1.06,,,,,,,0.95532,2.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00054814622,NDC,,,facility,outpatient,1,EA,24.30000,7.05000,Aetna,Local,,12.34,,,,,,,8.76,19.88,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,00054485906,NDC,,,facility,outpatient,1,EA,5.35000,1.55000,Aetna,Local,,2.72,,,,,,,1.93,4.38,percent of total billed charges,
Tamoxifen 10mg T(Nolvadex),800038074,CDM,637,RC,00054483121,NDC,,,facility,outpatient,1,EA,13.40000,3.89000,Aetna,Local,,6.80,,,,,,,4.83,10.96,percent of total billed charges,
Pseudoephedrine HCl 60mg T,800019124,CDM,637,RC,00054474425,NDC,,,facility,outpatient,1,EA,0.45000,0.13000,Aetna,Local,,0.22847,,,,,,,0.16223,0.36810,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00054467613,NDC,,,facility,outpatient,1,EA,19.20000,5.57000,Aetna,Local,,9.75,,,,,,,6.92,15.71,percent of total billed charges,
oxyCODONE 5mg T(RoxiCODONE),800072016,CDM,637,RC,00054465725,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Methadone HCl 10mg T,800075647,CDM,637,RC,00054457125,NDC,,,facility,outpatient,1,EA,3.55000,1.03000,Aetna,Local,,1.80,,,,,,,1.28,2.90,percent of total billed charges,
Methadone HCl 5mg T,800075555,CDM,637,RC,00054457025,NDC,,,facility,outpatient,1,EA,2.15000,0.62000,Aetna,Local,,1.09,,,,,,,0.77507,1.76,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00054439425,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
HYDROmorphone 8 mg T(Dilaudid),800081355,CDM,637,RC,00054437025,NDC,,,facility,outpatient,1,EA,10.55000,3.06000,Aetna,Local,,5.36,,,,,,,3.80,8.63,percent of total billed charges,
Furosemide 40mg T(Lasix),800015353,CDM,637,RC,00054429925,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00054429725,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00054428813,NDC,,,facility,outpatient,1,EA,62.35000,18.08000,Aetna,Local,,31.66,,,,,,,22.48,51.00,percent of total billed charges,
dexaMETHasone 1mg Tab UD,800062045,CDM,636,RC,J8540,HCPCS,00054418125,NDC,facility,inpatient,1,ME,2.10000,0.61000,Aetna,Local,,0.84000,,,,,,,0.75705,1.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00054414623,NDC,,,facility,outpatient,1,EA,20.70000,6.00000,Aetna,Local,,10.51,,,,,,,7.46,16.93,percent of total billed charges,
Clotrimazole 10mg Loz(Mycelex),800061696,CDM,637,RC,00054414622,NDC,,,facility,outpatient,1,EA,22.75000,6.60000,Aetna,Local,,11.55,,,,,,,8.20,18.61,percent of total billed charges,
oxyCODONE 5mg/5mL Oral Soln,800079524,CDM,637,RC,00054368263,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,Local,,1.88,,,,,,,1.33,3.03,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),800075274,CDM,637,RC,00054356699,NDC,,,facility,outpatient,1,EA,17.25000,5.00000,Aetna,Local,,8.76,,,,,,,6.22,14.11,percent of total billed charges,
Methadone 100mg/10mL Oral Conc,800025565,CDM,637,RC,00054355344,NDC,,,facility,outpatient,1,EA,67.60000,19.60000,Aetna,Local,,34.32,,,,,,,24.37,55.30,percent of total billed charges,
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00054354258,NDC,,,facility,outpatient,1,EA,42.45000,12.31000,Aetna,Local,,21.55,,,,,,,15.30,34.72,percent of total billed charges,
LORazepam 1mg/0.5mL Oral Conc,800025501,CDM,637,RC,00054353244,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,800053156,CDM,250,RC,00054350547,NDC,,,facility,outpatient,1,EA,6.80000,1.97000,Aetna,Local,,3.45,,,,,,,2.45,5.56,percent of total billed charges,
Fluticasone Prop 0.05% NS(Flonase),800073501,CDM,637,RC,00054327099,NDC,,,facility,outpatient,1,EA,607.45000,176.16000,Aetna,Local,,308.40,,,,,,,218.99,496.89,percent of total billed charges,
Diphenoxylate - Atrop 5mL UD Oral Liq,800015356,CDM,637,RC,00054319446,NDC,,,facility,outpatient,1,EA,56.00000,16.24000,Aetna,Local,,28.43,,,,,,,20.19,45.81,percent of total billed charges,
Mexiletine 200mg C(Mexitil),800017450,CDM,637,RC,00054261725,NDC,,,facility,outpatient,1,EA,5.80000,1.68000,Aetna,Local,,2.94,,,,,,,2.09,4.74,percent of total billed charges,
Mexiletine 150mg C(Mexitil),800051945,CDM,637,RC,00054261625,NDC,,,facility,outpatient,1,EA,4.90000,1.42000,Aetna,Local,,2.49,,,,,,,1.77,4.01,percent of total billed charges,
Lithium Carb 150mg C,800017633,CDM,637,RC,00054252625,NDC,,,facility,outpatient,1,EA,1.20000,0.35000,Aetna,Local,,0.60924,,,,,,,0.43260,0.98160,percent of total billed charges,
Albuterol 90 mcg/Inh,800040971,CDM,637,RC,00054074287,NDC,,,facility,outpatient,1,EA,592.65000,171.87000,Aetna,Local,,300.89,,,,,,,213.65,484.79,percent of total billed charges,
Dipyridamole 25mg T(Persantine),800017409,CDM,637,RC,00054043425,NDC,,,facility,outpatient,1,EA,6.70000,1.94000,Aetna,Local,,3.40,,,,,,,2.42,5.48,percent of total billed charges,
HYDROmorphone 5mg/5mL Oral Soln,800025677,CDM,637,RC,00054038663,NDC,,,facility,outpatient,1,EA,24.00000,6.96000,Aetna,Local,,12.18,,,,,,,8.65,19.63,percent of total billed charges,
Fluticasone-Salm 500/50 Inh,800078062,CDM,637,RC,00054032856,NDC,,,facility,outpatient,1,EA,3285.40000,952.77000,Aetna,Local,,1668.00,,,,,,,1184.39,2687.46,percent of total billed charges,
Fluticasone-Salm 250-50 Inh,800078088,CDM,637,RC,00054032756,NDC,,,facility,outpatient,1,EA,2566.35000,744.24000,Aetna,Local,,1302.94,,,,,,,925.17,2099.27,percent of total billed charges,
Fluticasone-Salm 100-50 Inh,800078070,CDM,637,RC,00054032656,NDC,,,facility,outpatient,1,EA,2121.10000,615.12000,Aetna,Local,,1076.88,,,,,,,764.66,1735.06,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,00054029399,NDC,,,facility,outpatient,1,EA,677.00000,196.33000,Aetna,Local,,343.71,,,,,,,244.06,553.79,percent of total billed charges,
Letrozole 2.5 mg T(Femara),800017628,CDM,637,RC,00054026913,NDC,,,facility,outpatient,1,EA,128.40000,37.24000,Aetna,Local,,65.19,,,,,,,46.29,105.03,percent of total billed charges,
HYDROmorphone 4mg T(Dilaudid),800057223,CDM,637,RC,00054026424,NDC,,,facility,outpatient,1,EA,5.75000,1.67000,Aetna,Local,,2.92,,,,,,,2.07,4.70,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00054025922,NDC,,,facility,outpatient,1,EA,40.05000,11.61000,Aetna,Local,,20.33,,,,,,,14.44,32.76,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00054025913,NDC,,,facility,outpatient,1,EA,3.60000,1.04000,Aetna,Local,,1.83,,,,,,,1.30,2.94,percent of total billed charges,
Morphine 5mg/1.25 mL Oral Liq,800015448,CDM,637,RC,00054023849,NDC,,,facility,outpatient,1,EA,1.75000,0.51000,Aetna,Local,,0.88848,,,,,,,0.63087,1.43,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,00054023525,NDC,,,facility,outpatient,1,EA,4.15000,1.20000,Aetna,Local,,2.11,,,,,,,1.50,3.39,percent of total billed charges,
Morphine Sulf 15 mg T(Short Acting),800081538,CDM,637,RC,00054023524,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00054022625,NDC,,,facility,outpatient,1,EA,22.65000,6.57000,Aetna,Local,,11.50,,,,,,,8.17,18.53,percent of total billed charges,
Meloxicam 7.5 mg T,800017639,CDM,637,RC,00054022613,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,Local,,11.40,,,,,,,8.09,18.36,percent of total billed charges,
QUEtiapine 100mg T(SEROquel),800078187,CDM,637,RC,00054022125,NDC,,,facility,outpatient,1,EA,48.55000,14.08000,Aetna,Local,,24.65,,,,,,,17.50,39.71,percent of total billed charges,
QUEtiapine 25mg T(SEROquel),800078179,CDM,637,RC,00054022025,NDC,,,facility,outpatient,1,EA,28.30000,8.21000,Aetna,Local,,14.37,,,,,,,10.20,23.15,percent of total billed charges,
Famciclovir 250 mg T (Famvir),800017604,CDM,637,RC,00054019713,NDC,,,facility,outpatient,1,EA,49.20000,14.27000,Aetna,Local,,24.98,,,,,,,17.74,40.25,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00054012322,NDC,,,facility,outpatient,1,EA,12.75000,3.70000,Aetna,Local,,6.47,,,,,,,4.60,10.43,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00054011925,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,Local,,9.01,,,,,,,6.40,14.52,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00054011825,NDC,,,facility,outpatient,1,EA,17.75000,5.15000,Aetna,Local,,9.01,,,,,,,6.40,14.52,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,00054011625,NDC,,,facility,outpatient,1,EA,2.55000,0.74000,Aetna,Local,,1.29,,,,,,,0.91927,2.09,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,00054010825,NDC,,,facility,outpatient,1,EA,1.70000,0.49000,Aetna,Local,,0.86309,,,,,,,0.61285,1.39,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,00054010725,NDC,,,facility,outpatient,1,EA,1.60000,0.46000,Aetna,Local,,0.81232,,,,,,,0.57680,1.31,percent of total billed charges,
Ramipril 1.25 mg C(Altace),800082304,CDM,637,RC,00054010625,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,Local,,5.51,,,,,,,3.91,8.88,percent of total billed charges,
OXcarbazepine 300 mg T(Trileptal),800080928,CDM,637,RC,00054009825,NDC,,,facility,outpatient,1,EA,18.80000,5.45000,Aetna,Local,,9.54,,,,,,,6.78,15.38,percent of total billed charges,
OXcarbazepine 150mg T(Trileptal),800080910,CDM,637,RC,00054009725,NDC,,,facility,outpatient,1,EA,10.30000,2.99000,Aetna,Local,,5.23,,,,,,,3.71,8.43,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00054008720,NDC,,,facility,outpatient,1,EA,38.85000,11.27000,Aetna,Local,,19.72,,,,,,,14.01,31.78,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00054008625,NDC,,,facility,outpatient,1,EA,37.00000,10.73000,Aetna,Local,,18.78,,,,,,,13.34,30.27,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00054008620,NDC,,,facility,outpatient,1,EA,38.85000,11.27000,Aetna,Local,,19.72,,,,,,,14.01,31.78,percent of total billed charges,
Digoxin 125mcg/2.5mL (0.125mg/2.5mL) L UD,800048289,CDM,637,RC,00054005716,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Pilocarpine HCl 5mg T(Salagen),800017670,CDM,637,RC,00054005625,NDC,,,facility,outpatient,1,EA,10.80000,3.13000,Aetna,Local,,5.48,,,,,,,3.89,8.83,percent of total billed charges,
Ipratropium Br 0.03% 30mL NS(Atrovent),800075142,CDM,637,RC,00054004544,NDC,,,facility,outpatient,1,EA,713.10000,206.80000,Aetna,Local,,362.04,,,,,,,257.07,583.32,percent of total billed charges,
Clarithromycin 500mg T(Biaxin),800071604,CDM,637,RC,00054003721,NDC,,,facility,outpatient,1,EA,32.00000,9.28000,Aetna,Local,,16.25,,,,,,,11.54,26.18,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,00054002125,NDC,,,facility,outpatient,1,EA,3.30000,0.96000,Aetna,Local,,1.68,,,,,,,1.19,2.70,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00054002025,NDC,,,facility,outpatient,1,EA,3.80000,1.10000,Aetna,Local,,1.93,,,,,,,1.37,3.11,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,00054001125,NDC,,,facility,outpatient,1,EA,25.35000,7.35000,Aetna,Local,,12.87,,,,,,,9.14,20.74,percent of total billed charges,
Flecainide 100mg T(Tambocor),800081103,CDM,637,RC,00054001120,NDC,,,facility,outpatient,1,EA,25.35000,7.35000,Aetna,Local,,12.87,,,,,,,9.14,20.74,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00054000725,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00054000713,NDC,,,facility,outpatient,1,EA,9.05000,2.62000,Aetna,Local,,4.59,,,,,,,3.26,7.40,percent of total billed charges,
Albumin 25% 50mL I,800074731,CDM,636,RC,P9047,HCPCS,00053768032,NDC,facility,inpatient,12.5,GM,733.50000,212.71000,Aetna,Local,,293.40,,,,,,,264.43,600.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Albumin 5% 250mL I,800067578,CDM,636,RC,P9045,HCPCS,00053767031,NDC,facility,inpatient,12.5,GM,818.25000,237.29000,Aetna,Local,,327.30,,,,,,,294.98,669.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Alpha 1-Proteinase inhibitor human 10mg I(Zemaira),800051045,CDM,636,RC,J0256,HCPCS,00053720202,NDC,facility,inpatient,10,ME,58.55000,16.98000,Aetna,Local,,23.42,,,,,,,21.11,47.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Alpha 1-Proteinase inhibitor human 10mg I(Zemaira),800051045,CDM,636,RC,J0256,HCPCS,00053720102,NDC,facility,inpatient,10,ME,58.55000,16.98000,Aetna,Local,,23.42,,,,,,,21.11,47.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Thrombin Bovine 5000 IU,800016857,CDM,250,RC,00053710201,NDC,,,facility,outpatient,1,EA,506.70000,146.94000,Aetna,Local,,257.25,,,,,,,182.67,414.48,percent of total billed charges,
Etonogestrel 68 mg Implant,800062083,CDM,636,RC,J7307,HCPCS,00052433001,NDC,facility,inpatient,68,ME,6567.80000,1904.66000,Aetna,Local,,2627.12,,,,,,,2367.69,5372.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cosyntropin 0.25mg I(Cortrosyn),800010868,CDM,636,RC,J0834,HCPCS,00052073110,NDC,facility,inpatient,0.25,ME,85.90000,24.91000,Aetna,Local,,34.36,,,,,,,30.97,70.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00052045016,NDC,,,facility,outpatient,1,EA,129.80000,37.64000,Aetna,Local,,65.90,,,,,,,46.79,106.18,percent of total billed charges,
Rocuronium bromide 50mg/5mL I(Zemuron),800071554,CDM,250,RC,00052045015,NDC,,,facility,outpatient,1,EA,136.50000,39.58000,Aetna,Local,,69.30,,,,,,,49.21,111.66,percent of total billed charges,
Vecuronium Bromide 10mg/10mL I,800049782,CDM,250,RC,00052044115,NDC,,,facility,outpatient,1,EA,86.45000,25.07000,Aetna,Local,,43.89,,,,,,,31.17,70.72,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00052010590,NDC,,,facility,outpatient,1,EA,22.30000,6.47000,Aetna,Local,,11.32,,,,,,,8.04,18.24,percent of total billed charges,
Mirtazapine 15mg T(Remeron),800074814,CDM,637,RC,00052010530,NDC,,,facility,outpatient,1,EA,45.35000,13.15000,Aetna,Local,,23.02,,,,,,,16.35,37.10,percent of total billed charges,
Testosterone 1% TG 2.5G UD,800017791,CDM,637,RC,00051842530,NDC,,,facility,outpatient,1,EA,199.40000,57.83000,Aetna,Local,,101.24,,,,,,,71.88,163.11,percent of total billed charges,
hydrOXYzine HCl 25mg T(Atarax),800010826,CDM,637,RC,00049561066,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490073,NDC,,,facility,outpatient,1,EA,20.50000,5.94000,Aetna,Local,,10.41,,,,,,,7.39,16.77,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490066,NDC,,,facility,outpatient,1,EA,20.50000,5.94000,Aetna,Local,,10.41,,,,,,,7.39,16.77,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490041,NDC,,,facility,outpatient,1,EA,126.55000,36.70000,Aetna,Local,,64.25,,,,,,,45.62,103.52,percent of total billed charges,
Sertraline 50mg T,800071000,CDM,637,RC,00049490030,NDC,,,facility,outpatient,1,EA,126.55000,36.70000,Aetna,Local,,64.25,,,,,,,45.62,103.52,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00049399060,NDC,,,facility,outpatient,1,EA,199.30000,57.80000,Aetna,Local,,101.18,,,,,,,71.85,163.03,percent of total billed charges,
Ziprasidone 80 mg C(Geodon),800081934,CDM,637,RC,00049399041,NDC,,,facility,outpatient,1,EA,131.65000,38.18000,Aetna,Local,,66.84,,,,,,,47.46,107.69,percent of total billed charges,
Ziprasidone 20 mg C(Geodon),800081926,CDM,637,RC,00049396060,NDC,,,facility,outpatient,1,EA,163.40000,47.39000,Aetna,Local,,82.96,,,,,,,58.91,133.66,percent of total billed charges,
Ziprasidone 20mg Inj. (Geodon),800011924,CDM,636,RC,J3486,HCPCS,00049392083,NDC,facility,inpatient,20,ME,375.00000,108.75000,Aetna,Local,,150.00,,,,,,,135.19,306.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00049343526,NDC,facility,inpatient,200,ME,204.00000,59.16000,Aetna,Local,,81.60,,,,,,,73.54,166.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00049342041,NDC,,,facility,outpatient,1,EA,317.00000,91.93000,Aetna,Local,,160.94,,,,,,,114.28,259.31,percent of total billed charges,
Fluconazole 100mg T(Diflucan),800054972,CDM,637,RC,00049342030,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,Local,,4.90,,,,,,,3.48,7.89,percent of total billed charges,
Fluconazole 400mg200mL P(Diflucan),800013361,CDM,636,RC,J1450,HCPCS,00049337226,NDC,facility,inpatient,400,ME,1470.20000,426.36000,Aetna,Local,,588.08,,,,,,,530.01,1202.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fluconazole 200mg/100mL P(Diflucan),800055102,CDM,636,RC,J1450,HCPCS,00049337126,NDC,facility,inpatient,200,ME,1057.90000,306.79000,Aetna,Local,,423.16,,,,,,,381.37,865.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Voriconazole 200mg T(VFEND),800017738,CDM,637,RC,00049318030,NDC,,,facility,outpatient,1,EA,31.65000,9.18000,Aetna,Local,,16.07,,,,,,,11.41,25.89,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00049276066,NDC,,,facility,outpatient,1,EA,43.55000,12.63000,Aetna,Local,,22.11,,,,,,,15.70,35.62,percent of total billed charges,
Doxazosin 2mg T(Cardura),800071927,CDM,637,RC,00049276041,NDC,,,facility,outpatient,1,EA,7.50000,2.17000,Aetna,Local,,3.81,,,,,,,2.70,6.13,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00049275066,NDC,,,facility,outpatient,1,EA,43.55000,12.63000,Aetna,Local,,22.11,,,,,,,15.70,35.62,percent of total billed charges,
Doxazosin 1mg T(Cardura),800071661,CDM,637,RC,00049275041,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,Local,,4.26,,,,,,,3.03,6.87,percent of total billed charges,
glipiZIDE 2.5 mg XL T(Glucotrol XL),800082320,CDM,637,RC,00049162030,NDC,,,facility,outpatient,1,EA,6.35000,1.84000,Aetna,Local,,3.22,,,,,,,2.29,5.19,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00049052083,NDC,facility,inpatient,1,EA,122.10000,35.41000,Aetna,Local,,48.84,,,,,,,44.02,99.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00049052022,NDC,facility,inpatient,1,EA,122.10000,35.41000,Aetna,Local,,48.84,,,,,,,44.02,99.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 3g I(Unasyn),800012564,CDM,636,RC,J0295,HCPCS,00049001483,NDC,facility,inpatient,3,GM,139.80000,40.54000,Aetna,Local,,55.92,,,,,,,50.40,114.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin-Sulbactam 1.5g I(Unasyn),800054212,CDM,636,RC,J0295,HCPCS,00049001383,NDC,facility,inpatient,1.5,GM,74.05000,21.47000,Aetna,Local,,29.62,,,,,,,26.70,60.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Levothyroxine Sodium 175mcg T,800065564,CDM,637,RC,00048110003,NDC,,,facility,outpatient,1,EA,4.60000,1.33000,Aetna,Local,,2.34,,,,,,,1.66,3.76,percent of total billed charges,
Levothyroxine Sodium 112mcg T,800070481,CDM,637,RC,00048108003,NDC,,,facility,outpatient,1,EA,3.70000,1.07000,Aetna,Local,,1.88,,,,,,,1.33,3.03,percent of total billed charges,
Levothyroxine Sodium 88mcg T,800070473,CDM,637,RC,00048106003,NDC,,,facility,outpatient,1,EA,1.55000,0.45000,Aetna,Local,,0.78694,,,,,,,0.55878,1.27,percent of total billed charges,
Levothyroxine Sodium 75mcg T,800072909,CDM,637,RC,00048105013,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,Local,,0.76155,,,,,,,0.54075,1.23,percent of total billed charges,
Levothyroxine Sodium 25mcg T,800055805,CDM,637,RC,00048102005,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,Local,,1.02,,,,,,,0.72100,1.64,percent of total billed charges,
Gemfibrozil 600mg T(Lopid),800055698,CDM,637,RC,00047008420,NDC,,,facility,outpatient,1,EA,7.05000,2.04000,Aetna,Local,,3.58,,,,,,,2.54,5.77,percent of total billed charges,
Conj Estrogen 0.3mg T(Premarin),800017821,CDM,637,RC,00046110081,NDC,,,facility,outpatient,1,EA,60.10000,17.43000,Aetna,Local,,30.51,,,,,,,21.67,49.16,percent of total billed charges,
Conjugated Estrogen 30g Vag Cr,800034412,CDM,637,RC,00046087293,NDC,,,facility,outpatient,1,EA,744.55000,215.92000,Aetna,Local,,378.01,,,,,,,268.41,609.04,percent of total billed charges,
Conjugated Estrogen 30g Vag Cr,800034412,CDM,637,RC,00046087221,NDC,,,facility,outpatient,1,EA,3094.35000,897.36000,Aetna,Local,,1571.00,,,,,,,1115.51,2531.18,percent of total billed charges,
Conjugated Estrogen 30g Vag Cr,800034412,CDM,637,RC,00046087201,NDC,,,facility,outpatient,1,EA,317.20000,91.99000,Aetna,Local,,161.04,,,,,,,114.35,259.47,percent of total billed charges,
Conj Estrogen 0.3mg T(Premarin),800017821,CDM,637,RC,00046086881,NDC,,,facility,outpatient,1,EA,9.05000,2.62000,Aetna,Local,,4.59,,,,,,,3.26,7.40,percent of total billed charges,
Conj Estrogen 25mg I (Premarin),800012898,CDM,636,RC,J1410,HCPCS,00046074905,NDC,facility,inpatient,25,ME,2900.55000,841.16000,Aetna,Local,,1160.22,,,,,,,1045.65,2372.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Propranolol HCl 80mg ER C(Inderal LA),800054527,CDM,637,RC,00046047181,NDC,,,facility,outpatient,1,EA,31.85000,9.24000,Aetna,Local,,16.17,,,,,,,11.48,26.05,percent of total billed charges,
Propranolol HCl 60mg ER C(Inderal LA),800057090,CDM,637,RC,00046047081,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,00045152550,NDC,,,facility,outpatient,1,EA,108.35000,31.42000,Aetna,Local,,55.01,,,,,,,39.06,88.63,percent of total billed charges,
levoFLOXacin  500mg T(Levaquin),800073683,CDM,637,RC,00045152510,NDC,,,facility,outpatient,1,EA,78.50000,22.76000,Aetna,Local,,39.85,,,,,,,28.30,64.21,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,00045152050,NDC,,,facility,outpatient,1,EA,109.60000,31.78000,Aetna,Local,,55.64,,,,,,,39.51,89.65,percent of total billed charges,
levoFLOXacin  250mg T(Levaquin),800074947,CDM,637,RC,00045152010,NDC,,,facility,outpatient,1,EA,68.50000,19.86000,Aetna,Local,,34.78,,,,,,,24.69,56.03,percent of total billed charges,
levoFLOXacin  25mg/mL L,800081070,CDM,637,RC,00045151501,NDC,,,facility,outpatient,1,ML,6.50000,1.88000,Aetna,Local,,3.30,,,,,,,2.34,5.32,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00045065960,NDC,,,facility,outpatient,1,EA,14.05000,4.07000,Aetna,Local,,7.13,,,,,,,5.07,11.49,percent of total billed charges,
traMADol 50mg T(Ultram),800072008,CDM,637,RC,00045065910,NDC,,,facility,outpatient,1,EA,10.60000,3.07000,Aetna,Local,,5.38,,,,,,,3.82,8.67,percent of total billed charges,
Topiramate 25mg Sprinkle C(Topamax),800017731,CDM,637,RC,00045064565,NDC,,,facility,outpatient,1,EA,22.10000,6.41000,Aetna,Local,,11.22,,,,,,,7.97,18.08,percent of total billed charges,
Topiramate 100 mg T(Topamax),800080944,CDM,637,RC,00045064165,NDC,,,facility,outpatient,1,EA,54.85000,15.91000,Aetna,Local,,27.85,,,,,,,19.77,44.87,percent of total billed charges,
Topiramate 25 mg T(Topamax),800080936,CDM,637,RC,00045063965,NDC,,,facility,outpatient,1,EA,20.10000,5.83000,Aetna,Local,,10.20,,,,,,,7.25,16.44,percent of total billed charges,
Acet-Cod 300-30mg T(Tylenol #3),800031210,CDM,637,RC,00045051372,NDC,,,facility,outpatient,1,EA,1.85000,0.54000,Aetna,Local,,0.93924,,,,,,,0.66692,1.51,percent of total billed charges,
Chlorzoxazone 500mg T,800053131,CDM,637,RC,00045032510,NDC,,,facility,outpatient,1,EA,8.60000,2.49000,Aetna,Local,,4.37,,,,,,,3.10,7.03,percent of total billed charges,
Haloperidol Lactate 5mg/mL I,800011551,CDM,636,RC,J1630,HCPCS,00045025501,NDC,facility,inpatient,5,ME,64.60000,18.73000,Aetna,Local,,25.84,,,,,,,23.29,52.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Pancrelipase 5000-17,000-24,000units Cap",800059260,CDM,637,RC,00045009560,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
levoFLOXacin  500mg/100mL P,800013352,CDM,636,RC,J1956,HCPCS,00045006801,NDC,facility,inpatient,500,ME,341.65000,99.08000,Aetna,Local,,136.66,,,,,,,123.16,279.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  250mg/50mL P,800080399,CDM,636,RC,J1956,HCPCS,00045006701,NDC,facility,inpatient,250,ME,59.90000,17.37000,Aetna,Local,,23.96,,,,,,,21.59,49.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
levoFLOXacin  750mg/150mL P,800012504,CDM,636,RC,J1956,HCPCS,00045006601,NDC,facility,inpatient,750,ME,462.15000,134.02000,Aetna,Local,,184.86,,,,,,,166.61,378.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Collagenase 30g TO(Santyl),800075282,CDM,637,RC,00044527003,NDC,,,facility,outpatient,1,EA,8962.65000,2599.17000,Aetna,Local,,4550.34,,,,,,,3231.04,7331.45,percent of total billed charges,
Propafenone HCl 225 mg T(Rythmol),800081223,CDM,637,RC,00044502402,NDC,,,facility,outpatient,1,EA,19.85000,5.76000,Aetna,Local,,10.08,,,,,,,7.16,16.24,percent of total billed charges,
Propafenone HCl 150mg T(Rythmol),800055482,CDM,637,RC,00044502202,NDC,,,facility,outpatient,1,EA,11.25000,3.26000,Aetna,Local,,5.71,,,,,,,4.06,9.20,percent of total billed charges,
Verapamil HCl 120mg SR T(Isoptin SR,800069764,CDM,637,RC,00044182702,NDC,,,facility,outpatient,1,EA,4.30000,1.25000,Aetna,Local,,2.18,,,,,,,1.55,3.52,percent of total billed charges,
Verapamil HCl 180mg SR T(Isoptin SR),800055128,CDM,637,RC,00044182512,NDC,,,facility,outpatient,1,EA,6.95000,2.02000,Aetna,Local,,3.53,,,,,,,2.51,5.69,percent of total billed charges,
Verapamil HCl 120mg T(Isoptin),800040237,CDM,637,RC,00044182310,NDC,,,facility,outpatient,1,EA,4.40000,1.28000,Aetna,Local,,2.23,,,,,,,1.59,3.60,percent of total billed charges,
Verapamil HCl 40mg T(Isoptin),800052992,CDM,637,RC,00044182110,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
HYDROmorphone 2mg T(Dilaudid),800071133,CDM,637,RC,00044102245,NDC,,,facility,outpatient,1,EA,2.95000,0.86000,Aetna,Local,,1.50,,,,,,,1.06,2.41,percent of total billed charges,
Ramipril 5mg C(Altace),800070994,CDM,637,RC,00039010511,NDC,,,facility,outpatient,1,EA,10.95000,3.18000,Aetna,Local,,5.56,,,,,,,3.95,8.96,percent of total billed charges,
Ramipril 2.5mg C(Altace),800070564,CDM,637,RC,00039010411,NDC,,,facility,outpatient,1,EA,10.05000,2.91000,Aetna,Local,,5.10,,,,,,,3.62,8.22,percent of total billed charges,
Furosemide 20mg T(Lasix),800015346,CDM,637,RC,00039006710,NDC,,,facility,outpatient,1,EA,4.95000,1.44000,Aetna,Local,,2.51,,,,,,,1.78,4.05,percent of total billed charges,
glyBURIDE 2.5mg T(Diabeta/Micronase,800056746,CDM,637,RC,00039005111,NDC,,,facility,outpatient,1,EA,2.10000,0.61000,Aetna,Local,,1.07,,,,,,,0.75705,1.72,percent of total billed charges,
cefoTEtan 1g I(Cefotan),800070042,CDM,637,RC,00038037610,NDC,,,facility,outpatient,1,EA,92.95000,26.96000,Aetna,Local,,47.19,,,,,,,33.51,76.03,percent of total billed charges,
Carisoprodol 350mg T,800071349,CDM,637,RC,00037200101,NDC,,,facility,outpatient,1,EA,107.95000,31.31000,Aetna,Local,,54.81,,,,,,,38.92,88.30,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,00037024130,NDC,,,facility,outpatient,1,EA,840.15000,243.64000,Aetna,Local,,426.54,,,,,,,302.87,687.24,percent of total billed charges,
Azelastine 137 mcg/spr 30mL NS,800080142,CDM,637,RC,00037024110,NDC,,,facility,outpatient,1,EA,418.50000,121.36000,Aetna,Local,,212.47,,,,,,,150.87,342.33,percent of total billed charges,
Ketorolac 10mg T(Toradol),800017452,CDM,637,RC,00033243553,NDC,,,facility,outpatient,1,EA,7.60000,2.20000,Aetna,Local,,3.86,,,,,,,2.74,6.22,percent of total billed charges,
Lithium Carb 300mg CR T,800045558,CDM,637,RC,00032449201,NDC,,,facility,outpatient,1,EA,4.45000,1.29000,Aetna,Local,,2.26,,,,,,,1.60,3.64,percent of total billed charges,
Mesalamine 60mL Enema(Rowasa),800059872,CDM,637,RC,00032192482,NDC,,,facility,outpatient,1,EA,185.15000,53.69000,Aetna,Local,,94.00,,,,,,,66.75,151.45,percent of total billed charges,
Progesterone 100mg C(Prometrium),800017682,CDM,637,RC,00032170801,NDC,,,facility,outpatient,1,EA,25.00000,7.25000,Aetna,Local,,12.69,,,,,,,9.01,20.45,percent of total billed charges,
Lactulose 0.67g/mL Oral Liq,800034057,CDM,637,RC,00032160278,NDC,,,facility,outpatient,1,EA,0.40000,0.12000,Aetna,Local,,0.20308,,,,,,,0.14420,0.32720,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",800062051,CDM,637,RC,00032121207,NDC,,,facility,outpatient,1,EA,35.30000,10.24000,Aetna,Local,,17.92,,,,,,,12.73,28.88,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",800062051,CDM,637,RC,00032121201,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,Local,,18.51,,,,,,,13.14,29.82,percent of total billed charges,
"Pancrelipase 12,000-38,000-60,000units EC Cap",800062051,CDM,637,RC,00032004770,NDC,,,facility,outpatient,1,EA,36.45000,10.57000,Aetna,Local,,18.51,,,,,,,13.14,29.82,percent of total billed charges,
guanFACINE 1mg T(Tenex),800053057,CDM,637,RC,00031890163,NDC,,,facility,outpatient,1,EA,17.65000,5.12000,Aetna,Local,,8.96,,,,,,,6.36,14.44,percent of total billed charges,
Glycopyrrolate 1mg T(Robinul),800064971,CDM,637,RC,00031782463,NDC,,,facility,outpatient,1,EA,4.65000,1.35000,Aetna,Local,,2.36,,,,,,,1.68,3.80,percent of total billed charges,
Methocarbamol 750mg T(Robaxin),800072875,CDM,637,RC,00031744963,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Methocarbamol 1g/10mL Inj,800046536,CDM,636,RC,J2800,HCPCS,00031740994,NDC,facility,inpatient,1,GM,124.40000,36.08000,Aetna,Local,,49.76,,,,,,,44.85,101.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoclopramide HCl 10mg/2mL I(Reglan),800039890,CDM,636,RC,J2765,HCPCS,00031670972,NDC,facility,inpatient,10,ME,12.50000,3.62000,Aetna,Local,,5.00,,,,,,,4.51,10.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Amox-Clav 250mg/5mL L(Augmen,800050400,CDM,637,RC,00029609039,NDC,,,facility,outpatient,1,EA,35.65000,10.34000,Aetna,Local,,18.10,,,,,,,12.85,29.16,percent of total billed charges,
Amox-Clav 125mg/2.5mL L,800053917,CDM,637,RC,00029609022,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,Local,,8.88,,,,,,,6.31,14.31,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,00029608621,NDC,,,facility,outpatient,1,EA,45.20000,13.11000,Aetna,Local,,22.95,,,,,,,16.29,36.97,percent of total billed charges,
Amox-Clav 875-125mg T(Augmentin),800073600,CDM,637,RC,00029608612,NDC,,,facility,outpatient,1,EA,56.30000,16.33000,Aetna,Local,,28.58,,,,,,,20.30,46.05,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00029608031,NDC,,,facility,outpatient,1,EA,27.10000,7.86000,Aetna,Local,,13.76,,,,,,,9.77,22.17,percent of total billed charges,
Amox-Clav 500-125mg T(Augmentin),800050244,CDM,637,RC,00029608012,NDC,,,facility,outpatient,1,EA,42.15000,12.22000,Aetna,Local,,21.40,,,,,,,15.20,34.48,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00029485121,NDC,,,facility,outpatient,1,EA,15.55000,4.51000,Aetna,Local,,7.89,,,,,,,5.61,12.72,percent of total billed charges,
Nabumetone 500mg T(Relafen),800073592,CDM,637,RC,00029485120,NDC,,,facility,outpatient,1,EA,15.55000,4.51000,Aetna,Local,,7.89,,,,,,,5.61,12.72,percent of total billed charges,
PARoxetine 20mg/10mL Oral Liq.,800021981,CDM,637,RC,00029321548,NDC,,,facility,outpatient,1,EA,60.80000,17.63000,Aetna,Local,,30.87,,,,,,,21.92,49.73,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00029321159,NDC,,,facility,outpatient,1,EA,28.85000,8.37000,Aetna,Local,,14.65,,,,,,,10.40,23.60,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00029321121,NDC,,,facility,outpatient,1,EA,27.85000,8.08000,Aetna,Local,,14.14,,,,,,,10.04,22.78,percent of total billed charges,
PARoxetine 20mg T(Paxil),800073113,CDM,637,RC,00029321120,NDC,,,facility,outpatient,1,EA,23.75000,6.89000,Aetna,Local,,12.06,,,,,,,8.56,19.43,percent of total billed charges,
PARoxetine 10mg T(Paxil),800017660,CDM,637,RC,00029321013,NDC,,,facility,outpatient,1,EA,29.15000,8.45000,Aetna,Local,,14.80,,,,,,,10.51,23.84,percent of total billed charges,
Mupirocin 2% TO 22g (Bactroban),800060045,CDM,637,RC,00029152544,NDC,,,facility,outpatient,1,EA,871.50000,252.74000,Aetna,Local,,442.46,,,,,,,314.18,712.89,percent of total billed charges,
Terbutaline 1mg/mL 1mL I(Brethine),800035641,CDM,636,RC,J3105,HCPCS,00028750723,NDC,facility,inpatient,1,ME,119.65000,34.70000,Aetna,Local,,47.86,,,,,,,43.13,97.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoprolol 1mg/mL 5mL IS,800053446,CDM,250,RC,00028420133,NDC,,,facility,outpatient,1,EA,161.95000,46.97000,Aetna,Local,,82.22,,,,,,,58.38,132.48,percent of total billed charges,
Baclofen 10mg T,800038041,CDM,637,RC,00028002301,NDC,,,facility,outpatient,1,EA,5.15000,1.49000,Aetna,Local,,2.61,,,,,,,1.86,4.21,percent of total billed charges,
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,00026063603,NDC,facility,inpatient,1,EA,367.60000,106.60000,Aetna,Local,,147.04,,,,,,,132.52,300.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hepatitis B Immune Glob 0.5mL IPF Neonatal,800077908,CDM,636,RC,J1571,HCPCS,00026063600,NDC,facility,inpatient,1,EA,367.60000,106.60000,Aetna,Local,,147.04,,,,,,,132.52,300.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tetanus IG 250U I(Bay-Tet),800011759,CDM,636,RC,J1670,HCPCS,00026063402,NDC,facility,inpatient,250,UN,591.40000,171.51000,Aetna,Local,,236.56,,,,,,,213.20,483.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00025542134,NDC,,,facility,outpatient,1,EA,29.70000,8.61000,Aetna,Local,,15.08,,,,,,,10.71,24.29,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00025540134,NDC,,,facility,outpatient,1,EA,24.15000,7.00000,Aetna,Local,,12.26,,,,,,,8.71,19.75,percent of total billed charges,
metroNIDAZOLE 500mg T(Flagyl),800053537,CDM,637,RC,00025182150,NDC,,,facility,outpatient,1,EA,6.40000,1.86000,Aetna,Local,,3.25,,,,,,,2.31,5.24,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,00025171002,NDC,,,facility,outpatient,1,EA,106.60000,30.91000,Aetna,Local,,54.12,,,,,,,38.43,87.20,percent of total billed charges,
Eplerenone 25 mg T(Inspra),800081975,CDM,637,RC,00025171001,NDC,,,facility,outpatient,1,EA,125.60000,36.42000,Aetna,Local,,63.77,,,,,,,45.28,102.74,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00025152551,NDC,,,facility,outpatient,1,EA,139.50000,40.46000,Aetna,Local,,70.82,,,,,,,50.29,114.11,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00025152534,NDC,,,facility,outpatient,1,EA,132.85000,38.53000,Aetna,Local,,67.45,,,,,,,47.89,108.67,percent of total billed charges,
Celecoxib 200mg C(CeleBREX),800078856,CDM,637,RC,00025152531,NDC,,,facility,outpatient,1,EA,139.50000,40.46000,Aetna,Local,,70.82,,,,,,,50.29,114.11,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00025152051,NDC,,,facility,outpatient,1,EA,85.05000,24.66000,Aetna,Local,,43.18,,,,,,,30.66,69.57,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00025152034,NDC,,,facility,outpatient,1,EA,81.00000,23.49000,Aetna,Local,,41.12,,,,,,,29.20,66.26,percent of total billed charges,
Celecoxib 100mg C(CeleBREX),800077171,CDM,637,RC,00025152031,NDC,,,facility,outpatient,1,EA,85.05000,24.66000,Aetna,Local,,43.18,,,,,,,30.66,69.57,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00025146160,NDC,,,facility,outpatient,1,EA,49.95000,14.49000,Aetna,Local,,25.36,,,,,,,18.01,40.86,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00025146134,NDC,,,facility,outpatient,1,EA,49.15000,14.25000,Aetna,Local,,24.95,,,,,,,17.72,40.20,percent of total billed charges,
miSOPROStol  200mcg T(Cytotec),800054683,CDM,637,RC,00025146131,NDC,,,facility,outpatient,1,EA,49.95000,14.49000,Aetna,Local,,25.36,,,,,,,18.01,40.86,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00025145160,NDC,,,facility,outpatient,1,EA,33.95000,9.85000,Aetna,Local,,17.24,,,,,,,12.24,27.77,percent of total billed charges,
miSOPROStol 100mcg T(Cytotec),800075449,CDM,637,RC,00025145134,NDC,,,facility,outpatient,1,EA,35.60000,10.32000,Aetna,Local,,18.07,,,,,,,12.83,29.12,percent of total billed charges,
Spironolactone 25mg T(Aldactone),800010149,CDM,637,RC,00025100131,NDC,,,facility,outpatient,1,EA,23.25000,6.74000,Aetna,Local,,11.80,,,,,,,8.38,19.02,percent of total billed charges,
Dupilumab 200mg/1.14mL Inj,800052004,CDM,636,RC,C9399,HCPCS,00024591902,NDC,facility,inpatient,200,ME,8144.75000,2361.98000,Aetna,Local,,3257.90,,,,,,,2936.18,6662.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 200mg/1.14mL Inj,800052004,CDM,636,RC,C9399,HCPCS,00024591902,NDC,facility,outpatient,200,ME,8144.75000,2361.98000,Aetna,Local,,3257.90,,,,,,,2936.18,6662.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 200mg/1.14mL Inj,800052004,CDM,636,RC,C9399,HCPCS,00024591801,NDC,facility,inpatient,200,ME,8144.75000,2361.98000,Aetna,Local,,3257.90,,,,,,,2936.18,6662.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 200mg/1.14mL Inj,800052004,CDM,636,RC,C9399,HCPCS,00024591801,NDC,facility,outpatient,200,ME,8144.75000,2361.98000,Aetna,Local,,3257.90,,,,,,,2936.18,6662.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 300mg/2mL Inj,800046554,CDM,636,RC,C9399,HCPCS,00024591502,NDC,facility,inpatient,300,ME,8144.75000,2361.98000,Aetna,Local,,3257.90,,,,,,,2936.18,6662.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 300mg/2mL Inj,800046554,CDM,636,RC,C9399,HCPCS,00024591502,NDC,facility,outpatient,300,ME,8144.75000,2361.98000,Aetna,Local,,3257.90,,,,,,,2936.18,6662.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 300mg/2mL Inj,800046554,CDM,636,RC,C9399,HCPCS,00024591401,NDC,facility,inpatient,300,ME,8144.75000,2361.98000,Aetna,Local,,3257.90,,,,,,,2936.18,6662.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dupilumab 300mg/2mL Inj,800046554,CDM,636,RC,C9399,HCPCS,00024591401,NDC,facility,outpatient,300,ME,8144.75000,2361.98000,Aetna,Local,,3257.90,,,,,,,2936.18,6662.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00024542134,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,Local,,21.91,,,,,,,15.56,35.30,percent of total billed charges,
Zolpidem 10mg T(Ambien),800072719,CDM,637,RC,00024542131,NDC,,,facility,outpatient,1,EA,206.40000,59.86000,Aetna,Local,,104.79,,,,,,,74.41,168.84,percent of total billed charges,
Zolpidem 5mg T(Ambien),800072727,CDM,637,RC,00024540134,NDC,,,facility,outpatient,1,EA,43.15000,12.51000,Aetna,Local,,21.91,,,,,,,15.56,35.30,percent of total billed charges,
Alfuzosin 10 mg ER Tab,800017414,CDM,637,RC,00024420010,NDC,,,facility,outpatient,1,EA,104.65000,30.35000,Aetna,Local,,53.13,,,,,,,37.73,85.60,percent of total billed charges,
Dronedarone 400mg T,800081234,CDM,637,RC,00024414260,NDC,,,facility,outpatient,1,EA,114.70000,33.26000,Aetna,Local,,58.23,,,,,,,41.35,93.82,percent of total billed charges,
Dronedarone 400mg T,800081234,CDM,637,RC,00024414210,NDC,,,facility,outpatient,1,EA,93.25000,27.04000,Aetna,Local,,47.34,,,,,,,33.62,76.28,percent of total billed charges,
Hydroxychloroquine 200mg T,800080647,CDM,637,RC,00024156210,NDC,,,facility,outpatient,1,EA,33.30000,9.66000,Aetna,Local,,16.91,,,,,,,12.00,27.24,percent of total billed charges,
Morphine 4mg/1mL PF I,800060011,CDM,636,RC,J2270,HCPCS,00024125802,NDC,facility,inpatient,4,ME,5.70000,1.65000,Aetna,Local,,2.28,,,,,,,2.05,4.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Morphine 2mg/1mL PF I,800049428,CDM,636,RC,J2270,HCPCS,00024125702,NDC,facility,inpatient,2,ME,5.45000,1.58000,Aetna,Local,,2.18,,,,,,,1.96,4.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUPivacaine 0.5% 10mL I PF,800070648,CDM,250,RC,00024121310,NDC,,,facility,outpatient,1,EA,444.05000,128.77000,Aetna,Local,,225.44,,,,,,,160.08,363.23,percent of total billed charges,
HYDROmorphone 2mg/1mL  Inj,800014118,CDM,636,RC,J1171,HCPCS,00024072802,NDC,facility,inpatient,2,ME,9.60000,2.78000,Aetna,Local,,3.84,,,,,,,3.46,7.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oxaliplatin 100mg/20mL I,800079987,CDM,636,RC,J9263,HCPCS,00024059120,NDC,facility,inpatient,100,ME,18360.25000,5324.47000,Aetna,Local,,7344.10,,,,,,,6618.87,15018.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Meperidine HCl 25mg/1mL I(Demerol),800049410,CDM,636,RC,J2175,HCPCS,00024032402,NDC,facility,inpatient,25,ME,7.65000,2.22000,Aetna,Local,,3.06,,,,,,,2.76,6.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Permethrin 5% 60g TC (Elimite),800081033,CDM,637,RC,00023791560,NDC,,,facility,outpatient,1,EA,480.50000,139.34000,Aetna,Local,,243.95,,,,,,,173.22,393.05,percent of total billed charges,
Trimeth-Polymix 10mL Ophth Soln(Polytrim),800070739,CDM,637,RC,00023782410,NDC,,,facility,outpatient,1,EA,622.70000,180.58000,Aetna,Local,,316.14,,,,,,,224.48,509.37,percent of total billed charges,
Silodosin 4mg Cap,800025547,CDM,637,RC,00023614730,NDC,,,facility,outpatient,1,EA,74.05000,21.47000,Aetna,Local,,37.60,,,,,,,26.70,60.57,percent of total billed charges,
Iron Dextran 100mg/2mL I(Infed),800012496,CDM,636,RC,J1750,HCPCS,00023608210,NDC,facility,inpatient,100,ME,348.55000,101.08000,Aetna,Local,,139.42,,,,,,,125.65,285.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mesalamine 400mg ER C(Delzicol),800073451,CDM,637,RC,00023585318,NDC,,,facility,outpatient,1,EA,32.95000,9.56000,Aetna,Local,,16.73,,,,,,,11.88,26.95,percent of total billed charges,
Ketorolac 0.5% 5mL Ophth Soln(Acular),800077841,CDM,637,RC,00023218105,NDC,,,facility,outpatient,1,EA,1964.05000,569.57000,Aetna,Local,,997.15,,,,,,,708.04,1606.59,percent of total billed charges,
Onabotulinumtoxin A 100unit I(Botox),800010975,CDM,636,RC,J0585,HCPCS,00023114501,NDC,facility,inpatient,100,UN,2783.60000,807.24000,Aetna,Local,,1113.44,,,,,,,1003.49,2276.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,800041391,CDM,250,RC,00016031085,NDC,,,facility,outpatient,1,EA,686.90000,199.20000,Aetna,Local,,348.74,,,,,,,247.63,561.88,percent of total billed charges,
Ampicillin 2g I,800013636,CDM,636,RC,J0290,HCPCS,00015740599,NDC,facility,inpatient,2,GM,134.00000,38.86000,Aetna,Local,,53.60,,,,,,,48.31,109.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 500mg I,800012518,CDM,636,RC,J0290,HCPCS,00015740320,NDC,facility,inpatient,500,ME,32.80000,9.51000,Aetna,Local,,13.12,,,,,,,11.82,26.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nafcillin Na 2g I,800033646,CDM,636,RC,J2290,HCPCS,00015722699,NDC,facility,inpatient,2,GM,121.85000,35.34000,Aetna,Local,,48.74,,,,,,,43.93,99.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Butorphanol Tartrate 2mg/mL 1mL I(Stadol),800012493,CDM,636,RC,J0595,HCPCS,00015564633,NDC,facility,inpatient,2,ME,70.25000,20.37000,Aetna,Local,,28.10,,,,,,,25.33,57.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50mg/5mL Inj - 45mL vial,800015178,CDM,636,RC,J9045,HCPCS,00015321230,NDC,facility,inpatient,50,ME,906.15000,262.78000,Aetna,Local,,362.46,,,,,,,326.67,741.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARBOplatin 50 mg/5mL I - 15mL,800070911,CDM,636,RC,J9045,HCPCS,00015321130,NDC,facility,inpatient,50,ME,906.15000,262.78000,Aetna,Local,,362.46,,,,,,,326.67,741.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
mitoMYcin 20mg Inj,800019797,CDM,636,RC,J9280,HCPCS,00015300220,NDC,facility,inpatient,20,ME,2225.10000,645.28000,Aetna,Local,,890.04,,,,,,,802.15,1820.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Megestrol Acetate 40mg/mL L 10mL UD,800072800,CDM,637,RC,00015050842,NDC,,,facility,outpatient,1,EA,53.25000,15.44000,Aetna,Local,,27.04,,,,,,,19.20,43.56,percent of total billed charges,
cycloPHOSphamide 500mg I,800014269,CDM,636,RC,J9075,HCPCS,00015050241,NDC,facility,inpatient,500,ME,127.10000,36.86000,Aetna,Local,,50.84,,,,,,,45.82,103.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dexrazoxane 500mg Inj,800011926,CDM,636,RC,J1190,HCPCS,00013872789,NDC,facility,inpatient,500,ME,3569.30000,1035.10000,Aetna,Local,,1427.72,,,,,,,1286.73,2919.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,00013830304,NDC,,,facility,outpatient,1,EA,1896.10000,549.87000,Aetna,Local,,962.65,,,,,,,683.54,1551.01,percent of total billed charges,
Latanoprost 0.005% 2.5mL Ophth Soln(Xalatan),800074996,CDM,637,RC,00013830301,NDC,,,facility,outpatient,1,EA,995.90000,288.81000,Aetna,Local,,505.62,,,,,,,359.02,814.65,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,800072508,CDM,250,RC,00013111410,NDC,,,facility,outpatient,1,EA,283.00000,82.07000,Aetna,Local,,143.68,,,,,,,102.02,231.49,percent of total billed charges,
Miconazole Nitrate 2% 30g TC,800053685,CDM,250,RC,00009771802,NDC,,,facility,outpatient,1,EA,67.95000,19.71000,Aetna,Local,,34.50,,,,,,,24.50,55.58,percent of total billed charges,
Cromolyn Na Nasal Aer(Nasalcrom),800052349,CDM,637,RC,00009770902,NDC,,,facility,outpatient,1,EA,104.70000,30.36000,Aetna,Local,,53.16,,,,,,,37.74,85.64,percent of total billed charges,
Irinotecan HCl 100mg/5mL I,800022018,CDM,636,RC,J9206,HCPCS,00009752901,NDC,facility,inpatient,100,ME,1257.00000,364.53000,Aetna,Local,,502.80,,,,,,,453.15,1028.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00009737611,NDC,facility,inpatient,150,ME,325.85000,94.50000,Aetna,Local,,130.34,,,,,,,117.47,266.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00009737604,NDC,facility,inpatient,150,ME,429.85000,124.66000,Aetna,Local,,171.94,,,,,,,154.96,351.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00009519002,NDC,,,facility,outpatient,1,EA,111.15000,32.23000,Aetna,Local,,56.43,,,,,,,40.07,90.92,percent of total billed charges,
Tolterodine 2mg ER C(Detrol LA),800072437,CDM,637,RC,00009519001,NDC,,,facility,outpatient,1,EA,111.15000,32.23000,Aetna,Local,,56.43,,,,,,,40.07,90.92,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00009514001,NDC,facility,inpatient,600,ME,648.90000,188.18000,Aetna,Local,,259.56,,,,,,,233.93,530.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00009513803,NDC,,,facility,outpatient,1,EA,53.40000,15.49000,Aetna,Local,,27.11,,,,,,,19.25,43.68,percent of total billed charges,
Linezolid 600mg T(Zyvox),800079458,CDM,637,RC,00009513502,NDC,,,facility,outpatient,1,EA,1134.75000,329.08000,Aetna,Local,,576.11,,,,,,,409.08,928.23,percent of total billed charges,
Linezolid 600mg P,800010884,CDM,636,RC,J2020,HCPCS,00009499202,NDC,facility,inpatient,600,ME,441.90000,128.15000,Aetna,Local,,176.76,,,,,,,159.30,361.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009347523,NDC,facility,inpatient,80,ME,117.70000,34.13000,Aetna,Local,,47.08,,,,,,,42.43,96.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009347503,NDC,facility,inpatient,80,ME,125.90000,36.51000,Aetna,Local,,50.36,,,,,,,45.39,102.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009347501,NDC,facility,inpatient,80,ME,125.90000,36.51000,Aetna,Local,,50.36,,,,,,,45.39,102.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,00009338901,NDC,facility,inpatient,1,GM,177.70000,51.53000,Aetna,Local,,71.08,,,,,,,64.06,145.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00009338202,NDC,facility,inpatient,900,ME,217.60000,63.10000,Aetna,Local,,87.04,,,,,,,78.44,178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 900mg/ 50mL PB,800071448,CDM,636,RC,J0737,HCPCS,00009338201,NDC,facility,inpatient,900,ME,51.55000,14.95000,Aetna,Local,,20.62,,,,,,,18.58,42.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00009337502,NDC,facility,inpatient,600,ME,177.90000,51.59000,Aetna,Local,,71.16,,,,,,,64.13,145.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/50mL PB,800071430,CDM,636,RC,J0736,HCPCS,00009337501,NDC,facility,inpatient,600,ME,49.30000,14.30000,Aetna,Local,,19.72,,,,,,,17.77,40.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00009307323,NDC,facility,inpatient,40,ME,67.85000,19.68000,Aetna,Local,,27.14,,,,,,,24.46,55.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00009307303,NDC,facility,inpatient,40,ME,72.60000,21.05000,Aetna,Local,,29.04,,,,,,,26.17,59.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPRED Ace 40mg/mL I(DEPO-Medrol,800072545,CDM,636,RC,J1010,HCPCS,00009307301,NDC,facility,inpatient,40,ME,72.50000,21.02000,Aetna,Local,,29.00,,,,,,,26.14,59.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009090020,NDC,facility,inpatient,100,ME,25.80000,7.48000,Aetna,Local,,10.32,,,,,,,9.30,21.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009090013,NDC,facility,inpatient,100,ME,20.55000,5.96000,Aetna,Local,,8.22,,,,,,,7.41,16.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00009085608,NDC,,,facility,inpatient,1,EA,731.75000,212.21000,Aetna,Local,,292.70,,,,,,,263.80,598.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00009085608,NDC,,,facility,outpatient,1,EA,731.75000,212.21000,Aetna,Local,,292.70,,,,,,,263.80,598.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00009085605,NDC,,,facility,inpatient,1,EA,436.00000,126.44000,Aetna,Local,,174.40,,,,,,,157.18,356.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carboprost 250mcg/mL I(Hemabate),800066695,CDM,636,RC,00009085605,NDC,,,facility,outpatient,1,EA,436.00000,126.44000,Aetna,Local,,174.40,,,,,,,157.18,356.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009082501,NDC,facility,inpatient,100,ME,122.25000,35.45000,Aetna,Local,,48.90,,,,,,,44.07,100.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,00009077526,NDC,facility,inpatient,600,ME,28.25000,8.19000,Aetna,Local,,11.30,,,,,,,10.18,23.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Clindamycin Phos 600mg/4mL Inj,800010777,CDM,636,RC,J0736,HCPCS,00009077520,NDC,facility,inpatient,600,ME,110.90000,32.16000,Aetna,Local,,44.36,,,,,,,39.98,90.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 500mg I,800013378,CDM,636,RC,J2919,HCPCS,00009075801,NDC,facility,inpatient,500,ME,1585.55000,459.81000,Aetna,Local,,634.22,,,,,,,571.59,1296.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
medroxyPROGESTERone 150mg/mL I,800018757,CDM,636,RC,J1050,HCPCS,00009074630,NDC,facility,inpatient,150,ME,313.85000,91.02000,Aetna,Local,,125.54,,,,,,,113.14,256.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 1g I,800013425,CDM,636,RC,J2919,HCPCS,00009069801,NDC,facility,inpatient,1,GM,26.40000,7.66000,Aetna,Local,,10.56,,,,,,,9.52,21.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Colestipol 1g T(Colestid),800073097,CDM,637,RC,00009045003,NDC,,,facility,outpatient,1,EA,19.10000,5.54000,Aetna,Local,,9.70,,,,,,,6.89,15.62,percent of total billed charges,
methylPRED Ace 80mg/mL I(DEPO-Medrol),800079227,CDM,636,RC,J1010,HCPCS,00009030602,NDC,facility,inpatient,80,ME,117.15000,33.97000,Aetna,Local,,46.86,,,,,,,42.23,95.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Colestipol 5g Pkt(Colestid),800042779,CDM,637,RC,00009026001,NDC,,,facility,outpatient,1,EA,60.25000,17.47000,Aetna,Local,,30.59,,,,,,,21.72,49.28,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009019016,NDC,facility,inpatient,125,ME,16.25000,4.71000,Aetna,Local,,6.50,,,,,,,5.86,13.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009019009,NDC,facility,inpatient,125,ME,18.15000,5.26000,Aetna,Local,,7.26,,,,,,,6.54,14.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone 4mg 21 Dose Pk,800015874,CDM,636,RC,J7509,HCPCS,00009005604,NDC,facility,inpatient,4,ME,2.55000,0.74000,Aetna,Local,,1.02,,,,,,,0.91927,2.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALPRAZolam 0.5mg T(Xanax),800040559,CDM,637,RC,00009005501,NDC,,,facility,outpatient,1,EA,67.10000,19.46000,Aetna,Local,,34.07,,,,,,,24.19,54.89,percent of total billed charges,
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009004726,NDC,facility,inpatient,125,ME,66.50000,19.28000,Aetna,Local,,26.60,,,,,,,23.97,54.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009004722,NDC,facility,inpatient,125,ME,66.50000,19.28000,Aetna,Local,,26.60,,,,,,,23.97,54.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 125mg,800013334,CDM,636,RC,J2919,HCPCS,00009004704,NDC,facility,inpatient,125,ME,69.50000,20.15000,Aetna,Local,,27.80,,,,,,,25.05,56.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 40mg PF Inj,800013326,CDM,636,RC,J2919,HCPCS,00009003932,NDC,facility,inpatient,40,ME,41.30000,11.98000,Aetna,Local,,16.52,,,,,,,14.89,33.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
methylPREDNISolone NaSucc 40mg PF Inj,800013326,CDM,636,RC,J2919,HCPCS,00009003928,NDC,facility,inpatient,40,ME,41.30000,11.98000,Aetna,Local,,16.52,,,,,,,14.89,33.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydrocortisone 10mg T,800053032,CDM,637,RC,00009003101,NDC,,,facility,outpatient,1,EA,14.40000,4.18000,Aetna,Local,,7.31,,,,,,,5.19,11.78,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00009002946,NDC,,,facility,outpatient,1,EA,4.25000,1.23000,Aetna,Local,,2.16,,,,,,,1.53,3.48,percent of total billed charges,
ALPRAZolam 0.25mg T(Xanax),800040526,CDM,637,RC,00009002901,NDC,,,facility,outpatient,1,EA,53.85000,15.62000,Aetna,Local,,27.34,,,,,,,19.41,44.05,percent of total billed charges,
Triazolam 0.25mg T(Halcion),800060433,CDM,637,RC,00009001759,NDC,,,facility,outpatient,1,EA,26.10000,7.57000,Aetna,Local,,13.25,,,,,,,9.41,21.35,percent of total billed charges,
Hydrocortisone 5mg T,800017611,CDM,637,RC,00009001201,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009001104,NDC,facility,inpatient,100,ME,150.65000,43.69000,Aetna,Local,,60.26,,,,,,,54.31,123.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Hydrocortisone Na Succ 100mg I(S-CO,800013284,CDM,636,RC,J1720,HCPCS,00009001103,NDC,facility,inpatient,100,ME,153.20000,44.43000,Aetna,Local,,61.28,,,,,,,55.23,125.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pramipexole Dihydrochl 0.125mg T(Mirapex),800075365,CDM,637,RC,00009000202,NDC,,,facility,outpatient,1,EA,5.25000,1.52000,Aetna,Local,,2.67,,,,,,,1.89,4.29,percent of total billed charges,
Amiodarone 200mg T(Cordarone),800072701,CDM,637,RC,00008418806,NDC,,,facility,outpatient,1,EA,6.00000,1.74000,Aetna,Local,,3.05,,,,,,,2.16,4.91,percent of total billed charges,
Isosorbide Dinitrate 10mg T(Isordil),800015023,CDM,637,RC,00008415305,NDC,,,facility,outpatient,1,EA,2.30000,0.67000,Aetna,Local,,1.17,,,,,,,0.82915,1.88,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008400125,NDC,facility,inpatient,40,ME,32.40000,9.40000,Aetna,Local,,12.96,,,,,,,11.68,26.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Desvenlafaxine 100mg ER T,800040860,CDM,637,RC,00008122214,NDC,,,facility,outpatient,1,EA,124.00000,35.96000,Aetna,Local,,62.95,,,,,,,44.70,101.43,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121150,NDC,,,facility,outpatient,1,EA,98.75000,28.64000,Aetna,Local,,50.14,,,,,,,35.60,80.78,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121130,NDC,,,facility,outpatient,1,EA,124.05000,35.97000,Aetna,Local,,62.98,,,,,,,44.72,101.47,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121114,NDC,,,facility,outpatient,1,EA,124.00000,35.96000,Aetna,Local,,62.95,,,,,,,44.70,101.43,percent of total billed charges,
Desvenlafaxine 50 mg ER T,800072442,CDM,637,RC,00008121101,NDC,,,facility,outpatient,1,EA,124.05000,35.97000,Aetna,Local,,62.98,,,,,,,44.72,101.47,percent of total billed charges,
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008094103,NDC,facility,inpatient,40,ME,31.90000,9.25000,Aetna,Local,,12.76,,,,,,,11.50,26.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008094102,NDC,facility,inpatient,40,ME,31.90000,9.25000,Aetna,Local,,12.76,,,,,,,11.50,26.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092360,NDC,facility,inpatient,40,ME,32.40000,9.40000,Aetna,Local,,12.96,,,,,,,11.68,26.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092355,NDC,facility,inpatient,40,ME,32.40000,9.40000,Aetna,Local,,12.96,,,,,,,11.68,26.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092351,NDC,facility,inpatient,40,ME,31.90000,9.25000,Aetna,Local,,12.76,,,,,,,11.50,26.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg I(Protonix),800079292,CDM,636,RC,J2470,HCPCS,00008092303,NDC,facility,inpatient,40,ME,158.60000,45.99000,Aetna,Local,,63.44,,,,,,,57.18,129.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008084199,NDC,,,facility,outpatient,1,EA,68.30000,19.81000,Aetna,Local,,34.68,,,,,,,24.62,55.87,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008084181,NDC,,,facility,outpatient,1,EA,123.00000,35.67000,Aetna,Local,,62.45,,,,,,,44.34,100.61,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00008083722,NDC,,,facility,outpatient,1,EA,145.30000,42.14000,Aetna,Local,,73.77,,,,,,,52.38,118.86,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00008083721,NDC,,,facility,outpatient,1,EA,145.30000,42.14000,Aetna,Local,,73.77,,,,,,,52.38,118.86,percent of total billed charges,
Venlafaxine HCl 37.5 mg XR C(Effexor XR),800082254,CDM,637,RC,00008083701,NDC,,,facility,outpatient,1,EA,22.45000,6.51000,Aetna,Local,,11.40,,,,,,,8.09,18.36,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00008083622,NDC,,,facility,outpatient,1,EA,179.80000,52.14000,Aetna,Local,,91.28,,,,,,,64.82,147.08,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00008083621,NDC,,,facility,outpatient,1,EA,184.75000,53.58000,Aetna,Local,,93.80,,,,,,,66.60,151.13,percent of total billed charges,
Venlafaxine 150mg XR C(Effexor XR),800079334,CDM,637,RC,00008083601,NDC,,,facility,outpatient,1,EA,26.25000,7.61000,Aetna,Local,,13.33,,,,,,,9.46,21.47,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083322,NDC,,,facility,outpatient,1,EA,167.70000,48.63000,Aetna,Local,,85.14,,,,,,,60.46,137.18,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083321,NDC,,,facility,outpatient,1,EA,162.80000,47.21000,Aetna,Local,,82.65,,,,,,,58.69,133.17,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083320,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,Local,,50.69,,,,,,,36.00,81.68,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083303,NDC,,,facility,outpatient,1,EA,99.85000,28.96000,Aetna,Local,,50.69,,,,,,,36.00,81.68,percent of total billed charges,
Venlafaxine HCl 75mg XR C(Effexor XR),800079326,CDM,637,RC,00008083301,NDC,,,facility,outpatient,1,EA,25.15000,7.29000,Aetna,Local,,12.77,,,,,,,9.07,20.57,percent of total billed charges,
Amiodarone 150mg/3mL I(Cordarone),800012512,CDM,636,RC,J0282,HCPCS,00008081401,NDC,facility,inpatient,150,ME,1966.65000,570.33000,Aetna,Local,,786.66,,,,,,,708.98,1608.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00008078108,NDC,,,facility,outpatient,1,EA,17.50000,5.07000,Aetna,Local,,8.88,,,,,,,6.31,14.31,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00008078102,NDC,,,facility,outpatient,1,EA,13.35000,3.87000,Aetna,Local,,6.78,,,,,,,4.81,10.92,percent of total billed charges,
Venlafaxine HCl 37.5mg T(Effexor),800073527,CDM,637,RC,00008078101,NDC,,,facility,outpatient,1,EA,14.95000,4.34000,Aetna,Local,,7.59,,,,,,,5.39,12.23,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070108,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,6.13,13.91,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070107,NDC,,,facility,outpatient,1,EA,17.00000,4.93000,Aetna,Local,,8.63,,,,,,,6.13,13.91,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070102,NDC,,,facility,outpatient,1,EA,12.95000,3.76000,Aetna,Local,,6.57,,,,,,,4.67,10.59,percent of total billed charges,
Venlafaxine HCl 25mg T(Effexor),800073519,CDM,637,RC,00008070101,NDC,,,facility,outpatient,1,EA,14.50000,4.20000,Aetna,Local,,7.36,,,,,,,5.23,11.86,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008060701,NDC,,,facility,outpatient,1,EA,3.05000,0.88000,Aetna,Local,,1.55,,,,,,,1.10,2.49,percent of total billed charges,
Promethazine HCl 12.5mg Supp,800063320,CDM,637,RC,00008049801,NDC,,,facility,outpatient,1,EA,25.20000,7.31000,Aetna,Local,,12.79,,,,,,,9.08,20.61,percent of total billed charges,
Pantoprazole 40mg T(Protonix),800077197,CDM,637,RC,00008024199,NDC,,,facility,outpatient,1,EA,12.60000,3.65000,Aetna,Local,,6.40,,,,,,,4.54,10.31,percent of total billed charges,
rOPINIRole 2 mg T(Requip),800070013,CDM,637,RC,00007489320,NDC,,,facility,outpatient,1,EA,47.75000,13.85000,Aetna,Local,,24.24,,,,,,,17.21,39.06,percent of total billed charges,
rOPINIRole 1 mg T(Requip),800070012,CDM,637,RC,00007489220,NDC,,,facility,outpatient,1,EA,46.00000,13.34000,Aetna,Local,,23.35,,,,,,,16.58,37.63,percent of total billed charges,
rOPINIRole 0.25mg T(Requip),800017702,CDM,637,RC,00007489020,NDC,,,facility,outpatient,1,EA,47.75000,13.85000,Aetna,Local,,24.24,,,,,,,17.21,39.06,percent of total billed charges,
Carvedilol 25mg T(Coreg),800074608,CDM,637,RC,00007414220,NDC,,,facility,outpatient,1,EA,60.60000,17.57000,Aetna,Local,,30.77,,,,,,,21.85,49.57,percent of total billed charges,
Carvedilol 12.5mg T(Coreg),800073964,CDM,637,RC,00007414120,NDC,,,facility,outpatient,1,EA,60.60000,17.57000,Aetna,Local,,30.77,,,,,,,21.85,49.57,percent of total billed charges,
Carvedilol 6.25mg T(Coreg),800074616,CDM,637,RC,00007414020,NDC,,,facility,outpatient,1,EA,60.60000,17.57000,Aetna,Local,,30.77,,,,,,,21.85,49.57,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00007413955,NDC,,,facility,outpatient,1,EA,12.20000,3.54000,Aetna,Local,,6.19,,,,,,,4.40,9.98,percent of total billed charges,
Carvedilol 3.125 mg T(Coreg),800073956,CDM,637,RC,00007413920,NDC,,,facility,outpatient,1,EA,60.60000,17.57000,Aetna,Local,,30.77,,,,,,,21.85,49.57,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00007411719,NDC,,,facility,outpatient,1,EA,62.50000,18.12000,Aetna,Local,,31.73,,,,,,,22.53,51.12,percent of total billed charges,
Famciclovir 500mg T(Famvir),800073287,CDM,637,RC,00007411713,NDC,,,facility,outpatient,1,EA,52.25000,15.15000,Aetna,Local,,26.53,,,,,,,18.84,42.74,percent of total billed charges,
Lithium Carb 450mg ER T,800017632,CDM,637,RC,00007401020,NDC,,,facility,outpatient,1,EA,5.60000,1.62000,Aetna,Local,,2.84,,,,,,,2.02,4.58,percent of total billed charges,
Prochlorperazine 25mg Supp(Compazine,800017137,CDM,637,RC,00007336203,NDC,,,facility,outpatient,1,EA,23.95000,6.95000,Aetna,Local,,12.16,,,,,,,8.63,19.59,percent of total billed charges,
Prochlorperazine Edisylate 10mg/2mL I,800010835,CDM,636,RC,J0780,HCPCS,00007335216,NDC,facility,inpatient,10,ME,48.70000,14.12000,Aetna,Local,,19.48,,,,,,,17.56,39.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,00007323411,NDC,facility,inpatient,7.5,ME,689.95000,200.09000,Aetna,Local,,275.98,,,,,,,248.73,564.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 7.5 mg/0.6 mL I,800082460,CDM,636,RC,J1652,HCPCS,00007323402,NDC,facility,inpatient,7.5,ME,663.20000,192.33000,Aetna,Local,,265.28,,,,,,,239.08,542.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,00007323011,NDC,facility,inpatient,2.5,ME,329.30000,95.50000,Aetna,Local,,131.72,,,,,,,118.71,269.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fondaparinux 2.5 mg/0.5 mL I,800012174,CDM,636,RC,J1652,HCPCS,00007323002,NDC,facility,inpatient,2.5,ME,316.45000,91.77000,Aetna,Local,,126.58,,,,,,,114.08,258.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 500mg I (Ancef),800062014,CDM,636,RC,J0690,HCPCS,00007313116,NDC,facility,inpatient,500,ME,16.55000,4.80000,Aetna,Local,,6.62,,,,,,,5.97,13.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ceFAZolin 1000mg I(Ancef),800015127,CDM,636,RC,J0690,HCPCS,00007313016,NDC,facility,inpatient,1000,ME,33.20000,9.63000,Aetna,Local,,13.28,,,,,,,11.97,27.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 1mg/0.5mL I(Aquamephyto,800010264,CDM,636,RC,J3430,HCPCS,00006778433,NDC,facility,inpatient,1,ME,10.75000,3.12000,Aetna,Local,,4.30,,,,,,,3.88,8.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Phytonadione 10mg/1mL I(Aquameph,800013439,CDM,636,RC,J3430,HCPCS,00006778066,NDC,facility,inpatient,10,ME,3.40000,0.99000,Aetna,Local,,1.36,,,,,,,1.23,2.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
dexaMETHasone 0.1% 5mL Ophth Soln,800036904,CDM,637,RC,00006764303,NDC,,,facility,outpatient,1,EA,137.70000,39.93000,Aetna,Local,,69.91,,,,,,,49.64,112.64,percent of total billed charges,
Sugammadex 100mg/mL Inj 5mL(Bridion SD),800040851,CDM,250,RC,00006542515,NDC,,,facility,outpatient,1,EA,1183.40000,343.19000,Aetna,Local,,600.81,,,,,,,426.62,968.02,percent of total billed charges,
Sugammadex 100mg/mL Inj 2mL(Bridion SD),800025674,CDM,250,RC,00006542312,NDC,,,facility,outpatient,1,EA,714.05000,207.07000,Aetna,Local,,362.52,,,,,,,257.42,584.09,percent of total billed charges,
Measles-Mumps-Rubella Inj (MMR),800070770,CDM,636,RC,90707,HCPCS,00006468100,NDC,facility,inpatient,1,EA,526.40000,152.66000,Aetna,Local,,210.56,,,,,,,189.77,430.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Measles-Mumps-Rubella Inj (MMR),800070770,CDM,636,RC,90707,HCPCS,00006468100,NDC,facility,outpatient,1,EA,526.40000,152.66000,Aetna,Local,,210.56,,,,,,,106.45,430.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006394132,NDC,facility,inpatient,150,ME,2483.95000,720.35000,Aetna,Local,,993.58,,,,,,,895.46,2031.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Carbidopa-Levo 50-200 CR T(Sinemet),800064914,CDM,637,RC,00006391968,NDC,,,facility,outpatient,1,EA,21.40000,6.21000,Aetna,Local,,10.86,,,,,,,7.71,17.51,percent of total billed charges,
Carbidopa-Levo 25-100 CR T(Sinemet),800074863,CDM,637,RC,00006391868,NDC,,,facility,outpatient,1,EA,11.15000,3.23000,Aetna,Local,,5.66,,,,,,,4.02,9.12,percent of total billed charges,
Carbidopa-Levo 25-250 T(Sinemet),800071679,CDM,637,RC,00006391768,NDC,,,facility,outpatient,1,EA,12.65000,3.67000,Aetna,Local,,6.42,,,,,,,4.56,10.35,percent of total billed charges,
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006388432,NDC,facility,inpatient,150,ME,1468.00000,425.72000,Aetna,Local,,587.20,,,,,,,529.21,1200.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ertapenem 1g Inj (INVanz),800012521,CDM,636,RC,J1335,HCPCS,00006384371,NDC,facility,inpatient,1,GM,1090.55000,316.26000,Aetna,Local,,436.22,,,,,,,393.14,892.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00006382404,NDC,,,facility,outpatient,1,EA,39.90000,11.57000,Aetna,Local,,20.26,,,,,,,14.38,32.64,percent of total billed charges,
Famotidine 20mg/2mL Inj,800055458,CDM,636,RC,J1308,HCPCS,00006353904,NDC,facility,inpatient,20,ME,25.20000,7.31000,Aetna,Local,,10.08,,,,,,,9.08,20.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,00006351936,NDC,,,facility,outpatient,1,EA,593.05000,171.98000,Aetna,Local,,301.09,,,,,,,213.79,485.11,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,00006351935,NDC,,,facility,outpatient,1,EA,431.05000,125.00000,Aetna,Local,,218.84,,,,,,,155.39,352.60,percent of total billed charges,
Dorzolamide 2% 10mL Ophth Soln(Trusopt),800072073,CDM,637,RC,00006351903,NDC,,,facility,outpatient,1,EA,352.40000,102.20000,Aetna,Local,,178.91,,,,,,,127.04,288.26,percent of total billed charges,
Enalaprilat 2.5mg/2mL I(Vasotec,800057991,CDM,250,RC,00006350804,NDC,,,facility,outpatient,1,EA,175.15000,50.79000,Aetna,Local,,88.92,,,,,,,63.14,143.27,percent of total billed charges,
Timolol 0.5% 5mL Ophth Soln(Timoptic),800039205,CDM,637,RC,00006336703,NDC,,,facility,outpatient,1,EA,156.45000,45.37000,Aetna,Local,,79.43,,,,,,,56.40,127.98,percent of total billed charges,
cefOXitin 1g Inj (Mefoxin),800037381,CDM,636,RC,J0694,HCPCS,00006335645,NDC,facility,inpatient,1,GM,89.80000,26.04000,Aetna,Local,,35.92,,,,,,,32.37,73.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006306104,NDC,facility,inpatient,150,ME,2596.35000,752.94000,Aetna,Local,,1038.54,,,,,,,935.98,2123.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Fosaprepitant 150mg I (Emend),800016726,CDM,636,RC,J1453,HCPCS,00006306100,NDC,facility,inpatient,150,ME,2596.35000,752.94000,Aetna,Local,,1038.54,,,,,,,935.98,2123.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pembrolizumab 25mg/mL Inj 4mL,800046436,CDM,636,RC,J9271,HCPCS,00006302604,NDC,facility,inpatient,100,ME,31410.25000,9108.97000,Aetna,Local,,12564.10,,,,,,,11323.40,25693.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pembrolizumab 100mg/4mL Inj - Pt Own Supply,800051013,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,inpatient,100,ME,0.05000,0.01000,Aetna,Local,,0.02000,,,,,,,0.01802,0.04090,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pembrolizumab 25mg/mL Inj 4mL,800046436,CDM,636,RC,J9271,HCPCS,00006302602,NDC,facility,inpatient,100,ME,31410.25000,9108.97000,Aetna,Local,,12564.10,,,,,,,11323.40,25693.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096382,NDC,,,facility,outpatient,1,EA,14.35000,4.16000,Aetna,Local,,7.29,,,,,,,5.17,11.74,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096358,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,Local,,9.60,,,,,,,6.81,15.46,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096331,NDC,,,facility,outpatient,1,EA,18.90000,5.48000,Aetna,Local,,9.60,,,,,,,6.81,15.46,percent of total billed charges,
Famotidine 20mg Tab,800054501,CDM,637,RC,00006096328,NDC,,,facility,outpatient,1,EA,13.65000,3.96000,Aetna,Local,,6.93,,,,,,,4.92,11.17,percent of total billed charges,
Losartan 100mg T (Cozaar),800015380,CDM,637,RC,00006096031,NDC,,,facility,outpatient,1,EA,43.00000,12.47000,Aetna,Local,,21.83,,,,,,,15.50,35.17,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00006095254,NDC,,,facility,outpatient,1,EA,31.50000,9.14000,Aetna,Local,,15.99,,,,,,,11.36,25.77,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00006095231,NDC,,,facility,outpatient,1,EA,31.50000,9.14000,Aetna,Local,,15.99,,,,,,,11.36,25.77,percent of total billed charges,
Losartan 50mg T(Cozaar),800073493,CDM,637,RC,00006095228,NDC,,,facility,outpatient,1,EA,12.30000,3.57000,Aetna,Local,,6.24,,,,,,,4.43,10.06,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00006095158,NDC,,,facility,outpatient,1,EA,11.75000,3.41000,Aetna,Local,,5.97,,,,,,,4.24,9.61,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00006095154,NDC,,,facility,outpatient,1,EA,23.55000,6.83000,Aetna,Local,,11.96,,,,,,,8.49,19.26,percent of total billed charges,
Losartan 25mg T(Cozaar),800074293,CDM,637,RC,00006095128,NDC,,,facility,outpatient,1,EA,9.20000,2.67000,Aetna,Local,,4.67,,,,,,,3.32,7.53,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00006071468,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,Local,,5.51,,,,,,,3.91,8.88,percent of total billed charges,
Enalapril 20mg T(Vasotec),800071612,CDM,637,RC,00006071428,NDC,,,facility,outpatient,1,EA,12.35000,3.58000,Aetna,Local,,6.27,,,,,,,4.45,10.10,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00006071368,NDC,,,facility,outpatient,1,EA,8.85000,2.57000,Aetna,Local,,4.49,,,,,,,3.19,7.24,percent of total billed charges,
Enalapril 10mg T(Vasotec),800051309,CDM,637,RC,00006071328,NDC,,,facility,outpatient,1,EA,8.15000,2.36000,Aetna,Local,,4.14,,,,,,,2.94,6.67,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00006071268,NDC,,,facility,outpatient,1,EA,8.45000,2.45000,Aetna,Local,,4.29,,,,,,,3.05,6.91,percent of total billed charges,
Enalapril 5mg T(Vasotec),800051291,CDM,637,RC,00006071228,NDC,,,facility,outpatient,1,EA,7.25000,2.10000,Aetna,Local,,3.68,,,,,,,2.61,5.93,percent of total billed charges,
Hydrocortisone 10mg T,800053032,CDM,637,RC,00006061968,NDC,,,facility,outpatient,1,EA,1.80000,0.52000,Aetna,Local,,0.91386,,,,,,,0.64890,1.47,percent of total billed charges,
Felodipine 5mg ER T(Plendil),800070366,CDM,637,RC,00006045158,NDC,,,facility,outpatient,1,EA,9.50000,2.76000,Aetna,Local,,4.82,,,,,,,3.42,7.77,percent of total billed charges,
Raltegravir 400mg T (Isentress),800081144,CDM,637,RC,00006022761,NDC,,,facility,outpatient,1,EA,289.15000,83.85000,Aetna,Local,,146.80,,,,,,,104.24,236.52,percent of total billed charges,
SITagliptin 25 mg T (Januvia),800025461,CDM,637,RC,00006022131,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,Local,,47.44,,,,,,,33.69,76.44,percent of total billed charges,
SITagliptin 25 mg T (Januvia),800025461,CDM,637,RC,00006022128,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,Local,,47.44,,,,,,,33.69,76.44,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00006011754,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,Local,,25.33,,,,,,,17.99,40.82,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00006011731,NDC,,,facility,outpatient,1,EA,49.90000,14.47000,Aetna,Local,,25.33,,,,,,,17.99,40.82,percent of total billed charges,
Montelukast 10mg T(Singulair),800075803,CDM,637,RC,00006011728,NDC,,,facility,outpatient,1,EA,23.20000,6.73000,Aetna,Local,,11.78,,,,,,,8.36,18.98,percent of total billed charges,
SITagliptin 50 mg T(Januvia),800017359,CDM,637,RC,00006011254,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,Local,,47.44,,,,,,,33.69,76.44,percent of total billed charges,
SITagliptin 50 mg T(Januvia),800017359,CDM,637,RC,00006011231,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,Local,,47.44,,,,,,,33.69,76.44,percent of total billed charges,
SITagliptin 50 mg T(Januvia),800017359,CDM,637,RC,00006011228,NDC,,,facility,outpatient,1,EA,93.45000,27.10000,Aetna,Local,,47.44,,,,,,,33.69,76.44,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00006010682,NDC,,,facility,outpatient,1,EA,7.85000,2.28000,Aetna,Local,,3.99,,,,,,,2.83,6.42,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00006010658,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Lisinopril 10mg T(Zestril),800053123,CDM,637,RC,00006010628,NDC,,,facility,outpatient,1,EA,7.90000,2.29000,Aetna,Local,,4.01,,,,,,,2.85,6.46,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00006007258,NDC,,,facility,outpatient,1,EA,40.00000,11.60000,Aetna,Local,,20.31,,,,,,,14.42,32.72,percent of total billed charges,
Finasteride 5mg T(Proscar),800069798,CDM,637,RC,00006007231,NDC,,,facility,outpatient,1,EA,40.00000,11.60000,Aetna,Local,,20.31,,,,,,,14.42,32.72,percent of total billed charges,
Phytonadione 5mg T(Mephyton),800016005,CDM,637,RC,00006004368,NDC,,,facility,outpatient,1,EA,3.35000,0.97000,Aetna,Local,,1.70,,,,,,,1.21,2.74,percent of total billed charges,
Ivermectin 3 mg T(Stomectol),800017621,CDM,637,RC,00006003220,NDC,,,facility,outpatient,1,EA,39.55000,11.47000,Aetna,Local,,20.08,,,,,,,14.26,32.35,percent of total billed charges,
Demeclocycline HCl 150mg T(Declomycin),800054436,CDM,637,RC,00005921823,NDC,,,facility,outpatient,1,EA,29.90000,8.67000,Aetna,Local,,15.18,,,,,,,10.78,24.46,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00005542965,NDC,,,facility,outpatient,1,EA,7.70000,2.23000,Aetna,Local,,3.91,,,,,,,2.78,6.30,percent of total billed charges,
Nystatin Oral Susp 5mL UD,800027002,CDM,637,RC,00005542918,NDC,,,facility,outpatient,1,EA,287.10000,83.26000,Aetna,Local,,145.76,,,,,,,103.50,234.85,percent of total billed charges,
Pyrazinamide 500mg T,800077767,CDM,637,RC,00005509323,NDC,,,facility,outpatient,1,EA,8.55000,2.48000,Aetna,Local,,4.34,,,,,,,3.08,6.99,percent of total billed charges,
Bisoprolol 5 mg Tab,800017431,CDM,637,RC,00005381638,NDC,,,facility,outpatient,1,EA,10.60000,3.07000,Aetna,Local,,5.38,,,,,,,3.82,8.67,percent of total billed charges,
cloNIDine 0.1mg T(Catapres),800011469,CDM,637,RC,00005318023,NDC,,,facility,outpatient,1,EA,1.30000,0.38000,Aetna,Local,,0.66001,,,,,,,0.46865,1.06,percent of total billed charges,
Pneumococcal 20-Valent Conjugate Vaccine,800046481,CDM,636,RC,90677,HCPCS,00005200010,NDC,facility,inpatient,1,ML,1281.00000,371.49000,Aetna,Local,,512.40,,,,,,,461.80,1047.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pneumococcal 20-Valent Conjugate Vaccine,800046481,CDM,636,RC,90677,HCPCS,00005200010,NDC,facility,outpatient,1,ML,1281.00000,371.49000,Aetna,Local,,512.40,,,,,,,301.32,1047.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pneumococcal 20-Valent Conjugate Vaccine,800046481,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,inpatient,1,ML,1315.30000,381.44000,Aetna,Local,,526.12,,,,,,,474.17,1075.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pneumococcal 20-Valent Conjugate Vaccine,800046481,CDM,636,RC,90677,HCPCS,00005200002,NDC,facility,outpatient,1,ML,1315.30000,381.44000,Aetna,Local,,526.12,,,,,,,301.32,1075.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00004691106,NDC,,,facility,outpatient,1,EA,660.35000,191.50000,Aetna,Local,,335.26,,,,,,,238.06,540.17,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),800069111,CDM,250,RC,00004690414,NDC,,,facility,outpatient,1,EA,1143.85000,331.72000,Aetna,Local,,580.73,,,,,,,412.36,935.67,percent of total billed charges,
Midazolam 1mg/mL 5mL I PF,800072425,CDM,636,RC,J2250,HCPCS,00004199901,NDC,facility,inpatient,5,ME,134.40000,38.98000,Aetna,Local,,53.76,,,,,,,48.45,109.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Bumetanide MDV I - IV Room Use,800072040,CDM,636,RC,J1939,HCPCS,00004197001,NDC,facility,inpatient,0.25,ME,8.15000,2.36000,Aetna,Local,,3.26,,,,,,,2.94,6.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
cefTRIAXone 1g I(Rocephin),800013388,CDM,636,RC,J0696,HCPCS,00004196404,NDC,facility,inpatient,1,GM,538.10000,156.05000,Aetna,Local,,215.24,,,,,,,193.99,440.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Oseltamivir 30mg C(Tamiflu),800025560,CDM,637,RC,00004080285,NDC,,,facility,outpatient,1,EA,118.40000,34.34000,Aetna,Local,,60.11,,,,,,,42.68,96.85,percent of total billed charges,
Oseltamivir 75mg C(Tamiflu),800077338,CDM,637,RC,00004080085,NDC,,,facility,outpatient,1,EA,129.05000,37.42000,Aetna,Local,,65.52,,,,,,,46.52,105.56,percent of total billed charges,
Torsemide 20mg T,800081413,CDM,637,RC,00004026401,NDC,,,facility,outpatient,1,EA,10.85000,3.15000,Aetna,Local,,5.51,,,,,,,3.91,8.88,percent of total billed charges,
Torsemide 5mg T,800017732,CDM,637,RC,00004026201,NDC,,,facility,outpatient,1,EA,8.40000,2.44000,Aetna,Local,,4.26,,,,,,,3.03,6.87,percent of total billed charges,
Mycophenolate Mofetil 500 mg T,800010877,CDM,636,RC,J7517,HCPCS,00004026001,NDC,facility,inpatient,500,ME,152.85000,44.33000,Aetna,Local,,61.14,,,,,,,55.10,125.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ibandronate 3mg/3mL IS (Boniva),800011579,CDM,636,RC,J1740,HCPCS,00004019109,NDC,facility,inpatient,3,ME,2291.15000,664.43000,Aetna,Local,,916.46,,,,,,,825.96,1874.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Midazolam HCl 5mg/2.5mL L UD,800078849,CDM,637,RC,00004016851,NDC,,,facility,outpatient,1,EA,24.95000,7.24000,Aetna,Local,,12.67,,,,,,,8.99,20.41,percent of total billed charges,
Midazolam HCl 2mg/mL L(Versed),800075274,CDM,637,RC,00004016851,NDC,,,facility,outpatient,1,EA,10.00000,2.90000,Aetna,Local,,5.08,,,,,,,3.60,8.18,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00004014323,NDC,,,facility,outpatient,1,EA,9.65000,2.80000,Aetna,Local,,4.90,,,,,,,3.48,7.89,percent of total billed charges,
Calcitriol 0.25mcg C(Rocaltrol),800048461,CDM,637,RC,00004014301,NDC,,,facility,outpatient,1,EA,9.90000,2.87000,Aetna,Local,,5.03,,,,,,,3.57,8.10,percent of total billed charges,
Bumetanide 0.5mg T(Bumex),800047737,CDM,637,RC,00004012501,NDC,,,facility,outpatient,1,EA,1.50000,0.43000,Aetna,Local,,0.76155,,,,,,,0.54075,1.23,percent of total billed charges,
Flucytosine 250mg C(Ancobon),800064807,CDM,637,RC,00004007701,NDC,,,facility,outpatient,1,EA,24.85000,7.21000,Aetna,Local,,12.62,,,,,,,8.96,20.33,percent of total billed charges,
valGANciclovir 50mg/mL Oral Soln,800046469,CDM,637,RC,00004003909,NDC,,,facility,outpatient,1,EA,103.30000,29.96000,Aetna,Local,,52.45,,,,,,,37.24,84.50,percent of total billed charges,
valGANciclovir 450mg T(Valcyte),800017736,CDM,637,RC,00004003822,NDC,,,facility,outpatient,1,EA,681.95000,197.77000,Aetna,Local,,346.23,,,,,,,245.84,557.84,percent of total billed charges,
Cefepime HCl 2g I(Maxipime),800013337,CDM,636,RC,J0692,HCPCS,00003773395,NDC,facility,inpatient,2,GM,258.65000,75.01000,Aetna,Local,,103.46,,,,,,,93.24,211.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Cefepime HCl 1g I(Maxipime),800013346,CDM,636,RC,J0692,HCPCS,00003773299,NDC,facility,inpatient,1,GM,151.80000,44.02000,Aetna,Local,,60.72,,,,,,,54.72,124.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00003517805,NDC,,,facility,outpatient,1,EA,32.75000,9.50000,Aetna,Local,,16.63,,,,,,,11.81,26.79,percent of total billed charges,
Pravastatin Na 10mg T(Pravachol),800017678,CDM,637,RC,00003515405,NDC,,,facility,outpatient,1,EA,30.40000,8.82000,Aetna,Local,,15.43,,,,,,,10.96,24.87,percent of total billed charges,
Nivolumab 40mg/4mL I(Opdivo),800062007,CDM,636,RC,J9299,HCPCS,00003377211,NDC,facility,inpatient,40,ME,7335.80000,2127.38000,Aetna,Local,,2934.32,,,,,,,2644.56,6000.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nivolumab 120mg Inj - Pt Own Supply,800051025,CDM,636,RC,J9299,HCPCS,00003375614,NDC,facility,inpatient,120,ME,0.10000,0.03000,Aetna,Local,,0.04000,,,,,,,0.03605,0.08180,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nivolumab 120mg/12mL I(Opdivo),800051959,CDM,636,RC,J9299,HCPCS,00003375614,NDC,facility,inpatient,120,ME,21633.25000,6273.64000,Aetna,Local,,8653.30,,,,,,,7798.79,17696.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nivolumab 240mg Inj - Pt Own Supply,800051026,CDM,636,RC,J9299,HCPCS,00003373413,NDC,facility,inpatient,240,ME,0.25000,0.07000,Aetna,Local,,0.10000,,,,,,,0.09012,0.20450,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aztreonam 2g I (Azactam),800025558,CDM,636,RC,J0457,HCPCS,00003257016,NDC,facility,inpatient,2,GM,537.40000,155.85000,Aetna,Local,,214.96,,,,,,,193.73,439.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Aztreonam 1g I (Azactam),800054261,CDM,636,RC,J0457,HCPCS,00003256016,NDC,facility,inpatient,1,GM,280.55000,81.36000,Aetna,Local,,112.22,,,,,,,101.14,229.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ipilimumab 50mg/10mL I(Yervoy),800051077,CDM,636,RC,J9228,HCPCS,00003232711,NDC,facility,inpatient,50,ME,65381.15000,18960.53000,Aetna,Local,,26152.46,,,,,,,23569.90,53481.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Abatacept 250mg I(Orencia),800011587,CDM,636,RC,J0129,HCPCS,00003218713,NDC,facility,inpatient,250,ME,11347.00000,3290.63000,Aetna,Local,,4538.80,,,,,,,4090.59,9281.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Abatacept 250mg I(Orencia),800011587,CDM,636,RC,J0129,HCPCS,00003218710,NDC,facility,inpatient,250,ME,8651.10000,2508.82000,Aetna,Local,,3460.44,,,,,,,3118.72,7076.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Apixaban 5mg Tab (Eliquis),800017949,CDM,637,RC,00003089470,NDC,,,facility,outpatient,1,EA,85.85000,24.90000,Aetna,Local,,43.59,,,,,,,30.95,70.23,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),800017949,CDM,637,RC,00003089431,NDC,,,facility,outpatient,1,EA,85.85000,24.90000,Aetna,Local,,43.59,,,,,,,30.95,70.23,percent of total billed charges,
Apixaban 5mg Tab (Eliquis),800017949,CDM,637,RC,00003089421,NDC,,,facility,outpatient,1,EA,85.85000,24.90000,Aetna,Local,,43.59,,,,,,,30.95,70.23,percent of total billed charges,
Apixaban 2.5mg Tab (Eliquis),800017948,CDM,637,RC,00003089331,NDC,,,facility,outpatient,1,EA,85.85000,24.90000,Aetna,Local,,43.59,,,,,,,30.95,70.23,percent of total billed charges,
Apixaban 2.5mg Tab (Eliquis),800017948,CDM,637,RC,00003089321,NDC,,,facility,outpatient,1,EA,85.85000,24.90000,Aetna,Local,,43.59,,,,,,,30.95,70.23,percent of total billed charges,
Hydroxyurea 500mg C(Hydrea),800053636,CDM,637,RC,00003083050,NDC,,,facility,outpatient,1,EA,11.60000,3.36000,Aetna,Local,,5.89,,,,,,,4.18,9.49,percent of total billed charges,
Penicillin GK 5MU I,800015140,CDM,636,RC,J2540,HCPCS,00003067371,NDC,facility,inpatient,1,EA,329.35000,95.51000,Aetna,Local,,131.74,,,,,,,118.73,269.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Nystatin 100,00u/g Top Powder",800018531,CDM,637,RC,00003059320,NDC,,,facility,outpatient,1,EA,223.85000,64.92000,Aetna,Local,,113.65,,,,,,,80.70,183.11,percent of total billed charges,
Fludrocortisone Acetate 0.1mg T(Florinef),800014158,CDM,637,RC,00003042950,NDC,,,facility,outpatient,1,EA,5.50000,1.60000,Aetna,Local,,2.79,,,,,,,1.98,4.50,percent of total billed charges,
Triamcinolone Acetonide 40mg/mL Inj,800013323,CDM,636,RC,J3301,HCPCS,00003029305,NDC,facility,inpatient,40,ME,59.75000,17.33000,Aetna,Local,,23.90,,,,,,,21.54,48.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Pravastatin Na 20mg T(Pravachol),800069061,CDM,637,RC,00003017850,NDC,,,facility,outpatient,1,EA,12.85000,3.73000,Aetna,Local,,6.52,,,,,,,4.63,10.51,percent of total billed charges,
donanemab - azbt 350mg I,800051993,CDM,636,RC,J0175,HCPCS,00002940101,NDC,facility,inpatient,350,ME,5258.30000,1524.91000,Aetna,Local,,2103.32,,,,,,,1895.62,4301.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEMEtrexed 500mg Rec Inj,800022535,CDM,636,RC,J9305,HCPCS,00002762301,NDC,facility,inpatient,500,ME,22019.20000,6385.57000,Aetna,Local,,8807.68,,,,,,,7937.92,18011.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OLANZapine 10mg Inj (ZyPREXA),800081001,CDM,636,RC,J2359,HCPCS,00002759701,NDC,facility,inpatient,10,ME,301.55000,87.45000,Aetna,Local,,120.62,,,,,,,108.71,246.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 1000mg Inj,800010913,CDM,636,RC,J9201,HCPCS,00002750201,NDC,facility,inpatient,1000,ME,4188.15000,1214.56000,Aetna,Local,,1675.26,,,,,,,1509.83,3425.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Gemcitabine 200mg I,800074681,CDM,636,RC,J9201,HCPCS,00002750101,NDC,facility,inpatient,200,ME,894.30000,259.35000,Aetna,Local,,357.72,,,,,,,322.40,731.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Prasugrel 10mg T,800081235,CDM,637,RC,00002512377,NDC,,,facility,outpatient,1,EA,130.00000,37.70000,Aetna,Local,,66.00,,,,,,,46.87,106.34,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,00002512152,NDC,,,facility,outpatient,1,EA,130.00000,37.70000,Aetna,Local,,66.00,,,,,,,46.87,106.34,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,00002512130,NDC,,,facility,outpatient,1,EA,130.00000,37.70000,Aetna,Local,,66.00,,,,,,,46.87,106.34,percent of total billed charges,
Prasugrel 5mg T,800081236,CDM,637,RC,00002476030,NDC,,,facility,outpatient,1,EA,49.70000,14.41000,Aetna,Local,,25.23,,,,,,,17.92,40.65,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,00002475977,NDC,,,facility,outpatient,1,EA,49.70000,14.41000,Aetna,Local,,25.23,,,,,,,17.92,40.65,percent of total billed charges,
Prasugrel 10mg T,800081235,CDM,637,RC,00002475930,NDC,,,facility,outpatient,1,EA,49.70000,14.41000,Aetna,Local,,25.23,,,,,,,17.92,40.65,percent of total billed charges,
OLANZapine 5mg ODT(ZyPREXA Zydis),800017446,CDM,637,RC,00002445385,NDC,,,facility,outpatient,1,EA,142.15000,41.22000,Aetna,Local,,72.17,,,,,,,51.25,116.28,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00002416530,NDC,,,facility,outpatient,1,EA,56.05000,16.25000,Aetna,Local,,28.46,,,,,,,20.21,45.85,percent of total billed charges,
Raloxifene 60mg T(Evista),800077635,CDM,637,RC,00002416502,NDC,,,facility,outpatient,1,EA,42.50000,12.32000,Aetna,Local,,21.58,,,,,,,15.32,34.77,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00002411760,NDC,,,facility,outpatient,1,EA,81.40000,23.61000,Aetna,Local,,41.33,,,,,,,29.34,66.59,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00002411733,NDC,,,facility,outpatient,1,EA,156.65000,45.43000,Aetna,Local,,79.53,,,,,,,56.47,128.14,percent of total billed charges,
OLANZapine 10mg T(ZyPREXA),800017445,CDM,637,RC,00002411730,NDC,,,facility,outpatient,1,EA,202.35000,58.68000,Aetna,Local,,102.73,,,,,,,72.95,165.52,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00002411560,NDC,,,facility,outpatient,1,EA,54.05000,15.67000,Aetna,Local,,27.44,,,,,,,19.49,44.21,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00002411533,NDC,,,facility,outpatient,1,EA,51.90000,15.05000,Aetna,Local,,26.35,,,,,,,18.71,42.45,percent of total billed charges,
OLANZapine 5mg T(ZyPREXA),800075258,CDM,637,RC,00002411530,NDC,,,facility,outpatient,1,EA,133.80000,38.80000,Aetna,Local,,67.93,,,,,,,48.23,109.45,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00002411260,NDC,,,facility,outpatient,1,EA,35.40000,10.27000,Aetna,Local,,17.97,,,,,,,12.76,28.96,percent of total billed charges,
OLANZapine 2.5mg T(ZyPREXA),800078799,CDM,637,RC,00002411230,NDC,,,facility,outpatient,1,EA,113.40000,32.89000,Aetna,Local,,57.57,,,,,,,40.88,92.76,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00002327033,NDC,,,facility,outpatient,1,EA,51.45000,14.92000,Aetna,Local,,26.12,,,,,,,18.55,42.09,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00002327030,NDC,,,facility,outpatient,1,EA,79.45000,23.04000,Aetna,Local,,40.34,,,,,,,28.64,64.99,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,00002324090,NDC,,,facility,outpatient,1,EA,79.45000,23.04000,Aetna,Local,,40.34,,,,,,,28.64,64.99,percent of total billed charges,
DULoxetine 30 mg DRC(Cymbalta),800081777,CDM,637,RC,00002324030,NDC,,,facility,outpatient,1,EA,79.45000,23.04000,Aetna,Local,,40.34,,,,,,,28.64,64.99,percent of total billed charges,
DULoxetine 60 mg DRC(Cymbalta),800081769,CDM,637,RC,00002323730,NDC,,,facility,outpatient,1,EA,36.65000,10.63000,Aetna,Local,,18.61,,,,,,,13.21,29.98,percent of total billed charges,
DULoxetine 20 mg DRC(Cymbalta),800082189,CDM,637,RC,00002323560,NDC,,,facility,outpatient,1,EA,70.85000,20.55000,Aetna,Local,,35.97,,,,,,,25.54,57.96,percent of total billed charges,
Opium 10% (Deod Opium Tinc),800043462,CDM,637,RC,00002260658,NDC,,,facility,outpatient,1,EA,40.25000,11.67000,Aetna,Local,,20.43,,,,,,,14.51,32.92,percent of total billed charges,
methIMAzole 5mg Tab,800065614,CDM,637,RC,00002109402,NDC,,,facility,outpatient,1,EA,3.45000,1.00000,Aetna,Local,,1.75,,,,,,,1.24,2.82,percent of total billed charges,
NICU- DexAMETHasone 0.1mg/mL IV in D5W,800051126,CDM,636,RC,J1100,HCPCS,00000000300,NDC,facility,inpatient,5,ME,98.20000,28.48000,Aetna,Local,,39.28,,,,,,,35.40,80.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Remdesivir 100mg Inj,800062067,CDM,636,RC,J0248,HCPCS,00000000290,NDC,facility,inpatient,100,ME,3307.00000,959.03000,Aetna,Local,,1322.80,,,,,,,1192.17,2705.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NICU- Penicillin GK 100,000 unit/mL IM",800040896,CDM,636,RC,J2540,HCPCS,00000000284,NDC,facility,inpatient,100000,UN,19.95000,5.79000,Aetna,Local,,7.98,,,,,,,7.19,16.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Alteplase 0.5mg/1mL Inj Syr,800022089,CDM,636,RC,J2997,HCPCS,00000000272,NDC,facility,inpatient,0.5,ME,385.60000,111.82000,Aetna,Local,,154.24,,,,,,,139.01,315.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Mupirocin/Nystatin/Betameth/Antifungal Oint.,800022042,CDM,637,RC,00000000264,NDC,,,facility,outpatient,1,EA,603.90000,175.13000,Aetna,Local,,306.60,,,,,,,217.71,493.99,percent of total billed charges,
Alteplase 10mg/10mL Bolus Syringe,800022033,CDM,636,RC,J2997,HCPCS,00000000255,NDC,facility,inpatient,10,ME,4529.40000,1313.53000,Aetna,Local,,1811.76,,,,,,,1632.85,3705.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Indomethacin 0.1mg/1mL IS,800025705,CDM,252,RC,00000000253,NDC,,,facility,inpatient,1,EA,3504.40000,1016.28000,Aetna,Local,,1401.76,,,,,,,1296.63,2866.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Indomethacin 0.1mg/1mL IS,800025705,CDM,252,RC,00000000253,NDC,,,facility,outpatient,1,EA,3504.40000,1016.28000,Aetna,Local,,1779.18,,,,,,,1263.34,2866.60,percent of total billed charges,
Cholestyramine 5g/ZincOxide 20% TP,800025703,CDM,637,RC,00000000250,NDC,,,facility,outpatient,1,EA,77.30000,22.42000,Aetna,Local,,39.25,,,,,,,27.87,63.23,percent of total billed charges,
Dextrose (For TPN/PPN),800025672,CDM,250,RC,00000000239,NDC,,,facility,outpatient,1,EA,28.50000,8.26000,Aetna,Local,,14.47,,,,,,,10.27,23.31,percent of total billed charges,
Amino Acids (for TPN/PPN),800025671,CDM,250,RC,00000000238,NDC,,,facility,outpatient,1,EA,57.00000,16.53000,Aetna,Local,,28.94,,,,,,,20.55,46.63,percent of total billed charges,
NICU- cefTAZidime 50mg/mL IS,800025650,CDM,636,RC,J0713,HCPCS,00000000234,NDC,facility,inpatient,50,ME,52.00000,15.08000,Aetna,Local,,20.80,,,,,,,18.75,42.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 100mL Inj,800025641,CDM,636,RC,J7050,HCPCS,00000000233,NDC,facility,inpatient,1,EA,14.70000,4.26000,Aetna,Local,,5.88,,,,,,,5.30,12.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NS 250mL Inj IVR,800025640,CDM,636,RC,J7050,HCPCS,00000000232,NDC,facility,inpatient,1,EA,12.55000,3.64000,Aetna,Local,,5.02,,,,,,,4.52,10.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Ampicillin 1g I,800012563,CDM,636,RC,J0290,HCPCS,00000000225,NDC,facility,inpatient,1,GM,132.00000,38.28000,Aetna,Local,,52.80,,,,,,,47.59,107.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sodium Nitroprusside 50mg/2mL - for IV Set,800025512,CDM,250,RC,00000000221,NDC,,,facility,outpatient,1,EA,3313.20000,960.83000,Aetna,Local,,1682.11,,,,,,,1194.41,2710.20,percent of total billed charges,
ceFAZolin 3g/ NS 115mL P (Ancef),800020015,CDM,636,RC,J0690,HCPCS,00000000184,NDC,facility,inpatient,3,GM,87.40000,25.35000,Aetna,Local,,34.96,,,,,,,31.51,71.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Nitroglycerin 40mcg/mL D5W Vial - OR Use ONLY,800025569,CDM,250,RC,00000000183,NDC,,,facility,outpatient,1,EA,79.65000,23.10000,Aetna,Local,,40.44,,,,,,,28.71,65.15,percent of total billed charges,
NICU- Ampicillin 100mg/mL IV Syr,800025529,CDM,636,RC,J0290,HCPCS,00000000171,NDC,facility,inpatient,100,ME,33.50000,9.72000,Aetna,Local,,13.40,,,,,,,12.08,27.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
fentaNYL 10mcg/mL Cont Inf.,800018033,CDM,636,RC,J3010,HCPCS,00000000167,NDC,facility,inpatient,1,ME,212.50000,61.62000,Aetna,Local,,85.00,,,,,,,76.61,173.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Metoclopramide 5mg/5mL L UD,800072514,CDM,637,RC,00000000155,NDC,,,facility,outpatient,1,EA,2.00000,0.58000,Aetna,Local,,1.02,,,,,,,0.72100,1.64,percent of total billed charges,
Phenylephrine 100mcg/mL NS Syr 10mL,800081297,CDM,636,RC,J2371,HCPCS,00000000144,NDC,facility,inpatient,1,ME,230.90000,66.96000,Aetna,Local,,92.36,,,,,,,83.24,188.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Azithromycin 500mg/NS 250mL P,800081292,CDM,636,RC,J0456,HCPCS,00000000140,NDC,facility,inpatient,500,ME,177.50000,51.47000,Aetna,Local,,71.00,,,,,,,63.99,145.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"Heparin 25,000 unit/ 250mL IVPB",800013302,CDM,636,RC,J1644,HCPCS,00000000137,NDC,facility,inpatient,25000,UN,95.65000,27.74000,Aetna,Local,,38.26,,,,,,,34.48,78.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Acyclovir 7mg/mL IV,800019213,CDM,636,RC,J0133,HCPCS,00000000115,NDC,facility,inpatient,7,ME,376.00000,109.04000,Aetna,Local,,150.40,,,,,,,135.55,307.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
"NICU- Penicillin GK 50,000 unit/mL IV",800081197,CDM,636,RC,J2540,HCPCS,00000000114,NDC,facility,inpatient,50000,UN,30.00000,8.70000,Aetna,Local,,12.00,,,,,,,10.81,24.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Ampicillin 500mg/2mL IM,800081194,CDM,636,RC,J0290,HCPCS,00000000110,NDC,facility,inpatient,500,ME,53.20000,15.43000,Aetna,Local,,21.28,,,,,,,19.18,43.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Vancomycin 5mg/mL IV,800081192,CDM,636,RC,J3373,HCPCS,00000000109,NDC,facility,inpatient,5,ME,172.80000,50.11000,Aetna,Local,,69.12,,,,,,,62.29,141.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Gentamicin Sulf 5mg/mL IV,800081191,CDM,636,RC,J1580,HCPCS,00000000108,NDC,facility,inpatient,20,ME,1.60000,0.46000,Aetna,Local,,0.64000,,,,,,,0.57680,1.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEOnatal Lipid 20% Inf,800081154,CDM,252,RC,00000000102,NDC,,,facility,inpatient,1,EA,128.50000,37.26000,Aetna,Local,,51.40,,,,,,,47.55,105.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEOnatal Lipid 20% Inf,800081154,CDM,252,RC,00000000102,NDC,,,facility,outpatient,1,EA,128.50000,37.26000,Aetna,Local,,65.24,,,,,,,46.32,105.11,percent of total billed charges,
NICU- NEOnatal TPN Infusion,800081155,CDM,258,RC,00000000101,NDC,,,facility,outpatient,1,EA,836.80000,242.67000,Aetna,Local,,424.84,,,,,,,301.67,684.50,percent of total billed charges,
Parenteral Nutrition Chg,800012668,CDM,251,RC,00000000079,NDC,,,facility,outpatient,1,EA,970.00000,281.30000,Aetna,Local,,492.47,,,,,,,349.69,793.46,percent of total billed charges,
Open Heart Kit,800071505,CDM,251,RC,00000000050,NDC,,,facility,outpatient,1,EA,4044.10000,1172.79000,Aetna,Local,,2053.19,,,,,,,1457.90,3308.07,percent of total billed charges,
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",360,RC,27447,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64448,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,493.02,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43239,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45385,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27130,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB",360,RC,74420,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,173.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",360,RC,47562,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64415,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",360,RC,64450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45378,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52356,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION;",481,RC,93454,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22853,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",360,RC,52332,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",361,RC,10005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED)",360,RC,0421T,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC); WITH IMAGING GUIDANCE,361,RC,49083,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,363.66,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43235,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED",481,RC,93458,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",361,RC,36561,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1898.00,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",360,RC,58558,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64447,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,257.40,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",360,RC,23472,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",360,RC,63047,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",361,RC,19083,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",360,RC,49650,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20936,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4015.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; BIOPSY(IES) AND ASPIRATION(S),361,RC,38222,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",481,RC,93656,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,4265.00,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64473,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9600,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,4509.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",750,RC,43450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,434.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,750,RC,G0121,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,548.46,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",360,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",360,RC,58661,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NEEDLE ENTRY, WITH PERMANENT RECORDING AND REPORTING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,76937,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,16.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20930,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",360,RC,44970,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",360,RC,22551,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ADDITIONAL LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION OF THE LEFT OR RIGHT ATRIUM FOR TREATMENT OF ATRIAL FIBRILLATION REMAINING AFTER COMPLETION OF PULMONARY VEIN ISOLATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93657,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58571,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49594,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC GUIDANCE FOR VASCULAR ACCESS AND CATHETER MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHY RADIOLOGIC SUPERVISION AND INTERPRETATION, AND RADIOGRAPHIC DOCUMENTATION OF FINAL CATHETER POSITION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,77001,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,111.41,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",360,RC,31645,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",361,RC,38505,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,538.56,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63048,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,315.00,4125.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,360,RC,64721,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",360,RC,19301,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PROGRAMMED STIMULATION AND PACING AFTER INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93623,CPT,,,,,facility,outpatient,,,,,Aetna,National,,9959.00,,,,,,,849.52,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",360,RC,31629,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), ONE OR TWO MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31652,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRACARDIAC CATHETER ABLATION OF A DISCRETE MECHANISM OF ARRHYTHMIA WHICH IS DISTINCT FROM THE PRIMARY ABLATED MECHANISM, INCLUDING REPEAT DIAGNOSTIC MANEUVERS, TO TREAT A SPONTANEOUS OR INDUCED ARRHYTHMIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93655,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",360,RC,31628,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,77002,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,86.34,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",750,RC,43248,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,750,RC,G0105,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,548.46,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR",360,RC,29827,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH COMPUTER-ASSISTED, IMAGE-GUIDED NAVIGATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",360,RC,31627,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION",360,RC,76942,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,103.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC,361,RC,29125,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22845,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",361,RC,62323,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52352,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF INTRAUTERINE DEVICE (IUD),360,RC,58300,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,171.75,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,63685,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,81336.71,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORE NEEDLE BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",361,RC,32408,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",361,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11042,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSENDOSCOPIC ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) FOR PERIPHERAL LESION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",360,RC,31654,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; LUMBOSACRAL",361,RC,62304,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT/MRI SHOULDER ARTHROGRAPHY,361,RC,23350,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",361,RC,36590,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57288,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",361,RC,47000,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH CORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,29826,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",360,RC,31623,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITH IMAGING GUIDANCE",361,RC,32555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,542.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, NERVOUS SYSTEM",360,RC,64999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",361,RC,50590,CPT,,,,,facility,outpatient,,,,,Aetna,National,,7327.00,,,,,,,2721.18,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",360,RC,63655,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,57236.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36561,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",360,RC,63030,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52601,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",360,RC,20680,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",360,RC,29828,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",360,RC,69436,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1114.08,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ARTHROSCOPY",360,RC,29999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,210.63,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",360,RC,52287,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",481,RC,33285,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",360,RC,59820,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",360,RC,31653,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NEEDLE ENTRY, WITH PERMANENT RECORDING AND REPORTING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,76937,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,16.98,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",481,RC,93653,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,4265.00,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING STEREOTACTIC GUIDANCE",361,RC,19081,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS,360,RC,52001,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1154.34,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",361,RC,20611,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,259.20,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",360,RC,58662,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS) INCLUDING INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT ANGIOGRAPHY",481,RC,93455,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITH IMAGING GUIDANCE",490,RC,32555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,542.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22633,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,63867.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64488,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",361,RC,62328,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR,481,RC,33208,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2860.00,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,19084,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49591,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",361,RC,20610,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,481,RC,33228,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)",361,RC,74177,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,313.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49592,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",360,RC,29914,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES),360,RC,27570,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH",360,RC,55700,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,913.44,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE)",360,RC,36821,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL",361,RC,64483,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27829,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,10006,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",360,RC,49507,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",360,RC,52351,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12001,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCHANGE NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,50435,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",750,RC,43249,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",360,RC,36830,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49593,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",360,RC,59812,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29881,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")",361,RC,20550,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS 1 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22840,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC,360,RC,29125,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",361,RC,19285,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,43239,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,92928,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,1510.07,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING",360,RC,99285,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,304.92,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",360,RC,50081,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",360,RC,47563,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",360,RC,10060,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASOUND, TRANSRECTAL;",360,RC,76872,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,91.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",360,RC,36558,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,45381,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",360,RC,64590,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,57236.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,43247,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",361,RC,62321,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY",360,RC,38571,CPT,,,,,facility,outpatient,,,,,Aetna,National,,7327.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT) INCLUDING IMAGE GUIDANCE, IF PERFORMED",360,RC,64561,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55866,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",360,RC,43659,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21931,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, SIMPLE, COMPLETE",360,RC,19303,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR LEFT VENTRICULAR PACING, AT TIME OF INSERTION OF IMPLANTABLE DEFIBRILLATOR OR PACEMAKER PULSE GENERATOR (EG, FOR UPGRADE TO DUAL CHAMBER SYSTEM) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,33225,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)",360,RC,52234,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11406,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",360,RC,58563,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY,361,RC,58340,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,96375,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,33.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF MULTI-LAYER COMPRESSION SYSTEM; LEG (BELOW KNEE), INCLUDING ANKLE AND FOOT",360,RC,29581,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR",360,RC,29916,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY)",360,RC,28285,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",360,RC,58120,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE",360,RC,49505,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",481,RC,93654,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,4265.00,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",360,RC,43281,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER",360,RC,99152,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND MODERATE LEVEL OF MEDICAL DECISION MAKING",360,RC,99284,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,206.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA,361,RC,27093,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; MULTIPLE LEAD SYSTEM,481,RC,33264,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,85575.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36902,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",360,RC,26055,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY",490,RC,47562,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",361,RC,50200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, INCLUDING ALL IMAGING GUIDANCE, IMAGE DOCUMENTATION, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE INSERTION; AGE 5 YEARS OR OLDER",361,RC,36573,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1364.01,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36832,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",360,RC,36590,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF INTRAUTERINE DEVICE (IUD),360,RC,58301,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; BIOPSY(IES),361,RC,38221,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,235.62,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, SUBCUTANEOUS CARDIAC RHYTHM MONITOR",481,RC,33286,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,617.79,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",360,RC,57265,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION",361,RC,76942,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,103.79,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,43255,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12011,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),360,RC,52000,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,446.82,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS NEEDLE",361,RC,49180,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF PERMANENT IMPLANTABLE DEFIBRILLATOR SYSTEM, WITH TRANSVENOUS LEAD(S), SINGLE OR DUAL CHAMBER",481,RC,33249,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2860.00,85575.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS",360,RC,97597,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12002,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,360,RC,25609,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; SINGLE VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63052,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64484,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)",490,RC,58661,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),360,RC,29515,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",360,RC,57250,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27814,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",361,RC,97605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19285,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62323,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY",360,RC,50543,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC,490,RC,29125,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,360,RC,42820,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF MULTI-LAYER COMPRESSION SYSTEM; LEG (BELOW KNEE), INCLUDING ANKLE AND FOOT",490,RC,29581,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",360,RC,57425,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,52260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1154.34,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE),360,RC,55520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",361,RC,31500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,147.18,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S);,360,RC,60500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TENODESIS OF LONG TENDON OF BICEPS,360,RC,23430,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,52005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; CERVICAL",361,RC,62302,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS) WITH BYPASS GRAFT ANGIOGRAPHY",481,RC,93459,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75625,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)",360,RC,99153,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,360,RC,51715,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER",490,RC,99152,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,360,RC,64718,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52649,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64494,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43251,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",750,RC,43237,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",361,RC,22514,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,2860.00,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64636,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA",360,RC,49651,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",750,RC,43238,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27792,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG",360,RC,96374,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,33.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",360,RC,57522,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ARTHRODESIS; SUBTALAR,360,RC,28725,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOCLEISIS (LE FORT TYPE),360,RC,57120,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM),360,RC,52317,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45390,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",360,RC,20553,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,360,RC,51102,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",360,RC,27822,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE",360,RC,52281,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1154.34,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,361,RC,38792,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,151.14,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)",360,RC,52235,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,61783,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH INSERTION OF TUNNELED INTRAPERITONEAL CATHETER",360,RC,49324,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",360,RC,19125,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE",360,RC,52310,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1154.34,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,360,RC,51705,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,128.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,21552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20610,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC); WITH IMAGING GUIDANCE,490,RC,49083,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,363.66,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59151,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21933,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)",360,RC,44180,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75710,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS",360,RC,C9740,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,360,RC,11770,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY; SINGLE MAJOR CORONARY ARTERY OR BRANCH,481,RC,92920,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1359.24,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",360,RC,57282,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19737.41,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,92921,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF HYDROCELE; UNILATERAL,360,RC,55040,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC",361,RC,22513,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,2860.00,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11404,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58573,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S)",360,RC,58262,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL DECISION MAKING",360,RC,99283,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,128.04,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE",490,RC,43239,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST), SOFT TISSUE (EG, EXTREMITY, ABDOMINAL WALL, NECK), PERCUTANEOUS",361,RC,10030,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",360,RC,41899,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE",361,RC,20206,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,538.56,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY LITHOTRIPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,92972,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",360,RC,30140,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36831,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH",360,RC,28308,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",360,RC,58561,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),750,RC,43264,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1630.20,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL",360,RC,63045,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,45330,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY",490,RC,59812,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",360,RC,29824,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR",360,RC,96365,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,119.46,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",360,RC,27299,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",360,RC,62321,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA",490,RC,69436,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1114.08,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11043,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR",360,RC,63267,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64417,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY, CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36907,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED;",360,RC,57260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THYROIDECTOMY, TOTAL OR COMPLETE",360,RC,60240,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, WITHOUT IMAGING GUIDANCE; AGE 5 YEARS OR OLDER",361,RC,36569,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, FEMUR)",361,RC,20225,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64491,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",360,RC,64430,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; EACH ADDITIONAL PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,52442,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)",490,RC,99153,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",360,RC,42826,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR TUMORS, ORGAN ISCHEMIA, OR INFARCTION",361,RC,37243,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; MULTIPLE LEAD SYSTEM,481,RC,33229,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,50902.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION",360,RC,10140,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,866.58,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)",360,RC,43644,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,7492.10,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11402,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,22903,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",360,RC,38525,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",360,RC,49320,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT),490,RC,29515,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29888,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43244,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",360,RC,19120,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43235,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",490,RC,52356,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",490,RC,17250,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY",361,RC,G0260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2360.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29823,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED",481,RC,93460,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY",360,RC,52224,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",361,RC,36247,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL",361,RC,64493,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY,360,RC,27385,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL",360,RC,22856,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",360,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,360,RC,49422,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-GUIDANCE BASED ON CT/MRI IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,0055T,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF DRUG-ELUTING INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,C9601,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",360,RC,20694,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,22515,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",360,RC,20605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,C9607,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,4509.00,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,52284,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)",360,RC,52240,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT),360,RC,64581,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,360,RC,42821,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS",361,RC,97597,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",360,RC,57283,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19737.41,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL",360,RC,59320,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",360,RC,49616,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,11548.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",360,RC,60220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS",490,RC,11042,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22842,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",361,RC,64635,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,851.40,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT",360,RC,28740,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT",360,RC,28750,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC GUIDANCE FOR VASCULAR ACCESS AND CATHETER MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHY RADIOLOGIC SUPERVISION AND INTERPRETATION, AND RADIOGRAPHIC DOCUMENTATION OF FINAL CATHETER POSITION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,77001,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,111.41,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR VISUALIZATION OF ILEAL CONDUIT AND/OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE",361,RC,50690,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME),360,RC,51720,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,210.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STRAPPING; UNNA BOOT,360,RC,29580,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)",360,RC,29915,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43242,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",361,RC,19281,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION",360,RC,52354,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22614,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,3918.53,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)",360,RC,19357,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,46437.75,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64421,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",361,RC,10160,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49329,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",360,RC,12032,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,50432,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1798.70,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; 2 OR MORE REGIONS (EG, LUMBAR/THORACIC, CERVICAL/THORACIC, LUMBAR/CERVICAL, LUMBAR/THORACIC/CERVICAL)",361,RC,62305,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE,360,RC,11771,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, TOE; METATARSOPHALANGEAL JOINT",360,RC,28820,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),360,RC,29105,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23515,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER CLOSURE OF CONGENITAL INTERATRIAL COMMUNICATION (IE, FONTAN FENESTRATION, ATRIAL SEPTAL DEFECT) WITH IMPLANT",481,RC,93580,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,4509.00,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",481,RC,93620,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,4065.07,20253.32,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",360,RC,44238,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22846,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,7331.50,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL",360,RC,29804,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP",360,RC,36589,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",360,RC,29822,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY, WITH LITHOTRIPSY, AND URETERAL CATHETERIZATION FOR STEERABLE VACUUM ASPIRATION OF THE KIDNEY, COLLECTING SYSTEM, URETER, BLADDER, AND URETHRA IF APPLICABLE",360,RC,C9761,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),360,RC,46040,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1035.30,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63053,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11403,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12013,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY,360,RC,52276,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, SPERMATIC CORD",360,RC,55559,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANKLE, OPEN",360,RC,27870,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS",361,RC,31623,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON GRAFT",360,RC,24342,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP",361,RC,36589,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",490,RC,52332,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,C9604,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,4509.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22612,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION;",360,RC,93454,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10853.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11423,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT",360,RC,27654,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",361,RC,43762,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,213.55,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),490,RC,29105,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH BIOPSY(S)",360,RC,52204,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENIPUNCTURE, AGE 3 YEARS OR OLDER, NECESSITATING THE SKILL OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (SEPARATE PROCEDURE), FOR DIAGNOSTIC OR THERAPEUTIC PURPOSES (NOT TO BE USED FOR ROUTINE VENIPUNCTURE)",361,RC,36410,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,4610.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH",360,RC,62273,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",360,RC,36833,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, APPENDECTOMY",490,RC,44970,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTING GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO-JEJUNOSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, FROM A PERCUTANEOUS APPROACH INCLUDING IMAGE DOCUMENTATION AND REPORT",361,RC,49465,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,133.98,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL",361,RC,64490,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE",360,RC,19307,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",360,RC,42830,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (IE, PROUD FLESH)",360,RC,17250,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE;",360,RC,28730,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,63035,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,315.00,4125.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE)",360,RC,27702,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,63867.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24685,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",361,RC,36558,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1663.00,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED",360,RC,93458,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10853.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,96376,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",361,RC,20606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23473,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12,490,RC,42820,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER",490,RC,59820,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT",481,RC,93650,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,4265.00,20253.32,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION, RENAL TUMOR(S), UNILATERAL, PERCUTANEOUS, CRYOTHERAPY",361,RC,50593,CPT,,,,,facility,outpatient,,,,,Aetna,National,,7327.00,,,,,,,2860.00,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER INSERTION OR REPLACEMENT OF PERMANENT LEADLESS PACEMAKER, RIGHT VENTRICULAR, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, VENTRICULOGRAPHY, FEMORAL VENOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED",481,RC,33274,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,50902.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIVER ELASTOGRAPHY, MECHANICALLY INDUCED SHEAR WAVE (EG, VIBRATION), WITHOUT IMAGING, WITH INTERPRETATION AND REPORT",361,RC,91200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,128.88,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ABDOMINAL PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC); WITH IMAGING GUIDANCE,360,RC,49083,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,363.66,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED;",360,RC,50436,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64634,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE",360,RC,54161,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",361,RC,49450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",750,RC,45382,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAOPERATIVE IDENTIFICATION (EG, MAPPING) OF SENTINEL LYMPH NODE(S) INCLUDES INJECTION OF NON-RADIOACTIVE DYE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,38900,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11045,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER IMPLANTATION OF WIRELESS PULMONARY ARTERY PRESSURE SENSOR FOR LONG-TERM HEMODYNAMIC MONITORING, INCLUDING DEPLOYMENT AND CALIBRATION OF THE SENSOR, RIGHT HEART CATHETERIZATION, SELECTIVE PULMONARY CATHETERIZATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION, AND PULMONARY ARTERY ANGIOGRAPHY, WHEN PERFORMED",481,RC,33289,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2860.00,75877.73,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",360,RC,25607,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37225,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,45385,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45378,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",360,RC,30520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",360,RC,52214,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58570,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH MANIPULATION,360,RC,27818,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,335.94,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43270,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1665.66,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION;",490,RC,93454,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10853.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,63688,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,10030.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",360,RC,13160,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8341.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",360,RC,11982,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,27685,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS",360,RC,59412,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49521,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)",360,RC,27691,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27759,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT",360,RC,36903,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;",360,RC,36901,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43236,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",361,RC,31645,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE FOR INITIAL SECOND OR THIRD ORDER VESSEL AS APPROPRIATE)",361,RC,36248,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27327,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; PYELOPLASTY",360,RC,50544,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA,360,RC,37607,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF URETHROCELE, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED",360,RC,57240,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36247,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64445,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",490,RC,10005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, HERNIOTOMY",360,RC,49659,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,24075,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR MORE SELECTIVE, BRANCH (EG, LEFT ADRENAL VEIN, PETROSAL SINUS)",361,RC,36012,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13122,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",360,RC,26951,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11046,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS",360,RC,43774,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE",360,RC,24515,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",360,RC,57520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",490,RC,43235,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93621,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,877.76,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT/MRI SHOULDER ARTHROGRAPHY,360,RC,23350,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37221,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC",360,RC,23412,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",360,RC,11044,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, PELVIC, SELECTIVE OR SUPRASELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75736,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1968.78,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INGUINOFEMORAL NODE(S)",360,RC,38531,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR",360,RC,22558,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,63867.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",360,RC,27524,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22634,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND),361,RC,29105,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MANIPULATION OF TEMPOROMANDIBULAR JOINT(S) (TMJ), THERAPEUTIC, REQUIRING AN ANESTHESIA SERVICE (IE, GENERAL OR MONITORED ANESTHESIA CARE)",360,RC,21073,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,492.36,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,361,RC,32550,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2032.80,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE",360,RC,11012,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,291.72,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11422,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT",360,RC,27446,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",360,RC,29882,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, TOE; INTERPHALANGEAL JOINT",360,RC,28825,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",360,RC,58562,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36245,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",360,RC,29877,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,25075,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS",490,RC,97606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,360,RC,25608,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),360,RC,52318,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26418,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANT FROM FINGER OR HAND,360,RC,26320,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER",360,RC,26160,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING CENTRAL VENOUS ACCESS DEVICE, INCLUDING FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT",361,RC,36598,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,152.46,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",360,RC,10180,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64415,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; EXTERNAL",360,RC,92960,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,574.59,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",360,RC,29880,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37227,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR WITHOUT MANIPULATION",360,RC,29825,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),750,RC,43275,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1665.66,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LEFT HEART CATHETERIZATION BY TRANSSEPTAL PUNCTURE THROUGH INTACT SEPTUM OR BY TRANSAPICAL PUNCTURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93462,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",360,RC,28810,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR ONLY,481,RC,33233,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR",360,RC,63042,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASONIC GUIDANCE, INTRAOPERATIVE",360,RC,76998,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",360,RC,28297,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON",360,RC,28234,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CONTRAST INJECTION FOR ASSESSMENT OF ABSCESS OR CYST VIA PREVIOUSLY PLACED DRAINAGE CATHETER OR TUBE (SEPARATE PROCEDURE),361,RC,49424,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",360,RC,13121,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,215.16,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CURETTAGE, POSTPARTUM",360,RC,59160,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",360,RC,20552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY",360,RC,27827,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL VESSEL STUDIED AFTER BASIC EXAMINATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,75774,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,472.21,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL",360,RC,27695,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)",360,RC,25447,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); MORSELIZED (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,20937,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4015.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",750,RC,43259,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED;",360,RC,23615,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; INTRAOPERATIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,74300,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,18.09,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; RADICAL NEPHRECTOMY (INCLUDES REMOVAL OF GEROTA'S FASCIA AND SURROUNDING FATTY TISSUE, REMOVAL OF REGIONAL LYMPH NODES, AND ADRENALECTOMY)",360,RC,50545,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21556,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; SINGLE LEAD SYSTEM,481,RC,33262,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,59910.88,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR WITHOUT INTERNAL FIXATION",360,RC,28300,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION",490,RC,57522,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,31633,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD",490,RC,58662,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,750,RC,43262,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1630.20,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY,360,RC,51600,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,315.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, FEMUR OR KNEE",360,RC,27599,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED",481,RC,C9764,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,3456.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,360,RC,57460,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2",360,RC,22554,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); BICONDYLAR, WITH OR WITHOUT INTERNAL FIXATION",360,RC,27536,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, FOOT; TRANSMETATARSAL",360,RC,28805,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",360,RC,63650,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE",360,RC,64418,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS",360,RC,36581,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN",360,RC,27305,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",490,RC,36561,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER EXTREMITY, CATHETER, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75630,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C",490,RC,58558,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",360,RC,41800,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); VENTRICULAR,481,RC,33207,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2860.00,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS,360,RC,56405,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",490,RC,31500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,147.18,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITH ANESTHESIA,360,RC,27095,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF ACUTE TOTAL/SUBTOTAL OCCLUSION DURING ACUTE MYOCARDIAL INFARCTION, CORONARY ARTERY OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING ASPIRATION THROMBECTOMY WHEN PERFORMED, SINGLE VESSEL",481,RC,92941,CPT,,,,,facility,outpatient,,,,,Aetna,National,,9931.00,,,,,,,1692.15,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS",360,RC,31267,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",360,RC,50590,CPT,,,,,facility,outpatient,,,,,Aetna,National,,7327.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11401,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,22902,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",360,RC,20600,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",361,RC,49451,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CHANGE OF CYSTOSTOMY TUBE; COMPLICATED,360,RC,51710,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR BUTTON)",360,RC,20900,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS",360,RC,97606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADIOLOGIC EXAMINATION, ABSCESS, FISTULA OR SINUS TRACT STUDY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,76080,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,223.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13102,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT ANESTHESIA",360,RC,23650,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",481,RC,37224,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",360,RC,13101,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY (INCLUDING INTRODUCTION OF NEEDLE OR INTRACATHETER),361,RC,36005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;",360,RC,31535,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",360,RC,10061,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22585,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)",360,RC,29875,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",360,RC,43248,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),360,RC,29505,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION",361,RC,97602,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT",360,RC,28755,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DISTAL METATARSAL OSTEOTOMY, ANY METHOD",360,RC,28296,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, CALCANEUS;",360,RC,28118,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)",360,RC,28110,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",360,RC,49596,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,11548.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",490,RC,58571,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19286,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",361,RC,64633,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",360,RC,26615,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBCUTANEOUS; LESS THAN 3 CM",490,RC,22902,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE,360,RC,52640,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21930,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/OR GASTROESOPHAGEAL JUNCTION) STUDY WITH INTERPRETATION AND REPORT;,490,RC,91010,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,269.28,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF CEREBROSPINAL FLUID (BY NEEDLE OR CATHETER); WITH FLUOROSCOPIC OR CT GUIDANCE",361,RC,62329,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION, 1 OR MORE RENAL TUMOR(S), PERCUTANEOUS, UNILATERAL, RADIOFREQUENCY",361,RC,50592,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64448,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,493.02,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PROGRAMMED STIMULATION AND PACING AFTER INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93623,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,315.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",360,RC,58555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",490,RC,47000,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")",360,RC,20550,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",360,RC,58999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,8.58,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM",360,RC,11426,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",361,RC,49418,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2032.80,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,24071,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCHANGE OF BILIARY DRAINAGE CATHETER (EG, EXTERNAL, INTERNAL-EXTERNAL, OR CONVERSION OF INTERNAL-EXTERNAL TO EXTERNAL ONLY), PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,47536,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,45388,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1035.30,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY,360,RC,64585,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,9179.02,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",361,RC,20600,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,64634,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",360,RC,52353,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75716,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE (WITH OR WITHOUT FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75726,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",361,RC,37187,CPT,,,,,facility,outpatient,,,,,Aetna,National,,7327.00,,,,,,,2709.30,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",490,RC,10160,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43229,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; SUSPENSION, INCLUDING TRANSFER OR TRANSPLANT OF TENDON, WITH INTERPOSITION, WHEN PERFORMED",360,RC,25448,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",360,RC,49618,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,11548.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",360,RC,49613,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",490,RC,38505,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,538.56,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S);",360,RC,58150,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,7412.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75625,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1968.78,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",360,RC,58263,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)",360,RC,27687,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTING GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO-JEJUNOSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, FROM A PERCUTANEOUS APPROACH INCLUDING IMAGE DOCUMENTATION AND REPORT",360,RC,49465,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,133.98,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,31632,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) OPEN; ACUTE",360,RC,23410,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",490,RC,45378,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75820,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION OR BIOPSY, TEMPORAL ARTERY",360,RC,37609,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE)",360,RC,49322,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",360,RC,49321,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF GASTROSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",361,RC,49440,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITH IMAGING GUIDANCE",360,RC,32555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,542.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",750,RC,43762,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,213.55,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",360,RC,19083,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY",360,RC,25111,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DIALYSIS CIRCUIT PERMANENT VASCULAR EMBOLIZATION OR OCCLUSION (INCLUDING MAIN CIRCUIT OR ANY ACCESSORY VEINS), ENDOVASCULAR, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO COMPLETE THE INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36909,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS",360,RC,28122,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF CATHETER, AORTA",481,RC,36200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PARATHYROID AUTOTRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,60512,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,28200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, EXTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,61782,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA",490,RC,49650,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",360,RC,12031,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",750,RC,43274,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2850.00,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC; WITH FLUOROSCOPIC OR CT GUIDANCE",360,RC,62328,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,97598,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS)",360,RC,45172,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; COMPLEX (EG, STONE[S] > 2 CM, BRANCHING STONES, STONES IN MULTIPLE LOCATIONS, URETER STONES, COMPLICATED ANATOMY)",490,RC,50081,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED",490,RC,93458,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10853.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)",360,RC,16020,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",360,RC,37236,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63661,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,10030.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37228,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY",360,RC,29806,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",490,RC,52260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1154.34,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",360,RC,43249,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION",360,RC,29807,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)",490,RC,52352,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37224,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, SOFT TISSUE OF NECK OR THORAX",361,RC,21550,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",360,RC,10120,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,481,RC,33263,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,59910.88,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ALVEOLOPLASTY, EACH QUADRANT (SPECIFY)",360,RC,41874,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",360,RC,36905,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FACE OR SCALP, SUBCUTANEOUS; 2 CM OR GREATER",360,RC,21012,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; SINGLE VESSEL",481,RC,92937,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,1508.45,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",361,RC,12002,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; SINGLE IMPLANT",360,RC,52441,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,22901,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),360,RC,52500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)",360,RC,24341,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; INITIAL VEIN",361,RC,37248,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,22853,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,27829,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE",360,RC,31500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,147.18,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,44394,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,618.42,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY,490,RC,59151,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",360,RC,25605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,335.94,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; THORACIC",361,RC,62303,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE REGION",360,RC,27301,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,45331,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF MULTI-LAYER COMPRESSION SYSTEM; LEG (BELOW KNEE), INCLUDING ANKLE AND FOOT",361,RC,29581,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,360,RC,21320,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF INTRAUTERINE DEVICE (IUD),490,RC,58300,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,171.75,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64495,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR",360,RC,54405,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,53724.93,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",361,RC,31622,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STRAPPING; UNNA BOOT,490,RC,29580,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THERMAL DESTRUCTION OF INTRAOSSEOUS BASIVERTEBRAL NERVE, INCLUDING ALL IMAGING GUIDANCE; FIRST 2 VERTEBRAL BODIES, LUMBAR OR SACRAL",361,RC,64628,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,2860.00,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH",361,RC,62273,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC;",361,RC,62270,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50947,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26735,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION INCLUDING IMAGING SUPERVISION, INTERPRETATION, AND REPORT; FOR SUPRAVALVULAR AORTOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,93567,CPT,,,,,facility,outpatient,,,,,Aetna,National,,9959.00,,,,,,,9200.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. Secondary and subsequent procedures are not eligible for payment."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC",360,RC,63046,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLAVICULECTOMY; PARTIAL,360,RC,23120,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH LOCAL ADVANCEMENT FLAPS (V-Y, HOOD)",360,RC,26952,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, PATELLA; WITH PROSTHESIS",360,RC,27438,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",490,RC,33285,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL",490,RC,59320,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",750,RC,43266,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",490,RC,19301,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF A UNIPLANE (PINS OR WIRES IN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM",360,RC,20690,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; BIOPSY(IES) AND ASPIRATION(S),360,RC,38222,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, SINGLE SEGMENT",360,RC,63081,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8263.20,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27535,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44361,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,682.44,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF TRANSVENOUS PACEMAKER ELECTRODE(S); DUAL LEAD SYSTEM,481,RC,33235,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF ACUTE TOTAL/SUBTOTAL OCCLUSION DURING ACUTE MYOCARDIAL INFARCTION, CORONARY ARTERY OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF DRUG-ELUTING INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING ASPIRATION THROMBECTOMY WHEN PERFORMED, SINGLE VESSEL",481,RC,C9606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,9931.00,,,,,,,9200.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; INTRAOPERATIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,74300,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,18.09,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37229,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S),360,RC,43264,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT",360,RC,24359,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY,360,RC,43262,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMPLANTATION OF BIOLOGIC IMPLANT (EG, ACELLULAR DERMAL MATRIX) FOR SOFT TISSUE REINFORCEMENT (IE, BREAST, TRUNK) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15777,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES PROCEDURE)",360,RC,27698,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27043,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12004,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,481,RC,33241,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE OR INTRACATHETER, UPPER OR LOWER EXTREMITY ARTERY",481,RC,36140,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,360,RC,27726,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT/MRI SHOULDER ARTHROGRAPHY,490,RC,23350,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",361,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S)",360,RC,55250,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY,490,RC,58340,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64468,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITH ANESTHESIA,361,RC,27095,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,64491,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED",360,RC,29897,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,28043,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",750,RC,43277,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2850.00,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,21240,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",490,RC,49320,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY",360,RC,64595,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,9179.02,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY (INCLUDING INTRODUCTION OF NEEDLE OR INTRACATHETER),360,RC,36005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",481,RC,37226,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,361,RC,32552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.06,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27134,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS",360,RC,C9739,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",360,RC,20606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",361,RC,20553,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR STENT",360,RC,68815,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,64636,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",360,RC,31238,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW)",360,RC,24363,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SECOND LEVEL, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22858,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,360,RC,56440,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL",361,RC,64420,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTRAVENTRICULAR AND/OR INTRA-ATRIAL MAPPING OF TACHYCARDIA SITE(S) WITH CATHETER MANIPULATION TO RECORD FROM MULTIPLE SITES TO IDENTIFY ORIGIN OF TACHYCARDIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93609,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2984.17,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING",490,RC,93620,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,20253.32,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93621,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,315.00,4540.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAY, ACCESSORY ATRIOVENTRICULAR CONNECTION, CAVO-TRICUSPID ISTHMUS OR OTHER SINGLE ATRIAL FOCUS OR SOURCE OF ATRIAL RE-ENTRY",490,RC,93653,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ADDITIONAL LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION OF THE LEFT OR RIGHT ATRIUM FOR TREATMENT OF ATRIAL FIBRILLATION REMAINING AFTER COMPLETION OF PULMONARY VEIN ISOLATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93657,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION",490,RC,97602,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",750,RC,43245,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",750,RC,43246,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT",360,RC,24366,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44360,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,682.44,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION",360,RC,24545,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",490,RC,19083,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON",360,RC,25310,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11603,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST), SOFT TISSUE (EG, EXTREMITY, ABDOMINAL WALL, NECK), PERCUTANEOUS",360,RC,10030,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REALIGNMENT OF EXTENSOR TENDON, HAND, EACH TENDON",360,RC,26437,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM, OR LEADLESS PACEMAKER SYSTEM",481,RC,93288,CPT,,,,,facility,outpatient,,,,,Aetna,National,,563.00,,,,,,,32.74,10865.00,fee schedule,
REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT IMPLANT,360,RC,11970,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27337,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SUTURE OF INFRAPATELLAR TENDON; PRIMARY,360,RC,27380,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",360,RC,27427,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT",360,RC,27487,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION",360,RC,27810,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM",360,RC,12014,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)",360,RC,28270,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, FOOT OR TOES",360,RC,28899,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",360,RC,29883,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT MANIPULATION (SEPARATE PROCEDURE)",360,RC,29884,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE,360,RC,10080,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31276,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36246,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",360,RC,13132,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, NONCORONARY, NON-INTRACRANIAL, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); INITIAL VESSEL",360,RC,37184,CPT,,,,,facility,outpatient,,,,,Aetna,National,,7327.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",360,RC,14040,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15004,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",360,RC,37246,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37252,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY)",360,RC,38505,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,538.56,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S)",360,RC,38510,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,43247,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,45330,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",360,RC,46260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC CANNULATION OF PAPILLA WITH DIRECT VISUALIZATION OF PANCREATIC/COMMON BILE DUCT(S) (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE),750,RC,43273,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ANUS",360,RC,46999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,366.96,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR CHOLANGIOGRAPHY, PERCUTANEOUS, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,47531,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19084,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",360,RC,49614,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TOTAL OR NEAR TOTAL NON-INFECTED MESH OR OTHER PROSTHESIS AT THE TIME OF INITIAL OR RECURRENT ANTERIOR ABDOMINAL HERNIA REPAIR OR PARASTOMAL HERNIA REPAIR, ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,49623,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, BLADDER",360,RC,51999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52344,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROPLASTY; FIRST STAGE, FOR FISTULA, DIVERTICULUM, OR STRICTURE (EG, JOHANNSEN TYPE)",360,RC,53400,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH",360,RC,54530,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; (SEPARATE PROCEDURE),360,RC,55530,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS,360,RC,56420,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL)",360,RC,57200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,57287,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS",360,RC,58350,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK DISSECTION",360,RC,60252,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL",360,RC,60650,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING; WITH CONNECTION TO 2 OR MORE ELECTRODE ARRAYS",360,RC,61886,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,81336.71,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND REFILL",360,RC,62369,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,157.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63664,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,33284.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,43254,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1665.66,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75820,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,77002,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,86.34,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,96368,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",360,RC,47379,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS, INCLUDING ALL IMAGING GUIDANCE, IMAGE DOCUMENTATION, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE REPLACEMENT",361,RC,36584,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",361,RC,37193,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2003.76,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BIOPSY OF SALIVARY GLAND; NEEDLE,361,RC,42400,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,538.56,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",360,RC,37220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); PERITONEAL OR RETROPERITONEAL, PERCUTANEOUS",361,RC,49406,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",361,RC,50431,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,586.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; PRE-EXISTING NEPHROSTOMY TRACT",361,RC,50693,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY,361,RC,51600,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,315.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,21555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",361,RC,63650,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1663.00,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE",361,RC,64405,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,21932,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADIOLOGICAL GUIDANCE (IE, FLUOROSCOPY, ULTRASOUND, OR COMPUTED TOMOGRAPHY), FOR PERCUTANEOUS DRAINAGE (EG, ABSCESS, SPECIMEN COLLECTION), WITH PLACEMENT OF CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75989,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,118.31,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)",360,RC,31237,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),361,RC,77003,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,78.69,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF PERMANENT SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR SYSTEM, WITH SUBCUTANEOUS ELECTRODE, INCLUDING DEFIBRILLATION THRESHOLD EVALUATION, INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING FOR ARRHYTHMIA TERMINATION, AND PROGRAMMING OR REPROGRAMMING OF SENSING OR THERAPEUTIC PARAMETERS, WHEN PERFORMED",481,RC,33270,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,85575.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURES (EG, THROMBIN) FOR PERCUTANEOUS TREATMENT OF EXTREMITY PSEUDOANEURYSM",481,RC,36002,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,542.87,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",481,RC,36215,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH DRUG ELUTING INTRACORONARY STENT, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,C9602,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,4509.00,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64447,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,257.40,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO VERTEBRAL CORPECTOMY(IES) (VERTEBRAL BODY RESECTION, PARTIAL OR COMPLETE) DEFECT, IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH CONTIGUOUS DEFECT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22854,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES",490,RC,20553,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",490,RC,20611,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,259.20,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,23071,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR,490,RC,33208,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ACROMIOPLASTY OR ACROMIONECTOMY, PARTIAL, WITH OR WITHOUT CORACOACROMIAL LIGAMENT RELEASE",360,RC,23130,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11400,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",490,RC,45385,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY",360,RC,23470,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",490,RC,57288,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11421,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, LUMBAR OR SACRAL (CAUDAL); WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",490,RC,62323,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, SINGLE LEVEL",490,RC,64483,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, OLECRANON BURSA",360,RC,24105,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DRAINAGE OF FINGER ABSCESS; SIMPLE,360,RC,26010,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,93.72,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)",490,RC,26055,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",490,RC,26440,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",490,RC,26520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY; SINGLE VESSEL",481,RC,92943,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,1692.15,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)",360,RC,31255,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION",360,RC,31240,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,31231,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,122.76,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,46922,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",361,RC,37241,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL",360,RC,69209,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,52.15,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ORCHIOPEXY, INGUINAL OR SCROTAL APPROACH",360,RC,54640,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)",360,RC,29876,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP",360,RC,19020,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY),360,RC,68720,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,10065.14,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT AND LEFT HEART CATHETERIZATION INCLUDING INTRAPROCEDURAL INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN PERFORMED, CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS) WITH BYPASS GRAFT ANGIOGRAPHY",481,RC,93461,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",360,RC,12034,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",360,RC,46250,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY",360,RC,19370,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT SITE PREPARATION OF PERFORATION FOR CLOSURE, WITH OR WITHOUT PATCH",360,RC,69610,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,360,RC,45915,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1021.02,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",360,RC,43762,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,213.55,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",360,RC,43450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,434.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID",360,RC,15823,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,360,RC,12020,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS",360,RC,28120,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)",360,RC,15769,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9771.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR",490,RC,63030,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK",360,RC,15734,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9771.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,45341,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",490,RC,50200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX;",360,RC,21501,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP",360,RC,27823,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS); WITH MANIPULATION,360,RC,27788,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15275,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,215.16,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL",360,RC,38500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64416,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF MANDIBULAR FRACTURE; WITH INTERDENTAL FIXATION,360,RC,21462,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES",490,RC,41899,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER,490,RC,42821,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT EXCHANGED",750,RC,43276,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2850.00,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,360,RC,57454,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,230.34,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH DESTRUCTION OF CALCULI, ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY)",750,RC,43265,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1630.20,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37193,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR CHOLANGIOGRAPHY, PERCUTANEOUS, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",361,RC,47531,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)",490,RC,43247,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE",490,RC,10060,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (EG, FOLEY)",360,RC,51702,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE",360,RC,25260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63662,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,10030.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST",360,RC,25248,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",361,RC,36571,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1668.48,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",490,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",360,RC,37187,CPT,,,,,facility,outpatient,,,,,Aetna,National,,7327.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON;",360,RC,27650,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE STENTING, AND ALL ANGIOPLASTY IN THE CENTRAL DIALYSIS SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,36908,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY,360,RC,51610,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,315.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, PREPATELLAR BURSA",360,RC,27340,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXATION DEVICE",360,RC,27279,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, THROUGH SAME VENOUS ACCESS",360,RC,36582,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,25071,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, REDUCIBLE",490,RC,49591,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT",360,RC,23474,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, INCARCERATED OR STRANGULATED",490,RC,49594,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRIGEMINAL NERVE, EACH BRANCH (IE, OPHTHALMIC, MAXILLARY, MANDIBULAR)",490,RC,64400,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED,360,RC,11772,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DE QUERVAINS DISEASE)",360,RC,25000,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11424,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF VAGINAL CYST OR TUMOR,360,RC,57135,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RIGHT HEART CATHETERIZATION INCLUDING MEASUREMENT(S) OF OXYGEN SATURATION AND CARDIAC OUTPUT, WHEN PERFORMED",481,RC,93451,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,21554,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",360,RC,69706,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING BILIARY STENTS), INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,47537,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,823.23,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL,490,RC,64721,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION; TROCHANTERIC BURSA OR CALCIFICATION,360,RC,27062,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,64634,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE)",360,RC,24430,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA CAVA",360,RC,36010,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",360,RC,64633,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, COLON",361,RC,45399,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,800.53,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR ELBOW ARTHROGRAPHY,361,RC,24220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",360,RC,20611,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,259.20,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ALVEOLOPLASTY, EACH QUADRANT (SPECIFY)",490,RC,41874,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING, AND INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, INTRACARDIAC ECHOCARDIOGRAPHY WITH IMAGING SUPERVISION AND INTERPRETATION, RIGHT VENTRICULAR PACING/RECORDING, AND HIS BUNDLE RECORDING, WHEN PERFORMED",490,RC,93656,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33228,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROMIAL BURSA); WITHOUT ULTRASOUND GUIDANCE",490,RC,20610,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)",361,RC,20552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)",490,RC,20680,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,20930,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,20936,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4015.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING STEREOTACTIC GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,19082,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); PERITONEAL OR RETROPERITONEAL, PERCUTANEOUS",360,RC,49406,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING; WITH CONNECTION TO A SINGLE ELECTRODE ARRAY",360,RC,61885,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,72632.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORE NEEDLE BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,32408,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL",360,RC,20999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,210.63,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,37252,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22632,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2",490,RC,22551,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITH IMAGING GUIDANCE",361,RC,32557,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1364.01,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, EACH BONE",360,RC,26608,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",360,RC,97605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH SEPARATE ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,56606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER BRANCH (EG, RENAL VEIN, JUGULAR VEIN)",361,RC,36011,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION, LARVAL THERAPY), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION",360,RC,97602,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); VISCERAL (EG, KIDNEY, LIVER, SPLEEN, LUNG/MEDIASTINUM), PERCUTANEOUS",361,RC,49405,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1422.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)",490,RC,58120,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, METACARPOPHALANGEAL JOINT; WITH PROSTHETIC IMPLANT, EACH JOINT",360,RC,26531,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, EACH JOINT",360,RC,26520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON",360,RC,26440,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVASCULAR ULTRASOUND (NONCORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; EACH ADDITIONAL NONCORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37253,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH INTERPRETATION AND REPORT",360,RC,91110,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,682.44,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON",360,RC,26356,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",360,RC,47000,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE",490,RC,26615,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25628,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM",490,RC,27327,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,27792,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL",490,RC,64490,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS AND ULNA",360,RC,25575,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23044,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",490,RC,29881,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR",490,RC,63047,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOLUMINAL IMAGING OF CORONARY VESSEL OR GRAFT USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,92978,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,315.00,5111.18,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12",490,RC,42830,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11104,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS",360,RC,58579,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,176.65,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE",490,RC,43248,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON",360,RC,25290,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",360,RC,11441,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",490,RC,49329,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,24073,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,490,RC,69205,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,24579,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF SCAPULAR FRACTURE (BODY, GLENOID OR ACROMION) INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23585,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",490,RC,52351,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE",750,RC,44369,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1042.14,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY",490,RC,57250,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY)",360,RC,43775,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8635.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR WRIST ARTHROGRAPHY,361,RC,25246,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",361,RC,22999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,210.63,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",361,RC,22511,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2848.95,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",361,RC,20982,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",360,RC,11106,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,537.48,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, INTRAMUSCULAR); 2 CM OR GREATER",360,RC,21014,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF FINGER SPLINT; STATIC,361,RC,29130,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",361,RC,19125,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1683.66,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",361,RC,12011,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",361,RC,11981,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20985,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF SOFT TISSUE LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS, INCLUDING IMAGING GUIDANCE; FIRST LESION",361,RC,10035,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY",360,RC,G0260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2360.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED",360,RC,C9764,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND STRAIGHTFORWARD MEDICAL DECISION MAKING",360,RC,99282,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,81.84,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURES (EG, THROMBIN) FOR PERCUTANEOUS TREATMENT OF EXTREMITY PSEUDOANEURYSM",361,RC,36002,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,143.22,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA CAVA",361,RC,36010,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR",360,RC,96372,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,33.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,96367,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,33.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH COMPLEX SPINAL CORD OR PERIPHERAL NERVE (EG, SACRAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95972,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,80.60,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH CATHETER PLACEMENT(S) IN BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS GRAFTS) INCLUDING INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT ANGIOGRAPHY",360,RC,93455,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10853.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,361,RC,36556,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,731.94,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOLUMINAL IMAGING OF CORONARY VESSEL OR GRAFT USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,92978,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,315.00,5111.18,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIVER ELASTOGRAPHY, MECHANICALLY INDUCED SHEAR WAVE (EG, VIBRATION), WITHOUT IMAGING, WITH INTERPRETATION AND REPORT",360,RC,91200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,128.88,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS AND/OR GASTROESOPHAGEAL JUNCTION) STUDY WITH INTERPRETATION AND REPORT;,360,RC,91010,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,269.28,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75825,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, THROUGH SAME VENOUS ACCESS",361,RC,36582,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1898.00,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MICROSURGICAL TECHNIQUES, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,69990,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",361,RC,37191,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,360,RC,69424,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NERVE REPAIR; WITH SYNTHETIC CONDUIT OR VEIN ALLOGRAFT (EG, NERVE TUBE), EACH NERVE",360,RC,64910,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,20656.55,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED",360,RC,64708,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT",360,RC,64635,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,851.40,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY CONTINUOUS INFUSIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64489,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PARACERVICAL (UTERINE) NERVE",360,RC,64435,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11420,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37223,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL",360,RC,64420,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC)",360,RC,63056,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, MATERNITY CARE AND DELIVERY",360,RC,59899,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,8.58,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58291,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58554,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY,360,RC,58340,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,360,RC,57461,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED;",361,RC,50436,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BONE, OPEN; SUPERFICIAL (EG, STERNUM, SPINOUS PROCESS, RIB, PATELLA, OLECRANON PROCESS, CALCANEUS, TARSAL, METATARSAL, CARPAL, METACARPAL, PHALANX)",360,RC,20240,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PLASTIC REPAIR OF URETHROCELE,360,RC,57230,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, WITHOUT IMAGING GUIDANCE; AGE 5 YEARS OR OLDER",360,RC,36569,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE PROCEDURE)",360,RC,56810,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF BARTHOLIN'S GLAND OR CYST,360,RC,56740,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING,360,RC,56700,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VULVECTOMY SIMPLE; PARTIAL,360,RC,56620,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); 1 LESION,360,RC,56605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,230.34,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56515,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID",360,RC,60260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY,360,RC,20103,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,866.58,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL PROSTATECTOMY, SIMPLE SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY), INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED",360,RC,55867,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)",360,RC,19380,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REDUCTION OF TORSION OF TESTIS, SURGICAL, WITH OR WITHOUT FIXATION OF CONTRALATERAL TESTIS",360,RC,54600,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA",360,RC,23655,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY",360,RC,54057,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY,360,RC,19342,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,25540.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC, SINGLE LEVEL",361,RC,64479,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROMEATOPLASTY, WITH MUCOSAL ADVANCEMENT",360,RC,53450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSURETHRAL RESECTION; RESIDUAL OR REGROWTH OF OBSTRUCTIVE PROSTATE TISSUE INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",360,RC,52630,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BREAST REDUCTION,360,RC,19318,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",360,RC,51798,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,42.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC)",361,RC,64520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION",360,RC,51700,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,128.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50432,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE",360,RC,50200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), RECURRENT, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",360,RC,49615,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",360,RC,49553,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE",360,RC,49550,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE",360,RC,19281,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",360,RC,49452,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",360,RC,49450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED",360,RC,49325,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UMBILECTOMY, OMPHALECTOMY, EXCISION OF UMBILICUS (SEPARATE PROCEDURE)",360,RC,49250,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, RENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75831,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1968.78,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31571,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31536,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANOSCOPY; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,46600,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,42.90,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF THROMBOSED HEMORRHOID, EXTERNAL",360,RC,46320,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1035.30,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL",360,RC,46050,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,366.96,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)",490,RC,43249,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE)",360,RC,45400,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4015.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",361,RC,20604,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,259.20,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,481,RC,33215,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2763.68,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",360,RC,15260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, VASCULAR SURGERY",360,RC,37799,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,40.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; INITIAL VEIN",360,RC,37248,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",360,RC,37242,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37237,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",360,RC,14060,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37222,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)",360,RC,36838,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENIPUNCTURE, AGE 3 YEARS OR OLDER, NECESSITATING THE SKILL OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (SEPARATE PROCEDURE), FOR DIAGNOSTIC OR THERAPEUTIC PURPOSES (NOT TO BE USED FOR ROUTINE VENIPUNCTURE)",360,RC,36410,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF INFECTED GRAFT; EXTREMITY,360,RC,35903,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",481,RC,37221,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY",481,RC,37236,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED,360,RC,10081,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE),361,RC,49423,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1072.50,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,92929,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,0.02447,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",360,RC,31257,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,45338,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,411.18,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE",360,RC,29879,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION)",360,RC,29874,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",360,RC,12035,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28485,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE, WITH MANIPULATION, EACH",360,RC,28476,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28615,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;",360,RC,28415,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,28322,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, TARSAL BONES, OTHER THAN CALCANEUS OR TALUS;",360,RC,28304,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH LEFT VENTRICULAR PACING AND RECORDING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),481,RC,93622,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,3097.15,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)",360,RC,28232,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT",360,RC,28090,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, LEG OR ANKLE",360,RC,27899,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, LEG, THROUGH TIBIA AND FIBULA;",360,RC,27880,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27766,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,27752,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS",360,RC,27696,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)",490,RC,58999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,8.58,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); SUPERFICIAL (EG, ANTERIOR TIBIAL EXTENSORS INTO MIDFOOT)",360,RC,27690,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH TENDON",360,RC,27658,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA,360,RC,27560,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY, AND TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED",481,RC,C9765,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,3456.00,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST), SOFT TISSUE (EG, EXTREMITY, ABDOMINAL WALL, NECK), PERCUTANEOUS",490,RC,10030,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE",490,RC,10061,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; 1 COMPONENT",360,RC,27486,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; WITH FIXATION",360,RC,27450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS",490,RC,11043,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",360,RC,27422,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; MULTIPLE TENDONS (THROUGH SAME INCISION), EACH",360,RC,27686,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS",490,RC,97597,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE,490,RC,11770,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA,360,RC,27266,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITH INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE",360,RC,27245,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,786.83,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK",360,RC,27235,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",360,RC,27132,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA,360,RC,27093,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRACARDIAC ECHOCARDIOGRAPHY DURING THERAPEUTIC/DIAGNOSTIC INTERVENTION, INCLUDING IMAGING SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,93662,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,315.00,5111.18,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS",490,RC,19120,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,27045,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE",490,RC,19285,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA",360,RC,26990,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",490,RC,21235,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26765,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,26746,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER",490,RC,21552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER",360,RC,11719,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,25.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE",360,RC,26591,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH",490,RC,62273,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIECTOMY, PALM ONLY, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT)",360,RC,26121,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5 CM",360,RC,26115,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH LEFT VENTRICULAR PACING AND RECORDING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93622,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,315.00,4900.35,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), PLATELET RICH PLASMA, ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION WHEN PERFORMED",360,RC,0232T,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,42.90,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST",360,RC,10160,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN AND SUBCUTANEOUS TISSUES",360,RC,11010,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISIONAL BIOPSY OF SKIN (EG, WEDGE) (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11107,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11604,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EVACUATION OF SUBUNGUAL HEMATOMA,360,RC,11740,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,25.74,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",360,RC,12041,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM",360,RC,12044,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",360,RC,12052,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM",360,RC,13120,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,13133,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM",360,RC,13152,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA",360,RC,15271,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,215.16,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT EYELIDS, NOSE, EARS, OR LIPS",360,RC,15630,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FOREHEAD FLAP WITH PRESERVATION OF VASCULAR PEDICLE (EG, AXIAL PATTERN FLAP, PARAMEDIAN FOREHEAD FLAP)",360,RC,15731,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9771.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, MUSCLE; DEEP",360,RC,20205,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BONE, TROCAR, OR NEEDLE; SUPERFICIAL (EG, ILIUM, STERNUM, SPINOUS PROCESS, RIBS)",360,RC,20220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF IMPLANT; SUPERFICIAL (EG, BURIED WIRE, PIN OR ROD) (SEPARATE PROCEDURE)",360,RC,20670,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN 1 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE)",360,RC,20692,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ALLOGRAFT, STRUCTURAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20931,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE BONE TUMORS (EG, METASTASIS) INCLUDING ADJACENT SOFT TISSUE WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED; RADIOFREQUENCY",360,RC,20982,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION",360,RC,21196,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITHOUT STABILIZATION,360,RC,21315,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1114.08,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,360,RC,21453,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION FIRST AND/OR CERVICAL RIB;,360,RC,21615,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",360,RC,22630,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,63867.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION,360,RC,22852,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER",360,RC,23073,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; HUMERAL AND GLENOID COMPONENTS (EG, TOTAL SHOULDER)",360,RC,23335,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH CORACOID PROCESS TRANSFER",360,RC,23462,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,23630,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING APPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED)",360,RC,23700,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; HUMERAL AND ULNAR COMPONENTS",360,RC,24160,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN",360,RC,24358,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, HUMERUS OR ELBOW",360,RC,24999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, LESION OF TENDON SHEATH, FOREARM AND/OR WRIST",360,RC,25110,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS (EG, TENOSYNOVITIS, FUNGUS, TBC, OR OTHER GRANULOMAS, RHEUMATOID ARTHRITIS); EXTENSORS, WITH OR WITHOUT TRANSPOSITION OF DORSAL RETINACULUM",360,RC,25116,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES;,360,RC,25130,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25515,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIOTOMY, PALMAR (EG, DUPUYTREN'S CONTRACTURE); OPEN, PARTIAL",360,RC,26045,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,26111,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); DISTAL PHALANX OF FINGER",360,RC,26236,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, EXTENSOR TENDON, HAND, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26410,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON",360,RC,26480,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",360,RC,26605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, SINGLE",360,RC,26785,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, HANDS OR FINGERS",360,RC,26989,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27047,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27048,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, WITH OR WITHOUT ALLOGRAFT",360,RC,27138,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT ANESTHESIA",360,RC,27250,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY (EG, INFECTION)",360,RC,27310,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,27328,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27540,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF KNEE DISLOCATION; REQUIRING ANESTHESIA,360,RC,27552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL ANESTHESIA",360,RC,27606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; LESS THAN 3 CM",360,RC,27618,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OSTEOTOMY; TIBIA,360,RC,27705,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, FOOT; MULTIPLE AREAS",360,RC,28003,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIOTOMY, FOOT AND/OR TOE",360,RC,28008,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE)",360,RC,28060,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)",360,RC,28112,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR FASCIAL RELEASE",360,RC,28119,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD",360,RC,28288,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH DOUBLE OSTEOTOMY, ANY METHOD",360,RC,28299,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF FINGER SPLINT; STATIC,360,RC,29130,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT",360,RC,29846,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ARTHROSCOPICALLY AIDED POSTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION,360,RC,29889,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT",360,RC,29891,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29898,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",360,RC,31256,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, FLEXIBLE; DIAGNOSTIC",360,RC,31575,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,122.76,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITHOUT PLASTIC REPAIR,360,RC,31820,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER IMPLANTATION OF WIRELESS PULMONARY ARTERY PRESSURE SENSOR FOR LONG-TERM HEMODYNAMIC MONITORING, INCLUDING DEPLOYMENT AND CALIBRATION OF THE SENSOR, RIGHT HEART CATHETERIZATION, SELECTIVE PULMONARY CATHETERIZATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION, AND PULMONARY ARTERY ANGIOGRAPHY, WHEN PERFORMED",360,RC,33289,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,75877.73,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY",360,RC,35045,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR BLOOD VESSEL, DIRECT; UPPER EXTREMITY",360,RC,35206,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE OR INTRACATHETER, UPPER OR LOWER EXTREMITY ARTERY",360,RC,36140,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER,360,RC,36556,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,731.94,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, INCLUDING ALL IMAGING GUIDANCE, IMAGE DOCUMENTATION, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE INSERTION; AGE 5 YEARS OR OLDER",360,RC,36573,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS CIRCUIT",360,RC,36906,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",360,RC,37191,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37226,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED",360,RC,37231,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN",360,RC,37238,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37247,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; EACH ADDITIONAL VEIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37249,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS",360,RC,37766,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; ASPIRATION(S),360,RC,38220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,235.62,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",360,RC,38570,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAOPERATIVE IDENTIFICATION (EG, MAPPING) OF SENTINEL LYMPH NODE(S) INCLUDES INJECTION OF NON-RADIOACTIVE DYE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,38900,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MEDIASTINOSCOPY; WITH LYMPH NODE BIOPSY(IES) (EG, LUNG CANCER STAGING)",360,RC,39402,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE ABSCESS; PERITONSILLAR,360,RC,42700,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,203.91,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE",360,RC,42960,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE",360,RC,43246,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH CONTROL OF BLEEDING, ANY METHOD",360,RC,43255,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH DUCT",360,RC,43277,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)",360,RC,43280,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,45381,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",360,RC,46255,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS,360,RC,46270,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED",360,RC,46280,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING BILIARY STENTS), INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,47537,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,823.23,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, EXCLUSIVE OF APPENDICEAL ABSCESS, OPEN",360,RC,49020,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS NEEDLE",360,RC,49180,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION OF AIR OR CONTRAST INTO PERITONEAL CAVITY (SEPARATE PROCEDURE),360,RC,49400,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",360,RC,49451,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INGUINAL HERNIA, SLIDING, ANY AGE",360,RC,49525,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",360,RC,50389,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,446.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCHANGE NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50435,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; NEPHRECTOMY WITH TOTAL URETERECTOMY",360,RC,50548,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT",360,RC,50948,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, ANY TECHNIQUE",360,RC,51785,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,128.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED",360,RC,52315,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)",360,RC,52341,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROPLASTY, 1-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA",360,RC,53410,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, URINARY SYSTEM",360,RC,53899,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,73.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",360,RC,54001,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH",360,RC,54520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY",360,RC,54840,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EPIDIDYMECTOMY; UNILATERAL,360,RC,54860,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DRAINAGE OF SCROTAL WALL ABSCESS,360,RC,55100,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,866.58,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, MALE GENITAL SYSTEM",360,RC,55899,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,73.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LYSIS OF LABIAL ADHESIONS,360,RC,56441,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL;",360,RC,57106,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH,360,RC,57295,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPACTED VAGINAL FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57415,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",360,RC,58550,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G;",360,RC,58572,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY",360,RC,58679,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL",360,RC,58925,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",360,RC,59300,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS);,360,RC,59409,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL APPROACH",360,RC,60271,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ENDOCRINE SYSTEM",360,RC,60699,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; CERVICAL",360,RC,62302,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63003,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, CERVICAL",360,RC,63020,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC",360,RC,63055,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST,360,RC,64719,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL SUPERFICIAL",360,RC,65205,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,69.96,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN, WITH FREE MUCOUS MEMBRANE GRAFT",360,RC,67835,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,73040,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,264.66,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)",360,RC,74177,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,313.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROCYSTOGRAPHY, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,74450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,173.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, PELVIC, SELECTIVE OR SUPRASELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75736,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75827,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, LOWER EXTREMITY ARTERY(IES), EXCEPT TIBIAL/PERONEAL; WITH INTRAVASCULAR LITHOTRIPSY, AND TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL(S), WHEN PERFORMED",360,RC,C9765,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM",361,RC,11424,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",361,RC,12004,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PUNCTURE ASPIRATION OF CYST OF BREAST;,361,RC,19000,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,301.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION OF SINUS TRACT; DIAGNOSTIC (SINOGRAM),361,RC,20501,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",361,RC,25605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,335.94,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT; WITH MANIPULATION, EACH",361,RC,26742,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,99.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL",361,RC,27040,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION",361,RC,27810,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),361,RC,29505,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",361,RC,31628,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, PLEURA, PERCUTANEOUS NEEDLE",361,RC,32400,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VENOUS CATHETERIZATION FOR SELECTIVE ORGAN BLOOD SAMPLING,361,RC,36500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS",361,RC,36581,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1663.00,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR FOREIGN BODY (EG, FRACTURED VENOUS OR ARTERIAL CATHETER), INCLUDES RADIOLOGICAL SUPERVISION AND INTERPRETATION, AND IMAGING GUIDANCE (ULTRASOUND OR FLUOROSCOPY), WHEN PERFORMED",361,RC,37197,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2763.68,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OTHER THAN HEMORRHAGE OR TUMOR (EG, CONGENITAL OR ACQUIRED ARTERIAL MALFORMATIONS, ARTERIOVENOUS MALFORMATIONS, ARTERIOVENOUS FISTULAS, ANEURYSMS, PSEUDOANEURYSMS)",361,RC,37242,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; EACH ADDITIONAL VEIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,37249,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S)",361,RC,38525,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1663.00,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM",361,RC,38999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,226.38,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION, 1 OR MORE LIVER TUMOR(S), PERCUTANEOUS, RADIOFREQUENCY",361,RC,47382,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF CALCULI/DEBRIS FROM BILIARY DUCT(S) AND/OR GALLBLADDER, PERCUTANEOUS, INCLUDING DESTRUCTION OF CALCULI BY ANY METHOD (EG, MECHANICAL, ELECTROHYDRAULIC, LITHOTRIPSY) WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,47544,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION OF AIR OR CONTRAST INTO PERITONEAL CAVITY (SEPARATE PROCEDURE),361,RC,49400,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ASPIRATION AND/OR INJECTION OF RENAL CYST OR PELVIS BY NEEDLE, PERCUTANEOUS",361,RC,50390,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONVERT NEPHROSTOMY CATHETER TO NEPHROURETERAL CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, VIA PRE-EXISTING NEPHROSTOMY TRACT",361,RC,50434,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BALLOON DILATION, URETERAL STRICTURE, INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,50706,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CYSTOURETHROSCOPY (SEPARATE PROCEDURE),361,RC,52000,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,446.82,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, URINARY SYSTEM",361,RC,53899,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,73.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE",361,RC,60100,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,301.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH",361,RC,64450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64480,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,64492,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75822,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75827,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, VENOUS SINUS (EG, PETROSAL AND INFERIOR SAGITTAL) OR JUGULAR, CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75860,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,622.38,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,97598,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED",361,RC,C1889,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,4610.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER INSERTION OF PERMANENT DUAL-CHAMBER LEADLESS PACEMAKER, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY, RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED; COMPLETE SYSTEM (IE, RIGHT ATRIAL AND RIGHT VENTRICULAR PACEMAKER COMPONENTS)",481,RC,0795T,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,3976.00,50902.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RELOCATION OF SKIN POCKET FOR PACEMAKER,481,RC,33222,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1606.16,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; SINGLE LEAD SYSTEM,481,RC,33227,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF SINGLE OR DUAL CHAMBER IMPLANTABLE DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION,481,RC,33244,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",481,RC,92924,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1616.05,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; SINGLE, DUAL, OR MULTIPLE LEAD TRANSVENOUS IMPLANTABLE DEFIBRILLATOR SYSTEM, INCLUDING ANALYSIS OF HEART RHYTHM DERIVED DATA ELEMENTS",481,RC,93289,CPT,,,,,facility,outpatient,,,,,Aetna,National,,563.00,,,,,,,32.74,10865.00,fee schedule,
"CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR CORONARY ANGIOGRAPHY, INCLUDING INTRAPROCEDURAL INJECTION(S) FOR CORONARY ANGIOGRAPHY, IMAGING SUPERVISION AND INTERPRETATION; WITH RIGHT HEART CATHETERIZATION",481,RC,93456,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); SINGLE LESION",490,RC,11104,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM",490,RC,11403,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS",490,RC,12001,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",490,RC,12002,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM",490,RC,12032,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",490,RC,13132,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS",490,RC,14040,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",490,RC,21555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,22552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,22845,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; LESS THAN 3 CM",490,RC,24075,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE",490,RC,26605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, EACH BONE",490,RC,26608,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",490,RC,26735,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE",490,RC,26951,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA,490,RC,27093,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES),490,RC,29505,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED",490,RC,29880,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, PLEURA, PERCUTANEOUS NEEDLE",490,RC,32400,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORE NEEDLE BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,32408,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF,490,RC,32550,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPOSITIONING OF PREVIOUSLY IMPLANTED CARDIAC VENOUS SYSTEM (LEFT VENTRICULAR) ELECTRODE (INCLUDING REMOVAL, INSERTION AND/OR REPLACEMENT OF EXISTING GENERATOR)",490,RC,33226,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF PERMANENT IMPLANTABLE DEFIBRILLATOR SYSTEM, WITH TRANSVENOUS LEAD(S), SINGLE OR DUAL CHAMBER",490,RC,33249,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,85575.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, SUBCUTANEOUS CARDIAC RHYTHM MONITOR",490,RC,33286,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION",490,RC,36590,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE",490,RC,37187,CPT,,,,,facility,outpatient,,,,,Aetna,National,,7327.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",490,RC,45330,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA,490,RC,45915,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1021.02,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE),490,RC,46040,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1035.30,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY",490,RC,47563,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); VISCERAL (EG, KIDNEY, LIVER, SPLEEN, LUNG/MEDIASTINUM), PERCUTANEOUS",490,RC,49405,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); PERITONEAL OR RETROPERITONEAL, PERCUTANEOUS",490,RC,49406,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED",490,RC,49521,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); LESS THAN 3 CM, INCARCERATED OR STRANGULATED",490,RC,49592,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); 3 CM TO 10 CM, REDUCIBLE",490,RC,49593,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",490,RC,50432,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED;",490,RC,50436,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING",490,RC,51798,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,42.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER",490,RC,52287,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, SPERMATIC CORD",490,RC,55559,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX,490,RC,57460,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF INTRAUTERINE DEVICE (IUD),490,RC,58301,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)",490,RC,58555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY",490,RC,58562,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",490,RC,58570,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CURETTAGE, POSTPARTUM",490,RC,59160,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR FORCEPS);,490,RC,59409,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITH IMAGING GUIDANCE (IE, FLUOROSCOPY OR CT)",490,RC,62321,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER",490,RC,63685,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,81336.71,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PUDENDAL NERVE",490,RC,64430,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SCIATIC NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64445,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,64484,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL",490,RC,64493,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,64494,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT",490,RC,64633,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)",490,RC,74177,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,313.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEPATOBILIARY SYSTEM IMAGING, INCLUDING GALLBLADDER WHEN PRESENT;",490,RC,78226,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,276.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",490,RC,92928,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY LITHOTRIPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,92972,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTRAVENTRICULAR AND/OR INTRA-ATRIAL MAPPING OF TACHYCARDIA SITE(S) WITH CATHETER MANIPULATION TO RECORD FROM MULTIPLE SITES TO IDENTIFY ORIGIN OF TACHYCARDIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93609,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,315.00,4721.94,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,93613,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,315.00,6014.79,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) (INCLUDES FLUOROSCOPIC GUIDANCE, WHEN PERFORMED)",750,RC,43233,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1665.66,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,43260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1630.20,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,43261,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1630.20,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF ESOPHAGUS, OVER GUIDE WIRE",750,RC,43453,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,434.28,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, STOMACH",750,RC,43659,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2566.74,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44388,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45332,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,411.18,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY,750,RC,G0104,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,357.06,2433.43,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)",360,RC,31254,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY AND/OR INFUSION FOR THROMBOLYSIS, DIALYSIS CIRCUIT, ANY METHOD, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, DIAGNOSTIC ANGIOGRAPHY, FLUOROSCOPIC GUIDANCE, CATHETER PLACEMENT(S), AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S);",360,RC,36904,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF VAGINAL SEPTUM,360,RC,57130,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; LUMBOSACRAL",360,RC,62304,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL",360,RC,69705,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, COMMON CAROTID OR INNOMINATE ARTERY, UNILATERAL, ANY APPROACH, WITH ANGIOGRAPHY OF THE IPSILATERAL INTRACRANIAL CAROTID CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID AND CERVICOCEREBRAL ARCH, WHEN PERFORMED",481,RC,36223,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; IMPLANTABLE SUBCUTANEOUS LEAD DEFIBRILLATOR SYSTEM",481,RC,93260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,563.00,,,,,,,32.74,10865.00,fee schedule,
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE",490,RC,20605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM",490,RC,20694,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC DEFECT CLOSURE WITHIN THE ENTIRE GASTROINTESTINAL TRACT, INCLUDING UPPER ENDOSCOPY (INCLUDING DIAGNOSTIC, IF PERFORMED) OR COLONOSCOPY (INCLUDING DIAGNOSTIC, IF PERFORMED), WITH ALL SYSTEM AND TISSUE ANCHORING COMPONENTS",750,RC,C9901,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,3307.00,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR CONTRAST KNEE ARTHROGRAPHY OR CONTRAST ENHANCED CT/MRI KNEE ARTHROGRAPHY,361,RC,27369,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; THORACIC (WITH LATERAL TRANSVERSE TECHNIQUE, WHEN PERFORMED)",360,RC,22610,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA",360,RC,23030,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24343,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT",360,RC,24666,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TENODESIS AT WRIST; EXTENSORS OF FINGERS,360,RC,25301,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH",360,RC,26080,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT",360,RC,26540,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, EACH TENDON",360,RC,27665,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, SUBCUTANEOUS CARDIAC RHYTHM MONITOR",360,RC,33286,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; FEMOROPOPLITEAL, AORTOILIAC ARTERY, BY LEG INCISION",360,RC,34201,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CERVICAL LYMPHADENECTOMY (COMPLETE),360,RC,38720,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",360,RC,40812,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1114.08,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",360,RC,42104,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UVULECTOMY, EXCISION OF UVULA",360,RC,42140,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,492.36,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRUG-INDUCED SLEEP ENDOSCOPY, WITH DYNAMIC EVALUATION OF VELUM, PHARYNX, TONGUE BASE, AND LARYNX FOR EVALUATION OF SLEEP-DISORDERED BREATHING, FLEXIBLE, DIAGNOSTIC",360,RC,42975,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",360,RC,43238,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",360,RC,43259,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",360,RC,45390,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE)",360,RC,57268,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX,360,RC,57455,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,230.34,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",360,RC,58670,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOMY (SALPINGONEOSTOMY)",360,RC,58673,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,360,RC,59150,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,64466,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY),360,RC,64722,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH",360,RC,67904,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL",360,RC,69210,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,19126,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION(S); SINGLE TENDON ORIGIN/INSERTION,361,RC,20551,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION",361,RC,26645,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",361,RC,49452,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER,361,RC,51102,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1349.70,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS",361,RC,97606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF A SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",481,RC,33216,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",481,RC,93619,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,975.53,20253.32,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,11045,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM",490,RC,12013,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,78.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,490,RC,25608,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)",490,RC,43238,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)",490,RC,43245,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS",490,RC,43259,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMBINED ANTEROPOSTERIOR COLPORRHAPHY, INCLUDING CYSTOURETHROSCOPY, WHEN PERFORMED; WITH ENTEROCELE REPAIR",490,RC,57265,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION)",490,RC,58670,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACIC FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64466,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RECORDING AND CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS, INCLUDING INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING, RIGHT VENTRICULAR PACING AND RECORDING, LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM, AND HIS BUNDLE RECORDING, WHEN PERFORMED; WITH TREATMENT OF VENTRICULAR TACHYCARDIA OR FOCUS OF VENTRICULAR ECTOPY INCLUDING LEFT VENTRICULAR PACING AND RECORDING, WHEN PERFORMED",490,RC,93654,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,65478.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRACARDIAC CATHETER ABLATION OF A DISCRETE MECHANISM OF ARRHYTHMIA WHICH IS DISTINCT FROM THE PRIMARY ABLATED MECHANISM, INCLUDING REPEAT DIAGNOSTIC MANEUVERS, TO TREAT A SPONTANEOUS OR INDUCED ARRHYTHMIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,93655,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",750,RC,43231,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,43232,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",750,RC,45379,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)",750,RC,45398,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1035.30,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS",750,RC,47000,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS",360,RC,15240,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPAIR OF NAIL BED,360,RC,11760,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 3 CM OR GREATER",360,RC,25073,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, SIMPLE, COMPLETE",490,RC,19303,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,17406.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ""FASCIA"")",490,RC,20550,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS",360,RC,11200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PUNCH BIOPSY OF SKIN (INCLUDING SIMPLE CLOSURE, WHEN PERFORMED); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,11105,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)",360,RC,15100,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FINE NEEDLE ASPIRATION BIOPSY, WITHOUT IMAGING GUIDANCE; FIRST LESION",360,RC,10021,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,106.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY,361,RC,51610,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,315.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CHANGE OF CYSTOSTOMY TUBE; SIMPLE,361,RC,51705,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,128.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)",750,RC,57288,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,2670.00,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)",750,RC,52356,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",750,RC,45391,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,490,RC,21299,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,70.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S)",750,RC,45342,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,731.28,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL FIXATION,490,RC,21453,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF MANDIBULAR FRACTURE; WITH INTERDENTAL FIXATION,490,RC,21462,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLONOSCOPY THROUGH STOMA; WITH ENDOSCOPIC MUCOSAL RESECTION,750,RC,44403,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1035.30,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE",750,RC,44389,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",750,RC,44380,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,682.44,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL",490,RC,22511,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,22515,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, COMBINED POSTERIOR OR POSTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/OR DISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE, LUMBAR;",490,RC,22633,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,63867.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ESOPHAGUS",750,RC,43499,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,557.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS 1 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,22840,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH INJECTION SCLEROSIS OF ESOPHAGEAL/GASTRIC VARICES",750,RC,43243,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S) OVER GUIDE WIRE",750,RC,43226,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",750,RC,43217,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",750,RC,43201,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",750,RC,31645,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS",490,RC,97605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,97598,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
UNLISTED CARDIOVASCULAR SERVICE OR PROCEDURE,490,RC,93799,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,61.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA",490,RC,93619,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,20253.32,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOLUMINAL IMAGING OF CORONARY VESSEL OR GRAFT USING INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,92979,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,160.88,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF ACUTE TOTAL/SUBTOTAL OCCLUSION DURING ACUTE MYOCARDIAL INFARCTION, CORONARY ARTERY OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING ASPIRATION THROMBECTOMY WHEN PERFORMED, SINGLE VESSEL",490,RC,92941,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY; SINGLE MAJOR CORONARY ARTERY OR BRANCH,490,RC,92920,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,25628,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,490,RC,25652,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW,490,RC,64718,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",490,RC,64488,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LOWER EXTREMITY FASCIAL PLANE BLOCK, UNILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64473,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64468,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",490,RC,64417,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL",490,RC,63655,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,57236.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL",490,RC,63650,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,63048,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,315.00,4125.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; 2 OR MORE REGIONS (EG, LUMBAR/THORACIC, CERVICAL/THORACIC, LUMBAR/CERVICAL, LUMBAR/THORACIC/CERVICAL)",490,RC,62305,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT; WITHOUT ANESTHESIA",490,RC,26670,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC;",490,RC,62270,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS",490,RC,11044,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT",490,RC,27130,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),490,RC,61783,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)",490,RC,27447,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER))",490,RC,23472,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS AND ULNA",490,RC,25575,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB; WITH MANIPULATION, EACH",490,RC,26755,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",490,RC,27412,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR",490,RC,27427,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,27535,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,27814,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR",490,RC,27524,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, EXTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,61782,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THYROIDECTOMY, TOTAL OR COMPLETE",490,RC,60240,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE",490,RC,31624,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH COMPUTER-ASSISTED, IMAGE-GUIDED NAVIGATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",490,RC,31627,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE",490,RC,31628,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I)",490,RC,31629,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, INITIAL",490,RC,31645,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH ENDOBRONCHIAL ULTRASOUND (EBUS) GUIDED TRANSTRACHEAL AND/OR TRANSBRONCHIAL SAMPLING (EG, ASPIRATION[S]/BIOPSY[IES]), 3 OR MORE MEDIASTINAL AND/OR HILAR LYMPH NODE STATIONS OR STRUCTURES",490,RC,31653,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSENDOSCOPIC ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) FOR PERIPHERAL LESION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])",490,RC,31654,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY",490,RC,60220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER",490,RC,42826,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",490,RC,58573,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",490,RC,43242,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",490,RC,43244,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL FIXATION,490,RC,27726,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP",490,RC,27822,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH PLACEMENT OF ENDOSCOPIC STENT (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",490,RC,43266,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CORRECTION, HALLUX VALGUS WITH BUNIONECTOMY, WITH SESAMOIDECTOMY WHEN PERFORMED; WITH FIRST METATARSAL AND MEDIAL CUNEIFORM JOINT ARTHRODESIS, ANY METHOD",490,RC,28297,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)",490,RC,58563,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS NEEDLE",490,RC,49180,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",490,RC,49418,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",490,RC,50389,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,446.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE",490,RC,50590,CPT,,,,,facility,outpatient,,,,,Aetna,National,,7327.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA",490,RC,58561,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN",360,RC,15002,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,328.02,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",490,RC,58552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF VAGINAL SEPTUM,490,RC,57130,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH (EG, KELLY URETHRAL PLICATION)",490,RC,57220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)",490,RC,57425,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER",490,RC,57520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; CERVICAL",490,RC,62302,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION,360,RC,24655,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH INTERPRETATION AND REPORT",490,RC,91110,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,682.44,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIVER ELASTOGRAPHY, MECHANICALLY INDUCED SHEAR WAVE (EG, VIBRATION), WITHOUT IMAGING, WITH INTERPRETATION AND REPORT",490,RC,91200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,128.88,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS;",490,RC,58260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S);",490,RC,58150,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,7412.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CAUTERY OF CERVIX; LASER ABLATION,490,RC,57513,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE CONIZATION OF THE CERVIX,490,RC,57461,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE,490,RC,57454,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,230.34,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, LEVATOR MYORRHAPHY)",490,RC,57283,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19737.41,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PLASTIC REPAIR OF URETHROCELE,490,RC,57230,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF VAGINAL CYST OR TUMOR,490,RC,57135,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VULVECTOMY SIMPLE; PARTIAL,490,RC,56620,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)",750,RC,44376,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,682.44,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST,490,RC,56440,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF HYDROCELE; UNILATERAL,490,RC,55040,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN",490,RC,54001,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED)",490,RC,52601,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE),490,RC,52500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)",490,RC,52353,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS",490,RC,52214,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",490,RC,52005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK,490,RC,51715,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",490,RC,50695,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",750,RC,45349,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",490,RC,50551,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,446.82,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED; INCLUDING NEW ACCESS INTO THE RENAL COLLECTING SYSTEM",490,RC,50437,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCHANGE NEPHROSTOMY CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",490,RC,50435,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, INCARCERATED OR STRANGULATED",490,RC,49596,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,11548.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE",490,RC,49520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION,360,RC,24615,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED",490,RC,49507,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT",490,RC,49450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,409.86,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,490,RC,49422,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE)",490,RC,49321,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BALLOON DILATION OF BILIARY DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), PERCUTANEOUS, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, EACH DUCT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,47542,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF STENT(S) INTO A BILE DUCT, PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY, IMAGING GUIDANCE (EG, FLUOROSCOPY AND/OR ULTRASOUND), BALLOON DILATION, CATHETER EXCHANGE(S) AND CATHETER REMOVAL(S) WHEN PERFORMED, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",490,RC,47538,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS);,360,RC,24586,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING BILIARY STENTS), INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION",490,RC,47537,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,823.23,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPIC PROCEDURE, LIVER",490,RC,47379,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ANUS",490,RC,46999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,366.96,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FINE NEEDLE ASPIRATION BIOPSY, INCLUDING ULTRASOUND GUIDANCE; FIRST LESION",360,RC,10005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, 2 OR MORE COLUMNS/GROUPS;",490,RC,46260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM)",490,RC,44238,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS",490,RC,29828,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OF GASTROSTOMY TUBE, PERCUTANEOUS, INCLUDES REMOVAL, WHEN PERFORMED, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE; NOT REQUIRING REVISION OF GASTROSTOMY TRACT",490,RC,43762,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,213.55,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD",490,RC,30140,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE",360,RC,11005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH",490,RC,43281,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",490,RC,43237,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TANGENTIAL BIOPSY OF SKIN (EG, SHAVE, SCOOP, SAUCERIZE, CURETTE); SINGLE LESION",360,RC,11102,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,174.47,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",490,RC,43236,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES",490,RC,41800,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE",490,RC,38570,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; BIOPSY(IES) AND ASPIRATION(S),490,RC,38222,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); EXTREMITY",490,RC,37618,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RETRIEVAL (REMOVAL) OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED",490,RC,37193,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)",490,RC,36832,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)",490,RC,36830,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM",360,RC,11443,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR",360,RC,11450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT",490,RC,30520,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION, DRUG-DELIVERY IMPLANT (IE, BIORESORBABLE, BIODEGRADABLE, NON-BIODEGRADABLE)",360,RC,11981,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS",490,RC,36581,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER",490,RC,36558,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM,490,RC,33228,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,27932.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE",490,RC,31238,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES",490,RC,31625,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,691.02,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, FLEXIBLE; DIAGNOSTIC",490,RC,31575,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,122.76,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",490,RC,31276,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY",490,RC,31257,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;",490,RC,31256,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ARTHROSCOPY",490,RC,29999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,210.63,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)",490,RC,29914,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM",360,RC,13131,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",360,RC,24505,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG",360,RC,15833,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)",360,RC,16025,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",490,RC,36246,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION OF TOTAL ELBOW ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR ULNAR COMPONENT",360,RC,24370,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING MAGNETIC RESONANCE GUIDANCE",360,RC,19085,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)",490,RC,29883,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR LATERAL)",490,RC,29882,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)",490,RC,29877,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAGNETIC RESONANCE GUIDANCE",360,RC,19287,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,617.79,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)",490,RC,29824,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])",490,RC,29823,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF FINGER SPLINT; STATIC,490,RC,29130,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION",490,RC,27762,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION",490,RC,27752,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OSTEOTOMY; TIBIA,490,RC,27705,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF DRUG-DELIVERY DEVICE(S), DEEP (EG, SUBFASCIAL) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20701,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENDON GRAFT, FROM A DISTANCE (EG, PALMARIS, TOE EXTENSOR, PLANTARIS)",360,RC,20924,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",490,RC,27632,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)",490,RC,27422,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE",360,RC,21025,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21046,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE,360,RC,21299,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,70.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, PELVIS OR HIP JOINT",490,RC,27299,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF MANDIBULAR FRACTURE; WITHOUT INTERDENTAL FIXATION,360,RC,21461,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH LOCAL ADVANCEMENT FLAPS (V-Y, HOOD)",490,RC,26952,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA",490,RC,26770,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",490,RC,26746,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION",490,RC,26645,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, FLEXOR, FINGER, OPEN, EACH TENDON",490,RC,26455,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRAINAGE OF TENDON SHEATH, DIGIT AND/OR PALM, EACH",490,RC,26020,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS,490,RC,25609,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",490,RC,37241,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION",490,RC,25607,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION",490,RC,25605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,335.94,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; LESS THAN 3 CM",490,RC,25075,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; INITIAL VEIN",490,RC,37248,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",490,RC,23515,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TENODESIS OF LONG TENDON OF BICEPS,490,RC,23430,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION,490,RC,22852,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); SINGLE INTERSPACE, LUMBAR",360,RC,22857,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); SECOND INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22860,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL WALL, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,22900,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, RADIAL HEAD;",360,RC,24365,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR",490,RC,22514,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH SIMPLE REPAIR",490,RC,40812,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1114.08,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF STERNOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC; WITH FASCIAL GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,23532,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC; WITH FASCIAL GRAFT (INCLUDES OBTAINING GRAFT)",360,RC,23552,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF MANDIBULAR FRACTURE; WITHOUT INTERDENTAL FIXATION,490,RC,21461,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DEPRESSED FRONTAL SINUS FRACTURE,490,RC,21343,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13934.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE",490,RC,42104,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED;",360,RC,24665,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE",360,RC,24345,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF NASOETHMOID FRACTURE; WITHOUT EXTERNAL FIXATION,490,RC,21338,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION,490,RC,21320,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 3 CM",360,RC,25076,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",490,RC,42825,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT;",360,RC,25118,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITH ULTRASOUND GUIDANCE, WITH PERMANENT RECORDING AND REPORTING",490,RC,20606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROCENTESIS, ASPIRATION AND/OR INJECTION, SMALL JOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRASOUND GUIDANCE",490,RC,20600,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BONE, TROCAR, OR NEEDLE; SUPERFICIAL (EG, ILIUM, STERNUM, SPINOUS PROCESS, RIBS)",490,RC,20220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF ULNAR STYLOID FRACTURE,360,RC,25652,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION",490,RC,19125,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING ULTRASOUND GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,19084,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT; WITHOUT ANESTHESIA",360,RC,26670,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH",360,RC,26727,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION;",360,RC,26860,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING STEREOTACTIC GUIDANCE",490,RC,19081,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR",360,RC,0275T,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE),360,RC,24340,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS",490,RC,15260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK, INTERNAL FIXATION OR PROSTHETIC REPLACEMENT",360,RC,27236,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS",490,RC,14060,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1105.50,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED",490,RC,13160,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8341.21,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",490,RC,13121,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,215.16,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR AND POSTERIOR INCLUDING POPLITEAL AREA",360,RC,27335,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",490,RC,12051,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF FOREIGN BODY, DEEP, THIGH REGION OR KNEE AREA",360,RC,27372,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS",490,RC,12041,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS",490,RC,12031,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM",360,RC,13100,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE WITH INTERCONDYLAR EXTENSION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27513,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,30219.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM",490,RC,12014,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT",490,RC,11982,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR",490,RC,11462,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, ANKLE, WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY",360,RC,27620,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF LEG OR ANKLE AREA, SUBCUTANEOUS; 3 CM OR GREATER",360,RC,27632,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM",490,RC,11441,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM",490,RC,11422,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, RADIAL HEAD",360,RC,24130,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS",490,RC,11420,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",490,RC,11402,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION",490,RC,10180,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",490,RC,10120,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,182.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA",360,RC,27828,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION",360,RC,27846,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH",360,RC,28080,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS;",360,RC,28104,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS;",360,RC,24110,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH MANIPULATION, EACH",360,RC,28515,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RIGHT AND LEFT HEART CATHETERIZATION FOR CONGENITAL HEART DEFECT(S) INCLUDING IMAGING GUIDANCE BY THE PROCEDURALIST TO ADVANCE THE CATHETER TO THE TARGET ZONE(S); NORMAL NATIVE CONNECTIONS,481,RC,93596,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2824.19,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS",360,RC,12051,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY",481,RC,93308,CPT,,,,,facility,outpatient,,,,,Aetna,National,,563.00,,,,,,,212.24,10865.00,fee schedule,
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED)",490,RC,43270,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTERROGATION DEVICE EVALUATION(S) (REMOTE), UP TO 90 DAYS; SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM, OR LEADLESS PACEMAKER SYSTEM WITH INTERIM ANALYSIS, REVIEW(S) AND REPORT(S) BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",481,RC,93294,CPT,,,,,facility,outpatient,,,,,Aetna,National,,563.00,,,,,,,528.00,10865.00,fee schedule,
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; EACH ADDITIONAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,37247,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT LOWER EXTREMITY ARTERY(IES) FOR OCCLUSIVE DISEASE, INTRACRANIAL, CORONARY, PULMONARY, OR DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME ARTERY; INITIAL ARTERY",481,RC,37246,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",490,RC,43274,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, EACH ADDITIONAL IPSILATERAL ILIAC VESSEL; WITH TRANSLUMINAL ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,37222,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",481,RC,37220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SECONDARY PERCUTANEOUS TRANSLUMINAL THROMBECTOMY (EG, NONPRIMARY MECHANICAL, SNARE BASKET, SUCTION TECHNIQUE), NONCORONARY, NON-INTRACRANIAL, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS, PROVIDED IN CONJUNCTION WITH ANOTHER PERCUTANEOUS INTERVENTION OTHER THAN PRIMARY MECHANICAL THROMBECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,37186,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOMY, COMPLETE",360,RC,29845,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",481,RC,36247,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",481,RC,36246,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPOSITIONING OF PREVIOUSLY IMPLANTED SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE,481,RC,33273,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPOSITIONING OF PREVIOUSLY IMPLANTED CARDIAC VENOUS SYSTEM (LEFT VENTRICULAR) ELECTRODE (INCLUDING REMOVAL, INSERTION AND/OR REPLACEMENT OF EXISTING GENERATOR)",481,RC,33226,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2763.68,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES",490,RC,43450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,434.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OF PACEMAKER PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE LEADS,481,RC,33221,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,50902.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF SINGLE TRANSVENOUS ELECTRODE, PERMANENT PACEMAKER OR IMPLANTABLE DEFIBRILLATOR",481,RC,33218,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE),481,RC,33210,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; INTERNAL APPROACH",360,RC,30117,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER INSERTION OF PERMANENT SINGLE-CHAMBER LEADLESS PACEMAKER, RIGHT ATRIAL, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY AND/OR RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY, CAVOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED",481,RC,0823T,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,3976.00,50902.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE FOR SACROILIAC JOINT; ARTHROGRAPHY,361,RC,G0259,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD",360,RC,30901,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC",360,RC,30930,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM",360,RC,24076,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL)",361,RC,76999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,59.40,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASONIC GUIDANCE, INTRAOPERATIVE",361,RC,76998,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,4610.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)",361,RC,76857,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,59.40,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED",360,RC,31253,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED FLUOROSCOPIC PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL)",361,RC,76496,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,77.31,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FLUOROSCOPY (SEPARATE PROCEDURE), UP TO 1 HOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL TIME",361,RC,76000,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,83.16,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL;",360,RC,31530,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4602.78,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; BURSA",360,RC,23931,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHANGE OF PERCUTANEOUS TUBE OR DRAINAGE CATHETER WITH CONTRAST MONITORING (EG, GENITOURINARY SYSTEM, ABSCESS), RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75984,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,73.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75842,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1968.78,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, RENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75833,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1968.78,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE (WITH OR WITHOUT FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,75726,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1968.78,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UROGRAPHY, ANTEGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,74425,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,173.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERITONEOGRAM (EG, AFTER INJECTION OF AIR OR CONTRAST), RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,74190,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,223.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; PERIPHERAL NERVE (EXCLUDES SACRAL NERVE),361,RC,64555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1610.00,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",361,RC,64454,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND REFILL",361,RC,62369,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,157.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEMENT, INTERLAMINAR EPIDURAL OR SUBARACHNOID, CERVICAL OR THORACIC; WITHOUT IMAGING GUIDANCE",361,RC,62320,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,608.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR MYELOGRAPHY AND/OR COMPUTED TOMOGRAPHY, LUMBAR",361,RC,62284,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING",361,RC,59300,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1362.90,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE",361,RC,55876,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,899.58,3652.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",360,RC,32551,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,363.66,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, SHOULDER",360,RC,23929,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION,360,RC,23660,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH ENDOSCOPIC MUCOSAL RESECTION",490,RC,45390,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT (OTHER THAN HEMODIALYSIS GRAFT OR FISTULA);,360,RC,35875,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE COLUMNS/GROUPS",490,RC,46250,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36216,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SINGLE COLUMN/GROUP;",490,RC,46255,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT (FIRST-ORDER), MAIN RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE AND CATHETER PLACEMENT(S), FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POSTPROCESSING, PERMANENT RECORDING OF IMAGES, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS WHEN PERFORMED, AND FLUSH AORTOGRAM WHEN PERFORMED; BILATERAL",360,RC,36252,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC",361,RC,52351,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1734.48,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",361,RC,52005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1663.00,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT",361,RC,50947,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,2860.00,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23550,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",361,RC,50695,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING CENTRAL VENOUS ACCESS DEVICE, INCLUDING FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT",360,RC,36598,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,152.46,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS",360,RC,36620,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)",361,RC,50389,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,446.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT,360,RC,36825,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER,361,RC,49422,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1241.00,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE",361,RC,48102,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,638.22,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BALLOON DILATION OF BILIARY DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), PERCUTANEOUS, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, EACH DUCT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,47542,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; INTERNAL-EXTERNAL",361,RC,47534,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BILIARY DRAINAGE CATHETER, PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXTERNAL",361,RC,47533,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,2076.00,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF STERNOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;",360,RC,23530,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CHOLECYSTOSTOMY, PERCUTANEOUS, COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CHOLECYSTOGRAM WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,47490,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1925.22,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSCATHETER THERAPY, ARTERIAL INFUSION FOR THROMBOLYSIS OTHER THAN CORONARY OR INTRACRANIAL, ANY METHOD, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION, INITIAL TREATMENT DAY",360,RC,37211,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",361,RC,45381,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",361,RC,45380,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULORRHAPHY, ANTERIOR; WITH LABRAL REPAIR (EG, BANKART PROCEDURE)",360,RC,23455,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPOSITIONING OF A NASO- OR ORO-GASTRIC FEEDING TUBE, THROUGH THE DUODENUM FOR ENTERIC NUTRITION",361,RC,43761,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,213.55,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, VASCULAR SURGERY",361,RC,37799,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,40.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTING GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO-JEJUNOSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, FROM A PERCUTANEOUS APPROACH INCLUDING IMAGE DOCUMENTATION AND REPORT",490,RC,49465,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,133.98,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY",361,RC,37228,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY, UNILATERAL, EACH ADDITIONAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37232,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL/PERONEAL ARTERY, UNILATERAL, EACH ADDITIONAL VESSEL; WITH ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,37233,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8903.51,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES)",360,RC,37241,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, FEMORAL, POPLITEAL ARTERY(S), UNILATERAL; WITH TRANSLUMINAL ANGIOPLASTY",361,RC,37224,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL BALLOON ANGIOPLASTY, CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",361,RC,36907,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY",361,RC,36902,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,2860.00,15217.86,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING 2 CATHETERS VIA 2 SEPARATE VENOUS ACCESS SITES; WITH SUBCUTANEOUS PORT(S)",361,RC,36566,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1898.00,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT",360,RC,23334,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
AXILLARY LYMPHADENECTOMY; COMPLETE,360,RC,38745,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM),490,RC,52318,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS,360,RC,41100,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",361,RC,36246,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF PALATE, UVULA",360,RC,42100,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,492.36,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, SOFT TISSUE OF SHOULDER AREA; SUPERFICIAL",360,RC,23065,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,545.82,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12036,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY",361,RC,36245,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACENTESIS, NEEDLE OR CATHETER, ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE",361,RC,32554,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,542.87,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12",360,RC,42825,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)",361,RC,32551,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,363.66,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA TRACT,361,RC,31502,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,93.06,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION",360,RC,42962,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF BARTHOLIN'S GLAND OR CYST,490,RC,56740,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION",360,RC,43231,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STRAPPING; UNNA BOOT,361,RC,29580,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,74.58,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",360,RC,43242,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES",360,RC,43244,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM",360,RC,12006,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, ILIOCOCCYGEUS)",490,RC,57282,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19737.41,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE",360,RC,43251,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S),360,RC,43275,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF ANKLE IMPLANT,361,RC,27704,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1457.28,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR SACROILIAC JOINT, ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED",361,RC,27096,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA",361,RC,26770,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA",361,RC,26700,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS,361,RC,25608,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,2670.00,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RESECTION, HUMERAL HEAD",361,RC,23195,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,2139.06,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED MUSCULOSKELETAL PROCEDURE, HEAD",361,RC,21499,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,70.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, TEMPOROMANDIBULAR JOINT",361,RC,21010,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1644.06,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY(S)",360,RC,45379,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);",361,RC,19301,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1683.66,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, RECTUM",360,RC,45999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,366.96,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING STEREOTACTIC GUIDANCE",361,RC,19283,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,617.79,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF LIVER, NEEDLE; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,47001,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS",361,RC,17260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); OTHER AREA",361,RC,15839,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1122.66,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM",361,RC,12014,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS",361,RC,12001,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE",490,RC,58263,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM",361,RC,11404,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM",361,RC,11402,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM",361,RC,11307,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,58.08,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE",361,RC,11011,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION, FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM)",360,RC,G0413,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,23040,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK,360,RC,G0121,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,548.46,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK,360,RC,G0105,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,548.46,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,96366,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,33.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM",360,RC,49999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,823.23,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS NEPHROLITHOTOMY OR PYELOLITHOTOMY, LITHOTRIPSY, STONE EXTRACTION, ANTEGRADE URETEROSCOPY, ANTEGRADE STENT PLACEMENT AND NEPHROSTOMY TUBE PLACEMENT, WHEN PERFORMED, INCLUDING IMAGING GUIDANCE; SIMPLE (EG, STONE[S] UP TO 2 CM IN SINGLE LOCATION OF KIDNEY OR RENAL PELVIS, NONBRANCHING STONES)",360,RC,50080,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RIGHT AND LEFT HEART CATHETERIZATION FOR CONGENITAL HEART DEFECT(S) INCLUDING IMAGING GUIDANCE BY THE PROCEDURALIST TO ADVANCE THE CATHETER TO THE TARGET ZONE(S); NORMAL NATIVE CONNECTIONS,360,RC,93596,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,8584.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT",360,RC,93312,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,481.44,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF ACUTE TOTAL/SUBTOTAL OCCLUSION DURING ACUTE MYOCARDIAL INFARCTION, CORONARY ARTERY OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING ASPIRATION THROMBECTOMY WHEN PERFORMED, SINGLE VESSEL",360,RC,92941,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, URETER",360,RC,50949,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)",360,RC,51703,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,73.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER PLACEMENT OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH",360,RC,92928,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HEPATOBILIARY SYSTEM IMAGING, INCLUDING GALLBLADDER WHEN PRESENT;",360,RC,78226,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,276.54,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CAPSULAR CONTRACTURE RELEASE (EG, SEVER TYPE PROCEDURE)",360,RC,23020,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED FLUOROSCOPIC PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL)",360,RC,76496,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,77.31,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, VENOUS SINUS (EG, PETROSAL AND INFERIOR SAGITTAL) OR JUGULAR, CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75860,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,622.38,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,75822,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,622.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,74740,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,212.24,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,73525,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,264.66,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION",360,RC,52250,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW",360,RC,71045,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,77.31,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION",360,RC,69631,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA,360,RC,69205,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL ANESTHESIA,360,RC,69200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,42.90,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, 1 STAGE OR FIRST STAGE",360,RC,67971,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN",360,RC,67966,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH)",360,RC,67900,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS,360,RC,52320,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE,360,RC,67840,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,506.22,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH DRAINAGE ONLY,360,RC,67405,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT LAMP",360,RC,65220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,69.96,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NERVE REPAIR; WITH NERVE ALLOGRAFT, EACH NERVE, FIRST STRAND (CABLE)",360,RC,64912,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,20656.55,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY,490,RC,59150,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS",360,RC,64680,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,781.73,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY WITH INCISION, FULGURATION, OR RESECTION OF CONGENITAL POSTERIOR URETHRAL VALVES, OR CONGENITAL OBSTRUCTIVE HYPERTROPHIC MUCOSAL FOLDS",360,RC,52400,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TRANSURETHRAL INCISION OF PROSTATE,360,RC,52450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND THIRD DIVISION BRANCHES AT FORAMEN OVALE UNDER RADIOLOGIC MONITORING",360,RC,64610,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; PERIPHERAL NERVE (EXCLUDES SACRAL NERVE),360,RC,64555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROTOMY OR URETHROSTOMY, EXTERNAL (SEPARATE PROCEDURE); PERINEAL URETHRA, EXTERNAL",360,RC,53010,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) UNILATERAL; BY INJECTION(S) (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)",360,RC,64486,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING,360,RC,54450,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,210.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM",360,RC,22999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,210.63,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SUTURE OR REPAIR OF TESTICULAR INJURY,360,RC,54670,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS OR HEMATOMA)",360,RC,54700,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RESECTION OF SCROTUM,360,RC,55150,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; PLANTAR COMMON DIGITAL NERVE(S) (EG, MORTON'S NEUROMA)",360,RC,64455,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES",360,RC,64425,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH, METHYLMETHACRYLATE) TO INTERVERTEBRAL DISC SPACE OR VERTEBRAL BODY DEFECT WITHOUT INTERBODY ARTHRODESIS, EACH CONTIGUOUS DEFECT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,22859,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED",360,RC,63663,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,17516.97,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC",360,RC,63016,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL",360,RC,63015,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE),360,RC,57100,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,446.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING",360,RC,62362,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,47173.79,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; 2 OR MORE REGIONS (EG, LUMBAR/THORACIC, CERVICAL/THORACIC, LUMBAR/CERVICAL, LUMBAR/THORACIC/CERVICAL)",360,RC,62305,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYELOGRAPHY VIA LUMBAR INJECTION, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; THORACIC",360,RC,62303,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,693.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC;",360,RC,62270,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,257.40,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT,360,RC,11971,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CRANIECTOMY; WITH EXCISION OF TUMOR OR OTHER BONE LESION OF SKULL,360,RC,61500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4802.00,,,,,,,1232.85,7088.40,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF ISTHMUS",360,RC,60200,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF CERCLAGE SUTURE UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,59871,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL),360,RC,57410,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER",360,RC,59821,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; SINGLE VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,63052,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF ANTERIOR INSTRUMENTATION,360,RC,22855,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DELIVERY OF PLACENTA (SEPARATE PROCEDURE),360,RC,59414,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS)",360,RC,58740,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,4125.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)",360,RC,58720,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE (EG, BAND, CLIP, OR FALOPE RING)",360,RC,58671,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD)",360,RC,58560,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)",360,RC,58559,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS",360,RC,58545,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)",360,RC,58542,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE",360,RC,58353,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF ENTEROCELE",360,RC,58270,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G, ABDOMINAL APPROACH",360,RC,58146,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH",360,RC,58145,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF CERVICAL CANAL, INSTRUMENTAL (SEPARATE PROCEDURE)",360,RC,57800,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH",360,RC,57720,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE)",360,RC,57500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,446.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH,360,RC,57300,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PELVIC FIXATION (ATTACHMENT OF CAUDAL END OF INSTRUMENTATION TO PELVIC BONY STRUCTURES) OTHER THAN SACRUM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,22848,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF PERFORMED); VAGINAL APPROACH",360,RC,57285,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19737.41,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLPOPEXY, ABDOMINAL APPROACH",360,RC,57280,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,4125.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH (EG, KELLY URETHRAL PLICATION)",360,RC,57220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13175.82,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT DEVICE,360,RC,57160,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,104.28,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
COLPOSCOPY OF THE VULVA; WITH BIOPSY(S),360,RC,56821,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,104.28,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,56501,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"HYMENOTOMY, SIMPLE INCISION",360,RC,56442,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8486.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS",490,RC,64517,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOTACTIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE",360,RC,55706,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,913.44,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE PROCEDURE)",360,RC,55500,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS,360,RC,54512,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA,490,RC,69424,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS",360,RC,54406,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
1-STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH URETHROPLASTY BY LOCAL SKIN FLAPS AND MOBILIZATION OF URETHRA,360,RC,54326,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE INTERSPACE; CERVICAL BELOW C2 SEGMENT",360,RC,22600,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,54065,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION",360,RC,54060,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF URETHRAL STRICTURE OR VESICAL NECK BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA",360,RC,53605,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1154.34,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, RESERVOIR, AND CUFF",360,RC,53446,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)",360,RC,53440,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,34677.93,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"URETHROPLASTY, 2-STAGE RECONSTRUCTION OR REPAIR OF PROSTATIC OR MEMBRANOUS URETHRA; FIRST STAGE",360,RC,53420,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); FEMALE,360,RC,53230,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL",490,RC,69706,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)",360,RC,52648,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY; WITH URETERAL MEATOTOMY, UNILATERAL OR BILATERAL",360,RC,52290,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH STEROID INJECTION INTO STRICTURE",360,RC,52283,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS",360,RC,52007,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY OF STERNUM, PARTIAL",360,RC,21620,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,786.83,7701.61,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; SIMPLE",360,RC,51860,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,24681.46,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)",360,RC,51701,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,42.90,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION",360,RC,51050,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE",360,RC,51040,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
URETERONEOCYSTOSTOMY; WITH VESICO-PSOAS HITCH OR BLADDER FLAP,360,RC,50785,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BALLOON DILATION, URETERAL STRICTURE, INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,50706,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITH SEPARATE NEPHROSTOMY CATHETER",360,RC,50695,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; PRE-EXISTING NEPHROSTOMY TRACT",360,RC,50693,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE OF DIGITAL NERVE, HAND OR FOOT; 1 NERVE",360,RC,64831,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE",360,RC,11730,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE OF RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS, AND/OR PALPEBRAL CONJUNCTIVA DIRECT CLOSURE; FULL THICKNESS",360,RC,67935,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,6226.87,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
SNIP INCISION OF LACRIMAL PUNCTUM,360,RC,68440,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,204.60,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION",360,RC,68840,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,133.98,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT,360,RC,21480,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION, 1 OR MORE RENAL TUMOR(S), PERCUTANEOUS, UNILATERAL, RADIOFREQUENCY",360,RC,50592,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS",360,RC,50561,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;",360,RC,50551,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,446.82,13568.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DILATION OF EXISTING TRACT, PERCUTANEOUS, FOR AN ENDOUROLOGIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, WITH POSTPROCEDURE TUBE PLACEMENT, WHEN PERFORMED; INCLUDING NEW ACCESS INTO THE RENAL COLLECTING SYSTEM",360,RC,50437,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,50431,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,586.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM",360,RC,11646,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION PROCEDURE FOR ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM, COMPLETE DIAGNOSTIC PROCEDURE INCLUDING IMAGING GUIDANCE (EG, ULTRASOUND AND FLUOROSCOPY) AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS",360,RC,50430,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,586.07,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,50386,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,446.82,5467.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 3.1 TO 4.0 CM",360,RC,11644,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE, SECONDARY, OF ABDOMINAL WALL FOR EVISCERATION OR DEHISCENCE",360,RC,49900,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF ANTERIOR ABDOMINAL HERNIA(S) (IE, EPIGASTRIC, INCISIONAL, VENTRAL, UMBILICAL, SPIGELIAN), ANY APPROACH (IE, OPEN, LAPAROSCOPIC, ROBOTIC), INITIAL, INCLUDING IMPLANTATION OF MESH OR OTHER PROSTHESIS WHEN PERFORMED, TOTAL LENGTH OF DEFECT(S); GREATER THAN 10 CM, REDUCIBLE",360,RC,49595,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM",360,RC,11642,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE),360,RC,92921,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,6490.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION(S), BONE-SUBSTITUTE MATERIAL (EG, CALCIUM PHOSPHATE) INTO SUBCHONDRAL BONE DEFECT (IE, BONE MARROW LESION, BONE BRUISE, STRESS INJURY, MICROTRABECULAR FRACTURE), INCLUDING IMAGING GUIDANCE AND ARTHROSCOPIC ASSISTANCE FOR JOINT VISUALIZATION",360,RC,0707T,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DELAYED CREATION OF EXIT SITE FROM EMBEDDED SUBCUTANEOUS SEGMENT OF INTRAPERITONEAL CANNULA OR CATHETER,360,RC,49436,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1072.50,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
UNLISTED CARDIOVASCULAR SERVICE OR PROCEDURE,360,RC,93799,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,61.38,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"IMAGE-GUIDED FLUID COLLECTION DRAINAGE BY CATHETER (EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST); VISCERAL (EG, KIDNEY, LIVER, SPLEEN, LUNG/MEDIASTINUM), PERCUTANEOUS",360,RC,49405,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL (IE, PERITONEAL, MESENTERIC, RETROPERITONEAL), PRIMARY OR SECONDARY TUMOR(S) OR CYST(S), SUM OF THE MAXIMUM LENGTH OF TUMOR(S) OR CYST(S); 5 CM OR LESS",360,RC,49186,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT",360,RC,47579,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BALLOON DILATION OF BILIARY DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), PERCUTANEOUS, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, EACH DUCT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,47542,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF STENT(S) INTO A BILE DUCT, PERCUTANEOUS, INCLUDING DIAGNOSTIC CHOLANGIOGRAPHY, IMAGING GUIDANCE (EG, FLUOROSCOPY AND/OR ULTRASOUND), BALLOON DILATION, CATHETER EXCHANGE(S) AND CATHETER REMOVAL(S) WHEN PERFORMED, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; EXISTING ACCESS",360,RC,47538,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ABLATION, 1 OR MORE LIVER TUMOR(S), PERCUTANEOUS, RADIOFREQUENCY",360,RC,47382,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY)",360,RC,46924,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ANOSCOPY; WITH REMOVAL OF FOREIGN BODY,360,RC,46608,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,411.18,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF SINGLE EXTERNAL PAPILLA OR TAG, ANUS",360,RC,46220,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1021.02,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON",360,RC,46060,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF ANAL SETON, OTHER MARKER",360,RC,46030,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,366.96,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PLACEMENT OF SETON,360,RC,46020,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC",360,RC,45990,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS",360,RC,21470,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE,360,RC,21465,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, ANY METHOD",360,RC,45382,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,45331,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,411.18,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS)",360,RC,45171,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,7319.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPENDECTOMY;,360,RC,44950,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,16654.45,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM",361,RC,12005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM",361,RC,12034,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,215.16,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM",361,RC,13132,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE (SINGLE OR MULTIPLE PERFORATIONS); WITHOUT COLOSTOMY",360,RC,44604,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE; SINGLE PERFORATION",360,RC,44602,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,9075.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH PLACEMENT OF PERCUTANEOUS JEJUNOSTOMY TUBE",360,RC,44372,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1042.14,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL",360,RC,0238T,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,47928.08,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESECTION OF SMALL INTESTINE, SINGLE RESECTION AND ANASTOMOSIS",360,RC,44202,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLECTOMY, PARTIAL; WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE)",360,RC,44143,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL",360,RC,44020,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS",360,RC,11440,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,291.72,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, STOMACH",360,RC,43999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,557.70,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, ESOPHAGEAL LENGTHENING PROCEDURE (EG, COLLIS GASTROPLASTY OR WEDGE GASTROPLASTY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,43283,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITH IMPLANTATION OF MESH",360,RC,43282,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,27788.48,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ENDOSCOPIC CANNULATION OF PAPILLA WITH DIRECT VISUALIZATION OF PANCREATIC/COMMON BILE DUCT(S) (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE),360,RC,43273,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)",360,RC,43260,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1630.20,10154.63,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT",360,RC,21390,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES",360,RC,43237,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,835.56,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE",360,RC,43236,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,557.70,4061.89,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBCUTANEOUS; LESS THAN 3 CM",361,RC,21555,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1122.66,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER",360,RC,42831,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)",360,RC,42145,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF LACERATION OF TONGUE, FLOOR OF MOUTH, OVER 2.6 CM OR COMPLEX",360,RC,41252,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,203.91,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
TENODESIS OF LONG TENDON OF BICEPS,361,RC,23430,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,2347.00,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF DEPRESSED FRONTAL SINUS FRACTURE,360,RC,21343,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,13934.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXCISION OF LESION OF TONGUE WITH CLOSURE; POSTERIOR ONE-THIRD,360,RC,41113,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INCISION OF LINGUAL FRENUM (FRENOTOMY),360,RC,41010,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,492.36,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
OPEN TREATMENT OF NASOETHMOID FRACTURE; WITHOUT EXTERNAL FIXATION,360,RC,21338,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
VESTIBULOPLASTY; ANTERIOR,360,RC,40840,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT, OR COMPLEX",360,RC,40654,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,492.36,3953.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION PROCEDURE; RADIOACTIVE TRACER FOR IDENTIFICATION OF SENTINEL NODE,360,RC,38792,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,151.14,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION),360,RC,38724,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,4200.90,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM",360,RC,38589,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15572.44,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DIAGNOSTIC BONE MARROW; BIOPSY(IES),360,RC,38221,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,235.62,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS",360,RC,37765,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS",360,RC,37700,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); EXTREMITY",360,RC,37618,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR WITHOUT STABILIZATION",360,RC,21337,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); NECK",360,RC,37615,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LIGATION, INTERNAL JUGULAR VEIN",360,RC,37565,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, NONCORONARY, NON-INTRACRANIAL, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); SECOND AND ALL SUBSEQUENT VESSEL(S) WITHIN THE SAME VASCULAR FAMILY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY MECHANICAL THROMBECTOMY PROCEDURE)",360,RC,37185,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,3160.85,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, COMPLETE, OF A NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS",360,RC,36580,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,731.94,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER",360,RC,36571,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NON-SELECTIVE CATHETER PLACEMENT, THORACIC AORTA, WITH ANGIOGRAPHY OF THE EXTRACRANIAL CAROTID, VERTEBRAL, AND/OR INTRACRANIAL VESSELS, UNILATERAL OR BILATERAL, AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED",360,RC,36221,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY",360,RC,36215,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR MORE SELECTIVE, BRANCH (EG, LEFT ADRENAL VEIN, PETROSAL SINUS)",360,RC,36012,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER BRANCH (EG, RENAL VEIN, JUGULAR VEIN)",360,RC,36011,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; COMMON FEMORAL",360,RC,35371,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY,360,RC,35236,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,14428.30,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT",360,RC,21242,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSCATHETER CLOSURE OF THE LEFT ATRIAL APPENDAGE WITH ENDOCARDIAL IMPLANT, INCLUDING FLUOROSCOPY, TRANSSEPTAL PUNCTURE, CATHETER PLACEMENT(S), LEFT ATRIAL ANGIOGRAPHY, LEFT ATRIAL APPENDAGE ANGIOGRAPHY, WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION",360,RC,33340,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION, SUBCUTANEOUS CARDIAC RHYTHM MONITOR, INCLUDING PROGRAMMING",360,RC,33285,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,22089.33,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM,360,RC,33263,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,59910.88,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER OR IMPLANTABLE DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE,360,RC,33215,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERICARDIOCENTESIS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",360,RC,33016,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4146.27,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, LARYNX",360,RC,31599,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT)",360,RC,21235,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4540.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S)",360,RC,31545,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE",360,RC,31541,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION); MAXILLARY SINUS OSTIUM, TRANSNASAL OR VIA CANINE FOSSA",360,RC,31295,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION MIDFACE, LEFORT I; 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILATERAL ALVEOLAR CLEFT OR MULTIPLE OSTEOTOMIES)",360,RC,21147,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,13934.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION MIDFACE, LEFORT I; 2 PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT",360,RC,21142,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE)",360,RC,21060,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, NOSE",360,RC,30999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,70.62,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
REPAIR FISTULA; OROMAXILLARY (COMBINE WITH 31030 IF ANTROTOMY IS INCLUDED),360,RC,30580,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
LYSIS INTRANASAL SYNECHIA,360,RC,30560,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,205.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF URETERAL STENT, PERCUTANEOUS, INCLUDING DIAGNOSTIC NEPHROSTOGRAM AND/OR URETEROGRAM WHEN PERFORMED, IMAGING GUIDANCE (EG, ULTRASOUND AND/OR FLUOROSCOPY), AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION; NEW ACCESS, WITHOUT SEPARATE NEPHROSTOMY CATHETER",361,RC,50694,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,2860.00,9205.60,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION[S])",360,RC,21048,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,15789.42,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, WITH OR WITHOUT MANIPULATION; WITH INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY)",360,RC,29851,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,5200.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE",360,RC,29838,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29834,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROSCOPY, SHOULDER, SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY",360,RC,29819,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
APPLICATION OF RIGID TOTAL CONTACT LEG CAST,360,RC,29445,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,169.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, WITH TENDON LENGTHENING AND ADVANCEMENT, MIDTARSAL, TARSAL NAVICULAR-CUNEIFORM (EG, MILLER TYPE PROCEDURE)",360,RC,28737,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ARTHRODESIS; TRIPLE,360,RC,28715,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ARTHRODESIS; PANTALAR,360,RC,28705,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,49084.67,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"THORACIC FASCIAL PLANE BLOCK, BILATERAL; BY INJECTION(S), INCLUDING IMAGING GUIDANCE, WHEN PERFORMED",361,RC,64468,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH",360,RC,28525,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE",360,RC,20902,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MANUAL PREPARATION AND INSERTION OF DRUG-DELIVERY DEVICE(S), INTRA-ARTICULAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,20704,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,28505,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])",360,RC,28446,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (CERVICAL SYMPATHETIC)",361,RC,64510,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,493.02,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED TRANSMURAL INJECTION OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (EG, ANESTHETIC, NEUROLYTIC AGENT) OR FIDUCIAL MARKER(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS)",750,RC,43253,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1665.66,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; OTHER PHALANGES, ANY TOE",360,RC,28312,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE)",360,RC,28310,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INTRALUMINAL DILATION OF STRICTURES AND/OR OBSTRUCTIONS (EG, ESOPHAGUS), RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,74360,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,118.31,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ULTRASOUND, CHEST (INCLUDES MEDIASTINUM), REAL TIME WITH IMAGE DOCUMENTATION",361,RC,76604,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,59.40,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL",360,RC,28306,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE)",360,RC,28238,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS",360,RC,28190,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,545.82,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD",360,RC,28113,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), RADIOLOGICAL SUPERVISION AND INTERPRETATION",361,RC,77012,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,463.06,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBCUTANEOUS; 1.5 CM OR GREATER",360,RC,28039,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT",360,RC,28024,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL TUNNEL",360,RC,20526,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,172.26,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT,361,RC,G0463,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,113.16,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
INJECTION OF SINUS TRACT; DIAGNOSTIC (SINOGRAM),360,RC,20501,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,27784,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION",360,RC,27762,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, ANKLE; REVISION, TOTAL ANKLE",360,RC,27703,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4230.00,,,,,,,1232.85,41271.01,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR OSTEOTOMY",360,RC,27675,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK,360,RC,20102,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS",360,RC,19371,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY",360,RC,27610,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA",360,RC,27603,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)",360,RC,19330,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, OR SUPRACONDYLAR OR TRANSCONDYLAR, WITH OR WITHOUT INTERCONDYLAR EXTENSION, OR DISTAL FEMORAL EPIPHYSEAL SEPARATION",360,RC,27509,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"RECONSTRUCTION OF DISLOCATING PATELLA; (EG, HAUSER TYPE PROCEDURE)",360,RC,27420,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING MAMMOGRAPHIC GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,19282,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE)",360,RC,27418,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE",360,RC,27412,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY WITH MENISCUS REPAIR, KNEE",360,RC,27403,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF OR THROUGH CORONARY ARTERY BYPASS GRAFT (INTERNAL MAMMARY, FREE ARTERIAL, VENOUS), ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AND ANGIOPLASTY, INCLUDING DISTAL PROTECTION WHEN PERFORMED; EACH ADDITIONAL BRANCH SUBTENDED BY THE BYPASS GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",481,RC,92938,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,0.02447,10865.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT",360,RC,27386,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROTOMY, WITH EXCISION OF SEMILUNAR CARTILAGE (MENISCECTOMY) KNEE; MEDIAL OR LATERAL",360,RC,27332,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT ANESTHESIA,360,RC,27265,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), BY ABDUCTION, SPLINT OR TRACTION; WITH MANIPULATION, REQUIRING ANESTHESIA",360,RC,27257,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1020.36,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE;",360,RC,27146,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA",360,RC,26770,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY OF BREAST; OPEN, INCISIONAL",360,RC,19101,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,10220.70,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, EACH",360,RC,26756,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH",360,RC,26725,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,99.00,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION",360,RC,26650,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR TUMORS, ORGAN ISCHEMIA, OR INFARCTION",360,RC,37243,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,30268.98,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION",360,RC,26645,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, LESION OF PALATE, UVULA; WITH SIMPLE PRIMARY CLOSURE",360,RC,42106,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1114.08,8656.04,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT, CATHETER ONLY, OF CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION SITE",360,RC,36578,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,8400.95,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, EACH STENT",360,RC,43274,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,15888.57,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, EXTENSOR, HAND OR FINGER, OPEN, EACH TENDON",360,RC,26460,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE",360,RC,44361,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,682.44,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)",360,RC,44366,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1042.14,5063.24,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BIOPSY, BREAST, WITH PLACEMENT OF BREAST LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING STEREOTACTIC GUIDANCE",360,RC,19081,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COLONOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE RECTUM, SIGMOID, DESCENDING, TRANSVERSE, OR ASCENDING COLON AND CECUM, AND ADJACENT STRUCTURES",360,RC,45392,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,618.42,3147.07,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS;",360,RC,31540,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,9840.80,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"UNLISTED PROCEDURE, PANCREAS",360,RC,48999,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,301.62,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY;",360,RC,31287,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,18476.68,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"INSERTION OF TUNNELED INTRAPERITONEAL CATHETER (EG, DIALYSIS, INTRAPERITONEAL CHEMOTHERAPY INSTILLATION, MANAGEMENT OF ASCITES), COMPLETE PROCEDURE, INCLUDING IMAGING GUIDANCE, CATHETER PLACEMENT, CONTRAST INJECTION WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS",360,RC,49418,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,9419.37,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"TENOTOMY, FLEXOR, FINGER, OPEN, EACH TENDON",360,RC,26455,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1134.54,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS",360,RC,17110,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON",360,RC,26370,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OR ADVANCEMENT, FLEXOR TENDON, NOT IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY OR SECONDARY WITHOUT FREE GRAFT, EACH TENDON",360,RC,26350,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"MANIPULATION, FINGER JOINT, UNDER ANESTHESIA, EACH JOINT",360,RC,26340,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);",360,RC,26123,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, TUMOR, SOFT TISSUE, OR VASCULAR MALFORMATION, OF HAND OR FINGER, SUBFASCIAL (EG, INTRAMUSCULAR); 1.5 CM OR GREATER",360,RC,26113,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4324.56,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
STRAPPING; TOES,360,RC,29550,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,52.15,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DRAINAGE OF TENDON SHEATH, DIGIT AND/OR PALM, EACH",360,RC,26020,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1134.54,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHRODESIS, WRIST; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,25825,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR EPIPHYSEAL SEPARATION,360,RC,25606,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL;",360,RC,57110,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION,360,RC,25565,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,315.00,4271.65,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED",360,RC,25545,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"BLEPHAROPLASTY, LOWER EYELID;",360,RC,15820,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,4882.38,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION)",360,RC,25440,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE;",360,RC,27442,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,34342.69,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-GUIDANCE BASED ON CT/MRI IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,0055T,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,315.00,1717.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH FEMORAL OSTEOTOMY AND WITH OPEN REDUCTION OF HIP",360,RC,27156,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4125.00,,,,,,,1232.85,17079.64,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB; WITH MANIPULATION, EACH",360,RC,26755,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPLACEMENT OR REVISION OF CEREBROSPINAL FLUID SHUNT, OBSTRUCTED VALVE, OR DISTAL CATHETER IN SHUNT SYSTEM",360,RC,62230,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,20656.55,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE",490,RC,11005,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,1232.85,5605.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT)",360,RC,25405,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,19067.25,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",360,RC,15241,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,215.16,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION",360,RC,24640,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,99.00,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"OPEN IMPLANTATION OF CRANIAL NERVE (EG, VAGUS NERVE) NEUROSTIMULATOR ELECTRODE ARRAY AND PULSE GENERATOR",360,RC,64568,CPT,,,,,facility,outpatient,,,,,Aetna,National,,2209.00,,,,,,,1232.85,103676.34,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
DECOMPRESSION; PLANTAR DIGITAL NERVE,360,RC,64726,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,1232.85,5212.13,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS",490,RC,11056,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,58.08,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER (EG, CONTACT GROUP[S], INTERLEAVING, AMPLITUDE, PULSE WIDTH, FREQUENCY [HZ], ON/OFF CYCLING, BURST, MAGNET MODE, DOSE LOCKOUT, PATIENT SELECTABLE PARAMETERS, RESPONSIVE NEUROSTIMULATION, DETECTION ALGORITHMS, CLOSED LOOP PARAMETERS, AND PASSIVE PARAMETERS) BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; WITH SIMPLE CRANIAL NERVE NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER PROGRAMMING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL",360,RC,95976,CPT,,,,,facility,outpatient,,,,,Aetna,National,,4908.00,,,,,,,32.74,4908.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",490,RC,13101,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,315.00,3520.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)",490,RC,13122,CPT,,,,,facility,outpatient,,,,,Aetna,National,,1717.00,,,,,,,78.54,2860.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
"EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG",490,RC,15833,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3520.00,,,,,,,1232.85,7639.06,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
RADIAL STYLOIDECTOMY (SEPARATE PROCEDURE),360,RC,25230,CPT,,,,,facility,outpatient,,,,,Aetna,National,,3678.00,,,,,,,1232.85,8660.15,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,001,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,394296.27,,,,,,,176830.81,445482.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,002,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,159438.43,,,,,,,71503.66,181739.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",003,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,298638.56,,,,,,,133931.01,338059.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",004,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,194889.20,,,,,,,87402.33,221550.36,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,005,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,145068.73,,,,,,,76650.52,165602.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LIVER TRANSPLANT WITHOUT MCC,006,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,65242.59,,,,,,,35158.05,75958.55,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LUNG TRANSPLANT,007,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,182209.31,,,,,,,81715.76,207310.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,008,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,78856.72,,,,,,,42234.47,91247.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PANCREAS TRANSPLANT,010,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,43193.49,,,,,,,25756.46,116071.18,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",011,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,76739.19,,,,,,,34415.37,88869.13,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",012,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,59319.12,,,,,,,26602.96,69306.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",013,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,40546.93,,,,,,,18184.16,48225.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ALLOGENEIC BONE MARROW TRANSPLANT,014,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,169091.85,,,,,,,86963.29,192580.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,016,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,83430.88,,,,,,,43523.96,96383.81,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,017,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,68074.88,,,,,,,39975.02,88524.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,018,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,607582.00,,,,,,,272483.47,685000.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,019,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,93244.70,,,,,,,41817.63,115421.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,020,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,110714.02,,,,,,,49652.13,127022.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,021,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,74483.77,,,,,,,33403.88,86336.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,022,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,43266.66,,,,,,,19403.88,52896.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR ANTINEOPLASTIC IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,023,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,80625.32,,,,,,,36158.19,93233.20,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,024,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,55040.43,,,,,,,24684.09,64501.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,025,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,63972.07,,,,,,,28689.68,74531.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,026,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,43746.44,,,,,,,19619.05,51818.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,027,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,35497.20,,,,,,,15919.50,42554.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SPINAL PROCEDURES WITH MCC,028,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,84536.78,,,,,,,37912.37,97625.75,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,029,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,48001.21,,,,,,,21527.20,56596.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SPINAL PROCEDURES WITHOUT CC/MCC,030,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30886.46,,,,,,,13851.71,37376.97,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VENTRICULAR SHUNT PROCEDURES WITH MCC,031,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,63040.64,,,,,,,28271.96,73485.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VENTRICULAR SHUNT PROCEDURES WITH CC,032,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29983.17,,,,,,,13446.61,36362.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,033,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23397.00,,,,,,,10492.90,28966.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CAROTID ARTERY STENT PROCEDURES WITH MCC,034,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,54460.75,,,,,,,24424.12,63850.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CAROTID ARTERY STENT PROCEDURES WITH CC,035,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,33634.33,,,,,,,15084.06,40462.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,036,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27335.20,,,,,,,12259.07,33388.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EXTRACRANIAL PROCEDURES WITH MCC,037,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,46319.85,,,,,,,20773.15,54708.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EXTRACRANIAL PROCEDURES WITH CC,038,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22829.98,,,,,,,10238.61,28329.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,039,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16539.28,,,,,,,7417.40,21265.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",040,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,54327.08,,,,,,,24364.17,63700.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",041,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30935.71,,,,,,,13873.80,37432.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",042,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24308.74,,,,,,,10901.79,29990.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SPINAL DISORDERS AND INJURIES WITH CC/MCC,052,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25055.86,,,,,,,11236.85,31311.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,053,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13777.34,,,,,,,6178.75,18163.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NERVOUS SYSTEM NEOPLASMS WITH MCC,054,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21483.48,,,,,,,9634.74,26817.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,055,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14345.77,,,,,,,6433.68,18801.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,056,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32686.02,,,,,,,14658.76,39397.84,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,057,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18229.09,,,,,,,8175.24,23162.89,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,058,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24052.67,,,,,,,10786.94,29702.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,059,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17459.46,,,,,,,7830.08,22298.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,060,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12941.59,,,,,,,5803.94,17225.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",061,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,38792.40,,,,,,,17397.30,46255.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",062,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24723.80,,,,,,,11087.93,30456.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",063,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19751.47,,,,,,,8857.98,24872.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,064,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28294.77,,,,,,,12689.41,34466.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,065,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14214.92,,,,,,,6374.99,18655.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,066,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9629.51,,,,,,,4318.56,13505.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,067,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20664.61,,,,,,,9267.50,25897.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,068,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12162.11,,,,,,,5454.36,16349.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,069,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11239.12,,,,,,,5040.43,15313.20,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER CEREBROVASCULAR DISORDERS WITH MCC,070,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23423.74,,,,,,,10504.89,28996.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER CEREBROVASCULAR DISORDERS WITH CC,071,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14435.82,,,,,,,6474.06,18903.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,072,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10639.73,,,,,,,4771.62,14640.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,073,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22572.50,,,,,,,10123.13,28040.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,074,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14503.36,,,,,,,6504.35,18978.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VIRAL MENINGITIS WITH CC/MCC,075,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26979.22,,,,,,,12099.42,32989.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VIRAL MENINGITIS WITHOUT CC/MCC,076,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10535.62,,,,,,,4724.93,15730.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NONTRAUMATIC STUPOR AND COMA WITH MCC,080,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25466.70,,,,,,,11421.10,31290.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,081,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12601.09,,,,,,,5651.24,16842.71,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,082,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32158.39,,,,,,,14422.14,38805.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,083,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19638.91,,,,,,,8807.50,24746.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,084,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13448.11,,,,,,,6031.10,17793.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,085,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,31965.63,,,,,,,14335.69,38588.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,086,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18328.99,,,,,,,8220.04,23275.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,087,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12869.83,,,,,,,5771.76,17144.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CONCUSSION WITH MCC,088,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19019.83,,,,,,,8529.86,24050.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CONCUSSION WITH CC,089,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15457.30,,,,,,,6932.17,20050.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CONCUSSION WITHOUT CC/MCC,090,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11582.42,,,,,,,5194.39,15698.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,091,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24709.73,,,,,,,11081.62,30440.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,092,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14393.61,,,,,,,6455.13,18855.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,093,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11203.94,,,,,,,5024.65,15273.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,094,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,49517.96,,,,,,,22207.41,58299.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,095,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,36289.34,,,,,,,16274.75,43444.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,096,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,36289.34,,,,,,,16274.75,43444.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,097,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,50818.03,,,,,,,22790.46,59759.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,098,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32289.24,,,,,,,14480.82,38952.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,099,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19168.97,,,,,,,8596.74,24218.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SEIZURES WITH MCC,100,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27250.78,,,,,,,12221.21,33294.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12699.58,,,,,,,5695.41,16953.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HEADACHES WITH MCC,102,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15771.06,,,,,,,7072.88,20402.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11766.74,,,,,,,5277.05,15905.73,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,33079.98,,,,,,,14835.44,39840.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19036.71,,,,,,,8537.43,24069.80,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21596.04,,,,,,,9685.22,26943.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25439.97,,,,,,,11409.11,31260.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15264.54,,,,,,,6845.72,19833.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16367.63,,,,,,,7340.42,21072.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11056.21,,,,,,,4958.40,15107.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11236.30,,,,,,,5039.17,15310.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18616.02,,,,,,,8348.76,23597.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10802.95,,,,,,,4844.82,14823.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29760.86,,,,,,,13346.91,36978.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14285.27,,,,,,,6406.54,18734.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21009.32,,,,,,,9422.09,26285.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12468.83,,,,,,,5591.92,16694.16,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17005.00,,,,,,,10032.25,22216.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,60012.77,,,,,,,26914.04,70085.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30688.08,,,,,,,13762.74,37154.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22461.35,,,,,,,10073.28,27915.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,52714.66,,,,,,,23641.05,61889.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24381.90,,,,,,,10934.60,30072.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16916.36,,,,,,,7586.51,21688.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29791.82,,,,,,,13360.79,36147.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17890.01,,,,,,,8023.16,22782.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11215.20,,,,,,,5029.70,15286.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DYSEQUILIBRIUM,149,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10575.01,,,,,,,4742.60,14567.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EPISTAXIS WITH MCC,150,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18734.21,,,,,,,8401.76,23730.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10327.38,,,,,,,4631.54,14289.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16633.55,,,,,,,7459.68,21371.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10386.47,,,,,,,4658.04,14355.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21998.44,,,,,,,9865.68,27395.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12895.16,,,,,,,5783.11,17172.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9723.78,,,,,,,4360.84,13611.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24155.38,,,,,,,10833.01,29818.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12800.89,,,,,,,5740.84,17067.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9968.59,,,,,,,4470.64,13886.44,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,63058.93,,,,,,,28280.16,73506.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,35512.68,,,,,,,15926.44,42572.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26932.79,,,,,,,12078.60,32937.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,52589.44,,,,,,,23584.89,61749.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25373.84,,,,,,,11379.45,31186.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19225.25,,,,,,,8621.98,24281.55,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,41877.95,,,,,,,18781.08,49720.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19326.55,,,,,,,8667.42,24395.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11326.35,,,,,,,5079.55,15411.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21987.19,,,,,,,9860.64,27383.20,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13732.32,,,,,,,6158.56,18113.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10622.85,,,,,,,4764.05,14621.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24847.62,,,,,,,11143.46,30595.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15068.97,,,,,,,6758.01,19614.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10468.08,,,,,,,4694.64,14602.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21525.69,,,,,,,9653.67,26864.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14971.89,,,,,,,6714.47,19505.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11066.06,,,,,,,4962.81,15118.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21928.10,,,,,,,9834.14,27316.81,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13916.64,,,,,,,6241.22,18320.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10091.00,,,,,,,4525.53,14023.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17382.08,,,,,,,7795.37,22211.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15585.34,,,,,,,6989.59,20193.98,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11861.01,,,,,,,5319.33,16011.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9032.94,,,,,,,4051.02,12835.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18493.61,,,,,,,8293.86,23459.97,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11339.01,,,,,,,5085.23,15425.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8843.00,,,,,,,3965.84,12622.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26552.90,,,,,,,11908.23,32510.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13353.84,,,,,,,7962.95,17687.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10076.93,,,,,,,6008.92,14008.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24820.89,,,,,,,11131.47,30565.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15467.15,,,,,,,6936.58,20061.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10061.46,,,,,,,4512.28,13990.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13664.78,,,,,,,6128.27,18037.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9426.90,,,,,,,4227.70,13278.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11360.12,,,,,,,5094.69,15449.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25762.17,,,,,,,11553.61,31622.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13241.28,,,,,,,5938.34,17561.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,90536.23,,,,,,,40602.96,104363.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,38674.21,,,,,,,17344.30,46122.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
COMPLEX AORTIC ARCH PROCEDURES,209,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,159255.52,,,,,,,71421.63,181534.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,152998.59,,,,,,,68615.57,174507.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ENDOVASCULAR ABDOMINAL AORTA WITH ILIAC BRANCH PROCEDURES,213,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,80296.08,,,,,,,36010.54,92863.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,140094.99,,,,,,,62828.67,160017.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,137644.00,,,,,,,61729.47,157264.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,92514.47,,,,,,,41490.14,106584.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,92514.47,,,,,,,41490.14,106584.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,108033.68,,,,,,,48450.07,124012.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,75032.50,,,,,,,33649.97,86952.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,70915.61,,,,,,,31803.66,82329.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,69609.92,,,,,,,31218.09,80863.02,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,44313.46,,,,,,,19873.35,52455.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,118608.69,,,,,,,53192.67,135888.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,85300.78,,,,,,,38255.01,98483.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,107567.96,,,,,,,48241.21,123489.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,76860.19,,,,,,,34469.64,89005.03,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,82571.20,,,,,,,37030.87,95418.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,58936.42,,,,,,,26431.33,68876.80,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,69248.32,,,,,,,31055.93,80456.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,40106.54,,,,,,,17986.65,47731.00,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19478.51,,,,,,,8735.56,24566.00,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,44922.70,,,,,,,20146.57,53139.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29981.76,,,,,,,13445.98,36361.03,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25431.53,,,,,,,11405.33,31251.13,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,64192.97,,,,,,,28788.74,74779.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30707.78,,,,,,,13771.58,37176.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21027.62,,,,,,,9430.30,26305.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,49080.38,,,,,,,22011.17,57808.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,36520.09,,,,,,,16378.24,43703.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25068.52,,,,,,,11242.53,30843.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,37952.42,,,,,,,17020.59,45311.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23889.45,,,,,,,10713.75,29519.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15367.25,,,,,,,6891.78,19949.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,44209.35,,,,,,,19826.65,52338.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28450.95,,,,,,,12759.45,34641.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,45766.90,,,,,,,20525.17,54087.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26599.33,,,,,,,11929.06,32562.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22932.69,,,,,,,10284.67,28444.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,43017.62,,,,,,,19292.19,51000.13,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,47002.24,,,,,,,21079.19,55474.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AICD LEAD PROCEDURES,265,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,50908.07,,,,,,,22830.84,59861.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,86226.59,,,,,,,38670.20,99523.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,66984.46,,,,,,,30040.65,77914.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,96772.05,,,,,,,43399.55,111365.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,59420.42,,,,,,,26648.39,69420.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,74237.54,,,,,,,33293.45,86059.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,50037.14,,,,,,,22440.25,58883.00,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,35920.71,,,,,,,16109.43,43030.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,58045.79,,,,,,,26031.90,67876.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,46314.22,,,,,,,20770.63,54702.18,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,100324.73,,,,,,,44992.82,115355.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,84512.86,,,,,,,37901.65,97598.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,64982.29,,,,,,,29142.74,75666.25,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,78316.43,,,,,,,35122.72,90640.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,50742.05,,,,,,,22756.38,59674.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22569.69,,,,,,,10121.87,28037.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12931.74,,,,,,,5799.52,17213.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10174.02,,,,,,,4562.76,14117.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27869.86,,,,,,,12498.85,33989.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9739.25,,,,,,,4367.78,13628.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8426.52,,,,,,,3779.06,12154.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,31134.10,,,,,,,13962.77,37655.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15056.31,,,,,,,6752.33,19599.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,38076.23,,,,,,,17076.12,45451.02,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24016.08,,,,,,,10770.54,29661.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13080.88,,,,,,,5866.41,17381.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18063.07,,,,,,,8100.78,22976.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11945.43,,,,,,,5357.19,16106.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,7963.62,,,,,,,3571.46,11634.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21975.93,,,,,,,9855.59,27370.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8772.65,,,,,,,3934.28,12709.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,6403.26,,,,,,,2871.68,9882.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22972.09,,,,,,,10302.34,28489.23,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15019.73,,,,,,,6735.93,19558.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10126.18,,,,,,,4541.31,14063.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16836.16,,,,,,,7550.55,21598.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9471.92,,,,,,,4247.89,13328.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HYPERTENSION WITH MCC,304,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16743.30,,,,,,,7508.90,21494.36,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10624.26,,,,,,,4764.68,14622.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22171.51,,,,,,,12458.87,27590.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12848.72,,,,,,,7661.75,17120.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16940.28,,,,,,,7597.24,21715.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10351.30,,,,,,,4642.27,14316.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,7965.03,,,,,,,3572.09,11636.44,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ANGINA PECTORIS,311,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9875.73,,,,,,,4428.99,13782.18,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12263.41,,,,,,,5499.80,16463.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHEST PAIN,313,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10130.40,,,,,,,4543.20,14068.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29338.76,,,,,,,13157.61,35638.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13553.63,,,,,,,6078.42,17912.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9597.15,,,,,,,4304.05,13469.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,94079.05,,,,,,,42191.82,108341.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERCUTANEOUS CORONARY ATHERECTOMY WITHOUT INTRALUMINAL DEVICE,318,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,34080.35,,,,,,,15284.08,40963.71,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,62793.00,,,,,,,28160.90,73207.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,33842.57,,,,,,,15177.44,40696.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,38281.66,,,,,,,17168.25,45681.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24805.41,,,,,,,11124.53,30548.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,60886.52,,,,,,,27305.89,71066.74,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,44334.57,,,,,,,19882.81,52479.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,45170.33,,,,,,,20257.62,53417.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,70172.72,,,,,,,31470.49,81495.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,34389.89,,,,,,,15422.90,41311.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22544.36,,,,,,,10110.51,28008.89,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,64672.75,,,,,,,29003.92,75318.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,33728.60,,,,,,,15126.33,40568.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23678.40,,,,,,,10619.10,29282.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,50943.25,,,,,,,27049.25,59900.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32954.75,,,,,,,14779.28,39699.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23045.25,,,,,,,10335.15,28571.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,50242.56,,,,,,,22532.38,59113.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29669.41,,,,,,,13305.90,36010.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21597.45,,,,,,,9685.85,26945.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,36340.00,,,,,,,16297.47,43501.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21171.13,,,,,,,9494.66,26466.80,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16689.83,,,,,,,7484.92,21434.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32299.09,,,,,,,14485.24,38963.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18414.82,,,,,,,8258.53,23371.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12249.34,,,,,,,5493.49,16447.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,35061.03,,,,,,,15723.89,42064.98,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21449.72,,,,,,,9619.59,26779.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16430.95,,,,,,,7368.82,21143.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,40831.14,,,,,,,18311.62,48544.74,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23671.37,,,,,,,10615.94,29274.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18924.15,,,,,,,8486.95,23943.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,61806.70,,,,,,,27718.57,72100.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32719.78,,,,,,,14673.91,39435.77,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19668.45,,,,,,,8820.75,24779.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITH MCC,359,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,48381.10,,,,,,,21697.57,57023.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PERCUTANEOUS CORONARY ATHERECTOMY WITH INTRALUMINAL DEVICE WITHOUT MCC,360,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,33969.20,,,,,,,15234.23,40838.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22398.03,,,,,,,10044.89,27844.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14072.81,,,,,,,6311.26,18495.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9860.26,,,,,,,4422.05,13764.73,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24947.52,,,,,,,11188.26,30707.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14365.47,,,,,,,6442.51,18824.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10234.52,,,,,,,4589.89,14185.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30091.51,,,,,,,13495.20,36484.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17019.07,,,,,,,7632.58,21804.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13004.90,,,,,,,5832.33,17296.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25719.96,,,,,,,11534.68,31575.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13798.45,,,,,,,6188.22,18187.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8869.73,,,,,,,3977.82,12652.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27608.15,,,,,,,12381.48,33695.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15244.84,,,,,,,6836.89,19811.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11264.44,,,,,,,5051.79,15341.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19426.45,,,,,,,8712.22,24507.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12027.04,,,,,,,5393.79,16198.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22262.96,,,,,,,9984.31,27692.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13736.54,,,,,,,6160.45,18117.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9585.89,,,,,,,4299.00,13456.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20778.58,,,,,,,9318.61,26025.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11112.49,,,,,,,4983.64,15171.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,7654.08,,,,,,,3432.64,11287.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17844.98,,,,,,,8002.97,22731.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10968.97,,,,,,,4919.28,15009.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22502.15,,,,,,,10091.58,27961.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13165.30,,,,,,,5904.27,17476.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9131.43,,,,,,,4095.19,12946.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,33696.24,,,,,,,15111.82,40532.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21296.35,,,,,,,9550.82,26607.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16105.93,,,,,,,7223.06,20778.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,56568.43,,,,,,,25369.35,66217.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,76969.93,,,,,,,34518.86,89128.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,40805.81,,,,,,,18300.26,48516.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,31229.77,,,,,,,14005.68,37762.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,50167.99,,,,,,,22498.94,59029.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30634.61,,,,,,,13738.76,37094.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22338.94,,,,,,,10018.39,27778.20,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,46477.43,,,,,,,20843.82,54885.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29582.17,,,,,,,13266.77,35912.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23363.24,,,,,,,10477.75,28928.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,50125.78,,,,,,,22480.01,58982.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29078.47,,,,,,,13040.88,35346.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19181.63,,,,,,,8602.42,24232.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,33576.65,,,,,,,15058.18,40398.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23800.81,,,,,,,10674.00,29419.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19216.81,,,,,,,8618.20,24272.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,47937.90,,,,,,,21498.80,56525.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24446.62,,,,,,,10963.62,30145.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19690.97,,,,,,,8830.84,24804.57,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,58432.71,,,,,,,30847.19,68311.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30783.75,,,,,,,16826.20,37261.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21109.22,,,,,,,9466.89,26397.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,426,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,155068.28,,,,,,,69543.77,176831.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,101565.70,,,,,,,45549.37,116749.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,79101.54,,,,,,,35474.82,91522.03,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,126765.07,,,,,,,56850.58,145047.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,81143.10,,,,,,,36390.40,93814.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27692.57,,,,,,,12419.34,33790.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14860.73,,,,,,,6664.62,19380.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10024.88,,,,,,,4495.88,13949.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25842.37,,,,,,,11589.58,31712.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15914.58,,,,,,,7137.24,20563.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12005.93,,,,,,,5384.32,16174.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22936.91,,,,,,,10286.56,28449.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11835.68,,,,,,,5307.97,15983.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8743.10,,,,,,,3921.03,12510.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25251.43,,,,,,,11324.56,31048.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13581.77,,,,,,,6091.04,17943.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9844.78,,,,,,,4415.11,13747.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23509.56,,,,,,,10543.38,29092.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15398.21,,,,,,,6905.66,19983.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11640.11,,,,,,,5220.26,15763.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,94010.11,,,,,,,42160.90,108264.18,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,59668.06,,,,,,,26759.45,69698.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,74987.47,,,,,,,33629.78,86901.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,45451.73,,,,,,,20383.82,53733.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,118235.84,,,,,,,53025.45,135469.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,83900.82,,,,,,,37627.16,96911.55,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,58708.48,,,,,,,26329.11,68620.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,75423.64,,,,,,,33825.39,89957.77,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,37426.20,,,,,,,16784.60,44721.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,80191.96,,,,,,,35963.85,92746.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,43823.83,,,,,,,19653.76,51905.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25659.46,,,,,,,11507.55,31507.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,73239.98,,,,,,,32846.07,84939.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,49619.26,,,,,,,22252.85,58413.73,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,38664.36,,,,,,,17339.88,46111.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,42677.12,,,,,,,19139.49,50617.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27139.62,,,,,,,12171.36,33169.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,67939.81,,,,,,,30469.10,78987.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,41451.63,,,,,,,18589.89,49241.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,34349.09,,,,,,,15404.60,41265.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,60401.10,,,,,,,27088.20,70521.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32019.10,,,,,,,14359.67,38648.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16605.41,,,,,,,7447.06,21339.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,48606.22,,,,,,,21798.53,57276.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,34600.94,,,,,,,15517.55,41548.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26154.72,,,,,,,11729.66,32063.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,40976.06,,,,,,,18376.61,48707.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29469.62,,,,,,,13216.30,35785.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22948.17,,,,,,,10291.61,28462.35,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,39000.63,,,,,,,17490.69,46489.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,45405.30,,,,,,,20363.00,53681.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29421.78,,,,,,,13194.84,35732.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22036.43,,,,,,,9882.72,27438.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21437.05,,,,,,,9613.92,30641.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15713.38,,,,,,,7047.01,20337.75,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,51659.41,,,,,,,23167.80,60704.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,35682.93,,,,,,,16002.79,42763.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28231.46,,,,,,,12661.01,34395.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,51013.60,,,,,,,22878.17,59979.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25380.87,,,,,,,11382.61,31194.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16204.42,,,,,,,7267.23,21783.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,42446.38,,,,,,,22740.43,50358.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28348.24,,,,,,,12713.39,34526.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,44528.74,,,,,,,19969.89,52697.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24595.77,,,,,,,11030.51,30312.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18936.81,,,,,,,8492.63,23957.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,39270.78,,,,,,,17611.84,46792.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26299.64,,,,,,,11794.65,32226.02,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25224.70,,,,,,,11312.57,31018.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16878.37,,,,,,,7569.48,24009.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25416.05,,,,,,,11398.38,31233.73,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21307.61,,,,,,,9555.86,26620.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,42498.43,,,,,,,19059.35,50417.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29257.16,,,,,,,13121.01,35547.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23291.48,,,,,,,10445.57,28847.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22150.40,,,,,,,12448.17,27566.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14383.76,,,,,,,8509.66,18844.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,44839.68,,,,,,,20109.34,53046.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29238.87,,,,,,,13112.81,35526.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21621.37,,,,,,,9696.58,26972.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,52583.81,,,,,,,23582.36,61742.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28142.81,,,,,,,12621.26,34295.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21019.17,,,,,,,9426.51,26296.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,40383.71,,,,,,,18110.96,48042.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29796.04,,,,,,,13362.69,36152.44,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22057.54,,,,,,,9892.19,27462.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11341.83,,,,,,,5086.49,15428.55,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18037.74,,,,,,,8089.42,22948.02,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11362.93,,,,,,,5095.96,15452.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13427.00,,,,,,,6021.63,17770.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10134.62,,,,,,,4545.09,14072.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27713.68,,,,,,,12428.81,33813.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18238.94,,,,,,,8179.65,23173.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10855.00,,,,,,,4868.16,15133.07,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24854.65,,,,,,,11146.61,30603.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14463.96,,,,,,,6486.68,18934.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10617.22,,,,,,,4761.53,14614.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,34917.52,,,,,,,15659.53,41903.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16228.34,,,,,,,7277.95,20916.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11765.33,,,,,,,5276.42,15904.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27167.76,,,,,,,12183.98,33200.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16985.30,,,,,,,7617.43,21766.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12298.59,,,,,,,5515.57,16502.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23582.73,,,,,,,10576.19,29174.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13525.49,,,,,,,6065.80,17880.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18238.94,,,,,,,8179.65,23173.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11679.51,,,,,,,5237.93,15807.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18597.73,,,,,,,10646.58,23576.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11686.54,,,,,,,5241.09,15815.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20920.68,,,,,,,9382.34,26185.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12567.32,,,,,,,5636.09,16804.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26239.14,,,,,,,11767.52,32158.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15844.23,,,,,,,7105.69,20484.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11310.87,,,,,,,5072.61,15393.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20046.94,,,,,,,8990.49,25204.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12599.68,,,,,,,5650.60,16841.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21718.45,,,,,,,9740.12,27081.36,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13709.81,,,,,,,6148.46,18087.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10542.65,,,,,,,4728.08,14531.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,41381.28,,,,,,,18558.34,49162.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23771.26,,,,,,,10660.75,29386.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16128.44,,,,,,,7233.15,20803.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,92178.20,,,,,,,41339.33,106207.00,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,48842.60,,,,,,,21904.53,57541.57,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22984.75,,,,,,,10308.02,31085.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,68959.88,,,,,,,30926.57,80133.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,37295.35,,,,,,,16725.92,44574.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22602.05,,,,,,,10136.38,28073.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,45565.69,,,,,,,20434.94,53861.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24312.96,,,,,,,10903.68,29994.98,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20304.42,,,,,,,9105.96,25493.48,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27107.26,,,,,,,12156.85,33132.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24262.31,,,,,,,10880.96,29938.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30119.65,,,,,,,13507.82,36515.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27142.44,,,,,,,12172.62,33172.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27229.67,,,,,,,12211.74,33270.40,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN ULCERS WITH CC,593,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16691.24,,,,,,,7485.55,21435.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12195.88,,,,,,,5469.51,16387.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29838.25,,,,,,,13381.62,36199.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15230.77,,,,,,,6830.57,19795.81,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23456.10,,,,,,,10519.40,29032.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15917.39,,,,,,,7138.50,20566.84,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10316.12,,,,,,,4626.49,14848.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14655.31,,,,,,,6572.50,19149.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8512.35,,,,,,,3817.55,12251.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CELLULITIS WITH MCC,602,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19997.69,,,,,,,8968.40,25149.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12253.56,,,,,,,5495.38,16452.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20712.45,,,,,,,9288.95,25951.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12888.12,,,,,,,5779.96,17165.03,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21290.72,,,,,,,9548.29,26601.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12753.05,,,,,,,5719.38,17013.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30838.63,,,,,,,13830.26,37323.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19688.15,,,,,,,8829.58,24801.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,49067.72,,,,,,,22005.49,57794.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26315.12,,,,,,,11801.59,32243.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19955.48,,,,,,,8949.47,25101.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,40625.72,,,,,,,18219.49,48314.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22516.22,,,,,,,10097.89,27977.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21223.19,,,,,,,9518.00,26525.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,50077.94,,,,,,,26610.44,58928.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25240.17,,,,,,,11319.51,31036.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17614.23,,,,,,,7899.49,22472.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,42492.81,,,,,,,22763.96,50410.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21096.56,,,,,,,11913.76,26383.02,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18689.18,,,,,,,8381.57,23679.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,52436.08,,,,,,,23516.11,61576.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30655.72,,,,,,,13748.23,37117.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20535.17,,,,,,,9209.44,25752.55,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DIABETES WITH MCC,637,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20214.37,,,,,,,9065.58,25392.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DIABETES WITH CC,638,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12609.53,,,,,,,5655.02,16852.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8740.28,,,,,,,3919.77,12507.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18791.89,,,,,,,8427.64,23794.89,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10949.27,,,,,,,4910.44,14987.71,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20008.95,,,,,,,8973.45,25161.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23160.63,,,,,,,10386.89,28700.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14421.75,,,,,,,6467.75,18887.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10809.98,,,,,,,4847.97,14831.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,66148.70,,,,,,,29665.83,76976.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,52140.61,,,,,,,23383.60,61245.16,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY TRANSPLANT,652,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,45439.07,,,,,,,24864.48,53719.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,73113.35,,,,,,,38291.86,84797.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,39386.15,,,,,,,21188.55,46922.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29780.56,,,,,,,13355.75,36135.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,44796.07,,,,,,,20089.78,52997.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25748.10,,,,,,,11547.30,31606.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21833.83,,,,,,,9791.86,27210.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,35750.46,,,,,,,16033.08,42839.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18596.32,,,,,,,8339.93,23575.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14568.08,,,,,,,6533.37,19051.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,43075.31,,,,,,,19318.06,51064.93,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21389.21,,,,,,,9592.46,26711.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14729.88,,,,,,,6605.94,19233.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,43915.28,,,,,,,19694.77,52008.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24612.65,,,,,,,11038.08,30331.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15564.23,,,,,,,6980.12,20170.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,41084.40,,,,,,,22049.75,48829.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21836.64,,,,,,,9793.12,27214.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13750.61,,,,,,,6166.76,18133.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25255.65,,,,,,,14022.86,31053.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15188.57,,,,,,,8917.77,19748.40,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,59116.51,,,,,,,31193.97,69079.05,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32904.10,,,,,,,14756.57,39642.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23094.50,,,,,,,10357.23,28626.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20837.67,,,,,,,9345.11,26092.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RENAL FAILURE WITH CC,683,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12322.51,,,,,,,5526.30,16529.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8446.22,,,,,,,3787.89,12176.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25378.06,,,,,,,11381.35,31191.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14742.55,,,,,,,6611.62,19247.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11119.52,,,,,,,4986.79,15178.89,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16325.42,,,,,,,7321.49,21025.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11389.67,,,,,,,5107.94,15482.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
URINARY STONES WITH MCC,693,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18917.12,,,,,,,8483.80,23935.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10998.52,,,,,,,4932.53,15043.01,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16093.27,,,,,,,7217.38,20764.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9694.23,,,,,,,4347.59,13578.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
URETHRAL STRICTURE,697,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15164.65,,,,,,,6800.92,19721.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23277.41,,,,,,,10439.26,28832.13,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14281.05,,,,,,,6404.65,18729.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9706.89,,,,,,,4353.27,13592.56,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28144.22,,,,,,,12621.89,34297.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21586.19,,,,,,,9680.80,26932.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32742.30,,,,,,,14684.00,39461.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19714.88,,,,,,,8841.57,24831.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29319.07,,,,,,,16083.46,35616.82,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15472.78,,,,,,,6939.11,20067.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21152.84,,,,,,,9486.45,26446.18,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14877.62,,,,,,,6672.19,19399.22,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,31478.81,,,,,,,17178.68,38042.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20696.97,,,,,,,9282.01,25934.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26599.33,,,,,,,14704.27,32562.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18897.42,,,,,,,8474.96,23913.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25462.48,,,,,,,14127.76,31285.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16077.79,,,,,,,9368.70,20746.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8606.62,,,,,,,3859.83,13052.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16464.71,,,,,,,7383.96,21181.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10158.54,,,,,,,4555.82,14099.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20864.40,,,,,,,9357.10,26122.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11413.58,,,,,,,5118.67,15509.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14895.91,,,,,,,6680.40,19419.77,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9455.04,,,,,,,4240.32,13309.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29969.10,,,,,,,16413.10,36346.81,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18931.19,,,,,,,8490.10,23951.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,50293.21,,,,,,,22555.10,59170.58,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28992.64,,,,,,,13002.39,35250.23,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20661.79,,,,,,,9266.24,25894.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,49615.04,,,,,,,22250.95,59301.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25461.07,,,,,,,11418.58,31284.31,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20065.23,,,,,,,8998.69,25224.84,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25815.64,,,,,,,11577.59,31682.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17456.65,,,,,,,7828.82,22295.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28830.84,,,,,,,12929.82,35068.53,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16004.62,,,,,,,7177.62,20664.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24441.00,,,,,,,10961.10,30138.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11811.76,,,,,,,5297.24,16275.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19519.31,,,,,,,8753.86,24611.80,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,36126.13,,,,,,,16201.56,43261.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20764.51,,,,,,,9312.30,26010.12,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25912.72,,,,,,,14356.07,31791.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15305.35,,,,,,,8977.00,19879.57,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13514.24,,,,,,,6060.76,17868.16,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20146.83,,,,,,,9035.29,25316.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13774.53,,,,,,,6177.49,18160.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9336.85,,,,,,,4187.32,13176.98,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14175.52,,,,,,,6357.32,18610.75,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8014.27,,,,,,,3594.18,11705.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15077.41,,,,,,,2575.00,15077.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23775.49,,,,,,,10662.64,29391.42,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14107.99,,,,,,,6327.04,18534.92,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9211.63,,,,,,,4131.16,13036.36,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ABORTION WITHOUT D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10033.32,,,,,,,4499.66,15984.73,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,34543.26,,,,,,,4570.00,34543.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14915.61,,,,,,,4570.00,14915.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13476.25,,,,,,,4570.00,13476.25,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23208.47,,,,,,,4570.00,23208.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15713.38,,,,,,,4570.00,15713.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13490.32,,,,,,,4570.00,13490.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25356.95,,,,,,,11371.88,31167.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,83625.04,,,,,,,37503.49,96601.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,57110.13,,,,,,,25612.29,66825.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,34460.24,,,,,,,15454.45,41390.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,58666.27,,,,,,,26310.18,68573.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20765.91,,,,,,,9312.93,26011.69,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NORMAL NEWBORN,795,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,2811.19,,,,,,,909.00,5848.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16419.69,,,,,,,2575.00,17901.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14075.63,,,,,,,2575.00,15346.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13466.40,,,,,,,2575.00,14681.91,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,63721.62,,,,,,,28577.36,74250.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,39528.26,,,,,,,17727.31,47081.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26858.22,,,,,,,12045.16,32853.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,56056.29,,,,,,,25139.67,65642.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26154.72,,,,,,,11729.66,32063.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19078.92,,,,,,,8556.36,24117.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15184.34,,,,,,,2575.00,15184.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10608.78,,,,,,,2575.00,10608.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9485.99,,,,,,,2575.00,9485.99,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,31065.15,,,,,,,13931.85,37577.67,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17811.21,,,,,,,7987.83,22693.60,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14725.66,,,,,,,6604.05,19228.57,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19758.50,,,,,,,8861.13,24880.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12919.07,,,,,,,5793.84,17199.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
COAGULATION DISORDERS,813,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21460.97,,,,,,,9624.64,26792.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29922.67,,,,,,,13419.48,36294.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14266.98,,,,,,,6398.34,18713.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8892.24,,,,,,,3987.92,12677.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23750.16,,,,,,,10651.28,38742.15,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14832.59,,,,,,,6652.00,21007.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12098.79,,,,,,,5425.97,16278.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,82517.74,,,,,,,43060.90,95358.36,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,31497.10,,,,,,,17187.95,38062.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16940.28,,,,,,,7597.24,21715.54,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,64508.14,,,,,,,33928.09,75133.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,31876.99,,,,,,,14295.94,38489.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18986.06,,,,,,,8514.71,24012.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,65816.65,,,,,,,29516.92,76603.23,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32518.58,,,,,,,14583.67,39209.83,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23972.47,,,,,,,10750.98,29612.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,44461.20,,,,,,,19939.60,52621.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21175.35,,,,,,,9496.55,26471.51,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16919.17,,,,,,,7587.77,21691.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10152.91,,,,,,,4553.30,14093.41,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,7357.20,,,,,,,3299.50,10953.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ACUTE LEUKEMIA WITH MCC,834,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,77242.89,,,,,,,34641.27,89434.80,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ACUTE LEUKEMIA WITH CC,835,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29347.21,,,,,,,13161.40,35648.40,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ACUTE LEUKEMIA WITHOUT CC/MCC,836,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17158.37,,,,,,,7695.05,21960.47,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,67596.50,,,,,,,35494.22,78601.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29369.72,,,,,,,16109.15,35673.71,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20315.67,,,,,,,11517.77,25506.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,45515.04,,,,,,,20412.22,53804.71,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22953.80,,,,,,,10294.13,28468.68,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14216.33,,,,,,,6375.62,18656.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28066.84,,,,,,,12587.19,34210.57,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17128.82,,,,,,,7681.79,21927.29,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11982.01,,,,,,,5373.60,16147.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,36476.47,,,,,,,16358.67,43654.50,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18406.37,,,,,,,8254.74,23361.98,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11951.06,,,,,,,5359.71,16112.70,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
RADIOTHERAPY,849,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,38122.67,,,,,,,17096.94,45503.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,121839.16,,,,,,,54641.44,139515.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,69486.10,,,,,,,31162.57,80723.97,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28113.27,,,,,,,12608.01,34262.74,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21065.60,,,,,,,9447.33,26348.28,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,64000.21,,,,,,,28702.30,74563.37,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,30130.90,,,,,,,13512.86,36528.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19598.10,,,,,,,8789.20,24700.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25659.46,,,,,,,11507.55,31507.11,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14040.45,,,,,,,6296.75,18459.08,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12489.94,,,,,,,5601.39,16717.86,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21081.08,,,,,,,9454.27,26365.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12235.27,,,,,,,5487.18,16431.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29451.32,,,,,,,13208.09,35765.33,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14507.58,,,,,,,6506.24,18983.65,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,10266.88,,,,,,,4604.41,14221.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,97249.03,,,,,,,43613.46,111901.45,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27330.97,,,,,,,12257.17,33384.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14397.83,,,,,,,6457.02,18860.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,54379.14,,,,,,,24387.52,63759.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13510.01,,,,,,,720.00,17863.40,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13238.46,,,,,,,720.00,17558.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15108.37,,,,,,,720.00,19658.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,27665.84,,,,,,,720.00,33760.25,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22637.22,,,,,,,720.00,28113.19,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
PSYCHOSES,885,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19652.98,,,,,,,720.00,24761.87,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,29199.47,,,,,,,720.00,35482.49,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,15067.56,,,,,,,720.00,19612.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8679.78,,,,,,,720.00,12439.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,19917.49,,,,,,,720.00,25058.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24553.56,,,,,,,720.00,30265.20,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12421.00,,,,,,,720.00,16640.46,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,59046.16,,,,,,,26480.55,69000.03,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,26937.01,,,,,,,12080.50,32941.77,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16456.27,,,,,,,7380.18,21172.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,51680.52,,,,,,,27423.13,60728.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,20145.43,,,,,,,11799.58,26130.17,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24796.97,,,,,,,11120.74,33728.63,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,54018.95,,,,,,,24225.98,63354.52,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28072.46,,,,,,,12589.71,34216.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18469.69,,,,,,,8283.14,23433.06,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22998.82,,,,,,,10314.33,28519.24,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12458.99,,,,,,,5587.51,16683.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23660.11,,,,,,,10610.90,29261.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9374.84,,,,,,,4204.35,13219.66,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,22067.39,,,,,,,9896.60,27473.26,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12059.40,,,,,,,5408.30,16234.34,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,25759.36,,,,,,,11552.35,31619.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14102.36,,,,,,,6324.51,18528.61,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,9685.79,,,,,,,4343.80,13568.84,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24614.06,,,,,,,11038.71,30333.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,14319.04,,,,,,,6421.69,18771.94,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,259312.91,,,,,,,153551.43,340039.64,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,100919.89,,,,,,,52392.77,116023.79,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,45316.66,,,,,,,24195.95,53581.93,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,53700.97,,,,,,,29000.66,64221.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,31103.14,,,,,,,16988.17,37620.30,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28984.20,,,,,,,15913.64,35240.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,51053.00,,,,,,,22895.83,60023.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,32880.18,,,,,,,14745.84,39615.90,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,28529.74,,,,,,,12794.79,34730.38,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21788.80,,,,,,,9771.67,27160.40,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16135.48,,,,,,,7236.31,20811.76,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17860.46,,,,,,,8009.91,22748.89,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,11263.03,,,,,,,5051.15,15340.04,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16739.08,,,,,,,7507.01,21489.62,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,8831.74,,,,,,,3960.79,12609.74,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,7822.92,,,,,,,3508.36,11476.85,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,94706.58,,,,,,,42473.24,109046.32,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,52945.41,,,,,,,23744.53,62148.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,107211.99,,,,,,,48081.57,123089.77,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,59289.57,,,,,,,26589.71,69273.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,41423.49,,,,,,,18577.27,49209.95,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,38464.57,,,,,,,17250.28,45887.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,21563.68,,,,,,,9670.71,26907.59,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,13232.83,,,,,,,5934.56,17552.10,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,86126.69,,,,,,,38625.40,99411.21,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,37108.22,,,,,,,16641.99,44363.96,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,40606.02,,,,,,,18210.66,48291.93,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,18220.65,,,,,,,8171.45,23153.39,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,12585.61,,,,,,,5644.30,16954.88,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,17835.13,,,,,,,7998.56,23196.09,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,66013.63,,,,,,,29605.26,76824.44,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,34591.10,,,,,,,15513.14,41537.27,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,24115.98,,,,,,,10815.34,29773.78,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,48237.59,,,,,,,21633.20,56862.14,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,23125.45,,,,,,,10371.12,28661.43,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,,,facility,inpatient,,,,,Aetna,National,,16872.74,,,,,,,7566.95,21639.72,case rate,"Claims that exceed $301,526 in charges are subject to a stop loss reimbursement at 41.82% of charges."
Hetastarch 6% -NS 500mL,8724320,CDM,250,RC,,,,,facility,outpatient,,,356.81000,103.47000,Aetna,National,,190.54,,,,,,,128.63,291.87,percent of total billed charges,
ePHEDrine 50mg/mL 1mL Inj,8726055,CDM,250,RC,,,,,facility,outpatient,,,263.15000,76.31000,Aetna,National,,140.52,,,,,,,94.87,215.26,percent of total billed charges,
Dornase Alfa 2.5mg/2.5mL Inhl UD,8724890,CDM,250,RC,,,,,facility,outpatient,,,703.25000,203.94000,Aetna,National,,375.54,,,,,,,253.52,575.26,percent of total billed charges,
Rocuronium Bromide 50mg/5mL IS -Anesth,8725160,CDM,250,RC,,,,,facility,outpatient,,,48.33000,14.02000,Aetna,National,,25.81,,,,,,,17.42,39.53,percent of total billed charges,
Lidocaine-Prilocaine 2.5%-2.5% TC UD,8724697,CDM,250,RC,,,,,facility,outpatient,,,341.10000,98.92000,Aetna,National,,182.15,,,,,,,122.97,279.02,percent of total billed charges,
Cupric Cl (Copper) I 10mL,8723455,CDM,250,RC,,,,,facility,outpatient,,,197.42000,57.25000,Aetna,National,,105.42,,,,,,,71.17,161.49,percent of total billed charges,
Guaifenesin-DM 600-30mg/ ER T,8724717,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,National,,5.34,,,,,,,3.60,8.18,percent of total billed charges,
PrismaSol BGK 4/2.5 - 5L,8725288,CDM,250,RC,,,,,facility,outpatient,,,490.00000,142.10000,Aetna,National,,261.66,,,,,,,176.65,400.82,percent of total billed charges,
Sodium Chloride 23.4% Inj 30mL,8725323,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
dexmedeTOMIDine 4mcg/mL IV 100mL,8725332,CDM,250,RC,,,,,facility,outpatient,,,238.49000,69.16000,Aetna,National,,127.35,,,,,,,85.98,195.08,percent of total billed charges,
Sodium Bicarb 50mEq/50mL IS,8725361,CDM,250,RC,,,,,facility,outpatient,,,114.23000,33.13000,Aetna,National,,61.00,,,,,,,41.18,93.44,percent of total billed charges,
Calamine-Zinc Oxide 8% Topical Lotion,8725867,CDM,250,RC,,,,,facility,outpatient,,,16.65000,4.83000,Aetna,National,,8.89,,,,,,,6.00,13.62,percent of total billed charges,
Carbamide 6.5% 15mL Otic Soln(Debrox),8723468,CDM,250,RC,,,,,facility,outpatient,,,16.10000,4.67000,Aetna,National,,8.60,,,,,,,5.80,13.17,percent of total billed charges,
Potassium Phosphate Inj 5mL,8725748,CDM,250,RC,,,,,facility,outpatient,,,94.55000,27.42000,Aetna,National,,50.49,,,,,,,34.09,77.34,percent of total billed charges,
NS (Sterile Field) IS 10mL,8725796,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
Acetic Acid 3% TS 30mL,8725773,CDM,250,RC,,,,,facility,outpatient,,,30.20000,8.76000,Aetna,National,,16.13,,,,,,,10.89,24.70,percent of total billed charges,
Mannitol 20% 500mL,8723714,CDM,250,RC,,,,,facility,outpatient,,,194.35000,56.36000,Aetna,National,,103.78,,,,,,,70.06,158.98,percent of total billed charges,
Poractant 120mg/1.5mL Intratrach I(Curosurf),8725823,CDM,250,RC,,,,,facility,outpatient,,,2576.30000,747.13000,Aetna,National,,1375.74,,,,,,,928.76,2107.41,percent of total billed charges,
PrismaSol BGK 2/3.5 - 5L,8725381,CDM,250,RC,,,,,facility,outpatient,,,490.00000,142.10000,Aetna,National,,261.66,,,,,,,176.65,400.82,percent of total billed charges,
Norepinephrine 4mg/NS 250mL PF,8725393,CDM,250,RC,,,,,facility,outpatient,,,330.83000,95.94000,Aetna,National,,176.66,,,,,,,119.26,270.62,percent of total billed charges,
Sodium Nitroprusside 50mg/2mL - for IV Set,8725432,CDM,250,RC,,,,,facility,outpatient,,,3313.25000,960.84000,Aetna,National,,1769.28,,,,,,,1194.43,2710.24,percent of total billed charges,
Labetalol 100mg/20mL - for IV Set,8725436,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
Isoproterenol HCl 1mg/5mL Inj - for IV Set,8725438,CDM,250,RC,,,,,facility,outpatient,,,12883.50000,3736.21000,Aetna,National,,6879.79,,,,,,,4644.50,10538.70,percent of total billed charges,
Norepinephrine 8mg/8mL Inj - IV Set Use,8725440,CDM,250,RC,,,,,facility,outpatient,,,360.98000,104.68000,Aetna,National,,192.76,,,,,,,130.13,295.28,percent of total billed charges,
Hip/Knee Periarticular Syringe,8725500,CDM,250,RC,,,,,facility,outpatient,,,533.80000,154.80000,Aetna,National,,285.05,,,,,,,192.43,436.65,percent of total billed charges,
Nitroglycerin 40mcg/mL D5W Vial - OR Use ONLY,8725526,CDM,250,RC,,,,,facility,outpatient,,,79.70000,23.11000,Aetna,National,,42.56,,,,,,,28.73,65.19,percent of total billed charges,
Lidocaine 4% Topical Trach Kit,8725574,CDM,250,RC,,,,,facility,outpatient,,,253.50000,73.52000,Aetna,National,,135.37,,,,,,,91.39,207.36,percent of total billed charges,
HYDROmorphone 1mg/1mL Oral Soln,8725580,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
Amino Acids (for TPN/PPN),8725685,CDM,250,RC,,,,,facility,outpatient,,,57.00000,16.53000,Aetna,National,,30.44,,,,,,,20.55,46.63,percent of total billed charges,
Dextrose (For TPN/PPN),8725686,CDM,250,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,National,,26.70,,,,,,,18.02,40.90,percent of total billed charges,
Sugammadex 100mg/mL Inj 2mL(Bridion SD),8725653,CDM,250,RC,,,,,facility,outpatient,,,714.10000,207.09000,Aetna,National,,381.33,,,,,,,257.43,584.13,percent of total billed charges,
Mineral Oil Light 10mL(Muri-Lube),8723421,CDM,250,RC,,,,,facility,outpatient,,,194.90000,56.52000,Aetna,National,,104.08,,,,,,,70.26,159.43,percent of total billed charges,
Clotrimazole 1% 45g VC(Gyne-Lotr,8724133,CDM,250,RC,,,,,facility,outpatient,,,56.65000,16.43000,Aetna,National,,30.25,,,,,,,20.42,46.34,percent of total billed charges,
Bupivacaine-Epi 0.5% 30mL I PF,8723539,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
BUPivacaine 0.25% 30mL I PF,8723536,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
BUPivacaine 0.5% 30mL I PF,8723537,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
Sugammadex 100mg/mL Inj 5mL(Bridion SD),8725829,CDM,250,RC,,,,,facility,outpatient,,,1183.45000,343.20000,Aetna,National,,631.96,,,,,,,426.63,968.06,percent of total billed charges,
dilTIAZem 5mg/mL Inj 5mL,8725830,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
NUTR- Isosource HN (250mL),8725911,CDM,250,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,National,,26.70,,,,,,,18.02,40.90,percent of total billed charges,
Citric Acid/MgOx/Na pico Oral Soln,9005005,CDM,250,RC,,,,,facility,outpatient,,,1395.45000,404.68000,Aetna,National,,745.17,,,,,,,503.06,1141.48,percent of total billed charges,
NS 3000mL Irrigation - Bag,8725935,CDM,250,RC,,,,,facility,outpatient,,,87.80000,25.46000,Aetna,National,,46.89,,,,,,,31.65,71.82,percent of total billed charges,
Bupivacaine-Epi 0.5% 10mL I PF,8723416,CDM,250,RC,,,,,facility,outpatient,,,50.10000,14.53000,Aetna,National,,26.75,,,,,,,18.06,40.98,percent of total billed charges,
Sod Hyaluronate 10mg/mL 0.85mL Ophth inj,8723981,CDM,250,RC,,,,,facility,outpatient,,,751.85000,218.04000,Aetna,National,,401.49,,,,,,,271.04,615.01,percent of total billed charges,
Calcium Cl 1g/10mL (10%) Inj,8723426,CDM,250,RC,,,,,facility,outpatient,,,197.15000,57.17000,Aetna,National,,105.28,,,,,,,71.07,161.27,percent of total billed charges,
Potassium Phosphate Inj 15mL,8723469,CDM,250,RC,,,,,facility,outpatient,,,150.90000,43.76000,Aetna,National,,80.58,,,,,,,54.40,123.44,percent of total billed charges,
NS Bacteriostatic 0.9% 30mL I,8723541,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
Labetalol 5mg/mL 4mL I(Normodyne),8726135,CDM,250,RC,,,,,facility,outpatient,,,28.43000,8.24000,Aetna,National,,15.18,,,,,,,10.25,23.26,percent of total billed charges,
aminolevulinic acid 50mL REC Pwd Oral Soln,8726098,CDM,250,RC,,,,,facility,outpatient,,,17287.80000,5013.46000,Aetna,National,,9231.69,,,,,,,6232.25,14141.42,percent of total billed charges,
nirmatrelvir-ritonavir 300mg-100mg Dose Tab,8726145,CDM,250,RC,,,,,facility,outpatient,,,1091.85000,316.64000,Aetna,National,,583.05,,,,,,,393.61,893.13,percent of total billed charges,
NS Bacteriostatic 0.9% 10mL I,8726150,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
Lidocaine 2% Topical Jelly w/ Appl,8974995,CDM,250,RC,,,,,facility,outpatient,,,50.60000,14.67000,Aetna,National,,27.02,,,,,,,18.24,41.39,percent of total billed charges,
docusate/phosphate/water 250mL enema,8984010,CDM,250,RC,,,,,facility,outpatient,,,138.80000,40.25000,Aetna,National,,74.12,,,,,,,50.04,113.54,percent of total billed charges,
Sodium Chloride 7% Inhalation Soln,8986201,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,National,,5.34,,,,,,,3.60,8.18,percent of total billed charges,
etomidate 2mg/mL 20mL Inj,8986277,CDM,250,RC,,,,,facility,outpatient,,,25.55000,7.41000,Aetna,National,,13.64,,,,,,,9.21,20.90,percent of total billed charges,
sodium citrate 4%(120mg/3mL) IS,8986968,CDM,250,RC,,,,,facility,outpatient,,,77.20000,22.39000,Aetna,National,,41.22,,,,,,,27.83,63.15,percent of total billed charges,
Ethiodized Oil 480 mg/mL Inj Soln 10mL,8990224,CDM,250,RC,,,,,facility,outpatient,,,4628.20000,1342.18000,Aetna,National,,2471.46,,,,,,,1668.47,3785.87,percent of total billed charges,
trace elements (Cu/Mn/Se/Zn) 0.3mg-55mcg-60mcg-3mg/mL I,9000947,CDM,250,RC,,,,,facility,outpatient,,,166.88000,48.40000,Aetna,National,,89.11,,,,,,,60.16,136.51,percent of total billed charges,
Etomidate 2mg/mL 10mL Inj,8723404,CDM,250,RC,,,,,facility,outpatient,,,28.75000,8.34000,Aetna,National,,15.35,,,,,,,10.36,23.52,percent of total billed charges,
Sodium Bicarb 10mEq/10mL IS,8723394,CDM,250,RC,,,,,facility,outpatient,,,89.70000,26.01000,Aetna,National,,47.90,,,,,,,32.34,73.37,percent of total billed charges,
nirmatrelvir-ritonavir 150 mg-100 mg (Renal Dose) Tab,9090588,CDM,250,RC,,,,,facility,outpatient,,,1091.85000,316.64000,Aetna,National,,583.05,,,,,,,393.61,893.13,percent of total billed charges,
Norepinephrine 8mg/NS 250mL-Dbl Conc,9098880,CDM,250,RC,,,,,facility,outpatient,,,481.00000,139.49000,Aetna,National,,256.85,,,,,,,173.40,393.46,percent of total billed charges,
ePHEDrine sulfate 25mg/5mL IS,9115161,CDM,250,RC,,,,,facility,outpatient,,,78.85000,22.87000,Aetna,National,,42.11,,,,,,,28.43,64.50,percent of total billed charges,
Ketamine 10mg/mL Inj 10mL,9144896,CDM,250,RC,,,,,facility,outpatient,,,88.00000,25.52000,Aetna,National,,46.99,,,,,,,31.72,71.98,percent of total billed charges,
Ketamine 500mg/NS 250mL IV,9160464,CDM,250,RC,,,,,facility,outpatient,,,81.70000,23.69000,Aetna,National,,43.63,,,,,,,29.45,66.83,percent of total billed charges,
Labetalol 5mg/mL 20mL I(Normodyne),8723502,CDM,250,RC,,,,,facility,outpatient,,,25.30000,7.34000,Aetna,National,,13.51,,,,,,,9.12,20.70,percent of total billed charges,
Sodium Phosphate Inj,8723470,CDM,250,RC,,,,,facility,outpatient,,,324.18000,94.01000,Aetna,National,,173.11,,,,,,,116.87,265.18,percent of total billed charges,
Lidocaine HCl 4% 50mL Top Soln,8723583,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,National,,5.34,,,,,,,3.60,8.18,percent of total billed charges,
Calcium Chloride 1g/10mL (10%) Inj Syr,8723400,CDM,250,RC,,,,,facility,outpatient,,,107.10000,31.06000,Aetna,National,,57.19,,,,,,,38.61,87.61,percent of total billed charges,
Ketamine 50mg/mL Inj 10mL,8724145,CDM,250,RC,,,,,facility,outpatient,,,35.00000,10.15000,Aetna,National,,18.69,,,,,,,12.62,28.63,percent of total billed charges,
Bupivacaine-Epi 0.25% 30mL I PF,8723538,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
Alcohol (Dehydrated) - 5g/5mL Inj,8725953,CDM,250,RC,,,,,facility,outpatient,,,4154.10000,1204.69000,Aetna,National,,2218.29,,,,,,,1497.55,3398.05,percent of total billed charges,
Urea 15g Oral Rec Powder,8725966,CDM,250,RC,,,,,facility,outpatient,,,30.80000,8.93000,Aetna,National,,16.45,,,,,,,11.10,25.19,percent of total billed charges,
RAD- Iohexol 9mg/mL Oral  500mL,8726019,CDM,250,RC,,,,,facility,outpatient,,,85.85000,24.90000,Aetna,National,,45.84,,,,,,,30.95,70.23,percent of total billed charges,
Cisatracurium 200mg/20mL - for IV Set Use,8726023,CDM,250,RC,,,,,facility,outpatient,,,2410.10000,698.93000,Aetna,National,,1286.99,,,,,,,868.84,1971.46,percent of total billed charges,
Tranexamic Acid 1g/100mL Bolus,8726057,CDM,250,RC,,,,,facility,outpatient,,,214.37000,62.17000,Aetna,National,,114.47,,,,,,,77.28,175.35,percent of total billed charges,
Lidocaine-NaHCO1%-8.4% IS 10mL,8726089,CDM,250,RC,,,,,facility,outpatient,,,50.10000,14.53000,Aetna,National,,26.75,,,,,,,18.06,40.98,percent of total billed charges,
Multiple Vitamin Inj,8724124,CDM,250,RC,,,,,facility,outpatient,,,103.20000,29.93000,Aetna,National,,55.11,,,,,,,37.20,84.42,percent of total billed charges,
Selenium 2.5% 120mL Lotion,8723661,CDM,250,RC,,,,,facility,outpatient,,,140.20000,40.66000,Aetna,National,,74.87,,,,,,,50.54,114.68,percent of total billed charges,
Iodine-Potassium L(Lugols) 14mL,8723696,CDM,250,RC,,,,,facility,outpatient,,,319.40000,92.63000,Aetna,National,,170.56,,,,,,,115.14,261.27,percent of total billed charges,
Bismuth Subgallate Pwd,8723879,CDM,250,RC,,,,,facility,outpatient,,,16.85000,4.89000,Aetna,National,,9.00,,,,,,,6.07,13.78,percent of total billed charges,
Flumazenil 0.5mg/5mL I(Romazicon),8723818,CDM,250,RC,,,,,facility,outpatient,,,42.44000,12.31000,Aetna,National,,22.66,,,,,,,15.30,34.72,percent of total billed charges,
Lipids (fat emulsion) IV 20% 250mL,8724468,CDM,250,RC,,,,,facility,outpatient,,,196.35000,56.94000,Aetna,National,,104.85,,,,,,,70.78,160.61,percent of total billed charges,
BUPivacaine 0.5% 10mL I PF,8723382,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
BUPivacaine 0.25% 10mL I PF,8723414,CDM,250,RC,,,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,9.01,20.45,percent of total billed charges,
NICU- Sodium Acetate 2mEq/mL Inj,8725108,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
Tranexamic Acid 100mg/mL I 10mL,8725311,CDM,250,RC,,,,,facility,outpatient,,,53.65000,15.56000,Aetna,National,,28.65,,,,,,,19.34,43.89,percent of total billed charges,
Anticoag Citr Dextr-A 1L (ACDA),8725309,CDM,250,RC,,,,,facility,outpatient,,,118.95000,34.50000,Aetna,National,,63.52,,,,,,,42.88,97.30,percent of total billed charges,
Na Citrate 4% 500mL Inj,8724092,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
RX6308491,646493,CDM,250,RC,,,,,facility,outpatient,,,37.50000,10.88000,Aetna,National,,20.02,,,,,,,13.52,30.68,percent of total billed charges,
Sodium Bica 50mEq/50mL I,8723572,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
Tobramycin 1.2 g Powder Inj (Nebcin),8724175,CDM,250,RC,,,,,facility,outpatient,,,1206.00000,349.74000,Aetna,National,,644.00,,,,,,,434.76,986.51,percent of total billed charges,
Indocyanine Green 25 mg I,8724169,CDM,250,RC,,,,,facility,outpatient,,,868.19000,251.78000,Aetna,National,,463.61,,,,,,,312.98,710.18,percent of total billed charges,
Zinc Chloride 1mg/mL I 10mL,8724753,CDM,250,RC,,,,,facility,outpatient,,,151.03000,43.80000,Aetna,National,,80.65,,,,,,,54.45,123.54,percent of total billed charges,
Fluorescein Ophth Test Strip,8724831,CDM,250,RC,,,,,facility,outpatient,,,10.00000,2.90000,Aetna,National,,5.34,,,,,,,3.60,8.18,percent of total billed charges,
Polyethylene Glycol Pwd 3350 -238g,8724865,CDM,250,RC,,,,,facility,outpatient,,,77.85000,22.58000,Aetna,National,,41.57,,,,,,,28.06,63.68,percent of total billed charges,
EPINEPHrine 1:1000 Topical Soln 30mL,8725964,CDM,250,RC,,,,,facility,outpatient,,,1812.50000,525.62000,Aetna,National,,967.88,,,,,,,653.41,1482.62,percent of total billed charges,
Methyl Salicylate-Menthol TC(Bengay),8724288,CDM,250,RC,,,,,facility,outpatient,,,27.30000,7.92000,Aetna,National,,14.58,,,,,,,9.84,22.33,percent of total billed charges,
Isoflurane Inhl Sol 100mL,8723623,CDM,250,RC,,,,,facility,outpatient,,,169.95000,49.29000,Aetna,National,,90.75,,,,,,,61.27,139.02,percent of total billed charges,
dilTIAZem 125mg /125mL Premix IVPB,8726035,CDM,250,RC,,,,,facility,outpatient,,,237.15000,68.77000,Aetna,National,,126.64,,,,,,,85.49,193.99,percent of total billed charges,
pyRIDostigmine 10mg/2mL I,8724313,CDM,250,RC,,,,,facility,outpatient,,,102.15000,29.62000,Aetna,National,,54.55,,,,,,,36.83,83.56,percent of total billed charges,
Docosanol 10%  2g TC,8724343,CDM,250,RC,,,,,facility,outpatient,,,218.85000,63.47000,Aetna,National,,116.87,,,,,,,78.90,179.02,percent of total billed charges,
Glycerin Oral Gel(Saliva Subst),8724361,CDM,250,RC,,,,,facility,outpatient,,,74.65000,21.65000,Aetna,National,,39.86,,,,,,,26.91,61.06,percent of total billed charges,
Lido 40mg/Epi 0.5mg/Tetr 5mg Top Gel 3mL,8726034,CDM,250,RC,,,,,facility,outpatient,,,89.61000,25.99000,Aetna,National,,47.85,,,,,,,32.30,73.30,percent of total billed charges,
Miscellaneous Medication - Pharmacy,8726061,CDM,250,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
Parenteral Nutrition Chg,8723895,CDM,251,RC,,,,,facility,outpatient,,,970.00000,281.30000,Aetna,National,,517.98,,,,,,,349.69,793.46,percent of total billed charges,
Open Heart Kit,8723804,CDM,251,RC,,,,,facility,outpatient,,,4044.10000,1172.79000,Aetna,National,,2159.55,,,,,,,1457.90,3308.07,percent of total billed charges,
Poractant 240mg/3mL Intratrach Inj,8724729,CDM,252,RC,,,,,facility,inpatient,,,4895.45000,1419.68000,Aetna,National,,1958.18,,,,,,,1811.32,4004.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Poractant 240mg/3mL Intratrach Inj,8724729,CDM,252,RC,,,,,facility,outpatient,,,4895.45000,1419.68000,Aetna,National,,2614.17,,,,,,,1764.81,4004.48,percent of total billed charges,
NICU- Indomethacin 0.1mg/1mL IS,8725711,CDM,252,RC,,,,,facility,inpatient,,,3504.40000,1016.28000,Aetna,National,,1401.76,,,,,,,1296.63,2866.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NICU- Indomethacin 0.1mg/1mL IS,8725711,CDM,252,RC,,,,,facility,outpatient,,,3504.40000,1016.28000,Aetna,National,,1871.35,,,,,,,1263.34,2866.60,percent of total billed charges,
NEOnatal Lipid 20% Inf,8724911,CDM,252,RC,,,,,facility,inpatient,,,128.50000,37.26000,Aetna,National,,51.40,,,,,,,47.55,105.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEOnatal Lipid 20% Inf,8724911,CDM,252,RC,,,,,facility,outpatient,,,128.50000,37.26000,Aetna,National,,68.62,,,,,,,46.32,105.11,percent of total billed charges,
D50W 50mL Inj Syr,8723571,CDM,258,RC,,,,,facility,outpatient,,,121.37000,35.20000,Aetna,National,,64.81,,,,,,,43.75,99.28,percent of total billed charges,
D5 .45NS+KCl 20mEq 1000mL,8723735,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
0.45% Sodium Cl 500mL,8723722,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
0.45% Sodium Cl 1000mL,8723976,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
Normosol R (PlasmaLyte A) 1000 mL,8723746,CDM,258,RC,,,,,facility,outpatient,,,173.75000,50.39000,Aetna,National,,92.78,,,,,,,62.64,142.13,percent of total billed charges,
D5.45NS+ KCl 10mEq 1000mL,8723750,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
D10W 1000mL,8723741,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
D10W 250mL,8723683,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
NS + 20mEq KCl 1000mL,8723733,CDM,258,RC,,,,,facility,outpatient,,,106.17000,30.79000,Aetna,National,,56.69,,,,,,,38.27,86.85,percent of total billed charges,
D5NS+20 mEq KCl/L,8723732,CDM,258,RC,,,,,facility,outpatient,,,108.50000,31.46000,Aetna,National,,57.94,,,,,,,39.11,88.75,percent of total billed charges,
Water For Inj 50mL I,8723570,CDM,258,RC,A4216,HCPCS,,,facility,outpatient,,,32.16000,9.33000,Aetna,National,,17.17,,,,,,,0.63000,26.31,percent of total billed charges,
Sterile Water 1000mL,8723748,CDM,258,RC,A4217,HCPCS,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,3.80,81.80,percent of total billed charges,
NS 10mL PF Inj,8724129,CDM,258,RC,,,,,facility,outpatient,,,40.52000,11.75000,Aetna,National,,21.64,,,,,,,14.61,33.15,percent of total billed charges,
Water For Inj 10mL I,8723393,CDM,258,RC,A4216,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,0.63000,20.45,percent of total billed charges,
NEOnatal TPN Starter Bag,8726082,CDM,258,RC,,,,,facility,outpatient,,,213.00000,61.77000,Aetna,National,,113.74,,,,,,,76.79,174.23,percent of total billed charges,
D50W 50mL,8723573,CDM,258,RC,,,,,facility,outpatient,,,50.00000,14.50000,Aetna,National,,26.70,,,,,,,18.02,40.90,percent of total billed charges,
NICU- NEOnatal TPN Infusion,8724910,CDM,258,RC,,,,,facility,outpatient,,,836.80000,242.67000,Aetna,National,,446.85,,,,,,,301.67,684.50,percent of total billed charges,
NS 10mL IS(Saline Flush Lock Syr),8724905,CDM,258,RC,A4216,HCPCS,,,facility,outpatient,,,25.00000,7.25000,Aetna,National,,13.35,,,,,,,0.63000,20.45,percent of total billed charges,
0.45% Sodium Cl 250mL,8724936,CDM,258,RC,,,,,facility,outpatient,,,100.00000,29.00000,Aetna,National,,53.40,,,,,,,36.05,81.80,percent of total billed charges,
IV Infusion Sequential Drug,9094166,CDM,260,RC,96367,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,National,,199.72,,,,,,,62.50,305.93,percent of total billed charges,
IV Infusion First Drug Each Hour,9092696,CDM,260,RC,96366,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,National,,199.72,,,,,,,40.51,305.93,percent of total billed charges,
IV Infusion Concurrent Drug,9094167,CDM,260,RC,96368,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,National,,199.72,,,,,,,134.83,305.93,percent of total billed charges,
IV Push Additional drug,9094168,CDM,260,RC,96375,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,National,,199.18,,,,,,,40.51,305.11,percent of total billed charges,
Hydration IV Infusion Each Hour,9094170,CDM,260,RC,96361,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,National,,199.72,,,,,,,40.51,305.93,percent of total billed charges,
IV Infusion Initial First Hour,9092745,CDM,260,RC,96365,HCPCS,,,facility,outpatient,,,662.00000,191.98000,Aetna,National,,353.51,,,,,,,185.00,562.35,percent of total billed charges,
IV Push Sequential,9094169,CDM,260,RC,96376,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,National,,199.18,,,,,,,134.47,305.11,percent of total billed charges,
Initial IV Hydration First Hour,9094312,CDM,260,RC,96360,HCPCS,,,facility,outpatient,,,575.00000,166.75000,Aetna,National,,307.05,,,,,,,185.00,562.35,percent of total billed charges,
IV Push Initial,9092748,CDM,260,RC,96374,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,National,,352.97,,,,,,,185.00,562.35,percent of total billed charges,
IV Infusion 8Hrs Or More,9092697,CDM,260,RC,C8957,HCPCS,,,facility,outpatient,,,2936.00000,851.44000,Aetna,National,,1567.82,,,,,,,213.05,2401.65,percent of total billed charges,
IV Infusion Initial Of Pts Own,9094171,CDM,260,RC,96365,HCPCS,,,facility,outpatient,,,662.00000,191.98000,Aetna,National,FB,353.51,,,,,,,185.00,562.35,percent of total billed charges,
IV Infusion Ea Hr Of Pts Own Med,9094314,CDM,260,RC,96366,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,National,FB,199.72,,,,,,,40.51,305.93,percent of total billed charges,
IV Infusion Sequent Of Pts Own,9092746,CDM,260,RC,96367,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,National,FB,199.72,,,,,,,62.50,305.93,percent of total billed charges,
IV Infusion Concurrent Of Pts Own,9092747,CDM,260,RC,96368,HCPCS,,,facility,outpatient,,,374.00000,108.46000,Aetna,National,FB,199.72,,,,,,,134.83,305.93,percent of total billed charges,
IV Infusion 8Hrs Of Pts Own Med,9094320,CDM,260,RC,C8957,HCPCS,,,facility,outpatient,,,2295.00000,665.55000,Aetna,National,,1225.53,,,,,,,213.05,1877.31,percent of total billed charges,
IV Push Initial Of Pts Own Med,9094172,CDM,260,RC,96374,HCPCS,,,facility,outpatient,,,661.00000,191.69000,Aetna,National,FB,352.97,,,,,,,185.00,562.35,percent of total billed charges,
IV Push Of Pts Own Med,9094315,CDM,260,RC,96375,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,National,FB,199.18,,,,,,,40.51,305.11,percent of total billed charges,
IV Push Sequential of Pts Own Med,9092749,CDM,260,RC,96376,HCPCS,,,facility,outpatient,,,373.00000,108.17000,Aetna,National,FB,199.18,,,,,,,134.47,305.11,percent of total billed charges,
Irrigate Implanted Delivery Device Not pre or post injection,8997081,CDM,260,RC,96523,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,National,,139.37,,,,,,,52.15,213.50,percent of total billed charges,
Irrigate Implanted Delivery Device,8999394,CDM,260,RC,96523,HCPCS,,,facility,outpatient,,,261.00000,75.69000,Aetna,National,,139.37,,,,,,,52.15,213.50,percent of total billed charges,
PROGRAMMER,7697116,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,National,,2196.07,,,,,,,1482.56,3364.03,percent of total billed charges,
CHARGING SYSTEM,7695290,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,National,,3924.90,,,,,,,2113.62,6012.30,percent of total billed charges,
CHARGING SYSTEM,7969749,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,5465.25000,1584.92000,Aetna,National,,2918.44,,,,,,,1970.22,4470.57,percent of total billed charges,
PROGRAMMER,7736629,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,National,,982.56,,,,,,,663.32,1505.12,percent of total billed charges,
PROGRAMMER,7924581,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,2289.53,,,,,,,1545.64,3507.18,percent of total billed charges,
INTERSTIM PROGRAMMER,7968188,CDM,270,RC,C1787,HCPCS,,,facility,outpatient,,,4952.50000,1436.22000,Aetna,National,,2644.64,,,,,,,1785.38,4051.14,percent of total billed charges,
CATHETER DILATOR,7965295,CDM,270,RC,C1725,HCPCS,,,facility,outpatient,,,650.97000,188.78000,Aetna,National,,347.62,,,,,,,234.67,532.49,percent of total billed charges,
CHARGING SYSTEM IN KIT,8339348,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,56246.00000,16311.34000,Aetna,National,,30035.36,,,,,,,2113.62,46009.23,percent of total billed charges,
ROD,8437301,CDM,270,RC,L8699,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,National,,662.16,,,,,,,447.02,1014.32,percent of total billed charges,
RECHARGER,9084224,CDM,270,RC,L8689,HCPCS,,,facility,outpatient,,,5465.25000,1584.92000,Aetna,National,,2918.44,,,,,,,1970.22,4470.57,percent of total billed charges,
SCREW TORX,9093619,CDM,270,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,National,,348.44,,,,,,,235.23,533.75,percent of total billed charges,
Catheter 5fr,9082639,CDM,270,RC,C1887,HCPCS,,,facility,outpatient,,,88.52000,25.67000,Aetna,National,,47.27,,,,,,,31.91,72.41,percent of total billed charges,
Catheter 12fr,9098580,CDM,270,RC,C1887,HCPCS,,,facility,outpatient,,,28732.50000,8332.42000,Aetna,National,,15343.16,,,,,,,10358.07,23503.19,percent of total billed charges,
CAPSULE PILLCAM ENDOSCOPY SB 3,7694336,CDM,272,RC,,,,,facility,outpatient,,,2604.40000,755.28000,Aetna,National,,1390.75,,,,,,,938.89,2130.40,percent of total billed charges,
MORCELLATOR,7696744,CDM,272,RC,C1782,HCPCS,,,facility,outpatient,,,2426.60000,703.71000,Aetna,National,,1295.80,,,,,,,874.79,1984.96,percent of total billed charges,
MORCELLATOR,8328437,CDM,272,RC,C1782,HCPCS,,,facility,outpatient,,,1841.91000,534.15000,Aetna,National,,983.58,,,,,,,664.01,1506.68,percent of total billed charges,
HEMOSPRAY,8170766,CDM,272,RC,C1052,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,National,,4886.10,,,,,,,3298.57,7484.70,percent of total billed charges,
HEMOSPRAY,8170767,CDM,272,RC,C1052,HCPCS,,,facility,outpatient,,,9150.00000,2653.50000,Aetna,National,,4886.10,,,,,,,3298.57,7484.70,percent of total billed charges,
INCISION MANAGEMENT,7972134,CDM,272,RC,A6550,HCPCS,,,facility,outpatient,,,2676.00000,776.04000,Aetna,National,,1428.98,,,,,,,31.78,2188.97,percent of total billed charges,
MORCELLATOR,8168049,CDM,272,RC,C1782,HCPCS,,,facility,outpatient,,,1220.00000,353.80000,Aetna,National,,651.48,,,,,,,439.81,997.96,percent of total billed charges,
HANDPIECE,8950540,CDM,272,RC,C2596,HCPCS,,,facility,outpatient,,,12720.00000,3688.80000,Aetna,National,,6792.48,,,,,,,4585.56,10404.96,percent of total billed charges,
KIT PROCEDURE MILD,7695188,CDM,272,RC,C1889,HCPCS,,,facility,outpatient,,,12579.00000,3647.91000,Aetna,National,,6717.19,,,,,,,4534.73,10289.62,percent of total billed charges,
HEMOSTATIC NEXPOWDER,9012618,CDM,272,RC,C1052,HCPCS,,,facility,outpatient,,,3598.00000,1043.42000,Aetna,National,,1921.33,,,,,,,1297.08,2943.16,percent of total billed charges,
Catheter Mapping,9088702,CDM,272,RC,C1730,HCPCS,,,facility,outpatient,,,756.00000,219.24000,Aetna,National,,9959.00,,,,,,,272.54,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
Introducer,9091167,CDM,272,RC,C1766,HCPCS,,,facility,outpatient,,,3601.50000,1044.44000,Aetna,National,,1923.20,,,,,,,1298.34,2946.03,percent of total billed charges,
Catheter,9088876,CDM,272,RC,C1733,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,National,,9959.00,,,,,,,519.12,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
CATHETER,9088875,CDM,272,RC,C1887,HCPCS,,,facility,outpatient,,,3220.00000,933.80000,Aetna,National,,1719.48,,,,,,,1160.81,2633.96,percent of total billed charges,
KIT PROCEDURE MILD,9098522,CDM,272,RC,C1889,HCPCS,,,facility,outpatient,,,12579.00000,3647.91000,Aetna,National,,6717.19,,,,,,,4534.73,10289.62,percent of total billed charges,
PROBE,9180595,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,2276.00000,660.04000,Aetna,National,,1215.38,,,,,,,820.50,1861.77,percent of total billed charges,
Ablation Antenna,9184498,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,National,,4237.29,,,,,,,2860.57,6490.83,percent of total billed charges,
Ablation Antenna,9182903,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,National,,4237.29,,,,,,,2860.57,6490.83,percent of total billed charges,
Ablation Needle,9196884,CDM,272,RC,C2618,HCPCS,,,facility,outpatient,,,7935.00000,2301.15000,Aetna,National,,4237.29,,,,,,,2860.57,6490.83,percent of total billed charges,
Enteral Feeding Tube Declogging Kit,9074404,CDM,272,RC,,,,,facility,outpatient,,,112.00000,32.48000,Aetna,National,,59.81,,,,,,,40.38,91.62,percent of total billed charges,
OTS Orthotic Elbow Static Custom,4922320,CDM,274,RC,L3702,HCPCS,,,facility,inpatient,,,523.00000,151.67000,Aetna,National,,209.20,,,,,,,188.54,427.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Elbow Static Custom,4922320,CDM,274,RC,L3702,HCPCS,,,facility,outpatient,,,523.00000,151.67000,Aetna,National,,209.20,,,,,,,168.41,427.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Elbow Dynamic Custom,4922323,CDM,274,RC,L3730,HCPCS,,,facility,inpatient,,,1171.00000,339.59000,Aetna,National,,468.40,,,,,,,422.15,957.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Elbow Dynamic Custom,4922323,CDM,274,RC,L3730,HCPCS,,,facility,outpatient,,,1171.00000,339.59000,Aetna,National,,468.40,,,,,,,377.06,1207.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Elbow Wrist Hand Sta,4922326,CDM,274,RC,L3763,HCPCS,,,facility,inpatient,,,798.00000,231.42000,Aetna,National,,319.20,,,,,,,287.68,652.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Elbow Wrist Hand Sta,4922326,CDM,274,RC,L3763,HCPCS,,,facility,outpatient,,,798.00000,231.42000,Aetna,National,,319.20,,,,,,,256.96,790.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Splint Hand Wrist Elbow Dynamic Units,8185135,CDM,274,RC,L3763,HCPCS,,,facility,inpatient,,,798.00000,231.42000,Aetna,National,,319.20,,,,,,,287.68,652.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Splint Hand Wrist Elbow Dynamic Units,8185135,CDM,274,RC,L3763,HCPCS,,,facility,outpatient,,,798.00000,231.42000,Aetna,National,,319.20,,,,,,,256.96,790.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Elbow Wrist Hand Dyn,4922329,CDM,274,RC,L3764,HCPCS,,,facility,inpatient,,,838.00000,243.02000,Aetna,National,,335.20,,,,,,,302.10,685.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Elbow Wrist Hand Dyn,4922329,CDM,274,RC,L3764,HCPCS,,,facility,outpatient,,,838.00000,243.02000,Aetna,National,,335.20,,,,,,,269.84,830.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Splint Hand Wrist Elbow Static Units,8185127,CDM,274,RC,L3764,HCPCS,,,facility,inpatient,,,838.00000,243.02000,Aetna,National,,335.20,,,,,,,302.10,685.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Splint Hand Wrist Elbow Static Units,8185127,CDM,274,RC,L3764,HCPCS,,,facility,outpatient,,,838.00000,243.02000,Aetna,National,,335.20,,,,,,,269.84,830.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Finger Static Custom,4922332,CDM,274,RC,L3808,HCPCS,,,facility,inpatient,,,428.00000,124.12000,Aetna,National,,171.20,,,,,,,154.29,350.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Finger Static Custom,4922332,CDM,274,RC,L3808,HCPCS,,,facility,outpatient,,,428.00000,124.12000,Aetna,National,,171.20,,,,,,,137.82,382.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Finger Dynamic Custom,4922335,CDM,274,RC,L3806,HCPCS,,,facility,inpatient,,,728.00000,211.12000,Aetna,National,,291.20,,,,,,,262.44,595.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Finger Dynamic Custom,4922335,CDM,274,RC,L3806,HCPCS,,,facility,outpatient,,,728.00000,211.12000,Aetna,National,,291.20,,,,,,,234.42,595.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Static Custom,4922338,CDM,274,RC,L3906,HCPCS,,,facility,inpatient,,,453.00000,131.37000,Aetna,National,,181.20,,,,,,,163.31,370.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Static Custom,4922338,CDM,274,RC,L3906,HCPCS,,,facility,outpatient,,,453.00000,131.37000,Aetna,National,,181.20,,,,,,,145.87,449.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Dynam Custom,4922321,CDM,274,RC,L3905,HCPCS,,,facility,inpatient,,,1060.00000,307.40000,Aetna,National,,424.00,,,,,,,382.13,867.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Dynam Custom,4922321,CDM,274,RC,L3905,HCPCS,,,facility,outpatient,,,1060.00000,307.40000,Aetna,National,,424.00,,,,,,,341.32,1103.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Stat Cu,4922324,CDM,274,RC,L3913,HCPCS,,,facility,inpatient,,,370.00000,107.30000,Aetna,National,,148.00,,,,,,,133.38,302.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Stat Cu,4922324,CDM,274,RC,L3913,HCPCS,,,facility,outpatient,,,370.00000,107.30000,Aetna,National,,148.00,,,,,,,119.14,302.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Dynamic,4922327,CDM,274,RC,L3921,HCPCS,,,facility,inpatient,,,596.00000,172.84000,Aetna,National,,238.40,,,,,,,214.86,487.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Dynamic,4922327,CDM,274,RC,L3921,HCPCS,,,facility,outpatient,,,596.00000,172.84000,Aetna,National,,238.40,,,,,,,191.91,487.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Static Custom,4922330,CDM,274,RC,L3919,HCPCS,,,facility,inpatient,,,304.00000,88.16000,Aetna,National,,121.60,,,,,,,109.59,248.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Static Custom,4922330,CDM,274,RC,L3919,HCPCS,,,facility,outpatient,,,304.00000,88.16000,Aetna,National,,121.60,,,,,,,97.89,301.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Static Custom,4922333,CDM,274,RC,L3933,HCPCS,,,facility,inpatient,,,240.00000,69.60000,Aetna,National,,96.00,,,,,,,86.52,196.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Static Custom,4922333,CDM,274,RC,L3933,HCPCS,,,facility,outpatient,,,240.00000,69.60000,Aetna,National,,96.00,,,,,,,77.28,237.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Dynamic Cust,4922336,CDM,274,RC,L3935,HCPCS,,,facility,inpatient,,,267.00000,77.43000,Aetna,National,,106.80,,,,,,,96.25,218.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Dynamic Cust,4922336,CDM,274,RC,L3935,HCPCS,,,facility,outpatient,,,267.00000,77.43000,Aetna,National,,106.80,,,,,,,85.97,245.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Ankle Foot Stat Cus,4922339,CDM,274,RC,L1940,HCPCS,,,facility,inpatient,,,535.00000,155.15000,Aetna,National,,214.00,,,,,,,192.87,437.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Ankle Foot Stat Cus,4922339,CDM,274,RC,L1940,HCPCS,,,facility,outpatient,,,535.00000,155.15000,Aetna,National,,214.00,,,,,,,172.27,622.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Shoulder Prefab,4922322,CDM,274,RC,L3670,HCPCS,,,facility,inpatient,,,155.00000,44.95000,Aetna,National,,62.00,,,,,,,55.88,126.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Shoulder Prefab,4922322,CDM,274,RC,L3670,HCPCS,,,facility,outpatient,,,155.00000,44.95000,Aetna,National,,62.00,,,,,,,49.91,169.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Finger Prefab,4922325,CDM,274,RC,L3807,HCPCS,,,facility,inpatient,,,281.00000,81.49000,Aetna,National,,112.40,,,,,,,101.30,229.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Finger Prefab,4922325,CDM,274,RC,L3807,HCPCS,,,facility,outpatient,,,281.00000,81.49000,Aetna,National,,112.40,,,,,,,90.48,278.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Prefab,4922328,CDM,274,RC,L3908,HCPCS,,,facility,inpatient,,,76.00000,22.04000,Aetna,National,,30.40,,,,,,,27.40,62.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Wrist Hand Prefab,4922328,CDM,274,RC,L3908,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,National,,30.40,,,,,,,24.47,68.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Glove Pr,4922331,CDM,274,RC,L3912,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,National,,53.60,,,,,,,48.31,109.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Glove Pr,4922331,CDM,274,RC,L3912,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,National,,53.60,,,,,,,43.15,131.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Prefab,4922334,CDM,274,RC,L3923,HCPCS,,,facility,inpatient,,,134.00000,38.86000,Aetna,National,,53.60,,,,,,,48.31,109.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Hand Finger Prefab,4922334,CDM,274,RC,L3923,HCPCS,,,facility,outpatient,,,134.00000,38.86000,Aetna,National,,53.60,,,,,,,43.15,109.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Prefab Static,4922337,CDM,274,RC,L3927,HCPCS,,,facility,inpatient,,,76.00000,22.04000,Aetna,National,,30.40,,,,,,,27.40,62.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Prefab Static,4922337,CDM,274,RC,L3927,HCPCS,,,facility,outpatient,,,76.00000,22.04000,Aetna,National,,30.40,,,,,,,24.47,62.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Prefab Dyn,4922340,CDM,274,RC,L3925,HCPCS,,,facility,inpatient,,,253.00000,73.37000,Aetna,National,,101.20,,,,,,,91.21,206.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Finger Prefab Dyn,4922340,CDM,274,RC,L3925,HCPCS,,,facility,outpatient,,,253.00000,73.37000,Aetna,National,,101.20,,,,,,,71.46,206.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Orthotic Thumb Spica,8235904,CDM,274,RC,L3809,HCPCS,,,facility,inpatient,,,260.00000,75.40000,Aetna,National,,104.00,,,,,,,93.73,212.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Orthotic Thumb Spica,8235904,CDM,274,RC,L3809,HCPCS,,,facility,outpatient,,,260.00000,75.40000,Aetna,National,,104.00,,,,,,,83.72,278.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Orthotic Ulnar Drift,8235912,CDM,274,RC,L3917,HCPCS,,,facility,inpatient,,,122.00000,35.38000,Aetna,National,,48.80,,,,,,,43.98,99.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Orthotic Ulnar Drift,8235912,CDM,274,RC,L3917,HCPCS,,,facility,outpatient,,,122.00000,35.38000,Aetna,National,,48.80,,,,,,,39.28,117.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Orthotic Cool Comfort,8235908,CDM,274,RC,L3924,HCPCS,,,facility,inpatient,,,94.00000,27.26000,Aetna,National,,37.60,,,,,,,33.89,76.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OT Orthotic Cool Comfort,8235908,CDM,274,RC,L3924,HCPCS,,,facility,outpatient,,,94.00000,27.26000,Aetna,National,,37.60,,,,,,,30.27,99.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Humerus,8282801,CDM,274,RC,L3671,HCPCS,,,facility,inpatient,,,1680.00000,487.20000,Aetna,National,,672.00,,,,,,,605.64,1374.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OTS Orthotic Humerus,8282801,CDM,274,RC,L3671,HCPCS,,,facility,outpatient,,,1680.00000,487.20000,Aetna,National,,672.00,,,,,,,540.96,1374.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9116839,CDM,275,RC,C1713,HCPCS,,,facility,inpatient,,,3810.21000,1104.96000,Aetna,National,,1524.08,,,,,,,1373.58,3116.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,9116839,CDM,275,RC,C1713,HCPCS,,,facility,outpatient,,,3810.21000,1104.96000,Aetna,National,,1524.08,,,,,,,1226.89,3116.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER URETERAL,7694745,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1384.72000,401.57000,Aetna,National,,553.89,,,,,,,499.19,1132.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER URETERAL,7694745,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1384.72000,401.57000,Aetna,National,,553.89,,,,,,,445.88,1132.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lead Pacemaker,8063006,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,National,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Lead Pacemaker,8063006,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,National,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8400632,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,National,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,8400632,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,National,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE GRAFT DURAL,7694890,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,3527.83000,1023.07000,Aetna,National,,1411.13,,,,,,,1271.78,2885.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE GRAFT DURAL,7694890,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,3527.83000,1023.07000,Aetna,National,,1411.13,,,,,,,1135.96,2885.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STRAIT,7694566,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2347.00000,680.63000,Aetna,National,,938.80,,,,,,,846.09,1919.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STRAIT,7694566,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2347.00000,680.63000,Aetna,National,,938.80,,,,,,,755.73,1919.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,7694927,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,National,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,7694927,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,National,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695001,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON STONE EXTRACTOR RX,7695001,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702887,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,134.40000,38.98000,Aetna,National,,53.76,,,,,,,48.45,109.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7702887,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,134.40000,38.98000,Aetna,National,,53.76,,,,,,,43.28,109.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 90,7695079,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,7539.00000,2186.31000,Aetna,National,,3015.60,,,,,,,2717.81,6166.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 90,7695079,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,7539.00000,2186.31000,Aetna,National,,3015.60,,,,,,,2427.56,6166.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695074,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8145.00000,2362.05000,Aetna,National,,3258.00,,,,,,,2936.27,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7695074,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8145.00000,2362.05000,Aetna,National,,3258.00,,,,,,,2622.69,6662.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696776,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1532.00000,444.28000,Aetna,National,,612.80,,,,,,,552.29,1253.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696776,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1532.00000,444.28000,Aetna,National,,612.80,,,,,,,493.30,1253.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695460,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,National,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695460,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,National,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696556,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,National,,739.62,,,,,,,666.58,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696556,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,National,,739.62,,,,,,,595.39,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135822,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135822,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135823,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,432.25000,125.35000,Aetna,National,,172.90,,,,,,,155.83,353.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8135823,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,432.25000,125.35000,Aetna,National,,172.90,,,,,,,139.18,353.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135722,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135722,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135647,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,National,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135647,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,National,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696334,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696334,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696341,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696341,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8151668,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,National,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8151668,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,National,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696710,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2891.42000,838.51000,Aetna,National,,1156.57,,,,,,,1042.36,2365.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696710,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2891.42000,838.51000,Aetna,National,,1156.57,,,,,,,931.04,2365.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7702795,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2140.00000,620.60000,Aetna,National,,856.00,,,,,,,771.47,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7702795,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2140.00000,620.60000,Aetna,National,,856.00,,,,,,,689.08,1750.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694998,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,792.00000,229.68000,Aetna,National,,316.80,,,,,,,285.52,647.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694998,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,792.00000,229.68000,Aetna,National,,316.80,,,,,,,255.02,647.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696586,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,739.80000,214.54000,Aetna,National,,295.92,,,,,,,266.70,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7696586,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,739.80000,214.54000,Aetna,National,,295.92,,,,,,,238.22,605.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7695317,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,National,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7695317,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,National,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7695970,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2705.91000,784.71000,Aetna,National,,1082.36,,,,,,,975.48,2213.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7695970,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2705.91000,784.71000,Aetna,National,,1082.36,,,,,,,871.30,2213.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,National,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,National,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSSPHENOIDAL SELLAR IMPLANT,7696666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2455.20000,712.01000,Aetna,National,,982.08,,,,,,,885.10,2008.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSSPHENOIDAL SELLAR IMPLANT,7696666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2455.20000,712.01000,Aetna,National,,982.08,,,,,,,790.57,2008.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693596,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1460.00000,423.40000,Aetna,National,,584.00,,,,,,,526.33,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693596,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1460.00000,423.40000,Aetna,National,,584.00,,,,,,,470.12,1194.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SWAN,7695755,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,2532.48000,734.42000,Aetna,National,,1012.99,,,,,,,912.96,2071.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER SWAN,7695755,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,2532.48000,734.42000,Aetna,National,,1012.99,,,,,,,815.46,2071.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695042,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1432.24000,415.35000,Aetna,National,,572.90,,,,,,,516.32,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695042,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1432.24000,415.35000,Aetna,National,,572.90,,,,,,,461.18,1171.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7694368,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,368.13000,106.76000,Aetna,National,,147.25,,,,,,,132.71,301.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7694368,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,368.13000,106.76000,Aetna,National,,147.25,,,,,,,118.54,301.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7694367,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,337.25000,97.80000,Aetna,National,,134.90,,,,,,,121.58,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7694367,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,337.25000,97.80000,Aetna,National,,134.90,,,,,,,108.59,275.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7699403,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,789.08000,228.83000,Aetna,National,,315.63,,,,,,,284.46,645.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7699403,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,789.08000,228.83000,Aetna,National,,315.63,,,,,,,254.08,645.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694918,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4857.30000,1408.62000,Aetna,National,,1942.92,,,,,,,1751.06,3973.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694918,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4857.30000,1408.62000,Aetna,National,,1942.92,,,,,,,1564.05,3973.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695671,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,375.25000,108.82000,Aetna,National,,150.10,,,,,,,135.28,306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695671,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,375.25000,108.82000,Aetna,National,,150.10,,,,,,,120.83,306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694747,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,175.35000,50.85000,Aetna,National,,70.14,,,,,,,63.21,143.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694747,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,175.35000,50.85000,Aetna,National,,70.14,,,,,,,56.46,143.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695038,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,680.76000,197.42000,Aetna,National,,272.30,,,,,,,245.41,556.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695038,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,680.76000,197.42000,Aetna,National,,272.30,,,,,,,219.20,556.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696705,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,616.32000,178.73000,Aetna,National,,246.53,,,,,,,222.18,504.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696705,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,616.32000,178.73000,Aetna,National,,246.53,,,,,,,198.46,504.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694067,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,724.95000,210.24000,Aetna,National,,289.98,,,,,,,261.34,593.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694067,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,724.95000,210.24000,Aetna,National,,289.98,,,,,,,233.43,593.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694321,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2211.76000,641.41000,Aetna,National,,884.70,,,,,,,797.34,1809.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694321,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2211.76000,641.41000,Aetna,National,,884.70,,,,,,,712.19,1809.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696737,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4047.59000,1173.80000,Aetna,National,,1619.04,,,,,,,1459.16,3310.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696737,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4047.59000,1173.80000,Aetna,National,,1619.04,,,,,,,1303.32,3310.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696738,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1968.07000,570.74000,Aetna,National,,787.23,,,,,,,709.49,1609.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696738,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1968.07000,570.74000,Aetna,National,,787.23,,,,,,,633.72,1609.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702876,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2370.56000,687.46000,Aetna,National,,948.22,,,,,,,854.59,1939.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702876,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2370.56000,687.46000,Aetna,National,,948.22,,,,,,,763.32,1939.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696379,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,National,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696379,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,National,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7694438,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1805.00000,523.45000,Aetna,National,,722.00,,,,,,,650.70,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7694438,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1805.00000,523.45000,Aetna,National,,722.00,,,,,,,581.21,1476.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695452,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,National,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695452,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,National,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1861.44000,539.82000,Aetna,National,,744.58,,,,,,,671.05,1522.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1861.44000,539.82000,Aetna,National,,744.58,,,,,,,599.38,1522.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7702856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4182.50000,1212.92000,Aetna,National,,1673.00,,,,,,,1507.79,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7702856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4182.50000,1212.92000,Aetna,National,,1673.00,,,,,,,1346.77,3421.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698337,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1926.60000,558.71000,Aetna,National,,770.64,,,,,,,694.54,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698337,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1926.60000,558.71000,Aetna,National,,770.64,,,,,,,620.37,1575.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,National,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,National,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON ACHILLES,7702911,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8651.37000,2508.90000,Aetna,National,,3460.55,,,,,,,3118.82,7076.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON ACHILLES,7702911,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8651.37000,2508.90000,Aetna,National,,3460.55,,,,,,,2785.74,7076.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7741660,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,National,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7741660,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,National,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7696453,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16502.08000,4785.60000,Aetna,National,,6600.83,,,,,,,5949.00,13498.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7696453,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16502.08000,4785.60000,Aetna,National,,6600.83,,,,,,,5313.67,13498.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7702855,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,22795.38000,6610.66000,Aetna,National,,9118.15,,,,,,,8217.73,18646.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7702855,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,22795.38000,6610.66000,Aetna,National,,9118.15,,,,,,,7340.11,18646.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT ROPE,7702857,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8965.17000,2599.90000,Aetna,National,,3586.07,,,,,,,3231.94,7333.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT ROPE,7702857,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8965.17000,2599.90000,Aetna,National,,3586.07,,,,,,,2886.78,7333.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,National,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7696820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,National,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696265,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,4634.42000,1343.98000,Aetna,National,,1853.77,,,,,,,1670.71,3790.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696265,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,4634.42000,1343.98000,Aetna,National,,1853.77,,,,,,,1492.28,3790.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7702702,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5817.00000,1686.93000,Aetna,National,,2326.80,,,,,,,2097.03,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BAND ANNULOPLASTY,7702702,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5817.00000,1686.93000,Aetna,National,,2326.80,,,,,,,1873.07,4758.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695595,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,545.40000,158.17000,Aetna,National,,218.16,,,,,,,196.62,446.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695595,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,545.40000,158.17000,Aetna,National,,218.16,,,,,,,175.62,446.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695456,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,National,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695456,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,National,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,188.79000,54.75000,Aetna,National,,75.52,,,,,,,68.06,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,188.79000,54.75000,Aetna,National,,75.52,,,,,,,60.79,154.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702798,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,617.94000,179.20000,Aetna,National,,247.18,,,,,,,222.77,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702798,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,617.94000,179.20000,Aetna,National,,247.18,,,,,,,198.98,505.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7694049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,395.68000,114.75000,Aetna,National,,158.27,,,,,,,142.64,323.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7694049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,395.68000,114.75000,Aetna,National,,158.27,,,,,,,127.41,323.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694068,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,815.85000,236.60000,Aetna,National,,326.34,,,,,,,294.11,667.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694068,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,815.85000,236.60000,Aetna,National,,326.34,,,,,,,262.70,667.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RETRIEVAL DEVICE,7694844,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,1469.00000,426.01000,Aetna,National,,587.60,,,,,,,529.57,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RETRIEVAL DEVICE,7694844,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,1469.00000,426.01000,Aetna,National,,587.60,,,,,,,473.02,1201.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,National,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,National,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7694647,CDM,278,RC,,,,,facility,inpatient,,,340.61000,98.78000,Aetna,National,,136.24,,,,,,,122.79,278.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7694647,CDM,278,RC,,,,,facility,outpatient,,,340.61000,98.78000,Aetna,National,,136.24,,,,,,,109.68,278.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7703364,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,1432.00000,415.28000,Aetna,National,,572.80,,,,,,,516.24,1171.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7703364,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,1432.00000,415.28000,Aetna,National,,572.80,,,,,,,461.10,1171.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695655,CDM,278,RC,C1877,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695655,CDM,278,RC,C1877,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,375.11000,108.78000,Aetna,National,,150.04,,,,,,,135.23,306.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,375.11000,108.78000,Aetna,National,,150.04,,,,,,,120.79,306.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING,7695670,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,7505.27000,2176.53000,Aetna,National,,3002.11,,,,,,,2705.65,6139.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING,7695670,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,7505.27000,2176.53000,Aetna,National,,3002.11,,,,,,,2416.70,6139.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1544.00000,447.76000,Aetna,National,,617.60,,,,,,,556.61,1262.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1544.00000,447.76000,Aetna,National,,617.60,,,,,,,497.17,1262.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,7696140,CDM,278,RC,,,,,facility,inpatient,,,2230.00000,646.70000,Aetna,National,,892.00,,,,,,,803.91,1824.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
OCCLUDER,7696140,CDM,278,RC,,,,,facility,outpatient,,,2230.00000,646.70000,Aetna,National,,892.00,,,,,,,718.06,1824.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RENAL DILATOR,7694500,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1423.24000,412.74000,Aetna,National,,569.30,,,,,,,513.08,1164.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RENAL DILATOR,7694500,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1423.24000,412.74000,Aetna,National,,569.30,,,,,,,458.28,1164.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694846,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1902.32000,551.67000,Aetna,National,,760.93,,,,,,,685.79,1556.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694846,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1902.32000,551.67000,Aetna,National,,760.93,,,,,,,612.55,1556.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEPRA FILM,7694879,CDM,278,RC,C1765,HCPCS,,,facility,inpatient,,,1904.50000,552.30000,Aetna,National,,761.80,,,,,,,686.57,1557.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SEPRA FILM,7694879,CDM,278,RC,C1765,HCPCS,,,facility,outpatient,,,1904.50000,552.30000,Aetna,National,,761.80,,,,,,,613.25,1557.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7703356,CDM,278,RC,C1763,HCPCS,,,facility,inpatient,,,6177.50000,1791.48000,Aetna,National,,2471.00,,,,,,,2226.99,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7703356,CDM,278,RC,C1763,HCPCS,,,facility,outpatient,,,6177.50000,1791.48000,Aetna,National,,2471.00,,,,,,,1989.15,5053.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE MYRINGOTOMY,7696094,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,148.74000,43.13000,Aetna,National,,59.50,,,,,,,53.62,121.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE MYRINGOTOMY,7696094,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,148.74000,43.13000,Aetna,National,,59.50,,,,,,,47.89,332.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697045,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,National,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697045,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,National,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698916,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1591.04000,461.40000,Aetna,National,,636.42,,,,,,,573.57,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698916,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1591.04000,461.40000,Aetna,National,,636.42,,,,,,,512.31,1301.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696938,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,913.59000,264.94000,Aetna,National,,365.44,,,,,,,329.35,747.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696938,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,913.59000,264.94000,Aetna,National,,365.44,,,,,,,294.18,747.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696119,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,National,,2165.80,,,,,,,1951.93,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696119,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,National,,2165.80,,,,,,,1743.47,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7736634,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,336.30000,97.53000,Aetna,National,,134.52,,,,,,,121.24,275.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7736634,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,336.30000,97.53000,Aetna,National,,134.52,,,,,,,108.29,275.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696876,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696876,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7693894,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,311.13000,90.23000,Aetna,National,,124.45,,,,,,,112.16,254.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7693894,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,311.13000,90.23000,Aetna,National,,124.45,,,,,,,100.18,254.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694066,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,716.27000,207.72000,Aetna,National,,286.51,,,,,,,258.22,585.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7694066,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,716.27000,207.72000,Aetna,National,,286.51,,,,,,,230.64,585.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7696284,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1592.60000,461.85000,Aetna,National,,637.04,,,,,,,574.13,1302.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7696284,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1592.60000,461.85000,Aetna,National,,637.04,,,,,,,512.82,1302.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP,7695396,CDM,278,RC,C1772,HCPCS,,,facility,inpatient,,,31810.50000,9225.04000,Aetna,National,,12724.20,,,,,,,11467.69,26020.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP,7695396,CDM,278,RC,C1772,HCPCS,,,facility,outpatient,,,31810.50000,9225.04000,Aetna,National,,12724.20,,,,,,,10242.98,26020.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697085,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15710.00000,4555.90000,Aetna,National,,6284.00,,,,,,,5663.45,12850.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697085,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15710.00000,4555.90000,Aetna,National,,6284.00,,,,,,,5058.62,12850.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697114,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,National,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697114,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,National,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697120,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,National,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7697120,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,National,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7702853,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,39656.25000,11500.31000,Aetna,National,,15862.50,,,,,,,14296.08,32438.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7702853,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,39656.25000,11500.31000,Aetna,National,,15862.50,,,,,,,12769.31,32438.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696458,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,918.00000,266.22000,Aetna,National,,367.20,,,,,,,330.94,750.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7696458,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,918.00000,266.22000,Aetna,National,,367.20,,,,,,,295.60,750.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7696613,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,8787.00000,2548.23000,Aetna,National,,3514.80,,,,,,,3167.71,7187.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHUNT,7696613,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,8787.00000,2548.23000,Aetna,National,,3514.80,,,,,,,2829.41,7187.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7697058,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2800.00000,812.00000,Aetna,National,,1120.00,,,,,,,1009.40,2290.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7697058,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2800.00000,812.00000,Aetna,National,,1120.00,,,,,,,901.60,2290.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694669,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,418.19000,121.28000,Aetna,National,,167.28,,,,,,,150.76,342.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694669,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,418.19000,121.28000,Aetna,National,,167.28,,,,,,,134.66,342.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7707512,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,168.00000,48.72000,Aetna,National,,67.20,,,,,,,60.56,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7707512,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,168.00000,48.72000,Aetna,National,,67.20,,,,,,,54.10,137.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOBUTTON,7697179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1596.00000,462.84000,Aetna,National,,638.40,,,,,,,575.36,1305.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOBUTTON,7697179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1596.00000,462.84000,Aetna,National,,638.40,,,,,,,513.91,1305.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOBUTTON,7697181,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1928.00000,559.12000,Aetna,National,,771.20,,,,,,,695.04,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDOBUTTON,7697181,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1928.00000,559.12000,Aetna,National,,771.20,,,,,,,620.82,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697187,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1956.00000,567.24000,Aetna,National,,782.40,,,,,,,705.14,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697187,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1956.00000,567.24000,Aetna,National,,782.40,,,,,,,629.83,1600.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697235,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,6125.00000,1776.25000,Aetna,National,,2450.00,,,,,,,2208.06,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697235,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,6125.00000,1776.25000,Aetna,National,,2450.00,,,,,,,1972.25,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698060,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,National,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698060,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,National,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697251,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2414.00000,700.06000,Aetna,National,,965.60,,,,,,,870.25,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697251,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2414.00000,700.06000,Aetna,National,,965.60,,,,,,,777.31,1974.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694751,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,1667.28000,483.51000,Aetna,National,,666.91,,,,,,,601.05,1363.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694751,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,1667.28000,483.51000,Aetna,National,,666.91,,,,,,,536.86,1363.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697270,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697270,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,National,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7695346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,National,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696363,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,16987.50000,4926.38000,Aetna,National,,6795.00,,,,,,,6123.99,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696363,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,16987.50000,4926.38000,Aetna,National,,6795.00,,,,,,,5469.98,13895.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694310,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,National,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694310,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,National,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696449,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,577.47000,167.47000,Aetna,National,,230.99,,,,,,,208.18,472.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696449,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,577.47000,167.47000,Aetna,National,,230.99,,,,,,,185.95,472.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7697323,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1294.00000,375.26000,Aetna,National,,517.60,,,,,,,466.49,1058.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7697323,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1294.00000,375.26000,Aetna,National,,517.60,,,,,,,416.67,1058.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7697322,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,National,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7697322,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,National,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696269,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1406.00000,407.74000,Aetna,National,,562.40,,,,,,,506.86,1150.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696269,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1406.00000,407.74000,Aetna,National,,562.40,,,,,,,452.73,1150.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1272.00000,368.88000,Aetna,National,,508.80,,,,,,,458.56,1040.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1272.00000,368.88000,Aetna,National,,508.80,,,,,,,409.58,1040.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7695108,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7695108,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695338,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,505.40000,146.57000,Aetna,National,,202.16,,,,,,,182.20,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695338,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,505.40000,146.57000,Aetna,National,,202.16,,,,,,,162.74,413.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,563.54000,163.43000,Aetna,National,,225.42,,,,,,,203.16,460.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,563.54000,163.43000,Aetna,National,,225.42,,,,,,,181.46,460.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701062,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4752.34000,1378.18000,Aetna,National,,1900.94,,,,,,,1713.22,3887.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701062,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4752.34000,1378.18000,Aetna,National,,1900.94,,,,,,,1530.25,3887.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697384,CDM,278,RC,L8600,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697384,CDM,278,RC,L8600,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,764.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697388,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,National,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST PROSTHESIS,7697388,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,National,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2714.36000,787.16000,Aetna,National,,1085.74,,,,,,,978.53,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2714.36000,787.16000,Aetna,National,,1085.74,,,,,,,874.02,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697395,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5961.90000,1728.95000,Aetna,National,,2384.76,,,,,,,2149.26,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697395,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5961.90000,1728.95000,Aetna,National,,2384.76,,,,,,,1919.73,4876.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696850,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1568.00000,454.72000,Aetna,National,,627.20,,,,,,,565.26,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696850,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1568.00000,454.72000,Aetna,National,,627.20,,,,,,,504.90,1282.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,171.36000,49.69000,Aetna,National,,68.54,,,,,,,61.78,140.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,171.36000,49.69000,Aetna,National,,68.54,,,,,,,55.18,140.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER GLENOSPHERE REVERSE,7697434,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHOULDER GLENOSPHERE REVERSE,7697434,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697406,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,National,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697406,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,National,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,688.50000,199.66000,Aetna,National,,275.40,,,,,,,248.20,563.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,688.50000,199.66000,Aetna,National,,275.40,,,,,,,221.70,563.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697410,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1708.00000,495.32000,Aetna,National,,683.20,,,,,,,615.73,1397.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697410,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1708.00000,495.32000,Aetna,National,,683.20,,,,,,,549.98,1397.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696567,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,National,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696567,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,National,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8346.00000,2420.34000,Aetna,National,,3338.40,,,,,,,3008.73,6827.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8346.00000,2420.34000,Aetna,National,,3338.40,,,,,,,2687.41,6827.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695221,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,National,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695221,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,National,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695222,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,National,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695222,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,National,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135809,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135809,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135810,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135810,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135811,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135811,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER VENA CAVA,8135664,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,5718.83000,1658.46000,Aetna,National,,2287.53,,,,,,,2061.64,4678.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER VENA CAVA,8135664,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,5718.83000,1658.46000,Aetna,National,,2287.53,,,,,,,1841.46,4678.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697439,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6552.84000,1900.32000,Aetna,National,,2621.14,,,,,,,2362.30,5360.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697439,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6552.84000,1900.32000,Aetna,National,,2621.14,,,,,,,2110.01,5360.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697440,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,329.79000,95.64000,Aetna,National,,131.92,,,,,,,118.89,269.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697440,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,329.79000,95.64000,Aetna,National,,131.92,,,,,,,106.19,269.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694448,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,128.31000,37.21000,Aetna,National,,51.32,,,,,,,46.26,104.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694448,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,128.31000,37.21000,Aetna,National,,51.32,,,,,,,41.32,104.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7945880,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8271.00000,2398.59000,Aetna,National,,3308.40,,,,,,,2981.70,6765.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7945880,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8271.00000,2398.59000,Aetna,National,,3308.40,,,,,,,2663.26,6765.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7696663,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7696663,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,National,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,National,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697517,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5358.50000,1553.96000,Aetna,National,,2143.40,,,,,,,1931.74,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697517,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5358.50000,1553.96000,Aetna,National,,2143.40,,,,,,,1725.44,4383.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697529,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,964.71000,279.77000,Aetna,National,,385.88,,,,,,,347.78,789.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697529,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,964.71000,279.77000,Aetna,National,,385.88,,,,,,,310.64,789.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693595,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,981.00000,284.49000,Aetna,National,,392.40,,,,,,,353.65,802.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693595,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,981.00000,284.49000,Aetna,National,,392.40,,,,,,,315.88,802.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697567,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,National,,199.12,,,,,,,179.46,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697567,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,National,,199.12,,,,,,,160.29,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697538,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,National,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697538,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,National,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697550,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,843.75000,244.69000,Aetna,National,,337.50,,,,,,,304.17,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697550,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,843.75000,244.69000,Aetna,National,,337.50,,,,,,,271.69,690.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697612,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2670.40000,774.42000,Aetna,National,,1068.16,,,,,,,962.68,2184.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697612,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2670.40000,774.42000,Aetna,National,,1068.16,,,,,,,859.87,2184.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SUBSTITUTE,7697640,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9877.35000,2864.43000,Aetna,National,,3950.94,,,,,,,3560.78,8079.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE SUBSTITUTE,7697640,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9877.35000,2864.43000,Aetna,National,,3950.94,,,,,,,3180.51,8079.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5577.88000,1617.59000,Aetna,National,,2231.15,,,,,,,2010.83,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5577.88000,1617.59000,Aetna,National,,2231.15,,,,,,,1796.08,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697658,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3684.23000,1068.43000,Aetna,National,,1473.69,,,,,,,1328.16,3013.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697658,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3684.23000,1068.43000,Aetna,National,,1473.69,,,,,,,1186.32,3013.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697659,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2200.50000,638.14000,Aetna,National,,880.20,,,,,,,793.28,1800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697659,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2200.50000,638.14000,Aetna,National,,880.20,,,,,,,708.56,1800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697660,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4434.85000,1286.11000,Aetna,National,,1773.94,,,,,,,1598.76,3627.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697660,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4434.85000,1286.11000,Aetna,National,,1773.94,,,,,,,1428.02,3627.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697664,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1510.76000,438.12000,Aetna,National,,604.30,,,,,,,544.63,1235.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697664,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1510.76000,438.12000,Aetna,National,,604.30,,,,,,,486.46,1235.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697668,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1665.92000,483.12000,Aetna,National,,666.37,,,,,,,600.56,1362.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697668,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1665.92000,483.12000,Aetna,National,,666.37,,,,,,,536.43,1362.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935274,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,National,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935274,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,National,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER CERV,7702771,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,National,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER CERV,7702771,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,National,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697865,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1554.21000,450.72000,Aetna,National,,621.68,,,,,,,560.29,1271.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7697865,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1554.21000,450.72000,Aetna,National,,621.68,,,,,,,500.46,1271.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7774084,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,National,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7774084,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,National,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7695683,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,National,,822.40,,,,,,,741.19,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7695683,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,National,,822.40,,,,,,,662.03,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7916959,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,729.36000,211.51000,Aetna,National,,291.74,,,,,,,262.93,596.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7916959,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,729.36000,211.51000,Aetna,National,,291.74,,,,,,,234.85,596.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2948.00000,854.92000,Aetna,National,,1179.20,,,,,,,1062.75,2411.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2948.00000,854.92000,Aetna,National,,1179.20,,,,,,,949.26,2411.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7697897,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1843.60000,534.64000,Aetna,National,,737.44,,,,,,,664.62,1508.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7697897,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1843.60000,534.64000,Aetna,National,,737.44,,,,,,,593.64,1508.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7697914,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10515.00000,3049.35000,Aetna,National,,4206.00,,,,,,,3790.66,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7697914,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10515.00000,3049.35000,Aetna,National,,4206.00,,,,,,,3385.83,8601.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXPLOR HEAD,7697918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXPLOR HEAD,7697918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM AND SCREW,7697917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM AND SCREW,7697917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7697561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,National,,2076.76,,,,,,,1871.68,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM SPLINED KNEE,7697561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,National,,2076.76,,,,,,,1671.79,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7697553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9127.20000,2646.89000,Aetna,National,,3650.88,,,,,,,3290.36,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7697553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9127.20000,2646.89000,Aetna,National,,3650.88,,,,,,,2938.96,7466.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697933,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697933,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CORE REVISION,7697947,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4428.38000,1284.23000,Aetna,National,,1771.35,,,,,,,1596.43,3622.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CORE REVISION,7697947,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4428.38000,1284.23000,Aetna,National,,1771.35,,,,,,,1425.94,3622.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACL TIGHTROPE,7697360,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2330.00000,675.70000,Aetna,National,,932.00,,,,,,,839.97,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACL TIGHTROPE,7697360,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2330.00000,675.70000,Aetna,National,,932.00,,,,,,,750.26,1905.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697950,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697950,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,National,,1302.00,,,,,,,1173.43,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7697962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,National,,1302.00,,,,,,,1048.11,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7697964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1931.72000,560.20000,Aetna,National,,772.69,,,,,,,696.39,1580.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7697964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1931.72000,560.20000,Aetna,National,,772.69,,,,,,,622.01,1580.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697967,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7697967,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER,7697969,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,National,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BLOCKER,7697969,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,National,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697972,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697972,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695300,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,National,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695300,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,National,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695562,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2498.00000,724.42000,Aetna,National,,999.20,,,,,,,900.53,2043.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695562,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2498.00000,724.42000,Aetna,National,,999.20,,,,,,,804.36,2043.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRUCIATE TIBIAL,7698010,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3027.20000,877.89000,Aetna,National,,1210.88,,,,,,,1091.31,2476.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRUCIATE TIBIAL,7698010,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3027.20000,877.89000,Aetna,National,,1210.88,,,,,,,974.76,2476.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10658.40000,3090.94000,Aetna,National,,4263.36,,,,,,,3842.35,8718.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10658.40000,3090.94000,Aetna,National,,4263.36,,,,,,,3432.00,8718.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987302,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,National,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987302,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,National,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695378,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695378,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698099,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1485.60000,430.82000,Aetna,National,,594.24,,,,,,,535.56,1215.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698099,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1485.60000,430.82000,Aetna,National,,594.24,,,,,,,478.36,1215.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698159,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2649.80000,768.44000,Aetna,National,,1059.92,,,,,,,955.25,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698159,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2649.80000,768.44000,Aetna,National,,1059.92,,,,,,,853.24,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.84000,508.32000,Aetna,National,,701.14,,,,,,,631.90,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.84000,508.32000,Aetna,National,,701.14,,,,,,,564.41,1433.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRALIZER,7698167,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,National,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DISTAL CENTRALIZER,7698167,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,National,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT NECK LENGTH ADAPTER,7698168,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,National,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT NECK LENGTH ADAPTER,7698168,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,National,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT UNIPOLAR,7698169,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1810.88000,525.16000,Aetna,National,,724.35,,,,,,,652.82,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT UNIPOLAR,7698169,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1810.88000,525.16000,Aetna,National,,724.35,,,,,,,583.10,1481.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,850.50000,246.64000,Aetna,National,,340.20,,,,,,,306.61,695.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,850.50000,246.64000,Aetna,National,,340.20,,,,,,,273.86,695.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,National,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,National,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696660,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,215.25000,62.42000,Aetna,National,,86.10,,,,,,,77.60,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696660,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,215.25000,62.42000,Aetna,National,,86.10,,,,,,,69.31,176.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4887.75000,1417.45000,Aetna,National,,1955.10,,,,,,,1762.03,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7698021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4887.75000,1417.45000,Aetna,National,,1955.10,,,,,,,1573.86,3998.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7698195,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7698195,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698197,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5197.50000,1507.28000,Aetna,National,,2079.00,,,,,,,1873.70,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7698197,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5197.50000,1507.28000,Aetna,National,,2079.00,,,,,,,1673.60,4251.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR PATCH,7698211,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2196.00000,636.84000,Aetna,National,,878.40,,,,,,,791.66,1796.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR PATCH,7698211,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2196.00000,636.84000,Aetna,National,,878.40,,,,,,,707.11,1796.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21000.00000,6090.00000,Aetna,National,,8400.00,,,,,,,7570.50,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7696913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21000.00000,6090.00000,Aetna,National,,8400.00,,,,,,,6762.00,17178.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7695982,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,National,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7695982,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,National,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696120,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,11175.00000,3240.75000,Aetna,National,,4470.00,,,,,,,4028.59,9141.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696120,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,11175.00000,3240.75000,Aetna,National,,4470.00,,,,,,,3598.35,9141.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7698231,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3381.00000,980.49000,Aetna,National,,1352.40,,,,,,,1218.85,2765.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7698231,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3381.00000,980.49000,Aetna,National,,1352.40,,,,,,,1088.68,2765.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1995.20000,578.61000,Aetna,National,,798.08,,,,,,,719.27,1632.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1995.20000,578.61000,Aetna,National,,798.08,,,,,,,642.45,1632.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7698226,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,National,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7698226,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,National,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BEARING,7698228,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,National,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BEARING,7698228,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,National,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,7698229,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,National,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL TRAY,7698229,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,National,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,7698243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,National,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL AUGMENT,7698243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,National,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698068,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4255.65000,1234.14000,Aetna,National,,1702.26,,,,,,,1534.16,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698068,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4255.65000,1234.14000,Aetna,National,,1702.26,,,,,,,1370.32,3481.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP NECK ADAPTER,7698249,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1599.20000,463.77000,Aetna,National,,639.68,,,,,,,576.51,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP NECK ADAPTER,7698249,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1599.20000,463.77000,Aetna,National,,639.68,,,,,,,514.94,1308.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7697849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1949.08000,565.23000,Aetna,National,,779.63,,,,,,,702.64,1594.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7697849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1949.08000,565.23000,Aetna,National,,779.63,,,,,,,627.60,1594.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695880,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,389.50000,112.96000,Aetna,National,,155.80,,,,,,,140.41,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLIDEWIRE,7695880,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,389.50000,112.96000,Aetna,National,,155.80,,,,,,,125.42,318.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697269,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7697269,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7696310,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,814.50000,236.20000,Aetna,National,,325.80,,,,,,,293.63,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7696310,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,814.50000,236.20000,Aetna,National,,325.80,,,,,,,262.27,666.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO PUSHLOCK,7696346,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,National,,780.80,,,,,,,703.70,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO PUSHLOCK,7696346,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,National,,780.80,,,,,,,628.54,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698604,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,141.75000,41.11000,Aetna,National,,56.70,,,,,,,51.10,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698604,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,141.75000,41.11000,Aetna,National,,56.70,,,,,,,45.64,115.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698654,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,174.09000,50.49000,Aetna,National,,69.64,,,,,,,62.76,142.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698654,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,174.09000,50.49000,Aetna,National,,69.64,,,,,,,56.06,142.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,7696653,CDM,278,RC,C1760,HCPCS,,,facility,inpatient,,,1400.00000,406.00000,Aetna,National,,560.00,,,,,,,504.70,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CLOSURE DEVICE VASCULAR,7696653,CDM,278,RC,C1760,HCPCS,,,facility,outpatient,,,1400.00000,406.00000,Aetna,National,,560.00,,,,,,,450.80,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8380724,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,National,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,8380724,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,National,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698286,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,National,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698286,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,National,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698277,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6188.91000,1794.78000,Aetna,National,,2475.56,,,,,,,2231.10,5062.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698277,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6188.91000,1794.78000,Aetna,National,,2475.56,,,,,,,1992.83,5062.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING CAP,7698278,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,746.78000,216.57000,Aetna,National,,298.71,,,,,,,269.21,610.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING CAP,7698278,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,746.78000,216.57000,Aetna,National,,298.71,,,,,,,240.46,610.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698289,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698289,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698299,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3285.91000,952.91000,Aetna,National,,1314.36,,,,,,,1184.57,2687.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698299,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3285.91000,952.91000,Aetna,National,,1314.36,,,,,,,1058.06,2687.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698305,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3356.50000,973.38000,Aetna,National,,1342.60,,,,,,,1210.02,2745.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698305,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3356.50000,973.38000,Aetna,National,,1342.60,,,,,,,1080.79,2745.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7698335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7698335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698330,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2420.00000,701.80000,Aetna,National,,968.00,,,,,,,872.41,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698330,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2420.00000,701.80000,Aetna,National,,968.00,,,,,,,779.24,1979.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694428,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,139.13000,40.35000,Aetna,National,,55.65,,,,,,,50.16,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7694428,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,139.13000,40.35000,Aetna,National,,55.65,,,,,,,44.80,113.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3863.48000,1120.41000,Aetna,National,,1545.39,,,,,,,1392.78,3160.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3863.48000,1120.41000,Aetna,National,,1545.39,,,,,,,1244.04,3160.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7698362,CDM,278,RC,L8631,HCPCS,,,facility,inpatient,,,7443.00000,2158.47000,Aetna,National,,2977.20,,,,,,,2683.20,6088.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7698362,CDM,278,RC,L8631,HCPCS,,,facility,outpatient,,,7443.00000,2158.47000,Aetna,National,,2977.20,,,,,,,2396.65,6088.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695436,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,National,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695436,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,National,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698710,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1359.88000,394.37000,Aetna,National,,543.95,,,,,,,490.24,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698710,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1359.88000,394.37000,Aetna,National,,543.95,,,,,,,437.88,1112.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,National,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,National,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,National,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,National,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695611,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1256.00000,364.24000,Aetna,National,,502.40,,,,,,,452.79,1027.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695611,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1256.00000,364.24000,Aetna,National,,502.40,,,,,,,404.43,1027.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7702780,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2125.60000,616.42000,Aetna,National,,850.24,,,,,,,766.28,1738.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7702780,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2125.60000,616.42000,Aetna,National,,850.24,,,,,,,684.44,1738.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7695386,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1336.00000,387.44000,Aetna,National,,534.40,,,,,,,481.63,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7695386,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1336.00000,387.44000,Aetna,National,,534.40,,,,,,,430.19,1092.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1865.13000,540.89000,Aetna,National,,746.05,,,,,,,672.38,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1865.13000,540.89000,Aetna,National,,746.05,,,,,,,600.57,1525.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695813,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,National,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695813,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,National,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698444,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6433.32000,1865.66000,Aetna,National,,2573.33,,,,,,,2319.21,5262.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698444,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6433.32000,1865.66000,Aetna,National,,2573.33,,,,,,,2071.53,5262.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,121.96000,35.37000,Aetna,National,,48.78,,,,,,,43.97,99.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,121.96000,35.37000,Aetna,National,,48.78,,,,,,,39.27,99.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,National,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,National,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698255,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1648.40000,478.04000,Aetna,National,,659.36,,,,,,,594.25,1348.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698255,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1648.40000,478.04000,Aetna,National,,659.36,,,,,,,530.78,1348.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1634.88000,474.12000,Aetna,National,,653.95,,,,,,,589.37,1337.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1634.88000,474.12000,Aetna,National,,653.95,,,,,,,526.43,1337.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,878.67000,254.81000,Aetna,National,,351.47,,,,,,,316.76,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,878.67000,254.81000,Aetna,National,,351.47,,,,,,,282.93,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698471,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2348.72000,681.13000,Aetna,National,,939.49,,,,,,,846.71,1921.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698471,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2348.72000,681.13000,Aetna,National,,939.49,,,,,,,756.29,1921.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695368,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2004.00000,581.16000,Aetna,National,,801.60,,,,,,,722.44,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695368,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2004.00000,581.16000,Aetna,National,,801.60,,,,,,,645.29,1639.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.40000,189.49000,Aetna,National,,261.36,,,,,,,235.55,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.40000,189.49000,Aetna,National,,261.36,,,,,,,210.39,534.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698475,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2680.56000,777.36000,Aetna,National,,1072.22,,,,,,,966.34,2192.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698475,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2680.56000,777.36000,Aetna,National,,1072.22,,,,,,,863.14,2192.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698476,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2714.36000,787.16000,Aetna,National,,1085.74,,,,,,,978.53,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698476,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2714.36000,787.16000,Aetna,National,,1085.74,,,,,,,874.02,2220.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698508,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20837.50000,6042.88000,Aetna,National,,8335.00,,,,,,,7511.92,17045.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7698508,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20837.50000,6042.88000,Aetna,National,,8335.00,,,,,,,6709.68,17045.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7695900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702867,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,9312.00000,2700.48000,Aetna,National,,3724.80,,,,,,,3356.98,7617.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7702867,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,9312.00000,2700.48000,Aetna,National,,3724.80,,,,,,,2998.46,7617.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695332,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,National,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695332,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,National,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.22000,1054.50000,Aetna,National,,1454.49,,,,,,,1310.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.22000,1054.50000,Aetna,National,,1454.49,,,,,,,1170.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695459,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,108.73000,31.53000,Aetna,National,,43.49,,,,,,,39.20,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695459,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,108.73000,31.53000,Aetna,National,,43.49,,,,,,,35.01,88.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,569.52000,165.16000,Aetna,National,,227.81,,,,,,,205.31,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,569.52000,165.16000,Aetna,National,,227.81,,,,,,,183.39,465.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,777.47000,225.47000,Aetna,National,,310.99,,,,,,,280.28,635.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7698573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,777.47000,225.47000,Aetna,National,,310.99,,,,,,,250.35,635.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698589,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,National,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698589,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,National,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698590,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698590,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 60,7695237,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,7539.00000,2186.31000,Aetna,National,,3015.60,,,,,,,2717.81,6166.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 60,7695237,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,7539.00000,2186.31000,Aetna,National,,3015.60,,,,,,,2427.56,6166.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5747.00000,1666.63000,Aetna,National,,2298.80,,,,,,,2071.79,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7701070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5747.00000,1666.63000,Aetna,National,,2298.80,,,,,,,1850.53,4701.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7699269,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14010.75000,4063.12000,Aetna,National,,5604.30,,,,,,,5050.88,11460.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7699269,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14010.75000,4063.12000,Aetna,National,,5604.30,,,,,,,4511.46,11460.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7699090,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7699090,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7699249,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,National,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7699249,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,National,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TROCHANTERIC CLAW,7699101,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3698.10000,1072.45000,Aetna,National,,1479.24,,,,,,,1333.17,3025.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TROCHANTERIC CLAW,7699101,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3698.10000,1072.45000,Aetna,National,,1479.24,,,,,,,1190.79,3025.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7700811,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,National,,591.52,,,,,,,533.11,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7700811,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,National,,591.52,,,,,,,476.17,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7699108,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,873.00000,253.17000,Aetna,National,,349.20,,,,,,,314.72,714.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7699108,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,873.00000,253.17000,Aetna,National,,349.20,,,,,,,281.11,714.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699109,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7614.00000,2208.06000,Aetna,National,,3045.60,,,,,,,2744.85,6228.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699109,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7614.00000,2208.06000,Aetna,National,,3045.60,,,,,,,2451.71,6228.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,612.54000,177.64000,Aetna,National,,245.02,,,,,,,220.82,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,612.54000,177.64000,Aetna,National,,245.02,,,,,,,197.24,501.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695193,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,705.38000,204.56000,Aetna,National,,282.15,,,,,,,254.29,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695193,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,705.38000,204.56000,Aetna,National,,282.15,,,,,,,227.13,577.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699133,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,National,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699133,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,National,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7699135,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,National,,994.72,,,,,,,896.49,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOCKING RING,7699135,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,National,,994.72,,,,,,,800.75,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7696942,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,National,,2076.76,,,,,,,1871.68,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7696942,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,National,,2076.76,,,,,,,1671.79,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,National,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,National,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1613.16000,467.82000,Aetna,National,,645.26,,,,,,,581.54,1319.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1613.16000,467.82000,Aetna,National,,645.26,,,,,,,519.44,1319.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3410.82000,989.14000,Aetna,National,,1364.33,,,,,,,1229.60,2790.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3410.82000,989.14000,Aetna,National,,1364.33,,,,,,,1098.28,2790.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5048.37000,1464.03000,Aetna,National,,2019.35,,,,,,,1819.94,4129.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5048.37000,1464.03000,Aetna,National,,2019.35,,,,,,,1625.58,4129.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.32000,1538.83000,Aetna,National,,2122.53,,,,,,,1912.93,4340.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.32000,1538.83000,Aetna,National,,2122.53,,,,,,,1708.64,4340.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699725,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1971.60000,571.76000,Aetna,National,,788.64,,,,,,,710.76,1612.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699725,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1971.60000,571.76000,Aetna,National,,788.64,,,,,,,634.86,1612.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697489,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.22000,1054.50000,Aetna,National,,1454.49,,,,,,,1310.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697489,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.22000,1054.50000,Aetna,National,,1454.49,,,,,,,1170.86,2974.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBULAR SHAFT,7695784,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3121.80000,905.32000,Aetna,National,,1248.72,,,,,,,1125.41,2553.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIBULAR SHAFT,7695784,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3121.80000,905.32000,Aetna,National,,1248.72,,,,,,,1005.22,2553.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700794,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2408.00000,698.32000,Aetna,National,,963.20,,,,,,,868.08,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700794,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2408.00000,698.32000,Aetna,National,,963.20,,,,,,,775.38,1969.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,National,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7698146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,National,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699187,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5694.26000,1651.34000,Aetna,National,,2277.70,,,,,,,2052.78,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7699187,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5694.26000,1651.34000,Aetna,National,,2277.70,,,,,,,1833.55,4657.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700825,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,National,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7700825,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,National,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,National,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,National,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9249.00000,2682.21000,Aetna,National,,3699.60,,,,,,,3334.26,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7700520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9249.00000,2682.21000,Aetna,National,,3699.60,,,,,,,2978.18,7565.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702010,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2956.00000,857.24000,Aetna,National,,1182.40,,,,,,,1065.64,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702010,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2956.00000,857.24000,Aetna,National,,1182.40,,,,,,,951.83,2418.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2204.00000,639.16000,Aetna,National,,881.60,,,,,,,794.54,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2204.00000,639.16000,Aetna,National,,881.60,,,,,,,709.69,1802.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694402,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1352.00000,392.08000,Aetna,National,,540.80,,,,,,,487.40,1105.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694402,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1352.00000,392.08000,Aetna,National,,540.80,,,,,,,435.34,1105.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740529,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21567.50000,6254.58000,Aetna,National,,8627.00,,,,,,,7775.08,17642.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7740529,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21567.50000,6254.58000,Aetna,National,,8627.00,,,,,,,6944.73,17642.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7699599,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,8306.10000,2408.77000,Aetna,National,,3322.44,,,,,,,2994.35,6794.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT DISTAL,7699599,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,8306.10000,2408.77000,Aetna,National,,3322.44,,,,,,,2364.47,6794.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698235,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,National,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7698235,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,National,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7699524,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2476.00000,718.04000,Aetna,National,,990.40,,,,,,,892.60,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7699524,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2476.00000,718.04000,Aetna,National,,990.40,,,,,,,797.27,2025.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7697986,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,31050.00000,9004.50000,Aetna,National,,12420.00,,,,,,,11193.52,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7697986,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,31050.00000,9004.50000,Aetna,National,,12420.00,,,,,,,9998.10,25398.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135831,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,1652.00000,479.08000,Aetna,National,,660.80,,,,,,,595.55,1351.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8135831,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,1652.00000,479.08000,Aetna,National,,9959.00,,,,,,,531.94,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
PLATE,7699218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,829.85000,240.66000,Aetna,National,,331.94,,,,,,,299.16,678.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,829.85000,240.66000,Aetna,National,,331.94,,,,,,,267.21,678.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7697463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5105.63000,1480.63000,Aetna,National,,2042.25,,,,,,,1840.58,4176.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7697463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5105.63000,1480.63000,Aetna,National,,2042.25,,,,,,,1644.01,4176.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694850,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1652.76000,479.30000,Aetna,National,,661.10,,,,,,,595.82,1351.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694850,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1652.76000,479.30000,Aetna,National,,661.10,,,,,,,532.19,1351.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS,7693559,CDM,278,RC,C1750,HCPCS,,,facility,inpatient,,,414.92000,120.33000,Aetna,National,,165.97,,,,,,,149.58,339.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS,7693559,CDM,278,RC,C1750,HCPCS,,,facility,outpatient,,,414.92000,120.33000,Aetna,National,,165.97,,,,,,,133.60,339.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7694362,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,427.83000,124.07000,Aetna,National,,171.13,,,,,,,154.23,349.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PUTTY,7694362,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,427.83000,124.07000,Aetna,National,,171.13,,,,,,,137.76,349.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701183,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,361.00000,104.69000,Aetna,National,,144.40,,,,,,,130.14,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701183,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,361.00000,104.69000,Aetna,National,,144.40,,,,,,,116.24,295.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694442,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1372.00000,397.88000,Aetna,National,,548.80,,,,,,,494.61,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7694442,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1372.00000,397.88000,Aetna,National,,548.80,,,,,,,441.78,1122.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BARRIER ADHESION,7694666,CDM,278,RC,C1765,HCPCS,,,facility,inpatient,,,2308.40000,669.44000,Aetna,National,,923.36,,,,,,,832.18,1888.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BARRIER ADHESION,7694666,CDM,278,RC,C1765,HCPCS,,,facility,outpatient,,,2308.40000,669.44000,Aetna,National,,923.36,,,,,,,743.30,1888.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7694853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1466.40000,425.26000,Aetna,National,,586.56,,,,,,,528.64,1199.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7694853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1466.40000,425.26000,Aetna,National,,586.56,,,,,,,472.18,1199.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7694896,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17859.38000,5179.22000,Aetna,National,,7143.75,,,,,,,6438.31,14608.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7694896,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17859.38000,5179.22000,Aetna,National,,7143.75,,,,,,,5750.72,14608.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7695394,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,29632.50000,8593.42000,Aetna,National,,11853.00,,,,,,,10682.52,24239.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7695394,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,29632.50000,8593.42000,Aetna,National,,11853.00,,,,,,,9541.67,24239.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695887,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,868.50000,251.86000,Aetna,National,,347.40,,,,,,,313.09,710.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695887,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,868.50000,251.86000,Aetna,National,,347.40,,,,,,,279.66,710.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,342.00000,99.18000,Aetna,National,,136.80,,,,,,,123.29,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,342.00000,99.18000,Aetna,National,,136.80,,,,,,,110.12,279.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696123,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,8055.00000,2335.95000,Aetna,National,,3222.00,,,,,,,2903.83,6588.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696123,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,8055.00000,2335.95000,Aetna,National,,3222.00,,,,,,,2593.71,6588.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696128,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,940.69000,272.80000,Aetna,National,,376.28,,,,,,,339.12,769.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696128,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,940.69000,272.80000,Aetna,National,,376.28,,,,,,,302.90,769.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696129,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,932.73000,270.49000,Aetna,National,,373.09,,,,,,,336.25,762.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696129,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,932.73000,270.49000,Aetna,National,,373.09,,,,,,,300.34,762.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135599,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,722.25000,209.45000,Aetna,National,,288.90,,,,,,,260.37,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8135599,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,722.25000,209.45000,Aetna,National,,288.90,,,,,,,232.56,590.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135847,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135847,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135846,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135846,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135844,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135844,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135843,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135843,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135842,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135842,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135840,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8135840,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE SYSTEM,8135849,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2806.72000,813.95000,Aetna,National,,1122.69,,,,,,,1011.82,2295.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE SYSTEM,8135849,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2806.72000,813.95000,Aetna,National,,1122.69,,,,,,,903.76,2295.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE GOOSENECK,8135850,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,National,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SNARE GOOSENECK,8135850,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,National,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135469,CDM,278,RC,C1733,HCPCS,,,facility,inpatient,,,3447.50000,999.78000,Aetna,National,,1379.00,,,,,,,1242.82,2820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER ABLATION,8135469,CDM,278,RC,C1733,HCPCS,,,facility,outpatient,,,3447.50000,999.78000,Aetna,National,,9959.00,,,,,,,1110.10,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
GUIDE CATHETER,8135523,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,National,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135523,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,National,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135853,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,National,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135853,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,National,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135852,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,National,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135852,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,National,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135851,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,465.50000,135.00000,Aetna,National,,186.20,,,,,,,167.81,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8135851,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,465.50000,135.00000,Aetna,National,,186.20,,,,,,,149.89,380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP SET AIC IMPELLA,8135854,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,52000.00000,15080.00000,Aetna,National,,20800.00,,,,,,,18746.00,42536.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP SET AIC IMPELLA,8135854,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,52000.00000,15080.00000,Aetna,National,,20800.00,,,,,,,16744.00,42536.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135496,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,224.23000,65.03000,Aetna,National,,89.69,,,,,,,80.83,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,8135496,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,224.23000,65.03000,Aetna,National,,89.69,,,,,,,72.20,183.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699179,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2389.04000,692.82000,Aetna,National,,955.62,,,,,,,861.25,1954.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699179,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2389.04000,692.82000,Aetna,National,,955.62,,,,,,,769.27,1954.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699180,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1845.92000,535.32000,Aetna,National,,738.37,,,,,,,665.45,1509.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699180,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1845.92000,535.32000,Aetna,National,,738.37,,,,,,,594.39,1509.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7695520,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1658.08000,480.84000,Aetna,National,,663.23,,,,,,,597.74,1356.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7695520,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1658.08000,480.84000,Aetna,National,,663.23,,,,,,,533.90,1356.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699171,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,12150.00000,3523.50000,Aetna,National,,4860.00,,,,,,,4380.07,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699171,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,12150.00000,3523.50000,Aetna,National,,4860.00,,,,,,,3912.30,9938.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7698172,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIL BALLOON,7698172,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694311,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,National,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694311,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,National,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7695606,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,National,,6900.00,,,,,,,6218.62,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7695606,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,National,,6900.00,,,,,,,5554.50,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,494.48000,143.40000,Aetna,National,,197.79,,,,,,,178.26,404.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7695842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,494.48000,143.40000,Aetna,National,,197.79,,,,,,,159.22,404.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,National,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7699296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,National,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7699315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17887.00000,5187.23000,Aetna,National,,7154.80,,,,,,,6448.26,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7699315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17887.00000,5187.23000,Aetna,National,,7154.80,,,,,,,5759.61,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7695587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,National,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7695587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,National,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7695590,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12531.60000,3634.16000,Aetna,National,,5012.64,,,,,,,4517.64,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7695590,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12531.60000,3634.16000,Aetna,National,,5012.64,,,,,,,4035.18,10250.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699106,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,National,,3099.36,,,,,,,2793.30,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699106,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,National,,3099.36,,,,,,,2494.98,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7694881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2413.88000,700.03000,Aetna,National,,965.55,,,,,,,870.20,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7694881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2413.88000,700.03000,Aetna,National,,965.55,,,,,,,777.27,1974.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15425.00000,4473.25000,Aetna,National,,6170.00,,,,,,,5560.71,12617.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15425.00000,4473.25000,Aetna,National,,6170.00,,,,,,,4966.85,12617.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699343,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7635.00000,2214.15000,Aetna,National,,3054.00,,,,,,,2752.42,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699343,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7635.00000,2214.15000,Aetna,National,,3054.00,,,,,,,2458.47,6245.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1932.00000,560.28000,Aetna,National,,772.80,,,,,,,696.49,1580.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1932.00000,560.28000,Aetna,National,,772.80,,,,,,,622.10,1580.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699365,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,National,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699365,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,National,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7696939,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3759.70000,1090.31000,Aetna,National,,1503.88,,,,,,,1355.37,3075.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7696939,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3759.70000,1090.31000,Aetna,National,,1503.88,,,,,,,1210.62,3075.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699368,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699368,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698055,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14562.00000,4222.98000,Aetna,National,,5824.80,,,,,,,5249.60,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698055,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14562.00000,4222.98000,Aetna,National,,5824.80,,,,,,,4688.96,11911.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699356,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,National,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7699356,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,National,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5471.97000,1586.87000,Aetna,National,,2188.79,,,,,,,1972.65,4476.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5471.97000,1586.87000,Aetna,National,,2188.79,,,,,,,1761.97,4476.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699377,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2426.28000,703.62000,Aetna,National,,970.51,,,,,,,874.67,1984.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699377,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2426.28000,703.62000,Aetna,National,,970.51,,,,,,,781.26,1984.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7698918,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1208.00000,350.32000,Aetna,National,,483.20,,,,,,,435.48,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL CAP,7698918,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1208.00000,350.32000,Aetna,National,,483.20,,,,,,,388.98,988.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699572,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3777.94000,1095.60000,Aetna,National,,1511.18,,,,,,,1361.95,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699572,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3777.94000,1095.60000,Aetna,National,,1511.18,,,,,,,1216.50,3090.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699422,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2009.40000,582.73000,Aetna,National,,803.76,,,,,,,724.39,1643.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699422,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2009.40000,582.73000,Aetna,National,,803.76,,,,,,,647.03,1643.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7699428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7699428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699432,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699432,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699437,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1637.00000,474.73000,Aetna,National,,654.80,,,,,,,590.14,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699437,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1637.00000,474.73000,Aetna,National,,654.80,,,,,,,527.11,1339.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699185,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8611.20000,2497.25000,Aetna,National,,3444.48,,,,,,,3104.34,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7699185,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8611.20000,2497.25000,Aetna,National,,3444.48,,,,,,,2772.81,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699441,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3737.30000,1083.82000,Aetna,National,,1494.92,,,,,,,1347.30,3057.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699441,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3737.30000,1083.82000,Aetna,National,,1494.92,,,,,,,1203.41,3057.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7698527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17887.00000,5187.23000,Aetna,National,,7154.80,,,,,,,6448.26,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL IMPLANT,7698527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17887.00000,5187.23000,Aetna,National,,7154.80,,,,,,,5759.61,14631.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698529,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698529,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6077.86000,1762.58000,Aetna,National,,2431.14,,,,,,,2191.07,4971.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6077.86000,1762.58000,Aetna,National,,2431.14,,,,,,,1957.07,4971.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699461,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699461,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7694389,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,National,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7694389,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,National,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,National,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,National,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.80000,359.83000,Aetna,National,,496.32,,,,,,,447.31,1014.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.80000,359.83000,Aetna,National,,496.32,,,,,,,399.54,1014.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699463,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5693.10000,1651.00000,Aetna,National,,2277.24,,,,,,,2052.36,4656.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699463,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5693.10000,1651.00000,Aetna,National,,2277.24,,,,,,,1833.18,4656.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7696190,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,963.00000,279.27000,Aetna,National,,385.20,,,,,,,347.16,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7696190,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,963.00000,279.27000,Aetna,National,,385.20,,,,,,,310.09,787.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,National,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,National,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702394,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2993.56000,868.13000,Aetna,National,,1197.42,,,,,,,1079.18,2448.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702394,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2993.56000,868.13000,Aetna,National,,1197.42,,,,,,,963.93,2448.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7695589,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7695589,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699491,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,National,,1396.85,,,,,,,1258.91,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699491,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,National,,1396.85,,,,,,,1124.47,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699493,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7546.50000,2188.48000,Aetna,National,,3018.60,,,,,,,2720.51,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7699493,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7546.50000,2188.48000,Aetna,National,,3018.60,,,,,,,2429.97,6173.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,21330.00000,6185.70000,Aetna,National,,8532.00,,,,,,,7689.47,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,21330.00000,6185.70000,Aetna,National,,8532.00,,,,,,,6868.26,17447.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7699497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4955.13000,1436.99000,Aetna,National,,1982.05,,,,,,,1786.32,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7699497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4955.13000,1436.99000,Aetna,National,,1982.05,,,,,,,1595.55,4053.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7699498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7803.00000,2262.87000,Aetna,National,,3121.20,,,,,,,2812.98,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7699498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7803.00000,2262.87000,Aetna,National,,3121.20,,,,,,,2512.57,6382.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699499,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699499,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4298.84000,1246.66000,Aetna,National,,1719.54,,,,,,,1549.73,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4298.84000,1246.66000,Aetna,National,,1719.54,,,,,,,1384.23,3516.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT DUODENAL,7695159,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,9309.54000,2699.77000,Aetna,National,,3723.82,,,,,,,3356.09,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT DUODENAL,7695159,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,9309.54000,2699.77000,Aetna,National,,3723.82,,,,,,,2997.67,7615.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO ULTRA,7695245,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,8142.00000,2361.18000,Aetna,National,,3256.80,,,,,,,2935.19,6660.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO ULTRA,7695245,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,8142.00000,2361.18000,Aetna,National,,3256.80,,,,,,,2621.72,6660.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRASPING DEVICE TALON,7695186,CDM,278,RC,C1773,HCPCS,,,facility,inpatient,,,720.00000,208.80000,Aetna,National,,288.00,,,,,,,259.56,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRASPING DEVICE TALON,7695186,CDM,278,RC,C1773,HCPCS,,,facility,outpatient,,,720.00000,208.80000,Aetna,National,,288.00,,,,,,,231.84,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,7694306,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.16000,352.69000,Aetna,National,,486.46,,,,,,,438.43,994.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,7694306,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.16000,352.69000,Aetna,National,,486.46,,,,,,,391.60,994.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697453,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7697453,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695081,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,837.00000,242.73000,Aetna,National,,334.80,,,,,,,301.74,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7695081,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,837.00000,242.73000,Aetna,National,,334.80,,,,,,,269.51,684.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7768032,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,National,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7768032,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,National,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOCONVEX PATELLA,7768031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7665.00000,2222.85000,Aetna,National,,3066.00,,,,,,,2763.23,6269.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOCONVEX PATELLA,7768031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7665.00000,2222.85000,Aetna,National,,3066.00,,,,,,,2468.13,6269.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697309,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,6212.50000,1801.62000,Aetna,National,,2485.00,,,,,,,2239.61,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7697309,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,6212.50000,1801.62000,Aetna,National,,2485.00,,,,,,,2000.42,5081.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7694970,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,7350.00000,2131.50000,Aetna,National,,2940.00,,,,,,,2649.68,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7694970,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,7350.00000,2131.50000,Aetna,National,,2940.00,,,,,,,2366.70,6012.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694386,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,774.00000,224.46000,Aetna,National,,309.60,,,,,,,279.03,633.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7694386,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,774.00000,224.46000,Aetna,National,,309.60,,,,,,,249.23,633.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT INTRO,7695006,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,380.00000,110.20000,Aetna,National,,152.00,,,,,,,136.99,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT INTRO,7695006,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,380.00000,110.20000,Aetna,National,,152.00,,,,,,,122.36,310.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695192,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,337.68000,97.93000,Aetna,National,,135.07,,,,,,,121.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695192,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,337.68000,97.93000,Aetna,National,,135.07,,,,,,,108.73,276.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8148864,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3040.00000,881.60000,Aetna,National,,1216.00,,,,,,,1095.92,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8148864,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3040.00000,881.60000,Aetna,National,,1216.00,,,,,,,978.88,2486.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699512,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2808.00000,814.32000,Aetna,National,,1123.20,,,,,,,1012.28,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699512,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2808.00000,814.32000,Aetna,National,,1123.20,,,,,,,904.18,2296.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699513,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,3753.75000,1088.59000,Aetna,National,,1501.50,,,,,,,1353.23,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699513,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,3753.75000,1088.59000,Aetna,National,,1501.50,,,,,,,1208.71,3070.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699528,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15300.00000,4437.00000,Aetna,National,,6120.00,,,,,,,5515.65,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699528,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15300.00000,4437.00000,Aetna,National,,6120.00,,,,,,,4926.60,12515.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7698027,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,National,,7344.00,,,,,,,6618.78,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7698027,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,National,,7344.00,,,,,,,5911.92,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,National,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,National,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698920,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,National,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698920,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,National,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7698618,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7698618,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699544,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,51740.00000,15004.60000,Aetna,National,,20696.00,,,,,,,18652.27,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699544,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,51740.00000,15004.60000,Aetna,National,,20696.00,,,,,,,16660.28,42323.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699545,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,45837.00000,13292.73000,Aetna,National,,18334.80,,,,,,,16524.24,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7699545,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,45837.00000,13292.73000,Aetna,National,,18334.80,,,,,,,14759.51,37494.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1802.48000,522.72000,Aetna,National,,720.99,,,,,,,649.79,1474.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1802.48000,522.72000,Aetna,National,,720.99,,,,,,,580.40,1474.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1920.40000,556.92000,Aetna,National,,768.16,,,,,,,692.30,1570.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1920.40000,556.92000,Aetna,National,,768.16,,,,,,,618.37,1570.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699553,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2816.00000,816.64000,Aetna,National,,1126.40,,,,,,,1015.17,2303.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699553,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2816.00000,816.64000,Aetna,National,,1126.40,,,,,,,906.75,2303.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,823.50000,238.82000,Aetna,National,,329.40,,,,,,,296.87,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,823.50000,238.82000,Aetna,National,,329.40,,,,,,,265.17,673.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,159.60000,46.28000,Aetna,National,,63.84,,,,,,,57.54,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,159.60000,46.28000,Aetna,National,,63.84,,,,,,,51.39,130.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702688,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,3671.50000,1064.73000,Aetna,National,,1468.60,,,,,,,1323.58,3003.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7702688,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,3671.50000,1064.73000,Aetna,National,,1468.60,,,,,,,1182.22,3003.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699568,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,958.50000,277.96000,Aetna,National,,383.40,,,,,,,345.54,784.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699568,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,958.50000,277.96000,Aetna,National,,383.40,,,,,,,308.64,784.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8144.13000,2361.80000,Aetna,National,,3257.65,,,,,,,2935.96,6661.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8144.13000,2361.80000,Aetna,National,,3257.65,,,,,,,2622.41,6661.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701314,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1580.00000,458.20000,Aetna,National,,632.00,,,,,,,569.59,1292.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701314,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1580.00000,458.20000,Aetna,National,,632.00,,,,,,,508.76,1292.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697970,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,National,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7697970,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,National,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699615,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,National,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7699615,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,National,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699607,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1566.60000,454.31000,Aetna,National,,626.64,,,,,,,564.76,1281.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699607,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1566.60000,454.31000,Aetna,National,,626.64,,,,,,,504.45,1281.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695800,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,National,,336.13,,,,,,,302.94,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695800,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,National,,336.13,,,,,,,270.59,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698144,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698144,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19036.38000,5520.55000,Aetna,National,,7614.55,,,,,,,6862.61,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7698145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19036.38000,5520.55000,Aetna,National,,7614.55,,,,,,,6129.71,15571.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699636,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1894.12000,549.29000,Aetna,National,,757.65,,,,,,,682.83,1549.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7699636,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1894.12000,549.29000,Aetna,National,,757.65,,,,,,,609.91,1549.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696955,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,National,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696955,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,National,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699640,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,National,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TAPER,7699640,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,National,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699644,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,National,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7699644,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,National,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4765.92000,1382.12000,Aetna,National,,1906.37,,,,,,,1718.11,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4765.92000,1382.12000,Aetna,National,,1906.37,,,,,,,1534.63,3898.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7840.47000,2273.74000,Aetna,National,,3136.19,,,,,,,2826.49,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7840.47000,2273.74000,Aetna,National,,3136.19,,,,,,,2524.63,6413.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7698401,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15024.03000,4356.97000,Aetna,National,,6009.61,,,,,,,5416.16,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7698401,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15024.03000,4356.97000,Aetna,National,,6009.61,,,,,,,4837.74,12289.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7699107,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,National,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7699107,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,National,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699704,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2060.00000,597.40000,Aetna,National,,824.00,,,,,,,742.63,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699704,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2060.00000,597.40000,Aetna,National,,824.00,,,,,,,663.32,1685.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699703,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,327.75000,95.05000,Aetna,National,,131.10,,,,,,,118.15,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699703,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,327.75000,95.05000,Aetna,National,,131.10,,,,,,,105.54,268.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7407.00000,2148.03000,Aetna,National,,2962.80,,,,,,,2670.22,6058.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7407.00000,2148.03000,Aetna,National,,2962.80,,,,,,,2385.05,6058.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7697285,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,6650.00000,1928.50000,Aetna,National,,2660.00,,,,,,,2397.32,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7697285,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,6650.00000,1928.50000,Aetna,National,,2660.00,,,,,,,2141.30,5439.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,National,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,National,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7697960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3020.00000,875.80000,Aetna,National,,1208.00,,,,,,,1088.71,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7697960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3020.00000,875.80000,Aetna,National,,1208.00,,,,,,,972.44,2470.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699737,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3255.00000,943.95000,Aetna,National,,1302.00,,,,,,,1173.43,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7699737,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3255.00000,943.95000,Aetna,National,,1302.00,,,,,,,1048.11,2662.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697096,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7697096,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698320,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698320,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7699764,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,7575.00000,2196.75000,Aetna,National,,3030.00,,,,,,,2730.79,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE EXPANDER,7699764,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,7575.00000,2196.75000,Aetna,National,,3030.00,,,,,,,2439.15,6196.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.68000,235.10000,Aetna,National,,324.27,,,,,,,292.25,663.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.68000,235.10000,Aetna,National,,324.27,,,,,,,261.04,663.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699787,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,National,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699787,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,National,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699788,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2225.00000,645.25000,Aetna,National,,890.00,,,,,,,802.11,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7699788,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2225.00000,645.25000,Aetna,National,,890.00,,,,,,,716.45,1820.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698196,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698196,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7699792,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,National,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7699792,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,National,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699799,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7699799,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7699809,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,1957.20000,567.59000,Aetna,National,,782.88,,,,,,,705.57,1600.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7699809,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,1957.20000,567.59000,Aetna,National,,782.88,,,,,,,630.22,1600.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699841,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699841,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7699822,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8932.50000,2590.42000,Aetna,National,,3573.00,,,,,,,3220.17,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7699822,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8932.50000,2590.42000,Aetna,National,,3573.00,,,,,,,2876.26,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,643.50000,186.61000,Aetna,National,,257.40,,,,,,,231.98,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,643.50000,186.61000,Aetna,National,,257.40,,,,,,,207.21,526.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893608,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,National,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893608,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,National,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7893610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4673.59000,1355.34000,Aetna,National,,1869.44,,,,,,,1684.83,3823.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7893610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4673.59000,1355.34000,Aetna,National,,1869.44,,,,,,,1504.90,3823.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695623,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,236.25000,68.51000,Aetna,National,,94.50,,,,,,,85.17,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7695623,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,236.25000,68.51000,Aetna,National,,94.50,,,,,,,76.07,193.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7893912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893913,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7893913,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7893958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1820.00000,527.80000,Aetna,National,,728.00,,,,,,,656.11,1488.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7893958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1820.00000,527.80000,Aetna,National,,728.00,,,,,,,586.04,1488.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE CRYOABLATION,7852029,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,9600.00000,2784.00000,Aetna,National,,3840.00,,,,,,,3460.80,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE CRYOABLATION,7852029,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,9600.00000,2784.00000,Aetna,National,,3840.00,,,,,,,3091.20,7852.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE CRYOABLATION,7694870,CDM,278,RC,C2618,HCPCS,,,facility,inpatient,,,11280.00000,3271.20000,Aetna,National,,4512.00,,,,,,,4066.44,9227.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROBE CRYOABLATION,7694870,CDM,278,RC,C2618,HCPCS,,,facility,outpatient,,,11280.00000,3271.20000,Aetna,National,,4512.00,,,,,,,3632.16,9227.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1616.00000,468.64000,Aetna,National,,646.40,,,,,,,582.57,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1616.00000,468.64000,Aetna,National,,646.40,,,,,,,520.35,1321.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7894125,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,906.12000,262.77000,Aetna,National,,362.45,,,,,,,326.66,741.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7894125,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,906.12000,262.77000,Aetna,National,,362.45,,,,,,,291.77,741.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,7894202,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8550.00000,2479.50000,Aetna,National,,3420.00,,,,,,,3082.28,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,7894202,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8550.00000,2479.50000,Aetna,National,,3420.00,,,,,,,2753.10,6993.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,7894203,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,14700.00000,4263.00000,Aetna,National,,5880.00,,,,,,,5299.35,12024.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE VOID FILLER,7894203,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,14700.00000,4263.00000,Aetna,National,,5880.00,,,,,,,4733.40,12024.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699120,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,230.78000,66.93000,Aetna,National,,92.31,,,,,,,83.20,188.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7699120,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,230.78000,66.93000,Aetna,National,,92.31,,,,,,,74.31,188.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2078.68000,602.82000,Aetna,National,,831.47,,,,,,,749.36,1700.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2078.68000,602.82000,Aetna,National,,831.47,,,,,,,669.33,1700.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,National,,740.85,,,,,,,667.69,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,National,,740.85,,,,,,,596.38,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695301,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1254.80000,363.89000,Aetna,National,,501.92,,,,,,,452.36,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695301,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1254.80000,363.89000,Aetna,National,,501.92,,,,,,,404.05,1026.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9978.00000,2893.62000,Aetna,National,,3991.20,,,,,,,3597.07,8162.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9978.00000,2893.62000,Aetna,National,,3991.20,,,,,,,3212.92,8162.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7894315,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5675.25000,1645.82000,Aetna,National,,2270.10,,,,,,,2045.93,4642.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7894315,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5675.25000,1645.82000,Aetna,National,,2270.10,,,,,,,1827.43,4642.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7895648,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8100.00000,2349.00000,Aetna,National,,3240.00,,,,,,,2920.05,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7895648,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8100.00000,2349.00000,Aetna,National,,3240.00,,,,,,,2608.20,6625.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7895649,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7895649,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7895465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1854.68000,537.86000,Aetna,National,,741.87,,,,,,,668.61,1517.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7895465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1854.68000,537.86000,Aetna,National,,741.87,,,,,,,597.21,1517.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA,7895673,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA,7895673,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7698839,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,National,,1929.06,,,,,,,1738.57,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7698839,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,National,,1929.06,,,,,,,1552.89,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896397,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5600.00000,1624.00000,Aetna,National,,2240.00,,,,,,,2018.80,4580.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896397,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5600.00000,1624.00000,Aetna,National,,2240.00,,,,,,,1803.20,4580.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,National,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7896389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,National,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7896749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.00000,1485.96000,Aetna,National,,2049.60,,,,,,,1847.20,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7896749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.00000,1485.96000,Aetna,National,,2049.60,,,,,,,1649.93,4191.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896843,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7896843,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7896881,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,497.80000,144.36000,Aetna,National,,199.12,,,,,,,179.46,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7896881,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,497.80000,144.36000,Aetna,National,,199.12,,,,,,,160.29,407.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7896875,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,460.75000,133.62000,Aetna,National,,184.30,,,,,,,166.10,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7896875,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,460.75000,133.62000,Aetna,National,,184.30,,,,,,,148.36,376.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,National,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7698614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,National,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BRONCHIAL THERMOPLASTY,7896969,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,National,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BRONCHIAL THERMOPLASTY,7896969,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,National,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,National,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7882483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,National,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7897116,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7897116,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7897118,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,58000.00000,16820.00000,Aetna,National,,23200.00,,,,,,,20909.00,47444.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7897118,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,58000.00000,16820.00000,Aetna,National,,23200.00,,,,,,,18676.00,47444.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7897119,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7897119,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,7897120,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4494.00000,1303.26000,Aetna,National,,1797.60,,,,,,,1620.09,3676.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,7897120,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4494.00000,1303.26000,Aetna,National,,1797.60,,,,,,,1447.07,3676.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CHARGING SYSTEM,7897121,CDM,278,RC,C1822,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CHARGING SYSTEM,7897121,CDM,278,RC,C1822,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7897352,CDM,278,RC,,,,,facility,inpatient,,,3492.13000,1012.72000,Aetna,National,,1396.85,,,,,,,1258.91,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7897352,CDM,278,RC,,,,,facility,outpatient,,,3492.13000,1012.72000,Aetna,National,,1396.85,,,,,,,1124.47,2856.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7897359,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9144.09000,2651.79000,Aetna,National,,3657.64,,,,,,,3296.44,7479.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7897359,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9144.09000,2651.79000,Aetna,National,,3657.64,,,,,,,2944.40,7479.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910231,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,227.85000,66.08000,Aetna,National,,91.14,,,,,,,82.14,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910231,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,227.85000,66.08000,Aetna,National,,91.14,,,,,,,73.37,186.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7897361,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,National,,1577.80,,,,,,,1421.99,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7897361,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,National,,1577.80,,,,,,,1270.13,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7695586,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7695586,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,National,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7696403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,National,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7900150,CDM,278,RC,C1755,HCPCS,,,facility,inpatient,,,4980.50000,1444.34000,Aetna,National,,1992.20,,,,,,,1795.47,4074.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7900150,CDM,278,RC,C1755,HCPCS,,,facility,outpatient,,,4980.50000,1444.34000,Aetna,National,,1992.20,,,,,,,1603.72,4074.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7900141,CDM,278,RC,C1734,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,National,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7900141,CDM,278,RC,C1734,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,National,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900295,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4427.50000,1283.97000,Aetna,National,,1771.00,,,,,,,1596.11,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900295,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4427.50000,1283.97000,Aetna,National,,1771.00,,,,,,,1425.65,3621.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7900297,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7900297,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900326,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4448.19000,1289.98000,Aetna,National,,1779.28,,,,,,,1603.57,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900326,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4448.19000,1289.98000,Aetna,National,,1779.28,,,,,,,1432.32,3638.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900534,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4915.30000,1425.44000,Aetna,National,,1966.12,,,,,,,1771.97,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7900534,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4915.30000,1425.44000,Aetna,National,,1966.12,,,,,,,1582.73,4020.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7741812,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,21875.00000,6343.75000,Aetna,National,,8750.00,,,,,,,7885.94,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7741812,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,21875.00000,6343.75000,Aetna,National,,8750.00,,,,,,,7043.75,17893.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7699527,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22062.50000,6398.12000,Aetna,National,,8825.00,,,,,,,7953.53,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7699527,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22062.50000,6398.12000,Aetna,National,,8825.00,,,,,,,7104.12,18047.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7901616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7901616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7901621,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7901621,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7901700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7901700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7901703,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,National,,1441.78,,,,,,,1299.40,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7901703,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,National,,1441.78,,,,,,,1160.63,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PASTE BEADS,7698897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9810.03000,2844.91000,Aetna,National,,3924.01,,,,,,,3536.52,8024.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PASTE BEADS,7698897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9810.03000,2844.91000,Aetna,National,,3924.01,,,,,,,3158.83,8024.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901799,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,507.78000,147.26000,Aetna,National,,203.11,,,,,,,183.05,415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7901799,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,507.78000,147.26000,Aetna,National,,203.11,,,,,,,163.51,415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901853,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5936.39000,1721.55000,Aetna,National,,2374.56,,,,,,,2140.07,4855.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7901853,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5936.39000,1721.55000,Aetna,National,,2374.56,,,,,,,1911.52,4855.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7901859,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,National,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7901859,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,National,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7902103,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11173.20000,3240.23000,Aetna,National,,4469.28,,,,,,,4027.94,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7902103,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11173.20000,3240.23000,Aetna,National,,4469.28,,,,,,,3597.77,9139.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STERNA BAND,7702706,CDM,278,RC,,,,,facility,inpatient,,,152.25000,44.15000,Aetna,National,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STERNA BAND,7702706,CDM,278,RC,,,,,facility,outpatient,,,152.25000,44.15000,Aetna,National,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7902345,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4548.95000,1319.20000,Aetna,National,,1819.58,,,,,,,1639.90,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7902345,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4548.95000,1319.20000,Aetna,National,,1819.58,,,,,,,1464.76,3721.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7902350,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,National,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7902350,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,National,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRIP CABLE,7902352,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3493.00000,1012.97000,Aetna,National,,1397.20,,,,,,,1259.23,2857.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRIP CABLE,7902352,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3493.00000,1012.97000,Aetna,National,,1397.20,,,,,,,1124.75,2857.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7902637,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,646.47000,187.48000,Aetna,National,,258.59,,,,,,,233.05,528.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7902637,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,646.47000,187.48000,Aetna,National,,258.59,,,,,,,208.16,528.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902622,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902622,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,324.90000,94.22000,Aetna,National,,129.96,,,,,,,117.13,265.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7902655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,324.90000,94.22000,Aetna,National,,129.96,,,,,,,104.62,265.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700046,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,National,,2001.44,,,,,,,1803.80,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7700046,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,National,,2001.44,,,,,,,1611.16,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7901701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7901701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7902776,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6268.50000,1817.86000,Aetna,National,,2507.40,,,,,,,2259.79,5127.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7902776,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6268.50000,1817.86000,Aetna,National,,2507.40,,,,,,,2018.46,5127.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7880447,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,1220.00000,353.80000,Aetna,National,,488.00,,,,,,,439.81,997.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7880447,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,1220.00000,353.80000,Aetna,National,,488.00,,,,,,,392.84,997.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7902978,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4163.25000,1207.34000,Aetna,National,,1665.30,,,,,,,1500.85,3405.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7902978,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4163.25000,1207.34000,Aetna,National,,1665.30,,,,,,,1340.57,3405.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,918.05000,266.23000,Aetna,National,,367.22,,,,,,,330.96,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,918.05000,266.23000,Aetna,National,,367.22,,,,,,,295.61,750.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7903145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4500.30000,1305.09000,Aetna,National,,1800.12,,,,,,,1622.36,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7903145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4500.30000,1305.09000,Aetna,National,,1800.12,,,,,,,1449.10,3681.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7903148,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,National,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOSPHERE,7903148,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,National,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7903504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11521.50000,3341.23000,Aetna,National,,4608.60,,,,,,,4153.50,9424.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7903504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11521.50000,3341.23000,Aetna,National,,4608.60,,,,,,,3709.92,9424.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7903581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8952.00000,2596.08000,Aetna,National,,3580.80,,,,,,,3227.20,7322.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7903581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8952.00000,2596.08000,Aetna,National,,3580.80,,,,,,,2882.54,7322.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT HV FOR AUTOPLEX SYST,7903761,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3806.69000,1103.94000,Aetna,National,,1522.68,,,,,,,1372.31,3113.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT HV FOR AUTOPLEX SYST,7903761,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3806.69000,1103.94000,Aetna,National,,1522.68,,,,,,,1225.75,3113.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7903659,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3120.00000,904.80000,Aetna,National,,1248.00,,,,,,,1124.76,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7903659,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3120.00000,904.80000,Aetna,National,,1248.00,,,,,,,1004.64,2552.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911814,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,147.53000,42.78000,Aetna,National,,59.01,,,,,,,53.18,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911814,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,147.53000,42.78000,Aetna,National,,59.01,,,,,,,47.50,120.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911815,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,191.63000,55.57000,Aetna,National,,76.65,,,,,,,69.08,156.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911815,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,191.63000,55.57000,Aetna,National,,76.65,,,,,,,61.70,156.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911816,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,169.58000,49.18000,Aetna,National,,67.83,,,,,,,61.13,138.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7911816,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,169.58000,49.18000,Aetna,National,,67.83,,,,,,,54.60,138.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7912133,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1828.28000,530.20000,Aetna,National,,731.31,,,,,,,659.09,1495.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7912133,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1828.28000,530.20000,Aetna,National,,731.31,,,,,,,588.71,1495.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7912134,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2592.76000,751.90000,Aetna,National,,1037.10,,,,,,,934.69,2120.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7912134,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2592.76000,751.90000,Aetna,National,,1037.10,,,,,,,834.87,2120.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7776325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8700.00000,2523.00000,Aetna,National,,3480.00,,,,,,,3136.35,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7776325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8700.00000,2523.00000,Aetna,National,,3480.00,,,,,,,2801.40,7116.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909484,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909484,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912143,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912143,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7912168,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,34537.50000,10015.88000,Aetna,National,,13815.00,,,,,,,12450.77,28251.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7912168,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,34537.50000,10015.88000,Aetna,National,,13815.00,,,,,,,11121.08,28251.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7912141,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,National,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7912141,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,National,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7912137,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4554.38000,1320.77000,Aetna,National,,1821.75,,,,,,,1641.85,3725.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7912137,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4554.38000,1320.77000,Aetna,National,,1821.75,,,,,,,1466.51,3725.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912193,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,National,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7912193,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,National,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9633.75000,2793.79000,Aetna,National,,3853.50,,,,,,,3472.97,7880.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7912273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9633.75000,2793.79000,Aetna,National,,3853.50,,,,,,,3102.07,7880.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7912276,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11700.00000,3393.00000,Aetna,National,,4680.00,,,,,,,4217.85,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7912276,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11700.00000,3393.00000,Aetna,National,,4680.00,,,,,,,3767.40,9570.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,National,,290.04,,,,,,,261.39,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,National,,290.04,,,,,,,233.48,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912353,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2634.24000,763.93000,Aetna,National,,1053.70,,,,,,,949.64,2154.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7912353,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2634.24000,763.93000,Aetna,National,,1053.70,,,,,,,848.23,2154.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912614,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,391.40000,113.51000,Aetna,National,,156.56,,,,,,,141.10,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912614,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,391.40000,113.51000,Aetna,National,,156.56,,,,,,,126.03,320.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7912610,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7912610,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7912607,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,11025.00000,3197.25000,Aetna,National,,4410.00,,,,,,,3974.51,9018.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7912607,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,11025.00000,3197.25000,Aetna,National,,4410.00,,,,,,,3550.05,9018.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7912611,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7912611,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912753,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7912753,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912755,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,National,,936.00,,,,,,,843.57,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912755,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,National,,936.00,,,,,,,753.48,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7912756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,806.18000,233.79000,Aetna,National,,322.47,,,,,,,290.63,659.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7912756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,806.18000,233.79000,Aetna,National,,322.47,,,,,,,259.59,659.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912875,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5718.13000,1658.26000,Aetna,National,,2287.25,,,,,,,2061.39,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912875,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5718.13000,1658.26000,Aetna,National,,2287.25,,,,,,,1841.24,4677.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912884,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8723.25000,2529.74000,Aetna,National,,3489.30,,,,,,,3144.73,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7912884,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8723.25000,2529.74000,Aetna,National,,3489.30,,,,,,,2808.89,7135.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912894,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,National,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7912894,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,National,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912905,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,National,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7912905,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,National,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912921,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,968.63000,280.90000,Aetna,National,,387.45,,,,,,,349.19,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7912921,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,968.63000,280.90000,Aetna,National,,387.45,,,,,,,311.90,792.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913082,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,679.50000,197.05000,Aetna,National,,271.80,,,,,,,244.96,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913082,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,679.50000,197.05000,Aetna,National,,271.80,,,,,,,218.80,555.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913093,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3706.50000,1074.88000,Aetna,National,,1482.60,,,,,,,1336.19,3031.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913093,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3706.50000,1074.88000,Aetna,National,,1482.60,,,,,,,1193.49,3031.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913208,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913208,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913216,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913216,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913279,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7913279,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929998,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,308.75000,89.54000,Aetna,National,,123.50,,,,,,,111.30,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929998,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,308.75000,89.54000,Aetna,National,,123.50,,,,,,,99.42,252.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7913629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,National,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7913629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,National,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913652,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,National,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7913652,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,National,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATES IN A KIT,7913653,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5198.20000,1507.48000,Aetna,National,,2079.28,,,,,,,1873.95,4252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATES IN A KIT,7913653,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5198.20000,1507.48000,Aetna,National,,2079.28,,,,,,,1673.82,4252.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,174.88000,50.72000,Aetna,National,,69.95,,,,,,,63.04,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,174.88000,50.72000,Aetna,National,,69.95,,,,,,,56.31,143.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3465.42000,1004.97000,Aetna,National,,1386.17,,,,,,,1249.28,2834.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3465.42000,1004.97000,Aetna,National,,1386.17,,,,,,,1115.87,2834.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7913883,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1225.68000,355.45000,Aetna,National,,490.27,,,,,,,441.86,1002.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7913883,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1225.68000,355.45000,Aetna,National,,490.27,,,,,,,394.67,1002.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,National,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7913929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,National,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7913914,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7913914,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7914034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5257.46000,1524.66000,Aetna,National,,2102.98,,,,,,,1895.31,4300.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7914034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5257.46000,1524.66000,Aetna,National,,2102.98,,,,,,,1692.90,4300.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7914403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,498.75000,144.64000,Aetna,National,,199.50,,,,,,,179.80,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7914403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,498.75000,144.64000,Aetna,National,,199.50,,,,,,,160.60,407.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7914556,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,National,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7914556,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,National,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916467,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8559.00000,2482.11000,Aetna,National,,3423.60,,,,,,,3085.52,7001.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916467,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8559.00000,2482.11000,Aetna,National,,3423.60,,,,,,,2756.00,7001.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8025.00000,2327.25000,Aetna,National,,3210.00,,,,,,,2893.01,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8025.00000,2327.25000,Aetna,National,,3210.00,,,,,,,2584.05,6564.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697981,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7736.40000,2243.56000,Aetna,National,,3094.56,,,,,,,2788.97,6328.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7697981,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7736.40000,2243.56000,Aetna,National,,3094.56,,,,,,,2491.12,6328.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7916494,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,14990.53000,4347.25000,Aetna,National,,5996.21,,,,,,,5404.09,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7916494,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,14990.53000,4347.25000,Aetna,National,,5996.21,,,,,,,4826.95,12262.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916496,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,National,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916496,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,National,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7916709,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2057.00000,596.53000,Aetna,National,,822.80,,,,,,,741.55,1682.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7916709,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2057.00000,596.53000,Aetna,National,,822.80,,,,,,,662.35,1682.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7916710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,National,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7916710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,National,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909031,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7909031,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916927,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2934.80000,851.09000,Aetna,National,,1173.92,,,,,,,1058.00,2400.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916927,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2934.80000,851.09000,Aetna,National,,1173.92,,,,,,,945.01,2400.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7916929,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6300.00000,1827.00000,Aetna,National,,2520.00,,,,,,,2271.15,5153.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7916929,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6300.00000,1827.00000,Aetna,National,,2520.00,,,,,,,2028.60,5153.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916930,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13275.00000,3849.75000,Aetna,National,,5310.00,,,,,,,4785.64,10858.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916930,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13275.00000,3849.75000,Aetna,National,,5310.00,,,,,,,4274.55,10858.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5088.30000,1475.61000,Aetna,National,,2035.32,,,,,,,1834.33,4162.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7916935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5088.30000,1475.61000,Aetna,National,,2035.32,,,,,,,1638.43,4162.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING,7916982,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,5603.50000,1625.02000,Aetna,National,,2241.40,,,,,,,2020.06,4583.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING,7916982,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,5603.50000,1625.02000,Aetna,National,,2241.40,,,,,,,1804.33,4583.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7916997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7916997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917333,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2053.88000,595.63000,Aetna,National,,821.55,,,,,,,740.42,1680.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917333,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2053.88000,595.63000,Aetna,National,,821.55,,,,,,,661.35,1680.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7917356,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,National,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7917356,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,National,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7917667,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,17399.73000,5045.92000,Aetna,National,,6959.89,,,,,,,6272.60,14232.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7917667,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,17399.73000,5045.92000,Aetna,National,,6959.89,,,,,,,5602.71,14232.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7917697,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7917697,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7910312,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,National,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7910312,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,National,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7909290,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7909290,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7917854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7917854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7917894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.80000,400.43000,Aetna,National,,552.32,,,,,,,497.78,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7917894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.80000,400.43000,Aetna,National,,552.32,,,,,,,444.62,1129.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6270.39000,1818.41000,Aetna,National,,2508.16,,,,,,,2260.48,5129.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7917898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6270.39000,1818.41000,Aetna,National,,2508.16,,,,,,,2019.07,5129.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7918133,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,1648.40000,478.04000,Aetna,National,,659.36,,,,,,,594.25,1348.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7918133,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,1648.40000,478.04000,Aetna,National,,659.36,,,,,,,530.78,1348.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918134,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,National,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918134,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,National,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7816132,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6133.23000,1778.64000,Aetna,National,,2453.29,,,,,,,2211.03,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7816132,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6133.23000,1778.64000,Aetna,National,,2453.29,,,,,,,1974.90,5016.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,National,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,National,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7918404,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,National,,13473.00,,,,,,,12142.54,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7918404,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,National,,13473.00,,,,,,,10845.76,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918508,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,National,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918508,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,National,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7918862,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,7868.40000,2281.84000,Aetna,National,,3147.36,,,,,,,2836.56,6436.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7918862,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,7868.40000,2281.84000,Aetna,National,,3147.36,,,,,,,2533.62,6436.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7698317,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,11145.00000,3232.05000,Aetna,National,,4458.00,,,,,,,4017.77,9116.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7698317,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,11145.00000,3232.05000,Aetna,National,,4458.00,,,,,,,3588.69,9116.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1544.88000,448.02000,Aetna,National,,617.95,,,,,,,556.93,1263.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1544.88000,448.02000,Aetna,National,,617.95,,,,,,,497.45,1263.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1613.16000,467.82000,Aetna,National,,645.26,,,,,,,581.54,1319.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7918566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1613.16000,467.82000,Aetna,National,,645.26,,,,,,,519.44,1319.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7918560,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,906.12000,262.77000,Aetna,National,,362.45,,,,,,,326.66,741.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7918560,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,906.12000,262.77000,Aetna,National,,362.45,,,,,,,291.77,741.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918561,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7932.00000,2300.28000,Aetna,National,,3172.80,,,,,,,2859.49,6488.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918561,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7932.00000,2300.28000,Aetna,National,,3172.80,,,,,,,2554.10,6488.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7918628,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,National,,780.80,,,,,,,703.70,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7918628,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,National,,780.80,,,,,,,628.54,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7918629,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1928.00000,559.12000,Aetna,National,,771.20,,,,,,,695.04,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7918629,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1928.00000,559.12000,Aetna,National,,771.20,,,,,,,620.82,1577.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698879,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698879,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918643,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7918643,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7918811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7918811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7918812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,National,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,National,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7918816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7918816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7918817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918849,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4540.73000,1316.81000,Aetna,National,,1816.29,,,,,,,1636.93,3714.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7918849,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4540.73000,1316.81000,Aetna,National,,1816.29,,,,,,,1462.12,3714.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2780.00000,806.20000,Aetna,National,,1112.00,,,,,,,1002.19,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7918850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2780.00000,806.20000,Aetna,National,,1112.00,,,,,,,895.16,2274.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894080,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1963.88000,569.53000,Aetna,National,,785.55,,,,,,,707.98,1606.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7894080,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1963.88000,569.53000,Aetna,National,,785.55,,,,,,,632.37,1606.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7900102,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,National,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7900102,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,National,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903505,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,National,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7903505,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,National,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858116,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858116,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858113,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858113,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858110,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858110,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750487,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750487,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE MYRINGOTOMY,7694026,CDM,278,RC,L8613,HCPCS,,,facility,inpatient,,,96.78000,28.07000,Aetna,National,,38.71,,,,,,,34.89,79.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TUBE MYRINGOTOMY,7694026,CDM,278,RC,L8613,HCPCS,,,facility,outpatient,,,96.78000,28.07000,Aetna,National,,38.71,,,,,,,31.16,332.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918877,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13587.00000,3940.23000,Aetna,National,,5434.80,,,,,,,4898.11,11114.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918877,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13587.00000,3940.23000,Aetna,National,,5434.80,,,,,,,4375.01,11114.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918898,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8611.20000,2497.25000,Aetna,National,,3444.48,,,,,,,3104.34,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918898,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8611.20000,2497.25000,Aetna,National,,3444.48,,,,,,,2772.81,7043.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918937,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7918937,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7918945,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9102.00000,2639.58000,Aetna,National,,3640.80,,,,,,,3281.27,7445.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7918945,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9102.00000,2639.58000,Aetna,National,,3640.80,,,,,,,2930.84,7445.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918977,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6114.33000,1773.16000,Aetna,National,,2445.73,,,,,,,2204.22,5001.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7918977,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6114.33000,1773.16000,Aetna,National,,2445.73,,,,,,,1968.81,5001.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7918989,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,National,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7918989,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,National,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7910999,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7800.00000,2262.00000,Aetna,National,,3120.00,,,,,,,2811.90,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7910999,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7800.00000,2262.00000,Aetna,National,,3120.00,,,,,,,2511.60,6380.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7919019,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2657.48000,770.67000,Aetna,National,,1062.99,,,,,,,958.02,2173.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7919019,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2657.48000,770.67000,Aetna,National,,1062.99,,,,,,,855.71,2173.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
THYROPLASTY IMPLANT IN KIT,7916655,CDM,278,RC,C1878,HCPCS,,,facility,inpatient,,,1912.00000,554.48000,Aetna,National,,764.80,,,,,,,689.28,1564.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
THYROPLASTY IMPLANT IN KIT,7916655,CDM,278,RC,C1878,HCPCS,,,facility,outpatient,,,1912.00000,554.48000,Aetna,National,,764.80,,,,,,,615.66,1564.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,National,,1825.25,,,,,,,1645.01,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,National,,1825.25,,,,,,,1469.33,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7700111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8480.40000,2459.32000,Aetna,National,,3392.16,,,,,,,3057.18,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7700111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8480.40000,2459.32000,Aetna,National,,3392.16,,,,,,,2730.69,6936.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7920398,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10194.00000,2956.26000,Aetna,National,,4077.60,,,,,,,3674.94,8338.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7920398,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10194.00000,2956.26000,Aetna,National,,4077.60,,,,,,,3282.47,8338.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920468,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1771.48000,513.73000,Aetna,National,,708.59,,,,,,,638.62,1449.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920468,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1771.48000,513.73000,Aetna,National,,708.59,,,,,,,570.42,1449.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2072.52000,601.03000,Aetna,National,,829.01,,,,,,,747.14,1695.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7920470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2072.52000,601.03000,Aetna,National,,829.01,,,,,,,667.35,1695.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7920462,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,National,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER,7920462,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,National,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7920488,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,National,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7920488,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,National,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7912365,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7912365,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7920509,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1552.00000,450.08000,Aetna,National,,620.80,,,,,,,559.50,1269.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7920509,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1552.00000,450.08000,Aetna,National,,620.80,,,,,,,499.74,1269.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1952.00000,566.08000,Aetna,National,,780.80,,,,,,,703.70,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1952.00000,566.08000,Aetna,National,,780.80,,,,,,,628.54,1596.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920546,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,National,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7920546,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,National,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3783.50000,1097.21000,Aetna,National,,1513.40,,,,,,,1363.95,3094.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3783.50000,1097.21000,Aetna,National,,1513.40,,,,,,,1218.29,3094.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5845.00000,1695.05000,Aetna,National,,2338.00,,,,,,,2107.12,4781.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7707521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5845.00000,1695.05000,Aetna,National,,2338.00,,,,,,,1882.09,4781.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT EXTENDER,7920563,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,11775.00000,3414.75000,Aetna,National,,4710.00,,,,,,,4244.89,9631.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT EXTENDER,7920563,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,11775.00000,3414.75000,Aetna,National,,4710.00,,,,,,,3791.55,9631.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699560,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,179.55000,52.07000,Aetna,National,,71.82,,,,,,,64.73,146.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7699560,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,179.55000,52.07000,Aetna,National,,71.82,,,,,,,57.82,146.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7921011,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4656.75000,1350.46000,Aetna,National,,1862.70,,,,,,,1678.76,3809.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7921011,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4656.75000,1350.46000,Aetna,National,,1862.70,,,,,,,1499.47,3809.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7921145,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,National,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7921145,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,National,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7921146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7921147,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7500.00000,2175.00000,Aetna,National,,3000.00,,,,,,,2703.75,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7921147,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7500.00000,2175.00000,Aetna,National,,3000.00,,,,,,,2415.00,6135.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695834,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5729.99000,1661.70000,Aetna,National,,2292.00,,,,,,,2065.66,4687.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695834,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5729.99000,1661.70000,Aetna,National,,2292.00,,,,,,,1845.06,4687.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7786150,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,National,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7786150,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,National,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921296,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2351.80000,682.02000,Aetna,National,,940.72,,,,,,,847.82,1923.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921296,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2351.80000,682.02000,Aetna,National,,940.72,,,,,,,757.28,1923.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO TRANSFIX,7702903,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1653.80000,479.60000,Aetna,National,,661.52,,,,,,,596.19,1352.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIO TRANSFIX,7702903,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1653.80000,479.60000,Aetna,National,,661.52,,,,,,,532.52,1352.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921297,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2438.72000,707.23000,Aetna,National,,975.49,,,,,,,879.16,1994.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921297,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2438.72000,707.23000,Aetna,National,,975.49,,,,,,,785.27,1994.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921298,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2947.72000,854.84000,Aetna,National,,1179.09,,,,,,,1062.65,2411.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7921298,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2947.72000,854.84000,Aetna,National,,1179.09,,,,,,,949.17,2411.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7922475,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,National,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7922475,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,National,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7695239,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,National,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7695239,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,National,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7786155,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7786155,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7922574,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1976.48000,573.18000,Aetna,National,,790.59,,,,,,,712.52,1616.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7922574,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1976.48000,573.18000,Aetna,National,,790.59,,,,,,,636.43,1616.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE EXTENDER,7922871,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1385.00000,401.65000,Aetna,National,,554.00,,,,,,,499.29,1132.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE EXTENDER,7922871,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1385.00000,401.65000,Aetna,National,,554.00,,,,,,,445.97,1132.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP,7698319,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,32951.25000,9555.86000,Aetna,National,,13180.50,,,,,,,11878.93,26954.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP,7698319,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,32951.25000,9555.86000,Aetna,National,,13180.50,,,,,,,10610.30,26954.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7923285,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.70000,1465.86000,Aetna,National,,2021.88,,,,,,,1822.22,4134.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7923285,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.70000,1465.86000,Aetna,National,,2021.88,,,,,,,1627.61,4134.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7923287,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7923287,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924580,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2200.00000,638.00000,Aetna,National,,880.00,,,,,,,793.10,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924580,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2200.00000,638.00000,Aetna,National,,880.00,,,,,,,708.40,1799.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,7699612,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROGRAMMER,7699612,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7924638,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,422.85000,122.63000,Aetna,National,,169.14,,,,,,,152.44,345.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7924638,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,422.85000,122.63000,Aetna,National,,169.14,,,,,,,136.16,345.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7924634,CDM,278,RC,C1886,HCPCS,,,facility,inpatient,,,10128.00000,2937.12000,Aetna,National,,4051.20,,,,,,,3651.14,8284.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER HALO 360,7924634,CDM,278,RC,C1886,HCPCS,,,facility,outpatient,,,10128.00000,2937.12000,Aetna,National,,4051.20,,,,,,,3261.22,8284.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924774,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3636.50000,1054.58000,Aetna,National,,1454.60,,,,,,,1310.96,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924774,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3636.50000,1054.58000,Aetna,National,,1454.60,,,,,,,1170.95,2974.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3930.50000,1139.84000,Aetna,National,,1572.20,,,,,,,1416.95,3215.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3930.50000,1139.84000,Aetna,National,,1572.20,,,,,,,1265.62,3215.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7911781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7911781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707465,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,National,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7707465,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,National,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7924873,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,294.50000,85.40000,Aetna,National,,117.80,,,,,,,106.17,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7924873,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,294.50000,85.40000,Aetna,National,,117.80,,,,,,,94.83,240.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2520.00000,730.80000,Aetna,National,,1008.00,,,,,,,908.46,2061.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2520.00000,730.80000,Aetna,National,,1008.00,,,,,,,811.44,2061.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,549.00000,159.21000,Aetna,National,,219.60,,,,,,,197.91,449.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7924878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,549.00000,159.21000,Aetna,National,,219.60,,,,,,,176.78,449.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5456.50000,1582.38000,Aetna,National,,2182.60,,,,,,,1967.07,4463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7924879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5456.50000,1582.38000,Aetna,National,,2182.60,,,,,,,1756.99,4463.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,7924904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,National,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,7924904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,National,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7924903,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6079.50000,1763.05000,Aetna,National,,2431.80,,,,,,,2191.66,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7924903,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6079.50000,1763.05000,Aetna,National,,2431.80,,,,,,,1957.60,4973.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,7924913,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,940.19000,272.66000,Aetna,National,,376.08,,,,,,,338.94,769.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HOLE COVER,7924913,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,940.19000,272.66000,Aetna,National,,376.08,,,,,,,302.74,769.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7925233,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,National,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7925233,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,National,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8586.00000,2489.94000,Aetna,National,,3434.40,,,,,,,3095.25,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8586.00000,2489.94000,Aetna,National,,3434.40,,,,,,,2764.69,7023.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7924900,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4822.65000,1398.57000,Aetna,National,,1929.06,,,,,,,1738.57,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7924900,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4822.65000,1398.57000,Aetna,National,,1929.06,,,,,,,1552.89,3944.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925243,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2525.64000,732.44000,Aetna,National,,1010.26,,,,,,,910.49,2065.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925243,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2525.64000,732.44000,Aetna,National,,1010.26,,,,,,,813.26,2065.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7912606,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,172.99000,50.17000,Aetna,National,,69.20,,,,,,,62.36,141.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7912606,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,172.99000,50.17000,Aetna,National,,69.20,,,,,,,55.70,141.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,832.50000,241.42000,Aetna,National,,333.00,,,,,,,300.12,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,832.50000,241.42000,Aetna,National,,333.00,,,,,,,268.06,680.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1216.00000,352.64000,Aetna,National,,486.40,,,,,,,438.37,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7925397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1216.00000,352.64000,Aetna,National,,486.40,,,,,,,391.55,994.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7925455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,129.50000,37.56000,Aetna,National,,51.80,,,,,,,46.68,105.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7925455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,129.50000,37.56000,Aetna,National,,51.80,,,,,,,41.70,105.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7925627,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7925627,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7954585,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,30065.63000,8719.03000,Aetna,National,,12026.25,,,,,,,10838.66,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7954585,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,30065.63000,8719.03000,Aetna,National,,12026.25,,,,,,,9681.13,24593.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7894318,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,National,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7894318,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,National,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7925633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,National,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7925633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,National,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702213,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702213,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,National,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7925797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,National,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7925800,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,23000.00000,6670.00000,Aetna,National,,9200.00,,,,,,,8291.50,18814.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7925800,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,23000.00000,6670.00000,Aetna,National,,9200.00,,,,,,,7406.00,18814.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7908759,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,National,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7908759,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,National,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913091,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,National,,968.70,,,,,,,873.04,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913091,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,National,,968.70,,,,,,,779.81,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7925917,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,National,,4521.24,,,,,,,4074.77,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7925917,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,National,,4521.24,,,,,,,3639.60,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926501,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,National,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926501,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,National,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7926526,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9222.90000,2674.64000,Aetna,National,,3689.16,,,,,,,3324.86,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7926526,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9222.90000,2674.64000,Aetna,National,,3689.16,,,,,,,2969.77,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926548,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,National,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926548,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,National,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926549,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,National,,6252.00,,,,,,,5634.61,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926549,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,National,,6252.00,,,,,,,5032.86,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12526.95000,3632.82000,Aetna,National,,5010.78,,,,,,,4515.97,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7926551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12526.95000,3632.82000,Aetna,National,,5010.78,,,,,,,4033.68,10247.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7926564,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13350.00000,3871.50000,Aetna,National,,5340.00,,,,,,,4812.68,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7926564,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13350.00000,3871.50000,Aetna,National,,5340.00,,,,,,,4298.70,10920.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926577,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21272.50000,6169.02000,Aetna,National,,8509.00,,,,,,,7668.74,17400.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7926577,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21272.50000,6169.02000,Aetna,National,,8509.00,,,,,,,6849.74,17400.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7926579,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9083.55000,2634.23000,Aetna,National,,3633.42,,,,,,,3274.62,7430.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RADIAL HEAD,7926579,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9083.55000,2634.23000,Aetna,National,,3633.42,,,,,,,2924.90,7430.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926650,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,National,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926650,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,National,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926672,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18000.00000,5220.00000,Aetna,National,,7200.00,,,,,,,6489.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL DISC,7926672,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18000.00000,5220.00000,Aetna,National,,7200.00,,,,,,,5796.00,14724.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7926711,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20750.00000,6017.50000,Aetna,National,,8300.00,,,,,,,7480.38,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7926711,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20750.00000,6017.50000,Aetna,National,,8300.00,,,,,,,6681.50,16973.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3447.33000,999.73000,Aetna,National,,1378.93,,,,,,,1242.76,2819.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3447.33000,999.73000,Aetna,National,,1378.93,,,,,,,1110.04,2819.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926932,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6510.00000,1887.90000,Aetna,National,,2604.00,,,,,,,2346.86,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7926932,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6510.00000,1887.90000,Aetna,National,,2604.00,,,,,,,2096.22,5325.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIMULATOR,7926956,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,54586.00000,15829.94000,Aetna,National,,21834.40,,,,,,,19678.25,44651.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIMULATOR,7926956,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,54586.00000,15829.94000,Aetna,National,,21834.40,,,,,,,17576.69,44651.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926982,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,934.20000,270.92000,Aetna,National,,373.68,,,,,,,336.78,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7926982,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,934.20000,270.92000,Aetna,National,,373.68,,,,,,,300.81,764.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7926984,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8053.20000,2335.43000,Aetna,National,,3221.28,,,,,,,2903.18,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7926984,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8053.20000,2335.43000,Aetna,National,,3221.28,,,,,,,2593.13,6587.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2750.00000,797.50000,Aetna,National,,1100.00,,,,,,,991.38,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2750.00000,797.50000,Aetna,National,,1100.00,,,,,,,885.50,2249.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7927051,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,National,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7927051,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,National,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,National,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,National,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7927136,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3249.75000,942.43000,Aetna,National,,1299.90,,,,,,,1171.53,2658.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7927136,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3249.75000,942.43000,Aetna,National,,1299.90,,,,,,,1046.42,2658.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,37091.48000,10756.53000,Aetna,National,,14836.59,,,,,,,13371.48,30340.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,37091.48000,10756.53000,Aetna,National,,14836.59,,,,,,,11943.46,30340.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS SHORT TERM,7736620,CDM,278,RC,C1752,HCPCS,,,facility,inpatient,,,428.23000,124.19000,Aetna,National,,171.29,,,,,,,154.38,350.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DIALYSIS SHORT TERM,7736620,CDM,278,RC,C1752,HCPCS,,,facility,outpatient,,,428.23000,124.19000,Aetna,National,,171.29,,,,,,,137.89,350.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927181,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4053.00000,1175.37000,Aetna,National,,1621.20,,,,,,,1461.11,3315.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927181,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4053.00000,1175.37000,Aetna,National,,1621.20,,,,,,,1305.07,3315.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7736435,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,National,,3795.60,,,,,,,3420.78,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7736435,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,National,,3795.60,,,,,,,3055.46,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927183,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3783.50000,1097.21000,Aetna,National,,1513.40,,,,,,,1363.95,3094.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7927183,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3783.50000,1097.21000,Aetna,National,,1513.40,,,,,,,1218.29,3094.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7927186,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,National,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7927186,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,National,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7927258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7927258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7927270,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7927270,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927271,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,National,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927271,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,National,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7707520,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19837.50000,5752.88000,Aetna,National,,7935.00,,,,,,,7151.42,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7707520,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19837.50000,5752.88000,Aetna,National,,7935.00,,,,,,,6387.68,16227.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927338,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11499.00000,3334.71000,Aetna,National,,4599.60,,,,,,,4145.39,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7927338,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11499.00000,3334.71000,Aetna,National,,4599.60,,,,,,,3702.68,9406.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7927340,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3468.50000,1005.86000,Aetna,National,,1387.40,,,,,,,1250.39,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7927340,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3468.50000,1005.86000,Aetna,National,,1387.40,,,,,,,1116.86,2837.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7927342,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3458.00000,1002.82000,Aetna,National,,1383.20,,,,,,,1246.61,2828.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7927342,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3458.00000,1002.82000,Aetna,National,,1383.20,,,,,,,1113.48,2828.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7927344,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,National,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7927344,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,National,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927348,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.26000,228.89000,Aetna,National,,315.70,,,,,,,284.53,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7927348,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.26000,228.89000,Aetna,National,,315.70,,,,,,,254.14,645.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,27998.44000,8119.55000,Aetna,National,,11199.38,,,,,,,10093.44,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7924912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,27998.44000,8119.55000,Aetna,National,,11199.38,,,,,,,9015.50,22902.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,National,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7927351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,National,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1350.80000,391.73000,Aetna,National,,540.32,,,,,,,486.96,1104.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1350.80000,391.73000,Aetna,National,,540.32,,,,,,,434.96,1104.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7927506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,576.99000,167.33000,Aetna,National,,230.80,,,,,,,208.00,471.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
END CAP,7927506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,576.99000,167.33000,Aetna,National,,230.80,,,,,,,185.79,471.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7927548,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3170.00000,919.30000,Aetna,National,,1268.00,,,,,,,1142.79,2593.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7927548,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3170.00000,919.30000,Aetna,National,,1268.00,,,,,,,1020.74,2593.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929693,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,132.20000,38.34000,Aetna,National,,52.88,,,,,,,47.66,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7929693,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,132.20000,38.34000,Aetna,National,,52.88,,,,,,,42.57,108.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7929702,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,5439.00000,1577.31000,Aetna,National,,2175.60,,,,,,,1960.76,4449.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7929702,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,5439.00000,1577.31000,Aetna,National,,2175.60,,,,,,,1751.36,4449.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7929705,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3469.34000,1006.11000,Aetna,National,,1387.74,,,,,,,1250.70,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7929705,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3469.34000,1006.11000,Aetna,National,,1387.74,,,,,,,1117.13,2837.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7929723,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12426.00000,3603.54000,Aetna,National,,4970.40,,,,,,,4479.57,10164.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7929723,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12426.00000,3603.54000,Aetna,National,,4970.40,,,,,,,4001.17,10164.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7929725,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,4284.00000,1242.36000,Aetna,National,,1713.60,,,,,,,1544.38,3504.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7929725,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,4284.00000,1242.36000,Aetna,National,,1713.60,,,,,,,1379.45,3504.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7929741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,National,,1344.00,,,,,,,1211.28,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7929741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,National,,1344.00,,,,,,,1081.92,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929752,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,National,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,7929752,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,National,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7930116,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3896.38000,1129.95000,Aetna,National,,1558.55,,,,,,,1404.64,3187.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7930116,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3896.38000,1129.95000,Aetna,National,,1558.55,,,,,,,1254.63,3187.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1889.00000,547.81000,Aetna,National,,755.60,,,,,,,680.98,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1889.00000,547.81000,Aetna,National,,755.60,,,,,,,608.26,1545.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7895932,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5836.95000,1692.72000,Aetna,National,,2334.78,,,,,,,2104.22,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER HIP CEMENT,7895932,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5836.95000,1692.72000,Aetna,National,,2334.78,,,,,,,1879.50,4774.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7930146,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1700.00000,493.00000,Aetna,National,,680.00,,,,,,,612.85,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7930146,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1700.00000,493.00000,Aetna,National,,680.00,,,,,,,547.40,1390.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7930181,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,20250.00000,5872.50000,Aetna,National,,8100.00,,,,,,,7300.12,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7930181,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,20250.00000,5872.50000,Aetna,National,,8100.00,,,,,,,6520.50,16564.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700832,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13117.38000,3804.04000,Aetna,National,,5246.95,,,,,,,4728.82,10730.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700832,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13117.38000,3804.04000,Aetna,National,,5246.95,,,,,,,4223.80,10730.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7930203,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,484.88000,140.62000,Aetna,National,,193.95,,,,,,,174.80,396.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7930203,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,484.88000,140.62000,Aetna,National,,193.95,,,,,,,156.13,396.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7930206,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9222.90000,2674.64000,Aetna,National,,3689.16,,,,,,,3324.86,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7930206,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9222.90000,2674.64000,Aetna,National,,3689.16,,,,,,,2969.77,7544.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FINGER IMPLANT,7930262,CDM,278,RC,L8630,HCPCS,,,facility,inpatient,,,4560.50000,1322.54000,Aetna,National,,1824.20,,,,,,,1644.06,3730.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FINGER IMPLANT,7930262,CDM,278,RC,L8630,HCPCS,,,facility,outpatient,,,4560.50000,1322.54000,Aetna,National,,1824.20,,,,,,,412.46,3730.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930267,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2592.00000,751.68000,Aetna,National,,1036.80,,,,,,,934.42,2120.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7930267,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2592.00000,751.68000,Aetna,National,,1036.80,,,,,,,834.62,2120.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7930308,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,444.13000,128.80000,Aetna,National,,177.65,,,,,,,160.11,363.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7930308,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,444.13000,128.80000,Aetna,National,,177.65,,,,,,,143.01,363.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7926648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,National,,936.00,,,,,,,843.57,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7926648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,National,,936.00,,,,,,,753.48,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR TEST,7922458,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,National,,744.00,,,,,,,670.53,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR TEST,7922458,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,National,,744.00,,,,,,,598.92,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696557,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,National,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7696557,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,National,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696542,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2252.60000,653.25000,Aetna,National,,901.04,,,,,,,812.06,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7696542,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2252.60000,653.25000,Aetna,National,,901.04,,,,,,,725.34,1842.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696872,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4112.50000,1192.62000,Aetna,National,,1645.00,,,,,,,1482.56,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696872,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4112.50000,1192.62000,Aetna,National,,1645.00,,,,,,,1324.22,3364.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,National,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,National,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7702698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7702698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696879,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3902.50000,1131.72000,Aetna,National,,1561.00,,,,,,,1406.85,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7696879,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3902.50000,1131.72000,Aetna,National,,1561.00,,,,,,,1256.61,3192.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7550.10000,2189.53000,Aetna,National,,3020.04,,,,,,,2721.81,6175.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7697959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7550.10000,2189.53000,Aetna,National,,3020.04,,,,,,,2431.13,6175.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736531,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,National,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736531,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,National,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7933915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,620.33000,179.90000,Aetna,National,,248.13,,,,,,,223.63,507.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7933915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,620.33000,179.90000,Aetna,National,,248.13,,,,,,,199.75,507.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7933955,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13059.00000,3787.11000,Aetna,National,,5223.60,,,,,,,4707.77,10682.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7933955,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13059.00000,3787.11000,Aetna,National,,5223.60,,,,,,,4205.00,10682.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7934011,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3358.53000,973.97000,Aetna,National,,1343.41,,,,,,,1210.75,2747.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7934011,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3358.53000,973.97000,Aetna,National,,1343.41,,,,,,,1081.45,2747.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7934019,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,National,,3864.00,,,,,,,3482.43,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7934019,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,National,,3864.00,,,,,,,3110.52,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7934020,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3281.25000,951.56000,Aetna,National,,1312.50,,,,,,,1182.89,2684.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7934020,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3281.25000,951.56000,Aetna,National,,1312.50,,,,,,,1056.56,2684.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7934021,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9660.00000,2801.40000,Aetna,National,,3864.00,,,,,,,3482.43,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7934021,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9660.00000,2801.40000,Aetna,National,,3864.00,,,,,,,3110.52,7901.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7934063,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,737.60000,213.90000,Aetna,National,,295.04,,,,,,,265.90,603.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7934063,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,737.60000,213.90000,Aetna,National,,295.04,,,,,,,237.51,603.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSCONNECTOR SPINAL,7695522,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7657.02000,2220.54000,Aetna,National,,3062.81,,,,,,,2760.36,6263.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TRANSCONNECTOR SPINAL,7695522,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7657.02000,2220.54000,Aetna,National,,3062.81,,,,,,,2465.56,6263.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7935071,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7935071,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7935114,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,19710.00000,5715.90000,Aetna,National,,7884.00,,,,,,,7105.45,16122.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7935114,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,19710.00000,5715.90000,Aetna,National,,7884.00,,,,,,,6346.62,16122.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7935107,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,National,,1818.04,,,,,,,1638.51,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7935107,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,National,,1818.04,,,,,,,1463.52,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7695327,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,8079.00000,2342.91000,Aetna,National,,3231.60,,,,,,,2912.48,6608.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7695327,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,8079.00000,2342.91000,Aetna,National,,3231.60,,,,,,,2601.44,6608.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7696921,CDM,278,RC,,,,,facility,inpatient,,,2288.00000,663.52000,Aetna,National,,915.20,,,,,,,824.82,1871.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7696921,CDM,278,RC,,,,,facility,outpatient,,,2288.00000,663.52000,Aetna,National,,915.20,,,,,,,736.74,1871.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694978,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,153.30000,44.46000,Aetna,National,,61.32,,,,,,,55.26,125.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694978,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,153.30000,44.46000,Aetna,National,,61.32,,,,,,,49.36,125.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BULKING AGENT,7696685,CDM,278,RC,L8606,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,National,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BULKING AGENT,7696685,CDM,278,RC,L8606,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,National,,600.00,,,,,,,268.67,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935272,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935272,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,National,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,National,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2750.40000,797.62000,Aetna,National,,1100.16,,,,,,,991.52,2249.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2750.40000,797.62000,Aetna,National,,1100.16,,,,,,,885.63,2249.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,National,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7935335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,National,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694587,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1476.00000,428.04000,Aetna,National,,590.40,,,,,,,532.10,1207.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694587,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1476.00000,428.04000,Aetna,National,,590.40,,,,,,,475.27,1207.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7700511,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1490.84000,432.34000,Aetna,National,,596.34,,,,,,,537.45,1219.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7700511,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1490.84000,432.34000,Aetna,National,,596.34,,,,,,,480.05,1219.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7696455,CDM,278,RC,C1727,HCPCS,,,facility,inpatient,,,2163.68000,627.47000,Aetna,National,,865.47,,,,,,,780.01,1769.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7696455,CDM,278,RC,C1727,HCPCS,,,facility,outpatient,,,2163.68000,627.47000,Aetna,National,,865.47,,,,,,,696.70,1769.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696019,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30730.50000,8911.84000,Aetna,National,,12292.20,,,,,,,11078.35,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7696019,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30730.50000,8911.84000,Aetna,National,,12292.20,,,,,,,9895.22,25137.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING GRAFT,7696357,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,8728.27000,2531.20000,Aetna,National,,3491.31,,,,,,,3146.54,7139.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING GRAFT,7696357,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,8728.27000,2531.20000,Aetna,National,,3491.31,,,,,,,2810.50,7139.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935340,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,National,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935340,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,National,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7944264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6095.50000,1767.70000,Aetna,National,,2438.20,,,,,,,2197.43,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7944264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6095.50000,1767.70000,Aetna,National,,2438.20,,,,,,,1962.75,4986.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696248,CDM,278,RC,C1877,HCPCS,,,facility,inpatient,,,5321.54000,1543.25000,Aetna,National,,2128.62,,,,,,,1918.42,4353.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696248,CDM,278,RC,C1877,HCPCS,,,facility,outpatient,,,5321.54000,1543.25000,Aetna,National,,2128.62,,,,,,,1713.54,4353.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696767,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,5398.72000,1565.63000,Aetna,National,,2159.49,,,,,,,1946.24,4416.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696767,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,5398.72000,1565.63000,Aetna,National,,2159.49,,,,,,,1738.39,4416.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7696809,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1518.80000,440.45000,Aetna,National,,607.52,,,,,,,547.53,1242.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7696809,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1518.80000,440.45000,Aetna,National,,607.52,,,,,,,489.05,1242.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR PATCH,7694425,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,1436.00000,416.44000,Aetna,National,,574.40,,,,,,,517.68,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VASCULAR PATCH,7694425,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,1436.00000,416.44000,Aetna,National,,574.40,,,,,,,462.39,1174.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7696940,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3220.70000,934.00000,Aetna,National,,1288.28,,,,,,,1161.06,2634.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ADAPTER,7696940,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3220.70000,934.00000,Aetna,National,,1288.28,,,,,,,1037.07,2634.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7694371,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,National,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDE CATHETER,7694371,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,National,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935389,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4625.25000,1341.32000,Aetna,National,,1850.10,,,,,,,1667.40,3783.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935389,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4625.25000,1341.32000,Aetna,National,,1850.10,,,,,,,1489.33,3783.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935390,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5843.25000,1694.54000,Aetna,National,,2337.30,,,,,,,2106.49,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935390,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5843.25000,1694.54000,Aetna,National,,2337.30,,,,,,,1881.53,4779.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935395,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4345.25000,1260.12000,Aetna,National,,1738.10,,,,,,,1566.46,3554.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935395,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4345.25000,1260.12000,Aetna,National,,1738.10,,,,,,,1399.17,3554.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935396,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5514.25000,1599.13000,Aetna,National,,2205.70,,,,,,,1987.89,4510.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7935396,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5514.25000,1599.13000,Aetna,National,,2205.70,,,,,,,1775.59,4510.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697082,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,National,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7697082,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,National,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699837,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4345.25000,1260.12000,Aetna,National,,1738.10,,,,,,,1566.46,3554.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7699837,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4345.25000,1260.12000,Aetna,National,,1738.10,,,,,,,1399.17,3554.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772038,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1408.00000,408.32000,Aetna,National,,563.20,,,,,,,507.58,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772038,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1408.00000,408.32000,Aetna,National,,563.20,,,,,,,453.38,1151.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MENISCAL DART,7935473,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,706.73000,204.95000,Aetna,National,,282.69,,,,,,,254.78,578.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MENISCAL DART,7935473,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,706.73000,204.95000,Aetna,National,,282.69,,,,,,,227.57,578.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697291,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,16562.50000,4803.12000,Aetna,National,,6625.00,,,,,,,5970.78,13548.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7697291,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,16562.50000,4803.12000,Aetna,National,,6625.00,,,,,,,5333.12,13548.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697433,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8736.57000,2533.61000,Aetna,National,,3494.63,,,,,,,3149.53,7146.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7697433,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8736.57000,2533.61000,Aetna,National,,3494.63,,,,,,,2813.18,7146.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935533,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,National,,1441.78,,,,,,,1299.40,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7935533,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,National,,1441.78,,,,,,,1160.63,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7935560,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8524.20000,2472.02000,Aetna,National,,3409.68,,,,,,,3072.97,6972.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7935560,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8524.20000,2472.02000,Aetna,National,,3409.68,,,,,,,2744.79,6972.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7699624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,7935590,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,16057.50000,4656.67000,Aetna,National,,6423.00,,,,,,,5788.73,13135.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,7935590,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,16057.50000,4656.67000,Aetna,National,,6423.00,,,,,,,5170.52,13135.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,7935591,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,National,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXCLUDER,7935591,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,National,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION LEAD,7935588,CDM,278,RC,C1883,HCPCS,,,facility,inpatient,,,2678.39000,776.73000,Aetna,National,,1071.36,,,,,,,965.56,2190.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION LEAD,7935588,CDM,278,RC,C1883,HCPCS,,,facility,outpatient,,,2678.39000,776.73000,Aetna,National,,1071.36,,,,,,,862.44,2190.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935613,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10977.00000,3183.33000,Aetna,National,,4390.80,,,,,,,3957.21,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935613,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10977.00000,3183.33000,Aetna,National,,4390.80,,,,,,,3534.59,8979.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIC PROTECTOR,7697570,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,National,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIC PROTECTOR,7697570,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,National,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935722,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7410.00000,2148.90000,Aetna,National,,2964.00,,,,,,,2671.30,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935722,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7410.00000,2148.90000,Aetna,National,,2964.00,,,,,,,2386.02,6061.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935723,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,19620.00000,5689.80000,Aetna,National,,7848.00,,,,,,,7073.01,16049.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7935723,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,19620.00000,5689.80000,Aetna,National,,7848.00,,,,,,,6317.64,16049.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7927397,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7927397,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7962570,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,National,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7962570,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,National,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7945882,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,23750.00000,6887.50000,Aetna,National,,9500.00,,,,,,,8561.88,19427.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7945882,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,23750.00000,6887.50000,Aetna,National,,9500.00,,,,,,,7647.50,19427.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918349,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,35212.50000,10211.62000,Aetna,National,,14085.00,,,,,,,12694.11,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7918349,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,35212.50000,10211.62000,Aetna,National,,14085.00,,,,,,,11338.42,28803.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702261,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702261,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7766038,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,National,,4858.80,,,,,,,4378.99,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7766038,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,National,,4858.80,,,,,,,3911.33,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935807,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2592.00000,751.68000,Aetna,National,,1036.80,,,,,,,934.42,2120.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7935807,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2592.00000,751.68000,Aetna,National,,1036.80,,,,,,,834.62,2120.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7700076,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15217.50000,4413.08000,Aetna,National,,6087.00,,,,,,,5485.91,12447.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7700076,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15217.50000,4413.08000,Aetna,National,,6087.00,,,,,,,4900.03,12447.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7744661,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AORTIC EXTENSION,7744661,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700124,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,30307.50000,8789.17000,Aetna,National,,12123.00,,,,,,,10925.85,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7700124,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,30307.50000,8789.17000,Aetna,National,,12123.00,,,,,,,9759.01,24791.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7700126,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,National,,4858.80,,,,,,,4378.99,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7700126,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,National,,4858.80,,,,,,,3911.33,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7707536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10473.00000,3037.17000,Aetna,National,,4189.20,,,,,,,3775.52,8566.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7707536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10473.00000,3037.17000,Aetna,National,,4189.20,,,,,,,3372.31,8566.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7935027,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10473.00000,3037.17000,Aetna,National,,4189.20,,,,,,,3775.52,8566.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7935027,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10473.00000,3037.17000,Aetna,National,,4189.20,,,,,,,3372.31,8566.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8869.20000,2572.07000,Aetna,National,,3547.68,,,,,,,3197.35,7255.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8869.20000,2572.07000,Aetna,National,,3547.68,,,,,,,2855.88,7255.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935848,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,National,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7935848,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,National,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935880,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2340.00000,678.60000,Aetna,National,,936.00,,,,,,,843.57,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7935880,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2340.00000,678.60000,Aetna,National,,936.00,,,,,,,753.48,1914.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THROMBECTOMY,7698210,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,15800.00000,4582.00000,Aetna,National,,6320.00,,,,,,,5695.90,12924.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER THROMBECTOMY,7698210,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,15800.00000,4582.00000,Aetna,National,,6320.00,,,,,,,5087.60,12924.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7917307,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,1431.96000,415.27000,Aetna,National,,572.78,,,,,,,516.22,1171.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7917307,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,1431.96000,415.27000,Aetna,National,,572.78,,,,,,,461.09,1171.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3944.50000,1143.90000,Aetna,National,,1577.80,,,,,,,1421.99,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7935940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3944.50000,1143.90000,Aetna,National,,1577.80,,,,,,,1270.13,3226.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DILATION URETRAL BALLOON,7696485,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,1574.88000,456.72000,Aetna,National,,629.95,,,,,,,567.74,1288.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER DILATION URETRAL BALLOON,7696485,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,1574.88000,456.72000,Aetna,National,,629.95,,,,,,,507.11,1288.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694335,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,89.89000,26.07000,Aetna,National,,35.96,,,,,,,32.41,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694335,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,89.89000,26.07000,Aetna,National,,35.96,,,,,,,28.94,73.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936056,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9950.01000,2885.50000,Aetna,National,,3980.00,,,,,,,3586.98,8139.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936056,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9950.01000,2885.50000,Aetna,National,,3980.00,,,,,,,3203.90,8139.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936057,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19864.05000,5760.57000,Aetna,National,,7945.62,,,,,,,7160.99,16248.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936057,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19864.05000,5760.57000,Aetna,National,,7945.62,,,,,,,6396.22,16248.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936058,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10667.67000,3093.62000,Aetna,National,,4267.07,,,,,,,3845.70,8726.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936058,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10667.67000,3093.62000,Aetna,National,,4267.07,,,,,,,3434.99,8726.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7936060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16741.50000,4855.04000,Aetna,National,,6696.60,,,,,,,6035.31,13694.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7936060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16741.50000,4855.04000,Aetna,National,,6696.60,,,,,,,5390.76,13694.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ROTATION,7936061,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6613.88000,1918.03000,Aetna,National,,2645.55,,,,,,,2384.30,5410.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ROTATION,7936061,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6613.88000,1918.03000,Aetna,National,,2645.55,,,,,,,2129.67,5410.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7936062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25606.63000,7425.92000,Aetna,National,,10242.65,,,,,,,9231.19,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7936062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25606.63000,7425.92000,Aetna,National,,10242.65,,,,,,,8245.33,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936089,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1608.00000,466.32000,Aetna,National,,643.20,,,,,,,579.68,1315.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936089,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1608.00000,466.32000,Aetna,National,,643.20,,,,,,,517.78,1315.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7904345,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7904345,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7936111,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2500.00000,725.00000,Aetna,National,,1000.00,,,,,,,901.25,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7936111,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2500.00000,725.00000,Aetna,National,,1000.00,,,,,,,805.00,2045.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936114,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4074.00000,1181.46000,Aetna,National,,1629.60,,,,,,,1468.68,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7936114,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4074.00000,1181.46000,Aetna,National,,1629.60,,,,,,,1311.83,3332.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7936117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10929.00000,3169.41000,Aetna,National,,4371.60,,,,,,,3939.90,8939.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7936117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10929.00000,3169.41000,Aetna,National,,4371.60,,,,,,,3519.14,8939.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7808031,CDM,278,RC,L8659,HCPCS,,,facility,inpatient,,,7886.67000,2287.13000,Aetna,National,,3154.67,,,,,,,2843.14,6451.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7808031,CDM,278,RC,L8659,HCPCS,,,facility,outpatient,,,7886.67000,2287.13000,Aetna,National,,3154.67,,,,,,,2364.47,6451.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7936395,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11472.00000,3326.88000,Aetna,National,,4588.80,,,,,,,4135.66,9384.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7936395,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11472.00000,3326.88000,Aetna,National,,4588.80,,,,,,,3693.98,9384.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936398,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9232.50000,2677.42000,Aetna,National,,3693.00,,,,,,,3328.32,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7936398,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9232.50000,2677.42000,Aetna,National,,3693.00,,,,,,,2972.86,7552.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698909,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,895.50000,259.70000,Aetna,National,,358.20,,,,,,,322.83,732.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698909,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,895.50000,259.70000,Aetna,National,,358.20,,,,,,,288.35,732.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7937667,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7937667,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937697,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,National,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937697,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,National,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7937699,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,National,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7937699,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,National,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7937700,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7937700,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937701,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7937701,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937719,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,National,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7937719,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,National,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7937737,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4920.30000,1426.89000,Aetna,National,,1968.12,,,,,,,1773.77,4024.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7937737,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4920.30000,1426.89000,Aetna,National,,1968.12,,,,,,,1584.34,4024.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7937748,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16050.00000,4654.50000,Aetna,National,,6420.00,,,,,,,5786.02,13128.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7937748,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16050.00000,4654.50000,Aetna,National,,6420.00,,,,,,,5168.10,13128.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880522,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,National,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7880522,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,National,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7918609,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,National,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7918609,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,National,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7937956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,National,,4589.28,,,,,,,4136.09,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7937956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,National,,4589.28,,,,,,,3694.37,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7762384,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3604.44000,1045.29000,Aetna,National,,1441.78,,,,,,,1299.40,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7762384,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3604.44000,1045.29000,Aetna,National,,1441.78,,,,,,,1160.63,2948.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6058.50000,1756.96000,Aetna,National,,2423.40,,,,,,,2184.09,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6058.50000,1756.96000,Aetna,National,,2423.40,,,,,,,1950.84,4955.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7938337,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7938337,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938778,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938778,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7938909,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,15637.50000,4534.88000,Aetna,National,,6255.00,,,,,,,5637.32,12791.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7938909,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,15637.50000,4534.88000,Aetna,National,,6255.00,,,,,,,5035.27,12791.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18360.00000,5324.40000,Aetna,National,,7344.00,,,,,,,6618.78,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18360.00000,5324.40000,Aetna,National,,7344.00,,,,,,,5911.92,15018.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7938928,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12638.40000,3665.14000,Aetna,National,,5055.36,,,,,,,4556.14,10338.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7938928,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12638.40000,3665.14000,Aetna,National,,5055.36,,,,,,,4069.56,10338.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938965,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8362.50000,2425.12000,Aetna,National,,3345.00,,,,,,,3014.68,6840.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7938965,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8362.50000,2425.12000,Aetna,National,,3345.00,,,,,,,2692.72,6840.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938994,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938994,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938996,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7938996,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938997,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7938997,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,National,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7939039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,National,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7939263,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7939263,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7697859,CDM,278,RC,,,,,facility,inpatient,,,14132.91000,4098.54000,Aetna,National,,5653.16,,,,,,,5094.91,11560.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7697859,CDM,278,RC,,,,,facility,outpatient,,,14132.91000,4098.54000,Aetna,National,,5653.16,,,,,,,4550.80,11560.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7939277,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,4529.00000,1313.41000,Aetna,National,,1811.60,,,,,,,1632.70,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG,7939277,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,4529.00000,1313.41000,Aetna,National,,1811.60,,,,,,,1458.34,3704.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,National,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7939317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,National,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7939319,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,National,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7939319,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,National,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939305,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,National,,2225.88,,,,,,,2006.07,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7939305,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,National,,2225.88,,,,,,,1791.83,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939306,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13275.00000,3849.75000,Aetna,National,,5310.00,,,,,,,4785.64,10858.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939306,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13275.00000,3849.75000,Aetna,National,,5310.00,,,,,,,4274.55,10858.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7939311,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18082.50000,5243.92000,Aetna,National,,7233.00,,,,,,,6518.74,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL TRAY,7939311,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18082.50000,5243.92000,Aetna,National,,7233.00,,,,,,,5822.56,14791.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7939312,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18910.00000,5483.90000,Aetna,National,,7564.00,,,,,,,6817.06,15468.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7939312,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18910.00000,5483.90000,Aetna,National,,7564.00,,,,,,,6089.02,15468.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7939327,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,National,,1244.80,,,,,,,1121.88,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7939327,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,National,,1244.80,,,,,,,1002.06,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939415,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3360.00000,974.40000,Aetna,National,,1344.00,,,,,,,1211.28,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939415,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3360.00000,974.40000,Aetna,National,,1344.00,,,,,,,1081.92,2748.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939425,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,National,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939425,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,National,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939426,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3819.38000,1107.62000,Aetna,National,,1527.75,,,,,,,1376.89,3124.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939426,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3819.38000,1107.62000,Aetna,National,,1527.75,,,,,,,1229.84,3124.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4095.00000,1187.55000,Aetna,National,,1638.00,,,,,,,1476.25,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7939428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4095.00000,1187.55000,Aetna,National,,1638.00,,,,,,,1318.59,3349.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702332,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,482.93000,140.05000,Aetna,National,,193.17,,,,,,,174.10,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702332,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,482.93000,140.05000,Aetna,National,,193.17,,,,,,,155.50,395.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7939860,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,32256.00000,9354.24000,Aetna,National,,12902.40,,,,,,,11628.29,26385.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7939860,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,32256.00000,9354.24000,Aetna,National,,12902.40,,,,,,,10386.43,26385.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7939861,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,558.23000,161.89000,Aetna,National,,223.29,,,,,,,201.24,456.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7939861,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,558.23000,161.89000,Aetna,National,,223.29,,,,,,,179.75,456.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7939433,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,136.50000,39.58000,Aetna,National,,54.60,,,,,,,49.21,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7939433,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,136.50000,39.58000,Aetna,National,,54.60,,,,,,,43.95,111.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939953,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4667.92000,1353.70000,Aetna,National,,1867.17,,,,,,,1682.79,3818.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7939953,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4667.92000,1353.70000,Aetna,National,,1867.17,,,,,,,1503.07,3818.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7940060,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3154.52000,914.81000,Aetna,National,,1261.81,,,,,,,1137.20,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7940060,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3154.52000,914.81000,Aetna,National,,1261.81,,,,,,,1015.76,2580.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5648.51000,1638.07000,Aetna,National,,2259.40,,,,,,,2036.29,4620.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5648.51000,1638.07000,Aetna,National,,2259.40,,,,,,,1818.82,4620.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7940794,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,National,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7940794,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,National,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940797,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8979.00000,2603.91000,Aetna,National,,3591.60,,,,,,,3236.93,7344.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7940797,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8979.00000,2603.91000,Aetna,National,,3591.60,,,,,,,2891.24,7344.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7940826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7940826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941863,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,National,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7941863,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,National,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942655,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,National,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7942655,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,National,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE IN A KIT,7699083,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,National,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE IN A KIT,7699083,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,National,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9489.00000,2751.81000,Aetna,National,,3795.60,,,,,,,3420.78,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9489.00000,2751.81000,Aetna,National,,3795.60,,,,,,,3055.46,7762.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7943248,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7943248,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943288,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,National,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943288,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,National,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3192.92000,925.95000,Aetna,National,,1277.17,,,,,,,1151.05,2611.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3192.92000,925.95000,Aetna,National,,1277.17,,,,,,,1028.12,2611.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943319,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3342.96000,969.46000,Aetna,National,,1337.18,,,,,,,1205.14,2734.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7943319,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3342.96000,969.46000,Aetna,National,,1337.18,,,,,,,1076.43,2734.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943400,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6668.38000,1933.83000,Aetna,National,,2667.35,,,,,,,2403.95,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943400,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6668.38000,1933.83000,Aetna,National,,2667.35,,,,,,,2147.22,5454.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7943627,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,National,,13473.00,,,,,,,12142.54,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7943627,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,National,,13473.00,,,,,,,10845.76,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7943679,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11303.10000,3277.90000,Aetna,National,,4521.24,,,,,,,4074.77,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SHOULDER,7943679,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11303.10000,3277.90000,Aetna,National,,4521.24,,,,,,,3639.60,9245.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943725,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,National,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943725,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,National,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7943806,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16425.00000,4763.25000,Aetna,National,,6570.00,,,,,,,5921.21,13435.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7943806,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16425.00000,4763.25000,Aetna,National,,6570.00,,,,,,,5288.85,13435.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943807,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1478.80000,428.85000,Aetna,National,,591.52,,,,,,,533.11,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943807,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1478.80000,428.85000,Aetna,National,,591.52,,,,,,,476.17,1209.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943844,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,National,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7943844,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,National,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943912,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,National,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943912,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,National,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943916,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7943916,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7943918,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7943918,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943923,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3629.50000,1052.55000,Aetna,National,,1451.80,,,,,,,1308.43,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7943923,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3629.50000,1052.55000,Aetna,National,,1451.80,,,,,,,1168.70,2968.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943930,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,National,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7943930,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,National,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,7943971,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,7943971,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1753.28000,508.45000,Aetna,National,,701.31,,,,,,,632.06,1434.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7944034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1753.28000,508.45000,Aetna,National,,701.31,,,,,,,564.56,1434.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7944036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25225.20000,7315.31000,Aetna,National,,10090.08,,,,,,,9093.68,20634.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7944036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25225.20000,7315.31000,Aetna,National,,10090.08,,,,,,,8122.51,20634.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7944037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,National,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7944037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,National,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7944075,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14790.00000,4289.10000,Aetna,National,,5916.00,,,,,,,5331.80,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7944075,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14790.00000,4289.10000,Aetna,National,,5916.00,,,,,,,4762.38,12098.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7944204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3872.44000,1123.01000,Aetna,National,,1548.98,,,,,,,1396.01,3167.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7944204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3872.44000,1123.01000,Aetna,National,,1548.98,,,,,,,1246.93,3167.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7944206,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10701.00000,3103.29000,Aetna,National,,4280.40,,,,,,,3857.71,8753.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7944206,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10701.00000,3103.29000,Aetna,National,,4280.40,,,,,,,3445.72,8753.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7944207,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,National,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7944207,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,National,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7944226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,11550.00000,3349.50000,Aetna,National,,4620.00,,,,,,,4163.77,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7944226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,11550.00000,3349.50000,Aetna,National,,4620.00,,,,,,,3719.10,9447.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13105.59000,3800.62000,Aetna,National,,5242.24,,,,,,,4724.57,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7944262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13105.59000,3800.62000,Aetna,National,,5242.24,,,,,,,4220.00,10720.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOMONITOR 2 AF,8136109,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,National,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BIOMONITOR 2 AF,8136109,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,National,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7953969,CDM,278,RC,C1753,HCPCS,,,facility,inpatient,,,8782.32000,2546.87000,Aetna,National,,3512.93,,,,,,,3166.03,7183.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7953969,CDM,278,RC,C1753,HCPCS,,,facility,outpatient,,,8782.32000,2546.87000,Aetna,National,,3512.93,,,,,,,2827.91,7183.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136108,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,113.66000,32.96000,Aetna,National,,45.46,,,,,,,40.97,92.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136108,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,113.66000,32.96000,Aetna,National,,45.46,,,,,,,36.60,92.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911544,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911544,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882791,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7882791,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750492,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750492,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750483,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7750483,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136120,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,National,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136120,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,National,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136121,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,National,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136121,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,National,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136119,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1236.00000,358.44000,Aetna,National,,494.40,,,,,,,445.58,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136119,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1236.00000,358.44000,Aetna,National,,494.40,,,,,,,397.99,1011.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8136221,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,National,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8136221,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,National,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LASER ARTHRECTOMY CATHETER,8136224,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,National,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LASER ARTHRECTOMY CATHETER,8136224,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,National,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8136225,CDM,278,RC,C1885,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,National,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABLATION CATHETER,8136225,CDM,278,RC,C1885,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,National,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701403,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13329.00000,3865.41000,Aetna,National,,5331.60,,,,,,,4805.10,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7701403,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13329.00000,3865.41000,Aetna,National,,5331.60,,,,,,,4291.94,10903.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697528,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,790.20000,229.16000,Aetna,National,,316.08,,,,,,,284.87,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697528,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,790.20000,229.16000,Aetna,National,,316.08,,,,,,,254.44,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136227,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136227,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988115,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1564.00000,453.56000,Aetna,National,,625.60,,,,,,,563.82,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8988115,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1564.00000,453.56000,Aetna,National,,625.60,,,,,,,503.61,1279.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7944414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4266.50000,1237.28000,Aetna,National,,1706.60,,,,,,,1538.07,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7944414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4266.50000,1237.28000,Aetna,National,,1706.60,,,,,,,1373.81,3490.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7944417,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,11472.00000,3326.88000,Aetna,National,,4588.80,,,,,,,4135.66,9384.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7944417,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,11472.00000,3326.88000,Aetna,National,,4588.80,,,,,,,3693.98,9384.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7944553,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5463.50000,1584.42000,Aetna,National,,2185.40,,,,,,,1969.59,4469.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7944553,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5463.50000,1584.42000,Aetna,National,,2185.40,,,,,,,1759.25,4469.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7944566,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,715.50000,207.49000,Aetna,National,,286.20,,,,,,,257.94,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7944566,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,715.50000,207.49000,Aetna,National,,286.20,,,,,,,230.39,585.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7944573,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,790.20000,229.16000,Aetna,National,,316.08,,,,,,,284.87,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7944573,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,790.20000,229.16000,Aetna,National,,316.08,,,,,,,254.44,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7945881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,National,,808.32,,,,,,,728.50,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7945881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,National,,808.32,,,,,,,650.70,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7945949,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,National,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7945949,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,National,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7945951,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1320.00000,382.80000,Aetna,National,,528.00,,,,,,,475.86,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7945951,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1320.00000,382.80000,Aetna,National,,528.00,,,,,,,425.04,1079.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698064,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7844.40000,2274.88000,Aetna,National,,3137.76,,,,,,,2827.91,6416.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698064,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7844.40000,2274.88000,Aetna,National,,3137.76,,,,,,,2525.90,6416.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3907.58000,1133.20000,Aetna,National,,1563.03,,,,,,,1408.68,3196.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER KNEE,7698065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3907.58000,1133.20000,Aetna,National,,1563.03,,,,,,,1258.24,3196.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697936,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,National,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7697936,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,National,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7946021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7946021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7946023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7946023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7946040,CDM,278,RC,C2625,HCPCS,,,facility,inpatient,,,647.19000,187.69000,Aetna,National,,258.88,,,,,,,233.31,529.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7946040,CDM,278,RC,C2625,HCPCS,,,facility,outpatient,,,647.19000,187.69000,Aetna,National,,258.88,,,,,,,208.40,529.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7946119,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,69264.00000,20086.56000,Aetna,National,,27705.60,,,,,,,24969.67,56657.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7946119,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,69264.00000,20086.56000,Aetna,National,,27705.60,,,,,,,22303.01,56657.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7946120,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,22607.50000,6556.17000,Aetna,National,,9043.00,,,,,,,8150.00,18492.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7946120,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,22607.50000,6556.17000,Aetna,National,,9043.00,,,,,,,7279.61,18492.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7947887,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15630.00000,4532.70000,Aetna,National,,6252.00,,,,,,,5634.61,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7947887,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15630.00000,4532.70000,Aetna,National,,6252.00,,,,,,,5032.86,12785.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7947893,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7947893,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7947896,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3762.50000,1091.12000,Aetna,National,,1505.00,,,,,,,1356.38,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7947896,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3762.50000,1091.12000,Aetna,National,,1505.00,,,,,,,1211.53,3077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7947914,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,32951.25000,9555.86000,Aetna,National,,13180.50,,,,,,,11878.93,26954.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7947914,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,32951.25000,9555.86000,Aetna,National,,13180.50,,,,,,,10610.30,26954.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7947922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,National,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7947922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,National,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7947952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10935.00000,3171.15000,Aetna,National,,4374.00,,,,,,,3942.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7947952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10935.00000,3171.15000,Aetna,National,,4374.00,,,,,,,3521.07,8944.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948061,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1433.16000,415.62000,Aetna,National,,573.26,,,,,,,516.65,1172.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948061,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1433.16000,415.62000,Aetna,National,,573.26,,,,,,,461.48,1172.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,202.78,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,562.50000,163.12000,Aetna,National,,225.00,,,,,,,181.12,460.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7948096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7948096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7948097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7948097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948124,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12426.00000,3603.54000,Aetna,National,,4970.40,,,,,,,4479.57,10164.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948124,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12426.00000,3603.54000,Aetna,National,,4970.40,,,,,,,4001.17,10164.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2760.00000,800.40000,Aetna,National,,1104.00,,,,,,,994.98,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2760.00000,800.40000,Aetna,National,,1104.00,,,,,,,888.72,2257.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7948152,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11828.25000,3430.19000,Aetna,National,,4731.30,,,,,,,4264.08,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7948152,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11828.25000,3430.19000,Aetna,National,,4731.30,,,,,,,3808.70,9675.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7948170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5287.28000,1533.31000,Aetna,National,,2114.91,,,,,,,1906.06,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7948170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5287.28000,1533.31000,Aetna,National,,2114.91,,,,,,,1702.50,4325.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7948206,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,3804.50000,1103.30000,Aetna,National,,1521.80,,,,,,,1371.52,3112.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7948206,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,3804.50000,1103.30000,Aetna,National,,1521.80,,,,,,,1225.05,3112.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS,7948209,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9888.00000,2867.52000,Aetna,National,,3955.20,,,,,,,3564.62,8088.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DERMIS,7948209,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9888.00000,2867.52000,Aetna,National,,3955.20,,,,,,,3183.94,8088.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948225,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,803.25000,232.94000,Aetna,National,,321.30,,,,,,,289.57,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948225,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,803.25000,232.94000,Aetna,National,,321.30,,,,,,,258.65,657.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948226,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2741.76000,795.11000,Aetna,National,,1096.70,,,,,,,988.40,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948226,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2741.76000,795.11000,Aetna,National,,1096.70,,,,,,,882.85,2242.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948227,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,340.58000,98.77000,Aetna,National,,136.23,,,,,,,122.78,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7948227,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,340.58000,98.77000,Aetna,National,,136.23,,,,,,,109.67,278.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948214,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,National,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948214,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,National,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948218,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,National,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948218,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,National,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948219,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948219,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13650.00000,3958.50000,Aetna,National,,5460.00,,,,,,,4920.82,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13650.00000,3958.50000,Aetna,National,,5460.00,,,,,,,4395.30,11165.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948228,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2975.44000,862.88000,Aetna,National,,1190.18,,,,,,,1072.65,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7948228,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2975.44000,862.88000,Aetna,National,,1190.18,,,,,,,958.09,2433.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,7948230,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,National,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE BASE,7948230,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,National,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948357,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6214.74000,1802.27000,Aetna,National,,2485.90,,,,,,,2240.41,5083.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7948357,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6214.74000,1802.27000,Aetna,National,,2485.90,,,,,,,2001.15,5083.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7948358,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1748.32000,507.01000,Aetna,National,,699.33,,,,,,,630.27,1430.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7948358,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1748.32000,507.01000,Aetna,National,,699.33,,,,,,,562.96,1430.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948359,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17212.25000,4991.55000,Aetna,National,,6884.90,,,,,,,6205.02,14079.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948359,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17212.25000,4991.55000,Aetna,National,,6884.90,,,,,,,5542.34,14079.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948360,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15369.90000,4457.27000,Aetna,National,,6147.96,,,,,,,5540.85,12572.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7948360,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15369.90000,4457.27000,Aetna,National,,6147.96,,,,,,,4949.11,12572.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948411,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33862.50000,9820.12000,Aetna,National,,13545.00,,,,,,,12207.43,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948411,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33862.50000,9820.12000,Aetna,National,,13545.00,,,,,,,10903.73,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7948412,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9945.00000,2884.05000,Aetna,National,,3978.00,,,,,,,3585.17,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIBIAL CONE,7948412,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9945.00000,2884.05000,Aetna,National,,3978.00,,,,,,,3202.29,8135.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,7948519,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR IN KIT,7948519,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TESTICULAR IMPLANT,7948610,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8499.00000,2464.71000,Aetna,National,,3399.60,,,,,,,3063.89,6952.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TESTICULAR IMPLANT,7948610,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8499.00000,2464.71000,Aetna,National,,3399.60,,,,,,,2736.68,6952.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7948232,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,National,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7948232,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,National,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948596,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,17425.00000,5053.25000,Aetna,National,,6970.00,,,,,,,6281.71,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7948596,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,17425.00000,5053.25000,Aetna,National,,6970.00,,,,,,,5610.85,14253.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948606,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948606,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948525,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,National,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7948525,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,National,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7948683,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10871.25000,3152.66000,Aetna,National,,4348.50,,,,,,,3919.09,8892.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7948683,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10871.25000,3152.66000,Aetna,National,,4348.50,,,,,,,3500.54,8892.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7948614,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,National,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7948614,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,National,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7948749,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4403.00000,1276.87000,Aetna,National,,1761.20,,,,,,,1587.28,3601.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7948749,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4403.00000,1276.87000,Aetna,National,,1761.20,,,,,,,1417.77,3601.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948778,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,National,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948778,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,National,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7948815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6107.50000,1771.18000,Aetna,National,,2443.00,,,,,,,2201.75,4995.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6107.50000,1771.18000,Aetna,National,,2443.00,,,,,,,1966.62,4995.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,10914.00000,3165.06000,Aetna,National,,4365.60,,,,,,,3934.50,8927.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7948895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,10914.00000,3165.06000,Aetna,National,,4365.60,,,,,,,3514.31,8927.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948864,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,National,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7948864,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,National,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER IN A KIT,7948866,CDM,278,RC,C1880,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,National,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FILTER IN A KIT,7948866,CDM,278,RC,C1880,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,National,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950093,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950093,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7950154,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,77000.00000,22330.00000,Aetna,National,,30800.00,,,,,,,27758.50,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
VALVE,7950154,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,77000.00000,22330.00000,Aetna,National,,30800.00,,,,,,,24794.00,62986.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7950207,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9672.00000,2804.88000,Aetna,National,,3868.80,,,,,,,3486.76,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TALAR,7950207,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9672.00000,2804.88000,Aetna,National,,3868.80,,,,,,,3114.38,7911.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950343,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15570.00000,4515.30000,Aetna,National,,6228.00,,,,,,,5612.98,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7950343,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15570.00000,4515.30000,Aetna,National,,6228.00,,,,,,,5013.54,12736.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702498,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,461.65000,133.88000,Aetna,National,,184.66,,,,,,,166.42,377.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702498,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,461.65000,133.88000,Aetna,National,,184.66,,,,,,,148.65,377.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7950458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1688.00000,489.52000,Aetna,National,,675.20,,,,,,,608.52,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7950458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1688.00000,489.52000,Aetna,National,,675.20,,,,,,,543.54,1380.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950460,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950460,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950498,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7950498,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950551,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2992.00000,867.68000,Aetna,National,,1196.80,,,,,,,1078.62,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7950551,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2992.00000,867.68000,Aetna,National,,1196.80,,,,,,,963.42,2447.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7945854,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,5264.00000,1526.56000,Aetna,National,,2105.60,,,,,,,1897.67,4305.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7945854,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,5264.00000,1526.56000,Aetna,National,,2105.60,,,,,,,1695.01,4305.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7950558,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,National,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7950558,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,National,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7951863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8464.05000,2454.57000,Aetna,National,,3385.62,,,,,,,3051.29,6923.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7951863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8464.05000,2454.57000,Aetna,National,,3385.62,,,,,,,2725.42,6923.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7699723,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22591.50000,6551.54000,Aetna,National,,9036.60,,,,,,,8144.24,18479.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROXIMAL BODY,7699723,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22591.50000,6551.54000,Aetna,National,,9036.60,,,,,,,7274.46,18479.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7951935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19208.75000,5570.54000,Aetna,National,,7683.50,,,,,,,6924.75,15712.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7951935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19208.75000,5570.54000,Aetna,National,,7683.50,,,,,,,6185.22,15712.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT IMPLANTS IN KIT,7953868,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9126.00000,2646.54000,Aetna,National,,3650.40,,,,,,,3289.92,7465.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT IMPLANTS IN KIT,7953868,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9126.00000,2646.54000,Aetna,National,,3650.40,,,,,,,2938.57,7465.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7953912,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1994.00000,578.26000,Aetna,National,,797.60,,,,,,,718.84,1631.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7953912,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1994.00000,578.26000,Aetna,National,,797.60,,,,,,,642.07,1631.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7953972,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,National,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7953972,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,National,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7954116,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7954116,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954127,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5054.00000,1465.66000,Aetna,National,,2021.60,,,,,,,1821.97,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954127,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5054.00000,1465.66000,Aetna,National,,2021.60,,,,,,,1627.39,4134.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954135,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,National,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954135,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,National,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7954474,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,3112.00000,902.48000,Aetna,National,,1244.80,,,,,,,1121.88,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7954474,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,3112.00000,902.48000,Aetna,National,,1244.80,,,,,,,1002.06,2545.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7954587,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7954587,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954612,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,10608.00000,3076.32000,Aetna,National,,4243.20,,,,,,,3824.18,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7954612,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,10608.00000,3076.32000,Aetna,National,,4243.20,,,,,,,3415.78,8677.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954648,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8790.00000,2549.10000,Aetna,National,,3516.00,,,,,,,3168.80,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7954648,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8790.00000,2549.10000,Aetna,National,,3516.00,,,,,,,2830.38,7190.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954649,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7954649,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7954747,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7954747,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7954749,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7954749,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7954750,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,6475.00000,1877.75000,Aetna,National,,2590.00,,,,,,,2334.24,5296.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7954750,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,6475.00000,1877.75000,Aetna,National,,2590.00,,,,,,,2084.95,5296.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7954791,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7954791,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7954792,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7954792,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7955062,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,National,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7955062,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,National,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7955808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1681.44000,487.62000,Aetna,National,,672.58,,,,,,,606.16,1375.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7955808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1681.44000,487.62000,Aetna,National,,672.58,,,,,,,541.42,1375.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7956547,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1606.12000,465.77000,Aetna,National,,642.45,,,,,,,579.01,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7956547,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1606.12000,465.77000,Aetna,National,,642.45,,,,,,,517.17,1313.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7956662,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,National,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7956662,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,National,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7956683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,National,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7956683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,National,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7956955,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,3249.05000,942.22000,Aetna,National,,1299.62,,,,,,,1171.28,2657.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7956955,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,3249.05000,942.22000,Aetna,National,,1299.62,,,,,,,1046.19,2657.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABSORBABLE SECURESTRAP,7697287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2503.71000,726.08000,Aetna,National,,1001.48,,,,,,,902.59,2048.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ABSORBABLE SECURESTRAP,7697287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2503.71000,726.08000,Aetna,National,,1001.48,,,,,,,806.19,2048.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7957694,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,36060.75000,10457.62000,Aetna,National,,14424.30,,,,,,,12999.90,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7957694,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,36060.75000,10457.62000,Aetna,National,,14424.30,,,,,,,11611.56,29497.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7957716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9777.00000,2835.33000,Aetna,National,,3910.80,,,,,,,3524.61,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7957716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9777.00000,2835.33000,Aetna,National,,3910.80,,,,,,,3148.19,7997.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957760,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7716.45000,2237.77000,Aetna,National,,3086.58,,,,,,,2781.78,6312.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957760,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7716.45000,2237.77000,Aetna,National,,3086.58,,,,,,,2484.70,6312.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7957790,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,National,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7957790,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,National,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,7957816,CDM,278,RC,C1897,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,National,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD KIT,7957816,CDM,278,RC,C1897,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,National,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,National,,590.72,,,,,,,532.39,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,National,,590.72,,,,,,,475.53,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1476.80000,428.27000,Aetna,National,,590.72,,,,,,,532.39,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7957846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1476.80000,428.27000,Aetna,National,,590.72,,,,,,,475.53,1208.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7957909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,National,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7957909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,National,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7957910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,National,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7957910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,National,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7957913,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,National,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7957913,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,National,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957935,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11473.20000,3327.23000,Aetna,National,,4589.28,,,,,,,4136.09,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957935,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11473.20000,3327.23000,Aetna,National,,4589.28,,,,,,,3694.37,9385.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957959,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7957959,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7958052,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1304.00000,378.16000,Aetna,National,,521.60,,,,,,,470.09,1066.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7958052,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1304.00000,378.16000,Aetna,National,,521.60,,,,,,,419.89,1066.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7958095,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,National,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7958095,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,National,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958103,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,National,,811.20,,,,,,,731.09,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958103,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,National,,811.20,,,,,,,653.02,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958108,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,210.00000,60.90000,Aetna,National,,84.00,,,,,,,75.70,171.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7958108,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,210.00000,60.90000,Aetna,National,,84.00,,,,,,,67.62,171.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7958109,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,17000.00000,4930.00000,Aetna,National,,6800.00,,,,,,,6128.50,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7958109,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,17000.00000,4930.00000,Aetna,National,,6800.00,,,,,,,5474.00,13906.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7959591,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,33862.50000,9820.12000,Aetna,National,,13545.00,,,,,,,12207.43,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7959591,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,33862.50000,9820.12000,Aetna,National,,13545.00,,,,,,,10903.73,27699.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7959958,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,National,,936.32,,,,,,,843.86,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7959958,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,National,,936.32,,,,,,,753.74,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4348.75000,1261.14000,Aetna,National,,1739.50,,,,,,,1567.72,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7959983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4348.75000,1261.14000,Aetna,National,,1739.50,,,,,,,1400.30,3557.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7744546,CDM,278,RC,C1726,HCPCS,,,facility,inpatient,,,9038.94000,2621.29000,Aetna,National,,3615.58,,,,,,,3258.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON DILATOR,7744546,CDM,278,RC,C1726,HCPCS,,,facility,outpatient,,,9038.94000,2621.29000,Aetna,National,,3615.58,,,,,,,2910.54,7393.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7960019,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,6125.00000,1776.25000,Aetna,National,,2450.00,,,,,,,2208.06,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7960019,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,6125.00000,1776.25000,Aetna,National,,2450.00,,,,,,,1972.25,5010.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7960041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,National,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7960041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,National,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7960155,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,National,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7960155,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,National,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7962229,CDM,278,RC,,,,,facility,inpatient,,,1400.00000,406.00000,Aetna,National,,560.00,,,,,,,504.70,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATOR,7962229,CDM,278,RC,,,,,facility,outpatient,,,1400.00000,406.00000,Aetna,National,,560.00,,,,,,,450.80,1145.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7962243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4812.50000,1395.62000,Aetna,National,,1925.00,,,,,,,1734.91,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7962243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4812.50000,1395.62000,Aetna,National,,1925.00,,,,,,,1549.62,3936.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962545,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,National,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962545,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,National,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962546,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7962546,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7962643,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,National,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7962643,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,National,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7963012,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8077.50000,2342.48000,Aetna,National,,3231.00,,,,,,,2911.94,6607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7963012,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8077.50000,2342.48000,Aetna,National,,3231.00,,,,,,,2600.95,6607.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7963934,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,National,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7963934,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,National,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,7963957,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,325.85000,94.50000,Aetna,National,,130.34,,,,,,,117.47,266.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,7963957,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,325.85000,94.50000,Aetna,National,,130.34,,,,,,,104.92,266.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,7963958,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,360.48000,104.54000,Aetna,National,,144.19,,,,,,,129.95,294.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SHEATH,7963958,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,360.48000,104.54000,Aetna,National,,144.19,,,,,,,116.07,294.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7963961,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4365.90000,1266.11000,Aetna,National,,1746.36,,,,,,,1573.91,3571.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7963961,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4365.90000,1266.11000,Aetna,National,,1746.36,,,,,,,1405.82,3571.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,7964335,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,National,,2225.88,,,,,,,2006.07,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,7964335,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,National,,2225.88,,,,,,,1791.83,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7964476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10092.00000,2926.68000,Aetna,National,,4036.80,,,,,,,3638.17,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7964476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10092.00000,2926.68000,Aetna,National,,4036.80,,,,,,,3249.62,8255.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964479,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4133.50000,1198.71000,Aetna,National,,1653.40,,,,,,,1490.13,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7964479,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4133.50000,1198.71000,Aetna,National,,1653.40,,,,,,,1330.99,3381.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7964997,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,3983.00000,1155.07000,Aetna,National,,1593.20,,,,,,,1435.87,3258.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7964997,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,3983.00000,1155.07000,Aetna,National,,1593.20,,,,,,,1282.53,3258.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965057,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,3587.50000,1040.38000,Aetna,National,,1435.00,,,,,,,1293.29,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965057,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,3587.50000,1040.38000,Aetna,National,,1435.00,,,,,,,1155.17,2934.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965061,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,National,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7965061,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,National,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7965235,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16187.50000,4694.38000,Aetna,National,,6475.00,,,,,,,5835.59,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7965235,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16187.50000,4694.38000,Aetna,National,,6475.00,,,,,,,5212.38,13241.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7965448,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,National,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7965448,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,National,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7965452,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,17040.00000,4941.60000,Aetna,National,,6816.00,,,,,,,6142.92,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT STENT,7965452,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,17040.00000,4941.60000,Aetna,National,,6816.00,,,,,,,5486.88,13938.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7965480,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,10224.57000,2965.13000,Aetna,National,,4089.83,,,,,,,3685.96,8363.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7965480,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,10224.57000,2965.13000,Aetna,National,,4089.83,,,,,,,3292.31,8363.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7965485,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,33682.50000,9767.92000,Aetna,National,,13473.00,,,,,,,12142.54,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7965485,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,33682.50000,9767.92000,Aetna,National,,13473.00,,,,,,,10845.76,27552.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7965924,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,12000.00000,3480.00000,Aetna,National,,4800.00,,,,,,,4326.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7965924,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,12000.00000,3480.00000,Aetna,National,,4800.00,,,,,,,3864.00,9816.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965929,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2666.00000,773.14000,Aetna,National,,1066.40,,,,,,,961.09,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7965929,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2666.00000,773.14000,Aetna,National,,1066.40,,,,,,,858.45,2180.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7966067,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,National,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7966067,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,National,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966068,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8535.00000,2475.15000,Aetna,National,,3414.00,,,,,,,3076.87,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966068,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8535.00000,2475.15000,Aetna,National,,3414.00,,,,,,,2748.27,6981.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966069,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1704.00000,494.16000,Aetna,National,,681.60,,,,,,,614.29,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966069,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1704.00000,494.16000,Aetna,National,,681.60,,,,,,,548.69,1393.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7966070,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1266.60000,367.31000,Aetna,National,,506.64,,,,,,,456.61,1036.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7966070,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1266.60000,367.31000,Aetna,National,,506.64,,,,,,,407.85,1036.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7966074,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1652.00000,479.08000,Aetna,National,,660.80,,,,,,,595.55,1351.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7966074,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1652.00000,479.08000,Aetna,National,,660.80,,,,,,,531.94,1351.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966075,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,National,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7966075,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,National,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7966077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2432.00000,705.28000,Aetna,National,,972.80,,,,,,,876.74,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7966077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2432.00000,705.28000,Aetna,National,,972.80,,,,,,,783.10,1989.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7966086,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3780.00000,1096.20000,Aetna,National,,1512.00,,,,,,,1362.69,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7966086,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3780.00000,1096.20000,Aetna,National,,1512.00,,,,,,,1217.16,3092.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7966087,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2428.28000,704.20000,Aetna,National,,971.31,,,,,,,875.39,1986.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7966087,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2428.28000,704.20000,Aetna,National,,971.31,,,,,,,781.91,1986.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7975017,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,National,,5042.40,,,,,,,4544.46,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7975017,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,National,,5042.40,,,,,,,4059.13,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIM,7966235,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,54586.00000,15829.94000,Aetna,National,,21834.40,,,,,,,19678.25,44651.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL CORD STIM,7966235,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,54586.00000,15829.94000,Aetna,National,,21834.40,,,,,,,17576.69,44651.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7967968,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,National,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7967968,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,National,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7967971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5404.11000,1567.19000,Aetna,National,,2161.64,,,,,,,1948.18,4420.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7967971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5404.11000,1567.19000,Aetna,National,,2161.64,,,,,,,1740.12,4420.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7967960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11374.50000,3298.60000,Aetna,National,,4549.80,,,,,,,4100.51,9304.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7967960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11374.50000,3298.60000,Aetna,National,,4549.80,,,,,,,3662.59,9304.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7967962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5771.50000,1673.74000,Aetna,National,,2308.60,,,,,,,2080.63,4721.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7967962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5771.50000,1673.74000,Aetna,National,,2308.60,,,,,,,1858.42,4721.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7967974,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,21158.90000,6136.08000,Aetna,National,,8463.56,,,,,,,7627.78,17307.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7967974,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,21158.90000,6136.08000,Aetna,National,,8463.56,,,,,,,6813.17,17307.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,26350.50000,7641.64000,Aetna,National,,10540.20,,,,,,,9499.36,21554.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,26350.50000,7641.64000,Aetna,National,,10540.20,,,,,,,8484.86,21554.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUTOGRAFT,7968114,CDM,278,RC,C9399,HCPCS,,,facility,inpatient,,,3286.50000,953.08000,Aetna,National,,1314.60,,,,,,,1184.78,2688.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUTOGRAFT,7968114,CDM,278,RC,C9399,HCPCS,,,facility,outpatient,,,3286.50000,953.08000,Aetna,National,,1314.60,,,,,,,1058.25,2688.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968116,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,415.67000,120.54000,Aetna,National,,166.27,,,,,,,149.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968116,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,415.67000,120.54000,Aetna,National,,166.27,,,,,,,133.85,340.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968117,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968117,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,7968118,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,7968118,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7969242,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,National,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7969242,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,National,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968123,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5564.69000,1613.76000,Aetna,National,,2225.88,,,,,,,2006.07,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968123,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5564.69000,1613.76000,Aetna,National,,2225.88,,,,,,,1791.83,4551.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7968187,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,43616.25000,12648.71000,Aetna,National,,17446.50,,,,,,,15723.66,35678.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7968187,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,43616.25000,12648.71000,Aetna,National,,17446.50,,,,,,,14044.43,35678.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7968189,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MODULAR HEAD,7968189,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968220,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1869.80000,542.24000,Aetna,National,,747.92,,,,,,,674.06,1529.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968220,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1869.80000,542.24000,Aetna,National,,747.92,,,,,,,602.08,1529.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968225,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1445.72000,419.26000,Aetna,National,,578.29,,,,,,,521.18,1182.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968225,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1445.72000,419.26000,Aetna,National,,578.29,,,,,,,465.52,1182.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968230,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3480.33000,1009.30000,Aetna,National,,1392.13,,,,,,,1254.66,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968230,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3480.33000,1009.30000,Aetna,National,,1392.13,,,,,,,1120.67,2846.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7974720,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,National,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7974720,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,National,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7968236,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,National,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7968236,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,National,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968237,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,National,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968237,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,National,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972176,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,National,,1409.80,,,,,,,1270.58,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972176,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,National,,1409.80,,,,,,,1134.89,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7903716,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,22271.88000,6458.85000,Aetna,National,,8908.75,,,,,,,8029.01,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7903716,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,22271.88000,6458.85000,Aetna,National,,8908.75,,,,,,,7171.55,18218.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7903720,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7447.50000,2159.77000,Aetna,National,,2979.00,,,,,,,2684.82,6092.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7903720,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7447.50000,2159.77000,Aetna,National,,2979.00,,,,,,,2398.09,6092.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1527.56000,442.99000,Aetna,National,,611.02,,,,,,,550.69,1249.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7903728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1527.56000,442.99000,Aetna,National,,611.02,,,,,,,491.87,1249.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903784,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,National,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903784,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,National,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7736565,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,15675.00000,4545.75000,Aetna,National,,6270.00,,,,,,,5650.84,12822.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7736565,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,15675.00000,4545.75000,Aetna,National,,6270.00,,,,,,,5047.35,12822.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903791,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,21347.50000,6190.78000,Aetna,National,,8539.00,,,,,,,7695.77,17462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903791,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,21347.50000,6190.78000,Aetna,National,,8539.00,,,,,,,6873.90,17462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903793,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,22570.00000,6545.30000,Aetna,National,,9028.00,,,,,,,8136.48,18462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903793,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,22570.00000,6545.30000,Aetna,National,,9028.00,,,,,,,7267.54,18462.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903778,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,25885.00000,7506.65000,Aetna,National,,10354.00,,,,,,,9331.54,21173.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903778,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,25885.00000,7506.65000,Aetna,National,,10354.00,,,,,,,8334.97,21173.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903780,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,27960.75000,8108.62000,Aetna,National,,11184.30,,,,,,,10079.85,22871.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NERVE GRAFT,7903780,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,27960.75000,8108.62000,Aetna,National,,11184.30,,,,,,,9003.36,22871.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7866113,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,National,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7866113,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,National,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7904053,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,National,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7904053,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,National,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894169,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,National,,375.23,,,,,,,338.17,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7894169,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,National,,375.23,,,,,,,302.06,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7904148,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,122.87000,35.63000,Aetna,National,,49.15,,,,,,,44.29,100.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7904148,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,122.87000,35.63000,Aetna,National,,49.15,,,,,,,39.56,100.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694140,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1938.32000,562.11000,Aetna,National,,775.33,,,,,,,698.76,1585.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694140,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1938.32000,562.11000,Aetna,National,,775.33,,,,,,,624.14,1585.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7904740,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7904740,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7904977,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7904977,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7905308,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,National,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7905308,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,National,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7694586,CDM,278,RC,,,,,facility,inpatient,,,2171.64000,629.78000,Aetna,National,,868.66,,,,,,,782.88,1776.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7694586,CDM,278,RC,,,,,facility,outpatient,,,2171.64000,629.78000,Aetna,National,,868.66,,,,,,,699.27,1776.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7760137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4959.50000,1438.26000,Aetna,National,,1983.80,,,,,,,1787.90,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7760137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4959.50000,1438.26000,Aetna,National,,1983.80,,,,,,,1596.96,4056.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905389,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2659.08000,771.13000,Aetna,National,,1063.63,,,,,,,958.60,2175.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905389,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2659.08000,771.13000,Aetna,National,,1063.63,,,,,,,856.22,2175.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905455,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1979.40000,574.03000,Aetna,National,,791.76,,,,,,,713.57,1619.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905455,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1979.40000,574.03000,Aetna,National,,791.76,,,,,,,637.37,1619.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905403,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,3228.96000,936.40000,Aetna,National,,1291.58,,,,,,,1164.04,2641.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905403,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,3228.96000,936.40000,Aetna,National,,1291.58,,,,,,,1039.73,2641.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905404,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2974.12000,862.49000,Aetna,National,,1189.65,,,,,,,1072.17,2432.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905404,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2974.12000,862.49000,Aetna,National,,1189.65,,,,,,,957.67,2432.83,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905410,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,2293.12000,665.00000,Aetna,National,,917.25,,,,,,,826.67,1875.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7905410,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,2293.12000,665.00000,Aetna,National,,917.25,,,,,,,738.38,1875.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7804053,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7804053,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7905548,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,2056.00000,596.24000,Aetna,National,,822.40,,,,,,,741.19,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,7905548,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,2056.00000,596.24000,Aetna,National,,822.40,,,,,,,662.03,1681.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7905550,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1991.36000,577.49000,Aetna,National,,796.54,,,,,,,717.89,1628.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7905550,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1991.36000,577.49000,Aetna,National,,796.54,,,,,,,641.22,1628.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7905567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1720.00000,498.80000,Aetna,National,,688.00,,,,,,,620.06,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7905567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1720.00000,498.80000,Aetna,National,,688.00,,,,,,,553.84,1406.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7802049,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,National,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7802049,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,National,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7893762,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,National,,1879.08,,,,,,,1693.52,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7893762,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,National,,1879.08,,,,,,,1512.66,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905617,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,National,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7905617,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,National,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702146,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1982.48000,574.92000,Aetna,National,,792.99,,,,,,,714.68,1621.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702146,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1982.48000,574.92000,Aetna,National,,792.99,,,,,,,638.36,1621.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698877,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698877,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908235,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908235,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908258,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908258,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5191.90000,1505.65000,Aetna,National,,2076.76,,,,,,,1871.68,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5191.90000,1505.65000,Aetna,National,,2076.76,,,,,,,1671.79,4246.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7698227,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7698227,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7908365,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5781.58000,1676.66000,Aetna,National,,2312.63,,,,,,,2084.26,4729.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7908365,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5781.58000,1676.66000,Aetna,National,,2312.63,,,,,,,1861.67,4729.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908499,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3328.50000,965.26000,Aetna,National,,1331.40,,,,,,,1199.92,2722.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908499,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3328.50000,965.26000,Aetna,National,,1331.40,,,,,,,1071.78,2722.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7908507,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,6286.00000,1822.94000,Aetna,National,,2514.40,,,,,,,2266.10,5141.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7908507,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,6286.00000,1822.94000,Aetna,National,,2514.40,,,,,,,2024.09,5141.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908597,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908597,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7908714,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1910.00000,553.90000,Aetna,National,,764.00,,,,,,,688.55,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7908714,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1910.00000,553.90000,Aetna,National,,764.00,,,,,,,615.02,1562.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7878470,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8445.00000,2449.05000,Aetna,National,,3378.00,,,,,,,3044.42,6908.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7878470,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8445.00000,2449.05000,Aetna,National,,3378.00,,,,,,,2719.29,6908.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7908749,CDM,278,RC,,,,,facility,inpatient,,,1936.00000,561.44000,Aetna,National,,774.40,,,,,,,697.93,1583.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7908749,CDM,278,RC,,,,,facility,outpatient,,,1936.00000,561.44000,Aetna,National,,774.40,,,,,,,623.39,1583.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7909029,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7909029,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909287,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5152.00000,1494.08000,Aetna,National,,2060.80,,,,,,,1857.30,4214.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909287,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5152.00000,1494.08000,Aetna,National,,2060.80,,,,,,,1658.94,4214.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909307,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7909307,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909325,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7909325,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909327,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6102.04000,1769.59000,Aetna,National,,2440.82,,,,,,,2199.79,4991.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7909327,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6102.04000,1769.59000,Aetna,National,,2440.82,,,,,,,1964.86,4991.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7698399,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4139.10000,1200.34000,Aetna,National,,1655.64,,,,,,,1492.15,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7698399,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4139.10000,1200.34000,Aetna,National,,1655.64,,,,,,,1332.79,3385.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7909407,CDM,278,RC,C1766,HCPCS,,,facility,inpatient,,,2740.00000,794.60000,Aetna,National,,1096.00,,,,,,,987.77,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7909407,CDM,278,RC,C1766,HCPCS,,,facility,outpatient,,,2740.00000,794.60000,Aetna,National,,1096.00,,,,,,,882.28,2241.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700436,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,National,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7700436,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,National,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PLUG,7909414,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE PLUG,7909414,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700406,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,National,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700406,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,National,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7909483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1640.00000,475.60000,Aetna,National,,656.00,,,,,,,591.22,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PATELLA IMPLANT,7909483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1640.00000,475.60000,Aetna,National,,656.00,,,,,,,528.08,1341.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7909485,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7909485,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910125,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,312.08000,90.50000,Aetna,National,,124.83,,,,,,,112.50,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910125,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,312.08000,90.50000,Aetna,National,,124.83,,,,,,,100.49,255.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910136,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,National,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910136,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,National,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5950.35000,1725.60000,Aetna,National,,2380.14,,,,,,,2145.10,4867.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5950.35000,1725.60000,Aetna,National,,2380.14,,,,,,,1916.01,4867.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910162,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,804.60000,233.33000,Aetna,National,,321.84,,,,,,,290.06,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7910162,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,804.60000,233.33000,Aetna,National,,321.84,,,,,,,259.08,658.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7910164,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9409.02000,2728.62000,Aetna,National,,3763.61,,,,,,,3391.95,7696.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7910164,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9409.02000,2728.62000,Aetna,National,,3763.61,,,,,,,3029.70,7696.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910198,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,16350.00000,4741.50000,Aetna,National,,6540.00,,,,,,,5894.18,13374.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910198,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,16350.00000,4741.50000,Aetna,National,,6540.00,,,,,,,5264.70,13374.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910199,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,28192.50000,8175.82000,Aetna,National,,11277.00,,,,,,,10163.40,23061.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910199,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,28192.50000,8175.82000,Aetna,National,,11277.00,,,,,,,9077.99,23061.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910200,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,43357.50000,12573.68000,Aetna,National,,17343.00,,,,,,,15630.38,35466.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910200,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,43357.50000,12573.68000,Aetna,National,,17343.00,,,,,,,13961.11,35466.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910201,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,52520.00000,15230.80000,Aetna,National,,21008.00,,,,,,,18933.46,42961.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910201,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,52520.00000,15230.80000,Aetna,National,,21008.00,,,,,,,16911.44,42961.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910202,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,35797.50000,10381.28000,Aetna,National,,14319.00,,,,,,,12905.00,29282.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910202,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,35797.50000,10381.28000,Aetna,National,,14319.00,,,,,,,11526.80,29282.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910203,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,42232.50000,12247.42000,Aetna,National,,16893.00,,,,,,,15224.82,34546.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7910203,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,42232.50000,12247.42000,Aetna,National,,16893.00,,,,,,,13598.86,34546.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910204,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,13629.00000,3952.41000,Aetna,National,,5451.60,,,,,,,4913.25,11148.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910204,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,13629.00000,3952.41000,Aetna,National,,5451.60,,,,,,,4388.54,11148.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910205,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,20345.00000,5900.05000,Aetna,National,,8138.00,,,,,,,7334.37,16642.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910205,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,20345.00000,5900.05000,Aetna,National,,8138.00,,,,,,,6551.09,16642.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910206,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,28273.50000,8199.31000,Aetna,National,,11309.40,,,,,,,10192.60,23127.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910206,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,28273.50000,8199.31000,Aetna,National,,11309.40,,,,,,,9104.07,23127.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PROXIMAL,7698363,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10362.00000,3004.98000,Aetna,National,,4144.80,,,,,,,3735.50,8476.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PROXIMAL,7698363,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10362.00000,3004.98000,Aetna,National,,4144.80,,,,,,,3336.56,8476.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PROXIMAL,7910253,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8658.00000,2510.82000,Aetna,National,,3463.20,,,,,,,3121.21,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PROXIMAL,7910253,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8658.00000,2510.82000,Aetna,National,,3463.20,,,,,,,2787.88,7082.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7910310,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5604.20000,1625.22000,Aetna,National,,2241.68,,,,,,,2020.31,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7910310,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5604.20000,1625.22000,Aetna,National,,2241.68,,,,,,,1804.55,4584.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7910275,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5791.42000,1679.51000,Aetna,National,,2316.57,,,,,,,2087.81,4737.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MEDPOR IMPLANT,7910275,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5791.42000,1679.51000,Aetna,National,,2316.57,,,,,,,1864.84,4737.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7910504,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7910504,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7910512,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2757.82,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7910512,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7650.00000,2218.50000,Aetna,National,,3060.00,,,,,,,2463.30,6257.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7910540,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2322.80000,673.61000,Aetna,National,,929.12,,,,,,,837.37,1900.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7910540,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2322.80000,673.61000,Aetna,National,,929.12,,,,,,,747.94,1900.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE HELMET,7910541,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1764.64000,511.75000,Aetna,National,,705.86,,,,,,,636.15,1443.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE HELMET,7910541,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1764.64000,511.75000,Aetna,National,,705.86,,,,,,,568.21,1443.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910692,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,National,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7910692,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,National,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910976,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,792.32000,229.77000,Aetna,National,,316.93,,,,,,,285.63,648.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910976,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,792.32000,229.77000,Aetna,National,,316.93,,,,,,,255.13,648.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910978,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1244.80000,360.99000,Aetna,National,,497.92,,,,,,,448.75,1018.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7910978,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1244.80000,360.99000,Aetna,National,,497.92,,,,,,,400.83,1018.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7911003,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,National,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7911003,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,National,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7911005,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4136.90000,1199.70000,Aetna,National,,1654.76,,,,,,,1491.35,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7911005,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4136.90000,1199.70000,Aetna,National,,1654.76,,,,,,,1332.08,3383.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7911035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7911035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1412.84000,409.72000,Aetna,National,,565.14,,,,,,,509.33,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1412.84000,409.72000,Aetna,National,,565.14,,,,,,,454.93,1155.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911243,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,National,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911243,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,National,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911246,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7911246,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION DEVICE IMPLANT IN KIT,7911304,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4494.00000,1303.26000,Aetna,National,,1797.60,,,,,,,1620.09,3676.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION DEVICE IMPLANT IN KIT,7911304,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4494.00000,1303.26000,Aetna,National,,1797.60,,,,,,,1447.07,3676.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911312,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6153.00000,1784.37000,Aetna,National,,2461.20,,,,,,,2218.16,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7911312,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6153.00000,1784.37000,Aetna,National,,2461.20,,,,,,,1981.27,5033.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7794037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11466.00000,3325.14000,Aetna,National,,4586.40,,,,,,,4133.49,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7794037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11466.00000,3325.14000,Aetna,National,,4586.40,,,,,,,3692.05,9379.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,322.57000,93.55000,Aetna,National,,129.03,,,,,,,116.29,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,322.57000,93.55000,Aetna,National,,129.03,,,,,,,103.87,263.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOTAL KNEE,7911437,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15250.00000,4422.50000,Aetna,National,,6100.00,,,,,,,5497.62,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOTAL KNEE,7911437,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15250.00000,4422.50000,Aetna,National,,6100.00,,,,,,,4910.50,12474.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7911440,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7911440,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP BIPOLAR M,7911441,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,National,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP BIPOLAR M,7911441,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,National,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DRILL GUIDE,7911589,CDM,278,RC,,,,,facility,inpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1186.05,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DRILL GUIDE,7911589,CDM,278,RC,,,,,facility,outpatient,,,3290.00000,954.10000,Aetna,National,,1316.00,,,,,,,1059.38,2691.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911720,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,National,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7911720,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,National,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7911724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911741,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1380.40000,400.32000,Aetna,National,,552.16,,,,,,,497.63,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911741,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1380.40000,400.32000,Aetna,National,,552.16,,,,,,,444.49,1129.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911778,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,National,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7911778,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,National,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,National,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,National,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7968227,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2028.40000,588.24000,Aetna,National,,811.36,,,,,,,731.24,1659.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7968227,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2028.40000,588.24000,Aetna,National,,811.36,,,,,,,653.14,1659.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7968234,CDM,278,RC,C1778,HCPCS,,,facility,inpatient,,,7596.00000,2202.84000,Aetna,National,,3038.40,,,,,,,2738.36,6213.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7968234,CDM,278,RC,C1778,HCPCS,,,facility,outpatient,,,7596.00000,2202.84000,Aetna,National,,3038.40,,,,,,,2445.91,6213.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7968246,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,9321.42000,2703.21000,Aetna,National,,3728.57,,,,,,,3360.37,7624.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7968246,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,9321.42000,2703.21000,Aetna,National,,3728.57,,,,,,,3001.50,7624.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968354,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12606.00000,3655.74000,Aetna,National,,5042.40,,,,,,,4544.46,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7968354,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12606.00000,3655.74000,Aetna,National,,5042.40,,,,,,,4059.13,10311.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7968409,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8097.00000,2348.13000,Aetna,National,,3238.80,,,,,,,2918.97,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7968409,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8097.00000,2348.13000,Aetna,National,,3238.80,,,,,,,2607.23,6623.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968420,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,National,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968420,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,National,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968430,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7968430,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968431,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968431,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968434,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,National,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968434,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,National,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7968435,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,18250.00000,5292.50000,Aetna,National,,7300.00,,,,,,,6579.12,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7968435,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,18250.00000,5292.50000,Aetna,National,,7300.00,,,,,,,5876.50,14928.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968483,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2091.92000,606.66000,Aetna,National,,836.77,,,,,,,754.14,1711.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7968483,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2091.92000,606.66000,Aetna,National,,836.77,,,,,,,673.60,1711.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7968506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,432.25000,125.35000,Aetna,National,,172.90,,,,,,,155.83,353.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7968506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,432.25000,125.35000,Aetna,National,,172.90,,,,,,,139.18,353.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968525,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968525,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968507,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7968507,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7968510,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,26000.00000,7540.00000,Aetna,National,,10400.00,,,,,,,9373.00,21268.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL SPACER,7968510,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,26000.00000,7540.00000,Aetna,National,,10400.00,,,,,,,8372.00,21268.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975099,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1344.04000,389.77000,Aetna,National,,537.62,,,,,,,484.53,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975099,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1344.04000,389.77000,Aetna,National,,537.62,,,,,,,432.78,1099.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7967963,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3070.00000,890.30000,Aetna,National,,1228.00,,,,,,,1106.73,2511.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7967963,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3070.00000,890.30000,Aetna,National,,1228.00,,,,,,,988.54,2511.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7967964,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2080.00000,603.20000,Aetna,National,,832.00,,,,,,,749.84,1701.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7967964,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2080.00000,603.20000,Aetna,National,,832.00,,,,,,,669.76,1701.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7968693,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,630.00000,182.70000,Aetna,National,,252.00,,,,,,,227.12,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL ADAPTER,7968693,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,630.00000,182.70000,Aetna,National,,252.00,,,,,,,202.86,515.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968698,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8913.30000,2584.86000,Aetna,National,,3565.32,,,,,,,3213.24,7291.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968698,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8913.30000,2584.86000,Aetna,National,,3565.32,,,,,,,2870.08,7291.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968699,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2020.80000,586.03000,Aetna,National,,808.32,,,,,,,728.50,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968699,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2020.80000,586.03000,Aetna,National,,808.32,,,,,,,650.70,1653.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2142.40000,621.30000,Aetna,National,,856.96,,,,,,,772.34,1752.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2142.40000,621.30000,Aetna,National,,856.96,,,,,,,689.85,1752.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7968723,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3341.63000,969.07000,Aetna,National,,1336.65,,,,,,,1204.66,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7968723,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3341.63000,969.07000,Aetna,National,,1336.65,,,,,,,1076.00,2733.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7968825,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,805.50000,233.59000,Aetna,National,,322.20,,,,,,,290.38,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7968825,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,805.50000,233.59000,Aetna,National,,322.20,,,,,,,259.37,658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7968954,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4028.15000,1168.16000,Aetna,National,,1611.26,,,,,,,1452.15,3295.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7968954,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4028.15000,1168.16000,Aetna,National,,1611.26,,,,,,,1297.06,3295.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968960,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,National,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968960,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,National,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968959,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,National,,1548.40,,,,,,,1395.50,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7968959,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,National,,1548.40,,,,,,,1246.46,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7968967,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,25750.00000,7467.50000,Aetna,National,,10300.00,,,,,,,9282.88,21063.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7968967,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,25750.00000,7467.50000,Aetna,National,,10300.00,,,,,,,8291.50,21063.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968968,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,323.00000,93.67000,Aetna,National,,129.20,,,,,,,116.44,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7968968,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,323.00000,93.67000,Aetna,National,,129.20,,,,,,,104.01,264.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7968969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4308.50000,1249.46000,Aetna,National,,1723.40,,,,,,,1553.21,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM EXTENSION,7968969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4308.50000,1249.46000,Aetna,National,,1723.40,,,,,,,1387.34,3524.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969007,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1874.88000,543.72000,Aetna,National,,749.95,,,,,,,675.89,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969007,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1874.88000,543.72000,Aetna,National,,749.95,,,,,,,603.71,1533.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.31000,1115.14000,Aetna,National,,1538.12,,,,,,,1386.23,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.31000,1115.14000,Aetna,National,,1538.12,,,,,,,1238.19,3145.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969025,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3524.50000,1022.10000,Aetna,National,,1409.80,,,,,,,1270.58,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969025,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3524.50000,1022.10000,Aetna,National,,1409.80,,,,,,,1134.89,2883.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969028,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,National,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969028,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,National,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969029,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,National,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7969029,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,National,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969033,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969033,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,National,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,National,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7969024,CDM,278,RC,C1714,HCPCS,,,facility,inpatient,,,13185.00000,3823.65000,Aetna,National,,5274.00,,,,,,,4753.19,10785.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7969024,CDM,278,RC,C1714,HCPCS,,,facility,outpatient,,,13185.00000,3823.65000,Aetna,National,,5274.00,,,,,,,4245.57,10785.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969023,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5618.62000,1629.40000,Aetna,National,,2247.45,,,,,,,2025.51,4596.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969023,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5618.62000,1629.40000,Aetna,National,,2247.45,,,,,,,1809.20,4596.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7969316,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10371.00000,3007.59000,Aetna,National,,4148.40,,,,,,,3738.75,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7969316,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10371.00000,3007.59000,Aetna,National,,4148.40,,,,,,,3339.46,8483.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969317,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969317,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969321,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3315.76000,961.57000,Aetna,National,,1326.30,,,,,,,1195.33,2712.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969321,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3315.76000,961.57000,Aetna,National,,1326.30,,,,,,,1067.67,2712.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974079,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12183.00000,3533.07000,Aetna,National,,4873.20,,,,,,,4391.97,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974079,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12183.00000,3533.07000,Aetna,National,,4873.20,,,,,,,3922.93,9965.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7969473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6317.50000,1832.07000,Aetna,National,,2527.00,,,,,,,2277.46,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7969473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6317.50000,1832.07000,Aetna,National,,2527.00,,,,,,,2034.23,5167.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7969476,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,National,,889.18,,,,,,,801.38,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7969476,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,National,,889.18,,,,,,,715.79,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7969540,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1958.96000,568.10000,Aetna,National,,783.58,,,,,,,706.21,1602.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7969540,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1958.96000,568.10000,Aetna,National,,783.58,,,,,,,630.79,1602.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969481,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2283.52000,662.22000,Aetna,National,,913.41,,,,,,,823.21,1867.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969481,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2283.52000,662.22000,Aetna,National,,913.41,,,,,,,735.29,1867.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969482,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2137.68000,619.93000,Aetna,National,,855.07,,,,,,,770.63,1748.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969482,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2137.68000,619.93000,Aetna,National,,855.07,,,,,,,688.33,1748.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969484,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1939.04000,562.32000,Aetna,National,,775.62,,,,,,,699.02,1586.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969484,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1939.04000,562.32000,Aetna,National,,775.62,,,,,,,624.37,1586.13,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969485,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1631.80000,473.22000,Aetna,National,,652.72,,,,,,,588.26,1334.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969485,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1631.80000,473.22000,Aetna,National,,652.72,,,,,,,525.44,1334.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969544,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,National,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969544,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,National,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7969566,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4076.63000,1182.22000,Aetna,National,,1630.65,,,,,,,1469.63,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7969566,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4076.63000,1182.22000,Aetna,National,,1630.65,,,,,,,1312.67,3334.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969634,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969634,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6637.02000,1924.74000,Aetna,National,,2654.81,,,,,,,2392.65,5429.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6637.02000,1924.74000,Aetna,National,,2654.81,,,,,,,2137.12,5429.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7969679,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,610.20000,176.96000,Aetna,National,,244.08,,,,,,,219.98,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7969679,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,610.20000,176.96000,Aetna,National,,244.08,,,,,,,196.48,499.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969714,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,National,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969714,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,National,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7976331,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18668.00000,5413.72000,Aetna,National,,7467.20,,,,,,,6729.81,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7976331,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18668.00000,5413.72000,Aetna,National,,7467.20,,,,,,,6011.10,15270.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7969724,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5145.70000,1492.25000,Aetna,National,,2058.28,,,,,,,1855.02,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7969724,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5145.70000,1492.25000,Aetna,National,,2058.28,,,,,,,1656.92,4209.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7969747,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,39829.50000,11550.55000,Aetna,National,,15931.80,,,,,,,14358.53,32580.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7969747,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,39829.50000,11550.55000,Aetna,National,,15931.80,,,,,,,12825.10,32580.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7969748,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,3578.56000,1037.78000,Aetna,National,,1431.42,,,,,,,1290.07,2927.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7969748,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,3578.56000,1037.78000,Aetna,National,,1431.42,,,,,,,1152.30,2927.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969742,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,990.00000,287.10000,Aetna,National,,396.00,,,,,,,356.89,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969742,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,990.00000,287.10000,Aetna,National,,396.00,,,,,,,318.78,809.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969746,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2028.00000,588.12000,Aetna,National,,811.20,,,,,,,731.09,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969746,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2028.00000,588.12000,Aetna,National,,811.20,,,,,,,653.02,1658.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5941.78000,1723.12000,Aetna,National,,2376.71,,,,,,,2142.01,4860.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5941.78000,1723.12000,Aetna,National,,2376.71,,,,,,,1913.25,4860.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7969784,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1244.00000,360.76000,Aetna,National,,497.60,,,,,,,448.46,1017.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7969784,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1244.00000,360.76000,Aetna,National,,497.60,,,,,,,400.57,1017.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969785,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7969785,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7969826,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6210.33000,1801.00000,Aetna,National,,2484.13,,,,,,,2238.82,5080.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7969826,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6210.33000,1801.00000,Aetna,National,,2484.13,,,,,,,1999.73,5080.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969827,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9564.00000,2773.56000,Aetna,National,,3825.60,,,,,,,3447.82,7823.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7969827,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9564.00000,2773.56000,Aetna,National,,3825.60,,,,,,,3079.61,7823.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969828,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,National,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7969828,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,National,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972280,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2484.00000,720.36000,Aetna,National,,993.60,,,,,,,895.48,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972280,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2484.00000,720.36000,Aetna,National,,993.60,,,,,,,799.85,2031.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969831,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,National,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969831,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,National,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,7969833,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15500.00000,4495.00000,Aetna,National,,6200.00,,,,,,,5587.75,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER SPINAL,7969833,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15500.00000,4495.00000,Aetna,National,,6200.00,,,,,,,4991.00,12679.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7969832,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,114.19000,33.12000,Aetna,National,,45.68,,,,,,,41.17,93.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7969832,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,114.19000,33.12000,Aetna,National,,45.68,,,,,,,36.77,93.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7969868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7971855,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1547.56000,448.79000,Aetna,National,,619.02,,,,,,,557.90,1265.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7971855,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1547.56000,448.79000,Aetna,National,,619.02,,,,,,,498.31,1265.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7971861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,National,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7971861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,National,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7971854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2876.80000,834.27000,Aetna,National,,1150.72,,,,,,,1037.09,2353.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7971854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2876.80000,834.27000,Aetna,National,,1150.72,,,,,,,926.33,2353.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972002,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2168.72000,628.93000,Aetna,National,,867.49,,,,,,,781.82,1774.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972002,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2168.72000,628.93000,Aetna,National,,867.49,,,,,,,698.33,1774.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972020,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6562.50000,1903.12000,Aetna,National,,2625.00,,,,,,,2365.78,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972020,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6562.50000,1903.12000,Aetna,National,,2625.00,,,,,,,2113.12,5368.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7972021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,National,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7972021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,National,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972022,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2820.00000,817.80000,Aetna,National,,1128.00,,,,,,,1016.61,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972022,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2820.00000,817.80000,Aetna,National,,1128.00,,,,,,,908.04,2306.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972129,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4616.50000,1338.78000,Aetna,National,,1846.60,,,,,,,1664.25,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972129,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4616.50000,1338.78000,Aetna,National,,1846.60,,,,,,,1486.51,3776.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7973848,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,National,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7973848,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,National,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972172,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972172,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972173,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972173,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972174,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7972174,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972182,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,National,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7972182,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,National,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7972278,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,National,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7972278,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,National,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972238,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4545.10000,1318.08000,Aetna,National,,1818.04,,,,,,,1638.51,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972238,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4545.10000,1318.08000,Aetna,National,,1818.04,,,,,,,1463.52,3717.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5527.55000,1602.99000,Aetna,National,,2211.02,,,,,,,1992.68,4521.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5527.55000,1602.99000,Aetna,National,,2211.02,,,,,,,1779.87,4521.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6180.65000,1792.39000,Aetna,National,,2472.26,,,,,,,2228.12,5055.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6180.65000,1792.39000,Aetna,National,,2472.26,,,,,,,1990.17,5055.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972234,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3892.18000,1128.73000,Aetna,National,,1556.87,,,,,,,1403.13,3183.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7972234,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3892.18000,1128.73000,Aetna,National,,1556.87,,,,,,,1253.28,3183.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972263,CDM,278,RC,C1789,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,National,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BREAST IMPLANT,7972263,CDM,278,RC,C1789,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,National,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7972277,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,26545.00000,7698.05000,Aetna,National,,10618.00,,,,,,,9569.47,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7972277,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,26545.00000,7698.05000,Aetna,National,,10618.00,,,,,,,8547.49,21713.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,National,,873.60,,,,,,,787.33,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,National,,873.60,,,,,,,703.25,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7972594,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4309.20000,1249.67000,Aetna,National,,1723.68,,,,,,,1553.47,3524.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7972594,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4309.20000,1249.67000,Aetna,National,,1723.68,,,,,,,1387.56,3524.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972581,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,National,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7972581,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,National,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,7972583,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5012.00000,1453.48000,Aetna,National,,2004.80,,,,,,,1806.83,4099.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STAPLE,7972583,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5012.00000,1453.48000,Aetna,National,,2004.80,,,,,,,1613.86,4099.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FUSION DEVICE,7972656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FUSION DEVICE,7972656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7973830,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4945.50000,1434.20000,Aetna,National,,1978.20,,,,,,,1782.85,4045.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE GRAFT,7973830,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4945.50000,1434.20000,Aetna,National,,1978.20,,,,,,,1592.45,4045.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7973839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5153.40000,1494.49000,Aetna,National,,2061.36,,,,,,,1857.80,4215.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7973839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5153.40000,1494.49000,Aetna,National,,2061.36,,,,,,,1659.39,4215.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694901,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,4541.88000,1317.15000,Aetna,National,,1816.75,,,,,,,1637.35,3715.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7694901,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,4541.88000,1317.15000,Aetna,National,,1816.75,,,,,,,1462.49,3715.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,7962808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,382.38000,110.89000,Aetna,National,,152.95,,,,,,,137.85,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW LOCKING,7962808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,382.38000,110.89000,Aetna,National,,152.95,,,,,,,123.13,312.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8160823,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,National,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8160823,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,National,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160911,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,National,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8160911,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,National,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160913,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,847.80000,245.86000,Aetna,National,,339.12,,,,,,,305.63,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160913,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,847.80000,245.86000,Aetna,National,,339.12,,,,,,,272.99,693.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160915,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,National,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160915,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,National,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160917,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,588.60000,170.69000,Aetna,National,,235.44,,,,,,,212.19,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8160917,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,588.60000,170.69000,Aetna,National,,235.44,,,,,,,189.53,481.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8160919,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8160919,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160970,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5793.90000,1680.23000,Aetna,National,,2317.56,,,,,,,2088.70,4739.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8160970,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5793.90000,1680.23000,Aetna,National,,2317.56,,,,,,,1865.64,4739.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8160983,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9180.00000,2662.20000,Aetna,National,,3672.00,,,,,,,3309.39,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8160983,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9180.00000,2662.20000,Aetna,National,,3672.00,,,,,,,2955.96,7509.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8160984,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,National,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,8160984,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,National,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8160985,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8160985,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8160981,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8462.70000,2454.18000,Aetna,National,,3385.08,,,,,,,3050.80,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,8160981,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8462.70000,2454.18000,Aetna,National,,3385.08,,,,,,,2724.99,6922.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161263,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,National,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161263,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,National,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8161098,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4733.68000,1372.77000,Aetna,National,,1893.47,,,,,,,1706.49,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8161098,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4733.68000,1372.77000,Aetna,National,,1893.47,,,,,,,1524.24,3872.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HUMAN TISS,8161100,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,6083.00000,1764.07000,Aetna,National,,2433.20,,,,,,,2192.92,4975.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT HUMAN TISS,8161100,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,6083.00000,1764.07000,Aetna,National,,2433.20,,,,,,,1958.73,4975.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8161261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8161261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8161144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,National,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW POLYAXIAL,8161144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,National,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8161167,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,National,,6725.00,,,,,,,6060.91,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL FIXATION,8161167,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,National,,6725.00,,,,,,,5413.62,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161168,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.00000,516.20000,Aetna,National,,712.00,,,,,,,641.69,1456.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161168,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.00000,516.20000,Aetna,National,,712.00,,,,,,,573.16,1456.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8161169,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,National,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8161169,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,National,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161170,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,National,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161170,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,National,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT CORE,8161173,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,15750.00000,4567.50000,Aetna,National,,6300.00,,,,,,,5677.88,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
IMPLANT CORE,8161173,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,15750.00000,4567.50000,Aetna,National,,6300.00,,,,,,,5071.50,12883.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8161174,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,National,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8161174,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,National,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8161175,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2120.00000,614.80000,Aetna,National,,848.00,,,,,,,764.26,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ENDPLATE,8161175,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2120.00000,614.80000,Aetna,National,,848.00,,,,,,,682.64,1734.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8161299,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,50390.40000,14613.22000,Aetna,National,,20156.16,,,,,,,18165.74,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8161299,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,50390.40000,14613.22000,Aetna,National,,20156.16,,,,,,,16225.71,41219.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161260,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,National,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161260,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,National,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8161301,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3500.00000,1015.00000,Aetna,National,,1400.00,,,,,,,1261.75,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8161301,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3500.00000,1015.00000,Aetna,National,,1400.00,,,,,,,1127.00,2863.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8161366,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,National,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,8161366,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,National,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONET FEMORAL,8161367,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,356.25000,103.31000,Aetna,National,,142.50,,,,,,,128.43,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONET FEMORAL,8161367,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,356.25000,103.31000,Aetna,National,,142.50,,,,,,,114.71,291.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG MICROVASCULAR,8161369,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,6020.00000,1745.80000,Aetna,National,,2408.00,,,,,,,2170.21,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLUG MICROVASCULAR,8161369,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,6020.00000,1745.80000,Aetna,National,,2408.00,,,,,,,1938.44,4924.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8161373,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,National,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8161373,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,National,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8161375,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEMORAL,8161375,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,National,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,National,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161408,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,National,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161408,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,National,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8161409,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,National,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8161409,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,National,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161410,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,National,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161410,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,National,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8161404,CDM,278,RC,C1785,HCPCS,,,facility,inpatient,,,11250.00000,3262.50000,Aetna,National,,4500.00,,,,,,,4055.62,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8161404,CDM,278,RC,C1785,HCPCS,,,facility,outpatient,,,11250.00000,3262.50000,Aetna,National,,4500.00,,,,,,,3622.50,9202.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8161547,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8061.39000,2337.80000,Aetna,National,,3224.56,,,,,,,2906.13,6594.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8161547,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8061.39000,2337.80000,Aetna,National,,3224.56,,,,,,,2595.77,6594.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161549,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,715.77000,207.57000,Aetna,National,,286.31,,,,,,,258.04,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161549,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,715.77000,207.57000,Aetna,National,,286.31,,,,,,,230.48,585.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161592,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161592,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8161594,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,20820.00000,6037.80000,Aetna,National,,8328.00,,,,,,,7505.61,17030.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8161594,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,20820.00000,6037.80000,Aetna,National,,8328.00,,,,,,,6704.04,17030.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8161595,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,8161595,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3968.20000,1150.78000,Aetna,National,,1587.28,,,,,,,1430.54,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8161596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3968.20000,1150.78000,Aetna,National,,1587.28,,,,,,,1277.76,3245.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8161598,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11889.60000,3447.98000,Aetna,National,,4755.84,,,,,,,4286.20,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,8161598,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11889.60000,3447.98000,Aetna,National,,4755.84,,,,,,,3828.45,9725.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,153.56000,44.53000,Aetna,National,,61.42,,,,,,,55.36,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7966236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,153.56000,44.53000,Aetna,National,,61.42,,,,,,,49.45,125.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161724,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,National,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161724,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,National,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161726,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,National,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161726,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,National,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161736,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,National,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161736,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,National,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161728,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,National,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161728,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,National,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161730,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,National,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161730,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,National,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161732,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,National,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161732,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,National,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,31331.25000,9086.06000,Aetna,National,,12532.50,,,,,,,11294.92,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,8161774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,31331.25000,9086.06000,Aetna,National,,12532.50,,,,,,,10088.66,25628.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161776,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5124.39000,1486.07000,Aetna,National,,2049.76,,,,,,,1847.34,4191.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8161776,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5124.39000,1486.07000,Aetna,National,,2049.76,,,,,,,1650.05,4191.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8161799,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2540.00000,736.60000,Aetna,National,,1016.00,,,,,,,915.67,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8161799,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2540.00000,736.60000,Aetna,National,,1016.00,,,,,,,817.88,2077.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161801,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,National,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8161801,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,National,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,8161803,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,National,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,8161803,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,National,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8163806,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5022.50000,1456.52000,Aetna,National,,2009.00,,,,,,,1810.61,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD HUMERAL,8163806,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5022.50000,1456.52000,Aetna,National,,2009.00,,,,,,,1617.24,4108.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8163807,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,16812.50000,4875.62000,Aetna,National,,6725.00,,,,,,,6060.91,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8163807,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,16812.50000,4875.62000,Aetna,National,,6725.00,,,,,,,5413.62,13752.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8163808,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4322.50000,1253.52000,Aetna,National,,1729.00,,,,,,,1558.26,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8163808,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4322.50000,1253.52000,Aetna,National,,1729.00,,,,,,,1391.85,3535.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163862,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,National,,1738.80,,,,,,,1567.09,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163862,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,National,,1738.80,,,,,,,1399.73,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,National,,1738.80,,,,,,,1567.09,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,National,,1738.80,,,,,,,1399.73,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4347.00000,1260.63000,Aetna,National,,1738.80,,,,,,,1567.09,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8163866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4347.00000,1260.63000,Aetna,National,,1738.80,,,,,,,1399.73,3555.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8163983,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,652.50000,189.22000,Aetna,National,,261.00,,,,,,,235.23,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8163983,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,652.50000,189.22000,Aetna,National,,261.00,,,,,,,210.10,533.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166016,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,394.25000,114.33000,Aetna,National,,157.70,,,,,,,142.13,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166016,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,394.25000,114.33000,Aetna,National,,157.70,,,,,,,126.95,322.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8166017,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3709.13000,1075.65000,Aetna,National,,1483.65,,,,,,,1337.14,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,8166017,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3709.13000,1075.65000,Aetna,National,,1483.65,,,,,,,1194.34,3034.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8166018,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,National,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8166018,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,National,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8166020,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,National,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,8166020,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,National,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166021,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10050.00000,2914.50000,Aetna,National,,4020.00,,,,,,,3623.03,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166021,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10050.00000,2914.50000,Aetna,National,,4020.00,,,,,,,3236.10,8220.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166126,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,4567.50000,1324.57000,Aetna,National,,1827.00,,,,,,,1646.58,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166126,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,4567.50000,1324.57000,Aetna,National,,1827.00,,,,,,,1470.73,3736.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166128,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8082.00000,2343.78000,Aetna,National,,3232.80,,,,,,,2913.56,6611.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166128,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8082.00000,2343.78000,Aetna,National,,3232.80,,,,,,,2602.40,6611.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166224,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,8082.00000,2343.78000,Aetna,National,,3232.80,,,,,,,2913.56,6611.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166224,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,8082.00000,2343.78000,Aetna,National,,3232.80,,,,,,,2602.40,6611.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166130,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,11970.00000,3471.30000,Aetna,National,,4788.00,,,,,,,4315.19,9791.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166130,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,11970.00000,3471.30000,Aetna,National,,4788.00,,,,,,,3854.34,9791.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166132,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17460.00000,5063.40000,Aetna,National,,6984.00,,,,,,,6294.33,14282.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166132,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17460.00000,5063.40000,Aetna,National,,6984.00,,,,,,,5622.12,14282.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166134,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17460.00000,5063.40000,Aetna,National,,6984.00,,,,,,,6294.33,14282.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166134,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17460.00000,5063.40000,Aetna,National,,6984.00,,,,,,,5622.12,14282.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166136,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,National,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166136,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,National,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166138,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,28462.50000,8254.12000,Aetna,National,,11385.00,,,,,,,10260.73,23282.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,8166138,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,28462.50000,8254.12000,Aetna,National,,11385.00,,,,,,,9164.92,23282.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166143,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7734.60000,2243.03000,Aetna,National,,3093.84,,,,,,,2788.32,6326.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166143,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7734.60000,2243.03000,Aetna,National,,3093.84,,,,,,,2490.54,6326.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166144,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,National,,582.62,,,,,,,525.09,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166144,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,National,,582.62,,,,,,,469.01,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166145,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1456.56000,422.40000,Aetna,National,,582.62,,,,,,,525.09,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166145,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1456.56000,422.40000,Aetna,National,,582.62,,,,,,,469.01,1191.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166146,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,12810.00000,3714.90000,Aetna,National,,5124.00,,,,,,,4618.01,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,8166146,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,12810.00000,3714.90000,Aetna,National,,5124.00,,,,,,,4124.82,10478.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166140,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2340.80000,678.83000,Aetna,National,,936.32,,,,,,,843.86,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166140,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2340.80000,678.83000,Aetna,National,,936.32,,,,,,,753.74,1914.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8166141,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5306.70000,1538.94000,Aetna,National,,2122.68,,,,,,,1913.07,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,8166141,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5306.70000,1538.94000,Aetna,National,,2122.68,,,,,,,1708.76,4340.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166142,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,National,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,8166142,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,National,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8166291,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8166291,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8167850,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,National,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8167850,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,National,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8166264,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8166264,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
insert,8166266,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
insert,8166266,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8166268,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6216.00000,1802.64000,Aetna,National,,2486.40,,,,,,,2240.87,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,8166268,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6216.00000,1802.64000,Aetna,National,,2486.40,,,,,,,2001.55,5084.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8167808,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,National,,1825.25,,,,,,,1645.01,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8167808,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,National,,1825.25,,,,,,,1469.33,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING LCKNG,8167809,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2486.80000,721.17000,Aetna,National,,994.72,,,,,,,896.49,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING LCKNG,8167809,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2486.80000,721.17000,Aetna,National,,994.72,,,,,,,800.75,2034.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8167810,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,National,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8167810,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,National,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8167811,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4563.13000,1323.31000,Aetna,National,,1825.25,,,,,,,1645.01,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HEAD FEM,8167811,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4563.13000,1323.31000,Aetna,National,,1825.25,,,,,,,1469.33,3732.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8167812,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9921.30000,2877.18000,Aetna,National,,3968.52,,,,,,,3576.63,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER ACETABULAR,8167812,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9921.30000,2877.18000,Aetna,National,,3968.52,,,,,,,3194.66,8115.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8167852,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,21412.50000,6209.62000,Aetna,National,,8565.00,,,,,,,7719.21,17515.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,8167852,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,21412.50000,6209.62000,Aetna,National,,8565.00,,,,,,,6894.82,17515.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8167854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,National,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,8167854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,National,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8167963,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,6545.00000,1898.05000,Aetna,National,,2618.00,,,,,,,2359.47,5353.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RING ANNULOPLASTY,8167963,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,6545.00000,1898.05000,Aetna,National,,2618.00,,,,,,,2107.49,5353.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911543,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7911543,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701908,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6620.25000,1919.87000,Aetna,National,,2648.10,,,,,,,2386.60,5415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701908,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6620.25000,1919.87000,Aetna,National,,2648.10,,,,,,,2131.72,5415.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7701605,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3434.90000,996.12000,Aetna,National,,1373.96,,,,,,,1238.28,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7701605,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3434.90000,996.12000,Aetna,National,,1373.96,,,,,,,1106.04,2809.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701954,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,479.75000,139.13000,Aetna,National,,191.90,,,,,,,172.95,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7701954,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,479.75000,139.13000,Aetna,National,,191.90,,,,,,,154.48,392.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697909,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7697909,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702144,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,49275.00000,14289.75000,Aetna,National,,19710.00,,,,,,,17763.64,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7702144,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,49275.00000,14289.75000,Aetna,National,,19710.00,,,,,,,15866.55,40306.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695340,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,National,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695340,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,National,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701576,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5520.87000,1601.05000,Aetna,National,,2208.35,,,,,,,1990.27,4516.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701576,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5520.87000,1601.05000,Aetna,National,,2208.35,,,,,,,1777.72,4516.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702161,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,National,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702161,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,National,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7702166,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1260.00000,365.40000,Aetna,National,,504.00,,,,,,,454.23,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7702166,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1260.00000,365.40000,Aetna,National,,504.00,,,,,,,405.72,1030.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701783,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,502.55000,145.74000,Aetna,National,,201.02,,,,,,,181.17,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7701783,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,502.55000,145.74000,Aetna,National,,201.02,,,,,,,161.82,411.09,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695610,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,National,,307.80,,,,,,,277.40,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695610,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,National,,307.80,,,,,,,247.78,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,7699669,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,594.00000,172.26000,Aetna,National,,237.60,,,,,,,214.14,485.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,7699669,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,594.00000,172.26000,Aetna,National,,237.60,,,,,,,191.27,485.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702222,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4879.00000,1414.91000,Aetna,National,,1951.60,,,,,,,1758.88,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702222,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4879.00000,1414.91000,Aetna,National,,1951.60,,,,,,,1571.04,3991.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION LIMB,7702228,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12147.00000,3522.63000,Aetna,National,,4858.80,,,,,,,4378.99,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EXTENSION LIMB,7702228,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12147.00000,3522.63000,Aetna,National,,4858.80,,,,,,,3911.33,9936.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702232,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1709.67,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7702232,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4742.50000,1375.32000,Aetna,National,,1897.00,,,,,,,1527.09,3879.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702974,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,National,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702974,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,National,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7702252,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7702252,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,7702255,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3408.13000,988.36000,Aetna,National,,1363.25,,,,,,,1228.63,2787.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE CEMENT,7702255,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3408.13000,988.36000,Aetna,National,,1363.25,,,,,,,1097.42,2787.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7702239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1332.80000,386.51000,Aetna,National,,533.12,,,,,,,480.47,1090.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PEG,7702239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1332.80000,386.51000,Aetna,National,,533.12,,,,,,,429.16,1090.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698672,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3745.00000,1086.05000,Aetna,National,,1498.00,,,,,,,1350.07,3063.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698672,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3745.00000,1086.05000,Aetna,National,,1498.00,,,,,,,1205.89,3063.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702270,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5376.95000,1559.32000,Aetna,National,,2150.78,,,,,,,1938.39,4398.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702270,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5376.95000,1559.32000,Aetna,National,,2150.78,,,,,,,1731.38,4398.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702273,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1752.00000,508.08000,Aetna,National,,700.80,,,,,,,631.60,1433.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702273,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1752.00000,508.08000,Aetna,National,,700.80,,,,,,,564.14,1433.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1337.60000,387.90000,Aetna,National,,535.04,,,,,,,482.20,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1337.60000,387.90000,Aetna,National,,535.04,,,,,,,430.71,1094.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702278,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,National,,69.15,,,,,,,62.32,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7702278,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,National,,69.15,,,,,,,55.67,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702284,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2345.64000,680.24000,Aetna,National,,938.26,,,,,,,845.60,1918.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702284,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2345.64000,680.24000,Aetna,National,,938.26,,,,,,,755.30,1918.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699877,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,National,,672.32,,,,,,,605.93,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699877,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,National,,672.32,,,,,,,541.22,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701820,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2050.40000,594.62000,Aetna,National,,820.16,,,,,,,739.17,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701820,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2050.40000,594.62000,Aetna,National,,820.16,,,,,,,660.23,1677.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1548.80000,449.15000,Aetna,National,,619.52,,,,,,,558.34,1266.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1548.80000,449.15000,Aetna,National,,619.52,,,,,,,498.71,1266.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701827,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1601.60000,464.46000,Aetna,National,,640.64,,,,,,,577.38,1310.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701827,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1601.60000,464.46000,Aetna,National,,640.64,,,,,,,515.72,1310.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1414.56000,410.22000,Aetna,National,,565.82,,,,,,,509.95,1157.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1414.56000,410.22000,Aetna,National,,565.82,,,,,,,455.49,1157.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2499.20000,724.77000,Aetna,National,,999.68,,,,,,,900.96,2044.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2499.20000,724.77000,Aetna,National,,999.68,,,,,,,804.74,2044.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702288,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2811.20000,815.25000,Aetna,National,,1124.48,,,,,,,1013.44,2299.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7702288,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2811.20000,815.25000,Aetna,National,,1124.48,,,,,,,905.21,2299.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736587,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,15087.50000,4375.38000,Aetna,National,,6035.00,,,,,,,5439.04,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736587,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,15087.50000,4375.38000,Aetna,National,,6035.00,,,,,,,4858.18,12341.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772034,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1311.20000,380.25000,Aetna,National,,524.48,,,,,,,472.69,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7772034,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1311.20000,380.25000,Aetna,National,,524.48,,,,,,,422.21,1072.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701870,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1680.80000,487.43000,Aetna,National,,672.32,,,,,,,605.93,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701870,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1680.80000,487.43000,Aetna,National,,672.32,,,,,,,541.22,1374.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1944.80000,563.99000,Aetna,National,,777.92,,,,,,,701.10,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1944.80000,563.99000,Aetna,National,,777.92,,,,,,,626.23,1590.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701881,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4067.70000,1179.63000,Aetna,National,,1627.08,,,,,,,1466.41,3327.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701881,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4067.70000,1179.63000,Aetna,National,,1627.08,,,,,,,1309.80,3327.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701886,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1958.00000,567.82000,Aetna,National,,783.20,,,,,,,705.86,1601.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701886,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1958.00000,567.82000,Aetna,National,,783.20,,,,,,,630.48,1601.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701889,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4137.00000,1199.73000,Aetna,National,,1654.80,,,,,,,1491.39,3384.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701889,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4137.00000,1199.73000,Aetna,National,,1654.80,,,,,,,1332.11,3384.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701891,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2882.00000,835.78000,Aetna,National,,1152.80,,,,,,,1038.96,2357.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701891,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2882.00000,835.78000,Aetna,National,,1152.80,,,,,,,928.00,2357.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8932.50000,2590.42000,Aetna,National,,3573.00,,,,,,,3220.17,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7701904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8932.50000,2590.42000,Aetna,National,,3573.00,,,,,,,2876.26,7306.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7694909,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1280.00000,371.20000,Aetna,National,,512.00,,,,,,,461.44,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7694909,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1280.00000,371.20000,Aetna,National,,512.00,,,,,,,412.16,1047.04,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699290,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,National,,3438.00,,,,,,,3098.50,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7699290,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,National,,3438.00,,,,,,,2767.59,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7702625,CDM,278,RC,L8641,HCPCS,,,facility,inpatient,,,3712.80000,1076.71000,Aetna,National,,1485.12,,,,,,,1338.46,3037.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TOE IMPLANT,7702625,CDM,278,RC,L8641,HCPCS,,,facility,outpatient,,,3712.80000,1076.71000,Aetna,National,,1485.12,,,,,,,428.55,3037.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7702621,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5215.00000,1512.35000,Aetna,National,,2086.00,,,,,,,1880.01,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL CUP,7702621,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5215.00000,1512.35000,Aetna,National,,2086.00,,,,,,,1679.23,4265.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6030.05000,1748.71000,Aetna,National,,2412.02,,,,,,,2173.83,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6030.05000,1748.71000,Aetna,National,,2412.02,,,,,,,1941.68,4932.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702646,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7360.47000,2134.54000,Aetna,National,,2944.19,,,,,,,2653.45,6020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702646,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7360.47000,2134.54000,Aetna,National,,2944.19,,,,,,,2370.07,6020.86,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702667,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7419.12000,2151.54000,Aetna,National,,2967.65,,,,,,,2674.59,6068.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7702667,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7419.12000,2151.54000,Aetna,National,,2967.65,,,,,,,2388.96,6068.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695283,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4830.00000,1400.70000,Aetna,National,,1932.00,,,,,,,1741.21,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695283,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4830.00000,1400.70000,Aetna,National,,1932.00,,,,,,,1555.26,3950.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7703022,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2360.00000,684.40000,Aetna,National,,944.00,,,,,,,850.78,1930.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7703022,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2360.00000,684.40000,Aetna,National,,944.00,,,,,,,759.92,1930.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7707439,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2520.00000,730.80000,Aetna,National,,1008.00,,,,,,,908.46,2061.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7707439,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2520.00000,730.80000,Aetna,National,,1008.00,,,,,,,811.44,2061.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695373,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,National,,1619.80,,,,,,,1459.84,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7695373,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,National,,1619.80,,,,,,,1303.94,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736064,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2519.40000,730.63000,Aetna,National,,1007.76,,,,,,,908.24,2060.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736064,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2519.40000,730.63000,Aetna,National,,1007.76,,,,,,,811.25,2060.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698919,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5726.70000,1660.74000,Aetna,National,,2290.68,,,,,,,2064.48,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7698919,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5726.70000,1660.74000,Aetna,National,,2290.68,,,,,,,1844.00,4684.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7736079,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7564.05000,2193.57000,Aetna,National,,3025.62,,,,,,,2726.84,6187.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TIGHTROPE,7736079,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7564.05000,2193.57000,Aetna,National,,3025.62,,,,,,,2435.62,6187.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7695235,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,872.55000,253.04000,Aetna,National,,349.02,,,,,,,314.55,713.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7695235,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,872.55000,253.04000,Aetna,National,,349.02,,,,,,,280.96,713.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7736085,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,580.50000,168.34000,Aetna,National,,232.20,,,,,,,209.27,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PIN,7736085,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,580.50000,168.34000,Aetna,National,,232.20,,,,,,,186.92,474.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7700188,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,15691.15000,4550.43000,Aetna,National,,6276.46,,,,,,,5656.66,12835.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPACER,7700188,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,15691.15000,4550.43000,Aetna,National,,6276.46,,,,,,,5052.55,12835.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736096,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1459.52000,423.26000,Aetna,National,,583.81,,,,,,,526.16,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7736096,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1459.52000,423.26000,Aetna,National,,583.81,,,,,,,469.97,1193.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7736107,CDM,278,RC,C1728,HCPCS,,,facility,inpatient,,,10252.50000,2973.22000,Aetna,National,,4101.00,,,,,,,3696.03,8386.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER CONTURA,7736107,CDM,278,RC,C1728,HCPCS,,,facility,outpatient,,,10252.50000,2973.22000,Aetna,National,,4101.00,,,,,,,3301.30,8386.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736115,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2720.00000,788.80000,Aetna,National,,1088.00,,,,,,,980.56,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7736115,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2720.00000,788.80000,Aetna,National,,1088.00,,,,,,,875.84,2224.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700179,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700179,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699418,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,National,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7699418,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,National,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7736131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7731.00000,2241.99000,Aetna,National,,3092.40,,,,,,,2787.03,6323.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7736131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7731.00000,2241.99000,Aetna,National,,3092.40,,,,,,,2489.38,6323.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699388,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3423.00000,992.67000,Aetna,National,,1369.20,,,,,,,1233.99,2800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7699388,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3423.00000,992.67000,Aetna,National,,1369.20,,,,,,,1102.21,2800.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7736170,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,20587.50000,5970.38000,Aetna,National,,8235.00,,,,,,,7421.79,16840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7736170,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,20587.50000,5970.38000,Aetna,National,,8235.00,,,,,,,6629.18,16840.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736186,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3430.00000,994.70000,Aetna,National,,1372.00,,,,,,,1236.52,2805.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736186,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3430.00000,994.70000,Aetna,National,,1372.00,,,,,,,1104.46,2805.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7736197,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14382.00000,4170.78000,Aetna,National,,5752.80,,,,,,,5184.71,11764.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7736197,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14382.00000,4170.78000,Aetna,National,,5752.80,,,,,,,4631.00,11764.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695215,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,9471.66000,2746.78000,Aetna,National,,3788.66,,,,,,,3414.53,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695215,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,9471.66000,2746.78000,Aetna,National,,3788.66,,,,,,,3049.87,7747.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736204,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3911.25000,1134.26000,Aetna,National,,1564.50,,,,,,,1410.01,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736204,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3911.25000,1134.26000,Aetna,National,,1564.50,,,,,,,1259.42,3199.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1540.00000,446.60000,Aetna,National,,616.00,,,,,,,555.17,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1540.00000,446.60000,Aetna,National,,616.00,,,,,,,495.88,1259.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736211,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736211,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736212,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736212,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736217,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,555.75000,161.17000,Aetna,National,,222.30,,,,,,,200.35,454.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736217,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,555.75000,161.17000,Aetna,National,,222.30,,,,,,,178.95,454.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736221,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736221,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698194,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5862.50000,1700.12000,Aetna,National,,2345.00,,,,,,,2113.43,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7698194,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5862.50000,1700.12000,Aetna,National,,2345.00,,,,,,,1887.72,4795.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700422,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5407.50000,1568.18000,Aetna,National,,2163.00,,,,,,,1949.40,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700422,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5407.50000,1568.18000,Aetna,National,,2163.00,,,,,,,1741.21,4423.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736272,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4060.00000,1177.40000,Aetna,National,,1624.00,,,,,,,1463.63,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736272,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4060.00000,1177.40000,Aetna,National,,1624.00,,,,,,,1307.32,3321.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736273,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3675.00000,1065.75000,Aetna,National,,1470.00,,,,,,,1324.84,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7736273,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3675.00000,1065.75000,Aetna,National,,1470.00,,,,,,,1183.35,3006.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7697458,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7697458,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700414,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,National,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7700414,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,National,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7736351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736352,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,National,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7736352,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,National,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736353,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3720.50000,1078.94000,Aetna,National,,1488.20,,,,,,,1341.24,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736353,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3720.50000,1078.94000,Aetna,National,,1488.20,,,,,,,1198.00,3043.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7736354,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7736354,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7736448,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6696.76000,1942.06000,Aetna,National,,2678.70,,,,,,,2414.18,5477.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7736448,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6696.76000,1942.06000,Aetna,National,,2678.70,,,,,,,2156.36,5477.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1664.96000,482.84000,Aetna,National,,665.98,,,,,,,600.22,1361.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7860047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1664.96000,482.84000,Aetna,National,,665.98,,,,,,,536.12,1361.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5934.95000,1721.14000,Aetna,National,,2373.98,,,,,,,2139.55,4854.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5934.95000,1721.14000,Aetna,National,,2373.98,,,,,,,1911.05,4854.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736496,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4049.50000,1174.36000,Aetna,National,,1619.80,,,,,,,1459.84,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7736496,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4049.50000,1174.36000,Aetna,National,,1619.80,,,,,,,1303.94,3312.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7736506,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,906.53000,262.89000,Aetna,National,,362.61,,,,,,,326.80,741.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CABLE,7736506,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,906.53000,262.89000,Aetna,National,,362.61,,,,,,,291.90,741.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7736512,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON,7736512,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736538,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1780.76000,516.42000,Aetna,National,,712.30,,,,,,,641.96,1456.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7736538,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1780.76000,516.42000,Aetna,National,,712.30,,,,,,,573.40,1456.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736542,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7736542,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736544,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,2050.34,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7736544,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5687.50000,1649.38000,Aetna,National,,2275.00,,,,,,,1831.38,4652.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7973840,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,486.88000,141.20000,Aetna,National,,194.75,,,,,,,175.52,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7973840,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,486.88000,141.20000,Aetna,National,,194.75,,,,,,,156.78,398.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7973841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,892.35000,258.78000,Aetna,National,,356.94,,,,,,,321.69,729.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7973841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,892.35000,258.78000,Aetna,National,,356.94,,,,,,,287.34,729.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2001.72000,580.50000,Aetna,National,,800.69,,,,,,,721.62,1637.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2001.72000,580.50000,Aetna,National,,800.69,,,,,,,644.55,1637.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973844,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3042.72000,882.39000,Aetna,National,,1217.09,,,,,,,1096.90,2488.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973844,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3042.72000,882.39000,Aetna,National,,1217.09,,,,,,,979.76,2488.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4361.25000,1264.76000,Aetna,National,,1744.50,,,,,,,1572.23,3567.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BONE MATRIX,7973845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4361.25000,1264.76000,Aetna,National,,1744.50,,,,,,,1404.32,3567.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7973849,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,280.65,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7973849,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,778.50000,225.76000,Aetna,National,,311.40,,,,,,,250.68,636.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7973851,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,25250.00000,7322.50000,Aetna,National,,10100.00,,,,,,,9102.62,20654.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NEUROSTIMULATOR,7973851,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,25250.00000,7322.50000,Aetna,National,,10100.00,,,,,,,8130.50,20654.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974026,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,National,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974026,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,National,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974077,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7974077,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974141,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,National,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7974141,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,National,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7974588,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7974588,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974595,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7974595,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7974596,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7974596,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7974648,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,612.00000,177.48000,Aetna,National,,244.80,,,,,,,220.63,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,7974648,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,612.00000,177.48000,Aetna,National,,244.80,,,,,,,197.06,500.62,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974656,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,National,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974656,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,National,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7974702,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1895.60000,549.72000,Aetna,National,,758.24,,,,,,,683.36,1550.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7974702,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1895.60000,549.72000,Aetna,National,,758.24,,,,,,,610.38,1550.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974703,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4559.07000,1322.13000,Aetna,National,,1823.63,,,,,,,1643.54,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974703,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4559.07000,1322.13000,Aetna,National,,1823.63,,,,,,,1468.02,3729.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7974756,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,17250.00000,5002.50000,Aetna,National,,6900.00,,,,,,,6218.62,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7974756,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,17250.00000,5002.50000,Aetna,National,,6900.00,,,,,,,5554.50,14110.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982428,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1849.04000,536.22000,Aetna,National,,739.62,,,,,,,666.58,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982428,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1849.04000,536.22000,Aetna,National,,739.62,,,,,,,595.39,1512.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1153.60,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7974766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3200.00000,928.00000,Aetna,National,,1280.00,,,,,,,1030.40,2617.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974759,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5003.60000,1451.04000,Aetna,National,,2001.44,,,,,,,1803.80,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7974759,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5003.60000,1451.04000,Aetna,National,,2001.44,,,,,,,1611.16,4092.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7974815,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7974815,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974817,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,National,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974817,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,National,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7974816,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8175.00000,2370.75000,Aetna,National,,3270.00,,,,,,,2947.09,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7974816,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8175.00000,2370.75000,Aetna,National,,3270.00,,,,,,,2632.35,6687.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7974856,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,National,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7974856,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,National,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976743,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976743,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7976741,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,National,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7976741,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,National,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974861,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,National,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974861,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,National,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1419.47,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7974908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3937.50000,1141.88000,Aetna,National,,1575.00,,,,,,,1267.88,3220.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974906,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4822.93000,1398.65000,Aetna,National,,1929.17,,,,,,,1738.67,3945.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7974906,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4822.93000,1398.65000,Aetna,National,,1929.17,,,,,,,1552.98,3945.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7975021,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,444.13000,128.80000,Aetna,National,,177.65,,,,,,,160.11,363.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BUTTON,7975021,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,444.13000,128.80000,Aetna,National,,177.65,,,,,,,143.01,363.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7975047,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5995.50000,1738.70000,Aetna,National,,2398.20,,,,,,,2161.38,4904.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7975047,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5995.50000,1738.70000,Aetna,National,,2398.20,,,,,,,1930.55,4904.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7975065,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7975065,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7975066,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7975066,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980714,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,National,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980714,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,National,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975078,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2755.24000,799.02000,Aetna,National,,1102.10,,,,,,,993.26,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975078,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2755.24000,799.02000,Aetna,National,,1102.10,,,,,,,887.19,2253.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975087,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5162.50000,1497.12000,Aetna,National,,2065.00,,,,,,,1861.08,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7975087,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5162.50000,1497.12000,Aetna,National,,2065.00,,,,,,,1662.33,4222.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975094,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1301.00000,377.29000,Aetna,National,,520.40,,,,,,,469.01,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975094,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1301.00000,377.29000,Aetna,National,,520.40,,,,,,,418.92,1064.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975119,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,626.18000,181.59000,Aetna,National,,250.47,,,,,,,225.74,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7975119,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,626.18000,181.59000,Aetna,National,,250.47,,,,,,,201.63,512.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,7975185,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAP,7975185,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7975186,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7975186,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982825,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,National,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982825,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,National,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7976362,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8595.00000,2492.55000,Aetna,National,,3438.00,,,,,,,3098.50,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7976362,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8595.00000,2492.55000,Aetna,National,,3438.00,,,,,,,2767.59,7030.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2940.00000,852.60000,Aetna,National,,1176.00,,,,,,,1059.87,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2940.00000,852.60000,Aetna,National,,1176.00,,,,,,,946.68,2404.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7976428,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7976428,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7976429,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7976429,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976435,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6167.00000,1788.43000,Aetna,National,,2466.80,,,,,,,2223.20,5044.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7976435,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6167.00000,1788.43000,Aetna,National,,2466.80,,,,,,,1985.77,5044.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976536,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3753.65000,1088.56000,Aetna,National,,1501.46,,,,,,,1353.19,3070.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976536,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3753.65000,1088.56000,Aetna,National,,1501.46,,,,,,,1208.68,3070.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7976531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,701.28000,203.37000,Aetna,National,,280.51,,,,,,,252.81,573.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CEMENT,7976531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,701.28000,203.37000,Aetna,National,,280.51,,,,,,,225.81,573.65,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7976624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,961.81,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7976624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2668.00000,773.72000,Aetna,National,,1067.20,,,,,,,859.10,2182.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,7950.00000,2305.50000,Aetna,National,,3180.00,,,,,,,2865.97,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,7950.00000,2305.50000,Aetna,National,,3180.00,,,,,,,2559.90,6503.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976644,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3642.00000,1056.18000,Aetna,National,,1456.80,,,,,,,1312.94,2979.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7976644,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3642.00000,1056.18000,Aetna,National,,1456.80,,,,,,,1172.72,2979.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7976652,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,National,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7976652,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,National,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976756,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,National,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7976756,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,National,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982821,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,384.75000,111.58000,Aetna,National,,153.90,,,,,,,138.70,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982821,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,384.75000,111.58000,Aetna,National,,153.90,,,,,,,123.89,314.73,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7982902,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,10500.00000,3045.00000,Aetna,National,,4200.00,,,,,,,3785.25,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7982902,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,10500.00000,3045.00000,Aetna,National,,4200.00,,,,,,,3381.00,8589.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIC PROTECTOR,7976733,CDM,278,RC,C1884,HCPCS,,,facility,inpatient,,,14217.00000,4122.93000,Aetna,National,,5686.80,,,,,,,5125.23,11629.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
EMBOLIC PROTECTOR,7976733,CDM,278,RC,C1884,HCPCS,,,facility,outpatient,,,14217.00000,4122.93000,Aetna,National,,5686.80,,,,,,,4577.87,11629.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7978329,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,922.50000,267.52000,Aetna,National,,369.00,,,,,,,332.56,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7978329,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,922.50000,267.52000,Aetna,National,,369.00,,,,,,,297.05,754.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987805,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1603.08000,464.89000,Aetna,National,,641.23,,,,,,,577.91,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987805,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1603.08000,464.89000,Aetna,National,,641.23,,,,,,,516.19,1311.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7978416,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3544.10000,1027.79000,Aetna,National,,1417.64,,,,,,,1277.65,2899.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7978416,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3544.10000,1027.79000,Aetna,National,,1417.64,,,,,,,1141.20,2899.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7980352,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,1860.00000,539.40000,Aetna,National,,744.00,,,,,,,670.53,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7980352,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,1860.00000,539.40000,Aetna,National,,744.00,,,,,,,598.92,1521.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980366,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,National,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980366,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,National,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ELBOW,7980402,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9450.00000,2740.50000,Aetna,National,,3780.00,,,,,,,3406.72,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ELBOW,7980402,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9450.00000,2740.50000,Aetna,National,,3780.00,,,,,,,3042.90,7730.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ELBOW,7980403,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ELBOW,7980403,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980404,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13950.00000,4045.50000,Aetna,National,,5580.00,,,,,,,5028.98,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980404,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13950.00000,4045.50000,Aetna,National,,5580.00,,,,,,,4491.90,11411.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980405,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16750.00000,4857.50000,Aetna,National,,6700.00,,,,,,,6038.38,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980405,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16750.00000,4857.50000,Aetna,National,,6700.00,,,,,,,5393.50,13701.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980406,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5488.28000,1591.60000,Aetna,National,,2195.31,,,,,,,1978.52,4489.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980406,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5488.28000,1591.60000,Aetna,National,,2195.31,,,,,,,1767.23,4489.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7980407,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3140.00000,910.60000,Aetna,National,,1256.00,,,,,,,1131.97,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7980407,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3140.00000,910.60000,Aetna,National,,1256.00,,,,,,,1011.08,2568.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980595,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2205.72000,639.66000,Aetna,National,,882.29,,,,,,,795.16,1804.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980595,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2205.72000,639.66000,Aetna,National,,882.29,,,,,,,710.24,1804.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980688,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,29129.40000,8447.53000,Aetna,National,,11651.76,,,,,,,10501.15,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7980688,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,29129.40000,8447.53000,Aetna,National,,11651.76,,,,,,,9379.67,23827.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980689,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,National,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7980689,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,National,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARDIAC DEFIBRILLATOR,7980699,CDM,278,RC,C1882,HCPCS,,,facility,inpatient,,,44887.50000,13017.38000,Aetna,National,,17955.00,,,,,,,16181.94,36717.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CARDIAC DEFIBRILLATOR,7980699,CDM,278,RC,C1882,HCPCS,,,facility,outpatient,,,44887.50000,13017.38000,Aetna,National,,17955.00,,,,,,,14453.77,36717.97,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7980698,CDM,278,RC,C1898,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LEAD,7980698,CDM,278,RC,C1898,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980711,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6110.16000,1771.95000,Aetna,National,,2444.06,,,,,,,2202.71,4998.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980711,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6110.16000,1771.95000,Aetna,National,,2444.06,,,,,,,1967.47,4998.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7980712,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7980712,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7980713,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7980713,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980815,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5844.02000,1694.77000,Aetna,National,,2337.61,,,,,,,2106.77,4780.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980815,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5844.02000,1694.77000,Aetna,National,,2337.61,,,,,,,1881.77,4780.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980835,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2616.04000,758.65000,Aetna,National,,1046.42,,,,,,,943.08,2139.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980835,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2616.04000,758.65000,Aetna,National,,1046.42,,,,,,,842.36,2139.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980836,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2649.80000,768.44000,Aetna,National,,1059.92,,,,,,,955.25,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980836,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2649.80000,768.44000,Aetna,National,,1059.92,,,,,,,853.24,2167.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980838,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2781.96000,806.77000,Aetna,National,,1112.78,,,,,,,1002.90,2275.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980838,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2781.96000,806.77000,Aetna,National,,1112.78,,,,,,,895.79,2275.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980839,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2815.80000,816.58000,Aetna,National,,1126.32,,,,,,,1015.10,2303.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980839,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2815.80000,816.58000,Aetna,National,,1126.32,,,,,,,906.69,2303.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980841,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2846.52000,825.49000,Aetna,National,,1138.61,,,,,,,1026.17,2328.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980841,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2846.52000,825.49000,Aetna,National,,1138.61,,,,,,,916.58,2328.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7981158,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5724.57000,1660.13000,Aetna,National,,2289.83,,,,,,,2063.71,4682.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7981158,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5724.57000,1660.13000,Aetna,National,,2289.83,,,,,,,1843.31,4682.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980842,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5987.98000,1736.51000,Aetna,National,,2395.19,,,,,,,2158.67,4898.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980842,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5987.98000,1736.51000,Aetna,National,,2395.19,,,,,,,1928.13,4898.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980843,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,789.66000,229.00000,Aetna,National,,315.86,,,,,,,284.67,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980843,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,789.66000,229.00000,Aetna,National,,315.86,,,,,,,254.27,645.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980845,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8271.03000,2398.60000,Aetna,National,,3308.41,,,,,,,2981.71,6765.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980845,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8271.03000,2398.60000,Aetna,National,,3308.41,,,,,,,2663.27,6765.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,172.88000,50.14000,Aetna,National,,69.15,,,,,,,62.32,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,172.88000,50.14000,Aetna,National,,69.15,,,,,,,55.67,141.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980849,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,522.50000,151.52000,Aetna,National,,209.00,,,,,,,188.36,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980849,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,522.50000,151.52000,Aetna,National,,209.00,,,,,,,168.25,427.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980852,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,711.09000,206.22000,Aetna,National,,284.44,,,,,,,256.35,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980852,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,711.09000,206.22000,Aetna,National,,284.44,,,,,,,228.97,581.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980866,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,938.07000,272.04000,Aetna,National,,375.23,,,,,,,338.17,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980866,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,938.07000,272.04000,Aetna,National,,375.23,,,,,,,302.06,767.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,840.33000,243.70000,Aetna,National,,336.13,,,,,,,302.94,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,840.33000,243.70000,Aetna,National,,336.13,,,,,,,270.59,687.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980869,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,653.18000,189.42000,Aetna,National,,261.27,,,,,,,235.47,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980869,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,653.18000,189.42000,Aetna,National,,261.27,,,,,,,210.32,534.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980878,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,592.38000,171.79000,Aetna,National,,236.95,,,,,,,213.55,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980878,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,592.38000,171.79000,Aetna,National,,236.95,,,,,,,190.75,484.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980882,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,609.84000,176.85000,Aetna,National,,243.94,,,,,,,219.85,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7980882,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,609.84000,176.85000,Aetna,National,,243.94,,,,,,,196.37,498.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982323,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,911.30000,264.28000,Aetna,National,,364.52,,,,,,,328.52,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982323,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,911.30000,264.28000,Aetna,National,,364.52,,,,,,,293.44,745.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980833,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3845.35000,1115.15000,Aetna,National,,1538.14,,,,,,,1386.25,3145.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7980833,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3845.35000,1115.15000,Aetna,National,,1538.14,,,,,,,1238.20,3145.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7981168,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,National,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7981168,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,National,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982341,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,155.72000,45.16000,Aetna,National,,62.29,,,,,,,56.14,127.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982341,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,155.72000,45.16000,Aetna,National,,62.29,,,,,,,50.14,127.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982342,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,112.82000,32.72000,Aetna,National,,45.13,,,,,,,40.67,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982342,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,112.82000,32.72000,Aetna,National,,45.13,,,,,,,36.33,92.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982369,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,721.58000,209.26000,Aetna,National,,288.63,,,,,,,260.13,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982369,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,721.58000,209.26000,Aetna,National,,288.63,,,,,,,232.35,590.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982385,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,185.12000,53.68000,Aetna,National,,74.05,,,,,,,66.74,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982385,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,185.12000,53.68000,Aetna,National,,74.05,,,,,,,59.61,151.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982391,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,197.35000,57.23000,Aetna,National,,78.94,,,,,,,71.14,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982391,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,197.35000,57.23000,Aetna,National,,78.94,,,,,,,63.55,161.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7982397,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,670.59000,194.47000,Aetna,National,,268.24,,,,,,,241.75,548.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WASHER,7982397,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,670.59000,194.47000,Aetna,National,,268.24,,,,,,,215.93,548.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982400,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5868.45000,1701.85000,Aetna,National,,2347.38,,,,,,,2115.58,4800.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982400,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5868.45000,1701.85000,Aetna,National,,2347.38,,,,,,,1889.64,4800.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982401,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5974.36000,1732.56000,Aetna,National,,2389.74,,,,,,,2153.76,4887.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982401,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5974.36000,1732.56000,Aetna,National,,2389.74,,,,,,,1923.74,4887.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982403,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5230.30000,1516.79000,Aetna,National,,2092.12,,,,,,,1885.52,4278.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982403,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5230.30000,1516.79000,Aetna,National,,2092.12,,,,,,,1684.16,4278.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982405,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5284.58000,1532.53000,Aetna,National,,2113.83,,,,,,,1905.09,4322.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982405,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5284.58000,1532.53000,Aetna,National,,2113.83,,,,,,,1701.63,4322.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982408,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5436.69000,1576.64000,Aetna,National,,2174.68,,,,,,,1959.93,4447.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982408,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5436.69000,1576.64000,Aetna,National,,2174.68,,,,,,,1750.61,4447.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982410,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1855.24000,538.02000,Aetna,National,,742.10,,,,,,,668.81,1517.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982410,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1855.24000,538.02000,Aetna,National,,742.10,,,,,,,597.39,1517.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982411,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,878.67000,254.81000,Aetna,National,,351.47,,,,,,,316.76,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982411,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,878.67000,254.81000,Aetna,National,,351.47,,,,,,,282.93,718.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982412,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1802.48000,522.72000,Aetna,National,,720.99,,,,,,,649.79,1474.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982412,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1802.48000,522.72000,Aetna,National,,720.99,,,,,,,580.40,1474.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982413,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,456.14000,132.28000,Aetna,National,,182.46,,,,,,,164.44,373.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982413,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,456.14000,132.28000,Aetna,National,,182.46,,,,,,,146.88,373.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982414,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,474.62000,137.64000,Aetna,National,,189.85,,,,,,,171.10,388.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982414,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,474.62000,137.64000,Aetna,National,,189.85,,,,,,,152.83,388.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982416,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.69000,96.48000,Aetna,National,,133.08,,,,,,,119.93,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982416,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.69000,96.48000,Aetna,National,,133.08,,,,,,,107.13,272.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982417,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,358.53000,103.97000,Aetna,National,,143.41,,,,,,,129.25,293.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982417,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,358.53000,103.97000,Aetna,National,,143.41,,,,,,,115.45,293.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982424,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3215.28000,932.43000,Aetna,National,,1286.11,,,,,,,1159.11,2630.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982424,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3215.28000,932.43000,Aetna,National,,1286.11,,,,,,,1035.32,2630.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982427,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2078.68000,602.82000,Aetna,National,,831.47,,,,,,,749.36,1700.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982427,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2078.68000,602.82000,Aetna,National,,831.47,,,,,,,669.33,1700.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982457,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1383.48000,401.21000,Aetna,National,,553.39,,,,,,,498.74,1131.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982457,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1383.48000,401.21000,Aetna,National,,553.39,,,,,,,445.48,1131.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982458,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1445.56000,419.21000,Aetna,National,,578.22,,,,,,,521.12,1182.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7982458,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1445.56000,419.21000,Aetna,National,,578.22,,,,,,,465.47,1182.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7982463,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,650.66000,188.69000,Aetna,National,,260.26,,,,,,,234.56,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BOLT,7982463,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,650.66000,188.69000,Aetna,National,,260.26,,,,,,,209.51,532.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7982777,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,National,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT TIBIAL,7982777,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,National,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7982774,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7982774,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7982775,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3867.50000,1121.57000,Aetna,National,,1547.00,,,,,,,1394.23,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7982775,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3867.50000,1121.57000,Aetna,National,,1547.00,,,,,,,1245.34,3163.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982786,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,National,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7982786,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,National,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7982868,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,13680.00000,3967.20000,Aetna,National,,5472.00,,,,,,,4931.64,11190.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LIGAMENT,7982868,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,13680.00000,3967.20000,Aetna,National,,5472.00,,,,,,,4404.96,11190.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7982898,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER IN A KIT,7982898,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7982906,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7982906,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7982907,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7982907,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7983031,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5204.50000,1509.30000,Aetna,National,,2081.80,,,,,,,1876.22,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CUP,7983031,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5204.50000,1509.30000,Aetna,National,,2081.80,,,,,,,1675.85,4257.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7983032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12166.50000,3528.28000,Aetna,National,,4866.60,,,,,,,4386.02,9952.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7983032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12166.50000,3528.28000,Aetna,National,,4866.60,,,,,,,3917.61,9952.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7983035,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,9298.80000,2696.65000,Aetna,National,,3719.52,,,,,,,3352.22,7606.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT ACETABULAR,7983035,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,9298.80000,2696.65000,Aetna,National,,3719.52,,,,,,,2994.21,7606.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,7983036,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3497.90000,1014.39000,Aetna,National,,1399.16,,,,,,,1260.99,2861.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR AUGMENT,7983036,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3497.90000,1014.39000,Aetna,National,,1399.16,,,,,,,1126.32,2861.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7983037,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4213.65000,1221.96000,Aetna,National,,1685.46,,,,,,,1519.02,3446.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STRUT CORTICAL,7983037,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4213.65000,1221.96000,Aetna,National,,1685.46,,,,,,,1356.80,3446.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7983041,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,909.00000,263.61000,Aetna,National,,363.60,,,,,,,327.69,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7983041,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,909.00000,263.61000,Aetna,National,,363.60,,,,,,,292.70,743.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7983045,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5952.66000,1726.27000,Aetna,National,,2381.06,,,,,,,2145.93,4869.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7983045,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5952.66000,1726.27000,Aetna,National,,2381.06,,,,,,,1916.76,4869.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7985605,CDM,278,RC,C1767,HCPCS,,,facility,inpatient,,,124381.00000,36070.49000,Aetna,National,,49752.40,,,,,,,44839.35,101743.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7985605,CDM,278,RC,C1767,HCPCS,,,facility,outpatient,,,124381.00000,36070.49000,Aetna,National,,49752.40,,,,,,,40050.68,101743.66,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986469,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,33394.50000,9684.40000,Aetna,National,,13357.80,,,,,,,12038.72,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986469,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,33394.50000,9684.40000,Aetna,National,,13357.80,,,,,,,10753.03,27316.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986566,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,12645.00000,3667.05000,Aetna,National,,5058.00,,,,,,,4558.52,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7986566,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,12645.00000,3667.05000,Aetna,National,,5058.00,,,,,,,4071.69,10343.61,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7986604,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2968.00000,860.72000,Aetna,National,,1187.20,,,,,,,1069.96,2427.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7986604,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2968.00000,860.72000,Aetna,National,,1187.20,,,,,,,955.70,2427.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986853,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2132.80000,618.51000,Aetna,National,,853.12,,,,,,,768.87,1744.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986853,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2132.80000,618.51000,Aetna,National,,853.12,,,,,,,686.76,1744.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986855,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2172.40000,630.00000,Aetna,National,,868.96,,,,,,,783.15,1777.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986855,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2172.40000,630.00000,Aetna,National,,868.96,,,,,,,699.51,1777.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986857,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2212.00000,641.48000,Aetna,National,,884.80,,,,,,,797.43,1809.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7986857,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2212.00000,641.48000,Aetna,National,,884.80,,,,,,,712.26,1809.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7987151,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,2251.60000,652.96000,Aetna,National,,900.64,,,,,,,811.70,1841.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7987151,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,2251.60000,652.96000,Aetna,National,,900.64,,,,,,,725.02,1841.81,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7986863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7986865,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,292.00,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7986865,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,810.00000,234.90000,Aetna,National,,324.00,,,,,,,260.82,662.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URINARY CONTROL SYSTEM,7987206,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,24850.00000,7206.50000,Aetna,National,,9940.00,,,,,,,8958.42,20327.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URINARY CONTROL SYSTEM,7987206,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,24850.00000,7206.50000,Aetna,National,,9940.00,,,,,,,8001.70,20327.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS URETHRAL,7987208,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,13440.00000,3897.60000,Aetna,National,,5376.00,,,,,,,4845.12,10993.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PROSTHESIS URETHRAL,7987208,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,13440.00000,3897.60000,Aetna,National,,5376.00,,,,,,,4327.68,10993.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URINARY CONTROL PUMP,7987210,CDM,278,RC,C1815,HCPCS,,,facility,inpatient,,,24100.00000,6989.00000,Aetna,National,,9640.00,,,,,,,8688.05,19713.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
URINARY CONTROL PUMP,7987210,CDM,278,RC,C1815,HCPCS,,,facility,outpatient,,,24100.00000,6989.00000,Aetna,National,,9640.00,,,,,,,7760.20,19713.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7987238,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT PATELLA,7987238,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987582,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,4004.53000,1161.31000,Aetna,National,,1601.81,,,,,,,1443.63,3275.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987582,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,4004.53000,1161.31000,Aetna,National,,1601.81,,,,,,,1289.46,3275.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987556,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3184.00000,923.36000,Aetna,National,,1273.60,,,,,,,1147.83,2604.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987556,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3184.00000,923.36000,Aetna,National,,1273.60,,,,,,,1025.25,2604.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987524,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11412.00000,3309.48000,Aetna,National,,4564.80,,,,,,,4114.03,9335.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987524,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11412.00000,3309.48000,Aetna,National,,4564.80,,,,,,,3674.66,9335.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987577,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,1529.60000,443.58000,Aetna,National,,611.84,,,,,,,551.42,1251.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987577,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,1529.60000,443.58000,Aetna,National,,611.84,,,,,,,492.53,1251.21,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987578,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2068.40000,599.84000,Aetna,National,,827.36,,,,,,,745.66,1691.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987578,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2068.40000,599.84000,Aetna,National,,827.36,,,,,,,666.02,1691.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987580,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,5720.58000,1658.97000,Aetna,National,,2288.23,,,,,,,2062.27,4679.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987580,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,5720.58000,1658.97000,Aetna,National,,2288.23,,,,,,,1842.03,4679.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987581,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,2382.00000,690.78000,Aetna,National,,952.80,,,,,,,858.71,1948.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987581,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,2382.00000,690.78000,Aetna,National,,952.80,,,,,,,767.00,1948.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987583,CDM,278,RC,Q4100,HCPCS,,,facility,inpatient,,,5720.58000,1658.97000,Aetna,National,,2288.23,,,,,,,2062.27,4679.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COLLAGEN,7987583,CDM,278,RC,Q4100,HCPCS,,,facility,outpatient,,,5720.58000,1658.97000,Aetna,National,,2288.23,,,,,,,1842.03,4679.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7987619,CDM,278,RC,C1813,HCPCS,,,facility,inpatient,,,34008.75000,9862.54000,Aetna,National,,13603.50,,,,,,,12260.15,27819.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PENILE IMPLANT,7987619,CDM,278,RC,C1813,HCPCS,,,facility,outpatient,,,34008.75000,9862.54000,Aetna,National,,13603.50,,,,,,,10950.82,27819.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987621,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,National,,968.70,,,,,,,873.04,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7987621,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,National,,968.70,,,,,,,779.81,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7987677,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,796.50000,230.98000,Aetna,National,,318.60,,,,,,,287.14,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NUT,7987677,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,796.50000,230.98000,Aetna,National,,318.60,,,,,,,256.47,651.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7987733,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,6324.50000,1834.10000,Aetna,National,,2529.80,,,,,,,2279.98,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7987733,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,6324.50000,1834.10000,Aetna,National,,2529.80,,,,,,,2036.49,5173.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION DEVICE IN KIT,7987803,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9652.50000,2799.22000,Aetna,National,,3861.00,,,,,,,3479.73,7895.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FIXATION DEVICE IN KIT,7987803,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9652.50000,2799.22000,Aetna,National,,3861.00,,,,,,,3108.11,7895.74,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7748.40000,2247.04000,Aetna,National,,3099.36,,,,,,,2793.30,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7748.40000,2247.04000,Aetna,National,,3099.36,,,,,,,2494.98,6338.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987904,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7987904,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7987908,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,National,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7987908,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,National,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7987910,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16743.20000,4855.53000,Aetna,National,,6697.28,,,,,,,6035.92,13695.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7987910,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16743.20000,4855.53000,Aetna,National,,6697.28,,,,,,,5391.31,13695.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987912,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4958.73000,1438.03000,Aetna,National,,1983.49,,,,,,,1787.62,4056.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7987912,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4958.73000,1438.03000,Aetna,National,,1983.49,,,,,,,1596.71,4056.24,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7987914,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,25606.63000,7425.92000,Aetna,National,,10242.65,,,,,,,9231.19,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7987914,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,25606.63000,7425.92000,Aetna,National,,10242.65,,,,,,,8245.33,20946.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8147624,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,877.50000,254.48000,Aetna,National,,351.00,,,,,,,316.34,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHEATH,8147624,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,877.50000,254.48000,Aetna,National,,351.00,,,,,,,282.56,717.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136122,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136122,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136123,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136123,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136124,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136124,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136125,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136125,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136126,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136126,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136127,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136127,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136128,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136128,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136129,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136129,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136130,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136130,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136131,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136131,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136132,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136132,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136133,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136133,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136134,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136134,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136135,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136135,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136136,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136136,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136137,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136137,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136138,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136138,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136139,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136139,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136140,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136140,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136141,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136141,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136142,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136142,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136143,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136143,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136144,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136144,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136145,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136145,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136146,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136146,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136147,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136147,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136148,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136148,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136149,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136149,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136150,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136150,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136158,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136158,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136162,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136162,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136166,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136166,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136170,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136170,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136174,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136174,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136178,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136178,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136182,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136182,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136151,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136151,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136155,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136155,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136159,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136159,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136163,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136163,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136167,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136167,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136171,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136171,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136175,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136175,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136179,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136179,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136183,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136183,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136186,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136186,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136189,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136189,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136152,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136152,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136156,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136156,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136160,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136160,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136164,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136164,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136168,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136168,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136172,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136172,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136176,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136176,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136180,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136180,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136184,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136184,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136187,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136187,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136190,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136190,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136153,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136153,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136157,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136157,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136161,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136161,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136165,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136165,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136169,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136169,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136173,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136173,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136177,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136177,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136181,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136181,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136185,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136185,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136188,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136188,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136191,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136191,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136238,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,National,,746.00,,,,,,,672.33,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136238,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,National,,746.00,,,,,,,600.53,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136239,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,National,,746.00,,,,,,,672.33,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136239,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,National,,746.00,,,,,,,600.53,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8136236,CDM,278,RC,C1786,HCPCS,,,facility,inpatient,,,26375.00000,7648.75000,Aetna,National,,10550.00,,,,,,,9508.19,21574.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PACEMAKER,8136236,CDM,278,RC,C1786,HCPCS,,,facility,outpatient,,,26375.00000,7648.75000,Aetna,National,,10550.00,,,,,,,8492.75,21574.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8148644,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,6037.50000,1750.87000,Aetna,National,,2415.00,,,,,,,2176.52,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8148644,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,6037.50000,1750.87000,Aetna,National,,2415.00,,,,,,,1944.08,4938.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATOR,8136237,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,138.92000,40.29000,Aetna,National,,55.57,,,,,,,50.08,113.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
DILATOR,8136237,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,138.92000,40.29000,Aetna,National,,55.57,,,,,,,44.73,113.64,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136038,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136038,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136240,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,1865.00000,540.85000,Aetna,National,,746.00,,,,,,,672.33,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER GUIDE,8136240,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,1865.00000,540.85000,Aetna,National,,746.00,,,,,,,600.53,1525.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136241,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3440.50000,997.74000,Aetna,National,,1376.20,,,,,,,1240.30,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136241,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3440.50000,997.74000,Aetna,National,,1376.20,,,,,,,1107.84,2814.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8148865,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1167.12,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8148865,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3237.50000,938.87000,Aetna,National,,1295.00,,,,,,,1042.47,2648.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sensor and Delivery System,8136242,CDM,278,RC,C2624,HCPCS,,,facility,inpatient,,,57000.00000,16530.00000,Aetna,National,,22800.00,,,,,,,20548.50,46626.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
Sensor and Delivery System,8136242,CDM,278,RC,C2624,HCPCS,,,facility,outpatient,,,57000.00000,16530.00000,Aetna,National,,22800.00,,,,,,,18354.00,46626.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOOP RECORDER,8143326,CDM,278,RC,C1764,HCPCS,,,facility,inpatient,,,15000.00000,4350.00000,Aetna,National,,6000.00,,,,,,,5407.50,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LOOP RECORDER,8143326,CDM,278,RC,C1764,HCPCS,,,facility,outpatient,,,15000.00000,4350.00000,Aetna,National,,6000.00,,,,,,,4830.00,12270.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7750486,CDM,278,RC,C2623,HCPCS,,,facility,inpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1448.49,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7750486,CDM,278,RC,C2623,HCPCS,,,facility,outpatient,,,4018.00000,1165.22000,Aetna,National,,1607.20,,,,,,,1293.80,3286.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136284,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136284,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136285,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,2840.00000,823.60000,Aetna,National,,1136.00,,,,,,,1023.82,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136285,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,2840.00000,823.60000,Aetna,National,,1136.00,,,,,,,914.48,2323.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136286,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136286,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136287,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1797.99,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8136287,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,4987.50000,1446.38000,Aetna,National,,1995.00,,,,,,,1605.97,4079.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8155957,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8155957,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8155958,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8155958,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159922,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159922,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159924,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159924,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159926,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159926,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159928,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159928,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159930,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159930,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159932,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159932,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159934,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159934,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159936,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159936,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159938,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159938,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159940,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159940,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159942,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159942,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159944,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159944,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159946,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159946,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159948,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159948,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159950,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159950,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159952,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159952,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159954,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159954,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159956,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159956,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159958,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159958,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159960,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159960,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159962,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159962,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159964,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159964,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159966,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159966,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159968,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159968,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159970,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159970,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159972,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159972,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159974,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159974,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159976,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159976,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159978,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159978,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159980,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159980,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159982,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159982,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159984,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159984,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159986,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159986,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159988,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159988,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159990,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159990,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159992,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159992,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159994,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159994,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159996,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159996,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159998,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8159998,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160000,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160000,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160002,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160002,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160004,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160004,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160006,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160006,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160008,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160008,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160010,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160010,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160012,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160012,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160014,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160014,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160016,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160016,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160018,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160018,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160020,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160020,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160022,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160022,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160024,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160024,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160026,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160026,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160028,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8160028,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8161163,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,251.45,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8161163,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,697.50000,202.27000,Aetna,National,,279.00,,,,,,,224.59,570.55,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8161164,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8161164,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8161165,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8161165,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8161166,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8161166,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8167879,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,364.17000,105.61000,Aetna,National,,145.67,,,,,,,131.28,297.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8167879,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,364.17000,105.61000,Aetna,National,,145.67,,,,,,,117.26,297.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167880,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167880,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167881,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167881,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167882,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,145.55,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8167882,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,403.75000,117.09000,Aetna,National,,161.50,,,,,,,130.01,330.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8167893,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2460.00000,713.40000,Aetna,National,,984.00,,,,,,,886.83,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8167893,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2460.00000,713.40000,Aetna,National,,984.00,,,,,,,792.12,2012.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8168647,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,769.50000,223.15000,Aetna,National,,307.80,,,,,,,277.40,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,8168647,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,769.50000,223.15000,Aetna,National,,307.80,,,,,,,247.78,629.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8168648,CDM,278,RC,C2628,HCPCS,,,facility,inpatient,,,4305.00000,1248.45000,Aetna,National,,1722.00,,,,,,,1551.95,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,8168648,CDM,278,RC,C2628,HCPCS,,,facility,outpatient,,,4305.00000,1248.45000,Aetna,National,,1722.00,,,,,,,1386.21,3521.49,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170299,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170299,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170300,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170300,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170301,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170301,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170302,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170302,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170303,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170303,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170304,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4736.97,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,8170304,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13140.00000,3810.60000,Aetna,National,,5256.00,,,,,,,4231.08,10748.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8214486,CDM,278,RC,C1730,HCPCS,,,facility,inpatient,,,8625.00000,2501.25000,Aetna,National,,3450.00,,,,,,,3109.31,7055.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8214486,CDM,278,RC,C1730,HCPCS,,,facility,outpatient,,,8625.00000,2501.25000,Aetna,National,,9959.00,,,,,,,2777.25,9959.00,case rate,"If multiple procedures are billed, the primary surgical procedure will be identified as the highest applicable category. The primary procedure will be reimbursed at 100.00% of the contracted rate. The secondary procedure will be reimbursed at 50.00% of the contracted rate. Subsequent procedures will be reimbursed at 25.00% of the contracted rate."
ROD,8994477,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1340.00000,388.60000,Aetna,National,,536.00,,,,,,,483.07,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,8994477,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1340.00000,388.60000,Aetna,National,,536.00,,,,,,,431.48,1096.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698622,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3315.38000,961.46000,Aetna,National,,1326.15,,,,,,,1195.19,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698622,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3315.38000,961.46000,Aetna,National,,1326.15,,,,,,,1067.55,2711.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7698633,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,17750.00000,5147.50000,Aetna,National,,7100.00,,,,,,,6398.88,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL ASSEMBLY,7698633,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,17750.00000,5147.50000,Aetna,National,,7100.00,,,,,,,5715.50,14519.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR ASSEMBLY,7698635,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,16500.00000,4785.00000,Aetna,National,,6600.00,,,,,,,5948.25,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ULNAR ASSEMBLY,7698635,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,16500.00000,4785.00000,Aetna,National,,6600.00,,,,,,,5313.00,13497.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7698637,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14649.00000,4248.21000,Aetna,National,,5859.60,,,,,,,5280.96,11982.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7698637,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14649.00000,4248.21000,Aetna,National,,5859.60,,,,,,,4716.98,11982.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698666,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1445.56000,419.21000,Aetna,National,,578.22,,,,,,,521.12,1182.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698666,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1445.56000,419.21000,Aetna,National,,578.22,,,,,,,465.47,1182.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7698625,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,5512.50000,1598.62000,Aetna,National,,2205.00,,,,,,,1987.26,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7698625,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,5512.50000,1598.62000,Aetna,National,,2205.00,,,,,,,1775.03,4509.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913092,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2421.76000,702.31000,Aetna,National,,968.70,,,,,,,873.04,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7913092,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2421.76000,702.31000,Aetna,National,,968.70,,,,,,,779.81,1981.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698705,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1743.52000,505.62000,Aetna,National,,697.41,,,,,,,628.54,1426.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698705,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1743.52000,505.62000,Aetna,National,,697.41,,,,,,,561.41,1426.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698706,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7523.40000,2181.79000,Aetna,National,,3009.36,,,,,,,2712.19,6154.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698706,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7523.40000,2181.79000,Aetna,National,,3009.36,,,,,,,2422.53,6154.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7698717,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7698717,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698738,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5692.40000,1650.80000,Aetna,National,,2276.96,,,,,,,2052.11,4656.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698738,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5692.40000,1650.80000,Aetna,National,,2276.96,,,,,,,1832.95,4656.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698764,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2556.64000,741.43000,Aetna,National,,1022.66,,,,,,,921.67,2091.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698764,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2556.64000,741.43000,Aetna,National,,1022.66,,,,,,,823.24,2091.33,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698765,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2745.96000,796.33000,Aetna,National,,1098.38,,,,,,,989.92,2246.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698765,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2745.96000,796.33000,Aetna,National,,1098.38,,,,,,,884.20,2246.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698766,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1852.12000,537.11000,Aetna,National,,740.85,,,,,,,667.69,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698766,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1852.12000,537.11000,Aetna,National,,740.85,,,,,,,596.38,1515.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698767,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3028.40000,878.24000,Aetna,National,,1211.36,,,,,,,1091.74,2477.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698767,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3028.40000,878.24000,Aetna,National,,1211.36,,,,,,,975.14,2477.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698349,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7698349,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698781,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2159.40000,626.23000,Aetna,National,,863.76,,,,,,,778.46,1766.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698781,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2159.40000,626.23000,Aetna,National,,863.76,,,,,,,695.33,1766.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697486,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3646.34000,1057.44000,Aetna,National,,1458.54,,,,,,,1314.51,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7697486,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3646.34000,1057.44000,Aetna,National,,1458.54,,,,,,,1174.12,2982.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698803,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,19768.75000,5732.94000,Aetna,National,,7907.50,,,,,,,7126.63,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698803,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,19768.75000,5732.94000,Aetna,National,,7907.50,,,,,,,6365.54,16170.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698813,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1440.00000,417.60000,Aetna,National,,576.00,,,,,,,519.12,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698813,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1440.00000,417.60000,Aetna,National,,576.00,,,,,,,463.68,1177.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698827,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,3457.48000,1002.67000,Aetna,National,,1382.99,,,,,,,1246.42,2828.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7698827,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,3457.48000,1002.67000,Aetna,National,,1382.99,,,,,,,1113.31,2828.22,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698817,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7698817,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698819,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8241.00000,2389.89000,Aetna,National,,3296.40,,,,,,,2970.88,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7698819,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8241.00000,2389.89000,Aetna,National,,3296.40,,,,,,,2653.60,6741.14,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698198,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8319.00000,2412.51000,Aetna,National,,3327.60,,,,,,,2999.00,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698198,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8319.00000,2412.51000,Aetna,National,,3327.60,,,,,,,2678.72,6804.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698846,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2748.16000,796.97000,Aetna,National,,1099.26,,,,,,,990.71,2247.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698846,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2748.16000,796.97000,Aetna,National,,1099.26,,,,,,,884.91,2247.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695809,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,National,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7695809,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,National,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695864,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1281.04000,371.50000,Aetna,National,,512.42,,,,,,,461.81,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695864,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1281.04000,371.50000,Aetna,National,,512.42,,,,,,,412.49,1047.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697657,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,204.86000,59.41000,Aetna,National,,81.94,,,,,,,73.85,167.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7697657,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,204.86000,59.41000,Aetna,National,,81.94,,,,,,,65.96,167.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695863,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1206.60000,349.91000,Aetna,National,,482.64,,,,,,,434.98,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7695863,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1206.60000,349.91000,Aetna,National,,482.64,,,,,,,388.53,987.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698939,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3257.10000,944.56000,Aetna,National,,1302.84,,,,,,,1174.18,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698939,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3257.10000,944.56000,Aetna,National,,1302.84,,,,,,,1048.79,2664.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698100,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7698100,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698978,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2463.52000,714.42000,Aetna,National,,985.41,,,,,,,888.10,2015.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698978,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2463.52000,714.42000,Aetna,National,,985.41,,,,,,,793.25,2015.16,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693562,CDM,278,RC,C1757,HCPCS,,,facility,inpatient,,,383.71000,111.28000,Aetna,National,,153.48,,,,,,,138.33,313.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7693562,CDM,278,RC,C1757,HCPCS,,,facility,outpatient,,,383.71000,111.28000,Aetna,National,,153.48,,,,,,,123.55,313.87,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911607,CDM,278,RC,C1751,HCPCS,,,facility,inpatient,,,1234.00000,357.86000,Aetna,National,,493.60,,,,,,,444.86,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7911607,CDM,278,RC,C1751,HCPCS,,,facility,outpatient,,,1234.00000,357.86000,Aetna,National,,493.60,,,,,,,397.35,1009.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696883,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2810.64000,815.09000,Aetna,National,,1124.26,,,,,,,1013.24,2299.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7696883,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2810.64000,815.09000,Aetna,National,,1124.26,,,,,,,905.03,2299.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7695666,CDM,278,RC,C1768,HCPCS,,,facility,inpatient,,,2905.48000,842.59000,Aetna,National,,1162.19,,,,,,,1047.43,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7695666,CDM,278,RC,C1768,HCPCS,,,facility,outpatient,,,2905.48000,842.59000,Aetna,National,,1162.19,,,,,,,935.56,2376.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698713,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,168.95000,49.00000,Aetna,National,,67.58,,,,,,,60.91,138.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7698713,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,168.95000,49.00000,Aetna,National,,67.58,,,,,,,54.40,138.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694874,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,345.36000,100.15000,Aetna,National,,138.14,,,,,,,124.50,282.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7694874,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,345.36000,100.15000,Aetna,National,,138.14,,,,,,,111.21,282.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696456,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,133.61000,38.75000,Aetna,National,,53.44,,,,,,,48.17,109.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7696456,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,133.61000,38.75000,Aetna,National,,53.44,,,,,,,43.02,109.29,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696127,CDM,278,RC,C1781,HCPCS,,,facility,inpatient,,,948.64000,275.11000,Aetna,National,,379.46,,,,,,,341.98,775.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
MESH,7696127,CDM,278,RC,C1781,HCPCS,,,facility,outpatient,,,948.64000,275.11000,Aetna,National,,379.46,,,,,,,305.46,775.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698779,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3603.64000,1045.06000,Aetna,National,,1441.46,,,,,,,1299.11,2947.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7698779,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3603.64000,1045.06000,Aetna,National,,1441.46,,,,,,,1160.37,2947.78,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736559,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,435.91000,126.41000,Aetna,National,,174.36,,,,,,,157.15,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7736559,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,435.91000,126.41000,Aetna,National,,174.36,,,,,,,140.36,356.57,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694694,CDM,278,RC,C1758,HCPCS,,,facility,inpatient,,,403.42000,116.99000,Aetna,National,,161.37,,,,,,,145.43,330.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7694694,CDM,278,RC,C1758,HCPCS,,,facility,outpatient,,,403.42000,116.99000,Aetna,National,,161.37,,,,,,,129.90,330.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695665,CDM,278,RC,C2617,HCPCS,,,facility,inpatient,,,770.99000,223.59000,Aetna,National,,308.40,,,,,,,277.94,630.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7695665,CDM,278,RC,C2617,HCPCS,,,facility,outpatient,,,770.99000,223.59000,Aetna,National,,308.40,,,,,,,248.26,630.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987921,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6563.80000,1903.50000,Aetna,National,,2625.52,,,,,,,2366.25,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7987921,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6563.80000,1903.50000,Aetna,National,,2625.52,,,,,,,2113.54,5369.19,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ROTATION,7987922,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6613.88000,1918.03000,Aetna,National,,2645.55,,,,,,,2384.30,5410.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT ROTATION,7987922,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6613.88000,1918.03000,Aetna,National,,2645.55,,,,,,,2129.67,5410.15,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRANIAL IMPLANT,7987935,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,National,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CRANIAL IMPLANT,7987935,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,National,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7987937,CDM,278,RC,C1889,HCPCS,,,facility,inpatient,,,5047.00000,1463.63000,Aetna,National,,2018.80,,,,,,,1819.44,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COIL,7987937,CDM,278,RC,C1889,HCPCS,,,facility,outpatient,,,5047.00000,1463.63000,Aetna,National,,2018.80,,,,,,,1625.13,4128.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7987949,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7987949,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7987951,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7987951,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7987971,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,11850.00000,3436.50000,Aetna,National,,4740.00,,,,,,,4271.93,9693.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GRAFT,7987971,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,11850.00000,3436.50000,Aetna,National,,4740.00,,,,,,,3815.70,9693.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7988511,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,28828.13000,8360.16000,Aetna,National,,11531.25,,,,,,,10392.54,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7988511,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,28828.13000,8360.16000,Aetna,National,,11531.25,,,,,,,9282.66,23581.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7988515,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6292.13000,1824.72000,Aetna,National,,2516.85,,,,,,,2268.31,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7988515,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6292.13000,1824.72000,Aetna,National,,2516.85,,,,,,,2026.07,5146.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7988521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5131.18000,1488.04000,Aetna,National,,2052.47,,,,,,,1849.79,4197.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WEDGE,7988521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5131.18000,1488.04000,Aetna,National,,2052.47,,,,,,,1652.24,4197.31,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING SYSTEM,7696292,CDM,278,RC,C1771,HCPCS,,,facility,inpatient,,,7766.97000,2252.42000,Aetna,National,,3106.79,,,,,,,2799.99,6353.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLING SYSTEM,7696292,CDM,278,RC,C1771,HCPCS,,,facility,outpatient,,,7766.97000,2252.42000,Aetna,National,,3106.79,,,,,,,2500.96,6353.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7989146,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,18625.00000,5401.25000,Aetna,National,,7450.00,,,,,,,6714.31,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HUMERAL,7989146,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,18625.00000,5401.25000,Aetna,National,,7450.00,,,,,,,5997.25,15235.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989241,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,National,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989241,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,National,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE WEDGE,7989185,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,8130.00000,2357.70000,Aetna,National,,3252.00,,,,,,,2930.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TISSUE WEDGE,7989185,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,8130.00000,2357.70000,Aetna,National,,3252.00,,,,,,,2617.86,6650.34,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7989268,CDM,278,RC,C1762,HCPCS,,,facility,inpatient,,,4946.10000,1434.37000,Aetna,National,,1978.44,,,,,,,1783.07,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ALLOGRAFT,7989268,CDM,278,RC,C1762,HCPCS,,,facility,outpatient,,,4946.10000,1434.37000,Aetna,National,,1978.44,,,,,,,1592.64,4045.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989396,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,8534.25000,2474.93000,Aetna,National,,3413.70,,,,,,,3076.60,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989396,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,8534.25000,2474.93000,Aetna,National,,3413.70,,,,,,,2748.03,6981.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7989503,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4158.25000,1205.89000,Aetna,National,,1663.30,,,,,,,1499.05,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7989503,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4158.25000,1205.89000,Aetna,National,,1663.30,,,,,,,1338.96,3401.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989502,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989502,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7989565,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,7395.00000,2144.55000,Aetna,National,,2958.00,,,,,,,2665.90,6049.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7989565,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,7395.00000,2144.55000,Aetna,National,,2958.00,,,,,,,2381.19,6049.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989618,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,National,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989618,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,National,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989567,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,National,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989567,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,National,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989633,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1308.00000,379.32000,Aetna,National,,523.20,,,,,,,471.53,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989633,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1308.00000,379.32000,Aetna,National,,523.20,,,,,,,421.18,1069.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989569,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,National,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989569,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,National,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989571,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,891.00000,258.39000,Aetna,National,,356.40,,,,,,,321.21,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989571,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,891.00000,258.39000,Aetna,National,,356.40,,,,,,,286.90,728.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989573,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1420.00000,411.80000,Aetna,National,,568.00,,,,,,,511.91,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989573,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1420.00000,411.80000,Aetna,National,,568.00,,,,,,,457.24,1161.56,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7989580,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,686.25000,199.01000,Aetna,National,,274.50,,,,,,,247.39,561.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7989580,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,686.25000,199.01000,Aetna,National,,274.50,,,,,,,220.97,561.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7989584,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,967.50000,280.58000,Aetna,National,,387.00,,,,,,,348.78,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD,7989584,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,967.50000,280.58000,Aetna,National,,387.00,,,,,,,311.54,791.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989582,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,National,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989582,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,National,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989586,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,4902.21000,1421.64000,Aetna,National,,1960.88,,,,,,,1767.25,4010.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989586,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,4902.21000,1421.64000,Aetna,National,,1960.88,,,,,,,1578.51,4010.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7989620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3195.20000,926.61000,Aetna,National,,1278.08,,,,,,,1151.87,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7989620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3195.20000,926.61000,Aetna,National,,1278.08,,,,,,,1028.85,2613.67,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989587,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,National,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989587,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,National,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989588,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,914.63000,265.24000,Aetna,National,,365.85,,,,,,,329.72,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989588,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,914.63000,265.24000,Aetna,National,,365.85,,,,,,,294.51,748.17,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7989635,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,13245.00000,3841.05000,Aetna,National,,5298.00,,,,,,,4774.82,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7989635,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,13245.00000,3841.05000,Aetna,National,,5298.00,,,,,,,4264.89,10834.41,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7989637,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7989637,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BODY,7989638,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,11571.00000,3355.59000,Aetna,National,,4628.40,,,,,,,4171.35,9465.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL BODY,7989638,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,11571.00000,3355.59000,Aetna,National,,4628.40,,,,,,,3725.86,9465.08,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989655,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9531.00000,2763.99000,Aetna,National,,3812.40,,,,,,,3435.93,7796.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989655,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9531.00000,2763.99000,Aetna,National,,3812.40,,,,,,,3068.98,7796.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989657,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6569.50000,1905.16000,Aetna,National,,2627.80,,,,,,,2368.30,5373.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989657,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6569.50000,1905.16000,Aetna,National,,2627.80,,,,,,,2115.38,5373.85,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7989636,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2860.00000,829.40000,Aetna,National,,1144.00,,,,,,,1031.03,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONNECTOR SPINAL,7989636,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2860.00000,829.40000,Aetna,National,,1144.00,,,,,,,920.92,2339.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7989674,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5414.50000,1570.20000,Aetna,National,,2165.80,,,,,,,1951.93,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7989674,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5414.50000,1570.20000,Aetna,National,,2165.80,,,,,,,1743.47,4429.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7989675,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,48037.50000,13930.87000,Aetna,National,,19215.00,,,,,,,17317.52,39294.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7989675,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,48037.50000,13930.87000,Aetna,National,,19215.00,,,,,,,15468.08,39294.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7989676,CDM,278,RC,C1787,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CONTROLLER,7989676,CDM,278,RC,C1787,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7989677,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10350.00000,3001.50000,Aetna,National,,4140.00,,,,,,,3731.18,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL CONE,7989677,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10350.00000,3001.50000,Aetna,National,,4140.00,,,,,,,3332.70,8466.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7989672,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7989672,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON SHEATH,7989698,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,5428.50000,1574.26000,Aetna,National,,2171.40,,,,,,,1956.97,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
TENDON SHEATH,7989698,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,5428.50000,1574.26000,Aetna,National,,2171.40,,,,,,,1747.98,4440.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7989726,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON,7989726,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989830,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,National,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989830,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,National,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7989832,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2222.96000,644.66000,Aetna,National,,889.18,,,,,,,801.38,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7989832,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2222.96000,644.66000,Aetna,National,,889.18,,,,,,,715.79,1818.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7989877,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2822.60000,818.55000,Aetna,National,,1129.04,,,,,,,1017.55,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7989877,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2822.60000,818.55000,Aetna,National,,1129.04,,,,,,,908.88,2308.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7989890,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,819.00000,237.51000,Aetna,National,,327.60,,,,,,,295.25,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7989890,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,819.00000,237.51000,Aetna,National,,327.60,,,,,,,263.72,669.94,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989891,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,7404.00000,2147.16000,Aetna,National,,2961.60,,,,,,,2669.14,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7989891,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,7404.00000,2147.16000,Aetna,National,,2961.60,,,,,,,2384.09,6056.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989898,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,National,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989898,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,National,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989899,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,National,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989899,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,National,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989900,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,National,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989900,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,National,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989901,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,National,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989901,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,National,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989902,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1960.00000,568.40000,Aetna,National,,784.00,,,,,,,706.58,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989902,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1960.00000,568.40000,Aetna,National,,784.00,,,,,,,631.12,1603.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7989892,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3530.63000,1023.88000,Aetna,National,,1412.25,,,,,,,1272.79,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7989892,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3530.63000,1023.88000,Aetna,National,,1412.25,,,,,,,1136.86,2888.06,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989894,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3136.40000,909.56000,Aetna,National,,1254.56,,,,,,,1130.67,2565.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989894,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3136.40000,909.56000,Aetna,National,,1254.56,,,,,,,1009.92,2565.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989895,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3136.40000,909.56000,Aetna,National,,1254.56,,,,,,,1130.67,2565.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989895,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3136.40000,909.56000,Aetna,National,,1254.56,,,,,,,1009.92,2565.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989896,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3064.40000,888.68000,Aetna,National,,1225.76,,,,,,,1104.72,2506.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7989896,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3064.40000,888.68000,Aetna,National,,1225.76,,,,,,,986.74,2506.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989897,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1863.64000,540.46000,Aetna,National,,745.46,,,,,,,671.84,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7989897,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1863.64000,540.46000,Aetna,National,,745.46,,,,,,,600.09,1524.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7989952,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2302.69,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SHELL,7989952,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6387.50000,1852.37000,Aetna,National,,2555.00,,,,,,,2056.78,5224.98,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989954,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989954,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7989956,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7989956,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989958,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,National,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7989958,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,National,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989960,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7989960,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989962,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,National,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989962,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,National,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989964,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,6606.25000,1915.81000,Aetna,National,,2642.50,,,,,,,2381.55,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7989964,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,6606.25000,1915.81000,Aetna,National,,2642.50,,,,,,,2127.21,5403.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7989966,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,2057.21,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7989966,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5706.54000,1654.90000,Aetna,National,,2282.62,,,,,,,1837.51,4667.95,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7989969,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,14250.00000,4132.50000,Aetna,National,,5700.00,,,,,,,5137.12,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7989969,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,14250.00000,4132.50000,Aetna,National,,5700.00,,,,,,,4588.50,11656.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990084,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,447.02,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990084,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1240.00000,359.60000,Aetna,National,,496.00,,,,,,,399.28,1014.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7990086,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9528.00000,2763.12000,Aetna,National,,3811.20,,,,,,,3434.84,7793.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7990086,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9528.00000,2763.12000,Aetna,National,,3811.20,,,,,,,3068.02,7793.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7990089,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7990089,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7990090,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7990090,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7990091,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,1520.00000,440.80000,Aetna,National,,608.00,,,,,,,547.96,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BALLOON CATHETER,7990091,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,1520.00000,440.80000,Aetna,National,,608.00,,,,,,,489.44,1243.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7990103,CDM,278,RC,C1820,HCPCS,,,facility,inpatient,,,47362.50000,13735.12000,Aetna,National,,18945.00,,,,,,,17074.18,38742.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GENERATOR,7990103,CDM,278,RC,C1820,HCPCS,,,facility,outpatient,,,47362.50000,13735.12000,Aetna,National,,18945.00,,,,,,,15250.73,38742.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7990104,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1500.00000,435.00000,Aetna,National,,600.00,,,,,,,540.75,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7990104,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1500.00000,435.00000,Aetna,National,,600.00,,,,,,,483.00,1227.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7990113,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,807.52,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT HEAD,7990113,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2240.00000,649.60000,Aetna,National,,896.00,,,,,,,721.28,1832.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7990115,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,National,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7990115,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,National,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7990126,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8120.25000,2354.87000,Aetna,National,,3248.10,,,,,,,2927.35,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7990126,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8120.25000,2354.87000,Aetna,National,,3248.10,,,,,,,2614.72,6642.36,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7990129,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9750.00000,2827.50000,Aetna,National,,3900.00,,,,,,,3514.88,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
BASEPLATE,7990129,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9750.00000,2827.50000,Aetna,National,,3900.00,,,,,,,3139.50,7975.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990131,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,663.32,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990131,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1840.00000,533.60000,Aetna,National,,736.00,,,,,,,592.48,1505.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990133,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7990133,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7990135,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10650.00000,3088.50000,Aetna,National,,4260.00,,,,,,,3839.32,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7990135,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10650.00000,3088.50000,Aetna,National,,4260.00,,,,,,,3429.30,8711.70,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7990137,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2974.12,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7990137,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8250.00000,2392.50000,Aetna,National,,3300.00,,,,,,,2656.50,6748.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7990139,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7990139,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7991223,CDM,278,RC,C1821,HCPCS,,,facility,inpatient,,,10074.00000,2921.46000,Aetna,National,,4029.60,,,,,,,3631.68,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SPINAL IMPLANT,7991223,CDM,278,RC,C1821,HCPCS,,,facility,outpatient,,,10074.00000,2921.46000,Aetna,National,,4029.60,,,,,,,3243.83,8240.53,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991224,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2184.00000,633.36000,Aetna,National,,873.60,,,,,,,787.33,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991224,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2184.00000,633.36000,Aetna,National,,873.60,,,,,,,703.25,1786.51,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991256,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991256,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991258,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3482.50000,1009.92000,Aetna,National,,1393.00,,,,,,,1255.44,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991258,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3482.50000,1009.92000,Aetna,National,,1393.00,,,,,,,1121.37,2848.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991260,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,2824.00000,818.96000,Aetna,National,,1129.60,,,,,,,1018.05,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991260,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,2824.00000,818.96000,Aetna,National,,1129.60,,,,,,,909.33,2310.03,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7991281,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7991281,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7698927,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,119.87,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SLEEVE,7698927,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,332.50000,96.42000,Aetna,National,,133.00,,,,,,,107.06,271.99,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,7991284,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOID,7991284,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7991285,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7991285,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7991497,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,12750.00000,3697.50000,Aetna,National,,5100.00,,,,,,,4596.38,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT GLENOID,7991497,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,12750.00000,3697.50000,Aetna,National,,5100.00,,,,,,,4105.50,10429.50,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991498,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,National,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991498,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,National,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7991499,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7991499,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991500,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2952.49,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991500,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8190.00000,2375.10000,Aetna,National,,3276.00,,,,,,,2637.18,6699.42,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991501,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1602.42,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991501,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4445.00000,1289.05000,Aetna,National,,1778.00,,,,,,,1431.29,3636.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7991623,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,1110.34,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7991623,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3080.00000,893.20000,Aetna,National,,1232.00,,,,,,,991.76,2519.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991624,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8355.00000,2422.95000,Aetna,National,,3342.00,,,,,,,3011.98,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991624,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8355.00000,2422.95000,Aetna,National,,3342.00,,,,,,,2690.31,6834.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7991625,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,8162.25000,2367.05000,Aetna,National,,3264.90,,,,,,,2942.49,6676.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT TIBIAL,7991625,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,8162.25000,2367.05000,Aetna,National,,3264.90,,,,,,,2628.24,6676.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991626,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,374.30000,108.55000,Aetna,National,,149.72,,,,,,,134.94,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991626,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,374.30000,108.55000,Aetna,National,,149.72,,,,,,,120.52,306.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991627,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3535.00000,1025.15000,Aetna,National,,1414.00,,,,,,,1274.37,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991627,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3535.00000,1025.15000,Aetna,National,,1414.00,,,,,,,1138.27,2891.63,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991628,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,1872.00000,542.88000,Aetna,National,,748.80,,,,,,,674.86,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ROD SPINAL,7991628,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,1872.00000,542.88000,Aetna,National,,748.80,,,,,,,602.78,1531.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991629,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4602.50000,1334.72000,Aetna,National,,1841.00,,,,,,,1659.20,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991629,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4602.50000,1334.72000,Aetna,National,,1841.00,,,,,,,1482.01,3764.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991630,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13548.21000,3928.98000,Aetna,National,,5419.28,,,,,,,4884.13,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991630,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13548.21000,3928.98000,Aetna,National,,5419.28,,,,,,,4362.52,11082.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7991631,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,10291.29000,2984.47000,Aetna,National,,4116.52,,,,,,,3710.01,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CAGE,7991631,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,10291.29000,2984.47000,Aetna,National,,4116.52,,,,,,,3313.80,8418.28,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991678,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,553.50000,160.51000,Aetna,National,,221.40,,,,,,,199.54,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991678,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,553.50000,160.51000,Aetna,National,,221.40,,,,,,,178.23,452.76,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991680,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,904.50000,262.30000,Aetna,National,,361.80,,,,,,,326.07,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991680,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,904.50000,262.30000,Aetna,National,,361.80,,,,,,,291.25,739.88,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4637.50000,1344.88000,Aetna,National,,1855.00,,,,,,,1671.82,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4637.50000,1344.88000,Aetna,National,,1855.00,,,,,,,1493.28,3793.47,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991704,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,National,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991704,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,National,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991706,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5827.50000,1689.98000,Aetna,National,,2331.00,,,,,,,2100.81,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
COMPONENT FEMORAL,7991706,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5827.50000,1689.98000,Aetna,National,,2331.00,,,,,,,1876.45,4766.90,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7991708,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1305.91,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7991708,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,3622.50000,1050.52000,Aetna,National,,1449.00,,,,,,,1166.44,2963.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991710,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,9000.00000,2610.00000,Aetna,National,,3600.00,,,,,,,3244.50,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991710,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,9000.00000,2610.00000,Aetna,National,,3600.00,,,,,,,2898.00,7362.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991712,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1340.96000,388.88000,Aetna,National,,536.38,,,,,,,483.42,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991712,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1340.96000,388.88000,Aetna,National,,536.38,,,,,,,431.79,1096.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7991714,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2997.44000,869.26000,Aetna,National,,1198.98,,,,,,,1080.58,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR CUP,7991714,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2997.44000,869.26000,Aetna,National,,1198.98,,,,,,,965.18,2451.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991854,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10725.00000,3110.25000,Aetna,National,,4290.00,,,,,,,3866.36,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7991854,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10725.00000,3110.25000,Aetna,National,,4290.00,,,,,,,3453.45,8773.05,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991855,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,National,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991855,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,National,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,399.00000,115.71000,Aetna,National,,159.60,,,,,,,143.84,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,399.00000,115.71000,Aetna,National,,159.60,,,,,,,128.48,326.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991857,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,4189.50000,1214.96000,Aetna,National,,1675.80,,,,,,,1510.31,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991857,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,4189.50000,1214.96000,Aetna,National,,1675.80,,,,,,,1349.02,3427.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991858,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,National,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991858,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,National,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,666.00000,193.14000,Aetna,National,,266.40,,,,,,,240.09,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,666.00000,193.14000,Aetna,National,,266.40,,,,,,,214.45,544.79,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991861,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1948.00000,564.92000,Aetna,National,,779.20,,,,,,,702.25,1593.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991861,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1948.00000,564.92000,Aetna,National,,779.20,,,,,,,627.26,1593.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991859,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,3871.00000,1122.59000,Aetna,National,,1548.40,,,,,,,1395.50,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7991859,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,3871.00000,1122.59000,Aetna,National,,1548.40,,,,,,,1246.46,3166.48,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991969,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,879.62,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INSERT,7991969,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,2440.00000,707.60000,Aetna,National,,976.00,,,,,,,785.68,1995.92,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991971,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,National,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991971,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,National,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991973,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2970.00000,861.30000,Aetna,National,,1188.00,,,,,,,1070.68,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7991973,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2970.00000,861.30000,Aetna,National,,1188.00,,,,,,,956.34,2429.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7993519,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10950.00000,3175.50000,Aetna,National,,4380.00,,,,,,,3947.47,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7993519,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10950.00000,3175.50000,Aetna,National,,4380.00,,,,,,,3525.90,8957.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7993521,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7993521,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7993523,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7993523,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7993525,CDM,278,RC,C1874,HCPCS,,,facility,inpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5676.97,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT GRAFT,7993525,CDM,278,RC,C1874,HCPCS,,,facility,outpatient,,,15747.50000,4566.77000,Aetna,National,,6299.00,,,,,,,5070.69,12881.45,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993527,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,5577.88000,1617.59000,Aetna,National,,2231.15,,,,,,,2010.83,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993527,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,5577.88000,1617.59000,Aetna,National,,2231.15,,,,,,,1796.08,4562.71,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993529,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,National,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993529,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,National,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993531,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,National,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993531,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,National,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993533,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,National,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993533,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,National,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993535,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,725.09000,210.28000,Aetna,National,,290.04,,,,,,,261.39,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993535,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,725.09000,210.28000,Aetna,National,,290.04,,,,,,,233.48,593.12,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993537,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,National,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993537,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,National,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993539,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,131.09000,38.02000,Aetna,National,,52.44,,,,,,,47.26,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993539,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,131.09000,38.02000,Aetna,National,,52.44,,,,,,,42.21,107.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993575,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2205.24000,639.52000,Aetna,National,,882.10,,,,,,,794.99,1803.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993575,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2205.24000,639.52000,Aetna,National,,882.10,,,,,,,710.09,1803.89,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993577,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,National,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993577,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,National,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993579,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,634.28000,183.94000,Aetna,National,,253.71,,,,,,,228.66,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993579,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,634.28000,183.94000,Aetna,National,,253.71,,,,,,,204.24,518.84,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7993593,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1545.64,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HUMERAL HEAD,7993593,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4287.50000,1243.38000,Aetna,National,,1715.00,,,,,,,1380.58,3507.18,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993597,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,229.95000,66.69000,Aetna,National,,91.98,,,,,,,82.90,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993597,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,229.95000,66.69000,Aetna,National,,91.98,,,,,,,74.04,188.10,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993603,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,9885.00000,2866.65000,Aetna,National,,3954.00,,,,,,,3563.54,8085.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7993603,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,9885.00000,2866.65000,Aetna,National,,3954.00,,,,,,,3182.97,8085.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993605,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,313.50000,90.92000,Aetna,National,,125.40,,,,,,,113.02,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7993605,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,313.50000,90.92000,Aetna,National,,125.40,,,,,,,100.95,256.44,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7993606,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,13653.09000,3959.40000,Aetna,National,,5461.24,,,,,,,4921.94,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7993606,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,13653.09000,3959.40000,Aetna,National,,5461.24,,,,,,,4396.29,11168.23,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135984,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,153.20000,44.43000,Aetna,National,,61.28,,,,,,,55.23,125.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135984,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,153.20000,44.43000,Aetna,National,,61.28,,,,,,,49.33,125.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135985,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,790.20000,229.16000,Aetna,National,,316.08,,,,,,,284.87,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135985,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,790.20000,229.16000,Aetna,National,,316.08,,,,,,,254.44,646.38,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8143404,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,152.25000,44.15000,Aetna,National,,60.90,,,,,,,54.89,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER,8143404,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,152.25000,44.15000,Aetna,National,,60.90,,,,,,,49.02,124.54,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135986,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,295.07000,85.57000,Aetna,National,,118.03,,,,,,,106.37,241.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135986,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,295.07000,85.57000,Aetna,National,,118.03,,,,,,,95.01,241.37,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROWN DIAMONDBACK,8135988,CDM,278,RC,C1724,HCPCS,,,facility,inpatient,,,13635.00000,3954.15000,Aetna,National,,5454.00,,,,,,,4915.42,11153.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CROWN DIAMONDBACK,8135988,CDM,278,RC,C1724,HCPCS,,,facility,outpatient,,,13635.00000,3954.15000,Aetna,National,,5454.00,,,,,,,4390.47,11153.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135987,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,1220.00000,353.80000,Aetna,National,,488.00,,,,,,,439.81,997.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8135987,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,1220.00000,353.80000,Aetna,National,,488.00,,,,,,,392.84,997.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER TRANSEPTAL,8135989,CDM,278,RC,C1893,HCPCS,,,facility,inpatient,,,855.00000,247.95000,Aetna,National,,342.00,,,,,,,308.23,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER TRANSEPTAL,8135989,CDM,278,RC,C1893,HCPCS,,,facility,outpatient,,,855.00000,247.95000,Aetna,National,,342.00,,,,,,,275.31,699.39,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700200,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7700200,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7818076,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7818076,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7741655,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7741655,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696333,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696333,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696335,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696335,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696337,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696337,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696340,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696340,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696342,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696342,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696343,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696343,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696344,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696344,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858082,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858082,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858080,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858080,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858088,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858088,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858263,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858263,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7794048,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7794048,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858086,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858086,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858087,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858087,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858092,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858092,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858093,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858093,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858100,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858100,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858098,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858098,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858099,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858099,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858104,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858104,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858117,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858117,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858105,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858105,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858107,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858107,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858109,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858109,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858112,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858112,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858115,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7858115,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135991,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135991,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135992,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135992,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135993,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135993,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135995,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135995,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135996,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135996,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135997,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135997,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135998,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135998,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135999,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135999,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136000,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136000,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136001,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136001,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136002,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136002,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136003,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136003,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136004,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136004,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136005,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136005,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136006,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136006,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136007,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136007,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136008,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136008,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136009,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136009,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136010,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136010,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136011,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136011,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136012,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136012,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136013,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136013,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136014,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136014,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136015,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136015,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136016,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136016,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136017,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136017,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136018,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136018,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136019,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136019,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136020,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136020,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136021,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136021,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136022,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136022,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136023,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136023,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136024,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1924.17,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136024,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,5337.50000,1547.88000,Aetna,National,,2135.00,,,,,,,1718.67,4366.07,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136025,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,3412.50000,989.62000,Aetna,National,,1365.00,,,,,,,1230.21,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136025,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,3412.50000,989.62000,Aetna,National,,1365.00,,,,,,,1098.83,2791.43,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136026,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,National,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136026,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,National,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136027,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,National,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136027,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,National,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136028,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,3570.00000,1035.30000,Aetna,National,,1428.00,,,,,,,1286.98,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136028,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,3570.00000,1035.30000,Aetna,National,,1428.00,,,,,,,1149.54,2920.26,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136029,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136029,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136030,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136030,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136031,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136031,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136032,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136032,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136033,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136033,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136034,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136034,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136035,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136035,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136036,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136036,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136037,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136037,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136039,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136039,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136040,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136040,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136041,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136041,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136042,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136042,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7927605,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7927605,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136043,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136043,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136044,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136044,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7927606,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,7927606,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136045,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,154.11,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8136045,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,427.50000,123.98000,Aetna,National,,171.00,,,,,,,137.66,349.69,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136046,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136046,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136047,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136047,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136048,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136048,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136049,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT LIFESTENT,8136049,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7894328,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,720.00000,208.80000,Aetna,National,,288.00,,,,,,,259.56,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,7894328,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,720.00000,208.80000,Aetna,National,,288.00,,,,,,,231.84,588.96,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136052,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,506.83000,146.98000,Aetna,National,,202.73,,,,,,,182.71,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136052,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,506.83000,146.98000,Aetna,National,,202.73,,,,,,,163.20,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136050,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1514.10,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT BILIARY,8136050,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,4200.00000,1218.00000,Aetna,National,,1680.00,,,,,,,1352.40,3435.60,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136053,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,506.83000,146.98000,Aetna,National,,202.73,,,,,,,182.71,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136053,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,506.83000,146.98000,Aetna,National,,202.73,,,,,,,163.20,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136054,CDM,278,RC,C1894,HCPCS,,,facility,inpatient,,,506.83000,146.98000,Aetna,National,,202.73,,,,,,,182.71,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136054,CDM,278,RC,C1894,HCPCS,,,facility,outpatient,,,506.83000,146.98000,Aetna,National,,202.73,,,,,,,163.20,414.59,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136051,CDM,278,RC,C1892,HCPCS,,,facility,inpatient,,,319.20000,92.57000,Aetna,National,,127.68,,,,,,,115.07,261.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
INTRODUCER SAFESHEATH,8136051,CDM,278,RC,C1892,HCPCS,,,facility,outpatient,,,319.20000,92.57000,Aetna,National,,127.68,,,,,,,102.78,261.11,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696336,CDM,278,RC,C1876,HCPCS,,,facility,inpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,951.72,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STENT,7696336,CDM,278,RC,C1876,HCPCS,,,facility,outpatient,,,2640.00000,765.60000,Aetna,National,,1056.00,,,,,,,850.08,2159.52,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP SET IMPELLA CP,8136105,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,62000.00000,17980.00000,Aetna,National,,24800.00,,,,,,,22351.00,50716.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PUMP SET IMPELLA CP,8136105,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,62000.00000,17980.00000,Aetna,National,,24800.00,,,,,,,19964.00,50716.00,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136107,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,115.92000,33.62000,Aetna,National,,46.37,,,,,,,41.79,94.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GUIDEWIRE,8136107,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,115.92000,33.62000,Aetna,National,,46.37,,,,,,,37.33,94.82,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8136106,CDM,278,RC,C1769,HCPCS,,,facility,inpatient,,,456.00000,132.24000,Aetna,National,,182.40,,,,,,,164.39,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
WIRE,8136106,CDM,278,RC,C1769,HCPCS,,,facility,outpatient,,,456.00000,132.24000,Aetna,National,,182.40,,,,,,,146.83,373.01,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136103,CDM,278,RC,C1887,HCPCS,,,facility,inpatient,,,3377.50000,979.47000,Aetna,National,,1351.00,,,,,,,1217.59,2762.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,8136103,CDM,278,RC,C1887,HCPCS,,,facility,outpatient,,,3377.50000,979.47000,Aetna,National,,1351.00,,,,,,,1087.56,2762.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135994,CDM,278,RC,C1725,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER BALLOON,8135994,CDM,278,RC,C1725,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908715,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,678.38000,196.73000,Aetna,National,,271.35,,,,,,,244.56,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908715,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,678.38000,196.73000,Aetna,National,,271.35,,,,,,,218.44,554.91,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904940,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7904940,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947860,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,275.78,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7947860,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,765.00000,221.85000,Aetna,National,,306.00,,,,,,,246.33,625.77,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7904978,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7904978,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7937702,CDM,278,RC,L8699,HCPCS,,,facility,inpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,3190.43,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CERVICAL STABILZATION,7937702,CDM,278,RC,L8699,HCPCS,,,facility,outpatient,,,8850.00000,2566.50000,Aetna,National,,3540.00,,,,,,,2849.70,7239.30,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905032,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905032,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905033,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905033,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905034,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905034,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905035,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905035,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905036,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905036,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905037,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905037,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905038,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905038,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905039,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905039,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905040,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905040,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905044,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905044,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905045,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,2088.20,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
LINER,7905045,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5792.50000,1679.82000,Aetna,National,,2317.00,,,,,,,1865.18,4738.27,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7911244,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,10611.00000,3077.19000,Aetna,National,,4244.40,,,,,,,3825.27,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
HIP MODULAR,7911244,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,10611.00000,3077.19000,Aetna,National,,4244.40,,,,,,,3416.74,8679.80,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7905310,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,2171.64000,629.78000,Aetna,National,,868.66,,,,,,,782.88,1776.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
RESERVOIR,7905310,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,2171.64000,629.78000,Aetna,National,,868.66,,,,,,,699.27,1776.40,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7951856,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,1868.00000,541.72000,Aetna,National,,747.20,,,,,,,673.41,1528.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ANCHOR,7951856,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,1868.00000,541.72000,Aetna,National,,747.20,,,,,,,601.50,1528.02,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7866104,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7866104,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912230,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7912230,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920463,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,634.48,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
FEMORAL HEAD,7920463,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,1760.00000,510.40000,Aetna,National,,704.00,,,,,,,566.72,1439.68,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7905551,CDM,278,RC,C1729,HCPCS,,,facility,inpatient,,,1991.36000,577.49000,Aetna,National,,796.54,,,,,,,717.89,1628.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
CATHETER,7905551,CDM,278,RC,C1729,HCPCS,,,facility,outpatient,,,1991.36000,577.49000,Aetna,National,,796.54,,,,,,,641.22,1628.93,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7905578,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,National,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7905578,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,National,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7920464,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,National,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7920464,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,National,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7939309,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,National,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7939309,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,National,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7939854,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,12900.00000,3741.00000,Aetna,National,,5160.00,,,,,,,4650.45,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
NAIL,7939854,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,12900.00000,3741.00000,Aetna,National,,5160.00,,,,,,,4153.80,10552.20,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7905616,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,National,,1879.08,,,,,,,1693.52,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7905616,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,National,,1879.08,,,,,,,1512.66,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7918961,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4697.70000,1362.33000,Aetna,National,,1879.08,,,,,,,1693.52,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
AUGMENT FEMORAL,7918961,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4697.70000,1362.33000,Aetna,National,,1879.08,,,,,,,1512.66,3842.72,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916495,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,National,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7916495,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,National,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918976,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4388.09000,1272.55000,Aetna,National,,1755.24,,,,,,,1581.91,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7918976,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4388.09000,1272.55000,Aetna,National,,1755.24,,,,,,,1412.96,3589.46,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905620,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,National,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7905620,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,National,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926502,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,2064.00000,598.56000,Aetna,National,,825.60,,,,,,,744.07,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
PLATE,7926502,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,2064.00000,598.56000,Aetna,National,,825.60,,,,,,,664.61,1688.35,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908236,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908236,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908237,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908237,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908238,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908238,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908239,CDM,278,RC,C1713,HCPCS,,,facility,inpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,61.51,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
SCREW,7908239,CDM,278,RC,C1713,HCPCS,,,facility,outpatient,,,170.63000,49.48000,Aetna,National,,68.25,,,,,,,54.94,139.58,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908259,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908259,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908260,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908260,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908261,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908261,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908262,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7908262,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7858549,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,205.70,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
ACETABULAR RING,7858549,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,570.60000,165.47000,Aetna,National,,228.24,,,,,,,183.73,466.75,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806233,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806233,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806351,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7806351,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7832097,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7832097,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7850174,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7850174,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908469,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908469,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908470,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908470,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908471,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908471,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908472,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908472,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908473,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908473,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908474,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908474,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908475,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908475,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908476,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908476,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908477,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908477,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908478,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908478,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908479,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908479,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908480,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908480,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908481,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908481,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908482,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908482,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908483,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,2115.95,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
STEM,7908483,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,5869.50000,1702.16000,Aetna,National,,2347.80,,,,,,,1889.98,4801.25,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7700295,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7700295,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7832098,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7832098,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7901683,CDM,278,RC,C1776,HCPCS,,,facility,inpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1608.73,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7901683,CDM,278,RC,C1776,HCPCS,,,facility,outpatient,,,4462.50000,1294.12000,Aetna,National,,1785.00,,,,,,,1436.92,3650.32,percent of total billed charges,"Separately reimbursable if the charges exceed $1,200 per revenue code line"
GLENOSPHERE,7908337,CDM,278,RC,C1776,HCPCS,,,facilit